@DrVijay wrote:
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
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].
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
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].
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
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].
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
Ans. The key is C. Sodium chromoglycate. [Chrommoglycate should be used in exercise induced asthma (Samson note)].
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
Ans. The key is E. Reassurance. [A case of mumps. Self limiting condition].
A 75yo man with adenocarcinoma of the prostate which has spread outside the capsule of the
gland has ARF. What is the most appropriate next inv?
a. MRI spine
b. Radionuclide bone scan
c. Trans rectal US
d. US pelvis
e. US KUB
Ans. The key is E. US KUB. [extension beyond capsule may cause obstruction of ureters, causing loin pain, anuria, symptoms of acute kidney injury or chronic kidney disease (here ARF)] ref: patient.info
A 57yo male presents with sudden onset severe abdominal pain and rigidity against a 4d
background of LIF pain and pyrexia. He has no PM/SHx of note and isn’t on any meds. What is
the most likely dx?
a. Intussusception
b. Ischemic colon
c. Sigmoid volvulus
d. Perforated diverticulum
e. Perforated Meckel’s diverticulum
Ans. The key is D. Perforated diverticulum. [Sudden onset, severe abdominal pain, rigidity, left iliac fossa pain and fever are in favour of perforated diverticulum].
A 46yo woman has weight gain, sensitivity to cold, pulse=50bpm, heart is enlarged with murmur.
What is the single most likely dx?
a. Hypothyroidism
b. Hyperthyroidism
c. Cushing’s syndrome
d. Addison’s disease
e. Pheochromocytoma
Ans. The key is A. Hypothyroidism. [The given presentations are classic presentation of hypothyroidism].
An alcoholic who has completely given up drinking hears voices. What is the most appropriate tx?
a. Olanzapine
b. Diazepam
c. Acamprosate
d. Disulfiram
e. Haloperidol
Ans. The key is A. Olanzapine. This is wrong key. Correct key is B. Diazepam. [A case of delirium tremens. Treated with benzodiazepines like chlordiazepoxide or diazepam].
A 6yo boy has completed an induction course of chemo for ALL. He has an enlarged left scrotum.
What is the most appropriate next step?
a. Herniotomy
b. CT abdomen
c. Biopsy
d. Immediate surgery
e. Reassurance
Ans. The key is B. CT abdomen. [Secondaries/relapse involving directly testis and other abdominal viscera. So CT abdomen is to be done here].
A 32yo miner is rescued after being trapped under a fallwn rock for 4h. After applying a bladder
catether, 15-20ml of reddish brown urine was obtained. HR=120bpm, SBP=100mmHg. What
would be the next appropriate step?
a. Dopamine IV
b. Fluid challenge
c. Furosemide IV
d. 20% Mannitol IV
e. Antibiotics
Ans. The key is B. Fluid challenge. [The diagnosis is rhabdomyolysis. So IV fluid is the next appropriate step].
A 60yo man has had spontaneous painful swelling of his right knee for 3days. 5days prv he had
an inguinal hernia repaired as a day case. He takes bendroflumethiazide 2.5mg daily. He is
apyrexial. What is the single most appropriate diagnostic inv?
a. Blood culture
b. CRP
c. D-dimer
d. XR knee
e. Serum uric acid
Ans. The key is E. Serum uric acid. [Thiazide diuretics causes hyperuicemia which can precipitate acute attack of gout].
A 27yo woman with anxiety and weight loss has tachycardia, tremor and mild proptosis. What
single mechanism accounts for her weight loss?
a. Deficiency in thyroid hormone
b. Increased level of calcitonin
c. Increased metabolic rate
d. Insulin resistance
e. Reduced caloric intake
Ans. The key is C. Increased metabolic rate. [The given features are of thyrotoxicosis in which increased metabolism causes loss of patients weight].
A man with carcinoma and multiple metastasis presents with intractable nausea and vomiting.
He has become drowsy and confused. What is the most appropriate management?
a. Dexamethasone IM
b. Dexamethasone PO
c. Ondansetron IM
d. Ondansetron PO
e. Morphine oral
Ans. The key is C. Ondensatron IM. [For cancer or chemotherapy induced vomiting ondensatron is the drug of choice. As here vomiting is intractable IM ondensatron should be given not oral].
A 19yo man presents with weight loss, increasing thirst and increasing frequency of going to the
washroom. His father, grandfather and 2 sisters have been dx with DM. What is the most likely
type of DM this pt suffers from?
a. IDDM
b. NIDDM
c. LADA
d. MODY
e. DKA
Ans. The key is D. MODY. [Key features of MODY are: Being diagnosed with diabetes under the age of 25 and having a parent with diabetes, with diabetes in two or more generations].
A 42yo woman with a PMH of severe headache treated in the ED presents with signs and
symptoms of renal failure. She has been seen by her GP for HTN and abdominal pain with OP inv
pending. Which inv is most likely to lead to a dx?
a. US KUB
b. CT brain
c. IVU
d. Renal artery Doppler
e. Renal biopsy
Ans. The key is A. US KUB. [Hypertension, abdominal pain and features of renal failure indicates the diagnosis of ADPKD for which the diagnosis is best made by US KUB].
In perforation of a post gastric ulcer, where will the fluid accumulate in the peritoneal cavity?
a. Left paracolic gutter
b. Pelvic cavity
c. Lesser sac
d. Under the diaphragm
e. Right paracolic gutter
Ans. The key is C. Lesser sac.
A 62yo male is brought to the ED by his daughter because of his persistent lying. He is a known
alcoholic and has been admitted recently with delirium tremens. On questioning, he denies any
problem with memory. He knows his name and address and states that was at the betting shop
this morning, but his daughter interjects calling him a liar explaining that he was at her home.
What is the most likely dx?
a. Ganser syndrome
b. Cotard syndrome
c. Wernicke’s encephalopathy
d. Korsakoff psychosis
e. Alcohol withdrawal
Ans. The key is D. Korsakoff psychosis. [In Korsakoff psychosis there is confabulation (a memory disturbance, defined as the production of fabricated, distorted or misinterpreted memories about oneself or the world, without the conscious intention to deceive) which may present like this].
A 70yo man presented with muscle weakness and inability to climb the stairs. Inv: CPK raised,
ESR 15. What is the most likely dx?
a. Polymyositis
b. Polymyalgia rheumatic
c. Reactive arthritis
d. RS
e. Duchenne’s MD
Ans. The key is A. Polymyositis. [Proximal muscle weakness and raised CPK points towards polymyositis].
A 65yo known alcoholic is brought into the hospital with confusion, aggressiveness and
ophthalmoplegia. He is treated with diazepoxide. What other drug would you like to prescribe?
a. Antibiotics
b. Glucose
c. IV fluids
d. Disulfiram
e. Vit B complex
Ans. The key is E. Vit B complex. [This is a case of Wernicke’s encephalopathy which is treated with Vit B complex].
A pt suffering from schizophrenia laughs while talking about his father’s death. Which term best
describes his condition?
a. Depression
b. Flat affect
c. Emotional liability
d. Incongruent affect
e. Clang association
Ans. The key is D. Incongruent affect.
A 72yo man has been on warfarin for 2yrs because of past TIAs and strokes. What is the most
imp complication the pt should be careful with?
a. Headache
b. Osteoporosis
c. Ear infection
d. Limb ischemia
e. Diarrhea
Ans. The key is B. Osteoporosis. It is a wrong key. The correct option is A. Headache. [Headache from intracranial hemorrhage is more important complication about which patient should be careful with (it is more important than osteoporosis)].
A 24yo woman is afraid to leave her house as whenever she goes out, she tends to have SOB
and sweating. She has stopped going out except with her husband. What is the most likely dx?
a. Social phobia
b. Claustrophobia
c. Depression
d. Panic disorder
e. Agoraphobia
Ans. The key is E. Agoraphobia. [Agoraphobia: Extreme or irrational fear of open or public places].
A pt on HTN drugs develops hyperkalemia. Which anti-HTN is likely to cause it?
a. Ramipril
b. Lorsartan
c. Thiazide
d. Nifedipine
e. Furosemide
Ans. The key is A. Ramipril. [Both ramipril and losartan can cause hyperkalemia].
A young man develops itching worse at night and following bathing. Exam: greysish white linear
rash can be seen on the wrist and periumbilical area. What is the dx?
a. Scabies
b. Polycythemia
c. Urticarial
d. Atopic eczema
e. Lichen planus
Ans. The key is A. Scabies.
A 40yo lady who has been a smoker since she was a teenager has the following blood result:
Hgb=19. What hormone should you check?
a. Aldosterone
b. Cortisol
c. Erythropoietin
d. T4
e. TSH
Ans. The key is C. Erythropoetin. [Smoking causes raised carboxyhemoglobin level causing hypoxemia and raised erythropoeitin which leads to raised hemoglobin level (secondary polycythemia)].
A 25yo man presents with hoarseness of voice. He has swollen vocal cords. His BMI=32 and he
smokes 20-25 cigarettes/day. What would you advise him?
a. Stop smoking
b. Lose weight
Ans. The key is A. Stop smoking.
A 64yo male was admitted to the medical ward with complaint of diarrhea, abdominal pain and
weight loss for few months. Exam: clubbing, perianal skin tags and abdominal tenderness.
Colonscopy reveals transmural granulomatous inflammation involving ileocecal junction. He was
dx with what?
a. CD
b. UC
c. Bowel cancer
d. Gastric cancer
e. IBD
Ans. The key is A. CD. [The given picture is typical of Crohn’s disease].
A pt presents with hemoptysis 7d after tonsillectomy. What is the next step?
a. Packing
b. Oral antibiotics and discharge
c. Admit and IV antibiotics
d. Return to OT and explore
e. Ice cream and cold fluids
Ans. The key is C. Admit and IV antibiotics. [Secondary hemorrhage can occur from sloughing of tissue from surgical wound following infection].
A 55yo man presents with HTN. He complains of headache and visual disturbances. He also
reports itching after a hot bath and burning sensation in finger and toes. His face is flushed red.
PE: mild splenomegaly. Inv: Hgb=20g/dl, WBC=20, plt=500, EPO normal. What is the likely dx?
a. Myelofibrosis
b. Polycythemia rubra vera
c. Essential thrombocythemia
d. CML
e. CLL
Ans. The key is B. Polycythemia rubra vera. [Raised hemglobin, raised cell counts and normal erythropoeitine along with symptoms of hyperviscosity like headache and associated hypertension are diagnostic of polycythemia rubra vera].
An old man having T2DM with increased skin tanning, heart failure and having high ferritin
(hemochromatosis) level is refusing tx. Where is the first site of cancer?
a. Testes
b. Adrenal
c. Liver
d. Pancreas
Ans. The key is C. Liver.
