Breast MCQ - Part II - Surgery - with answers

01. 60yrs old lady presented with 2cm painless lump in the left breast for 2 weeks duration. In clinical examination it suggested malignancy which of the following are T/F

a) Tethering with skin indicate poor prognosis 

b) Mammography is done of the triple assessment 

c) FNAC negative no need to go for further investigation 

d) Hormonal treatment compare with CT is best in this patient than young patient with same features 

e) If decided to do breast conservation surgery, radiotherapy should not given

02. Regarding breast carcinoma;

a) Detected by self breast examination is free of metastatic disease 

b) In 80 year old woman can effectively treat with tamoxifen only. 

c) Her-2-neu receptor represents poor prognosis 

d) Micro metastases can be excluded if the isotope bone scan is normal 

e) Treated with mastectomy has better overall survival rather than breast conservative surgery combined with radiotherapy

03. Features of metastatic breast CA

a) Bone pain 

b) High ALP level 

c) Hypocalcaemia 

d) Pathological fractures 

e) Pleural effusions

04. Regarding breast CA

a) Fibro adenoma is an AND! arising from a single terminal duct lobule 

b) Typical hyperplasia of fibrocystic disease has a high risk for developing malignancies c) USS is a method of screening 

d) Hormonal therapy is the first line therapy for elderly patients

05. A 40 year old female presented with pain in both breasts & upper limbs for 6 months. Features favoring the diagnosis of fibrocystic disease are,

a) Cyclical pain 

b) Nodules like feeling in the respective area c) Presence in upper medial quadrant 

d) Bilateral involvement

06. What is the most common complication following simple mastectomy and axillary clearance

a) Bleeding 

b) Thoracodorsal never damage 

c) Seroma formation 

d) Surgical site infection 

e) Flap necrosis mastectomy

07. Risk factors for breast carcinoma 

a) Hormone replacement therapy 

b) Menopause at 35y of age

c) Oral contraceptive pills for 5 years 

d) Null parity 

e) Breast feeding

08. Regarding breast disorders, 

a) Acute mastitis needs incision and drainage. 

b) Female with malignant lump without any metastasis can be treated with lumpectomy. c) Cyclical mastalgia can be treated with cyst aspiration. 

d) 2cm fibro adenoma need wide local excision. 

e) Mastalgia is common at perimenopause age.

09. Breast carcinoma, 

a) Characterized by macro calcifications on mammogram. 

b) Detected on self breast examination stands the best chance of cure. 

c) When locally advanced, best treated with neo adjuvant chemotherapy. 

d) Micro metastasis cannot be excluded if the isotope bone scan is normal. 

e) Survival is superior when treated by modified radical mastectomy comparing with breast conservation surgery combine with radiotherapy.

10. Regarding breast carcinoma 

a) Tumor situated in sub areolar area is the best situation for breast conservative surgery

b) Estrogen receptor positive breast carcinoma has good prognosis

c) Estrogen ,progesterone and HER2 receptors can be identified

d) Usually sensitive to chemotherapy

11. True or False regarding benign breast disease

a) Fibro adenoma has irregular margins

b) Usually grows up to 2-3cm in size

c) Giant fibro adenoma can be seen in pregnancy

d) Well lobulated

12. WOF are true or false

a) Middle thyroid vein drains to the internal jugular vein

b) Clinical features of L5/S1 disc prolapse affecting the S1 root includes parasthesia of the lateral aspect of the foot

c) 80% of blood supply to the liver is from the portal vein

d) Iliohypogastric nerve passes through the external inguinal ring along with the spermatic cord

e) Abductor pollicis brevis muscle is supplied by the ulnar nerve

Answers 

01. a) T b) T c) F d) F e) F

02. a) F b) F c) T d) F e) F

03. a) T b) T c) F d) T e) T

04. a) T b) F c) T d) F

05. a) T b) T c) F d) T

06. a

07. a) T b) F c) T d) T e) F

08. a) F b) F c) F d) F e) F

09. a) F b) F c) T d) T e) F

10. a) F b) T c) T d) T

11. a) F b) T c) F d) F

12. a) T b) T c) T d) F e) F

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Rickets - Short Note - Paediatrics

Vitamin D deficiency

    • Bony deformity and rickets.
    • Without bone abnormalities but with symptoms of hypocalcaemia, i.e. seizures, neuromuscular irritability (tetany), apnoea, stridor. (common before 2 years of age and in adolescence-high demand for calcium in rapidly growing bone results in hypocalcaemia before rickets develops)

Rickets

    • Rickets signifies a failure in mineralisation of the growing bone or osteoid tissue.
    • Failure of mature bone to mineralise is osteomalacia.

