PFMSG FORUM

by **drwatson** » Mon Nov 29, 2010 2:13 pm

A. Echovirus
B. Measles
C. Lyme disease
D. Juvenile rheumatoid disease
E. Rubella
F. Chicken pox
G. Meningococcemia
H. Erythema infectiosum

For each question below, choose the SINGLE most likely answer from the above list of options. Each may be used once, more than once, or not at all.

1. A 6-year-old child develops fever, arthralgias and a confluent rash on the face with a “slapped check” appearance.
2. A 4-year-old child presents with a generalised blanching and an erythematous rash. He also has fever, conjunctivitis, photophobia and coryza. Red lesions with white centers are present on the buccal mucosa.
3. A 12-year-old girl presents with low-grade fever, postauricular lymphadenopathy and a maculopapular rash that began on the face spread to the trunk. She also has splenomegaly.
4. A 5-year-old is brought with purpuric rashes over his body. He has had a fever for 3 days. He looks very ill and toxic.
5. An 8 old child is brought to the clinic with fever, malaise, and eruption of vesicular lesion on the face, scalp and trunk. Two other children in the school had similar complaints recently.

Answers: Rashes in Children

1. (H)
Caused by Human parvovirus type B19. Also called fifth disease.

2. (B)
Caused by RNA Paramyxovirus. Incubation 7-12 days. Infective from first prodromal symptom until 5 days after rash starts.

3. (E)
Caused by RNA virus. Incubation 14-21 days. Patient is infective 5 days before and 5 days after the rash starts.

4. (G)
Is very deadly and kills swiftly. Always think about this and start treatment before reports confirm the diagnosis.

5. (F)
Cause Varicella Zoster. Typical presentation. Incubation 11-21 days. Spreads very rapidly.

Theme: Management of Arrhythmias

Options
A. External pacing
B. Digoxin
C. Reassurance
D. Lignocaine
E. Amiodarone
F. Permanent dual chamber pacing
G. DC cardioversion
H. Flecainide
I. Atropine
J. Cardiopulmonary resuscitation

For each question below, choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all.

6. A 63-year-old lady following cardiac arrest underwent 10 minutes of cardio-pulmonary resuscitation. The ECG now shows ventricular standstill with ‘P’ waves.
7. A 60-year-old fit and active housewife has episodes of pre-syncope. A 24-hour Holter monitor shows evidence of intermittent complete heart block with long pauses on the rhythm strips coinciding with symptoms.
8. A 75-year-old lady with a long-standing history of untreated palpitations is now admitted with acute shortness of breath and palpitations. Examination reveals an irregularly irregular pulse with bilateral basal crepitations and ECG shows absent ‘P’ waves with rate of 140 beats per minute.
9. A 23-year-old male presents with a history of flutter in his chest. His girl friend has noticed his pulse to be irregular at times. An ECG shows ventricular ectopics of 4-5 per minute. A tread mill test is unremarkable and his ectopics disappear when his heart rate increases.
10. A 40-year-old anxious male feels faint and sweaty during a coronary angiogram procedure. His heart rate is 35 per minute and BP is 47/55.
11. A 45-year-old male presents with a 2-hour history of sudden onset of palpitations. ECG shows ventricular tachycardia. He is otherwise well and haemodynamically stable.

Answers: Management of Arrhythmias

6. (A)
Electromechanical dissociation. Sometimes termed electrical pulseless activity.

7. (G)
Dual chamber pacemakers pace atria and ventricles sequentially, helping stroke volumes.

8. (B)
Is used to slow ventricular rate. Dangerous in HOCM and WPW. Elderly are at risk of toxicity. Start at low doses.

9. (C)
Asymptomatic Stable Ventricular Ectopics does not require any intervention.
ATROPINE is the drug of choice for bradycardia.

10. (J)
This is used to increase the heart rate.

11. (D) or (E)
Treatment for VF. Other drugs that can be used include Adenosine and Procainamide. Amiodarone is the drug of choice according to the new guidelines & had replaced lignocaine.

Theme: Diagnosis of Chest Pain

Options
A. Unstable angina
B. Stable angina
C. Prinzmetal angina
D. MI
E. Peptic ulcer
F. Ankylosing spondylosis
G. Pleuritis
H. Oesophageal rupture
I. Gastric ulcer
J. Panic attack

For each question below, choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all.

12. A 56-year-old male under investigation for? CA stomach underwent endoscopy yesterday. He presents to you today with severe central pain with difficulty in breathing.
13. A 56-year-male presents with 2 episodes of central chest pain while having his evening tea. The episode lasted for 15 minutes. He is not known to have angina but has had two similar episodes in the past one month.
14. A 45-old abscess smoker presents with central chest pain, burning in nature that started 30 min after lying down after a heavy meal. No radiation.
15. A 60-year-male presents to A&E anxious, sweaty and distressed with central chest pain radiating to the neck. He points to the pain by placing a clenched fist over his chest. BP-180/120, pulse-110/min.
16. A 32-year-old female woke up sleep with severe palpitations, sweating and shortness of breath lasting for about 15 minutes. ECG is normal. Non smoker and no family history of heart disease.

Answers: Diagnosis of chest pain

12. (H)
Typical history of oesophageal rupture.

13. (A)
Stable angina is typically brought on by exertion and is usually rapidly relieved by rest & nitrates. Unstable angina is severe or frequent angina superimposed on chronic stable angina, angina at rest or minimal exertion or angina of new onset brought on by minimal exertion.

14. (E)
Dyspepsia is often the presenting complaint of peptic ulcer disease.

15. (D)
Here, the patient is demonstrating Levine’s sign.

16. (J)
Negative symptoms and history should lead one to this diagnosis.

Them: Diagnosis of Jaundice

Options
A. Chronic Active Hepatitis
B. Primary Sclerosing Cholangitis
C. Gilberts Syndrome
D. Gall stones
E. Leptospirosis
F. Halothane
G. Hemolytic anaemia
H. Carcinoma pancreas
I. Primary biliary cirrhosis
J. Alcoholic Hepatitis
K. Primary hepatocellular Carcinoma
L. Hemochromatosis

For each question below, choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all.

17. A 43 old woman has severe pruritus, pigmented deposits on her eyelids and skin creases, and hepatosplenomegaly. She develops jaundice 4 years after the onset of her initial symptoms.
18. A 47-year-old man develops bronze pigmentation of his skin and hepatomegaly. He had abnormal glucose tolerance test.
19. A 53-year-old man from India develops jaundice, weight loss, fever, and a dull right hypochondrial pain. He has associated proximal myopathy.
20. A 39-year-old man develops pruritus, jaundice, abdominal pain and fever. He is on treatment for inflammatory bowel disease.
21. A 40-year-old man presents with, jaundice, abdominal pain, high fever and distension of the abdomen. O/E: Enlarged liver, ascites. Liver biopsy shows Mallory bodies and giant mitochondria.

Answers: Diagnosis of Jaundice

17. (I)
Pruritus is very common and troublesome symptom and can occur in the absence of jaundice.

18. (L)
Clinical triad of diabetes, hepatomegaly and bronze pigmentation is seen in a third of patients with hemochromatosis.

19. (K)
Worldwide 5%-25% of people are hepatitis B carriers and is a common cause of hepatocellular carcinoma.

20. (B)
Primary sclerosing cholangitis occurs more commonly with ulcerative colitis.

21. (D)
Initially shows fatty change, which is reversible on withdrawal of alcohol.

Theme: Diagnosis of Inguinal and Scrotal Swelling

Options
A. Varicocele
B. Primary hydrocele
C. Secondary hydrocele
D. Epididymal cyst
E. Teratoma
F. Inguinal hernia
G. Femoral hernia
H. Seminoma
I. Torsion of testis
J. Idiopathic scrotal oedema
K. Epididymoorchitis.

For each question below, choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all.

22. A 20-year-old male presents with sudden onset lower abdominal & groin pain associated with vomiting. On examination, elevation of the testis increases the pain.
23. A 30-year-old male presenting with a two-day history of frequency & dysuria. Has now developed pain in the testis and fever. On examination, elevation of the testis eases the pain.
24. A 50-year-old male, presents with dragging discomfort in his right testis, more on standing & walking. On examination, the testis feels like a bag of worms. Cough impulse is also present.
25. A 35-year-old male presents with right testicular swelling and discomfort. Examination reveals firm, smooth enlarged testis. No history of previous injury to the testis.
26. A 42-year-old male noticed a swelling in his left testis two months back, which has been progressively increasing in size. His both testis are involved now. On examination, tense transilluminable swelling, which feels, like a tiny bunch of grapes.

Answers: Diagnosis of inguinal and scrotal swelling

22. (I)
Commonly presents between the ages of 10 and 25 years of age. Treat with manipulation and early operative fixation.

23. (K)
Infection. Treat with antibiotics.

24. (A)
Various dilatation of the veins draining the testis. Operation not indicated unless causing symptoms.

25. (H)
Staging is important before treatment. Seminomas are radiosensitive.

26. (D)
Usually found in the middle aged is often bilateral. Treatment is excision.

Theme: Disease of the liver

Options
A. Alcoholic Liver failure
B. Cardiac cirrhosis
C. Amoebic liver abscess
D. Primary biliary cirrhosis
E. Hepatitis A infection
F. Haemochromatosis
G. Hepatocellular degeneration
H. Hepatocellular carcinoma
I. Hepatorenal syndrome
J. Chronic active hepatitis
K. Amyloidosis
L. 1-antitrpysin deficiency

For each question below, choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all.

27. A 50-year-old female admitted in the surgical ITU with deterioration in her condition. She underwent surgery for cholecystectomy & CBD stone removal in the morning and now presents with vomiting, signs of fluid overload and peripheral shutdown.
28. A 23-year-old with learning disabilities presents with jaundice, dysarthria and cognitive impairment. He has also noticed jerky, purposeless hand movements. O/E, tremors and a brownish discoloration of his sclera.
29. A 45-year-old male presents with joint pains and impotence. On examination skin is pigmented with enlarged liver. There is a family history of liver disease.
30. A 55-year-old female, a known case of Ulcerative Colitis, presents with malaise, weight loss and anorexia since 3-months. She does not have jaundice. Examination shows a hard, enlarged liver with an arterial bruit over the liver.
31. A 35-year-old HIV positive male presents with fatigue, upper abdominal pain, and jaundice since the past 10 months. Examination reveals clubbing, leukonychia ascites and splenomegaly. He also has evidence of needle tracks on his limbs.
32. A 45-year-old hirsute female presents with fatigue and pruritus. On examination; skin pigmentation, xanthelasmas and tendon xanthomas. She is on a gluten free diet.

Answer: Diseases of the liver

27. (I)
Patients with obstructive jaundice are prone to develop renal failure after surgery. This may be because of the toxic effect of bilirubin on the kindness.

28. (G)
Wilson’s Disease. Copper disposition in the liver and brain can cause cirrhosis and basal ganglia destruction.

29. (F)
Autosomal recessive. Overload of iron in the body with deposition in the liver, heart, pancreas and pituitary.

30. (H)
Chest X ray may reveal raised right hemidiaphragm.

31. (J)
Slowly progressive condition. Strong link between liver cancer and chronic hepatitis B infection

32. (D)
Commoner in women. Pruritus is the most prominent symptom. Associated with other autoimmune diseases.

Theme: Management of Skin Conditions

Options
A. Retinoids
B. Sulfonamides
C. Oxytetracycline
D. Topical Metronidazole
E. Malathion
F. PUVA
G. Topical Steroids
H. Systemic Steroids
I. Antihistamines

For each question below, choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all.

33. A 5-year-old adult develops itchy eruptions on the finger webs, buttocks and groin.
34. An 18-year-old adult develops itchy purple papular lesions on the flexor aspects of the ankle and the leg. Patient is a Hep-C carrier.
35. A 63-year-old with tense blisters on a reddened base
36. A 21-year-old male develops erythematous lesions on the chin and nose with papules and pustules. It is associated with flushing with alcohol and spicy food.
37. A 43-year-old with flaccid blisters on the skin and the oral mucosa

Answers: Management of Skin Condition

33. (E)
Scabies presents with severe pruritus, which is more in the night, and characteristic burrows can be seen on close examination.

34. (G)
Purple, plane polygonal, pruritic lesions on the ankle are characteristic of Lichen planus.

35. (H)
The bullae in pemphigoid are subepidermal and are tense as compared to those in pemphigus, which occur within the epidermis and are flaccid.

36. (C)
Acne Rosacea
Presence of pustules is an indication of treatment with antibiotics.

37. (H)
Pemphigus is often associated with oral lesions unlike pemphigoid.

Theme: Antepartum Hemorrhage

Options
A. Endometriosis
B. Battledore placenta
C. Circumvallate placenta
D. Hydatidiform mole
E. Ectopic pregnancy
F. Pre eclampsia
G. Velamentous placenta
H. Placenta previa
I. Abruptio placentae
J. Septic abortion
K. UTI
L. Threatened abortion
M. Red degeneration
N. Uterine rupture
O. Inevitable abortion
P. Missed abortion

For each question below, choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all.

38. An 18-year-old girl at 11-weeks of gestation presents with bleeding PV followed by abdominal pain. PV examination reveals closed cervical os.
39. A 40-year-old female presents with bleeding PV in 15th week of gestation. She has been having severe morning sickness. She has also noticed clots and has passed some tissue per vaginam. She also complains of abdominal pain. Abdominal examination reveals a fundal height corresponding to 20 weeks.
40. A 28-year-old female, 33-weeks pregnant, has back pain and severe lower abdominal pain. FHS shows signs of distress.
41. A 32-year-old female, 32-weeks gestation is brought to A&E in shock. She’s bleeding PV. The Foetal lie and presentation are abnormal. The FHS appears to be normal at the moment. Likely diagnosis.
42. Vasa previa is likely to occur in __ type of placenta.

Answers: Antepartum Hemorrhage

38. (L)
Rest is advised. Associated with subsequent preterm rupture of membranes and preterm delivery.

39. (D)
Proliferated chorionic villi. Ultrasound show’s snowstorm in the uterus.

40. (I)
Part of placenta become detached form the uterus. May cause Foetal anoxia or death.

41. (H)
Placenta lies in the lower uterine segment and bleeding is always revealed

42. (G)
Umbilical vessels pass within the membranes before insertion. If vessels break Foetal blood is lost.

Theme: Causes of Secondary Hypertension

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Options
A. Alcohol intake
B. Pregnancy associated hypertension
C. Cushing’s syndrome
D. Hyperparathyroidism
E. Congenital adrenal hyperplasia
F. Renal artery stenosis
G. Aortic incompetence
H. Phaeochromocytoma
I. Acromegaly
J. Conn’s syndrome

For each question below, choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all.

43. A 65-year-old male smoker is noted to have a blood pressure of 160/90 and suffers from peripheral vascular disease.
44. A 60-year-old female treated with bendrofluazide 2.5 mg/day for hypertension has recently developed muscle cramps. The only abnormality on investigations is a plasma potassium concentration of 3.0 mmol/l.
45. A 30-year-old obese woman with a history of polycystic ovarian disease presents with 3 month history of weight gain, amenorrhoea and thirst. She has a blood pressure of 145/90 and fasting plasma glucose of 7.2 mmol/I. Investigations reveal a low LH and FSH, with high oestrogen and prolactin concentrations.
46. A 23-year-old female with Turner’s syndrome is found to have a blood pressure of 160/102.
47. A 26-year-old female with an ejection systolic murmur in the 2nd right intercostal space is noted to have a blood pressure of 180/100.
48. A 40-year-old female presents with palpitations, sweating and tightness in the chest and ‘pins & needle’ sensation. Urine screening test during the attack shows presence of glucose.

Answers: Causes of Secondary Hypertension

41. (F)
Diagnosis of peripheral vascular disease in hypertension should alert one to the risk of renal artery stenosis.

44. (K)
Hypokalemia seen commonly in Conn’s Syndrome (primary hyperaldosteronism).

45. (B)
Inverts tigstion scults suggest pregnancy.

46. (I)
Recognized association of Turnner’s Syndrome.

47. (I)
By exclusion of other diagnoses.

48. (H)
Typical presentation of phaeochromocytoma

Theme: Investigations

Options
A. X-ray hands
B. CT Brain
C. Skeletal survey
D. Bleeding time
E. Electromyogram & Nerve conduction studies
F. Arteriogram
G. Bone scan
H. MRI
I. Serum Ceruloplasmin Levels
J. Serum icon levels
K. PET
L. SPECT
M. Radioimmunoassay
N. No investigation required

For each question below, choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all.

49. A 35-year-old male typist has noticed that he is waking up during the night with numbness and tingling in his fingers.
50. A 28-year-old male suffered a posterior knee dislocation following an accident, which has been reduced successfully. Post reduction X-rays are normal and there is no fracture. Which additional study should be ordered?
51. A 20-year-old is brought with tremors and facial dystonia. His father died of cirrhosis of the liver. O/E he has brownish green discoloration around the cornea.
52. A 4-year-old boy is brought with history of fall 5 days ago. The mother did not think it was anything serious though he had been in pain. He has several areas of ecchymosis on both arms and legs. X-ray shows a displaced fracture of the tibia and an old healing fracture of the leg.
53. A 78-year-old woman with history of ischaemic heart disease is brought to A&E with left sided weakness and eye deviation to the right.

Answers: Investigations

49. (E)
Carpal tunnel syndrome. Common in people whose wrists are exposed to regular friction. This is the study of choice.

50. (F)
To rule out vascular lesions which can prove dangerous.

51. (I)
Wilson’s Disease.

52. (C)
Non-accidental injury, Always suspect this in a presentation like the above scenario.

53. (B)
Features of Cerebrovascular accident. CT-Brain indicated to confirm diagnosis and for mapping of site of lesion.

Theme: Investigations in childhood urinary tract infection

Options
A. Plain Abdominal X-ray
B. MSU culture
C. Suprapubic aspirate culture
D. Bag urine culture
E. Clean catch urine culture
F. Ultrasound
G. DTPA scan
H. DMSA scan
I. Intravenous urogram
J. Micturating cystourethrogram (MCU)
K. Cystoscopy
L. MCU + DTPA scan

For each question below, choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all.

54. A 7-month-old infant presents with fever, vomiting and irritability. You suspect UTI. What investigation will you usually do to confirm UTI?
55. The above investigation confirms the presence of UTI. What investigation will you next carry out to ascertain the cause?
56. In the same patient the above investigation does not suggest any abnormality. What investigation will you order next to reach the diagnosis?
57. A 3-year-old girl presents with a diagnosis of UTI. She has a history of recurrent UTI’s. Repeat ultrasound done shows a grossly dilated system. What should be ordered for next?
58. A 7-year-old boy presents with an episode of renal colic, which you suspect may be due to a calculus. Which is the preferred investigation to be carried out?

Answers: Investigations in childhood Urinary Tract Infection

54. (E)
Bag urine culture has many false positives.

55. (F)
Ultrasound detects a dilated system and also severe vesicoureteric reflux.

56. (H)
DMSA scan is done next in infants with a normal USG, which detects scarring and obstructive uropathy.

57. (J)
MCU to detect reflux.

58. (A)
Most renal calculi are radio-opaque.

Theme: Diagnosis of Neck Swelling

Options
A. Branchial cyst
B. Cystic hygroma
C. Sialoadenitis
D. Pleomorphic adenoma
E. Thyroglossal cyst
F. Simple goitre
G. Hodgkin’s Lymphoma
H. Ranula
I. Carotid body tumour
J. Medullary carcinoma of thyroid
K. Pharyngeal pouch
L. Cold abscess
M. Submandibular calculi
N. Salivary calculus

For each question below, choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all.

59. A 45-year-old man presents with a painless slow growing swelling at the angle of his jaw. O/E a firm, non-tender, mobile swelling is seen.
60. A 59-year-old female presents with recurrent painful swelling of the angle of the jaw present only during meals.
61. A 19-year-old female presents with a swelling protruding from the anterior border of the upper third of the sternocleidomastoid. The swelling is fluctuant but not trans-illuminable. She is otherwise well.
62. A 3-month-old baby has developed a trans-illuminant swelling occupying the lower third of the neck. It enlarges when the child cries.
63. A 2-year-old child presents with swelling of the neck in the region of the thyroid cartilage. The swelling moves upwards on protrusion of the tongue.

Answers: Diagnosis of Neck Swelling

59. (D)
Treat with surgery. A margin of normal gland is removed as well.

60. (M)
Submandibular calculi are the most common. Can be demonstrated by plain radiography. Operative removal is the treatment of choice.

61. (A)
Arise form the vestigial remnants of the second branchial cleft. Treat with excision.

62. (B)
Excision is the treatment of choice.

63. (E)
Excision is the treatment of choice. If left untreated, there is the risk of infection.

