{"T1": {"n": 1, "t": "Internal Medicine I", "d": "Sep 18 2026", "q": [{"n": 1, "s": "A 29-year-old man with hypertrophic cardiomyopathy and prior resuscitated cardiac arrest is on guideline therapy. What should be implanted?", "o": [["A", "Implantable loop recorder only"], ["B", "Implantable cardioverter-defibrillator"], ["C", "Dual-chamber pacemaker alone"], ["D", "Ranolazine"]], "c": ["B)", "Implantable cardioverter-defibrillator"], "co": "HCM with survived SCD/VT: secondary-prevention ICD", "ct": "Interpretation", "w": "Survived cardiac arrest due to VT/VF tachycardia/fibrillation, or spontaneous sustained VT, is the strongest trigger for secondary-prevention ICD in HCM.", "d": "Resuscitated SCD in HCM is a class I secondary-prevention ICD indication", "t": "Device-selection trap — ICD vs loop recorder", "f": "HCM + survived arrest/VT → ICD, no matter what medical therapy is on board.", "r": "HCM survivors of SCD receive secondary-prevention ICD; asymptomatic low-risk patients need no device.", "x": [["A) Implantable loop recorder only", "Implanted-record therapy documents rhythm risk instead of treating a survivor who has already manifested lethal arrhythmia."], ["C) Dual-chamber pacemaker alone", "A pacemaker treats bradyarrhythmias; it does not defibrillate VT/VF."], ["D) Ranolazine", "No drug therapy (including betablockers) obviates the ICD indication after survived arrest."]]}, {"n": 2, "s": "A 52-year-old woman on dialysis presents with hypotension, muffled heart sounds and distended neck veins. Echo shows a large circumferential pericardial effusion with right-atrial and right-ventricular diastolic collapse. Immediate treatment?", "o": [["A", "Increase ultrafiltration"], ["B", "Emergency pericardiocentesis"], ["C", "High-dose NSAIDs and colchicine"], ["D", "Pericardiectomy"]], "c": ["B)", "Emergency pericardiocentesis"], "co": "Tamponade physiology with RA/RV diastolic collapse = decompress now", "ct": "Interpretation", "w": "Diastolic collapse of RA then RV with clinical hypotension defines tamponade requiring urgent pericardiocentesis; fluid removal via ultrafiltration could make things catastrophically worse by further reducing preload across compressed cardiac chambers.", "d": "Hypotension + tachycardia + RA/RV diastolic collapse = tamponade; drainage to decompress is the treatment", "t": "Sequence trap — treating tamponade with dehydration rather than decompression", "f": "Tamponade clue triad: hypotension + muffled sounds + JVP-raised with pulsus paradoxus; echo RA/RV diastolic collapse.", "r": "Tamponade physiology: emergent pericardiocentesis; send fluid for analysis (infective, malignant, uraemic).", "x": [["A) Increase ultrafiltration", "Ultrafiltration removes intravascular volume and worsens filling pressure across a compressed heart."], ["C) High-dose NSAIDs and colchicine", "Anti-inflammatory therapy addresses uraemic/w drug-refractory recurrent pericarditis, not acute haemodynamic collapse."], ["D) Pericardiectomy", "Pericardiectomy is surgical management of constrictive pericarditis, not acute tamponade."]]}, {"n": 3, "s": "A 78-year-old woman with syncope has HR 35/min, cananonical carotid pulsations, and wide-complex escape QRS. Atropine gives no sustained improvement. Best next step?", "o": [["A", "Continue atropine infusion"], ["B", "Temporary transvenous pacing"], ["C", "Adrenaline infusion"], ["D", "Discharge with holter"]], "c": ["B)", "Temporary transvenous pacing"], "co": "Symptomatic complete heart block with wide escape → temporise with pacing", "ct": "Interpretation", "w": "Complete heart block with a wideinfra-His escapee responded poorly to atropine — the standard is temporary transvenous pacing with a plan for definitive permanent pacemaker.", "d": "Wide escape QRS is unstable/I non-reliable; atropine is unreliable in infra-His block", "t": "Next-step trap — repeating atropine in infra-nodal block", "f": "Complete heart block + wide escape + syncope → temporary then permanent pacing.", "r": "Symptomatic high-grade/complete AV block at or below the His requires temporary pacing; atropine is for-t nodal blocks only.", "x": [["A) Continue atropine infusion", "It already failed; repetition amounts to waiting for asystole."], ["C) Adrenaline infusion", "Adrenaline is a bridge when pacing is unavailable, not a substitute when pacing is accessible."], ["D) Discharge with holter", "Sent-home-on-monitor neglect is what kills these patients within days."]]}, {"n": 4, "s": "A 55-year-old man with long-standing uncontrolled hypertension develops exertional dyspnoea and orthopnoea. Echo: EF 30%, global hypokinesis, no regional wall-motion abnormality, no CAD on CT angiogram. Most likely cause of his heart failure?", "o": [["A", "Hypertensive heart disease with dilated (non-ischaemic) cardiomyopathy"], ["B", "Ischaemic cardiomyopathy requiring revascularisation"], ["C", "restrictive cardiomyopathy from amyloid"], ["D", "Valve stenosis"]], "c": ["A)", "Hypertensive heart disease with dilated (non-ischaemic) cardiomyopathy"], "co": "Dilated (non-ischaemic) cardiomyopathy from chronic hypertension", "ct": "Interpretation", "w": "Chronic hypertension drives a hypertensive heart-disease course through diastolic dysfunction, fibrosis and final dilated hypokinetic state (EF 30%) without infarct-pattern regional defects or obstructive coronary disease.", "d": "Unified global hypokinesis + absence of regional wall-motion defects/ CAD = non-ischaemic dilated cardiomyopathy", "t": "Clinical Mimic — dilated vs ischaemic cardiomyopathy", "f": "Global hypokinesis without coronary disease/scars = DCM (hypertensive/idiopathic); GDMT + reverse-remodelling potential.", "r": "Non-ischaemic DCM: global systolic dilated heart without coronary territories/infarction pattern; manage with quadruple GDMT ± device (ICD if EF ≤35% sustained).", "x": [["B) Ischaemic cardiomyopathy requiring revascularisation", "Ischaemic cardiomyopathy would show regional/ territory-dependent wall-motion defects or occlusive disease."], ["C) restrictive cardiomyopathy from amyloid", "Amyloid gives thick walls with granular speckling, EF preserved until late, often concomitant conduction disease."], ["D) Valve stenosis", "Valvular stenosis produces corresponding valvular obstruction patterns on echo/ auscultation, absent here."]]}, {"n": 5, "s": "A 62-year-old man with DVT confirmed on ultrasound, Wells score 3 (active cancer, calf swelling, tenderness along deep veins). What is the next step?", "o": [["A", "D-dimer to rule out DVT"], ["B", "Start therapeutic anticoagulation — no further testing needed"], ["C", "Venous duplex after 1 week"], ["D", "Thrombolysis"]], "c": ["B)", "Start therapeutic anticoagulation — no further testing needed"], "co": "High-pretest-probability DVT: anticoagulate pending/following imaging without D-dimer", "ct": "Analysis/Synthesis", "w": "With high pretest probability, D-dimer is not done (it can be false-positive anyway and ''); in addition to the already positive ultrasound, therapeutic anticoagulation begins immediately, typically DOAC or LMWH (in cancer, LMWH preferred at diagnosis).", "d": "High Wells score (≥2–3): D-dimer unnecessary; anticoagulation started while awaiting/ following sonography", "t": "Test-selection trap — D-dimer in high-probability patients", "f": "Wells high (≥2–3) + positive US → start anticoagulation now; D-dimer only for low/safe-to-rule-out patients.", "r": "High pretest DVT → ultrasound; positive → immediate therapeutic anticoagulation (DOAC or LMWH; cancer = LMWH preferred initially); no D-dimer needed once probability is high.", "x": [["A) D-dimer to rule out DVT", "D-dimer adds nothing now; the ultrasound is already diagnostic and anticoagulation is urgent."], ["C) Venous duplex after 1 week", "Week-delay doubles embolic risk; anticoagulation cannot wait for convenience."], ["D) Thrombolysis", "Thrombolysis is reserved for limb-threatening phlegmasia or massive PE, not uncomplicated calf/thigh DVT."]]}, {"n": 6, "s": "A 49-year-old is prepped for dental extraction; history includes a mechanical mitral valve replacement 6 years ago. What prophylaxis is recommended pre-procedure?", "o": [["A", "No prophylaxis — routine dental care"], ["B", "Amoxicillin 2 g orally 30–60 min before the procedure"], ["C", "Gentamicin IM before the procedure"], ["D", "Oral vancomycin"]], "c": ["B)", "Amoxicillin 2 g orally 30–60 min before the procedure"], "co": "Endocarditis prophylaxis: prosthetic valve + dental procedure = amoxicillin", "ct": "Recall", "w": "Prosthetic valve patients undergoing dental procedures with gum/periapical manipulation receive amoxicillin 2 g (clindamycin if penicillin-allergic/cephalexin/azithro) 30–60 mins pre-procedure; most other cardiac conditions no longer need prophylaxis.", "d": "High-risk cardiac conditions (prosthetic valve, prior IE, certain CHD) + dental procedures manipulating gingiva = antibiotic prophylaxis", "t": "Over/under-prophylaxis trap", "f": "Dental prophylaxis only for prosthetic valve, previous IE, some unrepaired cyanotic CHD/transplant valvulopathy — amoxicillin 2 g.", "r": "Prophylaxis indications: prosthetic valves/materials, prior IE, unrepaired cyanotic CHD/repaired with residual, valve regurgitation post-transplant; amoxicillin 2 g PO (or cefazolin IM/IV or clindamycin if allergic) 30–60 min before manipulation.", "x": [["A) No prophylaxis — routine dental care", "Prosthetic valves are explicitlytargeted for dental prophylaxis due to life-threatening IE potential."], ["C) Gentamicin IM before the procedure", "Aminoglycosides are not prophylaxis agents for dental work."], ["D) Oral vancomycin", "Oral vancomycin does not generate systemic levels and is not used in prophylaxis."]]}, {"n": 7, "s": "A 58-year-old man presents with 40 minutes of crushing chest pain and diaphoresis. ECG shows a new left bundle branch block with concordant ST-segment elevation in V5-V6. Troponin is pending. What is the immediate management?", "o": [["A", "Wait for troponin before deciding"], ["B", "Reperfusion therapy as an acute coronary occlusion"], ["C", "Discharge with outpatient echocardiogram"], ["D", "Start a calcium channel blocker and observe"]], "c": ["B)", "Reperfusion therapy as an acute coronary occlusion"], "co": "New LBBB with Sgarbossa-concordant changes is treated as STEMI", "ct": "Interpretation", "w": "Sgarbossa-concordant ST changes in a new LBBB are highly specific for acute coronary occlusion, so the patient is managed as STEMI with immediate reperfusion rather than waiting for troponin.", "d": "New LBBB + concordant ST changes = occlusive MI until proven otherwise; troponin waits never", "t": "Next-step trap — waiting for biomarkers in an occlusion pattern", "f": "New LBBB with concordant ST elevation = STEMI-equivalent; activate reperfusion.", "r": "New/presumed-new LBBB with Sgarbossa concordance is managed as STEMI with urgent reperfusion.", "x": [["A) Wait for troponin before deciding", "Biomarkers confirm necrosis but reperfusion decisions are made on the ECG; delay costs myocardium."], ["C) Discharge with outpatient echocardiogram", "An occlusion pattern with ongoing symptoms needs reperfusion, not outpatient workup."], ["D) Start a calcium channel blocker and observe", "Rate/rhythm control drugs do not address the occluded artery."]]}, {"n": 8, "s": "A 55-year-old diabetic man 3 days after inferior MI develops a new harsh pansystolic murmur at the left sternal border with worsening hypotension. Echocardiography shows a step-up in oxygen saturation from right atrium to right ventricle. What has occurred?", "o": [["A", "Papillary muscle infarction with severe MR"], ["B", "Ventricular septal rupture"], ["C", "RV infarction extension"], ["D", "Dressler pericarditis"]], "c": ["B)", "Ventricular septal rupture"], "co": "Post-MI VSD — pulmonary step-up confirms left-to-right shunt", "ct": "Interpretation", "w": "A new left-to-right shunt rising oxygen saturation across the ventricular septum confirms ventricular septal rupture, a mechanical complication typically 2–5 days post-MI.", "d": "O2 step-up RA→RV + harsh LSB murmur post-MI = septal rupture", "t": "Distractor pairing — VSD vs papillary muscle rupture (both post-MI murmurs)", "f": "New harsh murmur + O2 step-up RA→RV post-MI = VSR; MR lacks the step-up.", "r": "Ventricular septal rupture post-MI: harsh left sternal border murmur, PA step-up on saturation run; surgical repair after stabilization.", "x": [["A) Papillary muscle infarction with severe MR", "Papillary muscle rupture gives severe MR with a murmur maximal at the apex radiating to axilla and no oxygen step-up."], ["C) RV infarction extension", "RV extension causes hypotension with clear lungs, not a new pansystolic murmur or shunt."], ["D) Dressler pericarditis", "Pump failure produces congestion without a new murmur or saturation step-up."]]}, {"n": 9, "s": "A 68-year-old man on verapamil presents dizzy with HR 38 and BP 95/60; no prior conduction disease documented; potassium 4.1, creatinine 0.9. What is the immediate therapy approach?", "o": [["A", "Calcium salts + glucagon bridge & temporary pacing input where unresponsive, stopping verapamil"], ["B", "Adrenaline bolus and discharge"], ["C", "Fludrocortisone"], ["D", "Oral potassium"]], "c": ["A)", "Calcium salts + glucagon bridge & temporary pacing input where unresponsive, stopping verapamil"], "co": "Calcium-channel-blocker overdose: calcium + glucagon + pacing", "ct": "Analysis/Synthesis", "w": "CCB toxicity/ idiosyncratic response manifests as profound bradycardia/ vasodilation; management combines IV calcium gluconate (supports excitation-contraction coupling), glucagon (increases cAMP bypass), high-dose insulin-euglycemia therapy in true overdose and temporary transvenous pacing when rhythms gear down; the offending calcium-channel blocker must be stopped.", "d": "Bradycardia + hypotension from verapamil: give calcium salts, consider glucagon and, if unresponsive, temporary pacing — drug discontinued", "t": "Next-step trap — mis-locating the fault", "f": "Bradycardia + hypotension on verapamil: calcium + consider glucagon/HIE + pacing; hold the CCB; reconsider permanent beta-blo/ CCB-naïve regimens.", "r": "Verapamil-induced bradycardia: calcium chloride/gluconate first, glucagon/insulin-euglycaemia in true toxicity, transvenous pacing if unresponsive; discontinue culprit drug.", "x": [["B) Adrenaline bolus and discharge", "Adrenaline is a short-lived bridge, not a definitive response; potential immediate pacing/calcium is more directed."], ["C) Fludrocortisone", "Fludrocortisone manages neurogenic orthostatic hypotension, not drug-induced heart block."], ["D) Oral potassium", "Potassium is normal; measuring potassium replacement doesn't treat an AV-nodal drug effect."]]}, {"n": 10, "s": "A 55-year-old woman post-hip surgery suddenly becomes hypotensive (BP 82/60) with sharp pleuritic chest pain, HR 128, SpO2 86% on room air; CTPA confirms central saddle pulmonary embolism with RV strain. Immediate treatment?", "o": [["A", "Therapeutic anticoagulation and monitor"], ["B", "Systemic thrombolysis"], ["C", "Aspirin"], ["D", "Inferior vena cava filter only"]], "c": ["B)", "Systemic thrombolysis"], "co": "Massive (high-risk) PE → reperfusion (lysis) not anticoagulation alone", "ct": "Analysis/Synthesis", "w": "Hypotension (SBP <90 mmHg for >15 min or requiring support) with confirmed central PE and RV dysfunction categorises high-risk PE where systemic thrombolysis (alteplase 100 mg over 2h) is the standard to relieve RV collapse, followed by anticoagulation.", "d": "Hypotension (SBP <90) + central PE + RV strain = high-risk PE; thrombolysis restores flow fastest", "t": "Severity-classification trap — low-risk vs high-risk PE management", "f": "High-risk PE (hypotension + RV strain): systemic lysis first, then anticoagulate; stable PE = anticoagulation alone.", "r": "Massive/high-risk PE: systemic thrombolysis (or surgical/percutaneous embolectomy if contraindicated); standard PE without hypotension anticoagulation only.", "x": [["A) Therapeutic anticoagulation and monitor", "Anticoagulation prevents clot extension but does not clear obstructing thrombus in time to rescue a failing right ventricle."], ["C) Aspirin", "Aspirin has no role in acute PE treatment."], ["D) Inferior vena cava filter only", "IVC filters are for anticoagulation-contraindicated or recurrent-embolism patients — a substitute, not a reperfusion strategy."]]