Quiz based in MBBS syllabus

1. SYNAPSE 2019
Senior Medillectuals
MAINS

2. ROUND 1

3. Rules
• There are 6 teams and 12 questions.
• Each team will cyclically face two questions.
• Question for the slotted team can be answered by the team
itself. Points: +20,0
• Or by other teams by using “Pounce”.
• Pounce window will be of 15 seconds. Points for Pounce:
+30, -15
• Self- Pounce: The slotted team can pounce upon its own
question to get more points.
• You need to get the answer completely correct on pounce
to score points, else it’ll be taken as a complete negative.
• If the slotted team is unable to answer it will be passed on
to the next team. Points: +10/0

4. Q1 Identify the algorithm, and its use

6. A1
• Brugada Algorithm
• To determine whether a wide complex
tachycardia is from ventricular tachycardia or
supraventricular tachycardia with aberrancy.

7. Q2
• An 18-year-old woman presented with a history of reduced sleep, increased
talk, irritability, and aggressive and abusive behaviour of 2 weeks duration.
She was diagnosed with bipolar affective disorder and treated with lithium
(800 mg/day), carbamazepine (600 mg/day), chlorpromazine (200 mg/day)
and benzhexol (4 mg/day). Ten days after starting the medication, she
developed high-grade, intermittent fever and erythematous maculopapular
lesions over the neck and face spreading to other parts of the body. By day
13, the lesions had spread all over the body including the palms and soles,
involving more than 90% of the total body surface area. The distribution of
the lesions was symmetrical. A mucopurulent discharge was seen on the
oral, nasal and conjunctival mucous membranes and there was
haemorrhagic crusting of the lips. The eyelids were matted with a purulent
discharge. The Nikolsky sign was found to be positive. By day 14, many
lesions had become bullae, and bullous lesions involved about 20% of the
body surface area.
• What is the diagnosis? Name the score used for assessing mortality in this
condition.

9. A2
• Diagnosis: SJS/ TEN overlap (10-30% skin
involvement is overlap)
• The SCORTEN scale (SCORe for Toxic Epidermal
Necrosis) is a severity-of-illness scale with
which the severity of certain bullous
conditions can be systematically determined.

10. Q3
• 2 brothers are diagnosed to have
diseases on the same clinical
spectrum. The first one has no
complaints except the incidental X Ray
findings, while the second brother has
full blown MM.
• A) State the treatment of choice for
the first brother
• B) The second brother is started on
LBD therapy for induction. Name two
extremely specific drug prophylaxis he
needs to take along with this line of
therapy.

12. A3
• A) Local radiation
• B) Acyclovir, Heparin

13. Q4
• A 64 year old patient was complaining of a breast mass and
pain at the left hip. She was diagnosed with breast cancer
with multiple bone, lung and lymph node metastases. She
received treatment with local radiotherapy delivered to the
breast tumor and some of the bone metastases but did not
receive chemotherapy due to her poor performance status.
However, 10 months after radiotherapy, spontaneous
regression was observed, not only within the irradiated field,
but also in the non-irradiated areas. All signs of cancer
throughout the body disappeared, and the patient's
performance status drastically improved. Explain.

15. A4
• Abscopal Effect: hypothesis in the treatment of
metastatic cancer whereby shrinkage of untreated
tumors occurs concurrently with shrinkage of tumors
within the scope of the localized treatment. R.H.
Mole proposed the term “abscopal” (‘ab’ - away
from, ‘scopus’ - target) in 1953 to refer to effects of
ionizing radiation “at a distance from the irradiated
volume but within the same organism.”

16. Q5
A 70-year-old man was admitted to the medicine ward with
complaints of fever, jaundice, dyspnea, and generalized rash
after 3 months of allopurinol treatment for gout. On physical
examination, he was found to have fever (38.5°C), jaundice, and
generalized maculopapular rash. Leukocytosis, eosinophilia,
elevation of liver enzymes, and hyperbilirubinemia were
detected in his blood analysis. Skin biopsy is shown.
What is the diagnosis?
Allopurinol treatment was stopped and steroid treatment was
launched. At day 24 of admission, the patient died because of
multiple organ failure.

19. A5
• Allopurinol induced DRESS syndrome (Drug
Reaction with eosinophilia and systemic
symptoms)

20. Q6
Connect

22. A6
All are a/w Dupuytren’s contracture
•Diabetes
•Peyronie's disease
•Alcohol
•Nodular plantar fibromatosis
(Ledderhose disease)

23. Q7
• A pregnant female, multigravida G3P2L1A1,
with a POG of 27weeks +4 days came to ANC
OPD for a routine checkup. Patient has no
significant past history. On obtaining her
previous obstetric history, the obstetrician
ordered an investigation as shown below.
• Name the ordered test and its principle.

