1. A 65yo man presents with painless hematuria, IVU is normal, prostate is mildly enlarged with mild frequency. What is the most appropriate next step?
a. US Abdomen b. Flexible cystoscopy c. MRI
d. Nuclear imaging e. PSA
Q. 1. What is the key?
Q. 2. Points in favour of the key.
Ans. 1. The key is B. Flexible cystoscopy.
Ans. 2. Painless hematuria in an elderly (here 65 years old man) indicates carcinoma bladder for which flexible cystoscopy is done.
An elderly gentleman complaining of painless hematuria : always exclude bladder cancer The most important and definite Investigation for bladder cancer is a cystoscopy+ Biopsy. Initially : Urine microscopy but it does not rule out CA.
Other causes of painless hematuria are rhabdomyolysis , coagulation disorder , prostate cancer , hemolytic anemia , renal tumor , and polycystic kidney disease
you can exclude those by absence of : 1- History of crush injury for rhabdomyolysis
2- No bleeding from other orifices for coagulation disorder 3- No symptoms of prostatism for Prostate Cancer 4- No signs of anemia
5- No tenderness in loin or masses (renal tumor) 6- No hypertension (in polycystic kidney)
although other investigations like Mid urine sample , IVU , may show UTI , other findings like filling defects , etc.. they dont help with diagnosis and prognosis
Diagnosis : Bladder CA. (1 in 10,000)
Most common : Transistional cell CA. 3x in MEN of 50+ age. Inc factors :
Smoking, schistosomiasis, rubber dye industries, White ppl, recurrent infections. Symptoms :
Painless hematuria (on and off) Pain in lower abdomen
Treatment :
TUR with 1 chemotherapy within 24 hours. If needed, BCG is used for next chemo
cycles.
2. A 74yo smoker presented to his GP with cough and SOB. Exam revealed
pigmentation of the oral mucosa and also over the palms and soles. Tests show that he is diabetic and hypokalemic. What is the most probable dx?
a. Pseudocushing syndrome b. Conns disease
c. Ectopic ACTH d. Cushings disease e. Hypothyroidism
Q. 1. What is the likely key? Q. 2. Please explain the key.
Ans. 1. The key is C. Ectopic ACTH.
Ans. 2. The patient is smoker and probably developed small cell lung cancer which is working as a tumour producing ectopic ACTH resulting in pigmentation. Resultant raised cortisol is leading to diabetes and hypokalemia.
the features can be explained by increased levels of ACTH and adrenocortical hormones. So the question is : ectopic or pituitary ACTH excess? It seems to be from an ectopic source since the patient is smoker and has SOB and cough ( Lung tumor whether small cell CA bronchus or carcinoid tumor- both may secrete ectopic ACTH ) . Furthermore , Cushing's disease is often the result of pituitary ACTH-secreting adenoma that also causes pressure symptoms like headache and visual disturbances which are absent in this case.
Ectopic ACTH increase the secretion of aldosterone from adrenal gland and aldosteronism causes hypernatraemia and hypokalaemia.
Cortisol is a form of stress hormone. So it induces glycogenolysis causing increase in blood glucose. No pigmentation in conn
Conns must have hypertension n not necessarily hypokalemia but it presents with signs of hypokalemia like weakness quadriparsis cramps.
Why not Cushings?
SCLC is a direct cause of ectopic ACTH (statement is clear cut - Smoker). Further ectopic acth can lead to cushings at later stages but its major cause is use of steroids and pituitary adenoma while ectopic acth is down the list. And if cushings happen, the major indicative symptoms are stria, moon face, easily fractured bones, plethora.
Diagnosis : Small Cell Lung CA causing ectopic ACTH.
Main reason : SMOKING for years. At Least 20 so age goes up to 50 to 60. Male. Symptoms :
Persistent cough, hemoptysis, chest n shoulder pains, SOB, clubbing. +/- pleural effusion, pneumonia, pins and needles in arm n shoulder sensation.
Invs :
Initial : CXR. Shows shadowing
Confirmatory : CT chest THEN Biopsy thru bronchoscope or transthoracic needle biopsy. Depends on the location.
Pleural Tap can be done if pleural effusion. Treatment :
Surgery, radio and chemo.
Prognosis : Good if early diagnosed. Bad if late.
3. A 44yo woman has lost weight over 12 months. She has also noticed episodes where her heart beats rapidly and strongly. She has a regular pulse rate of 90bpm. Her ECG shows sinus rhythm. What is the most appropriate inv to be done?
a. Thyroid antibodies b. TFT
c. ECG
d. Echocardiogram e. Plasma glucose Q. 1. What is the key? Q. 2. What is the diagnosis?
Q. 3. What is the significance of episodes of rapid strong heart beat? Ans. 1. The key is B. TFT.
Ans. 2. Thyrotoxicosis [weight loss over 12 months, episodes of rapid strong heart beet (thyrotoxicosis induced paroxysmal atrial fibrillation) points towards the diagnosis of thyrotoxicosis].
Ans. 3. Episodes of rapid strong heart beat indicates thyrotoxicosis induced paroxysmal atrial fibrillation.
Diagnosis : Hyperthyroidism/thyrotoxicosis.
Gender : more in females. 20 to 50 age.
Most common : Graves'
Symptoms :
Irritable, always on the go, losing weight despite increase appetite, palpitations, heat
intolerance, sweating, Diarrhea, SOB, itch, very light periods, increase risk of AF
and osteoporosis.
Meds that cause it : Amiodarone and lithium.
Invs : TFTS. Low TSh and high T4.
Treatment :
1. Carbimazole for 12 to 18 months.
Pregnancy - Propylthiouracil
2. Radioiodine. Should not be pregnant and conceive for at least 6 months. Father at
least 4 months.
3. Surgery
4. Beta blockers (propranolol, atenolol)
Follow up every year is very imp.
4. 79yo anorexic male complains of thirst and fatigue. He has symptoms of frequency, urgency
and terminal dribbling. His urea and creatinine levels are high. His serum calcium is 1.9 and he is anemic. His BP is 165/95 mmHg. What is the most probable dx?
a. BPH
c. Chronic pyelonephritis d. Benign nephrosclerosis Explanation of Question no. 4:
First to say in this case (almost all features goes in favour of prostatic carcinoma like- frequency, urgency and terminal dribbling are features of prostatism; Age, anorexia and anaemia favours carcinoma prostate diagnosis and it would be accurate presentation if it was hypercalcaemia. But given calcium level is of hypocalcaemic level and it is the main cause of discrepancy of this question). Renal failure can be an association of malignant disease and can cause high BP. Thirst is a feature of hypercalcaemia (here may be erroneously calcium level is given in hypocalcaemic level ; probably a bad recall). Prostate biopsy is the confirmatory diagnosis and others like PSA is suggestive. This is what I could pointed out. If there is any better explanation please place it to correct the answer- any one please.
Calcium 2.1-2.6 mmol/l
I think this patient has CKD secondary to prostate CA which leads to hypocalcemia
due to vit D def.
Osteoblastic metastases — Occasional patients with widespread osteoblastic metastases, particularly those with breast or prostate cancer, have hypocalcemia.
Diagnosis : Prostate Cancer
Most common CA in men of uk. 1 in 8 men. After 65.
Risk factors: Fatty diet, exposure to cadmium, ageing n family history. Symptoms :
Poor stream, hesitancy, dribbling, frequency, urgency, poor emptying. Invs :
Examine. PSA levels. Confirmatory test : Biopsy. Grading : Gleason Score.
4 or less - well differentiated. 10 yr risk of local progression 25% 5 - 7 - moderately differentiated. 50% risk
Over 7 - poorly differentiated. 75% risk Risk assessment PSA levels.
Low - <10 and gleason score 6 or below Intermediate - psa 10 to 20 or gleason score 7 High - psa >20 or gleason 8 to 10.
Staging : MRI preferred over CT.
Treatment : Surgery. Radical prostatectomy. S/E impotence, incontinence of urine. Radiotherapy. External and internal (brachytherapy)
HRT to stop TESTOSTERONE.
Medicines - LHRH. Goserelin, leuprorelin, triptorelin (act on pitutary) and Flutamide, cyproterone (anti androgenic)
Prognosis : variable. Depends on the stage. Complications :
UTi, AKI, CKD, sexual dysfunction, metastasis.
Note : Prostate CA has increased risk with HYPERCALCEMIA. Not hypo. So the statement seems to be wrong. Even BPH has nothing to do with Ca levels.
5. A 64yo man has recently suffered from a MI and is on aspirin, atorvastatin and ramipril. He has been having trouble sleeping and has been losing weight for the past 4 months. He doesn’t feel like doing anything he used to enjoy and has stopped socializing. He says he gets tired easily and can’t concentrate on anything. What is the most appropriate tx?
a. Lofepramine b. Dosulepin c. Citalopram d. Fluoxetine e. Phenelzine
Ans. The key is C. Citalopram. [Citalopram is the antidepressant of choice in IHD]
Citalopram is associated with dose-dependent QT interval prolongation and is contra-indicated in patients with known QT interval prolongation or congenital long QT syndrome.
Sertraline can also be used in patients with IHD for depression. sertraline is considered the drug of choice post-MI
1. Depression with obesity=fluoxetine (It helps without weight loss) 2. Depression with sexual dysfunction=mirtazapine
3. Post stroke depression use nortriptyline (TCA)
4. Depression with obsessive compulsive disorder=clomipramine (TCA) 5. Depression with ischemic heart disease=SSRI e. g citalopram
6. A 67yo man after a stroke, presents with left sided ptosis and constricted pupil. He also has loss
of pain and temp on the right side of his body and left side of his face. Which part of the brain is most likely affected?
a. Frontal cortex b. Cerebellum c. Pons d. Medulla e. Parietal cortex Q. 1. What is the key?
Q. 2. What is the name of this condition? Ans. 1. The key is D. Medulla.
Ans. 2. The name of the condition is “Lateral medullary syndrome” [ipsilateral Horner syndrome and contralateral loss of pain and temperature sense]
Lateral medullary syndrome, also known as Wallenberg's syndrome, occurs following occlusion of the posterior inferior cerebellar artery
Cerebellar features
ataxia
nystagmus
Brainstem features
ipsilateral: dysphagia, facial numbness, cranial nerve palsy e.g. Horner's
contralateral: limb sensory loss
Lateral medullary or Wallenberg's syndrome:
Usually from occlusion of the vertebral artery.
Occasionally from occlusion of the posterior inferior cerebellar artery. Involvement of the vestibular system causes nausea, vomiting and vertigo. Ipsilateral features:
o Ataxia from cerebellar involvement.
o Horner's syndrome from damage to descending sympathetic fibres.
o Reduced corneal reflex from descending spinal tract damage. o Nystagmus.
o Hypacusis. o Dysarthria. o Dysphagia.
o Paralysis of palate, pharynx, and vocal cord. o Loss of taste in the posterior third of the tongue. Contralateral findings:
o Loss of pain and temperature sensation in the trunk and limbs (anterior spinothalamic tract).
o Tachycardia and dyspnoea (cranial nerve X).
o Palatal myoclonus (involuntary jerking of the soft palate, pharyngeal muscles and diaphragm).
7. A 60yo man presents with dysphagia and pain on swallowing both solids and liquids. A barium meal shows gross dilatation of the esophagus with a smooth narrowing at the lower end of the esophagus. What is the SINGLE most likely cause of dysphagia?
a. Achalasia
b. Myasthenia gravis c. Esophageal carcinoma d. Esophageal web e. Systemic sclerosis
Ans. The key is A. Achalasia.
Achalasia typically presents in middle-age and is equally common in men and women
Investigations
manometry: excessive lower oesophageal sphincter tone which doesn't relax on swallowing -
considered
most important diagnostic test
barium swallow shows grossly expanded oesophagus, fluid level, 'bird's beak' appearance. This
is in contrast to the rat's tail appearance of carcinoma of the oesophagus
CXR: wide mediastinum, fluid level
Gold standard - Manometry Treatment
intra-sphincteric injection of botulinum toxin
Heller cardiomyotomy for fit young patients.
balloon dilation for old unwell patients.
Complications : Aspiration pneumonia, perforation, GERD, Oesophagus CA.
Dysphagia
The table below gives characteristic exam question features for conditions causing dysphagia:
Oesophageal cancer
Dysphagia may be associated with weight loss, anorexia or vomiting during eating
Past history may include Barrett's oesophagus, GORD, excessive smoking or alcohol use
Oesophagitis May be history of heartburn
Odynophagia but no weight loss and systemically well
Oesophageal candidiasis
There may be a history of HIV or other risk factors such as steroid inhaler use
Achalasia Dysphagia of both liquids and solids from the start Heartburn
Regurgitation of food - may lead to cough, aspiration pneumonia etc
Pharyngeal pouch
More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen
Systemic sclerosis
Other features of CREST syndrome may be present, namely Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia
As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased. This contrasts to achalasia where the LES pressure is increased
Myasthenia gravis
Dysphagia with liquids as well as solids
Globus hystericus May be history of anxiety
Symptoms are often intermittent and relieved by swallowing Usually painless - the presence of pain should warrant further investigation for organic causes
8. A man undergoes a pneumonectomy. After surgery, invs show hyponatremia. What could be the
cause of the biochemical change? a. Removal of hormonally active tumor b. Excess dextrose
c. Excess colloid d. Excessive K+ e. Hemodilution
Ans. The key is A. Removal of hormonically active tumour.
Small cell lung carcinoma produces acth like peptide which stimulates aldosterone secretion causing hypernatremia. Removal of that will lead to hyponatremia.
OHCM 170...Lung tumors may secrete both ACTH and ADH. If it was an ACTH secreting tumor then it's removal may cause hyponatremia. As ACTH helps in absorption of Na and water by releasing Aldosterone from adrenal gland. On the other hand if it was an SIADH secreting tumor then opposite would happen.
9. A pregnant lady came with pain in her calf muscle with local rise in temp to the antenatal clinic. What tx should be started?
a. Aspirin b. LMWH c. Paracetamol d. Cocodamol
e. Aspirin and heparin Ans. The key is B. LMWH.
During pregnancy :
Start LMWH and continue throughout pregnancy. Stop the injections 24 hours before labour and then restart them 4 hours post op. Warfarin is Contraindicated in pregnancy.
If NO pregnancy : the protocol is different. - LMWH stat
- Start Warfarin within 24 hours
- Monitor INR and withdraw LMWH when value is 2.0
- Depending on provoked or non provoked, give Warfarin for 3 and 6 months respectively and then stop.
- IVC filter is used when anticoagulants fail
Wells' diagnostic algorithm
[1] Score one point for each of the following: Active cancer (treatment ongoing or within the previous six months, or palliative).
Paralysis, paresis or recent plaster immobilisation of the legs.
Recently bedridden for three days or more, or major surgery within the previous 12 weeks, requiring general or regional anaesthesia.
Localised tenderness along the distribution of the deep venous system (such as the back of the calf).
Entire leg is swollen.
Calf swelling by more than 3 cm compared with the asymptomatic leg (measured 10 cm below the tibial tuberosity).
Pitting oedema confined to the symptomatic leg. Collateral superficial veins (non-varicose). Previously documented DVT.
Subtract two points if an alternative cause is considered at least as likely as DVT.
The risk of DVT is likely if the score is two or more, and unlikely if the score is one or less.
invs :
initial - Duplex USG
Gold standard - invasive venography
10. A 53yo female presents with an acute painful hot knee joint. She is a known case of RA. On
examination, the knee is red, tender and swollen. The hamstring muscles are in spasm. Her
temp is 38.5C and BP is 120/80mmHg. What is the SINGLE best next inv? a. Joint aspiration for cytology and culture and sensitivity
b. Joint aspiration for positive birefrengent crystals c. Joint aspiration for negative birefrengent crystals d. Blood culture
e. Serum uric acid
Q. 1. What is the likely key here?
Q. 2. Is there any link in septic arthritis and rheumatoid arthritis?
Q. 3. What is the likely organism in this age group?
Q. 4. What is the likely organism in younger age group?
Ans. 1. A. Joint aspiration for cytology and culture and sensitivity.
Ans. 2. Any chronically arthritic joint is predisposed to infection.
Moreover chronic use of steroid in Rh. arthritis is one of the important
predisposing factor.
Ans. 3. Staphylococcus
RA always involves bilateral symmetrical joints with morning stiffness. The patient presented with new complaint which is monoarticular, swollen n hot. It's clearly Septic arthritis n u do joint aspiration. Chronic use of steroids is one of the important predisposing factors.
Diagnosis : Septic Arthritis due to persistent Rheumatoid Arthritis.
The classic picture is a single swollen joint with pain on active or passive movement. It is more common in patients with prior joint damage, as in gout, rheumatoid arthritis and systemic connective tissue disorders.
Fever and rigors. Chest wall pains.
Treatment :
Flucloxacillin and for MRSA - Vancomycin.
Penicillin with Gentamicin is being used as well.
11. An 80yo man presented with pain in his lower back and hip. He also complains of waking up in
the night to go to the washroom and has urgency as well as dribbling. What is the most likely dx? a. BPH b. Prostatitis c. UTI d. Prostate carcinoma e. Bladder carcinoma Q. 1. What is the likely key?
Q. 2. What are the points in favour of your diagnosis? Q. 3. What are the investigations?
Q. 4. What are the treatment options for carcinoma prostate?
DISCUSSED IN MCQ 4.
Ans. 1. D. Prostate carcinoma.
Ans. 2. Age, nocturia, urgency and dribbling points towards prostate pathology. Pain of lower back and hip points towards bony metastases from prostate cancer.
Ans. 3. Blood test for PSA; Prostate biopsy; MRI [if initial biopsy is negative, to decide repeat biopsy]. Source NICE.
Ans. 4. Treatment options: 1. Active treatment [i) radical prostatectomy ii) radical radiotherapy iii) hormone therapy iv) brachytherapy v) pelvic radiotherapy vi) orchidectomy]
2. Active surveillance 3. Watchful waiting
4. Palliative care [Source: NICE].
12. An 18yo female has periorbital blisters. Some of them are crusted, others secreting pinkish fluid. What is the most likely dx?
a. Shingles b. Chicken pox c. Varicella d. Rubella e. Measles
Q.1. What is the likely key?
Q. 2. Which nerve is involved here? Q. 3. Is this disease unilateral or bilateral?
Ans. 1. A. Shingles
Ans. 2. Ophthalmic division of trigeminal nerve. Ans. 3. Typically shingles is unilateral.
Short note everywhere. Mcq covers it up. Treatment :
Refer to ophthalmologist. Ocular lubricants, cool compressors, topical steroids, Botulinum toxin injection if neurotrophic ulcers form.
13. A 29yo lady who is a bank manager is referred by the GP to the medical OPC due to a long hx of tiredness and pain in the joints. An autoimmune screen result showed smooth muscle
antibodies positive. What is the most appropriate next inv? a. ECG
b. TFT c. LFT
d. Serum glucose e. Jejunal biopsy
Q. 1. What is the likely key? Q. 2. What is the diagnosis?
Q. 3. What is the definitive investigation? Q. 4. What is the treatment?
Ans. 1. C. LFT
Ans. 2. Autoimmune hepatitis.
Ans. 3. Definitive investigation is liver biopsy
Ans. 4. Steroid [start with high dose prednisolone]. Azathioprine is commonly added with steroid to reduce its dose as steroid has more side effects than azathioprine.
Diagnosis : Autoimmune hepatitis. Symptoms :
Tiredness, fatigue, mild pruritus, amenorrhea, pleuritis, abdominal discomfort, Oedema, Skin rashes, acne, weight loss. Nausea is prominent.
Signs :
Hepatomegaly, splenomegaly, spider angiomata, ascites, encephalopathy, jaundice in 50%
The autoantibodies present include antinuclear antibody (ANA), anti-smooth muscle antibody (ASMA), anti-liver-kidney microsomal-1 (anti-LKM-1) antibody, antibodies against soluble liver antigen (anti-SLA), antimitochondrial antibody (AMA) and antiphospholipid antibodies.
Invs :
1. Autoantibodies. Typical is ASMA.
2. Ig G is raised. (Can lead to hyperviscosity syndrome) 3. LFTs. ALT and AST are raised. ALP maybe normal. 4. USG abdomen.
5. Liver biopsy - Confirmatory. Treatment :
Budesonide + Azathioprine Prednisolone + Azathioprine
+/- methotrexate, Anti TNF alpha drugs Liver transplant.
14. A 5yo with recurrent chest pain, finger clubbing with offensive stool. Choose the single most
likely inv?
a. Endomysial/Alpha gliadin antibody b. Sweat test
c. Barium meal d. ECG
e. Glucose tolerance test Q. 1. What is the likely key? Q. 2. What is the diagnosis?
Q. 3. What is the mode of inheritance? Ans. 1. B.
Ans. 2. Cystic fibrosis
Ans.3. Autosomal recessive.
DIAGNOSIS : Cystic FIbrosis. Mutation of CFTR on chromosome 7.
It cause dehydration. Hence, bronchiectasis, bowel obstruction and bacterial growth,
Signs
Finger clubbing.
Cough with purulent sputum. Crackles.
Wheezes (mainly in the upper lobes). INVS :
Sweat Test. Chloride concentration > 60. Sinus X ray or CT scan - Opacities of sinuses.
Lung function tests, LFTs, Sputum microbiology.
17. A man with suspected active TB wants to be treated at home. What should be done to prevent
the spread of disease?
a. Immediate start of the tx with Anti-TB drugs
b. All family members should be immediately vaccinated with BCG vaccine c. Patient should be isolated in a negative pressure chamber in his house d. Universal prevention application protocol
Ans. d. Universal prevention application protocol.
This protocol isnt available anywhere on the internet. Everybody is suggesting D on the basis of exclusion.
18. A 7yo child is brought to the ED with a 1 day hx of being listless. On examination, the child is
drowsy with an extensive non-blanching rash. What advice would you give the parents? a. All family members need antibiotic therapy
b. Only the mother should be given rifampicin prophylaxis c. All family members need isolation
d. All family members should be given rifampicin prophylaxis Q. 1. What is the likely key?
Q. 2 What is the probable diagnosis? Q. 3. What is the diagnostic investigation? Q. 4. What is the initial management?
Ans. 1. D. All family member should be given rifampicin prophylaxis Ans. 2. Meningococcal disease.
Ans. 3. Blood or CCF PCR
Ans. 4. Prehospital management: Benzyl penicillin or cefotaxime.
DIAGNOSIS : Meningococcal infection. It can be meningococcal Septicemia which is without Meningitis, or can be Meningococcal Meningitis. This Mcq doesnt have meningitis signs so we will stick to M.Septicemia.
Caused by N.Meningitidis Signs and Symptoms :
Most common and important - Non - blanching rash Fever, headache
May have : Stiff neck, back rigidity, bulging fontanelle (in infants), photophobia. Altered mental state, unconsciousness, toxic/moribund state, Kernig's sign (pain and resistance on passive knee extension with hips fully flexed) and Brudziñski's sign (hips flex on bending the head forward)
Pre-Hospital Management :
Call 999 and give Benzyl penicillin or Cefotaxime
INVESTIGATIONS :
Blood cultures.
FBC (WCC), CRP, U&Es, renal function tests, LFTs.
Blood test for polymerase chain reaction (PCR): perform whole blood real-time PCR testing - (EDTA sample) - for N. meningitidis to confirm a
diagnosis of meningococcal disease
Investigations for disseminated intravascular coagulation: prothrombin time is elevated, activated partial thromboplastin time (aPTT) is elevated, platelet count is reduced and the fibrinogen level is low.
Lumbar puncture - once the patient is stable
Aspirate from other sterile sites suspected of being infected (eg, joints) for microscopy, culture and PCR.
TREATMENT :
Choice of antibiotics in hospital :
o Ceftriaxone is usually given to those over 3 months
o Cefotaxime and amoxicillin are usually given to those under 3 months.
o Vancomycin is given in addition, to those who have recently travelled outside the UK or have had prolonged or multiple exposure to antibiotics.
CHEMOPROPHYLAXIS :
To close contacts of cases, irrespective of vaccination status - for example, those who have had prolonged close contact with the case in a household-type setting during the seven days before onset of illness
Ciprofloxacin and rifampicin are both recommended by Public Health England (PHE) but ciprofloxacin is the preferred choice for most individuals.
Ciprofloxacin can be used in all ages and in pregnancy; it is easily available in a single dose and does not interfere with oral contraceptives (but is contra-indicated if there has been previous sensitivity):
o Adults and children aged >12 years - 500 mg orally stat. o Children aged 5-12 years - 250 mg orally stat.
o Children aged <5 years - 30 mg/kg up to a maximum of 125 mg orally stat.
Rifampicin is no longer the drug of choice as, although it is licensed for chemoprophylaxis, it has several disadvantages including important drug interactions
19. A 47yo man has a temp of 39C and is delirious. He has developed blisters mainly on his trunk,
which appeared a few hours ago. He is well and not on any medications. He last travelled 5
months ago to Italy. Which of the following is the most likely dx? a. Shingles
b. Chicken pox c. Pemphigoid
d. Bullous pemphigus Q 1. What is the likely key? Q. 2. Why delirium in this patient?
Q. Is his travel history has any link to the development of this disease? Ans. 1. B. Chicken pox
Ans. 2. Adults more commonly develop a more generalized brain inflammation ("encephalitis") whose symptoms may include delirium and seizures.
Ans. 3. Incubation period of chicken-pox is 10-21 days. So this travel history is not significant.
DIAGNOSIS : Chicken POX. Why not Shingles?
Shingles is painful, while mcq does not mention it.
Shingles have dermatomal distribution while chickenpox is mainly peripheral and truncal in distribution.
Chicken pox has 10 - 21 days incubation period, and so does shingles, so this 5 months thing is wrongly stated.
The patient is delirious - suggesting ENCEPHALITIS which is the main complication of C.pox.
Scraping the blisters and the skin and checking it with immunohistochemical and PCR.
CXR and LP for its complications. (Pneumonia and Encephalitis)
Management
Chickenpox in an otherwise healthy individual
Simple advice regarding adequate fluid intake, minimising scratching if possible and that the first 1-2 days they are most infectious.
Symptomatic treatment - eg, analgesia and antipyretics such as paracetamol. There is a possible association with non-steroidal
anti-inflammatory drugs (NSAIDs) and risk of necrotising soft tissue infections. Pruritus can be helped by sedating antihistamines and emollients.
Calamine lotion is no longer recommended, as when it dries it ceases to be effective. Secondary infection may require antibiotics.
Aciclovir should be considered if the patient presents within 24 hours Anyone with encephalitis - should be admitted to hospital.
20. A 64yo pt has been having freq episodes of secretory diarrhea, which is extremely watery, with large amts of mucus. A dx of villous adenoma was made after endoscopy. What electrolyte
abnormality is most likely in this pt? a. Hyperkalemia
b. Hypernatremia c. Hyponatremia d. Hypokalemia e. Hypercalcemia
Q. 1. What is the likely key? Q. 2. Why this occurs? Ans. 1. D
Ans. 2. There is active potassium secretion causing high fecal potassium concentration leading to this hypokalaemia in secretory diarrhea. There is also reduced potassium absorption in diarrhea.
Electrolyte loss in diarrhoea (Na, K, Mg, Cl). But potassium loss is more marked especially in severe, chronic and when associated with mucous loss. Villous adenomas secrete protein n potassium rich mucus so hypoalbuminemia n hypokalemia
Hypokalaemia is usually defined as a serum concentration of potassium <3.5 mmol/L. It can be classified as follows:
Mild - 3.1 - 3.5 mmol/L Moderate - 2.5 - 3.0 mmol/L Severe - <2.5 mmol/L
Flat T waves ST depression Prominent U waves
NB: the QT interval may appear prolonged, but this is usually a pseudo-prolongation as the flattened T waves merge into the U waves.
MAIN CAUSES OF HYPOKALEMIA.
KIDNEY causes :
Thiazide or loop diuretics (the most common cause) Renal tubular acidosis
Hypomagnesaemia
Hyperaldosteronism - eg, Conn's syndrome, renal artery stenosis, Cushing's disease Tubulo-interstitial renal disease due to Sjögren's syndrome or systemic lupus
erythematosus
Excess liquorice ingestion
Activation of the renin-angiotensin system - eg, Bartter's syndrome or Gitelman's syndrome
Via the GI tract: Diarrhoea
Vomiting (bicarbonate diuresis) Intestinal fistulae
Villous adenoma Pyloric stenosis Laxative abuse
Bowel preparation with oral sodium phosphate solution Via the skin:
Burns
Increased sweating - eg, exercising in a hot climate Increased loss in sweat - eg, cystic fibrosis
21. A pt with an acute gout attack came to the ED. What drug should be given to relieve symptoms?
a. NSAIDs b. Allopurinol c. Ibuprofen
Q. 1. What is the key?
Q. 2. What is the acute management of gout? Ans. 1. A
Ans. 2. Oral NSAIDs commenced immediately and continue for 1 – 2 weeks; Colchicine can be effective alternative but is slower to work than NSAIDs. Intra articular
DIAGNOSIS : GOUT Cause : Interleukin - 1
Risk factors
Male sex, Meat, Seafood, Alcohol (10 or more grams per day), Diuretics, Obesity, Hypertension, Coronary heart disease, Diabetes mellitus, Chronic renal failure, High triglycerides
Pharmacological therapeutic options include:
Non-steroidal anti-inflammatory drugs (NSAIDs) Colchicine
Corticosteroids
NOTE : This MCQ has NSAIDS and Ibuprofen in options which is from the same group
but the preferred NSAIDS are : Diclofenac, naproxen and indomethacin.
Colchicine is particularly appropriate when NSAIDs are poorly tolerated, in patients with heart failure and in those who are on anticoagulants.
30-35 mg of prednisolone reported a low incidence of side-effects
Allopurinol should never be started during an acute attack. Wait for 1-2 weeks after the attack resolves.
Co-prescribe colchicine or a low dose non-steroidal anti-inflammatory drug (NSAID) to prevent an attack of gout whilst initiating therapy, and continue until after hyperuricaemia has settled (usually a total of three months).
If an acute attack develops during treatment, maintain the dose of allopurinol but add colchicine or NSAIDs.
22. A pt was lying down on the operating table in a position with his arms hanging down for 3 hours. Soon after he woke up, he complains of numbness and weakness in that hand and has limited wrist movement/wrist drop and sensory loss over dorsum of that hand, weakness of extension of the fingers and loss of sensation at the web of the thumb. What structure is likely to be damaged?
a. Radial nerve b. Median nerve c. Ulnar nerve d. Axillary nerve
e. Suprascapular nerve ANS is A. Radial Nerve.
Radial nerve, in spiral grove on humerus is pressed and damaged. It is also called saturday night palsy.
