PLAB 1700G

Question 1

A 65yo woman had an excision of colonic tumor 3yrs ago. Now she is losing weight and feels lethargic. Exam: pale but no abdominal findings. What is the most appropriate inv?

a. CA 125
b. CA 153
c. CA 199
d. CEA
e. AFP

Answer 1

Ans. The key is D. CEA. [CA 125 = ovarian cancer; CA 153 = cancer breast; CA 199 = pancreatic cancer; CEA = colorectal carcinoma; AFP = hepatocellular carcinoma].

Question 2

A 46yo African-Caribbean man is found to have BP=160/90mmHg on 3 separate occasions. What
is the best initial tx?

a. ACEi
b. Beta-blockers
c. ARBs
d. None
e. CCB

Answer 2

Ans. The key is E. CCB. [If age less than 55 years but Afro-Caribbean origin then CCB].

Question 3

A 39yo woman will undergo tubal sterilization and she wants to know the failure rate of this type of sterilization.

a. 1:50
b. 1:200
c. 1:500
d. 1:1000
e. 1:5000

Answer 3

Ans. The key is B. 1:200.

Question 4

Which of the following reflexes and innervating spinal nerves are correctly paired?

a. Anal reflex – S1
b. Ankle jerk – L5
c. Biceps jerk – C7 & C8
d. Knee jerk – L3 & L4
e. Triceps jerk – T1

Answer 4

Ans. The key is D. Knee jerk – L3 & L4. [Anal reflex – S2-4; Ankle jerk – S1-2; Biceps jerk – C5-6; Knee jerk – L3-4; Triceps jerk – C7].

Question 5

A 62yo man with rheumatoid arthritis struck his hand against a door. He subsequently found that although he could extend the interphalangeal joint of his right thumb, the MCP joint of the thumb remained flex. What is the single most likely tendon to have been damaged?

a. Extensor carpi ulnaris
b. Extensor digitorum
c. Extensor indicis
d. Extensor pollicis brevis
e. Extensor pollicis longus

Answer 5

Ans. The key is D. Extensor pollicis brevis. [Action of extensor pollicis brevis = extension of thumb at metacarpophalangeal joint. Extensor pollicis longus = extends the terminal phalanx of the thumb].

Question 6

A 68yo lady complains of falls to the ground without any warning, maintains consciousness and no confusion. She says this has occurred at number of times. What is the dx?

a. Stokes Adams attack
b. Hypoglycemia
c. Vasovagal syncope
d. Drop attacks
e. Epilepsy

Answer 6

Ans. The key is D. Drop attacks. [Drop attacks are sudden spontaneous falls while standing or walking, with complete recovery in seconds or minutes. There is usually no recognized loss of consciousness, and the event is remembered].

Question 7

A 50yo man complains of being pursued by the police for a crime he denies committing. He has poor concentration and impaired short-term memory. He admits to drinking large amounts of alcohol for the last 20yrs. What is the most probable dx?

a. Dementia
b. Hallucination
c. Wernicke’s encephalopathy
d. Schizophrenia
e. Korsakoff psychosis

Answer 7

Ans. The key is E. Korsakoff psychosis. [Dementia, i.e. short term memory loss is seen in korsakoff psychosis].

Question 8

A pt with prv hx of HTN, the membranes have ruptured and the cervix is 3cm dilated. 4h later on examination showed that the cervix was still 3cm dilated. What is the single most appropriate management for her labor?

a. Repeat vaginal examination in 4h
b. CTG
c. C-section
d. External rotation
e. IV syntocin drip

Answer 8

Ans. The key is E. IV syntocinon drip. [There is no progress of labour in 4 hours. Hence syntocinon drip should be given].

Question 9

A 6yo girl has had 2 short episodes of cough and wheeze over the last 12m. These 2 acute episodes responded quickly to bronchodilator, she has no symptoms or abnormal physical signs. She has slight eczema and her mother has asthma. What is the single most appropriate inv?

a. CXR
b. Peak flow rate diary
c. Pulse oximetry
d. Spirometry
e. Sweat test

Answer 9

Ans. The key is D. Spirometry. [spirometry is the preferred initial test (if available) to assess the presence and severity of airflow obstruction less effort dependent and more repeatable though less applicable in acute severe asthma].

Question 10

A 45yo man had recently started taking anti-HTN therapy. 6m later his RBS=14mmol/l. Which single drug is most likely to have caused this?

a. Amlodipine
b. Bendroflumethiazide
c. Doxazosin
d. Lorsartan
e. Ramipril

Answer 10

Ans. The key is B. Bendroflumethiazide. [High blood sugar is a well known side effect of bendroflumethiazide].

Question 11

A 27yo waitress has pelvic pain, dysmenorrhea and increasingly heavy periods. She also complains of dyspareunia. There is generalized pelvic tenderness without peritonism. Pelvic US is normal. What is the most likely dx?

a. Endometriosis
b. Uterine fibroid
c. Pelvic congestion syndrome
d. PID
e. Tubal pregnancy

Answer 11

Ans. The key is C. Pelvic congestion syndrome. [In pelvic congestion syndrome there develops varicose veins in the lower abdomen from prolonged standing (as occurred here in a waitress who remains standing for long) with some pain syndromes like pelvic pain, dysmenorrea, dyspareunia and generalized pelvic tenderness without peritonism. Also there may be associated menorrhagia].

Question 12

A 14yo girl is clinically obese. She has not started her periods yet and has severe acne. Among her inv, a high insulin level is found. What is the most probable dx?

a. Cushing’s syndrome
b. Grave’s disease
c. Acquired hypothyroidism
d. PCOS
e. Addison’s disease

Answer 12

Ans. The key is D. PCOS. [It is not cushing’s as insulin levels in cushing’s are not usually raised! Here obesity, primary amenorrhea , acne and particularly high level of insulin makes the likely diagnosis to PCOS].

