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...Continued GAT Exam Practice Questions 21-30: Sequential and Pattern Recognition 21. 1, 2, 4, 8, ?  a) 10  b) 12  c) 16  d) 20 Answer: c) 16  Explanation: Doubling each time. 22. 2, 4, 8, 16, ?  a) 20  b) 24  c) 32  d) 40  Answer: c) 32  Explanation: Each number doubles. 23. 3, 6, 12, 24, ?  a) 36  b) 48  c) 54  d) 60  Answer: b) 48  Explanation: Doubling each time. 24. 5, 10, 20, 40, ?  a) 50  b) 60  c) 80  d) 100  Answer: c) 80  Explanation: Doubling each time. 25. 1, 3, 6, 10, ?  a) 12  b) 15  c) 16  d) 20  Answer: b) 15  Explanation: Sequence adds successive natural numbers: 1+2=3, 3+3=6, 6+4=10, 10+5=15. 26. 2, 4, 8, 14, ?  a) 20  b) 22  c) 24  d) 28  Answer: b) 22  Explanation: Adds 2, 4, 6, 8; next addition is 10, so 14+8=22. 27. Start with 10, subtract 2, then add 4, then subtract 6. What is the next step?  a) Add 8  b) Subtract 8  c) Add 6  d) Subtract 4  Answer: a) Add 8  Explanation: The pattern alternates subtracting and adding increasing even numbers. 28. Sequence: 2, 5, 10, 17, ?  a) 24  b) 26  c) 28  d) 30  Answer: b) 26  Explanation: Differences are +3, +5, +7, next +9; 17+9=26. 29. Pattern: 3, 6, 12, 24, ?  a) 36  b) 48  c) 54  d) 60  Answer: b) 48  Explanation: Each term doubles. 30. Number series: 2, 4, 8, 16, ?  a) 24  b) 30  c) 32  d) 36  Answer: c) 32  Explanation: Each number doubles. 31-40: Classification and Grouping 31. Which of the following is different?  a) Apple  b) Banana  c) Mango  d) Carrot  Answer: d) Carrot  Explanation: Apple, banana, mango are fruits; carrot is a vegetable. 32. Find the odd one out:  a) Rose  b) Tulip  c) Daisy  d) Mango  Answer: d) Mango  Explanation: Rose, tulip, daisy are flowers; mango is a fruit. 33. Choose the group of words that are related:  a) Pencil, Pen, Eraser  b) Apple, Banana, Carrot  c) Car, Bike, Bus  d) Dog, Cat, Cow  Answer: a) Pencil, Pen, Eraser  Explanation: All are stationery items. 34. Which word does not belong?  a) Circle  b) Square  c) Triangle  d) Rectangle  Answer: a) Circle  Explanation: Circle has no sides; others are polygons with sides. 35. Identify the set that is different:  a) Red, Blue, Green  b) Circle, Square, Triangle  c) Dog, Cat, Cow  d) Apple, Mango, Banana  Answer: b) Circle, Square, Triangle  Explanation: All are shapes; set c) is animals, set d) is fruits, set a) is colors. 36. Group the following words into a meaningful group:  a) Car, Bus, Train  b) Apple, Banana, Mango  c) Shirt, Pant, Shoe  d) Dog, Cat, Cow  Answer: a) Car, Bus, Train  Explanation: All are modes of transport. 37. Find the odd one out:  a) Ironing  b) Sewing  c) Painting  d) Baking  Answer: c) Painting  Explanation: Ironing, sewing, baking are household chores; painting is an art activity. 38. Choose the word that is different:  a) Cow  b) Sheep  c) Lion  d) Goat  Answer: c) Lion  Explanation: Cow, sheep, goat are domestic animals; lion is wild. 39. Identify the pair that is different:  a) Pen : Ink  b) Pencil : Graphite  c) Brush : Paint  d) Eraser : Lead  Answer: d) Eraser : Lead  Explanation: Eraser erases; lead is used in pencils, not erased by eraser. 40. Select the set which is different:  a) Rose, Lily, Tulip  b) Car, Bicycle, Boat  c) Mango, Apple, Banana  d) Dog, Cat, Horse  Answer: b) Car, Bicycle, Boat  Explanation: Different modes of transportation; other sets are plants

membrane looks normal. What is the tx option? a. Gentamicin topical b. Amoxicillin PO c. Analgesia d. Amoxicillin IV Q. 1. What is the key? Q. 2. What is the diagnosis? Ans. 1. The key is A. Gentamycin topical. Ans. 2. Diagnosis is otitis externa. 343. A 6wk child is very sick-looking. Bloods: Na+=124, K+=2.8. Dehydrated. What would you choose to resuscitate? a. 0.18% NS + 4% dextrose + 20mmol KCl b. 0.9% NS c. 0.45% NS d. 0.45% NS + 5% dextrose e. 0.45% NS + 5% dextrose + 20 mmol KCl Ans. The given key is E. But it is wrong key! The correct key is B. 0.9% NS. Explanation: Rsuscitation is mostly done with 0.9% NS or ringers lactate, or hartmans solution. Here is hypokalemia. To treat hypokalaemia the cut off value is below 2.5 mmol/L and absence of anuria during resuscitation. Maintenance is with fluid E. 344. A 68yo man gets repeated attacks of LOC and TIA. What is the most likely cause for this? a. Atrial fib b. Mitral stenosis c. Aortic stenosis d. HOCM e. Carotid artery stenosis   Ans. The key is E. Carotid artery stenosis.   345. Pt presented with hemoptysis 7d post-tonsillectomy. What is the next step? a. Packing b. Oral antibiotics + discharge c. Admit + IV antibiotics d. Return to theatre and explore e. Ice cream and cold fluids   Ans. The key is C. Admit + IV antibiotic. [infection is a common cause of secondary haemorrhage. Patient should be admitted to observe the course of bleeding and treatment is given with IV antibiotics].   346. A child was admitted following a RTA with initial GCS=15. Then during the night the noticed GCS reduced to 13. What is the management? a. Refer to neuro-surgeon b. IV fluids c. Oxygen d. CT brain e. Skull XR   Ans. The key is D. CT brain. [probable intracranial haemorrhage].   347. A 57yo woman who is suffering from HTN, presented to the hospital with complaints of recurrent falls when trying to get out of bed or getting up from sitting. She is on some anti-HTN therapy with no other med prbs. What is the cause of her fall? a. CCB b. Vertibrobasiliar insufficiency c. Thiazide d. Hypoglycemia e. Infection   Ans. The key is C. Thiazide. [It causes postural hypotension by volume depletion].   348. A 56yo woman with MS presents with drooping of the left side of her lips. She also has loss of sensation over her face, hearing impairment and some in-coordination of her movements. What is the most likely anatomical site affected? a. Cerebellum b. Cerebrum c. Spinal cord d. Brain stem e. Optic nerve   Ans. The key is D. Brain stem. Features of 5, 7, 8th cranial nerve and cerebellum involvement suggestive of brainstem lesion.   349. A 68yo male presented with swelling in the lower pole of the parotid gland for the last 10yrs. Exam: firm in consistency. What’s the most probable dx? a. Pleomorphic adenoma b. Adenolymphoma c. Mikulicz’s disease d. Parotiditis e. Frey’s syndrome   Ans. The key is A. Pleomorphic adenoma. [Pleomorphic adenoma (most common) - also called benign mixed tumour: is the most common tumour of the parotid gland and causes over a third of submandibular tumours. They are slow-growing and asymptomatic, having a malignant potentiality].   350. A 28yo shipyard worker was admitted for pain in calf while at work which has been increasing over the last 3m. There is no hx of HTN or DM but he is a smoker. Exam: loss of posterior tibial and dorsalis pedis pulsation along with a non-healing ulcer at the base of the right 1st MTP joint. What is the most probably dx? a. Thromboangitis obliterans b. Sciatica c. DVT d. Baker’s cyst e. Embolus   Q. 1. What is the key? Q. 2. What are the points in favour?   Ans. The key is A. Thromboangitis obliterans. Ans. 2. i) young age ii) smoker iii) pain in cuff iv) loss of posterior tibial and dorsalis pedis pulsation v) non-healing ulcer at the base of the right 1st MTP joint all are suggestive of Buerger’s disease.

