127. A 30yo man complains of hoarseness of voice. Exam: unilateral immobile vocal cord. What is the most probable dx?
a. Graves disease b. Hematoma
c. Unilateral recurrent laryngeal nerve injury d. External laryngeal nerve injury
e. Tracheomalacia
Ans. The key is C. unilateral recurrent laryngeal nerve injury.
Causes: 30% are cancers (larynx in ~40%; thyroid, oesophagus, hypopharynx, bronchus, or malignant node). 25% are iatrogenic, ie after parathyroidectomy. Other causes: CNS disease (polio; syringomyelia); TB; aortic aneurysm;
Symptoms: Symptoms of vocal cord paralysis are:
• Hoarseness with ‘breathy’ voice with a weak cough.
• Repeated coughing/aspiration (weak sphincter + supraglottic sensation).
• Exertional dyspnoea (glottis is too narrow to allow much air flow).
Nerve damaged with injury of superior thyroid artery: External laryngeal nerve Nerve damaged with injury to inferior thyroid artery: Recurrent laryngeal nerve
128. A 38yo woman has delivered after an induced labor which lasted 26h. choose the single most likely predisposing factor for postpartum hemorrhage?
a. Atonic uterus
b. Cervical/vaginal trauma c. Rupture uterus
d. Fibroid uterus e. Age of mother
Ans. The key is A. Atonic uterus.
Primary PPH is the loss of greater than 500mL (definitions vary) in the first 24h after delivery
Causes: uterine atony (90%), genital tract trauma (7%), clotting disorders— (3%)
Risks: Antenatal • Previous PPH or retained placenta BMI>35kg/m2 • Maternal
Hb<8.5g/dl at onset of labour • Antepartum haemorrhage Multiparity 4+ • Maternal age 35y+ • Uterine malformation or fibroids A large placental site (twins, severe rhesus disease, large baby) • Low placenta, Overdistended uterus (polyhydramnios, twins) • Extravasated blood in the myometrium (abruption).
In labour • Prolonged labour (1st, 2nd or 3rd stage) • Induction or oxytocin use •
Precipitant labour • Operative birth or caesarean section. Book mothers with risk factors for obstetric unit delivery.
Treatment: Give oxytocin 5U slowly IV for atonic uterus.
Attach oxygen, Give IV fluids, maintain systolic >100mmHg, Transfuse blood.
Is the placenta delivered? If it is, is it complete? If not, explore the uterus. • If the
placenta is complete, put the patient in the lithotomy position with adequate analgesia and good lighting. Check for and repair trauma.
• If the placenta has not been delivered but has separated, attempt to deliver it by controlled cord traction after rubbing up a uterine contraction. If this fails, ask an
experienced obstetrician to remove it under general anaesthesia.Beware renal shut down.
129. A 32yo woman in tears describing constant irritability with her 2 small children and inability to relax. She describes herself as easily startled with poor sleep and disturbed nightmares following a house fire a year ago, while the family slept. What is the single best tx?
Q. 2. What is the diagnosis?
Q. 3. What are the points in favour of your diagnosis?
Ans. 1 The key is E. Fluoxetine. The key is probably a wrong key. Likely correct key is B.
Relaxation therapy
Ans. 2. The diagnosis is post traumatic stress disorder.
Ans. 3. Points in favour of PTSD: i) H/O stressor (house fire a year ago) ii) Nightmares of the stressor iii) Hyper arousal (very anxious and inability to relax (leading to irritability) iv) associated depression (poor sleep, tearful).
Note: Fluoxetin and peroxetin are the drugs of choice in PTSD. CBT is the non-pharmacological treatment.
PTSD:
Symptoms: Fearful; horrified; dazed • Helpless; numb, detached • Emotional responsiveness
• Intrusive thoughts • Derealization • Depersonalization • Dissociative amnesia • Reliving of events • Avoidance of stimuli • Hypervigilance • Lack of Concentration • Restlessness•
Autonomic arousal: pulse; BP; sweating • Headaches; abdo pains Signs: Suspect this if symptoms become chronic, with these
signs (may be delayed years): difficulty modulating arousal; isolated-avoidant modes of living; alcohol abuse; numb to emotions and relationships; survivor guilt; depression;
altered world
view in which fate is seen as untamable, capricious or absurd, and life can yield no meaning
or pleasure.
Treatment: Watchful waiting for mild cases.
For severe cases: CBT or eye movement desensitization and reprocessing is done.
Drug treatment is not recommended but in case it is needed prescribe mirtazapine or paroxetine.
So i agree in this question it is PTSD and B should be the answer.
130. A 22yo woman with longstanding constipation has severe ano-rectal pain on defecation. Rectal exam: impossible due to pain and spasm. What is the most probable dx?
a. Anal hematoma b. Anal fissure c. Anal abscess d. Protalgia fugax e. Hemorrhoids
Ans. The key is B. Anal fissure.