Question 13

An 18yo girl with primary amenorrhea complains of severe abdominal pain every 4-8weeks which is now getting worse. Exam: lower abdominal mass is felt. What is the most probable dx?

a. Ectopic pregnancy
b. Ovarian carcinoma
c. Hematometrium
d. Biliary colic
e. Renal carcinoma

Answer 13

Ans. The key is C. Hematometrium. [Primary amenorrhea and periodic pain indicate hematometrium either secondary to imperforated hymen or vaginal septum].

Question 14

A 14yo boy with asthma suddenly developed chest pain and increasing breathlessness during a game of football. When seen in the ED he was not cyanosed. He has reduced breath sounds on the right side. His oxygen saturation is 94% on air. What is the single most appropriate inv?

a. Capillary blood gases
b. CXR
c. CT chest
d. Exercise challenge
e. MRI chest

Answer 14

Ans. The key is B. CXR. [Asthma is a predisposing factor for spontaneous pneumothorax. The presentation indicates pneumothorax for which most appropriate investigation is CXR].

Question 15

A 36yo woman was recently admitted to a psychiatric ward. She believes that the staff and other pts know exactly what she is thinking all the time. What is the most likely symptom this pt is suffering from?

a. Thought insertion
b. Thought withdrawal
c. Thought block
d. Though broadcasting
e. Hallucination

Answer 15

Ans. The key is D. Thought broadcasting.

Question 16

A 60yo woman is admitted to the hospital after a fall. She is noted to have poor eye contact. When asked how she is feeling, she admits to feeling low in mood and losing enjoyment in all her usual hobbies. She has also found it difficult to concentrate, feels that she is not good at anything, feels guilty over minor issues and feels very negative about the future. What is the
most likely dx?

a. Mild depression
b. Moderate depression
c. Severe depression
d. Psychosis
e. Seasonal depression

Answer 16

Ans. The key is A. Mild depression. [Mild depression: i)Low mood ii) Anhedonia iii) Guilt iv) Hopelessness v) Worthlessness vi) Inability to concentrate].

Question 17

A 70yo woman lives in a nursing home following a stroke has developed reddish scaly rash on her trunk. She has many scratch marks on her limbs and trunk with scaling lesions on her hands and feet. What is the single most appropriate initial tx?

a. Aqueous cream
b. Chlorphenaramine
c. Coal tar
d. 1% hydrocortisone ointment
e. Permethrin

Answer 17

Ans. The key is E. Permethrine. [This is a case of scabies and scaly rash denotes the infection of most severe type the crusted or Norwegian scabies. Should be treated with permethrine].

Question 18

A 16yo boy following a RTA was brought to the ED with a swelling and deformity in his right thigh. Exam: airway is patent and is found to have a pulseless leg. Which structure is involved in this fx?

a. Femoral artery
b. Posterior tibial artery
c. Common peroneal nerve
d. Dorsalis pedis

Answer 18

Ans. The key is A. Femoral artery.

Question 19

A man sat cross-legged for about 30mins. After this he was unable to dorsiflex his left foot and had loss of sensation in the web space between the big toe and the 2nd toe. He also has sensory loss on the same side of the foot after 2h. Which of the following was affected?

a. Femoral nerve
b. Sural nerve
c. Peroneal nerve
d. Sciatic nerve

Answer 19

Ans. The key is C. Peroneal nerve. [Common peroneal nerve winds round the fibular neck at knee joint and when a man sits cross legged for a considerable time pressure exerted on the nerve may cause nerve palsi].

Question 20

A 25yo woman is presenting with diarrhea and abdominal bloating over the last 4m. Exam: she
has blistering rash over her elbows. Biochemistry: low serum albumin, calcium and folate conc. On jejunal biopsy, there is shortening of the villi and lymphocytosis. What is the most likely dx?

a. Celiac disease
b. Whipple’s disease
c. Crohn’s disease
d. Tropical sprue
e. Giardiasis
f. Cystic fibrosis

Answer 20

Ans. The key is A. Celiac disease. [diarrhea, abdominal bloating, blistering skin rash over elbow (Dermatitis herpetiformis), low serum albumin, calcium and folate conc. Supported by shortening of villi and lymphocytosis on jejuna biopsy is classic presentation of celiac disease].

Question 21

A 19yo man presents for the 1st time with a firm and unshakable belief that he is being followed by terrorists who are plotting against him. What is the single best term for this man’s condition?

a. Delusion of persecution
b. Delusion of grandeur
c. Delusion of control
d. Delusion of reference
e. Delusion of nihilism

Answer 21

Ans. The key is A. Delusion of persecution. [Delusions of persecution refer to false beliefs or perceptions in which a person believes that they are being treated with malicious intent, hostility, or harassment – despite significant evidence to suggest otherwise].

Question 22

A 19yo female is brought in by her parents. They are concerned about her BMI which is 12. She is satisfied with it. What is the next step?

a. Psychiatric referral for admission
b. Family counselling
c. Social service
d. Start antidepo
e. Medical admission

Answer 22

Ans. The key is E. Medical admission. [The diagnosis is anorexia nervosa. At this critical low BMI medical admission is indicated to improve her deficiency states and proper nutrition. ((BMI <15kg/m2, rapid weight loss + evidence of system failure) requires urgent referral to eating disorder unit (EDU), medical unit (MU) or paediatric medical wards].

Question 23

A lady who works at a nursing home presents with itching. Exam: linear tracks on the wrist. She says that 2d ago she had come in contact with a nursing home inmate with similar symptoms. What is the mechanism of itching?

a. Infection
b. Destruction of keratinocytes
c. Allergic reaction
d. Immunosuppression
e. None

Answer 23

Ans. The key is C. Allergic reaction. [The probable diagnosis is scabies in which there is itching due to allergic reaction to mites (Sarcoptes scabii) waste products].

Question 24

A teacher had a respiratory infection for which she was prescribed antibiotics. After the antibiotic course when she rejoined school, she lost her voice completely. What is the single most appropriate dx?

a. Recurrent laryngeal nerve palsy
b. Angioedema
c. Laryngeal obstruction by medication
d. Laryngitis
e. Functional dysphonia/vocal cords

Answer 24

Ans. The key is E. Functional dysphonia/vocal cords. [Functional dysphonia is poor voice quality without any obvious anatomical, neurological or other organic difficulties affecting the larynx or voice box. It is often secondary to viral infection].