23. A pt who was previously on 120mg slow release oral morphine has had his dose increased to
200mg. He is still in significant pain. He complains of drowsiness and constipation. What is the
next step in the management?
a. Increase slow release morphine dose b. Fentanyl patch
c. Replace morphine with oral hydromorphone d. Replace morphine with oxycodone
e. Subcutaneous morphine
Q. 1. What is the likely key? D - Replace morphine with oxycodone. Q. 2. Why not other options? X
Morphine Start with oral solution 5–10mg/4h PO with an equal breakthrough dose as often as required. A double dose at bedtime can enable a good night’s sleep. Patient needs will vary greatly and there is no maximum dose; aim to control symptoms with minimum side-effects. If not effective, increase doses in 30–50% increments
(5mg10mg20mg30mg45mg). Change to modified release preparations (eg MST Continus® 12h) once daily needs are known by totalling 24h use and dividing by 2. Prescribe 1/6th of the total daily dose as oral solution for breakthrough pain. Side effects (common) are drowsiness, nausea/vomiting, constipation and dry mouth. Hallucinations and myoclonic jerks are signs of toxicity and should prompt dose review. If the oral route is unavailable try morphine/diamorphine IV/SC. If difficulty tolerating morphine/diamorphine, try oxycodone PO/IV/SC/PR, starting at an equivalent dose. It is as effective as morphine and is a useful 2nd-line opioid with a different range of receptor activity. There are also fentanyl transdermal patches which should usually be started under
specialist supervision (after opioid dose requirements have been established). Remove after 72h, and place a new patch at a different site. 45mg oral morphine/24h is
approximately equivalent to a 12mcg/h fentanyl patch.
24. A 40yo woman notices increasing lower abdominal distention with little/no pain. On examination, a lobulated cystic mass is felt and it seems to be arising from the pelvis. What is
the most appropriate inv? a. CA 125
b. CA 153 c. CA 199 d. CEA e. AFP
Q. 1. What is the likely key? Q. 2. What is the likely diagnosis? Ans. 1. A
Ans. 2. Ovarian ca. X DIAGNOSIS : Ovarian CA Age - 60 to 80 women SYMPTOMS :
Early symptoms are often vague, such as abdominal discomfort, abdominal distension or bloating, urinary frequency or dyspepsia. Constitutional symptoms include fatigue, weight loss, anorexia and depression.
It most commonly presents with a pelvic or abdominal mass that may be associated with pain. Abdominal, pelvic or back pain is usually a late sign It may cause abnormal uterine bleeding.
Often associated with ascites. One third of patients with ascites also have a pleural effusion.
INVESTIGATIONS :
CA-125 test.
If this is reported as raised (35 IU/mL or greater) arrange pelvic and abdominal ultrasound scans.
CT is the investigation of choice in the UK Treatment :
The standard comprehensive surgical staging approach consists of a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH and BSO)
The standard regime is paclitaxel and carboplatin given intravenously every three weeks for six cycles.
Radiotherapy. PRGNOSIS : Stage I: 92% Stage II: 55% Stage III: 21.9% Stage IV: 5.6%
25. A resident of a nursing home presented with rashes in his finger webs and also on his abdomen, with complaints of itching which is severe at night. He was dx with scabies. What the best tx for
his condition? a. 0.5% permethrin b. Doxycycline c. 5% permethrin d. Reassure e. Acyclovir
Q. 1. What is the likely key?
Q. 2. Will you consider any other treatment beside this? Ans. 1. C
Ans. 2. Scabies outbreaks in nursing homes and cases of crusted scabies may require combination therapy consisting of topical application of permethrin and 2 oral doses of ivermectin at 200 mcg/kg (administered 1 wk apart). X
DIAGNOSIS : SCABIES
signs and symptoms develop after 3-4 weeks. Symptoms reappear within 1-3 days if the person is re-infested due to prior sensitisation.
The most common presenting symptom is widespread itching. This is usually worse at night and when the person is warm. A history of several family members all suffering with itch is strongly suggestive of scabies. Scratching predisposes to secondary bacterial infection.
Lesions may be papules, vesicles, pustules, and nodules. Erythematous papular or vesicular lesions are usually seen in the sites of the burrows. The more widespread, symmetrical, itchy, papular eruption is not in the areas of burrows or obvious mite activity. This is most commonly seen around the axillae, the peri-areolar region of the breasts in women, and the abdomen, buttocks, and thighs.
The 'wake' sign is specific for scabies, can be seen with the naked eye and points towards the location of the mite.
Hyperkeratotic crusted lesions called as Crusted Norwegian Scabies INVS :
Ink Burrow Test.
Diagnosis can be confirmed by taking a skin scraping from an affected area. TREATMENT :
First line : Permethrin 5%
2nd line : malathion 0.5% aqueous liquid
26. A 34yo alcoholic is found passed out in front of a local pub. The ambulance crew informs you
that he was sweating when they found him and there were cans of cider lying empty around
him. What is the initial stage of inv? a. Capillary blood sugar
b. CT head c. MRI head d. ABG e. MCV key: A
Hypoglycemia: blood glucose <3.0 mmol/L
alcohol exerts hypoglycemic effects through inhibiting both gluconeogenesis and glycogenolysis , especially when the drinker already has starvation or adrenocortical insufficiency.
Here we need to find the causes of passed out..first thing first.glucose for hypo...ABG can help to find acidosis which is likely to find in alcohol poisoning..MCV it will b increased in alcoholic but we are more likely to look for anaemia in this as there may b H&M which could lead pt to pass out..CT head for SDH.
Tight glycaemic control.
Malabsorption.
Injection into lipohypertrophy sites.
Alcohol.
Insulin prescription error (notable in hospitalised patients).
Long duration of diabetes.
Renal dialysis.
Drug interactions between hypoglycaemic agents - eg, quinine, selective serotonin reuptake inhibitors (SSRIs).
Impaired renal function.
Lack of anti-insulin hormone function - eg, Addison's disease, hypothyroidism.
Initially
Glucose 10-20 g is given by mouth, either in liquid form or as granulated sugar (two teaspoons) or sugar lumps
Repeat capillary blood glucose after 10-15 minutes; if the patient is still hypoglycaemic then the above can be repeated (probably up to 1-3 times).
If hypoglycaemia causes unconsciousness, or the patient is unco-operative
75-80 ml 20% glucose or 150-160 ml of 10% glucose (the volume will be determined by the clinical scenario).
25 ml of 50% glucose concentration is viscous, making it more irritant and more difficult to administer, and is rarely used now.
Once the patient regains consciousness, oral glucose should be administered, as above.
If the patient is at home, or intravenous (IV) access cannot be rapidly
established
Glucagon 1 mg should be given by intramuscular (IM), or subcutaneous (SC) injection.
This dose is used in insulin-induced hypoglycaemia (by SC, IM, or IV injection), in adults and in children over 8 years (or body weight over 25 kg). NB: 1 unit of glucagon = 1 mg of glucagon.
The patient must be admitted to hospital if hypoglycaemia is caused by an oral antidiabetic drug, because the hypoglycaemic effects of these drugs may persist for 12-24 hours and ongoing glucose infusion or other therapies such as octreotide (see under 'Hypoglycaemia which causes unconsciousness or fitting is an emergency', below) may be required.
Glucagon
Glucagon can have variable absorption, as it is given SC or IM. It has a relatively slow onset of action and relies on glycogen stores. Therefore, it may not be effective in cachectic patients, those with liver disease, and in young children. It is contra-indicated in insulinoma and phaeochromocytoma. It also causes more insulin to be released and creates the potential for secondary rebound hypoglycaemia.
27. A young boy fell on his outstretched hand and has presented with pain around the elbow. He
has absent radial pulse on the affected hand. What is the most likely dx? a. Dislocated elbow
b. Angulated supracondylar fx c. Undisplaced fx of radial head d. Posterior dislocation of shoulder Q. 1. What is the key?
Q. 2. What is the cause of absent radial pulse? Q. 3. What is the immediate management? Ans. 1. b.
Ans. 2. Damage or occlusion of the brachial artery is the cause of absent radial pulse. Ans. 3. Open reduction to fix the occluded artery.
This scenario is classic for supracondylar fx,the distal humerus is displaced posteriorly causes vascular and nerve injuries which if not addressed properly leads to volkmann contracture
posterior dislocation can compromise vascular supply but falling on outstretched hand causes it unlikely. Other causes of pulseless radial artery except the two above ?
congenital absence,embolization, cervical rib, thoracic outlet syndrome
falling on an outstretched hands can lead to different type of fractures , like frac of clavicle , radius , supracondylar etc. but here it says that radial pulse is not felt ,which is a dreaded complication of supracondylar frac
Mechanism of injury in elbow fractures and dislocation
Radial head and neck fractures
Fall on to an outstretched hand
Olecranon fractures
Elderly - indirect trauma by pull of triceps and brachioradialis
Children - direct blow to elbow
Fractures of the coronoid process
Fall on to an extended elbow as for elbow dislocation
Fractures of the distal humerus
Fall on to an extended outstretched hand
Condylar fractures Direct blow to a flexed elbow
Capitellum fracture Fall on to an outstretched hand, or direct trauma
Elbow dislocation
Fall on to an extended elbow Common in sport in the young
28. A 65yo woman presented with transient arm and leg weakness as well as a sudden loss of vision in the left eye. Her symptoms resolved within the next couple of hours. What is the most
appropriate next inv? a. CT brain
b. Echo
c. Doppler USG d. Arteriography e. 24h ECG
Q. 1. What is the key?
Q. 2. What is the likely diagnosis?
Q. 3. What will be seen on dopplar USG? Q. 4. What is the management?
Ans. 1. The key is c. Ans. 2. TIA
Ans. 3. Carotid artery narrowing
Ans. 4. Aspirin 300 mg daily for 2 weeks then aspirin 75mg daily and modified released dipiridamol 200mg 12 hourly.
unilateral blindness is typical sign for carotid stenosis The duration is no more than 24 hours in tia
The most common source of emboli is the carotids, usually at the bifurcation.
People who have had a suspected TIA who need brain imaging (ie the vascular territory or pathology is uncertain) should undergo diffusion-weighted MRI except where contra-indicated, in which case CT should be used.
People who have a suspected TIA at high risk of stroke (eg, an ABCD2 score of 4 or above - see below) in whom vascular territory or pathology is uncertain should undergo urgent brain imaging (preferably diffusion-weighted MRI).
People with a suspected TIA at low risk of stroke (eg, an ABCD2 score of less than 4) in whom vascular territory or pathology is uncertain should undergo brain imaging within one week of onset of symptoms (preferably diffusion-weighted MRI).
Driving
Must not drive for one month.
No need to notify DVLA after a single TIA.
Multiple TIAs over a short period: require three months free from further attacks before resuming driving and DVLA should be notified.
Group 2 (lorry or bus)
Licence refused or revoked for one year following a stroke or TIA.
Assessment of the risk of stroke
An ABCD2 score of more than 4 suggests high risk of an early stroke.
Scoring System for Risk of Stroke after TIA (ABCD2 Score)
Age Age >60 1
Blood pressure BP>140 systolic and/or >90 diastolic 1
Clinical features Unilateral weakness 2
Speech disturbance without weakness 1
Other 0
Duration of symptoms >60 minutes 2
10-59 minutes 1
Diabetes Presence of diabetes 1
RCP recommendations
Patients with suspected TIA who are at high risk of stroke (eg, an ABCD2 score of 4 or above) should receive:
o Aspirin or clopidogrel (each as a 300 mg loading dose and then 75 mg daily) and a statin started immediately.
o NB: clopidogrel is not licensed for the management of TIA and therefore the
National Institute for Health and Care Excellence (NICE) and the British National Formulary (BNF) recommend aspirin plus modified-release dipyridamole.
o Specialist assessment and investigation within 24 hours of onset of symptoms.
People with crescendo TIA (two or more TIAs in a week), atrial fibrillation or those on anticoagulants should be treated as being at high risk of stroke even if they may have an ABCD2 score of 3 or below.
Patients with suspected TIA who are at low risk of stroke (eg, an ABCD2 score of 3 or below) should receive:
o Aspirin or clopidogrel (each as a 300 mg loading dose and then 75 mg daily) and a statin.
o NB: clopidogrel is not licensed for the management of TIA and therefore NICE
and the BNF recommend aspirin plus modified-release dipyridamole.
Patients with TIA in atrial fibrillation should be anticoagulated in the TIA clinic once intracranial bleeding has been excluded and if there are no other contra-indications.
29. A man complains of loss of sensation in his little and ring finger. Which nerve is most likely to be involved?
a. Median nerve b. Ulnar nerve c. Radial nerve
d. Long thoracic nerve e. Axillary nerve Ans. b.
30. A young man complains of double vision on seeing to the right. Which nerve is most likely to be involved? a. Left abducens b. Right abducens c. Left trochlear d. Right trochlear e. Right oculomotor Ans. b.
31. A 45yo man keeps having intrusive thoughts about having dirt under the bed. He can’t keep
himself from thinking about these thoughts. If he tries to resist, he starts having palpitations.
What is the most likely dx? a. OC personality
b. OCD
c. Schizophrenia d. Panic disorder e. Phobia
Q. 1. What is the key?
Q. 2. What is the managemment? Ans. 1. b.
Ans. 2. CBT 1st line. SSRIs.
intrusive thoughts and anxiety when trying to fight them mean OCD.
32. A 33yo man presents with an itchy scaly annular rash on his thigh after a walk in the park. Which of the following drugs will treat his condition?
b. Doxycycline c. Penicillin d. Amoxicillin
Q. 1. What is the key? Q. 2. What is the diagnosis? Ans. 1. b.
Ans. 2. Lyme disease.
Lyme disease is caused by the spirochaete Borrelia burgdorferi and is spread by ticks Features
early: erythema chronicum migrans + systemic features (fever, arthralgia) CVS: heart block, myocarditis
neuro: cranial nerve palsies, meningitis Investigation
serology: antibodies to Borrelia burgdorferi Management
doxycycline if early disease. Amoxicillin is an alternative if doxycycline is contraindicated (e.g. pregnancy)
ceftriaxone if disseminated disease
Jarisch-Herxheimer reaction is sometimes seen after initiating therapy: fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)
33. A pt with cerebral mets has polyuria and polydipsia. What part of the brain would be affected? a. Cerebral cortex b. Cerebellum c. Diencephalon d. Pons e. Medulla
Q. 1. What is the key? Q. 2. What is the diagnosis? Ans. 1. c.
Ans. 2. Cranial diabetes insipidus.
diencephalon contains hypothalamus centre for thirst. Other causes of polyuria and thirst.
Psychogenic or primary polydipsia (PP).
Diabetes mellitus.
Other osmotic diureses - eg, hypercalcaemia.
Diuretic abuse. Investigation
high plasma osmolality, low urine osmolality water deprivation test
34. A 32yo man presented with painless hematuria. He is hypertensive but the rest of the exam is
unremarkable. What is the most likely dx? a. Polycystic kidneys
b. Ca bladder c. Ca prostate d. TTP
e. HUS
Q. 1. What is the key?
Q. 2. What are the points to justify your answer? Q. What is the investigation of choice?
Ans. 1. A.
Ans. 2. Painless haematuria at an younger age with hypertension. Ans. 3. Renal ultrasound.
autosomal dominant
Gross haematuria following trauma is a classic presenting feature of ADPKD,Advise against participating in contact sports which risk abdominal trauma
polycystic kidneys can produce excess erythropoietin and hence raise Hb
Angiotensin-converting enzyme (ACE) inhibitors or angiotensin-II receptor antagonists are the preferred choice
35. A 45yo female complains of pain in the inner side of her right thigh. She was dx with benign
ovarian mass on the right. Which nerve is responsible for this pain? a. Femoral nerve
b. Obturator nerve c. Iliohypogastric nerve
d. Ovarian branch of splanchic nerve e. Pudendal nerve
Ans. B. [The Obturator nerve is responsible for the sensory innervation of the skin of the medial aspect of the thigh].
36. A 37yo lady strongly believes that a famous politician has been sending her flowers every day
and is in love with her. However, this is not the case. What is the most likely dx? a. Erotomania
b. Pyromania c. Kleptomania d. Trichotillomania e. Grandiosity
Ans. 1. A. [Erotomania is a type of delusion in which the affected person believes that another person, usually a stranger, high-status or famous person, is in love with them]. Pyromania fail to resist impulses to deliberately start fires, in order to relieve tension or for instant gratification.
Kleptomania is the inability to refrain from the urge to steal items.
Trichotillomania compulsive urge to pull out one's hair, leading to noticeable hair loss and balding.
Grandiosity refers to an unrealistic sense of superiority.
37. A 3yo child has been brought with facial lacerations. On examination he has some cuts over his right cheek and under the eye. The GCS on initial evaluation is 15. What is the appropriate next inv?
a. Skull XR b. Facial XR c. CT scan d. MRI e. Observation Ans. b.
If u have cuts over ur cheek..there is high chance that there can be a fracture of a facial bone..hence by observing u dont want to wait for a hematoma to form then go for a facial xr Skull xray isnt of any value as the gcs is 15!
38. A 73yo woman has lymphadenopathy and splenomegaly. She feels well but has had recurrent
chest infections recently. Choose the single most likely blood film findings? a. Atypical lymphocytes
b. Excess of mature lymphocytes c. Plasma cells
d. Multiple immature granulocytes with blast cells e. Numerous blast cells
Q. 1. What is the key? Q. 2. What is the diagnosis?
Q. 3. Points in favour of your answer? Ans. 1. B.
Ans. 2. CLL
Ans. 3. Age of patient (usually above 50 yrs), lymphadenopathy and splenomegaly, appearance of lymphocytes (mature lymphocytes – but functionally not normal). Repeated chest infection points towards abnormal function of lymphocytes against infection.
It's CLL because in CML the risk age is 40-60 years, and in CBC there should be increased myeloid cells(which is absent in options). If I exclude these factors, then the possible DX would be CLL and film finding is B.
1. Acute lymphoblastic leukemia- abnormal immature lymphocytes, (can be immature B or T lymphocytes) called lymphoblasts. 2. Chronic lymphocytic leuaemia- Excess of mature lymphocytes. 3. Acute myeloid leukaemia- blast cells (abnormal immature white cells) derived from myeloid stem cells. 4. Chronic myeloid leukaemia- near normal granulocytes developed from abnormal stem cells (these are mature cells). Also age is a factor ALL in any age but common in child, AML- age over 50, CLL common over age 60, CML- in adults and commoner with increasing age.
39. A lady presents with itching around the breast and greenish foul smelling discharge from the
nipple. She had a similar episode before. What is the most likely dx? a. Duct papilloma
b. Duct ectasia c. Breast abscess d. Periductal mastitis e. Mammary duct fistula Q. 1. What is the key?
Q. 2. What other options (breast conditions) frequently come in plab mcq? Ans. 1. Key is b.
Ans. 2. 1. Breast ca 2. Duct papilloma and intraductal papilloma (both are same thing) 3. Mammary duct fistula 4. Breast abscess. X
Mammary duct ectasia
Dilatation of the large breast ducts Most common around the menopause
May present with a tender lump around the areola +/- a green nipple discharge If ruptures may cause local inflammation, sometimes referred to as 'plasma cell mastitis'
Duct papilloma Local areas of epithelial proliferation in large mammary duct May present with blood stained discharge
Breast abscessMore common in lactating women Red, hot tender swelling purulent discharge.
Periductal mastitis occurs when the ducts under the nipple become inflamed and infected. It's a benign condition (not cancer), which can affect women of all ages but is more common in younger women. Symptoms include: the breast becoming tender and hot to the touch. the skin may appear reddened. Mammary duct fistulaThis is a communication between the skin and a major subareolar breast duct.
It may occur following incision and drainage of a non-lactating abscess, spontaneous discharge of a periareolar mass or following biopsy of a periductal inflammatory mass.
40. A young male whose sclera was noted to be yellow by his colleagues has a hx of taking OTC
drugs for some pain. Tests showed raised bilirubin, ALT and AST normal. The provocation test
with IV nicotinic acid is positive and produces further rise in the serum bilirubin levels. What is
the most likely dx? a. Acute hepatitis b. Drug hypersensitivity c. Gilberts syndrome d. Acute pancreatitis
Q. 1. Does nicotinic acid provocation test can differentiate between CLD and Gilberts? Q. 1. What is the key?
Q. 2. What are the points in favour of your diagnosis? Ans. 1. C.
Ans. 2. Only bilirubin is increased but not the liver enzymes. Also positive nicotinic acid provocation test is in its favour. X
Normal AST and ALT rules out any possible insult to the liver.
drug hypersensitivity will not give positive nicotinic acid provocation test.
autosomal recessive condition of defective bilirubin conjugation due to a deficiency of UDP glucuronyl transferase
unconjugated hyperbilirubinemia (i.e. not in urine)
diagnosed around puberty, and aggravated by intercurrent illness, stress, fasting or after administration of certain drugs
Investigation and management
investigation: rise in bilirubin following prolonged fasting or IV nicotinic acid
no treatment required *********************
41. A 24yo biker has been rescued after being trapped under rocks for almost 12h. He complains of reddish brown urine. His creatinine is 350umol/L and his urea is 15mmol/L. What is the most
imp step in the management of this patient? a. Dialysis
b. IV NS c. IV dextrose d. IV KCl e. Pain relief
Q. 1. What is the key?
Q. 2. What is the likely diagnosis? Ans. 1. Key is B.
Ans. 2. Rhabdomyolysis. X
Crush syndrome is characterised by:
Hypovolaemic shock
Metabolic acidosis .
Acute kidney injury.
Disseminated intravascular coagulation (DIC).
ECG may show changes secondary to hyperkalaemia.
In the adult, a saline infusion of 1,500 ml/hour should be initiated during extrication. Early, vigorous hydration (≥10 litres/day) helps preserve renal function.
42. A 74yo man who has been a smoker since he was 20 has recently been dx with SCLC. What
serum electrolyte picture will confirm the presence of SIADH? a. High serum Na, low serum osmolarity, high urine osmolarity b. Low serum Na, low serum osmolarity, high urine osmolarity c. Low serum Na, high serum osmolarity, high urine osmolarity d. High serum Na, low serum osmolarity, low urine osmolarity e. High serum Na, high serum osmolarity, low urine osmolarity Ans. b.
SIADH means excess ADH so water retention which will lead to dilutional hyponatremia and decrease in serum osmolarity and sebsequent increase in urine osmolarity
Management: treat the cause and restrict fluid.
if severe: salt+- loop diuretics vaptans can be used.
43. A man brought into the ED after being stabbed in the chest. Chest is bilaterally clear with
muffled heart sounds. BP is 60/nil. Pulse is 120bpm. JVP raised. What is the most likely dx? a. Pulmonary embolism b. Cardiac tamponade c. Pericardial effusion d. Hemothorax e. Pneumothorax Ans. b.
Beck's triad : low bp , muffled HS, raised jvp .. Cardiac tamponade Features
dyspnoea
raised JVP, with an absent Y descent - this is due to the limited right ventricular filling tachycardia
hypotension
muffled heart sounds pulsus paradoxus
Kussmaul's sign (much debate about this) ECG: electrical alternans
44. A 50yo pt is admitted for elective herniorraphy. Which of the following options will lead to a
postponement of the operation? a. SBP 110mmHg
b. MI 2 months ago c. Hgb 12g/dl
d. Pain around hernia e. Abdominal distention
Key is B. After MI elective surgery should not be done before 6 months post MI. Criteria for postponing elective surgery. ...Hb <10 ,
Plt count <50000 Systolic BP... <90
Uncontrolled HTN, DM , asthma MI within 3 months
45. A 32yo woman of 39wks gestation attends the antenatal day unit feeling very unwell with
sudden onset of epigastric pain associated with nausea and vomiting. Her temp is 36.7C. Exam:
she is found to have RUQ tenderness. Her blood results show mild anemia, low platelets,
elevated liver enzymes and hemolysis. What is the most likely dx? a. Acute fatty liver of pregnancy
b. Acute pyelonephritis c. Cholecystitis
d. HELLP syndrome e. Acute hepatitis Q. 1. What is the key?
Q. 2. What is the main treatment Ans. 1. D.
Ans. 2. The main treatment is to deliver the baby as soon as possible [as early as after 34 weeks if multisystem disease is present].
HELLP syndrome is a group of symptoms that occurs in pregnant women who have pre-eclampsia or pre-eclampsia and who also show signs of liver damage and abnormalities in blood clotting.
H aemolysis
EL (elevated liver) enzymes
LP (low platelet) count
46. A woman comes with an ulcerated lesion 3 cm in the labia majorum. What is
the lymphatic drainage of this area?
a. External iliac
b. Superficial inguinal LN
c. Para-aortic
d. Iliac
e. Aortic
47. A man post-cholecystectomy presented with jaundice, fever and dark urine. What is the most diagnostic inv? a. ERCP b. USG Abdomen c. CT Scan d. MRCP e. MRI
Q. 1. What is the key?
Q. 2. What is the likely diagnosis? Ans. 1. A. ERCP
Ans. 2. Cholangitis. Post cholescytectomy syndrome? investigation of choice in post cholecystectomy syndrome is ercp
Charcot's triad of right upper quadrant (RUQ) pain, fever and jaundice Management
intravenous antibiotics
endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
Acute pancreatitis (unless persistently raised or worsening bilirubin suggests ongoing obstruction)
Previous pancreatoduodenectomy
Coagulation disorder if sphincterotomy planned
Recent myocardial infarction
Inadequate surgical back-up
History of contrast dye anaphylaxis
Poor health condition for surgery
Severe cardiopulmonary disease
48. A 79yo stumbled and sustained a minor head injury 2 weeks ago. He has become increasingly
confused, drowsy and unsteady. He has a GCS of 13. He takes warfarin for Afib. What is the most likely dx?
a. Extradural hemorrhage b. Cerebellar hemorrhage c. Epidural hemorrhage d. Subdural hemorrhage e. Subarachnoid hemorrhage Q. 1. What is the key?
Q. 2. What is the management? Ans. 1. D.
Ans. 2. 1st line: Evacuation by burr hole craniostomy. 2nd line: Craniotomy if the clot is organized.
The gradual onset of symptoms supports the dx
Subdural hematoma as old shrunken /alcoholic brains are prone to develop tear in the veins which bleed slowly and eventually the hematoma gets big enough to show the symptoms
Also in this case the patient is on warfarin
Type of injury Notes
Extradural (epidural) haematoma
Often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.
Features
features of raised intracranial pressure some patients may exhibit a lucid interval
Subdural haematoma
Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes.
Slower onset of symptoms than a epidural haematoma.
Subarachnoid haemorrhage
Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury
worst headache.
49. A 25yo female complains of intermittent pain in her fingers. She describes episodes of
numbness and burning of the fingers. She wears gloves whenever she leaves the house. What is
the most probable dx? a. Kawasaki disease b. Takayasu arteritis c. Buerger’s disease d. Embolism e. Raynaud’s phenomenon Ans is e.
wearing glove is the catch phrase
Takayasu;pulseless disease, will present with other symptoms like unequal pulses,diziness,weakness fr buergers hx of smoking...age usually more then 40.buerger's disease should present with smoking hx of an aged male.
Management
first-line: calcium channel blockers e.g. nifedipine
IV prostacyclin infusions: effects may last several weeks/months
50. A 22yo lady has been unwell for some time. She came to the hospital with complaints of fever
and painful vesicles in her left hear. What is the most probable dx? a. Acne
b. Herpes zoster c. Chicken pox d. Insect bite e. Cellulitis
Q. 1. What is the key?
Q. 2. What is the specific name of the condition?
Ans. 1. Herpes Zoster
Ans. 2. Herpes zoster oticus/Ramsay hunt syndrome.
Ramsey hunt syndromePainful vesicles in her left ear
Features
auricular pain is often the first feature
facial nerve palsy
other features include vertigo and tinnitus Management
oral aciclovir and corticosteroids are usually given
51. A 5yo girl had earache and some yellowish foul smelling discharge, perforation at the attic and
conductive hearing loss. She has no past hx of any ear infections. What is the most appropriate dx? a. Acute OM b. OM with effusion c. Acquired cholesteatoma d. Congenital cholesteatoma e. Otitis externa
Q. 1. What is the key?
Q.2. What are the points in favour of your diagnosis? Ans. 1. The key is c. Acquired cholesteatoma. Ans. 2. Ans. 1. The key is c. Acquired cholesteatoma.
Ans. 2. acquired cholesteatomas develop as a result of chronic middle ear infection and are usually associated with perforation of the tympanic membrane at the attic (mass is seen in attic with perforation at pars flaccida- in contrast to medial to tympanic membrane which is in
congenital). Clinical presentation usually consists of conductive hearing loss, often with purulent discharge from the ear
In congenital
• mass medial to the tympanic membrane • normal tympanic membrane
• no previous history of ear discharge, perforation or ear surgery.
52. A female with T1DM would like to know about an deficiency of vitamins in pregnancy that can
be harmful. A deficiency of which vitamin can lead to teratogenic effects in the child? a. Folic acid
b. Vit B12 c. Thiamine d. Riboflavin e. Pyridoxine Ans. A. Folic acid.
Diet: To prevent neural tube defects (NTD) and cleft lip, all should have folate rich foods + folic acid 0.4mg daily >1 month pre-conception till 13wks (5mg/day if past NTD, on anti epileptics, obese (BMI ≥30), HIV+ve on co-trimoxazole prophylaxis, diabetic or sickle cell disease.
Smoking: decreases ovulations, causes abnormal sperm production (± less penetrating capacity),
rates of miscarriage (≈2), and is associated with preterm labour and lighter-for-dates babies placenta praevia and abruption. Reduced reading ability in smokers’ children up to 11yrs old shows that long term effects are important.
Alcohol consumption: High levels of consumption are known to cause the fetal alcohol syndrome. Mild drinking eg 1–2U/wk has not been shown to adversely affect the fetus. Especially harmful in weeks 3-8.Miscarriage rates are higher among drinkers of alcohol
53. A 23yo woman has been having pain at the base of her thumb, the pain is reproduced when
lifting her 3 month old baby or changing diapers and also with forceful abduction of the thumb
against resistance. What is the likely cause? a. Avascular necrosis of scaphoid
b. Trigger finger.
c. De Quervain’s tenosynovitis Q. 1. What is the key?
Q. 2. How will you diagnose the case?
Ans. 1. The key is c. De Quervain’s tenosinovitis. Ans. 2. Can be diagnosed by Finkelstein’s test:
The physician grasps the thumb and the hand is ulnar deviated sharply. If sharp pain occurs along the distal radius (top of forearm, about an inch below the wrist), de Quervain's syndrome is likely.
De Quervain's tenosynovitis is a common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed. It typically affects females aged 30 - 50 years old
Features
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
Finkelstein's test: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation
Management analgesia steroid injection
immobilisation with a thumb splint (spica) may be effective surgical treatment is sometimes required