148. A 41yo woman who has completed her family, has suffered from extremely heavy periods for many years. No medical tx has worked. She admits that she would rather avoid open surgery.
After discussion, you collectively decide on a procedure that wouldn’t require open surgery or
GA. Select the most appropriate management for this case.
a. Endometrial ablation b. Hysterectomy c. Fibroid resection d. Myomectomy
e. Uterine artery embolization
Ans. The key is uterine artery embolization.
Treating menorrhagia Drugs Progesterone-containing IUCDs, eg Mirena should be considered 1st line treatment for those wanting contraception.
effective for bleeding and also reduce the size of fibroid uterus.
2nd line recommended drugs are antifibrinolytics, antiprostaglandins or the Pill. Antifibrinolytics Taken during bleeding these reduce loss (by 49%)—eg tranexamic acid CI: thromboembolic disease—
Antiprostaglandins eg mefenamic acid 500mg/8h PO pc (CI: peptic ulceration) taken during
days of bleeding particularly help if there is also dysmenorrhoea. COCP can also be used if they are not contraindicated..
3rd line recommendation is progestogens IM or norethisterone Rarely gonadotrophin (LHRH) releasing hormones are used
Surgery Endometrial resection is suitable for women who have completed
their families and who have <10wk size uterus and fibroids <3cm. Contraception will be required. For women wishing to retain fertility who have fibroids >3cm consider uterine artery embolization or myomectomy
Women not wishing to retain fertility, with a uterus >10wk size and fibroids >3cm may benefit from hysterectomy, vaginal hysterectomy being the preferred route.
149. A girl with hx of allergies visited a friend’s farm. She got stridor, wheeze and erythematous rash. What is the most appropriate tx?
a. 0.25ml IM adrenaline b. 0.25ml PO adrenaline c. 0.25ml IM adrenaline d. IV chlorphearamine
Ans. The key is A. 0.25 ml IM adrenaline [Presence of stridor and wheeze are suggestive of anaphilaxis and treatment option is adrenaline].
Consider anaphylaxis when there is compatible history of rapid-onset severe allergic-type reaction with respiratory difficulty and/or hypotension, especially if there are skin changes present and the treatment of anaphylaxis is IM adrenaline not anti histamine
Treatment:ABCDE, Oxygen, IM Adrenaline. <6yrs0.15ml, 6-12yrs 0.3ml, >12 yrs 0.5ml 1:1000
Since the age of the girl is not mentioned here and options A & C are the same so A or C could be the answers supposing the girl was 6-12 yrs of age.
150. A 5yo boy is referred to the hospital and seen with his father who is worried that he has been listless. He is not sure why his GP suggested he should come to the ED and is keen to get some tablets and go home. Exam: tired and irritable, swelling around eyes.
Renal biopsy: remarkable
for podocyte fusion on EM. What is the most probable dx?
a. NAI
b. Myelodysplastic disease c. HSP
d. Membranous GN e. Minimal change GN
Ans. The key is E. Minimal change glomerulonephritis. [Podocyte fusion on electron microscopy]
Most common cause of nephrotic in children is minimal change disease. There will be hypoalbuminemia and peripheral edema too. Electron microscopy shows effacement of podocyte foot processes.. MCD has albumin selective proteinuria. Treatment is with steroids.
151. A 6yo boy is brought to the hospital for a 3rd episode of sore throat in 1 month. He is found
bleeding from gums and nose and has pale conjunctiva. What’s the single cell type?
a. Clumped platelets b. Microcytes
c. Granulocyte without blast cells d. Blast cells
e. Mature lymphocytes Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What are the points that favour diagnosis?
Ans. 1. The key is D. Blast cells.
Ans. 2. The diagnosis is ALL
Ans. 3. Points in favour: i) Age-6yrs ii) recurrent infection (sorethroat) due to neutrpenia and abnormal lymphoblasts which cannot protect from infection iii) thrombocytopenia causing gum and nose bleeding. Iii) anaemia (pale conjunctiva) due to reduced red cell production from marrow occupation by blast cells. [Here debate came why it is not aplastic anaemia? There is no risk factor mentioned for this patient for aplastic anaemia.