Question 25

A 43yo lady is admitted with pyrexia, arthropathy, breathlessness and syncope. She was recently dx with pulmonary emboli. There is an early diastolic sound and a mid-diastolic rumble. Her JVP is elevated with prominent a-waves. What is the most likely cause? a. Mitral regurgitation b. Ventricular ectopics c. Pulmonary regurgitation d. Atrial myxoma e. Complete heart block

Answer 25

Ans. The key is D. [Pyrexia, arthropathy, breathlessness, syncope and early diastolic sound and a mid diastolic rumble are known features of atrial myxoma].

Question 26

A 28yo man presents with a maculopapular rash over his trunk and palms. He also has numerous mouth ulcers. He had a penile ulcer which healed 2wks ago. What will you do to confirm the dx? a. PCR for treponemal and non-treponemal antibiodies b. Dark ground microscopy from mouth ulcer c. Blood culture for treponema d. Dengue fever

Answer 26

Ans. The key is A. PCR for treponomal and non-treponemal antibodies. [Non treponemal antibody test if positive indicate that there may be syphilis and it is not confirmatory alone. That is why treponemal antibody test should also be done to confirm it. On the other hand resolved disease may show negative treponemal test which is confirmed by positive non-treponemal test].

Question 27

A 34yo man complains of arthralgia, abdominal pain and vomiting, a facial rash that is worse in the summer and hematuria. Urea and creatinine are slightly elevated with urinalysis demonstrating red cell casts. PMH is remarkable for childhood eczema. Which inv is most likely to lead to a dx? a. US KUB b. Joint aspiration c. Auto antibodies d. IVU e. Renal biopsy

Answer 27

Ans. The key is C. Auto antibodies. [Likely diagnosis is SLE for which auto antibody (anti ds DNA antibody) should be done].

Question 28

A 56yo woman has had severe abdominal pain for 24h radiating to her back and is accompanied by nausea and vomiting. She appears to be tachycardic and in shock. She was found to have gallstones, 2yrs ago. What is the most likely inv to confirm dx? a. US abdomen b. LFT c. Serum lipase d. Angiography e. CT abdomen

Answer 28

Ans. The key is C. Serum lipase. [The likely diagnosis is pancreatitis hence serum lipase].

Question 29

A 32yo female with axillary freckles and café au lait spots wants to know the chances of her child also having similar condition. a. 1:2 b. 1:4 c. No genetic link d. 1:16 e. Depends on the genetic make up of the partner

Answer 29

Ans. The key is E. Depends on genetic make up of the partner. [Depends on the make up of the partner, ideally it's 1:2 since it's autosomal dominant with complete penetrance but if the patients spouse also has neurofibromatosis, it raises it to at least 75% with a possible 100%].

Question 30

A 40yo man has pain, redness and swelling over the nasal end of his right lower eyelid. The eye is watery with some purulent discharge. The redness extends on to the nasal peri-orbital area and mucoid discharge can be expressed from the lacrimal punctum. What is the single most appropriate clinical dx? a. Acute conjunctivitis b. Acute dacrocystitis c. Acut iritis d. Retrobulbar neuritis e. Scleritis

Answer 30

Ans. The key is B. Acute dacrocystitis.

Question 31

A 60yo lady has severe chest pain. ECG shows changes of inferior wall MI. ECG also shows progressive prolongation of PR interval until a QRS complex is dropped. What is the most probable dx? a. Atrial fibrillation b. VT c. SVT d. Mobitz type I 2nd degree heart block e. Mobitz type II 2nd degree heart block

Answer 31

Ans. The key is D. Mobitz type I 2nd degree heart block. [Inferior MI is frequently associated with conduction defect].

Question 32

A 52yo woman speaks rapidly without any pause and ignores interruptions. She doesn’t even pause to take enough breaths. What term best describes this kind of speech? a. Flight of ideas b. Broca’s aphasia c. Wernicke’s aphasia d. Pressure of speech e. Verbal dysphasia

Answer 32

Ans. The key is D. Pressure of speech.

Question 33

A 30yo woman has been feeling low and having difficulty in concentrating since her mother passed away 2m ago. She feels lethargic and tends to have breathlessness and tremors from time to time. What is the most likely dx? a. Adjustment disorder b. PTSD c. Panic disorder d. GAD e. Bereavement

Answer 33

Ans. The key is A. Adjustment disorder. [When 2 months passed it is no more normal bereavement but major depression or adjustment disorder].

Question 34

A 32yo man on psychiatric medications complains of inability to ejaculate. Which drug is most likely to cause these symptoms? a. Lithium b. Haloperidol c. Chlorpromazine d. Fluoxetine e. Clozapine

Answer 34

Ans. The key is D. Fluoxetine. [SSRIs are frequently associated with delayed ejaculation].

Question 35

A 4yo boy is brought by his parents with complains of wetting his bed at night and whenever he gets excited. What would be the most appropriate management for this child? a. Desmopressin b. Oxybutanin c. Behavioural therapy d. Tamsulosin e. Restrict fluid intake

Answer 35

Ans. The key is C. Behavioural therapy. Probably this is wrong option! There is no correct option for this question. [The question is inappropriate. Child is of 4 yrs of age and before 5 yrs only reassurance, no treatment is indicated].

Question 36

A 34yo DM pt is undergoing contrast radiography. What measure should be taken to prevent renal damage with contrast dye? a. Reduce contrast dye b. Plenty of fluids c. NSAIDS d. ACEi e. IV dextrose

Answer 36

Ans. The key is B. Plenty of fluids.

Question 37

A 75yo woman presents to the breast clinic having noticed that she has had a blood stained discharge from the left nipple, together with dry skin over the left areola. Exam: blood stained discharge with dry flaky skin noted on the left areola. The nipple was noted to be ulcerated. What is the most appropriate inv? a. FNAC b. MRI c. Punch biopsy d. Open biopsy e. Stereotactic biopsy

Answer 37

Ans. The key is C. Punch biopsy. [As the lesion is on the surface punch biopsy can be well obtained].

