Telegram Group Recalls Flashcards

Question 1

Q

Answer

A

Ewing’s Sarcoma

“sunburst” periosteal reaction of the distal fibular Diaphysis

Question 2

Q

Answer

A

Anterior Shoulder Dislocation

Inferomedial subcoracoid displacement of the humeral head

Axillary view is diagnostic and shows Hill-Sachs and Bankhurt lesions

Question 3

Q

Answer

A

Gout

Large Erosions with overhanging margins of the great toe MTP joint

Dense Periarticular swelling
Sparing of the Joint space

Question 4

Q

Treatment of EBV (in scenario here the patient with tonsillar exudates, lymphadenopathy, splenomegaly)?

A. Oral Acyclovir
B. Oral Antibiotic
C. IM or Acyclovir
D. Supportive

Answer

A

D. Supportive

Question 5

Q

Patient with coloured pustules around his mouth, organism show herpes simplex type 1. What is the treatment?

A. Oral Antiviral
B. IV antiviral
C. Supportive

Answer

A

A. Oral Antiviral

The patient’s clinical presentation and positive organism finding suggest an HSV-1 infection (herpes simplex virus type 1), which can cause oral herpes or cold sores around the mouth.

Oral antivirals are the mainstay of treatment for HSV-1 infections. Medications such as acyclovir, valacyclovir, or famciclovir can be used to reduce the severity and duration of symptoms, promote healing of the sores, and prevent recurrence. These medications can be taken orally at home, so no hospitalization or IV antiviral is necessary in most cases.

Question 6

Q

Child with radial head discolouration. What is the next management?

A. Reduction
B. Xray
C. MRI

Question 7

Q

In cervical LNS there are well differentiated thyroid cells, during operation you find no lesion on thyroid what will you do next?

A. Total Thyroidectomy
B. Total Thyroidectomy + radical cervical LNS dissection
C. Total Thyroidectomy + specific LNS dissection
D. Thyroid Lobectomy

Answer

A

C. Total Thyroidectomy + specific LNS dissection

Question 8

Q

Irritable Bowel syndrome, rapid intestinal transit produce which symptom?

A. Vomiting
B. Diarrhea
C. Constipation
D. Abdominal Pain

Answer

A

B. Diarrhea

This is because the faster movement of stool through the intestines can result in loose or watery stools, which is characteristic of diarrhea

Question 9

Q

Free fluid accumulate in abdominal cavity cause?

A. Hypovolemic Shock
B. Cardiogenic Shock
C. Sepsis
D. Emesis

Answer

A

C. Sepsis

The accumulation of free fluid in the abdominal cavity, also known as ascites, can be a sign of several medical conditions. The most common cause of ascites is liver cirrhosis; however, when there is no obvious underlying cause, further diagnostic tests are necessary to identify the underlying condition.

Sepsis can lead to increased permeability of the blood vessels, allowing fluid to leak into the abdominal cavity. It’s important to note that other conditions, such as liver disease or heart failure, can also cause fluid accumulation in the abdominal cavity

Question 10

Q

Female had history of severe depressiin, many episodes she got her remission for three months with Paroxitine (SSRIs) now she is pregannt. What is your advise?

A. Stop SSRIs because it cause fetal malformation
B. Stop SSRIs because it cause premature labor
C. Continue SSRI and monitor her depression

Answer

A

C. Continue SSRI and monitor her depression

Question 11

Q

Mid clavicle fracture

A. Surgery is always indicated if fracture is displaced
B. Figure * dressing ha better outcomes than simple sling
C. Figure * dressing is strongly indicated in patient with union risk
D. Both Figure 8 and simple sling has similar outcomes

Answer

A

D. Both Figure 8 and simple sling has similar outcomes

Question 12

Q

Pediatric patient came to you in the ER wheezing, dyspnea, muscle retractions (most probably asthma) What is the best to give initially?

A. Theophylline
B. Albuterol Nebulizers
C. Oral steroids

Answer

A

B. Albuterol Nebulizers

The initial management of acute asthma exacerbations in children typically involves the rapid administration of short-acting β2-agonists like albuterol, delivered via a nebulizer or metered-dose inhaler. This is often combined with systemic corticosteroids, but the bronchodilator is usually administered first to quickly relieve bronchoconstriction.

Albuterol is a short-acting beta-agonist that works by relaxing the muscles in the airways, making it easier to breathe. It is the first-line treatment for acute asthma exacerbations in children, and it can be administered through a nebulizer or metered-dose inhaler

Question 13

Q

Male came to you complaining of sudden progressive loss of vision of the Left eye last 2 to 3 days, also pain on the same eye, on Fundoscopy optic disk swelling was seen. What is the Diagnosis?

A. Central Retinal Artery Occlusion
B. Central Retinal vein Occlusion
C. Optic Neuritis
D. Macular Degeneration

Answer

A

C. Optic Neuritis

The symptoms of sudden, progressive vision loss and pain in the eye, along with the finding of a swollen optic disc on fundoscopy, are most consistent with optic neuritis. This condition often presents with these symptoms and is typically unilateral, affecting one eye at a time

Common symptoms of optic neuritis include pain with eye movement and temporary vision loss in one eye
. The exact cause of optic neuritis is unknown, but it is believed to develop when the immune system mistakenly targets the substance covering the optic nerve, resulting in inflammation and damage to the myelin.

Question 14

Q

4yo child what can he do?

A. Copy square and triangle
B. Speak Sentences

Answer

A

B. Speak Sentences

Question 15

Q

A man present with painless ulcer in his penis with indurate base and everted edge so diagnosis is

A. Syphilis
B. gonorrhea
C. Choncroid
D. HSV

Answer

A

A. Syphilis

Question 16

Q

female complain of painless odorless and colorless vaginal discharge that appears after intercourse so ttt

A. Give antibiotic
B. Douche after intercourse
C. Cervical Cancer
D. Maybe due to chronic Salphingitis

Answer

A

D. Maybe due to chronic Salphingitis

Question 17

Q

Female patient is 4 weeks postpartum, not smoker diagnosed to have asthma. Her asthma was not controlled she attended ER 3 times last month, on Beta agonist and oral steroid, She came c/o wheezing and sob mildly cyanosed using her intercostal muscles, and wheezy chest.

BP 160/100 PR: 120 PO2: 72 PEF: 36

There is swelling edema in her foot up to the knee, the most likely diagnosis is:
A. COPD
B. Pulmonary Embolism
C. Acute Asthma Attack
D. Angioedema

Answer

A

C. Acute Asthma Attack

Question 18

Q

Epidemic disease in poor sanitation areas affecting children and young adults: What is most likely?

A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D

Answer

A

A. Hepatitis A

Question 19

Q

19yo after bike accident, he can’t bring the spoon in front of himself to eat, the lesion is in

A. Temporal Lobe
B. Cerebellum
C. Parietal Lobe
D. Occipital Lobe

Answer

A

C. Parietal Lobe

Question 20

Q

Patient came after RTA, GCS 14 near complete amputation of the arm. What is the first step?

A. Secure Air way
B. Tourniquet in the arm
C. Debridement of the arm
C. Antibiotic

Answer

A

A. Secure Air way

Question 21

Q

Sildenafil is contraindicated with?

A. Nitrate
B. Methyldopa
C. Gabapentine

Answer

A

A. Nitrate

Question 22

Q

Patient with TB, had ocular toxicity symptoms, the drug responsible is?

A. INH
B. Ethambutol
C. Rifampicin
D. Streptomycin

Answer

A

B. Ethambutol

It can cause optic neuritis, leading to symptoms such as blurred vision, decreased visual acuity, and loss of red-green color vision.

Ethambutol is a first-line medication used in the treatment of tuberculosis, and it has been associated with ocular toxicity since its introduction in the 1960s. Ocular toxicity due to ethambutol usually develops after two months of therapy and is related to the dose

Question 23

Q

Most common intra-abdominal abdominal tumor in children?

A. Wilm’s Tumor
B. Lymphoma
C. Appendix Tumour
D. Colon Tumor

Answer

A

Neuroblastoma then Wilm’s tumor

Wilm’s tumor, also known as nephroblastoma, is the most common intra-abdominal tumor in children. It is a tumor that arises from the kidney and mostly occurs in children between the ages of 3 and 4 years.

Wilm’s tumor is generally considered a highly responsive cancer to multi-modal therapy and is associated with a favorable prognosis. Surgical removal of the affected kidney, along with chemotherapy and radiation therapy, is the standard treatment approach for the majority of Wilm’s tumor cases.

Question 24

Q

What is the most common cause of death in marfan’s Syndrome?

Answer

A

Aortic Root Aneurysm Rupture or Dissection

Question 25

Q

Regarding COPD to reduce complication we should give

A. Theophylline
B. Pneumococcal Vaccine
C. Smoking Cessation

Answer

A

C. Smoking Cessation

Question 26

Q

term neonate 9 days on breast feeding develop jaundice, what type?

A. Breastfeed Jaundice
B. Pathological Jaundice
C. Physiological Jaundice
D. Prolonged Jaundice

Answer

A

A. Breastfeed Jaundice

Question 27

Q

30 yo patient c/o feeling heaviness in the lower abdomen, having buldge palpable int he scrotum that was reducible and increasing in Valsalva maneuver. What is the diagnosis?

A. Hydrocele
B. VAricocoele
C. Indirect Inguinal Hernia
D. Direct inguinal Hernia

Answer

A

C. Indirect Inguinal Hernia

They develop when a portion of the intestine or other abdominal tissue protrudes through the inguinal canal, which is a passageway from the abdomen to the genitals.. In males, the hernia can extend into the scrotum, resulting in a palpable bulge.. The bulge is typically reducible, meaning it can be pushed back into the abdomen. The bulge may become more prominent during activities that increase intra-abdominal pressure, such as coughing, straining, or the Valsalva maneuver
6

Question 28

Q

70 yo man c/o fever, vesicular rash over the forehead. What is the management?

A. IV antibiotics
B. IV antiviral
C. Acyclovir
D. Monitoring

Answer

A

C. Acyclovir or Antivirals

The presence of a vesicular rash, along with the location on the forehead, suggests a possible diagnosis of herpes zoster, also known as shingles. Herpes zoster is caused by the reactivation of the varicella-zoster virus, which remains dormant in the body after a previous infection with chickenpox. Antiviral medications, such as acyclovir, famciclovir, or valacyclovir, are effective in reducing the severity and duration of symptoms when initiated within 72 hours of symptom onset.

Acyclovir, which is an antiviral medication, is commonly used in the treatment of this condition

Question 29

Q

RTA with hip dislocation and shock. What is the cause of shock?

A. Blood loss
B. Urethral Injury
C. Neurogenic
D. Vasovagal

Answer

A

A. Blood loss

Question 30

Q

Twins one male and other female. his father notice that the female become puberty before male so what can you say to the father?

A. Female enter puberty 1-2 year before male
B. Female enter puberty 2-3 years before male
C. Femae enter puberty at the same age male

Answer

A

A. Female enter puberty 1-2 year before male

Question 31

Q

In developing countries to prevent dental carries. It is added to water?

A. Fluoride
B. Zinc
C. Copper
D. Iodide

Answer

A

A. Fluoride

Question 32

Q

A female after a vaginal hysterectomy complains of urine coming from the vagina what is the diagnosis?

A. Vesicovaginal Fistula
B. Urethrovaginal fistula
C. Ureterovaginal fistula

Answer

A

A. Vesicovaginal Fistula

It is an abnormal connection between the bladder and vagina, resulting in continuous urine leakage through the vagina, and can occur after a hysterectomy

Question 33

Q

Lactating women presented with breast engorgement and tenderness. What is your management?

A. Warm compress and continue breastfeeding
B. Dicloxacillin and continue breastfeeding
C. Dicloxacillin and milk expression
D. Discontinue breastfeeding and cold compress

Answer

A

A. Warm compress and continue breastfeeding

Question 34

Q

50yo male presents with fever and malaise for 4 months and pain in the knee and ankles. Blood tests are normal apart from a raised ESR. Chest Xray shows bilateral hilar adenopathy and Pulmonary infiltrates most severe in the upper and mid zones. The Mantoux test is negative. What is the most likely diagnosis?

A. TB
B. Sarcoidosis
C. Asbestosis
D. Berylliosis
E. Malignancy

Answer

A

B. Sarcoidosis

The symptoms of fever, malaise, joint pain, raised ESR, bilateral hilar adenopathy, and pulmonary infiltrates, especially in the upper and mid zones, are characteristic of sarcoidosis.

Question 35

Q

A 54yo man presents with a variety of physical symptoms that have been present for the past 9 years. Numerous investigations and review by a variety of specialties. have indicated no organic basis for his symptoms. This is an example of :

A. Munchausen’s syndrome
B. Hypochondrial disorder
C. Dissociative Disorder
D. Somatisation Disorder
E. Conversion Disorder

Answer

A

D. Somatisation Disorder

Somatization disorder is a type of somatic symptom disorder characterized by multiple, recurrent, and medically unexplained physical symptoms that cause significant distress and impairment in daily functioning

Question 36

Q

A 37 yo primigravida woman presented 30 weeks gestation with a 4 month history of pruritic pustules on her torso, arms and legs. What is the most likely diagnosis?

A. Atopic eruption of pregnancy
B. Disseminated herpes
C. Pemphigoid Gestationis
D. Polymorphic Eruption of Pregnancy
E. Secondary Syphilis

Answer

A

C. Pemphigoid Gestationis

Pemphigoid Gestationis, also known as gestational pemphigoid, is a rare autoimmune skin disorder that occurs during pregnancy and is characterized by the formation of pruritic pustules or itchy blisters on the skin, particularly the abdomen, arms, and legs.

The condition develops when the body produces antibodies against its skin cells that can cause inflammation and blistering. Pemphigoid Gestationis typically develops in the second or third trimester of pregnancy, but can also occur immediately after childbirth. It is treated with topical and/or systemic corticosteroids to reduce inflammation and control symptoms.

Question 37

Q

A 25 yo man presented to the outpatient clinic with a 1-month history of pain and swelling in the scrotum and low-grade fevers. On examination, there was swelling and tenderness of the right side of the scrotum. Laboratory studies showed peripheral eosinophilia. An ultrasound of the scrotum showed echogenic, linear structures moving within the lymphatic channels (arrowhead) adjacent to the epididymal head and testis (asterisk) - a finding known as “filarial” dance sign”. What vector is responsible for transmitting the nematode causing this disease?

A. Aquatic snail
B. Blackfly
C. Mosquito
D. Sandfly
E. Tsetse fly

Answer

A

C. Mosquito

Lymphatic filariasis, caused by infection with nematodes of the family Filariodidea, is transmitted to humans through mosquito bites. Mosquitoes of various genera, including Culex, Anopheles, Aedes, Mansonia, and Coquillettidia, can serve as vectors for filariasis, depending on the geographical location. The nematodes invade the skin through mosquito bites and then travel to the lymphatic system, where they form nests and multiply.

Question 38

Q

A 58 yo man with coronary artery disease presented to the Emergency Department with a 1 day history of intermittent chest pain at rest. An ECG was obtained on arrival, at which time the patient reported no chest pain. Which of the following is the most likely site of the culprit lesion?

A. Right Coronary Artery
B. Left Circumflex Artery
C. Left Coronary Artery
D. Posterior Descending Artery
E. Left Anterior Descending Artery

Answer

A

E. Left Anterior Descending Artery

The left anterior descending artery (LAD) is the most common site of the culprit lesion in cases of acute coronary syndrome. It supplies blood to the anterior wall of the left ventricle, the interventricular septum, and the apex. The blockage of LAD can lead to a significant reduction in coronary blood flow, resulting in myocardial ischemia or infarction.

In this scenario, the patient’s symptoms of intermittent chest pain at rest, combined with coronary artery disease, increase the likelihood of acute coronary syndrome. The ECG obtained on arrival can help identify any changes in the heart’s electrical activity and suggest the site of the coronary artery lesion.

ECG - Wellen’s Syndrome - biphasic or deep precordial T wave inversions particularly in leads V2 and V3.

Question 39

Q

A 35 yo woman with idiopathic pulmonary arterial hypertension and a pulmonary aneurysm presented with Chest pain. Computed Tomography of the chest is shown. What is the most likely diagnosis?

A. Aortic Dissection
B. Aortic pseudoaneurysm
C. Intramural Hematoma
D. Pulmonary artery dissection
E. Pulmonary Artery Rupture

Answer

A

D. Pulmonary artery dissection

Question 40

Q

19yo woman presented with a 6 month history of a slowly growing asymptomatic dark spot on her palm. Examination was notable for nonscaling, nonpalpable brown patch (left). Dermatoscopy revealed pigmented spicules, and palmar skin scrapings were prepared (right). What is the most likely diagnsosis?

A. Acral Lentiginous melanoma
B. Lichen planus
C. Secondary Syphilis
D. Tinea nigra
E. TInea versicolor

Answer

A

A. Acral Lentiginous melanoma

The clinical and dermoscopic findings of a slow-growing, asymptomatic, dark spot with pigmented spicules on the palm, along with non-scaling, non-palpable brown patch, are highly suspicious for Acral Lentiginous melanoma (ALM), which is a distinct subtype of melanoma.

ALM is a rare but aggressive melanoma subtype that typically occurs on the palms, soles, or nail beds. It is characterized by the presence of pigmented spicules on the dermoscopy exam and is commonly misdiagnosed, leading to delays in diagnosis and treatment.

other answered D

Question 41

Q

An 8 month old girl presented with strabismus and developmental delay. On examination, she was noted to have macrocephaly, intermittent exotropia in the left eye and hypotonia. Fundoscopic exam results are shown in the image, MRI of the brain revealed inadequate myelination diffusely and a thin corpus callosum. What is the diagnosis?

A. Myotonic Dystrophy
B. Pompe disease
C. Prader-Willi Syndrome
D. Spinal Muscular Atrophy
E. Tay Sach-s Disease

Answer

A

E. Tay Sach-s Disease

Tay-Sachs disease is an autosomal recessive genetic disorder that results from the deficiency of an essential enzyme called hexosaminidase A. As a result, there is an accumulation of a substance called GM2-ganglioside in the nervous system, leading to the widespread destruction of neurons.

The clinical features of the disease can depend on the age of onset and the severity of the condition. In the infantile form of Tay-Sachs disease, symptoms typically appear between 3 and 6 months of age and usually include deficits in motor function, developmental delays, and progressive microcephaly. Fundus examination may reveal a cherry-red spot. The cherry red spot of the macula is a characteristic finding of this disease, caused by abnormally whitened, lipid-laden neurons surrounding and accentuating the color of the fovea.

Question 42

Q

A 37yo old man presented to the ED with a 1-week history of pain and swelling in the left upper arm that had started after blunt trauma during soccer practice. The heart rate was 120 beats per minute, the blood pressure is 96/54 mmHg, and the body temperature was 37.9 C. Examination of the left upper arm was notable for swelling, tenderness, and crepitus. the overlying skin was red and warm to the touch. An initial radiography is shown, which of the following factors is most associated with increased mortality in this diagnosis?

A. Delay in surgical intervention > 24 hrs
B. Involvement of the upper extremity
C. Negative Blood Cultures
D. Patient < 60 years
E. Presence of Erythema

Answer

A

A. Delay in surgical intervention > 24 hrs

Question 43

Q

A 17 yo girl with systemic lupus erythematosus presented to the opthalmology clinic with a 2 day history of decreased vision in her right eye and a 6 month history of intermittent headaches. She stopped treatment with methylprednisolone and hydroxychloroquine 2 years ago. Examination of the fundus of the right eye is as shown. What is the diagnosis?

A. Antiphospholipid Syndrome
B. Retinal Toxoplamosis
C. Lupus Retinal Vasculitis
D. Susac’s syndrome
E. Hydroxychloroquine Induced maculopathy

Answer

A

A. Antiphospholipid Syndrome

Question 44

Q

A 2yo old boy is brought into the emergency room with complaint of fever for 6 days and the development of the limp. On examination, he is found to have an eythematous macular exanthema over his body as shown in th eimage. Bilateral conjunctivitis, dry and crackled lips, a red throat and cervical lymphadenopathy. There is grade 2/6 Vibratory ejection murmur at the lwoer left sternal border. WBCs and differential show predominant neutrophils with increased platelets. He later developed desquamation of skin of palms and sole around the finger tips with edema.
What is your diagnosis? Give your diagnostic criteria and how will you manage this case?

Answer

A

Kawasaki Diseease

Kawasaki disease, a condition that primarily affects children and involves inflammation in the walls of medium-sized arteries throughout the body. The diagnostic criteria include fever for 5 or more days, plus at least 4 of the following: rash, conjunctivitis, changes in the lips or oral cavity, changes in the extremities, and cervical lymphadenopathy, a red throat, and a strawberry tongue.

Laboratory findings may include an elevated white blood cell count with predominant neutrophils and increased platelets, as well as positive urine analysis for proteinuria and RBC cast.

Management typically involves high-dose aspirin and intravenous immunoglobulin to reduce inflammation and prevent coronary artery abnormalities

Question 45

Q

Pregnant woman, 32 weeks, has contact with a child with chicken pox and comes to you because she is worried. She had been checked before pregnancy and IgG for varicella was negative. What do you do?

A. Check IgG now
B. Give Immunoglobulin
C. Give oral Acyclovir
D. Give Oral Famciclovir

Answer

A

A. Check IgG now or IgG?

Yes, giving immunoglobulin straight away (B) is also an option for prophylaxis in pregnant women who are not immune to varicella and have been exposed to the virus. The decision to give immunoglobulin or check IgG status depends on the timing of the exposure and the availability of the IgG assay. If the exposure occurred within the past 96 hours, VZIG or immunoglobulin should be given immediately. If the exposure occurred more than 96 hours ago, checking IgG status is appropriate. If the IgG assay is negative, prophylaxis with VZIG or immunoglobulin should be given.

The pregnant woman should be tested for varicella IgG to determine her immune status as a preliminary step towards management. If IgG is positive, the woman is immune to varicella and does not require any further action. If IgG is negative, then the woman is susceptible to varicella and should be closely monitored for any signs of the disease.

If the woman develops chickenpox during pregnancy, she should be referred for further management and treatment as appropriate depending on the stage of her pregnancy.

Question 46

Q

50 years old eating peanuts, suddenly presented SOB and collapsed. On auscultation, stridor and wheezes present. What do you do next?
A. O2 with nasal prong
B. O2 with face mask
C. Bronchoscopy
D. Nebulization with Salbutamol

Answer

A

B. O2 with face mask

The patient’s symptoms suggest a severe allergic reaction, possibly anaphylaxis, which can cause airway swelling and difficulty breathing. Immediate treatment should include administration of oxygen. However, the most critical initial treatment is the administration of intramuscular epinephrine. Nebulization with Salbutamol can be considered as it helps to relieve bronchospasm, a common feature in anaphylaxis. It’s important to note that this is a medical emergency and the patient should be closely monitored and further treated based on response and clinical guidelines

Question 47

Q

Old woman has come to the ED with severe epigastric pain 10/10 which occurred 20 minutes after dinner. She says pain is constant and doesn’t radiate anywhere. On exam her pulse is 110 and BP is 74/50. She feels cold and clammy. Abdominal exam reveals no tenderness but marked rigidity. What is the most likely diagnosis?

A. pancreatitits
B. Perforated Duodenal Ulcer
C. Pancreatic Pesudocyst
D. Burst Appendic
E. , Mesenteric ISchaemia

Answer

A

B. Perforated Duodenal Ulcer

The sudden onset of severe epigastric pain, which occurred shortly after dinner, suggests an acute upper gastrointestinal event, such as a perforated peptic ulcer.

The presence of marked rigidity on abdominal examination may indicate peritonitis, which can occur as a result of a perforated ulcer. Additionally, the patient’s vital signs are concerning for hypovolemic shock.

Often located in the epigastric region and may be constant and not radiate anywhere

Question 48

Q

A case of dysphagia. Barium swallow showing diffuse esophageal spasm. What is long-term management?

A. Nifedipine
B. Laparoscopic Cardiomyotomy
C. Botulinum Toxin
D. Beta Blockers
E. Conservative

Answer

A

E. Conservative

Question 49

Q

Which of the following is the least described as primary prevention?

A. Reduce Incidence
B. Improve lifestyle
C. Giving vaccination
D. Reduce Prevalence
E. Identify the predisposing factors early

Answer

A

D. Reduce Prevalence

Primary prevention aims to prevent the development of disease in healthy individuals by addressing risk factors and promoting healthy behavior. It includes measures such as providing education to promote healthy lifestyles, vaccination, and early identification of risk factors.

Reducing prevalence (Option D) is a measure of secondary prevention that focuses on reducing the impact of the disease once it has occurred. It involves early diagnosis and prompt treatment to slow the progression of the disease and prevent complications.

Reducing incidence (Option A) is a primary prevention measure that aims to reduce the number of new cases of a disease. It may involve measures such as vaccination, education, and behavior change.

Improving lifestyle (Option B) is a primary prevention measure that focuses on promoting healthy behaviors that can help prevent the development of diseases. Lifestyle changes such as diet modification, exercise, and smoking cessation can help reduce the risk of developing many chronic diseases.

Giving vaccination (Option C) is a primary prevention measure that protects individuals from developing infectious diseases such as measles, mumps, rubella, and influenza.

Identifying predisposing factors early (Option E) is a primary prevention measure that aims to identify individuals who may be at risk of developing a disease based on their genetics, family history, or other risk factors. Early identification can help individuals take steps to prevent the development of the disease or manage it more effectively if it does occur.

Question 50

Q

A young boy is brought to you in a rural ER. The Neurosurgery unit is 1 hour away. Earlier today he was hit during football where he lost consciousness and fell to the ground. A few minutes he regained his consciousness and walked out of the field. His family brought him to you complaining that he has developed a headache after the incident. His GCS is 10/15. What is the next plan for him?

A. Do a CT Scan
B. Transfer to neurosurgery unit
C. Hyperventilation and Mannitol Infusion
D. Burr Hole
E. craniectomy

Answer

A

A. Do a CT Scan

The patient has a significant head injury with loss of consciousness followed by headache, indicating the need for further evaluation for traumatic brain injury. A computed tomography (CT) scan is the initial diagnostic imaging test of choice for suspected head injury as it can quickly identify the presence of a life-threatening or treatable injury.

