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Ans. The key is B. First stage starts with softening of cervix with start of opening of cervix and ends when cevix is fully dilated (i.e. 10 cm dilated). [Question is asking stage of labour]. 1o1. A 2yo boy fell off his tricycle and hurt his arm. He got up to start crying, but before there was any sound, he went pale, unconscious and rigid. He recovered after 1-2 mins but remained pale. After an hour he was back to normal. His mother says she was afraid he was going to die, and that he had a similar episode 3 months prior after falling down some steps. What single inv is indicated? a. CT head b. EEG c. CBC d. None e. Skeletal survey Q. 1. What is the key? Q. 2. What is the diagnosis? Ans. 1. The key is D. None. Ans. 2. Diagnosis is breath holding spell. 102. A 29yo woman had just delivered a still born vaginally, following a major placental abruption. Choose the single most likely predisposing factor for developing PPH in this lady? a. Retained product b. DIC c. Fibroid uterus d. Uterine infection e. Large placental site Q. 1. What is the key? Q. 2. What are the causes of this condition here? Ans. 1. The key is B. DIC. Ans. 2. Pregnancy itself is a risk factor for DIC. Placental abruption is a more common cause of DIC. Other causes of pregnancy related DIC are: eclampsia, retention of a dead fetus, amniotic fluid embolism, retained placenta or bacterial sepsis. 103. A 28yo woman has delivered with rotational forceps after an 8h labor and 3h second stage. Choose the single most likely predisposing factor for PPH for this pt? a. Atonic uterus b. Cervical/vaginal trauma c. Retained product d. Preterm labor e. Uterine infection Ans. The key is B. Cervical/vaginal trauma. [complication of forceps delivery]. 104. A 50yo man has had anterior resection of the rectum for carcinoma. He expressed concerns about control of post-op pain in discussions with the anaesthetist before surgery. What is the best management strategy? a. Oral diclofenac b. Oral codeine c. IM morphine d. IM dihydrocodeine e. Ondansetron oral Ans. The key is C. IM morphine. [Some post operative pain is severe pain which needs strong opioid analgesic]. 105. A 73yo male presents with enlarged cervical nodes. He has had recurrent infections over the last year. His conjunctiva is pale. Choose the single cell type you will find on the blood film. a. Granulocyte without blast cells b. Myelofibroblasts c. Plasma cells d. Mature lymphocytes Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. What are the points in favour of your diagnosis? Ans. 1. The key is D. Mature lymphocytes. Ans. 2. The diagnosis is CLL. Ans. 3. It is CLL because of his age (73 yrs), cervical lymphadenpathy, recurrent infections (mature but functionally defective lymphocytes), and pale conjunctiva (anaemia). 106. A 45yo lady has 10m hx of SOB. She is found to have irregularly irregular pulse and loud P2 with fixed splitting and ejection systolic murmur in left 2nd ICS. What is the probable dx? a. TOF b. ASD c. VSD d. PDA e. CoA Q. 1. What is the key? Q. 2. What is the diagnosis? Ans. 1. The key is B. Atrial septal defect. Ans. 2. Diagnosis is ASD with atrial fibrillation. [i) atrial fibrillation = irregularly irregular pulse. ii) ASD = SOB, fixed splitting with loud P2, ESM in pulmonary area]. This picture is typical. One should not misdiagnose SOB, ESM in pulmonary area and loud P2 as pulmonary hypertension (though in elderly this can develop with ASD). 107. A 5m baby present with recurrent vomiting. Mother noticed some of the vomitus is blood stained. Choose the single most likely inv? a. Upper GI endoscopy b. Barium meal c. US d. Colonoscopy e. CT abdomen Ans. The key is A. upper GI endoscopy. 108. A 76yo is treated with HTN. He suffers from pain and redness at the MTP joint of his right big toe. Which of the following anti-HTN cause this symptoms? a. Losartan b. Bendroflumethiazide c. Ramipril d. Bisoprolol e. Verapamil Q. 1. What is the key? Q. 2. What is the diagnosis?

94. A 64yo man has been waking up in the middle of the night to go to the bathroom. He also had difficulty in initiating micturition and complains of dribbling. A dx of BPH was made after a transrectal US guided biopsy and the pt was prepared for a TURP. What electrolyte abnormality is highly likely due to this surgery? a. Hypokalemia b. Hypocalcemia c. Hyperkalemia d. Hyponatremia e. Hypernatremia Q. 1. What is the key? Q. 2. Why this happens? Ans. 1. The key is D. Hyponatremia. Ans. 2. Absorption of fluid used for bladder irrigation to flush out blood clots and IV fluids all may lead to hypervolaemia and dilutional hyponatremia. 95. A 56yo lady has developed severe right sided headache which worsens whenever she comes to bright light since the last 4 days. She feels nauseated, but doesn’t vomit. What is the most likely dx? a. SAH b. Brain tumor c. Migraine d. Cluster headache e. Subdural headache Q. 1. What is the key? Q. 2. What is the type of the given case? Q. 3. What are the points in favour of mentioned type? Ans. 1. The key is C. Migraine. Ans. 2. It is migraine without aura. Ans. 3. Criteria of migraine without aura: ≥5 headaches lasting 4-72 hours + nausea/vomiting (or photo/phono-phobia) + any 2 of: i) unilateral ii) pulsating iii) worsen by routine activity [OHCM, 9th edition, page-462]. 96. A 35yo man presented with hematuria, abdominal swelling and has a BP of 190/140. What is the most diagnostic inv? a. Cystoscopy b. USG c. CT d. Renal biopsy e. Urine analysis Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. What will be the USG findings to establish diagnosis in given case? Ans. 1. The key is B. USG. Ans. 2. The diagnosis is ADPKD. Ans. 3. In given case patients age is 35. So the USG diagnostic criteria is: Age 18 – 39 yrs>3 unilateral or, bilateral cysts, 40 – 59 yrs >2 cysts in each kidney, >60 yrs >4 cysts in each kidney. [OHCM, 9th edition, page- 312]. 97. A young man is brought to the ED after an RTA. His GCS on initial evaluation is 6. What is the most appropriate next step? a. CT b. MRI c. IV fluids d. Skull XR e. Secure airway Ans. The key is E. Secure airway. 98. A 65yo man presented with frank hematuria. He has no other urinary symptoms. What is the most appropriate next step that will lead to the dx? a. IVU b. US Abdomen c. Cystoscopy d. Mid-stream urine for culture e. Transrectal US Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. What are the reasons for this diagnosis? Q. 4. If there is painless haematuria in young (say 25-30yrs) what diagnosis will come first? Ans.1. Key is C. Cystoscopy. Ans. 2. Bladder cancer. Ans. 3. Age 65, asymptomatic haematuria. Ans. 4. ADPKD [at the beginning there is very few or no symptoms]. 99. A 30yo woman had a gradual decrease of visual acuity since the last 3 years. Now she has a disability due to very low vision. What’s the dx? a. Glaucoma b. Cataract c. Macular degeneration d. Retinitis pigmentosa e. Keratitis Q. 1. What is the key? Q. 2. Why it is not the other given D/D s? Ans. 1. The key is D. Retinitis pigmentosa. Ans. 2. i) It is not angle closure glaucoma as angle closure glaucoma occurs usually after the age of 50; In open angle glaucoma visual loss is not evenly gradual rather occurs a bit suddenly at its later part. It is not cataract as cataract occurs usually in elderly. In macular degeneration near blindness does not occur rather causes inability to identify face or cannot read small prints; otherwise peripheral vision is not that depressed. In keratitis will be pain, redness, photophobia and vision is ok. 100. A 27yo lady has had an uncomplicated pregnancy so far. She came to the hospital 2h ago after her water broke. The midwife is looking at her now. She has regular contractions. P.V exam revealed 2cm dilated cervix. Vital signs are normal. What stage of labour is she in? a. Second stage b. First stage c. Latent stage d. Third stage e. Active phase

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Ans. The key is C. Polycythemia. [Itching after hot shower; dizziness and angina due to hyperviscosity and splenomegaly are well known features of polycythemia]. 1463. A man presented with carcinoma of the bladder and has been working in factories. He wants to know what dye has caused it. What is the single most likely cause? a. Aniline b. Asbestos c. Latex d. Silica Ans. The key is A. Aniline. [Aniline dye is a well known cause of bladder cancer].

