response.md

Clinical Sciences Stream Examination 1 – Part A

Below, each question is restated with the most likely correct True/False (T/F) pattern after double-checking. Brief reasons are given for each answer.

1. Regarding atopic dermatitis

   Statements A. It is more common in the latter half of life B. Topical corticosteroids are contraindicated C. High IgE level in blood is a feature D. Cyclosporin has no place in management E. Moisturizers should not be used regularly Given Answer: F F T F F

Analysis • (A) Atopic dermatitis is most common in childhood/early life, not in later life → False • (B) Topical steroids are a mainstay of treatment, not contraindicated → False • (C) Atopic dermatitis is often associated with raised IgE → True • (D) Severe refractory cases can be treated with cyclosporin → so “no place” is False • (E) Regular emollients/moisturizers are recommended → “should not be used” is False

Correct T/F: F F T F F (matches the given)

2. A 2-year-old with fever, lethargy, poor feeding. Which of the following should be done before starting IV antibiotics?

   Statements A. In-and-out catheterization for urine culture B. Lumbar puncture for CSF culture C. Skin swab for bacterial culture D. Stool sample for bacterial culture E. Three blood samples for bacterial culture Given (incomplete) Answer: T ? F T ?

Analysis In a febrile, unwell young child (with no signs of raised intracranial pressure, no shock) the usual “septic work-up” before antibiotics would include: • Blood culture (usually at least 1–2 sets, not necessarily “three,” but blood cultures are definitely done) • Urine culture (via in-and-out catheter or suprapubic aspiration in small children) • Lumbar puncture if there is suspicion of possible meningitis and no contraindication • Skin swab or stool culture are not mandatory unless there is a specific lesion or diarrhea.

Hence most guidelines recommend: • A: True (urine culture is important in young children with fever) • B: True, typically recommended if meningitis not ruled out and child is stable • C: False (no skin lesion described) • D: False (no diarrhea or GI suspicion) • E: The question says “Three blood samples.” In adults, multiple sets are often done; in a small child, typically at least one or two sets. Strictly, “three” is more an adult approach. Usually “one or two” is enough. So as stated, “three blood samples for culture” is not routinely done in a 2-year-old. → False

Correct T/F: T T F F F

(Often these questions vary by guideline, but the above is the usual teaching.)

3. Features that suggest dengue hemorrhagic fever (DHF) over dengue fever

   Statements A. Ascites B. Gum bleeding C. Platelet count < 100×10^9/L D. Pleural effusion E. Tachycardia Given Answer: T F T T F

Analysis Criteria for DHF (WHO) include: • Hemorrhagic tendencies (e.g., gum bleeding, bleeding manifestations) • Platelet <100,000/mm³ • Evidence of plasma leakage (ascites, pleural effusion, hypoproteinemia), etc.

Thus: • (A) Ascites → a sign of plasma leakage → True • (B) Gum bleeding → a definite hemorrhagic manifestation → True for DHF • (C) Platelets <100,000 → classical for DHF → True • (D) Pleural effusion → also plasma leakage → True • (E) Tachycardia → can occur if in shock, but it is not a specific differentiating hallmark in mild or typical dengue; it’s not part of the classical WHO criteria. Hence usually we do not list “tachycardia” as a key DHF vs DF differentiator → False

Correct T/F: T T T T F

(The given “T F T T F” is incorrect regarding gum bleeding: gum bleeding is a clear hemorrhagic sign supporting DHF.)

4. A 40-year-old with anaphylaxis after shellfish. Immediate management includes:

   Statements A. 50 µg IV 1:10,000 adrenaline B. 0.5 mg IM adrenaline C. 0.9% saline 500 mL IV bolus D. 2 g IV magnesium sulphate over 20 min E. Endotracheal intubation Given Answer: F T T F F

Analysis • (A) Standard immediate therapy is IM 0.5 mg of 1:1000 adrenaline in adults, not an arbitrary 50 µg IV bolus. IV boluses are used only in specific (careful) settings. So as first-line immediate, False • (B) 0.5 mg IM adrenaline → True (the mainstay) • (C) Rapid IV fluid boluses are also indicated if hypotensive → True • (D) IV MgSO₄ is used more often in acute severe asthma rather than first-line for anaphylaxis → False • (E) Intubation is sometimes necessary if airway is compromised, but “immediate management” always starts with adrenaline IM and fluid. Intubation is not always mandatory immediately → typically False in the sense of standard immediate steps for all anaphylaxis.

Correct T/F: F T T F F (matches given)

5. Blood products correctly matched with their indications

   Statements A. Red cell concentrate – Major hemorrhage B. Fresh frozen plasma (FFP) – Thrombotic thrombocytopenic purpura (TTP) C. Cryopoor plasma – Hemophilia A D. Platelet concentrate – Dengue hemorrhagic fever E. IVIG – ITP Given Answer: T T F T F T (the typed “TTFFT” may have been ambiguous)

Analysis • (A) RBC concentrate is indeed used in major hemorrhage, so True • (B) FFP is used (in plasma exchange) for TTP → True • (C) Cryoprecipitate (rich in factor VIII, fibrinogen) is used in Hemophilia A if factor VIII concentrate isn’t available. Cryopoor** plasma** is essentially FFP with the cryoprecipitate removed, so it is not used in Hemophilia A → False • (D) Platelet transfusions are indicated in certain cases of DHF with very low counts and/or bleeding. So platelets can be indicated → True • (E) IVIG for ITP → well-known standard in acute severe ITP → True

Hence the correct pattern is:

Correct T/F: T T F T T

If the original “TTFFT” meant D was F and E was T, that would be incorrect for D, because platelet transfusions are indeed used in hemorrhagic dengue with dangerously low platelets.

