76. A 65yo HTN man presents with lower abdominal pain and back pain. An expansive abdominal mass is palpated lateral and superior to the umbilicus. What is the single most discriminating inv?
a. Laparascopy b. KUB XR c. Pelvic US d. Rectal exam e. Abdominal US Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What are the points given here in favour of your diagnosis?
Ans. 1. The key is E. Abdominal US.
Ans. 2. The diagnosis is Abdominal aortic aneurism.
Ans. 3. Points in favour of AAA are i) hypertension ii) abdominal pain iii) back pain iv) expansile abdominal mass lateral and superior to the umbilicus.
RISK Factors include : Family Hx , tobacco smoking is an important factor.
Male sex.
Increasing age.
Hypertension.
Chronic obstructive pulmonary disease.
Hyperlipidaemia
UNRUPTURED AAA is commonly asymptomatic and is an accidental finding.
Ruptured AAA may present with:
Pain in the abdomen, back or loin - the pain may be sudden and severe.
Syncope, shock or collapse:
The degree of shock varies according to the site of rupture and whether it is contained - eg, rupture into the peritoneal cavity is usually dramatic, with death before reaching hospital; whereas rupture into the retroperitoneal space may be contained initially by a temporary seal forming.
Ultrasound is simple and cheap; it can assess the aorta to an accuracy of 3 mm. It is used for initial assessment and follow-up.
SCANS :
CT Scan provides more anatomical details - eg, it can show the visceral arteries, mural
thrombus, the 'crescent sign' (blood within the thrombus, which may predict imminent rupture) and para-aortic inflammation. CT with contrast can show rupture of the aneurysm.
MRI angiography may be used.
If size exceeds 5.5cm, we go for surgery.
77. A 55yo man has had severe pain in the right hypochondrium for 24h. The pain comes in waves and is accompanied by nausea. Nothing seems to relieve the pain. He feels hot and sweaty but has normal temp. What is the most appropriate next inv:
A.US Abdomen b. ERCP c. MRCP
d. Serum amylase e. UGI endoscopy Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What are the points in favour of your diagnosis?
Ans. 1. The key is A. US abdomen.
Ans. 2. The diagnosis is biliary colic.
Ans. 3. Points in favour- i) severe right hypochondrial pain. ii) colicky nature of the pain (comes in waves) iii) nausea iv) absence of fever iv) absence of jaundice.
Biliary colic :
The pain starts suddenly in the epigastrium or right upper quadrant (RUQ) and may radiate round to the back in the interscapular region.
Contrary to its name, it often does not fluctuate but persists from 15 minutes up to 24 hours, subsiding spontaneously or with analgesics.
Nausea or vomiting often accompanies the pain, which is visceral in origin and occurs as a result of distension of the gallbladder due to an obstruction or to the passage of a stone through the cystic duct.
Differential diagnosis include reflux, peptic ulcers, irritable bowel syndrome, relapsing pancreatitis and tumours - eg, stomach, pancreas, colon or gallbladder. Two or more of these conditions may overlap, so the diagnosis may not be easy.
ULTRASOUND is the best way to demonstrate stones, being 90-95% sensitive.
78. A 67yo man has deteriorating vision in his left eye. He has longstanding COPD and is on multiple drug therapy. What single medication is likely to cause this visual deterioration?
a. B2 agonist b. Corticosteroid c. Diuretic
d. Theophylline
Q. 1. What is the key?
Q. 2. What is the cause of deteriorating vision?
Ans. 1. The key is B. Corticosteroid.
Ans. 2. Prolonged corticostiroids [also topical i.e. eye drop] can cause cataract.
79. A woman who returned from abroad after 3 weeks of holiday complains of severe diarrhea of 3 weeks. She also developed IDA and folic acid def. What condition best describes her situation?
a. Jejunal villous atrophy b. Chronic diarrhea secretions c. Malabsorption
d. Increased catabolism e. Increased secretions of acid Q. 1. What is the key?