}, {"n": 11, "s": "A 50-year-old farmer with excessive salivation, miosis, abdominal cramping and fasciculations after spraying crops; BP 160/90, HR 48. Diagnosis and antidote?", "o": [["A", "Organophosphate poisoning — atropine (signs) ± pralidoxime"], ["B", "Carbamate with contraindicated atropine"], ["C", "Pyrethroid poisoning — decontamination only"], ["D", "Warfarin rodenticide — vitamin K"]], "c": ["A)", "Organophosphate poisoning — atropine (signs) ± pralidoxime"], "co": "Organophosphate toxidrome: SLUDGE + fasciculations → atropine + pralidoxime", "ct": "Interpretation", "w": "Combined muscarinic (salivation, miosis, cramps, brady/hypertension variation) and nicotinic (fasciculations) signs after pesticide exposure confirms organophosphate/ carbamate cholinesterase inhibition; high-dose atropine targets muscarinic load and pralidoxime reactivates acetylcholinesterase when given early.", "d": "Cholinergic muscarinic excess (salivation, miosis, cramps) + nicotinic fasciculations in crop sprayer = organophosphate", "t": "Toxidrome matching trap", "f": "SLUDGE + fasciculations in pesticide exposure = organophosphate; atropine + pralidoxime.", "r": "Organophosphate poisoning: decontaminate, atropine until drying secretions/adequate oxygenation, pralidoxime early (2-PAM), benzodiazepines for seizures.", "x": [["B) Carbamate with contraindicated atropine", "Atropine remains indicated (and life-prolonging) even in carbamate cases; withholding it is dangerous."], ["C) Pyrethroid poisoning — decontamination only", "Pyrethroids give paresthesia and occasional tremor — not the full cholinergic toxidrome."], ["D) Warfarin rodenticide — vitamin K", "Warfarin rodenticides bleed, with no cholinergic features."]]}, {"n": 12, "s": "A 21-year-old athlete collapses and dies during a football match. Autopsy reveals asymmetric septal hypertrophy. Which of his first-degree relatives is at greatest risk of the same condition and should undergo what screening?", "o": [["A", "All first-degree relatives — clinical exam + echocardiogram ± ECG screening"], ["B", "Only symptomatic relatives"], ["C", "Female relatives only because of transmission pattern"], ["D", "No screening needed as disease is not inherited"]], "c": ["A)", "All first-degree relatives — clinical exam + echocardiogram ± ECG screening"], "co": "HCM: autosomal dominant; cascade screening of first-degree relatives", "ct": "Analysis/Synthesis", "w": "Hypertrophic cardiomyopathy is the commonest cause of sudden cardiac death in young athletes and inherited in ~50–60% as autosomal dominant; first-degree relatives need clinical-exam + 12-lead ECG + echocardiographic screening (adults every 2–5 years, children puberty age-periodically).", "d": "HCM is AD with incomplete penetrance; SCD in athlete points to family cascade screening pooled echo+ECG", "t": "Screening-interval trap — 'who and how' of inherited cardiac disease", "f": "Any HCM diagnosis or HCM sudden death triggers first-degree-family cascade screening.", "r": "HCM family screening: first-degree relatives, clinical exam + ECG + echocardiography, repeated periodically since penetrance is age-dependent.", "x": [["B) Only symptomatic relatives", "HCM often stays silent until the fatal event; 'no symptoms' never rules a family member out."], ["C) Female relatives only because of transmission pattern", "Autosomal-dominant inheritance passes through both sexes equally."], ["D) No screening needed as disease is not inherited", "HCM is among the most heritable cardiac muscle-disease patterns known."]]}, {"n": 13, "s": "A 71-year-old man with hypertension and diabetes has paroxysmal atrial fibrillation on Holter. CHA2DS2-VASc score is 2 (hypertension + diabetes, no stroke, age <75, male). What is indicated?", "o": [["A", "Aspirin alone"], ["B", "No antithrombotic therapy"], ["C", "Oral anticoagulation"], ["D", "Aspirin plus clopidogrel"]], "c": ["C)", "Oral anticoagulation"], "co": "CHA2DS2-VASc ≥2 (male) → anticoagulate, even for paroxysmal AF", "ct": "Interpretation", "w": "With a score of 2 in a male patient, guideline-level risk is high enough that oral anticoagulation (DOAC preferred) is recommended; paroxysmal pattern does not lower the threshold, and aspirin is no longer an acceptable substitute.", "d": "Paroxysmal AF carries the same stroke risk as persistent; score ≥2 in a man mandates anticoagulation", "t": "Class misconception — aspirin replacing anticoagulation in AF", "f": "AF stroke prevention: oral anticoagulation per CHA2DS2-VASc; aspirin is not anticoagulation.", "r": "Male CHA2DS2-VASc ≥2 or female ≥3: oral anticoagulation indicated regardless of AF pattern.", "x": [["A) Aspirin alone", "Aspirin's stroke prevention in AF is inadequate and combined major-bleed risk rivals anticoagulation without equivalent efficacy."], ["B) No antithrombotic therapy", "With a score of 2, active stroke risk exceeds bleeding risk; withholding therapy is wrong."], ["D) Aspirin plus clopidogrel", "Dual antiplatelet therapy is for acute coronary syndromes/stents, never stroke prevention in AF."]]}, {"n": 14, "s": "A 58-year-old man on atorvastatin 40 mg develops significant myalgias at week 3; CK 3.5x ULN, no dark urine, renal function normal. What is the appropriate next step?", "o": [["A", "Stop statin permanently; no rechallenge ever"], ["B", "Pause statin, resume at reduced dose/ alternate statin after symptoms settle, aiming to retain some statin therapy"], ["C", "Add niacin"], ["D", "Continue the same dose and ignore"]], "c": ["B)", "Pause statin, resume at reduced dose/ alternate statin after symptoms settle, aiming to retain some statin therapy"], "co": "Statin myalgia: pause, dechallenge, rechallenging with lower dose/ different statin", "ct": "Analysis/Synthesis", "w": "Statin-associated muscle symptoms with CK 3–4x ULN warrant temporary discontinuation; after symptoms resolve, rechallenge at lower dose/ hydrophilic alternative (rosuvastatin, pravastatin) or alternate-day rosuvastatin maintains LDL benefit at tolerable exposure.", "d": "CK >4x ULN with symptoms → stop, dechallenge; CK <10 ULN no rhabdomyolysis; resumption at reduced dose/ alternative statin to retain protection", "t": "Class trap — Statin permanent disqualification fallacy", "f": "Statin myopathy CK >4x ULN: stop, dechallenge, low-dose/ alternate-day rechallenge to keep LDL control.", "r": "Statin muscle symptoms + CK >4x ULN: discontinue statin; rechallenge with lower dose, alternate statin, or alternate-day dosing; once CK >10x or rhabdo, do not resume.", "x": [["A) Stop statin permanently; no rechallenge ever", "Most statin-intolerant patients tolerate other statins at lower/ alternate doses; abandonment forfeits major mortality benefit."], ["C) Add niacin", "Niacin is not a substitute lipid-lowering here."], ["D) Continue the same dose and ignore", "Persevering on the same dose at CK 3.5x ULN with symptoms can tip into rhabdomyolysis."]]}, {"n": 15, "s": "A 24-year-old man develops pleuritic chest pain after a viral illness. ECG: diffuse concave ST elevation; echocardiogram normal. What therapy reduces recurrence risk best?", "o": [["A", "Colchicine added to NSAID therapy"], ["B", "High-dose corticosteroids first-line"], ["C", "Aspirin alone forever"], ["D", "Percutaneous pericardiectomy"]], "c": ["A)", "Colchicine added to NSAID therapy"], "co": "Acute pericarditis: NSAID + colchicine lowers recurrence", "ct": "Recall", "w": "Acute pericarditis is treated with NSAID (aspirin/ibuprofen/indomethacin) plus colchicine for 3 months, which both speeds resolution and substantially cuts recurrence; steroids are reserved for recurrences or connective-tissue/ uraemic/perinatal neoplastic causes.", "d": "Diffuse concave ST elevation + pleuritic pain = acute pericarditis; colchicine halves recurrence", "t": "Class trap — steroid-first reflex in pericarditis", "f": "Acute pericarditis: NSAID + colchicine 3 months; steroids only specialist-justified.", "r": "First-line acute pericarditis: NSAID or aspirin + colchicine (3 months); restrict exercise until CRP normalises.", "x": [["B) High-dose corticosteroids first-line", "Corticosteroids first-line increase recurrence risk in idiopathic/ viral pericarditis."], ["C) Aspirin alone forever", "NSAID/aspirin-only courses do not cut recurrence; colchicine does."], ["D) Percutaneous pericardiectomy", "Pericardiectomy is for constrictive disease, not acute self-pericardial inflammation."]]}, {"n": 16, "s": "A 45-year-old man with heterozygous familial hypercholesterolaemia (LDL 8.2 mmol/L) has no known ASCVD. What is the intensity of lipid management?", "o": [["A", "High-intensity statin ± ezetimibe, target LDL <1.4–1.8 mmol/L if achievable"], ["B", "Diet and exercise alone first, review in 2 years"], ["C", "Niacin"], ["D", "Bile-acid sequestrants monotherapy"]], "c": ["A)", "High-intensity statin ± ezetimibe, target LDL <1.4–1.8 mmol/L if achievable"], "co": "HeFH: high-intensity statin early; combo therapy to reach LDL goals", "ct": "Interpretation", "w": "Familial hypercholesterolaemia carries lifelong extreme LDL burden; management is high-intensity statin (atorvastatin 40–80, rosuvastatin 20–40) from early adulthood with ezetimibe ± PCSK9 inhibitor to reach LDL <1.4 mmol/L (ESC) or <1.8 (varies by region).", "d": "HeFH (LDL >4.9 mmol/L baseline, tendon xanthomas, family history) = lifelong high-intensity therapy from young age", "t": "Class trap — undertreating inherited hyperlipidaemia", "f": "LDL >4.9 mmol/L with tendon xanthomas / family cluster = FH; high-intensity statin now, add-on if needed.", "r": "HeFH: high-intensity statin immediately, add ezetimibe then PCSK9i as needed; aim LDL <1.4–1.8 mmol/L depending on risk.", "x": [["B) Diet and exercise alone first, review in 2 years", "Two-year lifestyle-only wait abandons a genetically-determined high-risk patient mid-stream; risk accrues from teenage LDL exposure."], ["C) Niacin", "Niacin has fallen out of standard use with unfavourable outcome data and tolerability."], ["D) Bile-acid sequestrants monotherapy", "Sequestrants alone neither achieve targets nor match statin outcome-evidence and are GI-intolerable long-term."]]}, {"n": 17, "s": "A 62-year-old woman is admitted with chest pain and transient ST depression in V4-V6. Troponin rises to 3x the 99th percentile. She continues to have pain despite optimal medical therapy. What is the next step?", "o": [["A", "Discharge after 48 hours of medical therapy"], ["B", "Coronary angiography within 24 hours"], ["C", "Treadmill exercise test before discharge"], ["D", "Repeat troponin in 12 hours"]], "c": ["B)", "Coronary angiography within 24 hours"], "co": "High-risk NSTEMI refractory to therapy needs angiography within 24 hours", "ct": "Interpretation", "w": "Refractory chest pain with dynamic ST changes and elevated troponin places her at very high risk, mandating early invasive angiography within 24 hours.", "d": "Recurrent ischaemia despite therapy = very-high-risk pathway, not discharge-and-watch", "t": "Next-step trap — under-triaging refractory NSTEMI", "f": "Recurrent ischaemia + rising troponin = angiography within 24 hours.", "r": "NSTEMI refractory to medical therapy or with dynamic changes should undergo coronary angiography within 24 hours.", "x": [["A) Discharge after 48 hours of medical therapy", "Continued pain on therapy definesfailure of the conservative pathway; ischaemic risk persists."], ["C) Treadmill exercise test before discharge", "Stress testing is for low-risk chest pain after ischaemia is stabilized, not during refractory NSTEMI."], ["D) Repeat troponin in 12 hours", "Serial troponins classify risk but do not treat ongoing ischaemia."]]}, {"n": 18, "s": "A 31-year-old woman has fasting triglycerides 14 mmol/L with a clearing-cream serum sample, normal ALT, and an inherited lipid profile from mother with similar pattern; no pancreatitis to date. Highest-priority intervention?", "o": [["A", "Aggressive lifestyle + fibrate; optimise glycaemic/thyroid/oestrogen factors; avoid secondary-cause triggers (alcohol)"], ["B", "High-dose statin monotherapy"], ["C", "Diet then reassess in 3 years"], ["D", "Plasma exchange weekly"]], "c": ["A)", "Aggressive lifestyle + fibrate; optimise glycaemic/thyroid/oestrogen factors; avoid secondary-cause triggers (alcohol)"], "co": "Severe hypertriglyceridaemia: pancreatitis prevention through multifactorial lowering", "ct": "Analysis/Synthesis", "w": "TG >11.3 mmol/L (set pancreatitis risk) calls for aggressive lifestyle measures (weight, carbohydrate/alcohol cut, omega-3), fibrates ± icosapent ethyl, plus removing secondary factors (glycaemia, thyroid, oestrogens, alcohol) — statins treat ASCVD risk, not TG-centred risk, and can be adjunct later.", "d": "TG >11.3 mmol/L (1000 mg/dL) — the pancreatitis danger zone — is addressed first with triglyceride-specific therapy, not statins", "t": "Priority trap — lipid-goal mismatch (TG vs LDL target)", "f": "TG >11.3 mmol/L: fibrate + lifestyle ± omega-3 targeting TG first; statin secondary.", "r": "Very high triglycerides (>11.3 mmol/L): lifestyle + fibrate ± omega-3, address secondary factors, then statin if ASCVD risk also high.", "x": [["B) High-dose statin monotherapy", "Statins modestly reduce triglycerides but at 14 mmol/L pancreatitis prevention requires TG-specific lowering."], ["C) Diet then reassess in 3 years", "A 3-year wait courts pancreatitis; the interval should be weeks-to-months with active therapy."], ["D) Plasma exchange weekly", "Plasmapheresis is an acute rescue for TG-crisis/ pancreatitis, not routine maintenance."]]}, {"n": 19, "s": "A 60-year-old man with HFrEF (EF 28%) on sacubitril-valsartan, evidence-based beta blocker and spironolactone remains in symptomatic congestion with persistent EF 26%. Which drug should be added to reduce death and hospitalisation regardless of EF?", "o": [["A", "Dapagliflozin"], ["B", "Verapamil"], ["C", "Flecainide"], ["D", "Amlodipine"]], "c": ["A)", "Dapagliflozin"], "co": "SGLT2 inhibitors reduce CV death/hospitalisation across the EF range", "ct": "Recall", "w": "SGLT2 inhibitors (dapagliflozin/empagliflozin) reduce cardiovascular death and heart failure hospitalisation in HFrEF and HFpEF and are added once a patient remains symptomatic on triple therapy.", "d": "On maximal GDMT + persistent symptoms → SGLT2 inhibitor, the only class benefiting HFrEF and HFpEF equally", "t": "Class trap — CCBs in HFrEF", "f": "Symptomatic HFrEF on triple GDMT → add SGLT2 inhibitor (quad therapy).", "r": "Quadruple therapy in HFrEF: ARNI/ACEi + beta blocker + MRA + SGLT2 inhibitor.", "x": [["B) Verapamil", "Non-dihydropyridine CCBs are negative inotropes contraindicated in HFrEF."], ["C) Flecainide", "Flecainide is contraindicated in structural heart disease."], ["D) Amlodipine", "Amlodipine may be used for angina/HTN in HF but does not reduce death or hospitalisation."]]}, {"n": 20, "s": "A 75-year-old man with exertional syncope has an ejection systolic murmur radiating to the carotids, slow-rising pulse, and echocardiographic aortic valve area 0.9 cm² with mean gradient 45 mmHg. Management?", "o": [["A", "Nitrates for symptom control and review"], ["B", "Aortic valve replacement"], ["C", "Balloon mitral valvotomy"], ["D", "Statin therapy only"]], "c": ["B)", "Aortic valve replacement"], "co": "Symptomatic severe AS → valve replacement", "ct": "Interpretation", "w": "Symptomatic severe AS (any of angina/syncope/dyspnoea, AVA <1.0 cm² with an appropriate gradient) is a class I indication for valve replacement — nitrates risk precipitate collapse, and no drug therapy relieves the mechanical obstruction.", "d": "Exertional syncope + small valve area + high gradient = symptomatic severe AS; area >0.6 and gradient >40 qualify", "t": "Clinical course trap — treating obstructive AS symptomatically", "f": "Severe AS + any symptom → valve replacement without delay.", "r": "Severe AS (AVA <1 cm², mean gradient >40 mmHg) once symptomatic → SAVR or TAVI per surgical risk.", "x": [["A) Nitrates for symptom control and review", "Nitrates can precipitate syncope in AS preload-dependent physiology; symptom relief means fixing the valve."], ["C) Balloon mitral valvotomy", "Balloon mitral valvotomy addresses rheumatic mitral stenosis, a different valve and different path."], ["D) Statin therapy only", "Statin therapy does not slow symptomatic progression in calcific AS to a clinically meaningful degree."]]