Medicine Medicine 1. Patient having pH 7.3 and Paco2 35. He is suffering from. A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis 1. Ans. C. Metabolic acidosis The details provided in the question: pH and PaC02. Solving the MCQ: It's very clear that pH is suggestive of acidosis. Now the next step is to find out respiratory or metabolic, which is very easy from the following derivation a. If both moves in opposite direction the primary disturbance is respiratory. b. Here pH is reduced and PaCO2 is also reduced, i.e. both moves in the same direction. Hence the diagnosis is metabolic acidosis. 2. In aortic stenosis all are true except? A. Bruit is heard over carotid. B. Apex shift towards left C. Pulsus bisferiens D. BP is maintained in initial phase 2. Ans. C. Pulsus bisferiens Aortic Stenosis a. The rhythm is generally regular until late in the course b. The peripheral arterial pulse rises slowly to a delayed peak (pulsus parvus et tardus) c. The LV impulse is usually displaced laterally d. The systemic arterial pressure is usually within normal limits. In the late stages, however, when stroke volume declines, the systolic pressure may fall and the pulse pressure narrow e. The murmur of AS is characteristically an ejection (mid) systolic murmur that commences shortly after the S1 increases in intensity to reach a peak toward the middle of ejection, and ends just before aortic valve closure Pulsus bisferiens: characterized by two systolic peaks of the aortic pulse during left ventricular ejection separated by a midsystolic dip. Seen in aorticregurgitation. 3. A 52 year old diabetic patient complaints of palpitations. His ECG is as below. The first line of management is Page 1 Medicine A. Primary PCI B. Cardioversion C. IV amiodarone D. Adenosine Ans. D. Adenosine a. ECG shows narrow complex tachycardia most probably SVT. Next line of management is IV adenosine. b. Approach to narrow complex tachycardia (QRS <120 ms) c. If irregular - AF ,MAT d. IF regular look for visible p waves i. No p waves - AVNRT ii. P waves visible-atrial rate> ventricular rate - Atrial flutter iii. P waves visible-atrial rate < ventricular rate look for RP interval • Short - AVNRT, AVRT • Long - atrial tachycardia ,atypical AVNRT 4. A 45 yr patient of nephrotic syndrome suddenly developed palpitations breathlessness, ABG was given. what should be the next step. A. PCI B. Unfractionated Heparin C. Tissue plasminogen activator / thrombectomy D. IVC filter 4. Ans. B. Unfractionated Heparin Clinical features 1. These depend on the number, size, and distribution of the emboli; 2. Small emboli may be asymptomatic Q, whereas large emboli are often fatal Q. 3. It is asymptomatic in 70% cases (AIPG 07) 4. Sudden onset of breathlessness is the most common symptom. 5. Pleuritic chest pain 6. Hemoptysis Q; (LQ 2012) 7. Dizziness, 8. Syncope Q. Treatment: (Harrison 19th ed., Pg. 1635) 1. Oral anticoagulant a. Dabigatran (a direct thrombin inhibitor) b. Edoxaban (an anti-Xa agent) c. Rivaroxaban or apixaban (both are anti-Xa agents) (AIIMS May 2014) 2. Parenteral anticoagulants are a. Unfractionated heparin (UFH) b. Low-molecular-weight heparin (LMWH) c. Fondaparinux. 3. Placement of a vena caval filter Q in patients who develop emboli despite adequate anticoagulation 5. For hypercalcemia what should be the next step ? A. IV fluids B. Thiazide diuretics C. IV steroid D. IV bisphosphonate 5. Ans. A. IV fluids Management of Acute hypercalcemia 1. Mild hypercalcemia (up to) 12 mg/dl → Managed by hydration alone 2. More severe hypercalcemia 13 to 15 mg/dl → Hydration with saline, Forced diuresis: saline : Loop diuretics (Furosemide) promotes calcium excretion. Page 2 Medicine Extra Edge Thiazide cause hypercalcemia so are never used in the treatment of hypercalcemia!!! Management of chronic hypercalcemia 1. Bisphosphonates : Bisphosphonates reduce calcium resorption a. 1st generation Etidronate b. 2nd generation Pamidronate c. 3rd generation Zoledronate 2. Glucocorticoids : Effective in particular situations such as Vitamin D intoxication : Sarcoidosis, Malignancy 3. Calcitonin 4. Phosphate: 5. Plicamycin 6. Gallium Nitrate 7. Dialysis - Quick and effective and is likely to be needed in severe cases with renal failure 8. Surgical excision of the adenoma The question is about the immediate next line of management. So the immediate treatment option is hydrating the patient by infusing fluids. Only loop diuretics are used in used in management of hypercalcemia and not thiazides Treatment Onset of action Duration of action Hydration with saline Hours During infusion Forced diuresis; saline plus loop diuretic Hours During treatment Pamidronate 1-2 days 10 - 14 days to weeks Zoledronate 1-2 days >3 weeks Calcitonin Hours 1-2 days Phosphate Oral 24h During use Glucocorticoids Days Days, weeks Dialysis