Theme Red eye

Options
A. Orbital Tumour
B. Glaucoma
C. Corneal Ulceration
D. Retinitis pigmentosa
E. Subconjunctival hemorrhage
F. Diabetic retinopathy
G. Orbital cellulitis
H. Episcleritis
I. Conjunctivitis
J. FB
K. Uveitis
L. Scleritis

For each question below, choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all.

64. This 36-year-old man on DVT prophylaxis was alarmed to see a red uniform patch in his left eye. It was completely painless.
65. A 72-year-old man developed reduced vision, pain and circumcorneal congestion on his right eye. O/E: hazy cornea and a fixed dilated pupil.
66. A 32-year-old lady developed sudden onset severe right-eye-pain, photophobia, blurred vision, circumcorneal redness and lacrimation. O/E: pain increased as the patient converged the eye and a small pupil.
67. A 67-year-old man a k/c of rheumatoid arthritis develops redness in the left eye with a dull ache. O/E: Engorged vessels seen which can be easily moved over the area.
68. A 21-year-old lady presents with itchy red eye, lacrimation and purulent discharge involving both the eyes. O/E: hyperemic vessels seen which can be easily moved over the area.

Answers: Red eye

64. (E)
It is seen in-patient on anticoagulants and is a common accompaniment of direct trauma to the eye.

65. (B)
Is associated with severe unilateral headache and vomiting.

66. (K)
It is associated with various connective tissue diseases.

67. (H)
Scleritis can cause thinning of sclera and is in danger of perforation on severe cases “scleromalacia perforans”

68. (I)
It has to be treated with antibiotic drops and ointment to be applied at night.

Theme: Gynecology - Obstetrics Problems

Options
A. Inevitable abortion
B. Hydatidiform mole
C. Ectopic pregnancy
D. Uterine rupture
E. Placenta previa
F. Abruptio placentae
G. Septic abortion
H. UTI
I. Threatened abortion
J. Red degeneration
K. Pre eclampsia
L. Endometriosis
M. Missed abortion

For each question below, choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all.

69. A 22-year-old presents with abdominal pain. Her LMP was 2 months back and urine test for pregnancy was positive. In A&E, she developed mild vaginal bleeding, and pain on passing water. Examination shows a tender abdomen with cervical excitation.
70. A 42-year-old female, 28 weeks gestation presents with abdominal pain with vomiting and low grade fever. Prior to conception, she had heavy & prolonged periods with increase in frequency of urine.
71. A 23-year-old multipara has been in labour for twelve hours. She has mild abdominal pain and vaginal bleeding. Her condition rapidly deteriorates & she is in chock. On vaginal examination, the presenting part cannot be felt. There are signs of Foetal distress.
72. A 24-year-old at 14 weeks of gestation presents with bleeding PV and abdominal pain. On examination, the cervical os is dilated. She has passed few clots and pieces of tissue.
73. An 18-year-old had and abortion at 14 weeks in a clinic a week back. Today she developed severe abdominal pain, fever and discharge PV. On examination she has a tender abdomen with guarding, rigidity, and rebound tenderness.

Answers: Gynecology – obstetrics Problems

69. (C)
Fertilized ovum implants outside the uterine cavity. Always consider in a woman with abdominal pain preceding bleeding PV. Emergency management indicated.

70. (J)
Caused by thrombosis of a fibroid’s blood supply. Occurs in pregnancy.

71. (D)
Commonly due to dehiscence of caesarean section scar. Lower segment less likely to rupture than classical scars. Continuos PPH with a well contracted uterus is strongly suggestive.

72. (A)
Open os with severe symptoms.

73. (G)
Generally follows back-street abortion. Presents like acute salpingitis.

Theme: Adverse effects of antihypertensives

Options
A. Sodium Nitroprusside
B. Hydralazine
C. Prazosin
D. Minoxidil
E. Verapamil
F. Bendrofluazide
G. Clonidine
H. Enalapril
I. Alpha methyldopa
J. Nifedipine
K. Atenolol

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

74. A 35-year-old lady following treatment for eclampsia developed a photosensitive rash over the face with joint pains and fever.
75. A 50-year-old male being treated for essential hypertension develops sudden severed pain at the great toe. On examination joint is swollen tender and red-hot.
76. A 60-year-old lady developed dry cough following administration of this antihypertensive.
77. A 43-year-old man presents to A&E following a transient ischaemic attack and BP recorded is 180/105-mmHg. He was on anti-hypertensive medication since 6 months with regular follow-ups. He has not taken his medication since 2 days as he was on holiday.
78. Heart block if co-administrated with beta-blockers.

Answers: Adverse Effects of Antihypertensives

74. (B)
Can cause drug induced SLE. Anti nuclear factor is negative.

75. (F)
Diuretics can precipitate gout.

76. (H)
This is a common side effect of ACE inhibitor therapy.

77. (G)
Clonidine is a centrally acting antihypertensive and can cause rebound hypertension.

78. (E)
Co administration of verapamil and beta-blockers must be avoided.

by **drwatson** » Mon Nov 29, 2010 2:14 pm

Theme: Nutritional deficiencies

Options
A. Ascorbic acid
B. Niacin
C. Copper
D. Manganese
E. Vitamin-A
F. Vitamin-K
G. Zinc
H. Thiamine
I. Vitamin B12
J. Vitamin-D
K. Chromium

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

79. An 85-year-old woman living alone is lethargic and weak. She also has bleeding gums and joint pains.
80. A 78-year-old woman on Total-parental-nutrition has a rash and eczematous scaling of the perineum and face.
81. A 45-year-old chronic alcoholic is confused and has nystagmus, ataxia, and peripheral neuropathy.
82. A patient on total parental nutrition develops pancytopenia.
83. A 78-year-old woman on high dose antibiotics is deficient in a vitamin synthesized by intestinal flora.

Answers: Nutritional Deficiencies

79. (A)
Scurvy; deficiency of Vitamin-C.

80. (G)
Zinc deficiency, common in people on TPN without supplementation.

81. (H)
Thiamine deficiency is common in chronic alcohol consumption and leads to Wernicke’s encephalopathy and Korsakoff’s psychosis.

82. (C)
Deficiency of copper can occur in patients on TPN.

83. (F)
Vitamin K is synthesized by the intestinal flora and is necessary for coagulation of blood.

Theme: Causes of haematuria

Options
A. Cystitis
B. Renal tract calculi
C. Renal cell carcinoma
D. Bladder carcinoma
E. Good pasture’s syndrome
F. Wegener’s granulomatosis
G. Prostatitis
H. Post retention
I. Infective endocarditis
J. Glomerulonephritis
K. Interstitial nephritis
L. Polycystic kidney disease

For each question below, choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all.

84. A 50-year-old female develops haematuria with exquisite right loin pain. On examination abdomen is soft with tenderness over the right lumber region. She is afebrile.
85. A 40-year-old man with hypertension presents with frank haematuria. Physical examination shows a palpable mass over right lumber area. Other biochemical abnormalities are: mildly elevated urea and creatinine. He gives a history that his uncle recently underwent a renal transplant the cause for which he is unaware of and his mother died of renal failure.
86 A 65-year-old male presents with haematuria, right loin pain, and night sweats. Physical examination reveals a mass in the right loin. Preliminary investigations slow a normochromic normocytic anaemia.
87. A 15-year-old boy with recurrent episodes of haematuria following a flu-like illness. He is otherwise well and examination is normal.
88. A 30-year-old man comes with frank haematuria and haemoptysis. Chest X-ray shows bilateral infiltrates in the lower zones.
89. A 42-year-old man presents with haematuria frequency dysuria lower abdominal pain and fever. Abdomen is non-tender but rectal examination is very painful.

Answers: Causes of haematuria

84. (B)
Stones in the kidney will cause loin pain. In the ureter cause colic, bladder cause strangury, urethra cause obstruction.

85. (L)
Adult polycystic kidney is a autosomal dominant condition. There is a gradual decline in renal function and is common cause of CRF.

86. (C)
Classical triad of loin pain, abdominal mass and haematuria.

87. (J)
IgA disease is a common cause of recurrent haematuria in young men and it often follows viral infection.

88. (E)
Proliferative glomerulonephritis and lung symptoms caused by anti-basement membranae antibodies.

89. (G)
Non gonococcal urethritis is a commonest case of genitourinary infection in males.

Theme: Bleeding PV

Options
A. Adenomyosis
B. Anaemia
C. DUB
D. Endometrial carcinoma
E. Endometriosis
F. Chronic Pelvic infection
G. Bartholin’s abscess
H. Pregnancy
I. IUCD
J. Cancer Cervix
K. Fibroids
L. Hypothyroidism

For each question below, choose the SINGLE most likely answer from the above list of options. Each may be used once, more than once, or not at all.

90. A middle-aged female with excessive periods since the last 1-year c/o weight gain, edema and constipation. She has poor appetite and is infertile.
91. A 56-year-old postmenopausal obese nulliparous female with heavy bleeding since the last four weeks is most likely to have.
92. A couple has been trying for a child for 4 years. The female is 32-years-old has dysmenorrhea and dyspareunia. PV examination reveals a fixed retroverted uterus with nodules in the uterosacral ligaments. The most likely cause for the symptoms.
93. A 15-year-old girl with menorrhagia but no dyspareunia, discharge. Abdominopelvic USG is normal. No other obvious pathology is apparent.
94. A 55-year-old female perimenopausal with IDDM, mother had colonic carcinoma, now uses about 35-40 pads during her periods, which lasts for more than a week.
95. A 42-year-old female on combined OCP’s with heavy & prolonged periods, with increase in frequency of urine. She has been given mefenamic acid, progesterones, and danazol but to no avail. The cause for her troubles is likely to be.
96. This couple has been trying for 4 years. The female 32 years old, has dysmenorrhea and dyspareunia. PV (per vaginam) examination reveals an enlarged boggy tender uterus.

Answers: Bleeding PV

90. (L)
Typical features of hypothyroidism.

91. (D)
Classical presentation

92. (E)
Foci of endometrial glandular tissue found beyond the uterine cavity. If asymptomatic, no treatment required. Otherwise treat with hormones (Danazol, Buserelin) or surgery.

93. (C)
Bleeding without known cause.

94. (D)
Always consider in postmenopausal females.

95. (K)
Benign tumors of smooth muscle present with menorrhagia, infertility, mass or pain.

96. (A)
Endometrial tissue within the uterine muscle wall.

Theme: Gynecological Malignancies

Options
A. Ovarian carcinoma
B. Vulval carcinoma
C. Cervical carcinoma
D. Endometrial carcinoma
E. Vaginal carcinoma

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

97. Presents with pruritus.
98. Presents with ascites.
99. Presents with postmenopausal bleeding.
100. Presents with post coital bleeding.
101. Causes most deaths.

Answers: Gynecological Malignancies

97. (B)
Common mode of presentation.

98. (A)
Or mass abdomen with associated general signs of malignancy.

99. (D)
Always think of CA endometrium in postmenopausal bleeding.

100. (C)
Patient screening with regular cervical smear is important.

101. (A)
Though this is not the most common gynecological malignancy. It causes the most deaths because it is frequently asymptomatic in the early stage and hence results in late diagnosis.

Theme: Management of hypertension

Options
A. Hydralazine
B. Calcium antagonist
C. Sodium nitroprusside
D. Diuretic (thiazide)
E. Alpha-blocker
F. Alpha-methyldopa
G. Angiotensin-2 receptor blocker
H. Beta blocker
I. ACE inhibitor
J. Minoxidil
K. None

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

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102. A 38-year-old pregnant female is noted to have blood pressure of 145/90 at 30 weeks gestation. Urine protein is negative and she is generally asymptomatic.
103. A 60-year-old male is newly diagnosed with type-2 diabetes with fasting plasma glucose of 7.6 mmol/l, HbA1c of 6.8% negative urinalysis and blood pressure of 130/80.
104. A 70-year-old following a transient ischaemic attack is noted to have an average blood pressure of 160/80. His past history includes dyslipidemia (for which he takes a fibrate) and gout.
105. A 68-year-old patient is noted to be consistently hypertensive with a mean blood pressure of 165/100. In his past history he was diagnosed with asthma but does not take any therapy.
106. A 30-year-old male type-1 diabetic on annual assessment is noted to have a blood pressure of 120/80 but a urine protein excretion of 0.4-g/day.

Answers: Management of Hypertension

102. (F)
Methyldopa is the first line treatment for pregnancy-induced hypertension.

103. (K)
No indication for antihypertensive therapy

104. (B)
Diuretics are contraindicated in gout.

105. (D)
Since beta-blockers are contraindicated, a low course diuretic should be tried.

106. (I)
Though the blood pressure is normal the patient has diabetic nephropathy indicated by he microalbuminuria and hence should be treated with an ACE inhibitor.

Theme: Contraceptives of choice

Options
A. Condom
B. Depot hormonal contraception
C. Diaphragm
D. Spermicides
E. IUCD
F. Natural method
G. Implant hormonal contraception
H. COCP
I. No contraception required

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

107. In a female of 24 years of age in a stable relationship seeking contraception for a few years, with one child and a history of migraine.
108. For a female of 20 with a previous history of ectopic pregnancy, no menstrual problems, any other medical conditions or family history of cancer.
109. For a female with multiple partners, many short term relationships.
110. In a single female in stable relationship seeking a no fuss contraceptive method lasting for four to five years but easily reversible. She does not have any menstrual problems.
111. A 30-year-old female has just undergone sterilization. She is worried about immediate contraceptive cover.

Answers: Contraceptives of Choice

107. (E)
Oral contraceptives can exacerbate migraine.

108. (H)
IUCDs predispose to ectopics.

109. (A)
Prevents sexually transmitted diseases.

110. (G)
5 years contraception with one implantation

111. (A)
An IUCD should be left in place till the next period, if this is not done than barrier is the most effective and easy choice.

Theme: Causes of chronic renal failure

Options
A. Diabetic nephropathy
B. Hypertensive nephropathy
C. Bladder outflow obstruction
D. Glomerulonephritis
E. Gout amyloidosis
F. Amyloidosis
G. Chronic pyelonephritis
H. Interstitial nephritis
I. Hypercalcemia
J. Systemic vasculitis
K. Nephrotoxic drugs
L. Polycystic kidney disease

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

112. A 50-year-old man presents with an episode of renal colic. He also gives a history of intermittent knee pain.
113. A 55-year-old woman is found to have chronic renal impairment on a routine blood test prior to a coronary angiogram. She is on no medication apart from anti-anginals.
114. A 40-year-old woman being investigated for hypertension is found on routine blood test to have chronic renal impairment. She suffered recurrent UTI’s, as a child but has been asymptomatic since.
115. A 40-year-old woman has renal failure and proteinuria. She also complains of visual impairment and numbness over her peripheries.
116. A 50-year-old man suffers daily headaches subsequent to an accident at work sustained four years previously. He now complains of increasing malaise and joint pains and is found to have renal impairment.
117. A 65-year-old man presents with a two-year history of urinary frequency, hesitancy and poor stream. On examination he has a palpable mass arising from the pelvis extending half way to the umbilicus and dull on percussion.

Answers: Causes of Chronic Renal Failure

112. (E)
Diagnosis is by raised serum uric acid and presence of negatively birefringently crystals in polarized light in the synovial fluid.

113. (B)
Seen in long standing poorly controlled patients.

114. (G)
Present as CRF or one of its complications and probably arises form children UTI associated with reflux and scarring.

115. (A)
Main feature is proteinuria starts as intermittent microalbuminuria, which leads to constant proteinuria and occasionally nephrotic syndrome.

116. (K)
Prolonged use of analgesics can cause analgesic nephropathy.

117. (C)
USG or CT scan may be required to ascertain the cause of the mass.

Theme: Management of psychiatric illness

Options
A. Psychodynamic Psychotherapy
B. Family Therapy
C. Cognitive Therapy
D. Exposure and Response prevention (Behavioral Therapy)
E. Systematic Desensitizations (Behavioral therapy)
F. Electro convulsive Therapy
G. Social skills training
H. Relaxation therapy
I. Anxiety Management

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

118. A 33-year-old lady presents with a long history of depression. She works as a shop assistant and has a good appetite and sleeps 8 hours per night. She has never had suicidal thoughts.
119. A couple brings their 12-year-old son to the clinic as he is having problems at school and is always getting into trouble. While describing his problems, the parents start arguing with other and blame each other for the boy’s problems.
120. A 30-year-old lady presents with dermatitis of both her hands. She is very particular about cleanliness and has to wash her at least 20 times per day.
121. A 38-year-old man presents with low mood, which started after he had an accident 10 months ago. Ha has frequent nightmares and flashbacks of the incident and is constantly thinking about it.
122. A 35-year-old lady who refuses to go out, as she is phobic of dogs.

Answers: Management of Psychiatric illness

118. (C)
This is NOT a case of clinical depression. Just having low mood does not meet the criteria for depression. This is case of dysthymia. The intervention of choice would be cognitive therapy. This form of therapy encourages people to look at the maladaptive patterns of thinking that makes them depressed. It is carried out by a therapist over 16 to 20 sessions and the patient has to keep a diary and do home works etc. it is used for depression, anxiety, dysthymia, PTSD etc.

119. (B)
Many of the problems especially that children have result dysfunctional family interactions. In these situations it is family therapy that would be the therapy of choice.

120. (D)
This lady has OCD. The therapy would involve encouraging her to make herself dirty (exposure) and letting her remain dirty and not allowing her to wash herself (response prevention). This has to be repeated over a number of sessions. Behavior is being altered and hence it is a form of Behavior therapy.

121. (C)
PTSD. See explanation to 1.

122. (E)
Getting rid of a phobia by gradual exposure to the feared stimulus, along with relaxation.

Theme: Mechanism of action of antihypertensives

Options
A. Alpha methyldopa
B. Bendrofluazide
C. Carvedilol
D. Prazosin
E. Hydralazine
F. Losartan
G. Minoxidine
H. Nebivolol
I. Nifedipine
J. Quinapril

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

123. A combined alpha and beta-receptor antagonist
124. A selective beta-1 receptor antagonist
125. Blocks the angiotensin-II receptor
126. Acts by reducing central sympathetic nervous system activity
127. A specific alpha- receptor antagonist

Answers: Mechanism of action of antihypertensives

123. (C)
This has both alpha and beta blocking effects.

124. (I)
This is a selective beta-1-antagonist and hence has reduced beta-2 mediated effects like cold peripheries.

125. (F)
Losartan, Eprosartan and irbesartan – all of these are angiotensin antagonists.

126. (H)
This is an imidazoline agonist acting on the sympathetic nuclei in the medulla reducing sympathetic activity.

127. (D)
Doxazosin is also an alpha-1 antagonist.

Theme: Management of antepartum hemorrhage

Options
A. Platelets
B. FDP
C. Caseation section
D. Basophils
E. Set up ivi with rapid saline infusion
F. Amniotomy to deliver the child
G. Oxytocics
H. Tocolytics
I. Prostaglandins

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

128. A 33-year-old, 34 weeks gestation is brought in shock. The first step of management would be______
129. A 32-year-old, 32 weeks gestation is brought to A&E in shock. She is bleeding PV. Her blood pressure the previous evening was 150/100 when measured at home. But the shock appears to be out of proportion to the bleeding. She is started on a saline infusion your next step would be.
130. In a case of Abruptio placenta, is recommended in the third stage of labour.
131. A 24-year-old primi presents with, rupture of membranes without onset of labour. The most appropriate method of induction would be.

Answers: Management of Antepartum Hemorrhage

128. (E)
Adequate resuscitation of patient most important.

129. (B)
Given to normalize APTT and PT.

130. (G)
To reduce bleeding.

131. (G)
To reduce the possibility of ascending infection.

by **drwatson** » Mon Nov 29, 2010 2:14 pm

Theme: Normal childhood development

Options
A. One month
B. Three months
C. Six months
D. Nine months
E. One year
F. Two Years
G. Three years
H. Four Years
I. Six years
J. 18 months

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

132. Stands unsupported.
133. Transfers objects from one hand to the other.
134. Smiles spontaneously.
135. Builds tower of 2 cubes.
136. Dresses without supervision.
137. Says ‘dada’ or ‘mama’ appropriately.

Answers: Normal Childhood Development

132. (E)
Neat pincer grip and able to speak dada or mama.

133. (C)
Stands holding on and pulls to sit without head lag.

134. (B)
Prone with head up to 90 degree and able to bring hands together

135. (J)
75% of children able to build 2 towers and able to walk backwards.

136. (H)
Catches bouncing ball.

137. (E)
Neat pincer grip and able to speak dada or mama.