1452. An 87yo woman with a hx of HTN has acute breathlessness. She has a RR=32bpm, widespread lung crackles, pulse=120bpm, BP=160/90mmHg and elevated venous pressure. Her peripheral O2 sat=85%. What is the single most appropriate initial management? a. IV antibiotics b. IV furosemide c. Nitrate infusion d. Neb. Salbutamol e. 100% oxygen Ans. The key is E. 100% oxygen. [Most appropriate initial management is E. 100% oxygen.Oxygen saturation is low. So we have to give oxygen initially]. 1453. A 25yo man presented with painless cervical lymphadenopathy with lethargy, night sweats and itching. What is the single most likely causative factor? a. Lymphoma b. Polycythemia c. IDA d. Uremia e. Drug induced Ans. The key is A. Lymphoma. [Cervical lymphadenopathy, lethargy, night sweats and itching are well known features of lymphoma]. 1454. A 25yo male presents with fever and pain in the right lower thigh of 1m duration. Exam: lower third of his thigh is red, hot and tender. The XR showed new bone formation. What is the most probable dx? a. Osteosarcomoa b. Ewing’s sarcoma c. Tuberculus arthritis d. Exotosis e. Fibrosarcoma Ans. The key is B. Ewing’s sarcoma. 1455. A 76yo man presents with sore throat, local irritation by hot food, dysphagia and a sensation of a lump in his throat. He has a 20y hx of smoking. What is the single most likely dx? a. Nasopharyngeal ca b. Pharyngeal ca c. Sinus squamous cell ca d. Squamous cell laryngeal ca e. Hypopharyngeal ca Ans. The key is B. Pharyngeal Ca. 1456. A 42yo female who is obese comes with severe upper abdominal pain and right shoulder tip pain with a temp=37.8C. She has 5 children. What is the most probable dx? a. ERCP b. LFT c. Serum amylase d. MRCP e. US abdomen Ans. The key is US abdomen. [5 “f”. Fat, female, fair, fourty, fertile = cholecystitis]. 1457. A 37yo laborer comes with hx of redness of left eye with foreign body sensation in the same eye. What is the single most appropriate option? a. Ciliary body b. Sclera c. Conjunctivitis d. Cornea e. Iris Ans. The key is D. Cornea. [Redness with foreign body sensation of eye in a labourer are most likely due to foreign body in cornea]. 1458. An 11yo boy came to the hospital with pain after falling off his bicycle. XR= fx at distal radius with forward angulations. What is the single most probable dx? a. Dinner fork deformity b. Cubitus valgus c. Gun stock deformity d. Garden spade deformity e. Genu valgus Ans. The key is D. Garden spade deformity. 1459. A middle aged man with a lump in front of his neck which moves up while he’s swallowing. US shows a mass replacing the left lobe of thyroid. And spread to the sternocleidomastoid and adjacent muscles. What is the most probable dx? a. Thyroid ca b. Pharyngeal pouch c. Bronchus ca d. Thyroid cyst e. Larynx ca Ans. The key is A. Thyroid Ca. 1460. A 28yo male complains of severe pain while trying to grasp any object. It started since he participated in skiing and had a fall and caught his thumb in the matting. Exam: rupture of the ulnar collateral ligament of MCP joint of the thumb. What is the single most probable deformity? a. Dinner fork deformity b. Game keeper thumb c. Mallet finger d. Gun stock deformity e. Garden spade deformity Ans. The key is B. Game keeper thumb. [Gamekeeper's thumb is an insufficiency of the ulnar collateral ligament (UCL) of the metacarpophalangeal (MCP) joint of the thumb]. 1461. A 25yo male had an injury to the knee while playing football. XR=condylar fx of tibia. What is the single most probable deformity? a. Dinner fork deformity b. Gibbus c. Cubitus valgus d. Garden spade deformity e. Genu valgus Ans. The key is E. Genu valgus. 1462. A 50yo man presents with itching after hot shower with dizziness, chest pain after exercise. Exam: splenomegaly. What is the single most likely causative factor? a. ALL b. Lymphoma c. Polycythemia d. Scabies e. Eczema

1441. A 20yo student who recently visited Asia came to the OPD with complains of low grade fever, night sweats, anorexia and productive cough. Inv: CXR=cavitatory lesions in upper lobes. What is the single most likelt causative organism? a. Mycoplasma b. Klebsiella c. TB d. PCP Ans. The key is C. TB. [Low grade fever, night sweats, anorexia, dry (initially) or productive cough, and upper lobe cavitary lesions are highly suggestive of TB]. 1442. A 35yo man with T1DM is dehydrated with BP=90/50mmHg. What is the single most appropriate initial inv? a. ABG b. CBC c. HbA1c d. LFT e. BUE Ans. The key is A. ABG. [The likely dx is DKA. Among the given options ABG is the most appropriate inv. To demonstrate acidosis]. 1443. A 45yo woman presents with pruritis. Exam: skin pigmentation. Inv: raised ALP and presence of anti-mitochondrial antibodies. What is the single most likely dx? a. Psoriasis b. Scabies c. Atopic eczema d. Dermatitis herpetiformis e. Hyperthyroidism f. Primary biliary cirrhosis Ans. The key is F. Primary biliary cirrhosis. [Pruritus, skin pigmentation (increased amounts of melanin, widely dispersed throughout both epidermis and dermis), raised ALP, and presence of AMA are diagnostic of primary biliary cirrhosis]. 1444. A 60yo man complains of tiredness, lethargy and itching that is severe after a hot bath. He also has nocturia, polyuria and nausea and vomiting. Exam: pallor, pigmentation and generalized edema. What is the single most likely dx? a. Hyperthyroidism b. Lichen planus c. Lymphoma d. Eczema e. Liver failure f. CRF Ans. The key is F. CRF. [Given picture is typical of CRF]. 1445. A 30yo man complains of vague pain in the loin with BP=140/90mmHg. He is found to have proteinuria and hematuria. What is the inv to confirm the dx? a. Abdominal US b. ANCA c. ANA d. Urine microscopy and culture e. Stool culture Ans. The key is A. Abdominal US. [The likely dx is ADPKD for which US is diagnostic investigation]. 1446. A 54yo man comes with sudden onset of palpitations and breathlessness. His HR=164bpm. What is the single most appropriate tx in the acute phase? a. Adenosine b. Metaprolol c. Verapamil d. Amiodarone Ans. The key is A. Adenosine. [Common arrhythmias we encounter are AF, SVT, VT in exams. Here no suggestive feature for AF and SVT is the commonest presentation as in described case. So first we shall give adenosine to establish the diagnosis]. 1447. A 29yo woman has developed an itchy scaly rash particularly over her wrist with fine white streaks overlying the lesion. Her nails have ridges and her buccal mucosa is lined with a lacy white pattern. What is the single most likely dx? a. Psoriasis b. Scabies c. Urtericaria d. Dermatitis herpetiformis e. Hyperthyroidism f. Lichen planus Ans. The key is F. Lichen planus. [“Lacy white pattern” is used as a diagnostic description of lichenplanus]. 1448. The artery that runs in the ant inter-ventricular groove. What is the single most appropriate option? a. Acute marginal branch b. Left ant descending artery c. Coronary sinus d. Circumflex artery e. Right coronary artery Ans. The key is B. Left ant descending artery. 1449. Which virus is transmitted by the fecal-oral route? a. Hep C b. Coxsackie virus c. Dengue d. None of the above Ans. The key is B. Coxsackie virus. 1450. A 40yo woman presented with generalized itching and tiredness for few months. She gave a hx of heavy menstrual periods. Exam: pallor. What is the single most likely causative factor? a. IDA b. Lichen planus c. Dermatitis herpitiformis d. Eczema e. Uremia Ans. The key is A. IDA. [IDA is one of the cause of pruritus. Heavy periods, pallor and tiredness further supports the diagnosis]. 1451. A 7yo child presents with lesions on the trunk. Exam: some lesions are weeping and others are crusted with a red base. What is the causative organism? a. Herpes simplex b. Varicella zoster c. Rubella virus d. Herpes zoster Ans. The key is B. Varicella zoster.

