A 37-year-old sheep farmer has a 2-mopnth history of am undulating fever, weight loss,

constipation and undulating fever. Hes found to be depressed with marked generalised lymphadenopathy. You right ! This is - Brucellosis!

Drinks from a cup. You right ! This is - 10-14 months! Lifts up head from prone position. Rai Ali! You are WRONG, the right answer is months!

1-2

Puts 2 cubes into a tower. Rai Ali! You are WRONG, the right answer is - 14-16 months! Walks hanging onto furniture. Rai Ali! You are WRONG, the right answer is - 7-10 months! Transfers a toy from one hand to another. Rai Ali! You are WRONG, the right answer is - 57 months!

Puts 9 cubes into a tower. You right ! This is - 2-3 years! A 70-year-old man complains of dysnoea. He has a history of rheumatic heart disease and his
JVP is found to be raised with a large wave, although no cannon waves are visible. You are WRONG, the right answer is - Pulmonary hypertension! history of symmetrical joint pain. She is found to have a JVP. arthritis! Rai Ali!

A 57-year-old woman reports with a 3-month history of dyspoea and cough. She has a 2-year
You right ! This is - Reumatoid

A 41-year-old man complains of dysnoea. He has a history of rheumatic heart disease. His JVP is
found to be raised with a pattern that shows an abrupt X and y descent , pericardial knock was clearly audible on auscultation. Rai Ali! You are WRONG, the right answer is - Tuberculosis!

A 5-year-old girl is brought to A & E after she showed an aversion to bright lights. In addition the
child has a 6-hour history of diarrhoea and drowsiness. mother is asthmatic. peas and carrots. You right ! This is - Soya Milk! Rai Ali! You are WRONG, the right answer is - No Action! You right ! This is - Soya Milk!

> An 8-month-old baby boy has 7 attacks of diarrhoea after being weaned onto cows milk. This A 2-year-old girl is brought to A & E with diarrhoea. Her mother described the stool as being like A 13-year-old girl complains of diarrhoea. On examination shes found to have an iron deficiency
anaemia and a high level of titre of anti-reticulin and anti-gliadin antibodies. She has denied any history of gastrointestinal upsets after eating, rice, Soya or potatoes. You right ! This is Gluten free diet!

A 13-year-old girl complains of diarrhoea. On examination shes found to have an iron deficiency
anaemia and a high level of titre of anti-reticulin and anti-gliadin antibodies. She has denied any history of gastrointestinal upsets after eating, rice, Soya or potatoes. You right ! This is Gluten free diet!

 A 54-year-old man complains of palpitations and reports 2 episodes of sudden loss of

consciousness over the last 2-weeks. A 24-hour ECG shows episodes of tachycardia with intervening period that showed a prolonged QT interval. Rai Ali! You are WRONG, the right answer is - Torsades de pointes!

A 43-year-old man reports difficulty in breathing with chest pain. He has a history of palpitations
and his ECG shows a tachycardia of 100beats/min and a wide QRS complex that begins with a slur. Rai Ali! You are WRONG, the right answer is - Wolf Parkinson white syndrome!

A 35-year-old complains of palpitations and diarrhoea. She has a history of weight loss despite a
healthy appetite. Rai Ali! You are WRONG, the right answer is - Atrial fibrillation!

An obese 60-year-old man is brought to A & E unconscious. He had a 2-year history of

palpitation and is pulseless with his respiration becoming shallower. His ECG shows disorganised complexes. Rai Ali! You are WRONG, the right answer is - Ventricular fibrillation!

A 13-year-old girl of a headache then 3-hours later starts vomiting and feels progressively
drowsy. You right ! This is - Benzylpenicillin!

An 9-month old girl has suffered vomiting associated with episodic crying. When examined she
draws up her legs with each episode of crying and a sausage shaped mass is felt on abdominal examination. You right ! This is - Nasogastric tube!

An 8-year-old boy with an 8-week history of flank pain reports to A & E. On examination an
abdominal mass is found on his left flank and haematuria on dipstick. Rai Ali! You are WRONG, the right answer is - Vincristine and doxorubicin!

A 42-year-old woman, who suffers long-term rheumatoid arthritis and swinging pyrexia, reports
with a swollen, inflamed, right knee. Rai Ali! You are WRONG, the right answer is - Joint aspiration and blood culture!

A 24-year-old labourer has increasing backpain and stiffness in the morning. He is already on
medication for ankylosing spondylitis. Rai Ali! You are WRONG, the right answer is - Oral nonsteroidal anti-inflammatory Drugs with gastric protection!

A 57-year-old executive, who is obese and drinks 40 units of alcohol a week, reports a fifth
attack on red, hot ankle. Uric acid crystals are discovered in the joint on aspiration. You right ! This is - Colchincine!

A 77-year-old man, who suffers severe ischaemic heart disease, complains of stiff, painful hand,
neck, knees and feet. On examination his hands reveal Heberdens nodes. You right ! This is Paracetamol!

A 76-year-old woman complains of increasing pain in her left knee and occasions of the joint
giving way. The problem has resulted in her being unable to climb the stairs. When examined shes found to have a marked valgus deformity with instability. You right ! This is - Joint aspiration and blood culture!

 A 39-year-old multigravida, visits the clinic at 38 weeks of gestation. At her first 12 weeks her BP
was 140/95 mmHg. She reports no proteinuria and is well. You right ! This is - Recheck blood pressure in seven days!

A 80-year-old woman, who has undergone 4-hours of surgery to repair a ruptured abdominal
aneurysm, complains of difficulty in breathing and severe abdominal pain radiating from her back. Her blood pressure is 100/70mmHg. You right ! This is - Laparotomy!

A 69-year-old man, whos recovering from pancolectomy, reports a retrosternal chest pain and
increased sweating of 45 minutes duration. You right ! This is - ECG!

A 23-year-old woman reports that she is pregnant. She has already had two terminations and
has noted a small amount f watery brown, vaginal discharge and tenderness in the right iliac fossa. Rai Ali! You are WRONG, the right answer is - Ectopic pregnancy!

A 19-year-old student is about to take exams. She has missed a period but has tested negative
for pregnancy. She has worsening abdominal pain over three month. She is otherwise well. You right ! This is - Irritable bowel syndrome !

A 23-year-old woman who has not menstruated for 9-weeks and has had a positive result from a
home pregnancy test. Reports to A & E with a history of a 4-hour lower abdominal pain and bright red vaginal blood. On vaginal examination the uterus is tender and bulky, the cervical os is open. You right ! This is - Inevitable miscarriage!

A 56-year-old woman presents with markedly swollen ankles. She has chronic renal failure.Rai
Ali! You are WRONG, the right answer is - Frusemide!

A 58-year-old man has diabetes, mellitus and severe renal failure (serum 400 umol/l-and blood
glucose concentration of 59 mmol/l. (increased dosage)! effective treatment? sucrose)! Rai Ali! You are WRONG, the right answer is - Insulin

A 16-year-old youth has chronic renal failure and severe anaemia. Whats the most costRai Ali! You are WRONG, the right answer is - Iron Saccaharin (Iron

A 36-year-old man, with chronic renal failure and on dialysis, is found to have a high phosphate
concentration. Rai Ali! You are WRONG, the right answer is - Calcium carbonate!

A74-year-old man with inoperable obstructive gastric cancer and multiple liver metastases, is
taking large doses of oral analgesia. Despite this his pain is poorly controlled. You right ! This is A subcutaneous opiate infusion

A 32-year-old woman undergoing gold injection treatments for rheumatoid arthritis continues
to complain of stiffness and joint pain, especially in the first 2-hurs of the day.Rai Ali! You are WRONG, the right answer is - Oral non-steroidal anti-infammatory drugs!

 A 38-year-old, chronic asthmatic woman has undergone open cholecystectomy for empyema of
the gall bladder. Her asthma is being treated be bronchodilators and oral prednisolone (15mgs/day). Four hours after the operation her pulse rate is 110 beats/minute and blood pressure 90/60 mmHg. There is no evidence of internal bleeding; chest x-ray is normal, as is an electrocardiagram (ECG). She has only had antibiotics, to which she is not allergic and deep venous thrombosis (DVT) prophylaxis. Rai Ali! You are WRONG, the right answer is - Adrenal insufficiency!

A 36-year old woman, who routinely uses tampons, reports feeling unwell. After her last period
she suffered an offensive vaginal discharge. She is sweating, pallid, has a pulse rate of 130 beats/minute, and blood pressure 80/40 mmHg. Her lower abdomen is tender and there is an offensive discharge from the vagina. You right ! This is - Staphylococcal sepsis!

A 63-year-old woman reports with ataxia and confusion. She is known to have atrophic gastritis.
Rai Ali! You are WRONG, the right answer is - Schilling Test! Not Vitamin B12 levels.

A thin 20-year-woman on examination is found to have iron deficiency anaemia and

amenorrhoea. You right ! This is - Dietary History!

A 58-year-old man on examination is found to have a macrocytic anaemia and abnormal liver
function test. This includes an increased level of gamma glutamyi transferase activity. You right ! This is - Alcohol history!

A 7-year-old girl is pallid and appears slightly jaundiced. She is increasingly tired and suffers
slight breathlessness.Rai Ali! You are WRONG, the right answer is - Haemoglobin electrophoresis!

This is an inherited autosomal dominant condition that affects 1 in 5,000 of the population and
is associated with typical skeletal manifestation. You right ! This is - Marlan syndrome!

Moderate consumption of alcohol reduces the incidence of? You right ! This is - Ischaemic
heart disease.

This is the largest cause of death in adults in the United Kingdom. You right ! This is - Ischaemic
heart disease!

After a myocardial infraction the use of an angiotensin converting enzyme (ACE) inhibitor
improves morbidity. Rai Ali! You are WRONG, the right answer is - Left ventricular failure!

A 12-month old girl has no meaningful words, is unable to sit, play with toys, or laugh and has
bad interaction with siblings. You right ! This is - Refer for developmental assessment!

A mother is very concerned that her 12-month-old daughter is not vocalizing and doesnt
respond to loud noise. Her motor milestones are normal. You right ! This is - Arrange hearing test!

 An 18-month old girl has a vocabulary of 12 words and cannot form sentences.
are WRONG, the right answer is - Reassure! speech. You right ! This is - Refer to ear, nose and throat (ENT) surgeon!

Rai Ali! You

A 3-year-old boy, is restless at night, snores and is tired in the day. He has an indistinct nasal A 4-year-old girl has been treated for bacterial meningitis with antibiotics for 24-hours. A
routine blood test shows serum sodium concentration to be 125 mmol/l. Restrict fluid intake! You right ! This is -

A 7-year-old boy reports with headaches, fever and increasing drowsiness. No rash seen of neck
stiffness reported. He has started treatment for meningitis with antibiotics. Rai Ali! You are WRONG, the right answer is - Request computed tomography! Followed by LUMBER PUNCTURE.

A 12-year-old boy has been unwell for 6-weeks with night fever, weight loss and an intermittent
headache. He has a divergent squint and neck stiffness. A cerebrospinal fluid (CSF) examination showed protein 960 mg/dl, glucose 2.0 mmil/l and lymphocytes 6.0 X 10{9}/l. Standard cultures are negative. You right ! This is - Request Ziehl-Neelsen stain!

A 7-year-old North African boy has been diagnosed with bacterial meningitis. He has positively
responded to standard treatment but after 7-days has developed a headache, vomiting and swinging fever. You right ! This is - Request computed tomography!

A 43-year-old woman reports increasing dysarthria with clumsiness of the fingers on the left
side. Nystagmus is identified on lateral gaze and she has a positive pointing test on the left side. You right ! This is - Cerebellum!

A 24-year-old man reports double vision when looking to the left side, although he has no loss of
hearing but does have slight facial numbness and mild dysphagia. On examination a sixth nerve palsy of the left side is revealed. You right ! This is - Brain stem!

18-year-old woman reports increased urgency of miculurition and in walking. She tests positive
for the Rombergs test and increased deep tendon reflexes in all four limbs is increased. You right ! This is - Cervical spinal cord!

A 32-year-old man has reported two episodes of acute loss of vision in his left eye at 6-month
intervals. He has recovered but an ophthalmoscopy reveals some temporal pallor of the optic disc. Rai Ali! You are WRONG, the right answer is - Optic nerve!

An 18-year-old student is suffers from bloody diarrhoea and is opening her bowls 10-times a
day. She has urgency and tenesmus. A rectal histology shows inflammation and granulomala. Rai Ali! You are WRONG, the right answer is - Crohns colitis!

A 27-year-old woman has loose, pale stools, weight loss, is deficient in iron and suffers folale
deficiency anaemia. Her sigmoidoscopy is normal. You right ! This is - Coeliac disease!

 A 24-year-old student has suffered recurrent diarrhoea for three-years. The diarrhoea is
accompanied by some mucus and left iliac fossa pain that is relieved on defecation. His Sigmoidoscopy examination is normal. Rai Ali! You are WRONG, the right answer is - Irritable bowel syndrome with diarrhea!

A 63-year-old euthyroid man (normal serum fT{4} concentration) reports with an asymmetrical
thyroid swelling. Rai Ali! You are WRONG, the right answer is - Ultrasound of thyroid!