Theme: Side effects of psychotropic

Options
A. Monoamine oxidase inhibitors
B. Lithium
C. Sodium Valproate
D. Carbamazepine
E. Haloperidol
F. Selective serotonin reuptake inhibitor
G. Tricyclic antidepressants

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

138. A 42-year-old male was started medication for depression. One morning he collapses as soon as he gets up from bed.
139. A 32-year lady with depression has nausea, vomiting and GI upset a few hours after taking her medication.
140. A 24-year-old male is started on medication. Three days later he develops fever, rigidity, and has a fluctuating blood pressure. He becomes confused and his CPK is raised.
141. A 28-year-old male develops severed spasm of his neck muscles soon after he takes his medication.
142. A 34-year-old patient with depression on medication develops a headache sometime after eating a sandwich. His blood pressure is noted to be 220/150-mmHg.

Answers: Side Effects of Psychotropic

138. (G)
Postural hypotension is common side effect of Tricyclic antidepressants.

139. (F)
GI upset is a common side effect of SSRI’s (Fluoxetine). Other side effects are insomnia and an increase in anxiety.

140. (E)
Neuroleptic malignant syndrome is a side effect of neuroleptics with the above features. Other side effects of neuroleptics are acute dystonias, tremors, parkinsonian features & tardive dyskinesia.

141. (E)
Acute dystonia

142. (A)
“Cheese reaction” with MAOI. Foods containing tyramine should be avoided by patients taking MAOI, eg. cheese, red wine, Avocado etc.

Theme: Dementia

Options
A. Pick’s Diseases
B. Parkinson’s Disease
C. Huntington’s Disease
D. Subdural haematoma
E. HIV
F. Alcoholic Dementia
G. Vascular Dementia (Multi infarct dementia)
H. Dementia of frontal lobe type
I. Lewy body Dementia
J. Creutzfeldt-Jacob Disease
K. Alzheimer’s Disease
L. Normal Pressure hydrocephalus

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

143. A 68-year-old lady has been brought to the clinic. Her daughter says that over the past 3 years, she has become increasingly forgetful and they have to repeat things, which they have just told her. Over the past few months she has also not been able to dress herself not eat with a fork and knife. Overall there has been a gradual decline in her level of functioning.
144. A 42-year-old bank clerk is sent from his work place for an assessment as he has become inefficient at work and is becoming forgetful, in the clinic, he is uncomfortable and has twitchings in his face. His hand movements are also jerky. His father died at the age of 46 of unknown cause.
145. A 36-year-old man became forgetful and disorientated about 2 years ago. His mental state showed marked fluctuation with disorientation and bizarre memory disturbances alternating with periods of lucidity. He was emotionally revealed myoclonic jerks, apraxia & choreoathetoid movements. He was also incontinent of urine and feces.
146. A 49-year-old man presents with lethargy, easy fatigability, and vague weakness in the legs. For past 6 months, his family has noted him to be dull & forgetful. He was slow in motor responses with mild impairment of memory. Of late, he has also become incontinent of urine.
147. A 72-year-old man had sudden weakness in his right upper limb and could not move it for 8 hours. It recovered on its own. His memory has been poor since then. A week ago, he had another similar episode and his memory has deteriorated still further. He is also being treated for hypertension.

Answers: Dementia

143. (K)
Most common cause of dementia.

144. (C)
Autosomal dominant. Presents with chorea, tremors, personality changes psychiatric disorders, rigidity & fits in any order.

145. (J)
Equal in males & females. Features are personality changes fatigue, slowness depression, memory impairment, psychosis, seizures, myoclonic, jerks, cortical blindness, not in any particular order.

146. (L)
Memory impairment, slowness, apathy, unsteady gait and incontinence are features of this condition. Treatment is ventriculoatrial shunt to lower intraventricular pressure.

147. (G)
Multiple minor strokes can result in dementia.

Theme: Substance Misuse

Options
A. Delirium Tremens
B. Opiate withdrawal
C. Benzodiazepine withdrawal
D. Stimulant (Cocaine, Amphetamine, Ecstasy) Abuse
E. Opiate dependence
F. Alcohol dependence
G. LSD
H. Harmful alcohol abuse

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

148. A 28-year-old man who lives alone, presents to A&E with pain abdomen. He is vomiting and sweating profusely. He also has diarrhea. He has not been eating for the past 3 days, as he did not have any money. His pupils are dilated.
149. A 48-year-old man was admitted to the medical ward three days ago. Today he is shaky, sweaty, and scared and says that ”the devil is here to get me for my sins” and is picking at imaginary objects.
150. An 18-year-old girl is brought to A&E at 6-am. In the morning after she collapsed in a nightclub. She spent the whole night dancing.
151. A 45-year-old male is brought to the clinic by his wife as their marriage is on the rocks because of his heavy drinking. He admits to drinking 2 bottles of whiskey everyday for the past 6 years. He gets shakes when he wakes up and has to drink to steady himself and continues to drink through the day.
152. Multiple injection marks and pinpoint pupils are features of

Answers: Substance Misuse

148. (B)
These are the typical features of opiate withdrawal. Not having money buy the substances and dilated pupils suggest the diagnosis.

149. (A)
In all patients, irrespective of the condition they are being treated for it is important to take an alcohol history.

150. (D)
Ecstasy use is common among night-clubbers. It can cause cardiac arrhythmias and death from dehydration.

151. (F)
Features of Alcohol dependence syndrome are (Any 3 for diagnosis).
 Stereotyped pattern of drinking
 Prominence of drink seeking behavior
 Increased tolerance to alcohol
 Withdrawal symptoms
 Compulsion to drink
 Relief of withdrawal symptoms
 Reinstatement after abstinence

152. (E)
Opiate dependence

Theme: Treatment of stroke

Options
A. Percutaneous endoscopic gastronomy (PEG) feeding
B. Physiotherapy
C. Observe and monitor patient
D. Nasogastric tube (NG) feeding
E. Lipid lowering agent
F. Referral to psychiatrist
G. Warfarin
H. Aspirin and dipyridamole
I. Graduated compression stocking
J. Anti-hypertensive agent
K. Vascular or neuro-surgery

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

153. A 76-year-old woman presents with a two-week history of right sided weakens which has more or less resolved. Computed tomography of head confirms cerebral infraction. Her pulse is irregularly irregular, but her heart sounds are normal. She is not on any medication.
154. A 76-year-old woman is found collapsed at home. On arrival at hospital her Glasgow, coma scale score is 3. Her computed tomography of head shows cerebral hemorrhage.
155. A 56-year-old man has been waking up in the early hours of the morning and at times, been tearful since his stroke 2 months ago. However he denies depression. On examination he is apathetic and has a dense right hemiparesis.
156. A 56-year-old man presents with a transient slurring of speech and dropping of the mouth. He is normally fit and well. A carotid ultrasound Doppler scan has confirmed 80% stenosis of the origin of right internal carotid artery. All his other investigations have been normal.
157. A 67-year-old man has been admitted into hospital for the last 1 week with a dense left hemiparesis. He has kept nil-by-mouth since his admission, because of his unsafe sallow.

Answer: Treatment of Stroke

153. (G)
Warfarin reduces the risk of primary and secondary strokes. It is more effective than aspirin in patients with atrial fibrillation.

154. (C)
Anticoagulants are contraindicated and antiplatelet therapy should be avoided. The patient is comatose and should managed conservatively.

155. (F)
Post stroke depression a common entity affecting 30- 40% of patients with stroke.

156. (K)
Endarterectomy is indicated in symptomatic patients with extracranial carotid stenosis of more than 70%.

157. (D)
Patients should start receiving feeds if their swallowing is impaired, initially with NG feed and later with a PEG.

Theme: Infertility treatment

Options
A. Surgery
B. GIFT
C. 20 %
D. IVF
E. LHRH analogues
F. AID (Artificial insemination Donor)
G. 10 %
H. Bromocriptine
I. Clomiphene
J. AIH (Artificial insemination husband)
K. Gonadotrophins

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

158. The method of choice for assisted fertilization in tubal problems
159. Method of choice for assisted fertilization when tubes are patient
160. In an infertile with pituitary microadenoma, the treatment is ___
161. Initial treatment for anovulation would be with __
162. For a couple trying for a child where the male partner is diagnosed to have impotence the best method to be offered would be __

Answers: Infertility Treatment

158. (D)
Embryos are returned to the uterus, done as an outpatient procedure.

159. (B)
Gametes placed in the tubes by laparoscopic cannulation

160. (H)
Surgery generally not indicated

161. (I)
To stimulate follicle development

162. (J)
Artifical insemination by sperm

Theme: Causes of hallucinations & delusions

Options
A. Schizophrenia
B. Psychotic depression
C. Mania
D. Toxic confusional state
E. Delirium tremens
F. Korsakoff’s psychosis
G. Paraphrenia
H. Drug-induced personality disorder
I. Hysteria

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

163. A 35-year-old man is agitated and euphoric. He claims to be helping the Prime minister with economic policy, although this is not true when checked.
164. A 20-year-old man complains that all his movements are being watched. Sometimes he feels as though his actions are being controlled by his radio. At other times he is aware of voices describing what he is doing.
165. A 50-year-old man complains of being pursued, by the police for a crime he denies committing. He has poor concentration and impaired short-term memory. He admits to drinking large amounts of alcohol.
166. A 65-year-old woman says that she died three months ago and is very distressed that nobody has buried her. When she is outdoors, she hears people say that she is evil and needs to be punished.
167. A 40-year-old tee-total woman is recovering from a hysterectomy two days ago. At night she becomes agitated and complains of seeing animals and children walking round the ward.

Answers: Causes of hallucinations and delusions

163. (C)
Other features include increased appetite, disinhibition, increased sexual drive, decreased insight and grandiose delusion.

164. (A)
First rank symptoms (seen in 70%), Thought insertion, thought broadcasting, thought withdrawal, passivity feeling, primary delusions, somatic hallucinations and hearing voices (3rd person).

165. (F)
May follow Wernicke’s encephalopathy and is due to thiamine deficiency and is associated to with confabulation and decreased ability to acquire new memory.

166. (B)
This is cotords syndrome, depression of psychotic features, mainly, in elderly.

167. (D)
Common in hospitalized patients.

Theme: Syndromes

Options
A. Treacher-Collin Syndrome
B. Allport’s Syndrome
C. Edwards Syndrome
D. Downs Syndrome
E. Laurence Moon Biedl Syndrome
F. Noonan’s Syndrome
G. Turner’s Syndrome
H. Klinefelters Syndrome
I. Prader will’s Syndrome
J. Williams Syndrome

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

168. A 13-year-old girl is short with wide carrying angle, apubertal. On examination there is rediofemoral delay.
169. An 8-year-old child with ptosis, down slanting eyes, low set ears, webbed neck and easy bruising. On examination there is a Pansystolic murmur.
170. A newborn baby low set malformed ears, protruding eyes & rockerbottom feet.
171. A newborn baby who is hypotonic and very sleepy. On examination, the baby has blue eyes and blond hair.
172. A newborn with lower eyelid notching oblique palpebral fissures, flat malar bones and absent zygoma.

Answers: Syndromes

168. (G)
Seen in girls, lack of a sex chromosome. Gonads are rudimentary or absent.

169. (F)
Autosomal dominant, height and intelligence are below average.

170. (C)
Trisomy-18, rigidity, mental retardation, cleft lip, hernias, and short sternum are other features. The index finger overlaps the third digit.

171. (I)
Lesion on chromosome-15. Later on in life, they develop hyperphagia, obesity, hypogonadism, short stature and hyperglycemia.

172. (A)
These are the main feature.

Theme: Treatment of movement disorders

Options
A. Beta blockers
B. Tetrabenazine
C. Levodopa
D. Botulinum toxic
E. Physiotherapy
F. Apomorphine
G. Procyclidine
H. Amantadine
I. Baclofen
J. Penicillamine
K. Withdraw drug

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

173. A 30-year-old asthmatic is admitted with exacerbation of asthma, and has made a good recovery with nebulized bronchodilators and oral steroids. However she has noticed a fine tremor affecting her hands since admission. The best way to manage the tremors would be.
174. A 25-year-old man presents with dysarthria, tremor, involuntary movements and chronic liver disease. He is noted to have Kayser-Fleischer rings affecting his eyes.
175. A 45-year-old man with known Huntington’s disease is distressed with his choreiform movements. He has not been tried on any medication yet.
176. A 15-year-old girl was recently started on metoclopramide for nausea, following a bout of gastroenteritis. Soon after taking her first tablet, she had a severe reaction. Her eyes were forced upwards and she lost voluntary movements of her eyes.
177. A 67-year-old man presents with one-year history of worsening resting tremor. Both his muscle tone and walking is normal. He finds the tremor embarrassing.

Answers: Treatment of Movement Disorders

173. (K)
Salbutamol causes tremors. Treatment includes or stopping the drug.

174. (J)
Wilson’s disease, Treat with penicillamine.

175. (B)
Used in controlling movement disorders in Huntington’s, Hemiballismus and chorea.

176. (G)
Oculogyric crisis due to extrapyramidal effects of metoclopramide. Can be treated with anticholinergics.

177. (A)
Begin essential tremor. Affects hand and trunk. Alcohol & beta-blockers relieve symptoms.

Theme: Management of pelvic inflammatory disease PID

Options
A. Monilial vaginitis
B. Trichomonas vaginalis
C. Foreign body
D. Atrophic vaginitis
E. Endometrial carcinoma
F. Normal discharge of pregnancy
G. Normal periods
H. Ovulation

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

178. An 8-year-old child is brought with offensive discharge per vaginam since the past three months. She has received three courses of antibiotics from the GP but to no avail. The external genitalia appear normal except for the purulent discharge.
179. A 65-year-old postmenopausal female has had a profuse, purulent and occasionally blood stained discharge per vaginam with some discomfort and soreness at the vulva. The GP has treated her with ethynylestradiol but the response has been poor. The condition to be ruled out is.
180. A 24-year-old female presents with intense vulval irritation and thick white vaginal discharge.
181. A 20-year-old, 28 weeks gestation, presents with sudden onset of scanty yellow discharge with mild vulval irritation. The vaginal wall has multiple punctate ulcers.
182. A 58-year-old presents with profuse purulent discharge. The vaginal walls are inflamed. Microscopy does not reveal any organism.

Answers: Management of Pelvic Inflammatory Disease

178. (C)
Unlikely to be due to STD as the external genitalia appears normal. The resistance to treatment and the age of the patient makes the diagnosis possible.

179. (E)
Bleeding PV in a postmenopausal woman is CA endometrium until proven otherwise. It is important to rule out this condition in bleeding or if improvement of senile vaginitis is not achieved rapidly following treatment.

180. (A)
Characteristic discharge. Confirm diagnosis by microscopy.

181. (B)
Trichomoniasis may manifest during pregnancy. The characteristic discharge is profuse, offensive, yellow and frothy.

182. (D)
In the absence of bleeding, the first diagnosis to be considered in this case is atrophic vaginitis.

Theme: Fitness to drive

Options
A. Banned from driving
B. Should not drive for 1 month
C. Should not drive for 2 months
D. Must not drive for 3 months
E. Must no drive for one year
F. May not drive for two years
G. May not drive for three years
H. Should not drive for 48 hours
I. Should not drive for six weeks
J. May drive (but inform DVLA)
K. No need to inform DVLA

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

183. A 45-year-old IDDM with no complications or other medical problems.
184. A 35-year-old has epilepsy with attacks occurring during sleep. How long must he wait before he can resume driving?
185. A 25-year-old lady has undergone a wisdom tooth extraction under general anesthesia. What advice do you give her about driving?
186. A drill worker has complete loss of vision in his left eye following and accidental injury at work. He is otherwise well and has 6/6 vision with a normal visual field on the right.
187. A 50-year-old has undergone a coronary angioplasty. How long should he not drive after the operation?
188. A 50-year-old lady is diagnosed to have glaucoma. Visual acuity is normal but binocular field of vision is limited to the central 60o only.

Answers: Fitness to Drive

183. (J)
All patients on oral hypoglycemic and insulin must inform the DVLA.

184. (G)
License may be granted if free from attach for 1-year prior to license validity or if previous 3-year attack only during sleep.

185. (H)
______

186. (J)
Monocular vision is allowed only if visual field is full.

187. (B)
Others include pacemaker, heart valve or artery surgery or uncomplicated MI.

188. (A)
Binocular field of vision must be > 120.

Theme: Management of chronic joint diseases

Options
A. Steroids
B. Chloramphenicol
C. Sulfasalazine
D. Penicillin
E. Physiotherapy
F. Rifampicin
G. Dextropropoxyphene
H. INH
I. Methotrexate

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

189. A 30-year-old farmer presents with history of myalgia, fatigability, with occasional bouts of fever, depression, and right knee-joint pain, for the past 6 months. On examination, there is wasting of the muscles of the hand and limited movements of the joints.
190. A 46-year-old lady with a known h/o duodenal ulcers on treatment, develops pain, swelling and stiffness of the metacarpophalangeal, distal interphalangeal and wrist joints, which has been progressively getting worse. On examination, there is wasting of the muscles of the hand and limited movements of the joints.
191. A 21-year-old man presents with episodic pain in both buttocks, low back pain and stiffness worse in the mornings.
192. A 30-year-old lady presents with severe scaly erythematous lesions all over her body, with swelling and severe pain on her DIP joints which is severely disabled as she is unable to move the joint.
193. A 22-year-old homosexual man develops high-grade fever associated with pustules on the hands with severe joint pain. He later develops swelling and redness of the left knee.

Answers: Management of Chronic Joint Diseases

189. (F)
Brucellosis; commonly seen in people handling animals.

190. (C)
As this lady has a duodenal ulcer, it is not possible to give NSAID’s

191. (E)
Exercise and Physiotherapy are the main ways of managing this condition

192. (I)
Extensive Psoriasis

193. (D)
Gonococcal infection

Theme: Causes of UTI in children

Options
A. Asymptomatic bacteriuria
B. Acute pyelonephritis
C. Acute glomerulonephritis
D. Posterior urethral valve
E. Sexual abuse
F. Urethral stricture
G. Spina bifida
H. Trauma
I. Ureterocele
J. Secondary Enuresis
K. Secondary to indwelling catheter

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

194. A 10-year-old girl brought by her mother diagnosed as UTI. This is the fourth episode in the past 1 year. She also complains of mild bleeding per vaginam. She has been going for horse riding classes since one year.
195. A 4-year-old boy presents with poor urinary stream and has a bloated appearance. Investigations done show hyponatremia, and ultrasound shows bilateral hydronephrosis and hydroureter.
196. A mother brings her 6-year-old child concerned that she is bed-wetting at night. She says that this has started since 1 month, prior to which she insists that bladder control was normal.
197. A 7-year-old boy with a urethral stricture diagnosed to have UTI, which grew staphylococcus epidermidis.
198. A 12-year-old girl presents with fever and passing smoky urine since 4 days. She had recovered from a sore throat 3 weeks back. Urine microscopy shows presence of red and white cells and culture grew significant colony of E. coli.

Answers: Causes of UTI in Children

194. (E)
Recurrent unexplained UTI in a child within a short period of time.

195. (D)
Secondary to the posterior urethral valve.

196. (J)
Typical history of secondary enuresis that can be a cause for UTI.

197. (K)
Staph. Epidermidis is the commonest organism causing UTI secondary to indwelling catheter. The urethral stricture necessitates catheterization.

198. (C)
History suggestive of post-streptococcal glomerulonephritis.

Theme: Diagnosis of peripheral neurological lesions

Options
A. Median nerve lesion
B. Ulnar nerve lesion
C. Brachial plexus lesion
D. Cord compression
E. Cauda equina lesion
F. Autonomic neuropathy
G. Radial nerve lesion
H. Peripheral neuropathy
I. Multiple sclerosis (demyelination)
J. Anterior horn cell disease (motor neurone disease)
K. Sciatic nerve lesion

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

199. A 38-year-old pregnant woman complaints of tingling sensation in her hands, worse at night. Her Tinel’s and Phalen’s signs were positive.
200. A 72-year-old woman presents with bilateral foot drop and spastic weakness with muscle fasciculation of her legs. Recently, she has been prone to having chest infections. Her tongue was wasted and fasciculating.
201. A 70-year-old diabetic man complains of impotence and intermittent vomiting, with abdominal distension after eating. He also has postural hypotension.
202. A 55-year-old man complains of left shoulder pain and weight loss. There is evidence of miosis and partial ptosis of his left eye.
203. A 75-year-old man complains of bilateral lower limb weakness, numbness and urinary incontinence. His knee and ankle reflexes are absent. There is loss of sensation in the sacral dermatomes.

Answers: Diagnosis of Peripheral Neurological Lesions

199. (A)
Carpal tunnel syndrome

200. (J)
Motor neurone disease is associated with degeneration of motor neurons, somatic motor nuclei of cranial nerves and cortex. Confirmed by Electromyography.

201. (F)
Diabetes with autonomic features.

202. (C)
Horner’s syndrome. Carcinoma of the apex of lung can erode the ribs and lower part of the brachial plexus.

