UNIVERSITY OF KELANIYA - FACULTY OF MEDICINE FINAL MBBS EXAMINATION –

JUNE 2020 2012/2013 (25th PROPER)

MEDICINE – PAPER I
15th JUNE - 2020
Time – 2 hours

True/False Type Questions

1. True or false regarding subarachnoid hemorrhages

A. Normal non contrast CT excludes SAH

B. Xanthochromia present in CSF only after 24 hours.
C. Nimodipine is given to prevent vascular spasm
D. Prophylactically anticonvulsants are routinely given.
E. Percutaneous evacuation of hematoma is done.

A B C D E

F F T F F

A) sensitivity of CT to detect SA Blood is 95% within 24 hours of onset but much lower over
subsequent days.[* non-contrast CT scan– +ve - <24h - 90-95%, 3d -80%, 5d -70%, 7d -50%,
2 weeks -30%]

B) xanthochromia on spectrophotometry appears within 12 hours of SAH and remain detectable

for 2 weeks [*occurs only after 2 hours - time of red cell lysis , >12 hours -90%,3 weeks -70%,
4 weeks - 40%]

C) The primary function of nimodipine is to block voltage-gated L-type calcium channels in their
inactive conformation, to prevent vasoconstriction(vasospasm). It has a preference to act on
cerebral blood vessels since it is lipophilic and can cross the blood-brain barrier. So it prevent
delayed cerebral ischaemia and reduce mortality in SAH.

D) F

E) F
( K&C 9th edition page 839 and lecture note of Chamila Mettananda, Senior lecturer and
Consultant Physician 05.02.2019)

2. Hypokalemia and hypertension are the features of,

A. Cushing’s disease
B. Primary hyperaldosteronism
C. Hypothyroidism
D. Addison’s disease
E. Renal artery stenosis

A B C D E

T T F? F F
3. Regarding acute ischemic stroke

A. Atrial fibrillation is a causative factor

B. Catheter-based retrieval of clot is a treatment option
C. Thrombolysis should be done within 4.5h from the onset of symptom.
D. Can cause dementia
E. A CT Scan of the brain is required for the diagnosis
A B C D E

T T T T

A) Atrial fibrillation is the commonest cause for cardio embolic stroke. Cardiac valve disease,
mural thrombosis due two akinetic segments, patent foramen ovalae and pulmonary arterio
venous fistulae are other causes.
B)
C) Thrombolysis should commence as soon as possible and up to 4.5 hours after an acute stroke.
(Kumar and Clark 9th Edition – Chapter 21- page 837- Practical box 21.36)
D) Multi infarct dementia/ Vascular (page 835 K&C 9th)
E. CT scan excludes haemorrhagic stroke and assistive in diagnosis though MRI is more sensitive.

4. Which of the following have trinucleotide repeat mutation?

A. Friedrich ataxia
B. Sickle cell anemia
C. Duchene muscular dystrophy
D. Huntington disease
E. Fragile X syndrome
 A B C D E

T F F T T

sickle cell anaemia - autosomal recessive (at least one of the β-globin subunits in haemoglobin A
is replaced with what is known as haemoglobin S.)
Duchene muscular dystrophy - X-linked recessive pattern.

(K & C 9th page 115)

5. A medical student touches a piece of ice with his left index finger. What are the
components for the correct direction of the cold sensation?

A. Nociceptors
B. Pacinian corpuscle
C. A-delta fibers
D. Spinothalamic tract
E. Post central gyrus

A B C D E

F F T T T

Mechanoreceptors - Aß
Mechanoreceptors
Nociceptors - Aδ
Cold receptors
Nociceptors
Thermoreceptors- -C
Mechanoreceptors

6. Regarding peptic ulcer disease

A. Steroid use is the main factor for peptic ulcer disease

B. UGIE is preferred on diagnosis of peptic ulcer disease
C. In acute peptic ulcer bleeding routine H. pylori investigation is recommend
D. H. pylori eradication was confirmed by serology testing.
E. Duodenal ulcers are commoner than gastric ulcers

A B C D E

F T F F T

A) The peptic ulcer disease is being more prevalent in developing countries related to the high H.
Pylori infection. In the developed world, the percentage of NSAID induced peptic ulcers is
increasing as the prevalence of H. Pylori declines. (kumar and clerk pg. 379)
Around 90% duodenal ulcers and 70% gastric ulcers caused by H. Pylori infection. Remaining 30%
of gastric ulcers are due to NSAID use. ( Davidson)

B) Endoscopy is the preferred investigation of peptic ulcers. Gastric ulcers are may occasionally be
malignant and therefore must always be biposied and followed up to ensure healing.

C) In acute peptic ulcer bleeding routine H. Pylori eradication therapy is commenced.

D) serological tests detect IgG antibodies, used in diagnosis and in epidemiological studies. IgG
titres may take up to 1 year to fall by 50% after eradication therapy and therefore are not useful for
confirming eradication or the presence of a current infection.

E) Duodenal ulcers affect approximately 10% of the adult population and are 2-3 times more
common than gastruc ulcers. (Kumar and clerk pg378)

7. Regarding Diabetes kidney disease?

A. Metformin cannot give if GFR < 30 ml/min

B. Can be detected during the first presentation of type 1 DM
C.Hyper filtration is the earliest manifestation
D. Hypertension management improve the prognosis
E. SLGT2 inhibitors can use to decrease the disease progression

A B C D E

T F T T T

A) CONTRA-INDICATIONS -Acute metabolic acidosis (including

lactic acidosis and diabetic ketoacidosis)
In adults avoid if eGFR is less than 30 mL/minute/1.73 m2 (BNF 76ed)

B) usually menifest 15-25 years after diagnosis

C) initially increase GFR

D) hypertension and blood glucose control prevent progress to ESKD

E) inhibits renal glucose absorption in the proximal tubule, the site in the kidney where
approximately 90% of glucose reabsorption occurs. It is also accompanied by increased urinary
excretion of sodium, which, in turn, may help with further blood pressure lowering, which could be
an advantage in patients with diabetic kidney disease and hypertension.