Aetiology

Nutritional (primary) rickets

Risk factors

• Living in northern latitudes
• Dark skin
• Decreased exposure to sunlight
• Maternal vitamin D deficiency
• Diets low in calcium, phosphorus and vitamin D, e.g. exclusive breast-feeding into late infancy
• Macrobiotic, strict vegan diets
• Prolonged parenteral nutrition in infancy

Intestinal malabsorption
• Small bowel enteropathy (e.g. coeliac disease)
• Pancreatic insufficiency (e.g. cystic fibrosis)
• Cholestatic liver disease
• High phytic acids in diet (e.g. chapattis)

Defective production of 25(OH)D2
• Chronic liver disease

Increased metabolism of 25(OH)D3
• Enzyme induction by anticonvulsants (e.g. phenytoin, phenobarbital)

Defective production of 1,25(OH)2D3
• Hereditary type I vitamin D-resistant (or dependent) rickets (mutation which abolishes activity of renal hydroxylase)
• Familial (X-linked) hypophosphataemic rickets (renal tubular defect in phosphate transport)
• Chronic renal disease
• Fanconi syndrome (renal loss of phosphate)

Target organ resistance to 1,25(OH)2D3
• Hereditary vitamin D-dependent rickets type II
(due to mutations in vitamin D receptor gene).

Clinical manifestations

• Misery
•  Failure to thrive/short stature
•  Frontal bossing of skull
•  Craniotabes (ping-pong ball sensationof the skull elicited by pressing firmly over the occipital or posterior parietal bones)- Earliest sign
•  Delayed closure of anterior fontanelle
•  Delayed dentition
•  Rickety rosary (palpable or visible costochondral junctions)
•  Harrison sulcus (a horizontal depression on the lower chest corresponding to attachment of the softened ribs and with the diaphragm)
    • Pigeon chest / violin case deformity
    • Pot belly
    • Kyphoscoliosis
•  Expansion of metaphyses (especially wrist in crawling individuals, in ankle in walking infants)
•  Bowing of weight-bearing bones
    • Knock knees
•  Hypotonia
    • Proximal myopathy resulting waddling gait
    • Bone pain- axial skeleton, spine, shoulders, ribs & pelvis
    • Localized pain due to green stick fractures
•  Seizures & tetani due to hypocalcaemia

Diagnosis

• Dietary history for vitamin and calcium intake
• Blood tests – serum calcium is low or normal, phosphate low, plasma alkaline phosphatase activity greatly increased, 25-hydroxyvitamin D may be low and parathyroid hormone elevated.

• X-ray of the wrist joint – shows cupping and fraying of the metaphyses and a widened epiphyseal plate, looser’s zone

Management

Nutritional rickets is managed by,
    • Balanced diet,
    • Correction of predisposing risk factors
    • Administration of vitamin D3 (cholecalciferol).

Healing occurs in 2–4 weeks and can be monitored from the,
    • Lowering of alkaline phosphatase,
    • Increasing vitamin D levels
    • Healing on X-rays (but complete reversal of bony deformities may take years)

Jaundice - Short Note - Paediatric

Jaundice in Children

Babies become clinically jaundiced when the bilirubin level reaches about 80 μmol/L.

Management varies according to

• Infant’s gestational age

• Age at onset

• Bilirubin level and rate of rise

• Overall clinical condition

Age at onset

1. Jaundice <24 h of age

2. Jaundice at 2 days to 2 weeks of age

3. Jaundice at >2 weeks of age

1. Jaundice <24 h of age

Usually results from haemolysis

a. Haemolytic disorders

Rhesus haemolytic disease

• Unconjugated bilirubin

• Antibodies may develop to rhesus anti­gens other than D and to the Kell and Duffy blood groups, but haemolysis is usually less severe.

ABO incompatibility

• Unconjugated bilirubin

• More common than rhesus haemolytic disease

• Most ABO antibodies are IgM so do not cross the placenta, but some group O women have an IgG anti-A-haemolysin effect blood group A infant.

• Occasionally, group B infants are affected by anti-B haemolysins.

• Can cause severe jaundice but it is usually less severe than in rhesus disease.

• The Hb level normal or only slightly reduced

• No hepatosplenomegaly

• Direct Coombs’ test positive

• The jaundice usually peaks in the first 12–72 h.

G6PD deficiency–

• Unconjugated bilirubin

• X linked recessive inheritance

• some females develop significant jaundice

Spherocytosis –

• Unconjugated Bilirubin

• 
  

b. Congenital infection

• Conjugated bilirubin

• Abnormal clinical signs, such as growth restriction, hepatosplenomegaly and thrombocyto­penic purpura.

2. Jaundice at 2 days to 2 weeks of age

a. Physiological jaundice

• Mildly or moderately jaun­diced

• Unconjugated bilirubin

• Term ‘physiological jaun­dice’ can only be used after other causes have been considered.

• Due to high Hb concentration at birth, Short RBC life span (70 days), less efficient hepatic bilirubin metabolism

b. Breast milk jaundice

• Common and more prolonged in breast-fed infants.