Anal fissures: Acute If less than 6weeks, >6wks chronic.
Causes: Most are due to hard faeces. Spasm may constrict the inferior rectal artery, causing ischaemia, making healing difficult and perpetuating the problem.
History of constipation almost always present. Examination is almost impossible due to severe pain.
Treatment: Acute: Increase fluid intake, fiber diet. Bulk forming laxatives are first line.
Topical anesthetics are used. Lactulose can be tried.
Chronic: Topical GTN is the first line and mainstay of treatment. If ineffective for
>8wks surgical referral for use of botulinum toxin.
131. A 20yo student attends the OPD with complaint of breathlessness on and off, cough and sputum. His sleep is disturbed and skin is very dry in flexural areas of the body. Exam: tachypnea, hyperresonant percussion and wheezing on auscultation. What is the most likely dx?
a. Extrinsic allergic alveolitis b. Asthma
c. Wegener’s granulomatosis d. COPD
e. Cystic fibrosis Q. What is the key?
Q. What are the diagnostic criteria?
Ans. The key is B. Asthma.
Ans. 2. Diagnostic criteria of asthma: i) Airway hyper-responsiveness to certain stimuli ii) Recurrent variable airflow limitation usually reversible iii) presents as wheezing,
breathlessness, chest tightness and cough.
ASTHMA.
Symptoms: Dyspnea, wheeze, cough (with or without sputum), chest tightness (4 most important) particularly if symptoms are worse at night or early morning and in response to certain triggers like cold, exercise, allergens. Symptoms exacerbated by use of
NSAIDs and Beta blockers. Mostly there is history of allergy (atopy) as in this question there is history of dry skin. Try to find the precipitating factor.
Signs Tachypnoea; audible wheeze; hyperinflated chest; hyperresonant percussion note; reduced air entry ; widespread, polyphonic wheeze.
Management: CHRONIC (LONG TERM)
132. A pt with thought disorder washes hands 6x each time he uses the toilet. What is
Q. 2. What is the diagnosis?
Ans. 1. The key is B. CBT.
Ans. 2. The diagnosis is obsessive compulsive disorder.
OCD:
Compulsions are senseless, repeated rituals. Obsessions are stereotyped, purposeless words, ideas, or phrases that come into the mind.
Repetitive behavior and an urge to do it.
Treatment: CBT is first line. Clomipramine (start with 25mg/day PO) or SSRIs (eg fluoxetine)
133. A 25yo woman presented to her GP on a routine check up. Upon vaginal exam, she was fine except for finding of cervical ectropion which was painless but mild contact bleeding on touch. What is the next management?
a. Endometrial ablation b. Cervical smear c. Colposcopy d. Antibiotics e. Vaginal US
f. Pack with gauze and leave to dry Q. 1. What is the key?
Q. 2. Points in favour of key.
Ans. 1. The key is D. Antibiotics. WRONG KEY!
Ans. 2. Points in favour of antibiotic: Ectropion and contact bleeding can occur in infection. In the given case swab is taken to establish or rule out infection. As this is not in options then the best response is antibiotics. If improves with antibiotics then repeat smear in 6 months.
There is a red ring around the os because the endocervical epithelium has extended its territory over the paler epithelium of the ectocervix. Ectropions extend temporarily under hormonal influence during puberty, with the combined Pill, and during pregnancy. As columnar epithelium is soft and glandular, ectropion is prone to bleeding, to excess mucus production, and to infection. Treatment: Once a normal cervical smear has been confirmed, it is actively managed only if there are symptoms. After stopping any oestrogen-containing contraceptive, treatment options are controversial but include diathermy, cryotherapy, surgery with laser treatment and microwave therapy.
SO THE CORRECT ANSWER IS B.
134. A 32yo had a normal vaginal delivery 10 days ago. Her uterus has involuted normally. Choose the single most likely predisposing factor for PPH?
a. Retained product b. DIC
c. Uterine infection
d. Von Willebrand disease e. Primary PPH
Q. 1. What is the key?
Q. 2. What type of PPH it would be?
Ans. 1. The key is C. uterine infection.
Ans. 2. Secondary PPH
Loss of >500ml blood in the first 24hrs after delivery is PRIMARY PPH.
Secondary PPH: This is excessive blood loss from the genital tract after 24h from delivery. It usually occurs between 5 and 12 days and is due to infections (most common cause) (endometritis) or retained placenta.
Look for history of extended labour, difficult third stage, ragged placenta, PPH.
Symptoms: Abdominal pain. Offensive smelling lochia. Abnormal vaginal bleeding - PPH. Abnormal vaginal discharge. Dyspareunia. Dysuria.
Signs: are those of sepsis. Tachycardia, fever, rigors, suprapubic tenderness.
Treatment: For endometritis: IV antibiotics if there are signs of severe sepsis. If less systemically unwell, oral treatment may be sufficient. Piperacilin and tazobectum may be used.
If RPOC are suspected, elective curettage with antibiotic cover may be required. Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective of ultrasound findings
135. A 37yo man slipped while he was walking home and fell on his out stretched hand.
He complains of pain in the right arm. XR showed fx of the head of radius. What is the single most associated
nerve injury?
a. Radial nerve
b. Musculocutaneous nerve c. Median nerve
d. Ulnar nerve
Q. 1. What is the key?
Q. 2. What is the root value?
Ans. 1. The key is A. Radial nerve.
Ans. 2. Root value of radial nerve: C5,6,7,8 and T1.
136. A butcher stabbed accidently his groin. He bled so much that the towel was soaked in blood and BP=80/50mmHg, pulse=130bpm. What % of circulatory blood did he lose?
a. <15%
b. 15-30%
c. 30-40%
d. 40-50%
e. >50%
Q. 1. What is the key?
Q. 2. What is the classification of blood loss according to vital sign?
Ans. 1. The key is C. 30-40%
Ans. 2. Hypovolemic shock Classification:
1. Class 1 up to 15% of blood volume lost: pulse <100; systolic BP normal; pulse
pressure normal; Respiratory rate 14-20; urine output greater than 30 ml/hour.
2. Class 2 15%-30% blood volume lost: pulse 100-120; systolic blood pressure
normal; pulse pressure decreased; respiratory rate 20-30; urine output 20-30 ml/hour.
3. Class 3 30%-40% blood volume lost: pulse 120-140; systolic BP decreased; pulse
pressure decreased, respiratory rate 30-40; urine output 5-15 ml/hr
4. Class 4, blood loss of greater than 40%: pulse rate >140; systolic BP decreased;
pulse pressure decreased’ respiratory rate >35; urine output negligible.
137. A 67yo man presents with palpitations. ECG shows an irregular rhythm and HR=140bpm. He is otherwise stable, BP=124/80 mmHg. What is the most appropriate management?
a. Bisoprolol b. ACEi c. Ramipril d. Digoxin
Ans. The key is A. Bisoprolol.
The patient has Atrial fibrillation. Irregularly irregular pulse and tachycardia.
Agents used to control rate in patients with atrial fibrillation
beta-blockers
calcium channel blockers
digoxin (not considered first-line anymore as they are less effective at controlling the heart rate during exercise. However, they are the preferred choice if the patient has coexistent heart failure)
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation
sotalol
amiodarone
flecainide
others (less commonly used in UK): disopyramide, dofetilide, procainamide, propafenone, quinidine
TREATMENT CHOICE:
In the given question since the patient is above the age of 65 so rate control is done! For which either a beta blocker or calcium channel blocker is used!
138. A 78yo man is depressed after his wife’s death. He has been neglecting himself.
His son found him in a miserable state when he went to visit. The son can’t deal with his father. What is the appropriate management?
a. Voluntary admission to psychiatry ward b. Hand over to social worker
c. Request son to move in with father d. Send pt to care home
Ans. The key is A. Voluntary admission to psychiatry ward.
139. An old alcoholic presents with cough, fever, bilateral cavitating consolidation. What is the most probable cause?
a. Gram +ve diplococcic b. Coagulase +ve cocci c. Gram –ve cocci d. AFB
e. Coagulase –ve cocci Q. 1. What is the key?
Q. 2. What is the organism?
Ans. 1. The key is B. Coagulase +ve cocci.
Ans. 2. Name of organism is Staphylococcus aureus.
• Legionella: hotel stay, foreign travel, flu like symptoms, hyponatremia, pleural effusion.
TEST: urinary antigen. CXR shows bi-basal consolidation
• Mycoplasma Pneumonae: Rash (erythema multiforme), unusual symptoms (abd pain, dry cough), long duration of symptoms, hyponatremia, Diagnosis by serology. CXR: reticular-nodular shadowing or patchy consolidation
• Staphylococcal pneumonia may complicate influenza infection and is seen most
frequently in the elderly and in intravenous drug users or patients with underlying disease. Shows bilateral cavitations.
• Pneumonia associated with COPD: H.influenze (more likely) or P.aeruginosa
• P.aeruginosa: Common in bronchiectasis or CF. Also causes hospital acquired infection.
• Klebsiella pneumoniae is classically in alcoholics
• Strept pneumonia: Associated with herpes labialis. commoner in the elderly,
alcoholics, post-splenectomy, immunosuppressed and patients with chronic heart failure or pre-existing lung disease
• Pneumocystis pneumonia (PCP) causes pneumonia in the immunosuppressed (eg HIV). CXR may be normal or show bilateral perihilar interstitial shadowing.
Diagnosis: visualization of the organism in induced sputum, bronchoalveolar lavage, or in a lung biopsy specimen