Hours During use and 24-48 h afterward 6. Most important parameter to monitor patient status in dengue hemorrhagic fever A. Hematocrit B. Platelets C. WBCs D. Total leukocyte count 6. Ans. A. Hematocrit Features of Dengue Hemorrhagic Fever 1. Fever, 2-7 days, occasionally biphasic 2. Hemorrhagic tendencies, at least one a. A positive tourniquet test b. Petechiae or purpura c. Bleeding from injection site, mucosa and GIT d. Hematemesis or melena 3. Decreased platelets (<100000/cumm) 4. Plasma leakage due to increased vascular permeability manifested by one of the following a. A rise in hematocrit ≥20% b. A drop in hematocrit following volume replacement equal to or greater than 20% of the baseline c. Pleural effusion, ascites or hypoproteinemia All four of the above PLUS evidence of circulatory failure, manifested by a. Rapid weak pulse b. Pulse pressure (<20mmHg) OR c. Hypotension Page 3 Medicine d. Restlessness and cold skin Monitoring Patient with DHS a. Patients should be monitored for measurement of vital signs every 30 minutes. T b. He hematocrit should be measured every 2 hour for 6 hours and then 4 hourly till the patient is stable. c. Besides, platelets should be monitored every twelve hours. d. A fluid balance sheet should be religiously maintained and urine output should be recorded. e. Any bleeding manifestations should be recorded and seriously considered. f. It's clearly evident from the above Hematocrit is the key in evaluating patient with DHS Hematocrit Aids in Deciding Treatment a. If shock persists, and the hematocrit is rising, plasma, plasma substitutes, or albumin should be given as a rapid bolus and repeated if necessary to a total dose or 20-30 ml/kg of colloid. b. If shock persists, and particularly if the hematocrit decreases, fresh whole- blood transfusion may be required (10 ml/kg). 7. A 76 year old male came to emergency department with complaints of retrosternal pain for 6 hours. The following is the ECG of the same patient. The appropriate next line of management of this patient is A. IV abciximab B. IV thrombolysis C. Primary percutaneous intervention D. Low molecular weight heparin 7. Ans. C. Primary percutaneous intervention The given ECG is easy to interpret with the classical clinical scenario. Now we have to know the details of management of Ml Synopsis for management of acute MI: (Read care full-the symptom duration as well as the transportation time matters) a. Patients facing a transport time <30 minutes should be transferred for primary PCI. b. Thrombolytic-eligible patients who present <2 to 3 hours from onset of symptoms and have >30 minutes transport time should receive thrombolytic therapy. c. Patients presenting >2 to 3 hours after the onset of chest pain and have a transport time of 60 minutes or less should be promptly transported for primary PCI. Page 4 Medicine d. If the anticipated transport time is >60 minutes, patients can be treated with either thrombolytic therapy or primary PCI e. Now coming to our question, we have only the details of the duration of the symptoms, which is 6 hours. (>2-3 hour scale) f. Now our option depends on the transportation time (which Is not provided in the question) g. Transportation time < 60 min-Primary PCI h. Transportation time> 60 minutes-thrombolysis or primary PCI i. So in both case primary PCI is an option, so we choose it as the answer. 8. A patient with suspected cardiac tamponade is admitted to your ward. You examined the patient. Which of the following is correct in this regard A. The blood pressure cuff is inflated atleast 20 mm Hg above systemic pressure B. Pulsus paradoxus may be absent in patient with low pressure cardiac tamponade C. The patient is asked to take deep breaths during BP measurements D. The blood pressure is measured when the 1st koraskoff sound is heard only during expiration 8. Ans. B. Pulsus paradoxus may be absent in patient with low pressure cardiac tamponade a. A more than 10 mm Hg fall in systolic pressure with inspiration (pulsus paradoxus) is considered pathologic and a sign of pericardial or pulmonary disease. b. Pulsus paradoxus is measured by noting the difference between the systolic pressure at which the Korotkoff sounds are first heard (during expiration) and the systolic pressure at which the Korotkoff sounds are heard with each beat, independent of respiratory phase. c. Low pressure tamponade: seen in haemodialysis patient. Signs are less prominent. d. Tamponade without pulsus paradoxus: aortic regurgitation, and atrial septal defect. e. Reverse pulsus paradoxus: HOCM, IPPV 9. The difference between alveolar partial pressure and arterial partial pressure of O2 is maximum in A. Interstitial lung disease B. Acute severe asthma C. Pulmonary embolism D. Upper airway obstruction due to foreign body 9. Ans. A. Interstitial lung disease