A 60yo DM lady presents with severe peri-anal pain and swelling. What’s the cause?
a. Anal carcinoma
b. Anal fissure
c. Hemorrhoid
d. Anal abscess
Ans. The key is D. Anal abscess.
A woman is sad, fatigues and she is eating more and also has sleeping disturbance and hears the
voice of her husband who died 3yrs ago. What is the dx?
a. OCD
b. Psychotic depression
c. Grieving
d. Severe depression
Ans. The key is B. Psychotic depression. [Here features of atypical depression along with hallucination makes the likely diagnosis to be psychotic depression].
A 40yo teetotaler woman is recovering from a hysterectomy 2days ago. At night she becomes
agitated and complains of seeing animals and children walking around the ward. What is the
most likely dx?
a. Delirium tremens
b. Toxic confusional state
c. Hysteria
d. Mania
e. Drug induced personality disorder
Ans. The key is B. Toxic confusional state. [This is not delirium tremens as the womean is teetotaler].
A woman with a hx of drug abuse and increased alcohol intake, now comes for help and she is
concerned about her problem. What is the most appropriate management option?
a. Voluntary admission
b. Psychiatry team
c. Mental health team
d. Psychiatry voluntary admission
Ans. The key is B. Psychiatry team. [Drug abuse and alcohol intake are signs of psychological involvement. As he has insight it is better for psychiatry team to evaluate him whether he needs voluntary admission or can be treated as outpatient basis].
A 28yo woman who is 32 wks pregnant in her 3rd pregnancy is diagnosed as a case of placental
abruption. After all the effective measures, she is still bleeding. What is the underlying
pathology?
a. Clotting factor problem
b. Clauser’s syndrome
c. Platelet problem
d. Succiturate lobe
e. Villamentous insertion of placenta
Ans. The key is A. Clotting factor problem.
An old woman having decreased vision can’t see properly at night. She has changed her glasses
quite a few times but with no effect. She has normal pupils and cornea. What is the most likely
dx?
a. Cataract
b. Glaucoma
c. Retinal detachment
d. Iritis
e. GCA
Ans. The key is A. Cataract.
A 53yo man was admitted to the hospital for inv of hemoptysis. 3 days after admission he
developed alternating state of consciousness, ataxic gait and some visual problems. What is the
most appropriate management of this pt?
a. Acamprosate
b. Chlordiazepoxide
c. Diazepam
d. High potent vitamins
e. Disulfiram
Ans. The key is D. High potent vitamins. [This is a case of Wernicke’s encephalopathy (as hospital admission prevented him from consuming alcohol) and the treatment for this is high potent vitamins].
A pt underwent hip surgery. Later he presents with SOB and chest pain. What is the dx?
a. Pulmonary embolism
b. MI
c. Tension pneumothorax
d. Fat embolism
e. None
Ans. The key is A. Pulmonary embolism.
A 25yo man presents with hx of breathlessness. A transthoracic echo reveals a patent foramen
ovale. What diagnostic inv would you do for a patent foramen ovale?
a. Transesophageal echo
b. Bubble echo
c. Transthoracic echo
d. ECG
Ans. The key is B. Bubble echo.
A 25yo woman with a hx of several episodes of depression is brought to the ED after she was
found with several empty bottles of her meds. She complains of coarse tremor, nausea and
vomiting. Which of the following drugs is likely to have caused her symptoms?
a. Fluoxetine
b. Amitryptilline
c. Lithium
d. Phenelzine
e. Olanzapine
Ans. The key is C. Lithium. [Side effect of lithium is fine tremor but lithium toxicity or lithium poisoning causes coarse tremor. Coarse tremor, nausea and vomiting are well known feature of lithium overdose].
A 23yo man feels anxious and agitated when faced with stress. He has an interview in 3days and
would like some help in relieving his symptoms. What is the most appropriate management?
a. SSRI
b. CBT
c. Propranolol
d. Diazepam
Ans. The key is C. Propranolol. [Inappropriate anxiety during interview is performance phobia which is better helped by propranolol when help needed in short time like here as 3 days].
An 8yo boy dx with asthma is on salbutamol and beclomethasone. However, he wakes up at
night due to his symptoms. What is the next appropriate management?
a. LABA
b. High dose steroid
c. Aminophylline
d. Oral prednisolone
e. Sodium cromoglycate
Ans. The key is A. LABA. [Patient is getting step 2 treatment (SABA + Inhaled steroid-beclomethasone. Still he is getting night symptoms and needs step up to step 3 treatment which is to add LABA].
A woman presents with a hx of poisoning 10x with different substances. There are no obvious
signs of depression or suicidal behavior. What is the best preventive step?
a. Open access to ED
b. 24h help line
c. CBT
d. Anti-depressants
e. Insight into problem
Ans. The key is E. Insight into problem. [Patient is not depressed and there is no suicidal behaviour. Despite repeated poisoning may indicate she is facing some stress and so insight into her problem should be sought for].
A boy was rushed to the ED unconscious after he had taken methadone belonging to the sister.
He was given naloxone and he regained consciousness. After a while he started getting drowsy
again. What is responsible for his present drop in level of consciousness?
a. Naloxone is absorbed faster than methadone
b. Methadone is absorbed faster than naloxone
c. He has also taken another substance apart from methadone
d. The methadone had already caused some brain damage
e. Naloxone is eliminated faster than methadone
Ans. The key is E. Naloxone is eliminated faster than methadone.