333. A 60yo pt who has had a MI a week back presents with dyspnea and pericardial rub. ECG shows ST elevation. CXR: loss of margin at costo-vertebral angle. What is the single most likely cause? a. Cardiac tamponade b. Mitral regurge c. Dressler’s syndrome d. Atrial fib e. Emboli   Q. 1. What is the key? Q. 2. Why it is not reinfarction as there is ST elevation?   Ans. 1. The key is C. Dressler’s syndrome. Ans. 2. There is pericardial rub there is pericarditis and in pericarditis there is widespread ST elevation. So the condition is not new MI but Dressler’s syndrome.   334. A 12yo girl presented with tics, LOC, no residual sign and no post-ictal phase. EEG abnormality in temporal lobe. The girl had a rapid recovery. What is the most probably dx? a. Generalized tonic-clonic b. Myoclonic c. Partialgeneralized seizure d. Atonic seizure e. Febrile convulsion   Ans. The key is C. Partial –> generalized seizure   335. A 48yo woman who has been taking medications for asthma for a long time has now presented with decreasing vision. What is the most probable cause for her decrease in vision? a. Inhaled salbutamol b. Inhaled steroids c. Aminophylline d. Beta-blockers e. Oral steroids   Q. 1. What is the key? Q. 2. Justify the key.   Ans. 1. The key is E. Oral steroid. Ans. 2. Prolonged steroid use leads to cataract formation.   336. A 34yo man after a car crash is in the ED and deteriorating. His GCS has fallen from 13 to 7. What is the most appropriate next step? a. CT b. Burr hole c. MRI d. Intubation e. IV fluids   Ans. The key is D. Intubation. [ABC protocol].   337. A pt with alternating swings or episodes from elation and depression had underwent tx and gotten better. What medication needed to be continued so he can stay well? a. Anxiolytics b. Mood stabilizers c. Antidepressants d. Antipsychotics   Ans. The key is B. Mood stabilizers [bipolar disorder treated with mood stabilizers].   338. A 40yo male with pre-existing glumerulonephritis having proteinuria and hematuria suddenly deteriorates and presents with oliguria and serum K+=7.8mmol/L, urea=13mmol/L, creat=342mmol/L, GFR=19mL/h. The best management would be? a. Calcium supplement b. Calcium resonate enema 30g c. 10units insulin with 50% dextrose d. Nebulized salbutamol e. 10ml of 10% calcium gluconate f. Hemodialysis urgent   Q. 1. What is the key? Q. 2. Justify the key.   Ans. 1. The key is E. 10 ml of 10% calcium gluconate.   Ans. 2. To prevent cardiac arrhythmia. [Actually calcium gluconate neither shifts K+ to cells nor reduces serum K+ level that much. It just prevents cardiac arrest or life threatening cardiac arrhythmia and buys time till definitive measures are taken].   339. 34yo man was brought to the ED after a RTA. BP=50/0mmHg and chest wall not moving symmetrically, RR=34bpm. What would be initial action? a. IV fluid infusion b. Intubation and ventilation c. CT chest d. Transfer to ITU   Ans. The key is B. Intubation and ventilation [ABC protocol].   340. A pt complains of SOB, wheeze, cough and nocturnal waking. He has dry scaly shin with rashes that are itchy. What is the single most likely dx? a. Scabies b. Eczema c. Rheumatism d. Dermatitis e. Psoriasis   Ans. The key is B. Eczema. [Asthma may be associated with atopy].   341. A 54yo woman has presented with episodes of abdominal ache, vomiting and postural hypotension. She also has a dark pigmentation of her skin. A dx of Addison’s disease was made. What is the most likely electrolyte abnormality expected in this pt? a. High Na+, Low K+ b. Low Na+, High K+ c. Low Na+, Low K+ d. High Na+, High K+ e. Low Na+, Normal K+ Ans. The key is B. Low Na+, High K+. [ with Addison disease, the sodium, chloride, and carbon dioxide levels are often low, while the potassium level is high]. 342. An 8yo returned from Spain with severe pain in one ear. Exam: pus in auditory canal, tympanic

d. Meningioma e. Otosclerosis Q. 1. What is the key?   Q. 2. Justify the key. Ans. 1. The key is B. Acoustic neuroma. Ans. 2. Hearing loss, feeling of pressure in the ear with tinnitus, vertigo and involvement of cranial nerve i.e. right abducent nerve are suggestive of acoustic neuroma. 325. In 85% of the population this artery is dominant. What is the single most appropriate option? a. Left ant descending artery b. Coronary sinus c. Circumflex artery d. Left main stem, post descending artery e. Right coronary artery Q. 1. What is the key? Q. 2. Justify the key. Ans. 1. The key is E. Right coronary artery. Ans. 2. If the posterior discending artery is supplied by the circumflex artery then it is left dominant and if posterior descending artery is supplied by the right coronary artery then it is right dominant. As in 85% of population posterior descending artery is supplied by right coronary artery it is called the dominant that is right coronary artery is dominant. 326. A 54 yo lady presents with sudden, severe pain in the left half of her skull. She also complains of pain around her jaw. What is the next likely step? a. CT b. MRI c. Fundoscopy d. ESR e. Temporal artery biopsy 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 ESR. Ans. 2. The diagnosis is Giant cell arteritis or temporal arteritis. Ans. 3. Points in favour: i) Age >50yrs ii) Female sex iii) Severe pain in the left half of skull iv) Pain around the jaw (jaw claudication). 327. A teenage girl who was ‘fine’ until her boyfriend said he didn’t want the relationship anymore. She took 10 tablets of paracetamol in front of his mother after taking alcohol. What should you do? a. Refer to psychiatry b. Counselling c. GP to sort out family issues d. Return to work to relieve her anger Ans. The key is A. Refer to psychiatry. [1o tablets of paracetamol is not a life threatening toxic dose and simultaneous drug overdose and alcohol consumption needs psychiatric evaluation]. 328. A 6yo fell on outstretched hand while playing. He feels tender at the elbow but otherwise well. What is the most likely dx? a. Spiral fx b. Green stick fx c. Compound fx d. Supracondylar fx e. Pulled elbow Ans. The key is B. Green stick fracture. 329. A man has a BP of 160/90mmHg, proteinuria++. KUB US are equally reduced in size with smooth borders and normal pelvic calyceal system. What is the cause of HTN in the pt? a. Chronic glomerulonephritis b. Chronic pyelonephritis c. Bilateral renal artery stenosis d. Essential HTN e. Polycystic kidney Ans. The key is bilateral renal artery stenosis. This is probably a wrong key. The correct key should be A. Chronic glomerulonephritis. [In bilateral renal artery stenosis BP is very high]. 330. A lady presents with abdominal pain, dysuria, dyspareunia and vaginal discharge. What si your next step? a. Laparoscopy b. High vaginal swab c. Hysteroscopy d. Laparotomy e. US Ans. The key is B. High vaginal swab. [Probable diagnosis is PID].                    331. An old lady 72yo staying at a nursing home for a few years, a known HTN on reg tx presented with sudden dysphagia while eating with drooling of saliva and req urgent inv. What would be your next step? a. Ba swallow b. Chest CT c. Endoscopy d. Laryngoscopy e. CXR f. Endoscopy with biopsy  Ans. The key is C. Endoscopy.  [Probable impacted food bolus (usually meat)which can be visualized and removed with the aid of endoscopy]. 332. A man presents with outward deviation of his right eye and diplopia. Which nerve is affected? a. Left trochlear b. Left oculomotor c. Right trochlear d. Right abducens e. Right oculomotor Ans. The given key is B. Left oculomotor! It is wrong key! As in oculomotor nerve lesion there is ipsilateral symptoms so the correct answer is E. Right oculomotor.