Ans. The key is C. Pleural effusion. [Shipyard worker are exposed to asbestos and presenting case has developed mesothelioma causing pleura thickening and pleural effusion. Though it is usual that in pleural effusion pleural rub reduces or becomes absent but it is also possible to get pleural rub even in pleural effusion and the like diagnosis is pleural effusion here]. 1433. A 67yo female presents with balance prbs. Exam: nystagmus on left lateral gaze, a loss of the left corneal reflex and reduced hearing in the left ear. What is the most likely dx? a. Meniere’s disease b. Acoustic neuroma c. Cerebral abscess d. Pituitary tumor e. Gentamicin Ans. The key is B. Acoustic neuroma. [nystagmus, loss of corneal reflex, hearing loss, balance problem are well known feature of acoustic neuroma]. 1434. A 22yo man reports a 2d hx of hoarseness of voice. He denies any weight loss but he has been smoking for 4yrs. What is the single most appropriate inv? a. None b. Laryngoscopy c. Bronchoscopy d. BAL e. CXR Ans. The key is B. Laryngoscopy. It is a wrong key! Correct key is A. None. [If horseness is of >3 weeks in man >50 yrs and smoker and heavy drinker to rule out cancer do CXR and\or laryngoscopy- NICE guideline]. 1435. A 34yo IVDA (intravenous drug addict) presents with a 4m hx of productive cough. He has lost 10kgs. What is the single most appropriate inv? a. Sputum for AFB b. Laryngoscopy c. Bronchoscopy d. CT neck e. CXR Ans. The key is A. Sputum for AFB. [In IVDA immunity becomes low and easily gets infected with TB]. 1436. A 25yo pt came to the OPD with complaint of fever, malaise, breathlessness, cough and anorexia. His gf has got similar symptoms. He had hx of sore throat and ear discharge a month ago. What is the single most likely causative organism? a. Legionella b. Mycoplasma c. Chlamydia pneumonia d. PCP e. Chlamydia psitacci Ans. The key is C. Chlamydia pneumonia. 1437. A 72yo male presents with acute confusion. He has been in the hosp for 2wks having been treated for a DVT. The nurses have noticed that he became increasingly drowsy. Exam: small scalp laceration, a GCS of 8 and bilateral up-going plantar response. a. Infection toxicity b. Delirium tremens c. Extradural hematoma d. Subdural hematoma e. Electrolyte imbalance Ans. The key is D. Subdural hematoma. [Even trivial head trauma can lead to subdural hematoma. Presence of small scalp laceration, confusion and becoming increasingly drowsy Glasgow coma scale of 8 are suggestive of subdural hematoma]. 1438. A 50yo DM pt came to the OPD with complaint of fever, muscle ache, dry cough and anorexia. Inv: CXR=upper lobe cavitation. What is the single most likely causative organism? a. Legionella b. Mycoplasma c. Staphylococcus d. Klebsiella e. Streptococcus Ans. The key is D. Klebsiella. [Upper lobe cavitation favours Klebsiella pneumonia. Also it is well known that staphylococcal and klebsiella pneumonia are more common in DM than normal person]. 1439. A 20yo 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. What is the most probable dx? a. Mania b. Drug induced psychosis c. Delusion of control d. Schizophrenia e. Korsakoff psychosis Ans. The key is D. Schizophrenia. 1440. A 35yo is agitated and euphoric. He claims to be helping the prime minister with economic policy, although this is not true when checked. What is the most likely dx? a. Mania b. Schizophrenia c. Hypomania d. Drug induced personality disorder e. Delusion of grandeur Ans. The key is E. Delusion of grandeur. Key is wrong! Correct key should be mania. [Agitated, euphoric and delusion of grandiosity makes the likely dx to be “Mania”. Agitation and euphoria are not feature of delusion of grandiosity but mania].

1423. A 63yo male presents after having had a seizure. Exam: alert and oriented. Exam: inattention on the left side and hyperreflexia of the arm. What is the most probable dx? a. Cerebral tumor b. Pituitary adenoma c. Cerebellar abscess d. Huntington’s chorea e. Parkinsonism Ans. The key is A. Cerebral tumour. 1424. A 70yo lady on Raloxifene for osteoporosis has recently to the UK from Australia. She now presents with severe chest pain, SOB and suddenly collapsed in the ED. What is the single most appropriate dx? a. MI b. Aortic dissection c. Pulmonary embolism d. Costochondritis e. Pneumothorax Ans. The key is C. Pulmonary embolism. [Prolonged air travel is a risk factor for pulmonary embolism]. 1425. A 35yo woman complains of hoarseness of voice 3h after partial thyroidectomy. She had no hx of phonation probs before the surgery. What is the single most appropriate inv? a. Laryngoscopy b. Bronchoscopy c. CT neck d. CXR e. Barium swallow Ans. The key is A. Laryngoscopy. [Probable diagnosis is recurrent laryngeal nerve palsy]. 1426. A 40yo pt came to OPD with complaint of fever, pleuritic chest pain, productive cough and painful vesicles around the lips. Exam: temp=38C. He has a hx of splenectomy last yr. What is the single most likely causative organism? a. Pneumococcal pneumonia b. Staphylococcus c. Klebsiella d. Streptococcus e. Chlamydia psitacci Ans. The key is A. Pneumococcal pneumonia. [painful vesicles around the lips is well known association of pneumococcal pneumonia. Also pleuritic chest pain and productive cough are present in pneumococcal pneumonia]. 1227. A 37yo male pt who recently returned back to UK from UAE attends the OPD with complaint of dry cough, breathlessness and anorexia. According to him he had flu like symptoms a week ago. He is slightly confused. Inv: lymphopenia & decreased Na+. CXR: bi-basal consolidation. What is the single most likely causative organism? a. Legionella b. Chlamydia pneumonia c. PCP d. Viral pneumonia e. Chlamydia psitacci Ans. The key is A. Legionella. [H/O travel (staying in AC and watersystem of hotel), lymphopenia, decreased Na+, bi-basal consolidation are well known features of legionnaires disease]. 1228. A 20yo student came to the OPD with complains of headache, malaise, dry cough, joint pain and vomiting. Exam: temp=39C. CXR: patchy consolidation. What is the single most likely causative organism? a. Pneumococcal pneumonia b. Mycoplasma c. Klebsiella d. Streptococcus e. PCP Ans. The key is B. Mycoplasma. 1229. A 45yo man presented to his GP with vague symptoms of headache, proximal muscle weakness and nocturia. Test results show him to be severely HTN (230/130mmHg) and hypokalemic. What is the most probable dx? a. Addison’s disease b. Conn’s disease c. Familial hyperaldosteronism d. Cushing’s disease e. Cushing’s syndrome Ans. The key is B. Conn’s disease. [High BP is often the only presentation of Conn’s syndrome. Loss of K+ in urine leads to hypokalemia which in turn causes muscle weakness and polyuria particularly nocturia]. 1230. A man says his insides are rotting and nobody has buried him. Which term best describes his condition? a. Delusion of nihilism b. Delusion of guilt c. Delusion of persecution d. Incongruent affect e. Clang association Ans. The key is A. Delusion of nihilism. 1431. A man with chronic cough presents with copious purulent sputum. What is the single most dx? a. Bronchitis b. Bronchiectasis c. COPD d. Pneumonia e. Emphysema Ans. The key is B. Bronchiectasis. 1432. A 32yo man working in a shipyard comes with SOB. Exam: dullness on left side of the chest, pain in left side of chest, pleuritic rub and crackles been heard on the same side. What is the single most likely dx? a. Pericarditis b. Pleurisy c. Pleural effusion d. CCF e. TB

Why it is not hiatus hernia? Ans. Differentiating point:-i) In hiatus hernia usually you will get associated GORD ii) Also in hiatus hernia there may be nausea or vomiting. Why it is not pharyngeal pouch? Ans. In pharyngeal pouch there will be halitosis. 1492. A retired ship worker has pleural effusion and pleural thickening on right side with bilateral lung shadowing. What would you do to improve his symptoms? a. Aspiration b. Chest drain c. Chemotherapy d. Diuretic Ans. The key is C. Chemotherapy. It is a wrong key! Correct key is B. Chest drain. [Respond to chemotherapy and life expectancy is poor in mesothelioma. To improve symptoms chest drain should be undertaken]. 1493. An 88yo woman is a known smoker. She had an attack of MI 2y back and is known to have peripheral vascular disease. She presents with an irreducible herniation over the incision region of a surgery which she underwent in her childhood. What is the most appropriate tx? a. Truss b. Elective herniorrhaphy c. Urgent herniorrhaphy d. Elective herniotomy e. Reassure Ans. The key is B. Elective hernioraphy. [Truss can not be used as hernia is irreducible; urgent herniorrhaphy in strangulation; elective herniotomy- in herniotomy the hernia will not subside or recur; only reassure is not an option as irreducibe hernia may become strangulated or may develop intestinal obstruction]. 1494. A 72yo woman who is taking loop diuretics for left ventricular failure. She now is suffering from palpitations and muscle weakness. What is the electrolyte imbalance found? a. Na+=130mmol/L, K+=2.5mmol/L b. Na+=130mmol/L, K+=5.5mmol/L c. Na+=140mmol/L, K+=4.5mmol/L d. Na+=150mmol/L, K+=3.5mmol/L e. None Ans. The key is A. Na+=130mmol/L, K+=2.5mmol/L. [Loop diuretics causes hyponatremia and hypokalemia]. 1495. A young woman who is a marathon runner comes with secondary amenorrhea. Inv: normal LH, FSH and estradiol, prolactin=600. What is the most likely dx? a. Hypothalamic amenorrhea b. Pregnancy c. PCOS d. Prolactinoma e. Anorexia Ans. The key is D. Prolactinoma. It is a wrong key. Correct key is A. Hypothalamic amenorrhea. [Generally in hypothalamic amenorrhea there is slight low level of LH, FSH and Oestrogen and mild elavation of prolactin]. 1496. A 4yo child comes with a sprain in his foot. Hx reveals that the child has had recurrent admissions to the hosp due to severe asthma. What is the most appropriate analgesic? a. Diclofenac sodium b. Ibuprofen c. Paracetamol d. Codeine Ans. The key is C. Paracetamol. 1497. A 34yo pregnant woman, 38wk GA is in labor. She had a long 1st stage and troublesome 2nd stage, has delivered a baby. After her placenta was delivered she had a convulsion. What is the most probable management? a. MgSO4 IV b. Diazepam IV c. IV fluid d. Hydralazine IV e. Anti-epileptic Ans. The key is A. MgSO4 IV. [Eclampsia, tx is IV MgSO4]. 1498. A 23yo woman presents with offensive vaginal discharge. Vaginal pH=4.5. What is the most likely organism? a. Gardenella b. Trichomonas c. Candida d. Mycoplasma Ans. The key is A. Gardenella. 1499. A 62yo man has had ano-rectal pain aggravated by defecation for 3d. Rectal exam: purple, tender lump at the anal verge. Flexible aigmoidoscopy: normal rectal mucosa and hard feces. What is the best management strategy? a. Anal hematoma b. Anal fissure c. Rectal ca d. Diverticulitis e. Angiodysplasia Ans. The key is A. Anal hematoma. 1500. A 43yo presents with severe vertigo on moving sidewards whilst sleeping. What test would you do to confirm the dx? a. Hallpikes maneovure b. Romberg’s test c. Trendelenburg test d. Heel-shin test Ans. The key is A. Hallpike maneovure. [Hallpike maneovure is the preferred method to detect benign positional vertigo].

1483. A pregnant woman returns from Sudan, now presenting with intermittent fever, rigor and seizures. What is the dx? a. TB b. Malaria c. Meningitis d. Lyme disease Ans. The key is B. Malaria. [Intermittent fever is seen in malaria. In meningitis fever is not intermittent]. 1484. A pt is unresponsive and cyanosed. What is the most definitive 1st step in management? a. Chest compressions b. Check airway c. Call 999 d. Mouth to mouth e. Recovery position Ans. The key is B. Check airway. 1485. A man was bitten by a drug addict and comes to the hosp with a wound. What inv should be undertaken? a. Hep C b. Lyme disease c. Hep B d. Syphilis e. Hep A Ans. The key is C. Hepatitis B. 1486. An 18yo woman says that she can’t walk around as she is very big for that room. What is the most likely hallucination? a. Extracampine visual hallucinations b. Liliputian visual hallucinations c. Alice in wonderland syndrome d. Hypnagogic hallucinations Ans. The key is B. Lilliputian visual hallucination. [B. Liliputian visual hallucinations and C. Alice in wonderland syndrome are same]. 1487. A middle aged lady presented with fever, altered sensorium, bleeding gums and jaundice. Labs: deranged renal function tests, normal PT/APTT, fragmented RBCs and low plts. What’s the most likely dx? a. Cholesterol emboli b. HUS c. TTP d. Hepatorenal syndrome e. Sepsis Ans. The key is C. TTP. [Fever and altered sensorium suggest the diagnosis of TTP]. 1488. A child came to the ED with severe asthma and not responding to salbutamol nebulizer and vomiting many times. What is the most appropriate management? a. Salmetrol b. Montelukast c. Prednisolone d. Budesonide inhaler e. Oxygen f. IV salbutamol Ans. The key is A. Salmeterol which is a wrong key!! The correct option is F. IV salbutamol. [In acute attack there is no place for salmeterol. In the given case most appropriate management is IV salbutamol]. 1489. A 73yo woman with skeletal and brain mets from breast ca has worsening low back pain and blurring of vision. She has weakness of her legs, minimal knee and absent ankle tendon reflexes, a palpable bladder, a power of 2/5 at the hip, 3/5 at the knee and ankle, and tenderness over the 2nd lumbar vertebra. There is reduced sensation in the perineum. She has been started on dexamethasone 16mg daily.What is the single most likely cause of her weakness? a. Paraneoplastic neuropathy b. Progression of brain tumor c. PID at L2/L3 d. Spinal cord compression e. Steroid induced myopathy Ans. No key is given! The likely correct option is D. Spinal cord compression. [Brain metastasis induced cerebral oedema can explain blurring of vision secondary to raised intracranial pressure. Rest of the features including weakness can well explain spinal cord compression]. 1490. A 78yo woman presents with unilateral headache and pain on chewing. ESR=70mm/hr. She is on oral steroids. What is the appropriate additional therapy? a. Bisphosphonates b. HRT c. ACEi d. IFN e. IV steroids Ans. The key is A. Bisphosphonates. [Oral steroid can lead to decrease in bone mineral density. To overcome this Bisphosphonate can be administered]. ***1491. A 48yo woman is admitted to the ED with a productive cough and mod fever. She often has central chest pain and she regurgitates undigested food most of the time but doesn’t suffer from acid reflux. These symptoms have been present for the last 3.5m which affects her daily food intake. CXR: air-fluid level behind a normal sized heart. What is the single most likely dx? a. Pharyngeal pouch b. Hiatus hernia c. Bulbar palsy d. Achalasia e. TB Q. 1. What is the key? Q. 2. What are the points in favour? Ans. 1. The key is B. Hiatus hernia. This is a wrong key. Correct key should be D. Achalasia. Ans. 2. Points in favour: Aspiration pneumonia due to retained food and fluid in oesophagus. In achalasia usually there is no acid reflux. Dysphagia for both food and drink. Air-fluid level behind heart.

b. Co-codamol c. IM morphine d. IV ondansetron e. PO ondansetron Ans. The key is D. IV ondensatron. [As there is repeated retching and vomiting pt. cannot keep oral medication down. So IV ondansatron]. 1474. A pt with renal failure has serum K+=7.5, raised creatinine and broad complex tachycardia. What is the most appropriate management? a. Calcium gluconate b. Sodium bicarbonate c. Dialysis d. Furosemide e. Sotalol Ans. The key is A. Calcium gluconate. [Calcium gluconate don’t shift K+ to cell or reduce potassium level but it prevents arrythmogenic action of raised K+ till definitive measure is taken]. 1475. An 18yo lady in her 30th wk of pregnancy is brought to the hospital in an altered sensorium. She is taking slow, shallow breaths and her breath has a fruity smell. An ABG: pH=7.20, urine ketones: +ve. What is the most probable dx? a. HONK b. DKA c. HELLP syndrome d. PIH e. GDM Ans. The key is B. DKA. [Shallow breath and fruity smell with acidosis in ABG and positive ketone body in urine suggests the diagnosis of DKA]. 1476. A 26yo man presented with abdomen distension and pain. His stools have been mucoid and sometimes blood stained. What is the most appropriate inv? a. Stool C&S b. Gastroscopy c. IgG tissue transglutaminase d. Barium meal e. Jejunal biopsy Ans. The key is D. Barium meal. [Probable diagnosis is Crohn’s disease. Can be demonstrated by barium meal]. 1477. An 83yo elderly woman presented in the ED with cough, fever and sneezing. Tx was given but she became confused and again presented with above said symptoms. What is the cause of her condition? a. Aspiration due to confusion b. Alveolar damage due to drugs c. Drug toxicity d. Pneumothorax Ans. The key is A. Aspiration due to confusion. 1478. A 37yo man presents with some raised lesions on the shin. He came with cough and also complains of arthralgia. Exam: bilateral hilar lymphadenopathy and erythema nodosum is present. What is the single most likely cause? a. CD b. UC c. Sarcoidosis d. Streptococcal infection e. TB Ans. The key is B. UC. It is a wrong key! Correct key is C. Sarcoidosis. [Cough, arthralgia, bilateral hilar lymphadenopathy and erythema nodosum are suggestive of sarcoidosis]. 1479. A young lady with cervical ectropion bleeds on touch. What is the most appropriate next inv? a. Transvaginal US b. Cervical smear c. Punch biopsy d. Serum estradiol e. Colposcopy Ans. B. Cervical smear. Wrong key! Correct key is E. colposcopy.[Screening test cervical smear is only done in scheduled time and not in on demand basis. So if it is scheduled now then it can be the option otherwise Colposcopy should be the key!! This is definitely an incomplete question]. 1480. A 28yo man with recent onset of dyspepsia after eating spicy food and alcohol consumption. H. pylori fecal antigen was negative. He returns after 1m with similar symptoms despite being given omeprazole 40mg. What is the single best initial inv? a. Hydrogen breath test b. Gastroscopy c. Barium meal d. None Ans. The key is B. Gastroscopy. 1481. A 35yo woman who usually has 4 days mid-cycle bleeding, had her period 10d ago. She has now presented with spots of blood. Her smear was normal 6m ago. Exam: cervical ectropion which doesn’t bleed on touch. What would you do? a. Cervical smear b. Endocervical swab c. US guided biopsy d. Laparotomy e. Transvaginal US f. Punch biopsy g. Serum estradiol h. Colposcopy Ans. The key is A. Cervical smear. Wrong key! Correct key is colposcopy! [Cervical smear can only be done on scheduled time and not in on need basis. In such case if investigation is needed colposcopy can be done]. *1482. A 7yo boy presents with epistaxis of 2h duration. The bleeding has been controlled. Inv: Plts=210, PT=13, APTT=42, bleeding time=normal. Which of the following is the most likely dx? a. Hemophilia b. Von willebrand disease c. ITP d. Vit K deficiency e. Liver disease f. Anatomical defect Ans. The key is F. Anatomical defect.

