Index
Heart Sounds and Murmurs - Page 1
Valvular Disease - Page 17
ECG and Arrythmias - Page 27
Ischemic Heart Disease - Page 36
Congenital Heart Disease - Page 48
Hypertension - Page 56
Cardiomyopathy and Diseases of Pericardium - Page 58
Conduction and its Defects - Page 72
Brugada Syndrome, RHD & Infective Endocarditis - Page 100
Previous Year Questions (Cardiology) - Page 116
BCLS,ACLS,Mechanical Ventilation - Page 221
ARDS,Snake Bite,High Altitude Pulmonary Edema - Page 230
Previous Year Questions (Emergency Medicine) - Page 240
Diseases of Thyroid Gland - Page 252
Diseases of Pancreas - Page 265
Diseases of Pituitary Gland - Page 281
Calcium Hemostasis - Page 289
Previous Year Questions (Endocrinology) - Page 312
Water & Electrolyte Imbalance - Page 359
Syndromes (Bartter Syndrome, Liddle syndrome, Gitelman Syndrome) - Page 386
Ciliopathies, Kidney Injury and TTP - Page 393
Kidney Urine Analysis - Page 405
Chronic Kidney Disease & Management - Page 415
Renal Tubular Acidosis and Renal Artery Stenosis - Page 424
Nephritic Syndrome & Nephrotic Syndrome - Page 429
Diabetic Nephropathy, Kidney Stone and Acute Renal Failure - Page 438
Previous Year Questions (Nephrology) - Page 452
GI Bleed - Page 484
Peptic Ulcer Disease - Page 492
Diseases of Adrenal Gland - Page 495
Zollinger Ellison Syndrome - Page 508
Inflammatory Bowel Disease - Page 511
Malabsorption Syndrome - Page 515
Irritable Bowel Syndrome. - Page 519
Previous Year Questions (Gastrointestinal System) - Page 522
Hodgkin's and Non-Hodgkin's Lymphoma - Page 544

Index
Acute Lymphoblastic Leukemia - Page 554
Chronic Lymphocytic Leukemia - Page 559
Chronic Myeloid Leukemia - Page 568
Acute Myeloblastic Leukemia - Page 576
Multiple Myeloma - Page 582
Thalassemia - Page 589
Sickle Cell Anemia,G6PD Deficiency,Hemolytic Anemia - Page 597
Blood Grouping & Transfusion - Page 622
Aplastic Anemia & Iron Deficiency Anemia - Page 641
Platelet Disorders - Page 660
Previous Year Questions (Hematology) - Page 681
Multiple Sclerosis - Page 716
Subarachnoid Hemorrhage. - Page 722
Epilepsy - Page 726
Intraparenchymal Hemorrhage and Other CNS Bleeds - Page 732
Intracranial Space Occupying Lesion - Page 737
Raised ICP And Brain Death - Page 741
Stroke,TIA - Page 745
Parkinsonism - Page 765
Alzheimer's Disease. - Page 779
Headache and Migraine  - Page 786
Meningitis - Page 798
Myasthenia Gravis - Page 823
Guillain Barre Syndrome - Page 830
Neuromyelitis Optica - Page 834
Amyotrophic Lateral Sclerosis - Page 837
Syringomyelia and Conus Medullaris Syndrome - Page 842
Channelopathies - Page 848
Previous Year Questions (Neurology) - Page 853
IgG4 Related Disease - Page 935
Ankylosing Spondylitis - Page 939
Scleroderma & Sjogren Syndrome - Page 945
Rheumatoid Arthritis - Page 955
Crystal Arthropathy  - Page 975
Vasculitis - Page 987
Scleroderma - Page 1004

Index
Sarcoidosis - Page 1010
SLE - Page 1016
Previous Year Questions (Rheumatology) - Page 1029
Hepatitis - Page 1057
Liver Cirrhosis & Complications - Page 1069
Wilson's Disease & Hemachromatosis - Page 1097
Hereditary Hyperbilirubinemia & Hepatic Encephalopathy - Page 1115
Budd Chiari Syndrome & Pancreatitis - Page 1136
Alcoholic Hepatitis,Hepatorenal Syndrome - Page 1150
Previous Year Questions (Hepatobiliary System) - Page 1178
Obstructive Sleep Apnea & Cystic Fibrosis - Page 1199
Pulmonary Embolism & Fat Embolism - Page 1219
Emphysema & Bronchiectasis - Page 1233
Bronchial Asthma & COPD - Page 1240
Acute Respiratory Distrress Syndrome & Respiratory Failure - Page 1262
Tuberculosis - Page 1265
Pneumoconiosis & Interstitial Lung Disease - Page 1272
Pneumothorax & Pleural Effusion - Page 1283
ABG Interpretation - Page 1291
Pulmonary Function Tests - Page 1305
Bronchopneumonia - Page 1314
Previous Year Questions (Pulmonology) - Page 1335
Fever of Unknown Origin - Page 1393
Aspergillosis,COVID,Dengue - Page 1398
AIDS,Nipah Virus,Zika Virus - Page 1402
Previous Year Questions (Infections) - Page 1410

Heart Sounds and Murmurs
1. A 66-year-old male presents with complaints of increasing dyspnea on exertion. On examination,
heaving apex beat and carotid thrill were present. Auscultatory findings showed ejection systolic
murmur with single S2. Which of the following is an incorrect transthoracic echocardiographic finding in
this condition?
(or)
Which of the following is an incorrect transthoracic echocardiographic finding in aortic stenosis?
A. Calcification of valves
B. Ejection velocity > 4m/sec
C. Transvalvular gradient (LV -AO ) > 40mmHg
D. Candle flame jet
----------------------------------------
2. A 2-month-old infant is brought to the pediatrician with symptoms of poor feeding, increased
sweating on the forehead, and irritability. On examination, a continuous heart murmur is heard upon
auscultation. Which of the following is not correct about this condition?
(or)
Which of the following clinical presentations regarding patent ductus arteriosus is incorrect?
A. Left to right shunt
B. Presents as isolated right ventricular failure
C. Increased risk of NEC
D. Narrow-split second heart sound
3. A 50-year-old female presents to the clinic with complaints of exertional dyspnea and fatigue. Upon
auscultation, the physician notes a narrow split second heart sound. Further evaluation is warranted to
determine the underlying cause of this auscultatory finding. Which of the following conditions is not
typically associated with a narrow split second heart sound?
(or)
Which of the following conditions is not typically associated with a narrow split second heart sound
(S2)?
A. Aortic Stenosis
B. Hypertrophic Obstructive Cardiomyopathy
C. Wet Beriberi
D. Mitral regurgitation
4. A 6-month-old infant is brought to the pediatric cardiology clinic for evaluation due to a heart murmur
noted by the parents. Upon examination, the physician identifies a ventricular septal defect (VSD).
Further assessment is required to determine the specific type of VSD present in the infant. Which of the
following types of VSD is the most common?
(or)
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Which of the following types of VSD is the most common?
A. Perimembranous
B. Muscular
C. Supracristal
D. Sinus venosus
5. A 25-year-old female presents to the cardiology clinic for evaluation of a heart murmur. She reports
experiencing occasional shortness of breath and fatigue but denies any chest pain or palpitations. On
physical examination, a fixed split-second heart sound is noted, along with a prominent systolic ejection
murmur along the left sternal border. Which of the following statements is incorrect about this
condition?
(or)
Which of the following statements about atrial septal defect (ASD) is incorrect?
A. Low-pressure shunt
B. Right ventricle will have volume overloading
C. P2 will be delayed
D. Ostium Primum is the most common type of ASD
6. A 28-year-old female presents to the emergency department with palpitations and dizziness. On
examination, she is found to have a regular rapid heart rate, and an electrocardiogram shows delta
waves. Which of the following statements is not true regarding this condition?
(or)
Which of the following statements is not true regarding Wolf Parkinson White (WPW) Syndrome?
A. Pre-exciattion syndrome
B. Low cardiac output
C. Sudden cardiac death
D. Implantable cardioverter-defibrillator
7. During a routine physical examination, a physician auscultates the heart of a 25-year-old female
patient. While listening at Erb's point, the physician hears a splitting of the heart sounds that varies with
respiration. Where is Erb's point located?
(or)
Where is Erb's point located?
A. Erb's point is located at the third intercostal space on the left side along the parasternal line
B. Erb's point is located at the third intercostal space on the right side along the parasternal line
C. Erb's point is located at the fifth intercostal space on the left side along the midclavicular line
D. Erb's point is located at the fourth intercostal space on the right side along the midclavicular line
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8. Which of the following statements regarding heart sounds is incorrect?
A. S1 & S2 are heard as lub & dub respectively
B. The duration of systole is less than diastole
C. Systole is the period between S1 & S2
D. The ejection click comes just after S2.
9. Which of the following is not a low-pitched heart sound?
A. S3
B. S4
C. S1
D. Murmur of mitral stenosis
10. A 30-year-old male was brought to the clinic with breathlessness that increases while sitting and
resolves on lying down. On auscultation, tumor plop sound and mid diastolic murmur are heard. Which
of the following is the investigation of choice in this condition?
(or)
Which of the following is the investigation of choice for atrial myxoma?
A. Transthoracic echocardiography
B. Ultrasonography
C. ECG
D. Troponin
11. A 45-year-old male presents to the emergency department with complaints of chest pain at rest,
night sweats, low-grade fever, involuntary weight loss, and pain radiating to the left shoulder. An ECG
shows widespread ST elevation with concavity upwards. Which of the following auscultatory sound will
be heard in this condition?
(or)
Which of the following is the auscultatory sound heard in tubercular pericarditis?
A. Pericardial friction rub
B. Mid to late diastolic murmur
C. S3
D. S4
12. A 50-year-old male presents to the emergency department with complaints of chest pain and
shortness of breath. He is a known case of long-standing hypertension. Upon auscultation of the heart,
the physician hears an additional heart sound just before the first heart sound. Which of the following is
heard?
(or)
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The additional heart sound heard just before the first heart sound (S1) in patients with long-standing
hypertension is known as:
A. S2
B. S3
C. S4
D. S5
13. Which of the following conditions is most likely to cause a loud first heart sound (S1)?
A. Congestive Heart Failure
B. Hypothyroidism
C. Inferior Wall MI
D. Sick Sinus Syndrome
14. A 55-year-old male presents to the cardiology clinic with complaints of palpitations and shortness of
breath. On examination, an elevated jugular venous pressure (JVP) is noted, along with a cannon "A"
wave. This is seen in which of the following condition?
(or)
Which of the following is the condition where a cannon 'A' wave is seen in JVP?
A. Tricuspid regurgitation
B. Pulmonic Stenosis
C. Mitral Stenosis
D. Ventricular tachycardia
15. A 25-year-old male was brought to the emergency department due to fainting. On examination, he
has low blood pressure, S1, and S2 are muffled, and absent Y descent was seen in JVP. Which of the
following is the treatment option in this condition?
(or)
Which of the following is the treatment option in the condition characterized by fainting, low blood
pressure, muffled S1 and S2, and absent Y descent in JVP?
A. Echocardiographic guided pericardiocentesis
B. Transesophageal echocardiography
C. Balloon valvuloplasty
D. IV Digoxin
16. A 45-year-old female presents to the cardiology clinic with complaints of dyspnea on exertion,
orthopnea, and paroxysmal nocturnal dyspnea. On examination, the physician notes a tapping apex
beat and auscultates a loud S1 with a mid-diastolic murmur that accentuates with pre-systolic
accentuation. Additionally, a narrow split S1 is heard on auscultation. Which conditions are most likely
responsible for the patient's symptoms and examination findings?
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Page 5
(or)
Examination findings such as a tapping apex beat, loud S1, and a mid-diastolic murmur accentuated
with pre-systolic accentuation are seen in?
A. Mitral regurgitation
B. Mitral stenosis
C. Aortic regurgitation
D. Aortic stenosis
17. A 45-year-old woman presents to the cardiology clinic with complaints of shortness of breath and
fatigue on exertion. On examination, she is found to have a Mid-diastolic murmur heard best at the
apex, along with signs of right-sided heart failure. A chest X-ray shows a straightening of the left heart
border and a double atrial shadow. Which of the following is not typically associated with the workup of
(or)
Which of the following findings is not typically associated with the workup of Mitral Stenosis?
A. Increased duration of P wave on ECG
B. Narrowing of carinal angle on chest X-ray
C. Hockey stick sign on TTE
D. P-pulmonale
18. A 55-year-old male presents to the cardiology clinic with complaints of exertional dyspnea and
fatigue. On auscultation, a diastolic murmur is heard at the apex of the heart. An echocardiogram
confirms severe aortic regurgitation. Which of the following is the murmur typically associated with this
(or)
Which of the following is the murmur typically associated with severe aortic regurgitation?
A. Graham Steele murmur
B. Austin Flint Murmur
C. Seagull murmur
D. Carey Coombs murmur
19. A 32-year-old male presents to the cardiology clinic with complaints of chest pain and shortness of
breath. On auscultation, a continuous murmur is heard during both systole and diastole. Which of the
following conditions is least likely to present with a continuous murmur?
(or)
Which of the following conditions is least likely to present with a continuous murmur?
A. Coarctation of aorta
B. Patent ductus arteriosus
C. Peripheral pulmonary stenosis
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Page 6
D. Rheumatic heart disease
20. A 50-year-old male presents to the cardiology clinic with complaints of chest pain and dyspnea on
exertion. On examination, a systolic murmur is auscultated along the left sternal border, which
increases in intensity with maneuvers that decrease left ventricular volume. Which of the following is
the echocardiography finding that will be seen in this case?
(or)
Which of the following is the echocardiography finding seen in hypertrophic obstructive
cardiomyopathy?
A. Systolic anterior movement of the mitral valve
B. Systolic posterior movement of the mitral valve
C. Systolic medial movement of the mitral valve
D. Systolic lateral movement of the mitral valve
21. A 22-year-old female presents to the clinic with complaints of intermittent chest pain and exertional
dyspnea. On examination, a brachio-femoral pulse delay is noted. This patient is a known case of 45
XO syndrome and also exhibits signs of cyanosis in her toes but has pink fingers. Which of the
following statements is true regarding the auscultatory findings in this patient?
(or)
Which of the following statements is true regarding the auscultatory findings in the coarctation of the
aorta?
A. The murmur peaks at S1
B. The murmur is heard predominantly in diastole
C. The murmur is continuous and peaks at S2
D. The murmur is loudest at the apex of the heart
Correct Answers
Question Correct Answer
Question 1 4
Question 2 2
Question 3 4
Question 4 1
Question 5 4
Question 6 4
Question 7 1
Question 8 4
Question 9 3
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Question 10 1
Question 11 1
Question 12 3
Question 13 1
Question 14 4
Question 15 1
Question 16 2
Question 17 2
Question 18 2
Question 19 4
Question 20 1
Question 21 3
Solution for Question 1:
Correct Option D - Candle flame jet:
 Transthoracic echocardiography (TTE) is an essential tool for diagnosing Aortic stenosis.
 It provides valuable information such as the size of the reduced orifice, ejection velocity >4m/sec, and
transvalvular gradient (LV -AO ) >40mmHg.
 Candle flame jet is seen in mitral stenosis. 
 
Incorrect Options:
Options A, B, C:
 These are the correct echocardiographic findings seen in aortic stenosis.
Solution for Question 2:
Correct Option B - Presents as isolated right ventricular failure:
 Patent ductus arteriosus is characterized by a left-to-right shunt, where blood flows from the
higher-pressure systemic circulation to the lower-pressure pulmonary circulation due to the persistence
of the ductus arteriosus after birth.
 This leads to increased pulmonary blood flow and left ventricular overload and presents as left-sided
heart failure.
 However, biventricular failure will later ensue.
Option A - Left to right shunt: This is a characteristic feature of PDA, as described above.
Option C—Increased risk of NEC: In PDA, the shunting of blood to the pulmonary artery reduces the s
planchnic circulation, leading to an increased risk of necrotizing enterocolitis. 
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Page 8
Option D - Narrow-split second heart sound: It occurs due to left ventricular failure.
 
Solution for Question 3:
Correct Option D - Mitral regurgitation:
 Mitral regurgitation causes early A2 and wide split S2.
 A narrow split second heart sound (S2) refers to a decreased interval between the closure of the
aortic and pulmonic valves during expiration.
 This phenomenon occurs due to conditions that prolong the ejection time of the left ventricle relative to
the right ventricle, leading to a closer timing of closure of the aortic and pulmonic valves.
 Conditions associated with a narrow split S2 include Aortic Stenosis, Hypertrophic Obstructive
Cardiomyopathy, and Wet Beriberi.
 
Option A - Aortic Stenosis: Aortic stenosis is associated with a
narrow split S2 due to the prolongation of left ventricular ejection time.
Option B
- Hypertrophic Obstructive Cardiomyopathy: Hypertrophic obstructive cardiomyopathy can lead to a
narrow split S2, especially when subvalvular obstruction is present.
Option C - Wet Beriberi: Wet Beriberi, a manifestation of thiamine deficiency, can result in a
narrow split S2 due to impaired cardiac function and prolonged left ventricular ejection time.
Solution for Question 4:
Correct Option A - Perimembranous:
 The most common type of VSD is the perimembranous type, which is found in 80% of cases.
 This type of VSD is located in the membranous portion of the ventricular septum. 
 
Option B - Muscular: Muscular VSDs, also known as trabecular or mid-muscular VSDs, are located wit
hin the muscular portion of the ventricular septum. It may undergo spontaneous closure.
Option C - Supracristal: Supracristal VSDs, also known as conal or outlet VSDs, are situated above the
 level of the aortic valve. They are less common than perimembranous VSDs.
Option D - Sinus venosus: Sinus venosus defects are a type of atrial septal defect (ASD), not VSDs. T
hey involve the atrial septum, specifically the area where the superior or inferior vena cava enters the ri
ght atrium.
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Page 9
Solution for Question 5:
Correct Option D - Ostium Primum is the most common type of ASD:
 Wide fixed split S2 is a key finding seen in atrial septal defect. 
 The statement that "Ostium Primum is the most common type of ASD" is incorrect. The most common
type of ASD is Ostium Secundum, accounting for approximately 70-80% of all ASD cases. Ostium
Primum defects are less common and account for a smaller proportion of cases.
 
Option A - Low-pressure shunt: ASD is a low-pressure left-to-right shunt with a gradient of 4
mm Hg. This leads to overloading of the right atrium.
Option B - Right ventricle will have volume overloading: Due to the left-to-right shunt, the right ventricle 
experiences volume overload as it receives excess blood from the left atrium. Over time, this can lead t
o right ventricular enlargement and dysfunction.
Option C
- P2 will be delayed: This delay is primarily due to delayed closure of the pulmonic valve (P2) as a resu
lt of increased blood flow to the right heart. Since the normal split of S2 that occurs with respiration is c
anceled due to shunt, it is called wide fixed split S2. 
Solution for Question 6:
Correct Option D - Implantable cardioverter-defibrillator:
 In Wolf Parkinson White (WPW) Syndrome, radiofrequency ablation is done to destroy the accessory
pathway.
 An implantable cardioverter-defibrillator is used to terminate tachyarrhythmias. 
 
Option A
- Pre-excitation syndrome: This is correct, as the bundle of Kent does not have decremental property. 
Option B - Low cardiac output: This is correct as the ventricles do not get enough time to get filled with 
blood and contract prematurely. 
Option C - Sudden cardiac death: True. A fast beating heart can cause crashing of blood pressure. 
Solution for Question 7:
Correct Option A
- Erb's point is located at the third intercostal space on the left side along the parasternal line:
 Erb's point is located at the third intercostal space on the left side along the parasternal line.
 It is the area where the physiological splitting of heart sounds is best heard. Physiological splitting
varies with respiration and is approximately less than 30 milliseconds. This is typically heard during
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Page 10
inspiration.
 
Option B, C, and D: These options do not represent the location of Erb's point. 
Solution for Question 8:
Correct Option D - The ejection click comes just after S2:
 The ejection click typically occurs just after S1.
 It is associated with the opening of the semilunar valves (aortic and pulmonary) during the initial
phase of ventricular systole.
 After S2, opening snap is present. 
 
Option A - S1 & S2 are heard as lub & dub respectively: This statement is correct. S1 represents the cl
osure of the mitral and tricuspid valves (lub), while S2 represents the closure of the aortic and pulmona
ry valves (dub).
Option B - The duration of systole is less than diastole: This statement is correct. 
Option C - Systole is the period between S1 & S2: This statement is correct. Systole begins with the cl
osure of the mitral and tricuspid valves (S1) and ends with the closure of the aortic and pulmonary valv
es (S2).
Solution for Question 9:
Correct Option C - S1:
 S1 is a high-pitched sound caused by the closure of the mitral and tricuspid valves during ventricular
systole.
 It is best heard using the diaphragm of the stethoscope.
 
Option A - S3: S3 is a low-pitched heart sound that occurs due to rapid early diastolic filling of the ventr
icles. It is often heard in conditions such as heart failure and volume overload.
Option B - S4: S4 is another low-pitched heart sound caused by atrial contraction against a stiffened ve
ntricle during late diastole. It is commonly associated with conditions like hypertension and ischemic he
art disease.
Option D - Murmur of mitral stenosis: The murmur of mitral stenosis is typically a low-pitched rumbling 
sound heard during mid-diastole. It is best appreciated using the bell of the stethoscope due to its low f
requency.
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Page 12
 
Option A - S2: The second heart sound (S2) is typically heard at the beginning of the diastole, marking 
the closure of the aortic and pulmonic valves.
Option B - S3: The third heart sound (S3) is heard during the rapid ventricular filling phase and is norm
al in children, pregnant women, and adults up to 35 years of age. It is not specifically associated with lo
ng-standing hypertension.
Option D - S5: There is no fifth heart sound (S5) described in standard cardiac auscultation.
Solution for Question 13:
Correct Option A - Congestive Heart Failure:
 Congestive heart failure is a condition characterized by impaired cardiac function leading to abnormal
filling of the ventricles and tachycardia.
 In this condition, the mitral valve apparatus is subjected to increased tension during ventricular
systole, resulting in a louder closure of the mitral valve and, thus, a louder S1.
Options B, C & D:
 Hypothyroidism, inferior wall MI, and sick sinus syndrome produce a soft S1.
 These conditions have a common finding of bradycardia.
Solution for Question 14:
Correct option D - Ventricular tachycardia:
 Ventricular tachycardia is a condition where a cannon A wave is seen in JVP
 Other conditions where a cannon A wave is seen in JVP are:
Options A, B & C:
 
Solution for Question 15:
Correct Option A - Echocardiographic guided pericardiocentesis:
 Echocardiographic-guided pericardiocentesis is the primary treatment for cardiac tamponade leading
to compression of the heart chambers and diastolic collapse of ventricles.
 This compression results in symptoms such as fainting (syncope), low blood pressure (hypotension),
muffled heart sounds (S1 and S2), and an absent Y descent in the jugular venous pulse (JVP).
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Page 13
 Pericardiocentesis, guided by echocardiography, allows for the drainage of the pericardial fluid,
relieving the pressure on the heart and improving hemodynamic stability.
 
Option B
- Transesophageal echocardiography: It may aid in the diagnosis of cardiac tamponade but is not a
treatment modality.
Option C - Balloon valvuloplasty: Balloon valvuloplasty is a procedure used to treat certain types of val
vular heart disease, such as mitral stenosis or aortic stenosis, and is not indicated for cardiac tampona
de.
Option D - IV Digoxin: Digoxin is a medication used to manage certain heart conditions, such as heart f
ailure and atrial fibrillation, but it is not indicated for treating cardiac tamponade. 
Solution for Question 16:
Correct Option B - Mitral stenosis:
 The patient's clinical presentation, including dyspnea on exertion, orthopnea, and paroxysmal
nocturnal dyspnea, along with examination findings such as a tapping apex beat, loud S1, and a
mid-diastolic murmur accentuated with pre-systolic accentuation, suggest mitral stenosis.
 Additionally, the presence of a narrow split S1 further supports the diagnosis of mitral stenosis.
 In mitral stenosis, the narrowing of the mitral valve orifice leads to increased left atrial pressure,
resulting in symptoms of pulmonary congestion and the characteristic auscultatory findings described.
 
Option A - Mitral regurgitation: Mitral regurgitation typically presents with a
holosystolic murmur and is not associated with a narrow split S1 or mid-diastolic murmur.
Option C - Aortic regurgitation: Aortic regurgitation is characterized by a
diastolic murmur heard best at the left sternal border and is not typically associated with a
narrow split S1 or mid-diastolic murmur.
Option D - Aortic stenosis: Aortic stenosis presents with a
systolic murmur heard best at the right upper sternal border and is not associated with a
Solution for Question 17:
Correct Option B - Narrowing of carinal angle on chest X-ray:
Workup Findings in mitral stenosis
 Chest X-Ray: Straightening of left heart border: Suggests left atrial enlargement. Double atrial
shadow/ Double atrial contour: Indicative of double contour of the atria, commonly seen in cases of left
atrial enlargement. Widening of carinal angle (Tracheal bifurcation) is seen, and not narrowing.
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Page 16
 Prior to extensive development of the collaterals, a systolic ejection murmur is heard. 
 
Option A - The murmur peaks at S1: In coarctation of the aorta, the murmur typically peaks at S2.
Option B - The murmur is heard predominantly in diastole: While the murmur may extend into diastole, 
it is typically heard throughout the cardiac cycle and peaks at S2.
Option D - The murmur is loudest at the apex of the heart: In coarctation of the aorta, the murmur is typ
ically heard over the left sternal border, not at the apex.
16

Valvular Disease
1. A 63-year-old male presents to the clinic complaining of fatigue, shortness of breath, and occasional
palpitations. He has a medical history of hypertension and hyperlipidemia, for which he takes
medications regularly. He appears tired, and his blood pressure is 140/90 mmHg. Auscultation reveals
a pansystolic murmur best heard at the apex, radiating to the axilla. What is the most likely diagnosis?
(or)
What is the most likely diagnosis for a patient with fatigue, shortness of breath, occasional palpitations,
pallor, and a pansystolic murmur best heard at the apex radiating to the axilla?
A. Aortic stenosis
B. Mitral regurgitation
C. Ventricular septal defect
D. Tricuspid regurgitation
2. A 42-year-old female presents to the clinic due to occasional palpitations, mild exertional shortness
of breath, and chest discomfort. Her blood pressure is 120/80 mmHg, heart rate is 82 beats per minute,
and regular. There is a mid-systolic click heard best at the apex, followed by a late systolic murmur. The
murmur increases in intensity with the Valsalva maneuver and decreases with squatting.Which of the
following additional finding can not be found in this patient?
(or)
What additional finding is less likely to be present in an otherwise healthy patient with a mid-systolic
click followed by a late systolic murmur that intensifies with the Valsalva maneuver and decreases with
squatting?
A. Fibrillin-1 protein defect
B. Hyperextended joints
C. Sacroiliitis
D. Blue sclera
3. A 45-year-old male, presents to the clinic with fatigue, exertional dyspnea, and swelling in his legs for
the past few months. There is bilateral pitting edema in his lower limbs and an elevated jugular venous
pressure. Auscultation reveals a soft, low-pitched, rumbling sound following S2. Which of the following
conditions will match the given clinical profile?
(or)
Which of the following will have auscultatory finding of a soft, low-pitched, rumbling sound following S2?
B. Hypertrophic Cardiomyopathy
C. Atrial Fibrillation
D. Chronic Mitral regurgitation
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Page 2
4. A 25-year-old female with a webbed neck presents to the clinic complaining of mild exercise
intolerance and occasional palpitations. A fourth heart sound and a systolic ejection murmur over the
left upper sternal border are heard on auscultation. Which of the following chromosomal defects is most
likely to be associated with her condition?
(or)
What chromosome defect is most commonly associated with the presence of a fourth heart sound and
systolic ejection murmur over the left upper sternal border in a young woman with a congenital heart
disease?
A. Chromosome 21
B. Chromosome 12
C. Chromosome 13
D. Chromosome 18
5. A 32-year-old male presents to the clinic due to palpitations, fatigue, and right upper quadrant
discomfort due to hepatomegaly. Auscultation reveals a pansystolic murmur that is louder on
inspiration. ECG shows right axis deviation. Echocardiography reveals defective coaptation of leaflets,
and there is leakage of blood from the right ventricle to the right atrium with reverse systolic flow in the
liver on a Doppler. Which of the following JVP findings would be found in this patient?
(or)
What JVP findings are likely to be observed in a patient with defective coaptation of leaflets, and blood
leakage from the right ventricle to right atrium with reverse systolic flow in the liver?
A. Large a wave
B. Giant CV wave
C. Blunted y descent
D. Steep x descent
6. A 60-year-old male presents to the clinic due to fatigue and leg swelling for the past few weeks. On
examination, jugular venous distention, hepatomegaly, and peripheral edema are noted. A mid-diastolic
murmur is heard over the lower left sternal border. The patient's history is significant for balloon
dilatation done for rheumatic heart disease. What is the most likely underlying cause?
(or)
What is the most likely cause of right heart failure in a patient with a history of rheumatic heart disease?
A. Tricuspid stenosis
B. Pulmonic stenosis
7. A 65-year-old male presents to the clinic due to shortness of breath on exertion, chest pain, and
occasional fainting episodes. His blood pressure is elevated. Cardiac auscultation reveals a narrowly
split S2 and a murmur over the right upper sternal border. Which of the following murmurs would be
found in this patient?
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Page 3
(or)
Which murmur is present in an elderly patient with a triad of exertional dyspnea, angina, and syncope?
A.
B.
C.
D.
8. A 60-year-old male with long-standing hypertension visits a clinic for a routine check-up. He
mentions occasional episodes of exertional dyspnea and fatigue. His blood pressure is elevated, and
an irregularly irregular heart rhythm is noted. A low-pitched sound is heard immediately preceding the
first heart sound on auscultation. No other abnormalities are present. Which of the following is the
possible explanation of the low-pitched sound?
(or)
What is the likely explanation for a low-pitched sound heard immediately preceding the first heart sound
in a patient with long-standing hypertension?
A. Rapid passive ventricular filling
B. Increased stiffness of left ventricular wall
C. Closure of pulmonic valve
D. Restricted motion of aortic cusps
9. A 60-year-old female presents to the clinic with complaints of exertional dyspnea and occasional
chest discomfort. She has had well-controlled hypertension for the past five years. A systolic murmur is
heard over the right upper sternal border on cardiac auscultation. Her family history is remarkable for
cardiovascular diseases. Which of the following is not related to this presentation?
(or)
Which of the following is unrelated to a woman's exertional dyspnea, chest discomfort, well-controlled
hypertension, and a systolic murmur heard over the right upper sternal border?
A. Turner syndrome
B. Rheumatic heart disease
C. NOTCH 3 gene
D. Shone complex
10. A 40-year-old female presents to a clinic complaining of breathlessness and chest pain on exertion.
She feels uncomfortable in the supine position. Examination reveals capillary pulsations in the nail bed,
single S2 with an early diastolic murmur. Echocardiography shows LVEF = 42 %. What is the most
likely diagnosis?
(or)
What is the likely diagnosis of a condition that causes capillary pulsations in the nail bed, a single S2,
an early diastolic murmur, and LVEF of 42% on echocardiography?
A. VSD
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Page 4
B. ASD
C. Aortic Regurgitation
D. Severe pulmonary regurgitation
11. A 45-year-old male presents to a clinic with progressively worsening fatigue, shortness of breath,
and palpitations over the past few months. He has history of rheumatic fever during childhood. On
examination, you note a wide pulse pressure, a diastolic murmur best heard at the left sternal border,
and bounding peripheral pulses. An echocardiogram reveals a dilated left ventricle. On auscultation, a
pistol shot sound is heard over the femoral artery. What is this sign known as?
(or)
What is the term used for the 'pistol shot sound' over the femoral artery on auscultation in a patient with
a history of rheumatic fever, a diastolic murmur, and a dilated left ventricle?
A. Traube’ sign
B. De Musset’s sign
C. Hill’s sign
D. Duroziez’ sign
Question 1 2
Question 2 3
Question 4 2
Question 5 2
Question 6 1
Question 8 2
Question 10 3
Correct Option B - Mitral regurgitation:
 The patient's clinical presentation, including fatigue, shortness of breath, and a pansystolic murmur at
the apex radiating to the axilla, is highly suggestive of mitral regurgitation.
 Tricuspid regurgitation also has pansystolic murmur but it does not radiate to the axilla. 
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Page 6
Option B - Hyperextended joints: Hyperextended joints are often seen in patients with connective tissu
e disorders, such as Ehlers-Danlos syndrome or Marfan syndrome. Joint hypermobility can be a
feature of these conditions and can coexist with mitral valve prolapse.
Option D - Blue sclera: It is seen in conditions such as osteogenesis imperfecta, a genetic disorder cha
racterized by brittle bones. While blue sclera is not specific to mitral valve prolapse, it can occur in som
e connective tissue disorders that may also be associated with MVP.
Correct Option D – Chronic Mitral Regurgitation (MR):
 The auscultatory sound, described as a soft, low-pitched, rumbling sound following S2 is a flow
murmur due to increased flow across the mitral valve.
 The blood that leaks from LV to LA has to flow back to LV during diastole. 
Option A - Aortic Stenosis: Aortic stenosis produces a systolic ejection murmur.
Option B - Hypertrophic Cardiomyopathy: Hypertrophic Cardiomyopathy produces an ejection systolic 
murmur heard at the left sternal border, which increases with Valsalva maneuver and decreases with s
quatting.
Option C - Atrial Fibrillation: Atrial Fibrillation is an irregular heart rhythm characterized by rapid and ch
aotic atrial contractions.
Correct Option B - Chromosome 12:
 The murmur and other clinical findings in this young patient are consistent with the diagnosis of
pulmonic stenosis.
 Auscultatory findings in pulmonic stenosis: Ejection systolic murmur Presence of S4, soft, single S2,
normal A2, and soft P2
 Ejection systolic murmur
 Presence of S4, soft, single S2, normal A2, and soft P2
 Pulmonic stenosis is one of the common cardiac abnormalities observed in individuals with Noonan
syndrome.
 Noonan syndrome is caused by mutations in several genes, including the PTPN11 gene located on
chromosome 12.
Option A Chromosome 21: Defects in chromosome 21 result in Down syndrome. It is associated with t
he atrial septal defect, ventricular septal, and patent ductus arteriosus. 
Option C Chromosome 13: Defects in chromosome 13 lead to Patau syndrome. Cardiac abnormalities 
associated with this syndrome include ASD, VSD, PDA, and Tetralogy of Fallot. 
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Page 7
Option D Chromosome 18: Edward syndrome results from trisomy 18. Associated cardiac abnormalitie
s are ASD, VSD, and PDA.
 
Correct Option B - CV wave:
 The constellation of findings suggests the diagnosis of tricuspid regurgitation in this patient.
 A pansystolic murmur can be heard which increases on inspiration. This is known as the Caravallo
Sign.
 Dilation of the right chambers will cause right axis deviation. 
 The clinician would observe a giant CV wave in the jugular venous pressure findings in this patient
with TR.
Option A - Large a wave: The a wave in the JVP represents atrial contraction and is typically elevated i
n conditions such as tricuspid stenosis. 
Option C - Blunted y descent: The "y" descent in the JVP represents the rapid emptying of blood from t
he right atrium into the right ventricle during diastole. In tricuspid regurgitation, the y
descent will be exaggerated.
Option D - Steep x descent: Tricuspid regurgitation shows absent "x" descent.
Correct Option A - Tricuspid stenosis:
 Based on the patient's symptoms and examination findings, the most likely cause is tricuspid stenosis.
 It usually unmasks after percutaneous mitral balloon valvuloplasty done for mitral stenosis.
 This results in increased pressure in the right atrium, leading to jugular venous distention,
hepatomegaly (enlarged liver), and peripheral edema (swelling in the legs). The diastolic murmur heard
over the lower left sternal border is a characteristic finding in tricuspid stenosis.
Option B - Pulmonic stenosis: Pulmonic stenosis primarily affects the flow of blood from the right ventri
cle to the pulmonary artery and is associated with a
systolic murmur heard over the left upper sternal border.
Option C - Aortic regurgitation: It produces early or mid-diastolic murmur. 
Option D - Mitral regurgitation: It produces pansystolic murmur.
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Page 8
Correct Option A -
 The clinical presentation of exertional dyspnea, angina, and syncope, along with a murmur
auscultated over the right upper sternal border, is highly suggestive of Aortic Stenosis (AS). Aortic
stenosis is characterized by a narrowing of the aortic valve, leading to obstruction of blood flow from the
left ventricle to the aorta.
 The murmur is typically a systolic ejection murmur, also known as a crescendo-decrescendo murmur.
It starts after the first heart sound (S1) and peaks in intensity in mid-systole. Then, it gradually
decreases in intensity as blood is ejected from the left ventricle.
Option B - Holosystolic murmur at apex: Characteristic of mitral regurgitation (MR), where blood flows 
back from the left ventricle to the left atrium during systole due to a dysfunctional mitral valve. 
Option C - Midsystolic click followed by systolic murmur: Characteristic of mitral valve prolapse (MVP), 
where the mitral valve leaflets prolapse into the left atrium during systole. 
Option D - Opening snap followed by mid-diastolic murmur: Characteristic of mitral stenosis (MS), wher
e the mitral valve is narrowed, causing obstruction of blood flow from the left atrium to the left ventricle 
during diastole. 
Correct Option B - Increased stiffness of left ventricular wall:
 The additional low-pitched sound heard immediately preceding the first heart sound (S1) in this
patient is likely the fourth heart sound (S4). The S4 sound is an extra heart sound that occurs during
late diastole, just before the first heart sound (S1).
 It is caused by the rapid active ventricular filling of blood into the stiffened left ventricle.
 In patients with long-standing hypertension and left ventricular hypertrophy, the left ventricle can
become stiff and less compliant, making it harder for the ventricle to relax and fill with blood during
diastole. T
 his increased stiffness of the left ventricular wall is responsible for producing the S4 sound.
Option A - Rapid passive ventricular filling: Rapid passive ventricular filling is associated with the third 
heart sound (S3), which occurs in early diastole. The S3 sound is often heard in conditions such as con
gestive heart failure.
Option C
- Closure of the pulmonic valve: The pulmonic valve closure produces the P2 sound, which is a
component of the second heart sound (S2) and is heard over the left upper sternal border.
Option D - Restricted motion of aortic cusps:
 Restricted motion of aortic cusps is observed in aortic stenosis. 
 The typical murmur is a high-pitched, "diamond-shaped" crescendo-decrescendo, midsystolic ejection
murmur heard best at the right upper sternal border radiating to the neck and carotid arteries.
 AS can also cause LV hypertrophy and production of S4. However, there is no evidence of AS in this
patient with hypertension. 
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Page 9
Correct Option C - NOTCH 3 gene:
 The patient's clinical presentation and a systolic murmur over the right upper sternal border are
suggestive of aortic stenosis.
 Aortic stenosis is characterized by narrowing of the aortic valve opening, which can lead to
obstruction of blood flow from the left ventricle to the aorta.
 The NOTCH 3 gene is associated with cerebral autosomal dominant arteriopathy with subcortical
infarcts and leukoencephalopathy (CADASIL), a hereditary small vessel disease that affects the brain's
blood vessels. It is unrelated to AS.
 Mutations in the NOTCH 1 gene are associated with bicuspid aortic valve disease predisposing to AS.
Option A - Turner Syndrome: Turner Syndrome is associated with a high incidence of aortic valve abno
rmalities, especially bicuspid aortic valve, which is one of the causes of aortic stenosis. 
Option B - Rheumatic Heart Disease: Rheumatic fever, caused by an untreated streptococcal infection,
 can lead to inflammation and damage to heart valves, including the aortic valve. Rheumatic heart dise
ase is one of the causes of aortic stenosis.
Option D - Shone Complex: Shone complex is a combination of cardiac defects that can lead to left-sid
ed heart obstruction, including aortic stenosis. It is associated with pediatric aortic stenosis. Componen
t of this complex:
Solution for Question 10:
Correct Option C - Aortic Regurgitation:
 Clinical findings of capillary pulsations in the nail bed, called Quincke’s Sign, a single S2, and an early
diastolic murmur in the setting of chest pain on exertion and breathlessness reflect a diagnosis of aortic
regurgitation, which occurs due to inadequate closure of the aortic valve.
 Key–Hodgkin murmur is the diastolic murmur of AR with a raspy quality, likened to the sound of a 'saw
cutting through wood.'
 A single S2 is due to inadequate closure of aortic valves, which eliminates the A2 component.
 Hence, only the P2 component is heard due to the closure of pulmonary valves.
Option A – VSD: Pansystolic murmur is seen in the Ventricular septal defect.
Option B – ASD: No shunt murmur due to extremely low-pressure gradient, instead only flow murmur is
 present in the left upper sternal border due to increased blood flow across pulmonary valves.
Option D - Severe pulmonary regurgitation: Severe PR →
RV dilation due to chronic volume overload causing eccentric hypertrophy → Tricuspid regurgitation →
Pansystolic murmur. 
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Page 10
Solution for Question 11:
Correct Option A - Traube’ sign:
 Traube's sign, also known as "pistol-shot sound," is a clinical finding associated with aortic
regurgitation.
 It is characterized by a loud, high-pitched, and tapping sound heard over the femoral artery when
auscultated with a stethoscope.
 This sound occurs due to the rapid rise and fall of the arterial pressure during systole and diastole in
the presence of aortic regurgitation.
Option B - De Musset's sign: De Musset's sign is a clinical finding characterized by a rhythmic nodding 
or bobbing of the head with each heartbeat. It is also typically associated with aortic regurgitation.
Option C - Hill's sign: Hill's sign refers to a clinical finding in patients with aortic regurgitation. In this, a
systolic and diastolic murmur heard over the femoral artery when auscultated with a
stethoscope and compressed with a sphygmomanometer cuff.
Option D - Duroziez's sign: Duroziez's sign is a clinical finding in aortic regurgitation. It occurs when a c
ontinuous murmur is heard over the femoral artery when auscultated with a
stethoscope and compressed with a sphygmomanometer cuff. This phenomenon is due to the turbulen
t blood flow through the narrowed femoral artery.
26

ECG and Arrythmias
1. What does the image below represent in terms of murmurs?
A. End diastolic
B. Pan systolic
C. Ejection systolic
D. Mid diastolic
2. A 42-year-old male presents to the cardiology clinic with complaints of intermittent palpitations and
lightheadedness. His electrocardiogram reveals a pattern consistent with Lown-Ganong Levine
Syndrome.Which of the following ECG findings is not characteristic of this condition?
(or)
Which of the following ECG findings is not characteristic of Lown-Ganong Levine Syndrome?
A. PR interval is short
B. QRS is normal
C. PJ interval is short
D. PJ interval is long
3. A 65-year-old male presents to the clinic for a routine check-up. During the examination, his resting
heart rate is noted to be 70 beats per minute, and his blood pressure is within normal limits. The
physician notices that the duration between the P wave and the QRS complex on the electrocardiogram
is consistently prolonged, measuring at 0.24 seconds. Which of the following is the best
recommendation for this patient?
(or)
Which of the following is the treatment of choice in first-degree heart block?
A. No specific treatment
B. Digoxin
C. Amiodarone
D. Labetalol
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Page 2
4. A 60-year-old male presents to the emergency department with complaints of palpitations and
shortness of breath. An electrocardiogram is performed, revealing an irregularly irregular rhythm. Which
of the following ECG waves is absent in the patient?
(or)
Which of the following waves is absent in the ECG of a patient with atrial fibrillation?
A. P wave
B. T wave
C. Q wave
D. U wave
5. A 60-year-old male patient presents to the clinic with complaints of occasional dizziness and
lightheadedness. An electrocardiogram reveals a pattern consistent with Mobitz Type 1 (Wenckebach)
phenomenon. Which of the following statements best describes this condition?
(or)
Which of the following statements best describes Wenckebach phenomenon on ECG?
A. Accelerated AV nodal conduction
B. Progressive decrease in PR interval with each beat and a missed beat
C. Progressive increase in PR interval with each beat and a missed beat
D. The PR interval before and after the missed beat are equal
6. A 65-year-old male patient with a history of hypertension and previous myocardial infarction presents
to the emergency department with complaints of dizziness and near-fainting episodes. An
electrocardiogram is performed, revealing a pattern consistent with Mobitz II. Which of the following is
not seen in this pattern?
(or)
Which of the following features is not seen in Mobitz II?
A. Infranodal block
B. PR interval is normal before a missed beat
C. PR interval is increased before a missed beat
D. PR intervals before and after the missed beat are equal
7. A 60-year-old male patient presents to the emergency department with palpitations and shortness of
breath. His ECG reveals atrial flutter with a rapid ventricular response. The patient's blood pressure is
stable, and he is hemodynamically well. Which of the following interventions would be most appropriate
as a first-line treatment for rate control of this patient?
(or)
Which of the following interventions is the first-line treatment for rate control of atrial flutter?
A. Intravenous Esmolol
B. Chemical cardioversion with intravenous Amiodarone
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Page 3
C. Electrical cardioversion with biphasic DC shock
D. Anticoagulation with unfractionated heparin
8. A 45-year-old male patient undergoes an electrocardiogram (ECG) as part of a routine health
check-up. The ECG report indicates a prolonged QT interval.
(or)
What does the QT interval signify in an electrocardiogram (ECG)?
A. Ventricular depolarization
B. Ventricular depolarization and ventricular repolarization
C. Ventricular repolarization
D. Septal activation
9. A 25-year-old patient presents with recurrent episodes of palpitations and recurrent syncopal attacks.
An electrocardiogram performed in the clinic shows normal findings. The physician advises the patient
to undergo Holter monitoring which reveals paroxysmal supraventricular tachycardia. What is not
correct about this condition?
(or)
Which of the following is not an ECG finding seen in paroxysmal supraventricular tachycardia?
A. Wide QRS complex
B. ST segment depression
C. R-R interval decrease
D. Hidden P waves
10. A 30-year-old patient with a history of panic attacks presents to the emergency department with
palpitations and chest discomfort. Blood pressure is 110/70mmHg and pulse rate is 150 bpm. An
electrocardiogram shows findings of paroxysmal supraventricular tachycardia. Which of the following is
the best treatment for this patient?
(or)
Which of the following is the most appropriate intervention for symptom control in a patient with PSVT,
blood pressure on admission 110/70 mmHg, and heart rate 150 bpm?
A. Oral verapamil
B. Carotid sinus massage
C. Intravenous adenosine
D. Electrical cardioversion
11. A 60-year-old patient with a history of CAD presents to the emergency department with palpitations
and chest discomfort. An electrocardiogram shows wide QRS complex tachycardia. Which of the
following is not an ECG finding seen in this patient?
(or)
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Page 4
Which of the following is not an ECG finding seen in Ventricular tachycardia?
A. Rabbit ear appearance
B. Josephson's sign
C. Capture beats
D. QTc prolongation
Question 1 3
Question 2 4
Question 3 1
Question 5 3
Question 6 3
Question 9 1
Question 10 2
Question 11 4
Correct Option C: Ejection systolic
 An ejection systolic murmur occurs during the ejection phase of the cardiac cycle when blood is being
pumped out of the heart. It is characterized by a continuous or crescendo-decrescendo sound that
starts after the first heart sound (S1) and ends before the second heart sound (S2).
 The ejection systolic murmur is typically heard best over specific areas of the heart, such as the aortic
or pulmonary valve areas, depending on the underlying cause of the murmur. It is caused by turbulent
blood flow through a narrowed or abnormal valve or aorta during systole.
Incorrect Options
Option A: End diastolic: An end diastolic murmur occurs during late diastole, just before the next systol
e begins. It is commonly associated with conditions such as mitral stenosis or tricuspid regurgitation. T
he image does not show features or timing consistent with an end diastolic murmur.
Option B: Pan systolic: A pan systolic (or holosystolic) murmur is heard throughout systole, starting wit
h or immediately after S1 and continuing until S2. It is typically associated with conditions such as mitra
l regurgitation or ventricular septal defects. The image does not show features or timing consistent with
 a pan systolic murmur.
Option D: Mid diastolic: A mid diastolic murmur occurs during mid-diastole, after S2 and before S1. It is
 commonly associated with conditions such as mitral stenosis or tricuspid stenosis. The image does no
30

Page 6
Option B - T wave: The T wave represents ventricular repolarization.
Option C - Q wave: The Q wave represents septal activation.
Option D - U wave: If present, the U wave follows the T
wave and represents repolarization of the Purkinje fibers or papillary muscles.
 
Correct Option C - Progressive increase in PR interval with each beat and a missed beat:
 Mobitz Type 1 (Wenckebach) phenomenon is an intranodal conduction defect that leads
to progressive increase in the PR interval with each beat until a beat is dropped (a missed
beat) followed by a reset of the conduction sequence. 
 
Option A - Accelerated AV nodal conduction: Instead, there is a
progressive slowing of AV nodal conduction.
Option B - Progressive decrease in PR interval with each beat and a
missed beat: PR interval typically lengthens rather than decreases.
Option D - The PR interval before and after the missed beat are equal: This is incorrect as the PR inter
val before and after the missed beat are unequal in Mobitz Type 1
(Wenckebach) phenomenon due to the progressive lengthening of the PR interval.
Correct Option C - PR interval is increased before a missed beat:
 Typically, there is a sudden skipped beat without a change in the PR interval in Mobitz type II heart
block.
 This results in intermittent failure of conduction from the atria to the ventricles. Therefore, option a is
the correct choice, as it describes the anatomical location of the block in Mobitz II/Infranodal heart
block.
 
Option A - Infranodal block: In Mobitz II/Infranodal heart block, the conduction block occurs below the A
V node, specifically within the Bundle of His.
Option B - PR interval is normal before a
missed beat: Mobitz II/Infranodal heart block is characterized by sudden skipped beats without a
change in the PR interval.
Option D - PR interval before and after the missed beat are equal: In Mobitz II/Infranodal heart block, th
e PR interval after the missed beat is usually longer than the PR interval before the missed beat.
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Page 7
Correct Option A - Intravenous Esmolol:
 In the acute management of atrial flutter with a rapid ventricular response, the priority is rate control to
reduce symptoms and prevent hemodynamic compromise.
 Intravenous beta-blockers like Esmolol or calcium channel blockers like Verapamil are commonly
used for rate control in this setting.
 Esmolol acts rapidly and can effectively control heart rate in patients with atrial flutter without
compromising cardiac output.
 
Option B - Chemical cardioversion with intravenous Amiodarone: While Amiodarone may be used for c
hemical cardioversion in certain cases of atrial fibrillation, it is not typically the first-line treatment for ac
ute atrial flutter.
Option C - Electrical cardioversion with biphasic DC shock: Electrical cardioversion may be considered 
if the patient is hemodynamically unstable or if rate control measures fail, but it is not usually the initial t
reatment in stable patients with atrial flutter.
Option D - Anticoagulation with unfractionated heparin: Anticoagulation is important in atrial flutter, esp
ecially before cardioversion to prevent thromboembolic events, but it is not the first-line treatment for ac
ute management of atrial flutter with a rapid ventricular response.
Correct Options B - Ventricular depolarization and ventricular repolarization:
 The QT interval on an electrocardiogram (ECG) represents the time from the start of ventricular
depolarization to the end of ventricular repolarization.
 It encompasses both the electrical events of ventricular contraction (depolarization) and relaxation
(repolarization).
 Prolongation of the QT interval can predispose individuals to ventricular arrhythmias, including
Torsades de Pointes, and is associated with an increased risk of sudden cardiac death.
 
Option A - Ventricular depolarization: The QRS complex on an ECG represents ventricular depolarizati
on, not the QT interval.
Option C - Ventricular repolarization: While the QT interval includes ventricular repolarization, it also in
cludes ventricular depolarization.
Correct Option D - Septal activation: The Q
wave on an ECG represents septal activation, not the QT interval.
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Page 8
Correct option A - Wide QRS complex:
 Paroxysmal supraventricular tachycardia presents with a narrow QRS complex on the ECG, as the
arrhythmia originates above the bundle of His.
 Therefore, a wide QRS complex is not an ECG finding observed in PSVT.
 The other options, including ST segment depression, decreased R-R interval, and hidden P waves,
are commonly seen in PSVT due to rapid atrial activation and aberrant atrioventricular conduction.
 
 These are the ECG findings seen in paroxysmal supraventricular tachycardia.
 Correct  Option B
- Carotid sinus massage: Carotid sinus massage is first-line treatment in patients with PSVT.
Option A - Oral verapamil: Oral verapamil is used to prevent PSVT rather than for acute management. 
It may not provide immediate relief during an acute episode.
Option C - Intravenous adenosine:
 In the acute management of PSVT, intravenous adenosine is the preferred initial intervention,
especially when the systolic blood pressure is ≥ 90 mmHg.
 Adenosine helps terminate the tachyarrhythmia by transiently blocking conduction through the
atrioventricular node.
 but first-line of management without any contraindications (carotid bruit) is carotid sinus massage. 
Option D - Electrical cardioversion: Electrical cardioversion is reserved for patients with hemodynamic i
nstability or failed pharmacological interventions.
 
Correct Option D - QTc Prolongation:
 Ventricular tachycardia (VT) is characterized by broad QRS complexes on the ECG due to aberrant
conduction through the ventricles.
34

Ischemic Heart Disease
1. A 55-year-old male with a medical history of hypertension and hyperlipidemia presents to the clinic
due to intermittent chest pain for the past six months. He describes a squeezing chest pain and
shortness of breath that are brought on by exertion and relieved with rest. His blood pressure is 140/90
mmHg. No other abnormal findings were noted during the examination. Which of the following
parameters is not used to assess the risk of atherosclerosis?
(or)
Which of the following parameters is not used to assess risk of atherosclerosis?
A. Increased LDL and decreased HDL
B. Homocysteinemia
C. Positive high sensitivity CRP values
D. Low Lipoprotein B /Apolipoprotein A ratio
2. A 60-year-old man with a 25-year history of smoking presents to a clinic due to recurrent chest pain
whenever he walks fast. It is a squeezing sensation in the center of his chest and radiates to his left
arm. His blood pressure is 160/100 mmHg and heart rate is 110 beats per minute. Stress test shows
downsloping ST segment depression in leads II, III, and aVF. What is the diagnostic test of choice?
(or)
Which of the following is the investigation of choice for a patient who presents with exertional chest pain
and downsloping ST segment depression on the stress test?
A. Coronary CT Angiography
B. Multiple Uptake Gated Acquisition (MUGA) scan
C. Holter monitoring
D. Myocardial Perfusion Imaging
3. A 55-year-old male with a medical history of hypertension and hyperlipidemia, presents to the
emergency department due to episodes of tight, squeezing sensation in the center of his chest
occurring at rest. His blood pressure is 140/90 mmHg, heart rate is 80 beats per minute, and respiratory
rate is 18 breaths per minute. Auscultation is normal. ECG reveals deeply inverted symmetric T waves
in leads V2 and V3. What is the most likely diagnosis?
(or)
What is the most likely diagnosis for a patient with recurrent central, squeezing, chest pain and deeply
inverted T-waves in leads V2-V3 on ECG?
A. Stable Angina
B. Prinzmetal Angina
C. Pulmonary Embolism
D. Wellens Syndrome
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Page 2
4. A 60-year-old male with a history of smoking, hypertension, and diabetes presents to the emergency
department with severe, crunching, central chest pain radiating to the left arm and jaw that started
approximately 2 hours ago. Despite percutaneous coronary intervention, he succumbed to sudden
cardiac arrest. The pathologist examines the patient's heart tissue from an autopsy and identifies the
following changes: Based on the histological cues of vacuolation and waviness of cardiac fibers, what is
the approximate time since the myocardial infarction (MI) has occurred?
(or)
What is the approximate time since the myocardial infarction (MI) has occurred based on the following
histopathological tissue findings?
A. 30 minutes to 4 hours
B. 4 hours to 12 hours
C. 12 hours to 24 hours
D. 24 hours to 48 hours
5. 56-year-old male presents with severe chest pain and shortness of breath. His blood pressure is
150/90 mmHg, heart rate is 110 bpm, respiratory rate is 22 breaths per minute, and oxygen saturation
is 93% on room air. Significant ST-segment elevation in leads II, III, and aVF are noted on ECG. The
drug given to treat him results in tachycardia and constipation. Which of the following statements is true
about this drug?
(or)
Which of the following statements is true about the drug used to treat STEMI, which causes
constipation and an increased heart rate?
A. It is metabolized by an enzyme called aldehyde dehydrogenase
B. The patient will never develop tolerance to this drug
C. It can be given to a patient taking sildenafil for erectile dysfunction
D. It is a drug of choice for cyanide poisoning
6. A 60-year-old male with a past medical history of hypertension, dyslipidemia, and type 2 diabetes
presented to the emergency department with crushing chest pain radiating to his arm and jaw. Low
blood pressure and tachycardia are present. There is ST-segment elevation in leads II, III, and AVF.
Which of the following statements is true about the management of this disease?
(or)
37

Page 3
What is true regarding the recommended management for STEMI?
A. Treatment of choice is Fibrinolytic therapy
B. Door-to-balloon time should be less than 30 minutes
C. Sublingual nitroglycerine should not be given to a patient with inferior wall MI
D. Morphine is given to prevent reinfarction
7. A 55-year-old male presents to the emergency department with severe, crushing chest pain radiating
to the left jaw that started 2 hours ago. ECG reveals ST-segment elevation in leads I, aVL, and V2-V6.
He undergoes percutaneous coronary intervention and is started on antiplatelet and antithrombotic
medications. Three weeks later, he returned with chest pain and a friction rub on auscultation. What is
the pathogenesis of the problem that has arisen in this patient?
(or)
What is the pathogenesis behind the development of chest pain and a friction rub 3 weeks after a
myocardial infarction?
A. Infection
B. Autoimmunity
C. Infarction
D. Adverse Drug reaction
8. A 65-year-old male with a past medical history of hypertension and dyslipidemia presents to the
emergency department with complaints of sudden-onset severe chest pain. The patient was diagnosed
with myocardial infarction based on his clinical history and investigations. Which of the following is not
true about the cardiac biomarkers of this disease?
(or)
Which of the following is not true regarding the cardiac biomarkers in myocardial infarction?
A. Myoglobin is the last cardiac enzyme to rise
B. Heart fatty acid binding protein is the first one to rise
C. Troponin I is the best test for reinfarction
D. CK-MB rises before the rise of AST
9. A 58-year-old male with a past medical history of hypertension and dyslipidemia presents to the
emergency department with sudden-onset severe chest pain that started approximately 2 hours ago.
He describes the pain as crushing and radiating to his left arm and jaw. The ECG of the patient is given
below: Which of the following vessels is most likely to be blocked in this patient's condition?
(or)
Which coronary vessel is most likely blocked in a patient with the given ECG?
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Page 4
A. Left Anterior Descending (LAD) artery
B. Right Coronary Artery (RCA)
C. Left Circumflex (LCX) artery
D. Posterior Descending Artery
10. A 35-year-old male with a history of recreational drug use is rushed to the emergency department
after collapsing at a party. He appears agitated and diaphoretic and complains of severe chest pain. His
blood pressure is 160/100 mmHg, heart rate is 110 beats per minute, and respiratory rate is 24 breaths
per minute. An ECG reveals ST-segment elevation in leads II, III, and aVF. What type of myocardial
infarction is most likely in this patient?
(or)
What type of myocardial infarction is most likely in a young patient with recreational drug use?
A. Type I
B. Type II
C. Type III
D. Type IV
11. A 45 yr old male presents to the Medicine OPD with complaints of chest pain. He describes his pain
as stabbing and has put his fist on his chest while localizing the pain. After further investigations , a
diagnosis of STEMI is made and the patient is started on thrombolytic therapy. Which of the following
statements is not true about this treatment modality?
(or)
Which of the following statements is not true regarding thrombolytic therapy in a patient with a
diagnosis of STEMI?
A. Alteplase has rapid onset of action than streptokinase
B. Streptokinase and urokinase might lead to allergy
C. It is contraindicated in NSTEMI
D. Use of Tenecteplase will lead to increased dosing error
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Page 5
Question 2 1
Question 5 1
Question 7 2
Question 8 1
Correct Option D - Low Lipoprotein B /Apolipoprotein A ratio:
 The clinical scenario suggests stable angina, which is commonly associated with atherosclerosis.
Atherosclerosis is characterized by the deposition of fatty plaques in the arterial walls, leading to
narrowing and reduced coronary blood flow.
 The high lipoprotein A / Apolipoprotein B ratio increases the risk of atherogenicity. 
Option A: Increased LDL and decreased HDL: Increased LDL cholesterol is associated with plaque for
mation, while decreased HDL cholesterol is associated with impaired reverse cholesterol transport and 
40

Page 6
increased risk of atherosclerosis.
Option B - Homocysteinemia: Homocysteine, is an amino acid that, when present at high levels in the b
lood (homocysteinemia), has been associated with an increased risk of premature cardiovascular disea
se. Elevated homocysteine levels can contribute to endothelial dysfunction, oxidative stress, and inflam
mation, which are involved in the pathogenesis of atherosclerosis.
Option C - Positive high sensitivity CRP values: High-sensitivity C-reactive protein (hsCRP) is a
marker of systemic inflammation and is an important predictor of future coronary events. 
Correct Options A - Coronary CT Angiography:
 The clinical scenario and stress test findings of downsloping ST segment depression in leads II, III,
and aVF are diagnostic of reversible ischemia, which is seen in patients with Chronic Stable Angina.
 The best investigation (noninvasive) is coronary CT angiography to determine the site, location, and
percentage of blockages. 
Option B - Multiple Uptake Gated Acquisition (MUGA) scan: MUGA scan is used to calculate the ejecti
on fraction. 
Option C - Holter monitoring: It is used to detect rhythm disorders of the heart.
Option D - Myocardial Perfusion Imaging: Myocardial Perfusion Imaging uses radioactive tracers inject
ed into the bloodstream to assess blood flow to the heart muscle. It is a non-invasive imaging test that 
can identify areas of reduced blood flow, indicating myocardial ischemia. While it is a useful test, it is le
ss accurate than coronary CT angiography. Gold standard test in conventional coronary angiography.
Correct Option D - Wellens Syndrome:
 In this clinical scenario, the most likely diagnosis based on the clinical presentation of chest pain
occurring mainly during rest and the ECG findings of deeply inverted, symmetric T-waves in leads
V2-V3 is Wellens syndrome. 
 Wellens syndrome, also known as "LAD coronary T-wave syndrome," refers to characteristic ECG
findings that are highly suggestive of critical proximal left anterior descending (LAD) artery stenosis.
 Hypertension, diabetes, and dyslipidemia are common risk factors for the development of coronary
artery disease, including LAD artery stenosis.
 Immediate coronary angiography and intervention are necessary when Wellens syndrome is identified
on the ECG.
 This condition is considered a "pre-infarction" state, and urgent revascularization is crucial.
Option A - Stable Angina: Stable angina is characterized by chest pain that occurs predictably with exe
rtion and is relieved by rest or nitroglycerin. While Mr. Thompson's chest pain occurs mainly during rest
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Page 7
, the ECG findings of deeply inverted, symmetric T-waves in leads V2-V3 are not typical for stable angi
na.
Option B - Prinzmetal Angina: Prinzmetal angina is characterized by chest pain that occurs at rest or wi
th minimal exertion and is unpredictable in its pattern. It is due to the spasm of epicardial coronary arter
ies causing ST elevation.
Option C - Pulmonary Embolism: Pulmonary embolism (PE) is a condition caused by a blood clot that t
ravels to the lungs, obstructing blood flow in the pulmonary arteries. While PE can cause chest pain an
d shortness of breath, the ECG findings of deeply inverted T-waves in leads V2-V3 are not characteristi
c of this condition
Correct Option A - 30 minutes to 4 hours:
 The presence of vacuolation of cardiac cells and waviness of cardiac fibres in the histological
examination is characteristic of the early stages of myocardial infarction. These changes are typically
observed within 30 minutes to 4 hours after the onset of the MI.
 The vacuolation represents the cellular response to ischemia, and the waviness of cardiac fibers
indicates early structural changes in the heart muscle.
Correct Option A - It is metabolized by an enzyme called aldehyde dehydrogenase:
 When nitrate is given, it is metabolized and turned into nitric oxide.
 Mitochondrial aldehyde dehydrogenase is an enzyme used to metabolize nitrate. These enzymes are
present more in the veins than in the arteries. Soluble guanylate cyclase converts GTP into cGMP. This
cGMP inhibits Myosin light-chain kinase, resulting in smooth muscle relaxation.
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Page 8
 Indications of nitrates: Stable angina  Prinzmetal angina  Acute coronary syndrome (Unstable angina,
NSTEMI, STEMI) Esophageal spasm Acute CHF Hypertensive emergency
 Stable angina 
 Prinzmetal angina 
 Acute coronary syndrome (Unstable angina, NSTEMI, STEMI)
 Esophageal spasm
 Acute CHF
 Hypertensive emergency
Option B - The patient will never develop tolerance to this drug: With prolonged use of nitroglycerin, tol
erance can develop, leading to a diminished therapeutic effect. To prevent tolerance, it is necessary to 
provide drug-free periods to avoid desensitization of the vasodilatory response. 
Option C - It can be given to a patient taking sildenafil for erectile dysfunction: Nitroglycerin and sildena
fil (Viagra) are both vasodilators and their concurrent use can cause a dangerous drop in blood pressur
e, thus, Nitroglycerin and other nitrates are contraindicated in patients taking sildenafil or other phosph
odiesterase-5 (PDE-5) inhibitors.
Option D - It is a drug of choice for cyanide poisoning: Nitroglycerin is not a drug of choice for cyanide 
poisoning. In cases of cyanide poisoning, the primary treatment is usually with antidotes like hydroxoco
balamin or sodium thiosulfate, which help neutralize cyanide.
Correct Option C - Sublingual nitroglycerine should not be given to a patient with inferior wall MI:
 In the given clinical scenario, the patient presents symptoms suggestive of an inferior wall STEMI
because his ECG shows ST-segment elevation in leads II, III, and AVF. 
 Inferior wall MI causes hypotension. 
 Giving nitrates will worsen the hypotensive state. 
Option A - Treatment of choice is Fibrinolytic therapy: Treatment of choice for MI especially STEMI, is 
Primary Percutaneous Intervention (PCI), and not fibrinolytic therapy. 
Option B - Door-to-balloon time should be less than 30 minutes: The guideline-recommended door-to-b
alloon time for primary PCI is less than 90 minutes, not 30 minutes.
Option D - Morphine is given to prevent reinfarction: Morphine is used in the acute setting to manage p
ain and reduce pulmonary edema. Long-term management to prevent reinfarction involves medications
 like dual antiplatelet therapy, beta-blockers, and ACE inhibitors/ARBs, along with lifestyle modification
s, to prevent future cardiac events.
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Correct Option B - Autoimmunity:
 The constellation of symptoms in this patient is consistent with Dressler syndrome (post-MI
pericarditis)
 Dressler syndrome is a delayed autoimmune-mediated inflammatory response that occurs several
weeks after an acute myocardial infarction (MI). It is characterized by inflammation of the pericardium,
which can lead to chest pain and a friction rub heard on auscultation.
 The immune system mistakenly targets healthy cardiac tissue, causing inflammation and the
characteristic symptoms associated with Dressler syndrome.
Post-MI Complication
Time Frame
Arrhythmias
Hours to days
Heart Failure
Cardiogenic Shock
Hours
Ventricular Septal Rupture
Days
Papillary Muscle Rupture
Free Wall Rupture
Dressler Syndrome
Weeks
Thromboembolism
Days to weeks
Ventricular Aneurysm
Option A - Infection: While infections can lead to inflammation of the pericardium (pericarditis), the timi
ng and clinical presentation described in the case scenario are more indicative of Dressler syndrome
Option C - Infarction: The patient's initial presentation was of infarction event. However, the problem th
at has arisen during the follow-up visit, characterized by chest pain and a friction rub, is not due to a
new infarction. It is more consistent with Dressler syndrome
Option D - Adverse Drug Reaction: While adverse drug reactions are always possible, there is no evide
nce or indication in the case scenario to suggest that the patient's current symptoms of chest pain and 
a friction rub are due to an adverse drug reaction. The patient's symptoms are more in line with Dressle
r syndrome
Correct Option A - Myoglobin is the last cardiac enzyme to rise:
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 Last to rise is LDH and not myoglobin. 
 Myoglobin is one of the earliest enzymes to rise in MI patients, though it can also be released from
skeletal muscles after DC shock. Hence, it is difficult to know the source.
 The first to rise in the case of an MI is HFABP ( Heart Fatty Acid Binding Protein), which rises in about
1 hour.
Other Options:
Option B
- Heart fatty acid binding protein is the first one to rise: This is correct. HFABP rises by one hour.
Option C - Troponin I is the best test for reinfarction: Troponin I is a highly sensitive and specific biomar
ker for myocardial injury. 20% rise over admission values indicates reinfarction. If reinfarction occurs af
ter 72 hours, CK-MB is used. 
Option D - CK-MB rises before the rise of AST: This statement is also true. 
Correct Option A - Left Anterior Descending (LAD) artery:
 The ECG shows ST-segment elevation in the anterior leads, specifically leads V2-V4. The LAD artery
is the culprit vessel responsible for an anterior wall MI. The LAD artery supplies the anterior and apical
regions of the left ventricle, and its occlusion leads to ischemia and infarction in these areas.
Option B - Right Coronary Artery (RCA): In RCA occlusion, ECG displays ST-segment elevation in infe
rior wall leads (II, III, and aVF) with reciprocal ST-segment depression in V1–V3.
Option C - Left Circumflex (LCX) artery: The LCX artery supplies the lateral wall of the left ventricle. An
 occlusion of the LCX artery usually results in lateral wall MI, which may present with ST-segment elev
ations in leads I, AVL, V5, and V6.
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Option D - Posterior Descending Artery: Posterior descending artery occlusion is best picked up by lea
ds V7, V8, and V9.
Correct Option B - Type II:
 Type II MI is characterized by an imbalance between myocardial oxygen supply and demand, often
caused by conditions like severe anemia, cocaine overdose, or carbon monoxide poisoning.
 In this patient's case, the history of recreational drug use and the presence of severe chest pain,
agitated state, and ST-segment elevation in leads II, III, and aVF on the ECG are suggestive of a type II
MI.
Option A - Type I MI: Type I
MI is caused by atherosclerosis and coronary artery thrombosis, leading to the sudden occlusion of a c
oronary artery. While this type of MI is common in patients with atherosclerosis or coronary artery dise
ase, it is less likely in this patient with a
known history of recreational drug use and an acute presentation at a party.
Option C - Type III MI: Type III MI causes sudden cardiac death due to life-threatening arrhythmias, su
ch as ventricular fibrillation or Mobitz II heart block. 
Option D - Type IV MI: Type IV MI is related to complications during percutaneous coronary interventio
n (PCI) or coronary stent placement. While it is possible for this patient to have had a previous stent pl
acement or PCI, the acute presentation with severe chest pain and ST-segment elevation on the ECG 
suggests a more acute and ongoing event, which is more consistent with Type II MI due to oxygen sup
ply-demand imbalance.
Correct Option D - Use of Tenecteplase will lead to increased dosing error:
 Tenecteplase is a newer thrombolytic drug that was developed to simplify dosing compared to older
agents like alteplase, streptokinase, and urokinase.
 Unlike alteplase, which requires weight-based dosing, tenecteplase has a fixed-dose regimen and it is
given as a single bolus, making it less likely to result in dosing errors.
Option A - Alteplase has a rapid onset of action than streptokinase:
 Alteplase is a tissue plasminogen activator (tPA) that works by converting plasminogen to plasmin,
which helps break down blood clots.
 Alteplase has a relatively short half-life in the body but a more rapid onset than streptokinase, and
hence, the reperfusion of occluded vessels is faster.
Option B - Streptokinase and urokinase might lead to allergy:
 Streptokinase is derived from group c streptococcal bacteria and can induce an immune response,
leading to hypersensitivity reactions in some patients.
46

Congenital Heart Disease
1. Which of the following is a Major NADAS criterion?
A. Abnormal S2
B. Abnormal ECG
C. Diastolic murmur
D. Systolic murmur grade I
2. A 2-year-old boy is brought to the clinic by his mother who noticed his lips turning blue whenever he
cries or gets sick. She says that the squatting position relieves the bluish discoloration. Examination
revealed a harsh holosystolic murmur at the left parasternal area. His complete blood count shows a
hemoglobin 18 g%. What is the underlying defect?
(or)
Which condition has squatting episodes and polycythemia in a boy with repeated episodes of dusky
discoloartion of lips when he cries?
A. Acyanotic heart disease
B. Cyanotic heart disease
C. Eisenmenger syndrome
D. Lutembacher syndrome
3. Which of the following does not cause central cyanosis?
A. Methemoglobinemia
B. Pulmonary arteriovenous fistula
C. High altitude
D. Hypothermia
4. A 25-year-old pregnant woman presents to the obstetrics clinic for a prenatal checkup. She has a
history of bipolar disorder. On prenatal ultrasound, the fetus exhibits cardiac abnormalities, including an
inferiorly displaced tricuspid valve, tricuspid regurgitation, a small right ventricle, and
Wolff-Parkinson-White syndrome. Which of the following drugs is most likely responsible for the
following finding?
(or)
If taken during pregnancy, which drug used to treat bipolar disorder is most likely responsible for
causing fetal cardiac abnormalities such as tricuspid valve displacement, tricuspid regurgitation, a small
right ventricle, and WPW syndrome?
A. Lithium
B. Valproate
C. Captopril
D. Carbamazepine
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5. A one-week-old infant is brought to the clinic due to extreme bluish discoloration of the lips, skin, and
nail beds. The baby tires quickly during feeds and often appears fatigued. On examination, the infant is
visibly cyanotic. Cardiac auscultation reveals a single loud S1, single S2. There is cardiomegaly on the
chest X-ray. What is the diagnosis?
(or)
What is the most likely congenital heart defect in a one-week-old infant with cyanosis, cardiomegaly,
single loud S1 and single S2?
A. Tetralogy of Fallot
B. Patent Ductus Arteriosus
C. Tricuspid Atresia
D. Coarctation of the Aorta
6. A 10-year-old boy is admitted to the hospital for pneumonia. Further evaluations reveal an atrial
septal defect. There is no family history of heart disease except for ischemic heart disease in the
grandfather. Which of the following is incorrect regarding atrial septal defect?
(or)
Which of the following is incorrect regarding atrial septal defect?
A. Pulmonary plethora leads to pulmonary artery hypertension
B. Harsh murmur presents early in the course of the disease
C. Flow murmur is mid-diastolic murmur
D. Shunt murmur is absent
7. A 4-month-old infant with a history of Tetralogy of Fallot presents with fever and loose stools. The
patient is stabilized with IV fluids and antibiotics. Which of the following is compatible with the diagnosis
of hypercyanotic spells?
(or)
Which of the following is diagnostic of hypercyanotic spells in a child with ToF?
A. O2 saturation < 70% in room air
B. Inability to hear a murmur
C. Hepatomegaly
D. S3 gallop rhythm
8. A 40-year-old female patient presents with palpitations and difficulty in breathing. Auscultation
reveals a mid-diastolic murmur and JVP shows a prominent 'a' wave. What is the most likely diagnosis?
(or)
Prominent 'a' wave on JVP is seen in?
A. Mitral stenosis
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Page 3
B. Tricuspid stenosis
C. Mitral regurgitation
9. A 6-week-old baby is having failure to thrive and poor activity. On auscultation, you hear a harsh
systolic ejection murmur and a single second heart sound. Select the most appropriate chest X-ray for
the given clinical situation.
(or)
Which of the following chest X-rays corresponds to a 6-week-old baby with failure to thrive and
cyanosis worsening during crying and feeding?
A.
B.
C.
D.
Question 6 2
Correct Option C - Diastolic murmur:
NADAS criteria are used for evaluating heart murmurs in pediatric patients:
Major criteria include:
 
Option A - Abnormal S2: Abnormal S2, or the second heart sound, is a minor NADAS criterion.
Option B - Abnormal ECG: Abnormal ECG findings are also a
minor criterion in the NADAS criteria, not a major one. 
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Option B - Pulmonary arteriovenous fistula: A
pulmonary arteriovenous fistula is an abnormal connection between an artery and a vein in the lung. T
his can result in the bypassing of oxygenated blood from the lungs to the systemic circulation, leading t
o a decrease in arterial oxygen saturation and central cyanosis.
Option C - High altitude: At high altitudes, the partial pressure of oxygen in the atmosphere is lower, re
sulting in hypobaric hypoxia. This can cause central cyanosis due to reduced oxygen availability.
Correct Option A - Lithium:
 Lithium used in bipolar disorder is known to be associated with congenital heart defects especially
when taken during the first trimester of pregnancy. 
 Ebstein anomaly involves the apical displacement of the tricuspid valve, the adherence of the septal
and posterior leaflets to the myocardium, and the atrialization of the inlet portion of the right ventricle.
 It includes conduction defects like Wolff-Parkinson-White syndrome.
Option B - Valproate: Valproate is an antiepileptic drug that has been associated with an increased risk
 of neural tube defects when taken during pregnancy.
Option C - Captopril: Captopril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypert
ension. It causes renal agenesis.
Option D - Carbamazepine: Associated with neural tube defects in the fetus when used during first trim
ester of pregnancy.
Correct Option C - Tricuspid Atresia:
 Tricuspid Atresia is a congenital heart defect in which the tricuspid valve is absent or poorly
developed. This results in the absence of the right atrioventricular connection. In Tricuspid Atresia, a
single functional ventricle (usually the left ventricle) pumps blood to systemic circulation resulting
in neonatal cyanosis.
The clinical findings in this case align with Tricuspid Atresia:
Option A - Tetralogy of Fallot: Tetralogy of Fallot has boot shaped heart with a
normal S1 and single S2. It also has ejection systolic murmur due to sub-pulmonic stenosis.
Option B - Patent Ductus Arteriosus (PDA): It usually presents with a
continuous machine-like murmur and causes CHF.
Option D - Coarctation of the Aorta: It can present with high blood pressure in the upper extremities an
d weak pulses in the lower extremities, but it does not explain the central cyanosis or heart sounds des
cribed.
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Option A - O2 saturation < 70% in room air:
 Hypoxia provokes a hypercyanotic spell but is not a diagnostic feature of a Tet spell. 
Option C - Hepatomegaly:
 Hepatomegaly is seen in congestive heart failure.
Option D - S3 gallop rhythm:
 S3 gallop is seen in volume-overloaded conditions like severe anemia, dilated cardiomyopathy, heart
failure, and wet beriberi. 
Correct Option B: - Tricuspid stenosis:
 Mid-diastolic murmur is seen in tricuspid stenosis and mitral stenosis.
 Prominent 'a' wave is seen in tricuspid stenosis. It is also seen in long-standing mitral stenosis, where
pulmonary artery hypertension will be present.
 Since no features of PAH are present in this patient, mitral stenosis can be ruled out, 
 
Option A - Mitral stenosis: Mitral stenosis causes a
change in left atrial pressure. Only long-standing mitral stenosis will produce 'a' wave changes.  
Option C - Mitral regurgitation: Mitral regurgitation causes backflow of blood from the left ventricle into t
he left atrium during contraction of the ventricle. There are trivial  ‘v’ waves in the JVP wave due to incr
eased left atrial compliance. There is no change in the ‘a’ waves noticed due to mitral regurgitation.
Option D - Tricuspid regurgitation: Tricuspid regurgitation causes backflow of blood from the right ventri
cle into the right atrium during contraction of the ventricle. Tricuspid regurgitation causes obliteration of 
the ‘x’ wave, CV wave, and a steep 'y' descent.
Correct Option A: This CXR shows a "boot-shaped heart"
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 The clinical presentation described in this case is consistent with the Tetralogy of Fallot (TOF).
 The classic CXR finding associated with TOF is a "boot-shaped heart."
 It occurs due to an upturned cardiac apex due to right ventricular hypertrophy and a concave
pulmonary arterial segment due to overriding of the aorta. 
Option B: CXR shows an egg on a
string sign. This is found in the case of the Transposition of great vessels.
Option C: CXR shows the presence of snowman heart. This is associated with total anomalous pulmon
ary venous return (TAPVR).
Option D: CXR shows the 3
SIGN of the heart. It is associated with coarctation of the aorta, where there is a
narrowing of the aorta near the site of the ductus arteriosus. 
55

Hypertension
1. A 60-year-old female with poorly controlled hypertension presents to the emergency department with
severe headache, blurred vision, and shortness of breath. Her blood pressure is 210/140 mmHg.
Examination reveals papilledema. What is the most appropriate initial management for this patient?
(or)
What is the most appropriate initial management for a 60-year-old female with blood pressure of
210/140 mmHg, severe headache, blurred vision, shortness of breath, and papilledema?
A. Administer sublingual nitroglycerin
B. Begin oral antihypertensive medication as outpatient management
C. Admit the patient to the ICU and start IV labetalol
D. Order a head CT scan to rule out intracranial hemorrhage
2. Review the statements about the control of blood pressure and identify the incorrect one.
A. Physical activity like brisk walking for 30 minutes a day will reduce systolic blood pressure by
approximately 10-20 mmHg.
B. Tracking of blood pressure implies that if a person is hypertensive in childhood, then the person
remains hypertensive in adulthood.
C. The Rule of Halves is seen in hypertension, where only 50% of people who are aware of their
hypertension receive treatment.
D. DASH stands for Dietary approaches to stop hypertension.
Correct Option C - Admit the patient to the ICU and start IV labetalol:
 In this scenario, the patient presents with severe symptoms including headache, blurred vision, and
shortness of breath, along with a significantly elevated blood pressure of 210/140 mmHg. The presence
of papilledema indicates end-organ damage and suggests the presence of a hypertensive emergency.
 The most appropriate initial management strategy is to admit the patient to the ICU and initiate
intravenous antihypertensive medication.
 For patients with hypertensive encephalopathy such as this patient, the preferred parenteral
antihypertensive drugs are nitroprusside, nicardipine, and labetalol.
Option A - Administer sublingual nitroglycerin: Sublingual nitroglycerin is not appropriate for hypertensi
ve emergencies and is more commonly used for angina or cardiac conditions.
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Option B - Begin oral antihypertensive medication as outpatient management: Oral antihypertensive m
edication is not suitable for immediate blood pressure control in a hypertensive emergency.
Option D - Order a head CT scan to rule out intracranial hemorrhage: A Head CT scan may be necess
ary to rule out intracranial hemorrhage but should not delay the immediate management of the hyperte
nsive emergency.
Correct Option A - Physical activity like brisk walking for 30 minutes a
day will reduce systolic blood pressure by approximately 10-20 mmHg:
 Physical activity like brisk walking for 30 minutes a day reduces systolic BP by approximately 4-9
mmHg and not by 10-20 mmHg as given in the statement.
Modification Recommendation
Approximate Systolic BP Reduction
Weight reduction
5-20 mmHg / 10kg weight loss
Adopt the DASH eating plan
8-14 mmHg
Dietary sodium reduction
2-8 mmHg
Physical activity
4-9 mmHg
Moderation of alcohol consumption
2-4 mmHg
Option B - Tracking of blood pressure implies that if a person is hypertensive in childhood, then the per
son remains hypertensive in adulthood: Tracking of blood pressure implies that BP levels of individuals
 are followed up from early childhood into adult life. It means that a person who is hypertensive in child
hood will remain hypertensive in adulthood. Tracking is about monitoring and observing blood pressure
 levels over time.
Option C - The Rule of Halves is seen in hypertension, where only 50% of people who are aware of the
ir hypertension receive treatment: The Rule of Halves is seen in hypertension, where only 50% of peop
le who are aware of their hypertension receive treatment.
Option D - DASH stands for Dietary approaches to stop hypertension: DASH stands for Dietary approa
ches to stop hypertension.
57

Cardiomyopathy and Diseases of Pericardium
1. A 38-year-old male, presents with chest pain and shortness of breath for 4 months. He experiences
dizziness and fainting episodes on exertion. His family history is remarkable for the sudden cardiac
death of his brother. On examination, a systolic murmur is heard at the left sternal border that increases
with Valsalva maneuver and decreases with squatting. Which of the following pathological findings
would be present in this patient's heart?
(or)
What pathological findings are expected in a patient's heart who has a family history of sudden cardiac
death and a systolic murmur that increases with Valsalva and decreases with squatting?
A. Orphan Annie eye nucleus
B. Helter-skelter appearance
C. Ninja star nucleus
D. Psammoma bodies
2. Match the following : 1. Hypertrophic cardiomyopathy A. Dicrotic pulse 2. Dilated cardiomyopathy B.
S3 gallop 3. Restrictive Cardiomyopathy C. Pulsus bisferians 4. Takotsubo cardiomyopathy D. Square
root wave sign E. History of spouse death
1. Hypertrophic cardiomyopathy A. Dicrotic pulse
2. Dilated cardiomyopathy B. S3 gallop
3. Restrictive Cardiomyopathy C. Pulsus bisferians
4. Takotsubo cardiomyopathy D. Square root wave sign
E. History of spouse death
A. 1:A ; 2:B, D ; 3:C ; 4:E
B. 1:C ; 2:A,B ; 3:D ; 4:E
C. 1:B,C ; 2:A ; 3: D; 4: E
D. 1:A,D ; 2:B ; 3:C ; 4:E
3. A 55-year-old male presents to the clinic with symptoms of progressive shortness of breath, fatigue,
and exercise intolerance. Cardiac examination reveals a displaced point of maximal impulse. A
myocardial biopsy is performed, and histological examination reveals the following: Which of the
following is the most likely underlying cause of the observed histological finding?
(or)
What is the most likely underlying cause of the observed histological findings in a 55-year-old male with
a displaced point of maximal impulse on cardiac examination?
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Page 2
A. Tobacco smoking
B. Genetic mutations
C. Viral infection
D. Ischemic injury
4. A 45-year-old male patient presents to the emergency department with bilateral pedal edema,
discomfort in the right upper quadrant of the abdomen, and orthopnea. Chest auscultation reveals
bilateral creptitaions, a loud S1 sound, and a pansystolic murmur. Point of maximal impulse is
hypokinetic and diffuse. What is the most likely diagnosis?
(or)
What is the most likely diagnosis in a 45-year-old male presenting with bilateral pedal edema,
abdominal discomfort, orthopnea, and a displaced point of maximal impulse?
A. Cardiomyopathy
B. Acute cor pulmonale
C. Alcoholic hepatitis
D. Pulmonary artery hypertension
5. A 60-year-old woman with a history of hypertension presents to the emergency department with
severe chest pain and shortness of breath. Symptoms started abruptly after an intense argument with
her son. Her blood pressure is 180/100 mmHg, heart rate is 110 bpm, and respiratory rate is 24 breaths
per minute. An ECG shows ST-segment elevation in leads I, aVL, and V2 to V6. Cardiac biomarkers
are significantly elevated. Select the most appropriate image that correlates with this presentation.
(or)
A 60-year-old woman presents to the emergency department with severe chest pain and shortness of
breath that developed after an intense argument with her son, ST-segment elevation on ECG, and
elevated cardiac biomarkers. Select the most appropriate image that correlates with this presentation.
A.
B.
C.
D.
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6. A 15-year-old boy is brought to the emergency department in the early morning hours by his father,
who reports that his son was having agonal respiration. His blood pressure is 80/50 mmHg with no
palpable pulse. There is a family history of sudden death in a sibling. Workup shows a mutation in the
SCN5A gene. Which of the following ECG patterns can be seen?
(or)
Which ECG finding is seen in Brugada syndrome?
A. ST elevation, cove pattern
B. ST elevation, Pardee sign
C. ST depression, downsloping
D. ST depression, upsloping
7. A 20-year-old female presents with palpitations and exercise intolerance. She reports recurrent
syncopal episodes since her teenage years. On examination, she has sparse, coarse, and frizzy hair
and thickened skin on the palms and soles. Her sister died at the age of 25. An echocardiogram reveals
right ventricular abnormalities, including fatty infiltration and thinning of the myocardium. Which of the
following genetic mutations is most likely to be associated?
(or)
Which genetic mutation is most likely associated with the clinical presentation of a 20-year-old female
with exercise intolerance, woolly hair, palmoplantar keratoderma, a family history of sudden death?
A. SCN5A gene mutation
B. MYH7 gene mutation
C. DSP gene mutation
D. Plakoglobin gene mutation
8. A 45-year-old male with hypertrophic cardiomyopathy presents with increased exertional dyspnea
and chest pain. The patient's symptoms worsen despite receiving nitroglycerin at the hospital. There is
a subsequent drop in blood pressure and the drug is stopped. Further evaluation confirms dynamic left
ventricular outflow tract obstruction, worsened by nitroglycerin. Which drug is not contraindicated in
such patients?
(or)
Which of the following drugs is not contraindicated in a patient with hypertrophic cardiomyopathy with
dynamic left ventricular outflow tract obstruction?
A. Digoxin
B. Furosemide
C. Amlodipine
D. Verapamil
9. A 35-year-old male presents to the clinic due to easy bruising, fatigue, and bone pain. He has a
history of frequent infections. On examination, he has hepatosplenomegaly. Laboratory tests reveal a
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low platelet count and elevated levels of glucocerebroside in the blood. This condition is a lysosomal
storage disorder caused by a deficiency of glucocerebrosidase. Which cardiomyopathy is associated
with this disease?
(or)
Which cardiomyopathy is commonly associated with a lysosomal storage disorder caused by a
deficiency of the enzyme glucocerebrosidase?
A. Hypertrophic Cardiomyopathy
B. Dilated Cardiomyopathy
C. Restrictive Cardiomyopathy
D. Arrhythmogenic Right Ventricular Cardiomyopathy
10. A 30-year-old male presents to the clinic due to exertional fatigue and difficulty breathing for the
past few weeks. His blood pressure is 150/90 mmHg, heart rate is 80 beats per minute, respiratory rate
is 16 breaths per minute, and SpO2 is 98%. Examination reveals a dicrotic pulse. Which of the
following changes can be seen in this disease?
(or)
What changes can be seen in the disease of a 30-year-old male patient presenting with exertional
fatigue, dyspnea, and a dicrotic pulse?
A. Increased EDV, Increased ESV, Increased contractility
B. Decreased EDV, Increased ESV, Increased contractility
C. Increased EDV, Increased ESV, Decreased contractility
D. Increased EDV, Decreased ESV, Decreased contractility
11. A 34-year-old primigravida woman at 37 weeks gestation comes to the physician because of a
1-week history of progressive fatigue and shortness of breath. On examination, there are bibasilar lung
crackles, jugular venous distention, and 2+ pitting edema of the lower extremities. Urinalysis shows 1+
protein. Echocardiography shows a left ventricular ejection fraction of 0.35. Which of the following
statements is true regarding the most likely diagnosis?
(or)
Which of the following statements about peripartum cardiomyopathy is true?
A. Peripartum cardiomyopathy occurs within 24 hours of delivery
B. Peripartum cardiomyopathy occurs within 7 days after pregnancy
C. Peripartum cardiomyopathy occurs within 6 weeks after pregnancy
D. Peripartum cardiomyopathy occurs within the last month of pregnancy or up to 6 months after
pregnancy
12. A 50-year-old male presents to the emergency department with diffuse chest pain at rest. He says
the pain radiates to his left shoulder and is relieved when he sits up. A scratchy sound that persists
when the patient holds his breath is heard on cardiac auscultation along with normal S1 and S2. What
is the most common etiology of this presentation?
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(or)
What is the most common etiology for a condition characterized by diffuse chest pain relieved by sitting
up and a scratchy sound on cardiac auscultation?
A. Idiopathic
B. Viral
C. Autoimmunity
D. Malignancy
13. A 42-year-old female presents to the ER with progressively worsening shortness of breath and
chest discomfort for the past week. On examination, distant heart sounds, elevated jugular venous
pressure with blood pressure 80/60 mmHg are noted. ECG shows low voltage QRS complexes. What
is the most likely diagnosis?
(or)
What is the most likely diagnosis for a 42-year-old female with shortness of breath, chest discomfort,
distant heart sounds, elevated jugular venous pressure with hypotension, and low-voltage QRS
complexes on ECG?
A. Acute myocardial infarction
B. Acute pericarditis
C. Cardiac tamponade
D. Pericardial effusion
14. You are an intern measuring the blood pressure in the ER. You notice inspiratory fall of systolic
blood pressure >12 mmHg. Which of the following conditions will not show this finding?
(or)
Pulsus paradoxus is seen in all of the following, except?
A. Pregnancy
B. Constrictive pericarditis
C. Pericardial effusion
D. Massive pulmonary embolism
15. A 40-year-old male presents to the clinic due to increasing shortness of breath and leg swelling for
the past few months. On examination, jugular venous pressure is elevated and rises during deep
inspiration. Chest auscultation reveals bilateral fine crepitations and a distinct pericardial shudder.
Which of the following represents this patient's chest X-ray?
(or)
What chest X-ray findings are most likely associated with the condition in a 40-year-old male with
elevated JVP, a pericardial shudder, prominent S4 heart sound, and bilateral fine lung crepitations?
A.
B.
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C.
D.
Question 3 2
Question 7 4
Question 12 1
Question 13 3
Question 14 3
Question 15 2
Correct Option B - Helter-skelter appearance:
 The combination of chest pain, shortness of breath, dizziness, and fainting episodes, along with a
systolic murmur that increases with the Valsalva maneuver and decreases with squatting, is diagnostic
of hypertrophic cardiomyopathy (HCM).
 In HCM, histological examination of the heart would reveal a disorganized arrangement of cardiac
muscle fibers, giving a characteristic "helter-skelter" appearance. This abnormal arrangement of
muscle fibers is also called myocardial disarray.
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Option A - Orphan Annie eye nucleus: This term is associated with papillary thyroid carcinoma.
Option C
- Ninja star nucleus: In dilated cardiomyopathy, histological examination of the heart may reveal a
"Ninja star nucleus," which is a
term used to describe the appearance of enlarged and irregularly shaped cardiac myocyte nuclei. 
Option D - Psammoma bodies: Psammoma bodies are concentrically laminated calcifications commonl
y seen in certain types of tumors, such as papillary thyroid carcinoma, ovarian serous carcinoma, and 
meningiomas. 
Correct Option B - 1:C; 2:A,B; 3:D; 4:E:
 
Correct Option B - Genetic mutations:
 The "ninja star nucleus" appearance is a characteristic histological finding seen in certain genetic
mutations associated with dilated cardiomyopathy.
 These genetic mutations can lead to abnormalities in the structure and function of myocardial cells,
resulting in the dilatation of all cardiac chambers and reduced systolic function.
 TITIN or TTN mutation is most frequently implicated. Ninja star nuclei are commonly seen in Titin
gene mutations.
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Option A - Tobacco smoking: Alcohol abuse can lead to alcoholic cardiomyopathy, which is a
type of dilated cardiomyopathy. 
Option C - Viral infection: While viral myocarditis can lead to dilated cardiomyopathy with dilatation of c
ardiac chambers and reduced systolic function, the specific histological finding of a
"ninja star nucleus" is not typically associated with viral infections. 
Option D - Ischemic injury: Ischemic cardiomyopathy is a
type of dilated cardiomyopathy that occurs as a
result of chronic coronary artery disease and reduced blood flow to the heart muscle. 
Correct Option A - Cardiomyopathy:
 Patients have findings of biventricular failure that would be seen in cardiomyopathy.
Option B - Acute cor pulmonale:
 It is seen with massive pulmonary embolism. 
Option C - Alcoholic Hepatitis:
 It does not present with heart failure. 
Option D - Pulmonary artery hypertension:
 It will not have lung crepitations and features of left ventricular failure. 
Correct Option C:
 Image 3 shows ballooning left ventricle on coronary angiography.
 The patient's presentation with severe chest pain and shortness of breath following an intense
emotional trigger (argument with a family member) raises suspicion for a catecholamine surge-related
cardiac condition. The most likely diagnosis is Takotsubo cardiomyopathy.
 ST-segment elevation in leads I, aVL, and V2 to V6 may initially be mistaken for an acute myocardial
infarction. Takotsubo cardiomyopathy can be identified on echocardiography. 
 TTCM is characterized by a transient ballooning of the left ventricle, typically involving the apex, which
gives the heart the appearance of an "octopus trap" or "apical ballooning" on a chest X-ray.
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Option A: This X-ray finding of a boot-shaped heart is seen in Tetralogy of Fallot. 
Option B: This X-ray shows a snowman-shaped heart or figure-of-eight-shaped heart. It is associated 
with Total Anomalous Pulmonary Venous Connection.
Option D: An X-ray of an egg-shaped heart is associated with Transposition of the Great Arteries.
Correct Option A: ST elevation, cove pattern:
 The above clinical scenario of Brugada syndrome is a cardiac channelopathy caused by a mutation in
the SCN5A gene, which leads to a defective sodium channel function. The clinical presentation of the
patient includes syncopal attacks, a family history of sudden death, episodes of palpitations, and
dizziness.
Option B: ST elevation, Pardee sign: It is seen in myocardial infarction. 
Option C: ST depression, downsloping: It is seen in chronic stable angina.
Option D: ST depression, upsloping: It is seen in chronic stable angina.
 
Correct Option D - Plakoglobin gene mutation:
 This clinical scenario highly suggests Naxos Syndrome, an autosomal recessive disorder caused by a
mutation in the Plakoglobin (JUP) gene. Plakoglobin is a protein involved in maintaining the integrity of
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desmosomes, which are cell-to-cell junctions in the heart.
 Naxos Syndrome is characterized by a combination of Arrhythmogenic Right Ventricular
Cardiomyopathy (ARVC), woolly hair, and palmoplantar keratoderma.
 Key features in the patient's presentation include palpitations, exercise intolerance, recurrent
syncope, and a family history of sudden cardiac death. Additionally, the presence of woolly hair
(sparse, coarse, and frizzy hair) and palmoplantar keratoderma (thickened skin on the palms and soles)
further supports the diagnosis.
 Echocardiography shows fatty infiltration and thinning of the myocardium, particularly in the right
ventricle.
 Genetic testing for plakoglobin gene mutation aids diagnosis.
 Treatment is aimed at managing arrhythmias and cardiac symptoms.
 Regular cardiac monitoring and follow-up.
 
Option A - SCN5A gene mutation: SCN5A gene mutation is associated with conditions like Brugada Sy
ndrome and Long QT Syndrome.
Option B
- MYH7 gene mutation: MYH7 gene mutation is associated with Hypertrophic Cardiomyopathy (HCM).
Option C - DSP gene mutation: DSP gene mutation is associated with another form of Arrhythmogenic 
Right Ventricular Cardiomyopathy (ARVC) known as Carvajal Syndrome.
Correct Option D - Verapamil:
 The left ventricular outflow tract obstruction in hypertrophic obstructive cardiomyopathy in this patient
worsened with the administration of nitroglycerin, a vasodilator.
 Propranolol is the drug of choice for managing patients with HCM. 
 Verapamil is also a calcium channel blocker that can be used as an alternative to propranolol,
particularly in patients who cannot tolerate beta-blockers due to conditions like asthma or COPD.
Option A - Digoxin: Digoxin increases the force of contraction of the heart (inotropy) and can worsen lef
t ventricular outflow tract obstruction in patients with HCM. Therefore, it is contraindicated in HCM as it 
can exacerbate symptoms and lead to adverse effects.
Option B - Furosemide: Furosemide causes fluid loss and decreases LV filling. This will worsen hypote
nsion in these patients. 
Option C - Amlodipine: Amlodipine is a dihydropyridine calcium channel blocker that is contraindicated 
in HCM due to its potential to worsen left ventricular outflow tract obstruction (LVOTO) in these patients
. Unlike verapamil (a non-dihydropyridine CCB), amlodipine acts on vascular smooth muscle cells to ca
use vasodilation and worsen the condition. 
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Correct Option C - Restrictive Cardiomyopathy:
 Gaucher Disease, a lysosomal storage disorder caused by a deficiency of the enzyme
glucocerebrosidase, can lead to the accumulation of glucocerebroside in various tissues, including the
heart.
 This accumulation in the heart can cause infiltration and fibrosis of the cardiac muscle and other
structures, leading to the development of Restrictive Cardiomyopathy.
Option A - Hypertrophic Cardiomyopathy: Occurs due to MYH7 mutation. 
Option B - Dilated Cardiomyopathy: Seen with alcohol, viruses, and Duchenne muscular dystrophy. 
Option D - Arrhythmogenic Right Ventricular Cardiomyopathy: ARVC is a
condition characterized by the replacement of the right ventricular myocardium with fibrofatty tissue. 
Correct Option C - Increased EDV, Increased ESV, Decreased contractility:
 Dicrotic pulse with exertional dyspnea indicates dilated cardiomyopathy. 
 Increased End-Diastolic Volume (EDV): DCM is characterized by enlargement and dilation of the left
ventricle, which leads to an increase in the volume of blood filling the ventricle during diastole, resulting
in increased EDV.
 Increased End-Systolic Volume (ESV): As the heart's ability to contract and pump blood is impaired in
DCM, the left ventricle is less effective in ejecting blood during systole. This results in an increased
residual volume of blood remaining in the ventricle at the end of systole, leading to increased ESV.
 Decreased Contractility: DCM leads to a decrease in the heart's contractile function. The heart muscle
becomes weakened and is less able to pump blood effectively, resulting in decreased contractility.
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Options A, B, and D: These are not the appropriate changes in cardiac parameters that result from dilat
ed cardiomyopathy.
 
Correct Option D - Peripartum cardiomyopathy occurs within the last month of pregnancy or up to 6
months after pregnancy:
 Peripartum cardiomyopathy (PPCM) is characterized by the development of idiopathic heart failure
with reduced ejection fraction (HFrEF) months after or before birth.
 It is diagnosed based on a left ventricular ejection fraction (LVEF) of < 0.45 on echocardiography and
in the absence of other potential causes of heart failure.
 Most patients experience partial or complete postpartum resolution of heart failure within 6 months of
delivery, but others require continued management with heart failure medications, devices, or heart
transplantation.
Incorrect Options: 
Options A, B, C
Solution for Question 12:
Correct Option A – Idiopathic:
 The clinical features of diffuse chest pain at rest that are relieved on sitting up, radiation of pain to the
left shoulder, and the presence of a scratchy sound on auscultation (pericardial friction rub) are typical
of pericarditis.
 Pericarditis can have various causes, and in most cases, the exact cause remains unknown. Thus,
idiopathic pericarditis is the most common.
Options B, C, D
Correct Option C - Cardiac tamponade:
 The findings of Beck's triad—distant heart sounds, elevated jugular venous pressure, and
hypotension—indicate cardiac tamponade.
 The low-voltage QRS complexes on ECG are seen in both tamponade and pericardial effusion. 
 Blood pressure is the differentiating factor. 
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Option A - Acute myocardial infarction: Acute myocardial infarction causes ST segment and T
wave changes on the ECG.
Option B - Acute pericarditis: Acute pericarditis can present with chest pain and a
pericardial friction rub on auscultation.
Option D - Pericardial effusion: It will not cause hemodynamic instability. 
Correct Option C - Pericardial effusion:
 Inspiratory fall of >10 mmHg indicates pulsus paradoxus. 
 It is seen in cardiac tamponade but not in pericardial effusion.
 Tamponade causes diastolic collapse of ventricles, causing severe hypotension and a fall of systolic
blood pressure. 
Option A - Pregnancy: During pregnancy, pressure on the IVC by the gravid uterus can reduce overall 
blood flow to the heart. This can lead to decreased blood pressure during inspiration, known as "physio
logical pulsus paradoxus." 
Option B - Constrictive pericarditis: Constrictive pericarditis leads to pulsus paradoxus due to impaired 
diastolic filling of the heart caused by the rigid pericardium. During inspiration, the increased venous ret
urn cannot be accommodated, leading to a significant drop in systolic blood pressure. 
Option D - Massive pulmonary embolism: Massive pulmonary embolism can cause pulsus paradoxus, 
especially if it leads to significant strain on the right ventricle and impairs left ventricular filling.
Correct Option - B
 The clinical presentation, including elevated JVP with a rise during inspiration (Kussmaul sign),
pericardial shudder, prominent S4 heart sound, and bilateral fine crepitations indicative of pulmonary
edema, suggests constrictive pericarditis.
 Chest X-ray shows pericardial calcification called egg-in-cup appearance. 
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Option A - CXR of water bottle appearance: It is seen in pericardial effusion.
Option C - CXR of Boot-Shaped Heart: It is seen in the Tetralogy of Fallot.
Option D - Hemithorax with meniscus sign: It is seen in pleural effusion. 
71

Conduction and its Defects
1. Based on the findings of the His Bundle Electrogram, if the AH Interval is prolonged, the block is
most likely located at?
A. Below the bundle branches
B. Within the AV node
C. In the atria
D. In the ventricles
2. Which of the following statements is/are true about the conduction of heart ? Depolarization spreads
from apex to base Depolarization spreads from epicardium to endocardium Apical endocardium is the
first part of the heart to get repolarised
A. Both 1 and 2 are true
B. Only 1 is true
C. Both 2 and 3 are true
D. All of them are true
3. A 65-year-old male with a medical history of hypertension and ischemic heart disease presents to the
emergency department due to intermittent fainting episodes. He describes feeling dizzy and
lightheaded before losing consciousness, and each episode lasts for a few seconds. His heart rate is
slow with an irregular rhythm. ECG shows P waves at 100/min and QRS complexes at 30/min. What is
the most likely diagnosis?
(or)
What is the most likely diagnosis for a patient with intermittent fainting episodes and ECG showing P
waves at 100/min and QRS complexes at 30/min?
A. Atrial Fibrillation
B. Stokes-Adams Syndrome
C. Ventricular Tachycardia
D. Supraventricular Tachycardia
4. A 68-year-old male patient with COPD presents to the emergency department with palpitations,
dizziness, and shortness of breath. His heart rate is 110 beats per minute and the rhythm is irregular,
and auscultation reveals multiple rapid heartbeats. The ECG shows an irregular R-R interval, and
P-waves are present, but they appear with varying morphologies. What is the most likely diagnosis?
(or)
Irregular R-R intervals with variable P wave morphologies on ECG in a patient with COPD is seen in?
A. Ventricular Tachycardia
B. Multifocal Atrial Tachycardia
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Page 2
D. Sinus Tachycardia
5. A 45-year-old female presents to the clinic with palpitations and irregular heartbeats. On evaluation,
an arrhythmia is detected, and the patient is prescribed an antiarrhythmic medication. The patient
returns after a few weeks with malar rash and joint pain. Which of the following drugs has a similar
antiarrhythmic mechanism of action as the medication initially prescribed?
(or)
A patient developed a malar rash and joint pain when he was prescribed an anti-arrhythmic drug.
Which of the following will have similar pharmacological action?
A. Amiodarone
B. Lidocaine
C. Flecainide
D. Disopyramide
6. A 40-year-old male with a history of recurrent episodes of atrial fibrillation is prescribed quinidine, an
antiarrhythmic medication. Which of the following statements regarding quinidine is true?
(or)
Which of the following is true about the features of quinidine?
A. Quinidine is a class Ib antiarrhythmic drug.
B. It primarily acts by blocking sodium channels, thereby prolonging the action potential duration.
C. Quinidine is known to cause a shortening of the QT interval on the electrocardiogram (ECG).
D. The most common adverse effect of Quinidine is hypokalemia.
7. Which of the following drugs has been withdrawn due to the side effect of polymorphic ventricular
tachycardia?
A. Domperidone
B. Omeperazole
C. Ebastine
D. Cisapride
8. A child with a congenital heart disease is on digoxin. He develops prostration and is given IV
lignocaine in the emergency department. Which rhythm disorder would have developed in this child?
(or)
For which type of arrhythmia has Lidocaine, also known as lignocaine, been approved for use?
A. Atrial fibrillation
B. Paroxysmal supraventricular tachycardia
C. Ventricular bigeminy
D. Premature ventricular contractions
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9. A 25-year-old male presents with palpitations and recurrent syncopal attacks. There is a family
history of sudden cardiac death of the brother. There are no abnormalities on examination. An ECG
reveals the following findings: PR interval is short. QRS complex is normal. PJ interval is short. Based
on these clinical and ECG findings, what is the most likely diagnosis for this patient?
(or)
What is the most likely diagnosis for a 25-year-old male with palpitations, recurrent syncopal attacks, a
family history of sudden cardiac death, and ECG findings of a short PR interval and short PJ interval?
A. Wolff-Parkinson-White Syndrome
B. Lown-Ganong-Levine Syndrome
C. Long QT Syndrome
D. Brugada Syndrome
10. A 75-year-old female with a history of hypertension and diabetes, presents to the clinic due to
palpitations, dizziness, and shortness of breath for several months. An ECG confirms atrial fibrillation.
She is concerned about her risk of stroke and wants to understand her prognosis and treatment
options. What are the components included in the risk assessment tool used to evaluate the risk of
stroke in such patients?
(or)
What components are included in the risk assessment tool used to evaluate the risk of stroke in
patients with atrial fibrillation?
A. Age, sex, and presence of hypertension
B. Ejection fraction, cholesterol levels, and blood pressure
C. Family history, smoking status, and BMI
D. Hemoglobin levels, platelet count, and INR values
11. A 62-year-old male patient presents to the emergency department with complaints of weakness,
palpitations, and chest discomfort. He has a history of chronic kidney disease and hypertension. What
ECG finding is the earliest to be seen in patient with hyperkalemia?
(or)
What ECG finding is the earliest to be seen in a patient with hyperkalemia?
A. Tall tented T wave
B. ST elevation
C. Absent P wave
D. QRS complex broad
12. A 32-year-old male presents to the emergency department with palpitations and dizziness that
started abruptly 2 hours ago. He mentions experiencing occasional episodes of rapid heartbeats in the
past, lasting for a few minutes and then spontaneously resolving. He is alert and oriented without any
abnormalities on examination. An ECG showed the following findings: Heart rate: 150 bpm Regular
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Page 4
rhythm PR interval: 0.08 seconds QRS duration: 0.10 seconds Delta wave Wide QRS complexes What
(or)
What is the most likely diagnosis in a 32-year-old male presenting with palpitations and an ECG
showing a regular rhythm, heart rate of 150 bpm, delta wave, and wide QRS complexes?
B. Supraventricular Tachycardia due to an accessory pathway
D. Sinus Tachycardia with premature ventricular contractions
13. A 68-year-old male with a history of COPD presents to the ER with palpitations, shortness of
breath, and dizziness. He is on long-term theophylline therapy. His heart rate is 120 beats per minute,
blood pressure is 100/80 mmHg, respiratory rate is 24 breaths per minute, and SpO2 is 92% on room
air. An electrocardiogram is performed, which is shown below: Which of the following statements are
true about the treatment of this condition?
(or)
What are the true statements regarding treating the condition in a patient on theophylline therapy for
COPD, and the following ECG findings?
A. DC shock is the preferred treatment of choice
B. Amiodarone cannot be given as a long term treatment modality
C. Verapamil acts on SA node and stabilizes the heart rate
D. Metoprolol when given causes stabilization of the membrane
14. A 65-year-old male, presents to the emergency department due to persistent dizziness, fatigue,
shortness of breath, and near-fainting for a week. He underwent percutaneous coronary intervention six
months ago to address a severe blockage in one of his coronary arteries. His blood pressure is 130/80
mmHg, heart rate is 40 bpm, and respiratory rate is 20 breaths/min. ECG was performed which is given
below : Which of the following is the cause of the patients symptoms?
(or)
What is the likely cause of dizziness, fatigue, a heart rate of 40 bpm, and the provided ECG findings, in
the context of his medical history of coronary artery disease and recent PCI procedure?
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Page 5
A. Degenerative changes in the SA node
B. Damage to the AV node
C. Reentrant circuit
D. Ectopic foci
15. A 20-year-old otherwise healthy female presents to the emergency department with complaints of
recurrent episodes of fainting and palpitations. The episodes have been occurring for the past few
months and are triggered by sudden loud noises or emotional stress. Her heart rate is regular. ECG
showed the following findings : Which of the following antiarrhythmics would be contraindicated in this
condition ?
(or)
In a 20-year-old female with recurrent episodes of fainting and palpitations triggered by loud noises or
emotional stress and ECG findings, which antiarrhythmic would be contraindicated?
A. Beta blocker
B. Amiodarone
C. Lignocaine
D. MgSO4
16. A 65-year-old male with a history of hypertension and diabetes presents to the emergency
department with sudden-onset weakness on the right side of his body and difficulty speaking. On
examination, the patient has right-sided facial droop, right arm and leg weakness, and slurred speech.
His blood pressure is elevated, and he has an irregular heartbeat on auscultation. He appears confused
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Page 6
and disoriented. What is the most likely cause?
(or)
What is the most likely cause of the 65-year-old male patient's symptoms, including right-sided
weakness, slurred speech, elevated blood pressure, irregular heartbeat, and confusion?
B. Atrial flutter
C. Multifocal atrial tachycardia
17. A 28-year-old female presents to the ER with sudden onset palpitations and dizziness. She reports
feeling her heart racing, which began abruptly about 30 minutes ago. Her heart rate is 180 beats per
minute, and her blood pressure is 100/80 mmHg. ECG findings are given below. Which of the following
statements is not true about the drug of choice for this condition ?
(or)
Which statement regarding the drug of choice for the patient's condition, characterized by sudden
palpitations and an ECG showing specific findings, is not true?
A. It can produce asystole or atrial fibrillation
B. It is contraindicated in asthmatic patient
C. Its activity is increased by the methylxanthines
D. Its increase leads to coronary steal phenomenon.
18. A 70-year-old hypertensive patient presented to the clinic complaining of sudden onset of
palpitations, dizziness, and loss of consciousness. His heart rate was 150 beats/minute, and his blood
pressure was 80/60 mmHg. ECG was done, which showed the following findings. Diagnosis is?
(or)
What is the most likely diagnosis for a 70-year-old hypertensive patient with sudden palpitations,
dizziness, and loss of consciousness whose ECG is shown below?
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Page 7
A. Atrial flutter
B. Atrial fibrillation
D. PSVT
19. 55-year-old lady presents to ER with complaints of fatigue and prostration. She is known case for
C.K.D and is on multiple medications. BP is 160/100 mm Hg and severe pallor is noted. ECG shows?
(or)
Based on the clinical presentation and ECG findings, what is the likely diagnosis for the 55-year-old
woman with a history of chronic kidney disease, weakness, fatigue, and muscle cramps?
A. Hypokalemia
B. Hyperkalemia
C. Hypercalcemia
D. Hyponatremia
20. A 35-year-old patient with a history of recurrent episodes of supraventricular tachycardia presents
to the cardiology clinic. The clinician prescribes a beta blocker. Which interval of the ECG is most likely
to be affected by this drug?
(or)
A 35-year-old patient with supraventricular tachycardia is prescribed a beta blocker. Which ECG
interval is most likely to be affected by this drug?
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Page 8
A. C
B. D
C. B
D. E
21. A 32-year-old male presents to the emergency department with palpitations, and dizziness. An
ECG reveals a tachycardic rhythm with specific characteristics suggestive of Atrioventricular Reentrant
Tachycardia. Which of the following characteristics describes Antidromic Conduction in AVRT?
(or)
Which of the following is correct about Antidromic Conduction in Atrioventricular Reentrant Tachycardia
(AVRT)?
A. Retrograde conduction via bundle of Kent with narrow QRS complex
B. Anterograde conduction via bundle of Kent with broad QRS complex
C. Treatment of choice is defibrillation
D. Carotid sinus massage will prevent paroxysmal attacks
22. A 60-year-old man with hypertension is complaining of feeling dizzy with palpitations and
breathlessness. The blood pressure was 70/40 mm Hg and became unrecordable while ECG was
being recorded. What should be the first step in the management of this patient?
(or)
What is the best treatment for a crashing patient with following ECG recording?
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A. IV Amiodarone 150mg
B. IV Lasix 40mg
C. Defibrillation
D. Cardioversion
23. A 25-year-old man was brought after falling due to a syncopal attack an hour ago. He had similar
episodes in the past and family history of sudden death in sibling is present. ECG is given below. What
is the likely diagnosis?
(or)
Comment on diagnosis based on the ECG shown.
A. WPW syndrome
B. Hypokalemia
C. Arrhythmogenic right ventricular dysplasia
D. HOCM
24. What is the diagnosis if the axis is on the mark “?” from the diagram shown below?
A. Right axis deviation
B. Normal axis
C. Left axis deviation
D. Extreme axis deviation
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25. A 55-year-old man presented to the physician's office for a regular blood pressure checkup. On
physical examination, there was a wide split second heart sound. The physician recommended an ECG
for evaluation which revealed findings as shown below. Which of the following is the most likely
diagnosis?
(or)
On physical examination, there was a wide split second heart sound, and ECG is given below. Which of
the following is the most likely diagnosis?
A. Left bundle branch block
B. Right bundle branch block
C. Wolf Parkinson White Syndrome
D. Lown Ganong Levine Syndrome
Question 8 3
Question 9 2
Question 12 2
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Option C- In the atria: The AH interval represents the time taken for an electrical signal to travel from th
e atria to the ventricles. If it is prolonged, it implies a
delay in the AV node's conduction, not an issue in the atria.
Option D- In the ventricles: The AH interval does not directly assess conduction within the ventricles. In
stead, it primarily reflects AV node conduction. If there were an issue in the ventricles causing a prolon
ged AH interval, it would be indirectly due to the AV node's impaired ability to transmit signals effectivel
y.
Correct Option B- Only 1 is true:
Correct Option B- Stokes-Adams Syndrome:
 The ECG findings described align with the features of Stokes-Adams Syndrome.
 It is characterized by recurrent episodes of loss of consciousness due to third degree heart block
having no conduction via AV node. 
Option A- Atrial Fibrillation: Atrial Fibrillation is characterized by an irregularly irregular heart rhythm wit
h absent P waves on the ECG.
Option C- Ventricular Tachycardia: Ventricular Tachycardia presents with broad QRS complex tachyca
rdia. 
Option D- Supraventricular Tachycardia: Supraventricular Tachycardia presents with narrow QRS com
plex tachycardia. 
Correct Option B- Multifocal Atrial Tachycardia (MAT):
 The clinical scenario and ECG findings align with the features of Multifocal Atrial Tachycardia (MAT).
 MAT is a type of atrial tachycardia characterized by irregular and rapid heartbeats originating from
multiple ectopic foci in the atria.
 It is most commonly associated with underlying pulmonary disease (such as COPD in this patient),
cardiac disease, electrolyte abnormalities (mainly hypokalemia and hypomagnesemia), and chronic
renal failure.
Option A- Ventricular Tachycardia: Ventricular Tachycardia typically presents with wide QRS complexe
s on ECG.
Option C- Atrial Fibrillation: Atrial fibrillation has an irregularly irregular rhythm with absent P waves.
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Option D- Sinus Tachycardia: Sinus Tachycardia exhibits normal sinus rhythm. 
Correct Option D- Disopyramide:
 The drug initially prescribed to the patient is procainamide. Procainamide is an antiarrhythmic
medication used to treat various types of arrhythmias. However, after a few weeks of taking
procainamide, the patient developed symptoms of malar rash and joint pain, which are indicative of
drug-induced lupus.
 Disopyramide is another class IA antiarrhythmic medication, similar to procainamide, and has
comparable mechanism of action.
Option A- Amiodarone: Amiodarone is a class III antiarrhythmic medication with a
mechanism of action different from procainamide. It causes blue man syndrome.
Option B- Lidocaine: Lidocaine is a
class IB antiarrhythmic drug that works by blocking sodium channels, leading to a reduction in the cond
uction velocity in cardiac tissues. It is primarily used for the treatment of ventricular arrhythmias. 
Option C- Flecainide: Flecainide is a class IC antiarrhythmic drug that works by blocking sodium chann
els and slowing the conduction of electrical impulses in the heart. It is mainly used for the treatment of 
supraventricular and ventricular arrhythmias. 
Correct Option B- It primarily acts by blocking sodium channels, thereby prolonging the action potential
 duration:
 This action prolongs the action potential duration and refractory period in cardiac cells, helping to
stabilize the cardiac rhythm and prevent arrhythmias.
 Quinidine serves as a class 1a antiarrhythmic drug.
Option A- Quinidine is a class Ib antiarrhythmic drug: is incorrect because quinidine is a
class Ia antiarrhythmic drug.
Option C-Quinidine is known to cause a shortening of the QT interval on the electrocardiogram (ECG): 
is incorrect because quinidine is known to cause QT interval prolongation on the ECG.
Option D- The most common adverse effect of quinidine is hypokalemia: Also incorrect. Quinidine can 
cause various side effects, including gastrointestinal disturbances, cinchonism (a syndrome characteriz
ed by symptoms like tinnitus, hearing loss, and visual disturbances), and potential cardiac effects like 
QT prolongation and polymorphic ventricular tachycardia.
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Correct Option D- Cisapride:
 When a patient is taking cisapride for acid reflux disease, there is already a potential risk of QT
interval prolongation and development of polymorphic ventricular tachycardia.
 It also interacts with commonly prescribed macrolide, erythromycin, used for the treatment of
community-acquired pneumonia. It can inhibit the activity of CYP3A4 enzymes in the liver. This
inhibition can slow down the metabolism of cisapride, causing higher levels of cisapride to trigger
arrhythmia. 
 The increased levels of cisapride in the bloodstream, combined with its inherent propensity to prolong
the QT interval, can significantly raise the risk of developing a life-threatening arrhythmia like pulseless
ventricular tachycardia or torsades de pointes.
Option A- Domperidone: Domperidone is a
medication used to relieve symptoms of nausea and vomiting. 
Option B- Omeprazole: Omeprazole is a
proton pump inhibitor commonly used to treat acid reflux disease (GERD). 
Option C- Ebastine: Ebastine is an antihistamine used to relieve allergy symptoms. It is generally not k
nown to cause significant cardiac arrhythmias.
Correct Option C- Ventricular bigeminy:
 Lidocaine is a local anesthetic of the amino amide type. 
 It is the drug of choice for the treatment of digoxin-induced ventricular bigeminy.
 It reduces the enhanced automaticity of subsidiary pacemakers and AV nodal conduction in
therapeutic concentrations.
Option A- Atrial fibrillation:
 Beta-blockers and calcium channel blockers are the drugs of choice for atrial fibrillation.
Option B- Paroxysmal supraventricular tachycardia:
 Managed with vagal maneuvers, adenosine, or verapamil for chemical cardioversion. 
Option D- Premature ventricular contractions:
 Beta-blockers in low doses are the first-line therapy for reducing the burden of premature ventricular
contractions (PVC).
 Metoprolol and carvedilol are the beta blockers commonly used for this purpose.
 
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Correct Option B- Lown-Ganong-Levine Syndrome:
 This patient's clinical presentation with palpitations, recurrent syncopal attacks, and a family history of
sudden cardiac death, along with the ECG findings of a short PR interval, normal QRS complex, and
short PJ interval, is diagnostic of a pre-excitation syndrome called LGL syndrome.
 In Lown-Ganong-Levine Syndrome, an accessory pathway known as the James fibers allows
electrical impulses from the atria to bypass the atrioventricular (AV) node and directly reach the Bundle
of His.
Option A- Wolff-Parkinson-White Syndrome: Wolff-Parkinson-White Syndrome (WPW) is another pre-e
xcitation syndrome characterized by an accessory pathway (Bundle of Kent) is ruled because this has 
a normal PJ interval.
Option C- Long QT Syndrome: Long QT Syndrome is characterized by a
prolonged QT interval on the ECG and is associated with an increased risk of ventricular arrhythmias. 
Option D- Brugada Syndrome: It is a sodium channel defect (SCN5A) characterized by specific ECG fi
ndings, such as ST-segment elevation in the right precordial leads (V1-V3).
Correct Option A- Age, sex, and presence of hypertension:
 The components typically included in the risk assessment tool used to evaluate the risk of stroke in
patients with atrial fibrillation (AF) are age, sex, and the presence of hypertension. This risk assessment
tool is often referred to as the CHA2DS2-VASc score.
CHA2DS2 – VASs
Risk Factor
Score
Congestive HF (CHF)
1
Age ≥75
2
Diabetes mellitus
Stroke, TIA, or TE
Vascular disease (prior MI, PAD, or CABG)
Age 65-74
Sex category (female)
Option B- Ejection fraction, cholesterol levels, and blood pressure: Only hypertension is a
component of the CHA2DS2-VASc score.
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Option C- Family history, smoking status, and BMI: None of these are components of the CHA2DS2-V
ASc score.
Option D- Hemoglobin levels, platelet count, and INR values: None of these are components of the CH
A2DS2-VASc score.
Correct Option A- Tall tented T wave:
 Tall tented T waves are a classic earliest ECG findings associated with hyperkalemia. In
hyperkalemia, as serum potassium levels rise, the resting membrane potential of cardiac myocytes
becomes less negative. This leads to increased excitability of the cells, resulting in tall and peaked T
waves.
Option B- ST elevation: ST-segment follows the vector of T wave.
Option C- Absent P wave:  Hyperkalemia leads to changes in P wave morphology, including decreased
 amplitude and duration. Additionally, PR interval prolongation can occur. 
Option D- QRS complex broad:  In hyperkalemia, as serum potassium levels increase, the depolarizati
on phase of cardiac myocytes is affected. This can result in widening of the QRS complex on the ECG.
 A broad QRS complex is often a
prominent feature of severe hyperkalemia and can lead to life-threatening arrhythmias.
Correct Option B- Supraventricular Tachycardia (SVT) due to an accessory pathway
 The patient's clinical presentation of abrupt-onset palpitations and dizziness, along with a regular
rapid heart rate on examination, raises suspicion for SVT.
 The ECG findings are characteristic of Wolff-Parkinson-White (WPW) syndrome, which is accessory
pathway mediated tachycardia. 
Option A- Atrial Fibrillation: Atrial fibrillation presents with an irregularly irregular rhythm, with no discer
nible P waves and varying R-R intervals.
Option C- Ventricular Tachycardia (VT): Ventricular tachycardia is broad QRS complex tachycardia. Ho
wever, in this case, the QRS duration is not significantly prolonged (0.10 seconds), making VT less like
ly.
Option D- Sinus Tachycardia with premature ventricular contractions (PVCs): Sinus tachycardia is a
normal response of the heart to various stressors, and it is characterized by a regular rhythm with a
heart rate above 100 bpm. However, sinus tachycardia would have a normal PR interval (approximatel
y 0.12 to 0.20 seconds), unlike the short PR interval seen in this case. Additionally, premature ventricul
ar contractions (PVCs) would appear as ectopic beats with a
wide QRS complex and will not have delta wave.
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Correct Option B- Amiodarone cannot be given as a long-term treatment modality:
 The combination of an irregular rhythm with varying P-wave morphologies in a patient on theophylline
therapy for COPD is consistent with the diagnosis of Multifocal Atrial Tachycardia (MAT).
 Amiodarone, a class III antiarrhythmic medication with a membrane-stabilizing effect, can be
recommended for the treatment of MAT. However, its potential for toxicity limits its use as a long-term
treatment option.
Option A-DC shock is the preferred treatment of choice: DC shock is not the preferred treatment for Mu
ltifocal Atrial Tachycardia (MAT) because it is ineffective in the presence of theophylline toxicity and do
es not provide long-term benefit.
Option C- Verapamil acts on SA node and stabilizes the heart rate: Verapamil primarily acts on the AV 
node, not the SA node, and is not the preferred medication for managing MAT.
Option D- Metoprolol when given causes stabilization of the membrane: Metoprolol works by blocking a
drenaline's effects on the heart, but it does not directly stabilize the membrane. It is used to manage he
art rate and symptoms in MAT.
Correct Option B - Damage to the AV node:
 Based on the clinical presentation and the ECG showing P waves (atrial activity) that are not followed
by QRS complexes (ventricular activity) in a consistent pattern with slow ventricular rate and no
association between the P waves and QRS complexes confirms the diagnosis of third-degree heart
block on the ECG.
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 Damage to the AV nodal tissue is a potential cause of third-degree AV block.
 The underlying cause of the AV nodal tissue damage in this patient is likely related to his history of
coronary artery disease. CAD can lead to reduced blood flow to the AV node, resulting in tissue
damage.
Option A- Degenerative changes in the SA node: This option is incorrect because degenerative change
s in the SA nodal tissue typically result in sinus node dysfunction, which may lead to sinus bradycardia 
or sinus arrest. 
Option C- Reentrant circuit: This option is incorrect because a reentrant circuit is a
common mechanism in certain types of supraventricular tachycardias, not third-degree heart block. 
Option D- Ectopic foci: This option is incorrect because ectopic foci are abnormal pacemaker cells that 
generate electrical impulses outside of the SA node. While ectopic foci can cause irregular heart rhyth
ms, they are not responsible for the regular and slow heart rates seen in third-degree heart block. 
Correct Option B- Amiodarone:
 The ECG findings, specifically the prolonged QT interval, suggest Long QT Syndrome.
 LQTS is characterized by prolongation of the QT interval on the ECG, which can predispose
individuals to life-threatening arrhythmias, such as Torsades de Pointes.
 Amiodarone is contraindicated in patients with Long QT Syndrome due to its potential to prolong the
QT interval further, which can increase the risk of Torsades de Pointes and other dangerous
arrhythmias. 
 Other drugs that are contraindicated: Class 1A and III antiarrhythmics Macrolides and
fluoroquinolones Antipsychotics Antiemetics like ondansetron Antifungals like azoles
 Class 1A and III antiarrhythmics
 Macrolides and fluoroquinolones
 Antipsychotics
 Antiemetics like ondansetron
 Antifungals like azoles
Option A- Beta-blockers: Beta-blockers can be used as a
first-line treatment to manage LQTS, especially in patients with LQT1 subtype.
Option C- Lignocaine (lidocaine): Lignocaine (lidocaine) may be considered in certain situations to man
age arrhythmias in LQTS, although it may not be the first-choice therapy.
Option D- MgSO4: Magnesium sulfate (MgSO4) can be used in certain situations to correct electrolyte i
mbalances or manage arrhythmias. It is drug of choice for acute long QT syndrome.
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 Dipyridamole and Regadenoson (used in cardiac stress testing) can cause Coronary Steal
Phenomenon (CSP) due to increased Adenosine activity
 Adenosine's activity is antagonized by methylxanthines, such as caffeine, which can reduce its
effectiveness.
 Methylxanthines, therefore, diminish the desired effects of adenosine in terminating the arrhythmia.
Option A- It can produce asystole or atrial fibrillation: This statement is true for adenosine. While adeno
sine is used to terminate SVT, it can transiently cause asystole (temporary absence of heartbeat) due t
o its potent inhibitory effect on the AV node. This is usually a brief effect and is often necessary to brea
k the reentrant circuit causing the SVT. Adenosine can also transiently induce atrial fibrillation in some 
cases.
Option B- It is contraindicated in asthmatic patients: This statement is true for adenosine. Adenosine ca
n cause bronchoconstriction and exacerbate symptoms in patients with asthma or other obstructive lun
g diseases. It is generally contraindicated in patients with a history of asthma.
Option D- Its increase leads to coronary steal phenomenon: This statement is true for adenosine. Aden
osine is a potent vasodilator and can cause a phenomenon known as "coronary steal." This occurs wh
en adenosine-induced vasodilation in healthy coronary vessels diverts blood flow away from stenotic (n
arrowed) coronary vessels, potentially worsening ischemia in regions with pre-existing coronary artery 
disease.
Solution for Question 18:
Correct Option A- Atrial flutter:
 Atrial flutter (also called cavotricuspid isthmus-dependent atrial flutter) occurs due to a circuit around
the tricuspid valve annulus, bounded anteriorly by the annulus and posteriorly by the functional
conduction block in the crista terminalis. The wavefront passes between the inferior venacava and the
tricuspid valve annulus, known as the cavotricuspid isthmus.
 ECG shows, Flutter waves (negative saw tooth pattern)  in the lead II, III, and aVF. 3 flutter waves
before every QRS complex.
 Flutter waves (negative saw tooth pattern)  in the lead II, III, and aVF.
 3 flutter waves before every QRS complex.
Option B- Atrial fibrillation:
 In patients with AFib, a P wave will not be seen, with irregular R-R interval.
Option C- Multifocal atrial tachycardia:
 ECG findings include: Irregular R-R interval Variable P wave morphology: ≥ 3 different P wave
morphology Variable P-R interval: Usually variable P-R interval is seen with Brady arrhythmias Right
axis deviation will be present
 Irregular R-R interval
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Option D: E - Beta blockers may have some effect on the QT interval, but their primary action is on the 
PR interval, not the QT interval.
Solution for Question 21:
Correct Option B- Anterograde conduction via bundle of Kent with broad QRS complex:
 Antidromic conduction in AVRT involves anterograde conduction of electrical impulses through the
accessory pathway (Bundle of Kent), activating the ventricles that can reenter via the AV node,
resulting in a broad QRS complex. 
Option A- Retrograde conduction via bundle of Kent with narrow QRS complex: This description more 
closely resembles Orthodromic Conduction in AVRT, not Antidromic Conduction. Orthodromic conducti
on involves normal atrioventricular conduction through the AV node and retrograde conduction through
 the accessory pathway (Bundle of Kent), resulting in a narrow QRS complex.
Option C- Treatment of choice is defibrillation: Defibrillation is used for ventricular fibrillation or unstable
 ventricular tachycardia. For AVRT, the initial approach is usually aimed at terminating the tachycardia 
using other methods like vagal maneuvers and IV Adenosine.
Option D- Carotid sinus massage will prevent paroxysmal attacks: Carotid sinus massage and IV Aden
osine are used for acute termination of AVRT episodes, not for prevention. 
Solution for Question 22:
Correct Option C- Defibrillation:
The ECG shows broad QRS complex tachycardia called Monomorphic ventricular tachycardia.
 Since the blood pressure of the patient is crashing→ defibrillation needs to be done.
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Option A- IV Amiodarone 150 mg:
 IV Amiodarone is the drug of choice for monomorphic ventricular tachycardia if heart disease is
present. However, since the patient is hemodynamically unstable at this moment, the first step in
management should be to achieve hemodynamic stability.
Option B- IV Lasix 40 mg:
 IV Lasix is given in patients with left ventricular failure resulting in symptoms of volume overload, e.g.
pulmonary edema causing shortness of breath, cough and exertional fatigue.
Option D- Cardioversion:
 It is done in supraventricular tachycardia and is synchronous with the peak of R wave / carotid
pulsations. 
Solution for Question 23:
Correct Option C- Arrhythmogenic right ventricular dysplasia:
 ECG shows a "wiggle" at the terminal part of the QRS complex called the epsilon wave. 
 The epsilon wave is a characteristic ECG finding in ARVD, indicating delayed activation of the right
ventricle due to fibrofatty infiltration of the myocardium. This condition can lead to ventricular
arrhythmias and sudden cardiac death.
 Palpitations and syncope are also consistent with ARVD, an inherited cardiomyopathy affecting the
right ventricle.
Epsilon wave
Delta wave
Prominent U wave
Deep Q wave
A little deviation hidden after the QRS complex
It appears as an upswing of the R wave before the QRS complex
Seen after T waves
Are negative deflections after the P wave
Presents at leads V1 and V2
Occurs due to ventricular preexcitation
Are the ones who have > 1-2 mm or 25% of the height of the T wave
Considered when > 2 mm deep, > 40 ms wide, > 25% depth of QRS complex and seen in V1-V3
Seen in ARVD
Seen in WPW syndrome
Mostly seen in severe hypokalemia, bradycardia
Seen in myocardial infarction, hypertrophic cardiomyopathy
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Option A- WPW syndrome (Wolff-Parkinson-White syndrome): WPW syndrome is characterized by an 
accessory pathway called the Bundle of Kent that can cause pre-excitation of the ventricles. It typically 
presents with a short PR interval, a delta wave on the ECG, and a
risk of supraventricular tachycardias (e.g., atrioventricular reentrant tachycardia, AVRT). 
Option B- Hypokalemia: Hypokalemia is an electrolyte imbalance characterized by low serum potassiu
m levels. It can indeed lead to ECG changes, including U-waves and T-wave abnormalities. 
Option D- HOCM (Hypertrophic Obstructive Cardiomyopathy): HOCM is a condition characterized by h
ypertrophy of the left ventricular wall, leading to left ventricular outflow tract obstruction. HOCM-related 
ECG changes are more focused on left ventricular hypertrophy and repolarization abnormalities.
Solution for Question 24:
Correct Option A - Right axis deviation: 
Axis Calculation: The electrical axis reflects the average direction of ventricular depolarization during th
e ventricular contraction. The direction of depolarization (and electrical axis) is alongside the heart's lon
gitudinal axis (to the left and downwards).
 Normal Axis: -30° to +110°
 Right axis deviation is when the QRS complex shifts between 90° and 180°.
 Options B, C, and D are incorrect.
Solution for Question 25:
Option B: Right Bundle Branch Block
96

Brugada Syndrome, RHD & Infective Endocarditis
1. A 14-year-old girl presents with a 2-day history of walking with a limp due to ankle joint pain. Her
mother mentioned that the girl had a sore throat three weeks ago, which resolved on its own. There are
nontender nodules on the elbows bilaterally. What is the most likely diagnosis?
(or)
What is the most likely diagnosis in an adolescent with a history of sore throat presenting with fever,
joint pain, evanescent rash, and skin nodules?
A. Rheumatoid Arthritis
B. Infective Endocarditis
C. Kawasaki Disease
D. Acute Rheumatic Fever
2. A 13-year-old boy has had difficulty walking for one week due to joint pain. His mother reports a
history of untreated sore throat. His temperature is 38.8°C. On examination, tenderness is present in
the right knee joint, and a systolic murmur at the apex is present. The murmur radiates to his left axilla.
What pathogenesis is involved in developing this condition?
(or)
What is the underlying mechanism responsible for a new-onset systolic marmur radiating to the left
axilla in a young patient with a history of untreated throat infection?
A. Molecular mimicry
B. Direct toxic effects of bacterial exotoxins
C. Direct invasion by the organism
D. Mechanical obstruction to the valve
3. A 16-year-old female presents with recent episodes of palpitations and shortness of breath. On
examination, she has a systolic murmur at the cardiac apex. Laboratory evaluation shows elevated
anti-streptolysin O titers and erythrocyte sedimentation rate. An echocardiogram reveals moderate
regurgitation in the mitral valve. A biopsy of her heart tissue is performed, and a pathology image is
provided below. Which of the following statements about this pathology is not true?
(or)
Which statement is not true about the below pathology from a young patient's heart tissue whose
laboratory evaluation showed elevated anti-streptolysin O titers and ESR?
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Page 2
A. Present in myocardium and endocardium only
B. Fibrinoid necrosis in the center
C. Uncommon in chronic stages
D. Anitschkow cells
4. A 10-year-old child presents with a fever and a skin rash on the chest. There is a pansystolic murmur
at the cardiac apex on auscultation. Investigations reveal elevated inflammatory markers and evidence
of recent streptococcal infection. The child is diagnosed with acute rheumatic fever. Which of the
following statements regarding secondary prophylaxis for this condition is true?
(or)
Which of the following is the best recommendation for a child with acute rheumatic fever and a
pansystolic cardiac murmur?
A. Injections are given up to at least 21 years of age or a minimum of 10 years after the last attack,
whichever is longer
B. Injection are given till 21 years of age or 5 years after the last attack, whichever is longer
C. No prophylaxis is required as disease has already set in
D. The duration of antibiotic prophylaxis is till 40 years of age or 10 years after the last documented
attacks, whichever is longer
5. A 20-year-old male presents to the emergency department with complaints of fever, malaise, and
joint pain for the past week. Upon further questioning, he reports a recent upper respiratory tract
infection. On examination, he is found to have a heart murmur. Laboratory investigation results are
pending. Which of the following is false about the pathogenesis and/or disease course in this patient?
(or)
Which of the following is not true about the pathogenesis and/or disease of acute rheumatic fever?
A. It is an autoimmune disease caused by a type 2 hypersensitivity reaction
B. N-Acetyl galactosamine is the cross antigen that reacts with the antibodies responsible
C. If untreated, the disease course is up to 12 weeks
D. Primary prevention comprises of starting oral penicillin within 9 days of documented infection
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6. Which of the following statements about the features of acute rheumatic fever is not true?
A. Arthritis is the earliest manifestation
B. Sydenham’s chorea occurs after 6 months
C. Carditis can occur in 50-75% of the cases
D. Subcutaneous nodules have a high incidence of 60-70%
7. A 19-year-old male patient with a history of acute rheumatic fever is being administered antibiotics
for the prevention of rheumatic heart disease. If this prophylaxis is not given, which of the following is
most likely to occur?
(or)
What is the most likely cardiac outcome in patients with untreated acute rheumatic fever?
C. Tricuspid stenosis
D. Pulmonary hypertension
8. A 13-year-old boy presents to the clinic due to falling school grades and poor handwriting. He has a
history of throat infection. Physical examination reveals choreiform movements of the upper and lower
extremities. Which of the following statements is true about this condition?
(or)
Idnetify the correct statement regarding a condition characterized by choreiform movements of the
extremities in an adolescent with a history of throat infection?
A. It occurs due to damage in the caudate nucleus
B. It comprises hyperreflexia and spasticity in distal extremities
C. More common in males compared to females
D. It is not self limiting
9. A 12-year-old girl is brought to the clinic due to noticeable changes in her behavior and movements.
Her parents report that she has become increasingly irritable over the past few weeks and has difficulty
focusing on her schoolwork. She has a history of a sore throat a few weeks ago, which resolved without
treatment. On examination, you observe dance-like involuntary movements of her arms and face. What
is the inappropriate statement regarding the treatment of this manifestation?
(or)
Which statement is not appropriate regarding the treatment of a condition in an adolescent with
behavioral changes and choreiform movements following a recent sore throat?
A. IVIG is used for refractory cases
B. Steroids are used for faster resolution
C. Haloperidol is a first-line drug
D. Moderate to severe cases are treated with valproate
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10. A 35-year-old woman with a known history of systemic lupus erythematosus presents with a
new-onset heart murmur and fatigue. An echocardiogram reveals vegetations on the mitral valve. What
(or)
What is the most likely diagnosis in a woman with systemic lupus erythematosus who presents with a
new heart murmur and vegetations on the mitral valve detected by echocardiogram?
A. Rheumatic Heart Disease
C. Verrucous Endocarditis
D. Lupus Myocarditis
11. A 45-year-old male presents with a three-week history of fever, fatigue, and generalized body
aches. The patient is a known case of hypertrophic cardiomyopathy. A new-onset murmur is heard at
the tricuspid area. His temperature is 101.5°F. An echocardiogram reveals a mobile, oscillating mass
attached to the tricuspid valve. What is the diagnosis?
(or)
What is the most likely diagnosis in a patient with hypertrophic cardiomyopathy who presents with
fever, fatigue, a new onset murmur at tricuspid area, and echocardiographic findings of a mobile,
oscillating mass on the tricuspid valve?
A. Ventricular myxoma
B. Atrial myxoma
C. Non-Bacterial Thrombotic Endocarditis
D. Infective Endocarditis
12. Which of the following are correctly matched with the organism causing it ?
A. Early prosthetic valve endocarditis : Staphylococcus saprophyticus
B. Late prosthetic valve endocarditis (after 12 months ) : Staphylococcus aureus
C. Community acquired native valve endocarditis : Streptococcus
D. Hospital acquired native valve endocarditis : Coagulase-Negative Staphylococcus (CONS)
13. A 20-year-old male with a history of rheumatic heart disease presents with a three-month history of
fatigue, night sweats, and low-grade fever. He received antibiotics for a suspected respiratory infection,
but his symptoms persist. There is a diastolic murmur heard best in the aortic area. Blood cultures
obtained before antibiotics were initiated did not yield any growth. Transesophageal echocardiography,
reveals aortic valve vegetation. Which of the following is not responsible for this disease?
(or)
What is not responsible for aortic valve vegetations in a patient with rheumatic heart disease with
negative blood culture and persistent symptoms despite antibiotic treatment?
A. HACEK group
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Page 5
B. Pseudomonas
C. Bartonella
D. Mycobacterium chimaera
14. A 40-year-old man presents with fever, chills, weakness, and shortness of breath for two weeks. He
had recently undergone valve replacement for mitral valve prolapse. Three weeks ago, he had a dental
procedure. His blood pressure is 100/65 mm Hg, Pulse is 55/min, and BMI is 21 kg/m2. On
examination, he has hemorrhagic macules on his palms. Which of the following is the correct
description of his cutaneous findings?
(or)
A patient who had undergone mitral valve replacement last year presents with high-grade fever and
hemorrhagic macules on the palms following a recent dental procedure. What is the correct description
of his cutaneous findings?
A. Janeway lesions
B. Osler nodes
C. Erythema marginatum
D. Erythema nodosum
15. A 12-year-old girl presents with recurrent fever and joint pain for the past few weeks. She had a
sore throat about a month ago, which was treated with antibiotics. On examination, the girl has tender,
swollen joints and small painless nodules under her skin, mainly on her elbows and knees. A diastolic
murmur was heard at the apex of the heart. Laboratory tests show elevated anti-streptolysin O
titers.What type of cardiac vegetations are most likely to be seen in this patient?
(or)
What type of cardiac vegetation is most likely to be seen in a patient with recurrent fever, joint pain,
nodules, elevated ASO titers, and a diastolic murmur at apex?
A.
B.
C.
D.
Question 4 4
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 after accounting for age variability
 unless carditis is a major criterion
The presence of two major criteria and two minor criteria, along with evidence of preceding streptococc
al infection, confirms the diagnosis of ARF in the patient.
Option A - Rheumatoid Arthritis: It mostly affects middle-aged women. Patients present with pain and e
arly morning stiffness, especially in the small joints of the hands. There is no association with streptoco
ccal infections.
Option B - Infective Endocarditis: It is characterized by an infection of the heart valves, leading to fever 
and heart murmurs.  Osler nodes (painful subcutaneous nodules typically found on the fingertips), subu
ngual splinter hemorrhages, and Janeway lesions (painless hemorrhagic plaques on the palms/soles) 
are characteristic. 
Option C - Kawasaki Disease: Kawasaki Disease primarily affects children and can cause fever, rash, 
strawberry tongue, and coronary artery aneurysms. 
Correct Option A - Molecular mimicry:
 Patient's systolic murmur indicates mitral valve regurgitation, the characteristic manifestation of
carditis, in previously unaffected individuals with ARF.
 Acute rheumatic fever (ARF) is an autoimmune inflammatory disease that occurs following an
untreated or inadequately treated group A Streptococcus (GAS) pharyngitis.
 Molecular mimicry is the process by which antigens from infectious organisms resemble host
antigens, leading to cross-reactivity and subsequent autoimmune response.
 In the case of ARF, antigens from GAS bear structural similarity to proteins present in human tissues,
particularly cardiac tissues like the myocardium and heart valves.
 This similarity triggers an immune response against these host tissues, resulting in inflammation and
damage, including mitral valve regurgitation.
Option B - Direct toxic effects of bacterial exotoxins: Streptococcal exotoxins are involved in mediating 
scarlet fever. 
Option C - Direct invasion by the organism: The primary mechanism in ARF is not direct invasion by th
e organism but rather an autoimmune response triggered by a previous streptococcal infection. 
Option D - Mechanical obstruction to the valve: While mitral valve regurgitation can increase pressure i
n the left atrium, this pressure does not cause mechanical damage to the valve. Instead, the regurgitati
on is due to valve incompetence resulting from tissue damage.
 
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Correct Option A - Present in myocardium and endocardium only:
 This patient's presentation, including elevated anti-streptolysin O titers and elevated ESR with heart
valve involvement, suggests the diagnosis of acute rheumatic fever. The mitral and aortic valves are
mostly involved, with resultant regurgitations in the acute stages of the disease. 
 The pathology image shows a microscopic view of cardiac tissue stained with H&E; (Hematoxylin and
Eosin).
 Within the myocardium, there are characteristic Aschoff bodies, which appear as granulomatous
nodules containing central fibrinoid necrosis, foci of T lymphocytes, occasional plasma cells, and plump
activated macrophages.
 During acute RF, Aschoff bodies may be found in any of the three layers of the heart, resulting in
pericarditis, myocarditis, or endocarditis (pancarditis).
Option B
- Fibrinoid necrosis in the center: Aschoff bodies typically show fibrinoid necrosis in the center.
Option C - Uncommon in chronic stages: Aschoff bodies are rarely seen in patients with chronic RHD b
ecause of the long intervals between the initial insult and the development of valve deformity. They are 
most often seen only in patients with acute RF.
Option D - Anitschkow cells: Aschoff bodies are indeed surrounded by Anitschkow cells, the plump acti
vated macrophages that have abundant cytoplasm and central round-to-ovoid nuclei (occasionally binu
cleate) in which the chromatin condenses into a
central, slender, wavy ribbon (hence the designation “caterpillar cells”).
Correct Option D - The duration of antibiotic prophylaxis is until 40 years of age or 10 years after the la
st documented attacks, whichever is longer:
 The pansystolic cardiac murmur in this patient with ARF suggests valvular involvement. 
 Secondary antibiotic prophylaxis for acute rheumatic fever with valvular involvement is typically
recommended until the patient reaches 40 or for a minimum of 10 years after the last documented
attack, whichever is longer.
 Prophylaxis typically involves an intramuscular injection of benzathine penicillin every 4 weeks or oral
penicillin V (250 mg) twice daily. Oral penicillin is less effective.
 The goal of this extended prophylaxis is to provide long-term protection against recurrent attacks and
potential complications of rheumatic fever.
Option A - Injections are given up to at least 21 years of age or a minimum of 10 years after the last att
ack, whichever is longer: Secondary prophylaxis of this duration is given to patients with acute rheumat
ic fever with carditis but no residual valvular involvement unlike this patient with a
pansystolic cardiac murmur.
Option B - Injections are given till 21 years of age or 5 years after the last attack, whichever is longer: T
he duration of secondary prophylaxis until 21 years of age or a minimum of 5
years after the last documented attack is given to patients with acute rheumatic fever without carditis.
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Option C - No prophylaxis is required as the disease has already set in: Prophylaxis is recommended f
or individuals with a history of rheumatic fever to prevent recurrent attacks and complications, even if th
e disease has already occurred. It is an essential part of managing the condition and reducing the risk 
of further damage to the heart and other organs.
Correct Option B
- N-Acetyl galactosamine is the cross antigen that reacts with the antibodies responsible:
 The cross antigen involved in acute rheumatic fever and rheumatic heart disease is N-acetyl beta-D
glucosamine.
 It is the antigen common between the cell wall of the streptococcal bacteria and human connective
tissue.
Option A - It is an autoimmune disease caused by type 2 hypersensitivity reaction: Acute rheumatic fev
er is indeed considered an autoimmune disease caused by a Type 2 hypersensitivity reaction, where th
e immune system mistakenly targets self-antigens due to molecular mimicry.
Option C - If untreated, the disease course is up to 12 weeks: The course of acute rheumatic fever is 1
2 weeks if left untreated and 1-2 weeks if treated.
Option D - Primary prevention comprises starting oral penicillin within 9
days of documented infection: When commenced within 9 days of sore throat onset, a course of penicil
lin will prevent almost all cases of ARF that would have otherwise developed. This accurately describe
s the primary prevention strategy. 
Correct Option D - Subcutaneous nodules have a high incidence of 60-70%:
 Subcutaneous nodules and erythema marginatum are the two major skin manifestations in patients
with acute rheumatic fever.
 Subcutaneous nodules are mobile, painless, small (0.5 to 2 centimeters), and usually found over joint
extensor surfaces. They are most commonly present in patients with carditis.
 However, they have a much lower incidence overall, typically less than 5%, and are considered rare
manifestations of ARF.
Option A - Arthritis is the earliest manifestation: In the course of ARF, arthritis is indeed one of the earli
est manifestations and is often an initial symptom, characterized by joint pain and inflammation.
Option B - Sydenham's chorea occurs after 6 months: Sydenham's chorea is a
neurological manifestation of ARF and typically occurs about 6 months after the onset of a sore throat.
Option C - Carditis can occur in 50-75% of the cases: Carditis is a
common manifestation of ARF, and it can occur in a
significant proportion of cases, ranging from 50% to 75%.
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 Up to 60% of patients with acute rheumatic fever (ARF) progress to rheumatic heart disease (RHD).
Any of the three layers of the heart might become affected.
 Valvular damage is the hallmark of the disease. The mitral valve is almost always affected.
 In RHD, the mitral valve leaflets can be damaged, leading to incomplete valve closure during systole.
 This causes blood to flow back into the left atrium (mitral regurgitation).
Correct A
- Aortic stenosis: Aortic valve regurgitation is the second most common cardiac manifestation of ARF. 
Aortic stenosis typically results from calcification or congenital abnormalities rather than RHD.
Option C - Tricuspid stenosis: Tricuspid stenosis is less commonly associated with ARF. Damage to th
e tricuspid valve is secondary to increased pulmonary pressures resulting from left-sided valvular disea
se such as MR.
Option D - Pulmonary hypertension: Pulmonary hypertension is a complication that can occur in severe
 cases of Rheumatic heart disease, especially when there is significant damage to the mitral valve. Ho
wever, it is not a primary cardiac manifestation, and mitral regurgitation is a
more common initial finding in this condition.
Correct Option A - It occurs due to damage in the caudate nucleus:
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Option D - Moderate to severe cases are treated with valproate:
 Valproate is sometimes used in the treatment of moderate to severe Chorea, especially when other
treatments are not effective or if there are contraindications to the use of steroids or IVIG.
Correct Option C - Verrucous Endocarditis:
 Verrucous or Libman-Sacks Endocarditis is commonly associated with systemic lupus erythematosus.
 It results in sterile verrucous lesions on heart valves due to immune complex deposition.
 These sterile fibrofibrinous vegetations occur on the left-sided heart valves and usually form on the
ventricular surface of the mitral valve.
Option A - Rheumatic Heart Disease: Rheumatic Heart Disease (RHD) is typically associated with a his
tory of untreated streptococcal throat infections, not SLE. RHD results in valve deformities such as reg
urgitation and/or stenosis but does not typically involve vegetation.
Option B - Infective Endocarditis: SLE does not predispose to IE unless there are already Libman-Sack
s lesions in the heart.
Option D - Lupus myocarditis: It is characterized by inflammation of the myocardium and can occur in p
atients with SLE. However, it typically presents with symptoms such as chest pain, dyspnea, and signs 
of heart failure rather than new heart murmurs and vegetations on echocardiogram.
Correct Option D - Infective Endocarditis:
 IE is the most likely diagnosis, given the patient's presentation in the presence of structural heart
disease. 
 There are two main pointers in this case.
Option A - Ventricular myxoma: It presents with embolic features and impaired ventricular filling with pu
lmonary edema. 
Option B - Atrial Myxoma: It causes tumor plop sound with embolic features.
Option C - Non-Bacterial Thrombotic Endocarditis (NBTE): NBTE is characterized by thrombus formati
on on heart valves due to hypercoagulable states or systemic diseases, but it is not directly related to i
ntravenous drug use. 
Correct Option C - Community-Acquired Native Valve Endocarditis – Streptococcus:
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 Community-acquired Native Valve Endocarditis is often caused by Streptococcus species.
 Other important associations in IE:
 Gastrointestinal malignancy: Streptococcus gallolyticus
 IV drug users: Staphylococcus auereus
Option A - Early Prosthetic Valve Endocarditis : Staphylococcus saprophyticus: Early Prosthetic Valve 
Endocarditis is often caused by Coagulase-Negative Staphylococcus (CONS), not Staphylococcus sap
rophyticus.
Option B - Late Prosthetic Valve Endocarditis (after 12 months) : Staphylococcus aureus: Late Prosthet
ic Valve Endocarditis, occurring after 12 months, is more commonly associated with Streptococcus spe
cies, not Staphylococcus aureus.
Option D - Hospital-Acquired Native Valve Endocarditis : Coagulase-Negative Staphylococcus (CONS)
: Hospital-acquired Native Valve Endocarditis is typically associated with Staphylococcus aureus, not C
oagulase-Negative Staphylococcus (CONS).
Correct Option B - Pseudomonas:
 This scenario described is of culture-negative infective endocarditis.
 Pseudomonas is not typically associated with infective endocarditis. Pseudomonas aeruginosa is
more commonly associated with other infections, such as respiratory and urinary tract infections, but it
is not a typical causative organism for infective endocarditis, especially in culture-negative cases.
Option A - HACEK group: 
 The HACEK group of organisms, including Haemophilus species, Aggregatibacter species,
Cardiobacterium, Eikenella, and Kingella, is known to be associated with infective endocarditis,
including culture-negative cases. 
Option C - Bartonella: 
 Bartonella species, such as Bartonella henselae, are known to cause infective endocarditis, including
culture-negative cases. These organisms are associated with conditions like cat scratch disease and
can lead to culture-negative results in blood cultures.
Option D - Mycobacterium chimaera:
 While not as commonly associated with classic infective endocarditis, Mycobacterium chimaera can
still be responsible for culture-negative cases, especially in the context of prosthetic valve endocarditis
outbreaks linked to healthcare settings.
 It is relatively rare compared to other causative organisms but can lead to culture-negative results.
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 They are an important feature of RHD and can contribute to valvular abnormalities, such as mitral
stenosis or regurgitation.
Option B: Large and bulky vegetations are more commonly associated with infective endocarditis. IE is 
characterized by the formation of larger, often destructive vegetations on heart valves. These vegetatio
ns are typically composed of microorganisms, platelets, and fibrin.
Option C and D: Nonbacterial thrombotic endocarditis (NBTE) is characterized by the formation of steril
e vegetations on the heart valves. These vegetations primarily consist of fibrin and platelets and are ty
pically seen in the setting of underlying medical conditions, such as malignancies or autoimmune disea
ses. In NBTE, the vegetations tend to be small, bland, and friable. They are often seen on both sides of
 the valve leaflets and can lead to complications such as embolism.
 
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Previous Year Questions
1. A known case of lung cancer presents with breathing difficulty. On auscultation at the left
infrascapular area bronchial breathing is heard with a dull percussion note. What is the diagnosis?
A. Cardiac tamponade
B. Chronic constrictive pericarditis
C. Pulmonary embolism
D. Left-sided pleural effusion
2. Which of the following would not be indicated by the absence of loud S1 in mitral stenosis?
A. Calcified valve
B. Aortic regurgitation
C. First degree heart block
D. Mild mitral stenosis
3. What immunological abnormality is observed due to the absence of CD40 in B cells?
A. Total lack of NK cells
B. Lack of CD8 mediated cytotoxicity
C. Decreased IgG and increase in IgM
D. Inability of neutrophil to act against infections
4. What medication can be administered to a patient who experiences altered consciousness, a blood
pressure reading of 150/90 mm Hg, sweating, rapid heartbeat, persistent erection, and increased saliva
production, after visiting a temple with their grandmother?
A. ASV
B. Adrenaline
C. Steroid
D. Prazosin
5. All of the following are the causes of high output cardiac failure, except?
A. Cor pulmonale
B. Beri beri
C. Anemia
D. Systemic AV shunt
6. Which of the following is seen in Subclinical acute myocarditis?
A. Palpitations
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B. Elevated pro BNP, Trop T
C. Low LVEF on 2D ECHO
D. Elevated creatinine levels
7. Identify the disease?
C. Dilated cardiomyopathy
D. Hypertrophic obstructive cardiomyopathy
8. An intern observed that a patient in the ward was unresponsive, and an ECG which was performed
urgently showed a rhythm as depicted below. DC shock was delivered but the arrhythmia persisted and
the patient is still unresponsive. What is the next best step in the management of this patient?
A. Synchronized cardioversion
B. Start CPR
C. Deliver another DC shock
D. 1 mg epinephrine
9. A 65 year old male patient presented with chest pain, exertional dyspnea and syncope. He was
diagnosed as a case of aortic stenosis and his chest x-ray was taken which is shown below. What is the
most likely diagnosis?
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A. Dilated aortic root
B. Widening of aortic knob
C. Widening of vascular pedicle
D. Post stenotic dilatation of aorta
10. A 5 year old child has flexible fingers and can even touch the back of his hand with his wrist
extended. The child also demonstrates the sign shown in the image below. On auscultation, a click is
heard after S1, followed by a late systolic murmur. What is the probable diagnosis?
A. Ehlers-Danlos syndrome
B. Marfan’s syndrome
C. Loeys-Dietz syndrome
D. Osteogenesis imperfecta
11. The device seen in the following image is?
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A. Cardiac pacemaker
B. Chemo port device
C. Travel tract for accessory
D. Chest x ray artefact
12. Please select the incorrect statement regarding the bundle of Kent.
A. It is faster than AV nodal pathway
B. It is slower than AV nodal pathway
C. Leads to short PR interval
D. Leads to prolonged QRS duration
13. What is the diagnosis of this patient from the ECG shown below?
A. Normal ECG
B. Ventricular fibrillation
C. Ventricular tachycardia
D. Misplaced leads
14. Which organism is most likely responsible for the development of prosthetic valve endocarditis in a
patient following valve replacement surgery?
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A. Staphylococcus epidermidis
B. Staphylococcus aureus
C. Coagulase negative staphylococci
D. HACEK organisms
15. Which of the following conditions is linked to AV block?
A. Hypothyroidism
B. Cushing’s syndrome
C. Hyperthyroidism
D. Pheochromocytoma
16. Identify the following condition:
A. Hydropneumothorax
B. Pleural effusion
D. Pneumothorax
17. Resistant hypertension is defined as?
A. BP >160/90 mmHg with one antihypertensive
B. BP >140/90 mmHg with one antihypertensive
C. BP >160/90 mmHg with three or more antihypertensive
D. BP >140/90 mmHg with three or more antihypertensive
18. What is the optimal approach for treating a patient who is hemodynamically stable, has a broad
QRS complex on their ECG, and is experiencing antidromic tachycardia?
B. Oral Beta-blocker
C. Cardioversion
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D. Intravenous Procainamide
19. Which of the following is an incorrect procedure when dealing with W.P.W?
(or)
Which of the following is not done in W.P.W?
A. Treadmill test
B. Electrophysiological studies
C. Oral beta blocker
D. Procainamide
20. For which of the following conditions is rescue percutaneous coronary intervention (PCI)
performed?
A. Persistent chest pain with ST elevation > 60 min after thrombolysis
B. Persistent chest pain with ST elevation > 30 min after thrombolysis
C. Persistent chest persistent chest pain with ST elevation > 90 min after thrombolysis
D. Pain with ST elevation for > 120 min after thrombolysis
21. What are the effects on the fetus when Indomethacin is used in the uterus during the third
trimester?
A. Patent ductus arteriosus
B. Early closure of ductus arteriosus
D. Atrial septal defect
22. Continuous murmur is heard in?
B. VSD
C. ASD
D. Tetralogy of Fallout
23. What is the waist to hip ratio that is associated with an increased risk of heart disease?
A. > 0.80 in males
B. > 0.80 in females
C. > 0.85 in males
D. > 0.85 in females
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24. Which of the following is not correct about Defibrillation?
A. Only be used by a trained person
B. Decrease in success rate with delay in initiation
C. Improve prognosis
D. 1 minute gap between 2 shocks
25. Which of the following treatment options is not suitable for managing a patient with
non-ST-elevation myocardial infarction (NSTEMI)?
A. Aspirin
B. Clopidogrel
C. Streptokinase
D. Prasugrel
26. What should be the next course of action in managing a patient who presents to the emergency
room with symptoms of palpitation? The patient's pulse is measured at 180 beats per minute and their
blood pressure is 70 mmHg systolic. The electrocardiogram (ECG) reveals a narrow QRS complex
tachycardia with a regular heart rate.
A. DC cardioversion
B. Adenosine
C. Valsalva Maneuver
27. What would be the most appropriate management approach for a patient who arrives at the hospital
within 3 hours of experiencing chest pain, where an ECG shows ST depression in anterior chest leads
and T wave inversion?
A. PCI
B. Thrombolysis with alteplase
C. Prophylaxis for arrhythmia
D. Aspirin with heparin
28. A 45-year-old female patient presents to the clinic with complaints of increasing fatigue and
shortness of breath. Upon auscultation, the physician detects a pan systolic murmur that is best heard
at the right side of the heart. The murmur radiates to the axilla and is louder during inspiration. The
patient denies any history of fever, chest pain, or recent infections. What is the most likely diagnosis for
this patient's condition based on the described findings?
B. Mitral valve prolapse
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29. Correct sequence after p wave: A- ‘a’ wave B – 1st heart sound C – Rapid filling of ventricles D – ‘t’
wave
A. ABCD
B. ABDC
C. CABD
D. ACBD
30. A 68-year-old male admitted to the ICU for acute exacerbation of COPD develops a sudden onset
of palpitations. The following ECG changes are seen. What is the most likely diagnosis?
A. Ventricular tachycardia
B. Multifocal atrial tachycardia
C. Atrial fibrillation
D. Atrial tachycardia
31. Deep y descent in JVP is seen in all except:
B. Restrictive cardiomyopathy
C. Constrictive pericarditis
32. True about the definition of postural hypotension:
A. Decrease in systolic blood pressure 20 mmHg after 6 mins of standing
B. Decrease in systolic blood pressure 20 mmHg after 3 min of standing
C. Decrease in diastolic blood pressure 20 mmHg after 6 mins of standing
D. Decrease in diastolic blood pressure 20 mmHg after 3 mins of standing
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33. The ECG of a pregnant lady having pre-eclampsia is shown below. Her vitals are stable. What is
the best step in the management of the condition?
A. IV calcium
B. IV MgSO4
C. DC shock
D. Synchronized cardioversion
34. What should be the subsequent course of action in managing a patient with the following ECG, who
has already undergone carotid massage and received IV adenosine, but currently has a blood pressure
reading of 60/30 mm Hg upon presentation to the emergency room?
A. Repeat inj adenosine 6 mg
B. Inj amiodarone 300 mg
C. Synchronized cardioversion
D. DC cardioversion
35. What is the most likely diagnosis for an adult patient with a pulsatile swelling in the neck below the
jaw angle that causes an outward expansile impulse, based on the findings of an MRI angiography?
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A. Grave’s disease
B. Branchial cyst
C. Thymic cyst
D. Carotid body tumour
36. Identify the tachycardia depicted in the given ECG.
D. Ventricular fibrillation
37. Identify the diagnosis:
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38. What is the most likely diagnosis for a 45-year-old man who experiences chest pain and difficulty
breathing that worsens when lying down but improves when sitting upright, and has muffled heart
sounds during examination?
A. Pericardial effusion
B. Tetralogy of Fallot
C. Transposition of great arteries
39. Which is the best confirmatory method to ensure the central line is in the jugular vein?
A. Chest x-ray
B. Blood pH
C. Blood color
D. ETCO2
40. What is the purpose of using the Modified Duke Criteria in diagnosing?
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A. Infective endarteritis
B. Infectious mononucleosis
C. Inflammatory myopathy
D. Infective endocarditis
41. Which medication could be the cause of recurrent falls in an elderly male patient?
A. Prazocin
B. Metformin
C. Acarbose
D. Thiazide
42. In the New York Heart Association functional classification, what category does a person with
dyspnea belong to if they experience mild restrictions in physical activity and develop symptoms during
ordinary activities, but remain symptom-free while at rest?
A. Class I
B. Class II
C. Class III
D. Class IV
43. What is the probable diagnosis for a 55-year-old male patient who came to the hospital complaining
of palpitations, and during examination, a diastolic murmur is detected in the left third intercostal space,
along with the presence of a pistol shot sound over the femoral arteries?
A. Aortic regurgitation
B. Aortic stenosis
C. Tricuspid regurgitation
44. A 25-year-old patient with caries is scheduled for a dental extraction. Which of the following cardiac
conditions does not requires endocarditis prophylaxis prior to dental extraction?
A. Prior history of endocarditis
B. Atrial septal defect
C. Unrepaired cyanotic heart disease
D. Prosthetic heart valves
45. A patient presents to you with an irregularly irregular pulse of 120 beats/minute and a pulse deficit
of 20. Which of the following would be the jugular venous pressure (JVP) finding?
A. Absent p wave
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B. Absent a wave
C. Cannon a wave
D. Raised JVP with normal waveform
46. An 11-year-old child with a history of streptococcal pharyngitis presents to you with fever and
arthralgia. There is no past history of rheumatic heart disease or features of carditis or valvular disease.
The child weighs 25 kgs. How often is 6,00,000 IU of benzathine penicillin recommended for
prophylaxis of rheumatic heart disease?
A. Immediately
B. Thrice weekly lifelong
C. Once in four weeks for 5 years or till the age of 21, whichever is longer
D. Once in three weeks for 10 years or till the age of 25, whichever is longer
47. A 74-year-old patient with CAD presents with palpitations. ECG is shown below. Blood pressure is
120/84 mmHg. Which of the following is the best treatment for this patient?
A. Oral metoprolol
B. Oral amiodarone
C. Intravenous amiodarone
D. Intravenous metoprolol
48. A hypertensive patient who is non-compliant with medication presents to you with sudden onset
breathlessness. A chest x-ray was done, which is shown below. How will you manage this patient?
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A. Intravenous salbutamol
B. Intravenous nitro-glycerine
C. Nebulization with salbutamol
D. Oxygen and antibiotics
49. A patient on anti-depressants presented to you with hypotension. An ECG was done, which showed
wide QRS complexes and right axis deviation. How will you manage this patient?
A. Antiarrhythmics
B. Intravenous sodium bicarbonate
C. Propranolol
D. Wait and watch
50. Which of the following conditions is characterized by the absence of P waves?
B. Focal atrial tachycardia
C. Ventricular fibrillation
D. Atrial fibrillation
51. Interpret the ECG given below.
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A. Ventricular fibrillation
C. Supra ventricular tachycardia
52. J-wave is seen in?
A. Hypothermia
B. Heat stroke
C. High-altitude pulmonary edema
D. Drowning
53. A 26-year-old male patient, an accident victim started developing difficulty in breathing. On
examination, his BP as 80/40 mmHg and pulses were feeble, JVP was found to be elevated with an
absent Y descent, and heart sounds were muffled. What is the most likely diagnosis?
A. Constrictive pericarditis
B. Cardiac tamponade
C. Acute pericarditis
D. Cardiac failure
54. A known hypertensive patient is brought to the ER with palpitations and breathlessness. On
examination, his BP was 220/140 with signs of encephalopathy. All of the following can be used to treat
this condition except?
A. IV Nicardipine
B. IV Mannitol
C. IV Esmolol
D. IV Sodium Nitroprusside
55. A patient with chronic stable angina is having signs of heart failure. The use of which of the
following drugs can decrease mortality?
A. Nifedipine
B. Digoxin
C. Lisinopril
D. Torsemide
56. What is the probable diagnosis based on the ECG given below?
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C. Hypothermia
D. Hypocalcemia
57. A 19-year-old woman with no comorbidities presented with numbness and paraesthesia of the
fingers along with the characteristic finding shown in the image below. She has no other illnesses, and
she says these episodes occur when she is under excess stress or during cold temperatures. What is
A. Primary Raynaud’s phenomenon
B. Secondary Raynaud’s phenomenon
C. Cold sores
D. Scleredema
58. Identify the false statement regarding management of NSTEMI
A. Aspirin loading dose should be initated immediately
B. ACC/AHA guidelines call for either a P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) as a class I
recommendation
C. Glycoprotein IIB/IIIA inhibitors are useful adjuncts
D. Fibrinolytic therapy is useful in acute coronary syndrome without ST-segment elevation
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59. What is the diagnosis of a patient who exhibits dyspnea and increased distension of neck veins
upon inspiration, with no murmur detected?
D. Pulmonary arterial hypertension
60. Which medications decrease mortality in individuals suffering from heart failure?
A. Metoprolol
C. Prazosin
61. Please determine the medical condition related to the image provided.
C. Aortic stenosis
D. Mitral stenosis
62. What is the most likely condition for a male patient who has been experiencing limb weakness and
sensory loss for 3 months, along with angular stomatitis? In the examination, the patient shows a lack
of proprioception and vibration sensations, upper motor neuron (UMN) type weakness in the lower
limbs, and no ankle reflex.
A. Extradural cord compression
B. Amyotrophic lateral sclerosis
C. Multiple sclerosis
D. Subacute combined degeneration of cord
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63. A 40-year-old female patient presents with palpitations and difficulty in breathing. Auscultation
(or)
64. In a patient who is a chronic smoker, bilateral pitting pedal edema and abdominal distension were
observed. Further examination showed the presence of ascites and an S3 sound during auscultation.
What are the possible defects that can be observed in this patient?
B. Tricuspid regurgitation
65. Which of the following does not cause central cyanosis?
66. Which one of the following medications is not employed for the urgent (immediate) treatment of
hyperkalemia?
A. 10% calcium gluconate over 10 min
B. Salbutamol nebulisation
C. Insulin-dextrose
D. Injection MgSO4
67. Identify the conduction abnormality form the ECG give below?
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A. First degree heart block
B. Ventricular tachycardia
C. Third degree heart block
D. Second degree heart block
68. Which of the following is a contraindication for thrombolysis?
A. MRI showing density in less than 1/3rd of the area supplied by MCA
B. Blood pressure of more than 185/110 mmHg
C. Ischemic stroke within 2 hours
D. Onset of symptoms <4 hours
69. Which of the following is the initial treatment of choice for managing the condition in a female
patient who comes to the hospital with palpitations, having stable vital signs and an ECG showing the
following?
C. DC cardioversion
D. Primary PCI
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70. A patient with heart disease has breathlessness on going to the bathroom. What grade does he
belong to?
A. NYHA 3
B. NYHA 4
C. mMRC 4
D. mMRC 5
71. Based on the ECG given below, which of the following is not used in the management of the
A. Verapamil
B. Metoprolol
D. Non synchronised DC shock
72. A female patient presents to the AIIMS emergency department with severe fatigue. She is a known
case of chronic stable angina. While collecting a blood sample, you notice the blood has a brownish
hue. What is the underlying diagnosis?
A. Carboxy-hemoglobinemia
B. Sideroblastic anaemia
C. Methemoglobinemia
D. Sulfhemoglobinemia
73. Which of the following are signs of heart failure? Non-pulsatile rise of JVP Orthopnoea Dyspnoea
after 2 hours of sleep Right upper quadrant pain/right hypochondrial pain
A. 1 and 2
B. 1,2,3
C. 2,3,4
D. 1,3,4
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74. What is the antibody linked to the condition in which a 35-year-old woman experiences skin
thickening, muscle weakness, pale peripheries upon cold exposure, increased creatine kinase with
positive ANA, and biopsy revealing scl-70 positivity and perifascicular infiltration?
A. Anti PM scl antibody
B. Anti Jo1 antibody
C. Anti centromere antibody
D. Antinuclear antibody
75. What is the correct order for cardiac auscultation, from superior to inferior? a. Pulmonary b.
Tricuspid c. Mitral
A. a > b > c
B. b > a > c
C. c > a > b
D. c > b > a
76. What is the ECG depicted in the following image?
A. Pericarditis
B. Viral myocarditis
C. Torsades de pointes
D. Cardiac tamponade
77. Which of the following describes aortic regurgitation murmur?
A. Ventricular contraction
B. Ejection systolic murmur
D. Systolic murmur
78. A 20-year-old woman presents with breathlessness and chest pain. She is a known case of mitral
stenosis. Her pulse is irregularly irregular. No thrombus is seen on echocardiography. What is the best
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agent to prevent future thrombotic events?
A. Dabigatran
B. Aspirin 150mg
C. Oral warfarin
D. Aspirin + Clopidogrel
79. Evaluation of a patient revealed the presence of mild diastolic murmur. JVP showed prominent
a-waves. What is the likely diagnosis?
80. A 45 year old woman with a history of hypertension presented to the emergency room with loss of
consciousness, chest pain, and diaphoresis. On examination, she was unstable, and the bilateral
pulses were unequal. ECG showed nonspecific ST-T changes. Which of the following is particularly
useful in evaluating the function and integrity of cardiac valves?
A. MRI
B. Transoesophageal echocardiography
C. Cardiac enzymes
D. X-ray
81. What is the probable diagnosis for a male patient who presents with weak femoral pulses and an
upper-limb blood pressure reading of 186/90 mmHg, along with an enlarged intercostal arteries seen
on a chest x-ray?
C. Bicuspid aortic valve
D. Patent ductus arteriosus
82. A 50-year-old man presents with a history of recurrent retrosternal chest pain with each episode
lasting for 3-5 min and subsiding with sublingual nitrate. ECG shows left ventricular hypertrophy and flat
T-wave. He is a known case of hypertension, diabetes mellitus, and hypercholesterolemia currently on
aspirin, atenolol, metformin, and lovastatin. What is the next best step in management?
A. IV glyceryl trinitrate infusion
B. Injection enoxaparin
C. Add clopidogrel
D. Increase the dose of beta blocker
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83. What condition is linked to Dilated Cardiomyopathy?
A. Diphtheria
B. Syphilis
C. Meningococcus
D. Brucellosis
84. PR segment in ECG indicates
A. Atrial depolarization
B. Atrioventricular nodal conduction
C. Ventricular depolarization
D. Ventricular repolarisation
85. Which heart sound is always pathological?
A. S1
B. S2
C. S3
D. S4
86. In which of the following conditions is water hammer pulse observed?
C. Aortic stenosis and aortic regurgitation
87. What is the likely diagnosis for a 70-year-old man who has a medical history of diabetes mellitus
(DM) and hypertension (HTN), takes regular medication, and is now experiencing increasing difficulty
breathing during physical activity? Upon examination, the patient has an elevated jugular venous
pressure (JVP), positive hepatojugular reflux, crackling sounds in the lower lungs, an enlarged liver,
fluid buildup in the abdomen (ascites), and swelling in the feet (pedal edema).
A. Heart failure
B. Hypertrophic cardiomyopathy
D. Portal hypertension
88. Which one of the following is not an identifiable radiological observation in a patient experiencing
left heart failure?
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A. Kerley b lines
B. Focal oligemia
C. Increased venous blood in lung
D. Change in upper lobe circulation
89. A 60-year-old man presented with an episode of acute onset dizziness and loss of consciousness
which lasted for a few seconds followed by a regain of full consciousness. There were no similar
episodes in the past. Which of the following is a true statement regarding this scenario?
A. ECG to rule out atrial fibrillation
B. If ECG is normal, CT scan should be done
C. Tilt-table testing
D. Vestibular neuritis is a possible condition that can cause these symptoms
90. What is the probable diagnosis for an overweight elderly man who arrived at the emergency
department with intense chest pain lasting for two hours? He also experienced excessive sweating,
pain in the left arm, nausea, and one instance of vomiting. During examination, his pulse rate was
recorded as 58 beats per minute and his blood pressure was 90/60 mm of Hg. An electrocardiogram
(ECG) was conducted and revealed the following results. Additionally, the patient's cardiac biomarkers
indicated increased troponin levels.
A. Anterior wall
B. Inferior wall MI
C. Posterior wall MI
D. Pericarditis
91. What is the diagnosis if the axis is on the mark “?” from the diagram shown below?
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92. Please determine the rhythm displayed in the provided ECG rhythm strip.
C. Normal sinus rhythm
D. AV block
93. An intern observed that a patient was unresponsive, and an ECG which was performed urgently
showed an arrhythmia as below. DC shock was delivered but the arrhythmia persisted, and the patient
is still unresponsive. What is the next best step in the management of this patient?
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D. 1 mg epinephrine IV
94. Tall and tented T waves, wide QRS, and absent P wave are features of:
A. Bundle branch block
B. Acute MI
C. Hyperkalemia
D. Ventricular ectopic
95. In order to diagnose resistant hypertension, the patient must have uncontrolled high blood pressure
even after being treated with three different antihypertensive medications. One of these medications
should be:
A. Calcium channel blocker
B. Beta-blocker
C. Alpha blocker
D. Diuretic
96. Which of the following foods is not included in the DASH diet?
A. Rich in potassium
B. Rich in calcium
C. Rich in sodium
D. Rich in magnesium
97. A 68-year-old male presents with palpitations and shortness of breath. His medical history includes
hypertension, diabetes, and coronary artery disease. On examination, irregularly irregular heartbeats
are noted. An electrocardiogram (ECG) reveals irregularly irregular rhythm, no P waves, and absence
of an isoelectric baseline. His blood pressure is 132/84 mmHg, heart rate 130 bpm, and oxygen
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saturation 94% on room air. Given the patient's clinical presentation and history, which of the following
treatment options should be considered as a first-line approach for managing this case?
C. Electrical cardioversion
D. Direct oral anticoagulant (DOAC) therapy
98. Which of the following statements about heart failure is false? HFpEF refers to heart failure in which
the ejection fraction is preserved, while HFrEF refers to heart failure with a reduced ejection fraction.
A. Regardless of ejection fraction and the type of heart failure, the 5-year mortality rate is around 50%
B. Non-cardiovascular death is more in HFpEF-30-40% as compared to HFrEF-15%
C. Angiotensin-converting enzyme (ACE) inhibitors cause cough in 15% and angioedema in 1%
D. Atrial fibrillation is common in the elderly and is the cause of stroke in a quarter of the stroke cases
99. A patient has presented with features of cardiac tamponade. Which of the following is correct
regarding this condition?
A. Pulsus Paradoxsus is always present
B. Kussmaul sign is always present
C. Tall A wave is present
D. Jugular veins column is visibly distended without pulsations
100. What is the clinical diagnosis for a young male who has no symptoms but is found to have a wide
fixed split S2 during auscultation?
A. ASD
B. VSD
C. TOF
D. BAV
101. A chronic smoker presented with shortness of breath, bilateral pitting pedal edema, and abdominal
distension. On examination, jugular venous pulse was found to be elevated and liver was palpable 8 cm
below the costal margin. An abnormality in which of the following structures is responsible for the
patient’s symptoms?
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A. 1
B. 2
C. 3
D. 4
102. A 47 year old woman was brought to the casualty in an unconscious state after having suddenly
collapsed. As there was no pulse, cardiopulmonary resuscitation was started and the monitor showed
the following rhythm. What is the next step?
A. Defibrillation
B. Synchronized cardioversion
C. 1mg epinephrine
D. 0.5mg atropine
103. Pulsus paradoxus is seen in:
A. Coronary artery disease
B. Severe Asthma or Chronic Obstructive Pulmonary Disease
D. Right ventricular myocardial infarction
104. Takayasu arteritis most commonly involves:
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A. Pulmonary artery
B. Coronary arteries
C. Abdominal aorta
D. Arch of aorta
105. A 64-year-old man presents with complaints of palpitations and syncope. He has a history of
inferior-wall myocardial infarction a year ago. Holter study was done and his 24 hour ECG strip
obtained is given below. What is the long-term treatment for this condition?
B. Atropine only
C. Permanent pacemaker
D. Atropine and isoproterenol
106. A 50-year-old man presents with recurrent episodes of chest pain which is seen only on exertion
or exercise and lasts 2-5 minutes. He was assessed and was diagnosed with a case of stable angina
however his BP was consistently elevated. What is the most appropriate antihypertensive for this
patient?
A. Atenolol
B. Thiazides
C. Enalapril
D. Amlodipine
107. Which of the following is the most appropriate position for placement of pacemaker leads?
A. Right ventricle
B. Left atrium
C. Left ventricle
D. Superior vena cava
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108. A postoperative cardiac surgery patient developed sudden hypotension, raised central venous
pressure, pulsus paradoxus at the 4th post operative hour. The most probable diagnosis is.
A. Ventricular dysfunction
C. CHF
D. Excessive mediastinal effusion
109. What is the most probable diagnosis for a female patient, aged 65, who visits the outpatient
department with symptoms of breathlessness and fatigue? During examination, the patient's neck veins
were engorged, and her jugular venous pulse displayed a swift X and Y descent.
D. Restricted cardiomyopathy
110. A female patient with fever and malar rashes was found to have vegetations on either side of the
heart valves. What can be the diagnosis of the patient?
A. Infective endocarditis
B. Libman sacks endocarditis
C. Rheumatic Heart Disease
D. None of the above
111. A 50 year old lady with hypertension is brought with shortness of breath and dyspnea on exertion
for the past week. Physical examination reveals the presence of elevated jugular venous pressure and
crepitations in the lungs along with palpable liver 3 cm below the costal margin. The image of her legs
is given below what is the finding called?
A. Superficial venous thrombosis
B. Deep vein thrombosis
C. Clubbing
D. Pitting pedal edema
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112. Which cardiac chamber enlargement is seen in the case of mitral stenosis on chest x-ray initially?
A. Left atrium
B. Right atrium
D. Right ventricle
113. Osborn waves in ECG are seen in:
B. Hypothermia
C. Hypocalcaemia
D. Hypokalaemia
114. Which of the following murmur increases on standing?
A. HOCM
B. MR
C. MS
D. VSD
115. A 40 year old male patient came to ED with complaints of weakness, paresthesia, and breathing
difficulty. Relevant investigations were done. The ECG obtained is suggestive of:
A. Hypokalaemia
C. Hypocalcemia
D. Hypercalcemia
116. What is grade 2 hypertension values according to the American Heart Association?
A. >130/80 mmHg
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B. ≥140/90 mmHg
C. >150/96 mmHg
D. ≥160/100 mmHg
117. A 65 year old female patient is brought to the emergency department in a state of
unconsciousness. Her BP is 70/50 mm of Hg. Her ECG is shown below. What is the next best step in
the management of her condition?
A. IV verapamil
B. IV adenosine
C. Carotid massage
118. The observed myocardial stunning pattern does not match the patient's ECG findings. What is the
probable diagnosis?
A. Takotsubo cardiomyopathy
C. Brugada syndrome
D. Pericardial tamponade
119. For which of the following conditions is automatic implantable cardioverter-defibrillator (AICD)
implantation performed?
A. Brugada syndrome
C. Acute coronary syndrome with low ejection fraction
D. All the above
120. Who is classified as a category III non-heart-beating donor?
A. Dead on arrival
B. A patient who died after failed resuscitation after reaching the hospital
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C. A patient who was bought dead to the hospital
D. A patient who is awaiting cardiac arrest in the hospital
121. In which electrolyte abnormality is Pseudo P pulmonale observed?
B. Hyponatremia
122. A 50-year-old man was brought to the emergency in an unconscious state. He had a fever for the
past two days and is a known case of severe COPD. His ECG is given below. What is the most likely
123. Which of the following is used in the treatment of late cardiovascular syphilis?
A. Benzathine penicillin 2.4 million units weekly for three weeks
B. Benzathine penicillin 2.4 million units as single dose
C. Benzathine penicillin 12-24 million units for 21 days
D. Tetracycline 2g daily
124. Which of the following is NOT a component of Syndrome Z?
A. HDL cholesterol <40mg/dL in men
B. Blood pressure more than 130/85 mmHg
C. Fasting triglyceride of more than 150 mg/dl
D. LDL more than 100mg/dl
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125. Two brothers were arguing over a property dispute when the elder of the two complained of chest
pain and collapsed and was later declared brought dead by the hospital. His family says he was
previously healthy and there was no similar disease in the family members. What is the likely
A. Infective cardiomyopathy
B. Takotsubo cardiomyopathy
C. Acute myocardial infarction
D. Hypertrophic cardiomyopathy
126. 'a' wave in JVP corresponds to?
A. Right atrial contraction
B. Closure of tricuspid valve
C. Onset of ventricular systole
D. Maximal atrial filling
127. Relative bradycardia occurs in:
A. Typhoid fever
B. Q fever
C. Leptospirosis
D. All of the above
128. What is the distinguishing characteristic that sets apart cardiac tamponade and tension
pneumothorax?
A. Breath sounds
B. Muffled heart sounds
C. Increased heart rate
D. Raised JVP
129. Which electrocardiogram lead would display the highest R wave amplitude when the cardiac axis
is positioned at +90 degrees?
A. Lead aVF
B. Lead aVL
C. Lead I
D. Lead II
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130. A 70 year old man collapsed in his house and was rushed to the hospital. On arrival, his ECG
tracing was as shown below. Which of the following is the best intervention for this patient?
A. Use of automated external defibrillator
B. Injection of vasopressin 40 IU
C. Injection of Adrenaline 1mg IV
D. Injection of Atropine 0.5mg IV
131. An intern is asked to measure the blood pressure of a patient with cardiac tamponade. He/she
should ask the patient to:
A. Hold breath
B. Take rapid shallow breaths
C. Take long deep breaths
D. Breathe normally
132. What is the potential risk of adding verapamil to a hypertensive patient already on metoprolol?
B. Bradycardia with AV block
C. Tachycardia
D. Torsades de pointes
133. What is the duration of the HV interval observed in the his bundle electrogram for conduction?
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A. Through His – Purkinje system
B. From AV node to bundle of His
C. Purkinje to ventricular fibers
D. From bundle of His and bundle branches to ventricles
134. Which investigation is the most suitable for diagnosing myocardial infarction (MI) within a
timeframe of 2-4 hours, as reported by a patient with chest pain?
A. LDH
B. CKMB
C. Troponin-T
D. BNP
135. High anion gap acidosis with low bicarbonate levels is seen in all of the following conditions
except:
A. Renal disorders
B. Diabetic ketoacidosis
C. Lactic acidosis
D. Salicylate poisoning
136. All are true about steps followed in management of ventricular fibrillation except?
(or)
A 56-year-old unresponsive male was brought to the ER with GCS less than 7 and ECG shows
ventricular fibrillation. All are true about steps followed in the management of ventricular fibrillation
except?
A. CPR cycle duration is 2 minutes
B. Chest compressions at 100-120/min
C. Start CPR followed by immediate defibrillation
D. Rescue breaths 15:2
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137. In a 55-year-old male who arrives at the emergency department, symptoms of chest pain,
sweating, nausea, and difficulty breathing have been experienced for the past four hours. The patient
has a smoking history of one pack per day for 20 years and no previous medical conditions. Upon
examination, the patient's pulse is recorded at 76 beats per minute, and blood pressure measures
110/70 mmHg. An electrocardiogram (ECG) has been performed and is provided below. Based on the
information provided, what is the most probable diagnosis for this patient?
A. Prinzmetal angina
B. Myocardial ischemia
D. Hyperkalemia
138. Which of the following medications does not decrease mortality in a 70-year-old male patient
diagnosed with heart failure and an ejection fraction
B. Digoxin
D. K+ sparing diuretics
139. Which of the following leads to a continuous murmur?
A. Peripheral Pulmonic stenosis
B. Severe Pulmonary artery hypertension
C. Type A aortic dissection
D. Rupture of cardiac chamber
140. What is a valid statement concerning Postural Hypotension?
A. Decrease in systolic blood pressure 20 mm Hg within 6 mins of postural change
B. Decrease in systolic blood pressure 20 mm Hg within 3 mins of postural change
C. Decrease in diastolic blood pressure 20 mm Hg within 6 mins of postural change
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D. Decrease in diastolic blood pressure 20 mm Hg within 3 mins of postural change
141. What is the most accurate and distinctive marker for Myocardial Infarction (MI)?
A. Troponin
B. Cytokeratin
C. Myoglobin
D. CPK- MM
142. A 62 yr old man came to the hospital with a complaint of recurrent fainting episodes. His ECG
shows P waves at 75/min, and QRS complexes duration is normal at 35 beats/min. The clinical
diagnosis is?
A. 2nd degree AV block
B. Atrial tachycardia
C. First-degree AV block
D. Stokes adams syndrome
143. A Patient has muffled heart sounds with low blood pressure. Correct JVP finding is?
A. Steep x descent
B. Absent y descent
C. Steep y descent
D. Blunted x descent
144. A young male patient presents with sudden onset chest pain for one hour with ECG showing STE
in lead 2,3 and aVf. Which is the best treatment for this case of inferior wall MI in a multispeciality
hospital?
A. Alteplase
B. Streptokinase
C. Primary angioplasty
D. Dabigatran
145. A 55-year-old lady presents with complaints of dizziness and palpitations. ECG was done and is
shown below. What is the best treatment?
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A. Adenosine
C. Beta-blocker
D. Valsalva maneuver
146. A 52-year-old lady develops sudden onset facial deviation with slurring of speech and inability to
raise her right arm. The symptoms spontaneously begin to reduce and get completely resolved over the
next 48 hours. She has a mid-diastolic murmur on auscultation in the left side of the heart and an
irregular heart rhythm. What is the diagnosis?
A. T.I.A
B. Thrombo-embolic stroke
C. Cardio embolic stroke
D. Paradoxical embolism
147. A lady with mitral stenosis develops sudden onset respiratory difficulty, limb edema, and pain in
the calves. What is the clinical diagnosis in this patient?
A. Pulmonary embolism
B. Pulmonary edema
C. Cerebral embolism
148. All of the following conditions will have an elevated JVP that rises with deep inspiration except?
A. HOCM
B. Constructive pericarditis
C. Cor pulmonale
D. Restrictive cardiomyopathy
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Question 1 1
Question 3 3
Question 9 4
Question 14 1
Question 16 1
Question 17 4
Question 18 4
Question 19 1
Question 20 3
Question 21 2
Question 22 1
Question 23 4
Question 24 4
Question 25 3
Question 26 1
Question 27 4
Question 28 4
Question 29 2
Question 30 2
Question 31 1
Question 32 2
Question 33 2
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Question 34 3
Question 35 4
Question 36 2
Question 37 3
Question 38 1
Question 39 1
Question 40 4
Question 41 1
Question 42 2
Question 43 1
Question 44 2
Question 45 2
Question 46 3
Question 47 3
Question 48 2
Question 49 2
Question 50 4
Question 51 3
Question 52 1
Question 53 2
Question 54 2
Question 55 3
Question 56 3
Question 57 1
Question 58 4
Question 59 1
Question 60 1
Question 61 1
Question 62 4
Question 63 2
Question 64 2
Question 65 4
Question 66 4
Question 67 4
Question 68 2
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Question 69 2
Question 70 1
Question 71 4
Question 72 3
Question 73 3
Question 74 1
Question 75 1
Question 76 3
Question 77 3
Question 78 3
Question 79 2
Question 80 2
Question 81 1
Question 82 2
Question 83 1
Question 84 2
Question 85 4
Question 86 2
Question 87 1
Question 88 2
Question 89 1
Question 90 2
Question 91 1
Question 92 3
Question 93 2
Question 94 3
Question 95 4
Question 96 3
Question 97 2
Question 98 2
Question 99 4
Question 100 1
Question 101 4
Question 102 1
Question 103 2
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Question 104 4
Question 105 3
Question 106 4
Question 107 1
Question 108 2
Question 109 1
Question 110 2
Question 111 4
Question 112 1
Question 113 2
Question 114 1
Question 115 1
Question 116 4
Question 117 4
Question 118 1
Question 119 4
Question 120 4
Question 121 1
Question 122 2
Question 123 1
Question 124 4
Question 125 2
Question 126 1
Question 127 4
Question 128 1
Question 129 1
Question 130 3
Question 131 4
Question 132 2
Question 133 4
Question 134 3
Question 135 1
Question 136 4
Question 137 2
Question 138 2
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Question 139 1
Question 140 2
Question 141 1
Question 142 4
Question 143 2
Question 144 3
Question 145 1
Question 146 1
Question 147 2
Question 148 1
option a.
 Dullness to percussion and decreased breath sounds near the base of the left lung infra-scapular
location are characteristic findings in cardiac tamponade.
 Cardiac tamponade is a medical emergency that occurs when fluid accumulates in the pericardial
space, compressing the heart and impairing its ability to pump blood effectively. As a result, patients
with cardiac tamponade may present with symptoms such as shortness of breath, chest pain,
tachycardia, and hypotension. Normal SBP falls < 10 mm Hg on deep inspiration if it falls  > 10 mmHg
(in the case of cardiac tamponade) this is known as Pulsus paradoxus.
 Beck's Triad BP fall: Obstructive shock (IV fluid contraindicated) JVP: Elevated, non-pulsatile,
Kussmaul sign is absent S1S2 muffled/distant
 BP fall: Obstructive shock (IV fluid contraindicated)
 JVP: Elevated, non-pulsatile, Kussmaul sign is absent
 S1S2 muffled/distant
 
Incorrect Choices:
b. Chronic constrictive pericarditis involves the chronic inflammation and fibrosis of the pericardium, lea
ding to the thickening and stiffening of the pericardial sac. Patients with chronic constrictive pericarditis 
may present with symptoms such as dyspnea, fatigue, and peripheral edema. However, they are unlike
ly to have dullness to percussion and decreased breath sounds near the base of the left lung infra-scap
ular location.
c. Pulmonary embolism is a blockage of one or more pulmonary arteries by a blood clot, which can lea
d to symptoms such as dyspnea, chest pain, and tachycardia. However, patients with pulmonary embol
ism are more likely to have findings such as tachypnea, pleuritic chest pain, and clear breath sounds o
n auscultation.
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d: Left-sided pleural effusion involves fluid accumulation in the pleural space on the left side of the che
st, leading to symptoms such as dyspnea and chest pain. However, dullness to percussion and decrea
sed breath sounds are more commonly observed at the base of the affected lung, regardless of the loc
ation.  
Correct Option B - Aortic regurgitation:
 This option is correct because aortic regurgitation is unrelated to the production of the first heart
sound (S1). Aortic regurgitation involves the leakage of blood back into the left ventricle during diastole,
and it does not directly affect the closure of the mitral valve or the production of S1. Therefore, the
absence of a loud S1 sound is not indicative of aortic regurgitation.
Option A - Calcified valve: This option is incorrect because a
calcified valve in mitral stenosis can restrict the movement of the valve leaflets and result in a
reduced or absent opening snap (OS), leading to a softer S1 sound. Therefore, the absence of a
loud S1 sound is consistent with a calcified valve in mitral stenosis.
Option C - First degree heart block: The intensity of the first heart sound (S1) is decreased in patients 
with first-degree heart block. Therefore, the absence of loud S1 is consistent with first degree heart blo
ck.
Option D - Mild mitral stenosis: In mitral stenosis, the presence of a loud first heart sound (S1) is a
characteristic finding. Therefore, the absence of a
loud S1 sound would be inconsistent with mitral stenosis. A loud S1 is produced by mobile but stiff mitr
al leaflets unless the leaflets are substantially calcified. Since elevated left atrial pressure has maintain
ed the leaflets' rather wide spacing, the loud S1 is mostly caused by increased leaflet excursion during 
closure.
Correct Option C - Decreased IgG and increase in IgM:
 The lack of CD40 in B cells leads to an immunological abnormality known as Hyper-IgM syndrome.
 CD40 is a crucial co-stimulatory molecule required for the interaction between B cells and T cells
causing the generation of high-affinity antibodies, class switching, and memory B cell formation.  
 The lack of CD40 in B cells results in decreased IgG and IgA production, and an increase in IgM
production, which leads to an immunological abnormality characterized by a decreased ability to mount
an effective immune response against infections.
 Options A, B and D are incorrect.
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Correct Options D: Prazosin
 In the scenario described, the symptoms of altered sensorium, elevated blood pressure, sweating,
palpitations, priapism, and mouth secretion are consistent with a condition known as hypertensive crisis
or sympathomimetic crisis, which can be caused by excessive release or use of certain stimulant drugs
(e.g., amphetamines, cocaine). Prazosin, as an alpha-1 blocker, can help counteract the effects of
excessive sympathetic stimulation and lower blood pressure.
Incorrect options:
Options A:  ASV (Anti-snake venom): ASV is a specific treatment used for snakebite envenomation an
d is not indicated in the scenario described. The symptoms mentioned (altered sensorium, elevated blo
od pressure, sweating, palpitations, priapism, and mouth secretion) are not consistent with a
snakebite. Therefore, ASV would not be the appropriate treatment in this case.
Options B: Adrenaline (Epinephrine): Adrenaline is a hormone and medication that acts on the sympat
hetic nervous system. It is commonly used in emergency situations to treat severe allergic reactions (a
naphylaxis) and cardiac arrest. While some of the symptoms described, such as elevated blood pressu
re, palpitations, and sweating, may be associated with an adrenaline surge, it would not be the first-line
 drug of choice for this particular scenario.
Options C:  Steroid: Steroids, such as corticosteroids, have anti-inflammatory and immunosuppressive 
effects. They are used in various medical conditions, including allergic reactions, autoimmune diseases
, and asthma. However, the symptoms described in the scenario do not suggest an immediate need for
 steroids as the first-line treatment.
Correct Option A: Cor pulmonale
 Cor pulmonale, also known as pulmonary heart disease, is a condition characterized by right-sided
heart failure secondary to lung disorders, such as chronic obstructive pulmonary disease (COPD) or
pulmonary hypertension. Cor pulmonale is typically considered a cause of low output cardiac failure
rather than high output cardiac failure. In cor pulmonale, the right ventricle becomes enlarged and weak
due to increased pulmonary vascular resistance or chronic lung disease.
Option B: Beri beri:
 Beri beri is a nutritional deficiency disorder caused by a deficiency of thiamine (vitamin B1). Thiamine
is necessary for the proper functioning of the heart and nervous system. In severe cases of thiamine
deficiency , wet beri can develop. High-output cardiac failure occurs due to decreased vascular
resistance from vasodilation and the opening of AV shunts in the musculature. The combination of
decreased vascular resistance and dilated cardiomyopathy leads to high-output cardiac failure.
Option C: Anemia:
 Anemia leads to a reduced oxygen-carrying capacity of the blood, which stimulates an increase in
cardiac output to compensate for the decreased oxygen delivery. This increased cardiac output can
lead to high-output cardiac failure.
Option D: Systemic AV shunt:
 A systemic arteriovenous (AV) shunt is an abnormal connection between an artery and a vein in the
body, bypassing the normal capillary network. This can occur in conditions such as arteriovenous
malformations (AVMs) or large arteriovenous fistulas. In a systemic AV shunt, blood bypasses the
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capillaries and returns to the venous system without undergoing proper oxygen and nutrient exchange.
This leads to increased blood flow and high-output cardiac failure.
Correct Option B - Elevated pro-BNP, Trop T:
 Myocarditis encompasses a spectrum of immune-mediated processes affecting the heart,
characterized by lymphocyte and macrophage involvement, and antibody-mediated injury. This can
lead to structural and functional abnormalities in cardiomyocytes, resulting in contractile impairment,
chamber stiffness, or conduction system issues.
Criteria
Histological confirmation
Biomarker, ECG, or imaging abnormalities consistent with myocarditis
Possible subclinical acute myocarditis
In the clinical context of possible myocardial injury without cardiovascular symptoms but with at least o
ne of the following:
Absent
Needed
Probable acute myocarditis
In the clinical context of possible myocardial injury with cardiovascular symptoms and at least one of th
e following:
Definite myocarditis
Histological or immunohistological evidence of myocarditis
Not Needed
 Options A, C and D are incorrect.
 The given specimen is of mitral stenosis.
 The mitral valve opening is reduced in area and has a "fish mouth" appearance. It is difficult to assess
the left ventricle from this specimen, but there may be a degree of left ventricular hypertrophy.
The mitral valve opening is reduced in area and has a "fish mouth" appearance. It is difficult to assess t
he left ventricle from this specimen, but there may be a degree of left ventricular hypertrophy.
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Correct Option B - Start CPR:
 Based on the description provided, the next best step in the management of an unresponsive patient
with the displayed ECG rhythm, despite the delivery of a DC shock, is to start CPR (Cardiopulmonary
Resuscitation). The ECG rhythm depicted suggests ventricular fibrillation (VF), which is a
life-threatening arrhythmia characterized by rapid, irregular, and disorganized electrical activity of the
ventricles. Ventricular fibrillation results in ineffective pumping of the heart, leading to a lack of blood
flow to vital organs and ultimately cardiac arrest.
Option A - Synchronized cardioversion: While synchronized cardioversion is a potential treatment for c
ertain arrhythmias, such as supraventricular tachycardia or atrial fibrillation, it is not appropriate for vent
ricular fibrillation.
Option C - Deliver another DC shock: Ventricular fibrillation requires immediate CPR followed by defibri
llation (DC shock) as the initial treatment. Since the patient has already received a DC shock without c
onversion of the rhythm, repeating the shock without CPR in between is unlikely to be effective. Ventric
ular fibrillation (VF) is a serious and life-threatening abnormal heart rhythm that occurs when the electri
cal signals controlling the heart's contractions become chaotic. Instead of a coordinated contraction, th
e ventricles (the lower chambers of the heart) quiver or fibrillate, leading to ineffective pumping and a si
gnificant decrease in blood flow. During ventricular fibrillation, the heart is unable to effectively pump ox
ygen-rich blood to the body's vital organs and tissues. This can result in a sudden loss of consciousnes
s, cessation of pulse, and, if not promptly treated, irreversible brain damage or death within minutes.
Option D - 1 mg epinephrine: Administering 1 mg of epinephrine is a
component of advanced cardiac life support and is typically given during CPR after a
shock has been delivered. However, starting CPR should take priority over administering epinephrine.
 
Correct Option D - Post stenotic dilatation of aorta:
 Based on the given clinical presentation of chest pain, exertional dyspnea, and syncope, along with
the diagnosis of aortic stenosis and chest x-ray findings, the most likely diagnosis in this case is Post
stenotic dilatation of the aorta. The correct answer is: Post stenotic dilatation of aorta
 Aortic stenosis is a condition characterized by the narrowing of the aortic valve, leading to obstruction
of blood flow from the left ventricle into the aorta. This can cause symptoms such as chest pain,
exertional dyspnea, and syncope due to the decreased cardiac output and increased pressure load on
the left ventricle.
 Post stenotic dilatation of the aorta refers to the enlargement or dilation of the aorta just distal to the
stenotic aortic valve. It occurs as a compensatory mechanism in response to the increased pressure
gradient across the narrowed valve. The dilatation allows for better forward blood flow and helps to
reduce the afterload on the left ventricle.
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 On a chest x-ray, post stenotic dilatation of the aorta can be visualized as an enlargement of the aortic
contour immediately distal to the stenotic valve. It typically appears as a bulbous or widened
appearance of the aorta.
 Options A, B and C are incorrect.
 
Correct Option A - Ehlers-Danlos syndrome:
 Ehlers-Danlos syndrome (EDS) is a group of genetic disorders that affect the connective tissues in the
body. It is characterized by various systemic manifestations, primarily involving the skin, joints, and
blood vessels. Based on the given clinical features of joint hypermobility, the ability to touch the back of
the hand with the wrist extended, tongue to nose sign, and auscultatory findings of mitral valve prolapse
the likely diagnosis is EDS.
 Options B, C and D are incorrect.
 
Correct Option A - Cardiac Pacemaker:
  A cardiac pacemaker is a device implanted in the chest to regulate the heart's electrical activity. On a
chest X-ray, a cardiac pacemaker appears as a small, metallic object usually located in the upper chest
area or near the heart. It may appear as a well-defined structure with lead wires extending into the
heart.
Correct Option B - It is slower than AV nodal pathway:
 This statement is incorrect. The bundle of Kent is actually faster than the AV nodal pathway.
Option A - It is faster than the AV nodal pathway: This statement is correct. The bundle of Kent, being 
an accessory pathway, can conduct electrical impulses faster than the normal AV nodal pathway.
Option C - Leads to short PR interval: The presence of an accessory pathway, such as the bundle of K
ent, can lead to a short PR interval on an electrocardiogram (ECG).
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Option D - Leads to prolonged QRS duration: The bundle of Kent can cause a
delta wave on the ECG, which is an early ventricular activation, resulting in a
widened or prolonged QRS complex.
Correct Option C - Ventricular tachycardia:
 Ventricular tachycardia is characterized by a rapid heart rate originating from the ventricles, resulting
in a wide QRS complex. The absence of P waves suggests that the ventricles are not being activated
through the normal atrioventricular conduction pathway.
Option A - Normal ECG: This option is incorrect because the ECG presented does not represent a
normal rhythm. It shows a rapid heart rate, wide QRS complex, and absence of P
waves, which are indicative of an abnormal cardiac rhythm.
Option B - Ventricular fibrillation: ventricular fibrillation typically appears as a
chaotic, irregular rhythm with no discernible QRS complexes or P
waves. The ECG shown in the question displays a
regular rhythm with wide QRS complexes, which is more consistent with ventricular tachycardia.
Option D - Misplaced leads: This option is incorrect The ECG pattern shown is consistent with ventricul
ar tachycardia rather than an artifact caused by lead misplacement.
Correct Option A - Staphylococcus epidermidis:
 Staphylococcus epidermidis, is most commonly associated with prosthetic valve endocarditis.
Option B - Staphylococcus aureus: This statement is incorrect. While Staphylococcus aureus is a com
mon cause of infective endocarditis, including native valve endocarditis, it is less commonly associated
 with prosthetic valve endocarditis
Option C - Coagulase-negative staphylococci are more commonly associated with prosthetic valve end
ocarditis within 12 months.
Option D - HACEK organisms: This statement is incorrect.
Correct Option A - Hypothyroidism:
 Hypothyroidism, a condition characterized by an underactive thyroid gland and reduced production of
thyroid hormones, is known to be associated with AV block. The exact mechanism is not fully
understood, but it is believed that the low levels of thyroid hormones can have direct effects on the
electrical conduction system of the heart, leading to disturbances in the conduction pathway and
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potentially resulting in AV block.
 Options B, C and D are not associated with AV block.
Correct Option A - Hydropneumothorax:
 Hydropneumothorax refers to the presence of both air and fluid in the pleural cavity. On a chest X-ray,
it may appear as a radiolucent (dark) area with air-fluid levels seen within the pleural space. This
condition can occur in cases of trauma, infection, or underlying lung diseases.
Correct Option D:
 Resistant hypertension is defined as persistently elevated blood pressure (BP) that remains above the
target level despite the use of three or more antihypertensive medications, including a diuretic, at
optimal doses. The BP threshold for defining resistant hypertension is typically set at >140/90 mmHg.
 The rationale behind this definition is that it distinguishes individuals who are truly resistant to
treatment and require further evaluation and management. It indicates a failure to achieve adequate BP
control despite multiple therapeutic interventions, which may warrant additional investigations to identify
and address underlying causes or contributing factors.
Options A, B and C are incorrect.
Correct option D
 Intravenous procainamide: Procainamide is an antiarrhythmic medication that can be effective in
treating antidromic tachycardia with a broad QRS complex. It works by blocking certain cardiac ion
channels and restoring normal rhythm. Intravenous administration allows for rapid onset of action and
is the preferred treatment option in this scenario.
Incorrect options: Option A. Oral verapamil: Verapamil is a calcium channel blocker that can be effectiv
e in treating certain types of supraventricular tachycardias. However, in the case of antidromic tachycar
dia with a
broad QRS complex, verapamil is not recommended as it can potentially worsen the condition. Option 
B. Oral beta-blocker: Beta-blockers are commonly used for rate control in supraventricular tachycardia
s. However, in the case of antidromic tachycardia with a
broad QRS complex, oral beta-blockers may not be effective and are not the first-line treatment choice. 
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Option C. Cardioversion: Cardioversion involves the electrical conversion of an abnormal heart rhythm 
back to normal sinus rhythm. While cardioversion may be appropriate in certain situations, it is not the f
irst-line treatment for antidromic tachycardia with a broad QRS complex.
Solution for Question 19:
Correct option A: Treadmill test
 The treadmill test, also known as exercise stress testing, is not typically performed in individuals with
Wolff-Parkinson-White (WPW) syndrome. WPW is a condition characterized by an abnormal electrical
pathway (accessory pathway) in the heart that can cause rapid heart rates and potentially dangerous
arrhythmias. Exercise stress testing may not be recommended in WPW because it can potentially
induce tachycardias or ventricular fibrillation due to the presence of the accessory pathway.
Option B. Electrophysiological studies
 Electrophysiological studies (EPS) are commonly performed in individuals with WPW syndrome. EPS
involves the placement of catheters inside the heart to study the electrical conduction system and
identify the location of the accessory pathway. It helps in determining the risk of arrhythmias and
guiding further treatment options.
Option C. Oral beta blocker
 Beta blockers are often used in the management of WPW syndrome. They work by blocking the
effects of adrenaline on the heart, helping to slow down the heart rate and reduce the risk of
arrhythmias. Oral beta blockers are frequently prescribed to control heart rate and prevent arrhythmias
in individuals with WPW.
Option D. Procainamide
 Procainamide is an antiarrhythmic medication that is sometimes used in the acute treatment of
arrhythmias associated with WPW syndrome. It works by slowing down the electrical conduction
through the accessory pathway. However, its use is generally reserved for acute situations and may not
be the first-line treatment option.
Solution for Question 20:
Correct option C
 Persistent chest pain with ST elevation > 90 min after thrombolysis: This option is correct. Rescue PCI
is indicated when there is persistent chest pain accompanied by ST elevation more than 90 minutes
after thrombolysis. In this case, the patient has ongoing ischemia despite thrombolysis, and urgent PCI
is necessary to restore blood flow to the affected coronary artery. Therefore, option C is correct.
Option A. Persistent chest pain with ST elevation > 60 min after thrombolysis: This option is incorrect. 
Rescue PCI is not typically performed for chest pain persisting for 60 minutes after thrombolysis. In ge
neral, the window of opportunity for rescue PCI is shorter, and intervention is more effective when perf
ormed earlier.
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Option B. Persistent chest pain with ST elevation > 30 min after thrombolysis: This option is incorrect. 
Similarly to option A, rescue PCI is not typically performed for chest pain persisting for 30 minutes after
 thrombolysis. Earlier intervention is generally preferred.
Option D. Pain with ST elevation for > 120 min after thrombolysis: This option is incorrect. Although the
 duration of chest pain and ST elevation is longer in this option, rescue PCI is typically performed when
 there is persistent chest pain and ST elevation more than 90 minutes after thrombolysis. Waiting for 1
20 minutes may delay necessary intervention
Correct option B
 Early closure of ductus arteriosus: Indomethacin is a prostaglandin inhibitor, and its use in utero can
lead to premature closure of the ductus arteriosus before birth, which is the intended effect in certain
cases.
Option A. Patent ductus arteriosus: Indomethacin is actually used to treat patent ductus arteriosus (PD
A) in premature infants. PDA is a condition where the ductus arteriosus fails to close after birth. So, the
 use of Indomethacin would not lead to PDA.
Option C. Ventricular septal defect: Ventricular septal defect (VSD) is a congenital heart defect charact
erized by an abnormal opening between the ventricles. The use of Indomethacin is not associated with 
the development of VSD.
Option D. Atrial septal defect: Atrial septal defect (ASD) is a congenital heart defect characterized by a
n abnormal opening between the atria. The use of Indomethacin is not associated with the developmen
t of ASD.
Correct option A
 Patent ductus arteriosus (PDA): A continuous murmur is commonly heard in individuals with a patent
ductus arteriosus. PDA is a congenital heart defect characterized by the persistence of a connection
between the aorta and the pulmonary artery after birth. This connection, known as the ductus
arteriosus, should naturally close shortly after birth. However, in PDA, the ductus remains open,
causing blood to flow from the aorta to the pulmonary artery throughout the cardiac cycle, resulting in a
continuous murmur.
Option B. Ventricular septal defect (VSD): VSD is a common congenital heart defect characterized by a
n abnormal opening between the right and left ventricles. The murmur associated with VSD is typically 
a holosystolic (pansystolic) murmur, heard best at the lower left sternal border. It is not a
Option C. Atrial septal defect (ASD): ASD is a congenital heart defect characterized by an abnormal op
ening between the atria. The murmur associated with ASD is typically a
systolic ejection murmur, heard best at the upper left sternal border. It is not a continuous murmur.
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Option D. Tetralogy of Fallot (TOF): TOF is a complex congenital heart defect characterized by a
combination of four specific heart abnormalities. The murmur associated with TOF is typically a
systolic ejection murmur, often accompanied by a harsh or crescendo-decrescendo quality. It is not a
 > 0.85 in females: This option is correct. A waist-to-hip ratio greater than 0.85 in females is associated
with an increased risk of heart disease. It indicates a higher proportion of abdominal fat and is
considered a marker of central obesity, which is linked to cardiovascular health risks.
Option A. > 0.80 in males: While a waist-to-hip ratio greater than 0.80 in males may suggest central ob
esity, it is not specifically associated with an increased risk of heart disease. The threshold for increase
d risk is higher in males.
Option B. > 0.80 in females: This option is incorrect. A waist-to-hip ratio greater than 0.80 in females is 
not the commonly accepted threshold for increased risk of heart disease.
Option C. > 0.85 in males: This option is incorrect. While a waist-to-hip ratio greater than 0.80 in males 
may indicate central obesity, it is not specifically associated with an increased risk of heart disease. Th
e threshold for increased risk is typically lower in males compared to females.
 This option is incorrect. There is typically no fixed time interval between two defibrillation shocks. The
decision to deliver subsequent shocks is based on the specific circumstances and the response of the
patient. In some cases, it may be necessary to deliver multiple shocks in rapid succession, while in
other cases, a pause may be required to assess the patient's response or to provide additional
interventions.
Option A. Only be used by a trained person: This option is correct. Defibrillation is a medical procedure
 that involves delivering an electric shock to the heart to restore its normal rhythm. It is a
complex procedure that typically requires training and certification. Using a
defibrillator without proper training can be dangerous and potentially harmful.
Option B. Decrease in success rate with delay in initiation: This option is correct. Defibrillation is most e
ffective when it is performed promptly after identifying a cardiac arrest. The longer the delay in initiating
 defibrillation, the lower the success rate becomes. Early defibrillation is crucial for improving the chanc
es of survival in cardiac arrest cases.
Option C. Improve prognosis: This option is correct. Defibrillation is a critical intervention in cases of ca
rdiac arrest caused by ventricular fibrillation (VF) or ventricular tachycardia (VT). Delivering an electric 
shock through defibrillation can restore a normal heart rhythm, which significantly improves the progno
sis or outcome for the individual experiencing the cardiac arrest.
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 In a patient with non-ST-elevation myocardial infarction (NSTEMI), streptokinase is not typically used
for treatment. Streptokinase belongs to the class of fibrinolytic agents and is commonly used for the
management of ST-elevation myocardial infarction (STEMI) to dissolve blood clots causing the
blockage in the coronary arteries. However, in NSTEMI, the underlying mechanism is often different,
and the management approach focuses on antiplatelet therapy and anticoagulation rather than
fibrinolysis.
Option A: Aspirin: Aspirin is a fundamental component of the treatment for NSTEMI. It is an antiplatelet
 agent that inhibits platelet aggregation and helps prevent further clot formation. Aspirin is commonly pr
escribed in the acute phase of NSTEMI and continued as long-term therapy to reduce the risk of recurr
ent cardiovascular events.
Option B: Clopidogrel: Clopidogrel is another antiplatelet medication that is commonly used in the man
agement of NSTEMI. It belongs to the class of P2Y12 inhibitors and helps inhibit platelet activation and
 aggregation. Clopidogrel is often prescribed in combination with aspirin for dual antiplatelet therapy to 
further reduce the risk of thrombotic events.
Option D: Prasugrel: Prasugrel is a
potent antiplatelet medication that is also used in the management of NSTEMI. It is a newer P2Y12 inhi
bitor that provides more potent platelet inhibition compared to clopidogrel. Prasugrel is typically reserve
d for patients who undergo percutaneous coronary intervention (PCI) or have a
high risk of recurrent ischemic events.
Solution for Question 26:
Correct Option A:
 In a patient presenting with narrow QRS complex tachycardia, a regular heart rate, and signs of
hemodynamic instability (low blood pressure), immediate cardioversion is the most appropriate next
step in management.
 DC cardioversion involves delivering a synchronized electric shock to the heart in order to restore
normal sinus rhythm. It is the treatment of choice for unstable tachyarrhythmias, such as in this
scenario where the patient has a significantly elevated heart rate and low blood pressure.
Option B: Adenosine: Adenosine is commonly used for the acute termination of supraventricular tachyc
ardia (SVT) episodes. However, it is not the preferred initial treatment for a
patient with signs of hemodynamic instability and low blood pressure. Adenosine can cause a transient
 period of asystole when administered, which can further compromise the patient's blood pressure.
Option C: Valsalva Maneuver: The Valsalva Maneuver, which involves straining against a
closed glottis, can be attempted as a non-invasive method to terminate certain types of supraventricula
r tachycardias. However, in this scenario where the patient is hemodynamically unstable with low blood
 pressure, immediate intervention with DC cardioversion is required.
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Option D: Verapamil: Verapamil is a calcium channel blocker that can be effective in terminating certai
n types of supraventricular tachycardias, such as atrioventricular nodal reentrant tachycardia. However
, in a hemodynamically unstable patient with low blood pressure, immediate electrical cardioversion is t
he preferred and more effective approach.
 