• Unconjugated bilirubin

• May be due to increased enterohepatic circulation of bilirubin.

c. Dehydration/ Breast feeding jaundice

• Unconjugated bilirubin

• Due to poor milk intake or delay in establishing breast-feeding

• The infant becomes dehydrated

• Breast-feeding should be continued, some times IV fluid are needed to correct dehydration.

d. Infection

• Unconjugated hyper­bilirubinaemia due to poor fluid intake, haemolysis, reduced hepatic function and an increase in the enterohepatic circulation.

• In particular, urinary tract infection may present in this way.

e. haemolysis usually presents in the first day of life, it may occur during the first week.

f.  Extravascular blood

Bruising

cephal haematoma

IVH

Maternal blood in babies GIT

g. polycythaemia (venous haematocrit is >0.65) will exacerbate the infant’s jaundice

h. Crigler–Najjar syndrome- enzyme glu­curonyl transferase is deficient or absent, may result in extremely high levels of unconjugated bilirubin.

3. Jaundice at >2 weeks of age

Jaundice in babies more than 2 weeks old (3 weeks if preterm), is called persistent or prolonged neonatal jaundice.

Unconjugated hyperbilirubinaemia ( commonest cause)

• Breast milk jaundice’ is the most common cause, affecting up to 15% of healthy breast-fed infants; the jaundice gradually fades and disappears by 4–5 weeks of age.

• Infection, particularly of the urinary tract, needs to be considered.

• Congenital hypothyroidism may cause prolonged jaundice before the clinical features of coarse facies, dry skin, hypotonia and constipation become evident. Affected infants should be identified on routine neonatal biochemical screening (Guthrie test).

Conjugated hyperbilirubinaemia (>_25 μmol/L)

• neonatal hepatitis syndrome

• biliary atresia

sug­gested by the baby passing dark urine and unpig­mented pale stools. Hepatomegaly and poor weight gain are other clinical signs that may be present.

Severity of jaundice

• Blanching the skin with one’s finger.

• The jaundice tends to start on the head and face and then spreads down the trunk and limbs.

• If clinically jaundiced, the bilirubin should be checked with a transcutaneous bilirubin meter or blood sample.

Rate of change & bilirubin level (Neonatal Guideline page 29)

• The rate of rise tends to be linear until a plateau is reached, so serial measurements can be plotted on a chart and used to anticipate the need for treatment before it rises to a dangerous level.

Gestation(Neonatal Guideline page 28,27)

• Preterm infants are more susceptible to damage from raised bilirubin, so the intervention threshold is lower.

Clinical condition

• Infants who experience severe hypoxia, hypothermia or any serious illness may be more susceptible to damage from severe jaundice.

• Drugs which may dis­place bilirubin from albumin, e.g. sulphonamides and diazepam, are therefore avoided in newborn infants.

Management of Jaundice

• Breast-feeding & avoid dehydration (but studies have failed to show that routinely supplementing breast-fed infants with water or dextrose solution reduces jaun­dice)

• Phototherapy -Only given for unconjugated hyperbilirubinaemia

Preparation for phototherapy

• This involves exposure of the naked baby to blue light / CFL/LED of wave length 450-460nm

• Keep babies at the distance recommended by the manufacturer for the phototherapy lights to be maximally effective and safe (avoid hyperthermia). In case of fluorescent light phototherapy machines baby should be kept about 18 inches away from the light.

• Ideal irradiance: Use of intensive phototherapy with irradiance in blue-green spectrum of at least 20-30μW/cm2/nm and delivered to as much of the infant’s surface area as possible.

• The light waves convert the bilirubin to water soluble nontoxic forms which are then easily excreted.

• Advantages of phototherapy: non-invasive, effective, inexpensive and easy to use

• Frequent feeding, every 2-3 hours and change of posture should be promoted in an infant receiving phototherapy.

• Eyeshades should be fixed., External genitalia should be covered to prevent soiling from urine and stools. The nappy should cover only a minimum area of body surface of the baby.

Side effects of phototherapy

• Increased insensible water loss when providing phototherapy in cots: breastfeed more frequently / provide adequate fluids to avoid dehydration

• Loose green stools: weigh often and compensate with breast milk.

• Skin rashes (macular popular): harmless, no need to discontinue phototherapy;

• Bronze baby syndrome: occurs if baby has conjugated hyperbilirubinaemia. If so, discontinue phototherapy

• Hypo or hyperthermia: monitor temperature frequently.

All the side effects are reversible & no long term consequences noted.

Exchange transfusion

• Exchange transfusion is required if the bilirubin rises to levels which are considered potentially dangerous. Blood is removed from the baby in small aliquots, (usually from an arterial line or the umbilical vein) and replaced with donor blood (via peripheral or umbilical vein).