26. A7
• 1. Kleihauer–Betke ("KB") test based on the
Acid elution principle, is a blood test used to
measure the amount of fetal hemoglobin
transferred from a fetus to a mother's
bloodstream.

27. Q8 Connect
X ray Skull of a 2 year old
boy

28. A8
• Apical Lung Lesions – TB, Silicosis, Langerhans
Cell Histiocytosis, Pneumocystis jirovecii
pneumonia

30. Q9
• A patient admitted in the medicine ward was diagnosed with
ARDS due to severe pneumonia complicating cor pulmonale
He was started on low volume tidal ventilation with oxygen
therapy. The target PEEP was 10.
• Now, after 48h, the patient has an SpO2 of 88%, Ph 7.25 and
RR of 40/min with a BP of 100/70. He is currently afebrile.
• What are the next steps in complete management of this
patient (based on class A and B recommendations?)

32. A9
• Acidosis correction
• Diuresis with MAP>65
• ECMO +/-
• NM blockade

33. Q10
What is this?
ID purpose

35. A10
• REBOA (Resuscitative Endovascular Balloon
Occlusion of Aorta)
• To control hemorrhage and to augment
afterload in traumatic arrest and hemorrhagic
shock states.

36. Q11
A 56 years old female patient presented with chronic otitis after she
was unsuccesfully treated with antibiotics for several months in
another medical facility. Patient had a long history of left-side
otorrhoea and unilateral hearing loss along with ocasional vertigo
and headaches. Peripheral facial palsy ensued (Grade 4 according
to House-Brackmann Scale), with general deterioration and various
psychological symptoms.
The otoscopic finding is shown. After an accurate diagnosis was made
and susceptibility testing was established , she was treated accordingly.
She presented some months later with complaints bilateral hearing loss,
tinnitus , and episodes of vertigo. The audiograms corresponding to the
first and second presentation are shown. Give the diagnosis and explain
the audiograms

37. First
Second

39. A11
• Tuberculous OM later developing ototoxicity of MDR-
TB ATT. Hence, the second graph is showing high
frequency hearing loss.

40. Q12
• In a particular study, researchers are interested in
knowing whether the pulse rate of long distance
runners differs from that of other athletes. They
randomly sample 8 such runners and obtain the
following pulse rates:
45,42,64,54,58,49,48,56
The average resting pulse of athletes in general
population is 60/min.
Is the data significant at 0.05 level of significance?
(given SD= 7.3; t value = 2.365)

42. A12
• H0= Pulse of long distance runners=60
• HA= Pulse of long distance runners differs from 60
• Mean=416/8= 52
• SS= 374; s2 = 53.4; s= 7.3; SE= 2.6
• df=7
• t= (52-60)/2.6= 3
• tcrit at alpha 0.05= 2.365
• Reject null hypothesis, there is a difference.

43. Q16
Which investigation is being
performed?
AUDIENCE

44. Answer
• Enteroclysis (small bowel enema)
• Contrast injected through a tube into the
small intestine, to visualise jejunum to
ileocecal junction

45. ROUND 2- CATEGORIES

46. RULES
• Team with the highest points gets to go first.
• You will be given 2 clinical scenarios, and 45
seconds time to study each scenario.
• There will be 6 rapid fire questions in each
scenario, 60 seconds will be given for the
rapid fire.
• The time left at the end of the rapid fire will
be your score.

47. 1. EM ROOM
2. OT
3. WARDS
4. LABOUR ROOM/NURSERY
5. RADIO
6. BLOOD BANK AND THE LABS
CATEGORIES

48. EM ROOM 1
• 1. 5y old, 30 kg child.
Face spared

49. Q
• 1. Assuming there were deep burns noted around the
mouth and neck along with stridor, what would be the
a) time window and
b) maximum time for which, the prophylactic
intubation would be done?
• 2. Amount of fluid to be given in the first 8 hours?
• 3. If during fluid therapy, the patient begins to develop
signs of hypoperfusion, what is the next step in
management?
• 4. What complication might the patient land up with if
Mafenide is used in dressing the wound?
• 5. Name atleast 2 feeding formulae used to assess
feeding of a burns patient?

50. • 1. a) between 4-24 hours
b) 48 h
2. 4.4 L
3. Bolus 10mg/kg
4. Metabolic acidosis
5. Curreri, Sutherland, Davies

51. EM ROOM 2.
• A patient presents to the ER after a
neurosurgical clipping procedure done to treat
the Berry aneurysms arising from the internal
carotid artery. On examination, the patient is
found to have right sided hemiplegia with
hemianaethesia and homonymous
hemianopia. The patient, however, described
these defects as mild and showed significant
improvement in the next few days.

