172. A 44yo pt has sudden onset of breathlessness and stridor few minutes after extubation for
thyroidectomy. The pat had longstanding goiter for which he had the surgery. What is the most
likely dx?
a. Thyroid storm b. Hematoma
c. Unilateral recurrent laryngeal nerve injury d. External laryngeal nerve injury
e. Tracheomalacia
Ans. The key is tracheomalacia.
173. A 15yo boy presents with generalized edema. His urinalysis reveals protein +++, eGFR =110. What is the most likely dx?
a. IgA nephropathy
b. Membranous nephropathy c. Minimal change disease d. PSGN
e. Lupus nephritis
Ans. The key is C. Minimal change disease. [Points in favour: i) Age 15 yrs ii)
Generalized oedema iii) Protein in urine +++ vi) Normal eGFR of 110 (Normal range- 90 to 120 mL/min)].
Most common cause of nephrotic syndrome 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.
174. A 72yo man is receiving chemotherapy for SCLC. He has his 4th tx 8 days ago. He has a cough with some green sputum but feels well. Temp=37.6C. Chest exam = few coarse crepitations in the right base. HR=92bpm. CBC: Hgb=12.5g/dL, WBC=1.1, Neutrophils=0.6, Plt=89. Sputum, urine and blood culture sent to microbiology. What is the most appropriate management?
a. Broad spectrum antibiotics IV b. Broad spectrum antibiotics PO c. GCSF
d. Postpone tx until bacteriology results available e. Reassure and send home
Q. 1. What is the key?
Q. 2. What is the Diagnosis?
Q. 3. What is the treatment of low WBC count?
Ans. 1. The key is A. Broad spectrum antibiotics IV Ans. 2. The diagnosis is lower respiratory tract infection.
Ans. 3. GCSF subcutaneously. [it is the treatment of chemotherapy induced leucopenia]
Use of antibiotics in neutropenia:
Treat any known infection promptly.
• If T° >38°C or T° >37.5°C on 2 occasions, >1h apart, or the patient is toxic, assume septicaemia and start blind combination therapy—eg piperacillin–tazobactam—(+
vancomycin,if Gram +ve organisms suspected or isolated, eg Hickman line sepsis).
Check local preferences. Continue until afebrile for 72h or 5d course, and until neutrophils >0.5≈109/L. If fever persists despite antibiotics, think of CMV, fungi (eg Candida; Aspergillus) and central line infection.
• Consider treatment for Pneumocystis eg co-trimoxazole, ie trimethoprim
20mg/kg + sulfamethoxazole 100mg/kg/day PO/IV in 2 daily doses). Remember TB.
Avoid IM injections as they can lead to hematomas.
In this question the neutrophil count is 0.6 and temp is 37.6. So we should still start Iv antibiotics as they are dangerously close the ranges given in the text above.
Granulocytes colony stimulating factors are used to produce neutrophils and is used in preventing sepsis but the patient here is almost in sepsis! GCSF are mostly used in myeloproliferative disorders.
175. A 25yo woman with T1DM has delivered a baby weighing 4.5kg. Her uterus is well contracted. Choose the single most likely predisposing factor for PPH from the options?
a. Atonic uterus
Q. Reason for your answer.
Ans. 1. The key is B. Cervical/vaginal trauma
Ans. 2. The baby is a big baby. If patient’s uterus was not well contracted we would fear of atonic uterus! But as uterus is well contracted it is not atonic uterus. Rather most likely cause is trauma dring delivery of this big baby.
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.
176. A 23yo lady presents with headache. Exam: photophobia and generalized rash that doesn’t
blanch on pressure. What must be done immediately?
a. IV benzylpenicillin
b. Isolate pt
c. Gown and mask d. Blood culture
Ans. The key is A. IV benzylpenicillin.
When to act: Headache, pyrexia, neck stiffness, altered mental state: if any 2 co-exist and not yet in hospital, give benzylpenicillin 1.2g IM/IV before admitting.
Organisms: Meningococcus or pneumococcus. Less commonly Haemophilus influenzae;
Listeria monocytogenes. CMV, cryptococcus or TB if immunocompromised eg HIV +ve organ transplant, malignancy.
Features
Early: Headache, leg pains, cold hands and feet, abnormal skin colour.
Later:
• Meningism: neck stiffness, photophobia, Kernig’s sign (pain + resistance on passive knee extension with hip fully flexed).