203. (E)
Compression of the cauda equina causes these symptoms. Urgent surgery is indicated.

by **drwatson** » Mon Nov 29, 2010 2:16 pm

Theme: Failure to thrive

Options
A. Coeliac disease
B. Cystic fibrosis
C. Blind loop syndrome
D. Cows milk protein intolerance
E. Neglect
F. Hypogammaglobulinemia
G. Hirschsprung’s disease
H. Hypothyroidism
I. Munchausen syndrome by proxy
J. Inborn errors of metabolism
K. Gastroesophageal reflux disease

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

204. A 3-year-old child brought with inactivity, excessive sleeping, slow feeding and little crying. Developmental milestones are delayed. On examination: flat nasal bridge, protruded tongue with hypotonia.
205. A 2-year-old brought with fits and persistent diarrhea. Mother describes child’s urine as having a musty odor. There is evidence of impaired milestone development. On examination, child has light colored hair with eczema.
206. A 5 year boy with the history of recurrent chest infections and slow growth. He has been passing greasy foul smelling stools. On examination: child has clubbing and abdominal distension with marked muscle wasting of the buttocks. Investigations show increased blood glucose.
207. A 10-year-old girl presents with chronic diarrhea and vomiting. Her height was on the 50th centile and weight on the 15th centile. She also has marked pallor and is diagnosed to have severe iron deficiency anaemia.
208. A 6-month-old girl presents with failure to thrive. She was admitted two weeks back with loose stools and diarrhea, which stopped with ORS treatment. Her physical development prior to admission was normal. On examination, baby alert and responsive and it was noticed that mother insisted on feeding the baby herself and stayed continuously with the baby.
209. A 10-year-old girl presents with failure to thrive and recurrent infections needing repeated antibiotic treatment. She also complains of persistent cough with suppurative sputum production. On examination: pallor, clubbing, coarse crepitations and hepato-splenomegaly.

Answers: Failure to Thrive

204. (H)
Common cause of failure to thrive.

205. (J)
Phenylketonuria

206. (B)
Commonest autosomal recessive disease, Diagnose with sweat test.

207. (A)
Malabsorption caused by gluten. Treat with gluten free diet.

208. (I)
Usually applied to children this term is used when a patient is thought to be ill as a result of false history given by another individual.

209. (F)
Some form of this condition is congenital (eg. Wiskott Aldrich Syndrome) while other develops during adult life.

Theme: Choice of antibiotics

Options
A. None
B. Benzylpenicillin
C. Amoxicillin
D. Cefotaxime
E. Gentamicin
F. Metronidazole
G. Ciprofloxacin
H. Erythromycin
I. Trimethoprim
J. Rifampicin
K. Co-amoxiclav
L. Two or more Antibiotics together

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

210. A 17-year-old boy develops diarrhea with cramping abdominal pain after a party. More than half the guests are similarly affected.
211. A 27-year-old nurse complains of headache, neck stiffness, fever and purpuric rash. What antibiotic should be immediately given?
212. A 35-year-old male abattoir worker develops a lesion on his hand, which ulcerates forming a black eschar.
213. A 5-year-old girl presents with a painful left ear. On examination, the child is pyrexial and otoscopy reveals a bulging red eardrum.
214. A 35 -year-old woman, presents with increased frequency of micturition and burning sensation during micturition. On examination no loin tenderness or other signs.

Answers: Choice of Antibiotics

210. (G)
Useful in shigella, salmonella, campylobacter gastroenteritis. Also used in traveler’s diarrhea.

211. (B)
Empirical treatment should not be delayed if meningococcal infection is suspected.

212. (B)
Benzylpenicillin is the treatment of choice in anthrax.

213. (C)
May need aural toilet if not responding.

214. (I)
Treatment includes drinking plenty of fluids, urinating often, double-voiding, voiding after intercourse.

Theme: Diagnosis of proximal muscle weakness

Options
A. Cushing’s syndrome
B. Diabetic amyotrophy
C. Non-metastatic manifestation of malignancy
D. Polymyositis
E. Hypocalcemia
F. Thyrotoxicosis
G. Duchenne muscular dystrophy
H. Hypokalemia
I. Hypothyroidism
J. Polymyalgia rheumatica

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

215. A 70-year-old man complains of 2 months history of painful thighs and difficulty getting up from a chair. Examination revealed wasting of the quadriceps with absent knee reflexes. His glycosylated haemoglobin is elevated at 9%.
216. A 45-year-old woman with long standing asthma complains of obesity and proximal muscle weakness. She requires a maintenance steroid dose of at least 15-mg prednisolone per day.
217. A 7-year-old boy has hypertrophy of his calves and has a waddling gait. He also displays the Gower sign, due to weakness of his spine and knees.
218. A 56-year-old man with recently diagnosed chronic renal failure complains of paraesthesia, cramps, proximal muscle weakness and tetany. Both Chvostek’s and Trousseau’s sings were elicited.
219. A 47-year-old woman presents with symmetrical proximal muscle weakness and wasting. Her muscles are tender, with reduced tendon reflexes. Serum creatinine phosphokinase (CPK) is elevated.

Answers: Choice of Antibiotics

215. (B)
Proximal muscles commonly involved. Seen in long standing diabetics.

216. (A)
Long term use of steroids can cause Cushing’s syndrome with proximal myopathy.

217. (G)
Sex linked recessive. Serum creatine kinase raised. No specific treatment.

218. (E)
Conversion of vitamin-D to its active moiety is impaired in renal failure, hence resulting in hypocalcemia.

219. (D)
Symmetrical proximal muscle weakness resulting from muscle inflammation. Dysphagia and respiratory weakness may develop. A quarter of those affected has heliotrope rash. Diagnosed by CK, EMG and muscle biopsy.

Theme: Cranial nerve defects

Options
A. Olfactory (I)
B. Optic (II)
C. Oculomotor (III)
D. Trochlear (IV)
E. Trigeminal (V)
F. Abducens (VI)
G. Facial (VII)
H. Auditory (VIII)
I. Glossopharyngeal (IX)
J. Vagus (X)
K. Accessory (XI)
L. Hypoglossal (XII)

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

220. A 45-year-old man with type-1 (insulin-dependent) diabetes mellitus has a painful right eye and double vision. The pupil is enlarged and the eye deviated inferiorly and laterally. There is also ptosis.
221. A 35-year-old lady, previously well, complains of a ‘num’ feeling of the left side of her face and a watery left eye. There is a loss of the nasolabial fold and the left forehead creases. She is unable to whistle or show her teeth on the left. Sensation is normal.
222. A 70-year-old lady on prednisolone for rheumatoid arthritis complains of a painful eye and rash. There is a vesicular rash involving the right conjunctiva and right forehead, which is very tender to touch.
223. A 72-year-old man complains of great difficulty in walking downstairs and occasional diplopia. There are diminished eye movements on the right side where the eye is unable to move to the inferior and medical position.
224. A 20-year-old lady presents with blurring of vision. She has a mildly dilated right pupil and visual acuity of 6/40 in the right eye compared with 6/6 in the left eye. There is no ptosis.

Answers: Cranial Nerve Defects

220. (C)
Diabetes mellitus is the commonest cause if III-nerve palsy. Prognosis is usually Good.

221. (G)
Can be idiopathic, or caused by cholesteatoma, Herpes zoster, or tumour of the parotid gland.

222. (E)
Herpes zoster of the trigeminal nerve is commonly seen in the immunocompromised.

223. (D)
A trochlear nerve defect classically presents as difficulty in walking down stairs because there is a loss of movement in the superior oblique muscle.

224. (B)
Multiple sclerosis commonly affects the optic nerve.

Theme: Specific emergency management

Options
A. Check blood glucose
B. Hydrocortisone succinate
C. 50% glucose
D. IM chlorpromazine
E. Pass NG tube.
F. Propranolol
G. IV access, blood sampling & IV normal saline
H. IV access, blood sampling IV gelatin solution
I. 10 % Calcium gluconate
J. broad spectrum antibiotics
K. Urine cultures

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

225. A 45-year-old male, a known case of Addison’s is brought in shock. He had been complaining of dysuria and had a very high fever since yesterday. A diagnosis of addisonian crisis is made. Your first action would be……….
226. He is confused and has seizures and now seems to have right hemiparesis. Next step.
227. You have sent off the bloods and are awaiting results in the above patient and have stabilized his vitals, your next step would be………
228. Now the patient has improved, but the ECG shows broadened QRS complexes, tall T-waves and disappearing P-waves. He is likely to require……….
229. You have to admit him now and are preparing his drug chart. You would like to write up ……….
230. 45-year-old known hyperthyroid has been brought in with restlessness, tremors, palpitations, & tachycardia. You diagnose Thyrotoxic crisis. Your first step would be ……….
231. She continues to be restless and is thrashing around. Next step……….
232. She is gradually beginning to settle down. Next step ……….

Answers: Specific Emergency Management

225. (H)
Plasma expanders like gelatin solutions are preferred to normal saline. The first step in every shocked patient is resuscitation.

226. (A)
Hypoglycemia is a common cause of these symptoms in addisonian crisis Check blood glucose first

227. (B)
The crisis develops due to the shortage of steroids in the body. So replacement of the same is extremely important.

228. (I)
Hyperkalemia is a common accompaniment of addisonian crisis.

229. (J)
Infection, trauma, myocardial infarction and stress are some of the common Causes of addisonian crisis.

230. (G)
As the patient is not in shock in this case, normal saline is preferred.

231. (D)
Sedation is important.

232. (F)
Given together with carbimazole and iodine.

Theme: Management of dermatological infections

Options
A. Penicillin G
B. Erythromycin
C. Topical fusidic acid
D. Electrocautery
E. Oxytetracycline
F. Topical Miconazole
G. Laser
H. Itraconazole
I. Acyclovir
J. No treatment required

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

233. An 8-year-old girl presents with brown crusting lesions on the chin. She is otherwise doing well.
234. A 32-year-old butcher presents with purplish red lesions on the hands and forearm. He says that it started at the site of a cut on the forearm.
235. A 30-year-old lady presents with a blistering rash on the medial aspect of the left thigh. She had felt pain and tingling at the site prior to the onset.
236. A 49-year-old obese man presents with severe itching in his groin. On examination, small circular areas of erythema and pustules are present in front of an advancing edge. Raw areas are left behind when the plaques are scrapped off.
237. A 4-year-old child presents with multiple small papules on the face. On examination, there is central depression in the papules.

Answers: Management of Dermatological Infections

233. (C)
Impetigo. Treated with local application of Fusidic acid.

234. (A)
Erysipeloid: This distinctive skin infection is caused by direct cutaneous inoculation with Erysipelothrix rhusiopathiae. Because this organism is most often associated with fish and domestic swine, erysipeloid most commonly results from an occupational injury related to fishing (“fish-handler’s disease”) or slaughterhouse work. After an incubation period of several days, pain (often severe), edema, and a well-demarcated, purplish-red lesion develop. Definitive diagnosis requires isolation of the bacteria from a biopsy specimen, a tissue aspirate, or blood.

235. (I)
Herpes. Usually has a dermatomal distribution.

236. (F)
Candida, this can cause severe itching. Another treatment is topical Clotrimazole.

237. (J)
Caused by DNA virus.

Theme: Diagnosis of upper limb injuries

Options
A. Clavicular fracture
B. Humeral head/neck fracture
C. Colle’s fracture
D. Scaphoid fracture
E. Shoulder dislocation
F. Smith’s fracture
G. Bennett’s fracture
H. Carpal tunnel syndrome
I. Radial head subluxation
J. Supracondylar fracture
K. Radial head fracture
L. Dislocated elbow

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

238. A 20-year-old male had a fall on outstretched hand today. Reduced movement at right wrist. Anatomical snuffbox is tender. X-ray of the wrist is normal.
239. A 68-year-old lady with fall on outstretched hand. She has painful left wrists. On examination, wrist is unduly prominent on the dorsal aspect with radial deviation.
240. A 2-year-old child was brought to the A&E with inability to use the left upper limb, which followed his dad lifting him up, by the wrist while playing. On examination his elbow is flexed and pronated.
241. A 25-year-old male with fall on outstretched hand. Extension and flexion is limited, pronation and supination in normal. Elbow is swollen with fat pad sign on X-ray.
242. A 10-year-old had a fall on outstretched hand now has pain in right elbow. On examination the elbow is swollen and deformed. The relationship between the olecranon and condyles is preserved.

Answers: Diagnosis of Upper Limb Injuries

238. (D)
Is very easy to miss on X-rays and should be repeated after 2 weeks.

239. (C)
Common in osteoporotic postmenopausal females

240. (I)
Radial heads slips out of the annular ligament.

241. (K)
X-ray often shows an effusion and minor fractures are often missed.

242. (L)
The elbow should be kept in extension after the injury to prevent damage to the brachial artery.

Theme: Opportunistic infections in HIV

Options
A. Molluscum contagiosum
B. Hairy leukoplakia
C. Tuberculosis
D. Cryptosporidium
E. CMV infection
F. Candida infection
G. Pneumocystis carinii infection
H. Cryptococcal infection
I. Toxoplasma abscess
J. Aids dementia

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

243. A patient presents with diminishing visual acuity and headache. Fundoscopy shows large, multiple cotton wool spots in both eyes.
244. A patient presents with gradual onset of fever and headache with impaired level of consciousness. CSF shows no organisms on gram stain. CT brain is normal.
245. A patient complains of fever, dry cough and shortness of breath. He is tachypneic but chest is clear on examination. Oxygen saturation shows hypoxemia.
246. A patient presents with profuse watery diarrhea, abdominal pain, nausea and vomiting for past one month. He has tried several antidiarrheals without any relief in his symptoms.

Answers: Opportunistic Infections In HIV

243. (E)
CMV retinitis is seen in 45% of patients and can cause as decreased visual acuity or blindness.

244. (H)
Causes insidious meningitis in up to 8% of patients.

245. (G)
Diagnosed by bronchoalveolar lavage, induced sputum or lung tissue microscopy.

246. (D)
Fungal infection causing infection in 10-50% of patients.

Theme: Disorders affecting the mouth

Options
A. Leucoplakia
B. Lichen planus
C. Aphthous ulcers
D. Steven-Johnson syndrome
E. Psoriasis
F. Iatrogenic gingivitis
G. Candidiasis
H. Bechet’s disease
I. Pemphigoid
J. Peutz-Jeghers syndrome
K. Addison’s disease
L. Squamous cell carcinoma
M. Osler-Weber-Rendu Syndrome
N. Folate deficiency

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

247. A 36-year-old female, known epileptic presents to her GP with painful swollen gums.
248. A 60-year-old male smoker presents with a painful single indurated ulcer with rolled out edges in his right cheek.
249. This 56-year-old female had been treated for a UTI with amoxicillin by her GP. She has now developed fever, arthralgia and has vesicular eruptions in her mouth.
250. A 40-year-old man presents with abdominal pain and rectal bleeding. He is noted to have pigmented papules on his lips.
251. A 48-year-old male presents with purplish papules around his wrist that are intensely itchy. He also has lace like lesions in his mouth.
252. A 28-year-old female present sudden loss of vision in her right eye. A diagnosis of central retinal vein occlusion is made. She has previously has recurrent attacks of painful red eye with photophobia. She has been having recurrent painful ulcers on the labia. She has been administered a variety of treatments without success for the genital ulcers.

Answers: Disorders affecting the Mouth

247. (F)
Caused by phenytoin.

248. (L)
Squamous cell CA of the cheek is seen in smokers, heavy drinkers, those who chew ‘pan’ and in those who store plug inside their cheeks.

249. (D)
Stevens Johnson syndrome or erythema multiforme major presents with the above symptoms and may occur as a result of drugs (penicillins, sulfonamides and some sedatives), viral infections (orf, herpes), neoplasms or other systemic diseases.

250. (J)
Autosomal dominant condition. Peutz-Jeghers syndrome comprises of intestinal polyposis and black freckles on lips, oral mucosa and other areas. There may be massive GI bleeding. Gastric & duodenal polyps are premalignant.

251. (B)
LP usually presents in young adults and in middle age as purplish papular pruritic rashes mainly involving the writs, flexor aspects of the forearm, genitals, lumbar regions, ankles, there may be lace like lesions in the oral cavity. The glans may have annular white lesions. Wickman’s striate and Koebner’s phenomenon present. Resolves spontaneously within a year of onset. Betamethasone valerate cream may help.

252. (H)
Bechet’s disease presents with recurrent painful ulcers of the mouth, scrotum and labia, arthritis, iritis, keratitis, hypopyon, CRVO, meningoencephalitis, Parkinsonism, dementia and thrombophlebitis. Steroid cream for ulcers.

Theme: Diagnosis of hypercalcemia

Options
A. Hyperparathyroidism
B. Milk-alkali syndrome
C. Sarcoidosis
D. Thyrotoxicosis
E. Multiple myeloma
F. Small cell lung carcinoma
G. Squamous lung carcinoma
H. Bone metastases
I. Immobility
J. Thiazide diuretics
K. Vitamin-D toxicity
L. Paget’s disease

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

253. A 28-year-old marathon runner presents with nausea for about 2 months. He is otherwise fit and well and not on any prescribed medication, although he regularly takes various dietary and mineral supplements.
254. A 50-year-old ex-smoker presents with weight loss and thirst. He has clubbing and has right middle lobe consolidation demonstrated in his chest X-ray.
255. A 46-year-old woman develops progressively worsening breathlessness over the last 1 year. Chest X-ray shows reticulonodular shadowing and she was incidentally found to have raised calcium of 2.97 mmol/I.
256. A 70-year-old deaf woman presents to A&E following a minor fall. On examination she is found to have a deformity in her left leg and X-ray reveals fracture tibia with osteosclerotic changes. She was also found to have a slightly raised calcium.
257. A 73-year-old man presents with severe back pain. X-ray pelvis reveals osteolytic lesions. His erythrocyte sedimentation rate (ESR) is elevated at 85-mm/hour.
258. A 65-year-old woman present with increasing thirst and pain over the lumbar region. She is on Tamoxifen following a mastectomy for CA breast, which she had undergone 2 years back.

Answers: Diagnosis of Hypercalcemia

253. (K)
Vitamin D toxicity is usually iatrogenic.

254. (G)
Clues in history are ex-smoker, weight loss.

255. (C)
Think of sarcoidosis in anyone presenting with gradually and breathlessness and the characteristic bilateral hilar lymphadenopathy on chest X-ray. Raised calcium is due to increased Vitamin D turnover.

256. (L)
Characteristic presentation of Paget’s disease.

257. (E)
----------------------

258. (H)
Secondary bone deposits, especially over lumbar vertebrae following breast carcinoma in not uncommon and should be considered especially in association with Calcium levels.

Theme: Diagnosis of hyponatremia

Options
A. Addison’s disease
B. Nephrotic syndrome
C. Diuretics
D. Pseudohyponatremia
E. Artefactual
F. Syndrome of inappropriate anti-diuretic hormone secretion
G. Dilutional hyponatremia
H. Chronic liver disease
I. Hypothyroidism
J. Oliguric renal failure
K. Excessive sweating

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

259. A 16-year-old girl comes to A&E with confusion and fits. On examination she has a bloated appearance with pedal oedema. She is a known case of obsessive compulsive disorder with a history of drinking around 10 liters in the past 24 hours.
260. A 23-year-old diabetic lady on insulin complains of dizziness on standing form a sitting/lying position. She is pigmented with significant postural hypotension. Biochemistry investigations show serum Na is 128-mmol/I.
261. A 37-year-old male known case of IDDM is brought to A&E with confusion and stupor. Ward glucose test shows 22.3-mmol/I and urine dipstick shows presence of ketones. His serum sodium is 115-mmol/liter.
262. A 65-year-old male with a diagnosis of CA-bronchus presents with nausea, confusion and irritability. His plasma Na level are 114-mmol/l.
263. A 55-year-old woman, a known case of SLE is found to have oedema of her legs extending up to her thighs, and a serum sodium of 125-mmol/l.

Answers: Diagnosis of Hyponatremia

259. (G)
A case of psychogenic polydipsia leading to dilutional hyponatremia.

260. (A)
Patient has IDDM with postural hypotension, pigmentation & hyponatremia other electrolyte abnormality is hyperkalemia.

261. (D)
Patient with diabetic ketoacidosis.

262. (F)
SIADH may occur.

263. (B)
Nephrotics syndrome may occur in SLE leading to oedema and hyponatremia.