a. Minimal change disease b. Glomerulonephropathy c. Membranous glomerulonephropathy d. FSGS e. IgA nephropathy f. Mesangiocapillary Ans. The given key is C. Membranous glomerulonephritis. [Some authority claims FSGS as more common cause of nephrotic syndrome]. 318. A 53yo man presents complaining of weight loss, lethargy, increasing abdominal discomfort and gout for the past yr. Exam: spleen palpated 5cm below left costal margin, no fluid wave. CBC: Hgb=10.5g/dL, WBC=200 – 85% neutrophils, plts=100, Na+=140mmol/L, K+ 4mmol/L, create=151umol/L, urea=7mmol/L. Serum B12 increased. Philadelphia chromosome +ve. What is the most likely dx? a. CML b. CLL c. AML d. ALL e. Lymphoma Q. 1. What is the key? Q. 2. What are points in favour of this diagnosis? Ans. 1. The key is A. CML. Ans. 2. Points in favour: i) wt loss ii) lethargy iii) abdominal discomfort iv) splenomegaly v) gout [Elevated uric acid and vitamin B12 levels are found in 25% of patients of CML]. A blood picture is suggestive and +ve Philadelphia chromosome is diagnostic. 319. In a group of cancer pts, 10 died that wasn’t treated while 5 died in the tx group. Which statement is correct? a. Absolute risk =10 b. Relative risk =10 c. Relative risk =5 d. Absolute risk=5 e. Relative risk=2 Ans. Given key is E. relative risk = 2. [RR= Number of death in not treated group/number of death in treated group]. 320. A 67yo woman has presented with hard, irregular, poorly defined 5cm lump in her right breast. She has a bruise on the surface and there is no discharge. What is the most likely dx? a. Fibroadenosis b. Fat necrosis c. Fibroadenoma d. Duct ectasia e. Ca breast Q. 1. What is the key? Q. 2. Please justify the key. Ans. 1. The key is B. Fat necrosis. Ans. 2. Fat necrosis usually occurs following trauma or surgery. Given case is a fat necrosis of breast as there is no discharge and there is a bruise indicating prior trauma.   321. A 67yo female who had undergone a radical mastectomy now comes with the complaint of swelling and redness in her right upper limb. Involvement of which of the following structures explain these symptoms? a. Epitrochlear LN b. Cephalic vein c. Subclavian artery d. Axillary group of LN e. Long thoracic nerve Ans. The key is D. Axillary group of LN. [Axillary clearance compromise lymphatic flow and may results in swelling of upper limb]. 322. A 50yo smoker and heavy drinker presents with complaints of racing heart. A 24h ECG comes out normal. What is your next step in management? a. ECHO b. Reassure c. Stress test Ans. The key is B. Reassure. [Smoking and alcohol excess can cause palpitation without any recognizable arrhythmia and for this no treatment is required]. 323. A 47yo man comes to the GP with a swelling in his left groin which disappears on lying down. The swelling was bluish in color and felt like a bag of worms. He also complains of a mass in the left loin along with hematuria occasionally. What could be the possible dx? a. Left sided RCC b. Varicosity 2nd to liver disease c. Testicular tumor d. UTI e. IVC obstruction Q. 1. What is the key? Q. 2. What is the condition described? Q. 3. What is the link between these two conditions? Ans. 1. The key is A. Left sided Renal cell carcinoma. Ans. 2. Left sided varicocele. Ans. 3. Most common secondary cause of left sided varicocele is RCC. Newly diagnosed varicocele over the age of 40yrs are very much suggestive of RCC. Varicocele is common on left side as left testicular veins drain to the left renal vein, while the right testicular vein drain directly into IVC. 324. A man presents with muffled hearing and feeling of pressure in ear with tinnitus and vertigo. He also complains of double vision when looking to the right. What is the most appropriate dx? a. Meniere’s disease b. Acoustic neuroma c. Acute labyrinthytis

310.  An alcoholic 56yo man had ascetic fluid analysis done which was found to be yellow color. What is the most appropriate cause? a. Alcoholic hepatitis b. Decompensated cirrhosis c. TB peritonitis d. Pyogenic peritonitis e. Neoplasm Q. 1. What is the key? Q. 2. How this diagnosis is made? Ans. 1. The key is B. Decompansated cirrhosis. Ans. 2. If the patient experiences any of the serious problems described below his disease has progressed from compensated cirrhosis to decompensated cirrhosis: i)                    Bleeding varices (internal bleeding) ii)                   Ascites (fluid in the belly) iii)                 Encephalopathy (confusion) iv)                 Jaundice (yellowing of eyes and skin). 311. A 15yo boy presents with testicular pain for 2days. There is no hx of trauma. Exam: temp=38.5C, right hemi-scrotum tenderness. What is the single most appropriate management? a. Give antibiotics b. Give analgesia c. Reassure d. US scrotum e. Exploratory surgery Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. What are the points in favour? Ans. 1. The key is A. Give antibiotics. Ans. 2. The diagnosis is epididymo-orchitis. Ans. 3. Points in favour:  i) No history of trauma ii) testicular pain with fever points towards epididymo-orchitis. 312. A 58yo lady presented with urinary incontinence. She looks anxious for her condition. Urine culture is sterile. Her urodynamic study is normal. What is the next step? a. Antibiotics b. Topical estrogen c. Systemic estrogen d. Duloxetine e. Pelvic floor exercise Ans. The key is E. Pelvic floor exercise. 313. A 45yo lady came to family planning clinic for contraception advice. She is not keen to be pregnant for the next 3yrs. Her recent US showed multiple small submucosal fibroid. What is the best method of contraception for her? a. Etonogestrol b. COCP c. IUS d. POP e. IUCD Ans. The key is C. IUS. [IUS gives 3-5 yrs long contraception. It also helps to shrink the fibroid]. 314. A child presents with eczema. She was given two creams by the GP – emollient and steroid. What advice would you give her regarding application of the cream? a. Sparingly use both the cream b. First use emollient, then steroid c. Apply steroid then emollient d. Mix emollient & steroid before use e. Emollient at night with steroid Ans. The key is B. First use emollient, then steroid. [emmolient 30 minutes before steroid]. 315. All the following drugs do not cause bronchoconstriction except? a. Atenolol b. Salbutamol c. Salmetrol d. Ipratropium bromide e. Cocaine Ans. The key is A. Atenolol. It is a wrong key! Correct key is E. Cocaine. [Atenolol is a cardioselective beta blocker with negligible bronchoconstriction effect while cocaine is a potent bronchoconstrictor!!]. 316. A 28 yo female who delivered 6 weeks ago feels sad and has no interest to feeding the baby. She has been eating poorly and having difficulty sleeping. She feels weak throughout the day and has stopped taking the baby out of the house. She also says that the baby has evil eyes. What is the most likely diagnosis? a. Postpartum blues b. Postpaetum depression                      c. Postpurtum psychosis d. Schizophrenia e. Psychotic depression Q. 1. What is the key? Q. 2. What are the points in favour? Ans. 1. The key is C. Postpartum psychosis. Ans. 2. Points in favour: i) features of depression: feels sad, poor eating, difficulty sleep, feeling weak ii) delusional ideas: thinks baby has evil eyes and not taking the baby out of the house. These points to postpartum psychosis. [Postpartum psychosis starts within 2 wks (occasionally later) of delivery and it can take 6 -12 months or more to recover from postpartum psychosis]. 317. A 44yo man presents with periorbital and pedal edema. 24h urine shows 8g of protein/d and serum cholesterol=7mmol/L. Renal biopsy results are awaited. What would be the most likely dx?