1464. A 62yo man presents with left sided hearing loss and tinnitus. He also complains of vomiting and headache. Exam: papilledema and SNHL in the left ear. What is the single most likely dx? a. Meningioma b. Nasopharyngeal ca c. Acoustic neuroma d. Pharyngeal ca e. Meniere’s disease Ans. The key is C. Acoustic neuroma. [SNHL, tinnitus, papilledema (raised intracranial pressure) are suggestive of acoustic neuroma]. 1465. A HIV +ve 55yo man presents with painless lymphadenopathy, fever, night sweats and weight loss. What is the most probable dx? a. Hodgkin’s lymphoma b. NHL c. ALL d. AML e. CML Ans. The key is B. NHL. [NHL is more likely diagnosis in AIDS or immunodeficient state]. 1466. A 22yo man says that he can hear the voice of his deceased uncle telling him that he is being spied on. The pt is distressed by this becoming low in mood and anxious and has not left the house for 2wks. He is starting to drink increasing quantities of alcohol. He is noticed to have thought-block and passivity phenomena. What is the single most suitable med to treat his symptom? a. Diazepam b. Disulfiram c. Fluoxetine d. Lithium e. Olanzapine Ans. The key is E. Olanzapine. [Auditory hallucination, social withdrawal, thought block are features of schizophrenia. So olanzapine is the drug to be prescribed from the given option]. 1467. A middle aged Asian presents with episodes of fever with rigors and chills for last 1yr. Blood film: ring form of plasmodium with schuffners dots in RBCs. What is the drug to eradicate this infection? a. Doxycycline b. Mefloquine c. Proguanil d. Quinine e. Artesunate Ans. The key is B. Mefloquine which is a wrong key! None of the given option is correct!! [Shuffners dot indicate either vivax or ovale infection and the hepatic cycle only can be eradicated by primaquine. So none of the given drugs are the option!! It is a bad recall]. 1468. A 50yo man presents with flight of ideas which are rambling and disinhibited. He is distractable, confused and overactive. What is the most likely dx? a. Dementia b. Mania c. Schizophrenia d. Psychosis e. Acute confusional state Ans. The key is B. Mania. [Flight of ideas, dysinhibition, distractibility, confusion and overactivity are features of mania]. 1469. A pt presents with a lid lag, bulging eyes, opthalmoplegia and thyroid bruit. What inv will you do? a. TFT b. Eye sight c. Tensilon test d. US e. FNAC Ans. The key is TFT. [TFT should be done. Why not FNAC? Thyrotoxicosis is benign and not malignant]. 1470. A 30yo lady complaining of right ear deafness with decreased corneal reflex and past pointing. Acoustic analysis shows SNHL. What is the next most appropriate inv to do? a. CT brain b. CT acoustic canal c. MRI brain d. MRI acoustic canal e. PET brain Ans. The key is MRI brain. This is wrong key! Correct key is D. MRI acoustic canal. 1471. A 29yo woman who returned from Egypt 2wks ago now presents with difficulty in breathing, chest pain, cough and purulent sputum with an episode of blood staining. She is on COCPs. What is the most likely dx? a. Pulmonary embolism b. Pneumonia c. Lung abscess d. Pneumothorax e. Pulmonary edema Ans. The key is B. Pneumonia. [Purulent sputum is the clincher to differentiate pneumonia from pulmonary embolism here]. 1472. A 60yo pt recovering from a surgery for toxic goiter is found to be hypotensive, cyanosed in the recovery room. Exam: neck is tense. There is oozing of blood from the drain. What is the most probable dx? a. Thyroid storm b. Reactionary hemorrhage c. Secondary hemorrhage d. Primary hemorrhage e. Tracheomalacia Ans. No key is given. Correct key is B. Reactionary hemorrhage. [Hemorrhage within 1st 24 hours which usually occurs due to dislodgement of clot or slippage of a ligature]. 1473. A 40yo woman has had varicose vein surgery, planned as a day pt. After the op, she is distressed by repeated retching and vomiting. Her pain is currently well controlled. What is the best management strategy? a. Tramadol

1534. A 60yo DM pt presented with easy fatigability, weakness and numbness of hands and swollen feet. Exam: pedal edema, sensory neuropathy and palpable liver and spleen. Urine: proteinuria. US abdomen: enlarged kidney. Renal biopsy: amorphous homogenous substance that stained red with congo-red. What is the dx? a. DM retinopathy b. Sarcoidosis c. Wilms tumor d. Amyloidosis e. Glycogen storage disease Ans. The key is D. Amyloidosis [Amyloidosis is a common cause of organomegaly. Also in diabetic nephropathy kidneys may be enlarged]. 1535. A 75yo man has urinary symptoms of hesitancy, frequency and nocturia. Rectal exam: large hard prostate. What is the most appropriate inv? a. CA 125 b. CA 153 c. CA 199 d. CEA e. PSA Ans. The key is E. PSA. [Urinary symptoms and hard prostate on PR suggests prostatic cancer for which PSA should be done]. 1536. A child suffering from CF developed pneumonia. Which organism is responsible for this pneumonia? a. H. influenza b. Klebsiella c. S. aureus d. S. pneumonia e. Pseudomonas Ans. The key is E. Pseudomonas. 1537. An obese woman with hx of migraine presented with heavy bleeding during menstruation which is painful and needs contraception too. What is the best possible management for this pt? a. COCP b. Mirena coil c. Copper T d. UAE e. Depo provera Ans. The key is B. Mirena coil. 1538. A 2yo fell on outstretched hand on playground. He presents with pain on base of the thumb. XR=no fx. What is the single most likely dx? a. Colles fx b. Head of radius c. Mellet finger d. Scaphoid fx e. No fx Ans. The key is D. Scaphoid fx. [Scaphoid fracture is often missed in initial x-ray]. 1539. A pt was admitted with increased frequency of passing urine, increased thirst, weakness and muscle cramps. What is the most probable dx? a. Conn’s syndrome b. Cushing’s syndrome c. Pheochromocytoma d. Hyperthyroidism e. Hypoparathyroidism Ans. The key is A. Conn’s syndrome. [There is hypokalemia in Conn’s syndrome. Increased frequency of passing urine and increased thirst are from nephrogenic DI resulted from hypokalemia and hypokalemia also causes weakness and muscle cramps]. 1540. A 69yo male presented with sudden onset of dysphagia. He is neither able to swallow liquid nor solid, he recently had a denture fitting. What is the most probable dx? a. Foreign body b. Plummer vinson syndrome c. Achalasia cardia d. Esophageal rupture e. Esophageal ca 1 Ans. The key is A. Foreign body.

1524. A 25yo man attended in urological OPD has single testis. He was inv and other testis was located in the abdomen. What is the best management plan for this pt? a. Short trial of HCG b. Orchidectomy c. Orchidopexy d. Reassurance e. IV testosterone Ans. The key is C. Orchidectomy. [Ectopic testis is prone to develop testicular cancer and therefore it should be surgically removed]. *1525. A 56yo male who presented with epilepsy like symptoms has been dx with an intracranial space occupying lesion. He now complains of thirst and mild dehydration. His blood glucose is also increased. What is the single most appropriate immediate tx? a. Insulin b. IV fluids c. Stop dexamethasone d. Stop sodium valproate and change to another anti-epileptic Ans. The key is B. IV fluids. 1526. A mother brings her newborn to the hosp concerned about a blue patch on the buttocks. The newborn is of mixed race and was delivered normally. What is the most appropriate management? a. Reassurance b. CBC c. XR d. Plt count Ans. The key is A. Reassurance. [The diagnosis is mongolian blue or spot. Mongolian spot refers to a macular blue-gray pigmentation usually on the sacral area of healthy infants. Mongolian spot is usually present at birth or appears within the first weeks of life. Mongolian spot typically disappears spontaneously within 4 years but can persist for life. It is a benign condition requiring no intervention]. 1527. The ECG of a 65yo shows absent P waves, narrow QRS complex, ventricular rate of 120bpm and irregular R-R interval. What is the most probable dx? a. A-fib b. A-flutter c. SVT d. Mobitz type 1 2nd degree heart block e. Sinus tachycardia Ans. The key ia A. Atrial fibrillation. [In A-fibrillation fibrillatory f waves replaces p waves and R – R interval are irregular]. 1528. The ECG of an 80yo pt of IHD shows sawtooth like waves, QRS complex of 80ms, ventricular rate of 150bpm and regular R-R interval. What is the most probable dx? a. A-fib b. A-flutter c. SVT d. Mobitz type 1 2nd degree heart block e. Sinus tachycardia Ans. The key is B. Atrial flutter. [Sawtoothlike waves and regular R-R interval are diagnostic of atrial flutter]. 1529. A man brings his wife into the ED after finding her unconscious at home. He says at breakfast time she had complained of sudden severe headache. What is the most appropriate inv? a. MRI b. XR c. CT brain d. Carotid Doppler Ans. The key is C. CT brain. [Probable SAH. Among the given option most appropriate is CT brain]. 1530. A 68yo lady with T2DM. Which drug should be prescribed? a. Biguanides b. Sulphonyl urea c. Insulin d. Lifestyle modifications Ans. The key is A. Biguanide. [This is an incomplete question and BMI is needed to decide whether biguanide or sulphonylurea be prescribed]. 1531. In a laparoscopic mesh repair for hernia, when the trochar is inserted at midpoint between umbilicus and ischial spine. What structure will be pierced? a. Linea alba b. Rectus muscle c. Conjoint tendon d. External and internal oblique muscles e. Inguinal ligament Ans. The key is D. External and internal oblique muscles. *1532. A 48yo man has intermittent left sided lower abdominal pain and feels generally unwell. He has lost his appetite and has lost weight. Temp=38.3C and he has BP=190/100mmHg. What is the single inv most likely to lead to dx”? a. Colonoscopy b. Endomysial antibodies c. Fasting serum glucose conc d. TFT e. US abdomen Ans. The key is E. US abdomen. [Probable diagnosis is diverticulitis and preferred investigation from given list is US abdomen]. 1533. A man with DM comes to the ED after he collapsed at home. His GCS=10. What should be the next initial inv for this man? a. Capillary blood sugar b. MRI head c. CT head d. Serum electrolytes Ans. The key is A. Capillary blood sugar. [It may be either hypoglycemic or hyperglycemic coma which can be detected by checking capillary blood sugar].

Ans. The key is D. Alzheimer’s disease. [Pic’s dementia and fronto-temporal dementia are similar in some way (first personality change then dementia) but in pic’s there is odd social behavior like violating etiquettes and says vulgar. In huntington’s disease there is changes in personality, cognition and physical skills at the age of 35-45yrs and there is chorea. In vascular dementia there is multiple progressive infarcts and so neurological features may be associated with features of other vascular disease]. 1516. A 38yo woman with hemophilia who received several blood transfusions a few years ago presents with irritability and increasing memory deficit. She is unable to speak properly. He is on anti-TB tx. What is the single most likely dx? a. Creutzfeldt Jacob disease b. Drug toxicity c. Vascular dementia d. HIV associated dementia e. Space occupying lesion Ans. The key is D. HIV associated dementia. [Blood transfision is the clue for HIV transmission. Immunodeiciency is also responsible for TB]. 1517. An 18yo girl has menorrhagia and dysmenorrhea and requires contraception. What drug will you give her? a. COCP b. Mirena coil c. Copper T d. UAE e. Depo provera Ans. The key is A. COCP. It is a wrong key. Correct key should be B. Mirena coil. 1518. A pt of tuberculous abscess with the hx of prv abscess drainage presented with fever and tenderness between L2/L3 vertebra. Which is the best inv for this pt? a. XR b. CT c. US d. MRI e. Blood culture Ans. The key is D. MRI. [Vertebral collapse from TB infection is better seen on MRI]. 1519. A 4yo child presents with repeated chest infections. He has yellow discoloration of sclera and the mother gives a hx of diarrhea as well. What is the single inv most likely to lead to a dx? a. Sweat chloride test b. Anti-endomysial antiboides c. LFT d. Jejunal biopsy e. TFT Ans. The key is A. Sweat chloride test. [Repeated chest infections, and jaundice suggests dx of cystic fibrosis. In the hepatobiliary system which is damaged in about 25 to 30% of the cystic fibrosis patients, malfunctioning secretion can cause liver disease and gall stones, leading to pain and jaundice. For cystic fibrosis sweat chloride test can be done]. 1520. An 82yo woman has been admitted from a nursing home with dense hemiplegia and homonymous hemianopia. She is dysphasic. What vessel is most likely to be involved? a. Ant cerebral artery b. Mid cerebral artery c. Post cerebral artery d. Internal carotid artery e. Post inf cerebellar artery Ans. The key is B. Mid cerebral artery. [Hemiplegia, homonymous hemianopia, dysphasia these are common features of mid cerebral artery stroke]. 1521. A pt is dx with SIADH. Choose the appropriate biochemical change. a. Plasma Na+ decrease and urine osmolarity increase b. Plasma Na+ decrease and urine osmolarity decrease c. Plasma Na+ increase and urine osmolarity decrease d. Plasma Na+ increase and urine osmolarity increase Ans. The key is A. Plasma Na+ decrease and urine osmolarity increase. 1522. A newborn that is electively intubated at birth and is due for surgery 48h after birth. The condition was suspected on antenatal US on CXR. What is the most likely dx? a. CF b. Congenital diaphragmatic hernia c. Congenital cystic adenomatoid malformation d. RDS e. Alpha 1 antitrypsin deficiency Ans. The key is B. Congenital diaphragmatic hernia. 1523. A 63yo male undergoes abdominal surgery. On Monday morning, 3d post-op, repeat samples confirm serum K+=7.1mmol/l. His ECG shows broad QRS complexes. Which one of the following can be used as an effective tx for this pt’s hyperkalemia? a. Calcium chloride IV b. Calcium gluconate IV c. Insulin subcutaneously d. Furosemide IV Ans. The key is B. Calcium gluconate IV. [Calcium gluconate does not shift potassium into cells or reduce its level but prevents its arrythmogenic effect on heart and buys time till definitive measures are taken].

Ans. The key is E. Depot provera. [Hormone and barrier methods are all acceptable choices but intrauterine devices are not recommended, as they may be associated with uterine bleeding and infection. Depot contraceptive (Depo-Provera®) is safe and has been found to improve the blood picture and reduce pain crises]. 1509. A 70yo pt comes with swelling in the parotid region for the last 10y. Exam: gland is soft and cystic. Choose the most probable dx? a. Pleomorphic adenoma b. Carcinoma of the salivary glands c. Mikulicz’s disease d. Adenoid cystic carcinoma e. Parotid duct stones Ans. The key is D. Adenoid cystic carcinoma. [Pleomorphic adenoma is firm in consistency not soft and cystic. Also adenoid cystic carcinoma progresses slowly and 15 year cervival is 40%]. 1510. A 74yo man has been admitted unconscious with no hx. He has a GCS=6 and a dilated left puil which becomes insensitive to light. What is the single most likely dx? a. Extradural hematoma b. Meningitis c. Opioid OD d. Pontine hemorrhage e. SAH Ans. The key is E. SAH. [Extradural hematoma is very rare in elderly and there occurs lucid interval; Fteatures are not consistent with meningitis. Opioid and pontine hemorrhage causes myosis. So likely dx here is SAH]. 1511. A 27yo man presents to the ED with 2d hx of severe headache and pyrexia (38.9C). CT: petechial hemorrhage in the temporal and inf frontal lobes. What is the most likely dx? a. Brain abscess b. Meningococcal meningitis c. Cerebral malaria d. Herpes simplex encephalitis e. New variant CID Ans. The key is D. Herpes simplex encephalitis. [Petechial hemorrhage in the temporal and inferior frontal lobes are characteristic of Herpes simplex encephalitis]. 1512. A 44yo woman with memory loss, poor concentration and inability to recognize household projects. She has right-handed involuntary writhing movement. There is strong fam hx of similar complain. What is the single most likely dx? a. Pic’s dementia b. Wilson’s disease c. Huntington’s disease d. HIV associated dementia e. Fronto-temporal dementia Ans. The key is C. Huntington’s disease. [A person with Huntington's disease may appear to have a lack of drive, initiative and concentration. Involuntary jerking or writhing movements (chorea). Typical presentation is between 35-55 yrs]. 1513. A 54yo man has collapsed suddenly following a headache. He has hypertension and takes warfarin for prosthetic heart valve. GCS=4 and dilated left pupil. What is the single most likely dx? a. Ant circulation stroke b. Post circulation stroke c. Intracerebral hemorrhage d. Intracerebellar hemorrhage e. Pontine hemorrhage. Ans. The key is C. Intracerebral hemorrhage. [Headache, collapse, and warfarine use makes the dx of intracerebral hemorrhage most likely. “Pointers to bleeding (unreliable!): Meningism, severe headache, and coma within hours.” OHCM]. 1514. A 5wk breast fed baby whose birth weight was 3.5kg and is now 4.5kg is thriving well but is deeply jaundiced. What is the most likely dx? a. Galactosemia b. Breast milk jaundice c. Thalassemia d. Sickle cell disease e. Congenital storage disorder Ans. The key is B. Breast milk jaundice. [Breast milk jaundice is a type of neonatal jaundice associated with breastfeeding. It is characterized by indirect hyperbilirubinemia, presents in the first or second week of life, and can persist for as long as 12 weeks before spontaneous resolution. There is normal thrive and weight gain. In galactosemia there will be lethargy, vomiting, diarrhea and failure to thrive]. 1515. A 71yo man with no prv immediate hx is brought to the ED by his wife who says he has become progressively more forgetful, tends to lose his temper and is emotionally labile. There is no hx of infectious disease or trauma. What’s the single most likely dx? a. Pic’s dementia b. Fronto-temporal dementia c. Huntington’s disease d. Alzheimer’s disease e. Vascular dementia

1501. A 23yo man is having difficulty in speaking following a stab wound to the right of his neck. On being asked to protude his tongue, the tip deviated to the right. Which anatomical site is most likely to be affected? a. Facial nerve b. Hypoglossal nerve c. Vagus nerve d. Trigeminal nerve e. Glossopharyngeal nerve Ans. The key is B. Hypoglossal nerve. [In hypoglossal nerve palsy the tongue will be curved toward the damaged side, combined with the presence of fasciculations or atrophy]. 1502. A girl presents with signs of hyperventilation. What is the most likely ABG derangement? a. pH increased, PCO2 increased b. pH decreased, PCO2 increased c. pH increased, PCO2 decreased d. pH decreased, PCO2 decreased Ans. The key is A. pH increased, PCO2 increased. This is a wrong key. Correct key should be C. pH increased, PCO2 decreased. 1503. A pt presents with skin pigmentation, diarrhea, vomiting, abdominal pain and postural hypotension. What electrolyte abnormality is likely to occur? a. Na+=130, K+=6.5 b. Na+=130, K+=2.5 c. Na+=13, K+=6.0 d. Na+=140, K+=8 e. Na+=130, K+=1.5 Ans. The key is A. Na+=130, K+=6.5. [In Addison’s disease there is low Na+, low Cl-, low CO2 and raised K+]. 1504. A 10yo boy develops nasal bleeding. What is the best way to stop the bleeding from the nose? a. Pressure over base of the nose b. Ice packs c. Pressure over the soft tissues d. Nasal packing e. Surgery Ans. The key is C. Pressure over the soft tissues. 1505. A pt came to the hosp with a complaint of severe chest pain lasting for >1h. Following ECG test, pt revealed to have ST depression. He was already on aspirin. What is the most specific tx for this pt? a. GTN b. Simvastatin c. Clopidogrel d. BB e. LMWH Ans. The key is B. Simvastatin. It is a wrong key. Correct key should be LMWH. [Specific treatment means treatment particularly adapted to the special disease being treated. LMWH is vital to prevent further events or deterioration and seems to be the most specific drug in the given scenario]. 1506. A 69yo woman presents with a sudden onset of weakness of her right arm and leg. She is known to be hypertensive. There has been no headache, LOC, visual, speech or sensory symptoms. Exam: BP=180/90mmHg, pulse=100 and regular heart sounds, no carotid bruit. Higher mental function tests are normal. No apraxia or neglect. Speech, swallowing and sensation are normal. There are no visual field defects. There is a mild facial weakness sparing the forehead. The right arm and leg are flaccid and weak. Reflexes and tone are normal. There is a right extensor plantar response. What is the most likely cause of this pt’s symptoms? a. Cardioembolic stroke b. Lacunar stroke c. Right internal carotid artery atheroembolic stroke d. Right internal carotid artery dissection e. Right vertebral artery atheroembolic stroke Ans. The key is B. Lacunar stroke. [Weakness of right arm and leg. So lesion is on left side. Hence C,D and E can not be the option. Also no AF or carotid artery disease and features are very much consistent with lacunar infarct]. 1507. A 34yo man has an intermittent epigastric pain for 3wks. It is worse by food but helped by some tablets he obtained from the pharmacy. He had a similar episode 3yrs ago and his doctor gave him a course of 3 types of tablets at the time. What is the most appropriate next inv? a. Abdomen US b. Barium meal c. Serum H.Pylori antibodies d. C13 urea breath test e. Upper GI endoscopy Ans. The key is D. C13 urea breath test. [Patient was allright for 3yrs after eradication therapy. Now symptoms again may indicate recurrence of H. Pylori infection which can be demonstrated by C13 urea breath test. Serum antibody persist (IgG) for long and not reliable for recheck]. 1508. A girl with sickle cell anemia has painful bleeding and vaso-occlusive crisis during her periods. What is the best possible management for this pt? a. COCP b. Tranexamic acid c. Copper IUS d. UAE e. Depot provera

e. Tension pneumothorax Ans. The key is A. Aspiration pneumonitis. [Diffuse wheeze and raised temperature favours the diagnosis of aspiration pneumonitis]. 1574. A 23yo female presents with paresthesias and loss of distal pulses in her arms. She is noted to be hypertensive. She describes feeling unwell a month prior with fever and night sweats. What is the most probable dx? a. Kawasaki disease b. Takayasu arteritis c. Buerger’s disease d. Embolism e. Raynaud’s phenomenon Ans. The key is B. Takayasu arteritis [Takayasu arteritis is a granulomatous inflammation of the aorta and its major branches. Criteria: Age of 40 years or younger at disease onset Claudication of the extremities Decreased pulsation of 1 or both brachial arteries Difference of at least 10 mm Hg in systolic blood pressure between arms Bruit over 1 or both subclavian arteries or the abdominal aorta Arteriographic narrowing or occlusion of the entire aorta, its primary branches, or large arteries in the upper or lower extremities that is not due to arteriosclerosis, fibromuscular dysplasia, or other causes]. 1575. A 35yo woman presents with mass in the groin. Exam: mass found just below and lateral to the pubic tubercle. There is no cough impulse and it is irreducible. What is the most probable dx? a. Direct inguinal hernia b. Strangulated hernia c. Femoral hernia d. Saphenavarix e. Femoral aneurysm Ans. The key is C. Femoral hernia. [Mass below and lateral to the pubic tubercle is suggestive of femoral hernia]. 1576. A 30yo woman has injured her left lower chest in a RTA. She has BP=80/50mmHg, pulse=120bpm. Auscultation of chest=bowel sounds present. What is the single most likely dx? a. Diaphragmatic rupture b. Flail chest c. Fx ribs d. Ruptured esophagus e. Tension pneumothorax Ans. The key is A. Diaphragmatic rupture. [Bowel sound present on auscultation of chest following RTA causing lower chest injury is suggestive of diaphragmatic rupture]. 1577. A lady presents with a swelling below the groin crease that can be reduced. There is no med hx of note. What is the most probable dx? a. Inguinal hernia b. Strangulated hernia c. Testicular tumor d. Epidydimal cyst e. Femoral hernia Ans. The key is E. Femoral hernia.