Theme: Complications of fractures

Options
A. Delayed union
B. Non union
C. Pseudoarthrosis
D. Malunion
E. Sudeck’s atrophy
F. Contractures
G. Secondary infection
H. Compartment syndrome
I. Fat embolism
J. Myositis ossificans

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

264. A 55-year-old female presents to A&E a month after a radial head fracture. She has been treated for the condition and a recent x-ray revealed good healing. Now she complains of swelling of the hand & is very sensitive to touch. The hand appears and cyanosed.
265. A 36-year-old man was admitted with a femoral shaft fracture 4 days back. He has well when he complained of sudden onset of difficulty in breathing. He had seizures and went into coma. Examination revealed diffuse petechial rashes.
266. This 65-year-old lady who was treated for Colle’s fracture six months back is unable to use a can opener.
267. A 10-year-old child was treated for a right supracondylar fracture. He presents 4 weeks later with poor range of movement at the elbow, which worsened with physiotherapy. X-ray revealed a faint area of new bone formation with indistinct edges.
268. A 52-year-old man was diagnosed with right neck of femur fracture 4 months back. He still continues to have pain, swelling and reduced mobility. X-ray reveals closing off of the medullary cavity.

Answers: Complications of Fractures

264. (E)
Loss of vascular tone and supersensitivity to sympathetic neurons.

265. (I)
Characteristically occurs 3-10 days after the fracture (fat embolism)

266. (D)
Recognized complication of Colle’s fracture.

267. (J)
Calcification of particular haematoma leading to restriction of movement and loss of function.

268. (B)
Commoner in cortical bone.

Theme: Pediatrics-respiratory disorders

Options
A. Tracheoesophageal fistula
B. Choanal atresia
C. Bronchiolitis
D. Croup
E. Acute epiglottitis
F. Asthma
G. Hypothyroidism
H. Whooping cough

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

269. A 7-year-old presents with fever, running nose, cough, nasal flaring and hyper-expansion of the chest. Auscultation reveals expiratory wheezes.
270. A 6-month-old infant presents with fever, aspiratory stridor and flaring of the nostrils. The mother says that the child has had an upper respiratory infection for the past 2 days.
271. A 5-year-old child wakes up at night with high fever, sore throat, respiratory distress, drooling and stridor.
272. A 3-year-old child presents with bouts of coughing which end in vomiting. These episodes are worse at nigh and after feeds and are often associated with cyanosis. The child is afebrile.
273. A newborn infant has excess drooling, with coughing and choking during feeds. Cyanosis is present which is unrelieved by crying.

Answers: Pediatrics-Respiratory Disorders

269. (C)
Commonest lower respiratory tract infection of infancy. Caused by respiratory syncytial virus.

270. (D)
Caused by parainfluenza virus.

271. (E)
Diagnosed by laryngoscope. Lateral neck X-rays shows enlarged glottis. Caused by H influenzae. It is an emergency.

272. (H)
Caused by Bordetella pertussis. No wheeze

273. (A)
Treat with surgical correction of the fistula.

Theme: Symptoms and signs of cranial nerve lesions

Options
A. 1st cranial nerve
B. 2nd cranial nerve
C. 3rd cranial nerve
D. 4th cranial nerve
E. 5th cranial nerve
F. 6th cranial nerve
G. 7th cranial nerve
H. 8th cranial nerve
I. 9th cranial nerve
J. 10th cranial nerve
K. 11th cranial nerve
L. 12th cranial nerve

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

274. Patient presented with headache and vomiting. On examination, patient’s jaw moves to the right when opened. There is reduced facial sensation on the left with loss of corneal reflex.
275. A 65-year-old patient was walking in the garden when he noticed a drooping and weakness of the left side of the face and he is unable to raise the left eyebrow.
276. A patient complains of impairment of taste and smell. On formal testing, sense of smell is lost and taste is mildly reduced.
277. 74-year-old presents with headache and dizziness and instability of gait. The patient’s tongue deviates to the left when protruded. The patient cannot easily move the tongue from side to side.
278. 32-year-old male with IDDM presents with diplopia on looking to the right and is unable to abduct the right eye.
279. A patient has difficulty swallowing. There is impaired movement of the palate, which is pulled to the left on saying ‘Ah’. Gag reflex is absent.

Answers: Symptoms and Signs of Cranial Nerve Lesions

274. (E)
The trigeminal nerve has both sensory and motor components. The nerve transmits sensation from the face, mouth, lips, eyes, forehead and anterior part of the scalp as well as the dura of the anterior cranial and middle fossa. The three branches of the nerve are (a) ophthalmic division, (b) maxillary division and the mandibular division. Motor functions include supply to the muscles of mastication (the masseters, temporalis, medial and lateral pterygoids, anterior belly of the diagastric, mylohyoid, tensor veli palatini and tensor tympani muscles).

275. (G)
The facial nerve supplies the muscles of the face. In upper motor lesions, there is sparing of the area of the face above the eyebrows. So in this case, he has a lower motor neuron lesion of the facial nerve, which in the absence of any underlying lesion is called bells palsy.

276. (A)
Olfactory nerve lesion.

277. (L)
In upper motor hypoglossal nerve lesions, there is an inability to move the tongue. The tongue deviates to the affected side as the muscle of the healthy side pushes its.

278. (F)
The lateral rectus is supplied by the 6th cranial nerve, the lesion of which gives these signs including diplopia worse on looking to the side of the paretic LR. Lesion associated with diabetes.

279. (J)
The vagus nerve is the predominant motor supply to the upper pharynx, soft palate and the intrinsic muscles of the larynx and the cricothyroid.

Theme: Knee injuries

Options
A. Patellar fracture
B. Dislocation of patella
C. Posterior cruciate ligament rupture
D. Anterior cruciate ligament rupture
E. Collateral ligament injury
F. Ruptured patellar tendon
G. Osgood-Schlatter’s disease
H. Meniscal injury
I. Osteochondritis desiccans

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

280. A 45-year-old lady who was hit in the back of her knee by a car has a swollen knee and the inability to flex the knee. The knee repeatedly gives way. Anterior draw test is positive.
281. A 12-year-old boy has been having recurrent right knee pain. He presents to A&E with increased pain today. He played football a few hours back. He didn’t injure himself. On examination, right tuberosity is prominent with tenderness in the lower one third of the patellar tendon. X-ray shows enlarged and fragmented tuberosity.
282. A 30-year-old footballer kicked the ball with his right foot and soon after experienced sharp pain in the left knee. Left knee extension is limited and he is unable to weight bear. X-ray of left knee is normal.
283. A 35-year-old male presents following a fall on the knee, which is held in flexion. There is no knee swelling or signs of ligament injury. X-ray is normal.
284. A 20-year-old with recurrent pain and swelling of the knee, which is, increased post exercise. The knee is locked.

Answers: Knee Injuries

280. (D)
Typically follows posterior blows to the tibia or rotation injuries when the foot is fixed to the ground.

281. (G)
Anterior knee pain after exercise is characteristic.

282. (H)
Medial meniscal tears follow forced twists to a flexed knee.

283. (B)
Interpretation can be difficult as the patella overlies the distal femur on AP view and can obscure subtle fractures.

284. (I)
Local necrosis of the articular cartilage and its underlying bone.

Theme: Diagnosis of endocrine conditions

Options
A. Conns Syndrome
B. deQuervain’s thyroiditis
C. Benign parathyroid adenoma
D. Cushing’s syndrome
E. Addison’s disease
F. Reidel’s thyroiditis
G. Hashimoto’s thyroiditis
H. Secondary hyperaldosteronism
I. Follicular adenoma
J. Plummer disease
K. Diabetes mellitus

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

285. A 55-year-old lady with multinodular thyroid and hyperthyroidism.
286. A 55-year-old woman has hypercalcemia found as an incident finding. Physical examination is normal in all other respects.
287. A 40-year-old male admitted with cardiac failure. Biochemistry shows hypokalemic metabolic alkalosis and low plasma renin. He was on treatment with diuretics for control of his BP.
288. A mother brings her 4-year-old daughter worried that the child has persistent fever and lethargy since 2 weeks. She also complains of frequent wet nappies and has noticed weight loss in site of the child eating well.
289. A 28-year-old post partum lady develops a painful goitre. Her ESR is raised and there is no radioiodine uptake on the scan.

Answers: Diagnosis of endocrine conditions

285. (J)
Single or multiple toxic nodules

286. (C)
Common cause of hyperparathyroidism

287. (H)
Excess aldosterone as a result of high renin. Caused by renal artery stenosis. Accelerated hypertension, heart failure and hepatic failure.

288. (K)
Common IDDM.

289. (F)
Rare, diagnosis can be made with certainty only by biopsy.

Theme: Anticoagulants

Options
A. Heparin
B. Warfarin
C. Aspirin
D. Ibuprofen
E. Greenfield
F. Vena caval ligation
G. Phenindione

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

290. Standard of care in prophylaxis against DVT after surgery
291. Initial treatment for patient diagnosed with DVT.
292. Recommended for polytrauma with pelvic fracture
293. Drug that inhibits platelet aggregation
294. Anticoagulant in patients with known sensitivity to warfarin.

Answers: Anticoagulants

290. (A)
Low molecular weight heparin till patient is mobile.

291. (A)
Acts fast and is used as initial therapy to cover the time before warfarin to effective.

292. (E)
No explanation needed.

293. (C)
Vital role in unstable angina, MI and post CABG

294. (G)

Theme: Anatomical basis of stroke syndromes

Options
A. Anterior cerebral artery
B. Dominant middle cerebral artery
C. Posterior cerebral artery
D. Vertebrobasilar system
E. Posterior inferior cerebellar artery
F. Non-dominant middle cerebral artery
G. Brainstem
H. Cerebellum
I. Lacunar infraction

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

295. A patient has weakness of the right arm and side of the face. There is sensory neglect of that side and the patient is unable to dress or wash.
296. A patient has left homonymous hemianopia but no other defects.
297. A 64-year-old known hypertensive patient presents with mild hemisensory impairment.
298. A patient has weakness and reduced sensation in the right leg. The arm is mildly affected also.
299. A 64-year-old presents with sudden bilateral blindness, vertigo, dysphagia and drop attacks. Examination reveals left-sided weakness.
300. A 52-year-old surgeon presents with vomiting, vertigo and ataxia. Exanimation reveals ipsilateral facial numbness, diplopia, nystagmus and contralateral sensory loss.

Answers: Anatomical basis of stroke syndromes

295. (F)
Left sided parietal lesion.

296. (C)
When isolated, may be a part of the posterior circulation syndrome. The lesion is in the optic tract and beyond. (optic tract, radiations, temporal lobe, posterior, parietal lobe).

297. (I)
Lacunar infarcts are seen in hypertensives and consist of small infarcts in the region of the internal capsule (partial hemiparesis or sensory loss) pons (ataxia of cerebellar type, partial hemiparesis). Basal ganglia and thalamus. They are often multiple. Lacunae are often thought to be caused by the occlusion of small branch arteries or by rupture of Charcot-Bouchard aneurysms producing a small aneurysm, which resolves leaving an area of infarction.

298. (A)
Areas supplied by the ACA includes the frontal lobes and the medial cerebral hemispheres with the exception of the visual cortex of the occipital lobes. Cortical areas include motor and sensory areas of the lower limbs, a micturition center and supplementary motor cortex. Ischemia of the territory of one ACA produces weakness and sensory deficits in the opposite limbs. Some have mild transient aphasia.

299. (D)
Vertebrobasilar lesions are characterized by vertigo, ataxia, drop attacks, dysphagia (at least two of these should occur together). There may be bilateral or alternating weakness or sensory symptoms and sudden blindness in patient aged over 40 years.

300. (E)
AKA Wallenberg syndrome. Symptoms: Vomiting, vertigo, ipsilateral ataxia, contralateral pain, & temperature loss. Ipsilateral sign: facial numbness (V-CN, diplopia (VI-CN), nystagmus, ataxia, Horner’s syndrome, IX & X-CN lesions. Contralateral signs: Spinothalamic sensory loss and rarely, mild hemiparesis.

Theme: Tumour Markers

Options
A. Prostate specific antigen (PSA)
B. Alpha-fetoprotein (AFP)
C. Carcinoembryonic antigen (CEA)
D. CA-125
E. Urinary metanephrine’s
F. B-2 microglobulin

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

301. Ovarian carcinoma.
302. Hepatocellular carcinoma
303. Prostate cancer
304. Phaeochromocytoma
305. Colon cancer

Answers: Tumour Markers

301. (D)
Tumour markers are not diagnostic of a particular disease. They are more commonly used as a prognostic indicator.

302. (B)
Also raised in choriocarcinoma, testicular teratoma and germ cell tumors of the ovary and is useful in the antenatal diagnosis on various conditions.

303. (A)
<10 ng/ml has a better outcome & > 20 a poor outcome.

304. (E)
24-hrs vanillylmandelic acid, metadrenaline or normetadrenaline

304. (C)
Useful in following the progression but is not of diagnostic value.

Theme: Management of fractures

Options
A. IV antibiotics and dressing
B. POP Backslap
C. Mallet splint
D. Scaphoid cast and review in a fortnight
E. No treatment required
F. Manipulation under anesthesia
G. Analgesics only
H. Open reduction and internal fixation

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

306. A 65-year-old female fell in her bottom from a height of 3-feet. Examination including PR is normal. The x-ray shows a fractured coccyx.
307. A 35-year-old male was playing hockey when he was hit in his right shin by an opponent. X-ray shows a thin transverse fracture of the right tibia.
308. An 82-year-old had a fall on outstretched left hand. X-ray shows colles’ fracture with the radius at a 5 degree upward tilt. Your action would be.
309. A 70-year-old presents with difficulty in extending the distal interphalangeal joint of the little finger of her right hand with mild flexion of the joint. She noticed this after she prepared the bed in the morning.
310. A 22-year-old male is brought to A&E with a swollen right forearm after she was involved in a drunken brawl in the pub. Examination shows normal movements. X-ray shows fracture of the shaft of ulna, which shows angulation and displacement.

Answers: Management of fracture

306. (G)
Unless grossly displaced no active treatment required.

307. (B)
Comminuted or segmental fracture may require open reduction and internal fixation.

308. (F)
If involves the non-dominant hand in the very old can be ignored if the displacement is not significant.

309. (C)
Often involves forced flexion of the DIPJ, however in the elderly can result from minimal trauma.

310. (H)
Isolated ulnar fracture is commonly seen as a defense injury.

Theme: Muscle Weakness

Options
A. Guillain Barre Syndrome
B. Multiple sclerosis
C. Fibromyalgia
D. Polymyalgia rheumatica
E. Polymyositis
F. Paraneoplastic syndrome

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

311. A 72-year-old male with adenocarcinoma of the lung presents with proximal muscle weakness and raised creatinine kinase.
312. A 44-year-old man presents with fatigue, low-grade fever and weakness and can no longer climb stairs to his first floor flat.
313. A 56-year-old male with recent upper respiratory infection presents with progressive weakness in the lower extremities. He has diminished deep tendon reflexes. His CSF protein concentration is elevated.
314. A 38-year-old woman complains of hurting all over. She sleeps well but does not feel refreshed in the morning. She has multiple sore spots all over the body.
315. A 64-year-old lady complains of fatigue, morning stiffness, and inability to comb her hair because of arm weakness and an inability to get up from a chair without assistance. Her ESR is raised.

Answers: Muscle Weakness

311. (F)
Presentations include myasthenic syndrome, neuropathy, myopathy, dermatomyositis or cerebellar degeneration.

312. (E)
Symmetrical proximal muscle weakness resulting from muscle inflammation. Diagnose by muscle enzyme levels, EMG & muscle biopsy. Treat with steroids.

313. (A)
Motor polyneuropathy following different infections. Paralysis is progressive and ascending. Most recover in 3 to 6 months.

314. (C)
It is a common diagnosis made in rheumatology clinic in patients with pain and no obvious cause.

315. (D)
Aching and morning stiffness in proximal limbs for at least a month, also polyarthritis, depression, fatigue, fever and anorexia.

Theme: Abnormalities of the jugular venous pressure (JVP)

Options
A. Raised JVP, normal waveform
B. Raised JVP, no pulsation
C. Large a waves
D. ‘Cannon’ a waves
E. Absent ‘a’ waves
F. Systolic (cv) waves
G. Slow y decent
H. High JVP, rises on inspiration
I. Normal

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

316. A 20-year-old female is an untreated case of rheumatic fever. She presents with dyspnea, and an irregularly irregular pulse.
317. A 29-year-old heroin addict presents with high-grade fever with chills and pedal oedema and abdomen and has a pulsatile, tender enlarged liver.
318. A 40-year-old woman who was previously on combined oral contraceptive pills develops sudden on set of severe chest pain and breathlessness. O/E, pulse is 124/min with ankle oedema. She is cold and clammy. Chest examination is unremarkable.
319. A 68-year-old male complaining of chest pain with vomiting and sweating. ECG shows ventricular tachycardia.
320. A 55-year-old male, heavy smoker for 35 years presents with shortness of breath, severe cough, dysphagia and a history of blackouts, and facial oedema.
321. A 56-year-old male, known case of chronic renal failure on hemodialysis presents with breathlessness and collapse. He has a weak pulse 120/min, BP 90/50. Heart sounds are faint with low voltage QRS-complexes on ECG.

Answers: Abnormalities of the Jugular Venous Pressure (JVP)

316. (E)
Rheumatic fever leading to mitral stenosis leading to atrial fibrillation with is the only case for absent ‘a’ waves.

317. (F)
Tricuspid regurgitation is common secondary to endocarditis (iv drug abuse). Other causes being carcinoid syndrome, rheumatic and congenital (Ebstein’s anomaly). CV waves occur during ventricular systole.

318. (A)
Combined oral contraceptives have been shown to increase the chances of pulmonary embolism leading to right heart strain and failure. Other causes for raised JVP with normal waveform being fluid overload and bradycardia.

319. (D)
Cannon waves (large a wave with rapid fall) are caused due to atrial systole against a closed ventricular valve. Other causes being complete heart block, single ventricular pacing, atrial flutter, single chamber ventricular pacing, nodal rhythm and ventricular extrasystole.

320. (B)
Smoking predisposes to SVC obstruction.

321. (H)
Kussmaul’s sing: High plateau of JVP, which raises on inspiration with deep x and y descents.

by **drwatson** » Mon Nov 29, 2010 2:17 pm

Theme: Acute treatment of arrhythmias

Options
A. None
B. Amiodarone
C. Digoxin
D. Adenosine
E. Beta-blockers
F. Verapamil
G. Flecainide
H. Lignocaine
I. Magnesium
J. Synchronized cardioversion
K. Pacemaker
L. Carotid sinus massage

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

322. A 65-year-old man presents with a two-hour history of severe chest pains and palpitations. He has an irregular pulse and ECG shows SVT with a rate of 250/min. He suddenly loses consciousness. BP is 80/30 and still is SVT.
323. A 36-year-old man presents with palpitations for the first time. ECG shows a narrow complex tachycardia with a rate of 190/min. He is otherwise well and has normal blood pressure.
324. The first treatment you tried for this man was ineffective, what would you like to try now?
325. A 70-year-old female presents to A&E with a chest infection. She has an irregularly irregular pulse. ECG shows AF at 80/ min.
326. A 60-year-old man is admitted to Coronary Care Unit for treatment of an inferior myocardial infarction. Two hours later he develops ventricular tachycardia. He feels giddy but BP is normal.
327. A 70-year-old man is receiving Streptokinase for a lateral myocardial infarction. He develops VT with central chest pain and BP 80/50. He suddenly goes pulseless and arrests.
328. A 72-year-old man is brought to A&E with transient chest pain and palpitations. He is hemodynamically stable. ECG shows AF at 140/min.

Answers: Acute Treatment of Arrhythmias

322. (J)
All narrow complex tachycardias above the rate of 200/min, impaired consciousness, systolic BP <90, chest pain, heart failure are to be treated with synchronized cardioversion. If the rate is lower in the absence of these criteria, he may be treated with adenosine.

323. (L)
As above. As the patient is younger in this case, vagal maneuvers may be tried first.

324. (D)
As above

325. (A)
Asymptomatic AF requires no treatment.

326. (H)
If the patient is conscious and not hemodynamically compromised, he may be treated with lignocaine. If pulse is present with adverse signs (systolic BP <00 mm Hg, chest pain, heart failure, rate >150), synchronized DC shock administered.

327. (J)
Same as previous answer.

328. (C)
If the arrhythmia is known to be an AF, in the absence of adverse sings, may be treated with digoxin.

Theme: Benign Breast Disease

Options
A. Mastitis neonatorum
B. Lactational breast abscess
C. Cystic disease
D. Duct ectasia
E. Fat necrosis
F. Non-lactational abscess
G. Non-cyclical breast pain
H. Benign mammary dysplasia
I. Fibromatosis

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

329. A 42-year-old premenopausal lady presents with a discreet smooth breast lump to her GP. Aspiration reveals a yellow green fluid. It is not bloodstained she also has a mammogram and ultrasound and the lump is no longer present.
330. A one month following the delivery of her first child, a 24-year-old lady presents with a hot red tender swollen lump in her left breast.
331. A 50-year-old lady describes an intermittent clear, cheese-like discharge with occasional blood staining from her breast. Her nipple has become retracted. Fine needle aspiration cytology reveals benign cells & mammogram reveals coarse calcification.
332. A 26-year-old lady with no family history of breast cancer presents with a small lump in the upper outer quadrant of her breast, which is surgically removed. Histological exam: reveals proliferation of myelofibroblasts.
333. A 40-year-old lady presents with marked premenstrual breast nodularity and discomfort of the upper outer quadrant. No malignancy is found on fine needle aspiration cytology. A core-biopsy reveals multiple cysts, fibrosis and epitheliosis.

