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.
Treatment is by excision under antibiotic cover.
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
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
Q. 2. What is the likely diagnosis?
Ans. 1. Key is B.
Ans. 2. Rhabdomyolysis. X
Crush syndrome is characterised by:
Hypovolaemic shock
Hyperkalaemia
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?
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
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
Ans. Key is B. Superficial inguinal LN.
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
ERCP contraindications:
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.
Risk factors include old age, alcoholism and anticoagulation.
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 syndrome Painful vesicles in her left ear Features
auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear
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
54. A 6m child presents with fever and cough. His mother has rushed him to the ED asking for help. Exam: temp=39C and the child is feeding poorly. Dx?
a. Bronchiolitis b. Asthma c. Bronchitis
Q. 1. What is the key?
Q.2. What is the management?
Ans. 1. A. Bronchiolitis.
Ans. 2. Management: 1. Oxygen inhalation 2. Nasogastric feeding. DON’T USE: i) bronchodilator ii) steroid iii) antibiotics routinely. [OHCS, page-160]
Acute bronchiolitis is the big lung infection in infants
Symptoms: coryza precedes cough, low fever, tachypnoea, wheeze, inspiratory crackles, apnoea, intercostal recession ± cyanosis.
Cause: Winter respiratory syncytial virus. Others: Mycoplasma, parainfluenza, adenoviruses. Those <6 months old are most at risk.
Signs prompting admission: Poor feeding, >50 breaths/min, apnoea, dehydration, rib recession, patient or parental exhaustion
Tests: If severe: CXR (hyperinflation); blood gases/SpO2; FBC.
Treatment: O2 (stop when SpO2 92%); nasogastric feeds. 5% need ventilating
(mortality ≈1%; 33% if symptomatic congenital heart disease). Don’t use bronchiodilators and steroids routinely
55. A 75yo man collapsed while walking in his garden. He recovered fully within 30 mins with BP
110/80 mmHg and regular pulse of 70bpm. He has a systolic murmur on examination.
His
activities have been reduced lately which he attributes to old age. What is the definitive diagnostic inv that will assist you with his condition?
a. ECG
Q. 2. What are the possible causes of this syncope?
Ans. 1. B. Echo.
Ans. 2. i) Aortic stenosis – more likely in elderly. ii) hypertrophic cardiomyopathy – less likely in this age as presentation may present in an earlier age.
Aortic stenosis (AS)
Causes: Senile calcification is the commonest. Others: congenital (bicuspid valve, William’s syndrome, rheumatic heart disease.
Presentation: Think of AS in any elderly person with chest pain, exertional dyspnoea or syncope. The classic triad includes angina, syncope, and heart failure (usually after age 60). Also: dyspnoea; dizziness; faints; systemic emboli if infective endocarditis; sudden death.
Signs: Slow rising pulse with narrow pulse pressure (feel for diminished and delayed carotid upstroke—parvus et tardus); heaving, non-displaced apex beat; LV heave; aortic thrill; ejection systolic murmur (heard at the base, left sternal edge and the aortic area, radiates to the carotids).
There may be an ejection click (pliable valve) or an S4 (said to occur more often with bicuspid valves, but not in all populations).
Tests: ECG: P-mitrale, LVH with strain pattern; LBBB or complete AV block (calcified ring). CXR: LVH; calcified aortic valve post-stenotic dilatation of ascending aorta.
Echo: diagnostic.
Doppler echo can estimate the gradient across valves
Cardiac catheter can assess: valve gradient; LV function; coronary artery disease Management: If symptomatic, prognosis is poor without surgery.
If moderate-to-severe and treated medically, mortality can be as high as 50% at 2yrs, therefore prompt valve replacement is usually recommended.
In asymptomatic patients with severe AS and a deteriorating ECG, valve replacement is also recommended. If the patient is not medically fit for surgery, percutaneous
valvuloplasty/replacement (TAVI = transcatheter aortic valve implantation) may be attempted.
56. A 35yo man with a hx of schizophrenia is brought to the ER by his friends due to drowsiness. On examination he is generally rigid. A dx of neuroleptic malignant syndrome except:
a. Renal failure b. Pyrexia
c. Elevated creatinine kinase d. Usually occurs after prolonged tx e. Tachycardia
Ans. Key is D. Usually after prolonged tx. It usually occurs within 10 days of starting treatment. “renal failure” is the wrong answer as neuroleptic syndrome can lead to renal failure so we have to give IV fluids to prevent it.
Cause: antipsychotics or dopamenergic drugs (levodopa)
Management: STOP the drug causing it. IV fluids, Dantrolene, Bromocriptine
57. A 33yo drug addict wants to quit. She says she is ready to stop the drug abuse. She is supported by her friends and family. What drug tx would you give her?
a. Benzodiazepines
Q.2. What drugs should you use in i) tobacco abuse and in ii) alcohol abuse?
Ans. 1. Key is d. Methadone. (used in opiate abuse). Nalexone is the antidote.
Ans. 2. i) tobacco abuse: a) bupropion ii) alcohol: a) acamprosate decreases craving b) disulfirum is a deterrent.
58. A 16m child presents with drooling, sore throat and loss of voice. He has fever with a temp of
38.2C. What is your next step towards management?
a. Direct pharynoscopy b. Call ENT surgeon c. Call anesthesiologist d. IV fuilds
e. Start antibiotics Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. What is the urgent management?
Ans. 1.Key is C. Call anesthesiologist.
Ans. 2. Diagnosis is Acute epiglottitis.
Ans. 3. In given case urgent intubation is needed to secure airway to prevent blockage of respiration.
Differential: croup. Croup has barking cough which is worse at night and there is no drooling of saliva NO COUGH IN EPIGLOTITTIS. Croup caused by parainfluenza while epiglottitis is caused by H.influenze
Acute epiglottitis is rarer than croup but mortality is high: 1% if respiratory distress. It’s an emergency as respiratory arrest can occur.
Presentation: Often, history is short, septicaemia is rapid, and cough is absent. Also:
sore throat (100%), fever (88%), dyspnoea (78%), voice change (75%), dysphagia (76%), tender anterior neck ± cellulitis (27%), hoarseness (21%), pharyngitis (20%), anterior neck nodes (9%), drooling (head for ward tongue out), prefers to sit, refusal to swallow,
Cause: Haemophilus (vaccination has reduced prevalence); Strep pyogenes.
Investigation: Fibre-optic laryngoscopy remains the 'gold standard' for diagnosing epiglottitis
Management: Take to ITU; don’t examine throat (causes resp. arrest). Give O2 by mast, Give nebulized adrenaline, IV dexamethasone, antibiotics, antipyretics until the anesthetist arrives. Definitive management is intubation
59. A 62yo woman complains of unsteadiness when walking. On examination she has pyramidal
weakness of her left lower limb and reduced pain and temp sensation on right leg and right side
of trunk up to the umbilicus. Joint position sense is impaired at her left great toe but is normal
elsewhere. She has a definite left extensor plantar response and the right plantar response is
equivocal. Where is the lesion?
a. Left cervical cord
b. Midline mid-thoracic cord c. Right mid-thoracic cord d. Left mid-thoracic cord
e. Left lumbo-sacral plexus Q. 1. What is the key?
Q. 2. What is the name of this condition?
Ans. 1. The key is d. Left mid-thoracic cord.
Ans. 2. Brown-sequard syndrome.