• Twice the infant’s blood volume (2 × _80 ml/kg) is exchanged.

• Donor blood should be as fresh as possible

• Intravenous immunoglobulin reduces the need for exchange transfusion.

• There is no bilirubin level known to be safe or which will definitely cause kernicterus. In rhesus haemolytic disease, it was found that kernicterus could be pre­vented if the bilirubin was kept below 340 μmol/L (20 mg/dl).

Biliary Atresia - Short Note - Paediatrics

Biliary atresia is not very common. However it's the major differential diagnosis of Obstructive jaundice in a neonate. Here are the common DD for obstructive jaundice,

• Biliary atresia
• Neonatal hepatitis
• Choledocal cyst
• Tyrosinaemia
• Alpha 1 antitrypsin deficiency
  

Biliary atresia

    • This occurs in 1 in 14 000 live births.
    • It is a progressive disease, in which there is destruction or absence of the extra-hepatic biliary tree and intrahepatic biliary ducts.
    • This leads to chronic liver failure and death unless surgical intervention is performed.

Clinical features

    • Normal birth weight but fail to thrive as the disease progresses.
    • They are usually mildly jaundiced
    • Pale stools
    • Dark Urine
    • Hepatomegaly
    • Splenomegaly (secondary to portal hypertension)
    • Features of cirrhosis may be present in advance cases (clubbing, palmar erythema, spider nevi, gynaecomastia, caput medusa)

Investigations

    • Liver function tests - little value in the differential diagnosis.

    • Fasting abdominal ultrasound may demonstrate a contracted or absent gallbladder

    • Radioisotope scan with TIBIDA shows good uptake by the liver, but no excretion into the bowel.

    • Liver biopsy demonstrates features of extrahepatic biliary obstruction

    • Diagnosis is confirmed at laparotomy
 

Management

Surgical bypass of the fibrotic ducts, hepatoportoenterostomy (Kasai procedure)  -loop of jejunum is anastomosed to the cut surface of the porta hepatis, facilitating drainage of bile from any remaining patent ductules.

(If surgery is performed before the age of 60 days, 80% of children achieve bile drainage. The success rate diminishes with increasing age)

Postoperative complications  -cholangitis
                                               -malabsorption of fats and fat-soluble vitamins

                                               -cirrhosis and portal hypertension can occur even after Kasai procedure

If the operation is unsuccessful, liver transplantation  (Biliary atresia is the single most common indication for liver transplantation in the paediatric age group.)

Answer the following question.

01. A 3 week old breast fed infant has deep jaundice. On physical examination the liver is 3cm below the costal margin. What is the most important laboratory test in this child to diagnose the condition at this time?

a. Serum ceruloplasmin level

b. Direct and total bilirubin levels

c. Hepatic ultasonography

d. Full blood count

e. Urine urobilinogen level

Comment your answer.

Breast MCQ - Part I - Surgery - with answers

1. A 50 years old mother of two breast fed children presents with a lump in her right breast. There is no
personal or family history of breast cancer. The report on ultrasound and mammogram reads 'suggestive of malignancy. FNAC report reads C4. What is the next appropriate step in the management?

a. Perform a core biopsy
b. Excisional biopsy
c. Lumpectomy
d. Wide local excision
e. incisional biopsy


2. 30year old female ,4days after the delivery of her first baby, presented with pain and swelling of upper outer quadrant of the left breast. On examination the area is reddish. Which of the following is/are true

a) commonly caused by lactobacillus
b) diagnosed by USS
c) treat with cloxacillin
d) need to rest the breast until the pain subsidies
e) IM pethidine can be given for pain


3. 23 year old married women came to take an advice for nipple retraction since childhood. There are no palpable lumps. She wish to Breast feed her children. What is the most appropriate initial management option.

a) refer her to a surgeon for surgery
b) perform biopsy of nipple
c) request USS of breast
d) prescribe her a suction device
e) reassure her that this will resolve during pregnancy


4. 25-year-old woman complained of painless lump in l/breast for 2/52 her grandmother had breast CA @60uears.on examination well defined mobile lump 2cm in size @ the upper outer quadrant/breast is normal and lymphadenopathy. The next step of management

a) Perform FANC
b) Reassure and review in 6/12
c) Arrange mammogram
d) Arrange USS breast
e) Schedule her for excision of the lump


5. Risk factors for breast cancer includes

a) Hx of Breast CA on contralateral side of the breast
b) family history
c) breast feeding
d) null parity
e) OCP


6. 25yr female present with lump in right breast on EX lump was mobile, well demarcated non tender and 3*5cm in size. Mother Rx for breast CA .appropriate step in Mx

a) mammogram
b) USS
c) FANC
d) incision biopsy
e) reassurance and review in 6months


7. A 35 yr old female T4N1Mx breast carcinoma. What is the most appropriate initial treatment ?

a) Breast conservative surgery
b) salvage mastectomy
c) neo adjuvant chemotherapy
d) total mastectomy
e) tamoxifen therapy


