@ Medicine

Shown below is the excretory urography image .

http://img.medscapestatic.com/pi/meds/ckb/42/18742.jpg
The most likely case history of this patient is
a) A 65 year old man presenting with painless hematuria
b) A 32 year old female with SLE presenting with gross hematuria
c) A 53 year old patient with ankylosing spondylitis who regularily takes
analgesics

d) A 70 year old with anemia , bone pains, High ESR

Ans C
Excretory urography in a 53-year-old man with analgesic-induced nephropathy. A film
obtained at 15 minutes after administration of contrast shows a wavy renal outline
with tracks of contrast extending from fornix, ring shadows caused by the sloughing
of papillae, and an egg-in-a-cup appearance characteristic of renal papillary necrosis.
Note the bamboo spine, characteristic of ankylosing spondylitis.

analgesic-induced nephropathy. - Radiologically, ring sign. Also A/W sterile

pyuria, distal RTA and nephrocalcinosis, mild proteinuria, inability to

concentrate urine, anemia out of proportion to azotemia
@ Medicine
A 75 year old woman presenting with azotemia had a bone
marrow biopsy shown in Fig . The following features can occur
in association with her diagnosis except:

http://healthfavo.com/wp-content/uploads/2014/09/Multiplemyeloma.jpg
A.
Eosinophilic intraluminal cast.
B.
Interstitial multinucleated giant cells
C.
Distal RTA
D.
Post contrast ARF
Ans. C
Proximal RTA and Fanconi's syndrome occur in myeloma
kidney
@ Medicine
A 38 old female presents with eosinophiluria . Her renal biopsy
is shown in Fig .The following are features of this condition
except:

https://classconnection.s3.amazonaws.com/611/flashcards/3561611/
png/eosinophils__aain-142C55B7DFE5C8B93F1.png
A.
B.
C.
D.
Ans.

Fever
Massive proteinuria
Rash
Eosinophilia
B

eosinophils are the red dots; whole pic is acute allergic interstitial
nephritis
allergic interstitial nephritis - Also present are eosinophiluria
hematuria and pyuria.

@ 58.A 36 year old female had H/O joint pains ans her radiograph is
shown in Fig .The most common glomerular involvement seen
in this condition is:

http://nihdirectorsblog.files.wordpress.com/2013/01/05-05-0100.jpg
A.
MPGN
B.
Membranous nephropathy
C.
Amyloid nephropathy
D.
Minimal Change Disease
Ans. C
Xrayimageofthehandsofapatientwithrheumatoidarthritis.Notethatthejointsat
thebaseofthefingersareerodedandsome,liketheindexfingeronboth
hands,areactuallydislocated
@ A 32 year old femal presenting with dry mouth . Her labial
biopsy and physical findings are shown in Fig .The most
common renal manifestation of this condition is:

http://cdn2b.examiner.com/sites/default/files/styles/image_content_width/
hash/c1/07/c107839bec667bd77d04701bae7ebc43.jpg?
itok=MRuS-yqR

http://www.nature.com/nrrheum/journal/v2/n5/images/ncprheum016
5-f1.jpg
A.
Membranous nephropathy
B.
MPGN
C.
Tubulointerstitial disease
D.
None
Ans. C
Sjogren's syndrome - a histologic slide prepared from a labial minor

salivary gland biopsy that revealed lymphocytic infiltrates in two single

foci
@ Medicine The physical examination and Liver biosy of a 34 year
old male from Manipur presenting with hepatosplenomegaly
are presented in fig .Which of the following manifestations of
this condition is not reversed by phlebotomy?

http://www.intelligentdental.com/wp-content/uploads/2012/06/Pigmentation-ofthe-skin.jpg

http://fe867b.medialib.glogster.com/media/75/75157893ee937e9c3
265a7603a674cc7b03a45ee6c0af472c6517a3302eec4d8/ironoverload-jpg.jpg
A.
DM
B.
Hepatic fibrosis
C.
Cardiac failure
D.
Arthropathy
Ans. D
Hemochromatosis - Hypogonadism is also irreversible.

