501 to 600 Flashcards
(100 cards)
1
Q
- A 20yo boy is brought by his parents suspecting that he has taken some drug. He is agitated, irritated and can’t sleep. Exam: perforated nasal septum. Which of the following is the most likely to be responsible for his symptoms? a. Heroine b. Cocaine c. Ecstasy/MDMA/amphetamine d. Alcohol e. Opioids
A
Ans. The key is B. Cocaine. [drug abuse with perforated nasal septum indicates cocaine abuse].
2
Q
- For a pt presenting with Parkinson’s disease which of the following drugs is most useful in the management of the tremor? a. Apomorphine b. Cabergoline c. Selegiline d. Amantadine e. Benzhexol
A
Ans. The key is E. Benzhexol. [Benzhexol (an antiparkinsonian agent of anticholinergic class) is the drug of choice in parkinson’s disease induced tremor)].
3
Q
- A 26yo woman has become aware of increasing right sided hearing deficiency since her recent pregnancy. Her eardrums are normal. Her hearing tests show: BC-normal. Weber test lateralizes to the right ear. What is the single most likely dx? a. Encephalopathy b. Functional hearing loss c. Tympano-sclerosis d. Otosclerosis e. Sensorineural deafness
A
Ans. The key is D. Otosclerosis. [There are no features of encephalopathy. As Weber test is lateralized it is unlikely to be functional hearing loss. In tympanosclerosis ear drum becomes chalky white. So as the ear drum is normal it is not tympanosclerosis. Weber test is lateralized to right and deafness is also on the right. So it not sensorineural deafness but conductive deafness which makes oto
4
Q
- A 58yo T1DM on anti-HTN therapy for 13yrs developed central chest pain for 45 mins while driving a/w cold sweating and dyspnea. What is the single most appropriate dx? a. MI b. Pericarditis c. Pulmonary embolism d. Costochondritis e. Pneumothorax
A
Ans. The key is A. MI. [In pericarditis pain is aggravated by inspiration or lying flat and relieved by leaning forward. Pericardial rub may present and there may be fever. In pneumothorax pain is not central but pleuritic. Pulmonary embolism=dyspnoea and pleuritic chest pain. In costrochondritis localized pain/tenderness at the costochondral junction enhanced by motion, coughing, or sneezing. The
5
Q
- A man was brought to the ED from a shopping mall after collapsing there. He is conscious and answering questions now. His ECG shows irregular rhythm. Your choice of inv: a. CT b. MRI c. 24h ECG d. Echo
A
Ans. The key is D. Echo. [Echo may show clot in atrial appendage responsible for this attack of TIA secondary to atrial fibrillation].
6
Q
- A 10yo boy is clinically obese and the shortest in his class. He had a renal transplant last year and his mother is worried that he is being bullied. What is the most probable dx? a. Cushing’s syndrome b. Congenital hypothyroidism c. Pseudocushing’s syndrome d. Lawrence moon biedel syndrome e. Down’s syndrome
A
Ans. The key is A. Cushing’s syndrome. [Renal transplant–> immune suppression is needed-> exogenous steroid–> cushing syndrome. short stature–> if steroids are used in early age then they cause premature fusion of growth plate/calcification].
7
Q
- A 45yo man had cancer of head of pancreas which has been removed. He has a hx of longstanding heartburn. He now comes with rigid abdomen which is tender, temp 37.5C,\ BP=90/70mmHg, pulse=120bpm. What is the next step of the inv? a. CT abdomen b. XR abdomen c. MRI abdomen d. US abdomen e. Endoscopy
A
The answer is B. X-ray abdomen. [X-ray abdomen will help diagnosing perforation by showing gas under diaphragm. This is a case of perforated peptic ulcer with the features of shock, abdominal rigidity and raised temperature. Stress from serious disease and operation causes the body to produce higher amounts of acid, which can irritate preexisting ulcers leading to easy perforation].
8
Q
- A 50yo man presents to the ED with acute back pain radiating down to his legs. Pain which is usually relieved by lying down and exacerbated by long walks and prolong sitting. What inv would be the best option? a. MRI b. CT spine c. XR spine d. Dual energy XR abruptiometry e. Serum paraprotein electrophoresis
A
Ans. The key is A. MRI. [Back pain radiating to leg, pain releaved by lying down and exacerbated by long walk and prolonged sitting are characteristic of lumber (intervertebral) disc disease].
9
Q
- What is the most appropriate antibiotic to treat uncomplicated chlamydial infection in a 21yo female who isn’t pregnant? a. Erythromycin b. Ciprofloxacin c. Metronidazole d. Cefixime e. Doxycycline
A
Ans. The key is E. Doxycicline. [Doxycycline 100 mg twice-daily for seven days or a single dose of 1 g of azithromycin or Erythromyin 500 mg twice daily for 14 days or four times daily for seven days or Ofloxacin 200 mg twice-daily or 400 mg once-daily for 7 days. In pregnant Azithromycine 1g single dose is recommended then erythromycin 500 mg twice daily for fourteen days or four times daily for
10
Q
- A 45yo manual worker presented with a 2h hx of chest pain radiating to his left arm. His ECG is normal. What is the single most appropriate inv? a. Cardiac enzymes b. CXR c. CT d. ECG e. V/Q scan
A
Ans. A. Cardiac enzymes.
11
Q
- A 26yo woman had bipolar disorder for 10yrs and is on Lithium for it. She is symptom free for the past 4 years. She is now planning her pregnancy and wants to know whether she should continue taking lithium. What is the single most appropriate advice? a. Continue lithium at the same dose and stop when pregnancy is confirmed b. Continue lithium during pregnancy and stop when breast feeding c.
A
Ans. The key is D. Reduce lithium gradually and stop when pregnancy is confirmed.
12
Q
- A pt presents with dysphagia and pain on swallowing. He has sore mouth and soreness in the corners of the mouth. What is the single most likely dx/ a. Kaposi’s sarcoma b. Molluscum contagiosum c. CMV infection d. Candida infection e. Toxoplasma abscess
A
Ans. The key is D. Candida infection. [Candida is more common than CMV].