Answers: Benign Breast Disease

329. (C)
Most common in the last decade of reproductive life. If aspiration collapses the cyst and the aspirate is not blood stained, no further treatment required.

330. (B)
Usually due to staphylococcus aureus. If early cellulitic stage, treat with antibiotics. Any abscess to be drained.

331. (D)
Dilatation of breast ducts with periductal inflammation. May lead to periductal mastitis or abscess or fistula. Fibrosis eventually leads to nipple retraction. Associated with smoking. Nipple discharge may be any color, usually watery of grumous. Try antibiotics. Usually surgery required.

332. (I)
-------

333. (H)
-------

Theme: Treatment of peptic ulceration

Options
A. Truncal vagotomy
B. Highly selective vagotomy
C. Gastroenterostomy
D. Underrunning
E. Selective vagotomy
F. Nissen fundoplication
G. Total gastrectomy
H. Proton pump inhibitors
I. Omental patch

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

334. A 60-year-old man attends the clinic with a long history of peptic ulcer disease. He is dependent on NSAID’s for pain relief. He has been treated with H2 antagonists and proton pump inhibitors without success. He is now unable to tolerate the pain.
335. A 39-year-old executive who complains of a short history of epigastric pain. Upper GI endoscopy shows a small duodenal ulcer. Gastric biopsy for H. Pylori is negative.
336. An 80-year-old lady presents with hematemesis. She is hypotensive and despite resuscitation, her BP continues to fall. Endoscopy reveals an actively bleeding duodenal ulcer. Attempts at injection with adrenaline fail.
337. A 29-year-old man previously fit and well, presents to the casualty department with sudden onset of epigastric pain. On examination he has board-like rigidity of the abdomen and absent bowel sounds. Erect chest X-ray reveals a cresenteric area of free gas beneath the left hemidiaphragm.
338. A 60-year-old man had adequate symptom relief with medical management of his duodenal ulcer. He complains of a bloated feeling and starts to vomit profusely. He becomes dehydrated and is admitted for rehydration and nasogastric aspiration. The drainage is high in volume and a contrast X-ray reveals a tight stenosis around the site of his duodenal ulcer.

Answers: Treatment of Peptic Ulceration

334. (B)
Also called proximal gastric vagotomy. Preserves the innervation of the pylorus.

335. (H)
Since there is no H. pylori, treat with the proton pump inhibitors.

336. (D)
Aim of the operation is to stop the bleeding. Gastrotomy & Underrunning.

337. (I)
If due to a gastric ulcer, take a biopsy to rule out malignancy.

338. (C)
Pyloric stenosis is a complication of duodenal ulcer & surgical correction is indicated.

Theme: Peripheral vascular disease

Options
A. Carotid stenosis
B. Rhabdomyolysis
C. Saphena varix
D. Intermittent claudication
E. Neuropathic ulcer
F. Spinal stenosis
G. Neuropathic ulcer
H. Saddle embolus
I. Deep venous thrombosis
J. Sturge-Weber syndrome

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

339. A 52-year-old patient with diabetes complains of an ulcer of his foot. He has had diabetes for a long time and is erratic with taking medications. There is a reduction in sensation to vibration and light touch in his foot.
340. A 74-year-old man presents with transient loss of vision. On examination there is a bruit in the left carotid artery.
341. A 60-year-old man presents with a history of pain in the calf for the last 3 years. One year ago he was able to walk 300 yards but is now only able to achieve 50 yards and has to rest between periods of walking.
342. A 22-year man presents to A&E following an accident at work. A piece of scaffolding fell and trapped his left leg. His peripheral pulses are present on arrival in hospital 2 hours after the accident. He is admitted for observation when he becomes hypotensive with a poor urine output.
343. A 66-year-old man has undergone a major GI surgery and is recovering in the hospital. He complains of pain in his right calf, which on examination is tender, slightly swollen and red.

Answers: Peripheral Vascular Disease

339. (E)
Commonly seen in patients with diabetes.

340. (A)
May cause TIA’s Investigate with Duplex scan and later angiography. Treatment is carotid endarterectomy.

341. (D)
Cramp like pain, which is brought on by walking, and relieved by rest.

342. (B)
Seen following trauma and destruction of muscle. Result in renal failure.

343. (H)
Seen in 30% of surgical patients. Venography is the definitive test. Prevention is with early mobilization, heparin & support hosiery.

Theme: Soft tissue swellings

Options
A. Lipoma
B. Ganglion
C. Neuroma
D. Neurofibroma
E. Leiomyoma
F. Desmoid tumors
G. Kaposi’s sarcoma
H. Rhabdomyosarcoma
I. Baker’s cyst

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

344. These lumps arise following trauma. The cells regenerate in a disorganized manner. They are often found in amputation stumps resulting in pain.
345. Rare tumors, which may be part of a genetic syndrome. Highly vascularized fibrous tissue is present and they are not malignant. Recurrence is common and most frequently found in the abdominal wall.
346. Arise in skeletal muscle. They most commonly affect children and can be found in the head and neck, trunk and limbs.
347. Very common. Rarely become malignant. Usually asymptomatic but may be multiple and painful.
348. Presents as purple macules on the skin and mucosa and tend to be multiple. Seen in HIV positive patients.

Answers: Soft Tissue Swellings

344. (C)
Regeneration of nerve endings.

345. (F)
AKA false neuromas consisting of fibrous tissue and coiled nerve fibbers. Unencapsulated fibroma. Sometimes may occur repeatedly in spite of adequate excision. Hard. Usually below the level of umbilicus. Occasionally scars and other wounds. Intraperitoneal forms in Familial Polyposis coli (Gardner’s syndrome). Treatment by wide excision

346. (H)
Tumour arising in muscle – Head & neck sarcoma arises commonly in pediatric age group.

347. (A)
Slowly growing tumor composed of fat cells. If causing trouble, removal is indicated. If multiple and painful, neurolipomatosis. Decrums disease is an associated condition.

348. (G)
Derived from capillary endothelial cells or fibrous tissue. It metastasizes to lymph nodes. Diagnosis by biopsy. Treatment is by local radiotherapy, interferon or chemotherapy.

Theme: Male infertility

Options
A. Varicocele
B. History of Hodgkin’s Lymphoma
C. Peripheral vascular disease
D. Multiple sclerosis
E. Auto-antibodies
F. Retrograde ejaculation
G. Beta blocker medication
H. Depression

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

349. Erectile failure in a smoker of 40 cigarettes per day.
350. Normal sexual function but persistent azoospermic sample in a man who suffers from recurrent urinary tract infections.
351. Oligospermia and scrotal swelling in a 24-year-old.
352. Erectile dysfunction in a 44-year-old hypertensive.
353. Azoospermia in a 58-year-old businessman 3 year after prostate surgery.

Answers: Male Infertility

349. (C)
Peripheral vascular disease associated with buttock claudication and impotence (Leriche Syndrome) is common in heavy smokers.

350. (F)
Retrograde ejaculation leads to azoospermia and may follow lower urinary tract surgery or scarring.

351. (A)
Varicocele can usually be detected by palpating a soft scrotal swelling.

352. (G)
Drugs such as beta-blockers (and alcohol) may lead to erectile failure.

353. (F)
Is common following prostate surgery.

Theme: Antibiotic prophylaxis of endocarditis

Options
A. Single dose 3-gm oral amoxicillin pre-procedure
B. 1 gm i/v amoxicillin pre-procedure, then 500 mg oral amoxicillin
C. Single dose 600 mg oral clindamycin
D. 1 gm i/v amoxicillin + 120 mg gentamicin, then 500 mg oral amoxicillin
E. 1 gm i/v vancomycin + 120 mg gentamicin pre-procedure
F. None required

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

354. A 25-year-old lady with previous history of endocarditis undergoing wisdom tooth extraction under general anesthesia.
355. A patient with atrial myxoma and penicillin-allergy undergoing dental extraction under local anesthesia.
356. A 16-year-old boy known case of rheumatic heart disease under going a tonsillectomy.
357. A patient who has a congenital ventricular septal defect undergoing dental extraction under general anesthesia.
358. A patient with atrial septal defect undergoing dental extraction under general anesthetic.
359. A pregnant woman with a Starr-Edwards mitral valve replacement requiring a forceps delivery.

Answers: Antibiotic Prophylaxis of Endocarditis

Page 138 OHCM

 Local anesthetic + no risk
Single shot amoxicillin
If penicillin allergy give clindamycin

 G/A (no risk)
Single shot amoxicillin i/v pre-procedure
Followed by another shot of amoxicillin.

 G/A with endocarditis h/o prosthetic value
Pencilling + gentamicin pre-op followed by Penicillin Post-op

354. (D)
355. (C)
356. (A)
357. (B)
358. (F)
359. (D)

Theme: Management of asthma in children

Options
A. Inhaled low-dose corticosteroid
B. Inhaled high-dose corticosteroid
C. Oral steroid
D. Inhaled short-acting beta 2 stimulant
E. Inhaled long-acting beta 2 stimulant
F. Inhaled cromoglycate or oral necrodomil
G. Inhaled ipratropium
H. Oral beta 2 stimulant
I. Oral theophylline
J. Leukotriene antagonist
K. No treatment

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

360. A 14-year-old boy referred by his GP present with complaints of occasional wheezing since 2 weeks. He is diagnosed to have mild asthma. What treatment would you initiate?
361. He requires this drug more than once a day despite good compliance. What do you add?
362. This patient continues to have nocturnal wheezing despite good compliance with the above two medications. What would you substitute the second drug with?
363. After a week, he reports back complaining of increased wheeze. He continues to use the original medications properly and regularly. What do you try now in place of the second drug?
364. He is still wheezy. What do you try in addition to the current two drugs?
365. He developed side effects with the last drug, what are your going to try now?

Answers: Management of Asthma in Children

360. (D)
361. (F)
362. (A)
363. (B)
364. (E)
365. (I)

Note: The following sequence is followed in the treatment of bronchial asthma in children (BTS guidelines). (OHCS 270)

Step-I Occasional beta agonists. If needed > daily.
Step II Cromoglycate an inhaled powder
Step III Swap cromoglycate for budesonide 50-200 mcgm/12-hr by spacer
Step IV Increase budesonide to 400-mcgm/1-hrs + prednisolone +/- long acting beta agonist
Step V Slow release xanthine +/- nebulized beta agonist +/- alternate day prednisolone + - ipratropium or beta agonist infusion

by **drwatson** » Mon Nov 29, 2010 2:18 pm

Theme: Causes of Nystagmus

Options
A. Physiological
B. Vestibular neuronitis
C. Ménière’s disease
D. Benign positional vertigo
E. Multiple sclerosis
F. Vertebrobasilar ischaemia
G. Wernicke’s encephalopathy
H. Phenytoin toxicity
I. Left cerebellar infarction
J. Right cerebellar infarction
K. Korsakoff’s syndrome
L. Vestibular schwannoma

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

366. A 45-year-old alcoholic presents with vomiting and falls. On examination, GCS is 10 with nystagmus in all directions of gaze and an ataxic gait.
367. A 50-year-old woman presents with intermittent vertigo, tinnitus and deafness in the right ear. On examination she has horizontal nystagmus on looking to the right.
368. A 30-year-old presents with intermittent giddiness. On examination, three beats of nystagmus at the extremes of left and right gaze.
369. A 60-year-old man brought by his wife who reports increasing clumsiness while performing simple daily tasks and intermittent giddiness. O/E right sided tremor with ataxic gait and nystagmus on looking to the right.
370. A 20-year-old presents with acute onset of vertigo and nausea. He vomits on attempting to stand erect. On examination he has nystagmus on left gaze.
371. 25-year-old male was involved in an RTA 2-weeks back. He now has vertigo worsened by any movement.
372. A 55-year-old male presents with hearing loss in the right ear, nystagmus on right gaze with absent corneal reflex in right eye.

Answers: Causes of Nystagmus

366. (G)
Thiamine deficiency state: triad of nystagmus, ophthalmoplegia and ataxia. Ptosis, abnormal papillary reactions and altered consciousness. Headache, anorexia, vomiting. Treatment: Thiamine

367. (C)
Above symptoms in clusters, vomiting. Symptoms lasting 12-hours. Deafness sensorineural. Progressive
Symptomatic treatment with cyclizine/betahistine
Operative decompression of saccus endolymphaticus best treatment.

368. (A)
Pathological nystagmus >3 times.

369. (I)
Cerebral tr___, ataxia, asthenia, atonia.

370. (B)
Vomiting, vertigo and prostration worsened by movement. Cyclizine.

371. (D)
Post head injury, spontaneous degeneration of labyrinth, post viral illness, stapes surgery, chronic middle ear disease.

372. (L)
Involves the trigeminal facial nerve vestibules cochleas nerves.

Theme: Causes of weak legs

Options
A. Spinal cord compression
B. Myelitis
C. Friedreich’s ataxia
D. Multiple sclerosis
E. Cauda equina compression
F. Guillain-Barre syndrome
G. Hypokalemia
H. Syringomyelia
I. Motor neurone disease
J. B12 deficiency
K. Peripheral neuropathy
L. Myasthenia gravis

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

373. A 25-year-old woman presents with increasing bilateral leg weakness. O/E, she has increased tone and exaggerated reflexes in both legs with extensor plantar response. She also has pale optic discs on fundoscopy.
374. A 60-year-old man presents with progressive leg weakness. On examination, he has wasting of muscles of lower limb with fasciculation and power 2/5. Knee and ankle jerks are brisk and he has ankle clonus.
375. A 25-year-old man presents with a short history of progressive weakness of his legs with some weakness of the arms also. On examination, he has a flaccid weakness of his limbs with absent reflexes. FVC is reduced.
376. A 55-year-old woman presents with falls and weak legs for three years. On examination, she has pes cavus and wasting of the lower legs. She has a wide-based ataxic gait and Romberg’s test is positive. Ankle jerks are absent and vibration sense is lost to the knees. Plantars are down going.
377. A 50-year-old woman presents with weakness of hand’s and legs since a year. On examination loss of pain and temperature sensation over arms and trunk. Knee and ankle jerks are brisk with increased tone in lower limbs and extensor plantars.
378. A 40-year-old man with a recent history of back pain after lifting a crate presents with a 24-hour history of bilateral leg weakness and difficulty passing urine. He has increased leg tone and brisk knee and ankle jerks.

Answers: Causes of Weak Legs

373. (D)
Young adults. Episodic demyelination throughout the CNS. Peripheral nerves unaffected. Usual presentation with optic neuritis, isolated numbness, or with weakness of legs. Other features: vertigo, nystagmus, double vision, pain, incontinence, cerebellar signs, Lhermitte’s sign, facial palsy, epilepsy, aphasia, euphoria, dementia.

374. (I)
Both upper & lower motor neurons affected. Never any sensory abnormality, Never affects extraocular muscles. This part has Amyotrophic lateral sclerosis (combined LMN wasting & UMN hyperreflexia). Other types: Progressive muscular atrophy (Anterior horn cells, Distal muscles before proximal) and Bulbar palsy.

375. (F)
Acute post infective polyneuritis. Few weeks following mild infections, motor polyneuropathy. Ascending paralysis. Proximal muscles more affected. Trunk, resp and cranial nerves. Sensory involvement common. Supportive treatment. Recover in 3-6 months.

376. (K)
Romberg’s test is positive in loss of joint position sense, which in combination with the other signs is found in peripheral neuropathy.

377. (H)
Presents with weakness of the limbs with wasting of the arms & hand with loss of pain & temp over the trunk and arms (dissociated sensory loss) ‘cape distribution’. UMN signs in lower limbs. Horner’s syndrome, Charcot joints.

378. (A)
Spinal cord compression is an emergency & needs urgent treatment. Involvement of the sphincters is an ominins sign.

Them: Diagnosis of Earache

Options
A. Aerotitis
B. Otosclerosis
C. Otitis Media
D. Cholesteatoma
E. Glue ear
F. Furunculosis
G. Chronic suppurative otitis media
H. TM joint dysfunction
I. Bullous myringitis
J. Mastoiditis

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

379. A 34-year-old man with seborrheic dermatitis develops pain and discharge from the right ear. Movement of the auricle causes severe pain.
380. A 66-year-old IDDM develops severe ear pain on jaw movement. Tender tragus and boil seen on the external auditory meatus.
381. A 41-year-old woman develops severe left ear pain, foul smelling discharge associated with sensorineural deafness. O/E left sided facial palsy and attic perforation seen.
382. A 14-year-old girl complains of sudden onset left ear pain and deafness on a intercontinental flight. O/E fluid level and hemorrhagic areas seen on the drum.
383. An 8-year-old child develops fever, left sided ear pain, reduced hearing and foul smelling discharge. O/E downward displacement of the pinna noticed.

Answers: Diagnosis of Earache

379. (C)
Is a common association

380. (F)
Staphylococcal infection is common in patients with IDDM.

381. (D)
The stratified squamous epithelium erodes into various structures.

382. (A)
Glue ear can predispose to aerotitis.

383. (J)
Recognized complication of untreated otitis media.

Theme: Investigation in overdose

Options
A. U & E
B. Prothrombin time
C. Serum Calcium
D. APTT
E. ECG
F. Chest x-ray
G. ABGs
H. FBC
I. Serum Lithium
J. LFT
K. TFT
L. Platelet count

Select the MOST appropriate investigation for each of the clinical scenarios listed below. Each choice may be used once, more than once, or not at all.

384. A 33-year-old female was brought to the hospital in a drowsy state following an overdose of Dothiepin.
385. A 64-year-old man on prophylaxis for DVT was brought to A&E after having consumed a large quantity of his medication.
386. An 18-year-old adolescent has taken about 50 aspirin tables. He is brought to A&E with sweating, vomiting and dehydration.
387. A 34-year-old man was brought to A&E having consumed excess tablets of Salbutamol with vomiting, tremors and palpitations.
388. A 35-year-old female with Bipolar Affective Disorder is brought in a confused state having taken an overdose of her medications.

Answers: Investigation in Overdose

384. (E)
Tricyclics have adverse effects on the heart and hence an ECG should be performed in addition to the other investigations.

385. (B)
The overdose is likely to be Warfarin.

386. (G)
Comes metabolic acidosis.

387. (A)
Risk of hypokalemia.

388. (I)
The most likely medication that he is likely to have taken is Lithium.

Theme: Diagnosis of bacterial infections

Options
A. Streptococcus pneumoniae
B. Clostridium botulinum
C. E. coli
D. Tuberculosis
E. Leptospirae
F. Gonorrhoeae
G. Salmonella typhi
H. Borrelia burgdorferi
I. C. difficile
J. Staph aureus
K. Meningitidis
L. Legionella pneumophilia

Select the MOST appropriate investigation for each of the clinical scenarios listed below. Each choice may be used once, more than once, or not at all.

389. A 17-year-old girl with sickle cell disease developed gradual onset right knee joint pain and swelling associated with fever and inability to move the limb.
390. A 48-year-old farmer develops fever, headache, malaise and myalgia. He is a water sport enthusiast and had taken part in water sports in inland waters a week prior to this.
391. A 73-year-old man develops bloody diarrhea and abdominal cramps. He was hospitalized 10 days back for an infected wound on the leg.
392. A 45-year-old executive with fever and cough, he recently returned from a conference abroad.
393. A 13-year-old boy develops sudden onset generalized fatigue, abdominal discomfort, blurred vision and diplopia. History of eating hazelnut yoghurt the previous night.

Answers: Diagnosis of Bacterial Infections

389. (G)
S. typhi is the commonest organism causing Osteomyelitis in patients with sickle cell disease.

.

390. (E)
Affects people involved in sewage treatment plants or those who involve in inland waters.

391. (I)
Pseudomembranous colitis is seen in patients treated on broad spectrum antibiotics.

392. (L)
This is commonly transmitted through contaminated air conditioning systems.

393. (B)
This is one mode of transmission.

Theme: Diagnosis of abdominal pain

Options
A. Bowel perforation
B. Gastric ulcer
C. Duodenal ulcer
D. Acute cholecystitis
E. Oesophageal varices
F. Splenic rupture
G. Fracture femur
H. Bulimia nervosa
I. Anorexia nervosa

Select the MOST appropriate investigation for each of the clinical scenarios listed below. Each choice may be used once, more than once, or not at all.