@ Pediatrics Shown in Fig is a female newborn child .An antenatal

diagnosis of this condition can be made by demonstrating
increased levels of which of the following in amniotic fluid:

https://encrypted-tbn2.gstatic.com/images?q=tbn:ANd9GcTkdwDMcifkJTQ-A-okR8Nr1HpxEWdRyI4ZSLUITJqtHsoJqAc
A.
DHEA sulfate
B.
17-hydroxyprogesterone
C.
11-deoxycortisol
D.
None
Ans. B
CAH in female

@ Orthopedics
Dual-energy x-ray absorptiometry scan , radiograph and bone biopsy of a 72-yearold woman is presented in Fig

http://img.medscapestatic.com/pi/meds/ckb/47/39347.jpg

http://img.medscapestatic.com/pi/meds/ckb/46/39346.jpg

http://www.clinicalimagingscience.org/articles/2014/4/2/images/JClinI
magingSci_2014_4_2_1_129262_u5.jpg
Which of the following is true about the diagnosis?
A.
Ca++
B.
PO4
C.
Alkaline phosphatase
D.
All
Ans. C
Dual-energy x-ray absorptiometry scan of a 72-year-old woman with Paget disease
of the lower leg and typical bowing
Radiograph showing typical bowing.

Hematoxylin and eosin stained biopsy tissue (100) shows immature bone
either with osteoid and osteoblastic rimming, reversal lines, and
enough fibrovascular stroma (arrow)

@ Radiology

http://www.nature.com/nrendo/journal/v3/n6/images/ncpendmet051
3-f1.jpg
The imaging finding shown in Fig is because of which of the
following content:
A.
Carbohydrate
B.
Phospholipid
C.
Glycoprotein
D.
Hormone
Ans. B

Pituitary bright spot on MRI

@ Surgery

http://diseasespictures.com/wp-content/uploads/2013/02/GravesDisease-3.jpg
The following are risk factors for the condition shown in Fig except:
A.
Iodine deficiency
B.
Smoking
C.
Stress
D.
Postpartum period
Ans. A
Grave's disease - Iodine excess is a risk factor.

@Surgery
A 72-year-old male initially presented with left thyroid
enlargement. The patient was clinically and biochemically
euthyroid and without family history of thyroid disease,
malignancy or personal history of radiation exposure. Fine
needle aspiration is shown in Fig

http://images.radiopaedia.org/images/2124207/61695e7f081e707a8
58a179dd1e313_big_gallery.jpg

https://c1.staticflickr.com/9/8301/7782080648_618b75eecc_b.jpg
The following are true about papillary carcinoma thyroid except:
A.
Pathologically characterized by psammoma bodies.
B.
Orphan Anne nuclei
C.
Lymphatic spread
D.
Poor prognosis
Ans. D

Ultrasound revealed a 1.5 cm right thyroid nodule

Fine needle aspiration was suspicious for papillary thyroid
carcinoma with hypercellular sheets and papillary
arrangements of cells with occasional nuclear grooves

@ Pathology

The above shown histology of thyroid is a poor prognostic factor for:

A.
Papillary carcinoma thyroid
B.
Follicular carcinoma thyroid
C.
Anaplastic carcinoma thyroid
D.
Medullary carcinoma thyroid
Ans. B
Hurthle cell histology

The thyroid follicular cells undergo metaplastic changes as a

result of continuing inflammatory cell damage resulting in
so-called Hurthle cell or more appropriately Oxyphil
cell change. These cells are larger with abundant finely
granular eosinophilic cytoplasm and enlarged nuclei that
may show some atypia (arrow). The oxyphil thyroid
follicular cells either do not produce any thyroid
hormones or produce it in negligible amounts. Note the
presence of abundant lymphoplasmacytic infiltrate
around follicles (curved arrow).
@ 166. Biochemistry
A 67 year-old man with a history of hypertension and end stage
renal disease on hemodialysis presented with the findings shown in
Fig . . The lesions were painful but not pruritic . An enzyme-linked

immunosorbent assay was positive for hepatitis C virus antibody, and

serological tests were negative for other viral causes of hepatitis. The
following are true about this condition except?

http://www.dartmouth.edu/~thabif/weeklyclinic111901/pictures/19p
orphyriact.jpg

http://imaging.ubmmedica.com/consultantlive/images/articles/2007/
01092007/0709Con1PCTardaB.jpg
A.
Cutaneous photosensitivity
B.
Neurological manifestations include autonomic neuropathy.
C.
Patients are at risk to develop hepatocellular carcinoma
D.
Treatment includes phlebotomy
Ans. B
Porphyria cutanea tarda - No neurological manifestations
observed.
A 67 year-old man with a history of hypertension and end stage renal
disease on hemodialysis presented with a blistering skin rash on his hands
and face. Two weeks prior, the patient noticed blisters on his right and left
hands; a blister on his lower lip developed and burst. The lesions were
painful but not pruritic. On exam the patients blood pressure was
elevated, but he was afebrile and vital signs were otherwise normal. His
non- dermatologic exam was normal. The skin exam revealed a swollen,
hypopigmented lower lip, and multiple flesh- toned plaques and ulcers on

palmar and dorsal hands. No vesicles were intact, and there were no
lesions on his trunk, lower extremities, or genitals. An HIV ELISA was
negative, but the hepatitis C (HCV) viral load >100,000/mL. Fractionated
plasma porphyrins were elevated with uroporphyrin 262.4 mcg/L
(<0.2mcg/L), heptaporphyrin 214.4 mcg/L (<0.2mcg/L), hexaporphyrin 7.8
mcg/L (<0.3mcg/L), pentaporphyrin 81.5 mcg/L (<0.4mcg/L) and
coproporphyrin 12.8 mcg/L (<0.8mcg/L). Skin biopsy of the right hand was
consistent with porphyria cutanea tarda (PCT). Based on the presence of
elevated plasma porphyrins and characteristic skin biopsy, the patient was
diagnosed with PCT.

@Medicine

MostlikeyhistoryofthepatientwithECGshowninFigis

a) A38yearoldfemalewithh/opalpitations,diffuse
enlargementofthyroid
b) A42yearoldpatientsufferingfromsepsiswith
hypothermia
c) A49yearoldfemalewithMitralstenosistakingdigoxin
d) 54 year old man with schizophrenia, bipolar affective
disorde who developed ventricular fibrillation
AnsD
The classic ECG pattern of Brugada is pseudo-RBBB with ST segment elevation in leads V1 through
V3 . Clinical manifestations are nine times more common in men than women and more common in
Southeast Asian populations. The pathophysiology is related to a defective myocardial sodium channel
gene (SCN5A) in most patients, with variably penetrant autosomal dominant inheritance.
However, the syndrome is clearly heterogenous since the characteristic ECG findings can be seen with
early right ventricular dysplasia, cocaine abuse, and certain psychotropic drugs. AICD implantation is
the definitive treatment for Brugada syndrome, though one study suggests that administration of highdose quinidine prevents arrhythmia while being both less expensive and less invasive. A proper
diagnosis of Brugada syndrome will further allow the internist to screen the patient s family through
regular ECG testing and to counsel avoidance of common medications that can precipitate a ventricular
fibrillation pattern, including tricyclic anti-depressants and sodium channel blockers.

@ Pathology
Peripheral smear shown in Fig is seen in:

http://www.mclno.org/webresources/kbase/cellatlas/cell
%20images/Acanthocyte.jpg
A.
Uremia
B.
Prosthetic valve
C.
Cirrhosis
D.
Folate deficiency
Ans. C
Acanthocytes

@ pHARMACOLOGY
Liver histopathology is shown in Fig .The following drugs must
be avoided in this patient except:

https://upload.wikimedia.org/wikipedia/commons/9/94/Cirrhosis_high
_mag.jpg
A.
Indapamide
B.
Paracetamol
C.
Diazepam
D.
Aspirin
Ans. B
Cirrhosis
Paracetamol can be given in a dose of less than 2g/ d.
@ Pharmacology A 44 year old female presenting with pruritis with
serologic positivity of anti-mitochondrial antibodies. Her Liver biopsy
is shown in Fig .All of the following is used to treat this condition
except ?

http://www.ojrd.com/content/figures/1750-1172-3-1-1-l.jpg
A.
Ursodiol
B.
Cholestyramine
C.
Zinc supplementation
D.
Pegylated interferon
Ans. D

Primary biliary cirrhosis, demonstrating chronic non-suppurative

destructive cholangitis (stage 1 of Scheuer's classification).
@ Medicine
A 47 year old patient with antiphospholipid syndrome
presented with abdominal pain . The physical findings and
angiogram are shown in Fig .Which of the following is not a
clinical feature of this condition ?

http://api.ning.com/files/YbGJ6hGc0xTcxW5c8K4CV2KyU35phR8yf1X7tJweMfglSCHTeV96q4RM0f1rglN/

NewPicture.bmp?width=399&height=600

http://images.radiopaedia.org/images/1363866/95b1e965fe3b6897b
06902cef949fc.jpg
A.
Tender hepatomegaly
B.
Intractable ascites
C.
Increased JVP
D.
Right upper quadrant pain
Ans. C
Spider web appearance - Budd - Chiari syndrome
@Surgery A 75 year old patient with refractory peptic ulcer . His CT
abdomen image is shown in Fig . The most sensitive test for
diagnose of this condition is:

http://lh3.ggpht.com/-cZnHu4jiduo/UtHgserCCI/AAAAAAAAOZE/35r4sHz2nmw/image_thumb1.png?
imgmax=800
A.
BAO/MAO >0.6
B.
Increased fasting gastrin
C.
Calcium infusion study
D.
Secretin stimulation test
Ans. D

Radiology images of gastrinoma in a 75-year-old man. Transverse

precontrast CT identifies enlargement of the pancreatic head (arrow).
@ Pathology

http://jcp.bmj.com/content/62/6/481/F6.large.jpg
The following are causes of the condition shown in Liver biopsy in
Fig except:
A.
Alcoholic liver disease
B.
Reye's syndrome
C.
Syndrome X

D.
Lipodystrophy
Ans. B
macrovesicular hepatic steatosis
Microvesicular fat.
@Surgery
A 57-year-old alcoholic man is being treated for acute hemorrhagic
pancreatitis. He was in the intensive care unit for 1 week, where he
required chest tubes for pleural effusions and was on a respirator for
several days. Eventually, he improved sufficiently to be transferred to the
floor. Three days after leaving the unit, and about 2 weeks after the onset
of the disease, he spikes a fever and develops leukocytosis The following

are risk factors for his condition except:

http://www.joplink.net/prev/200605/07_fig01.jpg
A.
B.
C.
D.
Ans.

Post-op pancreatitis
Early laparotomy
Injudicious use of antibiotics
Late oral feeding.
D
Early oral feeding risk factor.
pancreatic abscess

Contrast-enhanced computed tomography (CECT) of the abdomen

showing two hypodense collections with a thick enhancing wall
(pancreatic abscess).
@ Medicine
Which of the following is not a feature of the condition shown in a a
32-year old woman from Kolkata presenting with hempptysis and lung
biopsy was done ?

http://www.aafp.org/afp/2005/0315/afp20050315p1062-uf1.jpg

http://images.rheumatology.org/image_dir/album75674/md_05-120115.jpg
A.
Granulomatous vasculitis of upper respiratory tract
B.
Granulomatous vasculitis of lower respiratory tract
C.
Granulomatous glomerulonephritis
D.
All are true
Ans. C
Chest radiography showing a large infiltrate with a central cavitation in the
right upper pulmonary field.
Right upper lobe lung nodule biopsy from a 32-year old Asian woman showed
a necrotizing granuloma of loosely arranged mononuclear and
polymorphonuclear leukocytes with giant cells (left, low power),
consistent with diagnosis of Wegeners granulomatosis. High power
close-up of Langhans giant cell (right), characterized by peripheral
localization of nuclei. (haematoxylin-eosin, low and high power of same
lesion)
Granulomas are only rarely seen on renal biopsy.

@ Medicine
A 32 year old patient sexually active male with single partner
without promiscuity presented with blurring of vision and
findings as shown in Fig . His diagnosis is characterized of all
except

https://www.rareconnect.org/uploads/assets/behcet-s-photos/singleoral-aphthous-ulcer.JPG

https://upload.wikimedia.org/wikipedia/commons/a/a0/Hypopyon.jpg
A.
Oral ulceration
B.
Genital ulceration
C.
Pathergy test positivity
D.
pANCA positivity
Ans. D
Behcet's syndrome A person with hypopyon which can be seen in

anterior uveitis in a patient with Behcet's disease

@ Medicine
The physical and radiologic features of 34 year old female from
Mumbai presenting with pulmonary hypertension are shown in
Fig .The following are increased in patients with this diagnosis
except:

http://www.immunologyclinic.com/jpg/300_96dpi/HH8_300.jpg

http://images.radiopaedia.org/images/130254/88c9ef8dc8ecd819c9
2dedcb755332_big_gallery.JPG
A.
EDRF
B.
ICAM-1
C.
von Willebrand factor
D.
Endothelin
Ans. A.
systemic sclerosis EDRF not increased appropriately,
suggesting impaired synthesis.

@ Pediatrics

A 12 year old child with past h/o measles that subsided presents
with myoclonic seizures .His neuroimaging findings are shown
in Fig . Which is not true regarding his diagnosis?

http://www.infobik.com/wp-content/uploads/2011/11/SSPE.jpg
A.
Chronic form of measles encephalitis
B.
associated with defective measles versus
C.
Antibody response to measles
D.
Common in children who develop measles before the age of 2
Ans. C
High levels of antibody to measles versus in blood andCSF.