Senior Medillectuals, held at Synapse 2018, Maulana Azad Medical College

1. SENIOR MEDILLECTUALS
Finals
SYNAPSE 2018

2. Rules
• There will be 5 rounds. Each round is scored differently,which will be
specified at the beginning of each round.
• there is pounce allowed in some rounds. if so, please wait for 15
seconds before answering the question to allow the other teams to
submit their answers.
• two rounds will be A-F, and two rounds F-A.
• the marking in most cases is on an all-or-none basis. However, if a
situation of conflict arises, the decision of the Quizmaster will be
final.

3. ROUND1

4. Round 1
• Each question carries 20 points for the team to which it is directed.
• There are two parts. Each carries 10 points.
• Partial answers will Not be awarded any points.
• The pounce window is the first 15 seconds after the quizmaster has
finished reading the question. The teams who wish to pounce must
write their answers on a piece of paper and hand it over to the
volunteer within this window. the marking for pounce is +10/-5*
• No passing.

5. TEAM A

6. A 79-year-old Korean man was admitted to hospital due to cough and dyspnea. He was diagnosed
with cancer of the right, upper lobe through a computed tomogram (CT) scanning on December 11,
2012. After 1 week, he was diagnosed as NSCLC squamous cell carcinoma through a biopsy at a
university hospital. Another week later, he was finally diagnosed as having stage IV NSCLC due to
multiple metastatic nodules in the upper and lower lobes of the left lung, the right supraclavicular
lymph nodes and the body of pancreas through a PET-CT scan.
A new drug has been approved as a 1st line treatment to treat the disease above, which is
exceptional in that fact that it was the first time the FDA had approved a drug based on genetics of
the disease rather than tissue type or site. It is an IgG4 isotype antibody that blocks a protective
mechanism of cancer cells, and allows the immune system to destroy
those cancer cells (provided they do not have EGFR or ALK
mutations).
A)What is the drug being talked of?
B)For which disease was it initially approved by the FDA for?

8. • Pembrolizumab
• Metastatic melanoma
(Nivolumab will not be considered since
1. It is not the first line treatment.
2. It is used to treat cancers with EGFR or ALK mutations,
whereas for Pembrolizumab, it has been found that it
is not very effective in tumors having these
mutations.)

9. Team B

10. A 38-yr-old man presented with progressive dry cough and dyspnoea on exertion of 6-month duration. His personal
history indicated that he was a former smoker (10 pack-year cigarette smoking history). For the last 10 months prior
to his disease, he worked in a setting to blast stainless steel materials before welding.
Bronchoscopy with bronchoalveolar lavage was performed which revealed a picture of chronic bronchitis. Cytology of
bronchoalveolar lavage fluid (BALF) showed lymphocytic alveolitis with a slightly increased percentage of eosinophils
(lymphocytes 46%, eosinophils 1% and alveolar macrophages 53%) and numerous PAS-positive amorphous material.
Microbiological examination of BALF was negative. No abnormalities in the adjacent lymph nodes were detected.
There was no improvement in his condition.
DIAGNOSE

12. ANSWER
• Acute silicosis/silicoproteinosis/ “secondary” PAP (only PAP is not
acceptable)
• Characterised by a rapid progression, typically within a year, with
clinical findings similar to PAP. Silicotic fibrous scars and egg shell
calcifications are typical findings of CHRONIC silicosis, not acute.
• HRCT- Crazy paving

13. Team C

14. A 47 year old Mexican lady presented by generalized vesiculo-pustular
lesions’ involving mucous membrane. On history it was revealed that
she was on a drug (as shown in the image below); no history of any
other drug intake for some time. On arrival to the country, she had
started taking only half dose of the same medication.
The pustular fluid was sent to the lab and came out to be sterile. Punch
biopsy of skin revealed epidermal neutrophils collected as a
microabscess and suprapapillary thinning.
Diagnosis?

16. • Acute generalised pustular Psoriasis/ Von Zumbusch Disease
(only psoriasis not acceptable)
Answer

17. Team D

18. What is the morphological lesion seen
on the face in general dermatology
terms?
Give the technical name of the clinical
finding seen which is similar in eyelids
and lips.

