120. A 12yo child with episodes of sudden bluish discoloration and brief loss of consciousness. Exam: clubbing, central cyanosis, systolic thrill with systolic ejection murmur in 2nd left ICS. What is the most probable dx?
a. TOF
ASD, VSD, PDA are all acyanotic congenital heart diseases. TOFF is the most common cyanotic congenital heart disease that survives to adulthood.
Typical features:
1 Ventricular septal defect (VSD)
2 Pulmonary stenosis (most imp feature) 3 Right ventricular hypertrophy
4 The aorta overriding the VSD
During a hypoxic spell, the child becomes restless and agitated and may cry
inconsolably. Toddlers may squat, which is typical of TOF. Clubbing, difficulty of feeding, failure to thrive all are features.
Chest Xray Shows BOOT SHAPED HEART. Echo is also done.
In acute stage give O2, place the child in knee chest position, give morphine. Surgery is required within 1st yr of life otherwise mortality is 95%.
121. An 8yo child who is tall for his age and has a refractory error for which he wears glasses has
presented with severe crushing chest pain. What is the most likely dx?
a. Fragile X syndrome b. Prader-willi syndrome c. DiGeorge syndrome d. Marfans syndrome Q. 1. What is the key?
Q. 2. What is the cause of this severe crushing chest pain?
Q. 3. What are the most common cardiac abnormalitis found in this disease?
Ans. 1. The key is D. Marfans syndrome.
Ans. 2. Cause of severe crushing chest pain may be aortic dissection.
Ans. 3. Most common cardiac abnormalities in Marfans syndrome are: dilatation of the aorta and mitral regurgitation.
Marfans syndrome diagnosis:
Major criteria (diagnostic if >2): Lens dislocation (ectopia lentis) aortic dissection or dilatation; dural ectasia; skeletal features: arachnodactyly (long spidery fingers), armspan > height, pectus deformity, scoliosis, pes planus. Minor signs: Mitral valve prolapse, high-arched palate, joint hypermobility. Diagnosis is clinical.
DANGER IS AORTIC DISSECTION. Surgery is done when aorta >5cm Can also cause pneumothorax.
122. A 4yo child presents with pain of spontaneous onset in his knee of 2 days duration.
He has
developed mild fever in the 2nd day. He can walk but has a limp. Exam: painful restriction in the
right hip. What is the most probable dx?
Q. 2. What are the points in favour of your diagnosis?
Ans. Given key is E. Osteomyelitis which is a wrong key. The correct answer is B. Septic arthritis.
Ans. Points in favour of diagnosis: i) Pain in joints (knee and hip) ii) Fever iii) Painful restricted movement of joint.
Not sure about the correct answer here. But i think osteomyelitis.
Osteomyelitis mostly has a primary source of infection via which the infection spreads to bone.
PRESENTATION: Pain of gradual onset over the course of a few days—with tenderness,
warmth, and erythema at the affected part; unwillingness to move. Vertebrae and distal femur mostly affected.
Diagnosis: FBC, ESR, CRP, blood culture. Bone biopsy and culture is gold standard.
Staph aureus (MR the most common organism found.)
Treatment Drain abscesses and remove sequestra by open surgery. Antibiotics:
vancomycin 1g/12h and cefotaxime 1g/12h IVI until the organism and its sensitivities are known. Fusidic acid or clindamycin can also be used.
Septic Arthritis: Exclude septic arthritis in any acutely inflamed joint, as it can destroy a joint
in under 24h. Knee & hip joint are most commonly involved.
Risk factors for septic arthritis include:
Increasing age
Diabetes mellitus
Rheumatoid arthritis
Joint surgery
Hip or knee prosthesis
Skin infection in combination with joint prosthesis
Infection with HIV
Diagnosis: Urgent joint aspiration for synovial fluid microscopy and culture is
the key investigation. The joint is usually swollen, warm, tender and exquisitely painful on movement.
Flucloxacillin or clindamycin as empirical treatment.
123. A man with anterior resection and end to end anastomosis done complains of severe pain in the chest and abdominal distension. What is the most appropriate inv likely to review the cause this deterioration?
a. XR abdomen
b. Exploratory laparoscopy c. CT
d. US
e. Laparotomy
Ans. The key is E. Laparotomy. [diagnostic and therapeutic].
124. Pt with hx of alcoholism, ataxic gait, hallucinations and loss of memory. He is given acamprosate. What other drug can you give with this?
a. Chlordiazepoxide
Q. 2. What is the diagnosis?
Q. 3. What are the points in favour of diagnosis?
Ans. 1. The key is B. Thiamine.
Ans. 2. The diagnosis is Wernicke’s encephalopathy.
Ans. 3. Points in favour of diagnosis: i) history of alcoholism ii) ataxic gait iii) hallucination iv) memory loss.
Thiamine (vitamin B1) deficiency with a classical triad of 1 confusion 2 ataxia (wide-based gait) and 3 ophthalmoplegia (nystagmus, lateral rectus or conjugate gaze palsies). Always
consider this diagnosis in alcoholics: it may also present with memory disturbance.
TREATMENT: early treatment is essential to prevent progression to the irreversible Korsakoff syndrome. Alcoholics can present with hypoglycemia so make sure you give thiamine BEFORE glucose as glucose can precipitate wernicke’s encaph.
125. A 35yo male builder presented with sudden onset of severe abdominal pain. He was previously fit and well other than taking ibuprofen for a long term knee injury. On examination he is in severe pain, pulse=110bpm, BP=110/70mmHg and has a rigid abdomen. What is the most likely dx?
a. Biliary peritonitis b. Ischemic colon c. Pancreatic necrosis d. Perforated diverticulum e. Perforated peptic ulcer
Ans. The key is E. Perforated peptic ulcer. [NSAIDs induced perforation].
Peritonitis (Perforation of peptic ulcer/duodenal ulcer, diverticulum, appendix,
bowel, or gallbladder) Signs: prostration, shock, lying still, +ve cough test tenderness (±
rebound/percussion pain), board-like abdominal rigidity, guarding and no bowel sounds.
Erect CXR may show gas under the diaphragm.
NB: acute pancreatitis causes these signs, but does not require a laparotomy so don’t be caught out and always check serum amylase
126. A woman 5 days post-op for bilateral salphingo-oopherectomy and abdominal hysterectomy has developed abdominal pain and vomiting a/w abdominal distension and can’t pass gas. No bowel sounds heard, although well hydrated. What is the most
appropriate next step?
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What are the causes of it?
Q. 4. What is the management?
Ans. 1. The key is A. X-ray abdomen.
Ans. 2. The diagnosis is paralytic ileus.
Ans. 3. Causes of paralytic ileus: i) electrolyte imbalance ii) gastroenteritis iii) appendicitis iv) pancreatitis v) surgical complications and vi) certain drugs.
Ans. 4. Management of paralytic ileus: i) nil by mouth ii) nasogastric suction to alleviate the distension and remove the obstruction.
Bowel sounds are absent in paralytic ileus But bowel sounds are exaggerated in mechanical obstruction.