A 24yo male on remand in prison for murder is referred by the prison doctor. He is noted to be
behaving oddly whilst in prison and complains of seeing things. He has a prv hx of IV drug abuse.
On questioning he provides inappropriate but approximate answers to all questions stating that
Bill Clinton is the prime minister of England. What is the prisoner suffering from?
a. Capgras syndrome
b. Cotard syndrome
c. Ganser syndrome
d. Ekbom syndrome
e. Tourette’s syndrome
Ans. The key is C. Ganser syndrome. [Ganser syndrome is characterized by nonsensical or wrong answers to questions or doing things incorrectly often with visual pseudohallucinations and a decreased state of consciousness. It is also sometimes called prison psychosis, because the syndrome occurs most frequently in prison inmates, where it may represent an attempt to gain leniency from prison or court officials].
A 32yo lady has recently become more active, sleeps less and bought a house and 2 new cars.
What is the most likely dx?
a. Bipolar disorder
b. Mania
c. Hypomania
d. Schizophrenia
Ans. The key is C. Hypomania. [Individuals in a hypomanic state have a decreased need for sleep, are extremely outgoing and competitive, have a great deal of energy and are otherwise often fully functioning (unlike full mania where unlike fully functioning there is a. obvious difficulties at work or in social relationships and activities b. requires admission to hospital to protect the person or others, or c. the person is suffering psychosis)].
The body of a 65yo man who was treated for TB and bronchitis was seen at autopsy. His legs
were swollen and his liver showed signs of a transudate fluid. What was the cause of the
transudate?
a. Liver cirrhosis
b. Alcoholic liver disease
c. Cardiac failure
d. Budd-chiari syndrome
e. TB
Ans. The key is C. Cardiac failure.
A 60yo woman has tiredness. She has noticed that her skin looks permenantly tanned and she
describes dizziness on standing up. What is the single most likely electrolyte pattern to be found?
a. Na+=120mmol/L, K+=5.9mmol/L
b. Na+=125mmol/L, K+=2.9mmol/L
c. Na+=140mmol/L, K+=4.5mmol/L
d. Na+=150mmol/L, K+=3.5mmol/L
e. Na+=150mmol/L, K+=5.9mmol/L
Ans. The key is A. Na+=120mmol/L, K+=5.9mmol/L. [Tanned skin (hyperpigmentation) and postural hypotension in a tired women points towards Addison’s disease where hyponatremia and hyperkalemia is seen].
A 20yo girl with amenorrhea and BMI of 14 still thinks she has to lose weight. What is the most
likely dx?
a. Anorexia nervosa
b. Bulimia nervosa
c. OCD
d. Depression
e. Body dysmorphic disorder
Ans. The key is A. Anorexia nervosa.
A guy who has several convictions and has been imprisoned several times, breaks up with his
family and doesn’t contact his children. What type of personality disorder is this?
a. Borderline
b. Antisocial
c. Schizotypal
d. Schizoid
e. Criminal
Ans. The key is B. Antisocial. [Antisocial personality disorder is characterized by a pervasive pattern of disregard for, or violation of, the rights of others. There may be an impoverished moral sense or conscience and a history of crime, legal problems, and impulsive and aggressive behavior].
A 17yo lady presents with a worm in her ear. She is very agitated and anxious. What is the next
step?
a. Remove under GA
b. Suction
c. Alcohol drops
d. Forceps
Ans. The key is C. Alcohol drops. [It is a living object. So it should be killed first and so alcohol drop is the correct option].
A 20yo male smoker is noted to have intense rubor of the feet and absent foot pulse. Exam:
amputated right 2nd toe. What is the most probable dx?
a. Intermittent claudication
b. Cardiovascular syphilis
c. Buerger’s disease
d. Embolism
e. Acute limb ischemia
Ans. The key is C. Buerger’s disease. [ The traditional diagnosis of Buerger's disease is based on 5 criteria (smoking history, onset before the age of 50 years, infrapopliteal arterial occlusive disease, either upper limb involvement or phlebitis migrans, and absence of atherosclerotic risk factors other than smoking). As there is no specific diagnostic test and an absence of positive serologic markers, confident clinical diagnosis should be made only when all these 5 criteria have been fulfilled].
754. A young lady after a heavy bout of drinking last night comes to the ED with dizziness, abdominal
pain, vomiting blood with cool peripheries. After initial resuscitation, oxygen and fluids, she still
continues to bleed with pulse=130bpm and BP=85/58mmHg. What would be your next best
management?
a. Clotting screen
b. US
c. CT
d. Endoscopy
e. Omeprazole
Ans. The key is D. Endoscopy. [In young it is unlikely to get oesophageal varices rather than the bleeding is from probable gastric erosion and endoscopy should be done (diagnostic and therapeutic- like sclerotherapy].
755. A 12yo boy complains of acute development of purpura on the dependent areas of his body
2wks after a URTI. The purpura doesn’t blanch on pressure, tests reveal: Hgb=12, plts=50,
WBC=5. Bleeding time=10mins, APTT=40s, PT=1.02. What is the most likely dx?
a. ITP
b. TTP
c. Von Willebrand’s disease
d. Hemophilia A
e. Hemophilia B
Ans. The key is A. ITP. [Isolated thrombocytopenia and H/O prior URTI with development of purpura on the dependent areas of the body favours the diagnosis of ITP. (In ITP BT is prolonged which is present here but here is also prolonged APTT which is controversial)].
756. A woman presents with hx of falls, becomes pale and clumsy. She is hypertensive and takes
atenolol, bendroflumethiazide and amlodipine. What inv is needed?
a. 24h ECG
b. 24h BP monitoring
c. ECG
d. Echo
e. CT head
Ans. The key is B. 24h BP monitoring. [All these drugs (particularly prolonged use of thiazide and amlodipine) are well established cause of postural hypotension. So 24 hour BP monitoring should be done].
757. A 43yo woman has been feeling lethargic and tired. Her BP=160/90mmHg. Bloods:
Na+=140mmol/L, K+=3.1mmol/L. What is the most likely dx?
a. Cushing’s syndrome
b. Conn’s syndrome
c. Hyperparathyroidism
d. Renal disease
e. Pheochromocytoma
Ans. The key is B. Conn’s syndrome. [It can also be cushing’s syndrome! So if we like to be sure we have to know aldosterone and rennin level. i) Renin low, aldosterone high- Conn’s syndrome (primary hyperaldosteronism) ii) Renin low, aldosterone low- Cushing’s syndrome iii) Renin high, aldosterone high- Renovascular disease (secondary hyperaldosteronism)].
A 2yo child aspirated a foreign object which was removed at the hosp. the parents are now
asking how to remove it if that ever happens at home. What do you advise?
a. Hemlich maneuver
b. Bring to the hospital
c. Turn the child on his back and give thumps
d. CPR
e. Remove manually by fingers
Ans. The key is C. Turn the child on his back and give thumps.
A 28yo pregnant lady presents with severe lower abdominal pain with excessive per vaginal
bleeding at 34wks gestation. What should be the initial inv of choice?
a. Coagulation profile
b. US abdomenu
c. CT pelvis
d. D-dimer
e. Kleiuber test
Ans. The key is B. US abdomen. [Likely case of abruption placenta (as excessive bleeding probably revealed type) for which initial investigation of choice is US abdomen. Other features that will favour abruptio is hard uterus and evidence of fetal distress. It will be difficult to feel the fetal parts].
A 3yo child with severe diarrhea and vomiting, looks lethargic, has sunken eyes and a feeble cry.
What is the choice of fluids?
a. 0.9%NS
b. 0.9%NS + 5%Dextrose
c. 0.45%NS + 5%Dextrose
d. 0.45%NS
Ans. The key is A. 0.9% NS. [Patient has features of severe dehydration and should be resuscitated first and for resuscitation fluid of choice is 0.9% NS].
A lady with depression has a bag full of meds. She now presents with coarse tremors. Which
drug caused her symptoms?
a. Lithium
b. Thyroxine
c. Amitriptyline
d. Sodium valproate
e. Tetrabenazine
Ans. The key is A. Lithium. [Side effect of lithium in therapeutic range is fine tremor but in lithium poisoning there occurs coarse tremor, nausea and vomiting].
A 38yo man has had a liver biopsy as part of inv for abnormal LFTs. The pathologist report states:
special stains demonstrate the presence of a very large amount of iron pigment within the
hepatocytes. What single condition is identified by the pathologists report?
a. Alpha 1 antitrypsin deficiency
b. Hemangioma
c. Hemochromatosis
d. Hemosiderosis
e. Wilson’s disease
Ans. The key is D. Hemosiderosis. It is a wrong key! The correct key should be C. Hemochromatosis. [In hemochromatosis distribution pattern of iron in liver biopsy by pearl’s stain is more prominent iron granules in periportal hepatocyte and relative sparing of kupffer cells and decreased intensity near the central vein. By contrast iron overload in hemosiderosis causes to accumulation of iron granules predominantly in kupffer cells and more in central area rather than peripheral hepatocyte. In given case there are large amount of iron pigment in hepatocyte which is diagnostic of hemochromatosis].
A 27yo man presents to the ED after a RTA where his foot was stuck under a truck for several
hours. He now has swelling on the foot. Exam: foot tenderness, loss of sense in the space
between the 3rd metatarsal and big toe and his dorsalis pedis is not felt. What is the most likely
dx?
a. Compartment syndrome
b. Arterial rupture
c. Arterial embolus
d. DVT
e. Fibular fx
Ans. The key is A. Compartment syndrome. [Acute compartment syndrome occurs after a traumatic injury such as a car crash. The trauma causes a severe high pressure in the compartment which results in insufficient blood supply to muscles and nerves. Acute compartment syndrome is a medical emergency that requires surgery to correct. If untreated, the lack of blood supply leads to permanent muscle and nerve damage and can result in the loss of function of the limb].
You are a FY doctor in the ED when a mother brings her 2yo son to you with a 1h hx of noisy
breathing. She state that although he had mild coryza over the last week, he was improving and
so they had gone to a children’s picnic with nursery friends. Another parent had found him
coughing and spluttering, and ever since his breathing has remained noisy. Though he appears
well in the ED, his current observations demonstrate a raised RR and sat=91% on air. What is the
most likely dx?
a. Anaplyaxis
b. Croup
c. Foreign body aspiration
d. Epiglottitis
Ans. The key is C. Foreign body aspiration.
A pt taking doxycycline complains of nausea, indigestion, abdominal pain and vomiting. What
will you advise?
a. Take it after meals
b. Take it before meals
c. Stop the drug
d. Take antiacids
e. Take antiemetic
Ans. The key is A. Take it after meal.
A 52yo man with hx of ant MI 3 wks ago developed sudden onset of dyspnea. Exam:
BP=100/60mmHg, pulse=100bpm, SaO2=88%, chest=bilateral crackles. Which inv would you do
to find the underlying cause?
a. CXR
b. Echo
c. D-dimer
d. Radionucleotide lung scan
e. Troponin
Ans. The key is A. CXR. It is wrong key. Correct key should be B. Echo. [The question does not want to know the features of pulmonary oedema rather it is clearly mentioned “which investigation would you do to find out the UNDERLYING CAUSE”. As in this patient sudden papillary muscle rupture or VSD may be the likely cause (ventricular aneurism may take a more slower course) so echo seems to be more logical approach].
A 49yo man lost his job and now is homeless. He was found wandering in the park. He is
muttering that some people are after him. Alcohol was tested and it was negative. What will
your next step be?
a. Thiamine
b. Neuropsycho analysis
c. Mini mental state
d. CT head
e. MRI head
Ans. The key is B. Neuropsychoanalysis. [As the patient has persecutory delusion he is likely suffering from psychosis for which neuropsychoanalysis is the logical approach].
A pt with SNHL and loss of corneal reflex on the left side. What is the most definitive inv?
a. CT of internal auditory meatus
b. Nuclear imaging of brain
c. MRI of internal auditory meatus
d. Radio isotope scan
e. XR skull
Ans. The key is C. MRI of internal auditory meatus. [The likely cause is acaustic neuroma for which appropriate investigation is MRI brain (mainly posterior fossa) as the tumour arise from inner end of internal acoustic meatus but grows mainly in posterior cranial fossa. As it is not given in option so from the given options MRI of internal acoustic meatus is the best option].
A middle aged man complains of a node which has been growing on his nose for several months.
Now it’s firm with central depression. It is 0.6cm in size. What is the single most likely dx?
a. Basal cell carcinoma
b. Squamous cell carcinoma
c. LN
d. Melanoma
e. Kaposi’s sarcoma
f. Keratoacanthoma
g. Molluscum contagiosum
Ans. The key is A. Basal cell carcinoma. [A pearly white umbilicated ulcer (with central depression) any where in the face with rolled edges / inverted edge is basal cell carcinoma. Any ulcer which is located above the neck is always basal cell carcinoma until proven otherwise. Derma Samson note].
A 45yo woman presents with rotational vertigo, nausea and vomiting, especially on moving her
head. She also had a similar episode 2yrs back. These episodes typically follow an event of runny
nose, cold, cough and fever. What is the most probable dx?
a. Acoustic neuroma
b. Meniere’s disease
c. Labyrinthitis
d. BPPV
e. Vestibular neuronitis
Ans. The key is E. Vestibular neuronitis. [Here no sensoryneural hearing loss (SNHL present in acoustic neuroma, Meniere’s disease and labyrinthitis). Runny nose, cold, cough and fever are recognized trigger of vestibular neuronitis but not BPPV].
A 65yo man with cancer of middle 1/3 of the esophagus presents with dysphagia. What is the
most immediate management?
a. Chemotherapy
b. Radiotherapy
c. Stenting
d. Gastrostomy
e. TPN
Ans. The key is C. Stenting.
A 1yo child is brought to ED. He woke up in the middle of the night crying severely. What initial
measure should be taken for this child?
a. Refer to surgeon
b. Discharge with advice
c. Analgesia
d. Antibiotic
Ans. The key is C. Analgesia.
A 30yo lady was playing volleyball when her hand got injured with the ball. The right hand is not
swollen and there is tenderness under the root of the thumb. XR is normal. What is the most
appropriate next management?
a. Arm sling for 1 wk
b. Raise hand for 2d
c. Repeat XR
d. Full arm cast
Ans. The key is C. Repeat XR. [Likely diagnosis is scaphoid fracture where X-ray may not show the fracture right away. In such case put her wrist in a splint for a week or two and a new X-ray will be taken to see if the fracture will become visible. If fracture is confirmed arm and hand is placed in a below elbow cast].
A 33yo female presents with sudden severe colicky abdominal pain in her RIF. A mobile mass is
felt on examination. What is the most likely dx?
a. PID
b. Appendicitis
c. Ovarian torsion
d. Constipation
Ans. The key is C. Ovarian torsion.
A middle aged male is feeling unwell after a recent MI. The recent ECG shows prolonged QRS
complex and tented T wave. Na+=136mmol/l, K+=6.2mmol/l, urea=5mmol/l. What is the most
appropriate management?
a. Calcium gluconate
b. Calcium resonium
c. Calcium with vit D supplement
d. Vit D
e. Calcium
Ans. A. Calcium gluconate. [ECG change of prolonged QRS complex and tented T wave are suggestive of hyperkalaemia which is further supported by K+ level of 6.2 mmol/l. So to protect the heart from arrhythmia calcium gluconate should be given].
A 68yo man with DM and HTN was noted to have cholesterol level of 3.4mmol/l. he was also
noted to have microalbuminuria. What is the best drug to add to his regimen?
a. ACEi
b. Statin
c. Amylodipine
d. Biguanides
Ans. The key is A. ACEI. [ACEI is renoprotective and prevents progress in albuminuria].
A child playing with toys suddenly develops breathlessness and stridor. Which inv will lead to
the dx?
a. Laryngoscopy
b. CXR
c. Peak flow meter
d. ABG
Ans. The key is A. Laryngoscopy. [Breathlessness and stridor in a child playing with toy is most likely due to aspiration of foreign body (toy or part of toy) for which laryngoscopy should be done].
Anxious parents ask you for resus technique for their 3yo. What do you tell them?
a. 5 compression: 1 breath
b. 5 compression: 2 breaths
c. 15 compression: 2 breaths with nose pinched
d. 15 compression: 2 breaths without nose pinched
e. 30 breaths: 2 compressions
Ans. The key is C. 15 compression:2 breaths with nose pinched.
A 56yo man complains of increased vol of sputum with specks of blood and chest pain. He has a
hx of DVT. Exam: clubbing. What is the cause of blood in his sputum?
a. Pulmonary thrombosis
b. Bronchial carcinoma
c. Bronchiectasis
d. Pulmonary TB
Ans. The key is C. Bronhiectasis. [Increased volume of blood streaked sputum and clubbing points towards bronchiectasis].
A 32yo female has a hx of SOB and fever. Pre-broncho-dilation test was done and it was 2/3.5
and post-bronchodilator was 3/3.7. The pt was dx of eczema and TB. What is the possible dx?
a. COPD
b. Asthma
c. Pneumonia
d. Bronchiectasis
Ans. The key is B. Asthma. [Here post bronchodilator value is >80% which excludes COPD and reversibility is >23% which is diagnostic of asthma].
A 2yo male pt was brought by his mother with a swelling in the right side of his neck extending
from the angle of the mouth to the middle 1/3 of the sternocleidomastoid muscle. The swelling
was on the anterolateral side of the sternocleidomastoid and was brilliantly transilluminant.
What is the likely dx?
a. Lymphangioma
b. Branchial cyst
c. Thyroglossal cyst
d. Ranula
e. Thyroid swelling
Ans. The key is B. Branchial cyst. It is a wrong key. Correct key is A. Lymphangioma. [Both lymphangioma and brancheal cyst are lateral neck mass. 90% of lymphangioma occur in children less than 2 yrs. Brancheal cyst usually does not transilluminate whereas lymphangioma usually transilluminate brilliantly].
A 50yo newly dx with HTN complains of urinary freq and dysuria. The urinalysis reveals presence
of white cells and protein. Choose the single most appropriate tx?
a. Imipramine
b. Adjust diuretics
c. Vaginal estrogen
d. Trimethoprim
Ans. The key is D. Trimethoprim. [UTI. Treatment is with triethoprim].
A boy injured his ear during a rugby match. He reported it being painful. Exam: red and tender
pinna. Tympanic membrane was normal. What would be the next appropriate step?
a. Topical gentamicin
b. Oral flucloxacillin
c. IV flucloxacillin
d. Refer to ENT specialist
e. No further intervention needed.
Ans. The key is E. No further intervention needed. [As tympanic membrane is normal so this transient inflammation of pinna from injury during rugby match is self limiting which needs no further intervention].
A 2yo girl prv well presents with a hx of vomiting and diarrhea for 4hrs. What is the most
suitable indication for IV fluid administration?
a. Capillary refill time >4s
b. HR >90bpm
c. Increased RR
d. Stool >10x/d
e. Weight of child = 10kgs
Ans. The key is A. Capillary refill time >4s. [Capillary refill time >4s is sign of severe dehydration indicating need for IV fluid administration. Features of severe dehydration: i) abnormally sleepy or lethargic ii) sunken eyes iii) drinking poorly or not at all iv) reduced skin turgr > 2 seconds v) dry tongue and mucous membrane vi) absent tears vii) oliguria viii) hypotension ix) tachycardia x) prolonged capillary refill time xi) depressed anterior frontanelle].
*785. A 44yo woman with breast cancer had an extensive removal and LN clearance. She needs an
adjunctive tx. Her mother had cancer when she was 65. Which of the following factors will be
against the tx?
a. Fam hx
b. Tumor grading
c. LN involvement
d. Her age
Ans. The key is D. Her age.
A 45yo man presents with hearing loss and tinnitus in the right ear. Exam: weber test lateralizes
to the left. Audiometry: AC > BC in both ears. What is the next best inv?
a. CT
b. MRI brain
c. Angiogram
d. Otoscopy
Ans. The key is B. MRI brain. [AC>BC indicate Rinne positive; i.e. The deafness is not conductive. Again hearing loss is on right side. Weber lateralized to left. We know weber lateralized to same side if conductive deafness and to opposite if there is sensoryneural deafness. So it is now obvious that the deafness of right ear is sensoryneural deafness for which MRI brain is the next best investigation].
A 74yo lady called an ambulance for an acute chest pain. She has a hx of DM and HTN, and is a
heavy smoker. Paramedics mentioned that she was overweight and recently immobile because
of a hip pain. She collapsed and died in the ambulance. What is the most likely cause of death?
a. Pulmonary embolism
b. MI
c. Stroke
d. Cardiac arrhythmia
e. Cardiac failure
Ans. The key is A. Pulmonary embolism. [Immobilisation for hip pain is the clincher of pulmonary embolism here].