20. ANSWER
• Icthyosis
• Ec-tropion (eyes) and ec-labium (lips)

21. Team E

22. • What is this condition known as?
• What is the causative factor for
this condition?

24. ANSWER
• Porotic hyperostosis, also known as osteoporosis symmetrica, cribra
crani, hyperostosis spongiosa, symmetrical osteoporosis (ANY 1)
• Iron Deficiency Anaemia

25. Team F

26. • A patient presented to the OPD with complaints of occasional
episodes of palpitations and shortness of breath. He’s had one
episode of syncope which was preceded by severe palpitations.
He’s a known case of congenital heart disease.
Examination is normal except for a loud S1. HR is normal.
DIAGNOSE.

28. ANSWER
• Lown Ganong Levine syndrome
• OVERVIEW
• bypass close to the AV node connecting the left atrium and the His bundle.
• cause of accessory path arrhythmia
• CLINICAL FEATURES
• palpitations
• collapse
• INVESTIGATIONS
• ECG:
-> very short PR intervals
-> sinus rhythm with ventricular extrasystoles
-> no delta wave (how to differentiate from WPW)
-> normal QRS

29. ROUND 2
Visual Connect

30. • Each team will be shown a set of pictures which are related in some
manner.
• there are 30 points to be earned by the team to which it is directed.
10 for the correct connect and 20 for the correct explanation of All
the pictures.
• Pounce for guessing the connect is allowed in the first 15 seconds.
points would be +10/-5. However, if the team to which the question
was directed is unable to guess the connect/ incompletely explains
it, the teams that have pounced and guessed the connect correctly
will get a chance to explain the connect in the order of A-F. if
explained, they will earn an extra 10 points.

31. Team A

34. Vector is hard tick(ixodid tick)
• Erythema chronicam migrans of Lymes Disease
• Babesiosis
• Tularemia( Rabbit and ulcerative lesion at site of bite)
• Spotted fever

35. Team B

38. All are caused by contaminated soil
• Mycetoma
• Cutaneous anthrax( characteristic central eschar with surrounding
halo) And bamboo stick appearance
• Copper penny bodies of chromoblastomycosis
• Tetanus

39. Team C

42. Niacin
• Salt and pepper appearance on electron microscope (carcinoid)
• Cutaneous flushing
• Maize (tryptophan Deficient)
• Hyperuricema -> gout -> crystals

43. Team D

46. Clubbing
• Bronchiectesis
• Splinter hemorrhage- Infective endocarditis
• Non casseating granuloma – Crohns
• TOF

47. Team E

50. Overt Diabetes in Pregnancy
• Sacral Agenesis
• Heart
• Shoulder Dystocia
• Turtle sign

51. Team F

54. HCV
• Membranoproliferative glomerulonephritis- TRAM TRACK on silver
stain
• Leukocytoclastic vasculitis
• Type III cryoglobinemia (polygonal IgM and IgG)
• Lichen planus

55. Audience

58. Hand Schuller Christian disease
• Reniform nuclei
• Christian Bale
• Central Diabetes Incipidus
• Lytic skull lesion

59. ROUND 3
What Next/Explain why

60. Team A

61. A 60-year-old man presents to the Emergency Department with new onset shortness of breath which
started 2 days before. He says he thinks his heart is beating too fast. He denies any similar episodes in
the past. He stopped smoking about 10 years ago (40 pack years) and gained 40 pounds. He drinks 3
mixed drinks per night and enjoys wine with dinner on the weekends. His wife says he snores and
sometimes stops breathing at night, but he has never been tested for sleep apnea.
His Past History and Review of Systems are otherwise not significant. Physical examination reveals a
heart rate of 170 and an irregularly irregular rate; blood pressure is 82/48mmHg; Respirations are 26
per minute; he is afebrile; O2 sat is 90% on room air. He weighs 250 pounds and is 6 ft tall.
WHAT IS THE NEXT BEST STEP OF MANAGEMENT IN THIS PATIENT and WHY?

63. ANSWERS
• Transesophageal Echocardiography
• To detect any mural thrombus in the LA (cardioversion might dislodge
it enters systemic circulation  goes to the brain  stroke)
• Basically patient has AF, did not subside with beta blockers, so
Cardioversion should be done, but AF present for >=48 hours,
therefore mandates use of TEE to check for thrombus formation.