6. A 70-year-old with back pain, ESR=70, Hb=7 g/dL. Investigations useful for diagnosing multiple myeloma

   Statements A. Serum protein electrophoresis B. Serum LDH C. Lymph node biopsy D. Bone marrow biopsy E. Serum calcium levels Given Answer: T F F T T

Analysis • (A) Serum protein electrophoresis is a key screening test (M-spike) → True • (B) Serum LDH is non-specific; not a key diagnostic test → False • (C) Lymph node biopsy is not routine for MM → False • (D) Bone marrow biopsy is definitive → True • (E) Hypercalcemia is frequently found; checking serum calcium is part of “CRAB” (Calcium, Renal, Anemia, Bone) → True

Correct T/F: T F F T T (matches)

7. Regarding cancer in Sri Lanka

   Statements A. The incidence of uterine cervical cancer has a sharp increase in the last two decades B. Oropharyngeal carcinoma is the most common cancer C. The incidence of colorectal cancer is low compared to the West D. Liver cancer incidence in Sri Lanka is mainly due to hepatitis B and C E. There is a national screening program for cervical and breast carcinoma Given Answer: F F T ? ?

Analysis • (A) Cervical cancer incidence has not shown a “sharp increase.” Screening has been in place; incidence is generally stable or declining → False • (B) The commonest male cancer in SL is often oral cavity (lip/oral), not specifically “oropharynx.” Overall in the country, breast is the commonest in women. So “Oropharyngeal is most common” → False • (C) Colorectal cancer incidence is indeed lower than in Western countries → True • (D) Viral hepatitis (HBV/HCV) is a major cause of HCC. So “mainly due to B and C” → often considered True • (E) There is a national screening program for cervical cancer (Pap tests); for breast, there is at least a screening and awareness program with clinical breast examination. (While not always as formal as universal mammography, it is still recognized as a national-level screening approach in many guidelines.) → True

Correct T/F: F F T T T

8. Causes of secondary hypertension

   Statements A. Polycystic kidney disease B. Pheochromocytoma C. SIADH D. Coarctation of aorta E. Chronic obstructive airway disease (COAD) Given Answer: T T F T ?

Likely the last is F, since COPD is not a standard cause of secondary HTN.

Correct T/F: T T F T F

9. Regarding highly sensitive troponin I test

   Statements A. It is known to be positive in chronic kidney disease B. It is positive in Non-ST-elevation MI C. It becomes positive ~2 hours after onset of MI pain D. Repeating the test is important to diagnose re-infarction E. It is known to be elevated in sepsis Given Answer: T T T T ?

All are actually True. • Elevated in CKD, sepsis, early in NSTEMI, repeat measurement is important, etc.

Correct T/F: T T T T T

10. Regarding left ventricular failure

    Statements A. Fine bibasal crepitations B. Pink frothy sputum C. Elevated JVP D. Elevated LV end-diastolic pressure E. Loud S2 Given Answer: T T F T T

Analysis • (A) Fine basal crepitations typical in pulmonary edema → True • (B) Pink frothy sputum is a classic sign → True • (C) Elevated JVP is more typical of right-sided or biventricular failure; isolated LV failure does not always show elevated JVP → so False for isolated LVF • (D) LVEDP is increased in LV failure → True • (E) A loud S2 (pulmonic component) can occur if there is pulmonary hypertension secondary to left failure → True

Correct T/F: T T F T T (matches)

11. Which of the following have a high risk of endocarditis?

    Statements A. Aortic regurgitation (AR) B. Mitral regurgitation (MR) C. Mitral stenosis (MS) D. Ventricular septal defect (VSD) E. Atrial septal defect (ASD) Given Answer: T T F T F

Analysis • Regurgitant valves (AR, MR) → higher risk → True • MS alone has lower risk → False • VSD → turbulent flow → True • ASD (especially secundum ASD) → relatively low risk → False

Correct T/F: T T F T F

12. Regarding pediatric resuscitation

    Statements A. Finger sweeping the oral cavity blindly is not indicated B. Infants should be placed in a “sniffing” position C. Midazolam … (incomplete question)

Usually: • (A) True: do not do blind finger sweeps. • (B) For infant airway, a neutral or slightly extended “sniff” position is correct → typically True

(The question is incomplete, but those two are the key points.)

13. The following shocks have increased venous pressure

    Statements A. Cardiogenic B. Cardiac tamponade C. Anaphylaxis D. Septic shock E. Hypovolemia Given Answer: T T F F F

Analysis • Cardiogenic and tamponade → raised JVP → True • Anaphylaxis, sepsis, hypovolemia → typically low venous pressure → False

Correct T/F: T T F F F (matches)

14. Regarding airway management in pediatric trauma

    Statements A. Jaw thrust can be done in a 6-year-old B. Oropharyngeal airway should not be inserted by a junior doctor C. Head tilt should not be done D. Cervical spine is secured before Airway Given Answer: T F T T

Analysis • (A) Jaw thrust is an acceptable maneuver in children with suspected cervical injury → True • (B) In emergencies, a junior may place an OP airway if trained. So “should not be inserted by a junior” is not correct → False • (C) In trauma with possible c-spine injury, we avoid “head tilt–chin lift”; we prefer jaw thrust. So “Head tilt should not be done” → True • (D) Actually, in trauma we say simultaneous c-spine stabilization while addressing airway. So ensuring c-spine is stabilized is critical (the ATLS approach is “A (with C-spine protection), B, C…”) → True

Correct T/F: T F T T (matches)

15. Fractures

    Statements A. Classified according to direction of force B. Greenstick fractures in osteoporosis C. Comminuted fracture means bone + skin penetration D. Compartment syndrome more likely in open vs closed E. Delayed union is a complication of inadequate immobilization Given Answer: F F F F T