}, {"n": 21, "s": "A 40-year-old woman presents with a 1-week history of severe anterior neck pain radiating to the ear, fever, and transient palpitations. The thyroid is tender and firm. She recently had a viral upper respiratory infection. What is the most likely diagnosis?", "o": [["A", "Subacute (de Quervain) thyroiditis"], ["B", "Graves disease"], ["C", "Hashimoto thyroiditis"], ["D", "Acute bacterial thyroiditis"]], "c": ["A)", "Subacute (de Quervain) thyroiditis"], "co": "Subacute thyroiditis — painful thyroid after viral illness, transient thyrotoxicosis", "ct": "Analysis/synthesis", "w": "Subacute (de Quervain) thyroiditis is a viral granulomatous thyroiditis causing a painful, tender thyroid, fever, and an initial phase of thyrotoxicosis (from follicle rupture releasing stored hormone) followed by hypothyroidism, then recovery. It is self-limited; NSAIDs/steroids relieve pain. The PAIN distinguishes it from painless Graves/Hashimoto.", "d": "PAINFUL thyroid + fever + post-viral + transient thyrotoxicosis = de Quervain (subacute) thyroiditis", "t": "Clinical Mimic — painful thyroid (de Quervain) vs painless (Graves/Hashimoto)", "f": "Painful tender thyroid + post-viral + transient thyrotoxicosis = subacute (de Quervain) thyroiditis", "r": "De Quervain (subacute) thyroiditis: painful tender thyroid + viral prodrome + transient thyrotoxicosis; NSAIDs/steroids", "x": [["B) Graves disease", "Graves causes a painless diffuse goitre with bruit, not pain/fever."], ["C) Hashimoto thyroiditis", "Hashimoto is painless with hypothyroidism, not acute pain/fever."], ["D) Acute bacterial thyroiditis", "Acute bacterial thyroiditis is rare and toxic, not self-limited post-viral."]]}, {"n": 22, "s": "A 40-year-old man is found to have asymptomatic hypercalcaemia with a normal PTH and a low urine calcium/creatinine ratio. He has a family history of 'high calcium' with no stones or fractures. What is the likely diagnosis?", "o": [["A", "Primary hyperparathyroidism"], ["B", "Malignancy (PTHrP)"], ["C", "Familial hypocalciuric hypercalcaemia (FHH)"], ["D", "Sarcoidosis"]], "c": ["C)", "Familial hypocalciuric hypercalcaemia (FHH)"], "co": "FHH — benign familial hypercalcemia with LOW urine calcium (not primary HPT)", "ct": "Interpretation", "w": "Familial hypocalciuric hypercalcaemia is an autosomal dominant (CaSR mutation) benign condition causing lifelong mild hypercalcaemia with inappropriately LOW urine calcium (low calcium/creatinine clearance ratio). Unlike primary hyperparathyroidism, it does not cause stones/bone disease and does NOT benefit from parathyroidectomy. Recognising it prevents unnecessary surgery.", "d": "Asymptomatic hypercalcemia + low urine Ca + family history + no complications = FHH (benign)", "t": "Clinical Mimic — FHH (low urine Ca, benign) vs primary HPT (high urine Ca, operative)", "f": "Asymptomatic hyperCa + LOW urine Ca + family hx = FHH (benign, no parathyroidectomy)", "r": "FHH: benign familial hypercalcemia, low urine Ca/creatinine ratio; no surgery (vs primary HPT)", "x": [["A) Primary hyperparathyroidism", "Primary HPT has high urine calcium and benefits from surgery if indicated."], ["B) Malignancy (PTHrP)", "Malignancy (PTHrP) has suppressed PTH and systemic illness, not a benign family history."], ["D) Sarcoidosis", "Sarcoidosis causes hypercalcemia via calcitriol, with respiratory/GI symptoms."]]}, {"n": 23, "s": "A 70-year-old woman with a long-standing multinodular goitre develops palpitations, weight loss, and atrial fibrillation. There is no exophthalmos. What distinguishes this from Graves disease and guides therapy?", "o": [["A", "Graves — start antithyroid drugs first"], ["B", "Thyroiditis — observe only"], ["C", "Thyroid cancer — urgent surgery"], ["D", "Toxic multinodular goitre — nodular goitre, no exophthalmos; treat with radioiodine"]], "c": ["D)", "Toxic multinodular goitre — nodular goitre, no exophthalmos; treat with radioiodine"], "co": "Toxic multinodular goitre — elderly, nodular goitre, no exophthalmos; radioiodine", "ct": "Analysis/synthesis", "w": "Toxic multinodular goitre causes thyrotoxicosis in older patients with a longstanding nodular goitre and lacks the exophthalmos and diffuseness of Graves disease (intel #60: exophthalmos = Graves). Therapy is radioiodine (or surgery); antithyroid drugs are not first-line. Recognising the absence of eye signs avoids misdiagnosing Graves.", "d": "Elderly + nodular goitre + thyrotoxicosis WITHOUT exophthalmos = toxic MNG (vs Graves)", "t": "Clinical Mimic — TMG (nodular, no exophthalmos) vs Graves (diffuse + exophthalmos)", "f": "Nodular goitre + thyrotoxicosis, no exophthalmos = toxic MNG → radioiodine (not Graves tx)", "r": "Toxic MNG: elderly + nodular goitre + thyrotoxicosis, NO exophthalmos; treat with radioiodine", "x": [["A) Graves — start antithyroid drugs first", "Graves has exophthalmos and a diffuse goitre; TMG is nodular without eye signs."], ["B) Thyroiditis — observe only", "This is thyrotoxic, not thyroiditis; observation is insufficient."], ["C) Thyroid cancer — urgent surgery", "There is no suggestion of malignancy; urgent cancer surgery is wrong."]]}, {"n": 24, "s": "A 35-year-old woman with Graves disease and proptosis develops worsening eye pain, periorbital oedema, and diplopia. She is a smoker. Which factor worsens her orbital disease and what is the mainstay of urgent treatment for severe disease?", "o": [["A", "Hypothyroidism worsens it; start thyroxine"], ["B", "Smoking worsens it; high-dose steroids / orbital decompression for severe disease"], ["C", "Radioiodine alone cures it"], ["D", "Levothyroxine suppression prevents progression"]], "c": ["B)", "Smoking worsens it; high-dose steroids / orbital decompression for severe disease"], "co": "Thyroid eye disease — smoking worsens; steroids/decompression for severe", "ct": "Interpretation", "w": "Graves orbitopathy (thyroid eye disease) causes proptosis, lid retraction, ophthalmoplegia, and in severe cases compressive optic neuropathy. Smoking is the strongest modifiable risk factor. Urgent severe disease (optic nerve compromise) needs high-dose corticosteroids and/or orbital decompression; simple measures include smoking cessation and selenium. Thyroxine alone does not treat the orbitopathy.", "d": "Graves exophthalmos + smoking + severe eye involvement = thyroid eye disease → steroids/decompression", "t": "Severity under-recognition — exophthalmos needs steroids/decompression, not just thyroxine", "f": "Graves eye disease: smoking worsens; severe = steroids + orbital decompression (thyroxine alone insufficient)", "r": "Thyroid eye disease: smoking worsens; severe (optic compression) → steroids/orbital decompression", "x": [["A) Hypothyroidism worsens it; start thyroxine", "Hypothyroidism does not drive orbitopathy; euthyroidism is the goal, not suppression."], ["C) Radioiodine alone cures it", "Radioiodine can actually transiently worsen eye disease; it does not cure it."], ["D) Levothyroxine suppression prevents progression", "Levothyroxine does not treat the inflammatory orbitopathy."]]}, {"n": 25, "s": "A 55-year-old man has recurrent episodes of confusion and diaphoresis relieved by eating, occurring fasting or post-exercise. A 72-hour fast reproduces symptoms with a low glucose, elevated insulin, and detectable C-peptide. What is the diagnosis?", "o": [["A", "Factitious hypoglycaemia (exogenous insulin)"], ["B", "Addison disease"], ["C", "Reactive postprandial hypoglycaemia"], ["D", "Insulinoma"]], "c": ["D)", "Insulinoma"], "co": "Insulinoma — endogenous hyperinsulinaemic fasting hypoglycaemia (Whipple triad)", "ct": "Analysis/synthesis", "w": "Insulinoma is a beta-cell tumour causing fasting hypoglycaemia with inappropriately HIGH insulin and C-peptide (proving endogenous secretion) — Whipple's triad (symptoms with low glucose, relieved by glucose, reproduced fasting). Factitious hypoglycaemia (exogenous insulin) shows high insulin but LOW/undetectable C-peptide. Management is surgical enucleation.", "d": "Fasting hypoglycaemia + HIGH insulin + C-peptide = insulinoma (endogenous); low C-peptide = factitious", "t": "Severity under-recognition — fasting hypoglycaemia + high insulin/C-peptide = insulinoma", "f": "Fasting hypo + high insulin + C-peptide = insulinoma; high insulin + low C-peptide = factitious", "r": "Insulinoma: fasting hypoglycaemia + inappropriately high insulin + C-peptide (Whipple triad); surgery", "x": [["A) Factitious hypoglycaemia (exogenous insulin)", "Factitious (exogenous insulin) has HIGH insulin but LOW C-peptide — opposite here."], ["B) Addison disease", "Addison causes hypoglycaemia but with low insulin and cortisol deficiency."], ["C) Reactive postprandial hypoglycaemia", "Reactive hypoglycaemia is postprandial, not fasting, and insulin would be appropriately low."]]}, {"n": 26, "s": "A newborn girl is noted to have ambiguous genitalia and, at 2 weeks, develops vomiting, dehydration, and hypotension. Serum electrolytes show hyponatraemia and hyperkalaemia. What is the most likely diagnosis?", "o": [["A", "Primary hyperaldosteronism"], ["B", "Congenital adrenal hypoplasia"], ["C", "Turner syndrome"], ["D", "Congenital adrenal hyperplasia (21-hydroxylase deficiency)"]], "c": ["D)", "Congenital adrenal hyperplasia (21-hydroxylase deficiency)"], "co": "21-hydroxylase deficiency CAH — salt-wasting + virilization + hypoNa/hyperK", "ct": "Analysis/synthesis", "w": "Classic 21-hydroxylase deficiency (the commonest CAH) causes deficient cortisol and aldosterone synthesis with shunting to androgens. Girls present with virilized (ambiguous) genitalia; both sexes develop a salt-wasting crisis in the neonatal period with hyponatraemia, hyperkalaemia, and hypotension. Treatment is glucocorticoid + mineralocorticoid replacement. 17-OH progesterone is the diagnostic marker.", "d": "Female infant + ambiguous genitalia + salt-wasting crisis (hypoNa/hyperK) = 21-OH deficiency CAH", "t": "Clinical Mimic — CAH (salt-wasting + virilization) vs other causes of ambiguous genitalia", "f": "Neonatal ambiguous genitalia + salt-wasting crisis (hypoNa/hyperK) = 21-OH deficiency CAH", "r": "21-OH deficiency CAH: ambiguous genitalia + salt-wasting crisis (hypoNa/hyperK) + ↑17-OH progesterone", "x": [["A) Primary hyperaldosteronism", "Primary hyperaldosteronism causes hypertension with hypokalaemia, not salt-wasting or virilization."], ["B) Congenital adrenal hypoplasia", "Adrenal hypoplasia presents with adrenal insufficiency but not virilization."], ["C) Turner syndrome", "Turner syndrome has streak gonads and lymphedema, not virilization or salt-wasting."]]}, {"n": 27, "s": "A 70-year-old man in the ICU with severe sepsis has a low free T3, a normal TSH, and a normal free T4. He is clinically euthyroid. What explains these thyroid tests?", "o": [["A", "Primary hypothyroidism"], ["B", "Non-thyroidal illness (euthyroid sick syndrome)"], ["C", "Central hypothyroidism"], ["D", "Hyperthyroidism"]], "c": ["B)", "Non-thyroidal illness (euthyroid sick syndrome)"], "co": "Non-thyroidal illness — low T3, normal TSH/fT4 in acute illness; do not treat", "ct": "Interpretation", "w": "Non-thyroidal illness (euthyroid sick syndrome) occurs in severe acute illness (sepsis, starvation, surgery): T3 falls (reduced conversion), reverse-T3 rises, and TSH is typically normal or mildly abnormal, with normal T4. It is an adaptive response; thyroid function normalises with recovery and treatment is NOT indicated (and can be harmful). The normal TSH argues against primary/central thyroid disease.", "d": "Acute severe illness + low T3 + normal TSH/T4 + euthyroid = euthyroid sick syndrome", "t": "Clinical Mimic — euthyroid sick (low T3, normal TSH) vs true hypothyroidism", "f": "Acute illness + low T3 + normal TSH/T4 = euthyroid sick syndrome (don't treat thyroid)", "r": "Euthyroid sick syndrome: low T3, normal TSH/fT4 in severe illness; recovers; no thyroid treatment", "x": [["A) Primary hypothyroidism", "Primary hypothyroidism would show high TSH and low T4, not this pattern."], ["C) Central hypothyroidism", "Central hypothyroidism would show low T4 with inappropriately normal/low TSH."], ["D) Hyperthyroidism", "Hyperthyroidism would show suppressed TSH and high T4/T3."]]}, {"n": 28, "s": "A 68-year-old postmenopausal woman has a DEXA T-score of -3.0 at the lumbar spine after a low-trauma wrist fracture. What is the most appropriate first-line treatment to reduce fracture risk?", "o": [["A", "Calcium alone"], ["B", "Bisphosphonate (e.g., alendronate)"], ["C", "Thyroid hormone"], ["D", "High-dose vitamin D only"]], "c": ["B)", "Bisphosphonate (e.g., alendronate)"], "co": "Postmenopausal osteoporosis — bisphosphonate first-line for fracture prevention", "ct": "Interpretation", "w": "Postmenopausal osteoporosis is defined by low bone density (T-score ≤ -2.5) and/or fragility fractures. First-line therapy to reduce vertebral and hip fracture risk is a bisphosphonate (alendronate, risedronate, zoledronate). Calcium and vitamin D are adjuncts, not sufficient alone. Thyroid hormone is unrelated.", "d": "Postmenopausal osteoporosis (T-score ≤-2.5 + fragility fracture) → bisphosphonate first-line", "t": "Treatment ladder — bisphosphonate first-line (not calcium/vit D alone)", "f": "Postmenopausal osteoporosis: bisphosphonate first-line; calcium/vit D are adjuncts", "r": "Postmenopausal osteoporosis (T≤-2.5 or fragility fracture): bisphosphonate first-line + Ca/vit D", "x": [["A) Calcium alone", "Calcium alone does not reduce fracture risk sufficiently in established osteoporosis."], ["C) Thyroid hormone", "Thyroid hormone is not a treatment for osteoporosis."], ["D) High-dose vitamin D only", "Vitamin D alone is insufficient; bisphosphonate is first-line for established disease."]]}, {"n": 29, "s": "A 7-year-old boy is below the 3rd centile for height with a height velocity below the 25th centile, but normal body proportions. Bone age is delayed. What is the most likely underlying issue if GH deficiency is confirmed?", "o": [["A", "Growth hormone deficiency causing proportionate short stature with delayed bone age"], ["B", "Achondroplasia"], ["C", "Turner syndrome"], ["D", "Constitutional growth delay"]], "c": ["A)", "Growth hormone deficiency causing proportionate short stature with delayed bone age"], "co": "Growth hormone deficiency — proportionate short stature + reduced growth velocity + delayed bone age", "ct": "Interpretation", "w": "Growth hormone deficiency in children causes proportionate short stature with a subnormal growth velocity and delayed bone age (unlike achondroplasia, which has short limbs/disproportion, or Turner, which has specific dysmorphism). Confirmation is provocative GH stimulation testing. Treatment is recombinant GH. Constitutional delay shows a family history and eventual catch-up.", "d": "Child: short stature + low growth velocity + delayed bone age + normal proportions = GH deficiency", "t": "Clinical Mimic — GH deficiency (proportionate, low velocity) vs achondroplasia/Turner/constitutional", "f": "Child short stature + low growth velocity + delayed bone age + normal proportions = GH deficiency", "r": "GH deficiency: proportionate short stature + reduced growth velocity + delayed bone age; stim test confirms", "x": [["B) Achondroplasia", "Achondroplasia causes disproportionate (rhizomelic) shortening, not proportionate stature."], ["C) Turner syndrome", "Turner syndrome has webbing, streak gonads, and specific features, not isolated GH deficiency."], ["D) Constitutional growth delay", "Constitutional delay has a family history and normal/late catch-up, not necessarily low velocity."]]}, {"n": 30, "s": "A 50-year-old woman has a 1.5 cm thyroid nodule. Ultrasound shows microcalcifications, irregular margins, marked hypoechoic echotexture, and a taller-than-wide shape. What is the most appropriate next step?", "o": [["A", "Repeated ultrasound in 1 year"], ["B", "Total thyroidectomy without biopsy"], ["C", "Radioiodine ablation"], ["D", "Fine-needle aspiration (FNA) biopsy"]], "c": ["D)", "Fine-needle aspiration (FNA) biopsy"], "co": "Thyroid nodule — suspicious sonographic features warrant FNA", "ct": "Interpretation", "w": "Thyroid nodule sonographic features that raise malignancy risk are microcalcifications, irregular/spiculated margins, marked hypoechogenicity, taller-than-wide shape, and intranodular vascularity. Such nodules warrant fine-needle aspiration (FNA) per TI-RADS/Bethesda guidance. Benign-appearing nodules are observed. Surgery without cytology is not first-line.", "d": "Nodule with microcalcification/irregular margin/hypoechoic/taller-than-wide = suspicious → FNA", "t": "One-word discriminator — microcalcification/irregular margin/taller-than-wide = suspicious nodule → FNA", "f": "Suspicious USS features (microcalcification, irregular margin, taller-than-wide) → FNA, not watch", "r": "Thyroid nodule: microcalcification + irregular margin + taller-than-wide = suspicious → FNA biopsy", "x": [["A) Repeated ultrasound in 1 year", "Suspicious features require tissue diagnosis, not just surveillance."], ["B) Total thyroidectomy without biopsy", "Operating without FNA risks removing a benign nodule unnecessarily."], ["C) Radioiodine ablation", "Radioiodine is for hyperthyroidism/ablation, not a solid suspicious nodule."]]}, {"n": 31, "s": "A 65-year-old man has bone pain and an elevated alkaline phosphatase with normal calcium and phosphate. X-ray of the pelvis shows cortical thickening and a 'cotton-wool' appearance. What is the diagnosis?", "o": [["A", "Paget disease of bone"], ["B", "Osteomalacia"], ["C", "Osteoporosis"], ["D", "Multiple myeloma"]], "c": ["A)", "Paget disease of bone"], "co": "Paget disease — elevated ALP, normal Ca/PO4, 'cotton-wool' bone on X-ray", "ct": "Interpretation", "w": "Paget disease of bone is disordered remodelling (osteoclast overactivity then blastic compensation) causing bone pain, deformity, and complications (fracture, deafness from skull base involvement, high-output cardiac failure). Alkaline phosphatase is markedly elevated while calcium and phosphate stay normal (unlike osteomalacia, which has low Ca/PO4). Bisphosphonates are first-line.", "d": "Bone pain + high ALP + normal Ca/PO4 + cotton-wool bone = Paget disease", "t": "One-word discriminator — elevated ALP + normal Ca/PO4 + cotton-wool bone = Paget", "f": "Bone pain + high ALP + normal Ca/PO4 + cotton-wool X-ray = Paget disease", "r": "Paget disease: high ALP, normal Ca/PO4, cortical thickening/cotton-wool bone; bisphosphonates", "x": [["B) Osteomalacia", "Osteomalacia shows low Ca/PO4 (or low-normal) with high ALP, not the cotton-wool pattern."], ["C) Osteoporosis", "Osteoporosis has normal Ca/PO4/ALP; it is loss of bone density, not remodelling."], ["D) Multiple myeloma", "Myeloma causes lytic lesions and CRAB features, not cotton-wool cortical thickening."]]}, {"n": 32, "s": "A woman who had bilateral adrenalectomy for Cushing disease 5 years ago now presents with progressive visual field loss and a rapidly enlarging pituitary mass. What is the diagnosis?", "o": [["A", "Pituitary apoplexy"], ["B", "Craniopharyngioma"], ["C", "Nelson syndrome"], ["D", "Metastatic lung cancer"]], "c": ["C)", "Nelson syndrome"], "co": "Nelson syndrome — pituitary tumour enlargement after bilateral adrenalectomy for Cushing", "ct": "Interpretation", "w": "Nelson syndrome is the development of an aggressive, often ACTH-producing pituitary macroadenoma after bilateral adrenalectomy for Cushing disease, due to loss of cortisol negative feedback. It presents with visual field defects (chiasmal compression) and sometimes skin pigmentation. It is prevented by pituitary radiotherapy at adrenalectomy.", "d": "Bilateral adrenalectomy for Cushing + enlarging pituitary mass + visual loss = Nelson syndrome", "t": "Severity under-recognition — post-bilateral-adrenalectomy pituitary tumour = Nelson", "f": "Bilateral adrenalectomy for Cushing + growing pituitary mass = Nelson syndrome", "r": "Nelson syndrome: pituitary macroadenoma after bilateral adrenalectomy for Cushing (loss of feedback)", "x": [["A) Pituitary apoplexy", "Apoplexy is acute haemorrhage/infarction, not a slowly enlarging mass years later."], ["B) Craniopharyngioma", "Craniopharyngioma is a distinct calcified suprasellar tumour, not post-adrenalectomy."], ["D) Metastatic lung cancer", "Metastatic lung cancer would not have this surgical history."]]}, {"n": 33, "s": "A 30-year-old woman on an antipsychotic for schizophrenia develops galactorrhoea and amenorrhoea. Prolactin is markedly elevated. What should be considered before assuming a prolactinoma?", "o": [["A", "Drug-induced hyperprolactinemia (antipsychotic/metoclopramide) — review the medication"], ["B", "Prolactinoma confirmed — refer for transsphenoidal surgery"], ["C", "Primary hypothyroidism"], ["D", "Pregnancy is the only cause"]], "c": ["A)", "Drug-induced hyperprolactinemia (antipsychotic/metoclopramide) — review the medication"], "co": "Drug-induced hyperprolactinemia — antipsychotics/D2 blockers before prolactinoma", "ct": "Interpretation", "w": "Many drugs elevate prolactin by blocking dopamine D2 receptors — antipsychotics (risperidone, typicals), metoclopramide, domperidone, verapamil, opioids. A careful drug history is essential before attributing hyperprolactinemia to a prolactinoma. Discontinuation (where safe) normalises prolactin. True prolactinoma is treated with dopamine agonists.", "d": "Hyperprolactinemia on antipsychotic/metoclopramide = drug-induced; review drug before imaging", "t": "Treatment misdirection — assuming prolactinoma without checking drug causes", "f": "Hyperprolactinemia + antipsychotic/metoclopramide = drug-induced; review med before pituitary MRI", "r": "Drug-induced hyperprolactinemia: antipsychotics/metoclopramide (D2 blockade); review drug before prolactinoma workup", "x": [["B) Prolactinoma confirmed — refer for transsphenoidal surgery", "Surgery is for prolactinoma, not drug-induced hyperprolactinemia; the drug should be reviewed first."], ["C) Primary hypothyroidism", "Hypothyroidism can raise prolactin mildly but not typically with galactorrhoea on an antipsychotic."], ["D) Pregnancy is the only cause", "Pregnancy is one cause but not the only one; drugs are a key consideration here."]]}, {"n": 34, "s": "A 55-year-old man has an adrenal mass (3 cm) found incidentally on CT for renal colic. He is hypertensive with hypokalaemia. What is the most appropriate next step?", "o": [["A", "Immediate adrenalectomy"], ["B", "Observe without testing"], ["C", "Endocrine workup (exclude Cushing, pheochromocytoma, Conn) before any surgery"], ["D", "Chemotherapy"]], "c": ["C)", "Endocrine workup (exclude Cushing, pheochromocytoma, Conn) before any surgery"], "co": "Adrenal incidentaloma — exclude hormonal hyperfunction before considering surgery", "ct": "Interpretation", "w": "An adrenal incidentaloma requires exclusion of hormonal hyperfunction — Cushing (dexamethasone suppression), pheochromocytoma (metanephrines, NEVER biopsy if suspected), and primary aldosteronism (if hypertensive/hypokalaemic) — before any intervention. Most are non-functioning and observed. Functioning tumours or masses >4 cm with suspicious features warrant surgery.", "d": "Incidental adrenal mass → biochemical workup (Cushing/pheo/Conn) before surgery", "t": "Treatment misdirection — operating on an incidentaloma without endocrine workup", "f": "Adrenal incidentaloma: biochemical workup first (Cushing/pheo/Conn); most are non-functioning", "r": "Adrenal incidentaloma: exclude Cushing/pheochromocytoma/Conn biochemically before surgery; most observed", "x": [["A) Immediate adrenalectomy", "Immediate adrenalectomy without ruling out pheochromocytoma is dangerous (catecholamine crisis)."], ["B) Observe without testing", "Observation without endocrine testing misses functioning tumours."], ["D) Chemotherapy", "Chemotherapy is not indicated for a benign incidentaloma."]]}, {"n": 35, "s": "A 45-year-old man presents with coarse facial features, enlarged hands and feet, and worsening glucose intolerance. Which screening test is most appropriate first?", "o": [["A", "Random growth hormone level"], ["B", "Serum IGF-1 level"], ["C", "MRI pituitary immediately"], ["D", "Oral glucose tolerance test alone"]], "c": ["B)", "Serum IGF-1 level"], "co": "Acromegaly — IGF-1 screening; GH excess from pituitary adenoma", "ct": "Interpretation", "w": "Acromegaly is GH hypersecretion (usually a pituitary adenoma) causing coarse facial features, enlarging hands/feet, prognathism, glucose intolerance, and cardiovascular risk. Because GH is pulsatile, the stable downstream marker IGF-1 is the screening test; confirmation is a failed GH suppression on oral glucose tolerance test. Colon cancer screening is advised. Treatment is transsphenoidal surgery/somatostatin analogues.", "d": "Coarse features + enlarging hands/feet + glucose intolerance = acromegaly → check IGF-1 first", "t": "Clinical Mimic — acromegaly (coarse features, enlarging ring/shoe size) vs normal ageing", "f": "Coarse features + growing hands/feet + glucose intolerance = acromegaly → screen with IGF-1", "r": "Acromegaly: GH adenoma → screen with IGF-1 (stable), confirm with OGTT GH suppression", "x": [["A) Random growth hormone level", "Random GH is pulsatile and unreliable for screening; IGF-1 is preferred."], ["C) MRI pituitary immediately", "MRI is done after biochemical confirmation, not as first screening."], ["D) Oral glucose tolerance test alone", "OGTT is confirmatory, not the initial screen; IGF-1 comes first."]]}, {"n": 36, "s": "A 28-year-old woman in the postpartum period presents with headache, bitemporal hemianopia, and mild diabetes insipidus. MRI shows a homogenously enhancing pituitary mass. What is the most likely diagnosis?", "o": [["A", "Craniopharyngioma"], ["B", "Lymphocytic hypophysitis"], ["C", "Pituitary adenoma"], ["D", "Metastasis"]], "c": ["B)", "Lymphocytic hypophysitis"], "co": "Lymphocytic hypophysitis — postpartum pituitary mass with DI", "ct": "Interpretation", "w": "Lymphocytic hypophysitis is autoimmune inflammation of the pituitary, classically presenting in late pregnancy or the postpartum period with headache, visual field defects, and anterior/posterior (DI) hormone deficits. It can mimic a pituitary adenoma on imaging. Corticosteroids are first-line; diabetes insipidus (from posterior lobe involvement) is a clue pointing away from a simple adenoma.", "d": "Postpartum woman + pituitary mass + diabetes insipidus = lymphocytic (autoimmune) hypophysitis", "t": "Clinical Mimic — lymphocytic hypophysitis (postpartum + DI) vs pituitary adenoma", "f": "Postpartum pituitary mass + diabetes insipidus = lymphocytic hypophysitis", "r": "Lymphocytic hypophysitis: postpartum/late-pregnancy pituitary mass + DI; steroids first-line", "x": [["A) Craniopharyngioma", "Craniopharyngioma is calcified and not typically postpartum or associated with lymphocytic infiltration."], ["C) Pituitary adenoma", "A macroadenoma can compress but DI and postpartum onset favour hypophysitis."], ["D) Metastasis", "Metastasis would have a known primary and does not have this postpartum pattern."]]}, {"n": 37, "s": "A 50-year-old man with fatigue and hypotension has hyponatraemia but a normal potassium. He has pale skin with no pigmentation. Which statement is correct?", "o": [["A", "Findings confirm PRIMARY adrenal insufficiency"], ["B", "Findings suggest SECONDARY adrenal insufficiency (no hyperkalaemia/pigmentation)"], ["C", "Hyperkalaemia is expected"], ["D", "Skin pigmentation is expected"]], "c": ["B)", "Findings suggest SECONDARY adrenal insufficiency (no hyperkalaemia/pigmentation)"], "co": "Primary vs secondary adrenal insufficiency — hyperkalaemia + pigmentation only in PRIMARY", "ct": "Analysis/synthesis", "w": "Primary adrenal insufficiency (Addison) destroys the cortex, causing cortisol AND aldosterone deficiency → hyponatraemia, hyperkalaemia, and ACTH-driven skin pigmentation. Secondary (pituitary/hypothalamic) causes only cortisol deficiency (aldosterone is renin-driven, spared) → hyponatraemia WITHOUT hyperkalaemia and WITHOUT pigmentation. This patient's normal potassium and absent pigmentation point to secondary disease.", "d": "Adrenal insufficiency WITHOUT hyperkalaemia/pigmentation = secondary (pituitary); primary has both", "t": "Opposite — primary (hyperK + pigmentation) vs secondary (normoK, no pigmentation)", "f": "Adrenal insufficiency: hyperK + pigmentation = PRIMARY; normal K, no pigment = SECONDARY (pituitary)", "r": "Primary AI: low cortisol + low aldosterone → hypoNa + hyperK + pigmentation. Secondary: cortisol only → hypoNa, normal K, no pigment", "x": [["A) Findings confirm PRIMARY adrenal insufficiency", "Primary disease would show hyperkalaemia and pigmentation, neither present here."], ["C) Hyperkalaemia is expected", "Hyperkalaemia occurs in primary, not secondary, adrenal insufficiency."], ["D) Skin pigmentation is expected", "Pigmentation is a feature of primary (ACTH excess), not secondary."]]}, {"n": 38, "s": "A 40-year-old woman has galactorrhoea and amenorrhoea. MRI shows an empty sella with a thin pituitary stalk displaced, but no discrete adenoma. Prolactin is mildly elevated. What explains the hyperprolactinemia?", "o": [["A", "Prolactin-secreting macroadenoma"], ["B", "Primary hypothyroidism"], ["C", "Stalk effect — interrupted dopamine inhibition from stalk compression"], ["D", "Renal failure"]], "c": ["C)", "Stalk effect — interrupted dopamine inhibition from stalk compression"], "co": "Stalk effect — hyperprolactinemia from interrupted dopamine (stalk compression)", "ct": "Interpretation", "w": "The hypothalamus delivers dopamine (PIF) via the pituitary stalk to inhibit prolactin. Any mass or process that compresses or interrupts the stalk (including a non-secreting lesion, sarcoid, or even an 'empty sella' with stalk displacement) removes this inhibition — the 'stalk effect' — causing mild-to-moderate hyperprolactinemia without a prolactinoma. A discrete adenoma would appear as a mass on MRI.", "d": "No adenoma but high prolactin + stalk compression = stalk effect (lost dopamine inhibition)", "t": "Classification trap — stalk effect (no adenoma) vs prolactinoma (mass)", "f": "Hyperprolactinemia without adenoma + stalk compression = stalk effect (lost dopamine inhibition)", "r": "Stalk effect: stalk compression interrupts hypothalamic dopamine → hyperprolactinemia without prolactinoma", "x": [["A) Prolactin-secreting macroadenoma", "A prolactinoma would be a visible enhancing mass, not an empty sella."], ["B) Primary hypothyroidism", "Hypothyroidism raises prolactin via TRH but would show low free T4/high TSH."], ["D) Renal failure", "Renal failure can raise prolactin but is not suggested by the empty sella here."]]}, {"n": 39, "s": "A 60-year-old man with a known pituitary macroadenoma suddenly develops a severe headache, bilateral visual loss, and hypotension with hypoglycaemia. What is the urgent diagnosis and action?", "o": [["A", "Pituitary apoplexy — give glucocorticoids and arrange urgent surgery"], ["B", "Migraine — analgesia and observe"], ["C", "Subarachnoid haemorrhage — wait for CT"], ["D", "Pituitary adenoma benign — no action"]], "c": ["A)", "Pituitary apoplexy — give glucocorticoids and arrange urgent surgery"], "co": "Pituitary apoplexy — acute haemorrhage/infarction; steroids + urgent decompression", "ct": "Analysis/synthesis", "w": "Pituitary apoplexy is acute haemorrhagic infarction of a pituitary adenoma causing sudden severe headache, visual field loss (chiasmal compression), ophthalmoplegia, and — because of acute cortisol deficiency — hypotension and hypoglycaemia (a medical emergency). Immediate high-dose glucocorticoids and urgent surgical decompression are required.", "d": "Pituitary macroadenoma + sudden HA + visual loss + hypotension/hypoglycaemia = apoplexy (emergency)", "t": "Severity under-recognition — apoplexy = sudden HA + visual loss + adrenal crisis", "f": "Pituitary macroadenoma + acute HA + vision loss + hypotension = apoplexy → steroids + urgent surgery", "r": "Pituitary apoplexy: acute HA + visual loss + cortisol-deficiency shock → IV steroids + urgent decompression", "x": [["B) Migraine — analgesia and observe", "This is an endocrine emergency, not migraine; observation is fatal."], ["C) Subarachnoid haemorrhage — wait for CT", "SAH causes thunderclap headache but not the endocrine/visual-field profile of apoplexy."], ["D) Pituitary adenoma benign — no action", "No action is dangerous; apoplexy is life-threatening."]]}, {"n": 40, "s": "A 50-year-old woman has an elevated TSH (8.5 mIU/L) with a normal free T4 on routine screening. She is asymptomatic. Which management is most appropriate?", "o": [["A", "Start high-dose levothyroxine immediately"], ["B", "Refer urgently for thyroid scan"], ["C", "Start antithyroid drugs"], ["D", "Observe and repeat; treat if TSH >10 or symptoms/TPO antibodies develop"]], "c": ["D)", "Observe and repeat; treat if TSH >10 or symptoms/TPO antibodies develop"], "co": "Subclinical hypothyroidism — observe unless TSH>10 or symptoms/antibodies", "ct": "Interpretation", "w": "Subclinical hypothyroidism is defined by elevated TSH with normal free T4. Most asymptomatic patients are observed and TSH repeated; treatment (levothyroxine) is generally recommended when TSH >10 mIU/L, or if symptoms, pregnancy, or positive TPO antibodies with goitre. Immediate high-dose thyroxine is unnecessary and risks iatrogenic hyperthyroidism.", "d": "Elevated TSH + normal T4 + asymptomatic = subclinical hypothyroidism → observe unless TSH>10", "t": "Treatment misdirection — overtreating mild/subclinical hypothyroidism", "f": "Subclinical hypothyroidism: observe unless TSH>10 or symptoms/TPO+; don't start thyroxine routinely", "r": "Subclinical hypothyroidism: treat if TSH>10 or symptomatic/TPO+; otherwise observe", "x": [["A) Start high-dose levothyroxine immediately", "Routine immediate high-dose thyroxine is not indicated for asymptomatic mild elevation."], ["B) Refer urgently for thyroid scan", "Urgent scan is not needed for stable subclinical disease."], ["C) Start antithyroid drugs", "Antithyroid drugs are for hyperthyroidism, not hypothyroidism."]]}, {"n": 41, "s": "A 45-year-old with fatigue and jaundice has laboratory evidence of haemolysis and a positive direct Coombs (antiglobulin) test. This immune haemolytic anaemia is best classified under which type of hypersensitivity reaction?", "o": [["A", "Type II (antibody/cytotoxic)"], ["B", "Type I (anaphylactic)"], ["C", "Type III (immune complex)"], ["D", "Type IV (delayed cell-mediated)"]], "c": ["A)", "Type II (antibody/cytotoxic)"], "co": "Autoimmune haemolytic anaemia - Type II hypersensitivity (Coombs positive)", "ct": "Interpretation", "w": "Autoimmune haemolytic anaemia is an antibody-mediated (Type II) hypersensitivity reaction in which auto-antibodies (and complement) target red cell surface antigens, producing a positive direct antiglobulin (Coombs) test and extravascular haemolysis. This is a recalled exam pattern (Q17).", "d": "Positive Coombs test + haemolysis = antibody against self RBCs = Type II cytotoxic hypersensitivity", "t": "Assigning AIHA to immune complex (III) or cell-mediated (IV) hypersensitivity", "f": "Positive Coombs + haemolytic anaemia = Type II (antibody-mediated) hypersensitivity", "r": "AIHA (positive Coombs) is a Type II antibody-mediated hypersensitivity with extravascular haemolysis.", "x": [["B) Type I (anaphylactic)", "Type I is mediated by IgE/mast cells (anaphylaxis, allergy), not anti-RBC antibodies"], ["C) Type III (immune complex)", "Type III is immune-complex mediated (e.g. serum sickness), not directed at self RBC antigens"], ["D) Type IV (delayed cell-mediated)", "Type IV is delayed T-cell mediated (e.g. TB, contact dermatitis), not antibody-mediated haemolysis"]]}, {"n": 42, "s": "A woman with placental abruption develops generalized oozing from venepuncture sites. Laboratories show prolonged PT and aPTT, low fibrinogen, thrombocytopenia and a markedly raised D-dimer. Which is the most appropriate description and treatment?", "o": [["A", "Disseminated intravascular coagulation; treat the underlying cause and support with blood products"], ["B", "Haemophilia; give factor VIII"], ["C", "Immune thrombocytopenia; corticosteroids"], ["D", "Vitamin K deficiency; vitamin K"]], "c": ["A)", "Disseminated intravascular coagulation; treat the underlying cause and support with blood products"], "co": "DIC - consumption coagulopathy; treat the cause + supportive products", "ct": "Interpretation", "w": "Disseminated intravascular coagulation is a consumption coagulopathy driven by massive tissue factor release (obstetric abruption, sepsis, malignancy), causing bleeding with prolonged PT/aPTT, thrombocytopenia, low fibrinogen and high D-dimer. The cornerstone is treating the underlying cause with supportive blood product replacement (platelets, FFP, cryoprecipitate).", "d": "Placental abruption + bleeding + low fibrinogen/platelets + high D-dimer = DIC; treat cause + supportive", "t": "Treating DIC as a single-factor deficiency - it is a consumption process needing cause control + products", "f": "Bleeding + low fibrinogen/platelets + high D-dimer + obstetric/septic trigger = DIC; treat the cause", "r": "DIC: consumption of factors/platelets after tissue-factor release (abruption, sepsis); low fibrinogen, high D-dimer; treat cause + blood products.", "x": [["B) Haemophilia; give factor VIII", "haemophilia is a single-factor (VIII/IX) deficiency, not a consumption coagulopathy with low fibrinogen"], ["C) Immune thrombocytopenia; corticosteroids", "ITP gives isolated thrombocytopenia without prolonged PT or low fibrinogen"], ["D) Vitamin K deficiency; vitamin K", "vitamin K deficiency gives prolonged PT but not thrombocytopenia or low fibrinogen"]]}, {"n": 43, "s": "A 60-year-old with a urinary tract infection develops fever (40 C), cold peripheries, tachycardia and confusion. WBC is 2100/mm3 and PT/INR is prolonged. What is the most likely diagnosis?", "o": [["A", "Uncomplicated UTI"], ["B", "Septic shock with disseminated intravascular coagulation (DIC)"], ["C", "Cardiogenic shock"], ["D", "Massive pulmonary embolism"]], "c": ["B)", "Septic shock with disseminated intravascular coagulation (DIC)"], "co": "Septic shock + DIC - fever, leucopenia, coagulopathy", "ct": "Interpretation", "w": "In sepsis, release of procoagulants and consumption of clotting factors produces DIC, reflected by thrombocytopenia, prolonged PT/aPTT, low fibrinogen and high D-dimer. Leucopenia and a coagulopathy on top of shock point to septic shock with DIC rather than simple infection or embolic/cardiogenic causes. A recalled exam pattern (Q76).", "d": "Source of sepsis + hypotension/confusion + low WBC + prolonged PT = septic shock with DIC", "t": "Reading the prolonged PT/INR as an isolated liver problem or missing DIC in sepsis", "f": "Sepsis + shock + low WBC + prolonged PT = septic shock with DIC", "r": "DIC complicates sepsis: prolonged PT/aPTT, thrombocytopenia, low fibrinogen, high D-dimer; treat the underlying sepsis.", "x": [["A) Uncomplicated UTI", "uncomplicated UTI does not cause shock, leucopenia and coagulopathy"], ["C) Cardiogenic shock", "cardiogenic shock has a raised JVP/pulmonary oedema and does not explain the coagulopathy"], ["D) Massive pulmonary embolism", "massive PE causes acute right-heart strain, not leucopenia with prolonged PT"]]}, {"n": 44, "s": "A patient with thrombotic thrombocytopenic purpura (TTP) has microangiopathic haemolytic anaemia, thrombocytopenia and neurological features. What is the most common cause of death in TTP?", "o": [["A", "Intracranial haemorrhage"], ["B", "Myocardial infarction"], ["C", "Pulmonary embolism"], ["D", "Hepatic failure"]], "c": ["A)", "Intracranial haemorrhage"], "co": "TTP - most common cause of death is intracranial haemorrhage", "ct": "Recall", "w": "In thrombotic thrombocytopenic purpura the classical pentad includes fever, microangiopathic haemolytic anaemia, thrombocytopenia, renal and neurological involvement. Severe thrombocytopenia predisposes to intracranial haemorrhage, the most common lethal event. Treatment is plasma exchange. A recalled exam pattern (Q25).", "d": "TTP: intracranial haemorrhage is the most common cause of death (thrombocytopenia + microangiopathy)", "t": "Attributing TTP death to cardiac emboli - intracranial bleed is the leading cause", "f": "TTP + severe thrombocytopenia -> intracranial haemorrhage is the most common cause of death", "r": "TTP (MAHA, thrombocytopenia, neuro/renal signs): intracranial haemorrhage is the main cause of death; plasma exchange is definitive.", "x": [["B) Myocardial infarction", "cardiac ischaemia is not the leading cause of death in TTP"], ["C) Pulmonary embolism", "pulmonary embolism is not the typical fatal event"], ["D) Hepatic failure", "hepatic failure is not the main cause of death in TTP"]]}, {"n": 45, "s": "A 30-year-old previously well person develops petechiae and bruising and has an isolated severe thrombocytopenia (platelets 15,000) with an otherwise normal FBC and blood film. No lymphadenopathy or splenomegaly. What is the most likely diagnosis and first-line treatment?", "o": [["A", "Immune thrombocytopenia (ITP); corticosteroids are first line"], ["B", "TTP; plasma exchange"], ["C", "Acute leukaemia; chemotherapy"], ["D", "Vitamin K deficiency; vitamin K"]], "c": ["A)", "Immune thrombocytopenia (ITP); corticosteroids are first line"], "co": "Immune thrombocytopenia - isolated thrombocytopenia; first-line steroids", "ct": "Interpretation", "w": "Immune thrombocytopenia (ITP) is an autoimmune process (antiplatelet antibodies) causing isolated thrombocytopenia with a normal blood film, no splenomegaly, and mucocutaneous bleeding. First-line treatment is corticosteroids (plus, if severe, IVIg). It is a diagnosis of exclusion after ruling out leukaemia/TTP/vitamin K deficiency.", "d": "Isolated severe thrombocytopenia, normal film, no splenomegaly = ITP; first-line corticosteroids", "t": "Choosing TTP or leukaemia - isolated thrombocytopenia without anaemia, schistocytes or blasts favours ITP", "f": "Isolated low platelets, normal film, no splenomegaly = ITP; first-line steroids", "r": "ITP: isolated thrombocytopenia, normal film, no splenomegaly; first-line corticosteroids (IVIg if severe).", "x": [["B) TTP; plasma exchange", "TTP has microangiopathic haemolytic anaemia with schistocytes and fever/neuro/renal signs"], ["C) Acute leukaemia; chemotherapy", "leukaemia shows blasts/pancytopenia and organ infiltration"], ["D) Vitamin K deficiency; vitamin K", "vitamin K deficiency causes coagulopathy (prolonged PT), not isolated low platelets"]]}, {"n": 46, "s": "A 14-year-old girl has Hb 9 g/dL, MCV 70 fL, serum ferritin 8 ng/mL and TIBC 450 ug/dL. What is the most likely diagnosis?", "o": [["A", "Iron deficiency anaemia"], ["B", "Thalassaemia minor"], ["C", "Sickle cell anaemia"], ["D", "Vitamin B12 deficiency"]], "c": ["A)", "Iron deficiency anaemia"], "co": "Iron deficiency anaemia - microcytic, low ferritin, high TIBC", "ct": "Interpretation", "w": "Iron deficiency anaemia is microcytic/hypochromic with low ferritin, low serum iron, and high total iron-binding capacity (TIBC). Ferritin is the most specific marker; here it is clearly low (8). This is a recalled exam pattern (Q103). Thalassaemia minor also gives microcytosis but with normal/high ferritin and mild anaemia.", "d": "Microcytic (MCV 70) + low ferritin + high TIBC = iron deficiency (ferritin is diagnostic if low)", "t": "Choosing thalassaemia minor - ferritin 8 (low) and high TIBC confirm iron deficiency, not thalassaemia", "f": "Low MCV + LOW ferritin + HIGH TIBC = iron deficiency; thalassaemia has normal/high ferritin", "r": "Iron deficiency: microcytic, low ferritin, low iron, high TIBC. Ferritin is the discriminator vs thalassaemia minor.", "x": [["B) Thalassaemia minor", "thalassaemia minor has microcytosis but normal/high ferritin and often only mild anaemia"], ["C) Sickle cell anaemia", "sickle cell anaemia is normocytic with sickling on crisis, not this iron profile"], ["D) Vitamin B12 deficiency", "B12 deficiency is macrocytic (high MCV), not microcytic"]]}, {"n": 47, "s": "On a peripheral blood film, which single finding best supports a megaloblastic (B12/folate) anaemia?", "o": [["A", "Hypersegmented neutrophils (and macro-ovalocytes)"], ["B", "Microcytes and target cells"], ["C", "Spherocytes"], ["D", "Sickle-shaped cells"]], "c": ["A)", "Hypersegmented neutrophils (and macro-ovalocytes)"], "co": "Megaloblastic anaemia - hypersegmented neutrophils + macro-ovalocytes", "ct": "Recall", "w": "Megaloblastic anaemia (B12 or folate deficiency) shows macro-ovalocytes and hypersegmented neutrophils (neutrophils with >5 nuclear lobes) on the film, along with an elevated MCV. Microcytes/target cells suggest iron deficiency or thalassaemia; spherocytes suggest spherocytosis; sickling suggests sickle cell disease.", "d": "Hypersegmented neutrophils + macrocytosis = megaloblastic (B12/folate) anaemia", "t": "Choosing microcytic or hemolytic film changes - hypersegmented neutrophils are specific for megaloblastic anaemia", "f": "Hypersegmented neutrophils + macro-ovalocytes on film = megaloblastic (B12/folate) anaemia", "r": "Megaloblastic film: macro-ovalocytes and hypersegmented neutrophils; MCV elevated. Seen in B12/folate deficiency.", "x": [["B) Microcytes and target cells", "microcytes and target cells suggest iron deficiency or thalassaemia, not megaloblastic change"], ["C) Spherocytes", "spherocytes suggest spherocytosis/AIHA"], ["D) Sickle-shaped cells", "sickle cells suggest sickle cell disease"]]}, {"n": 48, "s": "A 70-year-old incidentally has a markedly raised lymphocyte count (WBC 95,000) with a mature lymphocytosis and smudge cells on the film, mild lymphadenopathy, and no anaemia or thrombocytopenia. Most likely diagnosis?", "o": [["A", "Chronic lymphocytic leukaemia"], ["B", "Acute lymphoblastic leukaemia"], ["C", "Hairy cell leukaemia"], ["D", "Follicular lymphoma"]], "c": ["A)", "Chronic lymphocytic leukaemia"], "co": "Chronic lymphocytic leukaemia - mature lymphocytosis + smudge cells in elderly", "ct": "Interpretation", "w": "Chronic lymphocytic leukaemia is common in older adults, with a persistent mature lymphocytosis (often >5,000 and seen at very high counts), smudge cells on the film, and lymphadenopathy. It may be asymptomatic and is staged with the Rai system; treatment is reserved for symptoms/cytopenias. Smudge cells are a characteristic artefactual finding.", "d": "Elderly + high mature lymphocyte count + smudge cells = CLL", "t": "Confusing CLL (mature lymphocytosis, elderly) with ALL (blasts, children) or hairy cell (pancytopenia + hairy cells)", "f": "Elderly + mature lymphocytosis + smudge cells = CLL", "r": "CLL: mature lymphocytosis with smudge cells in the elderly, lymphadenopathy; treat if symptomatic/cytopenic.", "x": [["B) Acute lymphoblastic leukaemia", "ALL is a childhood blast-cell acute leukaemia, not an elderly mature lymphocytosis"], ["C) Hairy cell leukaemia", "hairy cell leukaemia often has pancytopenia and hairy cytoplasmic projections"], ["D) Follicular lymphoma", "follicular lymphoma is primarily nodal lymphoma, not a marked peripheral lymphocytosis with smudge cells"]]}, {"n": 49, "s": "A boy develops acute jaundice and dark urine a day after taking an antimalarial and eating fava beans, with a normal blood film except for bite cells and Heinz bodies. Which is the most likely diagnosis?", "o": [["A", "Glucose-6-phosphate dehydrogenase (G6PD) deficiency"], ["B", "Hereditary spherocytosis"], ["C", "Autoimmune haemolytic anaemia"], ["D", "Thalassaemia major"]], "c": ["A)", "Glucose-6-phosphate dehydrogenase (G6PD) deficiency"], "co": "G6PD deficiency - X-linked, oxidative haemolysis after fava/primaquine, Heinz bodies", "ct": "Interpretation", "w": "G6PD deficiency is an X-linked trait causing acute oxidative haemolysis when exposed to fava beans and oxidant drugs (primaquine, sulfonamides, dapsone). It presents with jaundice, dark urine, and Heinz bodies/bite cells on the film. It is more common in males and is diagnosed by enzyme assay (best measured when not in crisis).", "d": "Triggers (fava beans, oxidant drugs) + acute haemolysis + Heinz bodies = G6PD deficiency (X-linked)", "t": "Confusing G6PD (trigger-related X-linked) with spherocytosis (membrane) or AIHA (Coombs positive)", "f": "Fava beans/oxidant drug + acute haemolysis + Heinz bodies (males) = G6PD deficiency", "r": "G6PD deficiency: X-linked, acute oxidative haemolysis with fava/oxidant drugs, Heinz bodies; avoid triggers, supportive care.", "x": [["B) Hereditary spherocytosis", "spherocytosis causes persistent spherocytes and gallstones, not trigger-related Heinz bodies"], ["C) Autoimmune haemolytic anaemia", "AIHA is Coombs positive without the drug/fava trigger pattern"], ["D) Thalassaemia major", "thalassaemia major is a transfusion-dependent chronic microcytic anaemia"]]}, {"n": 50, "s": "A patient with malabsorption and prolonged antibiotic use develops a bleeding tendency. Coagulation tests show a prolonged prothrombin time (PT) with a normal platelet count and aPTT is only mildly prolonged. Which deficiency is most likely?", "o": [["A", "Vitamin K (affecting factors II, VII, IX, X)"], ["B", "Factor VIII"], ["C", "Von Willebrand factor"], ["D", "Platelet dysfunction (thrombocytopenia)"]], "c": ["A)", "Vitamin K (affecting factors II, VII, IX, X)"], "co": "Vitamin K deficiency - prolonged PT (factor VII first) in malabsorption", "ct": "Interpretation", "w": "Vitamin K is required for synthesis of factors II, VII, IX and X (and proteins C and S). Malabsorption, liver disease or broad-spectrum antibiotics (reducing gut flora) cause vitamin K deficiency, giving a prolonged PT - factor VII has the shortest half-life, so PT rises first. Treatment is vitamin K.", "d": "Malabsorption/antibiotics + prolonged PT + normal platelets = vitamin K deficiency (factors II, VII, IX, X)", "t": "Blaming factor VIII/VWD (which prolong aPTT more) - vitamin K deficiency prolongs PT", "f": "Malabsorption + prolonged PT = vitamin K deficiency; PT rises first (factor VII)", "r": "Vitamin K deficiency (malabsorption/antibiotics/liver) prolongs PT via factors II, VII, IX, X; treat with vitamin K.", "x": [["B) Factor VIII", "factor VIII deficiency (haemophilia A) prolongs aPTT, not mainly the PT"], ["C) Von Willebrand factor", "VWD affects platelet adhesion with normal aPTT/PT in mild cases"], ["D) Platelet dysfunction (thrombocytopenia)", "thrombocytopenia reduces platelet count, but the platelet count is normal here"]]}, {"n": 51, "s": "A 60-year-old has headache, pruritus after a hot shower, ruddy complexion and an elevated haemoglobin (Hct 60%) with normal oxygen saturation. Which is the most likely diagnosis and genetic marker?", "o": [["A", "Secondary polycythaemia; low EPO"], ["B", "Polycythaemia vera; JAK2 V617F mutation"], ["C", "Chronic hypoxia; high EPO with lung disease"], ["D", "Iron deficiency; low MCV"]], "c": ["B)", "Polycythaemia vera; JAK2 V617F mutation"], "co": "Polycythaemia vera - JAK2V617F, aquagenic pruritus, high Hct with normal SpO2", "ct": "Interpretation", "w": "Polycythaemia vera is a myeloproliferative neoplasm driven by the JAK2 V617F mutation, presenting with an elevated haematocrit, aquagenic pruritus (itch after shower), thrombotic risk and splenomegaly, with normal arterial oxygen saturation (excluding secondary causes). Management includes venesection, aspirin and cytoreduction.", "d": "Erythrocytosis + aquagenic pruritus + normal SpO2 = polycythaemia vera (JAK2 mutation)", "t": "Confusing PV (primary, JAK2, normal SpO2) with secondary polycythaemia (low SpO2/high EPO)", "f": "High Hct + aquagenic pruritus + normal SpO2 = polycythaemia vera (JAK2 V617F)", "r": "PV: high Hct with normal SpO2, aquagenic pruritus, JAK2 V617F; venesection + aspirin (+ cytoreduction).", "x": [["A) Secondary polycythaemia; low EPO", "secondary polycythaemia follows chronic hypoxia (low SpO2) with high EPO"], ["C) Chronic hypoxia; high EPO with lung disease", "lung-disease hypoxia causes secondary polycythaemia with low SpO2, not PV"], ["D) Iron deficiency; low MCV", "iron deficiency is microcytic and does not raise the haematocrit with pruritus"]]}, {"n": 52, "s": "A 45-year-old woman receiving chemo-radiotherapy for breast cancer presents with fatigue. FBC shows Hb 10 g/dL with low serum iron but normal/high ferritin. Which is the most likely cause of her anaemia?", "o": [["A", "Iron deficiency anaemia"], ["B", "Anaemia of chronic disease"], ["C", "Vitamin B12 deficiency"], ["D", "Haemolytic anaemia"]], "c": ["B)", "Anaemia of chronic disease"], "co": "Anaemia of chronic disease - low iron but normal/high ferritin (functional block)", "ct": "Interpretation", "w": "Anaemia of chronic disease (inflammation/malignancy) features low serum iron with NORMAL or HIGH ferritin (an acute-phase reactant) because hepcidin sequesters iron in stores. This contrasts with iron deficiency, where ferritin is low. A recalled exam pattern (Q182).", "d": "Chronic illness + low serum iron + normal/high ferritin = anaemia of chronic disease (hepcidin blocks iron release)", "t": "Calling it iron deficiency - the normal/high ferritin with chronic illness favours ACD", "f": "Low iron + normal/high ferritin + chronic disease = anaemia of chronic disease", "r": "ACD: low iron, normal/high ferritin (hepcidin blocks store release), normocytic, in inflammation/malignancy. Ferritin distinguishes from iron deficiency.", "x": [["A) Iron deficiency anaemia", "iron deficiency has LOW ferritin, unlike the normal/high ferritin here"], ["C) Vitamin B12 deficiency", "B12 deficiency is macrocytic with neurological signs, not this profile"], ["D) Haemolytic anaemia", "haemolytic anaemia shows reticulocytosis and raised LDH/bilirubin"]]}, {"n": 53, "s": "A 12-year-old with sickle cell disease has severe pain in the hands and back, fever 38 C and no localizing chest/abdominal signs. What is the most appropriate initial management of a vaso-occlusive crisis?", "o": [["A", "Analgesia (paracetamol/NSAIDs/opioids), hydration, oxygen if hypoxic, and detect/prevent complications"], ["B", "Blood transfusion for all crises"], ["C", "Prophylactic antibiotics only"], ["D", "Immediate splenectomy"]], "c": ["A)", "Analgesia (paracetamol/NSAIDs/opioids), hydration, oxygen if hypoxic, and detect/prevent complications"], "co": "Sickle cell vaso-occlusive crisis - analgesia, hydration, oxygen", "ct": "Interpretation", "w": "Vaso-occlusive (painful) crises are managed with prompt analgesia, adequate hydration and oxygen if hypoxic, plus identifying triggers (infection, dehydration). Blood transfusion is reserved for complications such as acute chest syndrome or stroke, not every crisis. Hydroxyurea reduces crisis frequency. This is exam-relevant management.", "d": "Painful crisis in sickle cell = analgesia, hydration, oxygen; transfusion only for specific complications (e.g. stroke, chest syndrome)", "t": "Transfusing all crises - reserved for complications (chest syndrome, stroke, splenic sequestration)", "f": "Sickle vaso-occlusive crisis = analgesia + hydration + oxygen; transfusion only for complications", "r": "Vaso-occlusive crisis: analgesia, hydration, oxygen, treat infection/trigger. Transfuse only for complications (acute chest syndrome, stroke, sequestration).", "x": [["B) Blood transfusion for all crises", "transfusion is not needed for every crisis, only for complications"], ["C) Prophylactic antibiotics only", "antibiotics alone do not relieve the pain of a vaso-occlusive crisis"], ["D) Immediate splenectomy", "splenectomy is not the treatment for an acute painful crisis"]]}, {"n": 54, "s": "A patient on warfarin (INR 9) presents with a nosebleed. In addition to withholding the warfarin, which is the most appropriate immediate treatment?", "o": [["A", "Vitamin K"], ["B", "Protamine sulphate"], ["C", "Desmopressin"], ["D", "Platelet transfusion"]], "c": ["A)", "Vitamin K"], "co": "Warfarin overdose - vitamin K antidote", "ct": "Recall", "w": "Warfarin acts as a vitamin K antagonist, inhibiting clotting factors II, VII, IX and X. Its antidote is vitamin K (with prothrombin complex concentrate if life-threatening bleeding). Protamine sulphate reverses heparin; desmopressin is used in von Willebrand disease/platelet dysfunction. A recalled exam pattern (Q5).", "d": "Warfarin (vitamin K antagonist) reversal = vitamin K; protamine reverses heparin", "t": "Using protamine (which reverses heparin, not warfarin)", "f": "Warfarin/INR reversal = vitamin K; protamine is the heparin antidote", "r": "Warfarin (vitamin K antagonist) is reversed with vitamin K (PCC if life-threatening); protamine reverses heparin.", "x": [["B) Protamine sulphate", "protamine sulphate reverses heparin (unfractionated), not warfarin"], ["C) Desmopressin", "desmopressin (DDAVP) is used in VWD/platelet function disorders, not to reverse warfarin"], ["D) Platelet transfusion", "platelet transfusion does not correct vitamin K-dependent factor deficiency"]]}, {"n": 55, "s": "A 60-year-old vegetarian has progressive fatigue, glossitis and peripheral paraesthesia with an unsteady gait. FBC shows macrocytosis (MCV 115 fL) and hypersegmented neutrophils. What is the most likely diagnosis?", "o": [["A", "Iron deficiency anaemia"], ["B", "Vitamin B12 deficiency (megaloblastic)"], ["C", "Thalassaemia minor"], ["D", "Anaemia of chronic disease"]], "c": ["B)", "Vitamin B12 deficiency (megaloblastic)"], "co": "B12 deficiency - macrocytic + glossitis + neuropathy (subacute combined degeneration)", "ct": "Interpretation", "w": "Vitamin B12 deficiency causes a megaloblastic macrocytic anaemia with hypersegmented neutrophils, glossitis, and neurological features (peripheral neuropathy, subacute combined degeneration of the cord from impaired myelin). Vegans and pernicious anaemia are common causes. Unlike folate deficiency, B12 deficiency has neurological involvement.", "d": "Macrocytosis + glossitis + peripheral neuropathy/gait = B12 deficiency (also causes neurological signs)", "t": "Choosing iron (microcytic) - macrocytosis with neuropathy clearly indicates B12, not iron", "f": "Macrocytic anaemia + glossitis + neuropathy = B12 deficiency; folate does not cause neuropathy", "r": "B12 deficiency: macrocytic (MCV high), hypersegmented neutrophils, glossitis, neuropathy/SCD; treat with B12 - folate alone would not correct neurology.", "x": [["A) Iron deficiency anaemia", "iron deficiency is microcytic without neuropathy or hypersegmentation"], ["C) Thalassaemia minor", "thalassaemia minor is microcytic and mild"], ["D) Anaemia of chronic disease", "ACD is normocytic with low iron but high/normal ferritin and no neuropathy"]]}, {"n": 56, "s": "A young adult has pancytopenia (anaemia, leucopenia, thrombocytopenia) with a hypocellular bone marrow on trephine biopsy and no evidence of infiltration or fibrosis. What is the most likely diagnosis?", "o": [["A", "Aplastic anaemia"], ["B", "Acute myeloid leukaemia"], ["C", "Multiple myeloma"], ["D", "Iron deficiency anaemia"]], "c": ["A)", "Aplastic anaemia"], "co": "Aplastic anaemia - pancytopenia + hypocellular marrow", "ct": "Recall", "w": "Aplastic anaemia is a stem-cell disorder causing bicytopenia/pancytopenia with a hypocellular (empty) marrow that lacks blast infiltration or fibrosis. Causes include drugs, toxins, viral (parvovirus/EBV), and idiopathic. Management is supportive care, immunosuppression (anti-thymocyte globulin) or stem-cell transplant.", "d": "Pancytopenia with a HYPOCELLULAR marrow (no blasts/fibrosis) = aplastic anaemia", "t": "Choosing AML (which would show blasts) - the hypocellular empty marrow without blasts is aplastic anaemia", "f": "Pancytopenia + hypocellular (empty) marrow = aplastic anaemia", "r": "Aplastic anaemia: pancytopenia, hypocellular marrow without blasts/fibrosis; immunosuppression or transplant.", "x": [["B) Acute myeloid leukaemia", "AML shows blasts and a hypercellular marrow, not an empty hypocellular marrow"], ["C) Multiple myeloma", "myeloma shows plasma cells and an M-protein, not pancytopenia with an empty marrow"], ["D) Iron deficiency anaemia", "iron deficiency is not pancytopenic and has an iron-deficient (not hypocellular) picture"]]}, {"n": 57, "s": "A 61-year-old woman has low-grade fever, anaemia, abdominal pain, gum hyperplasia, and circulating blasts with Auer rods; myeloperoxidase (MPO) is positive and WBC is 42,000. Most probable diagnosis?", "o": [["A", "Chronic lymphocytic leukaemia"], ["B", "Acute lymphoblastic leukaemia"], ["C", "Chronic myeloid leukaemia"], ["D", "Acute myeloid leukaemia"]], "c": ["D)", "Acute myeloid leukaemia"], "co": "Acute myeloid leukaemia - Auer rods + MPO positive + gum infiltration", "ct": "Interpretation", "w": "Acute myeloid leukaemia presents with circulating blasts containing Auer rods, positive myeloperoxidase (MPO), and organ infiltration (gum hyperplasia points to the monocytic subtype M4/M5). This distinguishes it from ALL (MPO negative, PAS positive, children) and CML (BCR-ABL, chronic phase). A recalled exam pattern (Q135).", "d": "Blasts + Auer rods + MPO positive = AML; gum hyperplasia is classic for monocytic AML", "t": "Choosing CLL/ALL - Auer rods + MPO positivity are specific for myeloid (AML)", "f": "Blasts + Auer rods + MPO positive (+ gum infiltration) = AML", "r": "AML: myeloblasts with Auer rods, MPO positive, gum/skin infiltration, older adults; M4/M5 monocytic. Distinct from ALL and CML.", "x": [["A) Chronic lymphocytic leukaemia", "CLL is a mature lymphocytic leukaemia of older adults without blasts/Auer rods"], ["B) Acute lymphoblastic leukaemia", "ALL is MPO negative, PAS positive, common in children"], ["C) Chronic myeloid leukaemia", "CML has a chronic phase with basophilia and the BCR-ABL fusion, not gum-infiltrating blasts with Auer rods"]]}, {"n": 58, "s": "A boy has recurrent bleeding into his knees/elbows and easy bruising since early childhood, and his maternal uncle has a similar bleeding disorder. Which factor deficiency is most likely and how is it inherited?", "o": [["A", "Factor VIII deficiency; X-linked recessive"], ["B", "Factor IX deficiency; autosomal dominant"], ["C", "von Willebrand factor deficiency; autosomal recessive"], ["D", "Vitamin K-dependent factors; autosomal recessive"]], "c": ["A)", "Factor VIII deficiency; X-linked recessive"], "co": "Haemophilia A - factor VIII deficiency, X-linked recessive, joint bleeds", "ct": "Interpretation", "w": "Haemophilia A is an X-linked recessive deficiency of factor VIII causing recurrent haemarthroses and deep soft-tissue bleeding, classically in males with maternal transmission. Treatment is factor VIII replacement (and tranexamic acid). Factor IX deficiency is haemophilia B; the maternal-uncle pattern points to X-linked inheritance.", "d": "Recurrent haemarthroses + maternal lineage = haemophilia A (factor VIII, X-linked recessive)", "t": "Choosing factor IX (haemophilia B) or VWD - factor VIII with X-linked pattern is haemophilia A", "f": "Joint bleeds + X-linked family history = haemophilia A (factor VIII deficiency)", "r": "Haemophilia A: X-linked factor VIII deficiency, haemarthroses; replace factor VIII. Haemophilia B = factor IX.", "x": [["B) Factor IX deficiency; autosomal dominant", "factor IX deficiency is haemophilia B; it is still X-linked, not autosomal dominant"], ["C) von Willebrand factor deficiency; autosomal recessive", "VWD is autosomal, affects mucocutaneous bleeding (not deep joints), and is not X-linked"], ["D) Vitamin K-dependent factors; autosomal recessive", "vitamin K-dependent factor deficiency differs and is not X-linked recessive joint bleeding"]]}, {"n": 59, "s": "A 55-year-old has fatigue, weight loss, massive splenomegaly and a very high WBC with a left shift, basophilia and thrombocytosis. Peripheral blood cytogenetics show the Philadelphia chromosome. Which is the most likely diagnosis?", "o": [["A", "Acute myeloid leukaemia"], ["B", "Chronic myeloid leukaemia"], ["C", "Chronic lymphocytic leukaemia"], ["D", "Myelofibrosis"]], "c": ["B)", "Chronic myeloid leukaemia"], "co": "Chronic myeloid leukaemia - Philadelphia chromosome (t9;22 BCR-ABL), massive splenomegaly", "ct": "Interpretation", "w": "Chronic myeloid leukaemia is a myeloproliferative neoplasm with reciprocal translocation t(9;22) producing the Philadelphia chromosome (BCR-ABL fusion). It presents with a very high leucocyte count with left shift and basophilia, splenomegaly, and often thrombocytosis. First-line targeted therapy is a tyrosine kinase inhibitor (imatinib). A plan anchor (CML BCR-ABL).", "d": "High WBC + left shift + basophilia + splenomegaly + Philadelphia chromosome = CML (BCR-ABL)", "t": "Confusing CML (chronic, Ph+, splenomegaly) with AML (acute blasts) or CLL (mature lymphocytosis)", "f": "Philadelphia chromosome (BCR-ABL) + high WBC + splenomegaly + basophilia = CML", "r": "CML: t(9;22) BCR-ABL (Philadelphia), leucocytosis with basophilia, splenomegaly; treat with TKI (imatinib).", "x": [["A) Acute myeloid leukaemia", "AML has circulating blasts with Auer rods and marrow failure, not a chronic left shift with splenomegaly"], ["C) Chronic lymphocytic leukaemia", "CLL shows a mature lymphocytosis with smudge cells in older adults, not basophilia/Ph chromosome"], ["D) Myelofibrosis", "myelofibrosis has teardrop cells and a dry tap with an enlarged spleen but is Ph negative"]]}, {"n": 60, "s": "A 26-year-old with transfusion-dependent beta-thalassaemia major develops leg oedema and exertional dyspnoea despite regular transfusions. Which is the most likely culpable process?", "o": [["A", "Chronic renal failure"], ["B", "Dilated cardiomyopathy from transfusional iron overload"], ["C", "Liver cirrhosis alone"], ["D", "Pulmonary embolism"]], "c": ["B)", "Dilated cardiomyopathy from transfusional iron overload"], "co": "Thalassaemia major - iron overload cardiomyopathy from repeated transfusions", "ct": "Interpretation", "w": "Repeated transfusions in thalassaemia major cause transfusional iron overload (haemosiderosis). Myocardial iron deposition produces a dilated cardiomyopathy with heart failure (oedema, exertional dyspnoea). This is a recalled exam pattern (Q67). Chelation therapy (deferasirox/desferrioxamine) is used to prevent it.", "d": "Transfused thalassaemia major + oedema/dyspnoea = iron-overload dilated cardiomyopathy (ferritin/LIC)", "t": "Blaming renal or hepatic causes - cardiac iron overload is the classic lethal complication", "f": "Transfused thalassaemia + heart failure = iron-overload dilated cardiomyopathy; chelation prevents", "r": "Transfusion iron overload in thalassaemia causes dilated cardiomyopathy (HF); use iron chelation to prevent organ damage.", "x": [["A) Chronic renal failure", "chronic renal failure is not the typical cause of the heart failure here"], ["C) Liver cirrhosis alone", "cirrhosis does not cause exertional dyspnoea and oedema primarily as a cardiac complication"], ["D) Pulmonary embolism", "pulmonary embolism is not the expected process with transfusion history"]]}, {"n": 61, "s": "A 42-year-old woman reports progressive difficulty swallowing both liquids and solids for 2 years, with regurgitation of undigested food and a 4 kg weight loss. Barium swallow shows a smooth tapered 'bird-beak' narrowing at the gastro-oesophageal junction. What is the most appropriate definitive management?", "o": [["A", "Botulinum toxin injection"], ["B", "Proton pump inhibitor trial"], ["C", "Laparoscopic Heller myotomy"], ["D", "Oesophagectomy"]], "c": ["C)", "Laparoscopic Heller myotomy"], "co": "Achalasia — definitive management (myotomy vs botox)", "ct": "Interpretation", "w": "Progressive dysphagia to liquids and solids with a smooth bird-beak narrowing is achalasia (failed lower oesophageal sphincter relaxation). Definitive treatment is pneumatic balloon dilation or laparoscopic Heller myotomy. Botox is a temporary option reserved for poor surgical candidates.", "d": "Dysphagia to BOTH liquids and solids + bird-beak on barium = achalasia; definitive = pneumatic dilation or Heller myotomy", "t": "Treatment ladder — botox as definitive when it is only temporary", "f": "Bird-beak + dysphagia to liquids = achalasia → dilate or myotomy, not botox (unless frail)", "r": "Achalasia = bird-beak + liquids>solids → pneumatic dilation or Heller myotomy (botox is temporary)", "x": [["A) Botulinum toxin injection", "Botulinum toxin relieves symptoms only temporarily (~6 months) and is reserved for elderly/frail patients who cannot tolerate definitive therapy."], ["B) Proton pump inhibitor trial", "A PPI trial treats reflux, not achalasia; the bird-beak appearance is not reflux."], ["D) Oesophagectomy", "Oesophagectomy is for carcinoma; achalasia is a benign motility disorder managed by myotomy."]]}, {"n": 62, "s": "A 45-year-old man presents with painless bright red bleeding per rectum and a lump that prolapses on defecation but reduces spontaneously. What is the diagnosis?", "o": [["A", "External haemorrhoids"], ["B", "Second-degree internal haemorrhoids"], ["C", "Third-degree internal haemorrhoids"], ["D", "Anal fissure"]], "c": ["B)", "Second-degree internal haemorrhoids"], "co": "Haemorrhoids — grading of internal haemorrhoids", "ct": "Interpretation", "w": "Internal haemorrhoids are above the dentate line (painless). Grading: first degree bleed but don't prolapse; second degree prolapse on defecation but reduce spontaneously; third degree require manual reduction; fourth degree are irreducible. External haemorrhoids are below the dentate line and painful when thrombosed.", "d": "Painless bleeding + prolapse that reduces spontaneously = second-degree internal haemorrhoids", "t": "Opposite — internal (painless) vs external (painful) haemorrhoids", "f": "Prolapse that self-reduces = 2nd degree; needs manual reduction = 3rd; irreducible = 4th", "r": "Internal haemorrhoids = painless (above dentate line); external = painful when thrombosed", "x": [["A) External haemorrhoids", "External haemorrhoids are below the dentate line and painful, especially when thrombosed."], ["C) Third-degree internal haemorrhoids", "Third-degree internal haemorrhoids require manual reduction — this one reduces spontaneously."], ["D) Anal fissure", "Anal fissure causes tearing pain during defecation, not painless bleeding."]]}, {"n": 63, "s": "A 45-year-old man develops sudden severe lower chest pain and shortness of breath immediately after a bout of violent vomiting. On examination he is febrile with subcutaneous emphysema felt in the neck. What is the most appropriate next step?", "o": [["A", "Barium swallow"], ["B", "Electrocardiogram and troponins"], ["C", "Water-soluble contrast oesophagogram"], ["D", "Plain chest X-ray and reassurance"]], "c": ["C)", "Water-soluble contrast oesophagogram"], "co": "Boerhaave syndrome — diagnosis with water-soluble contrast", "ct": "Analysis/synthesis", "w": "Vomiting followed by chest pain and subcutaneous emphysema is Boerhaave syndrome (transmural oesophageal rupture). Diagnosis is by water-soluble contrast study or CT — barium is contraindicated because leakage into the mediastinum causes severe mediastinitis.", "d": "Violent vomiting + chest pain + subcutaneous emphysema = oesophageal rupture → water-soluble (Gastrografin) contrast, NOT barium", "t": "Investigation hierarchy — barium (contraindicated) vs water-soluble contrast", "f": "Vomiting + chest pain + neck emphysema = Boerhaave → water-soluble contrast, never barium", "r": "Boerhaave = post-emetic transmural rupture → water-soluble contrast (barium contraindicated)", "x": [["A) Barium swallow", "Barium leaking into the mediastinum causes chemical mediastinitis and is contraindicated in suspected rupture."], ["B) Electrocardiogram and troponins", "ECG/troponins evaluate for MI but do not diagnose oesophageal rupture; the emphysema is the key finding."], ["D) Plain chest X-ray and reassurance", "A plain CXR may show pneumomediastinum but reassurance is wrong — this is a surgical emergency."]]}, {"n": 64, "s": "A 55-year-old man with alcohol-related cirrhosis presents with haematemesis. Upper GI endoscopy reveals tortuous dilated veins in the distal oesophagus. What is the first-line therapeutic intervention?", "o": [["A", "Sclerotherapy"], ["B", "Endoscopic band ligation"], ["C", "Octreotide infusion alone"], ["D", "Transjugular intrahepatic portosystemic shunt (TIPS)"]], "c": ["B)", "Endoscopic band ligation"], "co": "Oesophageal varices — first-line treatment of acute haemorrhage", "ct": "Interpretation", "w": "Endoscopic band ligation is first-line for acute oesophageal variceal haemorrhage — it is superior to sclerotherapy (fewer perforation and stricture complications). Octreotide is an adjunct that lowers portal pressure; TIPS is a rescue after failed endoscopic therapy.", "d": "Cirrhosis + haematemesis + distal oesophageal varices → endoscopic band ligation is first-line", "t": "Treatment misdirection — sclerotherapy/octreotide over banding", "f": "Cirrhosis + haematemesis = band first; octreotide/terlipressin is the bridge, not the answer", "r": "Acute variceal bleed → endoscopic band ligation first-line; TIPS is rescue", "x": [["A) Sclerotherapy", "Sclerotherapy is now second-line — banding has better outcomes and fewer complications."], ["C) Octreotide infusion alone", "Octreotide reduces portal pressure as a pharmacologic adjunct but is not the primary intervention."], ["D) Transjugular intrahepatic portosystemic shunt (TIPS)", "TIPS is reserved for refractory or recurrent bleeding after endoscopic therapy fails."]]}, {"n": 65, "s": "A 68-year-old woman with hypertension presents with sudden crampy left-sided abdominal pain followed by bloody diarrhoea. She has no history of atrial fibrillation. CT shows segmental colonic wall thickening at the splenic flexure. What is the most likely diagnosis?", "o": [["A", "Acute mesenteric ischaemia"], ["B", "Ulcerative colitis"], ["C", "Infectious colitis"], ["D", "Ischaemic colitis"]], "c": ["D)", "Ischaemic colitis"], "co": "Ischaemic colitis — watershed splenic flexure, non-occlusive", "ct": "Analysis/synthesis", "w": "Ischaemic colitis results from low-flow (non-occlusive) hypoperfusion, classically at the 'watershed' splenic flexure. It presents with sudden abdominal pain then bloody diarrhoea in an elderly patient. It is distinct from acute mesenteric ischaemia (occlusive, AF, pain out of proportion).", "d": "Elderly + sudden LIF pain + bloody diarrhoea + splenic flexure (watershed) thickening = ischaemic colitis", "t": "Clinical Mimic — ischaemic colitis vs acute mesenteric ischaemia", "f": "Elderly + LIF pain + bloody diarrhoea + splenic flexure = ischaemic colitis; AF + pain out of proportion = mesenteric ischaemia", "r": "Ischaemic colitis = watershed splenic flexure, pain then bloody diarrhoea, usually self-limited", "x": [["A) Acute mesenteric ischaemia", "Acute mesenteric ischaemia is occlusive (AF/embolus) with pain out of proportion, not primarily bloody diarrhoea at the splenic flexure."], ["B) Ulcerative colitis", "Ulcerative colitis is a chronic relapsing disorder in younger patients with continuous rectal involvement."], ["C) Infectious colitis", "Infectious colitis usually has a clear infectious prodrome and lacks watershed distribution."]]}, {"n": 66, "s": "A 40-year-old man reports recurrent epigastric pain that is relieved by eating but wakes him at night. Endoscopy shows a duodenal ulcer. Which pain pattern best characterises his condition?", "o": [["A", "Pain relieved by food"], ["B", "Pain worsened by food"], ["C", "Retrosternal burning after meals"], ["D", "Right upper quadrant pain after fatty meals"]], "c": ["A)", "Pain relieved by food"], "co": "Duodenal ulcer pain — relieved by food, nocturnal", "ct": "Interpretation", "w": "Duodenal ulcer pain classically improves with eating and recurs 2-3 hours later (nocturnal). Gastric ulcer pain is worsened by food. This temporal relationship to food is the discriminator between duodenal and gastric ulcers.", "d": "Duodenal ulcer pain is relieved by food and recurs at night; gastric ulcer pain is worsened by food", "t": "Opposite — duodenal (relieved by food) vs gastric (worsened by food)", "f": "Duodenal ulcer = food relieves + nocturnal; gastric ulcer = food worsens + weight loss", "r": "Duodenal ulcer pain relieved by food; gastric ulcer pain worsened by food", "x": [["B) Pain worsened by food", "Pain worsened by food is the gastric ulcer pattern, not duodenal."], ["C) Retrosternal burning after meals", "Retrosternal burning after meals describes GERD, not PUD."], ["D) Right upper quadrant pain after fatty meals", "RUQ pain after fatty meals suggests biliary colic, not PUD."]]}, {"n": 67, "s": "A 65-year-old woman develops profuse watery diarrhoea 7 days after completing a course of clindamycin. Sigmoidoscopy shows yellow-white adherent plaques. What is the most appropriate treatment?", "o": [["A", "Oral vancomycin"], ["B", "Intravenous ceftriaxone"], ["C", "Loperamide"], ["D", "Oral amoxicillin-clavulanate"]], "c": ["A)", "Oral vancomycin"], "co": "Pseudomembranous colitis — C. difficile → oral vancomycin", "ct": "Interpretation", "w": "Antibiotic-associated pseudomembranous colitis is caused by Clostridioides difficile. First-line treatment is oral vancomycin or fidaxomicin (metronidazole only for mild/non-severe where preferred). Anti-motility agents (loperamide) are avoided, and further antibiotics worsen it.", "d": "Post-antibiotic watery diarrhoea + pseudomembranes = C. difficile → oral vancomycin (or fidaxomicin)", "t": "Guideline Version — metronidazole reflex when vancomycin is now first-line", "f": "Post-antibiotic diarrhoea + pseudomembranes = C. diff → oral vancomycin, never loperamide", "r": "C. difficile colitis → stop offending antibiotic + oral vancomycin/fidaxomicin (avoid loperamide)", "x": [["B) Intravenous ceftriaxone", "IV ceftriaxone is a broad-spectrum antibiotic that would worsen C. difficile colitis."], ["C) Loperamide", "Loperamide is contraindicated — it can precipitate toxic megacolon."], ["D) Oral amoxicillin-clavulanate", "Adding another antibiotic (amoxicillin-clavulanate) worsens the infection; the offending agent must be stopped."]]}, {"n": 68, "s": "A 30-year-old woman reports severe tearing pain during defecation with a few drops of bright red blood on the toilet paper. She is otherwise well. What is the most likely diagnosis?", "o": [["A", "Internal haemorrhoids"], ["B", "Anal fistula"], ["C", "Colorectal carcinoma"], ["D", "Anal fissure"]], "c": ["D)", "Anal fissure"], "co": "Anal fissure — tearing pain + fresh blood on wiping", "ct": "Interpretation", "w": "Anal fissure causes a sharp, tearing pain during defecation with fresh blood on the paper. Haemorrhoids bleed painlessly; a fistula causes discharge; carcinoma causes occult bleeding. The pain is the key discriminator.", "d": "Tearing pain on defecation + fresh blood on paper = anal fissure (haemorrhoids are painless)", "t": "Clinical Mimic — anal fissure (painful) vs haemorrhoids (painless)", "f": "Tearing pain + blood on paper = anal fissure; painless fresh bleed = haemorrhoids", "r": "Anal fissure = tearing pain + fresh bleeding; haemorrhoids = painless bleeding", "x": [["A) Internal haemorrhoids", "Internal haemorrhoids cause painless bleeding, not tearing pain."], ["B) Anal fistula", "Anal fistula presents with recurrent purulent discharge and a history of abscess, not sharp pain with bleeding."], ["C) Colorectal carcinoma", "Carcinoma causes occult bleeding/change in bowel habit, not acute painful defecation in a young woman."]]}, {"n": 69, "s": "A 75-year-old man presents with painless, large-volume bright red bleeding per rectum. He is otherwise well and haemodynamically stable. What is the most likely diagnosis?", "o": [["A", "Diverticulitis"], ["B", "Colorectal carcinoma"], ["C", "Diverticulosis"], ["D", "Internal haemorrhoids"]], "c": ["C)", "Diverticulosis"], "co": "Diverticulosis — painless bleeding in the elderly", "ct": "Interpretation", "w": "Diverticulosis is the most common cause of painless, often large-volume lower GI bleeding in the elderly. Diverticulitis is the inflamed form (fever + left iliac fossa pain). The absence of pain and inflammation points to diverticulosis.", "d": "Painless large-volume PR bleed in an elderly patient = diverticulosis (no fever, no LIF pain)", "t": "Clinical Mimic — diverticulosis (painless bleed) vs diverticulitis (inflamed)", "f": "Painless PR bleed in elderly = diverticulosis; add fever + LIF pain = diverticulitis", "r": "Diverticulosis = painless bleeding; diverticulitis = fever + LIF pain", "x": [["A) Diverticulitis", "Diverticulitis presents with fever and left lower quadrant pain, not painless bleeding."], ["B) Colorectal carcinoma", "Carcinoma typically causes chronic occult bleeding/weight loss, not acute painless large-volume bleed."], ["D) Internal haemorrhoids", "Haemorrhoids cause small-volume bright blood on wiping, not large-volume bleed."]]}, {"n": 70, "s": "A 72-year-old woman with aortic stenosis presents with recurrent episodes of intermittent, painless bright red bleeding per rectum and iron-deficiency anaemia. Colonoscopy is normal. What is the most likely diagnosis?", "o": [["A", "Angiodysplasia"], ["B", "Diverticulosis"], ["C", "Colorectal carcinoma"], ["D", "Haemorrhoids"]], "c": ["A)", "Angiodysplasia"], "co": "Angiodysplasia — right-colon vascular ectasia (Heyde syndrome)", "ct": "Interpretation", "w": "Angiodysplasia is a vascular ectasia, typically in the right colon, causing intermittent painless bleeding in the elderly. The association with aortic stenosis (Heyde syndrome) and a normal colonoscopy (lesions may be subtle or missed) support the diagnosis; angiography/capsule may localise it.", "d": "Elderly + aortic stenosis + recurrent painless bleed + normal colonoscopy = angiodysplasia (often right colon)", "t": "Clinical Mimic — angiodysplasia (right colon, subtle) vs diverticulosis (left, brisk)", "f": "Elderly + aortic stenosis + recurrent painless PR bleed = angiodysplasia (right colon)", "r": "Angiodysplasia = right colon, intermittent painless bleed, linked to aortic stenosis (Heyde)", "x": [["B) Diverticulosis", "Diverticulosis bleeds are typically larger-volume and originate from the left colon."], ["C) Colorectal carcinoma", "Carcinoma causes occult bleeding with weight loss/altered habit, and is usually seen on colonoscopy."], ["D) Haemorrhoids", "Haemorrhoids cause small-volume bright blood on wiping, not recurrent anaemia."]]}, {"n": 71, "s": "A 78-year-old nursing-home resident presents with gross abdominal distension, constipation, and vomiting. Abdominal X-ray shows a massively dilated loop of colon with a 'coffee bean' appearance. What is the most appropriate initial management?", "o": [["A", "Endoscopic (sigmoidoscopic) detorsion"], ["B", "Immediate laparotomy"], ["C", "Barium enema"], ["D", "Intravenous antibiotics and observation"]], "c": ["A)", "Endoscopic (sigmoidoscopic) detorsion"], "co": "Sigmoid volvulus — coffee-bean sign → endoscopic detorsion", "ct": "Interpretation", "w": "Sigmoid volvulus is a twist of a redundant sigmoid colon, common in elderly/institutionalised patients. The coffee-bean sign is characteristic. In a stable patient without peritonitis or perforation, flexible sigmoidoscopic detorsion is the initial treatment; laparotomy is for failure or gangrene.", "d": "Elderly + massive distension + coffee-bean sign = sigmoid volvulus → endoscopic detorsion first (if no peritonitis)", "t": "Investigation hierarchy — sigmoidoscopy (therapeutic) vs barium", "f": "Coffee-bean sign in an elderly patient = sigmoid volvulus → scope to detort (unless peritonitis)", "r": "Coffee-bean sign = sigmoid volvulus → endoscopic detorsion first (laparotomy if gangrene/peritonitis)", "x": [["B) Immediate laparotomy", "Laparotomy is reserved for failed detorsion, peritonitis, or gangrenous bowel."], ["C) Barium enema", "Barium enema is contraindicated in obstruction/possible perforation."], ["D) Intravenous antibiotics and observation", "Observation allows bowel ischaemia to progress; detorsion is urgent."]]}, {"n": 72, "s": "A 70-year-old woman presents with right upper quadrant pain, fever with rigors, and jaundice. What is the most appropriate initial management?", "o": [["A", "Elective laparoscopic cholecystectomy"], ["B", "IV fluids and observation"], ["C", "IV antibiotics and urgent biliary drainage (ERCP)"], ["D", "Percutaneous liver biopsy"]], "c": ["C)", "IV antibiotics and urgent biliary drainage (ERCP)"], "co": "Ascending cholangitis — Charcot triad → antibiotics + urgent ERCP", "ct": "Interpretation", "w": "Charcot's triad (RUQ pain, fever, jaundice) is ascending cholangitis, a life-threatening infection of an obstructed biliary tree. Management is IV antibiotics plus urgent biliary drainage by ERCP. Cholecystectomy is done after the acute episode resolves.", "d": "RUQ pain + fever + jaundice = Charcot triad = ascending cholangitis → antibiotics + urgent biliary decompression (ERCP)", "t": "Clinical Mimic — Charcot triad vs Murphy's sign (cholecystitis)", "f": "Charcot triad (pain+fever+jaundice) = cholangitis → ERCP now; Murphy's (pain only) = cholecystitis", "r": "Charcot triad = ascending cholangitis → antibiotics + urgent ERCP (add hypotension/AMS = Reynolds pentad)", "x": [["A) Elective laparoscopic cholecystectomy", "Cholecystectomy is delayed until after the acute cholangitis resolves; urgent drainage comes first."], ["B) IV fluids and observation", "Observation without drainage lets septic cholangitis progress — mortality is high."], ["D) Percutaneous liver biopsy", "Liver biopsy is not indicated and is dangerous in biliary obstruction."]]}, {"n": 73, "s": "A 9-month-old boy has episodes of sudden crying, drawing up his legs, and passage of red 'currant jelly' stool. A sausage-shaped mass is palpable in the right upper quadrant. What is the most appropriate first-line management?", "o": [["A", "Immediate laparotomy"], ["B", "Intravenous antibiotics"], ["C", "Air or contrast enema reduction"], ["D", "Observation and oral rehydration"]], "c": ["C)", "Air or contrast enema reduction"], "co": "Intussusception — air enema reduction in a stable infant", "ct": "Interpretation", "w": "The classic triad of intussusception is colicky abdominal pain, currant-jelly stool, and a sausage-shaped mass. In a stable infant without peritonitis or perforation, air/contrast enema is both diagnostic and therapeutic, reducing the intussusception in most cases.", "d": "Infant + colicky pain + currant-jelly stool + sausage mass = intussusception → air enema reduction (if stable, no peritonitis)", "t": "Age-appropriate differential — adult appendicitis reflex in an infant", "f": "Infant + currant jelly + sausage mass = intussusception → air enema first (unless peritonitis)", "r": "Intussusception (stable) → air/contrast enema reduction; laparotomy if peritonitis/perforation", "x": [["A) Immediate laparotomy", "Laparotomy is reserved for failed enema reduction, peritonitis, or perforation."], ["B) Intravenous antibiotics", "Antibiotics do not reduce the intussusception and are not first-line."], ["D) Observation and oral rehydration", "Observation is unsafe — unreduced intussusception causes bowel ischaemia."]]}, {"n": 74, "s": "A 68-year-old diabetic man presents with fever, right upper quadrant pain, and vomiting. CT shows gas within the gallbladder wall. What is the most appropriate management?", "o": [["A", "Outpatient oral antibiotics"], ["B", "Elective cholecystectomy in 6 weeks"], ["C", "Analgesia and observation"], ["D", "Urgent cholecystectomy with broad-spectrum antibiotics"]], "c": ["D)", "Urgent cholecystectomy with broad-spectrum antibiotics"], "co": "Emphysematous cholecystitis — gas in GB wall in a diabetic → urgent surgery", "ct": "Analysis/synthesis", "w": "Gas in the gallbladder wall indicates emphysematous cholecystitis, a necrotising infection caused by gas-forming organisms (often Clostridium) seen mainly in diabetics. It carries a high perforation risk and needs urgent cholecystectomy plus antibiotics.", "d": "Diabetic + gas within gallbladder wall = emphysematous cholecystitis → urgent cholecystectomy", "t": "Severity under-recognition — downgrading a necrotising infection in a diabetic", "f": "Diabetic + gas in gallbladder wall = emphysematous cholecystitis → urgent surgery, not observation", "r": "Gas in GB wall (diabetic) = emphysematous cholecystitis → urgent cholecystectomy", "x": [["A) Outpatient oral antibiotics", "Oral outpatient antibiotics are inadequate for a necrotising gallbladder infection."], ["B) Elective cholecystectomy in 6 weeks", "Delaying surgery 6 weeks risks perforation and sepsis."], ["C) Analgesia and observation", "Observation is unsafe — emphysematous cholecystitis has high morbidity without urgent surgery."]]}, {"n": 75, "s": "A 74-year-old woman presents with colicky abdominal pain, vomiting, and constipation. Abdominal X-ray shows small-bowel obstruction, air in the biliary tree (pneumobilia), and a calcified opacity in the right iliac fossa. What is the most likely diagnosis?", "o": [["A", "Adhesive small-bowel obstruction"], ["B", "Gallstone ileus"], ["C", "Sigmoid volvulus"], ["D", "Caecal carcinoma"]], "c": ["B)", "Gallstone ileus"], "co": "Gallstone ileus — Rigler's triad", "ct": "Analysis/synthesis", "w": "Rigler's triad — small-bowel obstruction, pneumobilia, and an ectopic gallstone — is diagnostic of gallstone ileus, where a large gallstone erodes through a cholecysto-enteric fistula and impacts the terminal ileum. Surgery removes the obstructing stone.", "d": "SBO + pneumobilia + ectopic calcified gallstone (Rigler's triad) = gallstone ileus", "t": "Pattern recognition — Rigler's triad overlooked as simple adhesions", "f": "SBO + pneumobilia + ectopic stone = gallstone ileus (Rigler's triad)", "r": "Rigler's triad (SBO + pneumobilia + ectopic gallstone) = gallstone ileus", "x": [["A) Adhesive small-bowel obstruction", "Adhesions are the most common cause of SBO but do not produce pneumobilia or an ectopic stone."], ["C) Sigmoid volvulus", "Sigmoid volvulus gives a dilated loop with a 'coffee bean' sign, not pneumobilia."], ["D) Caecal carcinoma", "Caecal carcinoma causes obstruction but without pneumobilia or a migratory stone."]]}, {"n": 76, "s": "A 70-year-old woman presents with vomiting, abdominal distension, and a tender irreducible lump in the right groin below and lateral to the pubic tubercle. The overlying skin is warm and red. What is the most appropriate management?", "o": [["A", "Attempt manual reduction in clinic"], ["B", "Elective hernia repair in 2 weeks"], ["C", "Antibiotics and observation"], ["D", "Urgent surgical exploration"]], "c": ["D)", "Urgent surgical exploration"], "co": "Strangulated femoral hernia — urgent surgery", "ct": "Analysis/synthesis", "w": "A femoral hernia presents below and lateral to the pubic tubercle and has a high strangulation risk. Tender irreducible lump with signs of obstruction and skin changes indicates strangulation (compromised blood supply) — an emergency requiring urgent exploration, not manual reduction.", "d": "Irreducible tender groin lump + obstruction + erythema = strangulated femoral hernia → urgent surgery", "t": "Severity under-recognition — treating strangulation as a reducible hernia", "f": "Irreducible + tender + obstructed femoral hernia = strangulated → theatre, never push it back", "r": "Femoral hernia = below/lateral to pubic tubercle; irreducible + tender + obstruction = strangulated → urgent surgery", "x": [["A) Attempt manual reduction in clinic", "Manual reduction of a strangulated hernia can reduce necrotic bowel into the abdomen — contraindicated."], ["B) Elective hernia repair in 2 weeks", "Elective repair delays life-saving surgery for strangulation."], ["C) Antibiotics and observation", "Antibiotics do not address the ischaemic bowel; surgery is urgent."]]}, {"n": 77, "s": "A 60-year-old man presents with melaena and is haemodynamically stable after initial fluid resuscitation. What is the single most appropriate next step?", "o": [["A", "Barium meal"], ["B", "Urgent upper GI endoscopy"], ["C", "CT angiography"], ["D", "Observation with serial haemoglobin"]], "c": ["B)", "Urgent upper GI endoscopy"], "co": "Upper GI bleed — endoscopy is diagnostic AND therapeutic", "ct": "Interpretation", "w": "In a haemodynamically stable upper GI bleed, early endoscopy is both diagnostic and therapeutic — it localises the source and allows haemostasis (banding, injection, clips). Barium is obsolete, CT angiography is for massive/ongoing bleed where endoscopy fails.", "d": "Stable upper GI bleed after resuscitation → early endoscopy (diagnostic + therapeutic), always first", "t": "Priority inversion — imaging before endoscopy", "f": "Upper GI bleed = endoscopy first (diagnose + treat in one step); CTA only if massive or endoscopy fails", "r": "Endoscopy is both diagnostic and therapeutic in UGIB — always first", "x": [["A) Barium meal", "Barium meal is obsolete and cannot provide haemostasis; it also obscures future endoscopy."], ["C) CT angiography", "CT angiography is for massive ongoing bleeding or after failed endoscopy, not first-line in a stable patient."], ["D) Observation with serial haemoglobin", "Observation alone risks re-bleeding; the source must be identified and treated endoscopically."]]}, {"n": 78, "s": "A 60-year-old woman presents with fever, left lower quadrant pain, and leukocytosis. Diverticulitis is suspected. What is the most appropriate imaging to confirm the diagnosis?", "o": [["A", "CT abdomen with IV contrast"], ["B", "Barium enema"], ["C", "Colonoscopy"], ["D", "Abdominal ultrasound"]], "c": ["A)", "CT abdomen with IV contrast"], "co": "Acute diverticulitis — CT diagnosis (barium/colonoscopy contraindicated)", "ct": "Interpretation", "w": "CT abdomen with contrast is the investigation of choice for acute diverticulitis — it confirms inflammation and detects complications (abscess, perforation). Barium enema is contraindicated in the acute setting (risk of perforation), and colonoscopy risks perforation in acute inflammation.", "d": "Fever + LIF pain → diverticulitis → CT (barium enema and colonoscopy contraindicated in acute phase)", "t": "\"What NOT to do\" — barium enema in acute diverticulitis", "f": "LIF pain + fever = diverticulitis → CT, never barium or scope in the acute phase", "r": "Acute diverticulitis → CT; barium enema and colonoscopy are contraindicated acutely", "x": [["B) Barium enema", "Barium enema risks perforation in acute inflammation and is contraindicated."], ["C) Colonoscopy", "Colonoscopy risks perforation during acute diverticulitis; it is deferred 6-8 weeks."], ["D) Abdominal ultrasound", "Ultrasound is less sensitive than CT for diverticulitis and its complications."]]}, {"n": 79, "s": "A 6-year-old boy presents with painless passage of dark red blood per rectum and iron-deficiency anaemia. Which of the following is the most likely cause?", "o": [["A", "Intussusception"], ["B", "Juvenile polyp"], ["C", "Meckel's diverticulum"], ["D", "Ulcerative colitis"]], "c": ["C)", "Meckel's diverticulum"], "co": "Meckel's diverticulum — rule of 2s, painless PR bleed in a child", "ct": "Interpretation", "w": "Meckel's diverticulum is the most common cause of painless lower GI bleeding in children — ectopic gastric mucosa acidifies and ulcerates the adjacent ileum. The rule of 2s: 2% of the population, 2 inches long, 2 feet from the ileocaecal valve, on the anti-mesenteric border.", "d": "Painless PR bleeding in a young child = Meckel's (rule of 2s: 2% population, 2 feet from ileocaecal valve, 2 inches, anti-mesenteric)", "t": "Clinical Mimic — Meckel's (painless) vs intussusception (painful, currant-jelly)", "f": "Painless PR bleed in a child = Meckel's; painful currant-jelly stool = intussusception", "r": "Meckel's = painless PR bleed in a child, anti-mesenteric, rule of 2s", "x": [["A) Intussusception", "Intussusception presents with intermittent colicky abdominal pain, 'currant jelly' stool, and a sausage-shaped mass."], ["B) Juvenile polyp", "Juvenile polyps cause bleeding but are less common than Meckel's for significant painless bleeding with anaemia."], ["D) Ulcerative colitis", "Ulcerative colitis causes bloody diarrhoea with cramps, not isolated painless bleeding."]]}, {"n": 80, "s": "A 38-year-old man presents after several episodes of forceful vomiting following a binge, followed by small-volume bright-red haematemesis. He is haemodynamically stable. What is the most likely diagnosis?", "o": [["A", "Boerhaave syndrome"], ["B", "Oesophageal varices"], ["C", "Peptic ulcer disease"], ["D", "Mallory-Weiss tear"]], "c": ["D)", "Mallory-Weiss tear"], "co": "Mallory-Weiss tear — mucosal tear after retching", "ct": "Interpretation", "w": "Repeated forceful retching causes a longitudinal mucosal tear at the gastro-oesophageal junction (Mallory-Weiss), the classic cause of post-vomiting haematemesis in an otherwise stable patient. Boerhaave is a full-thickness rupture with chest pain and sepsis.", "d": "Haematemesis AFTER repeated forceful vomiting, in a stable patient = Mallory-Weiss mucosal tear", "t": "Clinical Mimic — Mallory-Weiss (mucosal) vs Boerhaave (transmural)", "f": "Haematemesis after retching = Mallory-Weiss; add chest pain + subcutaneous emphysema = Boerhaave", "r": "Post-vomiting haematemesis (stable) = Mallory-Weiss; full-thickness rupture with emphysema = Boerhaave", "x": [["A) Boerhaave syndrome", "Boerhaave is a transmural oesophageal rupture presenting with severe chest pain, subcutaneous emphysema, and sepsis — not isolated haematemesis."], ["B) Oesophageal varices", "Varices occur with portal hypertension/cirrhosis; there is no liver history and vomiting is the trigger."], ["C) Peptic ulcer disease", "Peptic ulcer bleeding is not classically preceded by forceful vomiting."]]}], "c": 80}}

Test Series 2026