If the patient has dyspepsia at any age with any of the following alarm symptoms:[13]
Chronic GI bleeding.
Progressive unintentional weight loss.
Progressive dysphagia.
Persistent vomiting.
Iron-deficiency anaemia.
Epigastric mass.
Suspicious barium meal.
NB: patients aged 55 years or older with unexplained and persistent recent-onset dyspepsia should be referred urgently for endoscopy
If age less than 55 and no alarm signs, try life style modifications and simple antacids. If no improvement then do H.pylori testing (antibodies). If it is positive do eradication and review in 4 weeks.
If resolved, no further action required.
If symptoms are not resolved, do urea breath test.
If it is positive, again eradication for H.pylori If it is negative, do upper GI endoscopy
If the initial H.pylori testing was negative give PPIs or H2 blockers for 4 weeks and review if symptoms resolve no action needed if they dont resolve do upper GI endoscopy.
111. A 15yo male has bilateral ankle edema. His BP=110/70mmHg and urinalysis shows protein++++.
What is the most likely dx?
a. HUS
Q. 2. What are the points in favour of your diagnosis?
Q. 3. What is the treatment?
Ans. 1. The key is D. Minimal change disease.
Ans. 2. Points in favour: i) Age 15 ii) Ankle oedema iii) Normotension iv) Heavy proteinuria.
Ans. 3. Treatment of choice is steroid (prednisolone). Failure of steroid or frequent relapse (>3) cyclophosphamide.
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.
IgA nephropathy is nephritic and will also show HTN and microscopic hematuria and follows upper resp tract infection.
Membranous GN also presents as nephrotic but age and since MCD is most common we choose MCD.
Nephrotic syndrome itself is not a diagnosis.
112. A 28yo man has developed a red, raised rash on trunk after playing football. His PMH shows he had childhood asthma. The rash is becoming increasingly itchy. What is the most appropriate tx?
Q. 2. What is the diagnosis?
Ans. 1. The key is A. Oral chlorpheneramine.
Ans. 2. Diagnosis is Atopy (allergy).
Since it is an allergic reaction only 2 options are suitable. A & C. IM adrenaline is used in anaphylactic shock which can occur due to allergy. But this is just a mild allergic reaction here so anti histamine (chlorpheneramine) is adequate.
Anaphylaxis presents with:
Sudden onset and rapid progression of symptoms.
Life-threatening airway and/or breathing and/or circulation problems
Patient will be mostly in shock.
Mostly commonly caused by certain foods like peanuts, pulses, fish, eggs. Also by venom (bee,wasps) and drugs like antibiotics.
Treatment:ABCDE, Oxygen, IM Adrenaline. <6yrs0.15ml, 6-12yrs 0.3ml, >12 yrs 0.5ml 1:1000
113. A 72yo man has been advised to have antibiotic prophylaxis for some years now before dental tx. He has never experienced chest pain. Three weeks ago, he noticed breathlessness on exertion and for one week he had orthopnea. His pulse is normal.
What is the most probable dx?
a. Aortic regurgitation
b. Ischemic mitral regurgitation c. Mitral valve prolapse
d. Pulmonary stenosis e. Mitral valve stenosis
Ans. The kay is E. Mitral valve stenosis.
The patient has mitral stenosis or Aortic regurgitation. he is given prophylaxis for infective endocarditis. According to OHCM, such prophylaxis has no benefit and should not be given.
RISK FACTORS for IE: aortic or mitral valve disease; tricuspid valves in IV drug users;
coarctation; patent ductus arteriosus; VSD; prosthetic valves
Mitral Stenosis: Presentation: dyspnoea; fatigue; palpitations; chest pain; systemic emboli; haemoptysis; chronic bronchitis-like picture
CAUSES: Rheumatic, congenital, mucopolysaccharidoses, endocardial fibroelastosis, malignant carcinoid, prosthetic valve.
SIGNS: Malar flush on cheeks (due to ↑ cardiac output); low-volume pulse; AF common;
tapping, non-displaced, apex beat (palpable S1). On auscultation: loud S1; opening snap (pliable valve); rumbling mid-diastolic murmur (heard best in expiration, with patient on left side
ECG shows P-mitrale… ECHO is diagnostic. CXR: left atrial enlargement (double shadow in right cardiac silhouette)
TREATMENT: balloon valvuloplasty (if pliable, non-calcified valve), open mitral valvotomy
or valve replacement.
Complications: Pulmonary hypertension, emboli, pressure from large LA on local structures, eg hoarseness (recurrent laryngeal nerve), dysphagia (oesophagus), bronchial obstruction; infective endocarditis
AORTIC REGUGITATION: CAUSES Acute: Infective endocarditis, ascending aortic dissection,
chest trauma.
SYMPTOMS: Exertional dyspnoea, orthopnoea, and paroxysmal nocturnal dyspnoea.
palpitations, angina, syncope, CCF
Signs: Collapsing (water-hammer) pulse (p40); wide pulse pressure; displaced,
hyperdynamic apex beat; high-pitched early diastolic murmur (heard best in expiration, with patient sitting forward).
The diagnosis here is mitral stenosis because of the “normal pulse”. I think the information in the question is too deficient for such a disease and diagnosis!
FEVER + NEW MURMUR IS ENDOCARDITIS UNTIL PROVEN OTHERWISE
114. A 37yo woman presents with fatigue. Exam: angular stomatitis, no koilonychea.Choose the single cell type you will find on the blood film.
a. Macrocytes b. Microcytes
c. Granulocytes wthout blast cells d. Blast cells
Q. 1. What is the key?
Q. 2. What is the cause here?
Q. 3. What are the points in favour of mentioned cause?
Ans. 1. The given key is A. Macrocytes.
Ans. 2. The cause here is VIT. B12 or folate deficiency.
Ans. 3. Points in favour of Vit. B12 or folate deficiency: i) fatigue (anaemia) ii) angular stomatitis (can be seen in Vit. B12 or folate deficiency) iii) absence of koilonychea is against IDA.
SIGNS in ANEMIA:
Koilocychia (spoon shaped nails) iron deificiency anemia atrophic glossitis in iron def.
post cricoid webs (plummer vinson syndrome)
Angular stomatitis (cheilosis) in both vit B12 and iron def.
glossitis (beefy-red sore tongue) Vit. B12 def.
115. A 4yo boy with a febrile convulsion lasting eight minutes has been given IV lorazepam to control them. What is the single most likely serious side effect?
a. Amnesia
b. Anaphylactic shock c. Apnea
d. Bronchospasm e. Cardiac arrhythmia Ans. The key is C. Apnoea.
Due to respiratory depression caused by benzodiazepines. They can also cause amnesia but it wont be in acute setting.
116. A 4wk girl has been dx of having breast milk jaundice. She is otherwise well. What is the single most appropriate management?
a. Continue breastfeeding
b. Exchange transfusion c. Increase fluid intake d. Phototherapy e. Stop breastfeeding Q. 1. What is the key?
Q. 2. What is breast milk jaundice?
Q. 3. What type of hyperbilirubinemia occurs in breast milk jaundice?
Q. 4. What is the cause of this jaundice?
Ans. 1. The key is A. Continue breast feeding.
Ans. 2. If jaundice lasts past the first week of life in a breastfed baby who is otherwise healthy, the condition may be called "breast milk jaundice."
Ans. 3. Unconjugated hyperbilirubinaemia.
Ans. 4. Cause of breast milk jaundice: factors in a mother's milk that help a baby absorb bilirubin from the intestine.