52. Q.
• 1, ID the culprit vessel.
• 2. Why was there minimal deficit noticed in this case?
• 3. On catheterising a patient with stroke under
treatment, if one single size Foley’s has to be chosen
for a single careful attempt, what would it be?
• 4. Assuming the patient had been put on IV
anticoagulation for the surgery 3 days ago, would you
choose to thrombolyse the patient?
• 5. In case the hemianaesthesia was replaces with a
severe burning pain in the affected area,
• A) The affected structure
B) this syndrome would be known as?
Back to categories

53. • 1. Anterior choroidal artery
• 2. Well developed collateral supply from PCA
and MCA
• 3. 16-20F
• 4. Yes
• 5. A) Thalamus
B) Dejerine Rousseau syndrome

55. OT1
• A 10 year old child is to be taken up for
excision of a lower abdominal mass of
uncertain etiology.

56. Q
• 1. What is the preffered method of induction?
• 2. Which anaesthetic drug may have a dreaded side
effect of chest wall rigidity?
• 3. Spinal needles are classified on the basis of which
part?
• 4. Delirium would be seen in which stage of
anaesthesia?
• 5. Recently, point of care tests like
Thromboelastography have been approved for which
purpose in trauma patients?
• 6. Name the maneuver

57. • 1. Inhalational
• 2. Fentanyl
• 3. Tip
• 4. stage 2
• 5. Need for blood product transfusion
• 6. Sellick maneuver

58. OT2
• A 40 y old male presented in the surgery OPD with suspected
perforation peritonitis. He was given a dose of IV antibiotics and
prepped for surgery. He was then taken up for an immediate
surgery. However, due to dense matting of the bowel loops, the
surgery went on for 6 hours and approximately 150 cm of small
bowel (with the ICJ) was left; the rest was removed and an
anastomosis was done.
• 4 days post-op the man developed fever. He was given aggressive IV
antibiotic therapy for the same.
• A month later, he again presented with complaints of altered
sensorium and slurring of speech. He also complained of severe gait
ataxia. NCCT Head was WNL excepr for mild cerebral edema. An
ABG was suggestive of High anion gap metabolic acidosis with
normal lactate levels.

59. Q
• 1. What could be the most common cause of
fever in this patient post op?
• 2. How could it have been prevented intra-op?
• 3. Diagnosis of the condition a month later?
• 4. Which is the preferred suture for a bowel
anastomosis?
• 5. Why would this patient be more prone to
develop renal stones?
• 6. Expand STEP surgery for this condition.
Back to categories

60. • 1. SSI
• 2. Repeat a dose of IV antibiotics intra op
• 3. d-lactic acidosis
• 4. Vicryl
• 5. free oxalate
• 6. serial transverse enteroplasty

62. WARD 1.
• An 36 year old male patient with a history of
Type 1 DM & chronic smoking, and presenting
with DKA is admitted in the Medicine Ward.
He had a short history of abdominal pain with
repeated vomiting. You are instructed by the
DOD to obtain an ABG of the patient. You
proceed to do so from the Radial artery.

63. ABG
• pH 7.27
pCO2 27
HCO3- 12
Na 140
K 4.8
Cl 98
BS 355

64. Q.
• 1. Diagnose the ABG
• 2. In such a case vignette, what is the most important
precaution/ thing to be checked for (in respect of the
patient) before you obtain the ABG?
• 3. Suppose you have to obtain additional samples for a
Hemogram, coagulation profile and a Renal profile, along
with the ABG of the patient. State all the anticoagulants
involved in the process.
• 4. Explain: the patient is dehydrated despite a normal
serum sodium level.
• 5. Is Bicarbonate replacement necessary in this patient?
• 6. As instructed by the DOD, how frequently do you need to
monitor the dextrose and ABG of the patient for the first 24
hours, once stable?

65. • 1. High AG metab acidosis with metab alkalosis
• 2. Allen test
• 3. Heparin, EDTA, Na citrate
• 4. Hyperglycemia correction; 1.6 meq reduction
for each 100 mg/dl rise in s. glucose
• 5. No, ph>7
• 6. dextrose 1-2 h
ABG every 4h for 1st 24 h

66. WARD 2.

67. Q.
• 1. Treatment of choice in patient?
• 2. If the TOC is not available, what alternative can be used
till it is made available?
• 3. If the child doesn’t have dehydration anymore, but
diarrhoea still persists beyond 14 days, name the antibiotic
of choice is this case.
• 4. Assuming the child is 11 months of age, when and how
much Vitamin A should be given to him?
• 5. Name the transporter exploited by ORS to maintain
hydration.
• 6. Assuming the child presents to you on his second
birthday with a similar history. Why/why not will you
immunise him against Rotavirus?
Back to categories

69. A.
• 1. IV fluids: RL/NS
• 2. orogastric feeding
• 3. none
• 4. stat dose of 1 lakh IU
• 5. GLUT
• 6. Low prevalence of rotavirus as a cause of
diarrhoea over 1 year.