8. 50yr old women presented with chronic diarrhea with passage of undigested food
particles in stools. Her BMI is 15kgm2. What would be the cause?

A. Caecal tuberculosis
B. Whipple disease
C. Ulcerative colitis
D. Diverticulitis
E. Crohn disease
A B C D E

F F F F T

Clinical features
A). Caecal tuberculosis –
These are abdominal pain, weight loss, anaemia, fever with night sweats, obstruction, right iliac
fossa pain or a palpable mass. The ileocaecal area is most commonly affected, but the colon -and,
rarely, other parts of the gastrointestinal tract -can be involved. One-third of patients present
acutely with intestinal obstruction or generalized peritonitis; 50% have X-ray evidence of pulmonary
TB.( undigested food particles unlikely)

B). Whipple's disease is a rare infectious bacterial disease caused by Tropheryma whipplei. Some
87% of patients are males, and are usually white and middle-aged. Whipple's presents with
arthritis and arthralgia, progressing over years to weight loss and diarrhoea with abdominal pain,
and systemic symptoms of fever and weight loss. Peripheral lymphadenopathy and involvement of
the heart, lung, joints and brain occur, simulating many neurological conditions.

C). The major symptom in UC is diarrhoea with blood and mucus, sometimes accompanied by
lower abdominal discomfort. General features include malaise, lethargy and anorexia with weight
loss, although these features are not as severe as with CD. Aphthous ulceration in the mouth may
be seen. The disease can be mild, moderate or severe, and in most patients runs a course of
remissions and exacerbations. Disease extent is defined as limited to the rectum (proctitis),
leftsided or extensive. Proctitis is characterized by the frequent passage of blood and mucus,
urgency and tenesmus. There are normally few constitu-tional symptoms and the stool, when
passed, may be solid. Patients are nevertheless greatly inconvenienced by the frequency of
defecation.

D). Diverticular disease is asymptomatic in 95% of cases and is usually discovered incidentally on
colonoscopy or barium enema examina-tion. No treatment other than advice to increase dietary
fibre is required in those patients. In symptomatic patients, intermittent left iliac fossa pain or
discomfort and an erratic bowel habit commonly occur, which are difficult to differentiate from the
irritable bowel syndrome. In severe disease, luminal narrowing results in severe pain and
constipation.

E). The major symptoms are diarrhoea, abdominal pain and weight loss. Constitutional symptoms
of malaise, lethargy, anorexia, nausea, vomiting and low-grade fever may be present and in 15%
of these patients there are no gastrointestinal symptoms. Reduced growth velocity and delayed
puberty may be the main presenting features in children. Despite the recurrent nature of this
condition, some patients have an almost normal lifestyle. However, patients with extensive disease
have frequent recurrences and progress from inflammatory to stricturing and penetrating disease.
Approxi-mately 50% of patients will require an intestinal resection within 5years of diagnosis.
Clinical features are very variable and depend partly on the region of the bowel that is affected.
The disease may present insidi-ously or acutely. Abdominal pain can be colicky, suggesting
obstruction, but it usually has no special characteristics and some-times in colonic disease only
minimal discomfort is present. Diar-rhoea occurs in 80% of all cases and in colonic disease it
usually contains blood, making it difficult to differentiate from UC. Steator-rhoea can be present in
small bowel disease. Diarrhoea can also be due to bile acid malabsorption, occurring as a
consequence of ileal resection or ileal disease. CD can also present as an emergency with acute
right iliac fossa pain mimicking appendicitis.
(Reference Kumar & Clark 9th edition)

9. Consequences following drainage of acute urinary retention

A. Oliguria
B. Hyponatremia
C. Hematuria
D. Tubular damage
E. Hypertension

A B C D E

F T T T? F

UpToDate

Rate of decompression — We recommend complete drainage of the bladder in patients with AUR.
At one time, rapid complete bladder decompression was thought to increase the rate of potential
complications (transient hematuria, hypotension, and postobstructive diuresis). However, partial
drainage and clamping does not reduce these complications and may increase risk for urinary tract
infection.

Complications of decompression — Complications associated with bladder decompression include:

Hematuria – Hematuria occurs in 2 to 16 percent of patients but is rarely clinically significant. For
example, one trial found that hematuria occurred in approximately 11 percent of patients with AUR;
hematuria resolved with irrigation for almost all patients.
Transient hypotension – After initial bladder decompression, patients may experience a transient
hypotension. However, blood pressure usually normalizes without intervention and does not
progress to clinically significant hypotension.
Postobstructive diuresis – Relief of urinary tract obstruction can lead to a postobstructive diuresis,
which is defined as a diuresis that persists after decompression of the bladder. A postobstructive
diuresis is primarily a problem with chronic, not acute, urinary retention and usually represents an
appropriate attempt to excrete excess fluid retained during the period of obstruction.

Any patient with urinary retention can develop postobstructive diuresis. Many patients can manage
the increase in urine output by increasing oral fluid intake. In patients who are unable to do so or
have severe postobstructive diuresis, we measure the urine output and replace one-half the urine
volume with one-half isotonic saline. However, the rate of replacement and choice of replacement
fluid may differ based on initial volume status and whether or not hypo- or hypernatremia is also
present.