8. A 35yr old came female came with blood stained nipple discharge from the R breast. On examination there is no lump. She has no past hx or family hx of breast carcinoma. On examination there was no palpable lump in the breast. What is the most likely diagnosis?

a) Duct ectasia
b) Intraductal papilloma
c) Phylloid tumor
d) Atypical duct hyperplasia
e) Fibrocystic disease


9. Regarding the Breast carcinoma

a) BRCA tumour suppressor genes
b) Due to mutation of BRACA gene.
c) Most of the breast carcinoma has family inheritance
d) Women with mutated gene can undergo prophylactic mastectomy
e) Patient with Breast carcinoma need to refer to genetic service


10. 56yr old patient undergone wide local excision and axillary clearance. Resu its came as stage 1 invasive ductal CA. Two core biopsies were taken, but came as normal. What is the next management?

a. Tamoxifen
b. Radiotherapy to axilla
c. Radiation to the breast
d. Reassure and follow up the patient
e. 6 cycles of chemotherapy


11. 28yr old female R quadrant Breast lump. USS done, no significant finding. 2 core biopsies also done and they are normal. What is the next step of management?

a) Repeat core biopsy
b) Breast MRJ
c) Excision biopsy
d) PET scan
e) Wide local excision


12. 50yr old lady had undergone wide local excision and sentinel nod biopsy. Hist report revealed complete excision of invasive ductal carcinoma and sentinel node contained to metastatic features.ER receptor negative. What is the most appropriate next step of Mx

a) Aromatase inhibitor
b) Chemotherapy
c) Radiotherapy for whole Breast
d) Systemic therapy
e) Mastectomy

Answers 

1. d

2. a) F b) T c) T d) T e) F

3. d

4. d

5. a) T b) T c) F d) T e) T

6. b

7. c

8. b

9. a) T b) T c) T d) T e) -

10. d

11. c

12. b

Renal MCQ - Part II - Renal Failure - with answers

Acute Kidney Injury

01. Increase serum Creatinine seen in 

a) Pregnancy
b) Myocardial infarction
c) Treatment with cimetidine
d) Early DM nephropathy
e) Russell’s Viper bite

02. Increased blood urea is seen in 

a) Na valproate treatment,
b) Rhabdomyolysis.
c) Addison's disease
d) Severe liver disease
e) Tetracycline therapy

03. In acute renal failure, due to a pre-renal cause WOTF can be true, 

a) BP = 80/60 mmHg
b) Severely dehydrated patient
c) Concentrated urine
d) Serum K+ level of 6.2 mmol/l.
e) Sepsis

04. Acute renal failure 

a) Commonest cause is acute tubular necrosis
b) Presence of anemia should raise the suspicion of Rhabdomyolysis
c) Small kidneys on USS
d) May have prolonged bleeding time
e) Long QT syndrome may be a rare cause of death

05. Regarding a patient with acute renal failure, the following are correctly paired, 

a) Red cell casts - acute glomerular nephritis
b) Field full of pus cells - pyelonephritis
c) Microscopic haematuria - Leptospirosis d) Jaundice and bleeding - Hepato renal syndrome
e) Hypernatremia - acute tubular necrosis

Chronic Kidney Disease 

06. Expected findings in CKD 

a) Sclerosed glomeruli in biopsy
b) 15.5cm sized kidneys
c) Pallor
d) Increased serum potassium level
e) A negative mantoux despite exposure to TB

07. Typical biochemical abnormalities of CKD

a) Hyperglycemia

b) Hypophosphatemia
c) Hypercalcaemia
d) Metabolic acidosis
e) Proteinuria> 3.5g/l

08. Features suggestive of CKD

a) Intravascular volume constriction
b) Hypophosphatemia
c) Hyperuricaemia
d) Hypertriglyceridemia
e) Hypernatremia

09. Which of the following helps in diagnosis of CKD over AKI? 

a) Raised S.Cr
b) Small kidneys
c) Normochromic normocytic anemia
d) Raised urea with normal S.Cr
e) Osteodystrophy

10. Factors that help to differentiate CKD from AKI

a) B/L small kidneys
b) Increase in creatinine level
c) Anemia
d) Hyperkalemia
e) Bilateral ankle oedema

11. Regarding treatment of CKD

a) Blood transfusions are best avoided in treatment of anemia
b) Osteoporosis is a complication due to treatment
c) Glycosuria is an indication to start anti DM drugs
d) Moderate protein restriction may have a value
e) Blood pressure should be reduced to 130/90mmHg