70. LABOUR ROOM 1.
• An unbooked primigravida of 34 wks POG presents to the
casualty with complaints of headache since morning, several
episodes of vomiting and abdominal discomfort.
• O/E: BP: 180/110, fundus: papilloedema, microscopic
hematuria with 3+ albumin.
• Umblical artery Doppler:

71. Q.
1. Tell me the step-wise sequence of drug therapy before the
definitive management in this case?
2. What is the definitive management in this case at the current
POG?
3. What is the rate at which the BP should be lowered in this patient,
assuming she’s had this complaint for 5 months?
4. Smoking is said to decrease the likelihood of this condition by
upregulation of which molecule?
5. If at a point, the patient develops a low RR with reduced DTRs,
what must be done before or concomitantly with administration
of calcium gluconate?
6. On P/V examination during the first stage, the fetal head is in
partial extension with 3 bony points being felt. Name the engaging
diameter in this case.

72. • 1. Inj. Mgso4-antiHTN-T.O.P
• 2. Immediate TOP
• 3. Immediate
• 4. Adrenomedullin
• 5. Stop MgSo4 and send serum levels
• 6. none

73. LABOUR ROOM 2.
• The woman is blessed with a son, who did not
cry immediately after birth…

74. Q.
• 1. The Apgar score at 1 minute is 1. What change is to
be made in the initial resuscitative steps?
• 2. After 30 sec, the heart rate is 72/min and the child is
not breathing. Next step?
• 3. If the child is born through meconium stained liquor,
what size of suction catheter is to be used for
suctioning the ET tube?
• 4. Size of ET tube used for an extremely low BW baby.
• 5. 2 IM injections to be given in routine care to the
newborn.
• 6. The child was born at 34 wks gestation. Which
component of Moro’s reflex will be present?

75. • 1. No change
• 2. PPV with spo2 monitoring
• 3. No need to do
• 4. 2.5 mm
• 5. VitK, HepB
• 6. extension, abduction, hand opening
Back to categories

77. BLOOD/LABS 1.
• A polytrauma patient with severe crush injury was brought
to the ER in severe hypovolemic shock. An urgent blood
transfusion call is sent to the Blood bank. They are quick to
release the blood (under ULS ;) and the infusion is started.
Immediately, the patient develops widespread wheals on
the body with generalised itching and discomfort. The
blood is re-evaluated for the Blood group. It is re-confirmed
to be O-ve.
• A few weeks later, the patient was transfused 2 pack FFP
and an equal volume of platelets. He had also been given
the same on his initial presentation. He developed fever,
severe hypoxemia with respiratory distress and
cardiopulmonary decompensation and passed away soon.

78. Q.
1. Identify the INITIAL type of reaction.
2. What is the next step in it’s management?
3. On closer analysis, it is revealed that the patient’s blood
may have deficiency of a certain antigen, making them
susceptible to reactions on transfusion of O-ve blood as
well. This is incredibly rare. What is the mode of
inheritance of this antigen?
4. SECOND REACTION: ID the type of cells responsible.
5. Exclusion of which group of population from the blood
donors would reduce this complication?
6. Assuming the patient was started on 2 units of RL IV
during transportation and 2 packs FFP on presentation.
What is the amount of PCV needed according to the ATLS
guidelines?

79. A.
• 1. Allergic urticarial reaction
• 2. don’t stop transfusion, antihistaminics
given.
• 3. autosomal recessive
• 4. Neutrophils
• 5. Multiparous woman
• 6. 2 PCV

80. BLOOD/LABS 2.
• 65 year old man with a history of severe chest
pain since 30 minutes, not relieved on rest.

81. • 1. TropT vs TropI in Renal impairment?
• 2. What modification is suggested to increase the
specificity of CK-MB in diagnosing MI?
• 3. You have used a 10 ml syringe to draw blood from
this patient for various tests. Pick up the vials in the
correct order of draw of blood.
• 4. Antibodies to vWF will derange what: BT, PT, aPTT,
Ristocetin aggregation time?
• 5. The enzyme responsible for attachment of glucose
to the hemoglobin molecule, estimated as HbAIc?
• 6. I would be staining my PS with brilliant cresyl blue to
stain what compund?