• Decreased Conscious level , coma.
• Seizures (~20%) ± focal CNS signs (~20%) ± opisthotonus
• Petechial rash (non-blanching ; may only be 1 or 2 spots, or none).
Signs of galloping sepsis: slow capillary refill; DIC; dec BP. inc T° and pulse: inc or normal.
Management:
Start antibiotics immediately.
<55yrs: cefotaxime 2g/6h slow IV.
>55yrs: cefotaxime as above + ampicillin 2g IV/4h (for Listeria).
Prophylaxis: (discuss with public health/ID) •Household contacts in droplet range. Give rifampin or ciprofloxacin.
If in this question there was an option for IV cefotaxime that would have been the correct answer since here the patient has presented in the hospital. Benzylpenicilline is given before admission or before taking the patient to the hospital
177. A 4yo baby has generalized tonic-clonic seizure and fever of 39C. his mother informs you that this has happened 3-4x before. What is the most likely dx?
a. Febrile convulsion b. Absence seizures c. Epilepsy
d. Partial complex seizure
Ans: The key is C. Epilepsy! Probably wrong key! Epilepsy doesn’t occur with fever!
Likely correct key is A. Febrile convulsion.
FEBRILE CONVULSION is a single tonic–clonic, symmetrical generalized seizure lasting <20min, occurring as T° rises rapidly in a febrile illness—typically in a normally developing child (½–5yrs old).
Think of meningo-encephalitis, CNS lesion, epilepsy, trauma, hypoglycemia, dec Ca2+, or dec Mg2+ if: • Focal CNS signs or CNS abnormality • Previous history of epilepsy • The seizure lasts >15min • There is >1 attack in 24h.
Examination: Find any infection; if any neck stiffness consider meningitis. : Management: Put in recovery position; if fit is lasting >5min: lorazepam IV, buccal midazolam or diazepam PR. Tepid sponging if hot; paracetamol syrup
Labs: Consider FBC, U&E, Ca2+, glucose, MSU, CXR, ENT swabs.
Avoid LP in the postictal period. If you suspect meningitis, then treat now.
Parental education: Allay fear (a child is not dying during a fit). For the 30% having recurrences, teach carers to use buccal midazolam or rectal diazepam 0.5mg/ kg Further prevention: Diazepam PR during fevers has a role; other anticonvulsants are
‘never’ needed. Explain that all fevers (eg vaccination-associated) should prompt oral antipyretics.
Prognosis: In typical febrile convulsions there is no progress to epilepsy in 97%.
178. A middle aged Asian presents with episodes of fever with rigors and chills for last 1y. Blood film: ring form plasmodium with schaffners dots in RBCs. What is the drug to eradicate this infection?
Q. 2. What does Shuffner’s dot in RBC indicate?
Ans. 1. The key is B. Mefloquine.
Ans. 2. Shuffners dot indicates, it is plasmodium ovale or plasmodium vivax infestation.
MALARIA:
Plasmodium vivax and ovale: cyclical fever every 48 hours.
P.malariae: Cyclical fever every 72 hours. Can cause glomerulonephritis. Rarely fatal.
P. falciparum: fevr 36-48hrs cyclical. Fulminant disease.
Presentation: 3 phases:
1 Shivering (1h): “I feel so cold.”
2 Hot stage (2–6h): T ≈ 41°C, flushed, dry skin; nausea/vomiting; headache.
3 Sweats (~3h) as T° falls
Also malaise, fatigue, anorexia, myalgias...
Signs: Anaemia, jaundice, and hepatosplenomegaly. No rash or lymphadenopathy Protective factors: G6PD lack; sickle- cell trait; melanesian ovalocytosis;
Complications: Hemolytic anemia can occur.
5 grim signs: 1 dec Consciousness/coma (cerebral malaria) 2 Convulsions 3 Coexisting chronic illness 4 Acidosis (eg esp bad if HCO3 – <15mmol/L) 5 Renal failure
Diagnosis: Serial thin & thick blood films.
P. vivax ring forms partly hidden by Schuffner’s dots. P. malariae: ring and band forms P. falciparum: sausage-like gametocytes in RBC ghosts.
Treatment: If the patient has taken prophylaxis, don’t use the same drug for treatment.