Question 51

Q

A 28 yo man comes to the physician because of a 3-month history of pain in his left shoulder. He is physically active and plays baseball twice a week. The pain is reproduced when the shoulder is externally rotated against resistance. Injury of which of the following tendons is most likely in this patient?

A. Teres Major
B. Pectoralis Major
C. Supraspinatus
D. Infrsspinatus
E. Subscapularis

Answer

A

Infraspinatus

The infraspinatus muscle is one of the rotator cuff muscles that is responsible for external rotation of the shoulder, and it is commonly injured in overhead athletes such as baseball players

The Supraspinatus muscle is involved in the initial 15 degrees of arm elevation, while the Infraspinatus muscle is primarily responsible for external rotation of the shoulder. Given that the patient’s pain is reproduced when the shoulder is externally rotated against resistance, it is more likely to be an injury to the Infraspinatus tendon rather than the Supraspinatus tendon.

While the supraspinatus tendon (C) is the most frequently injured tendon of the rotator cuff, it is less likely in this case as the pain is reproduced with external rotation against resistance, which is more indicative of an infraspinatus injury

Question 52

Q

An otherwise healthy 45 yo woman comes to the physician because of a 2-week history of an itchy rash on her left nipple. The rash began as small vesicles on the nipple and spread to the areola. It has become a painful ulcer with a yellow, watery discharge that is occasionally blood-tinged. She has asthma treated with theophylline and inhaled salbutamol. Her younger sister was diagnosed with endometrial cancer a year ago. Examination shows a weeping, ulcerated lesion involving the entire left nipple-areolar complex. There are no breast masses, dimpling or axillary lymphadenopathy. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?

A. inflammatory Breast Cancer
B. mastitis
C. Breast ABscess
D. Breast Fibroadenoma
E. Paget’s disease of the breast

Answer

A

E. Paget’s disease of the breast

This condition often presents as a rash on the nipple and areola, which can progress to ulceration and discharge. It can be misdiagnosed as eczema or dermatitis, but the persistence of symptoms and lack of response to topical treatments should raise suspicion for Paget’s disease. It is often associated with an underlying in situ or invasive breast carcinoma

Paget’s disease of the breast is a rare form of breast cancer that affects the nipple and areola and typically presents with symptoms such as itching, redness, flaky or scaly skin on the nipple, and a yellow or bloody discharge

. The disease may start as a small lesion on the nipple and spread to the areola and other areas of the breast.
Inflammatory breast cancer (A), mastitis (B), breast abscess (C), and breast fibroadenoma (D) are less likely diagnoses in this case, as they do not typically present with the characteristic symptoms of Paget’s disease of the breast.

Question 53

Q

Known hypertension presented with muscle weakness K. 6.5 What could be the cause?

A. Enalapril
B. Amiloride
C. Simvastatin
D. Thiazide
E. Amlodipine

Answer

A

B. Amiloride.

Amiloride is a potassium-sparing diuretic that inhibits the reabsorption of sodium and reduces the loss of potassium in the urine. This medication is often used in the treatment of hypertension and edema.

However, amiloride can cause hyperkalemia (high potassium levels) in some patients, particularly those with impaired renal function or those taking other medications that increase potassium levels.

Enalapril (Option A) and Amlodipine (Option E) are not typically associated with hyperkalemia.

Simvastatin (Option C) is a cholesterol-lowering medication and is not expected to cause muscle weakness or hyperkalemia.

Thiazide diuretics (Option D) may cause hypokalemia (low potassium levels) but not hyperkalemia.

Question 54

Q

8 month old boy is brought due to fever and decreased appetite. Patient awake only 2 hours today, most of that time he was crying. Appears sleepy and has a high pitched cry when roused. Anterior fontanelle is bulging. What is the next step?

A. Ct Scan of the head
B. Dexamethasone therapy
C. Lumbar puncture

Answer

A

C. Lumbar puncture.

The presence of fever, decreased appetite, excessive crying, sleepiness, and bulging anterior fontanelle in this 8-month-old infant can be suggestive of meningitis. Therefore, performing a lumbar puncture is necessary to diagnose or rule out meningitis.

Question 55

Q

Middle-aged presented to the ER with a complaint of seizure, diagnosed as a case of generalized tonic-clonic seizures. He has a history of stroke and hypertension and takes warfarin and other drugs. What will be your best drug of choice for him?

A. Amiodarone
B. Sodium Valproate
C. Carbamazepine
D. Phenytoin
E. Topiramate

Answer

A

B. Sodium Valproate

Sodium valproate is a broad-spectrum anticonvulsant medication with efficacy against generalized tonic-clonic seizures. It is also often used for patients with a history of stroke or cardiovascular disease, as it does not have significant cardiovascular effects or interact with warfarin metabolism.

Question 56

Q

Cardio patient with polypharma presented with repeated syncope, ECG strip was given and asked about combination responsible about that.

A. Amlodipine + Amiodarone
B. Furosemide + amiodarone
C. Aspirin + Amiodarone
D., Furosemide + Amlodipine

Answer

A

A. Amlodipine + Amiodarone.

Amlodipine is a calcium channel blocker used to treat hypertension, whereas Amiodarone is an antiarrhythmic medication used to treat cardiac arrhythmias. Both medications have the potential to cause hypotension or bradycardia, which can lead to syncope in susceptible individuals.

Furosemide (Option B and D) is a diuretic used to treat congestive heart failure, whereas aspirin (Option C) is an antiplatelet medication used to treat and prevent heart attacks and strokes. Although these medications can cause side effects, they are generally not associated with syncope.

Question 57

Q

53 yo man comes due to persistent fatigue. Started a therapeutic dose of fluoxetine 2 months ago after being diagnosed with major depressive disorder. Medical history includes hypertension treated with Enalapril. 4kg weight gain over the past 2 months. Appears depressed and speaks softly. What is the next step?

A. Continue Fluoxetine and Add methylphenidate
B. Discontinue Fluoxetine and begin Ibupropion

Answer

A

A. Continue Fluoxetine and Add methylphenidate.

The patient is presenting with persistent fatigue, weight gain, and depression, which can be symptoms of major depressive disorder. As he has already been diagnosed with major depressive disorder and has been receiving fluoxetine therapy for 2 months, the first step would be to continue Fluoxetine and add methylphenidate to manage his fatigue.

Methylphenidate is a central nervous system stimulant used to treat attention deficit hyperactivity disorder (ADHD) and narcolepsy, but it can also be useful in managing fatigue and cognitive dysfunction associated with depression.

Discontinuing fluoxetine (Option B) is not recommended since depression is a chronic condition that requires appropriate maintenance therapy. Discontinuing fluoxetine may result in relapse of depressive symptoms and cause more harm.

Ibuprofen (Option B) is a nonsteroidal anti-inflammatory drug used for pain relief and is not effective in managing depressive symptoms associated with major depressive disorder.

Question 58

Q

30 yo man comes to the physician because of a painful swollen knee for the past several weeks. He had several episodes of painful urination before the onset of his knee pain. Physical examination shows an edematous knee and bilateral conjunctivitis with mucopurulent discharge.

A. Osteoarthritis
B. Rheumatoid Arthritis
C. Osteochondritis Dessicans
D. Pigmented Vilonodular tenosynovitis
E. Gout

Answer

A

E. Gout

Previous episodes of painful urination, and bilateral conjunctivitis with mucopurulent discharge is much more suggestive of gout, as these are classic features associated with acute gouty arthritis.

Question 59

Q

A scenario of hoarding disorder. The wife brings his husband to the GP complaining she can’t use her kitchen and toilet as her husband brings and collects rubbish. These symptoms are from past 20 years. When his wife aks about collection of rubbish he replies nothing is waste. It might be useful one day. Underlying cause of the behaviour?

A. Social avoidant
B.. Childhood sexual abuse

Answer

A

Neither social avoidance nor childhood sexual abuse is directly linked to HD as a cause.

Genetics play a role.

Question 60

Q

A homosexual man asking for Pre-exposure prophylaxis. HIV test negative.

A. Daily tenofovir and Emtricitabine
B. Tenofovir and Emtricitabine after exposure
C. Tenofovir and Emtricitabine before high-risk exposure
D. Do Hiv Test

Answer

A

A. Daily tenofovir and Emtricitabine

Pre-exposure prophylaxis (PrEP) is a medication that people at risk of HIV take to prevent getting HIV from sex or injection drug use. Tenofovir and emtricitabine are two antiretroviral medications that are used for PrEP and have been shown to be highly effective in preventing HIV when taken as prescribed

Question 61

Q

4yo old boy was brought by his mom because of jaundice of eyes and intermittent pallor with normal WBC, and platelet. Only anemia is present with HB 80 mg/dL. And there is a respiratory viral infection. patient with marked pallor and splenomegaly. What is the most appropriate management?

A. BT
B. oral Iron
C. Splenectomy
D. Folic Acid and Vitamin B12

Question 62

Q

The pregnant lady at 39 weeks presents with painless bleeding of 1000 ml fetal Hr 155. Mother’s heart rate is 100. Cervix dilated and 5cm effaced, no contractions of the uterus which of the option will help to assist in the diagnosis?

A. no contractions
B. Fetal HR
C. mother HR

Answer

A

B. Fetal HR

Question 63

Q

A 4 yo boy was brought by his mom because of jaundice of the eyes and intermittent pallor with normal WBC and platelet. Only anemia is present with HB 80 mg/DL. There is a respiratory viral infection. patient with marked pallor and splenomegaly. What is the most appropriate management?

A. BT
B. Oral Iron
C. Splenectomy
C. Folic acid and Vitamin B12

Question 64

Q

Each of the following is characteristic of adult rheumatoid arthritis. Except:

A. Morning stiffness of joints
B. Soft tissue swellings
C. HErberden’s Nodes
D. Subcutaneous nodules at pressure points
E. Symmetrical Joint involvement

Answer 61

A

C. Cease Warfarin

Answer 62

A

D) CT Head.

Temporal lobe epilepsy is a seizure disorder characterized by recurrent seizures that originate from the temporal lobe of the brain, and blinking of eyes and lips can be one of the common symptoms of partial seizures.

CT head or magnetic resonance imaging (MRI) of the brain is the preferred first-line diagnostic imaging modality to evaluate for structural lesions in the brain, such as tumors, infarctions, hematomas, or cysts, which are some of the most common causes of focal seizures. These imaging modalities can also provide detailed information on the size, location, and characteristics of the lesion that could aid in further management.

Urine R/E (Option A), or urine routine and microscopic examination, is used to diagnose various renal and urinary tract infections, but it is not the most appropriate investigation for this patient’s presenting symptoms of episodic blinking of eyes and unresponsiveness.

EMG (Option B), or electromyography, is a diagnostic tool used to diagnose muscular or peripheral neuropathic disorders and would not be helpful in diagnosing temporal lobe epilepsy.

Blood sugar (Option C) can be an essential parameter to measure when investigating for seizures; however, it is less likely to cause this kind of presentation, so should not be the first test requested.

Answer 63

A

A) Fluticasone.

Fluticasone is an inhaled corticosteroid that is the first-line preventer therapy for asthma in children and adults, as it is effective in reducing inflammation in the airways and preventing asthma symptoms in the long term.

Sodium cromoglycate (Option B) is a mast cell stabilizer that can be used as a preventive therapy for children with mild-to-moderate asthma, but it is less effective than inhaled corticosteroids and may not be suitable for all patients. It is typically used as an alternative to inhaled corticosteroids in those with mild intermittent asthma and can be combined with a short-acting bronchodilator, such as salbutamol.

LABA (Option C), or long-acting beta-agonists, are usually not recommended initially as monotherapy but can be added to inhaled corticosteroids to control asthma symptoms in those with moderate-to-severe disease. Therefore, LABA is not the initial preventer option for this child.

Montelukast (Option D) is a leukotriene receptor antagonist that can be used as an alternative or addition to inhaled corticosteroids to prevent asthma symptoms, particularly in those with mild-to-moderate persistent asthma. However, the effectiveness of montelukast as a monotherapy is limited and it is not the most effective option for most people with asthma.

Answer 64

A

D. Ductogram

A ductogram is a specialized imaging test that involves injecting a contrast agent into the affected duct and then taking X-rays to visualize the ductal system.

This test can help identify the location and extent of the lesion causing the nipple discharge and can also help guide further diagnostic and therapeutic intervention

Answer 65

A

D. Ductogram

A ductogram is a specialized imaging test that involves injecting a contrast agent into the affected duct and then taking X-rays to visualize the ductal system.

This test can help identify the location and extent of the lesion causing the nipple discharge and can also help guide further diagnostic and therapeutic intervention

Answer 66

A

D. Inform the Senior Medical

Answer 67

A

D. Chemo Side effect

The diagnosis is likely D. Chemo Side effect. The symptoms described, such as neck pain and unusual sensations in the hands, could be due to chemotherapy-induced peripheral neuropathy (CIPN). This is a common side effect of chemotherapy, affecting about 30 to 40 percent of patients, and can cause symptoms like tingling, numbness, and pain

Answer 68

A

B. Indwelling Urethral catheter

The immediate treatment for acute urinary retention (AUR) is bladder decompression using urethral or suprapubic catheterization. An indwelling urethral catheter (Option B) is commonly used. However, it’s important to note that surgical treatment carries a higher rate of morbidity and mortality in men presenting with

AUR, and urgent prostatic surgery after AUR are associated with greater morbidity and mortality than delayed prostatectomy (Option C). Therefore, Option B, an indwelling urethral catheter, is the most appropriate immediate management for this patient.
Acute urinary retention is a medical emergency that requires immediate intervention to relieve the bladder and prevent complications such as bladder damage, kidney damage, and sepsis

. Indwelling urethral catheterization is the most common and effective method of relieving acute urinary retention

. The catheter is inserted through the urethra into the bladder to drain the urine and relieve the pressure on the bladder

Answer 69

A

C. Cease Antihypertensive

Answer 70

A

A. Document

Answer 71

A

D. Talk to your colleague

Answer 72

A

A. Lithotripsy Laser: is a less invasive procedure that involves using a laser or ultrasound waves to break and remove the kidney stone. It is typically used for stones less than 2 cm in size.

B. ESWL (Extracorporeal Shockwave Lithotripsy): ESWL uses shock waves to break the stone into smaller pieces that can be passed out of the body naturally. It may be an option for small to medium-sized stones that are causing symptoms.

D. Basket extraction: This procedure is a minimally invasive technique to remove stones from the ureter or kidney. It involves using a small basket-like device to scoop out the stone.

Answer 73

A

Current pregnancy: A new pregnancy could be the cause of the elevated B hCG levels. However, it is important to rule out other possible causes, such as persistent gestational trophoblastic neoplasia (GTN), which can occur after a hydatidiform mole

Persistent gestational trophoblastic neoplasia (GTN): GTN is a rare complication that can occur after a hydatidiform mole. It is characterized by persistently elevated B hCG levels and can lead to invasive mole or choriocarcinoma if left untreated

In summary, the possible cause of the new presentation of B hCG of 900 seven weeks after the first pregnancy with a hydatidiform mole and D&C could be a current pregnancy or persistent gestational trophoblastic neoplasia (GTN)

Answer 74

A

B. Jaw thrust and head tilt position
The patient’s symptoms and behavior suggest agitation, which can be caused by various underlying medical or psychiatric conditions

The initial approach should focus on ensuring the patient’s safety and addressing any potential life-threatening conditions

.
The jaw thrust and head tilt position can be used to open the patient’s airway and ensure proper breathing

This maneuver can be performed by gently lifting the patient’s jaw forward while maintaining the head in a neutral position

It is important to maintain a calm and non-confrontational approach when dealing with an agitated patient to minimize the risk of escalation

Answer 75

A

D. Rubeola

Rubeola (Measles) is a highly contagious viral infection that is characterized by fever, coryza, conjunctivitis, and a maculopapular rash that starts on the head and neck and spreads to the trunk and extremities

The rash is typically preceded by a prodrome of malaise, fever, and other symptoms, which can last for several days. Koplik spots, which are pinpoint white lesions on the buccal mucosa, are a classic feature of rubeola and can help differentiate it from other viral infections

Other possible causes of a maculopapular rash in children include rubella, parvovirus, and other viral and bacterial infections

Answer 76

A

A. Multiple Sclerosis

Answer 77

A

C. Charcot-Marie-Tooth
Charcot-Marie-Tooth (CMT) disease is a group of inherited disorders that affect the peripheral nerves, leading to muscle weakness and atrophy, as well as sensory loss in the limbs

CMT can cause foot deformities, including pes cavus (high arches), pes planus (flat feet), and hindfoot valgus (outward turning of the heel)

Plantar flexed ankle, always abducted lower limb, and wide base gait can be indicative of foot deformities associated with CMT

Answer 78

A

A. Resolving paralytic ileus

Paralytic ileus is a condition characterized by the temporary paralysis or decreased function of the intestines, leading to a disruption in normal bowel movements. It can occur as a result of surgery, including appendectomy

After surgery, the intestines may temporarily slow down or stop functioning properly, leading to symptoms such as abdominal pain and diarrhea

The empty rectum suggests that there is a delay in the passage of stool through the intestines, which is consistent with paralytic ileus

Paralytic ileus is a self-limiting condition that typically resolves on its own within a few days to a week after surgery

Answer 79

A

C. Immunodeficiency

Answer 80

A

C. Transfer patient for PCI

Answer 81

A

C. hemodialysis

The given lab investigations suggest that the patient is suffering from acute kidney injury (AKI) with hyperkalemia, which can lead to life-threatening complications such as cardiac arrhythmias and respiratory failure

The initial management of hyperkalemia includes the administration of medications such as insulin, glucose, calcium, and sodium bicarbonate to stabilize the patient’s condition

However, in severe cases of hyperkalemia with AKI, hemodialysis is the most effective and rapid method of removing excess potassium from the body and correcting the underlying cause of the condition

Hemodialysis can also help correct other electrolyte imbalances and remove uremic toxins from the body, which can improve the patient’s overall condition

Answer 82

A

C. Lumbar Puncture

A lumbar puncture, also known as a spinal tap, is a medical procedure in which a needle is inserted into the spinal canal to collect cerebrospinal fluid (CSF) for diagnostic testing

Lumbar puncture is commonly used to help diagnose diseases of the central nervous system, including the brain and spine, such as meningitis and subarachnoid hemorrhage

.
In this case, the patient’s symptoms of confusion and dizziness, along with the abnormal lab findings, may suggest the possibility of an underlying neurological condition that requires further evaluation through a lumbar puncture

The analysis of CSF obtained from a lumbar puncture can provide valuable information about the presence of infectious, inflammatory, or neoplastic diseases affecting the central nervous system

Lumbar puncture can also be used therapeutically in some conditions, such as the

Answer 83

A

B. Cease Metoprolol and Add Verapamil.

The soft-blowing precordial murmur at the left sternal border suggests aortic stenosis, which may be causing ventricular ectopics in the patient. Metoprolol should be ceased as it is contraindicated in aortic stenosis. Verapamil, a calcium channel blocker, can be added as it is better tolerated with aortic stenosis and can also help to manage the ventricular ectopics. Warfarin is not indicated at this time.

Answer 84

A

A. Retained products of conception

. Retained products of conception is the most likely cause of light, bright red vaginal bleeding and abdominal cramping in a 5-day postpartum mother. Despite the fact that there was a complete placenta delivery and no need for suturing, there still might be a possibility that some placental tissue remains in the uterus that could be causing postpartum bleeding. As the lochia has been decreasing for the past few days, the sudden onset of bleeding suggests retained products of conception. It is recommended to do an ultrasound to confirm the diagnosis and appropriate treatment should be given accordingly.

Answer 85

A

C- Serum parathyroid hormone assay

Serum parathyroid hormone assay. The patient’s laboratory findings indicate hypercalcemia, which can be caused by several conditions, including hyperparathyroidism, malignancy, sarcoidosis, among others. A serum parathyroid hormone (PTH) assay can help determine if primary hyperparathyroidism is the cause of hypercalcemia.

Answer 86

A

B.Lamotrigine

Lamotrigine is known to cause rashes as a side effect, and this can range from mild to severe. In some cases, the rash can be a sign of a more serious condition, such as Stevens-Johnson syndrome or toxic epidermal necrolysis. The fact that the girl recently started taking lamotrigine and developed a rash and fever suggests that this could be a drug reaction.

The development of a maculopapular rash and fever after starting treatment with lamotrigine is a known adverse drug reaction, which may indicate an allergic reaction or Stevens-Johnson syndrome. The recent history of UTI and amoxicillin use was several weeks ago, so it is less likely to be the cause of the current presentation. Valproate is not typically associated with a maculopapular rash. Sepsis may cause a fever and rash, but Lamotrigine-induced rash should be considered first.

Answer 87

A

Diabetic neuropathy

Diabetic neuropathy is a common complication of diabetes that affects the nerves in the feet and legs. It can cause a loss of sensation in the feet, making it difficult to feel pain or discomfort. This can lead to the development of foot ulcers, which can become infected and lead to serious complications. Other contributing factors to foot ulcerations in diabetic patients include peripheral vascular disease, biomechanical structural deformities, and soft tissue changes

Answer 88

A

c/ Renal ultrasound

The patient’s current symptoms of flank pain, fever, and chills combined with a history of acute pyelonephritis suggest a possible renal abscess, which can be diagnosed through a renal ultrasound. An abscess should be suspected in patients with ongoing symptoms or clinical deterioration despite appropriate antibiotic therapy for pyelonephritis. Therefore, a renal ultrasound is the next appropriate step in this situation.

Answer 89

A

2) there’s no need for anticoagulants

In a healthy patient, without any specific risk factors for deep vein thrombosis (DVT)/pulmonary embolism (PE) undergoing an elective cholecystectomy, the risks of anticoagulation (such as bleeding) will likely outweigh the benefits. Therefore, there’s generally no need for anticoagulants unless the patient has additional risk for thrombotic events.

Answer 90

A

B. Gout

Gout is a type of arthritis that occurs when there is a buildup of uric acid crystals in the joints, leading to inflammation and pain. The joints most commonly affected by gout are the big toe, ankle, and knee, but it can also affect other joints, including those in the foot. The presence of pain in the first and second metatarsal joint, along with knee joint pain, is consistent with gout.

Gout is caused by the build-up of uric acid crystals inside the joints. It typically affects one joint at a time, often the big toe, but could also affect other joints. Its symptoms may also include redness, swelling, and severe pain that comes on suddenly, often at night. An episode of gout usually resolves within 1-2 weeks with treatment and can show elevated uric acid levels in the blood.

Reactive arthritis, on the other hand, is typically caused by an infection in another part of the body (genital, urinary, or gastrointestinal system). It usually manifests as joint pain and swelling (often in the lower extremities), but may also involve the eyes (conjunctivitis or uveitis), skin (rash or ulcers), and urogenital tract (urethritis, cervicitis). This condition usually occurs within 1-4 weeks after the infection and is often self-limiting. It doesn’t commonly involve the big toe or the metatarsals, like gout tends to.

Answer 91

A

D. Registrar who’s doing the surgery

Answer 92

A

Electrolyte disturbance.

Electrolyte disturbances, such as hyponatremia (low sodium levels) or hypernatremia (high sodium levels), can occur as a side effect of venlafaxine use. These imbalances can lead to neurological symptoms, including confusion and agitation

It is important to monitor electrolyte levels regularly in individuals taking venlafaxine, especially if they are experiencing new symptoms.
While it is possible that other factors, such as drug interactions or underlying brain pathology, could contribute to the symptoms, the given information does not provide enough evidence to support those causes. Electrolyte disturbance is a known side effect of venlafaxine and should be considered as a potential cause in this case.

Answer 93

A

a) Vaginal swab

Answer 94

A

D. No treatment

No treatment is required for infectious mononucleosis as it is caused by the Epstein-Barr virus, which does not respond to antiviral medications such as Acyclovir. Antibiotics are also not effective against viral infections. Prednisolone may provide some symptom relief but is not necessary for all patients. The primary treatment for infectious mononucleosis is supportive care and management of symptoms.

Answer 95

A

5) prophylactic LMWH now & upto 6wks postpartum

Prophylactic LMWH now and up to 6 weeks postpartum is also a recommended treatment for pregnant women with a history of DVT and hereditary prothrombin G20210A gene mutation. This option is considered in cases where the individual has no ongoing additional risk factors for thrombosis. However, if the individual has a high risk of recurrent DVT or there are additional risk factors, option 2) therapeutic LMWH now and up to 6 weeks postpartum may be preferred.

Answer 96

A

C. Cholecystectomy

Answer 97

A

Malunion: When the broken bones do not heal in the correct position leading to deformity and limited function.

Carpal Tunnel Syndrome: Pressure on the median nerve, which crosses the wrist can result in carpal tunnel syndrome, causing tingling, numbness, or weakness in the hand.
Complex Regional Pain Syndrome: It is a rare but serious complication and characterized by severe pain, swelling, and changes in the skin and nails of the affected limb.
Arthritis: A Colles fracture may lead to arthritis, which can cause pain, swelling, stiffness, and limited mobility in the wrist joint.
Tendon injuries: Tendons connecting the muscles to the bones, as well as the ligaments that surround the wrist joint, may be damaged due to the fracture, leading to decreased strength and mobility.
Infection: Although rare, a Colles fracture can result in infection if there is an open wound or a break in the skin.

Answer 98

A

D. Somatisation disorder

D. Somatization disorder (also known as somatic symptom disorder) is a condition in which an individual experiences a variety of unexplained physical symptoms for an extended period of time, typically several years or more, for which no organic basis can be found despite extensive medical investigations. These symptoms can include chronic pain, gastrointestinal distress, fatigue, and neurological complaints. Patients with this disorder may become preoccupied with their symptoms and may seek medical attention repeatedly, possibly from multiple providers in multiple settings.

Hypochondrial disorder involves excessive preoccupation with the fear of having a serious medical illness despite medical evaluation and reassurance to the contrary.

Dissociative disorders and conversion disorders are dissociative states that can cause physical manifestations and neurological symptoms, but they are usually of a more sudden onset and have identifiable triggers.

Munchausen’s syndrome is a rare disorder in which an individual deliberately falsifies symptoms or causes self-harm in order to gain attention or sympathy from medical professionals.