82. A.
• 1. Trop I
• 2. Dividing mass by activity
• 3. Blood culture-blue-red-lavender-gray
• 4. All
• 5. none
• 6. rRna
Back to categories

84. RADIO 1
• A 56 year old obese
male presents to the
OPD with complaints
of intermittent
claudication and the
following investigation
done previously:

86. Q
• 1. ID the investigation
• 2. In case the patient is a poorly controlled diabetic, why
might one choose an alternative investigation over this?
• 3. What could be one reason this investigation was chosen
over the standard duplex scan?
• 4. A repeat investigation over a few weeks later revealed: ID
the complication
• 5. In the first image, Assuming this is the only involved
unilateral vessel involved by this process, what will the
treatment of choice?
• 6. Which finding and what value of that, on physical
examination is the most important predictor of imminent
gangrene?

87. • 1. DSA
• 2. impaired renal function since dye is needed
• 3. obese patient, difficult visualisation, OR
intervention may be planned
• 4. false aneurysm
• 5. Bypass grafting
• 6. ABPI <0.3

88. RADIO 2.
• A middle aged man presented to the ER with
pain and swelling in his right hand after a fall
on his outstretched hand. There was pain on
axial compression of the thumb and on
moving it.
X ray on presentation:

89. Q
• 1. Identify the most probable fracture.
• 2. X is the most specific site to be palpated to elicit
tenderness in this fracture. Name it’s boundaries
• 3. In case an MRI is not available, what may be done to
radiologically confirm the diagnosis in the standard
view?
• 4. What specific view can be used to diagnose this
fracture instead?
• 5. What is the film- thumb distance to obtain a
desirable radiograph?
• 6. Most specific complication of this fracture?
Back to categories

90. answers
• 1. fracture scaphoid
• 2. EPL, EPB, AbPL
• 3. repeat after 10-15 days
• 4. 15 deg oblique view
• 5. 100 cm
• 6. Non union due to AVN

92. AUDIENCE
• CONNECT:

93. BIDDING

94. RULES
• There are 6 teams and 6 questions.
• Once presented with the question, you may place
your bids.
• Minimum bid of 10 points. Max 50
• Correct answer gets you same number of points
as your bid.
• Incorrect answer deducts half the number of
points as you bid.
• Each team bids individually

95. Q1
• A 65 yr old female presented to the ER with complaints of severe dyspnea, central cyanosis
and undocumented fever. She complained that she’d this gradually rising breathlessness
since several decades now, but it often exacerbated like this occasionally. She complained
that she now has to stop and catch her breath even after walking short distances.
The patient had a 35-40 year history of working on the chulha, but had moved to the city 5
years ago and subsequently shifted to gas cylinders. On further enquiry, it was revealed she
had been quite compliant with her medications, which included MDI Salbutamol sos, with
MDI Formeterol, Budesonide and Tiotropium OD. She had been in and out of the ER with
similar complaints 4-5 times in the last year.
O/E: PR: 110/min, irregularly irregular, RR: 38/min, spO2: 84%
BP: 120/78, Temp: 102 deg F
Old spirometry record: FEV1 <50% with CXR changes s/o chronic bronchitis
The patient was immediately started on emergency treatment. An ABG and ECG (shown on next
page) were obtained. Serum electrolytes and all other investigations were WNL.
After the episode, what add-on therapy would be recommended before the patient is to be
discharged, considering her clinical scenario and investigations?

98. Q2
Diagnose the acid base disorder and give a plausible
explanation for each component
• A young alcoholic man was found by the police to be unconscious by
the roadside. He was completely soiled in his own vomit. On
admission, his ABG and routine investigations were obtained and
were as follows:
• pH 7.17 Hct 32%
pCO2 65 BG 56
HCO3 22 s. lactate 1.5 mmol/L
Na 136 s. albumin = 1.6
K 3.4 T. protein = 6.6
Ca 9.1

100. Q3
• Patricia lost her husband Paul to cancer at age 50, in January 2018. They were very close. Twenty years
later she still describes his death as the hardest thing she ever went through. She had a vivid memory of
the night Paul died.
She was surprised at how strange she felt afterward. Even though she had known he was dying, it was
hard to comprehend the fact that he was really gone. This was very different. For the first month after
Paul died, Patricia could think about little else. She felt intense feelings of yearning and longing for him,
often to the extent of wanting to join him in the afterworld immediately. She was grateful that her
friends and family brought food and made sure someone was always with her. Their kind words and
gentle encouragement weren’t really comforting, but it seemed important that they were there. Several
times, she found herself smiling and remembering the good times in their company.
Patricia felt her mind was in a fog and she had little control over her emotions or her thoughts. She
knew she wasn’t herself. She kept having a strange sensation that Paul would walk through the door.
Once, she had awakened in the middle of the night to see him standing at the foot of the bed. He
seemed to be saying something but she could not understand him. Organising several things around the
house in a proper sequence, something she’d been extremely particular about, however it did not seem
as important now. She developed insomnia, which was only variably relieved on OTC medications.
• As July came along, the monsoon showers helped her ‘lift’ the veil of sadness. She started focusing her
mind back on her job, although Paul still ‘visited’ her every night and they had a conversation, although
not as frequently.
• On Paul’s birthday, however, Patricia was overcome with sorrow and uncontrollable crying. She decided
to visit a counsellor and seek pharmacotherapy. What would your diagnosis as per DSM V and the
treatment opinion be for the patient?