Q. 2. What are the points in favour?
Q. 3. What are the signs of deficiency may be present?
Ans. 1. The key is C. Malabsorption.
Ans. 2. Diarrhoea, IDA and folic acid deficiency.
Ans. 3.· Iron-deficiency anaemia.
· Folate deficiency or vitamin B12 deficiency.
· Bleeding, resulting from low vitamin K.
· Oedema, which occurs in protein/calorie malnutrition.
Tropical sprue is seen in residents of, and visitors to, tropical areas and it tends to begin with an acute episode of diarrhoea, fever and malaise before settling into a more chronic presentation of steatorrhea, malabsorption, nutritional deficiency, anorexia, malaise and weight loss. Folate deficiency is a significant part of the clinical picture.
80. A 35yo male is bitterly annoyed with people around him. He thinks that people are putting ideas into his head. What is the single most likely dx?
a. Thought block b. Thought insertion c. Thought broadcasting d. Thought withdrawal e. Reference
Q. 1. What is the key?
Q. 2. In which disease you will find this feature?
Ans. 1. The key is B. Thought insertion.
Ans. 2. It is seen in schizophrenia.
Symptoms called disorders of thought possession may also occur in schizophrenia.
These include:
Thought insertion. This is when someone believes that the thoughts in their mind are not their own and that they are being put there by someone else
.Thought withdrawal. This is when someone believes that thoughts are being removed from their mind by an outside agency.
Thought broadcasting. This is when someone believes that their thoughts are being read or heard by others.
Thought blocking. This is when there is a sudden interruption of the train of thought before it is completed, leaving a blank. The person suddenly stops talking and cannot recall what he or she has been saying.
81. A 10yo girl presents with hoarseness of the voice. She is a known case of bronchial asthma and has been on oral steroids for a while. What is the most likely cause of hoarseness?
a. Laryngeal candidiasis b. Infective tonsillitis
c. Laryngeal edema d. Allergic drug reaction e. Ludwigs angina
Hoarseness may be a feature of laryngeal obstruction - so can be a warning of impending airway obstruction.
This may occur in:
Infections - acute epiglottitis, diphtheria, croup, laryngeal abscess, laryngitis
Inflammation/oedema - airway burns, anaphylaxis, physical trauma, angio-oedema, hereditary angio-oedema.
Vocal cord immobility - laryngeal nerve palsy (depending on the position of the cords) or cricoarytenoid joint disease.
Immuno compromised states lead to fungal infections. These include HIV, Diabetes etc.
Patients taking long term steriods (inhalar or oral), antibiotics n those having vitb12 and folic acid deficiecy are at a risk of having oral thrush.
Q. 1. What is the key?
Q. 2. What is the reason for this condition?
Ans. 1. The key is A. Laryngeal candidiasis.
Ans. 2. Steroids predisposes to fungal infection.
82. A lady with breast cancer has undergone axillary LN clearance. She develops arm swelling after being stung by a bee. What is the most likely mechanism responsible for the swelling?
a. Lymphedema b. Cellulitis
c. Hypersensitivity reaction d. DVT
e. Fluid retention Q. 1. What is the key?
Q. 2. What is the reason for this condition?
Ans. 1. The key is A. Lymphoedema.
Ans. 2. Reason is compromised lymphatic drainage of arm due to axillary LN clearance.
83. A 34yo pt presents with 50% partial thickness burns. What should be the most appropriate management?
a. IV fluids calculated from the time of hospital arrival b. IV fluids calculated from the time of burn
c. No IVF
d. IV dextrose stat e. Burns ointment Q. 1. What is the key?
Q. 2. How the calculation of fluid is made?
Ans. 1. The key is B. IV fluids calculated from the time of burn.
Ans. 2. Resuscitation fluids required in the first 24 hours from the time of injury.
For adults: 3 ml (in partial thickness burn) of Hartmann’s solution/kg body weight/% total
Body surface area.