Answer 99

A

B. SARCOIDOSIS

Based on the provided information and the search results, the most likely diagnosis for the 50-year-old male with fever, malaise, pain in the knees and ankles, raised ESR, and findings of bilateral hilar adenopathy and pulmonary infiltrates most severe in the upper and mid zones on chest x-ray is B. Sarcoidosis. Sarcoidosis is a condition characterized by the formation of granulomas in various organs, most commonly the lungs and lymph nodes

. It can present with a wide range of symptoms, including fever, fatigue, joint pain, and respiratory symptoms. The raised ESR and the findings of bilateral hilar adenopathy and pulmonary infiltrates on chest x-ray are consistent with sarcoidosis

Berylliosis, also known as chronic beryllium disease (CBD), is a granulomatous disease caused by exposure to beryllium. Symptoms of berylliosis include cough, fever, night sweats, and fatigue. A definitive diagnosis of berylliosis is based on occupational history, positive blood or bronchoalveolar lavage (BAL) beryllium lymphocyte proliferation test (BeLPT), and granulomatous inflammation on lung biopsy. While the symptoms and findings of the 50-year-old male are consistent with berylliosis, the provided search results do not mention any history of beryllium exposure or any other specific features that would suggest berylliosis as the most likely diagnosis.
In contrast, sarcoidosis is a more common condition that can present with similar symptoms and findings, including fever, joint pain, raised ESR, and bilateral hilar adenopathy and pulmonary infiltrates on chest x-ray
4
. The negative Mantoux test also makes TB less likely as a diagnosis. However, a definitive diagnosis of sarcoidosis requires further evaluation, such as a biopsy of affected tissues, to confirm the presence of non-caseating granulomas. It is important to note that a definitive diagnosis for the 50-year-old male cannot be made without further evaluation and consultation with a healthcare professional.

Answer 100

A

a. Ask the podiatrist to review.

This patient has a diabetic foot ulcer that requires specialized care from a podiatrist. It is important to involve a podiatrist early in the management of diabetic foot ulcers to facilitate healing and prevent complications. The yellow-colored discharge may indicate infection, which would require treatment with antibiotics. The podiatrist can assess the wound and determine if antibiotic therapy is needed, as well as provide recommendations for wound dressings and offloading to promote healing. MRI or intravenous antibiotics may be used in more severe cases, but this is not indicated at this point in the management of this patient.

A podiatrist is a medical professional who specializes in the diagnosis, treatment, and prevention of foot and ankle conditions. They are trained to manage a wide range of foot and ankle problems, including diabetic foot ulcers, ingrown toenails, plantar fasciitis, and fractures. Podiatrists may use medical, surgical, and orthotic interventions to treat their patients, depending on the specific case. They may also provide advice on footwear, foot hygiene, and foot-related exercises. The goal of podiatric care is to help patients maintain healthy feet and ankles, alleviate pain and discomfort, and improve mobility and quality of life.

Answer 101

A

B aspirin and clopidogrel

The initial management for a patient with STEMI when the time to reach the nearest tertiary care hospital is 4 hours would be to administer aspirin and clopidogrel to inhibit platelet aggregation and prevent further clot formation. If PCI cannot be performed within 120 minutes, thrombolytic therapy (TPA) should be considered. However, the decision between these options should be individualized based on the patient’s risk factors and contraindications

Aspirin and clopidogrel antiplatelet therapy is indicated as the initial management for a patient with ST-elevation myocardial infarction (STEMI) while they are awaiting transfer to a tertiary care hospital for percutaneous coronary intervention (PCI). The benefit of administering thrombolytic therapy, like TPA, diminishes significantly after 3-4 hours of symptom onset and therefore, the patient is not an ideal candidate for TPA, given the time taken to reach the hospital. Heparin can be initiated upon arrival at the tertiary care hospital. Transfer for PCI as soon as possible is also necessary to reduce the damage done to the myocardium. However, administration of aspirin and clopidogrel within the first hour of presentation can improve survival rates and help prevent further clotting and occlusion of the coronary artery until PCI can be performed.

In the given scenario, aspirin and clopidogrel antiplatelet therapy is recommended as the initial management while the patient is being transferred to a tertiary care hospital for PCI, and heparin can be initiated upon arrival at the hospital.

Regarding the use of TPA (A), it can be considered as a treatment option for patients with STEMI who arrive within 3 to 4.5 hours of symptom onset, especially in cases where timely transfer for PCI is not possible. However, in this case, the patient has taken 4 hours to reach the tertiary care hospital, which is beyond the recommended time limit for administration of TPA.

Regarding transfer for PCI (C), it is a definitive treatment for STEMI and is necessary for the patient, as it helps restore blood flow to the heart and minimizes damage to the myocardium. However, as the patient is currently presenting with chest pain and is not stable for transfer, antiplatelet therapy is the initial step in management until the patient can be transferred to the hospital.

Therefore, the initial management for this patient with STEMI presenting after 4 hours from symptom onset would be B. aspirin and clopidogrel.

Primary PCI is the preferred reperfusion therapy for patients with STEMI if it can be performed within 90 minutes of first medical contact. However, if this time frame is not possible, then fibrinolytic therapy is preferred for those without contraindications. Therefore, the patient should be transferred to the nearest tertiary care hospital with the capability to perform primary PCI as soon as possible. In the meantime, the patient should receive aspirin and clopidogrel and heparin to reduce the risk of further thrombotic events. Morphine sulfate can be given for chest discomfort refractory to nitrates and other anti-ischemic therapies

It is important to note that the management of STEMI is time-sensitive, and delays in reperfusion therapy can lead to worse outcomes

Answer 102

A

A toxic multinodular goitre

T3-secreting adenoma is a type of thyroid nodular disease marked by a solitary thyroid nodule that produces excessive amounts of thyroid hormone in the form of T3. This can lead to the development of hyperthyroidism, which is characterized by symptoms such as weight loss, tremor, sweating, palpitations, and anxiety. Patients with T3-secreting adenomas will typically have a low TSH level, an elevated T3 level, and a mildly elevated T4 level. Due to the significantly elevated T3 levels, serum T3 forms the main diagnostic laboratory test for T3-secreting adenomas.

Toxic multinodular goitre is a type of thyroid nodular disease marked by the presence of multiple nodules within the thyroid gland that become overactive and produce excessive amounts of thyroid hormone. Patients with toxic multinodular goitre will present with a large goitre and symptoms of hyperthyroidism such as weight loss, tremors, sweating, palpitations, and anxiety. They may also present with features of Graves’ disease such as exophthalmos, pretibial myxedema, and thyroid acropachy. Patients with toxic multinodular goitre will typically have a low TSH level and an elevated T3 and T4 level. There may be a greater increase in T4 relative to T3 in toxic multinodular goitre when compared to T3-secreting adenomas. T3 levels are usually elevated, but not to the degree seen in T3-secreting adenomas.

In summary, while both conditions can lead to hyperthyroidism, T3-secreting adenomas involve a solitary thyroid nodule that overproduces T3, leading to elevated T3 levels and only mild elevation of T4 levels. In contrast, toxic multinodular goitre involves the presence of multiple nodules that overproduce both thyroid hormones (T3 and T4) leading to a significant elevation of both hormones in the blood. Serum T3 levels are usually elevated but not to the degree seen in T3-secreting adenomas.

You are correct, my previous response made an assumption about multiple nodules based on the terminology of toxic multinodular goitre. However, given that the case only mentions a large non-tender goitre without specifying multiple nodules, it would indeed be more appropriate to consider this as a solitary thyroid nodule rather than toxic multinodular goitre.

With a solitary thyroid nodule and a low TSH level along with elevated T4 and T3 levels, the most likely diagnosis in this case would be a T3-secreting adenoma rather than toxic multinodular goitre. T3-secreting adenoma is characterized by the presence of a single autonomous nodule that produces excessive amounts of T3.

I apologize for the earlier confusion and any misinformation caused by my previous responses. Based on the information provided in the case, a T3-secreting adenoma is the more likely diagnosis.

Answer 103

A

Hashimoto’s thyroiditis is an autoimmune disorder that leads to chronic inflammation of the thyroid gland. Over time, the inflammation can lead to hypothyroidism due to the destruction of thyroid tissue and a decrease in the production of thyroid hormones. The clinical manifestations of Hashimoto’s thyroiditis include fatigue, weight gain, constipation, cold intolerance, as well as depression and poor memory. Physical examination typically reveals a diffusely enlarged goitre that feels firm or rubbery to the touch. Laboratory findings in Hashimoto’s thyroiditis reveal elevated levels of serum TSH and decreased levels of serum T4 and T3. Patients with Hashimoto’s thyroiditis will typically have thyroid peroxidase (TPO) and thyroglobulin (TG) antibodies present in their serum.

De Quervain’s thyroiditis is a self-limiting viral infection that affects the thyroid gland. It is characterized by a sudden onset of symptoms such as thyroid pain, swelling, tenderness, fever, and malaise. The thyroid gland may be diffusely enlarged and tender, and the patient may experience pain in the neck and jaw area that may worsen with swallowing. Laboratory findings in de Quervain’s thyroiditis reveal a temporary increase in serum T4 and T3 levels. In addition, patients may have an elevated erythrocyte sedimentation rate (ESR), and thyroid stimulating immunoglobulin (TSI) levels may be elevated.

In summary, Hashimoto’s thyroiditis is an autoimmune disorder that leads to chronic inflammation and hypothyroidism, while de Quervain’s thyroiditis is a self-limiting viral infection that causes transient thyroid gland inflammation and transient hyperthyroidism. While both diseases may be associated with enlarged thyroid glands and neck pain, Hashimoto’s thyroiditis causes destruction of thyroid tissue and leads to hypothyroidism, while de Quervain’s thyroiditis is usually self-limited and characterized by transient episodes of hyperthyroidism.

Answer 104

A

Folic Acid

Based on the given information and the search results, the treatment of choice for the 33-year-old woman with active RA on methotrexate, who feels tired and lethargic, and has low hemoglobin, low normal MCH, decreased serum iron, and decreased TIBC, is option 5: Folic Acid.
Folic acid supplementation is recommended for patients with RA who are taking methotrexate, as methotrexate can interfere with folate metabolism and lead to anemia. Folic acid supplementation has been shown to reduce the incidence of methotrexate-induced anemia and improve hemoglobin levels. Therefore, folic acid supplementation should be initiated in this patient to address the anemia. Other treatment options, such as packed RBC, IV iron, low dose CTs, and erythropoietin injection, may be considered in severe cases of anemia, but are not the initial treatment of choice

Folate supplements can help improve anemia, fatigue, and other adverse effects associated with methotrexate treatment.

Methotrexate works by inhibiting the enzyme dihydrofolate reductase, which can lead to folate deficiency.

Answer 105

A

B.breast cyst

You are correct that fibroadenomas are typically painless, and the given information suggests that the lump is painful. Therefore, based on the given information and the search results, the most likely cause of the 3mm regular lump that is painful inferiorly and hyperechoic in a 30-year-old female is option B: breast cyst.

Breast cysts are a common cause of breast lumps in women between 35 and 50 years of age, and are characterized by a well-defined, round or oval, anechoic structure with a thin wall. Breast cysts can be painful, and tenderness may increase before menstruation

On ultrasound, fibroadenomas can appear as a well-circumscribed solid mass with variable echogenicity. Therefore, fibroadenoma is a possibility (option A), but other clinical features can help to differentiate between fibroadenoma and breast cysts. In the given scenario, the fact that the lump is painful and inferiorly located, along with a hyperechoic appearance on ultrasound favors the diagnosis of a breast cyst (Option B).

Breast cysts are fluid-filled sacs that can cause a palpable mass or lump, and they are typically non-cancerous. The cyst may be painful or tender, especially if it is located near the surface of the breast. Hyperechoic appearance on ultrasound is also a common finding with breast cysts. Fibroadenomas (Option A) are another common benign breast lump, but they are usually not painful and may have a different appearance on ultrasound. Breast cancer (Option C) is less likely in a young patient with a small, painful, and diffuse lump,

Answer 106

A

B. Sle

SLE is often associated with positive ANA, anti-dsDNA, and ENA tests. Sjögren’s Syndrome is typically associated with positive ANA and anti-Ro tests.

The presence of positive ANA and ENA along with anti-dsDNA and anti-Ro antibodies is suggestive of SLE. A negative anti-CCP result would argue against Rheumatoid Arthritis (option A). Sjogren’s Syndrome (Option C) is another autoimmune disorder that can cause joint pain in addition to dry eyes and mouth, but the presented lab results are not entirely consistent with this diagnosis. Additionally, there is no mention of dry eyes or mouth in the case description. Mixed Connective Tissue Disorder (Option D) is also a possibility since it overlaps with features of SLE, scleroderma, and polymyositis/dermatomyositis, but more information and additional tests would be needed to make an accurate diagnosis.

Answer 107

A

C- Serum parathyroid hormone assay

Given the patient’s clinical presentation and laboratory findings, the most appropriate investigation would be option C- Serum parathyroid hormone assay. The results show that the patient’s total calcium and ionized calcium levels are both elevated, which can be suggestive of hyperparathyroidism. The parathyroid hormone (PTH) assay can measure the levels of PTH in the blood, which can help to confirm the diagnosis of hyperparathyroidism. A high serum PTH level in the presence of elevated calcium would confirm primary hyperparathyroidism as the underlying cause of the patient’s symptoms.

This test can help determine if the patient has hyperparathyroidism, a condition where the parathyroid glands produce too much parathyroid hormone, leading to elevated levels of calcium in the blood

Options A, B, D, and E are not typically indicated in the diagnosis of hyperparathyroidism. A 24-hour urinary calcium (Option A) may be ordered to help assess calcium excretion, but it is not a primary test for hyperparathyroidism. Glucose tolerance test (Option B) may be ordered to test for diabetes, but it is not relevant in this case. A bone scan (Option D) or a serum angiotensin-converting enzyme (Option E) may be helpful in diagnosing other conditions, such as osteoporosis or sarcoidosis, respectively, but would not be specific in diagnosing hyperparathyroidism.

Answer 108

A

e) Parvovirus

Answer 109

A

A. Stop POP and use condoms

Yes, I’m sure. Doubling the dose of the progestin-only pill (POP) is not recommended because carbamazepine, an enzyme-inducing antiepileptic drug, can reduce the effectiveness of hormonal contraceptives like POPs. Even with higher doses, contraceptive safety cannot be guaranteed due to the drug interaction

A. Stop POP and use condoms. Carbamazepine is known to interact with hormonal contraceptives and decrease their effectiveness. Therefore, it is recommended to stop using the POP and switch to a non-hormonal method of contraception such as condoms.

Answer 110

A

D) VENOUS Doppler

Doppler ultrasound is considered the initial imaging modality to assess arterial and venous blood flow and to exclude peripheral arterial disease in patients with foot ulcers.
The non-healing ulcer in a diabetic patient with non-palpable foot pulses suggests the possibility of peripheral vascular disease. A venous Doppler can help to assess blood flow to the foot and the presence of any blockages in the veins. This information is crucial in determining the appropriate management plan for the patient, which may include treatment of the underlying vascular disease, debridement of the ulcer, antibiotic therapy, and offloading to reduce pressure on the foot.

Blood culture, white cell scan, and swab from ulcer may be indicated to help guide antibiotic therapy, but these tests do not provide information about vascular status. An MRI is not typically used as a first-line diagnostic test for non-healing foot ulcers.

Answer 111

A

4, Add metoprolol

Answer 112

A

2.program of rest n minimal walking

Graded resistance exercise (option 5) is a reasonable management option for knee osteoarthritis, especially when the patient has mild symptoms and good function. Resistance training can help to improve muscle strength, joint stability, and overall function.

In the scenario provided, the patient has mild swelling and warmth, which suggests there may be active inflammation present, and as such, a period of rest and minimal walking is indicated to allow for the inflammation to settle before initiating graded resistance exercise.

Therefore, depending on the severity of the patient’s symptoms and their functional capacity, both options 2 (program of rest and minimal walking) and 5 (graded resistance exercise) could be considered as appropriate management strategies.

Program of rest and minimal walking.

The patient’s symptoms suggest the presence of knee osteoarthritis, and rest along with the application of heat or cold therapy is usually the first line non-pharmacological management.

Answer 113

A

Monitor antibody titer levels

An Rh-negative mother with Rh alloimmunization requires close monitoring throughout the pregnancy to ensure timely identification of any possible complications. A titre of 1:32 indicates that the mother’s immune system has produced antibodies against Rh-positive blood cells, which could cross the placenta and cause hemolytic disease of the newborn (HDN) in the next pregnancy. However, the risk of HDN depends on several factors, including gestational age, titre levels, and other maternal and fetal factors.

Therefore, the next step would be to monitor the antibody titre levels throughout the pregnancy to assess the risk of HDN and determine the appropriate management. The exact frequency and timing of the titres will depend on the individual case and should be determined by a healthcare provider.

Checking the partner’s blood group (option 1) is important for determining the risk of Rh alloimmunization but is not necessary at this stage since the mother is already Rh negative.

Rhogam is not indicated at this point since it is a prophylactic medication given to Rh-negative mothers to prevent Rh alloimmunization during and after pregnancy. It does not typically reduce the antibody titre that is already present in the mother’s bloodstream.

Answer 114

A

Unable to extend neck

The sudden onset of neck pain, limited range of motion, and inability to extend the neck after a motor vehicular accident require further evaluation to rule out any serious injuries such as a cervical spine fracture. In this case, an imaging study, such as a cervical spine X-ray or CT scan, is indicated to assess for any fractures or other structural damage.

While the patient’s history of osteoporosis (option 1) is relevant and may increase the risk of a fracture, it is not the main indication for a radiologic examination in this scenario.

Similarly, limited range of motion (option 2) can be a symptom of a cervical spine injury, but it is not the main reason for imaging. The inability to extend the neck, on the other hand, is a red flag symptom that should prompt immediate imaging to rule out any serious cervical spine injury.

Answer 115

A

A ADT

The T3 NOM1 classification in prostate cancer staging refers to the extent of the local (T) tumor and regional nodal (N) metastasis, as well as the presence of distant metastasis (M).

“T3” indicates that the prostate cancer has advanced beyond the outer layer of the prostate gland and may have extended into nearby tissues, such as the seminal vesicles.

“N0” indicates no regional lymph node involvement, while “M1” indicates the presence of distant metastasis, in this case, to the lumbar vertebrae.

Therefore, T3 NOM1 prostate cancer in the lumbar vertebrae indicates that the cancer has spread beyond the prostate gland and regional lymph nodes and has metastasized to the lumbar vertebrae, which are bones in the lower back. This is considered advanced stage prostate cancer with distant metastasis, which requires systemic therapy with both hormonal and radiation treatments.

If I were to choose only one treatment option for this patient, it would be A) ADT (Androgen Deprivation Therapy), which is typically the first-line treatment for metastatic prostate cancer and can help to reduce the size of the tumor and reduce symptoms such as bone pain.

However, it is important to note that combination therapy with both ADT and EBRT is considered the standard of care for patients with metastatic castration-sensitive prostate cancer like this patient. Therefore, if possible, a combination of ADT and EBRT should be considered to provide the best outcomes.

A) ADT (Androgen Deprivation Therapy) is typically the first-line treatment in patients with metastatic prostate cancer. It involves the use of medications that reduce or block the production of testosterone, which is the main hormone that drives the growth of prostate cancer.

D) EBRT (External Beam Radiation Therapy) can help to relieve pain and shrink tumors in the lumbar vertebrae in patients with metastatic prostate cancer.

Other treatment options mentioned in the search results include:
Radical prostatectomy (option 2): Radical prostatectomy is a surgical procedure to remove the prostate gland. However, in the case of metastatic prostate cancer involving the lumbar vertebrae, surgery may not be the primary treatment approach

B/l orchidectomy (option 3): Bilateral orchidectomy, or surgical removal of the testicles, is another method to reduce androgen levels in the body. However, it is less commonly performed compared to ADT with medications

Answer 116

A

D) Oral Fluconazole

Fluconazole is an antifungal medication that is effective against candidiasis and is the recommended first-line treatment for recurrent vulvovaginal candidiasis. Oral fluconazole is usually given as a single-dose regimen and has been shown to have a high efficacy rate.

Oral Nystatin (option A) and Vaginal Nystatin (option E) are not usually recommended for vulvovaginal candidiasis as they are less effective than fluconazole, especially in cases of recurrent candidiasis.

Oral Grisofulvin (option B) is not a recommended treatment for candidiasis, as it is primarily indicated for the treatment of fungal infections of the skin and nails.

Oral Ketoconazole (option C) is an antifungal medication that can be effective against candidiasis, but it is no longer recommended as a first-line therapy for recurrent candidiasis due to its potential for serious liver toxicity.

Answer 117

A

d) Refer for colposcopy

Helen Jones’ symptoms and clinical examination suggest cervical ectropion, a benign condition where the soft cells lining the inside of the cervical canal spread to the outer surface of the cervix. This condition can cause symptoms such as painless post-coital bleeding and is common in women of reproductive age, especially those using estrogen-containing contraceptives like Helen. The Pap smear result of “inflammatory” is also consistent with this condition.

Colposcopy is a procedure that allows for a closer examination of the cervix, which can help identify any abnormalities and guide further management

Changing the oral contraceptive pill (OCP) to a more progestogenic balance (option E) is not supported by the available information. While hormonal imbalances can contribute to certain gynecological issues, such as irregular bleeding, it is important to first investigate the cause of post-coital bleeding before considering changes to contraceptive methods.
It is always best to consult with a healthcare professional for an accurate diagnosis and appropriate management plan.

Answer 118

A

b. Reactive arthritis

Reactive arthritis, also known as Reiter’s syndrome, is a type of inflammatory arthritis that typically occurs following an infection, often involving the genitourinary or gastrointestinal tract.. It commonly presents with joint inflammation, especially in the lower extremities, along with other symptoms such as fever, rash, and swollen lymph nodes. The presence of a febrile illness, joint swelling, maculopapular rash, and palpable cervical lymph nodes align with the clinical features of reactive arthritis.. Additionally, there is no history of relevant travel outside Australia, which makes infectious causes less likely.

Answer 119

A

Emergency dialysis

Hyperkalemia is a medical emergency that can lead to life-threatening cardiac arrhythmias and requires prompt treatment. In this scenario, the patient has multiple risk factors for hyperkalemia, including the use of medications like ARBs, thiazide, and digoxin. The high urea and creatinine levels also suggest impaired kidney function, which can exacerbate hyperkalemia by reducing the kidney’s ability to excrete potassium.

In such a situation, emergency dialysis is the best option to remove excess potassium and improve kidney function. Dialysis can quickly and effectively remove potassium and other harmful substances from the bloodstream, alleviate symptoms, and prevent further complications.

IV glucose (option 1) and insulin and glucose (option 2) are useful adjuncts to manage hyperkalemia, but they are not effective as monotherapy for acute hyperkalemia with high urea and creatinine levels. These treatments help shift potassium into cells, but can also exacerbate hypoglycemia and worsen acidemia.

You are correct that IV insulin and glucose (option 2) can be used as a treatment for hyperkalemia. Insulin stimulates the movement of potassium inside the cells, while glucose helps to prevent hypoglycemia as insulin can cause blood sugar levels to drop.

However, it is important to note that this treatment is usually a temporizing measure to stabilize hyperkalemia and is not sufficient for patients with severe hyperkalemia with high urea and creatinine levels. Dialysis is indicated in these scenarios as it can remove potassium as well as other toxins from the bloodstream.

In the provided scenario of a patient with multiple medications and hyperkalemia with high urea and creatinine levels, dialysis is the most appropriate treatment option. It can provide rapid and effective removal of excess potassium and improve renal function by removing other accumulated toxins. Once stable, insulin and glucose infusion can be initiated to prevent reoccurrence of hyperkalemia.

Answer 120

A

Fibroadenoma.

Fibroadenomas are benign breast masses that can present as a hypoechoic or, more often, a hyperechoic mass with a characteristic whorled appearance on ultrasound. They are well-circumscribed and tend to be mobile and smooth. Fibroadenomas typically occur in those under the age of 30 and are more common in women in their teenage years and early twenties.

While a breast cyst (option 3) can also present as a hypoechoic mass and is a common cause of breast lumps, a hyperechoic appearance is usually seen in fibroadenomas.

Fibroadenomas are benign breast tumors that commonly occur in women under 30 years of age. They are estrogen-induced tumors that form in adolescence and usually present as a firm, smooth, oval-shaped, freely movable mass. Fibroadenomas are typically well-defined and appear as a hypoechoic lesion on ultrasound

In general, fibroadenomas are more commonly hyperechoic on an ultrasound and have a whorled appearance, but a fibroadenoma’s echogenicity can depend on several factors. For example, an early-stage fibroadenoma may be less well-circumscribed and appear more hypoechoic, while a later-stage fibroadenoma may have a more heterogeneous appearance due to the development of cystic areas within the solid fibrous tissue.

While fibroadenomas are often hyperechoic, it is possible for them to appear hypoechoic, and further evaluation may be required to fully characterize the lesion.

Answer 121

A

Karyotype

In a child with mildly enlarged breasts (gynecomastia), small testes, and sparse pubic and axillary hair, it is important to consider disorders of sex development (DSD) or intersex conditions. Therefore, a karyotype analysis would be an appropriate initial test to evaluate for any chromosomal abnormalities, such as Klinefelter syndrome (47,XXY) or other DSDs. Additionally, a testosterone level can also be helpful in assessing androgen production and to help confirm the diagnosis.

Answer 122

A

A. Umbilical hernia

Without cough impulses being assessed, it is difficult to definitively diagnose the cause of the abdominal swelling. However, based on the location described (just above the umbilicus), the most likely diagnosis would be an umbilical hernia.

how about epigastric are u sure it is not epigastric?
Epigastric hernias typically occur in the upper abdominal region, between the navel and the lower part of the ribcage. They usually cause a small bulge or swelling in that area and can cause discomfort or pain. The location described in the question is just above the umbilicus, which is more consistent with an umbilical hernia.

However, it is important to note that the exact cause of the abdominal swelling cannot be accurately determined based on the information provided alone and a proper physical examination and assessment would be needed to confirm the diagnosis.