102. COMMON SYMPTOMS OF ACUTE GRIEF THAT ARE WITHIN NORMAL LIMITS WITHIN
THE FIRST 6–12 MONTHS AFTER
•Recurrent, strong feelings of yearning, wanting very much to be reunited with the
person who died; possibly even a wish to die in order to be with deceased loved one
•Pangs of deep sadness or remorse, episodes of crying or sobbing, typically
interspersed with periods of respite and even positive emotions
•Steady stream of thoughts or images of deceased, may be vivid or even entail
hallucinatory experiences of seeing or hearing deceased person
•Struggle to accept the reality of the death, wishing to protest against it; there may be
some feelings of bitterness or anger about the death
•Somatic distress, e.g. uncontrollable sighing, digestive symptoms, loss of appetite, dry
mouth, feelings of hollowness, sleep disturbance, fatigue, exhaustion or weakness,
restlessness, aimless activity, difficulty initiating or maintaining organized activities,
altered sensorium
•Feeling disconnected from the world or other people, indifferent, not interested or
irritable with others

104. Q4• 12-year-old girl presented with cervical lymphadenitis and liver dysfunction, which she had since 1
month prior to presentation. Physical examination showed no abnormalities except for slight swelling of
the right cervical lymph nodes.
• Initial laboratory results: normal complete blood cell count, with an elevated aspartate
aminotransferase AST, ALT and anti-CMV immunoglobulin M (IgM) antibodies (3.08). Based on these
results: first diagnosed transient liver dysfunction due to CMV infection. As CMV is self limiting, Patient
was discharged but was lost to follow up.
• Two months after our examination, the patient returned with recurrent fever, and palmar erythema. On
examination, her vital signs were normal . Her neurologic exam also was normal. Nikolsky’s sign was
negative, there were no mucosal erosions or blisters. Abdominal examination did not reveal
hepatosplenomegaly. Investigation: -leucopenia and thrombocytopenia (white blood cell count,
5000/μL; neutrophil count, 4075/μL; lymphocyte count, 650/μL; hemoglobin level, 12.3 g/dL; platelet
count, 12.3 × 104/μL).
• Her international normalized ratio, partial thromboplastin time, and C-reactive protein level were within
normal limits, and her serum creatinine level was 0.77 mg/dL. Liver dysfunction showed slight
improvement compared with the assessment performed 2 months prior (AST level, 76 IU/L; ALT level, 77
IU/L).
• ANA positive. DNA Immunofluorescence showed : Anti-Ro, anti-La, anti-Sm, and anticentromere
antibodies were also negative. Anti-CMV IgM antibodies were elevated (4.16), as were anti-CMV IgG
antibodies (9.1) (EIA; positive titer, >4.0). CMV DNA was detected in her urine, but not in her blood, by
polymerase chain reaction (PCR). Her twenty-four-hour urinary protein level was 2.4 g/d. Renal biopsy
was performed.
• Diagnosis? With explanation

107. Q5
• A 56-year-old male was admitted with history of alteration of
sensorium and inability to move his left upper and lower
limbs. Onset of the symptoms was following head injury on
the left side due to fall from a bicycle two weeks earlier.
Clinical evaluation revealed a well built and nourished
normotensive individual with Glasgow Coma score of 11/15.
He had grade 1/5 power in left upper limb with upper motor
neuron type of facial palsy, and grade 3/5 power in left lower
limb. Left plantar response was extensor. The right eye is
displaced down and out, with ptosis and mydriasis. CT Scan
was done. Explain her findings.

110. Q6
• A 65 year old male diagnosed as AML-M3 was started on an anthracycline and
ATRA+ATO based regimen after initial failed induction. The patient showed a good
hematopoietic response. 3 weeks later, however, he developed rapidly increasing
fever with chest pain and fluid retention with pleural and pericardial effusion. ECG
was as follows:
Dx? Basis? Treatment?