Increased Alveolar arterial gradient is usually seen when there is diffusion defect. It means there is Oxygen is Alveoli but unable to reflect the same amount in artery. Considering the Options a. Severe asthma there will be profound bronchoconstriction resulting in defect in ventilation causing low alveolar O2 and low PaO , increasing PaCOas the alveolar capillary membrane is not affected the alveolar arterial can be 2 normal. b. Foreign body in large airway results defect in ventilation causing low alveolar O2 and low PaO2 and increasing PaCO2 as the alveolar capillary membrane is not affected the alveolar arterial gradient can be normal Other Two Options a. Now for increase A-a gradient there must be either V/Q mismatch as in Pulmonary embolism, abnormal barrier as in ILD. b. Both can increase A-a gradient when its massive Pulmonary embolism and well developed ILD. c. The recent references say that in PE at presentation A-a gradient may be normal and in ILD at presentation it will be increased. d. So ILD can be a better option Page 5 Medicine 10. Nimodipine given in- A. SAH B. Extradural C. Intra parenchymal D. Subdural 10. Ans. A. SAH Treatment – 1. Medical support a. Airway protection b. BP management c. Prevent vasospasm – Nimodipine, volume expansion. 2. Triple H method of Rx → Hypertension, hemodilution & hypervolemia (Ref. Harrison 18th ed., Pg- 2264) 3. If vasospasm persists a. Intracranial papaverine b. Phenytoin given as prophylactic therapy. c. Surgery – Clipping of aneurysm. 4. Recent Advances = Endovascular coiling Extra Edge 1. Vasospasm remains the leading cause of morbidity and mortality following aneurysmal SAH. 2. Treatment with the calcium channel antagonist nimodipine improves outcome, by preventing ischemic injury rather than reducing the risk of vasospasm. 3. Symptomatic cerebral vasospasm can also be treated by increasing the cerebral perfusion pressure by raising mean arterial pressure through plasma volume expansion and the judicious use of IV vasopressor agents, usually phenylephrine or norepinephrine. 4. Raised perfusion pressure is associated with clinical improvement in many patients, but high arterial pressure may promote rebleeding in unprotected aneurysms. 5. Treatment with induced hypertension and hypervolemia generally requires monitoring of arterial and central venous pressures; it is best to infuse pressors through a central venous line as well. 6. Volume expansion helps prevent hypotension, augments cardiac output, and reduces blood viscosity by reducing the hematocrit. 7. This method is called "triple-H" (hypertension, hemodilution, and hypervolemic) therapy. 11. Sounds on auscultation in post TB bronchiectasis A. Crackles basilar B. Mixed crackles C. Tubular breathing D. Crackles heard on inspiration only 11. Ans. B. Mixed crackles 1. The question is specific on post tubercular bronchiectasis. And not in general bronchiectasis. So we will find the answer below. 2. TB and Bronchiectasis a. Tuberculosis affects the upper lobes usually b. So the secretions formed are able to drain with the aid of gravity - the same reason TB most of the time presents with dry bronchiectasis associated with fibrosis(bronchiectasis sicca) - Thus producing fine crepts c. Middle lobe syndrome - formation of bronchiectasis as a result of progression from primary complex, which affects the middle lobe d. So it's evident that the finding are more confined to the upper lobe or middle lobe and presents with coarse as well as fine crepts Page 6 Medicine 3. Other Confusing Options a. Other infections often involve dependent parts of the lungs - resulting in bibasilar creps b. Tubular breathing is seen in consolidation 12. You are posted in emergency duty, a second year medicine resident asks you to do an ABG, all are true regarding that except A. Radial artery is the preferred site B. The syringe is filled with 0.3 ml heparin prior to drawing blood C. Normal levels of HCO3, PaCO2, pH does not exclude acid base disturbance D. Different site is chosen if modified allens test is positive on the side 12. Ans. B. The syringe is filled with 0.3 ml heparin prior to drawing blood Heparin and ABG Analysis a. Heparin should be flushed out usually. b. Heparin has a dilutional effect on the ABG values so its generally flushed out c. The volume of heparin should be thus kept constant in order to prevent it's dilutional effect. To be precise the volume should be 0.05 ml for 1 ml of blood. d. Thus 0.1 ml is sufficient for 2 ml and a maximum of 0.2 ml taken for 5 ml of blood. e. The value of 0.3 ml seems to be in excess - and it's not recommended Other Options a. Radial artery is most commonly preferred, usually of the non-dominant hand b. If Allen test abnormal, definitely an alternate site is to be chose. 