Answer 123

A

D. Breast cancer?

Answer 124

A

B. Ectopic

During pregnancy, BHCG levels typically increase rapidly and can be detected in a blood or urine test as early as 10 days after a missed menstrual period. In general, BHCG levels double every 48-72 hours in the early stages of pregnancy, peaking at around 8-10 weeks and then gradually declining.

The BHCG level can vary among different women based on the duration of pregnancy, individual embryonic growth rates, and individual variations. However, a BHCG level that is lower than expected for the stage of pregnancy (based on the last menstrual period or other factors) could indicate a potential problem with the pregnancy, such as an ectopic pregnancy or a miscarriage.

Therefore, during pregnancy, BHCG levels are expected to be high and to increase over time. However, the specific values can vary widely between individuals and between pregnancies.

However, if the patient presented with a BHCG level of 800 after having previously experienced high BHCG levels followed by normalization, the possibility of an ectopic pregnancy should be considered. As mentioned earlier, ectopic pregnancy is a potential complication in which the fertilized egg implants outside the uterus, typically in the fallopian tubes, rather than in the uterus.

Answer 125

A

C. Renal ultrasound (USG)

The presence of RBCs, leukocytes, and traces of protein in the urine analysis of a 7-year-old girl with a history of nocturnal enuresis suggests the need for further evaluation. In this case, the persistence of abnormalities in urine analysis even after resolution of the upper respiratory tract infection (URTI) raises concerns about a possible underlying renal pathology or structural issue.

The most appropriate next investigation in this scenario would be a renal ultrasound (USG). This imaging modality can help assess the structure of the kidneys and identify any abnormalities, such as kidney stones, urinary tract obstruction, or congenital anomalies. The finding of non-glomerular RBCs in the urine suggests a potential non-glomerular source of bleeding, which could be related to a structural issue in the urinary tract.

Urine culture (A) and blood culture (D) may be considered in cases of suspected urinary tract infection (UTI) or systemic infection, but they are less specific in evaluating structural issues or identifying the cause of persistent urine abnormalities.
DM5A (B) is not a recognized medical term, so it is unclear what this refers to and its relevance to the case.

Answer 126

A

Rheumatoid arthritis

Answer 127

A

D. Limited lateral neck movement (C spine rule 3 limited lateral 30° rotation).

The Canadian C-spine rule is a set of criteria used to decide whether cervical spine imaging (e.g., X-ray) is indicated in patients who have suffered neck trauma. According to the C-spine rule 3, cervical spine imaging is recommended if the patient complains of any of the following: limited neck rotation (less than 45°), age greater than 65 years, dangerous mechanism of injury, or paresthesias (e.g., numbness or tingling) in the extremities. In this case, the patient has limited lateral neck movement and therefore satisfies the indication for cervical spine imaging.

While osteoporosis and alendronate use may increase the risk of vertebral fractures, they are not specific indicators for obtaining a neck X-ray. Pain at the lateral side of the neck and radiation of pain to the upper arm are common symptoms of cervical spine injuries but by themselves are not sufficient indications for cervical spine imaging.

Answer 128

A

B. Jaw thrust and head tilt position

Answer 129

A

Electrolyte disturbance

You are correct. An electrolyte imbalance can indeed cause confusion and agitation, and it should be considered as a potential cause in this case. Medications like venlafaxine can sometimes affect electrolyte levels, especially sodium, leading to hyponatremia, which can result in neurological symptoms.

Hyponatremia, characterized by low levels of sodium in the blood, can cause confusion, agitation, disorientation, and other cognitive symptoms. It is important to assess the patient’s electrolyte levels, particularly sodium, through blood tests to confirm if an electrolyte imbalance is the cause of their symptoms.

Answer 130

A

B. Serum cu and seruloplasmin

Based on the given information, the most appropriate investigation to diagnose this condition would be to check serum copper and serum ceruloplasmin levels. Wilson’s disease is a genetic condition characterized by abnormal copper metabolism, leading to copper accumulation in various organs, particularly the liver and brain. Symptoms of Wilson’s disease can include wide-based gait, tremors, forgetfulness, slurred speech, and other neurological symptoms.

The diagnosis of Wilson’s disease can be made by measuring serum copper and ceruloplasmin levels, as well as performing genetic testing, liver biopsy, or other imaging studies. In Wilson’s disease, copper levels in serum and urine are increased, while serum ceruloplasmin levels are decreased.

Answer 131

A

1.nothing to do

Gilbert syndrome is a benign condition in which there is reduced hepatic uptake and conjugation of bilirubin, leading to an increase in unconjugated bilirubin levels in the blood. It is typically asymptomatic and does not require any specific treatment. Hence in a patient with Gilbert Syndrome with no physical signs and increased bilirubin, no additional therapeutic or diagnostic interventions are necessary.

However, patients with Gilbert syndrome may experience transient episodes of jaundice or mild gastrointestinal discomfort during times of stress, fasting, or illness. In such cases, supportive measures such as avoiding fasting, increasing hydration, and treating any underlying illness may be helpful in managing symptoms.

In summary, patients with Gilbert syndrome do not require a specific management plan, but they should be counseled about the benign nature of the condition and informed about symptom management during episodes of stress or illness.

Answer 132

A

Explore her preferred sources

The most appropriate next step would be to explore her preferred sources.

Given that the doctor has a pre-existing social relationship with the couple and also treats them, it is important to maintain professionalism and establish appropriate boundaries in this situation. It would not be appropriate for the doctor to directly involve themselves in the marital issues of their patients.

Instead, the doctor should encourage the wife to seek professional help from a qualified therapist, counselor, or psychologist who specializes in couples therapy or marital counseling. Exploring her preferred sources would involve discussing different options and potentially providing her with referrals to trusted professionals who can provide the appropriate support for her and her husband.

Answer 133

A

A. FNAC

Option A, fine-needle aspiration cytology (FNAC), is the appropriate next step for the evaluation of a parotid gland mass with CT evidence of superficial lobe involvement without facial nerve palsy.

FNAC, which involves using a small needle to obtain a sample of the mass for cytological examination and analysis, can help differentiate between benign and malignant lesions.

USS (option B) is still useful as it can help identify the size and location of the parotid gland mass and assess surrounding structures, including the facial nerve. However, it is not typically the first-line diagnostic test for evaluation of a parotid mass that requires tissue sampling.

Surgical management options for parotid gland masses, such as superficial or total parotidectomy (options C and D), would depend on the cytological findings and the overall management strategy. Therefore, option A, FNAC, would be the most appropriate next step in the evaluation of a parotid gland mass with CT evidence of superficial lobe involvement without facial nerve palsy.

Answer 134

A

A. Autistic spectrum disorder < 39

Based on the given information, the most likely diagnosis for this child’s behavioral and developmental symptoms is option A, Autistic Spectrum Disorder (ASD) with associated social communication difficulties and repetitive behaviors.

The child presents with social communication and interaction difficulties such as leaving class earlier or staying alone in his room, odd behavior such as placing toys in parallel and shouting out loud, and restricted and repetitive interests such as not talking much or having no friends at school. These symptoms are consistent with the diagnostic criteria of ASD.

Eye contact is reported to be present, which could indicate that it is not severe autism. However, further evaluation would be necessary to determine the severity of the ASD and to rule out other possible diagnoses.

Answer 135

A

B. Avascular necrosis

Avascular necrosis is a condition where the blood supply to the bone is disrupted, leading to bone death and collapse. It commonly affects the hip joint and can cause pain, stiffness, and difficulty walking . The multiple bruises may be due to the patient’s age and increased fragility of the skin. The low MMSE score may indicate cognitive impairment, which can be associated with avascular necrosis.
Therefore, the most appropriate diagnosis for this patient would be avascular necrosis. It is important to note that a comprehensive evaluation by a healthcare professional, such as an orthopedic surgeon or rheumatologist, is necessary to confirm the diagnosis and develop an appropriate management plan.
The evaluation may involve a thorough assessment of the patient’s medical history, physical examination, and imaging studies, such as X-rays or MRI. The management of avascular necrosis may involve conservative measures, such as pain management and physical therapy, or surgical intervention, depending on the severity and location of the disease

Answer 136

A

B. Atorvastatin

Atorvastatin therapy is associated with mild, asymptomatic, and usually transient serum aminotransferase elevations in 1% to 3% of patients

Answer 137

A

C. Charcot marie tooth

Friedrich Ataxia typically presents with symptoms such as difficulty with balance and coordination, slurred speech, and heart disease, which were not mentioned in the query. While it can cause gait abnormalities, the specific symptoms of a plantar flexed ankle, abducted lower limb, and wide-based gait are more characteristic of Charcot-Marie-Tooth disease

Answer 138

A

C-night time sedation

Weight gain is another potential side effect of Risperidone, particularly in children, and it can occur quickly. However, weight gain is not typically an initial side effect and may take longer to develop

Answer 139

A

A Ultrasound of the lump.

An ultrasound of the lump is the best investigation to consider in this patient as it can help to confirm the presence of an inguinal hernia, which can present with constipation and abdominal distension, and also to exclude other possible causes of the lump, such as an abscess or a tumor.

Answer 140

A

f. Angioplasty

Angioplasty is a procedure used to open blocked or narrowed blood vessels, particularly in the context of acute coronary syndrome (ACS).
. The presence of chest pain, EKG changes, and the potential for a cardiac cause of the symptoms warrant urgent evaluation and intervention

Answer 141

A

C. Tension headache

Based on the description of the patient’s symptoms, the most likely cause of her headache is tension headache. Tension headaches are the most common type of headache and are characterized by dull, non-pulsating pressure or aching pain around the forehead, temples, or back of the head and neck. These types of headaches can be caused by different factors including stress, fatigue, poor posture, and lack of sleep.

In this case, the woman works part-time as an office cleaner, and this may involve long hours on her feet, which may lead to fatigue and muscle tension in the neck and shoulders, contributing to her headache. Additionally, her use of paracetamol and ibuprofen for relief of symptoms suggests that she is experiencing recurrent or chronic headaches.

Drug rebound headache may occur with frequent or overuse of pain medications and can cause headaches that worsen with medication withdrawal. Migraine is characterized by recurrent headaches, often with nausea, vomiting, and sensitivity to light and sound, and is less likely in this case due to the absence of these accompanying symptoms. Cerebral tumor is a rare cause of headache and is usually associated with other neurological symptoms. Pre-menstrual headache is another possible cause of headache, but it is usually predictable in relation to menstrual cycle and is typically associated with other pre-menstrual symptoms.

Answer 142

A

A. Iv fluid

The patient with asplenia and anemia who experiences chills and rigors during blood transfusion should be suspected of having a transfusion reaction. In this case, the transfusion should be stopped immediately, and the patient should be examined for any signs of anaphylaxis, acute hemolytic reaction, febrile non-hemolytic transfusion reaction, or other potential transfusion reactions.

Since anaphylaxis cannot be ruled out, the patient should be closely monitored and given supportive care such as supplemental oxygen, intravenous fluids, and medications, as appropriate, while the cause and severity of the transfusion reaction are determined.

Therefore, the most appropriate next step in this scenario would be to give the patient supportive care, including IV fluids, and closely monitor for signs of anaphylaxis or other transfusion reactions. Reassuring the patient and resuming the transfusion would not be appropriate until it is confirmed that the transfusion reaction has been resolved and it is safe to resume transfusion. Neither Epipen nor paracetamol would be appropriate as the first-line management of a transfusion reaction.

Answer 143

A

a. Parkinsonism

The clinical feature that is helpful in differentiating Lewy body dementia from Alzheimer’s disease is Parkinsonism. While both conditions may share similar symptoms, such as memory loss and cognitive decline, the presence of Parkinsonism, which includes symptoms like tremors, rigidity, and impaired movement, is more commonly associated with Lewy body dementia

Answer 144

A

b. ABO incompatibility

The most likely cause of the anemia in this scenario is ABO incompatibility.

ABO incompatibility occurs when a mother with blood type O gives birth to a baby with blood type A, B, or AB. In this case, the baby has blood type O, which is compatible with the mother’s blood type. However, if the baby’s blood type is A or B, the mother’s immune system may produce antibodies against the baby’s blood cells, leading to hemolysis and anemia.

Laboratory findings in ABO incompatibility may include:
- Low hematocrit and hemoglobin levels
- High reticulocyte count, indicating increased red blood cell production
- Elevated bilirubin levels, indicating breakdown of red blood cells
- Presence of hemoglobinuria or hemoglobinemia
- Positive direct antiglobulin (Coombs) test, indicating the presence of antibodies on the surface of the baby’s red blood cells.

Feto-maternal transfusion, sickle-cell anemia, and iron-deficiency anemia are less likely causes of anemia in this scenario. Physiologic anemia of the newborn is a common condition seen in the first few months of life and is due to the normal decrease in fetal hemoglobin and increase in red blood cell mass after birth. However, it usually does not lead to significant anemia at birth.

Answer 145

A

A. Mammary duct ectasia.

Mammary duct ectasia is a benign condition that occurs when the milk ducts under the nipple become inflamed and dilated. It can result in a thick, greenish-yellow discharge from the nipple, as well as breast pain and swelling. The condition is more common in women over 50 years of age and can occur in both breasts.

In this case, the bilateral mastalgia and bilateral greenish-yellow nipple discharge are consistent with mammary duct ectasia. On examination, multiple ducts are seen to be involved, further supporting the diagnosis. Additionally, the imaging findings of dilated main ducts and absence of a focal mass or asymmetry also support the diagnosis of mammary duct ectasia.

Answer 146

A

2.Dysmenorrhea

Dysmenorrhea is a medical term for painful menstrual periods or menstrual cramps. The woman has a regular 4-6 week cycle and no mass on abdominal palpitation and clear adnexal. Her cervical Os is closed, and there is no fever. The pain on the first day of menstruation since long ago, but this time, the pain becomes more severe, which is consistent with dysmenorrhea.

Answer 147

A

b. 02 with face mask

Answer 148

A

B. Gout

Gout is a type of arthritis caused by the deposition of uric acid crystals in the joints, leading to severe pain, swelling, and redness. It commonly affects the big toe joint, but can also affect other joints such as the knee and foot. Gout can also be associated with other conditions such as kidney stones and impotence.

Rheumatoid arthritis (RA) is another type of arthritis that can cause joint pain, but it typically involves multiple joints and is associated with other symptoms such as morning stiffness and swelling. Reactive arthritis is a type of arthritis caused by an infection, typically in the gastrointestinal or genitourinary tract, and is characterized by joint pain, swelling, and inflammation.

Answer 149

A

C. Incision and drainage.

An abscess is a localized collection of pus that typically requires drainage to promote healing and resolution of the infection. In this scenario, the abscess is clearly visible as a reddened, swollen area with whitish-yellow pus. Incision and drainage would involve making a small incision in the abscess to release the accumulated pus and promote drainage. This procedure can help alleviate symptoms, reduce swelling, and facilitate healing.

Oral antibiotics such as Amoxicillin or IV antibiotics like Flucloxacillin may be considered as an adjunctive treatment to help control the infection. However, antibiotics alone may not be sufficient to resolve the abscess completely.

Topical chloramphenicol or topical steroids are not appropriate in this scenario. Chloramphenicol is an antibiotic ointment typically used for bacterial conjunctivitis, not abscesses. Topical steroids should be used with caution in the eye area due to the risk of worsening infection or other potential complications

Answer 150

A

The most likely diagnosis in this scenario is D. Birth asphyxia.

Birth asphyxia refers to a lack of oxygen to the baby’s brain during the birth process. This can occur due to a variety of reasons, including a prolonged labor, umbilical cord prolapse, placental abruption, or other complications during delivery. The prolonged labor (36 hours) in this case is a risk factor for birth asphyxia.

The low APGAR score in the first minute and even at 5 minutes indicates that the baby was not getting sufficient oxygen during birth, which can lead to metabolic acidosis as seen in the blood investigations.

Congenital diaphragmatic hernia, chest infection, and hypoglycemia are also possible causes of a low APGAR score and metabolic acidosis in a newborn. However, based on the information provided, the most likely diagnosis is birth asphyxia.

Answer 151

A

D. Cervical spondylitis

The presence of UMN signs such as spasticity and hyperactive tendon reflexes favors a diagnosis of cervical spondylitis. On the other hand, a diagnosis of MND would require a combination of both upper and lower motor neuron involvement.

Answer 152

A

©) Arrange for FBE, blood cultures, and chest X-ray

The most appropriate next step in management in this scenario is (c) arrange for FBE, blood cultures, and chest X-ray.

A generalized seizure occurring in a child with a fever can be an indication of a febrile seizure. While febrile seizures are usually benign and do not cause any long-term harm, the fever may indicate an underlying infection. Therefore, blood tests such as a full blood examination (FBE) and blood cultures, as well as a chest X-ray should be arranged to identify if there is an underlying infection that may require further treatment.

Performing a lumbar puncture may be necessary in certain cases, but it is not the first-line investigation in this case. Likewise, commencing valproate prophylactically is not recommended in a child who has had a single febrile seizure as it may not be required and has risks related to the medication.

While arranging an outpatient neurological review with EEG may be necessary, it is not the immediate next step. If the underlying cause of the seizure is identified and treated promptly, further investigations and review may be unnecessary.

Therefore, arranging for FBE, blood cultures, and chest X-ray is the most appropriate next step in management to identify any potential underlying infection or risk factors that may require further management.

Answer 153

A

A. Multiple sclerosis

MS is a chronic autoimmune disease that affects the central nervous system, including the brain, spinal cord, and optic nerves. The symptoms of MS can vary widely and may include vision problems, muscle weakness, difficulty with coordination and balance, and cognitive impairment. The diagnosis of MS is usually made based on a combination of clinical symptoms, imaging studies, and laboratory tests.

The acute loss of vision and pain in the eye, along with the subsequent improvement in acuity, is consistent with optic neuritis, which is a common presenting symptom in multiple sclerosis. The presence of slurred speech, poor rapid alternating movement, and ocular dysmetria are also consistent with other neurological signs that can present in multiple sclerosis.

Answer 154

A

C) Carotid endarterectomy

Carotid endarterectomy is a surgical procedure that involves removing the plaque buildup from the carotid artery to improve blood flow and reduce the risk of stroke. In this case, the patient’s symptoms of right-sided weakness suggest a potential transient ischemic attack (TIA) or a small infarct, which may warrant surgical intervention. Adding warfarin (option A) or clopidogrel (option B) may be considered in certain cases, but the initial management for symptomatic carotid artery stenosis is typically carotid endarterectomy
1
. Continuing the same dose of aspirin (option D) is not sufficient for managing the underlying stenosis, and increasing the dose of aspirin (option E) may not provide adequate protection against stroke in this situation.

Answer 155

A

D. Rubeola (Measles)

Answer 156

A

D. Clostridium difficile infection. After an appendectomy, the use of antibiotics can disrupt the natural gut microbiota and allow for the overgrowth of Clostridium difficile bacteria. This can cause diarrhea, abdominal pain, and other symptoms. It is important to get a proper diagnosis and treatment for this infection, as it can be very serious if left untreated.

Paralytic ileus can occur after surgery such as appendectomy and can cause abdominal pain, nausea, and vomiting. It is characterized by the temporary loss of function of the muscles in the intestines, which leads to a buildup of gas and stool in the intestines. This can cause discomfort and difficulty passing stool. However, diarrhea is not typically a symptom of paralytic ileus. Therefore, the correct diagnosis in this case would be diarrhea and abdominal pain due to Clostridium difficile infection rather than resolving paralytic ileus.

Answer 157

A

D-spinal MRI

The presented signs and symptoms suggest malignancy, especially considering the tenderness over L4-L5 vertebra and the weight loss. The spinal MRI is more accurate than X-ray and CT scan in detecting spinal cord compression, assessing the extent of spinal involvement, and identifying metastasis. Additionally, it can help identify if the back pain is arising from the intervertebral discs, spinal cord or nerves, or any other surrounding soft tissue structures. PSA, PET scan, and ultrasound may help with the diagnosis, but spinal MRI is the most appropriate test in this cas

Answer 158

A

A. placental insufficiency

Answer 159

A

A. maxillary sinusitis.

Sinusitis is an inflammation or infection of the sinuses, which are air-filled spaces located in the bones of the face around the nose and eyes. Maxillary sinusitis refers to inflammation or infection of the maxillary sinuses, which are located on either side of the nose in the cheeks. The continuous burning pain in the maxillary region and redness over the area of the projection of the maxillary sinus could be indicative of maxillary sinusitis. However, a definitive diagnosis would require further evaluation by a healthcare provider, which may include imaging studies or other diagnostic tests.

Answer 160

A

D. Application of heat and gentle massage.

The presentation of a painful lump in the upper eyelid of a relatively healthy individual with intact visual acuity and normal eye movements may suggest a chalazion. A chalazion is a small, round, non-tender nodule in the eyelid that develops as a result of an obstruction to the oil glands in the eyelid causing accumulation of secretions and inflammation.

Application of heat and gentle massage is usually sufficient to treat a chalazion. The heat can help to soften the oil that is blocking the gland and promote drainage while the gentle massage with a clean finger can help to express the contents of the gland. This can provide relief from the inflammation and pain, as well as promote healing of the affected area. Further intervention, such as incision and curettage under local anesthesia, may be required if the symptoms persist or become severe. The use of antibiotics may not be indicated unless there is clinical evidence of infection. CT scan of the orbit is not necessary in the absence of other symptoms or signs suggestive of an orbital complication. Topical chloramphenicol could be used to prevent secondary bacterial infection but it is unlikely to resolve the chalazion.

Answer 161

A

Giardiasis

Giardiasis is an intestinal infection caused by the parasite Giardia lamblia. It is often associated with contaminated food or water, especially in areas with poor sanitation. The symptoms of giardiasis include diarrhea, abdominal cramps, bloating, flatulence, and nausea. In some cases, fever and/or perianal abscess may also be present.

Answer 162

A

A. Continue CTG monitoring

Answer 163

A

C. CT pulmonary angiogram

CT pulmonary angiogram (CTPA) is a diagnostic imaging test that uses computed tomography (CT) angiography to
. It is the preferred choice for diagnosing pulmonary embolism (PE), which is a potentially life-threatening condition characterized by blood clots in the pulmonary arteries. In this case, the patient’s symptoms, history of renal failure, and elevated D-dimers raise suspicion for PE, and a CTPA can help confirm or rule out this diagnosis

Answer 164

A

A. Rest

Rest: Resting and avoiding activities that may exacerbate pain or further injury is often recommended initially

Answer 165

A

D. Verapamil

Verapamil is the first-line prophylactic therapy for the prevention of cluster headache attacks.

Cluster headache is an uncommon type of headache that is characterized by severe, one-sided head pain. It often involves tearing of the eyes, a droopy eyelid, and a stuffy nose. The pain is typically described as “boring,” burning, or piercing and can come on very quickly, often without warning. Cluster headaches occur in cyclical patterns or cluster periods, where attacks last from 15 minutes to 3 hours and can occur daily or almost daily for weeks or months

Answer 166

A

D. HIV screening with consent yearly

Under the Sex Work Act 1994 and the Sex Work Regulations 2016 in Victoria, Australia, it is an offence for a sex worker to work if they are aware they have a sexually transmitted infection (STI) including HIV. By law, sex workers working in Victoria are required to have mandatory HIV and STI screening every three months
However, the frequency of sexual health assessments should be determined by the individual sex worker and their doctor

Answer 167

A

A. BPH

Symptoms related to BPH may include straining during urination, decreased urinary stream, dribbling, feeling that the bladder is not completely empty, and frequent urination, among others. In the provided scenario, the absence of nocturnal voiding indicates that the bladder capacity and storage capacity are adequate.
the most likely cause of a man with difficulty in initiating urine and dribbling at the end, but who empties the bladder completely and does not need to wake up at night to void, is benign prostatic hyperplasia (BPH) (option A)

BPH is a non-cancerous enlargement of the prostate gland that can cause urinary symptoms such as hesitancy, weak urine stream, and dribbling at the end of urination

BPH is a common condition that affects many men as they age

Urethral stricture (option C) is a narrowing of the urethra that can cause difficulty with urination, but it is less common than BPH and is often caused by injury or infection

Cancer of the prostate (option B) is a less common cause of urinary symptoms and is typically associated with other symptoms such as blood in the urine, bone pain, or weight loss

Cancer of the bladder (option D) is also a less common cause of urinary symptoms and is typically associated with other symptoms such as blood in the urine, pain during urination, or frequent urination

Answer 168

A

C. Dementia

Peripheral neuropathy is a type of nerve damage that affects the nerves responsible for transmitting messages to and from the brain to other parts of the body. It is a common neurological complication of CKD, and it can cause various symptoms such as numbness, tingling, and burning pain in the hands and feet.

Dementia, a group of cognitive disorders characterized by memory loss and impairment, is another common neurological complication that can occur with CKD, especially in advanced stages of the condition. The exact cause of dementia in CKD remains unclear, but factors such as hypertension, diabetes, and metabolic disturbances may contribute to its development.

Answer 169

A

A. Malignancy

The most commonly associated condition with a unilateral undescended testis is testicular malignancy.

Evidence suggests that boys with an undescended testis are at an increased risk of developing testicular cancer, particularly if the testis remains undescended into adulthood. Therefore, regular surveillance and follow-up are essential for early detection and treatment of testicular malignancy in patients with an undescended testis.

Varicocele, an indirect inguinal hernia, and hydrocele may also occur in cases of undescended testis but are less common. Torsion, which refers to a twisting of the testis on its own blood vessels, is more likely to occur in an undescended testis than in a normally descended one, but it is still relatively uncommon. Therefore, it is important to monitor for signs of testicular malignancy in individuals with unilateral undescended testis.

Answer 170

A

D. Catheter flush

It is not uncommon for patients who have undergone prostatectomy and/or have been catheterized to have urinary retention and obstruction, which can lead to decreased urine output and potential complications such as urinary tract infections. The patient’s low urine output is an indication that the catheter may be obstructed or displaced, and therefore, flushing the catheter should be considered as a first-line intervention to alleviate the obstruction. It is also important to assess the catheter for any kinking, dislodgement, or obstruction to ensure proper placement.

A catheter flush involves flushing the catheter with a sterile solution to ensure proper functioning and to clear any potential blockages or obstructions
In this case, the low urine output may be due to catheter-related issues, such as catheter blockage or inadequate flow. Performing a catheter flush can help address any potential issues and improve urine flow

Answer 171

A

B. Hemodialysis.

Hyperkalemia refers to a condition in which potassium levels in the blood are abnormally high, and it can be associated with various causes, such as kidney disease, medication side effects, or metabolic disturbances. In this case, the high levels of urea and creatinine suggest a possible underlying kidney disease that may be contributing to the hyperkalemia.