13
Q
- A 30yo lady has epistaxis for 30mins. Her Hgb is normal, MCV normal, WBC normal, PT/APTT/Bleeding time are normal. Where is the defect? a. Plts b. Coagulation factor c. Sepsis d. Anatomical e. RBC
A
Ans. The key is D. Anatomical. [bleeding time, coagulation profile, Hb%, cell count and parameters are normal. So the cause of bleeding here is anatomical defect].
14
Q
- Midpoint between the suprasternal notch and pubic symphysis. What is the single most appropriate landmark? a. Fundus of the gallbladder b. b. Mcburney’s point c. c. Stellate ganglion d. d. Deep inguinal ring e. e. Transpyloric plane
A
Ans. The key is E. Transpyloric plane.
15
Q
- Tip of the 9th costal cartilage. What is the single most appropriate landmark? a. Fundus of the gallbladder b. Deep inguinal ring c. Termination of the spinal cord d. Transpyloric plane e. Vena cava opening in the diaphragm
A
Ans. The key is A. Fundus of the gallbladder.
16
Q
- A child complains of RIF pain and diarrhea. On colonoscopy, granular transmural ulcers are seen near the ileo-cecal junction. What should be the management? a. Sulfasalazine b. Paracetamol c. Ibuprofen d. Metronidazole
A
Ans. The key is A. Sulfasalazine. [Pain in RIF, diarrhea, granular transmural ulcers near the ileo-cecal junction points towards the diagnosis of Crohn’s diseas (predominantly ileo-cecal type)].
17
Q
- A 60yo woman presents with acute onset of bone and back pain following a rough journey in a car. Exam: tenderness at mid-thoracic vertebra with spasm, she feels better once she bends forward. What is the single most probable dx? a. Osteoporotic fx verterbra b. Myofacial pain c. Whiplash injury d. MI e. Pancreatitis
A
Ans. The key is B. Myofacial pain. [Myofascial pain syndrome is a chronic pain disorder. In myofascial pain syndrome, pressure on sensitive points in your muscles (trigger points) causes pain in seemingly unrelated parts of your body. This is called referred pain. Myofascial pain syndrome typically occurs after a muscle has been contracted repetitively].
18
Q
- A 70yo woman presents with recurrent episodes of parotid swelling. She complains of difficulty in talking and speaking and her eyes feel gritty on waking in the morning. What is the single most likely dx? a. C1 esterase deficiency b. Crohns disease c. Mumps d. Sarcoidosis e. Sjogrens syndrome
A
Ans. The key is E. Sjogrens syndrome. [parotid swelling, difficulty talking and speaking (due to dryness or less salive), eyes feeling gritty on waking in the morning due to dryness of eye are suggestive of Sjogrens syndrome].
19
Q
- A 39yo woman has not had her period for 10months. She feels well but is anxious as her mother had an early menopause. Choose the single most appropriate initial inv? a. Serum estradiol conc. b. Serum FSH/LH c. Serum progesterone conc. d. None e. Transvaginal US
A
Ans. The key is B. Serum FSH/LH [here serum oestrogen is also important as i) low oestrogen + low FSH + low LH suggest hypothalamic amenorrhoea and i) low oestrogen + high FSH + high LH suggest premature ovarian failure! So the main determinant is serum FSH/LH. Likely cause here is premature ovarian failure].
20
Q
- A 50yo man with DM suddenly develops persistent crushing central chest pain radiating to the neck. What is the single most appropriate dx? a. Angina b. Costochondritis (tietz’s disease) c. Dissecting aneurysm d. MI e. Pulmonary embolism
A
Ans. The key is C. Dissecting aortic aneurism. Probably wrong key. Correct key should be D. MI. [The features described is insufficient and can be seen in both aortic dissection and MI. However dissection pain is described as tearing and crushing pain is often used for mi pain. Both dissection and mi can have pain radiation to neck. History of diabetes goes with mi as it is a recognized risk facto
21
Q
521 A 22yo man has rushed into the ED asking for help. He describes recurrent episodes of fearfulness, palpitations, faintness, hyperventilation, dryness of the mouth with peri-oral tingling and cramping of the hands. His symptoms last 5-10 mins and have worsened since their onset 3months ago. He is worried he may be having a heart attack. An ECG shows sinus tachycardia. What is the single most ap
A
Ans. The key is C. Rebreathing into paper bag. [Patient has anxiety disorder (panic) which causes hyperventilation and CO2 washout leading to respiratory alkalosis. Symptoms will improve by rebreathing into paper bag as it will cause gradual increase of CO2 in paper bag and decrease the severity of respiratory alkalosis].
22
Q
- An 8yo boy has longstanding asthma. He has admitted with a severe episode and is tired and drowsy. He has not improved on oxygen, inhaled B2 agonist and IV hydrocortisone. CXR shows bilateral hyperinflation. He is too breathless to use a peakflow meter and is O2 sat <90%. What is the single most appropriate inv? a. CBG b. CXR c. CT chest d. Pulse oximetry e. Spirometry
A
Ans. The key is A. CBG. [It will point towards acidosis and indicate whether assisted ventilation is needed or not].
23
Q
- A man was operated for colorectal ca. His pain is relieved with morphine 60mg bd PO but now he can’t swallow medications. What will be the next regimen of analgesic administration? a. Oxycodone b. Fentanyl patch c. Morphine 60mg IV/d d. Morphine 240mg IV/d
A
Ans. The key is B. Fentanyl patch. [Here S/C morphine 1/2 the dose of oral can be given (not present in option) or I/V morphine 1/3rd the oral dose can be given. Here I/V doses are not appropriate so we should go for B. Fentanyl patch as required morphine dose is known].
24
Q
- Just above the mid-inguinal point. What is the single most appropriate landmark? a. Femoral artery pulse felt b. Mcburney’s point c. Stellate ganglion d. Deep inguinal ring e. Transpyloric plane
A
Ans. The key is D. Deep inguinal ring.
25
525. 5th ICS in the ant axillary line. What is the single most appropriate landmark? a. Apex beat b. Chest drain insertion c. Stellate ganglion d. Transpyloric plane e. Vena cava opening into the diaphragm
Ans. B. Chest drain insertion.
26
526. A 34yo man with MS has taken an OD of 100 tablets of paracetamol with intent to end his life. He has been brought to the ED for tx but is refusing all intervention. a. Assessment b. Evaluate pt’s capacity to refuse tx c. Establish if pt has a prv mental illness
Ans. The key is B. Evaluate patients capacity to refuse treatment.
27
527. A 23yo woman with painless vaginal bleeding at 36wks pregnancy otherwise seems to be normal. What should be done next step? a. Vaginal US b. Abdominal US c. Vaginal exam d. Reassurance
Ans. The key is B. Abdominal US. This is a wrong key. The correct key is A. Vaginal US.[Painless vaginal bleeding at 36 weeks indicates the diagnosis of placenta previa, which can be better evaluated by vaginal US].
28
528. A 29yo lady admitted with hx of repeated UTI now developed hematuria with loin pain. What is the most probable dx? a. Acute pyelonephritis b. Chronic pyelonephritis c. UTI d. Bladder stone
Ans. The key is A. Acute pyelonephritis. [In a patient having hematuria and loin pain with history of repeated UTI suggest acute pyelonephritis].
29
529. A 45yo chronic smoker attends the OPD with complaints of persistent cough and copious amount of purulent sputum. He had hx of measles in the past. Exam: finger clubbing and inspiratory crepitations on auscultation. What is the single most likely dx/ a. Interstitial lung disease b. Bronchiectasis c. Asthma d. COPD e. Sarcoidosis
Ans. The key is B. Bronchiectasis. [Persistent cough with copious purulent sputum and finger clubbing points towards the diagnosis of bronchiectasis. Severe lung infections such as tuberculosis (TB),whooping cough, pneumonia or measles can damage the airways at the time of infection. Bronchiectasis may then develop (WHO)].
30
530. A 68yo man has had malaise for 5 days and fever for 2 days. He has cough and there is dullness to percussion at the left lung base. What is the single most appropriate inv? a. Bronchoscopy b. CXR c. CT d. MRI e. V/Q scan
Ans. The key is B. CXR. [Given presentation is suggestive of pneumonia for which investigation of choice is CXR].
31
531. A 5yo child was admitted with hx of feeling tired and lethargic all the time, bleeding gums and sore throat since the last 3months. Exam: hepatosplenomegaly. What is the most probable dx? a. ALL b. AML c. CML d. CLL e. Lymphoma
Ans. The key is A. ALL. [Commonest leukemia in children is ALL. Bleeding gums (low platelet), feeling tired and lethargic, sorethroat, hepatosplenomegally all are well known features of ALL].
32
532. A 65yo man presents with back pain. Exam: splenomegaly and anemia. Blood: WBC=22,Hgb=10.9, Plt=100, ESR=25. He has been found to have Philadelphia chromosome. What is the single most likely dx? a. ALL b. AML c. CML d. CLL e. Lymphoma
Ans. The key is C. CML. [anaemia, raised WBC count, low platelet (platelet may be variable) are known features of CML, splenomegaly (particularly if massive) is very suggestive of CML and Philadelphia chromosome is characteristic of CML].
33
533. A 24yo woman has 8wk amenorrhea, right sided pelvic pain and vaginal bleeding. She is apyrexial. Peritonism is elicited in the RIF. Vaginal exam reveals right sided cervical excitation. What is the most probable dx? a. Ectopic pregnancy b. Salpingitis c. Endometriosis d. Ovarian torsion e. Ovarian tumor
Ans. The key is A. [Salpingitis, Endometriosis, overian torsions do not associated with amenorrhoea. In ovarian tumour three main features are i) increased abdominal size and persistent bloating (not bloating that comes and goes) ii) persistent pelvic and abdominal pain iii) difficulty eating and feeling full quickly,or feeling nauseous. Patient with pelvic pain and vaginal bleeding, peritonism an
34
534. A 64 yo woman has been treated for breast cancer with tamoxifen. What other drug should be added to her tx regime? a. Bisphosphonates b. Calcium c. Vit D d. Calcitonin e. Phosphate binders
Ans. The key is A. Bisphosphonates. [ bisohosphonates reduce the risk of bone metastasis in cancers and is normally taken as adjuvant therapy in many types of tumours including breast cancer. Plus it prevents bone resorption].
35
535. A 26yo woman with regular menses and her 28yo partner comes to the GP surgery complaining of primary infertility for 2yrs. What would be the single best investigation to see whether she is ovulating or not? a. Basal body temp estimation b. Cervical smear c. Day2 LH and FSH d. Day21 progesterone e. Endometrial biopsy
Ans. The key is D. Day 21 progesterone. [Mid-luteal progesterone level to assess ovulation: If low, it may need repeating, as ovulation does not occur every month. The blood test is taken seven days before the anticipated period, that is on day 21 of a 28-day cycle. However, this day will need to be adjusted for different lengths of cycle. Ref: patient.co.uk].
36
536. A 10yo boy who takes regular high dose inhaled steroids for his longstanding asthma has been advised to use bronchodilators to control his acute attacks. His parents are unsure when should he use his bronchodilator. What is the single most appropriate inv? a. CXR b. None c. Peak flow rate diary d. Pulse oximetry
Ans. The key is C. Peak flow rate diary. [Peak flow rate diary shows diurnal variation. This diary shows when the bronchoconstriction remains worse and guides to use bronchodilators prior to that times].
37
537. A woman presented with blurred vision and intermittent clumsiness for 3m. Reflexes are brisk in her arm and optic disc is pale. What is the single most appropriate test to confirm dx? a. CSF analysis b. CT c. MRI d. EEG e. EMG
Ans. The key is C. MRI. [Features are suggestive of multiple sclerosis. Investigation of choice is gadolinium enhanced MRI].
38
538. A 63yo man presents after having a seizure. Exam: alert, orientated, inattention on the left side and hyperreflexia of the arm. What is the most probable dx? a. Cerebral tumor b. Pituitary adenoma c. Cerebellar abscess d. Huntingtons chorea e. Parkinsonism
Ans. The key is A. Cerebral tumour.
39
539. A 40yo man with a 25y hx of smoking presents with progressive hoarseness of voice, difficulty swallowing and episodes of hemoptysis. He mentioned that he used to be a regular cannabis user. What is the single most likely dx? a. Nasopharyngeal cancer b. Pharyngeal carcinoma c. Sinus squamous cell carcinoma d. Squamous cell laryngeal cancer e. Hypopharyngeal tumor
Ans. The key is D. Squamous cell laryngeal cancer. Chronic hoarseness is the most common early symptom. Other symptoms of laryngeal cancer include pain, dysphagia, a lump in the neck, sore throat, earache or a persistent cough. Patients may also describe breathlessness, aspiration, haemoptysis, fatigue and weakness, or weight loss.