13. L-asparginase used in A. ALL B. CLL C. AML D. CML 13. Ans. A. ALL Management of ALL ALL Remission induction CNS prophylaxis Prednisolone Intrathecal methotrexate (or cytarabine) Vincristine Cranial irradiation Daunorubicin L- Asparaginase Methotrexate Consolidation Maintenance Cyclophosphamide Prednisolone Vincristine Vincristine Cytarabine Daunorubicin 6-Mercaptopurine L – Asparaginase Methotrexate 6-MP Combination of intrathecal methotrexate and cranial irradiation for CNS involvement. Agents used for intrathecal chemotherapy a. Methotrexate b. Cytarabine c. Thiotepa Page 7 Medicine 14. An image of a medical student checking DTR in knee A. The doctor is performing the reflex incorrectly B. Root value is L1 L2 L3 C. Always absent in peripheral neuropathy D. Always brisk in motor neuron disease 14. Ans. A. The doctor is performing the reflex incoreectly The original picture was that of an Indian doctor in same scenario, covering the thigh completely where the response should be looked for. So the answer is the examiner was doing the test wrongly. Look at the picture below showing the correct method of examination. Also in the original image the doctor was standing on the left .. NOTE- This question has highlighted the importance of basic clinical skills. Such questions will continue being asked Knee jerk – classical method Method of eliciting pendular knee jerk Page 8 Medicine Knee Jerk a. The knees are partially flexed and rested on the examiner's forearm, The quadriceps tendon is then visible contraction of the b. struck with knee hammer c. Root value: L2, 3, 4 (femoral nerve) d. To look for: Extension of knee and VISIBLE CONTRACTION OF QUADRICEPS. (which cannot be looked for if thigh has not been exposed) Grading of Deep Tendon Reflexes a. Grade 0 -Absent reflexes b. Grade 1 -present reflexes (as a normal ankle jerk) c. Grade 2 - brisk reflex (as a normal knee jerk) d. Grade 3 -exaggerated e. Grade 4 - clonus From above its seen that BRISK = normal knee jerk. In motor neuron disease the knee jerk is generally exaggerated and in peripheral nerve disease the reflex is reduced or absent (NOT ALWAYS ABSENT) 15. Vegetation along line of closure of mitral valve with commissural fusion as shown below. Which type of endocarditis is it ? A. Rheumatic endocarditis B. Infective endocarditis C. Libman sack endocarditis D. NBTE 15. Ans. A. Rheumatic endocarditis Answer is evident from the question. Vegetations along the line of closure, picture here is just an additive. ! Table from Robbins Rheumatic Fever Non Bacterial Thrombotic (Marantic Libman Sack's Endocarditis Infective Endocarditis Endocarditis) • Small, warty Firm • Small, warty Friable • Medium sized (small) • Large. Bulky Friable • Along lines of closure • Flat, Verrucous • Irregular • Along lines of • Sterile • Irregular • Very friable closure • Embolisation is common • On surface of cusps. (under • Vegetations on the • Sterile (no • In cancers (like M3-AML, pancreatic surface is more likely valve organism) cancer), deep vein thrombosis, affected). • cusps. Less often on • Embolization is Trosseau syndrome In pockets of valves mural uncommon • Sterile • endocardium • In rheumatic • Embolisation is uncommon • Non-sterile- bacteria Page 9 Medicine heart disease • In SLE • Embolisation is very common (max chances) • In infective endocarditis 16. Tourniquet test is done for A. Dengue fever B. Typhoid fever C. Zika virus D. Chikungunya 16. Ans. A. Dengue fever Tourniquet Test a. It's a part of the new WHO case definition for dengue. , b. It's a marker for capillary fragility. Even if a tourniquet test was previously done, it should be repeated if i. It was previously negative ii. There is no bleeding Procedure a. Record patients BP, b. Inflate the cuff to a point midway between SBP and DBP and maintain for 5 minutes. c. Reduce and wait 2 minutes. d. Count the number of petechiae below antecubital fossa. e. Positive> 10 petechiae is seen per square inch 17. A 26 year old man presents with fever for 3 days duration, hypotension and rash over the extremities. The most likely diagnosis is A. Enteric fever B. Dengue haemorrhagic fever C. Meningococcemia D. Scrub typhus 17. Ans. B. Dengue haemorrhagic fever Now we have to deduce the question with the given clinical data. Step by step a. It is not enteric fever-symptoms don't suggest enteric fever b. Scrub typhus is ruled out since the patient will be having eschar and regional lymphadenopathy. Clearly the above picture is not that of an eschar. c. Now we are left with two options. DHF or meningococciemia, the clinical picture of fever, hypotension and rash are seen in both the above i. The twist is in the duration of the disease - 3 days. Hypotension and failure is generally a late sign of meningococcemia. ii. So by ruling out the other option, the best possible diagnosis is Dengue Haemorrhagic Fever. Page 10