Half of this calculated volume is given in the first 8 hours and the other half is given over the following 16 hours.
84. A 54yo man has recently been dx with moderate depression. He has hx of MI and is suffering from insomnia. What is the drug of choice for him?
a. Citalopram b. Lofepramine
c. ECT
d. Haloperidol e. Diazepam
Ans. Key is A. Citalopram. [Citalopram is the antidepressant of choice post MI].
85. A man presented with cellulitis and swelling. He was started on flucloxacillin. What other medication do you want to add?
a. Vancomycin b. Penicillin c. Metronidazole d. Ceftriaxone e. Amoxicillin
Q. 1. What is the key?
Q. 2. Is it justified to add this drug? If justified please mention why?
Ans. 1. The key is B. Penicillin.
Ans. 2. Custom and practice has traditionally combined the use of benzylpenicillin and flucloxacillin in the management of hospitalised patients with cellulitis. In most cases this is not seen as practical or necessary. Flucloxacillin covers both beta-haemolytic
streptococci and penicillinase-resistant staphylococci.
But for exam purpose, treatment of cellulitis = Benzylpenicillin + Flucloxacillin.
Drug of choice for cellulitis is flucloxacillin. IT Is sufficient alone. If needed to add something, add penicilin ,, or add doxycycline if exposed to salt water,,, add
erythromycin if there is penicillin allergy, or add ciprofloxacin if exposed to fresh water.
86. A 24yo college student presents with nausea, vomiting, headache, neck stiffness and a fever of 38.4C. What is the most appropriate empirical antibiotic to be started?
a. Ceftriaxone b. Penicillin
c. Gentamicin d. Tazobactam e. Meropenem
Ans. The key is A. Ceftriaxone. [In OHCM-Cefotaxime <55yrs and Cefotaxime + Ampicillin if age >55yrs].
One should start benzyl penicillin before admission. After admission, ideally cefotaxime
should be given as per new guidelines. But, as there was no option of cefotaxime, we would go for ceftriaxone (also 3rd gen cephalosporin)
87. A man with prosthetic heart valve underwent hemicolectomy and after some days complains of left hypochondriac pain, fever and has a systolic murmur. What is the next inv to ascertain the cause of HF?
a. CT
b. Blood culture c. ECG
d. MRI
e. Radioactive thyroid scan Infective Endocarditis
Risk factors:
Cardiac conditions considered to increase a patient's risk of developing infective endocarditis:
Valvular heart disease with stenosis or regurgitation. Valve replacement.
Structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding: Isolated atrial septal defect. Fully repaired ventricular septal defect. Fully repaired patent ductus arteriosus. Closure devices that are judged to be endothelialized.
Investigations
Nonspecific signs of infection - eg, elevated CRP or ESR, leukocytosis, anaemia and microscopic haematuria.
CXR: as part of the initial assessment.
Electrocardiogram is useful to detect the 10% of patients who will develop conduction defects.
Blood cultures:
Should be taken prior to starting treatment in all cases. Meticulous aseptic technique is required.
Echocardiography Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. Why have you made this diagnosis?
Q. 4. What are the important risk factors for this condition?
Ans. 1. The key is B. Blood culture.
Ans. 2. The diagnosis is infective endocarditis.
Ans. 3. Fever + new murmur = endocarditis until proven otherwise.
Ans. 4. Important risk factors: dermatitis, IV injections, renal failure, organ
transplantation, DM, post operative wound. Risk factors for abnormal valves: aortic or mitral valve disease, tricuspid valve in IV drug users, prosthetic valves.
88. A 45yo man with posterior gastric ulcer presented with severe excruciating pain which subsided after conservative treatment. 10 days later he developed swinging pyrexia. US shows a collection in the peritoneum. What will be the most likely location of the collection?
a. Hepatorenal pouch
b. Left paracolic gutter c. Subphrenic
d. Pelvic cavity e. Lesser sac
Ans. The key is E. Lesser sac.