While intravenous normal saline (Option A), calcium gluconate (Option C), and Resonium (Option D) may be used to manage hyperkalemia in some cases, they may not be effective in patients with significant renal impairment, as they may further affect renal function and cause complications. Therefore, the most appropriate next step in this case would be hemodialysis, which can help to rapidly eliminate excess potassium and other waste products from the bloodstream, and also improve kidney function in patients with underlying renal disease.

Answer 172

A

C. NA Valproate

Based on the symptoms described, the child is likely experiencing an absence seizure, also known as a petit mal seizure. Treatment for absence seizures typically involves anticonvulsant medications, and the most commonly prescribed medications are ethosuximide, valproic acid, and lamotrigine

Answer 173

A

D. Resonium (Sodium Polystyrene Sulfonate)

Hyperkalemia with high urea and creatinine levels suggests that the patient may have chronic kidney disease and is not able to excrete potassium effectively. In this case, treatment with Resonium can help to remove potassium from the body by exchanging sodium ions for potassium ions in the colon, reducing the potassium levels in the blood. IV normal saline may be used in acute hyperkalemia to temporarily shift potassium into the cells, but it is not a definitive treatment. Hemodialysis is an option in severe cases of hyperkalemia, but it is invasive and may not be necessary in all cases. Calcium gluconate is given intravenously to stabilize the cardiac membrane during hyperkalemia, but it is not a definitive treatment for hyperkalemia and will not decrease potassium levels.

In the case of hyperkalemia with high urea and creatinine, treatment options can include intravenous (IV) normal saline, hemodialysis, calcium gluconate, and resins like Resonium (sodium polystyrene sulfonate). The choice depends on the severity of hyperkalemia and kidney function. IV normal saline can help in mild cases, while hemodialysis is used for severe cases or when kidney function is significantly impaired. Calcium gluconate is used to stabilize the heart, and Resonium helps remove potassium from the body

Answer 174

A

C. Needle Thoracostomy

While chest tube placement is the definitive treatment for tension pneumothorax, in the case described where the patient has decreased breath sounds and stony dullness, immediate intervention is necessary to relieve the pressure and restore normal breathing

Therefore, the next best step would be to perform a needle thoracostomy, which involves inserting a needle into the chest to release the air that is causing the pressure

This is a temporary measure to stabilize the patient until a chest tube can be inserted to fully drain the air and prevent the pneumothorax from recurring

In this case, needle thoracostomy is the preferred initial intervention to rapidly decompress the pleural space and stabilize the patient. A chest tube can be considered after the needle thoracostomy if further management is needed.

Answer 175

A

Conductive deafness right side

You are correct that a positive Rinne test is typically associated with a sensorineural hearing loss (SNHL), rather than conductive hearing loss (CHL). A positive Rinne test indicates that air conduction is better than bone conduction, suggesting that the inner ear and auditory nerve are functioning properly.

Given the symptoms described (bilateral cerumen impaction, lateralization of the Weber’s test to the right), a more accurate diagnosis would be conductive hearing loss on the right side due to the physical obstruction of the ear canal by impacted cerumen. Sensorineural hearing loss would not typically be associated with these symptoms.

The presented symptoms of bilateral cerumen impaction, lateralization of Weber’s test to the right, and positive Rinne test bilaterally suggest that the patient has conductive deafness, which is affecting the right ear. The impacted cerumen is physically blocking the ear canal, thus decreasing the patient’s hearing ability, and is the likely cause of conductive hearing loss. This loss affects the ability of sound waves to pass through the outer and middle ear to reach the inner ear, leading to a muffled sound. Treatment typically involves the removal of the impacted cerumen through irrigation or manual removal by a healthcare professional, which should improve the hearing loss.

A positive Rinne test and lateralization of the Weber’s test to the right indicate that the right ear is affected. Conductive hearing loss occurs when there is a problem in the outer or middle ear that prevents sound waves from reaching the inner ear, and cerumen impaction is a common cause of conductive hearing loss. Sensorineural hearing loss, which is characterized by difficulty in hearing faint sounds and a muffled or distorted hearing, results from problems in the inner ear or the auditory nerve. Therefore, the presentation is more consistent with conductive deafness on the right side rather than sensorineural hearing loss.

Answer 176

A

Conductive hearing loss (CHL) is a type of hearing loss that occurs when there is a physical problem that prevents sound waves from passing through the middle or outer ear effectively. This type of hearing loss is typically characterized by a decrease in the volume or intensity of sound, and patients often report that sounds seem muffled or unclear. Common causes of CHL include ear infections, cerumen (earwax) impaction, fluid buildup in the middle ear, and damage to the eardrum or ossicles of the middle ear. Treatment may involve medical management, surgery, or the use of hearing aids.

Sensorineural hearing loss (SNHL) involves damage to the inner ear or to the nerve pathways that transmit sound signals from the inner ear to the brain. SNHL is usually characterized by a decrease in the clarity and quality of sound. Patients may experience difficulty hearing faint sounds, and speech may sound muffled or distorted. Common causes of SNHL include aging, exposure to loud noises, trauma, and disease. Treatment for SNHL may include hearing aids or cochlear implants, depending on the extent of the damage to the inner ear or auditory nerve. In some cases, medical management can help to address the underlying cause of SNHL.

Answer 177

A

Mirena insertion

Mirena is a long-acting reversible contraceptive (LARC) that provides contraception for up to 5 years after insertion. It is a good option for women who want long-term contraception with minimal maintenance. As the patient has irregular and light menstrual bleeding, Mirena may be an appropriate choice. Mirena works by releasing a small amount of a hormone called levonorgestrel, which thickens the cervical mucus, making it difficult for sperm to reach the egg. It also thins the lining of the uterus, which helps to prevent implantation.

Answer 178

A

B) Retinal detachment

The most likely cause of the decreased vision in the left eye after being hit by a squash ball is a retinal detachment. This condition can occur when a blunt force trauma, like a squash ball hitting the eye, causes the retina to pull away from its normal position. It’s a serious condition that can lead to permanent vision loss if not treated promptly.

A vitreous hemorrhage can also cause decreased vision, and it is frequently associated with blunt trauma, such as a squash ball injury. However, it would not typically cause different visual acuities between the left and right eyes, as the patient in this scenario presents. Vitreous hemorrhage would normally result in an overall reduction of visual acuity. Therefore, while vitreous hemorrhage is a possibility, retinal detachment remains the most likely cause of the patient’s symptoms given the differing visual acuities between the left and right eyes.

Answer 179

A

D. Antibiotics

You are correct. In the case of a basilar skull fracture with CSF leakage, the next best step would be to administer antibiotics (Option D) to reduce the risk of bacterial meningitis. The presence of CSF leakage puts the patient at a high risk of developing an infection, and prompt administration of antibiotics is considered a crucial step in preventing or treating potential infections. Oral gastric/pharyngeal tube (Option B) may also be considered to prevent aspiration of CSF, but immediate administration of antibiotics should be prioritized in this scenario.

Answer 180

A

B. Apixaban

There may not be sufficient evidence to answer exactly. However, an irregularly irregular rhythm with a rapid heart rate could suggest atrial fibrillation. Anticoagulation, such as Apixaban, is often used to prevent stroke in atrial fibrillation. Metoprolol and Verapamil can be used to control heart rate. Adenosine is typically used for supraventricular tachycardia, not atrial fibrillation.

It is not clear from the scenario what is causing the M-spike QRS complex in all leads. However, in this case, we can infer that the patient has an irregularly irregular rhythm with a high heart rate of 150 bpm, which could be suggestive of atrial fibrillation (AF).

In view of the patient’s hypertension and AF, the most appropriate choice of medication from the given options would be B. Apixaban, which is a direct oral anticoagulant (DOAC) used for stroke prevention in patients with non-valvular AF and is considered a first-line therapy. This is because patients with AF are at an increased risk of stroke due to blood clots forming in the heart, and anticoagulation is used to reduce this risk.

Answer 181

A

The initial treatment for sigmoid volvulus is sigmoidoscopy or flexible endoscopy. The primary objective of the procedure is to untwist the sigmoid loop and decompress the bowel. Therefore, the next best step for this patient would be to perform a flexible sigmoidoscopy. However, given the patient’s comorbidities and medications, consultation with the patient’s physician or gastroenterologist is warranted to determine the appropriate management plan, since sigmoidoscopy carries a small risk of bowel perforation.

Answer 182

A

B. continue for another few years

Given her age and duration of menopausal hormone therapy (MHT), it may be less favorable to continue due to potential risks such as cardiovascular disease and cognitive impairment. However, her severe hot flushes should be considered. Non-hormonal management approaches or alternative therapies like acupuncture could be explored. It’s crucial to discuss this with her doctor to make an informed decision

Answer 183

A

B. Chlamydia

As the patient is sexually active, she should be screened for sexually transmitted infections (STIs), especially since she has a BMI of 31, which increases her risk of comorbidities. Chlamydia is a common STI that can often be asymptomatic and leads to several health complications if left untreated, including pelvic inflammatory disease (PID), ectopic pregnancy, and infertility. Therefore, Chlamydia screening is important for all sexually active individuals aged under 25 years, including those who seek contraceptives.

Answer 184

A

B. 25

The incidence of diabetes in this community from 2000 to 2010 can be calculated by subtracting the initial number of cases (45) from the final number of cases (50), which gives us 5 new cases. Since the population is 200, the incidence per 1000 would be (5/200)*1000 = 25 per 1000. So, the correct answer is B. 25.

Answer 185

A

E. Hepatitis E

The most likely cause of a person with jaundice who has received Hepatitis A vaccine is hepatitis E. Hepatitis A vaccine provides protection against the Hepatitis A virus, but does not provide protection against other types of hepatitis viruses, including hepatitis E.

Hepatitis E virus is transmitted by the fecal-oral route, primarily through contaminated water or food. People traveling to countries with poor sanitation are at an increased risk of contracting hepatitis E.

Therefore, the answer is E.

Answer 186

A

The management of hemorrhoids depends on the severity of symptoms and the degree of prolapse.

For mild hemorrhoids, conservative measures such as dietary fiber, stool softeners, and topical creams to alleviate itching and inflammation may be recommended.

For more severe hemorrhoids, various surgical procedures may be considered. Band ligation, hemorrhoidal artery ligation (HAL), excisional hemorrhoidectomy, or stapled hemorrhoidopexy are among the most common options.

Regarding the options provided, cryotherapy (freezing the hemorrhoid to cause tissue death) is not a commonly used treatment for hemorrhoids.

Band ligation is a safe and effective intervention and has become the most common method of treating hemorrhoids. In this technique, a rubber band is placed around the base of the hemorrhoid to cut off the blood supply and cause the hemorrhoid to shrink and fall off after a few days.

Hemorrhoidal artery ligation (HAL) uses a Doppler device to locate and ligate the blood vessels that supply the hemorrhoidal plexus. The procedure effectively treats both internal and external hemorrhoids.

Therefore, either band ligation or hemorrhoidal artery ligation may be effective options for the management of hemorrhoids, depending on the individual patient’s preferences and clinical presentation.

Answer 187

A

Other factors that may increase the risk of developing Dupuytren’s contracture include smoking, alcoholism, diabetes, nutritional deficiencies, and certain medications used to treat seizures

The condition tends to get worse slowly over time, and it most commonly affects the ring and little fingers

There is no cure for Dupuytren’s contracture, but treatments can relieve symptoms and slow the progression of the condition.

Dupuytren’s contracture is a condition that causes one or more fingers to bend towards the palm of the hand

It is caused by the thickening and tightening of the tissue under the skin of the palm and fingers

The exact cause of Dupuytren’s contracture is not known, but it is believed to be hereditary, meaning that family history and ancestry play a role

Answer 188

A

Estrogen Only pill

Answer 189

A

Breast Cancer medications eg Tamoxifen

Answer 190

A

C. Refer to psychiatry for assessment

The surgery should be done in the patient’s best interest (B) after the patient’s mental state has been assessed and treated.
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Answer 191

A

Take verbal consent

The staff could document verbal consent in their records and provide patients with a written summary of information about the vaccine to take home. Verbal consent can be considered a valid form of consent in emergency situations, such as when a printer is not working. However, efforts should be made to obtain written consent as soon as possible once the printer is operational again.

Answer 192

A

B. Inhaled Fluticasone.

Based on the given information, the 8-year-old child has been experiencing asthma attacks frequently over the past 12 months. Therefore, it is likely that the child has persistent asthma, which requires ongoing controller therapy to prevent future attacks. Inhaled fluticasone is a type of corticosteroid medication that is commonly used for the long-term management of asthma. It works by reducing inflammation and swelling of the airways, which can help to prevent asthma attacks.

Answer 193

A

e) Parvovirus

Parvovirus infection can cause anemia by reducing red blood cell production, leading to symptoms of hemolytic anemia. In individuals with hereditary spherocytosis, a parvovirus B19 infection can worsen anemia and cause a hemolytic crisis.

Answer 194

A

C, FNAC

The middle-aged man presenting with anorexia, weight loss, and a mass on the supraclavicular region is exhibiting symptoms that are concerning for an underlying malignancy. The most appropriate next step would be to perform a fine-needle aspiration cytology (FNAC) of the supraclavicular mass.

FNAC is a minimally invasive diagnostic procedure that involves inserting a thin, hollow needle into the mass and removing a sample of cells for examination under a microscope. It can help to determine whether the mass is cancerous or benign, and can also provide information about the type of cancer if it is present.

Answer 195

A

b. advice after 10 years of age best recommended-12-14 yrs

However, it can be safely administered to children as young as 9 years old. So, it would be best to recommend the vaccine in a couple of years, ideally at ages 11 or 12

Answer 196

A

A. Lithium

Lithium is a mood stabilizer and has been shown to be effective in treating both mania and depressive symptoms of bipolar disorder

Answer 197

A

A. Band ligation

Band ligation: This is a procedure in which a rubber band is placed around the base of the hemorrhoid, cutting off its blood supply and causing it to shrink and eventually fall off.

Hemorrhoidal artery ligation: This is a minimally invasive procedure that uses a specialized instrument to locate and tie off the blood vessels that supply the hemorrhoids, causing them to shrink. Hemorrhoidal artery ligation is typically used for grade II or III hemorrhoids.

Cryotherapy: This involves using freezing temperatures to destroy the hemorrhoid tissue. Cryotherapy is not commonly used for hemorrhoids.

Severe or recurrent cases may require surgical intervention such as hemorrhoidectomy.

Answer 198

A

A. Conductive hearing loss to the right

A positive bilateral Rinne test indicates that air conduction is better than bone conduction in both ears, which is normal. However, Weber’s test lateralizing to the right ear suggests that there is conductive hearing loss in the right ear, as the sound is perceived louder in the affected ear due to cerumen impaction blocking external sounds and making the bone-conducted sound relatively louder

Answer 199

A

D. Subcutaneous emphysema.

The patient is presenting with symptoms of neck swelling with crepitation, which is suggestive of subcutaneous emphysema. This can occur due to air leaking from the respiratory tract and spreading into the soft tissues of the neck. In this case, the most likely cause is bronchial rupture, which can occur with severe coughing or vomiting.

Answer 200

A

A. Suprapubic catheter

Inserting a suprapubic catheter helps to divert urine and avoid further damage to the urethra.

Answer 201

A

B. Left parietal stroke.

The patient is presenting with symptoms of agraphia (inability to write), acalculia (inability to perform simple arithmetic), and difficulty with spatial orientation (inability to tell left from right side), which are suggestive of left parietal lobe damage.

The left parietal lobe is responsible for processing sensory information and plays a crucial role in language, comprehension, orientation, and arithmetic functions. Damage to this region can impair cognition, language abilities, and spatial orientation.

Answer 202

A

A. Inj ticaricillin calcinate IV

Answer 203

A

A. Stop antibiotics.

The presence of a white coating on enlarged tonsils and generalized adenopathy in a patient with a recent history of URTI who was given amoxicillin suggests the possibility of an infectious mononucleosis (also known as glandular fever) or another viral infection, rather than a bacterial infection. Amoxicillin is an antibiotic that is effective against bacteria but is not effective against viral infections.

In this case, it would be appropriate to stop the antibiotics. The clinical presentation suggests a viral etiology and antibiotics would not be of any benefit in treating viral infections. In addition, discontinuing the antibiotics can prevent the development of antibiotic resistance and reduce the risk of potential side effects associated with antibiotic use.

Answer 204

A

B. OA

The patient, an elderly female, is presenting with pain in the first metacarpophalangeal (MP) joint and DIP (distal interphalangeal) joint, which are characteristic locations of osteoarthritis. Osteoarthritis is a degenerative joint disease that commonly affects older individuals and is characterized by the breakdown of cartilage in the joint.

In contrast, rheumatoid arthritis (RA) is an autoimmune disease that can affect people of all ages and typically causes symmetrical joint swelling and pain, with a preference for the MCP and PIP (proximal interphalangeal) joints. However, in this case, the pain is in only one metacarpophalangeal joint and several DIP joints, which is more indicative of osteoarthritis.

The presentation of pain in the first metacarpophalangeal joint and DIP joints is more commonly seen in OA, which is the most likely diagnosis based on the information given. In patients aged over 80 years, OA is more common than RA. RA typically causes symmetric involvement of the small joints of the hand, and less frequently has an asymmetric involvement of those joints. Therefore, the combination of focal pain in a specific area of the hand may strongly favor the diagnosis of osteoarthritis in the context of an elderly female patient.

Answer 205

A

A. Aortic valve replacement

In a patient with symptomatic aortic stenosis with an EF of 35% and a systolic pressure gradient of 45 mmHg across the aortic valve, aortic valve replacement (option A) would be the best management option. Aortic stenosis is a progressive condition that typically requires surgical intervention when the valve is severely narrowed and is causing symptoms, such as shortness of breath, chest pain, or fatigue, as seen in this case.

Percutaneous Balloon valvuloplasty (option B) may be considered as an initial treatment in patients with severe aortic stenosis who are not good candidates for surgery, such as those at high risk for complications due to age or other comorbidities. However, it is not as effective as aortic valve replacement in terms of long-term outcomes, and may require repeat procedures or eventual valve replacement.

Answer 206

A

B. Apixaban

In a patient with atrial fibrillation with a heart rate above 130 beats per minute and a CHADS-VASc score of >2, the first-step in management would be to initiate anticoagulation therapy to reduce the risk of stroke.

Answer 207

A

A. pleural tap

While a CT scan would be an appropriate next step for diagnosing Boerhaave syndrome or other potential causes of pleural effusion, a pleural tap (option A) is a more immediate management step that can be taken to identify the nature of the pleural effusion.

In the context of a patient with vomiting and a worrisome clinical presentation, a pleural tap may provide valuable information about the nature and severity of the pleural effusion. A sample of the pleural fluid can be obtained for analysis, which can help to determine the cause of the effusion and guide further management decisions.

Answer 208

A

A. Sterno cleido mastoid tumor

In a child between 2 to 3 years of age with neck swelling and keeping the head tilted, the most likely diagnosis is a Sternocleidomastoid (SCM) tumor, also known as a congenital muscular torticollis.

The SCM muscle is located in the neck and is responsible for the rotation of the head. When this muscle is damaged, it can result in a stiff and shortened muscle, leading to a characteristic tilt of the head and neck swelling.

A cystic hygroma is a type of lymphatic malformation that typically presents as a soft, painless swelling in the neck region, which can be seen in infants and young children. However, it is not typically associated with head tilting like an SCM tumor.

Answer 209

A

B.start manitol

Mannitol, on the other hand, is an osmotic diuretic that can help reduce intracranial pressure and treat cerebral edema. It is also commonly used in the treatment of head injuries.
In this scenario, starting mannitol would be the recommended next step. Mannitol can help reduce intracranial pressure, which is a common complication of severe head injuries

Answer 210

A

c. Gambling disorder

Answer 211

A

B. Orbital cellulitis

Orbital cellulitis is a serious infection of the tissues surrounding the eye that can cause severe inflammation and swelling. The infection can spread rapidly and affect eye movement, vision, and other neurological functions.

Answer 212

A

d) Measure BP in lying and standing position.

The symptoms described suggest the possibility of orthostatic hypotension, a drop in blood pressure upon standing that can cause dizziness and disorientation. Measuring her blood pressure in both lying and standing positions can help determine if this is the case. If the results confirm orthostatic hypotension, further evaluation and treatment can be pursued.

Answer 213

A

E. Vitamin K.

A high INR (International Normalized Ratio) value in a patient taking warfarin suggests that they are at an increased risk of bleeding. Black colored stool and lower GI bleeding raise suspicion for gastrointestinal bleeding.

The treatment for warfarin-associated bleeding is to reverse the effects of warfarin. In this case, the appropriate treatment is Vitamin K. Vitamin K is administered to reduce the INR and reverse the effect of warfarin.

If the bleeding is severe, additional treatments such as prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP) may be necessary to help restore the blood’s ability to clot. However, in this particular scenario, as specific mention of severe hemorrhage is not provided and considering the limited information, Vitamin K is the most appropriate treatment to manage the patient’s INR level.

Answer 214

A

A. Central diabetes insipidus.

Central diabetes insipidus, a condition in which the body does not properly regulate the amount of water it excretes through urine, leading to excessive urination

Answer 215

A

B) Start inhaled fluticasone.

The patient’s symptoms of increased use of short-acting beta-agonist (SABA) and night cough suggest that his asthma control is worsening. The presence of wheezing on physical examination indicates that he is still experiencing airway inflammation and bronchoconstriction.

The next most appropriate management would be to start inhaled corticosteroid (ICS) therapy with fluticasone. ICS is the mainstay of asthma treatment and is indicated for patients with persistent asthma symptoms. It helps to reduce airway inflammation and prevent asthma exacerbation

Answer 216

A

d) Bilateral ulnar nerve palsy

The distal weakness and atrophy of the small muscles of both hands, including the interossei, lumbricals, thenar, and hypothenar muscles, suggest a peripheral nerve problem involving the ulnar nerves. The ulnar nerves are responsible for innervating the intrinsic muscles of the hand, which are the smaller muscles responsible for fine motor movements and grip strength.

Answer 217

A

B. PSA.

The patient’s symptoms of nocturia and dribbling urine are suggestive of a prostate problem, and the smooth prostate palpable on digital rectal exam (DRE) may indicate benign prostatic hyperplasia (BPH).

The next most appropriate step would be to obtain a Prostate Specific Antigen (PSA) test. PSA is a protein that is produced by both normal and cancerous prostate cells. While an elevated PSA level does not necessarily indicate the presence of prostate cancer, it can be an early indicator of the disease or BPH.

If the PSA level is elevated, further evaluation with a transrectal ultrasound (TRUS) or biopsy of the prostate may be necessary to confirm the diagnosis. However, if the PSA level is normal, bladder dysfunction, urinary tract infection, or other non-prostate-related conditions may be the cause of the patient’s symptoms, and additional testing may be necessary to determine the underlying cause of the patient’s symptoms.

Answer 218

A

C. IV fluids.

The patient’s post-operative status, confusion, tachycardia, and fever suggest that she may be experiencing delirium and has an infection. The fact that she has undergone a cholecystectomy 48 hours ago warrants closer attention to her post-operative course, including monitoring for potential complications such as infection.

The most appropriate next step in management would be to start IV fluids to address any potential dehydration, which can contribute to confusion and tachycardia. Dehydration can also exacerbate infections, which may be underlying her delirium and fever.

Antibiotics may be necessary if there is a confirmed bacterial infection, which can be confirmed with appropriate diagnostic tests such as blood cultures or imaging studies. However, starting antibiotics without proper diagnostic evidence may lead to overuse of antibiotics and potential side effects.

Haloperidol may be used to treat agitation in some cases of delirium, but it should be reserved for cases of severe agitation that are unresponsive to other measures. It should be used with caution in elderly patients and is not typically recommended in the initial management of delirium

Answer 219

A

b. External beam radiotherapy

Answer 220

A

B. PSA

The most appropriate next step for a man with urinary retention and an enlarged prostate would be to measure the Prostate-Specific Antigen (PSA) levels. This test can help determine if the enlargement is due to benign prostatic hyperplasia (BPH) or prostate cancer.

Answer 221

A

A. Adenosine.

The patient’s symptoms of lightheadedness and weakness, along with a history of chronic stable angina and chest discomfort at rest, are suggestive of an ongoing cardiac event (such as a myocardial infarction) or unstable angina, which requires immediate attention.

Answer 222

A

B. Arterial thrombosis

The patient’s predisposition is likely to be arterial thrombosis. This is because popliteal vein thrombosis, a type of deep vein thrombosis (DVT), can lead to the formation of blood clots that can break loose and travel to the heart and lungs, causing severe circulation and respiratory problems, and strokes 1. Risk factors for DVT include recent surgery, immobility, and cancer, all of which apply to this patient 12. Enoxaparin, a type of anticoagulant, is a common treatment for DVT

Answer 223

A

E. Level of consciousness.

The most important sign of head injury is the level of consciousness. The level of consciousness on presentation, measured by the Glasgow Coma Scale (GCS), is a predictor of the severity of the head injury and guides the appropriate management.

The GCS grades the level of consciousness based on the patient’s responses in three areas: eye-opening, verbal response, and motor response. The scores range from 3 to 15, with higher scores indicating more alertness and responsiveness. A lower score indicates a more severe head injury.

Answer 224

A

C, Depression

Depression can manifest in various ways, including changes in behavior, social withdrawal, decreased interest in activities, and negative thoughts or self-talk. It can significantly impact a person’s mood, energy levels, and overall functioning, including academic performance

Answer 225

A

B. Serum copper and ceruloplasmin levels

They are typically checked as part of the diagnostic work-up for Wilson disease. A liver biopsy may also be performed to confirm the diagnosis if necessary. Genetic testing can help identify individuals who are at risk for the disease but may not necessarily be used for definitive diagnosis.

Answer 226

A

b. Plasma exchange is the first line of treatment

The correct statement is that are the treatment of choice for Guillain-Barre syndrome.

. IVIG is a therapy that involves giving high doses of antibodies obtained from healthy donors to help modulate the immune response and reduce the severity and duration of symptoms in GBS patients.

Answer 227

A

e. DNR does not necessarily preclude surgery.

The patient’s wishes for a DNR order should be respected, but surgery may still be necessary to address the bowel obstruction. The medical team can work to ensure that the surgery is conducted with minimal risk and discomfort to the patient, and can take steps to minimize the potential need for interventions like intubation. However, ultimately the decision to proceed with surgery will depend on the specific circumstances of the case and the judgment of the medical team.

Answer 228

A

D. telling the patient it is a normal procedure consequence

Answer 229

A

C) Cholesteatoma

It is the most suspected sequel in the given case of an Aboriginal child with greenish discharge from nostrils and ears. Cholesteatoma is an abnormal skin growth in the middle ear that commonly occurs as a complication of chronic ear infections. It can cause hearing loss, tinnitus, vertigo and other complications. It is also a serious condition that requires prompt medical attention and surgical intervention.

Answer 230

A

C. Bone mineral density

This test can help determine the density of the bones and assess the risk of developing osteoporosis. In addition, the lady can take steps to prevent osteoporosis by adopting a bone-healthy lifestyle,

Answer 231

A

c. avoidant personality disorder

One clear differentiation is avoidant personality disorder involves avoidance of most or all social areas of life, while social anxiety may only involve avoidance of a few specific situations (e.g., walking to the front of a classroom or going to a party).

Answer 232

A

B. Ultrasound.

As the patient has symptoms of hematuria and dysuria, and there are pus cells in the urine, an ultrasound can be the next appropriate investigation to perform. This test can evaluate for any structural or functional abnormalities in the urinary system, such as stones or tumors that can cause hematuria and UTI-like symptoms. If the ultrasound is normal, further evaluation such as cystoscopy may be necessary to examine the bladder and urethra for abnormal growths or strictures.

Answer 233

A

a) Cystoscopy

The most appropriate next step in the diagnosis of the Indian university student with dysuria, hematuria, and frequency, with normal urine tests except for RBCs and WBCs ++ in urine and negative urine culture, would be to perform a cystoscopy. A cystoscopy is a procedure that allows doctors to examine the inside of the bladder and urethra using a cystoscope, a lighted tube with a camera or viewing lens

Answer 234

A

a. Cant drive for 8 months

According to the Australian Government’s guidelines on fitness to drive, after a first-time seizure, a driver must not drive for at least 6 months, provided that no further seizures occur during this period, and they meet specific criteria for fitness to drive. These criteria include the ability to maintain adequate levels of attention, reaction time, and coordination.

Answer 235

A

C. she should not drive 6 months

Following a hypoglycemic crisis, the Australian recommendation is a driving ban for a minimum of 6 months for private vehicle license holders. The lady should consult with her healthcare professional, such as an endocrinologist, who can evaluate her condition, provide appropriate treatment, and advise her on when it is safe to resume driving.

Answer 236

A

A. More antiplatelet

Answer 237

A

B. Refer to neurologist to decide about driving clearance

Answer 238

A

C. Cant drive for 6 months

Based on the clinical presentation of the patient, it is likely that she suffered a transient ischemic attack (TIA) or a stroke. The residual symptoms of left homonymous hemianopia indicate that she has sustained damage to the right visual cortex, either due to a TIA or a stroke.

Therefore, the patient’s fitness to drive must be assessed, as the residual visual field defect can significantly impact her ability to drive safely and could pose a risk to herself and other road users.

In this case, the patient’s inability to see objects in her left visual field significantly impacts her ability to navigate road conditions, and it is highly likely that she will not meet the fitness-to-drive requirements in the Australian Transport Department’s guidelines. According to these guidelines, individuals with a residual visual field defect that cannot be corrected by glasses or medications are not eligible to drive for a period of at least 6 months post-event.

Answer 239

A

E. Ask him to wear seatbelts

A reduction in weight would be beneficial for the patient in terms of his overall health as it would likely help to lower his blood pressure, improve his respiratory function and several other health risks. However, weight loss is not an immediate measure for the management of the patient’s risk of road accidents associated with his non-compliance with wearing a seatbelt.

Seatbelt use while driving is critical as it can prevent serious injury and death in the event of an accident. Accordingly, it is the most pressing concern to address in the patient’s management.

Therefore, the recommended immediate measure for the management of the patient’s risk of road accidents is E) Ask him to wear seatbelts. Once this issue is resolved, other measures such as improving his cardiovascular health, such as reducing weight, lowering blood pressure, stopping smoking, and reducing alcohol intake can be addressed further.

Answer 240

A

C- 12mths

According to the Australian guidelines on fitness to drive, individuals treated with antiepileptic medications such as sodium valproate must be seizure-free for at least 12 months before returning to driving. The waiting time for an individual who has had abnormal movements of the hands may vary, and the patient needs to be reviewed by a qualified specialist to determine when it is safe to return to driving.

Answer 241

A

1.she should not drive at all

Given her age, wrist fracture, and the presence of an irregular pupil, it is advisable for her not to drive at all. These factors may affect her ability to safely operate a vehicle and could potentially increase the risk of accidents.
It is important to prioritize her safety and the safety of others on the road. Driving with a wrist fracture can impair her ability to have full control of the steering wheel and other vehicle controls. An irregular pupil may indicate underlying neurologicalissues that could affect her vision and reaction time while driving.

Answer 242

A

b. Inform the police.

Stolen vehicles are viewed as a serious criminal offense and could be considered as theft. Therefore, the police must be informed immediately to prevent further legal complications. It is also necessary to ensure that the child is safe and to provide her with any necessary medical care.

While the patient may feel apprehensive about informing her parents, the medical personnel must inform the authorities, who can then inform her parents of the situation. This is necessary to ensure that the appropriate legal and social support can be provided to the patient to help her deal with the aftermath of the accident.

Answer 243

A

B. Obesity

Obesity is a strong risk factor for endometrial cancer and is associated with high levels of estrogen, which can lead to the growth of endometrial cells in the uterus. Weight management and other lifestyle modifications like smoking cessation can also be suggested and can help reduce the risk of endometrial cancer and other health conditions.

Answer 244

A

B. Cellulitis.

Cellulitis is a bacterial skin infection that can cause redness, warmth, and swelling of the affected area and is a common complication of DVT

Answer 245

A

b. Plasma exchange is the first line treatment

Answer 246

A

A. Refer to pediatric cardiologist.

A grade 2-3/6 ejection systolic murmur in a child during a routine physical examination can indicate underlying structural or functional heart problems, such as congenital heart defects or valve issues. Therefore, the most appropriate next step would be to refer the child to a pediatric cardiologist for further evaluation and management.

The pediatric cardiologist will order additional tests such as an electrocardiogram, echocardiogram, chest X-ray, or any other appropriate diagnostic tests to determine the cause and severity of the murmur. Based on the findings, the cardiologist will recommend the appropriate course of treatment and advise on the child’s future follow-up care.

Answer 247

A

b. More than 20 fold increase in risk

Answer 248

A

A. Phenytoin

Phenytoin is indeed a pharmaceutical cause of cleft lip when exposed to during early facial development in the 5th to 6th weeks of gestation

Answer 249

A

B. Obtain LN Biopsy.

Answer 250

A

d) Displacement

The specific behavior described in the question (spending money recklessly and accusing the government for the loss due to drought) suggests that he is displacing his anger and frustration from the drought onto other outlets, which is characteristic of displacement

Displacement: Transferring one’s emotional burden or emotional reaction from one entity to another. This defense mechanism may be present in someone who has a stressful day at work and then lashes out against their family at home.

Reaction formation: Replacing one’s initial impulse toward a situation or idea with the opposite impulse. This defense mechanism may be present in someone who teases or insults a romantic interest whom they like. Conversely, reaction formation may be present in someone who is overly kind to someone whom they dislike

Projection: Attributing one’s own maladaptive inner impulses to someone else. For example, someone who commits an episode of infidelity in their marriage may then accuse their partner of infidelity or may become more suspicious of their partner.

Rationalization: The justification of one’s behavior through attempts at a rational explanation. This defense mechanism may be present in someone who steals money but feels justified in doing so because they needed the money more than the person from whom they stole.

Answer 251

A

4.Enlarged adenoids

Enlarged adenoids are a common cause of recurrent respiratory infections and tympanic membrane redness in young children. Antibiotics may provide temporary relief from the symptoms but do not treat the underlying cause. Adenoids may be evaluated by a pediatrician or otolaryngologist, who may recommend treatment options such as adenoidectomy in certain cases. CF and immunodeficiency may also cause recurrent respiratory infections, but enlarged adenoids are a more common and likely cause in this age group.

Answer 252

A

B. Bromocriptine

The patient’s symptoms suggest he may be experiencing neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction to antipsychotic medications. If the patient fails to improve with supportive measures, the most appropriate medication to administer at this time would be B. Bromocriptine. Bromocriptine is a dopamine agonist that has been used effectively in the treatment of NMS.

A fever, tachycardia, hypertension, and altered mental status in a patient with a history of psychiatric illness on antipsychotic medication raises concern for neuroleptic malignant syndrome (NMS). The most appropriate medication to treat NMS is dantrolene or bromocriptine

Answer 253

A

A. Thoracotomy

Answer 254

A

A. Lithium

In a patient with bipolar disorder experiencing a hypomanic episode, several options could be considered. Lithium is a first-line treatment for bipolar disorder, but if the patient has been non-compliant, other options may be more suitable.

Answer 255

A

Incidence refers to the number of new cases of a disease within a specific time period in a defined population.

To calculate the incidence of diabetes in this population, we need to determine the number of new cases that developed within the one-year time period. In this case, the number of new cases would be 50 - 45, which equals 5.

Next, we need to divide the number of new cases (5) by the total population (200) and multiply by 1000 to get the incidence per 1000.

Therefore, the incidence of diabetes would be (5/200) x 1000 = 25 cases per 1000 people.

The correct answer is option B (25).

Answer 256

A

A. Atrial fibrillation

Atrial fibrillation (AF) is also commonly associated with chronic obstructive pulmonary disease (COPD). AF is a supraventricular tachyarrhythmia characterized by disorganized, rapid atrial activity, which can lead to an irregular ventricular rate. In patients with COPD, the hypoxia and chronic pulmonary vasoconstriction can lead to right atrial enlargement and pulmonary hypertension, which can increase the risk of AF. Studies have shown that patients with COPD have an increased risk of AF compared to those without COPD.

Therefore, both MAT and AF can be commonly associated with COPD, and careful evaluation is necessary to determine the underlying dysrhythmia

Answer 257

A

C. pelvic exercise

Option C (Pelvic floor muscle exercises) can help strengthen the pelvic floor muscles, which can improve symptoms of pelvic organ prolapse. These exercises are often recommended as a first-line treatment for mild to moderate pelvic organ prolapse.

Answer 258

A

Option B (Serotonin syndrome) is a potential concern as sertraline is a selective serotonin reuptake inhibitor (SSRI) and temazepam is a benzodiazepine. Both medications can increase serotonin levels in the brain, and when used in combination, there is a risk of developing serotonin syndrome. The symptoms of agitation, tremor, and restlessness can be seen in serotonin syndrome.

Cyproheptadine may be used to reverse the effects of serotonin syndrome.

Answer 259

A

2) Ulnar nerve at the elbow

The symptoms described, including numbness and weakness in the little and ring fingers, are indicative of an issue with the ulnar nerve. The ulnar nerve runs along the little finger’s side of the arm and hand. When it’s affected, it usually causes numbness in the pinky and ring fingers. Given the carpenter’s profession, which involves repetitive motion, he could have developed ulnar nerve entrapment at the elbow, a common site for this condition 1. Therefore, the most likely site of the causative lesion is the ulnar nerve at the elbow.

Answer 260

A

C. Nitrates

Answer 261

A

a. CT scan of the abdomen and pelvis

The patient’s symptoms and medical history suggest the possibility of an infection, and a CT scan can help identify the source of the infection, such as diverticulitis or cholecystitis

Answer 262

A

a. Complete spontaneous abortion

Answer 263

A

C. Nitrates

Answer 264

A

Option A (Tamsulosin) is an alpha-1 blocker like doxazosin, but is more selective for the receptors in the prostate and bladder neck. It may be added to the current regimen to provide additional relief of BPH symptoms.

Option B (Dutasteride) and Option C (Finasteride) are 5-alpha-reductase inhibitors and can be considered for patients with enlarged prostate who have not responded to alpha blockers like doxazosin. These medications work by reducing the size of the prostate gland as well as easing symptoms of BPH.

Option D (Prazosin) is another medication used to treat hypertension and BPH, but it may present more side effects than the other options.

Option E (Nifedipine) is a calcium channel blocker that would not be an appropriate medication choice for BPH.

Therefore, the most appropriate step to take in this scenario for a patient with BPH symptoms not relieved by doxazosin is to consider adding tamsulosin (Option A) to the medication regimen. If this approach is not successful, 5-alpha-reductase inhibitors like dutasteride (Option B) or finasteride (Option C) may be considered.

alternative is Doxazosin

Answer 265

A

A. life style modification and diet

For a woman with irregular periods and a weight of 130 kg, the first step in management should be lifestyle modification and diet. Being overweight can affect hormonal function, leading to irregular ovulation and menstruation, making it difficult to conceive 21. Maintaining a healthy weight through a well-balanced diet and regular exercise can help regulate periods and improve fertilit

Answer 266

A

B. Echo (Echocardiogram)

An echocardiogram is a non-invasive imaging test that uses sound waves to create detailed images of the heart. It can provide valuable information about the structure and function of the heart, including the presence of any abnormalities or conditions that may be causing the symptoms. In this case, an echocardiogram can help evaluate the heart’s valves, chambers, and overall function, which can be useful in identifying any potential issues that may be causing the chest pain and systolic murmur.

Answer 267

A

C. repeat screening 1 year

C. Repeat screening 1 year
According to the guidelines, in cases where HPV types 16 and 18 are negative and LSIL is positive, the recommended management is to repeat the screening after 1 year.

This approach allows for monitoring any changes in the cervical cells over time and provides an opportunity to detect any potential progression or regression of the abnormality.

Answer 268

A

C Anti lupus anticoagulant.

Yes, the presence of Anti-lupus anticoagulant (C) can indeed predispose to the condition. Lupus anticoagulants are associated with an increased risk of blood clots, which could lead to symptoms such as acute limb swelling and pain, followed by dyspnea and pleuritic chest pain, as seen in conditions like deep vein thrombosis and pulmonary embolism

Answer 269

A

Based on the information provided, the most likely diagnosis is Schizophrenia (D), not Delirium. The patient’s recurring symptoms after stopping medication are characteristic of schizophrenia, a chronic condition that often requires long-term medication management. Delirium, on the other hand, is typically an acute and often reversible condition, commonly caused by a general medical condition or substance-induced. It’s important to note that a comprehensive assessment is necessary to confirm the diagnosis

Answer 270

A

E. Schedule another appointment for discussion

Answer 271

A

B. testis sonography

A varicocele is an abnormal enlargement of the veins in the scrotum that can cause discomfort. In this patient with a 2-year history of a right-sided varicocele that has become bigger in the evening and causes heaviness, the most appropriate evaluation would be a testicular sonography.

A testicular sonography can help to confirm the diagnosis of a varicocele and assess the severity of the condition, including the size and extent of the veins involved. It can also be used to evaluate for any other abnormalities of the testis or surrounding structures.

Answer 272

A

B. Physiotherapy

Physiotherapy is a non-invasive treatment option that can help manage shoulder pain and improve range of motion. It involves exercises and manual therapy techniques that can help strengthen the muscles around the shoulder joint, improve flexibility, and reduce pain and inflammation

Answer 273

A

Serum copper and ceruloplasmin tests can be used as initial screening tests for Wilson’s disease, but they are not definitive. They can’t confirm or exclude the disease with 100% certainty. A liver biopsy, which directly measures the amount of copper in the liver, provides a more definitive diagnosis. Therefore, the correct answer remains:

D. Liver biopsy - correct answer

A. Serum cu and ceruloplasmin - initial diagnostic tests.

Wilsons disease
- chief complaint of dark urine, hand tremors, mood depression, personality changes, and Kayser Fleischer rings would be:
- A. Serum copper and ceruloplasmin
Wilson’s disease is a rare genetic disorder that causes copper to accumulate in the body, leading to liver damage, neurological symptoms, and psychiatric disturbances.

Answer 274

A

A-SIADH

Therefore, based on the given information, the most likely diagnosis for this dehydrated child with low sodium levels in the urine and normal adrenal function would be SIADH (Option A),.

Answer 275

A

A. No antibiotic

The absence of fever and bloody diarrhea suggests that the patient has a mild or self-limited case of Salmonella infection, which may not require antibiotic therapy.

In cases of mild Salmonella gastroenteritis, the use of antibiotics is not usually recommended as it could prolong the duration of the symptoms and increase the risk of antibiotic resistance. Instead, the primary management strategy is supportive care, which includes adequate hydration, electrolyte replacement, and rest.

Therefore, based on the given information in the question stem, Option A (No Antibiotics) would be an appropriate management strategy for this patient with mild or uncomplicated Salmonella infection.

Answer 276

A

B. Evaluate the Geriatric Depression scale

Answer 277

A

D. Amitriptyline

Answer 278

A

A. TCA

Tricyclic antidepressants (TCAs, Option A) are known to interfere with the accuracy of plasma catecholamine measurement by causing false-positive elevation of plasma normetanephrine and norepinephrine levels. TCAs inhibit the reuptake of catecholamines, resulting in an accumulation and false elevation of their levels in plasma. Therefore, Option A (TCA) is the correct answer to the question regarding the most common cause of false-positive evaluation of plasma normetanephrine and norepinephrine levels in a patient with suspected pheochromocytoma

Answer 279

A

D. Ampullary cancer has the worse prognosis that carcinoma of the
body of the pancreas.

This statement is false because ampullary cancer has a better prognosis than pancreatic cancer.

Answer 280

A

B. Cease metformin

Answer 281

A

D. Annual mammo

Answer 282

A

B. Physio

Answer 283

A

b. Anxiety (globus pharyngeus)
Anxiety can cause physical symptoms, including a sensation of having a lump or something stuck in the throat, known as globus pharyngeus or globus sensation

. This sensation can be triggered by stress or anxiety and may occur intermittently. The fact that the symptoms have been relieved by drinking water in the past suggests that the sensation is not due to a structural or anatomical issue in the throat.

Answer 284

A

D) Add vancomycin

The presence of a positive culture for coagulase-negative staphylococci (CoNS) raises concern for a possible hospital-acquired infection, particularly if the patient has been recently hospitalized or has other risk factors for hospital-acquired infections. CoNS are commonly found as skin contaminants, but may also indicate a true infection in certain settings.

Based on the information provided, it would be appropriate to consider Option D, adding vancomycin to the current antibiotic regimen, to cover possible methicillin-resistant CoNS (MRCoNS) infection.

Answer 285

A

D. Withdraw Venlafaxine

The patient is presenting with symptoms suggestive of mania, which could be related to the use of venlafaxine. The most appropriate next step would be to discontinue venlafaxine therapy.

Answer 286

A

herefore, the correct answer is Option A: Conductive hearing loss to the right. Bilateral cerumen impaction can interfere with sound transmission and lead to conductive hearing loss. The hearing aids, if being worn, may still allow some sound to transmit through bone conduction. However, this is unlikely to offset the loss of sound conduction through the ear canal due to cerumen impaction. The presence of presbycusis in the left ear cannot be excluded, but the tests do not support this diagnosis.

Answer 287

A

C. Femoral hernia’s

The absence of an expansive cough impulse is more characteristic of a femoral hernia.

Given the location of the swelling below and medial to the pubic tubercle. Femoral hernias can often be mistaken for inguinal hernias, but are less common and typically occur in women.

Answer 288

A

D) add vancomycin

The best course of action would likely be D) add vancomycin. Coagulase-negative staphylococci are often resistant to many common antibiotics, including amoxicillin, but are usually sensitive to vancomycin.

Answer 289

A

A. Partial nephrectomy

Partial nephrectomy is a surgical procedure that involves removing only the part of the kidney that contains the tumor while preserving the remaining healthy kidney tissue. It is the preferred treatment option for small renal masses (less than 4 cm) that are localized and confined to the kidney.

Answer 290

A

A. Report

Answer 291

A

A. Depression

Increased sleep is also a common symptom of depression in children and adolescents.

Answer 292

A

Randomized Controlled Trials (RCTs) are the most reliable method to study the effects of nutritional supplements on Osteoarthritis (OA). RCTs allow for a direct comparison between a group receiving the supplement and a control group, minimizing bias and providing stronger evidence of effectiveness.

Answer 293

A

A, Woman’s age

Answer 294

A

B. Autism

The symptoms described, such as difficulty with social interaction, repetitive behaviors, and adherence to routines, are consistent with the diagnostic criteria for autism spectrum disorder (ASD). Children with ASD may have difficulty with communication, social interaction, and behavior, and may exhibit a range of symptoms, including restricted interests, repetitive behaviors, and sensory sensitivities

Answer 295

A

Given the travel history to India and the symptoms of fever, chills, and jaundice, the most likely diagnosis is Hepatitis E. Hepatitis E is common in many tropical countries like India and can present with these symptoms. The patient was vaccinated for Hepatitis A before travel, which makes Hepatitis A less likely. Hepatitis B, C, and D are usually associated with sexual contact, drug abuse, or other specific risk factors, which the patient does not have.

Answer 296

A

C. Cholangitis

Ascending cholangitis is a serious infection of the bile duct (cholangitis) often caused by bacteria ascending from its junction with the duodenum (the first part of the small intestine). It can cause higher than normal temperatures, abdominal pain, jaundice, and can progress rapidly to severe illness if not treated promptly.

Answer 297

A

The best course of action would be to D. Check MMSE. The Mini-Mental State Exam (MMSE) is a tool used to assess cognitive function and can help determine if the patient’s psychotic symptoms are related to cognitive impairment or dementia, which are common in the elderly population

Answer 298

A

However, a complete blood count (CBC, Option B) can help provide a broad picture of a patient’s general health status and identify signs of certain diseases and conditions, including some infections and inflammations. It can give information about the number of white blood cells and can sometimes suggest whether an infection is more likely caused by a bacterial or viral agent.

Answer 299

A

This patient’s presentation is suggestive of Reactive Arthritis (formerly known as Reiter’s Syndrome - Option A). Reactive arthritis is characterized by the classic triad of urethritis, arthritis (often described as “sausage digits” due to diffuse swelling), and conjunctivitis. It often follows an infection, commonly genitourinary (like Chlamydia) or gastrointestinal. The rash on the palms and soles could be keratoderma blennorrhagicum, which is associated with reactive arthritis. Furthermore, reactive arthritis is seronegative, meaning that Rheumatoid Factor (RF) is typically negative.

Answer 300

A

The history of IV drug use increases her risk for HIV, which in turn increases the risk for herpes zoster due to immunosuppression. Therefore, conducting an HIV serology test (Option C) would be an appropriate next step. If the rash is indeed due to herpes zoster and the patient is HIV positive, antiviral therapy should be initiated.

Answer 301

A

A. IVF (In Vitro Fertilization)
When the vas deferens is absent or non-functional, sperm cannot be transported from the testicles to the urethra for ejaculation. In such cases, assisted reproductive technologies, such as IVF, offer a solution for achieving pregnancy.

IVF involves the retrieval of eggs from the female partner, fertilizing them with sperm in a laboratory setting, and transferring the resulting embryos into the uterus

Answer 302

A

B. Conditional license.

It is important to ensure that the woman’s hypoglycemia is well-managed and controlled to prevent any accidents or health complications while driving. A conditional license may be granted with certain restrictions, such as monitoring blood sugar levels before driving and carrying appropriate snacks or treatments in case of another hypoglycemic episode. It is important for the woman to follow up with her healthcare provider and obtain clearance before resuming driving.

Answer 303

A

The symptoms and test results suggest a diagnosis of Choledocholithiasis (E). This condition, characterized by gallstones in the bile duct, can cause jaundice and elevated bilirubin and alkaline phosphatase levels. The mildly raised AST also aligns with this diagnosis.

Answer 304

A

Delete
B. Uterine fundus massage.

Postpartum hemorrhage (PPH) is defined as blood loss of 500ml or more after vaginal delivery or 1000ml or more after cesarean delivery. In this case, the patient has PPH of 1000ml, but the delivery was normal and the placenta was delivered 5 minutes later. The palpable uterus above the pubic symphysis suggests uterine atony, which can cause or contribute to PPH. The first-line management for uterine atony is uterine fundus massage. This is done to stimulate uterine contractions and help the uterus to contract down and reduce the bleeding. Checking the placenta and vaginal lacerations may be necessary as the next steps, but uterine fundus massage is the immediate intervention to potentially stop the hemorrhage. Syntocinon may also be administered to help reduce postpartum bleeding by inducing contractions. However, uterine massage is the immediate first-line management in this scenario.

Answer 305

A

Pelvic abscess is a possibility in this case, given the history of open laparoscopy for appendix with lavage, and tenderness on rectal exam. Pelvic abscess can cause fever, tenderness on rectal exam, and in some cases, diarrhea. So it should also be considered as a possible diagnosis in this case, along with C. diff.

Answer 306

A

B. All 4 Anti-TB drugs.

IGRA positivity, a positive Mantoux test of 12 cm, and CXR findings suggestive of inactive patchy lesions indicate latent tuberculosis (TB) infection. As per the guidelines, the standard treatment for latent TB infection is to initiate Isoniazid (INH) or Rifampicin therapy for 6 to 9 months. However, in cases where the risk of progression to active TB is high or in patients with extensive TB disease, the preferred treatment regimen is to initiate all four anti-TB drugs for two months, followed by two drugs (isoniazid and rifampicin) for an additional four months. The 4-drug regimen provides a more effective treatment option, prevents the development of drug-resistant TB, and decreases the risk of disease progression.

Answer 307

A

D. Adjustment Disorder
The man’s history of stressful life events and use of Diazepam suggests the possibility of an underlying adjustment disorder

Adjustment disorder is a stress-related condition that can occur in response to a significant life event, such as a divorce, job loss, or financial difficulties.