Question 38

A 50yo man presents with low mood, poor concentration, anhedonia and insomnia. He has had 2 episodes of increased activity, promiscuity and aggressive behavior in the past. He was arrest 8m ago for trying to rob a bank claiming it as his own. Which drug is most likely to benefit him? a. Haloperidol b. Citalopram c. Desipramine d. Carbamazepine e. Ethosuximide

Answer 38

Ans. The key is D. Carbamazepine. [It is a case of bipolar disorder. Mainstay of treatment is mood stabilizers such as i) Lithium carbonate ii) Anticonvulsant medicines iii) Antipsychotic medicines. So from the given options Carbamazepine is the most appropriate drug].

Question 39

A 25yo woman complains of dizziness, nausea, vomiting, visual disturbances and anxiety which keep coming from time to time. Most of the attacks are a/w sudden change in posture. What is the most likely dx? a. Panic disorder b. Carotid sinus syncope c. BPPV d. Vertebrobasilar insufficiency e. Postural hypotension

Answer 39

Ans. The key is C. Benign paroxysmal positional vertigo (BPPV). [Dizziness, nausea, vomiting and nystagmus which keep coming from time to time are common features of BPPV].

Question 40

A 56yo man was recently put on anti-HTN meds and recent biochemistry on 2 occasions showed: Na+=132, K+=7.6, Urea=11.3, Creat=112. Which of the following drugs is responsible for this result? a. Amlodipine b. Bendroflumethiazide c. Doxazosin d. Atenolol e. Ramipril

Answer 40

Ans. The key is E. Ramipril. [ACEI and ARB are known to raise the serum potassium level].

Question 41

A 46yo woman has offensive yellow discharge from one nipple. She had a hx of breast abscess 3yrs ago. What is the possible dx? a. Duct papilloma b. Duct ectasia c. Duct fistula d. Breast cancer

Answer 41

Ans. The key is C. Duct fistula.

Question 42

A 35yo woman undergoing tx for TB presents with malar rash, photosensitivity and hematuria. What is the single most likely positive antibody? a. Anti Ds DNA b. Anti Sm c. Anti Histone d. Anti La e. Anti centromere

Answer 42

Ans. The key is C. Antihistone antibody. [Anti histone antibody is present in 95% cases of drug induced lupus].

Question 43

A 6wk child with profuse projectile vomiting. What is the first thing you will do? a. US b. Check serum K+ level c. ABG d. NG tube e. IV fluids

Answer 43

Ans. The key is B. Check serum K+ level. This is a wrong key! Correct key is E. IV fluid. [We shall resuscitate first with normal saline].

Question 44

A 55yo woman who attends the clinic has recently been dx with a depressive episode. She complains of unintentionally waking early in the morning, a recent disinterest in sex and a loss of appetite, losing 5kg weight in the last month. She feels that her mood is worse at the beginning of the day. What is the most likely dx for this pt? a. Mild depression b. Moderate depression c. Severe depression d. Low mood e. Pseudo depression

Answer 44

Ans. The key is B. Moderate depression. [Sleep disturbance, disinterest in sex and loss of appetite points towards the diagnosis of moderate depression].

Question 45

An employer sent his worker to the ED after having hit his head on a machine. Exam: normal. What is the single most likely inv you would do? a. Skull XR b. CT head c. MRI head d. Reassure

Answer 45

Ans. The key is A. Skull XR. This is wrong key! Correct key should be B. CT head.

Question 46

A lady with fam hx of ovarian carcinoma has a pelvis US that fails to reveal any abnormality. What is the single most appropriate inv? a. Pelvic CT b. CA 125 c. CA 153 d. Laparoscopy e. MRI

Answer 46

Ans. The key is B. CA 125. [CA 125 is tumour marker for ovarian tumour].

Question 47

A 10yo boy is taken to his GP by his parents with behavioural prbs. He attends a special school due to inappropriate behavior and during the interview with his parents the boy barks at infrequent episodes and shouts expletives. What is the most likely dx? a. Asperger syndrome b. Cotard syndrome c. Rett syndrome d. Ekbom syndrome e. Tourette’s syndrome

Answer 47

Ans. The key is E. Tourette’s syndrome. [Tourete’s syndrome may have motor tics like blinking, facial grimacing, shoulder shrugging. Other complex motor tics may be sniffing, touching objects, hopping, jumping, bending or twisting. It has vocal tics like throat clearing, sniffing, grunting or barking and more complex like coprolalia (uttering socially inappropriate words) or echolalia (repeating the word or phrase of others)].

Question 48

A 52yo male presents with sudden complete loss of vision from right eye. He also had been complaining of right sided headaches which would come up more on chewing. On fundoscopy, the retina was pale and a cherry red spot could be seen in the macular region. What caused this vision loss? a. CRAO b. CRVO c. Branch RAO d. Branch RVO e. Circumciliary vein occlusion

Answer 48

Ans. The key is A. CRAO. [Pale retina with cherry red spot in macular region is seen in CRAO].

Question 49

A 48yo woman presents with left-sided severe headache. She also has a red, watering eye and complains of seeing colored haloes in her vision. What is the most appropriate next step? a. Measure IOP b. Relieve pain with aspirin c. 100% oxygen d. CT e. Relieve pain with sumatriptan

Answer 49

Ans. The key is A. Measure IOP. [Probable case of angle closure glaucoma requiring measurement of IOP to establish the diagnosis].

Question 50

A 31yo woman presents with 7-10days following childbirth, with loss of feeling for the child, loss of appetite, sleep disturbance and intrusive and unpleasant thoughts of harming the baby. What is the best tx for this pt? a. Fluoxetine b. Haloperidol c. CBT d. Reassurance e. ECT

Answer 50

Ans. The key is A. Fluoxetine. [The diagnosis is post-partum depression. Treatment is fluoxetine. The mode of treatment may be 1. Drugs like a) Antidepressant b) Antypsychotic or c) Mood stabilizers like lithium. If drug treatment fails then 2. ECT].

Question 51

A 56yo male pt presents with intermittent vertigo, tinnitus and hearing loss. What is the best drug tx for this pt? a. Buccal prochlorperazine b. Oral flupenphenazine c. TCA d. Gentamicin patch on the round window e. No med tx available

Answer 51

Ans. The key is A. Buccal prochlorperazine. [Probable case of Menieres disease. Treated with prochlorperazine].

Question 52

An 82yo woman has developed painful rash on one side of her forehead and ant scalp. Lesions have also affected her cornea. What is the single most appropriate option? a. Accessory nerve b. Facial nerve c. Olfactory nerve d. Optic nerve e. Trigeminal nerve

Answer 52

Ans. The key is E. Trigeminal nerve. [Probable herpes zoster opthalmicus].

Question 53

A 24yo woman presents with episodes of peri-oral tingling and carpo pedal spasms every time she has to give a public talk. This also happens to her before interviews, exams and after arguments. What is the best management strategy for this pt? a. Diazepam b. Rebreathe in a paper bag c. Desensitization d. Buspirone e. Propranolol

Answer 53

Ans. The key is B. Rebreathe in a paper bag. This is wrong key. More correct option is C. Desensitization.[Desensitization is the treatment of choice in long run. For prevention proranalol before expected exposure and if patient presents with an attack then rebreathing in a paperbag to subside her acute problems].

Question 54

A 32yo woman P3 of 39wks gestation reports having spontaneous ROM 4days ago. She didn’t attend the delivery suite as she knew that would happen and had already decided on a home birth. Today she feels very hot and sweaty. She thought that she was starting to have labour pains but she describes the pain as more constant. Exam: uterus is tender throughout. Blood tests show raised CRP and WBC. Select the most likely dx? a. Round ligament stretching b. Chorioamnionitis c. Uterine rupture d. Labor e. DIC

Answer 54

Ans. The key is B. Chorioamnionitis. [Prolonged rupture of membrane can lead to chorioamnionitis].

Question 55

A 63yo man continues to experience chest pain and has a temp of 37.8C 2 days after an acute MI. His ECG shows widespread ST elevation with upward concavity. What is the single most likely explanation for the abnormal inv? a. Acute pericarditis b. Cardiac tamponade c. Atrial thrombus d. Left ventricular aneurysm e. Dressler syndrome

Answer 55

Ans. The key is A. Acute pericarditis. [Chest pain, raised temperature and ECG findings of widespread ST elevation with upwards concavity is diagnostic of acute pericarditis particularly after MI].

Question 56

A 55yo man presents with an ulcer of the scrotum. Which of the following LN is involved? a. External iliac LN b. Pre-aortic LN c. Aortic LN d. Inguinal LN e. Iliac LN f. Submental LN g. Submandibular LN h. Deep cervical LN

Answer 56

Ans. The key is D. Inguinal LN.

Question 57

A 35yo woman has butterfly rash on her face and she suffers symmetrical joint pains on knee and elbow, ESR is raised. What is the most discriminative inv for dx? a. Anti DNA antibodies b. Anti Jo1 antibodies c. Anti nuclear antibodies d. Anti centromere antibodies e. Anti la antibodies

Answer 57

Ans. The key is A. Anti DNA antibodies. [Anti DNA antibodies to diagnose SLE].

Question 58

Pt had a fight following which he developed bleeding, ringing and hearing loss from one ear. What is the inv of choice? a. CT b. XR skull c. Otoscopy d. MRI vestibule e. Coagulation study

Answer 58

Ans. The key is A. CT. This is a wrong key! Correct key is Otoscopy.

Question 59

A 35yo IVDA (Intra Venous Drug Abuser) on penicillin and flucloxacillin for cellulitis now presents with jaundice, pale stools and dark urine. What is the single most likely dx? a. Hep A b. Cholestatic jaundice c. Chronic active hepatitis d. Primary biliary cirrhosis e. Hep B

Answer 59

Ans. The key is B. Cholestatic jaundice. [Flucloxacillin can cause cholestatic jaundice].

Question 60

A 79yo woman has been dx with T2DM. Her BMI=22. RBS are 8 and 10mmol/l. Her BP=130/80mmHg. Her fasting cholesterol=5.7mmol/l. She is currently symptom-free but has microalbuminuria. What is the single most appropriate drug management? a. ACEi and glibenclamide b. ACEi and metformin c. Statin and ACEi d. Statin and glibenclamide e. Statin and metformin

Answer 60

Ans. The key is C. Statin and ACEi. [Diabetic patients are advocated statin irrespective of cholesterol levels and diabetic microalbuminuria is best treated by ACEI. As initially we shall give lifestyle advice and no medicine for diabetes even then we shall start with statin and ACEI].

Question 61

A 68yo woman is unable to extend the IP joint of her right thumb 7wks following a fx of the right radius. Other finger and thumb movements are normal. What is the single most likely tendon to be damaged? a. Abductor pollicis longus b. Extensor pollicis brevis c. Extensor pollicis longus d. Flexor digitorum profundus e. Flexor pollicis longus

Answer 61

Ans. The key is C. Extensor policis longus. [Full extension of right thumb is achieved by extensor pollicis longus].

Question 62

A mother presents her 6m son who is vocalizing. She has noticed that he doesn’t respond to loud noises. His motor milestones are normal. What is the best management strategy? a. Arrange hearing test b. Assess development milestones c. Reassure d. Refer to speech therapist e. MRI brain

Answer 62

Ans. The key is A. Arrange hearing test. [Normal motor milestones indicate normal development but unable to respond to loud noise at 6 months may indicate deafness].

Question 63

A 39yo man presents to the ED with persistent cough, sputum and dyspnea. He gave a hx of smoking 20 cigarettes/d for the last 10 years. Pt was given oxygen in ambulance but he is not improving. What is the next step? a. Prednisolone b. Salbutamol c. Check ABG d. CXR e. ECG

Answer 63

Ans. The key is C. Check ABG. [The patient has COPD and as no improvement with oxygen, next step is to check ABG to give guidance for next treatment plan].

Question 64

A 66yo woman has been brought to the hospital on a number of occasions with a hx of loss of memory. Her PMH is significant for an MI 6yrs ago. It is noted that she has a step wise decline of her cognitive functions. What is the most likely dx? a. Alzhemiers b. Vascular dementia c. Pick’s dementia d. Huntington’s disease e. Lewy body dementia

Answer 64

Ans. The key is B. Vascular dementia. [Age 65 yrs (vascular dementia is rare at age before 65), history of MI and stepwise decline of cognitive function indicates vasculopathy and hence vascular dementia].

Question 65

A 55yo man returns for routine follow up 6wks after an MI. He gets breathless when walking uphill. His ECG shows ST elevation in leads V1, V2, V3 and V4. What is the single most likely explanation for the abnormal investigation? a. Heart block b. Right ventricular strain c. Atrial thrombus d. Left ventricular aneurysm e. Dressler’s syndrome

Answer 65

Ans. The key is D. Left ventricular aneurism. [Features of heart failure and persistent ST elevation suggests the dx of left ventricular aneurysm].

Question 66

A 4m girl has severe FTT (Failure To Thrive) and increasing jaundice which was 1st noticed at 1wk of age. She has an enlarged liver and scratches on her skin. Her parents have been unable to seek medical care. What is the most likely dx? a. Biliary atresia b. G6PD deficiency c. Hep B d. Spherocytosis

Answer 66

Ans. The key is A. Biliary atresia. [Increasing jaundice at this age with failure to thrive, enlarged liver and scratches (itching) indicate cholestatic jaundice likely from biliary atresia]

Question 67

A 76yo man suddenly collapsed and died. At post mortem exam, a retroperitoneal hematoma due to ruptured aortic aneurysm was noted. What is the most likely underlying cause of the aortic aneurysm? a. Atheroma b. Cystic medial necrosis c. Dissecting aneurysm d. Polyarteritis nodosa e. Syphilis

Answer 67

Ans. The key is A. Atheroma.

Question 68

A 33yo male came to the hospital with complaint of occasional left sided chest pain that lasts <30mins, following exercise, which relieves upon taking rest. What is the most probable dx? a. Unstable angina b. Decubitus angina c. Stable angina d. Coronary spasm e. MI

Answer 68

Ans. The key is C. Stable angina.

Question 69

A 42yo overweight smoker comes with heavy periods. A scan reveals a normal uterus. She would like a long term tx with minimal side effects that would offer tx for the menorrhagia and provide contraception. She is unsure whether she would like more children. She is adamant that she doesn’t want surgery as she is terrified of the prospect. Select the best management for her menorrhagia? a. COCP b. GrH analogues c. IU/systemic progesterone d. NSAIDs e. Copper containing IUCD

Answer 69

Ans. The key is C. IU/systemic progesterone. [As patient is smoker, COCP should be avoided. In the given case option C. i.e. mirena is most suitable].

Question 70

A 10yo male child was brought by his mother complaining that her child watches TV at very high volumes, doesn’t like to play outside and instead has become more sincere with reading. She also says that her son doesn’t respond to her. What do you expect to see on otoscopy? a. Flamingo pink tympanic membrane b. Attic perforation c. Bluish grey tympanic membrane with air fluid levels d. Inflamed tympanic membrane with cart wheel appearance of vessels e. Red and inflamed tympanic membrane

Answer 70

Ans. The key is C. Bluish grey tympanic membrane with air fluid levels. [In glue air there occur conductive deafness so the child watch tv with high volume and does not respond to others for this deafness].

Question 71

A lady underwent debulking surgery for ovarian carcinoma. Soon after the surgery she presents with signs of intestinal obstruction. What is the single most appropriate inv? a. Pelvic CT b. CA 125 c. Laparotomy d. Laparoscopy e. Abdominal US

Answer 71

Ans. The key is C. Laparotomy. [In cancer patient obstruction does not respond to medical treatment and hence diagnostic and therapeutic laparotomy is the option of choice].

Question 72

A 45yo woman undergoing tx for RA for the last 5yrs presents with dizziness, easy fatigabiliy and lack of energy. A blood film shows MCV 106. What could be the most probable reason for her anemia? a. Steroids b. Chronic disease c. NSAIDs d. Methotrexate e. Sulfasalazine

Answer 72

Ans. The key is D. Methotrexate. [Methotrexate leads to folate deficiency anaemia].

Question 73

A 62yo man who has recently had flu-like illness has woken to find his speech altered. Movement of his eyelids and lips are weak on the right side. Exam: normal. Which anatomical site is most likely to be affected? a. Facial nerve b. Hypoglossal nerve c. Oculomotor nerve d. Trigeminal nerve e. Glossopharyngeal nerve

Answer 73

Ans. The key is A. Facial nerve. [Viral infection is a common cause of facial nerve palsy].

Question 74

A 5yo girl has had an URTI for 3 days and has been treated with paracetamol by her mother. For the last 12h she has been hot and irritable with severe pain in her right ear. What is the most likely dx? a. Herpes zoster infection b. Impacted ear wax c. Mumps d. OM e. Perforation of eardrum

Answer 74

Ans. The key is D. OM.

Question 75

A 35yo man has a temp=39C, cough with purulent sputum and right sided chest pain on inspiration. He has herpes labialis. What is the single most likely causative organism? a. Coagulase +ve cocci in sputum b. Gram -ve diplococci in sputum c. Gram +ve diplococci in sputum d. Pneumocystis carinii in sputum e. Serology for legionella

Answer 75

Ans. The key is C. Gram +ve diplococcic in sputum. [High temperature, cough with purulent sputum, pleuritic chest pain and herpes labialis are recognized feature of pneumococcal pneumonia (pneumococcus=Gram +ve diplococci].