There may be congenital aplastic anaemia but again it would present earlier in life. So it goes more with leukaemia but it cannot be confirmed unless we do bone marrow
aspiration.]
ALL: This is a malignancy of lymphoid cells, affecting B or T lymphocyte cell lines, arresting
maturation and promoting uncontrolled proliferation of immature blast cells, with marrow failure and tissue infiltration.
Causes: Genetic susceptibility, environmental factors (ionizing radiations) Down’s syndrome.
Commonest cancer of childhood.
Signs and symptoms:
• Marrow failure: Anaemia (Hb), infection (WCC), and bleeding (platelets).
• Infiltration: Hepatosplenomegaly, lymphadenopathy—superficial or mediastinal, orchidomegaly, CNS involvement—eg cranial nerve palsies, meningism.
INVESTIGATIONS: Characteristic blast cells on blood film and bone marrow CXR and CT scan to look for mediastinal and abdominal lymphadenopathy.
Lumbar puncture should be performed to look for CNS involvement.
TREATMENT: Blood transfusions, prophylactic antibiotics, IV antibiotics in case of infection. Main stay of treatment is chemotherapy.
Prognosis Cure rates for children are 70–90%; for adults only 40%
152. A 23yo man has been stabbed in the back and has SOB. The trachea is not deviated, he has engorged neck veins and absent breath sounds on the right. What is the most appropriate dx?
Q. 2. What are the point in favour of your answer?
Ans. 1. The key is A. Tension pneumothorax.
Ans. 2. Points in favour: i) Stab wound in the back ii) SOB iii) Engorged neck vein iv) Absent breath sound.
153. A 44yo pt comes with right hemiparesis. Exam: left sided ptosis and left dilated pupil. Where is the lesion?
a. Cerebral infarct
Q. 2. What is the name of this condition?
Ans. 1. The key is E. Midbrain.
Ans. 2. Weber syndrome [presence of ipsilateral oculomotor nerve palsy and contralateral hemiparesis or hemiplagia].
Ptosis + miosis = horners syndrome Ptosis + mydriasis= oculomotor nerve palsy.
CN3 nucleus lies in the midbrain.
Fore brain: CN 1,2 Mid brain: CN 3,4 Pons: CN 5,6,7,8 Medulla: CN 9,10,12
Weber’s syndrome (superior alternating hemiplegia) Ipsilateral oculomotor
nerve palsy with contralateral hemiplegia, due to infarction of one-half of the midbrain,
after occlusion of the paramedian branches of the basilar or posterior cerebral arteries
154. A 50yo man has a stab wound to his left anterior chest at the level of the 4th ICS. He has a BP 80mmHg, pulse=130bpm. His neck veins are dilated and his heart sounds are faint. His trachea is central. What is the most appropriate dx?
a. Cardiac tamponade b. Diaphragmatic rupture c. Fractured ribs
d. Tension pneumothorax e. Traumatic rupture of aorta Q. 1. What is the Key?
Q. What are the points in favour of your answer?
Ans. 1. The key is Cardiac tamponade.
Ans. 2. Points in favour: i) Systolic BP 80 mmHg ii) Pulse 130 bpm iii) Engorged neck vein iv) Faint heart sounds v) Trachea is central.
Essence:Pericardial fluid collects intrapericardial pressure rises heart cannot fill pumping stops.
Causes: Trauma, lung/breast cancer, pericarditis, myocardial infarct, bacteria, eg TB.
Signs: Falling BP, a rising JVP, and muffled heart sounds (Beck’s triad); JVP on inspiration
(Kussmaul’s sign); pulsus paradoxus (pulse fades on inspiration) (also in severe
asthma). Echocardiography may be diagnostic. CXR: globular heart; left heart border convex or straight; right cardiophrenic angle <90°. ECG: electrical alternans
Management: Prompt pericardiocentesis. While waiting give O2, IV fluids, monitor ECG.
155. A 15yo boy has a soft painless swelling in the left scrotum, blue in color and can be compressed. What is the most appropriate next step?
a. Analgesia
Q.2. What is the name of this condition?