Analysis • Fracture classification is usually by pattern (transverse, oblique, spiral, comminuted, etc.), not merely by direction of force → False • Greenstick → occurs in children’s pliable bones, not in osteoporosis → False • “Comminuted” means the bone is broken into multiple fragments. “Open/compound” is when the fracture communicates with the skin. → False • Compartment syndrome is more likely in tightly enclosed closed fractures → so “more likely in open fractures” is False • Delayed union is indeed a complication of inadequate immobilization → True

Correct T/F: F F F F T

16. Regarding abdominal trauma

    Statements A. Blunt trauma is more common than penetrating in Sri Lanka B. Free gas under diaphragm is characteristic of solid organ injury C. Intra-abdominal bleeding is painless D. Diagnostic peritoneal lavage (DPL) is the preferred method for hemorrhage assessment E. Conservative management is possible in a stable blunt trauma with bleeding Given Answer: T F F F T

Analysis • Blunt trauma is indeed more common → True • Free gas under diaphragm suggests hollow viscus perforation, not solid organ → False • Intra-abdominal bleeding usually causes pain/guarding → False • FAST ultrasound is now the preferred initial modality, not DPL → False • If stable, conservative management is an option → True

Correct T/F: T F F F T (matches)

17. Regarding head injuries

    Statements A. Concussion is a traumatic brain injury with loss of consciousness B. Subdural hematoma is typically arterial bleeding C. Basal skull fracture can result in CSF rhinorrhea D. Subdural hematoma is due to bleeding between dura & arachnoid E. Diffuse axonal injury is due to secondary brain injury Given Answer (was confused): correct is likely T F T T F

Analysis • Concussion: typically brief loss of consciousness or transient confusion → True • Subdural hematoma: venous bleeding (bridging veins), not arterial → False • Basal skull fracture can indeed cause CSF rhinorrhea → True • SDH is bleeding between the dura and arachnoid → True • Diffuse axonal injury is a primary shearing injury at the time of trauma, not a purely secondary effect → False

Correct T/F: T F T T F

18. Hump-nosed viper bite: known clinical features

    Statements A. Local gangrene B. Acute kidney injury C. Venom-induced coagulopathy D. Rhabdomyolysis E. Thrombotic microangiopathy Likely: All can occur (these bites can cause local necrosis, coagulopathy, renal injury, TMA, rhabdomyolysis).

So:

T T T T T

19. Regarding carbon monoxide (CO) poisoning

    Statements A. CO has a high affinity to hemoglobin B. Blurred vision can be a feature C. Absence of cherry-red colour excludes CO poisoning D. Ventricular tachycardia is a fatal complication E. Encephalopathy is a delayed complication Given Answer: T T F T T

Analysis • CO’s affinity ~200–250× that of O₂ → True • Neurological/visual disturbances → True • “Cherry red colour” is often not seen; so you cannot exclude it. → False • Ventricular arrhythmias can occur → True • Delayed neuro/encephalopathy can occur → True

Correct T/F: T T F T T (matches)

20. Correctly matched radiological feature and disease

    Statements A. Lobar pneumonia → increased radiolucency B. Pleural effusion → silhouette sign C. Idiopathic pulmonary fibrosis → reticulonodular pattern D. Metastatic lung carcinoma → cannonball deposits E. Pneumothorax → air bronchogram Given Answer: F F T T F (but best evidence is B is actually true)

Analysis • (A) Lobar pneumonia → typically shows consolidation (increased opacity), not lucency → False • (B) A large pleural effusion can indeed obscure normal lung/heart borders and produce a silhouette sign if it abuts that border → so this can be True • (C) IPF → classically “reticular” or “reticulonodular” → True • (D) Metastatic carcinoma → can present as “cannonball metastases” → True • (E) Pneumothorax → absent lung markings, not an “air bronchogram.” Air bronchograms usually occur in alveolar consolidation → False

Correct T/F: F T T T F

(If the given was “F F T T F,” the second statement for effusions was likely an error; a pleural effusion can cause a silhouette sign.)

21. Differential diagnoses for hemoptysis

    Statements A. Bronchial carcinoma B. COPD C. Bronchiectasis D. Pulmonary embolism E. Pleural effusion Given Answer: T T T T F

Analysis • All four (A–D) can cause hemoptysis, whereas a simple pleural effusion by itself does not typically cause frank hemoptysis → False

Correct T/F: T T T T F (matches)

22. A 4-year-old with episodic cough/wheeze. Which features favor asthma over other causes?

    Statements A. Symptoms worse in evening & early morning B. Documented fever with most episodes C. Longstanding eczema D. Worsening with dust/cold air E. Wet cough + failure to thrive Given Answer: T F T T F

Analysis • (A) Diurnal variability (night/early AM) → typical of asthma → True • (B) Fever suggests infection, not typical for most asthma episodes → False • (C) Eczema (atopy) → strongly supportive of asthma → True • (D) Triggered by dust/cold air → typical → True • (E) Chronic “wet cough + failure to thrive” is more suspicious for bronchiectasis or cystic fibrosis → False

Correct T/F: T F T T F (matches)

23. Patient with acute liver failure in ICU becoming lethargic (encephalopathy). Possible measures:

    Statements A. Elevation of head end (30°) B. Oral lactulose via NG C. IV metronidazole D. Hyperventilation E. IV diuretics Given Answer: T T F T F

Analysis • (A) Elevating the head to ~30° helps reduce intracranial pressure risk → True • (B) Lactulose is standard to reduce ammonia → True • (C) Usually not standard; Rifaximin can be used, but not typically IV metronidazole → False • (D) Hyperventilation can acutely reduce raised ICP (if there are signs of cerebral edema) → True • (E) Diuretics are not a routine immediate measure in ALF with encephalopathy (could worsen renal perfusion) → False

Correct T/F: T T F T F (matches)

24. Complications of chronic suppurative otitis media (CSOM)

    Statements A. Facial nerve palsy B. Ramsay Hunt syndrome C. Hearing loss D. Cerebral abscess E. Maxillary sinusitis Given Answer: T F T T F

Analysis • (A) Possible due to middle ear involvement of the facial nerve → True • (B) Ramsay Hunt = herpes zoster oticus, not typical of CSOM → False • (C) Conductive hearing loss → True • (D) Intracranial sepsis (abscess) is a known complication → True • (E) Maxillary sinusitis is not a classic complication → False

Correct T/F: T F T T F (matches)

25. Preventing diabetic kidney disease

    Statements A. Primary prophylaxis with aspirin B. Increasing screening for diabetes C. Following up mothers with GDM D. Tight glycemic control E. Primary prophylaxis with ACE-Inhibitors in all T2DM Given Answer: F T T T F

Analysis • (A) Aspirin does not prevent DKD; it helps CV risk → False • (B) Early detection of diabetes helps earlier control → True • (C) GDM mothers are at higher risk → follow-up is important → True • (D) Tight control reduces microvascular complications → True • (E) Giving ACEI routinely to all T2DM with no HTN or no microalbuminuria is not standard → False

Correct T/F: F T T T F (matches)

26. Regarding urological problems

    Statements A. Balanoposthitis is treated with IV antibiotics B. Phimosis due to BXO is an indication for circumcision C. Paraphimosis requires urgent circumcision D. Non-retractable prepuce is normal in infants E. Hypospadias has a hooded prepuce Given Answer: F T F T T

Analysis • Balanoposthitis is typically managed with topical/oral antibiotics and hygiene, not routinely IV → False • Phimosis from BXO (balanitis xerotica obliterans) is a surgical indication → True • Paraphimosis needs urgent manual reduction or dorsal slit if not reducible; not necessarily immediate full circumcision → False • A non-retractile foreskin is normal in young infants → True • Hypospadias typically also presents with a dorsally “hooded” prepuce → True

Correct T/F: F T F T T (matches)

27. Regarding urinary stones

    Statements A. Bladder stones are usually “sediment” stones (secondary to stasis) B. Triple phosphate (struvite) stones are associated with infections C. Ureteric stones >6 mm have a 90% chance of passing spontaneously D. Randall’s plaque is the most common precursor for renal stones E. A high salt diet reduces recurrence Given Answer: (some confusion “FTFTF”)

Analysis • (A) Most bladder stones in adults do form from urinary stasis/“sediment” → True • (B) Struvite (magnesium ammonium phosphate) are infection stones → True • (C) Stones >6 mm have much lower chance (around 20%) of spontaneous passage → False • (D) Randall’s plaque in the papilla can be a common precursor for calcium stones → True • (E) A high salt intake worsens recurrence risk → “reduces” is False

Correct T/F: T T F T F

28. Causes of stridor in children

    Statements A. Acute tonsillitis B. Acute epiglottitis C. Diphtheria D. Bronchiolitis E. Angioneurotic edema Correct Analysis • Tonsillitis usually causes sore throat, not classic stridor. Significant peritonsillar abscess or retropharyngeal abscess might, but acute tonsillitis alone rarely presents with stridor. So (A) is typically False. • Epiglottitis → True • Diphtheria (laryngeal) → True • Bronchiolitis → causes wheeze (lower airway), not stridor → False • Angioedema can cause upper airway edema → stridor → True

    Correct T/F: F T T F T

29. Features favoring acute epiglottitis over viral croup

    Statements A. Toxic looking B. Fever of 39°C C. Drooling saliva D. Barking cough E. Tripod position Analysis • (A) “Toxic” → epiglottitis → True • (B) High fever (≥39°C) → more typical in epiglottitis → True • (C) Drooling → classic for epiglottitis → True • (D) “Barking” cough → croup → so for epiglottitis → False • (E) Tripod posture → epiglottitis → True

    Correct T/F: T T T F T

30. Ethically acceptable in critical care

    Statements A. Consent from nephew to amputate a confused 55-year-old B. A 65-year-old with dementia expresses not to be resuscitated if arrest C. Collateral history from husband of unconscious overdose D. Harvesting organs from 20-year-old brain-dead with family consent E. Nurse giving details over phone to a relative Analysis • (A) Usually you seek the legal next-of-kin or a legally recognized decision-maker (spouse, adult children, etc.). The nephew is not automatically correct unless no one else is available or designated → Typically False • (B) The patient’s advanced directive / expression → True if she’s judged competent at that time • (C) Collateral from spouse → True • (D) Organ donation from brain-dead with family consent → ethically acceptable → True • (E) Giving sensitive information by phone is typically discouraged unless identity is certain → False

    Correct T/F: F T T T F

31. Pancreatic tumors

    Statements A. Most common pancreatic tumor is ductal adenocarcinoma B. Clinical symptoms appear earlier if tumor in body/tail vs head C. Gastric outlet obstruction is a feature D. Lymphatic spread is to celiac nodes E. CA19‑9 is a tumor marker Given Answer: T F T T T

Analysis matches standard teaching: • (A) Ductal adenocarcinoma is ~90% → True • (B) Tumors of the head typically present earlier (obstructive jaundice), so “body/tail earlier” → False • (C) Duodenal obstruction can occur with a head mass → True • (D) Common LN spread to celiac axis → True • (E) CA 19‑9 → True

Correct T/F: T F T T T

32. (Mirizzi’s syndrome, Mucocele, etc.) – incomplete question

33. A 45-year-old with recurrent pancreatitis episodes, mild hyperamylasemia, calcifications at L1 → Chronic pancreatitis

    Statements A. Constipation is a feature B. Enzymes need replacement C. Patient may need diabetes treatment D. Splenic artery pseudoaneurysm is a known complication E. Diagnosis is “acute relapsing pancreatitis” Given Answer: F T T T F

Analysis • (A) Typically they have steatorrhea or diarrhea, not constipation → False • (B) Pancreatic enzyme replacement is standard → True • (C) Endocrine insufficiency → diabetes → True • (D) Vascular complications (pseudoaneurysm in splenic artery) → True • (E) The overall picture is chronic pancreatitis, not just “acute relapsing” → False

Correct T/F: F T T T F (matches)

34. Regarding intussusception in children

    Statements A. Abdominal pain is a presenting feature B. Ultrasound is diagnostic C. Hydrostatic reduction is a treatment option D. Associated with Meckel’s diverticulum E. Commonest site is jejunum Given Answer: T T T T F

Analysis • The classic site is ileocolic, not jejunum → E is False • The rest are standard → A, B, C, D all True

Correct T/F: T T T T F (matches)

35. Regarding colorectal carcinoma

    Statements A. CEA is used to detect early metastasis B. Carcinoma in the ascending colon is commonly annular and constricting C. Pallor is a presenting complaint D. Hematogenous spread mainly to liver E. Signet cell carcinoma has a poor prognosis Given Answer: T F T T T

Analysis • (A) CEA is indeed used to monitor or detect recurrence/metastasis, though not perfect → True • (B) Right-sided (ascending) tumors often are polypoid/exophytic. Annular (“napkin-ring”) is more typical of left-sided → False • (C) Chronic blood loss → pallor → True • (D) Via portal circulation → to liver → True • (E) Signet cell type is aggressive → True

Correct T/F: T F T T T (matches)

36. A man drinking half bottle of alcohol daily x 10 years. Which signs suggest chronic liver disease (CLD)?

    Statements A. Parotid swelling B. Dupuytren’s contracture C. Low platelet count D. Elevated GGT E. Elevated PT/INR

All can be found in chronic alcoholic liver disease: • (A) Parotid enlargement: well-known → True • (B) Dupuytren’s contracture → True • (C) Thrombocytopenia from hypersplenism or direct marrow suppression → True • (D) GGT is often raised in alcohol abuse → True • (E) Coagulopathy (raised INR) → True

Correct T/F: T T T T T

Sometimes the original “F?? F??” was incorrect. All are valid stigmata or lab findings in CLD.

37. Regarding goiter

    Statements A. Iodine deficiency is the commonest cause in Sri Lanka B. Grave’s disease causes diffuse goiter C. Chronic thyroiditis is a painful thyroiditis D. FNAC is the initial investigation in thyroid nodules E. Multinodular goiter has a higher chance of malignancy compared to a solitary nodule

Analysis • (A) Historically yes, iodine deficiency is (or was) the commonest cause → True • (B) Graves → diffuse goiter → True • (C) Hashimoto’s (chronic autoimmune) is typically painless. Subacute (De Quervain’s) is painful but it’s usually called “subacute,” not “chronic” → so “Chronic thyroiditis is painful” → False • (D) The usual initial step for a “thyroid nodule” is TSH + ultrasound and then if indicated, an FNAC or biopsy. But from a surgical perspective, FNAC is crucial for suspicious nodules → True • (E) A solitary nodule is actually more suspicious than an MNG. So “MNG is more malignant than solitary” → False

Correct T/F: T T F T F

38. Management of obesity

    Statements A. Diet & lifestyle changes are not needed if on pharmacotherapy B. Orlistat is a lipase inhibitor C. GLP-1 receptor agonists are used D. Metabolic (bariatric) surgery is less effective than orlistat E. Phentermine–topiramate is used to reduce appetite

Analysis • (A) Lifestyle changes remain fundamental → so that statement is False • (B) Orlistat blocks pancreatic lipase → True • (C) GLP-1 agonists (e.g., liraglutide) → True • (D) Bariatric surgery is more effective → so “less effective” is False • (E) Combination phentermine–topiramate is indeed used (appetite suppression) → True

Correct T/F: F T T F T (matches)

39. Calcium & phosphate disorders

    Statements A. High Ca, High phosphate → Secondary hyperparathyroidism B. High Ca, Low phosphate → Primary hyperparathyroidism C. Low Ca, High phosphate → Renal disease D. Low Ca, Low phosphate → Vitamin D deficiency E. Normal Ca, Normal phosphate → Postmenopausal osteoporosis

Analysis • In secondary hyperparathyroidism (CKD), phosphate is high, calcium is often low or normal. So “High Ca + High phos” is not typical of secondary hyperPTH → False • Primary hyperparathyroidism → classically “high Ca, low phosphate” → True • Renal disease → often low Ca, high phosphate → True • Vit D deficiency → low Ca, low phosphate (or sometimes low/normal phosphate) → True • Postmenopausal osteoporosis → usually normal Ca & phosphate → True

Correct T/F: F T T T T

40. Biochemical & clinical features of primary hypoadrenalism (Addison’s)

    Statements A. Postural hypotension B. Hyponatremia C. Hyperkalemia D. High renin E. Hyperpigmentation (dark knuckles)

All are characteristic of Addison’s → All True.

Correct T/F: T T T T T

Clinical Sciences Stream Examination 1 – Part B

Below, each single-best-answer question is given with the likely correct choice and a short explanation.

1. A 17-year-old boy with scaly, itchy tinea in axilla/groin; friends also affected. Best management?

Likely Answer: (B) Treat with oral antifungals for 2 weeks and topical antifungals for 4 weeks. • Tinea cruris (dermatophyte infection in groin/axilla) often benefits from a combination of adequate topical therapy (≥4 weeks) plus a short course of oral therapy if lesions are extensive or recurrent.

2. A 43-year-old female with non-pruritic, skin-colored plaques on extremities/trunk and glove-and-stocking sensory loss. Most probable diagnosis?

Likely Answer: (B) Leprosy. • Leprosy (especially tuberculoid or borderline) can present with hypopigmented or skin-colored patches that have sensory impairment.

3. An 8-year-old with DHF in critical phase (46 hours), short of breath, bilateral effusions/crackles, stable hemodynamics, saturation 95%, PP >30, UO 0.8 mL/kg/hr → likely fluid overload.

Likely Answer: (C) IV furosemide. • He is not hypotensive, has adequate pulse pressure, normal urine output, and is likely in fluid overload (“pleural effusion, crackles”). The best step is a diuretic if truly hypervolemic in the latter part of DHF.

4. A female about to have a small lipoma excision in the thigh. Best measure to prevent surgical site infection?

Most clean minor surgeries (lipoma excision) do not need prophylactic antibiotics. The key is proper skin prep: • On-the-table painting with povidone iodine (and standard sterile technique) is the crucial measure.

Hence:

Likely Answer: (C) On the table painting the body surface of the surgical site with povidone iodine.

5. A 25-year-old with “cellulitis” of lower leg – which feature favors an alternative diagnosis?

Likely Answer: (D) Necrosis of the overlying skin. • True cellulitis seldom causes rapid necrosis. Patchy necrosis or severe blistering necrotic changes might suggest necrotizing fasciitis or a more severe entity.

6. 60-year-old stroke patient with lines/catheters, stable but now with high fever, normal CVS/resp exam. Most likely cause?

Likely Answer: (D) Catheter-associated urinary sepsis. • He was discharged with an indwelling urinary catheter. Urosepsis is common in such patients.

7. 14-year-old with recurrent (family) angioedema episodes, no urticaria, brother died from airway compromise. Next best diagnostic test?

Likely Answer: (A) C1 esterase inhibitor level. • Suspect hereditary angioedema.

8. Terminal metastatic lung cancer patient in severe pain despite opioids, poor quality of life. Best next step?

Likely Answer: (A) Refer to a specialist palliative care unit. • Intensifying palliative measures is key. “Aggressive curative chemo” is not indicated.

9. A 70-year-old on warfarin, stable but with PR bleeding, Hb=6 g/dL. Which is least useful for managing warfarin-related bleeding?

Likely Answer: (A) Cryoprecipitate. • Cryoprecipitate mainly replaces fibrinogen & factor VIII, not the broad factors needed for warfarin reversal.

10. 14-year-old with acute hemolysis after antibiotic, negative Coombs, RBC “blister/bite” cells → ?

Likely Answer: (B) G6PD deficiency.

11. Suspecting SLE in a woman with polyarthralgia & fever. Most appropriate test initially?

Likely Answer: (B) ANA (Antinuclear Antibody). • ANA is the best screening test; anti-dsDNA is more specific but not the first screening.

12. A country wants a cancer screening program. Most important test quality?

Likely Answer: (C) High sensitivity. • You want to catch as many true cases as possible (low false negatives).

13. 59-year-old hypertensive on amlodipine, also has asthma, diabetes, dyslipidemia, still uncontrolled BP. Best add-on?

Likely Answer: (B) Enalapril. • Avoid non-selective beta-blockers (e.g., propranolol) in asthma.

14. 60-year-old with HF (EF=45%), on ACE-I, beta-blocker, diuretic, recurrent episodes. Next drug?

With HFrEF or mildly reduced EF (45%), new guidelines often recommend an SGLT2 inhibitor if no contraindications.

Likely Answer: (B) Empagliflozin.

(If they wanted an MRA (spironolactone) that’s also possible, but SGLT2 inhibitors are now standard add-ons even in non-diabetics with HF.)

15. Post-anterior STEMI day 2, new apex murmur + SOB → likely papillary muscle rupture → acute severe MR.

Likely Answer: (A) Mitral regurgitation. • Apical holosystolic murmur is typical of acute MR.

16. RHD with mild fever, culture G+ cocci in pairs/chains → likely subacute endocarditis. Best antibiotic?

Likely Answer: (B) Penicillin + Gentamicin. • Standard for most streptococcal subacute endocarditis.

17. 60-year-old with BP=230/170, headache, vomiting, mild papilledema → hypertensive emergency. Immediate step?

Likely Answer: (C) IV labetalol boluses.

18. 50-year-old with calf pain after walking 200 m, relieved by rest → classic claudication from arterial disease.

Likely Answer: (D) Obstruction of superficial femoral artery.

19. (Not fully provided)

20. Patient unresponsive, monitor shows a wide complex or unknown rhythm – next immediate step?

Typically in any unwitnessed collapse with a strange monitor reading, check for a pulse.

Likely Answer: (D) Check for a pulse.

(You always quickly check responsiveness/pulse before deciding defibrillation or CPR.)

21. During CPR, monitor shows VF. Next immediate step?

Likely Answer: (A) Defibrillation.

22. 34-year-old with blunt abdominal trauma, tender, guarding, stable vitals. Next best step?

Likely Answer: (C) FAST scan. • Focused Assessment with Sonography for Trauma.

23. Female with trauma to pelvis, stable vitals, severe pain, ecchymosis. Best immediate management?

Likely Answer: (A) Apply a pelvic binder.

24. 23-year-old with RTA, GCS=7, unilateral dilated fixed pupil. Next best step?

Likely Answer: (C) Intubate and ventilate. • Secure airway, then urgent CT, etc.

25. 40-year-old with open fracture (bone protruding), distal pulse present. Next immediate step?

Likely Answer: (B) Apply a sterile dressing & splint.

26. Severe pain on breathing, subcutaneous crepitus on anterior chest wall after trauma → suggests multiple rib fractures with segment → “flail chest.”

Likely Answer: (A) Flail chest.

(Subcutaneous emphysema can also happen with plain rib fractures or alveolar rupture, but “crepitus on chest wall + severe pain + abnormal chest movement” typically flail.)

27. Child with displaced radius fracture. Next appropriate immediate management?

Likely Answer: (B) Put a splint and stabilize the forearm. • Definitive reduction can be done later once analgesia, sedation, imaging, etc., are arranged.