Symptoms of adjustment disorder can include anxiety, depression, and behavioral issues, such as insomnia

Answer 308

A

B. Depression.

The patient’s symptoms of difficulty sleeping, low mood, and tremor following a few days of alcohol abstinence suggest depression. Alcohol withdrawal can cause tremors, and low mood is also a common symptom of depression. Additionally, the behavior of counting before smoking also suggests the possibility of obsessive-compulsive disorder (OCD); however, the absence of other OCD symptoms and the presence of other depressive symptoms like low mood and difficulty sleeping makes depression more likely.

Answer 309

A

A. Clostridial myonecrosis.

The development of worsening pain and swelling of the left hand, as well as the circumferential eschar formation in a patient who spilled hot coffee on their forearm, suggest the possibility of clostridial myonecrosis. Clostridial myonecrosis, also known as gas gangrene, is a rare and serious bacterial infection caused by Clostridium bacteria that can occur following traumatic injuries, such as burns, and can result in tissue necrosis and gas production. The progression of this infection can be rapid and severe and can lead to systemic toxicity, sepsis, and even death if left untreated. Treatment generally includes surgical debridement to remove the infected tissue and antimicrobial therapy.

Answer 310

A

B. Intravenous corticosteroids.

The patient’s symptoms and history suggest a possible diagnosis of temporal arteritis, also known as giant cell arteritis. This condition is a vasculitis that primarily involves the large and medium-sized arteries, especially the branches of the carotid artery, including the temporal artery. Symptoms can include new-onset headache, vision changes (such as the right-sided vision loss the patient experienced 6 months ago), and general symptoms like fatigue and malaise, which align with the patient’s lethargy. The condition is more common in older adults and can lead to serious complications, such as blindness, if not treated promptly.

The first-line treatment for temporal arteritis is high-dose glucocorticoids, hence “intravenous corticosteroids” is the most appropriate next step.

Answer 311

A

The next step would be to get a urinalysis and culture to identify any possible urinary tract infections, which may cause urinary incontinence. Urinary tract infections are a common cause of bladder irritation and incontinence. If the urinalysis and urine culture show no signs of infection, then further evaluation with urodynamic testing can be considered to assess bladder function, urine flow, and identify any underlying neurological or anatomical issues. But as the patient is presenting with symptoms of incontinence, it is important to first rule out a simple urinary tract infection, as this would be the most common cause of the patient’s symptoms. Therefore, a urine culture is the most appropriate next step for this patient.

Answer 312

A

D. Catheter.

The presentation of an enlarged and soft prostate with both lobes enlarged and a residual urine volume of 20 ml suggests benign prostatic hyperplasia (BPH). BPH is a common condition where the prostate enlarges and can cause urinary retention, which is consistent with the patient’s inability to void. The initial management of acute urinary retention in cases of BPH involves catheterization to relieve the urinary obstruction and drain the bladder. Therefore, the most appropriate next step in this case is catheter placement. This will allow for drainage of urine and may provide immediate symptomatic relief. Further diagnostic tests such as PSA and creatinine may be performed after catheterization, depending on the patient’s clinical response and the results of initial diagnostic tests. Prostatectomy may be considered as a long-term management option for BPH, while PSA and creatinine testing will help identify any underlying malignancy or renal impairment, respectively. However, catheterization is the most urgent and critical management step at this time to relieve the patient’s acute urinary retention.

Answer 313

A

D. Normal development.

The behavior of staying in the room and becoming a vegetarian is not necessarily indicative of any mental health diagnosis. At 16 years old, it is typical for teenagers to explore new identities and preferences, including social, cultural, dietary, and personal values. At times, these choices may bring some conflicts or tension between the adolescent and their parents, particularly when it comes to lifestyle choices. The behavior of staying in the room may be a reflection of a typical adolescent’s development toward establishing more independence and privacy, testing limits, and exploring new interests. The behavior is not necessarily a sign of a mental health disorder or condition.

Answer 314

A

C. FBC during labor
The pregnant female’s laboratory results suggest the possibility of an underlying medical condition, such as anemia, infection, or thrombocytopenia

Answer 315

A

Maternal age - As women get older, their fertility decreases, and their risk of infertility increases. At the age of 49, the natural decline in the quality and quantity of eggs makes it more difficult to conceive. Therefore, the woman’s age could be a contributing factor.

Answer 316

A

Option B, performing a Doppler ultrasound, could also be a reasonable next step to investigate leg swelling after a vein harvest for CABG. A Doppler ultrasound can evaluate for the presence of blood clots, deep venous thrombosis (DVT), venous insufficiency, or other vascular problems. This test can also help identify the direction and velocity of blood flow through the vessels. It is a non-invasive diagnostic test that can provide valuable information on the vascular status of the region.

Answer 317

A

The most common type of ear cancer is squamous cell carcinoma, which can start as skin cancer in the ear canal or skin of the outer ear.

Answer 318

A

D. No Ix (investigation)

You are correct that observation (option D) can be the initial management strategy for lateral epicondylitis. Non-imaging management options for lateral epicondylitis include:
- Rest and modification of activities that trigger symptoms
- Ice or heat therapy to relieve pain
- Nonsteroidal anti-inflammatory medications
- Physical therapy to stretch and strengthen the affected area
- Wearing a counter-force brace to reduce strain on the elbow

If conservative management measures do not provide significant symptom relief after a reasonable amount of time (usually 6-12 weeks), further investigations may be needed. Therefore, initial observation with reassessment of symptoms over time can be an appropriate management strategy for lateral epicondylitis.

Answer 319

A

B. Surveillance

In the case of the elderly man with prostate cancer who had a PCL done 18 months ago, the most appropriate management would be surveillance, which involves regular follow-up blood tests, rectal exams, and prostate biopsies to monitor the progression of the cancer.

Answer 320

A

A. Detrusor instability
Detrusor instability, also known as overactive bladder, can cause a frequent and sudden urge to urinate that may be difficult to control.

Detrusor instability occurs when the bladder muscle contracts and causes an urgent need to urinate, leading to frequent urination. This condition may be provoked by stimuli such as stress, caffeine, or alcohol and can sometimes occur without any apparent trigger. It is commonly associated with the overactive bladder syndrome and urge incontinence.

Answer 321

A

Depending on the symptoms, different investigations might be needed. For example, an ultrasound (USS) might be used for abdominal issues, an X-ray for bone or lung concerns, or a CT scan for detailed images of certain body parts.

Answer 322

A

B. Fundal massage.

After a party has delivered the placenta completely and is experiencing bleeding of 750 ml of blood, the next step should be a fundal massage. This is important to help the uterus contract and prevent excessive bleeding. A fundal massage involves applying gentle pressure to the uterus through the abdomen to help it contract and reduce bleeding.

Answer 323

A

A. Doppler

Doppler ultrasound is a non-invasive imaging modality that can provide valuable information about the blood flow in the veins and arteries of the affected leg

. It can help identify any vascular abnormalities, such as deep vein thrombosis (DVT) or venous insufficiency, which can contribute to the erythema and tenderness

. Doppler ultrasound can also be used to monitor the progression of the disease and guide the appropriate management

Answer 324

A

All of the above.

A. Mood: Always look into the emotional and mental wellbeing of an individual. Any signs of persistent sadness, hopelessness, feelings of worthlessness or guilt, irritability and restlessness, or loss of interest in activities once enjoyed should be considered.

B. Sleep pattern: Changes in sleep pattern such as insomnia or excessive sleeping are common signs of depression and should be evaluated. In postpartum depression, fatigue and tiredness can be even more pronounced due to the demands of caring for a newborn.

C. Premorbid Personality: Evaluating the personality traits and behaviors of an individual before the onset of a psychiatric disorder can help identify any noticeable changes. Some people may have a history of depression or anxiety disorders, which can increase the risk of postpartum depression.

Answer 325

A

The correct answer is B. Weight reduction.

Polycystic Ovary Syndrome (PCOS) is a hormonal disorder commonly found in women of reproductive age. Women with PCOS may have infrequent or prolonged menstrual periods or high levels of male hormones (androgens). The ovaries may develop numerous small collections of fluid (follicles) and fail to regularly release eggs.

Obesity is a major factor influencing PCOS and it can worsen PCOS symptoms, hence weight reduction is often the first line of treatment recommended. Lifestyle modifications, such as a healthy diet and regular physical activity, can lead to weight loss, improved fertility, and significantly reduce symptoms.

Answer 326

A

The appropriate study design for assessing prevalence during a recent outbreak would be a cross-sectional study.

In a cross-sectional study, data is collected at a single point in time or over a limited period from individuals who are representative of the population of interest. It involves the observation of exposure and outcome status at the same time. In the context of assessing prevalence during an outbreak, a cross-sectional study would involve collecting data on the number of affected individuals and those who \are not, within a given population at a specific point in time.

This study design is useful for quickly obtaining an estimate of the prevalence of a disease or condition in a given population. Furthermore, it can identify certain risk factors associated with the outbreak and also determine the level of exposure in the population. This data will be helpful in guiding public health officials in their response to the outbreak and developing appropriate intervention strategies

Answer 327

A

If the culture becomes positive for coagulase-negative staphylococcus (CoNS) in a patient with a serious infection, who is treated with antibiotics for pyelonephritis with acute kidney injury, and their symptoms are resolving but still mild symptoms are present, the next step would depend on clinical judgement.

CoNS are often considered as contaminants, but they can also cause infections, particularly in patients who are immunocompromised or have risk factors such as catheterization or implanted devices. If there is clinical correlation with CoNS and symptoms, treatment may be needed.

Therefore, if the patient is responding well to the current antibiotic therapy and the symptoms are mild, no change in therapy may be required.

On the other hand, if the mild symptoms are considered concerning for the possibility of ongoing infection, and there is evidence of a CoNS infection, the healthcare provider may choose to modify the current therapy. Options C and D are not likely to be the best choices. Benzylpenicillin (Option C) is not typically used to treat pyelonephritis, and vancomycin (Option D) is often reserved for serious infections due to resistant Gram-positive bacteria.

Option A of continuing the same antibiotics may still be the best choice if the patient is responding well. However, if a change in therapy is required, the healthcare provider may consider the use of another antibiotic active against CoNS, with the narrowest spectrum possible, based on culture and sensitivity results.

Answer 328

A

The correct answer is D. Past history of squamous cell carcinoma.

A past history of squamous cell carcinoma (SCC) is the highest risk factor for developing another SCC. A history of SCC indicates a susceptibility to the development of cancerous skin lesions, and the patient should be advised to seek regular medical evaluations to monitor any new skin lesions.

Fair skin color (Option A) and the tendency to tan rather than burn (Option B) are also risk factors for skin cancers, including SCC, but they are not as significant as a history of SCC itself.

An absence of sunburns as a child (Option C) might suggest that the patient has had less sun exposure in their life, which could be a protective factor against SCC. However, this factor does not outweigh the significance of a past history of SCC.

While age (Option E) can also be a risk factor for SCC with advanced age increasing the risk, a past history of SCC is a stronger risk factor.

Therefore, the best choice for this question is an option (D) history of squamous cell carcinoma.

Answer 329

A

The best indicator of prognosis for melanoma is the invasion of the dermis (Option D).

Melanoma is a type of skin cancer that develops in the cells that produce melanin. The risk of the cancer spreading and prognosis are related to the depth of the melanoma cells’ invasion into the skin. If the melanoma has not yet invaded the dermis, it is known as “in situ” melanoma, which has a better prognosis. On the other hand, if the cancer has penetrated through the basement membrane and has invaded the dermis, it poses a significant risk of metastasis, and the prognosis is wors

Answer 330

A

The correct answer is B. Skin scrapings.

For a patient presenting with an erythematous scaly lesion, various skin conditions can be the underlying cause. In this case, the differential diagnosis includes tinea, psoriasis, and pityriasis rosea, among others.

Among these options, performing skin scrapings would be the most appropriate tool to reach a definitive diagnosis. Skin scrapings can be used to detect the presence of fungi responsible for tinea infections. A potassium hydroxide (KOH) test can be performed on scrapings to

Answer 331

A

The correct answer is A. Punch biopsy.

The first step in the management of a changing lesion on the cheek is to conduct a biopsy. A punch biopsy is a simple and minimally invasive procedure that will remove a small sample of the suspicious tissue for examination under a microscope. This can be performed by a general practitioner or a dermatologist in an outpatient setting.

Answer 332

A

D. Wide excision.

Malignant melanomas are aggressive forms of skin cancer that require prompt and thorough management. Once a malignant melanoma is diagnosed and excision biopsy is performed, the next step is to perform a wide excision. A wide excision is a surgical procedure that removes any remaining cancerous tissue around the initial biopsy site and prevents its spread to nearby structures and lymph nodes.

The extent of the wide excision will depend on the depth of the melanoma and the size of the biopsy site. The goal of the wide excision is to obtain negative margins, which means that no tumor cells are present at the edge of the excised tissue. This procedure not only achieves complete removal of the cancer tissue but also helps prevent recurrence and further complications.

Wide excision is the next step in managing malignant melanoma after excision biopsy, as it helps to ensure complete removal of the melanoma and reduces the risk of recurrence and further complications. Once a wide excision has been performed, a follow-up review in 3 months (Option E) would be appropriate to assess the healing status and evaluate for possible recurrence.

Answer 333

A

The most likely diagnosis in this case is A. Pyogenic granuloma.

Pyogenic granulomas are benign skin tumors that can appear anywhere on the body, but frequently occur on the face, neck, and hands. They are red, raised, and firm with a shiny or smooth surface and often bleed easily. Pyogenic granulomas can be caused by minor skin injuries, hormonal changes during pregnancy, or certain medications.

The appearance of the tag on the neck, the recent development, and the history of bleeding on catching it suggest that it may be a pyogenic granuloma. However, a biopsy may be required to confirm this diagnosis.

Answer 334

A

Delete
The appropriate initial management for a patient with a peanut allergy who presents with wheezing, urticaria (welts), and swelling of the face is Option A, intramuscular (IM) adrenaline.

Anaphylaxis is a severe and life-threatening allergic reaction that can occur due to exposure to an allergen like peanuts. Symptoms can be diverse, but they typically begin within minutes to a few hours after exposure and can progress rapidly. The symptoms may include swelling of the face, tongue, or throat; urticaria; wheezing, coughing, or difficulty breathing; and abdominal pain or cramps.

IM adrenaline, also known as epinephrine, is the first-line treatment for anaphylaxis. It works by constricting blood vessels, raising blood pressure, and relaxing airway muscles, thus reversing the potentially life-threatening symptoms. Antihistamines like Option B can help to alleviate symptoms of urticaria but are less effective in addressing airway constriction and shock. Hydrocortisone (Option C) is also often used as adjunctive therapy, but it is not typically first-line treatment for acute anaphylaxis.

Answer 335

A

If some of the children are still experiencing itching after the use of permethrin to treat a diagnosis of scabies, the next appropriate step would be Option D, to repeat permethrin.

Permethrin is the first-line treatment for scabies, and it is usually an effective treatment to eliminate the mites that cause the condition. However, at times, treatment can be unsuccessful. This may occur if the initial treatment was not applied correctly or if there is a re-infection after treatment.

If some of the children are still experiencing itching at the site of the lesions after using permethrin correctly for three weeks, a repeat dose may be warranted. The repeat treatment is usually given one to two weeks after the initial application of permethrin.

Answer 336

A

The most appropriate investigation to perform for a 26-year-old pregnant woman who presents with a clear vaginal discharge and no abdominal pain is a Low vaginal swab (Option B).

Clear vaginal discharge is a common symptom during pregnancy, but it can also indicate certain infections that can pose a risk to the pregnancy, such as bacterial vaginosis and yeast infections.

Performing a low vaginal swab allows for the identification of any bacterial or fungal infections that may be causing the discharge. This information is essential for treatment, as untreated vaginal infections during pregnancy can lead to complications, including miscarriages, preterm labor, and low birth weight.

Answer 337

A

Therefore, in a pregnant woman presenting with arthralgia, erythematous papular rashes on the leg that spare the central area after being bitten by an insect, the most appropriate treatment would be oral amoxicillin (Option D). In non-pregnant individuals, oral doxycycline is usually the first-line treatment for Lyme disease. However, in a pregnant woman, the use of doxycycline is contraindicated due to potential harm to the developing fetal bones and teeth.

Answer 338

A

Bowen’s disease is a more appropriate diagnosis for the erythematous scaly raised lesion described in the scenario.

Bowen’s disease, or squamous cell carcinoma in situ, is a type of non-melanoma skin cancer. It typically presents as a red, scaly, and slightly raised patch on the skin, which can occasionally itch. Bowen’s disease commonly occurs on sun-exposed areas of the body, but it can rarely develop on areas that have not been frequently exposed to the sun, such as the legs.

While basal cell carcinoma (BCC) can also present as a scaly raised lesion on the skin, it typically appears as a waxy or pearly nodule rather than a flat lesion, which is more characteristic of Bowen’s disease.

Therefore, the most appropriate answer for the described erythematous scaly raised lesion on an old lady’s shin is C. Bowen’s disease. Thank you for bringing this to my attention and I apologize for any confusion my earlier response may have caused.

Answer 339

A

The most likely cause of hair loss in this patient after receiving chemotherapy with paclitaxel and carboplatin is Option C, interruption of follicular keratinocyte proliferation.

Chemotherapy aims to kill rapidly dividing cells, which can include cancer cells but also healthy cells that divide rapidly, such as hair follicle cells. Paclitaxel and carboplatin are commonly used chemotherapy agents for treating ovarian cancer but can have the side effect of hair loss or thinning (alopecia).

Hair loss due to chemotherapy is caused by interruption or inhibition of follicular keratinocyte proliferation, leading to a decrease in the number of hair follicles in the anagen (growth) phase. This interruption occurs because the rapidly dividing cells of the hair follicle, along with cancer cells, are targeted by chemotherapy agents, resulting in hair loss or thinning.

Answer 340

A

The diagnosis is likely A. Metastatic Melanoma. Melanoma is a type of cancer that can spread (metastasize) to other parts of the body, including the brain. The man’s history of melanoma and the presence of a whitish irregular shadow in the left hemisphere of his brain on a CT scan suggest that his melanoma may have metastasized to his brain, causing his headaches

Answer 341

A

Tubal damage is the most likely cause of infertility in this case. The history of Chlamydia infection increases the risk of tubal damage and obstruction, which can prevent the sperm and egg from meeting and fertilizing. The previous surgery for endometriosis and uterosacral ligament may also have contributed to tubal damage. Age and endometriosis may also play a role, but tubal damage is the most likely cause in this scenario. Early menopause is unlikely since the patient’s menstrual cycle is normal.

Answer 342

A

B. Anovulation is a possible cause of infertility in this case. The woman is in her early 40s, which can be a contributing factor to decreased fertility, but she has a history of a previous pregnancy. Oligospermia or antisperm antibodies in the male partner can also be a cause of infertility, but there is no information provided about the male partner in this scenario. Therefore, anovulation is the most likely cause of infertility. The cycles of 27 to 35 days indicate some irregularity, and the woman may not be ovulating regularly, which can make it difficult to conceive.

Answer 343

A

c- Physiotherapy is the initial management for a tear in the long head of biceps and mild rupture of supraspinatus muscle in a 72-year-old man with pain and decreased range of motion. Surgery may not be necessary for every case, especially if the tear and rupture are mild. NSAIDs may help to relieve pain, but they do not treat the underlying problem and may have side effects, especially in an elderly patient. Steroids may have a role in some cases, but they also have potential side effects and may not be the first-line treatment. Physiotherapy can help to improve range of motion, reduce pain, and strengthen the affected muscles, which can improve function and quality of life. If physiotherapy does not provide enough improvement, then other interventions such as surgery or medication may be considered.

Answer 344

A

Test for HLAB 27 is the most appropriate next step in the management of a young girl with red eye and back pain whose brother has Ankylosing Spondylitis. HLA-B27 is a genetic marker that is strongly associated with the development of Ankylosing Spondylitis, which is a type of inflammatory arthritis that primarily affects the spine. The presence of HLA-B27 does not necessarily mean the patient has Ankylosing Spondylitis, but it is an important risk factor that can guide further diagnostic testing and management. ANA and RF are tests that help to diagnose other types of autoimmune diseases, but they are not specific for Ankylosing Spondylitis. X-ray lumbosacral can provide additional information but may not be necessary at this stage. Ds DNA is a test used to diagnose systemic lupus erythematosus (SLE) and is not specific for Ankylosing Spondylitis.

Answer 345

A

Because early detection of dementia leads to better prognosis, the tool for research on dementia in Italian speaking elderly population should aim to facilitate early detection and diagnosis. The design of the tool should include standardized screening tests and diagnostic criteria for dementia, which should be feasible and practical for use in the target population. It should be sensitive and specific enough to detect early signs of cognitive decline that may indicate dementia. Additionally, the tool should be culturally and linguistically appropriate for Italian-speaking elderly population to increase participation and accuracy of results. It is important to study dementia in the elderly population to better understand the prevalence, risks, and management of the condition, and to develop effective interventions that can improve the quality of life for elderly individuals and their families.

Answer 346

A

B. Left parietal lobe is the site of lesion in Gerstmann syndrome. Gerstmann syndrome is a neurological disorder that results from damage or dysfunction of the left parietal lobe, typically caused by a stroke or other brain injury. The classic signs and symptoms include impaired ability to perform calculations (acalculia), inability to identify numbers or their sequence (finger agnosia), difficulty with left and right orientation (left-right disorientation), and difficulty with writing and spelling (agraphia). Additionally, some patients may experience difficulty with language processing and spatial awareness. As the left parietal lobe is responsible for processing and integrating sensory information related to spatial awareness, language, and cognition, damage to this region can result in the characteristic symptoms of Gerstmann syndrome.

Answer 347

A

The HPV vaccine is recommended for all individuals aged 11 or 12, regardless of sexual activity or condom use, as it can protect against six different types of cancer caused by the human papillomavirus (HPV)

Answer 348

A

A. IV fluid should be the next step in managing a patient with asplenia who experiences chills and rigors during blood transfusion. Chills and rigors are common symptoms of transfusion reactions, which can occur due to a variety of reasons, including blood incompatibility and bacterial contamination. In this case, after confirming that the correct blood bag was used, it is important to provide supportive care to the patient. IV fluid can help to stabilize the blood pressure and improve hydration.

Answer 349

A

Projection is a defense mechanism where a person attributes their undesirable thoughts, feelings, or motives onto another person. In this scenario, the farmer is projecting his anger and frustration about the drought towards the government and accusing them of causing the loss. He is also projecting his own feelings of guilt and spending recklessly onto women whom he is paying for service. Therefore, the correct answer is c) Projection.

Answer 350

A

A. Increase warfarin dose is the next step to manage a patient who has been on Enoxaparin and Warfarin for 1 week, and their INR is 1.8. The goal INR range for most patients on warfarin depends on the underlying medical condition and the patient’s individual risk factors for thrombosis and bleeding. However, an INR of 1.8 is below the recommended range for most indications. The typical management in such circumstances is to increase the dose of warfarin and monitor the patient’s INR closely until it reaches the desired therapeutic range. In contrast, continuing the same treatment or stopping Enoxaparin and increasing warfarin may result in what will be non-compliance of patient’s treatment plan, by not getting enough anticoagulation which may lead to thrombotic events. Finally, stopping Enoxaparin and checking INR after 3 days with no intervention could be inappropriate, and the patient may be at risk for a thrombotic event.

Answer 351

A

OVID arm is a rare reaction to the COVID-19 vaccine, particularly the Moderna and Pfizer-BioNTech vaccines, that typically occurs around one week after the first or second shot vaccination

. It causes a red or discolored rash, often covering a large area of skin at the vaccination site, along with pain, swelling, and itching

. While COVID arm is uncomfortable, it is generally harmless and resolves on its own within a few weeks

. Treatment for COVID arm may include over-the-counter pain relievers and antihistamines to relieve itching and pai

Answer 352

A

A. IV Remdesivir is not the next step in managing a patient who has come in contact with a COVID positive family member and is presenting with fever, nausea, diarrhea, and hypotension with a fever of 103.5 F (39.7 C) after starting IV fluids. It is important to note that Remdesivir is an antiviral drug that is used to treat hospitalized patients with severe COVID-19 infections who require supplemental oxygen or mechanical ventilation. This case does not mention if the patient has tested positive for COVID-19 or is positive with severe symptoms that require hospitalization and supplemental oxygen or mechanical ventilation.

Answer 353

A

B. Furosemide

In patients with chronic kidney disease who are on regular dialysis, the accumulation of fluid or volume overload between dialysis sessions can contribute significantly to high blood pressure. This is further suggested by the noted weight gain of 3-5 kg between dialysis sessions in the patient.

Furosemide is a loop diuretic that works in the kidney to increase the excretion of sodium and water, reducing fluid accumulation and helping lower blood pressure. While loop diuretics are often ineffective in end-stage renal disease due to the significantly decreased renal function, they may still have some effect in patients with residual renal function and can help manage fluid overload and hypertension in these patients.

Answer 354

A

B. Stop and start some other drug

Sodium valproate is known to have potential teratogenic effects. It is one of the antiepileptic drugs that carry a high risk of causing congenital malformations and neurodevelopmental disorders when used during pregnancy.

If the patient wants to conceive, it would be advisable to switch to another, safer anti-epileptic medication. This should be done in consultation with a neurologist or a specialist in epilepsy management. It is essential that this transition is managed carefully to ensure seizure control as seizures themselves can also cause harm to both the mother and developing baby.

Answer 355

A

Bowen’s disease is a form of skin cancer that begins in the top layer of the skin. It generally has a slow progression. Topical creams, cryotherapy, photodynamic therapy, radiation or curettage, and cautery are usually used in the treatment, depending on the location and size of the affected area.
Pyogenic granuloma is a common, benign growth that appears as a small, reddish bump on the skin. It can bleed easily. Treatment often involves surgical removal, laser therapy, or topical medication. The most common treatment is surgical excision.
Psoriasis is a chronic, autoimmune skin disease that speeds up the growth cycle of skin cells. It can cause cells to build up rapidly on the surface of the skin, leading to the formation of scales and red patches that are itchy and sometimes painful. The treatment for psoriasis is multifaceted and typically includes topical therapy (corticosteroids, retinoids, vitamin D derivatives, coal tar), phototherapy (narrowband UVB, psoralen plus ultraviolet A) and, for severe cases, systemic agents (methotrexate, cyclosporine) or biologics focusing on specific components of the immune system.