If species unknown or mixed infection, treat as P. falciparum. Nearly all P. falciparum is resistant to chloroquine and in many areas also to Fansidar (pyrimethamine +
sulfadoxine).
Chloroquine is 1st choice for benign malarias in most parts of the world. Never rely on chloroquine if used singly for prophylaxis.
Treating uncomplicated P. ovale, P. vivax, & P. malariae: Chloroquine base: 10mg/
kg, then 5mg/kg at 6h, 24h and 48h. In resistant cases, try Malarone® (atovaquone and proguanil) ,quinine, or Riamet®. Primaquine dose in P. vivax: 500μg/kg (max.30mg)
daily for 14d; P. ovale: 250μg/kg (max. 15mg) daily for 14d—given after chloroquine to treat liver stage and prevent relapse. Screen for G6PD deficiency first. CI: pregnancy. P.
malariae does not need primaquine.
Treating uncomplicated P.falciparum malaria:
Artemether-lumefantrine—if >35kg: 4 tabs stat, then 4 tablets at 8, 24, 36, 48 and 60h. • Artesunate-amodiaquine; if a fixed combination pill is available.
Dihydroartemisinin-naphthoquine • Dihydroartemisinin piperaquine. • Atovaquone-proguanil. can be used.
In pregnancy: Artemisinins are OK in children and pregnancy from 13 weeks;
(use quinine + clindamycin in 1st trimester).
In addition give symptomatic treatment for fever, blood transfusion if required.
Prophylaxis:
If little/no chloroquine resistance: Proguanil 200mg/24h+chloroquine base 300mg/wk.
If chloroquine-resistant P. falciparum: Mefloquine 250mg/wk (18d before to 4wks after trip) or doxycycline 100mg/d (1d before to 4wks after) or atovaquone 250mg + proguanil 100mg (Malarone®) 1 tab/d (1d before travel to 7d after).
179. A 35yo woman had an uneventful lap chole 18h ago. She has a pulse=108bpm, temp 37.8C. There are signs of reduced air entry at the right base but the CXR doesn’t show an obvious abnormality. What is the most appropriate management strategy?
a. Cefuroxime PO b. Ceftriaxone IV
c. Chlorpheniramine PO d. Chest physiotherapy e. Reassure
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Ans. 1. The key is D. Chest physiotherapy.
Ans. 2. Atelactasis.
Best visible on CT scan and not on chest xray. Mostly occurs as a complication of anaesthesia.
Arrange physiotherapy and antibiotics.
180. A 20yo pop star singer complains of inability to raise the pitch of her voice. She attributes this to the thyroid surgery she underwent a few months back. What is the most likely dx?
a. Thyroid storm
b. Bilateral recurrent laryngeal nerve injury c. Unilateral recurrent laryngeal nerve injury d. External laryngeal nerve injury
e. Thyroid cyst
Ans. The key is D. External laryngeal nerve injury.
Complications of thyroid surgery:
1. Bleeding, which may cause tracheal compression.
2. Recurrent laryngeal nerve injury:
Innervates all of the intrinsic muscles of the larynx, except the cricothyroid muscle.
Patients with unilateral vocal fold paralysis present with postoperative hoarseness.
Presentation is often subacute and voice changes may not present for days or weeks. Unilateral paralysis may resolve spontaneously.
Bilateral vocal fold paralysis may occur following a total thyroidectomy and usually presents immediately after extubation. Both vocal folds remain in the paramedian position, causing partial airway obstruction.
Superior (external) laryngeal nerve injury:
o The external branch provides motor function to the cricothyroid muscle.
o Trauma to the nerve results in an inability to lengthen a vocal fold and thus to create a higher-pitched sound.
o The external branch is probably the most commonly injured nerve in thyroid surgery.
o Most patients do not notice any change but the problem may be career-ending for a professional singer.
Hypoparathyroidism: the resulting hypocalcaemia may be permanent but is usually transient. The cause of transient hypocalcaemia postoperatively is not clearly understood.
Thyrotoxic storm: is an unusual complication of surgery but is potentially lethal.
Infection: occurs in 1-2% of all cases. Peri-operative antibiotics are not recommended for thyroid surgery.
Hypothyroidism.
Damage to the sympathetic trunk may occur but is rare.
