Past Paper Part 4 (Preview)

 

🟪 73 yrs man on warfarin for AF, recently started clarithromycin, and now his INR is 10.3 + On exam: There is no active bleeding, no bruising + After omitting warfarin what are the most additional steps required >> Add oral Vitamin-K. 

 

 

 

🟪 39-yrs lady presented with fever, headache, multiple joint pain, and maculopapular rash following a trip to the Caribbean + On exam: ™ is raised, BP: 95/60 mmHg + On lab test: WBC: 4.5 × 10 ^9 /L (Lymphopenia); Low platelet, High creatinine, High ALT + Most likely diagnosis + Most likely dx >> Chikunguniya fever. 

 

 

 

🟪 19 yrs student presented with passage of red brown urine; just started amoxicillin for streptococcal throat infection 1 week ago + on exM: BP: 152/8+ mmHg,  high Creatinine, High CRP + On lab tests: Urine (Blood 3+, Protein 3+) + Most likely diagnosis >> Post streptococcal gromerulonephritis. 

 

 

 

🟪 32 32-year-old pt presented with night sweats, weight loss, rapidly enlarging cervical and axillary lymph node + On exam and Lab test: Stage 2 diffuse large B cell Non-Hodgkin lymphoma is seen + Most appropriate intervention >> R-CHOP. 

 

 

 

🟪 21 yrs student returned to the UK from sub-Saharan Africa,  now presented with increasing urinary frequency and passing of blood + On exam: looks pale and tenderness in the suprapubic region + On lab test: WBC: 10.2× 10^9 /l (Eosinophil: 3.2×10^9/L), Urine (blood +++, white cell ++, Protein ++); Intervention is most likely to benefit >> Praziquantel (Dx: Schistosoma haematobium)

 

 

 

🟪 55 yrs man presented with anginal pain during walking with his dog He has impaired fasting glucose, USG: Non-Alcoholic fatty liver disease, BP: 152/90 mmHg + Lab tests: LDL and Triglyceride cholesterol is increased + Optimal way to control his cholesterol >> Atorvastatin. (Dx: Metabolic syndrome)

 

 

 

🟪 26 yr pt breastfeeding presented with anxious feelings, and intermittent chest pain + On exam: Continuous Systolic flow murmur at the apex, no sign of heart failure + Most likely dx >> Mammary souffle. 

★ Mammary souffle is a flow murmur because of increased flow murmur through the internal mammary artery  (Tx: no tx is required)

 

 

 

🟪 26 yrs lady with a known case of Coeliac disease well controlled now presented with no menstrual period for the last few months + Multiple urine pregnancy tests are negative + On lab test: FSH is high + Most likely dx >> Premature ovarian failure. 

 

 

 

🟪 37 yrs man with known Ulcerative colitis on infliximab presented with increasing tiredness, and intermittent itching + On exam: Spider naevi, some scratch marks on abdomen + On lab test: low platelet, high Bilirubin, high ALT, high ALP, P-ANCA is positive + Most likely dx >> Primary sclerosing cholangitis. 

 

 

 

🟪 34 yrs old man came to STD clinic following unprotected sexual exposure on holiday + Now pt complaint of rectal bleeding, intermittent fever, and RUQ pain + on exam: Tenderness in RUQ pain + On lab test: ALT is high, stool negative for E. histolytica + Most likely dx >> Cytomegalovirus proctitis. 

 

 

 

🟪 PT with known AF and IHD on warfarin now presented with severe lower abdominal pain + CT abdomen shows Caecal perforation with suspicion of colonic neoplasm for which requires urgent laparotomy + On lab test: INR: 5.0 and he was given vit K + Intervention should be administered before surgery >> Dried prothrombin complex concentrate. 

 

 

 

🟪 22 yrs Lady presented with spiking fever, salmon pink macular rash, and joint pain affecting knees and wrists despite being treated with prednisolone and Methotrexate + On lab tests: High WBC, high CRP and High Ferritin + Next appropriate intervention >> Anti-Tumor Necrosis Factor (anti-TNK) monoclonal

 

 

 

🟪 73 yrs lady presented with a fluctuating level of activity, poor short-term memory, and visual hallucination + On exam: Tremor and a minor increase in tone affecting his left-hand side and has paucity in his face + Most likely dx  >> Dementia with lewy body. 

 

 

 

🟪 35 yrs man with known HIV Pt poorly compliant with HAART presented with severe headache, neck stiffness, and drowsiness for the last 24-48 hrs + On exam: short-term memory loss, fever + On lab test: CSF study shows: high opening pressure, high protein, and low glucose + Most likely dx >> Cryptococcus meningitis. 

 

 

 

🟪 24 yrs man who has been teaching in northern Thailand and moved to the UK, presents with weight loss, night sweat, and RUQ pain + On exam: RQU pain and fever + On lab test: High ESR, high ALP, AST; E. Histolytica Serology is positive, USG liver reveals: 3-cm liver abscess + Most appropriate initial intervention >> Metronidazole (Dx: Amoebic liver abscess)

 

 

 

🟪 22 yrs student presented with paroxysmal atrial fibrillation which required direct current cardioversion + On exam; Pulse and BP are normal,  no sign of heart failure + ECG shows short PR interval with Wide QRS complex + Most appropriate long-term intervention  >> Radiofrequency ablation ( Dx: WPW syndrome)

 

🟪 44 yrs smoker and demolition worker presented with SOB and dull Rt-sided chest pain + On exam: Rt-sided pleural effusion + CXR: evidence of pleural plaques, moderate Rt-sided pleural effusion; Thoracoscopy with pleural biopsy-sarcomatous type mesothelioma + Feature go against suitability for surgical resection >> Histology type of mesothelioma.

 

🟪 64 yrs known Rheumatoid arthritis pt on infliximab and T2DM pt presented with cough, night sweat, and a positive quantifiers gamma test + Had tuberculosis as a child and now suspect she may have reactivation of the previous infection  + Most likely medication is responsible for >> Infliximab.

• Infliximab can cause reactivation of latent TB

 

 

 

🟪 35 yrs Turkish man presented with an episode of posterior uveitis + On exam: oral ulcer, genital ulcer, and multiple joint pain + On lab test: CRP is high; Anti- phospholipid antibody is positive + Most likely dx >> Behchet’s disease. 

 

 

 

🟪 20 yrs lady was brought to ED following a collapse after hearing bad news about her grandfather + The first responder found ventricular fibrillation + On exam: BP and HR now normal; no sign of cardiac arrest + ECG: Long QT syndrome + Most likely cause of her presentation >> Long QT syndrome. 

 

 

 

🟪 39 yrs electrician with known chronic plaque psoriasis poorly responsive to tazarotene gel presented with rash affecting scalp and extensor surface of arms,  knees + Pain and stiffness consistent with psoriatic arthritis + Most appropriate next step >> Infliximab. 

 

 

 

🟪23 yrs lady presented with palpitation and anxiety following flu-like illness + One exam: fine tremor and tenderness over the neck + On lab test: TSH is very low,  with high T3 and high T4 + What would be an isotope scan of the thyroid gland  >> Global decreased uptake (Dx: Subacute thyroiditis)

 

 

 

🟪 44 yr lady presented with chronic constipation + suffered pain in defecation and intermittent bright blood on the toilet paper + Most likely dx >> Anal fissure. 

 

 

 

🟪 67 yrs pt presented with dry cough, pleuritic chest pain, and diarrhea following return from Mexico travel + On exam: fever, tachycardic and bronchial breathing on Rt base + Lab test: High WBC, High CRP, High ALT, and  low Na+; CXR: Rt lower lobe consolidation + Most appropriate intervention >> Levofloxacin (Dx: Legionella)

 

🟪19 yrs lady presented with poor controlled HTN And abnormal creatinine level + H/O recurrent childhood UTI + ON exam: BP: 155/95 mmHg  + On lab test: high creatinine, low HCO3-, Most likely cause of her HTN >> Chronic ureteric reflux.  

 

 

 

🟪 67 yrs known smoker and COPD pt presented with SOB despite trying oral steroid  + On exam: polyphonic wheeze throughout the lung field and low FEV1 + Most appropriate next step in mx >> LAMA and LABA.

 

 

 

🟪 52 yrs known T2 DM presented with swollen Lt knee + On lab test: high CRP, synovial fluid aspirates show: positively birefringent crystal, sparse neutrophil + X-ray knee: Chondrocalcinosis + Most appropriate initial intervention >> Oral naproxen (Dx: Pyrophosphate arthropathy).

 

🟪 62 yrs smoker presented with difficulty getting out of a chair and climbing the stairs + On exam: proximal muscle weakness affecting shoulder and hip, deep tendon reflex are reduced, improvement occurs after repeated movement  + Most appropriate initial treatment >> 3,4 diaminopyridine (Dx: Lambert Eaton Myasthenic syndrome due to underlying Lung cancer) 

 

 

 

🟪 54 yrs lady presented with increasing pain in her finger + On exam: tenderness affecting both hands, more marked on the proximal finger + On lab test: High Ca++, Low PO4-; Most likely cause of hand pain >> Primary hyperparathyroidism.

 

 

 

🟪 44 yr known T2 DM and Alcoholic depressed pt admitted following overdose of  PCM + On exam: BMI: 34kg/m2; four-hour paracetamol level is measured at 180 mg/l + Highest risk of liver damage related to overdose >> Chronic Alcohol consumption. 

 

 

 

🟪 Pt with known toxic multinodular goiter came for follow up + Most appropriate way to assess for extrinsic obstruction related to the goitre >> Flow volume loop.

 

 

 

🟪 63 yrs known IHD and Chronic heart failure pt come for review + On bislol, aspirin, clopidogrel, frusemide, spironolactone + On exam: bibasal crepitation and bilateral tender gynecomastia + Drug most likely cause of gynaecomastia >> Spironolactone. 

 

 

 

🟪 74 yrs gardener presented with a lesion on the nose which is enlarging slowly The picture shows: a small vessel and telangiectasia over the lesion + Most likely lesion >> Basal cell carcinoma.

★ Sun-exposed areas head and neck are the common sites for the development of basal cell carcinoma. 

 

🟪 54 yrs pt with known case of idiopathic membranous nephropathy + now wants to try therapy to reduce the risk of progression to end-stage renal disease >> Prednisolone and cyclophosphamide. 

 

 

 

🟪 30 yrs alcoholic man is found in a collapsed state + On exam: he is unwell and has GCS: 13, BP: 155/100 mmHg + not moving the left-hand side of the body + CT scan shows a bi-convex lesion on the Rt side of brain + Most likely dx on CT scan >> Extradural hematoma. 

 

🟪 45 yrs. pt with known T2DM reviewed in clinic following unprovoked pulmonary embolism + On exam: lost few Kg, epigastric tenderness + On lab test: Low Hb%, low platelet, high liver enzyme particularly ALP: Anti-Phospholipid antibody-not detected + most appropriate next step >> Abdomen and pelvis computed tomography (CT) scan. (Dx: underlying pancreatic ca)

★Anemia, abnormal LFT, wt. loss, T2DM >> Pancreatic ca.

 

 

 

🟪 42 yrs lady with known malignant melanoma presented with increasing fatigue + On exam: he is thin, has low BMI, Liver edge is palpable + On lab test: anemia, low platelet, High liver enzyme + Most likely to benefit >> Pembrolizumab.

★Pembrolizumab binds to the PD-1 receptor, blocking the binding of PD-L1 and PD-L2 which are immune-suppressing ligands. 

 

 

 

🟪 29 yrs athlete lady presented with frequent urination in nighttime + drinks 4 liters per day + On exam: no postural drop + all lab test is normal + Most likely cause of her polydipsia >> Primary polydipsia 

 

 

 

🟪 44 alcoholic pt admitted for variceal hemorrhage, despite giving lactulose pt is more confused + On exam: presence of liver flap, low BP, Atrial fibrillation, and fever + Most appropriate next step to treat his encephalopathy >> Rifaximin. 

 

 

 

🟪 74 yrs lady presented with urinary incontinence + on exploration: she has uncontrollable urges and is often incontinent before she makes it to the bathroom + Medication is most appropriate to control her symptoms >> Oxybutynin.

 

 

 

🟪 73 yrs lady presented with flu-like illness and diarrhea following eating unpasteurized milk on a France tour + On exam; neck stiffness, Severe unremitting headache, appears muddled, GCS: 14/15 CSF study shows: high protein, high lymphocytes + best treatment regimen for her >> Intravenous amoxicillin and gentamycin.

 

 

 

🟪 18 yrs old student presented with 3rd episode of periorbital oedema which was previously responsive to prednisolone + On lab test: low albumin, urine protein: +++; Most appropriate intervention >> Prednisolone. 

 

 

 

🟪 72 yr heart failure pt on bisoprolol, ramipril, ivabradine, furosemide, spironolactone, and atorvastatin now presented with SOB + On exam: pulse irregular, AF and ankle swelling in both lower limbs and scattered crackles at lung bases + most appropriate next intervention >> Stop ivabradine.

 

 

 

🟪 42 yrs obese man presented with intermittent dyspepsia which gets worse when he eats a hot curry or drinks alcohol excessively + On exam: bp: 155/85 mmHg + Most appropriate next step >> Omeprazole (Dx: Gastroesophageal reflux disorder)

 

 

 

🟪 49 yrs. man presented with weakness affecting both lower limbs + intermittent urinary incontinence + On exam: bilateral spastic paraparesis with hyperreflexia and ankle clonus; minor loss of vibration sense affecting both feet + Most likely cause of symptoms >> Human T-cell leukemia virus type 1 (HTLV -1) infection.

 

 

 

🟪 28 yrs man presented with increasing lumbar spine pain following an open femoral fracture + On exam: has a fever, was unable to move, and severe pain over the T8/T9 disc space on palpation + Bilateral leg weakness more marked on Lt leg than Right; upgoing planter on Lt with loss of anal tone + On lab test: Hogh WBC, HIGH CRP + x-ray normal + Most appropriate intervention while waiting for MRI >> Intravenous Flucloxacillin (Dx: Spinal discitis by stap aureus) 

 

 

 

🟪 68 yrs pt presented with deteriorating central vision, particularly for near object + Bilateral fundoscopy shows: Optic nerve drusen + Most likely dx >>Macular degeneration. 

 

🟪 20 yrs pt presented with pharyngitis, severe bruising, bleeding from gum + On lab tests: Anemia, thrombocytopenia, and clotting abnormalities + Most significant abnormality seen in >> Auer body (Dx: AML)

 

 

 

🟪 19 yrs motorcyclist was brought to the clinic following a significant head injury and being diagnosed as vegetative state + their parents want to know his chance of becoming more aware >> just over 50% pt like he regained consciousness.  

 

 

 

🟪 71 71-year-old lady presented with a rapidly enlarging lesion on her left shoulder + On exam: developed a blackened center + most likely dx >> Keratoacanthoma. 

 

🟪 69 yrs T2DM pt presented with dull, colicky pain a few hours after eating accompanied with diarrhea + on exam: Atrial Fibrillation, pedal edema on both ankles + On lab test: high creatinine + Most likely dx >> Mesenteric angina.

★ CT abdomen with IV contrast is the radiographic investigation of choice. 

 

 

 

🟪 45 yrs pt with known CLD presented with spider naevi in the upper body, mild ascites, and mild ankle swelling + she looked tanned + On lab test: Raised liver enzyme and High Ferritin + Mutation most likely to be carrying >> C282Y. (Dx: Haemochromatosis)

 

🟪 49 yrs lady presented with increasing lethargy, nausea, and vomiting + On further exploration: night sweat, three episodes of hemoptysis + On exam: BP: 155/95 mmHg, crackles on auscultation + on lab test: high ESR and CRP; C-ANCA is positive, urine (blood ++, protein ++); CXR: patchy opacification + Most likely dx >> Granulomatosis and polyangiitis. 

 

 

 

🟪 25 yrs Electrician presented with persistent tremors affecting both hands + His father had the same problem + Other Neurological exam is normal + Most appropriate intervention >> Propranolol (Dx: Essential tremor).

 

 

 

🟪 70 yrs pt with unexplained tiredness + blood films shows: Tear drop poikilocytosis + most likely dx >> Myelofibrosis.

 

🟪 29 yrs heroin addict presented with increasing muscle weakness in all limbs, involuntary muscle spasms + a large injecting abscess in her LT ante-cubital fossa + tetanus immunoglobulin was administered after being debrided + The most appropriate next step >> Metronidazole IV. 

★ After wound debridement and administration of immune globulin antibiotics are recommended to eradicate the remaining tetanus. 

 

 

 

🟪 45 yrs. known Hodgkin lymphoma pt on chemo-radiotherapy since 18 yrs. + the risk of developing of which cancer is most increased in pt with Hodgkin lymphoma >> Breast carcinoma. 

 

 

 

🟪 35 yrs pt presented with fever, joint pain, and dry cough following return from travel of farm + On exam: fever, occasional wheeze, mild tenderness on abdominal palpation + On lab test: High liver enzyme + Brucella immunoglobulin M (IgM) antibody is positive + Most appropriate intervention >> Doxycycline and Rifampicin. (Dx: Uncomplicated brucellosis) 

 

 

 

🟪 23 yrs lady presented with lower back pain, stiffness, and pain in the wrist, finger of feet following a trekking holiday in India + H/O GI illness and took IV antibiotics + In exam: rash in both shin + Blood test: high CRP + Most likely cause of abdominal pain while in India >> Yersinia enterocolitica.

 

 

 

🟪 22 yr PT presented with fever, headache, vomiting, worst bone and muscle pain following tour to Queensland + On exam: Fever and muscle pain all over the body + On lab test: low platelet, high Liver enzyme, high CRP + Most likely dx >> Dengue fever.

 

 

 

🟪 54 yr lady presented with dull-sided chest pain and SOB + On exam: chest is dull on percussion and decreased breath sound on the Lt hand side + On lab test: High WBC; pleural aspirates are turbid, and blood stained + pleural fluid protein is high; pH is low and pleural fluid glucose is low + CXR: Lt sided homogenous opacity + Most useful next step >> abdominal and thoracic ultrasound. (To dx Massive pleural effusions) 

 

 

 

🟪 71 yrs pt brought to ED following collapsed + on exam: Bilateral basal crackles, mild pitting edema; Cardiac monitoring: a short run of VT consistent with torsade’s + ECG: sinus rhythm, inferior Q wave, QT interval 470 ms + most appropriate intervention >> Magnesium intravenously.

 

 

 

🟪 47 yrs obese man presented with weight gain, known to have HTN, high blood sugar + Most useful initial screening test for Cushing syndrome >> 24-hr urinary free cortisol. 

 

 

 

🟪 45 yrs man recently moved to the UK from Pakistan and presented with lumbar pain and transient pain and weakness affecting his left leg + His relative was recently diagnosed with Tuberculosis + On exam: wheeze on auscultation, tenderness at L3/4 + QuantiFERON gamma test is positive, Lumbar X-ray – evidence of collapse affecting L3/4: CXR: Rt upper lobe fibrotic change + Most appropriate initial intervention >> Rifampicin, Ethambutol, Isoniazid and pyrazinamide 

★ 4 drug regimens are recommended for the initial treatment of spinal tuberculosis.

 

 

 

🟪 34 yrs lady presented with abdominal pain and poor sleep at nighttime + Upper and lower GI endoscopy shows normal + physical exam: Entirely normal, looks unkempt + Most appropriate intervention >> Sertraline (Dx: Major depression)

 

 

 

🟪 35 yrs lady presented with increasing painful proximal muscle weakness + On exam: developed rash with a red violet discoloration around eyes + Creatine kinase: 3250 IU/L + Antibodies most specific for underlying diagnosis >> Anti Mi-2 antibody. (Dx: Dermatomyositis)

 

 

 

🟪 65 yrs COPD pt admitted within few minutes following a deliberate overdose of Theophylline + On lab test: Low K+ count, low HCO3-; most appropriate next step >> Activated charcoal.

★ Multiple doses of activated charcoal in theophylline overdose can reduce serum half-life by 50%. 

 

 

 

🟪 45 yr known pt with manic depressive psychosis on Li presented with polyuria and polydipsia + On exam: BMI: 35Kg/M2, serum osmolarity 335 mOsm/kg, urine osmolarity 280 mOsm /kg + Most likely dx >> Nephrogenic diabetes insipidus. 

 

 

 

🟪 70 yrs pt presented known to have CLL, lab test shows High WBC (High lymphocyte) + Most appropriate next step >> Reviews in 3 months.  

 

 

 

🟪 22 yrs professional rugby player was brought to ED following collapse + on exploration: he was unconscious for 3-4 minutes, GCS: 14, no sign of heart failure + ECG: Lt ventricular hypertrophy, Q wave in 1, aVL, V5, V6, QT interval 390 ms + most likely dx >> Hypertrophic obstructive cardiomyopathy. 

 

 

 

🟪 35 yrs lady presented with weight loss, palpitation, and heat intolerance + On exam: small-sided nodule; Isotope scan: increased uptake within thyroid nodule + On lab test: TSH is very low + most appropriate intervention >> Radioactive iodine therapy. 

★Toxic solitary nodule >> Radioiodine is the intervention of choice. 

 

 

 

🟪 Nasogastric tube was placed in a hemiplegic stroke pt + Unable to aspirate gastric fluid for pH testing + Best course of action >> X-ray for position of the tube. 

 

 

 

🟪 56 yrs man presented with refractory HTN despite taking amlodipine and ACE inhibitor + On further exploration: he experienced an increase in creatinine and K+ one week after starting therapy + On lab test: high Potassium, high creatinine, and presence of protein + Most useful investigation >> MR angiography. 

★The deterioration of renal function with hyperkalemia in a likely vasculopathy is suggestive of renal artery stenosis.  

 

 

 

🟪 72 yrs man presented with increasingly tired, intermittent fever, weight loss, and HO Transient ischemic attack + On exam: bleeding around the gum, purpuric rash + On lab test: immunoglobulin M paraprotein band is identified + Most likely dx >> Waldenstrom Macroglobulinemia. 

 

 

 

🟪 74 yrs man presented with acute urinary retention + On exam: BP: 153/95 mmHg, suprapubic tenderness and smoothly enlarged prostate + on Lab test: High creatinine, bladder scan: more than 500 ml within the bladder + Most appropriate next step in mx >> Catheterization and intravenous fluid.

 

 

 

🟪 37 yrs lady with known RA on MTX and sulfasalazine presented with significant residual joint pain + On lab test: CRP is raised + Most appropriate next step in management >> Etanercept. 

 

 

 

🟪60 yrs man known to have GERD and T2 DM presented with Anterior MI followed by stenting to LAD was done + antiplatelet aspirin and clopidogrel + Current medication should be switched to omeprazole. 

 

 

 

🟪Diagnosis of Barrett’s esophagus is confirmed by >> Presence of Columnar epithelium and on biopsy. 

 

 

 

🟪 73 yrs pt presented with intermittent palpitation, recently started oral fluconazole for recurrent esophageal candidiasis + On exam: QT interval 450 ms, BP: 95/60 mmHg, ECG: shows ventricular tachycardia and treated successfully + Antibiotic most likely cause the similar arrhythmia >> Clarithromycin. 

★ QT prolongation exacerbated by azole antifungal and clarithromycin 

★ Recurrent VT likely to be benefitted by IV magnesium. 

 

 

 

🟪 18 yrs man was admitted following a seizure + on further exploration: struggled with poor health, less energy, shorter in height than his siblings + on lab tests: low Ca++, High PO4-, normal PTH + Most likely dx >> Hypothyroidism. 

★ Low calcium, elevated phosphate, and normal ALP are consistent with hypoparathyroidism. 

 

 

 

🟪 54 yrs old man was brought to ED from the dental clinic where he was removed 3 teeth + on exam: anxious, pleuritic chest pain, slightly cyanosed and tachypneic, Pulse oximetry: 90% oxygen, EXG: Widespread ST depression across inferior and anterior lead + Most likely dx >> Methemoglobinemia. 

 

 

 

🟪 46 yrs lady known to have Li induced Nephrogenic diabetic insipidus presented with polyuria and polydipsia despite stopping Li + On exam: has a postural drop of 20 mmHg on standing + most useful next intervention >> Hydrochlorothiazide. 

★Thiazide diuretics are an initial intervention of choice in pt with Nephrogenic diabetic insipidus where symptoms are not resolved completely after discontinuation of Li. 

 

 

 

🟪54 yrs obese driver presented with complaints of falling asleep late at night + On exam: Apneic index score: 18, BP: 155/90 mmHg + Most appropriate initial intervention for the sleep apnea >> Nasal continuous positive airway pressure.  

 

 

 

🟪 Risk of Long-term use of nitrofurantoin >> Folate deficiency. 

 

 

 

🟪 29 yrs Non-smoker pt presented with recurrent hemoptysis + suffered 2 episodes of Rt lower lobe pneumonia + On exam: diminished breath sound at Rt lower base + On lab exam: CXR shows: Rt lower lobe collapse + Most likely dx >> Bronchial carcinoid. 

 

🟪 75 A smoker presented with hematuria and occasional awaking in the night + On exam: Smoothly enlarged prostate gland + On lab test: Low Hb%,  High ESR + Most useful investigation >> Cystoscopy to rule out Transitional cell carcinoma. 

 

 

 

🟪 28 yrs man presented with a progressive macular rash with the area of depigmentation + On exam: the rash extends over his face,  upper limbs, and trunk + physical exam: normal + Most appropriate intervention >> Topical ketoconazole (Dx:Pityriasis versicolor)

 

 

 

🟪 23 yrs man came for cardiology review with a H/O sudden death of his father and brother + On exam: everything is normal + ECG shows: ST elevation followed by T inversion in V1-V3 lead + Most appropriate intervention >> Implantable cardioverter defibrillator.  (Dx: Brugada syndrome)

 

 

 

🟪 50 yrs lady presented with worsening headache, change in facial appearance, and difficulty in managing BP + On exam: prominent lower jaw, large tongue, and facial acne + On lab tests: Glucose: 8.9 mmol/ l + Most appropriate initial investigation >> Insulin-like growth factor. (Dx: Acromegaly)

 

 

 

🟪 77 yrs man was brought to ED following 3rd episode collapse + H/O increasing angina + On exam: Ejection systolic murmur at aortic area,  bibasal crepitation, ECHO: gradient of valve 60 mmHg across the valve + on lab test: High creatinine + Strongest indication for valve replacement >> Syncopal episode (Dx: Aortic stenosis)

 

 

 

🟪 42 yrs Lady presented with a lesion on their finger that developed gradually over a few months as a ring of small red spots, overtime it developed a sunken area in the middle + Most likely dx >> Granuloma annulare. 

 

🟪 Pt with chronic renal impairment presented with fall + On exam: AF, rt hip is shortened and externally rotated + On lab test: Low Ca++, High PO4-, High ALP, very high creatinine + X-ray hip shows: Fracture at Rt femoral head + Most likely cause of her hip fracture >> Secondary hyperparathyroidism. (Due to Renal impairment) 

 

 

 

🟪 42 yrs lady known to have systemic sclerosis presented with muscle pain and weakness, headache, and blurred vision + On exam: BP: 155/90 mmHg, Fundoscopy shows: several retinal hemorrhages consistent with hypertensive retinopathy + On lab test: Cr: 189 mg/dl (up from 105)  + CK: 3210 U + Most appropriate next intervention >> Ramipril. (Dx: Systemic Renal crisis)

 

🟪 64 yr Rheumatoid Arthritis pt on etanercept presented with night sweat, weight loss, hemoptysis + on Lab rest: Quantiferon gamma test is positive, CXR: Rt upper lobe consolidation + what should you do in respect to her therapy >> Stop etanercept and give quadruple antitubercular therapy. 

 

 

 

🟪 36 yrs lady presented with SOB and Rt-sided pleuritic chest pain for 24 hours + on exAm: ™ is high, Coarse crackles on Rt hand side of chest + Most likely dx >> Rt middle lobe pneumonia.

 

🟪 39 yrs old man presented with increasing headache, uncontrolled HTN, and sweating + On exam: BP is high, a large tongue + On Lab test: IGF-1 and s prolactin is high + MRI brain: 0.4 cm pituitary adenoma + Most appropriate intervention before surgery >> Octreotide  (Pt has Acromegaly)

 

 

🟪 70 yrs known CKD and HTN pt with H/O two transient ischaemic attack now taking warfarin due to AF + on test result shows: eGFR fell to 20 ml/min; she wants to keep her anticoagulant + most appropriate next step >> Switch to Rivaroxaban (an oral factor Xa inhibitor) 

 

 

 

🟪 76 yrs man was brought to ED by police + A neighbor complained about the rubbish around the garden + police found her house filthy, with piles of newspaper, she is unkempt, hasn’t changed her clothes for years + Most likely dx >> Senile Squlor syndrome. 

 

 

 

🟪 22 yrs lady with P/H/O paracetamol overdose was brought to ED following a collapse + her mother said she was suffering from diarrhea + On exam: presence of Postural drop,  fine hair over arms and legs,  BMI: 17.5 kg/M2 + On lab test: low Hb%, Low K+,  Most likely dx >> Laxative abuse.