40
540. A 30yo lady complains of intermittent diarrhea, chronic abdominal and pelvic pain and tenesmus. Sometimes she notices blood in her stool. Select the most likely cause leading to her symptoms? a. Inflammatory bowel disease b. Diverticulosis c. Irritable bowel disease d. Adenomyosis e. UTI
Ans. The key is A. Inflammatory bowel disease. [Tenesmus excludes diverticulitis, occasional blood in stool excludes irritable bowel disease. Features are not consistent with adenomyosis or UTI but suggestive of inflammatory bowel disease].
41
541. A 50yo lady with weak limbs when examined was found to have burn marks on finger tips, wasted and weak hands with diminished felexes. She also has weak spastic legs and dissociated sensory loss. What is the dx? a. MS b. Syringomyelia c. MND d. Guillian-barre e. Freidriech’s ataxia
Ans. The key is B. Syringomyelia. [weak limbs, burn mark on fingertip (as pain and temperature sensation are lost due to spinothalamic tract damage), wasted and weak hands with diminished reflexes, weak spastic legs with dissociated sensory loss are features suggestive of Syringomyelia]. Common features are given below: Sensory features: 1) loss of pain and temperature sensation 2) sensory loss is
42
542. A 23yo woman is being followed up 6wks after a surgical procedure to evacuate the uterus following a miscarriage. The histology has shown changes consistent with a hydatidiform mole. What is the single most appropriate inv in this case? a. Abdominal US b. Maternal karyotype c. Paternal blood group d. Serum B-HCG e. Transvaginal US
Ans. The key is D. Serum β-HCG. [When you are first diagnosed with a hydatidiform mole, your hCG level will be raised. When the hydatidiform mole is treated (removed), the hCG level will usually return to a normal, non-pregnant amount and should remain so. If you develop GTN, the hCG level can remain elevated or continue to rise further. So, this blood test is a good way to check for the possible
43
543. A 67yo man with hx of weight loss complains of hoarseness of voice. CT reveals opacity in the right upper mediastinum. He denied any hx of difficulty breathing. What is the single most appropriate inv? a. Laryngoscopy b. Bronchoscopy c. LN biopsy d. Bronchoalevolar lavage e. Barium swallow
Ans. The key is C. Lymph node biopsy. [There is weight loss and there is an opacity in right upper mediastinum. May indicate enlarged lymph node or lymphoma causing pressure on right recurrent laryngeal nerve resulting in horseness. As CT didn't reveal any bronchial lesion and no breathing difficulty it is unlikely to be a bronchial pathology. So CT guided lymph node biopsy can reveal the diagnosi
44
544. A 52yo man whose voice became hoarse following thyroid surgery 1 wk ago shows no improvement. Which anatomical site is most likely affected? a. Bilateral recurrent laryngeal nerve b. Unilateral recurrent laryngeal nerve c. Unilateral external laryngeal nerve d. Bilateral external laryngeal nerve e. Vocal cords
Ans. The key is B. Unilateral recurrent laryngeal nerve.
45
545. A 73yo male presents with a 12m hx of falls. His relatives have also noticed rather strange behavior of late and more recently he has had episodes of enuresis. Exam: disorientation to time and place, broad-based, clumsy gait. What is the most probable dx? a. Dementia b. Pituitary adenoma c. CVD d. Syringomyelia e. Normal pressure hydrocephalus
Ans. The key is E. Normal pressure hydrocephalus. [hx of falls and broad based clumsy gait (balance and gait disturbance), strange behavior and disorientation to time and place (due to dementia), episodes of enuresis (urinary incontinence) points towards normal pressure hydrocephalus. Classic triad of normal pressure hydrocephalus: i) gait abnormality ii) urinary incontinence and iii) dementia].
46
546. A 75yo nursing home resident complains of headache, confusion and impaired vision for 4days. She has multiple bruises on her head. What is the most likely cause of confusion in this pt/ a. Alcohol intoxication b. Infection c. Subdural hematoma d. Hypoglycemia e. Hyponatremia
Ans. The key is C. Subdural hematoma. [elderly patient with multiple bruises on her head suggest head injury which can lead to subdural hematoma. Headache, confusion and impaired vision for 4 days indicate subacute subdural hematoma (three pahges i) acute ii) subacute 3 – 7 days and iii) chronic 2 – 3weeks]. Symptoms of subdural hematoma: a headache that keeps getting worse feeling and being s
47
547. A 50yo woman returned by air to the UK from Australia. 3days later she presented with sharp chest pain and breathlessness. Her CXR and ECG are normal. What is the single most appropriate inv? a. Bronchoscopy b. Cardiac enzymes c. CT d. MRI e. Pulse oximetry f. V/Q scan g. CTPA
Ans. The key is G. CTPA. [Prolonged plane journey is a recognized risk factor for thromboembolism and hence pulmonary embolism also! Sharp chest pain and breathlessness after 3 days of plane journey is highly suggestive of pulmonary embolism the investigation of choice for which is CTPA].
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548. A tall thin young man has sudden pain in the chest and becomes breathless while crying. What is the single most appropriate inv? a. Cardiac enzymes b. CXR c. CT d. ECG e. V/Q scan
Ans. The key is B. CXR. [tall thin young men are particularly prone to develop pneumothorax. Sudden pain and breathlessness in this young man are highly suggestive of pneumothorax. So investigation of choice is CXR].
49
549. A 21yo woman has had several sudden onset episodes of palpitations, sweating, nausea and overwhelming fear. On one occasion she was woken from sleep and feared she was going insane. There is no prv psychiatric disorder. What is the most probable dx? a. Pheochromocytoma b. Panic disorder c. GAD d. Phobia e. Acute stress disorder
Ans. The key is B. Panic disorder. [here closest d/d to panic disorder is pheochromocytoma. But in pheochromocytoma the most important feature is resistant hypertension and other important features are headache and abdominal pain which all are absent here. Moreover overwhelming fear is more suggestive of panic disorder. Hence here the diagnosis is B. Panic disorder].