181. A 28yo woman at 39wk gestation is in labor. She develops abdominal pain and HR=125bpm, BP=100/42mmHg, temp=37.2C and saturation=99%. Exam: lower abdomen is exquisitely tender. CTG=prv normal, now showing reduced variability and late deceleration develops with slow recovery. She has had 1 prv LSCS for a breech baby. Choose the most appropriate CS
complication for this lady?
Ans. The key is E. Uterine rupture.
Uterine rupture: Its an obstetrical emergency
Causes: ~70% of UK ruptures are due to dehiscence of caesarean section scars.
Other risk factors: • Obstructed labour in the multiparous, especially if oxytocin is used • Previous
cervical surgery • High forceps delivery • Internal version • Breech extraction. Rupture is usually during the third trimester or in labour.
Vaginal birth after caesarean (trial of scar): Vaginal birth will be successful in 72–
76%. Endometritis, need for blood transfusion, uterine rupture and perinatal death are commoner than repeated elective C section.
Signs and symptoms Rupture is usually in labour. In a few (usually a caesarean scar dehiscence) rupture precedes labour. Pain is variable, some only having slight pain and tenderness over the uterus. In others pain is severe.
Vaginal bleeding is variable and may be slight (bleeding is intraperitoneal). Unexplained maternal tachycardia, sudden maternal shock, cessation of contractions, disappearance of the presenting part from the pelvis, and fetal distress are other presentations.
Postpartum indicators of rupture: continuous PPH with a well-contracted uterus; if bleeding continues postpartum after cervical repair; and whenever shock is present.
Management If suspected in labour, perform laparotomy, deliver the baby by caesarean section, and explore the uterus. If rupture is small Repair or if vagina or cervix are involved in the tear hysterectomy may be needed.
182. An 8m infant presented with FTT and constipation. Exam: large tongue and fam hx of prolonged neonatal jaundice. What is the most likely dx?
a. Downs syndrome b. Fragile X syndrome c. Praderwilli syndrome d. DiGeorge syndrome e. Congenital hypothyroidism Q. 1. What is the key?
Q. 2. What are the points in favour?
Congenital Hypothyroidism: Thyroid hormone is necessary for growth and neurological development.
Signs: May be none at birth—or prolonged neonatal jaundice, widely opened posterior fontanelle, poor feeding, hypotonia, and dry skin are common. Inactivity, sleepiness, slow feeding, little crying, and constipation may occur. Look for coarse dry hair, a flat nasal
bridge, a protruding tongue, hypotonia, umbilical hernia, slowly relaxing reflxes, pulse, and poor growth and mental development if it has not been picked up. Other later signs:
dec IQ, delayed puberty (occasionally precocious), short stature, delayed dentition.
Universal neonatal screening: Cord blood or filter paper spots (at ~7 days, from heel prick) allow early diagnosis (the‘Guthrie card’).
Tests: Decreased T4, Increased TSH (but undetectable in secondary hypothyroidism), Decreased I131 uptake, dec Hb. Bone age is less than chronological age. As it is unwise to X-ray the whole skeleton, the left wrist and hand are most commonly used.
Treatment: Levothyroxine (LT4): Start neonates with ~15μg/kg/day; adjust by 5μg/kg every 2
weeks to a typical dose of 20–50μg/day. Avoid high TSH levels.
Ans.1. The key is E. Congenital hypothyroidism.
Ans. 2. Points in favour:i) FTT ii) constipation iii) macroglossia iv) prolonged neonatal jaundice.
183. A 3m infant has presented with recurrent infections. He has abnormal facies and CXR shows absent thymic shadow. What is the most likely dx?
a. Downs syndrome b. Fragile X syndrome c. DiGeorge syndrome d. Marfans syndrome Q. 1. What is the key?
Q. 2. What are the points in favour?
Ans. 1. The key is C. DiGeorge syndrome.
Ans. 2. Points in favour: i) Early age of onset ii) abnormal facies iii) absent thymic shadow on Chest X-ray iii) history of recurrent infection [in newborne can be recognized by convulsions from hypocalcaemia due to malfunctioning parathyroid glands and low level of parathyroid hormones].
DiGeorge’s syndrome A deletion of chromosome 22q11.2 causes absent thymus,
fits, small parathyroids ( decreased Ca2+), anaemia, lymphopenia, dec growth hormone, dec T-cell-immunity. It is related to velo-cardiofacial syndrome: characteristic
face, multiple anomalies, eg cleft palate, heart defects, cognitive defects
Management:
Cardiac defects are the usual focus of clinical management.