A 77yo woman suffered diarrhea 4d ago. What would be her blood gas result?
a. pH =7.2, PaCO2 =8
b. pH =7.4, PaCO2 =1.5
c. pH =7.4, PaCO2 =2.6
d. pH =7.4, PaCO2 =2.8
Ans. The key is B. pH = 7.4, PaCO2 = 1.5
A man presents with abdominal pain, vomiting, pulse=120bpm, BP=90/60mmHg and a rigid
abdomen. His chest is clear. What is the immediate management?
a. Call radiology
b. Admit to medical ward
c. Urgent admission to ITU
Ans. The key is C. Urgent admission to ITU.
A 60yo man presents with weight loss and Hgb=6. Hx reveals that he has abdominal pain and
diarrhea for the past 6m. What is the most appropriate inv?
a. Barium enema
b. Colonoscopy
c. Sigmoidoscopy
Ans. The key is B. Colonoscopy. [Likely diagnosis is IBD. So Colonoscopy should be done].
A 35yo primigravida post C-section complains of inability to void. She denies dysuria but
complains of fullness. She was treated with an epidural for analgesia. What is the single most
appropriate inv?
a. MSU
b. US abdomen
c. US KUB
d. Serum calcium
Ans. The key is B. US abdomen. This is a wrong key. Correct key should be C. US KUB. [This is a case of POUR (post operative urinary retention). We should do US to know the urinary volume (urine volume in bladder). If <400ml we shall observe. When volume is >600ml we should do catheterization].
A female pt with HTN and serum K+=2.7mmol/l. which hormone would you be looking for?
a. Aldosterone
b. Cortisol
c. Thyrotoxin
d. Renin
e. Testosterone
Ans. The key is A. Aldosterone. [Hpt and hypokalemia is seen in hyperaldosteronism. So we should look for aldosterone].
A 25yo male with a hx of frequent binge drinking presents 4h after having had a take away meal
following a nights heavy drinking. He complains of nausea and has vomited on several occasions.
After the last vomiting episode, he vomited approximately a cupful of blood. On admission, he
smells of alcohol, pulse=100bpm, BP=140/80mmHg. He has some tenderness in the epigastrium.
What is your dx?
a. Gastric carcinoma
b. Mallory-weiss tear
c. Esophageal carcinoma
d. Esophageal varices
e. Esophageal varices
f. Peptic ulceration
Ans. The key is Mallory-weiss tear. [Repeated retching and vomiting is a recognized cause of Mallory-weiss tear which is supported here by vomiting a cupful of blood].
A young boy presented with bilateral periorbital edema, ankle swelling and increase in body
weight. What is the most likely dx?
a. Chronic heart failure
b. Nephrotic syndrome
c. Renal failure
d. Acute heart failure
e. Glomerulonephritis
Ans. The key is B. Nephrotic syndrome.
A 53yo man with prv hx of COPD presents with breathlessness and purulent sputum. O2 stat=85%
on air. ABG: PaO2=7.6, PaCOS=7. What is the appropriate management for his condition?
a. 24% oxygen
b. Mechanical ventilation
c. 100% oxygen
d. Nebulized salbutamol
Ans. The key is A. 24% oxygen. [Patient has hypoxemia and hypercapnea (type2 respiratory failure). Hence he should be put on 24% oxygen. 100% oxygen will abolish hypoxic drive and worsen hypercapnea].
A 34yo man was involved in a RTA and whilst in the ambulance his GCS deteriorated and RR
increased from 30-48. What is the most appropriate management for this pt?
a. IV fluid
b. Needle thoracocentesis
c. 100% oxygen
d. Portable XR
Ans. The key is 100% oxygen.
A 44yo lady who has PCKD is concerned because her 38yo brother has just died of an
intracranial insult. She knows he was not hypertensive. What was the most likely cause of her
brother’s death?
a. Subdural hematoma
b. Subarachnoid hemorrhage
c. Cerebral infarct
d. Epidural hematoma
Ans. The key is B. Subarachnoid hemorrhage. [Cerebral aneurisms are recognized association of PCKD which may lead to subarachnoid hemorrhage].
A 36yo male dx with glioblastoma since last 5m has cerebral edema and is on dexamethasone.
He has diarrhea and vomiting for the last 3days. He has been suffering from repeated falls today.
What could be the possible cause for his falls?
a. Adrenal insufficiency
b. Dehydration
c. Dexamethasone therapy
d. Raised ICP
Ans. The key is A. Adrenal insufficiency. [Prolonged dexamethason use suppresses adrenal axis and intercurrent illness can lead to adrenal insufficiency (addisonian crisis) in such cases].
A 2yo child is brought by his mother. The mother had hearing impairment in her early childhood
and is now concerned about the child. What inv would you do?
a. Audiometry
b. Distraction testing
c. Scratch test
d. Tuning fork
Ans. The key is A. Audiometry. [Conditioned response audiometry 2-4 years, pure tone audio gram for greater than 5 years, less than 6 months otoacoustic emission or brainstem evoked response, distraction test for 6-18 months, Ohcs ENT].
An 8yo child presents with recurrent abdominal pain, occasional headaches but maintains a
good appetite. Exam: normal. CBC, BUE, etc are normal. What would you do for her next?
a. US abdomen
b. CT head
c. Reassure
d. Analgesics
Ans. The key is C. Reassure. [Recurrent abdominal pain and headaches with no abnormal finding on examination and investigation points to Abdominal Migraine. Management is reassurance].
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