1.

A 65yo man presents with painless hematuria, IVU is normal,

prostate is mildly enlarged with mild frequency. What is the
most appropriate next step?
a. US Abdomen
b. Flexible cystoscopy
c. MRI
d. Nuclear imaging
e. PSA
Ans. The key is B. Flexible cystoscopy. [Painless hematuria in an
elderly (here 65 years old man) indicates carcinoma bladder for which
flexible cystoscopy is done.
Here BEP is not advanced to cause hemorrhage. There is mild
enlargement of prostate and mild symptoms of prostration and
hemorrhage is unlikely at this initial stage of BEP which makes
Bladder cancer as the likely cause of painless hematuria.
It is also less likely to be prostate cancer as symptoms of prostration
are mild (indicates disease is not advanced). Moreover bleeding in
cancer prostate is less common].

2. A 74yo smoker presented to his GP with cough and SOB. Exam

revealed pigmentation of the oral
mucosa and also over the palms and soles. Tests show that he is
diabetic and hypokalemic.
What is the most probable dx?
a. Pseudocushing syndrome
b. Conns disease
c. Ectopic ACTH
d. Cushings disease
e. Hypothyroidism
Ans. The key is C. Ectopic ACTH. [The patient is smoker and
probably developed squamous cell lung cancer which is working as a
tumour producing ectopic ACTH causing pigmentation. Resulting
raised cortisole is leading to diabetes and hypokalemia (though small
cell carcinoma is usual cause but squamous cell carcinoma can
produce ectopic ACTH as paraneoplastic syndrome also)].

3. A 44yo woman has lost weight over 12 months. She has also
noticed episodes where her heart
beats rapidly and strongly. She has a regular pulse rate of 90bpm. Her
ECG shows sinus rhythm.
What is the most appropriate inv to be done?
a. Thyroid antibodies
b. TFT
c. ECG
d. Echocardiogram
e. Plasma glucose
Ans. The key is B. TFT. [The patient has paroxysmal atrial fibrillation
That is why there is no arrhythmia in between attacks. From the given
option TFT is the appropriate test as thyrotoxycosis is a leading cause
of paroxysmal atrial fibrillation and this ladies weight loss also makes
thyrotoxycosis as the probable cause here].

4. A 79yo anorexic male complains of thirst and fatigue. He has

symptoms of frequency, urgency
and terminal dribbling. His urea and creatinine levels are high. His
serum calcium is 1.9 and he is
anemic. His BP is 165/95 mmHg. What is the most probable dx?
a. BPH
b. Prostate carcinoma
c. Chronic pyelonephritis
d. Benign nephrosclerosis

Ans. The key is B. Prostate Carcinoma.

Explanation for Question no. 4:
First to say in this case (almost all features goes in favour of prostatic
carcinoma like- frequency, urgency and terminal dribbling are
features of prostatism; Age, anorexia and anaemia are constitutional
features of carcinoma prostate and it would be accurate presentation if
it was hypercalcaemia. But given calcium level is of hypocalcaemic
level and it is the main cause of discrepancy of this question). Renal
failure can be an association of malignant disease and can cause high
BP. Thirst is a feature of hypercalcaemia (here may be erroneously
calcium level is given in hypocalcaemic level ; probably a bad recall).
Prostate biopsy is the confirmatory diagnosis and others like PSA is
suggestive.
***There are some suggestion that Renal Failure may be the cause of
hypocalcemia.

5. A 64yo man has recently suffered from an MI and is on aspirin,

atorvastatin and ramipril. He has
been having trouble sleeping and has been losing weight for the past 4
months. He doesn’t feel
like doing anything he used to enjoy and has stopped socializing. He
says he gets tired easily and
can’t concentrate on anything. What is the most appropriate tx?
a. Lofepramine
b. Dosulepin
c. Citalopram
d. Fluoxetine
e. Phenelzine
Ans. The key is C. Citalopram. [Among SSRIs Sertraline is the drug
of choice for ischemic heart disease. Next choice is citalopram (as it is
often related to torsades de pointes it is not 1st choice). If SSRI cannot
be used Mirtazapine is recommended as next antidepressant].

6. A 67yo man after a stroke, presents with left sided ptosis and
constricted pupil. He also has loss
of pain and temp on the right side of his body and left side of his face.
Which part of the brain is
most likely affected?
a. Frontal cortex
b. Cerebellum
c. Pons
d. Medulla
e. Parietal cortex

Ans. The key is D. Medulla. [The name of the condition is “Lateral

medullary syndrome” [ipsilateral Horner syndrome and contralateral
loss of pain and temperature sense].

7. A 60yo man presents with dysphagia and pain on swallowing

both solids and liquids. A barium
meal shows gross dilatation of the esophagus with a smooth
narrowing at the lower end of the
esophagus. What is the SINGLE most likely cause of dysphagia?
a. Achalasia
b. Myasthenia gravis
c. Esophageal carcinoma
d. Esophageal web
e. Systemic sclerosis
Ans. The key is A. Achalasia. [Dysphagia for both solid and liquid or
prominently liquid suggest achalasia where dysphagia to solid suggest
stricture. Also gross dilatation of oesophagus with smooth narrowing
at lower end is seen in achalasia. In achalasia dysphagia is usually
described as progressive].

8. A man undergoes a pneumonectomy. After surgery, invs show

hyponatremia. What could be the
cause of the biochemical change?
a. Removal of hormonally active tumor
b. Excess dextrose
c. Excess colloid
d. Excessive K+
e. Hemodilution

Ans. The key is A. Removal of harmonically active tumour. [Ectopic

ACTH secreting tumour causes hypernatremia and body's
homeostatic mechanism try to lower the level of high sodium and do a
lesser degree though sodium remains in hypernatremic level or even it
may be normal (this question does not mention any preoperative
hypernatremia). Removal of that tumour results in negative sodium
balance for time being which results hyponatremia while gradually it
tends to rise again to normal level].

9. A pregnant lady came with pain in her calf muscle with local
rise in temp to the antenatal clinic.
What tx should be started?
a. Aspirin
b. LMWH
c. Paracetamol
d. Cocodamol
e. Aspirin and heparin
Ans. The key is B. LMWH. [Injections with low molecular weight
heparin (LMWH) are usually used to treat pregnant women with
DVT. LMWH is an anticoagulant, which means it prevents the blood
clot getting bigger. It does not affect the developing baby
(www.nhs.uk)].

10. A 53yo female presents with an acute painful hot knee joint. She
is a known case of RA. On
examination, the knee is red, tender and swollen. The hamstring
muscles are in spasm. Her
temp is 38.5C and BP is 120/80mmHg. What is the SINGLE best next
inv?
a. Joint aspiration for cytology and culture and sensitivity
b. Joint aspiration for positive birefrengent crystals
c. Joint aspiration for negative birefrengent crystals
d. Blood culture
e. Serum uric acid
Ans. The likely key is A. Joint aspiration for cytology and culture
and sensitivity. [Case of septic arthritis. Any chronically arthritic joint
is predisposed to infection. Moreover chronic use of steroid in Rh.
arthritis is one of the important predisposing factor. In this age group
likely organism is Staphylococcus. In younger age group Neisseria
gonorrhea is more common].

11. An 80yo man presented with pain in his lower back and
hip. He also complains of waking up in
the night to go to the washroom and has urgency as well as dribbling.
What is the most likely dx?
a. BPH
b. Prostatitis
c. UTI
d. Prostate carcinoma
e. Bladder carcinoma
Ans. The key is D. Prostate carcinoma. [Age, nocturia, urgency and
dribbling points towards prostate pathology. Pain of lower back and
hip points towards bony metastases from prostate cancer. Blood test
for PSA; Prostate biopsy; MRI (if initial biopsy is negative, to decide
repeat biopsy).
Treatment options: 1. Active treatment [i) radical prostatectomy ii)
radical radiotherapy iii) hormone therapy iv) brachytherapy v) pelvic
radiotherapy vi) orchidectomy
2. Active surveillance
3. Watchful waiting
4. Palliative care (Source: NICE)].