89. A 23yo lady was prescribed with azithromycin 1gm for her chlamydial pelvic infection. She has got a new boyfriend for the last 2 months. She has recently started contraception to avoid conception. Which of the following contraception method will be affected by azithromycin?
a. Barrier b. IUCD c. POP d. COCP
Ans. None of them! Before it was thought that hepatic enzyme inhibitor drugs may affect COCP but later it was established that actually there is no such significant effect. Only drugs like rifampicin and rifambuin can cause this. No other antibiotic alters COCP levels. Moreover, POP is not affected by any antibiotic other than rifampicin. Barrier method has nothing to do with any antibiotic as its a mechanical method. IUCD has no proved interaction with antibiotics.
90. An 11yo boy is being checked by the diabetic specialist nurse. His HbA1c was high and he has been skipping meals recently. He has been unhappy at school. Which single member of the clinical team would you refer him to next?
a. GP
b. Pediatrician
c. Dietician
d. Clinical psychologist
Ans. The key is D. Clinical psychologist. [Unhappy at school, skipping meals these are psychological issue. He needs psychological counseling].
There was a discussion on plab forum that the answer should be pediatrician , but here the problem is psychological. Had he missed any medication, he would have had to see pediatrician.
91. A 35yo man who has served in the army presents with lack of interest in enjoyable activities and feeling low. He doesn’t feel like reading the news or watching movies as he believes there is
violence everywhere. What is the most appropriate first line therapy?
a. Citalopram b. Lofepramine c. CBT
d. Chlordiazepoxide e. Desensitization Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What is the first line treatment?
Q. 4. Here why 1st line treatment is not considered?
Ans. 1. The key is C. CBT
Ans. 2. The diagnosis is depressive illness.
Ans. 3. In depressive illness 1st line therapy is SSRI
Ans. 4. In this patient abnormal thinking of presence of violence everywhere is the trigger for his depression and in this situation CBT gives the best result.
[It is not post traumatic stress disorder as constant vivid flashbacks of the experience which is the main feature of PTSD is absent here. In the given scenario depression has a trigger of abnormal thought process that there is violence everywhere! So cognitive behavioural therapy is the best treatment here (though in typical depression drug of
first choice is SSRI- according to samson note)].
(personally not sure about this one as pt has all the features of ptsd except the flashbacks.
Though, the answer would still be cbt )
92. A man has reducible bulge below the pubic tubercle, and on occlusion of the deep inguinal ring, cough impulse is present. What is the most likely dx?
a. Direct inguinal b. Indirect inguinal c. Femoral
d. Spigelian e. Lumbar
Q. 1. What is the key?
Q. 2. What are the points in favour of your answer?
Ans. 1. The key is C. Femoral hernia.
Ans. 2. It is just below the pubic tubercle that is just below the inguinal ligament.
Note: this question is a very bad recall as hernia below pubic tubercle is femoral and cough impulse felt in occluded deep ring is seen in inguinal hernia. In femoral hernia positive cough impulse is found in femoral ring.
Features of femoral hernia:
Below and lateral to the pubic tubercle
More common in women, particularly multiparous ones
High risk of obstruction and strangulation
Surgical repair is required
Other hernias :
Types of abdominal wall hernias:
Type of hernia Details
Inguinal hernia Inguinal hernias account for 75% of abdominal wall hernias.
Around 95% of patients are male; men have around a 25%
lifetime risk of developing an inguinal hernia.