301. A 27yo presents with abdominal pain, bleeding, vomiting and diarrhea. Her LMP was 7wks ago. Exam: abdominal tenderness, BP=90/60mmHg. What is the next appropriate management? a. Immediate laparotomy b. Laparoscopy c. Salpingotomy d. Salpingectomy e. MTX Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. Justify the key. Ans. 1. The key is A. Immediate laparotomy. Ans. 2. The diagnosis is ruptured ectopic pregnancy . Ans. 3. In ruptured ectopic pregnancy if there is shock we should go for immediate laparotomy. 302. A woman presents with complains of abdominal pain, unsteadiness, numbness of lower limb and palpitations. All inv are normal. What is the dx? a. Manchausen b. Somatization c. Hypochondriac d. Bipolar Ans. The key is B. Somatization. [This is multiple, recurrent, medically unexplained symptoms usually starting early in life. Usually patient presents with one symptom at a time. Investigations are normal]. 303. A 34yo African-caribbean man with a hx of sarcoidosis has presented with bilateral kidney stones. What is the most likely cause for this pt’s stones? a. Hypercalcemia b. Hyperuricemia c. Diet   d. Recurrent UTIs e. Hyperparathyroidism Q. 1. What is the key? Q. 2. Why this occurs? Ans. 1. The key is A. Hypercalcemia. Ans. 2.  Hypercalcemia in sarcoidosis is due to the uncontrolled synthesis of 1,25-dihydroxyvitamin D3 by macrophages. 1,25-dihydroxyvitamin D3 leads to an increased absorption of calcium in the intestine and to an increased resorption of calcium in the bone.  304. Which of the following is NOT a physiological change during pregnancy? a. Tidal volume 500ml b. RBC vol 1.64L c. Cardiac output 6.5L/min d. Uterus weight 1.1kg e. ESR up by 4x Ans. The key is A. Tidal volume 500 ml. 305. A 10yo boy presents with nose bleed. What measure should be taken to stop the bleeding? a. Press base of the nose b. Ice packs c. Press soft parts of the nose d. Start tranexemic acid e. IV fluids Ans. The key is C. Press soft parts of the nose. 306. An MI pt who is already on aspirin no longer smokes and his cholesterol, ECG, echo and BP are normal. Choose the best option for him: a. Give statin b. Give statin+warfarin c. Low cholesterol diet d. Statin+ACEi Ans. The key is D. Statin + ACEi. [Offer all people who have had an acute MI treatment with the following drugs: ACE (angiotensin-converting enzyme) inhibitor dual antiplatelet therapy (aspirin plus a second antiplatelet agent) beta-blocker statin. [2007, amended 2013] [NICE guideline]. 307. A 46yo man is being treated for a pleural effusion. A chest drain has been sited just below the 4th rib in the mid-axillary line on his right side. What single structure is at particular risk of injury? a. Arzygos vein b. Diaphragm c. Intercostal artery d. Internal thoracic artery e. Liver Ans. The key is C. Intercostal artery. [Most vulnerable structure is intercostal nerve, then intercostal artery then intercostals vein. As intercostal nerve is not in option intercostal artery is the answer here]. 308. What advice would you give for the parents of a child with repeated UTI? a. Surgery            b. Prophylactic antibiotics c. Increase fluids d. Toilet training e. Laxatives Ans. The given key is A. Surgery. This is a wrong key. Correct option is B. Prophylactic antibiotic.[For repeated UTI prophylactic antibiotic should be given]. 309. A pt presents with complete anuria following prolonged hypotension and shock in a pt who bled profusely from a placental abruption. What is the most probable dx? a. Post viral infection b. Acute papillary necrosis c. Acute cortical necrosis d. HUS e. Renal vein thrombosis Q. 1. What is the key? Q. 2. What is the reason for this? Ans. 1. The key is C. Acute cortical necrosis. Ans. 2. There are 2 reasons for this acute cortical necrosis. i) significant diminished arterial perfusion of the kidneys due to spasm of the feeding artery secondary to profuse bleeding from placental abruption ii) DIC secondary to placental abruption.

b. Desmopressin c. Reassure d. Behavior training e. Imipramine Ans. The given key is B. Desmopressin.  This is wrong key! Correct key is D. Behavior training. [behavior training seems to be more appropriate. Desmopressin is given for short term relief generally and after alarm bells fail to control symptoms, it is used in children above 7 yrs whereas given case is of a child of 6 yrs]. 292. A 27yo 34wk pregnant lady presents with headache, epigastric pain and vomiting. Exam: pulse=115, BP=145/95mmHg, proteinuria ++. She complains of visual disturbance. What is the best medication for the tx of the BP? a. 4g MgSO4 in 100ml 0.9%NS in 5mins b. 2g MgSO4 IV bolus c. 5mg hydralazine IV d. Methyldopa 500mg/8h PO e. No tx Ans. The given key is A. 4g MgSO4 in 100ml 0.9%NS in 5mins. It is a wrong key. Correct key is E. No tx. [Here, question specifically asked for tx of BP. In case of BP of 145/95 mmHg no treatment for BP is needed. Ref: NICE guideline]. 293. A 24yo lady who is 37wk pregnant was brought to the ED. Her husband says a few hours ago she complained of headache, visual disturbance and abdominal pain. On arrival at the ED she has a fit. What is the next appropriate management for this pt? a. 4g MgSO4 in 100ml 0.9%NS in 5mins b. 2g MgSO4 IV bolus c. 2g MgSO4 in 500ml NS in 1h d. 4g MgSO4 IV bolus e. 10mg diazepam in 500ml 0.9%NS in 1h Ans. The key is A. 4g MgSO4 in 100ml 0.9%NS in 5mins [NICE]. [Dx is eclumpsia]. 294. What is the pathological change in Barret’s esophagitis? a. Squamous to columnar epithelium b. Columnar to squamous epithelium c. Dysplasia d. Metaplasia e. Hyperplasia Ans. The key is A. Squamous to columner epithelium. 295. A 34yo male presents with hx of headache presents with ataxia, nystagmus and vertigo. Where is the site of the lesion? a. Auditory canal b. 8th CN c. Cerebellum d. Cerebral hemisphere e. Brain stem Ans. The key is C. Cerebellum. [Features described are consistent with cerebellar lesion]. 296. A 24yo girl comes to the woman sexual clinic and seeks advice for contraception. She is on sodium valproate. a. She can’t use COCP b. She can use COCP with extra precaution c. She can use COCP if anticonvulsant is changed to carbamezapin. d. She can use COCP with estrogen 50ug and progesterone higher dose e. She can use COCP Ans. The key is E. She can use COCP. [sodium valproate has no effect on cocp] 297. A 27yo lady came to the ED 10 days ago with fever, suprapubic tenderness and vaginal discharge. PID was dx. She has been on the antibiotics for the last 10days. She presents again with lower abdominal pain. Temp=39.5C. what is the most appropriate next management? a. Vaginal swab b. Endocervical swab c. US d. Abdominal XR e. Laparoscopy Ans. The key is C. US. [Initial presentation was of PID. But recurrance of symptoms suggests resistant condition like abscess formation]. 298. An 18yo man complains of fatigue and dyspnea, he has left parasternal heave and systolic thrill with a harsh pan-systolic murmur at left parasternal edge. What is the most probable dx? a. TOF b. ASD c. VSD d. PDA e. TGA Ans. The key is C. VSD. 299. A young girl presenting with fever, headache, vomiting, neck stiffness and photophobia. She has no rashes. What is the most appropriate test to confirm dx? a. Blood culture b. Blood glucose c. LP d. CXR e. CT Ans. The key is C. LP. [case of meningitis. LP will confirm the diagnosis]. 300. A 65yo HTN man wakes up in the morning with slurred speech, weakness of the left half of his body and drooling. Which part of the brain is affected? a. Left parietal lobe b. Right internal capsule c. Right midbrain d. Left frontal lobe Ans. The key is B. Right internal capsule. [As symptoms are on left side lesion is on right side of the brain. So answer should be either b) right internal capsule or c) right midbrain. If it was midbraine there would have cranial nerve involvement. On the other hand given picture is very much consistent with lacunar infarction of internal capsule!]

at booking (8-10 weeks)- if less than 11  at 28 weeks and further- if less than 10.5 if less than these values=> give iron]. 283. A 47yo man who is a chronic alcoholic with established liver damage, has been brought to the hospital after an episode of heavy drinking. His is not able to walk straight and is complaining of double vision and is shouting obscenities and expletives. What is the most likely dx? a. Korsakoff psychosis b. Delirium tremens c. Wernickes encephalopathy d. Tourettes syndrome e. Alcohol dependence Ans. The key is C. Wernicke’s encephalopathy. [triad of i) ophthalmoplegia, ii) ataxia iii) confusion]. 284. A 32yo woman of 39wks gestation attends the antenatal day unit feeling very unwell with sudden onset of epigastric pain a/w nausea and vomiting. Temp 36.7C. Exam: RUQ tenderness. Bloods: mild anemia, low plts, elevated LFT and hemolysis. What is the most likely dx? a. Acute fatty liver of pregnancy b. Acute pyelonephritis c. Cholecystitis d. HELLP syndrome e. Acute hepatitis Ans. The key is D. HELLP syndrome. [H=hemolysis, EL=elevated liver enzyme, LP=low platelet count]. 285. A 57yo woman presents with dysuria, frequency and urinary incontinence. She complains of dyspareunia. Urine culture has been done and is sterile. What is the most appropriate step? a. Oral antibiotics b. Topical antibiotics c. Topical estrogen d. Oral estrogen e. Oral antibiotics and topical estrogen Ans. The key is C. Topical estrogen. [There may be UTI like symptoms and dyspareunia in atrophic vaginitis for which topical oestrogen can be used]. 286. A pt came to the ED with severe lower abdominal pain. Vitals: BP=125/85mmHg, Temp=38.9C. Exam: abdomen rigid, very uncomfortable during par vaginal. She gave a past hx of PID 3 years ago which was successfully treated with antibiotics. What is the appropriate inv? a. US b. Abdomen XR c. CT d. High vaginal e. Endocervical swab Ans. The key is A. US. [Patient had previous PID. Current symptoms of severe cervical motion tenderness with significant rise of temperature is very much suggestive of pelvic abscess]. 287. A pregnant woman with longterm hx of osteoarthritis came to the antenatal clinic with complaints of restricted joint movement and severe pain in her affected joints. What is the choice of drug? a. Paracetamol b. Steroid c. NSAID d. Paracetamol+dihydrocoiene e. Pethadine Ans. The key is A. Paracetamol. 288. A 24yo 18wk pregnant lady presents with pain in her lower abdomen for the last 24h. She had painless vaginal bleeding. Exam: abdomen is tender, os is closed. What is the most probable dx? a. Threatened miscarriage b. Inevitable miscarriage c. Incomplete miscarriage d. Missed miscarriage e. Spontaneous miscarriage Ans. The key is A. Threatened miscarriage. [gestational age 18 weeks, lower abdominal pain, tender abdomen, closed os and painless vaginal bleeding indicates threatened abortion]. 289. A 2yo child playing in the garden had a clean cut. She didn’t have any vaccinations. Also, there is no contraindication to vaccinations. Parents were worried about the vaccine side effects. What will you give? a. Clean the wound and dress it b. Give TT only c. Give DPT only d. Give DPT and tetanus Ig e. Give complete DPT vaccine course Ans. The key is E. Give complete DPT vaccine course. 290. A 32yo female who has had 3 prv miscarriages in the 1st trimester now comes with vaginal bleeding at 8wks. US reveals a viable fetus. What would be the most appropriate definitive management? a. Admit b. Aspirin c. Bed rest 2 weeks d. Cervical cerclage e. No tx Ans. The key is B. Aspirin. [Early miscarriage is more common in antiphospholipid syndrome and treated with heparin or aspirin when become pregnant]. 291. A 6yo girl started wetting herself up to 6x/day. What is the most appropriate tx? a. Sleep alarms

since yesterday. Exam: BP=90/40mmhg, pulse=110bpm, temp=38C, uterus tender on palpation and fundus 2cm above umbilicus, blood clots +++. Choose the single most likely dx/ a. Abruption of placenta 2nd to pre-eclampsia b. Concealed hemorrhage c. Primary PPH d. Secondary PPH e. Retained placenta f. Scabies Q. 1. What is the key? Q. 2. How the condition is defined? Ans. 1. The key is D. Secondary PPH. Ans. 2. Secondary PPH: Secondary PPH is defined as abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally. [www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/]. 275. A 32yo female with 3 prv 1st trimester miscarriages is dx with antiphospholipid syndrome. Anticardiolipin antibodies +ve. She is now 18wks pregnant. What would be the most appropriate management? a. Aspirin b. Aspirin & warfarin c. Aspirin & heparin d. Heparin only e. Warfarin only Ans. The key is C. Aspirin & heparin. 276. A 23yo presents with vomiting, nausea and dizziness. She says her menstrual period has been delayed 4 weeks as she was stressed recently. There are no symptoms present. What is the next appropriate management? a. Refer to OP psychiatry b. Refer to OP ENT c. CT brain d. Dipstick for B-hCG e. MRI brain Q. 1. What is the key? Q. 2. What is the likely diagnosis? Ans. 1. The key is D. Dipstick for B-hCG. Ans. 2. Likely diagnosis is pregnancy. [Features like vomiting, nausea and dizziness are consistent with early pregnancy supported by delayed menstruation]. 277. A 16yo girl came to the sexual clinic. She complains of painful and heavy bleeding. She says she doesn’t a regular cycle. What is the most appropriate management? a. Mini pill b. Combined pill c. IUS d. Anti-prostoglandins e. Anti-fibrinolytics Ans. The key is B. Combined pill. 278. A 36yo man walks into a bank and demands money claiming he owns the bank. On being denied, he goes to the police station to report this. What kind of delusions is he suffering from? a. Delusion of reference b. Delusion of control c. Delusion of guilt d. Delusion of persecution e. Delusion of grandeur Ans. The key is E. Delusion of grandeur. 279. Which method of contraception can cause the risk of ectopic pregnancy? a. COCP b. IUCD c. Mirena d. POP Ans. The key is B. IUCD. 280. A woman has pernicious anemia. She has been prescribed parenteral vitamin B12 tx but she is needle phobic. Why is oral tx not preferred for this pt? a. IM B12 is absorbed more b. Intrinsic factor deficiency affects oral B12 utilization c. IM B12 acts faster d. IM B12 needs lower dosage e. Pernicious anemia has swallowing difficulties Ans. The key is B. Intrinsic factor deficiency affects oral B12 utilization.   281. An old man comes to the doctor complaining that a part of this body is rotten and he wants it removed. What is the most likely dx? a. Guilt b. Hypochondriasis c. Munchausen’s d. Nihilism e. Capgras syndrome Ans. The key is D. Nihilism. [nihilism (medical term is nihilistic delusion): parts of the body do not exist or are dead] Guilt: an emotion that occurs when a person feels that they have violated a moral standard. Hypochondriasis:  worry about having a serious illness.  Munchausen’s: a psychiatric factitious disorder wherein those affected feign disease, illness, or psychological trauma to draw attention,sympathy, or reassurance to themselves.  Capgras syndrome: a delusion that a friend, spouse, parent, or other close family member (or pet) has been replaced by an identical-looking impostor. 282. A 31yo woman who is 32weeks pregnant attends the antenatal clinic. Labs: Hgb=10.7, MCV=91. What is the most appropriate management for this pt? a. Folate supplement b. Ferrous sulphate 200mg/d PO c. Iron dextran d. No tx req Ans. The key is D. No tx required. [According to NICE, cut offs for iron supplements:

a. CML b. CLL c. Polycythemia vera d. Myelofibrosis e. NHL   Q. 1. What is the key? Q. 2. What are the points in favour?   Ans. 1. The key is C. Polycythemia vera. Ans. 2. Points in favour: i) hyperviscosity symptoms (headache, dizziness, tinnitus, visual problem) ii) pruritus, typically after a hot bath, iii)splenomegaly iv) RBC=87, Hb=31.9, Plt=796.   266. A 29yo male brought to ED in unconscious state. There is no significant past hx. Which of the following should be done as the initial inv? a. CT b. Blood glucose c. ABG d. MRI e. CBC   Ans. The key is B. Blood glucose.   267. A 45yo woman comes with red, swollen and exudating ulcer on the nipple and areola of right breast with palpable lump under the ulcer. What do you think is causing this skin condition? a. Inflammatory cells releasing cytokines b. Infiltration of the lymphatics by the carcinomatous cells c. Infiltration of the malignant skin cells to the breast tissue   Ans. The key is B. Infiltration of the lymphatics by the carcinomatous cells.   268. A 20yo young lady comes to the GP for advice regarding cervical ca. she is worried as her mother past away because of this. She would like to know what is the best method of contraception in her case? a. POP b. Barrier method c. IUCD d. COCP e. IUS   Ans. The key is A. POP.  Probably wrong key! Correct key should be B. Barrier method! [spermatozoa itself acts as a carcinogen!!! So barrier method is the best protection from the given option!!].   269. A 66yo man, an hour after hemicolectomy has an urine output of 40ml. However, an hour after that, no urine seemed to be draining from the catheter. What is the most appropriate next step? a. IV fluids b. Blood transfusion c. Dialysis d. IV furosemide e. Check catheter   Ans. The key is E. Check catheter.   270. A 24yo pt presented with anaphylactic shock. What would be the dose of adrenaline? a. 0.5ml of 1:1000 b. 0.5ml of 1:10000 c. 1ml of 1:500 d. 5ml of 1:1000 e. 0.05ml of 1:100   Ans the key is A. o.5 ml of 1:1000. [in cardiac arrest 1 ml of 1:1000 iv].   271. A 44yo woman complains of heavy bleeding per vagina. Transvaginal US was done and normal. Which of the following would be the most appropriate inv for her? a. Hysterectomy b. Endometrial biopsy c. CBC d. High vaginal swab e. Coagulation profile Ans. The key is E. Coagulation profile. [Transvaginal US is normal i.e. no endometrial hyperplasia, no fibroid or obvious cause for heavy bleeding was found. So now most appropriate investigation should be coagfulation profile].   272. A 60yo woman presented to OPD with dysphagia. No hx of weight loss or heartburn. No change in bowel habits. While doing endoscopy there is some difficulty passing through the LES, but no other abnormality is noted. What is the single most useful inv? a. CXR b. MRI c. Esophageal biopsy d. Esophageal manometry e. Abdominal XR Q. 1.  What is the key? Q. 2. What is the diagnosis? Q. 3. What is the treatment. Ans. 1. The key is D. Oesophageal manometry. Ans. 2. Achalasia cardia Ans. 3. i) Oral medication: Nitrates or CCB ii) Balloon dilatation of the spincter iii) Oesophagomyotomy.   273. A 24yo woman presents with deep dyspareunia and severe pain in every cycle. What is the initial inv? a. Laparoscopy b. Pelvic US c. Hysteroscopy d. Vaginal Swab Q. 1. What is the key? Q. 2. What is the likely diagnosis? Q. 3 What is the treatment? Ans. 1. The key is B. Pelvic US. Ans. 2. The likely diagnosis is endometriosis. Ans. 3. Treatment: There is no cure for endometriosis, but a number of treatments may improve symptoms. This may include pain medication [NSAIDs such as naproxen], hormonal treatments [COCP, or mirena], or surgery [Surgical removal of endometriosis when other measures fail]. 274. A 38yo woman, 10d postpartum presents to the GP with hx of passing blood clots per vagina

Ans. 1. The key is E. Hypomania. Ans. 2. i) elevated mood ii) more energy than before iii) getting more work done at the office (loss of inhibition).  These features are common for both mania and hypomania!! Then why it is not mania? It is not mania as in mania you will get psychotic symptoms like i) delusion of grandeur ii) auditory hallucinations, which are absent here!   259. A 35yo female attempts suicide 10x. There is no hx of psychiatric problems and all neurological exams are normal. What is the best tx? a. Problem focused tx b. CBT c. Antipsychotic d. Antidepressant e. ECT   Ans. The key is A. Problem focused tx. [patient is not psychotic and with normal neurology! So she may getting some problem in family life, finance, job or somewhere like this which she is not able to cope with and that is leading to her suicidal thoughts].   260. A 57yo man presents with weight loss, tiredness, fever and abdominal discomfort. Exam: spleen palpable up to the umbilicus. Labs: WBC=127, Hgb=8.7, Plt=138. What is the most likely dx? a. CML b. AML c. CLL d. AML e. Polycythemia   Q. 1. What is the key? Q. 2. Why it is so diagnosed? Ans. 1. The key is A. CML. Ans. 2. Points in favour of CML: i) Age 57 years ii) weight loss iii) abdominal discomfort iv) anaemia v) fever vi) marked splenomegaly.   261. A baby born at 34 weeks with a heart murmur is kept in the incubator for almost 4 weeks. There is no murmur at discharge. What is the likely cause of this murmur? a. PDA b. TOF c. Aneurysm of sinus of Valsalva d. Aorto-pulmonary septal defect e. AVM   Q. 1. What is the key? Q. 2. Why it was present in this baby? Q. If it is present after birth what is the management?   Ans. 1. The key is A. PDA. Ans. 2. As it is more common in premature baby! Ans. 3. Management:  indomethacin closes the connection in the majority of cases  if associated with another congenital heart defect amenable to surgery then prostaglandin E1 is useful to keep the duct open until after surgical repair.   262. A 6yo girl who has previously been well presented with a hx of tonic-clonic seizures lasting 4mins. Her mother brought her to the hospital and she appeared well. She is afebrile and didn’t lose consciousness during the episode of seizure. She has no neurologic deficit. What is the most appropriate inv for her? a. ABG b. Serum electrolytes c. ECG d. Blood glucose   Q. 1. What is the key? Q. 2. What are the points in favour?    Ans. 1. The key is B. Serum electrolyte. Ans. 2. In epilepsy patient becomes unconscious. The child has no previous illness and she was conscious during the episode of seizure. So electrolyte imbalance may be the cause.   263. A 60yo woman was found by her son. She was confused and had urinary incontinence. She has recovered fully after 6h with no neurological complaints. What is the most likely dx? a. Stroke b. Vestibular insufficiency c. TIA d. Intracranial hemorrhage   Ans. The key is C. TIA.   264. A 34yo woman presents 3 weeks after childbirth. She has had very low mood and has been suffering from lack of sleep. She also has thought of harming her little baby. What is the most appropriate management for this pt? a. ECT b. CBT c. IV haloperidol d. Paroxethine e. Amitryptiline   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 A. ECT. Ans. 2. The diagnosis is post purtum psychosis. Ans. 3. Points in favour: i) onset 3 weeks after childbirth ii) Depressive symptoms (very low mood, insomnia) iii) thought of harming her little baby.   265. A 65yo woman presents with headache. She also complains of dizziness and tinnitus. She has Recently realized she has visual problems. There is hx of burning sensation in fingers and toes. On exam: splenomegaly, itchy after hot bath. Labs: RBC=87, Hgb=31.9, Plt=796. What is the dx?

251. A 7yo is brought by his mother who says that he was well at birth but has been suffering from repeated chest and GI infections since then. She also says that he is not growing well for this age. What is the likely condition of this child? a. CF b. SCID c. Primary Tcell immunodeficiency d. Primary Bcell immunodeficiency e. Malabsorption   Q. 1. What is the key? Q. 2. What are the points in favour?   Ans. 1. The key is A. cystic fibrosis. Ans. 2. CF involved in production of sweat, respiratory mucous, digestive fluid and mucous. These secretion becomes thick than normal predisposing to lung and GI infections since birth.   252. A 3yo child has a high temp for 4 days and he had not seen a doctor. Then mother notices rashes on buccal mucosa and some around the mouth. What is the most appropriate dx? a. Measles b. Roseola infectiosum c. Rubella d. Chicken pox e. Impetigo   Ans. The key is B. Roseola infectiosum. It is a wrong key! The correct key should be A. Measles! [As the rash developed after 4 days fever the dx is measles!].       253. A 70yo lady presents with fever for 3d and confusion. There is no significant PMH. What is the most probable dx? a. Delirium b. Hypoglycemia c. Alzheimers d. DKA   Ans. The key is A. Delirium. Delirium is an acute confusional state and declined cognitive function which involves changes in arousal (hyperactive, hypoactive or mixed), perceptual deficits, altered sleep-wake cycle, and psychotic features such as hallucinations and delusions.   254. An obese mother suffers from OSAS. Which of the following inv is best for her? a. ABG b. Overnight pulse-oximetry c. Polysomnography d. EEG   Ans. The key is B. Overnight pulse-oxymetry. [It is already a diagnosed case of OSAS. So no need for reconfirmation with polysomnography. If like to know the current status or monitor overnight pulse oxymetry is good].   255. A 28yo business man came to the sexual clinic. He was worried that he has HIV infection. 3 HIV tests were done and all the results are negative. After a few months, he comes back again and claims that he has HIV. What is the dx? a. Somatization b. Hypochondriac c. Mancheusens d. OCD e. Schizophrenia   Ans. The key is B. Hypochondriac.  [worry about having a serious illness].   256. A 6wk child presents with progressive cyanosis, poor feeding, tachypnea over the first 2 wks of life and holosystolic murmur. What is the most appropriate condition? a. ASD b. VSD c. Tricuspid atresia d. PDA e. TOF   Q. 1. What is the key? Q. 2. What are the points in favour?     Ans. 1. The key is E. Tetralogy of Fallot. It is a wrong key!! Correct answer is C. tricuspid atresia. Ans. 2. Points in favour: i) tachypnoea over first 2 wks of life ii)progressive cyanosis iii) poor feeding iv) holosystolic murmur of VSD.     257. A 29yo woman who was dx to have migraine presents with severe onset of occipital headache. She lost her consciousness. CT=normal. Neurological exam=normal. What is the most appropriate management? a. Repeat CT b. MRI c. LP d. XR e. No inv required   Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. What are the points in favour?   Ans. 1. The key is E. No investigation required. Ans. 2. The diagnosis is basilar migraine. Ans. 3. Points in favour i) history of migraine ii) severe occipital headache iii) LOC iv) CT normal v) neurological examination is normal.   258. A 19yo man has been happier and more positive than usual, with more energy than he has ever felt before for no particular reason. He has been getting more work done at the office today and has been socializing with his friends as usual. What is the most likely dx? a. Atypical depression b. Marked depression c. Bipolar syndrome d. Psychosis e. Hypomania   Q. 1. What is the key? Q. 2. What are the points in favour of this diagnosis?

Q. 2. What are the lab. Values that suggests the diagnosis here? Ans. 1. The key is A. Glandular fever. Ans. 2. Suggestive lab. Values: WBC=25 (leucocytosis), Hgb=10.9 (usually patient is not anaemic), Plt=45 (thrombocytopenia-leading to easy bruising), Positive paul bunnel test. 148. A 41yo woman who has completed her family, has suffered from extremely heavy periods for many years. No medical tx has worked. She admits that she would rather avoid open surgery. After discussion, you collectively decide on a procedure that wouldn’t require open surgery or GA. Select the most appropriate management for this case. a. Endometrial ablation b. Hysterectomy c. Fibroid resection d. Myomectomy e. Uterine artery embolization Ans. The key is E. Uterine artery embolization. [Done by interventional radiologist expert in arterial embolization technique. Particles are placed in uterine artery to block circulation to uterine body. No operation or GA is required]. 149. A girl with hx of allergies visited a friend’s farm. She got stridor, wheeze and erythematous rash. What is the most appropriate tx? a. 0.25ml IM adrenaline b. 0.25ml PO adrenaline c. 0.25ml IV adrenaline d. IV chlorphearamine Ans. The key is A. 0.25 ml IM adrenaline [Presence of stridor and wheeze are suggestive of anaphilaxis and treatment option is IM adrenaline]. 150. A 5yo boy is referred to the hospital and seen with his father who is worried that he has been listless. He is not sure why his GP suggested he should come to the ED and is keen to get some tablets and go home. Exam: tired and irritable, swelling around eyes. Renal biopsy: remarkable for podocyte fusion on EM. What is the most probable dx? a. NAI b. Myelodysplastic disease c. HSP d. Membranous GN e. Minimal change GN Ans. The key is E. Minimal change glomerulonephritis. [Podocyte fusion on electron microscopy]

Ans. 2. Points in favour: i) Dyspnoea on exertion ii) Straight left border of the cardiac silhouette. To straighten the left heart border it requires underfilling of the left ventricle and aorta which occurs in mitral stenosis. Iii) Atrial fibrillation is a common association. 142. A 60yo diabetic complains of pain in thigh and gluteal region on walking up the stairs for the last 6 months. She is a heavy smoker and has ischemic heart disease. What is the most appropriate dx? a. Thromboangitis Obliterans b. Sciatica c. DVT d. Atherosclerosis e. Embolus Q. 1. What is the key? Q. 2. What are the points in favour? Ans. 1. The key is D. Atherosclerosis. Ans. 2. i) It is not sciatica as sciatica pain is worse when sitting. There may be weakness, numbness, difficulty moving the leg or foot. A constant pain on one side of the rear. A shooting pain that makes it difficult to stand up. ii) It is not DVT as no swelling, warmth or redness of skin are there iii) It is not thromboangitis obliterans as pulses are ok, no colour change or reduced hair growth, no ulceration or gangrene iv) not embolism as no pain (rest pain), no numbness, no redness or itching or rash, no ulceration of skin. 143. A 3yo child who looks wasted on examination has a hx of diarrhea on and off. The mother describes the stool as bulky, frothy and difficult to flush. What is the single inv most likely to lead to dx? a. Sweat chloride test b. Anti-endomysial antibodies c. LFT d. US abdomen e. TFT Q. 1. What is the key? Q. 2. What is the diagnosis? Ans. 1. The key is B. Anti-endomysial antibody Ans. 2. The diagnosis is celiac disease. [It is not cystic fibrosis as lung problem is most commonly seen in cystic fibrosis along with GI problem like indigestion]. 144. A 45yo woman has had severe epigastric and right hypochondrial pain for a few hours. She has a normal CBC, serum ALP is raised, normal transaminase. 3 months ago she had a cholecystectomy done. What is the most appropriate inv? a. US abdomen b. ERCP c. MRCP d. CT abdomen e. Upper GI endoscopy Q. 1. What is the key? Q. 2. What is the diagnosis? Ans. 1. The key is B. ERCP. It is probably a wrong key and correct key should be C. MRCP. [Post operative US of abdomen does not give good result for hepatobiliary system. ERCP is invasive procedure and it has its considerable complications like cholangitis, injury, pancreatitis etc. Among given options MRCP is most appropriate. We shall go for ERCP after making the dx confirm. For this MRCP is preferred. If the question asks which is the “DEFINITIVE” or the “MOST DIAGNOSTIC” then the option will be ERCP]. Ans. 2. Diagnosis is choledocolithiasis. 145. A 53yo woman presented with pain in the eye, blurry vision and clumsiness for 3 months. She has a hx of difficulty in swallowing and weakness in her right upper limb 2y ago. What is the inv of choice? a. CSF analysis b. EEG c. EMG d. MRI brain e. Visual evoked response test Q. What is the key? Q. What is the diagnosis? Ans. 1. The key is D. MRI brain. Ans. 2. Diagnosis is multiple sclerosis. 146. A 55yo male presents with malaise and tiredness. Exam: spleen approaching RIF, no lymphadenopathy. Choose the single cell type? a. Helmet shaped cell b. Sickle cell c. Granulocyte without blast cells d. Blast cells Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. What are the diagnostic features? Ans. 1. The key is C. Granulocyte without blast cells. Ans. 2. The diagnosis is CML. Ans. 3. Diagnostic features are i) increased number of mature granulocytes ii) huge splenomegaly. [* Helmet shaped cells (or shistocytes) = hemolytic or Microangiopathic hemolytic anemia * Sickle cell = sickle cell anemia * Blast cells (immature cells) = in acute leukemia]. 147. A 6yo pt comes with easy bruising in different places when she falls. CBC: WBC=25, Hgb=10.9, Plt=45. Her paul bunnel test +ve. What is the most likely dx? a. Glandular fever b. ITP c. Trauma d. NAI e. Septicemia Q. 1. What is the key?

Class 1 up to 15% of blood volume lost: pulse <100; systolic BP normal; pulse pressure normal; Respiratory rate 14-20; urine output greater than 30 ml/hour. Class 2 15%-30% blood volume lost: pulse 100-120; systolic blood pressure normal; pulse pressure decreased; respiratory rate 20-30; urine output 20-30 ml/hour. Class 3 30%-40% blood volume lost: pulse 120-140; systolic BP decreased; pulse pressure decreased, respiratory rate 30-40; urine output 5-15 ml/hr Class 4, blood loss of greater than 40%: pulse rate >140; systolic BP decreased; pulse pressure decreased’ respiratory rate >35; urine output negligible. 137. A 67yo man presents with palpitations. ECG shows an irregular rhythm and HR=140bpm. He is otherwise stable, BP=124/80mmHg. What is the most appropriate management? a. Bisoprolol b. ACEi c. Ramipril d. Digoxin Ans. The key is A. Bisoprolol. [In acute AF (<48h) if stable rate control by verapamil 40-120mg/8hourly po or bisoprolol 2.5-5mg/d po. In chronic AF (>48h) rate control with beta-blocker or rate limiting CCB; OHCM, 9th edition, page-124]. 138. A 78yo man is depressed after his wife’s death. He has been neglecting himself. His son found him in a miserable state when he went to visit. The son can’t deal with his father. What is the appropriate management? a. Voluntary admission to psychiatry ward b. Hand over to social worker c. Request son to move in with father d. Send pt to care home Ans. The key is A. Voluntary admission to psychiatry ward. [This is much too a controversial question!! Patient is neglecting himself and is in a measerable state. His son can’t deal with the patient! So it seems impossible for care home staff to deal with him and social worker as well. If son move in with father will be of no benefit as he can not deal with the patient. So voluntary admission to psychiatry ward is the only option to which we can look but still with doubt as whether he is able to understand or give consent for voluntary admission. Even though A seems to be the likely option!!] 139. An old alcoholic presents with cough, fever, bilateral cavitating consolidation. What is the most probable cause? a. Gram +ve diplococcic b. Coagulase +ve cocci c. Gram –ve cocci d. AFB e. Coagulase –ve cocci Q. 1. What is the key? Q. 2. What is the organism? Ans. 1. The key is B. Coagulase +ve cocci. [The picture is of pneumonia and bilateral cavitating consolidation favours staphylococcus as the causative agent]. Ans. 2. Name of organism is Staphylococcus aureus. [Both coagulase positive and coagulase negative cocci are staphylococci. Gram positive diplococcic is pneumococcus and gram negative nisseria, moraxella catarrhalis and hemophilus influenza. For AFB there should be low grade evening fever with night sweats, weight loss, anorexia etc]. 140. A 67yo man had successful thrombolysis for an inf MI 1 month ago and was discharged after 5days. He is now readmitted with pulmonary edema. What is the most probable dx? a. Aortic regurgitation b. Ischemic mitral regurgitation c. Mitral valve prolapse d. Pulmonary stenosis e. Rheumatic mitral valve stenosis Ans. The key is B. Ischaemic mitral regurgitation. [ischaemic mitral regurgitation > raised pulmonary capillary pressure > pulmonary oedema]. [ Inferior myocardial infarction causes left ventricular remodeling, which displaces posterior papillary muscle away from its normal position, leading to ischemic mitral regurgitation]. 141. A 60yo lady who had stroke 3 years ago now reports having increased dyspnea on exertion and atrial fibrillation. CXR: straight left border on the cardiac silhouette. What is the most probable dx? a. Aortic regurgitation b. Ischemic mitral regurgitation c. Mitral valve prolapse d. Pulmonary stenosis e. Rheumatic mitral valve stenosis Q. 1. What is the key? Q. 2. What are the points in favour of your answer? Ans. 1. The key is E. Rheumatic mitral valve stenosis.