50
550. A 55yo woman with a persistent cough and hx of smoking develops left sided chest pain exacerbated by deep breathing with fever and localized crackles. What is the single most appropriate dx? a. Dissecting aneurysm b. Pericarditis c. Pneumonia d. Pneumothorax e. Pulmonary embolism
Ans. The key is C. Pneumonia. [chest pain exacerbated with deep breathing, fever and localized crackles are highly suggestive of pneumonia].
51
551. A 40yo woman complains of dysphagia for both solids and liquids. She sometimes suffers from severe retrosternal chest pain. Barium swallow reveals a dilated esophagus which tapers to a fine distal end. What is the best management strategy? a. Reassurance b. Antispasmodics c. Dilatation of the LES d. Endoscopic diverticulectomy e. Barium swallow
Ans. The key is C. Dilatation of LES. [Dysphagia for both solids and liquids suggest neuromuscular dysphagia while dysphagia only for solid suggests mechanical obstruction. Here features are consistent with achalasia for which lower oesophageal sphincter dilation (balloon dilatation) is a treatment modality].
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552. A 38yo female G4 at 32wks of pregnancy presented with thick white marks on the inside of her mouth for 3wks. Her mouth including her tongue appeared inflamed on examination. She smokes 20 cigarettes/day despite advice to quit. She attends her ANC regularly. What is the most probable dx? a. Lichen planus b. Aphthous ulcer c. Smoking d. Candidiasis e. Leukoplakia
Ans. The key is D. Candidiasis. [lichen planus may have lace like appearance and not thick white mark. Aphthous ulcer has yellowish floor and surrounded by erythematous halo. Smoking may cause tongue coating but not like thick white mark on the inside of mouth. Leukoplakia is with raised edges/Bright white patches and sharply defined and cannot be rubbed out like candida patch; here also inflamed
53
553. A 69yo woman has had a stroke. Her left upper and lower limbs are paralyzed and she is having difficulty in speaking. Which anatomical site is most likely affected? a. Hippocampus b. Cerebellum c. Internal capsule d. Thalamus e. Brain stem
Ans. The key is C. internal capsule. [Hippocampal lesion causes mainly memory impairment. Cerebellum has its diagnostic features that is not present here. Thalamic lesion can lead to impairment of arousal, orientation, learning and memory, facial paresis, language deficit, hemispatial neglect, hemisensory loss, hemiparesis, hemiataxia and visual field defect. Brainstem stroke causes impaired consc
54
554. A 72yo man brought to the ED with onset of paraplegia following a trivial fall. He was treated for prostatic malignancy in the past. What is the single most probable dx? a. Paget’s disease b. Osteoporotic fx of vertebre c. Secondary d. Multiple myeloma e. Spondylosis
Ans. The key is C. Secondary. [In male osteoporotic fracture is less common. As patient had prostatic malignancy pathological fracture from secondary metastasis to bone (here vertebra leading to paraplegia) is more common].
55
555. A 14yo girl has developed an itchy, scaly patch on her scalp. She had a similar patch that cleared spontaneously 2yrs ago. Her aunt has a similar undiagnosed rash on the extensor aspects of her elbows and knees. What is the single most likely dx? a. Eczema b. Fungal infection c. Impetigo d. Lichen planus e. Psoriasis
Ans. The key is E. Psoriasis. [itchy, scaly patch on scalp are classic presentation of scalp psoriasis. Her aunts presentations (similar rash on extensor aspects of her elbow and knees) are suggestive of psoriasis. It is thought to be an immunological disease].
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556. A pt after transurethral prostatic biopsy. What electrolyte imbalance can he develop? a. Hyperkalemia b. Hyponatremia c. Hypocalcemia d. Hypernatremia e. Hypercalcemia
Ans. The key is B. Hyponatremia. [Use of fluid for bladder irrigation may lead to hyponatremia].
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557. A 28yo woman has been admitted at 38wks gestation. Her BP=190/120mmHg and proteinuria +++. Immediately following admission she has a grand-mal seizure. What is the single most appropriate initial management? a. Diazepam IV b. Fetal CTG c. Hydralazine IV d. Immediate delivery e. Magnesium sulphate IV
Ans. The key is E. Magnesium sulphate IV. [patient has established eclampsia. So she should be treated with Magnesium sulphate as with 4g magnesium sulfate in 100mL 0.9% saline IVI over 5min + maintenance IVI of 1g/h for 24h. Beware depressed respiration. If recurrent seizure give 2g IVI magnesium sulfate over 5 min. Check tendon reflexes and respiratory rate every 15min. Stop magnesium sulfate IV
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558. A 27yo woman had pre-eclampsia and was delivered by C-section. She is now complaining of RUQ pain different from wound pain. What inv will you do immediately? a. Coagulation profile b. LFT c. Liver US d. MRCP e. None
Ans. The key is B. LFT. [In a post ceasarian patient having pre-eclampsia RUQ pain different from wound pain points towards the diagnosis of HELLP syndrome. So immediate investigation to be done is LFT]. [OHCS, 9th edition, page 26].
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559. A 10yo girl has been referred for assessment of hearing as she is finding difficulty in hearing her teacher in the class. Her hearing tests show: BC normal, symmetrical AC threshold reduced bilaterally, weber test shows no lateralization. What is the single most likely dx? a. Chronic perforation of tympanic membrane b. Chronic secretory OM with effusion c. Congenital sensorineural deficit d.
Ans. The key is B. Chronic secretory OM with effusion.
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560. A thin 18yo girl has bilateral parotid swelling with thickened calluses on the dorsum of her hand.What is the single most likely dx? a. Bulimia nervosa b. C1 esterase deficiency c. Crohn’s disease d. Mumps e. Sarcoidosis
Ans. The key is A. Bulimia nervosa. [18 year thin girl, bilateral parotid swelling and thickened calluses on the knuckles from self induced vomiting are suggestive of Bulimia nervosa. Bulimia often is associated with bilaterak parotid swelling (parotid hypertrophy)].
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561. A 48yo presents with severe chest pain since the last 40mins. In the ED he is given oxygen, GTN, morphine. ECG=ST elevation. Bloods=increased troponin levels. What is the next step of management? a. Beta blockers b. Percutaneous angiography c. Anticoagulant & heparin d. Clopidogrel e. Aspirin
Ans. The key is B. Percutaneous angiography. This is a wrong key! Correct key is E. Aspirin. [In any case of IHD, most important initial management is aspirin].
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562. A 34yo female presents with a foul smelling discharge. What set of organisms are we looking for to be treated here? a. Chlamydia, gonorrhea b. Chlamydia, gardenella c. Chlamydia, gonorrhea, gardenella d. Gonorrhea, gardenella e. Gardenella only
Ans. The key is E. Gardenella only. [Here foul smelling discharge is caused by gardenella. So most acceptable answer is E. Gardenella only].
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563. A 6wk formula fed baby boy is found at the child health surveillance to be deeply jaundiced. His weight gain is poor and his stools are pale. What is the most likely dx? a. Galactosemia b. Biliary atresia c. G6PD deficiency d. Rh incompatibility e. Congenital viral infection
Ans. The key is B. Biliary atresia. [Deep jaundice at 6th week with pale stools suggests obstructive jaundice. So most likely diagnosis here is biliary atresia].
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564. A 45yo man with colon cancer now develops increased thirst, increased frequency in urination and weight loss. His fasting blood glucose=9mmol/L. what is the most appropriate management? a. Oral hypoglycemic b. Insulin long acting c. Short acting insulin before meal d. IV insulin e. Subcutaneous insulin
Ans. The key is A. Oral hypoglycemic. [Increased thirst and increased frequency in urination along with weight loss is suggestive of DM supported by fasting blood glucose of 9 mmol/L. At the age of 45 most likely type of diabetes is NIDDM or type 2 DM which is treated by oral hypoglycemic agents].
65
565. A 34yo man from Zimbabwe is admitted with abdominal pain to the ED. An AXR reveals bladder calcification. What is the most likely cause? a. Schistosoma mansoni b. Sarcoidosis c. Leishmaniasis d. TB e. Schistosoma hematobium
Ans. The key is E. Schistosoma hematobium. [Bladder involvement is caused by Schistosoma hematobium while Schistosoma mansoni causes intestinal disease].
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566. A 6yo came with full thickness burn. He is crying continuously. What is the next step of management? a. Refer to burn unit b. IV fluid stat c. Antibiotic d. Analgesia e. Dressing
Ans. The key is analgesia. This is a wrong key. Correct key should be B. IV fluid stat. [Here already mentioned full thickness burn which is painless. Child often cry from anxiety for hypoxaemia and hypovolaemia rather than pain. The patient then responds better to oxygen or increased fluid administration rather than to narcotic analgesics. Ref: patient.info].
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567. A 78yo nursing home resident is revived due to the development of an intensely itchy rash. Exam: white linear lesions are seen on the wrists and elbows and red papules are present on the penis. What is the most appropriate management? a. Topical permethrin b. Referral to GUM clinic c. Topical betnovate d. Topical ketoconazole e. Topical selenium sulphidehyosine
Ans. The key is A. Topical permathrine. [The intensely itchy rash, scratch marks and burrows on wrist and elbow red papules on penis are suggestive of scabies. Topical permethrine are used to treat it].
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568. A 4yo has earache and fever. Has taken paracetamol several times. Now it’s noticed that he increases the TV volume. His preschool hearing test shows symmetric loss of 40db. What is the most likely dx? a. OM with effusion b. Otitis externa c. Cholesteatoma d. CSOM e. Tonsillitis
Ans. The key is A. OM with effusion. This is a wrong key. Correct key is B. Otitis externa. [The childs preschool hearing loss and increasing the tv volume suggests that he has OM with effusion but present earache and fever points towards the diagnosis of otitis externa].
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569. A pt presents with gradual onset of headache, neck stiffness, photophobia and fluctuating LOC. CSF shows lymphocytosis but no organism on gram stain. CT brain is normal. What is the single most likely dx? a. Hairy leukoplakia b. TB c. CMV infection d. Candida infection e. Cryptococcal infection
Ans. The key is B. TB. [Fungal meningitis can also present like this but it is much more rare. Moreover negative gram stain excludes fungal cause here. Hence TB meningitis is more acceptable answer].
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570. An 18m boy has been brought to the ED because he has been refusing to move his left arm and crying more than usual for the past 24h. He has recently been looked after by his mother’s new bf while she attended college. Assessment shows multiple bruises and a fx of the left humerus which is put in plaster. What is the single most appropriate next step? a. Admit under care of pediatrician b. Dis
Ans. The key is A. Admit under care of pediatrician. [This is NAI. So the child cannot be handover to the risk again and should be admitted to protect him from further injury done by mothers boyfriend while serial x-rays and relevant investigations done and asked for child protection unit’s help].
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571. A 74yo female presents with headache and neck stiffness to the ED. Following a LP the pt was started on IV ceftriaxone. CSF culture = listeria monocytogenes. What is the appropriate tx? a. Add IV amoxicillin b. Change to IV amoxicillin + gentamicin c. Add IV ciprofloxacin d. Add IV co-amoxiclav e. Continue IV ceftriaxone as mono-therapy
Ans. The key is B. Change to IV amoxicillin + gentamycin. [From the given option B is the most acceptable. However Ampicillin + gentamycin is the drug combination of choice].
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572. A pt presents with fever, dry cough and breathlessness. He is tachypneic but chest is clear. Oxygen saturation is normal at rest but drops on exercise. What is the single most likely dx? a. CMV infection b. Candida infection c. Pneumocystis carinii infection d. Cryptococcal infection e. Toxoplasma abscess
Ans. The key is C. Pneumocystis carinii infection. [Fever, dry cough, breathlessness, tachypnoea with clear chest is seen in pneumocystis carinii pneumonia. Normal oxygen saturation which drops on exercise is characteristic of pneumocystis carinii pneumonia].
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573. A 14yo boy fell and hit his head in the playground school. He didn’t lose consciousness. He has swelling and tenderness of the right cheek with a subconjuctival hemorrhage on his right eye. What is the most appropriate initial inv? a. CT brain b. EEG c. MRI d. Skull XR e. Facial XR
Ans. The key is E. Facial X-ray. This is a wrong key Correct key is A. CT brain. [With the risk of basal fracture we should do CT scan to diagnose this. In present case CT is better than MRI. Skull X-rays are no longer recommended as first line investigation].
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574. A 15m child is due for his MMR vaccine. There is a fam hx of egg allergy. He is febrile with acute OM. What is the single most appropriate action? a. Defer immunization for 2wks b. Don’t give vaccine c. Give half dose of vaccine d. Give paracetamol with future doses of the same vaccine e. Proceed with standard immunization schedule
Ans. The key is A. Defer immunization for 2 wks.
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575. A 33yo lady with Hodgkin’s lymphoma presents with temp=40C, left sided abdominal pain and lymphadenitis. Blood was taken for test. What will you do next? a. Wait for blood test b. Start broad spectrum IV antibiotics c. Oral antibiotics d. CBC e. Monitor pyrexia
Ans. The key is B. Start broad spectrum IV antibiotics. [The patient is immunocompromized with signs of infection (temp=40◦C, left sided abdominal pain and lymphadenitis) broad spectrum IV antibiotic should be started empirically while waiting for blood reports].
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576. A 40yo man with marked weight loss over the preceding 6m has bilateral white, vertically corrugated lesion on the lateral surfaces of the tongue. What is the single most likely dx? a. C1 esterase deficiency b. Crohns disease c. HIV disease d. Sarcoidosis e. Sjogren’s syndrome
Ans. The key is C. HIV disease. [The lesion described is leukoplakia which is likely association of HIV disease].
77
577. A 3m baby was miserable and cried for 2h following his 1st routine immunization with DTP, HiB and meningitis. What is the single most appropriate action? a. Defer immunization for 2wks b. Don’t give vaccine c. Give half dose of vaccine d. Give paracetamol with future doses of the same vaccine e. Proceed with standard immunization schedule
Ans. The key is E. Proceed with standard immunization schedule.
78
578. A 65yo man with HTN develops gingival hyperplasia. What is the single most likely dx? a. ACEi b. Beta blockers c. Crohns disease d. Nifedipine e. Sarcoidosis
Ans. The key is D. Nifedipine. [Gingival hyperplasia is a recognized side effect of calcium channel blockers].
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579. A 65yo woman is undergoing coronary angiography. What measure will protect her kidneys from contrast? a. Furosemide b. Dextrose c. 0.45% saline d. 0.9% saline
Ans. The key is D. 0.9% saline.
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580. An 83yo woman who is a resident in a nursing home is admitted to hospital with a 4d hx of diarrhea. She has had no weight loss or change in appetite. She has been on analgesics for 3wks for her back pain. She is in obvious discomfort. On rectal exam: fecal impaction. What is the single most appropriate immediate management? a. Codeine phosphate for pain relief b. High fiber diet c. Oral laxat
Ans. The key is D. Phosphate enema. [In feacal impaction oral laxative is not the choice but phosphateenema is the best option here].
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581. A 26yo woman being treated for a carcinoma of the bronchus with steroids presents with vomiting, abdominal pain and sudden falls in the morning. What is the most specific cause for her symptoms? a. Steroid side effects b. Postural hypotension c. Adrenal insufficiency d. Conn’s disease e. Cushing’s disease
Ans. The key is C. Adrenal insufficiency. [Patients on steroid develop suppression of hypothalamic pituitary adrenal axis and frequently may lead to adrenal insufficiency (here vomiting, abdominal pain and sudden falls in the morning secondary to postural hypotension on getting up from bed points towards the diagnosis of adrenal insufficiency)].
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582. A 78yo woman presents with unilateral headache and pain on chewing. ESR=70mm/hr. She is on oral steroids. What is the appropriate additional tx? a. Bisphosphonates b. HRT c. ACEi d. IFN e. IV steroids
Ans. The key is A. Bisphosphonates. [The elderly lady with giant cell arteritis is getting high dose steroid which can lead to demineralization and osteopenia or osteoporosis. So to prevent this bisphosphonates are given].
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583. A 30yo man is suffering from fever, rash and photophobia. Doctors are suspecting he is suffering from meningitis. Which is the best medication for this condition? a. Ampicilling b. Cefotaxime c. Tetracycline d. Acyclovir e. Dexamethasone
Ans. The key is B. Cefotaxime. [The patient is getting probable meningococcal meningitis. Before confirming the diagnosis suggested treatment is, where the organism is unknown: • <55yrs: cefotaxime 2g/6h slow IV. • >55yrs: cefotaxime as above + ampicillin 2g IV/4h (for Listeria). So in given case Cefotaxime is the option. Ref: OHCM, 9th edition, page 832].
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584b. A 15yo girl was admitted with anemia, chest infection and thrombocytopenia. She was treated and her symptoms had regressed. She was brought again with fever and the same symptoms a few days later. She also seems to have features of meningitis. What is the most likely dx? a. AML b. ALL c. Aplastic anemia d. CML e. CLL
Ans. The key is B. ALL. [The age supports the diagnosis of ALL along with the given picture. Same picture can happen in aplastic anaemia but there is not a single factor mentioned in favour of it. So ALL can be taken as best option in the given scenario].
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585. A pt was admitted to the ED after a head injury. When examined on arrival his GCS=15 and then at night his GCS deteriorated to 12. What investigation should be done? a. CT head b. XR skull c. IV mannitol d. Drill a burr hole e. Shift to OR
Ans. The key is A. CT head. [Initial GCS 15 followed by later GCS 12 are suggestive of intracranial haemorrhage. So the best investigation to be done is CT head].
86
586. A 4yo boy who prv had normal hearing, has a mild earache relieved by paracetamol. He has been noticed to turn up the vol on the TV. He has bilateral dull tympanic membranes. His preschool hearing test shows symmetrical loss of 40dB. What is the single most likely dx? a. Acute otitis externa b. Acute OM c. Ear wax d. Foreign body e. OM with effusion
Ans. The key is OM with effusion.
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587. An 18yo man presents to his GP with thirst and polyuria. Some 6m ago he had a significant head injury as the result of a RTA. He is referred to the local endocrine clinic. Which of the following results would be the most useful in confirming the dx of diabetes insipidus after a water deprivation test (without additional desmopressin)? a. Plasma sodium of 126mmol/l b. Plasma sodium of 150mmol/
Ans. The key is E. Plasma osmolality of 335 mosmol/kg and urine osmolality of 200 mosmol/kg. [In DI plasma osmolality will be high due to excess fluid loss with urine and urine osmolality will be low due to polyuria. Hence E. is the best option here(normal plasma osmolality 275-295 mosmol/kg and normal urine osmolality is 300-900 mosmol/kg)].
