Mock 11

Question 1

40-year old man + feeling weak and tired + complains of headache + hypertensive at 210/100 + not on any medications + normal serum sodium + hypokalemia at 2.9

Most likely diagnosis?

Answer 1

PRIMARY HYPERALDOSTERONISM

Hypokalemia and hypertension = Think of primary hyperaldosteronism

Question 2

Differentiate Conn from Addison

Answer 2

Addison’s Disease = ALL DROP - drop in aldosterone, drop in sodium, drop in BP, drop in weight, drop in energy. ONLY POTASSIUM IS INCREASED

Conn’s is exact opposite of Addison - hypertension, hypernatremia (or high of normal), HYPOKALEMIA

Question 3

How do you manage Conn’s?

Answer 3

Medical: Spironolactone (aldosterone antagonists)
Surgical: definitive - adrenalectomy

Question 4

When do you think of Conn’s syndrome?

Answer 4

1. HTN + hypokalemia
2. Refractory hypertension despite more than 3 antihypertensive drugs
3. Hypertension occurring before age 40

Question 5

Lymphatic drainage: skin (scrotum, vulva, perineum)

Answer 5

Superficial inguinal LN

Question 6

Lymphatic drainage: all below umbilicus except gonad and lateral foot

Answer 6

Superficial inguinal LN

Question 7

Lymphatic drainage: testes and ovaries

Answer 7

Para-aortic LN

Question 8

Lymphatic drainage: lateral foot

Answer 8

Popliteal LN (then to the SILN)

Question 9

Lymphatic drainage: lateral foot

Answer 9

Popliteal LN (then to the SILN)

Question 10

Lymphatic drainage: deep lymphatic of glans and clitoris

Answer 10

External iliac LN

Question 11

Superficial inguinal LN drains all structures below the umbilicus except for these structures:

Answer 11

Gonads (ovaries and testes) - para-aortic LN
Lateral foot - popliteal lymph nodes (then later drains into the inguinal LN)
*Deep lymphatics of glans and clitoris - external iliac LN

Question 12

What is (Arya) Fregoli delusions?

Answer 12

Delusion of doubles - various persons are indeed one person in disguise or changes in apperance

Question 13

What is the difference between Fregoli and Capgras?

Answer 13

Fregoli (as in Arya Fregoli) is the delusion wherein a person is just in disguise (think of Arya Stark in disguise as other persons) while Capgras is similar identical to the person YOU KNOW but he is not the real person.

Question 14

What is the difference between Fregoli and Capgras?

Answer 14

Fregoli (as in Arya Fregoli) is the delusion wherein a person is just in disguise (think of Arya Stark in disguise as other persons) while Capgras is similar identical to the person YOU KNOW but he is not the real person.

Question 15

Ganser syndrome?

Answer 15

Prison psychosis in an attempt to gain leniency from prison

Question 16

Breastfeeding advice for mother with mastitis

Answer 16

Continue breastfeeding

Question 17

Breastfeeding advice for mother with breast abscess

Answer 17

Continue

Question 18

Breastfeeding advice for mother with nipple candidiasis

Answer 18

Continue breastfeeding

Question 19

Breastfeeding advice for mother with maternal HIV

Answer 19

Avoid breastfeeding

Question 20

Breastfeeding advice for mother with maternal hepatitis B

Answer 20

Continue (Breastfeeding safe but make sure baby has received HBV prophylaxis)

Question 21

Management of recurrent UTI with identified trigger

Answer 21

Single-dose antibiotic prophylaxis

Question 22

Management of recurrent UTI with no identifiable triggers

Answer 22

Low-dose antibiotic prophylaxis daily (TMP, Nitrofurantoin or Cefalexin)

Question 23

Management of recurrent URI in post-menopausal women

Answer 23

Oestrogen replacement

Question 24

Management of recurrent UTI with residual urine present

Answer 24

Optimize bladder emptying by intermittent catheterization

Question 25

Breastfeeding advice for mother with maternal hepatitis C

Answer 25

Continue (BF safe unless mother has cracked or bleeding nipple)

Question 26

PLABABLE’s 3 never-forget points for DKA

Answer 26

1. NSS 2. Insulin and KCl 3. If glucose falls below 14 mmol/L, started 10% glucose + saline

Question 27

Other name for RItter’s disease

Answer 27

Staphylococcal Scalded Skin Syndrome

Question 28

2 y/o boy + irritable and lethargic for the past two days with rash and fever + rash started as red patches which developed into blisters + painful and distressing + fever preceded the rash + no significant PMH + not on any meds + Nikolsky sign positive

Answer 28

SSSS

Question 29

Common causes of CN XII injury

Answer 29

1. LMN Lesions - polio, syringomyelia 2. Stroke 3. Bulbar palsy 4. Neck trauma 5. Carotid endarterectomy

Question 30

Pseudohypoparathyroidism vs. Fanconi syndrome vs. Vit D deficiency vs. Primary hyperparathyroidism

Answer 30

Pseudohyparathyroidism - associated with congenital syndrome; hypocalcemia + elevated PTH and phosphate Vit D deficiency - reduced Ca absorption from GIT; increased PTH Fanconi syndrome - Type II RTA where there is defect of the proximal renal tubule; hypocalcemia + hypophosphatemia + hypomagnesemia + metabolic acidosis

Question 31

Management for neutropenic sepsis

Answer 31

Piperacillin-Tazobactam

Question 32

When would you suspect neutropenic sepsis?

Answer 32

1. Fever more than 38.5ºC or two occasions of high temp two hours apart 2. ANC ≤ 0.5 x 10^9/L 3. Recipients of chemotherapy within the last 4 weeks 4. Recipients of bone marrow transplant

Question 33

What is the caveat regarding laboratory parameters in DIC?

Answer 33

Everything is elevated except for fibrinogen and platelet. In DIC, platelet may be decreased or normal. aPTT is elevated. Fibrin products (including D-dimer) are elevated. Protime is elevated. Fibrinogen is decreased.

Question 34

Laboratory findings in a patient with subclinical hypothyroidism

Answer 34

Elevated TSH | Normal T4

Question 35

TIA and DVLA

Answer 35

For group 1 driver - do not drive for 1 month. No need to notify DVLA if suffered from 1 TIA only. (Notify DVLA if suffered multiple TIA) For group 2 driver - Notify DVLA

Question 36

Which type of antihypertensive medications should be omitted prior to surgery? And how many hours should they be omitted?

Answer 36

Omit ACE inihibitors as well as ARBs 24 hours prior to surgery. ***These medications can result in severe hypotension after induction of general anesthesia.

Question 37

Treatment for Dressler syndrome

Answer 37

NSAIDs

Question 38

Maintenance fluid for diarrhea in children

Answer 38

PNSS + 5% dextrose

Question 39

Painless bilateral swelling of the face + mild-grade fever + dry mouth + CXR finding of bilateral perihilar lymphadenopathy

Answer 39

Mikulicz’s syndrome

Question 40

Most preferred treatment for trigeminal neuralgia

Answer 40

CARBAMAZEPINE > lamotrigine/ phenytoin/ gabapentin

Question 41

Presence of Paul-Bunnell would prompt you into this diagnosis + sore throat + palatal petechiae

Answer 41

Glandular fever

Question 42

When would you consider using Clozapine?

Answer 42

After two failed attempts of antipsychotics