Solution for Question 27:
 The patient presented within 3 hours of the onset of chest pain, which suggests an acute coronary
syndrome (ACS). The ECG findings of ST depression in anterior chest leads and T wave inversion are
consistent with myocardial ischemia.
 In this scenario, the patient is a candidate for early antithrombotic therapy to prevent further ischemic
events and complications. Aspirin and heparin are commonly used in the initial management of ACS.
 Aspirin is an antiplatelet agent that inhibits platelet aggregation, reducing the risk of clot formation. It is
administered promptly to patients suspected of having ACS to minimize ongoing thrombosis.
 Heparin is an anticoagulant that helps prevent the formation and propagation of blood clots. It is often
used in combination with aspirin in the early management of ACS to provide additional anticoagulant
effects.
Option A: PCI (percutaneous coronary intervention): PCI is a preferred treatment option for patients wit
h ST-segment elevation myocardial infarction (STEMI). However, in this case, the ECG findings indicat
e ST depression and T wave inversion, which are suggestive of non-ST-elevation myocardial infarction
 (NSTEMI) or unstable angina. PCI is not the first-line treatment for NSTEMI or unstable angina within t
he initial hours of symptom onset.
Option B: Thrombolysis with alteplase: Thrombolysis, or clot-dissolving therapy, is primarily indicated fo
r patients with STEMI who present within a specific time window and are not candidates for primary PC
I. In this case, the patient's ECG findings suggest NSTEMI or unstable angina, and thrombolysis is not 
the preferred treatment for these conditions.
Option C: Prophylaxis for arrhythmia: While arrhythmias can be a complication of ACS, prophylactic tre
atment for arrhythmias is not the primary management strategy in the acute phase. The focus initially is
 on addressing the underlying ischemia and preventing further thrombosis through antiplatelet and anti
coagulant therapy.
 
Solution for Question 28:
Option D) Tricuspid Regurgitation: Tricuspid regurgitation is characterized by a pan systolic murmur he
ard best along the right side of the heart and it radiates to the right of the sternum. However, the murm
ur does not typically radiate to the axilla. Additionally, tricuspid regurgitation is often secondary to other
 conditions affecting the right side of the heart, such as pulmonary hypertension or right heart failure, w
hich might lead to clinical signs not mentioned in the case.
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Correct Answer: D) Tricuspid Regurgitation
In Summary: The characteristics of a pan systolic murmur heard at the right side of the heart and radiat
ing to the axilla, along with the absence of signs of aortic stenosis, mitral valve prolapse, and ventricula
r septal defect, point toward tricuspid regurgitation as the most likely diagnosis in this case. It's importa
nt to consider the entire clinical picture and potentially perform further tests (e.g., echocardiography) to 
confirm the diagnosis and assess the severity of the condition.
The key points, in this case, are the characteristics of the murmur (pan systolic, right sided location, ra
diation to axilla, louder during inspiration) and the absence of fever or infections, which helps to differe
ntiate the options.
Option A) Aortic Stenosis: Aortic stenosis typically presents with a crescendo-decrescendo systolic eje
ction murmur best heard at the right upper sternal border, and it often radiates to the carotid arteries. T
his does not match the characteristics of the murmur described in the case.
Option B) Mitral Valve Prolapse: Mitral valve prolapse is characterized by a
mid-systolic click followed by a late systolic murmur. The murmur usually occurs after the click and is n
ot pan systolic. Additionally, mitral valve prolapse is not typically associated with radiation of the murm
ur to the axilla.
Option C) Ventricular Septal Defect (VSD): A VSD would cause a harsh, holosystolic murmur heard be
st at the left lower sternal border, as blood flows from the higher-pressure left ventricle to the lower-pre
ssure right ventricle. The characteristics and location of the murmur in this case do not match those of 
a VSD.
 
Solution for Question 29:
Correct Option B:
The correct sequence after the P wave is as follows:
 A. 'a' wave: The 'a' wave represents atrial contraction. It occurs during atrial systole when the atria
contract to push blood into the ventricles.
 B. 1st heart sound: The 1st heart sound, also known as S1, is the closure of the atrioventricular (AV)
valves (mitral and tricuspid valves) at the beginning of ventricular systole. It marks the onset of
ventricular contraction.
 D. 't' wave: The 't' wave is a repolarization phase of the ventricles. It represents the relaxation and
resetting of the ventricles after contraction.
 C. Rapid filling of ventricles: After the 't' wave, the ventricles enter the diastole phase, during which
they passively fill with blood from the atria. This is known as rapid ventricular filling.
Therefore, the correct sequence is ABDC: 'a' wave, 1st heart sound, rapid filling of ventricles, and 't' wa
ve.
Option A: ACBD: This option incorrectly places the rapid filling of ventricles (C) before the 'a' wave (A). 
The correct sequence is 'a' wave (A), 1st heart sound (B), rapid filling of ventricles (C), and 't' wave (D).
Option C:. CABD: This option incorrectly places the rapid filling of ventricles (C) before the 'a' wave (A) 
and the 1st heart sound (B). The correct sequence is 'a' wave (A), 1st heart sound (B), rapid filling of v
entricles (C), and 't' wave (D).
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Option D: ACBD: This option incorrectly places the rapid filling of ventricles (C) before the 'a' wave (A). 
 
Solution for Question 30:
Correct Option:
Option B: Multifocal atrial tachycardia (MAT) is characterized by an irregular rhythm with at least three 
distinct P-wave morphologies in the same lead. The ECG changes described in the scenario, specifical
ly the presence of multiple P-wave morphologies, are consistent with MAT.
 
Incorrect Option:
Option A: Ventricular tachycardia (VT) is characterized by wide QRS complexes and is usually a
regular rhythm. The ECG shown in the scenario does not exhibit the characteristics of VT.
Option C: Atrial fibrillation (AF) is characterized by irregularly irregular rhythm with absent P
waves and irregularly spaced QRS complexes. The scenario does not describe the absence of P
waves, making AF less likely.
Option D: Atrial tachycardia is characterized by a regular rhythm with a
single P-wave morphology. The presence of multiple P-wave morphologies in the ECG suggests a
different diagnosis than atrial tachycardia.
Solution for Question 31:
Correct option:
Option A: Cardiac tamponade typically presents with an elevated JVP but a blunted or absent y
descent due to impaired filling of the right ventricle during diastole. Therefore, deep y
descent is not seen in cardiac tamponade.
 
Option B: Restrictive cardiomyopathy is characterized by stiffening of the heart muscle, leading to impa
ired ventricular filling. It can result in a prominent and rapid y descent in the JVP waveform.
Option C: Constrictive pericarditis involves the thickening and stiffening of the pericardium, leading to i
mpaired cardiac filling. It is associated with a prominent and rapid y descent in the JVP waveform.
Option D: Tricuspid regurgitation is a condition in which the tricuspid valve fails to close properly, causi
ng blood to flow backward into the right atrium during systole. This leads to an elevated JVP and a
large v wave, but it does not affect the y descent.
Solution for Question 32:
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Option B: Decrease in systolic blood pressure 20 mmHg after 3 min of standing: This option is correct. 
Postural hypotension, also known as orthostatic hypotension, is defined as a
decrease in systolic blood pressure of 20 mmHg or more or a
decrease in diastolic blood pressure of 10 mmHg or more within 3 minutes of standing up from a
sitting or lying position
 
Option A: Decrease in systolic blood pressure 20 mmHg after 6
mins of standing: This option is incorrect. The definition of postural hypotension does not specify a
specific duration of standing as 6 minutes.
Option C: Decrease in diastolic blood pressure 20 mmHg after 6
specific duration of standing as 6 minutes, and it focuses on the systolic blood pressure drop rather tha
n the diastolic blood pressure drop.
Option D: Decrease in diastolic blood pressure 20 mmHg after 3
mins of standing: This option is incorrect. While a decrease in diastolic blood pressure can contribute t
o postural hypotension, the primary criterion for its diagnosis is a
decrease in systolic blood pressure of 20 mmHg or more.
Solution for Question 33:
Option b. IV MgSO4 (Magnesium sulfate): Magnesium sulfate is the preferred treatment for torsades d
es pointes, especially in the setting of pre-eclampsia. Magnesium sulfate has antiarrhythmic properties 
and can effectively stabilize the cardiac rhythm.
 
Option a. IV calcium: Intravenous calcium is not the recommended treatment for torsades des pointes. 
It is more commonly used in the management of calcium channel blocker overdose or hypocalcemia.
Option c. DC shock: Direct current (DC) shock, also known as defibrillation, is not the primary treatmen
t for torsades des pointes. It is typically reserved for life-threatening ventricular arrhythmias such as ve
ntricular fibrillation or pulseless ventricular tachycardia.
Option d. Synchronized cardioversion: Synchronized cardioversion is not the appropriate treatment for 
torsades des pointes. It is used for the conversion of certain supraventricular tachycardias and hemody
namically unstable ventricular arrhythmias.
Solution for Question 34:
Option C.
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  Synchronized cardioversion: Synchronized cardioversion is the next best step of management in this
scenario. It involves delivering a synchronized electrical shock to the heart at a specific moment in the
cardiac cycle to restore normal sinus rhythm. It is an effective method for terminating PSVT and can
rapidly improve the patient's condition.
Option A. Repeat inj adenosine 6 mg: Adenosine is a medication used to treat supraventricular tachyca
rdia (SVT). However, since the patient has already received adenosine and it did not result in the termi
nation of the arrhythmia, repeating the same dose is unlikely to be effective.
Option B. Inj amiodarone 300 mg: Amiodarone is an antiarrhythmic medication that can be used for var
ious types of arrhythmias. However, in this case, the patient's blood pressure is already low, and amiod
arone may further lower the blood pressure, potentially causing hemodynamic instability.
Option D. DC cardioversion: DC cardioversion, also known as defibrillation, is not appropriate for this p
atient as it is used to treat life-threatening arrhythmias such as ventricular fibrillation or pulseless ventri
cular tachycardia. In PSVT, which is a
regular but rapid rhythm, synchronized cardioversion is the preferred approach.
Solution for Question 35:
Correct Option D: Carotid body tumour
 In the above case, there is a pulsatile swelling, and on MRI angiography, it shows Lyre,s sign which is
splaying of internal and external arteries, which is diagnostic of carotid body tumour. It is a
slow-growing tumour and presents mainly after 40 years of age.
Option A: Grave’s disease is a
hyperthyroid condition with bulging eyes, and the neck swelling is not pulsatile.
Option B: Branchial cysts are small fluid-filled sacs that look like lumps under the skin on the side of th
e neck and are more common in children than adults.
Option C: Thymic cyst is a
benign mediastinal disease and presents with dyspnea, chest pain, cough, hoarseness and dysphagia.
Solution for Question 36:
Correct Option B: Atrial flutter
 The above ECG is that of atrial flutter as it shows narrow QRS complexes and sawtooth-shaped
waves.
Option A: In atrial fibrillation, the QRS complexes are irregularly irregular, is RR intervals vary.
Option C: Ventricular tachycardia has broad QRS complexes.
Option D: Ventricular Fibrillation has no identifiable P wave or QRS complexes.
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Solution for Question 37:
Correct Option C: Ventricular tachycardia
 The above ECG is ventricular tachycardia as it has a vast QRS complex. P waves are absent, and the
heart rate is over 100 beats per minute.
Option A: The above is not a normal ECG as it has tachycardia, absent P
wave, and vast QRS complexes.
Option B: Ventricular fibrillation has no identifiable QRS complex.
Option D: This is not the case for misplaced leads.
Solution for Question 38:
Correct Option A: Pericardial effusion
 The above presentation of breathlessness on lying down and it being relieved on sitting, and the x-ray
given which shows an enlarged cardiac silhouette is suggestive of a probable diagnosis of pericardial
effusion. It is also known as a money bag or leather bottle-shaped heart.
Option B: Tetralogy of Fallot shows a boot-shaped heart on an x-ray.
Option C: Transposition of great arteries shows an egg-on-string appearance on x-ray.
Option D: Pulmonary hypertension shows a pruned tree appearance of the pulmonary vasculature.
Solution for Question 39:
Correct Option A: Chest x-ray
 X-ray is the best confirmatory method to ensure the central line is in the jugular vein.
Option B: Blood pH is inconclusive and not the best confirmatory method.
Option C: Blood color is very subjective and may be misleading.
Option D: ETCO2 is not used in this case.
Solution for Question 40:
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 The Modified Duke criteria are widely used criteria for the diagnosis of infective endocarditis, which is
an infection of the endocardium (inner lining) of the heart, including heart valves. The criteria help in
establishing a diagnosis based on clinical, laboratory, and echocardiographic findings. They take into
account major and minor criteria, as well as the presence of predisposing factors, to classify the
likelihood of infective endocarditis.
 Major Criteria Description Positive Blood Culture - Typical organisms isolated from 2 separate blood
cultures.  - Persistently positive blood cultures, with typical organisms isolated from cultures done > 12
hours apart.  - Coxiella infection (Q fever) demonstrated by a single positive blood culture with Phase I
IgG titre > 1:800. Echocardiographic Evidence - Evidence of vegetation or oscillating intracardiac mass
on echocardiography. - Transesophageal echocardiography (TEE) is preferred over transthoracic
echocardiography (TTE).  - New valvular regurgitation or partial dehiscence of prosthetic valve. New
Onset Murmur in Patient with Pre-existing Heart Lesion - Development of a new heart murmur in a
patient with pre-existing heart disease. Minor Modified Criteria Description Predisposition - Presence of
pre-existing heart disease or history of intravenous drug usage. Fever > 38°C - Fever with temperature
exceeding 38°C. Vascular Phenomenon - Major embolic phenomenon.  - Septic pulmonary infarction. -
Mycotic aneurysm.  - Intracranial hemorrhage.  - Janeway lesions (palm, soles). Immunological
Phenomenon (Mnemonic – ROG) - Roth spots.  - Rheumatoid factor positivity.  - Osler nodes (tip of
fingers).  - Glomerulonephritis. Microbiological Evidence - Positive blood culture not meeting major
criteria. - Moderate-high clinical suspicion warrants transesophageal echocardiography (TEE), while
low suspicion warrants transthoracic echocardiography (TTE).  - Additional diagnostic modalities
include SHOT metagenomics, FDG PET-CT, and multi-slice CT angiography.  
 
Option A (Infective endarteritis) is incorrect because infective endarteritis is not a
recognized term or condition. It may be a confusion with infective endocarditis.
Option B (Infectious mononucleosis) is incorrect because the Modified Duke criteria are not used for th
e diagnosis of infectious mononucleosis, which is caused by the Epstein-Barr virus.
Option C (Inflammatory myopathy) is incorrect because the Modified Duke criteria are not used for the 
diagnosis of inflammatory myopathy, which refers to a
group of muscle disorders characterized by muscle inflammation.
Solution for Question 41:
 Prazosin is an alpha-1 blocker medication used primarily for the treatment of hypertension and benign
prostatic hyperplasia. However, one of the common side effects of prazosin is orthostatic hypotension,
which can increase the risk of falls, especially in the elderly. Orthostatic hypotension refers to a sudden
drop in blood pressure upon standing, leading to dizziness or lightheadedness, and can result in falls.
Option B: Metformin is a medication used for the management of diabetes mellitus, and it is not typicall
y associated with an increased risk of falls.
Option C: Acarbose is an alpha-glucosidase inhibitor used in the treatment of diabetes mellitus. It does 
not commonly cause orthostatic hypotension or an increased risk of falls.
Option D: Thiazide refers to a class of diuretic medications commonly used for blood pressure control. 
While they can sometimes cause orthostatic hypotension, it is not a
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common side effect compared to prazosin.
Solution for Question 42:
Correct Option B: Class II
 As the patient has dyspnea on light physical activity, there is slight limitation of physical activity. He is
asymptomatic at rest. This is Class II in NYHA classification.
Option A: Class I
has no limitations and no symptoms with ordinary exertion or day to day daily physical activity.
Option C: Class III has marked limitation of physical activity and less than ordinary activities cause sym
ptoms. The individual is asymptomatic at rest.
Option D: Class IV has inability to carry out any physical activity without discomfort and symptoms are 
present even at rest.
Solution for Question 43:
Correct Option A: Aortic regurgitation
 The above patient presents with the diastolic murmur and the pistol shot over femoral arteries which is
suggestive of aortic regurgitation. There is a backflow of blood from the aorta to the ventricle at the time
of diastole.
Option B: Aortic stenosis presents with a midsystolic ejection murmur at the upper sternal border.
Option C: Tricuspid regurgitation presents with a holosystolic murmur at the lower left sternal border.
Option D: Mitral regurgitation presents with a
systolic murmur at the apex of the heart with radiation to the left axilla.
Solution for Question 44:
Correct Option B - Atrial septal defect:
 Patients with atrial septal defects do not require endocarditis prophylaxis prior to dental extraction.
Option A - Prior history of endocarditis
Option C - Unrepaired cyanotic heart disease
Option D - Prosthetic heart valves
 Patients with a prior history of endocarditis, unrepaired cyanotic heart disease, and prosthetic heart
valves require endocarditis prophylaxis prior to dental procedures.
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Solution for Question 45:
Correct Option B - Absent a wave:
 The likely diagnosis in this patient with an irregularly irregular pulse and an accompanying pulse
deficit is atrial fibrillation. The corresponding finding on JVP examination would be 'absent a wave' due
to inadequate/absent atrial contractions.
Option A - Absent p wave: Absent p wave on ECG is a
finding seen in patients with atrial fibrillation. It is not seen on JVP examination.
Option C - Cannon a wave: Cannon a wave on JVP examination is seen in conditions such as atriovent
ricular dissociation and is not seen in patients with atrial fibrillation.
Option D - Raised JVP with normal waveform: Raised JVP with normal waveforms may be seen in con
ditions such as heart failure and constrictive pericarditis and not in atrial fibrillation.
Solution for Question 46:
Correct Option C - Once in four weeks for 5 years or till the age of 21, whichever is longer:
 This patient likely has Rheumatic Fever without carditis. He fulfills 2 major criteria for the diagnosis of
Rheumatic Fever → Fever and polyarthralgia. This child should be initiated on secondary prophylaxis.
Since this child weighs less than 27 kgs, the dose of benzathine penicillin G is 600,000 IU (1.2 million
IU if the child weighs more than 27 kgs). The duration of prophylaxis in a patient with rheumatic fever
without carditis is 'once in 3-4 weeks for 5 years after the last attack or 21 years of age whichever is
longer'
Solution for Question 47:
Correct Option C - Intravenous amiodarone:
 The diagnosis in this patient is stable ventricular tachycardia. The patient has a history of structural
heart disease; hence, the appropriate course of management would be IV amiodarone.
 
Solution for Question 48:
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 The ECG in the question shows a narrow QRS complex with an increased heart rate. Supraventricular
tachycardia (SVT) is a type of arrhythmia that originates above the ventricles and can cause a rapid
heartbeat. The ECG tracing for SVT shows a regular rhythm with a narrow QRS complex, often with a
sudden onset and termination. Thus, the above ECG indicates supraventricular tachycardia.
Option A - Ventricular fibrillation: Ventricular fibrillation is a life-threatening arrhythmia that occurs when
 the ventricles (lower chambers) of the heart quiver instead of contracting properly, leading to a
lack of blood flow to the body's vital organs. The ECG tracing for ventricular fibrillation shows a
rapid and chaotic pattern with no identifiable P, QRS, or T waves.
Option B - Atrial fibrillation: Atrial fibrillation is a common arrhythmia that occurs when the atria (upper c
hambers) of the heartbeat irregularly and often rapidly, leading to inefficient blood flow to the ventricles.
 The ECG tracing for atrial fibrillation shows an irregular rhythm with no discernible P
waves and an irregularly spaced QRS complex
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Option D - Ventricular tachycardia: Ventricular tachycardia is a
type of arrhythmia that originates in the ventricles and can lead to a
fast and potentially life-threatening heart rate. The ECG tracing for ventricular tachycardia shows a
regular or irregular rhythm with a wide QRS complex, often with a repeating pattern.
 
Solution for Question 52:
Correct Option A - Hypothermia:
 J wave, also known as an Osborn wave, is a small hump or notch that appears on the QRS complex
of an electrocardiogram (ECG) in certain conditions. It is most commonly associated with hypothermia,
a condition in which the body temperature drops below normal.
 The exact mechanism by which J waves develop in hypothermia is not fully understood, but it is
believed to be related to changes in the electrical properties of the heart caused by cold temperatures.
Specifically, hypothermia can cause a decrease in the speed of electrical conduction in the heart, which
can lead to the development of the J wave.
 Options B, C, and D are not associated with J waves.
Solution for Question 53:
Correct Option B - Cardiac tamponade:
 The given scenario describes a young male patient who has developed difficulty in breathing and has
signs of hemodynamic compromise, including hypotension and weak pulses, elevated jugular venous
pressure with absent Y descent, and muffled heart sounds. Based on these findings, the most likely
diagnosis is cardiac tamponade.
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 Cardiac tamponade is a medical emergency that occurs when there is an accumulation of fluid in the
pericardial sac surrounding the heart, leading to compression of the cardiac chambers and impaired
filling during diastole. This can result in decreased cardiac output and hemodynamic compromise,
which may manifest as hypotension, tachycardia, elevated jugular venous pressure, and muffled heart
sounds. Cardiac tamponade can be caused by a variety of conditions, including trauma, infection,
malignancy, and autoimmune disorders.
Option A - Constrictive pericarditis: Constrictive pericarditis is a chronic condition that results from the t
hickening and fibrosis of the pericardial sac, leading to impaired diastolic filling of the heart chambers. 
This can result in similar symptoms to those seen in cardiac tamponade, including elevated jugular ven
ous pressure and muffled heart sounds, but the onset is typically more gradual, and the symptoms are 
not as severe. Constrictive pericarditis is also associated with other signs, such as Kussmaul's sign an
d pericardial knock.
Option C - Acute pericarditis: Acute pericarditis is an inflammatory condition of the pericardial sac, whic
h can lead to chest pain, fever, and pericardial friction rub on auscultation. However, the signs and sym
ptoms are not typically as severe as those seen in cardiac tamponade, and there is no significant hemo
dynamic compromise.
Option D - Cardiac failure: Cardiac failure is incorrect because while cardiac tamponade can lead to he
art failure, it is not the primary diagnosis in this case. Furthermore, cardiac failure typically presents wit
h different symptoms such as shortness of breath, fatigue, and fluid accumulation in the legs.
Solution for Question 54:
Correct Option B - IV Mannitol:
 IV Mannitol does not play a role in the management of patients with hypertensive encephalopathy.
 Option A, C and D can be used in the treatment of hypertensive encephalopathy.
Solution for Question 55:
Correct Option C - Lisinopril:
 Lisinopril is an ACE inhibitor used to treat high blood pressure and heart failure and improve survival
in patients with a history of myocardial infarction. It works by blocking the conversion of angiotensin I to
angiotensin II, a hormone that causes blood vessels to constrict and retain fluid, leading to increased
blood pressure and fluid buildup.
 Studies have shown that lisinopril improves survival in patients with heart failure and reduces the risk
of hospitalization due to heart failure. It also improves symptoms such as shortness of breath, fatigue,
and leg swelling.
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Solution for Question 56:
Correct Option C - Hypothermia:
 Hypothermia is a medical emergency that occurs when the body temperature drops below 35°C
(95°F). As the body temperature drops, various physiological functions are affected, including heart
function. The ECG changes seen in hypothermia are due to alterations in the electrical conduction
system of the heart and are often reversible with rewarming.
 The ECG findings shown above indicate it to be hypothermia; it includes bradycardia, prolonged PR
interval, widened QRS complex, and J waves/Osborn waves. Osborn waves/J waves are positive
deflections at the end of the QRS complex in the leads V3-V6 and are sometimes referred to as the
"camel hump" sign.
Option A - Hypokalemia: Hypokalemia is an electrolyte imbalance that can also affect the heart and ca
use ECG changes. Hypokalemia can cause flattened or inverted T
waves, ST segment depression, and U
waves. However, in this ECG, the findings are not consistent with either hypokalemia or hyperkalemia.
Option B - Hyperkalemia: Hyperkalemia is also an electrolyte imbalance that can affect the heart and c
ause ECG changes. Hyperkalemia can cause peaked T waves, widened QRS complex, and a
sine wave pattern.
Option D - Hypocalcemia: Hypocalcemia can also cause ECG changes, such as QT prolongation and 
ST segment depression. However, these changes are not seen in the given ECG, making hypocalcemi
a an unlikely diagnosis.
Solution for Question 57:
Correct Option A - Primary Raynaud’s phenomenon:
 Primary Raynaud’s phenomenon is a condition in which the blood vessels in the fingers and toes
narrow in response to cold temperatures or emotional stress. As a result, the fingers and toes may feel
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numb or cold and may turn white or blue. This condition occurs without any underlying disease and is
more common in women than men. The patient in this case has no other comorbidities and has
symptoms that are typical of Primary Raynaud's phenomenon.
Solution for Question 58:
Correct Option D
- Fibrinolytic therapy is useful in acute coronary syndrome without ST-segment elevation:
 Fibrinolytic therapy is not recommended for NSTEMI because the underlying cause of the condition is
not a complete occlusion of a coronary artery by a blood clot. Fibrinolytic therapy is typically reserved
for patients with STEMI (ST-segment elevation myocardial infarction) who have evidence of a complete
occlusion of a coronary artery.
Option A - Aspirin loading dose should be initiated immediately: True. Aspirin is a
cornerstone of the treatment of NSTEMI, and a
loading dose of 162-325 mg should be given immediately upon diagnosis.
Option B - ACC/AHA guidelines call for either a
P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) as a class I recommendation: True. P2Y12 inhibit
ors are recommended as part of the standard treatment for NSTEMI, as they help to prevent platelet a
ggregation and reduce the risk of further cardiac events.
Option C - Glycoprotein IIB/IIIA inhibitors are useful adjuncts: True. Glycoprotein IIB/IIIA inhibitors are p
otent antiplatelet agents that can be used as adjunctive therapy in patients with NSTEMI who are at hig
h risk for adverse cardiac events.  
Solution for Question 59:
Correct Option A - Constrictive pericarditis:
 Constrictive pericarditis is a condition characterised by inflammation and fibrosis of the pericardium.
 This leads to stiffening of the pericardium, impairing the ability of the heart to expand and fill properly
during diastole
 The key clinical findings include dyspnea  and distended neck veins that increase with inspiration,
known as Kussmaul's sign.
 During inspiration, the intrathoracic pressure decreases, causing an increase in venous return to the
heart. In constrictive pericarditis, the rigid pericardium prevents the heart from expanding adequately,
resulting in an exaggerated rise in jugular venous pressure. This also results in muffled heart
sounds/absence of murmurs.
Option B - Aortic regurgitation: Aortic regurgitation typically presents with a diastolic murmur, which is n
ot mentioned in the patient's presentation. Additionally, aortic regurgitation would not cause the specific
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 findings of distended neck veins that increase with inspiration.
Option C - Tricuspid stenosis: Tricuspid stenosis is associated with a diastolic murmur and symptoms s
uch as fatigue, edema, and ascites. The key finding in tricuspid stenosis is an elevated jugular venous 
pressure, but it does not increase with inspiration, as seen in the patient's presentation.
Option D - Pulmonary arterial hypertension: Pulmonary arterial hypertension can lead to symptoms of d
yspnea and distended neck veins but it does not typically cause an increase in jugular venous pressure
 with inspiration. It is important to note that pulmonary arterial hypertension can result from constrictive 
pericarditis, but it is not the primary diagnosis based solely on the given presentation.
Solution for Question 60:
Correct Option A - Metoprolol:
 Metoprolol, a beta-blocker, has been shown to lower mortality in heart failure patients. ACE inhibitors
have also been shown to decrease mortality in patients with heart failure.
Solution for Question 61:
Correct Option A - Mitral regurgitation:
 The likely diagnosis, according to the image provided, is Marfan's syndrome
 Marfan syndrome is an inherited autosomal dominant disorder of connective tissue with a high risk of
aortic aneurysm and dissection.
 A common cardiovascular complication in patients with Marfan’s syndrome is mitral regurgitation due
to improper connective tissue formation. 
 
Solution for Question 62:
Correct Option D - Subacute combined degeneration of cord:
 The clinical presentation is suggestive of Subacute combined degeneration which occurs due to the
Vitamin B12 deficiency.
 According to the vignette, the patient has a stocking-like distribution of loss of proprioception, vibration
sensations, and UMN type of lower limb weakness.
 He also has angular stomatitis.
 Both neurological and dermatological findings are suggestive of vitamin B12 deficiency in the patient.
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 The neurological findings correspond to subacute combined degeneration of the cord which is a
complication of vitamin B12 deficiency.
Option A - Extradural cord compression: Extradural cord compression in an adult can occur due to a m
ultitude of causes like abnormal spine alignment (scoliosis), injury to the spine, spinal tumor, rheumatoi
d arthritis, infection, etc. Symptoms of cord compression include burning sensation, numbness, and los
s of sensation over the hand, legs, buttocks, etc, because of injury to the nerve. There is an LMN type 
of nerve injury because the compression causes damage to the peripheral nerves.
Option B - Amyotrophic lateral sclerosis: Amyotrophic lateral sclerosis, or Lou Gehrig’s disease, is a
neurological disease that causes damage to motor neurons. The patients present with a combination of
 signs of both LMN and UMN types of nerve damage. This patient only presents with UMN type of lesio
ns, hence, making ALS a very unlikely cause of the patient’s symptoms.
Option C - Multiple Sclerosis: Multiple Sclerosis is an immunological disorder that occurs because of th
e immune system’s response against the nerves of the body. There is the destruction of the oligodendr
ocytes, cells responsible for the formation of the myelin sheath around the nerve, which causes exposu
re of the nerves. This leads to episodes of pain, loss of sensation or numbness and tingling, muscle sp
asms, stiffness, and weakness that remit and recur. This patient does not have a
history of remission and recurrence, making MS an unlikely diagnosis.
 
Solution for Question 63:
 
Solution for Question 64:
Correct Option B - Tricuspid regurgitation:
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 The clinical findings of this patient, which reveal reciprocal pitting pedal edema,  ascites, and an S3 on
auscultation, are suggestive of right ventricular failure.
 A history of chronic smoking likely suggests that the patient is suffering from chronic obstructive
pulmonary disease leading to cor pulmonale (RV failure due to noncardiogenic causes)
 Increased RV pressure leads to tricuspid regurgitation
 Options A, C, and D are incorrect.
Solution for Question 65:
Correct Option D - Hypothermia:
 Hypothermia refers to a decrease in core body temperature below the normal range. It occurs when
the body temperature drops below 95 degrees Fahrenheit (35 degrees Celsius).
 Hypothermia causes peripheral cyanosis.
 Central cyanosis is seen due to decreased oxygen saturation or oxygen-carrying capacity of the
blood.
Option A
- Methemoglobinemia: Methemoglobin is oxidized hemoglobin due to nitrate exposure. This leads to a
reduced oxygen-carrying capacity of the blood and can result in central cyanosis.
Solution for Question 66:
Correct Option D - Injection MgSO4:
 Magnesium sulfate (MgSO4) is not typically used for the immediate management of hyperkalemia. It
may be used in certain situations, such as if the patient has concurrent magnesium deficiency, which
can contribute to electrolyte imbalances. However, it is not the primary drug of choice for immediate
intervention in hyperkalemia.
Option A - 10% calcium gluconate over 10 min: Calcium gluconate is commonly used in the emergency
 management of hyperkalaemia. It helps stabilise the cardiac membrane and counteracts the effects of 
elevated potassium levels on the heart.
Option B - Salbutamol nebulisation: Salbutamol, a beta-2 agonist, is frequently used for the immediate 
management of hyperkalaemia. It promotes the cellular uptake of potassium, effectively lowering its co
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ncentration in the blood.
Option C - Insulin-dextrose: Insulin, often administered with dextrose, is a key component of emergenc
y hyperkalaemia management. Insulin drives potassium from the bloodstream into the cells, reducing s
erum potassium levels.
Solution for Question 67:
Correct Option D - Second-degree heart block:
 This conduction abnormality is characterized by intermittent blockage of electrical impulses between
the atria and ventricles. It can be further classified into two types:
 Mobitz Type I (Wenckebach) - is characterized by a progressive prolongation of the PR interval until a
beat is dropped
 Mobitz Type II - involves intermittent blocked beats without progressive PR interval prolongation.
Option A - First-degree heart block: This conduction abnormality is characterized by a
prolonged PR interval on the ECG. It indicates a
delay in the electrical conduction between the atria and ventricles.
Option B - Ventricular tachycardia: Ventricular tachycardia is a
rapid heart rhythm originating from the ventricles. On the ECG, it appears as a
wide QRS complex with a heart rate exceeding 100 beats per minute.
Option C - Third-degree heart block (complete heart block): This is a
severe conduction abnormality characterised by atrioventricular dissociation.
 
Solution for Question 68:
Correct Option B - Blood pressure of more than 185/110 mmHg:
 Thrombolysis is generally contraindicated in patients with very high blood pressure.
 Options A, C and D can be considered as indications for thrombolysis.
Solution for Question 69:
Correct Option B - Adenosine:
 Adenosine is the correct answer for first-line management of the presented condition.
 The ECG pattern shown suggests paroxysmal supraventricular tachycardia (PSVT), a common
arrhythmia characterized by rapid heart rates originating above the ventricles. Adenosine is a potent
vasodilator and affects the electrical conduction system of the heart. It activates specific receptors in
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the heart, particularly the adenosine A1 receptors, which help to slow down the conduction through the
AV node. This interruption of the abnormal electrical pathway in SVT can restore normal sinus rhythm.
Solution for Question 70:
Correct Option A - NYHA 3:
 NYHA functional classification assesses the impact of heart disease on a patient's daily activities.
 NYHA 3 indicates moderate symptoms. Patients classified as NYHA 3 experience symptoms such as
marked limitation of physical activity, becoming symptomatic with less than ordinary activity (such as
going to the bathroom), and having no symptoms at rest.
Option B - NYHA 4: NYHA 4 indicates severe symptoms. Patients classified as NYHA 4
experience symptoms even at rest and are unable to carry out any physical activity without discomfort.
Option C - mMRC 4: The mMRC dyspnea scale is used to assess dyspnea (shortness of breath) in pati
ents with respiratory conditions. mMRC 4 indicates severe dyspnea, where patients become too breath
less to leave the house or experience significant discomfort even while at rest.
Option D - mMRC 5: mMRC 5 is not a
standard category in the MMRC dyspnea scale. The scale typically ranges from 0 to 4, with 0
indicating no dyspnea and 4 indicating the most severe dyspnea.
 
Solution for Question 71:
Correct Option D - Non-synchronised DC shock:
 ECG is suggestive of atrial fibrillation as there is an irregularly irregular rhythm and absent P waves
with narrow QRS complexes are present.
 In atrial fibrillation, synchronised DC shock/cardioversion can be used. Nonsynchronised DC shock
(Defibrillation) is not used in the management of these patients.
 Option A, B and C can be used in the management of patients with atrial fibrillation.
 
Solution for Question 72:
Correct Option C - Methemoglobinemia:
 The underlying diagnosis in this case is methemoglobinemia. 
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 The correct order for auscultation of the heart sound from superior to inferior is pulmonary > tricuspid
> mitral.
Solution for Question 76:
Correct Option C - Torsades de pointes:
 In this ECG, there is a gradual change in QRS amplitude, twisting around the baseline and giving a
"twisting" appearance. The QRS complexes may appear to "morph" or change in amplitude and
direction. The QRS complexes may be wide and irregular, varying in amplitude and shape. Torsades
de pointes is associated with a prolonged QT interval, often greater than 500 ms.
 Torsades de Pointes is a polymorphic ventricular tachycardia marked by QRS complex twisting
around an isoelectric line on ECG, often associated with QTc prolongation (>450 ms in males, >460 ms
in females). QTc >500 ms correlates with 2-3 fold higher risk. It may spontaneously resolve or
degenerate into ventricular fibrillation.
 Causes include congenital or acquired QTc prolongation, often drug-related. Risk factors include older
age (>65), female gender, electrolyte imbalances (hypokalemia and hypomagnesemia), bradycardia,
heart disease, and diuretic use. Genetic variants are Romano-Ward and Jervell and Lange-Nielsen
syndromes, the latter involving congenital deafness.
 Options A, B and D are incorrect and are not associated with the findings shown in the image below.
Solution for Question 77:
Correct Option C - Diastolic Murmur: 
 Aortic regurgitation is a valvular disorder where there is abnormal leakage or backward flow of blood
from the aorta into the left ventricle during diastole (relaxation phase of the cardiac cycle). This causes
a characteristic murmur that is heard during diastole.
Solution for Question 78:
Correct Option C - Oral warfarin:
 Oral warfarin is the best agent to prevent future thrombotic events in this patient with mitral stenosis. It
addresses the underlying risk of thrombus formation in the left atrium associated with the irregularly
irregular pulse seen in atrial fibrillation, which commonly coexists with mitral stenosis. Regular
monitoring of the INR is necessary to maintain the therapeutic range and minimize bleeding risk.
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Solution for Question 79:
Correct Option B - Tricuspid Stenosis:
 Tricuspid stenosis is the likely diagnosis based on the mild diastolic murmur and the presence of
prominent a-waves on the JVP. These findings are consistent with the narrowing of the tricuspid valve
and the resulting elevated right atrial pressure.
 Due to the narrow opening, when blood passes from Right Atrium to the right ventricle, turbulence is
formed leading to the formation of mild diastolic murmur.
 Options A, C and D are not associated with this clinical presentation.
Solution for Question 80:
Correct Option B - Transoesophageal echocardiography:
 The likely diagnosis in this patient is aortic dissection and the most appropriate investigation out of
these options would be transesophageal echocardiography.
 Transoesophageal echocardiography is a diagnostic procedure that involves inserting a specialized
probe into the esophagus to obtain high-resolution images of the heart and its structures. It allows for a
detailed evaluation of cardiac function, valve function, and potential sources of cardiac pathology, such
as blood clots, dissections, or structural abnormalities. 
Option A - MRI (Magnetic Resonance Imaging): MRI is a powerful imaging modality that provides detail
ed images of the body's structures. However, in an acute setting where a patient is unstable with sympt
oms of loss of consciousness, chest pain, and diaphoresis, MRI is not the most appropriate initial inves
tigation. MRI scans take time to perform and may not be readily available in emergency situations. Add
itionally, in this case, the patient's condition suggests a
potential acute cardiovascular event, for which other investigations would be more suitable.
Option C - Cardiac enzymes: Cardiac enzymes, such as troponin and creatine kinase-MB (CK-MB), ar
e blood tests that assess myocardial damage. Elevated levels of these enzymes indicate injury or infar
ction of the heart muscle, which can occur in conditions like a heart attack. While cardiac enzymes are 
essential in the evaluation of chest pain and suspected myocardial injury, they do not provide immediat
e information about the current hemodynamic instability and the cause of the patient's symptoms. Ther
efore, in this acute and unstable scenario, the priority lies in assessing the cardiac structures, which ca
n be achieved through TOE.
Option D - X-ray: X-ray imaging can be useful for evaluating certain conditions, such as lung pathology 
or signs of heart enlargement. However, it is not the most appropriate investigation in this case where t
he patient's presentation suggests an acute cardiovascular event. 
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Solution for Question 81:
Correct Option A - Coarctation of the aorta:
 Coarctation of the aorta is a congenital heart defect characterized by a narrowing of the aorta,
typically occurring after the branching of the left subclavian artery. This narrowing obstructs blood flow
and leads to increased blood pressure in the upper extremities and decreased blood pressure in the
lower extremities. The feeble femoral pulses and elevated upper-limb blood pressure (186/90 mmHg)
seen in the patient are consistent with the findings seen in coarctation of the aorta. Enlarged intercostal
arteries on the chest X-ray can also be seen as collateral circulation develops to bypass the aortic
obstruction.
Solution for Question 82:
Correct Option B - Injection enoxaparin:
 This option is the correct answer. The patient's clinical presentation, history of recurrent chest pain,
and ECG findings of left ventricular hypertrophy and flat T-waves raise concerns for unstable angina or
acute coronary syndrome. Injection enoxaparin, a low molecular weight heparin, is often used as an
initial treatment to prevent clot formation and progression of coronary artery disease. It is an
appropriate choice in this setting to reduce the risk of thrombotic complications.
 Option A, C and D are not appropriate next steps in this patient with unstable angina.
Solution for Question 83:
Correct Option A - Diphtheria:
 One of the common complications of diphtheria is the inflammation of heart muscles or myocarditis.
This can eventually result in cardiomyopathies.
 Options B, C and D are not characteristically associated with cardiomyopathies.
Solution for Question 84:
Correct Option B - Atrioventricular nodal conduction:
 The PR segment indicates atrioventricular nodal conduction.
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Option A - P wave indicates atrial depolarization in the ECG. 
Option C - The QRS complex indicates ventricular depolarization.
Option D - The T wave represents ventricular repolarization in the ECG.
Solution for Question 85:
Correct Option D - S4:
 S4 heart sound is always pathological.
 An S4 heart sound is often a sign of diastolic heart failure or active ischemia. It is rarely a normal
finding, unlike an S3.
 In individuals with active myocardial ischemia, adequate adenosine triphosphate cannot be
synthesized to release myosin from actin. The myocardium will not be able to relax as a result of this. In
such conditions, S4 will be present.
 In a patient experiencing atrial fibrillation, the S4 heart sound will not be heard if the atria do not
contract.
 The S4 sound is low-pitched. It is best heard at the apex with the patient in the left lateral decubitus
position.
 Options A, B and C are incorrect. 
Solution for Question 86:
 Water hammer pulse, also known as Corrigan's pulse or pistol-shot pulse, refers to a forceful and
rapidly collapsing arterial pulse. It is commonly associated with aortic regurgitation, a condition where
the aortic valve fails to close properly, leading to backflow of blood from the aorta into the left ventricle
during diastole.
Solution for Question 87:
Correct Option A - Heart failure:
 This is the correct answer. The patient's symptoms, examination findings, and medical history are
consistent with heart failure. The presence of dyspnea on exertion, elevated jugular venous pressure
(JVP), positive hepatojugular reflux, crackles at the lung bases, hepatomegaly, ascites, and pedal
edema are classic signs of congestive heart failure. The patient's history of diabetes mellitus (DM) and
hypertension (HTN) are common risk factors for the development of heart failure.
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Solution for Question 88:
Correct Option B - Focal oligemia:
 Focal oligemia is not a typical radiological finding in a patient with left heart failure. Focal oligemia
refers to decreased blood flow to a specific area of the lung. While decreased blood flow can occur in
various lung conditions, it is not a specific radiological finding associated with left heart failure.
Option A - Kerley B lines: Kerley B
lines are thin linear opacities seen peripherally in the lung fields on a chest X-ray or CT scan. They repr
esent interstitial edema and are commonly associated with left heart failure.
Option C - Increased venous blood in lung: Left heart failure can lead to increased pressure in the pulm
onary veins, causing congestion and the accumulation of venous blood in the lung. This can be visualiz
ed on imaging studies such as chest X-rays as increased vascular markings and diffuse opacities in th
e lung fields.
Option D - Change in upper lobe circulation: In left heart failure, there can be redistribution of blood flo
w within the lung, leading to changes in the upper lobe circulation. This may manifest as increased blo
od flow to the upper lobes and decreased blood flow to the lower lobes on imaging studies.
Solution for Question 89:
Correct Option A - ECG to rule out atrial fibrillation:
 In this scenario, the patient experienced a brief episode of dizziness and loss of consciousness,
followed by a rapid return to full consciousness. This suggests a transient episode of syncope
(temporary loss of consciousness) or near-syncope. Syncope can have various causes, including
cardiac, neurological, and vasovagal etiologies.
 Performing an ECG (electrocardiogram) is an appropriate initial step to evaluate this patient. Atrial
fibrillation (a type of abnormal heart rhythm) can cause episodes of syncope, particularly if it leads to
significant changes in heart rate or rhythm. Therefore, ruling out atrial fibrillation is an important
consideration.
Option B - If ECG is normal, CT scan should be done: If the ECG is normal, it does not necessarily excl
ude other potential causes of syncope. Further evaluation may still be required. CT scan is not typically
 the initial investigation for transient episodes of syncope unless there are specific indications based on
 the patient's history or examination findings.
Option C - Tilt-table testing: Tilt-table testing is generally reserved for patients with recurrent or unexpla
ined syncope and is not typically indicated for a single episode with no previous similar events.
Option D - Vestibular neuritis is a possible condition that can cause these symptoms: While vestibular 
neuritis can cause dizziness, it does not typically cause loss of consciousness. It is not the most likely 
diagnosis in this case.
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Solution for Question 90:
Correct Option B - Inferior wall MI:
 The diagnosis of an Inferior Wall myocardial infarction is made by elevated cardiac biomarkers (Trop I,
CPK MB, LDH ), the ECG changes of myocardial Ischemia and the clinical symptoms (Levine sign)
such as profuse sweating pain radiating to the left and nausea and vomiting. Here the ECG depicts
evident ST elevation in leads II, III and aVF.
Option A - Anterior wall: In Anterior Wall MI, ECG changes in V1 to V4, aVL are seen.
Option C - Posterior wall MI: Posterior Wall MI, V1 to V4 ST segment involvement is seen.
Option D - Pericarditis: Pericarditis presents clinically with diffuse chest pain. Patient ECG reveals PR s
egment depression and ST-segment elevation (saddle-like) in all leads except aVR.
Solution for Question 91:
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Solution for Question 92:
Correct Option C - Normal sinus rhythm:
 The above ECG strip is that of a normal sinus rhythm. The QRS complexes are narrow, each QRS
complex is preceded by a P wave, the PR interval is constant and the RR interval is constant.
Solution for Question 93:
 Starting CPR is the next best step.
 The ECG reveals ventricular fibrillation which is a life-threatening arrhythmia having high-frequency
ventricular contraction resulting in decreased cardiac output and hemodynamic collapse. Since one
cycle of defibrillation is already given and the patient is still unresponsive, CPR has to be given for 2
minutes, after which the rhythm is to be assessed again.
Solution for Question 94:
Correct Option C - Hyperkalemia:
 Hyperkalemia is characterized by increased serum potassium levels. ECG reveals tall tented T waves
with ST elevation with broad QRS complex and absent p waves.
Solution for Question 95:
Correct Option D - Diuretic:
 Resistant hypertension is defined as uncontrolled blood pressure despite using three different
antihypertensive medications from different drug classes, including a diuretic. The diuretic is an
essential component in treating hypertension as it helps reduce fluid volume and decrease blood
pressure. It is recommended that at least one of the three antihypertensive drugs used in the treatment
of resistant hypertension should be a diuretic.
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Solution for Question 96:
Correct Option C - Rich in sodium:
 The DASH diet recommends limiting the intake of sodium, as high sodium consumption is associated
with increased blood pressure. The diet suggests reducing the use of table salt and avoiding processed
foods that are typically high in sodium, such as fast food, canned soups, and salty snacks.
Option A - Rich in potassium: The DASH diet encourages foods that are rich in potassium, such as fruit
s (e.g., bananas, oranges), vegetables (e.g., spinach, broccoli), and legumes (e.g., beans, lentils). Pota
ssium is known to help lower blood pressure.
Option B - Rich in calcium: The DASH diet also includes foods that are rich in calcium, such as low-fat 
dairy products (e.g., milk, yogurt, cheese) and calcium-fortified foods (e.g., tofu, cereals). Calcium is im
portant for maintaining strong bones and teeth.
Option D - Rich in magnesium: The DASH diet promotes foods that are rich in magnesium, such as wh
ole grains (e.g., brown rice, whole wheat bread), nuts, seeds, and green leafy vegetables. Magnesium i
s beneficial for various body functions, including maintaining normal blood pressure.
 
Solution for Question 97:
Correct Option B - Metoprolol:
 In this case, the patient's age, comorbidities (hypertension, diabetes, coronary artery disease), and
irregularly irregular heartbeats are indicative of atrial fibrillation (AF). The first step in managing AF is
often to control the heart rate, especially in cases where the ventricular rate is elevated and causing
symptoms like palpitations and shortness of breath. Beta-blockers, like metoprolol, are commonly used
for rate control in AF. They slow down the heart rate and improve symptoms by reducing the frequency
of ventricular response to the irregular atrial activity.
Option A - Amiodarone: While amiodarone is an antiarrhythmic medication that can be used to restore 
normal sinus rhythm, it is typically reserved for rhythm control strategies and not the first-line approach 
in managing rate control in AF.
Option C - Electrical cardioversion: Cardioversion might be considered for patients with severe sympto
ms or hemodynamic instability, but it's not usually the initial step unless urgent intervention is required.
Option D - Direct oral anticoagulant (DOAC) therapy: While anticoagulation is important in patients with
 AF to reduce the risk of thromboembolic events, initiating anticoagulation is not the primary step when 
dealing with the patient's palpitations and shortness of breath. Rate control and symptom management
 take precedence in this acute scenario.
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Solution for Question 98:
Correct Option B - Non-cardiovascular death is more in HFpEF-30-40% as compared to HFrEF-15%:
 Heart failure with reduced ejection fraction (HFrEF) is associated with a higher rate of
non-cardiovascular deaths compared to heart failure with preserved ejection fraction (HFpEF). In
HFrEF, approximately deaths are attributed to non-cardiovascular causes, such as infections or other
comorbidities. In contrast, HFpEF tends to have a lower proportion of non-cardiovascular deaths,
estimated to be around 15%. Therefore this statement is false.
Option A - Regardless of ejection fraction and the type of heart failure, the 5-year mortality rate is arou
nd 50%: This statement is generally true. Heart failure, whether with preserved ejection fraction (HFpE
F) or reduced ejection fraction (HFrEF), is associated with a significant risk of mortality. The 5-year mor
tality rate for heart failure is indeed high, estimated to be around 50%, regardless of the specific type or
 ejection fraction.
Option C - Angiotensin converting enzyme (ACE) inhibitors cause cough in 15% and angioedema in 1
%: This statement is generally true. ACE inhibitors, commonly prescribed medications for heart failure 
management, can cause side effects such as cough and angioedema. Approximately 15% of patients t
aking ACE inhibitors may experience a dry, persistent cough.
Option D - Atrial fibrillation is common in the elderly and is the cause of stroke in a
quarter of stroke cases: This statement is generally true. Atrial fibrillation (AF) is a
common cardiac arrhythmia, particularly in the elderly population. It is estimated that AF is present in a 
significant proportion of elderly individuals. AF is associated with an increased risk of stroke, and it is e
stimated to be the cause of stroke in approximately one-quarter of all stroke cases.
Solution for Question 99:
Correct Option D - Jugular veins column is visibly distended without pulsations:
 Cardiac tamponade refers to the accumulation of fluid in the pericardial sac, which puts pressure on
the heart and impairs its ability to pump effectively.
 Jugular veins column is visibly distended without pulsations: This is a characteristic finding in cardiac
tamponade. Due to the increased pressure in the pericardial sac, the jugular veins become visibly
distended, but the normal pulsations with each heartbeat are diminished or absent.
Option A - Pulsus Paradoxus is always present: Pulsus paradoxus is a finding characterized by an abn
ormal drop in blood pressure during inspiration. While it can be seen in cardiac tamponade, it is not alw
ays present and can vary depending on the severity of tamponade and other factors.
Option B - Kussmaul sign is always present: Kussmaul sign refers to an abnormal rise in jugular venou
s pressure during inspiration. It is not specific to cardiac tamponade and can be seen in various cardiac
 and respiratory conditions. It is not always present in cardiac tamponade.
Option C - Tall A wave is present: The A wave represents atrial contraction on the jugular venous pulse
 waveform. In cardiac tamponade, the elevated pressure in the pericardial sac can impair atrial filling, l
eading to a reduced or absent A wave rather than a tall A wave.
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Solution for Question 100:
Correct Option A - ASD:
 An atrial septal defect is a congenital heart defect characterized by an abnormal opening in the
septum (the wall) between the two atria of the heart. A wide fixed split S2 on auscultation is a
characteristic finding in atrial septal defects (ASD), where there is abnormal communication between
the atria. It allows increased blood flow from the left atrium to the right atrium, causing a delay in the
closure of the pulmonic valve, resulting in a wide fixed split S2.
Option B - VSD (Ventricular Septal Defect): A ventricular septal defect is another type of congenital he
art defect where there is an abnormal opening in the septum between the two ventricles. It typically pro
duces a harsh holosystolic murmur, rather than a wide fixed split S2 heard on auscultation.
Option C - TOF (Tetralogy of Fallot): Tetralogy of Fallot is a
congenital heart condition characterized by a combination of four heart defects: ventricular septal defec
t, pulmonary stenosis, right ventricular hypertrophy, and overriding aorta. The characteristic murmur in 
TOF is a systolic ejection murmur and not specifically associated with a wide fixed split S2.
Option D - BAV (Bicuspid Aortic Valve): Bicuspid aortic valve is a congenital heart condition in which th
e aortic valve has two cusps instead of the normal three. While it can be associated with aortic stenosis
 or regurgitation, it is not specifically associated with a wide fixed split S2.
Solution for Question 101:
Correct Option D - 4:
 The combination of shortness of breath, bilateral pitting pedal edema, elevated jugular venous pulse,
and hepatomegaly suggests right sided congestive heart failure (CHF).
 4th arrow points at the right ventricle the likely affected chamber in this case.
Option A - 1: The first points at the left atrium, but the diagnosis here is that of a
patient with right sided heart failure.
Option B -2:  The second arrow points at the left ventricle. Therefore this option is also incorrect.
Option C -3: The third  arrow points toward the right atrium.
 
Solution for Question 102:
Correct Option A - Defibrillation:
 Based on the information provided and the rhythm strip, the likely diagnosis is ventricular fibrillation.
Out of the given options, the most appropriate next step in management would be unsynchronized
cardioversion/defibrillation.
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 Options B, C, and D are incorrect
 
Solution for Question 103:
Correct Option B - Severe Asthma or Chronic Obstructive Pulmonary Disease:
 During severe asthma attacks or exacerbations of COPD, airway resistance increases significantly
during inspiration. This leads to increased negative intrathoracic pressure, affecting venous return to
the heart and causing a drop in systolic blood pressure during inspiration.
 Options A, C and D are not associated with pulsus paradoxus.
 
Solution for Question 104:
Correct Option D - Arch of aorta:
 Takayasu arteritis typically affects the aorta and its major branches, particularly the branches arising
from the arch of the aorta. The disease leads to inflammation, thickening, and narrowing of these
arteries, which can result in reduced blood flow to various organs and tissues. The most commonly
involved area in Takayasu arteritis is the aorta, specifically the branches arising from the aortic arch,
which includes the brachiocephalic trunk, left common carotid artery, and left subclavian artery.
Option A - Pulmonary artery: The involvement of the pulmonary artery, coronary arteries, and abdomin
al aorta can occur in Takayasu arteritis, but it is less common compared to the involvement of the arch 
of the aorta. Pulmonary artery involvement, known as pulmonary artery arteritis, occurs in a
small proportion of cases. It can lead to pulmonary hypertension and other pulmonary complications.
Option B - Coronary arteries: Coronary artery involvement, known as coronary arteritis, can occur in Ta
kayasu arteritis but is relatively rare. It can result in reduced blood flow to the heart, leading to sympto
ms such as chest pain (angina) or even heart attack.
Option C - Abdominal aorta: Abdominal aorta involvement can also be seen in Takayasu arteritis, but it
 is less common compared to the involvement of the arch of the aorta
 
Solution for Question 105:
Correct Option C - Permanent pacemaker:
 Based on the given information, the correct long-term treatment option for the condition described
would be a "Permanent pacemaker." The 24-hour ECG strip suggests the presence of sinus node
dysfunction (sick sinus syndrome) characterized by bradycardia (slow heart rate), pauses, and sinus
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arrests. This condition is commonly seen in individuals who have had a previous myocardial infarction.
Option A - Amiodarone: Amiodarone is an antiarrhythmic medication used to treat various cardiac arrhy
thmias. However, it is not the primary treatment for sinus node dysfunction. In this case, the patient's s
ymptoms are related to bradycardia (slow heart rate) rather than a specific arrhythmia.
Option B - Atropine only: Atropine is a medication used for acute management of symptomatic bradyca
rdia. However, in the long term, it is not a
suitable treatment for sinus node dysfunction. Atropine is typically used in emergency situations or as a
temporary measure before definitive treatment such as a pacemaker is implemented.
Option D - Atropine and isoproterenol: Isoproterenol is a medication that acts as a cardiac stimulant an
d can increase heart rate. While it may be used in certain acute situations, it is not an appropriate long-
term treatment for sinus node dysfunction. Additionally, combining atropine and isoproterenol is not a
typical approach for managing this condition.
 
Solution for Question 106:
Correct Option D - Amlodipine:
 The most appropriate antihypertensive for a patient with stable angina and consistently elevated blood
pressure would be Amlodipine. 
 Amlodipine is a calcium channel blocker that is frequently used to treat hypertension. It is particularly
beneficial in patients with stable angina, as it can improve coronary blood flow by reducing vasospasm
and decreasing myocardial oxygen demand. Additionally, amlodipine has a favorable effect on blood
pressure control, which makes it suitable for patients with both stable angina and hypertension.
 Therefore, based on the patient's diagnosis of stable angina and consistently elevated blood pressure,
the most appropriate antihypertensive choice would be Amlodipine.
 Stable angina is a condition characterized by chest pain or discomfort that occurs during physical
exertion or stress and is relieved by rest or nitroglycerin. It is commonly associated with underlying
coronary artery disease.
 In this case, the patient has stable angina and consistently elevated blood pressure. Treating
hypertension is an essential component of managing stable angina, as uncontrolled high blood
pressure can worsen ischemic symptoms and increase the risk of cardiovascular events.
Option A - Atenolol: Atenolol is a beta-blocker commonly used to treat hypertension. While beta-blocke
rs can be effective in managing stable angina by reducing heart rate and myocardial oxygen demand, t
hey are not the ideal choice in patients with consistently elevated blood pressure, as they may further 
worsen blood pressure control.
Option B - Thiazides: Thiazide diuretics are a class of medications used to treat hypertension. They hel
p reduce blood pressure by promoting diuresis and decreasing fluid volume. However, they may not be
 the most appropriate choice in this case since the patient already has stable angina, and thiazides are 
not specifically indicated for the treatment of angina.
Option C - Enalapril: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that is commonly us
ed in the management of hypertension. While ACE inhibitors are effective antihypertensive agents, the
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y may not be the initial choice in this case, considering the patient's primary symptom of stable angina. 
Other factors, such as heart rate control and relief of ischemic symptoms, need to be considered.
Solution for Question 107:
Correct Option A - Right ventricle:
 The pacemaker lead is typically placed in the right ventricle for most pacemaker implantations. This
positioning allows the electrical impulses generated by the pacemaker to be delivered to the right
ventricle, which then stimulates the heart muscle to contract and maintain an appropriate heart rhythm.
 
Solution for Question 108:
 Based on the symptoms described in the postoperative cardiac surgical patient, the most probable
 Cardiac tamponade is a medical emergency characterized by the accumulation of fluid or blood in the
pericardial sac, which leads to compression of the heart and impaired cardiac function. The symptoms
typically include sudden hypotension (low blood pressure), raised central venous pressure (elevated
jugular venous distention), and pulsus paradoxus (an exaggerated drop in blood pressure during
inspiration). These symptoms usually occur within the first few hours to days after surgery.
Option A - Ventricular dysfunction: While ventricular dysfunction can cause hypotension and cardiac sy
mptoms, it does not typically present with raised central venous pressure or pulsus paradoxus. Additio
nally, the sudden onset of symptoms in this case suggests a
more acute problem like cardiac tamponade rather than chronic ventricular dysfunction.
Option C - CHF (Congestive Heart Failure): CHF can cause fluid retention, leading to increased venou
s pressure and symptoms such as dyspnea and edema. However, it does not typically present with sud
den hypotension, raised central venous pressure, or pulsus paradoxus. Cardiac tamponade is a
more likely explanation for the acute symptoms in this case.
Option D - Excessive mediastinal effusion: Excessive mediastinal effusion can potentially cause compr
ession of the heart and lead to symptoms similar to cardiac tamponade. However, the specific mention 
of raised central venous pressure and pulsus paradoxus points more towards cardiac tamponade as th
e likely diagnosis.
 
Solution for Question 109:
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 Constrictive pericarditis is a condition characterized by inflammation and fibrosis of the pericardium,
the sac-like structure surrounding the heart. It leads to the stiffening of the pericardium, impairing the
normal filling and functioning of the heart.Therefore, based on the given clinical features of shortness of
breath, tiredness, engorged neck veins, and JVP showing rapid X and Y descent, the most likely
diagnosis is constrictive pericarditis.
 Options B, C and D are not associated with the features described in the vignette and are incorrect.
 
Solution for Question 110:
Correct Option B - Libman sacks endocarditis:
 Based on the given clinical findings, the most probable diagnosis for the patient is Libman-Sacks
endocarditis.
 Libman-Sacks endocarditis is a form of nonbacterial endocarditis (also known as nonbacterial
thrombotic endocarditis) that is commonly associated with systemic lupus erythematosus (SLE). It is
characterized by the presence of small, sterile vegetations on the heart valves, particularly the mitral
and aortic valves.
Option A - Infective endocarditis: While infective endocarditis can also cause vegetations on the heart v
alves, the presence of malar rashes suggests an autoimmune condition like SLE rather than an infectio
us etiology.
Options C and D are incorrect.
Solution for Question 111:
Correct Option D - Pitting pedal edema:
 Pitting pedal edema refers to the swelling of the feet and ankles that occurs when pressure is applied
to the affected area, causing an indentation or "pit" that persists for some time after the pressure is
released. This type of edema is commonly associated with congestive cardiac failure.
 
Solution for Question 112:
Correct Option A - Left atrium:
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 Mitral stenosis leads to increased pressure in the left atrium, causing left atrial enlargement. On a
chest x-ray, this can be visualized as a bulge or enlargement of the left heart border.
Options B, C, and D are incorrect.
Solution for Question 113:
Correct Option B - Hypothermia:
 Osborn waves, also known as J waves or camel humps, are a characteristic ECG finding seen in
hypothermia. They appear as positive deflections at the J point, just following the QRS complex. These
waves are most prominent in the precordial leads (V2-V6) and can be seen in other leads as well.
Solution for Question 114:
Correct Option A - HOCM (Hypertrophic Obstructive Cardiomyopathy):
 In HOCM, the murmur increases on standing due to decreased preload. This is known as the
"standing murmur" phenomenon. HOCM is characterized by the hypertrophy of the left ventricular wall,
particularly the septum. This hypertrophy causes obstruction to the outflow of blood from the left
ventricle during systole, resulting in a murmur.
 Options B, C and D are not associated with a murmur that increases on standing.
Solution for Question 115:
Correct Option A - Hypokalemia:
 This option is correct because the ECG findings in the question, such as ST segment depression,
decreased amplitude of T waves, and increased amplitude of U waves, are characteristic of
hypokalemia. Hypokalemia refers to low levels of potassium in the blood, which can lead to
disturbances in cardiac electrical conduction.
Option B - Hyperkalemia: Hyperkalemia is characterized by different ECG changes, including peaked T
waves, prolonged PR interval, widened QRS complex, and a sine wave pattern.
Option C - Hypocalcemia: Hypocalcemia can present with its own characteristic ECG changes, such as
 prolonged QT interval, but those findings are not mentioned in the question.
Option D - Hypercalcemia: Hypercalcemia can lead to various ECG changes, including short QT interv
al and prolonged PR interval, but these findings are not mentioned in the question.
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Solution for Question 116:
Correct Option D - ≥160/100 mmHg:
 According to the current guidelines of AHA, immediate pharmacological management should be
initiated in patients with hypertension if their blood pressure readings are consistently at or above
≥160/100 mmHg
Solution for Question 117:
Correct Option D - DC cardioversion:
 DC cardioversion is the correct option. In the case of a patient with atrial fibrillation who is
unconscious and hemodynamically unstable, the next best step in management is immediate DC
cardioversion. DC cardioversion involves delivering an electric shock synchronized with the patient's
heartbeat to restore normal heart rhythm. This intervention is necessary to stabilize the patient and
restore normal cardiac output.
 Options A, B, and C are not appropriate management choices for this patient with AF with
hemodynamic compromise.
 
Solution for Question 118:
Correct Option A - Takotsubo cardiomyopathy:
 Takotsubo cardiomyopathy, also known as "broken heart syndrome," is a condition characterized by
transient left ventricular dysfunction that typically occurs following an emotional or physical stressor.
 The ECG findings in Takotsubo cardiomyopathy can vary and may not always match the observed
myocardial stunning pattern.
 This discrepancy between ECG findings and myocardial function is a characteristic feature of
Takotsubo cardiomyopathy.
Option B - Restrictive cardiomyopathy: Restrictive cardiomyopathy is a type of cardiomyopathy charact
erized by stiffening of the heart muscle, which impairs its ability to relax and fill with blood. The ECG fin
dings in restrictive cardiomyopathy may show features such as low voltage QRS complexes and atrial 
abnormalities, but they are not typically associated with a
discrepancy between ECG findings and myocardial stunning pattern.
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Option C - Brugada syndrome is an autosomal dominant disorder associated with a loss of function mu
tation in cardiac sodium channels that predisposes affected individuals to fatal cardiac arrhythmias.
Option D - Pericardial tamponade: Pericardial tamponade is a condition characterized by the accumula
tion of fluid in the pericardial sac, which compresses the heart and impairs its ability to fill properly. The
 ECG findings in pericardial tamponade often show specific patterns, such as electrical alternans and l
ow voltage QRS complexes.
Solution for Question 119:
Correct Option D - All the above:
 Automatic implantable cardioverter-defibrillator (AICD) implantation is indicated for all of the
mentioned conditions.
Option A - Brugada syndrome: AICD implantation is recommended for patients with Brugada syndrome
 who have a
history of aborted sudden cardiac death (SCD), syncope, or documented ventricular arrhythmias.
Option B
- Ventricular fibrillation: AICD implantation is the treatment of choice for patients who have survived a c
ardiac arrest due to ventricular fibrillation (VF) or sustained ventricular tachycardia (VT) with hemodyna
mic compromise.
Option C - Acute coronary syndrome with low ejection fraction: AICD implantation is considered for pati
ents with acute coronary syndrome who have reduced left ventricular ejection fraction (EF) (typically ≤3
5%) and are at risk of sudden cardiac death.
Solution for Question 120:
Correct Option D - A patient who is awaiting cardiac arrest in the hospital:
 This refers to a patient who is in a critical condition and expected to die imminently within the hospital
setting. These patients may have conditions such as end-stage organ failure, irreversible brain
damage, or severe trauma that cannot be treated successfully. They are kept under palliative care until
their natural death occurs, at which point their organs may be considered for donation.
Option A - Dead on arrival: This is a category 1 donor.
Option B - A patient who died after failed resuscitation after reaching the hospital: This is a category 2 
donor. In this case, resuscitation efforts were attempted upon the patient's arrival at the hospital but we
re unsuccessful. While this patient did experience cardiac arrest, they would not fall under the category
 of no-heart-beating donor as resuscitation attempts were made.
Option C - A patient who was bought dead to the hospital: If a patient is brought dead to the hospital, it 
means they were already deceased upon arrival. Similar to the first option, this patient would not meet t
he criteria for no-heart-beating donation.
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 Late cardiovascular syphilis refers to the tertiary stage of syphilis where the infection has progressed
and affected the cardiovascular system. It is characterized by the formation of gummas (soft,
non-cancerous growths) in the cardiovascular tissues, including the heart, aorta, and blood vessels.
 The treatment of choice for late cardiovascular syphilis is benzathine penicillin. Benzathine penicillin is
a long-acting form of penicillin that is administered intramuscularly. The recommended regimen for late
cardiovascular syphilis is benzathine penicillin 2.4 million units administered once weekly for three
weeks. This treatment regimen ensures adequate antibiotic levels in the blood to effectively eliminate
the Treponema pallidum bacteria that cause syphilis.
 
Solution for Question 124:
Correct Option D - LDL more than 100mg/dl:
 Syndrome Z, also known as Metabolic Syndrome, is a cluster of risk factors that increase the risk of
cardiovascular disease and type 2 diabetes. It is characterized by a combination of obesity (especially
abdominal obesity), insulin resistance or glucose intolerance, hypertension (blood pressure more than
130/85 mmHg), and dyslipidemia (elevated triglycerides and/or reduced HDL cholesterol).
 LDL more than 100mg/dl: This is the correct answer. While LDL (low-density lipoprotein) cholesterol is
an important lipid parameter to assess cardiovascular risk, it is not specifically included as a component
of metabolic syndrome. However, it is worth noting that dyslipidemia in metabolic syndrome typically
involves elevated triglycerides and decreased HDL cholesterol levels rather than specific LDL cutoffs.
 Options A, B and C are components of metabolic syndrome
Solution for Question 125:
Correct Option B - Takotsubo cardiomyopathy:
 Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy or broken heart syndrome,
is a condition characterized by sudden temporary weakening of the heart muscle. It is typically triggered
by intense emotional or physical stress. The name "Takotsubo" refers to the shape of the affected left
ventricle, which resembles a Japanese octopus trap.
 In the given scenario, the sudden onset of chest pain and collapse in the elder brother during an
argument over a property dispute suggests a possible emotional trigger, which is commonly associated
with Takotsubo cardiomyopathy. It is important to note that emotional stressors, such as arguments or
intense emotional experiences, can lead to the release of stress hormones that can have a direct
impact on the heart, causing transient cardiac dysfunction.
Option A - Infective cardiomyopathy: Infective cardiomyopathy refers to myocardial inflammation cause
d by an infection, such as viral or bacterial myocarditis. While infective cardiomyopathy can present wit
h chest pain and sudden death, there is no mention of an infectious illness or symptoms suggestive of 
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an infection in the given scenario.
Option C - Acute myocardial infarction: Acute myocardial infarction, commonly known as a
heart attack, occurs when there is a
sudden blockage of blood flow to the heart muscle, usually due to a clot in a
coronary artery. While chest pain and sudden death can be associated with a
heart attack, the absence of risk factors, such as atherosclerosis or a
previous history of heart disease, and the presence of emotional stress as a
triggering factor make acute myocardial infarction less likely in this case.
Option D - Hypertrophic cardiomyopathy: Hypertrophic cardiomyopathy is a genetic heart condition cha
racterized by abnormal thickening of the heart muscle, leading to impaired heart function. While hypertr
ophic cardiomyopathy can cause sudden cardiac death, the absence of a
family history of similar diseases makes it less likely in this scenario.
Solution for Question 126:
Correct Option A - Right atrial contraction: 
 'a' wave in JVP corresponds to right atrial contraction.
 In the jugular venous pulse (JVP) waveform, there are different waves that correspond to specific
events in the cardiac cycle. The 'a' wave represents the contraction of the right atrium, specifically the
atrial systole.
 During the cardiac cycle, the 'a' wave occurs following the 'c' wave. The 'c' wave is caused by the
bulging of the tricuspid valve into the right atrium during ventricular contraction. As the ventricles
contract and the tricuspid valve closes, the right atrium contracts, leading to a rise in pressure. This
atrial contraction creates the 'a' wave in the JVP waveform.
  Options B, C and D are incorrect.
 
Solution for Question 127:
Correct Option D - All of the above:
 Relative bradycardia refers to a situation where the heart rate is lower than expected in the presence
of an elevated body temperature. It is characterized by a heart rate that is relatively slower compared to
the degree of fever. Relative bradycardia can occur in various infectious diseases, including typhoid
fever, Q fever, and leptospirosis.
 In typhoid fever, caused by Salmonella typhi, relative bradycardia is a classic finding. The fever is
typically high but the heart rate remains disproportionately lower than expected.
 There are no incorrect choices in this question, as all of the options A, B & C (typhoid fever, Q fever,
and leptospirosis) are correct
 
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Solution for Question 128:
 In tension pneumothorax, breath sounds are diminished or absent on the affected side. The
accumulation of air compresses the lung, leading to reduced air entry and decreased breath sounds.
Options B, C and D are associated with cardiac tamponade and tension pneumothorax.
 
Solution for Question 129:
 The cardiac axis represents the overall direction of electrical activity in the heart. The positive (+) sign
indicates that the electrical activity is predominantly directed towards the positive electrode in a
particular lead.
 Lead aVF: Lead aVF is positioned on the bottom of the hexaxial reference system, and it looks
upwards towards the heart. In a normal heart with a +90-degree axis, the electrical activity is directed
downwards and to the left side of the body. Therefore, lead aVF would show a maximum R wave, as it
is oriented towards the direction of the electrical activity.
Options B, C and D are incorrect.
Solution for Question 130:
Correct Option: C
 In the case of an ECG tracing showing asystole, which represents the absence of any electrical
activity in the heart, the best intervention is immediate cardiopulmonary resuscitation (CPR) followed by
the administration of intravenous epinephrine (adrenaline) 1mg.
 Injection of Adrenaline (epinephrine) 1mg IV: This is the correct intervention for asystole. Epinephrine
is a vasopressor and cardiac stimulant that helps increase coronary and cerebral blood flow during
CPR, enhancing the chances of successful resuscitation.
Options A, B, and D are not the best treatment options in this patient. The appropriate course of manag
ement would be to start CPR followed by IV adrenaline.
Solution for Question 131:
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 When measuring blood pressure in a patient with cardiac tamponade, it is important to ensure that the
patient is in a relaxed state and breathing normally. This is because taking deep breaths or holding the
breath can potentially alter the intrathoracic pressure and affect the hemodynamic status of the patient.
 Cardiac tamponade is a condition characterized by the accumulation of fluid or blood in the pericardial
space, which puts pressure on the heart and impairs its ability to fill and pump effectively. This can lead
to decreased cardiac output and compromised blood pressure.
 In this scenario, it is crucial to measure the patient's blood pressure accurately to assess the severity
of the tamponade and guide appropriate management. Asking the patient to breathe normally helps
maintain stable intrathoracic pressure and provides a more accurate reflection of the patient's true
blood pressure.
 
Solution for Question 132:
 Metoprolol is a beta-blocker medication that primarily works by blocking beta-adrenergic receptors in
the heart, leading to a decrease in heart rate and cardiac contractility. Verapamil, on the other hand, is
a calcium channel blocker that primarily acts by blocking calcium channels in the heart and blood
vessels, resulting in vasodilation and a decrease in heart rate.
 When verapamil is added to metoprolol, there is an increased risk of bradycardia (slow heart rate) with
AV block (impairment of electrical conduction between the atria and ventricles). This is because both
medications have negative chronotropic effects, meaning they decrease the heart rate. The
combination of these drugs can potentiate this effect and lead to excessive slowing of the heart rate,
potentially resulting in bradycardia and AV block.
Options A, C and D are incorrect.
 
Solution for Question 133:
Correct Option: D
The correct answer for the HV interval in the given His bundle electrogram is "From bundle of His and 
bundle branches to ventricles."
 The HV interval represents the time it takes for electrical conduction to occur from the His bundle and
bundle branches to the ventricles of the heart.
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Solution for Question 134:
Troponin-T is a cardiac biomarker that is highly specific to cardiac muscle injury. It is released into the 
bloodstream when there is damage to the heart muscle, such as in myocardial infarction (MI). Troponin
-T levels typically start to rise within 3-4 hours after the onset of myocardial injury and remain elevated 
for several days. Therefore, it is considered the best investigation for diagnosing MI within 2-4 hours of 
symptom onset.
Troponin-T measurement is widely used in clinical practice for the diagnosis of MI, as it provides high s
ensitivity and specificity for cardiac injury. Elevated troponin-T levels, in conjunction with clinical sympt
oms and other diagnostic tests, help confirm the diagnosis of MI and guide appropriate management.
Option A. LDH (Lactate dehydrogenase): LDH is an enzyme found in various tissues, including the hea
rt. However, it lacks specificity for cardiac injury. LDH levels may increase in MI, but it is not the best in
vestigation for early diagnosis within 2-4 hours.
Option B. CK-MB (Creatine kinase-MB): CK-MB is an isoform of the enzyme creatine kinase that is pre
dominantly found in the heart. It is released into the bloodstream following cardiac muscle injury. Howe
ver, CK-MB levels may take several hours to rise, and it is not as specific for early diagnosis of MI as tr
oponin-T.
Option D. BNP (B-type natriuretic peptide): BNP is a hormone released by the ventricles of the heart in 
response to increased stretching of cardiac muscle cells. It is primarily used for diagnosing and assessi
ng the severity of heart failure. BNP levels are not specific to myocardial infarction and do not provide ti
mely diagnosis within 2-4 hours.
Solution for Question 135:
High anion gap acidosis with low bicarbonate levels is a characteristic finding in several metabolic acid
osis conditions. However, renal disorders, specifically renal tubular acidosis (RTA), typically present wit
h a normal anion gap acidosis rather than a high anion gap acidosis.
In RTA, the kidneys are unable to properly excrete hydrogen ions or reabsorb bicarbonate, resulting in 
a normal anion gap metabolic acidosis. This condition is often associated with a
normal or near-normal bicarbonate level.
Option B. Diabetic ketoacidosis: Diabetic ketoacidosis (DKA) is a condition characterized by high blood
 glucose levels and the production of ketones due to insulin deficiency. It is a common cause of high an
ion gap metabolic acidosis. In DKA, there is an increase in the production of ketones (such as beta-hyd
roxybutyrate and acetoacetate), leading to the acidosis.
Option C. Lactic acidosis: Lactic acidosis occurs when there is an excessive production or reduced cle
arance of lactic acid. It can result from various conditions, such as tissue hypoperfusion, severe infectio
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ns, certain medications, and underlying metabolic disorders. Lactic acidosis is typically associated with 
a high anion gap and low bicarbonate levels.
Option D. Salicylate poisoning: Salicylate poisoning, often seen with aspirin overdose, can lead to high 
anion gap metabolic acidosis. Salicylates can directly affect cellular metabolism, leading to the producti
on of organic acids and a
subsequent increase in anion gap. Bicarbonate levels are typically decreased in salicylate poisoning.
Solution for Question 136:
Correct option D: 
 Rescue breaths are given in the ratio of 30:2 not 15:2
 Therefore this option is the answer 
Option A: CPR cycle duration is 2
minutes. This is true and represents the recommended duration for each cycle of CPR (i.e., a combinat
ion of chest compressions and rescue breaths) before reassessment of the patient's rhythm and pulse.
Option B: Chest compressions at 100-120/min. This is true and represents the recommended rate of c
hest compressions during CPR. Adequate chest compressions help maintain blood circulation and imp
rove the chances of successful defibrillation.
Option C: Start CPR followed by immediate defibrillation. This is true and represents the standard appr
oach to managing ventricular fibrillation. In the event of a cardiac arrest due to ventricular fibrillation, im
mediate CPR (consisting of chest compressions and rescue breaths) should be initiated, and defibrillati
on should be performed as soon as a defibrillator is available. Early defibrillation is crucial in restoring a
normal heart rhythm.
 
Solution for Question 137:
Correct option: B
Explanation
 In the ECG given above, the ST segment elevation is present in the: Anterior leads (V2-V4) Lateral
leads (V5-V6, I, and aVL)
 Anterior leads (V2-V4)
 Lateral leads (V5-V6, I, and aVL)
 The patient’s symptoms and ECG findings are suggestive of myocardial infarction in the anterior and
lateral walls of the heart.
 The most likely cause of it is an occlusion in the proximal left anterior descending artery.
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Incorrect options
Solution for Question 138:
Correct  option B. 
 Digoxin is primarily used to control symptoms and improve quality of life in patients with heart failure.
It helps in reducing heart rate and controlling certain arrhythmias associated with heart failure, but it has
not been shown to reduce mortality.
Option A. Metoprolol: Metoprolol is a beta-blocker and has been shown to reduce mortality in patients 
with heart failure. It improves symptoms, reduces hospitalizations, and improves overall survival.
Option C. Captopril: Captopril is an ACE inhibitor and has been demonstrated to reduce mortality and i
mprove outcomes in patients with heart failure. It helps in reducing afterload, improving cardiac functio
n, and slowing disease progression.
Option D. K+ sparing diuretics: K+ sparing diuretics such as spironolactone and eplerenone are used i
n combination with other heart failure medications. They help in reducing fluid retention and edema but
 have also been shown to reduce mortality in patients with heart failure.
 
Solution for Question 139:
Correct option: A
 Continuous murmurs begins in systole, peaks near the second heart sound, and continues into all or
part of diastole.
 It is seen in Peripheral pulmonic stenosis
 Peripheral pulmonic stenosis is a Congenital heart defect
 Narrowing of one or more branches of the pulmonary artery is known as Peripheral pulmonic stenosis
 Due to narrowing there will be turbulence which will be present in both systole and diastole
Options B, C and D are not associated with a continuous murmur.
Solution for Question 140:
Correct option B:
 "Decrease in systolic blood pressure 20 mm Hg within 3 mins of postural change."
216

BCLS,ACLS,Mechanical Ventilation
1. A 50-year-old female collapsed to the ground while walking. You happened to be a bystander and
approached the patient .On examination, a pulse was felt but breathing efforts were absent. .What is
the next step in managing this patient?
A. One cycle of cardiopulmonary resuscitation in 2 minutes
B. 10-12 breaths/minute or 1 breath every 6 seconds
C. Monitor the patient until the emergency services arrive
D. Automated External Defibrillator
2. During a cardiopulmonary resuscitation (CPR) scenario, what is the recommended rate for chest
compressions, and how often should 2 rescue breaths be administered in accordance with the standard
compression-to-ventilation ratio?
A. Chest compressions at a rate of 80-100/minute with 2 rescue breaths every 15 compressions (15:2)
B. Chest compressions at a rate of 120-140/minute with 2 rescue breaths every 20 compressions (20:2)
C. Chest compressions at a rate of 100-120/minute with 2 rescue breaths every 30 compressions
(30:2)
D. Chest compressions at a rate of 60-80/minute with 2 rescue breaths every 10 compressions (10:2)
3. A medical rescue team approached a man who collapsed in the middle of the road.Mark the option
with the appropriate positioning of the doctor.
A. Head end
B. Foot end
C. Left side
D. Right side
4. During cardiopulmonary resuscitation (CPR), what is the most commonly injured solid organ?
A. Kidneys
B. Spleen
C. Liver
D. Lungs
5. Which of the following are true regarding mechanical ventilation? a. Tidal volume in ARDS is 12ml/kg
b. Fi O2 is started from 0.4 c. Tidal volume can be adjusted according to the weight of the patient d.
Respiratory rate is increased in DKA and raised ICT e. Peak pressure of 30 cm of water to limit
Barotrauma f. PEEP of 5 cm of water will help in the recruitment of alveoli
A. a,c,e,f
B. b,d,e,f
C. b,c,d,e
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D. a,d,e,f
6. During the use of an Automated External Defibrillator (AED), what is the standard energy level,
measured in joules, delivered in a direct current (DC) shock when the device detects a shockable
rhythm?
A. 50 Joules
B. 100 Joules
C. 150 Joules
D. 200 Joules
7. A newborn who was delivered through LSCS has no signs of breathing. Which of the following is true
regarding CPR in this patient?
A. 3:2 with 1-2 rescuers
B. 30:2 with 1 rescuer
C. 15:2 with 2 rescuers
D. 3:1 with 2 rescuers
8. A 55-year-old male who collapsed was rushed to the Emergency department for rescue. The ECG
was taken and is shown below. The doctor started resuscitation and failed even after giving two rounds
of non-synchronized DC shock, CPR , and epinephrine administration.What is the next step in
management?
A. Advanced airway
B. 3rd non-synchronized DC shock
C. IV Amiodrone
D. Targeted temperature management
9. Synchronized DC shock is given at the peak of which wave?
A. Peak of P wave
B. Peak of Q wave
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C. Peak of R wave
D. Peak of T wave
10. Which of the following is stored at room temperature?
A. Platelets
B. PRBC
C. FFP
D. Plasma
11. Administration of 4 units of PRBC,4 units of FFP, one unit of SDP is done in which round of massive
blood transfusion?
A. Round 1
B. Round 2
C. Round 3
D. Round 4
12. Which of the following correctly describes massive transfusion protocol?
A. Replacement of the entire blood volume with more than 10 Units of whole blood within 24 hours
B. Replacement of the entire blood volume with more than 3 units of whole blood given within 4 hours
period
C. Replacement of the entire blood volume with by more than 10 Units of whole blood within 12 hours
D. Replacement of the entire blood volume more than 2.5 L of whole blood given within 2 hours period
13. The assessment of blood component score (ABC score) during massive blood transfusion includes
all of the following except
A. HR
B. RR
C. SBP
D. Penetrating injury
14. Identify the correct ratio of PRBC:FFP:SDP to be administered in a massive transfusion protocol?
A. 1:1:1
B. 1:2:1
C. 1:1:6
D. 1:1:0.25
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Question 4 3
Question 11 2
Question 13 2
Correct Option B - 10-12 breaths/minute or 1 breath every 6 seconds:
 Absent respiration and positive pulse is an indication to give rescue breaths
Option A - One cycle of cardiopulmonary resuscitation is 2
minutes: This is indicated when both pulse and respiration are absent
Option C - Monitor the patient until the emergency services arrive: This is indicated when both pulse an
d respiration is present but there is loss of consciousness.
Option D - Automated External Defibrillator: This is done by trained paramedic staff and doctors once t
he emergency services arrive.
Correct Option C - Chest compressions at a rate of 100-120/minute with 2
rescue breaths every 30 compressions (30:2):
 In cardiopulmonary resuscitation (CPR), the recommended rate for chest compressions is 100-120
compressions per minute. The standard compression-to-ventilation ratio is 30 compressions followed
by 2 rescue breaths. This sequence helps maintain an effective balance between chest compressions
and ventilation to optimize blood circulation and oxygenation during CPR.
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Option A - Chest compressions at a rate of 80-100/minute with 2
rescue breaths every 15 compressions (15:2): This option suggests a compression rate lower than the 
recommended range (80-100/minute) and an unusual compression-to-ventilation ratio (15:2).
Option B - Chest compressions at a rate of 120-140/minute with 2
rescue breaths every 20 compressions (20:2): This option suggests a
higher compression rate (120-140/minute) than the recommended range and a
different compression-to-ventilation ratio (20:2).
Option D - Chest compressions at a rate of 60-80/minute with 2
rescue breaths every 10 compressions (10:2): This option suggests a lower compression rate (60-80/m
inute) than the recommended range and an unusual compression-to-ventilation ratio (10:2).
Correct Option C - Left side:
 Doctor/ nurse stands to the left to gain IV access
 
Options - A, B, D are incorrect statements
Correct Option C - Liver:
 During CPR, the most commonly injured solid organ is the liver. The liver is located in the right upper
quadrant of the abdomen, beneath the ribcage. The forceful chest compressions involved in CPR can
lead to injury, particularly when the hands are placed on the lower third of the sternum. Placing the
hands too low, such as on the xiphisternum (pointed part of the sternum), can cause injury to the liver.
 
Option A - Kidneys: The kidneys are not typically at risk of injury during chest compressions in CPR. Th
ey are located in the retroperitoneal space, well-protected by the spine and muscles.
Option B - Spleen: The spleen is located in the left upper quadrant of the abdomen. While it is an organ
 that can be injured in traumatic situations, it is less commonly affected during standard chest compres
sions in CPR.
Option D - Lungs: Lungs are not considered solid organs; they are soft and elastic tissues. During CPR
, the focus is on chest compressions to circulate blood, and lung injury is not a common occurrence.
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- Replacement of the entire blood volume with more than 10 Units of whole blood within 24 hours:
Definition of massive transfusion protocol
 Replacement of the entire blood volume of the patient by more than 10 Units of whole blood within 24
hours or more than 2.5 L (5 units) of whole blood given within 4 hours period.
Options B, C, D- Refer to the above explanation.
Correct Option B- RR is not assessed in ABC score:
Triggers of massive transfusion protocol
 Assessment of blood component score (ABC score)
Components
Points
Penetrating injury
1
FAST positive
HR >100/min
SBP <90 mm Hg
 
 If ABC score ≥ 2 then there is 75% accuracy in the prediction of massive transfusion protocol (MTP)
Options A, C, D: Components of ABC score
Correct Option D - 1:1:0.25: 
 6 units of platelet-rich plasma are condensed into a single bag and are available as SDP (Single
donor Platelet) which is prepared by Apheresis.
 Efficacy of SDP is same as 6 Units of Platelet Rich Plasma (PRP) ·
 If single donor platelets is used then the ratio is 1:1:0.25
Incorrect Option-A, B, C-refer to the above explanation
 
229

ARDS,Snake Bite,High Altitude Pulmonary Edema
1. A 25-year-old male was rushed to the nearby hospital after two days of mountain climbing with a
complaint of unexplained cough, vomiting, dizziness, and shortness of breath. He admitted that he is
having trouble sleeping at night after mountaineering. Clinical examination showed a raised heart rate
and respiratory rate. Auscultation revealed crackles in the middle lobes of the lungs. All of the following
are the findings in the diagnosis except?
A. ABG shows Respiratory Alkalosis
B. RV strain pattern on echocardiography
C. Batwing edema with cardiomegaly
D. Normal pulmonary capillary wedge pressure
2. A 25-year-old male who met with a road traffic accident with polytrauma was posted for a massive
blood transfusion and was monitored carefully. The vitals showed no improvement even after the
second round of transfusion hence started round 3. The patient started to have breathing difficulty,
unexplained cough, turned cyanotic. A chest x ray was taken and is shown below. The PaO2 / FiO 2 is
150. Identify the condition and mark the option with the most important diagnostic criteria according to
BERLIN criteria?
A. Sudden onset respiratory distress
B. Bilateral pulmonary infiltrates
C. PaO / FiO less than 300
D. Absence of left arterial Hypertension
3. Refractory hypoxia is seen in which phase of ARDS
A. Exudative phase
B. Transudative phase
C. Proliferative phase
D. Fibrotic phase
4. All of the following are features of ARDS except-
A. High protein pulmonary edema
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B. CP angle is normal
C. Elevated Hydrostatic pressure
D. Exudative pulmonary edema
5. All of the following are management protocols regarding ventilation in a patient with pH- 7.40 pO2 -
60 ,· pCO2 - 40 except?
A. Increase FiO2
B. Increase PEEP
C. Maintain the same tidal volume
D. Increase Respiratory rate
6. Which of the following statements are true regarding the most common mode of invasive mechanical
ventilation?
A. Used in patients with no spontaneous breathing
B. Hypoventilation is one of its side effects
C. The breathing is synchronized
D. Helps in weanING off the patient from ventilator
7. Match the following 1)CPAP a) Supports patient breathing efforts 2)BiPAP b)Used for weaning off
patients from ventilation 3)ACMV c)Positive pressure varies in inspiration and expiration 4)SIMV
d)helps to limit the inflation of the lungs 5)PCV e)Positive pressure generated is continuous for both
inspiration and expiration
1)CPAP a) Supports patient breathing efforts
2)BiPAP b)Used for weaning off patients from ventilation
3)ACMV c)Positive pressure varies in inspiration and expiration
4)SIMV d)helps to limit the inflation of the lungs
5)PCV e)Positive pressure generated is continuous for both inspiration and expiration
A. 1-e,2-c,3-a,4-b,5-d
B. 1-a,2-d,3-b,4-e,5-c
C. 1-c,2-e,3-b,4-d,5-a
D. 1-d,2-a,3-c,4-b,5-e
8. All of the following are indications for CPAP use except?
A. Hyaline membrane disease
B. Obstructive sleep apnoea
C. COPD
D. Cardiogenic pulmonary edema
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9. Which of the followingsnakes is responsible for affecting the presynaptic transmission of release of
acetylcholine?
A. Cobra
B. Krait
C. Russels viper
D. Humped nose viper
10. A farmer who was working in the field visited his nearby rural medical practitioner saying he was
bitten by a snake but not sure which one. The patient started to have pain at the site of the bite,his eyes
started turning red as shown below. He was referred to the nearby PHC and the doctor observed
purpura over the skin, and tender lymphadenopathy. BP was recorded to be 90/80 mmHg. The patient
started to have severe abdominal pain and bleeding through the nose. Identify the snake responsible
for the features.
A. Viper
B. Krait
C. Cobra
D. Common sand Boa
11. What is the bite-to-needle time for administration of Polyvalent snake venom in a snake bite?
A. 4 hours
B. 2 hours
C. 6 hours
D. 5 hours
12. All of the following responds to anti-snake venom except
A. Cobra
B. Krait
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13. All of the following are used to manage a case of snake bite except?
A. Immobilize the patient
B. Reassure
C. Apply a tourniquet
D. Check for clot features in the test tube after 20 min
14. Match the following presentations with their respective treatment of choice? 1)Acute mountain
sickness a)Dexamethasone 2)High altitude pulmonary edema b)Acetazolamide 3)High altitude cerebral
edema c)Nifedipine
1)Acute mountain sickness a)Dexamethasone
2)High altitude pulmonary edema b)Acetazolamide
3)High altitude cerebral edema c)Nifedipine
A. 1-a,2-b,3-c
B. 1-b,2-c,3-a
C. 1-a,2-c,3-a
D. 1-b,2-a,3-c
Question 12 4
Question 14 2
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Options B, C, D: Refer to the above explanation
Correct Option C - COPD:
 COPD-is not an indication for CPAP
 Non-invasive ventilation is used in COPD
Options A,B,D all are indications for CPAP use.
 
Correct Option B - Krait:
 Krait is neurotoxic, mainly affects presynaptic transmission that is release of ACh at the
neuro-muscular junction is affected
Option A - Cobra- (Neurotoxic): Affects postsynaptic transmission. It hampers the action of ACh at the 
neuromuscular junction.
Option C
- Russels viper- It is hemotoxic and causes acute kidney injury/ acute tubular necrosis and uremia
Option D - Humped nose viper: This is also hemotoxic and causes acute kidney injury/ acute tubular ne
crosis and uremia.
Correct Option A - Viper:
 The question shows pain at the bite site, tender lymphadenopathy and bleeding manifestations such
as subconjunctival hemorrhage, purpura, abdominal pain(due to bleeding in the stomach), lepistaxis
and hypotension due to multiple bleeding sites and release of histamine are all features of Viper bite.
Options  B - Krait: Neurotoxic snake and the features like local pain and tender lymphadenopathy are a
bsent here
Options C - Cobra: Same explanation as Krait
Options D - Common sand Boa: This is a non venomous Indian snake
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Correct Option B - 1-b,2-c,3-a:
1)Acute mountain sickness- b)Acetazolamide
2)High altitude pulmonary edema- c)Nifedipine
3)High altitude cerebral edema- a)Dexamethasone
 
Options A, C, D: Refer to the above explanation.
239

1. Please match the following medical conditions with their corresponding descriptions: A) Caplan
syndrome- 1) Initially observed in coal workers B) Asbestosis- 2) Presents with a characteristic "crazy
pavement" appearance C) Mesothelioma- 3) Affects the lower lobe of the lungs D) Sarcoidosis- 4)
Exhibits the presence of pleural effusion
A. A-1, B-4, C-3, D-2
B. A-4, B-2, C-3, D-1
C. A-3, B-4, C-2, D-1
D. A-2, B-4, C-3, D-1
2. Which of the following is NOT a complication of blood transfusion in a 25-year-old mother who
developed acute postpartum hemorrhage (PPH), hypovolemic shock, and underwent major blood
transfusion after delivering a baby boy?
A. Hypocalcemia
3. What is the lifelong treatment for individuals who have received a potent prosthetic mitral valve
replacement?
A. Aspirin
C. Atorvastatin
D. Warfarin
4. A farmer has come with symptoms of pinpoint pupils, excessive salivation, and increased secretion
from the body. The most probable diagnosis is
A. Opioid overdose
B. Organophosphate poisoning
C. Stroke
D. Heat stroke
5. What is the optimal temperature for the water bath recommended for a patient with frostbite?
A. 42 degree C
B. 37 degree C
C. 32 degree C
D. 30 degree C
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6. Except for the following, which of the options listed can be used to manage a person experiencing
breathlessness at a high altitude of 3000m?
A. Intravenous digoxin
B. Oxygen supplementation
C. Immediate descent
D. Acetazolamide
7. During a scorching summer afternoon, a man, who had been toiling in a field, unexpectedly
collapsed. Upon examination, there were no apparent physical indications of dehydration, although his
radial pulse was detectable. The doctor determined that the man's serum electrolyte levels were within
the normal range. Shockingly, the man's body temperature measured 106 degrees Fahrenheit.
Considering these circumstances, which of the following should be administered as an initial form of
immediate assistance?
A. Inject epinephrine immediately
B. Cover with hot damp sheets
C. Cover with cool damp sheets
D. Start CPR
8. What are the most appropriate tests to perform in a 62-year-old male patient with heart failure who is
scheduled for a heart transplant and experiences severe respiratory distress four hours after receiving
2 units of whole blood transfusion, and is found to be hypoxemic, tachycardic, and with elevated mean
arterial pressure, considering that his renal function test is abnormal and his hemoglobin level is
6gm%? 1. Chest X-ray 2. Brain natriuretic peptide (BNP) level 3. Absolute neutrophil count 4.
Leucocyte antibodies 5. Platelets
A. 4 and 5
B. 3 and 5
C. 1 and 2
D. 2 only
9. A patient who is a tour guide of Mount Everest presented with blisters on her hand as shown in the
figure below. She has severe pain and on examination is erythematous and tender. Which of the
following is used in the management of this patient?
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A. Oxygen
B. Apply heat to the area and cast it as soon as possible
C. Pentoxyphylline
D. NSAID’s
10. An elderly diabetic and hypertensive patient was carried to the emergency room in a comatose
state. On examination, the blood pressure was 170/100 mmHg and pulse rate was >100/min. Plantar
reflex was bilateral extensor. What is the next step to do?
A. Check blood sugar level
B. Give antihypertensive
C. IV mannitol
D. CT brain
11. Which of the following is not done before drawing blood for arterial blood gas analysis?
A. Allen's test
B. Rinse syringe with heparin
C. Flexion of wrist
D. Placing needle at 45 degree angle
12. Refractory Septic shock is defined as?
A. Shock persisting > 1 hour after IVF administration
B. Shock persisting > 1 hour after IVF administration and high dose vasopressors
C. Shock that is refractory to medical treatment
D. Shock that does not improve despite treatment for 24 hours
13. Which of the following animal is most likely responsible for biting a 10-year-old child who presented
with symptoms of tachycardia, hypertension, tongue fasciculation, hypersalivation, dilated pupils, and
mild erythema at the site of the wound? The child recalls that the animal had a curved tail pointing
upwards.
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A. Sea urchin
B. Caterpillar
C. Scorpion
D. Shellfish
14. Which test is the most sensitive for diagnosing Organophosphate poisoning among the following
options?
A. Plasma acetylcholinesterase
B. Organophosphate level in blood
C. Organophosphate level in plasma
D. RBC transaminase levels
15. In a post-operative patient, after 2 hours of receiving FFP, sudden onset dyspnea, hypoxemia,
tachypnea, hypotension, and bilateral pulmonary infiltrates on chest X-ray occur. What is the most likely
A. TRALI
B. TACO
C. Pulmonary edema
D. ARDS
E. Sepsis
Question 7 3
Question 11 3
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The correct match for the given options is:
A-1, B-4, C-3, D-2
Explanation:
A) Caplan syndrome - 1) Found first in coal worker Caplan syndrome is a condition characterized by th
e presence of rheumatoid arthritis along with lung nodules or masses. It was initially described in coal 
miners who were also suffering from rheumatoid arthritis.
B) Asbestosis - 4) Pleural effusion is seen Asbestosis is a lung disease caused by the inhalation of asb
estos fibers. Pleural effusion, the accumulation of fluid in the pleural space surrounding the lungs, can 
be seen in advanced stages of the disease.
C) Mesothelioma - 3) Involves lower lobe Mesothelioma is a type of cancer that primarily affects the me
sothelial cells, which line the outer surface of the body's internal organs. While mesothelioma can invol
ve various organs, it often affects the pleura (lining of the lungs). The involvement of the lower lobe of t
he lung can be observed in cases where the tumor affects that particular region.
D) Sarcoidosis - 2) Crazy pavement Sarcoidosis is a systemic inflammatory disease that can affect mul
tiple organs, but it most commonly involves the lungs and lymph nodes. The term "crazy pavement" is 
not specifically associated with sarcoidosis. It is a radiographic appearance seen in certain lung conditi
ons, particularly pulmonary alveolar proteinosis, where the lung tissue exhibits a
mosaic pattern resembling crazy paving.
To summarize: A) Caplan syndrome - 1) Found first in coal worker B) Asbestosis -
4) Pleural effusion is seen C) Mesothelioma - 3) Involves lower lobe D) Sarcoidosis -
2) Crazy pavement
Correct Options B: Hypokalemia
 Hypokalemia is not seen with blood transfusions. Instead, hyperkalemia occurs due to leakage of
potassium from red blood cells in stored blood.   
 
Options A: Hypocalcemia: Hypocalcemia refers to low levels of calcium in the blood. While blood transf
usion can potentially cause citrate-induced hypocalcemia, which is a
temporary decrease in calcium levels due to the anticoagulant (citrate) present in stored blood, it is a
recognized complication of blood transfusion.
Options C: Hypothermia: Hypothermia refers to abnormally low body temperature. Blood transfusion is 
generally administered at a temperature close to normal body temperature, and measures are taken to 
prevent hypothermia during transfusion. However, in certain situations, such as rapid transfusion or lar
ge-volume transfusion, hypothermia can occur as a complication of blood transfusion.
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Options D: Hyperkalemia occurs due to leakage of potassium from red blood cells in stored blood
Option D.
Warfarin is the most recommended anticoagulant in people who have undergone prosthetic mitral valv
e replacement. Warfarin helps prevent thrombogenic events by inhibiting the clotting proteins in the blo
od.
Option A. Warfarin and aspirin are both anticoagulants. But aspirin acts on blood platelets only. Warfari
n, instead, inhibits the circulating blood clotting proteins in the blood.
Option B. Clopidogrel also has anti-platelet action like aspirin. Both these drugs act on platelets and no
t on clotting proteins.
Option C. Atorvastatin is an anti-dyslipidemic drug. Patients with prosthetic valve requirements require 
regular intake of anticoagulants, more than anti-dyslipidemic.
Correct option: 
Option B.
Miosis pupil or pinpoint pupil, increased salivation, and body secretion are characteristic clinical feature
s of organophosphorus poisoning.
 
Option A. In opioid posing, the patient may present with pinpoint pupils. But they may not have features
 of increased salivation or body secretion.
Option C. In stroke, pinpoint pupils are present. But this essentially does not mean the patient had a str
oke. Moreover, the patient may present with other neurological symptoms instead of increased body flu
id secretion.
Option D. The patient suffers from extreme dehydration in heat stroke instead of increased salivation.
Correct Option A.
 The correct answer is 42 degree Celsius. When managing frostbite, one of the primary goals is to
rewarm the affected tissue gradually. The recommended temperature for a water bath in the treatment
of frostbite is typically set at 40-42 degree Celsius (104-107.6 degree Fahrenheit). This temperature
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helps to promote vasodilation and improve blood flow to the affected area, aiding in the rewarming
process.
Option B. 37 degree Celsius: While this temperature is within the normal body temperature range, it ma
y not provide sufficient warmth to effectively rewarm the frostbitten tissue.
Option C. 32 degree Celsius: This temperature is below body temperature and would not be effective i
n rewarming the tissue adequately.
Option D. 30 degree Celsius: Similar to 32 degree Celsius, this temperature is too low for effective rew
arming of frostbitten tissue.
Correct option : A
 When a person complains of breathlessness at a high altitude of 3000m, it is likely due to altitude
sickness, specifically high altitude pulmonary edema (HAPE). HAPE is a potentially life-threatening
condition characterized by fluid accumulation in the lungs, leading to breathlessness and respiratory
distress.
 Intravenous digoxin: Digoxin is a medication commonly used for heart conditions, particularly to treat
heart failure and certain arrhythmias. However, in the context of high altitude breathlessness or HAPE,
digoxin does not play a role in the management. HAPE is primarily caused by increased pulmonary
artery pressure due to low oxygen levels and constriction of blood vessels in the lungs. Intravenous
digoxin does not address these underlying mechanisms and is not indicated for the treatment of HAPE.
Option B) Oxygen supplementation: Oxygen supplementation is a crucial intervention for managing hig
h altitude breathlessness. It helps increase the oxygen content in the blood, alleviating the symptoms a
nd improving oxygenation to the body's tissues. Supplemental oxygen is commonly used in the manag
ement of altitude sickness, including HAPE.
Option C) Immediate descent: Immediate descent to a
lower altitude is the most effective treatment for altitude sickness. If a
person is experiencing severe symptoms, including breathlessness, prompt descent to a
lower altitude allows for a decrease in altitude-related stress on the body, leading to improved oxygena
tion and relief of symptoms.
Option D) Acetazolamide: Acetazolamide is a medication that helps prevent and treat altitude sickness.
 It works by stimulating increased breathing and reducing the build-up of fluid in the body, including the 
lungs. Acetazolamide can be used as a
prophylactic measure before ascending to high altitudes or as a
treatment option for mild to moderate altitude sickness, including breathlessness.
 
Correct Option C: 
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 The above patient seems to be suffering from a heat stroke. There are no signs of dehydration and
the body temperature is quite high and the radial pulse is present. The next best step is to cover the
body with cool damp sheets.
Option A: Epinephrine injection can be fatal for the patient.
Option B: Cool and not hot damp cloth is used to cool the body down.
Option D: CPR is not required as a steady radial pulse is perceived and the patient is not in shock.
 
Correct Choice: C
 The patient developed severe respiratory distress after receiving a blood transfusion in the given
scenario. This raises concerns about a possible transfusion reaction. To investigate the situation, the
following investigations would be relevant:
 Chest X-ray: A chest X-ray can help assess the condition of the lungs and identify any signs of
pulmonary edema or other respiratory abnormalities that may be causing respiratory distress.
 Brain natriuretic peptide (BNP) level: BNP is a hormone released by the heart in response to
increased stretching of the cardiac chambers. Elevated BNP levels can indicate cardiac dysfunction,
including heart failure. In this case, measuring BNP levels can help evaluate the extent of cardiac
involvement and assess the impact of the transfusion reaction on the patient’s heart.
 These 2 are the best investigations for the above scenario. Therefore, option c is correct.
Option A. Leucocyte antibodies: Testing for leucocyte antibodies can help identify potential immune rea
ctions or transfusion-related complications, such as febrile non-hemolytic transfusion reactions or trans
fusion-related acute lung injury (TRALI). These antibodies can trigger immune-mediated reactions and 
should be assessed in cases of suspected transfusion reactions.
Platelets: Platelet levels may be assessed to evaluate the patient’s overall blood count and rule out any
 platelet-related complications or abnormalities contributing to the clinical presentation. However, as alr
eady mentioned above, CXR and BNP are the best investigations for the patient.
Option B: Absolute neutrophil count: This investigation assesses the number of neutrophils in the blood
stream, a type of white blood cell. It helps evaluate the patient’s immune response and determine if the
re is any evidence of an inflammatory reaction or infection that could be contributing to respiratory distr
ess. Platelet levels may be assessed to evaluate the patient’s overall blood count and rule out any plat
elet-related complications therefore, this option is incorrect.
Option D. BNP alone cannot help the patient as there is the option for CXR also available. Therefore, t
he best option is BNP and CXR.
The correct answer Option D: NSAIDs:
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 Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to relieve pain and reduce inflammation
associated with blisters. They may help alleviate the severe pain experienced by the patient in this
case. NSAIDs can be beneficial as part of the overall management of blister-related pain.
 The recommended approach includes protecting the blister, keeping it clean, and using pain-relieving
measures such as NSAIDs, if necessary.
Option A: Oxygen:
 Oxygen is not typically used in the management of blisters on the hand. Oxygen therapy is commonly
used in various medical conditions to improve oxygenation in the body, but it is not a specific treatment
for blisters.
Option B: "Apply heat to the area and cast it as soon as possible."
 Apply heat to the area and cast it as soon as possible: This option is not recommended for the
management of blisters. Applying heat can increase inflammation and discomfort while enclosing the
blister in a case may create a warm and moist environment that can promote bacterial growth and
increase the risk of infection. It is important to avoid applying heat to the blistered area.
Option C: Pentoxyphylline:
 Pentoxyphylline is a medication that can improve blood flow and is sometimes used in the treatment
of vascular disorders. However, it is not a standard treatment for blisters and is not typically used in
their management.
 
 In the given scenario, the patient is elderly and presents in a comatose state with hypertension and
tachycardia. The presence of bilateral extensor plantar reflex suggests significant neurological
involvement. Given the patient's history of diabetes and hypertension, it is important to first check the
blood sugar level (Choice A) to evaluate for hypoglycemia.
Option B. Give antihypertensive: While the patient's blood pressure is elevated, administering antihyper
tensive medications (Choice B) without identifying the underlying cause can be potentially harmful. The
 patient's comatose state and neurological findings indicate a
need for further evaluation before initiating specific treatment.
Option  C. IV mannitol: IV mannitol (Choice C) is commonly used in the treatment of raised intracranial 
pressure or cerebral edema. However, the decision to administer mannitol should be based on a
definitive diagnosis, which requires further evaluation such as a CT scan of the brain.
Option D. CT brain: A
CT scan of the brain (Choice D) is an important diagnostic tool in the evaluation of a comatose patient 
with neurological findings. However, it should not be the immediate next step before considering other 
essential investigations, such as checking the blood sugar level
 
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Correct Option C
 Flexion of wrist: This statement is incorrect. Flexion of the wrist is not a step that is typically performed
before drawing blood for ABG analysis. Flexing the wrist can affect the arterial blood flow and
potentially alter the accuracy of the blood gas measurement. It is important to keep the wrist in a neutral
or slightly extended position during arterial puncture.
Option
 Before drawing blood for arterial blood gas (ABG) analysis, several steps are typically performed to
ensure accurate and safe sampling.
Option A. Allen's test: This test is performed to assess the collateral circulation in the hand before obtai
ning an arterial blood sample. It involves applying pressure to both the ulnar and radial arteries while th
e patient makes a fist. The release of pressure on one artery should result in prompt color return to the 
hand, indicating adequate collateral circulation. Allen's test helps to minimize the risk of ischemia or ne
crosis in case of arterial occlusion during the blood sampling.
Option B. Rinse syringe with heparin: Heparin is commonly used to prevent blood clotting in the syring
e and maintain the integrity of the blood sample. Before drawing arterial blood, the syringe is typically ri
nsed with heparin to ensure that the collected sample does not clot.
Option D. Placing needle at a
45-degree angle: When performing an arterial puncture, the needle is typically inserted at a 45-degree 
angle to the skin surface. This angle helps to ensure proper entry into the arterial vessel and minimize 
complications such as arterial wall damage or hematoma formation.
 
 Shock persisting > 1 hour after IVF administration and high-dose vasopressors: This is the correct
option. Refractory septic shock is defined as shock that persists for more than 1 hour after adequate
fluid resuscitation (IVF administration) and requires high-dose vasopressors. This indicates that despite
receiving fluids and medications to increase blood pressure, the patient's condition remains unstable
and unresponsive to treatment.
Option A. Shock persisting > 1 hour after IVF administration: This option does not fully define refractory
 septic shock. While persistent shock after intravenous fluid (IVF) administration may indicate a lack of 
response to initial fluid resuscitation, it does not encompass the additional criterion of high-dose vasopr
essors.
Option C. Shock that is refractory to medical treatment: This option is too broad and does not specifical
ly address the criteria of IVF administration and high-dose vasopressors. While refractory septic shock 
can be described as shock that does not respond to medical treatment, the definition requires the additi
onal factors mentioned in option B.
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Option D. Shock that does not improve despite treatment for 24 hours: This option sets a specific time f
rame of 24 hours, which is not consistent with the definition of refractory septic shock. The duration of s
hock persistence is not limited to 24 hours but rather focuses on the lack of response to IVF administra
tion and high-dose vasopressors
Correct Option C: Scorpion
 Tachycardia, hypertension, tongue fasciculation, hypersalivation, and dilated pupil following a bite is
most suggestive of a bite of a scorpion.The venom is clear, colorless and is a hemolytic or neurotoxic,
and is an autonomic stimulator that causes the release of large amounts of catecholamines from the
adrenals.
Option A: Sting from a
sea urchin causes granulomatous nodular lesions along with joint pain and dermatitis.
Option B: Caterpillar sting presents as pain, itching, and rash.
Option D: Shellfish sting usually leaves a purple or red painful mark.
Correct option A: 
Organophosphate poisoning occurs due to exposure to organophosphate compounds, which inhibit the
 enzyme acetylcholinesterase, leading to an accumulation of acetylcholine and excessive cholinergic a
ctivity. The most sensitive test for the diagnosis of organophosphate poisoning is the measurement of 
plasma acetylcholinesterase levels. Reduced levels of plasma acetylcholinesterase activity indicate org
anophosphate poisoning.
Option B (Organophosphate level in blood) is incorrect because the measurement of organophosphate
 levels in the blood is not the primary diagnostic test for organophosphate poisoning. The clinical effect
s and acetylcholinesterase activity are more indicative of the poisoning.
Option C (Organophosphate level in plasma) is incorrect because the measurement of organophospha
te levels in the plasma is not the primary diagnostic test for organophosphate poisoning. The clinical eff
ects and acetylcholinesterase activity are more indicative of the poisoning.
Option D (RBC transaminase levels) is incorrect because RBC transaminase levels are not relevant to 
the diagnosis of organophosphate poisoning.
Option A. TRALI (Transfusion-related acute lung injury).
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 TRALI is a serious complication of blood transfusion characterized by acute respiratory distress and
pulmonary edema. It occurs within a few hours of transfusion and is not related to circulatory overload
(TACO), pulmonary edema, ARDS, or sepsis.
Option B. TACO (Transfusion-associated circulatory overload) -
Presents with circulatory overload and pulmonary edema, but not tachypnea.
Option C. Pulmonary edema -
General term for fluid accumulation in the lungs, but does not explain the specific findings mentioned.
Option D. ARDS (Acute respiratory distress syndrome) - Presents with severe respiratory distress, but t
he X-ray appearance is different (diffuse alveolar damage).
Option E. Sepsis - Infection-related, but does not explain the specific findings mentioned.
 
251

Diseases of Thyroid Gland
1. What is the preferred medication to treat Grave's disease in a woman during her first trimester of
pregnancy?
A. Carbimazole
B. Methimazole
C. Propylthiouracil
D. Radioactive ablation
2. A 35-year-old male presents with symptoms of weight gain, fatigue, constipation, and cold
intolerance. Physical examination reveals dry skin, coarse hair, and a slow heart rate. Laboratory
investigations revealed reduced serum levels of T3, T4, and TSH. Which of the following mechanisms
is primarily responsible for the observed hormonal changes in this patient?
(or)
What mechanism is primarily responsible for the hormonal changes observed in a male with weight
gain, fatigue, constipation, cold intolerance, dry skin, coarse hair, and reduced TSH, T4, and T3 serum
levels?
A. Impaired iodide uptake by thyroid follicular cells
B. Defective synthesis of thyroglobulin
C. Inadequate conversion of T4 to T3 in peripheral tissues
D. Reduced synthesis of thyroid-stimulating hormone (TSH) by the anterior pituitary gland
3. A 45-year-old female presents with fatigue, weight gain, cold intolerance, and constipation. Physical
examination reveals dry skin, coarse hair, and a diffuse, non-tender enlargement of the thyroid gland.
Laboratory investigations show increased TSH and decreased serum levels of T4 and T3. A
fine-needle aspiration biopsy of the thyroid gland is shown below. Which of the following mechanisms is
most likely responsible for the patient's clinical presentation?
(or)
What mechanism is most likely responsible for the clinical presentation in a female with fatigue, weight
gain, cold intolerance, thyroid enlargement, elevated TSH, and decreased T3 and T4 levels, as
indicated by the thyroid fine-needle aspiration biopsy?
A. Autoimmune destruction of thyroid follicular cells
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B. Excess production of thyroglobulin by thyroid follicular cells
C. Activation of the hypothalamic-pituitary-thyroid axis
D. Decreased iodine intake in the diet
4. What is the drug of choice to manage thyroid storm intraoperatively in a patient with congestive
cardiac failure?
A. Methimazole
B. Propranolol
D. Hydrocortisone
5. Which of the following helps precipitate the thyroid storm?
A. Saturated solution of potassium iodide
B. Consumption of iodized salt for years
C. Methimazole
D. Cholestyramine
6. Which radioactive iodine isotope is used for the ablation of the thyroid gland to treat Grave’s
disease?
A. Iodine 123
B. Iodine 131
C. Iodine 132
7. A 34-year-old female presents with complaints of palpitations and heat intolerance. She gave a
history of consuming ayurvedic tablets for weight loss. Lab investigation revealed reduced levels of
TSH and elevated levels of T4 and T3. What is the condition this patient is suffering from?
(or)
What is the likely diagnosis in a female experiencing palpitations and heat intolerance after consuming
ayurvedic tablets for weight loss?
B. Thyrotoxicosis factitia
C. Toxic multinodular goitre
D. Pituitary adenoma
8. A 32-year-old female presents with complaints of weight loss, palpitations, heat intolerance, and
increased sweating for the past few months. On physical examination, she has a diffusely enlarged
thyroid gland with a bruit. Her eyes appear prominent with lid lag. Laboratory tests reveal decreased
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TSH and increased T3 and T4 levels. Thyroid-stimulating immunoglobulins are positive. Which of the
following is the most likely diagnosis?
(or)
What is the most likely diagnosis for a female with weight loss, palpitations, heat intolerance, sweating,
diffuse thyroid enlargement with a bruit, prominent eyes, lid lag, decreased TSH, increased free T4, and
positive thyroid-stimulating immunoglobulins?
A. Hashimoto's thyroiditis
B. Toxic multinodular goiter
C. Graves' disease
D. Subacute thyroiditis
9. Which of the following options suggest the diagnosis of Hashimoto’s thyroiditis?
A.
B.
C.
D.
10. Which of the following is the earliest feature of Grave’s Ophthalmopathy?
A. Proptosis
B. Lid lag
C. Exposure keratitis
D. Diplopia
11. A 68-year-old unconscious female with a known history of hypothyroidism was brought to the
emergency department. Her medical records revealed she was diagnosed with a UTI 3 days back.
Upon examination, the patient is lethargic, with a body temperature of 35 °C, bradycardia, and low
blood pressure. Laboratory investigations reveal low free thyroxine (T4) and elevated
thyroid-stimulating hormone (TSH) levels. ECG revealed increased PR interval. What is the most likely
(or)
What is the most likely diagnosis for a 68-year-old female with altered mental status, hypothermia,
bradycardia, and ECG showing increased PR interval, along with low free T4 and elevated TSH levels,
who has a known history of hypothyroidism, and recently diagnosed with UTI?
B. Myxedema coma
D. Thyroid storm
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12. A 55-year-old patient is admitted to the hospital with severe illness and multiple organ dysfunction.
Laboratory investigations reveal low serum levels of triiodothyronine, normal levels of thyroxine, and
normal or slightly elevated levels of thyroid-stimulating hormone. This pattern of thyroid function is most
consistent with which of the following processes is defective?
(or)
What process is most likely defective in a severely ill 55-year-old patient with low T3, normal T4, and
normal/slightly elevated TSH levels?
A. Conversion of T4 to T3 in peripheral tissues
B. Release of TSH from the pituitary gland
C. Production of T4 by the thyroid gland
D. Uptake of iodine by the thyroid gland
13. A 25-year-old female presents to the clinic with complaints of weight gain, cold intolerance, change
in voice, and menorrhagia. Upon examination, hoarseness of voice is noted. Lab investigation revealed
reduced levels of T3, T4, and TSH. What is the most reliable examination sign of this condition?
(or)
What is the most reliable examination sign of hypothyroidism?
A. Coarse skin
B. Hung up ankle jerk
C. Galactorrhoea
D. Pale yellow skin
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Correct Option C – Propylthiouracil:
Antithyroid Drugs
 Propylthiouracil is the drug of choice during 1st trimester of pregnancy/ breastfeeding as it has high
protein binding. On prolonged usage of propylthiouracil, hepatotoxicity can occur.
 Carbimazole/ Methimazole is the drug of choice in 2nd Trimester. In 1st trimester it can cross the
placenta and can cause Aplasia cutis and Choanal atresia.
Options A and B (Carbimazole & Methimazole): These are incorrect. Refer to Option C
for an explanation.
Option D - Radioactive ablation: It is contraindicated in pregnancy or breastfeeding.
- Reduced synthesis of thyroid-stimulating hormone (TSH) by the anterior pituitary gland:
 The clinical presentation of weight gain, fatigue, constipation, feeling cold, dry skin, coarse hair, and a
slow heart rate is consistent with hypothyroidism. The reduced levels of T4, T3, and TSH levels suggest
the diagnosis of secondary hypothyroidism due to reduced synthesis of thyroid stimulating hormone.
Primary Hypothyroidism
Secondary Hypothyroidism
Thyroid gland is involved
Pituitary gland is involved
T4↓ T3↓, TSH↑
Causes
Option A - Impaired iodide uptake by thyroid follicular cells: Iodide uptake by thyroid follicular cells is ne
cessary for the synthesis of thyroid hormones. Impaired iodide uptake would lead to decreased hormon
e production, but it would not explain the reduced TSH levels observed in this patient.
Option B - Defective synthesis of thyroglobulin: Thyroglobulin is a protein precursor for thyroid hormon
e synthesis. Defects in thyroglobulin synthesis would result in decreased hormone production, but it wo
uld not explain the reduced levels of TSH seen in this patient.
Option C - Inadequate conversion of T4 to T3 in peripheral tissues: Peripheral conversion of T4 (thyroxi
ne) to T3 (triiodothyronine) is important for the active form of thyroid hormone. However, the primary is
sue in this patient is reduced thyroid hormone synthesis due to deficiency of TSH, not inadequate conv
ersion of T4 to T3.
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Correct Option A - Autoimmune destruction of thyroid follicular cells:
 This patient's clinical presentation of fatigue, weight gain, cold intolerance, constipation, dry skin, and
coarse hair is consistent with hypothyroidism. The laboratory findings of increased TSH
levels, decreased T3 and T4 levels, and diffuse non-tender enlargement of the thyroid gland
are suggestive of primary hypothyroidism. The fine-needle aspiration biopsy shows lymphocytic
infiltration and Hurthle cells seen in Hashimoto's thyroiditis.
 Hashimoto's thyroiditis is an autoimmune disorder that causes primary hypothyroidism. Autoimmune
destruction occurs due to the production of autoantibodies against thyroid antigens, resulting in chronic
inflammation and progressive destruction of thyroid follicular cells. Hashimoto's thyroiditis is the most
common cause of primary hypothyroidism in India.
Option B - Excess production of thyroglobulin by thyroid follicular cells: While thyroglobulin is a protein i
nvolved in thyroid hormone synthesis, excess production of thyroglobulin would lead to increased prod
uction of thyroid hormones rather than decreased production of thyroid hormones as given in question.
Option C - Activation of the hypothalamic-pituitary-thyroid axis: This mechanism would lead to increase
d TSH production and subsequent thyroid hormone synthesis, resulting in hyperthyroidism, not hypothy
roidism.
Option D - Decreased iodine intake in the diet: Although iodine deficiency can cause hypothyroidism, th
is patient's presentation and histology findings is more consistent with autoimmune thyroiditis rather tha
n iodine deficiency.
Correct Option C - Propylthiouracil:
 Propylthiouracil (PTU) is an antithyroid medication used to block the synthesis of thyroid hormones. It
acts quickly to inhibit the conversion of T4 to the more active form T3. In the setting of a thyroid storm,
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PTU can help rapidly reduce thyroid hormone levels and mitigate the life-threatening effects of
excessive thyroid hormone activity.
Option A - Methimazole: Methimazole is another antithyroid medication similar to propylthiouracil (PTU)
. It is the drug of choice to manage conditions like Grave’s disease.
Option B - Propranolol: Propranolol is not suggested in a
patient with established congestive heart failure. It is a
long-acting drug and it worsens the falling blood pressure, hence not recommended.
Option D - Hydrocortisone: Hydrocortisone is a corticosteroid medication that is used to manage thyroi
d storms by increasing the cortisol level and helping to manage stressful conditions.
Correct Option B - Consumption of iodized salt for years:
 Increased consumption of iodized salt for long duration increases the iodine trapping, which in turn
increases the production of T4 and its conversion to T3, hence precipitating the thyroid storm. It is
called the Jod-Basedow effect.
Option A - Saturated solution of potassium iodide (SSKI): SSKI for 10 days is used to prevent thyroid st
orm by decreasing iodide trapping and decreasing the production of T4 and T3. It is also known as the 
Wolf-Chaikoff effect.
Option C - Methimazole: Methimazole is an antithyroid medication used to treat hyperthyroidism by inhi
biting thyroid hormone synthesis. It helps manage hyperthyroidism and prevent thyroid.
Option D - Cholestyramine: Cholestyramine is a bile acid sequestrant used to lower the levels of thyroi
d hormones (T4 and T3), hence preventing thyroid storm.
Correct Option B – Iodine 131:
 Radioactive iodine therapy for the ablation of the thyroid gland in the treatment of Graves' disease
typically utilizes radioactive iodine-131. This isotope emits beta particles that can destroy thyroid tissue,
the half-life of iodine-131 is 8 days.
Option A - Iodine 123: Iodine-123 is used for the imaging of the thyroid gland. The half-life of iodine-12
3 is 13.2 hours.
Option C
- Iodine 132: Iodine-132 is also used for the imaging of the thyroid gland. The half-life of iodine-132 is 2
to 3 hours.
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Correct Option B - Thyrotoxicosis factitia:
 Thyrotoxicosis factitia refers to thyrotoxicosis caused by the ingestion of exogenous sources of thyroid
hormones, such as medications or supplements, with a normal functioning thyroid gland.
 In this case, the patient's symptoms of palpitations and heat intolerance, along with the history of
consuming ayurvedic tablets (containing levothyroxine) for weight loss and thyroid profile, strongly
suggest thyrotoxicosis factitia as the underlying condition.
Option A - Grave’s disease: Grave's disease is an autoimmune disorder characterized by the productio
n of autoantibodies that stimulate the thyroid gland to overproduce thyroid hormones.
Option C - Toxic multinodular goitre: Toxic multinodular goiter refers to the presence of multiple nodule
s in the thyroid gland, some of which autonomously produce thyroid hormones, leading to hyperthyroidi
sm.
Option D - Pituitary adenoma: Pituitary adenoma is a condition in which there will be an increased synt
hesis of TSH, which results in increased T4 and T3 levels.
Correct Option C - Graves' disease:
 The patient's symptoms of weight loss, palpitations, heat intolerance, and increased sweating, along
with a diffusely enlarged thyroid gland, presence of lid lag, and positive TSI, are characteristic of
Graves' disease.
 Graves' disease, aka diffuse toxic goiter, is an autoimmune disorder with a long-acting
thyroid-stimulating antiobody (LATS) or thyroid-stimulating autoantibody against the TSH receptor,
resulting in increased synthesis and release of thyroid hormones (T3 and T4) and reduced TSH. This
causes clinical features of primary hyperthyroidism, such as weight loss, tachycardia, heat intolerance,
and increased sweating. The diffusely enlarged thyroid gland with a bruit, known as a "thyroid thrill," is
a characteristic finding in Graves' disease.
Option A - Hashimoto's thyroiditis: Hashimoto's thyroiditis is an autoimmune disorder that leads to hypo
thyroidism,
Option B - Toxic multinodular goiter: Toxic multinodular goiter that is characterized by multiple nodules 
in the thyroid gland causing hyperthyroidism.
Option D - Subacute thyroiditis: Subacute thyroiditis presents with painful thyroid enlargement and tran
sient hyperthyroidism followed by hypothyroidism.
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 Hashimoto's thyroiditis is an autoimmune disease. This results in the destruction of the thyroid gland
and decreased diffuse uptake of radioactive iodine.
Hashimoto's thyroiditis
Grave’s disease
Malignancy
Toxic multinodular goitre
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 2 = Soft tissue involvement (periorbital edema)
 3 = Proptosis (>22 mm)
 4 = Extraocular muscle involvement (diplopia)
 5 = Corneal involvement
 6 = Sight loss
Options A, C, and D- Proptosis, Exposure keratitis & Diplopia: These are incorrect. Refer to Option B
Correct Option B - Myxedema coma:
The most likely diagnosis for this patient's presentation is Myxedema coma.
 Myxedema coma is a severe and life-threatening form of hypothyroidism that is triggered by any
intercurrent illness like UTI. It is characterized by extreme manifestations of hypothyroidism, including
altered mental status, hypothermia, respiratory distress, and profound weakness.
 In the given scenario, the patient's altered mental status, hypothermia, and respiratory distress are
indicative of a severe decompensation of hypothyroidism. The presence of bradycardia decreased
respiratory rate, and ECG showing prolonged PR interval further support the diagnosis of myxedema
coma.
 Laboratory investigations revealing low free thyroxine (T4) and elevated thyroid-stimulating hormone
(TSH) levels are consistent with the diagnosis of severe hypothyroidism.
 
Option A – Hypothyroidism: It is a broad term for an underactive thyroid gland, but myxedema coma re
presents an extreme and life-threatening form of hypothyroidism, which is a
more appropriate diagnosis in this case.
Option C – Hyperthyroidism: It is the opposite of hypothyroidism and would not explain the patient's clin
ical features and laboratory findings.
Option D - Thyroid storm: It is a severe form of hyperthyroidism characterized by an exaggerated relea
se of thyroid hormones. It presents with hypermetabolic symptoms such as high fever, tachycardia, an
d agitation, which are contrary to the patient's hypometabolic and hypothermic state. Therefore, it is not
 the correct diagnosis in this case.
Correct Option A - Conversion of T4 to T3 in peripheral tissues:
 Sick euthyroid syndrome is a condition characterized by abnormal thyroid hormone levels in the
absence of primary thyroid gland dysfunction. It commonly occurs in critically ill patients with severe
systemic illness or sepsis.
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 In this condition, there is a decrease in the peripheral conversion of the inactive prohormone thyroxine
(T4) to the active form triiodothyronine (T3) in peripheral tissues. This results in low T3 levels, normal
T4 levels, and normal or slightly elevated levels of thyroid-stimulating hormone (TSH).
 
Option B - Release of TSH from the pituitary gland: It is not the defective process in Sick Euthyroid Syn
drome. TSH levels can be normal or slightly elevated due to feedback mechanisms.
Option C - Production of T4 by the thyroid gland: It is generally not impaired in Sick Euthyroid Syndrom
e. The thyroid gland can still produce and release normal levels of T4.
Option D - Uptake of iodine by the thyroid gland: It is also not typically affected in Sick Euthyroid Syndr
ome. The thyroid gland can still take up iodine and produce T4, but the conversion of T4 to T3 is decre
ased.
Correct Option B - Hung up ankle jerk:
 The clinical presentation of weight gain, cold intolerance, hoarseness of voice, menorrhagia, and lab
investigation of reduced serum levels of T3, T4, and TSH is suggestive of hypothyroidism.
 On Examination
Options A, C, and D - (Coarse skin, Galactorrhoea &
Pale yellow skin): These are incorrect. Refer to Option B for an explanation.
264

Diseases of Pancreas
1. A 45-year-old female is brought to the emergency department in a confused state. Her capillary
blood glucose level was 44 mg/dl. Her bystander reported a history of similar recurrent illnesses and
mentioned that she is always irritable, aggressive, and eats a lot. Lab investigations reveal elevated
insulin and C peptide levels. Which of the following is the drug of choice for the management of this
patient's condition?
(or)
What is the drug of choice for managing the recurrent episodes of hypoglycemia in a 45-year-old
female with elevated insulin and C peptide levels?
A. Metformin
B. Glucagon
C. Diazoxide
D. Sulfonylureas
2. A 55-year-old male presents with complaints of a persistent skin rash, diarrhea, and weight loss for
the past 6 months. Upon examination, a rash characterized by necrolytic migratory erythema in the
groin is noted. Laboratory investigation reveals impaired glucose tolerance. The hormone responsible
for the patient's symptoms is involved in which physiological processes?
(or)
Which physiological process is primarily affected by the hormone responsible for the clinical
manifestations in a patient with a pancreatic mass, weight loss, necrolytic migratory erythema and
glucose intolerance?
A. Inhibit hepatic glycogenolysis
B. Enhancing adipose tissue lipolysis
C. Promoting gluconeogenesis in the liver
D. Inhibiting protein synthesis in muscle tissue
3. A 45-year-old female, recently diagnosed with diabetes, presents with complaints of recurrent
episodes of greasy diarrhea and right upper quadrant pain for the past 8 months. An ultrasound
abdomen reveals gallstones and a mass located in the pancreas. Which of the following is the most
A. Glucagonoma
B. Insulinoma
C. Somatostatinoma
D. VIPoma
4. A 58-year-old male presents to the clinic with a 6-month history of intermittent episodes of flushing
and diarrhea. The patient's stool shows an osmolar gap of less than 50 mOsm and has a rice-water
appearance. The lab investigation reveals a potassium level of 2.8 mmol/L. What is the diagnosis?
(or)
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What is the likely diagnosis for a male with a history of flushing, rice-water diarrhea, an osmolar gap of
less than 50 mOsm, and a potassium level of 2.8 mmol/L?
A. Carcinoid syndrome
B. Somatostatinoma
C. WDHA syndrome
D. Glucagonoma
5. A 28-year-old male presents with a two-day history of nausea, vomiting, and abdominal pain. He
reports feeling extremely thirsty and has been urinating frequently. On examination, his breath has a
fruity odor. His blood glucose level is 380 mg/dL (21.1 mmol/L). An arterial blood gas (ABG) analysis is
performed. Which of the following ABG findings would be most consistent with the patient's condition?
(or)
What ABG finding would be most consistent with the condition of a male presenting with nausea,
vomiting, fruity breath odor, and a blood glucose level of 380 mg/dL?
A. pH 7.30, PaCO2 30 mmHg, HCO3- 18 mEq/L
B. pH 7.45, PaCO2 40 mmHg, HCO3- 24 mEq/L
C. pH 7.50, PaCO2 50 mmHg, HCO3- 28 mEq/L
D. pH 7.40, PaCO2 45 mmHg, HCO3- 28 mEq/L
6. A 62-year-old male with a history of type 2 diabetes presents to the clinic for a routine follow-up
appointment. He reports experiencing nausea, vomiting blurred vision, numbness, tingling sensations in
his feet, and constipation. Fundoscopic examination reveals dot and blot hemorrhages and cotton wool
spots. Which of the following complications is the patient most likely experiencing?
(or)
What complication is likely experienced by a male with type 2 diabetes, blurred vision, peripheral
neuropathy symptoms, constipation, and retinal findings like dot & blot hemorrhages and cotton wool
spots?
A. Bradycardia
B. Gastroparesis
C. Loss of light reflex
D. Hyperreflexia
7. A 65-year-old male with a known history of type 2 diabetes presents to the emergency department
with altered mental status, extreme thirst, and frequent urination. Laboratory investigations reveal a
blood glucose level of 600 mg/dL and an arterial pH of 7.35. Urine dipstick testing shows negative
ketones. The patient is profoundly dehydrated. What is the most appropriate treatment for this patient?
(or)
What is the most appropriate treatment for a severely dehydrated male with altered mental status, high
blood glucose, negative ketones in urine, and a pH of 7.35 in the emergency department?
A. Intravenous administration of regular insulin
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Page 3
B. Intravenous administration of bicarbonate solution
C. Intravenous administration of DNS solution
D. Intravenous administration of sodium bicarbonate
8. A 52-year-old female presents to the clinic with a 3-year history of polyuria, polydipsia, and
unintentional weight loss. She also complains of recurrent urinary tract infections (UTIs) characterized
by dysuria, frequency, and urgency. Urine investigations revealed increased glucose excretion. Which
of the following antidiabetic medications is most likely responsible for the patient's increased
susceptibility to UTIs?
(or)
Which antidiabetic medication is most likely responsible for increased susceptibility to urinary tract
infections (UTIs) presenting with increased urinary excretion of glucose in a diabetic patient?
A. Canagliflozin
C. Glimepiride
D. Sitagliptin
9. A 12-year-old girl came to the pediatric clinic with excessive thirst, frequent urination, weight loss,
and fatigue. During examination, she appeared dehydrated, and tests showed a blood glucose level of
350 mg/dl and ketone bodies in urine. Her family has a history of autoimmune disorders. Which of the
following preparations is the drug of choice for this condition with the shortest duration of action?
(or)
Which preparation of the drug of choice for a 12-year-old female with symptoms of hyperglycemia,
dehydration, and positive urine glucose and ketones has the shortest duration of action?
A. Regular
B. NPH
C. Glargine
D. Lispro
10. A 60-year-old man with type 2 diabetes complains of weakness, fatigue, and shortness of breath.
During a physical examination, the patient appears pale and has conjunctival pallor. Lab tests show low
hemoglobin levels and elevated MCV. Peripheral smear shows the following findings. What is the
mechanism of action of the drug responsible for the patient's condition?
(or)
What is the antidiabetic mechanism of action of the drug prescribed to a male with type 2 diabetes
presented with fatigue, weakness, shortness of breath, and laboratory findings of low hemoglobin and
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Page 4
A. Inhibition of hepatic glucose production and glucose absorption
B. Stimulation of insulin secretion
C. Inhibition of glucagon release
D. Enhancement of renal glucose excretion
11. A 45-year-old female with type 1 diabetes mellitus presents to the endocrinology clinic for a routine
follow-up visit. She is on insulin and reports experiencing episodes of postprandial hyperglycemia. On
further evaluation, it was decided to add a medication that specifically target postprandial
hyperglycemia in her treatment regimen. The drug is an analog of a certain hormone that is released
by?
(or)
In the management of postprandial hyperglycemia in a female with type 1 diabetes on insulin, a drug is
added to her regimen, which is an analog of hormone that is released by?
A. Alpha cells of the pancreas
B. Beta cells of the pancreas
C. Delta cells of the pancreas
D. F cells of the pancreas
12. What is the mechanism of action of the recently added diabetes medication that may exacerbate
congestive heart failure symptoms in a male with a history of CHF?
A. Beta-adrenergic receptor antagonist (beta-blocker)
B. Angiotensin-converting enzyme (ACE) inhibitor
C. PPAR gamma upregulation
D. GLP-1 agonists
13. A 55-year-old male with a 10-year history of type 2 diabetes presents to the endocrinology clinic for
a routine follow-up visit. He has been managing his diabetes with lifestyle modifications and metformin.
However, recent laboratory investigations show elevated urinary albumin levels and declining estimated
glomerular filtration rate (eGFR). Histopathology of the kidney is given below: Considering his renal
impairment, which antidiabetic drug would be suitable to be added to his treatment regimen?
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(or)
Which antidiabetic drug would be suitable to add to the treatment regimen of a 55-year-old male with
type 2 diabetes, elevated urinary albumin levels, declining estimated GFR, and kidney histopathology
indicative of renal impairment?
B. Glibenclamide
C. Primlantide
D. Linagliptin
14. A 25-year-old female came for a medical checkup to the clinic. On lab investigation, her fasting
blood glucose levels are elevated, and an oral glucose tolerance test confirms impaired glucose
tolerance. She has a family history of diabetes in every generation and the patient does not have any
evidence of autoimmunity. What is the mechanism of action for the drug of choice in this patient's
treatment regimen?
(or)
What is the mechanism of action of the drug of choice for a female with persistent hyperglycemia, a
family history of diabetes, impaired glucose tolerance, and no evidence of autoimmunity?
A. Inhibition of alpha-glucosidase enzymes
B. Sensitization of insulin receptors
C. Stimulation of pancreatic beta cells
D. Inhibition of renal glucose reabsorption
15. A 27-year-old woman with a family history of diabetes presents to the clinic with a recent diagnosis
of diabetes. The patient's blood glucose control has gradually worsened despite the initial response to
oral antidiabetic medications She tests positive for autoantibodies against pancreatic beta cells. Which
type of diabetes is responsible for her condition?
(or)
Which type of diabetes is most likely responsible for a 27-year-old female with a recent diagnosis of
diabetes, a family history of diabetes, initial response to oral antidiabetic medications, and positive
autoantibodies against pancreatic beta cells?
A. Type 1 diabetes mellitus
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B. Type 2 diabetes mellitus
C. Maturity-onset diabetes of the young (MODY)
D. Type 1.5 diabetes mellitus (LADA)
16. Which of the following statements about insulin is correct?
A. Insulin is synthesized from pre-pro-insulin, which is a short peptide.
B. The pro-insulin molecule consists of two peptide chains, A and C.
C. Bovine and porcine insulin have different amino acid sequences compared to human insulin.
D. Human insulin is no longer used in the treatment of diabetes mellitus due to antibody production.
17. Which of the following actions of insulin on adipose tissue is incorrect?
A. Insulin stimulates lipoprotein lipase (LPL) activity.
B. Insulin increases the uptake of free fatty acids into fat cells.
C. Insulin inhibits hormone-sensitive lipase (HSL) activity.
D. Insulin promotes the breakdown of triglycerides into free fatty acids.
18. Which of the following statements about release of insulin is true?
A. For insulin to be released from a beta cell, both potassium and calcium channel need to be opened.
B. The calcium and potassium channels are both voltage gated
C. Potassium channels are blocked by a drug named Sulfonylurea
D. Incretins are the hormones secreted from cardiovascular system and act on the beta cells to release
insulin
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Question 13 4
Question 15 4
Question 16 3
Question 18 3
Correct Option C - Diazoxide:
 The clinical presentation, characterized by aggressive behavior, easy irritability, and frequent eating,
along with recurrent episodes of hypoglycemia with elevated insulin and C peptide levels, is highly
suggestive of insulinoma. Insulinoma is a pancreatic neuroendocrine tumor that secretes excessive
amounts of insulin, leading to hypoglycemia.
 Diazoxide is the drug of choice for the medical management of insulinoma. It acts by inhibiting insulin
release from pancreatic beta cells. It promotes hyperpolarization of beta cells, leading to decreased
calcium influx and subsequent inhibition of insulin secretion.
Option A
- Metformin: It is an oral antidiabetic medication commonly used for the management of type 2 diabete
s. However, it is not effective in treating insulinoma as it does not directly target insulin secretion.
Option B - Glucagon: It is a hormone that has the opposite effect of insulin, as it raises blood glucose le
vels. It can be used in emergency situations to treat severe hypoglycemia but is not the drug of choice f
or long-term management of insulinoma.
Option D - Sulfonylureas: These are oral hypoglycemic agents that stimulate insulin secretion from pan
creatic beta cells. However, their use in insulinoma is contraindicated, as they can exacerbate hypogly
cemia by further increasing insulin secretion.
Correct Option C - Promoting gluconeogenesis in the liver:
 The clinical presentation of the patient is suggestive of glucagonoma, a rare pancreatic tumor that
produces excessive amounts of glucagon. One of the key actions of glucagon is to promote
gluconeogenesis in the liver.
 Glucagonoma is a malignant tumor of the tail of the pancreas characterized by necrolytic
migratory erythema present mostly in the intertriginous area, diarrhea, weight loss, impaired glucose
intolerance, and plasma glucagon level of more than 1000 pg/ml.
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Options A - Inhibit hepatic glycogenolysis: Glucagon stimulates hepatic glycogenolysis.
Option B - Enhancing adipose tissue lipolysis: It is not primarily regulated by glucagon but rather by hor
mones such as adrenaline and growth hormone.
Option D
- Inhibiting protein synthesis in muscle tissue: Inhibiting protein synthesis in muscle tissue is not a direc
t action of glucagon. Instead, glucagon favors protein breakdown in peripheral tissues to provide amino
 acids for gluconeogenesis. It does not directly inhibit protein synthesis.
Correct Option C - Somatostatinoma:
 The clinical presentation suggests the diagnosis of somatostatinoma, which is a type of
neuroendocrine tumor that occurs in the pancreas or duodenum. This condition is characterized by
excess secretion of somatostatin, which can cause diabetes, secretory diarrhea, steatorrhea, and
gallbladder disease (such as gallstones). These symptoms occur because somatostatin inhibits insulin,
pancreatic amylase, and cholecystokinin.
Option A - Glucagonomas: Glucagonomas are tumors that secrete excessive amounts of glucagon and
 typically present with a
characteristic skin rash called necrolytic migratory erythema, diarrhea, and weight loss.
Option B—Insulinomas: Insulinomas are pancreatic neuroendocrine tumors that produce excessive am
ounts of insulin, leading to hypoglycemia characterized by confusion, aggressive behavior, frequent eat
ing, and weight gain.
Option D - VIPomas: VIPomas are tumors that secrete vasoactive intestinal peptide (VIP) and are asso
ciated with watery diarrhea, hypokalemia, and achlorhydria (WDHA) syndrome.
Correct Option C - WDHA syndrome:
 The patient's clinical presentation is suggestive of VIPoma (Verner-Morrison syndrome), also known
as WDHA syndrome (Watery Diarrhea, Hypokalemia, and Achlorhydria).
 VIPoma is a tumor of the tail of the pancreas, responsible for the excessive production of a vasoactive
intestinal polypeptide produced by F cells of the pancreas. It causes secretory diarrhea (osmolar gap of
stool less than 50 mOsm) which has a consistency of rice water stool, also known as pancreatic
cholera. Other features include hypokalemia, flushing episodes, achlorhydria, hyperglycemia, and
hypercalcemia.
Option A - Carcinoid syndrome: Carcinoid syndrome presents with flushing, diarrhea, wheezing, pruritis
, flushing, tricuspid insufficiency, and pulmonary stenosis.
Option B - Somatostatinoma: Somatostatinomas are characterized by fatty, foul-smelling diarrhea, diab
etes, and cholelithiasis (gallstones) due to excess somatostatin produced by the tumor, which inhibits o
ther hormones.
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Option D - Glucagonoma: Glucagonomas are pancreatic tumors that produce glucagon. Symptoms ma
y include a
characteristic rash called necrolytic migratory erythema, diabetes, weight loss, and diarrhea.
Correct Option A - pH 7.30, PaCO2 30 mmHg, HCO3- 18 mEq/L:
 The clinical presentation of nausea, vomiting, abdominal pain, fruity breath odor, and elevated blood
glucose levels suggests diabetic ketoacidosis (DKA), a potentially life-threatening complication of
uncontrolled diabetes. DKA is characterized by metabolic acidosis resulting from the accumulation of
ketone bodies (such as beta-hydroxybutyrate and acetoacetate) due to insulin deficiency and increased
gluconeogenesis.
 In DKA, ABG analysis typically reveals a low pH (acidosis), low bicarbonate (HCO3-) levels due to
metabolic acidosis, and low partial pressure of carbon dioxide (PaCO2) as a compensatory response to
increased ventilation and decreased carbon dioxide levels. Option A presents the most consistent ABG
findings for DKA, with a pH of 7.30 (normal range 7.35 - 7.45), PaCO2 of 30 mmHg (lower than the
normal range of 35-45 mmHg), and HCO3- of 18 mEq/L (lower than the normal range of 22-28 mEq/L).
Option B - pH 7.45, PaCO2 40 mmHg, HCO3- 24 mEq/L: represents a
normal pH and ABG values within the reference range, not indicative of DKA.
Option C - pH 7.50, PaCO2 50 mmHg, HCO3- 28 mEq/L: suggests respiratory alkalosis rather than me
tabolic acidosis seen in DKA.
Option D - pH 7.40, PaCO2 45 mmHg, HCO3- 28 mEq/L: represents a
Correct Option B - Gastroparesis:
 In the given case, the patient's symptoms of blurred vision and the fundoscopic findings of dot blot
hemorrhages and cotton wool spots are consistent with diabetic retinopathy and constipation,
numbness, and tingling sensation in the feet are suggestive of diabetic neuropathy involving the
autonomic nervous system and distal symmetric polyneuropathy.
 Among the listed options, gastroparesis is the complication this patient is suffering from due to
involvement of the autonomic neuropathy, resulting in delayed gastric emptying, presenting as nausea,
vomiting, and constipation (dominating sympathetic activation). Other features seen will be postural
hypotension and resting tachycardia.
Options A, C, and D (bradycardia, loss of light reflex, and hyperreflexia) are not directly related to the gi
ven symptoms and findings in this case.
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Correct Option A - Intravenous administration of regular insulin:
 In this case, the patient presents with altered mental status, extreme thirst, frequent urination,
tachycardia, and low blood pressure. These symptoms may initially lead one to suspect diabetic
ketoacidosis (DKA), which is characterized by hyperglycemia, ketosis, metabolic acidosis, and
dehydration. However, the absence of ketones on urine dipstick testing indicates a different condition.
 The clinical presentation and laboratory findings are consistent with Nonketotic Hyperosmolar Coma
(NKH), a severe complication of uncontrolled hyperglycemia in type 2 diabetes. In NKH, high blood
glucose levels lead to marked hyperosmolarity and severe dehydration, but without the presence of
significant ketosis.
 The most appropriate treatment for NKH is intravenous administration of regular insulin to lower blood
glucose levels and reverse the hyperosmolar state. Insulin helps to promote glucose uptake by the
cells, reducing blood glucose levels and resolving osmotic diuresis.
 
Options B, C & D: Options B (bicarbonate solution), C
(DNS: Dextrose and sodium chloride solution), and D
(sodium bicarbonate) are not the recommended treatments for NKH.  options B and D may be consider
ed in certain situations, such as severe acidosis or electrolyte imbalances, but they are not the primary 
treatment for NKH.  Dextrose in DNS can further worsen the condition of patient.
Correct Option A - Canagliflozin:
 Canagliflozin is a medication classified as a sodium-glucose co-transporter 2 (SGLT2) inhibitor. It
works by inhibiting the reabsorption of glucose in the kidneys, leading to increased urinary glucose
excretion and lowering blood glucose levels. However, a known side effect of SGLT2 inhibitors,
including canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin, is an increased risk of urinary tract
infections (UTIs).
 The mechanism behind the increased susceptibility to UTIs with SGLT2 inhibitors is related to the
presence of glucose in the urine. Since these medications enhance glucose excretion in the urine, the
elevated glucose levels in the urine can provide a favorable environment for bacterial growth,
increasing the risk of UTIs.
 
Option A - Sitagliptin: It is a dipeptidyl peptidase-4 (DPP-4) inhibitor. This class of medications increase
s insulin secretion and reduces glucagon levels, aiding in glycemic control. Sitagliptin does not have a
direct impact on urinary tract health and is not typically linked to an increased risk of UTIs.
Option B - Metformin: It is a commonly prescribed medication for type 2 diabetes that reduces hepatic 
glucose production and enhances insulin sensitivity. It does not directly increase the risk of UTIs.
Option C - Glimepiride: It is a sulfonylurea medication that stimulates insulin release from pancreatic be
ta cells. While sulfonylureas can lower blood glucose levels, they are not directly associated with an inc
reased risk of UTIs.
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Correct Option D - Lispro:
 In this case, the patient's presentation of excessive thirst, frequent urination, weight loss, fatigue,
hyperglycemia, presence of glucose and ketones in the urine, and a family history of autoimmune
disorders strongly suggests the diagnosis of diabetic ketoacidosis, likely due to type 1 diabetes.
 The drug of choice for type 1 diabetes is insulin. Insulin preparations can vary in their onset, peak
action, and duration of action. Among the options listed, insulin lispro has the shortest duration of
action.
 Lispro is a rapid-acting insulin analog with an onset of action of about 15 minutes, a peak action at
around 1-2 hours, and a duration of action of 3-4 hours. Its rapid onset makes it suitable for use just
before or after meals to control postprandial glucose levels.
Option A - Regular: Regular insulin is a
short-acting insulin with an onset of action of about 30 minutes, a
peak action of around 2-4 hours, and a duration of action of approximately 4-6 hours.
Option B - NPH: NPH (Neutral Protamine Hagedorn) insulin is an intermediate-acting insulin with an on
set of action of 1-2 hours, a peak action around 4-12 hours, and a duration of action of 14-24 hours.
Option C - Glargine: Glargine is a long-acting insulin with a
duration of action of approximately 24 hours and no pronounced peak action. It provides a
relatively constant level of insulin activity throughout the day.
Correct Option A - Inhibition of hepatic glucose production and glucose absorption:
 The presence of macrocytic anemia and elevated MCV suggests a potential deficiency in vitamin B12
or folate, leading to impaired red blood cell production and enlargement. The Howell-Jolly bodies seen
in the peripheral smear indicate a potential dysfunction of the spleen.
 The antidiabetic drug that inhibits hepatic glucose production and glucose absorption is a biguanide,
specifically metformin. While metformin does not directly cause macrocytic anemia or Howell-Jolly
bodies, long-term use of metformin has been associated with reduced levels of vitamin B12 and
possibly impaired spleen function.
Option B - Stimulation of insulin secretion: This mechanism of action is associated with sulfonylureas. 
Sulfonylureas work by stimulating insulin secretion from pancreatic beta cells. It is associated with hyp
oglycemia and weight gain.
Option C - Inhibition of glucagon release: This mechanism of action is associated with dipeptidyl peptid
ase-4 (DPP-4) inhibitors, which degrades incretin hormones like glucagon-like peptide-1 (GLP-1), resul
ting in increased insulin secretion and decreased glucagon release, associated with angioedema, urtic
arial, and immune-mediated dermatologic effects.
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Option D - Enhancement of renal glucose excretion: This mechanism of action is associated with sodiu
m-glucose co-transporter 2 (SGLT2) inhibitors. SGLT2 inhibitors work by inhibiting glucose reabsorptio
n in the kidneys, leading to increased glucose excretion in the urine. It is associated with urinary and g
enital infections, polyuria, and hyperkalemia.
Correct Option B - Beta cells of the pancreas:
 In the case where the drug used to target postprandial hyperglycemia is pramlintide, it is an analog of
amylin. Amylin is a hormone co-secreted with insulin by the beta cells of the pancreas. It functions
alongside insulin to regulate blood glucose levels. Pramlintide injected just before a meal slows gastric
emptying and suppresses glucagon but does not alter insulin levels and promotes satiety, all of which
contribute to the control of postprandial (after-meal) blood glucose levels. By mimicking amylin's
actions, pramlintide can help reduce postprandial hyperglycemia in individuals with type 1 or type 2
diabetes mellitus.
Option A - Alpha cells of the pancreas: Alpha cells of the pancreas secrete glucagon, a hormone that w
orks in opposition to insulin. Glucagon raises blood glucose levels by stimulating the liver to release sto
red glucose. However, the drug mentioned in the scenario, pramlintide, is an analogue of amylin, which
 is secreted by beta cells, not alpha cells.
Option C - Delta cells of the pancreas: Delta cells of the pancreas secrete somatostatin, a
hormone that inhibits the release of insulin and glucagon. While somatostatin plays a regulatory role in 
glucose metabolism, it is not the hormone mimicked by pramlintide, which is used to target postprandia
l hyperglycemia.
Option D - F cells of the pancreas: F cells, also known as pancreatic polypeptide (PP) cells, secrete pa
ncreatic polypeptide. Pancreatic polypeptide plays a role in regulating pancreatic exocrine function and
 may have some influence on appetite regulation. However, it is not the hormone mimicked by pramlinti
de for targeting postprandial hyperglycemia.
Correct Option C - PPAR gamma upregulation:
 In this case, the patient with a history of congestive heart failure (CHF) and diabetes mellitus is
experiencing worsening symptoms of CHF since starting a new medication for diabetes management.
The medication belongs to a class of drugs known as thiazolidinediones (pioglitazone and
rosiglitazone), which bind to the PPAR gamma (peroxisome proliferator-activated receptor
gamma). Agonists of this receptor regulate a large number of genes, promote adipocyte differentiation,
and increase peripheral utilization of glucose by increasing GLUT 4 Receptors on muscle/adipose
tissue, responsible for decreasing insulin resistance.
 However, PPAR GAMMA inhibitors have been associated with several adverse effects, including fluid
retention and worsening heart failure symptoms in patients with pre-existing cardiovascular conditions
such as CHF. These drugs can cause sodium and water retention, leading to increased fluid volume
and exacerbation of CHF symptoms.
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Option A and B: Beta-adrenergic receptor antagonists and Angiotensin-converting enzymes are comm
only used medications for the management of CHF and cardiovascular conditions. They have different 
mechanisms of action and are not typically associated with worsening CHF symptoms in patients with 
appropriate indications and monitoring.
Option D - GLP-1 agonists: These are a class of medications used for the management of diabetes. Th
ey work by stimulating the GLP-1 receptors to increase insulin secretion, decrease glucagon secretion,
 and delay gastric emptying. GLP-1 agonists have shown cardiovascular benefits and are not typically 
associated with worsening CHF symptoms.
Correct Option D - Linagliptin:
 Based on the given clinical scenario and the histopathology findings (which show Kimmelsteil Wilson
lesions, i.e., nodular glomerulosclerosis due to diabetes), the most suitable antidiabetic drug to be
added to the treatment regimen for this patient with declining renal function and elevated urinary
albumin levels would be linagliptin.
 Linagliptin is a dipeptidyl peptidase-4 (DPP-4) inhibitor that helps regulate blood glucose levels by
reducing the degradation of glucagon-like peptide-1 (GLP-1) produced by enterocytes responsible for
increased uptake of glucose by adipose tissue. Unlike other antidiabetic drugs, linagliptin does not
require dose adjustment based on renal function and has a favorable renal safety profile as
it undergoes bile elimination and enterohepatic recycling. Therefore, it is a suitable choice for patients
with renal impairment, including those with diabetic nephropathy.
Option A - Metformin: Metformin is generally considered the first-line drug for managing type 2 diabete
s. However, in the presence of declining renal function and elevated urinary albumin levels, metformin 
may need to be used with caution or discontinued due to the risk of lactic acidosis.
Option B - Glibenclamide: Glibenclamide is a sulfonylurea that stimulates insulin secretion from pancre
atic beta cells. However, it is metabolized by the liver and excreted by the kidneys. With declining renal
 function, the risk of hypoglycemia may increase. Therefore, glibenclamide may not be the best choice i
n this case.
Option C - Pramlintide: Pramlintide is an analog of amylin, a hormone that is co-secreted with insulin b
y the beta cells of the pancreas. While pramlintide can be beneficial in certain cases, it is not primarily i
ndicated for the management of renal impairment or diabetic nephropathy.
Correct Option C - Stimulation of pancreatic beta cells:
 The clinical presentation suggests the possibility of MODY (Maturity-Onset Diabetes of the Young). It
is an asymptomatic condition with early onset of diabetes (starts at 25 years of age), strong familial
inheritance, high blood glucose level, and absence of autoimmune markers.
 The drug of choice for MODY is sulfonylureas, which acts by stimulating pancreatic beta cells to
release insulin. Sulfonylureas bind to the ATP-sensitive potassium channels on beta cells, causing
depolarization and subsequent release of insulin. This mechanism of action enhances insulin secretion,
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thereby improving glucose control in patients with MODY.
Option A - Inhibition of alpha-glucosidase enzymes: Refers to the mechanism of action of another class
 of antidiabetic drugs known as alpha-glucosidase inhibitors. These medications work by slowing down 
the breakdown and absorption of carbohydrates in the intestine, thereby reducing postprandial blood gl
ucose levels. However, they are not the drug of choice for MODY.
Option B - Sensitization of insulin receptors: Refers to the mechanism of action of insulin sensitizers su
ch as thiazolidinediones (TZDs). These drugs improve insulin sensitivity in target tissues, such as skele
tal muscle and adipose tissue. However, they are not the drug of choice for MODY.
Option D - Inhibition of renal glucose reabsorption: Refers to the mechanism of action of sodium-glucos
e co-transporter 2 (SGLT2) inhibitors. These medications reduce glucose reabsorption in the kidneys, l
eading to increased urinary glucose excretion. While SGLT2 inhibitors are effective in managing type 2
diabetes, they are not typically the drug of choice for MODY.
Correct Option D - Type 1.5 diabetes mellitus (LADA):
 In this case, the patient's clinical presentation, family history, and positive autoantibody status strongly
suggest a diagnosis of type 1.5 diabetes mellitus, also known as LADA. Type 1.5 diabetes mellitus
(LADA - latent autoimmune diabetes in adults), is a subtype of diabetes that shares characteristics of
both type 1 and type 2 diabetes.
 It is characterized by a gradual onset of autoimmune beta cell destruction in adulthood. The patient's
positive autoantibody status and the progressive decline in blood glucose control align with LADA,
making it the most likely type of diabetes responsible for her condition.
Option A - Type 1 diabetes mellitus: Type 1 diabetes is characterized by autoimmune destruction of pa
ncreatic beta cells, leading to absolute insulin deficiency. The patient's positive autoantibody status sup
ports an autoimmune component, making type 1 diabetes a possible consideration. However, the grad
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ual onset and initial response to oral antidiabetic medications suggest a different subtype of diabetes.
Option B - Type 2 diabetes mellitus: Type 2 diabetes is characterized by insulin resistance and relative 
insulin deficiency. While the patient's age, family history, and lack of obesity may align with type 2 diab
etes, the positive autoantibody status indicates an autoimmune component, which is not typically assoc
iated with type 2 diabetes.
Option C) - Maturity-onset diabetes of the young (MODY): MODY refers to a group of monogenic forms
 of diabetes caused by mutations in specific genes. Although family history is present, the positive auto
antibody status suggests an autoimmune mechanism, making MODY less likely in this case.
- Bovine and porcine insulin have different amino acid sequences compared to human insulin:
 Bovine and porcine insulin have the same total number of amino acids as human insulin (51).
However, there are slight differences in the sequence of amino acids in the A and B chains of bovine
and porcine insulin compared to human insulin. These differences do not impact the overall activity and
effectiveness of the insulin in the body.
 
Option A - Insulin is synthesized from pre-pro-insulin, which is a
short peptide: Insulin is synthesized from pre-pro-insulin, which is a long peptide consisting of 51 amin
o acids. It undergoes processing to form pro-insulin, which contains three peptide chains: A, B, and C. 
Therefore, the statement that pre-pro-insulin is a short peptide is incorrect.
Option B - The pro-insulin molecule consists of two peptide chains, A
and C: The pro-insulin molecule consists of three peptide chains: A, B, and C. The A and B
chains are the primary chains that form the insulin hormone, while the C peptide is cleaved during insul
in synthesis. Therefore, the statement that the pro-insulin molecule consists of two peptide chains, A
and C, is incorrect.
Option D - Human insulin is no longer used in the treatment of diabetes mellitus due to antibody produc
tion: Human insulin is still widely used in the treatment of diabetes mellitus. The development of antibo
dies against human insulin is a rare occurrence, and it does not significantly impact its efficacy or use. 
Therefore, the statement that human insulin is no longer used due to antibody production is incorrect.
Correct Option D - Insulin promotes the breakdown of triglycerides into free fatty acids:
 Insulin has various actions on adipose tissue, primarily aimed at promoting the storage of energy in
the form of triglycerides. However, insulin does not promote the breakdown of triglycerides into free
fatty acids. The correct action is the inhibition of hormone-sensitive lipase (HSL) activity.
Option A - Insulin stimulates lipoprotein lipase (LPL) activity: Insulin indeed stimulates the activity of lip
oprotein lipase, an enzyme that breaks down triglycerides into free fatty acids for uptake into fat cells.
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Option B - Insulin increases the uptake of free fatty acids into fat cells: Insulin promotes the uptake of fr
ee fatty acids into fat cells by stimulating the activity of GLUT-4 transporters, which allow glucose and f
ree fatty acids to enter the cell.
Option C - Insulin inhibits hormone-sensitive lipase (HSL) activity: Hormone-sensitive lipase is responsi
ble for breaking down triglycerides into free fatty acids. Insulin inhibits the activity of HSL, preventing th
e breakdown of triglycerides and promoting their storage.
Correct Option C - Potassium channels are blocked by a drug named Sulfonylurea:
 Potassium channels in pancreatic beta cells play a crucial role in regulating insulin release. The
closure of potassium channels leads to membrane depolarization, which triggers the opening of
voltage-gated calcium channels and subsequent insulin secretion.
 Sulfonylurea drugs, such as glibenclamide, are commonly used in the treatment of type 2 diabetes.
They work by binding to and blocking ATP-sensitive potassium channels, preventing potassium efflux
and promoting membrane depolarization. This ultimately leads to increased insulin release from beta
cells.
 
Option A - For insulin to be released from a beta cell, both potassium and calcium channels need to be
 opened: While both potassium and calcium channels play a role in the release of insulin, they have diff
erent functions. Potassium channels in beta cells are involved in maintaining the resting membrane pot
ential and controlling membrane potential changes. Calcium channels, on the other hand, are responsi
ble for the influx of calcium ions, which triggers insulin secretion. Both channels do not need to be simu
ltaneously opened for insulin release to occur.
Option B - The calcium and potassium channels are both voltage-gated: While calcium channels involv
ed in insulin release are voltage-gated, the potassium channels are ATP-sensitive potassium channels,
 which are regulated by intracellular ATP levels.
Option D - Incretins are hormones secreted from the cardiovascular system and act on beta cells to rel
ease insulin: Incretins are gastrointestinal hormones secreted by specialized cells in the intestine in res
ponse to food intake. The two main incretins are glucagon-like peptide-1 (GLP-1) and glucose-depend
ent insulinotropic peptide (GIP). Incretins act on beta cells of the pancreas to enhance insulin secretion
 in a glucose-dependent manner, meaning they stimulate insulin release when blood glucose levels are
 elevated.
280

Diseases of Pituitary Gland
1. A 25-year-old male presents with complaints of gradually increasing hand and shoe sizes, facial
changes, joint pain, and excessive sweating. Upon examination, the patient was noted to have
spade-like hands, coarse facies, and macroglossia. What is the leading cause of mortality in patients
suffering from this disease?
(or)
What is the leading cause of mortality in patients suffering from acromegaly?
A. Stroke
B. Cardiovascular disease
C. Colonic malignancy
D. Obstructive sleep apnea
2. A 20-year-old male presents with complaints of enlarged chest and milk secretion. Upon
examination, spade-like hands, coarse facies, and macroglossia are noted. What is the cause of this
(or)
What is the cause of galactorrhoea in a male with features of acromegaly?
A. Somatotroph adenoma
B. Hypothalamic hamartoma
C. Carcinoid tumor
D. Mixed mammosomatotroph adenoma
3. What is the investigation of choice to diagnose acromegaly?
A. Level of insulin-like growth factor
B. Oral glucose tolerance test
C. TSH level
D. Heel pad thickness
4. What is the treatment of choice for a patient with severe cardiomegaly due to increased growth
hormone secretion by somatotroph adenoma?
A. Trans-sphenoidal surgery
B. Pegvisomant
C. Octreotide
5. A 26-year-old female presents with complaints of mood swings, constipation, weight gain, cold
intolerance, and amenorrhea. Her medical history revealed that she suffered postpartum hemorrhage
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after the delivery. Lab investigation reveals hypoglycemia and reduced levels of T3, T4, and TSH. What
is the condition the patient is suffering from?
(or)
What is the diagnosis of a female presenting with mood swings, constipation, weight gain, cold
intolerance, amenorrhea, and hypoglycemia following postpartum hemorrhage, with reduced levels of
T3, T4, and TSH?
A. Addison’s disease
C. Sheehan syndrome
D. Grave’s disease
6. What is the first hormone to fall in a female with Sheehan’s syndrome?
A. Adrenocorticotropic hormone
B. Growth hormone
C. Follicle-stimulating hormone
D. Thyroid stimulating hormone
7. What will be the acute presentation in a female with Sheehan’s syndrome?
A. Secondary hypothyroidism
B. Hypoglycemia
C. Amenorrhea
D. Failure of lactation
8. Which of the following is not used as a part of treatment for a female with a history of postpartum
hemorrhage now presenting with secondary hypothyroidism, hypoglycemia, and amenorrhea?
(or)
Which of the following is not used for treating Sheehan’s syndrome?
A. Fludrocortisone
B. Dexamethasone
C. Combined oral contraceptives
D. Levothyroxine
9. An 18-year-old male presents with complaints of mood swings, constipation, weight gain, and cold
intolerance. Lab investigation revealed hypoglycemia, reduced levels of T3, T4, and TSH, and
secondary hypogonadism. A peripheral blood smear of the patient revealed sickle cells, anisocytosis,
and poikilocytosis. What is the diagnosis?
(or)
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What is the likely diagnosis in a patient with secondary hypothyroidism, hypoglycemia, secondary
hypogonadism, and a peripheral blood smear showing sickle cells, anisocytosis, and poikilocytosis?
A. Sheehan’s syndrome
B. Addison’s disease
C. Cushing’s disease
D. Simmond’s disease
10. In an 8-year-old child with a shrill voice, doll-like facies, and a height below the 3rd percentile, what
diagnostic test is most appropriate to confirm suspected hormone deficiency?
(or)
What is the investigation of choice to confirm the diagnosis of hypopituitarism?
A. Salt loading test
B. Insulin tolerance test
C. Oral glucose tolerance test
D. Water deprivation test
11. What is the most common functioning tumor of the pituitary gland?
B. Corticotroph adenoma
C. Prolactinoma
D. Thyrotroph adenoma
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Correct Option B - Cardiovascular disease:
 The symptoms described in the scenario, such as spade-like hands (increase in size of hands and
feet), coarse facies (frontal bossing and large fleshy nose), joint pain (arthropathy), excessive sweating,
and macroglossia, are indicative of acromegaly caused by excessive production of growth hormone
(GH) usually due to a pituitary adenoma.
 Acromegaly leads to cardiomegaly, which results in fatal arrhythmia and is the leading cause of
mortality. Other manifestations include stroke due to hypertension, colonic polyps with a risk of
malignancy, and obstructive sleep apnea (OSA) due to an enlarged tongue.
Options A, C and D are incorrect. Refer to Option B for an explanation.
Correct Option D - Mixed Mammosomatotroph Adenoma:
 The symptoms described in the scenario, including spade-like hands, coarse facies, and
macroglossia, are indicative of acromegaly. The presentation of galactorrhoea in males, along with
features of acromegaly, suggest that both growth hormone and prolactin are increased.
 Mixed mammosomatotroph adenoma is responsible for secreting increased levels of prolactin and
growth hormone, resulting in galactorrhoea and hypogonadism.
Option A - Somatotroph adenoma: This tumor results in excess secretion of growth hormone, and the p
atient presents only with features of acromegaly.
Option B - Hypothalamic hamartoma: This tumor is responsible for releasing growth hormone-releasing
 hormone (GHRH), resulting in increased secretion of growth hormone from the pituitary gland.
Option C - Carcinoid tumor: Carcinoid tumors usually arise from neuroendocrine cells and release GH
RH, resulting in increased growth hormone secretion from the pituitary gland.
Correct Option B - Oral glucose tolerance test:
Work Up for acromegaly
 Screening test is insulin-like growth factor 1 (IGF-1) levels.
 The investigation of choice is an oral glucose intolerance test. In normal individuals, 75 grams of
glucose suppresses the growth hormone. Failure to suppress growth hormone (less than 0.4 ■g/liters
is seen in acromegaly). Prolactin levels increased.
 In normal individuals, 75 grams of glucose suppresses the growth hormone.
 Failure to suppress growth hormone (less than 0.4 ■g/liters is seen in acromegaly).
 Prolactin levels increased.
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 TSH is normal or may be suppressed.
 MRI head: To localize the pituitary adenoma.
 X-ray foot (Lateral:) Heel pad thickness is increased.
Correct Option C - Octreotide:
Management of acromegaly
 The treatment of choice is Trans-sphenoidal surgery.
 In patients who deny surgery or are frail, like those with severe cardiomegaly, somatostatin receptor
ligand analogs like octreotide, lanreotide, and pasireotide are given. These somatostatin analogs act on
the SST 2 and SST 5 receptors, which are highly expressed in these tumors. These somatostatin
analogs inhibit the release of growth hormone.
 Pegvisomant is given in the recurrence of the tumor and if there is a poor response to somatostatin
receptor ligand analogs. It acts by blocking the growth hormone receptors.
Options A, B, and D are incorrect. Refer to Option C for an explanation.
Correct Option C - Sheehan syndrome:
 The patient's symptoms, including constipation, weight gain, cold intolerance, and reduced levels of
T3, T4, and TSH, are suggestive of hypothyroidism, specifically secondary hypothyroidism. The history
of postpartum hemorrhage, along with hypoglycemia, amenorrhoea and secondary hypothyroidism,
suggests the diagnosis of Sheehan’s syndrome, which is caused by damage to the anterior pituitary by
hypovolemia. Leading to a panhypopituitarism, resulting in these symptoms.
Option A - Addison’s disease: Addison's disease is characterized by reduced cortisol levels produced b
y the adrenal gland. It presents as fatigue, weight loss, low blood pressure, and hyperpigmentation.
Option B - Cushing’s syndrome: Cushing's syndrome results from prolonged exposure to high levels of 
corticosteroids. Symptoms can include weight gain, particularly in the upper body and face (moon face)
, high blood pressure, and mood swings.
Option D - Grave’s disease: Grave's disease is an autoimmune condition leading to overactivity of the t
hyroid gland and excess production of thyroid hormones. Common symptoms include weight loss, heat
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Progesterone. Levothyroxine.
 Dexamethasone is 1st to be supplemented. It replaces cortisol deficiency and stabilizes blood sugar
levels.
 Combined oral contraceptives: Estrogen and Progesterone.
 Levothyroxine.
 Fludrocortisone is a mineralocorticoid, which is not decreased in Sheehan’s syndrome. It is used for
treating adrenal insufficiency like Addison’s disease.
levels.
Options B, C, and D are incorrect. Refer to Option A for an explanation.
Correct Option D - Simmond’s disease:
 The clinical presentation of constipation, weight gain, and cold intolerance, along with reduced levels
of T3, T4, and TSH, is suggestive of secondary hypothyroidism. Peripheral blood smear is suggestive
of sickle cell disease.
 Simmond’s disease is the cause of non-obstetric damage to the anterior pituitary, presenting with
features of secondary hypothyroidism, secondary hypogonadism, and hypoglycemia. It occurs in
patients with hypertension, sickle cell disease, or rupture of AV Malformation
Option A - Sheehan’s syndrome: Sheehan’s syndrome is caused by damage to the anterior pituitary, s
een in patients with a history of postpartum hemorrhage.
Option B – Addison’s disease: Addison's disease is characterized by reduced cortisol levels produced 
by the adrenal gland. It presents as fatigue, weight loss, low blood pressure, and hyperpigmentation.
Option C - Cushing’s disease: Cushing's syndrome results from prolonged exposure to high levels of c
orticosteroids. Symptoms can include weight gain, particularly in the upper body and face (moon face), 
high blood pressure, and mood swings.
Correct Option B - Insulin tolerance test:
 The clinical presentation of a shrill voice, doll-like facies, and a height below the 3rd percentile is
suggestive of hypopituitarism, i.e., deficiency of growth hormone seen in the pediatric population.
 The investigation of choice to confirm the diagnosis is insulin tolerance test/arginine challenge test.
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Option A - Salt loading test: It is the diagnostic test for Conn syndrome.
Option C - Oral glucose tolerance test: It is the diagnostic test for acromegaly.
Option D - Water deprivation test: It is the diagnostic test for diabetes insipidus.
Correct Option C – Prolactinoma:
 The most common functioning tumor of the pituitary gland is prolactinoma. Prolactinomas are benign
tumors that produce excess prolactin, a hormone responsible for stimulating milk production in the
breast. They are often associated with symptoms like anovulation, amenorrhea, secondary infertility,
galactorrhoea, and bitemporal hemianopia due to pressure on optic chiasma.
Options A - Somatotroph adenoma: These tumors produce excess growth hormone, leading to acrome
galy. Acromegaly is characterized by enlarged hands, feet, facial changes, and other systemic effects. 
Prolactinomas are more common than somatotroph adenomas.
Option B - Corticotroph adenoma: These tumors result in excess secretion of adrenocorticotropic horm
one (ACTH), causing Cushing's disease. Symptoms include weight gain, central obesity, hypertension, 
and moon face. Prolactinomas are more prevalent.
Option D - Thyrotroph adenoma: These tumors lead to excess secretion of thyroid-stimulating hormone
 (TSH), causing hyperthyroidism. Symptoms include weight loss, tremors, heat intolerance, and palpitat
ions. Prolactinomas are more frequent than thyrotroph adenomas.
288

Calcium Hemostasis
1. A 28-year-old woman presents to the emergency department with complaints of numbness and
tingling in her hands and around her mouth. She reports feeling lightheaded and having muscle cramps
in her legs. The patient has been experiencing increased anxiety and has been hyperventilating due to
stress. Chvostek's sign is positive. Which of the following is the most likely explanation for the patient's
symptoms?
(or)
What is the most likely explanation for a 28-year-old woman's symptoms, including numbness, tingling,
lightheadedness, and muscle cramps, along with a positive Chvostek's sign, when she has been
hyperventilating due to stress?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
2. A 65-year-old postmenopausal woman presents with a history of multiple fragility fractures over the
past few years. Dual-energy X-ray absorptiometry (DEXA) scan reveals low bone mineral density.
Laboratory investigations show normal calcium, phosphate levels and Serum 25-hydroxyvitamin D
levels. Which of the following best explains the mechanism underlying the development of this disease
in this patient?
(or)
What is the most likely mechanism underlying the development of low bone mineral density in a
sedentary postmenopausal woman with fragility fractures, normal calcium and phosphate levels, and
normal 25-hydroxyvitamin D levels?
A. Increased osteoclast activity and bone resorption
B. Defective mineralization of bone matrix
C. Impaired collagen synthesis
D. Reduced osteoblast function and bone formation
3. A 60-year-old postmenopausal woman with a history of osteoporosis presents with complaints of
bone pain and a recent fracture. She has been prescribed a medication that inhibits osteoclast
activation and causes osteoclast apoptosis. Which of the following side effects is not associated with
this medication?
(or)
Which common side effect is not associated with bisphosphonates?
A. renal failure
B. Esophagitis
C. Osteonecrosis of the jaw bone
D. vertigo
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4. A 65-year-old postmenopausal woman with a history of osteoporosis presents for treatment. After a
thorough evaluation, the physician decides to prescribe a medication that acts as an anabolic agent
and forms bone. This medication is administered subcutaneously and is primarily used in severe cases
of osteoporosis. Which of the following medications fits the description provided?
(or)
Which subcutaneously administered medication, primarily used in severe cases of osteoporosis, acts
as an anabolic agent and promotes bone formation in a postmenopausal woman with a history of
osteoporosis?
A. Teriparatide
B. Denosumab
C. Bisphosphonates
D. Calcitonin
5. A 4-month-old male infant is brought to the pediatrician with concerns of recurrent respiratory
infections and has difficulty feeding. On examination, the infant appears small for his age, with
distinctive facial features including a small jaw and widely spaced eyes. The pediatrician notes a heart
murmur on auscultation. Which of the following is the most likely diagnosis for this infant's condition?
(or)
What is the most likely diagnosis for a 4-month-old male infant with growth and developmental
concerns, recurrent respiratory infections, feeding difficulties, small jaw, widely spaced eyes, and a
heart murmur?
A. Down syndrome
B. Marfan syndrome
C. Turner syndrome
D. DiGeorge syndrome
6. A 45-year-old female presents to her primary care physician with complaints of bone pain and
frequent kidney stones. On physical examination, there is palpable tenderness in the left lower
abdomen. Laboratory investigations reveal elevated serum calcium levels and decreased serum
phosphate levels. Which of the following symptoms is most likely associated with this patient's
(or)
Which symptom is most likely associated with bone pain, kidney stones, elevated serum calcium,
decreased serum phosphate levels, and palpable tenderness in the left lower abdomen?
A. Easy fatigability and muscle weakness
B. Excessive hair growth and oily skin
C. Cold intolerance and weight gain
D. Heat intolerance and weight loss
7. A 60-year-old male with a history of chronic kidney disease presents to the clinic with complaints of
fatigue, bone pain, and recurrent urinary tract infections. Laboratory investigations reveal elevated
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serum phosphate levels, decreased serum calcium levels, Which of the following statements regarding
the patient's condition is most accurate?
(or)
What is the most accurate statement about the condition of a 60-year-old male with chronic kidney
disease, presenting with fatigue, bone pain, recurrent urinary tract infections, elevated serum
phosphate levels, and decreased serum calcium levels?
A. Primary hyperparathyroidism
B. Secondary hyperparathyroidism
C. Tertiary hyperparathyroidism
D. Familial hyperparathyroidism
8. Which of the following statements about the treatment of parathyroid carcinoma is correct?
A. Surgical management involves unilateral neck exploration and en bloc resection of the tumor.
B. Recurrence of signs and symptoms of hypercalcemia after surgery is rare.
C. Distant metastasis is found in the majority of patients with parathyroid carcinoma.
D. Cinacalcet is the first-line treatment for parathyroid carcinoma.
9. A 35-year-old female presents with tingling sensation around her lips and fingertips three days after
undergoing a total thyroidectomy for papillary thyroid cancer. Physical examination reveals muscle
twitching around her lips and a positive Chvostek sign. The patient's serum calcium level is found to be
below 7 mg%. Which of the following is the most likely cause of her symptoms?
(or)
What is the most likely cause of tingling, muscle twitching, and hypocalcemia in a 35-year-old female
following a total thyroidectomy for papillary thyroid cancer, with a positive Chvostek sign?
A. Surgical hypoparathyroidism
B. Digeorge syndrome
C. Wilsons syndrome
D. Idiopathic hypoparathyroidism
10. A 10-year-old male presents with short stature, obesity, brachydactyly, and low IQ. Physical
examination reveals a dimpled appearance over the knuckles. Laboratory findings show decreased
serum calcium and increased phosphate levels. Serum alkaline phosphatase (SAP) is within the normal
range. Which of the following best explains the underlying pathophysiology of this patient's condition?
(or)
What is the underlying pathophysiology that best explains the combination of short stature, obesity,
brachydactyly, low IQ, knuckle dimpling, decreased serum calcium, increased phosphate levels, and
normal serum alkaline phosphatase in a 10-year-old male?
A. Hypoparathyroidism
B. Pseudohypoparathyroidism
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C. Pseudopseudohypoparathyroidism
D. Familial hypoparathyroidism
11. A 65-year-old woman with osteoporosis is started on a new medication to improve bone density.
The drug acts by inhibiting osteoclast activity and reducing bone resorption. Which of the following
hormones is likely the target of this medication?
(or)
Which hormone is likely the target of the medication prescribed to a 65-year-old woman with
osteoporosis, which inhibits osteoclast activity and reduces bone resorption to improve bone density?
A. Vitamin D
B. Calcitonin
C. Parathyroid hormone (PTH)
D. Insulin
12. A 4-year-old child presents with bowing of the legs and difficulty walking. Laboratory findings reveal
decreased calcium and phosphate levels, increased serum alkaline phosphatase (SAP) levels, and
elevated parathyroid hormone (PTH) levels. The child is diagnosed with vitamin D-dependent rickets.
Which of the following types of vitamin D-dependent rickets is most likely responsible for the patient's
symptoms?
(or)
Which type of vitamin D-dependent rickets is most likely responsible for the symptoms of a 4-year-old
child presenting with bowing of the legs, difficulty walking, decreased calcium and phosphate levels,
increased serum alkaline phosphatase (SAP), and elevated parathyroid hormone (PTH) levels?
A. Type 1
B. Type 2
C. Type 3
D. Type 4
13. Which of the following statements is true about the PTH (parathyroid hormone)?
A. It is secreted by oxyphil cells of the parathyroid gland
B. PTH is inhibited by hypercalcemia, hypermagnesemia and vitamin D
C. It stimulates 1 alpha hydroxylase enzyme in kidneys
D. It increases calcium reabsorption from DCT through TRPV 3 and 4 channels
14. A 25-year-old male presents with a painless lump in the anterior neck that has been gradually
increasing in size. Physical examination reveals a firm, non-tender thyroid nodule. The patient also
reports a family history of medullary thyroid carcinoma. Laboratory investigations show elevated serum
calcitonin levels. Further evaluation reveals bilateral adrenal masses on imaging. Which gene mutation
is most likely responsible for this patient's condition?
(or)
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Which gene mutation is most likely responsible for the development of a thyroid nodule, elevated serum
calcitonin levels, and bilateral adrenal masses in a male with a family history of similar thyroid nodules
and medullary thyroid carcinoma?
A. RET gene
B. TP53 gene
C. BRCA1 gene
D. APC gene
15. What specific finding can be seen in a female with a history of kidney stones, fatigue, elevated
serum calcium, decreased serum phosphate, a parathyroid adenoma, and a pituitary adenoma?
A. Increased serum gastrin levels
B. Elevated serum cortisol levels
C. Hypokalemia
D. Impaired liver function
16. A 35-year-old man presents with complaints of recurring headaches and visual disturbances. Upon
further evaluation, the patient was diagnosed with multiple hemangioblastomas in the cerebellum and
retina. A renal ultrasound also revealed the presence of multiple renal cysts. The patient's family history
is significant, with his father having a history of bilateral pheochromocytomas. Based on these findings,
what is the most likely diagnosis for this patient?
(or)
What is the most likely diagnosis for a male with recurrent headaches, visual disturbances, multiple
cerebellar and retinal hemangioblastomas, renal cysts, and a family history of bilateral
pheochromocytomas in his father?
A. Neurofibromatosis type 1 (NF1)
B. Von Hippel-Lindau (VHL) syndrome
C. Multiple endocrine neoplasia type 1 (MEN1)
D. Hereditary paraganglioma-pheochromocytoma syndrome
17. A 35-year-old male presents to the endocrinology clinic with a history of multiple endocrine
neoplasia. He reports a family history of similar endocrine disorders. On examination, the patient has
enlarged lips, a thickened tongue, and multiple neuromas on the mucosal surfaces of his lips, tongue,
and conjunctiva. He also has marfanoid habitus, with long limbs and hyperextensible joints. Laboratory
investigations reveal elevated levels of calcitonin and catecholamines. Based on the patient's clinical
presentation, which chromosome is most likely involved in this condition?
(or)
Which chromosome is most likely involved in the condition of a male with multiple endocrine
neoplasias, enlarged lips, thickened tongue, mucosal neuromas, marfanoid habitus, and elevated
levels of calcitonin and catecholamines, who also has a family history of similar endocrine disorders?
A. Chromosome 10
B. Chromosome 11
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C. Chromosome 16
D. Chromosome 20
18. A 32-year-old woman presents to the endocrinology clinic with a history of multiple endocrine
abnormalities. She reports fatigue, weight loss, recurrent infections, and irregular menstrual cycles. On
examination, she has dry skin, oral thrush, and mild hypotension. Laboratory investigations reveal low
levels of thyroid hormones, low parathyroid hormone (PTH) levels, and positive autoantibodies against
the pancreatic islet cells. What is the most likely diagnosis for this patient?
(or)
What is the most likely diagnosis for a woman with a history of multiple endocrine abnormalities,
including low thyroid hormones, low PTH levels, oral thrush, dry skin, and positive autoantibodies
against pancreatic islet cells, and presents with symptoms of fatigue, weight loss, recurrent infections,
and irregular menstrual cycles?
A. Type-1 Autoimmune Polyendocrine Syndrome (APS)
B. Type-2 Autoimmune Polyendocrine Syndrome (APS)
C. Addison's disease
D. Celiac disease
19. A 45-year-old woman presents to the dermatology clinic with multiple skin findings. She has a
history of benign breast masses and thyroid nodules. On examination, she is noted to have multiple
hamartomatous skin lesions, including trichilemmomas on her face and acral keratoses on her hands
and feet. Her family history is significant for breast cancer in her mother and grandmother. Which of the
following conditions is most likely to be associated with this patient's presentation?
(or)
Which condition is most likely associated in a woman with a history of benign breast masses and
thyroid nodules, as well as multiple hamartomatous skin lesions, trichilemmomas on her face, acral
keratoses on her hands and feet, and a family history of breast cancer in her mother and grandmother?
A. Cowden syndrome
B. Neurofibromatosis type 1
C. Tuberous sclerosis
D. Gorlin syndrome
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 S: Stops(inhibits) osteoclast activation
 P: used to treat PAGETS DISEASE
 H: used to treat HYPERCALCEMIA OF PREGNANCY
 O: causes Osteonecrosis of the jaw
 S: causes Stomach problems orally (esophagitis)
 Ph: inhibits farnesyl PyroPhosphate
 ONATE: e.g. zoledrONATE, risedrONATE, alendronate
Option A
- Nephrotoxicity: Nephrotoxicity can occur with intravenous administration of Zoledronate, but it is not a
commonly associated side effect of BPNs in general.
Option B - Gastritis and esophagitis: Gastritis and esophagitis are adverse effects that can occur when 
BPNs are administered orally. However, the given information states that BPNs are primarily administe
red intravenously, so this side effect is less likely.
Option C - Osteonecrosis of the jaw bone: It is a direct side effect of BPNs. 
 
Correct Option A - Teriparatide:
 Teriparatide is a recombinant parathormone (rPTH) that is an anabolic agent. It is made up of 1 to 34
subunits and is not a complete parathormone unit. Teriparatide is administered subcutaneously and is
prescribed only in severe cases of osteoporosis. However, it is associated with some important
considerations and potential adverse effects.
 One of the notable adverse effects of teriparatide is hypercalcemia, which can occur due to its
parathormone derivative nature. Prolonged use of teriparatide, exceeding two years, has been
associated with an increased risk of osteosarcoma due to its stimulatory effect on osteoblast activity. As
a result, a black box warning has been issued, recommending its use only in severe cases of
osteoporosis and not in patients with mild to moderate osteoporosis.
Drug
Mechanism of Action
Route of Administration
Indications
Adverse Effects
Bisphosphonates
Inhibit osteoclast activation and cause apoptosis
Oral or Intravenous
Postmenopausal osteoporosis, steroid-induced osteoporosis, Paget's disease, osteolytic bone metasta
sis
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Gastritis, esophagitis, osteonecrosis of the jaw bone, increased risk of fractures with prolonged use
Denosumab
Monoclonal antibody against RANK ligand
Subcutaneous
Postmenopausal osteoporosis, steroid-induced osteoporosis, prevention of skeletal-related events in c
ancer patients with bone metastasis
Hypocalcemia, infusion reactions, osteonecrosis of the jaw bone
Teriparatide
Recombinant parathormone
Severe cases of osteoporosis
Hypercalcemia, increased risk of osteosarcoma with prolonged use
Raloxifene
Selective estrogen receptor modulator
Oral
Postmenopausal osteoporosis
Hot flashes, leg cramps, increased risk of venous thromboembolism
Romosozumab
Targets sclerostin produced by osteocytes
Postmenopausal women at high risk for fracture
Cardiovascular events, hypersensitivity reactions, increased risk of stroke
Calcitonin
Inhibits osteoclast activity
Intranasal
Postmenopausal osteoporosis, Paget's disease
Nasal irritation, nasal ulceration
Strontium ranelate
Stimulates osteoblasts and inhibits osteoclasts
Cardiovascular events, hypersensitivity reactions
Estrogen/Hormone Therapy
Replaces declining estrogen levels
Oral or Transdermal
Increased risk of breast cancer, blood clots
 
Option B - Denosumab: It is a monoclonal antibody against the RANK ligand, which inhibits the activati
on of osteoclasts. It is not an anabolic agent like teriparatide.
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Correct Option A - Easy fatigability and muscle weakness:
 Symptoms given in the scenario with bone pain, kidney stones, elevated serum calcium, and
decreased serum phosphate levels, and palpable tenderness in the left lower abdomen points towards
the diagnosis of primary Hyperparathyroidism
Features of Primary Hyperparathyroidism
 Causes of Primary Hyperparathyroidism:
 Parathyroid Adenoma
 Parathyroid Hyperplasia
 Parathyroid Carcinoma
 Rare genetic syndromes (familial isolated hyperparathyroidism, neonatal severe hyperparathyroidism,
hyperparathyroidism-jaw tumor syndrome)
 
Option B - Excessive hair growth and oily skin: This symptom is not typically associated with hyperpara
thyroidism. It is more commonly seen in conditions such as polycystic ovary syndrome (PCOS) or hirsu
tism.
Option C - Cold intolerance and weight gain: These symptoms are not specific to hyperparathyroidism. 
Cold intolerance and weight gain are often seen in hypothyroidism due to an underactive thyroid gland.
Option D - Heat intolerance and weight loss: These symptoms are not characteristic of hyperparathyroi
dism. Heat intolerance and weight loss are more commonly associated with hyperthyroidism, which is 
an overactive thyroid gland.
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Correct Option B - Secondary hyperparathyroidism:
 The patient's history of chronic kidney disease, along with symptoms of fatigue, bone pain, and
recurrent urinary tract infections, and laboratory findings of elevated serum phosphate levels,
decreased serum calcium levels, and increased PTH levels, are consistent with the diagnosis of
secondary hyperparathyroidism.
 Secondary hyperparathyroidism occurs as a compensatory response to chronic kidney disease,
where there is impaired renal clearance of phosphate and reduced production of active vitamin D. The
parathyroid glands become hyperactive and release excess PTH, resulting in increased bone
resorption, decreased serum calcium levels, and elevated serum phosphate levels.
 Difference B/W Primary, Secondary and Tertiary Hyperparathyroidism
Condition
Cause
Serum Calcium
Serum Phosphate
Parathyroid Hormone (PTH)
Primary Hyperparathyroidism
Abnormal parathyroid gland function
Increased
Decreased
Secondary Hyperparathyroidism
Underlying condition (e.g., chronic renal failure, vitamin D deficiency)
Tertiary Hyperparathyroidism
Long-standing secondary hyperparathyroidism leading to autonomous parathyroid gland function
Variable
Increased Markedly
 
Option A - Primary hyperparathyroidism: Primary hyperparathyroidism is characterized by excessive se
cretion of PTH from one or more parathyroid adenomas, leading to hypercalcemia and hypophosphate
mia. However, the patient in this scenario has decreased serum calcium levels, making primary hyperp
arathyroidism less likely.
Option C - Tertiary hyperparathyroidism: Tertiary hyperparathyroidism occurs as a result of long-standi
ng secondary hyperparathyroidism, typically in the setting of chronic renal failure. It is characterized by 
autonomous hypersecretion of PTH by the parathyroid glands, leading to persistent hypercalcemia eve
n after the underlying cause of secondary hyperparathyroidism has been corrected. However, there is 
no indication of persistent hypercalcemia or evidence of long-standing secondary hyperparathyroidism 
in this case.
Option D - Familial hyperparathyroidism: Familial hyperparathyroidism is a rare genetic disorder charac
terized by the development of parathyroid adenomas or hyperplasia. It can be inherited in an autosoma
l dominant pattern and is associated with specific genetic mutations. However, there is no information i
n the question stem to suggest a
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family history or specific genetic mutation, making familial hyperparathyroidism less likely in this case.
Correct Option D - Cinacalcet is the first-line treatment for parathyroid carcinoma:
 Cinacalcet, a medication that works on the calcium-sensing receptor (CASR) of the parathyroid gland,
is used to control hypercalcemia in refractory cases of parathyroid carcinoma. It is not the first-line
treatment but can be employed when surgical management is not sufficient or feasible.
Parathyroid Carcinoma
Category
Information
Incidence
Approximately 1% of cases of primary hyperparathyroidism
Hypercalcemia
Present, with serum calcium levels >14 mg/dL
Markedly elevated levels (>5 times the normal value)
Clinical Features
Severe symptoms, palpable parathyroid gland, serum calcium >14 mg/dL
Route of Spread
Local invasion involving adjacent structures, such as the thyroid gland
Lymph Node Metastasis
Present in approximately 50% of cases, requiring ipsilateral MRND if positive
Distant Metastasis
Found in about 33% of patients
Surgical Management
Bilateral neck exploration and en bloc resection of the tumor
Recurrence
Possible, indicated by the reappearance of hypercalcemia symptoms
Management
Reoperation for recurrence or metastatic disease, Cinacalcet for refractory cases
 
Option A - Surgical management involves unilateral neck exploration and en bloc resection of the tumo
r: Surgical management of parathyroid carcinoma typically involves bilateral neck exploration to ensure
 thorough evaluation and removal of affected parathyroid glands. En bloc resection of the tumor is perf
ormed, along with ipsilateral thyroid lobe resection if necessary. Unilateral neck exploration is insufficie
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nt in addressing the extent of the disease and ensuring complete removal.
Option B - Recurrence of signs and symptoms of hypercalcemia after surgery is rare: Recurrence of si
gns and symptoms of hypercalcemia after surgery for parathyroid carcinoma is possible, indicating the 
potential for disease recurrence or metastasis. Close monitoring is necessary, and if hypercalcemia rec
urs, further evaluation and reoperation may be required.
Option C - Distant metastasis is found in the majority of patients with parathyroid carcinoma: While par
athyroid carcinoma can spread to distant sites, such as the lungs, bones, and liver, it is found in approx
imately 33% of patients, not the majority. Distant metastasis is a
serious complication of parathyroid carcinoma, but it is not present in the majority of cases.
Correct Option A - Surgical hypoparathyroidism:
 The patient's symptoms, such as tingling sensation around the lips and fingertips, along with muscle
twitching and a positive Chvostek sign, are consistent with hypocalcemia. Hypocalcemia is a common
complication following thyroidectomy due to accidental removal or damage to the parathyroid glands,
leading to decreased parathyroid hormone (PTH) production and subsequent hypoparathyroidism. This
scenario is often referred to as surgical hypoparathyroidism.
 
Causes
Description
Surgical hypoparathyroidism
Inadvertent removal or damage to the parathyroid glands during neck or thyroid surgery
Most common location where parathyroid gland is placed is BRACHIORADIALIS
Autoimmune hypoparathyroidism
Autoimmune destruction or dysfunction of the parathyroid glands
Congenital hypoparathyroidism
Genetic or developmental abnormalities leading to underdeveloped or absent glands
DiGeorge syndrome
Genetic disorder affecting the development of the parathyroid glands
Hereditary hypoparathyroidism
Inherited genetic mutations affecting parathyroid gland function
Idiopathic hypoparathyroidism
Hypoparathyroidism of unknown cause
Radiation-induced hypoparathyroidism
Damage to the parathyroid glands due to radiation therapy or exposure
Medications or toxins-induced hypoparathyroidism
Certain medications or toxins can impair parathyroid function
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Hypomagnesemia-induced hypoparathyroidism
Low magnesium levels can disrupt parathyroid gland function
Other rare causes
Rare conditions such as infiltrative disorders, infiltrating tumors, or trauma
Option B - DiGeorge syndrome: DiGeorge syndrome is a genetic disorder characterized by the abnorm
al development of several organs, including the parathyroid glands. It can lead to hypoparathyroidism a
nd hypocalcemia. However, in this case, the patient's symptoms following a
total thyroidectomy indicate a surgical cause rather than a genetic disorder like DiGeorge syndrome.
Option C - Wilson's syndrome: Wilson's syndrome, or Wilson-Mikity syndrome, is a genetic disorder tha
t affects the parathyroid glands and can result in hypoparathyroidism. However, it is an extremely rare 
condition. In this case, the patient's symptoms are more likely related to the recent thyroidectomy rathe
r than Wilson's syndrome.
Option D - Idiopathic hypoparathyroidism: Idiopathic hypoparathyroidism refers to hypoparathyroidism 
where the cause is unknown. While it is a
possibility, in this case, the timing of the symptoms after thyroidectomy suggest a
surgical cause rather than idiopathic hypoparathyroidism.
Correct Option B - Pseudohypoparathyroidism:
 The clinical presentation of short stature, obesity, brachydactyly, and low IQ, along with the dimpled
appearance over the knuckles, is consistent with Albright hereditary osteodystrophy, which is a
characteristic feature of pseudohypoparathyroidism. Pseudohypoparathyroidism is caused by a defect
in the GNAS gene, leading to resistance to the actions of parathyroid hormone (PTH) at the receptor
level. This resistance results in decreased responsiveness to PTH in the kidney, leading to decreased
serum calcium levels and increased phosphate levels. The normal serum alkaline phosphatase (SAP)
distinguishes pseudohypoparathyroidism from other conditions associated with low calcium levels.
 
Option A - Hypoparathyroidism: Hypoparathyroidism is characterized by low levels of PTH and would n
ot explain the clinical features observed in this patient.
Option C - Pseudopseudohypoparathyroidism: It is a rare condition in which the patient exhibits physic
al characteristics of pseudohypoparathyroidism but has normal calcium, phosphate, and PTH levels. It i
s inherited from the paternal side, which is not applicable in this case.
Option D - Familial hypoparathyroidism: It is a rare genetic condition characterized by low PTH levels, 
but it does not present with the specific clinical features and laboratory findings described in the patient
.
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Correct Option B - Calcitonin:
 Calcitonin is a hormone produced by the thyroid gland that plays a role in regulating calcium and bone
metabolism. It acts by inhibiting osteoclast activity, which reduces bone resorption. By inhibiting
osteoclasts, calcitonin helps to prevent excessive bone breakdown and maintain bone density.
Therefore, a medication that inhibits osteoclast activity and reduces bone resorption is likely targeting
calcitonin.
 
Option A - Vitamin D: Vitamin D plays a crucial role in calcium absorption from the intestines and prom
oting renal reabsorption of calcium. However, it does not directly inhibit osteoclast activity or reduce bo
ne resorption. Vitamin D
is involved in maintaining calcium and phosphate homeostasis and promoting bone mineralization.
Option C - Parathyroid hormone (PTH): PTH is responsible for regulating calcium and phosphate levels
 in the body. It acts on the bones, kidneys, and intestines to increase calcium levels by promoting bone
 resorption, enhancing renal calcium reabsorption, and increasing intestinal calcium absorption. In this 
case, the medication described does not target PTH but rather inhibits osteoclast activity.
Option D - Insulin: Insulin is a hormone produced by the pancreas that regulates glucose metabolism. I
t is not directly involved in bone metabolism or the regulation of calcium levels. Therefore, it is not the t
arget hormone for a medication aimed at improving bone density by inhibiting osteoclast activity and re
ducing bone resorption.
Correct Option B - Type 2:
 In Type 2 vitamin D-dependent rickets, there is end-organ resistance to the active form of vitamin D.
Although the active vitamin D is present, the target tissues do not respond properly to its effects. This
also leads to decreased calcium and phosphate levels, increased SAP levels, and increased PTH
levels. Therefore, type 2 is the right answer.
Type 1
Type 2
 Previously known as pseudo vitamin D resistant rickets.
 The gene that encodes 1 a hydroxylase activity is defective.
 Synthesis of the active form of vitamin D is decreased. Calcium levels are decreased. Phosphate
levels are decreased. SAP increased. PTH increased.
 Calcium levels are decreased.
 Phosphate levels are decreased.
 SAP increased.
 PTH increased.
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Option B - PTH is inhibited by hypercalcemia, hypermagnesemia and vitamin D: This statement is false
. PTH secretion is regulated by negative feedback mechanisms, and elevated levels of calcium, and vit
amin D can inhibit PTH secretion but it is rather inhibited by severe hypomagnesemia.
Option D - It increases calcium reabsorption from DCT through TRPV 3 and 4 channels: This statemen
t is false. PTH primarily acts on the distal convoluted tubule (DCT) to increase calcium reabsorption thr
ough the activation of the TRPV5 channel, not TRPV3 and TRPV4 channels.
Correct Option A - RET gene:
 MEN 2 syndrome is an autosomal dominant inherited disorder characterized by the development of
tumors in multiple endocrine glands. It consists of three subtypes: MEN 2A, MEN 2B, and familial
medullary thyroid carcinoma (FMTC). These subtypes are differentiated based on the presence or
absence of additional clinical features.
 MEN 2 is primarily associated with medullary thyroid carcinoma (MTC), pheochromocytoma, and
parathyroid hyperplasia or adenomas. The RET gene, located on chromosome 10q11.2, encodes a
receptor tyrosine kinase involved in cell signaling pathways. Mutations in the RET gene lead to the
development of MEN 2 syndrome.
 
Option B - TP53 gene: The TP53 gene is associated with Li-Fraumeni syndrome, which is characterize
d by an increased risk of various cancers, including sarcomas, breast cancer, brain tumors, and others.
 It is not directly related to MEN 2 syndrome.
Option C - BRCA1 gene: The BRCA1 gene is associated with hereditary breast and ovarian cancer syn
drome. Mutations in this gene increase the risk of developing breast and ovarian cancers but are not i
mplicated in MEN 2 syndrome.
Option D - APC gene: The APC gene is associated with familial adenomatous polyposis (FAP), an inhe
rited condition characterized by the development of multiple polyps in the colon and rectum. It is not rel
ated to MEN 2 syndrome, which primarily involves tumors in the endocrine glands.
Correct Option A - Increased serum gastrin levels:
 The likely diagnosis of this patient is Multiple Endocrine Neoplasia type 1 (MEN1). MEN1 is a
hereditary condition characterized by the development of tumors involving multiple endocrine glands. It
is associated with mutations in the MEN1 gene. The classic triad of MEN1 includes parathyroid
adenomas, pancreatic neuroendocrine tumors (e.g., insulinomas, gastrinomas), and pituitary
adenomas.
 The development of gastrinomas leads to increased serum gastrin levels and the development of
Zollinger-Ellison syndrome (ZES). ZES is characterized by hypersecretion of gastric acid, resulting in
recurrent peptic ulcers and other gastrointestinal symptoms.
 
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Option B - Elevated serum cortisol levels: Elevated serum cortisol levels are not typically associated wit
h parathyroid adenomas or Multiple Endocrine Neoplasia Type 1 (MEN1) syndrome. Elevated cortisol l
evels are characteristic of conditions such as Cushing's syndrome, which involves excessive productio
n of cortisol from the adrenal glands.
Option C - Hypokalemia: Hypokalemia, or low potassium levels, is not directly associated with parathyr
oid adenomas or MEN1 syndrome. It is more commonly seen in conditions such as primary aldosteroni
sm or certain kidney disorders.
Option D - Impaired liver function: Impaired liver function is not a typical finding in patients with parathy
roid adenomas or MEN1 syndrome. Liver dysfunction is more commonly associated with liver diseases
, such as hepatitis, cirrhosis, or liver failure.
Correct Option B - Von Hippel-Lindau (VHL) syndrome:
 The most likely diagnosis for this patient is Von Hippel-Lindau (VHL) syndrome. VHL syndrome is an
autosomal dominant disorder due to a defect in a pVHL gene located at chromosome 3p25.
 Von Hippel-Lindau (VHL) syndrome is characterized by the development of various tumors and cysts
in multiple organs. The presence of hemangioblastomas in the cerebellum and retina, along with renal
cysts and a family history of pheochromocytomas, are classic features of VHL syndrome. It is also
associated with the development of renal cell carcinoma, clear cell carcinoma.
Option A - Neurofibromatosis type 1 (NF1): Neurofibromatosis type 1 is a genetic disorder characterize
d by the development of multiple neurofibromas, café-au-lait spots, and other characteristic features.
Option C - Multiple endocrine neoplasia type 1 (MEN1): MEN1 syndrome is an autosomal dominant dis
order characterized by the development of tumors in multiple endocrine organs such as the parathyroid
, pancreas, and pituitary.
Option D - Hereditary paraganglioma-pheochromocytoma syndrome: Hereditary paraganglioma-pheoc
hromocytoma syndrome is a
genetic disorder characterized by the development of paragangliomas and pheochromocytomas.
Correct Option A - Chromosome 10:
 MEN 2B, also known as MEN 2B syndrome, is a rare genetic disorder caused by mutations in the
RET proto-oncogene. The RET gene is located on chromosome 10. Mutations in the RET gene result
in the activation of signaling pathways that lead to the development of multiple endocrine neoplasia.
 The features seen in MEN 2B include characteristic physical findings such as enlarged lips, a
thickened tongue, and multiple neuromas on the mucosal surfaces of the lips, tongue, and conjunctiva.
Patients may also have a marfanoid habitus, with long limbs and hyperextensible joints. The condition
is associated with the development of medullary thyroid carcinoma and pheochromocytoma, leading to
elevated levels of calcitonin and catecholamines, respectively.
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Correct Option A - Type-1 Autoimmune Polyendocrine Syndrome (APS):
 The most likely diagnosis for this patient is Type-1 Autoimmune Polyendocrine Syndrome (APS). This
syndrome involves multiple endocrine glands and is associated with a defect in chromosome 21.
 In this patient, there is evidence of autoimmune thyroiditis (low thyroid hormone levels),
hypoparathyroidism (low PTH levels), and autoimmune damage to the pancreas leading to type-1
diabetes mellitus. Additionally, the destruction of the adrenal glands presents as Addison's disease.
The presence of two out of these three findings is required for the diagnosis of Type-1 APS.
 
Option B - Type-2 Autoimmune Polyendocrine Syndrome (APS): Type-2 APS is similar to Type-1 APS 
but does not include hypoparathyroidism. Therefore, option B is not the correct answer.
Option C - Addison's disease: It is characterized by adrenal gland destruction but does not explain the i
nvolvement of other endocrine glands in this patient.
Option D - Celiac disease: It is associated with Type-2 APS but does not explain the entire constellatio
n of symptoms and endocrine abnormalities in this case.
Correct Option A - Cowden syndrome:
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 The most likely condition associated with this patient's presentation is Cowden syndrome. Cowden
syndrome is an autosomal dominant disorder due to a mutation in the PTEN gene, characterized by
multiple hamartomas and an increased risk of various malignancies, including breast, thyroid, and
endometrial cancers. The presence of benign breast masses, thyroid nodules, and hamartomatous skin
lesions such as trichilemmomas and acral keratoses are characteristic findings in Cowden syndrome.
 