64. Team B

65. A 65 year old male patient was diagnosed with right early renal cell carcinoma, for
which nephrectomy was done 2 weeks ago was kept in surgical Oncology ward for
observation. Today he developed breathlessness, chest pain and hempotysis . On
examination HR- 127 per minute, Bp- 110/78mmHg. Chest X ray and Ecg were within
normal limits. Hemoptysis stopped within few minutes. Trop T kit test was negative.
What is the next investigation you will order?

67. ANSWER
• CTPA/CECT
CHEST
• Since Well’s
score 5, imaging
needed

68. Team C

69. A NCBI REPORT STATES:
A 5½-year-old girl, ER, was referred to us for short stature. She was accompanied by her father who had
adopted her at the age of 3½ years. ER was a shy, but well-behaved child.
ER was thin and did not have any significant findings on examination. She had history of increased food intake
for the past 3 years. She had craving for food, stole food from lunchboxes of other children in her class, used to
hoard food, and get up at night to eat. Father said that she could eat a dozen bananas at one go. In spite of this
voracious appetite, she was not gaining weight and height.
Her height and weight were 91.6 cm and 10.5 kg, respectively, which were <<3rd centile. She did not have any
features suggestive of malnutrition.
Her baseline routine investigations including hemogram, liver and renal function tests were normal. Her peak
GH levels on clonidine and insulin-induced hypoglycemia tests were low (3.47 ng/ml and 3.24 ng/ml,
respectively). The thyroid, cortisol axes were normal. Magnetic resonance imaging of the pituitary did not
reveal any abnormality. Thus, she was diagnosed to have isolated growth hormone deficiency (GHD) and
started on GH therapy (10 U/week).
She was followed three monthly. At the end of 6 months of GH therapy, the response in terms of height gain
was very dismal (1.5 cm gain in 6 months).
“This made us rethink about where we had gone wrong in her management.”
WHERE DO YOU THINK THEY WERE WRONG?
IDENTIFY THE PATHOLOGICAL PROCESS HERE, AND WHAT STEPS WOULD YOU TAKE TO TREAT THIS CHILD?

71. ANSWERS
• Kasper Hauser syndrome
• Psychotherapy/ find out living conditions and relations with adopting family,
remove from stressful environment.
(Psychosocial short stature (PSS) or psychosocial dwarfism, sometimes called psychogenic or stress
dwarfism, or Kaspar Hauser syndrome, is a growth disorder that is observed between the ages of 2
and 15, caused by extreme emotional deprivation or stress. The symptoms include
decreased growth hormone (GH) and somatomedin secretion, very short stature, weight that is
inappropriate for the height, and immature skeletal age. This disease is a progressive one, and as
long as the child is left in the stressing environment, his or her cognitive abilities continue to
degenerate. It can cause the body to completely stop growing but is generally considered to be
temporary; regular growth will resume when the source of stress is removed.
An environment of constant and extreme stress causes PSS. Stress releases hormones in the body
such as epinephrine and norepinephrine engage what is known as the 'fight or flight' response. In
PSS, the production of growth hormone (GH) is thus affected. As well as lacking growth hormone,
children with PSS exhibit gastrointestinal problems due to the large amounts of epinephrine and
norepinephrine, resulting in their bodies lacking proper digestion of nutrients and further affecting
development.
The children could either be unresponsive to GHRH, or too sensitive to GHIH.)

72. Team D

73. 62years old, 50Kg man presented to emergency with severe abdominal pain for
2 hours. On history he revealed that he had been taking Indomethacin on and
off regularly for last few months for his migraine.
On examination Abdomen was tender, slightly distended, local temperature was
raised , obliteration of liver dullness and rebound tenderness was present.
There were no other findings on general physical examination.
BP was 74/40mmhg and pulse was 127 per minute.
2L ringer lactate was given by wide bore canula in the next 15 minutes, BP was
still 80/46mmHg. Dopamine and Noradrenaline were started at maximum
therapeutic dose. But despite that BP was 86/50 mmHg. The anaesthesia
department in emergency OT refused to give PAC clearance to the patient.
What is the next step of management?

75. Answer
• Put an abdominal Drain under LA ± irrigation

76. Team E

77. A middle aged male was brought to the emergency in an unconscious
state. There is no history available. Na- 140 mEq, K = 7mEq, serum
dextrose- 84, pH-7.30, HCO3- 21, pCO2- 40. An ECG was done and
shows the following. What is the next step of management?

79. Answer
• Treat ment of acute hyperkalemia despite no ECG changes
• IV Ca Glucunate + IV insulin in dextrose solution

80. Team F

81. A 7-week-old white boy presented with vomiting and weight loss.
Vomiting subsequently increased in frequency. Nonbilious but forceful
vomiting occurred with each feeding.The patient was born at term by
spontaneous vaginal delivery. The perinatal course had been
unremarkable. Birth weight was 2.5Kg.
The patient was active and alert. Physical examination revealed
decreased activity, dry lips and mucosal surface and sunken eyes. A
palpable mass in right upper quadrant during sleep. A visible gastric
peristalsis could be seen.
Biochemistry revealed serum urea (104 mg/dl), creatine (1.6 mg/dl),
Na+ (126 meq/l), K+ (2.9 meq/l), chloride (98 meq/l), aspartate amino
transferase (AST) 120 U/l.
Abdominal ultrasonography showed the length of the pyloric channel
to be 19.5 mm and the muscle width itself to be more than 6.9 mm.
What is the next step?

83. Answer
• First correct electrolytes and dehydration
• N/2 saline + 2.5% dextrose + KCl
(since there is hypochloremic hypokalemic metabolic acidosis with
dehydration)

84. Round 4
BIDDING

85. Rules of the Marketplace
• A question will be projected on the screen and read out, after which
bidding will start from 10 points, in multiples of 10. The cap for
bidding is 100 points for each question.
• the question will be ‘sold’ to the highest bidder. if he/she answers
correctly, they will gain as many points as they bid. Other teams can
submit their answers on a plane paper to the quizmaster.
• However, if the answer is incorrect, those many points will be
deducted from their previous total and redistributed equally
amongst the other teams only if they have answered it correctly on
their chits. However if no other team gets it correct, only half the of
the points will be deducted from the team total.
• if two teams bid equal points, answers will be taken in the written
form. However, a team that attempts the question shall not be a
beneficiary if their co-attempter gets it wrong. in this case the
points will be redistributed amongst 4 teams.

86. Question 1

87. An 40 year old man, with Acute Exacerbation of COPD, with no known
comorbidities, is being kept on mechanical ventilation with a PEEP of 5
cm, low tidal volume and a respiratory rate of 16/min, FiO2 of 30%. A
routine ABG is done, which shows
§ pH – 7.36
§ pO2 – 85
§ pCO2 – 54
§ HCO3 - 26
§ Saturation – 91%
What will you do next?

89. ANSWER
• Do nothing

90. Question 2

91. A 23 year old primi presented for routine ANC checkup at 22w pog. Her
blood group is B negative, husbands blood group is A positive and was
advised indirect coombs test. Her BP was 160/100mmHg, for which she
was started on a-methyldopa. At 22w, her indirect coombs test was
negative. Level 2 USG scan was normal. At 28w pog she presented with
complaints of fatigue. Her BP this time was 110/78mmHg.
On investigation carried at 28w pog Hb – 9gm%, Retic count - raised,
serum iron, b12- within normal range, direct coombs test positive.
Antenatal Ultrasound revealed normal findings for 28wks PoG.
• Identify the disease and pathology.

93. ANSWER
• Coombs test positive Hemolytic Anemia caused by a-Methyldopa

94. Question 3

95. Diagnose.
Explain why the disease
first occurred despite
previous two generations
of healthy individuals.

97. ANSWER
• NF
• Germline mosaicism
• (sporadic mutation is very unlikely since two children got the disease
from healthy parents)