111. Round 4: BACK TO THE CLINICS

113. Q1
• A 71-year-old Caucasian woman was referred because of a painless, rapidly progressive
visual loss in the left eye (LE) within a few months. Best corrected visual acuity was 6/6 in
the right eye (RE) and no light perception in the LE. Examination of the RE was completely
unremarkable. The left eye had an absolute afferent pupillary defect. Intraocular pressure
was within normal limits. Slit lamp examination of the LE showed iris neovascularization,
discrete angle neovascularization, and a few cells in the anterior chamber with iris nodules.
Fundus examination revealed a pale optic disc edema surrounded with round intraretinal
hemorrhages and several retinal infiltrates. Few choroidal folds were visible inferonasal of
the disc. The vasculature, both the arteries and veins, was very narrow to absent. On
fluorescein angiography, filling was limited to the disc and juxta-papillary region until the
late phase with leakage of the disc due to the disc edema. The macula and mid-periphery
were non-perfused without any neovascularization.
• At presentation, she also has a few episodes of nausea/vomiting and decreased appetite.
She feels she’s lost a lot of weight in these few months.
• The patient gave a history of GTCS, 2 episodes in the last 4 months (for which no treatment
was taken) and right sided facial deviation, a few months ago which resolved over time with
local medications. She is also a known case of old treated pulmonary Koch’s, but seems to
have no significant respiratory issues which she feels cannot be explained by her age. The
patient does not give any further history.
• Examination of Respiratory, CVS, GIT was unremarkable. On neurological examination, the
patient was found to have a low MMSE, could not comment well upon the sensations felt
with a cotton wisp and tuning fork, had difficulty chewing and swallowing. The motor and
cerebellar examination was WNL.

114. INVESTIGATIONS
• 1. BLOOD/ SERUM EXAM 10 points
• 2. CXR 20 points
• 3. MRI BRAIN+ ORBIT 30 points
• 4. OCULAR LESION BIOPSY 40 points

115. Inv 1
• Mild microcytic, hypochromic anemia
• Lymphocytic pleocytosis. Normal platelet count
• Negative TST
• • Toxoplasmosis IgG positive and IgM negative
• Epstein-Barr virus IgM and IgG negative
• Cytomegalovirus IgG positive and IgM negative
• Bartonella henselae IgG and IgM negative
• Borrelia/lyme screening: Negative
• HIV Ag and Ab negative
• Syphilis TPPA negative
• ESR negative 38 mm/h
• CRP negative 2.4 mg/L
Electrophoresis
• Albumine 57.3% (53.7–66.0%)
• Alpha 1-globulines 6.2% (4.8–
8.4%)
• Alpha 2-globulines 10.1%
(6.4–12.5%)
• Beta-globulines 9.2% (8.9–
14.6%)
• Gamma-globulines 27.2%
(8.7–17.7%)
Rheumatology• Anti-nuclear
antibodies negative
• Anti-neutrophil cytoplasmic
antibody negative

116. Inv 2

117. Inv 3
• Orbital MRI shows a perineural mass of the left optic nerve (arrows). a A
contrast-enhancing lesion compressing and infiltrating the left optic nerve
is seen on the initial MRI scan. b A second fat suppression MRI scan shows
a perineural T1 hypo-intense mass reaching from the bulbus oculi up to
the optic chiasm, with homogeneous contrast enhancement.
• Meningeal enhancement noted near brainstem and hypothalamus

118. Inv 4
• Non caseating granulomas surrounding optic nerve
sheath.
• Cd4 cells approx 4 times the number of Cd8 cells

120. Q2
• A 66-year-old woman who was referred to a memory clinic for further evaluation of a 5-
month history of rapidly progressive dementia, walks in supported by a couple of young men
holding her. The initial symptoms included memory loss, “feeling odd,” anorexia, and
unintentional weight loss. At her first visit to the memory clinic, her son and husband
reported that her cognitive problems had acutely worsened in the previous two months. She
now had problems with short-term memory and functional abilities, including getting
dressed, using the toilet, and getting lost in her house. Her husband also stated that she had
emotional lability and at times, did not trust her own family. Her vision was becoming blurry
and she had increasing somnolence.
• Her past history is significant for a multiple episodes of GTCS several years ago, for which a
complete workup was done including serum chemistries, implantable frontotemporal lead
based- EEG and a contrast enhanced MRI Brain. She was treated with AED therapy for some
years (poorly compliant) on account of a spike and wave discharge, and had no trouble
since.
• She has had to change her spectacle correction a few times in the past few months,
preceding her memory loss.
• Her neurological examination is remarkable for rigidity in all 4 limbs and hypoesthesia. She
has no tremors and cranial nerve deficit, apart from a decreased visual acuity. Her physical
exam was significant for perseveration, anomic aphasia, alexia, agnosia, and apraxia. he was
unable to complete the Mini-Mental State Examination (MMSE) or perform other
complicated tasks due to perseveration. For example, when asked about the month, date,
day, and year, she answered “December” for each, when in fact, it was already March. When
she answered “December” for the state, the MMSE was stopped.