Answer 356

A

B. Verapamil and Timolol.

Both Verapamil and Timolol can potentially cause bradycardia. Verapamil is a calcium channel blocker that relaxes the muscles of the heart and blood vessels, and this may result in a lower heart rate. Timolol is a non-selective beta-blocker that decreases heart rate, therefore, they may both contribute to bradycardia.

Captopril (an ACE inhibitor) and Metformin (an anti-diabetic drug) do not typically cause bradycardia. Ibuprofen (a nonsteroidal anti-inflammatory drug) might uncommonly influence heart rate or rhythm, but not typically bradycardia.

Therefore, the combination of Verapamil and Timolol is most likely to cause bradycardia.

Answer 357

A

B. Autoimmune hemolytic anemia

The presence of microspherocytes, reticulocytosis, splenomegaly, and a positive Coombs test (also known as the direct antiglobulin test) is most suggestive of autoimmune hemolytic anemia (AIHA). AIHA is a condition where your immune system produces antibodies against your own red blood cells, causing them to burst (hemolyze) prematurely. The Coombs test is used to detect these antibodies.

While hereditary spherocytosis could present with microspherocytosis and splenomegaly, it would not result in a positive Coombs test as this is not an autoimmune condition. AIHA is a better fit with all the given clinical features.

Answer 358

A

B. Radical Prostatectomy.

In a case of prostate cancer, where there is no evidence of lymph node involvement or metastasis, and the cancer is confined to the prostate and seminal vesicles (T3b stage), radical prostatectomy may be an appropriate treatment option. This procedure involves surgical removal of the entire prostate gland, the seminal vesicles, and adjacent tissues.

Answer 359

A

B. Analgesia and mobilise

Back pain that occurs after strain or exertion such as trying to open a window, especially when all tests including a spinal X-ray are normal, is likely due to a muscular or soft tissue injury. Acute management of such conditions typically involves the use of analgesics for pain control and early mobilization to prevent stiffness and deconditioning. Rest may be beneficial immediately after the injury, but prolonged inactivity is generally not encouraged as it might slow recovery.

Answer 360

A

A. IM Droperidol

The described condition seems to be an acute psychiatric emergency, and immediate intervention is warranted. If the patient poses a danger to self or others, sedation using antipsychotics may be considered for the safety of the patient and staff around them. Droperidol, an antipsychotic drug, can be administered to help manage acute agitation and psychosis. However, it is important to use it cautiously due to its potential for serious side effects like cardiotoxicity.

Answer 361

A

B. MRI
Bradykinesia is a symptom of Parkinson’s disease, which is a neurodegenerative disorder that can cause depression, memory problems, and other cognitive and motor symptoms. An MRI scan can help identify any structural changes or abnormalities in the brain that may be contributing to the patient’s symptoms. It can also help rule out other possible causes of the symptoms, such as stroke or traumatic brain injury. The clinical presentation of bradykinesia may include hypomimia (loss of or limited facial expressions), hypophonia (soft speech), difficulty with fine motor activities, reduced arm swings when walking, shuffling steps when walking, and small cramped handwriting. Treatment for bradykinesia may include medications, such as levodopa, dopamine agonists, and anticholinergics, as well as physical therapy and other supportive measures

Answer 362

A

B. Urine routine

Based on the presentation of lower abdominal pain and diarrhea, it seems most likely that this young boy is suffering from a gastrointestinal problem, perhaps an infection or a food intolerance. A urine routine could potentially help rule out urinary tract infection which may at times present with similar symptoms.

Answer 363

A

A. Admit and observe in ED

Considering that the old lady is delirious, which indicates an acute change in mental status, and has a urinary tract infection (which could be the reason for her delirium), there is a clear need for medical intervention. Moreover, being unable to secure a cannula suggests potential severe dehydration or other circulatory issues that need addressing. Even though the son, who has power of attorney, has said not to put in a cannula, it is not an absolute contraindication to other methods of treatment and close monitoring, especially if her condition is potentially life-threatening.

Therefore, admitting her and observing her in the emergency department would be the most appropriate course of action. During her observation, the medical team can work to understand the reason behind the son’s wish not to secure a cannula and discuss alternative treatment possibilities and likely outcomes with him.

Answer 364

A

C. Oxytocin

From the details provided, the pregnant woman is 39 weeks along, which is full term, and she has been having contractions every 5 minutes. Despite this, there has been no change in the dilation of the cervix or the position of the fetus over a period of 4 hours. This suggests that she is experiencing a protracted labor (labor that is progressing slower than normal).

One common management strategy in such cases is to administer oxytocin. Oxytocin is a hormone that can stimulate contractions, helping to speed up labor. If the labor does not progress with oxytocin, then a Cesarean section (C-section) may be considered.

Answer 365

A

C. ConstitutionalM macrocephaly

Constitutional macrocephaly is a condition in which a child has a head circumference that is larger than normal, but there are no other associated symptoms or underlying medical conditions. t is usually a benign condition that does not require treatment, and the child’s head size will typically normalize as they grow older

Answer 366

A

B. Microcephaly

The most likely cause of the decreased head circumference from the 50th to the 35th percentile in a pregnant woman with a history of infection at 24 weeks and gestational diabetes mellitus (GDM) would be microcephaly. Microcephaly is a condition characterized by a significantly smaller head size compared to other individuals of the same age and sex. It can be caused by various factors, including genetic abnormalities, infections during pregnancy (such as Zika virus infection), exposure to certain medications or toxins, and other congenital disorders. In this case, the history of infection during pregnancy may be a contributing factor to the development of microcephaly.

Answer 367

A

A. CT Sialogram

A swelling at the angle of the jaw is most commonly due to issues with the salivary glands, particularly the parotid gland which is located in this area. Conditions such as salivary gland stones (sialolithiasis), infection, or tumors could cause such a swelling.

A CT Sialogram is an imaging study that can help evaluate the salivary glands and ducts and identify abnormalities such as stones or blockages. It involves the use of a special dye that is injected into the salivary glands to make them and their ducts more visible on the CT images.

Answer 368

A

A. Colonoscopy

This patient has rectal bleeding and anemia, which indicates a significant loss of blood. While the vital stats are stable currently, it’s essential to locate the source of the bleeding.

A colonoscopy is often the first investigation of choice in such cases, as it allows direct visualization of the interior of the colon, potentially identifying the source of bleeding, and even allowing for interventions such as removing polyps or cauterizing bleeding vessels.

Answer 369

A

A. Repeat FOBT

You are correct. According to Australian guidelines, individuals who are asymptomatic, belong to low-risk category 1, and have a family history of colorectal cancer should start screening at age 50 and can have FOBT testing every two years. A colonoscopy is recommended for individuals with a positive FOBT.

Given the patient’s age, low-risk category 1 status, and negative FOBT, repeating the FOBT in two years would be an appropriate next step. A colonoscopy may still be recommended for this patient at a younger age due to his positive family history, but according to the current guidelines, has several options including interval colonoscopies from ages 45-49 or arranging colonoscopy surveillance at a higher interval depending on patient and family history.

Answer 370

A

B. LSCS

This situation seems to suggest that there is a potential life-threatening emergency, and the immediate priority would be to stabilize the patient and evaluate for fetal distress. The presence of PV bleeding, low blood pressure, and no fetal heart sounds all indicate an obstetric emergency that requires prompt intervention.

Answer 371

A

A. Stop Valproate, if feasible.

Sodium Valproate is a medication used for the management of epilepsy and other neurological conditions. While it is useful as a treatment, it has been shown to cause harm to developing fetuses, including an increased risk of neural tube defects and other congenital malformations.

Therefore, if a woman on Valproate wishes to conceive, the ideal scenario would be to stop the medication, if medically feasible. However, for some women, stopping the medication may not be possible due to the severity of their medical condition. In such cases, a consultation with a neurologist or epilepsy specialist would be recommended to weigh the risks and benefits of continuing the medication versus the potential risks to the developing fetus.

Answer 372

A

A. Refer to speech pathologist

Answer 373

A

A. Fear of contamination

If a person is frequently washing their walls despite no apparent need, one possible explanation could be a fear of contamination or obsessive-compulsive disorder (OCD). This condition can manifest in repetitive and compulsive behaviors that are not easy to control. A person with a fear of contamination might engage in obsessive or repetitive behaviors, such as continuous hand washing or cleaning.

Therefore, if a person is washing walls frequently and their behavior seems compulsive, it is reasonable to inquire about their level of concern for contamination and associated behavior and thoughts. It is important to approach this with empathy and without judgment because OCD is a severe condition that can affect an individual’s quality of life.

Answer 374

A

A. Canula site infection

Answer 375

A

You are correct that anticoagulant therapy, such as warfarin, is the first-line treatment option with a confirmed diagnosis of DVT.

The cord-like redness, along with calf pain, suggests the possibility of DVT. An ultrasound of the leg veins can confirm the diagnosis of DVT. Once confirmed, anticoagulant therapy is typically used to treat DVT. Warfarin is one of the most common anticoagulants used to treat DVT.

Surgery (option A) may be considered in rare situations, such as very large or severe blood clots, where there is an increased risk of clot breaking off and traveling to the lungs, known as pulmonary embolism (PE), despite anticoagulant therapy. Since surgery carries its own risks, it is not typically the first-line treatment option for DVT.

Answer 376

A

A. Delusional Disorder

A sudden onset of beliefs that are not shared by the general culture or the patient’s social group, such as a belief that aliens are trying to do something, is characteristic of delusional disorder. Given that the patient is a professor, previously fine, and not displaying typical features like hallucinations, dementia, or disorganized thoughts, it is not likely to be a diagnosis of late onset schizophrenia.

Delusional disorder is a psychiatric condition in which an individual has one or more fixed delusions, which are false beliefs that are resistant to reasoning or evidence and are not shared by the individual’s cultural or religious group. The delusions cause significant distress and impairment in work or social settings, but the person can function normally otherwise.

The bizarre nature of the belief about aliens shows that it is not following the norm for cultural or religious beliefs and could be pathological. Delusional disorder typically affects middle-aged to older adults and is often treated with medication, psychotherapy, or a combination of both.

Answer 377

A

Admit the patient: If the patient’s behavior is concerning or there is a risk of harm to themselves or others, they may need to be admitted to the hospital for further evaluation and treatment

Answer 378

A

B. Pulmonary embolism

Answer 379

A

A. Notify coroner
A coroner is a government official who is responsible for investigating and determining the cause of death when a person dies unexpectedly, violently, or under suspicious circumstances. The coroner is usually a medical or legal professional who works closely with law enforcement to investigate the circumstances surrounding the person’s death.

Answer 380

A

a. Physiotherapy

The most appropriate management for this patient would be physiotherapy. Exercises and gentle stretches can help lengthen and strengthen the shoulder muscles and relieve pain. These exercises can improve flexibility, increase the range of motion, and bring greater comfort and ease to movements. It’s recommended to do these exercises three to six times per week, starting with a 10-minute routine and gradually increasing the duration as the patient gets stronger and more flexible

Answer 381

A

The correct answer for this question is B. Decreased CSF absorption.

The clinical scenario described is consistent with normal pressure hydrocephalus (NPH), a condition characterized by gait disturbances, memory impairment, and urinary incontinence. The broad-based and shuffling gait is a classic finding in NPH. The underlying cause of NPH is thought to be decreased cerebrospinal fluid (CSF) absorption, which leads to an enlarged ventricular system. Ventriculoperitoneal shunt placement can help to improve symptoms in some patients with NPH.

Answer 382

A

In such a situation, the best course of action would be to A) call the police. This is because the patient is in immediate danger and the police are equipped to handle such situations. Additionally, it’s important to ensure the patient’s safety and provide medical treatment as needed. Domestic violence is a serious issue and should be reported to the authorities

Answer 383

A

A. Repeat FOBT

Answer 384

A

a. Physiotherapy

Answer 385

A

CT scan

However, in this particular case with a history of headache for several weeks, waking up due to pain in the night, and enlarged nodes in the neck, the priority should be to rule out any intracranial pathology. Therefore, the most appropriate next step would be a CT scan of the head to determine if there is any underlying neurological problem. Once the underlying cause of the headache is determined, appropriate treatment can be administered.

Answer 386

A

Document in incident reporting.

It is important to document the incident in the incident reporting system as soon as possible after discovering the mistake. This helps to ensure that everyone involved in the patient’s care is aware of the error and can take appropriate steps to monitor the patient’s condition and prevent further harm. The patient should also be informed about the error to ensure transparency and build trust.

In addition, the hospital manager should be informed of the incident so that appropriate measures can be taken to prevent similar errors from occurring in the future.

Answer 387

A

B. Wolff-Parkinson-White (WPW) Syndrome.

WPW Syndrome is a congenital condition in which there is an abnormal accessory pathway between the atria and ventricles, resulting in the characteristic delta wave pattern on ECG. This can lead to episodes of supraventricular tachycardia (SVT). The bradycardia in this case could be explained by a high vagal tone which could be seen in atheletes or it could be a normal finding in this young athlete.

It is important to note that while hypertrophic cardiomyopathy can also cause bradycardia, left and right bundle branch blocks, and other ECG abnormalities, it does not typically present with the characteristic delta wave pattern seen in WPW Syndrome. Similarly, left bundle branch block or right bundle branch block can cause ECG abnormalities, but not characteristic delta waves in V1-V3.

Answer 388

A

A. Hypomania.

The patient’s behavior and speech pattern indicate an elevated, euphoric mood, which can be a feature of hypomania. Hypomania is a milder form of mania and is a feature of bipolar disorder. Patients with hypomania often experience a decreased need for sleep, increased energy, racing thoughts, and increased impulsivity. They may also experience increased talkativeness and feel more sociable, as seen in the patient’s expression of affection towards his girlfriend.

Answer 389

A

4)Colposcopy and LLETZ Biopsy

CIN3 is a high-grade precancerous lesion that has the potential to develop into cervical cancer if not treated promptly. A colposcopy is recommended to visualize the cervix and identify the extent and location of the abnormal cells. LLETZ (Large Loop Excision of the Transformation Zone) biopsy is then done to remove the abnormal cells. LLETZ biopsy is a highly effective treatment and reliable option for removing any abnormal tissue and it preserves the structure of the cervix. Therefore, it is the most suitable option given the patient’s gestational age. Termination of pregnancy is not required if appropriate management is done to treat abnormal cervical cell changes.

Answer 390

A

A) Abruptio placentae.

The patient presents with painful contractions, vaginal bleeding, and lower abdominal/pelvic pain, which are all suggestive of abruptio placentae. A hypertonic uterus and moderate blood in the vaginal vault further support the diagnosis. Additionally, the patient has a history of hypertension, which is a risk factor for abruptio placentae. Normal labor or placenta previa would less likely cause hypertonic uterus and vaginal bleeding, respectively. Uterine rupture and Vasa previa may also cause vaginal bleeding and abdominal pain but are less likely given the presentation.

Answer 391

A

the pulmonary embolism and pregnancy is a complex issue and several factors need consideration.

A. The prevalence in most clinical series is < 10% - False. The prevalence of pulmonary embolism in pregnancy is higher than that in the general population. Pregnant women are at an increased risk of venous thromboembolism (VTE).

B. Ventilation-perfusion (VQ) scanning confers a lower radiation dose to the breast than does CT pulmonary angiography (CTPA) - True. VQ scanning is generally preferred over CTPA in pregnant women as it exposes the breast to lower levels of radiation.

C. D-dimer is useful for screening pregnant women at low risk for PE in order to avoid the need for imaging - True. D-dimer can be a useful screening tool for excluding thromboembolic events in pregnant women at low risk.

D. Lower limb compression ultrasound shows evidence of DVT in about 35% of pregnant women with PE - False. Lower limb compression ultrasound is used to evaluate for deep vein thrombosis (DVT), which is a risk factor for pulmonary embolism, rather than a diagnostic indicator of pulmonary embolism. Also, the prevalence of DVT in pregnant women with pulmonary embolism varies according to different studies.

E. The radiation dose conferred to the fetus is substantially lower for CTPA than for VQ scanning - False. As stated earlier, VQ scanning is the preferred imaging modality in pregnant women as it exposes the mother and fetus to lower levels of radiation than CTPA.

Answer 392

A

The most appropriate management in this case is 1) Give IG (Immune Globulin).

Varicella zoster virus (chickenpox) can cause severe complications in pregnant women and their unborn children. Previous infection with the virus does not confer complete immunity, and exposure to someone with active infection can result in reactivation of the virus, known as shingles or herpes zoster. Therefore, in this case, it is important to provide prophylaxis to prevent infection or reduce the severity of the infection if it occurs.

IG contains antibodies against the Varicella zoster virus and is effective in preventing or reducing the severity of the disease if given within a few days of exposure. Vaccine is not recommended during pregnancy and should be given before pregnancy or after delivery. Therefore, the most appropriate next step would be to give IG to prevent or reduce the effects of the infection.

Answer 393

A

The next step to reduce chest pain in this patient with acute anterior MI would be C. Nitrates.

Nitrates are a class of medication that are used to relieve chest pain (angina) by dilating blood vessels and increasing oxygen to the heart. In the case of acute MI, nitrates can help relieve chest pain by reducing the workload on the heart and increasing blood flow to the affected area. Morphine may also be given to relieve chest pain but is typically reserved for patients with severe pain who do not respond to nitrates. Naproxen and paracetamol are not typically used for chest pain relief in acute MI. While beta-blockers are a mainstay of acute MI management, they are generally not used immediately for the relief of chest pain in the emergency room setting. Rather, they are used after the patient’s pain is stabilized, and once the diagnosis is confirmed.

Answer 394

A

Yes, it is possible that the presentation is consistent with normal pressure hydrocephalus (NPH), which is characterized by the triad of gait disturbances, urinary incontinence, and cognitive impairment. The broad-based shuffling gait and urinary incontinence are consistent with NPH. The inability to remember items after 5 minutes is also a finding seen in NPH, but it is less specific to this condition than in Alzheimer’s disease.

The underlying cause of NPH is thought to be decreased cerebrospinal fluid (CSF) absorption, which leads to an enlarged ventricular system. Ventriculoperitoneal shunt placement can help to improve symptoms in some patients with NPH.

Answer 395

A

b) Mechanical irritation of pilosebaceous follicles
The presence of red papules and pustules in the axillae suggests a follicular-based rash, which can be caused by mechanical irritation of the pilosebaceous follicles
. The patient’s use of crutches for ambulation may contribute to the mechanical irritation of the axillary skin. Additionally, smoking and prediabetes are risk factors for skin infections, which can also cause follicular-based rashes

Answer 396

A

The most likely risk in this scenario is C. Recurrence.

Shoulder dislocation is a common injury in sports, especially in basketball players. The fact that the coach placed the arm in a sling suggests that the dislocation was reduced shortly after the injury. However, the risk of recurrence after a primary shoulder dislocation is high, even with the appropriate management and rehabilitation. Limited range of motion and tenderness on palpation are also common findings after a shoulder dislocation.

Answer 397

A

B. Echocardiogram

The patient’s symptoms are consistent with low cardiac output syndrome, which is a condition characterized by inadequate cardiac output to meet the metabolic demands of the body

. The presence of hypothermia, hypotension, and tachycardia suggests that the patient is in shock, which is a life-threatening condition that requires immediate intervention

. An echocardiogram can help evaluate the patient’s cardiac function and identify any structural abnormalities or complications that may be contributing to the low cardiac output

Answer 398

A

The most likely diagnosis for this round lesion on a farmer’s big toe is B. Squamous Cell Carcinoma (SCC).

Bowen’s disease is a form of SCC that presents as a small, slow-growing, red to brown scaly patch that enlarges slowly over several months. It may develop into an irregularly shaped Bowen lesion on the skin with a raised, scaly surface, often with a central crust or ulceration.

Answer 399

A

A. You disagree him

Answer 400

A

ABO incompatibility.

ABO incompatibility is the most common cause of severe hyperbilirubinemia in newborns, where maternal antibodies against infant ABO blood cells cross the placenta and cause destruction of red blood cells. Jaundice in ABO incompatibility is typically seen on the 2nd or 3rd day of life and is associated with high levels of bilirubin.

Answer 401

A

C. Physiological jaundice.

Physiological jaundice is a common condition that can occur in the first few days after birth and is due to a transient increase in bilirubin levels. It typically develops after the first 24 hours of life and commonly peaks around the third to fourth day before resolving by the end of the first week. However, jaundice occurring within the first 6 hours of life is not a feature of physiological jaundice.

Answer 402

A

Yes, incarcerated uterus is also a possible cause of a large, hard, and contracted uterus with a palpable lump, especially in the context of a missed diagnosis of multiple pregnancies. It occurs when the gravid uterus becomes entrapped in the pelvis due to a pelvic mass or adhesions.

Answer 403

A

The best management for a 70-year-old lady with stress incontinence who has undergone urodynamic studies and pelvic floor exercises could be a Tension-free Vaginal Tape (TVT) procedure. This is a commonly used surgical option for stress urinary incontinence, especially when conservative treatments like pelvic floor exercises are not sufficien

Answer 404

A

The best next management for this patient could be weight reduction. Obesity is a risk factor for overactive bladder and urinary incontinence, and weight loss may help reduce symptoms. However, it’s unclear how much weight loss is needed. Pelvic floor exercises can also help strengthen the pelvic floor muscles and reduce symptoms of urinary incontinence

Answer 405

A

The most important management for this patient, after bladder exercises have failed, would be surgery for rectocele. This is because the patient’s symptoms are related to a rectocele, which is a form of pelvic organ prolapse.

Answer 406

A

A. laxative

Answer 407

A

a. Constipation with overflow

Constipation with overflow
Constipation with overflow is a common cause of encopresis in children. It occurs when a child has chronic constipation and stool builds up in the rectum, leading to leakage of liquid stool around the impacted stool

. The child may experience pain with bowel movements and become reluctant to pass stool, leading to further constipation and soiling

Answer 408

A

Breastfeeding may need to be temporarily stopped in the case of a breast abscess. This is a painful collection of pus that forms in the breast due to a bacterial infection. However, breastfeeding can usually continue on the unaffected breast.

Answer 409

A

D. Paralysis is the most urgent, as it indicates the most advanced stage of ischemia and the highest likelihood of permanent nerve damage or tissue death.

Answer 410

A

D. Risk assessment helps you to interpret the results of subsequent diagnostic testing.

Assessing a patient’s pre-test risk of pulmonary embolism is important because it helps you to interpret the results of subsequent diagnostic testing. The pre-test probability of pulmonary embolism can influence the interpretation of diagnostic testing, such as D-dimer assay or imaging, and can help determine the appropriate course of action in terms of further diagnostic testing or treatment.

Answer 411

A

D. Pre-eclampsia

Given the onset of high blood pressure during week 10 of her first pregnancy, the presence of protein in her urinalysis, and her low haemoglobin levels, pre-eclampsia is the most likely cause of her hypertension. This condition occurs commonly in pregnancy and is characterized by high blood pressure, protein in the urine, and sometimes low levels of red blood cells. It is a serious condition that requires medical attention and monitoring to prevent complications for both the mother and baby. Chronic glomerulonephritis, chronic pyelonephritis, and renal artery stenosis are all possible causes of hypertension, but are unlikely given her clinical presentation and history. Essential hypertension without a prior history of hypertension is also unlikely in this case.

Answer 412

A

A) Abruptio placentae

Answer 413

A

1) Give IG

Answer 414

A

2) CTG.

When a pregnant woman who is at term presents with reduced fetal movements, it is important to check the fetal well-being to ensure fetal safety. The most appropriate initial step in this scenario is to perform a CTG (Cardiotocographic) monitoring to assess fetal heart rate and uterine contractions. CTG can detect fetal hypoxia or distress and provide immediate feedback on fetal well-being. If the CTG is reassuring, it is safe to discharge the patient if fetal movements are felt and further observation is necessary. However, if the CTG is non-reassuring, further evaluation and management are required.

Answer 415

A

D) Call the police to arrest him and take over.

Answer 416

A

b. Infection

Infection is the most common early complication of hemorrhagic pancreatitis. Hemorrhagic pancreatitis is a severe form of acute pancreatitis that can develop due to pancreatic necrosis and bleeding. Infection can arise due to the compromised integrity of the pancreatic tissue, resulting in the spread of infection to other parts of the body. Pseudocysts, obstructive jaundice, pancreatic fistula, and renal failure are all potential complications of pancreatitis, but are not as common or likely to occur as early as infection.

Answer 417

A

d. breast abscess

Answer 418

A

Based on the information provided and the search results, the most appropriate course of action for the mother requesting a medical certificate for her son with URTI for the past 3 days would be:
A) Give a medical certificate for carer
Providing a medical certificate for carer would allow the mother to take time off work to care for her son without specifying the exact nature of the illness

. This option is often recommended for minor illnesses or conditions that do not require a specific diagnosis or treatment

. It is important to note that the specific requirements for medical certificates may vary depending on the employer and the jurisdiction, and it is important to consult with the employer or a healthcare provider for guidance on the appropriate course of action

Answer 419

A

C. Retained placenta

The sudden drop in blood pressure, profuse bleeding, and clotting problems suggests that the patient may have experienced a retained placenta after delivery. Retained placenta occurs when part or all of the placenta remains in the uterus after delivery, leading to excessive bleeding and other complications. This can be a medical emergency and requires immediate intervention, such as manual removal of the placenta or surgical evacuation of the uterus. Anaphylaxis to an anesthetic medication, amniotic fluid embolism, uterine inversion, and extended tear to the uterosacral ligament are all potential complications after delivery but are less likely in this scenario given the patient’s history and clinical presentation.

Answer 420

A

b. Epididymo-orchitis

The most likely diagnosis in this scenario is epididymo-orchitis, which is characterized by inflammation and swelling of the epididymis and testes. A distinguishing feature of this condition is the presence of swelling and redness in the penis itself, which often occurs due to inflammation spreading from the epididymis and testicles to the penis. Torsion of testes would cause sudden and severe pain, with one testis appearing higher than the other. Strangulated incarcerated hernia would typically cause a painless swelling in the inguinal area. Hydrocele would cause fluid accumulation in the scrotum but not necessarily lead to redness and swelling of the penis. Idiopathic scrotal edema is uncommon and would be a diagnosis of exclusion.

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