Answers 

01. a) F b) - c) T d) F e) T

02. a) F b) F c) T d) F e) T

03. a) T b) T c) T d) F e) T

04. a) T b) - c) F d) T e) F

05. a) T b) T c) T d) T e) F

06. a) T b) F c) T d) T e) T

07. a) F b) F c) F d) T e) -

08. a) F b) F c) T d) T e) F

09. a) F b) T c) T d) F e) T

10. a) T b) F c) T d) F e) F

11. a) T b) T c) F d) F e) F

Renal MCQ - Part I - Glomerular Diseases - with answers

01. Regarding proteinuria in glomerular diseases 

a) Is between 150mg/day and 2g/day in glomerular leakage 
b) Is > 3.5g/day is invariably due to glomerular disease 
c) Is usually greater in the night than during the day 
d) In patients with suspected myoglobinuria appositive dipstick maybe produced 
e) In early diabetic nephropathy typically predominantly albumin is present


02. RBC casts can be seen in 

a) Diabetes mellitus 
b) Chronic GN 
c) Bladder carcinoma 
d) Renal stone 
e) BPH


03. Microscopic hematuria is expected in

a) DM nephropathy 
b) Minimal change disease 
c) Focal segmental glomerulonephritis 
d) Membranous proliferative nephropathy e) AKI


04. Microscopic hematuria features of 

a) G6PD deficiency 
b) DM nephropathy, 
c) Krait bite. 
d) Malignant HT. 
e) OP poisoning


05. 32 year old male presented with haematuria for 1 day duration. There is a past history of haematuria 1 month back. He is on treatment for DM. No oedema. BP elevated. UFR, RBC-200, Pus cells - 3-4, protein- nil. No dysmorphic RBC or hyaline casts. Serum creatinine - Normal. Urinary protein - high. Possibilities are:-

a) Post streptococcal GN 
b) UTI 
c) Renal cell CA 
d) IGA nephropathy 
e) CKD


06. Causes of Nephrotic syndrome are 

a) Infective endocarditis 
b) Gold 
c) Penicillamine 
d) Amyloidosis 
e) Falciparum malaria


07. Which of the following are more favor of minimal change nephritic syndrome? 

a) Highly selective proteinuria 
b) Plasma volume increased 
c) Increased risk of thromboembolism 
d) Mainly peri-orbital oedema 
e) Microscopic haematuria


08. Clinical and biochemical features of minimal change disease are 

a) Proteinuria >3g/24hrs 
b) Gross oedema 
c) Microscopic haematuria 
d) High LDL cholesterol 
e) Venous thrombosis


09. 36 year old male has facial and ankle swelling for 3 weeks. Which is more suggestive of nephritic syndrome?

a) UFR +++ protein
b) Serum albumin- 2.8 
c) 24hour urine protein- 4g 
d) Serum cholesterol- 328 
e) Serum creatinine- 1.6


10. 36 year old female presented with B/L ankle oedema. Her BP is 130/80mmHg. Her Ix results are as follows
S.Cr. Normal UFR - protein 3+
Red cell/hyaline granular casts 24 hr. urinary protein - 3.4g What is the most likely histological type in renal biopsy? 

a) Minimal change GN 
b) Post streptococcal GN 
c) Membrano-proliferative GN 
d) Chronic interstitial nephritis 
e) Diffuse mesangioproliferative with crescent formation

Answers

01. a) F b) T c) F d) T e) T

02. a) F b) T c) F d) F e) F

03. a) F b) F c) T d) T e) T

04. a) F b) F c) F d) T e) -

05. a) F b) T c) T d) T e) -

06. a) F b) T c) T d) T e) T

07. a) T b) F c) T d) T e) F

08. a) T b) T c) F d) T e) T

09. e

10. a

Gallstones MCQ - Surgery - with answers

1. A 34 year old female presented with acute cholecystitis. She was treated with Co-amoxiclav 1.2g IV. After 48 hours of treatment, she develops swinging fever with severe right hypochondrial tenderness. Most appropriate next investigation is, 

a. CT scan 
b. ERCP 
c. MRCP 
d. FBC 
e. USS of abdomen


2. Regarding gallstones 

a. Calcium bilirubinate is the predominant constituent of the mixed stones 
b. Pigment stones are caused due to haemolytic anaemia 
c. Majority of stones are radiolucent 
d. Majority of stones are pigment stones. 
e. Majority are of mixed type


3. A 50 year old otherwise healthy male presented with recurrent, vague upper abdominal pain which was worsening after meals. He had lost 5 kg during last 2 months. USS showed multiple stones in gallbladder with mild thickening of the gallbladder wall. Extrahepatic ducts looked normal. No pericholedochal fluid. What is the next appropriate step of management? 

a. ERCP 
b. ESWL 
c. Laparoscopic cholecystectomy 
d. MRCP 
e. UGIE


4. 45 year old female in routine USS Scan found 4cm solitary stone in gall bladder; 

a. Most likely is a pigment stone 
b. Acute cholecystitis is likely to occur 
c. Requires regular USS to monitor size of the stone 
d. Is at an increased risk of malignancy 
e. Should undergo Cholecystectomy to prevent complications