Ans. 1. The key is E. Reassurance.
Ans. 2. Name of the condition is Varicocele.
Testicular lump = cancer until proved otherwise.
Acute, tender enlargement of testis = torsion until proved otherwise Diagnosing scrotal masses
• Cannot get above ≈ inguinoscrotal hernia or hydrocele extending proximally
• Separate and cystic ≈ epididymal cyst
• Separate and solid ≈ epididymitis/varicocele
• Testicular and cystic ≈ hydrocele
Testicular and solid—tumour, haematocele, granuloma, orchitis, gumma. USS may help.
Varicocele Dilated veins of pampiniform plexus. Left side more commonly affected.
Often visible as distended scrotal blood vessels that feel like ‘a bag of worms’.
Patient may complain of dull ache. Associated with subfertility, but repair (via surgery
or embolization) seems to have little effect on subsequent pregnancy rates.
156. A 12yo pt presents with copious diarrhea. Exam: urine output=low, mucous membrane=dry, skin turgor=low. What is the most appropriate initial management?
a. Antibiotic
Q. 2. What is the diagnosis and why?
Ans. 1. The key is D. Fluid replacement.
Ans. 2. Diagnosis is severe dehydration. Points in favour: i) low urine output ii) dry mucous membrane and iii) low skin turgor.
Gastroenteritis Rotavirus is the most common cause of gastroenteritis in infants and children.
Norovirus (most common cause in adults)
ASSESSMENT OF DEHYDRATION:
Mild dehydration: Decreased urine output.
5% dehydration: Dry mucous membranes; decreased urine output.
10% dehydration: The above + sunken fontanele, inc pulse; hoarse cry; dec skin turgor.
>10%: The above, but worse, with: shock, drowsiness, and hypotension.
MANAGEMENT
Mild: Treated at home by oral rehydrating therapy.
Moderate: Oral fluids, via NG or IV fluids can be used. ‘Rapid rehydration’ involves 4 hours of
10mL/kg/h 0.9% NaCl then maintenance after if needed. Monitor U & Es
Severe: If not in shock oral or NG route can be used. If in shock. 0.9% saline 20mL/kg IVI bolus, while calculations are performed. Continuously monitor pulse, BP, ECG. • Continue with boluses until the signs of shock ease.
• Then give the daily requirement + fluid deficit
157. A 60yo smoker presents with cramp-like pain in the calves relieved by rest and non-healing ulcers. Exam: cold extremities with lack of hair around the ankles, absent distal pulses. What is the
most probable dx?
a. Intermittent claudication b. Chronic ischemia of the limbs c. Buerger’s disease
d. DVT e. DM
Q. 1. What is the key?
Q. 2. Points that support your diagnosis.
Ans. 1. The key is B. Chronic ischaemia of the limb.
Ans. 2. Intermittent claudication is a symptom not diagnosis. It is not buerger’s disease as buerger occur in more younger heavy smoker (before the age of 50yrs) mostly limited
to the extremities, It is not DVT as dvt pain or tenderness is not of an intermittent claudication pattern. Again in DM there is no intermittent claudication.
158. An otherwise healthy 13yo boy presents with recurrent episodes of facial and tongue swelling and abdominal pain. His father has had similar episodes. What is the most likely dx?
a. C1 esterase deficiency b. HIV
c. Mumps d. Sarcoidosis
e. Sjogren’s syndrome Q. 1. What is the key?
Q. 2. What is the name of this condition?
Q. 3. Why it is not acquired?
Ans. 1. The key is A. C1 esterase inhibitor deficiency.
Ans. 2. Hereditary angioedema.
Ans. 3. Acquired angioedema usually manifest after the age of 40 yrs.
The oedema is triggered by increased permeability of the blood vessels.The net result is episodes of massive local oedema, ie angio-oedema. (In angio-oedema, the swelling is subcutaneous or submucosal rather than epidermal, so urticaria is absent.) It can mimic anaphylaxis.
Type I has low levels of C1-INH (C1 esterase inhibitor) (the majority of cases).
Type II has impaired function of C1-INH.