394. A 39-year-old female presents with fever, severe abdominal pain and tenderness. Her chest x-ray reveals free air under the diaphragm.
395. A 40-year-old lady, known smoker presents with mid epigastric pain relieved by ingestion of milk.
396. A 45 -year-old obese female presents with high fever, vomiting and severe right upper quadrant pain. Tenderness is elicited on palpation at the midpoint of the right subcostal margin on inspiration.
397. A 35-year-old man is involved in an RTA. He presents a few hours later to A&E with a bloated abdomen & pain in the left shoulder.
398. A 30-year-old lady present with severe abdominal pain. Examination revealed anaemia, enlarged parotid glands, callouses on the knuckles and dental erosions.

Answers: Diagnosis of Abdominal Pain

394. (A)
Free air under the diaphragm is a classical finding in bowel perforation.

395. (C)
This is a typical presentation.

396. (D)
Common organisms are E. coli, Klebsiella, and Streptococcus faecalis.

397. (F)
Kehr’s sign, due to blood in contact with the undersurface of the diaphragm.

398. (H)
One to induced vomiting. Can cause rupture of the stomach.

Theme: Brain region localization

Options
A. Nondominant frontal lobe
B. Dominant frontal lobe
C. Nondominant temporal lobe
D. Dominant parietal lobe
E. Nondominant parietal lobe
F. Dominant temporal lobe
G. Occipital lobe
H. Temporo-occipito parietal junction
I. Cerebellum

Select the MOST appropriate investigation for each of the clinical scenarios listed below. Each choice may be used once, more than once, or not at all.

399. A 67-year-old stroke patient cannot tell his left hand from his right hand.
400. A 50-year-old man with stroke can understand what others say to him but is unable to respond verbally.
401. A patient with stroke cannot add a column of 4 single digit numbers.
402. A 55-year-old stroke patient cannot copy a simple drawing.
403. A 65-year-old man presents with a history of falling to one side. On examination, he has dysarthria, hypotonia and nystagmus.

Answers: Brain Region Localization

399. (D)
400. (B)
401. (D)
402. (E)
403. (I)

Theme: Cardiotocography (CTG)

Options
A. Foetal anaemia
B. Foetal cardiac arrhythmia
C. Foetal heart block
D. Beta sympathomimetic drug use
E. Foetal hypoxia
F. Raising foetal intracranial pressure
G. Cord compression

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

404. A 30-year-old female at 37 weeks gestation. The pregnancy has been uneventful so far. A routine CTG showed a loss of base line variability.
405. CTG shows variable decelerations.
406. CTG shows late decelerations.
407. CTG shows baseline tachycardia of >200. Mother is afebrile. She has not been taking any medications.
408. CTG shows spasmodic bradycardia.

Answers: Cardiotocography (CTG)

404. (E)
May also suggest sleeping foetus or drug effects.

405. (G)

406. (E)
Suggest Foetal hypoxia.

407. (B)

408. (G)

Theme: Prophylactic treatment

Options
A. Vancomycin and gentamicin
B. Cefuroxime and gentamicin
C. Ampicillin IV
D. Sodium stibogluconate
E. Mefloquine
F. Chloroquine and proguanil
G. Zidovudine
H. Rifampicin
I. Isoniazid
J. Tetracycline
K. Clindamycin
L. Interferon

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

409. A 45-year-old lady due to undergo cholecystectomy at the city hospital.
410. An 18-year-old girl, known case of rheumatic heart disease due for dental scaling under local anerethisia. She is allergic to penicillin.
411. A mother brings her 4-year-old child to A&E worried that she may have been exposed to meningococcal meningitis following and outbreak in the local nursery.
412. A 30-year-old pregnant lady going on vacation to Sub-Saharan Africa for one month. She is worried about contracting malaria and would like adequate protection to prevent infection.
413. A 25-year-old pregnant HIV positive woman concerned about minimizing the risk of transmission of HIV to her fetus.

Answers: Prophylactic Treatment

409. (C)
For biliary surgery ampicillin 500-mg iv/8-hr for 3 doses or cefuroxime 750 mg/ 8h for 3 doses iv / im.

410. (K)
Clindamycin 600-mg 1-hour before local anesthetic procedure. If can tolerate penicillin, amoxicillin 3 gram 1 hour before procedure.

411. (H)
Rifampin is indicated in the treatment of closed contacts of patients with proved or suspected infection caused by Neisseria meningitides. These contacts include other household members, children in nurseries, persons in day care centers, and closed populations, such as military recruits. Health care providers who have intimate exposure (e.g. mouth-to-mouth resuscitations) with index cases also should receive prophylactic therapy. Household members and other close contacts of patients with recently diagnosed tuberculosis who have a positive tuberculin skin test (PPD) of 5-mm, [tuberculin-negative children and adolescents who have been close contacts of infections person within the past 3 months are also candidates for preventative therapy until a repeat PPD is done 12 weeks after contact with the infectious source].

412. (F)
Chloroquine crosses the placenta. Use is not recommended during pregnancy except in the suppression or treatment of malaria or hepatic amebiasis since malaria poses greater potential danger to the mother and fetus (ie. abortion and death) than prophylactic administration of chloroquine. Chloroquine, given in weekly chemoprophylactic doses, has not been shown to cause adverse effects on the fetus.

413. (G)
Zidovudine is indicated for the prevention of maternal-Foetal HIV transmission as part of a regiment that includes oral zidovudine beginning between 14 and 34 weeks gestation, continuous intravenous infusion of zidovudine during labor, and administration of zidovudine syrup to the neonate for the first six weeks of life. However, transmission to infect may still occur in some cases despite the use of this regimen.

by **drwatson** » Mon Nov 29, 2010 2:19 pm

Theme: Diagnosis of poisoning

Options
A. Benzodiazepines
B. Tricyclic antidepressants
C. Carbon monoxide
D. Organophosphate insecticides
E. Lithium
F. Carbon tetrachloride
G. Ethylene glycol
H. Paracetamol
I. Cyanide
J. Strychnine
K. Lead poisoning
L. Antifreeze
M. Paraquat

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

414. A 23-year-old girl presents with coma and convulsions. One examination tachycardia, hyperreflexia and dilated pupils.
415. A young couple brought to A&E with acute onset of fever, headache, restlessness and nausea. On examination GCS is 9 and the skin shows a pink color.
416. A 6-year-old child brought with burns in mouth, dysphagia, abdominal pain and distension. There is progressive respiratory distress with hypoxemia.
417. A 6-year-old child presents with restlessness, pyrexia and convulsions. On examination, hypertonia and hyperflexia.
418. A 35-year-old female brought to A&E in a comatose state. She is noticed to have flushed pink skin and her breath has a distinctive odor of “bitter almonds”.
419. A 27-year-old industry worker presents with sudden onset of vomiting, diarrhea, abdominal pain and seizures following accidental ingestion of solvent. On examination tender hepatomegaly and jaundice.
420. A 30-year-old woman with known history of psychiatric illness, on medication, brought with tremors and convulsions. On examination hyperflexia, rigidity and nystagmus. Investigations shows hypokalemia.

Answers: Diagnosis of Poisoning

414. (B)
TCA overdose. Phenothiazine also presents similarly.

415. (C)
Probably by falling asleep in a closed vehicle with engine left running.

416. (M)
Accidental ingestion by children common.

417. (J)
Can mimic tetanus.

418. (I)
May follow excessive use of sodium nitroprusside. Treated with dicobate edetate or sodium nitrite.

419. (F)
Used as a solvent in industrial processes. Rapid onset of symptoms.

420. (E)
On lithium for bipolar disorder with acute overdose.

Theme: Diagnosis of pruritus

Options
A. Primary biliary cirrhosis
B. Psoriasis
C. Dermatitis herpetiformis
D. Urticaria
E. Hypothyroidism
F. Lymphoma
G. Atopic eczema
H. Seborrheic dermatitis
I. Scabies
J. Lichen planus
K. Uremia
L. Polycythemia

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

421. A 35-year-old male present with and itchy scaly rash particularly over his wrists. Rash is papular and mauve topped. His buccal mucosa shows lace like steaks.
422. A 30-year-old nurse presents with generalized itching. There are widespread excoriation marks on her trunk and arms, with linear tracts around his wrists and between his fingers.
423. A 25-year-old woman complains of itching since 2 days. There is whealing of the skin after she has scratched it, which lasts for up to an hour.
424. A 50-year-old woman complains of pruritus and skin pigmentation. She is found to have anti-mitochondrial antibodies.
425. A 65-year-old man complains of malaise, lethargy and pruritus. He also has nocturia and polyuria, with nausea and vomiting. On examination pallor, pigmentation with sings of fluid overload.

Answers: Diagnosis of Pruritus

421. (J)
Lichen planus (LP) is a papulosquamous disorder in which the primary lesions are pruritic, polygonal, flat-topped, violaceous papules. Close examination of the surface of these papules will often reveal a network of gray lines (Wickham’s striae). The skin lesions may occur anywhere, but they have a predilection for the wrists, shins, lower back, and genitalia. Involvement of the scalp may lead to hair loss. LP commonly involves mucous membranes, particularly the buccal mucosa, where it can present as a white netlike eruption. Its etiology is unknown.

422. (I)
Transfer of newly fertilized female mites from person to person occurs by intimate personal contact and is facilitated by crowding, uncleanliness, and sexual promiscuity. Medical practitioners are at particular risk of infestation. Outbreaks occur in nursing homes, mental institutions, and hospitals. Patients with scabies report intense itching that worsens at night and after a hot shower. Typical burrows may be difficult to find because they are few in numbers and may be obscured by excoriations. The possibility of other sexually transmitted diseases should be excluded in adults with scabies. Sites include finger webs, wrists, elbows, ankles, genitalia and breasts. Treat with Malathion or permethrin.

423. (D)
Urticaria (hives) are transient lesions that are composed of a central wheal surrounded by an erythematous halo. Individual lesions are round, oval or figurate, and they are often pruritic. Acute and chronic urticaria has a wide variety of allergic etiologies.

424. (A)
Antimitochondrial antibody (AMA) is detected in more than 90 percent of patients with primary biliary cirrhosis amount patients with symptomatic disease, 90 percent are women aged 35 to 60. Often the earliest symptom is pruritus, which may be either generalized or limited initially to the palms and soles. In addition, fatigue is commonly a prominent early symptom. After several months or years, jaundice and gradual darkening of the exposed areas of the skin (melanosis) may ensue.

425. (K)
Uremic symptoms include fatigue, breathlessness, ankle swelling, anorexia, vomiting, nocturia and pruritus. Examination can reveal pigmentation, pallor and brown nails.

Theme: Diagnosis of sore throat

Options
A. Acute otitis media
B. HIV
C. Infectious mononucleosis
D. Diphtheria
E. Agranulocytosis
F. Scarlet fever
G. Acute follicular tonsillitis
H. Pharyngitis

Instructions: Match each clinical scenario below with the MOST appropriate diagnosis from the list of the options above. Each option may be used once, more than once and not at all.

426. A 30-year-old woman presents to her GP with score throat. She is being treated for thyrotoxicosis currently.
427.A 7-year-old child is presented to his GP with sore throat, a punctate erythematous rash and circumoral pallor.
428. A 4-year-old child complain of sore throat and earache. He is pyrexial. On examination tonsils enlarged and hyperemic exude pus when pressed upon.
429. A 30-year-old man presents in A&E department with difficulty in breathing. He has returned from India recently. Examination of his throat revealed grey membranes on the tonsils and uvula. Pyrexia is mild.
430. A 23-year-old man presents with severe malaise and sore throat. He has red tonsils with yellow membranes and cervical lymphadenopathy.

Answers: Diagnosis of Sore Throat

426. (E)
Agranulocytosis is a recognized side effect of carbimazole, used for the treatment of thyrotoxicosis. Patients receiving this drug should be warned, therefore, to see their GP if sore throat/mouth ulcers/fever develops.

427. (F)
It is difficult to make a mistake dealing with such a bright clinical picture. In addition these patients have a characteristic tongue, which is described as ‘strawberry and cream’.

428. (G)
The child has typical follicular tonsillitis. The pus exuding from the crypts is characteristic. Earache in that case is usually referred.

429. (D)
Diphtheria has become rare in the UK but it is emerging again in some parts of eastern Europe and south east Asia. Hence, recent travel to these continents is characteristic. Diphtheria presents sometimes as an emergency when severe oedema and membranes lead to airway obstruction and as phyxia. Firmly attached grey membranes that are difficult to remove and that leave a bleeding surface after an attempt to peel them off point towards the diagnosis.

430. (C)
The clues to the diagnosis in this young man are malaise, which is often more severe than in acute tonsillitis, yellow membranes on the tonsils and enlarged lymph nodes. Diagnosis is confirmed by lymphocytosis in the peripheral blood and positive Paul-Bunnel test.

Theme: Treatment of Diabetic Complication

Options
A. Oxybutynin
B. Amitriptyline
C. Atenolol
D. Captopril
E. Dexamethasone
F. Fludrocortisone
G. Metoclopramide
H. Metronidazole
I. Ampicillin
J. Tetracycline
K. Testosterone
L. Sildenafil

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

431. A 60-year-old type-2 diabetic female complains of dizziness following exercise or after a heavy meal. She is noted to have a blood pressure of 120/80 in supine position and 90/65-mmHg in the erect position.
432. A 40-year-old IDDM female complains of weight loss. Breath hydrogen analysis shows increased exhaled hydrogen and reduced gut motility.
433. A 43-year-old male diabetic complains of dysphagia and vomiting. Barium swallow done shows a gastric dilatation and reduced motility.
434. A 63-year-old type-2 female diabetic complains of incontinence. Investigation reveals a sphincter dyssynergia.
435. A 60-year-old type-2 diabetic male complains of decreased libido and importance. The only abnormalities confirm a primary hypogonadism.
436. A 45-year-old male diabetic is admitted with evidence of peripheral vascular disease. He is found to have hypertension.

Answers: Treatment of Diabetic Complications

431. (F)
Fludrocortisone is used in conjunction with increased sodium intake in the treatment of idiopathic orthostatic hypotension.

432. (I)
This patient has bacterial overgrowth as illustrated by the positive hydrogen breath test. The most suitable antibiotic to reduce overgrowth would be tetracycline.

433. (G)
Metoclopramide is indicated for the relief of symptoms of acute and recurrent diabetic gastroparesis. Previously, cisapride was a particularly good treatment although this has been withdrawn due to the prolongation of the QT-interval.

434. (A)
Oxybutynin is indicated for the relief of symptoms associated with voiding, such as frequent urination, urgency, urge incontinence, nocturia, and incontinence in those patients with reflex neurogenic bladder.

435. (K)
This patient has primary hypogonadism, which is a reduced testosterone and raised LH/FSH. This most appropriate therapy is testosterone replacement.

436. (D)
ACE inhibitors are used for treatment of essential, malignant, refractory, or accelerated hypertension, and for treatment of renovascular hypertension (except in patients with bilateral renal artery stenoses or renal artery stenosis in a solitary kidney). Captopril has been shown to slow the progression of diabetic nephropathy in normotensive and hypertensive IDDM patients with documented diabetic retinopathy.

Theme: Chest pain

Options
A. Angina
B. Tietze’s syndrome
C. Aortic dissection
D. Tabes dorsalis
E. Esophagitis
F. Pleuritic pain
G. Neurosis
H. Pericarditis
I. Myocardial infarction
J. Da Costa’s syndrome
K. Chronic pain syndrome

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

437. A 55-year-old male presents to A&E with intense dull central chest pain with associated nausea and vomiting lasting 3-hours. On examination pulse is irregular and BP is 96/60-mmHg.
438. A 50-year-old lady presents with history of cheat pain of continually varying nature. Investigations done suggest no apparent cause. She is prescribed a course of low dose tricyclics with which she responds favorably.
439. A 40-year-old man reports with a constricting epigastric pain, which occasionally radiates to the neck and jaw, precipitated following his meals and increases in the supine position. The pain improves slowly with the administration of glyceryl trinitrate.
440. A 55-year-old lady presents with a sharp constant sternal pain, which is worse on inspiration, coughing and is relieved on sitting forward. She was admitted with a diagnosis of MI ten days back. On examination, superficial sound heard best at left sternal edge.
441. A 22-year-old male presents with a sharp localized chest pain exacerbated on running or sneezing. He is worried that it may be cardiac in origin. O/E, marked tenderness over the sternal edge of 2nd rib.

Answers: Chest pain

437. (I)
Wide range of symptoms.

438. (K)
Recognized syndrome & no apparent cause but respond to low dose tricyclics.

439. (E)
Pain radiating to the back worsening with steeping and has _______. Can result in anaemia, strictures and Barrett’s ulcer.

440. (H)
Sharp constant sternal pain relieved by sitting forward ______________ left shoulder. May be made worse by lying on ____________________ & swallowing. Also Known as __________ syndrome. Treat with _____

441. (B)
Costochondritis. Treat with NSAID’s.

Theme: Diagnosis of falls

Options
A. Stokes Adams attack
B. Postural hypotension
C. Sick sinus syndrome
D. Vasovagal episode
E. Acute labyrinthitis
F. Benign positional vertigo
G. Menière’s disease
H. Parkinson’s disease
I. Sensory ataxia
J. Cerebellar involvement
K. Impaired vision
L. Drop attacks

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

442. A 75-year-old woman presents with history of several falls over the past 5 months. She says that they come on suddenly without warning and reports no loss of consciousness.
443. A 70-year-old woman brought by her daughter with a history of being off legs. Her balance has been poor for some time and she walks with a stamping gait. Romberg’s test is positive.
444. A 65-year-old man presents with history of several falls over the past one year. He finds it increasingly difficult to dress by himself and carry out activities of daily living. Examination revealed a tremor in the upper limb with hypotonia. He could not stand erect even with his eyes open.
445. A 60-year-old lady complains of giddiness and vomiting since the last 3 days. Her symptoms are exacerbated by head movements and she cannot stand without support.
446. A 58-year-old woman presents with recurrent falls associated with giddiness, particularly on getting up in the mornings. She has underlying ischaemic heart disease and is on aspirin, an oral nitrate and a beta-blocker.

Answers: Diagnosis of falls

442. (L)
Drop attacks resulting from impaired blood supply to the motor pathways of the brainstem cause sudden paraparesis or quadriparesis, usually lasting only a few seconds. Sudden drop attacks may mimic syncope. Isolated loss of consciousness is rare.

443. (I)
Imbalance with sensory ataxia is characterized by marked worsening when visual feedback is removed. The patient can often assume the upright stance with feet together cautiously with eyes open. With eye closure, balance is rapidly lost (positive Romberg’s signs) in various directions at random. Sensory examination reveals impairment of proprioception at the toes and ankles, usually associated with an even more prominent abnormality of vibratory perception. Prompt evaluation for vitamin B12 deficiency is important, as this disorder is reversible if recognized early. Depression or absence of reflexes points to peripheral nerve disorders. Spasticity with extensor plantar responses suggest posterior column and spinal cord disorders.

444. (J)
Once a desired position is reached, imbalance may be surprisingly mild. As walking begins, the imbalance recurs. Patients usually learn to lessen the imbalance by walking with the legs widely separated. Clinical signs of cerebellar limb ataxia include dysmetria, intention tremor, dysdiadochokinesia, and abnormal rebound. Muscle tone is often modestly reduced; this contributes to the abnormal rebound due to decreased activation of segmental spinal cord reflexes and also to pendular reflexes, i.e, a tendency for a tendon reflex to produce multiple swings to and fro after a single tap.

445. (E)
Imbalance with vestibular dysfunction is characterized by a consistent tendency to fall to one side. The patient commonly complains of vertigo rather than imbalance, especially if the onset is acute. Acute vertigo associated with lateralized imbalance but no other neurologic signs is often due to disorders of the semicircular canal.

446. (B)
Hypotension is a side-effect of most anti-anginal medications.

Theme: Diagnosis of constipation

Options
A. Dietary Deficiency
B. Old age
C. Diverticulosis
D. Crohn’s disease
E. Medication related
F. Autonomic neuropathy
G. Irritable bowel syndrome
H. Spinal injury
I. Multiple sclerosis
J. Colorectal carcinoma
K. Fissure in ano

447. A 40-year-old female presents with abdominal pain and distension relieved by passage of flatus. She also complains of dyspareunia, urinary frequency and altered bowel habits. She says that she has suffered numerous such episodes in the past 5 years, which remit spontaneously. Examination is unremarkable.
448. A 65-year-old female complains of increasing constipation since 5 days. She is in hospital for a week following a fall sustaining a fracture neck of femur.
449. A 50-year-old male presents with a history of abdominal pain and altered bowel habits. He also reports a weight loss of 20 lbs over the past 3 months. Examination shows pallor and a mass in the left iliac fossa.
450. A 30-year-old female presents with episodes of numbness and tingling over his hands and difficulty in walking. The episodes spontaneously subside with full recovery. She has also developed recent onset constipation and urinary incontinence.
451. A 28-year-old male homosexual presents with passage of hard stools and painful defaecation since one week. He is uncomfortable in the sitting position often moving to the edge of the chair. Examination shows the presence of a ‘sentinel pile’.