A 27-year-old, euthyroid woman (normal serum fT{4} concentration) has an ultrasound scan. A
solitary, solid thyroid nodule is confirmed.Rai Ali! You are WRONG, the right answer is - Fine needle aspiration! NOT RADIO IODINE UPTAKE..

A 34-year-old woman has palpitations, tremor and weight loss. Her serum fT {4} concentration is
normal. You right ! This is - Tri-iodothyronine (T{3})!

Theme: The Scientific basis of hearing loss. For each condition described select the SINGLE most likely result from the options below. Options: A. Unilateral sensory hearing loss. B. Bilateral conductive hearing loss C. Bilateral total deafness D. Unilateral mixed conductive and sensory hearing loss E. Unilateral conductive hearing loss F. Bilateral normal hearing G. Bilateral mixed conductive and sensory hearing loss H. Bilateral sensory hearing loss I. Unilateral neutral hearing loss A 4-year-old child with olitis media with effusion. You right ! This is - Unilateral conductive hearing loss!

Presbyacusis.You right ! This is - Bilateral sensory hearing loss! Rai Ali! You are WRONG, the right answer is - Bilateral

Hearing loss induced by noise. sensory hearing loss! Accoustic neuroma. hearing loss!

Rai Ali! You are WRONG, the right answer is - Unilateral neutral

Papular urticaria You right ! This is - Contact with domestic pets!

Scabies rash.Rai Ali! You are WRONG, the right answer is - Toxin released by the gravid ferrad mite! Candidal nappy rash. Rai Ali! You are WRONG, the right answer is - Spread of gastrointestinal tract! NOT IMMUNO INCOMPETENCE.

A 33-year-old woman was treated a year ago for breast cancer with 12/20 nodes positive. She reports with a 2-day history of increasing confusion. Her husband states she had a severe thirst for the past week. You right ! This is - Hypercalcaemia! A 42-year-old woman presents to the Accident and Emergency unit in confusion, vomiting and with a headache. Two-years ago she was treated for a Grade 3 auxiliary node positive breast cancer. When examined she was found to be drowsy but no local neurological signs were discovered. Also she has suffered blurring of the optic disc margins. Rai Ali! You are WRONG, the right answer is - Bone metastases. NOT CEREBRAL METS. A 24-year-old woman, who has been diagnosed schizophrenic since 15-years-old is living with her supportive parents but has never fully recovered. She has been on a range of appropriate medication in correct dosages since diagnosis. Rai Ali! You are WRONG, the right answer is - Clozapine! A 30-year-old man is being treated for paranoid schizophrenia during detention in hospital, with depot anti-psychotic medication. He has stabbed his father with a kitchen knife. Now he is symptom free and is ready for discharge to return to his family home. His parents are worried. You right ! This is - Family therapy! A 36-year-old man with a history of 9 admissions to hospital over the last 6 years has been detained in hospital for treatment. He has been arguing with neighbours and his family at home and is known not to take his antipsychotic tablets when he is not in hospital. You right ! This is - Depot antisychotic medications! A 90-year-old woman is convinced shes being persecuted by the government and has not eaten or slept for three-weeks. She refuses to eat or drink and her physical state is deteriorating although she agrees to treatment. Rai Ali! You are WRONG, the right answer is Electroconvulsive therapy (ECT)! A 3-month-old girl has episodes of vomiting with fever. She has no diarrhea and rash. Her weight velocity is declining away from her centile line. She is alert on examination and appears normal. Rai Ali! You are WRONG, the right answer is - Urinary tract infection.! NOT PYLORIC STENOSIS OR GASTROENTERITIS. A 3-month old girl has vomited several times daily since she was born, although she continues to thrive and feed. Her mother notices that vomiting is reduced when the baby is strapped in a car seat and has reduced since solid feeding was introduced 2-weeks ago. You right ! This is - Gastro oesophageal reflux! A 6-month-old girl has been vomiting for 3-days. She has episodes of crying and drawing up her knees. Her mother reports red staining in her nappy. Her abdomen is examined and the right iliac fossa is felt to be empty and there is a sausage shaped mass across the epigastrium. You right ! This is Ihfussusception

A 4-week-old boy is suffering projectile vomiting. After 48-hours he still remains hungry, apyrxial and alert. When inspected after a feed, visible peristalsis is seen across his abdomen. You right ! This is - Pyloric stenosis! A 17-year-old boy in a residential learning unit has had escalating episodes of banging his head against walls and windows. Staff are very concerned that he will seriously injure himself. Rai Ali! You are WRONG, the right answer is - Behaviour therapy! NOT CBT. A 29-year-old man with schizophrenia has heard voices ordering him to kill himself by drinking ammonia. He is brought to the Accident and Emergency Unit. You right ! This is - Admit to general psychiatric ward! A 43-year-old man is admitted to the surgical ward after a car accident in which he sustained a minor head injury and leg fracture. After 9 days he is monosyllabic, unsmiling and unresponsive the other patients and staff although the injuries are healing well. There were no witnesses to the accident. Rai Ali! You are WRONG, the right answer is - Refer for psychiatric opinion! NOT PSYCHOTHERAPY A 29-year-old woman with two children aged 4 and 8 has no family support. She is recovering form influenza and her television broke down that morning. She comes to the Accident and Emergency unit after taking 8 aspirin tablets. You right ! This is - Counseling from community mental health team! A very thin 16-year-old girl with a longstanding history of intermittent bloody diarrhea and a painful swollen left knee. Rai Ali! You are WRONG, the right answer is - Enteropathic arthropathy! NOT REITERS DISEASE. A 53-year-old man with hypertension and a 9-year history of occasional acute severe pain and swelling in the left knee. Aspirate shows cloudy synovial fluid. Rai Ali! You are WRONG, the right answer is - Gout! A 37-year-old woman with a long history of depression and symmetrical polyarthritis complains of recurrent purple spots on her legs. Her erythrocyte sedimentation rate (ESR) was 79 mm/hr and a Schirmer test was positive. Rai Ali! You are WRONG, the right answer is Sjorgens syndrome! NOT SLE.. A 26-year-old man has recently returned from a holiday in Asia. He now has a short history of acute symmetrical swelling of both knees and ankles. His erythrocyte sedimentation rate (ESR) was 79 mm/hr and a Schirmer test was positive. You right ! This is - Reiters syndrome! A 14-year-old girl who started having periods at the age of 11, has been experiencing periods that are heavier and more painful that before. She reports exhaustion. Rai Ali! You are WRONG, the right answer is - Full blood count! NOT FSH R ESTROGEN LEVELS..cause we need to confirm de heavy bleeding.

A 21-year-old woman has been using oral contraceptive pill and has had three episodes of bright red post-coital breeding. Rai Ali! You are WRONG, the right answer is - Cervical smear! A 41-year-old West Indian woman who has had three children through Caesarian section has complained of heavy, regular, painful periods with clots. Her GP has informed her that she is anemic. Rai Ali! You are WRONG, the right answer is - Laparoscopy! A 45-year-oldman who suffers intermittent asthma and uses beta-agonists and low dose inhaled steroids. He has developed nasal polyps and is allergic to aspirin. He is still symptomatic. Rai Ali! You are WRONG, the right answer is - Leukotriene antagonist!
other signs of personality or thought disturbance.

Paranoid psychosis: psychotic behavior accompanied by persecutory or grandiose delusions with few Aspirin is not advised for primary prevention of ischaemic heart disease in a
low-risk population

A high protein level in the presence of low albumin level may indicate a

surreptitious monoclonal gammopathy, and considering myeloma is advisable at this stage. Serum calcium, immunoglobulins, electrophoresis and early morning urinary electrophoresis / Bence Jones protein assay complete a myeloma screen, with skeletal survey only being carried out should these be suggestive of myeloma. smokers appear to have a lower incidence of pre-eclampsia.
flights, or bus journeys.

Pre-eclampsia is a risk factor for consequent hypertension. Interestingly active Travellers returning from abroad are at high risk of DVT, especially after long-haul Patients with diabetes are at high risk of cardiovascular death. The fact that this
patient was treated for GORD may suggest that he had chest pain in the previous week and this may have in fact been a myocardial infarct. Diabetic patients may experience silent ischaemia, and a low threshold for investigation of ischaemia should be adopted in diabetic patients.

Alcohol abuse leads to a dilated cardiomyopathy, related to direct toxicity

and nutritional deficiencies.

Thiamine replacement often helps. There is a higher risk of atrial fibrillation and a risk of systemic
embolisation can occur secondary to this, or due to stagnation in a dilated heart.

Mitral regurgitation is a feature of any dilated cardiomyopathy.

 Pulmonary regurgitation is a feature seen in pulmonary hypertension and

is not associated with alcoholic cardiomyopathy.