PLAB EMQs

[drwatson]

Theme: Diagnosis of pediatric emergencies

Options
A. Metabolic encephalopathy
B. Brain herniation
C. Raised intracranial pressure
D. Heat stroke
E. Reye’s syndrome
F. Hypovolemic shock
G. Septicemic shock
H. Cardiogenic shock
I. Cardiac arrest
J. Drug toxicity
K. Hypoglycemia
L. Toxic shock 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.

496. A 12-year-old school girl has high fever with chills and sore throat. She has been passing loose watery stools. On examination, temperature is 38.70C. pulse is 130/min and BP is 90/60-mmHg. A generalized desquamative rash is noted all over the body.
497. An 8 months old infant is seen with high fever, chills and rigors of 8 hours duration. On examination child is irritable, crying excessively and is progressively getting drowsy. A pink macular rash is noticed all over the trunk and limbs.
498. A 5-year-old boy was observed by his mother to have a poor appetite since 2 weeks. He has since then complained of abdominal pains and vomited on several occasions. He progressively became drowsy and confused, slept throughout the day and stayed awake at nights. On examination, he was drowsy and jaundiced. A flapping tremor was demonstrable.
499. A 12-year-old girl on summer holidays with her family in Cyprus suddenly collapses in the beach. She is weak and drowsy. She is admitted in a local hospital. On assessment, her temperature is 38.8oC, pulse of 100/min and BP is 106/70-mmHg. She is given antipyretics and started on dextrose infusions. Her condition deteriorates and she becomes comatose with renal shutdown. Pulse is now 140/min and BP has fallen to 74/40-mmHg. On catheterization around 100ml of dark brown urine is collected.
500. A 2-year-old girl develops fever for which she is given crushed aspirin tablets by her mother. The fever persists and she becomes drowsy and hypotonic and then lapses into coma.



Answers: Diagnosis of Pediatric Emergencies

496. (L)
A severe septicemic illness with shock and a desquamative rash in a teenage girl is highly suggestive of toxic shock syndrome from tampons.



497. (G)
Meningococcal septicemia and septicemic shock. Always exclude meningococcus in any child with fever and rash. This is because it kills quickly and delay in commencing penicillin can be fatal.



498. (A)
This child is developing liver failure. Reversal of sleep rhythm and flapping tremor points to a liver or renal failure. The presence of jaundice narrows it to the liver.



499. (D)
This is heat stroke. The deterioration in her clinical state overnight was contributed to by the use of dextrose infusions alone rather than dextrose and saline. The brown urine is due to myoglobinuria and will worsen the hypovolemic renal failure. She is best managed in an ITU setting.



500. (E)
Fever, hypotonia and coma in a child of this age, who has used aspirin should make you think of Reye’s syndrome.



Theme: Investigation of abdominal pain in childhood

Options
A. Plain X-ray of the abdomen
B. HIV screening
C. Genotype
D. Upper gastrointestinal endoscopy
E. Factor VIII screen
F. No investigations required
G. Psychological evaluation
H. Electrolytes and urea and creatinine
I. Examination of urinary sediments
J. Blood sugar
K. Chest X-ray
L. Serum lead estimation
M. Stool for occult blood
N. Abdominal ultrasound

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.

501. Eight-month old infant with episodic crying, pulling up of the legs, vomiting and the passage of bright red blood per rectum. A sausage shaped mass is palpable per abdomen.
502. A mother, worried that her six-month old child is not growing, brings her to the outpatients. She has been treated twice for pneumonia. She has been regurgitating her feeds with distress and turns blue after feeding.
503. A 3year old Jamaican child has been having recurrent painful episodes in the abdomen and limbs. On examination, she is mildly pale and jaundiced and diffusely tender all over the abdomen.
504. An 8-year-old boy complains of fever with chills and rigors, cough with mucoid sputum, and right sided upper abdominal pains. There is no vomiting or diarrhoea. On examination, he is toxic, and jaundiced. There is vague tenderness and mild guarding in the right hypochondrium.
505. A 7-year-old boy has been complaining of repeated episodes of abdominal pains. Parents have newly migrated to UK from South Africa. Appendicitis, colitis and helminthiasis have been queried on different occasions. He has had frequent hospital admissions and extensive investigations and as a result, he has been unable to settle down in his new school. The pain is located in the left iliac fossa and radiates to the right hypochondrium. Abdominal examination; intensely tender in all areas but there is no guarding or rebound. Rest of the systems are normal.