121. INVESTIGATIONS
• 1. LUMBAR PUNCTURE 10 points
• 2. EEG 20 points
• 3. MRI BRAIN 30 points
• 4. SMALL BIT-BRAIN BIOPSY 40 points

122. Inv 1
• Cell counts, glucose, and protein were within
normal limits. Toxoplasma gondii, Bartonella
DNA, venereal disease research laboratory
(VDRL) test, and Lyme antibodies were
negative.
• Negative for tau protein, oligoclonal bands
and other IHC-compatible standard panel.

123. Inv 2
• left temporal slowing with a diffusely slow
and disorganized background, and there were
no periodic discharges noted. Periodically,
transient bursts of high voltage polyphasic
sharp wave discharges seen.

124. Inv 3
• Global parenchymal loss. Diffusion-weighted
FLAIR images showed increased intensity in
basal ganglia and cingulate/temporal gyri.

125. Inv 4
• Vacuoular degeneration of Brain matter

127. Q3
• A 36-year-old female was admitted to the Emergency Room (ER) because of pain in the right
side of the abdomen and chest, breathlessness and faintness lasting few hours. The patient
denied any trauma. Hypovolemia was corrected by the transfusion of four units of red blood
cells and crystalloid liquids in the ER. After that, the patient was admitted to the Department
of Thoracic surgery for further examination and treatment. She was diagnosed as a right
sided hemothorax. A chest tube was put in. The patient then became haemodynamically
stable, the bleeding through the chest probe was stopped. Because of that, no urgent
surgery was performed.
• A complete history obtained from the patient denied any history of cough and hemoptysis.
She had a history of mild chest pain, on and off since several years, occurring at varying
intervals. The patient was conscious of her weight though and seemed to think she’d lost
none of it despite her best attempts. She does, however recall a similar history of an episode
like hers in her mother a few decades ago. Her past medical history was significant for long
lasting iron deficiency anaemia (she had few blood transfusions) and lower abdominal pain.
She was advised OCPs for the same, but she stopped them later when wanting to conceive.
• Her blood pressure was 90/60 mmHg, and heart rate 119 times per min. Her skin and visible
mucous were pale. A systemic examination was unremarkable except for decreased air entry
and dullness on the right side of her chest. There was mild tenderness and presence of free
fluid in abdomen.
• She stayed under observation for a month in the ward. The very next day, she developed
sudden onset of severe symptoms similar to those at presentation and eventually, had to be

128. INVESTIGATIONS
• 1. THORAX BLOOD ANALYSIS 10 points
• 2. USG with Doppler 20 points
• 3. CT CHEST+ ABDOMEN 30 points
• 4. VATS FINDINGS 40 points

129. Inv 1
• Mainly consisting of clots
• Negative for Ca lung tumor markers
• Negative AFB
• Normal coagulation screen
• High levels of TNF and CA-125.

130. Inv 2
• High vascularity, rim enhanced multiple,
irregular circumscribed pleural lesions with
variable echogenicity, reflecting admixture of
clots and actively bleeding areas.

131. Inv 3
• Chest: Multiple irregularly circumscribed
nodules on pleura with variable density.
• Abdomen: free fluid, heterogenic nodules in
the uterus, and solid density masses in the
lower part of the abdomen were seen.

132. Inv 4

133. HISTORY Q1
• No spectacle use
• LMN type of palsy; self resolving
• Drinks water repeatedly
• No H/o paralysis, normal bowel bladder control
according to age, she feels
• Has some ‘allergies’, takes skin ointment from
local practioner, relieves
• Mild headache, on and off; my whole body aches
• No jaundice, palpitations, other systemic history.

134. HISTORY Q2
• History of (perform) abnormal jerks, even during
sleep
• Visibly expressionless (masklike face)
• No pleasure in daily activities; says I’m incapable
of feeling emotions.
• No H/o altered sensorium
• No H/o paralysis, bowel bladder disturbances
• No FAMILY HISTORY
• NO occupational exposure. Vegetarian diet.
• Non alcoholic

135. HISTORY Q3
• Can’t point site of chest pain
• Sudden onset complaints, can’t remember
much before
• Was unable to conceive, so stopped OCPs on
own. Didn’t consult doc for infertility.
• No past pulmonary complaints
• No bleeding from other sites.
• Chronic on/off pelvic pain.