10. Macrocytic anemia without megaloblastic bone marrow?

A. Pernicious anemia
B. B. Folate deficiency
C. C. Hypothyroidism
D. Whipple’s disease
E. Liver disease

A B C D E

F F T F T

Megaloblastic - B12, Folate Deficiency

Megaloblastic anaemia is caused due to abnormal DNA synthesis. Delayed nuclear development
results in large cells; nuclear cytoplasmic asynchrony which is called megaloblasts.
Any cause which impairs B12 absorption from the guy can lead to megaloblastic anemia.
(In pernicious anemia, autoantibodies results impaired B12 absorption leading megaloblastic
anemia)
Causes for Non-megaloblastic anemia
- Alcohol
- Liver disease
- Myelodisplastic syndrome
- Aplastic anemia
- Multiple myeloma
- Hypothyroidism

11. Causes of weak or absent left radial pulse.

A. Takayasu disease
B. Atherosclerosis
C. Aortic regurgitation
D. Dissection of the descending aorta
E. Subclavian steal syndrome
 A B C D E

T T F F T

A )Takayasu disease = Aortic arch syndrome/ pulseless disease

Affects aorta and its main branches. Granulomatous inflammation causes stenosis, thrombosis and
aneurysms. Aortic arch is often affected with cerebral,opthalmological and upper limb symptoms. (
dizziness, visual changes, weak arm pulsess) [ Oxford hand book of clinical Medicine 9th edition
page 726]

C) High volume collapsing pulse in AR

D) Dissection of the descending aorta does not cause weak upper limb pulses

E) Subclavian Steal Syndrome - finding of one weak radial pulse in a patient with symptoms of
vertebral-basilar ischemia (episodic vertigo, visual complaints, hemiparesis, ataxia, or diplopia)
suggests the subclavian steal syndrome. ) [ Oxford hand book of clinical Medicine 9th edition page
453]

12. Regarding gout

A. Distal interphalangeal joints are more frequently affected

B. Alcohol is a precipitant
C. Gouty tophi are seen over the fingers
D. A Normal serum uric acid level excludes the diagnosis of gout attack
E. Thiazide diuretics are given to reduce uric acid levels

A B C D E

F T T F F
TH
(K & C 9 Page 687)

A)1ST MTP joint

B) The attack occurs at any time, but may be precipitated by too much food or alcohol, by
dehydration or by starting a diuretic.
C) Individuals with very high levels of uric acid can present with chronic tophaceous gout, as
sodium urate forms smooth white deposits (tophi) in skin and around joints. They occur on the ear,
the fingers or the Achillestendon. Large deposits are unsightly and ulcerate. There is chronic joint
pain and sometimes superimposed acute gouty attacks.

D) Serum uric acid is usually raised (>600 μmol/L). If it is not, recheck it several weeks after the
attack, as the level falls immediately after an acute attack. Acute gout rarely occurs with a serum
uric acid in the lower half of the normal range below the saturation point of 360 μmol/L.
E) thiazide diuretics are associated with an increase serum urate level. So it can precipitate gout
Causes of hyperuricaemia
1)Impaired excretion of uric acid
Chronic renal disease (clinical gout unusual)
Drug therapy, e.g. thiazide diuretics, low-dose aspirin
Hypertension
Lead toxicity
Primary hyperparathyroidism or hypothyroidism
Increased lactic acid production from alcohol, exercise,
starvation
Glucose-6-phosphatase deficiency (interferes with renal excretion)
2) Increased production of uric acid
Increased purine synthesis de novo due to:
Hypoxanthine-guanine-phosphoribosyl transferase
(HGPRT) reduction (an X-linked inborn error causing the
Lesch–Nyhan syndrome)
Phosphoribosyl-pyrophosphate synthase overactivity
Glucose-6-phosphatase deficiency with glycogen storage
disease type 1
Increased turnover of purines due to:
Myeloproliferative disorders, e.g. polycythaemia vera
Lymphoproliferative disorders, e.g. leukaemia
Others, e.g. carcinoma,

13. The following are the neuropsychiatric manifestation of B12 deficiency?

A. Dementia
B. Bipolar affective disorder
C. Postural numbness
D. Wasting of the small muscles of the hand
E. Numbness of the foot
A B C D E

T T T T

Neurological changes of vitamin B12 deficiency are irreversible if left untreated for a long time.
Patients present with symmetrical paresthesia of fingers and toes, early loss of vibration and
propioception, progressive weakness and ataxia.
Dementia, Psychiatric problems, hallucinations, delusions and optic atrophy may occur.
(K&c 9th edition – chap 16 – page 528)

14. Isolated systolic hypertension,

A. Treated with beta blockers

B. Less complications than systolic and diastolic hypertension together
C. Best treated with beta blockers
D. Commonly occurs in young people
E. Diagnosis is by 24-hour blood pressure monitoring

A B C D E

T F? F- uptodate F F?

15. Causes for type 2 respiratory failure,

A. GBS
B. Myasthenia gravis
C. COPD
D. Pulmonary embolism
E Kyphoscoliosis

A B C D E

T T T F T

Type I failure: Hypoxemia with low/ normal PaCO2

Type II failure (ventilatory failure):Hypoxemia with arterial PCO2 more than 49mmHg
Aetiology of Respiratory Failure -Type I failure

a) Impaired transfer of O2 across A-C membrane (eg. Fibrosing alveolitis)

b) V/Q mismatch (Eg.Consolidation)

Aetiology of Respiratory Failure - Type II failure

a) Failure of central control eg. Brainstem death

b) Spinal cord injury
c) Impaired motor nerve function - eg. Guillain-Barrre syndrome
d) Abnormal conduction at neuromuscular junction - eg. Myasthenia Gravis
e) Muscle weakness - eg. Muscle dystrophy
f) Airway obstruction - eg. Severe bronchial asthma

16. Which of the following are effective in preventing central venous line infections of blood
stream.

A. Applies transparent plaster to the site of CVP line

B. Daily checking of the site and do necessities
C. Gives IV coamoxyclav dose before administering cvp line
D. Pneumococcal vaccine is given to high risk patients
E. Strict hand hygiene in health care workers

A B C D E

T T F F T

Measures to prevent infection of vascular catheters. (Davidson pg. 226)

• Strict attention to hand hygiene
• Optimal siting
• Full aseptic techniques on insertion and subsequent interventions.
• Skin asepsis with cholorhexidine and isopropyl alcohol.
• Daily inspection of catheter site
• Daily consideration of continuing requirements for catheterization.
• Use of catheters impinged with antimicrobials such as chlorhexidine or silver is advocated in
some settings.

17. Regarding Leprosy,

A. Isolation of organism from slit skin biopsy from lesion is essential for diagnosis
B. Is a cause for peripheral neuropathy
C. Is highly contagious disease
D. lepromatous leprosy is associated with impaired cell mediated immunity
E. Flattening of the nose occurs due to obliteration of nasal septum

A B C D E

F T F T F

A) The diagnosis of leprosy is essentially clinical with:

• hypopigmented/reddish patches with loss of sensation
• thickening of peripheral nerves
• acid-fast bacilli (AFB) seen on skin-slit smears/biopsy.
B) true ( chart below)
C) Leprosy was once feared as a highly contagious and devastating disease, but now ,it doesn’t
spread easily and treatment is very effective (CDC)

D) • Tuberculoid leprosy, a localized disease that occurs in individuals with a high degree of
cell-mediated immunity (CMI). The T-cell response to the antigen releases interferon, which
activates macrophages to destroy the bacilli (Th1 response) but with associated destruction
of the tissue.
• Lepromatous leprosy, a generalized disease that occurs in individuals with impaired CMI

E) F Inhalation of the mycobacterium allows for infiltration of the nasal mucosa and subsequent
destruction of the bony and cartilaginous skeleton along with the mucosal lining. This process
results in extensive remodeling of the nasal framework and significant ensuing deformities.

18. In chest X ray, findings are predominantly seen at the lung apex in following,

A. Aspiration pneumonia
B. Milliary TB
C. Idiopathic pulmonary fibrosis
D. Bronchiectasis
E. Ankylosing fibrosis

A B C D E

F F F F T

A). Aspiration pneumonia –

Acute aspiration of gastric contents into the lungs can produce an extremely severe and
sometimes fatal illness owing to the intense destructiveness of gastric acid. This can complicate
anaesthesia, particularly during pregnancy (Mendelson syndrome). Because of the bronchial
anatomy, the most usual sites for aspirated material to end up are the right middle lobe and apical
or posterior segments of the right lower lobe. The persistent pneumonia is often due to anaerobes
and progresses to lung abscess or even bronchiectasis if protracted. It is vital to identify any
underlying problem, since without appropriate corrective measures aspiration will recur.

B). Miliary disease occurs through haematogenous spread of the bacilli to multiple sites, including
the CNS in 20% of cases. Systemic upset is the rule, with respiratory symptoms in the majority.
Other findings are liver and splenic microabscesses with deranged liver enzymes or cholestasis
and gastrointestinal symptoms. The chest X-ray demonstrates multiple nodules, which appear like
millet seeds: hence the term 'miliary'.

C). Idiopathic pulmonary fibrosis (IPF) is the most common of the idi-opathic interstitial
pneumonias.
It is a progressive and ultimately fatal disease of unknown cause. There is significant worldwide
vari-ation in reported prevalence but the incidence appears to be increasing (6.8-8.8/100 000 in the
USA). Mean onset is in the sixties and presentation is very uncommon under the age of 50. Males
are twice as likely to be affected. Chest X-ray shows small-volume lungs with increased reticular
shadowing at the bases but may be normal in early disease.

D). Bronchiectasis describes abnormal and permanently dilated airways. The disease is
characterized by a vicious circle of neu-trophilic inflammation, recurrent infection and damage to
the airway. This further impairs mucociliary clearance, and persistent inflamma-tion leads to
impairment of immunity. Bronchiectasis is associated with a number of diseases but a cause will
only be found in around 50% of cases. Little is known about the epidemiology of bronchiectasis
and there is a wide vari-ation in reported incidence. Bronchiectasis related to cystic fibrosis (see p.
1088) is generally considered a separate entity. Chest X-ray may often be normal but tram track
airways, ring shadows and cysts may be seen. Basal areas are commonly involved. (lecture notes)
E). Ankylosing spondylitis
respiratory disease -rarely, chest wall rigidity is associated with interstitial lung disease.
Limitation of chest wall movement is often well compensated by diaphragmatic movement, and so
the respiratory effects of this disease are relatively mild (see also p. 684). It is occasionally
associated with upper lobe fibrosis

19. Which of the following infections respond to tetracycline treatment?

A. Scrub typhus
B. Chlamydia
C. Leptospirosis
D. Chlamydia urethritis
E. TB

A B C D E

T T T T T

Tetracyclines- Mode of action- interfere with protein synthesis by binding to bacterial ribosomes.
Examples-tetracycline ,doxycycline ,minocycline ,tigecycline
Drugs of first choice for infection with Chlamydiae (psittacosis, trachoma, PID, lymphogranuloma
venereum) ,Mycoplasma (pneumonia), rickettsiae (Q fever, typhus), Bartonella spp, and
borreliae( lyme disease,relapsing fever)
Also active against V.cholerae, Coxiella burnetii & brucella spp.
And has good overall activity against community acquired respiratory tract pathogens with low risk
for C.difficile infection
Doxycycline is used to treat atypical mycobacterial species & mild disease of leptospirosis.
Ref- clinical pharmacology-10th edition, kumar and clerk-9th edition, lecture note on drugs in TB
and leprosy.

20. Which of the following OHG and their indications are correctly matched?

A. Metformin- 25yr old woman with type 2 DM expecting to be pregnant

B. Glibenclamide - 85yr old woman with type 2 DM
C. Insulin- A young woman with gestational DM
D. Acarbose - 45yr old man with post prandial hyperglycemia
E. Pioglitazone - 35yr old man with type 2 DM and BMI of 35 kg/m2
 A B C D E

T F T T F

A) Out of oral hypoglycemics Metformin and Glibenclamide are the drugs that can be safely given
in pregnancy.

B) Hypoglycemia is a side effect of sulphonylureas. Glibenclamide is a sulphonylurea (T 1/2 = 10

hours) which is usually given as a daily dose. Due to long half-life not used in elderly.

C) Insulin is a first line medication used in diabetes in pregnant women.

D) Acarbose inhibits alpha-glucosidase enzymes which leads to reduction of absorption of injested

carbohydrates.
E) Glitazones reduces insulin resistance. It has a side effect of weight gain.

Single Best Answer Questions

21. A 23 years old girl previously diagnosed with SLE presented with fever, malar rash &
pain in small joints. Which of the investigation best confirms a flare of the disease?

A. Positive ANA
B. Raised procalcitonin level
C. Increased C3 & C4 levels
D. Increased CRP
E. Lymphopenia

Answer E ( K & C 9TH edition page 694)

She is a diagnosed patient with SLE. Autoantibodies of many different types may be present in
SLE but most significant are ANA, anti – dsDNA, anti-Ro, anti-m and Anti-La.
C3 and C4 level usually drop in SLE flares. Some types of lupus such as brain disease do not
cause low compliment levels
CRP is usually normal but may be high when patient has lupus pleuritis, arthritis or co-existing
infection. So not significant for SLE
FBC may show a leucopaenia, lymphopenia and/or thrombocytopaenia

22. 68 years old man presented with dizziness & headache. He is diagnosed patient with
hypertension for 15 years & smoker for 30 years. On examination he is plethoric,
splenomegaly, high BMI & high blood pressure.
Hemoglobin – 20mg/dl HCT – 60
WBC – 20
PLT – 500
What is the most likely diagnosis?
A. Polycythemia Vera
B. Chronic obstructive lung disease
C. Renal cell carcinoma
D.
E.
23. 65 years old male presented with 4 days history of rash over limbs and trunk. Two
weeks before he felt sensation of itching but no obvious rash except short lasted few
wheals & hives. He is a known patient with DM & hypertension & currently on metformin,
losartan & tamsulosin for five years. On examination there was bullous eruptions
predominantly over limbs & trunk. Bullous lesions are tense. Face & mucosal membranes
are spired. What is the most suggestive skin condition?

A. Bullous pemphigoid
B. herpetiform dermatitis
C. SLE
D. EKE
E. Toxic epidermal necrolysis

Answer A.
bullous phemphigoid. Commonly affects those over 60 years of age, tense bullous lesions,
mucosal membranes are usually spared. Early lesions that might persist for weeks may resemble
urticaria.
(K&C 9th edition – chap 31 – page 1369)

24. 45 years old man who was diagnosed to have community acquired pneumonia was
unable to respond 5 days treatment of co-amoxiclave 1.2g tds. What is the next
management step?

A. Change to co-amoxiclave to merapenam

B. Take CT chest to exclude abscess
C. Add clarithromycin
D. Sputum for cytology
E. Arrange a Monteux test

Answer C ( K & C 9TH Edition page 1102)

25.
A.
B.
C.
D. Use insecticide to prevent malaria
E. Start empirical chloroquine in suspected patients of malaria

26.
A. Lung carcinoma
B. Thyrotoxicosis
C. tertiary hyperparathyroidism
D. Primary hyperparathyroidism
E. Secondary hyperparathyroidism

27. 38 years old female presented with cough, fever & chest pain. On examination there
were left lower lobe consolidation. Other findings were normal. What is the best
management?

A. IV clarithromycin
B. Oral co-amoxiclav
C. Oral amoxicillin + clarithromycin
D.
E.

Answer ; C
Lobar pneumonia, best mx with typical and atypical coverage

28. A 35 years old female presented with 5 days history of fever.

Hemoglobin – 17.4 Platelet – 11 000 PCV – 54%
After admission she collapsed & blood pressure was unrecordable. What is the next
management option?
A. IV dextran bolus
B. IV Hartman bolus over 1 hour
C. IV methylprednisolone
D. Urgent blood transfusion
E. Free flow intravenous normal saline

Dengue Haemorrhagic Shock

Answer – E

29. 23 years old female presented with 10 days history of pain in neck, fine tremors. On
examination there were tender thyroid.
TSH – 0.01 T4 – 3.7
ESR – 78mm
What is the appropriate management option?
A. Carbimazole & propranolol
B. NSAIDs & propranolol
C. Radio iodine
D. Lugol’s iodine followed by thyroidectomy
E. Propranolol & co-amoxiclave

Answer B
De quervain’s thyroiditis
This is transient hyperthyroidism from an acute inflammatory process, probably viral in origin. Apart
from the toxicosis there is usually fever, neck pain with tachycardia & local tenderness. Thyroid
function tests show initial hyperthyroidism, high ESR. Transient hypothyroidism follows after a few
weeks. Treatment of the acute phase is with Aspirin, using short term prednisolone in severely
symptomatic cases.
Beta blockers are used to control symptoms like tremors.
Ref-Kumar & clerk 9th edition

30. 35 year old man presented with back pain & bilateral lower limb weakness for 1 week
duration. No history of trauma. On examination knee jerk & ankle jerk are brisk. Power 3/5 in
both lower limb. There is severe spinal tenderness over T8. Also temperature & pain
sensations are lost in both lower limb. What is the most likely diagnosis?
A. Transverse myelitis
B. Anterior spinal artery occlusion
C. Intervertebral disk prolapse
D. Spinal epidural abscess
E. Paraneoplastic myelopathy

Answer : D?

31.
A. Scrub typhus
B. Legionella pneumonia
C. Leptospirosis
D. Mycoplasma pneumonia
E. H1N1 Influenza

32. 15 year old boy presented with reduced hearing in left ear. On examination there were
cervical lymphadenopathy & generalized macular papular rash in body.
WBC – 6600 Neutrophil – 53% Lymphocyte – 38% Monocyte – 5% Eosinophil – 3% Blood
picture – normochromic normocytic anemia
(There was another investigation)
What is the diagnosis?

A. Infectious mononucleosis
B. Typhoid
C. Typhus
D. HIV
E.

Answer : C?( K&C 9TH edition page 292)

33. 45 year old man presented with polyuria & polydipsia for 2 months duration.
FBS – 108mg/dl
Potassium, Sodium, Calcium – normal
serum osmolality – 298mmol/l (upper normal)
Urine osmolality – 78mmol/l (low)
Water deprivation test was done. After desmopresin serum osmolality – upper normal
urine osmolality – 80mmol/l
What is the diagnosis?

A. SIADH
B. Central diabetes insipidus
C. Psychogenic polydipsia
D. Nephrogenic diabetes insipidus
E. Cerebral salt wasting syndrome

D. Nephrogenic diabetes Insipidus (as desmopressin do not concentrate urine >50%)

(K&C 9th edition – chap 26 – page 1234 –box 26.45)
34. 60 years old man presented with sudden onset ataxia. CT scan shows cerebellar ataxia.
One day after the admission he become drowsy. Examination shows one pupil of 5mm &
other pupil of 3mm. blood pressure is 200/100mmHg. What can be the cause for his
drowsiness?

A. Hydrocephalus
B. Hypertensive encephalopathy
C. Hypoglycemia
D. Hyponatremia
E. Seizures

Answer A?

35. Study on prevalence of chronic kidney disease in north province. Best method of
sample collection is,

A. Stratified sampling
B. Cluster sampling
C. Simple random sampling
D. Snow ball sampling
E. Simple stratified sampling

Answer C
This study is on prevalence so Simple random sampling is the best answer than selective methods
like Stratified sampling, Snow ball sampling

36. 26 year old male presented with blood pressure of 140/90mmHg. Urine analysis shows
protein 2+, no RBC or casts. Urine protein to creatinine ratio is 3.6 (high). Which of the
following suggest glomerular pathology?

A. Ankle edema
B. Hypertension
C. RBC in urine
D. Urine protein 2+
E. Urine protein to creatinine ratio > 3.5

Answer E

Glomerular disease is the third most common cause of ESKD. These are diseases in which,:
• There may be an immunologicaly mediated inflammatory injury to glomeruli, or
structural or functional glomerular damage without inflammation.
• Renal interstitial damage is a regular accompainment.
• The kidneys are involved symmetrically
• Haemodynamic consequences of a primary injury may further disturb glomerular
function
• Renal lesions may be part of generalized disease.

GFR remains constant owing to intrarenal regulatory mechanisms in healthy people. In disease
(reduction in intrarenal blood flow, damage to or loss of glomeruli,) GFR will fall. And creatinine will
rise
In this question more specific answer for renal Pathology is urine protein creatinine ratio. Red cell
cast is more specific in glomerular Pathology.

37. 55 year old male presented with high fever, malaise & right hypochondrial pain for 1
week duration. He is a social drinker. DM for several years. On oral hypoglycaemic drugs
with atorvastatin.
AST & ALT around 200
ALP marginally elevated
(There were more investigations)
What is the diagnosis?

A. Liver abscess
B. Viral hepatitis
C. Alcoholic hepatitis
D. Statin induce hepatitis
E. Leptospirosis

Answer ; A?

38. 36 years old obese women presented with progressive early morning headache &
blurring of vision. She is undergone a CT scan & it was normal. What is the most
appropriate next investigation?

A.
B. CSF manometry
C. CT venography
D. Magnetic resonance venography
E. Fluorescein angiography of retinal vein

Answer – B
Idiopathic intracranial hypertension (IIH) probably results from reduced CSF resorption. IIH
typically develops in younger, over-weight female patients, many of whom have polycystic ovaries.
Headaches and transient visual obscurations due to the florid papil-loedema are the presenting
features. A Vlth nerve palsy may develop -a false localizing sign (see p. 806). CSF pressure is very
elevated, with normal constituents. Brain imaging is normal, although ventricles may be small and
appear 'slit-like'. Various drugs, such as tetracyclines, and vitamin A supplements have been
implicated. Other causes of papilloedema should be excluded. Sagittal sinus thrombosis can cause
a similar picture and should always be looked for on MR venography. IIH is usually self-limiting.
However, optic nerve damage can result from longstanding severe papilloedema with progressive
loss of peripheral visual fields. Regular monitoring of visual fields with perimetry is essential.
Repeated LP, acetazolamide and thiazide diuretics are used to reduce CSF production. Weight
reduction is helpful. Ventriculoperitoneal shunt insertion or optic nerve sheath fenestration to
protect vision is sometimes necessary.

39. 45 year old man was treated for organophosphate poisoning. On the second day of
treatment he was found to be confused & pyretic. Pulse rate was 120bpm & blood pressure
was 160/100 mmHg. Chest was clear. What is the next step in the management?

A. Intubate & ventilate

B. stop atropine
C.
D.
E.

Answer B?
Atropinisation is done in OP poisoning to reduce its cholinergic effects. Giving too much atropine
causes atropine toxicity.
Features of atropine toxicity are hyperthermia, flushes,tachycardia,mucosal dryness,confusion,
coma,hallucinations. Next step of atropine toxicity should be withdrawal of atropine.
Ref-lecture note on principles of management of poisoning by Dr.Shaluka Jayamanne, emergency
medicine
40. 46 years old male patient presented with polyuria & bilateral renal calculi.
Arterial blood gas revealed PH – 7.2
Bicarbonate – 10
PO2 & PCO2 normal range potassium – 2.8
What is the most likely diagnosis?

A. Type 1 renal tubular acidosis

B. Chronic kidney disease
C. Salt losing nephropathy
D. Type 4 renal tubular acidosis
E. Diuretic use

Answer : A

41. 56 year old cirrhotic patient presented with upper GI bleeding. His pulse rate was
120bpm and blood pressure was 86/52 mmHg. Which of the following is the best initial
management option?

A. IV fluid resuscitation
B. IV terlipressin 2mg bolus
C. IV pantaprazole 80mg
D. Urgent blood transfusion
E. Emergency upper GI endoscopy

Answer A

42. 56 years old female presented with high fever for 2 days duration followed by left sided
hemiplegia. She has undergone mitral valve replacement 3 years back and on warfarin
since then. She is in atrial fibrillation and her INR is 2. Most likely cause for the hemiplegia
is,

A. ICH
B. Cortical vein thrombosis
C. septic emboli
D. cerebral abscess
E. encephalitis

Answer : C
High fever in the patient most likely to be Infective Endocarditis as she has risk factors like
replaced mitral valve. IE can cause embolic events.

43. 24 years old boy was brought to the ward fallowing self-ingestion of a agrochemical. He
is agitated and confused. He was given O2 via a face mask. SpoO2 is 72%.Despite the
above measures he is tachypneic and cyanosed. Arterial blood gas O2 level is 180mmHg.
What is the agrochemical he has ingested?

A. Glyphosate
B. Carbamate
C. Organophosphate
D. Parquet
E. Propanil

E - Propanil causes methaemoglobinaemia and results in low O2 saturations despite high arterial
O2 leves
( Principals of Management of Poisoning - Dr.Shaluka Jayamanne)

• Propanil - 3 - 4 DPA
Causes Methaemoglobinaemia
Antidote - Methelin Blue IV Oral
Exchange Transfusions

Paraquat
• Cause oxidative damage - Oxygen free radicals
• Early - Hypotension and multi organ failure - Death
• Late - up to 2- 4 weeks - Pulmonary fibrosis Liver failure
• Only effective treatment - Gastric decontamination
Activated charcoal / Fullers earth

Carbamates
Management and clinical presentation is same as OP
PAM is not effective
Same regimen of Atropin

Glyphosate
Glyphosate is a non selective herbicide of 41% Glyphosate
15% Surfactant
Glyphosate is an organophosphate but it does not act as an acetylcholinesterase inhibitor in man.
The surfactant is approximately three times as toxic as glyphosate
Mild - Predominantly gastrointestinal symptoms
Moderate - Gastrointestinal symptoms lasting longer than 24 hours, Hypotension, Pulmonary
dysfunction. oliguria
Severe - Pulmonary dysfunction requiring intubation, Renal failure requiring dialysis, Hypotension
requiring pressor amines Cardiac arrest Coma Repeated seizures Death

44. A 69 years old man presented to emergency unit with dysuria, flank pain and fever for 2
days duration. On examination his BP-90/60 mmHg, PR-120 bpm, RR-28m-1 and had left
side costovertebral angle tenderness, rest of the examination is normal. Blood and urine
has sent for investigation. What is the next best management option?

A. 5% dextrose
B. Ultrasound scan
C. Catheterization
D. Dopamine infusion
E. IV ceftriaxone

Answer E
Patient is having pyelonephritis /sepsis so after obtaining specimen for investigations have to start
empherical antibiotics

45. A 39 year old man who is a heavy alcoholic for 20 years, still using 1/2 a bottle per day,
was investigated for abdominal distention. No past history of melena or upper GI bleeding.
No peripheral stigmata of CLCD. On upper GI endoscopy three lines of varices were seen.
AST 80
ALT 40
Bilirubin 45
Plt 120
Bleeding time prolonged
(Some other investigations were given. They are normal).
What is the most appropriate method to prevent upper gi bleeding?

A. Isosorbide mono nitrate

B. sclerotherapy
C. liver transplantation
D. Banding
E. Carvedilol

Answer D?

46. 56 years old male who is taking losartan, diltiazem, hydrochlorothiazide for 6 months for
hypertension, found to have blood pressure with 165/100mmHg in routine clinic visit. All
other examination findings were normal. What is the next drug most add for best blood
pressure control?

A. Atenolol
B. Methyldopa
C. Enalapril
D. nifedepine
E. spironolactone

Answer E
In uncomplicated hypertension 1st step – ACEI or ARB+CCB or diuretic (dual combination)
2nd step- add diuretic to above 2 types of antihypertensives. (Triple combination)
3rd step – add spironolactone, or other diuretic, alpha blocker or beta blocker
Consider beta blockers at any treatment step when there is specific indication for their use. Eg:
heart failure, MI

47. 28 years old famer presented following a snake bite. His upper limb is inflamed without
bleeding manifestations. 20 min WBCT is normal, pulse 100bpm, BP 110/80mH, ptosis
present in examination. Anti-venom is given. After one hour his respiratory rate became 6
per minute, BP was 90/60 mmHg. What is the next step in management?
A. Fast normal saline bolus
B. IM adrenalin
C. Repeat atropine
D. Non-invasive ventilation (BiPAP)
E. Intubation and ventilation

Answer ;D respiratory faliure due to cobra bite (neurotoxic)

ABC approach, next mx D but definitive mx is incubation and ventilation

48. 32 years old male presents with back pain for six months duration. X-ray lumbosacral
spine shows bamboo spine and inter spinous ligament calcification. What is the best
investigation to confirm the clinical diagnosis?

A. Chest X ray
B. Echocardiogram
C. HLA B 27
D. Serum calcium
E. ALP

Answer – ?
Ankylosing spondylitis.
• Blood. ESR and CRP are usually raised.
• HLA testing. This is rarely of value because of the high frequency of HLA-B27 in the population,
but may give supporting evidence in a difficult case.
• X-rays. The medial and lateral cortical margins of both sacroiliac joints lose definition owing to
erosions and eventually become sclerotic (Fig. 18.27}. Radiological appearances in the spine of
blurring of the upper or lower vertebral rims at the thoracolumbar junction are caused by an
enthesitis at the insertion of the intervertebral ligaments and may eventually affect the whole spine.
Persistent inflammatory enthesitis causes bony spurs (syndesmophytes), which lead to bony
ankylosis and permanent stiffening. The sacroiliac joints eventually fuse, as may the costovertebral
joints, reducing chest expansion. Calcification of the intervertebral ligaments and fusion of the
spinal facet joints and syndesmophytes leads to what is often called a 'bamboo' spine (Fig. 18.28).
• MRI. MRI with gadolinium demonstrates sacroiliitis before it is seen on X-rays, as well as
persistent enthesitis.
(Kumar & Clark 9th edition)
The diagnosis of AS is generally made by combining the clinical criteria of inflammatory back pain
and enthesitis or arthritis with radiologic findings (Medscape)

49. 40 year old male is on warfarin for AF with MS. Routine INR test value was 6. No other
comorbidities or bleeding manifestation at the time of routine INR check-up. Warfarin was
withheld. What is the next step of management?

A. Give prothrombin complex concentrate

B. Give IV Tranexamic acid
C. Give IV vitamin K
D. FFP
E. Check the INR in 24 hours
Answer E

Anticoagulation
This is indicated in patients with atrial fibrillation related to rheumatic mitral stenosis or in the
presence of a mechanical prosthetic heart valve. In patients with non-valvular atrial fibrillation (in
the absence of mitral stenosis, artificial heart valves or mitral valve repair), a scoring system known
as CHA2DS2VASc is used as the first step in determining the need for anticoagulation.
Long-term prophylaxis against ischaemic stroke with oral anti-coagulation must be balanced
against the risk of haemorrhage. The HAS-BLED score is recommended by European, Canadian
and UK (NICE) guidelines. A high HAS-BLED score identifies patients with a high risk of bleeding.
When oral anticoagulation is required, either warfarin (dose adjusted to maintain an INR between
2.0 and 3.0) or one of the new oral anticoagulant agents (NOACs) can be used. These latter
agents fall into two classes: direct thrombin inhibitors (e.g. dabigatran) and oral direct factor Xa
inhibitors (e.g. rivaroxaban and apixaban). NOACs specifically block a single step in the
coagulation cascade, in contrast to warfarin, which blocks several vitamin K-dependent factors (II,
VII, IX and X). Unlike warfarin, the NOACs have a rapid onset of action, shorter half-life and fewer
food and drug interac-tions, and do not require INR testing. Trial data have shown them to be
equally effective as, and safer than, warfarin. However, these agents require dose reduction or
avoidance in patients with renal impairment, the elderly or those with low body weight.

Anticoagulation related bleeding

Bleeding is the most serious side-effect of warfarin. Bleeding occurs in up to 4% of patients on oral
anticoagulants per year, requires hospital admission in 2% and has a 0.25% morbidity associated
with it. The benefit of anticoagu-lants must therefore be notably more than the risk of bleeding.
Management of warfarin-related bleeding is dependent upon the INR and the degree of bleeding.
Minor bleeding may be treated with cessation of warfarin alone, while serious bleeding will require
additional use of vitamin K and factor concentrates.

50. A 68 year old man is admitted to casualty medical unit with chest pain for 1 hour. On
initial assessment he is in pain, heart rate 40 bpm and BP -86/50 mmHg.
Which one of the coronary artery is most likely to be affected?

A. Anterior interventricular artery

B. Left anterior descending artery
C. Left circumflex artery
D. Obtuse marginal artery
E. Right coronary artery

Answer E
Right coronary artery due to the involvement of SA node

Good Luck...