Answers: Investigation of Abdominal Pain in Childhood

501. (A)
The infant has intussusception. Barium enema would be the first choice but since it isn’t in the answers an x ray would be the most appropriate choice ‘ claw sign’.



502. (D)
Upper GI endoscopy is indicated for esophageal atresia and tracheoesophageal fistula.



503. (C)
Genotype for sickle cell disease-other causes of medical acute abdomen eg. diabetes, Henoch-Schönlein purpura, acute intermittent porphyria, scleroderma etc.



504. (K)
Pneumonia may present with jaundice and a septicemic illness.



505. (G)
This boy has recently moved to a new environment, a new school, and is now presenting with a pattern of abdominal pain that does not conform to a definite pathology. Each episode allows him time away from school. Is he unhappy, perhaps malingering. He should have a psychological evaluation. There are no fevers so Familial Mediterranean fever is not likely.



Theme: Investigation of abdominal pain in childhood

Options
A. Plain X-ray of the abdomen
B. HIV screening
C. Genotype
D. Upper gastrointestinal endoscopy
E. Factor VIII screen
F. No investigations required
G. Psychological evaluation
H. Electrolytes and urea and creatinine
I. Examination of urinary sediments
J. Blood sugar
K. Chest X-ray
L. Serum lead estimation
M. Stool for occult blood
N. Abdominal ultrasound

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.

506. A 12-year-old boy is woken up regularly at night by a gnawing epigastric pain, which is only relieved by eating. Except for epigastric tenderness, examination of the abdomen and rest of the systems are normal.
507. A 10-year-old hemophiliac complains of a sudden onset of right-sided upper abdominal pain, which radiates to the back on the right. This is followed two days later by a linear copy of vesicles over the site of the pain. The rest of the abdomen is not tender.
508. A 5-year-old boy has fever, cough and running nose. Three days after this, he develops a several abdominal pain. His mother notices a purples rash over the buttocks and legs. On closer look at the rashes is observed that they do not fade on pressure.
509. A 7-year-old boy complains of colicky abdominal pain. His parents report that he has been acting strangely latterly, eating objects like paper and clothes.
510. A 12-year-old girl reports to her mother that she has been having cramp-like lower abdominal pains, nausea and vomiting. This is followed the next day by the passage of blood per vagina. A similar sequence of pain and bleeding occurred five weeks ago and she is frightened that she may be dying.



Answers: Investigation of abdominal pain in childhood

506. (D)
Peptic ulcer; upper GI endoscopy.



507. (B)
Hemophiliac, blood transfusion, HIV, herpes zoster. Pain comes before the rash so may be mistaken for an acute abdomen.



508. (I)
Henoch Schönlein purpura.



509. (L)
Lead toxicity.



510. (F)
She has just attained menarche. Reassurance and a talk will help.



Theme: Management in epidemiological cases

Options
A. Barrier nursing
B. Contact racing
C. Quarantine
D. Refer to infectious disease consultant
E. Vaccination with Immunoglobulin
F. Isolation
G. Prophylaxis with Rifampicin

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.

511. A girl develops diarrhea after returning from a holiday to India. She had been to her grand father, who owns a restaurant there.
512. A pregnant lady says that she had a contact with a child who was diagnosed of suffering from rubella.
513. A child with fever develops erythematous maculopapular vascular rash.
514. A boy’s friend diagnosed of having meningococcal infection, mother is worried about her son getting the infection.



Answers: Management in Epidemiological Cases

511. (D)




512. (E)




513. (F)
Suspected measles infection for which isolation prevents risk of transmission to others.




514. (G)



Theme: Abnormal movements and movement disorders

A. Sydenham’s Chorea
B. Hemiballismus
C. Tics
D. Myoclonus
E. Dystonia
F. Wilson’s Disease
G. Athetosis
H. Parkinsonism
I. Tardive dyskinesia
J. Gilles de la Tourette’s syndrome
K. Huntington’s chorea
L. Akathisia

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.