Question 76

A 27yo female was brought to the ED by her friend from a movie theatre. She complains of sudden severe pain in the eye followed by vomiting and also was seeing colored halos. She gives a past hx of recurrent headaches which used to resolve spontaneously. Exam: fixed, dilated ovoid pupil seen. What is the first inv? a. CT head b. MRI orbits c. Blood culture and sensitivity d. Toxicology screen e. Applanation tonometry

Answer 76

Ans. The key is E. Applanation tonometry. [Darkness can cause dilatation of pupil (which occurred in the darkness of theatre room) which (halfway dilatation) most often precipitate acute attack of angle closure glaucoma and the test to diagnose this is applanation tonometry].

Question 77

A 82yo male suddenly becomes unconscious and fell down. He recovered completely within minutes. What is the best inv you to to dx the case? a. ECG b. EEG c. Blood glucose level d. CT e. CXR

Answer 77

Ans. The key is A. ECG. [Here sudden unconciuosness without any provocation, which makes arrhythmia the most likely cause; hence we should do ECG].

Question 78

A child admitted with progressive muscle weakness and frequent falls. What is the most probable dx? a. Duchenne’s MD b. Becker’s MD c. Polymyositis d. Dermatomyositis e. Polymyalgia rheumatic

Answer 78

Ans. The key is A. Duchenne’s MD.

Question 79

A 56yo man presents to the ED with chest pain. The following ECG was taken. What is the most likely dx? a. Anterior MI b. Inferior MI c. Lateral MI d. Posterior MI e. NSTEMI

Answer 79

Ans. The key is A. Anterior MI. [Here ST elevation in L1, aVL, v2,v3,v4 and v5. So the diagnosis is anterior MI (as L1 and aVL and v2-v5, anterolateral would be more appropriate description)].

Question 80

A schizophrenic says: life is unfair. I like fairs. Fairs have food. It must be good. What term describes this pt’s speech? a. Neologism b. Flight of ideas c. Broc1a’s aphasia d. Wernicke’s aphasia e. Clang association

Answer 80

Ans. The key is E. Clang association. [The rhymic use of words as described is known as clanging or clang association often seen in schizophrenia].

Question 81

A man comes to the ED with hx of pulsatile swelling in the abdomen, he has hx of HTN and exam: pulse=120bpm, BP=70/40mmHg. He is restless and in shock. What emergency management should be done on priority basis? a. Urgent abdominal CT b. Urgent abdominal US c. IV fluids 0.9% NS crystalloids to bring SBP to 90mmHg d. IV fluids 0.9% NS crystalloids to bring SBP to 120mmHg e. Dopamine inj

Answer 81

Ans. The key is C. IV fluids 0.9% NS crystalloids to bring SBP to 90mmHg [Probable ruptured aortic aneurism. Immediate IV normal saline to raise the BP to 90 mmHg to keep the vital organs perfused till definitive measures are taken].

Question 82

A 5yo boy has cough and swelling at the knee after falling on the ground with rashes on the buttocks which are non-blanching. PT=13, APTT=71, Hgb=11, WBC=8, Plt=200. Choose the most likely dx? a. NAI b. Hemophilia c. HSP d. Osler weber reindu syndrome e. Von-Willebrand disease

Answer 82

Ans. The key is B. Hemophilia. This is a controversial key! Correct key should be E. Von-Willebrand disease. [Likely D/D may be B or C! in von willebrands disease usually there is no hemarthrosis (except in type 3) and in hemophilia no nonblanching rash (there may bruising). isolated rise in APTT is highly suggestive of hemophilia (given case). This is an ill defined question and only likely diagnosis may be type 3 von willebrands disease].

Question 83

A 45yo woman presents with discharge from the left nipple. The discharge is brownish-green and foul smelling. What is the most likely dx? a. Duct papilloma b. Intra-ductal papilloma c. Duct ectasia d. Mammary duct fistula e. Breast abscess

Answer 83

Ans. The key is C. Duct ectasia. [Women near menopause are more affected by duct ectasia characterized by brown, green or cheesy discharge. This condition is harmless and tends to clear up without treatment].

Question 84

A 10yo boy presents with generalized swelling. This has been present for 4days and included swollen ankles and puffiness of the face. It started a few days after he had a mild cold with runny nose. His only PMH was eczema. Urine analysis: hematuria, proteinuria 10g/24h, creat 60umol/l and albumin=15g/l. What is the single most likely dx? a. IgA nephropathy b. HSP c. Minimal change nephropathy d. Wilson’s disease e. Cardiac failure

Answer 84

Ans. The key is A. IgA nephropathy. [10 yr old boy, history of URTI and hematuria points towards the diagnosis of IgA nephropathy. It may be present with proteinuria and generalized swelling. The important differentiating point from rapidly progressive GN is duration. IgA nephropathy <1o days (usually 4/5 days history of infection but in rapidly progressive GN history of infection for >10 days].

Question 85

A 28yo man complains of vertigo, nausea and vomiting for more than 30 mins and tinnitus, hearing loss in the left ear. What is the tx for this pt? a. Buccal prochlorperazine (2nd line) b. Metachlorpromide c. Cyclazine (1st line) d. Cotrimazole e. Ondansetron

Answer 85

Ans. The key is C. Cyclizine. More appropriate is A. Buccal prochlorperazine (patient.info). [Both prochlorperazine and cyclizine can be used in Meniere’s disease].

Question 86

A 16yo girl has been unwell for 5days with malaise, headache and dry cough. She has a few crackles in her chest. Her CXR shows patchy consolidation in the lower lobes. What is the single most likely causative organism? a. Cold agglutinins b. Gram –ve diplococci in sputum c. Gram +ve diplococcic in sputum d. Serology for legionella e. Sputum staining for mycobacterium TB

Answer 86

Ans. The key is A. Cold agglutinins. [Mycoplasma pneumonia, a form of atypical bacterial pneumonia related to cold agglutinin disease].

Question 87

A child with increasing jaundice and pale stools. Choose the appropriate test: a. Endomyseal antibodies b. Sweat test c. TFT d. LFT e. US

Answer 87

Ans. The key is E. US. [This is obstructive jaundice where US may show dilatation of common bile duct or stones].