Ans. 2. The diagnosis is post traumatic stress disorder. Ans. 3. Points in favour of PTSD: i) H/O stressor (house fire a year ago) ii) Nightmares of the stressor iii) Hyper arousal (very anxious and inability to relax (leading to irritability) iv) associated depression (poor sleep, tearful). Note: Fluoxetin and peroxetin are the drugs of choice in PTSD. CBT is the non-pharmacological treatment. 130. A 22yo woman with longstanding constipation has severe ano-rectal pain on defecation. Rectal exam: impossible due to pain and spasm. What is the most probable dx? a. Anal hematoma b. Anal fissure c. Anal abscess d. Protalgia fugax e. Hemorrhoids Ans. The key is B. Anal fissure. 131. A 20yo student attends the OPD with complaint of breathlessness on and off, cough and sputum. His sleep is disturbed and skin is very dry in flexural areas of the body. Exam: tachypnea, hyperresonant percussion and wheezing on auscultation. What is the most likely dx? a. Extrinsic allergic alveolitis b. Asthma c. Wegener’s granulomatosis d. COPD e. Cystic fibrosis Q. What is the key? Q. What are the diagnostic criteria? Ans. The key is B. Asthma. Ans. 2. Diagnostic criteria of asthma: i) Airway hyper-responsiveness to certain stimuli ii) Recurrent variable airflow limitation usually reversible iii) presents as wheezing, breathlessness, chest tightness and cough. 132. A pt with thought disorder washes hands 6x each time he uses the toilet. What is the best management? a. Psychodynamic therapy b. CBT c. Antipsychotics d. Refer to dermatology e. Reassure Q. 1. What is the key? Q. 2. What is the diagnosis? Ans. 1. The key is B. CBT. [For OCD CBT is the 1st treatment of choice and if fails comes drugs]. Ans. 2. The diagnosis is obsessive compulsive disorder. 133. A 25yo woman presented to her GP on a routine check up. Upon vaginal exam, she was fine except for finding of cervical ectropion which was painless but mild contact bleeding on touch. What is the next management? a. Endometrial ablation b. Cervical smear (2nd line) c. Colposcopy d. Antibiotics (1st line) e. Vaginal US f. Pack with gauze and leave to dry Q. 1. What is the key? Q. 2. Points in favour correct of key. Ans. The key is D. Antibiotics. This is a wrong key. The correct key is B. Cervical smear. [Before antibiotic we have to take swab]. Ans. 2. Cervical smear is a screaning service which follows its own schedule and can not be done unless it is due or overdue. As the Lady is of 25 years and has ectropion and contact bleeding smear is the best option here as in UK 1st smear is offered at 25 yrs. 134. A 32yo had a normal vaginal delivery 10 days ago. Her uterus has involuted normally. Choose the single most likely predisposing factor for PPH? a. Retained product b. DIC c. Uterine infection d. Von Willebrand disease e. Primary PPH Q. 1. What is the key? Q. 2. What type of PPH it would be? Ans. 1. The key is C. uterine infection. Ans. 2. Secondary PPH 135. A 37yo man slipped while he was walking home and fell on his out stretched hand. He complains of pain in the right arm. XR showed fx of the head of radius. What is the single most associated nerve injury? a. Radial nerve b. Musculocutaneous nerve c. Median nerve d. Ulnar nerve Q. 1. What is the key? Q. 2. What is the root value? Ans. 1. The key is A. Radial nerve. [At wrist, radial nerve injury cause finger drop with a normal wrist and intact sensation]. Ans. 2. Root value of radial nerve: C5,6,7,8 and T1. 136. A butcher stabbed accidently his groin. He bled so much that the towel was soaked in blood and BP=80/50mmHg, pulse=130bpm. What % of circulatory blood did he lose? a. <15% b. 15-30% c. 30-40% d. 40-50% e. >50% Q. 1. What is the key? Q. 2. What is the classification of blood loss according to vita sign? Ans. 1. The key is C. 30-40% Ans. 2. Classification:

NB This controversial question was debated and ultimately settled as septic arthritis by old plabbers. 123. A man with anterior resection and end to end anastomosis done complains of severe pain in the chest and abdominal distension. What is the most appropriate inv likely to review the cause this deterioration? a. XR abdomen b. Exploratory laparoscopy c. CT d. US e. Laparotomy Ans. The key is E. Laparotomy. It is a wrong key! Right key is C. CT. [This is likely an anastomotic leak]. 124. Pt with hx of alcoholism, ataxic gait, hallucinations and loss of memory. He is given acamprosate. What other drug can you give with this? a. Chlordiazepoxide b. Thiamine c. Diazepam d. Disulfiram e. Haloperidol Q. 1. What is the key? Q. 2. What is the diagnosis? Q. What are the points in favour of diagnosis? Ans. 1. The key is B. Thiamine. Ans. 2. The diagnosis is Wernicke’s encephalopathy. Ans. 3. Points in favour of diagnosis: i) history of alcoholism ii) ataxic gait iii) hallucination iv) memory loss. 125. A 35yo male builder presented with sudden onset of severe abdominal pain. He was previously fit and well other than taking ibuprofen for a long term knee injury. On examination he is in severe pain, pulse=110bpm, BP=110/70mmHg and has a rigid abdomen. What is the most likely dx? a. Biliary peritonitis b. Ischemic colon c. Pancreatic necrosis d. Perforated diverticulum e. Perforated peptic ulcer Ans. The key is E. Perforated peptic ulcer. [NSAIDs induced perforation. Points in favour- 1. Prolonged use of NSAIDs, 2. Sudden onset of severe abdominal pain, 3. Rigid abdomen]. 126. A woman 5 days post-op for bilateral salphingo-oopherectomy and abdominal hysterectomy has developed abdominal pain and vomiting a/w abdominal distension and can’t pass gas. No bowel sounds heard, although well hydrated. What is the most appropriate next step? a. XR abdomen b. Exploratory laparoscopy c. CT d. USG e. Barium enema Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. What are the causes of it? Q. 4. What is the management? Ans. 1. The key is A. X-ray abdomen. Ans. 2. The diagnosis is paralytic ileas. Ans. 3. Causes of paralytic ileus: i) electrolyte imbalance ii) gastroenteritis iii) appendicitis iv) pancreatitis v) surgical complications and vi) certain drugs. Ans. 4. Management of paralytic ileus: i) nil by mouth ii) nasogastric suction to alleviate the distension and remove the obstruction. 127. A 30yo man complains of hoarseness of voice. Exam: unilateral immobile vocal cord. What is the most probable dx? a. Graves disease b. Hematoma c. Unilateral recurrent laryngeal nerve injury d. External laryngeal nerve injury e. Tracheomalacia Ans. The key is C. unilateral recurrent laryngeal nerve injury. 128. A 38yo woman has delivered after an induced labor which lasted 26h. choose the single most likely predisposing factor for postpartum hemorrhage? a. Atonic uterus b. Cervical/vaginal trauma c. Rupture uterus d. Fibroid uterus e. Age of mother Ans. The key is A. Atonic uterus. [Prolonged labour is a risk factor for PPH secondary to atonic uterus]. 129. A 32yo woman in tears describing constant irritability with her 2 small children and inability to relax. She describes herself as easily startled with poor sleep and disturbed nightmares following a house fire a year ago, while the family slept. What is the single best tx? a. Rassurance b. Relaxation therapy c. Quetiapine d. Lofepramine e. Fluoxetine 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 E. Fluoxetine. [NICE guidelines suggest that trauma-focussed psychological therapies (CBT or EMDR) should be offered before medication, wherever possible. As these are not in option the best answer here is Fluoxetine (SSRI). At present, there is evidence that EMDR, psychotherapy, behaviour therapy and antidepressants are all effective. There is not enough information for us to say that one of these treatments is better than another].