515. A 14-year-old boy presenting with dysarthria, tremor, dysphagia and mental retardation. On examination has slow writhing movements of his left arm and leg.
516. An 18-year-old has frequent involuntary contractions of facial muscles, which make him wink or pout. He also has occasional aggressive verbal outbursts with searing.
517. A 45-year-old male presents with jerky, purposeless hand movements. His wife reports that he has become increasingly irritable and forgetful of late. His late uncle was also similarly affected.
518. A 60-year-old diabetic complains of involuntary movements of his left arm and leg. O/E, he is seen to make sudden violent kicking movements.
519. A 30-year-old schizophrenic male on antipsychotic medication is brought to A&E with restlessness and agitation. During overnight observation in the ward he is found to be frequently getting in and out of his bed with occasional pacing about in the room.
520. A 55-year-old woman on treatment for chronic schizophrenia complains of continuous involuntary movements of her mouth and tongues. On examination noticed to make frequent grimacing and chewing movements.



Answers: Abnormal Movements And Movement Disorders

515. (F)
Also known as hepatolenticular degeneration. Due to deposition of copper in liver brain & basal ganglia.



516. (J)
Usually begins in childhood and can present with wide varicty of symptoms.



517. (K)
Autosomal dominant. Insidious onset. Rapidly progressive to death.



518. (B)
Recognized association with Diabetes.



519. (L)
Side effects of neuroleptics. Can drive the patient to suicide in rare instances.



520. (I)
Adverse affects of neuroleptics. Treated with Tetrabenazine.

[drwatson]

Theme: Common or important adverse effect of drugs

A. Amiodarone
B. Amitriptyline
C. Atenolol
D. Captopril
E. Carbimazole
F. Chlorpromazine
G. Indomethacin
H. Lithium carbonate
I. Nifedipine
J. Prednisolone
K. Simvastatin
L. Sulfasalazine

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.

521. A patient has sustained a Colles’ fracture. For some time she has noticed weight gain, thirst and mood swings.
522. A patient has become prone to sunburn even after moderate exposure to the sun. He notices a grayish discoloration of his skin.
523. A patient complains of wheezing on exertion. He has also become impotent.
524. A patient complains of painful, swollen gums that bleed on brushing.
525. A patient develops a sore throat and is found to be neutropenic.
526. A patient develops painful, tender shoulder and thigh muscles. His creatine kinase is markedly elevated.



Answers: Common Or Important Adverse Effect of Drugs

521. (J)
Iatrogenic clsohinge syndrome.


522. (A)
Causes photosensitivity.


523. (C)
B-blockers induced impotence.


524. (I)
Given hyerestrophy also called by phenytoin.


525. (E)
Always alert & patient on cartinazole about the warming signs of neutropenia like fever, sore threat.


526. (K)
Myotis is a lewgnied application of station dryes.



Theme: Choice of radiological investigations

Options
A. Barium meal
B. Barium enema
C. Barium swallow
D. Ultrasound
E. CT scan
F. MRI
G. SPECT scan
H. HIDA scan
I. Intra venous urogram
J. Tcm DTPA scan
K. Tcm DMSA scan
L. Serum ferritin
M. Liver biopsy

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.

527. Assessment of vascular deficit in stroke.
528. To establish a diagnosis of hiatus hernia.
529. To confirm presence of ectopic pregnancy.
530. To diagnose atresia of biliary ducts.
531. Detection of urinary bladder pathology.
532. To study uptake and excretory pattern of each kidney i.e. renal function.
533. To diagnose hemochromatosis.



Answers: Choice of Radiological Investigations

527. (G)
528. (C)
529. (D)
530. (H)
531. (D)
532. (J)
533. (M)



Theme: Epidemiology

A. PSA screening
B. Mammography
C. High sensitivity test
D. High specificity test
E. Case control study
F. Cohort study
G. Double blind study
H. Gaussian distribution
I. Skewed distribution
J. Causal relationship
K. Evidence based practice

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.

534. Reliably detects subjects having the disease.
535. An example of an effective screening test.
536. Study which generates incidence data.
537. Demonstration of dose-response relationship is a good evidence of this.
538. A distribution where 5% of subjects lie outside the normal distribution curve.
539. “Streptokinase decreases mortality in MI patients”. The above was concluded after studies of numerous researches and is an example of…..



Answers: Epidemiology

534. (C)
535. (B)
536. (F)
537. (J)
538. (H)
539. (K)




Theme: Antidotes in poisoning

Options
A. Flumazenil
B. Pralidoxime
C. Dicobalt edetate
D. Digoxin specific antibody
E. Phytomenadione
F. Dimercaprol
G. Procyclidine
H. Iv Acetylcysteine
I. Naloxone
J. Atropine
K. Antitoxin
L. Glucagon
M. No specific antidote

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.

540. A 23-year-old student presents with diplopia, blurred vision, photophobia and paralysis. His cardiorespiratory status is severely compromised. He does not give history of any overdose but says that the previous night he had canned tuna.
541. A 65-year-old man, on antihypertensive medication, brought to A&E with collapse. He is living alone and was on discontinued treatment for depression. On examination pulse rate is 36/min and BP is 65/40-mmHg. His pulse rate does not pick up following administration of atropine.
542. A 28-year-old woman brought to A&E with fits and shock. She has a characteristic breath of bitter almonds.
543. A 30-year-old male with chronic schizophrenia, on neuroleptic medication, presents to A&E with torticollis, opisthotonus and glossopharyngeal dystonia.
544. A 65-year-old female brought to A&E with sweating and respiratory distress She also complains of salivation, lacrimation, urination and diarrhoea.
545. A 32-year-old woman presents with respirator arrest and severe constipation. On examination she has pinpoint pupils with signs of pulmonary fluid overload.



Answers: Antidotes in Poisoning

540. (K)
Characteristic of botulinum poisoning. Absence of GI symptoms.


541. (L)
Overdose of B-blockers. Glucagon given if atropine fails.


542. (C)
Cyanide poisoning.


543. (G)
Generally responds to Procyclidine.


544. (J)
Cholinergic symptoms probably from OP poisoning.


545. (I)
Given until breathing adequate.



Theme: Diagnosis of skin lesions

A. Pemphigus vulgaris
B. Pyoderma gangrenosum
C. Toxic epidermal necrolysis
D. Pretibial myxoedema
E. Bullous pemphigoid
F. Erythema multiforme
G. Dermatitis herpetiformis
H. Psoriasis
I. Erythema nodosum
J. Erythema marginatum
K. Erythema induratum
L. Seborrheic dermatitis
M. Secondary syphilis

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.

546. A 30-year-old lady developed painful blisters all over her body and buccal mucosa with painful micturition and defaecation. She is a known case of epilepsy on treatment with sodium valproate.
547. A 13year old girl present with an ulcerated rash over her leg. Biopsy done shows localized areas of fat necrosis.
548. A 17-year-old sexually active girl presents with painful, raised red lesions in the front of her shins and forearms. She uses the combined pill for contraceptive cover.
549. A 65-year-old woman presents with 4 months history of tense blisters forming over the trunk and lower limbs which was preceded by itching and burning sensation. There are no lesions in the mouth.
550. A 40-year-old man presents with a 6-month history of pruritus. Examination revealed widespread excoriations with blisters, most of which are ruptured. He is found to have anti-endomysial antibodies.
551. A 35-year-old woman has noticed reddish elevated skin lesions with an edematous appearance over her lower legs. Examination revealed exophthalmos.



Answers: Diagnosis of Skin Lesions
546. (F)
Erythema multiforme is an acute, self-limited inflammatory disorder of skin mucous membranes characterized by distinctive iris or target lesions, usually acrally distributed & often associated with sore throat & malaise. Many drugs, including sulfonamides, penicillin, phenytoin, & phenylbutazone, have been reported to cause. Infectious agents associated with EM include Mycoplasma pneumoniae, Histoplasma capsulatum, Coccidioides immitis, Yersinia enterocolitica, & several viruses. In young adults, infections with herpes simplex are the most common cause of EM. Stevens-Johnson syndrome (SJS) is a blistering disorder that is usually more severe than erythema multiforme. Fever & malaise also occur.

547. (K)
Erythema induratum/nodular vasculitis is an idiopathic disease; however, approximately 25 to 50 percent of patients, polymerase chain reaction (PCR) analysis will demonstrate Mycobacterium tuberculosis complex DNA. The lesions of lupus profundus are found primarily on the face, upper arms, & buttocks (sites of abundant fat) & are seen in both the cutaneous & systemic forms of lupus.

548. (I)
The most common associations are streptococcal infections, upper respiratory infections, sarcoidosis, & inflammatory bowel disease. The less common associations include tuberculosis, histoplasmosis, coccidioidomycosis psittacosis, drugs (oral contraceptives, sulfonamides, aspartame, bromides, iodides), cat-scratch fever, & infections with Yersinia, Salmonella, & Chlamydia.

549. (E)
Bullous pemphigoid (BP) is a subepidermal blistering skin disease usually seen in the elderly. Lesions typically consist of tense blisters on either normal-appearing or erythematous skin. The lesions are usually distributed over the lower abdomen, groin, & flexor surface of the extremities; oral mucosal lesions are found in 10 to 40 percent of patients (as compared to 90% of patients with or mucosal lesions in pemphigus vulgaris). Pruritus may be nonexistent or severe. As lesions evolve, tense blisters tend to rupture & be replaced by flaccid lesions or erosions with or without surmounting crust. Non traumatized blisters heal without scarring. Patients with BP do not have an increased incidence of malignancy.

550. (G)
Dermatitis herpetiformis (DH) is an intensely pruritic, chronic papulovesicular skin disease characterized by lesions symmetrically distributed over extensor surfaces (i.e. elbows, knees, buttocks, back, scalp, & posterior neck). Because pruritus is prominent, patients may present with excoriations & crusted papules but no observable primary lesions. Almost all DH patients have an associated, usually subclinical, gluten-sensitive enteropathy, & more than 90 percent express the HLA-B8/DRw3 & HLA-DQw2 haplotypes.

551. (D)
The dermopathy usually occurs over the dorsum of the legs or feet & is termed localized or pretibial myxedema. It is usually a late phenomenon but is not a manifestation of hypothyroidism. About half of cases occur during the active stage of thyrotoxicosis, & virtually all have ophthalmopathy. The affected area is usually demarcated from normal skin by being raised & thickened & having a peau-d’-orange appearance; it may also be pruritic & hyperpigmented. The most common presentation is a nonpitting edema, but the lesions may be plaque like, nodular, or polypoid in configuration.



Theme: diagnosis of shock & collapse in children

Options
A. Metabolic encephalopathy
B. Brain herniation
C. Raised intracranial pressure
D. Heat stroke
E. Reye’s syndrome
F. Hypovolemic shock
G. Septicemic shock
H. Cardiogenic shock
I. Cardiac arrest
J. Drug toxicity
K. Hypoglycaemia
L. Toxic shock 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.

552. An eight-year-old boy is discovered unconscious in bed in the morning. He lives alone with his divorced unemployed mother. She suffers from depression for which she takes tricyclic antidepressants. She had spent the night partying with friends, leaving the boy home alone. On examination, he is comatose and sweaty, his pulse is irregular and pupils are dialed.
553. An unemployed single parent brings her seven-month-old infant to the emergency. She complains that the child has been irritable and drowsy and has been vomiting. She denies any history of trauma. On examination, there is a right sided subconjunctival hemorrhage and right-sided papillary dilatation. Pulse is 50 beats per minutes and there is papilledema on fundoscopy.
554. A 12-year-old boy is receiving doxorubicin for a rhabdomyosarcoma. On follow-up in the clinic, he is observed to be weak and drowsy. He is not pale. His extremities are cold and clammy and the pulse is barely palpable. Jugular venous pressure is elevated. Blood pressure is 70/50-mmHg. Apex beat is not palpable and heart sounds appear distant.
555. A nine-year old girl complains of excessive urination and thirst. She has progressively become weaker and drowsy. On examination, she is severely dehydrated with a furred-coated tongue. The respiration is rapid and deep.
556. A ten-year old boy has sore throat, catarrh and a milk fever. A few days later he complains of palpitations and weakness. ON examination, his extremities are cold an clammy. Temperature is 37.2oC and pulse rate is 140 beats per minute, with several missed beats. A 3rd heart sound is audible at the apex.



Answers: Diagnosis of Shock and Collapse in Children

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552. (J)
Child of depressed mother on antidepressants. Child was left alone and has ingested the mother’s tablets. Anticholinergic effects (dilated pupils) and cardiac arrhythmias are the threats to life.


553. (C)
This child has raised intracranial pressure. This could have resulted either from neglect – (child falling off a couch and hitting the head) or from physical abuse (excessive shaking injury). Look for other evidence of physical abuse or neglect e.g. unusual fractures, multiple fractures, growth failure, and attitude of the child to the mother. All these must be documented in your notes.


554. (H)
Doxorubicin is a well-known cause of congestive cardiomyopathy and cardiogenic shock.



555. (F)
This is DKA and should be regarded as a hypovolemic shock rather than as metabolic encephalopathy because hypovolemia is the threat to life. Treatment consists of urgent infusion of saline and low dose insuline.



556. (H)
Cardiogenic shock preceded by upper respirator tract infection. Viral myocarditis is likely. Note the temperature pulse dissociation i.e. tachycardia out of proportion to fever. This is classical in carditis. Rheumatic fevers should also be considered but is less likely since the carditis in rheumatic fever seldom proceeds to severe shock.