98. Question 4

99. A 45 year old army man presented to the emergency with frank blood in vomitus. He admitted to daily
alcohol intake of 80 mL of whiskey for the past 30 years, which ‘My Punjabi liver handled it so well, I did
not even get tipsy after that’.
A few hours back, He went for a party with fellow retirees and does not recall how much he drank. A
passerby found him passed out and brought him to the hospital where he started vomiting blood. He’s a
known hypertensive with poor control of blood pressure, and a diabetes which is controlled largely on diet.
Past history of Spinal TB 2 years ago(treated with ATT for 1.5 years) is elicited, and he says the pain never
went away completely, with him popping a painkiller every day since last 6months .He swears this is the
first time he has drunk irresponsibly. No other significant history.
On examination, he is a little disoriented but coherent, able to answer questions with a little
circumstantiality. His BP is 150/82, with a pulse rate of 102/ min. His clothes, now soiled, were clean when
he came in, suggesting that he had no bouts of vomiting before being brought to the hospital. There are
scrapes over the extensor aspect of upper limb and hands, suggesting that he was conscious when he fell
and tried to break the fall. A CT scan of head is scheduled, to be done once the patient is hemodynamically
stable. Gastric lavage with cold saline reveals frank blood. What finding in this patient’s upper GI
endoscopy would you attribute the Hematemesis to?

101. Answer
• Peptic Ulcer
Risk factor- Nsaid.
NOT Mallory Weise tear because first episode of vomiting after binge
drinking never contains blood.

102. Emergency Room
Think On your feet!

103. Rules of this room
1. There are two patients : one is whose ECG is shown, and the other is a case
scenario with relevant clinical/radiological picture.
2. You will get 30 seconds per ECG case, and 30 seconds per case scenario (too see)
3. After that you'll be facing 6 questions on a rapid-fire pattern. You have 15 seconds
to answer each question.
The first two questions will be related to the ECG, the next two to case scenario.
•After a question has been read out, a countdown timer will start. The team
will have 15 seconds to answer each question. Only the first response will be
taken, and timer will be stopped the moment the answer is Finished. If the
answer is correct And complete, the points earned will be 5 + (time left*2).
The time will be rounded off to the closest second.
• If the answer is incorrect/incomplete, the correct answer will be told, the next
question will be asked and the timer will start again.
•Possible points to be earned 150!

104. #1

105. Case 1
ECG

106. Case
A 27 year-old man sustained an undisplaced midshaft fracture of his left tibia after his girlfriend inadvertently (or so
she said…) backed into him in her car, with the rear bumper pinning his leg against the car behind. Following an
orthopedic consult, he was put in a long leg cast and sent home, with orthopedics follow up arranged for the next
day.
Overnight he re-presented to the emergency department with increased pain in his leg and paraesthesiae in his
toes. The cast was removed.
He was taken to the operating theatre in the middle of the night after an anterior compartment pressure
measurement of 60 mmHg was obtained.

108. #2

109. 45-year old obese male with history of angina.
Now presented with chest pain for last 2 hours

110. A previously well 50 year old
presents with sharp severe
chest pain after a long haul
flight from North America. A
chest X-ray and ECG are
performed and reveal no
abnormalities. The
examination is
unremarkable.
The patient proceeds to a
CTA chest.

112. #3

113. 13 years old Japanese student with
sudden onset chest pain. Cardiac
markers were elevated. ECG is shown.
History of fever with rash for last three
days.

114. 50 year-old woman tripped down the last 5 steps of a flight of stairs. Her left forearm
bore the brunt of the impact. Fortunately, she sustained no other significant
injuries.The radiographs of her painful and swollen left wrist are shown below
:

116. #4

117. 7-year-old child with history of repeated
infections presented with seizure. Injection
midazolam was given followed by phenytoin
and the following ECG was obtained.

118. This 86 year-old male presented with shortness of
breath.He developed a complication after insertion
of a left chest drain. Here is his CT:

121. #5

122. Consider a 49 year-old female with a history of smoking and two weeks of increasing shortness of breath. She is
being treated for pneumonia on the ward for three days but getting worse. An ICU review is performed on the ward
and the following ECG is obtained.
On examination, there is no pulsus paradoxus.

123. You are managing a 56 year old woman with severe pneumonia in the Intensive Care Unit when you are called to
see her because her leg has suddenly turned blue.

125. #6

126. 26 year old man with sudden
onset breathlessness and chest
pain

127. A 26 year-old man presented
to the ED with chest pain, He
tripped on some steps and
the right-side of his chest
collided with the handrail.This
is his chest radiograph: