ANSWERS OF FB GROUP QUESTIONS
1. B - The answer is volvulus. Sigmoid volvulus should be included in the ddx of acute and
recurrent episode of abdominal pain as the consequences can be life threatening.
Barium enema confirm the diagnosis. More common in boys. Common symptom is
abdominal pain relieved by passage of stool or flatus.
2. C - Reason being is u need to prevent further damage to the target organ. Stat dose
only. Then swiftly need to proceed with CT brain and closely monitoring the BP and
GCS.
3. E- Most common presenting complain is painless neck in neck and 1/3 associated with
constitutional symptom and if any pt presented to us with painless neck mass which
was not respond to antibiotic, should be further investigated. Hodgkin can be one of the
differential diagnosis.
4. B - Chromosomal abnormalities [usually autosomal trisomies] which are incompatible
with life..other choices are also factors that may contribute to spontaneous abortion
5. D - This above condition is puerperal pyrexia. The most common cause is endometritis.
Others like UTI, mastitis, wound infection. The patient above need to be admitted to
start IV antibiotic and may need to be investigated.
6. A- Transfatty acids increase the risk while monounsaturated and polyunsaturated fatty
acids
reduce
the
risk
of
CAD...polysaccharides
are
long
chain
of
monosaccharides,increased glucose diet may also decrease the serum HDL (the good
cholesterol).
7. D - Longer duration of ruptured membranes may be associated with a higher rate of
mother-to-child transmission. The International Perinatal HIV group meta-analysis found
that the risk of vertical transmission increased by 2% for every increase of 1 hour in the
duration of ruptured membranes.
8. D - Infectious mononucleosis is relatively common in pts age 10 to 30 years old. It is
usually caused by EBV (90%) and minority caused by CMV. It spreads through saliva.
Also known as glandular fever and "kissing disease". Incubation period is btwn 4-7
weeks. Main complaints include sorethroat, fatigue, palatal petechiae, posterior cervical
or auricular lymphadenopathy, or inguinal lymphadenopathy. Pt might have
splenomegaly. Heterophile antibody test is usually positive. False-negative result are
relatively common in early course of infection. The test will be negative if it is caused by
CMV. Symptomatic Rx is the mainstay of care ie adequate hydration, analgesics,
antipyretics and adequate rest. Corticosteroids, antihistamine and acyclovir are not
recommended for routine Rx. Fatigue, myalgia and need for sleep may persist for
several months after the acute infection has resolved.
9. E - This pt has several risk factors for endometrial ca - age more than 40, obesity,
diabetes. Other risk factors for endometrial ca includes nulliparity, late menopause,
pcos, hypertension, family hx, h.o breast or ovarian ca. Menorrhagia in this patient
requiring endometrial sampling prior hormonal treatment. A younger patient can be
treated
with
medoxyprogrestrone
acetate
or
or
combinatiom
oral
contraceptives. Pathology : >90% adenocarcinoma of columnar endometrial gland
cells.
10. C
11. E - It is preferable to achieve anti HBs level >100mIu/ml. However level of 10-100 are
generally accepted.those with level <10 is considered non responder.thus a repeat
course of vaccine is recommended followed by retesting 1-2 mnth after completion the
3 dose series.
12. E - This patient is suffering from bacterial meningitis. Hip flexion in response to passive
neck flexion is Brudzinski’s sign. Kernig’s sign also occurs in meningitis and is elicited by
passively flexing the hip with the knee bent – any attempt to straighten the knee causes
pain and hamstring spasm. The most common organism implicated in meningitis in the
elderly is Streptococcus pneumoniae, which is an alpha-haemolytic streptococcus.A
cephalosporin such as ceftriaxone is first-line treatment in patients with streptococcal
meningitis.
13. D - This infant has ambiguous genitalia.The most common cause of ambiguous genitalia
is female pseudohermaphroditism,and congenitaladrenal hyperplasia (CAH) is the most
common cause of female pseudohermaphroditism. 21-Hydroxylase enzyme deficiency is
the most common enzyme deficiency and accounts for 90% ofcongenital adrenal
hyperplasia.It is critical that the precise etiology be delineated so that any urgent
metabolic abnormalities can be treated safely and quickly.In female pseudohermaphroditism,the gonadal tissue is represented by ovaries.The chromosomal
analysis shows 46,XX. Overexposure to androgens in utero causes severe
masculinization ofthe external genitalia.CAH patients display marked enlargement of the
phallus,which excretes urine through a single urogenital sinus opening. Many of these
infants experience salt wasting caused by reduced aldosterone production.Salt wasting
may cause a low plasma sodium with high renin and potassium concentrations.Death
may occur in the neonatal period if the ensuing electrolyte abnormalities are
unrecognized and untreated.Dehydration secondary to vomiting can lead to circulatory
collapse.
An arterial blood gas (choice A) is not helpful in the treatment of the underlying
condition.Although the gas will reveal an acidosis,the source ofthe dehydration and
lethargy is electrolyte abnormalities.
Karyotype (choice B) is important to determine the exact chromosomal makeup of the
infant.These results help in determining the sex of the infant for rearing,however,and
are not available immediately.It is an important test,but not one that will help this
lethargic,
dehydrated
infant
in
the
intensive
care
unit.
Pelvic ultrasound (choice C) can be used to determine the presence or absence of
various intraabdominal organs or the presence of nonpalpable testes.It does not provide
definitive answers,however,and will not help this dehydrated infant.In patients with CAH
caused by 21-hydroxylase or 11-beta-hydroxylase enzyme deficiency,the 17-alphahydroxyprogesterone serum level (choice E)is elevated. This piece of knowledge is
important for determining the underlying etiology,but in the intensive care unit,the
patient's electrolytes are of higher priority.
14. D - The key towards management is actually the vital signs, which is not stated in the
scenario. Therefore the answer could be debatable. however, as there is no free fluid
seen during scan, it doesnt seem like there is ongoing rupture. In view of rising beta
HCG level, this pregnancy is not failing. pregnancy of unknown location could have
potentially rupture with subsequent hemorrhage. Thus we use a cut off point of 200 for
beta HCG, if u want to advocate expectant management. This is also cited by ACOG, to
justify
ourselves.
with her beta HCG level, the answer given is D, with a successful rate as high as 90
percents!
Well, there are few criterias that she must fulfill before we offer her methotrexate
therapy:
1. low beta HCG level , preferably below 5000. (higher beta HCG level is not
contraindication, just that it results in higher treatment failure rate)
2. small ectopic mass, tubal size of less than 3-4cm, and no fetal cardiac activity seen.
(actually most studies try methotrexate on smaller ectopic mass, not many try on larger
mass, so we do not know. some people use actual gestation mass,others include the
surrounding hematoma, thus size become operator dependant. anyway, ectopic mass
doesnt
correlate
with
beta
HCG
level
)
3. no renal, hepatic or hematological disorder (methotrexate is cleared by kidney)
4. no signs of impending rupture in her case, she is still young, and has previous
surgery (anticipate adhesion if go in). methotrexate would be a suitable choice, we
need to reassure her that it doesnt appear to compromise future pregnancy or
pregnancy outcome, nor increase the risk of recurrent ectopic pregnancy.
Besides, methotrexate dose used for pregnancy of unknown location is relatively low, as
compared to dose used in oncology. tell her that it doesnt affect ovarian reserve. she
can attempt to conceive after the beta HCG is undetectable rather than waiting for one
or two ovulatory cycle. If interested, u can read more about how to follow up in
methotrexate treatment and combined use with mifepristone & leucovorin.
15. B - Can refer CPG on TB management. Give prophylaxis isoniazid for 6months then
BCG after stopping isoniazid or isoniazid for 3 months followed by tuberculin skin test
then BCG after stopping isoniazid if TST normal.
16. B - Concealed accidental haemorrhage has complicated this case.HELLP syndrome the
pain is localized to the liver and the uterus is neither tender nor unduly distended.the
rupture of the uterus occurs during labour,& and the uterus is smaller than it should be.
Abruptio placenta.was formely known as accidental haemorrhage until De Lee
suggested the term abruptio placenta and Holmes.suggested the term ablatio placenta.
17. C - This child should be treated with corticosteroid as with asthma patient, identifying
triggers, patient education, and close monitoring are important. Rescue medication
should be treated as needed. Long term study have not shown adrenal or growth
suppression with inhaled corticosteroid. The national and asthma education prevention
program examined studies using inhaled corticosteroid early in the course of asthma to
attempt to decrease the progression of the disease. Initial studies in children establised
the safety and effectiveness in establishing that inhaled steroid changed the disease
progression.
18. E - Transposition of great arteries. The baby clinically has cyanotic congenital heart
disease. The key features are deep cyanosis w/out major resp distress , indicative of a
physiological right-to-left shunt. So, the most likely diagnosis is TGA UNTIL the patent
ductus closes there maybe no symptoms or signs but as the pulmonary systemic
connection reaches critical point , cyanosis becomes overt. TOF, pulm atresia, tricuspid
atresia,anomalous pulm venous drainage and truncus arteriousus all will give rise to
similar pic but are much less common. A VSD is unlikely to cause symptoms at this age
and would manifest a heart failure without cyanosis . Persistent fetal circulation and
diaphragmatic hernias present as much 'sicker' baby who has more severe respiratory
signs and within the first few hours, if not sooner.
19. D - According to 2001 consensus guidelines, pt with LSIL should have colposcopy
because 15 to 30% risks will have biops-confirmed CIN 2 or 3. Our guideline also state
the same - for colposcopy. LLETZ or cryotherapy not appropriate without confirmation
of disease via colposcopy. HPV DNA typing not useful in pt with LSIL because 83% of
them are positive for high risk types. Repeating 4 to 6 months not recommended
because of the small but real risk of delaying diagnosis of invasive disease.
20. A - Menorrhagia and anemia is relative contraindications for copper IUCD. The rest are
absolute contraindications. However, mirena IUCD is use in d situation of Menorrhagia
because it reduce menorrhagia.
21. D - Copper IUCD does not significantly affect menstrual flow or pain in most patients.
However it does create a sterile inflammatory reaction in the uterus which may
exacerbate bleeding and pain in patient who suffer from significant menorrhagia or
dysmenorrhoea. Copper IUCD decreases the risk of ectopic pregnancy as long as it
remains properly inserted. Copper IUCD provide up to 10 years of highly effective
contraception with rapid return to fertility after removal. It does not interfere with
breastmilk and may be inserted immediately postpartum or post abortion.
Copper IUCD can be inserted at any time during their menses as long as pregnancy
been ruled out.
22. D - A vacuum can be placed in case of some malpositions, such as occiput posterior,
however, it cannot be utilized for a malpresentation eg breech. After a prolonged
second stage of labor, if AVD is necessary, it is always important to consider and
prepare for shoulder dystocia. The bladder must be empty prior AVD(assisted vaginal
delivery), but there is no reason for an indwelling catheter to be placed. In fact, it takes
up room under pubic arch. Vacuum deliveries carry a higher risk of cephalohematomas
while forceps carry a higher risk of maternal trauma. Both of vacuum and forceps need
the cervix completely dilated.
23. C - Intussusception is the most common cause for intestinal obstruction in children
under the age of 6 years. 60% are less than 12 months of age and 80% are less than 2
years of age. Obstruction occurs due to telescoping of the intestine upon itself and
trapping a segment of intestine within ad adjacent segment. 80% occurs at ileo-cecal
junction. The pressure on the trapped segment can cause vascular compromise,
oedema of the intestinal wall and in many instances there is some associated blood
loss. Characteristically, the blood is mixed with mucous giving the appearance of redcurrant jelly stools. The clinical picture of along with obstruction on abdominal
radiographs should prompt consideration of intussusception as a possible diagnosis.
Barium enema is not only confirm the diagnosis but may be curative in up to 80% of
cases. Surgery is necessary for those not successfully reduced by barium enema. The
other choices listed will lead to delay in appropriate treatment and increase the chance
of the patient needing surgical intervention. Untreated intussusception is fatal.
24. A
25. D - FOB test is generally only of value if there is suspected gastrointestinal blood loss or
unexplained anemia. There is a high false positive rate and in the absence of symptom
or signs investigations will have a very low yield.
26. A - The answer is A. Risk 1 in 1000 is considered low so not indicated for invasive
diagnostic investigation.
27. E - The clinical suspicion in this case is vesicoureteral reflux,which is best demonstrated
by filling the bladder with dye and doing fluoroscopy while the child voids. Cystoscopy
(choice A) as a rule is not indicated for the workup of suspected reflux.It might be
needed to further define abnormal anatomy, for instance, an ectopic ureter.It is not,
however,the best initial choice for this question. Intravenous pyelogram (choice B) or
ultrasound (choice C) can demonstrate the presence of dilation of the urinary
tract,which might have been produced by vesicoureteral reflux. The reflux
itself,however,is best demonstrated with the voiding cystourethrogram. Because it is so
safe, ultrasound often is used to begin urologic workups in children. Had the question
asked for the standard next step in management, ultrasound might have been a
reasonable
answer.Retrograde
urethrogram
(choice D) is used to evaluate urethral injuries in male patients with pelvic fracture and
blood at the meatus.
28. D,5 - Another differential is Adenovirus which we went on to treat.
You would find the white cell jumping high with raised CPK, AST, ALT and another
investigation is LDH. CXR as you all said would show interstitial pneumonia due to
alveoli breakdown. Mycoplasma is known to have systemic complications such as ARF,
liver failure Etc.
29. A
30. B - Raised level of HbA1C does not predict other complication.
31. C - Risk factor; STD (sexually active women), recurrent UTI, DM. Common causes gram
negative from Intestinal tract; E.Coli, Klebsiella, Stapphyloccus saphrophyticus, proteus,
pseudomonas, enterobacter. Management; complicated and uncomplicated UTI.
1st line; as what mentioned sulfur drug.Sent Urine for C&S (clean catch sample) and
treat accordingly.
32. B - Usually antibiotic of choice is cloxa (suspected organism staph)..erythromycin or first
generation cephalosporins may also be used if pt is penicillin allergic.
33. B - Silent MI, although more likely to occur in diabetics, does not carry a worse
prognosis because of that characteristic; however, an MI suffered in a diabetic appears
more likely to result in sudden death, with or without symptoms. Deep Q waves in leads
II, III, and AVF are characteristic of posterior or inferior MI, and
during the acute phase, an ST elevation is likely to be seen in those same leads. In the
acute phase, inferior MI is more likely to present with epigastria pain and even pain that
mimics “heartburn” than with the classic squeezing or pressing chest pain that radiates
into the left neck or left arm.
34. B - Iron deficiency anaemia is the most common nutritional deficiency in children
between 9-15months. Low availability of dietary iron, impaired absorption of iron
related frequent infections, high requirements for iron for growth and occasionally blood
losses, favour the development of iron deficiency in infants. a history regarding anaemia
in the family, blood loss and gestational age and weight can help to establish the cause
of an anaemia. The strong likelihood is that anaemia in a 1 year-old child is nutritional
in origin and its cause will be suggested by a detailed nutritional history.
35. D - Wenckebach,or Mobitz type 1 second degree heart block, is characterized on ECG by
progressive lengthening PR interval until there is a nonconducted P wave. The
magnitude of PR lengthening declines with each beat,so the RR interval
characteristically shorten prior to the dropped beat. It is almost always caused by
abnormal conduction across the AV node,the QRS COMPLEX is usually of normal
duration.
36. D - This is because in CKD, the ideal SBP - between 120-130/80-90. If the BP is lowered
down further, risk of developing CV events is higher. Or even more harmful.
All of these explanation are in Malaysian CKD CPG guideline.
37. A - NICE recommendations are first to classify the level of this lady's obesity. This can
easily be achieved by looking at the tables in the NICE quick-reference guide on obesity.
Her waist circumference is very high (> 88 cm) and, in the absence of co-morbidities,
we can see that the initial management should be diet and exercise with consideration
of drug treatment which should be discussed.
38. D - Most pacemakers either sense and pace in the ventricles, or sense and pace in both
chambers to allow synchronized cardiac contraction. The demand is level-sensed,
below which the pacemaker will cut in. The pacing spike is only seen when the
pacemaker cuts in, however it is determined by haemodynamic state; this is
determined by the 'demand' which would definitely be above the current 46 beats per
minute that Mr Aaron is experiencing. Driving restriction is indeed for 1 week after
pacemaker insertion, however Mr Aaron has also has MI so he must refrain from
driving for at least 4 weeks.
39. D
40. E - THIS MAN HAS A NARROW COMPLEX OR SVT. Although vagal manoeuvres are
often the first option, followed by adenosine, he is decompensating and fast becoming
unconscious. Furthermore adenosine can precipitate bronchoconstriction and would be
contraindicated in an asthmatic. Electrolyte disturbance can cause SvTs, and this is
important to investigate this at the earliest suitable opportunity, but the immediate
priority is to stabilise the patient. The best and quickest option for this man is therefore
DC cardioversion.