Answers: Diagnosis of constipation

447. (G)
International diarrhea, abdominal colic relieved by bowel action and bloated feelings. Diagnosis of exclusion.

448. (E)
Lack of mobility can cause constipation.

449. (J)
Presentation depends on the side. Right side: weight loss, abdominal pain left side: Bleeding PR, altered bowel habits, mass PR and tenesmus.

450. (I)
Myriad symptom complex with multisystem involvement

451. (K)
Midline longitudinal split in the squamous lining of the lower anus.

Theme: Treatment of urinary incontinence

Options
A. Oxybutynin
B. Anti-cholinergics
C. Ventricular shunting
D. Prostate surgery
E. Radiotherapy
F. Supportive care
G. Pelvic floor exercises
H. Bladder catheterization
I. Spinal surgery
J. Bladder retraining
K. Vaginal pessary

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.
452. A 70-year-old male with known prostatic carcinoma presents with an 8-hour history of being off legs and incontinence. Examination reveals spastic paraparesis with a sensory impairment at L1.
453. A 52-year-old woman presents with urinary incontinence on coughing or sneezing, increasingly becoming worse following the birth of her second child.
454. A 77-year-old man is admitted with two-month history of cognitive impairment, off legs and urinary incontinence. Examination reveals a gait apraxia.
455. A 40-year-old female with multiple sclerosis presents with urinary incontinence without urgency or frequency, worse over the last 6 months. She has evidence of spastic paraparesis with cerebellar syndrome.
456. A 65-year-old woman complains of urinary frequency and urgency. She does not like taking tablets. Examination is normal.

Answers: Treatment of urinary incontinence

452. (E)
The history is suggestive of acute cord compression, which can cause overflow incontinence, MRI is the investigation of choice. Radiotherapy is usually the treatment of choice, especially when metastatic disease is present. For localized cord compression from a newly diagnosed tumour or tumours with poor response to radiotherapy e.g. adenocarcinoma of lung or bowel, decompression surgery is alternative.

453. (G)
Post-natal pelvic floor muscle exercises are useful in preventing stress inconti-nence. The right movement is when urine is stopped mid-stream.

454. (C)
The classical presentation of normal pressure hydrocephalus is dementia, gait disturbance (pathognomonic ‘glued-to-the-floor’ sing) and incontinence. CT head shows disproportionate ventricular englargement compared with degree of cortical atrophy. Ventricular shunting is the definitive treatment.

455. (H)
Failure to fill and empty (uncoupling of detrusor and internal sphincter function) occurs with detrusor contractions against a closed sphincter. There will be overflow incontinence for which intermittent self-catheterization is the treatment of choice. Anticholinergics can be tried if urgency/frequency present.

456. (J)
Bladder retraining exercises is useful in urge incontinence. Increase intervals of regular toileting from initial 30 minutes, increasing by 10-15 minutes every few days until intervals of 2-4 hours reached. Anticholinergics are also used to control detrusor instability.

Theme: Child neglect

Options
A. Accidental trauma
B. Child neglect
C. Osteogenesis imperfecta
D. Physical abuse
E. Malnutrition
F. Sexual abuse
G. Normal

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

457. Child with nocturnal enuresis, not gaining weight.
458. A 7 month old infant with spiral fracture or femur. X –ray shows absence of callus formation.
459. An 8-year-old girl with bleeding PV following horse riding. The parents think it is an accident while riding the horse.
460. A 1-year-old child presents with a scalded burn over his forearm caused by the fall of a cup of hot tea. He was treated for extensive nappy rash 6 months ago.
461. A 10 days old baby brought to A & E his Caucasian father and Afro-Caribbean mother. Material grandmother is worried about the blue patches over the buttocks.

Answers: Child Neglect

457. (E)
The reason for failure to thrive is secondary to malnutrition especially to be considered in the light of nocturnal enuresis.

458. (C)
The absence of callus formation on X-ray suggests a non-healing fracture.

459. (F)
It is important to have a high index of suspicion for child neglect especially in young girls with genitourinary complaints.

460. (B)
Child neglect should be thought of in recurrent unusual presentations esp Resulting in injury / infection to the child.

461. (G)
This is nothing but Mongolian spots. The parental lineage is misleading here.

Theme: Bleeding PV

Options
A. Laparoscopy
B. Pelvic ultrasound to check placental position
C. B-HCG estimation
D. Shift to OT after referral with Gynecologist
E. Blood group and typing
F. Kleihauer’s acid elution test

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

462. Woman with 6 weeks amenorrhoea coming to A&E with acute abdominal pain and mild bleeding PV. Abdominal examination shows an empty uterus and no other significant findings. What do you do next?
463. Woman with history of recurrent haemorrhage and still birth in 2nd trimester in the previous 3 pregnancies presenting with mild bleeding PV at 28th week. What is the next course of action?
464. Patient with history of 10 weeks amenorrhoea (confirmed HCG positive) presenting with abdominal pain preceded by mild bleeding PV. How would you proceed next?

Answers: Bleeding PV

462. (B)
Pelvic ultrasound.

463. (F)
Kleihauer test.

464. (D)
Gynecologist referral and shift to OT.

by **drwatson** » Mon Nov 29, 2010 2:20 pm

Theme: Management of trauma case

Options
A. External fixation
B. Immediate shift to OT
C. Intravenous fluids
D. Reduction with splinting
E. X ray femur
F. Abdominal Ultrasound
G. CT-scan head
H. Blood transfusion
I. Shift to OT

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

465. Patient coming to A&E with polytrauma. All preliminary resuscitation measures have been carried out. On examination patient is noticed to have a deformed thigh. What is the next step in management?
466. Patient coming to A&E with polytrauma. All preliminary resuscitation measures have been carried out. On examination patient is noticed to have a deformed thigh. Pulse is 120/min and BP diastolic is 60-mmHg. What is the initial management step?
467. Patient coming to A&E with polytrauma. All preliminary resuscitation measures have been carried out. On examination patient is drowsy and appears confused. Pulse is 60/min and BP is 150/110-mmHg. How do you proceed next?

Answers: Management of Trauma Case

465. (E)
X-ray femur. Fracture femur is associated with significant hemorrhaging. It is ruled out by appropriate investigations.

466. (C)
Intravenous fluids. Fracture femur can cause hypovolemia and is likely to required fluid supplementation.

467. (G)
CT head. Increasing blood pressure with decreasing pulse, also called Cushing’s reflex is the result of an increase in intracranial pressure.

Theme: Preventive measure

Options
A. Cirrhosis
B. Hepatocellular carcinoma
C. Infectious mononucleosis
D. Leptospirosis
E. Lyme disease
F. Sclerosing cholangitis
G. Hepatitis A
H. Hepatitis B
I. Hepatitis C

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

468. Careful cleaning and cooking of shellfish.
469. Avoiding swimming in rivers.
470. Immunization of sewage workers.
471. Immunizing health workers in contact with body fluids.
472. Encouraging iv drug users to use needle exchange scheme centres.
473. Immunizing against hepatitis B ….. to prevent no only hepatitis B.

Answers: Preventive Measure

468. (G)
469. (D)
470. (G)
471. (H)
472. (H)
473. (B)

Theme: Pain abdominal film abnormalities

Options
A. Perforated peptic ulcer
B. Hiatus Hernia
C. Large bowel obstruction
D. Chronic pancreatitis
E. Ulcerative colitis
F. Infective colitis
G. Coeliac disease
H. diverticulitis
I. small bowel obstruction
J. Acute pancreatitis
K. Tropical sprue

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

474. A 50-year-old male presents with gradual central abdominal pain with copious vomiting. On examination weak pulse at 120/min, rigid abdomen with generalized tenderness. Pain abdominal X-ray shows absence of psoas shadow and meteorism sign over the epigastric region.
475. A 45-year-old female, known case of Crohn’s disease, presents with colicky abdominal pain preceded by nausea and vomiting. Supine AXR shows central gas shadows and erect AXR shows air fluid levels.
476. A 35-year-old female presents with fever, weight loss and severe bloody diarrhoea. On examination weak pulse 120/min, BP 85/55-mmHg and marked tenderness over lower abdomen with distension. AXR shows wide colon with loss of normal haustral pattern and absence of feces.
477. A 25-year-old man presents with fever, colicky abdominal pain and profuse bloody diarrhoea. He gives history of previous such episodes which subsided spontaneously without treatment. AXR shows air in the colonic wall.
478. A 38-year-old male presents with marked weight loss and epigastric pain, which bores through to the back and is relived by local application of heat. AXR shows speckled calcification is epigastric region. Biochemistry shows increased blood sugar and normal serum amylase.

Answers: Pain Abdominal Film Abnormalities

474. (J)
Self perpetuating acute inflammation of pancreas. Gradual or sudden severe central abdominal pain radiating to the back. Sitting forward may give relief. Causes: Gallstones, alcohol, hyperlipidemia, Polyarteritis nodosa, azathioprine, and diuretics.

475. (I)
Features: Pain, distension, vomiting & constipation.

476. (E)
Recurrent inflammatory disease of the large intestines always involving the rectum. Commonest cause of prolonged bloody diarrhoea. Diagnosis: Sigmoidoscopy, biopsy, barium enema.

477. (F)
Infective colitis caused by gas forming organisms.

478. (D)
Characterized by recurrent abdominal pain, steatorrhea, weight loss and diabetes mellitus. Pain radiates to the back. Mainly caused by chronic alcohol abuse.

Theme: Diagnosis of musculoskeletal pain

Options
A. Malingering
B. Chondroma
C. Spondylosis
D. Spondylolisthesis
E. Pyogenic infection
F. Disc prolapse
G. Stress fracture
H. Pathological Fracture
I. Osteoid Osteoma
J. Myositis ossificans
K. Scheuermann’s disease
L. Calvé’s disease
M. Brodie’s abscess
N. Overuse injury
O. Malignant metastasis

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

479. A 24-year-old man while lifting his luggage develops severe back pain, which is made worse by straining. He is unable to straighten up with numbness in the left leg.
480. A 14-year-old girl noted for playing truant from school, otherwise fit complains of backache and fatigue. Her parents are suspicious and also notice that the girl is increasingly becoming round shouldered. On examination movements are normal and a smooth hump in the thoracic region is seen.
481. Following an injury, a 27-year-old youth gradually developed a tender swelling near the elbow joint. X-rays show a fluffy density in the soft tissue near the joint.
482. A 28-year-old man complains of persistent pain in his right lower leg. He is an avid weight lifter and ignores the pain. He had been advised earlier by a physiotherapist to exercise in moderation. He also notices some wasting of the affected area a few days later. On subsequent X-ray examination a radiolucent area in the right tibia with surrounding sclerosis is seen.
483. A 55-year-old man present with severe diffuse back pain, impotence and cramps and burning of the lower limbs. He has a long history of back pain and invasive investigations.

Answers: Diagnosis of Musculoskeletal Pain

479. (F)
Treatment with analgesics and physiotherapy. With extensive neurological sings and cauda equina syndrome, surgery advocated.

480. (K)
Scheuermann’s disease.

481. (J)
Myositis ossificans.

482. (I)
Osteoid osteoma.

483. (O)
Malignant metastasis.

by **drwatson** » Mon Nov 29, 2010 2:21 pm

Theme: Diagnosis of lesions around the eye

Options
A. Malignant melanoma
B. Dacryoadenitis
C. Dacryocystitis
D. Molluscum contagiosum
E. Viral wart
F. Basal cell carcinoma
G. Squamous cell carcinoma
H. Stye
I. Chalazion
J. Xanthelasma
K. Xanthoma

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

484. A 60-year-old woman presents with a pearly nodular lesion on the right lower eyelid. A central ulcer is seen.
485. A 25-year-old man with a mildly tender smooth firm mass at the inner aspect of the lower lid.
486. A 20-year-old youth presents with a painful reddish pimple on lid margin.
487. A 40-year-old man presents with a painful swelling arising acutely in the superolateral aspect of the right upper lid.
488. A 55-year-old lady with soft yellowish skin lesions around both eyes.
489. A 5-year-old boy with small painless umbilicated papules around the eyes.

Answers: Diagnosis of Lesions around the Eye

484. (F)
Basal cell CA
There are several clinical types of BCC. The most common is noduloulcerative BCC, which begins as a small, pearly nodule, often with small telangiectatic vessels on its surface. The nodule grows slowly and may undergo central ulceration. Various amounts of melanin may be present in the tumour; tumors with a heavier accumulation are referred to as pigmented BCC. Superficial BCC consists of one or several erythematous, scaling plaques that slowly enlarge.

485. (I)
Chalazion (hordeolum internum)
A chalazion is a painless, granulomatous inflammation of a meibomian gland that produces a peal like nodule within the eyelid. It can be incised and drained, or injected with glucocorticoids.

486. (H)
Stye (hordeolum externum)
An external hordeolum (sty) is caused by staphylococcal infection of the superficial accessory glands of Zeis or Moll located in the eyelid margins.

487. (B)
Dacryoadenitis

488. (J)
Xanthelasma
Yellow-colored cutaneous papules or plaques, xanthelasma are found on the eyelids, whereas tendon xanthomas are frequently associated with the achillis and extensor finger tendons; The least specific sign for hyperlipidemia is xanthelasma because at least 50 percent of the patients with this finding have normal lipid profiles.

489. (D)
Molluscum contagiosum
A benign disease characterized by pearly, flesh-colored, umbilicated skin lesions 2 to 5 mm in diameter. The infection can be transmitted by closed contact, including sexual intercourse. Lesions typically occur in the genital region but can be found anywhere on the body except the palms and the soles. In most cases the disease is self-limited and has no systemic complications. Develops especially often in association with the advanced stages of HIV infection.

Theme: Diagnosis of joint pains

A. Ankylosing spondylitis
B. Gouty arthritis
C. osteoarthritis
D. Osteochondritis dissecans
E. Perthes disease
F. Polymyalgia rheumatica
G. Pseudogout
H. Psoriatic arthropathy
I. Reiter’s disease
J. Rheumatoid arthritis
K. Septic arthritis
L. Systemic lupus erythematosus

For each question below, choose the SINGLE most likely answer form the above list of options. Each option may be used once, more than once, or not at all.

490. A 28-year-old male comes with painful knees and ankles with a rash on his glans penis. He has a history of urethritis due to chlamydia trachomatis.
491. A 22-year-old male develops pain and stiffness of lower back for 6 months. Examination reveals pain over both the sacroiliac joints.
492. A 69-year-old diabetic lady has fever and pain in right knee for 1 day with chills and rigors.
493. A 62-year-old lady presents with severe pain stiffness in muscles of shoulders pelvis for 3 weeks, which is worse in the mornings. ESR is raised.
494. A 65-year-old woman has an insidious onset of pain affecting the distal joints of upper limbs symmetrically. On examination, tender interphalangeal joints with deformity.
495. A 20-year-old football player presents with swollen left knee with locking. He complains of pain after exercise. Examination shows wasting over the quadriceps and lateral aspect of the joint.

by **drwatson** » Mon Nov 29, 2010 2:24 pm

Answers: Diagnosis of Joint Pains

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490. (I) The triad of arthritis, urethritis, and conjunctivitis, became known as Reiter’s syndrome, often occurring with additional mucocutaneous lesions. A similar spectrum of clinical manifestations can be triggered by enteric infection with any of several Shigella, Salmonella, Yersinia, & Campylobacter species, by genital infection with Chlamydia trachomatis. Since most patients with spondyloarthropathy do not have the classic features of Reiter’s syndrome, it has become customary to employ the terms reactive arthritis. Constitutional symptoms are common, including fatigue, malaise, fever, & weight loss. The musculoskeletal symptoms are usually acute in onset. Arthritis is usually asymmetric & additive. The joints of the lower extremities, especially the knee, ankle, & subtalar, metatarsophalangeal, & toe interphalangeal joints, are the most common sites of involvement, tendinitis & fascitis are particularly characteristic lesions. Urogenital lesions may occur throughout the course of the disease. In males, urethritis may be marked or relatively asymptomatic. Prostatitis is also common. Similarly, in females, cervicitis or salpingitis may be caused. Ocular disease is common, ranging from transient, asymptomatic conjunctivitis to an aggressive anterior uveitis. Mucocutaneous lesions are frequent. Oral ulcers tend to be superficial, transient, & often asymptomatic. The characteristic skin, lesions, keratoderma blenorrhagica, consist of vesicles that become hyperkeratotic, ultimately forming a crust before disappearing. They are most common on the palms & soles but may occur elsewhere.
491. (A) The symptoms of the disease are usually first noticed in late adolescence or early adulthood consisting of low-back morning stiffness which becomes per sistent within months. Arthritis in the hips & shoulders (“root” joints) occurs in 25 to 35 percent of patients, in many cases early in the disease course. The most common extraarticular manifestation is acute anterior uveitis, which can antedate the spondylitis. Aortic insufficiency, sometimes producing symptoms of congestive heart failure, occurs in a few percent of patients, occasionally early in the course of the spinal disease. Up to half the patients have inflammation in the colon or ileum. This is usually asymptomatic, but in 5 to 10 percent of patients with AS, frank IBD will develop. The HLA-B27 gene is present in approximately 90 percent of patients with AS. X-ray shows “squaring” of the vertebral bodies. Exercise increases mobility & improves function. Most patients require anti-inflammatory agents to achieve sufficient symptomatic relief to be able to remain functional & carry out the exercise program.
492. (K) Ninety percent of patients present with involvement of a single joint: most commonly the knee. The usual presentation consists of moderate to severe pain that is uniform around the joint, effusion, muscle spasm, & decreased range of motion. Fever in the range of 38.3 to 38.90C (101 to 1020F). A focus of extraarticular infection, such as a boil or pneumonia, should be sought. Peripheral-blood leukocytosis & a left shift are common findings. Specimens of peripheral blood & synovial fluid should be obtained before antibiotics are administered. Blood cultures are positive in up to 50 percent of S. aureus infections but are less frequently positive in infections due to other organism. The synovial fluid is turbid, serosanguineous, or frankly purulent. Cultures of synovial fluid are positive in more than 90 percent of cases. Prompt administration of systemic antibiotics & drainage of the involved joint can prevent destruction of cartilage, postinfectious degenerative arthritis, joint instability, or deformity. A third-generation cephalosporin such as cefotaxime (1 g every 8 h) an oxacillin (2 g every 4 h) will provide adequate coverage for most infections.
493. (F) The polymyalgia rheumatica syndrome is characterized by stiffness, aching, & pain in the muscles of the neck, shoulders, lower back, hips, & thighs. In patients with involvement of the temporal artery, headache is the predominant symptom & may be associated with a tender, thickened, or nodular artery, which may pulsate early in the disease but become occluded later. Scalp pain & claudication of the jaw & tongue may occur. A well-recognized & dreaded complication of temporal arteritis, particularly in untreated patients, is ocular involvement due primarily to ischemic optic neuritis, which may lead to serious visual symptoms, even sudden blindness in some patiens. Characteristic laboratory findings in addition to the elevated ESR include a normochromic or slightly hypochromic anaemia. Levels of enzymes indicative of muscle damage such as serum creatine kinase are not elevated. The diagnosis is confirmed by biopsy of the temporal artery. Since involvement of the vessel may be segmental, the diagnosis may be missed on routine biopsy; serial sectioning of biopsy specimens is recommended. Temporal arteritis & its associated symptoms are sensitive to glucocorticoid therapy.
494. (J) Rheumatoid arthritis RA most often causes symmetric arthritis with characteristic involvement of certain specific joints such as the proximal in terphalangeal & metacarpophalangeal joints. The distal interphalangeal joints are realer involved. Synovitis of the wrist joints is a nearly uniform feature of RA & may lead to limitation of motion, deformity, & median nerve entrapment (carpal tunnel syndrome). Characteristic deformities of the hand include “Z” deformity, swan-neck deformity & boutonnière deformity Rheumatoid nodules develop in 20 to 30 percent of persons with Ra. Clinical weakness & atrophy of skeletal muscle are common. Rheumatoid vasculitis can cause polyneuropathy & mononeuritis multiplex, cutaneous ulceration & dermal necrosis, digital gangrene, & visceral infarction. Pleuropulmonary manifestations, which are more commonly observed in men, include pleural disease, interstitial fibrosis, pleuropulmonary nodules, pneumonitis, & arteritis. Rheumatoid factors, which are autoantibodies reactive with the Fc portion of 1gG, are found in more than two-thirds of adults with the disease. Widely utilized test largely detec IgM rheumatoid factors. The presence of rheumatoid factor does not establish the diagnosis of RA but can be of prognostic significance. The erythrocyte sedimentation rate is increased in nearly all patients with active RA. Juxta-articular osteopenia may become apparent within weeks of onset. Loss of articular cartilage & bone erosion develop after months of sustained activity.
495. (D) Osteochondritis dissecans.

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