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I have done my AMC1. This is the study note that I made during my study period of a year. I am sharing this note to help you, but not by price. None of these questions are belonged to me but from facebook study group property. I just tried to answers them with reference and share it in file back to you. Good luck to your upcoming exam. JM = John Murtaghs General Practice (5th edition) OHCM = Oxford handbook of Clinical Medicine OHCS = Oxford handbook of Clinical Specialities LJOG = Llewellyn-Jones Fundamentals of Obstetrics and Gynaecology GMP = Good Medical Practice HMCQ = Handbook of Multiple Choice Question TOS = Textbook of Surgery, 3rd Edition Tjandra B&L = Bailey and Love's Short Practice of Surgery 25th Edition

2013 March 13 Mahtab Shafiq.doc

1. A 34 year old man presents very first time with brisk epistaxis. What is the most likely cause? A.foregn body B.Hypertension C.Nasal trauma*** D.Coagulation prob 2. Patient with history of osteoarthritis of knee presents with tender, swollen, shiny knee. What is the most likely cause? A.Gout B.Pseudogout*** C.Septic arthritis D.Reactivearthritus E. Rheumatoid arthritis JM page 346: The finding of calcification of articular cartilage on X-ray examination is usually termed chondrocalcinosis. This is mainly a disorder of the elderly superimposed on an osteoarthritic joint. The acute attack is similar to an acute attack of gout. Risk factors for septic arthritis include: Existing joint problems. Chronic diseases and conditions that affect your joints such as osteoarthritis, gout, rheumatoid arthritis or lupus may increase your risk of septic arthritis. An artificial joint, previous joint surgery and joint injury also increase your risk 3. A true/false selection question about billing method of contraception Avoid intercourse in the follicular phase and 3 days after dryness Peak is the last day of the slippery sensation at the vulva. Ovulation occurs on Peak or up to day 2 past peak and is followed by menstruation 11 to 16 days later. By the end of the third day the ovum is dead.

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4. A male with azospermia and absent vas deference. What is the next investigation for infertility? A.Testosterone B.FSH/LH*** C.Pituitary scan Check CG screening Absence of the vas deferens may be detectable on physical examination and can be confirmed by a transrectal ultrasound (TRUS). If confirmed genetic testing for cystic fibrosis is in order. There is a strong association between unilateral vasal agenesis and ipsilateral renal anomalies due to their common embryological origin. Approximately 25% of men with unilateral vasal agenesis and about 10% with congenital bilateral absence of the vasa deferentia (CBAVD) also have unilateral renal agenesis that may be identified by abdominal ultrasonography. In azoospermic men with unilateral vasal agenesis, transrectal ultrasonography (TRUS) may help to demonstrate an associated contralateral segmental atresia of the vas deferens or seminal vesicle. JM page 1083: Further investigations (if necessary) If azoospermia or severe oligospermia: serum FSH level (if 2.5 times normal, indicates irreversible testicular fai lu re)-this is the most important endocrine test in the assessment of male infertility LH and inhibin (a low inhibin also indicates irreversible failure) anti sperm antibodies (in semen or serum) sperm function tests chromosome analysis: 46 XXY or 46 XXY /46 XY or microdeletion testosterone testicular ultrasound 5. A 24hours after PCI a pt develops 6cm swelling in the inguinal region. InitialMx? A.Compression*** B.Anti thrombin injectin C.FFP D.tranfuse platelets E .do noyhing Study Note by Chie_Kyi Page 2

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6. A 5th day postpartum patient develops vaginal bleeding but afebrile. Patient is allergic to penicillin. No abnormality detected. Which antibiotics will you give? A.ceftri+genta B.Genta+cephotaxime C.Clinda+metro*** 7. Loss of inversion, eversion and dorsiflexion but planter flexion is normal. A. L5*** B. Tibial N C. CPN D. S1 E. Sciatic nerve L5:Toe extensors and flexors, ankle dorsiflexor, everter and inverter, hip abductors L5: ankle dorsiflexion, eversion and inversion + hip abductors HMCQ page : MCQ 2.132 8. Loss of planter and dorsiflexion, inversion and eversion. Which nerve is effected? A. L5 B. Tibial N C. CPN D. S1 E. Sciatic nerve**** 9. Blue hand book Q 3.023 that is trochlear nerve signs. 10. Haloperidol has been given to a patient for agitation and psychosis give doses 3 and 4 times but no effect. What will you do next? A.CBC B.Urine for drug*** C.Haloperdole level Acute problems: single doses of 1 to 5 mg (up to 10 mg) oral or IM, usually repeated every four to six hours, not exceeding an oral dose of 100 mg daily. Doses used for IV injection are usually 5 to 10 mg as a single dose; not exceeding 50 mg daily. The British National Formulary recommends a maximum daily dose of 30 mg total (IM and oral) with a maximum of 18 mg by the IM route. 11. A woman to be found BHCG positive in her results.her husband calls for result; A.Tell him the result B. Ask him to bring his wife for an appointment*** C. No option of donot tell him or refuse him D. Ask the wife to make an appointment to get the results 12. Chronic leg ulcer reason for this= Venous ulcers are classically found in the gaiter area, which is the area from the mid calf to the ankle. Typical venous ulcer with surrounding erythema, hyperpigmentation, and hemosiderin deposits.

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13. Cerebral infarction CT scan. Patient was on warfarin asked for Dx?

The non contrast head CT is often negative (normal) with the first 4 hours of a stroke. It generally takes 4-6 hours for changes of ischemia to manifest on CT. In this patient, at 3 hours the head CT was normal. 1 day later you start to notice blurring of the gray-white differentiation within the anterior right MCA distribution consistent with cytotoxic edema. 3 months later these findings are much more obvious, now with areas of encephalomalacia or volume loss. 14. Cystic fibrosis in first baby what are the chances of second baby to be a CARRIER? A. 1% B. 0.5%*** C. 0.25% to be a carrier - 50% chance to be a normal 25% chance to be disease 25% chance 15. Lots of screening Qs breast,Ovarian and Colorectal carcinomas. 16. A man has weakness of wrist extension with finger extension,brachioradialis jerk normal, power of wrist normal and no other difficulty in movements of hand or forearm muscles. Nerve? Study Note by Chie_Kyi Page 4

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A- PIN B-AIN C- Radial nerve*** D- Median nerve E- Ulnar nerve 17. Coxa vara holding stick Opposite hand, effect foot, 18.Mesenteric ischemia=CT scan was done next? Digoxin level: Nonocclusive mesenteric ischemia induced by digitalis. Numerous endogenous and exogenous humoral factors are capable of affecting the splanchnic circulation. Norepinephrine and high levels of epinephrine produce intense vasoconstriction through the stimulation of adrenergic receptors. Other pharmacologic compounds that decrease splanchnic blood flow include vasopressin, phenylephrine, and digoxin 19. Patient with atrial fibrillation develops mesenteric ischemia 20. SLE in young lady most appro Dx test? DsDNA, 21.Turkish lady MVA CT scan was exactly like recalled by Sumreen Nawaz. 22. Ovarian rupture scenario in young lady 23. Craniopharagioma=N/S etc etc

Recall Dig Oxin

1. A mother brings 8yr old girl re familial hypercholestrolemia. She wants gene testing for her daughter , as there is family hx of IHD deaths and also girl's dad is dx with LDRL gene mutation. What is next? a. do gene testing. b. do pre -test counselling*** c. send girl for LDRL gene mutation test d. send whole family for LDRL gene m test e. send for special dietry specialists. four/5 qs on hemorroids... all diff scenarios , some asking for tx , some fr features . The treatment ofhaemorrhoids is based on three main procedures: rubber band ligation, cryotherapy and sphincterotomy. Injection is now not so favoured while a meta-analysis concluded that rubber band ligation was the most effective non-surgical therapy. Internal hemorrhoids : Grade I: The hemorrhoids do not prolapse Grade II: The hemorrhoids prolapse upon defecation but reduce spontaneously Grade III: The hemorrhoids prolapse upon defecation and must be reduced manually Grade IV: The hemorrhoids are prolapsed and cannot be reduced manually Dietary management consisting of adequate fluid and fiber intake as the primary medical treatment of symptomatic haemorrhoids. Study Note by Chie_Kyi Page 5

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For patients with medically refractory grades I and II hemorrhoids, we recommend an office-based procedure for initial surgical treatment. We recommend rubber band ligation as the initial officebased procedure. Grade III either rubbar band ligation or surgery. For patients with grade IV hemorrhoids or who have combined internal and external hemorrhoids with significant prolapse, we recommend surgical excision. For patients with thrombosed external hemorrhoids, we recommend either observation (oral and topical analgesics, stool softeners, and sitz baths) or excision of overlying skin and clot evaluation, if possible, within 72 hours of onset of symptoms. Definitive treatment is an excision of the external hemorrhoid. i had chest x rays same qs as described by ayesha malik.. (PSYCH) schezophrenia: 1. grandmother is schizophrenic . What is risk in grand child. 0.6 or 6% 2. Schizophrenic man, needing surgery after MVA, he is confused and says no.. What comes here? A. informed consent B. pt autonomy C. some term but in brackets it was written (means to get to end) D. beneficience*** HMCQ page 176: MCQ 2.117: Rational thinking disturbances must be looked for and taken into account: delirium, dementia, intoxications, intoxications, learning disability, illiteracy, effects of medication, mood and psychotic symptoms of delusions, hallucinations and thought disorder may all affect judgement and impair concentration. Mental illness alone does not preclude effective decision making and competence is always context-specific; for example, a patient with depresssion or schizophrenia may fully comprehend the implications of appendicitis or myocardial infarction and be competent to or refuse such treatment. Informed consent is the requirement that physicians share decision-making with patients. Informed consent is an extension of the principle of autonomy, introduced in FPC in the organs block. Informed consent is how physicians operationalize respect for patient autonomy. e.g. Mutual decision-making between the doctor and the patient. This is the broadest definition of informed consent. It involves an open exchange of information, education on options and alternatives for care, and assisting the patient in making a decision that is consistent with his/her values. Non-maleficence: Non-maleficence means to do no harm. Physicians must refrain from providing ineffective treatments or acting with malice toward patients. Beneficence is action that is done for the benefit of others. Beneficent actions can be taken to help prevent or remove harms or to simply improve the situation of others. 3. A man who is brought to you by wife , they were on a tour and he saying people are following him to kill him. They asked what helps in hx(old recall) and then in next TREATMENT. Similar question: A 63 y/o retired man had oversea holiday with his wife and complained that he felt New Zealand CIA was observation them during the holiday. Which of the following condition is most relevant to the patient's condition? a. He drank 2 liter of alcohol per day*** Study Note by Chie_Kyi Page 6

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b. He was caught of using cannabis when he was young c. He has pathologic gambling on holiday d. He suddenly decided to retire on the age of 63 (Psychiatric syndromes, such as severe anxiety, auditory hallucinations, and/or paranoid delusions, can also be experienced during heavy drinking and subsequent withdrawal. ) 4. Chef, confused , yellow fluid oozing from skin q, saying spices & herbs coming out of me otherwise hes well oriented. Poisoning. asked treatment? A. CBT B. indivisual psychotherapy C. drugs*** 5. A girl who admits cannabis addict, but dont want to lose time for next coming exam. What will u do? a. mathadone maintanence b.nalxne maintenence c. send to some group counselling*** d.do nothing Treatment and Rehabilitation of Cannabis Treatment of cannabis use rests on the same principles as treatment of other substances of abuse, abstinence and support. Abstinence can be achieved through direct interventions, such as hospitalization, or through careful monitoring on an outpatient basis by the use of urine drug screens, which can detect cannabis for up to 4 weeks after use. Support can be achieved through the use of individual, family, and group psychotherapies. Education should be a cornerstone for both abstinence and support programs. A patient who does not understand the intellectual reasons for addressing a substance-abuse problem has little motivation to stop. For some patients, an antianxiety drug may be useful for short-term relief of withdrawal symptoms. For other patients, cannabis use may be related to an underlying depressive disorder that may respond to specific antidepressant treatment. 6. A girl who has epilepsy, now her medicines are changed to valproate and lamotrigine recently, she also has history of recurrent UTIs, had amoxicillin 6 weeks back. Now she has developed maculopapular rash, 38C fever. What is the cause? a. valproate side effect b.lamotrigine side effect*** c. septicimia d. amoxi side effect Valporic acid inhibits metabolism of lamotrigine - resulting lamotrigine plasma level increased - and toxicity. The combination has risk of severe dermatological reactions (including SJsyndrome, toxic epidermal necrolysis). Adding lamotrigine to valproate: incidence of rash and other adverse effects. 7. A 16 year old girl who ran from her house a year back, comes after MVA, asks u not to tell her parents about her admission. What will you do? a. tell her parents. b. dont tell and do operation.*** c. taker her consent and do operation. d. ask court 8. same Q as above, askg what comes here, a. pt autonomy*** Study Note by Chie_Kyi Page 7

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b. beneficinece c. use of hospital resouces. 9. A girl who takes shower at night and hear noises.. What is diagnosis? A. delusional disorder B. depression C. Schi*** Similar question: A concerned mother brings her 19 you old university student daughter to the general practice. She is worried her daughter will fail her exams which are in 2 weeks time because she has not been studying for a month. She recently became vegetarian and takes long showers at the middle of the night because she thinks the neighbours are tapping on the walls to prevent her from studying. Most likely cause? A. Tinnitus B. Delusional disorder C. Schizophrenia prodrome*** D. Depression Schizophrenia is characterized by psychosis (loss of contact with reality), hallucinations (false perceptions), delusions (false beliefs), disorganized speech and behavior, flattened affect (restricted range of emotions), cognitive deficits (impaired reasoning and problem solving), and occupational and social dysfunction. The cause is unknown, but evidence for a genetic component is strong. Symptoms usually begin in adolescence or early adulthood. One or more episodes of symptoms must last 6 months before the diagnosis is made. Worldwide, the prevalence of schizophrenia is about 1%. The average age at onset is 18 years in men and 25 years in women. Onset is rare in childhood, but early adolescent or late-life onset (when it is sometimes called paraphrenia) may occur. This is a typical presentation of schizophrenia, where a promising teenager goes off to college or university then declines drastically. 10. Same Q asking treatment? A. CBT B. psychotherapy C. drugs Both the typical and atypical antipsychotic drugs have a beneficial effect on positive symptoms in schizophrenia. However, they differ with regard to negative symptoms. Atypical antipsychotics are much better at combating these. 11. A school teacher passing inapprpriate remarks /sexual beaviour . He becomes angry and doesnt care when confronted by others and still doing it. What is NEXT? there were again diff treatment options. 12. A school teacher who verbally pass sexual comments on his students despite of his collegues advice finds it difficult to change the topic during conversation .WOF is most likely? a)he can interpret the meaning of a phrase b)difficult to do a 3 step task*** c)loss of memory Alternating sequences task: Ask the patient to copy a segment with alternating M s and N s. Perseveration may occur in patients with frontal lobe lesions. Luria's 3-step motor program is a sequential performance of 3 movements, usually the fist-edgepalm test, which is making a fist, Study Note by Chie_Kyi Page 8

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laying the hand on edge, and laying the palm of the hand down on the table. Consider perseveration or failure to perform sequential movements an abnormal response. 12. A nurse giving less morphine Q. what will u do? a. formal complaint to head nurse. b. talks to nurse *** c. nurse supervisor Working with other health care professionals 4.1 Introduction Good relationships with medical colleagues, nurses and other health care professionals strengthen the doctorpatient relationship and enhance patient care. 4.2 Respect for medical colleagues and other health care professionals Good patient care is enhanced when there is mutual respect and clear communication between all health care professionals involved in the care of the patient. Good medical practice involves: 4.2.1 Communicating clearly, effectively, respectfully and promptly with other doctors and health care professionals caring for the patient. 4.2.2 Acknowledging and respecting the contribution of all health care professionals involved in the care of the patient. 4.4 Teamwork Most doctors work closely with a wide range of health care professionals. The care of patients is improved when there is mutual respect and clear communication, as well as an understanding of the responsibilities, capacities, constraints and ethical codes of each others professions. Working in a team does not alter a doctors personal accountability for professional conduct and the care provided. When working in a team, good medical practice involves: 4.4.1 Understanding your particular role in the team and attending to the responsibilities associated with that role. 4.4.2 Advocating for a clear delineation of roles and responsibilities, including that there is a recognised team leader or coordinator. 4.4.3 Communicating effectively with other team members. 4.4.4 Informing patients about the roles of team members. 4.4.5 Acting as a positive role model for team members. 4.4.6 Understanding the nature and consequences of bullying and harassment, and seeking to eliminate such behaviour in the workplace. MED; 1. Wrong filled chart/ paralytic ileus q. 2. A man had a fun night, drank heavily with friends, after drinks, had pizza and then vomited . he felt pain in epigastrium after vomit. Abdomen is mild tender and pain around stero notch. whats dx. A. esophagus rupture*** b. mallory weis c. acute pancreatitis 3. A 50 yrs old man with anemia. What is the most appropriate investigation ? A. FBC B. colonscopy*** C. FOBT D. Endoscopy Study Note by Chie_Kyi Page 9

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JM page 205: Investigations are based on the history and physical examination, including the rectal examination. If G IT bleeding is suspected the faecal occult blood test is not considered very valuable but appropriate investigations include gastroscopy and colonoscopy, small bowel biopsy and small bowel enema. 4. Similar q, man with anemia, asking whats next. a. iron tab b. colonoscopy*** c. check again d biopsy 5. A 35 yr old girl , feeling RUN DOWN AFTER HEAVY WORK... inv everything normal, but Ca 2.65mmol LFTs normal..(normal ca 2.60 was given) . Whats next? a. reassure b. do ca leevels after 2weeks c. do PTH level *** d. do vit D levels. 6. An old woman , bending had sharp point tenderness in back. she had colon ca hx. 2 qs,,, asking for dx , and investigations. a. bone scan b. densitometry c. Ca level d. xray*** Plain films of the lumbar sphie give a good overall assessment of the lumbosacral region. A CT is indicated only in a small selection of patients when conservative treatment fails or nerve root or thecal compression are suspected. Radiography remains the best method for characterizing bone metastases. Bone metastases may be osteolytic, sclerotic, or mixed on radiographs. Xray will show both fracture as well as metastasis lesion. 7. A 45 year old woman had amenorhea for few months, and ten hot flushes every night since then. What will u give? a. ca supplements b. estrogen /progestin*** c. temazepam d.realxation/ yoga Chest xrays, plumber coal miner, smoker , non smokers, silicosis exposure hx, everything was there. 8. A child having 37.4 fever, for 24 hrs,, mild cervical LNs, slightly conested tonsils, mild ear ache. What is most appropriate? a. iv amoxi b. amoxi syrup*** c oral paracetamol d. nothing 9. A child mile stones asked.. Study Note by Chie_Kyi Page 10

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10. one q normal deveopment 11. one was global delay 12. A man going to typhoid endemic area. What is the best advice? A. dont drink non boiled water B. tsetse flies precaution C. doxycycline D. dont shower in streams E. vaccine*** 13. Ovarian ca diagnosed , where is primary site? A. breast B. colon C. stomach *** D. kidneys Stomach> colon 14. Carbamezapine Qs. Interaction with other drugs. Interactions between erythromycin and carbamazepine can cause toxicity. 15. A child with morning headaches , with bilateral hemianopia. dx. a. craniopharngioma*** b, medulloblastoma c. glioma d. other tumors. 16. A 3 year old miserable child with fever 40C, sore throat, cervical LNs, rash, asking for tx? a. steroids b. immunoglobulin *** c. antibiotics d. aspirin Kawasaki has bilateral conjungtivitis, maculopapular rash,dry red lips,erythema oral, erythema palm soles desquamation fingertips, tender mass right hypochondrium. Kawasaki: Early treatment with immunoglobulin and aspirin has been shown to be effective in reducing the prevalence of coronary artery abnormalities. Echocardiography is indicated to detect these aneurysms and determine prognosis. Avoid corticosteroids in these patients. The patients are judged on four criteria, with one point added for each positive criterion:[1] History of fever Tonsillar exudates Tender anterior cervical adenopathy Absence of cough The point system is important in that it dictates management. Guidelines for management state:[1] 0 or 1 points - No antibiotic or throat culture necessary (Risk of strep. infection <10%) 2 or 3 points - Should receive a throat culture and treat with an antibiotic if culture is positive (Risk of strep. infection 32% if 3 criteria, 15% if 2) 4 or 5 points - Treat empirically with an antibiotic (Risk of strep. infection 56%) JM page 787: below if theres sore throat with no cough but fever>=38, tender neck gland, white spot antiviotic indicated Study Note by Chie_Kyi Page 11

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17. warfarin Qs. drug interactions. Category Drugs potentiate warfarin effects Antibiotics Co-trimoxazole, erythromycin, isoniazide, fluconazole, miconazole, ciprofloxacin, itraconazole and tetracycline Cardiac drugs Amiodarone, Clofibrate, propafenone, propranolol, and sulfinpyrazone, quinidine, simvastatin and acetyl salicyclic acid Others Pheylbutazone, piroxicam, acetaminophen (paracetamol), dextropropoxyphene, cimetidine, omeprazole, alcohol (only if concomittent liver disease is present),chloral lydrate, disulfiram, pheytoin, tamoxifen, anabolic steroids, influenza vaccine. 18. A 75 year old woman, brought after fall, confused, on warfarin, bruises on both thighs and buttocks, tropnin, 0.08, ck 1000. What is the diagnosis? A. Recent MI less than 12hrs B. MI in 4 hrs C. Rhabdomyolysis*** 19. 5 or 6 fundoscopies with asking options were , hypertensive , diabetic retinopathies, renal faliure, multi infarct, CRVO. 20. Ingrown toe nail Q. Treatment? Wedge resection was not there remove nail was in opions others were incisions . 21. A man on diff drugs, was admitted with pneumonia, he was given penicillin, he developed maculopapular and vesicular rash in 24hrs, picture was there of his chest and abdomen, rash. What is the diagnosis? a. amoxy allergic rash*** b. candida c. herpes d. chicken pox e. erythema nodsum 22. A man with weakness and fatigue sypmtoms, some strange other symptoms. Patient has waldenstrom macroglobulinemia. What is the treatment? Waldenstrm macroglobulinemia, one of the malignant monoclonal gammopathies, is a chronic, indolent, lymphoproliferative disorder. It is characterized by the presence of a high level of a macroglobulin (immunoglobulin M [IgM]), elevated serum viscosity, and the presence of a lymphoplasmacytic infiltrate in the bone marrow. Symptoms due to hyperviscosity syndrome, which can be life threatening, include the following: 1. Bleeding 2. Dizziness 3. Headache 4. Blurry vision 5. Hearing or visual problems Complications such as hyperviscosity, cytopenias and peripheral neuropathy Chlorambucil is the most common alkylating agent used for indolent lymphoproliferative disorders. Study Note by Chie_Kyi Page 12

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Plasmapheresis (for patients with symptomatic hyperviscosity) Rituximab (anti-CD20 antibody) Purine nucleoside analogues Alkylating agents Thalidomide Bortezomib Everolimus Alemtuzumab Interferon alfa Combination therapies High-dose chemotherapy Bone marrow transplantation

March 16 Ayesha Malik

1.) Patient has resting tremors (not on activity, and subside when he looks at them) and in parenthesis was written (mild tone involvement) but no cogwheel rigidity a. Selegeline b. Benzhexol*** c. Propranolol d. No option for levodopa 2.) Lady has diverticular disease and she has an abdominal surgery. Now her wound is not healing and she has given antibiotic courses four times already, but still everytime wound does not heal. She is taking the drugs sulfasalazine, meloxicam and some other drug cant remember. a. Cease sulfasalazine b. Cease meloxicam*** c. Surgical debridement The effect of NSAIDs on wound healing is controversial. NSAIDs inhibit cyclooxygenase (COX), thus decreasing the synthesis of prostaglandins. NSAIDs also blunt the inflammatory process by deactivation of platelets aggregation, which can impair the wound healing process, depending on how early in the inflammatory phase it is administered. Acetaminophen has an advantage in that it does not interfere with platelet function. OHCM page 547

3.) Man is on terminal care with prostatic carcinoma and is on pain controlled analgesia with morphine high dose. He is drowsy and disoriented, yet still complains of pain and irritability. Wife requests that you decrease morphine a. Increase morphine*** b. Decrease morphine c. Naloxone d. Midazolam 4.) Man comes in with a pole falling on his chest. Has chest wall injury, and is given 20 mg morphine prior to arriving at ED. What is your most appropriate initial management? a. Naloxone b. Intubate, ventilate***

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5.) 15 year old boy comes in apprenhensive about his growth. He is on tanner stage 2. Dad is 170 cm and mom is 160 cm. What is the cause of his growth delay? a. CAH b. Familial short stature c. Hypothyroidism d. Constitutional delay*** 6.) A man has a culturally arranged marriage, and now suspects his wife of infidelity. What is this an example of? a. Over valued idea*** 7.) Painless hematuria with atypical nucei. What will you do to confirm diagnosis? a. CT b. IVP c. Cystoscopy*** d. Renal ultrasound Voided urinary cytology is recommended in all patients who have risk factors for transitional cell carcinoma. This test can be a useful adjunct to cystoscopic evaluation of the bladder, especially in the determination of carcinoma in situ. In patients with asymptomatic microscopic hematuria who do not have risk factors for transitional cell carcinoma, urinary cytology or cystoscopy may be used. If cytology is chosen and malignant or atypical/suspicious cells are identified, cystoscopy is required because the presence of hematuria is a significant risk factor for malignancy in such patients. Intravenous urography, ultrasonography and computed tomography are used to evaluate the urinary tract in patients with microscopic hematuria. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2645872/ Patients > 40 years of age, those with positive or atypical cytology, or any patient with the presence of any of the following risk factors should have their lower tract assessed by cystoscopy (smoking history, occupational exposure to chemicals or dyes, history of irritative voiding symptoms, analgesic abuse with phenacitin, history of pelvic irradiation, or cyclophosphamide exposure). 8. There is a thyroid nodule on one side of neck. Patient has hoarseness of voice, dysphagia, and tracheal shift. What will you do to confirm the diagnosis? a. FNAC*** b. CTscan c. Ultrasound d. 60 Thyroid scan 9. A 25 year old woman with BMI 45 and smokes about 20 cigarettes/day. What is the best approach to decrease the risk of breast cancer? a. Lose weight*** b. Stop smoking 10. A man wants to travel to Papau New guinea and has depression. What drug will you prescribe for prophylaxis? a. Doxycycline*** b. Mefloquine c. Chloroquine Study Note by Chie_Kyi Page 14

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11.) Infected bartholin cyst a. Caused by staph aureus b. Will resolve after antibiotics*** 12.) 55 year old male with cough productive with green sputum. What is the best long term management? a. Postural drainage*** b. Low dose tetracycline for 12 days Physiotherapy and pulmonary rehabilitation Physiotherapy to enhance sputum clearance has been a longstanding mainstay of management and there is evidence it improves cough, exercise tolerance and, in children, lung function.42,43 Given the risk of silent aspiration, head-down sputum clearance techniques are now discouraged. There is evidence that pulmonary rehabilitation and tailored exercise programs improve exercise tolerance in people with bronchiectasis.44 Patients with bronchiectasis affecting their exercise tolerance or activities of daily living should be referred for pulmonary rehabilitation and/or have a tailored exercise program developed in consultation with a physiotherapist. This may occur in the community using available local exercise facilities. Other forms of physiotherapy-based intervention including focused inspiratory muscle training have not shown benefit in bronchiectasis and are not advocated.

Similar xray given https://www.google.com.au/search?q=xray+of+bronchiectasis&hl=en&safe=off&tbm=isch&tbo=u&s ource=univ&sa=X&ei=enZEUf3rHaWPiAf00oC4Bg&ved=0CDYQsAQ&biw=1600&bih=799#imgrc=AwJ 4Cuyj341JJM%3A%3BBpHxVuXvyT_aFM%3Bhttp%253A%252F%252F4.bp.blogspot.com%252FLD4Rx9nEnfw%252FTc7VBkggsYI%252FAAAAAAAAArA%252F6I3pcAu37c%252Fs1600%252Fbronchiectasis.jpg%3Bhttp%253A%252F%252Fradlog.blogspot.com%252F2011%252F05%252Fbronchiectasis-x-ray-features.html%3B576%3B634 Bronchiectasis - X - RAY features Various abnormal radiographic findings have been described as follows (see the images below): Parallel line opacities (tram tracks) caused by thickened dilated bronchi Ring opacities or cystic spaces as large as 2 cm in diameter resulting from cystic bronchiectasis, sometimes with air-fluid levels Study Note by Chie_Kyi Page 15

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Tubular opacities caused by dilated fluid-filled bronchi Increased size and loss of definition of the pulmonary vessels in the affected areas as a result of peribronchial fibrosis Crowding of pulmonary vascular markings from the associated loss of volume, usually caused by mucous obstruction of the peripheral bronchi Oligemia as a result of reduction in pulmonary artery perfusion (severe disease) 13.) A 60 year old male, smoker for 30 years and a plumber comes in with typical SCC scenario. Xray given with hilum shadow near aorta. https://www.google.com.au/search?q=xray+squamous+cell+carcinoma+of+lung&hl=en&safe=off&s ource=lnms&tbm=isch&sa=X&ei=E3dEUbtBOXxiAeWmYDwAQ&ved=0CAcQ_AUoAQ&biw=1600&bih=799#imgrc=SnTOfTsRMubNM%3A%3B2CDH6xCyrHyiBM%3Bhttp%253A%252F%252Fimages.radiopaedia.org%2 52Fimages%252F526616%252F5eed4b1a2e7c90273646921a095c50.jpg%3Bhttp%253A%252F%252F radiopaedia.org%252Fimages%252F526616%3B1772%3B1840

What is your most appropriate initial test? a. Bronchoscopy and biopsy b. CT*** c. Percutaneous biopsy OHCM page 170: Initial X ray, Staging CT scan, Diagnostic Bronchoscopy and biopsy JM page 445: CXR, CT scan 14.) A 14 year old girl with with increased fasting blood glucose (11 mmol) and acanthosisnigricans was described. a. Options has 4 antidiabetics Study Note by Chie_Kyi Page 16

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b. Last option was insulin Metformin or biguinides: Examples of biguanides: Metformin - widely used in treatment of diabetes mellitus type 2 Phenformin - withdrawn from the market in most countries due to toxic effects Buformin - withdrawn from the market due to toxic effects Proguanil - an antimalarial drug. 15.) One chronic paranoid schizophrenia man is obsessed with a lady and interested romantically. He openly writes her a letter, and he declares his love along with threatening her. What do you do? a. Confiscate letter and tell lady b. Report to the police*** 16.) Same CT as jahnheyrans paper kind of like this (https://www.google.com.au/search?q=xray+squamous+cell+carcinoma+of+lung&hl=en&safe=off&s ource=lnms&tbm=isch&sa=X&ei=E3dEUbtBOXxiAeWmYDwAQ&ved=0CAcQ_AUoAQ&biw=1600&bih=799#hl=en&safe=off&tbm=isch&sa=1&q =sigmoid+volvulus+on+ct&oq=sigmoid+volvulus+on+ct&gs_l=img.3..0i24l2.411451.416015.0.416306 .24.17.1.5.5.1.228.1770.8j6j3.17.0...0.0...1c.1.6.img.bMtPBEcEgac&bav=on.2,or.r_cp.r_qf.&bvm=bv. 43828540,d.dGI&fp=d1ccc09c53c22adc&biw=1600&bih=799&imgrc=VTt1gSmcTcNF5M%3A%3BBvE xEuNLBWTQzM%3Bhttp%253A%252F%252Fkonradreview.com%252FAbdomen%252Fimageq30.jpg%3Bhttp%253A%252F%252Fkonradreview.com%252FAbdomen%252FCT%252520Abdomen %252520and%252520Pelvis%252520Practice%252520Test.htm%3B832%3B495 Scenario had left lower quadrant pain and mass, colicky abdominal pain and distension. What is your most appropriate initial investigation? a. Laparotomy b. Colonoscopy*** c. NG tube d. CT Nasogastric tube The management of nasogastric (NG) tubes in the setting of a small bowel obstruction remains a matter of clinical judgment and may differ from patient to patient. In patients with complete or high-grade small bowel obstruction, placement of a nasogastric tube can decompress the distended stomach and improve patient comfort. 17.) 75 year old lady present with abdominal pain, distension, colic, no passage of fecus and there are some bowel sounds that are present. X ray had distended descending and transverse colon. But rectum seemed opaque. a. Colon carcinoma b. Fecal impaction*** c. Adhesion small bowel 18.) A 60 year old lady has hip replacement surgery and after 5 days she presents with abdominal colicky central pain, distension. a. Ng aspiration b. Colonoscopy c. Laparotomy d. Rectal tube 19.) HBV and CIN3- give vaccine and treat CIN Study Note by Chie_Kyi Page 17

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20.) Patient has ulcerative esophagitis- What key diagnostic finding makes you think of malignancy? a. Dysplasia Esophageal strictures complicating ulcerative esophagitis 21.) HBV 3 children question- give all 9 45 year old*** 22.) Warfarin interaction with glicazide or amoxicillin? 23.) Hypertensive patient with wide splitting, loud second heart sound with hepatomegaly, jvp 3 cm above, and ascites along with bilateral basal crep. What is cause? a. AS b. COPD c. Cor pulmonale*** 24.) SVT ECG GIVEN ..andbp 90/40. What is most appropriate initial management? a. i/v adenosine b. i/v metoprolol c. i/veamiodarone d. dc cardioversion*** 25.) hypertensive patient on irbesartan/hydrochlorothiazide comes with palpitations (no chestpain) ecg shows diffuse global t wave inversion. M pattenqrs complexes diffusely. What is most appropintitial investigation? a. Serum troponin b. Seum K+ c. Transthoracic echocardiography Causes of small, flattened or inverted T waves are numerous and include ischaemia, age, race, hyperventilation, anxiety, drinking iced water, LVH, drugs (e.g. digoxin), pericarditis, PE, intraventricular conduction delay (e.g. RBBB)and electrolyte disturbance. 26. a fib drive slow paper question 27. hep c and breastfeeding a. contraindicated b. continue 28. medial meniscus injury a. posterior drawer test b. anterior drawer test none ans 29. absent vas deferens in a male. Couple is trying to conceive for 2 years. What is the best test for screening in this couple? a. cf screening*** 30. widened mediastinum on xray with patient trying to withhold vomiting and restrosternal chest pain soon after. ECG was given (seemed like a distractor) a. ng*** b. troponin Study Note by Chie_Kyi Page 18

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c. I/C drain Conservative treatment includes continuous nasogastric suction, intravenous broad-spectrum antibiotics, and parenteral nutrition. The most successful surgical approach involves primary repair, with or without reinforcement mediastinal debridement and pleural drainage of the ruptured esophagus, mediastinal debridement, and pleural drainage 31.) A couple has one child with CF. What is the probability that next child will be a carrier? a. 0% b. 25% c. 50%*** 32.) CT given with cerebral hemorrhage on right side. Patient on warfarin and has afib. INR 4.5. What is most approp initial? Looked like this (https://www.google.com.au/search?q=ecg+right+bundle+branch+block&hl=en&safe=off&tbm=isch &tbo=u&source=univ&sa=X&ei=dn1EUfv9DuS8iAfizYGgCQ&ved=0CDwQsAQ&biw=1600&bih=799#h l=en&safe=off&tbm=isch&sa=1&q=cerebral+hemorrhage+ct+scan&oq=cerebral+hemorrhage+ct+sca n&gs_l=img.3..0.558655.563338.2.563551.27.20.0.7.7.2.251.2527.10j5j5.20.0...0.0...1c.1.6.img.B8fJi LoebQ&bav=on.2,or.r_cp.r_qf.&bvm=bv.43828540,d.dGI&fp=d1ccc09c53c22adc&biw=1600&bih=799 &imgrc=HsCF6t69a_YvYM%3A%3B1VkpQ1Tl5IxNcM%3Bhttp%253A%252F%252Fwww.uwmedicine. org%252FPatient-Care%252FeHealth-Articles%252FPublishingImages%252FCT-IntracerebralHemorrhage.jpg%3Bhttp%253A%252F%252Fwww.uwmedicine.org%252Fpatient-care%252Fourservices%252Fmedical-services%252Fstrokecenter%252Fpages%252Farticleview.aspx%253FsubId%253D79%3B570%3B40 a. ffp b. platelets c. vit k d. stop warfarin*** 33. perindopril/indapamide/warfarin hypoglycemia q 34. infant 1.6 kg at birth and 6kg at 6 months. Growth chart given a. weight is normal b. overweight*** c. underweight d. the weight gain is relatively slow but acceptable. Normal weight baby at 6 months the weight is double and at one year is triple 35. 65 year old lady present with low grade fever and cough. Xray described as left lower lobe having patchy infiltrate (not given) a. amoxicillin/clav*** b. amox c. azithromycin S pneumoniae causes 10-50% of all cases of community-acquired pneumonia (CAP). Radiographic consolidation of the alveoli begins in the peripheral airspaces, as in the image below. The disease usually causes a lobar or segmental pattern, and a patchy bronchopneumonic pattern involving the lower lobes is seen in the elderly

Study Note by Chie_Kyi

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36. Picture of legs given. One leg has laceration and femorotibial fracture described in scenario. What is ur next most approp initial manifestation? Tetanus prophylaxis 37. A pregnant lady comes with hb low, and thrombocytopenia (200). What could be the investigation? a. ds dna b. antiplatelet antibodies*** c. bone marrow biopsy 38. A child having ITP with platelet count less than 35,000 a. high dose steroid b. immunoglobins c. FBC*** 39. Scenario of varicose veins a. option had compression stockings*** b. rest were all related to the treatment of dvt 40. Male patient has trouble climbing stairs, and also shoulder movement problems. What is ur dx? a. polymyositis*** b. sle c. myasthenia d. MS 50. A computer executive presents with pain in the lateral elbow. How will you manage? A. Rest B. Circumferential band below elbow*** C. Pain killers D. Band above elbow 51. What is the most urgent sign of acute limb ischemia? A. Pain B. Paralysis*** C. Rubor D. Swelling E. Pulseless 52. A patient has been diagnosed with GBS. Which is an appropriate way to monitor his respiratory function? A. FVC*** B. Blood gas analysis C. Oxygen saturation D. CXR 53. A 55-year-old man comes to your clinic concerned about his family history. His father was diagnosed with prostate cancer at the age of 85. His neighbour was recently diagnosed with metastatic prostate cancer and he says that there is screening to detect early disease. On DRE prostate was smooth, and median sulcus felt. No other symptoms. What is the next step in management? a. PSA within 2 weeks*** b. Reassure Study Note by Chie_Kyi Page 20

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c. Transrectal USG d. DRE annually 54. A patient came in with weakness of wrist and finger extension. Tendon reflexes were normal. No other abnormalities noted. Where is the lesion? a. Anterior interosseus nerve b. Median nerve c. Ulnar nerve at the elbow d. Radial nerve*** e. Posterior interosseus nerve 55. A man comes complaining of weakness and dragging his left foot. On examination, Extension and flexion of the thighs are intact. There is loss of eversion, inversion, dorsiflexion and plantar flexion. Knee jerks is normal but there is decreased ankle jerk. Where is the lesion? a. L4 b. L5 c. Sciatic nerve*** d. Tibial nerve e. Common peroneal nerve 56. A 42-year-old female with 4 children came in due to a discrete patch of hair loss about 5x6cm in diameter. What is the most appropriate management? a. Hydrocortisone 1% cream b. Reassure that she will not become bald c. Clotrimazole cream d. Intralesionalmethyl prednisolone*** 57. A middle-aged man comes in complaining of bilateral leg weakness. He claims his legs feel deadless after walking 100m on level ground and 20 meters when it is inclined or on rough roads. What is the most appropriate next step in the evaluation of this patient? a. MRI b. Doppler Ultrasound*** c. Angiogram d. DSA Angio e. venogram 58. A 32-year-old woman comes in with 3 months history of palpitations and fatigue. On examination, she has fine tremors. Laboratory revealed TSH of 0.01 (low). What is the best investigation to come to a diagnosis? a. Anti-TSH receptor antibodies b. Low uptake on radioactive iodine c. High thyroxine and triiodothyronine*** d. Diffuse increased uptake on radioactive iodine 59. A patient was who underwent subtotal thyroidectomy a few hours ago complained of difficulty breathing and stridor. What is the next step in management? a. Intubate the patient b. Anesthetize the patient and explore the wound c. Remove superficial skin sutures d. Explore the wound in the ward*** Study Note by Chie_Kyi Page 21

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e. Arrange Operating Room Theater and explore the wound there 60. An elderly male presents with hemifacial paralysis. He cannot wrinkle his forehead and smile fully. He also has difficulty in swallowing and coughs when he sips water. What is the most likely diagnosis? a. Bell palsy b. Ramsay hunt syndrome c. Brainstem infarct d. Motor neuron disease*** 61. Picture of psoriasis similar to the one below but both legs were affected. What is the management?

a. Clotrimazole cream b. Ultraviolet B therapy*** c. Calcipotriol cream d. Oral corticosteroids For psoriasis which is widespread, severe, or causing disfigurement or disability, systemic therapy is indicated such as methotrexate or acitretin or cyclosporin. Phototherapy is also often used by dermatologists.

Examination has revealed the typical lesions of plaque type psoriasis. The plaques vary in size from a few mm to several cm. They are raised, pink and covered with a silvery waxy scale. The nails are not affected. The level of severity for this patient's psoriasis should be regarded as moderately severe. Study Note by Chie_Kyi Page 22

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62. A middle-aged man who was previously diagnosed with Wegeners granulomatosis and has been on azathioprine comes complaining of cough for 2 days with clear sputum. Physical examination was unremarkable. What is the diagnosis? a. Azathioprine-induced interstitial pneumonia b. Bronchopneumonia c. Reactivation of Wegeners granulomatosis*** d. Atypical pneumonia e. Tuberculosis 63. An 80-year-old retired plumber who has an 80-pack-year smoking history comes to your clinic because of exertional dyspnea for a few months. Spirometry revealed FEV1 50 of predicted value and FVC <70 of predicted value which is not reversed by bronchodilators. CXR is shown similar to the one below (both lungs were hazy with blunting of costodiaphragmatic angles which looked like pleural effusion). What is the next step in management of the patient? a. Chest CT scan*** b. Thoracoscopy and biopsy c. Prescribe a full course of antiobiotcs d. Pleural biopsy e. Give a trial of bronchodilator therapy 64. A previously healthy 25-year-old basketball player came in due to swelling of the right limb for 1 week. On examination, his right arm including his hand and forearm are dusky, swollen and edematous. He has non-tender axillary lymphadenopathy. He noticed that his pet cat is also unwell. What is the most likely diagnosis? a. Cellulitis- non tender LAP with fever b. Cat-scratch disease- tende3r lymphadenopathy, low grade fever, pustules c. Subclavian vein thrombosis- no lymphadenopathy and fever, d. Cervical rib 65. Which of the following is an unequivocal sign of chronic limb ischemia? a. Dependent rubor*** b. Intermittent pain c. Pallor d. Leg swelling 66. A 34 weeks pregnant lady who is Rh negative had been given RhD injection during the first pregnancy three years ago. She underwent orthopedic surgery and received blood transfusion 12months ago. Now she is Rh+. What is the reason for sensitization? A. Previous pregnancy B. Blood Transfusion*** C. Occult fetomaternal bleeding D. RhD injection 67. A 42-year-old woman comes in complaining of menorrhagia of 6 months duration. Bleeding usually lasts for 10 days. A few days ago, vaginal bleeding ensued despite having her last period 2 weeks back. Gynecologic assessment was scheduled. While waiting, what will you give in the interim? A. Norethisterone*** B. Low-dose combined OCP C. Combined HRT Study Note by Chie_Kyi Page 23

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D. Insert an IUD 69. What is the management for a CIN 2 dysplasia which extends above the transformation zone and up the cervix? A. Brachytherapy B. Cehmotherapy C. Hysterectomy D. Laser knife Cone Biopsy*** E. LLETZ 70. A lady came in with severe vomiting. On investigation, ketones +++ but no nitrities. LMP was 4 weeks ago. Her husband had acute gastroenteritis. What would be your investigation of choice? A. Beta-hCG*** B. Microurine and culture C. Stool culture D. Blood Sugar levels 71. A 30-year-old lady presents with secondary amenorrhea for 12 months. Laboratory tests revealed FSH 55, LH 51, estradiol slightly reduced. Prolactin and TSH were normal. Ultrasound shows 3-4 cysts. What is your diagnosis? A. Premature ovarian failure*** B. Pituitary adenoma C. PCOS D. Pregnancy 72. A 53-year-old woman weighing 125kg has been amenorrheic for 24 months. What would you most likely find in her evalution? a. Very low estrogen and very low FSH b. Very low estrogen and very high FSH c. Slightly low estrogen and moderately high FSH*** 73. A 10 weeks pregnant lady comes for antenatal checkup. Everything was found to be normal. Which of the following will affect the management of this patient at this time? a. HIV test b. Parvovirus antibodies c. Varicella antibodies*** d. No option for rubella antibodies 74. A pregnant lady comes concerned because she has been tested positive for hepatitis C. Which of the following statements is true regarding her pregnancy? a. She should bottlefeed the baby to avoid contracting the virus b. Hepatitis C testing must be carried out on the fetus c. Elective caesarean delivery should be done d. Fetal heart rate monitoring with scalp clips must be avoided*** e. Delivery will cause intrauterine hypoxia 75. A 56-year-old woman was managed as a case of colles fracture. Which of the following would increase her risk of recurrent fractures? a. Nulliparity b. Menopause at 48 years old Study Note by Chie_Kyi Page 24

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c. Smoking 10 cigarettes per day*** d. Drinking 2 glasses of wine a day e. Vegetarian 76. An 8-year-old child is being evaluated because of his 3rd episode of nephrotic syndrome. His progress is slow despite corticosteroid treatment of 2mg/kg/m2. He now has increased blood pressure and hematuria on urinalysis. What is the diagnosis? a. Membranoproliferative glomerulonephritis*** b. Post-streptococcal GN c. Focal segmental glomerulosclerosis d. PGN 77. An 18-year-old male is seen in general practice with complaints of poor coordination and difficulty playing sports. He is more than 97th percentile for height and on the 3rd percentile for weight. Which investigation would likely lead to the diagnosis? a. Karyotyping b. Cardiac ultrasound*** c. FBC d. Bone scan e. Growth hormone test 78. An 18-year-old male was brought by his father because he says that the boy is not developing like others. Father is 170cm and mother is 160cm in height. The boy was found to be on the 5th percentile for height and 25th percentile for weight. Pubic hair and testicular development was found to be at tanner stage 2. What is the probably diagnosis? a. Growth hormone deficiency b. Hypothyroidism c. Congenital adrenal hyperplasia d. Familial short stature e. Constitutional pubertal delay*** 79. Lithium monitoring in a driver who has moved interstate a. 1month b. 3months*** c. 6 months d. 1year 80. A husband comes to see you in your clinic with his wife because he noticed that his wife has recently had insomnia and kept on cleaning the house. She also began drinking alcohol and has been seen flirting with the husbands friends. On examination, she was flirtatious but then became irritable and aggressive. What is the most probable diagnosis? a. Hypomania*** b. Obsessive compulsive disorder c. Alcoholism d. Depression e. Histrionic personality disorder 81. A 25-year-old male who is a heroin addict comes to you saying that he has been trying to kick off the habit. He asks for prescription of diazepam to help him. What is the most appropriate step in management? Study Note by Chie_Kyi Page 25

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a. Tell him you cannot prescribe diazepam for this purpose*** b. Prescribe oxycodone instead c. Give him a 10-day prescription of diazepam d. Arrange a supervised daily dosing of diazepam in a pharmacy 82. A 20-year-old girl was brought by ambulance to the emergency department after she was found collapsed in the toilet of a nightclub. In the ED, she was noted to have a temperature of 40C, pulse rate of 110 and BP of 160/100mmHg. There were also some jerking movements of the hands noted. What is the initial step in management? a. Thiamine and oral rehydration b. Cold IV infusion and cold blanket*** c. IV dextrose/saline solution 83. A young male was brought to the ED by his friends after they noticed behavioral changes. At the bar, he began to say that a gang wanted to hurt him because he did not pay his debt. His friends became more concerned especially when the patient started becoming agitated when he heard guns (forgot if it was gunshot or he heard people talking about guns). They admit that the patient uses amphetamines. Which is most important to consider in the management of the patient? a. Concomitant use of drugs b. Deleterious cardiovascular effect of amphetamine*** 84. A patient was brought to your clinic for evaluation. When you asked what her mood was, she replied, Moon is not made out of cheese (+ 2 other unrelated statements). What is the diagnosis? a. Disorganized behavior*** b. Dissociation c. Depersonalization d. Delirium e. Depression Dissociation is a term in psychology describing a wide array of experiences from mild detachment from immediate surroundings to more severe detachment from physical and emotional experience. It is commonly displayed on a continuum.[1] The major characteristic of all dissociative phenomena involves a detachment from reality rather than a loss of reality as in psychosis. -Derailment / disorganized behaviour/ thought disorder/loosening of association 85. A man with a mental impairment (IQ of 60) was brought to the hospital after a brawl. he got into a fight with a fellow in the institution over the television. On examination, he is agitated and verbally abusive. He has a suspected injury in the hand and cannot sit still for xray. What is the most appropriate step? a. Call the security to restrain him b. Call the police c. Give him IM olanzapine*** 86. 5 yr old girl presented with high grade fever, poo feeding n dehydration. On exam tachycardia, sunken eyes, capillary refill > 3 sec. Initial fluid for resuscitation? a. Normal saline*** b. 0.45 n/s n Dextrose water c. Ringers d. Dextrose 50% 87. .Postmenopausal lady with hysterectomy n h/o Dvt presented with hot flushes. Next step in Mx? Study Note by Chie_Kyi Page 26

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a. Low dose Oestradiolvalerate b. Low dose combine oestrogen n progesterone c. Low dose Oestriol d. Estrogens dermal patch*** e. Implanon 88. . 22 yr old lady presented to u n requested for ovarienca screening as her friend is just dx with ovarian ca. What will u advise her? Ultrasound CA125 CA125 n U/S*** Laparoscopy 89. 35 yr old lady presented to u for breast ca screening as one of her paternal aunt is dx with Breast and ovatian ca. What will u advice her? a. 2 yarely mammography b. 2 yarely ultrasound c. Genetic risk screening*** d. BRCA gene screening e. 6 monthly self breast examinations. 90. Known HTN pt presented with muscle weakness. K 6.5. what could be the cause? a. Enalapril b. Amiloride*** c. Simvastatin d. Thiazide 91. 45 yr old male present with polyarthiritis, impotence and decrease libido. Which of the following inv will help to make Dx/ a. Iron studies*** b. Fasting blood sugar c. BP d. CT head e. Prolectin levels 92. 78 yr old man present in ER with upper abd pain which radiates to back and syncope. Next best inv? a. Ultrasound FAST*** b. Ct aortogram c. Xrayabd 93. Right sided inferior quadrentonope where is the lesiona) Temporal lobe b) parietal lobe *** c) optic chiasma d) optic tract 94. Pt with migraine and vomiting in pregnancy , management? a) PCM b) PCM + Codine Study Note by Chie_Kyi Page 27

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c) Codine + metachlopramide*** d) Codine +promethazine e) ergotamine and metoclopramide 95. Safest way to go off breast feeding A-bromocriptine B- tight bra and limit fluid intake*** C- OCP D- Danazol 96. Turkish lady ct 97. Drive slow afib question 98. Venlafaxine overdose q http://books.google.co.nz/books?id=WuA4LsWXXWEC&pg=PA500&lpg=PA500&dq=management+of +Venlafaxine+overdose&source=bl&ots=ijIvcL0yFe&sig=1pClkS8gQnW8i3OIXqqCoBG8mQk&hl=en&s a=X&ei=de1MUduuEo6PlQWd74DYBw&ved=0CHAQ6AEwCA#v=onepage&q=management%20of%2 0Venlafaxine%20overdose&f=false 99. A 10 day old infant brought by parents with rash on her body she is having good feed, thriving well, n had papulopustular lesions on bodywhat is the most likely diagnosis? A. congenital Varicella B. Rubella C. toxic erythema*** D. Measles 100. 24 year aboriginal male with lack of interest in normal life and is having visual hallucination, he is saying my mother died last month but it is not the case n mother died year ago, what is the likely diagnosis? A. depression B. depression with unresolved grief*** C. Depression n Psychosis D. Schizophrenia 101. 8 weeks pregnant lady has severe vomiting and cannot take any solids but can take only small amounts of liquids. Invest ketones 3+ .her partner has recently been diagnosed with gastroenteritis. What investigation to do ? a.pelvic usg b.urine stool n culture c.Stool routine and culture d.quantitative HCG*** 102. OA in right knee/stick question 103. A young athelete came in with a swollen,tender knee for 1 day. Management? A- MRI*** B- Aspiration C- Bed rest for 5 days D- Steroid injection Study Note by Chie_Kyi Page 28

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104. Parents brought their 10 yr old boy, who was riding a bicycle when he felt a stinging sensation at the lower part of his left leg. Snake bite suspected. Which is the best site to collect specimen from? A- Bite site*** B- Blood C- Clothes D- Urine E- CBC

Amrit March 16, 2013

1Back stiffness cause? A. Osteoporosis B. Disc prolapsed C. Cervical spondylosis JM page 645: Cervical spondylosis following disc degeneration and apophyseal joint degeneration is far more common than lumbar spondylosis and mainly involves the Cs-6 and C6-7 segments. The consequence is narrowing of the intervertebral foramen with the nerve roots of C6 and C7 being at risk of compression. Cervical spondylosis is generally a chronic problem but it may be asymptomatic. In some patients the pain may lessen with age, while stiffness increases. 2. Osteoporotic fracture 3. L5/S1lesion? Absent ankle jerk/weakness dorsiflexor JM page 392: One disc lesion= one nerve root (exception is L5-S1 disc). A disc lesion of L5-S1 can involve both L5 and S1 roots. However, combined L5 and S1 root lesions should still be regarded with suspicion (e.g. consider malignancy). The L5-S1 disc is the leg pain disc. JM page 697: Nerve root pain from a prolapsed disc is a common cause of leg pain. A knowledge of the derma tomes of the lower limb provides a pointer to the involved nerve root, which is usually L5 or S1 or both. The L5 root is invariably caused by an L4 L5 disc prolapsed and the S1 root by an L5S1 disc prolapse. 4. Estrogen/progesterone? A. Decreases breast cancer after 2 years usage B. Decreases cardiovascular disease C. Decreases thromboembolism JM page 985: The use of long-term HRT in postmenopausal women with an intact uterus using longterm combined oral oestrogen and progesterone. The trial did not include people using other forms ofHRT, such as patches, gels or implants. The findings were that there was a slightly increased risk of breast cancer (1.26-fold) , coronary heart disease (1.29 -fold), stroke (qr-fold) and pulmonary embolism (2.13-fold) with prolonged use greater than 5 years.4 The study also found a reduction in risk of bowel cancer and fracture in these women. Combined hormone therapy trial, risks included CHD events, stroke, VTE, and breast cancer, while benefits included a reduction of fracture and colorectal cancer risk. 5Pt. Taking HRT, what is the most likely problem in 2 years of time? Very tricky Study Note by Chie_Kyi Page 29

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For many, menopausal symptoms will be relatively shortlived; often within 2 years. Side effect: In the first 2-3 months the woman may experience oestrogenic side effects, but these usually resolve or stabilise. Starting with a lower dose may minimise these side effects. The main short-term risk of oral HRT in women aged 50-59 is venous thromboembolism. 6. Case related with pulmonary atelectasis 7. Post Op case sudden dysnea, most effective? A. CTPA*** B. Ddimer C. VQ 8. Wegeners granuloma? Wegener's granulomatosis is characterized by necrotizing granulomatous inflammation, small and medium-sized vessel vasculitis, and focal necrotizing glomerulonephritis, often with crescent formation. Typically, the upper and lower respiratory tract and the kidneys are affected, but any organ may be. Symptoms vary depending on the organs and systems affected. Patients may present with upper and lower respiratory tract symptoms (eg, recurrent nasal discharge or epistaxis, cough), followed by hypertension and edema, or with symptoms reflecting multiorgan involvement. Diagnosis usually requires biopsy. Treatment is with corticosteroids plus an immunosuppressant. Remission is usually possible, although relapses are common. 9. Lactose intolerance baby case? Lactose intolerance as a sequel explosive diarrhoea after introducing formula. Replace with a lactose-free formula. The commonest offending sugar is lactose. Diarrhoea often follows acute gastroenteritis when milk is reintroduced into the diet (some recommend waiting for 2 weeks). Stools may be watery, frothy, smell like vinegar and tend to excoriate the buttocks. 10. Ethics 3-4 questions 11. Very tricky question on Chlamydia infection azithromycin 1 g (o) single dose (preferred) or doxycycline 100 mg (o) 12 hourly for 7 days 12. Read STDs very carefully, i got about 3-4 qestion on those topics 13. Case of generalized lymphadenopathy, fever, painless maculopapular rash over penis in 21 years old man. What is the most common cause? A. Primary HIV B. Secondary syphilis*** 14. Lump over neck for 6 months, lady. Two weeks on and off? What is the diagnosis? A. Lymphoma B. CLL C. AML D. ALL E. Glandular 15. An 8 years old child with mobile lump over her right breast brought by her mother? What inv would u do? A. USG Study Note by Chie_Kyi Page 30

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B. Reasurence*** C. Surgery D. Wait till it grows The spectrum of breast lesions in children and adolescents varies markedly from that for adults, with the former lesions being overwhelmingly benign. A breast mass in a young boy or girl may arise from normal and abnormal breast development. Other causes of masses include infection, trauma, and cyst formation. Developmental lesions may be asymmetric or, uncommonly, unilateral, but unilateral enlargement or a palpable mass more often arises from a cystic lesion or the very common benign fibroadenoma. Premature thelarche is the onset of female breast development before age 78 years. In general, thelarche occurs earlier in African Americans girls than in white girls; thus, breast development is considered premature before age 7 years in the former group and prior to 8 years of age in the latter. As with age-appropriate thelarche, premature thelarche may be asymmetric or unilateral, in which case it may arouse clinical concern for a neoplasm. At sonography, premature thelarche appears as normal developing breast tissue without a discrete lesion. Benign premature thelarche is defined as isolated breast development in females aged 6 months to 9 years. Physical examination for this entity should carefully seek out other signs of puberty, such as development of pubic hair, thickening of the vaginal mucosa, and accelerated bone growth. If no other signs of puberty are present, reassure the patient and family that this is a benign finding. Examine the child every 6-12 months. If other signs of puberty are evident, precocious puberty should be entertained as a diagnosis. The most common breast abnormality seen in a primary caregivers office in children younger than 12 years is a unilateral breast mass corresponding to asymmetrical breast development. One breast commonly develops earlier than the other, although the breasts ultimately become symmetrical. 16. Myocardial infarction case- 3-4 questions 17. Case of COPD? Domestic o2 therapy case 18. Child with eye flutter some seconds? Gradually increasing. Eeg 3 spikes. What treatment is needed? A. Carbamazepine B. CT head C. Reassure Absence seizure (formerly called petit mal): involves loss of consciousness with no or only very minor bilateral muscle jerking, mainly of the face JM page 578: Absence seizure This type of generalised epilepsy typically affects children from 4 years up to puberty 2: child ceases activity and stares suddenly child is motionless (may blink or nod) no warning sometimes clonic (jerky) movement of eyelids, face, fingers may be lip-smacking or chewing (called complex absence) only lasts few seconds-usually 5-10 seconds child then carries on as though nothing happened usually several per day (not just one or two) may lead to generalised seizures in adulthood two types-childhood and juvenile Study Note by Chie_Kyi Page 31

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Diagnosis Best evoked in the consulting room by hyperventilation and windmill. EEG: classic 3 Hz wave and spike may be normal always include hyperventilation easier with sleep deprivation Medication ethosuximide (first choice) or sodium valp roate (second choice) or (others) e.g. clonazepam, gabapentin Childhood absence may not need pharmacotherapy Note: Beware ofhepatoxicity with sodium valproate, especially in those under 2 years. 19. Case on Alzheimer disease 20. Tibia/fibula fractures with diagram what would you do next? A. Reduction B. Tetanus toxoid C. Analgesics*** D. Surgery Fractures of both tibia and fibula The nature and management of these fractures vary considerably. Some fractures are caused by blunt injuries, such as a blow from a motor car bumper, while twisting forces cause a spiral fracture of both bones at different levels. As a general rule, referral of patients to a specialist is necessary, especially where soft-tissue damage is significant. Management of fractures with minimal soft-tissue damage can be summarised thus: No or minimal displacement: full-length cast as for isolated fracture of tibia Displacement: reduction under general anaesthesia, then application of cast as above (meticulous alignment essential l) period of immobilisation: adults 16 weeks, children 8 weeks Medscape: Parenteral analgesia should be administered when appropriate. Although management of pain has improved, pain due to long bone fractures is notably undertreated in the emergency department. Open fractures must be diagnosed and treated appropriately (also see Tibia Fractures, Open). Tetanus vaccination should be updated, and appropriate antibiotics should be given in a timely manner. Some recommend antibiotics within 3 hours of the accident.[5] This should involve antistaphylococcal coverage and consideration of an aminoglycoside for more severe wounds. Orthopedics should be consulted for emergent debridement and wound care. Fractures with tissue at risk for opening should be protected to prevent further morbidity. 21. Transilluminable swelling on posterior compartment neck? Diagnosis? A. cystic hygroma*** B. branchial cyst A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck, probably formed during coalescence of primitive lymph elements. It consists of thin-walled, single or multiple interconnecting or separate cysts which insinuate themselves widely into the Study Note by Chie_Kyi Page 32

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tissues at the root of the neck. Features: 50-65% present at birth, but occasionally may present later in childhood or adulthood Lobulated cystic swelling that is soft, fluctuant, and compressible (usually into another part of the cyst), located in the posterior triangle at the root of the neck Classically brilliantly transilluminable A large cyst may extend deeply into the retropharyngeal space Branchial cysts are seen mainly in young adults, presenting in the jugulodigastric region. They are not developmental but are probably due to epithelial cell rests in a lymph node. http://www.gpnotebook.co.uk/simplepage.cfm?ID=818937879 This arises from embryonic remnants of the second branchial cleft in the neck. It is most common in young adults where it presents as a smooth swelling in front of the anterior border of the sternomastoid at the junction of its upper and middle thirds. The position is characteristic. The cyst may enlarge during an upper respiratory tract infection and then persist. In the acute stage, it may be tender. On examination, it is usually fluctuant but does not transilluminate. It does not move on swallowing. Other enlarged lymph nodes are absent. Treatment is by excision. Care must be taken not to damage the carotid vessels and internal jugular vein which usually lie deep to the swelling. Removal may need to be delayed if the cyst is acutely inflamed because of the risk of creating a branchial fistula. 22. Venous ulcer with picture? Feb question A. Hemosiderin depositon B. Hemmorghage 23. West Nile fever encephalitis case, what would you do? A. Vaccination B. Avoid tse tse flies C. Mosquito repellants*** West Nile encephalitis caused by a mosquitotransmitted virus and carried by birds has surfaced in the US and beyond, causing thousands of cases and hundreds of deaths. Why should I use insect repellent? A. Insect repellents can help reduce exposure to mosquito bites that may carry viruses such as West Nile virus that can cause serious illness and even death. Using insect repellent allows you to continue to play and work outdoors with a reduced risk of mosquito bites. 24. Case on preeclampsia Antihypertensive drugs Contraindicated drugs are ACE inhibitors and diuretics. There is no place for the use of diuretics alone unless cardiac failure is present. Commonly used medications: beta-blockers (e.g. labetalol, oxprenolol and ate nolol) (used under close su pervis ion and after 20 weeks gestation) methyldopa: good for sustained BP control nifedip ine 25. Diabetic foot Study Note by Chie_Kyi Page 33

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26. Case with pinpoint pupil? Caused by what? A. Benzo overdose B. Cocaione overdose C. Heroin*** 27. Melanoma pic given? Many irrelevant options A. punch biopsy B. Excisional biopsy*** Management points for naevi and melanomas Do not inject local anaesthetic directly into the lesion. lncisional biopsy of a melanoma or suspicious mole is best avoided. Accurate clinical diagnosis, with the definitive treatment performed in one stage, is optimal, rather than excision biopsy with fol low-up surgery. 28. Question on pill endoscopy (thought it as a capsule endo) 29. Terminal painless hematuria 2 cases given? Investigation and management were asked Painless hematuria with atypical nucei. What will you do to confirm diagnosis? a. CT b. IVP c. Cystoscopy*** d. Renal ultrasound 30. SVT ECG given. A. Adenosine B. Carotid massage*** 31. Heart block ecg given diagnosis 32. Hypertrophic cardiomegaly ecg asked About 75-90% of persons with HCM have an abnormal electrocardiogram (ECG). Some abnormalities seen are due to LVH and include voltage abnormalities, ST segment and T wave abnormalities, prominent Q waves, and signs of LA enlargement. An ECG finding of giant negative T waves (inverted T wave) in the precordial leads is characteristic of apical HCM. 33. A 16 wks pregnant lady comes with 37cms pelvic enlargement? Cause? A. Hydatidiform mole B. Diabetic C. Multiple pregnancy*** 34Question on prevalence Prevalence refers to the total number of ind ivid uals who have the disease (or factor of interest) at a particular time in a population. - Example: the preva lence of multiple sclerosis in temperate climates is 1 in 1000-2000 compared with 1 in 10000 in the tropics. The incidence of multiple sclerosis in the Australian state of Victoria (population 4 400 ooo) is 8 per 100,000 per year. 35. Very tricky question on schizophrenia Study Note by Chie_Kyi Page 34

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36. Question on bone age 37. X ray and stem with empty rectum? Diagnosis Volvulus 38. Small bowel obstruction xray, hx of appendicectomy previously. Adesive obstruction 39. Pt admires u and wanna go for a dinner, u get attracted too. What would you do? A. Carry on dr/pt relation B. Refer to other doctor and explain why you cant continue the dr pt relationship*** 40Xray on aortic dissection A 55-year-old man, with a history of hypertension and smoking, presented with severe acute onset central chest pain, radiating through to the back and down to the umbilicus area of the abdomen. His blood pressure was 210/110 in both arms, peripheral pulses were normal, and there was no focal neurological sign. An electrocardiogram was normal. Chest x ray did not show obvious mediastinal widening, but incidentally the space between intimal calcification and the outer border of the aortic arch was>1 cm. A computed tomography scan confirmed aortic dissection type B, managed conservatively with intravenous labetolol and analgesia, with a good outcome 41. Case of aortic aneurysm 42. Question related with barium enema 2 questions were asked 43. Case of papua guinea repeated question 44. All the hepatic enzymes values were raised? What might be the causes? Viral serology 45. Overian mass? What would you do? Laparatomy Laparoscopic surgery*** 46. Question on mammography of microcalcification? What would you do? 47. Options were like A. Sentinel node biopsy*** B. Core biopsy C. Chemoradiation D. Excision Sentinel node biopsy is a surgical procedure used to determine if cancer has spread beyond a primary tumor into your lymphatic system. Sentinel node biopsy is used most commonly in evaluating breast cancer and melanoma. 48Gram positive cocci.. drugs? A. Ceftrixone B. Flucloxacillin*** Study Note by Chie_Kyi Page 35

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C. Penicillin 49Case of intermittent claudication.. most appropriate? A. Venography B. Doppler*** 50. Mode of inheritance percentage basis- b thallesemia and cystic fibrosis Autosomal recessive 51. A child immediately after birth presented with grunting and subcostal recession, pregnancy normal, no other complication noted? Meconium stained/pneumonia A. Respiratory Distress syndrome B. Transient tachypnoea of the new born*** Severity of respiratory distress (tachypnoea, intercostal/subcostal recession, accessory muscle use, grunting) HMCQ page 186 MCQ 2.127: Transient tachypnoea of the new born: is more commonly seen in term infants and often in association with CS closer to term 52. Right arm and leg weakness, lesion present? A. Frontal lobe B. parietal C. occipital D. temporal E. internal capsule*** 53Question related with levodopa Once present, dyskinesias are only partially improved by lowering the daily dose of levodopa and coadministering a D2 dopamine agonist. Therefore it appears to be necessary to use an NMDAantagonist, such as amantadine, as an antidyskinetic agent. Clozapine may also improve dyskinesia without worsening akinesia, but it requires strict haematological monitoring. 54. TURP complication? A. Epididymitis B. Bladder neck stenosis C. Retrograde ejaculation 55. Question related with rheumatic fever? 56. Surgical case and various fluids were given? A. Hartman solution B. 2 lit saline C. 5% dextrose Very irrelevant and mindboggling one Hartman solution: hypertonic. often used intraoperatively and postoperatively. Tjandra page 18: The normal daily fluid requirement to maintain a healthy 70-kg adult is between 2 and 3 L. The individual will lose about 1500 mL in the urine and about 500 mL from the skin, lungs and stool. If an otherwise healthy adult is deprived of the normal daily intake of fluid and electrolytes, suitable intravenous maintenance must be provided. One relatively simple regimen is 1 L of 0.9% saline and 12 L of 5% dextrose solution. The normal daily requirements of sodium and Study Note by Chie_Kyi Page 36

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potassium are 100150 mmol and 6090 mmol, respectively. This will balance the daily loss of these two cations in the urine. CORRECT regimen is 1 L of 0.9% saline + 2 L of 5% Dextrose every 30 hrs with 20-30 ml of K per L of fluid 57. Swelling infront of ear during eating? A. Submandibular B. Parotid*** C. Abscess Infections of the parotid from blockage of the parotid duct may result in fever and pain on eating especially with sour foods, which tend to increase the flow of saliva About 8 in 10 salivary stones form in one of the submandibular glands. The submandibular duct is a tube, which runs from under the front of the tongue to the submandibular gland. The larger parotid glands make saliva that is thinner than that produced by the submandibular glands. This means that stones less commonly form in parotid glands. It is rare for a stone to form in a sublingual gland. 58. Kid 3 mnths loose motion esr raised? Coeliac disease is an autoimmune disorder of the small intestine that occurs in genetically predisposed people of all ages from middle infancy onward. ESR raised in Coeliac as it is one of autoimmune. 59. Past stem where undescented testes is commonly asso with? Indirect inguinal hernia 60. Post partum psychosis? Appropriate treatment? A. ECT*** B. Cognitive BT C. Antipsychotics 61. Diagnosis of pregnancy of uncertain period question? How would you tell the date? Pelvic examination when its supra bulge or 24 weeks or 6 weeks or when bulge below umbilicus USG is the best way. 62. One stem on stroke and paralysis? Very tricky one

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