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588. A 75yo man has left-sided earache and discomfort when he swallows. There is ulceration at the back of his tongue and he has a palpable non-tender cervical mass. What is the single most likely dx? a. Acute mastoiditis b. Dental abscess c. Herpes zoster infection d. Oropharyngeal malignancy e. Tonsillitis
Ans. The key is D. Oropharyngeal malignancy. [Pain ear and discomfort during swallowing, ulceration at the back of the tongue and palpable non tender cervical lymphnode is suggestive of oropharyngeal malignancy. Acute mastoiditis and tonsillitis will not cause tongue ulcer. Similarly dental abscess will not cause tongue ulcer. In herpes zoster pain and vesicle will be in the affected nerve distrib
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589. A 42yo man has been tired and sleepy for the last few weeks in the morning. His work has started getting affected as he feels sleepy in the meetings. His BMI=36. What is the single most likely dx? a. Idiopathic hypersomnia b. Narcolepsy c. Chest hyperventilation syndrome d. OSAS e. REM-related sleep disorder
Ans. The key is D. OSAS. [Day time somnolence and obesity (high BMI of 36) points the diagnosis of OSAS].
90
590. A 35yo pregnant woman has been having tingling and numbness of her thumb, index and middle fingers for a while. She has been treated with local steroids but it hasn’t helped her much and now she has planned to undergo a surgical procedure. Which of the following structures will be incised? a. Flexor digitorum profundus b. Transverse carpal ligament c. Palmar aponeurosis d. Extensor retinaculu
Ans. The key is B. Transverse carpal ligament. [This is a case of carpal tunnel syndrome. So transverse carpal ligament is the structure which will be incised].
91
591. A 58yo pt presents with altered bowel habits and bleeding per rectum. Exam and sigmoidoscopy showed an ulcer. What is the single most likely dx? a. Colorectal carcinoma b. Celiac disease c. Crohns disease d. UC e. IBS
Ans. The key is A. Colorectal carcinoma. [Age, altered bowel habits, bleeding per rectum and isolated ulcer on sigmoidoscopy suggest colorectal cancer].
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592. A mother is concerned that her 18m son has a vocabulary of ten words but can’t form a sentence. What is the best management strategy? a. Arrange hearing test b. Assess developmental milestones c. Reassurance d. Refer to speech therapist e. MRI brain
Ans. The key is C. Reassurance. [Two words joining can be done in 2yrs and inability to form a sentence in 18 months is quite normal. So the option is reassurance].
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593. A 55yo man has weight loss, dyspnea and syncope. He smokes 20 cigarettes/day. Inv confirms squamous cell carcinoma in the left bronchus. What is the single most likely biochemical abnormality to be a/w the condition? a. Hypercalcemia b. Hyperkalemia c. Hypernatremia d. Hypocalcemia e. Hypomagnesium
Ans. The key is A. Hypercalcemia. [Hypercalcemia is common in squamous cell carcinoma].
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594. A 72yo man presents with intermittent difficulty in swallowing with regurgitation of stale food materials. Sometimes he wakes up at night with a feeling of suffocation. Choose the single most likely cause of dysphagia? a. Benign structure b. Esophageal carcinoma c. Esophageal spasm d. Pharyngeal pouch e. Systemic sclerosis
Ans. The key is D. Pharyngeal pouch. [In benign stricture, esophageal carcinoma and systemic sclerosis there is persistent dysphagia not intermittent. In oesophageal spasm there may be intermittent dysphagea but there will be no regurgitation of stale food material and no nocturnal regurgitation in recumbency. The clinical picture described well fits with pharyngeal pouch].
95
595. A 9m child is brought to the ED with an irreducible firm swelling which descended into the left groin when the child has been crying. Exam: both testicles are palpable in the scrotum. What is the most appropriate management strategy? a. Reassurance b. Emergency herniotomy c. Elective herniotomy d. Emergency herniotomy + orchidopexy e. Elective herniotomy + orchidopexy
Ans. The key is C. Elective herniotmy. [If there was features of strangulation we would go for emergency herniotomy. But as only irreducible we shall proceed to elective herniotomy].
96
596. A 37yo woman was admitted for femur fx repair after a RTA. On the 4th post-op day she became confused and starts picking on her bed sheets and complains of seeing spiders all over. What is the most likely dx? a. Delirium tremens b. Wernickes encephalopathy c. Korsakoffs psychosis d. Psychotic depression
Ans. The key is A. Delerium tremens. [withdrawal of alcohol due to hospital admission lead to delirium tremens. Warnicke’s encephalopathy has triad of i) mental confusion ii) abnormal eye movements & iii) unsteady gait. Korsakoff's syndrome cannot be diagnosed until the person has stopped drinking alcoholfor several weeks, to enable the immediate symptoms of alcohol intoxication and withdrawal to
97
597. A 36yo pt came with diarrhea, bleeding, weight loss and fistula. What is the single most likely dx? a. Celiac disease b. Crohns disease c. UC d. IBS
Ans. The key is B. Crohns disease.
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598. A 72yo woman who is taking loop diuretics is suffering from palpitations and muscle weakness. What is the electrolyte imbalance found? a. Na+ 130mmol/l, K+ 2.5mmol/l b. Na+ 130mmol/l, K+ 5.5mmol/l c. Na+ 140mmol/l, K+ 4.5mmol/l d. Na+ 150mmol/l, K+ 3.5mmol/l e. None
Ans. The key is A. Na+ 130mmol/l, K+ 2.5mmol/l. [Loop diuretic causes hypokalemia and hyponatremia].
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599. A 60yo diabetic pt on anti-diabetic medication developed diarrhea. What is the most likely cause for his diarrhea? a. Autonomic neuropathy b. Infective c. Celiac disease d. Crohns disease
Ans. The key is A. Autonomic neuropathy.
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600. Which artery runs in the anterior inter-ventricular groove? a. Acute marginal branch b. Left ant descending artery c. Septal branches d. Circumflex artery e. Right coronary artery
Ans. B. Left anterior descending artery.
