PLAB 1700F Flashcards
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
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].
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
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].
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
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].
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
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 seven days. Then amoxicillin 500 mg three times daily for 7 days.].
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
Ans. A. Cardiac enzymes.
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. Reduce lithium dosage but continue throughout pregnancy
d. Reduce lithium gradually and stop when pregnancy is confirmed
e. Switch to sodium valproate
Ans. The key is D. Reduce lithium gradually and stop when pregnancy is confirmed.
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
Ans. The key is D. Candida infection. [Candida is more common than CMV].
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
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].
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
Ans. The key is E. Transpyloric plane.
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
Ans. The key is A. Fundus of the gallbladder.
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
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)].
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
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].
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
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].
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
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].
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
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 factor for mi. Some may argue in DM mi will be painless! But it is not always the case. MI is only painless when autonomic neuropathy becomes well established].
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 appropriate immediate intervention?
a. High flow oxygen
b. IV sedation
c. Rebreathe into a paper bag
d. Refer for anxiety management course
e. Refer for urgent cardiology opinion
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].
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
Ans. The key is A. CBG. [It will point towards acidosis and indicate whether assisted ventilation is needed or not].
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
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].
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
Ans. The key is D. Deep inguinal ring.
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.
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.
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].
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].
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)].
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].
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].
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].
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 and cervical exitation obviously points towards Ectopic pregnancy].
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].
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].
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].
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].
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.
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.
(Patient.co.uk)
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].
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 experienced over the arms, shoulders and upper body 3) light touch, vibration and position senses in the feet are affected as the syrinx enlarges into the dorsal column.
Motor features: (when lower motor neurons of the anterior horn cells are affected) 1) muscle wasting and weakness begins in the hands and then affects the forearms and shoulders. 2) tendon reflexes are lost. Autonomic involvement like bladder and bowel can occur. [patient.co.uk]
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 development of GTN (Gestational trophoblastic neoplasia).
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 diagnosis].
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.
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].