Hypocalcaemia should be screened for by checking calcium levels three-monthly in infancy and then annually. Low calcium and high phosphate levels should prompt further testing of parathyroid hormone and vitamin D levels.
All patients should have baseline immunological testing and annual blood count
Cleft palates may be submucous. In particular, they should be sought if feeding difficulties are encountered in the neonatal period.
Gastro-oesophageal reflux needs to be managed appropriately with feed thickeners and anti-reflux medication. Nasogastric tube feeding and occasionally gastrostomy may be needed to deal with feeding issues.
184. A 30yo man presents with deep penetrating knife wound. He said he had TT when he left school. What will you do for him now?
a. Human Ig only b. Human Ig and TT
c. Full course of tetanus vaccine only
d. Human Ig and full course of tetanus vaccine e. Antibiotic
Ans. The key is B. Human Ig and TT.
185. A 32yo previously healthy woman has developed pain and swelling of both knees and ankles with nodular rash over her shins. As part of the inv a CXR has been
performed. What is the single most likely CXR appearance?
a. Apical granuloma
b. Bilateral hilar lymphadenopathy c. Lobar consolidation
d. Pleural effusion
e. Reticular shadowing in the bases Q. 1. What is the key?
Q. 2. What is the name of this condition? What are the points in favour?
Ans. 1. The key is B. bilateral hilar lymphadenopathy.
Ans. 2. The name is Lofgren’s syndrome. It is the triad of i) erythema nodosum ii) bilateral hilar lymphadenopathy and iii) arthralgia.
Apical granuloma: apical granuloma modified granulation tissue containing elements of chronic inflammation located adjacent to the root apex of a toothwith infected necrotic pulp.
Lobar consolidation: pneumonia
Sarcoidosis:
Presentation: Lungs are in involved in more than 90% cases of sarcoidosis. There is interstitial lung disease. The painful skin lesion is erythema nodosum. Also look for Lupus pernio (chronic raised hardened, often purple lesion) may be seen on the face.
Lofgren syndrome is often a part of sarcoidosis. The triad is i) Erythema nodosum ii) Bilateral hilar lymphadenopathy iii) Arthralgia
Sarcoidosis is a multisystem disease and can involve any system/organ
Tests: ESR is often raised. Serum ACE enzyme levels are raised in 60% of times Plain CXR may show bilateral hilar or paratracheal lymphadenopathy. High resolution CT should be done. There will be restricitve pattern of disease on pulmonary function tests.
Transbronchial biopsy can demonstrate the presence of non-caseating granulomata, giving a more accurate diagnosis
Bronchioalveolar lavage may also be done
186. A neonate’s CXR shows double bubble sign. Exam: low set ears, flat occiput. What is the most likely dx?
a. Downs syndrome b. Fragile X syndrome c. Turner’s syndrome d. DiGeorge syndrome Q. 1. What is the key?
Q. 2. What double bubble sign indicate?
Ans. 1. The key is A. Down’s syndrome.
Ans. 2. Double bubble sign indicate duodenal atresia.
Down’s syndrome:
Causes:
Non-disjunction of chromosome >88%
Mosaicism <8%
The robertsonian translocation trisomy 21 is the cause in 4% of Down’s syndrome Presentation:
simian palmar crease, hypotonia, flat face/round head, protruding tongue, broad hands, upward slanted palpebral fissures and epicanthic folds, speckled irises (Brushfield spots); mental and growth retardation; pelvic dysplasia, cardiac malformations, short, broad hands, hypoplasia of middle phalanx of (incurving) 5th finger, intestinal atresia and high arched palate.
.
Associated problems: Duodenal atresia; VSD; patent ductus; AVSD (foramen primum defects, and, later, a low IQ and a small stature.
Pr enatal diagnosis:
The combined test: combines nuchal translucency (NT) + free -human chorionic
gonadotrophin (HCG) + pregnancy associated plasma protein (PrAP-A or PAPP-A) + the woman’s age. Used between 10 weeks 3 days and 13 weeks 6 days. It achieves detection rates of 95% of all aneuploides, 86% trisomy-21, and 100% of trisomy-18 and trisomy-13
The quadruple test combines maternal -fetoprotein (AFP) + unconjugated estriol + free
The quadruple test combines maternal -fetoprotein (AFP) + unconjugated estriol + free