5. In a 50 year old man with gall stone disease who is otherwise healthy, the indications for cholecystectomy are 

a. History of biliary colic 
b. Passage of flatus after meals 
c. History of recurrent epigastric pain 
d. Porcelain gall bladder 
e. Serum cholesterol level of 425mg/dl


6. T/F regarding ascending cholangitis 

a. Considered as DD in patient presenting with collapse 
b. Caused by stone impacted in cystic duct 
c. Common bile duct stone obstruction is relieved by endoscopy 
d. Lead to liver abscess 
e. Usually caused by gram + organisms

7. 45 year old male presented with yellowish discolouration of eyes & pruritus for 2/52 which progressed gradually. 2/52 prior to presentation he noticed stools were tarry. On examination slightly pale, deeply icteric. The abdomen slightly distended, liver palpable 4cm below the costal margin. The gall bladder is palpable & non tender. The most likely diagnosis 

a. CBD calculus 
b. CA head of the pancrease 
c. Hilar cholangio CA 
d. Duodenal CA 
e. Periampullary CA


8. 40 year old female presented with right hypochondrial pain for 3 days duration with moderate fever. What features in this history most help distinguishing acute cholangitis from acute cholecystitis?

a. Family history of haemolytic anaemia 
b. LOA 
c. Passage of tea coloured urine 
d. Past history of biliary colic 
e. Radiation of pain to back


9. 30yr old male patient presented with progressive jaundice and darkening of urine. USS revealed dilated intrahepatic and common hepatic ducts. But CBD measured 7 mm.GB is not dilated and no GB calculi.What is the most appropriate management? 

a. Pecrutaneous transhepatic cholangiogram 
b. Contrast enhanced CT 
c. MRCP 
d. ERCP 
e. HIDA


10. 60yr old male with Hx of progressive jaundice going to have a CECT, his RFT are marginally elevated. Which of the following agent/fluid is needed to use during procedure 

a. 0.9% NS 
b. NaHCO3 
c. N-AC 
d. IV hydrocortisone 
e. N/2 + 5% Dextrose


11. A 60y old male presents with loss of appetite and loss of weight for 6 months. He is deeply icteric and USS of abdomen shows dilatation of intrahepatic ducts but no dilatation of cystic duct or gall bladder, What is the most probable diagnosis? 

a. Peri-hilar cholangiocarcinoma 
b. Pancreatic head carcinoma 
c. Peri-ampullary carcinoma 
d. Cholangiocarcinoma of distal CBD 
e. Malignant stricture of CBD


12. 65 year old man presented with worsening jaundice & pruritis for 2months, also has anorexia & loss of weight for 4 months. USS gallbladder not distended & has multiple gall stones. CBD not dilated but intrahepatic duct dilated. S.Bilirubin 220umol/, S.Alkaline phosphate -- 1250. What is the diagnosis 

a. Common bile cut stone 
b. Hilar cholangio CA 
c. Mirizi syndrome 
d. Periampulary CA 
e. Sclerosing cholangitis


13. Which of the following is not a recognized cause of postoperative jaundice following laparoscopic cholecystectomy? 

a. Ascending cholangitis 
b. Ligation of the left hepatic duct 
c. Ligation of the common hepatic duct 
d. Gallstone retention in the common bile duct 
e. Thermal injury due to use of electrocautery during dissection.


14. Operations that require perioperative use of antibiotics in otherwise healthy patient include 

a. Herniotomy repair in a 3yr old baby 
b. Thyroidectomy 
c. Elective left hemicolectomy 
d. Transurethral resection of prostate 
e. Knee joint replacement


15. Which of the following is not a risk factor for gallstone formation? 

a. Smoking 
b. Pregnancy 
c. Crohn's disease 
d. Diet high in fats 
e. Contraceptive pills


16. Laparoscopic cholesystectomy is contraindicated in, 

a. Acute cholecystitis 
b. Large solitary gallstone
c. Empyema of the gallbladder. 
d. Patient with bleeding disorder 
e. Carcinoma of the gallbladder

Answers

01. e

02. a) F b) T c) T d) F e) T

03. c

04. a) F b) F c) F d) T e) F

 

05. a) T b) F c) F d) T e) F

 

06. a) T b) F c) T d) T e) F

 

07. e

 

08. c

 

09. c

 

10. a

 

11. a

 

12. c

 

13. a) F b) T c) F d) F e) F

 

14. a) F b) F c) T d) T e) T

 

15. a) T b) T c) T d) T e) T

 

16. a) F b) F c) F d) T e) T

Rheumatology MCQ - Medicine - with answers

 1. Characteristic Features of RA.

a) Atlanto -axial subluxation.
b) Bone cyst formation.
c) Juxta-ordicular osteopenia.
d) Calcification of the spinal ligament.
e) Poriarticular bone erosion.


2. Pulmonary findings in rheumatoid arthritis.

a) Fibrosing alveolitis.
b) Pleural effusion.
c) Caplan syndrome.
d) Bronchoalveolar carcinoma.
e) Chronic Obstructive Pulmonary Disease


3. Regarding Rheumatoid arthritis.

a) Back ache is a common presentation.
b) DIP joints are involved.
c) Erethyma of the affected joints predominates.
d) May present with pyramidal signs.
e) Pleural effusions with high glucose content.


4. Characteristic features of rheumatoid arthritis.

a) Plantar fasciitis.
b) Atlanto-axial subluxation.
c) Scleritis.
d) Subcutaneous nodules.
e) Involvement of DIP joint.


5. Characteristic features of rheumatoid arthritis.

a) Asymmetrical arthritis.
b) Morning stiffness.
c) Male predominance.
d) Onset after 60 years.
e) Involvement of thoracolumbar spine.


6. In a patient with polyarthritis, the diagnosis is more likely to be rheumatoid arthritis than OA in the presence of.

a) Elevated ESR.
b) Symmetrical involvement of PIPjoints.
c) Involvement of temporo mandibular joints.
d) Presence of rheumatoid factor.
e) Symptomatic response to steroids.


7. Following statements about infective arthritis are true.

a) The onset is typically insidious.
b) Pre existing arthritis is a recognized predisposing factor.
c) Small peripheral joints are involved more commonly than larger joints.
d) H-influenzae is the commonest organism in adult patients.
e) Joint aspiration should be avoided due to risk of septicaemia.


8. In psoritic arthritis

a) DIP are involved.
b) Sacroilitis.
c) Oligoarthritis.
d) Arthritis mutilans.
e) Bamboo spine.


9. Clues for the cause of arthritis

a) Scaly lesions over extensors of knee
b) History of dysentery


10. A 50 year old lady presented with two weeks of right knee joint pain and swelling. Which of the following favours a diagnosis of osteoarthritis?

a) ESR 100/1st hour
b) pain on walking
c) history of trauma to knee joint
d) loss of joint space
e) .Neutrophil count over 10000


11. Polyarthragia is a common presenting complain in

a) Rubella
b) Depression
c) tuberculosis
d) Hypothyroidism
e) Chickungunya


12. Joint erosions seen in

a) Osteoarthritis
b) Psoriatic arthritis
c) Gout
d) SLE
e) Rheumatoid arthritis


13. Recognized causes of osteoporosis are,

a) Cushing's syndrome
b) Acromegaly
c) Long term steroid use
d) Early menopause
e) Acute renal failure


14. Tram line calcification in a skull x-ray can be seen in,

a) Thalassaemia
b) Tuberous sclerosis
c) Rickets
d) Sturge weber syndrome
e) Congenital toxoplasmosis


15. 56 yr old man presented with tender swollen 1 metatarsophalangeal joint. He was on frusemide for ankle oedema. Investigation revealed Hb-10.1g/dl, WBC-19,000; ESR -95 , S.cr-3.42. what is the most likely diagnosis,

a) Gouty arthropathy
b) cellulitis
c) TB arthropathy
d) Rheumatoid arthritis
e) Septic arthritis


16. A 41 year old male presents with pain and swelling in left knee for 3 days. He was a hypertensive patient started on HCT and amilodipine recently. On examination, knee joint is tender, warm and swollen, What is the appropriate investigation to get specific. diagnosis?

a) ESR
b) FBC
c) Joint aspiration
d) Rheumatic factor
e) X-ray knee joint


17. T/F

a) Duchenne's muscular dystrophy present at birth as a floppy baby
b) Dystrophiamyotonica patients can develop baldness & cataract
c) Patient with Duchenne's muscular dystrophy live longer than beckers
d) Cardiomyopathy is a recognized complication of Duchenne's muscular dystrophy
e) Chromosomal studies are needed for the diagnosis of Duchenne's muscular dystrophy


18. T/F regarding Duchenne's muscular dystrophy,

a) X linked recessive disorder
b) Has low level of dystrophin
c) Has good prognosis
d) Associated with learning difficulties
e) Serum creatine phosphokinase is elevated

Answers

01. a) T b) F c) T d) - e) T

02. a) T b) T c) T d) F

03. a) F b) F c) T d) T e) -

04. a) F b) T c) T d) T

05. a) F b) T c) F d) F e) F

06. a) T b) T c) F d) T e) F

07. a) T b) T c) F d) F e) F

08. a) T b) F c) T d) T e) F

09. a) T b) T

10. b

11. N/A

12. a) T b) T c) T d) F e) T

13. a) T b) F c) T d) T e F

14. d

15. a

16. c

17. a) F b) T c) F d) T e) F

18. a) T b) T c) F d) T e) T