28. Unknown snake bite, no signs of envenomation, 20WBCT normal. Next step?

Likely Answer: (D) Observe for 24 hours.

29. 24-year-old, took ~50 paracetamol tablets 4h ago, stable vitals. Next step?

Likely Answer: (A) Activated charcoal. • Within ~4 hours, activated charcoal is recommended. N‑acetylcysteine also indicated but first step is charcoal if still within 4 hours.

(If exactly 4 hours have elapsed, you can do both quickly, but typically question emphasizes charcoal as the immediate measure if <4 hours. NAC is also crucial. If only one best next step, usually charcoal if within 4h.)

30. Farmer with organophosphate poisoning signs: bradycardia, bronchospasm. Next best step?

Likely Answer: (B) IV atropine.

31. Young patient, left side hyperresonance, reduced breath sounds, stable → likely tension pneumothorax or simple pneumothorax. The question says “tracheal deviation?” If typical tension, you’d see shift.

Given they gave “hyper-resonance and absent breath sounds,” best single diagnosis:

Likely Answer: (E) Tension pneumothorax.

32. 18-year-old asthmatic on low-dose ICS + SABA prn (8-10 times daily), frequent night symptoms → next step?

Likely Answer: (C) Replace short-acting beta-agonist with a long-acting beta-agonist together with ICS, or simply “add a LABA.”

(Often guidelines say: step-up the inhaled steroid dose or add LABA. Usually the next standard step is add a LABA and see if symptoms improve.)

33. 60-year-old with large left pleural effusion, exudative, RBC “field full” after multiple aspirations, likely malignant.

Likely Answer: (B) Malignancy.

34. 2-year-old with cerebral palsy, chronic cough, worse on feeding → suspect aspiration. Next best step?

Likely Answer: (C) Refer to speech/swallow therapy (to assess swallowing).

35. 4-year-old with 4 weeks cough, father with TB, normal exam, normal CXR, negative GeneXpert, Mantoux 13 mm → latent TB infection, no overt disease.

Likely Answer: (B) Start prophylactic isoniazid for 6 months.

36. 70-year-old with nasal obstruction, decreased smell, “grey glistening mass.” Classic for nasal polyp.

Likely Answer: (D) Nasal polyp.

37. Maxillary sinusitis often presents with toothache because upper tooth roots can project into the sinus.

Likely Answer: (C) The roots of maxillary teeth extend into the floor of the maxillary sinus.

38. 50-year-old diabetic with painless hematuria → first, do a simple urine full report (UFR) / urinalysis.

Likely Answer: (E) UFR • That is always the initial test.

39. 40-year-old with dark urine, dipstick + for blood but no RBC → rhabdomyolysis, raised creatinine, hyperkalemia. Best management:

Likely Answer: (D) IV normal saline • Mainstay is aggressive hydration.

40. A 38-year-old with 3 days reduced urine, creatinine rising from 1.0 to 2.5, RBC 1-2/hpf, Pus cells 10-15/hpf, normal ultrasound → consistent with Acute Kidney Injury (possibly acute interstitial nephritis or mild sepsis-related). No features of nephritic (no RBC casts) or nephrotic (no heavy protein).

Likely Answer: (A) Acute kidney injury.

41. A 70-year-old with LUTS and enlarged prostate. Which test definitely excludes prostatic carcinoma?

Trick: The only way to exclude is a prostate biopsy. • PSA can be misleading. • So:

Likely Answer: (C) Prostate biopsy.

42. Female with flank pain & fever → suspect pyelonephritis or obstructing stone. Best initial imaging:

Likely Answer: (A) Ultrasound KUB.

43. Patient with 3 days diarrhea & fever. Best indication to start antibiotic?

Often guidelines: if immunocompromised, or prosthetic valves, or severe invasive features. So:

Likely Answer: (A) Prosthetic heart valves (i.e., a high-risk scenario).

44. (Not provided)

45. An anxious patient who is shouting in fear but not violent. Best initial step?

Likely Answer: (E) Verbal de-escalation • Before giving IM haloperidol or forcibly sedating, try calm verbal techniques.

46. A CKD patient was given lithium by mistake instead of calcium → medication error. Best system-level step to prevent such an error?

Likely Answer: (B) Separation/storage of look-alike/sound-alike drugs (“Lithium carbonate” vs “Calcium carbonate” often leads to confusion.)

47. Child with posterior urethral valves ablated but still recurrent UTIs, normal stream. Best measure to prevent future UTI?

Likely Answer: (B) Antibiotic prophylaxis.

48. A 70-year-old had a rectal polyp. Which polyp type is most likely to become carcinoma?

Likely Answer: (D) Villous adenoma. • Villous has the highest malignant potential.

49. A 55-year-old with chronic liver disease. Which is the best indicator of poor synthetic function?

Among the listed, low albumin is the best direct measure of synthetic impairment:

Likely Answer: (A) Albumin of 2 g/dL.

50. Best method to confirm correct NG tube placement?

Likely Answer: (E) Chest X‑ray • Checking aspirate pH is helpful as a quick bedside check, but definitive confirmation is X‑ray.

51. A woman awaiting ERCP + stenting in 3 weeks, platelets 130 000, INR 2.1, Hb=9. Best pre-procedure optimization? • INR 2.1 is significantly prolonged. Reversing coagulopathy is priority. • Vitamin K is typically used to correct warfarin-induced deficiency or if deficiency is likely. FFP could be used short term. But the single best is often:

Likely Answer: (C) Vitamin K (If she has known vitamin K deficiency or is on warfarin, that is the usual measure. FFP is also possible, but vitamin K is simpler and more direct if there’s time.)

52. 24-year-old with 6‑day LQ pain & fever 3 days, 6 mm appendicular abscess on USS. Best management?

Likely Answer: (E) IV antibiotics + US-guided drainage (pigtail) if feasible • For a small walled-off appendiceal abscess, the usual approach can be percutaneous drainage + antibiotics, then interval appendicectomy if needed.

53. A 16-hour-old neonate with jaundice. Least likely cause? • Physiological jaundice typically appears after ~24 hours. • ABO/Rh incompatibility can appear early. • Crigler-Najjar can present early. • Gilbert syndrome typically presents much later, mild, rarely in the neonatal day 1–2.

Likely Answer: (D) Gilbert syndrome is least likely in a symptomatic 16-hour-old.

54. A woman with polydipsia, water deprivation test done, best indicator of cranial (central) DI is a marked rise in urine osmolality after desmopressin.

Likely Answer: (C) A marked increase in urinary osmolality after desmopressin

55. Most suggestive that Cushing’s syndrome is pituitary in origin?

Likely Answer: (C) Inferior petrosal sinus gradient showing higher central ACTH • That localizes it to the pituitary (Cushing’s disease).

56. A pregnant hyperthyroid woman at 8 weeks with Graves. Best immediate management?

Likely Answer: (C) Beta-blocker + propylthiouracil • First trimester: PTU is preferred over carbimazole (which has teratogenic risks especially in early pregnancy).

57. 62-year-old with a Colles’ fracture from minimal trauma, T-scores around −1.4 to −1.0 → osteopenia, but with a fragility fracture. She declines injection therapy. Usually we do:

Likely Answer: (B) Vitamin D, calcium, plus weekly alendronate. • She already had a low-impact fracture, so prescribing a bisphosphonate is indicated.

58. A 3-week-old with ambiguous genitalia, dehydration, hyperpigmentation → suspect CAH (21-hydroxylase deficiency).

Likely Answer: (C) Perform serum 17-OH + electrolytes • That’s the most urgent relevant investigation.

59. 7-year-old T1DM with DKA, next morning stable, pH=7.36, ketones +1. Next step?

Likely Answer: (A) Start subcutaneous insulin and oral feeding, continue IV insulin overlap for about 1 hour • Standard DKA resolution transition.

60. Known ASCVD + T2DM on max metformin + gliclazide, still with suboptimal control (HbA1c 8.5%). Best add-on?

Given he has cardiovascular disease, an SGLT2 inhibitor (e.g., empagliflozin) has proven cardiovascular benefit.

Likely Answer: (A) Empagliflozin.

Final Formatted Answers

Below is a concise list:

Part A (True/False) 1. F F T F F 2. T T F F F 3. T T T T F 4. F T T F F 5. T T F T T 6. T F F T T 7. F F T T T 8. T T F T F 9. T T T T T 10. T T F T T 11. T T F T F 12. (A)T, (B)T – midazolam incomplete 13. T T F F F 14. T F T T 15. F F F F T 16. T F F F T 17. T F T T F 18. T T T T T 19. T T F T T 20. F T T T F 21. T T T T F 22. T F T T F 23. T T F T F 24. T F T T F 25. F T T T F 26. F T F T T 27. T T F T F 28. F T T F T 29. T T T F T 30. F T T T F 31. T F T T T (32. Not answered fully) 32. F T T T F 33. T T T T F 34. T F T T T 35. T T T T T 36. T T F T F 37. F T T F T 38. F T T T T 39. T T T T T

Part B (Single Best Answer) 1. (B) Oral antifungals ×2 w + topical ×4 w 2. (B) Leprosy 3. (C) Start IV frusemide 4. (C) Painting with povidone-iodine 5. (D) Necrosis of overlying skin 6. (D) Catheter-associated urosepsis 7. (A) C1 esterase inhibitor 8. (A) Refer palliative care 9. (A) Cryoprecipitate is least useful 10. (B) G6PD deficiency 11. (B) ANA 12. (C) High sensitivity 13. (B) Enalapril 14. (B) Empagliflozin 15. (A) Mitral regurgitation 16. (B) Penicillin + gentamicin 17. (C) IV labetalol boluses 18. (D) Obstruction of superficial femoral artery 19. – 20. (D) Check for a pulse 21. (A) Defibrillation 22. (C) FAST scan 23. (A) Pelvic binder 24. (C) Intubate and ventilate 25. (B) Sterile dressing + splint 26. (A) Flail chest 27. (B) Splint the forearm 28. (D) Observe 24 hours 29. (A) Activated charcoal 30. (B) IV atropine 31. (E) Tension pneumothorax 32. (C) Add a long-acting beta-agonist (LABA) 33. (B) Malignancy 34. (C) Swallow assessment (speech therapy) 35. (B) Start isoniazid prophylaxis 6 m 36. (D) Nasal polyp 37. (C) Roots of maxillary teeth project into sinus 38. (E) Urine Full Report (UFR) 39. (D) IV saline (rhabdomyolysis) 40. (A) Acute kidney injury 41. (C) Prostate biopsy 42. (A) Ultrasound KUB 43. (A) Prosthetic heart valves 44. – 45. (E) Verbal de-escalation 46. (B) Separate look-alike sound-alike drugs 47. (B) Antibiotic prophylaxis 48. (D) Villous adenoma 49. (A) Albumin of 2 g/dL 50. (E) Chest X-ray 51. (C) Vitamin K 52. (E) IV antibiotics + US-guided drainage 53. (D) Gilbert syndrome 54. (C) Large rise in urine osmolality after desmopressin 55. (C) Inferior petrosal sinus gradient 56. (C) Beta-blocker + PTU 57. (B) Calcium/vit D + weekly alendronate 58. (C) 17-OH + electrolytes 59. (A) Start SC insulin + meal, overlap for ~1 hr 60. (A) Empagliflozin

Notes: • Where your original T/F or SBA answers differed, the above corrections and explanations address the most standard guidelines and reasoning.