Above and medial to pubic tubercle
Strangulation is rare
Femoral hernia Below and lateral to the pubic tubercle
More common in women, particularly multiparous ones
High risk of obstruction and strangulation
Surgical repair is required
Umbilical hernia
Symmetrical bulge under the umbilicus
Paraumbilical hernia
Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus
Epigastric hernia
Lump in the midline between umbilicus and the xiphisternum
Most common in men aged 20-30 years
Incisional hernia
May occur in up to 10% of abdominal operations
Spigelian hernia
Also known as lateral ventral hernia
Rare and seen in older patients
A hernia through the spigelian fascia (the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally)
Obturator hernia
A hernia which passes through the obturator foramen. More common in females and typical presents with bowel obstruction
Richter hernia A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect
93. A 48yo woman is admitted to ED with a productive cough and moderate fever. She has often central chest pain and regurgitation of undigested food most times but doesn’t suffer from acid reflux. These symptoms have been present for the last 3.5 months which affects both food and drink. A CXR shows an air-fluid level behind a normal sized heart. What is the most likely dx?
a. Pharyngeal pouch b. Hiatus hernia
c. Bulbar palsy d. Achalasia e. TB
Q. 1. What is the key?
Q. 2. What are the points in favour?
Ans. 1. The key is D. Achalasia.
Ans. 2. Points in favour: Aspiration pneumonia due to retained food and fluid in oesophagus. Regurgitation of undigested food without acid reflux. Dysphagia for both food and drink. Air-fluid level behind heart.
Why it is not hiatus hernia? Ans. Differentiating point:-i) In hiatus hernia usually you will get associated GORD [particularly in sliding hernia which is the most common (99%).
However in rolling hernia there may be no reflux]. ii) In hiatus hernia x-ray chest may demonstrate a retrocardiac gas-filled structure rather than a air-fluid level iii) Also in hiatus hernia there may be nausea or vomiting.
Why it is not pharyngeal pouch? Ans. In pharyngeal pouch there will be halitosis.
Achlasia has been discussed before in detail.
94. A 64yo man has been waking up in the middle of the night to go to the bathroom. He also had difficulty in initiating micturition and complains of dribbling. A dx of BPH was made after a transrectal US guided biopsy and the pt was prepared for a TURP. What electrolyte abnormality is highly likely due to this surgery?
a. Hypokalemia b. Hypocalcemia c. Hyperkalemia d. Hyponatremia e. Hypernatremia
Q. 1. What is the key?
Q. 2. Why this happens?
Ans. 1. The key is D. Hyponatremia.
Ans. 2. Absorption of fluid used for bladder irrigation to flush out blood clots and IV fluids all may lead to hypervolaemia and dilutional hyponatremia.
95. A 56yo lady has developed severe right sided headache which worsens whenever she comes to bright light since the last 4 days. She feels nauseated, but doesn’t vomit.
What is the most likely dx?
a. SAH
b. Brain tumor c. Migraine
d. Cluster headache e. Subdural headache Q. 1. What is the key?
Q. 2. What is the type of the given case?
Q. 3. What are the points in favour of mentioned type?
Ans. 1. The key is C. Migraine.
Ans. 2. It is migraine without aura. There is presence of trigger (bright light) Ans. 3. Criteria of migraine without aura: ≥5 headaches lasting 4-72 hours +
nausea/vomiting (or photo/phono-phobia) + any 2 of: i) unilateral ii) pulsating iii) worsen by routine activity [OHCM, 9th edition, page-462].
It should be noted that as a general rule 5-HT receptor agonists are used in the acute treatment of migraine whilst 5-HT receptor antagonists are used in prophylaxis. NICE produced guidelines in 2012 on the management of headache, including migraines.
Acute treatment
first-line: offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol
for young people aged 12-17 years consider a nasal triptan in preference to an oral triptan
if the above measures are not effective or not tolerated offer a non-oral
preparation of metoclopramide* or prochlorperazine and consider adding a non-oral NSAID or triptan
Prophylaxis
prophylaxis should be given if patients are experiencing 2 or more attacks per month. Modern treatment is effective in about 60% of patients.
NICE advise either topiramate or propranolol 'according to the person's preference, comorbidities and risk of adverse events'. Propranolol should be used in preference to topiramate in women of child bearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives
NICE advise either topiramate or propranolol 'according to the person's preference, comorbidities and risk of adverse events'. Propranolol should be used in preference to topiramate in women of child bearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives