STATION-1

C-xray-I C-xray-II

Q.1. What are the findings ? Q.1. Name the prosthetic devices/material on this
Q.2. What is the diagnosis ? chest x-ray with their correct position ?
Answers Station-1

c-xray 1

Q.1. Multiple bilateral nodular well-circumscribed opacities with left mastectomy (3 marks)

Q.2. Most likely Metastatic deposits secondary to Left Breast Cancer (2 marks)

c-xray 2

1. Dual chamber pacemaker in left hemithorax implanted with atrial and ventricular leads. (2 marks)

2. Prosthetic valve in mitral position, (3 marks)

Recording leads are attached

Wires are visible in middle of sternum most likely indicative of previous thoracotomy for mitral valve
replacement
STATION-2

Case 1 85 years old male presented with shortness of breath

Q.1. Describe the ECG findings ?

Q.2. What is the diagnosis ?

Q.3. What is the treatment ?

Case 2 ECG strip recorded from 50 years old man presented to ER with chest pain and syncope

Q.1. what are the findings of this strip ?

Q.2. what is the diagnosis?

ANSWER Station-2

ECG-1
Q.1. Tachycardia, T wave inversions in precardial leads V1-V4, S 1Q3T3 pattern (2mark )
Q.2. Pulmonary Embolism (2marks)
Q.3. Anticoagulation if stable and Thrombectomy in OR if unstable (1marks)

ECG-2

Q.1. ST depression in first strip followed by Premature ventricular complex followed by

polymorphic VT (3marks)
Q.2. Ischemic ST depression followed by R-on-T phenomena followed by Torsade-de-pointes (2
marks)
STATION 4 (has 2 scenarios)

Case Scenario A_TOACS (static)

65 year old woman living alone, presents with history of extreme degree of lethargy and
myalgia’s for 3 days, shortness of breath and drowsiness for 1 day. She said that she was so
lethargic that she could not get up from floor; neither could she lift her arms for support. She
relates this to an incident 3 days back when some robbers entered her house, and she fell down
on the floor of her bedroom in fear. She had not lost consciousness during this time, but she
recalls that due to pain in her right thigh she could barely getup for 3 days. Recently she had
noticed some burning and dark urine in these days. She just managed to grab some fruits and
some water in these three days. She remembered that she was being asked to wake up by her
neighbors and she was then rushed to the hospital. There were no other associated symptoms.

On examination she was severely dehydrated, was drowsy but arousable. Her blood pressure was
110/60 mm hg, pulse was: 90 beats /minute. Respiratory rate was 18/breaths /minute and she was
afebrile. She had tenderness in her right things and there were bruises over that area and there
was some diffuse swelling. Her respiratory neurological, cardiovascular and abdominal exam
was normal

BUN: 60 mg/dl, creatinine : 3.6 mg/dl,Na 140 mmol/l, K 3.9 mmol/l.Cl: 100 mmol/l, HCO: 16
mmol/l Hb: 14.2 g/dl, WBC:17 *10E9/l, Platelet: 91 *10E9/l

a)What is the cause of her acute kidney injury? Mention 3 possible causes (3)

b) List any 3 investigations (4)

c) List the steps of management (3)

KEY FOR STATION 4 A

Case Scenario A_TOACS

a)What is the cause of her acute kidney injury? Mention 3 possible causes(3)

Rhabdomyolysis

Urosepsis

Meningitis

Inflammatory myositis

b) List any 3 investigations (4)

Urine DR, Urine spot sodium, Ca, Phosphorus, Albumin, CPK, RBS, •Serum aldolase

Lactate dehydrogenase (LDH

blood culture, Liver function test

Ultrasound kidneys, Xray right hip

Urine toxicology, urine myoglobin

D dimer, peripheral film

c) List the steps of management (3)

Hydration with normal saline, for adults, administer isotonic fluids at a rate of approximate

400 mL/h (may be up to 1000 mL/h based on type of condition and severity) and then titrate to
maintain a urine output of at least 200 mL/h

Hco infusion in some cases

Foleys, Monitor urine output

Obtain an ECG to monitor effects of hyperkalemia and other electrolyte disturbances.

Monitor for compartment syndrome

Avoid nephrotoxic drugs

Empiric antibiotics
STATION 4B

Case Scenario B _TOACS (static)

A 35 years old female came to ENT clinic with complaint of pain in front of neck and difficulty
in swallowing for last 4 days. She has running nose 5 days back. On examination she has
temperature of 39ᵒ C with a pulse of 120/min regular. Patient has fine tremors with sweating
palms. Neck examination revealed a firm symmetrical diffuse tender swelling just below the
tracheal cartilage with no bruit on auscultation. No exophthalmos was there. Labs are as follows:

TLC: 18,000
N: 78%

a. What is the diagnosis? (3)

b. What investigation you would like to do and what will it show?(3)
c. Give treatment of this condition. (4)
KEY FOR STATION 4B

Case Scenario B _TOACS (static)

a. Subacute thyroiditis (de Quervain’s ) (3 marks)

b. RAI thyroid scan (decreased uptake) (3 marks)
TSH: 0.01 (Range 0.04-4.2)low
FT4: 4.5 (0.9-1.7) (raised
FT3: 225 (95–190)(raised
ESR: 55(raised
Antithyroid antibodies: Negative
TSH-R antibody: Negative
c. Aspirin;propranolol;iopanoic acid/ipodate sodium (4 marks)
Thiourea drugs are not used.
 STATION 5 (INSTRUMENT A And B)

Q1) What is this instrument used for and what does it measure? (2)

Q2) What instructions would you give to the patient? (2)

Q3) How does it help in management? (1)

Station #5 A. Answers

1) This is a peak flow meter. Peak flow measurement is a procedure in which air flowing out of the
lungs is measured. The measurement obtained is called the peak expiratory flow rate (PEFR). (2
marks)

2) Generally, peak flow measurement follows this process: (2 marks)

 Before each use, make sure the sliding pointer on the PFM is reset to the zero mark.

 Hold the PFM by the handle.

 Stand up straight.

 Remove chewing gum or any food from your mouth.

 Take a deep breath and put the mouthpiece in your mouth. Seal your lips and teeth tightly around
the mouthpiece.

 Blow out as hard and as fast as you can.

 Note the number where the sliding pointer has stopped on the scale.

 Reset the pointer to zero.

 Repeat this routine three times. You will know you have done the technique correctly when the
three readings are close together.

 If you cough during a measurement, you should repeat it.

 Record the highest of the three readings. This is called your peak flow.

3) (1 mark)
a) A peak flow meter, when used properly, can reveal narrowing of the airways well in
advanced of an asthma attack.

b) Can help determine when to seek emergency medical care.

c) Helps evaluate effectiveness of asthma management and treatment plan.

Station # 5B (Instrument)

Q1) What is this instrument? (1)

Q2) What is the main indication for which it is used? (1)
Q3) What are its’ contraindications? (1)
Q4) Name three possible complications. (2)
Station #5B. Answers

1) Trucut biopsy needle. (1 mark)

2) Main indication is diagnosis of cancerous, pre-cancerous and inflammatory conditions. Organs and
tissues that can be biopsied include breast, thyroid, liver, and lymph node. (1 mark)

3) Contraindications: (1 mark)

 Uncontrolled bleeding diathesis

 Anticoagulation therapy
 Overwhelming sepsis
 Local infection near the biopsy site
 Uncooperative patient

4) Complications arise with reference to the site being biopsied and are mostly local complications like
hematoma, injury to vessels, nearby organs etc. (2 marks)
 STATION 6

This is scan of 35 years old man with c/o chest pain after every meals and this scan done with exercise.

Q.1. what are the findings ? (5)

Q.2. What is diagnosis ? (5)

Answer for station 6

1. Large predominantly reversible perfusion defect in anterior and apical territories (5)

2. Severe ischemia in anterior and apical territory during exercise myocardial perfusion scan
+ve scan for Myocardial Ischemia (Coronary Artery Disease) (5 )
STATION 8

A 48 year old man presented with complains of blackening of fingers of his hand for the past 6
weeks. He also noted a rash on his legs as shown in figure B. General physical examination is
unrevealing for bruits and peripheral pulses are uniformly palpable in the upper and lower limbs.
The cardiac and chest examination is normal on examination of the abdomen, there is
hepatomegaly along with splenomegaly. There is no evidence of lymphadenopathy.

a) What kind of rash is present on his legs? (2)

b) What tests are indicated in this patient’s work up? (5)

c) What is the underlying diagnosis? (3)

Answer Station 8

a) Livedo reticularis (2 )

b) The following tests can be done to look for systemic causes of vasculitis: (5)

 CBC
 ESR
 Urinalysis
 ANA
 RA factor
 ANCA
 Cryoglobulins
 Serum protein electrophoresis (SPEP)
 Hepatitis B and C serology
 Antiphospholipid antibodies
 C3 and C4 complement levels
 Echocardiography
 Angiogram of radial arteries

c) Polyarteritis nodosa (PAN) (3)

Station 9

SCAN-I 55 years old man presented with c/o of abdominal pain and fever for past 6 days

Q.1. what are the findings on this scan ? (2)

Q.2. what is the diagnosis ? (2)

Q.3. Outline the most preferred treatment ? (1)

SCAN-II 75 years old man presented with haematuria and left lower limb DVT, below is the scan

Q.1. What are the findings in this scan ? (2)

Q.2. What is the diagnosis and what is the possible cause ? (2)

Q.3. What is the treatment ? (1)

STATION 9 ANSWERS

SCAN-I

Q.1. A contrast-enhanced CT scan of the upper abdomen demonstrates a large gas-containing

abscess > 5 cm in the right lobe of the liver. (2)

Q.2. Pyogenic Liver Abscess (2)

Q.3. Along with antibiotics, preferred treatment is CT or U/S guided percutaneous catheter
drainage (1)

SCAN-II

Q.1. Axial contrast-enhanced CT image shows a large enhancing mass in the left kidney with
central necrosis (asterisk). A patent left renal vein (arrow) is noted medially. (2)

Q.2. Left sided renal cell carcinoma and possible causes of DVT in this patient will be
Polycythemia, metastatic Carcinoma itself, renal cell carcinoma itself can cause thrombotic state.
(2)

Q.3. Left Nepharectomy and anticoagulation for DVT (1)

STATION-10

Case 1 A 37-year-old woman with a 1-month history of right-sided numbness presenting with
a 3-day history of right-sided weakness

Q.1. What are the findings on the above scan (2)

Q.2. What is the differential diagnosis(2)

Q.3. what is the treatment of most likely diagnosis ?(1)

Case 2 35 years old male presented with c/o headache for 5 days

Q.1. What are the findings on this scan ?(2)

Q.2. What is the diagnosis ?(2)

Q.3. What is the treatment ? (1)

STATION 10

Q.1. Axial non-contrast scan shows obliteration of the sulci over the hemispheres and meningeal
enhancement was noted on contrast- enhanced CT scan (2)
Q.2. Meningitis(2)

Q.3. Admission in HDU, i/v cannulation and i/v fluids , Dexamethasone i/v , Antibiotics (third
generation cephalosporin and Vancomycin), analgesics(1)
STATION#11.

Station #11.

These are the hand and skin findings of a 26-year-old woman who complains of early satiety.
Her past medical history is notable for upper gastrointestinal bleeding and rectal prolapse.

Q1) What is shown in these two pictures? (3)

Q2) What is the diagnosis? (3)

Q3) What are the complications of this disease?(4)

Answers station #11:

1) a. Hyperextensible and lax joints. (3)

b. Hyperextensible and fragile skin.

2) Ehlers Danlos syndrome(3)

3) Patients are predisposed to the following: (4)

 Gastrointestinal motility disorders

 Visceral diverticulosis

 Mitral valve prolapse (up to 50% of patients)

 Dilatation of the aortic root

 Pes planus

 Scoliosis

 Degenerative arthritis

 Pneumothorax

 Dilatation of the pulmonary artery

 Angina
Station #12.

A 25 year old man presents with bloody diarrhea for the past 8 weeks. On examination he
appears pale with a waddling gait. On investigations he has an elevated ESR and CRP. At night
he often wakes up with low backache which gets better as he moves about.

Q1) What is shown in this radiograph?(3)

Q2) What is the diagnosis? (4)

Q3) What other features can be seen on spinal imaging?(3)

KEY CASE 12

1) Bilateral symmetrical sacro-iliitis. The cortices of both sides of the joints are poorly
defined (loss of the continuous white line) and there are also erosions. (3)

2) Seronegative spondyloarthropathy; Ankylosing spondylitis associated with IBD.(4)

3) Syndesmophyte formation, ligamentous ossifcation and articular ankylosis are

characteristic radiological features. Ankylosis of intervertebral facet joints and
ossification of interspinous and supraspinous ligaments can cause a bamboo-like
appearance. (Bamboo spine)(3)

Station #13.

Station #13.

A 55 year old lady presented with complains of poor vision. Fundoscopy was performed.

Q1.) What is shown in this fundal photograph? (3)

Q2.) What is the diagnosis? (4)

Q3) What treatment options are available? (3)

KEY CASE 13

1) Confluent hard exudates with pre-retinal hemorrhages in a subhyaloid position with

sharply defined margins in front of the retina and neovascularization. (3)

2) Proliferative retinopathy associated with diabetes mellitus.(4)

3) a) Pan-retinal photocoagulation can arrest the rapid progression of neovascularization

and subsequent loss of vision. It leaves the fundus with laser scars and some remnants
of the new vessels. (3)

b) Antiangiogenic VEGF inhibitors e.g. Bevacizumab (Avastin®)

c) Good glycemic and blood pressure control should be emphasized.

STATION-15 A

This is the image of a 37 years old female presented with shortness of breath 15 days after fall
followed by right hip fracture surgery

Q.1. Name the investigation and what are the findings on this scan ?(2)

Q.2. What is the Diagnosis (1)

Q.3. Outline the treatment(2)

ANSWERS Station-15

Q.1. CT scan chest with contrast showing bilateral thrombus in pulmonary arteries which also enhance in
periphery with contrast (2)

Q.2. Pulmonary thromboembolism(1)

Q.3. ICU admission, i/v fluids, anticoagulation if patient vitally stable and thrombectomy/embolectomy
in OR if vitally unstable(2)
Station # 15.

A 26-year-old man who smoked and had a long history of poorly controlled asthma and severe
environmental allergies was admitted for an exacerbation of asthma. He reported no recent
hospitalizations or exposure to tuberculosis and for more than a year had not been taking any medications.

Q1) What is shown in these images?(1)

Q2) What additional investigations establish the diagnosis?(3)

Q3) What is the diagnosis?(1)

Station #15. Answers

1) High resolution CT scan of chests showing cystic bronchiectasis and mucus plugging bilaterally (white
arrows) in upper lobes.(1)

2) Investigations to establish diagnosis (3)

a) Complete blood count would show marked eosinophilia > 350 cells/ mm3

b) Elevated serum IgE level >1000ng/ml.

c) Serum precipitins antibodies for Aspergillus fumigatus.

d) Positive skin prick allergen test to Aspergillus species.

e) Elevated serum IgE and IgG index to Aspergillus fumigatus.

f) Sputum culture positive for Aspergillus fumigatus.

3) Allergic Bronchopulmonary Aspergillosis (ABPA)(1)