Option B - Neurofibromatosis type 1: It is characterized by neurofibromas, café-au-lait spots, and Lisch 
nodules of the iris. It does not typically present with the specific skin findings described in the case.
Option C - Tuberous sclerosis: Tuberous sclerosis is characterized by the development of hamartomas
 in various organs, including the brain, heart, kidneys, and skin. It is not typically associated with trichile
mmomas or acral keratoses.
Option D - Gorlin syndrome: It is also known as nevoid basal cell carcinoma syndrome, is characterize
d by multiple basal cell carcinomas, skeletal abnormalities, and jaw cysts. It does not typically present 
with the specific skin findings described in the case.
311

1. Which of the subsequent is absent in MEN 2B syndrome?
A. Megacolon
B. Parathyroid adenoma
C. Mucosal neuroma
D. Marfanoid habitus
2. What should be the next course of action in managing a patient who has had diabetes mellitus for the
last 5 years and is currently experiencing vomiting and abdominal pain? The patient is not adhering to
medication and shows signs of dehydration. Diagnostic tests indicate a blood sugar level of 500 mg/dl
and the presence of ketone bodies.
A. Intravenous fluids with long-acting insulin
B. Intravenous fluids
C. Intravenous insulin
D. Intravenous fluids with regular insulin
3. What should be done next in the management of a patient who is diabetic and presents with
symptoms of vomiting and abdominal pain? Upon examination, the patient displays hyperventilation,
sweet breath, and low blood pressure. The blood glucose level is 320 mg/dL, and urine ketones are
detected.
A. IV insulin drip
B. IV soda-bicarbonate
C. Check blood ketone levels
D. IVF and check K+
4. Which medication is recommended as the primary treatment for high blood sugar in a 19-year-old
woman with a medical history of type 1 diabetes mellitus, who has been brought to the emergency
room due to symptoms of confusion, vomiting, and abdominal pain, and subsequently diagnosed with
diabetic ketoacidosis?
A. Regular insulin
B. Lente insulin
C. Glyburide
D. 70/30 insulin
5. A 25-year-old P1L1 woman is planning for her second child. She has been recently diagnosed with
Grave’s disease. Which of the following is the antithyroid drug to be used in early gestation?
A. Propylthiouracil
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C. Carbimazole
6. What drug is recommended for the treatment of a 29-year-old male patient who has been
experiencing coarse facial features and gradual enlargement of the hands and feet for the past decade,
and has been diagnosed with acromegaly based on elevated levels of IGF-1 and growth hormone that
did not suppress after a 75 g glucose challenge test?
A. Lanreotide depot formulation
B. Terlipressin
C. Ketoconazole
D. Leuprolide
7. A patient presents with complaints of sudden onset headache, palpitation, and profuse sweating.
The patient has had multiple similar episodes in the past. During these episodes, the patient's blood
pressure is elevated. A 24-hour urine metanephrine is elevated. What is the most likely diagnosis?
A. Addison's disease
B. Renal artery stenosis
C. Pheochromocytoma
D. Hyperthyroidism
8. What is the leading cause of death in diabetic ketoacidosis?
A. Acute respiratory distress syndrome
B. Cardiac arrhythmia
C. Cerebral edema
D. Acute kidney injury
9. In a 60-year-old male, what is the primary etiology typically associated with Cushing's disease?
A. Small-cell lung cancer
B. Adrenal tumor
C. Ectopic ACTH syndrome
D. Pituitary microadenoma
10. A 30-year-old female patient presented with bone pain and abdominal cramps. Her family reported
a previous history of abnormal behavior. The consultant doctor made a tentative diagnosis based on
the clinical symptoms. What would be the most appropriate investigative method to establish a
conclusive diagnosis?
A. MRI
B. Ultrasonogram
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C. Sestamibi scan
D. CT scan
11. Which type of neuroendocrine tumor could potentially cause these symptoms in a 49-year-old male
who is experiencing recurring episodes of watery diarrhea, dehydration, hypokalemia, and
achlorhydria?
A. Insulinoma
C. VIPoma
12. In a female patient with bronchial asthma, who arrives at the emergency department experiencing
intense restlessness, palpitations, and tremors, an examination reveals a swollen neck. Additionally,
her blood pressure is elevated, and tachycardia is observed. The ECG results indicate atrial fibrillation.
Which medication should be administered promptly for the initial treatment of this patient?
A. Diltiazem
C. Esmolol
D. Propylthiouracil
13. The patient in question is a 25-year-old male who presented with symptoms of palpitations,
sweating, and restlessness. He also mentioned experiencing sweaty palms. The image provided below
displays the clinical examination findings. Which diagnostic test is performed on this patient?
A. Anti-thyroglobulin antibody
B. Anti-thyroid peroxidase antibody
C. Thyroid receptor antibody
D. Elevated ultrasensitive thyrotropin levels
14. In the given sagittal brain section, the colored region corresponds to the paracentral lobule. What
structures would be impacted by a lesion in this particular area?
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A. Scapular region and neck
B. Trunk and shoulder
C. Perineum and leg
D. Face and neck
15. What recommendations would you give to a diabetic patient with a fasting blood glucose level of
160 mg/dL in terms of non-pharmacological management?
A. At least 80 mg of dietary fibre
B. <5 g sodium intake every day
C. <30% of the calories should come from fat
D. Cholesterol <100 mg
16. Which of the following is seen in MEN 2B syndrome?
A. Café au lait spot
B. Medullary thyroid carcinoma
C. Parathyroid adenoma
D. Optic nerve glioma
17. What is the probable diagnosis for a woman who has symptoms of altered mental state, difficulty
breathing, low blood pressure, and slow heart rate, along with non-pitting swelling in the limbs?
Additionally, she has a long-standing history of weight gain, constipation, sensitivity to cold, and heavy
menstrual bleeding.
A. Septic shock
B. Cardiogenic shock
C. Myxedema coma
18. Which of the following is a characteristic feature of Kallmann syndrome?
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A. Anosmia
B. Syndactyly in males
C. Precocious puberty in females
D. White forelock
19. All of the following are tests done for screening in patients with Turner's syndrome, except?
A. ANA
B. Audiometry
C. Echocardiography
D. Fasting blood glucose
20. Match the following? a. Trisomy 13 1. Huntington disease b. Trisomy 18 2. Patau syndrome c.
Trinucleotide repeat sequence 3. Sickle disease d. Hb point mutation of glutamate to valine 4. Edward
syndrome
a. Trisomy 13 1. Huntington disease
b. Trisomy 18 2. Patau syndrome
c. Trinucleotide repeat sequence 3. Sickle disease
d. Hb point mutation of glutamate to valine 4. Edward syndrome
A. a2-b4-c1-d3
B. b1-a3-d2-c4
C. a2-b1-c4-d3
D. a4-b1-c3-d2
21. Which of the microorganisms listed below will exhibit intrinsic resistance to meropenem and
aminoglycosides, but have sensitivity to cotrimoxazole?
A. Burkholderia cepacia
B. Acinetobacter
C. Pseudomonas
D. Stenotrophomonas
22. What is the most frequently encountered tumor in the anterior mediastinum?
A. Thymoma
B. Lymphoma
C. Neurogenic tumors
D. Fibroma
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23. Gynecomastia is caused by all except
A. Aromatase inhibitors
B. Liver failure
C. Spironolactone
D. Digoxin
24. What is the preferred medication for treating Hyperthyroidism during the second trimester of
A. Propyl Thiouracil
B. Carbimazole
C. Sodium iodide
D. Radioactive iodine
25. A patient came to the hospital with complaints of lethargy, increased sleep, and weight gain.
Investigations revealed low plasma TSH concentration. However, on the administration of TRH, the
TSH levels increased. Which of the conditions is likely in this patient?
A. Hyperthyroidism due to primary thyroid disease
B. Hypothyroidism due to disease in the pituitary
C. Hypothyroidism due to disease in the hypothalamus
D. Hyperthyroidism due to disease in the pituitary
26. Which of the subsequent manifestations is observed in pituitary apoplexy?
A. Hypertension
B. Shock
C. Unconsciousness
D. Fatigue
27. Which conditions are caused by a mutation in the gene for the aquaporin channel?
A. Liddle’s syndrome
B. Nephrogenic DI
C. Cystic fibrosis
D. Barter syndrome
28. What is the most appropriate course of action in managing a 12-year-old child with a history of type
1 diabetes mellitus who is experiencing confusion, drowsiness, rapid breathing, dry mucous
membranes, low blood pressure (70/50 mmHg), a random blood glucose level of 415 mg/dl, and urine
ketones of 4+?
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A. 2-3 L of normal saline over 1-3 hours
B. Insulin infusion at 0.1 units/kg/hour
C. Arterial blood gas
D. Insulin bolus of 0.1 units/kg given
29. What would be the most appropriate next step in managing a 40-year-old female patient who is
experiencing cold intolerance, dry skin, constipation, and has a slow ankle jerk on examination, with a
TSH level of 15 IU/L and low T3 and T4 levels?
A. Begin treatment with levothyroxine (LT4)
B. Measure thyroxine binding globulin (TBG)
C. Order a thyroid radionuclide uptake and scan
D. Order thyroid ultrasonography
30. What substances found in urine are utilized as a screening tool for pheochromocytoma?
A. Urinary metanephrines and VMA
B. Albumin
C. 5-HIAA
D. Glucose
31. What investigations are necessary for a 30-year-old female patient presenting with neck swelling,
weight loss, palpitations, exophthalmos, and a diffusely enlarged thyroid gland in the outpatient
department? 1. Thyroid scan 2. Fine needle aspiration cytology (FNAC) 3. Thyroid function tests 4.
Ultrasound of neck 5. Anti-thyroid antibody
A. 1,2,3,4 and 5
B. 1,3,5 only
C. 3,4,5 only
D. 1,3,4 and 5 only
32. What is the association of Rhino-cerebral Mucor mycosis?
A. Diabetic ketoacidosis
B. Pregnancy
C. Antibiotics
D. Inhaled steroids
33. What would be the most suitable course of action for managing a 65-year-old male who presented
with symptoms of weakness, lethargy, excessive cold intolerance, and slow ankle jerk? His thyroid
function test (TFT) revealed a TSH level of 16 Mu/L (normal range: 0.4 - 4.0 mu / l), T4 level of 0.3 ng/dl
(normal range: 0.6 - 1.6 ng / dl), and T3 level of 70 pg /dl.
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A. Start levothyroxine at 100 micrograms and decrease the dose gradually
B. Start levothyroxine at 25 micrograms and increase the dose gradually
C. Start levothyroxine at 25 micrograms and decrease the dose gradually
D. Give T3 and T4 drugs simultaneously
34. Which initial screening tests are employed in a primary healthcare center (PHC) for diagnosing
diabetes? HbA1c >6.5 Fasting blood sugar >126mg/dl Random blood sugar >200mg/dl 2-hour post
glucose load blood sugar
A. 1 and 2
B. 2 and 3
C. 2 and 4
D. 1,2 and 3
35. A comatose elderly patient with a weight of approximately 70 kilograms is presented to the
emergency department. During examination, it was determined that the patient's serum glucose levels
were 500mg/dL, arterial pH is 7.33, and there is an elevation in plasma ketones levels. However, the
serum potassium levels are within the normal range. In order to treat this patient, what substance
should be added to the saline solution?
A. Insulin
B. Bicarbonate
C. Potassium
D. 14 units of regular insulin intravenously
36. What is the most frequently observed delayed symptom of radiation therapy for the head and neck?
A. Dysphagia
B. Xerostomia
C. Myelopathy
D. Dysgeusia
37. In obesity, there is an increase in the production of which of the following hormones?
(or)
The production of which of the following hormones is increased in obesity?
A. Insulin
B. Thyroxine
C. Growth hormone
D. Adiponectin
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38. Calcitonin levels are increased in:
A. Hyperthyroidism
B. Hypoparathyroidism
C. Hyperparathyroidism
D. Cushing’s syndrome
39. Which prolactin levels are indicative of prolactinoma?
A. >50µg/L
B. >100µg/L
C. >150µg/L
D. >200µg/L
40. What is the most probable cause of hypokalemia, hypertension, and metabolic alkalosis in a
35-year-old female patient?
A. Bartter syndrome
B. Gitelman’s syndrome
C. Liddle’s syndrome
D. Fanconi’s syndrome
41. Which of the following statements accurately describes the thyroid function test results for a
middle-aged woman diagnosed with Grave's disease, presenting symptoms such as tremors,
palpitations, weight loss, and menstrual irregularities?
A. Low TSH levels
B. Low free T4 levels
C. Low serum T3 levels
D. Radioactive iodine uptake (RAIU) at 24 hours below normal
42. A middle-aged woman with a history of constipation, dry skin and menorrhagia presents to the ER
with altered sensorium, non-pitting edema, hypothermia, bradycardia, and hypotension. What is the
D. Hypoglycemia
43. A patient presented with chronic diarrhea and steatorrhea. D- xylose test was normal and the
Schilling test was abnormal. A duodenal biopsy was normal. What is the most likely diagnosis?
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A. Celiac disease
B. Ulcerative colitis
C. Intestinal lymphangiectasia
D. Pancreatic insufficiency
44. Which of the following statements correctly describes an ideal candidate for a renal graft transplant
in a patient with diabetic nephropathy?
A. The survival rate of graft is 95% in the first year
B. The transplantation is cost effective after the second transplant year
C. The life expectancy is doubled in a diabetic patient with renal transplant
D. The treatment of chronic rejection has improved over the last 10 years
45. What could be the possible reason for a diabetic patient to greet with a "namaste" gesture upon
entering your clinic? (Image provided)
A. Flexor tenosynovitis
B. Cheiroarthropathy
C. Dupuytrens contracture
D. Ankyloses
46. During her pregnancy, a woman who had Grave's disease was consistently taking antithyroid
medication. Consequently, the newborn suffered from aplasia cutis congenita. Which specific
medication could be attributed to the occurrence of this condition?
B. Levothyroxine
C. Methylthiouracil
D. Hydrouracil
47. In a medical camp established on a military base, a 20-year-old military recruit is discovered to
have an HbA1C level of 6.1% and a fasting blood glucose of 120 mg/dL. The individual does not have a
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familial background of diabetes mellitus and displays no indications or symptoms of diabetes. The
general physical examination shows no noteworthy findings. Which of the following options most
accurately characterizes the blood glucose levels in this patient?
A. Normal
B. Impaired Glucose tolerance
C. Diabetes Mellitus
D. Maturity onset diabetes in Young
48. What is the most frequent cause of fulminant diabetes?
(or)
Most common cause of fulminant diabetes is?
A. Viruses
B. Diabetic Ketoacidosis
C. Non-ketotic hyperosmolar coma
D. Autoimmunity
49. MC joint involved in diabetes is?
A. Ankle
B. Knee
C. Shoulder
D. Charcot
50. Which type of insulin should be administered to manage a 32-year-old male patient with a medical
history of peptic ulcer disease and diabetes mellitus, who presents to the emergency department
complaining of nausea, abdominal pain, and lethargy for the past two days? The patient also reports
occasional dark, tarry stools. Laboratory tests indicate elevated blood glucose levels and a high anion
gap metabolic acidosis on an arterial blood gas sample.
B. Lispro
D. Aspart
51. Slow onset of action is seen with?
A. Glargine
B. Lispro
C. Regular
D. NPH
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52. What is the main physical finding of prolactinoma that follows galactorrhea in a 19-year-old
nulligravida woman who has been experiencing milk discharge from her nipples for the last 5 months
and is diagnosed with prolactinoma?
A. Bitemporal hemianopia
B. Anovulatory cycles
D. Infertility
53. What is not observed in Tumor Lysis Syndrome?
A. Hypophosphatemia
B. Hypocalcemia
C. Hyperuricemia
54. What is the interpretation of elevated serum Calcium levels in a patient with normal SAP, PTH, and
Vitamin D3 levels?
A. Vitamin D intoxication
B. Hyperparathyroidism
C. Multiple myeloma
D. Nutritional rickets
55. Pheochromocytoma produces all except?
A. Epinephrine
B. Norepinephrine
C. Cortisol
D. Dopamine
56. Please calculate the sodium deficit in the patient, who weighs 60 kg, using the provided serum
electrolyte values: pH of 7.42, sodium (Na+) level of 120 mEq/L, and serum chloride (CI-) level of 90
mEq/L.
A. 20 mEq
B. 200 mEq
C. 400 mEq
D. 720 mEq
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57. A 56-year-old woman presented with a gradually diminishing visual field. She was found to have a
pituitary mass and underwent trans-sphenoidal hypophysectomy. Now she has low levels of ACTH,
TSH, FSH and LH. Which of the following hormone supplements is not needed in the patient
postoperatively?
A. Mineralocorticoids
B. Thyroid hormones
C. Glucocorticoids
D. Estradiol
58. Which condition is frequently linked to Addison's disease?
A. Autoimmune adrenalitis
B. Adrenocortical carcinoma
C. Hypernephroma
D. Medullary carcinoma thyroid
59. What is the treatment for hypercalcemia caused by vitamin D toxicity?
A. Dexamethasone
B. Hydroxychloroquine
C. Chloroquine
D. Ketoconazole
60. What is a macrovascular complication that develops in the advanced stages of diabetes?
B. Foot ulcer
C. Nephropathy
D. Retinopathy
61. What is the disease depicted in the image below?
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A. Acromegaly
B. PCOS
C. Cushing’s syndrome
D. Advanced obesity
62. Mark the true statements? 1. MEN 2B is also known as Sipple syndrome 2. MEN 1 is also known as
Werner syndrome 3. MEN 2B is characterized by the presence of Marfanoid Habitus. 4. MEN 4 is a/w
CDKN1B
A. 1 and 2 are true
B. 3 and 4 are true
C. 1, 2 and 4 are true
D. 2, 3 and 4 are true
63. Fulminant diabetes mellitus is seen in?
B. Coxsackie B virus
C. Non ketonic hyperosmolar coma
D. Autoimmune pancreatis
64. A high-dose dexamethasone suppression test was done on a chronic smoker with complaints of
weight gain and hyperpigmentation. The before and after ACTH values are high. What is the most likely
clinical diagnosis?
A. Pituitary adenoma
B. Ectopic source
C. Exogenous source
D. Adrenal adenoma.
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Question 15 3
Question 17 3
Question 18 1
Question 21 4
Question 23 1
Question 24 2
Question 26 2
Question 27 2
Question 28 3
Question 29 1
Question 30 1
Question 31 4
Question 32 1
Question 35 1
Question 37 1
Question 38 3
Question 39 4
Question 40 3
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Question 42 3
Question 43 4
Question 46 1
Question 47 2
Question 48 1
Question 49 4
Question 50 1
Question 51 1
Question 53 1
Question 54 3
Question 56 4
Question 58 1
Question 61 3
Correct Option B: Parathyroid adenoma
 Parathyroid adenoma is not visualized in MEN 2B syndrome.
 It is a common finding in another type of MEN syndrome, MEN 1, that occurs due to mutations in the
MEN1 gene. 
 In MEN 1 condition, patients may develop tumors in the parathyroid glands, pancreas, and pituitary
gland, that can cause hyperparathyroidism, pancreatic neuroendocrine tumors, and pituitary
adenomas, individually.
Option A: Megacolon
 Megacolon is a feature of Hirschsprung's disease and is associated with accompanying MEN 2B
syndrome.
Option C: Mucosal neuroma
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 Mucosal neuromas are a hallmark of MEN 2B syndrome and are visualized in the oral mucosa,
conjunctiva, and gastrointestinal tract.
Option D: Marfanoid habitus
 Marfanoid habitus is visualized in MEN 2B syndrome characterized by exaggerated stature, thin long
fingers, and hypermobility of joints.
Correct Option D: 
 The next best step in management for this patient is intravenous fluids with regular insulin. 
 Usually, since the patient is displaying diabetic ketoacidosis (DKA), it is possibly a life-threatening
complication of uncontrolled diabetes mellitus.
 In DKA, the body produces high levels of ketone bodies, driving to acidosis and electrolyte
imbalances. 
 Treatment includes replenishing fluid and electrolyte imbalances with intravenous fluids, taken after
insulin therapy to diminish blood glucose levels and ketone bodies. 
 Normal affront is utilized in a nonstop intravenous mixture until the blood glucose level is underneath
200 mg/dL, after which subcutaneous affront can be started.
Option A. Intravenous fluids with long-acting insulin: Long-acting insulin isn't fitting for the administratio
n of DKA, because it does not reduce blood glucose levels rapidly enough to treat the acute hyperglyce
mia related to DKA.
Option B. Intravenous fluids alone: Whereas intravenous liquids are a critical component of DKA mana
gement, insulin treatment is essential to reduce blood glucose levels and ketone bodies. Without insuli
n therapy, the patient's acidosis and electrolyte imbalances will not improve.
Option C. Intravenous insulin alone: Whereas insulin treatment is vital for DKA management, intraveno
us fluids are moreover required to correct liquid and electrolyte imbalances. Without intravenous fluids, 
the persistent may develop hypotension and declining electrolyte imbalances.
Option d:
The patient in the given scenario presents with symptoms of diabetic ketoacidosis (DKA), a potentially l
ife-threatening complication of diabetes. DKA occurs when the body starts breaking down fat for energ
y due to a lack of insulin, leading to the buildup of ketones in the blood.
The correct next step in managing this patient is to initiate intravenous fluid (IVF) therapy and check th
e potassium levels. This is because patients with DKA are typically dehydrated due to excessive urinati
on and vomiting, and they also lose potassium in the urine. Hypokalemia (low potassium levels) can oc
cur due to insulin therapy, so it is important to check and monitor potassium levels closely during treat
ment.
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a. IV insulin drip is a
necessary treatment for DKA. Still, it should be initiated after fluid resuscitation to avoid causing a
sudden drop in blood glucose levels, which can lead to cerebral edema.
b. IV soda-bicarbonate is not recommended for the initial management of DKA as it may worsen the ac
idosis by causing a shift in the acid-base balance.
c. While checking blood ketone levels is important for diagnosing DKA, it does not address the acute m
anagement of the condition.  
 In the management of DKA (diabetic ketoacidosis), the main goal is to lower the blood glucose level
and correct the acid-base and electrolyte imbalances. Regular insulin is the drug of choice for the
management of hyperglycemia in DKA. It is a fast-acting insulin that is given intravenously and has a
rapid onset of action, which helps to lower the blood glucose level quickly.
Incorrect choices:
 Option b: Lente insulin is a combination of short-acting and long-acting insulin, which is used for the
management of type 1 and type 2 diabetes mellitus. It has a delayed onset of action and is not effective
for the rapid correction of hyperglycemia in DKA. 
 Option c: 70/30 insulin is a combination of intermediate-acting and short-acting insulin, which is used
for the management of type 1 and type 2 diabetes mellitus. It is not appropriate for the rapid correction
of hyperglycemia in DKA.
 Option d: Glyburide is an oral hypoglycemic agent that is used for the management of type 2 diabetes
mellitus. It works by stimulating the release of insulin from the pancreas. It is not appropriate for the
management of DKA as it does not lower the blood glucose level quickly enough to be effective in the
treatment of this condition.  
Option a. Propylthiouracil:
 Grave's disease is an autoimmune disorder that causes hyperthyroidism, which results in the
overproduction of thyroid hormones by the thyroid gland. When a woman is planning for pregnancy or
is already pregnant, it is crucial to manage Grave's disease effectively to ensure the health of both the
mother and the developing fetus.
 Antithyroid drugs are the mainstay of treatment for Grave's disease, and among the antithyroid drugs,
Propylthiouracil (PTU) is the preferred drug for use during early pregnancy.
 Propylthiouracil (PTU) is an antithyroid drug that works by inhibiting the production of thyroid
hormones. PTU is the preferred drug for use during early pregnancy, particularly in the first trimester,
as it has a lower risk of causing birth defects compared to Methimazole.
Option b: Methimazole is also an antithyroid drug that works by inhibiting the production of thyroid hor
mones. Methimazole is usually avoided during the first trimester of pregnancy due to its potential risk of
 causing birth defects. However, it can be used during the second and third trimesters of pregnancy if P
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TU is not well-tolerated.
Option c: Carbimazole is a prodrug of Methimazole. Like Methimazole, it is avoided during the first trim
ester of pregnancy due to the risk of causing birth defects.
Option d: Propylthiouracil can be used in early gestation, but Methimazole and Carbimazole are avoide
d during the first trimester of the pregnancy.  
 Lanreotide is a somatostatin analog that inhibits the release of GH.
 It is administered as a long-acting depot injection. 
 Considered the preferred medical therapy for acromegaly due to its high efficacy in controlling GH and
IGF-1 levels, as well as its long duration of action. 
 Option B: Terlipressin Is a synthetic vasopressin analog used primarily for the treatment of
hepatorenal syndrome and bleeding esophageal varices
 Option C: Ketoconazol is antifungal medication that inhibits the synthesis of adrenal and gonadal
steroids. It has been used off-label for the medical management of acromegaly in the past,. However, it
is associated with significant adverse effects and has been largely replaced by more effective and safer
treatment options, such as somatostatin analogs (like lanreotide). 
 Option D: Leuprolide is a gonadotropin-releasing hormone (GnRH) agonist commonly used for the
treatment of conditions such as prostate cancer and endometriosis. It has no direct role in the
management of acromegaly and is not the preferred drug for this condition.  
Correct option C - Pheochromocytoma:
 Pheochromocytoma produces excessive amounts of catecholamines, leading to symptoms like
sudden onset headache, palpitation and profuse sweating.
 The diagnosis is confirmed by measuring elevated levels of urinary metanephrines.
 A 24-hour urine metanephrine test is a diagnostic test for pheochromocytoma. 
Option A - Addison's disease: It presents with symptoms like fatigue, weight loss, low blood pressure, a
nd skin hyperpigmentation. While adrenal crisis can cause symptoms such as headache and sweating,
 it does not cause an episodic elevation of blood pressure.
Option B - Renal artery stenosis: It can lead to high blood pressure but does not cause sudden onset h
eadaches, palpitation, and profuse sweating. An elevated 24-hour urine metanephrine is not associate
d with renal artery stenosis.
Option D - Hyperthyroidism: Hyperthyroidism symptoms include weight loss, increased appetite, tremor
s, heat intolerance, palpitations, and sweating. An elevated 24-hour urinary metanephrine is not associ
ated with hyperthyroidism.
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 Cerebral edema refers to fluid accumulation in the brain, leading to swelling and increased pressure
within the skull. It is a serious complication of DKA and can potentially be fatal.
 Option A: Acute respiratory distress syndrome (ARDS): While respiratory complications can occur in
DKA, ARDS is not the most common cause of mortality. DKA can lead to respiratory acidosis but is
typically reversible with appropriate treatment.
 Option B: Cardiac arrhythmia:  DKA can lead to electrolyte imbalances, including abnormalities in
potassium levels, which can contribute to cardiac arrhythmias, they are not the most common cause of
mortality.
 Option D:. Acute kidney injury (AKI): AKI can occur in the setting of DKA, but it is not the most
common cause of mortality. DKA can lead to dehydration and hypoperfusion, possibly contributing to
kidney injury.   
Option D: Pituitary microadenoma
 Pituitary microadenoma is the most common cause of Cushing's disease in a 60-year-old male.
 Cushing's disease is a type of hypercortisolism caused by an ACTH-secreting pituitary adenoma (a
benign tumour in the pituitary gland). 
 While other conditions can cause Cushing's syndrome, the term "Cushing's disease" is used when the
primary cause is an ACTH-secreting pituitary tumour. 
 This type of tumor overproduces ACTH, which stimulates the adrenal glands to produce excessive
cortisol.
Option A: Small-cell lung cancer
 Certain cancers, most notably small-cell lung cancer, can produce ACTH or ACTH-like substances,
resulting in Cushing's syndrome. However, especially in this age group, this is not the most common
cause of Cushing's disease.
Option B: Adrenal tumor
 An adrenal tumor, specifically an adrenal adenoma or adrenal carcinoma, can produce cortisol on its
own, resulting in Cushing's syndrome. However, as previously stated, the primary cause of Cushing's
disease is a pituitary microadenoma.
Option C: Ectopic ACTH syndrome
 Ectopic ACTH syndrome occurs when a non-pituitary tumor (e.g., lung, pancreas, or thymus)
produces ACTH, resulting in Cushing's syndrome. While this can be a cause of Cushing's syndrome, it
is not the most common cause of Cushing's disease in a 60-year-old male.  
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disease.
 Grave’s disease is an autoimmune disorder that causes the overproduction of thyroid hormones.
 This is because of thyroid receptor antibodies that mimic TSH, thus making the thyroid gland secrete
excess thyroid hormone. This is the gold standard test for confirming the presence of Grave’s disease. 
Option A: Anti-thyroglobulin antibody
 Anti-thyroglobulin antibody is a test that, when positive, represents an autoimmune disorder of lupus,
Hashimoto’s thyroiditis, or Grave’s disease. It is not as sensitive as the thyroid receptor antibody for
Grave’s disease and hence, does not need to be tested in the patient in the vignette.
Option B: Anti-thyroid peroxidase antibody
 Anti-thyroid peroxidase antibody is extremely specific for the presence of Hashimoto’s thyroiditis.
 Hashimoto’s thyroiditis is an autoimmune disorder that causes hypothyroidism, unlike the symptoms
presented by the patient. Hence, this test does not need to be performed on the patient in the vignette.
Option D: Elevated ultrasensitive thyrotropin levels
 Elevated ultrasensitive thyrotropin levels, or TSH levels are seen in cases of hypothyroidism. The
patient presents with hyperthyroidism symptoms; hence, this test does not need to be performed on the
patient in the vignette.
 
 The paracentral lobule isa district situated in the average part of the cerebral half of the globe,
neighbouring the longitudinal gap, and it is liable for the engine control of the lower limits, including the
perineum and leg.
 
 As a result, a lesion in this area can affect the motor function of the perineum and leg, causing
weakness, paralysis, or spasticity.
 Option a. Other parts of the brain, like the primary motor cortex, premotor cortex, and supplementary
motor area in the precentral gyrus and surrounding regions of the cerebral hemisphere, control motor
function in the scapular region and neck.
 Option b. The motor control of the trunk and shoulder is administered by different region of the
cerebrum, like the essential engine cortex, premotor cortex, and valuable engine region, which are
situated in the precentral gyrus and encompassing locales of the cerebral half of the globe.
 Option d. The primary motor cortex, which is located in the precentral gyrus of the frontal lobe, is
primarily in charge of the motor control of the face and neck. Spasticity or weakness of the face and
neck can result from lesions in these areas
Correct Option C - <30% of the calories should come from fat:
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 <30% of the calories should come from fat. It is recommended that people with diabetes consume
less than 30% of their total calories from fat, with less than 7% of calories from saturated fat.
Option A - At least 80 mg of dietary fibre: It is also important for people with diabetes, as it can help to i
mprove blood glucose control and reduce the risk of heart disease. However, the recommended daily d
ietary fiber intake is higher than 80 mg. The recommended daily intake of dietary fiber for adults is 25 g
rams for women and 38 grams for men.
Option B - <5 g sodium intake every day: It is important for people with diabetes who have high blood p
ressure or are at risk for developing high blood pressure. However, sodium intake is not directly related
 to blood glucose control, which is the focus of this question.
Option D - Cholesterol <100 mg: It is important for people with diabetes who have high cholesterol leve
ls or are at risk for developing high cholesterol. However, cholesterol intake is not directly related to blo
od glucose control, which is the focus of this question.
Correct Option B - Medullary thyroid carcinoma:
 Medullary thyroid carcinoma is a characteristic feature of MEN 2B syndrome. It is a malignant tumor
that arises from the C cells of the thyroid gland.
Option A - Café au lait spot: Café au lait spots are light brown patches on the skin and are commonly s
een in conditions such as neurofibromatosis.
Option C - Parathyroid adenoma: Parathyroid adenomas are not typically associated with MEN 2B syn
drome. MEN 2B syndrome primarily involves tumors of the thyroid gland, adrenal glands, and mucosal 
neuromas.
Option D - Optic nerve glioma: Optic nerve gliomas are not typically associated with MEN 2B syndrome
. They are more commonly seen in neurofibromatosis type 1.
Correct Option C - Myxedema coma:
 When the thyroid gland does not create enough thyroid hormones, the condition is known as
hypothyroidism.
 A complication of severe hypothyroidism is myxedema coma, commonly referred to as myxedema
crisis.
 The presence of altered sensorium, hypotension, bradycardia, long-standing history of weight gain,
constipation, cold intolerance, menorrhagia, and non-pitting edema are characteristic features of
myxedema coma.
Option A - Septic shock: While septic shock can cause altered sensorium, hypotension, and bradycardi
a, it typically presents with warm extremities rather than non-pitting edema. The patient's long-standing
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 history of weight gain, constipation, cold intolerance, and menorrhagia suggests an underlying chronic 
condition rather than an acute infection.
Option B - Cardiogenic shock: Cardiogenic shock is characterized by a low cardiac output leading to hy
potension, but it does not typically cause altered sensorium or non-pitting edema. The patient's history 
of weight gain, constipation, cold intolerance, and menorrhagia are more consistent with an endocrine 
disorder.
Option D - Hyperthyroidism: Hyperthyroidism is associated with symptoms such as weight loss, heat int
olerance, palpitations, and tremors. The patient's symptoms of weight gain, constipation, cold intoleran
ce, and menorrhagia are more indicative of hypothyroidism rather than hyperthyroidism.
Correct Option A - Anosmia:
 Anosmia which means loss of sense of smell is a key feature of Kallmann syndrome, and it is typically
present in all affected individuals.
Option B, C and D are not characteristic features of Kallman syndrome
 
Option A: ANA (Antinuclear Antibody) test:
 The ANA test is not typically performed as part of Turner mosaic screening. It is a blood test used to
detect the presence of autoantibodies that target the nucleus of cells. ANA testing is primarily used to
help diagnose autoimmune conditions such as systemic lupus erythematosus (SLE) or other
connective tissue diseases.
Option B:  Audiometry: Audiometry is a test used to screen for hearing loss at diagnosis and every one 
to five years thereafter in these patients. There is an association of Turner's syndrome with sensorineur
al hearing loss, which makes audiometry essential in these patients.
Option C: Echocardiography: It is an important component of screening Turner's patients every five to t
en years due to their increased risk of various cardiovascular abnormalities like aortic root dilatation. C
ardiac MRI has higher sensitivity. 
Option D: Fasting blood glucose: Annual fasting blood glucose is monitored as these patients are at inc
reased risk of developing metabolic diseases including diabetes mellitus. 
Correct Option A - a2-b4-c1-d3:
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a. Trisomy 13
2. Patau syndrome
b. Trisomy 18
4. Edward syndrome
c. Trinucleotide repeat sequence
1. Huntington disease
d. Hb point mutation of glutamate to valine
3. Sickle disease
 
Correct Option D: Stenotrophomonas
The correct microorganism that is resistant to meropenem and aminoglycosides but sensitive to cotrim
oxazole is Stenotrophomonas.
 Stenotrophomonas is a Gram-negative bacterium that can cause various infections, particularly in
immunocompromised individuals or those with underlying medical conditions. It is known for its intrinsic
resistance to many antibiotics, including meropenem and aminoglycosides.
 Meropenem is a carbapenem antibiotic, and aminoglycosides are a class of antibiotics commonly
used to treat severe bacterial infections. However, Stenotrophomonas species often exhibit resistance
mechanisms against these antibiotics, making them ineffective for treatment.
 On the other hand, cotrimoxazole (a combination of sulfamethoxazole and trimethoprim) and
levofloxacin can still be effective against Stenotrophomonas. These antibiotics are often used as
alternative treatment options due to their activity against Stenotrophomonas infections.
Option A,B, C: These organisms are susceptible to the drugs mentioned in the question.
Option A.
Thymoma is the most common tumor in the anterior mediastinum. Thymomas are malignant epithelial 
cell tumors that form in the Thymus. They are commonly found in the perivascular or anterior mediastin
um.
Option B. Lymphoma refers to the cancerous condition of lymph nodes.
Option C. Neurogenic tumors are tumors affecting the cell constituting the nervous system.
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Option D. Fibromas are tumors that form in the uterus. These are noncancerous and often referred to a
s fibroids.
Option A.
Gynecomastia refers to the increased development of breast gland tissue in males. This occurs due to 
an imbalance in the production of Testosterone and estrogen.
 
Option B. Liver diseases can cause increased SHBG, resulting in the development of breast gland tiss
ue.
Option C. Spironolactone causes decreased production of Testosterone, thereby causing Gynecomasti
a.
Option D. Digoxin has estrogenic action, contributing to the development of breast gland tissue.
Option B.
 Carbimazole is the drug of choice for Hyperthyroidism in the second trimester of pregnancy.
Option A. Propyl Thiouracil is the drug of choice in Hyperthyroidism seen in the first trimester.
Option C. Sodium iodide is highly contraindicated because it can completely cross the placenta.
Option D. Pregnant women should avoid radioactive iodine as it can potentially cause miscarriage.
The correct option is:
The scenario described in the question is indicative of a dysfunction at the level of the hypothalamus, w
hich is responsible for regulating the release of thyroid-stimulating hormone (TSH) from the pituitary gla
nd.
When the hypothalamus senses low levels of thyroid hormones (T3 and T4) in the bloodstream, it relea
ses thyrotropin-releasing hormone (TRH). TRH stimulates the anterior pituitary gland to release TSH, 
which, in turn, stimulates the thyroid gland to produce and release T3 and T4.
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In the given scenario:
 The patient has complaints of lethargy, increased sleep, and weight gain, which are typical symptoms
of hypothyroidism (low thyroid hormone levels).
 Investigations reveal low plasma TSH concentration, which is unexpected in primary hypothyroidism.
In primary hypothyroidism, TSH levels are usually elevated due to the lack of negative feedback from
thyroid hormones.
 However, when TRH is administered, the TSH levels increase. This suggests that the pituitary gland is
capable of responding to TRH and producing TSH.
Given this information, it's likely that the patient's hypothalamus is not producing sufficient TRH, leadin
g to decreased stimulation of the pituitary to produce TSH. This scenario points towards a
dysfunction in the hypothalamus rather than the pituitary or thyroid gland.
Let's analyze the other options:
Hyperthyroidism due to primary thyroid disease: This is unlikely since the patient's symptoms and the l
ow TSH levels indicate hypothyroidism rather than hyperthyroidism.
Hypothyroidism due to disease in the pituitary: This is unlikely because the administration of TRH leads
 to an increase in TSH levels, suggesting that the pituitary is capable of responding to TRH.
Hyperthyroidism due to disease in the pituitary: This is unlikely due to the patient's symptoms and the l
ow TSH levels. Additionally, administration of TRH would not result in increased TSH levels in a
hyperthyroid patient.
Correct Option B.
 Pituitary apoplexy refers to the sudden hemorrhage or infarction of the pituitary gland, typically
occurring in the presence of a pre-existing pituitary adenoma. It is characterized by acute-onset
symptoms due to the compression and damage to surrounding structures.In pituitary apoplexy,
bleeding or infarction within the pituitary gland can lead to the release of vasoactive substances and
cause a sudden drop in blood pressure. This can result in shock, which is characterized by decreased
blood perfusion to vital organs and subsequent organ dysfunction.
Option A. Hypertension: Hypertension, or high blood pressure, is not a
typical finding in pituitary apoplexy. Instead, pituitary apoplexy can cause a
drop in blood pressure due to the development of shock, as discussed below.
Option C. Unconsciousness: Pituitary apoplexy can cause varying degrees of neurological symptoms, i
ncluding headache, visual disturbances, and altered consciousness. However, the development of unc
onsciousness may not be a specific or universal feature in all cases.
Option D. Fatigue: Fatigue is a non-specific symptom and is not typically a prominent feature of pituitar
y apoplexy. Other symptoms, such as headache, visual changes, and hormonal disturbances, may be 
more characteristic.
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 Aquaporins are water channel proteins that play a crucial role in the reabsorption of water in the
kidney. They are responsible for allowing the movement of water molecules across cell membranes,
particularly in the renal tubules.
 In the case of Nephrogenic DI, there is a mutation in the gene for aquaporin channels, specifically
aquaporin-2 (AQP2). This mutation impairs the function of AQP2 channels in the collecting ducts of the
kidney, leading to an inability of the kidneys to concentrate urine and reabsorb water properly.
 As a result, individuals with Nephrogenic DI experience excessive thirst and polyuria (excessive urine
production), as the kidneys are unable to properly concentrate the urine and retain water. This condition
is typically resistant to the antidiuretic hormone (ADH), also known as vasopressin, which is responsible
for regulating water reabsorption in the kidneys.
Option A. Liddle's syndrome is a genetic disorder characterized by salt-sensitive hypertension and low 
plasma renin activity. It is caused by mutations in the epithelial sodium channel (ENaC) genes.
Option C. Cystic fibrosis is a genetic disorder that primarily affects the respiratory and digestive system
s, caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene.
Option D. Barter syndrome is a rare genetic disorder that affects the renal tubules and leads to abnorm
al salt and water reabsorption, resulting in electrolyte imbalances and excessive urine production.
Correct Option C.
 The next best step in the management of a 12-year-old child with type 1 diabetes mellitus presenting
with confusion, drowsiness, fast breathing (Kussmaul respirations), dry mucous membranes,
hypotension, high blood glucose, and urine ketones is to perform an arterial blood gas (ABG) test.
 The given clinical scenario suggests the presence of diabetic ketoacidosis (DKA), which is a
life-threatening complication of type 1 diabetes characterized by severe insulin deficiency and elevated
levels of ketones in the blood. ABG is important to assess the acid-base status and guide further
management.
Option A. 2-3 L of normal saline over 1-3 hours: This choice involves fluid resuscitation, which is a cruc
ial step in managing DKA. However, without knowing the ABG results, it is not appropriate to determine
 the volume and rate of fluid administration. ABG helps in assessing the acid-base status and guiding fl
uid therapy.
Option B. Insulin infusion at 0.1 units/kg/hour: Insulin is a key component in the treatment of DKA. How
ever, before initiating insulin infusion, it is important to evaluate the acid-base status and correct any flu
id and electrolyte imbalances.
Option  D. Insulin bolus of 0.1 units/kg given: While insulin administration is necessary in DKA manage
ment, it should not be given as a bolus without assessing the acid-base status and fluid status first.
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Correct Option A: 
 The above case is that of hypothyroidism as there are low levels of total and free T3 and T4 with high
TSH.
 Treatment with levothyroxine should be started. Available as 25 µg / 50 µg / 88 µg / 100 µg If dose is
>100µg, it increases O2 consumption → Resulting in Angina.
 Available as 25 µg / 50 µg / 88 µg / 100 µg
 If dose is >100µg, it increases O2 consumption → Resulting in Angina.
Option B: Measurement of TBG is not the next best step in case of hypothyroidism
Option C: Thyroid radionuclide uptake and scan is not the next best step.
Option D: A thyroid ultrasound is not the next best step in a case of hypothyroidism.
 
 Urinary metanephrine and VMA or analysed for 24 hours in urine for diagnosis of pheochromocytoma
which is a tumor of the adrenal Medulla also called chromaffinoma which produces norepinephrine and
epinephrine. The clinical triad of Pheochromocytoma is palpitations, headache/ hypertension and
diaphoresis.
Option B: Albumin, here the 24 hour Urinary Albumin Analysis is done to evaluate Proteinuria which is 
done in cases to evaluate Renal Disease especially nephrotic syndrome.
Option C: 5-HIAA is serotonin, the 24 hour urinary evaluation for serotonin is done in case of carcinoid 
tumors.
Option D: Glucose is to analyze the level of glucose in urine, mainly for diabetic patients.
 
The essential investigations for a patient with a diffusely enlarged thyroid gland, exophthalmos, weight l
oss, and palpitations suggestive of hyperthyroidism or Graves' disease include:
Thyroid scan: A thyroid scan, specifically a radioactive iodine uptake (RAIU) scan, can help determine t
he activity of the thyroid gland. In Graves' disease, the thyroid gland is typically hyperactive and takes 
up an excessive amount of radioactive iodine.
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Fine needle aspiration cytology (FNAC): FNAC may not be immediately necessary in this case becaus
e the presentation strongly suggests Graves' disease, an autoimmune condition. However, FNAC is m
ore commonly used to evaluate thyroid nodules when malignancy is suspected.
Thyroid function tests: These tests, which include measurements of thyroid hormones (T3 and T4) and 
thyroid-stimulating hormone (TSH), are crucial for diagnosing and monitoring hyperthyroidism. In Grav
es' disease, there is typically a low TSH level and elevated levels of T3 and T4.
Ultrasound of the neck: A neck ultrasound is valuable for assessing the size, shape, and characteristic
s of the thyroid gland, which can provide additional information about the nature of the enlargement an
d rule out structural abnormalities.
Anti-thyroid antibodies: In Graves' disease, the presence of antibodies such as anti-thyroid peroxidase 
antibodies and anti-thyroglobulin antibodies is often detected. These antibodies can help confirm the a
utoimmune nature of the disease.
So, the correct answer is 1, 3, 4, and 5. These investigations help in confirming the diagnosis of Grave
s' disease and assessing the extent of thyroid involvement
Option A: As the case suggests. FNAC is not required in this patient therefore we rule out this option a
s FNAC helps in evaluating the nature of any nodules or abnormalities within the thyroid gland.
Option B: Apart from investigation 1,3 and 5 we also need he help of ultrasound of neck for better asse
ssment of the patient. Therefore this option is also incorrect.
Option C: Apart from the investigations 3,4 and 5 we also need the help of thyroid scan for better asses
sment of the patient. Therefore this option is also incorrect.
 Rhino-cerebral mucormycosis, also known as zygomycosis, is a serious fungal infection caused by
various species of fungi belonging to the class Mucorales. It primarily affects the nose, sinuses, and
brain.
 Diabetic ketoacidosis (DKA): Rhino-cerebral mucormycosis is strongly associated with uncontrolled
diabetes, particularly diabetic ketoacidosis. DKA is a life-threatening complication of diabetes
characterized by high blood sugar levels, ketone production, and metabolic acidosis. The elevated
blood sugar levels and acidotic environment provide an ideal condition for the growth of Mucorales
fungi.
Option B: Pregnancy: Although pregnancy can cause immunological changes, it is not directly associat
ed with an increased risk of rhino-cerebral mucormycosis. However, there have been rare cases report
ed in pregnant women with uncontrolled diabetes or other predisposing factors.
Option C: Antibiotics: While the use of antibiotics can disrupt the normal microbial balance in the body 
and potentially lead to fungal infections, they are not specifically associated with rhino-cerebral mucor
mycosis. This condition is primarily caused by Mucorales fungi, which are not commonly targeted by an
tibiotics.
Option D: Inhaled steroids: The use of inhaled steroids, such as for asthma or chronic obstructive pulm
onary disease (COPD), is not directly associated with an increased risk of rhino-cerebral mucormycosi
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s. However, long-term and high-dose systemic corticosteroids (such as oral or intravenous) can suppre
ss the immune system and increase the risk of fungal infections.
 
 The patient in the scenario is presenting with symptoms of hypothyroidism, including weakness,
lethargy, excessive cold intolerance, and slow ankle jerk. The thyroid function test (TFT) results
indicate elevated TSH levels and decreased T4 levels, confirming the diagnosis of primary
 The most appropriate management for primary hypothyroidism is to initiate treatment with
levothyroxine, a synthetic form of thyroid hormone. The initial dose of levothyroxine should be low and
gradually increased until the patient reaches the optimal replacement dose. Starting with a dose of 25
micrograms is a common practice in such cases.
Option A: Start levothyroxine at 100 micrograms and decrease the dose gradually: This option suggest
s starting with a
higher dose of levothyroxine and then gradually reducing it. However, initiating treatment with a high do
se may lead to rapid correction of thyroid hormone levels, which can potentially cause adverse effects. 
Therefore, it is recommended to start with a
lower dose and adjust it based on the patient's response and follow-up thyroid function tests..
Option C: Start levothyroxine at 25 micrograms and decrease the dose gradually: This option suggests 
starting with a low dose and then gradually reducing it. However, in cases of primary hypothyroidism, t
he goal of treatment is to provide adequate thyroid hormone replacement, not to taper off the medicatio
n. Therefore, gradually decreasing the dose is not the recommended approach.
Option D: Give T3 and T4 drugs simultaneously: While combination therapy with T3 (triiodothyronine) a
nd T4 (thyroxine) may be considered in certain cases, such as specific thyroid conditions or patient pre
ferences, it is not the first-line treatment for primary hypothyroidism. Standard treatment involves the a
dministration of levothyroxine, which is a
T4 hormone replacement, as it can be converted to T3 as needed by the body.
 In a primary healthcare (PHC) setting, the initial screening tests used to diagnose diabetes includes
FBS ( fasting blood sugar) >126mg/dl and 2-hour post-glucose load blood sugar, which is also known
as an oral glucose tolerance test (OGTT as these two tests are less time taking and can be done at any
PHC.
Option A. 1 and 2: HbA1c (glycated hemoglobin) level greater than 6.5% is the marker to diagnose dia
betes but the process of checking the values of HbA1c is time taking and costly than the FBS and PPB
S. Therefore option A cannot be considered correct.
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Option B: 2 and 3: FBS is considered as an initial screening test for diabetes but Random blood sugar ( 
RBS) levels may fluctuate throughout the day and can be influenced by recent meals, making it less su
itable for screening purposes.
Option D: 1, 2 and 3: Due to the above mentioned reasons RBS and HbA1c can not be considered as t
he initial screening test for diabetes. Therefore option is D is also incorrect.
Correct choice: A
 The patient's clinical features suggest diabetic ketoacidosis (DKA), a potentially life-threatening
complication of uncontrolled diabetes. DKA is characterized by hyperglycemia, metabolic acidosis, and
the presence of ketones in the blood. To manage DKA, it is crucial to address the underlying cause of
hyperglycemia and correct metabolic derangements. Insulin is the mainstay of treatment in DKA as it
helps lower blood glucose levels and suppresses ketone production. Therefore, adding insulin to saline
is the appropriate choice in this scenario.
Option B. Bicarbonate administration is generally not recommended for DKA unless the patient has sev
ere acidosis (arterial pH <7.0). In this case, the arterial pH of 7.33 does not indicate severe acidosis, a
nd thus, bicarbonate is not necessary.
Option C. Potassium levels are normal in this patient, so additional potassium supplementation may no
t be required. However, regular monitoring of potassium levels is essential during the treatment of DKA
, as insulin administration can cause a shift of potassium into the cells, leading to potential hypokalemi
a. If the patient's potassium levels decrease during treatment, appropriate potassium supplementation 
can be initiated.
Option D. The specific dose of 14 units of regular insulin intravenously is not mentioned in the initial de
scription and cannot be determined solely based on the given information. The insulin dosage should b
e individualized based on the patient's clinical condition, blood glucose levels, and response to treatme
nt. It is typically administered as an initial bolus followed by continuous intravenous infusion.
 
Correct Option: B
The correct answer is "Xerostomia."
 Xerostomia: Xerostomia, also known as dry mouth, is the most common delayed symptom of head
and neck radiation therapy. Radiation to the head and neck area can damage the salivary glands,
leading to decreased saliva production and resulting in dry mouth.
Option A: Dysphagia: Dysphagia refers to difficulty in swallowing and can be a common side effect of h
ead and neck radiation therapy. However, it is not the most common delayed symptom.
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Option C: Myelopathy: Myelopathy refers to a condition affecting the spinal cord and is not a
common delayed symptom of head and neck radiation therapy.
Option D: Dysgeusia: Dysgeusia refers to a distorted or altered sense of taste. While taste changes ca
n occur after head and neck radiation therapy, xerostomia is more commonly observed as a
delayed symptom.
Correct Option A: Insulin
 Insulin: Obesity is associated with insulin resistance, a condition in which the body's cells become less
responsive to the effects of insulin. In response to insulin resistance, the pancreas produces and
releases more insulin to compensate for the decreased effectiveness. This increased insulin production
is a characteristic feature of obesity.
Option B: Thyroxine (T4)
 Thyroid hormones, including thyroxine, are involved in regulating metabolism. While obesity can affect
thyroid function, it typically does not cause a direct increase in thyroxine production.
Option C: Growth hormone
 Growth hormone (GH) levels may be altered in obesity, but the relationship is complex. In some
cases, obese individuals may have reduced GH secretion or impaired response to GH. However, it is
not a consistent finding that GH production is increased in obesity.
Option D: Adiponectin
 Adiponectin is an adipokine, a hormone secreted by adipose tissue. Its production is generally
decreased in obesity, rather than increased. Lower levels of adiponectin are associated with insulin
resistance and other metabolic abnormalities seen in obesity.
Correct Option
Option C: Hyperparathyroidism.
 Calcitonin is a hormone produced by the parafollicular or C-cells of the thyroid gland. Its primary
function is to regulate calcium and phosphate levels in the body. Normally, calcitonin levels are low in
healthy individuals.
 In hyperparathyroidism, there is excessive production of parathyroid hormone (PTH) by the
parathyroid glands. This condition leads to increased levels of PTH, which in turn can stimulate the
production of calcitonin by the thyroid gland. Therefore, in cases of primary hyperparathyroidism, there
can be a concomitant increase in calcitonin levels.
 However, it's important to note that measuring calcitonin levels alone is not typically used as a
diagnostic test for hyperparathyroidism. The primary diagnostic marker for hyperparathyroidism is the
measurement of PTH levels.
 
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Hyperthyroidism (option A) is characterized by an overactive thyroid gland and is not directly associate
d with increased calcitonin levels.
Hypoparathyroidism (option B) is a condition where there is an underproduction of parathyroid hormon
e, leading to decreased levels of PTH and subsequently decreased calcitonin levels.
Cushing's syndrome (option D) is a disorder caused by prolonged exposure to high levels of cortisol ho
rmone, typically due to adrenal gland dysfunction. It is not directly associated with changes in calcitonin
 levels.
Correct Option: D >200µg/L
 Prolactin levels above 200µg/L are highly suggestive of a prolactinoma.
 Prolactinomas are benign tumors of the pituitary gland that secrete excessive amounts of prolactin.
 Elevated prolactin levels are a hallmark feature of prolactinomas, and levels exceeding 200µg/L are
considered significantly elevated and strongly indicative of a prolactinoma.
Option A: >50µg/L: This statement is incorrect.
Option B: >100µg/L: This statement is incorrect.
Option C: >150µg/L: This statement is incorrect.
Correct Option C: Liddle’s syndrome
 Liddle's syndrome is characterized by hypertension, hypokalemia, and metabolic alkalosis.
 It is caused by mutations in the genes encoding the epithelial sodium channel (ENaC) in the distal
tubules of the kidney.
 These mutations lead to increased reabsorption of sodium and increased potassium and hydrogen ion
secretion, resulting in the observed electrolyte and acid-base abnormalities.
Option A- Bartter syndrome: Bartter syndrome is a rare genetic disorder that affects the loop of Henle i
n the kidney and leads to salt wasting, hypokalemia, and metabolic alkalosis. However, it does not typi
cally present with hypertension.
Option B- Gitelman's syndrome: Gitelman's syndrome is another genetic disorder that affects the distal 
convoluted tubules of the kidney and results in hypokalemia, metabolic alkalosis, and hypomagnesemi
a. However, hypertension is not a characteristic feature of Gitelman's syndrome.
Option D- Fanconi's syndrome: Fanconi's syndrome is a condition characterized by dysfunction of the 
proximal tubules of the kidney, leading to impaired reabsorption of various substances, including electr
olytes and glucose. Hypokalemia, metabolic acidosis, and other electrolyte abnormalities can occur, bu
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t hypertension is not typically associated with Fanconi's syndrome.
Correct Option A: Low TSH levels
 Low TSH levels is the correct answer. In Grave's disease, an autoimmune disorder causing
overactivity of the thyroid gland, the production and release of thyroid hormones (T3 and T4) are
increased. The elevated levels of thyroid hormones exert negative feedback on the pituitary gland,
suppressing the secretion of thyroid-stimulating hormone (TSH). Therefore, in Grave's disease, TSH
levels are typically low.
Option B- Low free T4 levels: In Grave's disease, there is excessive production of thyroid hormones, re
sulting in elevated levels of free T4. Therefore, low free T4 levels would be an unlikely finding in this co
ndition.
Option C- Low serum T3 levels: Grave's disease is characterized by increased production of both T3 a
nd T4. Thus, low serum T3 levels would not be expected in this condition.
Option D- Radioactive iodine uptake (RAIU) at 24 hours below normal: In Grave's disease, the thyroid 
gland is hyperactive and takes up iodine more than usual. This results in an increased radioactive iodin
e uptake (RAIU) on a nuclear medicine scan, not a below-normal uptake.
 Correct Option: C.
 Myxedema coma: Myxedema coma is a life-threatening condition characterized by severe
hypothyroidism. It is typically precipitated by factors such as infection, cold exposure, medication
noncompliance, or other medical conditions. Patients with myxedema coma present with altered mental
status, hypothermia, bradycardia, hypotension, and signs of systemic decompensation. The symptoms
of constipation, dry skin, and menorrhagia are also commonly associated with hypothyroidism.
Option A. Septic shock: Septic shock is a life-threatening condition caused by a severe infection leadin
g to systemic inflammation and organ dysfunction. While septic shock can present with altered sensori
um and hypotension, the presence of symptoms such as constipation, dry skin, menorrhagia, non-pittin
g edema, hypothermia, and bradycardia is not consistent with septic shock. These symptoms are more
 indicative of severe hypothyroidism.
Option B. Cardiogenic shock: Cardiogenic shock occurs when the heart's ability to pump blood is sever
ely compromised, leading to inadequate tissue perfusion. While cardiogenic shock can cause hypotens
ion and bradycardia, the constellation of symptoms described, including constipation, dry skin, menorrh
agia, non-pitting edema, and hypothermia, is not consistent with cardiogenic shock. These symptoms a
re more suggestive of myxedema coma.
Option D. Hypoglycemia: Hypoglycemia, or low blood sugar, can cause altered mental status and hypo
tension. However, the presence of symptoms such as constipation, dry skin, menorrhagia, non-pitting e
dema, and hypothermia points more towards a
systemic condition like myxedema coma rather than isolated hypoglycemia.
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 Pancreatic insufficiency refers to the inadequate production or secretion of pancreatic enzymes,
including lipase, amylase, and proteases. This can lead to malabsorption of nutrients, particularly fats,
resulting in chronic diarrhea and steatorrhea (excessive fat in the stool). In this case, the patient's
symptoms of chronic diarrhea and steatorrhea suggest impaired fat digestion and absorption.
 The D-xylose test is used to assess the absorption of xylose, a sugar, in the small intestine. A normal
D-xylose test result indicates that the small intestine is capable of absorbing this sugar properly, ruling
out malabsorption as the cause of symptoms.
 The Schilling test is used to evaluate the absorption of vitamin B12 and can help diagnose pernicious
anemia and other causes of vitamin B12 deficiency. An abnormal Schilling test result suggests
impaired absorption of vitamin B12. However, in this case, the Schilling test is mentioned as abnormal,
which is not specific to any particular diagnosis.
 A normal duodenal biopsy suggests that there are no structural abnormalities or significant
inflammation in the duodenum, which would help rule out conditions like celiac disease and intestinal
lymphangiectasia.
Option A. Celiac disease: Celiac disease is an autoimmune condition characterized by an abnormal im
mune response to gluten, leading to damage to the small intestine. It can cause malabsorption and res
ult in chronic diarrhea and steatorrhea. However, the normal duodenal biopsy in this case makes celiac
 disease less likely.
Option B. Ulcerative colitis: Ulcerative colitis is a form of inflammatory bowel disease primarily affecting
 the colon and rectum. While it can cause chronic diarrhea, it is not typically associated with steatorrhe
a. Additionally, the normal duodenal biopsy suggests that the small intestine is not affected.
Option C. Intestinal lymphangiectasia: Intestinal lymphangiectasia is a condition characterized by dilate
d lymphatic vessels in the intestinal wall, leading to the leakage of lymphatic fluid into the intestinal lum
en. It can cause protein and fat malabsorption, resulting in diarrhea. However, the normal duodenal bio
psy makes this condition less likely.
 Renal transplantation is considered the treatment of choice for end-stage renal disease (ESRD) in
patients with diabetic nephropathy. While the survival rate of the graft in the first year is generally high,
it is not accurately represented as 95% in all cases (option A). Survival rates can vary depending on
various factors, including patient characteristics, quality of the donor organ, and post-transplant
Option A: "The survival rate of the graft is 95% in the first year," is an overgeneralization. While the sur
vival rate of renal grafts in the first year can be relatively high, it is not consistently 95% for all patients. 
Success rates can vary based on individual factors, including the patient's overall health, adherence to 
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medications, and the compatibility of the donor organ.
Option C: "The life expectancy is doubled in a diabetic patient with renal transplant," is not entirely acc
urate. While renal transplantation can improve the quality of life and increase life expectancy in patient
s with ESRD, it does not necessarily double the life expectancy. Life expectancy improvements can var
y among individuals and depend on multiple factors, including the patient's overall health, age, and adh
erence to post-transplant care.
Option D: "The treatment of chronic rejection has improved over the last 10 years," is not directly addre
ssed in the given statement. Chronic rejection remains a challenge in renal transplantation, and while a
dvances have been made in understanding and managing rejection, the statement does not specificall
y mention this progress.
 
 Cheiroarthropathy: Cheiroarthropathy is a condition commonly associated with diabetes mellitus. It
refers to a thickening and tightening of the skin over the hands, resulting in limited joint mobility. This
condition can cause difficulty in fully extending the fingers, leading to a characteristic hand posture
resembling the "namaste" gesture. Cheiroarthropathy is thought to be related to long-standing poor
glycemic control and the accumulation of advanced glycation end-products (AGEs) in the skin and soft
tissues.
Option A: Flexor tenosynovitis: Flexor tenosynovitis refers to inflammation and swelling of the synovial 
sheath surrounding the flexor tendons in the hand. It can cause pain, swelling, and difficulty in flexing o
r extending the affected fingers. While flexor tenosynovitis can occur in individuals with diabetes, it doe
s not specifically explain the "namaste" gesture mentioned in the question.
Option C: Dupuytren's contracture: Dupuytren's contracture is a condition characterized by the progres
sive thickening and contracture of the palmar fascia, leading to the flexion deformity of the fingers. It pri
marily affects the ring finger and little finger, causing them to curl towards the palm. Although Dupuytre
n's contracture is associated with certain risk factors, such as family history and alcoholism, it is not dir
ectly related to the "namaste" gesture mentioned in the question.
Option D: Ankyloses: Ankylosis refers to the abnormal fusion or immobility of a joint due to pathological
 changes. While ankylosis can occur in various conditions, including certain forms of arthritis, trauma, o
r infection, it does not specifically explain the "namaste" gesture in the context of a diabetic patient.
 
Aplasia cutis congenita is a rare condition characterized by the absence of skin in localized or widespre
ad areas at birth. It is believed to result from impaired development of the skin during fetal developmen
t. While the exact cause of aplasia cutis congenita is not fully understood, certain medications have be
en associated with an increased risk of this condition, including antithyroid drugs such as carbimazole.
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Carbimazole is commonly used in the treatment of hyperthyroidism, including Grave's disease. It works
 by inhibiting the synthesis of thyroid hormones. Although it is generally well-tolerated, rare cases of apl
asia cutis congenita have been reported in infants born to mothers who took carbimazole during pregn
ancy. The precise mechanism by which carbimazole may lead to aplasia cutis congenita is not fully elu
cidated.
Option B. Levothyroxine: Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. It i
s not associated with an increased risk of aplasia cutis congenita. In fact, untreated maternal hypothyro
idism during pregnancy can have detrimental effects on the developing fetus, highlighting the importan
ce of appropriate thyroid hormone replacement therapy with levothyroxine during pregnancy.
Option C. Methylthiouracil: Methylthiouracil is another antithyroid medication used in the management 
of hyperthyroidism. Like carbimazole, it works by inhibiting thyroid hormone synthesis. However, there i
s no significant evidence linking methylthiouracil to an increased risk of aplasia cutis congenita.
Option D. Hydrouracil: Hydrouracil is not a commonly used antithyroid medication. It is not associated 
with an increased risk of aplasia cutis congenita.
 Correct option B: 
 The patient in the scenario has an HbA1C level of 6.1% and a fasting blood glucose level of 120
mg/dL. These values fall within the range that indicates impaired glucose tolerance (IGT).
 Impaired glucose tolerance (IGT) is a condition in which blood glucose levels are higher than normal
but not high enough to be classified as diabetes mellitus. It is considered a prediabetic state, indicating
an increased risk for developing diabetes in the future. The patient's fasting blood glucose level of 120
mg/dL falls within the range for impaired glucose tolerance.
Option A: Normal blood glucose levels typically fall within a range of 70-99 mg/dL for fasting blood gluc
ose and below 5.7% for HbA1C. Since the patient's fasting blood glucose level is 120 mg/dL, it is highe
r than the normal range, indicating an abnormality.
Option C: Diabetes Mellitus Diabetes mellitus is diagnosed when fasting blood glucose levels are consi
stently above 126 mg/dL or HbA1C levels are equal to or higher than 6.5%. Since the patient's fasting 
blood glucose level is 120 mg/dL and HbA1C is 6.1%, they do not meet the criteria for a
diagnosis of diabetes mellitus.
Option D: Maturity onset diabetes in Young (MODY) Maturity onset diabetes of the young (MODY) is a
type of diabetes characterized by a strong family history, early onset before the age of 25, and a
specific genetic etiology. The patient in the scenario does not have a
family history of diabetes, and the term "Maturity onset diabetes in Young" does not apply in this case.
 
Correct option A: Viruses
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 Fulminant diabetes, also known as fulminant type 1 diabetes or acute-onset type 1 diabetes, is a rare
and rapidly progressing form of diabetes characterized by severe hyperglycemia and a rapid loss of
insulin-producing beta cells in the pancreas.
 Viruses, particularly enteroviruses such as Coxsackie B virus, have been implicated as a potential
cause of fulminant diabetes. These viruses can infect and damage the pancreatic beta cells, leading to
their destruction and subsequent loss of insulin production. Viral infections are considered one of the
possible triggers for the development of fulminant diabetes.
Option B: Diabetic Ketoacidosis 
 While diabetic ketoacidosis (DKA) is a serious complication of diabetes, it is not the most common
cause of fulminant diabetes. DKA occurs primarily in individuals with established diabetes, particularly
in type 1 diabetes, and is characterized by the presence of hyperglycemia, ketosis, and acidosis.
Option C: Non-ketotic Hyperosmolar Coma
 Non-ketotic hyperosmolar coma is another severe complication of diabetes, typically seen in
individuals with type 2 diabetes. It is characterized by extremely high blood glucose levels and severe
dehydration. However, it is not the most common cause of fulminant diabetes.
Option D: Autoimmunity
 Autoimmunity is a major contributing factor in the development of type 1 diabetes. However, in the
case of fulminant diabetes, the rapid onset and progression of the disease suggest a different
underlying cause, such as viral infection, rather than the gradual autoimmune destruction of beta cells
seen in typical type 1 diabetes.
 
Solution for Question 49:
 In diabetes, one of the commonly affected joints is the Charcot joint, particularly the
metatarsophalangeal (MTP) joints.
 Charcot joint mainly involves the foot is frequently affected in individuals with diabetes.
 Complications such as peripheral neuropathy, and poor circulation (peripheral arterial disease) can
lead to foot-related issues such as ulcers, infections, and joint deformities.
Option A: Ankle While complications of diabetes can affect the ankle joint indirectly, such as peripheral 
neuropathy leading to instability and increased risk of ankle injuries, the ankle joint itself is not a
primary site of involvement in diabetes.
Option B: Knee Diabetes can lead to various complications and conditions that may affect the knee join
t indirectly, such as diabetic neuropathy or diabetic arthropathy (Charcot joint), but the knee joint itself i
s not a primary site of involvement.
Option C: Shoulder Shoulder joint involvement is not commonly associated with diabetes. Diabetes-rel
ated joint problems typically manifest in weight-bearing joints and those subjected to excessive pressur
e, such as the foot.
 
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Solution for Question 50:
 In the given clinical scenario, the patient presents with symptoms suggestive of diabetic ketoacidosis
(DKA), which is characterized by high blood glucose levels, metabolic acidosis, and ketosis. DKA is
considered a medical emergency and requires prompt treatment with insulin.
 Regular insulin, also known as short-acting insulin, is the most appropriate choice for managing DKA.
Regular insulin is the correct choice because it has an onset of action of approximately 30 minutes,
peaks in 2 to 4 hours, and lasts for about 6 to 8 hours. Its slower onset and longer duration of action
make it suitable for managing the prolonged hyperglycemia and metabolic acidosis associated with
DKA.
Option B: Lispro insulin is a rapid-acting insulin with a quick onset of action but a shorter duration comp
ared to regular insulin. It is commonly used to manage postprandial glucose spikes in individuals with d
iabetes. However, in the context of DKA, regular insulin is preferred due to its longer duration of action.
Option C: Glargine insulin is a long-acting insulin that provides a steady release of insulin over an exte
nded period (approximately 24 hours). It is used for basal insulin coverage and does not have a rapid o
nset or peak effect, making it less suitable for managing acute hyperglycemia and acidosis in DKA.
Option D: Aspart insulin is a rapid-acting insulin similar to lispro insulin. It has a
rapid onset and shorter duration of action, making it less suitable for the management of DKA
 
Solution for Question 51:
 Glargine insulin is a long-acting insulin that is characterized by a slow onset of action, typically taking
about 1 to 2 hours to begin working. It is designed to provide a steady release of insulin over an
extended period (approximately 24 hours). This slow onset and prolonged duration make it suitable for
providing basal insulin coverage.
Option B: Lispro insulin is a rapid-acting insulin that has a quick onset of action, typically within 15 minu
tes of administration. It is used to control postprandial glucose spikes after meals. Unlike glargine, lispr
o insulin has a fast onset rather than a slow onset.
Option C: Regular insulin, also known as short-acting insulin, has an onset of action of approximately 3
0 minutes. It is used for mealtime coverage or in combination with long-acting insulin for basal coverag
e. It is not characterized by a slow onset like glargine.
Option D: NPH (Neutral Protamine Hagedorn) insulin is an intermediate-acting insulin. It has a
slower onset compared to rapid-acting insulins but is not specifically known for having a
slow onset like glargine. NPH insulin typically takes about 1 to 2 hours to start working
 
352

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 Prolactinomas are benign tumors of the pituitary gland that secrete excessive amounts of prolactin, a
hormone responsible for milk production.Bitemporal hemianopia refers to a visual field defect where
there is loss of peripheral vision in both the outer (temporal) sides. Prolactinomas can cause
compression of the optic chiasm, which is located near the pituitary gland. This compression can result
in bitemporal hemianopia as a characteristic physical finding of prolactinoma.
Option B: Anovulatory cycles refer to menstrual cycles in which ovulation does not occur. While prolacti
nomas can disrupt normal menstrual cycles, leading to anovulatory cycles, it is not the characteristic ph
ysical finding after galactorrhea.
Option C: Amenorrhea refers to the absence of menstrual periods. Prolactinomas can cause hormonal 
imbalances, including elevated prolactin levels, which can disrupt normal menstrual cycles and lead to 
amenorrhea. However, it is not the characteristic physical finding after galactorrhea.
Option D: Infertility refers to the inability to conceive a child. Prolactinomas can disrupt normal hormona
l balance and interfere with ovulation, leading to difficulties in conceiving. However, infertility is not the 
characteristic physical finding after galactorrhea
 
  Hypophosphatemia: During TLS, there is a rapid release of intracellular phosphate from lysed cells,
leading to an increase in serum phosphate levels (hyperphosphatemia) rather than a decrease.
Option  B. Hypocalcemia: Hypocalcemia is commonly observed in Tumor Lysis Syndrome. The increas
ed phosphate levels caused by tumor lysis can bind to calcium, resulting in a
decrease in ionized calcium levels.
Option  C. Hyperuricemia:Hyperuricemia is a characteristic feature of Tumor Lysis Syndrome. The rele
ase of purines from the breakdown of DNA in tumor cells leads to increased uric acid production.
Option D. Hyperkalemia: Hyperkalemia is frequently seen in Tumor Lysis Syndrome. The release of int
racellular potassium from lysed cells, combined with impaired renal excretion, can result in increased s
 
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 Multiple myeloma: Multiple myeloma is a type of cancer that involves plasma cells in the bone
marrow. It can lead to the excessive production of monoclonal immunoglobulins (M-protein), which can
cause hypercalcemia. In multiple myeloma, the serum calcium levels can be elevated while SAP, PTH,
and vitamin D3 levels remain normal.
Option A. Vitamin D intoxication: In cases of vitamin D intoxication, both serum calcium and vitamin D3
 levels are typically elevated. The PTH levels are usually suppressed due to the feedback mechanism 
between vitamin D and PTH.
Option B. Hyperparathyroidism: Hyperparathyroidism is characterized by increased PTH levels, which 
stimulate the release of calcium from bone, resulting in elevated serum calcium levels. In this case, sin
ce PTH levels are normal, hyperparathyroidism is not the likely diagnosis.
Option D. Nutritional rickets: This option is incorrect. Nutritional rickets is a condition caused by a defici
ency of vitamin D, calcium, or phosphate. In this case, serum calcium levels would typically be decreas
ed rather than elevated.
 
Correct Answer Explanation (C): C) Cortisol
Cortisol: Pheochromocytomas are not associated with cortisol production. Cortisol is primarily produce
d by the adrenal cortex in response to adrenocorticotropic hormone (ACTH) stimulation, whereas pheo
chromocytomas originate from the adrenal medulla and are more focused on the production of catecho
lamines
Other Options: A) Epinephrine (Adrenaline): Pheochromocytomas often produce excessive amounts of
 epinephrine, contributing to the symptoms and complications associated with the condition.
B) Norepinephrine (Noradrenaline): Pheochromocytomas frequently overproduce norepinephrine, whic
h contributes to the elevated blood pressure and other symptoms seen in affected individuals.
D) Dopamine: It is produced in this tumor
To calculate the sodium deficit in the patient, we need to determine the patient's total body water (TBW
) and current sodium content, and then calculate the difference between the actual sodium content and
 the desired sodium level.
The formula to calculate sodium deficit is:
Sodium Deficit (mEq) = TBW (L) × (Desired Na+ - Current Na+)
To estimate the TBW, we can use the following formula:
TBW (L) = 0.6 × body weight (kg)
Given that the patient weighs 60 kg, the TBW would be:
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TBW (L) = 0.6 × 60 kg = 36 L
The desired Na+ level is typically around 140 mEq/L. Using the given values, we can calculate the sodi
um deficit:
Sodium Deficit (mEq) = 36 L × (140 mEq/L - 120 mEq/L) Sodium Deficit (mEq) = 36 L
× 20 mEq/L Sodium Deficit (mEq) = 720 mEq
Therefore, the correct option is D, "720 mEq."
Option A: 20 mEq: This value does not account for the TBW calculation or the difference between the d
esired and current sodium levels.
Option B: 200 mEq: This value also does not account for the TBW calculation or the difference betwee
n the desired and current sodium levels.
Option C: 400 mEq: Again, this value does not consider the TBW calculation or the difference between 
the desired and current sodium levels.
 
Option a. Mineralocorticoids: Mineralocorticoids, such as aldosterone, are responsible for regulating el
ectrolyte and water balance in the body. They are not produced by the pituitary gland but rather by the 
adrenal cortex. Therefore, the patient's deficiency in ACTH (adrenocorticotropic hormone) will not direc
tly affect mineralocorticoid production. Hence, mineralocorticoid supplementation is not needed in this 
case.
Option b. Thyroid hormones: Thyroid hormones, including TSH (thyroid-stimulating hormone), play a cr
ucial role in regulating metabolism. As the patient has low levels of TSH, indicating thyroid hormone de
ficiency, thyroid hormone supplementation is necessary to maintain normal thyroid function.
Option c. Glucocorticoids: Glucocorticoids, such as cortisol, are produced by the adrenal cortex under t
he stimulation of ACTH. With the deficiency of ACTH, the production of glucocorticoids is reduced. The
refore, glucocorticoid supplementation is needed to replace the deficient cortisol and provide the neces
sary physiological effects.
Optiond. Estradiol: Estradiol is a female sex hormone produced primarily by the ovaries. The deficiency
 of FSH (follicle-stimulating hormone) and LH (luteinizing hormone) indicates dysfunction of the gonado
tropins, which regulate the production of estradiol. Consequently, estradiol supplementation may be re
quired to maintain hormonal balance in premenopausal women.
Option A.
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 Autoimmune adrenalitis - This is the correct answer. Addison's disease, also known as primary
adrenal insufficiency, is commonly associated with autoimmune adrenalitis. In this condition, the body's
immune system mistakenly attacks and destroys the adrenal cortex, leading to inadequate production
of adrenal hormones.
Option B. Adrenocortical carcinoma - Adrenocortical carcinoma is a rare malignant tumor of the adrena
l cortex. While it can cause adrenal hormone imbalances, it is not commonly associated with Addison's 
disease.
Option C. Hypernephroma - Hypernephroma is an outdated term for renal cell carcinoma, which is a
type of kidney cancer. It is unrelated to Addison's disease.
Option D. Medullary carcinoma thyroid - Medullary carcinoma of the thyroid is a
type of thyroid cancer that arises from the parafollicular C
cells. It is not associated with Addison's disease.
Option A.
 Dexamethasone: Dexamethasone is a corticosteroid that can be used in the treatment of
hypercalcemia due to vitamin D toxicity. It works by reducing intestinal calcium absorption and
promoting renal calcium excretion.
Option B. Hydroxychloroquine: Hydroxychloroquine is an antimalarial medication that is not typically us
ed in the treatment of hypercalcemia due to vitamin D toxicity. Its main uses are in the treatment of mal
aria and certain autoimmune disorders such as rheumatoid arthritis and lupus.
Option C. Chloroquine: Similar to hydroxychloroquine, chloroquine is an antimalarial drug and is not co
mmonly used in the treatment of hypercalcemia due to vitamin D toxicity.
Option D. Ketoconazole: Ketoconazole is an antifungal medication and is not indicated for the treatmen
t of hypercalcemia due to vitamin D toxicity. Its primary use is in the treatment of fungal infections.
 
Correct Option A: Coronary artery disease
 Coronary artery disease is a macrovascular complication of diabetes, while others are all
microvascular complications.
Option B: Foot ulcer is a microvascular complication of diabetes.
Option C: Nephropathy is a microvascular complication of diabetes.
Option D: Retinopathy is a microvascular complication of diabetes.
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Correct Option C: Cushing’s syndrome
 The above image is that of Cushing’s syndrome which results from chronic exposure to
glucocorticoids. They present with moon facies, striae, abnormal masculinization, proximal muscle
weakness, hypertension, osteoporosis, hyperpigmentation, sepsis, hyperglycemia.
Option A: Acromegaly is due to excess growth hormone and symptoms include enlargement of face, h
ands, and feet.
Option B: PCOS is an hyper estrogenic state with presentation of the irregular menstrual cycle, acne a
nd hirsutism.
Option D: This is not the case of advanced obesity.
 Fulminant diabetes mellitus refers to a rapid and severe onset of diabetes symptoms and
complications. Coxsackie B virus, a type of enterovirus, has been associated with the development of
fulminant diabetes mellitus. The virus can cause damage to the pancreatic beta cells, leading to a
sudden and complete loss of insulin production.
Options A: Diabetic ketoacidosis (DKA): While DKA is a serious complication of diabetes characterized
 by high blood sugar, ketone production, and metabolic acidosis, it is not specifically associated with a
rapid and severe onset like fulminant diabetes.
Options C: Non-ketotic hyperosmolar coma: Non-ketotic hyperosmolar coma is a life-threatening compl
ication of diabetes characterized by extremely high blood sugar and severe dehydration. It is not typical
ly associated with a rapid and sudden onset like fulminant diabetes.
Options D: Autoimmune pancreatitis: Autoimmune pancreatitis is a
rare form of chronic pancreatitis caused by an autoimmune reaction. It is not typically associated with a
rapid and severe onset of diabetes.
357

Water & Electrolyte Imbalance
1. Which of the following conditions does not lead to hypokalemia?
A. Liddle syndrome
B. Renal tubular acidosis
C. Diabetic ketoacidosis
D. Respiratory alkalosis
2. Identify the ECG for Hypokalemia.
A.
B.
C.
D.
3. Which of the following is not an ECG finding seen in Hypokalemia?
A. T wave inversion
B. Sine wave pattern
C. Prominent U wave
D. ST depression
4. In a patient receiving amphotericin B who develops extreme lethargy, muscle weakness, and an
increase in carbon dioxide levels with hyperventilation, and a serum potassium level of 2.3 mEq/L, what
is the appropriate correction of potassium to be given to the patient?
(or)
What is the appropriate correction of potassium to be given to the patient with a serum potassium level
of 2.3 mEq/L?
A. 0.14 mEq of KCl/24hrs
B. 1.4 mEq of KCl/24hrs
C. 14 mEq of KCl/24hrs
D. 140 mEq of KCl/24hrs
5. Which of the following conditions are not associated with Hyperkalemia?
A. Gordon syndrome
B. RBC lysis
C. Liddles syndrome
D. Addison's disease
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6. A 30-year-old female came to the outpatient department with complaints of loss of appetite, weight
loss, and extreme fatigue for the past two months. The patient admitted that she developed a craving
for pickles recently. Her general examination showed dark skin on dependent areas like elbows, neck,
etc. She denied any irregular menstrual cycles. Her blood investigations showed an RBS of 70 mg/dl.
Guess the disease and the electrolyte imbalance associated with it and mark the option with
appropriate treatment for the electrolyte removal by GI/renal route.
A. Sodium bicarbonate
B. Patiromer
C. Calcium chloride
D. Salbutamol
7. Identify the condition associated with the sign shown below and mark the option with the appropriate
choice of treatment in its associated dyselectrolytemia.
A. Patiromeronate
B. ZS-9
C. Calcium gluconate
8. A 65-year-old male patient with a history of hypertension and heart failure is admitted to the hospital
due to exacerbation of his heart failure symptoms. During his hospitalization, he is started on diuretic
therapy to manage fluid overload. On examination, the patient is disoriented, with slurred speech,
decreased level of consciousness, and is refusing oral intake. Which of the following is causing these
symptoms?
(or)
Which of the following can cause cerebral edema in hospitalized patients??
A. Dehydration
B. Hypernatremia
C. Hyponatremia
9. What is the drug of choice to manage Hypercalcemic crisis?
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A. Bisphosphonates
B. Steroids
C. Calcitonin nasal spray
D. Furosemide drip.
10. A 55-year-old male patient with a known history of chronic alcohol abuse presents to the
emergency department complaining of increasing abdominal distention. On examination, there are
massive ascites and peripheral edema. serum sodium: 125 mEq/L and serum potassium: 4.0 mEq/L
The patient also reports increased salt intake for the past few weeks. Which of the following
mechanisms most likely contributes to the development of hypervolemic hyponatremia in this patient?
(or)
Which of the following mechanisms most likely contributes to the development of hypervolemic
hyponatremia in cirrhosis patients?
A. Activation of the renin-angiotensin-aldosterone system
B. Excessive intake of dietary sodium
C. Impaired secretion of antidiuretic hormone
D. Decreased reabsorption of water in the distal nephron
11. A 45-year-old woman presents to the emergency department with complaints of muscle cramps
and tingling sensations in her fingers and toes. On examination, she exhibits positive Chvostek's sign
and Trousseau's sign. Despite immediate intervention, the patient becomes unresponsive and dies.
What is the most likely cause of death in this patient?
(or)
What is the most likely cause of death in a patient with severe hypocalcemia?
A. Cardiac arrest
B. Cerebral edema
D. Respiratory failure due to laryngospasm
12. A 28-year-old male patient was admitted to the ED with the complaint of continuous vomiting and
loose watery stools unrelieved by over the counter medication for the past one day. He admitted that he
had street food the day before yesterday and suffered from severe abdominal pain. The lab
investigations are done and shown below. Mark the option with appropriate findings and management.
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A. Total Body Water ↓, Total Body Salts↑- IV Fluids
B. Total Body Water ↑, Total Body Salts-(n)-Vaptans
C. Total Body Water ↓, Total Body Salts ↓-IV fluids
D. Total Body Water ↑↑ , Total Body Salts ↑-Spironolactone
13. Choose the option that describes an appropriate treatment modality for the following electrolyte
abnormalities: 1. Na+ < 125 mEq/L a. Hemodialysis 2. K+ > 8 mEq/L b. MgSO4 3. Ca+ > 13 mg% c.
Hypertonic saline 4. Mg+ > 10 mEq/L d. KCl drip 5. Na+ > 158 mEq/L e. Ca chloride 6. K+ < 2.5 mEq/L
f. Ca gluconate 7. Ca+ < 7 mg% g. Ibandronate 8. Mg+ < 1 mEq/L h. 5 % dextrose
1. Na+ < 125 mEq/L a. Hemodialysis
2. K+ > 8 mEq/L b. MgSO4
3. Ca+ > 13 mg% c. Hypertonic saline
4. Mg+ > 10 mEq/L d. KCl drip
5. Na+ > 158 mEq/L e. Ca chloride
6. K+ < 2.5 mEq/L f. Ca gluconate
7. Ca+ < 7 mg% g. Ibandronate
8. Mg+ < 1 mEq/L h. 5 % dextrose
A. 1-a, 2-c, 3-b, 4-d, 5-e, 6-g, 7-f, 8-h
B. 1-c, 2-e, 3-g, 4-a, 5-h, 6-d, 7-f, 8-b
C. 1-f, 2-d, 3-a, 4-b, 5-c, 6-e, 7-h, 8-g
D. 1-h, 2-d, 3-g, 4-c, 5-f, 6-b, 7-e, 8-a
14. Using the image below, guess the infection and the electrolyte imbalance involved in it.
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A. Hypervolemic Hyponatremia
B. Isotonic Hyponatremia
C. Euvolemic hyponatremia
D. Hypertonic Hypernatremia.
15. Match the following electrolyte imbalances with their respective clinical features. 1.
Hypomagnesemia a. Diastolic arrest 2. Hypokalemia b. Asystole 3. Hyponatremia c. Laryngospasm 4.
Hyperkalemia d. Seizure 5. Hypocalcemia e. Diaphragmatic paralysis 6. Hypermagnesemia f. Systolic
arrest 7. Hypercalcemia g. Torsades de pointes
1. Hypomagnesemia a. Diastolic arrest
2. Hypokalemia b. Asystole
3. Hyponatremia c. Laryngospasm
4. Hyperkalemia d. Seizure
5. Hypocalcemia e. Diaphragmatic paralysis
6. Hypermagnesemia f. Systolic arrest
7. Hypercalcemia g. Torsades de pointes
A. 1-a, 2-d, 3-b, 4-e, 5-c, 6-f, 7-g
B. 1-d, 2-g, 3-c, 4-f, 5-b, 6-e, 7-a
C. 1-e, 2-c, 3-a, 4-b, 5-d, 6-g, 7-f
D. 1-g, 2-e, 3-d, 4-a, 5-c, 6-b, 7-f
16. Which of the following does not lead to metabolic acidosis?
B. Short bowel syndrome
C. Gastric outlet obstruction
D. Shock
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17. A 35-year-old male patient came to the outpatient department with a complaint of gradual
diminished vision from the past two days. He admitted that he lately experiences some hallucinations
and memory loss. His personal history shows he is a chronic alcoholic with a history of hooch
consumption. The patient also and had a seizure episode during a recent episode of binge drinking.
The ophthalmologist checked the eyes and the findings are shown below. Suggest an antidote to this
condition and the appropriate treatment recommended for this condition.
A. Diazepam-5%Dextrose
B. Activated charcoal-Normal saline
C. Fomepizole-Ringer lactate
D. Mannitol-Ringer lactate.
18. A 20-year-old female patient came to the outpatient department with complaint of recurrent
episodes of alternating constipation, diarrhea, and abdominal pain. Her lab investigations showed low
levels of K+ and H+. The physcian suspecting a malabsorption syndrome, ordered an intestinal biopsy
which revealed the findings shown in the image below. Identify the disease and the electrolyte
imbalance involved in it.
C. Euvolemic Hyponatremia
D. Hypovolemic Hypernatremia
19. Match the following 1) Cerebral salt wasting syndrome a) Hypervolemic hyponatremia 2) Oat cell
cancer b) Hypovolemic hyponatremia 3) Nephrotic syndrome c) Euvolemic hyponatremia
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1) Cerebral salt wasting syndrome a) Hypervolemic hyponatremia
2) Oat cell cancer b) Hypovolemic hyponatremia
3) Nephrotic syndrome c) Euvolemic hyponatremia
A. 1-a,2-c,3-b
B. 1-c,2-a,3-b
C. 1-b,2-c,3-a
D. 1-a,2-b,3-c
20. Metabolic alkalosis secondary to which of the following conditions is not considered saline
responsive?
A. Congenital Hypertrophic Pyloric Stenosis
B. Healed peptic ulcer disease.
C. Ca. stomach
D. Cirrhosis
21. A 20-year-old female patient weighing 60 kg was brought to the emergency department in an
unconscious state. Her mother revealed that the girl is on a crash diet including only water and juice for
quick weight loss. Lab investigations revealed sodium to be 125mEq.Calculate sodium correction to be
given over the next 24 hours.
A. 135mEq/24hr
B. 145mEq/24hr
C. 240mEq/24hr
D. 235mEq/24hr
22. A 40-year-old male was rushed to the emergency department in an unconscious state by his wife.
The patient is a known case of Diabetes mellitus type 1 for the past 15 years. History showed that he
was under a lot of pressure in the past two days and ignored his medication,. Prior to loss of
consciousness the patient reported symptoms of excess thirst, lethargy, and fruit-smelling breath. Lab
investigations are done and shown below. Identify the diagnosis and mark the option with the
appropriate electrolyte imbalance and fluid of choice.
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A. Hypokalemic Metabolic Alkalosis-Normal saline
B. Hyperkalemic Metabolic Acidosis-Normal saline
C. Hypokalemic Metabolic Alkalosis- 5% Dextrose
D. Hyperkalemic Metabolic Acidosis-5%Dextrose.
23. Pick the option that has correct statements regarding sodium. a) Fluid of choice for hyponatremia- 3
% saline b) 1 ml of normal saline = 0.5 mEq Na c) 0.9% saline = 154 mEq of Na and 154 mEq Cl Per
1000 ml d) Gradual sodium correction to be done in case of seizures during Hyponatremia.
A. a,c
B. b,d
C. a,d
D. b,c
24. Match the following disorders with their respective management. 1. Metabolic acidosis a. Paper bag
rebreathing 2. Respiratory acidosis b. Ringer Lactate 3. Metabolic alkalosis c. Positive pressure
ventilation 4. Respiratory alkalosis d. Normal Saline
1. Metabolic acidosis a. Paper bag rebreathing
2. Respiratory acidosis b. Ringer Lactate
3. Metabolic alkalosis c. Positive pressure ventilation
4. Respiratory alkalosis d. Normal Saline
A. 1-a, 2-c, 3-d, 4-b
B. 1-c, 2-d, 3-a, 4-b
C. 1-d, 2-c, 3-b, 4-a
D. 1-b, 2-c, 3-d, 4-a
25. Identify the respiratory or metabolic disorder associated with the respiratory graph given below (b),
Mark the option that is not associated with a similar disorder.
A. Pleural effusion
B. Acute asthma
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Page 9
C. High altitude pulmonary edema
D. COPD exacerbation
26. Which of the following conditions results in fine tremors?
A. Ammonia intoxication
B. Thyrotoxicosis
C. Uremia
D. CO2 narcosis
27. Which of the following is not a factor affecting plasma osmolality?
A. Sodium
B. Glucose
D. Total body water
28. Which of the following is the fluid of choice given to a patient with sodium levels>158mEq?
A. 3% saline
B. 0.9% saline
C. N/2 in 5% dextrose
D. 0.45% RL
29. Which of the following conditions can be associated with both hypernatremia and hyponatremia?
A. Hyperosmolar coma
B. Diabetes insipidus
C. Mannitol therapy
D. Extreme debilitation
30. A 25-year-old male patient weighing 60kg was brought to the emergency department in an
unconscious state by his father. He is a known case of Diabetes insipidus. His lab reports showed
sodium levels of 158mEq. Identify the electrolyte imbalance and calculate the volume for fluid
correction.
(or)
What is the fluid correction volume required in a 25-year-old male with known diabetes insipidus who
presents with serum sodium levels of 158 mEq/L after a body-building competition?
A. 4.6
B. 8.2
C. 6.5
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Page 10
D. 10
31. What's the corrected amount of potassium required for a 23-year-old male patient with serum
potassium levels of 2.5mEq/L, presenting extreme weakness and muscle cramps, after aggressive
treatment with steroids and salbutamol nebulization for a recent breathlessness episode?
(or)
What is the amount of corrected potassium that is to be given to a patient with serum potassium levels
of 2.5 mEq?
A. 100mEqKCl/24hr fluid
B. 140mEqKCl/24hr fluid
C. 120mEqKCl/24hr fluid
D. 150mEqKCl/24hr fluid
32. Which of the following is the actual formula for the initial correction of sodium bicarbonate?
A. 0.5 × weight (24 - actual value)
B. 0.5 × weight (15 - actual value)
C. TBW × ( Na actual - 140 )/140
D. TBW × (desired sodium - actual value)
33. What metabolic disorder is associated with the condition depicted in the image below?
A. Hypochloremic Hypokalemic Metabolic Acidosis
B. Hypochloremic Hyperkalemic Metabolic Alkalosis
C. Hypochloremic Hypokalemic Metabolic Alkalosis
D. Hyporchloremic Hypokalemic Metabolic Acidosis
34. A 23-year-old female patient came to the outpatient department with a history that she recently
collapsed after a rapid breathing episode during her new job interview. She experiences a numbing
feeling around her mouth a few minutes before the collapse. The patient also describes profuse
sweating and palpitations during this episode. The patient has a history of such episodes that occur
during stressful social encounters. Identify the disorder and mark the option with the next step in
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(or)
Mark the option with the correct treatment in a patient with signs of hyperventilation and tetany.
A. Administer Ringer Lactate
B. Paper bag rebreathing
C. Administer NS
D. Administer calcium gluconate
35. Match the following lab readings with their associated electrolyte imbalances. 1)TBW ↓, TBS ↓
a)Euvolemic hyponatremia 2)TBW ↑, TBS-(n) b)Isotonic hyponatremia 3)TBW ↑↑ , TBS ↑
c)Hypovolemic hyponatremia 4)High glucose d)Hypertonic hyponatremia 5)Hyperproteinemia
e)Hypervolemic hyponatremia
1)TBW ↓, TBS ↓ a)Euvolemic hyponatremia
2)TBW ↑, TBS-(n) b)Isotonic hyponatremia
3)TBW ↑↑ , TBS ↑ c)Hypovolemic hyponatremia
4)High glucose d)Hypertonic hyponatremia
5)Hyperproteinemia e)Hypervolemic hyponatremia
A. 1-a,2-c,3-b,4-d,5-e
B. 1-c,2-e,3-b,4-d,5-a
C. 1-c,2-a,3-e,4-d,5-b
D. 1-e,2-c,3-a,4-b,5-d
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Option D - Hyperkalemia: Hyperkalemia, characterized by serum potassium concentration >5.5 mEq/L,
 can occur in patients with heart failure due to impaired renal potassium excretion or as a side effect of 
certain medications such as potassium-sparing diuretics or angiotensin-converting enzyme (ACE) inhib
itors. However, the patient's symptoms are more consistent with hyponatremia-induced cerebral edem
a rather than hyperkalemia.
 
Correct Option A - Bisphosphonates:
 Bisphosphonates such Ibandronate are the drugs of choice  for patients in hypercalcemic crisis
(>13mg%)
 Options B, C and D are incorrect. Refer to the explanation of the correct answer and the learning
objective.
Correct Option A - Activation of the renin-angiotensin-aldosterone system:
 In this patient with cirrhosis, hyponatremia is likely due to the activation of the
renin-angiotensin-aldosterone system (RAAS).
 Cirrhosis leads to portal hypertension and decreased effective arterial blood volume, triggering the
release of renin from the kidneys.
 Renin then initiates the cascade of RAAS activation, leading to increased aldosterone secretion.
Aldosterone promotes sodium and water retention in the kidneys, expanding extracellular fluid volume
and dilutional hyponatremia.
 
Option B - Excessive intake of dietary sodium: Although excessive intake of dietary sodium may contrib
ute to fluid retention in some cases, it is not the primary mechanism in cirrhotic patients with hypervole
mic hyponatremia.
Option C - Impaired secretion of antidiuretic hormone (ADH): Impaired secretion of ADH can lead to hy
pervolemic hyponatremia in certain conditions such as diabetes insipidus, it is not typically seen in cirrh
osis.
Option D - Decreased water reabsorption in the distal nephron: Decreased water reabsorption in the di
stal nephron would lead to a hypovolemic, rather than hypervolemic, state.
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Correct Option D - Respiratory failure due to laryngospasm:
 The patient's symptoms of muscle cramps and tingling sensations, along with positive Chvostek's and
Trousseau's signs, are indicative of severe hypocalcemia.
 These signs are manifestations of neuromuscular irritability associated with low serum calcium levels.
Hypocalcemia can lead to laryngospasm or bronchospasm, which can result in respiratory failure and
subsequent death.
 
Option A - Cardiac arrest: Systolic arrest is the most common cause of death in hypercalcemia not hyp
ocalcemia.
Option B - Cerebral edema: Cerebral edema is not a
typical complication of hypocalcemia and is unlikely to cause sudden death.
Option C - Pulmonary embolism: Pulmonary embolism is a separate condition that typically presents wi
th symptoms such as chest pain, dyspnea, and hemoptysis. While it can be life-threatening, the sympto
ms described in the scenario are more consistent with neuromuscular manifestations of hypocalcemia.
Correct Option C - TBW ↓, TBS ↓-IV fluids:
 The lab report shows sodium levels of 130meq which is less when compared to its normal values i.e
135-145meq.
 Gastrointestinal fluid losses such as diarrhea (in the question) and vomiting can lead to to
hypovolemic hyponatremia.
Options A, B and D are incorrect. Refer to the explanation of Option C and the learning objective.
Correct Option B - 1-c, 2-e, 3-g, 4-a, 5-h, 6-d, 7-f, 8-b:
1. Na+ < 125 mEq/L
c. Hypertonic saline
2. K+ > 8 mEq/L
e. Ca chloride
3. Ca+ > 13 mg%
g. Ibandronate
4. Mg+ > 10 mEq/L
a. Hemodialysis
5. Na+ > 158 mEq/L
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h. 5 % dextrose
6. K+ < 2.5 mEq/L
d. KCl drip
7. Ca+ < 7 mg%
f. Ca gluconate
8. Mg+ < 1 mEq/L
b. MgSO4
Option A - 1-a, 2-c, 3-b, 4-d, 5-e, 6-g, 7-f, 8-h
Option C - 1-f, 2-d, 3-a, 4-b, 5-c, 6-e, 7-h, 8-g
Option D - 1-h, 2-d, 3-g, 4-c, 5-f, 6-b, 7-e, 8-a
Correct Option C - Euvolemic hyponatremia:
 The image shows the Brudzinski sign which is positive in patients with Meningitis.
 Meningitis leads to Euvolemic hyponatremia.
Incorrect Options: Eliminated by the explanation of the above options.
Option A - Hypervolemic Hyponatremia: Hypervolemic Hyponatremia-seen in Cirrhosis.
Option B - Isotonic Hyponatremia: Isotonic Hyponatremia-Lab errors mostly.
Option D - Hypertonic Hypernatremia: Hypertonic Hypernatremia-seen in mannitol infusion.
Correct Option D - 1-g, 2-e, 3-d, 4-a, 5-c, 6-b, 7-f:
1. Hypomagnesemia
g. Torsades de pointes
2. Hypokalemia
e. Diaphragmatic paralysis
3. Hyponatremia
d. Seizure
4. Hyperkalemia
a. Diastolic arrest
5. Hypocalcemia
c. Laryngospasm
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Option A, B & D: Eliminated by the explanation of the above options.
Correct Option B - Paper bag rebreathing:
 The patient describes hyperventialation, palpitations, and profuse sweating associated with stressful
social encounters. This along with a history of recurrent episodes in similar situations points towards a
diagnosis of social anxiety disorder.
 Rapid shallow breaths lead to Respiratory alkalosis.
 Respiratory alkalosis can trigger tetany (perioral paraesthesia)
Option A - Administer Ringer Lactate: If RL is given bicarbonate produced will worsen alkalosis and tet
any will worsen
Option C - Administer NS: This is used in the treatment of metabolic alkalosis.
Option D - Administer calcium gluconate Hypocalcemia is due to redistribution →
so calcium gluconate not given
Correct Option C - 1-c,2-a,3-e,4-d,5-b:
1)TBW ↓, TBS ↓-c)Hypovolemic hyponatremia
2)TBW ↑, TBS-(n)-a)Euvolemic hyponatremia
3)TBW ↑↑ , TBS ↑-e)Hypervolemic hyponatremia. The increase in TBW is much more significant when
 compared to the increase in TBW leading to hyponatremia.
4)High glucose-d)Hypertonic hyponatremia
5)Hyperproteinemia-b)Isotonic hyponatremia
 
Eliminated by the explanation of the above option
Option A - 1-a,2-c,3-b,4-d,5-e
Option B - 1-c,2-e,3-b,4-d,5-a
Option D - 1-e,2-c,3-a,4-b,5-d
385

Syndromes (Bartter Syndrome, Liddle syndrome,
Gitelman Syndrome)
1. A 35-year-old male patient presents to the clinic with complaints of excessive thirst and frequent
urination. He reports having to wake up multiple times during the night to urinate, and his urine output
during the day seems abnormally high. Laboratory investigations reveal a urine output exceeding 3
liters per day. Radiograph image is given below, what is the first line treatment for this patient?
(or)
What is the first line treatment for central DI ?
A. Desmopressin acetate (DDAVP)
B. Hydrochlorothiazide
C. Amiloride
D. Furosemide
2. A 17-year-old male came to the outpatient with complaints of high fever, vomiting, joint pains, and
confusion for the past three days. The blood cultures revealed a kidney-shaped gram-negative bacteria
and a positive Kernigs sign. Further investigations showed a dark orange yellow urine with increased
urinary sodium, reduced BUN, and a positive water load test. Identify the condition and mark the option
which is not part of the diagnostic criteria.
(or)
Identify the diagnosis in a patient with fever, confusion caused by gram-negative diplococci with a
positive Kernings sign, positive water load test, increased sodium, and reduced BUN. Mark the option
which is not a part of the disease diagnostic criteria.
A. Plasma osmolarity <275 mosm/Kg H2O
B. Clinical Euvolemia
C. Normal Thyroid function test
D. Timed 24-hour Urine studies
3. Match the following: 1) SIADH a) U.osmolarity↓, P.osmolarity↓, Na+ conc↓ 2) Diabetes insipidus b)
U.osmolarity↑, P.osmolarity↓, Na+ conc↓ 3) Psychogenic polydipsia c) U.osmolarity↑, P.osmolarity↑,
Na+ conc.↑ 4) Adipsic Hypernatremia d) U.osmolarity↓, P.osmolarity↑, Na+ conc↑
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1) SIADH a) U.osmolarity↓, P.osmolarity↓, Na+ conc↓
2) Diabetes insipidus b) U.osmolarity↑, P.osmolarity↓, Na+ conc↓
3) Psychogenic polydipsia c) U.osmolarity↑, P.osmolarity↑, Na+ conc.↑
4) Adipsic Hypernatremia d) U.osmolarity↓, P.osmolarity↑, Na+ conc↑
A. 1-a,2-c,3-b,4-d
B. 1-c,2-a,3-b,4-d
C. 1-b,2-d,3-a,4-c
D. 1-d,2-b,3-c,4-a
4. A 5-year-old male baby was brought to the outpatient department by his mother with a complaint
saying that she has to change his diapers multiple times a day. The baby is underweight. Clinical
examination revealed sunken anterior fontanelle, a poorly developed response of the reflex shown in
the image below, and dry dehydrated skin. Lab reports showed Na+ of 130mEq and Mg+ of 1mEq/L.
Identify the condition and mark the option with appropriate statements.
(or)
Which of the following is true regarding Gitelman syndrome ?
A. Investigation of choice is 24-hr urinary chloride
B. Defect in Na-K-2Cl co-transporter.
C. Hypokalemic metabolic acidosis
D. SNHL
5. A 12-year-old child presents to the pediatric clinic with complaints of hearing difficulties and frequent
bone pain. Upon examination, the child is found to have bilateral sensorineural deafness and signs
suggestive of calcium wasting, including nephrocalcinosis and renal rickets. Which medication is most
likely to be prescribed for the treatment of this condition?
(or)
Which medication is most likely to be prescribed for the treatment of Bartter syndrome?
A. Furosemide
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D. Indomethacin
6. A 40-year-old woman presents to her primary care physician with complaints of persistent
hypertension and occasional muscle weakness. Laboratory tests reveal hypokalemia and metabolic
alkalosis. Further evaluation indicates low renin levels. Which of the following medications is most
appropriate for the management of this patient's condition?
(or)
Which of the following is the treatment for liddle syndrome?
A. ACE inhibitor
D. Thiazide diuretic
7. Mark the option with correct statements regarding Diabetes insipidus. a) Urine output>3L/day b) First
line drug for central DI is Indomethacin c) Reduced Plasma Osmolarity d) Miller Moses test is used for
evaluation
A. b,c
B. a,d
C. a,c
D. b,d
8. All of the following can be treated with Indomethacin except?
B. Acute Gout
C. Bartter syndrome
D. Liddle syndrome
9. Which of the following laboratory findings is most likely to be observed in a patient with psychogenic
polydipsia?
A. Increased urine osmolarity, decreased plasma osmolarity, and decreased sodium concentration
B. Decreased urine osmolarity, increased plasma osmolarity, and increased sodium concentration
C. Decreased urine osmolarity, decreased plasma osmolarity, and decreased sodium concentration
D. Increased urine osmolarity, increased plasma osmolarity, and increased sodium
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Correct Option A - Desmopressin acetate (DDAVP):
 Desmopressin is the synthetic analog of vasopressin and is the first-line treatment for central diabetes
insipidus, as it helps to reduce excessive urination and thirst.
 
Option B - Hydrochlorothiazide: Hydrochlorothiazide is not typically used as a
first-line treatment for central diabetes insipidus. It is a
diuretic medication that may exacerbate symptoms by increasing urine output.
Option C - Amiloride: Amiloride is not typically used as a
potassium-sparing diuretic that may not address the underlying cause of excessive urination and thirst.
Option D - Furosemide: Thiazides are treatment choice for nephrogenic DI.
Correct Option D - Timed 24-hour Urine studies:
 Timed 24-hour Urine studies are not the diagnostic criteria for SIADH
 The diagnosis is SIADH (Syndrome of inappropriate antidiuretic hormone secretion)
 Fever, joint pains and a positive Kernigs sign hints towards meningitis caused by Neisseria
meningitidis (Gram-negative kidney-shaped Diplococci)
 Meningitis is one of the causative factors for SIADH (Concentrated Urine, Increased Urinary sodium,
reduced BUN, and a positive Water load test)
Option A - Plasma osmolarity <275 mosm/Kg H2O
Option B - Clinical Euvolemia
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Option A - Furosemide: Furosemide is a loop diuretic commonly used to treat conditions of fluid overlo
ad by promoting diuresis. However, it is not typically used in the treatment of Bartter syndrome as it ca
n exacerbate electrolyte imbalances.
Option B - Hydrochlorothiazide: Hydrochlorothiazide is a thiazide diuretic that promotes diuresis by inhi
biting sodium reabsorption in the distal convoluted tubule. While it may be used in some forms of Bartt
er syndrome to reduce calcium excretion, it is not the first-line treatment.
Option C - Spironolactone: Spironolactone is a potassium-sparing diuretic that acts by antagonizing ald
osterone receptors, leading to increased potassium retention and decreased sodium retention. It is not 
typically used in the treatment of Bartter syndrome.
Correct Option C - Amiloride:
 Amiloride is a potassium-sparing diuretic that directly inhibits the epithelial sodium channel (ENaC) in
the distal nephron, leading to decreased sodium reabsorption and potassium retention. It is indicated
for the management of hypokalemia and metabolic alkalosis, particularly in conditions associated with
low renin levels, such as primary aldosteronism.
 
Option A - ACE inhibitor: ACE inhibitors are not indicated in this case. They are typically used in conditi
ons such as hypertension and heart failure, but they would not address the underlying cause of hypoka
lemia and metabolic alkalosis with low renin levels.
Option B - Beta-blocker: Beta-blockers are not indicated in this case. While they are used to manage h
ypertension, they would not correct hypokalemia and metabolic alkalosis.
Option D - Thiazide diuretic: Thiazide diuretics are contraindicated in this case. They can exacerbate h
ypokalemia and metabolic alkalosis by promoting potassium loss in the urine. Therefore, they are not a
ppropriate for the management of this patient's condition.
Correct Option B - a,d:
 a)Urine output>3L/day-Polyuria
 d)Miller Moses test which is a Water deprivation test is used for the evaluation of diabetes insipidus.
Option A - b,c:
 b) First line drug for central diabetes insipidus is Desmopressin and not Indomethacin
 c) Diabetes insipidus leads to reduced Urine Osmolarity and increased Plasma Osmolarity
Option C & D - (a,c & b,d): Refer to the explanation of the correct answer.
 
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- Liddle syndrome is the only exception which is treated with Amiloride and not Indomethacin.
All the remaining options are the conditions that can be treated with indomethacin
Option A - Patent ductus arteriosus
Option B - Acute Gout
Option C - Bartter syndrome
 
- Decreased urine osmolarity, decreased plasma osmolarity, and decreased sodium concentration:
 Psychogenic polydipsia is characterized by excessive intake of water due to psychological factors,
leading to dilutional hyponatremia. In this condition, the excess intake of water dilutes the plasma,
resulting in decreased plasma osmolarity. The kidneys respond by excreting the excess water, causing
decreased urine osmolarity. Additionally, the excessive water intake can lead to a decrease in sodium
concentration in the blood due to dilutional effects. Therefore, the most likely laboratory findings in
psychogenic polydipsia are decreased urine osmolarity, decreased plasma osmolarity, and decreased
sodium concentration.
 
Option A - Increased urine osmolarity, decreased plasma osmolarity, and decreased sodium concentra
tion: This option describes findings more consistent with diabetes insipidus, where there is impaired wa
ter reabsorption leading to increased urine osmolarity and decreased plasma osmolarity and sodium co
ncentration.
Option B - Decreased urine osmolarity, increased plasma osmolarity, and increased sodium concentrat
ion: These findings are not typical of any specific condition and do not match the characteristics of psyc
hogenic polydipsia.
Option D - Increased urine osmolarity, increased plasma osmolarity, and increased sodium concentrati
on: This combination of findings is not typical of psychogenic polydipsia. Increased osmolarity and sodi
um concentration are more commonly associated with conditions such as dehydration or syndrome of i
nappropriate antidiuretic hormone secretion (SIADH).
392

Ciliopathies, Kidney Injury and TTP
1. Which of the following findings are seen on excretory urography in a patient with medullary sponge
kidney disease?
A. Flower vase appearance
B. Swiss cheese appearance
C. Bergman sign
D. Bouquet of flowers
2. Cilia is present in all of the following parts of the kidney except?
A. PCT
B. Loop of Henle
C. DCT
D. Collecting duct
3. A 2-day-old neonate was found dead in the neonatal ward. The child was delivered after an LSCS
two days back. The mother's antenatal checkup and history showed an AFI of 5. A review of antenatal
USG reports showed an enlarged and echogenic kidney of the fetus. The lungs are also noted to be
hypoplastic.Which of the following statement is not true regarding this patient?
(or)
Which of the following statement is not true regarding ARPKD?
A. PKD-1 gene on Chromosome 16
B. Polyductin is the defective protein
C. It is an Autosomal recessive condition
D. Can be picked up on Antenatal level 2 scan
4. Which of the following is not an extra-renal manifestation of Autosomal recessive polycystic kidney
disease?
A. Congenital hepatic periportal fibrosis
B. Caroli cysts
C. Pancreatic cysts
D. Biliary dysgenesis
5. Which of the following genes is not involved in Autosomal dominant tubulointerstitial kidney disease?
A. MCKD-1
B. UMOD
C. MUCIN-1
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D. MCKD -3
6. Which of the following is not an extra-renal manifestation of ADPKD?
B. Berrys aneurysm
C. GI diverticulosis
D. Caroli cysts.
7. A 55-year-old male presents to the clinic with complaints of recurrent episodes of flank pain over the
past few months. Upon further questioning, he mentions a family history of kidney problems, with his
father having been diagnosed with renal cysts. Physical examination reveals bilateral tenderness at the
costovertebral junction. Laboratory investigations show a mildly elevated serum creatinine level. Which
of the following is true regarding the genetic cause of this condition?
(or)
Which of the following genetic defect cause Adult polycystic kidney disease?
A. PKD -1 GENE encoding for protein POLYCYSTIN-1 on chromosome 16
B. PKD -2 GENE encoding for protein POLYCYSTIN-2 related to chromosome 14
C. PKD -2 GENE encoding for protein POLYCYSTIN-2 related to chromosome 12
D. PKD -1 GENE encoding for protein POLYCYSTIN-1 on chromosome 18
8. Which of the following is cystic disorders is associated with the appearance of the kidney given
below?
A. Autosomal dominant polycystic disease
B. Autosomal recessive polycystic disease
C. Medullary sponge kidney
D. Autosomal dominant tubulo interstitial kidney disease
9. Which of the following statements regarding extrarenal manifestations of autosomal dominant
polycystic kidney disease (ADPKD) is correct?
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Page 3
A. Lung cysts are commonly seen in ADPKD patients
B. Brain parenchyma is frequently affected by cyst formation in ADPKD
C. Arachnoid cysts are not associated with ADPKD
D. Mitral valve prolapse with mid-systolic clicks
10. Which of the following is a lab finding in Prenal AKI?
A. FeNa>1%
B. Urine Osmolarity>500mOsmol
C. Urinary sodium-High
D. Tubular damage
11. Match the following SET 1 1)Tumor lysis syndrome 2) Contrast-induced nephropathy 3)Ethylene
glycol poisoning SET 2 a)FomepizoleFomepizole b)Rasburicase c) N-Acetylcysteineiene
C. 1-a,2-b,3-c
D. 1-b,2-c,3-a
12. All of the following are the electrolyte disturbances observed in patient with tumor lysis syndrome on
cancer therapy except?
A. Hyperkalemia
C. Hyperphosphatemia
13. Match the following 1. Orange color urine a. Phenophthalene 2. Blue/green-color urine b.
Nitrofurantoin 3. Red colored urine c. Rifampicin 4. Purple color urine d. Amitriptyline 5. Dark brown
color urine e. Crush injury
1. Orange color urine a. Phenophthalene
2. Blue/green-color urine b. Nitrofurantoin
3. Red colored urine c. Rifampicin
4. Purple color urine d. Amitriptyline
5. Dark brown color urine e. Crush injury
A. 1-c,2-d,3-e,4-a,5-b
B. 1-a,2-c,3-b,4-d,5-e
C. 1-b,2-e,3-a,4-a,5-d
D. 1-e,2-a,3-d,4-b,5-c
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14. Which of the following describes the correct definition of CKD according to the old protocol?
A. GFR < 70 ml/min/1.73m² surface area with proteinuria X 6 months
B. GFR < 60 ml/min/1.73m² surface area with proteinuria X 3 months
C. GFR < 40 ml/min/1.73m² surface area with proteinuria X 6months
D. GFR < 960 ml/min/1.73m² surface area with proteinuria X 3 months
15. A 15-year-old boy presented to the outpatient department with complaints of abdominal pain, and
vomiting episodes since the past few days. He was admitted to the inpatient ward. and started on
empirical antibiotics.. Cultures showed E.coli . Further tests showed anemia, thrombocytopenia and
helmet cells on peripheral smear, and increased levels of BUN. Identify the diagnosis and mark the
option with the treatment choice that is not recommended for this disease.
A. Hemodialysis
B. Plasmapheresis
C. PRBC
D. Eculizumab
16. Which of the following antiplatelet drugs is associated with an increased risk of thrombotic
thrombocytopenic purpura (TTP)?
A. Aspirin
C. Ticagrelor
D. Dipyridamole
17. A 45-year-old woman presents to the oncology clinic for follow-up after receiving chemotherapy for
breast cancer. During the treatment course, she developed symptoms suggestive of thrombotic
thrombocytopenic purpura (TTP). Which of the following chemotherapeutic agents is most likely
responsible for inducing secondary TTP in this patient?
(or)
Which of the following chemotherapeutic agents is most likely responsible for inducing secondary TTP
A. Doxorubicin
B. Methotrexate
C. Mitomycin C
D. Paclitaxel
18. A 7-year-old child is brought to the pediatric clinic with complaints of abdominal pain, vomiting, and
bloody diarrhea for the past two days. On examination, the child appears pale, with petechiae and
non-palpable purpura on the skin. Laboratory tests reveal decreased platelet count, normal fibrinogen
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Page 5
levels, and schistocytes on peripheral blood smear. Ultrasound examination of the kidneys shows
normal echogenicity with bilateral kidney sizes within the normal range. Which of the following
conditions is most likely responsible for the patient's presentation?
(or)
Which of the following is associated with decreased platelet count, normal fibrinogen levels, and the
presence of schistocytes on peripheral blood smear?
A. Hemolytic Uremic Syndrome (HUS)
B. Thrombotic Thrombocytopenic Purpura (TTP)
C. Disseminated Intravascular Coagulation (DIC)
D. Hemorrhagic Stroke
Correct Option D - Bouquet of flowers/ Paintbrush/ Papillary brush appearance:
 On excretory urography in patients with medullary sponge kidney disease, bouquet of flowers/paint
brush/papillary brush appearance is seen.
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Option A - Autosomal dominant polycystic disease: Large cysts present in the cortex and medulla
Option C - Medullary sponge kidney: The cyst is only present in the medulla
Option D - Autosomal dominant tubulo interstitial kidney disease: The cysts are present at the cortex m
edullary junction also known as medullary cystic disease complex
Correct Option D - Mitral valve prolapse with mid-systolic clicks:
 Mitral valve prolapse (MVP) with mid-systolic clicks is a well-known cardiovascular manifestation of
autosomal dominant polycystic kidney disease (ADPKD). This is due to the connective tissue
abnormalities associated with ADPKD, which can affect the structure and function of the heart valves.
MVP is characterized by the abnormal movement of the mitral valve leaflets during systole, often
accompanied by characteristic mid-systolic clicks heard on auscultation.
 
Option A - Lung cysts are not commonly seen in ADPKD patients: While ADPKD primarily affects the ki
dneys, cyst formation can also occur in other organs such as the liver, pancreas, and spleen, but lung 
cysts are not a typical extrarenal manifestation.
Option B - Brain parenchyma is not frequently affected by cyst formation in ADPKD: While ADPKD can
 lead to intracranial manifestations such as arachnoid cysts and cerebral aneurysms, cyst formation wit
hin the brain parenchyma itself is not a common feature of the disease.
Option C - Arachnoid cysts are indeed associated with ADPKD: Arachnoid cysts, cerebral aneurysms, 
and arterial dolichoectasia are among the central nervous system (CNS) features that can occur in AD
PKD patients. Therefore, this statement is incorrect.
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Correct Option B - Urine Osmolarity>500mOsmol:
 Urine Osmolarity>500mOsmol is a finding in pre renal AKI
 Remaining options are lab findings of RENAL AKI
 
Correct Option D - 1-b,2-c,3-a:
 a) Fomepizole is used as an antidote for Ethylene glycol poisoning
 b) Rasburicase is used in the treatment of tumor lysis syndrome
 c) N-Acetylcysteine is used in the management of Contrast-induced nephropathy
Incorrect Options A,B,C- Refer to the above explanation
 
Correct Option B- Hypernatremia:Hypernatremia is not seen in tumor lysis syndrome
Incorrect Options- A,C &D; (Hyperkalemia, Hyperphosphatemia & 
Hypocalcemia): All are seen in tumor lysis syndrome
Correct Option A- 1-c,2-d,3-e,4-a,5-b:
Option B- 1-a,2-c,3-b,4-d,5-e:
Option C- 1-b,2-e,3-a,4-a,5-d:
Option D- 1-e,2-a,3-d,4-b,5-c:
Eliminated by the explanation of the above options
 
Correct Option B - GFR < 60 ml/min/1.73m² surface area with proteinuria X 3 months:
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 GFR < 60 ml/min/1.73m² surface area with proteinuria X 3 months was used to describe CKD before
the newer classifications based on eGFR were widely adopted.identifies the disease when 50% of
damage has already occurred.
 
Option A, C, D - Refer to the above explanation
Correct Option B - Plasmapheresis:
 The diagnosis is Hemolytic Uremic Syndrome.
 The predominance of gastrointestinal symtpoms, culture demonstrating E. coli, anemia,
thrombcytopenia, schistocytes and increased levels of BUN points towards a diagnosis of Hemolytic
Uremic Syndrome.
 Plasmapheresis is used in TTP, not HUS.
Options A, C, and D: Are treatment modalities in patients with HUS.
 
Correct Option B - Clopidogrel:
 Thrombotic thrombocytopenic purpura (TTP) can be triggered by various factors, including certain
medications. Among antiplatelet drugs, clopidogrel has been associated with an increased risk of TTP.
Clopidogrel, a thienopyridine derivative, inhibits platelet aggregation by irreversibly binding to the
P2Y12 adenosine diphosphate (ADP) receptor on platelets. However, its use has been linked to the
development of TTP, likely due to its impact on platelet function and the risk of microthrombi formation.
 
Option A - Aspirin: Aspirin is not associated with an increased risk of TTP.
Option C - Ticagrelor: Ticagrelor, a P2Y12 receptor antagonist, has not been specifically linked to TTP.
Option D
- Dipyridamole: Dipyridamole, another antiplatelet agent, is not commonly associated with TTP.
Correct Option C - Mitomycin C:
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 Secondary TTP can be induced by certain chemotherapeutic agents, including Mitomycin C and
Gemcitabine. These drugs can cause endothelial damage and trigger the formation of autoantibodies
against ADAM TS 13, leading to impaired cleavage of von Willebrand factor (VWF) and subsequent
TTP. In this case, the patient's presentation of TTP following chemotherapy suggests that Mitomycin C
is the likely culprit.
 
Option A - Doxorubicin: Doxorubicin is not typically associated with the development of TTP.
Option B - Methotrexate: Methotrexate is more commonly associated with mucositis and myelosuppres
sion rather than TTP.
 Option D - Paclitaxel: Paclitaxel is not known to induce secondary TTP.
Correct Option A - Hemolytic Uremic Syndrome (HUS):
 HUS typically presents with abdominal pain, vomiting, bloody diarrhea, and features of
microangiopathic hemolytic anemia (e.g., petechiae, purpura).
 Laboratory findings in HUS include decreased platelet count, normal fibrinogen levels, and the
presence of schistocytes on peripheral blood smear.
 Ultrasound examination of the kidneys in HUS typically shows normal echogenicity with bilateral
kidney sizes within the normal range.
 HUS is commonly seen in pediatric age groups and is often triggered by gastrointestinal infections,
especially those caused by certain strains of E. coli producing Shiga toxin.
 
Option B - Thrombotic Thrombocytopenic Purpura (TTP): While TTP shares some similarities with HUS
, such as the presence of microangiopathic hemolytic anemia and thrombocytopenia, it is typically asso
ciated with low or absent levels of ADAMTS13 enzyme and may present with neurologic symptoms. Ad
ditionally, kidney involvement in TTP is less common than in HUS.
Option C - Disseminated Intravascular Coagulation (DIC): DIC is characterized by systemic activation o
f coagulation, leading to the widespread formation of fibrin clots in the microvasculature. Laboratory fin
dings in DIC often include low platelet count, low fibrinogen levels, prolonged clotting times, and eviden
ce of ongoing coagulation and fibrinolysis. While DIC can present with bleeding manifestations, it typic
ally does not manifest with specific renal findings seen in HUS.
Option D - Hemorrhagic Stroke: This option is less likely given the absence of focal neurological deficit
s or signs suggestive of a cerebrovascular event in the clinical presentation described. HUS and TTP a
re more commonly associated with microvascular thrombosis and hemolysis rather than hemorrhagic s
troke.
404

Kidney Urine Analysis
1. A 50-year-old woman presents to her primary care physician with complaints of frequent urination
and abdominal discomfort. During the physical examination, the physician performs a dipstick test on
the patient's urine sample, which reveals a result of 3+ for proteinuria. Based on the dipstick test result,
what is the approximate protein concentration in the patient's urine?
(or)
What is the approximate protein concentration in the patient's urine if proteinuria in dipstick shows 3+?
A. 15-30 mg/dl
B. 30-100 mg/dl
C. 100-300 mg/dl
D. 300-1000 mg/dl
2. Identify the stage of acute kidney injury with the help of the given values of serum creatine 2.5 times
its original value and urine output<0.5ml/kg/hr over a duration of 12 hours.
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
3. Identify the condition that is not associated with (AER) /(UAC) ratio of 100 mg/gm.
A. Diabetic nephropathy
B. HTN
D. Glomerulonephritis
4. Identify the condition that is not associated with severely increased albuminuria.
A. Fever
B. CHF
C. Diabetic nephropathy
D. Para proteinuria
5. Using the image below, identify the condition and mark the option that is not its causative factor.
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A. Amyloidosis
B. Focal segmental glomerulosclerosis
C. Para-proteinuria
D. Membrano-glomerulonephritis
6. Which of the following is an appropriate screening test for Multiple myeloma"?
A. Bone marrow biopsy
B. Urine dipstickX-ray
C. Urine electrophoresis
D. Blood investigations
7. All of the following causes pink/red colored urine except?
A. Porphyrins
B. Rifampin
C. Clofazimine
D. Chloroquine
8. The stain that is used to evaluate Eosinophiluria?
A. Sternheimer and Malbin staining
B. Wright and Hansel's stain
C. Hematoxylin and eosin stain
D. Sternheimer staining
9. Amount of protein in the urine of a normal individual?
A. 150mg/day
B. 250mg/day
C. 190mg/day
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D. 200mg/day
10. Which of the following statements is true regarding significant hematuria.
A. >10RBC/ HPF
B. >3 RBC/ HPF centrifuged x 3 times; a gap of 1-week
C. > 100 RBC /HPF in single sample
D. >150 RBC/HPF
11. A 45-year-old male patient presents to the nephrology clinic with complaints of dark-colored urine
and swelling in his legs. Urine microscopy reveals the presence of RBC casts. What is the most likely
diagnosis for this patient based on the presence of RBC casts in the urine?
(or)
What is the most likely diagnosis for this patient based on the presence of RBC casts in the urine?
A. Acute glomerulonephritis
B. Chronic glomerulonephritis
C. Acute tubular necrosis
D. Chronic kidney disease
12. Using the image below, identify the condition which is not associated with it.
A. Nephrotic syndrome
B. Fat embolism
C. Chyluria
D. Pyelonephritis
13. A 7-month-old infant is brought to the pediatrician's office by her parents due to concerns about the
color of her urine. The parents report noticing a pinkish discoloration of the infant's diapers for the past
few days. Which of the follwoing organism is causeing this?
(or)
Which of the following organisms is likely causing the pinkish discoloration of the infant's diapers?
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A. Serratia marcescens
B. Escherichia coli
C. Staphylococcus aureus
D. Streptococcus pneumoniae
14. A 60-year-old male patient with a history of hypertension and diabetes mellitus presents to the
emergency department with complaints of decreased urine output and generalized weakness.
Urinalysis reveals the presence of muddy brown casts. What is the most likely diagnosis based on
these findings?
(or)
Presence of muddy brown casts is seen in?
A. Acute kidney injury (AKI) due to acute tubular necrosis (ATN)
B. Chronic kidney disease (CKD) exacerbation
C. Urinary tract infection (UTI)
D. Nephrotic syndrome
Correct Option D - 300 - 1000 mg/dl:
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 A dipstick result of 3+ for proteinuria indicates a significant amount of protein in the urine.
 According to the provided dipstick test scale, 3+ corresponds to a protein concentration range of
300-1000 mg/dl.
 This level of proteinuria suggests potential kidney dysfunction or another underlying condition
affecting the urinary system.
 
Option A - 15-30 mg/dl: This range corresponds to trace proteinuria on the dipstick test, which is less th
an the patient's observed proteinuria level.
Option B - 30-100 mg/dl: This range represents 1+ proteinuria on the dipstick test, which is lower than t
he observed proteinuria level.
Option C - 100-300mg/dl: This range corresponds to 2+proteinuria on the dipstick test, indicating a
higher protein concentration than observed in this case.
Correct Option B - Stage 2:
 The vignette describes a stage II AKI according to the AKIN(Acute Kidney Injury Network)
classification of AKI. Refer to the learning objective for the full classification.
 
Correct Option C - Multiple myeloma:
 Albumin excretion rate (AER) /Urinary albumin creatinine (UAC) ratio of 30-300 mg/gm = Moderately
increased albuminuria (earlier known as Microalbuminuria)
 Multiple myeloma is associated withseen in severely increased albuminuria.
 
Incorrect Options: Eliminated by the explanation of the above options
Correct Option C - Diabetic nephropathy:
 Albumin excretion rate (AER) /Urinary albumin creatinine (UAC) ratio is 300 mg–3500 mg per
gram/gm/g of urinary creatinine (U.C) is considered S severely increased albuminuria (earlier known as
Macroalbuminuria)
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 Diabetic nephropathy is associated with moderately increased albuminuria
Incorrect Options: All the other options show  Severely increased albuminuria
 
Correct Option C - Para-proteinuria is the odd option here:
 The image shows frothy and yellow-colored urine with proteinuria(turns yellow on-air exposure
 Albumin excretion rate (AER) /Urinary albumin creatinine (UAC) ratio is >3500 mg /gm = Nephrotic
Range proteinuria
 Paraproteinuria, seen in multiple myeloma is more commonly associated with ‘severely increased
albuminuria’ rather than nephrotic range proteinuria. Patients with multiple myeloma who develop
nephrotic range proteinuria usually have a coexisting disorder such as amyloidosis.
 Note - The urine dipstick test is good at picking up the presence of negatively charged proteins such
as albumin, but is not effective when it comes to picking up positively charged paraproteins. Hence,
Urine dipstick might be falsely negative in patients with multiple myeloma.
Incorrect Options: Eliminated by the explanation of the above option
Options A, B, and D -  Are associated with nephrotic range proteinuria.
 
Correct Option C - Urine electrophoresis:
 Screening Test for Multiple myeloma: Urine Electrophoresis showing an M-Spike.
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Options A, B and D - Are inappropriate ‘screening tests’ in patients with multiple myeloma. Refer to the 
explanation of the correct answer.-eliminated by the explanation of the above options.
Correct Option D - Chloroquine:
 Chloroquine causes brown-coloured urine.
Options A, B, and C cause pink/ red colored urine.
 
Correct Option B - Wright and Hansel's stain:
 Wright and Hansel's stain is used to evaluate eosinophilia
Option A - Sternheimer and Malbin staining: Used to stain urine sediments
Option C - Hematoxylin and eosin stain: This is a regular stain used in histopathology slides
Option D - Sternheimer staining: Used to stain urine sediments
 
Correct Option A - 150mg/day:
Proteins in urine
 The protein present in the urine of a normal individual: <150mg/day
 ~30 mg or <30 mg of this 150 mg/day is albumin from the glomerulus. Protein Glomerulus: Albumin
(<30mg/day)
 Protein Tubules: Tamm Horsfall proteins/ Uromodulin (120mg/day)
 From the tubules(ascending limb of Henle) produces Tamm Horsfall protein/Uromodulin. This
contributes to 120 mg/day of the total 150 mg/day.
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Fat in urine / Oval fat bodies are found in
1. Nephrotic syndrome
2. Fat embolism syndrome
3. Chyluria
 Maltese cross appearance in urine is associated with nephrotic syndrome and Fabry’s disease
(alpha-galactosidase deficiency)
 
Options A, B, and C: Are associated with oval light bodies in urine on polarized light microscopy.
Correct Option A - Serratia marcescens:
 Serratia marcescens is known to cause a phenomenon known as the "pink diaper syndrome." This
condition occurs when the bacteria produce a red pigment, resulting in pinkish discoloration of diapers.
It is typically benign and self-limiting, often resolving without the need for treatment.
 
Option B - Escherichia coli: While E. coli can cause urinary tract infections and hematuria in infants, it i
s not associated with the specific pink diaper syndrome described in the scenario.
Option C - Staphylococcus aureus: Staphylococcus aureus infections can lead to various clinical manif
estations, but it is not typically associated with pinkish discoloration of diapers.
Option D - Streptococcus pneumoniae: Streptococcus pneumoniae infections are primarily respiratory i
n nature and are not typically associated with urinary or diaper-related symptoms.
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Correct Option A - Acute kidney injury (AKI) due to acute tubular necrosis (ATN):
 Muddy brown casts are indicative of renal tubular epithelial cell casts, which are commonly seen in
acute tubular necrosis (ATN). ATN is a type of acute kidney injury characterized by damage to the renal
tubules, often caused by ischemia or nephrotoxic substances. The patient's history of hypertension and
diabetes mellitus increases the risk of AKI due to ATN.
 
Option B - Chronic kidney disease (CKD) exacerbation: CKD typically presents with persistent proteinu
ria, hypertension, and a gradual decline in kidney function over time. Muddy brown casts are not chara
cteristic of CKD exacerbation.
Option C - Urinary tract infection (UTI): UTI may present with symptoms such as dysuria, frequency, an
d urgency, along with pyuria on urinalysis. Muddy brown casts are not commonly associated with UTI.
Option D - Nephrotic syndrome: Nephrotic syndrome is characterized by heavy proteinuria (>3.5 g/day)
, hypoalbuminemia, edema, and hyperlipidemia. While nephrotic syndrome may lead to renal patholog
y, muddy brown casts are not typical findings in this condition.
414

Chronic Kidney Disease & Management
1. Identify the Grade of GFR for CKD in a patient with-GFR ml/ min/1.73m² surface area of 45 with
proteinuria.
A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4
2. Which is the most common cause of Chronic kidney disease?
A. Chronic glomerulonephritis
B. Diabetic nephropathy
C. Ischemic nephropathy
D. Chronic tubulointerstitial disorders
3. Which of the following complications is most likely to develop in a patient with chronic kidney disease
(CKD) classified as Grade 4?
B. Anemia
D. Uremia
4. Pick the option with appropriate statements regarding allogeneic renal transplantation. a) Prior
Doppler showing unilateral renal artery stenosis in the donor is a contraindication b) The Right kidney of
the donor is used c) The Donor's kidney is placed in the right iliac fossa of the recipient d) In recipients
with 3/6 HLA match, ATG(antithymocyteglobulin) induction therapy is given.
A. A and C only
B. A and B only
C. C and D only
D. B and D only
5. Which of the following is not true regarding the procedure shown in the image?
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Page 2
A. Refractory acidosis is an indication for this therapy
B. The presence of Bruit indicates a damaged fistula
C. The principle is diffusion followed by ultrafiltration
D. Cimino Brescia fistula is between the radial artery and cephalic vein.
6. A 45-year-old patient with end-stage renal disease undergoes kidney transplantation. Pre-transplant
testing reveals that the donor and recipient share only 3 out of 6 HLA antigens. What would be the
appropriate induction therapy for this patient to prevent graft rejection?
(or)
What would be the appropriate induction therapy for this patient to prevent graft rejection in a patient
with a mismatch of 3 out of 6 HLA antigens?
A. Anti-thymocyte globulin
B. Basiliximab
C. No induction required
D. Cyclosporine
7. A 35-year-old male patient who underwent kidney transplantation six months ago presents to the
clinic with complaints of persistent cough and shortness of breath. He reports being generally unwell
and experiencing fatigue. On further investigation, bronchoalveolar lavage reveals the presence of a
specific causative organism. Which opportunistic infection is most commonly responsible?
(or)
Which opportunistic infection is most common opportunistic infection responsible for the patient's
symptoms six months post-kidney transplantation?
A. BK virus
B. Pneumocystis jiroveci
C. Cytomegalovirus
D. Hepatitis B
8. HLA inheritance of the donor and recipient is given. Pick the option with appropriate matching Donor
Recipient A - 2, 29 B - 44, 8 DR - 4, 3 A - 2, 29 B - 44, 33 DR - 3, 4
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Page 3
Donor Recipient
A - 2, 29B - 44, 8DR - 4, 3 A - 2, 29B - 44, 33DR - 3, 4
A. 2/6
B. 1/6
C. 3/6
D. 6/6
9. Best method to calculate eGFR is?
A. CKD - EPI - Cystatin C Formula
B. Creatinine clearance
C. Cockroft Gault Formula
D. Inulin clearance
10. Pick the option with the accurate albumin grading of CKD with 30-300mg/g of urine albumin to urine
creatinine ratio?
A. A1
B. A2
C. A3
D. A4
11. A 65-year-old patient with a history of chronic kidney disease (CKD) presents to the clinic for a
routine follow-up visit. His latest laboratory results indicate a decline in kidney function, from CKD stage
G2 to G3. Which of the following changes is most likely to occur in response to this decline in kidney
function?
(or)
Which of the following changes is most likely to occur in kidney function, from CKD stage G2 to G3?
A. Decreased levels of parathyroid hormone (PTH)
B. Increased bone formation
C. Decreased risk of cardiovascular morbidity
D. Calci■cation of blood vessels
12. What is the pathology underlying the development of dialysis dementia, a condition often seen in
patients undergoing recurrent hemodialysis?
A. Accumulation of beta-amyloid in the brain
B. Deposition of tau protein aggregates in the brain
C. Increased levels of glutamate
D. Oxidative stress-induced neuronal damage.
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Page 4
13. A 40-year-old patient who underwent kidney transplantation presents with new-onset skin lesions.
On further evaluation, it is determined that the patient has post-transplantation lymphoma. Which of the
following infections is most commonly associated with post-transplantation lymphoma?
(or)
Which of the following infections is most commonly associated with post-transplantation lymphoma?
A. CMV (Cytomegalovirus)
B. EBV (Ebstein Barr Virus)
C. HSV (Herpes Simplex Virus)
D. HIV (Human Immunodeficiency Virus)
Correct Option C - Grade 3:
 The stage of CKD described in the vignette is Grade 3
Current GFR Grading for C.K.D
 Grade 1: GFR ml/ min/1.73m² surface area is > or = to 90 with proteinuria.
 Grade 2: GFR ml /min/1.73m² surface area is 60 to 89 with proteinuria.
 Grade 3: GFR ml/ min/1.73m² surface area is 30 to 59 with proteinuria. ·
 Grade 4: GFR ml /min/1.73m² surface area is 15 to 29 with proteinuria.
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Page 5
 Grade 5: GFR ml/min/1.73m² surface area is < 15 with proteinuria.
 End-stage renal disease, now called Renal failure. URAEMIA occurs.
 GFR can be greater than 125 ml in patients with diabetic nephropathy initially due to Hyperfiltration.
Incorrect options A,B,C: these options are incorrect due to the above given reasons
Correct Option B - Diabetic nephropathy:
 Diabetic nephropathy is the most common cause of Chronic kidney disease
 In chronic kidney disease (CKD) classified as Grade 4, the kidneys' function is significantly impaired,
leading to various complications. Hyperkalemia, which is characterized by elevated levels of potassium
in the blood, is a common complication in Grade 4 CKD. As kidney function declines, the kidneys have
difficulty removing potassium from the body, resulting in its accumulation in the bloodstream.
Hyperkalemia can lead to serious cardiac arrhythmias and other cardiovascular complications if not
properly managed.
 
Option A - Hypertension: While hypertension is a
common complication in CKD, it typically develops earlier in the disease progression, often in Grade 2
CKD.
Option B - Anemia: Anemia commonly develops in later stages of CKD, typically in Grade 3
due to decreased production of erythropoietin by the kidneys.
Option D - Uremia: Uremia, or the buildup of waste products in the blood, is a
severe complication of advanced CKD, typically occurring in Grade 5
CKD. It manifests with symptoms such as nausea, vomiting, fatigue, and neurological symptoms.
Correct Option A - 
True statements a and c
a) Prior Doppler showing unilateral renal artery stenosis in the donor is a contraindication
c) The donor's kidney is extraperitoneally placed in the right iliac fossa of the recipient for ease of remo
val.
 
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Page 6
Incorrect statements
b) Donor's left kidney is used not the Right kidney
d) In recipients with 3/6 HLA match, anti CD25 molecule(Basilixumab) is used for induction.
Correct Option B - 
 The image shows the procedure of Hemodialysis
 The presence of bruit indicates a functional fistula 
Option A, C, D
Refractory acidosis is an indication for hemodialysis
 The principle is diffusion followed by ultrafiltration
 Cimino Brescia fistula is between the radial artery and cephalic vein.
 
Correct option B - Basiliximab:
 The appropriate induction therapy for this patient with a mismatch of 3 out of 6 HLA antigens would be
using Basiliximab, an anti-CD25 monoclonal antibody. Basiliximab is indicated for patients who have a
3/6 HLA match and is used as induction therapy to prevent graft rejection. It works by inhibiting the IL-2
receptor on T cells, thereby reducing T cell activation and proliferation.
 
Option A - Anti-thymocyte globulin: This option is typically reserved for patients with a mismatch of 1
out of 6 or 2 out of 6 HLA antigens.
Option C - No induction required: This option is inappropriate for patients with a mismatch of 3 out of 6 
HLA antigens, as they are at increased risk of graft rejection compared to those with fewer mismatches
.
Option D - Cyclosporine: Maintenance therapy includes drugs such as steroids, calcineurin inhibitors (e
.g., tacrolimus or cyclosporine), mycophenolate, azathioprine, and sirolimus.
Option A - BK virus:
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Page 7
 The most common opportunistic infection responsible for the patient's symptoms six months
post-kidney transplantation is BK virus (polyomavirus) infection.
 
Option B - Pneumocystis jiroveci: Pneumocystis jiroveci (formerly Pneumocystis carinii) is typically see
n within the first six months post-transplantation. It presents with cough and shortness of breath sympt
oms and is diagnosed through bronchoalveolar lavage. Treatment involves cotrimoxazole.
Option C - Cytomegalovirus: Cytomegalovirus (CMV) infection is also common within the first six mont
hs after kidney transplantation and is associated with graft failure. It typically presents with systemic sy
mptoms and may affect various organs, including the lungs.
Option D - Hepatitis B: Hepatitis B and C infections are not typically considered opportunistic infections
 in the context of kidney transplantation. They are more commonly associated with chronic liver diseas
e and may require specific antiviral therapies.
Correct Option C - 3/6:
 Both A-2,29 are matching in both donor and recipient
 Only B-44 is matching in both and mismatch between donor and recipient regarding DR
  
Option A, B & D: Refer to the above explanation 
 
Correct Option A - CKD - EPI - Cystatin C Formula:
Incorrect Options - B, C, D
 
Correct Option B - A2:
Incorrect Options - A, C, D
 
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Page 8
Correct Option D - Calci■cation of blood vessels:
 As kidney function declines from CKD stage G2 to G3, there is a disruption in calcium and phosphate
homeostasis, leading to an increase in serum phosphate levels. Elevated phosphate levels contribute
to the formation of calcium-phosphate complexes, which can deposit in blood vessels and other soft
tissues, causing vascular calcification. This process is associated with an increased risk of
cardiovascular morbidity and mortality in patients with CKD.
 
Option A - Decreased levels of parathyroid hormone (PTH): In response to declining kidney function, th
ere is often an increase in PTH levels due to impaired phosphate excretion and decreased activation of
 vitamin D. Elevated PTH levels contribute to bone resorption and release of calcium from bone.
Option B - Increased bone formation: In CKD, there is typically an imbalance in bone metabolism chara
cterized by increased bone resorption due to elevated PTH levels and decreased bone formation. This 
imbalance can lead to bone loss and an increased risk of fractures.
Option C - Decreased risk of cardiovascular morbidity: CKD is associated with an increased risk of car
diovascular disease, including hypertension, coronary artery disease, and heart failure. As kidney funct
ion declines, the risk of cardiovascular morbidity typically increases due to factors such as vascular cal
cification, and volume overload, and dysregulation of mineral metabolism. Therefore, a
decline in kidney function would not decrease the risk of cardiovascular morbidity.
Correct Option A - Accumulation of beta-amyloid in the brain:
 Dialysis dementia, a condition primarily seen in patients undergoing recurrent hemodialysis, is
attributed to the accumulation of beta2-microglobulin, a protein normally cleared by healthy kidneys.
Beta2-microglobulin aggregates in the brain, forming insoluble beta-amyloid fibrils, similar to those
observed in Alzheimer's disease. This accumulation leads to neurotoxicity and cognitive decline.
 
Option B - Deposition of tau protein aggregates in the brain: This mechanism is associated with neurod
egenerative diseases like Alzheimer's disease and some forms of dementia, but not specifically with di
alysis dementia.
Option C - Increased levels of glutamate: Glutamate-mediated excitotoxicity is involved in various neur
odegenerative conditions but is not the primary mechanism underlying dialysis dementia.
Option D - Oxidative stress-induced neuronal damage: While oxidative stress can contribute to neuron
al damage in various conditions, it is not the primary cause of dialysis dementia.
Correct Option B - EBV (Ebstein Barr Virus):
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Page 9
 Post-transplantation lymphoma is most commonly associated with the Epstein-Barr virus (EBV)
infection. EBV is known to cause lymphoproliferative disorders in immunocompromised individuals,
such as those who have undergone solid organ transplantation. EBV-induced lymphomas can affect
various organs, including the skin, and may manifest as skin lesions in transplant recipients.
 
Option A - CMV (Cytomegalovirus): While cytomegalovirus (CMV) infection is also common in transpla
nt recipients and can lead to various complications, including tissue invasive disease, it is not typically 
associated with post-transplantation lymphoma.
Option C - HSV (Herpes Simplex Virus): Herpes simplex virus (HSV) infection can cause skin lesions, 
particularly in immunocompromised individuals. However, it is not a
common cause of post-transplantation lymphoma.
Option D - HIV (Human Immunodeficiency Virus): HIV infection is associated with an increased risk of 
various malignancies, including lymphoma. However, in the context of kidney transplantation, where th
e patient is likely to be immunosuppressed, HIV infection would not be the cause of post-transplantatio
n lymphoma.
423

Renal Tubular Acidosis and Renal Artery Stenosis
1. Which of the following is not the cause of Renal Tubular Acidosis Type 4 ?
B. AIDS-HIV nephropathy
C. Chronic tubulointerstitial disease
D. Scleroderma
2. Which of the following is not true regarding Renal tubular acidosis?
A. All Increased bicarbonates,glucose and amino acids in urine is found in RTA type 2
B. Urine anion gap is positive in all RTA
C. Nephrocalcinosis is seen in Type 4 RTA
D. Sodium bicarbonate is used as a treatment in all types of RTA
3. A 50-year-old patient with a history of scleroderma and recurrent kidney stones, complaints of
muscle weakness and metabolic acidosis prompted further evaluation. Lab results reveal hypokalemia
and nephrocalcinosis. Which type of renal tubular acidosis is this patient manifesting?
(or)
Which type of RTA is caused by scleroderma?
A. TYPE 1
B. TYPE 2
C. TYPE 3
D. TYPE 4
4. A 55-year-old male with a history of poorly controlled diabetes mellitus presents to the emergency
department with weakness, palpitations, and muscle cramps. Laboratory tests reveal hyperkalemia and
metabolic acidosis. Further investigation confirms the diagnosis of Type IV Renal Tubular Acidosis
(RTA 4). Which of the following treatment options would be most appropriate to manage the underlying
electrolyte abnormalities in this patient?
(or)
Which of the following treatment options would be most appropriate to manage hyperkalemia and
metabolic acidosis in Type IV Renal Tubular Acidosis?
B. Dietary potassium restriction
C. Furosemide
D. Sodium bicarbonate supplementation
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Page 2
5. A 42-year-old female patient presents to the nephrology clinic with complaints of fatigue, muscle
weakness, and occasional palpitations. She has a history of poorly controlled hypertension despite
being on medications. An ultrasound examination of the kidneys reveals asymmetric kidneys, with one
kidney appearing smaller in size while the contralateral kidney appears enlarged.Which of the following
is the most common cause contributing to the patient's symptoms?
(or)
Which of the following is the most common cause contributing to renal artery stenosis?
A. Atherosclerosis
B. Fibromuscular dysplasia (FMD)
C. Takayasu arteritis
D. Polyarteritis nodosa
6. A 55-year-old Afro-American male presents to the emergency department with severe headaches,
confusion, and visual disturbances. On examination, his blood pressure is significantly elevated.
Fundus examination reveals retinal hemorrhages, and laboratory investigations show evidence of
microangiopathic hemolytic anemia on peripheral smear. Based on these findings, which of the
following conditions is most likely responsible for the patient's presentation?
(or)
Severe hypertension, retinal hemorrhages, encephalopathy, deranged kidney function, and
microangiopathic hemolytic anemia are seen in?
C. Malignant hypertension
D. Polycystic kidney disease
Correct Option D - Scleroderma:
 Scleroderma causes renal tubular acidosis type 1 and results in Hypokalemia
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Option B - Type 2 RTA: This type of RTA involves impaired bicarbonate reabsorption in the proximal tu
bule and is not associated with hypokalemia.
Option C - Type 3 RTA: This type is a combination of Type 1 and Type 2
RTA and is not typically associated with scleroderma or nephrocalcinosis.
Option D - Type 4 RTA: This type is characterized by impaired aldosterone production or activity, result
ing in hyperkalemia rather than hypokalemia. It is not associated with scleroderma or nephrocalcinosis.
Correct Option A - Fludrocortisone:
 Fludrocortisone, a synthetic mineralocorticoid, is a suitable treatment option for Type IV RTA as it
helps to increase renal tubular absorption of sodium and water, while promoting the excretion of
potassium and hydrogen ions. This addresses the underlying aldosterone deficiency or resistance in
the distal tubule, thereby improving electrolyte balance.
 
Option B - Dietary potassium restriction: Dietary potassium restriction may help manage hyperkalemia t
o some extent, but it does not address the underlying cause of aldosterone deficiency or resistance.
Option C - Furosemide: Furosemide, a
loop diuretic, induces kaliuresis and may exacerbate potassium imbalance in patients with RTA 4.
Option D - Sodium bicarbonate supplementation: Sodium bicarbonate supplementation may correct me
tabolic acidosis, but it does not address the hyperkalemia associated with Type IV RTA.
Correct Option A - Atherosclerosis:
 Atherosclerosis, particularly atherosclerotic renal artery stenosis, is the most common cause of renal
artery stenosis . It is often associated with poorly controlled hypertension and can lead to electrolyte
imbalances such as hyperkalemia and metabolic acidosis.
 
Option B - Fibromuscular dysplasia (FMD): Fibromuscular dysplasia (FMD) can also cause renal artery
 stenosis but is more commonly associated with young females and may present with similar symptom
s. However, it is less common than atherosclerosis.
Option C - Takayasu arteritis: Takayasu arteritis is another cause of renal artery stenosis but is relativel
y rare and predominantly affects Asian populations.
Option D - Polyarteritis nodosa: Polyarteritis nodosa is not a
cause of renal artery stenosis and is unrelated to Type IV Renal Tubular Acidosis (RTA 4).
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Page 5
Correct Option C - Malignant hypertension:
 The patient's symptoms, including severe hypertension, retinal hemorrhages, encephalopathy,
deranged kidney function, and microangiopathic hemolytic anemia, are consistent with malignant
hypertension.
 This condition is characterized by a rapid rise in blood pressure, leading to end-organ damage,
particularly affecting the kidneys and brain.
 Malignant hypertension is more common in Afro-American individuals and has a high mortality rate if
left untreated.
 
Option A - Diabetic nephropathy: Diabetic nephropathy typically presents with gradual onset kidney dys
function in patients with diabetes mellitus.
Option B - Chronic glomerulonephritis: Chronic glomerulonephritis may present with renal dysfunction 
but is less commonly associated with the rapid onset of severe hypertension seen in malignant hyperte
nsion.
Option D - Polycystic kidney disease: Polycystic kidney disease is characterized by the presence of mu
ltiple cysts in the kidneys and is not typically associated with the acute symptoms described in maligna
nt hypertension.
428

Nephritic Syndrome & Nephrotic Syndrome
1. Which of the following is not a part of the diagnostic criteria for nephrotic syndrome?
A. Urine protein more than 2g of protein/ gram of urinary creatinine
B. Serum Albumin less than 2.5 gm%
C. Accelerated atherosclerosis
D. Oedema
2. A 40-year-old male who is a known case of HIV came to the outpatient department with complaints
of headache and frothysurinae. General examination showed that he was pale, had pedal edema and a
blood pressure of 140/100 mm Hg. Lab investigations showed more than 3RBC/HPF and a deranged
GFR.USG guided kidney biopsy showed segmental obliteration of glomerulus on light microscopy and
effaced podocytes accompanied by its vacuolization and detachment on electron microscopy. Identify
the type of Nephrotic syndrome and mark the right option?
A. Focal segmental glomerulonephrosis
B. Membranous Glomerulopathy
C. Minimal Change Disease
D. Finnish type of nephritic syndrome
3. A 65 year old male came to the outpatient department with a complaint of foamy urine. Examination
showed puffy eyes, pedal edema and increased blood pressure. Further lab tests showed fat bodies in
urine, Urine protein > 2g/gm of Urinary creatinine and Urinary protein electrophoresis reveals albumin.
Identify the diagnosis and mark the option with appropriate kidney biopsy changes on electron
microscopy?
(or)
Which of the following kidney biopsy changes seen on electron microscopy are associated with
membranous glomerulonephropathy?
A. Effaced podocytes
B. Subepithelial deposits and spikes
C. Podocyte vacuolization
D. Effaced podocytes
4. A 10-year-old boy presented to the outpatient department with a complaint of puffy eyes, swelling in
the scrotal area, and abnormal weight gain in the past 10 days. Investigations showed normal
BUN/creatinine and increased 24-hour urine protein. Kidney biopsy revealed a normal light microscopy
and podocyte effacement on electron microscopy. Identify the disease and its management.
(or)
Which of the following is the treatment option for minimal change disease?
A. Steroids
B. ARB
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D. Sodium Nitroprusside
5. A 20-year-old male patient came to the hospital with complaints of extreme headache and dark
brown colored urine for the past 10 days. The patient has a history of antibiotic therapy for his sore
throat three weeks back. A kidney biopsy showed a starry sky appearance in an immunofluorescence
study. Which of the following is the diagnosis of this condition?
(or)
A kidney biopsy showed a starry sky appearance in an immunofluorescence study is seen in?
A. PSGN
B. Bergers disease
C. IgA nephropathy
D. FSGS
6. All of the following are findings of Bergers IgA nephropathy except?
A. Renal function tests are Normal
B. BP is normal
C. C3 is normal
D. 3 weeks history of sore throat
7. Which of the following statements is correct about the definition of steroid dependent nephrotic
syndrome?
A. Two consecutive relapses when on alternate day steroid therapy
B. Two or more relapses in the initial 6-month period
C. More than 3 relapses in any 12 months
D. Two consecutive relapses within 3 weeks of its discontinuation.
8. A 45-year-old male with a history of diabetes mellitus presents to the clinic with complaints of
progressively worsening swelling in his legs and face over the past few weeks. On examination, you
note pitting edema and facial puffiness. Laboratory investigations reveal significant proteinuria on urine
dipstick testing. Further evaluation shows elevated serum lipid levels. Which of the following additional
findings is most likely to be present in this patient, given his clinical presentation?
(or)
Which of the following additional findings is most likely to be present in nephrotic syndrome.?
A. Increased serum antithrombin III levels
B. Presence of oval fat bodies in urine sediment
C. Elevated serum ferritin levels
D. Decreased ceruloplasmin levels in urine
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9. A 65-year-old female patient with a known history of diabetes and hypertension presents to the
nephrology clinic with complaints of swelling in her legs and foamy urine over the past few weeks.
Further evaluation reveals proteinuria with a 3.5 g/g urinary protein-to-creatinine ratio. Anti-PLA
Antibody is positive. Which complications are most concerning for this patient based on her diagnosis?
(or)
Which of the following is the the complication associated with Membranous glomerulonephritis ?
A. Acute kidney injury
B. Renal vein thrombosis
C. Nephrotic syndrome
D. Urinary tract infection
10. A 6-year-old boy with a history of nephrotic syndrome presents to the pediatric clinic for a follow-up
visit. His parents report that he has been doing well for the past few months with no signs of proteinuria
or edema. However, during today's visit, his urine dipstick test shows 3+ proteinuria. Upon further
investigation, it is found that this proteinuria has been present for the past three consecutive early
morning specimens. What term best describes the current status of the patient's nephrotic syndrome?
(or)
Which of the following is characterized by the recurrence of proteinuria (3+ or 4+) or significant
proteinuria (>40 mg/m2/h) for three consecutive early morning specimens?
A. Remission
B. Relapse
C. Frequent relapses
D. Steroid dependence
11. A 3-month-old male infant presents to the pediatric clinic with generalized swelling and foamy urine
noticed by his parents over the past week. On examination, the infant appears edematous, with marked
ascites and facial puffiness. Given the suspicion of congenital nephrotic syndrome, which of the
following laboratory tests would be most appropriate to confirm the diagnosis?
(or)
Given the suspicion of congenital nephrotic syndrome, which of the following laboratory tests would be
most appropriate to confirm the diagnosis?
A. Serum creatinine level
B. BUN
C. 24-hour urinary protein measurement
D. Serum electrolyte panel
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Correct Option C - Accelerated atherosclerosis:
 Accelerated atherosclerosis is not a part of diagnostic criteria for nephrotic syndrome.
Option A, B, D are incorrect options
Correct Option A - Focal segmental glomerulonephrosis:
 The age , pedal edema ,hypertension and headache are some of the clues for diagnosis of FSGS.
 HIV is one of the cause for FSGS
 Electron microscopic studies showing segmental obliteration of glomerulus on light microscopy and
effaced podocytes accompanied by its vacuolization and detachment on electron microscopy are
characteristic of FSGS.
All the options can be eliminated by using age as a reference
Option B - Membranous Glomerulopathy: This is seen in the age group of 60 years
Option C - Minimal Change Disease: This is seen in children
Option D - Finnish type of nephritic syndrome: This is a congenital nephrotic syndrome
 
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Options A, B and C are features of Bergers nephropathy(IgA nephropathy)
Correct Option A - Two consecutive relapses when on alternate day steroid therapy:
 Steroid dependent nephrotic syndrome is characterized by Two consecutive relapses when on
alternate day steroid therapy or within 14 days of its discontinuation.
Option B - Two or more relapses in the initial 6-month period
Option C - More than 3 relapses in any 12 months
B and C are both features of frequent relapse
Correct Option B - Presence of oval fat bodies in urine sediment:
 The patient's clinical presentation, including swelling (edema) in the legs and face, significant
proteinuria, and elevated serum lipid levels, suggests nephrotic syndrome. Oval fat bodies are
lipid-laden cells that can be observed in the urine sediment of patients with nephrotic syndrome due to
increased lipid excretion. These oval fat bodies have a characteristic appearance under the
microscope, resembling Maltese crosses, and their presence is indicative of lipiduria, a hallmark feature
of nephrotic syndrome.
 
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Option A - Increased serum antithrombin III levels: Antithrombin III levels may be decreased in nephroti
c syndrome due to urinary loss, leading to a hypercoagulable state.
Option C - Elevated serum ferritin levels: Serum ferritin levels may be increased in conditions of inflam
mation or iron overload, but it is not typically associated with nephrotic syndrome.
Option D - Decreased ceruloplasmin levels in urine: Ceruloplasmin is not typically measured in urine, a
nd its levels are not directly associated with nephrotic syndrome.
Correct Option B - Renal vein thrombosis:
 Membranous glomerulonephritis (MGN) is a glomerular disease characterized by the thickening of the
glomerular basement membrane, leading to proteinuria. One of the most important complications
associated with MGN is renal vein thrombosis
 The thickening of the glomerular basement membrane can disrupt normal blood flow within the
kidney, predisposing patients to the formation of blood clots in the renal veins.
 Renal vein thrombosis can lead to further impairment of kidney function and may require aggressive
management to prevent complications such as pulmonary embolism or renal infarction.
 
Option A - Acute kidney injury: While acute kidney injury can occur in patients with MGN, it is not the m
ost concerning complication associated with this condition.
Option C - Nephrotic syndrome: MGN itself is a cause of nephrotic syndrome due to significant protein
uria, but the development of renal vein thrombosis is a more serious complication.
Option D - Urinary tract infection: While urinary tract infections can occur in patients with kidney diseas
e, they are not typically considered the most concerning complication of MGN.
Correct Option B - Relapse:
 The patient's current status best fits the definition of a relapse in nephrotic syndrome. A relapse is
characterized by the recurrence of proteinuria (3+ or 4+) or significant proteinuria (>40 mg/m2/h) for
three consecutive early morning specimens, after having been in remission previously. Since the
patient had been doing well with no signs of proteinuria or edema for the past few months but now
presents with 3+ proteinuria on consecutive tests, this indicates a relapse of nephrotic syndrome.
 
Option A - Remission: Remission refers to the absence of proteinuria or significant reduction in protein
uria (nil or trace) for three consecutive early morning specimens. Since the patient is experiencing prot
einuria again, he is not in remission.
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Option C - Frequent relapses: Frequent relapses are defined as two or more relapses in the initial 6-mo
nth period or more than three relapses in any 12 months. The patient's history does not suggest freque
nt relapses.
Option D - Steroid dependence: Steroid dependence occurs when a patient experiences two consecuti
ve relapses when on alternate-day steroid therapy or within 14 days of its discontinuation. This scenari
o does not match the patient's current situation.
Correct Option C - 24-hour urinary protein measurement:
 Congenital nephrotic syndrome (Finnish variety) typically presents with significant proteinuria, leading
to foamy urine and generalized edema.
 To confirm the diagnosis, the most appropriate laboratory test is the measurement of urinary protein
excretion over a 24-hour period.
 This test allows for the quantification of proteinuria, which is a hallmark feature of nephrotic syndrome.
In this condition, the urinary protein excretion is markedly elevated, typically exceeding 40 mg/m^2
body surface area per hour.
 
Option A - Serum creatinine level: While serum creatinine may be elevated in some cases of nephrotic 
syndrome due to impaired renal function, it is not the primary diagnostic test for confirming the conditio
n.
Option B - BUN: Blood urea nitrogen (BUN) is another marker of kidney function, but like serum creatin
ine, it is not specific for diagnosing nephrotic syndrome. Elevated BUN levels may indicate impaired kid
ney function, but they do not directly assess the degree of proteinuria.
Option D - Serum electrolyte panel: While electrolyte abnormalities such as hypoalbuminemia and hyp
erlipidemia are common in nephrotic syndrome, they are not specific for diagnosis and are typically ass
essed as part of the overall management of the condition.
437

Diabetic Nephropathy, Kidney Stone and Acute Renal
Failure
1. Which of the following drugs leads to Non-oliguric Renal AKI?
A. Amphotericin B
B. Cysplatin
C. Gentamycin
2. Which of the following parameters needs to be monitored in a patient suspected to have contrast
induced nephropathy?
A. BUN
B. Urine output
C. Sr. Creatinine
D. Blood urea and Uric acid
3. Which of the following is the first investigation to be done in a patient with suspected Renal vein
thrombosis?
A. Doppler
B. X-ray
C. CT angiography
D. MRI
4. Using the two images below, Identify the type of AKI ?
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A. CKD
B. Prenal AKI
C. Post renal AKI
D. Renal AKI
5. A 35-year-old male patient came to the outpatient department with complaints of breathing difficulty,
severe vomiting, and hiccup for the past two days. He experiences retrosternal chest pain, especially at
night, and reduced urine frequency. The patient is a known case of hypertension. Clinical examination
revealed asterixis, loss of memory, confusion, and puffy eyes. The patient’s blood pressure is
190/120mmHg. Lab investigations show increased Sr.creatinine, increased BUN, Na+ of 130mEq, and
an ECG is shown below. Identify the condition and mark the option which is not an indication for its
treatment.
A. Correction of severe acidosis refractory to Medical Therapy
B. Hypertension refractory to medical therapy.
C. Severe Azotemia (BUN >100mg)
D. Volume expansion that cannot be managed with diuretics
6. A 65-year-old patient with a history of diabetes and hypertension presents to the emergency
department with complaints of decreased urine output and swelling in his legs for the past two days. On
examination, his serum creatinine level is found to be 2.5 mg/dL .Further assessment reveals that his
urine output has been consistently below 0.5 ml/kg/hour over the past 12 hours. Which of the following
stage is the patient suffering from?
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(or)
Which of the following stages of AKI presents with a serum creatinine: 2.5 mg/dL and urine output
below 0.5 ml/kg/hour over the past 12 hours
A. Stage I AKI
B. Stage II AKI
C. Stage III AKI
D. Stage IV AKI
7. A 60-year-old patient with a history of congestive heart failure presents to the emergency department
with complaints of decreased urine output and generalized swelling for the past two days. Laboratory
investigations reveal elevated serum creatinine and BUN levels. Which of the following conditions is
least likely contributing to the development of pre-renal AKI in this patient?
(or)
Which of the following conditions is least likely contributing to the development of pre-renal AKI?
A. Congestive heart failure
B. Hepatorenal syndrome
C. Cyclosporine use
D. Tacrolimus use
8. A 55-year-old male with a history of type 2 diabetes mellitus presents to his primary care physician
for a routine check-up. During the examination, the physician orders a spot urine sample to screen for
diabetic nephropathy. Which of the following laboratory tests would be most appropriate for assessing
renal function in this patient?
(or)
Which of the following laboratory tests would be most appropriate for assessing renal function in
diabetic nephropathy?
B. Blood urea nitrogen (BUN)
C. Urinary albumin creatinine ratio (UACR)
D. Urinary specific gravity
9. A 60-year-old male with a long-standing history of poorly controlled type 2 diabetes mellitus presents
to the nephrology clinic with worsening kidney function. His serum creatinine levels have been
gradually increasing over the past year. What histopathological finding is most characteristic in this
patient associated with the development of nodular glomerulosclerosis?
(or)
What histopathological finding is most characteristic of diabetic nephropathy and is associated with the
development of nodular glomerulosclerosis?
A. Diffuse glomerular sclerosis
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B. Armani-Ebstein change
C. Kimmelstiel-Wilson change
D. Damage to distal convoluted tubules (DCT)
10. A 65-year-old male patient with type 2 diabetes mellitus presents for a routine follow-up
appointment. His medical history is significant for chronic kidney disease (CKD), with an estimated
glomerular filtration rate (eGFR) of 25 mL/min/1.73m². He is currently taking metformin and glipizide for
glycemic control.Which of the following actions should be advised to this patient?
(or)
Which of the following is the best management for a diabetic nephropathy patient with an estimated
glomerular filtration rate (eGFR) of 25 mL/min/1.73m² and currently on metformin and glipizide for
glycemic control?
A. Continue metformin and glipizide at current doses
B. Discontinue metformin due to reduced kidney function
C. Discontinue glipizide due to reduced kidney function
D. Initiate linagliptin for better glycemic control
11. A 60-year-old patient with a history of hypertension and chronic kidney disease presents to the
clinic for a follow-up visit. Despite being on ACE inhibitor therapy for blood pressure management, the
patient's recent lab results show elevated potassium levels. What would be the most appropriate next
step in managing this patient's hypertension, considering the provided information?
(or)
What would be the most appropriate next step in managing this patient's hypertension if serum
potassium levels are high?
A. Increase the dose of ACE inhibitor
B. Switch to a different ACE inhibitor
C. Discontinue ACE inhibitor and initiate a calcium channel blocker
D. Add a thiazide diuretic to the ACE inhibitor therapy
12. 40-year-old male patient with a history of recurrent kidney stones, gross elevations in 24-hour urine
calcium levels, and the presence of envelope-shaped crystals in his recent urine analysis.What
treatment options should be considered for this patient?
A. Thiazides
B. Normal calcium diet
C. Sodium reduction in diet
13. A 40-year-old woman presents to the urology clinic with complaints of recurrent episodes of flank
pain and difficulty passing urine. Upon further inquiry, she mentions a history of hyperparathyroidism
diagnosed five years ago. Urinalysis reveals the presence of rosette-shaped crystals on microscopy.
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What is the most likely cause of the patient's current symptoms?
(or)
Rosette-shaped crystals on microscopy is a feature of?
A. Uric acid stones
B. Calcium phosphate stones
C. Struvite stones
D. Cystine stones
14. A 45-year-old female patient presents to the urology clinic with complaints of recurrent urinary tract
infections and flank pain. Upon further investigation, her urine microscopy reveals the presence of
coffin-lid-shaped crystals. urinary tract infections in this patient are caused by?
(or)
Urinary tract infections in a patient with triple phosphate stones is caused by?
A. Escherichia coli
B. Klebsiella pneumoniae
C. Enterococcus faecalis
D. Proteus mirabilis
15. A 55-year-old male patient presents to the emergency department with severe flank pain and
hematuria. A CT scan reveals the presence of kidney stones. Upon further analysis, the stones are
found to be soft and yellowish in color. What type of kidney stones is most likely responsible for the
formation of these stones?
(or)
What type of kidney stones is most likely found to be soft and yellowish in color?
A. Urate stones
B. Calcium stones
C. Cystine stones
D. Struvite stones:
16. A 40-year-old male patient presents to the urology clinic with a history of recurrent kidney stone
formation. His previous stone analysis revealed Cystine Stones. What medication would be most
appropriate to prevent the recurrence of kidney stones in this patient?
(or)
What medication would be most appropriate to prevent the recurrence of Cystine Stones?
A. Tiopronin
B. Probenecid
C. Allopurinol
D. D-penicillamine
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Correct Option C - Gentamycin:
 Aminoglycosides like gentamycin and Amikacin lead to non-oliguric Renal AKI
 Urine output > 400 ml/ day
 Aminoglycoside → Affects collecting duct, V2 Receptors impaired and reabsorption of water is
impaired
Option D - Cyclosporine: This drug leads to Pre-Renal AKI
Option A & B - (Amphotericin B & Cysplatin): Are exogenous nephrotoxins leading to renal AKI
 
Correct Option C - Sr. Creatinine:
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Page 8
 The first image shows:
Option A, B & C: Refer to the above explanation
Correct Option B- Hypertension refractory to medical therapy:
The likely diagnosis in this patient is AKI Diagnosis is AKI
The question describes shows vomiting, hiccups, Low urine output, signs of encephalopathy(loss of me
mory, confusion, and asterixis), and chest pain which are signs of Uremic encephalopathy and uremic 
pericarditis in AKI.
 The ECG shows tall tented T waves- hyperkalemia and the sodium of 130mEq
-Hyponatremia(Hypervolemic).
 The hypertension is in response to raised renin due to low GFR.
 The treatment for uremic manifestations is renal replacement therapy(Hemodialysis)Hemodialysis and
Hypertension refractory to medical therapy is not an indication for dialysis.
Option A- Correction of severe acidosis refractory to Medical Therapy
Option C- Severe Azotemia (BUN >100mg):
Option D- Volume expansion that cannot be managed with diuretics:
The above options are indications for hemodialysis.
Correct Option B - Stage II AKI:
 Stage II AKI is characterized by a serum creatinine level of 2.0 - 2.9 times normal and urine output
below 0.5 ml/kg/hour over a duration of 12 hours.
 In this case, the patient's serum creatinine level is 2.5 mg/dL, which falls within the range for Stage II
AKI.
 Additionally, the patient's decreased urine output below 0.5 ml/kg/hour over the past 12 hours further
supports the diagnosis of Stage II AKI.
 
Option A - Stage I AKI: The patient's serum creatinine level exceeds the upper limit for Stage I AKI.
Option C
- Stage III AKI: The patient's serum creatinine level does not meet the criteria for Stage III AKI.
Option D - Stage IV AKI: There are only 3 stages of AKI
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 Screening for diabetic nephropathy typically involves assessing urinary albumin excretion. The urinary
albumin creatinine ratio (UACR) obtained from a spot urine sample is a reliable measure for detecting
early signs of renal damage in diabetic patients.
 
Option A - Serum creatinine level: While serum creatinine is a common marker for renal function, it ma
y not be sensitive enough to detect early stages of diabetic nephropathy.
Option B - Blood urea nitrogen (BUN): BUN levels may be influenced by factors other than renal functio
n, and they are not specific for diabetic nephropathy screening.
Option D - Urinary specific gravity: Urinary specific gravity is a
measure of urine concentration and is not typically used for screening diabetic nephropathy.
Correct Option C - Kimmelstiel-Wilson change:
 Kimmelstiel-Wilson change, also known as nodular glomerulosclerosis, is a characteristic
histopathological finding of diabetic nephropathy. It presents as nodular deposits of mesangial matrix
within glomeruli, which are pathognomonic for diabetic kidney disease.
 
Option A - Diffuse glomerular sclerosis: While diffuse glomerular sclerosis is commonly seen in diabetic
 nephropathy, it is not specifically associated with the development of nodular glomerulosclerosis.
Option B - Armani-Ebstein change: Armani-Ebstein change refers to glycogen accumulation in the prox
imal convoluted tubules (PCT) and is not directly related to nodular glomerulosclerosis.
Option D - Damage to distal convoluted tubules (DCT): Damage to the distal convoluted tubules may le
ad to electrolyte disturbances, but it is not a
characteristic histopathological feature of diabetic nephropathy.
Correct Option B - Discontinue metformin due to reduced kidney function:
 Metformin is contraindicated in patients with an eGFR less than 30 mL/min/1.73m² due to the risk of
lactic acidosis. Therefore, it should be discontinued in this patient given his eGFR of 25 mL/min/1.73m².
Glipizide, on the other hand, can be safely used in patients with kidney disease as it is primarily
metabolized by the liver and does not require renal excretion.
 
Option A - Continue metformin and glipizide at current doses: Continuing metformin at the current dose
 would not be appropriate due to the patient's reduced kidney function.
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Option C - Discontinue glipizide due to reduced kidney function: Glipizide can be safely used in patient
s with kidney disease and does not require dosage adjustments.
Option D - Initiate linagliptin for better glycemic control: While linagliptin is a viable option for glycemic c
ontrol in patients with CKD, the priority in this case is to address the contraindicated medication (metfor
min) rather than initiating a new one.
Correct Option C - Discontinue ACE inhibitor and initiate a calcium channel blocker:
 ACE inhibitors (ACEIs) can lead to hyperkalemia, especially in patients with chronic kidney disease,
due to their effect on reducing aldosterone secretion and impairing potassium excretion.
 Since the patient is already experiencing elevated potassium levels, discontinuing the ACE inhibitor
would help prevent further exacerbation of hyperkalemia.
 Initiation of a calcium channel blocker (CCB) can provide effective blood pressure control without the
risk of worsening hyperkalemia.
 
Option A - Increase the dose of ACE inhibitor: Increasing the dose of ACE inhibitor would likely exacer
bate hyperkalemia.
Option B - Switch to a different ACE inhibitor: Switching to a different ACE inhibitor may not significantl
y alter the risk of hyperkalemia, as ACE inhibitors have similar mechanisms of action.
Option D - Add ARB : Side effect of ACEIs/ARBs: Hyperkalemia, often due to Type IV Renal Tubular A
cidosis (RTA).
Correct Option A - Thiazides:
 The most common cause of Calcium Oxalate Stones is Idiopathic Hypercalciuria. resulting from
defective handling of calcium by kidney tubules.
  Urine microscopy shows Envelope-shaped crystals.
 Thiazides are considered effective in preventing the recurrence of kidney stones, especially in
patients with hypercalciuria, as they reduce calcium excretion in the renal tubules. .
 
Option B - Normal calcium diet: While maintaining a normal calcium intake is important, it is not specific
 treatment for preventing recurrence of kidney stones in patients with hypercalciuria. In fact, reducing c
alcium intake excessively can lead to increased risk of kidney stone formation.
Option C - Sodium reduction in diet: Sodium reduction in the diet can help prevent certain types of kidn
ey stones, particularly those composed of sodium salts. However, it is not specifically indicated for pati
ents with hypercalciuria and envelope-shaped crystals in urine analysis.
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Option D - Furosemide: Furosemide, a loop diuretic, is contraindicated in patients with hypercalciuria a
s it increases urinary calcium excretion, potentially exacerbating the risk of kidney stone formation. The
refore, it is not an appropriate treatment option for preventing recurrence of kidney stones in this patien
t population.
Correct Option B - Calcium phosphate stones:
 The patient's history of hyperparathyroidism and chronic gastrointestinal issues suggests a potential
disturbance in calcium and phosphate metabolism, leading to the formation of calcium phosphate
stones. Hyperparathyroidism can cause hypercalcemia, which increases the risk of calcium phosphate
stone formation. Additionally, chronic use of antacids can lead to alkaline urine pH, further promoting
calcium phosphate stone formation. The presence of rosette-shaped crystals on urinalysis is
characteristic of calcium phosphate stones.
 
Option A - Uric acid stones: These are typically associated with conditions such as gout and are not co
mmonly seen in patients with hyperparathyroidism.
Option C - Struvite stones: These are associated with urinary tract infections and are typically compose
d of magnesium ammonium phosphate. The patient's clinical history does not suggest a
urinary tract infection.
Option D - Cystine stones: These are rare and typically seen in patients with cystinuria, a genetic disor
der characterized by defective renal tubular reabsorption of cystine. The patient's clinical history does n
ot suggest cystinuria.
Correct Option D - Proteus mirabilis:
 
 Triple phosphate stones are composed of MgNH4PO4.
 These three components crystallize to form a stone in an alkaline pH environment.
 They typically take the shape of the kidney and are often referred to as Struvite stones or Staghorn
Calculi.
 Proteus mirabilis converts urea to ammonia, contributing to the urine's alkaline pH and facilitating the
stone components' crystallization.
 Examining urine under the microscope may reveal crystals with a characteristic coffin lid appearance.
 These stones are commonly associated with urinary tract infections (UTIs) caused by
urease-producing bacteria, such as Proteus mirabilis.
 Therefore, the urinary tract infections in this patient are likely caused by Proteus mirabilis.
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Option A, B, and C are incorrect
Calculi.
  Examining urine under the microscope may reveal crystals with a characteristic coffin lid appearance.
Correct Option A - Urate stones:
 Urate stones are composed of uric acid, and they tend to be soft and yellowish in color. They are
commonly associated with conditions such as gout, where there are high levels of uric acid in the urine.
Urate stones form when there is an excess of uric acid in the urine, leading to the crystallization and
formation of stones within the kidney.
 
Option B - Calcium stones: These are the most common type of kidney stones and are typically hard a
nd whitish in color.
Option C - Cystine stones: These stones are composed of the amino acid cystine and are known for be
ing hard and yellowish-brown.
Option D - Struvite stones: These stones are composed of magnesium ammonium phosphate and are t
ypically large, staghorn-shaped stones associated with urinary tract infections. They are not typically d
escribed as soft or yellowish in color.
Correct Option A - Tiopronin:
 Cystine stones are composed of cystine, an amino acid. Tiopronin is a medication used to prevent the
formation of cystine stones by binding to cystine in the urine and forming a soluble compound that can
be excreted. Additionally, urine alkalinization helps to increase the solubility of cystine in the urine,
further reducing the risk of stone formation.
 
Option B
- Allopurinol: Allopurinol is used to prevent the formation of uric acid stones, not cystine stones.
Option C - Probenecid: Probenecid is used to increase uric acid excretion in under excretors with chron
ic gout, but it is not effective for preventing cystine stone formation.
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Option D - D-penicillamine: D-penicillamine was previously used to prevent cystine stone formation, but
 it has been replaced by Tiopronin due to better efficacy and fewer side effects.
451

1. A woman presents to you with fever, arthralgia, ulcers, fatigue for the past six months, and
new-onset hematuria. Urine examination reveals RBC casts and proteinuria. What is the likely
A. Acute interstitial nephritis
B. Poststreptococcal glomerulonephritis
C. Lupus nephritis
D. IgA nephropathy
2. What is the probable diagnosis for a male patient taking diuretics who presents with weakness and
an ECG revealing flattened T waves and prominent U waves?
B. Hyperkalaemia
C. Hypomagnesemia
D. Hypernatremia
3. Which of the following is the most probable diagnosis for a male patient who arrives at the
emergency department with the following arterial blood gas report: pH of 7.2, pCO2 of 81 mmHg, and
HCO3 of 40 meq/L?
A. Respiratory alkalosis
C. Respiratory acidosis
4. Among the given options, which of the following is the correct course of action after you witnessed a
person collapsing and initiated CPR in a road traffic accident (RTA) scenario, and the rescue team has
now arrived?
A. a.Continue 5 rounds of CPR @ 30:2 followed by application of AED
B. Continue CPR while the team applies AED paddies
C. c.Stop CPR and let them apply paddies
D. d.Handover the patient and leave
5. What is the appropriate treatment for a patient who experienced a sudden seizure episode and
became drowsy at the end of a dialysis session, with hypotension and pre-existing hyperkalemia and
elevated urea levels?
A. Bumetanide
B. Ethacrynic acid
C. Nesiritide
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Page 2
D. IV Mannitol
6. What is the most probable cause of the muteness, quadriplegia, and rigidity observed in an elderly
female patient who had a previous medical history of severe vomiting and was aggressively treated for
severe dehydration at a different hospital one week ago?
A. Malignant hyperthermia
B. Severe catatonia
C. Rapid sodium correction
D. Neuroleptic malignant syndrome
7. What is the likely diagnosis for a patient who complains of pain in the flank region accompanied by
hematuria, and has multiple calcifications (stones) observed in both kidneys on X-ray examination?
A. Parathyroid Adenoma
B. Renal calculi
C. Polycystic kidney disease
D. CKD
8. What acid-base imbalance is most likely to be observed in a middle-aged man with chronic renal
failure on dialysis who experiences sudden collapse in the emergency department and exhibits labored
breathing, as evidenced by tall, tented T waves on the ECG?
A. pH-7.14, pCO2-20 mmHg, HCO3- 5 mEq/L
B. pH-7.14, pCO2-20 mmHg, HCO3- 34 mEq/L
C. pH-7.54, HCO3- 27 mEq/L, pCO2- 34 mmHg
D. pH-7.4, HCO3- 27 mEq/L, pCO2- 40 mmHg
9. In a patient presenting with a seizure, when examining their urine osmolality (1000 mOsm/kg) and
serum osmolality (270 mOsm/kg), what electrolyte abnormality can be anticipated?
A. Hypernatremia
C. Hyperkalaemia
10. Which of the statements below is not true concerning pheochromocytoma?
A. Diagnosed by urine VMA & catecholamines
B. Surgical excision is the definitive treatment
C. Propranolol is given initially to manage hypertension
D. Can present as hypertension alone and sometimes with vomiting and pain abdomen
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11. Which of the options below is commonly linked to pauci-immune glomerulonephritis?
A. SLE nephritis
B. Anti-GBM glomerulonephritis
D. Granulomatosis with polyangiitis (GPA)
12. Which statement regarding syndrome of inappropriate antidiuretic hormone secretion (SIADH) is
incorrect?
A. Urinary sodium <20 mEq/L
B. Serum sodium <135 mEq/L
C. Urine osmolality >100 mOsm/kg
D. Patient can be clinically euvolemic to hypervolemic
13. What are the conditions that are linked to hypertension and hypokalemic metabolic alkalosis?
A. Barter syndrome
B. Liddle syndrome
C. Gitelman syndrome
D. Gordon syndrome
14. Please identify the urinary crystal displayed in the image provided.
A. Calcium oxalate
B. Calcium phosphate
C. Uric acid
D. Cysteine
15. What is the probable cause of the following symptoms in a 30-year-old male - sudden headache,
palpitation, and excessive sweating, with previous similar episodes, high blood pressure during these
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episodes, and elevated levels of 24-hour urinary metanephrine?
A. Fibromuscular dysplasia
16. A 30-year-old woman presents to the OPD with palpitation and weight loss. On examination of her
legs the following lesion was found which on applying pressure, the indentation does not persist on
release. ECG shows sinus rhtyhm. What is the probable cause of the edema?
A. Myxedema
B. Nephrotic syndrome
C. Chronic lymphangitis
D. Dilated cardiomyopathy
17. A hepatitis B positive person came to your opd on routine urine massive proteinuria (> 3.5 g/day),
Further renal biopsy was performed identify the disease?
A. Focal segmental glomerulosclerosis
B. Membranous glomerulonephritis
C. Membranoproliferative glomerulonephritis
D. Minimal change disease
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18. What metabolic abnormality is likely to be observed in a 55-year-old patient who presents with
chronic projectile vomiting and weight loss?
A. Hypokalemic hypochloremic metabolic alkalosis with hyponatremia
B. Hypokalemic hypochloremic metabolic alkalosis with hypernatremia
C. Hypokalemic hypochloremic metabolic alkalosis with hypercalcemia
D. Hypokalemic hypochloremic metabolic acidosis with hyponatremia
19. Which of the following laboratory values is observed in a patient who is experiencing approximately
20 episodes of loose stools per day and a decreased frequency of urination?
A. BUN: Cr >40:1, urine Na <40, FENa <1% urine osmolality >500
B. BUN: Cr >20:1, urine Na <20, FENa <1% urine osmolality >500
C. BUN: Cr >20:1, urine Na <20, FENa <1% urine osmolality >250
D. BUN: Cr >40:1, urine Na <20, FENa <1% urine osmolality >250
20. Which of the following symptoms will be observed in an 8-year-old girl who suddenly develops
fever, reduced urine output, nausea, dark urine, and swollen eyes? The parents also mention that she
had similar facial lesions as shown in the image below, but they are currently improving.
A. Nephrotic range proteinuria
B. RBC’s in urine
C. Derangement of liver enzymes
D. Neurological symptoms
21. Dialysis will prevent all except?
A. Seizures
B. Peripheral neuropathy
C. Metabolic acidosis
D. Uremic pericarditis
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22. Which of the following options represents the most severe manifestation of Chronic Kidney Disease
(CKD)?
A. Decreased GFR
B. Increased creatinine
D. Proteinuria
23. What is the probable diagnosis for a patient who has symptoms of frequent urination, nocturia, and
enuresis, along with a 24-hour urine volume of 7 liters, a urine osmolarity of 260 mOsm/L, an ADH
assay result of 0.8 pg/ml, and a brain MRI showing no bright spot on T1 weighted images?
A. Nephrogenic DI
B. Primary polydipsia
C. Pituitary DI
D. Mannitol infusion
24. The arterial blood gas findings of a patient are pH = 7.12, pCO2 = 50, HCO3 = 28. What is the
A. Respiratory acidosis with metabolic compensation
B. Metabolic acidosis with respiratory compensation
C. Respiratory alkalosis with metabolic compensation
D. Metabolic alkalosis with respiratory compensation
25. What is the probable reason for the quadriparesis developed by a 60-year-old patient after being
treated with a significant amount of hypertonic fluids for 24 hours following a history of hyponatremia?
A. Brain infarct
B. Brainstem injury
C. Central pontine myelinolysis
D. Rare cause of hypernatremia
26. AKIN and RIFLE criteria are used to classify
B. Chronic renal failure
C. Acute glomerulonephritis
27. A patient with chronic kidney disease came with complaints of vomiting and diarrhea. His blood gas
reports show pH = 7.40, HC03- = 23 mEq/L, Na+ = 145 mEq/L, = 100 mEq/L. What is your probable
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(or)
A patient with chronic kidney disease came with complaints of vomiting and diarrhea. His blood gas
A. No acid base abnormality
B. Respiratory acidosis
C. Metabolic alkalosis
D. High anion gap metabolic acidosis with metabolic alkalosis
28. Which of these is a Nephritic syndrome?
A. Minimal change disease
C. Post infectious Glomerulonephritis
D. Focal segmental glomerulosclerosis
29. A 26-year-old female named Rinku Devi, who works as a labourer, arrived with complaints of
abdominal pain, nausea, and restlessness for the past 4 hours. She also mentioned having
experienced two episodes of blood in her urine. An ultrasound scan revealed a 3x3 cm stone in her
right renal pelvis, with no signs of hydronephrosis. What would be the most suitable procedure for
treating this patient?
A. ESWL
B. PCNL
C. Antegrade Pyeloplasty
D. Retrograde pyeloplasty
30. Cut off for diagnosis of Priapism is?
A. 1 hours
B. 2 hours
C. 3 hours
D. 4 hours
31. Which of the following are not included in the components of the MELD (2016) score?
A. Bilirubin
B. Prothrombin time
C. Albumin
D. Creatinine
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32. Calculate the anion gap from the following values: Na+ = 137 mmol/L K+ = 4 mmol/L CI- = 100
mmol/L HCO3- = 15 mmol/L
A. 22 mmol/L
B. 16 mmol/L
C. 10 mmol/L
D. 12 mmol/L
33. AKIN and RIFLE criteria are used classify—
34. In the ICU, a patient experiencing renal failure presents with vomiting. Analysis of arterial blood
gases reveals a pH level of 7.4, sodium (Na+) concentration of 14 mEq/L, chloride (CI-) concentration
of 100 mEq/L, bicarbonate (HCO3-) concentration of 24 mEq/L, and a partial pressure of carbon
dioxide (PaCO2) of 40 mmHg. What metabolic abnormality is most likely occurring?
A. Normal ABG
B. Normal anion gap, metabolic acidosis
C. High anion gap metabolic acidosis with metabolic alkalosis
D. High anion gap metabolic alkalosis with normal metabolic acidosis
35. A 56-year-old man presents to the emergency with severe shortness of breath and fatigue for the
past 3 hours. He reports vomiting and epigastric pain 2 days back, for which he took an anti-emetic. His
past medical history is significant for hypertension and diabetes mellitus type 1. The lab values show
BSL=356mg/dL. The doctor advises immediate ABG analysis, which reveals a pH=7.32,
pCO2=38mEq/L, and HCO3-=15mEq/L. This type of acidosis has increased the anion gap. Which of
the following condition does not belong to the same classification of metabolic acidosis as this patient?
A. Renal failure
B. Lactic acidosis
C. Renal aciduria
D. Aspirin
36. What is the most probable diagnosis for a 5-year-old child who has been experiencing pedal edema
and facial puffiness for the last 5 days, with a blood pressure of 126/80 mm Hg, proteinuria of 3+, and
100 red blood cells per high power field in the urine examination?
A. Post – streptococcal glomerulonephritis
B. Minimal change disease
C. Membranous glomerulonephritis
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37. The patient is having the following hand movements. In which of the following conditions would this
be seen?
A. Thyrotoxicosis
B. Hypercarbia
C. Hemiballismus
D. Hypoxia
38. A 22-year-old patient has a fever with severe shortness of breath and red currant jelly sputum. On
examination, he has altered sensorium with an RR of 40/min. Lab investigations show serum creatinine
of 1.9 mg/dl and BUN with 5 mmol/L (Normal:<7 mmol/L). Which of the following is correct about its
A. OPD management with oral drugs
B. IPD management with IV drugs
C. ICU management with IV drugs
D. ICU management with oral drugs
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Question 19 2
Question 20 2
Question 22 3
Question 23 3
Question 24 1
Question 30 4
Question 31 3
Question 33 1
Question 35 3
Question 36 1
Question 37 2
Question 38 2
 The clinical features of fever, arthralgia, ulcers, fatigue, and hematuria in addition to RBC casts and
proteinuria on urine tests imply a disease of lupus nephritis.
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 Lupus nephritis is a common complication of systemic lupus erythematosus (SLE) and can present
accompanying differing dispassionate exhibitions, containing hematuria, proteinuria, and renal
degradation.
 The presence of RBC casts and proteinuria is suggestive of glomerular involvement, which is a
universal feature of lupus nephritis.
 In addition, the patient's syndromes of frenzy, arthralgia, and ulcers are still average features of SLE.
Option A: Acute interstitial nephritis: It is characterized by inflammation and damage to the renal intersti
tium and tubules, and can present with syndromes such as fever, rash, and eosinophilia. However, he
maturia and glomerular connection are not conventional features of severe interstitial nephritis.
Option B: Poststreptococcal glomerulonephritis: It is a
type of glomerulonephritis that happens after an infection accompanying group A
beta-hemolytic streptococcus. It usually presents accompanying manifestations to a degree of hematur
ia, proteinuria, and edema, but the lack of different clinical features such as fever, arthralgia, and ulcers
 makes this a rare disease.
Option D: IgA nephropathy: It is a chronic glomerulonephritis from the deposition of IgA antibodies in th
e glomerular mesangium. It usually presents accompanying manifestations such as hematuria, protein
uria, and renal impairment, but the lack of additional clinical features such as fever, arthralgia, and ulce
rs makes this an unlikely disease.
 
 The most likely diagnosis is hypokalemia.
 Diuretics such as thiazides and loop diuretics can cause potassium loss, which can influence
hypokalemia.
 The ECG judgments of flat T waves and prominent U waves are characteristic of hypokalemia. Other
manifestations of hypokalemia can involve muscle weakness, fatigue, muscle spasm, and palpitations.
Option B: Hyperkalemia: Hyperkalemia is a condition where there is an abnormally high level of potassi
um in the blood. ECG changes associated with hyperkalemia usually involve tall, pale T
waves, prolonged PR intervals, and a widened QRS complex. Flat T waves and prominent U
waves are not characteristic of hyperkalemia.
Option C: Hypomagnesemia: Hypomagnesemia is a condition where there is an unusually low level of 
magnesium in the blood. ECG changes associated with hypomagnesemia usually contain prolongation
 of the QT interval and T wave abnormalities. Flat T waves and prominent U
waves are not characteristic of hypomagnesemia.
Option D: Hypernatremia: Hypernatremia is a condition where there is an unusually high level of sodiu
m in the blood. ECG changes associated with hypernatremia are unique but can involve a
shortened QT interval and ST segment changes. Flat T waves and prominent U
waves are not characteristic of hypernatremia.
 
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 Based on the given arterial blood gas report, the patient has a low pH (acidemia) and extreme pCO2
(hypercapnia), signifying respiratory acidosis.
 The elevated bicarbonate (HCO3) levels imply that there can be little compensation occurring, likely
metabolic compensation.
 This pattern of results is most usually seen in patients accompanying hypoventilation, which leads to
an increase in carbon dioxide retention and a subsequent decrease in pH.
Option A: Respiratory alkalosis: This condition results from a raised pH (alkalemia) and decreased pC
O2, which is the opposite of the results seen in this patient. It is frequently produced by hyperventilatio
n, which results in excessive carbon dioxide removal from the body.
Option B: Metabolic acidosis: This condition results from a decreased pH and decreased bicarbonate l
evels. In metabolic acidosis, the kidneys are not able to excrete adequate acid, leading to an accumula
tion of acid in the body fluids.
Option D: Metabolic alkalosis: This condition results from a
raised pH and high bicarbonate levels. It happens when there is a
deficit of acid in the body, due to disgorging or through the use of diuretics.
The scenario mentioned in the question is a case of a Road Traffic Accident (RTA) where a person has
 collapsed, and the responder is performing Cardiopulmonary Resuscitation (CPR) to revive the person
. In such a
scenario, providing timely and appropriate care to the victim is crucial, as every second counts.
When the rescue team arrives, it is important to remember that they are equipped with advanced medi
cal equipment, including an Automated External Defibrillator (AED). This device can diagnose and treat
 a person suffering from cardiac arrest by delivering an electrical shock to the heart.
In this situation, the recommended action is to continue performing CPR while the rescue team applies 
the AED paddles. This is because CPR provides oxygenated blood to the victim's vital organs, includin
g the brain and heart, while the AED can deliver a shock to the heart to restore its natural rhythm.
Option a: Continue 5 rounds of CPR @ 30:2 followed by application of AED" is not recommended beca
use it suggests stopping CPR after five cycles and applying the AED. Instead, it is advisable to continu
e CPR until the AED is fully operational.
Option c: Stop CPR and let them apply paddles" is also not recommended because it suggests stoppin
g CPR altogether. This can be dangerous, leading to a
drop in blood flow to the vital organs, which can cause irreversible damage.
Option d: “Handover the patient and leave” is not recommended because the responder has a duty of c
are towards the victim until the arrival of the rescue team. Leaving the scene without handing over the 
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patient to the rescue team can be considered abandonment and can lead to legal consequences.  
 According to the vignette, the patient developed seizures after undergoing dialysis. The most common
cause of this is the development of dialysis disequilibrium syndrome. A range of symptoms occurs
during or post-dialysis due to the rapid urea clearance from the blood. It is treated by infusion of either
IV mannitol or IV hypertonic saline.
 Option a. Bumetanide is a loop diuretic that is used to treat edema in the body due to fluid retention.
Fluid retention commonly occurs due to an increase in the loss of protein from the body or due to
cardiac, renal, or hepatogenic causes. Fluid retention very rarely causes seizures, making it a very
unlikely cause that needs to be treated. Hence, there is no need to use bumetanide.
 Opton b. Ethacrynic acid is also a diuretic that functions similarly to loop-diuretics. Since the patient
does not have any fluid retention, its use in the patient is unnecessary.
 Option c. Nesiritide is a natriuretic peptide that is used in patients with acutely decompensated
congestive heart failure. It causes vasodilation which causes hemo-stability. The patient in the vignette
does not have any cardiac problems, hence making the use of this drug unnecessary in the patient. 
 
Correct Option C - Rapid sodium correction:
 Rapid correction of sodium levels, particularly in cases of hyponatremia (low sodium levels), can lead
to a condition known as osmotic demyelination syndrome (previously called central pontine
myelinolysis).
 It is characterized by the destruction of the protective myelin sheath in the central nervous system,
particularly in the pons region of the brainstem.
 This can result in various neurological manifestations, including mutism, quadriplegia, and rigidity.
Option A - Malignant hyperthermia: This is a rare, life-threatening reaction to certain medications used 
during general anesthesia. It is characterized by a
rapid increase in body temperature, muscle rigidity, and other signs of a hypermetabolic state.
Option B - Severe catatonia: Catatonia is a neuropsychiatric syndrome characterized by a range of sy
mptoms, including immobility, mutism, rigidity, and abnormal motor behaviors. However, catatonia is n
ot typically associated with severe vomiting or dehydration.
Option D - Neuroleptic malignant syndrome (NMS): NMS is a
potentially life-threatening condition that can occur as a reaction to certain medications, particularly anti
psychotic medications. It is characterized by hyperthermia, altered mental status, autonomic dysfunctio
n, and generalized muscle rigidity.
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Correct Options B: Renal calculi
 The presence of flank pain, hematuria, and multiple calcifications seen on X-ray in both kidneys
strongly suggests the presence of kidney stones. Further evaluation and diagnostic tests, such as a
renal ultrasound or CT scan, may be necessary to confirm the diagnosis and determine the appropriate
management approach.
Options A: Parathyroid Adenoma: Parathyroid adenoma refers to the enlargement of one or more of th
e parathyroid glands, which are responsible for regulating calcium levels in the body. This condition ca
n lead to hyperparathyroidism, causing elevated levels of calcium in the blood and kidney stones. How
ever the question does not state any other information regarding parathyroid adenoma therefore this o
ption is ruled out
Options C: Polycystic kidney disease: Polycystic kidney disease (PKD) is an inherited disorder charact
erized by the development of multiple cysts in the kidneys. While PKD can lead to kidney-related sympt
oms, such as flank pain and hematuria, the presence of multiple calcifications (stones) in both kidneys i
s not a typical feature of this condition. The calcifications seen in PKD are usually associated with the c
ysts themselves, rather than kidney stones.
Options D: CKD (Chronic Kidney Disease): Chronic kidney disease is a condition characterized by the 
gradual loss of kidney function over time. While CKD can lead to various complications, such as the for
mation of kidney stones, the presence of multiple calcifications (stones) in both kidneys on X-ray is not 
specific to CKD. It is important to note that CKD can be a risk factor for kidney stone formation, but it is 
not the primary diagnosis based on the information provided.
Correct Option A: pH-7.14, pCO2-20 mmHg, HCO3- 5 mEq/L: In this option, the pH is low (acidic) at 7.
14, indicating acidemia. The pCO2 is also low at 20 mmHg, suggesting respiratory alkalosis. The HCO
3- level is significantly decreased at 5
mEq/L, indicating metabolic acidosis. The presence of tall, tented T waves on the ECG is a characterist
ic finding in severe hyperkalemia, which can occur in the setting of metabolic acidosis. Therefore, the 
most likely acid-base imbalance in this patient is severe metabolic acidosis with respiratory compensati
on.
Option B: pH-7.14, pCO2-20 mmHg, HCO3- 34 mEq/L: In this option, the pH is low (acidic) at 7.14, indi
cating acidemia. The pCO2 is low at 20 mmHg, suggesting respiratory alkalosis. However, the HCO3- l
evel is elevated at 34 mEq/L, indicating metabolic alkalosis. This combination of low pCO2 and high H
CO3- is not consistent with a
physiological compensation pattern. Therefore, this option does not accurately represent a
typical acid-base imbalance.
Option C: pH-7.54, HCO3- 27 mEq/L, pCO2- 34 mmHg: In this option, the pH is high (alkaline) at 7.54, 
indicating alkalemia. The pCO2 is within the normal range at 34 mmHg, suggesting normal or compens
ated respiratory status. The HCO3- level is slightly elevated at 27 mEq/L, indicating metabolic alkalosis
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. This combination of high pH, normal pCO2, and elevated HCO3- is consistent with uncompensated or
 partially compensated metabolic alkalosis. However, this option does not align with the presented EC
G findings of tall, tented T waves, which are indicative of hyperkalemia. Therefore, this option is less lik
ely to be the correct acid-base imbalance in this case.
Option D: pH-7.4, HCO3- 27 mEq/L, pCO2- 40 mmHg: In this option, the pH is within the normal range 
at 7.4, indicating a normal acid-base balance. The pCO2 is within the normal range at 40 mmHg, sugg
esting normal or compensated respiratory status. The HCO3- level is also within the normal range at 2
7 mEq/L. This combination of normal pH, normal pCO2, and normal HCO3- does not indicate any signi
ficant acid-base imbalance. Therefore, this option is less likely to be the correct acid-base imbalance in
 this case.
Correct Option B. Hyponatremia: Hyponatremia is a condition characterized by a low level of sodium in
 the blood. The patient's serum osmolality of 270 mOsm/kg suggests normal tonicity, while the urine os
molality of 1000 mOsm/kg indicates concentrated urine. This pattern is consistent with a syndrome of i
nappropriate antidiuretic hormone secretion (SIADH), where excessive release of antidiuretic hormone 
(ADH) leads to increased water reabsorption in the kidneys and dilutional hyponatremia. Therefore, hy
ponatremia is the expected electrolyte abnormality in this patient.
Option A. Hypernatremia: Hypernatremia refers to an elevated level of sodium in the blood. In this case
, the patient's serum osmolality is 270 mOsm/kg, which is within the normal range. Hypernatremia woul
d typically be associated with increased serum osmolality due to a deficit of water in relation to sodium.
 Therefore, hypernatremia is not the expected electrolyte abnormality in this patient.
Option C. Hyperkalemia: Hyperkalemia refers to an elevated level of potassium in the blood. The provi
ded clinical information does not indicate the patient's potassium level or suggest any abnormalities rel
ated to potassium. Therefore, hyperkalemia is not the expected electrolyte abnormality in this case.
Option D.Hypokalemia: Hypokalemia is a condition characterized by a low level of potassium in the blo
od. The given information does not specifically indicate the patient's potassium level or provide any clu
es suggesting hypokalemia. Therefore, hypokalemia is not the expected electrolyte abnormality in this 
patient.
Correct Option C: Propranolol is given initially to manage hypertension This statement is incorrect. Pro
pranolol, a non-selective beta-blocker, is not typically given initially to manage hypertension in patients 
with suspected or confirmed pheochromocytoma. Administering a
beta-blocker without adequate alpha-blockade can worsen hypertension and lead to a hypertensive cri
sis. Therefore, it is essential to initiate alpha-blockade (e.g., with phenoxybenzamine) prior to beta-bloc
kade in these patients.
Option A Diagnosed by urine VMA & catecholamines This statement is correct. Pheochromocytoma, a 
rare adrenal gland tumor, can be diagnosed by measuring levels of vanillylmandelic acid (VMA) and ca
techolamines (such as epinephrine and norepinephrine) in urine. Elevated levels of these substances c
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an indicate the presence of a pheochromocytoma.
Option B: Surgical excision is the definitive treatment This statement is correct. Surgical excision is the 
definitive treatment for pheochromocytoma. Complete removal of the tumor is crucial to prevent further 
hormone secretion, control hypertension, and minimize the risk of complications associated with exces
s catecholamine release.
Option D: Can present as hypertension alone and sometimes with vomiting and pain abdomen This sta
tement is correct. Pheochromocytoma can present with a variety of symptoms, but the most common cl
inical feature is hypertension. However, it is important to note that pheochromocytoma can also manife
st with other symptoms, such as episodic or paroxysmal hypertension, headache, palpitations, sweatin
g, anxiety, flushing, vomiting, and abdominal pain. The presence of these symptoms should raise suspi
cion for pheochromocytoma and prompt further investigation.
Correct option : D
 Pauci-immune glomerulonephritis refers to a type of kidney inflammation characterized by a lack of
immune deposits within the glomeruli (the filtering units of the kidneys). It is typically associated with
small-vessel vasculitides, which are a group of disorders involving inflammation of the blood vessels.
 Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is one of the
small-vessel vasculitides associated with pauci-immune glomerulonephritis. GPA is an autoimmune
condition that primarily affects the respiratory tract and kidneys. It is characterized by the formation of
granulomas (areas of inflammation with immune cells) and necrotizing vasculitis (inflammation and
destruction of blood vessel walls).
Option A) SLE nephritis: Systemic lupus erythematosus (SLE) is an autoimmune disease that can affec
t multiple organs, including the kidneys. Lupus nephritis refers to kidney inflammation associated with 
SLE. However, SLE nephritis typically presents with immune deposits in the glomeruli, which differentia
tes it from pauci-immune glomerulonephritis.
Option B) Anti-GBM glomerulonephritis: Anti-GBM (glomerular basement membrane) glomerulonephriti
s is a rare autoimmune disorder characterized by the presence of antibodies directed against the glom
erular basement membrane. This condition causes severe kidney inflammation and damage. Unlike pa
uci-immune glomerulonephritis, anti-GBM glomerulonephritis exhibits immune deposits along the glom
erular basement membrane.
Option C) IgA nephropathy: IgA nephropathy, also known as Berger's disease, is a
kidney disorder characterized by the accumulation of immunoglobulin A (IgA) within the glomeruli. It is t
he most common form of glomerulonephritis worldwide. Unlike pauci-immune glomerulonephritis, IgA n
ephropathy involves immune deposits, specifically IgA, within the glomeruli.
 
Correct Option A - urinary sodium <20 mEq/L
 This statement is incorrect
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 In the syndrome of inappropriate antidiuretic hormone secretion (SIADH), there is excessive secretion
of antidiuretic hormone (ADH), also known as vasopressin, leading to water retention and dilutional
hyponatremia. While the other options listed are true about SIADH, the statement “urinary sodium <20
mEq/L” is not accurate.
 Option b. Serum sodium: SIADH is associated with hyponatremia, which is defined as serum sodium
levels less than 135 mEq/L. The excessive water retention dilutes the sodium concentration in the
blood.
 Option c. Urine osmolality: SIADH leads to impaired water excretion and concentrated urine. Urine
osmolality is typically greater than 100 mOsm/kg, indicating the kidneys’ inability to appropriately dilute
urine.
 Option d. Patient can be clinically euvolemic to hypervolemic: Patients with SIADH can present as
clinically euvolemic (normal volume status) or hypervolemic (excess fluid volume). The degree of
volume expansion depends on the underlying cause of SIADH and associated factors such as fluid
intake and comorbidities.
Liddle syndrome is a rare autosomal dominant disorder characterized by excessive sodium reabsorptio
n in the renal tubules, leading to volume expansion, hypertension, and hypokalemia as well as metabol
ic alkalosis.
Option A: Barter syndrome is rare autosomal recessive disorder that affects the kidney’s ability to reab
sorb sodium and chloride in the thick ascending limb of the loop of Henle. It leads to a similar electrolyt
e imbalance as Gitelman syndrome, including hypokalemia and metabolic alkalosis. However, hyperte
nsion is not typically associated with Barter syndrome.
Option C: Gitelman syndrome is a rare autosomal recessive disorder that affects the kidneys’ ability to 
reabsorb electrolytes, particularly sodium, chloride, and magnesium. This leads to excessive urinary lo
sses of these electrolytes. The main clinical features of Gitelman syndrome include hypokalemia (low p
otassium levels), metabolic alkalosis (elevated pH and bicarbonate levels).
Option D: Gordon syndrome is also known as pseudohypoaldosteronism type II, it is a rare autosomal 
dominant disorder characterized by hypertension, hyperkalemia (high potassium levels), and metabolic
 acidosis. It is not associated with hypokalemic metabolic alkalosis.
Correct Choice: A
 It is a common type of kidney stone that forms due to high levels of calcium and oxalate in the urine.
Calcium oxalate stones can vary in size and shape and may appear rough, brownish crystals.
 Factors contributing to calcium oxalate formation include a diet rich in oxalate-containing foods (such
as spinach, rhubarb, and beetroot), low fluid intake, certain medical conditions, and certain
medications. They can cause symptoms such as severe abdominal or back pain, blood in the urine,
frequent urination, and difficulty passing urine.
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Option B. Calcium phosphate: Calcium phosphate stones are another type of kidney stone that can for
m in the urinary system. These stones are composed primarily of calcium phosphate and other mineral
s such as calcium carbonate and magnesium phosphate.
Option C. Uric acid: Uric acid stones are a
type of kidney stone that forms due to high uric acid levels in the urine. Uric acid is a waste product tha
t is normally excreted by the kidneys. However, when there is excessive production of uric acid or the u
rine becomes too acidic, it can lead to the formation of uric acid stones.
Option D. Cysteine: Cysteine stones are a rare type of kidney stone that forms due to a
genetic disorder called cystinuria. Cystinuria is an inherited condition characterized by a
defect in the transport system that reabsorbs cysteine, an amino acid, in the kidneys. As a result, cystei
ne and other amino acids accumulate in the urine and can precipitate to form cysteine stones. Cysteine
 stones are typically yellow or brown and have a rough, jagged appearance.
 Based on the given clinical presentation and test results, the most likely etiology in this case is
pheochromocytoma. The correct answer is: Pheochromocytoma
 Pheochromocytoma is a rare neuroendocrine tumor that arises from chromaffin cells in the adrenal
medulla, leading to excessive production and release of catecholamines such as epinephrine and
norepinephrine. The clinical features of sudden-onset headache, palpitations, profuse sweating, and
episodes of high blood pressure (hypertension) are characteristic of pheochromocytoma.
 Elevated urinary metanephrine levels are a key diagnostic finding in pheochromocytoma.
Metanephrines are breakdown products of catecholamines, and increased levels in a 24-hour urine
collection suggest excessive production and secretion of catecholamines, supporting the diagnosis of
pheochromocytoma.
Option A: Fibromuscular dysplasia (FMD) is a non-inflammatory and non-atherosclerotic arterial diseas
e that primarily affects the medium-sized arteries. It commonly involves the renal arteries but is not typi
cally associated with the symptoms described in the scenario.
Option B: Renal artery stenosis refers to the narrowing of one or both renal arteries, often due to ather
osclerosis or fibromuscular dysplasia. While it can cause hypertension, it does not typically present wit
h sudden-onset headache, palpitations, and profuse sweating.
Option D: Hyperthyroidism is a condition characterized by excessive production of thyroid hormones by
 the thyroid gland. Although hyperthyroidism can cause symptoms such as palpitations and sweating, s
udden-onset headache and episodes of high blood pressure are not typical features of this condition.
Therefore, based on the given clinical presentation and elevated urinary metanephrine levels, the most
 likely etiology in this case is pheochromocytoma.
 
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 Based on the given clinical presentation and examination findings, the most probable cause for the
edema, in this case, is Nephrotic syndrome. The correct answer is: Nephrotic syndrome
 Nephrotic syndrome is a condition characterized by increased permeability of the glomerular filtration
barrier in the kidneys, resulting in the loss of protein, particularly albumin, in the urine. This leads to
hypoalbuminemia and subsequent fluid retention, causing edema.
 The presence of palpitation, weight loss, and the description of a non-pitting lesion on the legs
suggest an underlying systemic condition. Nephrotic syndrome can present with generalized edema,
including edema in the legs, due to hypoalbuminemia and fluid retention.
 The finding of non-pitting edema, where the indentation does not persist on release, is consistent with
nephrotic syndrome. The loss of albumin leads to a decrease in oncotic pressure, resulting in the
accumulation of interstitial fluid that does not readily shift with pressure changes.
 Sinus tachycardia on the ECG is a nonspecific finding and can be seen in various conditions,
including nephrotic syndrome. It is not specific to any particular cause of edema.
Option A: Myxedema refers to severe hypothyroidism and is not consistent with the presentation of pal
pitation and weight loss. It is unlikely to be the cause of the edema in this case.
Option C: Chronic lymphangitis refers to inflammation of the lymphatic vessels and can cause lymphed
ema. However, the presentation of palpitation, weight loss, and non-pitting edema is not consistent wit
h chronic lymphangitis.
Option D: Dilated cardiomyopathy is incorrect answer 
Therefore, based on the given clinical presentation, examination findings, and the most likely cause of t
he non-pitting edema, the probable cause for the edema in this patient is Nephrotic syndrome.
 
 Based on the presentation of a patient with Hepatitis B and heavy proteinuria the most likely finding on
renal biopsy would be membranous glomerulonephritis.
 Membranous glomerulonephritis is a type of glomerular disease characterized by the thickening and
immune complex deposition along the glomerular basement membrane. It can be associated with
various underlying conditions, including solid tumors
 The diffuse capillary and GBM thickening is characteristic finding
Option A: Focal segmental glomerulosclerosis (FSGS): FSGS is characterized by scarring and sclerosi
s of certain glomeruli in a focal and segmental pattern. this option is incorrect.
Option C: Membranoproliferative glomerulonephritis (MPGN): MPGN is characterized by both thickenin
g and proliferation of the glomerular basement membrane. This option is incorrect.
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Option D: Minimal change disease: Minimal change disease is a
common cause of nephrotic syndrome in children but is less common in adults. This option is incorrect.
 
Correct Options: A
The expected metabolic abnormality in a patient with chronic projectile vomiting and weight loss is hyp
okalemic hypochloremic metabolic alkalosis with hyponatremia.
 Chronic projectile vomiting can lead to significant fluid and electrolyte imbalances in the body. In this
case, the loss of gastric acid and chloride through vomiting results in a decrease in chloride levels
(hypochloremia) and an increase in bicarbonate levels (metabolic alkalosis).
 The vomiting also leads to potassium loss (hypokalemia) due to the loss of gastric fluid that contains
potassium ions. This can further contribute to the development of metabolic alkalosis.
 Additionally, the chronic vomiting may lead to dehydration and decreased fluid intake, which can
result in hyponatremia (low sodium levels) due to dilutional effects.
Now let's review the provided options:
Option A: Hypokalemic hypochloremic metabolic alkalosis with hyponatremia: This option accurately d
escribes the expected metabolic abnormality in a patient with chronic projectile vomiting. It reflects the l
oss of chloride and potassium through vomiting, resulting in metabolic alkalosis, hypochloremia, and hy
ponatremia.
Option B: Hypokalemic hypochloremic metabolic alkalosis with hypernatremia: This option is not consis
tent with the clinical presentation. Chronic vomiting typically leads to hyponatremia due to fluid loss and
 decreased intake, not hypernatremia.
Option C: Hypokalemic hypochloremic metabolic alkalosis with hypercalcemia: Hypercalcemia is not ty
pically associated with chronic vomiting and would not be the expected metabolic abnormality in this ca
se.
Options D: Hypokalemic hypochloremic metabolic acidosis with hyponatremia: This option does not ma
tch the expected metabolic abnormality. Chronic vomiting typically leads to metabolic alkalosis, not met
abolic acidosis.
Therefore, the correct answer is hypokalemic hypochloremic metabolic alkalosis with hyponatremia, ref
lecting the electrolyte and acid-base disturbances commonly seen in patients with chronic projectile vo
miting.
 
The correct answer is: BUN: Cr >20:1, urine Na <20, FENa <1% urine osmolality >500.
 BUN: Cr >20:1, urine Na <20, FENa <1% urine osmolality >500: This option matches the typical
laboratory values seen in the described patient. The BUN: Cr ratio is increased, urine sodium is low,
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FENa is less than 1%, and urine osmolality is greater than 500. These findings suggest prerenal
azotemia, a condition characterized by decreased renal perfusion leading to reduced urine output.
Option A: BUN: Cr >40:1, urine Na <40, FENa <1% urine osmolality >500: This option does not match t
he typical laboratory values seen in the described patient. In cases of acute tubular necrosis (ATN), wh
ich can cause acute kidney injury and decreased urine output, the FENa (Fractional Excretion of Sodiu
m) is typically higher than 1% and the urine osmolality is usually lower than 500.
Option C: BUN: Cr >20:1, urine Na <20, FENa <1% urine osmolality >250: This option does not match 
the typical laboratory values seen in the described patient. The urine osmolality is lower than expected 
in prerenal azotemia, where it is usually concentrated due to reduced urine output.
Option D: BUN: Cr >40:1, urine Na <20, FENa <1% urine osmolality >250: This option does not match 
the typical laboratory values seen in the described patient. The BUN: Cr ratio is higher than expected i
n prerenal azotemia, and the urine osmolality is lower than expected.
In summary, the laboratory values that are seen in the patient with loose stools and reduced urine freq
uency are: BUN: Cr >20:1, urine Na <20, FENa <1%, urine osmolality >500. These findings are consist
ent with prerenal azotemia, which can occur due to decreased renal perfusion in conditions such as de
hydration or volume depletion.
Based on the information provided, the most likely finding in this 8-year-old girl would be RBC's in the u
rine.
Explanation: The clinical presentation of abrupt onset fever, oliguria (reduced urine output), nausea, s
moky urine, and puffy eyes is suggestive of a poststreptococcal glomerulonephritis (PSGN) in a
child. PSGN is an immune-mediated glomerulonephritis that typically follows a
streptococcal infection, such as strep throat or impetigo.
The characteristic skin lesions described by the parents two weeks ago, which are now resolving, are c
onsistent with a previous streptococcal infection.
In PSGN, the glomeruli in the kidneys become inflamed due to immune complex deposition. This can l
ead to damage of the glomerular filtration barrier, causing red blood cells (RBCs) to leak into the urine, 
resulting in hematuria. Therefore, RBCs in the urine is a typical finding in PSGN.
Nephrotic range proteinuria, characterized by heavy proteinuria (>3.5 grams per day), is not a typical fe
ature of PSGN. PSGN is more commonly associated with hematuria and mild to moderate proteinuria.
Derangement of liver enzymes and neurological symptoms are not typically associated with PSGN. PS
GN primarily affects the kidneys and may present with symptoms related to kidney dysfunction, such a
s oliguria and smoky urine.
Therefore, based on the given information, the most likely finding in this patient would be RBC's in the 
urine (hematuria), indicating glomerular involvement in the context of poststreptococcal glomeruloneph
ritis.
 
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Peripheral neuropathy is a condition characterized by damage to the peripheral nerves, leading to sym
ptoms such as numbness, tingling, and weakness in the extremities. While dialysis is an important treat
ment modality for end-stage renal disease (ESRD), it may not directly prevent or reverse peripheral ne
uropathy. Peripheral neuropathy in patients with ESRD is typically caused by multiple factors, including
 diabetes, uremic toxins, and vitamin deficiencies. Dialysis primarily helps in removing waste products 
and excess fluid from the blood, but it may not directly address the underlying causes of peripheral neu
ropathy.
Option A. Seizures: Seizures can occur as a complication of uremia, which is the accumulation of wast
e products and toxins in the blood due to kidney dysfunction. Dialysis helps in removing these toxins, r
educing their impact on the brain, and lowering the risk of seizures. Therefore, dialysis can help preven
t or control seizures in patients with ESRD.
Option C. Metabolic acidosis: Metabolic acidosis is a condition characterized by an imbalance in the bo
dy's acid-base balance, resulting in excess acid accumulation. In patients with ESRD, metabolic acidos
is commonly occurs due to impaired kidney function. Dialysis helps in removing acid and restoring the 
acid-base balance, thereby preventing or correcting metabolic acidosis.
Option D. Uremic pericarditis: Uremic pericarditis is inflammation of the pericardium (the sac around th
e heart) caused by the accumulation of uremic toxins in the blood. Dialysis helps in removing these toxi
ns, reducing inflammation, and preventing or resolving uremic pericarditis.
Hyperkalemia refers to an elevated level of potassium in the blood. In the context of chronic kidney dis
ease (CKD), it is considered one of the most severe manifestations. As kidney function declines, the ab
ility of the kidneys to excrete potassium decreases, leading to its accumulation in the bloodstream.
Hyperkalemia can have significant consequences on cardiac function and can potentially cause life-thr
eatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. The increased risk of 
cardiac arrhythmias makes hyperkalemia a severe and potentially dangerous complication of CKD.
Option A. Decreased GFR: Decreased glomerular filtration rate (GFR) is a
hallmark of CKD and represents impaired kidney function. While decreased GFR is a key diagnostic cri
terion for CKD, it alone does not indicate the severity of the disease. The progression of CKD and its c
omplications, such as hyperkalemia, are influenced by factors beyond the GFR.
Option B. Increased creatinine: Elevated creatinine levels are commonly used as a marker of impaired 
kidney function. However, while increased creatinine levels are indicative of reduced kidney function in 
CKD, they do not directly reflect the severity of the disease. Creatinine levels can vary depending on v
arious factors, including muscle mass, age, and hydration status.
Option D. Proteinuria: Proteinuria, the presence of excess protein in the urine, is a common finding in 
CKD. While it is an important marker of kidney damage and can be associated with disease progressio
n, it is not considered the most severe manifestation of CKD. Proteinuria can be managed and controll
ed through various interventions, including medication and lifestyle modifications, to minimize the risk o
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f further kidney damage.
Correct Option: C:  Pituitary DI (diabetes insipidus)
 The patient's presentation of frequent urination, nocturia, and enuresis along with a 24-hour urine
volume of 7 liters and low urine osmolarity indicates the inability to concentrate urine, which is a
characteristic feature of diabetes insipidus.
 The low ADH (antidiuretic hormone) level detected by the assay suggests a The absence of the bright
spot on T1 weighted MRI is consistent with a lack of posterior pituitary gland hyperintensity, further
supporting the diagnosis of pituitary DI.
Option A - Nephrogenic DI: This statement is incorrect. Nephrogenic DI is characterized by impaired re
nal response to ADH, resulting in the inability to concentrate urine. However, in this scenario, the low A
DH level suggests a deficiency in ADH secretion rather than impaired renal response, indicating a
different etiology.
Option B - Primary polydipsia: This statement is incorrect. Primary polydipsia refers to excessive water 
intake leading to water diuresis. It is not associated with a
deficiency in ADH secretion or impaired renal response to ADH, which are seen in diabetes insipidus.
Option D - Mannitol infusion: This statement is incorrect. Mannitol infusion is a
medical intervention involving the administration of mannitol, a
diuretic agent, to increase urine output in specific clinical situations. It is not a
diagnosis for the patient's condition.
Correct Option: A. 
 Arterial blood gas (ABG) analysis is a diagnostic test used to assess a patient's acid-base balance
and oxygenation status. In this case, the ABG findings show the following: pH = 7.12: This value
indicates acidemia, as the pH is below the normal range of 7.35-7.45. pCO2 = 50: This value
represents the partial pressure of carbon dioxide in the arterial blood. An elevated pCO2 indicates
respiratory acidosis, as it suggests inadequate elimination of carbon dioxide by the lungs. HCO3 = 28:
This value represents the bicarbonate concentration in the blood, which is an indicator of metabolic
status. The HCO3 level is within the normal range, suggesting metabolic compensation.
 pH = 7.12: This value indicates acidemia, as the pH is below the normal range of 7.35-7.45.
 pCO2 = 50: This value represents the partial pressure of carbon dioxide in the arterial blood. An
elevated pCO2 indicates respiratory acidosis, as it suggests inadequate elimination of carbon dioxide
by the lungs.
 HCO3 = 28: This value represents the bicarbonate concentration in the blood, which is an indicator of
metabolic status. The HCO3 level is within the normal range, suggesting metabolic compensation.
 Based on these findings, the diagnosis is respiratory acidosis with metabolic compensation.
Respiratory acidosis occurs when there is a build-up of carbon dioxide in the blood due to inadequate
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ventilation or impaired gas exchange in the lungs. The kidneys respond to the acidosis by increasing
the reabsorption of bicarbonate, leading to metabolic compensation.
Option B. Metabolic acidosis with respiratory compensation: Metabolic acidosis is characterized by a lo
w pH and low bicarbonate level. The given ABG findings do not support metabolic acidosis, as the HC
O3 level is within the normal range. Additionally, respiratory compensation in metabolic acidosis would 
involve a decrease in pCO2, which is not seen in this case.
Option C. Respiratory alkalosis with metabolic compensation: Respiratory alkalosis is characterized by 
a high pH and low pCO2. However, the given ABG findings show acidemia (low pH) and an elevated p
CO2, which are inconsistent with respiratory alkalosis.
Option D. Metabolic alkalosis with respiratory compensation: Metabolic alkalosis is characterized by a 
high pH and high bicarbonate level. The given ABG findings do not support metabolic alkalosis, as the 
HCO3 level is within the normal range. Additionally, respiratory compensation in metabolic alkalosis wo
uld involve an increase in pCO2, which is not seen in this case.
Correct Option: C. 
 In the given scenario, the patient presented with hyponatremia and was treated with a large volume of
hypertonic fluids over a short period of time. Following this treatment, the patient developed
quadriparesis. These findings are suggestive of central pontine myelinolysis (Choice C).
 Central pontine myelinolysis (CPM) is a condition characterized by the destruction of the myelin
sheath in the central portion of the pons, which is a part of the brainstem. It is typically associated with
rapid correction of hyponatremia, especially when the correction occurs too quickly. In this case, the
hypertonic fluids caused a rapid increase in serum sodium levels, leading to osmotic changes in the
brain and subsequent damage to the myelin sheath in the pons.
Option A. Brain infarct: Brain infarct (Choice A) refers to the obstruction of blood flow to a specific area 
of the brain, resulting in tissue damage. While hyponatremia can contribute to the development of cere
bral edema and increase the risk of brain infarction, the rapid correction of hyponatremia in this case is 
more consistent with CPM.
Option B. Brainstem injury: Brainstem injury (Choice B) can result from trauma or other causes and ca
n lead to a range of neurological symptoms. However, the rapid development of quadriparesis followin
g the treatment with hypertonic fluids suggests a more specific diagnosis of CPM.
Option D. Rare cause of hypernatremia: Hypernatremia refers to an elevated serum sodium level. In thi
s case, the patient presented with hyponatremia and received hypertonic fluids, so the development of 
hypernatremia is not likely to be the cause of the patient's condition. Therefore, Choice D
is an incorrect option.
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Correct Option: A
 AKIN (Acute Kidney Injury Network) and RIFLE (Risk, Injury, Failure, Loss of kidney function, and
End-stage kidney disease) criteria are used to classify and diagnose acute kidney injury (AKI). These
criteria provide a standardized approach for assessing the severity of AKI based on changes in serum
creatinine levels, urine output, and the duration of kidney dysfunction.
 The AKIN criteria were developed in 2007 as an updated version of the RIFLE criteria. Both sets of
criteria categorize AKI into different stages based on the magnitude of serum creatinine increase or
decrease in urine output. They also consider the duration of kidney dysfunction and the presence of
other complications.
Incorrect Option :
Option B. Chronic renal failure: AKIN and RIFLE criteria are specifically designed to classify acute kidn
ey injury and are not applicable to chronic renal failure. Chronic renal failure is a progressive and irreve
rsible loss of kidney function over an extended period of time, whereas AKI represents a
sudden decline in kidney function over a shorter timeframe.
Option C. Acute glomerulonephritis: AKIN and RIFLE criteria are not used to classify acute glomerulon
ephritis. Acute glomerulonephritis is an inflammation of the glomeruli in the kidneys and is typically diag
nosed based on clinical features, laboratory tests (such as urine analysis and serology), and kidney bio
psy findings.
Option D. Nephrotic syndrome: AKIN and RIFLE criteria are not used to classify nephrotic syndrome. N
ephrotic syndrome is a clinical syndrome characterized by a specific set of symptoms, including heavy 
proteinuria, hypoalbuminemia, edema, and hyperlipidemia. It is usually diagnosed based on clinical an
d laboratory findings, including urine protein measurement and serum albumin levels.
 The given blood gas reports show a normal pH of 7.40, indicating no primary acid-base abnormality.
However, the bicarbonate (HCO3-) level of 23 mEq/L falls within the normal range, suggesting that
there is a compensatory mechanism in place. The sodium (Na+) level of 145 mEq/L is also within the
normal range.
 The key finding in this case is the elevated anion gap of 100 mEq/L, which indicates the presence of
an underlying metabolic acidosis. High anion gap metabolic acidosis is commonly seen in conditions
such as diabetic ketoacidosis, lactic acidosis, and renal failure. In this case, the patient's chronic kidney
disease is likely contributing to the development of high anion gap metabolic acidosis.
 Additionally, the presence of metabolic alkalosis is suggested by the elevated bicarbonate level
(HCO3-). Metabolic alkalosis can occur in conditions such as vomiting or excessive loss of gastric acid,
leading to an increase in bicarbonate levels.
 Therefore, the most probable diagnosis based on the given information is high anion gap metabolic
acidosis with metabolic alkalosis. The elevated anion gap indicates an underlying acidosis, while the
elevated bicarbonate level suggests concurrent metabolic alkalosis.
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Option A. No acid-base abnormality: This choice is incorrect because the blood gas reports indicate th
e presence of an abnormality, specifically a high anion gap metabolic acidosis with metabolic alkalosis.
Option B. Respiratory acidosis: The blood gas reports do not show any abnormalities in the partial pres
sure of carbon dioxide (pCO2), which is a
key indicator of respiratory acidosis. Therefore, respiratory acidosis is not the likely diagnosis.
Option C. Metabolic alkalosis: This choice is incorrect because it only accounts for the metabolic alkalo
sis component of the patient's acid-base disturbance. The elevated anion gap metabolic acidosis is als
o present and should be considered in the diagnosis.
Correct option C: 
 Nephritic syndrome is characterized by glomerular inflammation, which leads to various clinical
features such as hematuria (blood in the urine), proteinuria (excessive protein in the urine),
hypertension (high blood pressure), and decreased glomerular filtration rate.
 Post-infectious Glomerulonephritis: This is a type of nephritic syndrome that occurs after an infection,
most commonly caused by certain strains of Streptococcus bacteria (such as Streptococcus
pyogenes). It is characterized by glomerular inflammation and often presents with hematuria,
proteinuria, hypertension, and decreased kidney function. The inflammation is typically a result of
immune complex deposition in the glomeruli in response to the infection.
Option A. Minimal change disease: Minimal change disease is a type of nephrotic syndrome, not nephr
itic syndrome. It is characterized by minimal changes in the glomeruli on microscopic examination and i
s commonly seen in children. It typically presents with proteinuria, edema, and hypoalbuminemia.
Option B. Membranous Glomerulopathy: Membranous glomerulopathy is another type of nephrotic syn
drome, not nephritic syndrome. It is characterized by thickening of the glomerular basement membrane
 due to immune complex deposits. It typically presents with proteinuria, edema, and hypoalbuminemia.
Option D. Focal segmental glomerulosclerosis: Focal segmental glomerulosclerosis (FSGS) is another 
type of nephrotic syndrome, not nephritic syndrome. It is characterized by scarring and sclerosis of cert
ain segments of the glomeruli. It typically presents with heavy proteinuria, edema, and hypoalbuminemi
a.
 
 In this case, the patient presents with a 3x3 cm stone in the right renal pelvis, accompanied by
symptoms such as pain abdomen, nausea, restlessness, and episodes of hematuria. The absence of
hydronephrosis indicates that the stone has not caused significant obstruction in the urinary tract.
Based on these factors, the best procedure for management of this patient is PCNL (Percutaneous
Nephrolithotomy).
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Option A: ESWL (Extracorporeal Shock Wave Lithotripsy) is a non-invasive procedure that uses shock 
waves to break down kidney stones. However, in this case, the size of the stone (3x3 cm) is relatively l
arge, and ESWL may not be effective in fragmenting and removing the stone completely.
Option C: Antegrade Pyeloplasty is a surgical procedure used to treat ureteropelvic junction (UPJ) obst
ruction, which is not the primary concern in this case.
Option D: Retrograde Pyeloplasty is also a surgical procedure used for the treatment of UPJ obstructio
n, which is not the primary concern in this case.
 This is the correct option. Priapism is diagnosed when an erection persists for 4 hours or longer. This
duration indicates a pathological condition that requires immediate medical attention to prevent
complications.
Option A: 1 hour - This is an incorrect option. Priapism is defined as a
persistent erection lasting longer than 4 hours, so a cutoff of 1
hour would not be appropriate for diagnosis.
Option B: 2 hours - This is an incorrect option. A cutoff of 2
hours is also not appropriate for diagnosing priapism. The prolonged erection should persist for a
longer duration to meet the diagnostic criteria.
Option C: 3 hours - This is an incorrect option. A cutoff of 3
hours is still insufficient to diagnose priapism. The erection must persist for a
The MELD (Model for End-Stage Liver Disease) score is a numerical scoring system used to assess th
e severity and prognosis of liver disease. It is commonly used for liver transplant allocation. The MELD 
score is calculated using three laboratory parameters: bilirubin, creatinine, and prothrombin time- (INR)
.
Option A: Bilirubin: This option is incorrect. Bilirubin is included as one of the components of the MELD 
score.
Option B: Prothrombin time: This option is incorrect. Prothrombin time is included as one of the compo
nents of the MELD score.
Option D: Creatinine: This option is incorrect. Creatinine is included as one of the components of the M
ELD score.
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Correct Option : A
Anion Gap = [Na+] - ([Cl-] + [HCO3-])
Given the values: [Na+] = 137 mmol/L [Cl-] = 100 mmol/L [HCO3-] = 15 mmol/L
Anion Gap = 137 - (100 + 15) = 137 - 115 = 22 mmol/L
 
Incorrect option:
Option B: Incorrect answer
Option C. Incorrect answer
Option D. Incorrect Answer
Option A.
 Acute kidney injury This option is correct. AKIN (Acute Kidney Injury Network) and RIFLE (Risk, Injury,
Failure, Loss, End-stage kidney disease) criteria are used to classify and diagnose acute kidney injury.
These criteria consider changes in serum creatinine levels, urine output, and the time frame in which
these changes occur to determine the severity of acute kidney injury.
Option B. Chronic renal failure This option is incorrect. AKIN and RIFLE criteria are not used to classify
 chronic renal failure. Chronic renal failure is a progressive, long-term condition characterized by a per
manent loss of kidney function over time. It is usually diagnosed and classified based on the estimated 
glomerular filtration rate (eGFR) and the presence of kidney damage lasting for at least three months.
Option C. Acute glomerulonephritis This option is incorrect. AKIN and RIFLE criteria are not used to cla
ssify acute glomerulonephritis. Acute glomerulonephritis refers to the inflammation and damage of the 
glomeruli in the kidneys. It is typically diagnosed through clinical symptoms, laboratory tests, and kidne
y biopsies.
Option D. Nephrotic syndrome This option is incorrect. AKIN and RIFLE criteria are not used to classify
 nephrotic syndrome. Nephrotic syndrome is a collection of symptoms characterized by increased prote
inuria, hypoalbuminemia, edema, and hyperlipidemia. It is usually diagnosed based on clinical findings,
 urine tests, and blood tests.
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Correct
Option C:
Renal aciduria refers to a condition characterized by the inability of the kidneys to effectively reabsorb 
bicarbonate or excrete hydrogen ions, leading to a
decreased bicarbonate concentration and metabolic acidosis. It is a
form of renal tubular acidosis (RTA). In this patient's case, the metabolic acidosis is likely due to a
different cause, as indicated by the presence of an increased anion gap.
Options A. Renal failure: Renal failure can lead to the accumulation of metabolic waste products and i
mpaired acid-base regulation, resulting in metabolic acidosis. It can be classified as high anion gap me
tabolic acidosis or normal anion gap metabolic acidosis, depending on the underlying cause. Therefore
, renal failure can be associated with metabolic acidosis with an increased anion gap, similar to the pati
ent's condition.
Options B. Lactic acidosis: Lactic acidosis occurs when there is an overproduction or impaired clearanc
e of lactic acid. It can be caused by various conditions, such as tissue hypoperfusion, shock, sepsis, or 
certain medications. Lactic acidosis is typically associated with an increased anion gap metabolic acido
sis, similar to the patient's presentation.
Options D. Aspirin: Aspirin, when taken in high doses, can cause toxicity and lead to metabolic acidosi
s. Aspirin toxicity is characterized by increased production of organic acids and impaired respiratory co
mpensation. This type of metabolic acidosis is also associated with an increased anion gap, similar to t
he patient's condition.
Correct Ans: A
 Post-streptococcal glomerulonephritis (PSGN) is an immune-mediated glomerulonephritis that
typically occurs after a streptococcal infection, such as strep throat or skin infection. It commonly affects
children and presents with symptoms such as pedal edema (swelling of the feet), facial puffiness,
hypertension (elevated blood pressure), and proteinuria (presence of excess protein in the urine).
 In PSGN, the immune response triggered by the streptococcal infection causes immune complexes
(antigen-antibody complexes) to deposit in the glomeruli of the kidneys. This deposition leads to
inflammation and damage to the glomerular filtration barrier, resulting in the clinical manifestations
observed in the patient.
Option B. Minimal change disease: Minimal change disease is a common cause of nephrotic syndrome
 in children, characterized by proteinuria, hypoalbuminemia, edema, and normal renal function. It is usu
ally not associated with hematuria (presence of red blood cells in the urine), as seen in the patient's ca
se.
Option C. Membranous glomerulonephritis: Membranous glomerulonephritis is characterized by the thi
ckening of the glomerular basement membrane due to immune complex deposition. It typically present
s with nephrotic syndrome, including proteinuria, hypoalbuminemia, and edema. Hematuria is less com
monly observed in membranous glomerulonephritis.
Option D. Focal segmental glomerulosclerosis: Focal segmental glomerulosclerosis is a pattern of glo
merular injury that can be primary (idiopathic) or secondary to other conditions. It often presents with n
481

GI Bleed
1. A 45-year-old male presents to the emergency department with severe abdominal pain and rebound
tenderness. Upon further examination, the patient's history reveals a longstanding complaint of
epigastric discomfort. The patient's symptoms have escalated over the past 24 hours, and he reports
feeling lightheaded. An abdominal X-ray reveals the presence of gas under the diaphragm, consistent
with the "Moustache sign." Which of the following statements aligns correctly with the diagnosis of this
patient?
(or)
Which of the following statements aligns correctly with perforated duodenal ulcer?
A. Most common cause of peritonitis is a posteriorly located gastric ulcer
B. Bleeding is more commonly associated with duodenal ulcers with anterior location
C. "Moustache sign" on the abdominal X-ray indicates perforation peritonitis
D. Initial management of the perforated duodenal ulcer involves upper GI endoscopy with adrenaline
application at the base of the ulcer and electrocautery
2. A 38-year-old male presents to the emergency department with a complaint of severe hematemesis.
The patient reports a recent episode of excessive alcohol consumption during a binge drinking session.
He describes several bouts of forceful retching preceding the onset of hematemesis. On examination,
heart rate is increased, and blood pressure is 100/70 mmHg. Which of the following options accurately
corresponds to the likely diagnosis and management strategy for this patient?
(or)
Which of the following options accurately corresponds to Mallory-Weiss syndrome?
A. The patient is likely suffering from esophageal varices, and the initial management involves
beta-blockers for hemodynamic control
B. Mallory-Weiss syndrome is suspected, and if bleeding recurs, the recommended approach is upper
gastrointestinal endoscopy with local adrenaline injection and hemostatic clips
C. This patient's symptoms are indicative of a lower gastrointestinal bleed, and the initial diagnostic
step should include a colonoscopy
D. Given the history of alcohol consumption, the patient is likely experiencing an acute pancreatitis
episode, and treatment involves pancreatic enzyme replacement therapy.
3. A 55-year-old male, a known case of chronic liver disease, presents to the ER with an episode of
hematemesis and has splenomegaly on per abdomen examination. Which of the following accurately
describes the source of bleeding in this patient's presentation?
(or)
Which of the following accurately describes the source of bleeding in portal hypertension?
A. The bleeding is likely originating from the hepatic artery due to increased pressure in the portal
system
B. Esophageal varices with gastric veins are the source of bleeding in this patient with portal
hypertension
C. The source of bleeding is primarily from the superior mesenteric artery
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Page 2
D. Hematemesis in portal hypertension is commonly caused by erosive gastritis with involvement of the
gastric arteries
4. A 28-year-old woman presents to a clinic with complaints of colicky abdominal pain and episodes of
severe bloody diarrhea occurring 10-15 times a day. Physical examination reveals pallor, puffy eyes,
and pedal edema. What is the likely diagnosis for this patient, and which antibody test may aid in
confirming the specific subtype of inflammatory bowel disease?
A. The likely diagnosis is irritable bowel syndrome (IBS), and the antibody test for IBS is A.S.C.A (Anti
saccharomyces cerevisiae antibody)
B. This patient likely has Crohn's disease, and the associated antibody test for Crohn's disease is
p-ANCA
C. The diagnosis is ulcerative colitis, and the associated antibody test for ulcerative colitis is p-ANCA
D. The likely diagnosis is infectious gastroenteritis, and the antibody test for confirming the infection is
p-ANCA.
5. A 45-year-old woman presents with recurrent intermittent chest pain at rest, accompanied by
episodes of dysphagia. An ECG is normal. Patient undergoes barium swallow. Which of the following is
correct about the diagnosis and findings seen in this condition?
(or)
What is the characteristic barium swallow finding seen in diffuse esophageal spasm?
A. Barium swallow shows irregular narrowing of lower esophagus, suggesting stricture formation
B. Smooth and symmetric narrowing of the esophagus, consistent with diagnosis of esophageal
diverticulum
C. Corkscrew or Rosary bead appearance is consistent with the diagnosis of diffuse esophageal spasm
D. Dilated esophagus with impaired peristalsis, resembling a "bird's beak" appearance
6. A 40-year-old patient presents with painless rectal bleeding. Proctoscopy is performed to investigate
the source of bleeding, revealing internal hemorrhoids. Which of the following statements accurately
describes Grade III internal hemorrhoids?
(or)
Which of the following statements accurately describes Grade III internal hemorrhoids?
A. Only visible on proctoscopy
B. Veins prolapsing during defecation and show spontaneous reduction
C. Veins prolapse out during defecation and reduce only on digital repositioning
D. Veins prolapse out during defecation and do not reduce on digital repositioning
7. A 55-year-old patient presents with hematemesis and workup reveals a bleeding gastric ulcer. Which
of the following is correct about gastric ulcer?
(or)
Which of the following is correct about gastric ulcer?
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A. Most common site for gastric ulcers is the greater curvature
B. Gastric ulcers most commonly occur in the lesser curvature
C. Bleeding gastric ulcers are predominantly found in the fundus, and are associated with hiatal hernia
D. Gastric ulcers commonly occur at the pylorus
E.
8. A 50-year-old patient presents with sudden-onset chest pain after a bout of forceful vomiting. The
patient reports feeling a tearing sensation in the lower chest. Considering suspected diagnosis of
Boerhaave syndrome, which investigation is the most appropriate for confirming the rupture site and
guiding further management?
(or)
Which investigation is the most appropriate for confirming the rupture site and guiding further
management in Boerhaave syndrome?
A. Esophageal manometry
B. Upper gastrointestinal endoscopy
C. CT chest with oral contrast
D. Barium swallow
9. Which of the following conditions causes increased lower esophageal sphincter tone?
A. Achalasia Cardia
B. Gastroesophageal Reflux Disease
C. Diffuse Esophageal Spasm
D. Nutcracker Esophagus
10. A 35-year-old woman presents with progressive dysphagia, halitosis, and recurrent episodes of
regurgitation of undigested food items. Esophageal manometry reveals increased tone of the lower
esophageal sphincter. Which of the following is correct about the radiographic findings of this
(or)
What specific radiographic appearance is expected in achalasia cardia?
A. "Bird's beak" appearance in barium enema
B. Pencil tip appearance in barium swallow
C. Rat tail filling defect on barium swallow
D. "String of beads" appearance on barium swallow
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Correct Options C - "Moustache sign" on the abdominal X-ray indicates perforation peritonitis:
 The "Moustache sign" on an abdominal X-ray is characteristic of free intraperitoneal air, seen in cases
of perforated duodenal ulcers.
 This sign indicates the presence of gas under the diaphragm.
Option A - Most common cause of peritonitis is a posteriorly located gastric ulcer: The most frequent ca
use of peritonitis in duodenal ulcers is an anteriorly located perforation, not a posterior perforation. 
Option B- Bleeding is more commonly associated with duodenal ulcers with anterior location: Bleeding 
associated with duodenal ulcers primarily occurs from the posterior source, often involving the Gastrod
uodenal artery, not the anterior source.
Option D - Initial management of the perforated duodenal ulcer involves upper GI endoscopy with adre
naline application at the base of the ulcer and electrocautery: Initial management of a perforated duode
nal ulcer involves emergent surgery, not upper GI endoscopy. Adrenaline and electrocautery are used i
n the acute management of bleeding peptic ulcers.
Correct Option B - Mallory-Weiss syndrome is suspected, and if bleeding recurs, the recommended ap
proach is upper gastrointestinal endoscopy with local adrenaline injection and hemostatic clips:
 The patient's presentation with severe hematemesis following excessive alcohol consumption and
forceful retching is suggestive of Mallory-Weiss syndrome.
 This syndrome is characterized by submucosal tears near the gastroesophageal junction, often
associated with vigorous vomiting or retching. The primary site of the tear is the lower esophageal
sphincter, and the bleeding source is the left gastric artery.
 It is a self-limiting condition.
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 However, in case of recurrence, endoscopic adrenaline injection and hemostatic clips may
be required. 
 
Option A - The patient is likely suffering from esophageal varices, and the initial management involves 
beta-blockers for hemodynamic control: Esophageal varices are associated with chronic liver disease, 
not acute alcohol-related binge drinking. Initial management of esophageal varices involves vasoactive
 medications like octreotide or endoscopic intervention, not beta-blockers.
Option C - This patient's symptoms are indicative of a
lower gastrointestinal bleed, and the initial diagnostic step should include a colonoscopy: The presentat
ion and history suggest an upper gastrointestinal bleed (Mallory-Weiss syndrome) rather than a
lower gastrointestinal bleed. A colonoscopy is not the initial diagnostic step in this context.
Option D - Given the history of alcohol consumption, the patient is likely experiencing an acute pancrea
titis episode, and treatment involves pancreatic enzyme replacement therapy: The patient's symptoms 
and history are more indicative of Mallory-Weiss syndrome related to alcohol consumption and retching
, not acute pancreatitis. Pancreatic enzyme replacement therapy is not the appropriate treatment for thi
s scenario.
Correct Option B - Esophageal varices with gastric veins are the source of bleeding in this patient with 
portal hypertension:
 Portal hypertension, seen in chronic liver disease, leads to increased pressure in the portal venous
system. When the hepatic venous pressure gradient exceeds 5 mmHg and particularly when it
surpasses 12 mmHg, esophageal varices may rupture, resulting in hematemesis. The source of
bleeding is attributed to the rupture of esophageal varices and esophageal collaterals with gastric
veins.
 
Option A - The bleeding is likely originating from the hepatic artery due to increased pressure in the por
tal system: Portal hypertension does not lead to bleeding from the hepatic artery. The primary impact is
 on the portal venous system and its tributaries.
Option C - The source of bleeding is primarily from the superior mesenteric artery: The superior mesen
teric artery is not directly implicated in the source of bleeding in portal hypertension. The primary conce
rn lies in the portal venous system and its complications, such as esophageal varices.
Option D - Hematemesis in portal hypertension is commonly caused by erosive gastritis with involveme
nt of the gastric arteries: Erosive gastritis causes peptic ulceration.
- The diagnosis is ulcerative colitis, and the associated antibody test for ulcerative colitis is p-ANCA:
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 The patient's symptoms, including colicky abdominal pain, severe bloody diarrhea, and physical
examination findings of pallor, puffy eyes, and pedal edema, are suggestive of severe ulcerative colitis.
In ulcerative colitis, inflammation predominantly affects the colon, leading to bloody diarrhea and
systemic symptoms. The associated antibody for ulcerative colitis is p-ANCA (perinuclear antineutrophil
cytoplasmic antibody).
 
Option A - The likely diagnosis is irritable bowel syndrome (IBS), and the antibody test for IBS is A.S.C.
A (Anti saccharomyces cerevisiae antibody): The symptoms and clinical presentation described are mo
re indicative of inflammatory bowel disease (IBD), not irritable bowel syndrome (IBS). The associated a
ntibody for Crohn's disease is A.S.C.A, not IBS.
Option B - This patient likely has Crohn's disease, and the associated antibody test for Crohn's disease
 is p-ANCA: The symptoms and presentation align more with ulcerative colitis than Crohn's disease. Ad
ditionally, the correct antibody associated with Crohn's disease is A.S.C.A, not p-ANCA.
Option D - The likely diagnosis is infectious gastroenteritis, and the antibody test for confirming the infe
ction is p-ANCA: The symptoms described are more suggestive of chronic inflammatory conditions like 
IBD rather than infectious gastroenteritis. Additionally, p-ANCA is associated with ulcerative colitis, not 
infectious gastroenteritis.
- Corkscrew or Rosary bead appearance is consistent with the diagnosis of diffuse esophageal spasm:
 Diffuse esophageal spasm is associated with abnormal, uncoordinated contractions of the esophageal
muscles, leading to a corkscrew or Rosary bead appearance on a barium swallow study.
 This distinctive radiographic finding results from the simultaneous, high-amplitude contractions of the
esophageal wall. 
 
Option A - Barium swallow shows irregular narrowing of the lower esophagus, suggesting stricture form
ation: Narrowing at the lower esophagus is suggestive of stricture formation.
Option B - Smooth and symmetric narrowing of the esophagus, consistent with diagnosis of esophagea
l diverticulum: This description is suggestive of conditions such as achalasia or esophageal diverticula.
Option D - Dilated esophagus with impaired peristalsis, resembling a
"bird's beak" appearance: Dilated esophagus with impaired peristalsis, resembling a
"bird's beak" appearance, is more indicative of achalasia.
Correct Option C - Veins prolapse out during defecation and reduce only on digital repositioning:
In the grading system for internal hemorrhoids:
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 Grade I: Veins are visible on proctoscopy.
 Grade II: Veins prolapse out, with spontaneous reduction.
 Grade III: Veins prolapse out, and they can be manually repositioned successfully.
 Grade IV: Veins prolapse out, and digital repositioning fails.
 
Options A, B, and D: Are for grades I, II, and IV, respectively. 
Correct Option B - Gastric ulcers most commonly occur in the lesser curvature:
In the context of gastric ulcers:
 The most common site for gastric ulcers is the lesser curvature.
 The bleeding in gastric ulcers is attributed to the left gastric artery.
 The presentation of bleeding gastric ulcers and duodenal ulcers often involves crashing blood
pressure.
 
Option A, C, D: The most common site of gastric ulcer is the lesser curvature. 
Correct Option C - CT chest with oral contrast:
 In suspected Boerhaave syndrome, CT chest with oral contrast (commonly Gastrografin contrast) is
the investigation of choice. This imaging modality is effective in confirming the rupture site, evaluating
the extent of mediastinal involvement, and guiding further management.
 
Option A - Esophageal manometry: It is used for assessing esophageal motility disorders.
Option B - Upper gastrointestinal endoscopy: It is not the primary investigation for confirming the ruptur
e site. It can worsen the rupture.
Option D - Barium swallow: Barium swallow is not the preferred investigation in the acute setting of Bo
erhaave syndrome. It can lead to leakage of contrast into the mediastinum, causing chemical mediastin
itis. 
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Correct Option A - Achalasia Cardia:
 Due to the loss of nitric oxide and vasoactive intestinal peptide-releasing inhibitory neurons, loss of
inhibitory innervation in achalasia results in failure of LES relaxation as well as loss of esophageal
peristalsis. 
Options B, C, D: GERD will have reduced LES tone. Diffuse esophageal spasm and nutcracker esopha
gus will have non-coordinated esophageal contractions. 
 
Correct Option B - Pencil tip appearancein barium swallow:
 Achalasia cardia is the clinical diagnosis and shows smooth tapering of contrast in lower esophagus. 
Option A - "Bird's beak" appearance in barium enema: It is seen in sigmoid volvulus. 
Option C - Rat tail filling defect on barium swallow: It is seen in carcinoma esophagus.
Option D - "String of beads" appearance on barium swallow: It is seen in diffuse esophageal spasm. 
 
491

Peptic Ulcer Disease
1. A 35-year-old patient has been diagnosed with Peutz-Jeghers Syndrome. What is the most common
site for the development of polyps seen in this condition?
(or)
What is the most common site for developing polyps in Peutz-Jeghers Syndrome?
A. Colon
B. Duodenum
C. Jejunum
D. Ileum
2. Which artery is the source of bleeding in gastric ulcer?
A. Celiac artery
B. Left gastric artery
C. Superior mesenteric artery
D. Splenic artery
3. Which artery is the most common source of bleeding in duodenal ulcer?
A. Left gastric artery
B. Superior mesenteric artery
C. Gastroduodenal artery
4. A 60-year-old patient presents to the emergency department with severe left iliac fossa pain and
obstipation, unable to pass even flatus. Which radiological finding is most likely to be observed in this
patient's X-ray abdomen?
A. Cupola sign
B. Coffee bean sign
C. Target sign
D. Thumbprinting sign
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Correct Option C - Jejunum:
 In Peutz-Jeghers Syndrome, hamartomatous polyps are most commonly found in the jejunum.
 These polyps can lead to recurrent episodes of bleeding, obstruction, and intussusception.
 
Options A, B, and D are ruled out based on above explanation. 
Correct Option B - Left gastric artery: 
 The source of bleeding in gastric ulcer is primarily the left gastric artery. Gastric ulcers can erode into
blood vessels, leading to gastrointestinal bleeding.
 The left gastric artery, a branch of the celiac artery, supplies blood to the lesser curvature of the
stomach and is commonly implicated in bleeding associated with gastric ulcers.
Option A - Celiac artery:
 The celiac artery is the main arterial supply to the upper abdominal organs, including the stomach.
While it supplies blood to the stomach, the left gastric artery, a branch of the celiac artery, is specifically
responsible for bleeding in gastric ulcers.
Option C - Superior mesenteric artery:
 The superior mesenteric artery supplies blood to the small intestine and parts of the large intestine,
but it is not directly involved in bleeding associated with gastric ulcers.
Option A - Splenic artery:
 The splenic artery supplies blood to the spleen, pancreas, and parts of the stomach. While it
contributes to the blood supply of the stomach, it is not the primary source of bleeding in gastric ulcers.
Correct Option C - Gastroduodenal artery: 
 The most common source of bleeding in duodenal ulcer is the gastroduodenal artery. Duodenal ulcers
can erode into blood vessels, leading to gastrointestinal bleeding.
 The gastroduodenal artery, a branch of the common hepatic artery, supplies blood to the stomach and
duodenum. Bleeding from a duodenal ulcer typically occurs from the posterior branch of the
gastroduodenal artery.
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Option A - Left gastric artery:
 While the left gastric artery is a branch of the celiac artery and contributes to the blood supply of the
stomach, it is the primary source of bleeding in gastric ulcers not duodenal ulcers.
Option B - Superior mesenteric artery:
 The superior mesenteric artery supplies blood to the small intestine and parts of the large intestine but
is not directly involved in bleeding associated with duodenal ulcers.
Option D - Splenic artery:
 The splenic artery supplies blood to the spleen, pancreas, and parts of the stomach but is not the
primary source of bleeding in duodenal ulcers.
Correct Option B - Coffee bean sign:  
 The patient's symptoms and clinical presentation are indicative of sigmoid volvulus.
 The radiological finding most commonly associated with sigmoid volvulus on X-ray abdomen is the
"coffee bean sign." This sign appears due to the characteristic twisted appearance of the sigmoid colon
resembling two adjacent coffee beans.
 It is a result of the torsion and subsequent obstruction of the sigmoid colon.
Option A - Cupola sign:
 The cupola sign refers to the appearance of a rounded dome-like opacity seen on X-ray or CT scan in
cases of colonic pseudo-obstruction (Ogilvie syndrome), not sigmoid volvulus.
Option C - Target sign:
 The target sign is typically observed in imaging studies such as CT scans in cases of intussusception,
where the inner hypodense ring represents the intussusceptum and the outer hyperdense ring
represents the intussuscipiens.
Option D - Thumbprinting sign:
 The thumbprinting sign refers to the appearance of thumbprint-like indentations seen on abdominal
X-rays or CT scans in cases of acute colitis, often associated with inflammatory bowel disease or
ischemic colitis. It is not specific to sigmoid volvulus.
494

Diseases of Adrenal Gland
1. Which of the following statements accurately describes the functional characteristics of different
layers of the adrenal gland?
A. The zona glomerulosa primarily secretes cortisol
B. The zona fasciculata synthesizes mineralocorticoids such as aldosterone
C. The zona reticularis is responsible for the production of androgens.
D. The adrenal medulla secretes glucocorticoids.
2. A 12-year-old female presents with a lack of development of secondary sexual characteristics.
Laboratory investigations reveal low serum potassium and elevated levels of mineralocorticoids, as well
as decreased sex hormones and cortisol. Which of the following enzyme deficiencies is most likely
responsible for this patient's condition?
(or)
What enzyme deficiency is likely responsible for the lack of secondary sexual characteristics, with low
serum potassium, elevated mineralocorticoids, and decreased sex hormones and cortisol in a
12-year-old female?
A. 21-Hydroxylase Deficiency
B. 11-Beta Hydroxylase Deficiency
C. 17-Hydroxylase Deficiency
D. 3-Beta Hydroxysteroid Dehydrogenase Deficiency
3. Aldosterone exerts its effects on renal tubular cells to regulate sodium and potassium balance.
Which of the following statements accurately describes the mechanism of action of aldosterone?
(or)
Which of the following describes the mechanism of action of aldosterone?
A. Aldosterone acts directly on the intercalated cells of the collecting duct, stimulating the secretion of
acids in the urine.
B. Aldosterone binds to its receptor in the principal cells of the collecting duct, activating various
channels and the Na-K-ATPase pump.
C. Aldosterone primarily acts on the distal convoluted tubule, inhibiting the reabsorption of sodium and
enhancing the secretion of potassium.
D. Aldosterone exerts its effects by directly binding to cell membrane receptors, stimulating the activity
of H+ ATPase.
4. A 42-year-old woman with a history of persistent hypertension presents with muscle weakness,
frequent urination, and palpitations. Despite taking multiple antihypertensive medications for two years,
her blood pressure remains high at 160/98 mmHg. Lab results show a serum potassium level of 2.8
mEq/L, high serum bicarbonate of 32 mEq/L, and plasma aldosterone concentration of 310 ng/dL with
suppressed plasma renin activity. A salt loading test is performed to further evaluate her condition.
What test result would be consistent with the suspected diagnosis?
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Page 2
(or)
Which result from the salt loading test is most consistent with the suspected diagnosis in a female with
persistent refractory hypertension, hypokalemia, metabolic alkalosis, elevated plasma aldosterone
concentration, and suppressed plasma renin activity?
A. A significant decrease in plasma aldosterone concentration after salt loading
B. A significant increase in plasma aldosterone concentration after salt loading
C. A significant decrease in plasma renin activity after salt loading
D. A significant increase in plasma renin activity after salt loading
5. A 45-year-old male presents with a long history of uncontrolled hypertension despite receiving
multiple antihypertensive medications. Laboratory tests reveal persistently high potassium levels, a
blood pH of 7.35, hyperchloremia, and decreased renin activity. Which of the following conditions is the
most likely underlying cause?
(or)
What is the most likely underlying cause of uncontrolled hypertension, hyperkalemia, and metabolic
acidosis in a male?
A. Gordon's syndrome
B. Bartter Syndrome
D. Sheehan syndrome
6. A 35-year-old woman presents with weakness, weight loss, hyperpigmentation under her breast, and
increased craving for salty foods. Upon examination, low blood pressure and hyperpigmentation under
the breast were noticed. Lab tests indicate low cortisol levels and high plasma adrenocorticotropic
hormone levels, as well as a serum sodium level of 128 mEq/L and a serum potassium level of 6.2
mEq/L. Which of the following is true about the drug of choice for treating this condition?
(or)
Which statement is true regarding the drug of choice for the treatment of the disease in a female with
low blood pressure, hyperpigmentation, hyponatremia, hyperkalemia, low plasma cortisol, and elevated
plasma ACTH levels?
A. It exhibits a high mineralocorticoid to glucocorticoid ratio
B. It exhibits a low mineralocorticoid to glucocorticoid ratio
C. It exhibits equal mineralocorticoid and glucocorticoid activity
D. It exhibits potent glucocorticoid activity only
7. A 38-year-old female presents with symptoms of chronic fatigue, increased susceptibility to
infections, and difficulty coping with stress. Laboratory tests reveal low cortisol levels. Considering the
functions of cortisol, which of the following physiological processes is primarily associated with cortisol?
(or)
Which physiological process is primarily associated with cortisol?
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Page 3
A. Maintenance of calcium homeostasis and bone health
B. Regulation of body temperature and thermoregulation
C. Modulation of the body's stress response and immune function
D. Regulation of fluid balance and electrolyte levels
8. A 32-year-old male with a known history of asthma has been on long-term oral prednisone. He
presents to the clinic with complaints of easy bruising and poor wound healing. Upon examination, a
round face, central obesity, and thin skin with striae are observed. Lab investigations revealed elevated
blood glucose levels. Which of the following measures is the most appropriate to avoid the mentioned
complications in this patient?
(or)
What is the most appropriate measure to prevent complications like elevated blood glucose, round
face, central obesity, and poor wound healing in a male with asthma on long-term oral prednisone?
A. Increase the dose of oral corticosteroids for better control of asthma.
B. Switch to long-acting corticosteroids for a sustained effect.
C. Divide the daily corticosteroid dose into multiple administrations throughout the day.
D. Gradually taper the corticosteroid dose when discontinuing treatment.
9. A 40-year-old woman presents with a complaint of weight gain over the past 5 months. She has
central obesity, buffalo hump, and abdominal striae on physical examination. A diagnosis of Cushing's
syndrome is made. Mark the correct statement regarding the Cushing syndrome.
(or)
Mark the correct statement regarding the Cushing syndrome.
A. Leading cause of ACTH independent Cushing syndrome is Pituitary Corticotroph adenoma
B. ACTH independent Cushing syndrome constitutes 20% of total cases of Cushing syndrome
C. Leading cause of ACTH-dependent Cushing syndrome is Adrenocortical adenoma
D. Small cell lung cancer produces ectopic cortisol
10. A 60-year-old woman with a 40-pack-year history of smoking is experiencing shortness of breath
and difficulty climbing stairs. Examination revealed reduced breath sounds over the right lung base,
and a chest X-ray showed a lung mass in her right lower lobe. Her serum cortisol and ACTH levels are
at the upper limit of normal and are not suppressed after low-dose dexamethasone administration.
What changes are likely to occur in her cortisol and ACTH levels after administering high-dose
dexamethasone?
(or)
Which of the following changes are most likely to occur to ACTH and cortisol after administration of
high-dose dexamethasone in an old woman with small cell lung carcinoma?
A. Decrease, decrease
B. Increase, Increase
C. No change, No change
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Page 4
D. Increase , Decrease
11. A 38-year-old man with a family history of MEN2 presents with an intermittent and severe
headache, palpitations, and excessive sweating. A palpable mass is detected in his upper left abdomen
during the physical examination and his blood pressure is 180/100 mmHg. Laboratory tests reveal
increased urinary levels of metanephrines and catecholamines. What is the investigation of choice for
this patient?
(or)
What is the investigation of choice for a male who presents with intermittent headache, palpitations,
and profuse sweating with a family history of multiple endocrine neoplasia type 2 (MEN2) and
laboratory investigations demonstrating increased urinary levels of metanephrines and
catecholamines?
A. Contrast-enhanced CT scan of the abdomen
B. 24-hour urine collection for vanillylmandelic acid (VMA)
C. Plasma-free metanephrines
D. MRI of the abdomen
12. A 3-year-old child is brought a history of abdominal distension and diarrhea. The parents report that
the child has lost weight and appears pale recently. Physical examination reveals a firm, irregular mass
in the abdomen. Laboratory investigations show anemia and elevated urinary catecholamines. A biopsy
of the mass is performed, and a histological image is shown below. Which of the following factors is
most likely to be associated with a good prognosis in this patient?
(or)
What factor correlates with a favorable prognosis in a 3-year-old child with abdominal distension,
weight loss, anemia, elevated urinary catecholamines, and an irregular abdominal mass on physical
examination?
A. Age above 18 months
B. Poor differentiation (gangliocytic or schwannian)
C. High mitosis-karyorrhexis index (MKI >200/5000 cells)
D. TrkA expression
13. Which of the following diseases is NOT due to a peptide hormone?
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Page 5
A. Diabetes mellitus
B. Acromegaly
C. Cushing's disease
14. A 35-year-old female presents with complaints of fatigue, weakness, weight loss, dizziness, and low
blood pressure over the past few months. Upon examination, her skin appears hyperpigmented on the
knuckles, elbows, and knees. Lab investigations reveal hyponatremia, hyperkalemia, and elevated
plasma adrenocorticotropic hormone levels. Where are the receptors located for the involved hormone
in this disease?
(or)
Where are the receptors located for the hormone responsible for causing Addison's disease?
A. Intracytoplasmic
B. On the nucleus
C. On cell membrane
D. Both nuclear and intracytoplasmic
Correct Option C - The zona reticularis is responsible for the production of androgens:
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Page 6
 The zona reticularis synthesizes androgens, including dehydroepiandrosterone (DHEA) and
androstenedione. These androgens are precursors for the production of testosterone.
Option A - The zona glomerulosa primarily secretes cortisol: The zona glomerulosa is responsible for t
he production of mineralocorticoids, primarily aldosterone, which regulates electrolyte and fluid balance
.
Option B - The zona fasciculata synthesizes mineralocorticoids such as aldosterone:
The zona fasciculata produces glucocorticoids, primarily cortisol, which plays a
role in metabolism regulation and stress response.
Option D - The adrenal medulla secretes glucocorticoids: The adrenal medulla is responsible for the pr
oduction and secretion of catecholamines, specifically epinephrine (adrenaline) and norepinephrine, w
hich are involved in the "fight or flight" response.
Correct Option C - 17-Hydroxylase Deficiency:
 The patient's presentation of a lack of development of secondary sexual characteristics, with low
serum potassium, elevated levels of mineralocorticoids, decreased sex hormones, and cortisol, is
diagnostic of 17-hydroxylase deficiency.
 In male patients, there will be ambiguous genitalia and undescended testes.
Option A - 21-Hydroxylase Deficiency: Its deficiency leads to glucocorticoid deficiency, mineralocorticoi
d deficiency, and adrenal androgen excess.
Option B - 11-Beta Hydroxylase Deficiency: Its deficiency leads to glucocorticoid deficiency, mineraloc
orticoid excess, and adrenal androgen excess.
Option D - 3-Beta Hydroxysteroid Dehydrogenase Deficiency: Its deficiency leads to glucocorticoid defi
ciency, (mineralocorticoid deficiency), adrenal androgen excess (females and males), gonadal androge
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Page 7
n deficiency (males)
Correct Option B - Aldosterone binds to its receptor in the principal cells of the collecting duct, activatin
g various channels and the Na-K-ATPase pump:
 This statement accurately describes the mechanism of action of aldosterone. Aldosterone binds to its
receptor in the principal cells of the collecting duct. The hormone-receptor complex activates various
channels, including the ENaC (Epithelial sodium) channel, leading to increased sodium reabsorption.
Aldosterone also stimulates the Na-K-ATPase pump, facilitating sodium exit into the blood. This results
in the reabsorption of sodium and the secretion of potassium.
 
Option A - Aldosterone acts directly on the intercalated cells of the collecting duct, stimulating the secre
tion of acids in the urine: Aldosterone does not directly act on the intercalated cells responsible for acid
 secretion in the urine. Its main action occurs on the principal cells of the collecting duct.
Option C - Aldosterone primarily acts on the distal convoluted tubule, inhibiting the reabsorption of sodi
um and enhancing the secretion of potassium: Although aldosterone does play a role in regulating sodi
um and potassium balance, its main site of action is not the distal convoluted tubule but rather the princ
ipal cells of the collecting duct.
Option D - Aldosterone exerts its effects by directly binding to cell membrane receptors, stimulating the
 activity of H+ ATPase: While aldosterone does have cell membrane receptors, its main mechanism of 
action is not through these receptors. Aldosterone primarily acts through genomic action by binding to i
ts receptor in the nucleus and affecting gene expression, leading to the activation of various channels i
ncluding H+ ATPase.
Correct Option B - A significant increase in plasma aldosterone concentration after salt loading:
 The clinical features observed in this patient, including persistent hypertension that is difficult to
control, muscle weakness, frequent urination, are consistent with the manifestations of Conn's
syndrome. Hypertension is a hallmark of this condition and is often resistant to multiple
antihypertensive medications. The presence of muscle weakness can be attributed to hypokalemia
resulting from excessive aldosterone-induced potassium excretion in the kidneys. Metabolic alkalosis
occurs due to hydrogen ion secretion and potassium reabsorption in the renal tubules, further
reinforcing the suspicion of hyperaldosteronism.
 To confirm the suspected diagnosis, a salt loading test is performed. The rationale behind this test is
that a high-sodium diet or intravenous saline infusion should normally suppress aldosterone secretion
through feedback inhibition. However, in patients with Conn's syndrome, the autonomous aldosterone
production persists despite salt loading. Therefore, the expected result in this patient is a significant
increase in plasma aldosterone concentration after salt loading, as option B suggests.
 
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Option A - A significant decrease in plasma aldosterone concentration after salt loading: This option is i
ncorrect because in Conn's syndrome, the autonomous overproduction of aldosterone by the adrenal g
lands is not suppressed by salt intake. Therefore, instead of a
decrease, an increase in plasma aldosterone concentration is expected during the salt loading test.
Option C - A significant decrease in plasma renin activity after salt loading: This option is incorrect bec
ause in Conn's syndrome, plasma renin activity is usually suppressed due to the negative feedback ex
erted by aldosterone on the renin-angiotensin-aldosterone system. Therefore, a
decrease in plasma renin activity is expected even without salt loading.
Option D - A significant increase in plasma renin activity after salt loading: This option is incorrect beca
use in Conn's syndrome, plasma renin activity is typically suppressed rather than increased. The exces
sive production of aldosterone by the adrenal glands inhibits renin release and subsequently reduces p
lasma renin activity.
Correct Option A - Gordon's syndrome:
 Gordon's syndrome, also known as pseudohyperaldosteronism type II, is a genetic condition that
causes persistent high blood pressure, high levels of potassium and chloride in the blood, metabolic
acidosis, and decreased activity of renin in the plasma.
 This condition is caused by a gain of function in the sodium chloride cotransporter (NCC) at the distal
convoluted tubule, which results in increased absorption of sodium and chloride. This excess
absorption leads to a negative charge, which the body neutralizes by drawing hydrogen ions from the
collecting duct, ultimately causing acidosis.
 
Option B - Bartter syndrome: It is associated with persistent hypotension, hypokalemia, and metabolic 
alkalosis, but it is characterized by high plasma renin and aldosterone levels.
Option C - Addison's disease: It typically presents with symptoms such as fatigue, muscle weakness, a
nd hypotension. Laboratory findings include hyponatremia, hyperkalemia, and metabolic acidosis, high 
renin activity.
Option D - Sheehan syndrome: This occurs due to postpartum hemorrhage and subsequent pituitary gl
and damage and may lead to various hormone deficiencies (panhypopituitarism), but it does not typical
ly present with hypertension or altered potassium levels.
Correct Option C - It exhibits equal mineralocorticoid and glucocorticoid activity:
 The clinical presentation and laboratory findings described in the scenario are consistent with primary
adrenal insufficiency, also known as Addison's disease. Addison's disease is characterized by
insufficient production of adrenal hormones, including both glucocorticoids and mineralocorticoids.
 The drug of choice for the treatment of Addison's disease is hydrocortisone, a synthetic glucocorticoid.
Hydrocortisone closely mimics the actions of cortisol, the naturally occurring glucocorticoid hormone. It
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 Cortisol also influences immune function by decreasing circulating lymphocytes by increasing their
apoptosis and inhibiting the production of IL-2 and T lymphocytes.
 
Option A - Maintenance of calcium homeostasis and bone health: These are primarily regulated by hor
mones such as parathyroid hormone (PTH) and calcitonin, rather than cortisol.
Option B - Regulation of body temperature and thermoregulation: The regulation of body temperature p
rimarily involves the hypothalamus and other thermoregulatory mechanisms, with limited involvement o
f cortisol.
Option D - Regulation of fluid balance and electrolyte levels: The primary hormone involved in fluid bal
ance and electrolyte regulation is aldosterone.
Correct Option D - Gradually taper the corticosteroid dose when discontinuing treatment:
 The clinical features described in the patient, including a round face, central obesity, thin skin with
striae, easy bruising, poor wound healing, and elevated blood glucose levels, are suggestive of
Cushingoid features and hyperglycemia, which are commonly associated with prolonged and high-dose
corticosteroid therapy. To avoid these complications, it is essential to gradually taper the corticosteroid
dose when discontinuing treatment. Abrupt cessation of corticosteroids can lead to adrenal
insufficiency due to HPA (hypothalamic-pituitary-adrenal) axis suppression. Gradual tapering allows the
HPA axis to recover and resume normal cortisol production.
 
Option A - Increase the dose of oral corticosteroids for better control of asthma: It can further exacerbat
e the adverse effects.
Option B - Switch to long-acting corticosteroids for a
sustained effect: Switching to long-acting corticosteroids may provide a
sustained effect, but it does not address the issue of avoiding complications.
Option C - Divide the daily corticosteroid dose into multiple administrations throughout the day: Dividin
g the daily corticosteroid dose into multiple administrations can be helpful in some cases, but it does no
t directly address the need for tapering to prevent HPA axis suppression and related complications.
- ACTH-independent Cushing syndrome constitutes 20% of total cases of Cushing syndrome:
Classification of endogenous Cushing's syndrome
 ACTH-dependent – 80% Pituitary adenoma secreting ACTH (Cushing’s disease) – 70% Ectopic
ACTH syndrome (bronchial carcinoid, small-cell lung carcinoma, other neuro-endocrine tumour) – 10%
 Pituitary adenoma secreting ACTH (Cushing’s disease) – 70%
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Correct Option C - Plasma-free metanephrines:
 This clinical scenario is suggestive of a pheochromocytoma, a catecholamine-secreting tumor
typically arising from the adrenal medulla. Pheochromocytomas can cause paroxysmal hypertension,
severe headaches, palpitations, and sweating. The presence of a palpable mass in the left upper
abdomen further supports this diagnosis.
 Measurement of plasma-free metanephrines is the most sensitive and specific initial test for detecting
pheochromocytomas. Plasma-free metanephrines (metanephrine and normetanephrine) are the
breakdown products of catecholamines and are elevated in the setting of a pheochromocytoma.
 
Option A - Contrast-enhanced CT scan of the abdomen: It is a valuable imaging modality to localize th
e tumor once the diagnosis of pheochromocytoma is confirmed. However, it is not the initial investigatio
n of choice.
Option B - A 24-hour urine collection for vanillylmandelic acid (VMA): It is an older test that measures t
he breakdown product of epinephrine and norepinephrine. Although it can be used in the workup of ph
eochromocytoma, it is less sensitive and specific compared to plasma-free metanephrines.
Option D - MRI of the abdomen: It can provide detailed anatomical information about the tumor and sur
rounding structures. However, it is not the initial investigation of choice in this scenario.
Correct Option D - TrkA expression:
 In this case, the 3-year-old child presented with abdominal distension, diarrhea, weight loss, and a
firm, irregular mass in the abdomen. These clinical features are consistent with neuroblastoma, as
abdominal tumors are commonly seen in this condition. Additionally, laboratory investigations showed
anemia and elevated urinary catecholamines, which are often observed in neuroblastoma due to the
tumor's production of catecholamine metabolites.
 The presence of neuroblastic cells with scant cytoplasm and hyperchromatic nuclei is often observed.
Other characteristic features in the given histological image include Homer-Wright rosettes, which are
circular arrangements of tumor cells around a central neurofibril or the presence of undifferentiated
stroma. These features further support the diagnosis of neuroblastoma. The expression of TrkA, a
neurotrophic tyrosine kinase receptor, is associated with a good prognosis in neuroblastoma.
 
Option A
- Age above 18 months: In neuroblastoma, patients who are younger than 18 months of age have a mo
re favorable prognosis compared to those older than 18 months. Therefore, age above 18 months is as
sociated with a worse prognosis.
Option B - Poor differentiation (gangliocytic or schwannian): Poor differentiation, characterized by gang
liocytic or schwannian features in the tumor, is associated with a worse prognosis in neuroblastoma.
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Option C - High mitosis-karyorrhexis index (MKI >200/5000 cells): A high MKI, indicating a
higher mitotic rate and karyorrhexis (fragmentation of nuclei), is associated with a
worse prognosis in neuroblastoma. A low MKI(<200/500) would be more favorable.
Correct Option C - Cushing's disease:
 Cushing's disease is NOT due to a peptide hormone. Cushing's disease is a condition characterized
by the excessive production of cortisol, a steroid hormone. It is caused by a pituitary gland tumor that
stimulates the overproduction of adrenocorticotropic hormone (ACTH), which in turn leads to increased
cortisol production by the adrenal glands. ACTH is a peptide hormone produced by the anterior pituitary
gland.
 
Option A - Diabetes mellitus: Diabetes mellitus is a metabolic disorder characterized by high blood sug
ar levels. It can be caused by insufficient production or ineffective use of insulin, which is a
peptide hormone produced by the beta cells of the pancreas.
Option B - Acromegaly: Acromegaly is a rare hormonal disorder caused by an excess of growth hormo
ne (GH). Excessive GH production is usually due to a benign tumor of the pituitary gland. GH is a
peptide hormone secreted by the anterior pituitary gland.
Option D - None of the above: Cushing's disease is a
condition characterized by the excessive production of cortisol, a steroid hormone.
Correct Option D - Both nuclear and intracytoplasmic:
 In Addison's disease, there is a deficiency of cortisol due to the destruction or dysfunction of the
adrenal cortex. This results in decreased cortisol production and elevated levels of adrenocorticotropic
hormone (ACTH) from the anterior pituitary gland.
 The receptors for cortisol are present both in the cytoplasm and the nucleus of target cells. In the
cytoplasm, cortisol binds to its receptor, forming a hormone-receptor complex. This complex then
translocates to the nucleus, where it acts as a transcription factor, regulating gene expression and
influencing various cellular processes.
 
Options A, B, and C are incorrect. Refer to Option D for an explanation.
507

Zollinger Ellison Syndrome
1. A 38-year-old patient with giant duodenal ulcer is suspected to have Zollinger-Ellison Syndrome. To
identify the precise location of the tumor responsible for the excessive gastrin production, which
investigation should be done?
(or)
To identify the specific location of the tumor responsible for the excessive gastrin production in
Zollinger-Ellison Syndrome, which investigation should be done?
A. Secretin study
B. Fasting gastrin levels
C. Ga-68 DOTATATE PET-CT scan
D. Somatostatin scintigraphy
2. Which of the following statements incorrectly describes a border of the Passaro’s triangle?
A. Superiorly by the confluence of cystic and common bile ducts
B. Medially by the junction of the first and second part of the duodenum
C. Inferiorly by the junction of the second and third part of the duodenum
D. Medially by the junction of the neck and body of the pancreas.
3. A 40-year-old female presents with recurrent epigastric pain for which she has been taking proton
pump inhibitors (PPIs) for a prolonged period. She also reports experiencing diarrhea. What is the most
likely diagnosis based on this clinical scenario?
A. Peptic ulcer disease
B. Gastric cancer
C. Zollinger-Ellison Syndrome (Gastrinoma)
D. Irritable bowel syndrome (IBS)
Correct Option C - Ga-68 DOTATATE PET-CT scan:
 Zollinger Ellison Syndrome (ZES) is characterized by excessive gastrin production, leading to
recurrent peptic ulcers and acid reflux.
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 The most common site of gastrinoma is the duodenum, followed by the pancreas and stomach.
 To localize the tumor, Gallium-68 DOTATATE PET-CT scan is the preferred imaging modality. 
 It also the preferred imaging modality for pheochromocytoma. 
 
Option A - Secretin study: It is used to confirm the diagnosis of ZES by evaluating the increase in gastri
n levels after administration of secretin.
Option B - Fasting gastrin levels: It is a diagnostic test to measure elevated fasting gastrin levels, but it 
does not provide information about tumor localization.
Option D - Somatostatin scintigraphy: It is used for imaging metastatic ZES but is not the primary choic
e for initial tumor localization.
Correct Option B - Medially by the junction of the first and second part of the duodenum:
 Medially by the junction of the first and second parts of the duodenum is a wrong option because the
passaros triangle is bounded by the junction of the second and third parts of the duodenum inferiorly.
Passaro's triangle is formed by joining the following three points:
Options A, C, and D are incorrect, Refer to the explanation of the correct answer
 
Correct Option C - Zollinger-Ellison Syndrome (Gastrinoma) 
 Given the patient's clinical presentation of recurrent epigastric pain despite prolonged use of proton
pump inhibitors (PPIs) and diarrhea, along with the history of long-term PPI use, the most likely
diagnosis is Zollinger-Ellison Syndrome (Gastrinoma).
 This syndrome is characterized by the presence of gastrin-secreting tumors (gastrinomas), typically
located in the duodenum, pancreas, or stomach.
 These tumors lead to excessive gastrin production, resulting in increased gastric acid secretion,
peptic ulcers, and refractory symptoms despite PPI therapy.
Incorrect answer
Option A - Peptic ulcer disease:
 While peptic ulcer disease can cause recurrent epigastric pain, the patient's symptoms persist despite
prolonged use of proton pump inhibitors (PPIs), suggesting an underlying cause beyond typical peptic
ulcer disease.
Option B - Gastric cancer:
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 Gastric cancer may present with similar symptoms, but the history of long-term PPI use and the
presence of diarrhea are more indicative of Zollinger-Ellison Syndrome (Gastrinoma) than gastric
cancer.
Option D - Irritable bowel syndrome (IBS):
 While irritable bowel syndrome (IBS) can present with diarrhea and abdominal pain, the history of
long-term PPI use and the persistence of symptoms despite treatment are not typical of IBS.
Zollinger-Ellison Syndrome (Gastrinoma) is a more likely diagnosis in this case.
510

Inflammatory Bowel Disease
1. A 32-year-old patient with recurrent abdominal pain and diarrhea undergoes a barium meal
follow-through (enteroclysis) as part of the diagnostic work-up for suspected Crohn's disease. Imaging
reveals an irregular cobblestone pattern of the mucosa in the small intestine, and "String Sign of
Kantor." Which of the following is correct about "String Sign of Kantor"?
(or)
What is correct about the "String Sign of Kantor" in the case of Crohn's disease?
A. Signifies presence of deep serpiginous ulcers in the entire gut
B. Indicates the sparing of the rectum in Crohn's disease
C. Associated with the earliest presentation of aphthous ulcers
D. Stricture formation in the small intestine
2. A 60-year-old patient presents with explosive watery diarrhea, cramps, and abdominal pain following
recent antibiotic usage within the last 3 weeks. Which of the following antibiotics is most commonly
associated with the given presentation?
(or)
Which of the following antibiotics is most commonly associated with the development of
pseudomembranous colitis?
A. Penicillin
B. Tetracycline
C. Cephalosporins
D. Macrolides
3. A 28-year-old patient presents with chronic abdominal pain, diarrhea, and weight loss. A
colonoscopy reveals a cobblestone pattern of the mucosa in the terminal ileum. What is the most likely
diagnosis based on this clinical scenario?
A. Ulcerative colitis
B. Irritable bowel syndrome (IBS)
C. Crohn's disease
D. Diverticulitis
4. A 35-year-old patient presents with complaints of bloody diarrhea up to 15 times per day, anemia,
and puffy eyes. A colonoscopy reveals proctitis without granulomas on biopsy. Which condition is most
likely to be responsible for this clinical presentation?
A. Crohn's disease
C. Ulcerative colitis (UC)
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Correct Option D - Stricture formation in the small intestine:
 In Crohn's disease, the "String Sign of Kantor" refers to a characteristic radiographic finding observed
during a barium meal follow-through (enteroclysis).
 This sign is associated with the development of strictures in the small intestine. Strictures are areas of
narrowing and thickening of the intestinal wall, leading to a string-like appearance in imaging studies.
 The irregular cobblestone pattern of the mucosa and the "String Sign of Kantor" are indicative of
transmural involvement and submucosal fibrosis in Crohn's disease. 
 
Option A - Signifies presence of deep serpiginous ulcers in the entire gut: The "String Sign of Kantor" i
n Crohn's disease is not associated with deep serpiginous ulcers but rather with stricture formation in t
he small intestine.
Option B - Indicates the sparing of the rectum in Crohn's disease: The "String Sign of Kantor" is not rel
ated to the sparing of the rectum. Crohn's disease can involve any part of the gastrointestinal tract, incl
uding the rectum.
Option C - Associated with the earliest presentation of aphthous ulcers: The "String Sign of Kantor" is n
ot associated with the earliest presentation of aphthous ulcers. The earliest presentation in Crohn's dis
ease involves aphthous ulcers, but the "String Sign of Kantor" is a
later radiographic finding related to stricture formation.
Correct Option C - Cephalosporins:
 Pseudo Membranous Colitis (PMC) is often associated with the use of antibiotics, and cephalosporins
are among the antibiotics most commonly linked to its development. Other antibiotics, such as
clindamycin, are also known to be associated with PMC. Clostridium difficile toxin, resulting from
alteration in gut flora due to antibiotic use, is the causative factor in PMC. This condition typically
presents with explosive watery diarrhea, cramps, and abdominal pain.
 
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Options A, B, and D: These are less likely to cause PMC.
 Correct Option C - Crohn's disease:
 The patient's presentation of chronic abdominal pain, diarrhea, and weight loss, along with
colonoscopic findings of a cobblestone pattern of the mucosa in the terminal ileum, is highly suggestive
of Crohn's disease.
 Crohn's disease is characterized by chronic inflammation of the gastrointestinal tract, with the terminal
ileum being the most commonly affected site.
 The cobblestone appearance of the mucosa results from transmural involvement and submucosal
fibrosis, which is typical of Crohn's disease.
Option A - Ulcerative colitis:
 While ulcerative colitis is another form of inflammatory bowel disease, it typically presents with
continuous colonic involvement and does not exhibit the cobblestone pattern seen in Crohn's disease.
Option B - Irritable bowel syndrome (IBS):
 Irritable bowel syndrome (IBS) can cause abdominal pain and diarrhea, but it does not typically lead to
weight loss, and it does not cause the cobblestone pattern observed in Crohn's disease.
Option D - Diverticulitis:
 Diverticulitis involves inflammation of the diverticula, typically in the colon, and does not typically
present with a cobblestone pattern on colonoscopy.
 Additionally, diverticulitis usually occurs in older patients and is less commonly associated with weight
loss compared to Crohn's disease.
 
Correct Option C - Ulcerative colitis (UC): 
 The patient's symptoms of bloody diarrhea, anemia, and puffy eyes, along with colonoscopic findings
of proctitis without granulomas, are highly indicative of ulcerative colitis (UC).
 UC is a type of inflammatory bowel disease characterized by chronic inflammation and ulceration of
the colon and rectum. The hallmark feature of UC is bloody diarrhea, which can occur frequently
throughout the day.
 Anemia is common due to chronic blood loss, and protein-losing enteropathy can lead to
hypoalbuminemia, manifesting as puffy eyes.
 The most common site of involvement in UC is the rectum, and colonoscopy with biopsy is the
preferred diagnostic method.
Incorrect Options: Option A - Crohn's disease:
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 While Crohn's disease is another form of inflammatory bowel disease, it typically presents with skip
lesions, transmural inflammation, and granulomas on biopsy, which are not characteristic findings of
ulcerative colitis.
 Irritable bowel syndrome (IBS) can present with symptoms of diarrhea, but it does not typically cause
bloody diarrhea, anemia, or puffy eyes. Additionally, colonoscopic findings in IBS are typically normal.
 Diverticulitis is characterized by inflammation of the diverticula, typically in the colon, and is not
associated with the findings of proctitis seen in ulcerative colitis.
 Additionally, diverticulitis does not typically cause bloody diarrhea to the extent seen in ulcerative
colitis.
514

Malabsorption Syndrome
1. A 40-year-old patient presents with chronic abdominal pain, steatorrhea, and weight loss. Schilling
test is conducted and the results show normalization with supplementation of pancreatic enzymes.
What condition is most likely responsible for the abnormal Schilling test results in this patient?
(or)
What condition is most likely responsible for the appearance of normalization with supplementation of
pancreatic enzymes in Schilling test?
A. Small intestinal bacterial overgrowth
B. Chronic pancreatitis
C. Type A gastritis
D. Intestinal lymphangiectasia
2. A 10-year-old boy is brought to the clinic by his mother with complaints of developing lesions shown
below. She says that he has chronic diarrhea and has always been thin and skinny. Blood work was
done. Using the images below, identify the diagnosis and mark the option with correlating statements.
a) Anti-endomysial Ab is used for screening test b) Investigation of choice is a small intestine mucosal
biopsy c) Most common cause of death is osmotic diarrhea d)Dietary restrictions can reduce the
severity of the disease e) It predominantly affects absorption in the distal parts of the intestine f)
Diabetes mellitus can be one of its complications in the future
A. b, c, f
B. a, d, e
C. b, d, f
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D. a, c, e
3. A 50-year-old patient presents with symptoms of osmotic diarrhea, bloating, and weight loss. Patient
subsequently develops CNS features of dementia, nystagmus, and myoclonic jerks. What is the
causative organism responsible for the features described in this patient?
(or)
What is the causative organism for Whipple's disease?
A. E. coli
B. Tropheryma whipplei
C. Giardia lamblia
D. Clostridium difficile
4. A 30-year-old male comes to the outpatient department with complaints of numbing sensation in his
hands and feet. He has bloating, flatulence, diarrhea, and steatorrhea. His blood worked showed
increased folate levels. Identify the diagnosis and mark the correct option.
A. Tropical sprue
B. Bacterial overgrowth syndrome
C. Celiac disease
D. Whipples disease.
Correct Option B - Chronic pancreatitis:
 The Schilling test is primarily used to assess the absorption of vitamin B12 in the gastrointestinal tract.
 In chronic pancreatitis, there is insufficient production of pancreatic enzymes, including those needed
for the digestion and absorption of vitamin B12.
 The normalization of the Schilling test results with pancreatic enzyme supplementation suggests that
the malabsorption issue is related to pancreatic insufficiency.
 
516

Irritable Bowel Syndrome.
1. A 38-year-old patient presents with recurrent abdominal pain associated with defecation and
changes in the frequency and appearance of stool. The symptoms have been present for more than 3
months. Considering the patient's age and the clinical manifestations, IBS is being considered as a
possible diagnosis. To further investigate and differentiate between IBS and inflammatory bowel
disease, which laboratory test would be most helpful?
(or)
To further investigate and differentiate between IBS and inflammatory bowel disease, which laboratory
test would be most helpful?
A. Serum C-reactive protein (CRP) levels
B. Stool culture for bacterial pathogens
C. Fecal calprotectin levels
D. Anti-tissue transglutaminase (TTG) antibodies
2. A 32-year-old patient presents with recurrent abdominal pain, changes in stool frequency, and
alterations in stool appearance lasting for more than 3 months. The symptoms align with the criteria for
irritable bowel syndrome (IBS). As part of the diagnostic work-up, various investigations are
considered. One of the laboratory tests ordered is a complete blood count (CBC). What can be
concluded from the absence of anemia in this patient's CBC results?
(or)
What can be concluded from the absence of anemia in this patient's CBC results in the context of IBS?
A. The absence of anemia rules out IBS, suggesting an alternative diagnosis
B. Anemia is a common finding in IBS, and its absence does not impact the diagnosis
C. The lack of anemia is consistent with IBS, as it is not typically associated with this condition
D. The absence of anemia indicates the need for further investigations to explore alternative diagnoses.
3. A 35-year-old patient presents with a history of chronic diarrhea, bloody stools occurring 10-15 times
a day. On examination, anemia and pedal edema are noted. The workup shows serum albumin 2.0
g/dL, and the MR enterography report is awaited. Which of the following is correct about this condition?
(or)
Which of the following statements accurately identifies the most common site affected by ulcerative
colitis?
A. Most common site of involvement in UC is the terminal ileum
B. UC predominantly affects the cecum and ascending colon
C. Rectum is the most common site of involvement in UC
D. UC primarily targets the transverse colon and descending colon.
4. A 40-year-old female patient came to the OPD with complaints of recurrent abdominal pain. She has
frequent episodes of nausea, bloating, and pain after having lunch. General examination reveals an
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anxious patient with irregular bowel habits that alternate between loose motions and constipation. Mark
the wrong option regarding the clinical condition described.
A. Change in frequency of the stool
B. Recurrent abdominal pain for >3 days/week for 1-month
C. Pain relieved on defecation and passage of flatus
D. Change in the appearance of the stool
Correct Option C - Fecal calprotectin levels:
 Inflammatory bowel disease, such as Crohn's disease and ulcerative colitis, is associated with
inflammation in the gastrointestinal tract, leading to an increase in inflammatory markers.
 Fecal calprotectin, a protein released by neutrophils during inflammation, is elevated in the presence
of intestinal inflammation. Therefore, measuring fecal calprotectin levels can help differentiate between
irritable bowel syndrome and IBD.
 
 Serum C-reactive protein (CRP) levels, stool culture for bacterial pathogens, and anti-tissue
transglutaminase (TTG) antibodies are more relevant to assessing and diagnosing celiac disease.
Fecal calprotectin is a specific marker for intestinal inflammation, making it a valuable tool in
distinguishing between IBS and IBD.
- The lack of anemia is consistent with IBS, as it is not typically associated with this condition:
 Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by recurrent
abdominal pain and changes in bowel habits without evidence of structural or biochemical
abnormalities. In IBS, the absence of anemia is expected, as it is not a typical feature of the condition.
Anemia is more commonly associated with inflammatory bowel diseases (such as Crohn's disease and
ulcerative colitis) where chronic inflammation and gastrointestinal bleeding can lead to a decrease in
hemoglobin levels.
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Option A - The absence of anemia rules out IBS, suggesting an alternative diagnosis: This is incorrect 
because the absence of anemia does not rule out IBS; in fact, it is consistent with the condition.
Option B - Anemia is a common finding in IBS, and its absence does not impact the diagnosis: This is i
ncorrect because anemia is not a
common finding in IBS, and its absence aligns with the expected laboratory profile of IBS.
Option D - The absence of anemia indicates the need for further investigations to explore alternative di
agnoses: This is incorrect because the absence of anemia in the context of IBS does not necessarily w
arrant further investigations for alternative diagnoses.
Correct Option C - Rectum is the most common site of involvement in UC:
 The clinical diagnosis is ulcerative colitis. Proctitis explains anemia.
 UC is a protein-losing enteropathy that causes low serum albumin levels.
 
Options A, B, and D: Can be ruled out on the basis of the above explanation. 
Correct Option B - Recurrent abdominal pain for >3 days/week for 1-month:
 Recurrent abdominal pain for >3 days/week for min 1 month is an incorrect statement.
 The correct statement is recurrent abdominal pain >1 day/ week for min 3 months
 The question describes symptoms like recurrent abdominal pain, postprandial pain, bloating, nausea,
and alternating episodes of constipation and diarrhea help in the diagnosis of irritable bowel syndrome.
521

1. What is the most probable diagnosis for a patient with a past medical record of chronic liver disease,
who is currently experiencing abdominal distension, jaundice, and itching, and whose ascitic fluid
analysis shows a neutrophil count exceeding 650 per cubic mm?
A. Spontaneous bacterial peritonitis
B. Malignant ascites
C. Tubercular ascites
D. Intestinal obstruction
2. What is the probable diagnosis for a patient being assessed for jaundice, based on laboratory
findings of increased bilirubin and alkaline phosphatase levels, while the levels of other liver enzymes
remain within normal range?
A. Obstructive jaundice
B. Hemolytic jaundice
C. Hepatic jaundice
D. Prehepatic jaundice
3. Patient is identified as having a tumor in the ileum and leading to urinary 5 HIAA being elevated.
What is the diagnosis?
A. Carcinoid tumor
B. Neuroblastoma
C. c.Leiomyoma
D. d.Chromaffinoma
4. What is the probable diagnosis for a 50-year-old woman with a skin lesion visible in the provided
image, which initially appeared small but has now spread to her entire limb and abdomen? Despite
being on anticoagulation therapy, she has a longstanding history of diabetes and recurring deep vein
thrombosis episodes.
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B. Gastrinoma
C. Glucagonoma
D. VIPoma
5. Mark the correct statement regarding inflammatory bowel disease.
A. Skip lesions are present in Crohn’s disease
B. Mucosal layers are involved in Crohn’s while transmural involvement seen in ulcerative colitis
C. Inflammatory bowel disease doesn’t have a genetic predisposition
D. Crohn’s is curable through surgical resection of the affected segment
6. A patient presents with cough, cold, fever and malaise associated with weight loss and ascites. A
radiograph of the chest is shown below. Ascitic fluid analysis showed elevated adenosine deaminase.
Which of the following is the next step in management?
A. Biopsy
B. Start ATT after laparotomy stricture removal
C. Start anti-tubercular therapy
D. Symptomatic management
7. A patient with peptic ulcer was treated with an H. pylori regimen. Which of the following is used to
assess the success of treatment?
A. Endoscopy
B. IgG antibody study
C. Urea breath test
D. Urease test of biopsy
8. What is the enzyme deficiency in Pompe’s disease?
A. Lysosomal acid alpha glucosidase
B. Glucose 6 phosphatase
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C. Muscle phosphorylase
D. Phosphofructokinase
9. A 10-year-old child presented with recurrent pulmonary infections, and bulky greasy stools.
Quantitative estimation of the stool fat was more than 10 gm/day. Which of the following will be seen in
this child?
A. Protein-losing enteropathy
B. Distal intestinal obstruction
C. Hypernatremia
D. Rectal prolapse occurs after treatment
10. What is the underlying reason for the arterial blood gas (ABG) findings in a diabetic woman who
has been admitted to the hospital due to continuous vomiting after consuming food from outside, and
has a blood pressure reading of 90/60 mmHg? pH-7.52 HCO3 – 30 meq/L PaCO2 - 20 mmHg Na –
123 mEq/L K – 3.2 mEq/L CI – 67 mEq/L
B. Persistent vomiting
C. Septic shock
D. Renal tubular acidosis
11. A 15-year-old girl presented with fatigue, chronic diarrhoea, weight loss, bone pain and abdominal
distension. Investigations revealed iron deficiency anaemia and osteoporosis. Which of the following is
the single best test to be done for her evaluation?
A. TSH levels
B. C-peptide levels
C. Urine sugar and ketone
D. IgA tissue transglutaminase antibody
12. The blood investigation of a patient is given below. What is the probable diagnosis? HBsAg-
Nonreactive HBeAg- Nonreactive IgG anti-HbcAg – Reactive IgM anti-HbcAg – Nonreactive
A. Acute hepatitis B
B. Chronic hepatitis B
C. Remote infection of hepatitis B
D. Core window period
13. A male patient in his youth comes to the clinic complaining of a persistent high fever over the past 5
days. During the examination of his hands, painless lesions are observed, and a new regurgitant
murmur is detected. The echocardiogram reveals the existence of a mass on the mitral valve. Based on
these findings, which of the following abdominal findings would be expected in this case?
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A. Ascites
B. Splenomegaly
14. What clinical examination is being performed in the image?
A. Shifting dullness
B. Ascites
C. Puddle sign
D. Fluid thrill
15. Iritis is seen in all except:
A. SLE
B. Behcet’s disease
C. Ulcerative colitis
D. Rheumatoid arthritis
16. Except for which of the following, all the mentioned characteristics are associated with Crohn's
disease?
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A. Transmural involvement
B. Lead pipe appearance
C. Rectal sparing
D. Perianal fistula
17. Cushing’s ulcers are seen in
A. Burns
B. Stress
C. Head injury
D. Cell necrosis
18. In which condition are macrophages observed to be positive for periodic acid Schiff staining?
A. Agammaglobulinemia
B. Whipple’s disease
C. Abetalipoproteinemia
D. Crohn’s disease
19. The reason behind low levels of copper in the bloodstream, which is associated with the ATP7A
gene, is:
A. Dubin-Johnson syndrome
B. Wilson’s disease
C. Menke’s disease
D. Gilbert’s syndrome
20. A 22-year-old man presented with diarrhea and intolerance to dairy products. On investigation, he
was found to have a lactase deficiency. Which of the following agents is least likely to cause symptoms
of lactose intolerance?
A. Condensed Milk
B. Skimmed Milk
C. Yogurt
D. Ice Cream
21. What is the most common immediate complication following a splenectomy?
A. Hemorrhage
B. Fistula
C. Bleeding from gastric mucosa
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D. Pancreatitis
22. In what situations is surgery contraindicated for patients with Ulcerative Colitis?
A. Toxic megacolon
B. Colonic perforation
C. Colonic obstruction
D. Refractory fistula
23. Which of the options accurately describes the development of cancer in patients with ulcerative
colitis?
A. Bad prognosis if it involved only rectum
B. Good prognosis if it involves only rectum and is low grade
C. 2% chance of malignancy if present for 10 years
D. Young age onset has low chances as compared to old age onset
24. What is the probable diagnosis of a patient who has significant abdominal swelling and laboratory
analysis of the fluid obtained through paracentesis reveals SAAG <1.1 what is the likely diagnosis?
(or)
What is the probable diagnosis of a patient who has significant abdominal swelling and laboratory
B. Myxoedema
C. Budd Chiari syndrome
D. Tuberculosis
25. The following image shows?
A. Achalasia cardia
B. Diffuse oesophageal spasm
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C. Carcinoma Oesophagus spasm
D. Schatzki's Ring
26. Which of the following actions is not typically performed in cases of Carcinoma of the Esophagus?
A. Biopsy
B. pH-metry
C. CT chest
D. PET scan
27. What is the most likely diagnosis for the image displayed?
A. Pneumoperitoneum
B. Pneumothorax
C. Eventration of diaphragm
D. Pneumomediastinum
28. Which of the following has the least chance of developing malignancy?
(or)
Which of the following has the least chance of developing malignancy?
A. Chronic hyperplastic candiatisis
B. Oral submucosal fibrosis
C. Oral lichen planus
D. Leukoplakia
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Question 19 3
Question 21 1
Question 25 2
Question 27 1
 The patient's presentation of abdominal distension, jaundice, and pruritis is suggestive of liver
disease, which can cause the accumulation of fluid in the abdomen (ascites). 
 Neutrophil count >650 per cubic mm in the ascitic fluid signifies the closeness of spontaneous
bacterial peritonitis (SBP), an accepted condition of ascites in sufferers accompanying chronic liver
disease. SBP is induced by the migration of bacteria from the gut into the ascitic fluid, developing an
inflammatory response. 
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Option B. Malignant ascites: It is a
complication of cancer, and the presence of neutrophils in the ascitic fluid would be different.
Option C. Tubercular ascites: It is an infrequent proof of infection and usually guides a
lymphocytic predominance in the ascitic fluid.
Option D. Intestinal obstruction: It is an independent condition that presents accompanying manifestati
ons including abdominal pain, vomiting, and constipation.
 Elevated bilirubin and alkaline phosphatase levels are suggestive of obstructive jaundice, which
happens when there's hindrance of the biliary tree.
 Obstruction can happen due to different reasons, such as gallstones, tumors, or strictures. Alkaline
phosphatase levels raise due to the increased generation of the enzyme by the liver and biliary system,
whereas bilirubin elevated due to the collection of conjugated bilirubin within the bloodstream, which
cannot be excreted through the bile duct.
Option B: Hemolytic jaundice: Hemolytic jaundice is caused by the excessive breakdown of red blood c
ells, driving an increment in unconjugated bilirubin levels. Alkaline phosphatase levels are not elevated 
in hemolytic jaundice.
Option C: Hepatic jaundice: Hepatic jaundice happens due to liver cell damage, driving to impeded bilir
ubin processing and excretion. Alkaline phosphatase levels may not be elevated in hepatic jaundice.
Option D: Prehepatic jaundice: Prehepatic jaundice happens due to excessive red blood cell breakdow
n, driving an increment in unconjugated bilirubin levels. Alkaline phosphatase levels are ordinarily not e
levated in prehepatic jaundice.
Carcinoid tumors are a type of neuroendocrine tumor that can arise in various parts of the body, includi
ng the gastrointestinal tract (especially the ileum), lungs, and pancreas. They are usually slow-growing 
but can metastasize to other organs over time.
One of the hallmark features of carcinoid tumors is the secretion of serotonin, which can lead to elevat
ed levels of urinary 5-hydroxy indole acetic acid (5-HIAA). This is because serotonin is converted to 5-
HIAA in the liver and then excreted in the urine.
b. Neuroblastoma is a type of cancer that arises in immature nerve cells, usually in the adrenal glands (
located above the kidneys). It is most commonly diagnosed in infants and young children and can caus
e symptoms such as abdominal swelling or pain, fever, and weight loss. Neuroblastoma does not typic
ally secrete serotonin or cause elevated 5-HIAA levels.
c. Leiomyoma is a benign tumor arising from smooth muscle tissue and can occur in various parts of th
e body (including the uterus, gastrointestinal tract, and skin). It does not secrete serotonin or cause ele
vated 5-HIAA levels.
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d. Chromaffinoma (also known as a pheochromocytoma) is a type of tumor arising from chromaffin cell
s in the adrenal glands and sympathetic ganglia (part of the autonomic nervous system). Chromaffinom
as can cause symptoms such as high blood pressure, palpitations, sweating, and headache but do not 
typically secrete serotonin or cause elevated 5-HIAA levels (although they can secrete other hormones
 such as adrenaline and noradrenaline).  
 Based on the information provided, the most likely diagnosis for this patient's condition is
glucagonoma. A glucagonoma is a rare pancreatic neuroendocrine tumor that produces excessive
amounts of glucagon. The presence of a skin lesion that has spread to the entire limb and the
abdomen, along with a history of long-standing diabetes and recurrent deep vein thrombosis, are all
signs that suggest the presence of a glucagonoma. The skin lesion shown in the image is necrolytic
migratory erythema (NME), which is a characteristic skin rash associated with glucagonoma. NME is a
red, scaly rash that can appear in multiple locations on the body, including the lower extremities,
buttocks, groin, and perineum.
 Option a: An insulinoma is a pancreatic neuroendocrine tumor that secretes excessive amounts of
insulin. This condition can lead to hypoglycemia, which can cause symptoms such as weakness,
confusion, sweating, and palpitations. However, skin lesions and recurrent deep vein thrombosis are
not typically associated with insulinoma, so it is an unlikely diagnosis in this case.
 Option b: A gastrinoma is a pancreatic neuroendocrine tumor that produces excessive amounts of
gastrin, a hormone that stimulates the production of stomach acid. This can cause symptoms such as
abdominal pain, nausea, vomiting, and diarrhea. However, skin lesions and deep vein thrombosis are
not typically associated with gastrinoma, so it is an unlikely diagnosis in this case.
 Option d: A VIPoma is a rare pancreatic neuroendocrine tumor that produces excessive amounts of
vasoactive intestinal peptide (VIP), a hormone that regulates the secretion of fluids and electrolytes in
the intestines. This can cause symptoms such as watery diarrhea, dehydration, and electrolyte
imbalances. While VIPomas can cause skin lesions, they are not typically associated with recurrent
deep vein thrombosis or long-standing diabetes, so it is an unlikely diagnosis in this case.  
Correct Option  A - Skip lesions are present in Crohn’s disease:
 Skip lesions refer to the characteristic feature of Crohn's disease where there are areas of
inflammation that are separated by normal or unaffected segments of the bowel. This pattern of
involvement is not seen in ulcerative colitis. Skip lesions can occur throughout the entire
gastrointestinal tract, from the mouth to the anus, in Crohn's disease.
Option B - Mucosal layers are involved in Crohn's while transmural involvement seen in ulcerative coliti
s: This statement is incorrect. In Crohn's disease, the inflammation can involve all layers of the bowel w
all, which is known as transmural involvement. In ulcerative colitis, the inflammation is limited to the mu
cosal layer of the colon and rectum.
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Option C - Inflammatory bowel disease does have a strong genetic predisposition: This statement is in
correct. Both Crohn's disease and ulcerative colitis have a strong genetic component, indicating a
predisposition to developing these conditions. Family history of inflammatory bowel disease is a
known risk factor.
Option D - Crohn's is curable through surgical resection of the affected segment: This statement is inco
rrect. While surgical resection may be necessary in some cases of Crohn's disease to manage complic
ations or alleviate symptoms, it is not considered a cure. Crohn's disease is a chronic condition that req
uires long-term management and treatment to control inflammation and maintain remission.
Correct Option C - Start anti-tubercular therapy:
 Chest x-ray and clinical symptoms are suggestive of tuberculous peritonitis secondary to pulmonary
tuberculosis.
 It is typically managed with a combination of anti-tubercular drugs, including isoniazid, rifampicin,
pyrazinamide, and ethambutol
Option A - Biopsy: Biopsy may be considered if the diagnosis is uncertain or to establish the definitive 
diagnosis. However, in this case, the clinical presentation and adenosine deaminase elevation strongly
 suggest tuberculous peritonitis, making biopsy less necessary for initial management.
Option B - Start ATT after laparotomy stricture removal: Laparotomy stricture removal is not indicated i
n the management of tuberculous peritonitis. Anti-tubercular therapy (ATT) is the mainstay of treatment
 and should be initiated promptly.
Option D - Symptomatic management: Symptomatic management is inadequate and initiation of anti-tu
bercular therapy is a more appropriate option
 
Correct Option C - Urea breath test:
 This is the preferred method to assess the success of H. pylori treatment.
 It involves administering a solution containing labeled urea, which is metabolized by H. pylori if
present.
 The patient then exhales into a collection bag, and the breath sample is analyzed for the presence of
labeled carbon dioxide, indicating the presence or absence of H. pylori.
Option A, B and D are incorrect. Urea breath test is used to determine treatment response in patients o
n anti H.pylori regimens.
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Correct Option A: Lysosomal acid alpha glucosidase
 Pompe's disease, also known as glycogen storage disease type II, is caused by a deficiency of the
enzyme lysosomal acid alpha glucosidase, also called acid alpha-glucosidase or acid maltase. This
enzyme is responsible for breaking down glycogen, a stored form of glucose, into glucose molecules
within the lysosomes of cells.
Option B: Glucose 6 phosphatase:
 Glucose 6 phosphatase is an enzyme involved in gluconeogenesis and glycogenolysis. Deficiency of
this enzyme is seen in Von Gierke's disease (glycogen storage disease type I), not in Pompe's disease.
Option C: Muscle phosphorylase:
 Muscle phosphorylase, also known as myophosphorylase, is an enzyme involved in glycogenolysis
(the breakdown of glycogen into glucose) in muscle tissue. Deficiency of muscle phosphorylase leads
to McArdle disease (glycogen storage disease type V), characterized by exercise intolerance and
muscle cramps.
Option D: Phosphofructokinase:
 Phosphofructokinase is an enzyme involved in glycolysis, the breakdown of glucose to produce
energy. Deficiency of phosphofructokinase leads to Tarui disease (glycogen storage disease type VII),
characterized by exercise intolerance and muscle weakness.
Correct Option B: Distal intestinal obstruction:
 Distal intestinal obstruction refers to a blockage or narrowing in the lower part of the intestine, which
can lead to symptoms such as recurrent pulmonary infections, bulky greasy stools (steatorrhea), and
increased stool fat content.
 The obstruction hinders the proper absorption of fats and nutrients, resulting in the passage of
undigested fats in the stool.
 Signs and symptoms of DIOS include a sudden onset of crampy abdominal pain, vomiting, and a
palpable mass (often in the right lower quadrant) in the abdomen.
 X-rays of the abdomen may reveal stool in the colon and air-fluid levels in the small intestines.
Option A. Protein-losing enteropathy: Protein-losing enteropathy is a condition characterized by excess
ive loss of proteins from the intestines. It can result in edema, hypoalbuminemia, and other signs of pro
tein deficiency. While it can cause changes in stool consistency, such as frothy or pale stools, it is not t
ypically associated with bulky greasy stools.
Option C. Hypernatremia: Hypernatremia refers to elevated levels of sodium in the blood. It is not direct
ly associated with the symptoms described in the case, which are more suggestive of gastrointestinal 
malabsorption.
Option D. Rectal prolapse occurs after treatment: Rectal prolapse is a condition where the rectum protr
udes through the anus. While it can occur in some cases of chronic diarrhea and malabsorption, it is no
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t directly related to the symptoms mentioned in the case.
Correct Option B: Persistent vomiting: Persistent vomiting can lead to a
condition called metabolic alkalosis. When a
person vomits, they lose stomach acid (hydrochloric acid), which results in a decrease in hydrogen ion
s (H+). This loss of acid leads to an imbalance in the body's acid-base status, causing the blood pH to i
ncrease (become more alkaline). In the given ABG report, the pH of 7.52 is indicative of alkalosis, supp
orting the diagnosis of metabolic alkalosis due to persistent vomiting.
Option A: Diabetic ketoacidosis (DKA): DKA is a serious complication of diabetes characterized by high
 blood sugar levels, ketone production, and metabolic acidosis. In DKA, the pH of the blood is typically l
ow (acidic) due to the accumulation of ketones. In the given ABG report, the pH is 7.52, which indicate
s alkalosis rather than acidosis. Therefore, DKA is not the cause of the ABG findings.
Option C: Septic shock: Septic shock is a life-threatening condition caused by a
severe infection. It can lead to multiple organ dysfunction and a state of metabolic acidosis. In septic sh
ock, the body's cells are unable to effectively use oxygen, resulting in increased production of lactic aci
d. This accumulation of acid causes the blood pH to decrease (become more acidic). The pH of 7.52 in
 the ABG report suggests alkalosis rather than acidosis, so septic shock is unlikely to be the cause.
Option D: Renal tubular acidosis (RTA): RTA is a condition characterized by a
defect in the kidneys' ability to excrete acid, leading to a buildup of acid in the body. There are different
 types of RTA, but they generally result in metabolic acidosis rather than alkalosis. Since the ABG repo
rt shows alkalosis with a pH of 7.52, RTA is not the likely cause.
Correct Option D. 
 The correct answer is IgA tissue transglutaminase antibody (IgA-TTG) testing. This test is used to
evaluate for celiac disease, an autoimmune condition characterized by an immune reaction to gluten, a
protein found in wheat, barley, and rye. Celiac disease can lead to malabsorption, chronic diarrhea,
weight loss, fatigue, and other symptoms mentioned in the case.
Option A. TSH levels: Thyroid-stimulating hormone (TSH) levels are typically measured to evaluate thy
roid function. However, the symptoms described in the case (fatigue, chronic diarrhea, weight loss, bon
e pain, abdominal distension) are not typically associated with thyroid dysfunction, making TSH testing 
less relevant in this context.
Option B. C-peptide levels: C-peptide is a marker of insulin production and can be measured to assess
 pancreatic function. However, the symptoms described in the case are not suggestive of a primary pa
ncreatic disorder, and C-peptide testing is not typically indicated in the initial evaluation of the describe
d clinical presentation.
Option C. Urine sugar and ketone: Testing urine for sugar and ketones is often performed to evaluate f
or diabetes mellitus or diabetic ketoacidosis. However, the symptoms described in the case are not con
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sistent with diabetes or diabetic ketoacidosis, making this testing less relevant in this context.
 HBsAg (Hepatitis B surface antigen) nonreactive: The absence of HBsAg indicates that the patient is
not currently infected with the hepatitis B virus (HBV).
 HBeAg (Hepatitis B e antigen) nonreactive: The absence of HBeAg suggests that the patient is not
actively replicating HBV.
 IgG anti-HBcAg (IgG antibody to hepatitis B core antigen) reactive: The presence of IgG anti-HBcAg
indicates a previous or remote infection with HBV. IgG antibodies to HBcAg persist after the acute
phase of infection and can provide long-term immunity.
 IgM anti-HBcAg (IgM antibody to hepatitis B core antigen) nonreactive: The absence of IgM
anti-HBcAg suggests that there is no recent or ongoing acute hepatitis B infection. IgM antibodies to
HBcAg are typically present during the acute phase of infection.
 Based on the viral markers findings, we can diagnose Remote infection of hepatitis B.
Option A: The patient does not have acute hepatitis B because the key markers for active infection (HB
sAg and HBeAg) are non-reactive. Therefore, acute hepatitis B cannot be the diagnosis.
Option B: Based on these findings, the patient does not have chronic hepatitis B because the key mark
ers for active infection (HBsAg and HBeAg) are non-reactive. Therefore chronic hepatitis B
cannot be the diagnosis.
Option D: The core window period is not applicable in this case, as the core window period refers to a
specific phase of hepatitis B infection. During the window period, there may be a
temporary absence or low levels of detectable hepatitis B surface antigen (HBsAg) and hepatitis B
e antigen (HBeAg) in the blood, while the person may still have detectable IgM antibodies to hepatitis B
core antigen (IgM anti-HBcAg).
Based on the given clinical presentation, the most likely abdomen finding in this case would be spleno
megaly. The correct answer is: Splenomegaly
The presence of high-grade fever, painless lesions on the hands, and a new regurgitant murmur sugge
sts the possibility of infective endocarditis, which is an infection of the heart valves. The mitral valve inv
olvement indicated by the presence of a mass on the echocardiogram further supports this diagnosis.
In infective endocarditis, microorganisms can enter the bloodstream and colonize the heart valves, lea
ding to the formation of vegetations. These vegetations can embolize, causing systemic manifestations
 and affecting various organs, including the spleen.
Splenomegaly is a common finding in infective endocarditis due to septic emboli. As the infected embol
i reach the spleen, they can cause local inflammation and enlargement of the organ.
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While ascites, hepatomegaly, and portal hypertension can be seen in certain liver diseases, they are n
ot typically associated with infective endocarditis. Therefore, the correct answer is splenomegaly in this
 case.
 
 Fluid Thrill: Fluid thrill, also known as fluid wave, is another technique used to detect ascites. The
patient or an assistant places their hand firmly on the midline of the abdomen, and the examiner taps
one side of the abdomen sharply with their hand or fingers. If ascitic fluid is present, a palpable wave of
fluid can be felt across the abdomen.
Option A: Shifting Dullness: Shifting dullness is a maneuver used to assess the presence of fluid in the 
abdomen. During this examination, the patient lies supine, and percussion is performed along the flank
s and the midline of the abdomen. Initially, when the patient is on their back, a dull sound is heard over 
the dependent (lower) areas where fluid collects. However, as the patient is gradually rolled onto one si
de, the fluid shifts, and the previously dull areas become resonant (tympanic) due to the displacement 
of the fluid. The shifting dullness sign indicates the presence of free fluid (such as ascites) within the ab
domen.
Option B: Ascites: Ascites refers to the accumulation of excess fluid in the peritoneal cavity, resulting in
 abdominal distension. It is commonly associated with liver disease, such as cirrhosis, but can also occ
ur due to other conditions like heart failure, malignancies, or infections. On physical examination, ascite
s is characterized by a tense and protuberant abdomen.
Option A: Puddle Sign: The puddle sign is an extension of the shifting dullness maneuver. After elicitin
g shifting dullness, gentle palpation is performed over the areas of dullness. If there is a
significant amount of ascitic fluid present, the examiner's hand may sink into the fluid, giving a
sensation similar to palpating a puddle of water.
 
Iritis, also known as anterior uveitis, is inflammation of the iris, which is the colored part of the eye. It ca
n occur as a result of various underlying conditions. Among the options provided, rheumatoid arthritis (
RA) is not typically associated with iritis. While RA primarily affects the joints, it can also involve other o
rgans such as the skin, heart, lungs, and blood vessels. However, ocular involvement, specifically iritis,
 is not a characteristic feature of RA.
Option A. SLE (Systemic Lupus Erythematosus): SLE is an autoimmune disease that can affect multipl
e organs, including the eyes. Ocular manifestations in SLE can include iritis, uveitis, and other conditio
ns such as dry eyes and keratitis.
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Option B. Behcet's disease: Behcet's disease is a rare autoimmune condition characterized by recurre
nt oral and genital ulcers, skin lesions, and uveitis. Uveitis, including iritis, is a
well-known ocular manifestation of Behcet's disease.
Option C. Ulcerative colitis: Ulcerative colitis is a type of inflammatory bowel disease that primarily affe
cts the colon and rectum. While its primary manifestations are related to the gastrointestinal system, ex
traintestinal manifestations can occur, including ocular involvement. Uveitis, including iritis, can occur i
n patients with ulcerative colitis.
Option B
Lead pipe appearance: This feature is not typically associated with Crohn's disease. The term "lead pip
e appearance" is used to describe the smooth, uniform narrowing of the colon seen in conditions like ul
cerative colitis. In Crohn's disease, the involvement can be patchy and may lead to skip lesions or seg
mental involvement rather than a continuous, uniform appearance.
 
Option a. Transmural involvement: This is a characteristic feature of Crohn's disease. It refers to inflam
mation that extends through all layers of the intestinal wall, including the mucosa, submucosa, muscula
ris propria, and serosa.
Option c. Rectal sparing: This is a feature seen in Crohn's disease. It refers to the relative sparing of th
e rectum from inflammation. Crohn's disease often involves the terminal ileum (the last part of the small
 intestine) and can extend to other parts of the gastrointestinal tract, but the rectum is commonly spare
d.
Option d. Perianal fistula: Perianal fistulas are frequently associated with Crohn's disease. These abno
rmal connections between the intestine and the skin around the anus can cause pain, discharge, and r
ecurrent infections.
Option C: Head injury.
Cushing's ulcers can develop in patients with severe head injuries, particularly those with elevated intra
cranial pressure. The increased intracranial pressure leads to activation of the vagus nerve, which stim
ulates the release of gastric acid and increases gastric motility, resulting in the development of gastric 
ulcers.
 
Option a. Burns: Burns are not typically associated with the development of Cushing's ulcers. Gastric ul
cers in burn patients are more commonly attributed to other factors such as stress, decreased mucosal
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 blood flow, and altered acid secretion.
Option b. Stress: While stress can contribute to the development of gastric ulcers, it is not specific to C
ushing's ulcers. Stress-related ulcers, also known as stress ulcers, can occur in various conditions suc
h as severe illness, trauma, surgery, or critical illness.
Optiond. Cell necrosis: Cell necrosis alone is not a direct cause of Cushing's ulcers. The development 
of gastric ulcers involves complex mechanisms related to the autonomic nervous system and altered a
cid secretion.
Correct Option: B:  Whipple's disease
 Periodic acid-Schiff (PAS) positive macrophages are a characteristic finding in Whipple's disease.
 Whipple's disease is a rare systemic infectious disorder caused by the bacterium Tropheryma
whipplei.
 PAS staining is used to detect the presence of glycoproteins, which accumulate in the cytoplasm of
macrophages in affected tissues, including the small intestine, lymph nodes, and other organs.
Option A: Agammaglobulinemia: This statement is incorrect. Agammaglobulinemia refers to a
group of primary immunodeficiency disorders characterized by a lack of mature B
cells and reduced or absent immunoglobulin production. PAS-positive macrophages are not a
characteristic finding in agammaglobulinemia.
Option C: Abetalipoproteinemia: This statement is incorrect. Abetalipoproteinemia is a rare genetic diso
rder characterized by the absence of beta-lipoproteins, leading to impaired absorption and transport of 
dietary fats and fat-soluble vitamins. PAS-positive macrophages are not typically seen in abetalipoprot
einemia.
Option D: Crohn's disease: This statement is incorrect. Crohn's disease is a chronic inflammatory bowe
l disease that can affect any part of the gastrointestinal tract. While Crohn's disease is associated with t
he presence of macrophages and other immune cells in the affected intestinal tissue, PAS-positive ma
crophages are not a specific feature of Crohn's disease.
Correct Option C: Menke's disease
 Menke's disease, also known as Menkes syndrome or copper transport disease, is a rare X-linked
recessive disorder characterized by impaired copper absorption and transport.
 It is caused by mutations in the ATP7A gene, which encodes a copper-transporting ATPase involved
in the transport of copper into the cells.
Option A: Dubin-Johnson syndrome is a rare genetic disorder characterized by impaired bilirubin trans
port and conjugation in the liver. It does not affect copper levels.
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Option B: Wilson's disease is a genetic disorder characterized by impaired copper transport and metab
olism, leading to copper accumulation in various tissues, particularly the liver and brain. It does not cau
se low serum copper levels.
Option D: Gilbert's syndrome is a benign genetic disorder characterized by mild unconjugated hyperbili
rubinemia. It does not affect copper levels.
 Lactose intolerance is a condition characterized by the inability to digest lactose, a sugar found in
dairy products. It occurs due to a deficiency or reduced activity of the enzyme lactase, which is
responsible for breaking down lactose into simpler sugars for absorption.
 Yogurt is produced through the fermentation of milk by bacteria, typically Lactobacillus and
Streptococcus species. During the fermentation process, these bacteria produce lactase, which helps
break down lactose into simpler sugars. As a result, yogurt contains lower levels of lactose compared to
other dairy products.
Option A. Condensed Milk: Condensed milk is milk from which water has been removed, resulting in a
concentrated form. It contains a high concentration of lactose, and therefore, is likely to cause sympto
ms of lactose intolerance in individuals with lactase deficiency.
Option B. Skimmed Milk: Skimmed milk refers to milk from which the cream (high-fat portion) has been 
removed. While the fat content is reduced, lactose content remains relatively unchanged. Therefore, sk
immed milk can still cause symptoms of lactose intolerance in individuals with lactase deficiency.
Option D. Ice Cream: Ice cream is a dairy product that typically contains high amounts of lactose. It is 
made by combining milk or cream with sugar and flavorings. Therefore, ice cream is likely to cause sy
mptoms of lactose intolerance in individuals with lactase deficiency.
 Hemorrhage: This is the correct option. Hemorrhage, or bleeding, is one of the most common
immediate complications of splenectomy. The spleen is a highly vascular organ, and during surgery,
there is a risk of bleeding from the splenic artery or its branches. Measures are taken to control
bleeding during and after the procedure, but it remains a potential complication. Therefore, option A is
correct.
Option B. Fistula: Fistula formation is not a common immediate complication of splenectomy. A
fistula is an abnormal connection between two organs or structures. While it is possible for a fistula to d
evelop after splenectomy, it is not the most common immediate complication. Therefore, option B
is incorrect.
Option C. Bleeding from gastric mucosa: Bleeding from the gastric mucosa is not a common immediate
 complication of splenectomy. The spleen is not directly involved in regulating gastric mucosal integrity 
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or bleeding control. Therefore, option C is incorrect.
Option D. Pancreatitis: Pancreatitis is not a common immediate complication of splenectomy. The sple
en and the pancreas are separate organs with distinct functions. While complications related to the pan
creas can occur after splenectomy in some cases, pancreatitis itself is not the most common immediat
e complication. Therefore, option D is incorrect.
Correct Option A. Toxic megacolon: Fulminant colitis or toxic megacolon is a severe and potentially life
-threatening complication of UC characterized by acute colonic dilation and systemic toxicity. Surgery 
may be contraindicated if the patient is in an unstable condition, as the risk of surgical complications m
ay outweigh the potential benefits. Medical management and stabilization are typically attempted initiall
y, and surgery is considered if conservative measures fail.
option D - Refractory fistula: A fistula is an abnormal connection between two organs or structures. In 
UC, fistulas can occur, typically between the colon and adjacent organs such as the bladder or skin. W
hen a fistula is refractory, meaning it does not respond to medical treatments and causes persistent sy
mptoms or complications, surgical intervention may be considered.
Option B. Colonic perforation: Colonic perforation is a serious complication of UC that can lead to life-t
hreatening infections and requires prompt surgical intervention.
Option C. Colonic obstruction: Colonic obstruction is another complication of UC that can lead to signifi
cant symptoms and complications. In cases of complete or persistent colonic obstruction that does not 
resolve with conservative measures, surgery may be necessary.
 2% chance of malignancy if present for 10 years This statement is generally true.
 Patients with ulcerative colitis have an increased risk of developing colorectal cancer compared to the
general population. The risk is directly related to the duration of the disease. It is estimated that after 10
years of ulcerative colitis, the cumulative risk of developing colorectal cancer is around 2%.
 However, it is important to note that individual risks can vary depending on other factors such as
disease severity, extent, and presence of dysplasia.
Option A: Bad prognosis if it involved only rectum This statement is not entirely accurate. The prognosi
s of cancer developing in ulcerative colitis depends on various factors, including the extent and severity
 of the disease, the presence of dysplasia (precancerous changes), and the stage of the cancer. While 
rectal involvement can increase the risk of cancer development, the prognosis is determined by multipl
e factors and cannot be solely based on the involvement of the rectum.
Option B: Good prognosis if it involves only rectum and is low grade This statement is partially correct. 
The prognosis of colorectal cancer in ulcerative colitis can vary based on multiple factors, including the 
extent and grade of the cancer. Generally, if the cancer is confined to the rectum and is low grade, the 
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prognosis may be relatively better compared to more advanced or high-grade cancers. However, other 
factors such as the presence of dysplasia, depth of invasion, and lymph node involvement also play a
role in determining prognosis.
Option D: Young age onset has low chances as compared to old age onset This statement is not entire
ly accurate. While it is true that the risk of colorectal cancer increases with age, young individuals with 
ulcerative colitis can still develop cancer. The risk factors for cancer development in ulcerative colitis in
clude the duration and severity of the disease, the presence of dysplasia, family history, and other indiv
idual factors. Young age onset does not guarantee a low chance of developing cancer, and regular sur
veillance and monitoring are important regardless of age.
 Tuberculosis - SAAG score < 1.1 mg/dl is strongly suggestive of Tuberculosis.
Option A: Congestive heart failure: Congestive heart failure can also lead to the development of ascites
. However, in congestive heart failure, the SAAG is usually greater than 1.1 g/dL.
Option B: Myxoedema: the SAAG is usually greater than 1.1 g/dL in this condition.
Option C: Budd Chiari syndrome - the SAAG is usually greater than 1.1 g/dL in this condition.
 
 Diffuse oesophageal spasm is a motility disorder characterized by uncoordinated contractions of the
muscles in the esophagus. This condition leads to difficulties in swallowing, chest pain, and sometimes
regurgitation. The X-ray image provided shows the characteristic findings associated with Diffuse
Oesophageal Spasm, which include multiple contractions along the length of the esophagus, often
referred to as "corkscrew" or "rosary bead" appearance. These contractions result in a disorganized
and irregular movement of the esophageal muscles. Therefore, the X-ray image aligns with the
diagnosis of Diffuse Oesophageal Spasm.
Option A: Achalasia cardia: Achalasia cardia is a condition characterized by the inability of the lower es
ophageal sphincter (LES) to relax properly, leading to difficulty in swallowing. This condition is typically 
associated with a dilated esophagus and absent or weak peristalsis. The X-ray image does not display 
the typical findings associated with Achalasia cardia, such as a dilated esophagus or absent peristalsis
. Therefore, the image does not support the diagnosis of Achalasia cardia.
Option C: Carcinoma Oesophagus spasm: Carcinoma of the esophagus refers to cancerous growth in t
he esophageal tissues. It can cause various symptoms, including difficulty swallowing, weight loss, and
 pain. However, the X-ray image does not provide any evidence of a
tumor or cancerous growth, which is a characteristic feature of Carcinoma Oesophagus spasm. Theref
ore, the image does not support the diagnosis of Carcinoma Oesophagus spasm.
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Option D: Schatzki's Ring: Schatzki's ring, also known as an esophageal ring, is a
narrowing of the lower esophagus, typically caused by a band of tissue or fibrous ring. It can lead to sy
mptoms of dysphagia (difficulty swallowing) and food impaction. However, the X-ray image does not sh
ow any evidence of a narrowing or ring-like structure in the esophagus, which is characteristic of Schat
zki's Ring. Thus, the image does not support the diagnosis of Schatzki's Ring.
 pH-metry: pH-metry is not typically performed for the evaluation of Carcinoma Oesophagus. pH-metry
is a test used to measure the pH levels in the esophagus to evaluate for conditions such as
gastroesophageal reflux disease (GERD) or esophageal motility disorders. It is not specific to
Carcinoma Oesophagus.
Option A. Biopsy: A biopsy is typically performed to obtain a tissue sample from the suspected area of 
carcinoma in the esophagus. The tissue sample is then examined under a
microscope to confirm the diagnosis and determine the histological type and grade of the cancer.
Option C. CT chest: A CT (computed tomography) scan of the chest is commonly performed to evaluat
e the extent and stage of Carcinoma Oesophagus. It helps visualize the size and location of the tumor, 
as well as any spread to nearby lymph nodes or distant organs.
Option D. PET scan: A PET (positron emission tomography) scan is often used to detect the spread of 
Carcinoma Oesophagus beyond the primary tumor site. It can help identify metastases to distant organ
s or lymph nodes by detecting areas of increased metabolic activity.
Correct option A:
 The correct diagnosis based on the given description and the X-ray image showing air under the
diaphragm is pneumoperitoneum.
 Pneumoperitoneum refers to the presence of air or gas within the peritoneal cavity, which is the space
between the abdominal organs and the abdominal wall. It is commonly caused by perforation or rupture
of a hollow organ in the abdomen, such as the stomach, intestine, or appendix. The presence of air
under the diaphragm on an X-ray image is a classic finding seen in pneumoperitoneum.
 Pneumothorax: Pneumothorax is the presence of air or gas in the pleural cavity, which is the space
between the lung and the chest wall. It typically appears as air surrounding the lung tissue on an X-ray
image and may cause lung collapse.
 Eventration of diaphragm: Eventration of the diaphragm is a condition in which the diaphragm muscle
is abnormally thin or weak, leading to an elevated and dome-shaped appearance. It does not involve
the presence of air under the diaphragm.
 Pneumomediastinum: Pneumomediastinum refers to the presence of air or gas in the mediastinum,
which is the central region of the chest between the lungs. It can be caused by various factors,
including trauma or medical conditions, and is typically seen on X-ray as air surrounding the
mediastinal structures.
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Option A: Pneumothorax: Pneumothorax refers to the presence of air or gas in the pleural cavity, which
 is the space between the lung and the chest wall. It typically appears as air surrounding the lung tissu
e on an X-ray image. In the given scenario, the air is localized under the diaphragm, indicating pneumo
peritoneum, not pneumothorax.
Option C: Eventration of diaphragm: Eventration of the diaphragm is a condition in which the diaphrag
m muscle is abnormally thin or weak, leading to an elevated and dome-shaped appearance. It does not
 involve the presence of air under the diaphragm. The X-ray image showing air under the diaphragm is 
not consistent with eventration of the diaphragm.
Option D: Pneumomediastinum: Pneumomediastinum refers to the presence of air or gas in the media
stinum, which is the central region of the chest between the lungs. It can be caused by various factors, 
including trauma or medical conditions. However, in the given scenario, the air is localized under the di
aphragm and not in the mediastinum, making pneumomediastinum an incorrect diagnosis.
 Oral lichen planus (OLP) is a chronic inflammatory condition that affects the mucous membranes in
the mouth. It is not considered a pre-malignant condition in itself, but there have been discussions and
research about its potential association with an increased risk of oral squamous cell carcinoma
(OSCC), which is a type of oral cancer.
Oral lichen planus (OLP) is a
chronic inflammatory condition that affects the mucous membranes in the mouth. It is not considered a 
pre-malignant condition in itself, but there have been discussions and research about its potential asso
ciation with an increased risk of oral squamous cell carcinoma (OSCC), which is a type of oral cancer.
Option A (Chronic hyperplastic candidiasis) is incorrect because chronic hyperplastic candidiasis, caus
ed by the fungus Candida, is considered a
premalignant condition due to its association with an increased risk of oral cancer.
Option B (Oral submucosal fibrosis) is incorrect because oral submucosal fibrosis, typically caused by t
he chewing of betel nuts or other irritants, is considered a
premalignant condition associated with an increased risk of oral cancer.
Option D (Leukoplakia) is incorrect because leukoplakia, characterized by white patches in the oral mu
cosa, is considered a premalignant condition as it has a higher risk of progressing to oral cancer.
543

Hodgkin's and Non-Hodgkin's Lymphoma
1. A 28-year-old patient presents with painless swelling of cervical lymph nodes and intermittent fever.
Physical examination reveals rubbery lymph nodes.Lymph node biopsy is shown below. Which of the
following markers would not be positive for the diagnosis in this patient?
(or)
Which of the following markers will be positive in a disease with a biopsy showing Reed -Sternberg
cells as shown in the image?
A. CD15
B. CD30
C. PAX5
D. CD20
2. A 45-year-old male presents with painless swelling of multiple lymph nodes in the neck and groin. On
further evaluation, he is diagnosed with non-Hodgkin's lymphoma. Which of the following statements
regarding non-Hodgkin's lymphoma is correct?
(or)
Which of the following statements regarding non-Hodgkin's lymphoma is correct?
A. Non-Hodgkin's lymphoma has a favorable prognosis.
B. Spread of non-Hodgkin's lymphoma occurs primarily through direct invasion of contiguous lymph
nodes.
C. Subdiaphragmatic lymphadenopathy is commonly observed in non-Hodgkin's lymphoma.
D. Testicular involvement is a rare presentation of non-Hodgkin's lymphoma.
3. A 55-year-old patient presents with painless swelling of multiple lymph nodes in the neck and groin.
Biopsy of an affected lymph node reveals the presence of centrocytes and centroblasts.
Immunohistochemistry shows positive staining for Bcl2, CD19, and CD20. What is the most likely
(or)
A middle-aged patient presented with painless swelling of multiple lymph nodes in the neck and groin.
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Page 2
A. Diffuse Large B-cell Lymphoma
B. Hodgkin's Lymphoma
C. Follicular Lymphoma
D. Burkitt's Lymphoma
4. A 60-year-old male presents with generalized lymphadenopathy and B symptoms (fever, night
sweats, and weight loss). Biopsy of the lymph node reveals large, atypical lymphoid cells with positive
expression of CD30 and CD38, as well as BCL 6 rearrangements. The patient has a history of HIV
infection. What is the most likely diagnosis?
(or)
An elderly male with a history of HIV presented with generalized lymphadenopathy and B symptoms
(fever, night sweats, and weight loss). Biopsy of the lymph node reveals large, atypical lymphoid cells
with positive expression of CD30 and CD38, as well as BCL6 rearrangements. What is the most likely
A. Hodgkin's Lymphoma
B. Follicular Lymphoma
C. Diffuse Large B-cell Lymphoma (DLBCL)
D. Mantle Cell Lymphoma
5. A 5-year-old African child presents with painless swelling of the jaw. On examination, a visible
swelling is observed in the mandibular region. An image of the patient's jaw is shown below. Based on
the clinical presentation, findings, and biopsy image, All of the following chromosomal swaps are seen
in this patient except??
(or)
Which of the following chromosomal swaps is not seen in a patient with the following clinical feature
and biopsy finding?
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A. t(2:8)
B. t(8:14)
C. t(8:22)
D. t(8:20)
6. A 60-year-old patient presented with generalized lymphadenopathy and hepatosplenomegaly. The
lymph nodes are not tender. Flow cytometry analysis of the lymph node biopsy sample reveals
positivity for Cyclin D1, CD5 and CD23, while CD200 is negative. Based on the clinical presentation
and findings, what is the most likely diagnosis?
(or)
An elderly patient presented with generalized lymphadenopathy with non-tender lymph nodes and
hepatosplenomegaly. Flow cytometry analysis of the lymph node biopsy sample reveals positivity for
Cyclin D1, CD5, and CD23, while CD200 is negative. What is the most likely diagnosis?
A. Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
B. Mantle Cell Lymphoma
C. Marginal zone lymphoma (MZL)
D. Diffuse large B-cell lymphoma (DLBCL)
7. A 65-year-old patient visited her primary care physician with complaints of persistent fatigue, night
sweats, and painless swelling in her neck and armpits. She noticed a lump in her neck that has been
gradually increasing in size over the past few weeks. She denies any recent infections or significant
weight loss. Lymph Nodes appear enlarged and painless excisional biopsy of a cervical lymph node
reveals Reed-Sternberg cells All of the following are true regarding the condition that the patient is
suffering from except?
(or)
Which of the following statements is not true regarding Hodgkin's lymphoma?
A. Hodgkin lymphomas are unusual tumours of T cell origin
B. Reed-Sternberg (RS) cells are the malignant cells in Hodgkin's Lymphoma
C. Classic RS cells are common in the mixed-cellularity subtype
D. Hodgkin lymphomas arise in a chain of lymph nodes and typically spread in a stepwise fashion to
anatomically contiguous nodes.
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8. Regarding chemotherapy regimens, all of the following are true, except?
(or)
Regarding chemotherapy regimens, all of the following are true, except?
A. ATRA (All-trans retinoid acid) is used in the treatment of acute promyelocytic leukaemia
B. Hodgkin’s lymphoma is best treated by R-CHOP (Rituximab, cyclophosphamide,
hydroxydaunorubicin hydrochloride, oncovin and prednisone)
C. Imatinib mesylate is used in the treatment of chronic myeloid leukaemia.
D. Fludarabine is used in the treatment of chronic lymphocytic leukaemia.
9. A patient has been recently diagnosed with Hodgkin’s lymphoma. A relative of his was also
diagnosed with a type of lymphoma. He schedules an appointment with a haematologist to discuss the
details of his illness. Which of the following statements regarding lymphoma is not true?
(or)
Which of the following statements regarding lymphoma is not true?
A. A single classification system of Hodgkin’s disease is almost universally accepted
B. Hodgkin’s lymphoma tends to remain localized to a single group of lymph nodes and spreads by
contiguity
C. Several types of Non-Hodgkin’s lymphoma may have a leukemic phase
D. In general follicular NHL has worse prognosis compared to diffuse NHL
10. A student is assigned to give a presentation on the Reed-Sternberg cell to the class. To engage the
class actively, he starts the presentation by asking the following Question: Which of the following
statements is incorrect regarding the Reed-Sternberg cell?
(or)
Which of the following statements is incorrect regarding the Reed-Sternberg cell?
A. Popcorn variant of Reed-Sternberg cell is seen in Lymphocyte depleted Hodgkin’s disease
B. Mononuclear variant of Reed-Sternberg cell is seen in Mixed cellularity Hodgkin’s disease
C. Lacunar Variant of Reed-Sternberg cell is seen in Nodular sclerosis
D. Lacunar Variant of Reed-Sternberg cell is a Large cell with a hyperlobated nucleus, multiple small
nuclei and eosinophilic cytoplasm around the nucleus
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Page 6
 Non-hodgkin's lymphoma can also be presented as a testicular lump.
Correct Option C- Follicular Lymphoma:
 The clinical presentation of painless swelling of multiple lymph nodes and the histological features of
centrocytes and centroblasts are characteristic of Follicular Lymphoma. The positive staining for Bcl2,
CD19, and CD20 supports the diagnosis of Follicular Lymphoma.
Option A- Diffuse Large B-cell Lymphoma: Diffuse Large B-cell Lymphoma typically presents as rapidly
 growing lymphadenopathy, often involving a single lymph node or a localized group of lymph nodes. 
Option B- Hodgkin's Lymphoma: Hodgkin's Lymphoma is characterized by the presence of Reed-Stern
berg cells, which are not mentioned in the scenario. 
Option D- Burkitt's Lymphoma: Burkitt's Lymphoma typically presents as a rapidly growing mass, often 
involving the abdomen or jaw. Additionally, Burkitt's Lymphoma is associated with MYC translocation, 
which is not mentioned in the scenario. Biopsy shows "Starry Sky" appearance, tumor cells (sky), and t
ingible body macrophages (stars)
 
Correct Option C- Diffuse Large B-cell Lymphoma (DLBCL):
 Diffuse Large B-cell Lymphoma (DLBCL): DLBCL is the most common NHL worldwide and can
present with generalized lymphadenopathy, B symptoms, and the presence of large atypical cells with
positive expression of CD30 and CD38. BCL6 rearrangements are also frequently observed in DLBCL.
It is associated with HIV infection in some cases.
Option A- Hodgkin's Lymphoma: While Hodgkin's Lymphoma can also present with lymphadenopathy 
and B symptoms, the positive expression of CD30, CD38, and BCL6 rearrangements is more character
istic of DLBCL.
In Hodgkin's Lymphoma 
o CD 15 and 30 are positivity (cHL)
o CD 15 and 30 are negative in Atypical Hodgkin's lymphoma.
o As it is a B cell tumor: CD 19, CD 20 (Low or no expression)
o PAX 5 positivity is expressed.
Option B- Follicular Lymphoma: Follicular Lymphoma is an indolent (slow-growing) lymphoma and doe
s not typically exhibit large atypical cells or positive expression of CD30 and CD38. BCL6 rearrangeme
nts are not commonly seen in follicular lymphoma.
Flow cytometric markers of follicular lymphoma are: · CD 10 positive · CD 19 positive ·
CD 20 (dim) positive · CD 23 positive · CD 5 is not present · Cyclin D1 is not present
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Option D—Mantle Cell Lymphoma: Mantle Cell Lymphoma is a distinct subtype of NHL characterized b
y the t(11:14) translocation, which results in cyclin D1 overexpression. It typically presents with lympha
denopathy, but the immunophenotype differs from DLBCL, with CD30 and CD38 being negative and B
CL6 rearrangements not commonly seen. MCL is positive for B-cell markers (CD19, CD20, CD22, CD7
9a). It is distinguished from other B-cell lymphomas by diffuse positivity for cyclin D1 and SOX11.
Correct Option D- t(8:20):
 Burkitt's lymphoma, especially the endemic type, is strongly associated with Epstein-Barr virus (EBV)
infection and is commonly observed in African children. The clinical presentation of jaw swelling in an
African child, along with the image showing jaw involvement and the biopsy image demonstrating the
"Starry Sky" appearance, strongly supports the diagnosis of Burkitt's lymphoma
 t(8:20) is not seen in burkits lymphoma
Option A,B,C- t(2:8), t(8:14) & t(8:22):
 Chromosomal swaps in burkits lymphoma includes t(2:8),t(8:14) and t(8:22)
Correct Option B- Mantle Cell Lymphoma:
 Mantle Cell Lymphoma is characterized by the presence of translocation (11:14), Cyclin D1 positivity,
and CD5 positivity along with CD23 and CD200 negativity. The clinical presentation of generalized
lymphadenopathy and hepatosplenomegaly, along with the flow cytometry findings described, strongly
support the diagnosis of Mantle Cell Lymphoma.
Option A- Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL): CLL/SLL may also pr
esent with lymphadenopathy and hepatosplenomegaly.
CLL must be suspected if  the Absolute lymphocyte count is more than 5 × 10■ cells per ml for 3
consecutive months.
Option C- Marginal zone lymphoma (MZL): MZL typically presents with specific clinical features. MZL is
 an indolent B-cell lymphoma arising from marginal zone B-cells present in lymph nodes and extranoda
l tissues.
Option D- Diffuse large B-cell lymphoma (DLBCL): DLBCL is a common type of non-Hodgkin lymphom
a. It typically presents as rapidly growing lymphadenopathy, often involving a single lymph node or a
localized group of lymph nodes
Correct Option A- Hodgkin's lymphomas are unusual tumours of T cell origin:
550

Acute Lymphoblastic Leukemia
1. A 56-year-old male presented with anaemia & pallor and was found to have acute lymphoblastic
leukaemia (ALL). He is on induction chemotherapy with vincristine, L-asparaginase, prednisolone,
daunorubicin & intrathecal methotrexate. Which of the following is the most important prognostic
marker in patients with ALL?
(or)
What is the most important prognostic marker for acute lymphoblastic leukemia (ALL)?
A. Leucocyte count >50000
B. Hyperploidy
C. Response to treatment
D. Organomegaly
2. A 6-year-old child presents with fatigue, pallor, and recurrent infections for the past few weeks.
Physical examination reveals hepatosplenomegaly. Laboratory investigations show peripheral blood
and bone marrow samples with more than 20% lymphoblasts. Which of the following markers is
associated with this patient?
(or)
Which of the following markers is associated with ALL?
A. CD10
B. CD20
C. CD33
D. CD38
3. An 8-year-old patient Isha was brought by her mother to the pediatrician due to concerns about her
recent health. Over the past few weeks, they noticed changes in her behavior and appearance. she has
become unusually pale, experiences fatigue easily, and has developed an increased frequency of
bruising. A diagnosis of ALL was made and treatment was started. If present, which of the following
features would characterize Isha's cancer as a high risk ALL?
(or)
Which of the following features would be characterized as a high-risk ALL?
A. WBC count: <50000 per microlitre
B. Pre-B cell ALL
C. Hyperploidy
D. Hypoploidy
4. A 7-year-old girl child’s parents noticed changes in her behavior and overall well-being over the past
few weeks. She complained of severe headaches, experienced nausea and vomiting, and developed
an unsteady gait after she underwent a lumbar puncture. Which of the following would have prevented
this patient's condition?
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(or)
What is the method employed to treat or prevent the spread of cancer cells to the central nervous
system in leukemia?
A. Intrathecal methotrexate
B. Dasatinib
C. Blinatumomab
D. sulfasalazine
Option C: Response to treatment
 Response to treatment is the most important prognostic marker in ALL.
Option A: Leucocyte count >50000/uL
 Leucocyte count >50000/uL is associated with a poor prognosis.
Option B: Hyperploidy
 Hyperploidy is a favourable prognostic factor.
Option D: Organomegaly
 Organomegaly has a poor prognosis, which indicates the spread of cancer.
Correct Option A – CD10:
 The above mentionec scenario is suggestive of ALL
 CD10, also known as common acute lymphoblastic leukemia antigen (CALLA), is a cell surface
marker that is commonly used in the classification and diagnosis of leukemias and lymphomas,
particularly in the context of acute lymphoblastic leukemia (ALL)
Option B - CD 20: Is associated with CLL not ALL
Option C - CD33: Is associated with AML not ALL
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Option C – Blinatumomab: Is used for the treatment of Philadelphia chromosome-negative (Ph) relapse
d or refractory B-cell precursor ALL.
Option D – Sulfasalazine: Is a
disease-modifying anti-rheumatic drug (DMARD) and anti-inflammatory agent.
 
558

Chronic Lymphocytic Leukemia
1. An oncology resident is conducting research on the leading cause of death in patients with chronic
lymphocytic lymphoma. The results of his study affirm the current data on CLL patients' mortality
causes. What is the leading cause of death in patients with CLL?
(or)
What is the leading cause of death in patients with CLL?
A. Infections
B. Bleeding
C. Meningeal and ventricular extension
D. Disseminated intravascular coagulation
2. A 72-year-old male presented with complaints of progressive cervical lymphadenopathy, night
sweats. Initial investigations revealed B cell lymphocytosis. Flow cytometry results showed
CD19,CD20,CD21,CD23,CD5 positive. He is also found to have NOTCH1 mutations, del(17)(p13.1).
Which of the following transformation is likely to happen in this patient?
(or)
A patient with progressive cervical lymphadenopathy. CD19,CD20,CD21,CD23,CD5 positive and
NOTCH1 mutations, del(17)(p13.1). Which of the following transformation is likely to happen in this
patient?
A. Chronic lymphocytic lymphoma into diffuse large B cell lymphoma
B. Diffuse large B cell lymphoma into chronic lymphocytic lymphoma
C. Small cell lymphoma into chronic lymphocytic lymphoma
D. Chronic lymphocytic lymphoma into small cell lymphoma
3. A 72-year-old male is found to have clinical features of Chronic Lymphocytic Leukemia on a
peripheral smear. Initial investigations revealed B-cell lymphocytosis. All of the following genetic
abnormalities are related to the worse prognosis in patients with the above diagnosis, except?
(or)
All of the following genetic abnormalities are related to the worse prognosis in patients with Chronic
Lymphocytic Leukemia, except?
A. 11q Deletion
B. 12q Trisomy
C. 17p Deletion
D. 13q Deletion
4. A 68-year-old patient presents with fatigue and enlarged lymph nodes. Physical examination reveals
hepatosplenomegaly. A complete blood count shows an absolute lymphocyte count of 8,000/mm³. Flow
cytometry is performed, and microscopic examination reveals the presence of cells as shown below.
Based on the investigation findings, which of the following markers are most likely to be positive on flow
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Page 2
cytometry?
(or)
Which of the following markers are most likely to be positive on flow cytometry
A. CD 5 and CD 23
B. CD 19 and CD 20
C. CD 38 and CD 79
D. CD 10 and CD 200
5. A 65-year-old male patient presents to the clinic with complaints of fatigue, night sweats,
unintentional weight loss, and enlarged lymph nodes in the neck and axilla. Physical examination
reveals palpable splenomegaly. Laboratory investigations show an absolute lymphocyte count of 45 ×
10^9 cells/mL. Flow cytometry analysis confirms the presence of CD19, CD20 (dim), CD23, and CD5
positivity. The patient's medical history is unremarkable, and no other significant findings are noted.
Based on the clinical scenario and diagnostic findings, which of the following statements regarding the
genetic association of ZAP-70 and the above-mentioned clinical scenario is most accurate?
(or)
which of the following statements regarding the genetic association of ZAP-70 and CLL?
A. ZAP-70 mutation is seen in Chronic Myeloid Leukemia (CML), not CLL
B. ZAP-70 mutation is associated with a favorable prognosis in CLL
C. ZAP-70 mutation is associated with a poor prognosis in CLL
D. ZAP-70 mutation does not have any impact on the prognosis of CLL
6. A 65-year-old male patient presents to the clinic with complaints of persistent fatigue, unintentional
weight loss, and occasional night sweats over the past few months. He reports a feeling of fullness in
the upper abdomen after eating only small amounts of food. After further diagnosis, CLL was
confirmed. All of the following can be a complication in this patient except?
(or)
All of the following can be a complication in CLL except?
A. Autoimmune Hemolytic anemia
B. Autoimmune Glomerulonephritis
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Page 3
C. Autoimmune Vasculitis
D. Autoimmune Hepatitis
7. A 60 female was diagnosed with CLL three years ago. During a routine follow-up appointment, she
reported a sudden onset of worsening symptoms over the past few weeks such as increasing fatigue,
rapidly growing lymph nodes, unexplained weight loss, and night sweats. A biopsy of an enlarged
lymph node is performed, revealing transformation to diffuse large B-cell lymphoma (DLBCL). Which of
the following is appropriate for this patient's condition?
(or)
CLL transformation to diffuse large B-cell lymphoma is called ?
A. Evan Syndrome
B. Richter transformation
C. Mantle cell Lymphoma
D. Blast Crisis
8. An 80-year-old, asymptomatic man presents with a total leucocyte count of 100,000/uL, with 80%
lymphocytes and 20% polymorphonuclear cells. What is the most probable diagnosis?
(or)
What is the most probable diagnosis for an elderly man having total leucocyte count of 100,000/uL, with
80% lymphocytes and 20% polymorphonuclear cells?
A. Acquired immunodeficiency syndrome
B. Chronic myeloid leukaemia
C. Chronic lymphocytic leukaemia
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survival.
Option A—ZAP-70 mutation is seen in Chronic Myeloid Leukemia (CML), not CLL: The ZAP-70 mutatio
n is not typically associated with CML but rather with CLL. The presence of a
ZAP-70 mutation in CLL is associated with a poor prognosis.
Option B - ZAP-70 mutation is associated with a favorable prognosis in CLL: ZAP-70 positivity in CLL i
s associated with an unfavorable prognosis. High levels of ZAP-70 expression are indicative of a
more aggressive disease course and poorer outcomes.Zap 70 is not a
great diagnostic marker because the cut off value keeps changing over time 
Option D - ZAP-70 mutation does not have any impact on the prognosis of CLL: ZAP-70 expression ha
s been extensively studied as a prognostic marker in CLL, and its presence is associated with a
poor prognosis. It is used to assess disease aggressiveness and guide treatment decisions.
 
Correct Option D - Autoimmune Hepatitis:
 CLL is a type of leukemia characterized by the accumulation of abnormal lymphocytes, and the
altered immune response associated with CLL can lead to various autoimmune complications.
However, Autoimmune hepatitis is not a complication seen in CLL
Option A - Autoimmune Hemolytic Anemia (AIHA): It is a complication of CLL
 Evans syndrome: AIHA+ITP+CLL
 In AIHA, the immune system produces antibodies that target and destroy red blood cells, leading to
hemolysis (breakdown of red blood cells).
 Clinical Presentation: Fatigue, weakness, and pallor due to anemia. Jaundice (yellowing of the skin
and eyes) resulting from the release of bilirubin during red blood cell breakdown. Dark urine due to the
presence of hemoglobin.
 Fatigue, weakness, and pallor due to anemia.
 Jaundice (yellowing of the skin and eyes) resulting from the release of bilirubin during red blood cell
breakdown.
 Dark urine due to the presence of hemoglobin.
Option B - Autoimmune Glomerulonephritis: It is a complication of CLL
 Autoimmune glomerulonephritis involves the immune system attacking the glomeruli, which are the
filtering units in the kidneys. This can lead to inflammation and impaired kidney function.
564

Chronic Myeloid Leukemia
1. A 63-year-old man presented with a long history of upper abdominal discomfort, anorexia and two
episodes of recent gum bleeds without fever or other bleeding manifestations. Examination revealed
moderate hepatosplenomegaly. On investigation, he was found to have extreme thrombocytosis and
leucocytosis. He was investigated for CML and found to be positive for BCR-ABL by reverse
transcription PCR (RT-PCR). Vitamin B12 level in this patient would be?
(or)
What will be vitamin B12 level in CML patient would be?
A. Elevated
B. Decreased (slightly)
C. Normal
D. Markedly decreased
2. A 58-year-old male was diagnosed with chronic myeloid leukaemia after an incidental finding of
leukocytosis last year. He was treated with imatinib, and the treatment was changed to nilotinib
because of progressive leukocytosis. On follow-up, investigations revealed worsening of leukocytosis &
thrombocytopenia. His peripheral blood showed >30% blasts with promyelocytes. What is the most
effective treatment for this patient?
(or)
Chronic myeloid leukemia On follow-up has >30% blasts with promyelocytes on PBS. What is the most
A. Allogeneic bone marrow transplantation
B. Autologous bone marrow transplantation
C. Chemotherapy
D. Hydroxyurea & interferon
3. A 62-year-old male was found to have clinical features of Chronic Myeloid Leukemia(CML) on a
peripheral blood smear. On detailed evaluation, the patient also had a T315I mutation in BCR-ABL.
What is the first-line treatment for this patient?
(or)
A patient has Chronic Myeloid Leukemia(CML) and T315I mutation in BCR-ABL. What is the first-line
treatment for this patient?
A. Bosutinib
B. Tofacitinib
C. Ponatinib
D. Nilotinib
4. During the morning clinical round in the oncology ward, the professor attends to a patient with CML.
He then asks his residents. All of the following features can be present in patients with chronic myeloid
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Page 2
leukaemia (CML), except?
(or)
All of the following features can be present in patients with chronic myeloid leukaemia, except?
A. Pruritus
B. Infections
C. Shift of neutrophils to the left
D. Autoimmune hemolytic anaemia
5. A 45-year-old patient presents with fatigue, night sweats, and weight loss. Physical examination
reveals splenomegaly, and laboratory investigations show an elevated white blood cell count with a left
shift and increased basophils. FISH test was done and image is shown below. Based on these findings,
which of the following translocations and translocation products are most likely associated with this
(or)
Based on the fish test given below,which of the following translocations and translocation products are
most likely associated with CML
A. t(8:14) - MYC-IGH fusion
B. t(9:22) - BCR-ABL fusion
C. t(15:17) - PML-RARA fusion
D. No translocation is seen in this condition
6. A 55-year-old patient presents with fatigue, weight loss, and splenomegaly. Laboratory investigations
reveal an elevated white blood cell count and the presence of myelocytes, metamyelocytes, and
promyelocytes in the peripheral smear. Bone marrow examination shows a hypercellular marrow with
myeloid hyperplasia. Further testing confirms the presence of the Philadelphia chromosome. What is
the most appropriate treatment option for this patient?
(or)
What is the mainstay of treatment for CML?
A. Traditional leukemic chemotherapy
B. Radiation therapy
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C. Tyrosine kinase inhibitors (TKIs)
D. Bone marrow transplantation
7. You are a first-year medicine resident rotating in the department of haematology. A group of patients
came for follow-up after having allogeneic bone marrow transplantation. Which of the following has the
least 5-year survival rate following allogeneic bone marrow transplantation?
(or)
A group of patients came for a follow-up after having allogeneic bone marrow transplantation. Which
has the least 5-year survival rate?
A. Severe Combined Immunodeficiency state
B. Aplastic Anemia
C. Blast crisis in CML
D. Chronic lymphocytic leukaemia
8. A 45 year old male visited his primary care physician complaining of persistent fatigue, weight loss,
and abdominal discomfort. Blood tests revealed an elevated white blood cell count and the presence of
Philadelphia chromosome, confirming the diagnosis of Chronic Myeloid Leukemia (CML). Sokal Risk
Score is used to calculate the median survival of this patient.Which of the following is not a component
of Sokal Risk Score?
(or)
Which of the following is not a component of Sokal Risk Score?
A. Percentage of myeloblast in the peripheral smear
B. Platelet Count
C. White Blood Cell Count
D. Spleen Size
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Page 7
 Red represents: abl
Option A - t(8:14) - MYC-IGH fusion: This translocation is associated with Burkitt lymphoma, not Chroni
c Myeloid Leukemia (CML).
Option C - t(15:17) -
PML-RARA fusion: This translocation is associated with Acute Promyelocytic Leukemia (APL), a subty
pe of Acute Myeloid Leukemia (AML), characterized by the fusion of the PML (promyelocytic leukemia)
 gene on chromosome 15 and the RARA (retinoic acid receptor alpha) gene on chromosome 17.
Option D - No translocation is seen in this condition
 
Correct Option C - Tyrosine kinase inhibitors (TKIs):
 CML (Chronic Myeloid Leukemia) is a myeloproliferative neoplasm characterized by the presence of
the Philadelphia chromosome, resulting from the t(9:22) translocation. This translocation leads to the
formation of the BCR-ABL fusion gene, which produces a constitutively active tyrosine kinase
responsible for the pathogenesis of CML.
 The mainstay of treatment for CML is targeted therapy with tyrosine kinase inhibitors (TKIs). These
drugs specifically inhibit the activity of the BCR-ABL tyrosine kinase, reducing the proliferation of
leukemic cells and promoting disease control. Imatinib is the first-line TKI used in most cases of CML.
Second-generation TKIs such as Dasatinib and Nilotinib, as well as third-generation TKIs like
Ponatinib, are used in specific situations such as resistance or intolerance to Imatinib.
Option A – Traditional leukemic chemotherapy: Is not the preferred treatment for CML. TKIs have repla
ced traditional chemotherapy regimens as the standard of care for CML due to their targeted mechanis
m of action and improved efficacy.
Option B - Radiation therapy: Is not a primary treatment option for CML. It may be used in specific case
s where there is localized extramedullary blast proliferation or to palliate symptomatic splenomegaly.
Option D - Bone marrow transplantation (BMT): Also known as stem cell transplantation, is a treatment
 option for CML, particularly in patients who fail TKI therapy or progress to blast crisis. However, it is no
t the first-line treatment choice and is reserved for specific cases.
 
Option C: Blast crisis in CML
 Blast crisis in CML has the least five-year survival rate following allogeneic bone marrow
 The median survival time is <1.5 years.
574

Acute Myeloblastic Leukemia
1. A 67-year-old male complained of generalized fatigue associated with difficulty breathing. On
examination, pallor & gingival hypertrophy is noted. Initial investigations revealed hyperleukocytosis.
Follow-up investigations showed leukostasis. This feature is most predominantly seen in which of the
following disorders?
(or)
Leukostasis is most predominantly seen in which of the following disorders?
A. Acute lymphoblastic leukaemia (ALL)
B. Acute myeloid leukaemia (AML)
C. Chronic myelocytic leukaemia (CML)
D. Chronic lymphocytic leukaemia (CLL)
2. A 42-year-old male presented with complaints of generalized fatigue. His complaints are also
associated with petechiae & purpura. On detailed evaluation, peripheral blood smear showed
characteristic "Auer rods", suggesting Acute Myeloblastic Leukemia (AML). Which of the following
subtypes could be the probable diagnosis?
(or)
What is the probable diagnosis characterized by Auer rods on the peripheral blood smear?
A. M3-AML
B. M4-AML
C. M2-AML
D. M5-AML
3. A 55-year-old female presents with fatigue, weight loss, and easy bruising. On physical examination,
hepatosplenomegaly is noted. Laboratory investigations reveal a decreased hemoglobin level, low
platelet count, and elevated total leukocyte count. A bone marrow aspiration is performed and the
results are as shown below.Which of the following is not a cause for this condition?
(or)
Which of the following is not a cause for this condition?
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B. Downs syndrome
C. Diamond Black Fann syndrome
D. NF-1
4. Match the following appropriately 1. Acute monoblastic leukaemia A. M0 2. AML without maturation
B. M2 3. Acute myelomonocytic Leukaemia C. M5 4. AML with minimal di■erentiation D. M4 E. M1
1. Acute monoblastic leukaemia A. M0
2. AML without maturation B. M2
3. Acute myelomonocytic Leukaemia C. M5
4. AML with minimal di■erentiation D. M4
E. M1
A. 1-C, 2-E,3-D,4-A
B. 1-B, 2-A,3-D,4-E
C. 1-D, 2-E,3-C,4-B
D. 1-D, 2-E,3-A,4-B
5. A 67-year-old male presented with clinical features of Acute Myeloid Leukemia in peripheral blood
smear. Initial investigation revealed leukostasis. Which organ is mainly affected in patients with
Hyperleukocytosis - Leukostasis syndrome?
(or)
Which organ is mainly affected in hyperleukocytosis-leukostasis syndrome?
A. Liver
B. Heart
C. Kidney
D. Lung
577

Multiple Myeloma
1. A 55-year-old man complains of pain in his back, fatigue and occasional confusion. He admits to
polyuria and polydipsia. An X-ray examination reveals numerous lytic lesions in the lumbar vertebral
bodies. X-ray skull shows Classical ‘Rain drop’ lesions. Laboratory studies show hypoalbuminemia,
mild anaemia, and thrombocytopenia. A monoclonal IgG peak is demonstrated by serum
electrophoresis. What is the likely diagnosis?
(or)
A man with lytic lesions in the lumbar vertebra and ‘Raindrop’ lesions in the skull on X-ray, a
monoclonal IgG peak in serum electrophoresis. What is the likely diagnosis?
A. Burkitt’s lymphoma
B. Hodgkin’s lymphoma
D. Haemophilia
2. A 65-year-old male patient presents with bone pain, fatigue, and recurrent infections. On physical
examination, the patient has hypercalcemia and anemia. Laboratory investigations reveal the presence
of a monoclonal spike (M-spike) on serum protein electrophoresis. Which of the following will be seen in
the Arterial Blood Gas of this patient?
(or)
Which of the following will be seen in the Arterial Blood Gas in a case of multiple myeloma?
A. Normal anion gap
B. ncreased anion gap
C. Decreased anion gap
D. Both A and C
3. A 55-year-old man complains of pain in his back, fatigue, and occasional confusion. He admits to
bodies. X-ray skull shows Classical ‘Raindrop’ lesions. Laboratory studies show hypoalbuminemia, mild
anemia, and thrombocytopenia. A monoclonal IgG peak is demonstrated by serum electrophoresis.
Which of the following is done as a screening test in these patients?
(or)
Which of the following is done as a screening test in patients with Multiple myeloma?
A. FISH
B. Bone marrow biopsy
C. PET-CT
D. MRI
4. Diagnostic Criteria for Smouldering Myeloma include all of the following Except? Plasma cells in
bone marrow: >10%. M-component: >30 g/L. No evidence of CRAB or myeloma-like events in the
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patient. Evidence of CRAB or myeloma-like events in the patient. Plasma cells in peripheral blood -
>2,000/µL.
A. 1,2
B. 1,2,3
C. 4,5
D. 2,4,5
5. A 72-year-old woman with a history of hypertension and osteoarthritis presents with fatigue,
weakness, recurrent nosebleeds, and visual disturbances. Physical examination reveals pallor,
lymphadenopathy, and hepatosplenomegaly. Laboratory tests show a significantly reduced hemoglobin
level, leukocytosis with lymphocytosis, thrombocytopenia, and elevated total protein. After further
evaluation, a diagnosis of Waldenstrom Macroglobulinemia was made by the physician. Which of the
following is seen in this?
(or)
Which of the following is seen in Waldenstrom Macroglobulinemia ?
A. Excess IgM
B. Hypercalcemia
C. Bony lytic lesions
D. Excess IgG
6. A 65-year-old male patient presents with bone pain, fatigue, and elevated serum protein levels. A
urine protein electrophoresis test is performed, and the image below shows the electrophoresis pattern.
Based on the clinical presentation and the electrophoresis pattern, what is the most appropriate
(or)
What is the most appropriate treatment for Multiple myeloma based on the electrophoresis pattern?
A. Chemotherapy with vincristine and doxorubicin
B. Radiation therapy to the affected bones
C. Autologous bone marrow transplantation
D. Antibiotic therapy with broad-spectrum agents
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Option D - Antibiotic therapy with broad-spectrum agents: Antibiotic therapy is not the mainstay of treat
ment for multiple myeloma. This option does not address the underlying disease process and is not eff
ective in managing the condition.
 
Correct Option B - Smouldering Myeloma is defined by the presence of a
monoclonal protein (M-component) level of greater than 30 g/L:
Option A - In Monoclonal Gammopathy of Unknown Significance (MGUS), the presence of plasma cell
s in the bone marrow is less than 10%
Option C - Multiple Myeloma is diagnosed when there is evidence of CRAB or myeloma-like events alo
ng with an M-component level of greater than 30 g/L:Multiple Myeloma is diagnosed when there is evid
ence of CRAB (Calcium elevation, Renal dysfunction, Anemia, Bone lesions) or myeloma-like events al
ong with an M-component level of greater than 30 g/L.
Option D - Heavy Chain Disease is associated with the overproduction of Alpha mu and gamma chains
:Heavy Chain Disease is associated with the overproduction of alpha , mu chains or gamma chains. It 
presents with features such as palatal edema and involvement of Waldeyer's Ring.
 
588

Thalassemia
1. A 6-year-old girl from a Punjabi family is brought to the hospital complaining of pale-coloured skin,
fatigue and dyspnea. She has a history of repeated hospital admissions for blood transfusions. Physical
examination reveals a palpable liver and spleen. Her lab findings include haemoglobin 7.5 g/dl, MCV –
70 fL, RDW – 22 and decreased osmotic fragility. The peripheral smear reveals golf ball inclusion
bodies. What is the probable diagnosis in this case?
(or)
The peripheral blood smear stained with a supravital stain shows multiple inclusion bodies (Golf ball
inclusion), What is the likely diagnosis?
A. Iron deficiency anaemia
B. HbH disease
C. Pernicious anaemia
D. G6PD deficiency
2. A 13-year-old girl is brought to the hospital complaining of fatigue, weakness, pale-coloured skin and
shortness of breath. Lab findings reveal MCV 59 fl, MCH 26.1 pg, and target cells on peripheral blood
film. X-ray skull characteristically shows hair on end appearance. After proper evaluation, she is
diagnosed with β-thalassemia major, and the physician advises frequent blood transfusion. Which of
the following is the most appropriate drug that should be used to prevent iron overload in this patient?
(or)
Which drug can be used to prevent iron overload in β-thalassemia major with frequent blood
transfusion?
A. Oral desferrioxamine
B. Oral deferiprone
C. Intramuscular EDTA
D. Oral succimer
3. A 30-year-old female comes to the hospital for a healthcare check-up. She is healthy and has no
history of serious illness except chronic fatigue. Her menstrual cycle is regular and lasts 4-5 days with
moderate bleeding. She has no history of blood transfusion or IV substance abuse. On physical
examination, her vitals are normal, and lab findings include an RBC count of 4.5 million, MCV- 55 fl,
total lymphocyte count is 7000/µL, and Mentzer index of 12. Which of the following is the most probable
(or)
The lab findings of a 30-year-old female include an MCV- 55 fl and a Mentzer index of 12. Which of the
following is the most probable diagnosis?
B. Thalassemia major
C. Thalassemia minor
D. Megaloblastic anaemia
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4. A 19-year-old female comes to the outpatient department complaining of chronic fatigue. She has no
other history of chronic illness or transfusion history, or significant past medical history. Her menstrual
cycle is regular and lasts 3-5 days with moderate bleeding. On physical examination, her vitals are
normal, and lab findings include an RBC count of 4.5 million, Hb 9.7 gm/dl, MCV- 56 fl, and Mentzer
index of 11. Which of the following is incorrect about this patient's condition?
(or)
A female comes to the outpatient department complaining of chronic fatigue. Her lab findings include a
Hb 9.7 gm/dl, MCV- 56 fl, and Mentzer index of 11. Which of the following is incorrect about this
A. Hypochromic microcytic cells
B. Raised HbA2
C. Severe anemia
D. RBC count increased
5. A 28 years female comes to the office complaining of shortness of breath, weakness and fatigue.
She has no history of smoking or other illicit substance abuse. Her past medical or family history is
insignificant. On physical examination, she is anaemic, and her vitals are normal; lab studies reveal Hb
8.0 gm/dL. After a proper evaluation, she is diagnosed with the alpha-thalassemia trait. Which of the
following will be found in this patient's electrophoresis study?
(or)
A female is diagnosed with the alpha-thalassemia trait. Which of the following will be found in this
patient's electrophoresis study?
A. Increased HbF & normal HbA2
B. Normal HbF & normal HbA2
C. Normal HbF & decreased HbA2
D. Decreased HbF & normal HbA2
6. A 32-year-old man of Mediterranean descent presents with fatigue, weakness, and jaundice.
Laboratory investigations reveal a decreased hemoglobin level, microcytic hypochromic RBCs, and
elevated levels of total bilirubin. Skull X ray was taken and the findings are as shown below.. A
screening test was performed as shown below. Which of the following will be seen in the test shown
below for this patient?
(or)
Which of the following will be seen in the test shown below for a patient with the following Skull Xray?
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Page 3
A. Osmotic fragility is increased
B. Osmotic fragility has no change
C. Osmotic fragility is decreased
7. A 32-year-old pregnant woman presents to the emergency department at 30 weeks gestation with
complaints of decreased fetal movements and increased abdominal girth. Ultrasound reveals significant
edema involving the fetus, including generalized subcutaneous edema, ascites, and pleural effusion.
The fetal heart rate is irregular, and the mother reports a history of multiple miscarriages. Based on
these findings, which of the following conditions is most likely responsible for the presentation?
(or)
Which of the following condition is characterized by generalized edema involving the fetus, including
subcutaneous edema, ascites, and pleural effusion on ultrasound with a history of repeated
miscarriages?
A. Alpha-thalassemia trait
B. Hemoglobin H disease
C. Hydrops fetalis
D. Beta-thalassemia
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Page 8
Option D: Decreased HbF & normal HbA2
 This finding will be found in a normal adult individual.
Correct Option C- Osmotic fragility is decreased:
 The screening test shown in image is Nestroft Test :
 One of the screening tests for β thalassemia.
 It is the Naked Eye Single Tube RBC Osmotic Fragility.
 Osmotic fragility of RBCs in thalassemia is reduced
Option A- Osmotic fragility is increased:
 In Hereditary Spherocytosis, osmotic fragility is increased, which makes RBCs to burst easily
 Osmotic fragility of RBCs in thalassemia is reduced.
Option B- Osmotic fragility has no change:
Correct Option C- Hydrops fetalis:
C. Hydrops fetalis is a condition characterized by generalized edema involving the fetus, including subc
utaneous edema, ascites, and pleural effusion. In cases of severe hydrops fetalis, intrauterine death ca
n occur. The formation of gamma 4 tetramers, known as Hb Barts, is a
feature of alpha-thalassemia and is associated with hydrops fetalis.
Option A- Alpha-thalassemia trait: Alpha-thalassemia trait” refers to the condition where two alpha-glob
in genes are deleted, resulting in a mild form of alpha-thalassemia. It does not present with intrauterine
 death and the formation of gamma 4 tetramers.
Option B- Hemoglobin H disease: is caused by the deletion of three alpha-globin genes, resulting in the
 production of abnormal beta 4 tetramers. It is not associated with intrauterine death but may present w
ith anemia and other symptoms.
Option D- Beta-thalassemia: is a different type of thalassemia caused by mutations in the beta-globin g
ene. It does not involve the formation of gamma 4 tetramers or result in hydrops fetalis.
596

Sickle Cell Anemia,G6PD Deficiency,Hemolytic
Anemia
1. A 20-year-old previously healthy swimmer is admitted for new-onset severe fatigue and left upper
abdominal pain. She was treated two days ago in hospital for presumed typhoid fever with cefotaxime.
Her family or past medical history is insignificant except for recurrent typhoid fever. She is a
non-alcoholic and non-smoker. Her blood pressure is 120/85 mmHg, and her heart rate is 120 bpm.
Physical examination reveals a palpable spleen. The stool is negative for heme. Lab investigations
show haemoglobin of 5 g/dL with normal total lymphocyte count (TLC) and platelets. A peripheral blood
smear reveals IgG antibodies and an excess of spherocytes. Which of the following do not cause a
similar type of condition?
(or)
Which of the following does not cause autoimmune hemolytic anemia?
A. SLE
B. α-Methyldopa ingestion
C. Quinidine
D. Infectious mononucleosis
2. A 14-year-old girl is brought to the OPD complaining of fatigue, weakness, painful swelling of the
fingers and toes, pale-coloured skin, and dark urine. She also has a history of recurrent joint pains and
infections. Her lab findings include decreased Hb, high reticulocyte count and sickled RBC on PBF.
Which of the following is not true regarding this patient's condition?
(or)
Which of the following is not true regarding sickle cell anaemia?
A. HbA will be undetectable
B. She may have retinopathy
C. She can present with pulmonary bleeds
D. Hydroxyurea would help her
3. A 22 years male comes to OPD complaining of persistent painful erection of the penis for the last 6
hours. His past medical history includes severe anaemia in early childhood, for which he required a
blood transfusion several times. He also has a history of multiple episodes of non-healing leg ulcers
and abdominal and chest pain. His lab findings include decreased Hb, high reticulocyte count and an
abnormal shaped RBC on PBF. What may be the probable diagnosis for this patient?
(or)
What may be the probable diagnosis for a patient with early childhood history of severe anaemia with
acute, persistent painful erection, non-healing leg ulcers? His lab findings shows decreased Hb, high
reticulocyte count and an abnormal shaped RBC on PBF.
A. Sickle cell anaemia
B. Hairy cell leukaemia
C. ALL
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Page 2
D. Beta thalassemia
4. A 17-year-old male is brought to the OPD complaining of painful swelling of the fingers and toes for
the last 4 hours. He has no significant past medical or family history except several episodes of blood
transfusion for chronic anaemia. On examination, he is anaemic and icteric, and his lab findings include
sickled RBC on PBF. After a proper evaluation, he is diagnosed with an inherited disease caused by a
point mutation of the β -globin gene. Which of the following is not associated with this patient's
(or)
Which of the following is not associated with Sickle cell anemia?
A. Shortened RBC life span
B. Normal reticulocyte count
C. Abnormality in haemoglobin
D. Polymer formation is reversible
5. An 8-year-old boy is brought to the outpatient department by his mother, complaining of pale skin,
dark urine, fatigue, dyspnea, and extreme tiredness. On examination, a palpable spleen is found. After
a proper evaluation, he is diagnosed with an x-linked recessive disorder due to an enzyme deficiency
that helps the RBC to work properly. Regarding his condition, which of the following statement is not
true?
(or)
Which of the following statement is not true reagrding (G6PD) deficiency?
A. Bite cells
B. Intravascular hemolysis
C. Favism
D. Confers protection against plasmodium vivax
6. A 10-year-old boy is brought to the outpatient department complaining dark-colored urine, very pale
skin, yellow skin, and breathlessness. What is the diagnosis?
A. SLE
B. Myelodysplasia
C. Paroxysmal nocturnal hemoglobinuria
7. A 23-year-old male comes to the outpatient department complaining of new onset of yellow-coloured
skin and scleras. The patient has no significant past medical or family history and doesn't take any illicit
drugs. He is a hill climber and recently came from a hill trip. On physical examination, anaemia is found.
On blood smears under a microscope, crescent-shaped gametocytes are seen as in the image below.
What may be the most probable diagnosis for this patient?
(or)
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Page 3
A. Malaria
B. Hereditary spherocytosis
C. G6PD Deficiency
D. Thalassemia
8. A 30-year-old male comes to OPD complaining of worsening malaise, body weakness, abdominal
pain, and dark urine for 1 day. He has had a past medical history of a carbuncle on his buttock, for
which he received cotrimoxazole 3 days before. On physical examination, he is icteric with normal vital
signs. Investigations reveal that haemoglobin has fallen from 14.4 g/dL to 9.1 g/dL, and his bilirubin has
risen from normal to 3.5 mg/dL, urine dipstick is positive for bilirubin. A peripheral blood smear is shown
in the image below. What may be the most common cause of death regarding this patient's condition?
(or)
A peripheral blood smear is shown in the image below. What may be the most common cause of death
in G6PD deficiency patient's?
A. Low oxyhemoglobin values
B. Acute renal failure
C. Sequestration crisis
D. Low oxygen affinity
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Page 4
9. A 30-year-old male presented with a skin lesion in his right axilla. A presumptive diagnosis of
staphylococcal skin carbuncle is made & the patient is treated with empiric sulfamethoxazole. After 2
days, the patient comes to an emergency with excessive weakness, abdominal pain & dark-coloured
urine. On physical examination, his vitals are normal & jaundice is present. Lab studies show a drop in
Hb from 14 g/dl to 8 g/dl & significant rise in bilirubin levels. The urine dipstick is positive for bilirubin.
His peripheral blood smear is shown below. What may be the possible diagnosis of this patient?
(or)
A patient treated with sulfamethoxazole comes to an emergency with excessive weakness, abdominal
pain & dark-coloured urine. The urine dipstick is positive for bilirubin. His peripheral blood smear is
shown below. What may be the possible diagnosis of this patient?
A. Glucose 6-phosphate dehydrogenase (G6PD) deficiency
B. Hemolytic-uremic syndrome
C. Hereditary spherocytosis
D. Iron deficiency anaemia
10. A 25-year-old female comes to the outpatient department complaining of bony pain, dyspnea, fever
& cough. On examination, her heart rate is 110 beats/min, BP is 140/88 mmHg, and SpO2 is 85% at
room air. Lab findings reveal decreased Hb, increased reticulocyte count and sickled RBC on blood
film. CXR shows bilateral diffuse alveolar infiltrates. Her mother gives a history of four similar episodes
in the last 12 months. Regarding her condition, which of the following statement is not true?
(or)
A 25-year-old female has sickled RBCs on blood film. CXR shows bilateral diffuse alveolar infiltrates.
Her mother gives a history of four similar episodes in the last 12 months. Regarding her condition,
which of the following statement is not true?
A. Chronic therapy with oral hydroxyurea should be considered
B. She is suffering from a sickle cell acute chest syndrome
C. She should receive daily sildenafil
D. Hematocrit should be maintained at >30%
11. A 40-year-old female presented to the OPD complaining of pale-coloured skin, dark-coloured urine,
fatigue, shortness of breath and weakness. She has been non-diabetic but hypertensive for 15 years.
Her past medical history includes SLE and recurrent typhoid fever treated with intravenous ceftriaxone.
A palpable spleen is found on physical examination. Her peripheral blood smear shows spherocytes.
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Page 5
Which of the following is the best investigation to diagnose her condition?
(or)
Which of the following is the best investigation to diagnose autoimmune hemolytic anemia?
A. Reticulocyte count
B. Osmotic fragility test
C. Coombs test
D. Bone marrow aspiration
12. A 12-year-old girl is brought to the outpatient department complaining of generalized weakness and
fatigue, dark urine, pale conjunctiva and shortness of breath. She has no history of chronic infection or
significant past medical or family history. Lab findings include increased unconjugated bilirubin,
increased lactate dehydrogenase, decreased haptoglobin levels, and hemoglobinuria. For further
evaluation, the physician advises an osmotic fragility test. Which of the following is incorrect regarding
this test?
(or)
An adolescent girl has been advised an osmotic fragility test. Which of the following is incorrect
regarding this test?
A. Increased in hereditary spherocytosis
B. Decreased in thalassemia
C. Hemolysis on exposure to a hypertonic saline environment
D. Osmotic fragility decreased in iron deficiency
13. A 10-year-old Afro-American boy presents to the emergency department. On physical examination,
the patient has hepatosplenomegaly and skull X-ray as shown below. Laboratory findings show
reduced hemoglobin, elevated lactate dehydrogenase (LDH), and red blood cells as observed in the
peripheral blood smear given below. Which of the following is the most appropriate initial treatment for
(or)
Which of the following is the most appropriate initial treatment for a patient with skull X-ray and
peripheral smear as shown below?
A. Hydroxyurea therapy
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Page 6
B. Fresh blood transfusion
C. Phosphodiesterase-5 inhibitors
D. Monoclonal antibody therapy
14. A 5-year-old boy presents to the emergency department with sudden onset of pallor and jaundice.
The mother mentions that the boy had a fever for the past few days, which subsided a day before. The
family history is significant for a maternal uncle who had a similar episode in childhood. On
examination, there is no splenomegaly or gallstones. Peripheral smear is as shown below. Which of the
following is not contraindicated in this patient?
(or)
Which of the following is not contraindicated in a patient with peripheral smear is as shown below?
A. Aspirin
B. Nitrofurantion
C. Artesunate
D. Me■oquine
15. A 16-year-old African-American male presents to the emergency department with severe pain in his
left arm and leg. He also complains of shortness of breath and chest pain on deep inspiration. On
examination, the patient appears in distress and has tenderness and swelling in the affected
extremities. His vital signs are stable. On physical examination, the patient has hepatosplenomegaly
and skull X-ray as shown below. Laboratory findings show reduced hemoglobin, elevated lactate
dehydrogenase (LDH), and red blood cells as observed in the peripheral blood smear given below.
What is the most appropriate initial treatment for this patient?
(or)
What is the most appropriate initial treatment for a patient having severe pain? Laboratory findings
show reduced hemoglobin, elevated lactate dehydrogenase (LDH), and red blood cells as observed in
the peripheral blood smear given below.
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Page 7
A. Intravenous (IV) analgesia with IV fluids
B. Antibiotic therapy
C. Packed red blood cell transfusion
D. crizanlizumab
16. A 45-year-old woman presents to the emergency room with symptoms of fatigue, weakness, and
dark urine over the past week. She has a history of hypertension and is currently taking medication for
it. Hb:8.2 g/dL, Reticulocyte count: Elevated, Serum lactate dehydrogenase (LDH): Elevated, Serum
haptoglobin: Decreased and Coagulation studies: Normal. Which of the following is not associated with
this disease?
(or)
Which of the following is not associated with the below given blood smear?
A. Hemolytic uremic syndrome
B. Thrombotic thrombocytopenic purpura.
C. Eclampsia
D. Hereditary spherocytosis
17. A 35-year-old female presents to her primary care physician with complaints of chronic fatigue and
intermittent jaundice. She reports a history of similar episodes throughout her life. On physical
examination, mild splenomegaly is noted. Laboratory tests reveal decreased hemoglobin, reduced
mean corpuscular volume (MCV), and an increased reticulocyte count. A blood smear is obtained and
is as shown below. Which of the following conditions is the most likely cause of her symptoms?
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Page 8
(or)
Which of the following conditions is the most likely cause of a blood smear as shown below?
A. Hereditary Spherocytosis (HS)
B. Paroxysmal Nocturnal Hemoglobinuria (PNH)
C. Autoimmune Hemolytic Anemia (AIHA)
18. A 5-year-old boy presents to the emergency department with sudden onset of pallor and jaundice.
(or)
A. Aspirin
19. Which of the following is a true statement regarding sickle cell disease? X-ray shows squaring of
the metacarpals HbA is absent in Hemoglobin electrophoresis HbS is created when glutamate is
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Page 9
replaced with valine Blood supply of the upper and lower parts of the vertebral body is a■ected
A. 1,3,4
B. 2,3
C. 2,3,4
D. 1,4
20. Which of the following statements about autoimmune hemolytic anemia (AIHA) is incorrect?
A. Warm AIHA is characterized by IgG antibodies targeting the P-Antigen on red blood cells.
B. Cold AIHA is caused by IgM antibodies and primarily leads to intravascular hemolysis (IVH).
C. In Paroxysmal cold hemoglobinuria, the red blood cells are broken down, resulting in extravascular
hemolysis (EVH).
D. Both Warm AIHA and Cold AIHA can cause extravascular hemolysis (EVH).
Question 16 4
Question 17 1
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Option A: Increased in hereditary spherocytosis
 The osmotic fragility of RBC is increased in hereditary spherocytosis due to a smaller surface area to
volume ratio.
Option B: Decreased in thalassemia
 Thalassemia causes an increased surface area to volume ratio of RBC, resulting in decreased
osmotic fragility.
Option D: Osmotic fragility decreased in iron deficiency
 In iron deficiency anaemia, the RBC surface area to volume ratio increases, so osmotic fragility
decreases.
Correct Option A - Hydroxyurea therapy:
 Hydroxyurea therapy: Hydroxyurea is the recommended initial treatment for sickle cell disease. It
helps to increase fetal hemoglobin (HbF) levels, which mitigates the clinical manifestations of the
disease. Hydroxyurea decreases cell count and decreases the frequency of painful crises, acute chest
syndrome, and hospitalizations.
Option B - Fresh blood transfusion: Fresh blood transfusion is indicated in sickle cell disease but is typi
cally reserved for specific indications such as acute severe anemia, acute chest syndrome, or stroke. It
 is not the most appropriate initial treatment in this patient.
Option C - Phosphodiesterase-5 inhibitors: Phosphodiesterase-5 inhibitors, such as tadalafil, are used i
n the treatment of pulmonary artery hypertension (PAH) in sickle cell disease. While PAH is a
potential complication, it is not the most appropriate initial treatment in this patient.
Option D - Monoclonal antibody therapy: Monoclonal antibody therapy, such as crizanlizumab, is used 
to reduce the frequency of vaso-occlusive crises in sickle cell disease. However, it is not the most appr
opriate initial treatment in this patient.
Correct Option C - Artesunate:
 Artesunate, which is used in the treatment of malaria, is generally safe for individuals with G6PD
deficiency. It does not induce hemolysis and is considered an acceptable option for treating malaria in
areas where G6PD deficiency is prevalent.
Option A -  Aspirin:
 Aspirin oxidative stress and trigger hemolysis in G6PD-deficient individuals. Aspirin is commonly used
for pain relief, anti-inflammatory purposes, and as an antiplatelet agent.
Option B - Nitrofurantoin:
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 Nitrofurantoin can cause hemolysis in individuals with G6PD deficiency. It is considered
contraindicated in G6PD deficiency due to its potential to induce oxidative stress and damage red blood
cells.
Option D - Mefloquine:
 Explanation: Mefloquine is contraindicated for individuals with G6PD deficiency and is considered an
acceptable antimalarial option. It triggers intravascular hemolysis in G6PD-deficient individuals.
Correct Option A - Intravenous (IV) analgesia with iv fluids:
 Intravenous (IV) analgesia with iv fluids: Severe pain is a hallmark symptom of a sickle cell crisis, and
IV analgesia is the mainstay of treatment to provide pain relief. Opioids are effective in managing acute
pain episodes associated with sickle cell disease.
Option B - Antibiotic therapy: Although patients with sickle cell disease have an increased risk of infecti
ons, the presence of severe pain and acute chest pain in this scenario suggests a vaso-occlusive crisis
 rather than an infectious process. Antibiotic therapy would not be the most appropriate initial treatment
.
Option C - Packed red blood cell transfusion: Packed red blood cells should not be administered in sick
le cell anemia. Fresh blood transfusion is reserved for specific indications in sickle cell disease, such a
s acute severe anemia, acute chest syndrome, or stroke. While it may be necessary in some cases, it i
s not the initial treatment for a vaso-occlusive crisis.
Option D - Crizanlizumab: It is a monoclonal antibody that is used to reduce the frequency of vaso-occl
usive crises in sickle-cell patients. It is not the initial treatment of choice.
 
Correct Option D - Hereditary spherocytosis:
 The above given scenario and blood smear image showing schistocytes is suggestive of the
diagnosis of Microangiopathic Hemolytic Anemia (MAHA)
 Hereditary spherocytosis is not associated with MAHA
Option A, B & C:
Disorders associated with MAHA
 Hemolytic uremic syndrome caused by Escherichia coli O157:H7.
 Thrombotic thrombocytopenic purpura.
 Eclampsia.
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Correct Option A - Hereditary Spherocytosis (HS):
 Hereditary Spherocytosis (HS): HS is the most likely cause of the patient's symptoms. It is an
autosomal dominant disorder characterized by defects in the RBC membrane, leading to the formation
of spherical-shaped RBCs (spherocytes). The clinical presentation includes chronic fatigue, intermittent
jaundice, splenomegaly, decreased hemoglobin, reduced MCV, and an increased reticulocyte count.
 The image shows spherocytes seen in hereditary spherocytosis.
Option B - Paroxysmal Nocturnal Hemoglobinuria (PNH): PNH is characterized by a
mutation in the PIGA gene, resulting in a deficiency of glycosylphosphatidylinositol (GPI)-anchored prot
eins on the surface of RBCs. This leads to intravascular hemolysis, but it does not typically present wit
h spherocytes on blood smear examination.
Option C - Autoimmune Hemolytic Anemia (AIHA): AIHA is caused by the production of autoantibodies 
against RBCs, leading to their destruction. It can present with fatigue, jaundice, and anemia, but the pr
esence of spherocytes on blood smear examination is more indicative of HS.
Option D - Thalassemia: Thalassemia is a group of inherited disorders characterized by abnormal or d
eficient synthesis of globin chains in hemoglobin. It typically presents with microcytic hypochromic ane
mia, but spherocytes are not a characteristic finding
 
cells.
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Correct Option C - 2,3,4
True statement
Option B - 2,3: In hemoglobin electrophoresis,HbS, HbF, HbA2 is Present and HbA is absent whereas i
n sickle cell trait ,HbS, HbF, HbA2 and HbA is present.
Option C - 2,3,4: Hemoglobin S (HbS) is a variant of normal hemoglobin (HbA) where a
glutamic acid residue at position 6 of the beta-globin chain is replaced with valine. This single amino ac
id substitution results in the formation of abnormal hemoglobin molecules known as hemoglobin S.
Option D - 1,4: Fish vertebrae are often seen in the context of sickle cell disease, where vaso-occlusive
 crises can lead to ischemia and necrosis of bone tissue, including the vertebral bodies. The H-shaped 
appearance on imaging is a result of the spared central portion of the vertebral body, which retains its 
blood supply from the anterior and posterior segmental arteries.Blood supply of the upper and lower pa
rts of the vertebral body is a■ected
Option A - 1,3,4
 X-ray shows squaring of the metacarpals in thalassemia not in sickle cell disease.
 Hand X-ray shows dactylitis in sickle cell disease
- Cold AIHA is caused by IgM antibodies and primarily leads to intravascular hemolysis (IVH).
 This statement is incorrect. Cold AIHA is primarily caused by IgM antibodies and predominantly
causes extravascular hemolysis (EVH), not intravascular hemolysis (IVH).
Option A - Warm AIHA is characterized by IgG antibodies targeting the P-Antigen on red blood cells: 
 This statement is correct. Warm AIHA is characterized by IgG antibodies targeting the P-Antigen on
red blood cells.
Option C - In Paroxysmal cold hemoglobinuria, the red blood cells are broken down, resulting in extrav
ascular hemolysis (EVH):
 This statement is correct. In Paroxysmal cold hemoglobinuria, the red blood cells are indeed broken
down, resulting in extravascular hemolysis (EVH).
Option D - Both Warm AIHA and Cold AIHA can cause extravascular hemolysis (EVH):
 This statement is correct. Both Warm AIHA and Cold AIHA can cause extravascular hemolysis (EVH):
621

Blood Grouping & Transfusion
1. A 16-year-old male patient has come to the hospital for a follow-up. He was diagnosed with
leukaemia 1 year back. He is receiving chemotherapy according to his schedule. His last dose of
chemotherapy was one month back. Complete blood count showing less than 50,000 platelets. He has
been referred to the haematology department for platelet transfusion. What is the shelf life of platelets
in the blood bank?
(or)
What is the shelf life of platelets in the blood bank?
A. A. Storage temperature: 4°C; Shelf life: 35 days
B. B. Storage temperature: -30°C; Shelf life: 1 year
C. C. Storage temperature: 20-24°C; Shelf life: 5 days
D. D. Storage temperature: Varies; Shelf life: Not applicable
2. A 33-year-old man is brought to the ED by an ambulance after being involved in a road traffic
accident. He was an unrestrained passenger and sustained considerable trauma. The patient in ICU
receives an emergency blood transfusion as part of the resuscitation efforts. 3 hours later, SpO2 is
reduced to 75% with respiratory difficulty. CVP is 15cm water and PCWP is 25mm Hg. CXR is shown
below. What should be the probable diagnosis?
(or)
What is the diagnosis for presence of respiratory distress after 3hours of blood transfusion, along with
elevated CVP and PCWP with the following chest X-ray?
A. Tension pneumothorax
B. Transfusion-related acute lung injury
C. Transfusion-associated circulatory overload
D. Mismatched blood transfusion
3. Which of the following option is true regarding blood transfusion? Complete Packed RBC transfusion
within 6 hours of issue from the blood bank. Complete Platelet concentrate transfusion within 1 hour of
issue from the blood bank. Complete FFP transfusion within half hour of issue from the blood bank.
Complete Cryoprecipitate transfusion within 5 hours of issue from the blood bank.
A. 1
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B. 2 and 3
C. 3
D. 1 and 4
4. A 23-year-old man was brought to the ED by ambulance after sustaining a road traffic accident.
There were multiple abrasions in the patient's whole body and took multiple stitches at different sites of
the body. The patient in ED receives 3 emergency blood transfusions due to profound hypotension and
bleeding. Which of the following is a major complication of massive blood transfusion?
(or)
Which of the following is a major complication of massive blood transfusion?
A. Hyperthermia
C. Coagulopathy
5. A 30 years old man is brought to the hospital by ambulance after a road traffic accident. He was an
unrestrained passenger and sustained considerable trauma. He was given a blood transfusion in the
OT and developed tachycardia, hypotension (BP 70/40 mm of Hg), temperature 100°F and haematuria
within 10 minutes of starting the transfusion. Which of the following is most likely the reason for his
presenting symptoms?
(or)
Which of the following is most likely the reason for tachycardia, hypotension, hyperthermia and
hematuria to occur within 10 minutes of starting blood transfusion?
A. Anaesthetic drug hypersensitivity
B. Disseminated intravascular coagulation
C. Graft-versus-host disease
D. ABO incompatibility
6. A 16 year old female thalassemia patient has come to the hospital for follow-up. She has complained
of weakness and shortness of breath. CBC shows haemoglobin less than 6 mg/dl. The consultant
planned to transfuse 2 units of blood. On duty, an intern was sent to the blood bank to arrange the
blood. The blood bank personnel told the intern that the blood units had been in storage for a long time.
Which of the following is the most likely complication of transfusing prolonged stored blood?
(or)
A. Citrate intoxication
B. Potassium toxicity
C. Circulatory overload
D. Haemorrhagic diathesis
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7. A 25-year-old man is brought to the ED by ambulance immediately after a road traffic accident. The
patient in ICU receives an emergency blood transfusion as part of the resuscitation efforts. SpO2 is
reduced to 75% at room air three hours later with sudden respiratory difficulty. CVP is 15cm water and
PCWP is 16 mm Hg. Which of the following is the most likely associated with the diagnosis?
(or)
What is the most likely associated diagnosis when a patient has severe hypoxemia and ARDS like
features after 3 hours of blood transfusion?
A. Characterized by acute respiratory distress within 12 hrs of transfusion
B. Results from the donor plasma that contains high-titre anti-HLA antibodies
C. Leukocytes aggregate in the pulmonary vasculature and release mediators that decrease capillary
permeability
D. The implicated donors are frequently nulliparous women
8. What purpose is the device shown in the image used for?
(or)
A 20-year-old man is brought to the hospital after being involved in physical fights in a bar. He has
multiple injuries and fractures in his body. The patient receives an emergency blood transfusion as part
of the resuscitation. The nurse uses a device during a blood transfusion. What purpose is the device
shown in the image used for?
A. Prevent transmission of RBCs which have expired
B. Prevent transfusion-related reactions
C. Prevent transfusion-associated circulatory overload
D. Prevents transfusion-related acute lung injury
9. A 19-year-old girl came to the hospital with her parents with complaints of weakness and fatigue.
She doesn't have any other disease. On physical examination, her sclera was found to be whitish. CBC
reveals 7 g/dl of Hb. The physician has prepared her for an RBC transfusion. Which of the following is
the true statement?
(or)
Which of the following is a true statement about blood transfusion?
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A. CPDA is Citrate-Phosphate-Dextrose buffer supplemented with alanine
B. The shelf life of RBC concentrates in CPDA is 45 days
C. The shelf life of RBC concentrates in CPD is 21 days
D. The shelf life of RBC concentrates in ACD is 51 days
10. A 19-year-old was brought to the hospital by his parents after a road traffic accident. On physical
examination, multiple skin abrasions and cuts were present all over the body. Continuous bleeding was
occurring through multiple sites. His BP was 90/70 mmHg, and his pulse was 100/min. He was given 2
units of whole blood for resuscitation at the ED. After 3 hours, his temperature rises to 101°C.
Headache, chills, and flushing are predominant. Urine output is decreased, but the colour is straw.
What is the most common cause of the patient's present condition?
(or)
What is the most common cause of febrile non-haemolytic transfusion reaction?
A. ABO mismatch
B. Rh mismatch
C. HLA mismatch
11. Which of the following is true regarding this blood grouping system?
A. Most common blood group is AB positive
B. The ABO locus is located on chromosome 19
C. Most common blood group is O positive
D. ABO blood type is inherited in an autosomal recessive fashion
12. A 25-year-old male is brought to the hospital after sustaining a car accident. There are multiple
abrasions on his body and profuse bleeding. His BP is 100/70 mmHg, and his pulse is 97 beats/min.
The patient is prepared for neurosurgery due to a scalp fracture revealed in a scalp x-ray. Peripheral
blood film shows less than 100000/mm3 platelets, and the patient is selected for platelet transfusion.
Which of the following is a true statement regarding platelet transfusion?
(or)
A. Platelets are given either as pools of 4 to 6 prepared RDP (Random donor platelets) or as SDP
(Single donor platelets) from a single donor
B. Transfusion is indicated during childbirth if maternal blood is less than <200,000/mm3
C. Platelet transfusion is usually recommended to treat HIT
D. Platelets express the Rh antigens
13. A 10-year-old boy has come to the hospital for taking a blood transfusion. He is a known case of
thalassemia major and is on repeated packed RBC transfusions. He is on iron chelators and has a
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history of arrhythmias. He suddenly developed chest pain during the current blood transfusion and
looked very anxious. Which of the following will be the next management for this patient?
(or)
What is the next step in management when there is development of back pain, fever, chills, urticaria
and itching during the blood transfusion?
A. Observe for changes in the colour of the urine
B. Continue BT
C. Stop BT and wait for the patient to become normal, and then restart BT
D. Stop BT and perform a clerical check of the blood group
14. Which of the following group's FFP's can be transfused safely?
(or)
A 16-year-old male patient is brought to the emergency department immediately after an accident.. The
patient is actively bleeding in multiple sites of the body. Primary interventions have not stopped the
bleeding, and vitals are deteriorating. The physician has decided to give FFP's, but there is no time for
cross-matching. Which of the following group's FFP's can be transfused safely?
A. O –
B. O +
C. A+
D. AB +
15. A 9-year-old female child is brought to the hospital for a blood transfusion. She was diagnosed with
thalassemia in early childhood. After 15 minutes of the current blood transfusion, she suddenly
developed a fever, chills, and body aches. Blood transfusion is immediately stopped. What should have
been done to decrease the rate of reactions during blood transfusion?
(or)
What is done to decrease the rate of reactions during blood transfusion?
A. Leucocyte depletion
B. Antibiotics
C. Irradiation
D. Washed RBCs
16. What is the most likely diagnosis for the presence of respiratory distress within 8 hours after the
third blood transfusion, along with elevated CVP and PCWP ?
(or)
A 50-year-old male patient has come to the hospital to undergo dialysis. His Hb was 5.5 mg/dl at the
time of admission. Three units of blood transfusions were given as a part of resuscitation. After the third
blood transfusion, within 8 hours, he developed shortness of breath and hypertension, SpO2 was
reduced to 65%, CVP was 16cm water, and PCWP was 26mm Hg. Which of the following is the most
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Page 6
A. Allergic
B. Transfusion-related circulatory overload (TACO)
C. TRALI
D. Febrile non-hemolytic transfusion reaction(FNHTR)
17. Which of the following is the most likely ABG finding in the case of Massive blood transfusion?
(or)
A 30-year-old man has been admitted to the hospital for multiple injuries following an accident. At the
time of admission, his BP was 90/60 mmHg, pulse was 99 beats/min. There was active bleeding from
some injured sites. He has received 8 units of packed RBCs (PRBCs). Which of the following is the
most likely ABG finding in this patient?
A. Metabolic alkalosis
B. Respiratory alkalosis
D. Respiratory acidosis
18. A 32-year-old man is brought to the hospital by ambulance immediately after a car accident. The
patient receives three emergency blood transfusions due to active bleeding and persistent hypotension.
After 4 hours, the patient developed sudden respiratory distress. SpO2 is reduced to 80%, and PCWP
is 16 mm Hg. Which of the following can be the reason behind this symptom in this patient that can lead
to death?
(or)
Which of the following is the most common complication of blood transfusion leading to death?
B. Citrate toxicity
C. TRALI
627

Aplastic Anemia & Iron Deficiency Anemia
1. A panel of haemoglobin and iron studies is ordered for a female patient with SLE. Results are as:
Hemoglobin=9.8 gm%, MCV=70, serum iron= 50µg/dl, serum ferritin=100 ng/dl. Which of the following
(or)
A 28-year-old young female presents to you with complaints of tiredness and breathlessness. She
appears pale. Her medical history is significant for SLE. A panel of haemoglobin and iron studies is
ordered. Results are as: Hemoglobin=9.8 gm%, MCV=70, serum iron= 50µg/dl, serum ferritin=100
ng/dl. Which of the following is the most likely diagnosis?
A. Thalassemia intermedia
B. Chronic iron deficiency anaemia
C. Megaloblastic anaemia
D. Anaemia of chronic infection
2. The CBC shows anaemia and reticulocytosis. Increased cellularity is seen on bone marrow
aspiration. What is the most likely diagnosis of this patient presenting with pallor and splenomegaly?
(or)
An 8-year-old African child presents to you at the clinic complaining of tiredness and breathlessness.
On examination, pallor is noticed in the conjunctiva, and splenomegaly is also evident. A complete
blood count is ordered, which shows anaemia & shows reticulocytosis. On bone marrow aspiration,
increased cellularity is noted. What is the most likely diagnosis?
A. Pernicious anaemia
B. Hemolytic anaemia
C. Myelofibrosis
D. Hairy cell leukaemia
3. When she woke up this morning, a 32-year-old lady presented to the emergency room complaining
of severe abdominal pain. A complete blood count is ordered, and the report shows pancytopenia.
Ultrasound of the abdomen shows decreased doppler flow in the hepatic vein. A presumptive diagnosis
of paroxysmal hemoglobinuria is suspected. All of the following are consistent with paroxysmal
nocturnal hemoglobinuria (PNH), except?
(or)
All of the following are consistent with paroxysmal nocturnal hemoglobinuria, except?
A. Aplastic anaemia
B. Increased LAP scores
C. Venous thrombosis
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4. A 35-year-old female patient presents at the clinic complaining of bloating and tiredness from the last
2 months. Her medical history is significant for multiple sclerosis. A complete blood count is ordered,
and it shows macrocytic anaemia. A Schilling test is then performed, which comes out abnormal.
Antibiotics are then given for 5 days which results in normalization of the Schilling test. What is the
most likely diagnosis of the patient?
(or)
What is the most likely diagnosis of the patient with macrocytic anaemia and an abnormal schilling test?
A. Bacterial overgrowth syndrome
C. Atrophic gastritis
D. Ileocecal TB
5. During a haematology workshop, a station is placed with the following smear to test the candidates.
Identify the inclusions in RBC in the blood smear of a patient given below?
(or)
A. Pappenheimer Bodies
B. Cabot rings
C. Howell-Jolly Bodies
D. Heinz Bodies
6. A middle-aged chronic alcoholic man complains of a burning sensation in the mouth. On
examination, he has thickened, dry, smooth tongue without the filiform papillae. Mean corpuscular
volume(MCV) is 100 fl. Which of the following should be the first line of approach in the management of
(or)
Which of the following should be the first line of approach in the management of a patient with vitamin
B12 deficiency?
A. Estimation of Vitamin B12 levels
B. Brush biopsy
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Page 3
C. Start Antifungal therapy
D. Incisional biopsy
7. A 46-year-old patient presents to the clinic with severe pain in the finger joints. Her medical history is
significant for rheumatoid arthritis. Besides joint pain, she complains of excessive tiredness and
breathlessness. On general physical examination, pallor is noted in the conjunctiva. A panel of
complete blood count and iron studies is ordered. Regarding anaemia of chronic diseases, all of the
following are true, except?
(or)
All of the following are true regarding anaemia of chronic diseases, except?
A. Decreased serum iron
B. Decreased ferritin
C. Decreased total iron binding capacity
D. Increased bone marrow iron
8. A 43-year-old female presented to medical outdoors with complaints of fatigue, weakness, and
shortness of breath with minimal activity. Her friends and family have told her she appears pale, and
with her recent symptoms, she has decided to get checked out. She also states that her hair and
fingernails become extremely thin and brittle, causing even more concern. The patient started noticing
these symptoms a few months ago and has been getting progressively worse. Upon initial assessment,
her mucosal membranes and conjunctivae are pale. Considering the above scenario, which of the
following is the most sensitive and specific test to diagnose this deficiency anaemia?
(or)
A 43-year-old female presented with fatigue, weakness, and shortness of breath with minimal activity,
thin and brittle hair, and fingernails. Her mucosal membranes and conjunctivae are pale. What is the
most sensitive and specific test to diagnose iron deficiency anemia?
A. Serum iron levels
B. Serum ferritin levels
C. Serum transferring receptor population
D. Transferring saturation
9. A researcher is conducting a study on the morphological spectrum of iron deficiency anaemia on
blood smear of anaemic patients. All of the following are true about iron deficiency anaemia, except?
(or)
All of the following are true about iron deficiency anaemia, except?
A. Hyper-segmented neutrophils
B. Microcytosis precedes hypochromia
C. Mean corpuscular haemoglobin concentration MCHC<50%
D. Most common cause of anaemia in India
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10. Which of the following statements is incorrect about Aplastic anemia?
(or)
A 23-year-old male presented with a nosebleed. Lab parameters show Hb= 5 g/dl, Platelet count =
23,000/mm³ and absolute neutrophil count = 176/mm³. Bone marrow is hypocellular with fatty
infiltration. All of the following statements are true regarding this condition, except?
A. Can be cured by Hematopoietic stem cell transplantation
B. Lymphadenopathy and splenomegaly are highly typical
C. Bleeding is the most common symptom
D. Immunosuppressants are given to cure the disease
11. A 65-year-old man has anaemia, splenomegaly, and extramedullary hematopoiesis. He has
experienced easy fatigability, weight loss, and weakness. Bone marrow biopsy reveals a marked
proliferation of fibrous tissue (myelofibrosis). Which of the following is a characteristic finding in this
disorder?
(or)
Which of the following is a characteristic finding in myelofibrosis?
A. Depletion of bone marrow megakaryocytes
B. Teardrop-shaped erythrocytes
C. Autosplenectomy
D. Neoplastic plasma cells in the bone marrow
12. A 23-year-old female comes to the office complaining of continuous fatigue, dyspnea and
weakness. She has no other symptoms or significant past medical or family history. Her menstrual
cycle is regular but bleeds heavily and lasts 5-6 days. On physical examination, conjunctival pallor and
spoon-shaped nails are present. Lab findings include decreased iron, increased TIBC, and a decreased
ferritin level. Which of the following is the most probable diagnosis for this patient?
(or)
Low serum iron and ferritin with high TIBC are seen in which of the following condition?
B. Chronic kidney disease
C. Sideroblastic anaemia
D. Fanconi anaemia
13. A 13-year-old girl is brought to the outpatient department by his mother complaining of generalized
weakness and fatigue, pale skin, dark-coloured urine, and shortness of breath. She has no history of
chronic infection or significant past medical or family history. Lab findings include increased
unconjugated bilirubin, increased lactate dehydrogenase, decreased haptoglobin levels, and
hemoglobinuria. Which of the following is not true regarding this patient’s condition?
(or)
Which of the following is not true regarding hemolytic anemia?
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A. Increased indirect bilirubin in the serum
B. Decreased red cell survival
C. Increased number of reticulocytes
D. Decreased faecal urobilinogen
14. A 3 year old male child presents with fatigue, weakness, and generalized body ache. He reports
having a recent respiratory infection. On physical examination, he appears pale with a rash as shown in
the image below, and his conjunctiva and mucous membranes are noticeably pale as well. Laboratory
tests reveal a significant decrease in his red blood cell count and a normal white blood cell and platelet
count. Which of the following conditions is the most likely diagnosis for this patient?
(or)
The image cue of dog ear projections on erythroblasts is indicative of which of the following diagnosis ?
A. Pure Red Cell Aplasia (PRCA)
B. Iron deficiency anemia
C. Autoimmune hemolytic anemia
D. Sickle cell anemia
15. A 5-year-old boy presents to the emergency department with sudden onset of pallor and jaundice.
examination, there is no splenomegaly or gallstones. Peripheral smear is as shown below. What is the
most likely cause of the boy's symptoms?
(or)
What is the most likely cause of a patient with peripheral smear as shown below. ?
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Page 6
A. Iron deficiency anemia
C. Glucose-6-phosphate dehydrogenase (G6PD) deficiency
Option D: Anaemia of chronic infection
Interpretation of parameters provided in Question:
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Page 18
 Increased faecal urobilinogen
 Polychromatophilia
 Bone marrow erythroid hyperplasia.
Option A: Increased indirect bilirubin in the serum
 Hemolysis causes a breakdown of haemoglobin that releases free bilirubin in the blood, which leads
to excessive unconjugated bilirubin.
Option B: Decreased red cell survival
 A decrease in red cell survival leads to premature breakdown of RBC, resulting in haemolytic
anaemia.
Option C: Increased number of reticulocytes
 The reticulocyte number is increased in hemolytic anaemia because the bone marrow tries to
compensate for the decrease in RBC.
Correct Option A - Pure Red Cell Aplasia (PRCA):
 Parvovirus B19 infection leading to Pure Red Cell Aplasia (PRCA): This option is the correct answer.
Parvovirus B19 infection can cause PRCA, which is characterized by a selective absence of
erythroblasts in the bone marrow, resulting in decreased production of red blood cells. The image cue
of dog ear projections on erythroblasts is indicative of Parvovirus B19-associated PRCA.
Option B - Iron deficiency anemia: Iron deficiency anemia is a condition caused by a deficiency of iron i
n the body, leading to decreased production of red blood cells. However, it does not present with the s
elective absence of erythroblasts or the specific association with Parvovirus B19 infection seen in PRC
A.
Option C - Autoimmune hemolytic anemia: Autoimmune hemolytic anemia is a condition characterized 
by the destruction of red blood cells by the immune system. It does not involve the selective absence o
f erythroblasts in the bone marrow, as seen in PRCA.
Option D - Sickle cell anemia: Sickle cell anemia is an inherited blood disorder characterized by abnor
mal hemoglobin that causes red blood cells to become misshapen. It does not present with the selectiv
e absence of erythroblasts or the specific association with Parvovirus B19 infection seen in PRCA.
 
Correct Option C - Glucose-6-phosphate dehydrogenase (G6PD) deficiency:
 Glucose-6-phosphate dehydrogenase (G6PD) deficiency: G6PD deficiency is an X-linked recessive
disorder that commonly affects boys. It presents with intermittent episodes of pallor and jaundice, often
triggered by factors such as fever, infection, and certain drugs (e.g., antimalarials). Bite cells and Heinz
bodies are characteristic findings on peripheral smear. The absence of splenomegaly and gallstones
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further supports G6PD deficiency.
Option A - Iron deficiency anemia: Iron deficiency anemia typically presents with microcytic hypochromi
c red blood cells on peripheral smear. However, it does not cause the formation of bite cells or Heinz b
odies. Moreover, iron deficiency anemia does not have an association with pallor and jaundice in the a
bsence of other factors.
Option B - Hereditary spherocytosis: Hereditary spherocytosis is characterized by the presence of sphe
rocytes on peripheral smear. It can cause anemia, but it does not typically present with intermittent epis
odes of pallor and jaundice. Additionally, it is an autosomal dominant disorder and not X-linked recessi
ve like G6PD deficiency.
Option D - Thalassemia: Thalassemia is a group of inherited blood disorders characterized by reduced 
synthesis of globin chains. It can cause chronic hemolytic anemia, but intermittent episodes of pallor an
d jaundice are not typical. Peripheral smear findings in thalassemia include microcytosis, hypochromia,
 and target cells, rather than bite cells and Heinz bodies.
 
659

Platelet Disorders
1. Immune thrombocytopenia purpura (ITP) is the immune-mediated destruction of platelets. It is
characterized by autoantibodies that bind to the platelets, which are then removed by the splenic
macrophages. Which of the following statements is true regarding ITP?
(or)
Which of the following statements is true regarding ITP?
A. Acute ITP occurs in children between 2-6 years of age
B. Chronic ITP has Hemorrhagic bullae in the mouth
C. Acute ITP more common in girls than boys
D. Chronic ITP has spontaneous remission
2. A 27-year-old male complains of bruises on the legs. Complete blood counts show decreased
platelet levels. A diagnosis of ITP is made. He is started on steroid therapy and undergoes splenectomy
3 months later. The patient develops dyspnea on the 3rd postoperative day. Which of the following is
the likely diagnosis?
(or)
What is the most common early postoperative complication of splenectomy presenting with breathing
difficulty?
A. Left lower lobe atelectasis
B. Port site infection
C. Focal Intra-abdominal collection
D. UTI
3. Disseminated intravascular coagulation is a consumptive coagulopathy. It is characterized by
activation of the coagulation cascade throughout the body leading to decreased coagulation factors and
bleeding from the body orifices. Which of the following is not seen in DIC?
(or)
Which of the following is not seen in DIC?
A. Hyperfibrinogenemia
B. Increased fibrin degradation products
C. Prolonged PT
D. Increased APTT
4. Which of the following is not a causative factor of DIC?
(or)
Disseminated intravascular coagulation is a consumptive coagulopathy. It is characterized by activation
of the coagulation cascade leading to decreased coagulation factors and bleeding from the body
orifices. Which of the following is not a causative factor of DIC?
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A. Snakebite
B. Placenta Previa
C. Falciparum malaria
D. Hemophilia
5. Which of the following does not lead to a thrombotic event?
(or)
Thrombotic events are life-threatening complications of coagulation disorders. They can lead to death
in severe cases. Which of the following does not lead to a thrombotic event?
A. PNH
B. DIC
C. ITP
D. Heparin-induced thrombocytopenia
6. Which of the following is incorrect regarding ITP?
(or)
Idiopathic thrombocytopenic purpura (ITP) is an immune-mediated disorder resulting in platelet
destruction by autoantibodies. It can have an acute or chronic course. Which of the following is
incorrect regarding ITP?
A. The peak age of incidence of acute ITP is Children aged 2-6 years
B. Onset of bleeding is insidious in Chronic ITP
C. Lymphocytosis is common in Chronic ITP
D. Splenectomy is the best treatment for patients with relapse
7. Idiopathic thrombocytopenic purpura (ITP) is an immune-mediated disorder resulting in platelet
destruction by autoantibodies. It presents with skin and mucosal bleeding. Which of the following is not
a management option for the bleeding crisis in acute Idiopathic thrombocytopenic purpura?
(or)
Which of the following is not a management option for the bleeding crisis in acute Idiopathic
thrombocytopenic purpura?
A. RhIG
B. Prednisolone
C. Intravenous immunoglobulin
D. Eltrombopag
8. Bleeding time is the time required for a standardized incision to stop bleeding. It is a measure of
platelet function. Which of the following does not present with an increased bleeding time?
(or)
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Which of the following does not present with an increased bleeding time?
A. Thrombocytopenia
B. Thrombasthenia
C. Renal failure
9. A 24-year-old female presents to the dentist with severe tooth pain. She is diagnosed with dental
caries. Tooth extraction is planned for her. She is a known case of Von Willebrand disease. What
prophylaxis should be given before tooth extraction?
(or)
What prophylaxis should be given before tooth extraction for a known case of Von Willebrand disease?
A. Desmopressin
B. Blood transfusion
C. Fresh frozen plasma
D. Cryoprecipitate
10. Von Willebrand disease is a congenital disorder with quantitative or qualitative dysfunction of the
Von Willebrand factor. It has different types depending upon the kind of dysfunction and the levels of
Von Willebrand factor. Which is the rarest type of Von Willebrand disease?
(or)
Which is the rarest type of Von Willebrand disease?
A. vWD type 1
B. vWD type 2A
C. vWD type 2B
D. vWD type 3
11. Hereditary bleeding disorders are due to congenital deficiency of proteins involved in forming
platelet plugs or in the coagulation cascade. Which of the following is the most common inherited
bleeding disorder?
(or)
Which of the following is the most common inherited bleeding disorder?
A. von Willebrand disease
B. Bernard soulier syndrome
C. Glanzmann Thrombasthenia
D. ITP
12. Hemophilia B is a bleeding disorder caused by a deficiency of clotting factor IX. It is an inherited
coagulation disorder. Which of the following is the most common cause of death in hemophilia B?
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(or)
Which of the following is the most common cause of death in hemophilia B?
B. HIV, HBV, HCV due to transfusions
C. Transfusion reactions
D. Deep vein thrombosis
13. Factor VIII is a procoagulant protein involved in the intrinsic coagulation pathway. Antibodies
against factor VIII result in abnormal factor VIII function and an increased risk of bleeding. Which of the
following will most likely have anti-factor VIII antibodies?
(or)
Which of the following will most likely have anti-factor VIII antibodies?
A. Postpartum state
B. Hemophilia patients who have received an infusion of plasma concentrates
C. Both A & B
D. None
14. Von Willebrand disease is a congenital disorder with quantitative or qualitative dysfunction of the
Von Willebrand factor. Von Willebrand factor is involved in the formation of the platelet plug.
Dysfunction results in an increased risk of bleeding. Which of the following is true regarding this
disease?
(or)
Which of the following is true regarding Von Willebrand disease?
A. Normal partial thromboplastin time
B. Decreased platelets
C. Normal prothrombin time
D. Normal bleeding time
15. Which of the following tests differentiates between a coagulation factor deficiency and a factor
inhibitor?
(or)
A 22-year-old pregnant female presents to the hospital with labour pains. Following delivery, she
experiences severe postpartum haemorrhage. The blood loss is about 2 litres. Investigations reveal a
normal PT and a prolonged aPTT. Which of the following test differentiates between a coagulation
factor deficiency and a factor inhibitor?
A. Tissue thromboplastin inhibition time
B. Ecarin clotting time
C. Dilute Russel viper venom time
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Page 5
D. Mixing studies
16. A 30-year-old female presents to the hospital with a complaint of mucosal bleeding on trauma. She
has a history of menorrhagia. On investigations, BT and PTT are prolonged. The Ristocetin assay is
positive. What is the likely diagnosis?
(or)
What is the likely diagnosis of a patient with mucosal bleeding, menorrhagia, prolonged BT and PTT,
and positive ristocetin assay?
A. Immune thrombocytopenic purpura (ITP)
B. Hemophilia A
C. Hemophilia B
D. Von Willebrand disease
17. Which of the following best describes the factor V Leiden mutation?
(or)
A 33-year-old female with a history of knee arthroscopy seven days back is admitted to the hospital
with extensive lower extremity deep vein thrombosis (DVT). Her family history is significant for DVT.
Thorough investigations and work-up reveal factor V gene R506Q mutation. Which of the following best
describes the factor V leiden mutation?
A. Increased bleeding tendency
B. Factor V becomes resistant to cleavage by protein C
C. Arginine to glycine substitution
D. Deficiency of factor V
18. A 62-year-old male patient with a history of atrial fibrillation and a mechanical heart valve presents
to the emergency department with complaints of easy bruising and hematuria. He has been taking
Warfarin for anticoagulation therapy for the past three months. On examination, the patient appears
pale, and his vital signs are stable. Laboratory investigations reveal an International Normalized Ratio
(INR) of 5.0 (normal range: 2-3). Which of the following is the most appropriate initial treatment for the
patient's elevated INR and bleeding symptoms?
(or)
Which of the following is the most appropriate initial treatment for a patient with elevated INR and
bleeding symptoms?
A. Intravenous Vitamin K
B. Fresh Frozen Plasma (FFP) transfusion
C. Protamine Sulfate
D. Unfractionated Heparin (UFH) infusion
19. A 65-year-old male patient with a recent history of receiving heparin therapy for treatment of a
thromboembolic event presents with new-onset thrombocytopenia, accompanied by symptoms of limb
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Page 6
ischemia. Laboratory tests reveal the presence of platelet factor 4 antibodies. The patient's condition is
suspected to be related to heparin administration. Which of the following is the drug of choice for this
(or)
Which of the following is the drug of choice for heparin-induced thrombocytopenia?
A. Warfarin
B. Argatroban
C. Fondaparinux
D. Aspirin
20. A newborn infant presents with persistent bleeding from the umbilical cord stump. All routine
coagulation tests, including bleeding time (BT), clotting time (CT), prothrombin time (PT), activated
partial thromboplastin time (APTT), and thrombin time (TT), are within normal limits. Which of the
following tests is most appropriate to confirm the suspected diagnosis?
(or)
Which of the following tests is most appropriate to confirm suspected diagnosis of factor 13 deficiency?
A. Platelet aggregometry
B. Mixing studies
C. Urea clot solubility test
D. Thromboelastography (TEG)
21. Which of the following statements about thromboelastography (TEG) is incorrect?
A. Stage R represents the time taken to start forming the clot and is primarily affected by clotting
factors.
B. Stage K represents the clot firmness and is affected by fibrinogen levels.
C. Stage Alpha angle measures the speed of fibrin accumulation and is primarily affected by platelets.
D. Stage Maximum Amplitude (MA) reflects the highest vertical amplitude of TEG and is affected by
both platelets and clotting factors.
22. A 45-year-old male presents to the clinic with easy bruising and petechiae on his arms and legs. He
denies any recent history of viral infections. On examination, his platelet count is found to be
significantly low, and a peripheral smear reveals larger-sized platelets. Bleeding time is prolonged, and
bone marrow aspiration shows increased megakaryocyte size and count. Which of the following
statements about the condition described above is incorrect?
(or)
Which of the following statements about ITP is incorrect?
A. It is a quantitative platelet defect
B. Non-palpable purpura can be seen in this condition
C. Platelet transfusion is recommended since the platelet count is low
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Page 7
D. Elective splenectomy is done in chronic cases
23. A 67-year-old male presents with recurrent episodes of gastrointestinal bleeding characterized by
hematochezia. He also has a history of aortic stenosis. Which of the following conditions is most likely
causing his gastrointestinal bleeding?
(or)
Which of the following conditions is most likely cause of gastrointestinal bleeding and hematochezia for
a patient with aortic stenosis?
A. Heyde Syndrome
C. Von Willebrand Disease
D. Glanzmann Thrombasthenia
Question 10 4
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Page 19
 FFP contains various clotting factors, including those affected by Warfarin. It is sometimes used as a
source of clotting factors in patients with elevated INR and bleeding.
 However, FFP transfusion is not the initial treatment of choice in this scenario, as it may take time to
thaw and administer the product, delaying the reversal of anticoagulation.
Option C- Protamine Sulfate:
 Protamine sulfate is the specific antidote for unfractionated heparin (UFH) and not for Warfarin.
 It is not appropriate for reversing the effects of Warfarin.
Option D- Unfractionated Heparin (UFH) infusion:
 UFH is not the initial treatment of choice in this scenario. While heparin can be used for
anticoagulation, it is not indicated for the immediate reversal of Warfarin's effects.
 Heparin can be considered for bridge therapy once the effects of Warfarin are adequately reversed,
but it should not be used initially to address the elevated INR and bleeding.
Correct Option B- Argatroban:
 Argatroban: Argatroban is the drug of choice for heparin-induced thrombocytopenia. It is a direct
thrombin inhibitor that binds to the catalytic site of factor IIa, preventing thrombus formation. It is used
as an alternative anticoagulant in patients with heparin-induced thrombocytopenia.
Options A- Warfarin: Warfarin is not the drug of choice for heparin-induced thrombocytopenia. Warfarin
 is a vitamin K antagonist and is used for long-term anticoagulation therapy but is not effective in treatin
g acute heparin-induced thrombocytopenia.
Option C- Fondaparinux: Fondaparinux is not the drug of choice for heparin-induced thrombocytopenia
. Fondaparinux is a factor Xa inhibitor and can be used in treating heparin-induced thrombocytopenia b
ut is not the drug of choice. It may be used for prophylaxis or treatment of venous thromboembolism in 
patients without heparin-induced thrombocytopenia.
Option D- Aspirin: Aspirin is not the drug of choice for heparin-induced thrombocytopenia. Aspirin is an 
antiplatelet agent and is not effective in treating heparin-induced thrombocytopenia, which involves plat
elet activation and thrombus formation.
Correct Option C- Urea clot solubility test:
 Urea clot solubility test: The urea clot solubility test is the most appropriate test to confirm the
suspected diagnosis of factor 13 deficiency in this scenario. It directly measures the solubility of the clot
formed in the presence of urea. In factor 13 deficiency, the clot is soluble due to the lack of factor 13
activity.
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Page 20
Option A- Platelet aggregometry: Platelet aggregometry is a test used to assess platelet function and a
ggregation. It is not specific for diagnosing factor 13 deficiency, which is the suspected condition in this
 clinical scenario. Platelet function disorders would typically present with abnormal results in other coag
ulation tests as well.
Option B- Mixing studies: Mixing studies are performed to evaluate the presence of factor inhibitors or 
deficiencies. While mixing studies may be helpful in assessing certain coagulation disorders, they are n
ot specific to factor 13 deficiency.
Option D- Thromboelastography (TEG): Thromboelastography is a test that evaluates the entire proces
s of clot formation and breakdown, providing information about clot strength, stability, and fibrinolysis. 
While it can be useful in assessing overall coagulation function, it is not specific for diagnosing factor 1
3 deficiency.
Correct Option C- Stage Alpha angle measures the speed of fibrin accumulation and is primarily affect
ed by platelets:
 Stage Alpha angle measures the speed of fibrin accumulation. This stage is primarily affected by
fibrinogen levels, not platelets. Therefore, this statement is incorrect.
Option A- Stage R
represents the time taken to start forming the clot and is primarily affected by clotting factors:
 Stage R represents the time taken to start forming the clot. An elevated R-time indicates a problem
with clotting factors, not platelets.
Option B- Stage K represents the clot firmness and is affected by fibrinogen levels:
 Stage K represents the clot firmness. If the K-time is affected, it suggests a fibrinogen defect.
Option D- Stage Maximum Amplitude (MA) reflects the highest vertical amplitude of TEG and is affecte
d by both platelets and clotting factors:
 Stage Maximum Amplitude (MA) reflects the highest vertical amplitude of TEG. It is influenced by both
platelets and clotting factors. Decreased MA may indicate platelet dysfunction or deficiency of clotting
factors.
Correct Option C - Platelet transfusion is recommended since the platelet count is low:
 Platelet transfusion is recommended since the platelet count is low: This statement is incorrect.
Platelet transfusion is generally not recommended as a treatment option for ITP. The underlying
mechanism of ITP involves the destruction of platelets by autoantibodies rather than a deficiency in
platelet production. Platelet transfusion does not address the underlying immune-mediated pathology
and may not provide long-term benefit.
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Page 21
Option A - It is a quantitative platelet defect: This statement is correct. Immune thrombocytopenic purp
ura (ITP) is characterized by a decreased platelet count, indicating a
quantitative defect in platelet numbers.
Option B - Non-palpable purpura can be seen in this condition: This statement is correct. In ITP, purpur
a (bruising) is typically non-palpable, meaning it cannot be felt or raised on the skin surface.
Option D - Elective splenectomy is done in chronic cases: This statement is correct. In chronic cases of
 ITP, when medical management fails to control symptoms, elective splenectomy (surgical removal of t
he spleen) may be considered as a treatment option.
 
Correct Option A - Heyde Syndrome:
 Heyde Syndrome is a condition characterized by the association between aortic stenosis and
gastrointestinal bleeding. In patients with aortic stenosis, shear stress generated on red blood cells due
to turbulence can lead to a decrease in von Willebrand factor (VWF) activity. This reduction in VWF
activity is believed to contribute to the development of angiodysplasias in the gastrointestinal tract,
leading to bleeding and hematochezia. Given the patient's history of aortic stenosis and recurrent
episodes of gastrointestinal bleeding, Heyde Syndrome is the most likely cause.
Option  B - Hemophilia A: Is a disorder caused by factor VIII deficiency and is not directly associated wi
th aortic stenosis or gastrointestinal bleeding.
Option C - Von Willebrand Disease: is a bleeding disorder characterized by a deficiency or dysfunction 
of von Willebrand factor, but it is not specifically associated with aortic stenosis.
Option D - Glanzmann Thrombasthenia: Is a rare inherited platelet disorder that does not have a
direct association with aortic stenosis or gastrointestinal bleeding.
 
680

1. A 60-year-old man presents with fatigue, pallor, weight loss, and heaviness in the left
hypochondrium, for the past 2 months. Abdominal palpation reveals splenomegaly. His hemogram and
peripheral smear results are given below. What is the most likely diagnosis? Hemogram: Hb-10 gm/dl
WBC count – 1,65,000/cu.mm (leukocytosis) Platelet count – 3 lakhs/mm3 Peripheral smear:
Metamyelocytes – 15% Promyeloblasts – 30% Myeloblasts – 45%
A. Chronic lymphocytic leukemia
B. Chronic myeloid leukemia
C. Acute lymphoblastic leukemia
D. Acute myeloid leukemia
2. An elderly woman presented with symptoms of confusion, thirst, and abdominal pain. On
examination, she had pallor and thoracic spine tenderness. Her lab investigations showed the following
findings. An x-ray of her skull is shown below. What is the most likely diagnosis? Hb-6.9g/dl WBC
4000/cm3 with normal differential count Serum calcium 13mg/dl Creatinine 2.3mg/dl Albumin 2.4g/dl
Urinalysis: positive for Bence-Jones proteins
A. Metastatic breast cancer
B. Multiple myeloma
C. Primary hyperparathyroidism
D. Milk alkali syndrome
3. In which of the following conditions is elective splenectomy the preferred treatment option?
A. G6PD deficiency-Glucose-6-phosphate dehydrogenase deficiency
B. Paroxysmal nocturnal hemoglobinuria
D. Hairy cell leukemia
4. Which medication should be included in the treatment regimen of a patient with a history of
atherosclerosis who recently underwent a successful circumflex artery bypass and is currently taking
lisinopril, verapamil, and metoprolol?
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Page 2
A. PDE 3 inhibitor
B. Direct oral anticoagulant
C. P2Y12 receptor blocker
D. PDE 5 inhibitor
5. Sickle cell Anemia is
A. AD
B. AR
C. X-linked dominant
D. X-linked recessive
6. What is the usage of anti-CD 20 monoclonal antibodies in cancer therapy?
A. Methotrexate
B. Rituximab
C. Cisplatin
D. Cisplatin
7. Vitamin B12 deficiency leads to anemia which is
A. Normocytic normochromic
B. Microcytic hypochromic
C. Macrocytic hypochromic
8. Which conditions are associated with thrombocytopenia, eczema, and recurrent infections?
A. Wiskott-Aldrich syndrome
B. Chediak-Higashi syndrome
C. Thrombocytopenia – absent radius syndrome
D. Hermansky-Pudlak syndrome
9. What is the probable diagnosis for a ten-year-old boy who presents with fever, hand swelling, and a
history of recurrent hand swelling episodes, along with imaging showing a contracted spleen?
B. Malaria
C. Pancreatitis
D. Measles
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Page 3
10. An elderly woman presented with symptoms of confusion, thirst, and abdominal pain. On
findings. An x-ray of her skull is shown below. What is the most likely diagnosis? Hb – 6.9g/dL WBC
4000/cm3 with normal differential count Serum calcium 13 mg/dL Creatinine 2.3mg/dL Total protein
9g/dL Albumin 2.4g/dL Urinalysis: positive for Bence-Jones proteins
11. What is the most probable outcome for the patient after undergoing gastrectomy?
A. Folic acid deficiency
B. Vitamin B12 deficiency
C. Gastric ulcer
D. Constipation
12. A 68 year old male came to the physician with complaints of chronic back pain and easy fatigability
and past history of multiple urinary tract infections in the last 3 months. His ESR is elevated and an
x-ray of his skull is shown below. Which of the following investigations is useful for diagnosis?
A. MRI brain
B. PET scan
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Page 4
C. Head CT scan with contrast
D. Serum electrophoresis
13. What is the diagnosis of a 50-year-old man who presents with symptoms of anemia, fever, and
recurrent nosebleeds? The patient has hepatosplenomegaly and lab investigations indicate a
hemoglobin level of 6g/dL, a total leukocyte count of 40,000/cu.mm with 10% blasts, and a platelet
count of 12,000/cu.mm. Further investigation reveals the presence of t(8;21) in the blasts.
A. Acute lymphoblastic leukemia
B. Acute myeloblastic leukemia
C. Preleukemia
D. Aleukemic leukemia
14. Next, which of the following investigations should be conducted in a 7-month-old child who has a
hemoglobin level of 6.3, a history of recurrent blood transfusions, an MCV of 70fl, normal MCH, normal
MCHC, and a peripheral smear indicating a hypochromic microcytic image?
A. Serum iron
B. Direct coomb’s test
C. Osmotic fragility test
D. Hb electrophoresis
15. What is the probable diagnosis for an aged lady who exhibited symptoms of confusion, thirst, and
abdominal pain, and upon examination was found to have pallor and tenderness in the thoracic spine?
The X-ray results revealed the presence of osteolytic lesions, and her lab investigations demonstrated
the following findings. Hb -6.9g/dl WBC 4000/cm3 with normal differential count Serum calcium 13mg/dl
Creatinine 2.3mg/dl Total protein 9g/dl Albumin 2.4g/dl
16. A 68 year old male came to the physician with complaints of chronic back pain and easy fatigability
and past history of multiple urinary tract infections in the last 3 months. His ESR is elevated, and x-ray
of his skull is shown below. Which of the following investigations is useful for diagnosis?
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B. PET scan
C. Head CT can with contrast
17. A 30-year-old female patient complains of tiredness and shows signs of paleness during physical
examination. The patient's lab results are as follows: Hemoglobin level - 9.8 g/dL, Platelet count -
1,80,000/m3, Leukocyte count - 7800/mm3, Mean Corpuscular Volume (MCV) - 160 fl. Serum methyl
malonyl CoA levels are within the normal range. Based on these findings, which therapy should be
administered to this patient?
A. Vitamin B12
B. Iron
C. Vitamin C
D. Folic acid
18. What should be given to a 30-year-old woman who complains of body pain, excessive tiredness,
and difficulty in standing, and shows neurological findings of loss of vibration sense and proprioception,
with a haemoglobin level of 7gm/dL?
A. Vitamin B1
B. Vitamin C
C. Vitamin B12
D. Vitamin D
19. What is the most appropriate treatment strategy for a 25-year-old patient who presents with
symptoms of chronic diarrhea, fatigue, tiredness, and exhibits the nail findings shown below, with a
hemoglobin level of 8 gm%?685

Page 6
A. Folic acid
B. Metronidazole
C. Iron supplements
D. Vitamins B12
20. What would be the appropriate approach for managing a patient who presents with fatigue
symptoms and a blood smear indicating macrocytic anemia? Although the patient's methyl malonate
levels are normal, homocystinuria is observed, and serum B12 values are within the normal range.
A. Iron supplements
B. Treatment with folate and B12
C. Folate and vitamin b1
D. Folate therapy
21. A 47-year-old man with a diagnosis of acute myeloid leukemia with a blood type O negative blood
group presents to the transplant clinic to discuss proceeding with an allogeneic stem cell transplant.
Which of the following would be an optimal donor?
A. His identical twin brother
B. Umbilical cord transplant
C. His HLA identical brother who is otherwise healthy and is blood type O+
D. An HLA identical matched unrelated donor who is blood type
22. What is the most effective treatment for idiopathic thrombocytopenic purpura among the options
provided?
A. IV immunoglobulins
C. Splenectomy
D. Blood transfusion
23. Which statement is accurate regarding paroxysmal nocturnal hemoglobinuria (PNH)?
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Page 7
A. Inherited defect in PIG-A
B. Extravascular haemolysis
C. Deficiency of CD 55 and CD 59
D. Microcytic anaemia
24. What is the most probable condition that a 10-year-old boy is experiencing if he has been
complaining of recurrent episodes of intense pain in his fingers and toes that spontaneously resolve
over the course of the last year?
A. Alpha-thalassemia
B. Beta-thalassemia
C. Sickle cell anemia
D. Von Willebrand disease type 1
25. An 18-year-old girl with the diagnosis of acute promyelocytic leukemia was treated medically. She
developed fever and tachypnea and a chest X-ray showed pulmonary infiltrates. What drug should she
be given next?
A. Cytarabine
C. Doxorubicin
D. Methotrexate
26. What is the most frequently observed bleeding manifestation in individuals with severe hemophilia?
A. Recurrent hematomas
B. Recurrent hemarthrosis
C. Hematuria
D. Intracranial hemorrhage
27. A patient with thalassemia has a history of multiple blood transfusions, iron overload, and cardiac
arrhythmia. She has now come for blood transfusion and during the process, complains of backache
and looks very anxious. What would you do next?
A. Stop the blood transfusion
B. Continue the transfusion but do an ECG
C. Stop the transfusion. Wait for patient to become normal and then start it again
D. Do clerical check and get ECG
28. What is incorrect regarding Disseminated Intravascular Coagulation (DIC)?
A. Increased schistocytes
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B. Increased PT
C. Increased fibrinogen
D. Increased FDPs
29. For hairy cell leukemia, which drug is considered the preferred choice?
A. Rituximab
B. Vemurafenib
C. Cladribine
D. Interferon-alpha
30. What is the next course of action for the management of a 65-year-old woman who arrived at the
emergency department with a hemoglobin level of 5.4 g/dl, urea level of 86 mg/dl, creatinine level of 6
mg/dl, calcium level of 12, and potassium level of 4.4? Additionally, the bone marrow aspiration reveals
over 60% plasma cells.
A. Urgent consultation for dialysis
B. Dexamethasone + lenalidomide
C. Dexamethasone + fluids
31. Mark the true statements 1. Pernicious anemia is an example of Type II Hypersensitivity 2. Serum
Sickness is a example of Type III Hypersensitivity 3. Pathergy test is an example of Type IV
Hypersensitivity 4. Pathergy test is done for Reiter's disease
A. 1, 2 and 3 are true
B. 2, 3 and 4 are true
C. 1, 2, 3 and 4 are true
D. 3 and 4 are true
32. Which of the following factors hinder the absorption of iron?
A. Vitamin C
B. Phytates
C. Oxalate
D. Myoglobin
33. In fever of unknown origin, blood sample should be drawn how many times?
A. 2
B. 3
C. 4
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D. 5
34. What is the treatment for neutropenia following chemotherapy?
A. Leucovorin
B. Filgastrim
C. Ondansetron
D. Darbepoetin
35. Which of the following statements is correct regarding polycythemia vera?
A. Risk of thrombosis strongly correlates with the degree of thrombocytosis
B. Generalized pruritus is a consequence of mast cell activation by JAK 2 mutation
C. It is protective against H. Pylori infection
D. Acute myeloid leukaemia is the most common cause of mortality
36. A patient of haemophilia received multiple blood transfusions. Which of the following metabolic
abnormalities can be seen in a patient?
37. A 30-year-old female with a history of recurrent headaches presented for further evaluation. On
further workup, hemoglobin and total WBC count were normal, while an elevated platelet count was
seen. Bone marrow aspiration showed increased megakaryocytes and a JAK2 mutation. Which is the
(or)
A 30-year-old female with a history of recurrent headaches presented for further evaluation. On further
workup, hemoglobin and total WBC count were normal, while an elevated platelet count was seen.
Bone marrow aspiration showed increased megakaryocytes and a JAK2 mutation. Which is the most
A. Polycythemia vera
B. Essential thrombocytosis
C. Primary myelofibrosis
D. Chronic myelogenous leukemia
38. Which test is utilized for the diagnosis of DIC among the following options?
A. Fibrin degradation products
B. Activation partial thromboplastin time
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C. Prothrombin time
D. Dimer assay
39. What is the probable diagnosis for a girl who experiences prolonged menstrual bleeding and has
normal platelet count, PT, and aPTT, but an increased bleeding time, which was determined to be due
to a deficiency of GpIIb-IIIa after further analysis?
A. Bernard Soulier syndrome
B. Glanzmann thrombasthenia
C. Haemophilia A
40. True for von-willebrand disease
41. Translocation of lymphoma asked in match the following Column A Column B Burkitt lymphoma
Mantle cell lymphoma Marginal cell lymphoma Follicular lymphoma Ewing’s sarcoma t(11,18) t(14,18)
t(8,14) t(11,22) t(11,14)
Column A Column B
Burkitt lymphomaMantle cell lymphomaMarginal cell lymphomaFollicular lymphomaEwing’s sarcoma t(11,18)t(14,18)t(8,14)t(11,22)t(11,14)
A. 1-A, 2-E; 3-C; 4-B; 5-D
B. 1-C, 2-D; 3-A; 4-B; 5-E
C. 1-C, 2-E; 3-A; 4-D; 5-B
D. 1-C, 2-E; 3-A; 4-B; 5-D
42. Which type of cancer is not linked to viral infection among the options provided?
A. Kaposi sarcoma
B. Primary effusion lymphoma
C. Merkel cell carcinoma
D. Superficial spreading melanoma
43. Which of the following statements is false regarding the diagnosis of accelerated phase of chronic
myeloid leukemia (CML)?
(or)
Mark the false statement regarding diagnosis of accelerated phase of CML:
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A. Leukocytosis more than 1000 ×106 not responding to treatment
B. Thrombocytosis 100 × 109 not responding to treatment
C. Increased spleen size not responsive to therapy
D. No response to tyrosine kinase inhibitor
44. In which of the following conditions will the pneumococcal vaccine PPV-23 provide the greatest
advantage?
A. Recurrent rhinitis and sinusitis
B. Cystic fibrosis
D. Child <2 years
Question 20 4
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Question 24 3
Question 29 3
Question 30 3
Question 34 2
Question 35 2
Question 38 4
Question 39 2
Question 41 4
Question 42 4
Question 44 3
 The most likely diagnosis for the patient in this scenario is chronic myeloid leukemia (CML). The
patients presenting symptoms of fatigue, pallor, weight loss, and splenomegaly are common in CML.
The hemogram and peripheral smear results also support this diagnosis. The patient has leukocytosis
with a very high white blood cell count (1,65,000/cu.mm), which is a hallmark of CML. Additionally, the
peripheral smear shows an increase in myeloblasts, promyelocytes, and metamyelocytes, which are
immature forms of white blood cells commonly seen in CML.
 Option a: Chronic lymphocytic leukemia (CLL) is a type of leukemia that typically presents with
lymphocytosis, or an increase in lymphocytes, rather than leukocytosis. The peripheral smear would
also show an increase in lymphocytes rather than myeloid cells.
 Option c: Acute lymphoblastic leukemia (ALL) is a type of leukemia that typically presents with
symptoms such as fever, fatigue, and easy bruising or bleeding. The peripheral smear would show a
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predominance of lymphoblasts rather than myeloblasts.
 Option d: Acute myeloid leukemia (AML) is a type of leukemia that presents with symptoms such as
fatigue, fever, and easy bruising or bleeding. The peripheral smear would show a predominance of
myeloblasts, similar to the peripheral smear findings in this patient. However, AML typically presents
with more acute symptoms and a shorter disease course compared to CML.  
Option b. Multiple myeloma:
 Multiple myeloma is a cancer of plasma cells that often presents with symptoms such as bone pain,
fatigue, and weakness. The lab findings in the question, such as low albumin, high serum calcium, and
the presence of Bence-Jones proteins in urine, are consistent with multiple myeloma. Additionally, the
skull X-ray may show punched-out lesions, a common feature of multiple myeloma. Therefore, multiple
myeloma is the most likely diagnosis in this case.
 Option a: Metastatic breast cancer: Metastasis of breast cancer to the bones can cause
hypercalcemia, bone pain, and pathological fractures. However, the presence of Bence-Jones proteins
in the urine is not typically associated with breast cancer.
 Option c: Primary hyperparathyroidism is a condition in which there is an overproduction of
parathyroid hormone, leading to hypercalcemia. However, the presence of Bence-Jones proteins in the
urine is not typically associated with this condition.
 Option d: Milk alkali syndrome is a condition that can occur due to excessive intake of calcium and
absorbable alkali. This can lead to hypercalcemia and metabolic alkalosis. However, the low total
protein and albumin levels, as well as the presence of Bence-Jones proteins in the urine, are not
typically associated with milk alkali syndrome.
 Hereditary spherocytosis is an inherited disorder characterized by abnormal red blood cells that are
spherical in shape instead of the normal disc shape.
 By removing the spleen, which is responsible for destroying these abnormal red blood cells, a
splenectomy can help improve anemia and reduce the symptoms associated with the condition.
 Option A: G6PD deficiency is an inherited condition  leads to the breakdown of red blood cells,
causing anaemia. Splenectomy is not the preferred treatment for G6PD deficiency. In fact, splenectomy
may worsen the anaemia in these individuals because the spleen filters and removes damaged red
blood cells from the circulation. 
 Option B: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired disorder characterised by
the destruction of red blood cells, leading to anaemia, blood clots, and other complications. In PNH,
there is an abnormality in the complement system. Stem cell transplant is the best treatment.
 Option D: Hairy cell leukemia is not typically treated with splenectomy as the primary treatment.
Chemotherapy is the standard treatment for hairy cell leukemia. Splenectomy may be considered
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massively enlarged spleen or if there is resistance to other treatments. However, it is not the preferred
initial treatment option for hairy cell leukemia.  
 P2Y12 receptor blocker: P2Y12 receptor blockers, such as clopidogrel, ticagrelor, and prasugrel, are
antiplatelet medications commonly used in patients undergoing percutaneous coronary intervention
(PCI), including the placement of stents. These drugs inhibit platelet activation and aggregation,
reducing the risk of clot formation in the stent and preventing complications such as stent thrombosis.
Given that the patient in the scenario has undergone a stent placement, the addition of a P2Y12
receptor blocker, such as clopidogrel, would be appropriate to prevent stent-related complications.
Option A. PDE 3 inhibitor: Phosphodiesterase-3 (PDE 3) inhibitors, such as milrinone and cilostazol, ar
e primarily used for their vasodilatory effects and positive inotropic properties. They are commonly use
d in the treatment of heart failure and peripheral vascular disease. However, in the given scenario of a
patient with atherosclerosis who underwent a circumflex artery bypass, the addition of a PDE 3 inhibito
r is not typically indicated as the main purpose is to prevent further clot formation or complications relat
ed to the stent.
Option B. Direct oral anticoagulant: Direct oral anticoagulants (DOACs), such as rivaroxaban, apixaban
, and dabigatran, are medications used to prevent blood clot formation. They work by inhibiting specific
 coagulation factors in the blood. While anticoagulation may be considered in some patients with certai
n indications, such as atrial fibrillation or mechanical heart valves, the routine use of DOACs may not b
e necessary in all patients who undergo a circumflex artery bypass for atherosclerosis.
Option D. PDE 5 inhibitor: Phosphodiesterase-5 (PDE 5) inhibitors, such as sildenafil, tadalafil, and var
denafil, are primarily used for the treatment of erectile dysfunction and pulmonary arterial hypertension.
 They enhance the effects of nitric oxide, leading to vasodilation. However, in the given clinical scenari
o, the use of PDE 5
inhibitors is not directly indicated for the management of atherosclerosis or post-stent placement.
Option B.
Sickle cell anemia is a genetic disorder caused by the mislocation of valine in the position of glutamate 
at the β-6 position of the Haemoglobin gene. It is an inherited autosomal recessive disorder as the indi
vidual is symptomatic, but the parents each have a copy of the defective gene and are asymptomatic.
Option A. In an autosomal dominant disease, every individual with a copy of the gene is symptomatic. 
The trait, as such, is expressed in every individual carrying the defective gene.
Option C. In X-linked dominant disorders, mutations are passed down from parents via a single X
chromosome. In a female with a normal X and a mutated X
chromosome, the single mutated chromosome is enough to express the condition.
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Option D. In X-linked recessive disorders, mutations are passed down from parents via a single X
chromosome, such that a male carrying only one X chromosome is affected while a female carrying a
normal X and a mutated X chromosome is usually unaffected.
Option B.
Rituximab is an anti-CD 20 monoclonal antibody used in cancer treatments. It is used in cancer treatm
ent because it can attach to the CD 20 protein found on the surface of cancerous cells.
Option A. Methotrexate is an antimetabolite. It is also a chemotherapy agent and immune suppressant.
Option C. Cisplatin is an antineoplastic agent.
Option D. 5-Fluorouracil is a cytotoxic drug.
Option C.
Vitamin B12 is also called cobalamin. Cobalamine is essential for the formation of RBCs. Deficiency of 
cobalamin results in the production of abnormally large RBCs (macrocytic cells). Cobalamin deficiency 
can fail in Hb production as well. This can result in the production of hypochromic cells.
Option A. Normochromic means that the cell is of normal color. Normocytic means the blood cell is of n
ormal size. In vitamin B12 deficiency, neither of these happens.
Option B. Microcytic means the blood cells are very small in size. In vitamin B12 deficiency, the blood c
ells produced are extremely large compared to the normal size.
Option D. One of the options is right.
Correct Option A. 
 Wiskott-Aldrich syndrome is a rare genetic disorder characterized by the triad of thrombocytopenia
(low platelet count), eczema (skin rash), and recurrent infections. It is an X-linked disorder that primarily
affects males, although there have been rare cases reported in females.
Option B. Chediak-Higashi syndrome: Chediak-Higashi syndrome is a rare autosomal recessive disord
er characterized by abnormal immune system function and abnormal pigmentation of the skin and hair.
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 It can lead to recurrent infections, but thrombocytopenia and eczema are not typically associated with t
his syndrome.
Option C. Thrombocytopenia – absent radius syndrome: Thrombocytopenia –
absent radius syndrome (TAR syndrome) is a rare genetic disorder characterized by low platelet count 
(thrombocytopenia) and the absence or underdevelopment of the radius bone in the forearm. Eczema 
and recurrent infections are not typically part of this syndrome.
Option D. Hermansky-Pudlak syndrome: Hermansky-Pudlak syndrome is a rare genetic disorder chara
cterized by oculocutaneous albinism, bleeding problems due to platelet dysfunction, and various other 
symptoms. While thrombocytopenia and recurrent infections can occur in some cases, eczema is not a
typical feature of this syndrome.
 Sickle cell anemia is an inherited blood disorder characterized by the presence of abnormal
hemoglobin called hemoglobin S. It leads to the formation of sickle-shaped red blood cells that can
cause blockages in the blood vessels, leading to tissue damage and pain.
 In sickle cell anemia, the spleen can undergo progressive damage and become shrunken (splenic
atrophy). This is due to repeated episodes of vaso-occlusion, where sickle-shaped red blood cells block
the blood flow to the spleen, leading to infarction and subsequent scarring.
Option B. Malaria: While malaria can cause splenomegaly (enlarged spleen), it does not typically lead t
o splenic atrophy.
Option C. Pancreatitis: Pancreatitis is inflammation of the pancreas and is not associated with fever, ha
nd swelling, or splenic atrophy.
Option D. Measles: Measles is a viral infection that primarily affects the respiratory system. It does not 
cause splenic atrophy or hand swelling.
Correct Option B: 
 Multiple myeloma is a malignant plasma cell dyscrasia which is depicted by uncontrolled proliferation
of cells or bone marrow. Here The skull x-ray reveals Raindrop configuration of Lytic lesions of the skull
which is a characteristic feature for multiple myeloma. And the complaint or thoracic tenderness is one
of the most common and initial complaints of multiple myeloma. The other diagnostic modalities include
hypercalcaemia, creatinine > 2 mg and Bence Jones protein is typical in Urine analysis.
Option A: Metastatic breast cancer can be excluded as the radiography doesn’t match.
Option C: Primary hyperparathyroidism, Is a condition in which the PTH are made in excess which deg
enerates the bone tissue.The radiography in primary hyperparathyroidism reveals salt and pepper app
earance of the skull.
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Option A: MRI brain of multiple myeloma reveals diffuse bone marrow involvement.Osteolysis and oste
openia can also be detected.
Option B: Pet CT is having the highest sensitivity for extra medullary diseases and active lytic lesions o
f bone.
Option C:Head CT scan with contrast is not useful for diagnosis. It is very non specific.
 
The above is the case of AML as it has t(8;21). Generally to make a diagnosis of AML, blast cell count 
should be >=20% either in peripheral blood or bone marrow. In cases of low blast count, any one of the
 following being present is enough for its diagnosis:
 t(15;17)
 t(8;21)
 Inversion 16 or t(16;16)
Option A: ALL is the most common childhood leukaemia having symptoms such as fever night sweats 
unexplained weight loss painless lymphadenopathy bone pain which are not present here.
Option C: Pre-leukaemia Is a myelodysplastic syndrome
Option D: Aleukemic leukaemia Is a
rare type of leukaemia in which the leucocyte count is normal or to the lower side.
 
 The above case is most probably a case of thalassemia as there is a history of repeated transfusions,
low MCV and low Hb and the peripheral smear shows a picture that is hypochromic microcytic. The
next best step is to get Hb electrophoresis done.
Option A: Serum iron is measured to check for iron overload due to repeated blood transfusions and is 
not the next best step.
Option B: Direct coomb’s test is for autoimmune haemolytic anemia and not for thalassemia.
Option C: Osmotic fragility test is done for hereditary spherocytosis.
 
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Correct Answer Option B - Multiple myeloma
 Multiple myeloma is a malignant plasma cell disorder characterized by the proliferation of abnormal
plasma cells in the bone marrow. The disease can lead to various clinical manifestations and laboratory
abnormalities. The given finding, in this case, supports the diagnosis of multiple myeloma.
 Osteolytic lesions seen on X-ray spine: Multiple myeloma commonly involves the bones, destroying
bone tissue and the appearance of lytic lesions.
 Low hemoglobin (Hb): Multiple myeloma can cause anemia due to the infiltration of abnormal plasma
cells in the bone marrow, leading to a decrease in normal red blood cell production.
 Elevated serum calcium (hypercalcemia): Multiple myeloma can cause calcium release from the
bones, leading to high calcium levels in the blood.
 Abnormal kidney function (elevated creatinine): Multiple myeloma can affect the kidneys, leading to
impaired kidney function and elevated creatinine levels.
 Low albumin levels: Multiple myeloma can result in reduced production of normal proteins, including
albumin, by the liver.
 Option a. Metastatic breast cancer: While metastatic breast cancer can involve the bones and cause
similar symptoms, the presence of monoclonal gammopathy (elevated total protein) and anemia are
more suggestive of multiple myeloma.
 Option c. Primary hyperparathyroidism: Primary hyperparathyroidism typically presents with
hypercalcemia, but it is not associated with multiple myeloma-like bone lesions or the other laboratory
abnormalities seen in this case.
 Option d. Milk alkali syndrome: This condition is characterized by hypercalcemia, but it is caused by
excessive intake of calcium and alkali, which is not evident from the provided information.
The most appropriate investigation for the given clinical scenario would be "Serum electrophoresis."
 Serum electrophoresis: Serum electrophoresis is a blood test that separates proteins based on their
electrical charge and size. It is a valuable tool for evaluating various conditions, including plasma cell
disorders (e.g., multiple myeloma), which can present with chronic back pain, fatigue, and elevated
ESR. Additionally, multiple urinary tract infections could be associated with an underlying
immunoglobulin abnormality. Therefore, serum electrophoresis is a relevant investigation to consider in
this case to assess for any potential plasma cell disorders.
Option A: MRI brain: MRI brain is a useful imaging modality for evaluating structural abnormalities in th
e brain. However, in this case, the patient's complaints of chronic back pain, easy fatigability, and histor
y of urinary tract infections suggest a systemic condition rather than a primary brain pathology. Therefo
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re, an MRI brain may not provide specific information relevant to the diagnosis.
Option B: PET scan: PET scan (Positron Emission Tomography) is a nuclear medicine imaging techniq
ue that provides functional information about the body's metabolism and cellular activity. While it can b
e helpful in detecting certain cancers and evaluating brain function, it may not be the initial investigatio
n of choice for the presented symptoms.
Option C: Head CT scan with contrast: A head CT scan with contrast is primarily used to assess acute 
intracranial pathologies such as hemorrhage, stroke, or space-occupying lesions. Given the patient's c
hronic back pain, easy fatigability, and urinary tract infections, a
head CT scan may not provide relevant information for the diagnosis in this case.
In summary, among the given options, "Serum electrophoresis" is the most useful investigation for diag
nosis in a 68-year-old male presenting with chronic back pain, easy fatigability, and multiple urinary tra
ct infections, along with an elevated ESR. It can help identify any underlying plasma cell disorders or i
mmunoglobulin abnormalities.
 
Correct choice: D
 Based on the given information of a 30-year-old woman with fatigue, pallor on physical examination,
and laboratory values indicating low hemoglobin (9.8 g/dL) and high mean corpuscular volume (MCV)
(160 fl) while serum methyl malonyl CoA levels are normal, the correct option to administer as therapy
for this patient is Folic acid.
Option A. While Vitamin B12 deficiency can cause macrocytic anemia (high MCV), it is not the most lik
ely cause in this case because the serum methyl malonyl CoA levels are normal. Vitamin B12 deficienc
y is typically associated with elevated levels of serum methyl malonyl CoA. Therefore, administering Vit
amin B12 would not be the appropriate therapy in this scenario.
Option B. Iron deficiency anemia can cause microcytic (small-sized) anemia, but the laboratory values 
provided indicate a high MCV, which is inconsistent with iron deficiency anemia. Iron supplementation 
would not be the appropriate therapy based on the given information.
Option C. Vitamin C
deficiency is not typically associated with anemia or elevated MCV. While Vitamin C
is important for iron absorption, the lab values and symptoms described do not point to a Vitamin C
deficiency. Therefore, administering Vitamin C
would not address the underlying cause of the anemia and elevated MCV
 
Correct choice:C Explanation:
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 Based on the provided information of a 30-year-old lady with body pain, easy fatigability, problems
while standing, loss of vibration sense and proprioception on neurological examination, and a
hemoglobin level of 7gm/dL, the correct option to administer for the patient is Vitamin B12.
 Vitamin B12 (cobalamin) deficiency can lead to neurological symptoms and anemia, which are
consistent with the patient's presentation. The neurological symptoms, including loss of vibration sense
and proprioception, are characteristic of the neurological complications that can occur due to vitamin
B12 deficiency.
Incorrect options: Option A. Vitamin B1 deficiency can cause a condition called beriberi, which primarily
 affects the cardiovascular and nervous systems. However, the symptoms described by the patient, su
ch as loss of vibration sense and proprioception, are more indicative of vitamin B12 deficiency rather th
an vitamin B1 deficiency. Option B. Vitamin C deficiency can lead to scurvy, a condition characterized 
by fatigue, joint and muscle pain, and easy bruising. However, scurvy does not typically cause the neur
ological symptoms or anemia seen in the patient's presentation. Option D. Vitamin D deficiency is asso
ciated with various musculoskeletal symptoms, such as bone pain, muscle weakness, and difficulty sta
nding. However, it does not typically cause the specific neurological symptoms or anemia seen in the p
atient. Additionally, vitamin D deficiency is less likely to cause such severe anemia with a
hemoglobin level of 7gm/dL
Correct choice: C
 The nail findings shown in the image might indicate koilonychia, which is characterized by
spoon-shaped or concave nails. Koilonychia can be associated with iron deficiency anemia. Chronic
diarrhea, fatigue, tiredness, and a low hemoglobin level (anemia) can also be signs of iron deficiency.
The best treatment approach would be Iron supplements.
Option A. Folic acid is typically used to address folic acid deficiency anemia, which can also cause fatig
ue and tiredness. However, the specific nail findings described and the low hemoglobin level suggest ir
on deficiency rather than folic acid deficiency, making iron supplements the more appropriate choice in 
this case.
Option B. Metronidazole is an antibiotic used to treat certain types of infections, particularly those caus
ed by anaerobic bacteria and protozoa. It is not the appropriate treatment for iron deficiency anemia or 
the symptoms described.
Option D. Vitamin B12 is used to treat vitamin B12 deficiency anemia, which can cause fatigue and tire
dness. However, the presence of nail findings and a low hemoglobin level suggests iron deficiency ane
mia rather than vitamin B12 deficiency, making iron supplements the more suitable treatment choice.
 
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Based on the given information, the appropriate management for a patient with symptoms of fatigue, m
acrocytic anemia, normal methylmalonate levels, homocystinuria, and normal serum B12 values is trea
tment with folate therapy.
 Macrocytic anemia refers to the presence of larger-than-normal red blood cells (RBCs) in the
bloodstream. It can be classified into megaloblastic and non-megaloblastic anemia. Megaloblastic
anemia is characterized by impaired DNA synthesis, resulting in delayed maturation of RBC
precursors.
 In this case, the patient has macrocytic anemia with elevated homocystinuria but normal
methylmalonate levels and normal serum B12 values. Homocystinuria is associated with a deficiency in
enzymes involved in the metabolism of homocysteine, such as cystathionine beta-synthase (CBS)
deficiency. CBS deficiency leads to the accumulation of homocysteine and the conversion of
homocysteine to methionine is impaired. This can result in the increased production of methylmalonic
acid (methylmalonic aciduria) and homocystinuria.
 However, in this patient, methylmalonate levels are normal, indicating that the elevated
homocystinuria is not due to a deficiency of vitamin B12 or methylmalonic acid metabolism.
Additionally, the serum B12 values are normal, ruling out vitamin B12 deficiency as the cause of
macrocytic anemia.
 Folate (vitamin B9) is essential for DNA synthesis and red blood cell production. Folate deficiency can
lead to macrocytic anemia. In this case, providing folate therapy can help correct the folate deficiency
and improve the anemia. Folate therapy alone is appropriate because the patient's serum B12 levels
are normal and there is no evidence of vitamin B12 deficiency.
Option A: Iron supplements are not the appropriate management in this case since the patient does not
 have evidence of iron deficiency anemia. Iron deficiency anemia is characterized by microcytic (smalle
r-than-normal) red blood cells and low serum iron levels.
Option B: Treatment with folate and vitamin B12 is not necessary because the serum B12 levels are alr
eady normal, and there is no evidence of vitamin B12 deficiency.
Option C: Folate and vitamin B1 (thiamine) combination therapy is not indicated in this case as there is 
no evidence of thiamine deficiency or specific indications for its use in the given clinical presentation.
Therefore, folate therapy is the most appropriate management in this case of macrocytic anemia with n
ormal serum B12 levels and elevated homocystinuria.
 
Option C: His HLA identical brother who is otherwise healthy and is blood type O+ (Correct) -
 The correct option would be the patient's HLA identical brother who is otherwise healthy and has
blood type O+. HLA matching is a crucial factor in determining the compatibility of the donor for an
allogeneic stem cell transplant. As long as the HLA types match, the patient can receive stem cells from
a donor with a different blood type without significant adverse effects.
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Option A: His identical twin brother (Incorrect)- While an identical twin brother is a
perfect genetic match, an allogeneic stem cell transplant refers to receiving stem cells from a donor wh
o is not an identical twin. Therefore, an identical twin brother would not be considered an optimal donor
 in this case.
Option B: Umbilical cord transplant (Incorrect) Umbilical cord blood can be a
source of stem cells for transplantation, but the patient's blood type O negative may limit the availability
 of compatible cord blood units. Additionally, the HLA match from umbilical cord blood may not be as pr
ecise as that of a matched unrelated donor. Therefore, an umbilical cord transplant is not the most opti
mal choice in this scenario.
Option D: An HLA identical matched unrelated donor who is blood type (Not Provided) (Incorrect) The i
nformation regarding the blood type of the unrelated donor is not provided. Without knowing the blood t
ype compatibility, it is difficult to determine the suitability of this option. However, assuming the blood ty
pe is compatible, an HLA identical matched unrelated donor would be a
suitable option for transplantation. HLA matching is a
critical factor in minimizing the risk of GVHD and graft rejection.
 
Option C- Splenectomy.
 Splenectomy is considered the best treatment option for ITP in patients who do not respond to other
treatments or who have chronic or recurrent ITP. The spleen is the primary site of platelet destruction in
ITP, and removing it can help increase platelet counts and improve symptoms.
Option a. IV immunoglobulins: IV immunoglobulins (IVIG) are commonly used in the treatment of ITP, e
specially in acute cases or when immediate platelet count elevation is required. IVIG works by increasi
ng the platelet count temporarily. However, it is not considered the best long-term treatment option for I
TP.
Option b. Steroids: Steroids, such as prednisone, are often used as an initial treatment for ITP. They h
elp to suppress the immune system and reduce platelet destruction. Steroids can be effective in increa
sing platelet counts, but they are associated with potential side effects and are not considered the best 
long-term treatment option.
Option d. Blood transfusion: Blood transfusion is not a primary treatment for ITP. It may be used in spe
cific cases when there is severe bleeding or to manage acute complications, but it does not address th
e underlying immune dysfunction causing ITP and is not considered a curative treatment.
 
Option C. Deficiency of CD55 and CD59:
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 PNH is associated with a deficiency of CD55 (decay-accelerating factor) and CD59 (membrane
inhibitor of reactive lysis), which are GPI-anchored proteins that regulate the complement system and
protect blood cells from complement-mediated destruction.
 
Option A: Inherited defect in PIG-A. Paroxysmal nocturnal hemoglobinuria (PNH) is caused by a
somatic mutation in the PIG-A gene, which results in a deficiency of glycosylphosphatidylinositol (GPI)-
anchored proteins on the surface of blood cells. This defect is acquired and not inherited, so this option
 is ruled out.
Option B: PNH is characterized by intravascular hemolysis, not extravascular hemolysis. The deficienc
y of GPI-anchored proteins leads to the activation of the complement system, resulting in the destructio
n of red blood cells within the bloodstream.
Option D: PNH is not typically associated with microcytic anemia. Microcytic anemia is more commonly
 seen in conditions such as iron deficiency anemia or thalassemia.
Correct Option C: Sickle cell anemia
 Sickle cell anemia is a genetic blood disorder characterized by the presence of abnormal hemoglobin,
known as hemoglobin S.
 It is caused by a mutation in the HBB gene, resulting in the production of abnormal sickle-shaped red
blood cells.
 In sickle cell anemia, the abnormal red blood cells can become stiff and sticky, leading to blockages in
the blood vessels.
 These blockages can cause episodes of pain called vaso-occlusive crises of sickle cell crises. These
crises can occur in various parts of the body, including the bones, joints, and organs.
Option A: Alpha-thalassemia: Alpha-thalassemia is a genetic disorder characterized by reduced or abs
ent production of alpha-globin chains. It can lead to anemia, but it typically does not cause episodes of 
pain or resolve on its own.
Option B: Beta-thalassemia: Beta-thalassemia is a genetic disorder characterized by reduced or absen
t production of beta-globin chains. Similar to alpha-thalassemia, it can cause anemia but does not typic
ally present with episodes of pain that resolve spontaneously.
Option D: Von Willebrand disease type 1: Von Willebrand disease is a bleeding disorder caused by a
deficiency or dysfunction of von Willebrand factor, a protein involved in blood clotting. Type 1 is the mil
dest form of the disease, but it is not associated with symptoms of pain or episodes that resolve on thei
r own.
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 In this scenario, the 18-year-old girl with acute promyelocytic leukemia (APL) developed fever,
tachypnea, and pulmonary infiltrates on a chest X-ray. These symptoms and findings suggest the
development of a potentially serious complication called acute respiratory distress syndrome (ARDS)
associated with APL.
 Dexamethasone, a corticosteroid, is the appropriate choice of drug in this situation. It is commonly
used in the management of APL to help mitigate the differentiation syndrome, also known as retinoic
acid syndrome, which can occur during the initial treatment with all-trans retinoic acid (ATRA) or arsenic
trioxide (ATO). Differentiation syndrome is characterized by symptoms such as fever, respiratory
distress, pulmonary infiltrates, and multi-organ dysfunction. Dexamethasone has anti-inflammatory
properties and helps reduce the severity of the syndrome.
 
Option A. Cytarabine: Cytarabine is a chemotherapy drug commonly used in the treatment of acute my
eloid leukemia (AML), including certain subtypes of APL. However, in the context of the patient's sympt
oms and findings of pulmonary infiltrates, dexamethasone is a
more appropriate choice to address the potential complication of differentiation syndrome.
Option C. Doxorubicin: Doxorubicin is a chemotherapy drug commonly used in the treatment of various
 cancers, including APL. However, it is not the drug of choice for managing differentiation syndrome or 
its associated respiratory complications. Dexamethasone would be a
more appropriate choice in this situation.
Option D. Methotrexate: Methotrexate is a chemotherapy drug used in the treatment of various maligna
ncies, including certain types of leukemia. However, in the context of the patient's symptoms and findin
gs, dexamethasone is the preferred drug to address the potential complication of differentiation syndro
me associated with APL.
 In severe hemophilia, which is characterized by a deficiency of clotting factor VIII (hemophilia A) or
clotting factor IX (hemophilia B), the most common bleeding manifestation is recurrent hemarthrosis.
Hemarthrosis refers to bleeding into the joints, particularly the knees, ankles, and elbows. This occurs
because the lack of clotting factors impairs the blood's ability to form a stable clot, leading to prolonged
bleeding and accumulation of blood within the joint space. The repeated episodes of hemarthrosis can
cause joint pain, swelling, stiffness, and ultimately, joint damage.
Option A. Recurrent hematomas: While hematomas can occur in individuals with severe hemophilia, th
ey are not as common as recurrent hemarthrosis. Hematomas are localized collections of blood outsid
e the blood vessels, often caused by trauma or injury.
Option C. Hematuria: Hematuria, which is the presence of blood in the urine, can occur in hemophilia, 
but it is not the most common bleeding manifestation. Hematuria may result from bleeding in the urinar
y tract, such as in the kidneys or bladder.
Option D. Intracranial hemorrhage: Intracranial hemorrhage, which refers to bleeding within the skull or
 brain, is a severe complication of hemophilia but is relatively rare. It is more commonly seen in individu
als with severe hemophilia who have experienced head trauma or undergone invasive procedures. Intr
acranial hemorrhage can be life-threatening and requires immediate medical attention
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 In a patient with thalassemia who has a history of multiple blood transfusions, iron overload, and
cardiac arrhythmia, the presenting symptoms of backache and anxiety during a blood transfusion raise
concerns for a transfusion reaction, specifically an acute hemolytic transfusion reaction.
 An acute hemolytic transfusion reaction occurs when incompatible blood is transfused, resulting in the
destruction of red blood cells. The patient may experience symptoms such as back pain, fever, chills,
anxiety, dyspnea, and hemoglobinuria. This reaction is potentially life-threatening and requires
immediate intervention.
 In this scenario, the appropriate course of action is to stop the blood transfusion immediately to
prevent further complications. Once the transfusion is stopped, the patient should be closely monitored
for any signs of worsening symptoms, and supportive measures should be initiated as necessary. It is
important to assess the patient's vital signs, oxygen saturation, and urine output during this period.
Option B. Continue the transfusion but do an ECG: Continuing the transfusion without addressing the p
otential transfusion reaction can lead to further complications and risks the patient's safety. Performing 
an ECG alone would not address the underlying issue or provide appropriate management for the susp
ected transfusion reaction.
Option C. Stop the transfusion, wait for the patient to become normal, and then start it again: This appr
oach is not recommended because a suspected transfusion reaction requires prompt action. Stopping t
he transfusion is the first step to prevent the reaction from worsening and to ensure the patient's safety
. It is important to assess and manage the patient's condition before considering resuming the transfusi
on, if necessary.
Option D. Do clerical check and get ECG: While a clerical check and ECG may be relevant in certain si
tuations, such as ensuring the correct blood product is being transfused or assessing for potential cardi
ac complications, they should not take priority over stopping the transfusion when a transfusion reactio
n is suspected. Immediate cessation of the transfusion is crucial to prevent further harm to the patient
 
 Increased fibrinogen is wrong about DIC (Disseminated Intravascular Coagulation).
 DIC is a condition characterized by widespread activation of the coagulation system, leading to both
thrombotic and hemorrhagic complications. It is typically associated with an underlying condition such
as sepsis, trauma, or malignancy.
 In DIC, there is consumption and depletion of fibrinogen as it is converted to fibrin in the excessive
clotting process. Therefore, the levels of fibrinogen are decreased or reduced in DIC, not increased.
This is because fibrinogen is consumed in the formation of fibrin clots and is not available in the
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circulation to be measured.
Option A. Increased schistocytes: Schistocytes are fragmented red blood cells that result from mechani
cal destruction as they pass through areas of microvascular thrombosis. In DIC, the presence of schist
ocytes is a characteristic finding due to the formation of microvascular clots and the subsequent sheari
ng of red blood cells.
Option B. Increased PT: Prothrombin time (PT) is a laboratory test that measures the extrinsic pathway
 of the coagulation cascade. In DIC, there is activation of the coagulation system, leading to consumpti
on of clotting factors. This consumption results in prolongation of PT, indicating impaired clotting functi
on.
Option D. Increased FDPs: Fibrin degradation products (FDPs) are produced as a result of fibrinolysis, 
which occurs during the breakdown of fibrin clots. In DIC, there is increased activation of the fibrinolytic
 system, leading to increased levels of FDPs. Elevated levels of FDPs are often observed in DIC and c
an be used as a diagnostic marker.
 Cladribine (also known as 2-chlorodeoxyadenosine or 2-CdA) is a purine analog chemotherapy drug
that has shown high efficacy in the treatment of hairy cell leukemia. It is considered the drug of choice
for HCL because it achieves high response rates and durable remissions in most patients.
 Cladribine works by inhibiting DNA synthesis and causing the death of hairy cells, which are the
abnormal B lymphocytes characteristic of hairy cell leukemia. The drug is administered through an
intravenous infusion or subcutaneous injection over a series of treatment cycles.
Option A: Rituximab (incorrect): Rituximab is an immunotherapy drug that targets the CD20 antigen on 
B cells. While rituximab has shown efficacy in the treatment of various B-cell lymphomas, it is not the d
rug of choice for hairy cell leukemia. Cladribine is the preferred treatment for HCL.
Option B: Vemurafenib (incorrect): Vemurafenib is a targeted therapy drug primarily used for the treatm
ent of certain forms of metastatic melanoma with BRAF V600E mutation. It is not the drug of choice for 
hairy cell leukemia.
Option D: Interferon-alpha (incorrect): Interferon-alpha is a type of immunotherapy that has been used i
n the treatment of hairy cell leukemia in the past. However, it is less commonly used nowadays due to t
he superior response rates and durability of remission achieved with cladribine. Cladribine has become
 the preferred treatment option for HCL.
 
In this scenario, the patient's clinical presentation, laboratory findings, and bone marrow aspiration resu
lts suggest the possibility of multiple myeloma, a type of cancer involving plasma cells in the bone marr
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ow. The next line of management in this situation typically involves initiating treatment with a
combination of dexamethasone (a corticosteroid) and fluids.
Dexamethasone is a potent anti-inflammatory and immunosuppressive medication commonly used in t
he treatment of multiple myeloma. It helps in reducing plasma cell proliferation and suppressing the im
mune response against the abnormal plasma cells.
Fluids are also an essential component of the management plan, as patients with multiple myeloma oft
en experience dehydration and electrolyte imbalances due to increased protein production and renal d
ysfunction. Adequate hydration and electrolyte replacement help optimize the patient's renal function a
nd prevent complications.
Option A. Urgent consultation for dialysis: Dialysis is not the immediate next step in the management of
 the presented case. Dialysis is primarily used in cases of severe renal failure where conservative man
agement measures, including medications and fluid management, have failed to adequately manage th
e patient's condition. In this case, while the patient has elevated urea and creatinine levels, initiating di
alysis as the next line of management would be premature without attempting less invasive interventio
ns first.
Option B. Dexamethasone + lenalidomide: Dexamethasone is an appropriate component of the treatm
ent for multiple myeloma, as mentioned in the correct option. However, lenalidomide (an immunomodul
atory drug) is typically included in the treatment regimen for multiple myeloma, especially in combinatio
n with dexamethasone, but it is not the immediate next step. The initial management involves dexamet
hasone and fluids, and the addition of lenalidomide can be considered in subsequent treatment stages.
Option D. Bone marrow transplantation: Bone marrow transplantation is a treatment option for multiple 
myeloma in certain cases, particularly in younger patients or those with high-risk disease. However, it i
s not the immediate next step in the management of the presented case. Initial treatment with dexamet
hasone and fluids is typically undertaken before considering more intensive therapies such as bone ma
rrow transplantation.
 Pernicious anemia is an example of Type II Hypersensitivity.
 Serum Sickness is an example of Type III Hypersensitivity.
 Pathergy test is an example of Type IV Hypersensitivity.
 Pernicious anemia is an autoimmune condition characterized by the destruction of gastric parietal
cells, which produce intrinsic factors. Intrinsic factor is necessary for the absorption of vitamin B12. In
this condition, autoantibodies (specifically, anti-intrinsic factor antibodies and anti-parietal cell
antibodies) are produced, leading to the destruction of the gastric parietal cells. This immune response
is classified as Type II Hypersensitivity, where antibodies bind to specific cells or tissues, leading to
their destruction.
 Serum Sickness is a hypersensitivity reaction that occurs in response to the administration of foreign
serum or certain medications. It is characterized by the formation of immune complexes composed of
antigen and antibody. These immune complexes can deposit in various tissues, leading to inflammation
and tissue damage. Serum Sickness is an example of Type III Hypersensitivity, which involves immune
complex-mediated reactions.
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 Pathergy test is indeed an example of Type IV Hypersensitivity. It is a diagnostic test used to assess
abnormal skin reactions in certain diseases, such as Behçet's disease. In the Pathergy test, a small
incision or puncture is made on the skin, and the development of a localized papule or pustule at the
site of injury is observed. This abnormal skin reaction is indicative of a Type IV Hypersensitivity
response, which is mediated by T cells and involves delayed hypersensitivity reactions.
The false statement is:
 A Pathergy test is done for Reiter's disease.
 Explanation: The Pathergy test is not specifically performed for Reiter's disease. Reiter's disease, also
known as reactive arthritis, is characterized by joint inflammation, urethritis, and conjunctivitis. The
diagnosis of Reiter's disease is based on clinical features and does not involve the Pathergy test. The
Pathergy test is primarily associated with Behçet's disease and is not specific to Reiter's disease.
Option B. 2, 3 and 4 are true : this option is incorrect
Option C.1, 2, 3 and 4 are true : this option is incorrect
Option D.3 and 4 are true : this option is incorrect
 
Correct option B. 
 Phytates are naturally occurring compounds found in certain plant foods such as whole grains,
legumes, and nuts. They have the ability to bind to iron and form insoluble complexes, which reduces
the absorption of iron in the digestive tract. This can lead to decreased iron availability for the body.
Option A. Vitamin C: Vitamin C, also known as ascorbic acid, actually enhances iron absorption. It help
s in the conversion of non-heme iron (the form of iron found in plant-based foods) to a
more absorbable form. Therefore, vitamin C promotes iron absorption rather than interfering with it.
Option C. Oxalate: Oxalate, found in certain foods like spinach, rhubarb, and beet greens, can form ins
oluble complexes with calcium but does not significantly interfere with iron absorption. Oxalate-rich foo
ds can affect calcium absorption, but they do not directly inhibit iron absorption.
Option D. Myoglobin: Myoglobin is a protein found in muscle tissue that stores oxygen. While myoglobi
n does contain iron, it is not involved in the absorption of iron from the diet. The focus of iron absorptio
n is primarily on dietary sources and factors in the digestive tract rather than myoglobin.
 
 This option is correct. Drawing blood samples three times allows for a more comprehensive
evaluation. It enables the healthcare provider to assess any trends or changes in laboratory values over
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time and increases the chances of identifying potential causes of the fever.
Option A. 2: Drawing blood samples only twice may not provide sufficient information for identifying the
 cause of the fever. Additional samples are often needed to detect any evolving changes or to repeat c
ertain tests if necessary.
Option C. 4: While drawing blood samples four times may provide additional information, it is not typica
lly required in the initial evaluation of FUO. Three samples are generally sufficient, unless there are spe
cific clinical indications for further testing.
Option D. 5: Drawing blood samples five times is excessive and not routinely performed in the evaluati
on of FUO. It can lead to unnecessary blood loss and discomfort for the patient without significantly inc
reasing the diagnostic yield.
 In summary, in the evaluation of fever of unknown origin, it is recommended to draw blood samples at
least three times to maximize the chances of identifying the underlying cause.
 Filgrastim: Filgrastim is a granulocyte colony-stimulating factor (G-CSF) that stimulates the production
of neutrophils, a type of white blood cell. It is commonly used to treat neutropenia caused by
chemotherapy by promoting the production of new neutrophils in the bone marrow.
Option A. Leucovorin: Leucovorin is a medication that is used in combination with certain chemotherap
y drugs to enhance their effectiveness. It is not specifically indicated for the treatment of neutropenia.
Option C. Ondansetron: Ondansetron is an antiemetic medication used to prevent nausea and vomitin
g, particularly associated with chemotherapy or radiation treatment. It does not directly address neutro
penia.
Option D. Darbepoetin: Darbepoetin is a synthetic form of erythropoietin, a hormone that stimulates the
 production of red blood cells. It is used to treat anemia, but it does not have a
direct effect on neutropenia.
Option b. Generalized pruritus is a
consequence of mast cell activation by JAK2 mutation: In polycythemia vera, a mutation in the JAK2 g
ene (JAK2 V617F mutation) is commonly observed. This mutation leads to the overactivation of certain
 cells, including mast cells, which release mediators that can cause generalized pruritus (itching) as a
characteristic symptom of the disease.
 
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Option a. Risk of thrombosis strongly correlates with the degree of thrombocytosis: While polycythemia
 vera is associated with an increased risk of thrombosis, the degree of thrombocytosis alone does not s
trongly correlate with the risk. Other factors, such as increased red blood cell mass and abnormal clotti
ng factors, also contribute to the thrombotic risk.
Option c. It is protective against H. pylori infection: Polycythemia vera does not confer protection again
st Helicobacter pylori (H. pylori) infection. In fact, studies have suggested that H. pylori infection may b
e associated with an increased risk of developing polycythemia vera.
Optiond. Acute myeloid leukemia is the most common cause of mortality: While patients with polycythe
mia vera have an increased risk of developing acute myeloid leukemia (AML) and other myeloproliferat
ive neoplasms, it is not the most common cause of mortality in polycythemia vera. Thrombotic events, 
such as stroke or myocardial infarction, are the leading causes of morbidity and mortality in polycythem
ia vera.
Option a. Metabolic alkalosis: In patients with haemophilia who receive multiple blood transfusions, met
abolic alkalosis can occur as a result of the citrate anticoagulant used in stored blood products. Citrate 
is metabolized in the liver, which can lead to the generation of bicarbonate ions and an increase in seru
m bicarbonate levels, causing metabolic alkalosis.
 
Option b. Respiratory alkalosis: Respiratory alkalosis is characterized by a decrease in arterial carbon 
dioxide (CO2) levels, resulting in an increase in blood pH. It is not directly associated with multiple bloo
d transfusions in patients with haemophilia.
Option c. Metabolic acidosis: Metabolic acidosis is characterized by a decrease in blood pH and bicarb
onate levels. It is not typically associated with multiple blood transfusions in patients with haemophilia.
Option d. Respiratory acidosis: Respiratory acidosis is characterized by an increase in arterial carbon d
ioxide (CO2) levels, resulting in a decrease in blood pH. It is not directly associated with multiple blood 
transfusions in patients with haemophilia.
Correct Option B: Essential thrombocytosis
 The most probable diagnosis is essential thrombocytosis. It is a clonal stem cell disorder in which the
platelet count is significantly elevated with no evidence of prolonged platelet survival.
Option A: Polycythemia vera
 Patients have raised hemoglobin levels in polycythemia vera.
Option C: Primary myelofibrosis
 Bone marrow yields dry tap in primary myelofibrosis.
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Option D: Chronic myelogenous leukemia
 CML has a Philadelphia chromosome due to reciprocal translocation t (9;22) and hypercellular
marrow.
 DIC (Disseminated Intravascular Coagulation) is a condition characterized by widespread activation of
clotting factors, leading to both excessive clot formation and depletion of clotting factors, which can
result in bleeding. D-dimer assay is a blood test used to detect the presence of D-dimer, a fibrin
degradation product that is elevated in conditions associated with fibrin formation and breakdown, such
as DIC. Elevated D-dimer levels indicate the activation of the clotting system and can support the
diagnosis of DIC.
Option A (Fibrin degradation products) is incorrect because while the presence of fibrin degradation pr
oducts is a characteristic feature of DIC, the specific test used for their detection is the D-dimer assay.
Option B (Activated partial thromboplastin time) is incorrect because activated partial thromboplastin ti
me (aPTT) is a coagulation test that measures the intrinsic pathway of coagulation and is not specific t
o the diagnosis of DIC.
Option C (Prothrombin time) is incorrect because prothrombin time (PT) is a coagulation test that meas
ures the extrinsic pathway of coagulation and is not specific to the diagnosis of DIC.
Correct Option B: Glanzmann thrombasthenia
 The above case is that of Glanzmann thrombasthenia which is an autosomal recessive platelet
surface disorder of GPIIb/IIIa. It has normal platelet morphology, prolonged BT, absent or decreased
clot retraction, and normal platelet aggregation in the presence of ristocetin.
Option A: Bernard Soulier syndrome is an inherited deficiency of Ib-IX in which platelet count is decrea
sed, BT is increased, PT is normal, and aPTT is normal.
Option C: Haemophilia A is a hereditary bleeding disorder due to a deficiency of factor VIII.
Option D: Von Willebrand disease is due to qualitative and quantitative defects in VWF in which platele
t count is usually normal, BT is increased, PT is normal, and aPTT is increased.
Correct option C.
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 Von Willebrand disease (VWD) is a bleeding disorder caused by a deficiency or dysfunction of von
Willebrand factor (VWF), a protein involved in platelet adhesion and the stabilization of factor VIII in the
blood clotting cascade.
Explanation 
 Normal prothrombin time (PT): PT measures the extrinsic pathway of the coagulation cascade, which
primarily assesses the activity of factors VII, X, V, and II. Von Willebrand disease primarily affects the
platelet function and the intrinsic pathway, so it does not typically affect the prothrombin time.
Therefore, the prothrombin time is expected to be normal in patients with VWD.
Option A: "Normal partial thromboplastin time (PTT)": PTT measures the intrinsic pathway of the coagu
lation cascade, which includes factors VIII, IX, XI, and XII. Since von Willebrand factor is involved in sta
bilizing factor VIII, a deficiency or dysfunction of VWF can affect the PTT, leading to prolonged PTT in 
VWD. Therefore, option A is incorrect.
Option B: "Decreased platelets": Von Willebrand disease does not directly affect platelet production or 
cause a decrease in platelet count. Platelet count is generally normal in VWD. Therefore, option B
Option D: "Normal bleeding time": Bleeding time assesses the primary hemostasis and platelet function
. Since von Willebrand factor plays a crucial role in platelet adhesion, patients with VWD may have an i
ncreased bleeding time due to impaired platelet function. Therefore, option D is incorrect.
Correct Ans: D. 
 This option is correct. The translocations are accurately matched with the corresponding lymphoma
types. Burkitt lymphoma is associated with t(8,14), Mantle cell lymphoma is associated with t(11,14),
Marginal cell lymphoma is associated with t(11,18), Follicular lymphoma is associated with t(14,18),
and Ewing's sarcoma is associated with t(11,22).
Incorrect option: 
Option A: 1-A, 2-E; 3-C; 4-B; 5-D
 This option is incorrect. The correct translocations are not matched to the corresponding lymphoma
types. Therefore, this option is not valid.
Option B: 1-C, 2-D; 3-A; 4-B; 5-E
 This option is incorrect. The translocations are not matched correctly with the lymphoma types.
Therefore, this option is not valid.
Option C: 1-C, 2-E; 3-A; 4-D; 5-B
 This option is incorrect. While some of the translocations are correctly matched with the lymphoma
types, others are not. Therefore, this option is not valid.
Correct Ans: D 
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 Superficial spreading melanoma is a type of skin cancer that primarily occurs due to exposure to
ultraviolet (UV) radiation from the sun or artificial sources, such as tanning beds. It is not directly
associated with viral infections like the other options.
Incorrect Option: 
Option A: Kaposi sarcoma Kaposi sarcoma is caused by human herpesvirus 8 (HHV-8) infection. It co
mmonly affects individuals with weakened immune systems, such as those with HIV/AIDS.
Option B: Primary effusion lymphoma Primary effusion lymphoma is associated with human herpesviru
s 8 (HHV-8) infection. It primarily occurs in individuals with compromised immune systems, such as tho
se with HIV/AIDS.
Option C: Merkel cell carcinoma Merkel cell carcinoma is associated with Merkel cell polyomavirus (M
CV) infection. This virus is thought to play a role in the development of Merkel cell carcinoma, a
rare and aggressive form of skin cancer.
Option A. Leukocytosis more than 1000 × 10^6 not responding to treatment.
 This statement is false. Leukocytosis refers to an increased number of white blood cells in the blood.
In the accelerated phase of chronic myeloid leukemia (CML), the white blood cell count is typically
elevated. Therefore, leukocytosis more than 1000 × 10^6 is actually a characteristic feature of the
accelerated phase of CML. However, it's important to note that the response to treatment can vary, and
the lack of response to treatment is not specific to the diagnosis of the accelerated phase of CML.
Option B: Thrombocytosis 100 × 10^9 not responding to treatment.
 This statement is not mentioned in the question and cannot be evaluated as true or false.
Option C: Increased spleen size not responsive to therapy.
 This statement is true. In the accelerated phase of CML, the spleen typically becomes enlarged
(splenomegaly), and this enlargement may not respond adequately to therapy. The inability of the
spleen size to decrease or stabilize despite treatment is a characteristic feature of the accelerated
phase.
Option D: No response to tyrosine kinase inhibitor.
 This statement is true. In the accelerated phase of CML, there may be a reduced response or lack of
response to tyrosine kinase inhibitor (TKI) therapy, which is the standard treatment for CML.
Resistance to TKIs is a significant concern in managing CML in the accelerated phase.
 In summary, the false statement is Option A: Leukocytosis more than 1000 × 10^6 not responding to
treatment. In the accelerated phase of CML, leukocytosis is expected, and the lack of response to
treatment is not specific to the diagnosis of the accelerated phase.
 
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Option C.
 Sickle cell anemia: Sickle cell anemia is an inherited blood disorder that increases the risk of severe
bacterial infections, including pneumococcal infections. People with sickle cell anemia have functional
asplenia (loss or dysfunction of the spleen), which impairs their ability to fight off certain infections,
including those caused by Streptococcus pneumoniae. Vaccination, including the pneumococcal
vaccine PPV-23, is recommended to prevent pneumococcal infections in individuals with sickle cell
anemia.
Option A. Recurrent rhinitis and sinusitis: While recurrent rhinitis and sinusitis may be troublesome con
ditions, they are not specifically indications for the pneumococcal vaccine PPV-23. The vaccine primaril
y targets invasive pneumococcal diseases such as pneumonia, meningitis, and bloodstream infections.
Option B. Cystic fibrosis: Cystic fibrosis is a genetic disorder that primarily affects the respiratory and di
gestive systems. Individuals with cystic fibrosis are more susceptible to respiratory infections, including
 those caused by Streptococcus pneumoniae, the bacteria targeted by the pneumococcal vaccine. Ho
wever, there are specific guidelines and recommendations for vaccination in individuals with cystic fibro
sis, and the choice of pneumococcal vaccine (PPV-13 or PPV-23) may depend on various factors, incl
uding age and previous vaccination history. Therefore, while the pneumococcal vaccine is beneficial fo
r individuals with cystic fibrosis, the specific vaccine and timing may vary based on guidelines and indiv
idual circumstances.
Option D. Child <2 years: Vaccination against Streptococcus pneumoniae is essential for infants and c
hildren, and the pneumococcal conjugate vaccine (PCV) series is generally recommended in this age g
roup. The PPV-23 vaccine is typically given to individuals aged 2 years and older who are at increased 
risk of invasive pneumococcal disease. Therefore, while young children should receive pneumococcal 
vaccination, the PPV-23 vaccine is not the primary choice for this age group.
 
715

Multiple Sclerosis
1. A 32-year-old woman presents to the neurology clinic with complaints of progressive weakness and
numbness in her legs over the past several months. Neurological examination reveals bilateral lower
extremity weakness, hyperreflexia, and impaired sensation below the waist. Visual acuity testing shows
decreased vision in the left eye. Which of the following is not the pathophysiology involved in this
(or)
All are included under the pathophysiology of Multiple sclerosis except?
A. Myelin damage
B. Axon damage
C. B cells Involvement
D. Schwann cells response
2. A 32-year-old female presents to the neurology clinic with a history of recurrent episodes of blurred
vision, weakness in her legs, and difficulty coordinating movements. She reports experiencing
intermittent urinary urgency and frequency, along with occasional urinary incontinence. On
examination, the patient demonstrates signs of internuclear ophthalmoplegia (INO). All are associated
with this condition except?
(or)
All are the clinical features of Multiple sclerosis except?
A. Internuclear Ophthalmoplegia
B. One and half syndrome
C. Eight and half syndrome
D. Detrusor hyporeflexia
3. A 45-year-old male presents to the neurology clinic with complaints of shooting pain radiating down
his legs upon flexing his neck forward. The patient reports experiencing this symptom intermittently
over the past few weeks, particularly when bending his neck forward or looking down. On examination,
the neurologist elicits the Lhermitte sign .This is seen in all of the following except?
(or)
Which of the following is not a condition where the Lhermitte sign is seen?
A. Tabes dorsalis
B. Cervical spondylosis
D. Neuromyelitis Optica
4. A 20 year 20-year-old male came to the clinic with pins and needle sensation in one arm or both
arms and decreased vision for 1 day. On examination, Lhermitte sign was positive, Brisk deep tendon
reflexes and positive Babinski sign. The patient was managed with IV methylprednisolone. Which of the
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Page 2
following is the investigation of choice in this condition?
(or)
Which of the following is the investigation of choice in Multiple sclerosis ?
A. Gadolinium enhanced MRI
B. CSF study
C. CSF Electrophoresis
D. VEP
5. A 35-year-old female with a history of relapsing-remitting multiple sclerosis (MS) presents to the
neurology clinic for a follow-up visit. She has been receiving natalizumab as part of her treatment
regimen. Which of the following is the side effect of this medication?
(or)
Which of the following is the side effect of Natalizumab that is used for the management of Multiple
sclerosis?
B. Neutrophilia
C. Neutropenia
D. Progressive Multifocal Leukoencephalopathy
Correct Option D - Schwann cells response:
The pathophysiology of Multiple sclerosis includes the following:
 Myelin damage: MS is characterized by the immune system's attack on the myelin sheath, the
protective covering of nerve fibers in the central nervous system (CNS).
 Axon damage: Prolonged and repeated attacks on the myelin sheath can lead to damage or
destruction of the underlying nerve fibers (axons).
 B cell involvement: B cells within the brain start producing antibodies that target Myelin
Oligodendrocyte Glycoprotein (MOG), a component of myelin. These antibodies are produced locally
within the CNS, not originating from the bloodstream.
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 Oligodendrocyte response: Oligodendrocytes, the cells responsible for producing myelin, attempt to
repair the damage caused by the immune system. However, this repair process can result in gliosis
(scar tissue formation) and the formation of plaques in the white matter of the CNS.
 Plaque visualization: These plaques, areas of demyelination and scarring, can be visualized on MRI
scans. Periventricular plaques, known as Dawson's fingers, are a characteristic finding in MS and
appear near the brain's ventricles.
 Schwann cells are not affected in Multiple sclerosis
Options A,B,C:
 These are correct about the pathophysiology of Multiple sclerosis
Correct Option D - Detrusor hyporeflexia:
 Multiple sclerosis (MS) is a chronic autoimmune disease characterized by inflammatory demyelination
and neurodegeneration in the central nervous system (CNS).
 Some of the hallmark clinical manifestations of MS include: Internuclear Ophthalmoplegia (INO) is a
common ophthalmological finding in MS, characterized by impaired adduction of one eye during
horizontal gaze due to lesions affecting the medial longitudinal fasciculus (MLF) characterized by a
combination of horizontal gaze palsy in one direction and ipsilateral internuclear ophthalmoplegia
(INO). Eight and a half syndrome is another rare neurological syndrome characterized by horizontal
diplopia and facial weakness in association with one and half syndrome features. It results from pontine
tegmental lesions affecting multiple cranial nerve nuclei and the MLF.
 Internuclear Ophthalmoplegia (INO) is a common ophthalmological finding in MS, characterized by
impaired adduction of one eye during horizontal gaze due to lesions affecting the medial longitudinal
fasciculus (MLF) characterized by a combination of horizontal gaze palsy in one direction and ipsilateral
internuclear ophthalmoplegia (INO).
 Eight and a half syndrome is another rare neurological syndrome characterized by horizontal diplopia
and facial weakness in association with one and half syndrome features. It results from pontine
 Detrusor Hyperreflexia: Detrusor hyperreflexia, or overactive bladder, is a common autonomic
dysfunction observed in MS. Detrusor hyperreflexia results from disruption of neural pathways
controlling bladder function in the spinal cord and brainstem.Detrusor hyporeflexia, or underactive
bladder, is not typically associated with MS. Instead, detrusor hyperreflexia is the more common
bladder dysfunction observed in MS
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 These are the correct features of Multiple sclerosis
Correct Option D - Neuromyelitis Optica:
 The Lhermitte sign, also known as the "barber chair phenomenon," is a clinical finding characterized
by the sensation of an electric shock or tingling sensation that radiates down the spine and into the
limbs upon flexion of the neck.
 This sign is typically elicited by passively flexing the patient's neck forward, leading to the transient
sensation that travels along the spinal cord and peripheral nerves.
 Lhermitte sign is not seen in Neuromyelitis Optica
 Instead, the Lhermitte sign is more commonly observed in patients with lesions affecting the cervical
spinal cord, such as those seen in MS or cervical spondylosis.
 Lhermitte sign is seen in Tabes dorsalis, Cervical spondylosis, and Multiple sclerosis
Correct Option A - Gadolinium-enhanced MRI:
 Gadolinium-enhanced MRI is the cornerstone of the diagnostic work-up for multiple sclerosis (MS),
particularly to identify characteristic plaques or lesions in the central nervous system.
 The presence of these lesions, known as Dawson fingers, at specific sites is indicative of MS. Dawson
fingers are areas of demyelination that appear as finger-like projections extending perpendicular to the
ventricular surface of the brain.
 The key features to assess on MRI include the location and size of the plaques. Periventricular: This
is a common location for MS lesions and is characterized by hyperintense signals on T2-weighted MRI
sequences. Juxtacortical: Juxtacortical lesions are often perpendicular to the cortical surface and can
be visualized on MRI. Infratentorial: Infratentorial lesions are less common but can contribute to the
clinical manifestations of MS, including motor and coordination impairments. Size of plaque > 6 mm:
Plaques larger than 6 mm in diameter are considered significant findings on MRI and are suggestive of
MS.
 Periventricular: This is a common location for MS lesions and is characterized by hyperintense signals
on T2-weighted MRI sequences.
 Juxtacortical: Juxtacortical lesions are often perpendicular to the cortical surface and can be
visualized on MRI.
 Infratentorial: Infratentorial lesions are less common but can contribute to the clinical manifestations of
MS, including motor and coordination impairments.
719

Subarachnoid Hemorrhage.
1. Which of the following is not a cause of Subarachnoid hemorrhage?
A. Rupture of berry aneurysm
B. Arteriovenous malformation
C. Charcot Bouchard aneurysm
D. Diabetes mellitus
2. A 60-year-old female patient presents to the emergency department with sudden-onset severe
headache, vomiting, and loss of consciousness. A computed tomography (CT) scan reveals
subarachnoid hemorrhage. An electrocardiogram (ECG) is performed as part of the initial evaluation.
Which of the following is not an ECG change seen in this patient?
(or)
Which of the following is not an ECG change seen in Subarachnoid hemorrhage?
A. ST depression and T-wave inversion are seen
B. Peaked T waves may also be seen
C. QT prolongation
D. Narrow QRS complex
3. A 65-year-old male presents to the emergency department with a sudden onset of severe headache,
accompanied by nausea and vomiting. Upon examination, the patient is alert and oriented but appears
distressed due to the intensity of the headache. Which of the following is the grade of the Hunt Hess
Scale in this patient?
(or)
Which of the following is the grade of the Hunt Hess Scale when the patient has a severe headache?
A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4
4. A 55-year-old male patient presents to the emergency department with sudden-onset severe
headache, nausea, and vomiting. A computed tomography (CT) scan of the head reveals evidence of
subarachnoid hemorrhage (SAH). Which of the following is not useful in the management of this
patient?
(or)
Which of the following is not useful in managing Subarachnoid hemorrhage?
B. Labetalol
C. Nimodipine
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 ECG changes seen in subarachnoid hemorrhage include: ST depression and T-wave inversion, which
are indicative of myocardial ischemia or injury. Peaked T waves, which can result from sympathetic
nervous system activation and electrolyte disturbances. QT prolongation, which is often seen due to
autonomic dysfunction and catecholamine release.
 ST depression and T-wave inversion, which are indicative of myocardial ischemia or injury.
 Peaked T waves, which can result from sympathetic nervous system activation and electrolyte
disturbances.
 QT prolongation, which is often seen due to autonomic dysfunction and catecholamine release.
 In contrast, a narrow QRS complex is not characteristic of SAH. Instead, patients with SAH may
exhibit a broad QRS complex, which can be indicative of various cardiac abnormalities or electrolyte
imbalances secondary to sympathetic nervous system activation.
Option - A, B, C:
 These are the correct ECG changes seen in Subarachnoid hemorrhage
Correct Option B - Grade 2: 
 When a patient presents with a severe headache, he/she is classified under grade 2 of the Hunt Hess
Scale. Grade 2 indicates moderate to severe headache without neurological deficit, which aligns with
the patient's presentation in this scenario.
Option A - Grade 1: Grade 1 on the Hunt Hess Scale denotes a
mild headache without any neurological deficit. Since the patient in this scenario has a
severe headache, grade 1 is not applicable.
Option C - Grade 3: Grade 3 corresponds to somnolence and confusion. However, the patient in this sc
enario is alert and oriented, ruling out grade 3.
Option D - Grade 4: Grade 4 is characterized by stupor. Since the patient is alert and oriented, grade 4
is not appropriate for this case.
Correct Option A - Steroids:
 Subarachnoid hemorrhage (SAH) is a medical emergency characterized by bleeding into the
subarachnoid space surrounding the brain.
724

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 Steroids, such as dexamethasone, are not recommended in the treatment of SAH because they do
not provide significant benefits and may potentially increase the risk of complications.
Options - B, C, D:
 Labetalol: Labetalol is a beta-blocker that is commonly used to manage hypertension, which
frequently occurs in patients with SAH. It helps to control blood pressure and reduce the risk of
rebleeding and complications.
 Nimodipine: Nimodipine is a calcium channel blocker that is specifically indicated for the prevention
and treatment of cerebral vasospasm, a potentially serious complication of SAH. By blocking calcium
channels in cerebral blood vessels, nimodipine helps to prevent vasospasm and improve cerebral
perfusion.
 Aneurysmal clip: Surgical clipping of the ruptured aneurysm is a crucial intervention in the
management of SAH. Aneurysmal clipping involves placing a metallic clip across the neck of the
aneurysm to prevent further bleeding and reduce the risk of rebleeding.
 
725

Epilepsy
1. A 48-year-old male patient presents to the ED with complaints of 2 episodes of unprovoked seizures
within the last 2 days. While he is in the hospital, he starts seizing, IV access is not yet obtained. What
can be given to control his seizures?
(or)
Which of the following can be given to control a GTCS seizure in the absence of IV line?
A. IM Lorazepam
B. Subcutaneous Phenytoin
C. Rectal diazepam
D. Intranasal midazolam
2. A 2-year-old child presents to the pediatrician's office accompanied by their mother, who reports
episodes of repeated blinking of the eyes followed by sudden unresponsiveness. The child may appear
to be taking normally and then suddenly becomes unconscious, only to resume activity as if nothing
has happened. What is the drug of choice for this patient?
(or)
What is the drug of choice in a 2-year-old male child with absence seizures?
A. Valproate
B. lamotrigine
C. carbamazepine
D. Ethosuximide
3. A 7-year-old boy is brought to the OPD due to recurrent 3-4 min episodes of facial grimacing and
hand gestures over the past 2 weeks. He is nonresponsive during these episodes and doesn't
remember them afterward. He recalls smelling kerosene before the symptoms started. After the
incident, he feels lethargic and confused. What is the possible diagnosis?
(or)
Aura, motionless stare ,automatism and post ictal confusion is seen in?
A. Focal seizure with impaired awareness
B. Generalized tonic-clonic seizure
C. Atonic seizure
D. Absence seizure
4. A 58-year-old male patient has been brought to the hospital due to weakness in his left arm for two
days. According to the patient, two days ago, he developed involuntary movement in his left arm and
twitching on the left side of his face. He was aware and tried to stop the movement with his other hand,
but he was unable to do so. He has been experiencing weakness in his left arm since then. What is the
(or)
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Page 2
Which of the following manifests as temporary weakness following focal seizures, distinguishing it from
stroke or atonic seizures.
A. MCA stroke
B. Todd’s palsy
D. ACA stroke
5. What is the EEG pattern observed in patients with JANZ syndrome?
A. 3 Hz spike of slow wave pattern
B. 2.5 Hz spike and slow wave pattern
C. Grossly chaotic pattern
D. 4-6 Hz polyspike pattern
6. A previously healthy 24-year-old man is brought to the ED immediately after an episode of loss of
consciousness. He fell down and lost consciousness, this was followed by 4 minutes of violent jerky
movements of his arms and legs. He was confused after the episode. He has no recollection of the
events. What lab values do you expect in this patient?
(or)
Which of the following laboratory finding is seen after GTCS?
A. Hypomagnesemia
B. Increased serum prolactin
C. Increased serum calcium
D. Decreased serum prolactin
Correct Option C - Rectal diazepam:
727

Intraparenchymal Hemorrhage and Other CNS
Bleeds
1. A retired military personnel, aged 80, presents to the clinic for a routine checkup. He has no history
of diabetes or hypertension. However, earlier this morning, he experienced a brain hemorrhage,
leading to increased intracranial pressure and subsequent demise. Which of the following is most likely
involved in this case?
A. BRCA1 gene mutation
B. Mutations in the APP gene
C. Apolipoprotein E
D. Mutations in the LDLR gene
2. A 50-year-old banker presents to the emergency department with sudden onset speech difficulties
during a sales meeting. Upon examination, he is found to speak fluently but lacks comprehension or
understanding of his speech. Which blood vessel is most likely involved in this patient's condition?
A. Inferior branch of the left middle cerebral artery
B. Superior branch of the left middle cerebral artery
C. Posterior cerebral artery
D. Main trunk of the left middle cerebral artery
3. A 60-year-old male patient with a history of poorly controlled hypertension presents to the emergency
department with severe headache, nausea, and vomiting. On examination, his blood pressure is
measured at 230/140 mmHg. A head CT scan reveals signs of increased intracranial pressure (ICP)
with evidence of midline shift. What is the most appropriate initial management for this patient's
A. Initiate IV sodium nitroprusside infusion for blood pressure control
B. Perform decompressive hemicraniectomy
C. Administer IV mannitol for reduction of intracranial pressure
D. Insert a ventriculostomy for monitoring of intracranial pressure
4. A 25-year-old man is brought to the emergency department after sustaining a head injury from a bike
accident. He was not wearing a helmet at the time of the incident. Initially, he was conscious but later
lost consciousness. CT shows a middle meningeal artery bleed. Upon further assessment, the patient
was unconscious, began posturing, and eventually slipped into a coma. Which of the following
conditions is characterized by a lucid interval followed by deterioration in consciousness?
A. Meningitis
B. Subdural hemorrhage (SDH)
C. Extradural hemorrhage (EDH)
D. Cerebral contusion
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Page 2
5. A 70-year-old female with a history of type 2 diabetes and neuropathy slipped in the bathroom and
hit her head against the floor. Over the course of 10 days, her headache worsened, and she
experienced vomiting. On the 10th day, she developed weakness in her right arm and was unable to lift
it. Upon arrival at the hospital, her Glasgow Coma Scale (GCS) score was 15/15, but extensor plantar
reflexes were noted. What is the most appropriate management?
A. Prescribe acetazolamide for gradual improvement
B. Monitor closely for spontaneous resolution
C. Perform decompressive surgery
D. Administer anticoagulant therapy
Correct Option C - Apolipoprotein E:
 The weakening of brain vessels, resulting in cerebral amyloid angiopathy (CAA), is often associated
with genetic factors.
 Among them, Apolipoprotein E (APOE) gene polymorphisms are frequently implicated in the
pathogenesis of CAA.
 These genetic variations are linked to an increased risk of developing CAA, which can lead to cerebral
hemorrhage, as observed in the patient's case.
Option A - BRCA1 gene mutation: BRCA1 mutations are primarily associated with an increased risk of 
breast and ovarian cancer, and they are not related to cerebral amyloid angiopathy or brain hemorrhag
733

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e.
Option B - Mutations in the APP gene: Mutations in the amyloid precursor protein (APP) gene are linke
d to familial forms of Alzheimer's disease, characterized by abnormal accumulation of amyloid plaques 
in the brain. However, they are not directly associated with cerebral amyloid angiopathy leading to brai
n hemorrhage.
Option D - Mutations in the LDLR gene: Mutations in the LDLR gene are associated with familial hyper
cholesterolemia, a condition characterized by elevated levels of LDL cholesterol in the blood. While hig
h LDL cholesterol levels may contribute to atherosclerosis and vascular diseases, mutations in the LDL
R gene are not specifically linked to cerebral amyloid angiopathy.
Correct Option A - Inferior branch of the left middle cerebral artery:
 In this scenario, the patient's presentation of fluent speech without comprehension suggests the
involvement of the inferior branch of the left middle cerebral artery.
 This branch supplies the posterior portion of the frontal lobe and the temporal lobe, including
Wernicke's area, which is crucial for language comprehension.
 Damage to this area leads to receptive dysphasia, where the patient's speech remains fluent but lacks
meaning or understanding, termed as jargon speech.
 Manifestations of occlusion of Middle Cerebral Artery (MCA) branches: LMCA Superior branch: Loss
of ability of expression (fluency), termed as Motor aphasia. LMCA Inferior branch: Loss of reception,
resulting in receptive dysphasia. Fluency of speech remains, but words lack meaning or understanding,
termed as Jargon speech. LMCA Main Trunk: Results in global aphasia, involving both expression and
reception deficits.
 LMCA Superior branch: Loss of ability of expression (fluency), termed as Motor aphasia.
 LMCA Inferior branch: Loss of reception, resulting in receptive dysphasia. Fluency of speech remains,
but words lack meaning or understanding, termed as Jargon speech.
 LMCA Main Trunk: Results in global aphasia, involving both expression and reception deficits.
 The other options (b, c, d) are not consistent with the clinical features described in the case.
Correct Option C - Administer IV mannitol for reduction of intracranial pressure: Mannitol is an osmotic 
diuretic used to reduce intracranial pressure by drawing water out of brain tissue. It is commonly used 
as initial management in patients with signs of increased ICP, making it the most appropriate option in t
his scenario.
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Option A - Initiate IV sodium nitroprusside infusion for blood pressure control: Sodium nitroprusside ca
n be used in case of HTN control for this patient but nicardipine is the choice of drug as sodium nitropr
usside can cause rapid fall in BP in such situations.
Option B and D: Perform decompressive hemicraniectomy and Insert a ventriculostomy for monitoring 
of intracranial pressure: Decompressive hemicraniectomy and ventriculostomy is a surgical procedure 
performed to relieve intracranial pressure in cases of severe brain swelling, but it is typically considere
d in refractory cases or when there is impending herniation, and not as the initial management.
Correct Option C - Extradural hemorrhage (EDH):
 The above given case with lucid interval is suggestive of EDH
 Epidural hematoma typically results from bleeding from the middle meningeal artery, a branch of the
external carotid artery.
 On non-contrast CT scans, a convex hyperdensity may be observed, often described as a lenticular
hyperdensity, indicating the presence of the hematoma in the epidural space.
Option A - Meningitis: Meningitis typically presents with fever, headache, neck stiffness, and altered m
ental status but does not typically feature a lucid interval followed by deterioration in consciousness.
Option B - Subdural hemorrhage (SDH): A lucid interval can also be seen in SDH but middle meningea
l artery bleed suggests EDH
Option D - Cerebral contusion: Cerebral contusion results from direct trauma to the brain and can caus
e immediate loss of consciousness or altered mental status without a lucid interval.
 
Correct Option C - Perform decompressive surgery:
 In cases of subdural hemorrhage, the management depends on factors such as the volume of bleed
and the location. If the Glasgow Coma Scale (GCS) is low, the volume of bleed is substantial (>30 cc),
or the location of the bleed is infratentorial, decompressive surgery becomes necessary to alleviate
intracranial pressure and prevent further neurological deterioration.
 Acetazolamide may be sufficient for minimal bleeding and gradual improvement, but in cases where
the bleed is significant and causing neurological deficits, surgical intervention is required.
Options A and B: Prescribe acetazolamide for gradual improvement, and Monitor closely for spontaneo
us resolution are incorrect because they do not address the need for surgical intervention in cases of s
ubstantial bleeding and neurological deficits.
735

Page 5
Option D - Administering anticoagulant therapy: is inappropriate and could exacerbate the hemorrhage,
 leading to further complications.
 
736

Intracranial Space Occupying Lesion
1. A 30-year-old Rickshaw puller presents to the neurology clinic with multiple episodes of focal
seizures. Despite treatment with medications prescribed by a local doctor, he continues to experience
seizures. On physical examination, his Glasgow Coma Scale (GCS) score is 15/15, and cranial nerves
examination is normal, with normal deep tendon reflexes (DTR). Fundus examination reveals
papilledema, and the patient has lumps and bumps all over his body. Which of the following is the most
likely MRI findings in this patient?
A. Starry sky appearance
B. Popcorn appearance
C. Owl eye appearance
D. Tigroid appearance
2. A 25-year-old male presents to the emergency department with complaints of severe headaches,
dizziness, and generalized weakness for the past week. Upon further questioning, he mentions a
recent trip to a rural area where he consumed undercooked pork. Neurological examination reveals
signs of increased intracranial pressure, including papilledema. Which of the following treatment
strategies is most appropriate for managing cerebral edema in this patient?
A. Initiating IV Dexamethasone to reduce vasogenic cerebral edema.
B. Commencing Albendazole concurrently with IV Dexamethasone
C. Administering Carbamazepine to control focal seizures.
D. A Ventriculoperitoneal shunt should be placed to alleviate increased intracranial pressure.
3. A 55-year-old male presents to the clinic with a history of progressively worsening headaches over
the past few months. He describes the headaches as dull and constant, with occasional episodes of
sharp pain, especially in the morning. A brain tumour is being suspected in this patient. Which brain
tumor in this patient will have the worst prognosis?
A. Meningioma
B. Grade 4 Glioma/Glioblastoma multiforme
C. Pituitary adenoma
D. Schwannoma
4. A 3-year-old child presents to the pediatric clinic with complaints of frequent urination and excessive
thirst. On examination, the child is noted to have short stature and visual deficits consistent with
bitemporal hemianopia. Imaging studies reveal the presence of a tumor near the optic chiasm with
intracranial calcifications. Which of the following conditions is most likely responsible for the clinical
presentation of this patient?
A. Craniopharyngioma
B. Meningioma
C. Glioblastoma multiforme
D. Ependymoma
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Page 3
Correct Option A - Initiating IV Dexamethasone to reduce vasogenic cerebral edema: 
 IV Dexamethasone is used to reduce vasogenic cerebral edema associated with neurocysticercosis. It
is initiated first to prevent allergic reactions and reduce cerebral edema. After 48 hours, when cerebral
edema subsides, Albendazole can be started sequentially to treat the parasitic infection.
Option B - Commencing Albendazole concurrently with IV Dexamethasone : Albendazole should not b
e commenced concurrently with IV Dexamethasone. Sequential treatment is preferred, with Dexameth
asone initiated first to address cerebral edema.
Option C - Administering Carbamazepine to control focal seizures: It is not the primary treatment for ce
rebral edema associated with neurocysticercosis. Carbamazepine is used to control focal seizures, whi
ch may occur as a complication of neurocysticercosis.
Option D - A Ventriculoperitoneal shunt should be placed to alleviate increased intracranial pressure: V
entriculoperitoneal shunting is indicated for cases of raised intracranial pressure that do not respond to 
medical management. It is not the first-line treatment for cerebral edema associated with neurocysticer
cosis.
 
Correct Option B - Grade 4 Glioma/Glioblastoma multiforme:
 Grade 4 Glioma/Glioblastoma multiforme is a highly malignant brain tumor with the worst prognosis
among the options listed. Glioblastoma multiforme is known for its aggressive growth and resistance to
treatment. Despite advances in therapy, including surgery, radiation, and chemotherapy, the prognosis
remains poor, with a median survival of approximately 12 to 18 months from the time of diagnosis.
Option A - Meningioma: Meningiomas are typically benign tumors that arise from the meninges surroun
ding the brain and spinal cord. While they can cause symptoms and complications depending on their 
size and location, they generally have a better prognosis compared to glioblastoma multiforme.
Option C
- Pituitary adenoma: Pituitary adenomas are usually benign tumors of the pituitary gland and have a
relatively good prognosis, especially when diagnosed early and managed appropriately.
Option D - Schwannoma: Schwannomas, also known as vestibular schwannomas or acoustic neuroma
s when they arise from the vestibular nerve, are typically slow-growing benign tumors. They can cause 
symptoms related to compression of adjacent structures but generally have a
favorable prognosis compared to malignant brain tumors like glioblastoma multiforme.
Correct Option A - Craniopharyngioma: 
 Craniopharyngiomas develop from Rathke pouch and often present with symptoms such as short
stature, visual deficits (bitemporal hemianopia due to compression of the optic chiasm), and central
diabetes insipidus (polyuria and polydipsia). Intracranial calcifications are frequently observed on
739

Page 4
imaging.
Option B - Meningioma: Meningiomas are tumors arising from the meninges, typically located outside t
he brain parenchyma. They can cause various symptoms depending on their location but are less likely
 to present with the specific combination of findings described in the case.
Option C - Glioblastoma multiforme: Glioblastoma multiforme is a highly aggressive brain tumor that us
ually arises in the cerebral hemispheres. It is more commonly seen in adults and may present with sym
ptoms such as headache, seizures, and focal neurological deficits. While visual disturbances can occur
 with tumors in certain locations, the combination of symptoms described is not typical for glioblastoma 
multiforme.
Option D - Ependymoma: Ependymomas are tumors derived from ependymal cells lining the ventricles
 of the brain and the central canal of the spinal cord. They can lead to symptoms related to increased i
ntracranial pressure, such as headache, nausea, and vomiting, but are less commonly associated with 
the specific findings of short stature, bitemporal hemianopia, and diabetes insipidus seen in craniophar
yngiomas.
740

Raised ICP And Brain Death
1. A 45-year-old man with a history of chronic hypertension presents to the emergency department with
a severe headache and projectile vomiting. Upon examination, he is found to have altered sensorium,
with drowsiness progressing to stupor. Neurological examination reveals diplopia laterally. Which of the
following interventions is most appropriate for managing his condition?
A. Pentobarbital coma
B. Therapeutic hypothermia
C. Dopamine infusion
D. Increasing mean arterial pressure
2. A 45-year-old man presents to the emergency department after sustaining a head injury to the right
side in a motor vehicle accident. Upon examination, the physician observes unequal pupil size. The
right pupil is constricted, while the left pupil is normal. Further evaluation reveals no other neurological
deficits. Based on these findings, what stage of oculomotor nerve injury does this patient likely have?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
3. A 58-year-old man presents to the emergency department with altered mental status. His family
reports that he has been increasingly confused and lethargic over the past 24 hours. On examination,
the patient is found to have bilateral small pupils that react sluggishly to light. What is the most likely
cause of the patient's altered mental status and pupil abnormalities?
A. Head trauma
B. Ischemic stroke
C. Fulminant hepatic failure
D. Opioid poisoning
4. A 50-year-old male is brought to the emergency department after being found unresponsive at home.
On arrival, the patient is comatose with no response to painful stimuli. The medical team suspects a
potential reversible cause of the coma and decides to perform tests to rule out certain conditions.
Which of the following tests is contraindicated in this patient due to the presence of cervical spine
trauma?
A. Gag reflex test
B. Cough reflex test
C. Caloric stimulation test
D. Oculocephalic test
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Page 2
5. A 65-year-old male patient presents to the emergency department with sudden-onset weakness on
his right side and difficulty speaking. Upon examination, he demonstrates right-sided hemiparesis and
aphasia. A neurological examination reveals a preference for gaze towards the left side. Further
assessment of his eye movements reveals a slow downward movement of both eyes and rapid upward
movement. What is most likely responsible for these findings?
A. Cortical stroke
B. Brainstem stroke
C. Diffuse cortical anoxia
D. Basilar artery stroke
Correct Option D - Increasing mean arterial pressure:
 Increasing mean arterial pressure: In cases of increased intracranial pressure, maintaining adequate
cerebral perfusion pressure is crucial to prevent cerebral ischemia. Increasing mean arterial pressure
helps ensure adequate cerebral perfusion despite elevated intracranial pressure. This intervention can
counterbalance the increased intracranial pressure and maintain cerebral perfusion, thereby preventing
ischemia-related complications.
Option A - Pentobarbital coma: Pentobarbital coma is used in cases of severe refractory intracranial hy
pertension. It acts by reducing neuronal metabolism, thereby decreasing cerebral metabolic demand. 
While it may be considered in cases of severe intracranial pressure (ICP) elevation, it is typically a
tier II therapy after other measures have failed.
Option B Therapeutic hypothermia: Therapeutic hypothermia is used in various medical conditions, but 
it is not the first-line treatment for managing increased intracranial pressure. In this case, the patient's a
ltered sensorium and neurological symptoms suggest acute intracranial pathology requiring immediate 
intervention to reduce intracranial pressure.
Option C - Dopamine infusion: Dopamine is a vasopressor used in conditions like cardiogenic and septi
c shock. While it can increase blood pressure, it is not the primary intervention for managing intracrania
l hypertension. Moreover, dopamine may increase cerebral blood flow, potentially exacerbating intracra
nial pressure.
 
742

Page 3
Correct Option A - Stage 1 Hutchinson's Pupil:
 Pupil becomes dilated at the side of bleeding or hemorrhage (ipsilateral mid-dilated pupil).
 Reacts poorly to light.
This stage is characterized by unequal pupil size, with the affected pupil being smaller (constricted) du
e to irritation of the oculomotor nerve on that side. Since the patient's right pupil is constricted and the l
eft pupil is normal, this matches the findings of Stage 1, making it the correct answer.
Option B - Stage 2: In this stage, the pupil of the injured side becomes dilated due to paralysis of the o
culomotor nerve, while the pupil of the other side contracts. This stage typically follows Stage 1
and is not consistent with the findings described in the scenario.
Option C - Stage 3: Both pupils are dilated, and there is no reaction to light. This stage indicates sever
e oculomotor nerve injury and is not consistent with the findings described in the scenario.
Option D - Stage 4: Only 3 stages are seen
Correct Option C - Fulminant hepatic failure:
 Fulminant hepatic failure (FHF) can lead to metabolic encephalopathy, characterized by altered
mental status and bilateral small pupils that are reactive to light.
 FHF can cause elevated serum ammonia levels due to impaired ammonia metabolism by the liver.
 This condition can result in encephalopathy, leading to confusion and lethargy.
 A, B, and D are incorrect as they do not show bilateral small pupils that react sluggishly to light
Correct Option D - Oculocephalic Test:
 Also known as the Doll's eye reflex, this test involves moving the patient's head and observing the
independent movement of the eyes. Absence of this reflex may indicate brainstem dysfunction. It is
generally safe to perform unless there are concerns about cervical spine injury, as moving the head can
potentially worsen spinal cord damage.
 Options A, B, and C can be performed in a patient with cervical spine trauma
 
743

Page 4
Correct Option C - Diffuse cortical anoxia:
 Ocular dipping refers to a condition where the downward movement of the eyes is slow and the
upward movement is very fast. It is characteristic of diffuse cortical anoxia.
Option A - Cortical stroke: Patient will always look towards the site of the lesion
Option B
- Brainstem stroke: Patient will always look opposite to the site of the lesion (Crossed Feature)
Option D - Basilar artery stroke: Ocular bobbing, characterized by fast downward movement of both ey
es with very slow upward movement, often accompanied by nystagmus, is indicative of a
basilar artery stroke.
744

Stroke,TIA
1. Lacunar stroke is seen due to damage of the lenticulostriate branches which are branches of ?
A. M1: Horizontal part of middle cerebral artery
B. M2: Insular part of middle cerebral artery
C. M3: Opercular part of middle cerebral artery
D. M4: Cortical part of middle cerebral artery
2. All of the following are located on the lateral side of the brainstem except?
A. Spinothalamic tract
B. Spinocerebellar tract
C. Corticospinal tract
D. Sympathetic chain
3. A 45-year-old male with a history of hypertension and diabetes, went for a walk early in the morning.
He was rushed to the emergency department on feeling weakness in the left arm. His symptoms
started to resolve within 30 minutes of admission. A CT scan of the head was done and is shown
below. How long is the patient at maximum risk for progression of the condition?
A. 4.5 hrs
B. 24hrs
C. 48 hrs
D. 12 hrs
4. Identify the site of involvement and the artery supplying the area in a patient with a cerebrovascular
incident demonstrating the following clinical findings.
745

Page 2
A. Dominant parietal lobe-Left middle cerebral artery
B. Temporal lobe-Middle cerebral artery
C. Non dominant parietal lobe-Right middle cerebral artery
D. Frontal lobe-Anterior cerebral artery
5. All of the following are features of lateral medullary syndrome except?
A. Horner's syndrome
B. Crossed hemianesthesia
C. Aguesia and vertigo
D. Deviated tongue
6. CADASIL is associated with which of the following genes?
A. NOTCH 1
B. NOTCH 2
C. NOTCH 3
D. NOTCH 4
7. A 62-year-old male, who is a known case of hypertension and T2DM, experiences weakness in his
left arm and difficulty in speech while climbing stairs at home. His BP is 130/85mmHg, NIHSS score is
>5 and he gives no history of recent head injury. NCCT head findings are shown below. He managed to
746

Page 3
reach the hospital in 45 minutes What is the next step in the management of this patient?
(or)
What is the next step in the management of an acute ischemia stroke patient who reached the hospital
within 4.5 hours?
A. Thrombolysis
B. CT Angiography
C. MR venography
D. Thrombectomy
8. A 64-year-old male with a history of hypertension and T2DM is non-compliant to medication. Upon
waking up in the morning he cannot feel his left leg and is unable to speak. He was fine when he went
to sleep 7 hours ago at night. Upon reaching the hospital in the next 30 mins, his BP is 138/85mmHg,
and his NIHSS score is >5. NCCT head findings are shown below. What is the treatment of choice for
(or)
What is the treatment of choice if a patient experienced an acute ischemia stroke 7.5 hours before
reaching the hospital?
B. CT perfusion scan
C. Thrombectomy
D. Ventriculostomy
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Page 4
9. An elderly male patient with right upper and lower limb weakness that began 4 hours ago presents to
emergency OPD. His BP is 180/100 mmHg, INR is 1.65 and NCCT head shows a hypodensity
expanding to >2/3rd of MCA territory. He also had a laparoscopic cholecystectomy 3 months ago. Why
is thrombolysis contraindicated in this case?
(or)
Which of the following is a contraindication for thrombolysis
A. Raised BP
B. INR>1.7
C. Hypodensity expanding to >2/3rd of MCA territory
D. Major Surgery > 3 Months
10. A 64-year-old hypertensive male with poorly controlled diabetes, developed a sudden left arm
weakness, drooping of corners of the mouth, and inability to speak, in the early morning while going for
a walk. Upon reaching home after 45 minutes, his wife rushed him to the nearest hospital but his
symptoms started subsiding gradually on the way. NCCT is given below .what is the best course of
treatment in this patient?
(or)
Which of the following is a mainstay treatment for TIA in a patient having risk factors?
A. Dual antiplatelet therapy
B. Thrombolysis
C. Rosuvastatin
D. Idarucizumab
11. A 65-year-old male presents to the emergency department with sudden onset visual disturbances
and headache. Upon examination, he demonstrates symptoms consistent with an occipital lobe infarct.
Which of the following will not be seen?
(or)
Which of the following symptom(s) is not seen in a case of occipital lobe infarct?
A. Anton syndrome
748

Page 5
B. Asimultagnosia
C. Anosognosia
D. Gun-barrel vision
12. A 58-year-old male patient presents with drooping of left eyelids and weakness in right upper and
lower limbs. Which part of the brain is affected in his case?
(or)
Which of the following is affected in Weber syndrome?
A. Medial midbrain
B. Medial medulla
C. Pons
D. Thalamus
13. An elderly male with a history of chronic smoking and uncontrolled hypertension is brought to the
medicine outpatient department (OPD) by his wife. She reports that he has been experiencing
short-term memory disturbances and undue familiarity with unknown people. Upon investigation, a
diagnosis of stroke is made. Which of the following is not seen in this patient considering the affected
area?
(or)
Which of the following is not seen in a Temporal Lobe stroke?
A. Prosopagnosia
B. Visual hallucinations
C. Thought that his food is poisoned
D. Pure word deafness
14. A 65-year-old man is brought to the emergency department with sudden onset right-sided
weakness and difficulty speaking. The patient's wife reports that he was fine just an hour ago but
suddenly became unable to move his right arm and leg and began slurring his speech. Which of the
following is the drug of choice for thrombolysis in stroke?
(or)
Which of the following is the drug of choice for thrombolysis in stroke?
A. Dual antiplatelet
B. Dabigatran
C. Reteplase
D. Enoxaparin
15. Which of the following is true regarding TIA. Symptoms should resolve completely within 12 hours
Improvement of symptoms usually begins after 1 hour Dual antiplatelet therapy is the treatment of
choice AB2CD score is used to predict the risk of stroke ECG is done to rule out atrial fibrillation
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A. 1,2,3,5
B. 2,3,4
C. 2,3,5
D. 1,3,4,5
16. Which of the following symptom(s) is not seen in stroke due to marked artery involvement?
A. Abulia
B. Apathy
C. Urge incontinence
D. Anosognosia
17. A 68 year old smoker with T2DM, experiences weakness in right arm and leg when he is about to
start his morning walk at 6:30 AM. He immediately rushes to the nearby emergency room and reaches
by 7:30 AM, where he is evaluated further. His BP is 180/112 mmHg, INR is 1.3 and the NCCT head
shows a acute ischemic stroke. What is the next step in management of this patient?
(or)
which of the following is the next best management for an acute ischemic stroke patient < 4.5 hrs with
BP 180/112mm Hg?
B. Mannitol
D. BP control
18. A 65-year-old male presents to the emergency department with sudden onset weakness in his right
arm and slurred speech that lasted for about 20 minutes. His blood pressure is measured at 160/95
mmHg.A risk of stroke is being calculated using ABCD2 score. All of the following are true regarding
this score except?
(or)
All are correct factors of the ABCD2 score except?
A. Age should be more than 50 years
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Page 7
B. BP more than 140/90 mmHg
C. Arm weakness
19. A 65-year-old man presents to the emergency department with sudden onset weakness on the right
side of his body and difficulty speaking. A neurological examination reveals right-sided hemiparesis and
expressive aphasia. A CT scan of the brain confirms the diagnosis of acute ischemic stroke.Which of
the following is not a management option for this patient?
(or)
Which of the following is not a management option for acute ischemic Stroke?
A. Airway
B. BP control
C. Thrombolysis
D. Hemicraniectomy
20. A 65-year-old male patient with a known history of hypertension and diabetes presents to the
emergency department with sudden onset weakness on one side of his body and slurred speech. On
examination, he has facial droop, arm weakness, and difficulty speaking. A CT scan of the brain reveals
a hemorrhagic stroke. Which of the following is the most common site of hemorrhagic stroke in this
patient?
(or)
Which of the following is the most common site of hemorrhagic stroke?
A. Putamen
B. Internal capsule
C. Caudate nucleus
D. Substantia nigra
21. A 65-year-old male patient arrives at the emergency department presenting with sudden-onset
weakness on one side of his body and difficulty speaking. His family reports that these symptoms
started approximately 3 hours ago. All are indications for thrombolysis except?
(or)
All are indications for thrombolysis except?
A. NIHSS > 5: Clinical stroke
B. Age > 18 years
C. The onset of symptoms < 2.5 hours at the time of drug administration
D. CT scan showed no hemorrhage or edema for > 1/3rd MCA territory
22. A 37 year old female was brought to the emergency department with seizures and headache for
one day. On examination, paraplegia and increased ICP were present. The patient is taking oral
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contraceptice pills for quiet a long time. She was managed with Aspirin .Which of the following is the
investigation of choice in this condition?
(or)
Which of the following is the investigation of choice in the condition characterized by seizures,
paraplegia, headache and managed with Aspirin?
A. MRI head
B. CT head
C. Magnetic resonance venography
D. X-ray of spine
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Page 9
Correct Option A - M1: Horizontal part of middle cerebral artery:
 The branches that are seen arising superiorly from the M1 segment of the middle cerebral artery are
called lenticulostriate branches.
 If lenticulostriate branches are involved, it will contribute to the development of basal ganglia
manifestations.
 They are involved in lacunar stroke.
Option B - M2: Insular part of middle cerebral artery- present on the lateral surface of the insula.
Option C - M3: Opercular part of middle cerebral artery-runs in the Sylvian fissure. It separates the pari
etal from the temporal lobe.
Option D - M4: Cortical part of middle cerebral artery-supplies the cortical surface and is usually involv
ed in cortical stroke.
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Time period in TIA
 Improvement in symptoms begin within 1 hour
 Resolves completely within 24 hours
 Highest chance of developing stroke after TIA - within first 48 hours
 
Option A - 4.5 hrs: This is the window period for thrombolysis in stroke
Option B - 24hrs: The symptoms of TIA usually resolve within 24 hrs
Option D - 12 hrs: This option is irrelevant.
Correct option C - Non dominant parietal lobe-Right middle cerebral artery:
 The first image shows the patient was not able to copy and draw the pictures which indicates a
constructional apraxia and the second image shows a drawing with all the numbers to one side which
indicates hemineglect of one side of the body.
 All these are features of damage to the non dominant parietal lobe which is supplied by the right
middle cerebral artery.
 
Option A - Dominant parietal lobe: Supplied by the left middle cerebral artery; lesion is associated with 
acalculia, agraphia, facial agnosia
Option B - Temporal lobe: Supplied by the middle cerebral artery; lesion is associated with symptoms li
ke hallucinations, pure word deafness, pure word blindness, and amnesia
Option D - Frontal lobe: Supplied by the anterior cerebral artery; lesions associated with personality ch
anges and antisocial behavior, urge incontinence, abulia, appearance of primitive reflexes i.e., Moro's r
eflex and magnetic gait/gait apraxia
Correct Option D - Deviated tongue:
 Tongue deviation is caused by the 12th cranial nerve palsy, which originates medially and is
associated with medial medullary syndrome.
 
 Option A, B, C - are all features of lateral medullary syndrome.
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Option B - BP more than 140/90 mmHg: This is a correct factor of the ABCD2 score, contributing 1
point.
Option C - Arm weakness: This is a correct factor in the ABCD2 score, contributing 2 points.
Option D - Diabetes mellitus: This is a correct factor of the ABCD2 score, contributing 1 point if present.
Correct Option D – Hemicraniectomy:
 Hemicraniectomy is not used for the treatment of stroke. It is the treatment option for hemorrhagic
stroke, not ischemic stroke.
 Hemicraniectomy: While hemicraniectomy involves the surgical removal of part of the skull to relieve
intracranial pressure, it is typically performed in patients with large hemispheric hemorrhages rather
than ischemic strokes. In ischemic stroke management, the focus is on reperfusion therapies such as
thrombolysis or thrombectomy, along with supportive care and secondary prevention strategies.
Option A - Airway: Maintaining a patent airway is crucial in stroke management to ensure adequate oxy
genation and ventilation, especially in patients with impaired consciousness or compromised respirator
y function.
Option B - BP control: Blood pressure control is essential in acute ischemic stroke to prevent complicati
ons such as intracranial hemorrhage and worsening of ischemia. Optimal blood pressure targets depen
d on various factors such as the patient's comorbidities and eligibility for thrombolytic therapy.
Option C - Thrombolysis: Thrombolytic therapy, such as alteplase (tPA), is a cornerstone treatment for 
acute ischemic stroke, particularly when administered within the therapeutic window (typically within 4.
5 hours of symptom onset). It aims to dissolve the clot causing the ischemic stroke and restore blood fl
ow to the affected area of the brain
Correct Option A – Putamen:
 Hemorrhagic strokes, which occur due to bleeding in the brain, are often classified based on their
location. Among the options provided, the putamen, which is part of the basal ganglia, is the most
common site for hemorrhagic strokes.
 Bleeding in the putamen can lead to significant neurological deficits, including weakness, sensory
changes, and speech difficulties, which are consistent with the patient's presentation.
Options B, C, D:
 While bleeding can occur in these areas of the brain, they are not as commonly affected as the
putamen in cases of hemorrhagic stroke.
 Bleeding in the internal capsule, caudate nucleus, or substantia nigra can also result in neurological
deficits, but they are less frequently observed compared to putaminal hemorrhages.
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Parkinsonism
1. Which of the following correctly differentiates Alzheimer’s from parkinsonism ?
A. Low dopamine levels
B. Presence of Lewy bodies
C. Damaged Nucleus of Meynert basalis
D. Decreased Thalamus activity
2. A 75-year-old banker complains of increasing difficulty buttoning his shirt every morning and
brushing his teeth. He states that his hand shakes while relaxing in front of the TV but stops while
reaching for the remote and switching channels. Which of the following is the next most appropriate
step in managing this patient?
A. Deep brain stimulation
B. Send him for cognitive behaviour therapy (CBT)
C. Prescribe L-Dopa
D. Prescribe memantine
3. A patient who was recently started on medication for Parkinsonism and developed the following
condition (fig. a & b) after treatment of his ailment. What is the drug's mechanism of action likely to
cause this adverse effect?
(or)
After treatment for Parkinsonism, a patient develops a specific condition (fig. a & b). What is the
mechanism of action of the drug likely responsible for this adverse effect in dermatology?
A. D2 antagonism
B. NMDA antagonism
C. MAO inhibitor
D. Adenosine antagonist
4. A 55-year-old male with a history of Parkinson's disease abruptly discontinues his
levodopa-carbidopa therapy due to fears of side effects. Shortly after, he manifests severe muscle
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rigidity, hyperthermia, confusion, elevated heart rate, blood pressure fluctuations, and profuse
sweating. What is the most probable condition this patient is experiencing?
(or)
What condition is likely causing severe muscle rigidity, hyperthermia, confusion, and other symptoms in
a patient with a history of Parkinson's disease who abruptly stopped taking levodopa-carbidopa?
A. Wearing-off phenomenon
B. Atypical parkinsonism
C. Serotonin syndrome
5. A 60-year-old male presents to the neurology clinic with complaints of tremors, bradykinesia, and
stiffness in his limbs. He reports difficulty in initiating movements and experiences tremors primarily in
his hands at rest. On examination, the patient demonstrates cogwheel rigidity and a shuffling gait. What
is the gene present in this disease?
(or)
Which of the following is the disease in which the Parkin gene is found?
A. Parkinson's disease
B. Alzheimer's Disease
C. Corticobasal degeneration syndrome
D. Myasthenia gravis
6. A 65-year-old male patient with a history of Parkinson's disease presents to the neurology clinic for a
follow-up visit. He has been on levodopa therapy for several months, and the clinician is discussing
potential side effects of the medication except?
(or)
All of the following are the side effects of Levadopa except?
A. Dyskinesia
B. Nausea
C. Orthostatic hypotension
D. Obesity
7. A 40-year-old man is brought to the doctor by his family for rapid intellectual decline. His wife states
that he used to be fun and lively and has become verbally and physically aggressive. Examination
shows fast semi-purposive movements in hands. His father and grandfather had died from a similar
illness. Which of the following is the most likely diagnosis?
(or)
What is the most likely diagnosis for a 40-year-old man with rapid intellectual decline, increased
aggression, fast semi-purposive hand movements, and a family history of a similar illness?
A. Early onset Alzheimers disease
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B. Lewy body dementia
C. Corticobasal degeneration
D. Huntington’s chorea
8. A 35-year-old male presents with weakness persisting for 3 months, accompanied by tongue
fasciculations, 4+ deep tendon reflexes at the knee, and muscle atrophy in certain regions alongside
spasticity. Which additional test is warranted for this patient, considering suspected ALS?
A. V.E.P
B. MRI whole spine
C. CT whole Spine
D. Electromyography
9. What is the trinucleotide repeat sequence in Huntington's Disease?
A. CTG
B. CAG
C. CGG
D. GAA
10. A 16-year-old adolescent presents to the neurology clinic with a history of parkinsonism-like
symptoms, including tremors, rigidity, and difficulty with coordination. He also experiences migraine-like
headaches. These symptoms have been progressively worsening over the past few years. On further
evaluation, an MRI was done and findings are given below. Which mineral is responsible for this
(or)
Which mineral is responsible for parkinsonism-like symptoms in a 16-year-old with progressive
worsening and specific MRI findings?
A. Copper
B. Zinc
C. Iron
D. Magnesium
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Page 4
11. A 58-year-old woman presents to a neurology clinic. Her family reports that she has become
socially inappropriate, often making impulsive comments and displaying emotional bluntness.
Additionally, they have noticed difficulties in her language abilities, such as difficulty finding words and
forming coherent sentences. On examination, there are executive function deficits and memory
problems. Imaging studies reveal frontal and temporal lobe atrophy on brain MRI. Based on the
provided clinical information, what is the most likely diagnosis for this patient?
(or)
What is the likely diagnosis for a patient presenting with changes in behavior, impulsivity, language
difficulties, and frontal and temporal lobe atrophy on brain MRI?
A. Alzheimer's Disease
B. Pick's Disease
C. Multiple Sclerosis
D. Multiple system atrophy
12. A 58-year-old man presents to the neurology clinic with a complaint of several troubling symptoms.
He reports difficulty with balance and coordination, leading to frequent falls. He often feels lightheaded
when standing up, which has caused him to faint on several occasions. The patient also experiences
bladder and bowel dysfunction, including urinary urgency and constipation. On examination, you notice
orthostatic hypotension, marked rigidity, and bradykinesia. Based on the provided clinical information,
(or)
What is the most likely diagnosis for a 58-year-old man with balance and coordination difficulties,
orthostatic hypotension, rigidity, bradykinesia, and bladder/bowel dysfunction?
A. Parkinson's Disease
B. Pick's disease
C. Multiple System Atrophy
D. Huntington's Disease
13. A 40-year-old with a family history of similar symptoms comes to a neurology clinic with progressive
motor and cognitive issues, including involuntary movements, balance problems, and personality
changes. The diagnosis reveals an expanded trinucleotide repeat in the HTT gene. What's the
mechanism of action of the preferred medication for this condition?
(or)
What is the mechanism of action of the drug of choice for Huntington's disease?
A. MAO inhibitor
B. VMAT2 inhibitor
C. D2 inhibitor
D. AchE inhibitor
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Correct Option C - Damaged Nucleus of Meynert basalis:
 In Alzheimer’s disease, the neurotransmitter acetylcholine decreases. Acetylcholine is synthesized by
the nucleus of Meynert basalis, which is damaged in this disease. This decrease in acetylcholine further
leads to various degenerative changes in the brain.
 In Parkinson's Substantia nigra is damaged
Option A - Low dopamine levels: Parkinsonism, including Parkinson's disease, is characterized by a
significant reduction in dopamine levels in the brain, particularly in the substantia nigra region.
Option B - Presence of Lewy bodies: Lewy bodies are abnormal protein aggregates that are a hallmark
 of several disorders, including Parkinson's disease and Lewy body dementia. They are commonly see
n in Parkinsonism.
Option D— Decreased Thalamus activity: In parkinsonism, the thalamic activity decreases, whereas th
e activity of the globus pallidus interna increases.
Correct Option C- Prescribe L-dopa:
 Given the symptoms described, including difficulty with fine motor tasks and resting tremor that
improves with purposeful movement, this patient likely has Parkinson's disease.
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 L-Dopa is the mainstay of treatment for Parkinson's disease, as it helps to replenish dopamine levels
in the brain, alleviating motor symptoms.
 Initiation of L-Dopa therapy can significantly improve the patient's quality of life by reducing tremors
and enhancing motor function.
Option A- Deep brain stimulation:
 Deep brain stimulation can be done in Parkinson's disease patients when medical therapy fails.
Option B- Send him for cognitive behavioural therapy (CBT):
 Cognitive behavioural therapy has no role in improving parkinsonian symptoms.
Option D- Prescribe memantine:
 Memantine is a medication primarily used in the management of Alzheimer's disease and other forms
of dementia.
Correct Option B- NMDA antagonism:
 The purplish-red, net-like, blotchy spots on the skin shown in the images are consistent with livedo
reticularis, a condition characterized by a mottled, net-like pattern due to reduced blood flow in the
skin's capillaries. Amantadine, an antiviral and antiparkinsonian medication, has been associated with
the development of livedo reticularis as a potential adverse reaction.
 The mechanism of action of amantadine involves NMDA (N-Methyl-D-Aspartate) antagonism, which
affects glutamate neurotransmission and may contribute to its effects in Parkinson's disease. However,
this mechanism of action can also lead to various central and peripheral side effects, including livedo
reticularis in some cases.
Option A- D2 antagonism: D2 antagonists are not typically used as a primary treatment for Parkinson's 
disease. Instead, D2 agonists, which stimulate dopamine receptors, are more commonly employed. De
rmatological side effects such as photosensitivity, skin rashes, and pruritus. Livedo reticularis is not a
known adverse effect of D2 antagonism.
Option C- MAO inhibitor (Monoamine Oxidase Inhibitor): While some MAO inhibitors, such as selegilin
e and rasagiline, are used in the treatment of Parkinson's disease to prevent the breakdown of dopami
ne, they are not typically associated with livedo reticularis as an adverse effect. Dermatological side eff
ects such as rash, itching, and photosensitivity. Instead, MAO inhibitors can have other side effects, su
ch as potential interactions with certain foods and medications.
Option D- Adenosine antagonist: While some adenosine antagonists, such as istradefylline, are used in
 the treatment of Parkinson's disease , they are not typically associated with livedo reticularis as an adv
erse effect. Dermatological side effects such as rash and pruritus.
Correct Option D- Neuroleptic malignant syndrome:
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Page 7
 Neuroleptic Malignant Syndrome (NMS) is primarily associated with the use of antipsychotic
medications, which block dopamine receptors, particularly D2 receptors. This blockade can lead to
dysregulation of dopamine transmission in the brain, contributing to the development of NMS.
Additionally, abrupt withdrawal or reduction of dopamine agonist medications, such as
levodopa-carbidopa therapy used in Parkinson's disease, can also precipitate NMS due to sudden
changes in dopamine levels.
 The hallmark symptoms of NMS include severe muscle rigidity, hyperthermia, altered mental status
(confusion), and autonomic instability (elevated heart rate, blood pressure fluctuations, sweating, etc.).
 NMS is a medical emergency that requires immediate attention and typically involves hospitalization.
 Treatment of Neuroleptic Malignant Syndrome (NMS) involves halting the suspected neuroleptic
medication and, if the withdrawal of dopaminergic drugs triggered the syndrome, reinstituting them
promptly. Supportive medical care, including hydration and managing hyperthermia, is crucial.
Bromocriptine and dantrolene are commonly used pharmacological treatments, while other
dopaminergic agents and adjunctive medications may also be considered.
Option A - Wearing-off phenomenon:
 This refers to a phenomenon in which the effectiveness of Parkinson's disease medications, such as
levodopa, starts to wear off before the next dose is due. It is characterized by a return of Parkinson's
symptoms, such as tremors and rigidity, but it does not involve hyperthermia, severe muscle rigidity, or
altered mental status.
Option B- Atypical parkinsonism:
 Atypical parkinsonism refers to a group of neurodegenerative disorders that share some clinical
features with Parkinson's disease but have different underlying pathology.
 Conditions such as multiple system atrophy (MSA) and progressive supranuclear palsy (PSP) are
examples of atypical parkinsonism.
 These conditions may present with various symptoms including parkinsonism, autonomic dysfunction,
and cognitive impairment, but they usually have a more insidious onset rather than the abrupt
presentation described in the scenario.
Option C- Serotonin syndrome:
 Serotonin syndrome is a condition characterized by excessive serotonin activity in the central nervous
system. It can result from interactions between certain medications, including serotonergic
antidepressants.
 Symptoms may include agitation, confusion, muscle rigidity, hyperthermia, and autonomic instability,
resembling NMS. However, the context of abrupt withdrawal from levodopa is not typically associated
with serotonin syndrome.
 The treatment of choice for serotonin syndrome involves discontinuation of the offending medications,
supportive care, and in severe cases, administration of serotonin receptor antagonists such as
cyproheptadine.
Correct Option A - Parkinson's disease:
 The Parkin gene is found in Parkinson's disease
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 Another gene found in Parkinson's disease is PARK SCN4A gene
 These are the conditions that are not associated with the Parkin gene
Correct Option D – Obesity:
 Obesity is not typically listed as a side effect of levodopa therapy. While weight changes may occur in
patients with Parkinson's disease due to various factors such as changes in appetite, dietary habits, or
physical activity levels, obesity itself is not directly caused by levodopa medication.
 Dyskinesia, nausea, and orthostatic hypotension are the side effects of Levodopa
Correct Option D- Huntington’s chorea:
 Huntington's disease/Huntington's chorea is an autosomal dominant condition, so a family history of a
similar disease is always present.
 It is caused by trinucleotide repeat (CAG) expansion in the Huntington gene found on chromosome 4.
Decreased levels of acetylcholine and gamma-aminobutyric acid (GABA) are seen in the brain.
Neuronal death occurs due to glutamate excitotoxicity via NMDA (N-methyl D-aspartate) receptor
binding.
 DNA testing can confirm the diagnosis. On neuroimaging, atrophy of caudate and putamen with
subsequent ventriculomegaly is seen.
 Symptoms appear between the age of 20-50 years and include: Chorea (Huntington’s chorea) is fast
semi-purposive movements. It can involve the face, head and neck, tongue, trunk, and extremities. It
presents as abnormal involuntary movements. With advancing age, chorea reduces, and dystonia,
rigidity, and myoclonus appear. Athetosis (slow, continuous, involuntary writhing movement) Altered
behaviour (aggression, irritability, personality changes, antisocial behaviour, obsessive-compulsive
features, and psychosis) Depression. Dementia and intellectual decline are key features. Gait is
unsteady and irregular. Bradykinesia and rigidity may occur. Incontinence.
 Chorea (Huntington’s chorea) is fast semi-purposive movements. It can involve the face, head and
neck, tongue, trunk, and extremities. It presents as abnormal involuntary movements. With advancing
age, chorea reduces, and dystonia, rigidity, and myoclonus appear.
 Athetosis (slow, continuous, involuntary writhing movement)
 Altered behaviour (aggression, irritability, personality changes, antisocial behaviour,
obsessive-compulsive features, and psychosis)
 Depression.
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Option B- M.R.I. whole Spine:
 M.R.I. The Spine cannot visualize the loss of anterior horn cells or pyramidal cells in the cortex.
M.R.I. The Spine cannot visualize the loss of anterior horn cells or pyramidal cells in the cortex.
Option C- C.T whole Spine:
 CT spine cannot visualize the loss of anterior horn or pyramidal cells in the cortex.
Correct Option B - CAG: The trinucleotide repeat sequence of CAG is associated with Huntington's Dis
ease. In individuals with Huntington's Disease, there is an expansion of the CAG repeat in the HTT gen
e, leading to the production of a
mutated huntingtin protein, which causes the characteristic symptoms of the disease.
Disorder
Trinucleotide Repeat Sequence
Huntington's Disease
CAG
Myotonic Dystrophy Type 1
CTG
Fragile X Syndrome
CGG
Friedreich's Ataxia
GAA
Spinocerebellar Ataxia
Machado-Joseph Disease
Option A - CTG: This trinucleotide repeat sequence is associated with various disorders, including myo
tonic dystrophy.
Option C- CGG: This trinucleotide repeat sequence is associated with Fragile X Syndrome, a
different genetic disorder characterized by intellectual and developmental disabilities.
Option D - GAA: The GAA trinucleotide repeat sequence is associated with Friedreich's Ataxia, a
rare inherited disorder that affects muscle coordination.
Correct Option A- Copper:
 Wilson's disease, also known as hepatolenticular degeneration, is an autosomal recessive disorder
characterized by the abnormal accumulation of copper in various tissues, particularly the liver and
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brain.
 The typical clinical features of Wilson's disease include neurological symptoms such as tremors,
rigidity, dystonia, and difficulty with coordination, which resemble Parkinsonism.
 Other common symptoms include liver dysfunction, such as jaundice and hepatomegaly.
 Wilson's disease can also present with psychiatric symptoms, Kayser-Fleischer rings (copper deposits
in the cornea), and renal dysfunction.
 MRI findings in Wilson's disease often show abnormalities in the basal ganglia, particularly the
putamen, which may appear hyperintense on T2-weighted images.
 In the Lenticular nucleus, this copper accumulation can result in characteristic MRI findings known as
the "Face of Gaint Panda" appearance.
Option B- Zinc: Zinc is not responsible for the condition described in the case scenario. Wilson's Disea
se is specifically associated with copper accumulation.
Option C- Iron: Iron accumulation is associated with a different neurodegenerative disorder known as H
allervorden-Spatz Disease, which can lead to iron deposition in the globus pallidus and presents with a
n "Eye of the Tiger" appearance on MRI.
Option D- Magnesium: Magnesium is not related to the condition described. Wilson's Disease is primari
ly associated with copper accumulation, not magnesium.
Correct Option B- Pick's Disease: This is the correct answer. Pick's Disease is a subtype of frontotemp
oral dementia characterized by changes in behaviour, personality, and language abilities. Patients ofte
n exhibit social inappropriateness, impulsivity, and difficulties with language, all of which are consistent 
with the presented clinical scenario. Frontal and temporal lobe atrophy is a hallmark of Pick's Disease.
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Option A- Alzheimer's Disease:
 Alzheimer's disease typically presents with progressive memory loss and cognitive decline, including
difficulties with language and executive function. However, it is less likely to manifest as prominent
social inappropriateness and impulsivity early in the disease course, which are more characteristic of
Pick's Disease.
 In Alzheimer's, gyri and sulci blunting can mimic hydrocephalus on plain MRI due to
pseudo-enlargement of brain ventricles.
Option C- Multiple Sclerosis:
 Multiple sclerosis primarily presents with a wide range of neurological symptoms, including sensory
disturbances, weakness, and coordination problems. It does not typically lead to the specific
behavioural and language changes seen in Pick's Disease.
 Plaques or Dawson fingers are noted in periventricular, juxtacortical, and infratentorial areas, with
plaque size exceeding 6 mm in Multiple Sclerosis.
Option D- Multiple System Atrophy:
 Multiple system atrophy is characterized by motor symptoms, autonomic dysfunction, and cerebellar
signs, which are not in line with the behavioural and language changes described in the case scenario.
  
Correct Option C- Multiple System Atrophy (MSA):
 Shy-Drager Syndrome, or MSA, is a rare neurological disorder characterized by a combination of
motor symptoms (rigidity and bradykinesia), autonomic dysfunction (orthostatic hypotension, bladder
and bowel dysfunction), and cerebellar symptoms (balance and coordination problems). It often leads
to falls and fainting due to the blood pressure drop upon standing.
 Multiple system atrophy (MSA) often presents with parkinsonism, but patients also exhibit varying
degrees of dysautonomia, cerebellar involvement, and pyramidal signs. The prominence of these
manifestations, along with symmetry of onset and poor response to levodopa, suggests multiple system
atrophy (MSA) rather than Parkinson's disease (PD).
 This is an Atypical Parkinson's Syndrome.
Option A- Parkinson's Disease:
 Parkinson's disease does present with symptoms such as rigidity and bradykinesia, but it typically
does not cause significant orthostatic hypotension, bladder and bowel dysfunction, or frequent fainting.
These features are more suggestive of an atypical parkinsonism disorder like MSA.
Option B- Pick's Disease:
 Picks Disease, also known as Frontotemporal Dementia (FTD), primarily affects behavior, personality,
and language abilities, with symptoms such as social inappropriateness and language difficulties. It
does not typically cause the motor symptoms and autonomic dysfunction as described in the scenario.
Option D- Huntington's Disease:
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Page 14
 Huntington's disease is a genetic neurodegenerative disorder characterized by motor symptoms,
cognitive decline, and psychiatric features. While it can lead to balance and coordination problems, it
does not typically cause the significant autonomic dysfunction and orthostatic hypotension seen in
Shy-Drager Syndrome.
Correct Option B- VMAT2 Inhibitor (Vesicular Monoamine Transporter 2 Inhibitor): 
 The expanded trinucleotide repeat in the HTT gene indicates Huntington's disease (HD), a
neurodegenerative disorder.
 VMAT2 inhibitors, such as Tetrabenazine, are the drug of choice for Huntington's Disease.
 These drugs deplete presynaptic dopamine storage and reduce dopamine release, helping to manage
the chorea and hyperkinetic movements characteristic of the disease. This mechanism of action directly
targets the excessive dopamine activity seen in Huntington's Disease.
 Tetrabenazine is used to treat hyperkinetic movement disorders, including Huntington's disease and
tardive dyskinesia.
Option A- MAO Inhibitor (Monoamine Oxidase Inhibitor): MAO inhibitors work by inhibiting the enzyme 
monoamine oxidase, which is responsible for breaking down neurotransmitters like dopamine, serotoni
n, and norepinephrine. They are not typically used as the drug of choice for Huntington's Disease, as t
hey do not directly address the underlying pathophysiology of the disease.
Option C- D2 Inhibitor (Dopamine D2 Receptor Inhibitor): D2 inhibitors, by blocking dopamine receptor
s, diminish dopamine signaling. They serve as secondary medications if tetrabenazine proves ineffectiv
e and can also alleviate chorea symptoms.
Option D- AChE Inhibitor (Acetylcholinesterase Inhibitor): Acetylcholinesterase inhibitors are used in co
nditions like Alzheimer's Disease to increase acetylcholine levels in the brain. They are not typically us
ed to treat the motor and cognitive symptoms of Huntington's Disease.
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Alzheimer's Disease.
1. A 75-year-old man, devoid of comorbidities, presents at the outpatient department with recurring
instances of forgetting the route home from the nearby grocery store, a place he frequents, and
struggling to recall the names of common items he interacts with daily. Upon examination, his
Mini-Mental State Examination (MMSE) score is 22. The neurologist proceeds to request an MRI scan
of the brain, the results of which are provided below. What probable diagnosis does this scenario
suggest?
A. Alzheimer’s disease
B. Pick’s disease
C. Parkinson’s disease
D. Pseudodementia
2. All of the following are seen in Alzheimer’s except
A. Cortical dementia
B. Amnesia
C. Neurofibrillary tangles
D. Socially inappropriate behavior
3. An 80-year-old female presents to the outpatient clinic with complaints of forgetfulness over the past
6 months. A mini mental state examination a score of 19 out of 30. Given the clinical suspicion of
Alzheimer's disease which of the following can be done for further diagnostic evaluation to confirm the
diagnosis.?
(or)
Which of the following is a further diagnostic evaluation to confirm the diagnosis of Alzheimer's
disease?
A. Plain MRI
B. Functional MRI
C. Head CT
D. MMSE
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4. A 72-year-old female presents to the neurology clinic with progressive memory loss and difficulties in
daily functioning. Her family reports that she frequently forgets recent events, repeats questions, and
struggles with tasks that were once routine for her.Which of the following drugs are NOT used in the
condition this patient is suffering from?
(or)
Which of the following drugs are NOT used in the treatment of Alzheimer’s disease?
A. Donepezil
B. Memantine
C. Rivastigmine
D. Tacrine
5. A 60-year-old woman presents to the memory clinic with complaints of progressive forgetfulness and
difficulty in performing daily tasks. Her family history reveals a paternal grandmother who was
diagnosed with Alzheimer's disease in her late 70s. Which chromosome is associated with the
defective gene encoding Apolipoprotein E in affected individuals?
(or)
Which chromosome is associated with the defective gene encoding Apolipoprotein E in affected
individuals?
A. Chromosome 1
B. Chromosome 14
C. Chromosome 19
D. Chromosome 21
6. A 75-year-old woman presents to the neurology clinic with complaints of memory problems and
difficulty in performing daily tasks. Her family reports that she often forgets appointments and struggles
to follow conversations. The neurologist performs the clock face test during the assessment to evaluate
cognitive function. Which of the following is diagnosed by this test?
(or)
Which of the following is diagnosed by the Clock face test?
A. Dementia
B. Apraxia
C. Amnesia
D. Hemineglect
7. A 70-year-old patient presents to the primary care clinic with complaints of memory impairment and
difficulty performing daily activities. The physician suspects dementia and decides to perform a
Mini-Mental State Examination (MMSE) to assess cognitive function.All of the following are the parts of
the MMSE score for dementia except?
(or)
All of the following are the parts of the MMSE score for dementia except?
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A. The patient will be asked about the current date, month or year, or address
B. The patient will be asked to do basic calculations
C. Ask the patient to draw intersecting pentagons
D. Drawing clock face
8. A 78-year-old woman presents to the memory clinic with complaints of increasing forgetfulness and
difficulty in performing daily tasks. She frequently forgets appointments, repeats questions, and
struggles to manage her medications. healthcare moderate dementiawhich is categorized as?
(or)
Which among the following is the score of the MMSE for moderate dementia?
A. 12
B. 4
C. 6
D. 22
Correct option A - Alzheimer’s disease:
 It is the leading cause of cortical dementia.
 Earliest and most serious damage is seen in medial temporal lobe or entorhinal cortex; parietal and
temporal lobes are affected
 In the hippocampus, Nucleus of Meynert Basalisis is affected, reducing acetylcholine levels.
 Acetylcholine, noradrenaline and serotonin levels are reduced
 Genetic predisposition: Chromosome 1: Defective gene is Presenilin -2 Chromosome 14: Defective
gene is Presenilin-1 Chromosome 19: Defective gene is Apolipoprotein E4 allele Chromosome 2: Down
syndrome (die before 35 years due to pneumonia or congenital heart disease, if they survive after 35
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 Alzheimer's disease is a progressive neurodegenerative disorder characterized by cognitive decline,
memory impairment, and functional decline as given in the scenario
 Tacrine, also known as tetrahydroaminoacridine (THA), was one of the first drugs approved for the
treatment of Alzheimer's disease.
 However, its use has been discontinued due to significant hepatotoxicity and the availability of safer
alternatives such as donepezil, memantine, and rivastigmine.
Incorrect Options -
Option A- Donepezil is an acetylcholinesterase inhibitor, given in the initial stages to treat Alzheimer's.
Option B- Memantine, an NMDA receptor antagonist is also given for Alzheimer’s
Option C- Rivastigmine is also an acetylcholinesterase inhibitor used in treating Alzheimer’s.
Correct Option C - Chromosome 19:
 The defective gene associated with Alzheimer's disease and encoding Apolipoprotein E is located on
Chromosome 19. Specifically, the Apolipoprotein E 4 allele has been implicated as a risk factor for
late-onset Alzheimer's disease.
Option A - Chromosome 1: Chromosome 1 is associated with a defective gene encoding Presenilin-2, 
which is implicated in some cases of familial Alzheimer's disease.
Option B - Chromosome 14: Chromosome 14 is associated with a
defective gene encoding Presenilin-1, another gene implicated in familial Alzheimer's disease.
Option D - Chromosome 21: Chromosome 21 is associated with Down syndrome (Trisomy 21) but is n
ot directly linked to Alzheimer's disease. However, individuals with Down syndrome have an increased 
risk of developing Alzheimer's disease due to triplication of the Amyloid Precursor Protein (APP) gene l
ocated on Chromosome 21.
Correct Option A – Dementia:
 The clock face test is used to assess various cognitive functions, including visuospatial abilities,
executive function, and memory.
 In this test, the patient is asked to draw a clock face showing a specific time, typically 10 minutes past
11.
 Abnormalities in the drawing, such as missing numbers, incorrect placement of hands, or
disproportionate size, may indicate cognitive impairment consistent with dementia.
 These are not diagnosed by the clock face test
784

Headache and Migraine
1. The migraine disability assessment score is evaluated based on the history of headaches for how
many months?
A. 6 months
B. 1 year
C. 3 months
D. 1 month
2. A 25-year-old female comes to the OPD with a complaint of a throbbing one-sided headache which
starts with blurred vision and nausea followed by aversion to light and sound which lasts for 24 hrs. The
doctor examined the patient and gave a MIDAS score of 18. All of the following are the first line of
approach in the condition except?
(or)
What is the treatment for migraine with moderate disability?
A. Indomethacin
B. Triptans
C. Naproxen
D. Paracetamol
3. A 25-year-old female was watching movies at night with all the lights switched off, when she
suddenly developed severe pain and redness in the right eye along with 3 episodes of vomiting. What
A. Cluster headache
B. Angle-closure glaucoma
C. Migraine
D. Tension headache
4. Match the following migraine variants in set 1 with their features in set 2 SET 1 1) Ophthalmoplegic
Migraine 2) Retinal Migraine 3) Familial Hemiplegic Migraine SET 2 a) Calcium channel defect b) Ptosis
and squint c) Blindness and scotoma
C. 1-c,2-a,3-b
5. A 58-year-old male presents at the OPD reporting severe headaches, particularly in the area anterior
to the ears, exacerbated by chewing gum. He has recently experienced intermittent fever and has been
self-medicating with paracetamol. Laboratory results reveal a hemoglobin level of 11%, a white blood
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cell count of 15,000 cells/mm³, and an erythrocyte sedimentation rate (ESR) of 100 mm in 1 hour.
Temporal artery biopsy findings are shown in the image. What is the recommended course of action for
managing this patient?
A. Sumatriptan
B. Ibuprofen
C. Steroids
D. Celecoxib
6. A 28-year-old male presents to the hospital with a complaint of extreme headache with red and
watery eyes three to four times a day, each episode lasting for at least 20 minutes at about the same
hour everyday for the last 2 months. Which of the following should be used in this patient to prevent
future attacks?
(or)
Which of the following is used to prevent future attacks in cluster headache?
A. Lignocaine
B. Sumariptan
C. Verapamil
D. Aspirin
7. A 50-year-old woman presents to the emergency department with a sudden onset severe headache
described as "the worst headache of her life." Upon examination, she appears agitated and is
experiencing neck stiffness. NCCT is given below. Which of the following is not a cause of the condition
that the patient is suffering from?
(or)
Which of the following is not a cause of Subarachnoid hemorrhage?
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8. A 60-year-old female patient presents to the emergency department with sudden-onset severe
(or)
9. A 65-year-old male presents to the emergency department with a sudden onset of severe headache,
(or)
A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4
10. A 55-year-old male patient presents to the emergency department with sudden-onset severe
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 COX-2 inhibitors- Etoricoxib
 COX-3 inhibitors
 Paracetamol 1g with caffeine.
 
 Options A, C, and D belong to COX-1,2 inhibitors and are used as the first-line approach in acute
migraine with a MIDAS score of less than 20.
Correct Option B - Angle-closure glaucoma:
 Angle-closure glaucoma is a condition preferentially more common in females, where there is a
sudden increase in intraocular pressure due to blockage of the drainage angle in the eye. The
symptoms described in the case fit well with an acute angle-closure glaucoma attack.
 Severe pain and redness in the right eye: This is a classic symptom of acute angle-closure glaucoma.
The sudden increase in intraocular pressure causes intense pain and redness in the affected eye.
 Episodes of vomiting: Acute angle-closure glaucoma can cause nausea and vomiting due to the
severe pain and increased intraocular pressure affecting the autonomic nervous system.
 Watching movies at night with all lights switched off: This is a risk factor for angle-closure glaucoma
as it can cause dilation of the pupil, which can further narrow the drainage angle in susceptible
individuals, leading to an acute attack.
Option A - Cluster headache:
 Cluster headaches manifest as retroorbital pain accompanied by autonomic symptoms such as
epiphora, nasal stuffiness, and bulbar congestion. They typically occur with multiple daily attacks and
predominantly affect males. Restlessness is a common characteristic, and none of the
above-mentioned features in the patient points to this diagnosis.
Option C - Migraine:
 Migraine presents with a pulsating headache often accompanied by visual disturbances like aura or
zigzag lines, along with symptoms such as sensitivity to light and sound, and nausea. Attacks typically
last 4 to 72 hours, with an average duration of approximately 24 hours. None of the above-mentioned
features in the patient point to this diagnosis.
Option D - Tension headache:
 Tension headaches manifest as band-like pressure across the forehead and occipital area, often
linked with stress and anxiety, with a normal physical examination. Exclusion of other common
headache causes is essential, and none of the above-mentioned features in the patient points to this
diagnosis. 
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 Subarachnoid hemorrhage (SAH) can cause various ECG changes due to its impact on cardiac
function and autonomic regulation. However, a narrow QRS complex is not typically observed in
patients with SAH.
 The correct ECG changes seen in subarachnoid hemorrhage include: A - ST depression and T-wave
inversion, which are indicative of myocardial ischemia or injury. B - Peaked T waves, which can result
from sympathetic nervous system activation and electrolyte disturbances. C - QT prolongation, which is
often seen due to autonomic dysfunction and catecholamine release.
 A - ST depression and T-wave inversion, which are indicative of myocardial ischemia or injury.
 B - Peaked T waves, which can result from sympathetic nervous system activation and electrolyte
 C - QT prolongation, which is often seen due to autonomic dysfunction and catecholamine release.
 These are the correct ECG changes seen in Subarachnoid hemorrhage.
Correct Option B – Grade 2:
Correct Option A – Steroids:
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Aneurysmal clip: Surgical clipping of the ruptured aneurysm is a
crucial intervention in the management of SAH. Aneurysmal clipping involves placing a metallic clip acr
oss the neck of the aneurysm to prevent further bleeding and reduce the risk of rebleeding.
797

Meningitis
1. A 55-year-old patient presents to the emergency department with complaints of headache, fever, and
altered mental status. Lumbar puncture is performed, and cerebrospinal fluid (CSF) analysis is
conducted to evaluate for possible meningitis. Which of the following CSF findings is typically observed
in tuberculous meningitis?
(or)
Which of the following CSF findings is typically observed in tuberculous meningitis?
A. Low sugar
B. Eosinophils are predominant
C. Clear CSF
D. The opening pressure is normal
2. A 25-year-old patient presents to the emergency department with symptoms suggestive of
meningitis, including headache, photophobia, and neck stiffness. A lumbar puncture is performed, and
cerebrospinal fluid (CSF) analysis is consistent with viral meningitis. Which of the following CSF
findings is NOT typically observed in viral meningitis?
(or)
Which of the following is not a CSF finding seen in Viral meningitis?
A. Glucose is normal
B. Neutrophils < 100x10 6/L
C. Protein in the range of < 0.4 g/L
D. predominance of lymphocytes
3. A 25-year-old patient presents to the emergency department with fever, severe headache, and neck
stiffness. A lumbar puncture is performed to collect cerebrospinal fluid (CSF) for analysis. Which of the
following cerebrospinal fluid (CSF) findings is typically observed in bacterial meningitis?
(or)
Which of the following is the CSF finding seen in Bacterial meningitis?
A. Turbid CSF
B. The opening pressure is normal
C. Glucose is normal
D. Lymphocytic predominance
4. A 2-month-old infant is brought to the pediatric emergency department with fever, irritability, and poor
feeding. The infant's mother reports that the baby has been lethargic and difficult to console.
Suspecting acute bacterial meningitis, the physician plans to initiate antibiotic therapy promptly.Which
antibiotic regimen is the most appropriate initial treatment for this baby?
(or)
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Which antibiotic regimen is the most appropriate initial treatment for acute bacterial meningitis in a child
under 3 months of age?
A. Ceftriaxone and vancomycin
B. Ampicillin and cefotaxime
C. Ampicillin and ceftriaxone
D. Ampicillin, cefixime, and vancomycin
5. A 45-year-old patient presents to the emergency department with altered mental status, fever, and
focal neurological deficits. The physician suspects viral encephalitis and performs a lumbar puncture to
collect cerebrospinal fluid (CSF) for analysis. Which of the following findings would suggest a diagnosis
of traumatic lumbar puncture?
(or)
Which of the following findings on the cerebrospinal fluid (CSF) analysis would suggest a diagnosis of
traumatic lumbar puncture rather than subarachnoid hemorrhage?
A. Uniform presence of red blood cells (RBCs) in all three sequential CSF tubes
B. Gradual disappearance of RBCs in the second or third CSF tube
C. Bloody appearance of the CSF
D. Detection of periodic lateralized epileptiform discharge on EEG
6. A 60-year-old immunocompromised patient presents to the clinic with a persistent headache, fever,
and altered mental status. A lumbar puncture is performed, and cerebrospinal fluid (CSF) analysis
reveals evidence of fungal meningitis. What is the choice of investigation for confirming the diagnosis of
fungal meningitis caused by Cryptococcus species?
(or)
What is the investigation of choice for confirming the diagnosis of fungal meningitis caused by
Cryptococcus species?
A. CSF culture for Cryptococcus
B. CSF Gram stain
C. CSF ELISA for CrAg
D. CSF India ink stain
7. Which of the following is not a contraindication of Lumbar puncture?
A. Bleeding diathesis
B. Raised Intracranial pressure
C. Kyphoscoliosis
D. Chickenpox
8. A 30-year-old patient undergoes a lumbar puncture (LP) for diagnostic evaluation. Post-procedure,
the patient experiences a persistent headache. She tried painkillers and has been lying down as
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advised, but there is no improvement. What should be done next?
A. Bed rest for 8-12 hours
B. Painkillers
C. Intravenous caffeine
D. Codeine
9. A 70-year-old patient presents with a history of progressive gait disturbances, urinary incontinence,
and cognitive decline. The clinical presentation is suggestive of normal pressure hydrocephalus (NPH).
What is the therapeutic procedure used to assess and potentially alleviate symptoms in patients with
normal pressure hydrocephalus (NPH)?
A. Lumbar puncture with removal of 20 ml of cerebrospinal fluid (CSF)
B. Lumbar puncture with removal of 30 ml of cerebrospinal fluid (CSF)
C. Lumbar puncture with removal of 40 ml of cerebrospinal fluid (CSF)
D. Lumbar puncture with removal of 50 ml of cerebrospinal fluid (CSF)
10. A 40-year-old male came to the clinic with complaints of fever, headache, and vomiting for 3 days.
On examination, the kerning sign was positive, with bilaterally dilated pupils, and photophobia was
present. The doctor advised a Lumbar puncture for CSF analysis and was prescribed Antibiotics and
dexamethasone. The report which came after a few days showed > 100-1000 lymphocytes per cubic
mm and straw-coloured CSF. Which of the following is the treatment to be started?
(or)
Which of the following is the treatment to be started in the condition characterized by fever, headache,
vomiting, positive kerning sign, photophobia, and > 100-1000 lymphocytes per cubic mm and
straw-colored CSFon CSF analysis?
A. ATT at least for 6 months and continue steroids for 6-8 weeks
B. Ampicillin + cefotaxime
C. Ampicillin + Cefixime + Vancomycin
D. Ampicillin + Ceftazidime + Meropenem
11. A 68-year-old male came to the clinic with complaints of fever, headache, and vomiting for 3 days.
present. The doctor advised a lumbar puncture and the report showed turbid CSF,>1000 PMN, low
sugar, and spiked protein levels. Which of the following is the empiric antibiotic regimen to be started?
(or)
Which of the following is the empiric antibiotic regimen to be started in the condition characterized by
fever, headache, vomiting, positive kerning sign, photophobia and turbid CSF,>1000 PMN, low sugar,
and spiked protein levels on CSF analysis?
A. Ampicillin + Cefixime + Vancomycin
C. Ceftriaxone/cefixime and Vancomycin
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12. A 45-year-old male came to the clinic with complaints of fever, headache, and vomiting for 5 days.
On examination, kerning and Brudzinski signs were positive. The doctor advised a lumbar puncture
which showed turbid CSF and >1000 PMN. Which of the following is the empiric antibiotic regimen to
be started?
(or)
Which of the following is the empiric antibiotic regimen to be started in a case of Acute bacterial
meningitis?
A. Ceftriaxone/cefixime and Vancomycin
13. A 55-year-old immunocompromised patient presents to the clinic with symptoms suggestive of
meningitis, including headache, fever, and altered mental status. Lumbar puncture is performed, and
Cryptococcus is identified in the cerebrospinal fluid (CSF). What is the recommended treatment
regimen for this patient?
(or)
What is the recommended treatment regimen for fungal meningitis caused by Cryptococcus species?
A. Liposomal Amphotericin B (LAMB) and Fluconazole for 2 weeks
B. 5-Fluorocytosine and Fluconazole for 2 weeks
C. Liposomal Amphotericin B (LAMB) and 5-Fluorocytosine for 2 weeks, followed by Fluconazole for 6
weeks
D. Itraconazole and Voriconazole for 6 weeks
14. A 7-year-old child is brought to the pediatric clinic by their parents, who report that the child has
been experiencing a long-standing illness for several weeks, characterized by irritability, head banging,
drowsiness, and episodes of focal seizures. On physical examination, nuchal rigidity along with signs of
altered sensorium. A non-contrast CT scan of the head reveals basal exudates. Which of the following
treatments will be given to this patient?
(or)
Which of the following will be given as a treatment for Tubercular meningitis?
A. PCM
B. Lorazepam
C. Ampicillin + cefotaxime
D. Steroids
15. A 42-year-old patient with a confirmed diagnosis of multiple sclerosis and undergoing treatment
with Natalizumab, a monoclonal antibody, presents with worsening neurological symptoms. These
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symptoms include seizures, ataxia, visual impairment, and hemiparesis. MRI imaging reveals
subcortical demyelination. What is the probable diagnosis?
A. Menningococcal meningitis
B. Acute Viral Encephalitis
C. Progressive Multifocal Leukoencephalopathy (PML)
D. Guillain-Barré Syndrome
16. What is the most probable cause for a 22-year-old man who has a high-grade fever, a purpuric
rash, and a CSF sample showing gram-negative diplococci?
A. Neisseria meningitidis
B. Pseudomonas aeruginosa
C. Streptococcus pneumoniae
D. E.coli
17. A 25-year-old female presents to the emergency department with a severe headache, photophobia,
neck stiffness, and a high-grade fever. She also mentions experiencing nausea and vomiting. On
examination, the following sign is elicited. What is the most likely diagnosis?
A. Intracranial Space-Occupying Lesion ( ICSOL )
B. Bacterial Meningitis
D. Brain abscess
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18. Which of the following statements is not true about the causative organisms of bacterial meningitis?
A. In children, Pneumococcus is the leading cause for meningitis followed by Neisseria meningitidis
B. Pneumococcus is the leading cause of meningitis in adults
C. Globally, the most common cause is Klebsiella
D. Listeria monocytogenes cause meningitis in neonates
19. A 45-year-old male presents to the emergency department with a sudden onset of fever and altered
mental status. On examination, the patient is febrile with a temperature of 104°F (40°C). Neurological
examination reveals temporal lobe involvement with memory loss. An EEG shows periodic lateralized
epileptiform discharges. A lumbar puncture is performed, and the cerebrospinal fluid (CSF) appears
bloody. Which of the following diagnostic tests should be prioritized for this patient?
(or)
What diagnostic test should be prioritized for a 45-year-old male with fever, altered mental status,
temporal lobe involvement, memory loss, bloody CSF, and a history of herpes simplex virus (HSV)
infection?
A. MRI of the brain
B. PCR for HSV-1 on CSF
C. CT scan of the head
D. EEG with sleep deprivation
20. A 48-year-old male presents to the emergency department with a two-week history of progressively
worsening headache, fever, and altered mental status. He has a past medical history of HIV infection
and is currently not on antiretroviral therapy. On examination, the patient appears disoriented and
lethargic. He is febrile with a temperature of 102.5°F (39.2°C). Neurological examination reveals nuchal
rigidity. Laboratory tests show a CD4 cell count of 90 cells/µL. Cerebrospinal fluid (CSF) analysis
reveals pleocytosis, an elevated protein concentration, and a low glucose concentration. CSF Gram
stain shows the presence of encapsulated yeast-like organisms. What is the most appropriate course of
action for this patient?
(or)
What is the most appropriate treatment for cryptococcal meningitis in an AIDS patient?
A. Initiate antiretroviral therapy (ART)
B. Administer ceftriaxone and vancomycin
C. Start liposomal amphotericin-B (LAMB)
D. Order a brain MRI
21. A 25-year-old previously healthy female presents to the emergency department with a sudden
onset of severe headache, photophobia, high fever, and vomiting. On physical examination, she
exhibits neck stiffness, positive Brudzinski's sign, and Kernig's sign. Given the suspicion of acute
meningitis lumbar puncture is ordered . What is the correct sequence in which layers are pierced from
outwards to inside during a spinal procedure?
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(or)
In what order are the layers pierced from the outermost to the innermost layers during a spinal
procedure such as lumbar puncture?
A. Skin, Subcutaneous Tissue, Supraspinous ligament, Interspinous ligament, Ligamentum flavum,
Duramater and arachnoid mater
B. Skin, Subcutaneous Tissue, Interspinous ligament, Supraspinous ligament, Ligamentum flavum,
C. Skin, Subcutaneous Tissue, Supraspinous ligament, Ligamentum flavum, Interspinous ligament,
D. Skin, Subcutaneous Tissue, Ligamentum flavum, Interspinous ligament, Supraspinous ligament,
22. Which of the following statements is true about lumbar puncture ?
A. Site of doing lumbar puncture is L4-L5
B. For diagnostic purposes, 30 ml of CSF is removed
C. Drug of choice (DOC) in case of LP induced headache is caffeine
D. Quincke needle is an atraumatic needle
23. A 28-year-old previously healthy woman presents to the emergency department with a three-day
history of progressively worsening headache, fever, and neck stiffness. She denies any recent travel
but reports exposure to her friend who had a respiratory illness a week ago. On physical examination,
she has a fever (101.3°F or 38.5°C), neck stiffness, photophobia, and a positive Brudzinski's sign .A
lumbar puncture is performed, and cerebrospinal fluid (CSF) is collected. The CSF analysis results are
as follows: White Blood Cell Count (WBC): 350 cells/mm³ Differential: Predominantly lymphocytes Red
Blood Cell Count (RBC): 20 cells/mm³ Glucose Level: Normal Protein Level: Mildly elevated Based on
the provided clinical history and CSF findings, what is the most likely diagnosis for this patient's
(or)
What is the most likely diagnosis for a 28-year-old woman with worsening headache, fever, neck
stiffness, photophobia, and CSF findings of lymphocytosis mildly elevated protein, and normal glucose
levels, following exposure to a friend with a respiratory illness?
A. Bacterial Meningitis
B. Fungal Meningitis
C. Viral Meningitis
D. Tuberculous Meningitis
24. A 16-year-old adolescent presents with a prolonged history of illness characterized by irritability,
head banging, drowsiness, and episodes of focal seizures. On examination, nuchal rigidity is noted,
along with positive Kernig sign. A neuroimaging study reveals basal exudates. A lumbar puncture is
performed, and the cerebrospinal fluid (CSF) analysis shows elevated white blood cell count with
lymphocyte predominance, low glucose levels, and mildly elevated protein levels. Which of the
following is not associated with this disease ?
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(or)
Which of the following is not associated with tuberculous meningitis?
A. Basal exudates on NCCT
B. Crackpot sign
C. Sutural diastasis
D. Obstructive hydrocephalus
25. A 35-year-old HIV-positive male with a CD4 count of 80 cells/µL presents with a four-week history
of progressive neurological symptoms. He complains of severe headaches, altered mental status, and
difficulty with coordination. Physical examination reveals right-sided weakness, cranial nerve
abnormalities, and impaired fine motor skills. A brain MRI shows multiple ring-enhancing lesions with
surrounding edema in the basal ganglia and frontal lobes. Given the clinical presentation, further tests
are conducted. Based on the clinical history, MRI findings, and the patient's immunocompromised
status, which of the following is the most likely diagnosis for this patient's neurological condition?
A. Cerebral abscess due to Staphylococcus aureus
B. Neurocysticercosis
C. Primary central nervous system lymphoma (PCNSL)
D. Cerebral Toxoplasmosis
26. A 20-year-old male is admitted to a government hospital due to fever, vomiting, lethargy, altered
sensorium, and headache. He is a college student and lives in a dormitory. On the next day of
admission, he developed petechial hemorrhages on his body. Gram staining of the cerebrospinal fluid
reveals gram-negative cocci in pairs. The doctor on duty taking care of the patient is advised to get
prophylaxis against this infection. Which of the following is the drug of choice for prophylaxis of
meningitis in the healthcare worker caused by these organisms?
(or)
What is the drug of choice for prophylaxis of meningococcal meningitis in healthcare workers?
A. Ceftriaxone
B. Penicillin G
C. Cotrimazole
D. Doxycycline
27. A 30-year-old truck driver, who is known to be HIV/AIDS positive, presents with a history of not
feeling well and having a headache for several days. Initially, he took over-the-counter paracetamol
(PCM) for fever, but his headache worsened, and he developed severe photophobia. On physical
examination, nuchal rigidity, Brudzinski sign, and Kernig sign are present. Deep tendon reflexes (DTR)
are brisk. The patient's medical history includes a CD4 count of less than 100. Which of the following
findings is not present in this patient?
(or)
Which of the following is cryptococcal meningitis?
A.
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B.
C.
D.
28. A 30-year-old male was brought to the emergency department with an impaired ability to memorize
things and sudden jerky movements for one day. The bystander gave a history of regular intake of red
meat for the past 2 weeks. On examination, myoclonus was present. The doctor advised CSF analysis
and the report showed increased tau protein in CSF. Which of the following is the most likely cause of
disease?
(or)
Which of the following is the most likely cause of Creutzfeldt-Jacob disease?
A. Prions
B. Mycobacterium tuberculosis
C. HSV
D. Cryptococcus
29. A 30-year-old male,AIDS presented to the emergency department with seizures for one day. The
doctor advised an MRI brain on evaluation and examination, and the report showed lesions in the basal
ganglia. The MRI picture is given below.CSF IgM/IgG showed antibodies for Toxoplasma. Which of the
following is the treatment of choice in this condition?
(or)
Which of the following is the treatment of choice for Cerebral toxoplasmosis?
A. Sulfadiazine + Pyrimethamine
B. Azithromycin + Pyrimethamine
C. Streptomycin + Pyrimethamine
D. Penicillin + Sulfadiazine
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Question 25 4
Question 27 3
Question 28 1
Correct option a - Low sugar
 Low sugar levels in CSF: Hypoglycemia in the CSF is often observed in tuberculous meningitis due to
the increased utilization of glucose by the infecting Mycobacterium tuberculosis bacteria.
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 CSF lymphocytosis: Tuberculous meningitis typically presents with increased lymphocytes in the CSF,
reflecting the inflammatory response to the infection.
 Elevated opening pressure: The opening pressure during lumbar puncture is often elevated in cases
of tuberculous meningitis, indicating increased intracranial pressure due to inflammation and swelling
within the meninges.
 These are incorrect due to the above given reason.
Correct Option C - Protein in the range of <0.4 g/L:
 In viral meningitis, the protein concentration in the cerebrospinal fluid (CSF) typically ranges from 0.4
to 1 g/L.
 Therefore, a protein level exceeding 1 g/L is not a typical finding in viral meningitis.
 The other options, including normal glucose levels, a predominance of lymphocytes, and a neutrophil
count of less than 100x10^6/L, are commonly observed in viral meningitis.
 
Options A, B & D:
 These are the findings seen in Viral meningitis.
Correct Option A - Turbid CSF:
 Turbid or cloudy CSF is a characteristic finding in bacterial meningitis due to the presence of
increased white blood cells (WBCs) and bacteria in the CSF.
 This turbidity results from the inflammatory response and the presence of pus in the CSF.
 
Option B - Normal opening pressure: In bacterial meningitis, the opening pressure of CSF is typically el
evated due to increased intracranial pressure resulting from inflammation and edema.
Option C - Normal glucose level: Bacterial meningitis is associated with low CSF glucose levels due to 
bacterial consumption of glucose and impaired glucose transport across the blood-brain barrier.
Option D - Lymphocytic predominance: Bacterial meningitis is characterized by a predominance of neu
trophils (polymorphonuclear leukocytes) in the CSF, whereas lymphocytic predominance is more com
monly observed in viral meningitis.
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Correct Option B - Ampicillin and cefotaxime:
 In infants under 3 months of age, acute bacterial meningitis is commonly caused by pathogens such
as Listeria monocytogenes.
 Therefore, the initial antibiotic regimen should cover this organism.
 The recommended antibiotics for this age group are ampicillin plus a third-generation cephalosporin
such as cefotaxime.
 The combination of ampicillin and cefotaxime provides broad coverage against common pathogens,
including Listeria monocytogenes and Group B Streptococcus (GBS).
 
Option A - Ceftriaxone and vancomycin: While ceftriaxone is a component of antibiotic therapy for acut
e bacterial meningitis, vancomycin is not typically used in this age group unless there is a
specific indication, such as suspected methicillin-resistant Staphylococcus aureus (MRSA) infection.
Option C - Ampicillin and ceftriaxone: While ampicillin is appropriate for coverage of Listeria monocytog
enes, ceftriaxone is not used in infants due to the risk of jaundice.
Option D - Ampicillin, cefixime, and vancomycin: This regimen includes unnecessary antibiotics and do
es not provide optimal coverage for the likely pathogens in infants under 3 months of age.
Correct Option B - Gradual disappearance of RBCs in the second or third CSF tube:
 In a traumatic lumbar puncture, red blood cells (RBCs) in the CSF are present due to blood
contamination during the procedure.
 However, unlike subarachnoid hemorrhage (SAH), where the bleeding is uniform throughout the CSF
collection, in traumatic lumbar puncture, the number of RBCs typically decreases in subsequent CSF
tubes as the contamination is diluted.
 Therefore, the gradual disappearance of RBCs in the second or third CSF tube is more indicative of a
traumatic lumbar puncture.
 
Option A - Uniform presence of red blood cells (RBCs) in all three sequential CSF tubes: This finding is
 more consistent with subarachnoid hemorrhage (SAH) rather than traumatic lumbar puncture.
Option C - Bloody appearance of the CSF: While traumatic lumbar puncture can lead to a bloody appe
arance of the CSF, this finding alone does not differentiate between traumatic LP and SAH.
Option D - Detection of periodic lateralized epileptiform discharge on EEG: This finding is suggestive of
 underlying brain dysfunction, such as epilepsy, but it is not specific to traumatic lumbar puncture or SA
H.
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Correct Option C - Intravenous caffeine (preferred drugs): Tea and coffee
 Post-lumbar puncture headache is commonly managed with conservative measures such as bed rest
and painkillers.
 However, intravenous caffeine administration is often recommended if the headache persists despite
these measures.
 Caffeine constricts cerebral blood vessels and reduces intracranial pressure, thereby alleviating the
headache associated with cerebrospinal fluid leakage.
 
Option A - Bed rest for 8-12 hours: While bed rest is initially advised after an LP, it may not alleviate th
e headache if it persists beyond the usual recovery period.
Option B - Painkillers: Painkillers such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetamino
phen are commonly used for mild to moderate post-LP headaches. However, alternative treatments lik
e caffeine may be necessary if the headache persists despite their use.
Option D - Codeine: Codeine is an opioid analgesic that can be used to relieve pain, but it is not typicall
y the first-line treatment for post-LP headaches due to its potential side effects, such as constipation, w
hich may exacerbate the headache.
Correct Option B - Lumbar puncture with removal of 30 ml of cerebrospinal fluid (CSF):
 For therapeutic relief in normal pressure hydrocephalus (NPH), a lumbar puncture is performed with
the removal of approximately 30 ml of cerebrospinal fluid (CSF).
 This procedure, known as the Fisher Test, is used to assess the patient's response to CSF drainage.
 Improvement in gait following CSF removal is suggestive of NPH and may indicate a positive
response to further management, such as ventriculoperitoneal shunting.
 
Option A - Lumbar puncture with removal of 20 ml of cerebrospinal fluid (CSF): The standard amount o
f CSF removed for diagnostic purposes in NPH is approximately 20 ml
Options C and D: Lumbar puncture with removal of 40 ml of cerebrospinal fluid (CSF): Incorrect. Remo
ving 40 ml of CSF exceeds the typical amount removed for therapeutic relief in NPH and may pose risk
s of over-drainage.
Correct Option A - ATT at least for 6 months and continue steroids for 6-8 weeks:
 The condition described in the question is Tuberculous meningitis
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Page 15
 It is characterized by fever, headache, vomiting, positive kerning signs, bilaterally dilated pupils, and
photophobia
 The CSF analysis showed > 100-1000 lymphocytes per cubic mm and straw-colored CSF suggestive
of Acute bacterial meningitis
 The condition is treated with ATT at least for 6 months and steroids for 6-8 weeks
 
Options B - Ampicillin + cefotaxime: In a child < 3 months of age with listeria monocytogenes infection 
of Acute bacterial meningitis, the antibiotics given are Ampicillin + cefotaxime.
Option C - Ceftriaxone/cefixime and Vancomycin: Children> 3 months and adults up to 55 years of age
 with Acute bacterial meningitis, Ceftriaxone/cefixime, and Vancomycin are given for treatment.
Option D - Ampicillin + Ceftazidime +
Meropenem: For hospital-based Pseudomonas infection( Acute bacterial meningits), Ampicillin +
Ceftazidime +Meropenem are given.
Correct Option A - Ampicillin + Cefixime + Vancomycin:
 The condition described in the question is Acute bacterial meningitis
 The CSF analysis showed turbid CSF and >1000 PMN and low sugar, and spiked protein levels
suggestive of Acute bacterial meningitis
 The condition is treated with Ampicillin + Cefixime + Vancomycin
 
Options B - Ampicillin + cefotaxime: In a child <
3 months of age with listeria monocytogenes infection, the antibiotics given are Ampicillin + cefotaxime
Option C - Ceftriaxone/cefixime and Vancomycin: Child > 3 months and adults up to 55 years of age, C
eftriaxone/cefixime and Vancomycin are given for treatment
Meropenem: For hospital-based Pseudomonas infection, Ampicillin +
Ceftazidime +Meropenem are given
Correct Option A - Ceftriaxone/cefixime and Vancomycin:
 It is characterized by fever, headache, vomiting, positive kerning, and Brudzinski signs
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 The CSF analysis showed turbid CSF and >1000 PMN suggestive of Acute bacterial meningitis
 The condition is treated with Ceftriaxone/cefixime and Vancomycin
 
Option C - Ampicillin + Cefixime + Vancomycin: Patients >
55 years old patient with bacterial meningitis, Ampicillin + Cefixime + Vancomycin are given
Correct Option C - Liposomal Amphotericin B (LAMB) and 5-Fluorocytosine for 2
weeks, followed by Fluconazole for 6 weeks:
 For the treatment of fungal meningitis caused by Cryptococcus species, the recommended initial
regimen consists of induction therapy with Liposomal Amphotericin B (LAMB) in combination with
5-Fluorocytosine for 2 weeks to achieve rapid fungal clearance.
 Subsequently, maintenance therapy with Fluconazole is given for an additional 6 weeks to prevent
relapse and consolidate treatment.
 
Option A - Liposomal Amphotericin B (LAMB) and Fluconazole for 2 weeks:
While Liposomal Amphotericin B is part of the induction therapy, Fluconazole alone is not sufficient for 
the treatment of Cryptococcal meningitis.
Option B - 5-Fluorocytosine and Fluconazole for 2 weeks: Fluconazole alone is not recommended as t
he initial treatment for Cryptococcal meningitis; combination therapy with Amphotericin B
is required for induction therapy.
Option D - Itraconazole and Voriconazole for 6 weeks: Itraconazole and Voriconazole are not the prefe
rred agents for the treatment of Cryptococcal meningitis.
Correct Option D - Steroids:
 In the management of tubercular meningitis, steroids such as dexamethasone are often administered
as adjunctive therapy along with antitubercular medications.
 Steroids help to reduce inflammation and minimize complications associated with the infection, such
as cerebral edema and intracranial pressure.
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 They are particularly beneficial in cases where there is evidence of basal exudates on imaging
studies, as seen in this patient's non-contrast CT scan.
 Therefore, steroids would be an appropriate treatment option for this child with tubercular meningitis.
 
Option A - PCM (Paracetamol): Paracetamol may be used to manage fever and alleviate discomfort as
sociated with tubercular meningitis, but it does not address the underlying infection or inflammation.
Option B - Lorazepam: Lorazepam is a benzodiazepine medication used to control seizures and anxiet
y. While it may be administered to manage seizures in this patient, it does not directly target the underl
ying tubercular meningitis.
Option C - Ampicillin + cefotaxime: This combination of antibiotics is typically used to treat bacterial me
ningitis caused by organisms such as Streptococcus pneumoniae or Neisseria meningitidis.
Correct Option C- Progressive Multifocal Leukoencephalopathy (PML):
 PML is a rare but severe viral infection of the brain caused by the JC virus (JCV), a type of human
polyomavirus.
 Patients with multiple sclerosis (MS) who are treated with immunomodulatory drugs, particularly
Natalizumab, are at increased risk of developing PML. Natalizumab inhibits the migration of
lymphocytes into the CNS, which can lead to impaired immune surveillance against opportunistic
infections like JCV.
 PML typically presents with progressive neurological symptoms, including seizures, ataxia, visual
impairment, and hemiparesis, which align with the symptoms described in the patient.
 MRI findings in PML often show multifocal subcortical demyelination, which is consistent with the
imaging findings in this case.
 The diagnosis is confirmed by detecting JCV DNA in the cerebrospinal fluid (CSF) via polymerase
chain reaction (PCR) or brain biopsy.
 Treatment primarily involves discontinuing Natalizumab and immune reconstitution, if possible. There
is no specific antiviral therapy for PML, but strategies to enhance the immune response against JCV,
such as plasma exchange or infusion of JCV-specific T cells, may be considered.
Option A- Meningococcal meningitis:
 Meningococcal meningitis typically presents with symptoms such as fever, severe headache, neck
stiffness, photophobia, and a petechial rash. Seizures and hemiparesis are less common
presentations.
 MRI findings in meningitis may show leptomeningeal enhancement, but subcortical demyelination is
not a characteristic feature.
Option B- Acute Viral Encephalitis:
 Acute viral encephalitis presents with symptoms such as fever, altered mental status, headache,
seizures, and focal neurological deficits.
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Option C- Migraine:
 Migraines can indeed cause severe headaches and may be associated with nausea and vomiting.
 However, the presence of neck stiffness (Kernig’s sign) is not a typical feature of migraines.
Option D- Brain Abscess:
 Brain abscesses can also cause severe headaches and may lead to neurological symptoms.
 However, the combination of photophobia, neck stiffness, and Kernig sign is more suggestive of
meningitis than a brain abscess.
Correct Option C- Globally, the most common cause is Klebsiella:
 This statement is not true. Globally, Klebsiella is not the most common cause of bacterial meningitis.
While Klebsiella can cause meningitis, it is not the leading cause worldwide. Group B streptococcus is
the most common cause worldwide.
Option A- In children, Pneumococcus is the leading cause of meningitis followed by Neisseria meningiti
dis: which is true. Pneumococcus (Streptococcus pneumoniae) is a
common cause of bacterial meningitis in children.
Option B-Pneumococcus is the leading cause of meningitis in adults: Pneumococcus is indeed the lead
ing cause of meningitis in adults. Streptococcus pneumoniae is a
common cause of bacterial meningitis in both children and adults.
Option D- Listeria monocytogenes causes Meningitis in neonates: Listeria monocytogenes can cause 
meningitis in neonates. Listeria monocytogenes is a known cause of neonatal meningitis, especially in i
nfants born to mothers who have consumed unpasteurized dairy products and cold deli meats during p
regnancy.
Correct Option B- PCR for HSV-1:
 This patient's presentation is highly suggestive of HSV-1 encephalitis, characterized by fever, altered
mental status, temporal lobe involvement, memory loss, and EEG findings of periodic lateralized
epileptiform discharges (PSWC). The most suitable test for the diagnosis is PCR for HSV-1 on the CSF
sample.
Option A- MRI of the brain: is valuable for detecting specific brain abnormalities associated with encep
halitis, but PCR for HSV-1 should be performed first to confirm the diagnosis.
Option C- CT scan of the head: may reveal structural abnormalities but is less sensitive than MRI for d
etecting encephalitis-related changes.
Option D- EEG with sleep deprivation: is not the primary diagnostic test for HSV-1 encephalitis. EEG fi
ndings may support the diagnosis, but PCR for HSV-1 is essential for diagnosis.
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Correct Option C- Start liposomal amphotericin-B (LAMB):
 This is the most appropriate course of action (D.O.C) for this patient. Cryptococcal meningitis, caused
by Cryptococcus neoformans or Cryptococcus gattii, is a serious fungal infection that requires prompt
treatment. Liposomal amphotericin-B (LAMB) and flucytosine are the recommended antifungal agents
for initial therapy. This treatment should be initiated as soon as possible to improve the patient's
chances of recovery.
Option A-Initiate antiretroviral therapy (ART): Suggests initiating antiretroviral therapy (ART) as the initi
al course of action for this patient presenting with symptoms of fungal meningitis. However, this approa
ch is not appropriate as we give antifungal as initial treatment in a patient of cryptococcal meningitis.
Option B-Administer ceftriaxone and vancomycin: is wrong because Ceftriaxone and vancomycin are a
ntibiotics used to treat bacterial infections, not fungal infections like cryptococcal meningitis. Administer
ing these antibiotics would not effectively treat the underlying cause of the patient's symptoms.
Option D- Order a brain MRI: is wrong because while a brain MRI can provide valuable information abo
ut the patient's neurological condition, it should not be the initial course of action in a case of suspected
 cryptococcal meningitis. Treatment for the underlying fungal infection should take precedence, as it ca
n be life-threatening if not addressed promptly.
Correct Option A- Skin, Subcutaneous Tissue, Supraspinous ligament, Interspinous ligament, Ligamen
tum flavum, Duramater and arachnoid mater:
 Skin, Subcutaneous Tissue, Supraspinous ligament, Interspinous ligament, Ligamentum flavum,
Duramater and arachnoid mater.
 This option is correct. It correctly identifies the sequence in which layers are pierced during a spinal
procedure, starting from the skin, moving through the Subcutaneous Tissue, Supraspinous ligament,
Interspinous ligament, Ligamentum flavum, and finally the Duramater and arachnoid mater reaching the
subarachnoid space filled with CSF.
This option is correct. It correctly identifies the sequence in which layers are pierced during a spinal pro
cedure, starting from the skin, moving through the Subcutaneous Tissue, Supraspinous ligament, Inter
spinous ligament, Ligamentum flavum, and finally the Duramater and arachnoid mater reaching the su
barachnoid space filled with CSF.
Option B- Skin, Subcutaneous Tissue, Interspinous ligament, Supraspinous ligament, Ligamentum flav
um, Duramater and subarachnoid space:
 This option is incorrect because it places the Interspinous ligament before the Supraspinous ligament
in the sequence. The correct order is to pierce the Supraspinous ligament first before reaching the
Interspinous ligament.
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Option C- Skin, Subcutaneous Tissue, Supraspinous ligament, Ligamentum flavum, Interspinous ligam
ent, Duramater and subarachnoid space:
 This option is incorrect because it places the Ligamentum flavum before the Interspinous ligament in
the sequence. The correct order is to pierce the Interspinous ligament before reaching the Ligamentum
flavum.
Option D- Skin, Subcutaneous Tissue, Ligamentum flavum, Interspinous ligament, Supraspinous ligam
flavum.
Correct Option C - D.O.C in case of LP induced headache is caffeine:
 This statement is true. In case a lumbar puncture (LP) induces a headache, caffeine is often
considered the drug of choice for relief. It helps by constricting blood vessels in the brain and can be
administered intravenously.
Option A- Site of doing lumbar puncture is L4-L5:
 This statement is incorrect. The typical site for performing a lumbar puncture is between the L3 and L4
. This is often referred to as the L3-L4
Option B- For diagnostic purpose, 30 ml of CSF is removed:
 This statement is incorrect. For diagnostic purposes, typically, a smaller amount of cerebrospinal fluid
(CSF) is removed, which is around 20 ml. The amount may vary depending on the specific clinical
needs, but 30 ml is generally more than what is typically taken for diagnostic purposes.
Option D- Quincke needle is an atraumatic needle:
 This statement is incorrect. The Quincke needle is not an atraumatic needle; it is considered a
traumatic lumbar puncture needle because of its sharp bevel and pointed edge. An atraumatic lumbar
puncture needle, on the other hand, is designed to minimize trauma to the surrounding tissues and
reduce the risk of post-LP headaches.
Correct Option C- Viral Meningitis:
 This option is correct based on the provided information. The CSF findings in this case, including an
elevated white blood cell count with a predominance of lymphocytes, normal glucose levels, and mildly
elevated protein levels, are consistent with viral meningitis.
 Additionally, the patient's exposure to a friend with a recent respiratory illness suggests a viral
etiology. The clinical presentation, including fever, neck stiffness, photophobia, and a positive
Brudzinski's sign is suggestive of viral meningitis.
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Option A- Bacterial Meningitis:
 This option is incorrect because the CSF findings in this case do not support the diagnosis of bacterial
meningitis. In bacterial meningitis, CSF typically shows a marked elevation in white blood cell count ,
primarily neutrophils, along with elevated protein levels and decreased glucose levels. However, in this
case, the CSF reveals a predominantly lymphocytic pleocytosis, normal glucose levels, and only mildly
elevated protein levels, which is not characteristic of bacterial meningitis.
Option B- Fungal Meningitis:
 This option is incorrect because the CSF findings and the clinical presentation are not suggestive of
fungal meningitis. Fungal meningitis often presents with a chronic and indolent course, and CSF
analysis may show a lymphocytic pleocytosis along with elevated protein levels and low glucose levels.
However, the rapid onset of symptoms in this case is not typical of fungal meningitis.
Option D- Tuberculous Meningitis:
 This option is incorrect because tuberculous meningitis typically presents with a chronic and subacute
course, and CSF findings often include an elevated white blood cell count, predominantly lymphocytes,
elevated protein levels, and decreased glucose levels. The patient's rapid onset of symptoms and
normal glucose levels in the CSF make tuberculous meningitis less likely in this case.
Correct Option D- Obstructive hydrocephalus :
 This option is not associated with Tuberculous Meningitis. Tuberculous Meningitis primarily affects the
central nervous system and does not typically cause obstructive hydrocephalus. It primarily affects the
meninges and brain. In fact, it causes non obstructive hydrocephalus.
Option A- Basal exudates on NCCT: This option is associated with Tuberculous Meningitis. Basal exud
ates on neuroimaging such as Non-Contrast Computed Tomography or NCCT are a characteristic findi
ng in TBM and indicate the presence of inflammatory changes at the base of the brain.
Option B- Crackpot sign: This option is associated with Tuberculous Meningitis. The "Crackpot sign" is 
a clinical sign where there is a distinctive sound, similar to the sound of a wooden spoon tapping on a c
racked pot, when percussing the skull in patients with TBM. It indicates increased intracranial pressure 
due to the presence of exudates.
Option C- Sutural diastasis: This option is associated with Tuberculous Meningitis. Sutural diastasis ref
ers to the separation or widening of the cranial sutures seen on imaging studies, and it can occur in TB
M due to increased intracranial pressure.
Correct Option D- Cerebral Toxoplasmosis: This option is correct based on the clinical presentation, M
RI findings, and the patient's immunocompromised status. Cerebral toxoplasmosis is an opportunistic i
nfection commonly seen in individuals with HIV/AIDS, especially those with low CD4 counts. It often pr
esents with multiple ring-enhancing lesions in the brain, particularly basal ganglia, which can cause a v
ariety of neurological symptoms, including altered mental status, headaches, and focal neurological def
icits, as described in the case scenario.
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Page 24
 Ceftriaxone is also given to healthcare workers.
Option B - Penicillin G:
 Penicillin G is used in treating meningococcal meningitis. It is not used in prophylaxis of Neisseria
meningitidis meningitis.
Option C - Cotrimazole:
 Cotrimazole is an antifungal agent used to treat topical fungal infections.
Option D - Doxycycline:
 Doxycycline is a tetracycline used to treat infections caused by Borrelia burgdorferi, Mycoplasma
pneumoniae, Rickettsia, and Chlamydia. It is not used for prophylaxis of meningococcal meningitis.
Correct Option C- Diplococci Showing Pneumococcus: This finding is not associated with the disease. 
The presence of diplococci showing pneumococcus is characteristic of pneumococcal meningitis, whic
h is not the likely diagnosis in this patient. The clinical presentation, history of HIV/AIDS, and the menti
oned findings are more indicative of Cryptococcal Meningitis.
Option A- Capsule on India Ink Stain: This option is correctly present in this patient. Cryptococcal Meni
ngitis is associated with the presence of the Cryptococcus neoformans organism, which has a characte
ristic encapsulated structure. The India ink stain is used to highlight the capsule surrounding the Crypto
coccus organisms in cerebrospinal fluid (CSF) samples. It is a type of negative stain
Option B- Mucicarmine Stain: This option is correct in this case. Mucicarmine stain is used to highlight t
he capsule of Cryptococcus neoformans.
Option D- Soap Bubble Appearance on Head MRI: This option is correct in this case. A
"soap bubble" appearance on head MRI is associated with Cryptococcal Meningitis.
Correct Option A - Prions
 The condition described in the question is Creutzfeldt-Jacob disease, which is caused by Prions
 It is characterized by dementia and myoclonus and increased tau protein in CSF
 The patient has a history of consumption of poor quality beef
 It may contain Prion particles, which, upon entering the body, multiply in the cytoplasm of neurons and
cause irritation of neurons, leading to their abnormal firing.
 These are not the causative agents of Creutzfeldt-Jacob disease
821

Myasthenia Gravis
1. A 45-year-old woman presents to the neurology clinic with complaints of progressive muscle
weakness, particularly in her facial and proximal limb muscles. She reports difficulty in swallowing and
speaking, which worsens throughout the day and improves with rest. On examination, the patient
demonstrates ptosis, diplopia, and generalized weakness. All of these are the antibodies seen in this
condition except?
(or)
All of these are the antibodies seen in Myasthenia gravis except?
A. Anti-acetylcholine receptor antibody
B. Anti M.U.S.K antibody
C. Anti LRP4 antibody
D. Anti Netrin-3 receptor antibody
2. A 20-year-old male came to the clinic with complaints of nasal regurgitation of fluids and unclear
speech for 1 week. On examination, ptosis, diplopia, and nasal twang of voice were present. The doctor
advised an Anti AchR Antibody test and it showed positive results and was given Pyridostigmine for
treatment. Which of the following is not a clinical feature of this condition?
(or)
Which of the following is not a clinical feature of Myasthenia gravis?
A. Aspiration Risk
B. Oropharyngeal dysphagia
C. Proximall Muscle Weakness
D. DTR not preserved
3. A 45-year-old woman presents to the neurology clinic with complaints of intermittent double vision
and drooping of her eyelids, particularly worsening in the evenings. She also reports generalized
fatigue and weakness, especially after prolonged activity. On examination, the patient demonstrates
bilateral ptosis and limited eye movements. Which of the following is the mandatory test that should be
done in this patient?
(or)
Which of the following is the mandatory test that is used in all cases of Ocular Myasthenia gravis?
A. CT/MRI head
B. CT Chest
C. Ice pack test
D. Anti AchR Antibody
4. A 25-year-old female came to the clinic with complaints of unclear speech for 3 days. On
examination, the patient had ptosis, diplopia, nasal regurgitation of fluids, and oropharyngeal
dysphagia. The doctor advised an edrophonium test and the result was positive. Which of the following
823

Page 2
is the treatment of choice for the generalized condition?
(or)
Which of the following is the treatment of choice for Generalised Myasthenia gravis?
A. Thymectomy
B. Pyridostigmine
C. Plasmapheresis
D. Intravenous immunoglobulin.
5. A 30-year-old female, who is a known case of Myasthenia gravis delivered a baby by LSCS. During
breastfeeding the baby, the mother experienced regurgitation of milk and choking episodes in the baby.
Which of the following is the drug of choice for this condition?
(or)
Which of the following is the drug of choice for Neonatal Transient Myasthenia Gravis?
A. Physostigmine
B. Neostigmine
C. Edrophonium
D. Azithromycin
6. A 55-year-old male presents to the neurology clinic with complaints of progressive muscle weakness,
particularly in the proximal muscles of his limbs, dry mouth and constipation. He reports difficulty in
standing up from a seated position and lifting objects. On examination, the patient demonstrates
reduced deep tendon reflexes (DTRs) and fatigability upon repetitive muscle testing. All are true about
this syndrome except?
(or)
All are true about Lambert Eaton Syndrome except?
A. It is a paraneoplastic manifestation related to Oat cell lung cancer.
B. Lambert Eaton Syndrome is a post-junctional disease.
C. DTR is reduced
D. The drug of choice is 3,4 diaminopyridine.
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Page 5
 These are the clinical features of Myasthenia gravis
Correct Option A - CT/MRI head:
 Ocular myasthenia gravis (OMG) is a localized form of myasthenia gravis characterized by weakness
and fatigue of the extraocular muscles, leading to ptosis (drooping eyelids) and diplopia (double vision).
 Among the diagnostic tests used in OMG, the mandatory test is a CT or MRI head scan. This imaging
study is performed in all cases of OMG to rule out structural abnormalities or intracranial lesions
contributing to ocular manifestations such as ptosis and ophthalmoplegia.
 The CT/MRI head scan helps identify potential causes of ocular symptoms, including brain tumors,
vascular abnormalities (e.g., arteriovenous malformations), or other space-occupying lesions affecting
the cranial nerves or neuromuscular junction.
 
Option B - CT Chest: While not a mandatory test for OMG, CT imaging of the chest is indicated to eval
uate for thymic abnormalities, particularly thymoma, in patients with generalized myasthenia gravis.
Option C - Ice pack test: The ice pack test is a bedside diagnostic maneuver used to temporarily impro
ve ptosis in patients with suspected OMG. By applying a cold pack to the affected eyelid, the test explo
its the temperature sensitivity of acetylcholinesterase enzyme activity. Cold temperature reduces enzy
me activity, leading to increased acetylcholine levels at the neuromuscular junction and transient impro
vement in ptosis.
Option D - Anti AchR Antibody:
 It is a screening test positive in 85% of cases
 Testing for serum antibodies against the acetylcholine receptor (AchR) is a sensitive diagnostic test
for myasthenia gravis.
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Page 6
Correct option A - Thymectomy:
 The condition described in the question is Generalised Myasthenia gravis
 It is characterized by unclear, ptosis, diplopia,nasal regurgitation of fluids, and oropharyngeal
dysphagia
 Edrophonium test is used for the diagnosis of Generalised Myasthenia gravis
 Thymectomy is the treatment of choice for Generalised Myasthenia gravis.
 
Options B - Physostigmine: Pyridostigmine is the drug of choice for symptom relief in generalized myas
thenia gravis and not treatment of choice.
Option C - Plasmapheresis: In Myasthenic crisis patients, we will use plasmapheresis for the patients t
o get rid of the dangerous antibodies.
Option D - Intravenous immunoglobulin: In Myasthenic crisis patients, we will use plasmapheresis for t
he patients to get rid of the dangerous antibodies. If facilities for plasmapheresis are not available. It is i
ntravenous immunoglobulin.
Correct Option B - Neostigmine:
 The condition described in the question is Neonatal Transient Myasthenia Gravis
 The condition is characterized by regurgitation of milk and choking episodes in the baby
 The mother of the baby is a known case of Myasthenia gravis
 The antibodies that are found in this condition are immunoglobulin G class which can very easily cross
the placenta.
 The drug of choice for neonatal Transient Myasthenia Gravis is neostigmine.
 
Option A - Physostigmine: Pyridostigmine is the drug of choice for symptomatic relief in Generalised M
yasthenia gravis in adults.
Option C - Edrophonium: Edrophonium is a drug that is used for the diagnosis of Myasthenia gravis.
Option D - Azithromycin: Azithromycin is not used for the treatment of Myasthenia gravis.
828

Guillain Barre Syndrome
1. A 30-year-old male was brought to the clinic by his wife, complaining of weakness in both legs for
one day. On examination, biceps paralysis, neck floppiness, and bulbar palsy were present. The doctor
advised a CSF examination, which showed albumino cytological dissociation, which was managed with
plasmapheresis and intravenous immunoglobulin. Which of the following is the earliest manifestation
seen in this condition?
(or)
Which of the following is the earliest manifestation seen in Guillain Barre syndrome?
A. Distal areflexia
B. Truncal Paralysis
C. Facial Diplegia
D. Bulbar Palsy
2. Which of the following are the regions where damage is seen in the Demyelinating polyneuropathy
type of GBS?
A. Axons and Schwann cells
B. Dendrites and nucleus
C. Cell body and nucleus
D. Dendrites and cell body
3. Which of the following best describes the characteristic triad of symptoms seen in Miller Fisher
Syndrome?
A. Diplopia, dysarthria, and ataxia
B. Ptosis, ophthalmoplegia, and areflexia
C. Facial weakness, sensory loss, and autonomic dysfunction
D. Tremor, rigidity, and bradykinesia
4. A 32-year-old male presents to the emergency department with weakness and numbness in his legs
that has progressively worsened over the past few days. He reports having a diarrheal illness
approximately four weeks ago, which resolved without specific treatment. On examination, the patient
is noted to have decreased deep tendon reflexes and ascending paralysis. Which of the following
etiological agents is most commonly associated with this condition?
(or)
Which of the following etiological agents is most commonly associated with the development of
Guillain-Barré Syndrome (GBS), particularly following a recent diarrheal illness?
A. Covid-19
B. Zika virus
C. Campylobacter jejuni
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D. Epstein-Barr virus
5. Which of the following features is characteristic of Chronic Inflammatory Demyelinating
Polyneuropathy (CIDP)?
A. Rapidly ascending paralysis typically progressing over a 28-day period
B. Absence of post-void residual urine due to impaired bladder contraction
C. Symmetrical flaccid paralysis evolving over months, accompanied by sensory disturbances
D. Onion bulb appearance on nerve biopsy indicative of axonal degeneration
Correct Option A - Distal areflexia:
 The earliest manifestation seen in GBS is Distal areflexia
 The condition described in the scenario is Guillain Barre syndrome
 It is characterized by weakness in both legs, biceps paralysis, neck floppiness, and bulbar palsy
 CSF examination showed Albumino cytological dissociation
 These are not the earliest manifestations of GBS
Correct Option A - Axons and Schwann cells:
 Axons and Schwann cells are the parts where damage has occurred in the Demyelinating
polyneuropathy type of GBS.
Subtypes of GBS
 AIDP (Acute Inflammatory Demyelinating Polyneuropathy) is the most common subtype of GBS,
representing approximately 85% of cases.
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Correct Option C - Campylobacter jejuni:
 Guillain-Barré Syndrome (GBS) is commonly preceded by infections, with Campylobacter jejuni being
one of the most frequently implicated pathogens. Patients often develop GBS following a diarrheal
illness caused by Campylobacter jejuni infection. This bacterium triggers an immune response that
leads to the development of GBS, characterized by ascending paralysis and other neurological
Option A - COVID-19: While some cases of GBS have been reported in individuals with COVID-19, Ca
mpylobacter jejuni is a more established etiological agent associated with GBS.
Option B - Zika virus: Zika virus infection can lead to neurological manifestations, including GBS, but it i
s less commonly associated with GBS compared to Campylobacter jejuni.
Option D - Epstein-Barr virus: Epstein-Barr virus is not a common cause of GBS. While it is associated 
with other neurological complications, GBS is typically not directly linked to Epstein-Barr virus infection.
- Symmetrical flaccid paralysis evolving over months, accompanied by sensory disturbances:
 Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) typically presents with symmetrical
flaccid paralysis, often evolving over months, and is accompanied by sensory disturbances.
 This pattern of weakness distinguishes CIDP from other neuropathies. Additionally, CIDP is
associated with albuminocytological dissociation on lumbar puncture and prolonged latency periods on
nerve conduction studies.
 Urinary symptoms, such as overactive bladder and overflow incontinence, can also occur due to
autonomous bladder contraction. These features collectively support the diagnosis of CIDP.
Option A - Rapidly ascending paralysis typically progressing over a 28-day period: This description alig
ns more with the presentation of Guillain-Barré Syndrome (GBS), another demyelinating neuropathy.
Option B - Absence of post-void residual urine due to impaired bladder contraction: This statement is in
consistent with the described features of CIDP, as urinary symptoms such as overflow incontinence an
d post-void residual urine are commonly observed.
Option D - Onion bulb appearance on nerve biopsy indicative of axonal degeneration: While onion bulb
 appearance may be seen in nerve biopsies of patients with CIDP, it is not specific to CIDP and can als
o be observed in other neuropathies characterized by repeated cycles of demyelination and remyelinati
on.
833

Neuromyelitis Optica
1. A 32-year-old female presents to the neurology clinic and reports experiencing severe eye pain and
blurred vision in her right eye over the past week, accompanied by difficulty in walking and
coordination. On examination, the patient demonstrates decreased visual acuity in the right eye, along
with relative afferent pupillary defect (RAPD) and optic disc edema on fundoscopic examination.
Additionally, she exhibits spasticity and hyperreflexia in her lower limbs. Which of the following will not
be seen in this patient?
(or)
Which of the following is not a clinical finding seen in Neuromyelitis optica?
A. Area Postrema Syndrome
B. Acute Brainstem Syndrome
C. Optic neuritis
D. Retinal detachment
2. A 42-year-old female presents to the neurology clinic with visual disturbances, including blurred
vision and loss of color vision, along with weakness and sensory changes in her lower limbs.
Neurological examination reveals bilateral optic disc swelling and spastic paraparesis. All of the
following are the correct MRI findings seen in this patient except?
(or)
All of the following are the correct MRI findings seen in Neuromyelitis Optics except?
A. More than half the length of the optic nerve inflammation should be demonstrated definitely
B. Damage to the area postrema is seen
C. Periependymal brain lesions
D. Longitudinally extensive transverse myelitis (LETM) spreading over more than 2 segments
3. A 20 year old female was brought to the clinic with complaints of blindness in both eyes and tingling
sensation for 3 days. On examination, the patient had weakness in the lower limbs. The doctor advised
an MRI and it showed cloud-like lesions developing in the brain parenchyma and damage to the area
postrema. Which of the following is the drug of choice in this condition?
(or)
Which of the following is the drug of choice for Neuromyelitis Optics?
A. Methylprednisolone
B. Mycophenolate
C. Intravenous Immunoglobulin
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Correct Option D - Retinal detachment:
 Neuromyelitis Optica (NMO), also known as Neuromyelitis Optica Spectrum Disorder (NMOSD), is an
autoimmune inflammatory disorder characterized by recurrent episodes of optic neuritis and
longitudinally extensive transverse myelitis (LETM) involving the spinal cord.
 While NMOSD primarily affects the optic nerves and spinal cord, it can also involve other areas of the
central nervous system (CNS), leading to various clinical manifestations.
 Retinal detachment, characterized by the separation of the neurosensory retina from the underlying
retinal pigment epithelium (RPE), is not a typical clinical finding observed in NMOSD.
 While NMOSD primarily affects the optic nerves and spinal cord, it does not typically involve the retina
or predispose to retinal detachment.
Options A ,B, C:
 These are the clinical findings seen in Neuromyelitis Optica
Correct Option D - Longitudinally extensive transverse myelitis (LETM) spreading over more than 2
segments:
 Longitudinally extensive transverse myelitis (LETM)is a hallmark feature of NMO, characterized by
spinal cord inflammation extending over three or more contiguous vertebral segments on MRI.
Option A - More than half the length of the optic nerve inflammation should be demonstrated definitely:
 More than half the length of the optic nerve inflammation should be definitely demonstrated: Optic
nerve involvement in NMO typically extends over a significant portion of its length, often affecting more
than half of the optic nerve.
Option B - Damage to the area postrema is seen:
 Damage to the area postrema is seen: The area postrema, a region of the brainstem involved in the
control of vomiting, is commonly affected in NMO, leading to symptoms such as intractable nausea and
vomiting.
Option C - Periependymal brain lesions:
 Periependymal brain lesions: NMO is associated with periependymal brain lesions, which are
characterized by lesions adjacent to the ependymal lining of the ventricles in the brain. These lesions
can appear as longitudinally extensive lesions involving the periventricular regions.
835

Amyotrophic Lateral Sclerosis
1. A 55-year-old male presents to the neurology clinic with progressive weakness and muscle atrophy
in his limbs. He reports difficulty in performing daily activities such as walking and lifting objects. Upon
examination, the patient exhibits muscle fasciculations and hyperreflexia. All are the factors contributing
to the pathology of this condition except?
(or)
All are the factors contributing to the pathology of Amyotrophic lateral sclerosis except?
A. Defective protein degradation in neuron
B. Defective RNA processing
C. Increased Glutamate levels
D. Increased Methionine levels
2. A 20-year-old male was brought to the clinic by his parents with complaints of weakness in his legs
for 1 day. On examination by the Physician, he had fasciculations, a slapping gait, absent knee jerk in
one leg, and brisk biceps jerk. The doctor advised EMG which showed a denervation pattern in LMN
involved. Which of the following is not a treatment used to manage this condition?
(or)
Which of the following is not a treatment option used to manage Amyotrophic lateral sclerosis?
A. Physiotherapy
B. Finger extension splint
C. Tracheostomy
3. A 65-year-old male presents with progressive dysphagia, dysarthria, and difficulty in chewing for the
past few months. He also reports frequent choking episodes while eating and speech changes
characterized by slurred speech and nasal quality. On examination, the patient demonstrates
weakness and atrophy of the tongue, palate, and pharyngeal muscles, along with absent gag reflex and
weakness of the shoulder. Which of the following nerves are affected in this condition?
(or)
Which of the following nerves are affected in Bulbar palsy?
A. Damage to 9, 10, 11, and 12 cranial nerves
B. Damage to 9, 10, 11 cranial nerves
C. Damage to 7, 9, 11 cranial nerves
D. Damage to 9, 10, and 12 cranial nerves
4. A 25-year-old male presents to the neurology clinic with complaints of progressive difficulty walking
and coordination issues. He reports experiencing frequent falls and stumbling, along with weakness
and numbness in his extremities. Upon further evaluation, the patient demonstrates gait instability, limb
ataxia, and dysarthria, indicative of a cerebellar disorder. Family history reveals a sibling with similar
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symptoms. Which of the following is the etiology?
(or)
Which of the following is the cause of Friedreich's Ataxia?
A. Due to frataxin gene defect
B. Due to Vit B12 deficiency
C. Damage to Anterior horn cells (spinal cord) and Pyramidal neurons (brain)
D. Defective RNA processing
Correct option D - Increased Methionine levels:
 Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder characterized by the
degeneration of upper and lower motor neurons, leading to muscle weakness, atrophy, and eventual
paralysis.
 Several factors contribute to the pathology of ALS: Defective protein degradation in neurons:
Defective RNA processing In ALS, dysfunctional glutamate handling mechanisms, such as impaired
glutamate uptake by astrocytes and downregulation of glutamate transporters like EAAT2 (excitatory
amino acid transporter 2), lead to increased extracellular glutamate levels. Excessive glutamate
accumulation overactivates glutamate receptors, triggering calcium influx and subsequent neuronal
injury. Excitotoxicity contributes to motor neuron degeneration in ALS and is implicated in disease
pathogenesis.
 Defective protein degradation in neurons:
 Defective RNA processing
 In ALS, dysfunctional glutamate handling mechanisms, such as impaired glutamate uptake by
astrocytes and downregulation of glutamate transporters like EAAT2 (excitatory amino acid transporter
2), lead to increased extracellular glutamate levels.
 Excessive glutamate accumulation overactivates glutamate receptors, triggering calcium influx and
subsequent neuronal injury.
 Excitotoxicity contributes to motor neuron degeneration in ALS and is implicated in disease
 There is no increase in the level of Methionine in the pathology of Amyotrophic lateral sclerosis
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Correct Option A - Damage to 9, 10, 11, and 12 cranial nerves:
 Bulbar palsy refers to the weakness or paralysis of the muscles innervated by the motor nuclei of
several cranial nerves located in the bulbar region of the brainstem. The cranial nerves affected in
bulbar palsy include: Cranial nerve IX (glossopharyngeal nerve): Responsible for innervating the
muscles involved in swallowing (pharyngeal muscles) and the sensation of the posterior one-third of the
tongue. Cranial nerve X (vagus nerve): Innervates the muscles involved in swallowing (pharyngeal and
laryngeal muscles), phonation (voice production), and the sensation of the larynx and pharynx. Cranial
nerve XI (accessory nerve): Supplies the sternocleidomastoid and trapezius muscles, contributing to
head movement and shoulder elevation. Cranial nerve XII (hypoglossal nerve): Innervates the intrinsic
and extrinsic muscles of the tongue, controlling tongue movement and coordination.
 Cranial nerve IX (glossopharyngeal nerve): Responsible for innervating the muscles involved in
swallowing (pharyngeal muscles) and the sensation of the posterior one-third of the tongue.
 Cranial nerve X (vagus nerve): Innervates the muscles involved in swallowing (pharyngeal and
laryngeal muscles), phonation (voice production), and the sensation of the larynx and pharynx.
 Cranial nerve XI (accessory nerve): Supplies the sternocleidomastoid and trapezius muscles,
contributing to head movement and shoulder elevation.
 Cranial nerve XII (hypoglossal nerve): Innervates the intrinsic and extrinsic muscles of the tongue,
controlling tongue movement and coordination.
 
 These are not the correct options that include all the nerves damaged in Bulbar palsy.
Correct option A - Due to frataxin gene defect:
 Friedreich's ataxia is an autosomal recessive neurodegenerative disorder characterized by
progressive gait and limb ataxia, dysarthria, loss of proprioception and vibration sensation, and often
associated cardiomyopathy and diabetes mellitus.
 The condition typically manifests in childhood or adolescence and progresses over time, leading to
significant disability.
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 The underlying cause of Friedreich's ataxia is a mutation in the frataxin (FXN) gene, located on
chromosome 9q13-q21.1.
 
Options B - Due to Vit B12 deficiency: Vitamin B12 deficiency, option b, typically presents with subacut
e combined degeneration (SACD) of the spinal cord, characterized by sensory ataxia, weakness, and p
roprioceptive deficits due to demyelination of the dorsal and lateral columns of the spinal cord.
Option C - Damage to Anterior horn cells (spinal cord) and Pyramidal neurons (brain): Damage to anter
ior horn cells and pyramidal neurons, option c, is characteristic of motor neuron disease (MND) or amy
otrophic lateral sclerosis (ALS), which manifests with progressive weakness, muscle atrophy, and spas
ticity due to degeneration of upper and lower motor neurons.
Option D - Defective RNA processing: Defective RNA processing, option d, is implicated in the pathoge
nesis of ALS, particularly involving mutations in RNA-binding proteins such as TDP-43 and FUS, leadin
g to abnormal RNA metabolism and protein aggregation within motor neurons.
841

Syringomyelia and Conus Medullaris Syndrome
1. A 30-year-old male presents to the neurology clinic with complaints of progressive weakness and
sensory abnormalities in his upper extremities. After further evaluation, a diagnosis of syringomyelia
was made. All of the following are the features of this condition except?
(or)
All of the following are the features of Syringomyelia except?
A. Painless burn in hand
B. Non-healing ulcer on foot
C. Asymmetrical patchy loss of pain and temperature sensations
D. Bilateral brisk deep tendon reflexes.
2. A 20 year old female was brought to the clinic with a painless burn in hand for 4 days. On
examiantion, sensory deficit of pain and temperature progresses from shoulders (proximal) to palm
(distal), wasting of arms and hands were present. Which of the following is the investigation of choice of
the condition?
(or)
Which of the following is the investigation of choice in Syringomyelia?
A. MRI spine
B. X ray spine
C. CT spine
D. HRCT spine
3. A 45-year-old female reports experiencing neck pain and stiffness, along with numbness and tingling
sensations in her hands. Upon further evaluation, magnetic resonance imaging (MRI) reveals the
presence of a syrinx, or fluid-filled cavity, within the spinal cord .Which of the following is the treatment
of choice for this condition?
(or)
Which of the following is the treatment of choice for Syringomyelia?
A. Surgical decompression
C. Intravenous immunoglobulins
D. Mexiletine
4. A 50-year-old male presents to the emergency department with acute onset back pain following a fall
from a ladder. He complains of bilateral leg weakness, numbness in the saddle area, and difficulty with
bladder control. On examination, the patient has absent knee and ankle reflexes, sensory loss in the
perianal region, and urinary retention.
(or)
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Which of the following neurological conditions is most likely responsible for the patient's symptoms?
A. Conus Medullaris Syndrome
B. Cauda Equina Syndrome
C. Spinal Cord Injury
D. Lumbar Disc Herniation
5. A 55-year-old construction worker fell from a height and sustained a spinal fracture. He initially
presents with flaccid paralysis of the lower extremities and absent bulbocavernosus reflexes. One week
later, he begins to exhibit spasticity in the lower limbs below the level of the lesion. Which of the
following neurological phenomena is most likely to occur in this patient?
(or)
Which of the following neurological phenomena is most likely to occur in Spinal shock?
A. Development of upper motor neuron manifestations in the lower limbs
B. Persistence of lower motor neuron manifestations throughout the course of the illness
C. Recovery of bulbocavernosus reflexes within one week
D. Resolution of spasticity in the lower limbs within one week
6. A 55-year-old male presents to the emergency department with complaints of progressive weakness
in his lower limbs and difficulty with urination and defecation. Upon further questioning, he reports a
history of prostate carcinoma diagnosed two years ago, which has now metastasized. On examination,
the patient demonstrates decreased sensation in the perineal area, loss of ankle jerk reflexes, and
preserved knee jerk reflexes.
(or)
What is the most likely neurological syndrome affecting this patient, based on the clinical presentation
and history?
A. Cauda Equina Syndrome
B. Conus Medullaris Syndrome
C. Anterior Cord Syndrome
D. Brown-Séquard Syndrome
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 These are not the investigation of choice for the diagnosis of Syringomyelia
Correct option A - Surgical decompression:
 Surgical intervention is often the mainstay of treatment for syringomyelia, especially when associated
with Chiari malformation or spinal cord compression. Decompressive surgery aims to relieve pressure
on the spinal cord, restore cerebrospinal fluid (CSF) flow dynamics, and prevent further expansion of
the syrinx.
 Procedures may include posterior fossa decompression for Chiari malformation, laminectomy, syrinx
shunting, or syringo-subarachnoid shunt placement.
 Surgical decompression can help alleviate symptoms, improve neurological function, and halt disease
progression in syringomyelia.
 
 These are not the treatment options for Syringomyelia
Correct Option B - Cauda Equina Syndrome:
 Cauda equina syndrome and conus medullaris syndrome are two distinct neurological conditions
caused by injury or compression of different anatomical regions within the spinal cord. While they share
some similarities in clinical presentation, certain features help differentiate between the two conditions:
Conus Medullaris Syndrome:
 Mainly due to Mets: Conus medullaris syndrome is typically associated with metastatic cancer
involving the lower spinal cord segments.
 Bladder complaints: Patients may experience urinary symptoms such as retention or incontinence due
to involvement of sacral spinal cord segments controlling bladder function.
 Knee jerk preserved: Knee jerk reflexes (patellar reflexes) may be preserved or diminished in conus
medullaris syndrome, depending on the extent of spinal cord injury.
 S1-S5 lesion: Lesions primarily affect the sacral spinal cord segments (S1-S5), resulting in motor,
sensory, and autonomic deficits localized to the lower extremities and pelvic organs.
 
Option A - Conus Medullaris Syndrome: Conus Medullaris Syndrome is less likely given the absence of
 metastatic cancer and the involvement of lumbar and sacral nerve roots rather than the conus medulla
ris itself.
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Options C - Spinal Cord Injury and Option D: Lumbar Disc Herniation: May present with overlapping sy
mptoms but are less specific to the constellation of findings observed in this case.
Correct Option A - Development of upper motor neuron manifestations in the lower limbs:
 In spinal shock, patients initially exhibit lower motor neuron manifestations due to acute spinal cord
injury. However, after approximately one week, upper motor neuron manifestations may develop,
characterized by the appearance of spasticity below the level of the lesion. This phenomenon is
consistent with the patient's clinical course.
 
Option B - Persistence of lower motor neuron manifestations throughout the course of the illness: This i
s incorrect as spinal shock is typically transient, and upper motor neuron manifestations may develop a
fter one week.
Option C - Recovery of bulbocavernosus reflexes within one week: This is incorrect as bulbocavernosu
s reflexes typically return after one week in spinal shock, not resolve.
Option D - Resolution of spasticity in the lower limbs within one week: This is incorrect as spasticity ma
y develop after one week in spinal cord injuries involving the corticospinal pathway, contributing to upp
er motor neuron manifestations.
Correct Option B - Conus Medullaris Syndrome:
 Conus Medullaris Syndrome occurs when there is injury or compression affecting the terminal part of
the spinal cord, known as the conus medullaris, typically at the level of L1.
 In this patient with prostate carcinoma metastasized to the conus medullaris region, the involvement
of S1-S5 nerve roots results in characteristic clinical features.
 These include bowel and bladder dysfunction, such as over■ow incontinence or autonomous bladder,
due to impaired S2-S4 nerve root function.
 Additionally, loss of ankle jerk reflexes (associated with S1-S2) and preserved knee jerk reflexes
(associated with L2-L4) are consistent with the neurological deficits seen in Conus Medullaris
Syndrome.
 
Option A - Cauda Equina Syndrome:
 This syndrome involves compression or injury to the nerve roots below the level of the conus
medullaris, typically affecting the lumbar and sacral nerve roots.
 While it shares some features with Conus Medullaris Syndrome, such as bowel and bladder
dysfunction, the specific neurological deficits observed in this patient, such as loss of ankle jerk
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reflexes, are more indicative of Conus Medullaris Syndrome.
Option C - Anterior Cord Syndrome:
 This syndrome results from damage to the anterior portion of the spinal cord, leading to motor
paralysis and loss of pain and temperature sensation below the level of injury.
 The clinical presentation described in this patient, including perineal sensory changes and bowel and
bladder complaints, does not align with the characteristic features of Anterior Cord Syndrome.
Option D - Brown-Séquard Syndrome:
 This syndrome results from hemisection (damage to one half) of the spinal cord, leading to ipsilateral
motor weakness and contralateral loss of pain and temperature sensation below the level of injury.
 While it can present with some similar features, such as sensory deficits, the specific pattern of
neurological deficits observed in this patient, including perineal sensory changes and loss of ankle jerk
reflexes, is more consistent with Conus Medullaris Syndrome.
847

Channelopathies
1. A 30-year-old male presents to the emergency department complaining of recurrent episodes of
weakness and paralysis, particularly after meals. Initially, the healthcare provider suspects malingering
due to the episodic nature of the symptoms. However, further evaluation reveals these episodes
consistently occur after consuming carbohydrate-rich meals. All are correct about the workup of this
patient except?
(or)
All are correct about the workup of Hypokalemic periodic paralysis except?
A. Serum potassium is either normal or less
B. CPK-MM is normal
C. Nerve conduction velocity is normal
D. Genetic studies showed autosomal recessive inheritance
2. A 35-year-old male patient presents to the neurology clinic with a history of recurrent episodes of
muscle weakness and paralysis, which typically occur after exercise or consumption of high-potassium
foods. Which of the following is not a treatment option for this patient?
(or)
Which of the following is not a treatment of choice for hyperkalemic periodic paralysis?
A. Acetazolamide
B. Mexiletine
C. Lasix
D. Implantable Cardioverter Defibrillator
3. A 25-year-old female presents to the neurology clinic with complaints of progressive weakness and
muscle wasting in her lower extremities. Upon examination, her legs exhibit a characteristic "stork-leg"
appearance, with muscle atrophy particularly affecting the peroneal muscles. Which of the following is
not a feature of the disease that the patient is suffering from?
(or)
Which of the following is not a feature of Charcot Marie Tooth Disease?
A. Champagne bottle appearance
B. Foot contractures
C. Onion bulb appearance on biopsy
D. Waddling gait
4. Guess the leading cause of death in Duchenne's Muscular Dystrophy.
B. Congestive heart failure due to dilated cardiomyopathy
C. Stroke
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D. Liver failure
5. A 20-year-old male presents to the clinic with complaints of progressive weakness in his upper and
lower extremities. On examination, the patient demonstrates tenting of the upper lip, characteristic
myopathic facies, and bilateral cataracts with a Christmas tree appearance. All are true regarding the
features of this patient except?
(or)
All are the features of Myotonic dystrophy except?
A. Tenting of the upper lip
B. Myopathic facies/Hatchet facies
C. Cataract
D. Type 1 Diabetes Mellitus
Correct Option D - Genetic studies showed autosomal recessive inheritance:
 This is incorrect regarding the workup of Hypokalemic periodic analysis
 The correct statement is that the genetic studies showed autosomal dominant inheritance
 Hypokalemic periodic paralysis is a rare neuromuscular disorder characterized by recurrent episodes
of muscle weakness or paralysis associated with hypokalemia.
 These are the correct methods used for the workup of hypokalemic periodic paralysis
Correct Option D - Implantable Cardioverter Defibrillator:
 Implantable Cardioverter Defibrillator (ICD) is not a treatment of choice for hyperkalemic periodic
paralysis (HyperPP).
849

1. A female patient presents to you with a unilateral headache. It is associated with nausea,
photophobia, and phonophobia. What is the drug of choice for acute management?
A. Flunarizine
B. Sumatriptan
D. Topiramate
2. What is observed in cases of hypoglossal nerve injury?
A. a.Tongue deviation to the contralateral side
B. b.Tongue deviation to the same side
C. c.Falling of the tongue
D. d.Inability in tongue protrusion
3. A young man presents with a sudden onset of severe headache, dizziness, breathlessness, and
blurring of vision while trekking on a mountain at an altitude of 5000 meters. He is unable to climb any
further. Which of the following develops at high-altitude?
(or)
A young man presents with a sudden onset of severe headache, dizziness, breathlessness, and
D. Metabolic acidosis
4. What is the diagnosis for a 24-year-old female patient who presents with fever, headache, ataxia,
nausea, and vomiting for the past 3 days? The patient exhibits neck rigidity and hip and knee flexion
upon passive flexion of the neck. A lumbar puncture was performed, and the CSF findings are provided
below. Opening pressure – increased Color – cloudy white WBCs – 7000/µl; neutrophil predominant
Sugar – 15 mg/dl CSF/serum glucose ratio – 0.2 Protein – 70 mg/dl Latex agglutination – positive
Limulus lysate test – negative
A. Bacterial meningitis
B. Tubercular meningitis
C. Viral meningitis
D. Fungal meningitis
5. In myasthenia gravis, which type of hypersensitivity reaction is observed?
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A. Type 1 hypersensitivity reaction
B. Type 2 hypersensitivity reaction
C. Type 3 hypersensitivity reaction
D. Type 4 hypersensitivity reaction
6. What could be the possible diagnosis for a young patient who presents with a severe headache,
never experienced before, along with hypertension and nuchal rigidity on examination?
B. Subarachnoid haemorrhage
C. Encephalitis
D. Meningitis
7. What is the likely diagnosis for a 26-year-old male who had a respiratory tract infection 4 weeks ago
and has been experiencing progressive, symmetrical weakness, starting in the lower limbs and
gradually affecting the upper limbs? The weakness has made it difficult for him to stand or walk for the
past 2 weeks. On examination, there is a lack of reflexes, but pain sensation and proprioception are
normal.
A. Guillain Barre syndrome
B. Myasthenia gravis
C. Polymyositis
D. Multiple sclerosis
8. What is the recommended treatment for a patient who is HIV-positive and presents with a high-grade
fever, positive Kernig's sign, and laboratory findings of reduced glucose, increased protein, and
increased leukocytes in the CSF, leading to a diagnosis of cryptococcal meningitis?
A. Vancomycin
B. High dose fluconazole with flucytosine
C. Voriconazole
D. Liposomal amphotericin B
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9. What could be the likely cause of the headaches experienced by a woman who has a history of
headaches for the past 9 months that worsen when lying down and improve throughout the day?
Additionally, she reports using oral contraceptives and her fundal examination reveals papilledema,
with no presence of focal neurological deficits.
A. Myasthenia gravis
B. Temporal arteritis
C. Chronic migraine
D. Pseudotumor cerebri
10. What is the probable medical condition of a young male patient who experiences drooping of the
upper eyelid and muscular weakness that appears to intensify during the evening and alleviate in the
morning, and is relieved by neostigmine?
B. Huntington chorea
C. Amyotrophic lateral sclerosis
D. External ophthalmoplegia
11. Bell's palsy is characterized by
A. Ipsilateral upper and lower halves of the face.
B. Contralateral upper and lower halves of the face.
C. Ipsilateral lower half of the face.
D. Contralateral lower half of the face.
12. The patient's wife brings him to the outpatient department (OPD) and reports his difficulty in
expressing emotions and lack of involvement in daily activities. During the examination, the presence of
resting tremors and rigidity is observed. Considering the potential diagnosis, which specific region of
the patient's brain is impacted?
A. Basal ganglia
B. Hippocampus
C. Cerebellum
D. Premotor cortex
13. What is the most probable cause for the symptoms of seizures, along with a history of fever,
headache, and confusion, in a male patient who arrived at the emergency room? An MRI brain scan
revealed inflammation in the bitemporal lobe.
A. Cytomegalovirus
B. Toxoplasma gondii
C. Herpes simplex virus
D. Mycobacterium tuberculosis
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14. A patient with a history of hypertension and taking multiple anti-hypertensive medications presents
at the outpatient department (OPD). The provided ECG results indicate a particular drug as the cause
for the observed ECG findings. Which of the following medications is accountable for these ECG
findings?
A. Prazosin
C. Hydrochlorothiazide
D. Spironolactone
15. a 65-year-old patient presents with tremors, rigidity, and bradykinesia. Pathological examination
shows the presence of Lewy bodies within the neurons. What is the most probable diagnosis?
B. Prion disease
C. Huntington's chorea
D. Alzheimer's disease
16. A patient came to the medical OPD with complaints of polyuria. He has a history of undergoing total
hypophysectomy. His Na+ levels were found to be 155 mEq/ L, urine osmolarity was 200 mOsm/L.
What is the definitive management in this patient?
A. DDAVP for 2 weeks and then discontinue
B. DDAVP supplementation for lifelong
C. Upsetting of receptors so no treatment is required
D. Thiazides for 2 weeks
17. Which region of the internal capsule is responsible for the manifestation of left-sided hemiparesis in
a 50-year-old male patient?
A. Retrolentiform
B. Sublentiform
C. Anterior limb
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D. Posterior limb
18. Where is the site of the lesion that leads to the occurrence of hemiballismus in a patient displaying
forceful, flinging movements?
A. Putamen
B. Subthalamic nucleus
D. Globus pallidus
19. What is the cause of the following symptoms in a patient: Horner's syndrome and loss of pain and
temperature sensations in the face on the same side, along with vertigo, numbness, loss of sweating,
and dysarthria on the opposite side? A. Medial medulla B. Lateral medulla C. Ventromedial medulla D.
Lateral medulla including nucleus ambiguous and spinothalamic tract
A. B and D
B. B, C, D
C. A, B, C
D. A and B
20. What could be the possible diagnosis for a female patient who has experienced a loss of pain and
temperature sensation, but still retains her touch sensation, as indicated by imaging findings that reveal
cavitation around the central canal?
A. Brown-Sequard syndrome
B. Tabes dorsalis
C. Syringobulbia
D. Syringomyelia
21. All of the following aid in the localization of the lesion to the spinal cord except?
A. Contralateral hemiplegia
B. Fasciculation at the level of lesion
C. Upper motor neuron lesion and lower motor neuron lesion
D. Bladder involvement
22. Which of the following is not characteristic of Brown Sequard syndrome?
A. Complete transection of spinal cord
B. Ipsilateral loss of vibration & touch
C. Contralateral loss of pain & temperature
D. Ipsilateral loss of proprioception
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23. The following clinical examination was performed. What lesion would cause an exaggerated reflex?
A. Polyneuropathy
B. Radiculopathy
C. Upper motor neuron
D. Lower motor neuron
24. A young man is brought to the hospital with high-grade fever and altered consciousness. On
examination, he had neck rigidity and pain when bending the neck. A lumbar puncture was performed,
which showed a WBC count of 145 cells/µL, majorly lymphocytes, elevated opening pressure with
protein of 120 mg/dL, and glucose level of 35 mg/dL. How will you manage this patient?
A. Piperacillin + tazobactam
B. Vancomycin + ceftriaxone
C. Amphotericin B + flucytosine
D. Ceftriaxone + ampicillin
25. What could be the potential reason behind irreversible dementia?
A. NPH
B. Hypothyroid
C. Lewy body
D. Vitamin B12 deficiency
26. Why does a 35-year-old male patient with schizophrenia, who is currently receiving clozapine
treatment, require frequent blood monitoring?
(or)
Why does a patient with schizophrenia, who is receiving clozapine treatment, require frequent blood
monitoring?
A. Agranulocytosis
B. Myocarditis
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C. Cerebral bleed
D. Seizures
27. What is observed in the case of an abnormal accumulation of misfolded protein?
A. Creutzfeldt jakob disease
B. Nephritic syndrome
D. Megaloblastic anemia
28. What is the probable medical condition in a 37-year-old female patient who has been experiencing
headaches for the past 6 months and has been using painkillers consistently? The severity of the
headache recently worsened for a period of 3 days but improved upon discontinuing the analgesic
medication.
A. Medication overuse headache
B. Tension headache
D. Cluster headache
29. What is the most probable diagnosis for a 30-year-old man who experiences increased fatigue
towards the end of the day, which improves with rest, and has a history of ptosis, difficulty in speech,
and swallowing?
B. Lambert-Eaton syndrome
C. Duchenne muscular dystrophy
D. Systemic lupus erythematosus
30. “Office headache” simulation is
A. Frontal sinusitis
B. Maxillary sinusitis
D. Temporal arteritis
31. Which antiepileptic medication has the lowest teratogenic effects and is considered safe for use
during pregnancy?
A. Phenytoin
C. Carbamazepine
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D. Levetiracetam
32. SSPE is a complication of
A. Mumps
B. Measles
C. Rubella
D. RSV
33. Antidote for opioid poisoning is
A. Naloxone
B. Flumazenil
C. Fomepizole
D. Pethidine
34. What is the diagnosis of an elderly woman who is brought to the OPD with complaints of behavioral
changes, a history of multiple falls, urinary incontinence, and dementia?
A. Normal pressure hydrocephalus
B. Frontotemporal dementia
C. Parkinson disease
D. Creutzfeldt-Jakob disease
35. What type of aphasia is observed in individuals with lesions in the posterior region of the superior
temporal gyrus?
A. Fluent
B. Non fluent
C. Anomic
D. Conduction
36. What is shown in given below image
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A. Port Wine stain
B. Melanoma
C. Molluscum contagiosum
D. Squamous cell carcinoma
37. All are true about Brown Sequard Syndrome except
A. I/L loss of vibration
B. I/L loss of joint position
C. C/L loss of pain
D. C/L loss of vibration
38. Lesion producing incongruous homonymous hemianopia with wernicke’s pupil?
A. Optic tract
B. Visual cortex
C. Optic radiations
D. Optic nerve
39. In the scenario of paralysis of all Extraocular muscles, where would the suspected lesion be
located?
A. Frontal eye field
B. Cerebral surface
C. Midbrain and Pons
D. Spinal cord
40. What is the preferred medication for the presented case? A male patient, 54 years old, was brought
to the emergency room with symptoms of fever, headache, and a focal seizure. The EEG results
indicate the presence of spikes in the temporal lobe. Analysis of the cerebrospinal fluid (CSF) sample
reveals the presence of 50 cells, with 90% lymphocytes and 10% neutrophils.
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A. Valacyclovir
B. Acyclovir
C. Ganciclovir
D. Foscarnet
41. A patient comes with a blood pressure of 160/100 mmHg and left-sided facial paralysis and
weakness since 8 hrs. Her CT appears normal. What would be your next step?
A. Observation and monitoring
B. Intravenous labetalol
C. Intravenous thrombolysis
D. Oral Nifedipine
42. What is the most probable diagnosis for a 30-year-old man who experiences increased tiredness at
the end of the day that gets better with rest, along with symptoms of drooping eyelids, difficulty in
speaking, and swallowing?
43. What is the probable diagnosis for a patient who presented at the emergency department with a
complaint of intense headache, showing no specific neurological impairment except for the presence of
neck stiffness, and subsequently underwent an urgent CT scan that revealed the following result?
A. Subdural hemorrhage
B. Pituitary apoplexy
C. Subarachnoid hemorrhage
D. Pituitary carcinoma
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44. What is the diagnosis of a 20-year-old male who was brought for psychiatric evaluation due to
intellectual disability and has an IQ of 45? He exhibits physical characteristics such as a long face,
large ears, and large testis. Additionally, a cardiac murmur is detected during examination, and there is
a history of poor intellectual function in the paternal family.
A. Cushing’s syndrome
B. Rett syndrome
C. Fragile X syndrome
D. William syndrome
45. What is the treatment of Grade I Meningioma?
A. Reassurance
B. Surgical excision
D. Radiotherapy
46. What should be the next course of action in the management of a 50-year-old male who
experienced sudden onset of right-sided weakness and aphasia within a two-hour timeframe, with a
recorded blood pressure of 160/110mmHg and a clear non-contrast computed tomography (NCCT)
scan?
A. CT angiography to look for large vessel occlusion
B. MRI to look for infarct
C. Tab Labetalol 10 mg stat
D. Thrombolysis
47. What is the preferred treatment for relieving symptoms during an acute episode of cluster
headache?
A. Oral sumatriptan
B. Subcutaneous sumatriptan
C. 100% oxygen at 6 L/minute
D. 100% oxygen at 8 L/minute
48. Which of the following is not considered a primary diagnostic factor for neuromyelitis optica?
A. Area postrema syndrome
B. Acute myelitis
C. Focal epilepsy
D. Optic neuritis
49. Which of the following does not show hypokinesia movements?
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A. Parkinson’s disease
B. Apraxia
C. Catatonia
D. Chorea
50. Which of the following statements regarding electroencephalogram (EEG) is not correct?
(or)
Which of the following statements regarding electroencephalogram (EEG) is correct?
A. 1-5% of the population can have epileptiform discharges
B. Doing EEG is mandatory for diagnosis of seizures
C. Scalp EEG may be helpful in localizing frontal lobe epilepsy
D. Progressive multifocal leukoencephalopathy shows triphasic and slow waves on EEG
51. A 45-year-old male patient presented with a history of bilateral lower limb weakness, which
progressed to his upper limbs in a year. On examination, he had weakness in both lower limbs and
wasting in the left upper limb. Babinski sign was positive and the deep tendon reflexes were absent. He
has no sensory loss or any autonomic dysfunction. What is the likely diagnosis?
A. MS
B. ALS
C. GBS
D. Tropical spastic paraparesis
52. In a patient who is 66 years old and has a history of chronic hypertension, he arrives at the
emergency room with changes in mental state and high blood pressure measuring 210/110 mm Hg. A
brain CT scan shows bleeding within the brain tissue. The typical location of this bleeding in similar
cases is known as the:
A. Putamen
B. Thalamus
C. Pons
D. Cerebellum
53. What is the likely diagnosis for a 60-year-old female patient with a six-hour duration of weakness in
the right arm that gradually improves and resolves? The patient has a history of diabetes, hypertension,
and obesity.
A. Compressive neuropathy
B. Transient ischaemic attack
C. Ischaemic stroke
D. Diabetic neuropathy
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54. What is the Glasgow Coma Scale (GCS) score of a patient suffering from a head injury, who
exhibits eye-opening in response to a loud voice, pain localization, and confusion with disorientation?
A. E3M5V4
B. E3M6V5
C. E4M4V5
D. E3M5V5
55. What is the purpose of using AKIN and RIFLE criteria in the classification of...?
B. Chronic kidney failure
D. nephrotic syndrome
56. A 28-year-old male was brought to the emergency room with a history of RTA. GCS progressively
declines over hours and axial T2 MRI below shows multiple small hypointense lesions at the
corticomedullary junction and basal ganglia, what is the diagnosis?
A. Diffuse axonal injury
B. Extensive subarachnoid haemorrhage
C. Hypoxic cerebral injury
D. Multiple haemorrhagic contusion
57. In a patient undergoing visual field testing, the observed loss suggests a potential site of lesion
within the optic pathway.
A. Frontal visual field
B. Occipital lobe
C. Optic radiation
D. Optic chiasma
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58. What is the probable diagnosis for a 37-year-old male, who is a chronic alcoholic and has recently
stopped drinking alcohol, but presents to the emergency department after three days with symptoms of
disorientation, tremors, hallucinations, and hypertension?
A. Alcoholic hallucinosis
B. Korsakoff’s psychosis
C. Delirium tremens
D. Marchiafava-Bignami disease
59. Which of the following combinations of seizure and its corresponding medication is not accurate?
Generalized onset tonic – Clonic: Lamotrigine Focal seizures: Levetiracetam Typical absence seizures:
Topiramate Myoclonic: Valporic acid
A. 1
B. 2
C. 3
D. 4
60. A 30 year old man presents with distal leg weakness, reduced muscle stretch reflexes, with no
complaints of tingling or numbness. On examination, there is atrophy of the muscles below the knee.
The following clinical findings are seen and similar history is seen in elder brother. The most probable
diagnosis is—
A. Charcot-Marie-Tooth disease
B. Refsum’s disease
C. Neuropathy associated with Sjogren’s syndrome
61. What could be the most probable cause for the progressive vision loss in both eyes of a 25-year-old
male who has been undergoing low-dose oral steroid therapy for the past decade?
A. Cataract
B. Glaucoma
C. Cystoid macular edema
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62. Which of the subsequent options is not a viable treatment choice for Guillain Barre syndrome?
C. IVIG
D. Ventilator support
63. According to the ABCD2 scoring, which factors indicate a greater likelihood of a patient with TIA
experiencing a future stroke?
A. Age <60 years
B. SBP>140 mm Hg and DBP <90 mmHg
C. Duration of TIA >5 mins
D. Diabetes
64. Which of the following statements is false regarding Guillain-Barre syndrome?
A. Ascending paralysis
B. Descending paralysis is seen
C. Plasmapheresis is a treatment method
D. Demyelinating disorder
65. Which of the following statements is false regarding patients with trigeminal neuralgia?
A. More common in females
B. Pain along V2 and V3 division of trigeminal nerve
C. Deep seated pain
D. No objective signs of sensory loss
66. What is the most frequently observed form of Guillain-Barre syndrome among the options
provided?
A. Acute motor axonal neuropathy
B. Acute inflammatory demyelinating polyneuropathy
C. Acute motor sensory axonal neuropathy
D. Miller fisher syndrome
67. What is the consequence of thrombosis in the posterior inferior cerebellar artery?
A. Lateral medullary syndrome
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B. Weber syndrome
C. Medial medullary syndrome
D. Millard Gubler syndrome
68. Myasthenia gravis is associated witH___
A. Decreased acetylcholine release at the nerve endings
B. Decreased myosin
C. Absence of troponin C
D. Decreased synaptic transmission at thee myoneural junction
69. Which of the following statements about Weber's syndrome is incorrect?
B. Ipsilateral oculomotor nerve palsy
C. Contralateral parkinsonism
D. Ipsilateral paralysis of lower face
70. What is the typical pattern observed in Brown-Sequard syndrome?
A. Contralateral loss of joint sense and position
B. Contralateral loss of pain sensation
C. Ipsilateral loss of complete sensory functions
D. Contralateral motor functions
71. What medication is employed for mass chemoprophylaxis in the case of meningococcal meningitis?
A. Ciprofloxacin
B. Chloramphenicol
C. Tetracycline
D. Penicillin
72. A patient with a history of a backache for 10 days, has now presented with sudden onset difficulty in
micturition and defaecation. There was no history of a cough or fever previously. What is the diagnosis?
A. Pott's Spine
B. Gullian Barre Syndrome
C. Cauda Equina Syndrome
D. Multiple Sclerosis
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73. A 16-year-old girl, who is taking antiepileptics, has had a seizure-free period of 6 months. She has
no family history of epilepsy. Her EEG is now normal and she has a normal neurological exam and
intelligence. What would your advice be?
A. Stop the treatment and follow up
B. Gradually taper the drug and stop treatment
C. Continue treatment for another 2 years
D. Continue lifelong treatment with antiepileptics
74. A patient presents with left-sided facial paralysis and weakness for the past 1 hour. Her blood
pressure is 160/100 mmHg and CT appears normal. What would be your next step?
A. Nothing, since CT was normal
B. Start on aspirin + clopidogrel
D. Advice BP control
75. A patient walks with a stomping gait. When asked to close his eyes and walk, he is unable to do so.
Which of the following tracts is probably affected?
A. Spinocerebellar tract
B. Posterior column tract
C. Vestibulospinal tract
D. Rubrospinal tract
76. In the sagittal section of the brain given below, if the coloured area is affected, which of the
following is not seen?
A. Urinary incontinence
B. Gait apraxia
C. Perianal anesthesia
D. Fecal incontinence
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77. What is the recommended treatment for a patient who has a severe history of a road traffic accident
and exhibits signs of elevated intracranial pressure upon examination?
A. Administer antibiotics for potential infection.
B. Initiate anticoagulant therapy to prevent blood clot formation.
C. Perform immediate surgical intervention.
D. Administer mannitol
78. In hemiplegia caused by an ischemic stroke, which region of the internal capsule is impacted?
79. Which artery is involved in a patient who presents with vertigo, diplopia, hoarseness, dysphagia, left
Horner's syndrome, and numbness in the left face and right side limbs?
A. Posterior inferior cerebellar artery
B. Superior cerebellar artery
C. Anterior inferior cerebellar artery
D. Basilar artery
80. Which of the subsequent statements accurately describe tremors? PD is characterized by resting
tremor Tremor consist of alternate contraction of agonist and antagonist muscle in an oscillating
rhythmic manner Essential tremor is an uncommon movement disorder affecting 5% of the population
Normal individuals can have physiologic tremors that manifest as mild high frequency, postural or
action tremors
A. 1,2,3 only
B. 2,3,4 only
C. 1,2,4 only
81. A 37-year-old man is brought to the emergency room by his son. He complains of being unable to
move his left arm and leg. According to his son, the patient was reading a book half an hour ago when
he realized he couldn't lift his left arm to pick up another book. As he tried to move away from the table,
he noticed that his left leg also became very weak. Additionally, he experienced double vision. The
patient has a history of hypertension and hyperlipidemia. His body temperature is 36.1°C (97°F), blood
pressure is 165/100 mmHg, pulse is 85 beats/min, and he has a respiratory rate of 16 breaths/min.
During the examination, it is observed that the patient has drooping of the right eyelid and his right eye
is directed downwards and to the side. When requested to smile, there is a drooping of the left corner of
the mouth. The strength of the left upper and lower limbs is rated as 3 out of 5, whereas the strength of
the right upper and lower limbs is rated as 5 out of 5. Which region of his brain has experienced
ischemia among the following options?
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A. Inner capsule
B. Medulla
C. Midbrain
D. Occipital lobe
82. What is the most common cause of Berry aneurysm?
A. Endothelial injury of vessel due to HTN
B. Muscle intimal elastic lamina layer defect
C. Endothelial layer defect
D. Adventitia defect
83. A 65-year-old, male with hypertension develops sudden onset weakness on the right side of the
face & arm. His attender recalls history of headache, blurred vision in the patient which leads to the
suspicion of increased ICP. Which is the most common cranial nerve involved in raised ICP?
A. Abducens nerve
B. Facial nerve
C. Trigeminal nerve
D. Facial nerve
84. What is the recommended method for preventing meningococcal meningitis during pregnancy?
B. Rifampicin
C. Ciprofloxacin
D. Penicillin G
85. Which of the following symptoms is absent in Horner syndrome?
A. Mydriasis
B. Ptosis
C. Anhidrosis
D. Enophthalmos
86. A 16 year old girl, who is taking antiepileptics, has had a seizure-free period of 6 months. She has
intelligence. What would be your advice?
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87. Tigroid white matter on MR imaging is seen in which of the following conditions?
A. Pantothenate kinase deficiency
B. Pelizaeus-Merzbacher disease
C. Neuroferritinopathy
D. Aceruloplasminemia
88. Identify the diagnosis?
A. Facial nerve palsy
B. Plexiform neurofibromatosis
C. Masticator space abscess
D. Fibrous dysplasia
89. Which of the following is not one of the key clinical features used to diagnose Lewy body dementia?
A. Fluctuating cognition
B. Recurrent visual hallucinations
C. REM sleep behaviour disorder
D. Orthostatic hypotension
90. What is the probable diagnosis for a patient experiencing repeated inflammation of the optic nerve
in both eyes along with widespread inflammation of the spinal cord, and exhibiting visual acuity of 6/60
in the right eye and 6/18 in the left eye, with only a partial response to steroid treatment?
A. Neuromyelitis optica
B. Subacute combined degeneration of spinal cord
C. Posterior cerebral artery stroke
D. Neurosyphilis
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91. The given pattern of EEG is found in:
A. Hepatic encephalopathy
B. Creuzfeldt-Jakob disease
C. Generalized tonic clonic seizures
D. Herpes simplex encephalitis
92. What is the correct statement about the condition of a 32-year-old woman who visits the clinic with
complaints of frequent falls and walking difficulties? The patient has a history of smoking and type-1
diabetes but no history of hypertension or coronary artery disease. During examination, the patient
exhibits weakness in both lower limbs, increased reflexes and muscle tone, as well as an unsteady gait.
Furthermore, there is a decrease in proprioception and vibration sense in both lower limbs.
A. Only the dorsal column is involved.
B. All patients with a neurological impairment will show macrocytosis.
C. Vitamin B12 supplements do not improve the condition.
D. Copper deficiency produces similar symptoms.
93. What is the probable diagnosis for a 72-year-old former pilot who visits a neurologist, accompanied
by his wife, exhibiting symptoms of rapidly advancing dementia, myoclonus, ataxia, and visual
impairments? The provided FLAIR MRI scans can assist in confirming the diagnosis.
A. Alzheimer's disease
B. Vascular dementia
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C. Sporadic CJD
D. Variant CJD
94. Mental retardation is seen in?
A. Phenylketonuria
B. Alkaptonuria
C. Albinism
D. MSUD
95. Reversible dementia is seen in?
A. SACD
B. AD
C. CJD
D. Pick's disease
96. Which of the statements below is NOT accurate regarding Parkinson's disease?
A. Manganese can cause secondary Parkinsonism
B. Usage of Carbidopa leads to on and off phenomenon
C. Slight tremor in the hand or foot followed by jaw
D. Cog wheel rigidity or lead pipe rigidity is seen
97. What is the probable diagnosis for a patient who exhibits symptoms of increased urination,
nighttime urination, and involuntary urination, along with a recorded 24-hour urine volume of 7 liters and
a urine osmolarity of 260 mOsm/L? The ADH assay shows a recorded value of 0.8 pg/ml, and an MRI
of the brain reveals the absence of a bright spot on T1 weighted imaging.
98. As an intern in the neurology ward of the Department of Internal Medicine, you encounter a
48-year-old female patient who has been admitted due to muscle weakness. After conducting
investigations and examinations, it is found that her nerve conduction is normal, but she displays signs
of flaccidity. Based on these findings, what possible diagnosis would you consider?
B. GBS
C. Transverse myelitis
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D. Traumatic neuritis
99. What is the most probable diagnosis for a 30-year-old female patient who reports symptoms of
headache, vomiting, absence of menstruation, lactation without pregnancy, decreased sexual desire,
acromegaly, and infertility, along with the presence of bitemporal hemianopia during a physical
A. Corticotroph adenoma
B. Gonadotroph adenoma
C. Mammosomatotroph adenoma
D. Glioma
100. Extensor Reflex on pinching gastrocnemius muscle is called?
A. Gower Sign
B. Homan Sign
C. Oppenheim Sign
D. Gordon Sign
101. A patient was asked to copy the face of a clock and his drawing is shown below. What is the
correct term to be used here?
A. Confabulation
B. Hemispatial neglect
C. Kinetic apraxia
D. Asterixis
102. Which of the following statements about juvenile myoclonic epilepsy is false? Polygenic
inheritance Lamotrigine helps in controlling myoclonic jerks Benzodiazepines alone can control
myoclonic jerks Valproate should be avoided
A. 1,2 & 3 are correct
B. 1&3 are correct
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C. 2& 4 are correct
D. 1,2,3 and 4 are correct
103. What is the probable cause of the patient's condition based on the cerebrospinal fluid (CSF)
specimen shown below, which exhibits mononuclear cytosis, increased proteins, and decreased
sugars?
A. Tuberculous meningitis
B. Aseptic meningitis
C. Bacterial meningitis
D. Chemical meningitis
104. What is the most suitable medication for treating a female patient with galactorrhea, who has
tested negative for pregnancy and has been diagnosed with a significant pituitary tumor through an
MRI, considering her refusal for surgery?
A. Bromocriptine
B. Promethazine
D. Clozapine
105. What is the most probable cause for a 22-year-old man who has a high-grade fever, a purpuric
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D. E.coli
106. Unilateral pulsatile headache in a woman with photophobia and phonophobia which is
exaggerated on eating meals is seen in?
A. Migraine
C. Cluster headache
D. Malingering
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Question 34 1
Question 37 4
Question 39 3
Question 40 2
Question 42 1
Question 43 3
Question 46 4
Question 48 3
Question 50 2
Question 51 2
Question 54 1
Question 55 1
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Question 56 1
Question 57 2
Question 58 3
Question 59 3
Question 62 1
Question 63 4
Question 65 3
Question 66 2
Question 67 1
Question 68 4
Question 69 4
Question 70 2
Question 71 1
Question 74 3
Question 75 2
Question 77 4
Question 78 4
Question 79 1
Question 80 3
Question 81 3
Question 84 1
Question 85 1
Question 86 3
Question 87 2
Question 89 4
Question 90 1
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Question 91 2
Question 92 4
Question 93 4
Question 94 1
Question 95 1
Question 96 2
Question 97 3
Question 98 1
Question 99 3
Question 100 4
Question 101 2
Question 103 1
Question 104 1
Question 105 1
Question 106 1
 The patient's introduction suggests a migraine headache. 
 Sumatriptan is a serotonin 5-HT1B/1D receptor agonist and is considered the drug of choice for acute
administration of migraines. 
 It works by constricting the cranial blood vessels and decreasing the release of inflammatory peptides,
in this manner diminishing the headache and related symptoms.
Option A. Flunarizine: It is a calcium channel blocker that's used for migraine prophylaxis and not for ac
ute administration. It can take weeks to months to attain a therapeutic effect.
Option C. Propranolol: It is a beta-blocker that's moreover utilized for migraine prophylaxis and not for 
acute administration. It can take weeks to months to realize a therapeutic effect.
Option D. Topiramate: It is an anticonvulsant that's moreover utilized for migraine prophylaxis and not f
or acute administration. It can take weeks to months to realize a therapeutic effect.
The hypoglossal nerve is the 12th cranial nerve that controls the movement of the tongue. Injury to this
 nerve can result in a range of symptoms, depending on the location and severity of the injury.
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When the hypoglossal nerve is injured, tongue deviation to the same side as the injury is the most com
mon symptom. This is because the muscles on the affected side of the tongue become weak or paraly
zed while the muscles on the unaffected side remain functional. As a
result, the tongue will protrude towards the affected side, away from the midline.
a. Tongue deviation to the contralateral side is incorrect as it suggests that the tongue would move tow
ards the opposite side of the injury. However, this is not a
typical presentation of hypoglossal nerve injury.
c. Falling of the tongue is also incorrect, as this is a nonspecific symptom that could occur due to vario
us reasons, including weakness or paralysis of the tongue muscles. It is not a
specific symptom of hypoglossal nerve injury.
d. Inability in tongue protrusion is also incorrect. This symptom would suggest complete paralysis of th
e tongue muscles on the affected side, which is not always the case with hypoglossal nerve injury. In s
ome cases, the tongue can still be protruded, albeit with deviation towards the affected side.  
The correct answer is Option B - Respiratory alkalosis
Respiratory alkalosis is a condition characterized by a
higher-than-normal blood pH (alkaline) due to an increase in respiratory rate and a
decrease in carbon dioxide levels (hypocapnia). It can occur at high altitudes as a physiological respon
se to the reduced oxygen availability (hypoxia) that is commonly encountered at higher elevations. Her
e's how respiratory alkalosis can occur at high altitude:
Hyperventilation: At high altitudes, the partial pressure of oxygen (PO2) in the atmosphere decreases d
ue to lower oxygen concentration. As a result, the body's respiratory centers are stimulated, leading to 
an increase in respiratory rate (hyperventilation). This hyperventilation is an attempt to compensate for 
the reduced oxygen levels by increasing the removal of carbon dioxide (CO2) from the body.
CO2 Washout: The increased respiratory rate leads to a greater exhalation of carbon dioxide. Carbon 
dioxide is an acidic waste product that can combine with water in the blood to form carbonic acid (H2C
O3). When CO2 is removed from the blood through hyperventilation, it reduces the concentration of car
bonic acid and shifts the balance towards alkalinity.
Shift in Blood pH: With reduced CO2 levels, there is less carbonic acid formed, and this results in an in
crease in blood pH (alkalosis). The normal acid-base balance of the blood is disrupted, leading to respi
ratory alkalosis.
Other options are incorrect.
 The clinical presentation of the patient, including fever, headache, ataxia, nausea, vomiting, and neck
rigidity, suggests meningitis. The findings from the CSF analysis also support this diagnosis. The
presence of increased opening pressure, cloudy white color, neutrophil-predominant leukocytosis, low
CSF/serum glucose ratio, and elevated protein levels are all indicative of meningitis.
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 The positive latex agglutination test and negative Limulus lysate test suggest bacterial etiology. The
most common bacterial cause of meningitis in young adults is Neisseria meningitidis, followed by
Streptococcus pneumoniae and Haemophilus influenzae. The neutrophil-predominant leukocytosis and
low CSF/serum glucose ratio are typical of bacterial meningitis.
Incorrect choices: 
 Option b: tubercular meningitis. The positive latex agglutination test is suggestive of tuberculosis, and
the presence of neutrophil-predominant leukocytosis is typical of early-stage tubercular meningitis. The
low CSF/serum glucose ratio is also a characteristic finding in tubercular meningitis. But it is not the
correct option.
 Option c: Viral meningitis is typically a self-limiting condition caused by various viruses, including
enteroviruses, herpes simplex virus, and varicella-zoster virus. The clinical presentation of viral
meningitis is like bacterial meningitis and includes symptoms such as fever, headache, neck stiffness,
and photophobia. However, the CSF findings in viral meningitis are usually different from bacterial or
tubercular meningitis. In viral meningitis, the CSF typically shows lymphocytic pleocytosis, with normal
or slightly elevated protein levels and normal glucose levels.
 Option d: Fungal meningitis can also present with similar symptoms and CSF findings, including
increased opening pressure, low glucose, and elevated protein. However, fungal meningitis is rare and
usually occurs in immunocompromised individuals.  
Correct Option B - Type 2 hypersensitivity reaction:
 The type of hypersensitivity reaction seen in myasthenia gravis is a type 2 hypersensitivity reaction.
Hypersensitivity reactions are exaggerated immune responses that can cause tissue damage and
disease. They are classified into four types based on the mechanism of the immune response and the
timing of the reaction.
 Type 2 hypersensitivity reactions are caused by the activation of complement and the binding of IgG
or IgM antibodies to specific cells or tissues. This results in destruction of the target cells by
complement-mediated lysis, opsonization, or antibody-dependent cell-mediated cytotoxicity (ADCC).
Examples of type 2 hypersensitivity reactions include autoimmune hemolytic anemia, Goodpasture
syndrome, and myasthenia gravis.
 Myasthenia gravis is an autoimmune disorder that affects the neuromuscular junction and is caused
by the presence of autoantibodies that target and destroy acetylcholine receptors in muscle cells. This
results in muscle weakness and fatigue, particularly in the muscles responsible for eye movement,
swallowing, and breathing. The autoantibodies in myasthenia gravis are primarily of the IgG subtype
and lead to complement-mediated destruction of the acetylcholine receptors.
Option A - Type 1 hypersensitivity reaction: It is also known as immediate hypersensitivity reactions, ar
e caused by the release of IgE antibodies in response to an allergen. These reactions typically occur wi
thin minutes of exposure and can cause symptoms such as hives, itching, and anaphylaxis.
Option C - Type 3 hypersensitivity reaction: It is caused by the formation of immune complexes that de
posit in tissues, leading to inflammation and tissue damage. Examples of type 3
hypersensitivity reactions include systemic lupus erythematosus (SLE) and rheumatoid arthritis.
Option D - Type 4
hypersensitivity reaction: It is also known as delayed-type hypersensitivity reactions, are mediated by T
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cells and occur hours to days after exposure to an antigen. Examples of type 4
hypersensitivity reactions include contact dermatitis and some forms of drug reactions.
 A subarachnoid hemorrhage is a type of bleeding that occurs in the space between the brain and the
thin tissues that cover it. It is often caused by the rupture of a blood vessel, such as an aneurysm. 
 A severe headache is the hallmark symptom of a subarachnoid hemorrhage, often described as the
"worst headache of my life." The presence of hypertension and nuchal rigidity further supports this
diagnosis.
 .It is important to promptly assess and manage this condition, as it can be life-threatening. 
 Option A: Cluster headache: Cluster headaches are a type of primary headache disorder
characterised by severe, unilateral (one-sided) pain that is often centred around the eye. They are
called cluster headaches because they tend to occur in clusters or cycles, with frequent attacks over a
period of weeks to months followed by periods of remission. Cluster headaches are not associated with
hypertension or nuchal rigidity.
 Option C: Encephalitis: Inflammation of the brain, usually caused by an infection, such as a viral or
bacterial infection. While headache can be a symptom of encephalitis, it is not specific to this condition.
Encephalitis often presents with other symptoms such as fever, altered mental status, seizures, and
focal neurological deficits. Other signs, such as behavioral changes, abnormal movements, and
sensitivity to light, may be present in encephalitis.
 Option D: Meningitis: Meningitis is an infection or inflammation of the meninges. It can be caused by
various infectious agents, including bacteria, viruses, and fungi. Meningitis commonly presents with
symptoms such as severe headache, fever, neck stiffness (nuchal rigidity), and sensitivity to light
(photophobia). Other signs and symptoms, such as altered mental status, nausea and vomiting,
seizures, and a characteristic rash (in bacterial meningitis), may also be present.   
Guillain-Barre syndrome (GBS)-
 is a rare neurological disorder characterized by progressive muscle weakness and loss of reflexes. 
 The weakness in GBS is symmetrical and ascending, meaning it starts in the lower limbs and moves
upward symmetrically.
Incorrect Choices: 
 Option B: Myasthenia gravis: Myasthenia gravis is an autoimmune disorder characterized by muscle
weakness and fatigue. However, the weakness in myasthenia gravis typically worsens with repeated
use of the affected muscles and improves with rest. In addition, myasthenia gravis often affects the
muscles of the face and eyes before involving the limb
 Option C: Polymyositis: Polymyositis is an inflammatory muscle disease that causes symmetric
weakness in the proximal muscles (muscle) . deep tendon reflexes are usually preserved.
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 Opton D: Multiple sclerosis: Multiple sclerosis is a chronic autoimmune disease that primarily affects
the central nervous system . It does not typically present with ascending weakness or areflexia as seen
in GBS. Moreover, multiple sclerosis is not usually associated with a preceding respiratory tract
infection.  
 Liposomal amphotericin B is the preferred initial therapy for severe cryptococcal meningitis due to its
higher efficacy and better penetration into the central nervous system. 
 It is usually combined with flucytosine for induction therapy.
 Option A: Vancomycin is primarily used to treat bacterial infections, particularly those caused by
MRSA. It has no activity against fungal infections such as cryptococcal meningitis.
 Option B: High dose fluconazole with flucytosine: Fluconazole is commonly used for the treatment and
maintenance therapy of cryptococcal meningitis. Flucytosine works synergistically with fluconazole.
However, in severe cases like the one described in the scenario, initial induction therapy with liposomal
amphotericin B is preferred over fluconazole-based therapy. 
 Option C: Voriconazole is primarily used to treat invasive aspergillosis and other filamentous fungal
infections. It does not have significant activity against Cryptococcus species.  
 Pseudotumor cerebri, also known as idiopathic intracranial hypertension (IIH), is the probable cause
of the woman's headaches based on the information provided. 
 Pseudotumor cerebri is a condition characterized by increased intracranial pressure without any
identifiable cause, such as a tumor. 
 Option A; Myasthenia gravis: results in muscle weakness and fatigue. It is not typically associated
with headaches or papilledema.
 Option B: Temporal arteritis: also known as giant cell arteritis, is an inflammatory condition that affects
the blood vessels, especially the temporal arteries. It commonly presents with headaches, but there are
additional symptoms such as scalp tenderness, jaw pain, and vision problems. Fundal examination
may reveal ischemic optic neuropathy rather than papilledema. Additionally, temporal arteritis is more
commonly seen in older individuals.
 Option C: Chronic migraine: is a subtype of migraine headache that occurs on 15 or more days per
month for at least three months. While chronic migraines can cause daily headaches, they are usually
not associated with worsening in a recumbent position or papilledema.   
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 Option B: Upper and lower halves of the face are contralateral:Bell's palsy, on the other hand, affects
the facial nerve on the same side of the body, so the symptoms would not be contralateral.
 Option C: This option is incorrect because Bell's palsy affects both the upper and lower halves of the
face on the same side. It is not restricted to the lower half.
 Option D: Contralateral lower half of the face: For the same reasons as option B, this option is
incorrect. Bell's palsy does not affect the opposite side of the face or only the lower half of the face.  
 According to the vignette, the patient suffers from Parkinson’s disease. Parkinson’s disease is a
neurological disorder that occurs due to damage to neural cells in the substantia nigra. Substantia nigra
is a part of the basal ganglia. Parkinson’s disease results in tremors, rigidity, bradykinesia or akinesia
and postural instability, similar to the patient’s.
 Option b. The hippocampus consists of the dentate gyrus and the Cornu Ammonis. The hippocampus
is responsible for learning and memory. Damage to it causes amnesia that prevents patients from
forming new memories and/or recalling old ones. The patient in the vignette does not have any memory
problems. Hence, he has a normal, unaffected hippocampus.
 Option c. The cerebellum is responsible for the coordination of motor functions. A defect in it causes
ataxia, Intention tremors, akinesia, bradykinesia, dysphagia and fatigue of \which are absent in the
patient.
 Option d. The premotor cortex is responsible for the selection of movements. It also helps initiate
movements. Damage to the premotor cortex causes apraxia- the inability to perform skilled actions-
and deficits in contralateral fine motor control. 
 
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 According to the vignette, the patient has a headache, fever and confusion, with a presentation of
seizures in the emergency room. These signs are very indicative of meningitis, for which an MRI done
of the patient shows inflammation of the temporal lobe. Temporal lobe involvement during meningitis is
a pathognomic feature of Herpes Meningoencephalitis.
 Herpes simplex virus causes meningitis that involves the temporal lobe, most often, and the frontal
lobe.
 MRI brain shows, hyperintensity in the temporal lobe.
 Bilateral involvement is more common.
 Option a. Cytomegalovirus is a common cause of meningitis in adulthood. It preferentially infects the
ventricular and/or subventricular areas as it replicates in the neural stem or precursor cells residing in
that area. It very rarely causes inflammation of the temporal lobe.
 Option b. Toxoplasma gondii is a microbe that causes encephalitis of the brain. It predominantly
affects the brain's white matter surrounding the basal and basal ganglia. MRI of the brain in
toxoplasmosis shows multiple ring-enhancing regions all over the brain’s cerebral hemispheres. It is not
localised to the temporal lobes, like that seen in the patient.
 Option d. Mycobacterium tuberculosis causes inflammation of the meninges alone and very rarely
causes encephalitis. On an MRI, there is an enhancement of the leptomeningeal junction because of
the sedimentation of infectious material there. There is also an enhancement of the linear
periventricular region. Temporal lobes bilaterally are not affected.
 
Option D: Spironolactone
 The ECG of the patient shows signs of hyperkalemia that include peaked T-waves, PR interval
widening, and QRS interval widening.
 Hyperkalemia is a common side effect of potassium-sparing diuretics like spironolactone. 
 Spironolactone works to stop sodium reabsorption in the collecting tubule by blocking aldosterone
receptors.
 This causes the prevention of excessive K+ excretion in the urine and reduced water retention
causing increased levels of potassium i.e., hyperkalemia.
Option A: Prazosin
 Prazosin is an alpha-channel blocker that has a common side of orthostatic hypotension. Patients
consuming prazosin also present with first-dose hypotension. Because of these reasons, it is advised to
the patient to consume this tablet in the evening. It does not cause electrolyte abnormalities.
Option B: Metoprolol
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 Metoprolol is a beta blocker that causes bradycardia, hypotension, and arrhythmias when used for a
long period of time. It does not have any effect on the cells of the nephrons and hence does not alter
the excretion of potassium. 
Option C: Hydrochlorothiazide
 Hydrochlorothiazide is a thiazide diuretic that acts on the distal convoluted tubules of the nephrons. Its
side effects include hyperglycemia, hyperlipidemia, hyperuricemia, hypercalcemia, and hypokalemia.
 
Correct Option A- Parkinson’s disease: Parkinson’s disease is a movement disorder that affects the ne
rvous system. Its symptoms occur because of low dopamine levels in the brain.
 Early signs of the disease include tremors, a loss of a sense of smell, and coordination problems. It is
also many times accompanied by depression, visual hallucinations, and convulsions.
 On biopsy, of the brain of patients with Parkinson’s disease the presence of Lewy bodies, and unusual
clumps of the protein alpha-synuclein, are found.
Option B- Prion disease: Prion diseases are rare, fatal neurodegenerative disorders caused by misfold
ed prion proteins (PrP) in the brain. This can lead to memory loss, behavior changes, and movement p
roblems. There is no presence of Lewy bodies in these patients.
Option C- Huntington’s chorea: Huntington’s disease is a progressive brain disorder that causes uncon
trolled movements, emotional problems, and loss of thinking ability (cognition). Affected individuals ma
y have trouble walking, speaking, and swallowing. Huntington’s is rarely associated with depressive sy
mptoms like that present in the patient in the vignette.
Option D- Alzheimer's disease: Alzheimer’s disease is a type of dementia that affects memory, thinking
, and behavior. Symptoms eventually grow severe enough to interfere with daily tasks. There is a notab
le shrinking of the brain noticed in patients with Alzheimer’s and on biopsy, there is an increase in beta-
amyloid content or tau proteins.
 
Option B. DDAVP supplementation for lifelong:
 The patient underwent hypophysectomy following which he developed symptoms of polyuria with an
increase in serum sodium concentration and urine osmolality.
 These findings are indicative of central diabetes insipidus which is a result of inefficient function of the
pituitary. DDAVP (1-deamino-8-D-arginine vasopressin) is a synthetic analog of vasopressin, having a
prolonged action profile with minimal vasopressor activity.
 It can be administered orally, intranasally, subcutaneously, or intravenously.
 This patient requires its administration lifelong due to the loss of pituitary function.
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 Option A. DDAVP for 2 weeks and then discontinue: Since the patient has central diabetes insipidus
due to the loss of pituitary function permanently, the patient requires DDAVP (vasopressin) for a lifetime
and not 2 weeks only.
 Option C. Upsetting of receptors so no treatment is required: Since the patient has a deranged serum
sodium level and an abnormal urine osmolality, treatment needs to be provided. Also, the patient has
developed central diabetes insipidus after the surgery which is a disorder of insufficient secretion of
ADH and not receptors.
 Option D. Thiazides for 2 weeks: Thiazides are used to treat nephrogenic diabetes insipidus which
results due to the absence of vasopressin receptors on the nephrons. The patient has central diabetes
insipidus and is not nephrogenic, making this treatment with thiazides inefficient for him.
 
Correct Option - Posterior limb:
 The posterior limb of the internal capsule contains the corticospinal tract, which is responsible for
motor control of the limbs. Damage to this area can lead to contralateral hemiparesis, as seen in the
patient's left-sided weakness.
Option A - Retrolentiform: Damage to the retrolentiform part of the internal capsule would typically resul
t in sensory deficits, such as loss of sensation or abnormal sensation, rather than hemiparesis.
Option B - Sublentiform: Similar to the retrolentiform part, damage to the sublentiform part of the intern
al capsule is more likely to produce sensory deficits rather than hemiparesis.
Option C - Anterior limb: Damage to the anterior limb of the internal capsule can cause a variety of sym
ptoms, including contralateral weakness, but it usually affects the face more than the limbs. Therefore, 
it is less likely to be the cause of the isolated left-sided hemiparesis described in the scenario.
Correct Option B - Subthalamic nucleus:
 Hemiballismus is a movement disorder characterized by sudden, involuntary, and violent flinging
movements of one side of the body.
 It is typically caused by a lesion in the subthalamic nucleus (STN) of the basal ganglia.
Option A - Putamen: Lesions in the putamen are associated with chorea, not hemiballismus. Chorea is 
characterized by brief, irregular, and jerky movements.
Option C - Caudate nucleus: Lesions in the caudate nucleus are associated with Huntington's disease, 
which causes chorea as well. Hemiballismus is not specifically related to caudate nucleus lesions.
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Option D - Globus pallidus: Lesions in the globus pallidus can cause various movement disorders, suc
h as dystonia or Parkinson's disease, but they are not specifically associated with hemiballismus.
Correct Option A - B and D:
 The symptoms described in the question are consistent with a syndrome known as Wallenberg
syndrome or lateral medullary syndrome.
 This syndrome is caused by a lesion in the lateral part of the medulla oblongata, specifically involving
the lateral medulla.
 The features of Wallenberg syndrome -
 ipsilateral Horner's syndrome (ptosis, miosis, anhidrosis), Ipsilateral loss of pain and temperature
sensations in the face (due to involvement of the spinal trigeminal nucleus and tract), Vertigo with
numbness (due to involvement of the vestibular nuclei) Dysarthria on the contralateral side (due to
involvement of the corticobulbar fibers).
 Ipsilateral loss of pain and temperature sensations in the face (due to involvement of the spinal
trigeminal nucleus and tract),
 Vertigo with numbness (due to involvement of the vestibular nuclei)
 Dysarthria on the contralateral side (due to involvement of the corticobulbar fibers).
Option B - B, C, D: Lateral medulla lesions can cause the presented symptoms in question, but the ven
tromedial medulla does not because lesions in these areas would typically result in different sets of sy
mptoms.
Option C - A, B, C: Lateral medulla lesions can cause the presented symptoms in question, but the me
dial medulla and ventromedial medulla do not because lesions in these areas would typically result in d
ifferent sets of symptoms, such as contralateral hemiparesis and tongue deviation, rather than the spec
ific symptoms mentioned in the question.
Option D - A and B: Medial medulla lesions do not cause the presented symptoms.
Correct Option D - Syringomyelia:
 Syringomyelia is a neurological condition in which the spinal cord develops a fluid-filled cyst (syrinx).
 The syrinx can enlarge to the point that it injures the spinal cord and the nerve fibers that transmit
signals from the brain to the body.
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 Loss of pain and temperature sensation, with intact touch sensation, is indicative of syringomyelia.
Option A - Brown-Sequard syndrome: Brown-Sequard syndrome involves loss of joint position and vibr
ation senses and motor deficits on the same side of the lesion and contralateral pain and temperature i
s lost.
Option B - Tabes dorsalis: Tabes dorsalis is associated with sensory ataxia, lightning-like pain, and imp
aired proprioception, differing from the symptoms described.
Option C - Syringobulbia: Syringobulbia refers to the presence of a
syrinx (fluid-filled cavity) in the brainstem, which is not described in the case.
Correct Option A - Contralateral hemiplegia:
 Contralateral hemiplegia refers to weakness or paralysis affecting one side of the body that is
opposite to the side of the lesion. However, contralateral hemiplegia is not characteristic of lesions
within the spinal cord. It is more commonly associated with brainstem lesions.
Option B - Fasciculation at the level of the lesion: Fasciculation refers to involuntary muscle twitches or
 contractions. If fasciculation is observed at the uppermost level of the lesion in the spinal cord, it can p
rovide clues about the involvement of the corresponding spinal cord segment. Therefore, fasciculation 
can help in localizing the lesion.
Option C - Upper motor neuron (UMN) lesion and lower motor neuron (LMN) lesion: UMN and LMN les
ions indicate damage to different parts of the nervous system. UMN lesions involve the descending mo
tor pathways(corticospinal) originating from the brain and traveling through the spinal cord, while LMN l
esions affect the peripheral nerves or nerve roots exiting the spinal cord. The presence of UMN or LMN
 signs and symptoms can provide valuable information about the location of the lesion within the spinal 
cord.
Option D - Bladder involvement: Bladder involvement, such as urinary retention or incontinence, can in
dicate dysfunction or damage to the nerves controlling bladder function within the spinal cord. The spe
cific pattern of bladder involvement can help localize the transverse lesion within the spinal cord.
 
Correct Option A - Complete transection of spinal cord:
 Complete transection of the spinal cord is not a feature of Brown-Séquard syndrome. Brown-Séquard
syndrome is a specific pattern of spinal cord injury characterized by a hemisection of the spinal cord
(one half of the spinal cord is damaged or severed).
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Option B - Ipsilateral loss of vibration and touch: This is a
characteristic feature of Brown-Séquard syndrome.
Option C - Contralateral loss of pain and temperature: This is another feature of Brown-Séquard syndr
ome. The side of the body opposite to the lesion (contralateral side) will exhibit a
loss of pain and temperature sensation.
Option D - Ipsilateral loss of proprioception: This is also a feature of Brown-Séquard syndrome. The sid
e of the body with the lesion (ipsilateral side) will experience a loss of proprioception, which refers to th
e ability to sense the position and movement of one's own body.
Correct Option C - Upper motor neuron:
 Upper motor neuron lesion: An exaggerated reflex, also known as hyperreflexia, is a clinical finding
associated with dysfunction or pathology involving the upper motor neuron system.
Option A - Polyneuropathy: Polyneuropathy refers to a condition that affects multiple peripheral nerves.
 It typically results in sensory and motor deficits rather than exaggerated reflexes. In polyneuropathy, re
flexes may be diminished or absent due to the involvement of peripheral nerves.
Option B - Radiculopathy: Radiculopathy refers to compression, irritation, or damage to the nerve roots
 as they exit the spinal cord. Although radiculopathy can lead to abnormal reflexes, the reflexes are usu
ally diminished or weakened rather than exaggerated.
Option D - Lower motor neuron: Lower motor neuron lesions typically result in diminished or absent refl
exes rather than exaggerated reflexes. Damage or dysfunction in the lower motor neuron, which includ
es the spinal cord and peripheral nerves, can lead to decreased reflex activity.
 
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Correct Option C - Amphotericin B + flucytosine:
 Based on the clinical presentation and the results of the lumbar puncture, this patient is most likely
suffering from fungal meningitis. The WBC count is what gives away the diagnosis, hence,
Amphotericin B an anti-fungal will be used for the treatment. Amphotericin B is typically used in
conjunction with flucytosine to combat some fungal illnesses because it increases the uptake of
flucytosine by fungi.
Option A, B and D are not used to treat patients with fungal meningitis.
Correct Option C: Lewy body
 Lewy body dementia is generally considered a progressive condition with irreversible cognitive
decline. It commonly presents with cognitive impairment, visual hallucinations, and fluctuations in
alertness and attention
Option A: NPH (Normal Pressure Hydrocephalus): NPH is a condition characterized by the accumulati
on of cerebrospinal fluid in the brain's ventricles, leading to enlarged ventricles. It can cause a triad of s
ymptoms known as Hakim's triad, which includes gait disturbances, urinary incontinence, and cognitive
 impairment. NPH is potentially reversible with the surgical placement of a
shunt to drain the excess cerebrospinal fluid, thus alleviating the symptoms of dementia.
Option B: Hypothyroidism: Hypothyroidism occurs when the thyroid gland fails to produce an adequate 
amount of thyroid hormones. This condition can lead to various symptoms, including cognitive impairm
ent, depression, and memory problems. Reversing hypothyroidism through hormone replacement ther
apy can often result in the resolution or improvement of the associated cognitive symptoms.
Option D: Vitamin B12 deficiency: Vitamin B12 is essential for the proper functioning of the nervous sys
tem, and its deficiency can lead to neurological symptoms, including cognitive impairment and dementi
a-like symptoms. Replenishing vitamin B12 levels through supplementation or dietary changes can ofte
n reverse or improve the associated cognitive symptoms.
Correct Option A: Agranulocytosis
 Clozapine is an atypical antipsychotic medication commonly used in the treatment of schizophrenia.
While it can be an effective treatment, it is associated with certain side effects that require close
monitoring.
 One of the most significant side effects of clozapine is agranulocytosis, defined as neutrophil count of
less than 0.5 × 109/L (500/µL). Thus, blood cell counts are monitored.
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 On starting clozapine, blood counts are monitored every week for 6 months, then every other week for
6 months, then monthly, if all neutrophil counts are adequate. 
Option B:  Myocarditis: While clozapine can potentially cause myocarditis, it is a rare side effect. It typic
ally presents with symptoms such as chest pain, shortness of breath, and an abnormal increase in cert
ain cardiac enzymes. However, regular blood monitoring is not primarily performed to detect myocarditi
s.
Option C:  Cerebral bleed: Cerebral bleeding, or intracranial hemorrhage, is not a commonly reported s
ide effect of clozapine nor does regular blood tests help in assessing risk or occurrence of one.
Option D:  Seizures: Seizures can occur as a side effect of clozapine, particularly at higher doses. How
ever, regular blood monitoring is not useful in assessing risk for seizures.
Correct Option A: Creutzfeldt jakob disease
 Creutzfeldt-Jakob disease (CJD) is a neurodegenerative disorder characterized by the abnormal
accumulation of misfolded prion proteins in the brain. Prions are infectious agents composed of
abnormal isoforms of the prion protein (PrP). These misfolded proteins can induce the conversion of
normal PrP into the abnormal form, leading to the accumulation of amyloid plaques in the brain tissue.
This accumulation of misfolded proteins contributes to the progressive neurodegeneration seen in CJD.
Option B: Nephritic syndrome: Nephritic syndrome is a kidney disorder characterized by inflammation o
f the glomeruli, which are the filtering units of the kidney. It is primarily associated with immune-mediat
ed damage and not the accumulation of misfolded proteins.
Option C: Sickle cell anemia: Sickle cell anemia is a genetic disorder characterized by the presence of 
abnormal hemoglobin molecules in red blood cells. It is caused by a mutation in the hemoglobin gene, 
resulting in the production of abnormal hemoglobin S. While there is an abnormality in the structure of 
hemoglobin in sickle cell anemia, it does not involve the accumulation of misfolded proteins as seen in 
CJD.
Option D: Megaloblastic anemia: Megaloblastic anemia is a type of anemia characterized by the prese
nce of large, immature red blood cells (megaloblasts) in the bone marrow. It is typically caused by defic
iencies in vitamin B12 or folate. Megaloblastic anemia does not involve the accumulation of misfolded 
proteins
 The use of analgesics and anti-migraine medications frequently or regularly can increase headache
frequency and cause the transition from episodic to chronic headache. A patient who previously
experienced primary headaches and who takes analgesics on average of 15 days per month,
anti-migraine medications (triptans or ergot alkaloids), opioid medications, or combined analgesics on
average of 10 days per month is said to have a chronic headache caused by medication overuse.
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Option B: Tension headache is the most common one. There may be a feeling of a band around the he
ad or pressure at the vertex, and the pain is described as "dull," "tight," or as "pressure."
Option C: Migraine sufferers describe a
prodrome of fatigue, agitation, or behavioural changes that last for a
few hours or days. Typical migraine symptoms include a
strong, throbbing headache, photophobia, phonophobia, and vomiting that lasts 4 to 72 hours.
Option D: The 'cluster', which consists of runs of identical headaches starting at the same time and last
ing for weeks at a time. Cluster headaches are notably periodic.
In this case, the patient's symptoms of fatiguability, ptosis, difficulty in speech and swallowing are char
acteristic of myasthenia gravis
 Myasthenia gravis is an autoimmune disorder characterized by muscle weakness and fatiguability,
especially with repetitive use. It commonly affects the muscles controlling eye movements (causing
ptosis and diplopia), facial muscles (causing difficulty in speech and swallowing), and the skeletal
muscles of the limbs.
 The fatiguability typically improves with rest. Myasthenia gravis is caused by the production of
autoantibodies that block or destroy the acetylcholine receptors at the neuromuscular junction, leading
to impaired transmission of nerve impulses to the muscles.
Option B: Lambert-Eaton syndrome
 Lambert-Eaton syndrome (LES) is a rare autoimmune disorder characterized by muscle weakness
and fatiguability. It is often associated with an underlying malignancy, particularly small cell lung
cancer.
 Unlike myasthenia gravis, the weakness in LES typically improves with repeated muscle use
(post-exercise facilitation). In LES, autoantibodies target the presynaptic voltage-gated calcium
channels at the neuromuscular junction, leading to decreased release of acetylcholine.
Option C: Duchenne muscular dystrophy
 Duchenne muscular dystrophy (DMD) is a genetic disorder characterized by progressive muscle
weakness and wasting. It primarily affects boys and usually becomes evident in early childhood.
 Unlike myasthenia gravis, the weakness in DMD is not fatigable and typically involves the proximal
muscles of the limbs. DMD is caused by mutations in the dystrophin gene, leading to the absence or
dysfunction of dystrophin, an important protein for maintaining muscle integrity.
Option D: Systemic lupus erythematosus (SLE)
 Systemic lupus erythematosus is a chronic autoimmune disease that canaffect multiple organ
systems, including the musculoskeletal system. Muscle weakness and fatigue can occur in patients
with SLE, but it is not the primary feature of the disease.
 Other manifestations of SLE, such as arthritis, rash, renal involvement, and serositis, are typically
more prominent.
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Option A.
Office headache is the name given to indicate the pain pattern in frontal sinusitis. In this condition, Pain
 occurs in a specific time-bound ascending pattern. The Pain usually occurs near the brows.
 
Option B. In maxillary sinusitis, the Pain is characterized by aggravation on leaning forward or stooping
 forward.
Option C. Migraine headaches are characterized by an aura (classical) and sensory disturbances. Pain
 occurs mainly unilaterally.
Option D. In temporal arteritis, Pain mainly occurs in the temporal region. Pain is usually frequent and s
evere. Tenderness is also present over temples.
Option D.
Levetiracetam does not interact with other drugs, is excreted through the kidney, and has rapid onset a
ction. So it is used as the most preferred antiepileptic drug during pregnancy.
Option A. Exposure to Phenytoin can result in a complication called fetal hydantoin syndrome.
Option B. Exposure to Valproate can result in fetal Valproate syndrome.
Option C. Carbamazepine has teratogenic effects, such that it can cause developmental delay, growth 
retardation, and abnormal IQ.
Option B.
Subacute Sclerosing Panencephalitis occurs due to the reactivation of the measles virus or an inappro
priate immune response to the measles virus.
 
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Option A. Complications of mumps are expressed as inflammation of various organs such as orchitis, o
ophoritis, encephalitis, pancreatitis, etc.
Option C. Complications of rubella include heart problems, loss of hearing and eyesight, intellectual dis
ability, and liver or spleen damage.
Option D. The respiratory syncytial virus causes complications of the respiratory tract only.
Option A.
Naloxone sodium is used as an antidote for opioid poisoning cases. This is because Naloxone can bloc
k opioid receptors.
Option B. Flumazenil is used as the antidote for Benxodiazepene poisoning.
Option C. Fomepizole is used as an antidote in case of methanol poisoning.
Option D. Pethidine itself is a
kind of opioid used for relieving pain. The antidote for pethidine is Naloxone.
 
 The elderly woman's symptoms of behavioral change, history of falls, urinary incontinence, and
dementia are consistent with Normal Pressure Hydrocephalus (NPH). NPH occurs due to impaired
CSF absorption, leading to enlarged ventricles and the characteristic symptoms of Hakim's triad , which
includes gait disturbance (difficulty walking), cognitive impairment (dementia), and urinary incontinence.
Option B. Frontotemporal dementia: Frontotemporal dementia is a form of dementia characterized by p
rogressive changes in behavior, personality, and language difficulties. While behavioral changes and d
ementia are present in this case, urinary incontinence and gait disturbance are less commonly associat
ed with frontotemporal dementia.
Option C. Parkinson's disease: Parkinson's disease primarily presents with movement-related sympto
ms such as tremors, rigidity, bradykinesia (slowness of movement), and postural instability. While urina
ry incontinence and cognitive impairment can occur in advanced stages, they are not typically the pred
ominant features of Parkinson's disease.
Option D. Creutzfeldt-Jakob disease: Creutzfeldt-Jakob disease (CJD) is a rare degenerative neurologi
cal disorder that leads to rapid cognitive decline, involuntary movements, and muscle stiffness. The sy
mptoms progress rapidly, usually over a few months. While cognitive impairment is seen in CJD, the pr
esence of gait disturbance and urinary incontinence is less typical.
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 Fluent aphasia: This is the correct answer. Lesions in the posterior part of the superior temporal gyrus
typically result in fluent aphasia. Fluent aphasia, also known as Wernicke's aphasia, is characterized by
fluent speech with normal grammar and syntax but impaired comprehension and poor word choice.
Patients with fluent aphasia may produce speech that is fluent and effortless but lacks meaning and
coherence.
Option B. Non-fluent aphasia: This is an incorrect choice. Non-fluent aphasia, also known as Broca's a
phasia, is associated with lesions in the frontal lobe, particularly the posterior part of the frontal gyrus. It
 is characterized by non-fluent, effortful speech with impaired grammar and syntax but relatively preser
ved comprehension.
Option C. Anomic aphasia: This is an incorrect choice. Anomic aphasia is characterized by difficulty in f
inding and producing the appropriate words. It is typically associated with lesions in various regions of t
he brain, including the temporal and parietal lobes.
Option D. Conduction aphasia: This is an incorrect choice. Conduction aphasia is associated with lesio
ns in the arcuate fasciculus, a white matter tract connecting Broca's area and Wernicke's area. It is cha
racterized by difficulty repeating words and phrases despite intact comprehension and relatively fluent 
speech production.
Option A.
Port Wine Stain is a phenomenon seen in children. It is a
kind of hemangioma. It is usually present at birth and later fades with age. But it does not disappear. A
hemangioma is, in fact, a vascular birthmark.
Option B. Melanoma is one of the most severe skin cancer. It is seen as a
black-coloured mark on the skin.
Option C. Molluscum contagiosum is a
viral infection where the lesions are present in the form of dome-shaped pearly lesions.
Option D. Squamous cell carcinoma is the cancer of the skin's outer and middle layer squamous cells.
Option D.
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Contralateral loss of vibration is not a characteristic feature of Brown-Sequard Syndrome. In this syndr
ome, the loss of sensation occurs on the same side (ipsilateral) as the spinal cord injury. The incorrect 
option implies a loss of vibration sensation on the opposite side of the injury, which is not a
typical finding in Brown-Sequard Syndrome.
Brown-Sequard Syndrome is a neurological condition characterized by damage to one side of the spin
al cord, leading to specific sensory and motor deficits. The correct features associated with Brown-Seq
uard Syndrome are as follows:
Option A. It is feature of Brown-Sequard Syndrome
Option B. It is feature of Brown-Sequard Syndrome
Option C. It is feature of Brown-Sequard Syndrome
 Incongruous homonymous hemianopia refers to a visual field defect where there is loss of vision on
one side of the visual field in both eyes, but the defect does not match exactly between the eyes. In this
case, the lesion causing the incongruous homonymous hemianopia is associated with Wernicke's pupil.
 Wernicke's pupil, also known as an afferent pupillary defect or Marcus Gunn pupil, is a condition
where there is a relative pupillary dilation in response to direct light stimulation in the affected eye. It
indicates dysfunction of the afferent pathway carrying visual information from the retina to the brain.
 Incorrect options:
Option B) Visual cortex: Lesions in the visual cortex, which is located in the occipital lobe at the back of
 the brain, can cause visual field defects, but they typically result in congruous homonymous hemianopi
a. In congruous hemianopia, the defect matches between the eyes. Wernicke's pupil is not associated 
with lesions in the visual cortex.
Option C) Optic radiations: The optic radiations are nerve pathways that carry visual information from t
he visual cortex to the lateral geniculate nucleus (LGN) in the thalamus. Lesions in the optic radiations 
can cause visual field defects, but they typically result in congruous hemianopia. Wernicke's pupil is not
 associated with lesions in the optic radiations.
Option D) Optic nerve: Lesions in the optic nerve, which connects the eye to the brain, can cause visua
l field defects, but they typically result in monocular vision loss (loss of vision in one eye) rather than a
homonymous hemianopia. Wernicke's pupil is not associated with lesions in the optic nerve.
 
 When the midbrain and pons are affected the cranial nerves 3,4,5,6,7 and 8 are lost due to its
location. The oculomotor nerve loses its control and hence extraocular movements are lost hence extra
ocular muscles are paralyzed.
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Option A: Frontal Eye Field is located in the brodmann area 8 controlled by the cerebellum which for ho
rizontal gaze. It connects the extra ocular muscles with paramedian pontine reticular formation.
Option B: Cerebral surface the cerebral cortex mainly deals with motor-sensory pathways and associati
on areas.
Option D: Spinal Cord , a lesion/injury of the spinal cord care causes complete sensory and motor loss 
at the site of injury, compression or a
shame here resulting in flaccid areflexic paralysis below the level of injury.
 
 Acyclovir is the drug of choice here. Here the CSF analysis revealed lymphocytic predominance. CSF
Analysis with the clinical symptoms of fever, headache and seizures suggest infective etiology with viral
meningitis. The Focal temporal lobe spikes indicate HSV meningitis. The empirical therapy of HSV is
Acyclovir.
Option A: Valacyclovir Is indicated in Varicella Zoster associated meningitis.
Option C: Is mainly considered for cytomegalovirus associated meningitis and can be sometimes supp
ortively added with acyclovir in HSV.
Option D: It is the drug of choice for immunocompromised cytomegalovirus meningitis in drug-resistant 
ganciclovir cases.
 This patient may be experiencing a transient ischemic attack or an ischemic stroke if they have
sudden onset hemiparesis and a normal CT scan. For this patient, observation and monitoring would
be the next course of action.
 The preferred imaging method for stroke patients is non-contrast CT (NCCT). For the first few hours,
CT could appear normal, and the infarct might not be seen for 24-48 hours.
 The early detection of brain infarction is more easily detected using diffusion-weighted MRI (DW MRI).
Option B: Labetalol is used in the acute phase of stroke.
Option C: Intravenous thrombolysis this should be done only after confirmation of Ischemic stroke in th
e patient and should be initiated within 4.5 hours.
Option D: Oral Nifedipine can be an antihypertensive agent used in the acute phase of stroke.
 
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 In the above case the most probable diagnosis is that of myasthenia gravis as he presents with easy
fatigability towards the end of the day that improves with rest and also has a history of ptosis, difficulty
in speech and swallowing. It is due to the autoantibody-mediated destruction of the acetylcholine
receptors (AChRs) at the postsynaptic membrane. This consequently leads to a decreased
transmission at the neuromuscular junction. Failure of transmission results in muscle weakness.
Option B: In LEMS, the patient presents with proximal muscle weakness. The symptoms improve after 
brief exercise. They also present with absent or reduced deep tendon reflexes.
Option C: In Duchenne muscular dystrophy, the patient initially presents with proximal muscle weaknes
s. Calf muscle hypertrophy is a classical feature.
Option D: In SLE, there is a
discoid rash, malar rash, photosensitivity and lupus nephritis and is more commonly seen in women.
 The above image is that of subarachnoid haemorrhage and shows blood in the basal cistern. Trauma
is the most common cause. The patient defines it as the worst headache of their life. It is also known as
thunderclap headache. It presents with neck rigidity, transient loss of consciousness and no focal
neurological deficit.
Option A: Subdural hemorrhage is a venous bleed and CT shows a crescentic opacity.
Option B: In pituitary apoplexy there is sudden hemorrhage into pituitary gland due to hematogenic hyp
operfusion
Option D: MRI is used for pituitary carcinomas.
 
 The above case is that of Fragile X as the patient has a long face, large ears, large testis, cardiac
murmur and a history of poor intellectual function present in the paternal family. It is the second most
common cause of mental retardation. Fragile X syndrome is an X-linked dominant disease due to CGG
trinucleotide repeat expansion.
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Option A: Cushing syndrome is an endocrine disorder mainly due to high levels of cortisol, it can be ca
used exogenously because of glucocorticoid administration. Clinical features such as acne, hirsutism, t
hin skin, delayed wound healing, anxiety, irritability, depression are seen along with involvement of mu
sculoskeletal, endocrine and metabolic systems.
Option B: Rett syndrome is a progressive neurodevelopmental disorder that almost exclusively affects f
emales. Affected children often develop autistic-like behaviors, breathing irregularities, feeding and sw
allowing difficulties, growth retardation, and seizures. Most Rett syndrome cases are caused by identifi
able mutations of the MECP2 gene on the X chromosome and can present with a
wide range of disability ranging from mild to severe.
Option D: Williams syndrome is a developmental disorder that affects many parts of the body. This con
dition is characterized by mild to moderate intellectual disability or learning problems, unique personalit
y characteristics, distinctive facial features, and heart and blood vessel (cardiovascular) problems.
 The treatment of grade 1 meningioma is surgical excision.
 Meningiomas are benign tumors seen in adults and originate from the meningothelial cells of the
arachnoid. They are round, well-defined, and compress the underlying brain.
Option A: All meningioma need treatment. Reassurance is not enough.
Option C: Chemotherapy is not used for meningiomas.
Option D: Radiotherapy is employed in grade 2 and grade 3.
 
The next step in management would be CT Angiography. NCCT and CT Angiography must be done co
ncurrently during stroke evaluation. The given features of hemiparesis with aphasia and a
clear NCCT are suggestive of an acute ischemic stroke with a proximal large vessel occlusion. Therefo
re the patient should undergo immediate CT Angiography to localize.
 
Correct answer: Option B:
 Sumatriptan is a medication from the triptan class that is commonly used to treat acute migraine and
cluster headaches. It works by constricting blood vessels and reducing inflammation in the brain.
Subcutaneous administration of sumatriptan is considered an effective and fast-acting treatment for
cluster headaches. It can provide relief within 10 to 15 minutes, making it a suitable option for patients
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who require rapid pain relief.
 Option a. oral Sumatriptan: Sumatriptan, a medication from the triptan class, is commonly used to
treat acute migraine and cluster headaches. Oral sumatriptan is available in tablet form and is a
convenient option for patients who prefer oral administration. However, when it comes to the treatment
of cluster headaches, oral sumatriptan may not provide the same rapid relief as other forms of
administration, such as subcutaneous injection.
 Option c. 100% oxygen at 6 L/minute: This option refers to the administration of 100% oxygen at a
flow rate of 6 liters per minute for the treatment of an acute cluster headache. Oxygen therapy has
shown to be highly effective in relieving the intense pain associated with cluster headaches. The exact
mechanism by which oxygen relieves cluster headaches is not fully understood, but it is believed to
involve the regulation of cerebral blood flow. Therefore subcutaneous sumatriptan is considered first
line treatment instead of administration of 100% oxygen at a flow rate of 6 liters per minute.
 Option d. 100% oxygen at 8 L/minute: Although 100% oxygen is an effective treatment for cluster
headaches, the recommended flow rate is 6 liters per minute, not 8 liters per minute. Increasing the
flow rate to 8 liters per minute may not provide additional benefits and may lead to discomfort or a
waste of oxygen. Therefore, the option of 100% oxygen at 8 L/minute is not the recommended
approach for treating cluster headaches.
Neuromyelitis optica (NMO), also known as Devic’s disease, is an autoimmune inflammatory disorder t
hat primarily affects the optic nerves and spinal cord. It is characterized by recurrent episodes of optic 
neuritis (inflammation of the optic nerve) and acute myelitis (inflammation of the spinal cord).
Option A: Area postrema syndrome: This refers to symptoms related to inflammation of the area postre
ma, a region in the brainstem involved in regulating vomiting. Symptoms may include intractable hiccup
s, nausea, and vomiting.
Option B: Acute myelitis: This involves inflammation of the spinal cord, resulting in neurological sympto
ms such as limb weakness, sensory loss, and bladder/bowel dysfunction.
Option D: Optic neuritis: Inflammation of the optic nerves leading to visual impairment, often characteri
zed by pain behind the eyes and vision loss.
Option D - Chorea Chorea is a movement disorder that causes sudden, unintended, and uncontrollable
 jerky movements of the arms, legs, and facial muscles. Chorea is seen in many diseases and conditio
ns and is caused by an overactivity of the chemical dopamine in the areas of the brain that control mov
ement. Mainly there are hyperkinetic movements.
Option A: Parkinson’s disease is primarily characterized by hypokinetic movements, which reduce volu
ntary and automatic movements. The cardinal features of Parkinson’s disease include bradykinesia (sl
owness of movement), rigidity (stiffness), resting tremors, and postural instability. These symptoms refl
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ect the hypokinetic nature of the disease. As the disease progresses, it also shows hyperkinetic feature
s.
Option B: Apraxia-  Apraxia is the loss of ability to execute or carry out skilled movement and gestures,
 despite having the physical ability and desire to perform them.
Option C: Catatonia-  Catatonia, a neuropsychiatric syndrome characterized by abnormal movements, 
behaviors, and withdrawal, is a condition that is most often seen in mood disorders but can also be see
n in psychotic, medical, neurologic, and other disorders
The statement that is NOT correct among the options provided is:
b. Doing EEG is mandatory for the diagnosis of seizures.
1-5% of the population can have epileptiform discharges:
 This statement is correct. Epileptiform discharges on EEG can be found in a percentage of the
population without a history of clinical seizures.
Doing EEG is mandatory for the diagnosis of seizures:
 This statement is not correct. While EEG is a valuable tool in diagnosing and characterizing seizures,
it is not always mandatory. The diagnosis of seizures is often based on a combination of clinical history,
physical examination, and sometimes additional diagnostic tests. EEG is particularly useful when there
is uncertainty about the nature of events or when further information is needed to guide treatment, but it
is not mandatory for all cases.
Scalp EEG may be helpful in localizing frontal lobe epilepsy:
 This statement is correct. Scalp EEG can be valuable in localizing the origin of epileptic activity in the
brain, including identifying specific lobe involvement such as the frontal lobe.
Progressive multifocal leukoencephalopathy shows triphasic and slow waves on EEG:
 This statement is not accurate. Progressive multifocal leukoencephalopathy (PML) typically does not
show specific EEG patterns like triphasic and slow waves. EEG findings in PML can vary but often
show focal or multifocal abnormalities rather than a specific triphasic pattern.
 ALS (Amyotrophic Lateral Sclerosis) is a neurodegenerative disease affecting motor neurons, leading
to progressive muscle weakness and atrophy. The symptoms typically begin in one region of body
region and gradually spread to other areas. In this case, the patient initially experienced bilateral lower
limb weakness, which later progressed to involve the upper limbs.
 The presence of Babinski sign (upward movement of the big toe when the sole of the foot is
stimulated) and absent deep tendon reflexes indicate upper motor neuron involvement, a characteristic
feature of ALS.
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Option a: Multiple Sclerosis (MS) typically presents with a relapsing-remitting course and involves vario
us neurological symptoms, including sensory loss, autonomic dysfunction, and optic neuritis. These sy
mptoms are not described in the given scenario.
Option c: Guillain-Barré Syndrome (GBS) is characterized by ascending weakness and sensory loss, w
hich usually begins in the lower limbs and progresses upward. It typically presents with absent deep te
ndon reflexes, but it is less likely in this case as the weakness started in the upper limbs.
Option d: Tropical spastic paraparesis is a
condition associated with Human T-cell lymphotropic virus type 1 (HTLV-1) infection. It primarily affects
 the lower limbs, causing weakness and spasticity. In the given scenario, the upper limb involvement a
nd absent deep tendon reflexes are inconsistent with tropical spastic paraparesis.
Based on the given clinical scenario, the most common site of hemorrhage in cases of intraparenchym
al hemorrhage with chronic hypertension is the Putamen. The correct answer is: Putamen
In individuals with chronic hypertension, the most common site of intraparenchymal hemorrhage is with
in the deep structures of the brain. The basal ganglia, which includes the Putamen, is frequently affecte
d in these cases.
The Putamen is a component of the basal ganglia located deep within the brain. It plays a role in motor
 control and coordination. Chronic hypertension can lead to the development of hypertensive arteriopat
hy, which weakens the small blood vessels in the brain. Over time, this can result in vessel rupture and
 bleeding, leading to an intraparenchymal hemorrhage. The high pressure within the blood vessels, par
ticularly in the small perforating arteries, contributes to the vulnerability of the Putamen to hemorrhage.
While intraparenchymal hemorrhage can occur in other brain regions, such as the Thalamus, Pons, or 
Cerebellum, the Putamen is the most commonly affected site in cases of chronic hypertension-associat
ed hemorrhage.
 
 Based on the given clinical presentation, the probable diagnosis in this case is Transient Ischaemic
Attack (TIA). 
 Transient Ischaemic Attack (TIA) refers to a temporary episode of neurological symptoms that occur
due to a temporary disruption of blood flow to a specific area of the brain. TIAs are often considered a
warning sign of an impending stroke.
 The key feature in this case that suggests TIA is the sudden onset of weakness in the right arm, which
gradually becomes lesser and resolves completely. This transient nature of the symptoms is
characteristic of a TIA, where the blood flow obstruction is temporary, allowing the symptoms to resolve
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within 24 hours.
 The patient's medical history of diabetes, hypertension, and obesity are risk factors for vascular
diseases, including TIAs and strokes.
Option A: Compressive neuropathy refers to nerve compression due to factors like anatomical abnorm
alities, trauma, or repetitive use. It typically results in persistent symptoms rather than transient sympto
ms as described in the case.
Option C: Ischaemic stroke involves a more prolonged disruption of blood flow to a specific area of the 
brain, leading to persistent neurological deficits that do not resolve within 24 hours. In this case, the sy
mptoms gradually became lesser and completely resolved, suggesting a
TIA rather than an ischaemic stroke.
Option A: Diabetic neuropathy is a condition that affects peripheral nerves and typically presents with s
ymmetric sensory and motor symptoms. It is unlikely to cause transient weakness limited to one side of
 the body, as seen in this case.
 
 The Glasgow Coma Scale (GCS) is a neurological assessment tool used to evaluate the level of
consciousness in patients with head injuries. It consists of three components: eye opening response
(E), verbal response (M), and motor response (V). Each component is scored on a scale from 1 to 5 or
6, with higher scores indicating a higher level of consciousness.
 Based on the information provided, the GCS score for the patient would be E3M5V4. Here's a
breakdown of what each component score means in this context:
 Eye opening response (E3): The patient opens her eyes in response to a loud voice, which
corresponds to a score of 3 on the E component.
 Verbal response (M5): The patient is confused and disoriented, but is able to localize pain. This
corresponds to a score of 5 on the M component.
 Motor response (V4): The patient's motor response is localized to pain, indicating a withdrawal from
the painful stimulus. This corresponds to a score of 4 on the V component.
 Therefore, the overall GCS score for the patient is E3M5V4.
Option B. This option suggests a higher verbal response score of 6, indicating that the patient is oriente
d and conversing normally. However, the information provided states that the patient is confused and d
isoriented, which corresponds to a lower verbal response score of 5. Therefore, this option is incorrect.
Option C. This option suggests a higher eye opening response score of 4, indicating spontaneous eye 
opening. However, the information provided states that the patient opens her eyes in response to a
loud voice, which corresponds to a
lower eye opening response score of 3. Therefore, this option is incorrect.
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Option D. This option suggests a higher motor response score of 5, indicating localized response to pai
n. However, the information provided states that the patient's motor response is lower, with a
withdrawal from the painful stimulus, which corresponds to a
motor response score of 4. Therefore, this option is incorrect
 
 The AKIN (Acute Kidney Injury Network) and RIFLE (Risk, Injury, Failure, Loss, End-stage kidney
disease) criteria are used to classify and stage acute kidney injury (AKI). These criteria help healthcare
professionals assess the severity of AKI and guide treatment decisions.
Option B. and C AND Option D. AKIN and RIFLE CRITERIA ARE NOT USED TO CLASSIFY these 3
diseases.
 Based on the information provided, the most likely diagnosis in this case is diffuse axonal injury (DAI).
 Diffuse axonal injury (DAI) is a type of traumatic brain injury that occurs as a result of
acceleration-deceleration forces during a motor vehicle accident (RTA). It is characterized by
widespread shearing and tearing of the axons in the brain, particularly at the corticomedullary junction
and basal ganglia.
 The clinical presentation of a progressive decline in the Glasgow Coma Scale (GCS) over hours
following the RTA is consistent with DAI. DAI is often associated with a poor prognosis and can lead to
significant neurological impairments.
 The axial T2 MRI showing multiple small hypointense lesions at the corticomedullary junction and
basal ganglia is a characteristic finding of DAI. These lesions represent areas of axonal injury and can
be visualized on MRI scans.
Option B: Extensive subarachnoid hemorrhage: Subarachnoid hemorrhage occurs due to the rupture o
f blood vessels into the subarachnoid space. While it can be seen in traumatic brain injury, the presenc
e of multiple small hypointense lesions on MRI is more indicative of DAI.
Option C: Hypoxic cerebral injury: Hypoxic cerebral injury occurs due to a lack of oxygen supply to the 
brain. It can result from various causes such as cardiac arrest, near-drowning, or severe respiratory fail
ure. The MRI findings described in the scenario are not consistent with hypoxic cerebral injury.
Option D: Multiple hemorrhagic contusion: Hemorrhagic contusions are localized areas of bleeding and
 bruising within the brain tissue that occur as a result of direct trauma. While multiple hemorrhagic cont
usions can be seen in traumatic brain injury, the specific location of the lesions described in the scenari
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o (corticomedullary junction and basal ganglia) is more suggestive of diffuse axonal injury.
Considering the history of RTA, progressive decline in GCS, and the characteristic MRI findings, the m
ost likely diagnosis in this case is diffuse axonal injury (DAI).
 
Correct answer 
 
Option B: Occipital lobe.
 Occipital lobe: The occipital lobe is primarily responsible for processing visual information received
from the eyes. A lesion in the occipital lobe can result in various visual disturbances, such as visual
field defects, hallucinations, or difficulty with visual perception.
Option A:
 Frontal visual field: Lesion in the frontal visual field refers to damage or impairment in the area of the
visual field that is processed by the frontal part of the brain. It can result from a lesion in the frontal lobe
or the corresponding pathways involved in visual processing. The specific location of the lesion
determines the extent and nature of visual field loss in the frontal region.
Option C: Optic radiation:
 The optic radiation refers to the nerve fibers that transmit visual information from the lateral geniculate
nucleus of the thalamus to the primary visual cortex in the occipital lobe. A lesion in the optic radiation
can lead to visual field defects that are specific to the affected area. For example, a lesion in the
temporal optic radiation may result in a contralateral superior quadrantanopia.
Option D: Optic chiasm:
 Lesion at the optic chiasm, where the optic nerves partially cross over. Can cause visual field defects
involving the nasal visual field of each eye, such as bitemporal hemianopia.
The most likely diagnosis for the 37-year-old male who is a chronic alcoholic and presents with disorien
tation, tremors, hallucinations, and hypertension three days after abstaining from alcohol is "Delirium tr
emens."
 Delirium tremens: Delirium tremens (DT) is a severe form of alcohol withdrawal syndrome that usually
occurs 2 to 5 days after alcohol cessation. It is characterized by altered mental status, disorientation,
tremors, hallucinations (often visual), autonomic hyperactivity (such as hypertension), and can progress
to seizures and life-threatening cardiovascular complications if not managed promptly. DT is
considered a medical emergency and requires immediate medical attention.
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Option A: Alcoholic hallucinosis: Alcoholic hallucinosis is a condition characterized by auditory hallucin
ations that occur within 12 to 24 hours after alcohol cessation. However, it does not typically cause sig
nificant disorientation, tremors, or hypertension as seen in the patient's presentation.
Option B: Korsakoff's psychosis: Korsakoff's psychosis, also known as Wernicke-Korsakoff syndrome, i
s caused by thiamine (vitamin B1) deficiency, often associated with chronic alcoholism. It primarily pres
ents with severe memory loss and confabulation. While cognitive impairment may be present, it does n
ot typically manifest with significant disorientation, tremors, hallucinations, or hypertension as seen in t
he patient's presentation.
Option D: Marchiafava-Bignami disease: Marchiafava-Bignami disease is a rare disorder associated wi
th chronic alcoholism characterized by demyelination and necrosis of the corpus callosum, leading to n
eurological deficits. While it can present with cognitive impairment and neurological symptoms, it is not 
typically associated with significant disorientation, tremors, hallucinations, or hypertension as seen in th
e patient's presentation.
In summary, based on the patient's history of chronic alcoholism, the presentation of disorientation, tre
mors, hallucinations, and hypertension after alcohol cessation, the most likely diagnosis is "Delirium tre
mens."
 
 Topiramate is not typically used as a first-line medication for typical absence seizures.
 The first-line treatment for typical absence seizures is Ethosuximide or Valproic acid.
 Ethosuximide is considered the drug of choice for the treatment of typical absence seizures. Valproic
acid is also commonly used and has efficacy against various seizure types, including typical absence
seizures.
Option A. Lamotrigine is a commonly used medication for generalized onset tonic-clonic seizures, as w
ell as other seizure types. It is an antiepileptic drug that can be used as a
monotherapy or in combination with other medications.
Option B. Levetiracetam is an effective medication for focal seizures and is widely used as a
first-line treatment for this seizure type. It is also used as an adjunctive therapy for other seizure types.
Option D. Valproic acid (Sodium valproate) is commonly used for the treatment of various seizure type
s, including myoclonic seizures. It is considered one of the first-line medications for myoclonic seizures.
 
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 Charcot-Marie-Tooth disease is a hereditary neurological disorder that affects the peripheral nerves,
resulting in muscle weakness and wasting, particularly in the distal parts of the limbs. The characteristic
features of CMT include reduced muscle stretch reflexes (hyporeflexia or areflexia), muscle atrophy,
and weakness, which are consistent with the clinical findings described in the case. The absence of
tingling or numbness in the patient's complaints is also in line with CMT. Sensory symptoms such as
tingling and numbness are generally not prominent in CMT, as the primary manifestation of the
condition is motor dysfunction.
Option b. Refsum disease, also known as heredopathia atactica polyneuritiformis, is a rare genetic diso
rder characterized by the body's inability to break down phytanic acid, leading to its accumulation in var
ious tissues. This condition is caused by a mutation in the PHYH gene, resulting in a deficiency of the e
nzyme responsible for phytanic acid metabolism. The buildup of phytanic acid can cause a range of sy
mptoms, including peripheral neuropathy, retinitis pigmentosa, hearing loss, balance issues, muscle w
eakness, and skin changes. Anosmia, or loss of smell, is a
notable feature of Refsum disease. Treatment involves following a low-phytanic acid diet and, in sever
e cases, plasmapheresis to reduce phytanic acid levels. Early diagnosis and ongoing management can
 help alleviate symptoms and improve the quality of life for individuals with Refsum disease. Regular m
onitoring by a healthcare team comprising various specialists is crucial for effective treatment.
Option C. Sjögren's syndrome is a chronic autoimmune disorder that primarily affects the moisture-pro
ducing glands in the body, leading to symptoms of dryness in the eyes and mouth. It can also cause sy
stemic manifestations, affecting other organs and causing fatigue, joint pain, and dry skin. The conditio
n is more common in women and typically develops in middle-aged individuals. Diagnosis involves a c
ombination of medical history, physical examination, and specific tests to assess glandular function an
d detect specific antibodies. While there is no cure, treatment focuses on managing symptoms and pre
venting complications. This may involve the use of lubricating eye drops, saliva substitutes, medication
s to reduce inflammation, and lifestyle modifications. Regular monitoring by a healthcare team is import
ant to ensure proper management of Sjögren's syndrome and improve the quality of life for affected ind
ividuals.
Option D. Rheumatoid arthritis (RA) is a chronic autoimmune disease that primarily affects the joints, c
ausing inflammation, pain, stiffness, and swelling. It occurs when the body's immune system mistakenl
y attacks the synovium, the lining of the joints. This results in chronic inflammation that can lead to joint
 damage and deformity over time. Rheumatoid arthritis commonly affects the small joints of the hands 
and feet but can involve multiple joints throughout the body. The exact cause of RA is unknown, but it i
s believed to involve a combination of genetic and environmental factors. Women are more commonly 
affected, and the condition can develop at any age. Treatment for rheumatoid arthritis aims to manage 
symptoms, control inflammation, and prevent joint damage. This may involve a combination of medicati
ons, such as nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (D
MARDs), and biologic therapies. Physical therapy, joint protection techniques, and lifestyle modification
s, such as regular exercise and a healthy diet, can also play a
role in managing the disease. Regular medical monitoring and collaboration with a healthcare team, inc
luding rheumatologists, can help individuals with rheumatoid arthritis effectively manage their symptom
s and improve their quality of life.
 
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 The most likely reason for the progressive loss of vision in a 25-year-old male who has been on
low-dose oral steroid therapy for the last 10 years is Cataract.
 Cataract is the clouding of the lens in the eye, leading to progressive loss of vision. Prolonged use of
corticosteroids, such as oral steroids, is a known risk factor for the development of cataracts. Steroids
can accelerate the formation of cataracts by affecting the metabolism and structure of the lens.
Option B: Glaucoma is a condition characterized by increased intraocular pressure that can lead to opti
c nerve damage and vision loss. While long-term steroid use can cause secondary glaucoma in some 
cases, it is less likely to be the primary cause of progressive vision loss in this scenario.
Option C: Cystoid macular edema refers to the accumulation of fluid in the macula, the central part of t
he retina responsible for sharp, detailed vision. While steroid use can be associated with the developm
ent of macular edema, it typically presents with symptoms such as blurry vision, central vision loss, and
 distortion. The description of progressive loss of vision in both eyes is not consistent with cystoid macu
lar edema as the primary cause.
Option D: Retinal detachment is the separation of the retina from the underlying tissue. It can cause su
dden and dramatic vision loss, typically described as a curtain or shadow across the visual field. The pr
ogressive loss of vision described in the case is not consistent with retinal detachment as the primary c
ause.
Therefore, considering the patient's history of long-term oral steroid use and the symptom of progressiv
e loss of vision, cataract formation is the most likely reason for his symptoms.
 
Option A. Steroids: Steroids, such as corticosteroids, are generally not recommended as a treatment o
ption for Guillain-Barre syndrome. Studies have shown that steroid use does not provide significant be
nefits in GBS and may even prolong the recovery process. Therefore, steroids are not considered a
standard treatment for GBS.
Option B. Plasmapheresis: Plasmapheresis, also known as plasma exchange, is a recognized treatme
nt option for Guillain-Barre syndrome. It involves removing plasma from the patient's blood and replacin
g it with donor plasma or a plasma substitute. Plasmapheresis helps remove harmful antibodies that m
ay be contributing to the immune attack on peripheral nerves in GBS, potentially speeding up recovery.
Option C. IVIG (intravenous immunoglobulin): IVIG is another established treatment option for Guillain-
Barre syndrome. It involves administering high-dose immunoglobulin intravenously, which contains anti
bodies that can modify the immune response and reduce the severity and duration of the disease. IVIG
 is considered an effective and commonly used treatment for GBS.
Option D. Ventilator support: Ventilator support is an essential component of the management of Guilla
in-Barre syndrome, particularly in severe cases. GBS can lead to muscle weakness and paralysis, incl
uding the muscles involved in breathing. Ventilator support is provided to ensure adequate oxygenation
 and ventilation until the patient's respiratory muscles recover.
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The ABCD2 scoring system is used to assess the risk of stroke following a transient ischemic attack (TI
A). It assigns points to different factors associated with increased stroke risk. The higher the total score
, the higher the risk of subsequent stroke. In the ABCD2 scoring system, the presence of diabetes is on
e of the factors that contribute to a higher score and indicates an increased risk of stroke.
Diabetes is considered a significant risk factor for stroke in general. It is associated with vascular chan
ges, including endothelial dysfunction and increased atherosclerosis, which can contribute to the devel
opment of ischemic stroke. Patients with diabetes have a higher likelihood of experiencing a
subsequent stroke after a
TIA compared to those without diabetes. Therefore, the presence of diabetes in a
patient with TIA would suggest a higher risk for developing a
stroke in the future according to the ABCD2 scoring system.
Option A. Age <60 years: Age is a factor in the ABCD2 scoring system, but it is assigned points differe
ntly. Patients aged 60 years or older receive 1 point, while those younger than 60 do not receive any p
oints. Therefore, age <60 years does not contribute to a
higher risk according to the ABCD2 scoring system.
Option B. SBP >140 mm Hg and DBP <90 mmHg: Blood pressure is also a factor in the ABCD2 scorin
g system. However, specific blood pressure criteria are not mentioned in the options provided. Accordi
ng to the scoring system, patients with a systolic blood pressure (SBP) of 140 mm Hg or higher and a
diastolic blood pressure (DBP) of 90 mmHg or higher receive 1 point. The blood pressure range provid
ed in the option (SBP>140 mm Hg and DBP<90 mmHg) does not meet the criteria for assigning points,
 so it does not contribute to a higher risk according to the ABCD2 scoring system.
Option C. Duration of TIA >5 mins: The duration of TIA (transient ischemic attack) is another factor in t
he ABCD2 scoring system. TIAs lasting 60 minutes or longer receive 2
points, while those lasting less than 60 minutes receive 1 point. The option provided states a duration o
f TIA >5 minutes but does not specify if it exceeds 60 minutes. Therefore, based on the information pro
vided, it is not possible to determine whether it contributes to a
Option b: Descending paralysis is seen.
Guillain-Barre syndrome (GBS) is a neurological disorder characterized by an inflammatory condition t
hat affects the peripheral nerves. It is typically characterized by ascending paralysis, meaning that wea
kness and loss of muscle function start in the lower extremities and progress upward to the upper body
.
 
Option a. Ascending paralysis: GBS typically presents as ascending paralysis, meaning that muscle we
akness and loss of function start in the lower extremities and progress upward towards the upper body.
 This pattern is one of the hallmark features of GBS.
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Option c. Plasmapheresis is a treatment method: Plasmapheresis, also known as plasma exchange, is 
one of the treatment options for GBS. It involves removing the patient's plasma, which contains the har
mful antibodies, and replacing it with donated plasma or albumin.
Option d. Demyelinating disorder: GBS is characterized by damage to the myelin sheath, the protective
 covering of nerve fibers. This damage leads to impaired nerve signal transmission and contributes to t
he symptoms of GBS.
Option c. Deep-seated pain: The characteristic pain of trigeminal neuralgia is described as superficial, 
sharp, and lancinating. It is often triggered by certain activities such as eating, talking, or touching spec
ific areas of the face. The pain is not typically described as deep-seated.
 
Option a. More common in females: Trigeminal neuralgia is more commonly seen in females, although 
it can affect both sexes.
Option b. Pain along V2 and V3 division of trigeminal nerve: Trigeminal neuralgia typically presents wit
h severe, sharp, electric shock-like pain along the distribution of the trigeminal nerve, most commonly i
nvolving the V2 (maxillary) and V3 (mandibular) divisions.
Optiond. No objective signs of sensory loss: Patients with trigeminal neuralgia do not exhibit objective s
ensory loss in the affected areas. The pain is usually paroxysmal and does not cause long-term sensor
y deficits.
Option B: Acute inflammatory demyelinating polyneuropathy (AIDP).
Acute inflammatory demyelinating polyneuropathy (AIDP): This is the most common type of GBS, acco
unting for the majority of cases. It involves autoimmune-mediated demyelination of peripheral nerves, l
eading to motor and sensory dysfunction.
 
Option a. Acute motor axonal neuropathy (AMAN): This is a subtype of Guillain-Barre syndrome (GBS)
 characterized by axonal damage to motor nerves. It is less common than AIDP.
Option c. Acute motor sensory axonal neuropathy (AMSAN): This is another subtype of GBS characteri
zed by axonal damage to both motor and sensory nerves. It is less common than AIDP.
Optiond. Miller Fisher syndrome (MFS): This is a variant of GBS characterized by a
triad of symptoms: ataxia , ophthalmoplegia , and areflexia . It is less common than AIDP.
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Correct Option: A Lateral medullary syndrome
 Thrombosis of the posterior inferior cerebellar artery (PICA) can cause lateral medullary syndrome,
also known as Wallenberg syndrome.
 It is characterized by a range of neurological symptoms, including loss of pain and temperature
sensation on the contralateral side of the body, ipsilateral facial pain and temperature sensation loss,
dysphagia (difficulty swallowing), hoarseness, dizziness, and ataxia.
Option B - Weber syndrome: This statement is incorrect. Weber syndrome is not caused by thrombosis
 of the posterior inferior cerebellar artery. It is typically associated with lesions affecting the midbrain an
d manifests as a combination of contralateral hemiparesis (weakness on one side of the body) and ipsil
ateral oculomotor nerve palsy.
Option C - Medial medullary syndrome: This statement is incorrect. Medial medullary syndrome, also k
nown as Dejerine syndrome or anterior spinal artery syndrome, is caused by occlusion or thrombosis o
f the anterior spinal artery, not the posterior inferior cerebellar artery. It is characterized by contralateral
 hemiparesis (weakness on one side of the body) affecting the arm and leg, along with other symptoms
 such as contralateral loss of proprioception and vibration sense, and ipsilateral tongue deviation.
Option D - Millard Gubler syndrome: This statement is incorrect. Millard Gubler syndrome, also known 
as ventral pontine syndrome, is caused by a lesion affecting the pons, particularly involving the corticos
pinal tracts and abducens nerve (cranial nerve VI). It does not result from thrombosis of the posterior in
ferior cerebellar artery.
Correct Option D: Decreased synaptic transmission at thee myoneural junction
 Myasthenia gravis is an autoimmune disorder characterized by muscle weakness and fatigue.
 It is caused by the production of autoantibodies that target the acetylcholine receptors (AChRs) at the
 These autoantibodies disrupt normal synaptic transmission by blocking or destroying AChRs, leading
to a decreased ability of the nerve impulses to stimulate muscle contraction.
 As a result, there is a reduced synaptic transmission at the myoneural junction, causing muscle
weakness and fatigue.
Option A: Decreased acetylcholine release at the nerve endings: This option is incorrect. In myasthenia
 gravis, the primary defect lies in the postsynaptic membrane of the neuromuscular junction, where aut
oantibodies target and interfere with AChRs. The release of acetylcholine (ACh) from the nerve ending
s is not directly affected in myasthenia gravis.
Option B: Decreased myosin: This option is incorrect. Myosin is a
protein involved in muscle contraction. Myasthenia gravis does not involve a
decrease in myosin levels or dysfunction of myosin.
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Option C: Absence of troponin C: This option is incorrect. Troponin C is a component of the regulatory 
complex involved in muscle contraction. Its absence is not associated with myasthenia gravis.
Correct Options D: Ipsilateral paralysis of lower face
 Weber's syndrome typically does not involve paralysis of the lower face. Ipsilateral facial nerve palsy,
or paralysis of the facial muscles on the same side as the brain lesion, is more commonly associated
with other conditions, such as Bell's palsy or lesions affecting the facial nerve itself.
Option A - Contralateral hemiplegia: Weber's syndrome, also known as midbrain syndrome, is characte
rized by the presence of contralateral hemiplegia. This means that the paralysis or weakness affects th
e side of the body opposite to the side of the brain lesion.
Option B - Ipsilateral oculomotor nerve palsy: Weber's syndrome is associated with ipsilateral oculomot
or nerve palsy. This means that there is paralysis or weakness of the muscles controlled by the ipsilate
ral (same side) oculomotor nerve, which results in various eye movement abnormalities.
Option C - Contralateral parkinsonism: Weber's syndrome is commonly associated with contralateral p
arkinsonism. This refers to the presence of Parkinson's disease-like symptoms, such as resting tremor
s, bradykinesia (slowness of movement), and rigidity, on the side opposite to the brain lesion.
Correct Option B: Contralateral loss of pain sensation
 The characteristic pattern seen in Brown-Sequard syndrome is contralateral loss of pain sensation.
 Brown-Sequard syndrome is a neurological condition caused by damage to one half of the spinal
cord.
Option A - Contralateral loss of joint sense and position: This is not correct.
Option C - Ipsilateral loss of complete sensory functions: This is not correct
Option D - Contralateral motor functions: This is not correct
Correct Option A: Ciprofloxacin
 Ciprofloxacin is a broad-spectrum antibiotic that is effective against Neisseria meningitidis. It is the
drug of choice for mass chemoprophylaxis in individuals who have been in close contact with a person
diagnosed with meningococcal meningitis. The goal of mass chemoprophylaxis is to prevent the spread
of the bacteria to others who may be at risk. Ciprofloxacin is effective in eradicating the bacteria from
the nasopharynx, reducing the risk of transmission.
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Option B- Chloramphenicol: Chloramphenicol is an antibiotic with activity against many bacteria, includi
ng Neisseria meningitidis. While it can be used for the treatment of meningococcal meningitis, it is not t
he preferred choice for mass chemoprophylaxis. This is because other antibiotics, such as ciprofloxaci
n, have shown better efficacy and safety profiles for this purpose.
Option C- Tetracycline: Tetracycline is another antibiotic with activity against Neisseria meningitidis. Ho
wever, like chloramphenicol, it is not the drug of choice for mass chemoprophylaxis. Other antibiotics, s
uch as ciprofloxacin, are preferred due to their higher efficacy and lower risk of adverse effects.
Option D- Penicillin: Penicillin is effective against many strains of Neisseria meningitidis and is commo
nly used for the treatment of meningococcal meningitis. However, it is not the preferred drug for mass c
hemoprophylaxis. This is because penicillin is less effective in eradicating the bacteria from the nasoph
arynx compared to other antibiotics such as ciprofloxacin.
 Cauda Equina Syndrome is a medical emergency characterized by the compression of the cauda
equina nerve roots in the lower spinal canal. It typically presents with a combination of symptoms
including sudden onset difficulty in micturition (urination) and defecation (bowel movement), as well as
saddle anesthesia (loss of sensation in the areas that would touch a saddle), perineal numbness, and
varying degrees of lower limb weakness or paralysis.
 The compression of the cauda equina nerve roots can result from various causes, such as a herniated
disc, spinal stenosis, trauma, or tumors. In the given scenario, the patient's history of backache
followed by sudden onset difficulty in micturition and defecation suggests the possibility of cauda
equina syndrome. The symptoms arise due to the involvement of the nerves responsible for bladder
and bowel control, as well as sensation in the perineal area.
 
Option A. Pott's Spine: Pott's Spine, also known as spinal tuberculosis, is a form of tuberculosis that aff
ects the spine. It typically presents with chronic back pain, deformity, and constitutional symptoms such
 as weight loss and fever. While spinal tuberculosis can potentially lead to compression of the spinal co
rd or nerve roots, it does not specifically cause sudden onset difficulty in micturition and defecation as s
een in cauda equina syndrome.
Option B. Guillain-Barré Syndrome: Guillain-Barré Syndrome is an autoimmune condition characterize
d by ascending muscle weakness, usually starting in the legs and progressing upwards. It can also inv
olve sensory abnormalities and autonomic dysfunction. While it may cause bladder and bowel dysfunct
ion in some cases, the sudden onset difficulty in micturition and defecation without preceding muscle w
eakness or sensory changes described in the question is not typical of Guillain-Barré Syndrome.
Option D. Multiple Sclerosis: Multiple Sclerosis (MS) is a
chronic autoimmune disease affecting the central nervous system. It presents with a wide range of neu
rological symptoms, including muscle weakness, sensory changes, and coordination problems. Howev
er, sudden onset difficulty in micturition and defecation without other associated neurological symptom
s is not a typical presentation of multiple sclerosis.
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Solution for Question 73:
 Continue treatment for another 2 years: In this scenario, the patient has experienced a seizure-free
period of 6 months and has a normal EEG, normal neurological examination, and normal intelligence.
However, it is recommended to continue treatment with antiepileptic drugs (AEDs) for another 2 years
before considering the option of tapering or discontinuing the medication. This is because the risk of
seizure recurrence after a seizure-free period is highest within the first 2 years. Continuing treatment for
this duration helps to consolidate the remission and reduce the risk of relapse.
Incorrect options: :
Option A. Stop the treatment and follow up: Stopping the treatment abruptly in a patient with a
history of epilepsy, even after a seizure-free period, carries a
risk of seizure recurrence. It is important to maintain a
consistent treatment approach to prevent the occurrence of seizures.
Option
 B. Gradually taper the drug and stop treatment: Tapering and stopping the drug immediately after a 6-
month seizure-free period may increase the risk of seizure recurrence. Gradual tapering of AEDs is us
ually considered after a longer period of sustained seizure freedom and in consultation with a
neurologist.
Option D. Continue lifelong treatment with antiepileptics: Lifelong treatment with AEDs is not necessary
 in all cases of epilepsy. In some individuals, especially those who achieve long-term seizure control an
d meet specific criteria (such as normal EEG and normal neurological examination), the possibility of di
scontinuing AEDs can be considered. However, the recommended duration of continued treatment bef
ore considering discontinuation varies, and in this case, continuing treatment for another 2
years is the appropriate approach
 
Solution for Question 74:
 The presentation of left-sided facial paralysis and weakness in a patient with high blood pressure
suggests a possible ischemic stroke involving the territory of the middle cerebral artery. In this scenario,
the next step would be to initiate intravenous thrombolysis with a thrombolytic agent such as alteplase
(tissue plasminogen activator, tPA). Thrombolysis aims to dissolve the blood clot causing the ischemic
stroke and restore blood flow to the affected area of the brain. Time is a critical factor in the
administration of thrombolysis, and it is most effective when given within a few hours of symptom onset.
 Ischemic stroke Thrombolytic candidate To initiate thrombolysis first bring BP <185/110 mmHg with
Nicardipine Not a thrombolytic candidate If BP is 220/130 mmHg (first lower BP)
 Thrombolytic candidate To initiate thrombolysis first bring BP <185/110 mmHg with Nicardipine
 To initiate thrombolysis first bring BP <185/110 mmHg with Nicardipine
 Not a thrombolytic candidate If BP is 220/130 mmHg (first lower BP)
 If BP is 220/130 mmHg (first lower BP)
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Option Options:
Option A. Nothing, since CT was normal: While the CT scan may not show any immediate abnormalitie
s, it does not rule out an acute ischemic stroke. In the case of suspected acute ischemic stroke, clinical
 judgment takes precedence over imaging findings, and thrombolysis should not be withheld solely bas
ed on a normal CT scan.
Option B. Start on aspirin + clopidogrel: Dual antiplatelet therapy with aspirin and clopidogrel is commo
nly used for the prevention of recurrent strokes in patients with ischemic stroke of atherosclerotic origin
. However, in this acute setting, initiating antiplatelet therapy alone is not sufficient, as it does not addre
ss the underlying clot causing the current ischemic event.
Option D. Advice BP control: Blood pressure control is an essential aspect of managing acute ischemic
 stroke, but in this scenario, the immediate concern is the potential for thrombolysis. Blood pressure ma
nagement would typically be addressed concurrently or after thrombolysis, depending on the patient's 
blood pressure level and specific guidelines.
Solution for Question 75:
 The patient's presentation of a stomping gait and inability to perform the tandem walk (walking with
closed eyes) suggests a disturbance in proprioception and coordination. These functions are primarily
mediated by the posterior column tract.
 The posterior column tract, also known as the dorsal column-medial lemniscus pathway, carries
sensory information related to proprioception, fine touch, and vibration sense. It runs in the posterior
part of the spinal cord and ascends to the brainstem, where it synapses with the second-order neurons
before relaying the information to the thalamus and ultimately the sensory cortex.
 When the posterior column tract is affected, as seen in conditions such as vitamin B12 deficiency,
spinal cord injury, or posterior column lesions, patients may experience sensory ataxia. Sensory ataxia
is characterized by impaired proprioception and coordination, leading to an abnormal gait and difficulty
performing tasks that require precise movements.
Option A. Spinocerebellar tract: The spinocerebellar tracts carry proprioceptive information from the spi
nal cord to the cerebellum. Damage to these tracts can result in ataxic gait, but it would not specifically 
cause the stomping gait described in the question.
Option C. Vestibulospinal tract: The vestibulospinal tract originates from the vestibular nuclei in the brai
nstem and controls postural adjustments and balance. Lesions affecting this tract may result in disturba
nces of balance, but they are unlikely to cause the specific gait abnormality described in the question.
Option D. Rubrospinal tract: The rubrospinal tract is involved in the control of voluntary movements, pa
rticularly in the upper extremities. It does not play a major role in gait coordination, and therefore, its dy
sfunction is less likely to result in the stomping gait observed in the patient.
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 The sagittal section of the brain shown in the image likely represents a lesion in the area of the
cerebral cortex known as the precentral gyrus or primary motor cortex. This region is responsible for
motor control and coordination.
 Perianal anesthesia: Perianal anesthesia refers to the loss of sensation around the anus. The
precentral gyrus, which is primarily involved in motor function, is not directly responsible for sensory
perception. Sensory information, including perianal sensation, is processed in the somatosensory
cortex, which is located in the postcentral gyrus. 
Option A. Urinary incontinence: The precentral gyrus is involved in the control of voluntary movement, i
ncluding the coordination of the muscles involved in urinary continence. Damage to this area can disru
pt the normal control of urinary function, leading to urinary incontinence.
Option B. Gait apraxia: Gait apraxia refers to the inability to coordinate and perform voluntary moveme
nts involved in walking, despite the absence of any paralysis or muscle weakness. The precentral gyru
s is crucial for the initiation and coordination of voluntary movements, including walking. Therefore, da
mage to this area can result in gait apraxia.
Option D. Fecal incontinence: Fecal incontinence refers to the inability to control bowel movements, re
sulting in the involuntary passage of feces. The precentral gyrus is involved in the coordination of the m
uscles involved in maintaining bowel continence. Damage to this area can disrupt the normal control of
 bowel function, leading to fecal incontinence.
Correct Answer: D.
 Administer mannitol to reduce intracranial pressure.
  In cases of raised intracranial pressure, such as in traumatic brain injury, the administration of
mannitol is a common treatment approach. Mannitol is an osmotic diuretic that works by drawing fluid
out of the brain tissue and into the bloodstream, reducing cerebral edema and intracranial pressure. It
can help improve cerebral blood flow and oxygenation, preventing further damage to brain tissue.
Other option:
Option A . Administering antibiotics would be appropriate if there is evidence of an infection, but it may 
not directly address the raised intracranial pressure.
Option B. Initiating anticoagulant therapy may be indicated for certain conditions (e.g., deep vein throm
bosis), but it is not the primary treatment for raised intracranial pressure.
Option C. Immediate surgical intervention  may be necessary in some cases, such as for the evacuatio
n of an intracranial hematoma or for decompressive craniectomy. However, mannitol administration is 
often initiated as the first-line treatment to rapidly reduce intracranial pressure before considering surgi
cal options.
 
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 Hemiplegia refers to paralysis or weakness affecting one side of the body. In the context of an
ischemic stroke, where blood supply to a part of the brain is blocked, the posterior limb of the internal
capsule is the area commonly affected in hemiplegia.
 The internal capsule is a white matter structure located deep within the brain that carries nerve fibers
connecting the cerebral cortex to other parts of the central nervous system. It consists of three main
parts: the anterior limb, genu (bend), and posterior limb. The posterior limb of the internal capsule
contains motor fibers that originate from the motor cortex and descend to the spinal cord, carrying
signals responsible for voluntary motor control.
 When an ischemic stroke occurs in the area supplied by the blood vessels surrounding the posterior
limb of the internal capsule, the motor fibers within this region can be damaged. This results in
hemiplegia on the opposite side of the body from the affected internal capsule. For example, if the
stroke affects the right posterior limb, it would lead to left-sided hemiplegia.
Option A: Retrolentiform: This term is not anatomically accurate and does not correspond to a
specific part of the internal capsule.
Option B: Sublentiform: Similar to option A, this term is not anatomically accurate and does not corresp
ond to a specific part of the internal capsule.
Option C: Anterior limb: The anterior limb of the internal capsule primarily contains fibers involved in no
n-motor functions, such as connecting the prefrontal cortex to other brain regions involved in cognitive 
and emotional processing. Damage to the anterior limb can cause different symptoms but is not typicall
y associated with hemiplegia.
 
 The symptoms described in the patient, including vertigo, diplopia, hoarseness, dysphagia, left
Horner's syndrome, and numbness of the left face and right side limbs, are indicative of a lateral
medullary syndrome, also known as Wallenberg syndrome or posterior inferior cerebellar artery (PICA)
syndrome.
 The PICA is a branch of the vertebral artery and supplies the lateral medulla, including the
dorsolateral aspect of the medulla, inferior cerebellar peduncle, and parts of the cerebellum. Occlusion
or infarction of the PICA leads to ischemia in the corresponding territories, resulting in the characteristic
symptoms seen in Wallenberg syndrome.
Option B. Superior cerebellar artery: The superior cerebellar artery supplies the superior cerebellar he
misphere, midbrain, and parts of the cerebellar nuclei. It does not supply the lateral medulla or the stru
ctures associated with Wallenberg syndrome, so it is not the artery affected in this patient.
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Option C. Anterior inferior cerebellar artery: The anterior inferior cerebellar artery supplies the anterior i
nferior portion of the cerebellum, the lateral pons, and parts of the internal auditory canal. It is not direct
ly involved in the supply of the lateral medulla, where the symptoms of Wallenberg syndrome originate.
Option D. Basilar artery: The basilar artery is formed by the fusion of the vertebral arteries and supplies
 various structures in the brainstem, including the pons, midbrain, and cerebellum. The symptoms desc
ribed are specific to the involvement of the PICA territory.
True statements about tremors are:
 PD is characterized by resting tremor: Resting tremor is a hallmark feature of Parkinson's disease
(PD). It is typically present when the affected body part is at rest and diminishes or disappears during
voluntary movement. This tremor often begins in one hand and can later involve other limbs or body
parts.
 Tremor consists of alternate contraction of agonist and antagonist muscles in an oscillating rhythmic
manner: Tremors involve rhythmic oscillations of body parts and are typically caused by alternating
contractions of agonist and antagonist muscles. This pattern of muscle contractions creates the
characteristic shaking or trembling movement seen in tremors.
 Normal individuals can have physiologic tremors that manifest as mild high frequency, postural, or
action tremors: Physiologic tremors are normal variations in hand or body tremors that can occur in
healthy individuals. They are typically mild and high frequency, occurring during certain postures or
actions such as holding a position against gravity or during fine motor tasks. These tremors are usually
not indicative of any underlying neurological disorder.
 Essential tremor is an uncommon movement disorder affecting 5% of the population: Essential tremor
is actually a common movement disorder, affecting a significant portion of the population. It is
considered one of the most prevalent movement disorders, with estimates suggesting that it affects
around 5% to 10% of individuals, especially in older age groups. Essential tremor is characterized by
postural or action tremors, often involving the hands, head, or voice.
Option A : 1,2,3 only - this is the incorrect option
Option B. 2,3,4 only - this is the incorrect options
Option D. All of the above -this is the incorrect options
 The patient's clinical presentation is consistent with a lacunar infarct, which is a small, localized
ischemic stroke that occurs in the deep structures of the brain.
 Midbrain, also known as the mesencephalon, is a region of the brainstem that plays a role in
coordinating motor movements and controlling eye movements. In this case, the patient's symptoms,
including weakness on the left side of the body and abnormal eye movements (ptosis, downward and
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lateral deviation of the right eye), suggest an ischemic event affecting the midbrain.
Option A: Inner capsule refers to a structure in the brain that contains ascending and descending fibers
. Damage to the inner capsule can cause motor and sensory deficits. However, in this case, the patient
's symptoms are not consistent with an infarct in the inner capsule.
Option B: Medulla, also known as the medulla oblongata, is the lower part of the brainstem that control
s vital functions such as breathing and heart rate. While a stroke in the medulla can cause various neur
ological deficits, the patient's symptoms, such as weakness in the left arm and leg and double vision, a
re not specific to a medullary infarct.
Option D: Occipital lobe is responsible for visual processing. However, the patient's visual symptoms of
 double vision are more likely related to the involvement of the midbrain and its control over eye move
ments rather than a specific occipital lobe infarct
 
 Correct option B:
 "Muscle intimal elastic lamina layer defect."
 Berry aneurysms, also known as saccular aneurysms or intracranial aneurysms, are commonly
caused by a defect in the muscle intimal elastic lamina layer of the arterial wall. These aneurysms are
characterized by a localized outpouching or ballooning of the arterial wall, typically at the branching
points of cerebral arteries.
Option A is incorrect because while hypertension (HTN) can contribute to the weakening of blood vess
els, it is not the primary cause of berry aneurysms. The defect in the muscle intimal elastic lamina layer
 is the key factor.
Option C is incorrect because it mentions an endothelial layer defect, which is not the primary cause of 
berry aneurysms. Although endothelial dysfunction may play a role in aneurysm formation, the specific 
defect in the muscle intimal elastic lamina layer is more significant.
Option D is incorrect because adventitia defect alone is not the primary cause of berry aneurysms. The
 defect in the muscle intimal elastic lamina layer is the primary underlying abnormality
 
 Abducens nerve: This is the correct option. The abducens nerve (cranial nerve VI) is most commonly
affected in cases of increased ICP. The nerve supplies the lateral rectus muscle, which is responsible
for outward (abduction) movement of the eye. When the ICP increases, it can lead to compression or
stretching of the abducens nerve, resulting in weakness or paralysis of the lateral rectus muscle. This
leads to a characteristic finding called "abducens nerve palsy," which presents as an inability to move
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the affected eye laterally. Therefore, option A is correct.
Option B. Trochlear nerve: The trochlear nerve (cranial nerve IV) is responsible for the superior oblique
 muscle, which is involved in downward and inward (depression and intorsion) movement of the eye. W
hile increased ICP can potentially affect the trochlear nerve, it is not the most common cranial nerve in
volved in raised ICP. Therefore, option B is incorrect.
Option C. Trigeminal nerve: The trigeminal nerve (cranial nerve V) is responsible for sensory innervatio
n of the face and motor innervation of the muscles involved in chewing. While increased ICP can cause
 headache and facial pain, the trigeminal nerve itself is not typically affected as the primary cranial nerv
e involved in raised ICP. Therefore, option C is incorrect.
Option D. Facial nerve: The facial nerve (cranial nerve VII) is responsible for the motor innervation of th
e muscles of facial expression. While increased ICP can potentially affect the facial nerve, it is not the 
most common cranial nerve involved in raised ICP. Facial weakness or paralysis may be present in so
me cases, but it is not as common as abducens nerve involvement. Therefore, option D is incorrect.
Correct option A.
 Ceftriaxone is commonly used for the prophylaxis of meningococcal meningitis in pregnancy. It is a
broad-spectrum antibiotic effective against Neisseria meningitidis, the bacteria responsible for
meningococcal meningitis. It is given as a single intramuscular or intravenous dose for prophylaxis in
individuals who have had close contact with a person diagnosed with meningococcal disease.
Therefore, option A is correct.
Option B. Rifampicin: Rifampicin is also used for the prophylaxis of meningococcal meningitis; however
, it is not the preferred choice in pregnancy. Rifampicin is generally avoided during pregnancy unless th
e benefits outweigh the potential risks. Therefore, option B is incorrect.
Option C. Ciprofloxacin: Ciprofloxacin is effective against Neisseria meningitidis; however, it is not the f
irst-line choice for prophylaxis in pregnancy. It is generally avoided in pregnancy due to potential adver
se effects on the developing fetus. Therefore, option C is incorrect.
Option D. Penicillin G: Penicillin G is effective against many bacterial infections, but it is not the recom
mended prophylactic treatment for meningococcal meningitis. Other antibiotics like ceftriaxone are mor
e commonly used for prophylaxis. Therefore, option D is incorrect.
 Mydriasis (dilated pupil): This is incorrect. Horner syndrome is characterized by miosis (constricted
pupil) rather than mydriasis. The affected pupil appears smaller compared to the unaffected pupil due
to the disruption of sympathetic innervation.
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Option B. Ptosis (drooping eyelid): This is correct. Ptosis is one of the classic features of Horner syndro
me. It occurs due to the interruption of sympathetic innervation to the muscles that elevate the eyelid. A
s a result, the affected eyelid appears droopy or lower than the unaffected eyelid.
Option C. Anhidrosis (lack of sweating): This is correct. Anhidrosis or decreased sweating is commonly
 observed in Horner syndrome. Sympathetic innervation plays a role in regulating sweat production, an
d the disruption of sympathetic fibers can lead to reduced or absent sweating on the affected side of th
e face.
Option D. Enophthalmos (sunken appearance of the eye): This is correct. Enophthalmos, or a sunken 
appearance of the eye, can be observed in Horner syndrome. It is caused by the loss of sympathetic in
nervation to the smooth muscle surrounding the eye, leading to a slight retraction of the eyeball.
Option c: Continue treatment for another 2 years: This option is correct. The recommended approach i
n this scenario is to continue treatment for another 2 years. The duration of seizure freedom required b
efore considering discontinuation of antiepileptic drugs varies, but typically 2-5 years of seizure freedo
m is considered an appropriate period.
 
Option a. Stop the treatment and follow up: This option is incorrect. The 16-year-old girl has been seizu
re-free for 6 months, but it does not necessarily mean that she can safely stop the treatment altogether
. Stopping the treatment abruptly can increase the risk of seizure recurrence.
Option b. Gradually taper the drug and stop treatment: This option is incorrect. While the girl has been 
seizure-free for 6 months, it is generally recommended to continue treatment for a longer period before
 considering tapering and stopping the antiepileptic drug. Gradual tapering of the drug under medical s
upervision may be considered later, but not at this stage.
Optiond. Continue lifelong treatment with antiepileptics: This option is incorrect. Lifelong treatment with 
antiepileptic drugs is not necessary in all cases. If the girl remains seizure-free for a prolonged period (
usually 2-5 years), there may be an opportunity to gradually taper and discontinue the medication unde
r medical supervision.
Option B: Pelizaeus-Merzbacher disease is a genetic disorder characterized by abnormal myelination o
f the central nervous system. The tigroid white matter appearance on MR imaging is a
classic finding in this condition due to alternating areas of myelination and demyelination
 
Option A: Pantothenate kinase deficiency is a
rare neurodegenerative disorder characterized by impaired synthesis of coenzyme A
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(CoA). It is not specifically associated with a tigroid white matter pattern on MR imaging.
Option C: Neuroferritinopathy is an autosomal dominant neurodegenerative disorder characterized by 
abnormal iron deposition in the brain. It typically does not present with a
tigroid white matter pattern on MR imaging.
Option D: Aceruloplasminemia is a rare genetic disorder characterized by the absence or dysfunction o
f ceruloplasmin, leading to abnormal iron metabolism. It is not specifically associated with a
Option b. Plexiform neurofibromatosis: Plexiform neurofibromatosis is a
subtype of neurofibromatosis type 1 (NF1), a genetic disorder characterized by the development of neu
rofibromas, which are benign tumors arising from nerve tissue. Plexiform neurofibromas involve multipl
e nerves and can cause disfigurement and functional impairments.
 
Option a. Facial nerve palsy: Facial nerve palsy refers to the weakness or paralysis of the muscles inn
ervated by the facial nerve. It is not directly related to the image of plexiform neurofibromatosis.
Option c. Masticator space abscess: Masticator space abscess refers to an abscess (collection of pus) 
within the masticator space, which is an anatomical region containing the muscles of mastication (chew
ing). It is not related to the image of plexiform neurofibromatosis.
Option d. Fibrous dysplasia: Fibrous dysplasia is a bone disorder characterized by the abnormal devel
opment of fibrous tissue within the bone, leading to weakening and deformity. It is not directly related to
 the image of plexiform neurofibromatosis.
Option D.
  Orthostatic hypotension: This option is correct. Orthostatic hypotension, which refers to a drop in
blood pressure upon standing, is not a core clinical feature of LBD. While some individuals with LBD
may experience orthostatic hypotension, it is not specific to the diagnosis and can be seen in other
neurological or cardiovascular conditions as well.
Option A. Fluctuating cognition: This is a core clinical feature of Lewy body dementia (LBD). Patients w
ith LBD commonly experience variations in cognitive function, such as fluctuations in attention, alertnes
s, and ability to process information. These fluctuations can occur throughout the day or from one day t
o another.
Option B. Recurrent visual hallucinations: This is a
core clinical feature of LBD. Visual hallucinations, often vivid and detailed, are a common symptom in L
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BD. These hallucinations typically involve seeing people, animals, or objects that are not present.
Option C. REM sleep behavior disorder (RBD): This is a core clinical feature of LBD. RBD refers to a di
sturbance during REM sleep where individuals physically act out their dreams, sometimes leading to inj
ury or harm to themselves or their bed partners. RBD is considered a
prodromal symptom of LBD and can precede the onset of cognitive decline.
Option A. 
 Neuromyelitis optica (NMO): This option is correct. NMO is a rare autoimmune disorder characterized
by recurrent episodes of optic neuritis and transverse myelitis. It primarily affects the optic nerves and
spinal cord. Patients with NMO typically experience severe visual impairment and varying degrees of
motor and sensory deficits due to inflammation and damage to the optic nerves and spinal cord.
Steroids are often used as a treatment, and some patients may show a partial response to them.
Incorrect options: 
Option B. Subacute combined degeneration of spinal cord: This option is incorrect. Subacute combined
 degeneration of the spinal cord is typically associated with vitamin B12 deficiency, leading to neurologi
cal symptoms such as sensory disturbances, difficulty walking, and spasticity. Optic neuritis is not a
characteristic feature of this condition.
Option C. Posterior cerebral artery stroke: This option is incorrect. Posterior cerebral artery stroke refer
s to an ischemic stroke affecting the posterior cerebral artery territory of the brain. It can cause visual di
sturbances, but the presence of optic neuritis and transverse myelitis makes this diagnosis less likely.
Option D. Neurosyphilis: This option is incorrect. Neurosyphilis is a complication of syphilis infection th
at affects the central nervous system. It can present with various neurological symptoms, but recurrent 
optic neuritis and transverse myelitis are not typical features of neurosyphilis.
Option B.
  Creutzfeldt-Jakob disease is a rare degenerative neurological disorder. The EEG pattern in CJD
often shows characteristic findings, including periodic sharp wave complexes (PSWCs) and
generalized slowing, which are consistent with the given EEG pattern.
Option A. Hepatic encephalopathy is a condition that affects the brain due to liver dysfunction. The EE
G pattern in hepatic encephalopathy typically shows diffuse slowing rather than the specific pattern see
n in the given EEG.
Option C. Generalized tonic-clonic seizures (also known as grand mal seizures) typically manifest with 
a different EEG pattern characterized by generalized spike and wave discharges during the seizure act
ivity. This pattern differs from the findings seen in the given EEG.
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Option D. Herpes simplex encephalitis is a viral infection that affects the brain. The EEG findings in her
pes simplex encephalitis may show focal or multifocal abnormalities, such as periodic lateralized epilep
tiform discharges (PLEDs) or focal slowing, which are different from the EEG pattern observed in the gi
ven image.
Correct Option D.
Copper deficiency produces similar symptoms: The patient's clinical presentation is consistent with sub
acute combined degeneration (SCD) of the spinal cord, which is commonly caused by vitamin B12 defi
ciency. SCD primarily affects the posterior (dorsal) and lateral columns of the spinal cord. The posterior
 column involvement leads to decreased proprioception and vibration sense, resulting in ataxic gait. Ho
wever, it's important to note that the lateral corticospinal tracts are also affected, causing weakness, inc
reased reflexes, and increased tone in the lower limbs. Vitamin B12 supplements are the mainstay of tr
eatment for vitamin B12 deficiency, and they can improve the patient's condition.
Option A. Only the dorsal column is involved: This statement is incorrect because in subacute combine
d degeneration (SCD) of the spinal cord, both the posterior (dorsal) and lateral columns are involved. T
he posterior column involvement leads to sensory deficits, while the lateral column involvement results 
in motor deficits.
Option B. All patients with a neurological impairment will show macrocytosis: This statement is incorrec
t. While macrocytosis (enlarged red blood cells) can be seen in some cases of vitamin B12 deficiency, i
t is not a universal finding. Additionally, not all neurological impairments are associated with macrocyto
sis. Other causes of neurological impairment may not necessarily be associated with macrocytosis, suc
h as in this patient's case.
Option C. Vitamin B12 supplements do not improve the condition: This statement is incorrect. Vitamin 
B12 supplements are the standard treatment for vitamin B12 deficiency, including subacute combined 
degeneration (SCD) of the spinal cord. Early diagnosis and timely treatment with vitamin B12 supplem
entation can lead to improvement in symptoms and prevent further neurological deterioration.
Correct Option D: Variant CJD
 In the above-given case, there is rapidly progressive dementia, myoclonus, ataxia, and visual
disturbances. FLAIR MRI scans show a hyperintense signal involving the pulvinar and dorsomedial
thalamic nuclei bilaterally and are known as the hockey stick sign, which is diagnostic of variant CJD.
Option A: In the initial stages, the MRI is normal in Alzheimer’s, and in later stages shows temporal and
 parietal atrophy.
Option B: There is no history of stroke; hence vascular dementia is unlikely to be the diagnosis.
Option C: The hockey stick sign is not seen in sporadic CJD.
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 Phenylketonuria (PKU) is a genetic disorder characterized by the inability to properly metabolize the
amino acid phenylalanine. This is due to a deficiency in the enzyme phenylalanine hydroxylase, which
leads to the accumulation of phenylalanine in the body. If left untreated, the elevated levels of
phenylalanine can cause damage to the developing brain, leading to intellectual disability or mental
retardation. Therefore, mental retardation is a characteristic feature of untreated PKU.
Options B. Alkaptonuria: Alkaptonuria is a rare metabolic disorder characterized by the inability to meta
bolize the amino acids phenylalanine and tyrosine. However, it does not typically cause mental retardat
ion. Instead, it leads to the accumulation of homogentisic acid, which can cause dark urine, darkening 
of connective tissues, and joint problems.
Options C. Albinism: Albinism is a genetic condition characterized by a lack of melanin pigment in the s
kin, hair, and eyes. While individuals with albinism may have visual impairments, it does not directly ca
use mental retardation.
Options D. MSUD (Maple Syrup Urine Disease): MSUD is a rare metabolic disorder characterized by t
he inability to break down certain amino acids, including leucine, isoleucine, and valine. If left untreated
, it can lead to severe neurological symptoms. However, mental retardation is not a
typical feature of MSUD.
 Subacute Combined Degeneration (SACD) is a neurological condition characterized by the
degeneration of the spinal cord, peripheral nerves, and sometimes the brain. It is primarily caused by
vitamin B12 deficiency, which can occur due to various factors such as malabsorption, inadequate
dietary intake, or certain medical conditions. When vitamin B12 deficiency is identified and treated
early, the symptoms of SACD, including dementia, can be reversed or significantly improved.
Therefore, SACD is an example of reversible dementia.
Options B: AD (Alzheimer's Disease): Alzheimer's disease is a progressive neurodegenerative disorder
 characterized by memory loss, cognitive decline, and behavioral changes. Unfortunately, AD is current
ly irreversible, and the available treatments aim to manage symptoms rather than cure the disease.
Options C: CJD (Creutzfeldt-Jakob Disease): Creutzfeldt-Jakob disease is a rare, degenerative brain di
sorder caused by abnormal proteins called prions. It leads to rapid neurological decline, including dem
entia, and unfortunately, it is a fatal condition. CJD is not reversible.
Options D. Pick's Disease: Pick's disease, also known as frontotemporal dementia, is a type of dementi
a characterized by the degeneration of the frontal and temporal lobes of the brain. It leads to progressi
ve cognitive decline, personality changes, and behavioral disturbances. Pick's disease is not reversible
.
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Correct Option B- Usage of Carbidopa leads to on and off phenomenon:
 Carbidopa is commonly used in combination with levodopa as a treatment for Parkinson's disease.
Carbidopa is not known to directly cause the "on and off phenomenon." The "on and off phenomenon"
refers to fluctuations in motor response, where individuals with Parkinson's disease experience periods
of improved motor function (on) followed by periods of reduced or absent response to medication (off).
This phenomenon is more commonly associated with fluctuations in the effectiveness of levodopa itself,
rather than carbidopa.
Option A- Manganese can cause secondary Parkinsonism: Exposure to high levels of manganese, suc
h as through occupational or environmental sources, can lead to a
form of parkinsonism known as manganism.
Option C- Slight tremor in the hand or foot followed by jaw: One of the cardinal symptoms of Parkinson'
s disease is a resting tremor, typically starting in the hand or foot. The tremor can progress to involve o
ther body parts, including the jaw.
Option D- Cogwheel rigidity or lead pipe rigidity is seen: Rigidity is a
characteristic feature of Parkinson's disease. Cogwheel rigidity refers to a
jerky resistance to passive movement characterized by a
series of brief interruptions, while lead pipe rigidity refers to a
continuous resistance throughout the range of movement.
Correct Option C: Pituitary DI
 The above case is most suggestive of pituitary diabetes insipidus. There is polyuria and polydipsia.
The absence of a pituitary bright spot is suggestive of central DI.
Option A: In nephrogenic DI, the ADH levels are >1pg/ml.
Option B: In primary polydipsia, a pituitary bright spot will be observed.
Option D: In mannitol infusion, the urine osmolality is >300 mOsm/L.
 Explanation: The presentation of muscle weakness with normal nerve conduction and flaccidity
suggests a neuromuscular disorder rather than a primary nerve problem. Myasthenia gravis is an
autoimmune disorder characterized by muscle weakness and fatigue, typically caused by antibodies
targeting the neuromuscular junction. It can present with normal nerve conduction studies and a flaccid
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weakness pattern. In myasthenia gravis, weakness often worsens with exertion and improves with rest.
Option B (GBS - Guillain-Barré syndrome) is incorrect because GBS typically presents with a symmetri
cal pattern of ascending muscle weakness, starting in the lower extremities and progressing upward. It 
is characterized by reduced or absent deep tendon reflexes and can show abnormalities in nerve cond
uction studies.
Option C (Transverse myelitis) is incorrect because transverse myelitis involves inflammation of the spi
nal cord, leading to sensory and motor deficits at a specific spinal level. It is typically associated with a
bnormalities in nerve conduction studies and may present with spastic weakness rather than flaccid we
akness.
Option D (Traumatic neuritis) is incorrect because traumatic neuritis refers to nerve damage resulting fr
om trauma, leading to focal neurological deficits. It would not typically present with flaccid weakness an
d normal nerve conduction studies.
Correct Option C: Mammosomatotroph adenoma
 The above case is that of a mammosomatotroph adenoma of the pituitary which causes an excess of
prolactin and growth hormone secretion. Common symptoms include headache, vomiting, amenorrhea,
galactorrhoea, loss of libido, acromegaly, and infertility.
Option A: Corticotroph adenoma secretes ACTH and has features of Cushing’s.
Option B: Gonadotroph adenoma secretes FSH and LH and can present with PCOS and ovarian hyper
sensitivity syndrome.
Option D: Gliomas are derived from glial cells and present with headache, nausea, vomiting, and seizu
res.
 The extensor reflex on pinching the gastrocnemius muscle is known as the Gordon sign. It is an
abnormal reflex response where pinching the gastrocnemius muscle leads to extension of the big toe
instead of the normal flexion response. The Gordon sign can be seen in upper motor neuron lesions,
such as in pyramidal tract dysfunction.
Option A (Gower Sign) is incorrect because the Gower sign is associated with Duchenne muscular dys
trophy and refers to the characteristic way that individuals with muscle weakness in the lower extremiti
es rise from a
squatting or sitting position. They use their hands to "walk" up their legs and push themselves into a
standing position.
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Option B (Homan Sign) is incorrect because the Homan sign is a clinical finding associated with deep v
ein thrombosis (DVT) in the lower extremities. It is characterized by pain in the calf upon passive dorsifl
exion of the foot.
Option C (Oppenheim Sign) is incorrect because the Oppenheim sign is a test used to assess upper m
otor neuron dysfunction. It involves applying firm pressure along the anterior tibial surface from the kne
e to the ankle, and a positive sign is indicated by a downward movement of the big toe.
Correct Option B: Hemispatial neglect
 In the above image drawn by the patient, the clock is blank on one side. The hemispatial defect is the
most accurate term used. It is the inability to report, respond, and orient to stimuli in one-half of the
space despite having no motor or sensory deficits.
Option A: Confabulation is a
phenomenon in which the patient fills in memory gaps with made up stories and inaccurate facts.
Option C: Kinetic apraxia is the inability to perform a fine movement or task despite having the desire a
nd physical capability to do it. The lesion lies in the paracentral cortex.
Option D: Asterixis is a
type of negative myoclonus where irregular lapses of the posture of body parts is noted.
Option A (1, 2, and 3 are correct).
 This option correctly states that statements 1, 2, and 3 are true, while statement 4 is incorrect.
 
Option B. 1 & 3 are correct.
 This option incorrectly states that only statements 1 and 3 are correct. It omits statement 2, which is
true. Lamotrigine is indeed effective in controlling myoclonic jerks in juvenile myoclonic epilepsy.
Option C. 2 & 4 are correct.
 This option incorrectly states that statements 2 and 4 are correct. It omits statement 1, which is true.
Juvenile myoclonic epilepsy is associated with polygenic inheritance. Additionally, statement 4 is
incorrect as valproate is not contraindicated in the treatment of juvenile myoclonic epilepsy.
Option D. 1, 2, 3, and 4 are correct.
 This option incorrectly states that all statements are correct. However, statement 4 is incorrect, as
mentioned before. Valproate is not contraindicated in the treatment of juvenile myoclonic epilepsy.
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 Increased Protein and turbid in appearance. 
 However, bacterial meningitis has C/F, high fever, and altered mental status.
Option D- Chemical meningitis:
  It is caused by the disturbance of the meninges by different chemicals or medicines. 
Correct Option A- Bromocriptine:
 Bromocriptine is a dopamine agonist that prevents prolactin discharge and is the drug of choice for the
situation of prolactinomas, which are pituitary tumors that hide prolactin. 
 In this case, the patient has galactorrhea, which is an indication of hyperprolactinemia. Therefore,
bromocriptine is the choice of drug for the situation.
Option B- Promethazine: It is an antihistamine drug used to treat allergies, motion sickness, and nause
a. It has no role in the situation of pituitary tumors.
Option C- Octreotide: It is a somatostatin analog that restricts the discharge of various hormones, cont
aining development hormone and insulin-like growth factor-1. It is used to treat acromegaly and neuroe
ndocrine tumors but has no function in the situation of prolactinomas.
Option D-Clozapine: It is an antipsychotic drug used to treat emotional disorders and additional psychia
tric disorders. It has no role in the situation of pituitary tumors.
Correct Option A- Neisseria meningitidis:
 The above image is that of a purpuric rash which is seen in meningococcemia caused by Neisseria
meningitides. Neisseria meningitidis is a gram negative diplococci. Fulminant meningococcemia
presents with a very high fever and hemorrhagic rash.
Option B- Pseudomonas aeruginosa: Pseudomonas aeruginosa is a
gram-negative rod-shaped bacteria.
Option C- Streptococcus pneumoniae: Streptococcus pneumoniae is a
gram-positive, spherical bacteria.
Option D- E. Coli: E. Coli is a gram-negative rod-shaped bacteria.
Correct Option A - Migraine:
933

IgG4 Related Disease
1. A 55-year-old male presents with a persistent cough and chest discomfort. Imaging Imaging is given
below. Biopsy findings show lymphoplasmacytic infiltration of the lung tissue. Which of the following
treatment options is most appropriate for this patient?
A. Chemotherapy
B. Surgical resection
D. Corticosteroids
2. A 55-year-old male presents to the gastroenterology clinic with complaints of persistent abdominal
pain, diarrhea, and unintentional weight loss over the past few months. A CT scan of the abdomen is
given below. Which of the following symptoms is most likely associated with the organ involvement
shown in this condition?
A. Cholangiocarcinoma
B. Primary sclerosing cholangitis
C. Diabetes mellitus
D. Pancreatic adenocarcinoma
3. A 45-year-old male presents to the gastroenterology clinic with complaints of chronic diarrhea,
steatorrhea, and unintentional weight loss over the past few months. Which of the following is true
regarding histopathological findings of this patient?
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Page 2
A. IgM plasma cell infiltrate
B. Cris-cross infiltration of tissue known as Lymphoid follicles
C. Involvement of arteries known as Vasculitis
D. Involvement of veins known as Obliterative phlebitis
Correct Option D - Corticosteroids:
 Well-circumscribed mass present on the right upper zone following biopsy showing
lymphoplasmacytic infiltration of the lung the diagnosis is inflammatory pseudotumor
 Corticosteroids are the treatment of choice for inflammatory pseudotumors. These tumors typically
respond well to corticosteroid therapy, which helps reduce inflammation and lymphoplasmacytic
infiltration in the affected lung tissue.
Option A - Chemotherapy: Inflammatory pseudotumors are typically benign and do not respond well to 
chemotherapy. Chemotherapy is primarily used to treat malignant tumors and would not be the first-lin
e treatment for an inflammatory pseudotumor.
Option B - Surgical resection: Surgical resection may be considered if the tumor is causing significant s
ymptoms or if there is concern for malignancy. However, inflammatory pseudotumors often respond we
ll to less invasive treatments, and surgery may carry risks.
Option C - Antibiotics: Inflammatory pseudotumors are not caused by infection, so antibiotics would not
 be effective in treating this condition. Inflammatory pseudotumors are characterized by inflammatory c
ell infiltration rather than infection.
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Page 3
Correct Option C - Diabetes mellitus:
 In Type 1 autoimmune pancreatitis, endocrine involvement can lead to the development of diabetes
mellitus due to damage to the beta cells of the pancreas.
 The CT abdomen shows abnormal morphology of the pancreas due to lymphoplasmacytic infiltration
known as “Sausage pancreas”/ Type 1 autoimmune pancreatitis. This can be misdiagnosed as
Pancreatic adenocarcinoma
 As the autoimmune process affects the islets of Langerhans, insulin production may become
impaired, resulting in elevated blood glucose levels and the manifestation of diabetes mellitus.
 This can present with symptoms such as polyuria, polydipsia, and unexplained weight loss.
Option A and B - (Cholangiocarcinoma & Primary sclerosing cholangitis): 
 Biliary tract involvement mimics the manifestations of either Cholangiocarcinoma or Primary
sclerosing cholangitis. But it is not associated with inflammatory pseudotumor
Option D - Pancreatic adenocarcinoma:
 The CT abdomen shows “Sausage pancreas”/ Type 1 autoimmune pancreatitis. This can be
misdiagnosed as Pancreatic adenocarcinoma.
Correct Option D - Involvement of veins known as Obliterative phlebitis:
 The condition described exhibits characteristic histopathological findings, including IgG plasma cell
infiltrate, criss-cross infiltration of tissue known as Storiform fibrosis, and involvement of veins known as
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Page 4
Obliterative phlebitis seen in IgG4 related disease.
Option A - IgM plasma cell infiltrate: IgG4 plasma cell infiltrate, not IgM, is characteristic of the describe
d condition.
Option B - Cris-cross infiltration of tissue known as Lymphoid follicles: The interwoven appearance of ti
ssue, known as Storiform fibrosis, is characteristic, not lymphoid follicles.
Option C - Involvement of arteries known as Vasculitis: The involvement of veins, not arteries, is terme
d Obliterative phlebitis, characteristic of the described condition.
938

Ankylosing Spondylitis
1. A 28-year-old male presents to the clinic with complaints of low backache persisting for the past 3
months. Which of the following statements regarding the presentation of back pain is appropriate?
A. Back pain in sciatica and disc prolapse is diurnal.
B. Pain in neurogenic claudication worsens with standing.
C. Pain in Buerger's disease typically worsens at night.
D. Pain relief is typically observed with the use of gabapentin or pregabalin in ankylosing spondylosis.
2. Which of the following will be the earliest involvement in a 30-year-old male presenting with
complaints of chronic lower back pain and stiffness, particularly in the morning and after periods of
inactivity, along with buttock pain and difficulty bending forward to touch his toes?
A. Sacroiliitis
B. Pain at the sternoclavicular joint
C. Buttock muscle atrophy
D. Decreased height
3. A 62-year-old male presents to the rheumatologist with complaints of chronic lower back pain and
stiffness, On examination modified Schober's test and lateral bending are reduced. He also reports
episodes of eye redness and discomfort. Which of the following is the most common extra articular
manifestation of this patient?
A. Psoriasis
B. Uveitis
C. Rheumatoid nodules
D. Keratoconjunctivitis sicca
4. In a case of ankylosing spondylitis, which of the following manifestations is typically considered a late
involvement?
A. Bamboo spine formation
B. Intervertebral disc herniation
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Page 2
C. Bone marrow edema on MRI
D. Sacroiliitis on X-ray
5. A 45-year-old male presents to the cardiology clinic with a known history of ankylosing spondylosis.
He complains of intermittent chest pain and occasional palpitations. Which of the following will not be a
possibility in this patient?
C. Ischemic heart disease (IHD)
D. Third-degree heart block
6. Which of the following is a true statement regarding the diagnostic criteria for Ankylosing Spondylitis?
A. MRI of the spine may show bone marrow edema or sacroiliitis
B. The presence of HLA-B27
C. MRI of the spine show bone marrow edema with Enthesopathy
D. The presence of HLA-B27 along with psoriasis
7. A 45-year-old male presents to the rheumatology clinic with complaints of chronic lower back pain
and stiffness, particularly worse in the mornings and at night. He reports difficulty sleeping due to
nocturnal pain, which is affecting his productivity at work. His BADSAI Index is >5. Which of the
following treatment options would be most appropriate for this patient's condition?
A. NSAIDs
B. Sulphasalazine
C. Methotrexate
D. Infliximab infusion
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Page 3
Correct Option B - Pain in neurogenic claudication worsens with standing:
 Neurogenic claudication typically presents with pain that worsens with standing and walking
Option A - Back pain in sciatica and disc prolapse is diurnal:
 Back pain in sciatica and disc prolapse typically worsens with activities that involve bending, lifting, or
prolonged sitting. Physical activity tends to exacerbate the symptoms in these conditions.
Option C - Pain in Buerger's disease typically worsens at night:
 Pain in Buerger's disease, also known as thromboangiitis obliterans, is typically associated with
ischemia and usually worsens with physical activity or exposure to cold temperatures. It is not
specifically noted to worsen at night.
Option D
- Pain relief is typically observed with the use of gabapentin or pregabalin in ankylosing spondylosis: 
 While gabapentin and pregabalin are commonly prescribed for neuropathic pain, their effectiveness
varies among individuals. Pain relief is not typically observed in ankylosing spondylosis.
Correct Option A - Sacroiliitis:
 In Ankylosing Spondylitis (AS), tenderness or pain at the sacroiliac joint or sacroiliitis is one of the
earliest manifestations. It is often accompanied by radiological findings such as bone marrow edema.
Option B - Pain at the sternoclavicular joint: Sternoclavicular joint involvement is less common in AS co
mpared to the sacroiliac joint, and it typically occurs in later stages of the disease.
Option C -  Buttock muscle atrophy: Buttock muscle atrophy may occur in AS due to chronic inflammati
on and stiffness, but it is not typically an early manifestation.
Option D - Decreased height: Decrease in height is a consequence of AS-related changes such as thor
acic kyphosis and loss of lumbar lordosis, but it usually occurs in later stages of the disease after the s
pine has undergone significant structural changes.
Correct Option B - Uveitis:
 This patient's clinical presentation, including chronic lower back pain and stiffness, reduced spinal
mobility on examination, and episodes of eye redness and discomfort, are highly suggestive of
Ankylosing Spondylitis (AS).
 AS is a type of spondyloarthropathy characterized by inflammation primarily affecting the axial
skeleton, leading to chronic lower back pain and stiffness.
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Page 4
 The most common extra-articular manifestation of AS is uveitis, which involves inflammation of the
uveal tract of the eye. Uveitis can present with symptoms such as eye redness, discomfort, pain, and
blurred vision.
Option A - Psoriasis: While psoriasis can occur concurrently with AS and is part of the SPINE ACHE m
nemonic, it is not the most common extra-articular manifestation of AS.
Option C
- Rheumatoid nodules: Rheumatoid nodules are characteristic of Rheumatoid Arthritis (RA), not AS.
Option D - Keratoconjunctivitis sicca: While dry eyes (keratoconjunctivitis sicca) can occur in autoimmu
ne conditions like Sjögren's syndrome, it is not the most common extra-articular manifestation of AS.
 
Correct Option A - Bamboo spine formation:
 Bamboo spine formation and Dagger sign characterized by fusion of the vertebrae in the spine, is
typically considered a late manifestation of ankylosing spondylitis.
 This occurs due to progressive inflammation and ossification of the spinal ligaments, leading to the
characteristic rigid appearance of the spine seen on X-ray. 
Option B - Intervertebral disc herniation:
 Intervertebral disc herniation is not seen in ankylosing spondylitis
Option C and D - (Bone marrow edema on MRI & Sacroiliitis on X-ray):
 Bone marrow edema and Sacroiliitis occur early in the disease.
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Page 6
Correct Option D - Infliximab infusion:
 The BADSAI Index, developed by Dr. Bath, stands for Bath Ankylosing Spondylitis Disease Activity
Index.
 It is utilized to assess patients' response to treatment with prescribed medications. Patients are
regularly questioned about their symptoms, and if their BADSAI Index is greater than 4, it suggests that
biologicals should be initiated.
 The preferred drug in such cases is Infliximab infusion.
Option A - NSAIDs: While NSAIDs are commonly used as first-line management for ankylosing spondy
litis, this patient's nocturnal pain, which is disabling and affecting productivity, indicates inadequate res
ponse to NSAIDs alone.
Option B - Sulphasalazine: Sulphasalazine may help ease the manifestations of ankylosing spondylitis,
 but in patients with a high BADSAI Index (>4), biological agents like infliximab are preferred due to thei
r superior efficacy in reducing disease activity.
Option C - Methotrexate: Methotrexate is not typically used as a first-line treatment for ankylosing spon
dylitis. It may be considered in patients who do not respond adequately to NSAIDs or biological agents,
 but it does not have disease-modifying roles in ankylosing spondylitis
944

Scleroderma & Sjogren Syndrome
1. A 55-year-old male presents to the emergency department with severe hypertension and acute
kidney injury. He has a history of poorly controlled hypertension and diabetes mellitus. On examination,
his skin appears shiny and taut. Which of the following histopathological findings is most likely to be
observed in this patient's skin biopsy?
A. Loss of sweat and sebaceous glands
B. Thinning of the dermis
C. Hyperplasia of the sweat glands
D. Normal appearance of skin architecture
2. What cardiac manifestation is least likely manifested in a 50-year-old female patient presented to the
cardiology clinic with complaints of chest pain and shortness of breath.Upon examination, you notice
that her nose appears pinched, and her lips are tightly approximated. Additionally, her facial expression
seems diminished , you also note the presence of a pericardial friction rub and the following as shown
in the image?
A. Dilated cardiomyopathy
B. Sick sinus syndrome
C. Pericarditis
D. Diastolic malfunction of the heart
945

Page 2
3. A 50-year-old female patient presents with complaints characterized by episodic color changes in her
fingers in response to cold temperatures or emotional stress. She mentions experiencing these
symptoms for several years. Upon further examination, the patient is noted to have thickening and
tightening of the skin on her fingers. She also reports occasional episodes of ischemic pain in her digits,
particularly during cold weather. Which of the following antibodies is most likely to be positive in this
patient?
A. Anti-Centromere antibody
B. Anti-Topoisomerase antibodies
C. Ku antibody
D. U1 RNP
4. A 50-year-old female patient presents to the rheumatology clinic with complaints of skin changes and
difficulty in opening mouth. Upon examination there is tendon friction rub and she reports experiencing
dry mouth. She also mentions a history of Raynaud's phenomenon. Which subtype of systemic
sclerosis is most likely to be associated with these clinical features?
A. Diffuse cutaneous variety of systemic sclerosis
B. Limited cutaneous variety of systemic sclerosis
C. Systemic sclerosis sine scleroderma
D. Systemic sclerosis overlap syndrome
5. A 30-year-old female presents to her primary care physician with complaints of recurrent episodes of
discoloration and coldness in her fingertips, especially during cold weather or when she experiences
emotional stress. On examination, the physician notes pallor followed by cyanosis in the patient's
fingertips. Which of the following is the most appropriate diagnostic test to evaluate for the underlying
cause of these symptoms?
A. MRI of the hands
B. Nail fold capillaroscopy
C. Arterial blood gas analysis
D. Doppler ultrasound of the extremities
6. A 50-year-old woman with a known history of scleroderma presents to the emergency department
with BP 200/110 and low urine output. biopsy findings reveal an "onion skin" appearance. There is
presence of anti-RNA polymerase III antibody. Which of the following treatments is most appropriate for
managing this patient's condition?
A. Corticosteroids
C. ACE inhibitors
D. Anticoagulants
7. A 45-year-old woman presents to her rheumatologist with complaints of persistent dryness in her
eyes and mouth for the past several months. On further examination, she also mentions occasional
946

Page 3
joint pain and stiffness. Laboratory tests reveal the presence of anti-Ro antibodies.Which of the
following diagnostic tests would be most appropriate to confirm the suspected diagnosis in this patient?
A. Schirmer's test
B. Salivary gland biopsy
C. Lip biopsy
D. Tear breakup time test
8. A 55-year-old female presents to the ophthalmology clinic with complaints of dry eyes and a gritty
sensation in her eyes for the past several months. The ophthalmologist decides to perform an eye stain
test to assess the ocular surface. Which of the following stains is used in this patient?
A. Fluorescein
B. Lissamine Green
C. Indocyanine Green
D. Methylene Blue
9. A 45-year-old woman presents to her primary care physician with complaints of persistent dry eyes
and mouth. She reports experiencing frequent episodes of gritty sensation in her eyes and difficulty
swallowing dry food. In a suspected case of Sjogren's syndrome , which HLA associations would be
most relevant to investigate in this patient?
A. HLA DR4, Drw53
B. HLA DR5, Drw52
C. HLA DR3, Drw52
D. HLA DR2, Drw52
10. A 50-year-old woman presents to the rheumatology clinic with complaints of dry eyes and mouth for
the past several months. She also reports experiencing joint pain and fatigue. Which of the following
statements is true regarding the diagnostic criteria for Sjogren Syndrome in this patient?
A. Unstimulated salivary flow of 0.5 ml/min is indicative of Sjogren Syndrome.
B. A positive anti-La antibody test confirms the diagnosis of Sjogren Syndrome.
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Page 4
C. A Schirmer's test result of <5mm/5 mins in one eye is consistent with the diagnosis of Sjogren
Syndrome.
D. A rose bengal eye stain score of <5 is characteristic of Sjogren Syndrome.
Correct Option A - Loss of sweat and sebaceous glands:
 Damage to sweat and sebaceous glands can contribute to the shiny appearance of the skin observed
in systemic sclerosis.
 The above given image shows sclerodactyly:Tightening of the skin with loss of digital transverse
creases
 Vasculopathy/Microangiopathy in systemic sclerosis (SSc) can lead to various manifestations"
948

Page 5
Option B - Thinning of the dermis: Structural changes associated with systemic sclerosis, including der
mal thickening and atrophy of adrenal glands
Option C and D - (Hyperplasia of the sweat glands & Normal appearance of skin architecture):
Correct Option A - Dilated cardiomyopathy:
 Systemic sclerosis can lead to various cardiac manifestations however it does not manifest Dilated
cardiomyopathy.
949

Page 7
Options B, C, and D:
 Other antibodies such as Anti-Topoisomerase antibodies (anti-Scl-70), Ku antibody, and U1 RNP may
be seen in systemic sclerosis, they are less commonly associated with the limited cutaneous form
 
Correct Option B - Limited cutaneous variety of systemic sclerosis:
 The clinical features described, including a tendon friction rub , dry mouth (xerostomia), difficulty in
opening the mouth (microstomia), are characteristic of the limited cutaneous variety of systemic
sclerosis (Lc Ssc).
 This subtype is typically associated with skin involvement limited to the distal extremities, face, and
neck, along with involvement of internal organs such as the gastrointestinal tract.
Option A - Diffuse cutaneous variety of systemic sclerosis (Dc Ssc): This subtype typically presents wit
h more widespread skin involvement, affecting proximal extremities and trunk, and is associated with a
higher risk of interstitial lung disease and renal involvement.
Option C - Systemic sclerosis sine scleroderma: This refers to systemic sclerosis without apparent skin
 involvement but with internal organ manifestations.
Option D - Systemic sclerosis overlap syndrome: This term is used when systemic sclerosis coexists wi
th features of other autoimmune connective tissue diseases, such as systemic lupus erythematosus or 
polymyositis.
951

Page 8
Correct Option B - Nail fold capillaroscopy:
 The most appropriate diagnostic test to evaluate for the underlying cause of the patient's symptoms of
recurrent discoloration and coldness in her fingertips, consistent with Raynaud's Phenomenon, is nail
fold capillaroscopy.
 This test allows visualization of the nail bed capillaries and aids in the early diagnosis of systemic
sclerosis, which is commonly associated with Raynaud's Phenomenon.
Option A
- MRI of the hands: While MRI can provide detailed imaging of the hands, it is not typically used as a
first-line diagnostic test for Raynaud's Phenomenon.
Option C - Arterial blood gas analysis: Arterial blood gas analysis may be helpful in assessing oxygena
tion status but is not specific for diagnosing Raynaud's Phenomenon.
Option D - Doppler ultrasound of the extremities: Doppler ultrasound can assess blood flow in the extre
mities but is not the primary diagnostic test for Raynaud's Phenomenon.
Correct Option C - ACE inhibitors:
 The presentation described is consistent with scleroderma renal crisis, a serious complication of
systemic sclerosis known as Scleroderma Crisis characterized by severe hypertension, acute kidney
injury, microangiopathic hemolytic anemia, and thrombocytopenia. The "onion skin" appearance on
biopsy is indicative of fibrinoid necrosis of small arteries and arterioles.
 ACE inhibitors are commonly used for the management of hypertension crises in scleroderma
patients.
Option A, B and D are incorrect as they are not used in treatment of
 
Correct Option B - Salivary gland biopsy:
 Sjogren's syndrome is characterized by lymphocytic infiltration of exocrine glands, leading to
symptoms such as dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia). To confirm the
diagnosis of Sjogren's syndrome, a salivary gland biopsy is often performed. This biopsy typically
shows lymphoid infiltration of labial minor salivary glands, which is a characteristic histological finding in
Sjogren's syndrome.
Option A - Schirmer's test: While Schirmer's test can be used to evaluate tear production in cases of dr
y eyes, it is not specific for Sjogren's syndrome and does not confirm the diagnosis.
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Page 9
Option C - Lip biopsy: While lip biopsy may also show lymphocytic infiltration, it is less commonly perfo
rmed compared to salivary gland biopsy and may not yield as conclusive results for diagnosing Sjogren
's syndrome.
Option D - Tear breakup time test: This test measures the time it takes for tears to break up on the surf
ace of the eye. While it can indicate dry eye syndrome, it is not specific for Sjogren's syndrome and do
es not confirm the diagnosis.
Correct Option B - Lissamine Green:
 Lissamine Green is used to evaluate ocular surface damage and assess dry eye syndrome. It stains
devitalized or damaged cells on the ocular surface, including the conjunctiva and cornea, and helps
identify areas of inflammation and epithelial defects.
Option A - Fluorescein: Fluorescein is commonly used to assess corneal abrasions, ulcers, and defects
 in the corneal epithelium. It highlights damaged areas of the cornea under blue light.
Option C - Indocyanine Green: Indocyanine Green is primarily used in angiography to visualize choroid
al vasculature and retinal blood vessels. It is not typically used for assessing ocular surface damage or 
dry eye syndrome.
Option D - Methylene Blue: Methylene Blue is a dye commonly used in various medical procedures, bu
t it is not commonly used in ophthalmology for assessing ocular surface conditions.
Correct Option C - HLA DR3, Drw52:
 Sjögren's syndrome is associated with specific HLA associations, including HLA DR3 and Drw52.
 Therefore, investigating HLA DR3 and Drw52 would be most relevant in this patient to confirm the
diagnosis of Sjögren's syndrome.
Option A - HLA DR4, Drw53: While HLA DR4 is associated with other autoimmune diseases like rheum
atoid arthritis, it is not a common HLA association in Sjögren's syndrome.
Option B - HLA DR5, Drw52: HLA DR5 is not a known HLA association in Sjögren's syndrome.
Option D - HLA DR2, Drw52: While HLA DR2 is associated with other autoimmune diseases like multip
le sclerosis, it is not a common HLA association in Sjögren's syndrome.
Correct Option A - A Schirmer's test result of <5mm/5 mins in one eye is consistent with the diagnosis 
of Sjogren Syndrome:
953

Rheumatoid Arthritis
1. A 45-year-old postmenopausal woman presents with joint pain and morning stiffness that improves
with activity. There is bilateral symmetrical involvement of small hand joints, including the PIP, MCP,
and wrist joints with evidence of flexor tenosynovitis and reduced grip strength. What is the most likely
(or)
Which condition causes joint pain, morning stiffness involving small hand joints, including the PIP,
MCP, and wrist joints, with evidence of flexor tenosynovitis and reduced grip strength
A. Osteoarthritis
B. Rheumatic fever
C. Rheumatoid arthritis
D. Gout
2. Which pair mentioning the deformity name and the deformity involved is incorrect?
A. Swan-Neck Deformity: Extension at PIP and flexion at DIP.
B. Boutonniere Deformity: Extension at PIP and flexion at DIP.
C. Mallet Finger: No extension at PIP and flexion at DIP.
D. Z Line Deformity: Subluxation of the first metacarpophalangeal joint, subluxation of the distal radio
ulnar joint, and hyperextension of the interphalangeal joint.
3. Which of the following statements about rheumatoid nodules is incorrect?
A. Rheumatoid nodules are typically tender when palpated.
B. Lung involvement can occur in association with rheumatoid nodules.
C. Pulmonary rheumatoid nodules can lead to exudative pleural effusion.
D. Rheumatoid nodules can compress peripheral nerves, causing mononeuritis multiplex.
E. Rheumatoid nodules on the median nerve can contribute to Carpal Tunnel syndrome.
4. A 55-year-old female presents with a 6-month history of gradually worsening joint pain and stiffness,
predominantly involving the hands, wrists, and knees. On examination, there is symmetrical swelling
and tenderness of the proximal interphalangeal joints and metacarpophalangeal joints. Laboratory
investigations reveal positive anti-cyclic citrullinated peptide (anti-CCP) antibodies. Which ocular
manifestation is not typically associated with this patient’s condition?
(or)
Which of the following ocular manifestations is not typically associated with rheumatoid arthritis?
A. Keratoconjunctivitis sicca
B. Scleritis
C. Episcleritis
D. Uveitis
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Page 2
5. A 55-year-old male coal worker presents with a history of joint pain, stiffness, and swelling in multiple
joints, particularly in the hands and wrists. He also reports a chronic cough, shortness of breath, and a
history of working in a coal mine for the past 20 years. Chest X-ray reveals the presence of multiple
rounded opacities in the lungs. What is the name of the syndrome associated with the combination of
these symptoms?
(or)
Which of the following is associated with the combination of rheumatoid arthritis and pneumoconiosis?
A. Goodpasture syndrome
B. Caplan syndrome
C. Cushing syndrome
D. Guillain-Barré syndrome
6. A 57-year-old woman presents to OPD with pain in her right knee and wrist for 5 years. She
complains of increased morning stiffness in joints, which is relieved after some time on its own. She
also gives a history of recurrent throat and urinary infections. On examination, there is a restriction of
movement and tender symmetrical large joints. Also, her spleen is 2 fingers below the costal margin.
Which of the following clinical manifestation will be most likely present?
(or)
Which clinical manifestation will be present in a patient with likely rheumatoid arthritis and enlarged
spleen?
A. Normocytic normochromic anaemia
B. Hepatomegaly
D. Neuropathy
7. A 35-year-old female presents with joint pain, swelling, and morning stiffness that lasts for more than
an hour. The symptoms primarily affect her hands and wrists but have also gradually involved multiple
small joints. On examination, you observe tenderness and swelling in the affected joints. Based on the
clinical presentation, which of the following diagnostic criteria is not relevant?
(or)
Which of the following is not involved in the diagnosis of rheumatoid arthritis?
A. Involvement of at least one large joint
B. Low titer of rheumatoid factor (RA factor)
C. Duration of symptoms more than six weeks
D. Serological evidence of anti-cyclic citrullinated peptide (anti-CCP) antibodies
8. A 45-year-old woman has been experiencing joint pain, stiffness, and swelling in her hands and feet
for several months. She finds it challenging to perform her daily activities. Her rheumatologist suspects
an autoimmune disorder and prescribes a medication that inhibits the enzyme dihydroorotate
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Page 3
dehydrogenase. What drug could this be?
(or)
Which of the following drugs inhibits the enzyme dihydroorotate dehydrogenase?
B. Sulfasalazine
C. Leflunomide
D. Hydroxychloroquine
9. A 50-year-old man with rheumatoid arthritis is started on methotrexate but shows limited response
despite several weeks of treatment. Leflunomide is added, but the patient again fails to respond after
several weeks. Which of the following medications is likely to be prescribed next?
(or)
Which of the following medications is likely to be prescribed next if there is no improvement with
methotrexate and leflunomide in a patient with rheumatoid arthritis?
A. Try the same regimen
B. Adalimumab
C. Hydroxychloroquine
D. Sulfsalazine
10. A 57-year-old woman presents to OPD with symptoms involving pain in her right knee joint and right
wrist joint for 5 years now. She complains of increased morning stiffness in joints which relieves after
some time on its own. She also gives a history of the recurrent throat or urinary infections. On
examination, there is a restriction of movement and tender symmetrical large joints. Also, her spleen is
2 fingers below the costal margin. Physician orders CBC and a diagnosis of Felty’s syndrome is made.
Which of the following clinical manifestation will be most likely present in Felty Syndrome?
(or)
Diagnosis of felty’s syndrome is made. What will be present in this patient?
11. A 45-year-old post-menopausal woman presents with bilateral symmetrical involvement of small
hand joints, including the PIP, MCP, and wrist joints. She complains of inflamed joints, pain,
tenderness, and morning stiffness that improves with activity. On examination, there is evidence of
flexor tenosynovitis and reduced grip strength. Which of the following is the most likely diagnosis?
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Page 4
D. Gout
12. A 50-year-old man is diagnosed with Rheumatoid Arthritis.The rheumatologist initiates treatment
with Methotrexate, However, despite being on Methotrexate for several weeks the symptoms show
limited improvement. In response to the inadequate response to Methotrexate, the rheumatologist
decides to add a second DMARD to the treatment regimen. Leflunomide is chosen as an adjunct to
Methotrexate in an attempt to achieve better disease control and symptom remission. However, after a
few more weeks on this combination therapy the symptoms still persist and have not shown significant
improvement. Considering lack of improvement with Methotrexate and the addition of Leflunomide,
which of the following medications is likely to be prescribed next?
(or)
Methotrexate and Leflunomide in a patient with rheumatoid arthritis?
13. A 55-year-old male coal worker presents with a history of joint pain, stiffness, and swelling in
multiple joints, particularly in the hands and wrists. He also reports a chronic cough, shortness of
breath, and a history of working in a coal mine for the past 20 years. Chest X-ray reveals the presence
of multiple rounded opacities in the lungs. What is the name of the syndrome associated with the
combination of these symptoms?
(or)
14. Which pair mentioning the deformity name and the deformity involved is incorrect?
A. Swan-Neck Deformity: Extension at PIP and flexion at DIP
B. Boutonniere Deformity: Extension at PIP and flexion at DIP
C. Mallet Finger: No extension at PIP and flexion at DIP
ulnar joint, and hyperextension of the interphalangeal joint
15. A 55-year-old female patient with dryness of the eyes and mouth. She also complains of chest pain
and shortness of breath on exertion. She has a pericardial friction rub auscultated on cardiac
examination. Laboratory tests reveal positive anti-CCP antibodies. Which of the following ocular
manifestations is NOT typically associated with the patient’s condition ?
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Page 5
(or)
Which of the following ocular manifestations is NOT typically associated with Rheumatoid arthritis?
D. Uveitis
16. A 45-year-old woman, has been experiencing joint pain, stiffness, and swelling in her hands and
feet for several months. She finds it challenging to perform her daily activities due to the discomfort and
decreased range of motion in her joints. She visits her rheumatologist, who suspects an autoimmune
disorder based on her symptoms and physical examination. After careful evaluation, the rheumatologist
prescribes a medication that inhibits the enzyme Dehydro Orotate Dehydrogenase. Based on the
information provided, which drug has the rheumatologist prescribed for this patients condition?
(or)
Which of the following inhibits the enzyme Dehydro Orotate Dehydrogenase.?
17. Which of the following statements about Rheumatoid Nodules is incorrect?
A. Rheumatoid nodules are typically tender when palpated
B. Lung involvement can occur in association with rheumatoid nodules
C. Rheumatoid nodules can lead to exudative pleural effusion
D. Rheumatoid nodules can compress peripheral nerves, causing mononeuritis multiplex
E. Rheumatoid nodules on the median nerve can contribute to Carpal Tunnel syndrome
18. A 35-year-old female presents with joint pain, swelling, and morning stiffness that lasts for more
than an hour. The symptoms primarily affect her hands and wrists but have gradually involved multiple
small joints as well. She reports that the symptoms have been present for the past four months. On
examination, you observe tenderness and swelling in the affected joints. Based on the clinical
presentation, which of the following diagnostic criteria are NOTinvolved in the evaluation of this patient
suspected of having a specific condition?
(or)
Which of the following diagnostic criteria are NOTinvolved in the diagnosis of rheumatoid arthritis?
B. Low titre of rheumatoid factor (RA factor)
959

Page 16
Option A - Normocytic normochromic anaemia:
 Anaemia of chronic illness traditionally encompassed any long-standing inflammatory, infectious, or
malignant disease. Including rheumatoid arthritis, severe trauma, heart disease, or diabetes mellitus.
 There is primarily a decreased availability of iron, relatively decreased levels of erythropoietin, and a
mild decrease in the lifespan of RBCs to 70-80 days.
 Early-onset rheumatoid arthritis with positive rheumatoid factor is more likely to have normocytic
normochromic anaemia.
Option B - Hepatomegaly:
 Splenomegaly is a classic finding in Felty’s syndrome.
 Hepatomegaly is not seen in Felty's syndrome
Option D - Neuropathy:
 Neuropathy is not seen in Felty's syndrome
 
Correct Option C - Rheumatoid arthritis:
 The clinical features mentioned in the scenario are characteristic of rheumatoid arthritis. It is an
autoimmune disease that primarily affects women between the ages of 25 and 55, including
post-menopausal women. Rheumatoid arthritis commonly involves small hand joints, exhibits bilateral
symmetrical involvement, and presents with inflamed joints, pain, tenderness, morning stiffness, and
reduced grip strength. Flexor tenosynovitis is a hallmark manifestation of the disease.
Option A - Osteoarthritis: Osteoarthritis primarily affects weight-bearing joints such as the knees, hips, 
and spine. It is typically associated with aging, joint degeneration, and mechanical stress. Unlike rheum
atoid arthritis, osteoarthritis does not exhibit bilateral symmetrical involvement, flexor tenosynovitis, or s
ystemic symptoms like morning stiffness.
Option B - Rheumatic fever: Rheumatic fever is a systemic inflammatory condition that can occur follow
ing an untreated or inadequately treated streptococcal throat infection. It is characterized by migratory 
polyarthritis affecting large joints, along with other manifestations such as carditis, chorea, and subcuta
neous nodules. The clinical scenario described in the question is not consistent with rheumatic fever.
Option D - Gout: Gout is a form of inflammatory arthritis caused by the deposition of uric acid crystals i
n joints. It typically affects the big toe (first metatarsophalangeal joint) but can involve other joints as we
ll. The clinical features mentioned in the scenario, such as bilateral symmetrical involvement of small h
and joints and flexor tenosynovitis, are not consistent with gout.
Correct Option B – Adalimumab:
970

Page 17
 Given the patients insufficient response to Methotrexate and the addition of Leflunomide, the next
step in the treatment plan would be to introduce a Biological DMARD. Adalimumab is a TNF alpha
antagonist, which means it targets Tumor Necrosis Factor-alpha, a pro-inflammatory cytokine involved
in the pathogenesis of Rheumatoid Arthritis. By blocking TNF alpha, Adalimumab helps reduce
inflammation and slow down the progression of the disease.
Option A - Try the same regimen: Incorrect ,
because the patient is not improving and hence needs to be put on a biological DMARD.
Option C - Hydroxychloroquine: Hydroxychloroquine is a conventional DMARD with lower efficacy com
pared to Biological DMARDs. It is often used in milder cases of Rheumatoid Arthritis or as an adjunct t
o other therapies. However, in Mr. Johnson's case, where the symptoms have not improved despite bei
ng on two DMARDs, a Biological DMARD like Adalimumab may be more appropriate.
Option D - Sulfasalazine: This is the incorrect answer. Sulfasalazine is another conventional DMARD t
hat can be added to the treatment regimen in patients who do not respond adequately to Methotrexate 
in place of leflunomide. It has anti-inflammatory properties and is used in the management of Rheumat
oid Arthritis. Adalimumab is a
better option and is the next step in the treatment algorithm of the rheumatoid arthritis.
Correct Option B - Caplan syndrome:
 This syndrome is associated with the combination of rheumatoid arthritis and coal workers'
pneumoconiosis. In this case, the patient's symptoms of joint pain, swelling, and stiffness along with the
occupational history of coal mining suggest the presence of Caplan syndrome.
 
Option A - Goodpasture syndrome: A condition characterized by the presence of autoimmune antibodi
es attacking the lungs and kidneys, leading to lung hemorrhage and kidney damage. Not related to the 
symptoms described in the scenario.
Option C - Cushing syndrome: A disorder caused by prolonged exposure to high levels of cortisol horm
one, resulting in various symptoms such as weight gain, round face, and muscle weakness. Not related
 to the symptoms described in the scenario.
Option D - Guillain-Barré syndrome: A rare neurological disorder characterized by muscle weakness, n
umbness, and paralysis. Not related to the symptoms described in the scenario.
Correct Option B - Boutonniere Deformity: Extension at PIP and flexion at DIP: This statement is incorr
ect. In Boutonniere Deformity, there is flexion at the PIP and extension at the DIP, not the other way ar
ound.
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Page 18
Option A - Swan-Neck Deformity: Extension at PIP and flexion at DIP: This statement is correct. In Sw
an-Neck Deformity, there is extension at the proximal interphalangeal joint (PIP) and flexion at the dista
l interphalangeal joint (DIP).
Option C - Mallet Finger: No extension at PIP and flexion at DIP: This statement is correct. In Mallet Fi
nger, there is no extension at the PIP joint and flexion at the DIP joint. It occurs due to the avulsion of t
he extensor tendon related to the DIP.
Option D - Z Line Deformity: Subluxation of the first metacarpophalangeal joint, subluxation of the dista
l radio ulnar joint, and hyperextension of the interphalangeal joint: This statement is correct. Z Line Def
ormity involves three features: subluxation of the first metacarpophalangeal joint, subluxation of the dist
al radio ulnar joint, and hyperextension of the interphalangeal joint.
Correct Option D - Uveitis:
 Not commonly seen in rheumatoid arthritis, it causes eye redness, pain, and can lead to vision
problems if untreated.
 
Option A - Keratoconjunctivitis sicca: Dry eye syndrome due to reduced tear production or increased te
ar evaporation.
Option B - Scleritis: Inflammation of the sclera causing severe eye pain, redness, and tenderness.
Option C
- Episcleritis: Mild inflammation of the episclera characterized by localized redness and discomfort.
Correct Option C – Leflunomide:
 This option is the correct answer. Leflunomide is a DMARD that inhibits Dehydro Orotate
Dehydrogenase, an enzyme responsible for de-novo pyrimidine synthesis. By inhibiting this enzyme,
Leflunomide decreases T and B cell proliferation and exhibits immunosuppressive and
anti-inflammatory effects, making it effective in managing Rheumatoid Arthritis.
Option A - Methotrexate: This option is not the correct answer. While Methotrexate is a DMARD used i
n the treatment of Rheumatoid Arthritis, its mechanism of action involves inhibiting Dihydrofolate Redu
ctase, not Dehydro Orotate Dehydrogenase.
Option B - Sulfasalazine: This option is not the correct answer. Sulfasalazine is another conventional D
MARD used in the treatment of Rheumatoid Arthritis, but it does not inhibit Dehydro Orotate Dehydrog
enase. Sulfasalazine splits into 5-ASA and Sulfapyridine, which have anti-inflammatory properties.
Option D - Hydroxychloroquine: This option is not the correct answer. Hydroxychloroquine has anti-infl
ammatory effects but contains lower efficacy compared to other DMARDs. While it may be used in Rhe
umatoid Arthritis treatment, it does not inhibit Dehydro Orotate Dehydrogenase like Leflunomide.
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Page 19
Correct Option A - Rheumatoid nodules are typically tender when palpated: This statement is incorrect.
 Rheumatoid nodules are usually non-tender when palpated. They are firm, subcutaneous nodules co
mmonly found on the extensor surfaces of the body.
Option B - Lung involvement can occur in association with rheumatoid nodules: This statement is corre
ct. Rheumatoid nodules can involve the lungs, leading to complications such as pleural effusion.
Option C - Rheumatoid nodules can lead to exudative pleural effusion: This statement is correct. Rheu
matoid nodules can contribute to the development of exudative pleural effusion, a
buildup of fluid in the pleural space of the lungs.
Option D - Rheumatoid nodules can compress peripheral nerves, causing mononeuritis multiplex: This 
statement is correct. Rheumatoid nodules can compress peripheral nerves, resulting in mononeuritis m
ultiplex, which refers to multiple nerve damage and neuropathy occurring simultaneously.
Option E - Rheumatoid nodules on the median nerve can contribute to Carpal Tunnel syndrome: This s
tatement is correct. Rheumatoid nodules located on the median nerve can contribute to the developme
nt of Carpal Tunnel syndrome, a
condition characterized by compression of the median nerve in the wrist.
Correct Option: B – Low titre of rheumatoid factor (RA factor):
 It decreases the credibility of the diagnosis of rheumatoid arthritis
 High titre of RA factor and anti- CCP then the credibility of diagnosis is increased. If both are low then
the credibility is decreased
 RA factor: IgM class of antibodies. This test may be biologically false positive in 5% of the normal
population. This cannot be used as the best diagnosis. It is a screening test but it can't be the
investigation of choice
 
Option A - Involvement of at least one large joint: There could be 1 large joint, 2 to 10 large joint, 1 to 2
small joints, 4 to 10 small joint involvements. It could be even more than 10 joint involvements as well. 
The more the number of small joint involvement, the more credibility.
Option C - Duration of symptoms more than six weeks: If the duration of symptoms is more than 6
weeks then the diagnosis will be more credible
Option D - Serological evidence of anti-cyclic citrullinated peptide (anti-CCP) antibodies: Antibody -
cyclic citrullinated peptide antibody
 Low titre - means the value is less than 3 times upper limit of normal
 High titre - means more than 3 times of upper limit of normal
973

Crystal Arthropathy
1. A 55-year-old male with alcohol use disorder presents to the emergency department with
sudden-onset severe pain and swelling in his right big toe. He has a past medical history of
hypertension well-controlled with a calcium channel blocker. On examination, the affected toe appears
red, tender, and warm to touch. Which of the following is the most likely cause of his symptoms?
(or)
Which of the following is the most likely cause for a male with alcoholic use disorder who presents with
severe pain and swelling in his right big toe, which appears red, tender, and warm to touch?
A. Cellulitis
B. Osteoarthritis
D. Acute gout
2. A 60-year-old male presents with recurrent episodes of joint pain and swelling in his right big toe. He
describes the pain as sudden and excruciating, often waking him up at night. On examination, the
affected joint is warm, erythematous, and tender on palpation. Based on the clinical presentation and
the X-ray image shown below, what is the most likely diagnosis in this patient?
(or)
What is the diagnosis and what does the given X-ray depict?
A. Osteoarthritis with tophi formation
B. Rheumatoid arthritis with joint erosions
C. Gout with monosodium urate crystal deposition
D. Septic arthritis with joint effusion
3. A 45-year-old male presents with sudden-onset severe pain, redness, and swelling in his right big
toe. He describes the pain as excruciating, making it difficult to walk or even touch the affected joint. On
examination, the joint is warm and tender to palpation. Laboratory investigations reveal an elevated
serum uric acid level. What is the most appropriate treatment?
(or)
Which of the following is the most initial management for acute gout?
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A. Hot pack application
B. Ice pack application
C. Aspirin administration
D. Steroid injection
4. A 65-year-old male with a known history of renal failure presents to the clinic with recurrent episodes
of acute gout. He complains of severe pain, redness, and swelling in his left ankle joint. Laboratory
investigations reveal elevated serum uric acid levels. What is the most appropriate drug of choice for
managing his gout?
(or)
Which of the following is the treatment of choice for managing gout with renal failure?
A. Allopurinol
B. Colchicine
C. Prednisone
D. Febuxostat
5. A 60-year-old male presents with stiffness and limited range of motion in his right knee. On
examination, no significant swelling or redness is observed in the affected knee, which is non-tender to
palpation. The X-ray image is shown below. The patient undergoes synovial fluid aspiration and
microscopic examination of the synovial fluid. What type of crystals is most likely to be seen in this
patient's synovial aspirate?
(or)
Which type of crystals is most likely to be seen in the synovial aspirate in a condition whose X-ray
image is shown?
A. Monosodium urate (MSU)
B. Cystine
C. Calcium oxalate
D. Calcium pyrophosphate
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6. A 45-year-old male who works in a battery manufacturing factory presents to the emergency
department with joint pain and swelling. He complains of pain in his wrists, knees, and ankles. On
examination, there is evidence of joint effusion in multiple joints, including the wrists and knees.
Laboratory investigations reveal elevated levels of serum uric acid. What is the diagnosis for the
patient?
(or)
Which of the following is caused by a condition that manifesting in those who work in battery
manudactirng factories?
A. Gout
B. Pseudogout
D. Saturnine gout
7. Mr. Smith, a 58-year-old male patient, has been diagnosed with acute lymphoblastic leukemia and is
currently undergoing chemotherapy with 6-mercaptopurine. He has a history of chronic gout, and his
uric acid levels have been consistently high despite dietary modifications. His physician decides to
prescribe allopurinol to manage his chronic gout. What dose adjustment, if any, is required?
(or)
What dose adjustment, if any, is required when combining allopurinol with 6-mercaptopurine?
A. No Change
B. Increase the dose of 6-mercaptopurine
C. Decrease the dose of 6-mercaptopurine
D. Cannot give this combination together
8. A 62-year-old woman presented to the hospital experiencing an acute gout attack. Her physician
prescribes aspirin for another medical condition. Which of the following doses of aspirin would be
appropriate considering her symptoms of an acute gout attack?
(or)
Which of the following doses of aspirin would be appropriate for decreasing Uric acid by inhibiting re -
absorption ?
A. Dose > 5 gm/day
B. Dose 2-5 gm/day
C. Dose < 2 gm/day
D. All doses of aspirin have the same effect on uric acid levels
9. A 55-year-old male presents with sudden onset joint pain, redness, and swelling in his right big toe.
On examination, the affected joint is warm and tender. Laboratory investigations reveal an elevated
serum uric acid level. Synovial (joint) aspiration was done to evaluate fluid characteristics and cell
count. Which of the following correctly describes the nature of fluid seen in this condition?
(or)
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Which of the following correctly describes the nature of fluid seen in acute gout?
A. Turbid or chalky white fluid, increased cell count (2000 - 6000 cells/mm3)
B. Clear fluid, normal cell count (less than 200 cells/mm3)
C. Yellowish fluid, increased cell count (greater than 10,000 cells/mm3)
D. Bloody fluid, decreased cell count (less than 50 cells/mm3)
Correct Option D- Acute gout:
 Acute gout manifests as sudden and severe joint pain, swelling, redness, and tenderness. It
commonly affects the big toe but also other joints like the ankle, knee, wrist, or elbow.
 It occurs due to the buildup of uric acid crystals in the joints, triggered by consuming purine-rich foods
such as red meat, organ meats, certain seafood, or excessive alcohol consumption.
 During an acute attack, the affected joint becomes extremely sensitive, with pain described as
throbbing or excruciating, even the slightest touch can cause discomfort, and the joint may appear red,
swollen, and warm.
 Joint aspiration is commonly performed, where fluid is withdrawn and examined for uric acid crystals
under a microscope.
 Medications like NSAIDs, corticosteroids, or colchicine are used to manage symptoms during an
attack.
 Lifestyle modifications play a crucial role in managing gout, including avoiding trigger foods high in
purines and limiting alcohol intake to reduce uric acid levels in the blood.
 In some cases, medications like allopurinol or febuxostat are prescribed to lower uric acid levels and
prevent recurrent attacks by inhibiting its production or increasing its excretion.
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Option A - Cellulitis: This option is incorrect. Although acute gout can mimic cellulitis due to the presen
ce of redness, tenderness, and warmth, the history of sudden-onset severe pain, along with the patient'
s risk factors (e.g., hypertension, hyperuricemia), points towards acute gout as the more likely cause.
Option B - Osteoarthritis: This option is incorrect. While osteoarthritis can cause joint pain and swelling,
 acute gout typically presents with sudden-onset severe pain, redness, and warmth in a
joint, especially the big toe (podagra), which is not typical of osteoarthritis.
Option C - Rheumatoid arthritis: This option is incorrect. Rheumatoid arthritis is characterized by symm
etrical joint involvement and typically affects multiple joints, whereas acute gout commonly presents wit
h monoarticular involvement, often starting in the big toe.
Correct Option C - Gout with monosodium urate crystal deposition:
 The "Martel sign" is a radiographic finding associated with gout, a type of inflammatory arthritis
caused by the deposition of urate crystals in the joints.
 In gout, the Martel sign refers to the appearance of a sharply outlined triangular or V-shaped opacity
adjacent to the bone cortex at the joint margin, typically seen on X-rays of affected joints.
 This sign is most commonly observed in the first metatarsophalangeal joint (big toe), a common site of
gouty arthritis. The triangular opacity represents the deposition of urate crystals within the soft tissues
adjacent to the bone. 
 The presence of the Martel sign on X-ray, along with clinical symptoms and other imaging findings,
can help diagnose gout.
 However, it is important to note that the absence of the Martel sign does not exclude the diagnosis of
gout, as it may not always be present or visible in all cases.
 Other imaging modalities, such as ultrasound or MRI, can also aid in the diagnosis of gout and may
reveal findings not seen on X-ray.
Option A - Osteoarthritis with tophi formation: Osteoarthritis is a degenerative joint disease characteriz
ed by the breakdown of joint cartilage, while tophi formation is typically seen in gout.
Option B - Rheumatoid arthritis with joint erosions: Rheumatoid arthritis is an autoimmune condition tha
t primarily affects the joints, but it is characterized by symmetrical joint involvement and specific rheum
atoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibody testing. Joint erosions are a
hallmark feature of rheumatoid arthritis, but they are not specific to gout.
Option D - Septic arthritis with joint effusion: Septic arthritis is an infection of the joint caused by bacteri
a or other pathogens. It typically presents with a hot, swollen, and acutely painful joint, along with syste
mic signs of infection. Joint effusion (fluid accumulation) is a
common feature, but it is not specific to gout.
Correct Option B - Ice pack application:
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 The above clinical vignette points towards the diagnosis of acute gout, and the most appropriate initial
treatment for the patient is ice pack application.
 This is the correct treatment of choice. Applying an ice pack to the affected joint can help reduce
swelling and inflammation and provide pain relief in acute gout. In addition, NSAIDs are most important
for managing these patients.
Medication
Considerations/Notes
Ice packs
Apply to reduce swelling and inflammation, avoid hot packs
COX-1 inhibitors
Use indomethacin or naproxen for pain relief, but monitor for gastritis
Hypersensitivity to painkillers
Some patients may have allergies or adverse reactions, such as rashes or breathing problems
COX-2 inhibitors
Alternative option if there is intolerance to COX-1 inhibitors, but less effective
Steroids
Consider use in patients hypersensitive to painkillers, anti-inflammatory effect
Colchicine
Can be used after 2-3 days, but watch for diarrhea as a side effect
Aspirin
Contraindicated in acute gout due to potential worsening of symptoms
Allopurinol
Used for chronic gout, contraindicated in acute gout
Option A - Hot pack application: Applying a
hot pack can actually worsen the symptoms in acute gout by increasing inflammation and pain.
Option C - Aspirin administration: Aspirin is contraindicated in acute gout because it can interfere with t
he excretion of uric acid and potentially worsen the condition.
Option D - Steroid injection: Steroid injections can provide significant anti-inflammatory effects and pain
 relief in acute gout, particularly in patients who are hypersensitive to other pain medications or have co
ntraindications to NSAIDs. However, they are not the first-line treatment and are typically reserved for c
ases where other options have failed or are not feasible.
Correct Option D - Febuxostat:
 Febuxostat is a xanthine oxidase inhibitor that reduces uric acid production and is considered a
suitable alternative to allopurinol in patients with renal impairment. Unlike allopurinol, febuxostat does
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not require dose adjustment based on renal function.
 Therefore, it is the most appropriate drug of choice for managing gout in this patient with renal failure.
 Before initiating treatment with febuxostat, acute gout should be managed. The use of xanthine
oxidase inhibitors is contraindicated during a gout flare-up due to the possibility of worsening of the
acute condition. 
Summary
Treatment initiation
Start hypouricemic therapy when the patient's condition improves
Tophi disappearance
Continue therapy until tophi completely disappear
Uric acid levels
Maintain normal uric acid levels for 6 consecutive months
Dietary considerations
Limit non-vegetarian food and control purine intake
Weight management
Control weight to support management of gout symptoms
Diuretic adjustment
Adjust diuretic dosage or switch to calcium channel blockers, if necessary
24-hour urinary uric acid levels
Evaluate levels to determine if the patient is an overproducer or under excretor of uric acid
Option A - Allopurinol: Allopurinol is a commonly used medication for managing gout by reducing uric a
cid production. However, it is metabolized in the liver and excreted by the kidneys. In patients with rena
l failure, the dosage of allopurinol needs to be adjusted due to the increased risk of adverse effects and
 toxicity.
Option B - Colchicine: Colchicine is an anti-inflammatory medication used for the treatment of acute go
ut attacks. However, it is primarily metabolized in the liver and eliminated by the kidneys. In patients wit
h renal failure, colchicine can accumulate and lead to increased toxicity. Therefore, it is not the ideal ch
oice in this scenario.
Option C - Prednisone: Prednisone is a corticosteroid that can be used to manage acute gout attacks b
y reducing inflammation. It is not specifically contraindicated in patients with renal failure. However, it is
 not the drug of choice for long-term management of gout in these patients.
Correct Option D - Calcium pyrophosphate:
 Pseudogout, also known as calcium pyrophosphate deposition disease (CPPD), is a condition
characterized by the deposition of calcium pyrophosphate crystals in the joints.
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 Chondrocalcinosis: This term refers to the presence of calcium deposits within the cartilage of joints,
which is a hallmark feature of pseudogout.
 On X-rays, chondrocalcinosis may appear as linear or punctate calcifications within the joint space.
Commonly affected joints include the knees, wrists, hips, and shoulders.
 Other findings include joint space narrowing and subchondral cysts.
 Calcium pyrophosphate crystals are the crystals that are characteristic of pseudogout.
Needle Like
Rhomboid
Option A - Monosodium urate (MSU): Monosodium urate crystals are typically seen in gout, which is ch
aracterized by the deposition of uric acid crystals in joints and surrounding tissues. These crystals app
ear as needle-shaped crystals with negative birefringence under polarized microscopy.
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Option B - Cystine: Cystine crystals are associated with a genetic disorder called cystinuria, which lead
s to the formation of cystine kidney stones. However, cystine crystals are not commonly observed in sy
novial fluid, so this option is not applicable.
Option C - Calcium oxalate: Calcium oxalate crystals are commonly associated with kidney stones and 
are not typically seen in synovial fluid in the context of acute joint inflammation. Therefore, this option is
 not relevant to the given clinical scenario.
Correct Option D - Saturnine gout:
 Saturnine gout, also known as lead-induced gout, is a condition characterized by developing gout
symptoms due to chronic lead exposure. When lead exposure is the underlying cause of gout, it
is referred to as saturnine gout.
 Individuals working in battery manufacturing units are at risk of exposure to lead. 
 Lead exposure can disrupt the normal metabolism of uric acid in the body, leading to elevated levels
of uric acid in the blood. This excess uric acid can then crystallize in the joints, particularly in the big
toe, causing intense pain, swelling, redness, and stiffness, characteristic of gout attacks.
 Clinical manifestations of lead toxicity: abdominal pain, joint/muscle aches, fatigue, cognitive deficits,
and hypertension.
 Acute toxicity may present as "lead colic" and irritability, while chronic exposure can lead to anemia,
neurocognitive decline, tremors, and kidney damage.
Option A - Gout: Gout is a form of inflammatory arthritis caused by the deposition of urate crystals in th
e joints. It typically presents with sudden onset, severe joint pain, redness, and swelling. Gout is not th
e most likely condition in this scenario as lead poisoning is the main focus.
Option B - Pseudogout: Pseudogout, also known as calcium pyrophosphate deposition disease, is char
acterized by the deposition of calcium pyrophosphate crystals in the joints. It can cause acute joint pain
, swelling, and inflammation, similar to gout. However, in this specific scenario, the symptoms are asso
ciated with lead poisoning, making pseudogout less likely.
Option C - Rheumatoid arthritis: Rheumatoid arthritis is an autoimmune condition that causes chronic i
nflammation in the joints, leading to joint pain, swelling, and stiffness. It is not directly related to lead po
isoning and is less likely to cause joint symptoms in this scenario.
Correct Option C - Decrease the dose of 6-mercaptopurine:
 Allopurinol can enhance the effects of immunosuppressive drugs like 6-mercaptopurine (6-MP) and
azathioprine, as they are partly metabolized by xanthine oxidase.
 Thus, it is generally recommended to avoid allopurinol in patients taking these medications.
 In cases where severe gout necessitates allopurinol use, azathioprine doses are often reduced by at
least 50% while closely monitoring white blood cell counts.
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 However, many patients eventually need to discontinue azathioprine. In some cases, switching from
azathioprine to mycophenolate, which does not interact with allopurinol, might be considered an
alternative treatment option.
Option A - No Change: This option is not correct because when allopurinol is added to the treatment re
gimen, it inhibits xanthine oxidase, which can lead to an increase in the concentration of 6-mercaptopur
ine. This can result in 6-mercaptopurine toxicity, which may be harmful to the patient.
Option B - Increase the dose of 6-mercaptopurine: This option is not correct because, as mentioned ea
rlier, combining allopurinol with 6-mercaptopurine can increase the concentration of 6-mercaptopurine i
n the body. Increasing the dose would only exacerbate the risk of toxicity.
Option D - Cannot give this combination together: This option is not correct. While the combination of a
llopurinol and 6-mercaptopurine requires careful management due to potential drug interactions, it is no
t an absolute contraindication. With appropriate dose adjustments, this combination can be used safely
 and effectively to manage chronic gout and the underlying condition (ALL).
Correct Option A - Dose > 5 gm/day:
 This option is correct. During an acute gout episode, high doses of aspirin (> 5 gm/day) can decrease
uric acid levels by inhibiting the reabsorption of uric acid in the kidneys. This effect may be beneficial in
managing acute gout, as it helps in reducing uric acid levels in the blood and mitigating gout symptoms.
This option is correct. During an acute gout episode, high doses of aspirin (> 5 gm/day) can decrease 
 managing acute gout, as it helps in reducing uric acid levels in the blood and mitigating gout symptom
s.
Option B - Dose 2-5 gm/day: This option is incorrect. At doses between 2 and 5 gm/day, aspirin has no
 significant effect on uric acid levels. It neither increases nor decreases uric acid levels during an acute 
gout episode.
Option C - Dose < 2 gm/day: This option is incorrect. Lower doses of aspirin (< 2 gm/day) can increase
 uric acid levels by inhibiting the secretion of uric acid in the kidneys. Prescribing such doses during an 
acute gout episode might lead to higher uric acid levels in the blood, potentially worsening the gout sy
mptoms.
Option D - All doses of aspirin have the same effect on uric acid levels: This option is incorrect. Aspirin'
s effect on uric acid levels varies depending on the dose. Higher doses (> 5
gm/day) decrease uric acid levels by inhibiting reabsorption, while lower doses (< 2
gm/day) can increase uric acid levels by inhibiting secretion, especially during an acute gout episode.
Correct Option A - Turbid or chalky white fluid, increased cell count (2000 - 6000 cells/mm3):
 Synovial (joint) aspiration is the investigation of choice to confirm the diagnosis of gout. 
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 The synovial fluid in gout typically appears turbid or chalky white due to the presence of monosodium
urate crystals.
 Additionally, there is an increased cell count, ranging from 2000 to 6000 cells/mm3, indicating
inflammation in the joint.
Parameter
Normal Findings
Non-Inflammatory
Inflammatory
Septic
Haemarthrosis
Colour
Colourless
Straw-like/Yellow
Yellow
Yellow/Green
Red/Xanthochromic
Clarity
Translucent
Cloudy
Cloudy/Opaque
Bloody/Variable
Viscosity
↑
↓
Variable
WBC Count
<2000 cells/mm³
200-2000 cells/mm³
2000-50,000 cells/mm³
>50,000 cells/mm³
Neutrophil Count
<25%
>50%
>75%
50-75%
Gram Stain
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Negative
Positive
Crystals
 
Option B, C, D:  Synovial fluid aspiration will appear as turbid or chalky fluid in gout. 
986

Vasculitis
1. A 70-year-old male presents to the clinic due to stiffness and pain in his shoulders and hips for the
past few weeks. He feels fatigued, has a low-grade fever, and also complains of persistent throbbing
right-sided headache and jaw pain. On physical examination, a nodular swelling along the temporal
artery is noted. HPE image from his temporal artery biopsy is shown. What is the treatment of choice?
A. Nonsteroidal anti-inflammatory drugs (NSAIDs)
B. High-dose glucocorticoids (Steroids)
C. Disease-modifying antirheumatic drugs (DMARDs)
D. Acetaminophen (Paracetamol)
2. A 10-year-old child presents with a red raised rash on the buttocks and legs. The mother reports that
the child also has joint pains, abdominal pain, and fresh blood in the stool yesterday. Laboratory
investigations reveal elevated levels of IgA. What is the most likely diagnosis?
A. Henoch-Schonlein Purpura (HSP)
B. Idiopathic Thrombocytopenic Purpura (ITP)
C. Amyloidosis
D. Berger's Disease
3. A 6-year-old child presents with a sore throat, fever, and a skin rash. Oral examination shows
erythematous, enlarged tonsils. The skin rash is a blanching, papular rash that lacks confluence. Which
of the following is the most likely diagnosis?
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Page 2
(or)
Which of the following causes erythematous enlarged tonsils and a blanching, papular skin rash that
lacks confluence (shown in the image)?
A. Scarlet Fever
B. Kawasaki Disease
C. Measles
D. Hand, Foot, and Mouth Disease
4. A 3-year-old child is brought to the pediatric clinic with a high fever for the past five days. His parents
noticed redness in the child's eyes and a rash on the body. On examination, the physician observes
unilateral lymph node enlargement in the cervical region. The child's tongue appears to have a distinct
appearance. What is the most likely diagnosis for this child's condition?
(or)
Which of the following is the most common vasculitis that leads to death in children?
B. Kawasaki Disease (Mucocutaneous Lymph node Syndrome)
C. Measles
D. Rubella (German Measles)
5. A 3-year-old child presents with persistent fever (>5 days), bilateral conjunctival injection, strawberry
tongue, scarlet rash, and desquamation (peeling) of the skin on the palms and soles. The child also
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Page 3
complains of chest pain. On further evaluation, echocardiography reveals coronary artery vasculitis.
The ECG findings are given below. What is the most appropriate treatment for this patient?
(or)
Which of the following is the most appropriate treatment for Kawasaki Disease?
A. Intravenous immunoglobulin (IVIG)
B. Percutaneous coronary intervention
D. Unfractionated heparin (UFH)
6. A 22-year-old female from India presents with symptoms of arm claudication and a significant
difference in blood pressure between her left and right arms. On further evaluation, she is found to have
renal artery stenosis. Which of the following is the most likely diagnosis?
(or)
Which of the following can cause a disparity of blood pressure between the left arm and right arm with
associated renal artery stenosis?
A. Atherosclerosis of the renal artery
D. Coarctation of the aorta
7. A 45-year-old woman visits the clinic with complaints of abdominal pain, fever, and skin lesions. She
reports experiencing muscle aches, joint pain, and fatigue for the past few weeks. On examination,
palpable skin nodules, particularly on the lower extremities, are noted. The biopsy of a skin lesion is
shown in the image. Which of the following statements about the patient's condition is incorrect?
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Page 4
A. It is associated with medium vessel involvement.
B. The most common vessel affected is the renal vessel.
C. The patient's condition is most likely Rheumatoid Arthritis.
D. The microscopic image cue shows segmental, transmural fibrinoid necrosis.
8. A 30-year-old female presents with recurrent episodes of epistaxis, sinusitis, and nasal ulcers. She
also complains of hematuria and has lung lesions in the form of multiple cavities on chest imaging.
Laboratory tests reveal the presence of c-ANCA antibodies. Which of the following is the most likely
(or)
Which of the following is associated with the presence of c-ANCA antibodies?
A. Granulomatosis with polyangiitis (Wegener's granulomatosis)
B. Microscopic polyangiitis
C. Polyarteritis nodosa
D. Churg-Strauss syndrome
9. A 30-year-old male presents to the rheumatology clinic with complaints of recurrent sinus infections,
cough, and occasional coughing up of blood. He also reports experiencing joint pain and swelling in his
knees and ankles. On examination, the physician notices small, red, and swollen gums with a
characteristic appearance. Which organ system does the limited form of this condition involve?
(or)
Which organ system is involved in the limited form of Wegener's Granulomatosis?
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Page 5
A. Respiratory System
B. Musculoskeletal System
C. Gastrointestinal System
D. Nervous System
10. A 30-year-old male patient presents with recurrent painful oral aphthous ulcers, scrotal ulcers, and
hypopyon in the eye. Upon further evaluation, the patient is found to be HLA B5 positive. Which of the
(or)
HLA B5 positivity is seen in which of the following?
A. Behcet's Disease
B. Crohn's Disease
C. Herpes Simplex Virus Infection
D. Systemic Lupus Erythematosus
11. A 52-year-old male patient presents to the clinic with complaints of joint pain, cough, and
progressive fatigue over the past few weeks. On examination, you note purpura and petechiae on the
patient's lower extremities. Laboratory investigations show elevated creatinine levels and a positive
P-ANCA. Urinalysis reveals proteinuria and hematuria. What is the most likely diagnosis?
(or)
Which of the following is associated with p-ANCA?
A. Polyarteritis Nodosa (PAN)
B. Wegener's Granulomatosis (Granulomatosis with Polyangiitis)
C. Microscopic Polyangiitis (MPA)
D. Henoch-Schönlein Purpura (HSP)
12. A 62-year-old male with a history of poorly controlled hypertension presents to the emergency
department with sudden, excruciating chest pain radiating to the back. His blood pressure is 190/110
mmHg, and he appears diaphoretic. An urgent CT angiogram is performed, which reveals a tear in the
intima of the aorta near the aortic root and the ascending aorta. Based on the location of the tear, what
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Page 6
is the most likely classification of this aortic dissection?
(or)
If there is a tear in the intima of the aorta near the aortic root and the ascending aorta, what is the most
likely classification of this aortic dissection?
A. Stanford A/DeBakey 1
B. Stanford A/DeBakey 2
C. Stanford B/DeBakey 3
D. Stanford C/DeBakey 4
Correct Option B - High-dose glucocorticoids (Steroids):
 The above clinical scenario along with the biopsy image of fragmentation of internal elastic lamina, is
diagnostic of Temporal Arteritis.
 Temporal Arteritis or Giant Cell Arteritis causes unilateral headache, temporal artery tenderness, and
jaw claudication.
 Histology shows focal granulomatous inflammation with giant cells (black arrows in the image below).
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Page 11
Option C - Measles: Measles, caused by the measles virus, is characterized by a
high fever, cough, coryza, conjunctivitis, and a characteristic maculopapular rash that starts on the face
 and spreads downward. While it may cause changes in the oral mucosa, "Strawberry Tongue" is not a
specific finding in measles.
Option D - Rubella (German Measles): Rubella is caused by the rubella virus and is usually a
milder infection compared to measles. It presents with a rash that starts on the face and spreads to the
 trunk and extremities. Like measles, it may cause oral mucosal changes, but "Strawberry Tongue" is n
ot a characteristic finding in rubella.
Correct Option A - Intravenous immunoglobulin (IVIG):
 Intravenous immunoglobulin (IVIG): Correct. IVIG is the most appropriate treatment for Kawasaki
Disease, especially when coronary artery vasculitis is present. IVIG helps reduce inflammation and
prevent coronary artery damage. It is the standard of care for Kawasaki Disease.
 
Option B - Percutaneous coronary intervention: Percutaneous coronary intervention, which involves the
 use of stents or balloon angioplasty, is not the primary treatment for Kawasaki Disease. It is not indicat
ed for the management of coronary artery vasculitis associated with the condition.
Option C - Thrombolysis: Thrombolysis, the use of medications to dissolve blood clots, is not the appro
priate treatment for Kawasaki Disease. It is mainly used in the management of acute myocardial infarct
ion caused by coronary artery blockages, which is not the primary concern in this scenario.
Option D - Unfractionated heparin (UFH): Unfractionated heparin (UFH), a blood thinner, is not the mai
nstay of treatment for Kawasaki Disease or coronary artery vasculitis associated with the condition. It is
 primarily used in other clinical situations, such as deep vein thrombosis or pulmonary embolism.
Correct Option C - Takayasu arteritis:
 In this scenario, the most likely diagnosis is Takayasu arteritis.
 Takayasu arteritis is a large-vessel vasculitis commonly affecting young females, particularly from
India. It is associated with ostial narrowing of the major arteries, including the renal artery, which can
lead to reduced renal blood flow and hypertension.
 Histologically, there is granulomatous thickening and narrowing of the aortic arch and proximal great
vessels.
 Clinical features: Weak upper extremity pulses, blood pressure difference between left and right arms
Arm claudication Fever, night sweats Arthritis, myalgias Skin nodules Ocular disturbances 
 Weak upper extremity pulses, blood pressure difference between left and right arms
 Arm claudication
 Fever, night sweats
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Correct Option C - Microscopic Polyangiitis (MPA):
 MPA is a small vessel disorder without hepatitis B involvement.
 It commonly presents with pulmonary involvement, glomerulonephritis, and positive P-ANCA. The
presence of leukocytoclastic vasculitis microscopically and the absence of granulomas further support
this diagnosis.
Granulomas
Not observed, absence of granuloma formation
Microscopic Finding
Leukocytoclastic vasculitis
Inflammatory Cells
Presence of inflammatory cells (WBCs)
Broken Cells
Presence of broken cells in vessels
Lesion Stages
All lesions typically at the same stages
 Disease onset may be gradual, with initial symptoms of fever, weight loss, and musculoskeletal pain;
however, it is often acute. 
 Hemoptysis may be the first symptom of alveolar hemorrhage, which occurs in 12% of patients.
 Other manifestations include mononeuritis multiplex, gastrointestinal tract involvement, and
cutaneous vasculitis.
Option A - Polyarteritis Nodosa (PAN): PAN primarily involves medium to large vessels and is typically 
associated with hepatitis B infection. In this clinical scenario, there is no mention of hepatitis B
involvement, and the patient presents with symptoms more consistent with small vessel involvement.
Option B - Wegener's Granulomatosis (Granulomatosis with Polyangiitis): Wegener's granulomatosis is
 characterized by granulomas formation, which is not observed in this patient. Additionally, granulomat
osis with polyangiitis usually presents with upper and lower respiratory tract involvement, which is not 
mentioned in the scenario.
Option D - Henoch-Schönlein Purpura (HSP): HSP typically occurs in children and is characterized by 
palpable purpura, joint pain, abdominal pain, and renal involvement. While this patient presents with pu
rpura, joint pain, and renal involvement, the age of the patient (52-year-old) is not typical for HSP.
Correct Option A - Stanford A/DeBakey 1:
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 In this clinical scenario, the patient's sudden, severe chest pain radiating to the back, along with
poorly controlled hypertension, raises suspicion for aortic dissection.
 The CT angiogram revealing a tear in the intima near the aortic root and the ascending aorta indicates
involvement of both the ascending and descending aorta, classifying the aortic dissection as Stanford
A/DeBakey 1.
Definition
Aortic dissection is a condition with tears in the intima (innermost layer) of the aorta.
Chronic Dissection
Can cause a "Double Barrel Aorta" with both true and false lumens.
Common Cause of Hypertension
Aortic dissection is one of the most common causes of hypertensive emergencies.
Stanford/DeBakey Classification
A system to categorize the affected areas of the aorta:
Stanford A/DeBakey 1
Involves both the ascending and descending aorta.
Stanford A/DeBakey 2
Involves only the ascending aorta.
Stanford B/DeBakey 3
Involves only the descending aorta.
Option B - Stanford A/DeBakey 2: Involves only the ascending aorta. This option is not the correct ans
wer because the CT angiogram indicated the tear involves both the ascending and descending aorta, 
which corresponds to Stanford A/DeBakey 1.
Option C - Stanford B/DeBakey 3: Involves only the descending aorta. This option is not the correct an
swer as the CT angiogram showed the tear near the aortic root and the ascending aorta, indicating inv
olvement of both the ascending and descending aorta, which corresponds to Stanford A/DeBakey 1.
Option D - Stanford C/DeBakey 4: There is no such classification.
1003

Scleroderma
1. A 55-year-old male presents with red, violet, or purple discoloration of his toes upon exposure to
heat. He also experiences itching all over his body during warm baths. Additionally, he reports
occasional color changes in his lower limb extremities in response to cold temperatures. Which of the
following conditions is most likely responsible for these symptoms?
(or)
Which of the following condition causes erythromelalgia, aquagenic pruritus and Raynaud's
phenomenon?
B. Deep vein thrombosis (DVT)
C. Systemic lupus erythematosus (SLE)
D. Peripheral artery disease (PAD)
2. A 31-year-old woman presents with fatigue and difficulty swallowing for 8 weeks. She also complains
of painful discoloration in her fingers and toes when exposed to cold weather. She has smoked one
pack of cigarettes daily for 3 years. She appears younger than her stated age. Physical examination
shows smooth, swollen fingers with small white calcifications on the fingertips of both hands. Which of
the following features will definitely be seen in this patient?
(or)
Which of the following is most likely present in a woman with fatigue, dysphagia, painful finger
discoloration when exposed to cold, small calcifications on fingertips?
A. Tetany
B. Swan neck deformity
C. Sclerodactyly
D. Oesophagal atresia
3. Which of the following is the treatment of choice for managing hypertension in a patient with features
such as Raynaud's phenomenon, skin thickening, and dilated blood vessels presenting with a
progressive increase in blood pressure and reduced glomerular filtration rate (GFR)?
(or)
Which of the following is the treatment of choice for scleroderma crisis?
A. Beta-blocker
B. Calcium channel blocker
C. Angiotensin-converting enzyme (ACE) inhibitor
4. A female patient presents with a malar rash, Raynaud's phenomenon, bilateral proximal
interphalangeal and metacarpophalangeal pain, and wrist proximal muscle weakness. Laboratory
investigations reveal a positive ANA (Antinuclear Antibody). Which of the following antibodies is
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specifically associated with this condition?
(or)
Which of the following antibodies is specifically associated with Mixed Connective Tissue Disorder?
A. Anti-dsDNA (Double-stranded DNA) antibody
B. Anti-Ro (SSA) antibody
C. Anti-La (SSB) antibody
D. U1 RNP (Ribonucleoprotein) antibody
5. A 25-year-old female presents with disfigurement of her face. Upon examination, there are areas of
scarring and thickened skin without any history of injury. The patient does not exhibit any other
significant symptoms. What is the most likely diagnosis?
(or)
Which of the following is the cause of idiopathic scarring of the face leading to disfigurement?
A. Systemic Scleroderma (dcSSc)
B. Limited Scleroderma (lcSSc)
C. Mixed Connective Tissue Disorder (MCTD)
D. Localized Scleroderma
Correct Option A - Polycythemia vera:
 The clinical features described in the scenario are consistent with the diagnosis of Polycythemia vera.
 PV is a type of myeloproliferative neoplasm characterized by the excessive production of
RBCs independently from normal regulatory mechanisms.
 This condition presents with elevated hemoglobin and hematocrit levels, along with the possibility of
increased WBC and/or platelet counts.
 PV often presents with symptoms related to increased blood viscosity, such as venous or arterial
thrombosis (e.g., DVT, MI, stroke), pruritus, erythromelalgia (burning pain in the hands or feet), facial
redness, visual disturbances, and headaches.
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Page 5
 Usually delayed until at least six months after dialysis initiation to allow for potential kidney function
recovery.
 Immediate hospital admission is necessary. Goals include returning blood pressure to baseline within
72 hours.
 ACE inhibitors: Preferred for blood pressure control.
 Additional antihypertensive agents: May include dihydropyridine calcium channel blockers if needed.
 Monitoring response to therapy: Includes kidney function, electrolytes, and markers of hemolysis.
 Option for patients with SRC who progress to end-stage kidney disease.
recovery.
Option A - Beta-blockers: Beta-blockers may be used in specific cases or in combination with other anti
hypertensive medications but are not the preferred initial treatment in this scenario.
Option B - Calcium channel blockers: Calcium channel blockers are another class of antihypertensive 
medications commonly used in the management of hypertension but ACE inhibitors are considered the
 treatment of choice in patients with the given features.
Option D - Diuretics: Diuretics may be used to manage hypertension in certain cases but are not the pr
eferred initial treatment for patients with the described features.
Correct Option D - U1 RNP (Ribonucleoprotein) antibody:
 Mixed connective tissue disease (MCTD) is a rare autoimmune disease diagnosed when a specific
antibody known as anti-U1-ribonucleoprotein is present, and there are features of at least two
connective tissue diseases, including SLE, systemic sclerosis, polymyositis, dermatomyositis, and
rheumatoid arthritis. 
 Positive ANA (Antinuclear Antibody) is a non-specific finding that can be seen in various autoimmune
conditions, including MCTD, but the specific antibody associated with MCTD is U1 RNP.
 Initial symptoms of mixed connective tissue disease are usually non-specific and include arthralgia,
malaise, myalgia, and low-grade fever. Almost any organ system can be affected by MCTD.
Option A - Anti-dsDNA (Double-stranded DNA) antibody: It is associated with SLE.
Option B - Anti-Ro (SSA) antibody: Associated with Sjögren's disease, SLE, polymyositis, systemic scl
erosis, subacute cutaneous lupus erythematosus, primary biliary cholangitis, and neonatal lupus syndr
ome.
Option C - Anti-La (SSB) antibody: When co-existing with SS-A/Ro antibodies, relatively specific for Sjö
gren's disease but also present in some SLE patients. When present alone, their clinical significance is 
uncertain.
 
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Correct Option D - Localized Scleroderma/Morphea:
 Morphea, also known as localized scleroderma, is a relatively uncommon idiopathic inflammatory
disorder characterized by the development of sclerotic plaques in the skin. It affects both adults and
children and is more prevalent in females.
 Clinical presentation: Begins as inflammatory patches or plaques that evolve into firm, sclerotic
lesions. These lesions may involve the dermis alone or extend into underlying tissues such as
subcutaneous fat, muscle, or bone. Atrophic changes may persist after lesion resolution.
 Begins as inflammatory patches or plaques that evolve into firm, sclerotic lesions.
 These lesions may involve the dermis alone or extend into underlying tissues such as subcutaneous
fat, muscle, or bone.
 Atrophic changes may persist after lesion resolution.
 Diagnosis is mainly clinical. Biopsy of lesions may be indicated only in uncertain cases.
 There are no morphea specific antibodies; however, positive ANA, anti-histone Ab, and SS DNA Ab
are reported in some patients.
 This patient's facial disfigurement aligns with this diagnosis.
Option A - Systemic Scleroderma (dcSSc): Systemic scleroderma involves widespread skin involveme
nt and can affect internal organs. In this scenario, the patient does not exhibit systemic symptoms, rulin
g out systemic scleroderma.
Option B - Limited Scleroderma (lcSSc): Limited scleroderma typically presents with specific areas of s
kin involvement, such as fingers, hands, face, or lower legs. However, the patient's symptoms are limit
ed to disfigurement on the face without other systemic manifestations, suggesting localized scleroderm
a/morphea rather than limited scleroderma.
Option C - Mixed Connective Tissue Disorder (MCTD): MCTD is a condition that shares features of mul
tiple autoimmune disorders, including scleroderma, systemic lupus erythematosus, and polymyositis. H
owever, the patient's presentation is primarily consistent with localized scleroderma/morphea rather tha
n MCTD.
1009

Sarcoidosis
1. A 45-year-old male presents with a two-month history of progressive cough, dyspnea on exertion,
and night sweats. He also complains of weight loss. A chest X-ray is given in the image. Skin
examination shows painful nodules on the shin. Further evaluation reveals elevated calcium levels in
his blood work. What is the most likely diagnosis?
A. Tuberculosis (TB)
B. Lung Cancer
C. Sarcoidosis
D. Pulmonary Embolism
2. A 30-year-old female presents with a persistent dry cough, shortness of breath on exertion, and skin
nodules on her shins. Chest X-ray reveals bilateral hilar lymphadenopathy with eggshell calcification.
To confirm the suspected diagnosis, a transbronchial biopsy is performed. What are the characteristic
findings are likely to be seen in this patient's blood examination?
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A. ACE levels: Decreased CD4:CD8 ratio: Increased Calcium levels: No change
B. ACE levels: Increased CD4:CD8 ratio: Decreased Calcium levels: Increased
C. ACE levels: Increased CD4:CD8 ratio: Increased Calcium levels: Increased
D. ACE levels: Increased CD4:CD8 ratio: No change Calcium levels: Decreased
3. A 35-year-old male presents with a two-month history of a persistent dry cough, fatigue, and
shortness of breath. Biopsy showed the presence of naked granulomas. HRCT of the chest and
Gallium scan are given in the images. What is the first-line treatment for the most likely diagnosis?
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Page 3
B. Hydroxychloroquine (HCQ)
D. Azathioprine
4. A 35-year-old female presents with complaints of swollen and painful joints, along with a low-grade
fever and tender, erythematous nodules on her shins. X-RAY examination is as shown below. Based
on the clinical presentation and skin manifestations, which syndrome is the most likely diagnosis?
A. Behçet's Syndrome
B. Lofgren Syndrome
C. Reiter's Syndrome
D. Erythema Multiforme
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Page 6
 The "galaxy sign" observed on HRCT further supports the diagnosis, as it is a characteristic
radiological feature seen in sarcoidosis.
 Panda sign on GALLIUM scan also points towards sarcoidosis.
 Steroids are effective in reducing inflammation and granuloma formation, leading to symptom
improvement in most patients with sarcoidosis.
 
Option B - Hydroxychloroquine (HCQ): HCQ is a steroid-sparing agent used in sarcoidosis, but it is not 
the first-line treatment. It may be considered as an alternative when lymphopenia or other concerns limi
t the use of steroids.
Option C - Methotrexate: Methotrexate is another steroid-sparing agent used in the management of sar
coidosis. It may be considered in cases where steroids are not well-tolerated or fail to control the disea
se.
Option D - Azathioprine: Azathioprine is a third option as a steroid-sparing agent in the treatment of sar
coidosis. It can be considered when other treatment options are not suitable or effective.
Correct Option B - Lofgren Syndrome:
 Lofgren Syndrome (A variant of Sarcoidosis): The patient's clinical presentation aligns with Lofgren
Syndrome, which is a variant of sarcoidosis. The presence of lymphadenopathy, joint pains (Ouch),
fever, and erythema nodosum (EN) on the shins are characteristic features of Lofgren Syndrome.
 
Option A - Behçet's Syndrome: Behçet's Syndrome can present with oral ulcers, genital ulcers, and ski
n lesions. While joint pain may occur, it is not typically associated with bilateral hilar lymphadenopathy, 
which is a characteristic feature of Lofgren Syndrome.
Option C - Reiter's Syndrome (Reactive Arthritis): Reiter's Syndrome can present with joint inflammatio
n, especially following an infection, but it is not associated with bilateral hilar lymphadenopathy or speci
fic skin manifestations like erythema nodosum.
Option D - Erythema Multiforme: Erythema Multiforme is characterized by target-like skin lesions and 
mucous membrane involvement. It is not typically associated with bilateral hilar lymphadenopathy or joi
nt pains seen in Lofgren Syndrome.
1015

SLE
1. A 21-year-old female presents to the clinic with complaints of fatigue, weight loss, arthralgia, and an
erythematous rash over cheeks and nose, sparing nasolabial folds. Which of the following statements
is incorrect regarding the patient's likely diagnosis?
A. Renal failure is the most common cause of death in active SLE.
B. Infections become the leading cause of death if SLE is not active due to immunosuppressant use.
C. The female-to-male ratio in SLE is 9:1.
D. Klinefelter syndrome (47XXY) with SLE may exhibit less severe symptoms due to the presence of
additional X chromosomes.
2. A 45-year-old female presents with fatigue, joint pain, and a rash on her face. On examination, she
has an erythematous rash as shown in the image below. Laboratory tests reveal positive antinuclear
antibodies (ANAs) and anti-dsDNA antibodies. Which of the following is the most likely diagnosis?
A. Rosacea
B. Seborrheic dermatitis
D. Allergic contact dermatitis
3. A 19-year-old female recently diagnosed with SLE has been admitted to the hospital. She is being
tested for various autoantibodies related to SLE. Which of the following statements about the specific
autoantibodies in systemic lupus erythematosus (SLE) is incorrect?
(or)
Which of the following statements about the specific autoantibodies in systemic lupus erythematosus
(SLE) is incorrect?
A. Anti-Smith antibody is highly specific for SLE
B. Anti-Ro (SS-A) antibody is associated with photosensitivity and can cause complete heart block in
the fetus
C. Anti-dsDNA antibody correlates with disease activity in SLE and can be used to monitor response to
treatment
D. Anti-Lupus Anticoagulant decreases the risk of nephritis in SLE.
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Page 2
4. A 53-year-old woman presents for a follow-up visit after having a high BP on her last visit. She was
prescribed hydralazine, a β-blocker, and furosemide. She currently complains of fever, muscle aches,
joint pain, and rash. A physical exam reveals a scaling erythematous facial rash. The physician orders
an autoantibody panel: Antinuclear antibodies (ANA): Positive Anti-histone antibodies: Positive What is
(or)
What is the diagnosis for a woman using beta blocker, furosemide, and hydralazine for hypertension,
presenting with an erythematous facial rash, and nonspecific systemic symptoms and positive
anti-histone antibodies?
A. Systemic lupus erythematosus
B. Hydralazine-induced lupus erythematosus
C. β-blocker-induced systemic lupus erythematosus
D. Furosemide-induced systemic lupus erythematosus
5. A 35-year-old female presents with a history of recurrent abortions and absent fetal movements in
her previous pregnancy. Workup reveals a positive VDRL test. Which of the following is the most likely
diagnosis, and which antibody is the most specific for this condition?
(or)
Which of the following best explains the reason for recurrent abortions with a positive VDRL?
A. Systemic lupus erythematosus (SLE) - Anti-dsDNA antibody
B. Rheumatoid arthritis - Rheumatoid factor
C. Antiphospholipid antibody syndrome (APS) - Lupus anticoagulant
D. Sjogren's syndrome - Anti-SSA/Ro antibody
6. A 35-year-old female presents with fatigue and shortness of breath on exertion. On physical
examination, a holosystolic murmur is heard at the apex. Echocardiography reveals mitral regurgitation.
The patient has a history of systemic lupus erythematosus. Which of the following is the most likely
cause of her mitral regurgitation?
(or)
Which of the following is the most likely cause of mitral regurgitation in SLE?
C. Libman-Sacks endocarditis
D. Mitral valve prolapse
7. A 28-year-old female presents with joint pain and swelling involving multiple joints. She also
complains of low-grade fever. On examination, there is tenderness and soft tissue swelling in the
affected joints. Which of the following features is most likely associated with synovitis in systemic lupus
erythematosus (SLE)?
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Page 3
(or)
Which of the following features is most likely associated with synovitis in systemic lupus erythematosus
(SLE)?
A. Symmetrical joint involvement, small and large joints affected, intermittent polyarthritis, non-erosive
arthritis
B. Asymmetrical joint involvement, large joints predominantly affected, continuous polyarthritis, erosive
arthritis
C. Unilateral joint involvement, small joints predominantly affected, intermittent monoarthritis,
non-erosive arthritis
D. Bilateral joint involvement, large and small joints affected equally, continuous polyarthritis, erosive
arthritis.
8. A 28-year-old female presents with complaints of cola-colored urine, hypertension, and worsening
renal function. Laboratory investigations reveal hematuria with dysmorphic red blood cells, low C3
levels, and elevated creatinine and BUN. A renal biopsy is performed, and the immunofluorescence
image is shown below. What is seen in the immunofluorescence image in this patient?
(or)
Which of the following is seen in the immunofluorescence image of renal biopsy in SLE?
A. IgG deposition - Lupus nephritis, characteristic feature: IgG, IgA, and IgM deposition
B. IgA deposition - IgA nephropathy, characteristic feature: IgA deposition
C. IgM deposition - Membranous nephropathy, characteristic feature: IgM deposition
D. IgG, IgA, and IgM deposition - Lupus nephritis, characteristic feature: Full house effect
9. A 45-year-old male presents with a butterfly-shaped rash across his nose and cheeks, joint pain, and
fatigue. On examination, he has oral ulcers and non-scarring hair loss. Laboratory tests reveal a
positive ANA (Antinuclear Antibody) and low levels of complement proteins (C3 and C4). Which of the
following sets of diagnostic criteria is most consistent with the patient's presentation?
(or)
Which of the following sets of diagnostic criteria is most consistent with the SLE?
A. Morning stiffness >1 hour, symmetric arthritis, positive rheumatoid factor, radiographic evidence of
joint erosion
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Page 4
B. Elevated serum uric acid levels, tophi, acute episodes of monoarthritis
C. Intermittent arthritis, enthesitis, dactylitis, negative rheumatoid factor
D. Oral ulcers, non-scarring alopecia, positive ANA, low complement levels (C3 and C4)
Correct Option D - Klinefelter syndrome (47XXY) with SLE may exhibit less severe symptoms due to th
e presence of additional X chromosomes:
 This young patient with the characteristic malar rash (characterized by an erythematous flat or raised
rash across the bridge of the nose and cheeks, which usually spares nasolabial folds) most likely has
systemic lupus erythematosus. 
 Genes on the X chromosome that influence SLE, such as TREX1, may play a role in gender
predisposition, possibly because some genes on the second X in females are not silent. therefore
people with XXY karyotype (Klinefelter syndrome) have a significantly increased risk for SLE.
 The severity of SLE is directly related to the number of X chromosomes.
 Having an extra X chromosome (47XXY) in Klinefelter syndrome can potentially contribute to
increased severity.
Option A - Renal failure is a common cause of death in active SLE: Glomerulonephritis leading to sever
e persistent proteinuria, chronic renal failure, and end-stage renal disease remains one of the most sev
ere complications of SLE and is associated with significant morbidity and mortality. 
Option B -Infections can become the leading cause of death in non-active SLE due to immunosuppress
ant use: SLE treatment consists of immunosuppressive drugs that inhibit the activity of the immune sys
tem. Hydroxychloroquine is the mainstay and corticosteroids are often used for disease flare-ups. Long
-term use of these drugs renders the patients immunosuppressed and predisposes them to infections, 
which are the leading cause of death in non-active SLE.
Option C -SLE primarily affects females with a ratio of 9:1 compared to males: SLE is characterized by 
a 9:1 female-to-male ratio of disease incidence, with an even higher female predominance during peak
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Page 6
Option B - Seborrheic dermatitis: Seborrheic dermatitis presents with red, itchy, and greasy skin lesion
s, often affecting areas rich in sebaceous glands, including the scalp, face, and upper chest. However, 
the malar rash seen in this patient with involvement of the cheeks and bridge of the nose, along with its
 photosensitivity and persistence even after sun exposure, is not characteristic of seborrheic dermatitis.
 Hence, this option is unlikely to be the correct diagnosis.
Option D - Allergic contact dermatitis: Allergic contact dermatitis occurs when the skin comes into cont
act with an allergen, resulting in an inflammatory reaction. While it can cause a localized rash, the char
acteristic malar rash seen in this patient, along with systemic symptoms like fatigue and joint pain, poin
ts away from allergic contact dermatitis as the primary diagnosis. Thus, this option is less likely to be th
e correct diagnosis.
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Anti-ribonucleoprotein antibody (RNP)
Related to Mixed connective tissue disorder (MCTD).
Option A - Anti-Smith antibody is highly specific for SLE: Anti-smith antibody is highly specific for SLE, 
making it a useful diagnostic marker. 
Option B - Anti-Ro (SS-A) antibody is associated with photosensitivity and can cross the placenta, caus
ing complete heart block in the fetus: The statement is correct.
Option C - Anti-dsDNA antibody correlates with disease activity in SLE and can be used to monitor res
ponse to treatment: The levels of anti-dsDNA antibody tend to fluctuate with the disease course, and hi
gher levels are often associated with increased disease activity. Monitoring anti-dsDNA antibody levels
 can be helpful in assessing the response to treatment and disease progression in SLE.
Correct Option B - Hydralazine-induced lupus erythematosus:
 Drug-induced lupus (DIL) is an autoimmune phenomenon where drug exposure leads to the
development of systemic lupus erythematosus (SLE) )-like clinical features.
 DIL is a clear example of an environmental trigger leading to the development of lupus in a genetically
susceptible individual.
 It is common in whites, with less female predilection than in SLE.
 Causative agents include hydralazine (such as in this patient), procainamide, chlorpromazine,
isoniazid, methyldopa, minocycline, penicillamine, and diltiazem.
 Pathophysiology: Different mechanisms are used to induce autoimmunity through lupus-inducing
drugs. Some genetic risk factors, such as HLA-DR0301, HLA-DR4, and the complement C4 null allele,
vary between agents. The acetylators with genetic deficiency of N-acetyltransferase are at a higher risk
of DIL, especially procainamide and hydralazine.
 Different mechanisms are used to induce autoimmunity through lupus-inducing drugs.
 Some genetic risk factors, such as HLA-DR0301, HLA-DR4, and the complement C4 null allele, vary
between agents.
 The acetylators with genetic deficiency of N-acetyltransferase are at a higher risk of DIL, especially
procainamide and hydralazine.
 Positive ANA is nonspecific, but the sensitivity for DIL is 100%, so if ANA is negative, DIL can be ruled
out.
 Anti-histone antibodies are more often involved.
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Page 10
4. Premature birth at ≤34 weeks due to preeclampsia
4. Medium to high titer
5. 3 consecutive abortions at <10 weeks
5. At least 2 times, 12 weeks apart
6. Placental insufficiency at <34 weeks
 
Based on these classification criteria, patients who have at least one positive clinical and one positive l
aboratory criteria are considered to have a diagnosis of APS.
Option A - Systemic lupus erythematosus (SLE) - Anti-dsDNA antibody: SLE is an autoimmune diseas
e characterized by various manifestations, including lupus nephritis and lupus cerebritis. The presence 
of anti-dsDNA antibody is highly specific for SLE and correlates with disease activity.
Option B - Rheumatoid arthritis - Rheumatoid factor: Rheumatoid arthritis is an autoimmune disease th
at primarily affects the joints. Rheumatoid factor is an antibody commonly found in the blood of individu
als with rheumatoid arthritis, but it is not specific to this condition.
Option D - Sjogren's syndrome - Anti-SSA/Ro antibody: Sjogren's syndrome is an autoimmune disorde
r that primarily affects the salivary glands and tear ducts. Anti-SSA/Ro antibody is commonly found in i
ndividuals with Sjogren's syndrome but is not as specific as lupus anticoagulant in the diagnosis of AP
S.
Correct Option C - Libman-Sacks endocarditis:
 Libman-Sacks endocarditis is a non-infectious form of endocarditis that occurs in patients with SLE.
 It is characterized by very small vegetations, histologically characterized by organized platelet-fibrin
microthrombi surrounded by growing fibroblasts and macrophages.
 This condition predominantly affects the mitral valve. Malfunction of the chordae tendineae leads to
mitral regurgitation.
Option A - Infective endocarditis: Infective endocarditis is characterized by bacterial or fungal infection 
of the heart valves, leading to the formation of infective vegetations. It typically presents with fever, chill
s, and a
new-onset heart murmur. In this scenario, the patient's mitral regurgitation is more likely due to a
non-infectious cause related to her underlying autoimmune disease.
Option B - Rheumatic heart disease: Rheumatic heart disease is caused by rheumatic fever, a
systemic inflammatory condition triggered by group A streptococcal infection. It primarily affects the he
art valves, leading to scarring and deformities. While mitral regurgitation can occur in rheumatic heart d
isease, the patient's history of SLE suggests a different etiology.
Option D - Mitral valve prolapse: Mitral valve prolapse is a condition in which the valve leaflets do not cl
ose properly during systole, resulting in mitral regurgitation. It is a common finding and usually not asso
ciated with systemic autoimmune diseases like SLE. Therefore, it is less likely to be the cause of mitral 
regurgitation in this patient with a history of SLE.
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Correct Option A - Symmetrical joint involvement, small and large joints affected, intermittent polyarthrit
is, non-erosive arthritis:
 Synovitis is the most common presentation of SLE.
 In SLE, synovitis typically manifests as symmetrical joint involvement, affecting both small and large
joints.
 The arthritis is usually intermittent and non-erosive. These features help differentiate it from other
forms of arthritis, such as rheumatoid arthritis, which may have asymmetrical involvement,
predominantly affect large joints, and can be erosive.
 Unilateral joint involvement and intermittent monoarthritis are less characteristic of SLE-associated
synovitis.
Option B - Asymmetrical joint involvement, large joints predominantly affected, continuous polyarthritis,
 erosive arthritis: Rheumatoid arthritis, which may have asymmetrical involvement, predominantly affec
t large joints, and can be erosive.
Option C - Unilateral joint involvement, small joints predominantly affected, intermittent monoarthritis, n
on-erosive arthritis: Unilateral joint involvement and intermittent monoarthritis are less characteristic of 
SLE-associated synovitis.
Option D - Bilateral joint involvement, large and small joints affected equally, continuous polyarthritis, e
rosive arthritis: It is less likely associated with SLE
Correct Option D - IgG, IgA, and IgM deposition -
Lupus nephritis, characteristic feature: Full house effect:
 Lupus nephritis results from the deposition of circulating immune complexes composed of primarily
DNA and anti-DNA, which activate the complement cascade, leading to complement-mediated
damage, leukocyte infiltration, activation of procoagulant factors, and release of various cytokines.
 The most common clinical sign of the renal disease is proteinuria, but hematuria, hypertension,
varying degrees of renal failure, and active urine sediment with red blood cell casts can all be present.
 On immunofluorescence, the deposition of IgA, IgA, and IgM is visualized.
 The deposition of complement factors C3 and C1 is also evident (Full house effect).
Option A - IgG deposition - Lupus nephritis, characteristic feature: IgG, IgA, and IgM deposition Lupus 
nephritis, characteristic feature: Full house effect: While IgG deposition is seen in lupus nephritis, it is n
ot the only immunoglobulin involved. IgA and IgM depositions are also characteristic of lupus nephritis, 
leading to the full house effect.
Option B - IgA deposition - IgA nephropathy, characteristic feature: IgA deposition: IgA deposition is a s
pecific feature of IgA nephropathy, not lupus nephritis. In IgA nephropathy, only IgA is deposited, not Ig
1026

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G or IgM.
Option C - IgM deposition -
Membranous nephropathy, characteristic feature: IgM deposition: IgM deposition is a characteristic feat
ure of membranous nephropathy, not lupus nephritis. In membranous nephropathy, IgM is deposited al
ong the glomerular basement membrane.
- Oral ulcers, non-scarring alopecia, positive ANA, low complement levels (C3 and C4):
 These diagnostic criteria are consistent with systemic lupus erythematosus (SLE). The presence of a
butterfly-shaped rash, oral ulcers, non-scarring hair loss, positive ANA, and low complement levels are
all characteristics of SLE, making this the correct answer.
 Diagnostic Criteria:
 At least 4 features total, with at least 1 clinical and 1 immunological feature.
Immunological Features
Malar rash (psoriatiform or discoid)
Direct Coombs test (positive in AIHA)
Discoid lupus erythematosus
Anti-Smith antibody
Serositis (pleuritis and pericarditis)
ANA (Antinuclear Antibody)
Oral aphthous ulcers
Lupus anticoagulant
Non-scarring alopecia
ELISA Anticardiolipin (may give false positive VDRL)
Synovitis (≥ 2 joints - intermittent polyarthritis)
Anti-β2 Glycoprotein
Brain involvement (cognitive defects, psychosis)
Low C3 and C4
Renal involvement (Lupus Nephritis or ESRD)
 
Anemia (Anemia of chronic disease, Autoimmune hemolytic anemia)
Latest ACR criteria for SLE in 2019:
 The 2019 criteria include Fever as a new addition.
 Renal biopsy carries the highest weightage of 10 points.
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 A diagnosis of SLE is made if the total score is >10 with a positive ANA.
Option A - Morning stiffness >1 hour, symmetric arthritis, positive rheumatoid factor, radiographic evide
nce of joint erosion: These diagnostic criteria are consistent with rheumatoid arthritis, but they do not in
clude the characteristic butterfly-shaped rash, oral ulcers, or non-scarring hair loss described in the sce
nario. Therefore, this is not the correct answer.
Option B - Elevated serum uric acid levels, tophi, acute episodes of monoarthritis: These diagnostic crit
eria are consistent with gout, but they do not include the characteristic butterfly-shaped rash, oral ulcer
s, or non-scarring hair loss described in the scenario. Therefore, this is not the correct answer.
Option C - Intermittent arthritis, enthesitis, dactylitis, negative rheumatoid factor: These diagnostic criter
ia are consistent with psoriatic arthritis, but they do not include the characteristic butterfly-shaped rash, 
oral ulcers, or non-scarring hair loss described in the scenario. Therefore, this is not the correct answer
.
1028

1. Which condition necessitates the use of anti-nuclear antibodies for accurate diagnosis?
A. Scleroderma
B. Systemic lupus erythematosus
C. Drug induced lupus
D. Sjogren's syndrome
2. What could be the probable diagnosis for a 54-year-old female patient who visits you with symptoms
of finger swelling, heartburn, and occasional joint pain? During examination, her hands appear shiny,
tight, and thickened with non-pitting edema. Additionally, she has interstitial lung disease and tests
positive for ANA antibodies, topoisomerase I antibodies, and Anti-RNA polymerase III antibodies.
A. Limited cutaneous systemic sclerosis
B. Diffuse cutaneous systemic sclerosis
C. Raynaud's phenomenon
D. Peutz-jeghers syndrome
3. A patient presents to you with fever, night sweats, ptosis, and bilateral facial nerve palsy.
Investigations showed leukocytosis and bilateral hilar lymphadenopathy. Which of the following is the
A. Sarcoidosis
B. Tuberculosis
C. Lymphoma
D. Hypersensitive pneumonitis
4. What is the most probable diagnosis for a young male patient who experiences drooping eyelids that
worsens as the day progresses, along with increased fatigue towards the end of the day which
improves with rest? Additionally, the patient notices a significant decrease in drooping when placing an
ice pack over their eyes.
5. What is the likely diagnosis for a 50-year-old woman who is experiencing challenges with activities
such as climbing stairs, rising from a chair, and grooming her hair, along with the observation of
violaceous redness on her upper eyelids?
A. Inclusion body myositis
B. Dermatomyositis
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6. A young man came to the medical OPD with complaints of early morning backache and stiffness,
which improves on exercise, and persistent red eyes. On examination, lung expansion was less than 3
cm. X-ray is shown below. What is the most probable diagnosis?
A. Ankylosing spondylitis
B. Paget's disease
C. Healed tuberculosis
D. Osteopetrosis
7. A chronic alcoholic patient presents with acute pain and swelling of the left great toe. There is no
history of trauma. Synovial fluid analysis shows elevated1 leukocytes. Lab investigations show normal
serum uric acid levels. What is the most likely diagnosis?
A. Pseudogout
B. Acute gout
C. Reactive arthritis
D. Septic arthritis
8. Which of the following is not a first-line drug for the management of a patient with rheumatoid
arthritis?
A. Sulfasalazine
9. A young patient presents to the clinic with erythematous lesions over the exposed areas of the skin,
like hands, arms, and chest. He also complains of arthralgia and breathlessness. Measuring which
among the following antibodies will be useful in diagnosing the underlying conditions?
A. Antihistone antibodies
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B. Anti-dsDNA antibodies
C. Anticentromere antibodies
D. Antinuclear antibodies
10. A 36-year-old woman presented with claudication in the forearm, transient loss of vision, and
abdominal pain. Femoral pulses were weak. Fundus examination revealed retinal haemorrhages. What
A. Polyarteritis nodosa
B. Thromboangiitis obliterans
D. Microscopic polyangiitis
11. A woman presents with numbness of her fingertips. On examination, the skin over her face appears
tightened. The antinuclear antibody (ANA) is found to be positive and immunofluorescence shows the
nucleolar pattern. What is the likely diagnosis?
A. Systemic sclerosis
B. Sjogren’s syndrome
C. Systemic lupus erythematosus
12. What should be the first-line treatment for a patient with giant cell arteritis?
A. Abatacept
B. Tocilizumab
D. Aspirin
13. Which among the following is more common in limited cutaneous systemic sclerosis when
compared to diffuse systemic sclerosis?
A. Esophageal dysmotility
B. Myopathy
C. Interstitial lung disease
D. Scleroderma renal crisis
14. Which of the following is true about polyarteritis nodosa?
A. Necrotising inflammation of large vessels
B. Patient has hypogammaglobulinemia
C. 90% is associated with ANCA positivity
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D. 30% is associated with Hepatitis B
15. The slowing of conduction in multiple sclerosis is due to which of the following?
A. Gliosis
B. Loss of myelin sheath
C. Defect at node of Ranvier
D. Leaky Na+ channel
16. Which drugs are not used for a patient diagnosed with sarcoidosis?
D. Prednisone
17. A patient presents with severe pain and swelling in his knee joint for 10 days. He also complains of
pain and discomfort during urination. He says that he had diarrhea one month ago and he has been
unwell since then. What is the most likely diagnosis?
A. Reactive arthritis
B. Enteropathic arthritis
D. Psoriatic arthritis
18. Which drug is the preferred choice for managing primary progressive multiple sclerosis?
A. Natalizumab
B. Ocrelizumab
C. Fingolimod
D. Alemtuzumab
19. A patient presented with sinusitis, ulcerative lesions on the nasopharynx, nodular lesions with
cavitations of the lung, and renal failure. Which of the following is the most useful investigation for this
patient?
A. Test for ANCA
B. Biopsy to show granuloma
C. AFB staining of sputum
D. BAL
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20. A 52 year old woman presented with changes in the hand as shown below. There is decreased
motion in the small joints and loss of wrinkle lines on the facial skin. Her chest radiograph showed
prominent bilateral lower lobe infiltrates. Which of the following is the most likely diagnosis?
A. Rheumatoid arthritis
B. Scleroderma
C. Systemic lupus Erythematosus
D. Pneumonia
21. A 19 year old woman with no comorbidities presented with numbness and paraesthesia of the
fingers along with the characteristic finding as shown in the image below. She has no other illnesses
and she says these episodes occur when she is under excess stress or during cold climates. What is
D. Sclerodema
22. Identify the deformity depicted in the image:
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A. Swan neck deformity
B. Boutonniere deformity
C. Z line deformity
D. Trigger finger
23. A patient presents with flaccid bullous lesions as shown in the image below involving the entire
trunk and oral cavity. Acantholytic cells are seen on Tzank smear. What is the most probable
A. Pemphigus foliaceus
B. Pemphigus vulgaris
C. Dermatitis herpetiformis
D. Bullous pemphigoid
24. Which of the following condition leads to the development of wing beating tremor?
A. Wilson’s disease
B. Huntington’s chorea
C. Parkinsonism
D. Sydenham’s chorea
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25. What condition is likely in a patient who presents to the hospital with symptoms of lethargy,
increased sleep, and weight gain, and exhibits low plasma TSH concentration, low T3, and low T4
levels, but shows an increase in TSH levels after the administration of TRH?
A. Hyperthyroidism due to disease in the pituitary
D. Hyperthyroidism due to disease in the hypothalamus
26. The image shown below depicts a specific physical finding. Which of the following conditions is not
associated with this finding?
C. Liver cirrhosis
D. Hypoestrogenic state
27. A patient with rheumatoid arthritis has been treated with methotrexate and low-dose corticosteroids
for the past 4 months. However, the disease is still progressing. What would be your recommendation
for the further management of this patient?
A. Stop oral methotrexate and start parenteral methotrexate
B. Add sulfasalazine and hydroxychloroquine
C. Continue corticosteroids and methotrexate
D. Start only anti-TNF alpha agents
28. A female patient presents with fever, oral ulcer, photosensitivity, and rashes on her face as shown
below. What is the most likely diagnosis?
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A. Dermatomyositis
C. Rosacea
D. Melasma
29. What extra-articular manifestation is commonly observed in patients with rheumatoid arthritis?
A. Subcutaneous nodule
C. Felty’s syndrome
D. Vasculitis
30. What is the next recommended investigation to aid in diagnosing the condition of a patient who has
cutaneous vasculitis, glomerulonephritis, and peripheral neuropathy?
A. ANCA
B. RA factor
C. HbsAg
D. MIF
31. Which of the following medications is not used in the treatment of rheumatoid arthritis?
A. Febuxostat
B. Leflunomide
C. Etanercept
32. An elderly woman presents with a chronic history of pain in the small joints of hands with stiffness of
joints in the early hours of the day. The image of the patient's hands is given below. What is the most
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C. Complex Regional Pain Syndrome
D. Villonodular synovitis
33. A triad of asthma, systemic vasculitis and eosinophilia is seen in which of the following conditions?
A. Cryoglobulinemic vasculitis
B. Polyarteritis nodosa
C. Churg Strauss syndrome
D. Giant cell arteritis
34. Common neurological tumour in NF-2?
A. Vestibular Schwannoma
B. Optic glioma
C. Café-Au-Lait macules
D. Neurofibrosarcoma
35. All of the following characteristics are found in the pleural effusion fluid of a rheumatoid arthritis
patient except:
A. RA factor
B. High glucose
C. Cholesterol crystals
D. High LDH
36. What is the probable diagnosis of a 45-year-old woman who complains of dryness in her mouth and
eyes, and has positive anti-Ro and anti-La antibodies? The image below shows a positive test result
with a score of less than 5 mm in 5 minutes without anesthesia.
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B. Dehydration
C. Lacrimal duct stones
D. Sjogren syndrome
37. A 29-year-old female patient presents with multiple oral and genital ulcers. The patient claims these
ulcers resolve spontaneously and that she experiences such episodes at least four times a year. Ocular
examination reveals features of anterior uveitis. What is the likely diagnosis?
B. Psoriatic arthritis
C. SLE
D. Behcet’s disease
38. A 45-year-old presented with severe pain in the right leg below the knee. He had a history of
restricted ambulation and prolonged bed rest due to severe back pain. He has no other comorbidities.
On examination, the skin over his right calf appears shiny and taut. Additionally, tenderness and
increased girth of the right calf are also noted. What is the most probable clinical diagnosis?
A. Cellulitis of the leg
B. Compartment syndrome
C. Deep vein thrombosis
D. Arterial claudication
39. What is the accurate description of marble Schonberg disease?
A. Osteopetrosis
B. Osteomalacia
C. Osteosclerosis
D. Osteonecrosis
40. What is the accurate statement regarding rheumatoid nodules?
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A. Tender, located on extensor surface and seen with arthritis
B. Non tender, located on extensor surface and seen with arthritis
C. Non tender, located on flexor surface and seen with arthritis
D. Tender, located on flexor surface and seen with arthritis
Question 22 2
Question 23 2
Question 26 4
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Question 28 2
Question 33 3
Question 36 4
 Anti-nuclear antibodies (ANAs) are autoantibodies that target components within the cell nucleus.
They are important diagnostic markers for various autoimmune diseases, including systemic lupus
erythematosus (SLE).
 SLE is a chronic autoimmune disease characterized by the presence of a wide range of
autoantibodies, including ANAs. ANA testing is a valuable tool in the diagnosis of SLE, as it helps to
detect the presence of these antibodies in the patient's blood. The most common ANA pattern seen in
SLE is a homogeneous (diffuse) pattern, although other patterns can also be observed.
Option A. Scleroderma: ANAs are also present in scleroderma, another autoimmune disease, but their 
presence is not specific for scleroderma alone. Additional antibodies such as anti-centromere antibodie
s (ACA) and anti-topoisomerase I (Scl-70) antibodies are more specific for scleroderma diagnosis.
Option C. Drug-induced lupus: Drug-induced lupus is a condition that can occur as a result of certain m
edications, and it shares some clinical features with SLE. However, ANAs are not typically required for 
the diagnosis of drug-induced lupus. The presence of ANAs in drug-induced lupus is less common and
 usually of lower titer compared to SLE.
Option D. Sjogren's syndrome: ANAs are present in the majority of patients with Sjogren's syndrome, a
n autoimmune disorder characterized by dry eyes and mouth. However, the hallmark autoantibodies in 
Sjogren's syndrome are anti-SSA (Ro) and anti-SSB (La) antibodies. These antibodies are more specifi
c for the diagnosis of Sjogren's syndrome than ANAs alone.
Correct Option B: Diffuse cutaneous systemic sclerosis
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 In the above case, along with the clinical presentation of swollen fingers, heartburn, and occasional
joint pains, shiny and taut, thickened skin with non-pitting edema in the presence of ANA antibodies,
topoisomerase I antibodies and anti-RNA polymerase III antibodies. It is most suggestive of Diffuse
Cutaneous Systemic Sclerosis.
Option A: Limited cutaneous systemic sclerosis is positive for anti-centromere antibody or ACA.
Option C: Raynaud’s phenomenon is one of the characteristic presentations of diffuse cutaneous syste
mic sclerosis. Some body parts, like the fingers and nose, feel numb and cool in response to cold temp
eratures or stress.
Option D: Peutz-jeghers syndrome is an inherited condition that increases the risk of hamartomatous p
olyps in the GIT and cancers in the GIT and that of the breast, testicles, and ovaries. Since there are n
o polyps, PJS is unlikely to be the diagnosis.
Correct Option A - Sarcoidosis:
 The clinical presentation of fever, night sweats, bilateral facial nerve paralysis, and bilateral hilar
lymphadenopathy are suggestive of a systemic inflammatory condition affecting multiple organs. 
 Sarcoidosis is a multisystem granulomatous disorder that commonly presents with hilar
lymphadenopathy besides other features of systemic involvement such as facial nerve palsy.
Option B - Tuberculosis: It can display bilateral hilar lymphadenopathy and fever, but it is less likely to c
ause facial nerve palsy.
Options C and D (Lymphoma & Hypersensitive pneumonitis) are incorrect.
Correct Option A - Myasthenia gravis:
 Myasthenia gravis is an autoimmune disorder that affects the neuromuscular junction, causing muscle
weakness and fatigue. It is caused by antibodies that attack the acetylcholine receptors on the muscle,
leading to a decrease in the number of available receptors and impaired nerve transmission. Ptosis, or
drooping of the eyelid, is a common symptom. The ptosis tends to worsen through the day as more
acetylcholine receptors are involved. Patients may also experience double vision, difficulty speaking or
swallowing, and weakness in the limbs. 
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Correct Option B - Dermatomyositis:
 Based on the symptoms described the most likely diagnosis is Dermatomyositis.
 Dermatomyositis is an inflammatory myopathy that causes muscle weakness as well as skin
involvement.
 It affects both children and adults, with a higher prevalence in middle-aged people. 
 Dermatomyositis causes muscle weakness in the proximal muscles and can also affect the muscles
of the neck and throat, making swallowing  or speaking difficult.
Option A - Inclusion body myositis: Inclusion body myositis is an inflammatory muscle disorder that cau
ses muscle weakness and wasting. However, it usually affects older peopleand is associated with dista
l muscle weakness (e.g., finger flexors, quadriceps). 
Option C - Polymyositis: Polymyositis is an autoimmune inflammatory muscle disease that causes mus
cle weakness in the proximal muscles. It is not commonly associated with the skin manifestations seen
 in dermatomyositis, such as violaceous erythema on the upper eyelids. 
Option D - Scleroderma: Scleroderma, also known as systemic sclerosis, is a chronic autoimmune con
nective tissue disorder affecting the skin and various internal organs. While it can cause muscle weakn
ess, it does not usually present with the typical skin changes seen in dermatomyositis, such as violace
ous erythema of the upper eyelids. Skin thickening and fibrosis, involvement of multiple organ systems,
 and the presence of specific autoantibodies are all symptoms of scleroderma.
Correct Option A - Ankylosing spondylitis:
 In X-ray, the appearance of the Bamboo spine is seen, which is characteristic of Ankylosing
spondylitis.
 Low backache and nocturnal pain that decreases with activity is also suggestive of Ankylosing
 Ankylosing spondylitis is an inflammatory disease of the axial spine. It begins in the early years of life
when patients present with stiffness and pain in the spine, which gets relieved as the day progresses.
The inflammation can cause fusion of the bones, thus leading to the appearance of the “bamboo spine”,
as seen in the patient’s X-ray. If the fusion occurs at the thoracic vertebra level, it can lead to difficulty in
chest movement, causing decreased chest expansion, as seen in the patient.
 
Correct Option B - Acute gout:
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 Acute gout is a form of arthritis is characterized by severe pain, redness, and tenderness in joints,
most often the big toe.
 When too much uric acid crystallizes and accumulates in the joints, it can result in pain and
inflammation.
 The serum uric acid levels do not need to be raised for the uric acid to crystallize and deposit in the
joints, but an increased serum uric acid level does predispose patients to this condition.
 Gout attacks can come suddenly and are often at night. Increased consumption of alcohol also
facilitates the increased production of uric acid and its decreased excretion in urine, causing its
accumulation.
 Thus, the most likely diagnosis for the patient is acute gout.
Option A - Pseudogout: Pseudogout is a
condition that develops when tiny calcium pyrophosphate crystals gather in a joint and cause an immu
ne system reaction. Any joint can have pseudogout. The knee, wrist, or large knuckles of the hand (me
tacarpophalangeal joints) are the areas most likely to be affected, but they can also impact the hip, sho
ulder, and spine. Pseudogout, unlike gout, hardly ever affects the big toe.
Option C - Reactive arthritis: An infection of the gastrointestinal or genitourinary system can cause reac
tive arthritis, an inflammatory form of arthritis that develops days to weeks later. 
Option D - Septic arthritis: Infectious arthritis is another name for septic arthritis, which is typically brou
ght on by bacteria. This condition is an infection-related joint inflammation. Septic arthritis typically imp
acts one sizable joint, like the knee or hip.
Correct Option D - Azathioprine:
 Azathioprine is not considered a first-line drug for the management of rheumatoid arthritis (RA). It is
primarily used as an immunosuppressant in organ transplantation and certain autoimmune conditions
but is not typically recommended as an initial treatment for RA due to it’s inconsistent efficacy and high
toxicity.
Option A - Sulfasalazine: Sulfasalazine is one of the disease-modifying antirheumatic drugs (DMARDs)
 commonly used in the treatment of RA. It helps reduce inflammation and joint damage and is consider
ed a first-line treatment option for RA.
Option B - Hydroxychloroquine: Hydroxychloroquine is another DMARD used in the management of R
A. It has anti-inflammatory properties and can help control symptoms and slow disease progression. It i
s often prescribed as a first-line treatment option, especially in mild to moderate RA.
Option C - Methotrexate: Methotrexate is widely recognized as the first-line DMARD for the treatment o
f RA. It is highly effective in reducing symptoms, preventing joint damage, and improving long-term out
comes. Methotrexate is considered the anchor drug and is often prescribed as the initial treatment for 
most patients with RA.
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Correct Option B - Anti-dsDNA antibodies:
 The likely diagnosis in this patient is systemic lupus erythematosus.
 Anti-dsDNA antibodies are specific to systemic lupus erythematosus (SLE), a chronic autoimmune
disease. These antibodies target double-stranded DNA and are found in a significant number of
patients with SLE. Their presence is highly specific to SLE and is associated with lupus nephritis
(kidney involvement) and other manifestations of the disease.
Option A - Antihistone antibodies: Antihistone antibodies are antibodies that target histones, proteins a
ssociated with DNA in the nucleus. They are most commonly associated with drug-induced lupus, a co
ndition that resembles SLE but is caused by certain medications. In this scenario, where the symptoms
 are suggestive of SLE, testing for antihistone antibodies would be less relevant.
Option C - Anticentromere antibodies: Anticentromere antibodies are associated with a distinct autoim
mune disease called limited cutaneous systemic sclerosis, also known as CREST syndrome. This con
dition primarily affects the skin, blood vessels, and internal organs. The symptoms and clinical features
 described in the patient are not consistent with CREST syndrome, making testing for anticentromere a
ntibodies less useful in this case.
Option D - Antinuclear antibodies (ANA): Antinuclear antibodies target components within the cell nucle
us and can be found in various autoimmune diseases, including SLE. While antinuclear antibodies are 
a useful screening test for autoimmune diseases, including SLE, they are not as specific to SLE as anti
 dsDNA antibodies.
 Takayasu arteritis is a large vessel vasculitis that affects the aorta and its major branches. It primarily
affects young women and presents with symptoms related to the affected arteries. Common
manifestations include weak or absent pulses, claudication, blood pressure differences between arms,
and visual disturbances due to ocular artery involvement. The symptoms described in the case,
including claudication, weak femoral pulses, transient loss of vision, and retinal hemorrhages, are
highly suggestive of Takayasu arteritis. Therefore, Takayasu arteritis is the most likely diagnosis.
Option A - Polyarteritis nodosa: Polyarteritis nodosa is a systemic vasculitis that primarily affects mediu
m-sized arteries. It typically presents with constitutional symptoms such as fever, weight loss, and fatig
ue. It can involve multiple organ systems, including the skin, joints, kidneys, and gastrointestinal tract. 
However, the symptoms described in the case, such as claudication, transient loss of vision, and retina
l hemorrhages, are not characteristic of polyarteritis nodosa.
Option B
- Thromboangiitis obliterans: Thromboangiitis obliterans, also known as Buerger's disease, is a non-ath
erosclerotic segmental inflammatory disease that affects small and medium-sized arteries and veins, p
articularly in the extremities. It is strongly associated with tobacco smoking. The typical presentation in
cludes claudication, digital ischemia (such as ulcers or gangrene), and Raynaud's phenomenon. While 
the symptoms of claudication and peripheral arterial involvement are present in the case, the involvem
ent of the eyes (transient loss of vision, retinal hemorrhages) and abdominal pain make thromboangiitis
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 obliterans less likely.
Option D - Microscopic polyangiitis: Microscopic polyangiitis is a small vessel vasculitis that primarily af
fects capillaries, venules, and arterioles. It can involve multiple organ systems, including the kidneys, lu
ngs, skin, and peripheral nerves. While it can present with systemic symptoms and renal involvement, t
he specific symptoms described in the case, such as claudication, transient loss of vision, and retinal h
emorrhages, are not typical of microscopic polyangiitis.
Correct Option A - Systemic sclerosis (Scleroderma):
 Systemic sclerosis is an autoimmune connective tissue disorder characterized by excessive fibrosis
and thickening of the skin and internal organs. It can present with Raynaud's phenomenon, which is
often the initial symptom and can cause numbness of the fingertips. The tightening of the skin over the
face, known as "scleroderma," is a characteristic feature of systemic sclerosis. The presence of a
positive antinuclear antibody (ANA) with a nucleolar pattern on immunofluorescence testing is
associated with systemic sclerosis. Therefore, systemic sclerosis is the likely diagnosis in this case.
Option B - Sjogren's syndrome: Sjogren's syndrome is an autoimmune disorder that primarily affects th
e exocrine glands, leading to dryness of the eyes and mouth. 
Option C - Systemic lupus erythematosus (SLE): SLE is a
multisystem autoimmune disease that can affect various organs and tissues. It can present with a wide
 range of symptoms, including numbness and tingling in the extremities. However, the tightening of the 
face seen in systemic sclerosis and the nucleolar pattern on ANA immunofluorescence testing are not 
characteristic of SLE. Therefore, SLE is less likely to be the diagnosis in this case.
Option D - Rheumatoid arthritis: Rheumatoid arthritis primarily affects the joints, causing inflammation, 
pain, and stiffness. It does not typically involve numbness of the fingertips or the tightening of the face 
seen in systemic sclerosis. Additionally, the nucleolar pattern on ANA immunofluorescence testing is n
ot associated with rheumatoid arthritis. Therefore, rheumatoid arthritis is less likely to be the diagnosis i
Correct Option C - Steroids:
 Steroids, This option is the correct answer. Glucocorticoids (steroids) are the first-line treatment for
GCA. They have been shown to be highly effective in reducing inflammation and preventing
complications associated with GCA. The initial dosage of steroids is usually high, with gradual tapering
based on clinical response and laboratory markers of inflammation.
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Correct Option A - Esophageal dysmotility:
 In limited cutaneous systemic sclerosis, also known as limited scleroderma or CREST syndrome,
esophageal dysmotility is more common compared to diffuse cutaneous systemic sclerosis. Limited
cutaneous systemic sclerosis is characterized by skin involvement limited to the face, neck, and distal
extremities, while diffuse cutaneous systemic sclerosis involves more widespread skin fibrosis.
 Options B, C and D are more commonly associated with diffuse systemic sclerosis.
Correct Option D - 30% is associated with Hepatitis B:
 This statement is true. Approximately 30% of cases of polyarteritis nodosa are associated with chronic
Hepatitis B infection. The immune response triggered by the Hepatitis B virus can cause immune
complex deposition and subsequent inflammation in the arterial walls, leading to the development of
PAN.
Correct Option B - Loss of myelin sheath:
 This is the correct answer. Multiple sclerosis is a chronic autoimmune disorder characterized by the
destruction of myelin, the protective covering of nerve fibers in the CNS. The loss of myelin disrupts the
normal conduction of nerve impulses, resulting in a slowing of nerve transmission and the characteristic
neurological symptoms seen in MS patients.
 Sarcoidosis is an inflammatory disorder most commonly seen in the lungs. Patients may exhibit
symptoms like cough and dyspnoea, which are mostly treated with glucocorticoids. The
first-line treatment is glucocorticoids with additional DMARDS like methotrexate, hydroxychloroquine,
biologics like TNF alpha inhibitors, and Azathioprine.
 Fludrocortisone is a mineralocorticoid mainly used for Addison’s disease.
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 Options B, C and D are used in the management of patients with sarcoidosis.
Correct Option A - Reactive arthritis:
 In the above case, there is a history of knee swelling, urethritis, and diarrhea. It points towards the
diagnosis of reactive arthritis. It is a post-infectious autoimmune disease. The most common systems
affected would be the gastrointestinal or urinary tract.
Option B - Enteropathic arthritis: Enteropathic arthritis Is a spondyloarthropathy that is associated with i
nflammatory bowel diseases like Crohn’s and ulcerative colitis. It typically causes sacroiliitis and spond
ylitis and involves peripheral joints.
Option C - Rheumatoid arthritis: Rheumatoid arthritis is seen in mostly young females and presents wit
h painful tender joints. PIP and MCP are affected symmetrically in bilateral limbs. Patients experience 
morning stiffness and the hallmark feature is flexor tenosynovitis. Swan neck deformity and Boutonnièr
e deformity is also seen.
Option D - Psoriatic arthritis: Psoriatic arthritis is associated with a chronic inflammatory skin disorder. 
Psoriasis causes Inflammatory arthritis and primarily affects the hands, feet, or spine.
Correct Option B - Ocrelizumab:
 Ocrelizumab is an approved medication for the treatment of both relapsing forms of multiple sclerosis
(MS) and primary progressive MS. It is a monoclonal antibody that specifically targets CD20-positive B
cells, leading to their depletion. Ocrelizumab has shown efficacy in reducing disease activity and
slowing disability progression in patients with PPMS.
 
Correct Option A - Test for ANCA:
 The combination of sinusitis, ulcerative lesions on the nasopharynx, nodular lesions with cavitations of
the lung, and renal failure raises suspicion for a condition known as granulomatosis with polyangiitis
(GPA), formerly called Wegener’s granulomatosis. GPA is a systemic autoimmune vasculitis that
primarily affects the small and medium-sized blood vessels, leading to inflammation and tissue
damage.
 Testing for ANCA is crucial in evaluating patients with suspected GPA. ANCA, specifically the
c-ANCA (cytoplasmic ANCA) subtype, is present in many GPA cases. The presence of c-ANCA,
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directed against proteinase 3 (PR3) antibodies, supports the diagnosis of GPA. However, it’s important
to note that a small percentage of GPA cases may be ANCA-negative.
Option B - Biopsy to show granuloma: While granulomas can be seen in GPA, they are not always pre
sent, and their absence does not exclude the diagnosis. Biopsy findings can provide supportive eviden
ce but are not definitive on their own.
Option C - AFB staining of sputum: Acid-fast bacilli (AFB) staining is useful for detecting organisms suc
h as Mycobacterium tuberculosis, which causes tuberculosis. However, the clinical presentation descri
bed in the question is not suggestive of tuberculosis.
Option D - BAL (Bronchoalveolar Lavage): BAL can be helpful in evaluating lung involvement in GPA a
nd identifying inflammatory cells, but it is not the most useful investigation for confirming the diagnosis. 
ANCA testing provides more specific information in this scenario.
Correct Option B - Scleroderma:
 Based on the given clinical presentation and findings, the most likely diagnosis in this case is
Scleroderma. 
 Scleroderma, also known as systemic sclerosis, is a chronic autoimmune disease characterized by
fibrosis (hardening) of the skin and internal organs. The image in the vignette depicts Raynaud's
phenomenon, which is seen in patients with scleroderma.
 Loss of wrinkle lines on the facial skin, known as the "mask-like" facies, is another clinical
manifestation commonly seen in scleroderma. This occurs due to thickening and tightening of the skin.
 The prominent bilateral lower lobe infiltrates on the chest radiograph suggest pulmonary involvement,
which is common in scleroderma. Pulmonary fibrosis, interstitial lung disease, and pulmonary
hypertension are potential complications of scleroderma that can manifest as lung infiltrates.
 
 Based on the information provided, the most likely diagnosis for the 19-year-old woman is Primary
Raynaud's phenomenon.
 Raynaud's phenomenon is characterized by episodic vasospasm of the digital arteries, leading to
color changes, numbness, and paraesthesia of the fingers or toes. There are two main types: Primary
Raynaud's phenomenon and Secondary Raynaud's phenomenon.
 Primary Raynaud's phenomenon: This occurs without an underlying cause or associated medical
condition. It is usually triggered by cold temperatures or emotional stress. The color changes during an
episode include pallor (white discoloration) followed by cyanosis (bluish discoloration) and then reactive
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hyperemia (redness) as blood flow returns. The characteristic finding in Primary Raynaud's
phenomenon is the absence of any underlying disease or abnormal laboratory findings.
Option B - Secondary Raynaud's phenomenon: This occurs as a result of an underlying condition or di
sease, such as autoimmune disorders (e.g., systemic sclerosis, lupus), connective tissue diseases, art
erial diseases, or occupational exposure to certain chemicals or vibrations. In Secondary Raynaud's ph
enomenon, the episodes are often more severe and may be associated with tissue damage or ulcerati
on. Patients may also have abnormal laboratory findings or other signs and symptoms related to an un
derlying autoimmune disorder.
Options C & D (Cold sores & Sclerodema) are incorrect.
Given the absence of any comorbidities or underlying diseases, the association of symptoms with cold 
temperatures or stress, and the characteristic color changes during episodes, the most likely diagnosis 
in this case is Primary Raynaud's phenomenon.
 
Correct Option B - Boutonniere deformity:
 This deformity involves flexion of the proximal interphalangeal joint and hyperextension of the distal
interphalangeal joint of the finger, resulting in a finger with a bent appearance at the middle joint and
extended at the end joint.
 
Correct Option B - Pemphigus vulgaris:
 Based on the provided information, if the patient is presenting with flaccid bullous lesions involving the
entire trunk and oral cavity, along with the presence of acantholytic cells on Tzanck smear, the most
probable diagnosis would be Pemphigus vulgaris.
 Pemphigus vulgaris is known to involve both the skin and mucous membranes, including the oral
cavity. The presence of acantholytic cells in Tzanck smear is a characteristic finding in pemphigus
vulgaris. However, a definitive diagnosis would require additional clinical evaluation, including a biopsy
and direct immunofluorescence testing.
Option A - Pemphigus foliaceus: Althougus pemphigus foliaceous may present with similar features it d
oes not classically involve the mucous membranes.
Option C - Dermatitis herpetiformis: Dermatitis herpetiformis is a chronic, intensely itchy skin condition t
hat is associated with celiac disease. It is characterized by clusters of small, intensely itchy vesicles an
d papules on the extensor surfaces of the elbows, knees, and buttocks. It is caused by an autoimmune 
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reaction to gluten. A Tzanck smear is not typically used to diagnose dermatitis herpetiformis.
Option D - Bullous pemphigoid: Bullous pemphigoid is an autoimmune blistering disorder that primarily 
affects the elderly. It is characterized by tense bullae that typically occur on the flexural surfaces of the 
body, such as the armpits and groin. A
Tzanck smear is not typically used to diagnose bullous pemphigoid.
 
Correct Option A - Wilson’s disease:
 Wing beating tremor, also known as asterixis, refers to a flapping tremor of the hands and arms
resembling a bird's wing flapping. It is associated with the presence of hepatic encephalopathy, which
can occur in various conditions affecting the liver and central nervous system. Among the options
provided, Wilson's disease is the most likely cause of wing beating tremor. Wilson's disease is a
genetic disorder characterized by impaired copper metabolism, leading to copper accumulation in
various organs, including the liver, brain, and cornea. The accumulation of copper in the brain can
result in neurological symptoms, such as movement disorders. One of the characteristic movement
disorders seen in Wilson's disease is a wing beating tremor.
 Options B, C, and D are not characteristically associated with asterixis.
 
Correct Option C - Hypothyroidism due to disease in the hypothalamus:
 The patient presents with lethargy, increased sleep, and weight gain. These are classic symptoms of
hypothyroidism, which is characterized by an underactive thyroid gland. The plasma TSH concentration
is low, indicating a lack of stimulation to the thyroid gland. Additionally, both T3 and T4 levels are low,
which are the thyroid hormones responsible for regulating metabolism.
 TRH (thyrotropin-releasing hormone) is typically administered to evaluate the function of the
hypothalamus-pituitary-thyroid (HPT) axis. In this case, the administration of TRH results in an increase
in TSH levels. This indicates that the pituitary gland is capable of responding to TRH by releasing TSH.
This suggests a problem with the hypothalamus, which is responsible for producing TRH. Based on the
given information, the most likely condition in this patient is Hypothyroidism due to disease in the
hypothalamus.
 
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Correct Option D - Hypoestrogenic state:
 In a hypoestrogenic state, such as menopause or certain medical conditions, the levels of estrogen in
the body are reduced. Red hands or palmar erythema is not typically associated with a hypoestrogenic
state.
 Palmar erythema is more commonly seen in conditions related to increased estrogen levels, such as
pregnancy or hormonal disorders. In a hypoestrogenic state, the blood vessels in the skin may not be
dilated as much, leading to a normal or pale appearance of the hands rather than redness.
 Options A, B and C are associated with palmar erythema.
 
Correct Option B - Add sulfasalazine and hydroxychloroquine:
 When a patient with rheumatoid arthritis shows inadequate response to initial therapy with
methotrexate and low-dose corticosteroids, the addition of other disease-modifying antirheumatic drugs
(DMARDs) is often recommended. Sulfasalazine and hydroxychloroquine are commonly used
DMARDs and can be added to the treatment regimen to improve disease control.
Correct Option B - Systemic lupus erythematosus:
 SLE is a chronic autoimmune disease that can affect multiple organs and systems, including the skin,
joints, kidneys, heart, and lungs. The butterfly rash, also known as malar rash, is a hallmark feature of
SLE and typically appears on the face over the cheeks and bridge of the nose.
Correct Option A - Subcutaneous nodule:
 Subcutaneous nodules are the most common extra-articular manifestation of rheumatoid arthritis.
 These nodules typically develop over bony prominences or pressure points and are often found on the
extensor surfaces of the forearms and elbows.
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Option B - Sjogren's syndrome: While Sjogren's syndrome, an autoimmune disorder characterized by d
ry eyes and dry mouth, can occur in patients with rheumatoid arthritis, it is not the most common extra-
articular manifestation of the disease.
Option C - Felty's syndrome: Felty's syndrome is a rare complication of rheumatoid arthritis characteriz
ed by the triad of rheumatoid arthritis, splenomegaly, and neutropenia. It occurs in a small percentage 
of patients with rheumatoid arthritis but is not the most common extra-articular manifestation.
Option D - Vasculitis: Vasculitis, inflammation of blood vessels, can occur in rheumatoid arthritis but is 
not the most common extra-articular manifestation. It is less common compared to subcutaneous nodul
es.
Correct Option A - ANCA:
 The patient's presentation of cutaneous vasculitis, glomerulonephritis, and peripheral neuropathy is
suggestive of small vessel vasculitis.
 ANCA testing is a valuable investigation in such case.
 ANCA is a group of autoantibodies that target neutrophil cytoplasmic antigens.
 Two main patterns of ANCA are recognized: cytoplasmic (c-ANCA) and perinuclear (p-ANCA).
 c-ANCA is typically associated with antibodies against proteinase 3 (PR3) and is seen in
granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis).
 p-ANCA is associated with antibodies against myeloperoxidase (MPO) and is seen in microscopic
polyangiitis and eosinophilic granulomatosis with polyangiitis (formerly known as Churg-Strauss
syndrome).
Option B -  RA factor (rheumatoid factor): Rheumatoid factor is an autoantibody commonly associated 
with rheumatoid arthritis (RA). While RA can involve multiple systems, including joints, it is not typically 
associated with cutaneous vasculitis, glomerulonephritis, and peripheral neuropathy. Therefore, perfor
ming RA factor testing is unlikely to provide relevant diagnostic information in this case.
Option C - HbsAg (hepatitis B surface antigen): Hepatitis B infection can present with various clinical m
anifestations, but cutaneous vasculitis, glomerulonephritis, and peripheral neuropathy are not commonl
y associated with hepatitis B
infection. Therefore, testing for HbsAg is unlikely to help diagnose the underlying condition in this case.
Option D - MIF (migration inhibitory factor): Migration inhibitory factor is a pro-inflammatory cytokine th
at has been implicated in various inflammatory conditions. However, it is not specific to any particular d
isease or diagnostic entity. Testing for MIF alone would not provide sufficient diagnostic information to i
dentify the underlying cause of the patient's presentation with cutaneous vasculitis, glomerulonephritis, 
and peripheral neuropathy.
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Correct Option A - Febuxostat:
 Febuxostat is not used in the treatment of RA. It is a medication primarily used for the management of
hyperuricemia (elevated levels of uric acid) in patients with gout. It works by inhibiting the enzyme
xanthine oxidase, which is involved in the production of uric acid. While gout and RA are both
inflammatory conditions, the use of febuxostat is not considered a standard treatment for RA.
 Options B, C and D are used in the management of patients with rehumatoid arthritis.
 
Correct Option A - Rheumatoid Arthritis:
 In the given scenario, the patient is presenting with chronic pain in the small joints of the hands, along
with stiffness of the joints in the early hours of the day. The image of the patient's hands is consistent
with the characteristic findings seen in Rheumatoid Arthritis (RA).
 Rheumatoid Arthritis is a chronic autoimmune disease that primarily affects the joints. It typically
presents with symmetrical involvement of the small joints, such as those in the hands and wrists. The
characteristic features of RA include joint pain, swelling, and morning stiffness that lasts for at least one
hour. The image provided shows the presence of joint swelling, deformities (such as ulnar deviation
and swan neck deformity), and changes in the finger joints, which are commonly seen in RA.
Option B - Osteoarthritis: Osteoarthritis is a degenerative joint disease characterized by the breakdown
 of joint cartilage. While it can also affect the small joints of the hands, the image and the clinical featur
es described in the scenario are more indicative of Rheumatoid Arthritis. Osteoarthritis also does not pr
esent with symmetric involvement of joints unlike RA.
Option C - Complex Regional Pain Syndrome: Complex Regional Pain Syndrome, also known as Refle
x Sympathetic Dystrophy, is a condition characterized by chronic pain, swelling, and changes in skin co
lor and temperature in the affected limb. The presentation and image provided in the scenario are not c
onsistent with Complex Regional Pain Syndrome.
Option D - Villonodular Synovitis: Villonodular Synovitis is a rare condition characterized by the prolifer
ation of synovial tissue in joints, tendon sheaths, or bursae. While it can lead to joint pain and swelling, 
it typically presents with localized findings and is less likely to involve multiple small joints as seen in th
e image.
 
Correct Option C - Churg Strauss Syndrome:
 Churg Strauss syndrome, also known as eosinophilic granulomatosis with polyangiitis (EGPA), is a
rare autoimmune condition characterized by a triad of symptoms including asthma, eosinophilia, and
systemic vasculitis 
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Option A - RA factor: RA factor (rheumatoid factor) is an autoantibody commonly found in the blood of i
ndividuals with rheumatoid arthritis. It can also be detected in the pleural effusion fluid of RA patients.
Option C - Cholesterol crystals: Cholesterol crystals can be present in the pleural effusion fluid of rheu
matoid arthritis patients. These crystals may form due to inflammation and the breakdown of cellular m
embranes.
Option D - High LDH: High LDH (lactate dehydrogenase) levels are commonly seen in pleural effusions
, including those associated with rheumatoid arthritis. LDH is an enzyme released from damaged or infl
amed cells, and its elevation in the pleural fluid can indicate inflammation or tissue damage.
Correct Option D - Sjogren Syndrome: 
 The above image is that of Schirmer’s test, and in the above case, the patient, a 45-year-old female
patient, presents with dryness in the mouth and eyes. Schirmer’s was positive with a score of <5 mm in
5 minutes without anesthesia, indicating a tear deficiency The patient is also positive for anti-Ro and
anti-La antibodies. The likely diagnosis in this case is Sjogren syndrome.
Option A - Scleroderma: Scleroderma antibodies are anti-Scl-70 and anti-centromere.
Options B & C - Dehydration & Lacrimal duct stones: Dehydration & Lacrimal duct stones are unlikely s
ince this patient tested positive for anti Ro and anti La antibodies which are characteristic of Sjogren sy
ndrome.
Correct Option D - Behcet’s disease:
 Behcet's disease is a chronic autoimmune disorder characterized by recurrent oral and genital ulcers.
It is a multi-systemic vasculitis that can affect blood vessels of all sizes. One of the common
manifestations of Behcet's disease is uveitis. 
 Options A, B and C are incorrect and the presentation described in the vignette is more characteristic
of Behcet's disease.
Correct Option C - Deep vein thrombosis:
 In the above case, a 45-year-old presented with severe pain in the right leg below the knee. He had a
history of restricted ambulation and prolonged bed rest due to severe back pain. He has no other
comorbidities. On examination of his right calf, discoloration, significantly increased girth and
tenderness are noted. It is most suggestive of deep vein thrombosis due to immobilization.
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Correct Option A - Osteopetrosis:
 Osteopetrosis (Marble Bone/Albers Schonberg disease): In osteopetrosis there is a defect in the
normal process of bone resorption, resulting in excessive accumulation of dense, brittle bone tissue.
This leads to increased bone density and reduced bone marrow space. The term "marble bone" refers
to the appearance of the bones on imaging studies, which appear dense and resemble marble.
Osteopetrosis can be inherited as an autosomal recessive or autosomal dominant condition and can
manifest with various symptoms such as fractures, anemia, and impaired vision or hearing.
Correct Option B - Non tender, located on extensor surface and seen with arthritis:
 Rheumatoid nodules are subcutaneous nodules characteristic of rheumatoid arthritis. They are
usually painless (non-tender) and are typically found over bony prominences, especially on the
extensor surfaces of joints, such as the elbows. Rheumatoid nodules result from the accumulation of
inflammatory cells and fibrous tissue and are a specific clinical manifestation of rheumatoid arthritis.
1056

Hepatitis
1. Match the following hepatic viruses with their respective diseases: 1. Hepatitis B virus a.
Orthotopicliver transplant 2. Hepatitis E virus b. Co-infection 3. Hepatitis C virus c. Fulminant hepatic
failure in pregnancy 4. Hepatitis D virus d. Transfusion-related hepatitis
1. Hepatitis B virus a. Orthotopicliver transplant
2. Hepatitis E virus b. Co-infection
3. Hepatitis C virus c. Fulminant hepatic failure in pregnancy
4. Hepatitis D virus d. Transfusion-related hepatitis
A. 1-c,2-a,3-b,4-d
B. 1-c,2-a,3-d,4-b
C. 1-d,2-c,3-a,4-b
2. Which of the following is not a routinely done serological tests before blood transfusion?
A. HRP-2 dipstick
B. PCR HCV RNA
C. FTA-ABS
D. ELISA HIV
E. EIA-anti HAV antibody
3. A 50-year-old patient with decompensated cirrhosis presents with oliguria followed by anuria, raising
suspicion of hepatorenal syndrome (HRS). The patient has refractory ascites, and light microscopy
reveals normal glomeruli. Considering the pathophysiology of HRS, what role do vasodilatory
prostaglandins play in maintaining renal perfusion, and how is their loss implicated in the development
of pre-renal acute kidney injury in hepatorenal syndrome?
(or)
What role do vasodilatory prostaglandins play in maintaining renal perfusion in hepatorenal syndrome
(HRS)?
A. Vasodilatory prostaglandins are upregulated, leading to splanchnic vasodilation and increased
perfusion of glomeruli
B. The loss of vasodilatory prostaglandins in urine results in predominant renal vasoconstriction,
causing impaired kidney perfusion
C. Damaged cirrhotic liver produces vasoconstrictor prostaglandins, contributing to decreased
glomerular filtration rate
D. The absence of prostaglandins in hepatorenal syndrome has no impact on renal blood flow or
glomerular filtration rate.
4. Match the following liver function tests with their corresponding diagnosis: 1. ↑Serum Bilirubin +
↑SGOT + ↑SGPT + (n)Alk. Phosphatase a. Hemolytic jaundice 2. ↑Bilirubin (conjugated) + (n) SGOT +
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Page 2
(n) SGPT + ↑Alk. Phosphatase b. Hepatocellular jaundice 3. ↑Bilirubin (unconjugated) + (n) SGOT +
(n) SGPT + (n) Alk. Phosphatase c. Obstructive jaundice
1. ↑Serum Bilirubin + ↑SGOT + ↑SGPT + (n)Alk. Phosphatase a. Hemolytic jaundice
2. ↑Bilirubin (conjugated) + (n) SGOT + (n) SGPT +  ↑Alk. Phosphatase b. Hepatocellular jaundice
3. ↑Bilirubin (unconjugated) + (n) SGOT + (n) SGPT + (n) Alk. Phosphatase c. Obstructive jaundice
A. 1-c,2-a,3-b
B. 1-a,2-c,3-b
D. 1-c,2-b,3-a
5. Match the readings of various serum markers with their respective diagnosis: 1. HBs Ag⊕ + IgM
anti-HBc a. Gap period 2. Hbs Ag⊕ + IgG anti-HBc b. Vaccinated 3. Only IgM anti-HBcAg is present c.
Acute Hepatitis B 4. Anti HbsAg > 10 IU/ml d. Recovery 5. IgG Anti Hbc e. Chronic Hepatitis B 6. Anti
Hbs Ag(+), Anti Hbc Ig G(+) f. Low-level carrier
1. HBs Ag⊕ + IgM anti-HBc a. Gap period
2. Hbs Ag⊕ + IgG anti-HBc b. Vaccinated
3. Only IgM anti-HBcAg is present c. Acute Hepatitis B
4. Anti HbsAg > 10 IU/ml d. Recovery
5. IgG Anti Hbc e. Chronic Hepatitis B
6. Anti Hbs Ag(+), Anti Hbc Ig G(+) f. Low-level carrier
A. 1-a,2-c,3-e,4-b,5-d,6-f
B. 1-c,2-e,3-a,4-b,5-f,6-d
C. 1-b,2-f,3-a,4-d,5-c,6-e
D. 1-d,2-b,3-ie,4-f,5-c,6-a
6. Below are the various options showing the order of appearance of serum markers in Hepatitis B
infection. Pick the correct answer.
A. HBs Ag → IgM → HBe Ag → Anti-Hbs Ag → Anti-HBe Ag
B. HBs Ag → HBe Ag → IgM → Anti-HBe Ag → Anti-Hbs Ag
C. HBs Ag → HBe Ag → IgM → Anti-Hbs Ag → Anti-HBe Ag
D. HBe Ag → HBs Ag → IgM → Anti-Hbs Ag → Anti-HBe Ag
7. A 55-year-old patient with a history of intravenous drug abuse presents with features of end-stage
liver disease, including palmar erythema, Dupuytren's contracture, leukonychia, and clubbing. The
patient's condition is attributed to chronic hepatitis infection. What is the most common reason for liver
transplants in the world related to hepatitis?
(or)
What is the most common reason for liver transplants in the world related to hepatitis?
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A. Acute liver failure
B. Hepatocellular carcinoma
C. Alcoholic cirrhosis
D. Hepatitis C-induced cirrhosis
8. A 30-year-old intravenous drug abuser presents with jaundice and is found to be positive for both
HBsAg and IgM anti-HBcAg in February 2021. After relocating to a different workplace due to police
monitoring, the patient acquires the delta virus in March 2021, confirmed by the presence of IgM
anti-HDV Ag. What is the most likely consequence of this delta virus infection in terms of liver
pathology?
(or)
What is the most likely consequence of delta virus infection in terms of liver pathology?
A. Chronic hepatitis
B. Cirrhosis
C. Fulminant hepatic failure (FHF)
D. Asymptomatic carrier state
9. Fine tremors are present in all of the following except.
A. Grave's disease
B. Anxiety neurosis
10. Which of the following is not a parameter used in the MELD score?
A. Serum bilirubin
B. Albumin
C. INR
D. Serum creatinine
11. Which of the following is not a parameter of the Child-Pugh score?
A. Albumin
B. Asterixis
C. Serum creatinine
D. Ascites
12. A 32-year-old patient with a history of autoimmune hepatitis experiences a sudden exacerbation of
symptoms and a rise in liver enzyme levels. The patient denies any changes in medications or
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exposure to infectious agents. Upon further inquiry, the patient reveals the recent initiation of a drug for
acne management. Which of the following medications is most likely responsible for triggering the
exacerbation of autoimmune hepatitis in this case?
(or)
Which of the following medications is most likely responsible for triggering the exacerbation of
autoimmune hepatitis during acne therapy?
B. Prednisone
C. Minocycline
D. Propranolol
13. Below are the various physical findings in liver disorders. Match them accordingly. 1. a. Caput
medusae 2. b. Hemochromatosis 3. c. Spider angioma
1.
 a. Caput medusae
2.
 b. Hemochromatosis
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3.
 c. Spider angioma
A. 1-c, 2-b, 3-b
B. 1-c, 2-a, 3-b
C. 1-b, 2-a, 3-d
D. 1-a, 2-c, 3-b
14. All of the following viruses are RNA viruses except?
A. Hepatitis A virus
B. Hepatitis B virus
C. Hepatitis C virus
D. Hepatitis D virus
15. Match the following diseases with their respective HLA 1) HLA B27 a) Rheumatoid arthritis 2) HLA
DQ2 b) Sarcoidosis 3) HLA DR3 c) Ankylosing spondylitis 4) HLA B8 d) DM Type 1 5) HLA DR4 e)
Celiac disease
1) HLA B27 a) Rheumatoid arthritis
2) HLA DQ2 b) Sarcoidosis
3) HLA DR3 c) Ankylosing spondylitis
4) HLA B8 d) DM Type 1
5) HLA DR4 e) Celiac disease
A. 1-a,2-d,3-b,4-e,5-c
B. 1b,-2-e,3-c,4-d,5-a
C. 1-c,2-e,3-d,4-b,5-a
D. 1-c2-a,3-d,4-b,5-e
16. Match the following 1) Anti-LKM 1 a) HDV 2) Anti-LKM 2 b) HCV 3) Anti-LKM 3 c) Drug-induced
hepatitis
1) Anti-LKM 1 a) HDV
2) Anti-LKM 2 b) HCV
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Page 6
3) Anti-LKM 3 c) Drug-induced hepatitis
Question 2 5
Correct Option C - 1-d,2-c,3-a,4-b:
1. Hepatitis B virus - can lead to Transfusion-related hepatitis
2. Hepatitis E virus- can lead to Fulminant hepatic failure in pregnancy Fulminant hepatic failure in nor
mal people is caused by Hepatitis D virus
3. Hepatitis C virus is the most common cause of Orthotopic liver transplantation in patients with HCV-i
nduced cirrhosis.
4. Hepatitis D virus can cause Coinfection/Superinfection with Hepatitis B
Eliminated by the explanation of the above options.
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Option A - 1-c,2-a,3-b,4-d
Option B - 1-c,2-a,3-d,4-b
Option D - 1-d,2-b,3-c,4-a
Correct Option E - EIA-anti HAV antibody:
 Investigation for Hepatitis A virus is not needed before blood transfusion
These are used in serology tests before blood transfusion or any other medical intervention.
Option A - HRP-2 dip stick:
 Tests for malarial parasite
Option B - PCR HCV RNA:
 It is to detect Hepatitis C virus
Option C - FTA:
 ABS-To detect syphilis
Option D - ELISA HIV:
 To detect HIV
Correct Option B - The loss of vasodilatory prostaglandins in urine results in predominant renal vasoco
nstriction, causing impaired kidney perfusion:
 In hepatorenal syndrome (HRS), there is an imbalance between vasoconstriction and vasodilation
mechanisms in the body, leading to renal dysfunction. Vasodilatory prostaglandins, particularly
prostaglandin E2 (PGE) and prostacyclin (PGI2), play a crucial role in maintaining renal blood flow and
glomerular filtration rate. These prostaglandins are responsible for increasing renal blood flow and
promoting glomerular filtration.
 In HRS, vasodilatory prostaglandins are lost in urine, primarily due to the damaged cirrhotic liver. This
loss results in predominant renal vasoconstriction, causing impaired kidney perfusion and leading to
pre-renal acute kidney injury. The upregulation of vasoconstrictor mechanisms, such as endothelin-1,
further contributes to splanchnic vasodilation, shunting blood away from the kidneys and reducing
perfusion of the glomeruli.
 
 Options A, C, and D are incorrect because they do not accurately reflect the role of vasodilatory
prostaglandins in the context of HRS and their impact on renal perfusion.
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Correct Option C - 1-b,2-c,3-a:
 Options A, B and D are incorrect. Refer to the explanation of the correct answer.
Correct Option B - 1-c,2-e,3-a,4-b,5-f,6-d:
 Options A, C and D are incorrect. Refer to the explanation of the correct answer.
Correct Option C - HBs Ag → HBe Ag → IgM → Anti-Hbs Ag → Anti-HBe Ag:
 The sequence of appearence of the markers in Hepatitis b virus is surface antigen(HBsAg) followed
by antigen that represents the infectivity (HB eAg) and then antibody against core antigen (IgM)
followed by antibody against the surface antigen (Anti-Hbs Ag) and then antibody against Hbe
Ag(Anti-HBe Ag)
Option A - HBs Ag → IgM → HBe Ag → Anti-Hbs Ag → Anti-HBe Ag
Option B - HBs Ag → HBe Ag → IgM → Anti-HBe Ag → Anti-Hbs Ag
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Option D - HBe Ag → HBs Ag → IgM → Anti-Hbs Ag → Anti-HBe Ag
Correct Option D - Hepatitis C-induced cirrhosis:
 Chronic hepatitis C infection is a leading cause of end-stage liver disease (ESLD), and hepatitis
C-induced cirrhosis is the most common reason for liver transplants globally. The patient's clinical
features, such as palmar erythema, Dupuytren's contracture, leukonychia, and clubbing, are consistent
with the advanced stages of cirrhosis caused by chronic hepatitis C. Liver transplantation is often
required in cases of severe liver damage and failure associated with chronic hepatitis C infection.
 
Option A - Acute liver failure:
 Acute liver failure refers to the rapid development of severe acute liver injury with impaired synthetic
function and encephalopathy.
 While acute liver failure can be a reason for liver transplantation, it is not the most common reason
globally.
Option B - Hepatocellular carcinoma:
 Hepatocellular carcinoma (HCC) is a primary liver cancer that can arise in the context of chronic liver
disease, including cirrhosis.
 While HCC can lead to liver transplantation, it is not the most common reason globally.
Option C - Alcoholic cirrhosis:
 Cirrhosis caused by chronic alcohol consumption is a significant cause of end-stage liver disease.
 However, globally, hepatitis C-induced cirrhosis is more commonly associated with liver transplants
than alcoholic cirrhosis.
Correct Option C - Fulminant hepatic failure (FHF):
 The patient's acquisition of the delta virus (HDV) infection is concerning for the development of
fulminant hepatic failure (FHF). Hepatitis D is known to cause severe and rapidly progressing liver
disease, especially in individuals co-infected with hepatitis B. Fulminant hepatic failure is characterized
by a sudden and severe impairment of liver function, leading to life-threatening complications. The delta
virus is considered the most common cause of fulminant hepatic failure, accounting for approximately
20% of cases.
 
 Chronic hepatitis and cirrhosis are potential outcomes of hepatitis D infection, but fulminant hepatic
failure is the most immediate and critical consequence in this context. Asymptomatic carrier states are
less common, especially in the setting of acute delta infection.
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Correct Option C - Serum creatinine:
 Serum creatine is not a part of the Child-pugh score
 It is measured as a part of the MELD score
 All these are a part of the Child-pugh score.
Option A - Albumin
Option B - Asterixis
Option D - Ascites
Correct Option C - Minocycline:
 Minocycline, which is commonly used in the management of acne, has been associated with
drug-induced autoimmune hepatitis. It can trigger an immune response against the liver, leading to an
exacerbation of autoimmune hepatitis in susceptible individuals. This emphasizes the importance of
monitoring liver function in patients receiving minocycline and considering alternative treatments in
those with a history of autoimmune hepatitis.
 
Option A - Penicillin: Penicillin is not typically associated with autoimmune hepatitis.
Option B - Prednisone: Prednisone is a corticosteroid and is often used in the treatment of autoimmune
 hepatitis to suppress the immune response and reduce inflammation.
Option D - Propranolol: Propranolol is a beta-blocker used primarily for cardiovascular conditions and i
s not known to cause autoimmune hepatitis.
Correct Option B - 1-c, 2-a, 3-b:
Option A  - 1-c, 2-b, 3-b
Option C - 1-b, 2-a, 3-d
Option D - 1-a, 2-c, 3-b
 
1067

Liver Cirrhosis & Complications
1. Cirrhosis is scarring (fibrosis) of the liver caused by long-term liver damage. The scar tissue prevents
the liver from working properly. Cirrhosis is sometimes called an end-stage liver disease because it
happens after other stages of damage from conditions that affect the liver, such as hepatitis. Which of
the following is the most common cause of congestive splenomegaly?
(or)
Which of the following is the most common cause of congestive splenomegaly?
A. Chronic congestive cardiac failure
C. Hepatic vein occlusion
D. Stenosis of splenic vein
2. A cirrhotic patient presented with severe hematemesis and Hb level is 6 g/dL. Which of the following
is the management of choice?
(or)
A cirrhotic patient presented with severe hematemesis and Hb level is 6 g/dL. Which of the following is
the management of choice?
A. Whole blood transfusion
B. Colloids are preferred over crystalloids
C. Normal saline infusion
D. IV fluid with diuretics
3. Percussion is a method of tapping body parts with fingers, hands, or small instruments as part of a
physical examination. It is done to determine: The size, consistency, and borders of body organs.
Which one of the following statements is TRUE regarding the clinical sign being elicited in the given
picture?
(or)
picture?
A. This test helps to detect ascites
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B. This test is for eliciting shifting dullness
C. The hand on the midline below the umbilicus will feel the vibrations in patients with ascites
D. All of the above statements are true
4. A patient with chronic liver disease, ascites and no bleeding varices presented with hematemesis
and melena. What is the next step in management?
(or)
A patient with Chronic liver disease and ascites and no bleeding varices presented in a medical
emergency. He presents with hematemesis and melena. What is the next step in management?
A. Inj. vitamin K
B. Inj. Tranexamic acid
C. FFP transfusion
D. Platelet transfusion
5. A 45 years old male patient who is a known case of acute hepatic failure presented with ascites.
Ascitic fluid analysis shows an increased serum-ascites albumin gradient (SAAG) value. Which of the
following conditions will cause an increased serum-ascites albumin gradient?
(or)
A 45 years old male patient who is a known case of acute hepatic failure presents with OPD with
Ascites. Upon paracentesis Ascitic fluid is with increased SAAG. Which of the following condition will
present this finding?
A. Tuberculosis
B. Congestive Heart Failure
6. A 48-year-old alcoholic male who is a known case of cirrhosis presents to the Emergency
department with complaints of abdominal pain, swelling, nausea, vomiting, and other difficulties. On
examination, there was redness on the palms of the hands, yellowish discolouration of skin and sclera,
and spider-like blood vessels on the skin. USG showed severe Ascites despite compliance with dietary
sodium restrictions and administration of maximum doses of 400mg of spironolactone and 160 mg of
furosemide per day. What will be the next best management for the given condition?
(or)
A 48-year-old male with cirrhosis presents with abdominal pain and swelling. USG showed severe
ascites despite the administration of maximum doses of 400mg of spironolactone and 160 mg of
A. AV shunt
B. TIPS
C. Frusemide with Low volume paracentesis
D. Distal splenorenal shunt
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7. Ascites is present when there is an accumulation of free fluid in the peritoneal cavity. Small amounts
of ascites is asymptomatic, but with larger accumulations of fluid (> 1 L), there is abdominal distension,
fullness in the fanks, shifting dullness on percussion and, when the ascites is marked, a fluid thrill/fluid
wave. Ascites in cirrhosis of the liver are due to- 1. Portal hypertension 2. Hypoalbuminaemia 3.
Inappropriate ADH secretion 4. Secondary hyper-aldosteronism
(or)
Which of the following is the cause of ascites in liver cirrhosis? 1. Portal hypertension 2.
Hypoalbuminaemia 3. Inappropriate ADH secretion 4. Secondary hyper-aldosteronism
A. 1, 2 and 3 are correct
B. 1, 2 and 4 are correct
C. 2, 3, 4 are correct
D. 1, 3 and 4 are correct
8. A 55-year-old male patient presented in the Emergency with weakness, nausea and vomiting. On
examination, there was jaundice, reduced alertness and poor concentration, progressing through
behavioural abnormalities, such as restlessness and aggressive outbursts. He was found to have
Ascites and hepatic failure on further workup. He stated that he had taken alcohol every day for the last
20 years. Which one of the following is NOT true about the Ascitic fluid on paracentesis?
(or)
Which one of the following is NOT true about ascitic fluid analysis?
A. SAAG> 1.1 is seen with portal hypertension
B. SAAG < 1.1 is seen with Nephrotic syndrome
C. Pseudo-chylous ascites is milky, contains fatand seen with hypertriglyceridemia
D. Black ascitic fluid is seen with pancreatic necrosis
9. A patient who is a known case of Decompensated Liver disease presented with easy fatigue,
jaundice, bruising, recurrent variceal bleeding and refractory ascites. His serum albumin was <2.8g/dl,
and prothrombin time >6 sec. Doctors advised him to have Liver transplantation because of progressive
hepatic encephalopathy. He was approved for Liver transplantation and was put on the national
transplant list for Liver transplantation. Which of the following is an absolute contraindication to liver
transplantation?
(or)
Which of the following is an absolute contraindication to liver transplantation?
A. Age >70
B. Portal vein thrombosis
C. Severe obesity
D. AIDS
10. Which of the following diseases can present with this given finding?
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(or)
A patient presents to OPD with marks on the skin caused by enlarged blood vessels. Examination
findings are flat or slightly raised red to purple dots on the skin that are similar to a small pimple. The
dot has red to purple lines extending from the centre (that resemble spider legs). The clinical picture is
shown in the following diagram. Identify which of the following diseases can present with this given
finding.
B. Cirrhosis of the liver
C. Pregnancy
11. A 60-year-old man with a known case of Hemochromatosis, cirrhosis, and portal hypertension was
brought to ED with altered mental status. The attendant describes that the patient has been confused
for the last 3 days, with no h/o melena or hematemesis. For chronic ascites, diet control and
spironolactone are given regularly. He had an episode of variceal bleed in the past, for which he was
put on propranolol, and no episodes have been seen since then. On examination, he is not well
oriented to time and place but oriented to person. He is afebrile, vitals are stable, but ascites, and
asterixis, are notable. His laboratory investigation shows haemoglobin of 10.1mg/dl, Creatinine of 1.4
mg.dl, and Blood urea nitrogen of 45 mg/dl. On paracentesis, clear fluid with 800 WBC (40%
neutrophils) was seen. Which of the following is a false statement regarding this condition?
(or)
A 60-year-old man with cirrhosis presented with altered mental status. On examination, ascites and
asterixis are notable. On paracentesis, clear fluid with 800 WBC (40% neutrophils) was seen. Which of
the following is incorrect regarding this condition?
A. Ascites is preceded by infection
B. Clinical features are abdominal pain, fever, leucocytosis and altered mental status
C. Ascitic fluid protein of 1 gm/dl
D. Common organisms are Gram-negative organisms
12. You're the Psychiatric intern in a ward. Your favourite consultant asks you to join him for the
morning rounds; you accept and go with him. Your consultant asks the fourth patient in 2nd-row CAGE
Quess. In which of the following conditions do you think it is used?
(or)
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In which of the following conditions do you think CAGE questions are used?
A. Alcohol Abuse
B. Depression
C. Suicidal intention
D. Coma
13. Which of the following is not true about the condition given in the diagram?
(or)
A patient presented with a history of bone and joint aches, fatigue (extreme tiredness), itchy skin, dry
eyes and mouth and pain or discomfort in the upper right side of his tummy. Which of the following is
not true about the condition given in the diagram?
A. Increase 5’- nucleotidase
B. Median age of presentation is 50 years
C. The most common cause of cholangitis in children
D. PBC is frequently associated with CREST syndrome.
14. A patient with acute liver failure shows marked confusion and gross disorientation. He is drowsy but
responds to pain and voice stimuli. Which of the following is the Antibiotic of choice to prevent the given
(or)
Which of the following is the antibiotic of choice to prevent the given in Hepatic encephalopathy?
A. Neomycin
B. Ampicillin
C. Metronidazole
D. Rifaximin
15. A 25-year-old male came to your OPD to quit alcohol consumption. He has drinks daily for the last 5
years. His consumption is 2-3 beers daily and around 8-10 beers on weekends. He never drinks &
drives and never misses his work. But he had hung over in the office after weekends. In the last few
months, he had reported a few blackouts due to binge drinking. Which laboratory tests will you perform
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on this patient to identify heavy alcohol consumption?
(or)
Which laboratory tests will you perform on this patient to identify heavy alcohol consumption?
A. Carbohydrate deficient transferrin
B. 5-nucleotidase
C. SGPT raised
D. MCHC
16. A 38-year-old heavy drinker with Hepatitis B presented in medical OPD with complaints of jaundice,
abdominal pain and 2 episodes of hematemesis. Relevant investigations were ordered and a diagnosis
of DCLD was made. Which of the following is a characteristic feature of the cirrhotic liver in this patient?
(or)
Which of the following is a characteristic feature of the cirrhotic liver in this patient?
A. High serum albumin
B. Normocytic normochromic anaemia is present
D. Low serum globulin
17. A 25-year-old male came to your OPD to quit alcohol consumption. He has drunk daily for the last 5
months, he had reported a few blackouts due to binge drinking. His LFTs were deranged. Identify which
of the following enzymes is secreted from the marked structure?
(or)
Identify which of the following enzymes is secreted from the marked structure.
A. SGOT
B. SGPT
C. GGT
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18. A lady with a history of hepatitis C infection presents with unintentional weight loss and weakness.
Examination shows jaundice, splenomegaly, and caput medusae. Which of the following tests is the
most specific for this patient's diagnosis?
(or)
A 45-year-old lady with a history of hepatitis C infection comes to the hospital because of unintentional
weight loss and weakness. He has lost 6.8-kg (15 lbs) within the last 3 months. Physical examination
shows jaundice, splenomegaly, and caput medusae. Which of the following tests is the most specific for
this patient's diagnosis?
A. Alanine aminotransferase
B. Alkaline phosphatase
C. Aspartate aminotransferase
D. Blood urea nitrogen
19. Calculate child-pugh score total bilirubin 36 , serum albumin 30g/dl, PT INR 2 and mild ascites with
no hepatic encephalopathy.
(or)
Calculate child-pugh score total bilirubin 36 , serum albumin 30g/dl, PT INR 2 and mild ascites with no
hepatic encephalopathy.
A. Class A
B. Class B
C. Class C
D. Class D
20. An obese male patient who is a known case of diabetes has presented with OPD with increased
serum ferritin levels. Upon further investigations, it is found that he is a case of Non- alcoholic fatty liver
disease. Which of the following is the most common cause of Non- alcoholic fatty liver disease?
(or)
An obese man is diagnosed with non-alcoholic fatty liver disease. Which of the following is the most
common cause of this condition?
A. Reye syndrome
B. Syndrome-X
C. Cardiac syndrome-X
D. Pregnancy
21. Which of the following signs will NOT be present in a 55-year-old male with severe refractory
ascites, jaundice, abdominal distension, lower limb edema, spider naevi, and characteristic hand
features of liver disease?
(or)
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A 55-year-old male patient was found to have severe refractory Ascites and acute hepatic failure on
workup. He also gives a history of nausea, vomiting, fatigue, easy bruising, poor mentation and
restlessness. He states that he has taken alcohol every day for the last 20 years. Examination findings
are jaundice, swollen abdomen, lower limb oedema, spider naevi etc. Hand examination showed some
characteristic features of compensated liver disease. Which of the following signs of liver cell failure you
won’t expect in this patient?
A. Paper money skin
B. Clubbing
C. Dupuytren’s contracture
D. Splinter haemorrhages
22. You're the intern in Gastro OPD. An alcoholic patient who had a history of recurrent variceal
bleeding has come to the OPD now. He now complains of severe abdominal discomfort, fatigue,
nausea and hematemesis. He also had jaundice, hepatosplenomegaly, oedema and reduced alertness.
You have read the chapter regarding liver portal hypertension and its complications and took notes last
night; the following is written in your notes. Identify the incorrect statement regarding portal
(or)
Which of the following is an incorrect statement regarding portal hypertension?
A. Massive splenomegaly is seen in Banti’s syndrome
B. Hepatic venous pressure gradient is > 10 mm Hg for clinically Significant Portal hypertension
C. Most common cause of portal hypertension is Alcoholic cirrhosis
D. Schistosomiasis is the pre-hepatic cause of portal hypertension
23. Cirrhosis is scarring (fibrosis) of the liver caused by long-term liver damage. The scar tissue
prevents the liver from working properly. Cirrhosis is sometimes called an end-stage liver disease
because it happens after other stages of damage from conditions that affect the liver, such as hepatitis.
The gross morphologic appearance of a cirrhotic liver is categorised by the size of the parenchymal
nodules: micronodular, macronodular, or mixed. It can lead to various metabolic complications in the
body. Cirrhosis can lead to the development of?
(or)
Which of the following acid-base abnormalities can be seen in cirrhosis?
A. Metabolic alkalosis, chloride responsive
B. Metabolic alkalosis, chloride non-responsive
C. Hyperchloremic metabolic acidosis
D. Hypochloremic metabolic acidosis
24. A Sengstaken-Blakemore tube is a tube used in emergency medicine to stop bleeding in your
stomach or oesophagus. The technique used to place the tube is called balloon tamponade. The
bleeding is typically caused by gastric or oesophagal varices, which are veins that have swollen from
obstructed blood flow. It is a red tube with three ports on one end and two balloons on the other. Which
of the following statement is false regarding Sengstaken Blakemore tube?
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(or)
Which of the following statements is incorrect regarding Sengstaken Blakemore tube?
A. Used to arrest acute variceal bleed
B. Gastric balloon should be inflated with 200 mL of air
C. Pressure in the oesophageal balloon is <40 mm Hg.
D. Endotracheal intubation prior to tube insertion reduces the risk of pulmonary aspiration
25. A 30 year old male presents with right upper quadrant discomfort, nausea, fatigue and vomiting. He
also had yellowish discolouration of sclera and skin and moderate hepatomegaly. He denies any
history of alcohol intake, whereas laboratory findings are contradictory with elevations of AST, ALT and
GGT accompanied by hypertriglyceridemia and hyperbilirubinemia. Lab results show deranged levels
of urea, bilirubin and PT ratio. His wife narrates that his husband is a chronic alcoholic, and to aid her
statement; she shows his previous USG reports showing fatty liver Grade 3. Which of the following
statements is incorrect regarding the diagnosis being made?
(or)
Which of the following statements is incorrect regarding the fatty liver grade 3 of this patient?
A. Liver function tests are normal in the stage of steatosis
B. Stellate cell-mediated fibrosis leads to cirrhosis
C. Direct oxidative injury occurs in the stage of hepatitis
D. Apoptosis and necrosis in the stage of hepatitis are facilitated by Transforming growth factor beta
(TGF-β)
26. Which of the following is the correct statement regarding ascites?
(or)
Ascites is a condition in which fluid collects in spaces within your abdomen. As fluid collects in the
abdomen, it can affect your lungs, kidneys, and other organs. The cause of ascites is identified based
on the history, physical examination, laboratory tests, abdominal imaging, and ascitic fluid analysis. The
diagnosis of ascites is suspected based on the patient history and physical examination and is usually
confirmed by abdominal ultrasound. Read the following statements regarding Ascites and mark the
correct statement?
A. Hemorrhagic ascites is diagnosed when RBC count > 1000/mm3
B. Spontaneous Bacterial Peritonitis is diagnosed when the Neutrophil count >500/mm3
C. Large-volume paracentesis is not indicated in SBP
D. USG can detect as little as 100 ml of peritoneal fluid
E. Norfloxacin is the DOC in SBP.
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Question 22 4
Question 26 F,F,T,T,F
Option B: Cirrhosis
 Splenomegaly is an enlargement of the spleen that often results from blood-borne infections. The red
pulp expands as neutrophils accumulate in the spleen and encroaches on the lymphoid follicles. In
congestive splenomegaly, obstruction of venous outflow from the spleen leads to an increase in the
amount of red pulp. Initially, the red pulp is congested, but over time it becomes fibrotic. The main
cause of congestive splenomegaly is cirrhosis of the liver.
Option A: Chronic congestive cardiac failure
 Heart failure — sometimes known as congestive heart failure — occurs when the heart muscle does
not pump blood as well as it should. When this happens, blood often backs up, and fluid can build up in
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 Saline may be infused IV until packed RBCs are available for transfusion.
Option C: Normal saline infusion
Option D: IV fluid with diuretics
 Intravenous (IV) fluids with loop diuretics are the mainstay for the treatment of acute decompensated
heart failure (ADHF). Activation of the renin-angiotensin system with diuresis can result in intravascular
volume depletion despite total volume overload. Diuretic resistance and acute kidney injury can quickly
ensue.
Option A: This test helps to detect ascites
The above picture shows the method of percussion for the abdominal examination.
 One technique for evaluating ascites is an assessment of shifting dullness.
 In the ascitic abdomen, gas-filled bowel loops float to the top while the ascitic fluid falls to the
dependent portion of the abdomen. As a result, percussion notes are tympanitic over the bowel loops
and dull over the surrounding fluid.
 With the patient lying on his back, map out these areas of dullness and tympany. Then, ask the
patient to roll on his side and re-percuss. The ascites and, thus, dullness shift to the side the patient is
lying on, while the tympanitic area shifts to the top.
Option B: This test is for eliciting shifting dullness
Shifting Dullness:
Option C: The hand on the midline below the umbilicus will feel the vibrations in patients with ascites
 In palpating the abdomen, one should first gently examine the abdominal wall with the fingertips. This
will demonstrate the crunching feeling of crepitus of the abdominal wall, a sign of gas or fluid within the
subcutaneous tissues. In addition, it will demonstrate any irregularities of the abdominal wall (such as
lipomas or hernias) and give some idea as to areas of tenderness.
 Deep palpation of the abdomen is performed by placing a flat hand on the abdominal wall and
applying firm, steady pressure. It may be helpful to use two-handed palpation, particularly in evaluating
a mass.
 Here the upper hand is used to exert pressure, while the lower hand is used to feel. One should start
deep palpation in the quadrant directly opposite any area of pain and carefully examine each quadrant.
At each costal margin, it is helpful to have the patient inspired deeply to aid in the palpation of the liver,
gallbladder, and spleen.
Option D: All of the above statements are true
 All statements are not true for this picture.
Option C: FFP transfusion
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 Since this patient does not have varices, the cause of hematemesis in this patient is bleeding
diathesis due to liver disease.
 Bleeding in such patients is treated with FFP in acute situations.
Option A: Inj. vitamin K
 In liver cirrhosis, the synthesis of vitamin K–dependent clotting factors is diminished because of a
decrease in hepatic mass and under these circumstances, administration of parenteral vitamin K does
not improve the clotting factor or thrombin or prothrombin time.
Option B: Inj. Tranexamic acid
 Tranexamic acid (TA) is an antifibrinolytic that may help control the bleeding in this setting, as it
showed an unquestionable benefit in other indications. TA has previously been studied in both upper
gastrointestinal haemorrhage from any causes and in liver transplantation of cirrhotic patients.
Option D: Platelet transfusion
 Studies have now found increased platelet activation in cirrhosis, resulting in thrombotic
complications. Nonetheless, patients with a platelet count less than 50,000/mm3 frequently receive
platelet transfusion under the current standards of care.
Option B: Congestive Heart Failure
 Congestive heart failure is caused by structural abnormalities of the heart, functional abnormalities,
and other triggering factors
 The serum ascites albumin gradient (SAAG), which is based on the difference between the albumin
level of serum and of ascitic fluid, may be used to assess the extent of ascites
 Ascitic fluid with increased SAAG (>1.1g/dl) is found in CHF.
Option A: Tuberculosis
 In patients with suspected TBP, ascitic fluid protein of > 25 g/L, SAAG of < 11 g/L and LDH of > 90
U/L have high sensitivity for the disease. With coexistent chronic liver disease, a lower protein level and
higher SAAG are usually not helpful, but LDH > 90 U/L is a useful parameter for screening.
Option C: Nephrotic syndrome
 Nephrotic syndrome is a kidney disorder that causes your body to pass too much protein in your urine.
 Nephrotic syndrome is usually caused by damage to the clusters of small blood vessels in your
kidneys that filter waste and excess water from your blood. The condition causes swelling, particularly
in your feet and ankles, and increases the risk of other health problems.
 Treatment for nephrotic syndrome includes treating the condition causing it and taking medications.
Nephrotic syndrome can increase your risk of infections and blood clots. Your doctor might recommend
medications and dietary changes to prevent complications.
Option D: Pancreatitis
 Pancreatitis is inflammation of the pancreas. The pancreas is a long, flat gland that sits tucked behind
the stomach in the upper abdomen. The pancreas produces enzymes that help digestion and
hormones that help regulate the way your body processes sugar (glucose)
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Pathogenesis
The presence of portal hypertension contributes to the development of ascites in patients who have cirr
hosis
1) There is an increase in intrahepatic resistance, causing increased portal pressure,
2) There is also vasodilation of the splanchnic arterial system, which in turn results in an ↑
in portal venous inflow
3) Vasodilating factors such as nitric oxide are responsible for the vasodilatory effect. Both of these ab
normalities result in increased production of splanchnic lymph.
4) These hemodynamic changes result in sodium retention by causing activation of the RAAS system 
with the development of hyperaldosteronism.
5) Increased aldosterone leading to sodium retention also contributes to the development of ascites. Fl
uid accumulation and expansion of the extracellular fluid volume, which results in the formation of perip
heral oedema and ascites.
6) Hypoalbuminemia and reduced plasma oncotic pressure also contribute to the loss of fluid from the 
vascular compartment into the peritoneal cavity. Hypoalbuminemia is due to decreased synthetic functi
on in a cirrhotic liver.
 
Option C: Pseudo-chylous ascites is milky, contains fat  and seen with hypertriglyceridemia
 Pseudo-chylous ascites is seen in TB. The fluid is milky white but does not contain fat.
 White, milky fluid indicates the presence of triglycerides in levels >200 mg/dL (and often >1000
mg/dL), which is the hallmark of chylous ascites.
 It results from the lymphatic disruption that may occur with trauma, cirrhosis, tumor, tuberculosis, or
certain congenital abnormalities.
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 This is due to hypoalbuminæmia resulting in total protein concentrations which are normal or low.
Occasionally, particularly in chronic hepatitis, however, there is marked hypergammaglobulinæmia
associated with elevations in the total serum protein
Option A: SGOT
The given picture is of hepatocytes, and the marked structure is Mitochondria:
 SGPT and SGOT are found in the cytoplasm of hepatocytes, whereas SGOT is also found in the
mitochondria of hepatocytes.
 Aspartate aminotransferase (AST) is highest in the liver but can also be present in regions such as the
heart, skeletal muscle, brain, and pancreas. AST is not specific and can be elevated due to cardiac
infarction, muscular disease, pulmonary embolism, high protein intake, and many other conditions.
Option B: SGPT
 SGPT is found in the cytoplasm of hepatocytes
 Cirrhosis is characterized by fibrosis and disruption of normal liver architecture. ALT is believed to be
more specific than AST in diagnosing hepatic pathology.
Option C: GGT
 GGT is a membrane enzyme found in hepatocytes and biliary epithelial cells.
 A gamma-glutamyl transferase (GGT) test measures the amount of GGT in the blood. GGT is an
enzyme found throughout the body, but it is mostly found in the liver. When the liver is damaged, GGT
may leak into the bloodstream. High levels of GGT in the blood may be a sign of liver disease or
damage to the bile ducts. Bile ducts are tubes that carry bile in and out of the liver. Bile is a fluid made
by the liver. It is important for digestion.
 
Option D: All of the above
 All enzymes mentioned in the options are produced from the different structures of hepatocytes
Option A: Alanine aminotransferase
 Aminotransferases are usually mildly to moderately elevated with aspartate aminotransferase (AST)
greater than alanine aminotransferase (ALT)
Option B: Alkaline phosphatase
 Alkaline phosphatase is involved in the hydrolysis of organic phosphate esters at an alkaline pH,
although its specific purpose is still unknown. Marked elevation of serum alkaline phosphatase is
usually indicative of cholestasis, while moderate elevation can be seen in all types of liver disease.
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 Endotracheal intubation prior to tube insertion reduces the risk of pulmonary aspiration.
 The tube should be passed through the mouth into the stomach.
 The gastric balloon should be inflated with 300mL of air, and gentle traction applied to compress the
gastro-oesophageal junction.
Option A: Used to arrest acute variceal bleed
 The Sengstaken-Blakemore tube is a red tube used to stop or slow bleeding from
the oesophagus and stomach.
Option C: Pressure in the oesophageal balloon is <40 mm Hg.
 Inflation of the oesophageal balloon is rarely required. If the oesophageal balloon needs to be used
because of continued bleeding, pressure should be monitored with a sphygmomanometer (to maintain
<40mmHg), and it should be deflated for about every 10 minutes to avoid oesophagal mucosal
damage.
Option D: Endotracheal intubation prior to tube insertion reduces the risk of pulmonary aspiration
 Endotracheal intubation prior to tube insertion reduces the risk of pulmonary aspiration. The tube
should be passed through the mouth into the stomach.
Option D: Apoptosis and necrosis in the stage of hepatitis is facilitated by Transforming growth factor b
eta (TGF-β)
 Alcohol also affects the gut leading to dysbiosis and increased gut permeability, delivering
pathogen-associated molecular patterns (PAMPs) such as lipopolysaccharide and bacterial DNA via
the portal vein, which stimulate immune cells, leading to the release of tumour necrosis factor-alpha
(TNF-α) and interleukin (IL)-1, IL-2 and IL-8.
 All of these cytokines have been implicated in the pathogenesis of liver fibrosis.
Option A: Liver function tests are normal in the stage of steatosis
 LFTs are usually normal in fatty liver disease. Abdominal imaging technology is used to diagnose the
disease.
 Option B: Stellate cell-mediated fibrosis leads to cirrhosis
 Activated Hepatic stellate cells transform into myofibroblast-like cells to promote fibrosis in response
to liver injury or chronic inflammation, leading to cirrhosis and hepatocellular carcinoma.
Option C: Direct oxidative injury occurs in the stage of hepatitis
 The second stage of liver disease from alcohol is alcoholic hepatitis. Alcoholic hepatitis leads to
inflammation of the liver, degeneration of liver cells, and fibrosis or the development of excessive
amounts of scar tissue in the liver.
Option C: Large volume paracenetesis is not indicated in SBP
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 Treatment of transudative ascites is based on restricting sodium intake, promoting urine output with
diuretics and, if necessary, removing ascites directly by paracentesis. Exudative ascites due to
malignancy is treated with paracentesis, but fluid replacement is generally not required. Large-volume
paracentesis should not be done. The mainstay of treatment is antibiotic therapy.
Option D: USG can detect as little as 100 ml of peritoneal fluid
 Ascites are seen as an anechoic space on ultrasound. Ultrasound can quantify the volume of
ascites and aid in the decision process for fluid drainage.
Option A: Hemorrhagic ascites is diagnosed when RBC count >1000/mm3
 Hemorrhagic ascites were defined as an ascitic fluid red blood cell (RBC) count ≥10,000/µl. We
compared each patient with 3 age- and gender-matched controls (cirrhotic patients with ascites and an
ascitic RBC count <10,000/µl)
Option B: Spontaneous Bacterial Peritonitis (SBP) is diagnosed when Neutrophil count >500/mm3
 The diagnosis of SBP is established based on positive ascitic fluid bacterial cultures and the detection
of an elevated absolute fluid polymorphonuclear neutrophil (PMN) count in the ascites (>250/mm3)
without an evident intra-abdominal surgically treatable source of infection.
Option E: Norfloxacin is the DOC in SBP.
 Ciprofloxacin/ iv cefotaxime is the drug of choice in SBP.
1096

Wilson's Disease & Hemachromatosis
1. A 40 years old male labourer by occupation presented to opd with the complaint of discolouration of
nails. He also complains of decreased appetite, fatigue and backache. He has no history of serious
illness and takes no medication. He drinks two alcoholic beverages daily and takes no medications.
The nails show a typical appearance, as shown in the image below. All are possible diagnoses in these
changes in nails except?
(or)
Which of the following is not a possible diagnosis of this patient based on nail changes?
A. Peutz-Jeghers syndrome
B. Addison disease
C. Cushing disease
D. Wilson's disease
2. A 30-year-old man comes to the physician to evaluate a progressively worsening tremor in his
hands, and multiple falls over the past 3 months. The tremor occurs both at rest and with movement.
He also reports decreased concentration and a loss of interest in his normal activities over this time. He
has no history of serious medical illness and takes no medications. He drinks two alcoholic beverages
daily and does not use illicit drugs. Vital signs are within normal limits. Physical exam shows mild
jaundice, a flapping tremor, and a broad-based gait. Aspartate aminotransferase is elevated. Which of
the following is a possible diagnosis?
(or)
A man presents with a worsening tremor in his hands, along with decreased concentration and loss of
interest. Physical exam shows mild jaundice, a flapping tremor, and a broad-based gait. Aspartate
aminotransferase is elevated. Which of the following is a possible diagnosis?
A. Rheumatic Chorea
B. Westphal variant of Huntington's disease
C. Wilson disease
D. Hallervorden Spatz disease
3. Which of the following results would usually be seen in Menke’s kinky (Steely) hair disease?
(or)
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A 7-month-old infant was brought to you with a history of hypotonia, seizures, failure to thrive & growth
retardation. He is noted to have the appearance of the characteristic sparse, fragile, kinky hair and
hypo-pigmented skin. Initial investigations revealed anaemia & neutropenia. A probable diagnosis of
Menke’s kinky (Steely) hair disease was made. Which of the following results would usually be seen in
A. Low copper levels
B. Low zinc levels
C. Low iron levels
D. Low ceruloplasmin levels
4. Which of the following conditions are associated with liver cirrhosis with portal hypertension? Cystic
fibrosis Alpha 1 antitrypsin deficiency Wilson’s disease Schistosomiasis
(or)
A 59-year-old man with a history of alcoholic cirrhosis is brought to the physician by his wife for a
1-week history of progressive abdominal distension and yellowing of the eyes. For the past month, he
has been irritable, had difficulty falling asleep, became clumsy, and fallen frequently. Two months ago,
he underwent banding for oesophagal varices after an episode of vomiting blood. His vital signs are
within normal limits. Physical examination shows jaundice, multiple bruises, pedal oedema,
gynecomastia, loss of pubic hair, and small, firm testes. There are multiple small vascular lesions on his
chest and neck that blanch with pressure. His hands are erythematous and warm. A flapping tremor is
seen when extending the forearms and wrist. Which of the following conditions are associated with liver
cirrhosis with portal hypertension? Cystic fibrosis Alpha 1 antitrypsin deficiency Wilson’s disease
Schistosomiasis
A. 1, 2, 3 only
B. 3 & 4 only
C. 1, 2, 4 only
5. A 15-year-old child presents with falling school grades and developing an abnormal posture. On
examination, dystonia and increased muscle tone are noted. Resting tremors are also noted. Slit lamp
examination shows the presence of the Kayser Fleischer ring. LFTs are elevated. Liver biopsy for
copper will be stained by which of the following stain?
(or)
Liver biopsy for copper will be stained by which of the following stains?
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A. Perl's stain
B. Rubeanic acid
C. Supravital stain
D. Schmorl’s method
6. A 22-year-old woman is evaluated for dark urine and abdominal distension. Examination shows a
low-frequency tremor in her left hand. Liver enzymes are mildly raised. Abdominal ultrasonography
shows an appearing nodular liver and an enlarged spleen. Which is the most likely diagnosis?
(or)
A 22-year-old woman is evaluated in the emergency for a 3-day history of dark urine and abdominal
distension. On examination, she has a normal mental status; icterus is present, heart and lungs are
normal. Her speech is slurred and monotonous. Examination shows a broad-based gait and a
low-frequency tremor in her left hand. Lab findings include: Hematocrit: 26 Reticulocytes: 5% Platelets:
1.3 lakhs Alk. Phos: 30 units/L ALT: 110 units/L AST: 220 units/L Total bilirubin:13mg% (Direct:4 mg)
HbsAg is positive Hepatitis ‘A’&’C’ are negative. The urine drug screen is negative. Abdominal
ultrasonography shows a nodular appearing liver and an enlarged spleen. Which is the most likely
A. Acetaminophen intoxication
B. Acute viral hepatitis
C. Primary biliary cirrhosis
D. Wilson’s disease
7. A 40-year-old male chronic alcoholic presented with complaints of nausea and vomiting for the past 3
days. He also complained of right upper quadrant discomfort. Liver function tests revealed elevated
levels of serum AST & ALT. Histopathological examination showed eosinophilic deposits in
hepatocytes, as shown below. This characteristic histopathologic feature can be seen in all of the
following conditions except?
(or)
A man complained of right upper quadrant discomfort. With elevated levels of serum AST & ALT.
Histopathological examination showed eosinophilic deposits in hepatocytes, as shown below. In which
of the following conditions this histopathologic feature is not seen?
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B. Indian childhood cirrhosis
D. Hepatitis E
8. A 46-year-old female presented with progressive pain and stiffness in her hands. Her skin is very
sensitive to sunlight. She has diabetes mellitus controlled with insulin. A diagnosis of is made. Which of
the following features are not seen in Hemochromatosis?
(or)
A 46-year-old female presented to you with complaints of fatigue, progressive pain, and stiffness in her
hands for the past 3 months. She used to play tennis but stopped 1 month ago because of difficulties
holding the racket and her skin becoming “very sensitive to sunlight. She has diabetes mellitus
controlled with insulin. She does not smoke or drink alcohol. Vital signs are within normal limits. Both
hands' second and third metacarpophalangeal joints are tender to palpation, and the range of motion is
limited. Hemochromatosis is diagnosed in this patient. All of the following features can be seen in such
patients except:
A. CNS features
B. Bronze Pancreas
C. Hyperpigmentation
9. A 28-year-old male presented with complaints of 2 episodes of hematemesis associated with right
upper quadrant pain. He has no significant past medical history. Direct visualization via upper
endoscopy showed blood clots exiting the biliary tract, confirming the hemobilia diagnosis. Which of the
following is the most common cause of the above diagnosis?
(or)
A 28-year-old male presented with complaints of 2 episodes of hematemesis. Direct visualization via
upper endoscopy showed blood clots exiting the biliary tract, confirming the hemobilia diagnosis. Which
of the following is the most common cause of the above diagnosis?
A. Trauma
B. Hemangioma
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C. Rupture of hepatic artery aneurysm
D. Hepatitis
10. A 44-year-old male presented to you with a history of abdominal swelling. Over the last year, his
family has also noticed his speech becoming slower. The patient does not smoke or drink alcohol. He
takes no medications. Examination showed scleral icterus and some drooling. He is noted to have
features of dysarthria & asymmetrical tremors. The liver is palpated 2 to 3 cm below the right costal
margin, and the spleen is palpated 1 to 2 cm below the left costal margin. Slit-lamp examination
showed Kayser Fleischer's ring. Which of the following drug is not useful in such patients?
(or)
Which of the following drugs is not useful in Wilson's disease?
A. Trientine
B. Calcium
C. Penicillamine
D. Zinc
11. A 15-year-old child has presented to you with a history of dystonia and poor school grades. His
temperature is 37°C (98.6°F), his pulse is 70 beats/min, and his blood pressure is 120/80 mmHg. He is
alert and oriented to person, place, and time. On examination, he is noticed to have slurred speech,
tremors of hands, scleral icterus, abdominal swelling and an ataxic gait. The slit examination is shown
below. Which is the initial investigation recommended for the patient?
(or)
The slit examination shows Kayser Fleischer's ring. Which is the initial investigation recommended for
the patient?
A. Serum ceruloplasmin
B. Serum copper
C. 24-hour urinary copper
D. Liver biopsy
12. A 23-year-old woman comes to the emergency department complaining of tremors in her hands
and slurred speech for the past four months. When he wakes up in the morning, his pillow is soaked in
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Page 6
saliva. His vital signs are within normal limits. Examination shows scleral icterus and a broad-based
gait. Kayser-Fleischer's ring is noticed in his eye. He is diagnosed to have Wilson’s disease. Mark the
incorrect statement regarding Leipzig criteria used in Wilson's disease.
(or)
Which of the following is incorrect regarding Leipzig criteria?
A. Mutational analysis of ATP 7B gene
B. Family history of the disease
C. Total score > 4-Diagnosis is established
D. Coombs negative hemolytic anaemia
Option D: Wilson’s disease
 In patients with Wilson's disease, the lunula of the nail takes on a blue colouration called the azure
lunula.
 Excessive fluoride ingestion can turn nails brown or black. Hepatolenticular degeneration in Wilson’s
disease leads to bluish discolouration of the lanula or base of fingernails. In Wilson's disease, the
discolouration is most intense in the base and fades out proximally.
Systemic
Dermatological
Option A: Peutz-Jeghers syndrome.
1102

Hereditary Hyperbilirubinemia & Hepatic
Encephalopathy
1. What is the reason for the increased bilirubin level in prehepatic jaundice?
(or)
What is the reason for the increased bilirubin level in prehepatic jaundice?
A. Decreased bilirubin production in the liver.
B. Liver dysfunction impairs bilirubin processing.
C. Bilirubin cannot be excreted from the liver.
D. Increased hemolysis of red blood cells.
2. A twenty-six years old female presents to your clinic with complaints of abdominal pain, generalized
weakness, and yellow discolouration of skin and eyes. She says she has had these symptoms for the
past week, and they have been increasing in intensity. Physical examinations and testing are
performed. Her urine analysis shows the absence of urobilinogen. Which of the following could be the
possible cause of this patient’s condition?
(or)
A woman presents with abdominal pain, generalized weakness, and yellow discoloration of skin and
eyes. Her urine analysis shows the absence of urobilinogen. Which of the following could be the
A. Hemolysis
B. Hepatitis
C. Liver failure
D. Post hepatic obstruction
3. What is the likely diagnosis for a woman presenting with nausea, abdominal pain, positive jaundice
on physical examination, alkaline phosphatase of 550 IU/L, aspartate aminotransferase of 75 IU/L, total
serum bilirubin of 6.5 mg/dL, and conjugated bilirubin of 4.3 mg/dL?
(or)
A forty-year-old female presents to your clinic with a complaint of abdominal pain. She has had this
pain for the past week. She also has been feeling nauseous. She says she isn't bothered about the
pain, but her family forced her to visit the doctor as they say she's looking pale and yellow. Her physical
examination is positive for jaundice. Multiple tests are performed. Her liver enzymes are; alkaline
phosphatase 550 iu/l and aspartate aminotransferase 75 iu/l. Total serum bilirubin is 6.5mg/dl, and
conjugated bilirubin is 4.3 mg/dl. What is the diagnosis of this patient?
A. Dubin Johnson syndrome
B. Obstructive jaundice
C. Viral hepatitis
D. Cholelithiasis
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4. A forty-two years old woman presented to your clinic with a history of recurrent jaundice. She also
complains of losing her appetite despite not feeling nauseous. On examination, she is icteric. Routine
liver function tests reveal elevated levels of serum bilirubin. Her liver enzymes are within the normal
range. Prothrombin time is also normal. Serum bilirubin is predominantly unconjugated. Which of the
(or)
What is the most likely diagnosis for a woman presenting with a history of recurrent jaundice, elevated
serum bilirubin, normal liver enzymes, and predominantly unconjugated bilirubin?
A. Gilbert's Syndrome
B. Dubin Johnson syndrome
C. Rotor syndrome
D. Hepatocellular necrosis
5. A young male wanting to join the army is found to have mild jaundice during his medical fitness
examinations. He comes to your clinic for further evaluation. The patient has no complaints except for
passing dark-coloured urine even though he drinks plenty of water. Further testing revealed a mild
increase in his serum total bilirubin levels, with an increase in both conjugated and unconjugated
bilirubin levels. His gallbladder can be visualized on oral cholecystography. A liver biopsy is taken,
which shows no pigmentation. What is the diagnosis of this patient?
(or)
What is the likely diagnosis for a young male with mild jaundice, mild increase in serum total bilirubin
levels, increase in both conjugated and unconjugated bilirubin levels, and a liver biopsy showing no
pigmentation?
A. Rotor Syndrome
B. Dubin Johnson’s Syndrome
C. Crigler-Najjar Syndrome
D. Gilbert Syndrome
6. A forty-year-old male presents to your clinic with a complaint of fever and fatigue. He is a smoker and
has smoked one pack daily for the past twenty years. But currently, he has a complete aversion to
smoking. A physical examination is performed, which is positive for icterus. The liver is tender and
enlarged. Liver function tests are shown below. Total bilirubin 17.5 mg/dl Direct bilirubin 5.5 mg/dl
Aspartate aminotransferase 700 IU/l Alanine aminotransferase 900 IU/l Which investigations are
required to rule out acute viral hepatitis?
(or)
A man presents with fever and fatigue. Examination shows icterus. The liver is tender and enlarged.
Liver function tests show markedly raised aminotransferases. Which investigations are required to rule
out acute viral hepatitis?
Total bilirubin 17.5 mg/dl
Direct bilirubin 5.5 mg/dl
Aspartate aminotransferase 700 IU/l
Alanine aminotransferase 900 IU/l
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A. HBsAg, IgM anti HBc, Anti HCV, Anti HEV
B. Anti HAV, HBsAg, IgM Anti HBc, Anti HCV
C. HBAg, IgM anti HBc, Anti HDV, Anti HCV, Anti HEV
D. Anti HAV, IgM anti HBc, ANti HCV, Anti HEV
7. A thirty years old G2P1L1 female presents to your clinic with the complaint of intermittent jaundice.
He says she has had jaundice for the past four years, and it comes and goes on its own. She had
episodes of jaundice during each pregnancy, which used to start in the late second trimester. In
between pregnancies, there was minimal or no jaundice. Initial investigations show conjugated
hyperbilirubinemia. Further investigations reveal that she has an MRP2 transporter defect. Which of the
(or)
A 31-year-old G2P1L1 female presents with intermittent jaundice. She had episodes of jaundice during
each pregnancy. Investigations show conjugated hyperbilirubinemia and an MRP2 transporter defect.
Which of the following is the most likely diagnosis?
A. Menke’s disease
C. Familial intrahepatic cholestasis
D. Benign recurrent intrahepatic cholestasis
8. A sixty years old woman comes with recurrent epigastric pain associated with vomiting and
abdominal distention. CT-abdomen findings revealed impacted gallstone suggestive of . At which
location is the obstruction present in Bouveret syndrome?
(or)
A sixty years old woman comes to your clinic with complaints of recurrent epigastric pain for more than
6 months. Her abdominal pain had worsened over a period of 4 days and was associated with vomiting
and abdominal distention. Initial investigations are done. CT-abdomen findings revealed impacted
gallstone suggestive of Bouveret syndrome. In Bouveret syndrome, at which location is the
obstruction?
A. Pylorus
B. Jejunum
C. Terminal ileum
D. Ileocaecal valve
9. Which of the following conditions is associated with conjugated hyperbilirubinemia?
(or)
A sixty-four years old male presents to your clinic with a history of fatigue and weight loss. His
symptoms have progressively worsened. He says he experienced these symptoms a long time ago
when he was diagnosed with the Hepatitis virus. Examination findings are positive for jaundice.
Laboratory findings show an elevated total bilirubin level with a predominance of conjugated bilirubin.
Which of the following conditions is associated with conjugated hyperbilirubinemia?
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A. Cryoglobulinemia associated with hepatitis C
B. History of gout
C. Spherocytes in peripheral smear
D. Gallstone
10. A fifty years old male presents to your clinic with the complaint of abdominal pain. The patient leads
a sedentary lifestyle but does not smoke or drink alcohol. He likes to eat out, and his diet consists of
fried foods daily. On examination, his blood pressure is 140/90 mmHg, and his BMI is 32. Abdominal
examination shows an enlarged, non-tender liver. The liver span, on light percussion, is 20 cm. An
abdominal ultrasound is performed, which shows that his liver echogenicity is more than that of the
renal cortex and spleen. What is the diagnosis for this patient?
(or)
A patient presents with abdominal pain. His BMI is 32. Abdominal examination shows an enlarged,
non-tender liver. Ultrasound shows increased liver echogenicity. What is the diagnosis of this patient?
A. Marasmus
B. Metabolic Syndrome
D. Nutmeg liver
11. A 74 year old male is brought to the emergency department by his son. The patient is somnolent
but responds to voice commands. His son states that his father has been acting weird lately, and his
behaviour has been very inappropriate. He gets aggressive occasionally and is tired and lethargic the
rest of the while. Since then, he has become excessively drowsy now. He is a chronic patient of
hepatitis C. In which grade of disease has the patient presented?
(or)
In which grade of disease has a 73-year-old male, presenting with drowsiness, lethargy, somnolence,
responsiveness to voice commands, and inappropriate behavior, likely presented considering his
chronic hepatitis C condition?
A. Grade 4
B. Grade 3
C. Grade 2
D. Grade 1
12. A seventy-five years old male is brought to the emergency department in a state of
semi-consciousness. His son states that he is a chronic patient of Hepatitis C and has been
non-compliant with medications and his doctor appointment. On physical examination, he has signs of
ascites, jaundice, pedal oedema and gynecomastia. Multiple red spots are noted on his abdomen with
spider-like projections. The patient's son overhears some doctors talking about the Milan Criteria while
discussing his father and wants to know what it is. What are the Milan Criteria used for?
(or)
In which of the following conditions the Milan Criteria are used?
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A. Liver transplantation
B. Gastroesophageal reflux disease staging
C. Cirrhosis staging
D. Hepatic encephalopathy staging
13. A young female is brought to the emergency department in a semi-conscious, confused state. Her
parents state that she has had a few episodes of bloody vomiting and has felt nauseous and tired for
some time. After further probing, the parents cryingly admitted that she had made a suicide attempt and
ingested multiple tablets of acetaminophen. Given the patient's symptoms, which of the following is the
least likely to aggravate the patient's condition?
(or)
Which of the following factors is least likely to aggravate encephalopathy in a young female who has
made a suicide attempt by ingesting multiple tablets of acetaminophen and is currently in a
semi-conscious, confused state?
B. Anemia
C. Hypothyroidism
D. Barbiturates
14. In which grade of hepatic encephalopathy has a 75-year-old male with alcoholic liver disease
presented, exhibiting symptoms of lethargy, disorientation, flapping tremors in extended hands, and
hypoactive deep tendon reflexes?
(or)
A seventy-four years old male is brought to your clinic. His son states that his father has been acting
weird lately, and his behaviour has been very inappropriate. He gets aggressive from time to time, and
he is tired and lethargic the rest of the while. He was diagnosed with alcoholic liver disease by his
previous doctor, but he refused to go back to him because he told him to quit drinking. On examination,
the patient is disoriented and has tremors in his hand, which, when extended, resemble a bird flapping
its wings. His deep tendon reflexes are hypoactive. In which grade of disease has the patient
presented?
A. Grade I
B. Grade IV
C. Grade III
D. Grade II
15. A seventy-eight years old patient is brought to the emergency department by his daughter in a
semi-conscious state. His daughter states that she found him like this after returning from work. The
patient is a known case of hepatitis C and has not been feeling well for the past few days. He is only
responsive to painful stimuli. The daughter states that he has also been having problems with
concentration and seems to be confused for the past few days. Examinations and tests are performed
to assess the patient. He is admitted for further care. A brain biopsy is performed, and the findings are
shown below. What is the diagnosis of this patient?
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(or)
The diagnosis for a 68-year-old patient with hepatitis C, presenting in a semi-conscious state, only
responsive to painful stimuli, and brain biopsy revealing swollen astrocytes what is the diagnosis?
B. Alzheimer's
D. Binswanger disease
16. A young female is brought as she ingested multiple tablets of acetaminophen. She has become
completely unresponsive now. Which of the following is not advocated in the management of this
patient?
(or)
A young female is brought unconscious to the emergency department. She is unresponsive even to
pain stimuli. Her parents state that she has had a few episodes of bloody vomiting and has felt
nauseous and tired for some time. After further probing, the parents cryingly admitted that she had
made a suicide attempt and ingested multiple tablets of acetaminophen a few days back. Her condition
has deteriorated over time, and she has now become completely unresponsive. Which of the following
is not advocated in the management of this patient?
A. Oral Lactulose
B. Intravenous hydration
C. Protein diet restriction
D. If tests for blood in stool are positive, then give colonic washout
17. A twenty-five years old male is admitted to your hospital with Hepatitis A infection. His condition
shows rapid deterioration, and he is shifted to the intensive care unit for acute liver failure. The patient
now has an altered sleep pattern and changes in behaviour. He is mildly confused but responds to
voice stimuli. All of the following drugs are used to treat this condition except?
(or)
Which of the following drugs cannot be used to treat a 25-year-old male with acute liver failure, altered
sleep pattern, changes in behavior, and mild confusion but responds to voice stimuli?
A. L-ornithine L-aspartate (LOLA)
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Page 7
B. Rifaximin
C. Lactulose
D. Phenobarbitone
18. In a case of metabolic encephalopathy, which one of the following manifestations would be seen in
(or)
A young female is admitted to your hospital for acute liver failure. She was diagnosed with viral
hepatitis, and her symptoms have worsened. She now shows significant confusion and gross
disorientation. She is drowsy but responds to voice and pain stimuli. If this is a case of metabolic
encephalopathy, which one of the following manifestations would be seen in this patient?
A. Motor aphasia
B. Sensory aphasia
C. Conduction aphasia
D. Anomic aphasia
19. A sixty-two years old male is brought to the emergency department with complaints of marked
confusion and gross disorientation. He is a known case of Hepatitis C. The patient's family states that
his condition has worsened over time, and on their last hospital visit, they were informed that he was
going into liver failure. The patient is drowsy but responds to pain and voice stimuli. Which of the
following is usually the earliest symptom of the given condition?
(or)
Which of the following is usually the earliest symptom of Hepatic Encephalopathy?
A. Change in sleep patterns
C. Electroencephalogram (EEG) changes
D. Disorientation
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Here are four options to consider:
Option 1: Decreased bilirubin production in the liver. Explanation: This is not the correct answer. In pre
hepatic jaundice, the liver is functioning normally in terms of bilirubin production. The issue is primarily 
due to an increased breakdown of red blood cells, leading to an excess of unconjugated bilirubin.
Option 2: Liver dysfunction impairs bilirubin processing. Explanation: This is not the correct answer. In 
prehepatic jaundice, the liver itself is not dysfunctional; it's the excessive breakdown of red blood cells t
hat results in increased unconjugated bilirubin levels. The liver's ability to process bilirubin is not impair
ed.
Option 3: Bilirubin cannot be excreted from the liver. Explanation: This is not the correct answer. In pre
hepatic jaundice, bilirubin can be produced and processed by the liver. However, the problem lies in th
e increased production of unconjugated bilirubin due to hemolysis, and this bilirubin cannot be efficientl
y excreted by the liver.
Option 4: Increased hemolysis of red blood cells. Explanation: This is the correct answer. In prehepatic
 jaundice, the main reason for increased bilirubin levels is the increased breakdown of red blood cells (
hemolysis), which leads to an excess of unconjugated bilirubin in the bloodstream. The liver is not the 
primary cause of the problem, as it is still capable of processing bilirubin, but it cannot keep up with the
 excessive production due to hemolysis.
So, the correct answer is option 4: Increased hemolysis of red blood cells.
Option D: Post hepatic obstruction
 Following secretion into bile, conjugated bilirubin reaches the duodenum and passes down the
gastrointestinal tract without reabsorption by the intestinal mucosa.
 Urobilinogen is formed by bacterial metabolism in the gut from conjugated bilirubin.
1122

Budd Chiari Syndrome & Pancreatitis
1. A forty-five years old male is brought to the emergency department with complaints of unbearable
abdominal pain for the past 24 hours associated with 3 episodes of vomiting. He also states that he has
had a fever for the past 2 days and felt nauseous the whole time. Examinations and laboratory
investigations were performed. Blood reports show elevated serum lipase. An abdominal ultrasound is
performed, which indicates the presence of acute pancreatitis. Which of the following is not a cause of
acute pancreatitis?
(or)
Which of the following is not a cause of acute pancreatitis?
A. Hypocalcaemia
B. Valproic acid therapy
C. Biliary tract disease
D. Blunt trauma
2. A forty-eight years old male patient presents to the emergency department with a sudden loss of
vision and acute abdominal pain, mainly around the epigastric area radiating to the back. He has had a
history of alcohol abuse for the past twenty years. Physical examination is performed, and he is found
to be tachypnoeic and tachycardic. Laboratory investigations show elevated serum amylase and
leucocytes. Given the patient's condition, what is the cause of this patient's vision loss?
(or)
A Man presents with a sudden loss of vision and acute abdominal pain. He has had a history of alcohol
abuse. He has tachypnea and tachycardia. Labs show elevated serum amylase and leukocytes. What
is the cause of this patient's vision loss?
A. Purtscher retinopathy
B. Hyperglycaemia
C. Hypoxia
D. Central Retinal Vein Occlusion
3. A sixty-one years old male presents to your clinic with a history of loose stools for five years. He says
he has passed 3–4 semisolid stools daily. The stools are oily in nature without mucus or blood. He also
has associated dyspeptic symptoms, but there have been no episodes of frank abdominal pain. There
is no significant loss of weight or anorexia. He has been a known case of diabetes mellitus for the past
15 years and chronic pulmonary obstructive disease for the past 5 years. He is a reformed smoker and
drinks alcohol occasionally. There is no prior history of abdominal trauma or surgery. His clinical
examination is unremarkable. Which of the following diagnostic test is most suitable for this patient?
(or)
A man presents with loose stools that are oily in nature without mucus or blood. He is a reformed
smoker and drinks alcohol occasionally. His clinical examination is unremarkable. Which of the
following diagnostic tests is most suitable for this patient?
A. Schilling test
B. Serum lipase
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C. Serum amylase
D. Fecal elastase level
4. A forty-five years old male is brought to the emergency department with the complaint of unbearable
abdominal pain for the past 24 hours. The pain is associated with fever and three episodes of vomiting.
His medical history is positive for diabetes mellitus. He does not give any history of abdominal trauma.
An abdominal ultrasound is performed, which shows the presence of acute pancreatitis. Which of the
following will help you differentiate acute pancreatitis from diabetic ketoacidosis?
(or)
Which of the following will help you differentiate acute pancreatitis from diabetic ketoacidosis?
A. Serum amylase
C. Decreased glucagon
D. Hyperglycemia
5. A forty-five years old male is brought to the emergency department with the complaint of unbearable
abdominal pain for the past 24 hours. He had a party last night where he consumed a lot of alcohol. He
has had several episodes of vomiting since last night and feels like he has a fever. Physical
examinations and investigations are performed. CT scan of the abdomen is suggestive of acute
pancreatitis. Which of the following is not included in the criteria to diagnose acute pancreatitis?
(or)
Which of the following is not included in the criteria to diagnose acute pancreatitis?
A. Threefold or greater elevation in serum lipase and amylase
B. Typical abdominal pain in the epigastrium that may radiate to the back
C. Confirmatory findings of acute pancreatitis on cross-sectional abdominal imaging
D. Core temperature greater than 38°C
6. A female presents with severe abdominal pain. Examination shows jaundice, tender
hepatosplenomegaly, and mild ascites. What is the most likely diagnosis for this patient?
(or)
A twenty-five years old female presents to the emergency department with the complaint of severe
abdominal pain. The pain is on the upper right side and is not associated with nausea or vomiting.
Examination findings include jaundice, tender hepatosplenomegaly and mild ascites. She does not
have a history of any illness or trauma. What is the probable diagnosis for this patient?
A. Budd –Chiari syndrome
B. Acute Viral hepatitis
C. Acute Pancreatitis
D. Acute cholecystitis
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7. A young female presents to the emergency department with complaints of abdominal distention and
swelling in her legs. She has had these symptoms for the past 2 weeks, which have gradually
increased in intensity. She also states that she hasn’t been feeling hungry and doesn’t feel like eating
anything. She has lost some weight because of that. Physical examination reveals that she is also
jaundiced. You diagnose this as a case of Budd Chiari syndrome. The following is the least likely
manifestation in an acute case of Budd Chiari syndrome?
(or)
Which of the following is the least likely manifestation in an acute case of Budd Chiari syndrome?
A. Enlarged tender liver
B. Ascites
C. Jaundice
D. Venous collaterals
8. In the case of Budd Chiari syndrome, which vessel is most likely to be obstructed?
(or)
A young female is brought to the emergency department by her parents. She complains that her
stomach and legs have been swollen for the past two weeks. Her parents state that even though her
stomach has swollen, she hasn't been eating properly for the past couple of months and has lost
considerable weight. They also say that her eyes seem to be of a yellowish colour even though she has
no issues with her eyesight. An abdominal CT scan was performed, which showed a large amount of
abdominal ascites, mild hepatosplenomegaly, and retroperitoneal lymphadenopathy. If this is a case of
Budd Chiari syndrome, which vessel is most likely to be obstructed?
A. Inferior vena cava
B. Hepatic artery
C. Larger hepatic veins
D. Portal vein
9. A twenty-four years old female comes to your clinic with a history of swelling of her legs and stomach
and yellowing of her eyes and nails. She associated this with her sedentary lifestyle and only showed
up to the clinic because now she has started to develop pain in the right side of her abdomen. The only
medicines she takes are oral contraceptive pills. Her physical examination reveals an enlarged liver
and jaundice. Further investigations and blood testing were performed, and you made a provisional
diagnosis of Budd Chiari Syndrome. The concerned patient wants to know the cause of her disease.
What is the cause of the disease in this patient?
(or)
A diagnosis of Budd Chiari Syndrome was made. What is the most likely cause of disease in this
patient?
A. Polycythaemia
B. Oral contraceptive pills
D. Hepatocellular carcinoma
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10. A sixteen years old male is brought to your clinic by her mother for recurrent episodes of severe
abdominal pain. The pain was associated with fever and vomiting and resolved on its own after 2 days.
He has had 2-3 such episodes over the last year. He was recently diagnosed with type 1 diabetes, but
the pain episodes were not associated with hyperglycemia. After examinations and laboratory testing, a
diagnosis of hereditary pancreatitis is made. Which of the following is not true regarding hereditary
pancreatitis?
(or)
Which of the following is not true regarding hereditary pancreatitis?
A. Mutation of cationic trypsinogen gene
B. Autosomal recessive inheritance
C. Hereditary pancreatitis is associated with chromosome 7
D. Increased risk of pancreatic cancer
11. All of the following are used for routine medical treatment of acute pancreatitis except?
(or)
A forty-eight years old male presents to the emergency department with acute abdominal pain. Pain is
in the epigastric area and radiates to the back. He has 2-3 alcoholic drinks daily and yesterday had a
party with his friends, in which he had a lot of alcohol. He is nauseous and has had a few episodes of
vomiting since morning. On examination, he is tachypnoeic and tachycardic. Lab investigations show
an elevated leucocyte count and elevated serum amylase and lipase. All of the following are used for
routine medical treatment of the condition except?
A. Ringers Lactate
B. Normal Saline
C. IV opiates
D. Gabexate mesilate
12. A diagnosis of chronic pancreatitis is made. Which of the following vitamins is most likely deficient
(or)
A fifty-seven years old man presents to your clinic with the complaint of weight loss and abdominal
pain. The patient states that the abdominal pain has been present for a long time but comes and goes
on its own. If he has a sudden acute pain attack, he leans forward, and the pain gets slightly better. He
also complains of having greasy stools that have a very bad odour. Work up of the patient reveals a
diagnosis of chronic pancreatitis. In patients with chronic pancreatitis, deficiency of which of the
following vitamins is most likely?
B. Vitamin B2 (riboflavin)
C. Vitamin B6 (pyridoxine)
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13. A forty year old male is brought to the emergency department by his neighbour. The patient
complains of severe abdominal pain, which radiates to the back. The neighbour states that the patient
is an alcoholic. The patient is admitted with the suspicion of acute pancreatitis. A few hours after
admission, the patient starts vomiting and feels dizzy while standing. On examination, he has severe
tenderness in the right upper quadrant of the abdomen and decreased bowel sounds. A bluish
discolouration is noticed around his umbilicus. Further examinations would show which of the following
findings.
(or)
A patient with acute pancreatitis suddenly starts vomiting and feels dizzy while standing a few hours
after admission. He has decreased bowel sounds and a bluish discoloration around his umbilicus.
Which of the following findings can be seen in this patient?
A. A CT of the abdomen is likely to show severe necrotizing pancreatitis
B. Abdominal plain film is likely to show pancreatic calcification
C. Concomitant appendicitis
D. A pancreatico-aortic fistula
Option A: Hypocalcaemia
 Inflammation of the pancreas over a short period of time is known as acute pancreatitis.
 Acute pancreatitis commonly presents with fever, abdominal pain, nausea and vomiting.
 Elevated levels of serum pancreatic enzymes are used to diagnose acute pancreatitis.
1140

Alcoholic Hepatitis,Hepatorenal Syndrome
1. Maximum dose of albumin that can be used to treat patients with hepatorenal syndrome.
A. 50 gm
B. 100 gm
C. 25 gm
D. 150 gm
2. Which of the following graphs correctly depicts chronic liver disease?
A.
B.
C.
D.
3. What is the screening test for Wilson's disease?
A. MRI head
B. Liver biopsy
C. 24-hr urinary copper
D. LFT
4. A 40-year-old male was brought to the emergency department with blood oozing from his mouth. He
was hemodynamically unstable and had a history of binge alcohol drinking. He revealed that he had
constipation for a long time accompanied by occasional discomfort and fresh blood in stools during
defecation. Clinical examination showed positive Puddle sign. Identify the diagnosis in this patient and
mark the right option with relevant statements. a) Investigation of choice is a CT scan of the abdomen
b) Hepatic venous pressure gradient(HVPG) >5mmHg c) Overall the most common cause of
hematemesis. d) Splenomegaly is the earliest finding. e) Esophageal varices occur when HVPG is
>7mm Hg. f) Esophageal varices are managed by reducing the blood pressure with propranolol.
(or)
Identify the diagnosis in a patient with Hematemesis, hematochezia, positive puddles sign and mark the
option with the right statements. a) Investigation of choice is a CT scan of the abdomen b) Hepatic
venous pressure gradient(HVPG) >5mmHg c) Overall the most common cause of hematemesis. d)
Splenomegaly is the earliest finding. e) Esophageal varices occur when HVPG is >7mm Hg. f)
Esophageal varices are managed by reducing the blood pressure with propranolol.
A. b,d,f
B. a,d,e
C. a,c,e
D. b,c,f
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5. Match the following sets of drugs used in the treatment of Wilson's disease accordingly. SET 1 1)
Zinc acetate 2) Trientine 3) Tetrathiomolybdate SET 2 a) CNS manifestations b) Compensated
cirrhosis c) Hepatic Decompensation
A. 1-c,2-b,3-a
D. 1-a,2-c,3-b
6. Match the following regarding Iron metabolism. 1) Divalent metal transporter a) Importer of iron from
enterocyte into circulation. 2) Duodenal cyt B b) Converts Fe2+ into Fe3+ 3) Ferroportin c) Transport of
iron into enterocytes 4) Ceruloplasmin d) The storage form of iron. 5) Transferrin e) Reduction of Fe3+
to Fe2+ 6) Ferritin f) Transport of Fe3+ to bone marrow.
1) Divalent metal transporter a) Importer of iron from enterocyte into circulation.
2) Duodenal cyt B b) Converts Fe2+ into Fe3+
3) Ferroportin c) Transport of iron into enterocytes
4) Ceruloplasmin d) The storage form of iron.
5) Transferrin e) Reduction of Fe3+ to Fe2+
6) Ferritin f) Transport of Fe3+ to bone marrow.
A. 1-c,2-e,3-a,4-b,5-f,6-d
B. 1-a,2-d,3-b,4-e,5-c,6-f
C. 1-f,2-c,3-e,4-b,5-d,6-a
D. 1-e,2-c,3-a,4-b,5-d,6-f
7. Most common gene mutation is involved in hereditary hemochromatosis?
A. HFE gene mutation
B. Hemojuvelin mutation
C. Transferrin mutation
D. Ferroportin mutation
8. Which of the following is the most common cause of acquired hemochromatosis?
A. Cirrhosis
B. Thalassemia
C. NASH
D. Hepatitis C
9. Match the following causes of portal hypertension with their respective affected anatomical regions.
1) Pre-Hepatic a) Schistosomiasis 2) Hepatic-presinusoidal b) Constrictive pericarditis 3)
Hepatic-sinusoidal c) Banti syndrome 4) Hepatic-post sinusoidal d) Radiation 5) Post-Hepatic e)
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Cirrhosis
1) Pre-Hepatic a) Schistosomiasis
2) Hepatic-presinusoidal b) Constrictive pericarditis
3) Hepatic-sinusoidal c) Banti syndrome
4) Hepatic-post sinusoidal d) Radiation
5) Post-Hepatic e) Cirrhosis
B. 1-a,2-d,3-e,4-c,5-b
C. 1-c,2-d,3-a,4-e,5-b
D. 1-c,2-a,3-e,4-d,5-b
10. A 40-year-old female patient came to the outpatient department with complaints of irregular periods,
breathing difficulty, tiredness, and increased dark pigmentation of the skin for the past three months.
She is a known case of diabetes type 1 for the past 5 years. She admitted that she recently
experiences pain in the joints of her hand and occasional palpitations. Clinical examination showed
hepatomegaly. Blood investigations revealed increased Sr. iron and TIBC. Identify diagnosis and mark
the option with the appropriate statements. a) The most common symptom is skin pigmentation b) Liver
biopsy is the investigation of choice c) The most common cause of death is liver failure d) The most
common organ involved is the liver e) Jejunum is the site for this mineral absorption f) It is associated
with hypogonadotropic hypogonadism
(or)
Identify the diagnosis in a female patient with irregular periods, palpitations, dyspnea, dark skin
pigmentation, hepatomegaly, and increased values of serum iron and TIBC. Pick the option with
appropriate statements. a) The most common symptom is skin pigmentation b) Liver biopsy is the
investigation of choice c) The most common cause of death is liver failure d) The most common organ
involved is the liver e) Jejunum is the site for this mineral absorption f) It is associated with
hypogonadotropic hypogonadism
A. b,d,f
B. a,d,e
C. a,c,e
D. b,c,f
11. Which of the following is not a parameter used in PELD score?
A. Age
B. Albumin
C. Serum creatine
D. INR
12. Match the following clinical scenarios in portal hypertension with their respective choice of
treatment. SET 1 SET 2 a) Non-bleeding esophageal varices 1) Peritoneal venous shunt b) Bleeding
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esophageal varices 2) Esophageal variceal bleeding/Nadolol c) Recurrent bleed with Class A
child-pugh score 3) TIPS d) Recurrent bleed with class B and C Child-pugh score 4) I.V octreotide and
sclerotherapy with Ethanolamine oleate
SET 1 SET 2
a) Non-bleeding esophageal varices 1) Peritoneal venous shunt
b) Bleeding esophageal varices 2) Esophageal variceal bleeding/Nadolol
c) Recurrent bleed with Class A child-pugh score 3) TIPS
d) Recurrent bleed with class B and C Child-pugh score 4) I.V octreotide and sclerotherapy with Ethanolamine oleate
A. a-3,b-1,c-2,d-4
B. a-2,b-4,c-1,d-3
C. a-1,b-3,c-4,d-2
D. a-2,b-4,c-3,d-1
13. A 35-year-old female presented to the emergency department with a complaint of sudden onset
pain in the right upper abdomen. Examination showed icterus and increased liver span. She is a known
case of PCOS and was on oral contraceptive pillsfor a long time to regularize her menstrual bleeding.
Lab investigations showed increased bilirubin and grossly elevated SGOT and SGPT. USG showed an
enlarged caudate lobe of the liver. Identify the diagnosis and mark the option with appropriate
statements. a) Jaundice is a part of the triad of clinical features b) It is a prehepatic cause c)
Investigation of choice is Hepatic venography d) Balloon angioplasty is a part of the management of the
chronic form of this disease e) Wilms tumor can be an association f) It causes centrilobular necrosis.
(or)
Frame a diagnosis in a patient with prolonged usage of ocps, sudden onset right upper quadrant pain,
raised SGOT and SGPT, and enlarged caudate lobe of liver on USG. a) Jaundice is a part of the triad
of clinical features b) It is a prehepatic cause c) Investigation of choice is Hepatic venography d)
Balloon angioplasty is a part of the management of the chronic form of this disease e) Wilms tumor can
be an association f) It causes centrilobular necrosis.
A. a, c, d
B. c, e, f
C. b, e, f
D. a, b, d
14. Match the following clinical scenarios with their appropriate choice of treatment. 1) Ascites a)
Cefotaxime 2) Hepatopulmonary syndrome b) Albumin with octreotide 3) Refractory ascites c)
Norfloxacin 4) Hepatic encephalopathy d) Spironolactone + furosemide 5) Spontaneous bacterial
peritonitis e) Lactulose 6) To Prevent bacterial peritonitis f) Large volume paracentesis + albumin 7)
Hepatorenal syndrome g) Oxygen supplementation
1) Ascites a) Cefotaxime
2) Hepatopulmonary syndrome b) Albumin with octreotide
3) Refractory ascites c) Norfloxacin
4) Hepatic encephalopathy d) Spironolactone + furosemide
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5) Spontaneous bacterial peritonitis e) Lactulose
6) To Prevent bacterial peritonitis f) Large volume paracentesis + albumin
7) Hepatorenal syndrome g) Oxygen supplementation
A. 1-a,2-e,3-b,4-f,5-c,6-g,7-d
B. 1-e,2-c,3-a,4-b,5-d,6-f,7-g
C. 1-d,2-g,3-f,4-e,5-a,6-c,7-b
D. 1-g,2-e,3-f,4-d,5-b,6-c,7-a
15. Identify the procedure being done and mark the option with appropriate statements. a) >500ml fluid
required for the puddles sign to be detectable b) Minimum amount of peritoneal fluid needed for the
presentation to be clinically obvious is 1500 ml. c) Beta-blockers used for refractory episodes d)
Site-4cm superior to ASIS to prevent inferior epigastric artery injury e) Black fluid is seen in biliary tract
perforation f) Left side of the abdomen is preferred to avoid gut perforation on the right
A. a,d,e
B. a,c,e
C. b,c,f
D. b,d,f
16. Pick the option with correct statements regarding orthotopic liver transplantation. a) HLA matching
is not mandatory b) Ideal time for cold ischemia with University of Wisconsin(UW) solution is 20hrs c)
Lactobionate is one of the components used in the UW solution d) The right hepatic lobe of the donor
adult is used for orthotopic transplantation in children.
A. b, c
B. a, c
C. a, d
D. b,d
17. A 40-year-old female patient comes to the outpatient department with complaints of constant
fatigue, hair loss, and bone pain for the past two months. She denies a history of any irregular
menstrual cycles. She constantly has an urge to drink water and reports severe itching, especially at
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night. Clinical examination revealed hepatomegaly and icterus. Laboratory investigations reveal a
positive AMA antibody. Identify the diagnosis and mark the option with relevant statements. a) Elevated
LDL and reduced HDL in later stages b) Kayser - Fleischer Ring can be seen. c) USG is the
investigation of choice. d) Raised PT, INR, and normal SGOT, SGPT, ALP e) Treatment of choice is
liver transplant f) Macronodular cirrhosis is more common than micronodular cirrhosis.
(or)
Identify the diagnosis in a patient with fatigue, osteopenia, pruritus, dry mouth, hepatomegaly, and a
positive AMA. Pick the option with the correct statements. a) Elevated LDL and reduced HDL in later
stages b) Kayser - Fleischer Ring can be seen. c) USG is the investigation of choice. d) Raised PT,
INR, and normal SGOT, SGPT, ALP e) Treatment of choice is liver transplant f) Macronodular cirrhosis
is more common than micronodular cirrhosis.
A. a,b,e
B. b,d,e
C. c,d,f
D. c,e,f
18. Which of the following is not a part of SIRS (Systemic Inflammatory Respiratory Syndrome) criteria?
A. Tachypnea
B. Tachycardia
C. Hypotension
D. Leukocytosis
19. Using the images below, frame a diagnosis and mark the option with correct statements. a) Liver
transplant is the mainstay of treatment b) Investigation of choice is ERCP c) Increased risk of
malignancy. d) Elevated levels of IgM, Gamma GTP, and normal ALP e) P-ANCA is positive f) Albumin
is elevated.
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A. a,c,e
B. a,d,e
C. b,d,f
D. b,c,f
20. Which of the following statements regarding liver biopsy is true? a) Grading is done using METAVIR
score b) Preferred site is midaxillary line 5th/6th intercoastal space c) Mandatory normal coagulogram
before biopsy in cirrhotic patients d) Most accurate in assessing the severity of CLD
A. a,b,c
B. b,c,d
C. a,c,d
D. a,b,d
21. Which of the following options is the correct fibrotic stage according to the METAVIR score in a liver
biopsy showing fibrosis with the expansion of portal zones and occasional bridging?
A. F1
B. F2
C. F3
D. F4
22. The liver biopsy specimen of a deceased patient with chronic alcoholism and features of cirrhosis is
being presented at a forensic pathology conference. The patient passed away during an episode of
binge drinking. Histopathological examination of the specimen is shown below. Identify the diagnosis
and mark the option with the correct statements. a) SGOT/SGPT ratio is the best test. b) The marker
for heavy alcohol consumption is ALT c) Drug of choice is Prednisolone. d) 40-80gm per day of alcohol
to develop this disease
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A. b,d
B. b,c
C. a,d
D. a,c
23. Identify the ISHAK grade in a liver biopsy showing marked bridging with occasional nodules.
A. 0
B. 3
C. 5
D. 6
24. All of the following have Mallory-denk bodies except?
A. Indian childhood cirrhosis
D. Wilson disease.
25. Which of the following is not a part of the revised ICA-AKI criteria for the diagnosis of hepatorenal
syndrome?
A. Serum Creatinine
B. Shock
C. FeNa
D. Absece of Parenchymal disease
26. Which of the following is not a parameter used in the Glasgow Alcoholic Hepatitis score?
A. Age
B. BUN
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C. ALT
D. Bilirubin
27. Using the graph below, mark the option with relevant statements. a) A safe dose of PCM in an
alcoholic is 3gm per day b) Blood PCM>300microgram/ml is associated with a high chance of liver
damage c) Gastric lavage can be done within 2hr of PCM toxicity d) Orthotopic liver transplant in cases
of> 48hrs of PCM toxicity e) Maximum dose of PCM in combination with opioids is 625mg. f) N-acetyl
cysteine as an antidote in the first 8hrs of Toxicity
A. a,c,e
B. b,d,f
C. a,d,e
D. b,c,f
28. A 10-year-old boy presented to the outpatient department with his mother with a complaint of
severe behavioral issues. She admitted that the boy throws severe temper tantrums, cries excessively,
hits his classmates, and has unhygienic behavior despite repeated corrections. He has occasional
redness and itching of the hands in the night. His medical history revealed multiple hospitalizations and
medication for jaundice. Lab investigations showed anemia and an accidental eye examination
revealed brown coloured deposits in the cornea. His LFT and RFT are deranged.Frame a diagnosis
and mark the option with correct statements. a) It is due to the defect in the ATP 7A gene b) The liver is
the most common organ affected c) Lindsay's nail is one of its signs d) Brown corneal deposits along
with neurological manifestations are heavily diagnostic e) MRI head is the investigation of choice f)
Associated with Parkinson's like features
(or)
Identify the diagnosis in a 10-year-old boy with behavioral issues, icterus, deranged LFT and RFT, and
brown-colored deposits in the upper part of the cornea. Pick the option with appropriate statements. a)
It is due to the defect in the ATP 7A gene b) The liver is the most common organ affected c) Lindsay's
nail is one of its signs d) Brown corneal deposits along with neurological manifestations are heavily
diagnostic e) MRI head is the investigation of choice f) Associated with Parkinson's like features
A. c,d,e
B. a,c,e
C. b,d,f
D. b,c,f
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29. Match the following clinical lab readings with their respective diseases. 1) Albumin (↓), Globulin (↓)
a) Plasmacytoma 2) Albumin (↓), Globulin (↑) b) Nephrotic syndrome 3) Albumin (n), Globulin (↑↑↑) c)
Cirrhosis
1) Albumin (↓), Globulin (↓) a) Plasmacytoma
2) Albumin (↓), Globulin (↑) b) Nephrotic syndrome
3) Albumin (n), Globulin (↑↑↑) c) Cirrhosis
B. 1-b,2-a,3-c
30. Match the following 1) Gilbert syndrome a) Complete absence/Profound reduction of UDPGT
(UDP-glucuronosyltransferase) 2) Crigler-Najjar syndrome b) Defect in OATP B1 3) Dubin johnson
syndrome c) UDPGT (UDP-glucuronosyltransferase) activity is only 10-30% 4) Rotor syndrome d)
Protein defect-MRCP 2
1) Gilbert syndrome a) Complete absence/Profound reduction of UDPGT (UDP-glucuronosyltransferase)
2) Crigler-Najjar syndrome b) Defect in OATP B1
3) Dubin johnson syndrome c) UDPGT (UDP-glucuronosyltransferase) activity is only 10-30%
4) Rotor syndrome d) Protein defect-MRCP 2
C. 1-d,2-b,3-c,4-a
D. 1-d,2-b,3-a,4-c
31. Which staining technique is used for the diagnosis of wilson's disease?
A. Auramine
B. Prussian blue
C. Rubeanic acid
D. Von Kossa stain
32. Match the following types of hereditary hemochromatosis with their respective genes. 1) Type 1 a)
Transferrin receptor mutation 2) Type 2 b) HFE gene mutation 3) Type 3 c) Ferroportin mutation 4)
Type 4 d) Hepcidin mutation
1) Type 1 a) Transferrin receptor mutation
2) Type 2 b) HFE gene mutation
3) Type 3 c) Ferroportin mutation
4) Type 4 d) Hepcidin mutation
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B. 1-b,2-d,3-a,4-c
C. 1-d,2-a,3-b,4-c
D. 1-a,2-c,3-b,4-d
33. Which of the following is not associated with platypnea?
A. Atrial myxoma
C. Emphysema
D. Hepatopulmonary syndrome
34. A 40-year-old male presented to the outpatient department with complaints of breathing difficulty.
He is a chronic alcoholic and a known case of cirrhotic liver. He complained of respiratory discomfort
especially in the morning while waking from the bed. Clinical examination revealed pallor and a fall in
SPO2 to 78-80% while sitting upright from a sleeping position. Identify the diagnosis and mark the
option with appropriate statements. a)Triad includes intrapulmonary shunting+platypnea+cirrhosis b)
Fall in A-a gradient c) Investigation of choice is bubble contrast echocardiography d) Definitive
management is orthotopic liver transplant e) Vasoconstriction of pulmonary blood vessels due to
urinary loss of prostaglandins. f)Upright position causes SPO2 to fall by 10%
(or)
Which of the following statements are correct in a patient who presents with platypnea, cirrhotic liver,
and a decrease in SPO2 below 80%? a)Triad includes intrapulmonary shunting+platypnea+cirrhosis b)
A. a, c, d
B. a, e, d
C. b, e, f
D. b, c, f
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Question 26 3
Question 29 4
Correct Option B - 100 gm:
 Volume expansion in patients with hepatorenal syndrome is done using Albumin. It is safer to do
volume expansion with albumin. Dose: 1 g/kg Maximum dose that can be used is ~ 100 grams. Albumin
contributes to an increase in oncotic pressure and reduces the amount of ascites in the patient. If we
get the ascitic fluid back in the vascular compartment, there is a chance that kidney perfusion will
increase and urine output will also increase
 It is safer to do volume expansion with albumin.
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Correct Option A - 1-c,2-e,3-a,4-b,5-f,6-d:
1) Divalent metal transporter - c) Transport of iron into enterocytes
2) Duodenal cyt B - e) Reduction of Fe3+ to Fe2+
3) Ferroportin - a) Importer of iron from enterocyte into circulation
4) Ceruloplasmin - b) Converts Fe2+ into Fe3+
5) Transferrin - f) Transport of Fe3+ to bone marrow
6) Ferritin - d) The storage form of iron
 
Incorrect Options - Refer to the explanation of the correct answer:
Option B - 1-a,2-d,3-b,4-e,5-c,6-f
Option C - 1-f,2-c,3-e,4-b,5-d,6-a
Option D - 1-e,2-c,3-a,4-b,5-d,6-f
Correct Option A - HFE gene mutation:
 Present on chromosome 6p, C282Y homozygosity (most common) involved in Hereditary
hemochromatosis.
Incorrect Options - Refer to the explanation of the correct option.
Correct Option D - Hepatitis C
Incorrect Options A, B, D: Eliminated by the explanation of the above options.
Correct Option D - 1-c,2-a,3-e,4-d,5-b:
1) Pre-Hepatic-c)Banti syndrome
2) Hepatic-presinusoidal-a)Schistosomiasis
3) Hepatic-sinusoidal-e)Cirrhosis
4) Hepatic-post sinusoidal-d)Radiation
5) Post-Hepatic-b)Constrictive pericarditis
Option A - 1-a,2-d,3-b,4-e,5-c:
1166

1. A 20-year-old male presented with a history of yellowing of the skin and eyes for 11 weeks, but he
does not have any other symptoms. He had a viral infection 10 days ago and experienced a similar
episode of yellowing 2 years ago for 2 weeks. Upon further questioning, he mentioned having long
hours of basketball practice 2 years ago, which left him physically exhausted. His current blood tests
show a serum bilirubin level of 2.4 mg/dL, with unconjugated bilirubin at 2.1 mg/dL and conjugated
bilirubin at 0.3 mg/dL. His liver enzyme levels (AST and ALT) are normal. Based on these findings,
B. Crigler-Najjar type 1 syndrome
C. Gilbert syndrome
D. Rotor syndrome
2. A patient presents to the emergency department with a history of ingestion of ten tablets of
paracetamol. He has developed oliguria and liver function tests show deranged values. Which of the
following can be used in the management of this condition?
A. N-acetylcysteine
B. Dopamine
C. Ursodeoxycholic acid
3. A patient presents to you with a fever, jaundice, and malaise. What is the most likely diagnosis based
on the serology reports given below? Anti-HBc (IgM): Positive HBsAg: Positive Anti-HBs: Negative
Anti-HCV antibodies: Negative
B. Acute hepatitis C
C. Chronic hepatitis B
D. Chronic hepatitis C
4. A child presents to the emergency department with a history of ingestion of 10-20 ferrous sulphate
tablets. Arterial blood gas revealed acidosis. Which of the following can be used in the management of
A. Deferoxamine
B. Activated charcoal
C. Dimercaprol
D. Penicillamine
5. A 20-year-old male presented with a 1 weak history of yellow skin and sclerae but is otherwise
asymptomatic. He gives a history of viral upper respiratory infection 10 days ago, which resolved 2
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days back. There is a history of a similar episode of icterus 2 years back when the patient had long
hours of basketball practice. The current serum bilirubin is 2.4 mg/dl, unconjugated bilirubin is 2.1mg/dl,
and conjugated bilirubin is 0.3mg/dl. Serum AST and ALT levels are normal. Which of the following is
B. Criggler-Najar type 1 syndrome
6. Which of the following is not a component of Child-Pugh scoring?
A. Albumin
B. Bilirubin
C. Prothrombin Time
D. LFT
7. A 30-year-old male with chronic hepatitis B and HBeAg positivity presents for evaluation. The
patient’s viral load was 105 copies/ml and SGPT is found to be doubled. What is the appropriate
management in this patient?
A. Lamivudine for 30+ weeks
B. Tenofovir for > 48 weeks
C. Pegylated interferon for 24 weeks
D. Combined pegylated interferon with lamivudine
8. Which benzodiazepine is suitable for the safe administration to a 40-year-old chronic alcoholic
experiencing withdrawal symptoms, based on the liver function tests that indicated AST levels of 140
IU/L, ALT levels of 110 IU/L, and GGT levels of 500 IU/L?
A. Diazepam
B. Alprazolam
C. Clonazepam
D. Lorazepam
9. In methanol intoxication, which of the subsequent electrolyte abnormalities is observed?
A. Metabolic alkalosis with high anion gap
B. Metabolic acidosis with high anion gap
C. Metabolic acidosis with normal anion gap
D. Metabolic alkalosis with normal anion gap
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10. In a male patient who is a chronic alcoholic, he has come in with abdominal distension, reduced
urine output, and swelling in the feet (pedal edema). Upon examination, his serum creatinine level was
found to be 1.6 mg/dL. What would be the appropriate course of action in managing this patient?
B. Heparin
C. Torsemide
D. Octreotide plus albumin
11. For a patient with a serum bilirubin level of 2.5 mg/dl, serum albumin level of 3 g/dl, prothrombin
time of 5 seconds (INR = 2), encephalopathy of grade 1, and mild ascites, what would be the
child-Turcotte-Pugh class?
A. Class A
B. Class B
C. Class C
D. Class D
12. Which drug should be preferred for treating a 45-year-old individual with a history of chronic
alcoholism, who has been admitted to the hospital with symptoms of fever and abdominal pain, and
was previously diagnosed with liver cirrhosis two years ago, as indicated by a neutrophil count of 360
cells/microliter in the ascitic fluid?
A. Cefotaxime
C. Amoxicillin
D. Vancomycin
13. A 53-year-old patient was brought to the emergency room with a history of alcohol abuse, altered
sensorium, and rapid shallow breathing. His abdomen is distended with palpable hepatomegaly and
splenomegaly and sclerae are icteric. The other examination findings are given below. Laboratory tests
show that the AST: ALT ratio is 3:1. What is the most likely cause of this patient’s presentation?
A. Alcoholic liver disease
C. Autoimmune hepatitis
D. Acetaminophen poisoning
14. A 3-year-old boy has presented with multiple episodes of hematemesis. On admission, his vitals
were stable, and splenomegaly was noted. The mother says that at birth, the boy had developed
jaundice and an exchange transfusion procedure had been performed through the umbilicus after birth.
The most likely cause of hematemesis is?
A. Portal vein thrombosis
B. Sinusoidal fibrosis
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C. Hepatic sinusoidal obstruction
D. Budd chiari syndrome
15. Which among the following is incorrect?
A. Components of MELD (model for end stage liver disease) scoring system are creatinine, bilirubin,
international normalized ratio (INR), serum sodium (mEq/L)
B. Components of CTP (Child Turcotte Pugh) score are albumin, bilirubin, INR, ascites and
encephalopathy
C. Components of CTP (child Turcotte Pugh) are creatinine, bilirubin, international normalized ratio
(INR)
D. MELD score is used to assess and prioritize patients awaiting liver transplantation
16. Cryoglobulinemia is associated with:
A. Hepatitis C
B. Ovarian cancer
C. Diabetes
D. Leukaemia
17. A child presents with hepatitis and progressive neurological degeneration. A picture of his eye has
been provided below. Among the following options, what would be the initial step regarding the
investigations done for this child’s diagnosis?
A. Serum ceruloplasmin levels
B. Serum copper levels
C. Enzyme assay
D. Karyotyping
18. Which antiretroviral drug is not utilized in cases of concurrent HIV and hepatitis B infection?
A. Tenofovir
B. Abacavir
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C. Lamivudine
D. Emtricitabine
19. A 40-year-old male chronic smoker presents to the AIIMS OPD with fever, fatigue, yellow-colored
urine, and clay-colored stools. For the past few days, he has developed an aversion to cigarette
smoking. On examination icterus was present. Liver function test results are given below: Total Bilirubin
- 18.5 Direct Bilirubin — 7.5 SGOT - 723 SGPT-812 Which investigations would you advise to rule out
acute viral hepatitis?
A. HBsAg, lgM antiHBC, AntiHCV, AntiHEV
B. AntiHAV, HBsAg, lgM antiHBc, AntiHCV
C. HBsAg, lgM antiHBc, AntiHDV, AntiHCV, Anti HEV
D. AntiHAV, lgM antiHBc, AntiHCV, AntiHEV
20. Which of the following is the most specific marker for alcoholism?
A. ALT
B. GGT
C. ALP
D. LDH
21. The following serological status is noted in a patient: HbsAg positive and HbeAg positive. Diagnosis
is?
A. Carrier
B. Chronic viral hepatitis
C. Acute viral hepatitis with infectivity
D. Remote infection
22. Which of the following is the leading viral cause of End Stage Liver Disease?
A. HBV
B. HCV
C. HDV
D. HEV
23. Acute auto-graft rejection occurs within?
A. Few hours
B. < 10 days
C. < 6 months
D. >24 months
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24. AFP is a tumour marker for which of the following?
A. Hepatocellular carcinoma
B. Renal cell carcinoma
C. Oncocytoma
D. Chordoma
25. Which of the following is considered a post-hepatic cause of portal hypertension?
A. Budd Chiari syndrome
B. Banti disease
C. Portal vein thrombosis
D. Schistosomiasis
26. What is the most appropriate next step in the evaluation of a 6-year-old patient who has been
experiencing fever for the past 3 days and complains of pain in the right upper abdomen, and upon
examination, tenderness is observed in the right upper quadrant?
A. USG
B. Serology
C. LFT
D. CT abdomen
27. What is not a characteristic feature of Wilson's disease?
A. Autosomal recessive disease
B. No free radical injury
C. ATP7B gene involved
D. Presents before age 40 with liver disease
28. A patient with acute hepatitis B has recovered from the infection. Identify the serological marker
marked in the image:
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A. Anti-HBc Ab
B. Anti-HBs Ab
C. Anti-HBe Ab
D. HBs Ag
29. A 30-year-old female presents with unsteady gait, forgetfulness, and labile moods. During a
physical exam, the neurologist notices the findings shown in the image below. The most likely diagnosis
is:
A. Neurofibromatosis 2
C. Neurofibromatosis 1
D. Cataract
30. Which of the following is not a component of child pugh classification?
A. SGOT
C. Albumin
D. Prothrombin time
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Question 25 1
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 In the above patient there is presence of mild jaundice and it occurs under stressful circumstances.
There is also an increase in unconjugated bilirubin whereas AST, ALT levels are normal which leads to
the most probable diagnosis of Gilbert Syndrome.
Option A: Dubin Johnson has conjugated hyperbilirubinemia and brown black melanin like deposition o
n liver.
Option B: Crigler Najjar type 1 presents with kernicterus and neurological damage in babies.
Option D: Rotor is similar to Dubin Johnson syndrome but the presentation is mild and there is increas
ed conjugated bilirubin and the liver does not have black coloured deposits.
 
Correct Option A - N-acetylcysteine:
 N-acetylcysteine (NAC) is used for paracetamol toxicity. 
 It acts as a precursor of glutathione and replenishes the exhausted glutathione stores within the liver,
further assisting in the metabolism of NAPQI (the toxic metabolite of paracetamol. 
Options B, C and D do not play a specific role in the management of paracetamol toxicity.
Correct Option A - Acute hepatitis B:
 The most likely diagnosis, based on the serology reports given, is acute hepatitis B.
 The presence of HBsAg (Hepatitis B surface antigen) and anti-HBc (IgM) antibodies are suggestive
of acute hepatitis B.
 Anti-HBs (hepatitis B surface antibody) are negative, which suggests that the patient has not yet
developed immunity to the bacterium.
Correct Option A - Deferoxamine:
 In this scenario, the child has ingested a likely toxic quantity of ferrous sulphate tablets, leading to
acidosis.
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 Ferrous sulfate is a form of iron supplement, and an overdose can bring about iron toxicity, which can
cause multi-organ damage and even death if left untreated.
 The management of iron toxicity involves auxiliary care and chelation therapy. Deferoxamine is an
example of an iron chelator.
 Therefore, the correct choice for the management concerning this condition is deferoxamine.
 
Correct Option C - Gilbert syndrome:
 Based on the given history and laboratory findings, the most likely diagnosis is Gilbert syndrome. The
patient's age, male gender, and history of recent viral infection suggest an acute episode of
unconjugated hyperbilirubinemia, which is common in Gilbert syndrome. The normal levels of serum
AST and ALT exclude the possibility of liver injury or hepatitis. The elevated levels of unconjugated
bilirubin and normal levels of conjugated bilirubin are consistent with the diagnosis of Gilbert syndrome.
 Gilbert syndrome is a common genetic disorder that causes mild unconjugated hyperbilirubinemia due
to reduced activity of UDPGT enzyme. It is usually asymptomatic, but patients may present with
intermittent episodes of mild jaundice triggered by fasting, dehydration, and stress. In Gilbert syndrome,
serum levels of unconjugated bilirubin are elevated, while conjugated bilirubin levels are usually
normal. Serum AST and ALT levels are also normal.
Option A - Dubin-Johnson syndrome: Dubin-Johnson syndrome is a rare genetic disorder that causes c
hronic conjugated hyperbilirubinemia (increased levels of bilirubin conjugated with glucuronic acid) due
 to impaired excretion of bilirubin from hepatocytes. It is usually asymptomatic, but patients may presen
t with mild jaundice and dark urine. In Dubin-Johnson syndrome, serum levels of both conjugated and 
unconjugated bilirubin are elevated. Serum AST and ALT levels may also be elevated.
Option B - Criggler-Najar type 1 syndrome: Criggler-Najar type 1 syndrome is another rare genetic diso
rder that causes severe unconjugated hyperbilirubinemia due to impaired activity of uridine diphosphat
e glucuronyl transferase (UDPGT) enzyme. The condition is characterized by recurrent episodes of jau
ndice and kernicterus (a type of brain damage caused by bilirubin deposition in the brain) in infancy. In 
Criggler-Najar type 1 syndrome, serum levels of unconjugated bilirubin are significantly elevated, while 
conjugated bilirubin levels are usually normal.
Option D - Rotor syndrome: Rotor syndrome is a rare genetic disorder that causes chronic conjugated 
hyperbilirubinemia due to impaired uptake and storage of bilirubin in hepatocytes. It is usually asympto
matic, but patients may present with mild jaundice and dark urine. In Rotor syndrome, serum levels of c
onjugated bilirubin are elevated, while unconjugated bilirubin levels are usually normal. Serum AST an
d ALT levels may also be elevated.
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Correct Option D - LFT:
 Liver Function Tests are not included in the components of the Child-Pugh scoring.
 The Child-Pugh scoring system is a way to assess the severity of chronic liver disease and predict
prognosis. It includes components such as albumin, bilirubin, and prothrombin time, which directly
reflect liver function.
 Liver Function Tests (LFTs), which typically include enzymes like ALT (alanine aminotransferase) and
AST (aspartate aminotransferase), are not part of the Child-Pugh scoring system, as they are more
focused on assessing liver injury and inflammation rather than the functional reserve of the liver, which
is the primary concern in cirrhosis assessment.
Options A, B and C are components of the Child-Pugh scoring system.
Correct Option B - Tenofovir for > 48 weeks:
 According to the vignette, the patient has chronic hepatitis B and HBeAg positivity, which indicates an
active infection.
 As the patient has been diagnosed with chronic hepatitis B, with a viral load of more than 105
copies/ml and a doubled SGPT, the patient should be started on treatment.
 The treatment of chronic hepatitis includes treatment with antivirals like Tenofovir for 52 weeks (48
weeks+) or pegylated interferon for 48 weeks. The pegylated interferons and the antivirals are not
preferably combined.
Option A - Lamivudine for 30+ weeks: Lamivudine is no longer preferred in the management of chronic
 hepatitis B.
Option C - Pegylated interferon for 24 weeks: Pegylated interferons are administered for 48-52 weeks i
n clinical practice and not for 24 weeks. Oral Tenofovir for 48 weeks is a
more appropriate treatment option.
Option D
- Combined pegylated interferon with lamivudine: Pegylated interferon along with lamivudine is not a
recommended combination in clinical use.
 
Correct Option D - Lorazepam:
 Lorazepam is not extensively metabolized by the liver, and its clearance is less affected by liver
dysfunction compared to other benzodiazepines. It has a shorter half-life than diazepam, making it a
suitable option for managing alcohol withdrawal symptoms in patients with liver disease. Lorazepam is
commonly used in clinical practice for this purpose.
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Option A, B and C
are extensively metabolized by the liver and are not recommended in patients with liver disease.
 
Correct Option B - Metabolic acidosis with high anion gap:
 Metabolic acidosis with high anion gap. Methanol intoxication leads to the formation of toxic
metabolites, including formic acid, which causes metabolic acidosis. The acidosis results from the
accumulation of formic acid and its metabolites, leading to an increased anion gap.
Option A, C and D are incorrect
Correct Option D - Octreotide plus albumin:
 The correct answer is octreotide plus albumin. Octreotide is a synthetic analogue of somatostatin, a
hormone that inhibits the release of various substances in the body. When combined with albumin, it
can help manage hepatorenal syndrome (HRS), a condition characterized by renal dysfunction in
patients with advanced liver disease. HRS occurs due to severe vasoconstriction of the renal blood
vessels, leading to reduced renal blood flow and impaired kidney function. Octreotide helps alleviate
vasoconstriction, while albumin improves intravascular volume and renal perfusion.
Correct Option C - Class C:
 The Child-Turcotte-Pugh (CTP) classification is used to assess the severity of liver disease and
predict prognosis in patients with cirrhosis. It takes into account five clinical parameters: serum bilirubin
level, serum albumin level, prothrombin time (or INR), presence or absence of hepatic encephalopathy,
and severity of ascites. Serum bilirubin level of 2.5 mg/dl - 2 points Serum albumin level of 3 g/dl - 2
points Prothrombin time of 5 seconds (INR = 2) - 2 points encephalopathy of grade 1 - 2 points Mild
ascites - 2 points
 Serum bilirubin level of 2.5 mg/dl - 2 points
 Serum albumin level of 3 g/dl - 2 points
 Prothrombin time of 5 seconds (INR = 2) - 2 points
 encephalopathy of grade 1 - 2 points
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 Mild ascites - 2 points
 Bilirubin (2 point) + Albumin (2 point) + INR (2 point) + Encephalopathy (2 points) + Ascites (2 point) =
10 points
 Based on the total points, the patient falls into Class c of the Child-Turcotte-Pugh classification.
 The patient's clinical parameters correspond to Class c  in the Child-Turcotte-Pugh classification,
indicating moderate severity of liver disease.
Option A - Class A: Class A in the Child-Turcotte-Pugh classification corresponds to a
score of 5-6 points. Since this patient scored 10 points, they do not fall into Class C.
Option B - Class B: Class B in the Child-Turcotte-Pugh classification corresponds to a score of 7 - 9
points. Since this patient scored 10 points, they do not fall into Class C.
Option D - Class D: Class D is not a category in the Child-Turcotte-Pugh classification
Correct Option A - Cefotaxime:
 A third-generation cephalosporin such as Cefotaxime is the drug of choice in patients
with spontaneous bacterial peritonitis
 
Correct Option A - Alcoholic liver disease:
 Based on the given clinical presentation and laboratory findings, the most likely cause of this patient's
presentation is Alcoholic liver disease. 
 The key findings that point towards alcoholic liver disease, in this case, are the history of alcohol
abuse and the presence of hepatomegaly, splenomegaly, and icteric sclerae. The laboratory test result
indicating an AST: ALT ratio of 3:1 is also supportive of alcoholic liver disease.
 Alcoholic liver disease is a progressive condition that occurs due to chronic and excessive alcohol
consumption. It can manifest as a spectrum of liver diseases, including fatty liver, alcoholic hepatitis,
and cirrhosis. The characteristic features include hepatomegaly, splenomegaly, and jaundice.
 
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Correct Option - A - Portal vein thrombosis:
 The most likely cause of hematemesis in this 3-year-old boy with a history of neonatal jaundice and an
exchange transfusion procedure is portal vein thrombosis. Portal vein thrombosis occurs when there is
a blood clot formation within the portal vein, which is responsible for carrying blood from the
gastrointestinal tract, spleen, and pancreas to the liver. This condition can lead to increased pressure in
the portal vein system, known as portal hypertension, and can cause various complications, including
gastrointestinal bleeding. In this case, the boy's history of neonatal jaundice and exchange transfusion
procedure suggests an increased risk of thrombosis formation. The exchange transfusion itself,
performed through the umbilicus, may have contributed to the development of a thrombus. The
presence of splenomegaly (enlarged spleen) indicates increased pressure within the portal vein
system, which can occur due to portal vein thrombosis. The elevated pressure causes the development
of collateral blood vessels, such as esophageal varices, which are prone to bleeding and can result in
hematemesis (vomiting blood).
 Portal vein thrombosis occurs when there is a blood clot formation within the portal vein, which is
responsible for carrying blood from the gastrointestinal tract, spleen, and pancreas to the liver. This
condition can lead to increased pressure in the portal vein system, known as portal hypertension, and
can cause various complications, including gastrointestinal bleeding.
 In this case, the boy's history of neonatal jaundice and exchange transfusion procedure suggests an
increased risk of thrombosis formation. The exchange transfusion itself, performed through the
umbilicus, may have contributed to the development of a thrombus.
 The presence of splenomegaly (enlarged spleen) indicates increased pressure within the portal vein
Option B, C & D - Sinusoidal fibrosis, Hepatic sinusoidal obstruction & Budd chiari syndrome: Sinusoid
al fibrosis and hepatic sinusoidal obstruction are not typically associated with hematemesis in this clinic
al scenario. Budd-Chiari syndrome, on the other hand, involves obstruction of the hepatic veins, impairi
ng blood outflow from the liver, and is less likely in this case.
Therefore, based on the given information, the most likely cause of hematemesis in this 3-year-old boy 
is portal vein thrombosis.
 
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Correct Option C - Components of CTP (Child-Turcotte-Pugh) are creatinine, bilirubin, international nor
malized ratio (INR):
 The components of the CTP score are not creatinine, but rather albumin, bilirubin, INR, ascites, and
encephalopathy.
Option A - Components of MELD (Model for End-Stage Liver Disease) scoring system are creatinine, b
ilirubin, international normalized ratio (INR), serum sodium (mEq/L): The MELD score is a scoring syst
em used to assess the severity of liver disease and predict prognosis. It includes the components ment
ioned, which are used to calculate the MELD score.
Option B - Components of CTP (Child-Turcotte-Pugh) score are albumin, bilirubin, INR, ascites, encep
halopathy: The CTP score is a scoring system used to assess the severity of liver disease and predict 
prognosis in patients with cirrhosis. The components mentioned are used to calculate the CTP score.
Option D - MELD score is used to assess and prioritize patients awaiting liver transplantation: The MEL
D score is commonly used to assess the severity of liver disease and prioritize patients on the liver tran
splant waiting list. It helps determine the urgency of transplantation based on the calculated MELD scor
e.
Correct Option A - Hepatitis C: 
 Cryoglobulinemia refers to the presence of abnormal proteins called cryoglobulins in the blood.
 These cryoglobulins can precipitate and cause inflammation in small blood vessels, leading to various
symptoms and complications.
 Cryoglobunimea is associated with Hepatitis C infections.
 Cryoglobulinemia is not associated with Options B, C and D. hence these options are incorrect.
Correct Option A - Serum ceruloplasmin levels:
 The clinical presentation of hepatitis and progressive neurological degeneration, along with the
presence of Kayser-Fleischer (KF) rings in the eyes, is highly suggestive of Wilson's disease, an
autosomal recessive disorder characterized by impaired hepatic copper transport leading to copper
accumulation in various organs, including the liver, brain, and eyes. This leads to the characteristic KF
rings seen on ocular examination.
 The initial step in the diagnostic workup of a suspected case of Wilson's disease is to measure serum
ceruloplasmin levels. Ceruloplasmin is a copper-binding protein synthesized in the liver, and low levels
of ceruloplasmin are commonly observed in Wilson's disease due to impaired copper incorporation into
the protein.
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 Options B, C, and D are incorrect. Serum ceruloplasmin is a more appropriate diagnostic test in this
scenario.
Correct Option B - Abacavir:
 Abacavir is primarily used for the treatment of HIV but is not effective against hepatitis B. Therefore, it
is not typically used in the management of HIV and hepatitis B co-infection.
Option A - Tenofovir: Tenofovir is an antiretroviral drug that is commonly used in the treatment of both 
HIV and hepatitis B. It is effective against both viruses and is often included in the antiretroviral regime
n for individuals with HIV and hepatitis B co-infection.
Option C - Lamivudine: Lamivudine is an antiretroviral drug that is effective against both HIV and hepat
itis B. It is frequently used in the treatment of individuals with HIV and hepatitis B co-infection.
Option D - Emtricitabine: Emtricitabine is another antiretroviral drug that is effective against both HIV a
nd hepatitis B. It is commonly included in the treatment regimen for individuals with co-infection.
Correct Option B - AntiHAV, HBsAg, lgM antiHBc, AntiHCV:
 In the given clinical scenario, the patient presents with fever, fatigue, yellow-colored urine (suggestive
of jaundice), clay-colored stools, and icterus. These symptoms and signs are consistent with a
diagnosis of acute viral hepatitis.
 The liver function test results indicate elevated levels of total bilirubin, direct bilirubin, SGOT
(aspartate aminotransferase), and SGPT (alanine aminotransferase). These findings further support
the suspicion of acute viral hepatitis.
 To determine the specific etiology of acute viral hepatitis, appropriate serological tests are necessary.
The recommended investigations for ruling out acute viral hepatitis include: AntiHAV (IgM antibody
against hepatitis A virus): Hepatitis A virus (HAV) infection is characterized by the presence of IgM
antibodies against HAV during the acute phase of the infection. HBsAg (Hepatitis B surface antigen):
HBsAg is a marker of current hepatitis B virus (HBV) infection. Its presence indicates ongoing viral
replication and infectivity. IgM antiHBc (IgM antibody against hepatitis B core antigen): IgM antiHBc
appears during the acute phase of hepatitis B infection and is a marker of recent HBV infection.
AntiHCV (Antibodies against hepatitis C virus): AntiHCV antibodies are tested to detect hepatitis C
virus infection.
 AntiHAV (IgM antibody against hepatitis A virus): Hepatitis A virus (HAV) infection is characterized by
the presence of IgM antibodies against HAV during the acute phase of the infection.
 HBsAg (Hepatitis B surface antigen): HBsAg is a marker of current hepatitis B virus (HBV) infection.
Its presence indicates ongoing viral replication and infectivity.
 IgM antiHBc (IgM antibody against hepatitis B core antigen): IgM antiHBc appears during the acute
phase of hepatitis B infection and is a marker of recent HBV infection.
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Page 17
 AntiHCV (Antibodies against hepatitis C virus): AntiHCV antibodies are tested to detect hepatitis C
 The correct answer, option B, includes these specific serological tests (AntiHAV, HBsAg, IgM antiHBc,
AntiHCV) that are necessary to evaluate and rule out acute viral hepatitis.
 
Correct Option B - GGT:
 GGT is considered the most specific marker for alcoholism among the given options. GGT is
particularly sensitive to alcohol consumption, and elevated levels of GGT are commonly seen in
individuals who abuse alcohol or have alcohol use disorder. Monitoring GGT levels can be useful in
assessing alcohol-related liver damage and evaluating the response to treatment for alcoholism.
Option A - ALT (Alanine aminotransferase): ALT is a liver enzyme that is often used as a marker of live
r damage. While elevated ALT levels can be seen in alcohol-related liver disease, it is not as specific to
 alcoholism as GGT.
Options C & D (ALP & LDH) are not specific markers for alcohol consumption and are incorrect.
Correct Option C - Acute viral hepatitis with infectivity: 
 When a patient is positive for both HbsAg (hepatitis B surface antigen) and HbeAg (hepatitis B e
antigen), it indicates an active and replicating hepatitis B virus (HBV) infection. HbsAg is a marker of
HBV infection, and HbeAg is a marker of viral replication and infectivity.
 Therefore, a patient who is HbsAg positive and HbeAg positive is likely experiencing an acute phase
of viral hepatitis with high infectivity, indicating active viral replication and the potential for transmission
to others. This is commonly seen in acute hepatitis B infections.
Options A, B and D are incorrect.
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Correct Option B - HCV:
 HCV is the leading viral cause of End Stage Liver Disease. Hence, it is also the most common cause
of orthotopic liver transplant worldwide.
 
Correct Option: C - < 6 months:
 Acute auto-graft rejection typically occurs within the first 6 months following transplantation. In the
case of autografts, where the transplant involves using the patient's own tissues, the immune response
is generally less severe compared to allografts (grafts from another individual). However, rejection can
still occur, and it is typically observed within the first 6 months after the transplantation.
 
Correct Option A - Hepatocellular carcinoma:
 AFP (Alpha-fetoprotein) is a tumor marker primarily associated with hepatocellular carcinoma (HCC),
which is the most common type of liver cancer. Elevated levels of AFP in the blood can indicate the
presence of HCC. It is important to note that AFP is not specific to HCC and can also be elevated in
other conditions such as certain germ cell tumors and liver cirrhosis. However, in the context of the
given options, HCC is the most relevant association with AFP.
Correct Option A - Budd Chiari syndrome:
 Budd-Chiari syndrome: Budd-Chiari syndrome is a post-hepatic cause of portal hypertension. It is
characterized by the obstruction or narrowing of the hepatic veins, which impairs the blood flow out of
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the liver.
Option B - Banti disease: Banti disease, also known as non-cirrhotic portal fibrosis, is a
condition characterized by fibrosis and obstruction of the intrahepatic portal veins. It is considered a
pre-hepatic cause of portal hypertension.
Option C - Portal vein thrombosis: Portal vein thrombosis refers to the formation of a blood clot within t
he portal vein, which can lead to impaired blood flow and increased pressure in the portal system. It is 
a pre-hepatic cause of portal hypertension.
Option D - Schistosomiasis: Schistosomiasis is considered a
presinusoidal hepatic cause of portal hypertension.
Correct Option A - USG (Ultrasonography):
 Ultrasonography is a non-invasive imaging modality that can help visualize the liver, gallbladder, and
other abdominal structures.
 It can provide valuable information about the presence of any abnormalities such as hepatomegaly,
gallstones, or signs of inflammation in the right upper quadrant.
 The ultrasound pulses echo off tissues with different reflection properties and are returned to the
probe, which records and displays them as an image.
 Several modes of ultrasound are used in medical imaging: A-mode B-mode M-mode
 A-mode
 B-mode
 M-mode
 A-mode
 B-mode
 M-mode
Option B - Serology: Serological tests are blood tests used to detect specific antibodies or antigens in t
he blood. While serology can be helpful in certain situations, such as identifying specific infections or a
utoimmune conditions, it may not be the initial investigation of choice in this scenario.
Option C - LFT (Liver Function Tests): Liver function tests, including SGOT and SGPT, assess liver en
zymes to evaluate liver function. While these tests can provide information about liver health, they may 
not be the most appropriate initial investigation to assess the cause of pain in the right hypochondrium.
Option D - CT abdomen (Computed Tomography): CT abdomen is a cross-sectional imaging technique
 that provides detailed images of abdominal structures. While it can be useful in certain cases, such as 
when a more detailed evaluation is required, it may not be the initial investigation of choice in a
6-year-old patient due to concerns about radiation exposure and it being a
more expensive diagnostic test.
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Correct Option B - No Free radical injury:
 This statement is incorrect. Free radical injury due to an excess of copper ions is seen in patients with
Wilson's disease.
Options A, C, and D are features of Wilson's disease.
Correct Option A - Anti-HBc Ab:
  Anti-HBc antibody refers to antibodies against the core antigen of the hepatitis B virus (HBV). The
presence of anti-HBc antibodies indicates past or ongoing infection with HBV.
Option B - Anti-HBs Ab: This option refers to antibodies against the surface antigen of HBV. Anti-HBs a
ntibodies develop after successful vaccination against HBV or as a result of resolving a
previous HBV infection.
Option C - Anti-HBe Ab: Anti-HBe antibodies target the e
antigen of HBV. The presence of anti-HBe antibodies typically indicates a
transition from the acute phase of HBV infection to the recovery phase.
Option D - HBs Ag: This stands for hepatitis B surface antigen, which is a
protein present on the surface of HBV. The presence of HBsAg indicates an active HBV infection.
Correct Option B - Wilson’s disease:
 The above image shows fine pigmented and granular deposits, suggesting Wilson’s disease. These
are Kayser-Fleischer rings due to copper deposits in the descemet’s membrane.
Correct Option A - SGOT:
 Child-Pugh classification is a scoring system used to assess the severity of liver disease and to
predict the prognosis in patients with chronic liver disease, particularly cirrhosis.
 SGOT (serum glutamic-oxaloacetic transaminase) or AST (aspartate aminotransferase) is not
included in the Child-Pugh classification. 
1197

Obstructive Sleep Apnea & Cystic Fibrosis
1. Match the following drugs used in cystic fibrosis: 1) DNAase daily aerosol spray a) Reduces chances
of colonization of bacteria 2) N-acetyl cysteine followed by β-2 agonist nebulization b) Improves
chloride conductance 3) Nebulized 7% hypertonic saline c) Vibrations help to mobilize secretions 4)
Nebulized tobramycin and aztreonam d) Decreases viscosity of sputum 5) Handheld oscillometric
device e) For Burkholderia cepacia infection 6) Meropenem f) Causes vigorous cough and expectorate
7) Ivacaftor g) Draws water into periciliary mucus
1) DNAase daily aerosol spray a) Reduces chances of colonization of bacteria
2) N-acetyl cysteine followed by β-2 agonist nebulization b) Improves chloride conductance
3) Nebulized 7% hypertonic saline c) Vibrations help to mobilize secretions
4) Nebulized tobramycin and aztreonam d) Decreases viscosity of sputum
5) Handheld oscillometric device e) For Burkholderia cepacia infection
6) Meropenem f) Causes vigorous cough and expectorate
A. 1-a, 2-e, 3-b, 4-g, 5-c, 6-f, 7-d
B. 1-g, 2-e, 3-c, 4-a, 5-b, 6-d, 7-f
C. 1-d, 2-a, 3-g, 4-b, 5-c, 6-e, 7-f
D. 1-d, 2-f, 3-g, 4-a, 5-c, 6-e, 7-b
2. A 30-year-old male patient came to the outpatient department with complaints of productive cough
and episodes of difficulty breathing for a very long time and unrelieved with over the counter
medication. He consulted many doctors but the condition seems to recur. Clinical examination shows
hyper-resonant lungs and edema and the sputum culture showed colonies of Staphylococcus aureus
and Pseudomonas aeruginosa. A chest X-ray was taken which is shown below. A review of medical
records revealed abnormal sperm cells in his semen analysis. Frame a diagnosis and pick the option
with correct statements. a) It is also known as exocrinopathy b) It is an autosomal dominant condition c)
Most common mutation is F508 deletion d) Associated with chromosome 9 e) It is accompanied by
disturbed mobility of HCO3 ions and H20 f) The protein located in 1480 AA sequence is affected
A. a, c, d and f
B. a, c, e and f
C. b, d and f
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Page 2
D. b, c, e and f
3. A 30-year-old male attends the OPD with a complaint of increased daytime sleepiness and issues in
his marriage due to his disturbed sexual function. His wife revealed that she also has sleep
disturbances at night due to her husband's snoring and grunting. The patient has a BMI of 35.
Polysomnography showed sharp inspiratory uptake, a sequential plateau wave, and then a
scooped-out pattern of breathing. Identify the diagnosis and pick the option that helps in its diagnosis.
A. Apnea for <10 seconds associated with a 2% decrease in SaO2
B. Apnea for >10 seconds associated with a 3% decrease in SaO2
C. Hypopnea with <30% decrease in airflow for >10 seconds
D. Hypopnea with <30% decrease in airflow for <10 seconds
4. Which of the following parameters are assessed in polysomnography?
A. Electroculography
B. Electroencephalogram
C. Limb activity and position
5. Which of the following is not a risk factor for obstructive sleep apnea?
B. Turner syndrome
C. Menopause
D. Micrognathia
6. What is the treatment of choice for obstructive sleep apnea?
A. Weight loss
B. Change in sleeping position
C. Continuous Positive Airway Pressure (CPAP)
D. Upper airway device
7. Which of the following gene mutations is associated with congenital central hypoventilation
syndrome?
A. FOXP3
B. PHOX 2B
C. PHEX
D. IPEX
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8. What breathing pattern is observed in obstructive sleep apnea syndrome?
A. Kussmaul breathing
B. Cheyne-Stokes breathing
C. Biot's breathing
D. Ataxic breathing
9. Using the radiograph below, identify the sign and condition it is associated with.
A. Continous diaphragm sign-Pneumothorax
B. Signet ring sing- Bronchiectasis
C. Naclerio’s V sign-Pneumomediastinum
D. Spinnaker sail sign-Pneumonia
10. All of the following are included in WELLs criteria except?
A. Homan Sign
B. Cancers
C. Blood in sputum
D. Prior use of oral contraceptive pills
11. Which of the following is the most accurate test for cystic fibrosis?
A. Sweat chloride test
B. Transepithelial nasal potential test
C. DNA testing
D. Pulmonary function testing
12. A sweat chloride test is > 60 mEq/L. Match the following: 1) False positive results a) Anorexia
nervosa 2) False negative results b) Addison's disease c) Malnutrition d) Congenital adrenal
hyperplasia e) Edema
1) False positive results a) Anorexia nervosa
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2) False negative results b) Addison's disease
c) Malnutrition
d) Congenital adrenal hyperplasia
e) Edema
A. 1 - b and c; 2 - a, d and e
B. 1 - a, b and d; 2 - c and e
C. 1 - c and e; 2 - a, b and d
D. 1 - c, d and e; 2 - a and b
13. A 10-year-old boy was presented to the OPD with a complaint of lethargy and loss of appetite. A
general examination showed that the boy was underweight, and had pallor and icterus. His history
revealed multiple antibiotic therapies for his chronic cough and diarrhea. Clinical examination revealed
Splenomegaly, a barrel-shaped chest, and atypical salt crystals on the child's skin. Various blood tests
were done to rule out the diagnosis. A particular Sweat chloride test revealed a positive enhanced level
but was deemed equivocal by the physician. The doctor asked for a review report of the same after one
week. The tests yielded similar results. What is the next best investigation to be done in this medical
A. Pulmonary function test
B. DNA testing
C. Transepithelial nasal potential test
D. Serum ELISA for fecal elastase test.
14. Metabolic disorder found in Cystic fibrosis?
A. Hyperchloremic Hypokalemic Metabolic alkalosis
B. Hypochloremic Hypokalemic Metabolic acidosis
C. Hypochloremic Hyperkalemic Metabolic alkalosis
D. Hypochloremic Hypokalemic Metabolic alkalosis
15. Identify the condition in a patient with poor mucociliary clearance due to a defective Dyenin arm and
find the option that is not included in its triad.
A. Situs inversus
B. Male infertility
C. Recurrent pneumonia
D. Recurrent sinusitis.
16. Using the image below, Guess the diagnosis in this neonate and pick the option with the
investigation of choice.
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A. Double-contrast barium enema technique
B. Omnipaque contrast enema technique
C. Gastrograffin enema
D. Barium meal follow-through
17. In a newborn with abdominal distension and delayed passage of meconium, the clinical
presentation suggests meconium ileus, which is associated with cystic fibrosis. What is the
investigation of choice to confirm the diagnosis in this scenario?
(or)
What is the investigation of choice to confirm Meconium ileus a/w cystic fibrosis?
A. Abdominal ultrasound
B. Gastrografin enema
C. Meconium analysis
D. Small bowel biopsy
18. In a patient with cystic fibrosis, the increased loss of sodium and chloride in sweat causes activation
of the Renin-Angiotensin-Aldosterone System (RAAS). What role does aldosterone play in the
development of metabolic alkalosis in this context?
(or)
What role does aldosterone play in the development of metabolic alkalosis in cystic fibrosis?
A. Aldosterone induces metabolic acidosis by promoting hydrogen ion retention in the kidneys
B. Aldosterone directly inhibits bicarbonate reabsorption in the renal tubules, leading to metabolic
alkalosis
C. Aldosterone enhances chloride reabsorption in the kidneys, resulting in hypokalemic metabolic
alkalosis
D. Aldosterone increases bicarbonate reabsorption in the renal tubules, contributing to metabolic
alkalosis.
19. In a sleep study, a patient is observed to have a decrease in airflow by more than 30% for more
than 10 seconds, accompanied by a 3% decrease in arterial oxygen saturation (SaO2) and cortical
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arousal. What term is used to define this respiratory event?
A. Apnea
B. Bradypnea
C. Hypopnea
D. Tachypnea
20. A 45-year-old patient undergoes a sleep study to evaluate the severity of sleep-disordered
breathing. The results indicate a total of 30 apneic or hypopneic episodes throughout the night, and the
patient's total sleep duration is 6 hours. What is the Apnea Hypopnea Index (AHI) for this patient?
A. 2.5
B. 5
C. 10
D. 15
21. A 50-year-old patient reports persistent daytime sleepiness and fatigue. After completing the
Epworth Sleepiness Questionnaire, the score is found to be 10. According to the guidelines for a sleep
study, what is the recommended course of action based on the Epworth Sleepiness Questionnaire
score?
(or)
What is the recommended course of action if the Epworth Sleepiness Questionnaire score is 10?
A. No further action is required; the patient's score is within the normal range
B. Refer the patient for medical consultation and recommend a polysomnography
C. Suggest lifestyle modifications to improve sleep hygiene without further evaluation
D. Prescribe medications to manage daytime sleepiness directly without additional testing.
22. A 20-year-old patient presents with a history of absent responses to hypoxia or hypercapnia, and
the clinical evaluation suggests Central Hypoventilation Syndrome, also known as the ONDINE curse.
What genetic condition is primarily involved in the pathogenesis of Central Hypoventilation Syndrome?
(or)
A. SCN1A gene mutation
B. PHOX2B gene mutation
C. CFTR gene mutation
D. HBB gene mutation
23. When do you use CPAP for patients with OSA?
A. >15 hypopneic episodes or >5 apneic episodes per hour
B. >5 hypopneic episodes or >15 apneic episodes per hour
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C. >10 hypopneic episodes or >15 apneic episodes per hour
D. >15 hypopneic episodes or >10 apneic episodes per hour
24. How to prevent lung colonization in patients with Cystic fibrosis?
A. N-acetyl cysteine
B. Nebulised tobramycin
C. Meropenem
D. Inhalational steroids
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Option A: Kussmaul breathing: Seen in diabetic ketoacidosis
Option C and D: Biot's breathing and Ataxic breathing: Seen in neurological disorders
Correct Option C- Naclerio’s V sign-Pneumomediastinum:
 Lucent band of gas extending along the descending aorta and an intersecting band of gas that
extends along medial left hemi- diaphragm together forming a ‘V shape’. This sign is seen in patients
with pneumomediastinum.
Option A- Continuous diaphragm sign: It is seen in patients with pneumomediastimum.
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Page 12
Option B- Signet ring sign: is seen in bronchiectasis.
Options D- Spinnaker’s sail sign: is seen in patients with pneumonia
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Page 13
 
Correct Option D- Prior use of oral contraceptive pills: is not a part of WELLS criteria
Incorrect Options A,B & C (Homan Sign, Cancers & Blood in sputum): These are part of wells criteria
 
Correct option: C - DNA testing: CFTR mutation: Positive of at least 2 mutations
Incorrect options: Option A, B and D
CF - Tests:
 Pilocarpine iontophoresis method is used
 Sweat Cl- > 60 mEq/L (should come positive 2 times for diagnosis)
 
Correct option: B - 1 - a, b and d; 2 - c and e
Incorrect options: Option A, C and D
Sweat chloride test:
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Page 16
Option A- Double-contrast barium enema technique:
Option B- Omnipaque contrast enema technique:
Option D- Barium meal follow-through:
Refer to the above explanations
 
Correct Option B - Gastrografin enema:
 In a newborn presenting with abdominal distension and delayed passage of meconium, meconium
ileus is a concern, especially in the context of cystic fibrosis (CF). Meconium ileus is strongly
associated with CF. Gastrografin enema is the investigation of choice to confirm the diagnosis of
meconium ileus. It involves instilling a water-soluble contrast medium into the bowel through the
rectum, which can help visualize the obstruction and guide further management. This investigation is
particularly useful as it can both diagnose and treat meconium ileus by softening the stool and
facilitating its passage.
 
Option A - Abdominal ultrasound: While abdominal ultrasound may provide some information, it is not t
he investigation of choice for diagnosing meconium ileus. It may be used as an adjunctive imaging mo
dality to assess for complications or associated findings.
Option C - Meconium analysis: Meconium analysis can provide information about the composition of th
e stool and may reveal evidence of obstruction or underlying conditions. However, it is not typically the 
initial investigation used to diagnose meconium ileus.
Option D - Small bowel biopsy: Small bowel biopsy may be indicated in certain cases, especially if ther
e is suspicion for other gastrointestinal disorders or if meconium ileus is not clearly evident. However, it
 is not the primary investigation used to diagnose meconium ileus.
Correct Option C - Aldosterone enhances chloride reabsorption in the kidneys, resulting in hypokalemic
 metabolic alkalosis:
 In cystic fibrosis, increased sodium and chloride loss in sweat activate the
Renin-Angiotensin-Aldosterone System (RAAS).
 Aldosterone, a hormone released by the adrenal glands in response to RAAS activation, enhances
the reabsorption of chloride in the kidneys.
 The increased reabsorption of chloride is associated with the loss of hydrogen ions and potassium in
the urine, leading to hypokalemia (low potassium levels) and metabolic alkalosis (elevated blood pH).
 Therefore, the correct option is C, as aldosterone contributes to hypokalemic metabolic alkalosis in
cystic fibrosis.
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 Options A,B and D are incorrect as explained in the above explanation.
Correct Option C - Hypopnea:
 Hypopnea is defined as a decrease in airflow by more than 30% for more than 10 seconds,
accompanied by a 3% decrease in arterial oxygen saturation (SaO2) and cortical arousal. This
respiratory event represents a partial reduction in airflow, leading to disruptions in normal breathing
patterns during sleep.
 
Option A - Apnea: Apnea refers to a complete cessation of airflow for at least 10 seconds during sleep.
Option B - Bradypnea: Bradypnea is a term typically used to describe an abnormally slow respiratory ra
te, but it does not specifically relate to the observed characteristics in the given scenario.
Option D - Tachypnea: Tachypnea refers to an abnormally rapid respiratory rate, which is not in line wit
h the observed features described in the question.
 The Apnea-Hypopnea Index (AHI) is calculated by dividing the total number of apneic and hypopneic
episodes observed during a sleep study by the total number of hours of sleep.
 This calculation provides a measure of the average number of apneas and hypopneas per hour of
sleep, allowing for the assessment of the severity of sleep-disordered breathing, particularly obstructive
sleep apnea (OSA).
 In this case, the patient experienced 30 episodes during 6 hours of sleep.
       
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So, the Apnea Hypopnea Index (AHI) for this patient is 5.  
 Other options are incorrect, as explained by the equation.
 
Correct Option B - Refer the patient for medical consultation and recommend a polysomnography:
 A score of 10 on the Epworth Sleepiness Questionnaire indicates excessive daytime sleepiness.
According to guidelines, a score greater than 8 suggests the need for further evaluation. In this case,
the recommended course of action is to refer the patient for medical consultation and consider a
polysomnography to assess the possibility of sleep disorders contributing to the symptoms.
 
Option A - No further action is required; the patient's score is within the normal range: This option is inc
orrect because a score of 10 on the Epworth Sleepiness Questionnaire is considered higher than the r
ecommended threshold (8 or more). It suggests excessive daytime sleepiness, indicating a
need for further evaluation.
Option C - Suggest lifestyle modifications to improve sleep hygiene without further evaluation: This opti
on is incorrect because a score of 10 on the questionnaire indicates a significant level of daytime sleepi
ness. While lifestyle modifications may be beneficial, they are not sufficient in this case, and further eva
luation is warranted.
Option D - Prescribe medications to manage daytime sleepiness directly without additional testing: This
 option is incorrect because prescribing medications without a proper diagnosis or evaluation through p
olysomnography may not address the underlying cause of the daytime sleepiness. It is essential to ide
ntify potential sleep disorders before initiating specific treatments.
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Correct Option B - PHOX2B gene mutation:
 Central Hypoventilation Syndrome, also known as the ONDINE curse, is a genetic condition primarily
involving a mutation in the PHOX2B gene. This gene plays a crucial role in the development of the
autonomic nervous system, including the control of respiration. Patients with Central Hypoventilation
Syndrome may exhibit absent or inadequate responses to hypoxia or hypercapnia, leading to
hypoventilation, particularly during sleep.
 
Option A
- SCN1A gene mutation: SCN1A mutations are associated with conditions such as Dravet syndrome, a
severe form of epilepsy. This gene is not related to Central Hypoventilation Syndrome.
Option C - CFTR gene mutation: CFTR gene mutations are associated with cystic fibrosis, a genetic di
sorder affecting the respiratory, digestive, and reproductive systems. CFTR mutations are not implicate
d in Central Hypoventilation Syndrome.
Option D - HBB gene mutation: HBB gene mutations are associated with hemoglobinopathies, such as 
sickle cell disease and thalassemia. This gene is not related to Central Hypoventilation Syndrome.
Correct Option A - >15 hypopneic episodes or >5 apneic episodes per hour:
 CPAP is the treatment of choice for individuals with Obstructive sleep apnea. It is used in individuals
with >15 hypopneic episodes or >5 apneic episodes per hour.
 However, CPAP usage also has some disadvantages- Sometimes when a user is wearing a CPAP
machine, they will swallow air in the middle of the night. This can lead to uncomfortable bloating and
gas. Therefore, there’s a potential need for antacid use.
 
 Options B, C and D are incorrect according to the explanation.
Correct Option B - Nebulised tobramycin:
 Patients suffering with cystic fibrosis are predisposed to developing several opportunistic infections
such as Pseudomonas, S. aureus, Burkholderia etc.
 Nebulized tobramycin and aztreonam reduces the chances of lung colonization in these patients.
 
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Option A - N-acetyl cysteine: It is used as a mucolyitc in CF
Option C - Meropenem: It is the antibiotic of choice in treating Pseudomonas infections in CF
Option D
- Inhalational steroids: It is the treatment of choice for Allergic bronchopulmonary aspergillosis.
1218

Pulmonary Embolism & Fat Embolism
1. A 55-year-old patient presents with an acute onset of chest pain and dyspnea. The physician
suspects it is a case of pulmonary embolism. The patient is hemodynamically stable. Which
investigation is the initial imaging modality of choice in the given clinical scenario?
(or)
A 55-year-old patient is diagnosed with a case of pulmonary embolism. The patient is hemodynamically
stable. Which investigation is the initial imaging modality of choice in pulmonary embolism?
A. CTPA
B. V/P scan
C. HRCT
D. FAST
2. A man presents to the emergency department with difficulty breathing. He developed syncope,
hypotension, and tachycardia on the way. His tongue deviated to the left side on protrusion. An
elevated level of D-dimer (16.5 mg/mL) is noted. What is the most appropriate next investigation to be
done for this patient?
A. MRI chest
B. Bubble contrast echocardiography
C. CT scan chest
D. Impedance plethysmography
3. Pick the option with the correct statements regarding the treatment of pulmonary embolism a.
Primary therapy is pneumatic compression stockings b. Secondary prevention can be done by using
anticoagulation or IVC filters c. The target aPTT of 30–40 seconds is required for unfractionated
heparin therapy d. Warfarin and oral anticoagulants are to be started early e. Enoxaparin and
Fondaparinux require no monitoring f. Heparin-induced thrombocytopenia induced by unfractionated
heparin is controlled by bivalirudin
A. b, e and f
B. a, e and d
C. a, c and d
D. a, e and f
4. Which of the following diseases is not traditionally ruled out with a triple rule out CT chest?
A. Pulmonary Embolism
B. Acute aortic syndrome
C. Acute coronary syndrome
D. SVC syndrome
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5. Match the following options under 1. Massive pulmonary embolism and 2. Sub-massive pulmonary
embolism a. BP is reduced b. Normal chest x-ray c. ECG: S1 Q3 T3 d. BP is normal e. Right ventricle
hypokinesia f. Hampton hump on chest x-ray g. ECG shows sinus tachycardia h. Right ventricular
dilatation
A. 1 - b, d, g and h; 2 - a, c, e and f
B. 1 - a, d, e and h; 2 - b, c, f and g
C. 1 - b, c, f and g; 2 - a, d, e and h
D. 1 - a, c, e and f; 2 - b, d, g and h
6. All of the following signs are seen in a radiograph of a patient with pulmonary embolism, except
A. Palla's sign
B. Spinnaker sail sign
C. Hampton hump sign
D. Westermark sign
7. A 35-year-old male patient presented to the emergency department with complaints of confusion,
and breathing difficulty since the past hour. Examination showed petechiae all over the body, oxygen
saturation of 75% and heart rate of 120 beats per minute.The patient underwent surgical repair of his
fractured tibia four days ago. The patient’s chest X-ray revealed mild infiltrates in the lungs along with
some opacities.Identify the diagnosis, and pick the option which is least likely to cause this condition?
A. Total parental nutrition
B. Caissons disease
C. Cardiovascular surgery
D. Acute pancreatitis
8. All of the following are major criteria under Gurd and Wilson's criteria for the diagnosis of fat
embolism, except
A. Type 1 respiratory failure
B. Petechiae
C. Coma
D. Kidney dysfunction
9. In a patient presenting with recurrent deep vein thrombosis, which congenital hypercoagulable state
is most commonly associated with unopposed activity of factor V, leading to a procoagulant state?
A. Protein C deficiency
B. Antithrombin III deficiency
C. Factor V Leiden mutation
D. Factor XII deficiency
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Page 3
10. In a patient suspected of having a pulmonary embolism (PE), which radiographic sign indicates
focal oligemia due to emboli lodged in the right descending pulmonary artery?
A. Palla sign
B. Hampton hump
C. Westermark sign
D. S1Q3T3 pattern
11. In a patient with pulmonary embolism (PTE), which of the following changes is typically observed in
the left ventricle?
A. Increase in left ventricular cavity size
B. Increase in left ventricular end-diastolic volume (EDV)
C. Decrease in left ventricular cavity size
D. Decrease in left ventricular systolic volume (SV)
12. In a patient suspected of having a pulmonary embolism (PE), which sign is suggestive of deep vein
thrombosis when present along with other symptoms?
A. Murphy's sign
B. McBurney's sign
C. Blumberg's sign
D. Homan's sign
13. In a patient presenting with suspected sub-massive pulmonary thromboembolism (PTE), which of
the following findings is most likely to be observed on echocardiography?
A. Right ventricular dilation without left ventricular compromise
B. Left ventricular dilation without right ventricular involvement
C. Equal dilation of both right and left ventricles
D. Absence of ventricular dilation due to the small size of pulmonary emboli
14. Which of the following ECG findings is most indicative of Pulmonary Embolism (PE) in a patient
presenting with acute respiratory distress and chest pain?
A. Deep S wave in lead I
B. Deep Q wave in lead III
C. Inverted T wave in lead III
D. Tall R wave in lead V1
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15. A 55-year-old patient is diagnosed with pulmonary embolism and requires anticoagulation therapy.
Which of the following medications requires monitoring of activated partial thromboplastin time (aPTT)?
(or)
A. Unfractioned heparin
B. Enoxaparin
D. Novel oral anticoagulants
16. A 68-year-old patient has been diagnosed with pulmonary embolism and requires anticoagulation
therapy with warfarin. However, due to the delayed onset of action of warfarin, the patient needs to be
bridged with another anticoagulant for the first few days. Which of the following options best explains
the rationale for bridging therapy in this scenario?
(or)
Which of the following options best explains the rationale for bridging therapy in Warfarin?
A. To prevent heparin-induced thrombocytopenia
B. To achieve a more stable anticoagulant effect
C. To reduce the risk of bleeding complications
D. To avoid interactions with concomitant medications
17. A 55-year-old patient with a history of venous thromboembolism is at risk for developing massive
pulmonary thromboembolism (PTE). Which intervention best exemplifies primary prevention in this
scenario?
(or)
Which intervention best exemplifies primary prevention in massive pulmonary thromboembolism?
A. Alteplase therapy
B. Catheter-directed thrombolysis
C. Pneumatic compression stockings
18. A 20-year-old male presents to the emergency department after being involved in a motorcycle
accident resulting in a fractured femoral shaft. He undergoes surgery for the fracture, and within 12 to
72 hours postoperatively, he develops sudden onset dyspnea, altered sensorium, and petechiae that
are predominantly found in the axillary region compared to the rest of his body. Based on the clinical
presentation, which of the following is the most likely diagnosis?
(or)
What will be the diagnosis in a patient with fractured femoral shaft who developed sudden altered
sensorium, sudden onset dyspnea and petechiae that are predominantly found in the axillary region
compared to the rest of his body?
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Page 5
A. Acute respiratory distress syndrome (ARDS)
B. Pulmonary embolism (PE)
C. Fat embolism syndrome (FES)
D. Disseminated intravascular coagulation (DIC)
Correct option: A - CTPA
 Computed Tomography Pulmonary Angiography (CTPA) is the initial imaging modality of choice for
stable patients with a suspected pulmonary embolism
 Pulmonary angiography is the gold standard investigations that show emboli directly, but it is an
invasive procedure
 CT is noninvasive, cheaper, and widely available
 D-dimer is the screening investigation in patients with suspected pulmonary embolism
Incorrect option: B, C and D
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Page 8
Option C: a, c and d:
 c - The target aPTT is 60-80 seconds with unfractionated heparin (normal reference range for aPTT in
healthy adults is 30-40 seconds)
Option D: a, e and f - Refer to the above explanation
Correct Option D- SVC syndrome: SVC syndrome is not traditionally evaluated with a triple rule out CT 
scan.It is an investigation ordered in the setting of acute chest pain to evaluate the thoracic aortic, coro
nary and pulmonary arteries.
Triple rule-out CT Chest can be used to evaluate.
 Pulmonary Embolism
 Acute aortic syndrome
 Acute coronary syndrome
Incorrect Options A,B &C; (Pulmonary Embolism, Acute aortic syndrome &
Acute coronary syndrome: These are part of the triad
Correct Option: D - 1 - a, c, e and f; 2 - b, d, g and h
1. Massive pulmonary embolism
2. Sub-massive pulmonary embolism
a. BP is reduced
c. ECG: S1 Q3 T3
e. Right ventricle hypokinesia
f. Hampton hump on chest x-ray
b. Normal chest x-ray
d. BP is normal
g. ECG shows sinus tachycardia
h. Right ventricular dilatation
Incorrect options: A, B and C - Refer to the above explanation and learning outcome
Correct Option: B - Spinnaker sail sign:
 It is seen in pneumomediastinum
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Page 9
 
Incorrect options: A, C and D
Option A: Palla's sign - There is blockage by dislodged emboli on the pulmonary artery, which presents
 dilated to the proximal emboli, commonly seen in the right descending pulmonary artery
Option C: Hampton hump sign - Wedge-shaped infarction with apical sparing due to collaterals
Option D: Westermark sign - Due to focal oligemia resulting in a
collapse of vessels distal to the occlusion
Correct Option C- Cardiovascular surgery: is not typically a cause for fat embolism:
 In a patient presenting with breathing difficulty, confusion, tachycardia, and diffuse petechia following
long bone trauma, the likely diagnosis is fat embolism.
Options A, B, and D (Total parental nutrition, Caissons disease &
Acute pancreatitis): These are associated with an increased risk of fat embolism.
Correct option: D - Kidney dysfunction
 Kidney dysfunction comes under minor criteria of GURD
 The patient is having type I respiratory failure because of hyperventilation
 Retinal artery (breach in column)
 Petechiae
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Page 10
 Anuria
 Oliguria
Incorrect options: A, B and C - Type 1
respiratory failure, Petechiae and Coma - These are part of major Gurd and Wilson's criteria
 
Correct Option C - Factor V Leiden mutation:
 Factor V Leiden mutation is the most common congenital hypercoagulable state. This mutation results
in a procoagulant state where factor V is resistant to inactivation by protein C, leading to increased
thrombin generation and a higher risk of thrombosis. This mutation is a significant risk factor for
recurrent deep vein thrombosis and is often identified in patients with a personal or family history of
venous thromboembolism
 
Option A - Protein C deficiency: Protein C deficiency leads to decreased ability to regulate blood clottin
g, but it is not associated with unopposed activity of factor V.
Option B - Antithrombin III deficiency: Antithrombin III deficiency results in impaired inhibition of thrombi
n and other clotting factors, but it does not involve factor V specifically.
Option D - Factor XII deficiency: Factor XII deficiency is a rare disorder and is not commonly associate
d with recurrent deep vein thrombosis or unopposed factor V activity.
Correct Option C - Westermark sign:
 In a patient suspected of having a pulmonary embolism (PE), the Westermark sign on chest X-ray
indicates focal oligemia due to emboli lodged in the right descending pulmonary artery. This sign
manifests as a decreased vascular marking distal to the occlusion, resulting in a prominent area of
reduced vascularity in one lung compared to the other. It is characterized by a radiolucent area
representing pulmonary oligemia proximal to the embolism site.
 
Option A - Palla sign: This sign refers to the blockage by dislodged emboli in the pulmonary artery, cau
sing dilation proximal to the emboli. It is commonly seen in the right descending pulmonary artery.
Option B - Hampton hump: This sign refers to a wedge-shaped area of pulmonary infarction typically s
een on chest X-ray. It results from peripheral embolization leading to pulmonary infarction.
Option D - S1Q3T3 pattern: This ECG pattern is characterized by the presence of S waves in lead I, Q
waves in lead III, and T wave inversion in lead III. While it can suggest acute cor pulmonale associated
 with massive pulmonary embolism, it is not a radiographic sign seen on chest X-ray.
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Correct Option C - Decrease in left ventricular cavity size:
 In pulmonary embolism (PTE), the sudden increase in pulmonary vascular resistance due to
obstruction of the pulmonary arteries can lead to acute right ventricular (RV) strain and failure. As a
result, the right ventricle dilates while the left ventricular (LV) cavity size decreases. This decrease in
LV cavity size is caused by a decrease in left ventricular end-diastolic volume (EDV) due to reduced
filling secondary to impaired RV function and interventricular septal deviation towards the left ventricle.
This scenario typically results in a decrease in left ventricular systolic volume (SV) and blood pressure.
Therefore, option C is the correct choice.
 
Option A - Increase in left ventricular cavity size: This is not typically observed in pulmonary embolism. 
The RV strain and failure lead to a decrease in LV cavity size rather than an increase.
Option B - Increase in left ventricular end-diastolic volume (EDV): Pulmonary embolism causes a
decrease in LV EDV due to reduced filling, rather than an increase.
Option D - Decrease in left ventricular systolic volume (SV): This is a consequence of the decrease in L
V cavity size and EDV in pulmonary embolism, leading to reduced stroke volume and subsequent decr
ease in cardiac output.
Correct Option D - Homan's sign:
 Homan's sign is a clinical sign suggestive of deep vein thrombosis (DVT). It is elicited by dorsiflexing
the patient's ankle while their knee is flexed. A positive Homan's sign is indicated by pain in the calf
upon dorsiflexion. However, it's essential to note that Homan's sign alone is not highly specific for DVT
and must be considered along with other clinical findings and diagnostic tests for accurate diagnosis.
 
Option A - Murphy's sign: Associated with acute cholecystitis, where pain is elicited upon inspiration wh
ile palpating the gallbladder.
Option B - McBurney's sign: Indicates appendicitis, where there's tenderness at McBurney's point (loca
ted one-third of the distance from the anterior superior iliac spine to the umbilicus).
Option C - Blumberg's sign: Also known as rebound tenderness, it's indicative of peritonitis. Pain occur
s upon sudden release of pressure on the abdomen after palpation.
Correct Option A - Right ventricular dilation without left ventricular compromise:
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Page 12
 In sub-massive pulmonary thromboembolism (PTE), multiple small pulmonary emboli block small
arteries in the pulmonary artery, causing mild distension of the right ventricle without affecting the left
ventricle. This condition is characterized by right ventricular dilation without left ventricular compromise.
It's seen in about 65% of cases of PTE. Blood pressure tends to remain normal in patients with
sub-massive PTE.
 
Option B - Left ventricular dilation without right ventricular involvement: This scenario is less likely in su
b-massive PTE, as the primary effect is on the right side of the heart.
Option C - Equal dilation of both right and left ventricles: While it's possible for both ventricles to dilate i
n some cases, it's less characteristic of sub-massive PTE.
Option D
- Absence of ventricular dilation due to the small size of pulmonary emboli: Ventricular dilation is a com
mon finding in PTE, even with small emboli, especially when there are multiple emboli causing blockag
es in the pulmonary artery. Thus, the absence of ventricular dilation would be unexpected in suspected
 sub-massive PTE.
Correct Option C - Inverted T wave in lead III:
 Pulmonary embolism (PE) can lead to acute right heart strain due to increased pressure in the
pulmonary circulation. This strain can manifest as electrocardiogram (ECG) changes, particularly in the
right-sided leads. Inverted T wave in lead III is a common ECG finding suggestive of acute right heart
strain associated with PE. This finding is known as S1Q3T3 pattern, which includes a large S wave in
lead I, a Q wave and T wave inversion in lead III. These changes reflect acute right ventricular strain
and are consistent with PE.
 
Option A - Deep S wave in lead I: This may be seen in some cases of PE due to right ventricular overlo
ad, but it is not as specific as other ECG changes.
Option B - Deep Q wave in lead III: Deep Q wave in lead III, along with inverted T wave and large S wa
ve in lead I, is part of the S1Q3T3 pattern suggestive of acute right heart strain, but it is not as specific 
as the inverted T wave in lead III.
Option D - Tall R wave in lead V1: This finding is not typically associated with acute PE. Tall R
waves in lead V1 may be seen in conditions like right ventricular hypertrophy but are not specific to PE.
Option A -Unfractioned heparin
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 Unfractioned Heparin is an anticoagulant medication commonly administered parenterally
(intravenously or subcutaneously) for various indications, including the prevention and treatment of
thromboembolic disorders such as deep vein thrombosis (DVT) and pulmonary embolism (PE).
 It acts by potentiating the activity of antithrombin III, thereby inhibiting the activity of thrombin and
factor Xa in the coagulation cascade.
Option B - Enoxaparin:Enoxaparin is a low molecular weight heparin (LMWH) that is administered subc
utaneously and does not require monitoring of aPTT. However, it is given parenterally and is commonly
 used for the initial treatment of pulmonary embolism. Unlike unfractionated heparin (UFH), enoxaparin 
has a predictable anticoagulant effect, and monitoring is not routinely necessary.
Option C - Fondaparinux: Fondaparinux is a synthetic factor Xa inhibitor administered subcutaneously 
and does not require monitoring of aPTT. Similar to enoxaparin, it is used for initial treatment of pulmon
ary embolism. However, it differs in its mechanism of action, targeting factor Xa specifically.
Option D - Novel oral anticoagulants: Novel oral anticoagulants, such as dabigatran and betrixaban, ar
e direct oral anticoagulants (DOACs) that do not require parenteral administration or routine monitoring
 of coagulation parameters like aPTT or INR. They act by directly inhibiting specific coagulation factors,
 such as thrombin or factor Xa, and are often used as alternatives to warfarin for long-term anticoagulat
ion therapy.
 
Correct Option B - To achieve a more stable anticoagulant effect:
 When initiating warfarin therapy, it takes several days to achieve a therapeutic level due to its delayed
onset of action. During this time, there is a risk of thrombus progression or recurrence of
thromboembolic events. Bridging with another anticoagulant, such as unfractionated heparin (UFH),
low-molecular-weight heparin (LMWH), or fondaparinux, helps provide immediate anticoagulation until
warfarin reaches its therapeutic level. This approach ensures a more stable and continuous
anticoagulant effect, reducing the risk of thrombotic complications.
 
 Other answers are incorrect as explained.
Correct Option C - Pneumatic compression stockings:
 Primary prevention aims to prevent the occurrence of a condition or complication before it happens.
 In this case, the patient is at risk for developing massive PTE due to a history of venous
thromboembolism. Using pneumatic compression stockings is a form of mechanical prophylaxis to
prevent the formation of deep vein thrombosis (DVT), which can subsequently lead to pulmonary
embolism.
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 Pneumatic compression stockings exert pressure on the legs, helping to prevent blood stasis and
reducing the risk of DVT formation, particularly in patients with a history of venous thromboembolism.
 
 Options A and B involve thrombolytic therapy, which is typically used in the treatment of acute PTE
rather than primary prevention.
 Option D, anticoagulation with unfractionated heparin, is more commonly used as a secondary
prevention strategy or for the treatment of existing thromboembolic events rather than primary
prevention.
Correct Option C - Fat embolism syndrome (FES):
 The clinical presentation of sudden onset dyspnea, altered sensorium, and petechiae predominantly
in the axillary region following a femoral shaft fracture surgery strongly suggests fat embolism
syndrome (FES). Fat embolism occurs when fat globules enter the systemic circulation, often after
traumatic long bone fractures or orthopedic procedures. These fat globules can occlude pulmonary and
cerebral microvasculature, leading to respiratory and neurological symptoms, respectively. Petechiae,
particularly in the axillary region, are a classic finding in FES due to fat emboli impacting in the small
blood vessels of the skin.
 
 Other differential diagnoses, such as ARDS, PE, and DIC, may present with similar symptoms but are
less likely given the specific clinical scenario described. ARDS typically develops later and is
characterized by diffuse lung inflammation, PE typically presents with chest pain and hypoxemia, and
DIC often presents with bleeding manifestations alongside thrombosis.
1232

Emphysema & Bronchiectasis
1. A 42-year-old woman has been diagnosed with bronchiectasis. What is the investigation of choice for
bronchiectasis?
A. HRCT
B. Spiral CT
C. Bronchoscopy
D. Pulmonary angiography
2. A 29-year-old married male presents to the clinic with the complaint of recurrent chronic cough with
expectoration for the past 10-12 years. On auscultation, bilateral wheeze and right basal crackles are
audible, with heart sounds best heard on the right side of the chest. CT chest revealed dextrocardia,
and nodular opacities in bilateral lung fields suggest bronchiectasis. He also gives a history of not
having children despite being married for the last 4 years. Which of the following could be the probable
cause of infertility in patients with the above syndrome?
A. Oligospermia
B. Blockage of epididymis
C. Asthenospermia
D. Undescended testis
3. A patient was diagnosed with allergic bronchopulmonary aspergillosis (ABPA). Which of the following
findings will not be present in the patient?
(or)
A 28-year-old male patient was diagnosed with allergic bronchopulmonary aspergillosis (ABPA). Which
of the following findings will not be present in the patient?
A. Peripheral eosinophilia
B. Bronchiectasis
C. Pulmonary infiltrates
D. Thin sputum casts
4. A 35-year-old male patient comes to the outpatient department with complaints of breathing difficulty,
cough accompanied by excess amount of watery sputum for the past two months. His medical history
and prescriptions revealed that he is an HIV patient and is on antiretroviral therapy. Examination
showed low BMI, clubbing, and crepts on auscultation and an FEV1/FEC less than 0.7. A sputum exam
revealed copious mucopurulent discharge . Using the radiograph below, frame a diagnosis and mark
the option with the most common histopathological type and investigation of choice.
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Page 2
A. Cylindrical-CT
B. Tubular-Chest x-ray
C. Varicose-MRI
D. Saccular-CT
5. Which of the following causes of bronchiectasis traditionally involves the upper lobes?
A. Kartagener syndrome
B. Interstitial lung disease
C. Scleroderma
6. All of the following causes traction bronchiectasis except?
A. Radiation
C. Sarcoidoisis
D. Idiopathic pulmonary fibrosis
7. A 35-year-old patient with a history of asthma presents with recurrent episodes of cough, wheezing,
and increased dyspnea. The patient's serum IgE levels are elevated, and sputum examination reveals
fungal hyphae. A high-resolution computed tomography (HRCT) scan of the chest is performed to
further evaluate the respiratory findings. What characteristic finding is expected on the HRCT scan in
(or)
What characteristic finding is expected on the HRCT scan in Allergic Bronchopulmonary Aspergillosis
(ABPA)?
A. Peripheral consolidations
B. Ground-glass opacities
C. Subpleural blebs
D. Central bronchiectasis
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8. A 40-year-old patient presents with symptoms of chronic obstructive pulmonary disease (COPD),
including chronic cough, wheezing, and shortness of breath. The patient has a history of liver cirrhosis.
Upon further evaluation, it is discovered that the patient has impaired neutralization of elastase from
macrophages, leading to bronchiectasis. What is the underlying deficiency or dysfunction in this
(or)
Which of the following affect the neutralization of elastase and is associated with the development of
A. Deficiency of surfactant proteins
B. Dysfunction of cilia
C. Alpha-1 antitrypsin deficiency
D. Immunoglobulin deficiency
Option A: HRCT
 The investigation of choice for diagnosing bronchiectasis is HRCT (High-Resolution Computed
Tomography): It can identify focal areas of air trapping as an indicator of small airway disease (mosaic
attenuation) Airway dilatation can be gauged when seen in cross-section Luminal diameter >1.5 times
the adjacent vessel is indicative of bronchiectasis
 It can identify focal areas of air trapping as an indicator of small airway disease (mosaic attenuation)
 Airway dilatation can be gauged when seen in cross-section
 Luminal diameter >1.5 times the adjacent vessel is indicative of bronchiectasis
 Chest x-ray may be abnormal and shows the presence of increased pulmonary markings, ring-like
structures, atelectasis, dilated and thickened airways (tram lines), and mucus plugging (finger-in-glove)
 However, chest x-ray may be normal, even in bronchiectasis
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 The radiologic features include consolidation, tram track appearances due to mucus plugs in dilated
bronchi or permanent bronchiectasis or fibrosis.
 Ultimately, bronchial wall damage results in bronchiectasis, typically central bronchiectasis.
Option A - Peripheral eosinophilia:
 Peripheral eosinophilia is one of the minor criteria associated with ABPA
Option B - Bronchiectasis:
 Central bronchiectasis is characteristic
Option C - Pulmonary infiltrates:
 Pulmonary opacities disappear and appear in different areas of the lungs over a while as transient
pulmonary infiltrates
Correct Option A- Cylindrical CT: Cylindrical type is the most common type and -CT is the investigation
 of choice.
 The diagnosis is BRONCHIECTASIS
 Breathing difficulty, cough accompanied by bronchorrhea, in a patient in an immunocompromised
state and examination showing clubbing, ad crepitations on auscultation with FEV1/FEC < 0.7 helps in
the diagnosis of bronchiectasis.
 The CT shows dilated bronchi→ further confirming the diagnosis.
Option B- Tubular-Chest x-ray: Tubular is another name for the cylindrical subtype but it is incorrectly p
aired with Chest X ray as the investigation of choice.
Option C & D- (Varicose-MRI &
Saccular-CT): are also histological types but not the most common type.
Correct option: D (Tuberculosis): Tuberculosis is typically associated with upper lobe bronchiectasis
Lobes of lung involved in bronchiectasis
Upper lobe bronchiectasis:
Middle lobe bronchiectasis:
Lower lobe bronchiectasis: Usually seen in people with recurrent microaspiration
Correct option: B (Scleroderma): Scleroderma does not cause traction bronchiectasis
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Incorrect choices: Options A, C, and D can cause traction bronchiectasis.
Traction bronchiectasis: traction bronchiectasis is a type of bronchiectasis where airways become dilat
ed due to scarring or fibrosis in the surrounding lung tissue. There is a
distortion of the airways, which will hamper the ventilation and reduces the clearance of the lungs.
Causes of traction bronchiectasis:
Correct Option D - Central bronchiectasis:
 The clinical presentation, elevated serum IgE levels, and the presence of fungal hyphae in sputum
suggest Allergic Bronchopulmonary Aspergillosis (ABPA). On high-resolution computed tomography
(HRCT) of the chest in patients with ABPA, central bronchiectasis is a characteristic finding. This refers
to the dilation and distortion of the bronchi in the central or mid-lung zones.
 
Option A (Peripheral consolidations) and Option B (Ground-glass opacities) are not typical findings in A
BPA. Peripheral consolidations are often associated with other conditions, and ground-glass opacities 
are seen in various lung diseases but are not specific to ABPA.
Option C - Subpleural blebs: It is not a typical feature of ABPA on HRCT. Subpleural blebs are more co
mmonly associated with conditions like spontaneous pneumothorax rather than ABPA.
Correct Option C - Alpha-1 antitrypsin deficiency:
 Alpha-1 antitrypsin (AAT) is a protease inhibitor that plays a crucial role in neutralizing elastase, an
enzyme released by macrophages. In individuals with alpha-1 antitrypsin deficiency, there is a lack of
functional AAT, leading to the unopposed activity of elastase. This imbalance can result in damage to
the lung tissue, contributing to the development of bronchiectasis and panacinar emphysema.
 
Option A - Deficiency of surfactant proteins: Is not related to impaired neutralization of elastase; surfact
ant proteins are primarily involved in maintaining lung compliance and preventing alveolar collapse.
Option B - Dysfunction of cilia: It is not directly related to the impaired neutralization of elastase by alph
a-1 antitrypsin.
Option D - Immunoglobulin deficiency: It does not specifically affect the neutralization of elastase and i
s not associated with the development of bronchiectasis in the context described.
1239

Bronchial Asthma & COPD
1. Which of the following criteria will not require assisted ventilation in an asthmatic patient?
(or)
Which of the following criteria will not require assisted ventilation in an asthmatic patient?
A. PEFR 50-60% of predicted value
B. Rising PaCO2> 6 kPa (45 mmHg)
C. Diminishing level of consciousness
D. Falling PaO2< 8 kPa (60 mmHg)
2. Which of the following drugs or techniques is used in an adverse event following type 2 brittle
asthma?
(or)
A 32-year-old man comes to the emergency department with an acute asthma exacerbation. The
patient has a 9-year history of asthma, for which he uses an inhaler containing a combination of inhaled
corticosteroid (ICS) and long-acting β-agonist (LABA) as needed. For the past 2 years, he has been
using this combination inhaler about 2 times per week. The patient has seasonal allergies to ragweed
and is also allergic to peanuts. The patient does not use tobacco, alcohol, or illicit drugs. His family
history is significant for asthma in his grandfather. Which of the following drugs or techniques is used in
an adverse event following type 2 brittle asthma?
A. β-adrenergic agonist
B. Allergy desensitization
C. Ipratropium bromide
D. Subcutaneous epinephrine
3. A patient has had a persistent cough and difficulty breathing on exertion for the past 2 months.
Prominent wheezing is present. A sputum examination showed the following finding. What is the most
(or)
A 14-year-old male patient who has been having persistent coughing and difficulty breathing for the
past 2 months attends the OPD. On chest auscultation, wheezing is present. Blood cell counts, serum
electrolyte levels, and chest x-ray is normal. A sputum examination was done, showing the following
finding. What is the most likely diagnosis?
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Page 2
A. Tuberculous cavity
B. Asthma
C. Chronic bronchitis
D. Bronchiectasis
4. An increased Reid index is classically associated with which of the following conditions?
A. Chronic bronchitis
B. Emphysema
C. Bronchiectasis
D. Interstitial lung disease
5. A man comes with increasing shortness of breath, especially on exertion. History of smoking.
Oxygen saturation of 85% in room air at rest. The chest is barrel-shaped. Breath sounds are diminished
throughout, and the expiratory phase is prolonged. Which of the following decreases mortality in this
patient?
A. Influenza and pneumococcal vaccination
B. Bronchodilators
C. Long-term oxygen therapy(LTOT)
D. Mucolytics
6. Which of the following is used in the treatment of cough-variant asthma?
A. Low dose ICS once a day
B. LABA once at night
C. SABA twice daily
D. Antitussive lozenges when required
7. A 59-year-old man with a history of chronic obstructive pulmonary disease (COPD) comes to the
emergency department with gradually worsening shortness of breath and wheezing for the past several
days. On examination, FEV1/ FVC < 0.7 and FEV1 <30% predicted. Which GOLD group category is
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Page 3
this patient in?
A. Group 1
B. Group 2
C. Group 3
D. Group 4
8. An 18-year-old male with a history of cystic fibrosis. While attending a class, he suddenly begins to
cough up large volumes of bright red blood. He was admitted to a nearby hospital in the emergency
department. Which of the following vessel is most likely to bleed and results in hemoptysis in this
patient?
(or)
A cystic fibrosis patient. While attending a class, he suddenly begins to cough up large volumes of
bright red blood. Which of the following vessel is most likely to bleed and results in hemoptysis in this
patient?
A. Bronchial arteries
B. Alveolar capillaries
C. Gastric varices
D. Pulmonary artery
9. Which of the following is associated with the most severe form of alpha-1 antitrypsin deficiency?
A. PI M allele
B. PI S allele
C. PI Z allele
D. PI P allele
10. The image shows a questionnaire being done on a patient. Identify the disease for which it is done.
A. Bronchial asthma
B. COPD
C. Obstructive sleep apnea
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Page 4
11. The BODE index, which is used to predict the mortality of COPD patients, includes all of the
following except
A. BMI
B. HRCT
C. FEV1
D. 6 minute walk distance
12. A 25-year-old male patient presented to the emergency department with complaints of severe
breathing difficulty. The patient could only speak a few words. The patient got up from a supine position
and sat on the bed in a tripod position. The patient has tachycardia and tachypnea. Auscultation
revealed loud ronchi, and the sputum was sent for examination as shown below. The spirometry value
was found to be FEV1 of 30% of predicted with a PaO2 of 58 mmHg. The patient states that he had
such similar episodes in the past. Diagnose the disease and pick the option with the appropriate
A. Air-driven nebulization with salbutamol
B. Elective intubation with assisted controlled mechanical ventilation
C. Low-dose inhaled corticosteroids (ICS) with formoterol (LABA)
D. IV hydrocortisone + salbutamol nebulization
13. A 30-year-old female was accompanied by her friend to the emergency department with a
complaint saying that she suddenly started feeling drowsy and had breathing difficulty. The patient has
a history of similar episodes in the past, according to her friend. She has tachypnea and bradycardia
and appears drowsy and unable to talk or answer any questions. Examination revealed FEV of 20%,
PaO2 of 50 mmHg, and pCO2 > 46 mmHg. Diagnose the condition and mark the option with
appropriate management.
A. Elective intubation is recommended with SIMV with pressure support + Permissive hypercapnia
B. Elective intubation is recommended with volume limit assist control ventilation + Permissive
hypocapnia
C. Elective intubation is recommended with assisted controlled mechanical ventilation + Permissive
hypercapnia
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Page 5
D. Elective intubation is recommended with assisted controlled mechanical ventilation + Permissive
14. Match the following controller medication with their respective stages of asthma and FEV1 values 1)
Asthma attacks less than two days a week+ FEV1 more than 80% a) Low dose ICS+formetrol on daily
basis 2) Asthma attacks more than two days a week+FEV1 more than 82% b) Low dose
ICS+formetrol(as needed) 3) Daily asthma attacks+FEV1 of 70% c) High dose ICS + LABA with add on
therapies 4) Asthma attacks throughout the day+FEV1 of 50% d) Low dose ICS on daily basis
1) Asthma attacks less than two days a week+ FEV1 more than 80% a) Low dose ICS+formetrol on daily basis
2) Asthma attacks more than two days a week+FEV1 more than 82% b) Low dose ICS+formetrol(as needed)
3) Daily asthma attacks+FEV1 of 70% c) High dose ICS + LABA with add on therapies
4) Asthma attacks throughout the day+FEV1 of 50% d) Low dose ICS on daily basis
A. 1-d,2-b,3-c,4-a
C. 1-c,2-a,3-d,4-b
D. 1-c,2-a,3-b,4-d
15. Match the following sets with 1) types of asthma with 2) their respective management? SET 1 SET
2 1) Acute asthma 2) Severe acute asthma 3) Immitent respiratory arrest 4) Brittle asthma a) Intubation
with ACMV b) Epi-PEN c) Low dose ICS+LABA d) Nebulization with salbutamol + I.V. hydrocortisone
SET 1 SET 2
1) Acute asthma2) Severe acute asthma3) Immitent respiratory arrest4) Brittle asthma a) Intubation with ACMVb) Epi-PENc) Low dose ICS+LABAd) Nebulization with salbutamol + I.V. hydrocortisone
B. 1-d,2-b,3-c,4-a
C. 1-a,2-c,3-b,4-d
D. 1-c,2-d,3-a,4-b
16. A 30-year-old female reports that she walks slower than her peers, even on a flat surface, because
of breathlessness. Mark the option with the appropriate mMRC grading.
A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4
17. Match the following options: 1. Emphysema a. Tall thin smoker 2. Chronic bronchitis b. Normal
DLCO c. Hyperinflation seen on chest x-ray d. Type 2 respiratory failure e. Obese smoker f. Type 1
respiratory failure g. Increased bronchovascular markings seen on chest x-ray h. Reduced DLCO
1. Emphysema a. Tall thin smoker
2. Chronic bronchitis b.  Normal DLCO
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Page 6
c. Hyperinflation seen on chest x-ray
d. Type 2 respiratory failure
e. Obese smoker
f. Type 1 respiratory failure
g. Increased bronchovascular markings seen on chest x-ray
h. Reduced DLCO
A. 1 - a, d, g and h; 2 - b, c, e and f
B. 1 - a, c, f and h; 2 - b, d, e and g
C. 1 - b, c, e and f; 2 - a, d, g and h
D. 1 - b, d, e and g; 2 - a, c, f and h
18. Which of the following is not a contraindication for non invasive ventilation?
A. Myocardial infarction
B. Bilateral pneumonia
C. Hemodynamic instability
D. Unresponsive patient
19. In the diagnosis of bronchial asthma, which of the following changes in Forced Expiratory Volume in
1 second (FEV1) is considered diagnostic for bronchial asthma?
A. A decrease of 5% in FEV1
B. An increase of 10% in FEV1
C. A decrease of >12% or 200 mL from baseline in FEV1
D. No change in FEV1 after bronchodilator administration
20. A 30-year-old patient with a history of asthma has been using salbutamol (SABA) as the sole
treatment for symptom relief. However, recent updates in the GINA guidelines suggest a change in the
approach to asthma management. What is the primary concern associated with relying solely on SABA
for asthma treatment, as highlighted in the updated guidelines?
A. Reduced efficacy in providing quick relief of asthma symptoms
B. Increased risk of asthma-related death and urgent healthcare
C. Poor adherence to medication in patients with infrequent symptoms
D. Higher incidence of exacerbations in children aged 6-11 years
21. A 42-year-old patient with severe type 2 asthma has been experiencing persistent symptoms
despite standard asthma management. Which of the following medications is specifically indicated for
use as an add-on treatment in severe type 2 asthma?
A. Tiotropium
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Page 7
B. Omalizumab
C. Mepolizumab
D. Dupilumab
22. A 35-year-old patient with a history of asthma presents to the emergency department with
worsening symptoms. On examination, the patient's FEV1 is measured at 50% of the predicted value.
Arterial blood gas analysis reveals a PaO2 level of 65 mmHg. Based on these findings, how would you
classify the current asthma exacerbation?
A. Mild exacerbation
B. Moderate exacerbation
C. Severe exacerbation
D. The classification cannot be determined from the provided information.
23. In a patient presenting with chronic dyspnea and a long history of smoking, a physical examination
reveals paradoxical inward movement of the ribcage during inspiration. Which of the following options
best describes this characteristic finding, known as the "Hoover sign," commonly observed in patients
with chronic bronchitis?
(or)
Which of the following options best describes the "Hoover sign," commonly observed in patients with
chronic bronchitis?
A. Paradoxical elevation of the diaphragm during inspiration
B. Paradoxical expansion of the chest wall during expiration
C. Paradoxical inward movement of the ribcage during inspiration
D. Paradoxical bulging of the intercostal spaces during coughing
24. In a patient with chronic bronchitis and a history of smoking cessation attempts, which medication
acts as an α4 β2 partial agonist of nicotine receptors to aid in nicotine deaddiction?
A. Nicotine buccal spray
B. Bupropion
C. Varenicline
D. Video-assisted thoracoscopic surgery
25. A 65-year-old patient presents to the clinic with complaints of worsening shortness of breath and
chronic cough. Spirometry results show an FEV1/FVC ratio of less than 0.7. However, the FEV1
percentage is measured at 45%. Based on the GOLD classification of COPD, how would you
categorize the severity of this patient's condition?
A. Mild COPD
B. Moderate COPD
C. Severe COPD
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Page 8
D. Very Severe COPD
26. In a patient experiencing a severe exacerbation of COPD, which of the following FEV1 values is an
indication to initiate Non-Invasive Ventilation (NIV) therapy?
A. FEV1 < 20%
B. FEV1 < 40%
C. FEV1 < 60%
D. FEV1 < 80%
27. In patients with COPD, which of the following biomarkers indicates disease severity and serves as
an indication to start Inhaled Corticosteroids (ICS)?
A. Neutrophil count > 500
B. Eosinophil count > 300
C. Lymphocyte count > 400
D. Basophil count > 100
28. A 45-year-old patient reports a smoking history of 20 cigarettes per day for the past 25 years. What
is the patient's pack-year history?
A. 25 pack-years
B. 50 pack-years
C. 75 pack-years
D. 65 pack-years
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Page 14
Correct option: D - Group 4
Incorrect options: A, B and C
Option A: Bronchial arteries
 Hemoptysis is a common feature in patients with bronchiectasis and cystic fibrosis due to chronic
inflammation and anatomical abnormalities that bring the bronchial arteries closer to the mucosal
surface.
 These blood vessels are presently closer to air space, because of which even a smaller degree of
inflammation in these areas can lead to the rupture of vessels into the airway.
 Bronchial arteries are under systemic pressure; thus, they are prone to large amounts of bleeding.
Option B: Alveolar capillaries
 The lungs have a dual blood supply from the pulmonary arteries and the bronchial arteries.
 The latter arises as a rule from the aorta and is the source of 90% of the cases of hemoptysis.
 Bleeding into the alveolar spaces of the lungs characterizes the syndrome of diffuse alveolar
hemorrhage (DAH) and is due to disruption of the alveolar-capillary basement membrane.
Option C: Gastric varices
 Gastric varices (GV) are a bunch of vessels in the mucosa/submucosa of the stomach and part of a
complex collection of vascular shunts between the portal and systemic circulation that develop in the
setting of portal hypertension due to any etiology with or without cirrhosis.
 The increased pressure and portal blood flow in the portosystemic circulation due to the above factors
lead to gastric varices causing elevated intra-variceal pressure and wall tension, increasing the risk of
variceal rupture leading to a life-threatening GI bleed, not hemoptysis.
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Page 16
BODE (Body mass index, airflow Obstruction, Dyspnea, and Exercise) index:
Correct option: D - IV hydrocortisone + salbutamol nebulization
 The diagnosis is bronchial asthma
 The image shows Curschmann's spirals found in the sputum of asthmatic patients
 FEV1 of 30% of expected with PaO2 of 70mmHg = Severe acute asthma
 IV hydrocortisone + salbutamol nebulization helps in relieving the symptoms
Option A - Air-driven nebulization with salbutamol: Air-driven nebulization can lead to ventilation-perfusi
on mismatch
Option B - Elective intubation with assisted controlled mechanical ventilation: This is done in imminent r
espiratory failure
Option C - Low dose inhaled corticosteroids (ICS) with formoterol (LABA): This is a
basic controller or prevention medication and would be inadequate in this scenario
Correct option: C
- Elective intubation is recommended with assisted controlled mechanical ventilation +
Permissive hypercapnia
 Drowsiness, breathing difficulty, not answering any of the questions put forth by the doctor,
accompanied by tachypnea and bradycardia, and an FEV of 20%, a PaO2 of 50 mmHg, and a pCO2 >
46% help in the diagnosis of imminent respiratory failure caused by bronchial asthma
 ACMV ensures a backup minute ventilation in the absence of an intact respiratory drive and allows for
synchronization of the ventilator cycle with the patient's inspiratory effort
 Permissive hypercapnia aims to minimize lung damage during mechanical ventilation
Option A - Elective intubation is recommended with SIMV with pressure support + Permissive hypercap
nia: SIMV (Synchronized Intermittent Mandatory Ventilation) modality is not used here
Option B and D - Elective intubation is recommended with volume limit assist control ventilation + Perm
issive hypocapnia and Elective intubation is recommended with assisted controlled mechanical ventilati
on + Permissive hypocapnia: These options describe permissive hypocapnea: Permissive hypercapnia
 rather than hypocapnia is followed
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Correct Option B - Bilateral pneumonia:
 Is not a contraindication for NIV use
Option A, B and D: These are contraindications for the use of non invasive 
Correct Option C - A decrease of >12% or 200 mL from baseline in FEV1:
 The main diagnostic criteria for bronchial asthma involve the reversibility of airflow obstruction
demonstrated by spirometry.
 In patients with asthma, the baseline curve for the inspiration part remains the same, but there is
marked concavity in the expiration part due to difficulty pushing out air during expiration.
 After administering a bronchodilator like salbutamol, the test is repeated in 10-15 minutes. In cases of
asthma, there is a significant reduction in concavity.
 The diagnostic change in FEV1 for bronchial asthma is considered when there is a decrease of >12%
or 200 mL from the baseline value of FEV1 after bronchodilator administration.
 
Option A - A decrease of 5% in FEV1: This criterion is not sufficient for the diagnosis of bronchial asth
ma. The diagnostic threshold is >12% or 200 mL.
Option B - An increase of 10% in FEV1: An increase in FEV1 is not a
diagnostic criterion for bronchial asthma; the focus is on a decrease in FEV1.
Option D - No change in FEV1 after bronchodilator administration: Lack of improvement or no change i
n FEV1 after bronchodilator administration would not be consistent with the expected response in bron
chial asthma.
Correct Option B - Increased risk of asthma-related death and urgent healthcare:
 Recent updates in the GINA (Global Initiative for Asthma) guidelines no longer recommend the use of
SABA (Short-Acting Beta-Agonist) as the only treatment for asthma in adults. Studies have shown that
patients treated only with salbutamol (SABA) are found to have a higher incidence of asthma-related
death and urgent healthcare. While SABAs are effective for providing quick relief of asthma symptoms,
relying solely on them poses risks to patients, emphasizing the importance of comprehensive asthma
management strategies, including controller medications.
 
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Option A - Reduced efficacy in providing quick relief of asthma symptoms: This statement is not aligne
d with the explanation provided. SABAs are generally effective for quick relief of asthma symptoms. Th
e primary concern with using SABA alone is related to long-term outcomes, not immediate symptom rel
ief.
Option C - Poor adherence to medication in patients with infrequent symptoms: Adherence issues are 
not the primary concern highlighted in the updated guidelines. The focus is on the increased risk of ast
hma-related death and urgent healthcare when relying solely on SABA, irrespective of adherence.
Option D - Higher incidence of exacerbations in children aged 6-11 years: The guidelines mention poss
ible controller options for children aged 6-11 years, such as using inhaled corticosteroids (ICS) alongsi
de SABA. However, the primary concern mentioned in the updates is not about exacerbations in this a
ge group but rather the risk associated with using SABA alone in adults.
Correct Option D - Dupilumab:
 Dupilumab is an add-on treatment indicated for severe type 2 asthma. It functions as an anti-IL–4/4R,
targeting the interleukin-4 receptor, which plays a role in the type 2 inflammatory pathway associated
with severe asthma. This medication is specifically designed for patients with persistent symptoms
despite standard asthma management.
 
Option A - Tiotropium: Tiotropium is a long-acting anticholinergic bronchodilator (LAMA) that is used in 
the treatment of chronic obstructive pulmonary disease (COPD) but is not a
primary add-on treatment for severe type 2 asthma.
Option B - Omalizumab: Omalizumab is an anti-IgE monoclonal antibody used in severe allergic asthm
a. While it is effective in type 2 asthma, it targets IgE rather than IL–4/4R.
Option C - Mepolizumab: Mepolizumab is an anti-IL-5 monoclonal antibody indicated for severe eosino
philic asthma. It primarily targets the IL-5 pathway, which is associated with eosinophilic inflammation i
n asthma.
Correct Option B - Moderate exacerbation:
 Mild exacerbation: FEV1 > 70%, PaO2 Normal
 Moderate exacerbation: FEV1 40-69%, PaO2 > 60 mmHg
 Severe exacerbation: FEV1 < 40%, PaO2 > 60 mmHg
In this case, the patient's FEV1 is 50%, falling within the range for a moderate exacerbation. Additionall
y, the PaO2 is greater than 60 mmHg. Therefore, the classification of the current asthma exacerbation i
s moderate.
 
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 Other options are incorrect according to explanation.
Correct Option C - Paradoxical inward movement of the ribcage during inspiration:
 The "Hoover sign" is a characteristic finding observed in patients with emphysema. It refers to the
paradoxical inward movement of the lower ribcage during inspiration instead of the expected outward
expansion. This phenomenon occurs due to the loss of elastic recoil in emphysematous lungs, leading
to decreased lung volume and ineffective chest wall expansion during inspiration.
 
Option A - Paradoxical elevation of the diaphragm during inspiration: This option describes the opposit
e phenomenon known as paradoxical diaphragmatic movement, which is not typically associated with c
hronic bronchitis.
Option B - Paradoxical expansion of the chest wall during expiration: This option does not accurately d
escribe the Hoover sign. In chronic bronchitis, the chest wall tends to collapse inward during inspiration
 rather than expanding paradoxically during expiration.
Option D - Paradoxical bulging of the intercostal spaces during coughing: This option describes an unr
elated phenomenon and is not associated with the Hoover sign seen in chronic bronchitis.
Correct Option C - Varenicline:
 Varenicline is a medication used to aid in smoking cessation by acting as a partial agonist of the α4 β2
nicotinic acetylcholine receptor, which helps reduce nicotine cravings and withdrawal symptoms. It
works by both reducing the rewarding effects of nicotine and reducing the severity of withdrawal
symptoms. This makes it an effective option for individuals trying to quit smoking.
 
Option A - Nicotine buccal spray: This is a form of nicotine replacement therapy that delivers nicotine di
rectly into the bloodstream through the lining of the mouth, helping to reduce withdrawal symptoms duri
ng smoking cessation.
Option B - Bupropion: Bupropion is an antidepressant medication that is also used as an aid for smokin
g cessation. It works by reducing the desire to smoke and decreasing withdrawal symptoms.
Option D - Video-assisted thoracoscopic surgery: This surgical procedure, known as bullectomy, involv
es removing large air spaces (bullae) that have developed in the lungs, typically in patients with severe
 emphysema. It is not directly related to smoking cessation or nicotine addiction treatment.
 
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Correct Option C - Severe COPD:
 According to the GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification of
COPD, severity is categorized based on the post-bronchodilator FEV1 (forced expiratory volume in 1
second) percentage predicted and the FEV1/FVC (forced vital capacity) ratio.
 Severe COPD is defined by an FEV1/FVC ratio less than 0.7 and an FEV1 between 30% and 49% of
the predicted value.
 In this case, the patient's FEV1 percentage is measured at 45%, falling within the range for severe
COPD.
 
 Other options are incorrect as explained.
Correct Option B - FEV1 < 40%:
 During a severe exacerbation of COPD, the initiation of Non-Invasive Ventilation (NIV) therapy is
indicated when the FEV1 (Forced Expiratory Volume in 1 second) falls below 30-50% of the predicted
normal value. This signifies a significant impairment in lung function, indicating the need for ventilatory
support to assist with respiratory effort and gas exchange.
 
Option A - FEV1 < 20%: This level of FEV1 reduction is extremely severe and generally indicative of ve
ry severe COPD. However, NIV therapy is usually indicated at a
slightly higher FEV1 threshold of <30-50%.
Option C - FEV1 < 60%: While this level of FEV1 reduction indicates moderate to severe COPD, it doe
s not meet the criteria for initiating NIV therapy during an exacerbation, as the threshold is typically set 
lower at <30-50%.
Option D - FEV1 < 80%: This level of FEV1 reduction is indicative of mild to moderate COPD and does
 not meet the criteria for initiating NIV therapy during an exacerbation.
Correct Option B - Eosinophil count > 300:
 Eosinophil count greater than 300 cells/µL is considered a biomarker of disease severity in COPD and
indicates a higher risk of exacerbations. It serves as an indication to start Inhaled Corticosteroids (ICS),
which can help reduce exacerbations and improve outcomes in these patients.
 
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 Neutrophil count > 500, lymphocyte count > 400, and basophil count > 100 are not commonly used as
biomarkers of disease severity in COPD and are not specific indicators for initiating ICS therapy.
Correct Option A - 25 pack-years:
 To calculate pack-years, we multiply the number of cigarette packs smoked per day by the number of
years smoked, and then divide by 20.
Given:
Number of cigarettes smoked per day = 20
Number of years smoked = 25
Pack-years = (Number of cigarettes/day × years) / 20
= (20 × 25) / 20
= 25
So, the correct answer is:
 
 Other options are incorrect according to the explanation
1261

Acute Respiratory Distrress Syndrome & Respiratory
Failure
1. Match the following conditions with their respective types of respiratory failure 1. ARDS a.
Respiratory failure type 2 2. Status asthmaticus b. Respiratory failure type 4 3. Peri-operative
atelectasis c. Respiratory failure type 1 4. Cardiogenic shock d. Respiratory failure type 3
1. ARDS a. Respiratory failure type 2
2. Status asthmaticus b. Respiratory failure type 4
3. Peri-operative atelectasis c. Respiratory failure type 1
4. Cardiogenic shock d. Respiratory failure type 3
A. 1-d, 2-a, 3-c, 4-b
B. 1-a, 2-d, 3-b, 4-c
C. 1-c, 2-a, 3-d, 4-b
D. 1-a, 2-c, 3-b, 4-b
2. In a patient presenting with respiratory distress and cardiogenic shock, which type of respiratory
failure is primarily caused by underperfusion of respiratory muscles?
B. Type 2 respiratory failure
C. Type 3 respiratory failure
D. Type 4 respiratory failure
3. In a postoperative patient, which type of respiratory failure is primarily attributed to perioperative
atelectasis and inadequate analgesia?
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 Type 4 respiratory failure, also known as respiratory muscle pump failure, occurs due to
underperfusion of respiratory muscles, particularly in conditions such as cardiogenic shock. In
cardiogenic shock, decreased cardiac output leads to inadequate perfusion of respiratory muscles,
resulting in respiratory distress. Management involves addressing the underlying cause of shock, such
as with interventions like Impella or inotropes, and providing respiratory support with interventions like
endotracheal intubation and intermittent positive pressure ventilation.
 
Option A - Type 1 respiratory failure: Characterized by low arterial oxygen levels (hypoxemia) with nor
mal or low arterial carbon dioxide levels (normocapnia or hypocapnia). It is typically seen in conditions 
causing impaired gas exchange, such as pneumonia or pulmonary edema.
Option B - Type 2 respiratory failure: Characterized by low arterial oxygen levels (hypoxemia) along wit
h high arterial carbon dioxide levels (hypercapnia). It is commonly associated with conditions causing v
entilatory failure, such as severe COPD or neuromuscular diseases.
Option C - Type 3 respiratory failure: Due to Peri-op atelectasis
Correct Option C - Type 3 respiratory failure:
 Type 3 respiratory failure is caused by perioperative atelectasis, which commonly occurs in obese or
elderly patients under general anesthesia. Atelectasis leads to decreased functional residual capacity
(FRC) and collapse of basal lung segments, resulting in decreased oxygen saturation. Additionally,
inadequate analgesia can cause patients to hyperventilate, leading to carbon dioxide washout and
respiratory alkalosis. These factors collectively contribute to type 3 respiratory failure.
 
Option A - Type 1 respiratory failure: Characterized by low oxygen levels (hypoxemia) with normal or lo
w carbon dioxide levels. It is often caused by impaired gas exchange in the lungs, such as in pneumoni
a or pulmonary edema.
Option B - Type 2 respiratory failure: Characterized by low oxygen levels (hypoxemia) along with high c
arbon dioxide levels (hypercapnia). It is typically seen in conditions causing ventilatory failure, such as 
neuromuscular disorders or drug overdose.
respiratory failure: This type of respiratory failure, not mentioned in the context, is primarily due to a de
crease in oxygen levels (hypoxemia) secondary to circulatory failure or shock, as seen in cardiogenic s
hock or severe sepsis.
1264

Tuberculosis
1. A 67-year-old man presented to the OPD with complaints of chronic cough and fatigue for 2 weeks.
He was recently diagnosed with pulmonary tuberculosis and treated with a four-drug anti-tuberculous
treatment. The patient stated he had had small amounts of blood-streaked sputum for the past 2
weeks, but immediately before coming to the emergency department, he had coughed up a large
volume of blood, estimated to be greater than 250 ml of fresh blood. The procedure of choice for
controlling massive hemoptysis in this case is?
(or)
The procedure of choice for controlling massive hemoptysis in this case is?
A. Balloon catheter tamponade
B. Rigid bronchoscopy and photocoagulation
C. Bronchial artery embolization
D. Flexible bronchoscopy and cautery
2. Match the following nomenclature with their respective lesion sites in tuberculosis 1. Puhl's lesion a.
Inactive supraclavicular lesion 2. Assman focus b. TB meningitis 3. Weigerts focus c. Active
supraclavicular lesion 4. Rich focus d. Infraclavicular lesion 5. Simonds focus e. Liver 6. Simon focus f.
Pulmonary vein
1. Puhl's lesion a. Inactive supraclavicular lesion
2. Assman focus b. TB meningitis
3. Weigerts focus c. Active supraclavicular lesion
4. Rich focus d. Infraclavicular lesion
5. Simonds focus e. Liver
6. Simon focus f. Pulmonary vein
A. 1-c, 2-d, 3-f, 4-b, 5-e, 6-a
B. 1-a, 2-d, 3-b, 4-e, 5-c, 6-f
C. 1-f, 2-c, 3-e, 4-b, 5-d, 6-a
D. 1-e, 2-c, 3-a, 4-b, 5-d, 6-f
3. Most common site for Extrapulmonary TB?
A. Pleura
B. Lymph node
C. Abdominal TB
D. Genito-urinary TB
4. All of the following are indications for CBNAAT except?
A. Smear negative, X-ray positive.
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B. Extra-pulmonary TB
C. Smear negative, X-Ray unavailable.
D. Smear Positive, X-Ray negative
5. What is the treatment for a cold abscess?
A. Anti tubercular therapy
B. Incision and drainage
C. Anti tubercular therapy with antigravity drainage
D. Antibiotics
6. What is a ranke complex?
A. A Ghon focus with ipsilateral mediastinal lymphadenopathy
B. A calcified Gohn complex
C. A caseating granuloma
D. A primary calcification
7. Where is a Rassmusens aneurysm found?
B. Bronchial artery
D. Pulmonary vein
8. Snowstorm appearance on chest x-ray is seen in all these except?
A. Miliary TB
B. Silicosis
C. Hemosiderosis
D. Sarcoidosis
9. Which of the following is the correct order of most common to least common sites of extrapulmonary
tuberculosis?
A. Lymph node> pleura> genitourinary tract
B. Pleura> genitourinary tract>lymph node
C. Genitourinary tract>lymph node> pleura
D. Genitourinary tract>pleura>lymph node
10. All of the following are pleural fluid findings seen in pleural tuberculosis except
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A. Lymphocyte predominance
B. Decreased glucose levels
C. Elevated protein levels
D. Decreased levels of Adenosine deaminase (ADA)
11. XDR tb is resistant to all of the following drugs except?
A. Rifampin
B. Fluroquinolone
C. Kanamycin
D. Clofazimine
12. All of the following drugs are used in the treatment of HIV TB except
A. Rifampicin
B. Rifabutin
C. Isoniazid
D. Ethambutol
Correct option: C - Bronchial artery embolization
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Correct Option B - Lymph node:
 Lymph node is the most common site for extrapulmonary TB
 
Correct Option D - Smear Positive, X-Ray negative:
 A patient with a positive sputum smear for acid fast bacilli is considered to be a case of
microbiologically confirmed tuberculosis and does not require further testing with CBNAAT/GENE
Xpert.
Smear + CXR+
Smear + CXR +
Smear – CXR +
Smear –
CXR: Not available clinical suspicion
Microbiological confirmed TB
CBNAAT
PLHIV/MDR TB Suspicion
 
Correct Option - Option C:
 Anti tubercular therapy (given for 6 months) along with antigravity drainage is the choice of treatment
for cold abscess
 
Option A - Anti tubercular therapy: Anti tubercular therapy alone isn't sufficient in treating cold abscess
Option B - Incision and drainage: Incision and drainage should not be done for a
cold abscess because it contains live bacteria that can cause fistula formation.
Option D - Antibiotics: Antibiotics are not indicated for the treatment of cold abscess
1269

Pneumoconiosis & Interstitial Lung Disease
1. A 38-year-old female patient presents to the OPD with a productive cough and dyspnoea. The CT
chest of the patient is given below. Which of the following findings is shown in the CT scan?
(or)
Which of the following findings is shown in the CT scan?
A. Ground glass pattern
B. Honeycomb pattern
C. Crazy pavement pattern
D. Normal Scan
2. A 37-year-old male diagnosed with Sjogren syndrome presents to the clinic complaining of
progressive shortness of breath. Further evaluation revealed an interstitial lung disease. Which subtype
of interstitial lung disease is seen in patients with Sjogren syndrome?
(or)
Which subtype of interstitial lung disease is seen in patients with Sjogren syndrome?
A. Usual interstitial pneumonia
B. Non-specific interstitial pneumonia
C. Acute interstitial pneumonia
D. Cryptogenic organising pneumonia
3. A 55-year-old female patient presents with breathlessness on exertion and a dry cough for a month.
On chest examination, there are fine inspiratory crackles. HRCT shows a bilateral, subpleural and
basilar honeycombing pattern. Which pattern is expected in the pulmonary function tests of this
patient?
(or)
A patient presents with breathlessness on exertion and a dry cough for a month. On chest examination,
there are fine inspiratory crackles. HRCT shows a bilateral, subpleural, and basilar honeycombing
pattern. Which pattern is expected in the pulmonary function tests of this patient?
A. FEV1/FVC ratio increased, and DLCO increased
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B. FEV1/FVC ratio increased, and DLCO decreased
C. FEV1/FVC ratio decreased, and DLCO decreased
D. FEV1/FVC ratio decreased, and DLCO increased
4. All of the following conditions lead to nonspecific interstitial pneumonitis except?
B. Polymyositis
D. Dermatomyositis
5. Match the following 1. Asbestosis a. Hay 2. Silicosis b. Sugar cane dust 3. Farmer's lung c. Cement
4. Bagassosis d. Cotton dust 5. Byssinosis e. Glass industry
1. Asbestosis a. Hay
2. Silicosis b. Sugar cane dust
3. Farmer's lung c. Cement
4. Bagassosis d. Cotton dust
5. Byssinosis e. Glass industry
A. 1-a, 2-d, 3-b, 4-e, 5-c
B. 1-c, 2-e, 3-a, 4-b, 5-d
C. 1-c, 2-e, 3-b, 4-d, 5-a
D. 1-d, 2-b, 3-a, 4-c, 5-e
6. Match the interstitial lung diseases with their respective management a. Idiopathic pulmonary fibrosis
1. Steroids b. Non-specific interstitial pneumonitis 2. Pirfenidone + Nintedanib c. Connective tissue
disorders 3. Prednisolone + Mycophenolate + Rituximab
a. Idiopathic pulmonary fibrosis 1. Steroids
b. Non-specific interstitial pneumonitis 2. Pirfenidone + Nintedanib
c. Connective tissue disorders 3. Prednisolone + Mycophenolate + Rituximab
A. a-1, b-2, c-3
B. a-2, b-3, c-1
C. a-1, b-3, c-2
D. a-3, b-2, c-1
7. Which of the following ILDs is not strongly associated with Smoking?
A. Desquamative interstitial pneumonia
B. Respiratory Bronchiolitis
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C. Langerhans Cell Histiocytosis
D. Lymphangioleiomyomatosis
8. Which of the following is a drug which when used for a long period can cause Interstitial lung
disease?
B. Methylprednisolone
C. Streptomycin
9. Which of the following is the fungus that is directly involved in Farmer's lung?
A. Thermophilic Actinomycetes.
B. Ascomycetes
C. Candida
D. Basidiomycetes
10. Which of the following is the treatment of choice in Pulmonary Alveolar proteinosis?
A. Whole lung lavage
B. Lung Transplantation
D. Prednisolone with Mycophenolate with Rituximab
11. Identify the condition where the Reverse halo sign is present in HRCT in the image given below.
A. Cryptogenic Organizing pneumonia
B. Aspergillus infection
C. Tuberculosis
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12. All are correct about the pathophysiology of Pulmonary alveolar proteinosis except?
A. Type 2 Pneumocytes produce DPPC (Dipalmitoyl phosphatidylcholine) with surfactant Proteins
B. (Granulocyte-Macrophage colony-stimulating factor) produced by alveolar macrophages clears
surfactant.
C. Clearance of surfactant decreased due to increased bioactivity of GM-CSF
D. Accumulation of surfactant in alveoli and later develops Pulmonary fibrosis
13. A 60-year-old male child was brought to the clinic with shortness of breath, dry cough, and
hemoptysis for 3 days. On examination, cyanosis and clubbing, Cor Pulmonale were present.HRCT
shows the honeycomb pattern. Which of the following is the diagnosis?
(or)
Which of the following is the diagnosis of the condition characterized by shortness of breath, dry cough,
hemoptysis cyanosis, clubbing, Cor Pulmonale on examination, and honeycombing pattern on HRCT?
A. Interstitial Lung disease
C. Silicosis
14. A 30-year-old patient came to the clinic with complaints of breathlessness on exertion, fatigue, and
fever for 3 days. On examination by the Physician, the patient had chunky gelatinous sputum plugs.
The doctor then advised Chest Xray and HRCT which showed a "Bat-wing" appearance of lung
infiltrates and a “Crazy pavement" pattern respectively. Bronchoalveolar lavage was taken which
showed the Presence of PAS-positive Lipoproteinaceous material .Which of the following is the
diagnosis of this condition?
(or)
Which of the following is the diagnosis of the condition characterized bybreathlessness on exertion,
fatigue, and fever, "Bat-wing" appearance of lung infiltrates, and “Crazy pavement" pattern on Chest
x-ray and HRCT respectively?
A. Pulmonary alveolar proteinosis
C. Interstitial Lung disease
D. Asbestosis
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Page 8
 Causes Usual Interstitial Pneumonitis (UIP).
 
Option A, B & C: Are associated with nonspecific interstitial pneumonitis histologically
Correct option: B - 1-c, 2-e, 3-a, 4-b, 5-d
1. Asbestosis
c. Cement
2. Silicosis
e. Glass industry
3. Farmer's lung
a. Hay
4. Bagassosis
b. Sugar cane dust
5. Byssinosis
d. Cotton dust
Incorrect options: A, C & D - Refer to the above explanation
 
Correct option: B - a-2, b-3, c-1
Incorrect options: A, C & D - Refer to the above explanation 
Correct option D - Lymphangioleiomyomatosis:
 This Interstitial lung disease is not strongly associated with Smoking
1279

Pneumothorax & Pleural Effusion
1. A 45-year-old male with a history of obstructive sleep apnea (OSA), hyperlipidemia, hypertension,
diabetes, and 10 days of progressively increasing dyspnea with exertion presented. Thoracocentesis
was performed after a chest scan revealed a significant left pleural effusion. Which of the following is
not part of the criteria used to distinguish between exudate and transudate?
(or)
Which of the following is not part of the criteria used to distinguish between exudate and transudate?
A. Pleural fluid protein/serum protein ratio > 0.5
B. Pleural fluid lactate dehydrogenase (LDH)/serum LDH ratio > 0.6
C. Pleural fluid LDH level > two-thirds the upper limit of the laboratory’s reference range of serum LDH
D. Pleural fluid sugar < 2/3rd of blood sugar
2. A 24-year-old smoker presented to the emergency department with a non-productive cough,
shortness of breath, and sudden onset pleuritic pain on the right side of the chest. On physical
examination, the patient is afebrile and vitally stable. A chest examination showed diminished breath
sounds on the right hemithorax. The physician ordered a chest X-ray, and a subsequent diagnosis of
primary spontaneous pneumothorax (PSP) was made. Which of the following should be the appropriate
management step for the above-mentioned case?
A. Intermittent positive pressure ventilation (IPPV)
B. Closed drainage
C. Simple needle aspiration
D. Thoracotomy
3. Which of the following is not a feature of tension pneumothorax?
B. Decreased cardiac output
C. Decreased venous return
D. Absent breath sounds
4. Minimum Amount of fluid in the pleural cavity required for clinical detection is?
A. 100ml
B. 200ml
C. 300ml
D. 500ml
5. Which of the following causes increased hydrostatic pressure, leading to pleural effusion?
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B. Congestive heart failure
C. Protein-losing enteropathy
6. Which of the following is not part of Light's criteria?
A. Pleural fluid protein > 0.5 times of serum protein
B. Pleural fluid LDH > 0.6 times of serum LDH
C. Pleural fluid LDH > 2/3 times upper reference limit of serum LDH
D. Pleural fluid sugar < 60 mg%
7. Identify the procedure being done and mark the option that has the appropriate site for treating
pleural effusion
A. 8th ICS mid-scapular line
B. 6th ICS mid-axillary line
C. 5th ICS mid-scapular line
D. 8th ICS mid-axillary line
8. All of the following conditions have pleural fluid glucose levels equal to plasma, except
B. Pancreatitis
C. Empyema
D. Uncomplicated para pneumonia
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Correct option: D - Pleural fluid sugar < 60 mg%
 Pleural fluid protein > 0.5 times of serum protein
 Pleural fluid LDH > 0.6 times of serum LDH
 Pleural fluid LDH > 2/3 times upper reference limit of serum LDH
Incorrect options: A, B and C - Refer to the above explanation 
Correct option: A - 8th ICS mid-scapular line
 Preferred site for thoracentesis: 8th ICS in the mid-scapular line
Incorrect options: B, C and D - Refer to the above explanation
 
Correct option: C - Empyema
Etiology or type of effusion
Gross appearance
White Blood Cell Count (Cells/mcL)
Red blood Cell Count (Cells/mcL)
Glucose
Comments
Turbid to bloody: Occasionally serous
1000 to 100,000 M
100 to several hundred thousand
Equal to serum levels: <60 mg/dl in 15% of cases
Eosinophilia uncommon: Positive result on cytologic examination
Uncomplicated
para pneumonia
Clear to turbid
5000-25,000 P
< 5000
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Page 7
Equal to serum levels
Tube thoracostomy unnecessary
Empyema
Turbid to purulent
25,000 –100,000 P
<5000
Less than serum levels: Often very low
Drainage necessary: Putrid odor suggests anaerobic infection
Serous to
serosanguineous
5000 – 10,000 M
<10,000
Equal to serum levels: Occasionally 60mg/dL
Protein > 4.0g/dL (may exceed 5g/dL) eosinophils cells (>5%) make diagnosis unlikely
Rheumatoid
Turbid: Greenish yellow
1000-20,000 M or P
<1000
< 40 mg/dL
Secondary empyema common: High LD, low compliment, high rheumatoid factor, cholesterol crystal ar
e characteristic
Pulmonary
infarction
Serous to grossly bloody
1000- 50,000 M or P
100-100,000
Variable findings: No pathognomonic features
Esophageal
rupture
Turbid to purulent red-brown
<5000 to 50,000 P
1000 – 10,000
Usually, low
High amylase level (salivary origin): Pneumothorax in 25% cases: effusion usually on left side: pH <6.0
 strongly suggests diagnosis
1289

ABG Interpretation
1. A young male had an episode of sudden breathing difficulty and collapsed when he visited a hill
station. He is a known case of bronchial asthma. He was rushed to the ER, and the doctor diagnosed it
as severe acute asthma. Arterial blood gas investigation reveals: pH = 7.24 PaCO2 = 60 mmHg PaO2
= 65 mmHg HCO3 = 24 mEq/L What is the diagnosis?
A. Uncompensated respiratory acidosis
B. Compensated respiratory acidosis
C. Uncompensated respiratory alkalosis
D. Compensated respiratory alkalosis
2. A 35-yar-old male was rushed to the hospital with complaints of drowsiness, confusion and mild
shortness of breath in the night. ABG analysis shows pH 7.20, PCO2 of 70, PO2 of 65, HCO3 of 24,.
3. A 50-year-old female came to the hospital complaining of respiratory difficulty. She was
subsequently diagnosed with Chronic bronchitis. ABG shows a pH of 7.35, PCO2 of 55, HCO3 of
30,.What is the Acid-Base disorder?
A. Fully compensated respiratory acidosis
B. Uncompensated respiratory acidosis
C. Partially compensated respiratory alkalosis
D. Fully compensated respiratory alkalosis
4. A 50-year-old male presents to the emergency department with a complaint of severe breathing
difficulty. The patient looks cyanosed. ABG values show: pH = 7.31 PaCO2 = 75 mmHg HCO3 = 30
mEq/L What is the diagnosis?
B. Partially compensated respiratory acidosis
5. A 23-year-old female patient who was about to give her university exam started having a panic attack
and was hyperventilating. She started feeling dizzy and was rushed to the hospital. ABG analysis
shows pH of 7.49, PCO2 of 28, and HCO3 of 24mEq/L,. What is the diagnosis?
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Page 2
6. A 30-year-old man who has been studying the ecological changes at Mount Everest base camp for
the past 2 weeks gets a blood gas analysis done. His ABG analysis shows: pH = 7.51 PCO2 = 25
mmHg HCO3 = 19 mEq/L What is the diagnosis?
D. Partially compensated respiratory alkalosis
7. Identify the disorder with Arterial blood gas values of pH 7.48, PCO2 of 30, and HCO3 of 21mEq/L.
B. Partially Compensated respiratory acidosis
D. UnCompensated respiratory alkalosis
8. A 50-year-old female was rushed to the hospital with complaints of dizziness and shortness of
breath. The patient is a known case of DM type 2 but neglected medications for the past three days due
to a busy schedule. Examination showed tachypnea and tachycardia. ABG analysis shows a pH of
7.28, PCO2 of 35mmHg and HCO3 of 14mEq/L. What is the diagnosis?
A. Uncompensated Metabolic acidosis
B. Compensated Metabolic acidosis
9. A 40-year-old male who is a known case of chronic kidney disease complains of breathing difficulty
and lethargy for the past 5 days. ABG analysis shows a pH of 7.38, PCO2 of 29mmHg, and HCO3 of
18mEq/L. What is the diagnosis?
10. ABG analysis shows pH 7.30, PCO2 30mmHg,, HCO3 20mEq/L,. What is the diagnosis?
A. Partially compensated Metabolic acidosis
B. Fully Compensated Metabolic acidosis
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11. A 50-year-old male who is a known case of HTN, DM and heart failure on medications has an ABG
analysis. ABG analysis shows pH 7.38, PCO2 of 30mmHg, and HCO3 of 18mEq/L. What is the
12. ABG analysis shows pH 7.50, PCO2 of 40mmHg, and HCO3 of 32mEq/L. What is the diagnosis?
C. Uncompensated metabolic alkalosis
D. Compensated metabolic alkalosis
13. ABG analysis shows pH 7.47, PCO2 of 47mmHg,, and HCO3 of 33mEq/L,. What is the diagnosis?
A. Partially compensated respiratory acidosis
B. Fully Compensated respiratory acidosis
C. Partially compensated metabolic alkalosis
D. Fully Compensated metabolic alkalosis
1293

Pulmonary Function Tests
1. A coal mine worker develops progressively worsening breathlessness and cough with expectoration.
Spirometry values are: Forced expiratory volume (FEV1) = 1.4 L/min Functional vital capacity (FVC) =
2.8L/min What could be the cause?
A. Silicosis
B. Hypersensitivity pneumonitis
C. COPD
2. The diffusion capacity of the lung is decreased in all of the following conditions, except?
A. Interstitial lung disease
B. Goodpasture syndrome
C. Pneumocystis jirovecii
D. Primary pulmonary hypertension
3. A 62-year-old retired teacher has progressive dyspnea and a chronic cough. He has been smoking
cigarettes for 40 years, one pack per day. The following pattern is seen in pulmonary function tests:
FEV1 (Forced expiratory volume in the first second)= 1.3 L FVC (Forced vital capacity)= 3.1 L The
pattern is suggestive of which of the following?
(or)
A patient has progressive dyspnea and a chronic cough. History of smoking. Pulmonary function tests:
A. Normal lung function
B. Restrictive lung disease
C. Obstructive lung disease
4. A man presents with mild shortness of breath. A chest radiograph revealed bi-basilar reticular
markings. What is the probable diagnosis in a patient with the below-given flow volume curve after
spirometry?
(or)
A 48-year-old man presents with mild shortness of breath. A chest radiograph revealed bi-basilar
reticular markings. What is the probable diagnosis in a patient with the below-given flow volume curve
after spirometry?1305

Page 2
A. Emphysema
C. Bronchial asthma
D. Endobronchial neoplasm
5. Match the following flow volume curves with their respective diseases 1. a. Idiopathic pulmonary
fibrosis 2. b. Asthma 3. c. Tracheal stenosis 4. d. Retrosternal goiter
1.
 a. Idiopathic pulmonary fibrosis
2.
 b. Asthma
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Page 3
3.
 c. Tracheal stenosis
4.
 d. Retrosternal goiter
A. 1-d, 2-b, 3-c, 4-a
B. 1-b, 2-d, 3-c, 4-a
C. 1-c, 2-a, 3-b, 4-d
D. 1-a, 2-c, 3-b, 4-d
6. All of the following conditions are associated with reduced diffusing capacity of the lungs for carbon
monoxide(DLCO) except?
A. Pulmonary hemorrhage
B. COPD
C. Pulmonary arterial HTN
D. Anemia
7. Match the following statements regarding pulmonary function tests under 1. Obstructive lung disease
and 2. Restrictive lung disease a. Increased TLC b. Increased FEV1 /FVC c. Reduced timed vital
capacity d. Reduced FRC e. Reduced TLC f. Increased FRC g. Increased timed vital capacity h.
Reduced FEV1 /FVC
A. 1 - a, c, f and h; 2 - b, d, e and g
B. 1 - b, d, e and g; 2 - a, c, f and h
C. 1 - a, d, f and g; 2 - b, c, e and h
D. 1 - b, c, e and h; 2 - a, d, f and g
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Correct option: A - 1 - a, c, f and h; 2 - b, d, e and g
1. Obstructive lung disease
2. Restrictive lung disease
a. Increased TLC
c. Reduced timed vital capacity
f. Increased FRC
h. Reduced FEV1 /FVC
b. Increased FEV1 /FVC
d. Reduced FRC
e. Reduced TLC
g. Increased timed vital capacity
1313

Bronchopneumonia
1. Which associations are correctly paired with their clinical scenarios and associated pathogens?
Aspiration pneumonia: Streptococcus pyogenes Heavy alcohol use: Klebsiella pneumoniae Poor dental
hygiene: Chlamydia and Klebsiella pneumoniae Structural lung disease: Burkholderia
A. 1 and 2
B. 2 and 4
C. 3 and 4
D. 1 and 3
2. A 65-year-old male patient presents to the clinic complaining of a dry, productive cough with
rusty-coloured sputum, fever, and chills for 4 days. Respiratory examination revealed tachypnea with
dullness to percussion in the left lower lobe. The CURB-65 is used to assess the severity of this patient.
Which of the following is not associated with CURB 65?
(or)
A. Age≥ 65 years
B. RR > 30/min
C. SBP > 90 mmHg
D. BUN level >7 mmol/L
3. Which of the following is not a chest x-ray finding in a case of Staphylococcus pneumonia?
(or)
Which of the following is not a chest x-ray finding in a case of Staphylococcus pneumonia?
A. Pneumatocoele
B. Hilar lymphadenopathy
C. Empyema
D. Absent air bronchogram
4. A 35-year-old man presents to the emergency department with the complaint of shortness of breath,
a productive cough with yellow sputum, and daily fevers associated with drenching sweats for two
weeks. He also states that he has lost around 20 pounds during this period. A CT scan is done for the
following, with the image given below. All are the differential diagnosis of the condition shown in the CT
chest, except?
(or)
All are the differential diagnosis of the condition shown in the CT chest, except?
1314

Page 2
A. Hemosiderosis
B. Tropical pulmonary eosinophilia
C. Collagen vascular disorders
D. Diffuse pulmonary lymphangioleiomyomatosis
5. A 55-year-old man presents to the clinic with fever and breathlessness for 3 days. He has a known
diagnosis of HIV infection. He denies any history of travel or exposure to any ill person. A lung biopsy
from the lesion is shown in the image. What is the most probable clinical diagnosis?
(or)
A known case of HIV presented with fever and breathlessness for 3 days. A lung biopsy from the lesion
is shown in the image. What is the most probable clinical diagnosis?
A. CMV pneumonia
B. Cryptogenic organizing pneumonia
C. Small cell cancer of lung
D. TB
6. A 31-year-old male presents to the clinic with fever, productive cough, hemoptysis, and
breathlessness. The X-ray revealed evidence of total right upper lobe consolidation. Sputum
microscopy, culture, and blood culture confirmed Friedlander's bacillus as the etiology of this severe
community-acquired pneumonia. Friedlander Pneumonia refers to pneumonia caused by?
(or)
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Page 3
Friedlander Pneumonia refers to pneumonia caused by?
A. Klebsiella
B. Streptococcus Pneumonia
C. Haemophilus Influenzae
D. Staphylococcus
7. A 50-year-old patient presents to the clinic with a complaint of high fever, chills, and cough for 2
weeks. He also complains of chest pain. He has a smoking history, and his brother died of lung cancer
1 year ago. He reports no history of recent travel. An x-ray image is given below. Based on the
symptoms and findings, what is the most likely diagnosis?
(or)
A patient presents with a complaint of high fever, chills, and cough for 2 weeks. He also complains of
chest pain. An x-ray image is given below. Based on the symptoms and findings, what is the most likely
A. Round pneumonia
B. Lung abscess
C. Asbestosis coin lesion
D. Pulmonary hamartoma
8. A 40-year-old male smoker presents with two weeks history of chest pain, breathlessness, and
productive cough. He also states he used to be an IV drug user. An x-ray was done, showing the
following findings. All are recommended for treatment in this patient except?
(or)
A smoker presents with two weeks history of chest pain, breathlessness, and productive cough. He
also states he used to be an IV drug user. An x-ray was done, showing the following findings. All are
recommended for treatment in this patient except?
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Page 4
A. Moxifloxacin
B. Clindamycin
C. Amoxicillin- clavulanate
D. Metronidazole
9. Which of the following is correct regarding pulmonary anthrax presentation?
(or)
A 60-year-old male presents to the clinic with the complaint of mild fever, dyspnoea, non-bloody
sputum, anorexia, loss of appetite, and myalgia. He lives in a rural area and has a history of keeping
animals, including some sheep and goats, infected with anthrax. Which of the following is correct
regarding pulmonary anthrax presentation?
A. Lobar pneumonia
B. Broncho pneumonia
C. Atypical pneumonia
D. Haemorrhagic mediastinitis
10. A 55-year-old male patient presented to the emergency department in a collapsed state. The ECG
showed features of myocardial infarction and the patient was treated for the same. His recent history
revealed medical therapy for fever, cough, and shortness of breath. The notes of the previous physician
showed an increased respiratory rate, dullness on percussion, subcostal retraction, and bronchial
breathing accompanied by crackles on auscultation. Using the radiograph below, identify the diagnosis
and pick the option with the most common causative organism.
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Page 5
A. Pseudomonas
B. Pneumococcus
C. ABPA
D. Klebsiella
11. Which of the following organisms is not associated with walking pneumonia?
A. Mycoplasma pneumoniae
B. Legionella pneumophila
C. Chlamydia pneumoniae
D. Pneumococcal pneumonia
12. The CURB 65 criteria includes all of the following except?
A. Blood urea nitrogen
B. Heart rate
C. Blood pressure
D. Age
13. Which of the following is not considered a risk factor for early deterioration in community-acquired
pneumonia
A. Reduced albumin and platelets
B. Reduced neutrophils and sodium
C. High Erythocyte Sedimentation Rate
D. pH<7.3 and RR>30/min
14. Match the following clinical scenarios in SET 1 with their respective organisms in SET 2 SET 1 SET
2 MDR organism associated with ventilator associated pneumonia Alcohol and Red Currant Jelly
sputum Alcoholic and drug overdose manifest with decreased airway defense Most common organism
associated with community acquired pneumonia COPD & smokers Structural lung disease, a.
Anaerobes Causing Pneumonia b. Pseudomonas c. H. influenzae d. Klebsiella pneumonia e.
Burkholderia cepacia f. Pneumococcus
SET 1 SET 2
MDR organism associated with ventilator associated pneumoniaAlcohol and Red Currant Jelly sputumAlcoholic and drug overdose manifest with decreased airway defenseMost common organism associated with community acquired pneumoniaCOPD & smokersStructural lung disease, a. Anaerobes Causing Pneumoniab. Pseudomonasc. H. influenzaed. Klebsiella pneumoniae. Burkholderia cepaciaf. Pneumococcus
A. 1-a,2-d,3-b,4-e,5-c,6-f
B. 1-e,2-c,3-a,4-b,5-d,6-f
C. 1-f,2-c,3-e,4,b,5-d,6-a
D. 1-b,2-d,3-a,4-f,5-c,6-e
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Page 6
15. In a patient receiving mechanical ventilation, which of the following pathogens is most commonly
associated with multidrug-resistant (MDR) ventilator-associated pneumonia (VAP)?
A. Streptococcus pneumoniae
D. Klebsiella pneumoniae
16. What is the drug of choice for treating atypical pneumonia caused by Mycoplasma pneumoniae?
B. Amoxicillin
C. Doxycycline
17. A 60-year-old patient with pneumonia presents to the emergency department with confusion, a
respiratory rate of 35 breaths per minute, and a blood pressure of 100/70 mm Hg. The patient's BUN
level is within normal limits. Based on the CURB-65 scoring system, how should the treatment be
initiated for this patient?
(or)
How should the treatment be initiated for a patient with CURB score 2?
A. Outpatient basis treatment
B. Inpatient basis treatment
C. ICU basis treatment
D. Observation without any treatment
18. A 65-year-old patient presents to the emergency department with severe pneumonia. Further
evaluation reveals Legionella pneumonia. Which of the following interventions should be prioritized for
(or)
Which of the following interventions should be prioritized for a patient with Legionella pneumonia?
A. Initiation of antiviral therapy
B. Administration of bronchodilators
C. Intravenous hydration and antibiotic therapy
19. A 45-year-old patient presents to the clinic with symptoms of fever, cough, and shortness of breath.
The patient works at a pet store and reports recent contact with birds. Given this exposure history, what
pathogen should be considered as a potential cause of the pneumonia?
(or)
1319

Page 7
What pathogen should be considered as a potential cause of the pneumonia developed after contact
with birds?
A. Chlamydia psittaci
D. Haemophilus influenzae
20. In a patient admitted to the ICU with severe symptoms suggestive of community-acquired
pneumonia (CAP) and a CURB-65 score of 3, which organism is most commonly associated with the
A. Pneumococcus
B. Mycoplasma pneumoniae
C. Hemophilus influenzae
D. Pneumocystis jiroveci
21. In a patient diagnosed with ventilator-associated pneumonia (VAP), which medication is considered
the drug of choice for treatment?
B. Levofloxacin
C. Vancomycin
D. Piperacillin with Tazobactam
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Page 16
Incorrect Options - A, C and D (Pseudomonas, ABPA &
Klebsiella): These are incorrect. Pneumococcus is the most common cause of lobar pneumonia.
 
Correct Option D- Pneumococcal pneumonia:
 Walking pneumonia is also called atypical pneumonia and pneumococcus is not a causative organism
of atypical pneumonia.
Incorrect Options A, B, C (Mycoplasma pneumoniae, Legionella pneumophila & Chlamydia pneumonia
e): All these organisms cause walking pneumonia.
Correct Option B- Heart rate: Heart rate is not a part of the CURB-65 criteria
 CURB-65 is used to predict mortality in patients with pneumonia and assess the need for
hospitalization.
Confusion
1 point
BUN ≥7 mmol/L
Respiratory rate >30 / min
BP <90/60 mm Hg
Age >65 years
 
Score
Mortality
Rx
0
1.5%
OPD Basis
1-2
9.2%
IPD basis
22%
ICU basis
1329

Page 18
available.
 
Option A - Streptococcus pneumoniae: Streptococcus pneumoniae is a common cause of community-a
cquired pneumonia but is less frequently implicated in VAP, particularly cases of multidrug resistance.
Option C - Staphylococcus aureus: Staphylococcus aureus, including methicillin-resistant Staphylococc
us aureus (MRSA), is another important pathogen in VAP, especially in healthcare-associated settings.
 While it can be multidrug-resistant, it is not as commonly associated with MDR VAP as Pseudomonas 
aeruginosa.
Option D - Klebsiella pneumoniae: Klebsiella pneumoniae is a gram-negative bacterium frequently ass
ociated with healthcare-associated infections, including pneumonia. It can exhibit multidrug resistance, 
particularly in the form of extended-spectrum beta-lactamase (ESBL) production. While it is an importa
nt pathogen in VAP, it is not the most commonly associated with MDR VAP compared to Pseudomona
s aeruginosa.
Correct Option D - Azithromycin:
 Mycoplasma pneumoniae is a common cause of atypical pneumonia, often referred to as "walking
pneumonia" due to its mild symptoms. Azithromycin is the drug of choice for treating Mycoplasma
pneumoniae infection due to its efficacy and favorable pharmacokinetic profile. Azithromycin is a
macrolide antibiotic that effectively targets Mycoplasma pneumoniae and is preferred over other
antibiotics due to its once-daily dosing regimen and high tissue penetration.
 
Option A - Ciprofloxacin: Ciprofloxacin is a fluoroquinolone antibiotic commonly used to treat bacterial i
nfections, but it is not the preferred choice for treating Mycoplasma pneumoniae. Macrolides like azithr
omycin or tetracyclines like doxycycline are more effective against Mycoplasma pneumoniae.
Option B - Amoxicillin: Amoxicillin is a penicillin antibiotic primarily used to treat bacterial infections. Ho
wever, it is not effective against atypical pathogens like Mycoplasma pneumoniae. Azithromycin or dox
ycycline are preferred choices for treating atypical pneumonia caused by Mycoplasma pneumoniae.
Option C - Doxycycline: Doxycycline is a tetracycline antibiotic that is effective against a wide range of 
bacterial infections, including atypical pathogens like Mycoplasma pneumoniae. While it is an alternativ
e treatment option for atypical pneumonia, azithromycin is typically preferred due to its more favorable 
dosing regimen and side effect profile.
Correct Option B - Inpatient basis treatment:
 According to the CURB-65 scoring system, which helps assess the severity of pneumonia, this patient
has a score of 2. The presence of confusion, a respiratory rate > 30/min, and an age > 65 years each
contribute 1 point to the score. A CURB-65 score of 1 or 2 indicates the need for inpatient (IPD) basis
1331

Page 19
treatment. In this case, the patient's score of 2 suggests that hospitalization is warranted for appropriate
management and monitoring of pneumonia symptoms and complications.
 
Option A - Outpatient basis treatment: Reserved for patients with a
CURB-65 score of 0, indicating low severity and suitability for outpatient management.
Option C - ICU basis treatment: Typically recommended for patients with a CURB-65 score of 3
or more, indicating severe pneumonia requiring intensive care unit (ICU) level of care.
Option D - Observation without any treatment: Not suitable for this patient as they have a
CURB-65 score indicating the need for hospitalization and appropriate treatment.
Correct Option C - Intravenous hydration and antibiotic therapy:
 Legionella pneumonia, caused by Legionella pneumophila bacteria, is a severe form of pneumonia
that requires prompt and appropriate treatment. Antibiotics are the cornerstone of therapy for
Legionella pneumonia. The preferred antibiotics include macrolides (such as azithromycin) or
respiratory fluoroquinolones (such as levofloxacin). Intravenous hydration is also essential to maintain
adequate fluid balance and prevent dehydration, especially in severe cases of pneumonia.
 
 Antiviral therapy is not indicated for Legionella pneumonia, as it is a bacterial infection, not a viral one.
Bronchodilators are primarily used in the management of conditions such as asthma and chronic
obstructive pulmonary disease (COPD) but are not the mainstay of treatment for Legionella pneumonia.
Observation without treatment is not appropriate for severe pneumonia, including Legionella
pneumonia, as it can lead to complications and worsened outcomes.
Correct Option A - Chlamydia psittaci:
 Given the patient's recent contact with birds, particularly in a pet store setting, the potential pathogen
to consider causing pneumonia is Chlamydia psittaci. This bacterium is commonly associated with
psittacosis, a zoonotic infection transmitted from infected birds to humans. Symptoms typically include
fever, cough, and shortness of breath. Prompt recognition and treatment with antibiotics such as
tetracyclines or macrolides are essential for managing this infection.
 
Option B - Legionella pneumophila: While Legionella pneumophila can also cause pneumonia, it is typi
cally associated with water sources such as contaminated air conditioning systems or hot tubs, rather t
han bird exposure.
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Option C - Streptococcus pneumoniae: Streptococcus pneumoniae is a common cause of community-
acquired pneumonia but is not directly linked to bird exposure. It is more prevalent in general communit
y settings and among individuals with certain risk factors like age or underlying medical conditions.
Option D - Haemophilus influenzae: Haemophilus influenzae can cause pneumonia, especially in indivi
duals with chronic lung disease or weakened immune systems. However, it is not typically associated 
with bird exposure-related pneumonia, as seen with Chlamydia psittaci.
Correct Option A - Pneumococcus:
 Community-acquired pneumonia (CAP) is commonly associated with various organisms, but
Streptococcus pneumoniae, also known as pneumococcus, is the most frequent causative agent.
Patients with severe symptoms requiring ICU admission, as indicated by a CURB-65 score of 3, are
often infected with pneumococcus. This bacterium is a leading cause of CAP, especially in cases
requiring intensive care due to the severity of symptoms.
 
Option B - Mycoplasma pneumoniae: Mycoplasma pneumoniae is a common cause of atypical pneum
onia, but it is less frequently associated with severe CAP requiring ICU admission.
Option C - Hemophilus influenzae: While Hemophilus influenzae can cause pneumonia, it is not as co
mmonly associated with severe CAP requiring ICU admission compared to pneumococcus.
Option D - Pneumocystis jiroveci: Pneumocystis jiroveci pneumonia (PCP) is typically seen in immunoc
ompromised individuals, especially those with AIDS and low CD4 counts. It is less likely to be the caus
e of CAP in patients admitted to the ICU with severe symptoms and a
CURB-65 score of 3, unless the patient is immunocompromised.
Correct Option D - Piperacillin with Tazobactam:
 Ventilator-associated pneumonia (VAP) is often caused by multidrug-resistant (MDR) pathogens such
as Pseudomonas aeruginosa and Acinetobacter baumannii. Piperacillin with Tazobactam is a
broad-spectrum antibiotic combination that provides coverage against these MDR organisms, making it
the drug of choice for treating VAP caused by these pathogens.
 
Option A - Ceftriaxone: While ceftriaxone is a commonly used antibiotic for treating community-acquire
d pneumonia, it may not provide adequate coverage against the MDR pathogens often associated with
 VAP.
Option B - Levofloxacin: Levofloxacin is a fluoroquinolone antibiotic with broad-spectrum activity. While
 it may be effective against some VAP pathogens, it may not provide sufficient coverage against MDR 
organisms like Pseudomonas aeruginosa and Acinetobacter baumannii.
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Page 21
Option C - Vancomycin: Vancomycin is primarily used to treat infections caused by Gram-positive orga
nisms such as methicillin-resistant Staphylococcus aureus (MRSA). It is not the drug of choice for treati
ng VAP caused by MDR Gram-negative bacteria.
1334

1. A 30-year-old man came with complaints of fever and cough for 3 days. On examination, SPO2 is
98% RA, BP=110/70 mm Hg. Chest-x ray shows diffuse consolidation on both lungs. Nasopharyngeal
swab shows Rhinovirus. Which antibiotics are suitable for this patient?
A. Ceftazidime + Azithromycin
B. Ceftriaxone
C. Ceftriaxone + Levofloxacin
D. Piptaz + Ciprofloxacin
2. Blast lung is also known as?
A. COPD
B. Alveolar haemorrhage
D. ARDS
3. Which one of the following is a direct cause of Acute Respiratory Distress Syndrome (ARDS)?
A. Pneumonia
B. Fat embolism syndrome following femur shaft fracture
C. Sepsis
D. Transfusion-related lung injury
4. According to the Berlin definition, which of the following is not a characteristic of moderate ARDS?
A. 200 < PaO2/FiO2 =<300mm/Hg with PEEP Is moderate
B. Bilateral interstitial infiltrates
C. Symptom onset within a week
D. No cardiac failure in echocardiography
5. What should be the subsequent course of action for this patient, who is intubated and has undergone
an X-ray as depicted in the radiograph?
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Page 2
A. Suction
B. Chest physiotherapy
C. Start antibiotics and send and samples for culture
D. Ultrasound-guided aspiration
6. The patient being discussed has come in for medical evaluation following an injury to the chest.
During the examination, the presence of crepitus is detected. Based on these findings, what is the likely
A. Subcutaneous emphysema
B. Gas gangrene
D. Hyperbaric decompression sickness
7. What is the likely diagnosis for a 56-year-old woman who had a heart attack 2 years ago and is
currently experiencing a cough and difficulty breathing while walking short distances? Physical
examination revealed dullness upon percussion and reduced breath sounds on the right side. A chest
x-ray indicated the presence of moderate pleural effusion. Thoracocentesis, guided by ultrasound, was
performed and the laboratory results are provided below. Pleural fluid findings: Appearance: turbid pH:
7.1 Protein: 3.2 g/dL Lactate dehydrogenase: 80, U/L (normal serum LDH- 50-150 U/L) Pleural fluid
protein/serum protein ratio: 0.34 Pleural fluid LDH /serum LDH: 0.3 Glucose: 54 mg/dL WBC count:
4000 cells/µL with >50% lymphocytes Adenosine deaminase: 30 U/L AFB smear microscopy: negative
Gram staining and microscopy: no organisms, no pus cells
A. Parapneumonic pleural effusion
B. Malignant pleural effusion
C. Congestive heart failure
D. Tubercular pleural effusion
8. A 35-year-old female patient presents to you with fever, breathlessness, and cough with
expectoration. A CT scan was done which is shown below. What is the most likely diagnosis?
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Page 3
A. Consolidation with air bronchogram
B. Mediastinal mass
C. Pleural effusion
D. Diaphragmatic hernia
9. Which drugs are ineffective against multidrug-resistant (MDR) tuberculosis?
A. Isoniazid, rifampicin, and fluoroquinolone
B. Fluoroquinolones
C. Isoniazid and rifampicin
D. Isoniazid, rifampicin, and kanamycin
10. A male patient with a history of chronic smoking presents with the complaint of dysphagia. Out of
the following, which type of lung cancer is most likely to be found in this patient?
A. Squamous cell carcinoma
B. Adenocarcinoma
C. Large cell carcinoma
D. Bronchogenic carcinoma
11. A patient presents with chronic complaints of a productive cough in the morning. The expectoration
is yellow, foul smelling and increases on turning from left to right side. Which of the following lung
diseases is likely to be present?
A. Lung cancer
D. Pulmonary embolism
12. What is the diagnosis based on the image given below?
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Page 4
A. Pulmonary tuberculosis
B. Chronic obstructive pulmonary disease
13. Which of the following statements is accurate regarding the condition of cryptic tuberculosis, in
relation to a 65-year-old male who presented with unexplained fever and prolonged respiratory distress
despite receiving appropriate treatment?
A. Positive skin tuberculin test and negative chest X-ray
B. Positive skin tuberculin test and positive chest X-ray
C. Negative skin tuberculin test and negative chest X-ray
D. Negative skin tuberculin test and positive chest X-ray
14. In which medical condition is a ground-glass appearance observed on high-resolution computed
tomography (HRCT)?
A. Asbestosis
C. Anthracosis
D. Bagassosis
15. What can be identified as a contributing factor to the occurrence of exudative pleural effusion?
16. Which microorganism is responsible for the symptoms observed in a 70-year-old patient with a
history of smoking, presenting with high-grade fever, cough, confusion, and diarrhea? The patient's
chest X-ray shows infiltrates in both lower lung fields, while sputum gram stain does not detect any
1338

Page 5
organisms. Additionally, laboratory results show abnormal levels of Na (126mEq/L), AST (62), ALT
(56), RBS (112 mg/dl), and serum bilirubin (0.8mg%), as well as a positive HIV test.
A. Streptococcus
B. Legionella
C. Pneumocystis jeroveci
17. What would be the most appropriate course of action for managing a 45-year-old patient, who has
been smoking a pack of cigarettes daily for the last 15 years, and is now presenting with hemoptysis?
The chest X-ray reveals a 3cm mass in the upper lobe near the lung apex.
A. Bronchoscopy
B. CT-guided biopsy
C. Sputum cytology
D. Sputum for AFB
18. Which of the following is not a feature of Gaisböck syndrome?
A. Hypotension
B. Erythrocytosis
C. Normal leukocyte counts
D. Obesity
19. Which of the following is the initial probable diagnosis for a 5-year-old child who has been
experiencing recurring respiratory infections with thickened sputum, bronchial wall thickening observed
on a chest X-ray, and has had steatorrhea since birth?
C. Alpha 1 anti-trypsin deficiency
D. Malabsorption syndrome
20. A 65-year-old chronic smoker came to the medicine outpatient department with complaints of upper
chest discomfort and drooping of an eyelid. He also complained of pain radiating to the upper arm and
a tingling sensation in the 4th and 5th digits of his left hand. The chest X-ray is given below. Which of
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Page 6
A. Pancoast tumour
B. Upper lobe pneumonia
C. Superior vena cava obstruction
D. Aspergilloma
21. What should be the next appropriate action in the management of an elderly male who has been on
prolonged bed rest and is now experiencing symptoms of breathlessness and chest pain?
A. CT pulmonary angiogram
B. ECG
C. CT thorax
D. Echocardiography
22. A chronic cigarette smoker has now joined a construction company. His pulmonary function test
results are given below. What is the most likely diagnosis for this patient? Initial lung volumes were:
FEV1-0.9L FVC-1.9L FEV1/FVC-0.4 After bronchodilation: FEV1-1.9L FVC-3.9L FEV1/FVC-0.4
A. Vascular disease with bronchodilator reversibility
B. Restrictive lung disease with bronchodilator reversibility
C. Restrictive lung disease without bronchodilator reversibility
D. Obstructive disease with bronchodilator reversibility
23. Which location in the abdomen is most frequently affected by tuberculosis?
A. Rectum
B. Colon
C. Small intestine
D. Ileocecal junction
24. What does the given ECG show?
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A. P-pulmonale
B. Ventricular bigeminy
C. Electrical alternans
D. Improper calibration
25. A 65-year-old female patient weighing 60 kg is on mechanical ventilation for ARDS secondary to
urosepsis. The respiratory parameters are as follows: tidal volume – 360 mL; frequency – 30
breaths/min; PEEP - 5 cm of H2O; and FiO2-90%. The arterial blood gas findings are as follows;
paO2-50 mmHg; paCO2-38 mmHg; and pH-7.38. What is the next step?
A. Reduce FiO2
B. Increase tidal volume
C. Increase respiratory rate
D. Increase PEEP
26. An increased anion gap is seen in:
27. Hamman sign is seen in:
B. Pneumopericardium
C. Pneumomediastinum
D. Hydropneumothorax
28. The given image shows a normal graph on the left and the patient’s graph on the right. Which of the
following diagnosis can be inferred from the graph?
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A. Chest wall neuromuscular disease
B. Sarcoidosis
C. Idiopathic pulmonary fibrosis
29. A 40-year-old man presents with daytime sleepiness and impaired concentration and memory. On
examination his BMI is 41 kg/m2, BP is 160/100 mm Hg. His awake ABG analysis is given: PaO2=
66mm Hg, PaCO2= 50 mm Hg, HCO3= 28 mEq/L. What is the most likely diagnosis?
A. Obstructive sleep apnea
B. Narcolepsy
C. Obesity hypo-ventilation syndrome
D. Central sleep apnea
30. Which membrane channel is mainly affected in Cystic fibrosis?
A. Sodium
B. Chloride
C. Calcium
D. Potassium
31. A 68-year-old man presents with cough with yellowish sputum. Auscultation revealed bronchial
breath sounds. He is hemodynamically stable and not confused. On examination, his respiratory rate is
20/min and blood pressure is 110/70 mmHg. Lab reports show urea levels of 44 mg/dL. What is the
next best step in the management of this patient?
A. Given antibiotics and send the patient home
B. Admit to ICU without mechanical ventilation
C. Admit to ICU with invasive mechanical ventilation
D. Consider admission in a non ICU setting
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32. What might be the potential reason for the occurrence of carpo-pedal spasm in a woman
experiencing hyperventilation due to hysteria?
33. What is the probable diagnosis for a patient who has been experiencing fever, coughing at night,
difficulty breathing, and wheezing for a duration of 4 weeks, along with an absolute eosinophil count
exceeding 5000/microliter and a miliary pattern observed on the chest x-ray?
B. Miliary tuberculosis
C. Tropical pulmonary eosinophilia
D. Hypersensitivity pneumonitis
34. A 10-year-old child with AIDS presented with fever and a productive cough. On auscultation,
bronchial breath sounds and crepitations were heard in the right infra-scapular region. Chest x-ray
showed right lower lobe consolidation. The CD4 count was 55 cells/mm3. What is the most likely
causative organism for this condition?
A. Pneumocystis jirovecii
B. Streptococcus pneumonia
D. Mycoplasma
35. N95 respirator is used for:
A. Droplet precautions
B. Airborne precautions
C. Contact precautions
36. Which of the following statements accurately describes the initial management of a 60-year-old
male patient, previously diagnosed with COPD, who is currently experiencing an acute exacerbation
and has been admitted to the ICU?
A. Non-invasive PPV should be given
B. Invasive PPV should be given
C. Oxygen is not indicated
D. Permissive hypoapnia is allowed
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37. In a patient with suspected metabolic acidosis, which of the following arterial blood gas (ABG)
findings is most likely to be observed?
A. Increased pH, decreased bicarbonate (HCO3-)
B. Decreased pH, increased bicarbonate (HCO3-)
C. Decreased pH, decreased bicarbonate (HCO3-)
D. Increased pH, increased bicarbonate (HCO3-)
38. What should be the next course of action for a 20-year-old male who arrives at the emergency
department with difficulty breathing and low blood pressure after experiencing an injury? The patient
exhibits subcutaneous emphysema and there is no air movement observed in the right lung.
A. Start IV fluids with large bore cannula
B. Needle decompression into the 5th intercostal space anterior to the midaxillary line
C. Take the patient to the ICU and intubate him
D. Start positive pressure ventilation
39. A 55-year-old male presented with tachypnea and mental confusion. His blood sugar is 350mg/dl,
pH-7.2, HCO3-10, pCO2-30. What is the metabolic abnormality?
40. Which among the following is not a part of Well’s score?
A. Heart Rate
B. Respiratory rate
C. Hemoptysis
D. Clinical sign of DVT
41. Which of the following is shown in the image below?
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C. Consolidation
D. Cavity
42. A 60 year old man with a history of COPD presents with sudden onset increased shortness of
breath. His ABG analysis reveals pH – 7.24; pCO2 – 60 mm Hg, pO2 – 52 mmHg, HCO3 – 27 mmol/L.
What is the most appropriate treatment form the following:
A. Endotracheal intubation
B. Invasive positive pressure ventilation
C. Non-invasive positive pressure ventilation (NIPPV)
D. Lung volume reduction surgery
43. What is the diagnosis for a 72-year-old male who is experiencing weight loss, reduced appetite, and
iron deficiency anemia, based on the provided chest x-ray?
A. Lung metastasis
B. Bronchogenic carcinoma
C. Miliary tuberculosis
D. Mesothelioma
44. A 55 year old shipbuilding worker presents with dyspnea.He has been working in this industry for
the past 25 years. Which is the most specific malignancy that we can expect in this patient?
A. Bronchogenic carcinoma
B. Malignant mesothelioma
C. Small cell carcinoma of lung
D. Squamous cell carcinoma of lung
45. A 60-year-old male patient comes to your clinic with an 8-month history of shortness of breath and
non-productive cough. He has smoked half a pack of cigarettes for the past 30 years. On physical
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examination, clubbing is seen and fine crackles are heard on both sides during inspiration. You perform
pulmonary function tests and it shows an FEV1/FVC ratio of 92%. The CT scan of the chest is shown
below. What is the most probable diagnosis?
B. Pulmonary fibrosis
C. Pulmonary tuberculosis
D. Chronic obstructive pulmonary disease
46. In patients affected by COVID-19, which pattern is frequently observed in chest CT scans?
A. Interlobular septal thickening
B. Air bronchograms
C. Ground glass opacity
D. Crazy paving pattern
47. A patient was admitted to the ICU 48 hours after an accident in which he sustained a fracture of the
femur. The oxygen saturation in the rebreathing unit was 100% but his SpO2 remained at 60%. The
patient is in a state of confusion. Diffuse petechiae are noted on examination. Chest radiograph showed
lung fields to be clear. What is the most likely diagnosis?
C. ARDS
D. Occult pneumothorax
48. Which of the following imaging tests should be performed to confirm a diagnosis of pulmonary
embolism in a patient?
A. Doppler echocardiography
B. CT pulmonary angiography
C. Ventilation perfusion scan of lungs
D. MR pulmonary angiography
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49. In the management of a 35-year-old female patient with class II pulmonary hypertension who has
obtained a negative vasoreactive test, which of the following options is employed in the subsequent
step?
A. Iloprost
B. Ambrisentan
C. Nifedipine
D. Epoprostenol
50. What is the recommended course of action for a newly diagnosed HIV patient who is experiencing
symptoms of fever, cough, and haemoptysis, and whose sputum sample has revealed the presence of
acid-fast bacilli?
A. Start ART if CD4<200
B. Start ART and then ATT after 2 weeks
C. Start ATT and then ART after 2 weeks
D. Start ATT and ART simultaneously
51. What could be the potential cause when a patient presents with hypoxemia but a normal
alveolar-arterial oxygen gradient?
A. Right to left shunt
B. Ventilation/perfusion mismatch
C. Hypoventilation
D. Alveolar membrane damage
52. What is the likely diagnosis based on the presented flow-volume loop.
A. Variable small airway obstruction
B. Fixed central airway obstruction
C. Variable intrathoracic obstruction
D. Variable extrathoracic obstruction
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53. Acid-base imbalance is suspected in a patient. Which of the following would you use to determine
it? 1. Arterial pH 2. Venous pH 3. Venous pO2 4. Venous pCO2
A. 1,2
B. 1,2,3
C. 1,2,4
D. 1,2,3,4
54. Which of the following findings from a pleural fluid aspirate will suggest an exudative pleural
effusion? Normal values Total S. Protein: 6-8 gm% S.LDH: 140-280 IU S. glucose: 140-200
A. Pleural: Serum protein ratio > 0.5, pleural: Serum LDH ratio > 0.6 or pleural LDH > 2/3
B. Pleural fluid protein = 4.5 gm% and glucose = 30 mg%
C. Pleural fluid LDH = 90IU and glucose = 30 mg%
D. Pleural fluid protein = 3.5gm% and glucose = 90 mg%
55. A 45-year-old female presents to the emergency department with the following arterial blood gas
(ABG) results: pH 7.55, PaCO2 40 mmHg, HCO3- 32 mEq/L. Which of the following conditions is most
likely responsible for these findings?
A. Metabolic acidosis
B. Metabolic alkalosis
56. The flow - volume curve of a patient after spirometry is given below. The most likely diagnosis in
this patient is:
B. COPD
C. Myasthenia gravis
D. Vocal cord paralysis
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57. Addison's disease is characterized by all of the following symptoms except?
A. Hyperglycemia
D. Hypotension
58. Which of the following pneumoconiosis is associated with an increased incidence of tuberculosis?
C. Coal worker’s pneumoniosis
D. Berryliosis
59. A patient with a history of fever for the past 4 days and new onset of breathlessness was admitted
to ICU as he was deteriorating. He was unresponsive to the incremental flow rate of oxygen and his
oxygen saturation was progressively decreasing. A chest x-ray was ordered and the findings are shown
in the image below. What is the most likely diagnosis?
A. Atelectasis
B. Mediastinitis
C. Pulmonary fibrosis
D. ARDS
60. A 55-year-old patient presented with chronic projectile vomiting and weight loss. What is the
expected metabolic abnormality to be seen here?
B. Hypokalemic hypochloremic metabolic acidosis with hypernatremia
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61. What should be the subsequent course of action in managing a patient aged 60, who is a
diagnosed COPD patient, admitted to the ICU, and currently receiving 2 liters of oxygen therapy, but is
observed to be hypoventilating with an arterial blood gas analysis revealing a pH level of 7.33 and
pCO2 levels of 64 mmHg?
C. Increase the oxygen flow rate
D. Intubate and start on ventilator
62. A patient with no comorbidities presents with electrolyte values as shown below. The patient had a
normal ECG. What is the preferred treatment for this patient among the options given below? Serum
K+: 3.0mmol/L
A. Calcium gluconate
B. Sodium bicarbonate
C. Potklor
D. Insulin with dextrose
63. For which types of cancers is prophylactic cranial radiation administered?
B. Liver cancer
C. Prostate cancer
D. Breast cancer
64. What is the most effective diagnostic test for a 50-year-old individual who is a chronic smoker and is
experiencing mild, repeated episodes of coughing up blood without any accompanying symptoms of
fever or weight loss? The chest x-ray shows no abnormalities, and the sputum test is negative for
Acid-Fast Bacilli (AFB).
A. MRI
B. CT
C. Fiberoptic bronchoscopy
D. Bronchography
65. Nasal polyps are commonly associated with which of the following?
A. Intrinsic asthma
B. Brittle asthma
C. Extrinsic asthma
D. Exercise - induced asthma
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66. A 30-year-old HIV positive man presents with fever for 3 weeks, dry cough an significant weight
loss. His chest x-ray is given below. What is the most likely diagnosis?
A. Staphylococcal pneumonia
B. Pneumococcal pneumonia
D. Pneumocystis jirovecii pneumonia
67. On performing a pulmonary function test, reduction in FEV1/FVC is characteristic of:
A. Restrictive disease
B. Obstructive disease
C. Normal lung function
68. Which of the subsequent options is not typically observed in allergic bronchopulmonary
aspergillosis?
A. Low serum IgE levels
B. Cough
C. Wheezing
69. Which of the following options best represents 'very severe COPD' according to the GOLD criteria?
A. FEV1/FVC <0.7 and FEV1<30%
B. FEV1/FVC <0.7 and FEV1<70%
C. FEV1/FVC <0.7 and FEV1<50%
D. Both a and c
70. What is the cause of infertility in individuals with Kartagener's syndrome?
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B. Asthenospermia
C. Undescended testes
D. Epididymis obstruction
71. Among the following choices, which organism is the most probable cause of ventilator-associated
pneumonia?
A. Clostridium
B. Klebsiella
C. Acinetobacter
D. Hemophilus
72. Which of the following drugs is commonly used for treating community-acquired pneumonia in the
outpatient setting?
C. Azithromycin
D. Streptomycin
73. A 45-year patient working in a factory for the past 20 years presents with breathlessness. HRCT
chest shows pleural thickening and fibrosis. Diagnosis is?
B. Coal worker pneumoconiosis
D. Berylliosis
74. Which of the following is a causative agent of Farmer's Lung?
A. Thermophilic Actinomycetes
B. Aspergillus Fumigatus
C. Actinobacter
D. Aspergillus Flavus
75. Which of the following is associated with metastasis to the brain?
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76. Which of the following is false about Mycoplasma pneumoniae?
A. Responds well to amoxiclav
B. Antibodies are useful in diagnosis
C. Chest X-ray shows bilateral infiltrates
D. Can be cultured in a cell-free medium
77. In the given acid-base nomogram diagram, areas marked A and D indicated which of the following
conditions?
A. Chronic respiratory acidosis, acute metabolic alkalosis
B. Acute metabolic alkalosis, acute respiratory acidosis
C. Acute respiratory acidosis, acute respiratory alkalosis
D. Acute respiratory acidosis, acute metabolic alkalosis
78. What is the most common pulmonary manifestation of SLE?
A. Shrinking lung syndrome
B. Pleuritis
C. Intra alveolar hemorrhage
D. Interstitial inflammation
79. What is the most common presentation of inhalational anthrax?
A. Atypical pneumonia
B. Haemorrhagic mediastinitis
C. Lung abscess
D. Broncho-pulmonary pneumonia
80. A 30-year-old man presented the findings shown in the given image. What is this physical finding
called?
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A. Spoon-shaped nails
B. Raynaud's phenomenon
C. Pallor
D. Clubbing
81. Which of the following agents is most likely causing the condition in a 60-year-old woman, who had
a kidney transplant 2 months ago, and is now experiencing a high fever, severe difficulty in breathing,
and a dry cough with a hacking sound? Chest x-ray shows widespread interstitial infiltrates in both
lungs, and urine examination reveals the presence of cells with an 'owl-eye' appearance.
A. Adenovirus
B. Cytomegalovirus
C. Influenza virus
D. Respiratory syncytial
82. Which of the following features are true about Allergic Broncho Pulmonary Aspergillosis? Distal
bronchiectasis Serum precipitins to Aspergillus Increased lgE Levels Seen in asthmatics
C. 1,3,4 only
83. Why is COVID-19 a major global concern despite influenza spreading faster than COVID-19?
A. Median incubation period is more in influenza
B. Reproductive number for COVID-19 is 2-2.5
C. Serial interval is 5-6 days in influenza
D. Reproductive number for Influenza is higher
84. In good pasture syndrome, which organ is involved apart from lung?
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A. Kidney
B. Liver
C. Spleen
D. Heart
85. What is the clinical diagnosis for a patient who experiences sudden and severe respiratory distress
after undergoing internal jugular vein catheterization?
A. Pneumothorax
B. Sepsis
C. ARDS
D. Infective endarteritis
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Question 32 3
Question 41 2
Question 50 3
Question 52 2
Question 55 2
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Question 56 2
Question 58 2
Question 59 4
Question 62 3
Question 63 1
Question 65 1
Question 67 2
Question 68 1
Question 69 1
Question 71 3
Question 73 1
Question 76 1
Question 78 2
Question 80 4
Question 81 2
Question 83 2
Correct Option A - Ceftazidime + Azithromycin:
 Ceftazidime is a third-generation cephalosporin commonly used for severe infections, particularly
those caused by Gram-negative bacteria.
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 Azithromycin is a macrolide antibiotic effective against a broad range of respiratory pathogens as in
the question that suggests a secondary bacterial infection
Option B - Ceftriaxone: Ceftriaxone is a broad-spectrum antibiotic often used for various bacterial infect
ions. However, since the patient's nasopharyngeal swab showed Rhinovirus, which is a viral infection, 
ceftriaxone alone would not be an appropriate treatment choice. Antibiotics should be reserved for bact
erial infections or when there is a strong suspicion of a concurrent bacterial infection.
Option C - Ceftriaxone + Levofloxacin: Similar to option B, combining ceftriaxone with levofloxacin, ano
ther broad-spectrum antibiotic, would not be suitable for a viral infection like Rhinovirus. Using antibioti
cs unnecessarily can contribute to antibiotic resistance and should be avoided in viral infections.
Option D - Piptaz + Ciprofloxacin: Piptaz (piperacillin/tazobactam) is a
combination antibiotic effective against a wide range of bacterial infections. Ciprofloxacin is a fluoroqui
nolone antibiotic. However, as mentioned earlier, the patient's infection is caused by Rhinovirus, a
viral pathogen. Therefore, this combination of antibiotics would not be appropriate for treating a
viral infection.
Correct Option D - ARDS:
 blast lung is closely associated with ARDS (Acute Respiratory Distress Syndrome). ARDS is a severe
lung condition that can occur after trauma, including blast injuries. It is characterized by the sudden
onset of severe respiratory distress, with symptoms such as difficulty breathing, rapid breathing, and
low oxygen levels. ARDS can be caused by various factors, including trauma, sepsis, pneumonia, or
inhalation of harmful substances.
Option A
- COPD: Blast lung is not known as COPD. COPD (Chronic Obstructive Pulmonary Disease) is a chron
ic lung disease that is typically caused by long-term exposure to irritants, such as cigarette smoke, and
 is characterized by airflow limitation
Option B - Alveolar haemorrhage: Blast lung is not known as alveolar hemorrhage either. Alveolar hem
orrhage refers to bleeding in the alveoli, the small air sacs in the lungs. It can be caused by various con
ditions, such as autoimmune diseases, vasculitis, or infections.
Option C - Pulmonary edema: Pulmonary edema is also not another name for blast lung. Pulmonary ed
ema occurs when fluid accumulates in the lungs, usually due to increased pressure in the blood vessel
s or damage to the lung tissue. It can result from heart problems, kidney disease, or severe infections, 
among other causes.
 
Correct Option A - Pneumonia:
 Pneumonia is an infection of the lungs that primarily affects the alveoli.
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 Severe pneumonia can cause respiratory distress which directly leads to ARDS.
 Pneumonia is considered a parenchymal lung disease.
 Both Pneumonia > Sepsis are the leading causes of ARDS
Option B - Fat embolism syndrome following femur shaft fracture: Fat embolism syndrome occurs whe
n fat globules are released into the bloodstream, typically following long bone fractures. These fat glob
ules can obstruct blood vessels in the lungs, leading to inflammation and lung injury. Fat embolism syn
drome can cause ARDS at the blood-lung interface.
Option C - Sepsis: Sepsis is a systemic inflammatory response to infection that can lead to organ dysfu
nction. In severe cases, sepsis can cause ARDS, as the inflammatory response affects the blood-lung i
nterface and results in lung injury.
Option D - Transfusion-related lung injury: Transfusion-related lung injury (TRALI) occurs when donor 
antibodies or other components in blood products trigger an immune response, leading to lung injury. T
RALI can cause ARDS at the blood-lung interface.
Correct Option A - 200 < PaO2/FiO2 =<300mm/Hg with PEEP Is moderate:
 According to the Berlin definition, moderate ARDS is defined by a PaO2/FiO2 ratio of 100-200 mmHg.
A
 PaO2/FiO2 ratio of 200-300 mmHg would fall into the mild ARDS category.
Option B - Bilateral interstitial infiltrates: This statement is correct. 
Option C - Symptom onset within a week: This statement is correct. 
Option D - No cardiac failure in echocardiography: This statement is correct. 
Correct Option D - Ultrasound-guided aspiration:
 If the patient's X-ray reveals a significant amount of fluid or an airway obstruction, and the patient is
intubated, ultrasound-guided aspiration may be a reasonable next step. This procedure involves using
ultrasound guidance to identify the site of fluid accumulation or obstruction and performing an
aspiration to relieve the obstruction or drain the fluid. It is often done to improve respiratory function and
prevent complications associated with airway obstruction or fluid accumulation.
Option A - Suction: Suctioning is a routine procedure used to clear the airway of secretions or foreign 
material. While suctioning may be necessary for some intubated patients, it is not a specific next step b
ased solely on the information provided in the question. The appropriateness of suctioning would depe
nd on the patient's clinical condition and the presence of indications for suctioning.
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Option B - Chest physiotherapy: Chest physiotherapy techniques, such as postural drainage, percussio
n, and vibration, are often used to help mobilize secretions and improve airway clearance. While these 
techniques may be beneficial in certain cases, they are not specific next steps based solely on the infor
mation provided in the question. The decision to perform chest physiotherapy would depend on the pati
ent's clinical condition and the need for airway clearance.
Option C - Start antibiotics and send samples for culture: Initiating antibiotics and obtaining cultures ma
y be appropriate in certain situations, such as suspected or confirmed respiratory infection. However, t
he decision to start antibiotics and send samples for culture should be based on a comprehensive eval
uation of the patient's clinical presentation, including signs and symptoms of infection. It cannot be dete
rmined solely based on the information of an X-ray finding.
Correct Option A - Subcutaneous emphysema:
 Chest Trauma: The patient has presented after chest trauma, indicating that there has been an injury
to the chest area. Chest trauma can cause various injuries, including damage to the respiratory
structures.
 Crepitus refers to the sensation of crackling or crunching felt under the skin. It occurs when air or gas
escapes from the damaged respiratory or gastrointestinal tract and dissects through the subcutaneous
tissues. The presence of crepitus is a characteristic finding in subcutaneous emphysema.
 The description of the image-based question mentioning the face of the man showing edema is not
directly related to the diagnosis of subcutaneous emphysema. Edema refers to the swelling caused by
an accumulation of fluid in the tissues, and it can have various causes. However, it is not a specific
feature of subcutaneous emphysema.
Option B - Gas gangrene: Gas gangrene is a severe and potentially life-threatening infection caused by
 certain bacteria, such as Clostridium species. It is characterized by the rapid spread of infection, tissue
 destruction, and gas production within the affected tissues. Gas gangrene is not directly related to che
st trauma or the presence of crepitus, so it is an incorrect option in this case.
Option C - Acute tubular necrosis: Acute tubular necrosis (ATN) is a type of kidney injury that can occu
r due to various causes, such as ischemia, toxins, or infections. It involves damage to the renal tubules
, leading to impaired kidney function. ATN is not directly related to chest trauma or the presence of cre
pitus, so it is an incorrect option in this scenario.
Option D - Hyperbaric decompression sickness: Hyperbaric decompression sickness, commonly know
n as "the bends," is a condition that can occur in scuba divers when they ascend too quickly, leading to
 the formation of gas bubbles in the bloodstream. It primarily affects divers and is not directly related to 
chest trauma or the presence of crepitus. Therefore, it is an incorrect option in this context.
Correct Option C: Congestive heart failure
 The above case with the given clinical findings is suggestive of the diagnosis of congestive heart
failure. The effusion is transudative in nature here according to Light’s criteria.
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Option A: Parapneumonic pleural effusion has increased in WBCs, especially neutrophils and the appe
arance is cloudy.
Option B: Malignant pleural effusion is exudative in nature.
Option D: Tubercular pleural effusion is exudative in nature.
 
Correct Option A - Consolidation with air bronchogram:
 Consolidation with air bronchogram refers to a radiological finding on chest imaging, where a locale of
lung parenchyma shows up more opaque due to accumulation of fluid or inflammatory exudate, with
unmistakable air-filled bronchi inside it. 
 Causes can be bacterial or viral pneumonia, bronchiectasis, pulmonary hemorrhage, or other
inflammatory lung diseases.
 The CT scan reveals consolidation with an air bronchogram, which is a classic finding in pneumonia.
The patient moreover presents with fever, breathlessness, and cough with expectoration, which
are indications of pneumonia.
Option B - Mediastinal mass: A mediastinal mass is an anomalous development or tumor found within t
he mediastinum, the area between the lungs within the chest. The CT scan would show a
well-defined mass within the mediastinum. The side effects would depend on the size of the mass.
Option C - Pleural effusion: Pleural effusion is a buildup of liquid between the layers of tissue that line t
he lungs and chest wall. The CT scan would appear as a collection of fluid around the lungs. 
Option D - Diaphragmatic hernia: A diaphragmatic hernia may be a defect within the diaphragm that pe
rmits organs from the abdomen to move into the chest depth. The CT scan would clearly demonstrate t
he presence of abdominal organs in the chest. 
Correct Option C - Isoniazid and rifampicin:
 Multidrug-resistant (MDR) tuberculosis shows resistance to isoniazid and rifampicin, which are the two
most effective first-line anti-TB drugs. Therefore, the correct answer is (c) isoniazid and rifampicin.
Options A & B: Isoniazid, rifampicin, and fluoroquinolone & Fluoroquinolones: Fluoroquinolones are se
cond-line anti-TB drugs that are used to treat MDR-TB together with different drugs. MDR-TB does sho
w resistance to isoniazid and rifampicin but not to fluoroquinolones.
Option D - Isoniazid, rifampicin, and kanamycin: Kanamycin is a second-line anti-TB drug used in the tr
eatment of MDR-TB. MDR-TB does show resistance to isoniazid and rifampicin but not to kanamycin.
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Correct Option A - Squamous cell carcinoma:
 Dysphagia can be caused by various conditions, including cancer of the esophagus or lung. However,
lung cancer is more commonly associated with dysphagia when it involves the upper part of the lung or
the lymph nodes around the trachea, which can press on the esophagus and interfere with swallowing.
Given that the patient in question has a history of chronic smoking, squamous cell carcinoma is the
most likely type of lung cancer to be found. This is because squamous cell carcinoma is strongly
associated with smoking and tends to develop in the central part of the lung, near the bronchus.
Correct Option B - Bronchiectasis:
 Bronchiectasis is a chronic respiratory condition characterized by permanent dilation and thickening of
the bronchial walls, leading to impaired airway mucus clearance. This can result in persistent coughing,
often accompanied by sputum production, which can worsen on changing body position. 
 Here, the cough increases on turning from left to right side, known as the "dependent lung"
phenomenon. This occurs because when the patient turns onto the affected side, the mucus collects in
the dependent part of the lung and triggers a cough.
Correct Option D - Bronchiectasis:
 Bronchiectasis is a condition characterized by permanent and abnormal dilatation of the bronchi and
bronchioles, which results in impaired airway clearance and chronic infections. Imaging studies can
confirm the diagnosis of bronchiectasis. 
 The CT findings in bronchiectasis may include: Bronchial dilatation: The most important finding in
bronchiectasis is bronchial dilatation, which may be cylindrical or varicose in shape. The dilatation may
be segmental or involve entire lobes or lung segments. Thickening of bronchial walls. Mucus plugging:
Mucus accumulation in the bronchi can lead to obstruction and recurrent infections. CT may show the
presence of bronchial secretions or mucus plugging. Atelectasis: Due to chronic inflammation and
obstruction, there may be areas of atelectasis or collapse of lung tissue. Ground-glass opacities: These
are areas of hazy increased attenuation on CT, often due to inflammation or edema. Air trapping:
Bronchiectasis can lead to impaired airway clearance and air trapping, which may be seen as
hyperinflation of the lungs. Bronchial wall irregularity: In severe cases of bronchiectasis, the bronchial
walls may appear irregular and nodular, with loss of normal architecture.
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 Silicosis is a progressive lung disease caused by inhalation of crystalline silica dust, commonly seen
in occupations such as mining, quarrying, and sandblasting. 
 In the early stages, HRCT may show ground-glass opacities
 As the disease progresses, nodular opacities called silicotic nodules develop, typically with an upper
lung zone predominance. These nodules may calcify over time, resulting in eggshell calcifications. 
Option A - Asbestosis: Asbestosis is a chronic lung disease caused by the inhalation of asbestos fibers
. The fibers lead to chronic inflammation and scarring of lung tissue. On HRCT, the characteristic findin
gs in asbestosis include linear opacities that typically have a subpleural and lower lung zone predomin
ance. These opacities may appear as fine reticular lines, thick bands, or honeycombing.
Option C - Anthracosis: Anthracosis, or coal workers’ pneumoconiosis, is a lung disease caused by the
 inhalation and deposition of coal dust particles. The primary HRCT finding in anthracosis is the presen
ce of small, rounded opacities, often referred to as coal macules or coal nodules found in the upper lun
g zones and can resemble small dots or clusters. 
Option D - Bagassosis: Bagassosis is an acute hypersensitivity pneumonitis caused by the inhalation o
f moldy bagasse, HRCT findings in bagassosis can vary but may include ground-glass opacities. Centri
lobular nodules, which are small nodules around the central airways, can also be seen. Additionally, air
 trapping may be observed, indicating small airway involvement.  
 Rheumatoid arthritis is an autoimmune disease characterized by chronic inflammation, primarily
affecting the joints.
 However, the inflammation associated with rheumatoid arthritis can extend beyond the joints and
involve other tissues, including the pleura. 
 Inflammation of the pleura can cause damage to the blood vessels in the pleural membrane, leading
to increased vascular permeability and the leakage of fluid, proteins, and immune cells into the pleural
space.
Option A & B
(Heart failure & Liver failure) are characteristically associated with transudative pleural effusion.
Option D - Nephrotic syndrome: Characterized by increased permeability of the glomerular filtration bar
rier, resulting in the loss of large amounts of protein in the urine. the fluid accumulation typically occurs 
in the lower extremities (peripheral edema) rather than in the pleural cavity. Pleural effusion is not a
typical feature of nephrotic syndrome.
Correct Option B - Legionella:
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 Legionella cause a severe form of pneumonia known as Legionnaires' disease. Legionella is a strict
aerobe, poorly stained with gram stain and infection  acquired through inhalation of aerosols.   
 Immunocompromised individuals are at increaed risk
 The characteristic symptoms include high-grade fever, cough, confusion,diarrhoea and bilateral
infiltrates seen on chest X-ray and hyponatremia and elevated liver enzymes.
Option A - Streptococcus: Streptococcus pneumoniae is a
common cause of community-acquired pneumonia, but it typically presents with a productive cough wit
h rust-colored sputum. In this case, the sputum gram stain did not detect any organisms, making Strept
ococcus less likely.
Option C - Pneumocystis jiroveci: is a fungal pathogen that causes pneumonia, particularly in immunoc
ompromised individuals, such as those with HIV/AIDS. While the patient in question is HIV positive, the
 symptoms described and chest X-ray findings of bilateral infiltrates are not specific to Pneumocystis jir
oveci pneumonia.
Option D - Klebsiella: Klebsiella causes pneumonia in individuals with a
history of alcoholism or COPD. While the patient has a smoking history, the clinical presentation (includ
ing confusion and diarrhea) is inconsistent with Klebsiella pneumoniae infection. Additionally, the abse
nce of organisms on sputum gram stain makes Klebsiella less likely.
Correct Option B - CT-guided biopsy:
 CT-guided biopsy is a minimally invasive procedure where a radiologist uses CT imaging to guide the
insertion of a needle into the lung mass to obtain a tissue sample for analysis.
 This method allows for direct sampling of the suspicious area, even if it is located peripherally or near
the apex of the lung.
 It provides a more accurate diagnosis by providing histopathological information about the nature of
the mass, including whether it is cancerous or benign. 
Option A - Bronchoscopy: While bronchoscopy can be useful in evaluating central lesions or endobron
chial tumors, it may not be effective for evaluating peripheral lung masses, especially those located ne
ar the apex.. Therefore, bronchoscopy may not be the best initial step for evaluation.
Option C - Sputum cytology: It has limited sensitivity for detecting peripheral lung masses, especially s
maller ones. In this case, the patient has a
3 cm mass near the apex of the lung, and sputum cytology is unlikely to provide a definitive diagnosis.
Option D - Sputum for AFB: While TB can cause hemoptysis, the appearance of a
3cm upper lobe mass near the apex on chest X-ray is inconsistent with the typical presentation of TB. 
 
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Correct Option A - Hypotension:
 Hypotension, is not typically associated with Gaisböck syndrome.
 Gaisböck syndrome occurs in patients with chronic obstructive pulmonary disease (COPD).  In these
individuals, the primary cause of polycythemia is chronic hypoxemia The body responds to chronic
hypoxemia by producing more erythropoietin As a result, the number of red blood cells increases,
leading to erythrocytosis. Hypotension is not typically observed. In fact, patients with COPD-related
erythrocytosis often have high blood pressure due to the underlying respiratory disease.
 In these individuals, the primary cause of polycythemia is chronic hypoxemia
 The body responds to chronic hypoxemia by producing more erythropoietin
 As a result, the number of red blood cells increases, leading to erythrocytosis.
 Hypotension is not typically observed. In fact, patients with COPD-related erythrocytosis often have
high blood pressure due to the underlying respiratory disease.
Option B - Erythrocytosis: Erythrocytosis is a defining feature of Gaisböck syndrome. 
Option C - Normal leukocyte counts: Normal leukocyte counts are typically seen in Gaisböck syndrome
. While the total blood volume increases due to an increase in red blood cells, white blood cells, and pl
atelets, the white blood cell count is usually within the normal range.
Option D - Obesity: Obesity is a feature of Gaisböck syndrome
Correct Option B - Cystic fibrosis:
 Cystic fibrosis (CF) is a genetic disorder that primarily affects the lungs and digestive system. 
 Recurrent respiratory infections, thickened sputum, and bronchial wall thickening as seen on a chest
X-ray are all symptoms of cystic fibrosis.
 Steatorrhea since birth is indicative of pancreatic insufficiency, a common manifestation of CF.
Option A - Hyaline membrane disease: The presence of a
hyaline membrane in the lungs characterises hyaline membrane disease, a
respiratory condition that primarily affects premature infants. 
Option C and D -  Alpha 1 anti-trypsin deficiency & Malabsorption syndrome: Child's steatorrhea sugge
sting malabsorption, the presence of recurrent respiratory infections and bronchial wall thickening mak
es CF a more likely differential diagnosis.
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Correct Option A - Pancoast tumour:
 Pancoast tumor is a relatively uncommon primary lung cancer forming in the lung apex and invading
the surrounding soft tissues.
 This is a tumor that is difficult to treat because of its proximity and frequent metastasis to adjacent
structures such as the subclavian vessels, lymphatic system, brachial plexus, spine, second and third
ribs, stellate ganglion, and the sympathetic nervous system.
 Its proximity to the above-mentioned structures causes the symptoms seen in the patient- pain
radiating to the upper arm and a tingling sensation in the 4th and 5th digits of his left hand.
Correct Option A - CT pulmonary angiogram:
 History of bed rest from months in elder individualis and symptoms of brethlessness and chest pain
points toward pulmonary embolism
 Elderly with best rest are prone to develop deep vein thrombus which can lead to pulmonary
embolism
 Therefore next best investigation in this patient would be CT pulmonary angiography
 CT pulmonary angiogram (CTPA) is used to check for pulmonary embolism or blood clots in the lungs'
arteries. A contrast dye is injected into an arm vein, where it travels through the lungs' blood vessels
while CT scans are taken.
 
Correct Option D - Obstructive disease with bronchodilator reversibility:
 In people with asthma or chronic obstructive pulmonary disease (COPD), bronchodilator reversibility
test is commonly used. The purpose of the test is to determine whether the subject's airflow has
improved as a result of taking the bronchodilator medication. The given pulmonary function test results
indicate a diagnosis of obstructive lung disease with bronchodilator reversibility as the FEV1/FVC is
less than 0.7 so it is an obstructive disease and after bronchodilation there is an increase of >12% in
FEV1 hence it is reversible. Improved lung volumes after bronchodilation indicate a response to the
bronchodilator which is a feature of COPD.
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Option A - Vascular disease with bronchodilator reversibility: Vascular disease does not typically prese
nt with bronchodilator reversibility, so this option is unlikely.
Option B - Restrictive lung disease with bronchodilator reversibility: Restrictive lung diseases are chara
cterized by reduced lung volumes, but the given lung volumes do not suggest restriction. Additionally, i
mproved lung volumes after bronchodilation indicate a
response to the bronchodilator, which is not typically seen in restrictive lung diseases.
Option C - Restrictive lung disease without bronchodilator reversibility: The lung volumes provided do n
ot indicate restriction. Additionally, the lack of improvement in lung volumes after bronchodilation contr
adicts this option.
Correct Option D - Ileocecal junction:
 The ileocecal junction refers to the area where the small intestine (ileum) meets the large intestine
(cecum).
 It is a common site for the development of tuberculosis infection in the abdomen.
 Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis, and it can affect various
organs and systems in the body, including the gastrointestinal tract.
Option A, B and C - Rectum, Colon & Small intestine: 
 Although tuberculosis can affect the rectum, colon and the small intestine, the ileocaecal junction is
the most common site.
Correct Option A - P-pulmonale:
 In the given ECG, P-wave amplitude ≥2.5 mm in leads II, III, and aVF.
 P-wave axis deviation towards the right side indicates P-pulmonale.
Correct Option D - Increase PEEP:
 In the given scenario, the patient is experiencing ARDS (Acute Respiratory Distress Syndrome)
secondary to urosepsis and is on mechanical ventilation. The arterial blood gas (ABG) results show a
low paO2 level of 50 mmHg, indicating hypoxemia.To improve oxygenation in ARDS, the next step
would be to increase the positive end-expiratory pressure (PEEP). PEEP helps to recruit collapsed
alveoli, improve lung compliance, and maintain alveolar patency. By increasing PEEP, it helps to open
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up more lung units, improve oxygenation, and increase functional residual capacity (FRC).
Option A - Reduce FiO2: The FiO2 is already set at 90% to provide a high concentration of oxygen to t
he patient. Further reducing FiO2 may compromise oxygenation and worsen hypoxemia.
Option B - Increase tidal volume: Increasing tidal volume can lead to increased risk of ventilator-induce
d lung injury (VILI) and barotrauma. It is generally recommended to use lower tidal volumes (around 6
mL/kg of ideal body weight) in ARDS to minimize complications.
Option C - Increase respiratory rate: Increasing the respiratory rate may improve minute ventilation but 
does not directly address the issue of hypoxemia. It is not the ideal intervention to improve oxygenation
 in ARDS.
Correct Option C - Metabolic acidosis:
 Metabolic acidosis occurs when there is an excess of acid or a loss of bicarbonate (HCO3-) in the
body, leading to a decrease in the bicarbonate concentration and a decrease in pH.
 This decrease is compensated by an increase in chloride ions, resulting in an increased anion gap.
 Options A, B and D are not associated with an increased anion gap.
Correct Option C - Pneumomediastinum:
 Hamman's sign is heard during auscultation of the chest and is associated with a specific condition
called pneumomediastinum.
 It refers to the crunching or crackling sound synchronous with the heartbeat, known as crepitus,
caused by air within the mediastinum.
 The sound is best heard along the left sternal border.
 Option A, B and D are not associated with the Hamman's sign.
 Bronchiectasis is characterized by permanent dilation and thickening of the bronchial walls.
 Obstructive ventilatory impairment may be observed, leading to a reduced FEV1 and an decreased
FVC, resulting in a decreased FEV1/FVC ratio.
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 The volume/time graph may show a reduced peak expiratory flow rate and prolonged expiration.
Option A - Chest wall neuromuscular disease: Decreased respiratory muscle strength and endurance c
an lead to reduced FEV1 and FVC values but FEV1/FVC ratio is normal or increased.
Option B - Sarcoidosis: Pulmonary involvement in sarcoidosis can lead to restrictive lung disease. Both
 FEV1 and FVC may be reduced, but the FEV1/FVC ratio remains normal or even increased.
Option C - Idiopathic pulmonary fibrosis: Idiopathic pulmonary fibrosis is characterized by progressive s
carring of lung tissue. It typically presents as a
restrictive lung disease. Both FEV1 and FVC may be reduced proportionally, maintaining a
normal or near-normal FEV1/FVC ratio. The volume/time graph may show reduced lung volumes and a
flattened slope during inspiration and expiration.
 
Correct Option C - Obesity hypoventilation syndrome:
 OHS is defined by raised 'awake' arterial pressure of carbon dioxide levels in patients with obesity in
whom alternative causes of hypercapnia and hypoventilation have been excluded.
 This is caused due to obesity causing a restriction in lung filling. This causes hypoventilation.
 In this patient with hypercapnia while awake, with compensatory metabolic alkalosis, the diagnosis is
likely OHS.
Option A - Obstructive sleep apnea:
 Obstructive sleep apnea (OSA) is a disorder that is characterized by obstructive apneas and
hypopneas due to repetitive collapse of the upper airway during sleep.
 While most patients with OHS will have Obstructive sleep apnea(90%) the clinical features here point
to a diagnosis of OHS.
 The clinical features against OSA include hypercapnia and hyoxemia in an awake individual.
 OSA patients will demonstrate hyoxemia only while asleep and not while awake.
 Therefore even though this patient is likely to have OSA, OHS is the better answer given the scenario
and clinical information provided.
Option B - Narcolepsy:
 Narcolepsy is characterized by excessive daytime sleepiness, sudden loss of muscle tone
(cataplexy), and disrupted sleep patterns. While impaired concentration and memory can be seen in
narcolepsy. ABG is normal.
Option D - Central sleep apnea:
 Central sleep apnea is a condition in which there is a lack of respiratory effort during sleep, leading to
pauses in breathing. It is different from obstructive sleep apnea, where the airway is physically blocked.
Impaired concentration and memory can occur in central sleep apnea. The most likely diagnosis in this
case is Obesity hypoventilation syndrome (OHS) due to the combination of obesity (BMI 41 kg/m2),
daytime sleepiness, impaired concentration, and the ABG results showing elevated PaCO2 (50 mm
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Hg). 
Correct Option B - Chloride (Cl): 
 The defect in cystic fibrosis is specifically associated with the CFTR chloride channel. Mutations in the
CFTR gene result in a defective or absent CFTR protein, impairing the movement of chloride ions
across cell membranes. This disruption of chloride transport leads to the characteristic features of CF,
including the production of thick and sticky mucus in various organs.
Correct Option D - Consider admission in a non ICU setting:
 The correct answer is to consider admission in a non-ICU setting. The patient's presentation with
cough, yellowish sputum, and bronchial breath sounds indicates a lower respiratory tract infection,
which may require further evaluation and management. However, since the patient is hemodynamically
stable and not confused, and their respiratory rate and blood pressure are within normal limits,
admission to a non-ICU setting would be an appropriate initial step.
CURB-65 Score for Assessing Severity of Community-Acquired Pneumonia:
Criteria
Score
Confusion
1 point
Urea > 7 mmol/L
Respiratory rate ≥ 30 breaths/min
Blood pressure (systolic < 90 mmHg or diastolic ≤ 60 mmHg)
Age ≥ 65 years
Interpretation:
 0 points: Low risk (consider home treatment)
 1-2 points: Intermediate risk (consider hospitalization or close monitoring)
 ≥ 3 points: High risk (consider hospitalization and further evaluation)
As the score is 1, we keep the patient in a non-icu hospital setting.
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Correct Option C - Respiratory alkalosis:
 Respiratory alkalosis occurs when there is a decrease in carbon dioxide (CO2) levels in the blood,
leading to an increase in alkalinity. It can be caused by hyperventilation, anxiety, or high-altitude
exposure. Hyperventilation causes excessive elimination of carbon dioxide, leading to a decrease in
blood CO2 levels. This results in respiratory alkalosis. Symptoms may include lightheadedness,
dizziness, tingling sensations, and carpo-pedal spasms. In this case, the patient's hyperventilation and
subsequent carpo-pedal spasms suggest respiratory alkalosis as the likely cause.
 In a hyperventilating patient, Options A, B and D are unlikely.
Correct Option C - Tropical pulmonary eosinophilia:
 Tropical pulmonary eosinophilia (TPE) is a hypersensitivity reaction to filarial parasites (Wuchereria
bancrofti or Brugia malayi) and their products. It is more commonly seen in individuals living in endemic
areas. Symptoms include fever, nocturnal cough, breathlessness, wheezing, and an increased
eosinophil count (>500/µL). The miliary pattern on chest X-ray is typical of TPE.
 Therefore, the diagnosis is TPE.
Option A - Bronchial asthma:
 Bronchial asthma is a chronic respiratory condition characterized by inflammation and narrowing of
the airways, leading to symptoms such as wheezing, coughing (often nocturnal), breathlessness, and
occasionally fever.
 However, the presence of a miliary pattern on chest X-ray is not typical of bronchial asthma.
Therefore, bronchial asthma is less likely to be the diagnosis in this case.
Option B - Miliary tuberculosis:
  Miliary tuberculosis is a severe form of tuberculosis (TB) in which the infection spreads throughout
the body, including the lungs. It is characterized by the dissemination of tiny, millimeter-sized lesions
throughout various organs, including the lungs, giving a miliary pattern on chest X-ray.
 Symptoms can include fever, cough, breathlessness, and weight loss. The elevated absolute
eosinophil count is not typical of miliary tuberculosis. Therefore, miliary tuberculosis is less likely to be
the diagnosis in this case.
Option D - Hypersensitivity pneumonitis:
  Hypersensitivity pneumonitis (HP), also known as extrinsic allergic alveolitis, is an immune-mediated
lung disease caused by the inhalation of various organic substances such as dust, molds, or animal
proteins. Symptoms typically include fever, cough (often nocturnal), breathlessness, and wheezing. The
absolute eosinophil count can be elevated in some cases. However, the presence of a miliary pattern
on chest X-ray is not typical of HP. Therefore, HP is less likely to be the diagnosis in this case.
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Correct Option B - Streptococcus pneumonia:
 Streptococcus pneumoniae is a bacterium and a common cause of bacterial pneumonia in both
immunocompetent and immunocompromised individuals. In the context of a child with AIDS, a low CD4
count, fever, productive cough, and consolidation on chest X-ray, Streptococcus pneumoniae is the
most common and likely causative organism. It can cause lobar pneumonia, as indicated by the right
lower lobe consolidation on the chest X-ray.
Option A - Pneumocystis jirovecii: Pneumocystis jirovecii is a fungus that commonly causes pneumonia
 in immunocompromised individuals, especially those with AIDS. It typically presents with non-producti
ve cough, shortness of breath, and bilateral diffuse infiltrates on chest X-ray. While Pneumocystis jirov
ecii pneumonia (PJP) is a common opportunistic infection in patients with AIDS, the clinical presentatio
n described in the scenario, including fever, productive cough, and unilateral consolidation, is not typic
al of PJP. Therefore, Pneumocystis jirovecii is not the most likely causative organism in this case.
Option C - Staphylococcus aureus: Staphylococcus aureus is another bacterium that can cause pneum
onia in immunocompromised individuals, including those with AIDS. It is known for causing severe infe
ctions, including necrotizing pneumonia. While Staphylococcus aureus can be a
potential pathogen, S.pneumoniae is more commonly associated with this presentation.
Option D - Mycoplasma: Mycoplasma pneumoniae is an atypical bacterium that can cause pneumonia,
 particularly in children and young adults. It often presents with a milder respiratory illness, including a 
persistent cough, headache, and sore throat. The chest X-ray findings typically show patchy infiltrates r
ather than lobar consolidation. Although Mycoplasma can cause pneumonia, it is not the most likely ca
usative organism in this case, given the clinical presentation and imaging findings.
Correct Option B - Airborne precautions:
 Airborne infections are one of the five modes of transmission of diseases. N95 masks protect from
most diseases that arise through airborne transmission.
Option A - Droplet precautions: N95 masks do not provide complete protection from droplet spread infe
ction. The expelled droplets can cause infection on coming in contact with even the skin or conjunctiva.
Option C - Contact precautions: Using an N95 respirator alone is not essential to preventing diseases t
hat could be transmitted through contact with a patient.
Option D - All of the above: N95 alone does not protect from diseases requiring contact and droplet pre
cautions. So this option is incorrect.
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Correct Option A - Non-invasive PPV should be given:
 In the initial management of a patient with an acute exacerbation of chronic obstructive pulmonary
disease (COPD), non-invasive positive pressure ventilation (NIPPV) is a recommended intervention.
NIPPV involves the application of positive pressure through a mask or nasal prongs to assist with
breathing, improve oxygenation, and alleviate respiratory distress.
Option B - Invasive PPV should be given: Invasive positive pressure ventilation (IPPV) involves intubati
ng the patient and providing mechanical ventilation through an endotracheal tube. In the initial manage
ment of an acute exacerbation of COPD, NIPPV is preferred over IPPV, as it can often effectively impr
ove oxygenation and ventilation without the need for invasive procedures.
Option C - Oxygen is not indicated: Oxygen therapy is a
mainstay in the management of patients with COPD exacerbation
Option D - Permissive hypercapnia and not 'hypocapnia' is allowed: Permissive hypercapnia refers to a
ventilation strategy where a higher than normal level of carbon dioxide (hypercapnia) is tolerated to avo
id potential lung injury caused by high ventilatory pressures. 
Correct Option C - Decreased pH, decreased bicarbonate (HCO3-)
 Metabolic acidosis is a condition characterized by a decrease in blood pH and a decrease in
bicarbonate (HCO3-) levels. 
 Metabolic Acidosis: This type of acid-base imbalance occurs when there is an excess of acid in the
body or a loss of bicarbonate. Causes include conditions such as diabetic ketoacidosis, lactic acidosis,
renal failure, and ingestion of certain toxins.
 Therefore, in a patient with metabolic acidosis, you would expect to see an ABG with a decreased pH
and a decreased bicarbonate level. This combination indicates the presence of a metabolic acidosis.
 Option A, B and D are incorrect.
Correct Option B - Needle decompression into the 5th intercostal space anterior to the midaxillary line:
 Needle decompression into the 5th intercostal space anterior to the midaxillary line: This is the correct
next step in managing the patient. The clinical presentation, including respiratory distress, hypotension,
subcutaneous emphysema, and absent air entry on the affected side, is highly suggestive of a tension
pneumothorax. Needle decompression is an emergency procedure performed to release the trapped
air in the pleural space, providing immediate relief and improving the patient's respiratory and
hemodynamic status. It involves inserting a large-bore needle (such as an 18-gauge) into the 5th
intercostal space in the anterior axillary line to decompress the pleural cavity.
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Correct Option C - Non-invasive positive pressure ventilation (NIPPV):
 Non-invasive positive pressure ventilation is the right choice.
 Here, the arterial blood gas analysis shows that the patient was in respiratory acidosis, which is due to
an increase in carbon dioxide. this condition can be managed by administering Non-Invasive Positive
Pressure Ventilation through BiPaP and CPaP 
 Options A, B and D are incorrect and not indicated in this patient at present. NIPPV would be the most
appropriate choice of treatment at this juncture.
 
Correct Option A - Lung metastasis
 Lung metastasis is the correct answer. The radiological imaging reveals Canon Ball Metastasis of the
lung likely secondary to malignancies such as Renal Cell Carcinoma . The image shows large, multiple,
well-circumscribed, round pulmonary mets that look like cannon balls, hence the name.
Correct Option B - Malignant mesothelioma: 
 It is a tumor of mesothelial cells. It is the most specific malignancy seen in asbestosis.
Option A - Bronchogenic carcinoma: While bronchogenic carcinoma is the most common lung maligna
ncy, it is not the most specific malignancy associated with asbestos exposure (shipbuilding →
asbestos exposure)
Correct Option B - Pulmonary fibrosis:
 In the above case, the patient presents with shortness of breath and has a history of chronic smoking,
clubbing, and bilateral crackling sounds on auscultation. The most probable diagnosis is that of
pulmonary fibrosis. The image also shows honeycombing and traction bronchiectasis which are
characteristic CT findings seen in patients with pulmonary fibrosis.
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medications.
 Among the options provided, the most appropriate choice for the next step of management in this
scenario would be option b. Ambrisentan is a selective endothelin receptor antagonist that is commonly
used in the treatment of pulmonary arterial hypertension. It helps to improve exercise capacity and
delay disease progression in PAH patients. It acts by blocking the effects of endothelin, a substance
that promotes vasoconstriction and cell proliferation in the pulmonary arteries.
Option A - Iloprost: Iloprost is a prostacyclin analogue that can be administered intravenously or inhale
d. It is often used in more advanced stages of PAH or in patients who do not respond adequately to oth
er therapies.
Option C -  Nifedipine: Nifedipine is a calcium channel blocker that can help to relax and dilate blood ve
ssels. While calcium channel blockers can be effective in some cases of PAH, they are generally reser
ved for patients who demonstrate a positive response during a vasoreactive test.
Option D - Epoprostenol: Epoprostenol is a prostacyclin that is administered continuously via intraveno
us infusion. It is typically used in severe cases of PAH or in patients who do not respond to other thera
pies.
Correct Option C - Start ATT and then ART after 2 weeks:
 In this scenario, the presence of acid-fast bacilli in the sputum sample suggests a potential
co-infection with tuberculosis (TB). It is common for individuals with HIV to develop TB due to their
weakened immune systems.
 The recommended approach in managing HIV-TB co-infection is to initiate ATT first and then after 2
weeks ART. This approach is based on evidence showing improved outcomes and reduced mortality
rates.
Correct Option C - Hypoventilation:
 In a patient with hypoxemia and a normal alveolar-arterial oxygen gradient, hypoventilation is the
likely cause. Hypoventilation refers to inadequate ventilation of the alveoli, leading to a reduced
exchange of oxygen and carbon dioxide. This can result from various factors such as respiratory
muscle weakness, central nervous system depression, or mechanical abnormalities of the chest wall.
Option A - Right-to-left shunt: A right-to-left shunt refers to the mixing of oxygenated and deoxygenated
 blood, bypassing the normal oxygenation process in the lungs. It results in hypoxemia, but it would typi
cally be associated with an increased alveolar-arterial oxygen gradient rather than a normal gradient.
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Option B - Ventilation/perfusion (V/Q) mismatch: V/Q mismatch occurs when there is a mismatch betw
een the ventilation of the alveoli and the perfusion of blood to the capillaries surrounding the alveoli. It c
an lead to hypoxemia, and depending on the severity, it may cause an increased alveolar-arterial oxyg
en gradient.
Option D - Alveolar membrane damage: Damage to the alveolar membrane, such as in conditions like 
pulmonary fibrosis or acute respiratory distress syndrome (ARDS), can impair the diffusion of oxygen fr
om the alveoli into the bloodstream. This would typically result in an increased alveolar-arterial oxygen 
gradient rather than a normal gradient.
Correct Option B - Fixed central airway obstruction:
 Fixed central airway obstruction refers to a condition where there is a persistent and constant
narrowing or blockage of the central airways within the lungs. This obstruction occurs at a fixed or
unchanging location and does not vary with breathing or changes in lung volume. Various factors,
including tumors, strictures, foreign bodies, or scarring within the central airways can cause it. It leads
to impaired airflow and can result in symptoms such as shortness of breath, wheezing, and coughing.
Correct Option A - 1, 2:
 To determine acid-base imbalances in a patient, the following parameters can be used: Arterial pH:
Arterial blood gas (ABG) analysis measures arterial pH, which reflects the acidity or alkalinity of the
blood. It is a direct indicator of acid-base status. Venous pH: Venous blood gas (VBG) analysis can
also provide information about pH levels in venous blood. While arterial pH is the gold standard, venous
pH can be used as an alternative in certain clinical situations when arterial blood sampling is
challenging or not readily available.
 Arterial pH: Arterial blood gas (ABG) analysis measures arterial pH, which reflects the acidity or
alkalinity of the blood. It is a direct indicator of acid-base status.
 Venous pH: Venous blood gas (VBG) analysis can also provide information about pH levels in venous
blood. While arterial pH is the gold standard, venous pH can be used as an alternative in certain clinical
situations when arterial blood sampling is challenging or not readily available.
 These two parameters can help determine a patient's acid-base imbalance.
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Correct Option A - Hyperglycemia:
 Hyperglycemia, or high blood sugar levels, is not typically associated with Addison's disease. In fact,
individuals with Addison's disease may experience hypoglycemia (low blood sugar) due to the
inadequate production of cortisol, a hormone involved in regulating blood sugar levels.
Option B - Hyponatremia: Hyponatremia refers to low levels of sodium in the blood. It is commonly obs
erved in Addison's disease because insufficient levels of aldosterone, a hormone produced by the adre
nal glands, can lead to sodium loss. Thus, hyponatremia is associated with Addison's disease.
Option C - Hyperkalemia: Hyperkalemia refers to high levels of potassium in the blood. It is a characteri
stic feature of Addison's disease. Inadequate levels of aldosterone can impair the excretion of potassiu
m by the kidneys, leading to its accumulation in the bloodstream.
Option D - Hypotension: Hypotension, or low blood pressure, is commonly observed in Addison's disea
se. The insufficient production of adrenal hormones, including cortisol and aldosterone, can result in flu
id and electrolyte imbalances, leading to decreased blood volume and hypotension.
 
Correct Option B - Silicosis:
 Among the given options, the pneumoconiosis associated with an increased incidence of tuberculosis
is "Silicosis."
 Silicosis is a lung disease caused by the inhalation of crystalline silica particles. It commonly affects
individuals working in occupations such as mining, sandblasting, and stone cutting. Silicosis can impair
the immune system and increase the risk of developing tuberculosis. The presence of silica particles in
the lungs can create an environment conducive to Mycobacterium tuberculosis infection and growth.
 
 Based on the provided information and the chest X-ray findings, the most likely diagnosis for the
patient is Acute Respiratory Distress Syndrome (ARDS).
 ARDS is a severe lung condition characterized by widespread inflammation and damage to the alveoli
(air sacs) in the lungs. It can be triggered by various factors, including infection, sepsis, trauma, or
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inhalation injury. The key features of ARDS include acute onset of severe hypoxemia (low oxygen
levels) that is refractory to supplemental oxygen, bilateral pulmonary infiltrates on imaging (such as the
chest X-ray), and impaired lung compliance.
Option A - Atelectasis: Atelectasis refers to the collapse or incomplete expansion of lung tissue. It can r
esult from blockage of the airways, compression of the lung, or surfactant deficiency. While atelectasis 
can cause localized or segmental lung collapse, it typically does not lead to widespread bilateral infiltrat
es and severe hypoxemia as seen in the patient's presentation.
Option B - Mediastinitis: Mediastinitis refers to inflammation or infection of the mediastinum, which is th
e area between the lungs. It is usually caused by an infection that spreads from the nearby structures o
r as a complication of a surgical procedure. While mediastinitis can cause respiratory symptoms, it wou
ld not explain the diffuse infiltrates seen on the chest X-ray or the severe hypoxemia.
Option C - Pulmonary fibrosis: Pulmonary fibrosis is a chronic lung condition characterized by the form
ation of scar tissue in the lungs, leading to progressive and irreversible lung damage. It typically presen
ts with a gradual onset of symptoms, such as shortness of breath and cough, and the chest X-ray findi
ngs would show a reticular or honeycomb pattern. The acute onset, severe hypoxemia, and diffuse infil
trates seen in the chest X-ray are not consistent with pulmonary fibrosis
 
Correct Option A - Hypokalemic hypochloremic metabolic alkalosis with hyponatremia:
 Based on the provided information of chronic projectile vomiting and weight loss in a 55-year-old
patient, the expected metabolic abnormality is Hypokalemic hypochloremic metabolic alkalosis with
hyponatremia. Chronic vomiting can lead to loss of gastric acid (hydrochloric acid) and chloride ions
(hypochloremia). This loss of acid and chloride results in metabolic alkalosis. Additionally, prolonged
vomiting can lead to loss of potassium (hypokalemia) through gastric secretions. Hyponatremia (low
sodium levels) may occur as a result of fluid and electrolyte imbalances caused by vomiting.
 
 In patients with exacerbations of COPD who present with acute respiratory failure and hypoventilation,
NIPPV is considered the initial treatment of choice. NIPPV delivers positive pressure ventilation via a
mask or similar interface without the need for endotracheal intubation. It helps to improve ventilation,
oxygenation, and alleviate respiratory distress by assisting the patient's breathing effort.
Option B & D - Invasive PPV should be given &
Intubate and start on ventilator: Invasive positive pressure ventilation (intubation and starting on a venti
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lator) is generally reserved for cases where NIPPV fails or is contraindicated. It is associated with pote
ntial risks and complications, and therefore, NIPPV is preferred as the initial intervention in this scenari
o.
Option C - Increase the oxygen flow rate: Increasing the oxygen flow rate alone would not adequately a
ddress the underlying issue of hypoventilation and high pCO2 levels. It may improve oxygenation temp
orarily, but it does not address the ventilation problem and the resulting respiratory acidosis.
 
Correct Option C - Potklor:
 Hypokalemia is when the amount of potassium in your blood is too low. Normal levels of potassium for
an adult range from 3.5 to 5.2 mEq/L (3.5 to 5.2 mmol/L). Anything lower than 3 mEq/L (3 mmol/L) may
be considered severe hypokalemia. The preferred treatment for a patient with a serum potassium level
of 3.0 mmol/L and no comorbidities, along with a normal ECG, would be PotChlor (Oral potassium
chloride). It can help restore potassium levels to a normal range and alleviate the symptoms associated
with hypokalemia.
Option A - Calcium gluconate: Calcium gluconate is not the preferred treatment for hypokalemia. Calci
um gluconate is used to treat conditions such as hyperkalemia (high potassium levels) or to counteract 
the effects of calcium channel blocker overdose. It does not directly address low potassium levels.
Option B - Sodium bicarbonate: Sodium bicarbonate is not the preferred treatment for hypokalemia. So
dium bicarbonate is used to treat Metabolic acidosis.
Option D - Insulin with dextrose: Insulin with dextrose is used in the treatment of hyperkalemia, not hyp
okalemia. Insulin with dextrose helps shift potassium from the extracellular space into the cells, thereby
 lowering blood potassium levels. However, in this case, the patient's potassium level is low, so insulin 
with dextrose is not appropriate
 
Correct Option: A, D
Prophylactic cranial radiation (PCR) is given for the management of brain metastases in certain types o
f cancers. The correct answer from the given options is "Lung cancer" and "Breast cancer."
 Lung cancer: Prophylactic cranial radiation is commonly used in patients with small cell lung cancer
(SCLC) who are at high risk of developing brain metastases. SCLC has a strong tendency to spread to
the brain, and PCR is given to reduce the risk of metastatic disease in the brain.
 Breast cancer: Prophylactic cranial radiation may be considered in certain cases of breast cancer. It is
typically recommended for patients with breast cancer who have a high risk of developing brain
metastases, such as those with aggressive subtypes like HER2-positive or triple-negative breast
cancer.
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Option B: Liver cancer: Prophylactic cranial radiation is not routinely used for liver cancer. Liver cancer,
 also known as hepatocellular carcinoma (HCC), has a
different pattern of spread, and brain metastases are relatively uncommon in this cancer.
Option C: Prostate cancer: Prophylactic cranial radiation is generally not used for prostate cancer. Pros
tate cancer tends to metastasize to the bones, and brain metastases are relatively rare in this cancer.
Correct Option B - CT:
 In the given scenario, a 50-year-old chronic smoker with mild recurrent hemoptysis and normal chest
X-ray, CT scan (computed tomography) is the most useful diagnostic investigation. CT scan provides
detailed imaging of the lungs and can help identify subtle abnormalities that may not be visible on a
chest X-ray. It can detect small nodules, bronchial wall thickening, or other structural changes in the
lungs that could be contributing to the hemoptysis. CT scan is commonly used in the evaluation of
hemoptysis, especially when the chest X-ray is normal or inconclusive.
 Options A, C, and D are incorrect. CT scan is a more appropriate, non invasive, diagnostic next step
in the management of this patient.
Correct Option A - Intrinsic asthma: 
 Nasal polyps are commonly associated with intrinsic asthma. Intrinsic asthma, also known as
non-allergic or non-atopic asthma, is characterized by asthma symptoms that are not triggered by
specific allergens. It can be caused by factors such as respiratory infections, irritants, exercise, cold air,
stress, or certain medications. Nasal polyps are frequently seen in individuals with intrinsic asthma,
suggesting a connection between these two conditions.
 Options B, C and D are incorrect and are not characteristically associated with nasal polyps.
 
Correct Option D - Pneumocystis jirovecii pneumonia (PJP):
 Pneumocystis jirovecii pneumonia (formerly known as Pneumocystis carinii pneumonia) is a fungal
infection that commonly affects individuals with weakened immune systems, such as those with
HIV/AIDS. The presentation of fever, dry cough, significant weight loss, and chest X-ray findings of
diffuse interstitial infiltrates and symmetrical perihilar involvement are highly suggestive of PJP.
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Option D - Central bronchiectasis: Centeal bronchiectasis is a common feature of allergic bronchopulm
onary aspergillosis (ABPA). It is characterized by the dilation and thickening of the airways in the distal 
portions of the lungs.
Correct Option A - FEV1/FVC <0.7 and FEV1<30%:
 The Gold's criteria for very severe COPD is: FEV1/FVC <0.7 and FEV1 <30%
 GOLD Classification for COPD:
Mild COPD
FEV1/ FVC<0.7
FEV1≥80%
Moderate COPD
FEV1/ FVC <0.7
FEV1 = 50-80%
Severe COPD
FEV1 = 30-50%
Very sever COPD
FEV1 <30%
Correct Option B - Asthenospermia:
 Kartagener's syndrome, also known as primary ciliary dyskinesia (PCD), is a rare genetic disorder that
affects the structure and function of cilia. Cilia are hair-like structures present on the surface of cells,
including cells in the respiratory tract and reproductive organs. In Kartagener's syndrome, there is a
defect in the structure and/or function of cilia, leading to various clinical manifestations, including
respiratory problems and infertility.
 In the context of infertility in Kartagener's syndrome, the most likely cause is asthenospermia, which
refers to reduced or absent sperm motility. Cilia play a crucial role in sperm motility, as they provide the
propulsive force needed for sperm movement within the female reproductive tract. In Kartagener's
syndrome, the defective ciliary function can result in impaired sperm motility, leading to reduced fertility.
 Options A, C and D are not specific features of Kartagener's syndrome and are incorrect.
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Correct Option C - Acinetobacter:
 Ventilator-associated pneumonia (VAP) is a type of pneumonia that occurs in patients who are on
mechanical ventilation. It is typically acquired during the hospital stay and is often caused by bacterial
pathogens. Among the options provided, Acinetobacter is the most likely causative organism of VAP.
 Acinetobacter is a gram-negative bacterium that is known for its ability to survive on environmental
surfaces and medical equipment. It can colonize the respiratory tract of ventilated patients and has the
potential to cause serious infections, including pneumonia. Acinetobacter infections are often
associated with healthcare settings, especially intensive care units (ICUs).
 
Correct Option C - Azithromycin:
 Community-acquired pneumonia (CAP) refers to pneumonia that is acquired outside of healthcare
facilities. In the outpatient setting, the most common pathogens causing CAP are typically atypical
bacteria, such as Mycoplasma pneumoniae and Chlamydophila pneumoniae, as well as certain
respiratory viruses. Azithromycin, a macrolide antibiotic, is commonly used as an empiric treatment
option for CAP in the outpatient setting.
 Azithromycin has several advantages that make it suitable for outpatient management of CAP. It has
excellent activity against atypical pathogens, including Mycoplasma pneumoniae and Chlamydophila
pneumoniae. It also has a long half-life, allowing for once-daily dosing, which enhances patient
compliance. 
Option A - Vancomycin: Vancomycin is an antibiotic primarily used for the treatment of Gram-positive b
acterial infections, particularly those caused by methicillin-resistant Staphylococcus aureus (MRSA). It i
s not typically used as an initial empiric treatment for community-acquired pneumonia in the outpatient 
setting.
Option B - Ceftriaxone: Ceftriaxone is a broad-spectrum cephalosporin antibiotic commonly used for th
e treatment of various bacterial infections. While it may be used for the treatment of CAP in specific ca
ses, such as when there is a concern for more resistant pathogens or in patients with specific risk facto
rs, it is not the first-line treatment choice in most cases of outpatient CAP.
Option D - Streptomycin: Streptomycin is an aminoglycoside antibiotic that has activity against certain 
Gram-negative bacteria. However, it is not commonly used as a
first-line treatment for community-acquired pneumonia, especially in the outpatient setting.
Correct Option A - Asbestosis:
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 Asbestosis is a lung disease caused by long-term exposure to asbestos fibers. In this condition,
asbestos fibers cause inflammation and scarring of the lung tissue, leading to breathing difficulties and
other respiratory symptoms.
 The given clinical scenario of a 45-year-old patient with a history of working in a factory for 20 years
and presenting with breathlessness is suggestive of an occupational lung disease. The HRCT chest
findings of pleural thickening and fibrosis further support the diagnosis.
Option B - Coal worker pneumoconiosis: This is a lung disease caused by inhalation of coal dust. It is c
haracterized by the deposition of coal dust particles in the lungs, leading to inflammation and scarring. 
However, the presentation in the given scenario is not consistent with coal worker pneumoconiosis.
Option C - Silicosis: Silicosis is a lung disease caused by inhalation of crystalline silica particles. It com
monly affects individuals working in industries such as mining, construction, and sandblasting. The cha
racteristic HRCT findings in silicosis include multiple small nodules in the upper lung zones. Pleural thic
kening and fibrosis are not typical features of silicosis.
Option D - Berylliosis: Berylliosis is a lung disease caused by exposure to beryllium, commonly found i
n certain industries such as aerospace, electronics, and dental laboratories. It can lead to granulomato
us inflammation in the lungs. The clinical presentation and HRCT findings described in the scenario are
 not consistent with berylliosis.
 
Correct Option A - Thermophilic Actinomycetes:
 Farmer's Lung, also known as hypersensitivity pneumonitis, is an allergic lung disease caused by the
inhalation of various organic dust particles. Thermophilic Actinomycetes, which are bacteria-like
microorganisms commonly found in moldy hay, straw, and grain, are one of the causative agents of
Farmer's Lung. When individuals sensitized to these microorganisms inhale the dust containing them,
an immune response is triggered, leading to inflammation and lung damage.
 Options B, C and D are not associated with Farmer's lung.
 
Correct Option A - Lung cancer:
 Lung cancer is the most common primary cancer that metastasizes to the brain. The lungs are a
common site for the development of cancerous cells, and when these cells spread to other parts of the
body, including the brain, they can form brain metastases.
 
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Correct Option A - Responds well to amoxiclav:
 Mycoplasma pneumonia is caused by the bacterium Mycoplasma pneumoniae, and it is typically
treated with antibiotics such as macrolides (e.g., azithromycin) or tetracyclines (e.g., doxycycline).
Amoxiclav, which is a combination of amoxicillin and clavulanic acid, is not considered a first-line
treatment for Mycoplasma pneumonia. Therefore, the statement that mycoplasma pneumonia
responds well to amoxiclav is false.
Option B - Antibodies are useful in diagnosis: Antibodies are indeed useful in the diagnosis of Mycopla
sma pneumonia. Serologic testing, such as the detection of specific antibodies (IgM and IgG) against 
Mycoplasma pneumoniae, can be helpful in confirming the diagnosis. These antibodies can be detecte
d using tests like enzyme-linked immunosorbent assay (ELISA) or complement fixation tests.
Option C - Chest X-ray shows bilateral infiltrates: Chest X-ray findings in Mycoplasma pneumonia can 
vary, but bilateral infiltrates are commonly seen. Infiltrates may appear as patchy or diffuse opacities in 
both lungs. However, it is important to note that chest X-ray findings alone cannot definitively diagnose 
Mycoplasma pneumonia and should be correlated with clinical symptoms and other diagnostic tests.
Option D - Can be cultured in a cell-free medium: Mycoplasma pneumoniae is a
unique bacterium that lacks a cell wall and requires a specialized cell-free medium for culture. It cannot
 be grown on conventional culture media. The absence of a cell wall makes it resistant to certain antibi
otics that target cell wall synthesis, such as penicillins and cephalosporins.
 
Correct Option C - Acute respiratory acidosis, acute respiratory alkalosis:
 A - Acute respiratory acidosis: Acute respiratory acidosis occurs when there is an increase in the
partial pressure of carbon dioxide (PaCO2) in the blood due to inadequate ventilation. This can be
caused by conditions such as pneumonia, pulmonary edema, or airway obstruction.
 D - Acute respiratory alkalosis: Acute respiratory alkalosis occurs when there is a decrease in PaCO2
in the blood due to excessive ventilation. It can be caused by hyperventilation due to anxiety, fever, or
high altitude.
Correct Option B - Pleuritis:
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Page 56
 Pleuritis, inflammation of the pleura (the membranes lining the lungs and chest cavity), is the most
common pulmonary manifestation of SLE. It can cause chest pain, pleural effusion (accumulation of
fluid in the pleural space), and a characteristic friction rub on auscultation.
Option A - Shrinking lung syndrome: Shrinking lung syndrome is a rare complication of systemic lupus 
erythematosus (SLE) characterized by progressive dyspnea and restrictive lung function. However, it is
 not the most common pulmonary manifestation of SLE.
Option C - Intra-alveolar hemorrhage: Intra-alveolar hemorrhage refers to bleeding into the air sacs of t
he lungs. While it can occur in SLE, it is less common compared to pleuritis.
Option D - Interstitial inflammation: Interstitial inflammation refers to inflammation of the lung interstitiu
m, which is the tissue between the air sacs. While interstitial lung disease can occur in SLE, it is not th
e most common pulmonary manifestation.
Correct Option B - Haemorrhagic mediastinitis:
 This is the most common presentation of inhalational anthrax. It is characterized by severe chest pain,
shortness of breath, and mediastinal widening on imaging. Hemorrhagic mediastinitis refers to the
presence of bleeding and inflammation in the mediastinum, the area between the lungs.
Option A - Atypical pneumonia: This is not the most common presentation of inhalational anthrax. Whil
e respiratory symptoms can occur, they are not typically indicative of a typical pneumonia.
Option C - Lung abscess: Although lung abscess can occur in some cases of inhalational anthrax, it is 
not the most common presentation. Lung abscesses are localized collections of pus within the lung par
enchyma.
Option D - Broncho-pulmonary pneumonia: While pneumonia can occur in inhalational anthrax, it typic
ally presents as a severe form with features of haemorrhagic mediastinitis rather than a
typical broncho-pulmonary pneumonia.
Correct Option D - Clubbing:
 The above image is that of clubbing, which is a selective bulbous enlargement of the distal segments
of the fingers and toes due to the proliferation of connective tissues.
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Correct Option B - Cytomegalovirus:
 In the above case, owl’s eye intranuclear inclusion bodies are seen in cytomegalovirus infection. CMV
infection is a significant cause of mortality after an allogeneic transplant, especially in renal transplant
patients.
Correct Option B - 2,3,4 only:
 Distal bronchiectasis: This feature is not typically associated with Allergic Broncho Pulmonary
Aspergilloma (ABPA). Distal bronchiectasis is more commonly seen in other conditions such as cystic
fibrosis. In ABPA, Central Bronchiectasis is seen.
 Serum precipitins to Aspergillus: This is a characteristic feature of ABPA. Individuals with ABPA often
have detectable serum precipitins (specific antibodies) against Aspergillus.
 Increased IgE levels: ABPA is characterized by an elevated level of IgE (immunoglobulin E) in the
blood. This is a result of the allergic response to Aspergillus antigens.
 Seen in asthmatics: ABPA is frequently associated with asthma. It is estimated that about 10% of
individuals with asthma may develop ABPA.
Correct Option B - Reproductive number for COVID-19 is 2-2.5:
 The reproductive number (R0) represents the average number of people that an infected individual
will infect. The estimated R0 for COVID-19 is around 2-2.5, which means that each infected person, on
average, can transmit the virus to 2-2.5 others. This indicates the potential for sustained transmission
and makes COVID-19 highly contagious.
Option A - Median incubation period is more in influenza: The median incubation period of COVID-19 is
 generally longer compared to influenza. Influenza typically has a
shorter incubation period, ranging from 1-4 days, while COVID-19 has a
median incubation period of around 5-6 days.
Option C - Serial interval is 5-6 days in influenza: The serial interval refers to the time between the ons
et of symptoms in one infected individual and the onset of symptoms in the secondary infected individu
al. Influenza typically has a shorter serial interval, usually around 2-3 days, indicating a
relatively rapid spread of the virus from person to person.
Option D - Reproductive number for Influenza is more: The reproductive number for influenza is genera
lly lower compared to COVID-19. While the exact R0 for different influenza strains can vary, it is typicall
y lower than the estimated R0 for COVID-19. This means that COVID-19 has a
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higher potential for transmission within a susceptible population compared to influenza.
Correct Option A - Kidney:
 Goodpasture syndrome is an autoimmune disease characterized by the presence of autoantibodies
that target the basement membrane in the lungs and kidneys. These autoantibodies primarily bind to
the type IV collagen present in the alveolar basement membrane of the lungs and the glomerular
basement membrane of the kidneys.
 The binding of autoantibodies to the glomerular basement membrane in the kidneys leads to the
activation of an immune response and subsequent inflammation. This inflammatory response can
cause damage to the kidney tissue and impair its function.
Correct Option A - Pneumothorax:
 The sudden-onset severe respiratory distress following the placement of an internal jugular vein
catheter is highly suggestive of pneumothorax, which is the presence of air in the pleural space
surrounding the lungs. When air accumulates in the pleural space, it can cause the lung to collapse
partially or completely, leading to respiratory distress, chest pain, and other symptoms.
1392

Fever of Unknown Origin
1. A 35-year-old male came to the outpatient department with a complaint of fever for the past four
days. The patient is a butcher by Profession handling rabbit meat. The temperature was found to be 99
degrees Fahrenheit, and his heart rate was 65/min. Further clinical examination showed swellings in
the axillary region, which was axillary lymphadenopathy. Frame a diagnosis and pick the option with the
organism that is not related to it.
(or)
Find the organism that is not associated with FAGET sign in a patient who is a professional rabbit meat
butcher.
A. Scrub typhus
B. Eikenella
C. Legionella
D. Coxiella brunetti
2. Identify the pattern of fever being demonstrated in the graph?
A. Sustained fever
B. Remittent fever
C. Intermittent fever
D. Relapsing fever
3. A 50-year- old male patient complains of a fever of 38 degree centigrade for the past one month. She
denied any travel, food infection, or pets at home.She is a known case of diabetes and hypertension.
Investigations showed increased CRP with other normal values. The doctor finds no potential
diagnostic clues for fever. What should be the next step in management?
A. FDG PET
B. Exclude manipulation of thermometer
C. Scintigraphy
D. Cryoglobulins
1393

Aspergillosis,COVID,Dengue
1. A 25-year-old male came to the Outpatient department with history of fever for 3 days.He admitted
that he had multiple episodes of vomiting and restlessness. Lab investigations revealed elevated HCT
,platelet count of 70,000/mcL ,a positive IgM for dengue virus..He was admitted to the inpatient
department for further treatment.The HCT seemed to be elevated despite maximum fluid resuscitation.
What is the next step in management?
A. Packed red blood cells
B. Fresh frozen plasma
C. Albumin
D. Vaccination
2. A 30-year-old male presented to the outpatient department with complaints of extreme cough and
cold for the past 5 days, not relieved by over-the-counter medications. He admitted that he gradually
lost his appetite, taste, and smell sensation. He started to have mild breathing difficulty. Clinical
examination revealed Spo2 of 90% on room air and RR of 25/minute. Lab tests revealed raised ferritin,
CRP, and D-dimer values, and a positive RT-PCR test for SARS-COV-2. A chest X ray was taken and
is shown below. What is the most appropriate treatment in this patient?
A. Stage 1-Home care
B. Stage 2-Non rebreathing face mask
C. Stage 3-High flow nasal cannula
D. Stage 3-Non invasive ventilation
3. Which of the following is not a part of the lung protective strategy in a 40-year-old obese diabetic
male who was found positive for COVID and admitted to the ICU ?
A. Prone position with FiO2 > 0.6
B. Low tidal volume
C. Low PEEP
D. NM blockage
4. A 30-year-old male who is a known case of HIV infection came to the outpatient department with a
complaint of fever, excessive cough accompanied by thick sputum, breathing difficulty, and occasional
bouts of blood during cough from the past one week.. Lab investigations show elevated eosinophil
count and IgE levels of 1500 ng/ml. The chest X-ray findings are inconclusive and HRCT was
recommended and is shown below. Identify the infection and the causative organism.
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A. Aspergillus fumigatus
B. Aspergillus Flavus
C. Thermophilic actinomycetes
D. Aspergillus niger
Correct Option C - Albumin:
 Albumin (colloids) is the next step in management:
 The question clearly indicates the HCT remains same despite maximum fluid resuscitation- group c
(severe dengue)
1399

AIDS,Nipah Virus,Zika Virus
1. Which of the following routes of transmission has a 95% chance of getting infected with HIV
A. Blood transfusion
B. Unprotected Sexual intercourse
C. Needle stick injury
D. Needle sharing
2. Which of the following is not a part of the CDC definition for AIDS
A. )Cryptococcus neoformans meningitis
B. Cerebral toxoplasmosis:
C. Burkitt's lymphoma present in < 50 years of age
D. Progressive multifocal leuco-encephalopathy
3. Match the following regarding tests used in HIV infection 1. Most sensitive test for HIV a. Nucleic acid
amplification test 2. Most specific test for HIV b. PCR-HIV DNA 3. Best test for early diagnosis of HIV
infection c. Enzyme immunoassay 4. Best test for vertical transmission of HIV d. Western blot
1. Most sensitive test for HIV a. Nucleic acid amplification test
2. Most specific test for HIV b. PCR-HIV DNA
3. Best test for early diagnosis of HIV infection c. Enzyme immunoassay
4. Best test for vertical transmission of HIV d. Western blot
A. 1-c, 2-d, 3-a, 4-b
B. 1-a, 2-c, 3-b, 4-d
C. 1-d, 2-b, 3-c, 4-a
D. 1-c, 2-a, 3-b, 4-d
4. What is the next step in the investigation of a patient with a positive-HIV-1 enzyme immunoassay but
an indeterminate HIV-1 western blot
A. Diagnose as HIV-1 infection
B. Check for HIV-2 infection through EIA
C. Repeat the test after 4-6 weeks
D. Check for HIV-2 on western blot
5. Match the following opportunistic infections in HIV with their respective treatment options: 1.
Toxoplasmosis with encephalitis a. trimoxazole 2. Cryptococcus Coccidioides b. Valcyclovir 3.
Pneumocystis jiroveci c. Clarithromycin + Ethambutol + Rifabutin 4. CMV d. Pyrimethamine +
Sulfadiazine + Leucovorin 5. Mycobacterium Avium Intercellulare e. Nitazoxanide 6. Cryptosporidium
diarrhea f. Fluconazole
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Page 2
1. Toxoplasmosis with encephalitis a. trimoxazole
2. Cryptococcus Coccidioides b. Valcyclovir
3. Pneumocystis jiroveci c. Clarithromycin + Ethambutol + Rifabutin
4. CMV d. Pyrimethamine + Sulfadiazine + Leucovorin
5. Mycobacterium Avium Intercellulare e. Nitazoxanide
6. Cryptosporidium diarrhea f. Fluconazole
A. 1-a, 2-d, 3-b, 4-e, 5-c, 6-f
B. 1-d, 2-f, 3-a, 4-b, 5-c, 6-e
6. Which of the following is an appropriate treatment for oral candidiasis?
A. Fluconazole
C. Clarithromycin
D. Cotrimoxazole
7. All of the following drugs belong to Non-Nucleoside Reverse Transcriptase Inhibitors except?
A. Nevirapine
B. Tenofovir Alafenamide
C. Efavirenz
D. Delavirdine
8. Which of the following side-effects is common with protease inhibitors?
A. Anemia
B. Hepatotoxity
C. Lipodystrophy
D. Perpheral neuropathy
9. Which of the following has the highest incidence of transmission?
A. HBV
C. HCV
D. HIV
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Page 3
10. A 30-year-old male who is a fruit business owner presented to the Outpatient department with
complaints of fever, fatigue, breathing difficulty, and confusion for the last four days. . He admitted that
the fever did not relieve on antibiotics for two days. The patient started seizing during the examination
and was treated accordingly.Further lab investigation shows positive IgM antibodies for a henipavirus
virus and MRI brain showed multiple hyperdensities. What is the drug being developed ( in phase 1
trial) to prevent further brain damage in these cases?
A. M 102.4
B. M 104.2
C. M 102.2
D. M 101.1
11. What is the investigation of choice for Zika virus?
A. Blood RT-PCR
B. ELISA IgM
C. Urine triplex-PCR
D. Lumbar puncture
12. A 40-year-old male, who is a known case of AIDScame to the hospital with complaints of frequent
episodes of fever, cough, and breathing difficulty. His history revealed that he is on anti-retroviral
therapy. A bronchoalveolar lavage was examined with GMS stain and is shown below. The chest x-ray
showed perihilar infiltrates and HRCT was done, which is shown below. LDH is elevated with deranged
SpO2 and a CD4 count <200 cells/mm^3 of blood.What is the drug of choice for this patient?
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Page 5
Correct Options C - Burkitt's lymphoma present in < 50 years of age:
 Burkitts lymphoma present in < 50yrs is not a part of the CDC definition for AIDS.
 Option A, B, D: These are included in the CDC definition for AIDS
Correct Option A - 1-c, 2-d, 3-a, 4-b:
1. Most sensitive test for HIV
c. Enzyme immunoassay
2. Most specific test for HIV
d. Western blot
3. Best test for early diagnosis of HIV infection
a. Nucleic acid amplification test
4. Best test for vertical transmission of HIV
b. PCR-HIV DNA
Option B, C, D:
 Refer to above explanation 
Correct Option C - Repeat the test after 4-6 weeks:
 One needs to Repeat the test after 4-6 weeks if patient has positive-HIV-1 enzyme immunoassay but
Option A, B, D:
 Refer to the above explanation
Correct Option B - 1-d, 2-f, 3-a, 4-b, 5-c, 6-e:
1. Toxoplasmosis with encephalitis
d. Pyrimethamine + Sulfadiazine + Leucovorin
2. Cryptococcus Coccidioides
1406

1. Which one of the following is not transmitted during the perinatal period?
A. CMV
B. Rubella
C. Meningitis
2. A patient diagnosed to be retro-positive was started on highly active antiretroviral therapy (HAART).
Which of the following can be used to monitor treatment efficacy?
A. CD4+ T cell count
B. Viral load
C. p24 antigen
D. Viral serotype
3. What is the drug of choice for Legionnaire’s disease?
B. Azithromycin
D. Erythromycin
4. What is the likely diagnosis for a patient who has been experiencing fever and neck stiffness for 11
days? Their lumbar puncture results showed predominantly lymphocytes, with a sugar level of 50mg
and protein level of 3000mg/dl. Gram-staining was negative. Additionally, their chest X-ray revealed
upper lobe involvement and enlarged hilar lymph nodes.
B. Bacterial meningitis
C. Fungal meningitis
D. Viral meningitis
5. A 45-year-old HIV-positive male complained of persistent cough, weight loss, and neck stiffness. He
has skin lesions that appear as umbilicated papules and nodules predominantly on the face, trunk, and
upper extremities.Physical examination also reveals neck rigidity. Chest x-ray showed multiple bilateral
nodular infiltrates. His sputum CBNAAT for tuberculosis was negative, and he has a CD4 count of 20.
What is the probable diagnosis?
A. HIV with disseminated histoplasmosis
B. HIV with disseminated cryptococcosis
C. HIV with molluscum contagiosum
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Page 2
D. HIV with tuberculosis
6. A patient arrives at the hospital with symptoms of fever and chills. A fever profile test is conducted,
which rules out malaria and dengue as the cause. However, the rK39 test comes back positive. What is
the preferred treatment for this condition?
B. Griseofulvin
C. Dapsone
7. A patient, who is a known case of HIV with a CD4 count of 200 cells/cu.mm, presents with 5 days of
cough and high-grade fever without chills and rigors. There is no history of diarrhoea, vomiting, or
nuchal rigidity. The chest x-ray is normal. What treatment will you give?
A. Amoxicillin-clavulanic acid + Azithromycin
B. Amphotericin B
C. Co-trimoxazole only
D. Antitubercular treatment
8. Which antibiotic can be administered to a patient with diabetes who develops a urinary tract infection
(UTI) that is further complicated by hypotension unresponsive to intravenous fluids?
A. Piperacillin - Tazobactam
B. Amoxicillin - Clavulanate
C. Ceftriaxone
D. Nitrofurantoin
9. Which of the following is NOT a potential complication in a 40-year-old man who presents with a
15-day history of fever and 1-day history of altered sensorium, and is diagnosed with Plasmodium
falciparum through a rapid diagnostic test?
A. Blood glucose <40 mg/dL
B. Arterial pH >7.2
C. Serum creatinine -5.2
D. Unarousable coma
10. An HIV positive patient presented with a whitish plaque in the mouth and esophagus as shown in
the image below. Most likely diagnosis is:
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A. Oral leukoplokia
B. Hairy cell leukemia
C. Oral candidiasis
D. Oral cancer
11. Identify the correct ‘organism and drug to which it is intrinsically resistant’ pair.
A. Aspergillus niger - Voriconazole
B. Aspergillus fumigatus - Micafungin
C. Candida albicans - Amphotericin B
D. Candida Krusei - Fluconazole
12. During the discharge of a COVID patient treated with steroids and remdesivir, which of the following
will you inform him about? Repeat RT-PCR after 7 days of discharge Watch for the persistence of
Anosmia Watch for headache and nasal discharge Monitor glucose levels Watch for Sinusitis
symptoms
A. 1, 3 and 4
B. 2, 3 and 4
C. 2, 3, 4 and 5
D. 1,2,3,4 and 5
13. A 19-year-old male, chronic smoker, presented with fever, a painful lump over his left cheek just
below the ear, and difficulty in swallowing or talking. The patient also complained of mild testicular pain.
What is the most likely diagnosis?
A. Cervical tuberculosis
B. Diphtheria
C. Mumps
D. Lymphoma
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14. What is the most probable diagnosis for a 40-year-old man whose lab reports indicate positive IgG
Anti-HBc and negative HBsAg?
A. Recovering from hepatitis B
B. Hepatitis B in the remote past
C. Immunization with HBsAg
D. Both B & C
15. A 46 year old chronic alcoholic male presents to the OPD with fever, headache, shortness of
breath, chest pain, and productive cough with red currant jelly sputum for the last two days. On
examination, there was bronchial breathing on the right side, increased vocal fremitus, increased vocal
resonance, and a dull note on percussion. The patient’s plain radiograph is shown below. Which is the
most likely causative agent?
C. Pseudomonas aeruginosa
D. Haemophilus influenza
16. A patient with inflammatory bowel disease presents with the following lesion. What is the most likely
A. Erythema nodosum
B. Pyoderma gangrenosum
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C. Diabetic ulcer
D. Venous ulcer
17. All of the following are AIDS defining illnesses except:
A. Encephalopathy attributed to HIV
B. Invasive cervical cancer
C. Mycobacterium tuberculosis of any site
D. Oral candidiasis
18. What is the approximate time interval between HIV infection & manifestation of AIDS in an
untreated patient?
A. 7.5-years
B. 10 years
C. 12 years
D. 5 years
19. Which diagnostic test is preferred for detecting HIV in a newborn delivered by an HIV-positive
mother?
A. HIV DNA PCR
B. Cord blood ELISA
C. Western blot
D. Third generation ELISA
20. Following is a graphic representation of a patient admitted in the medicine ward with a fever. What
could be the possible diagnosis?
A. Cerebral malaria
B. Brucellosis
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D. Typhoid
21. You are posted as an intern in the emergency department. A 67-year-old man is brought to you with
complaints of chest pain. He has tested positive for COVID. Which of the following features will prompt
you to get this patient admitted to a dedicated COVID health center? A. Respiratory rate of 30/min B.
SpO2 88% C. Multiple comorbidities D. Chest pain E. Age
A. A & B only
B. A, B, C & E only
C. A, B, & C only
22. A 23-year-old medical student developed epistaxis that resolved spontaneously. He has been
afebrile for the last 24 hours, and his platelet count is 14,000/µL. His BP is 110/70 mmHg and there is a
28% rise in haematocrit. What should be the management? Give 4 units of platelets Give plenty of oral
fluids Give IV fluids Keep under observation Discharge the patient
A. 1 and 2
B. 1,2 and 4
C. 2,3 and 4
D. 2 and 5
23. Comment on the diagnosis?
A. Malaria
24. A 40-year-old male presents with abdominal pain and progressive weight loss for 2 months. He has
been suffering from migratory arthropathy for three years. There is no history of any chronic medical
conditions. He is taking corticosteroids to help with the arthropathy. Endoscopic investigation shows
dark staining of the duodenal mucosa. Histological examination of the biopsy reveals PAS-positive
macrophages, leading to a diagnosis of a rare multisystem disease. Which of the following statements
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is true regarding this patient's disorder? Caused by a protozoa Tropheryma whipplei PAS-positive
macrophages in the lamina propria of the small intestine Culture-negative endocarditis is a common
cardiac presentation Treated with IV Ceftriaxone
A. 1, 2 and 4 are true
C. 1, 2 and 3 are true
D. 1 and 2 are true
25. A new vaccine which was launched in 2018 in Thailand with the name CYD-TDV. In which of the
following condition it is used?
A. Dengue
B. Malaria
C. Yellow fever
D. Japanese encephalitis
26. Which of the following is the most common cause of infection post-solid organ transplantation?
B. Varicella zoster virus
C. Epstein – Barr virus
D. Herpes simplex virus
27. A veterinary surgeon presents with complaints of fever, muscle pain, joint pain, fatigue, and weight
loss for the past few weeks. On further inquiry, he says that his fever persists for weeks before it
resolves, only to be followed by a relapse. You obtain his blood sample and inoculate it on the medium
given below to isolate the suspected organism. Which of the following is the most likely organism?
A. Burkholderia
B. Brucella
C. Mycobacterium
D. Coxiella
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28. An HIV-positive patient presents with the following finding. What is the diagnosis & WHO clinical
stage of HIV?
A. Oral candidiasis & WHO stage 2
B. Oral hairy leukoplakia & WHO Stage 3
C. Oral candidiasis & WHO stage 3
D. Oral hairy leukoplakia & WHO stage 2
29. As seen below, A 49-year-old man presents with flu-like symptoms and a palmoplantar rash. On
examination, he has epitrochlear lymphadenopathy. Which of the following is the likely diagnosis?
A. Primary syphilis
B. Secondary syphilis
C. Pyoderma gangrenosum
D. Steven Johnson syndrome
30. What is the diagnosis for a 6-year-old patient who presents with a mild fever persisting for 7 days,
enlarged cervical lymph nodes, and a palpable spleen tip, and subsequently develops a widespread
rash after administration of ampicillin?
A. Infectious mononucleosis
B. Scarlet fever
C. Kawasaki
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D. Hodgkin's lymphoma
31. What is the most likely diagnosis for a 65-year-old man who is experiencing chronic pain in his
hand, knees, and hips, with increased pain in the hands during writing or typing? Additionally, he has
morning stiffness in his joints that lasts for about 30 minutes. On examination, Heberden's and
Bouchard's nodes are visible in the hands, and an X-ray of the knee shows narrowed joint space with
osteophytes.
A. Osteoporosis
D. Bone tumor
32. What is the most common presentation of inhalational anthrax?
33. A CSF examination in a patient with signs of meningeal irritation shows lymphocytosis with normal
sugar and elevated protein. What is the most likely diagnosis?
A. Pyogenic meningitis
B. Viral meningitis
C. Tubercular meningitis
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Question 31 2
Correct Options C - Meningitis:
 Meningitis is one of the infections that is not transmitted perinatally therefore this option is ruled out.
Options A - CMV (Cytomegalovirus): CMV can be transmitted from a
pregnant woman to her fetus during pregnancy, making it a perinatally transmitted infection. It is one of
 the most common causes of congenital infection. Therefore, CMV is transmitted perinatally.
Options B - Rubella: Rubella, also known as German measles, can be transmitted from a
pregnant woman to her fetus.
Options D - Hepatitis B: Hepatitis B
can be transmitted from an infected mother to her baby during childbirth. This is considered a
perinatal transmission route for hepatitis B. Babies born to mothers with hepatitis B
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Correct Option B - HIV with disseminated cryptococcosis:
 According to the vignette, the patient is an HIV-positive man with a CD4 count of 20, a negative
CBNAAT for tuberculosis and features of meningitis. He has an opportunistic infection that
has respiratory, dermatological, and neurological manifestations.
 Disseminated cryptococcosis likely explains this patient's symptoms.
Option A - HIV with disseminated histoplasmosis: Patients with disseminated histoplasmosis present wi
th respiratory and skin lesions like those of cryptococcosis, but the presence of meningeal involvement 
and the CD4 count make a diagnosis of cryptococcosis more likely.
Option C -  HIV with molluscum contagiosum: Patients with molluscum contagiosum present with flesh-
colored umbilicated papules or nodules only. They do not cause systemic involvement like that seen in 
the patient.
Option D - HIV with tuberculosis: The patient has tested negative for tuberculosis via CBNAAT, a
highly sensitive and specific test for tuberculosis, making tuberculosis a
highly unlikely reason for causing the patient’s condition.
 
Correct Option A - Amphotericin B:
 The given scenario is suggestive of Kala azar, and Amphotericin B is the drug of choice. K39 is an
epitope present on amastigotes of Leishmania spp that cause visceral leishmaniasis. Dipstick tests that
test for the recombinant K39(rK39) protein are available for the rapid diagnosis of Kala Azar.
 Amphotericin B is the correct answer for the treatment of visceral leishmaniasis (kala-azar). Visceral
leishmaniasis is caused by the parasite Leishmania donovani and is transmitted by sandflies.
Amphotericin B is the treatment of choice for this disease due to its high efficacy against Leishmania
parasites.
Correct Option C - Co-trimoxazole only:
 Co-trimoxazole treatment is recommended for patients with HIV who present with symptoms of a
respiratory tract infection and a CD4 count of less than 200 cells/cu.mm. Co-trimoxazole, a combination
of sulfamethoxazole and trimethoprim, is commonly used in AIDS patients with cough due to its
effectiveness against Pneumocystis jirovecii pneumonia (PJP). PJP is an opportunistic infection that
affects individuals with weakened immune systems, such as those with advanced HIV/AIDS.
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Correct Option A - Piperacillin-Tazobactam:
 In a patient with diabetes who develops a complicated urinary tract infection (UTI) and associated
hypotension resistant to IV fluids suggests that the patient is in septic shock. The choice of antibiotics
should take into consideration the likely causative organisms and their susceptibility patterns.
 Piperacillin-Tazobactam is a broad-spectrum antibiotic that covers a wide range of gram-negative and
gram-positive bacteria, including many common pathogens associated with complicated UTIs.
 It also has good activity against some antibiotic-resistant bacteria.
 The combination of piperacillin and tazobactam helps to overcome beta-lactamase-mediated
resistance.
Option B - Amoxicillin-Clavulanate: While amoxicillin-clavulanate is effective against many common uri
nary pathogens, it may not provide adequate coverage for the spectrum of bacteria typically associated
 with complicated UTIs, especially in patients with severe infection and hypotension.
Option C - Ceftriaxone: Although Ceftriaxone can be used in the management of patients with complica
ted UTI, drugs like piperacillin-tazobactam offer wider coverage against organisms such as pseudomon
as.
Option D - Nitrofurantoin: Nitrofurantoin is commonly used for uncomplicated lower urinary tract infectio
ns. However, it is generally not recommended for complicated UTIs, such as those associated with sys
temic symptoms and hypotension, as it may not achieve adequate tissue levels or cover the spectrum 
of bacteria involved.
Correct Option B - Arterial pH >7.2:
 Arterial pH >7.2 (alkalosis) is not a complication associated with Plasmodium falciparum infection. It is
important to note that severe malaria caused by P. falciparum can trigger metabolic acidosis in which
the arterial pH is less than 7.2.
Option A - Blood glucose <40 mg/dL: Hypoglycemia (blood glucose <40 mg/dL) can be a complication 
of severe malaria, particularly in cases of P. falciparum infection. The parasite's impact on the liver and
 the increased metabolic demands of the infection can lead to low blood sugar levels.
Option C - Serum creatinine -5.2: The presence of serum creatinine levels of -5.2 (indicating a
significant decrease in renal clearance) suggests acute kidney injury (AKI). AKI is a potential complicati
on of severe malaria, including P. falciparum infection. Malaria-associated AKI can result from various f
actors, such as decreased blood flow to the kidneys, direct parasite-mediated damage, or immune-me
diated injury.
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Option D - Unarousable coma: Unarousable coma is a severe neurological manifestation and a potenti
al complication of malaria caused by P. falciparum. Cerebral malaria, characterized by impaired consci
ousness and coma, is a severe complication that can occur in P. falciparum infection.
Correct Option C - Oral candidiasis:
 Oral Candidiasis is the likely diagnosis in these patients. In patients with HIV, there is decrease in the
number of T cells making them more susceptible to infections with such agents.
Correct Option D - Candida Krusei - Fluconazole:
 In the given organism-drug combinations, Candida krusei is known to have intrinsic resistance to
fluconazole, an antifungal medication commonly used to treat fungal infections. Echinocandins, such as
caspofungin, micafungin, and anidulafungin, are usually the drugs of choice for treating C. krusei
infections. Alternatives, drugs such as voriconazole or amphotericin B, may also be considered
 
Correct Option C - 2, 3, 4 and 5:
 Once a patient is discharged after being treated with steroids and remdesivir for COVID-19 infection,
the patient must be informed to watch for headache, nasal discharge, and other symptoms of sinusitis.
Headache and nasal discharge can be symptoms associated with COVID-19 or other conditions such
as mucormycosis. It is important to inform the patient to be vigilant for these symptoms and seek
medical attention if they develop or worsen.
 Monitoring glucose levels is important because steroids, such as dexamethasone, commonly used in
the treatment of COVID-19, can cause elevated blood glucose levels. Patients should be advised to
monitor their glucose levels regularly, especially if they have pre-existing diabetes or are at risk of
developing steroid-induced diabetes.
 Anosmia can persist in a patient after the resolution of other symptoms of COVID-19. Patients must
be counseled regarding it.
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Option A - Streptococcus pneumoniae: Streptococcus pneumoniae is a
common causative agent of community-acquired pneumonia, but it typically presents with a more acute
 onset and is associated with rust-colored sputum. It is less commonly associated with the clinical findi
ngs described in this case.
 
Correct Option B - Pyoderma gangrenosum:
 The most likely diagnosis in this case would be Pyoderma gangrenosum.
 Pyoderma gangrenosum is a rare, inflammatory skin condition characterized by the development of
painful, ulcerative lesions. It can occur in patients with inflammatory bowel disease, and the lower limbs
are a common site of involvement. The ulcers typically have undermined borders and may have a
necrotic or purulent appearance.
Correct Option D - Oral candidiasis:
 Oral candidiasis, also known as thrush, is a fungal infection caused by Candida species. While oral
candidiasis is commonly seen in individuals with HIV/AIDS, it is not considered an AIDS-defining
illness. It is a relatively common opportunistic infection that can occur in people with weakened immune
systems, including those with HIV/AIDS, but its presence does not meet the criteria for defining the
diagnosis of AIDS.
Options A, B and C are considered AIDS defining illnesses.
 
Correct Option B - 10 years:
 10 years: The approximate time interval between HIV infection and the manifestation of AIDS can vary
significantly among individuals.
 During this time, individuals infected with HIV may remain asymptomatic or experience mild
symptoms.
 As the disease progresses, the immune system becomes progressively weakened, leading to the
development of opportunistic infections and other AIDS-related complications.
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Option A - 7.5 years: This option underestimates the typical time interval between HIV infection and the
 manifestation of AIDS. It is important to note that the progression from HIV infection to AIDS can be inf
luenced by various factors, including individual differences, viral factors, and access to healthcare and 
antiretroviral therapy.
Option C - 12 years: This option overestimates the typical time interval between HIV infection and the 
manifestation of AIDS. While some individuals may experience a
longer latency period, the average duration is generally shorter than 12 years.
Option D - 5 years: This option significantly underestimates the typical time interval between HIV infecti
on and the development of AIDS. In most cases, it takes longer than 5
years for HIV infection to progress to AIDS.
Correct Option A - HIV DNA PCR:
 HIV DNA PCR (Polymerase Chain Reaction) is the correct diagnostic test of choice for HIV in a baby
born to an HIV-infected mother. This test detects the presence of HIV DNA in the baby's blood,
providing early and accurate diagnosis of HIV infection. It is highly sensitive and can detect HIV
infection as early as a few weeks after birth.
Correct Option C - Leptospirosis:
 Leptospirosis is a bacterial infection caused by the bacteria of the genus Leptospira. It is commonly
transmitted to humans through contact with water, soil, or food contaminated with the urine of infected
animals. Leptospirosis can present with symptoms such as fever, headache, muscle aches, and can
progress to more severe manifestations, including liver and kidney involvement. 
 The graphical representation in the vignette gives us the following information: Over time, this disease
can lead to complications such as uveitis and interstitial nephritis. CSF is a reservoir for the causative
organism and it is shed through urine.
 Over time, this disease can lead to complications such as uveitis and interstitial nephritis.
 CSF is a reservoir for the causative organism and it is shed through urine.
 These findings point towards a diagnosis of leptospirosis.
 
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Correct Option B - A, B, C and E:
 Tachypnea, low oxygen saturation, the presence of multiple comorbidities, and age(60 or above)
would prompt the consideration for admission in dedicated COVID care center.
Correct Option C - 2, 3 and 4:
 The likely diagnosis in this patient with fever(resolving), thrombocytopenia, and improving hematocrit
is Dengue. The appropriate management at this stage would be plenty of oral fluids and IV fluids to
ensure adequate hydration. In this patient, since his epistaxis resolved spontaneously and the
hematocrit is improving, he needs to be kept inpatient for observation.
Option A - 1 and 2: 1. Give 4 units of platelets: While the patient has a low platelet count, giving 4 units 
of platelets is not the recommended initial management in this scenario. The platelet count of 14,000/µ
L indicates thrombocytopenia, but it is important to assess the patient's clinical condition, bleeding risk,
 and associated factors before initiating platelet transfusion. Transfusion decisions are typically guided 
by the presence of bleeding symptoms or active bleeding and not solely based on the platelet count.
Option B - 1, 2 and 4 : is incorrect
Option D - 2 and 5: 5. Discharge the patient: Discharging the patient without proper evaluation and ma
nagement would not be appropriate in this case. Given the low platelet count and the previous episode 
of epistaxis, close monitoring, hydration, and further evaluation are necessary to ensure the patient's s
afety and manage potential complications.
Correct Option A - Malaria:
 The presence of banana-shaped gametocytes on histopathological examination is highly indicative of
malaria caused by Plasmodium falciparum. 
 
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Correct Option B - 2, 3 and 4 are true:
 2. PAS-positive macrophages in the lamina propria of the small intestine: The presence of
PAS-positive macrophages in the lamina propria of the small intestine is indicative of Whipple's
disease. PAS stands for periodic acid-Schiff stain, which is used to detect polysaccharides like
glycoproteins, which are seen in the macrophages in this condition.
 3. Culture-negative endocarditis is a common cardiac presentation: Whipple's disease can involve
various organs, including the heart. Endocarditis is a known cardiac presentation of the disease.
Importantly, it is often culture-negative, meaning that the causative bacteria cannot be readily grown in
laboratory cultures.
 4. Treated with IV Ceftriaxone: Whipple's disease is treated with a combination of antibiotics, typically
including intravenous ceftriaxone as one of the key agents. Other antibiotics, such as
trimethoprim-sulfamethoxazole (TMP-SMX), can also be used. Treatment is generally prolonged,
lasting several weeks to months
Option A - 1, 2 and 4 are true: This incorrect option as statement 1 is false
 Caused by a Protozoa Tropheryma whipplei: Whipple's disease is caused by the bacterium
Tropheryma whipplei, not a protozoa. Tropheryma whipplei is a gram-positive bacterium that infects
various tissues and organs, leading to the multisystem manifestations observed in Whipple's disease.
 
Correct Option A - Dengue:
 This is the correct option. CYD-TDV is a vaccine used for the prevention of dengue fever. It is
designed to protect against all four serotypes of the dengue virus. The vaccine was launched in 2018 in
Thailand under the trade name CYD-TDV (Dengvaxia). Therefore, option A is correct.
Correct Option A - Cytomegalovirus (CMV):
 CMV is a common viral infection that can cause significant complications in solid organ transplant
recipients. It can affect multiple organ systems and lead to pneumonia, hepatitis, gastrointestinal
disease, and other manifestations.
 Cytomegalovirus is more commonly seen in patients post solid organ transplantation, hence options
B, C and D are incorrect.
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Correct Option B - Brucella:
 The culture medium shown above is the image of Castenada biphasic medium. The most probable
diagnosis is that of Brucellosis which is caused by Brucella.
Option A - Burkholderia: Ashdown’s medium is used for Burkholderia.
Option C - Mycobacterium: Lowenstein Jensen medium is used for Mycobacterium.
Option D - Coxiella: Castenada biphasic medium is not used for Coxiella.
Correct Option C - Oral candidiasis & WHO stage 3:
 The lesion shown in the picture is that of oral candidiasis. According to WHO, oral candidiasis or
thrush is categorized as clinical stage 3. These occur in patients with CD4+ T cell counts of <200
cells/mm3.
Options A, B, and D are incorrect.
Correct Option B - Secondary syphilis:
 The patient above, a 49-year-old man, presents with flu-like symptoms, and a palmoplantar rash. On
examination, he has epitrochlear lymphadenopathy. The most likely diagnosis is that of secondary
syphilis.
Correct Option A - Infectious mononucleosis:
 The clinical presentation described is consistent with infectious mononucleosis, also known as
glandular fever. It is commonly caused by the Epstein-Barr virus (EBV). The symptoms include fever,
lymphadenopathy (enlarged lymph nodes), hepatosplenomegaly (enlarged liver and spleen), and a
characteristic rash that can occur after the administration of certain antibiotics like ampicillin.
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