Question 88

A 73yo woman with RA is unable to extend the fingers of her right hand at the MCP joint and IP joints following a fall. What is the single most likely tendon to have been damaged? a. Extensor carpi radialis b. Extensor carpi ulnaris c. Extensor digitorum d. Extensor indicis e. Flexor digitorum profundum

Answer 88

Ans. The key is C. Extensor digitorum. [The extensor digitorum extends the phalanges, then the wrist, and finally the elbow. It acts principally on the proximal phalanges].

Question 89

You are called to see a 20yo woman 2h post-LSCS. She has not passed urine since her operation. She denied any urinary symptoms preoperatively. Exam: appears unwell, temp=37.5C, BP=94/73mmHg, pulse=116bpm, sat=97%. Her abdomen is distended with tenderness in the left flank and suprapubic region. Bowel sounds are not audible. Choose the most appropriate post Csection complication for this lady? a. UTI b. Urinary tract injury c. Pleurisy d. Acute pyelonephritis e. Paralytic ileus

Answer 89

Ans. The key is B. Urinary tract injury.

Question 90

A 58yo man has a headache and confusion of 3 days after slipping and hitting his head in the garden. What is the most appropriate initial inv? a. XR skull b. XR face c. CT brain d. MRI brain e. EEG

Answer 90

Ans. The key is C. CT brain. [The likely diagnosis is subdural haematoma for which appropriate initial investigation is CT scan of brain].

Question 91

A 4yo boy has a cough and arthritis followed by rash on legs which are non-blanching on glass test. No hx of fever. PT=13, APTT=31, Hgb=12, WBC=6.5, Plt=300. What’s the most likely dx? a. Meningitis septicemia b. Hemophilia c. HSP d. ITP e. TTP

Answer 91

Ans. The key is C. HSP. [Usually occurs below 10 yrs of age. The characteristic rash and lab findings matches with HSP].

Question 92

A 72yo man presents to the ED with chest pain. The following ECG was taken What is the most likely dx? a. Anterior MI b. Inferior MI c. Lateral MI d. Posterior MI e. NSTEMI

Answer 92

Ans. The key is B. Inferior MI. [There is pathological Q wave and mild ST elevation in leads II, III and aVF].

Question 93

A young man has diarrhea, loss of weight and flatulence for 3 days. What is the most imp tx? a. Metronidazole b. Fluconazole c. Vancomycin d. Amoxicillin

Answer 93

Ans. The key is A. Metronidazole. [An incomplete question!!]

Question 94

A 6yo child presented with drooling of saliva and severe stridor. He is febrile and sick looking. XR Neck in extension shows a thumb sign. Choose the single most likely dx. a. Croup b. URTI c. Diphtheria d. Acute epiglottitis

Answer 94

Ans. The key is D. Acute epiglottitis. [Drooling of saliva and stridor along with thumb sign in neck X-ray are features of acute epiglottitis].

Question 95

A mother presents with her 3yo son who has indistinct nasal speech. He snores at night and has restless sleep. He is tired by day. What is the best management strategy? a. Arrange hearing test b. Assess development milestones c. Refer to ENT surgeon d. Refer to speech therapist e. MRI brain

Answer 95

Ans. The key is C. Refer to ENT surgeon. [Probable enlarged adenoid].

Question 96

A 17yo boy while playing football got a kick and now he is complaining of severe pain and swelling of the left side of his scrotum. What inv is the most appropriate to dx? a. Needle aspiration of scrotum b. US scrotum c. MSU d. Surgical exploration of scrotum e. Urine test for hematuria

Answer 96

Ans. The key is D. Surgcal exploration of scrotum. [This is a case of testicular torsion which needs urgent diagnostic and therapeutic surgical exploration of the scrotum].

Question 97

A 50yo man has had hoarseness of voice and drooping eyelid for 2m. a mass is palpable in the right supraclavicular fossa. He smokes 20 cigarettes/day for the last 30yrs. What is the most likely dx? a. Carcinoma larynx b. Carcinoma thyroid c. Carcinoma right bronchus d. Mesothelioma e. Pancoast tumor

Answer 97

Ans. The key is E. Pancoast tumour. [Hoarseness of voice is due to compression of the recurrent laryngeal nerve, ptosis due to compression of the sympathetic ganglion, palpable mass in right supraclavicular fossa due to involvement of the supraclavicular lymph node. History of smoking and given picture indicates the diagnosis of Pancoast tumour].

Question 98

An 84yo man got surgical pain which is well controlled by oral morphine 60mg BD. However, now this pt is unable to swallow. What is the most appropriate next step? a. Morphine 60mg state b. Morphine 60mg TDS c. Oxycodone 10mg OD d. Morphine 60mg IV e. Fentanyl patches

Answer 98

Ans. The key is E. Fentanyl patches. [When dose of oral morphine is known and rout should be changed Phentanyl patch is adviced as the fixed dose is known and patch can release the required dose for a given period (when we use patch we can not change the dose). But if the pain control is not optimal we should follow the next step (i.e. parenteral morphine) as per pain ladder. But as no correct dose of parenteral morphine is in the options (iv morphine dose is one-third of oral morphinre) we have to go for fentanyl patches].

Question 99

A 19yo man has exercise induced asthma. This has prv been controlled using a salbutamol inhaler as req, but he now gets attacks with exercise. What is the single most appropriate tx? a. Regular salbutamol b. Regular salbutamol and budesonide c. Sodium cromoglycate d. Oral steroid e. Inhaled steroid

Answer 99

Ans. The key is C. Sodium chromoglycate. This is wrong key! Correct key should be E. Inhaled steroid. [Chrommoglycate should be used in exercise induced asthma if inhaled steroid fails].

Question 100

A 3yo boy has a sudden onset of fever, vomiting and bilateral face swelling. Few days earlier the GP saw him for bilateral parotid pain and gave analgesics. What is the most appropriate next step? a. Analgesic b. Antibiotic c. Biopsy d. Immediate surgery e. Reassurance

Answer 100

Ans. The key is E. Reassurance. [A case of mumps. Self limiting condition].