Objective: Understand that psychiatric illness are an important differential diagnosis in a patient with premenstrual symptoms.

Critique: This patient presented with complaints of feeling tired, weakness, irritability and mood swings for the past 4 years. While the symptoms are aggravated prior to her menses, they are not relieved even 5 days after menses. There is no clear period, during which the symptoms are absent. This does not fit the diagnostic criteria of the premenstrual syndrome. Many of these patients have underlying psychiatric illness including major depression; clearly this patient warrants work up for underlying psychiatric illness. Pyridoxine is not beneficial. Empiric Fluoxetine has no role until a diagnosis of major depression had conclusively been made.

2. Correct Response: c

Objective: Identify the classical presentation of acute pancreatitis.

Critique: This patient has abdominal pain. There is associated radiation to the back. The patient clutches his abdomen and leans forward. This is a classical presentation of pancreatitis. Dependency of alcohol is suggestive of the diagnosis. While MSG poisoning and acute alcoholic gastritis are important differential diagnosis, the typical presentation makes acute pancreatitis a " cannot miss diagnosis" in this situation. Serum lipase and amylase help to confirm the diagnosis. Bacillus cereus poisoning is unlikely.

3. Correct Response: b

Objective: Identify acute peritonitis.

Critique: This patient most likely has perforated duodenal ulcer causing peritonitis. The onset of localizing pain lead to more generalized pain is suggestive of the diagnosis. The patient with peritonitis will demonstrate an unwillingness to change body position. He may remain in flexion with knees drawn up and will have a shallow breathing. Severe tenderness, board like rigidity and rebound tenderness will be present. Liver dullness will be obliterated (resonance on percussion) indicating free air under the diaphragm, which can be confirmed by a upright chest and upper abdominal film.

4. Correct Response: c

Objective: Identify children with contraindication to further doses of pertussis vaccination.

Critique: Pertussis vaccination is always been subject to controversy with doubts about occurrence of convulsion and encephalitis. Follow up systems have not established a cause effect relationship between immunization and convulsion. Pertussis vaccination is contra indicated in patients with progressive neurologic deficit. Further doses are withheld in children with screaming attacks lasting for more than one hour. In these children dual DT antigen is preferred. The other components of the DPT vaccine viz. Diptheria and OPV vaccination appear to be safe in this regard and may be used in such children.

5. Correct Response: d

Objective: Know the important differential diagnosis of dysmenorrhea.

Critique: This patient has pain related to the onset of menses. However, she has pain also relating to sexual intercourse. She also has tenderness on pelvic examination. Trial of nonsteroidals which usually, almost completely alleviates the pain in dysmenorrhoea has been unsuccessful. It is imperative that in such a patient a secondary cause like endometriosis is excluded. Meloxicam is a selective COX2 inhibitor and may not be useful in this setting. OCPs must not be given unless a secondary cause is excluded. Hysterectomy is too radical in a 26 year old woman.

6. Correct Response: a

Objective: Identify treatment options in patients with coital related UTI.

Critique: This patient has UTI that is clearly related to sexual activity. Gross anatomic abnormalities have been ruled out by ultrasound abdomen. Post coital prophylaxis with standard or 1/2 tab therapy, self treatment with 3 days course are all acceptable treatment options in this patient. Retrograde cystourethrogram is an invasive test that is reserved for patients with complicated UTI.

7. Correct Response: b

Objective: Identify public health measures to be taken in the event of a polio epidemic.

Critique: The recommendation for a polio outbreak currently is to give 2 doses of T OPV to all children under the age of 5 in the area at 4-6 weeks interval, even if a single case of polio is reported in the area of residence irrespective of previous immunization status. Parenteral polio vaccine is not recommended.

8. Correct Response: d

Objective: Understand principles and management of cystitis in young women.

Critique: UTI, especially, cystitis is very common in young women. This patient has burning micturition with suprapubic tenderness but no systemic symptoms suggestive of pyelonephritis. Urinalysis reveals > 7 WBCs which is highly suggestive of UTI. A clean catch specimen is not superior to simple midstream void for evaluation. In women who are not pregnant or have other indications of recurrent UTIs or indications of pyelonephritis a culture and sensitivity is not indicated. The likelihood of finding an anatomic abnormality responsible for UTI is very low in this patient. Therefore an ultrasound is not needed. While 7 day standard therapy is effective both single day and 3 day regimens have comparable efficacy. Because of risk of recurrence with single day regimen, the 3 day regimen is considered standard of care.

9. Correct Response: a

Objective: Identify drug interactions with Terfanidine.

Critique: Terfanidine is one of the newer generation antihistamines used in practice. When a patient is given a prescription for Terfanidine it is important to avoid certain medications especially erythromycin and ketaconazole because the combination of these drugs can prolong the QT interval in the electrocardiogram sufficiently to precipitate a ventricular arrhythmia known as Torsade-des-pointes. In the patient given this history of concomitant use of Terfanidine and Erythromycin, the cause of unresponsiveness is most likely to be a ventricular arrhythmia. While we cannot exclude other possibilities, based on this history "a" is the most likely diagnosis and hence the correct response.

10. Correct Response: d

Objective: Identify upper GI bleeding in a patient with a rectal lesion.

Critique: Melena is the presence of black tarry stools. Traditionally the presence of melena is considered to indicate that the bleeding is proximal to the ligament of trietz. Rarely in the presence of massive bleeding hematochezia or flank blood in the stool can occur in Upper GI bleeding due to rapid GI transit (blood is laxative). The converse, that is, rectal lesion producing melena almost never happens. While internal hemorrhoids are an important pathology in this patient, the priority is to identify a potential source of bleed in the Upper GI tract. Upper GI endoscopy will provide adequate visualization of the esophagus, stomach and duodenum and hence the most appropriate initial step for this purpose.

11. Correct Response: a

Objective: Know the management approach in catheterized patients with bacteriuria.

Critique: A Foley Catheter in the urinary tract is a foreign body and bacteruria with long-term catheterization is inevitable. The diagnosis is made when more than 100 CFU/ml of urine is identified in culture. This patient is asymptomatic and there is no evidence of immunosuppression. Therefore, treatment is not recommended. Prophylactic strategies have been used to delay onset of bacteriuria but have only lead to selection of resistant organisms. A cystourethrogram is not recommended in the situation. In the absence of symptoms this patient does not require treatment. Periodic change of catheters prevents formation of concretions and obstruction that can lead to infection. Therefore in this patient "a" is the correct response.

12. Correct Response: d

Objective: Know the correct approach to emergency pericardiocentesis.

Critique: Cardiac tamponade caused by sudden accumulation of blood in the pericardial sac impedes venous return and ventricle filling and is a major emergency. Urgent pericardiocentesis is required to remove the collection of blood in the pericardial sac. For Emergency Pericardial aspiration the recommended approach is from below the xiphoid sternum and to the left with the needle positioned at 45 de

gree angle and advanced towards the left scapula (see DFH-CP-1). Obviously the right 5th intercostal space or the suprasternal notch will not give direct access to pericardium easily. Left 5th intercostal space although helpful at times would mean going through the pleura and the lungs. In a pericardium that is distended the sub-xiphoid approach lends itself for easy direct cannulation as well when necessary.

13. Correct Response: c

Objective: Understand the urgency in the management of tension pneumothorax.

Critique: Tension pneumothorax caused by pushing mediastinum to the other side causes further compromise to the unaffected lung and reduces venous return. Unless the trapped air causing tension is removed death is immediate. Management of tension pneumothorax is best carried out by immediate needle thoracentesis through second intercostal space of the affected site. Waiting for x-ray confirmation would be disastrous and should be avoided. There is no time for obtaining a second opinion from any one. If the first contact physician is not able to give immediate care, the patient will die of tension pneumothorax. In the presence of tension pneumothorax endotracheal intubation and ventilation further complicates and increase the tension and unless the tension is removed by a needle thoracentesis, the patient will not improve.

14. Correct Response: c

Objective: Know when to close a wound primarily.

Critique: Primary wound closure is done within 8-12 hours in most parts of the body and over the face. A clean wound could be tackled even if it is a few hours longer than 18 hours. Eventhough the wound is 18 hours old because it is a clean cut wound due to glass and is on the face, good healing can be expected. Human bite injuries and dog bite injuries are generally not closed because they are usually contaminated and secondary infection will supervene (a & b). Laceration of the extremities of more than 24 hours duration is likely to be contaminated. A suture closure after a delay of 24 hours is generally not recommended.

15. Correct Response: d

Objective: Understand use of antibiotic prophylaxis in wound.

Critique: Antibiotics have to be utilised op

timally to reduce unnecessary expenses to patient and also to avoid resistance strains. Human bite injuries are usually contaminated and it is better to treat the wound with broad-spectrum antibiotics even prophylactically. All injures do not require antibiotic prophylaxis. Clean cut injuries dealt with adequate aseptic precautions early enough should heal well without antibiotics. Similarly, clean cut wounds of the face should heal well without antibiotic prophylaxis if properly taken care of. A closed fracture by definition means that there is no external injury for infection to be carried to the fracture site. The fracture requires to be reduced and immobilized and no antibiotic is necessary.

16. Correct Response: d

Objective: Know the proper selection of suture material for wounds in the face.

Critique: Selection of suture material depends upon the location of the wound, thickness of the skin. For closure of skin wounds of the face one should use very fine monofilament synthetic suture material. This gives very good cosmetic results. "d" is the correct response as 6'O' prolene satisfies the above criteria. No.4 silk (a) is very thick and should not be used for any skin wound. Note that No.4 is not same as 4 "O" silk. 2"O" nylon (b) although acceptable for skin closure is too thick for the face. 4-O or 5-O nylon could be utilised. Plain and chromic sutures cause considerable suture reaction and are not utilised for skin closure. They can be used for suturing the deeper tissues.

17. Correct Response: a

Objective: Know the ideal time to remove sutures.

Critique: The ideal time to remove skin sutures from the face is between 2-4 days. "a" is the correct response. The longer the suture stays in the face it is more likely to cause unnecessary suture reaction and the scars are cosmetically unacceptable. It is better to remove all skin sutures from the face after 48 hours and within 4 days.

18. Correct Response: d

Objective: Know the indications for use of adrenaline in local anaesthesia.

Critique: Novocaine when used with adrenaline is expected to produce anesthetic focal and local vaso constriction thereby reducing the capillary ooz and bleeding.

Novocaine with adrenaline for local anesthesia is best utilised in laceration over the trunk. "d" is the correct response. Adrenaline as a vaso constrictor has vaso spastic action and when used in the region of great toe (a) and finger can cause necrosis of the digits. In circumcision it is better to identify bleeding point and ligate them rather than constrict them with adrenaline. Although necrosis is unlikely it is better avoided in this area. Besides the amount of novocaine required may be larger than simple lacerations.

19. Correct Response: c

Objective: Understand correct use of Tetanus Toxoid in wound management.

Critique: Tetanus Prophylaxis both actively and passively should depend upon previous immunization status as well as the type of wounds dealt with. This 25 year old pedestrian who was injured has not received any childhood immunization which includes Tetanus Toxoid. Because he was on the road and sustained multiple lacerations Tetanus prophylaxis has to be considered and he needs protection not only by active immunization, but passive immunization also. For this reason he must receive the first dose of Tetanus Toxoid and also 250 units of human tetanus immunoglobulin for his immediate protection awaiting his own immunization response to respond to the Tetanus Toxoid injection. Giving Tetanus Toxoid alone (a) or antibiotics alone (b) or avoiding Tetanus Toxoid and giving Human Tetanus Immunoglobulin and amoxycillin would not still give him adequate protection. Note that the patient has to be encouraged to take 2nd and 3rd doses of Tetanus Toxoid active immunization schedule.

20. Correct Response: a

Objective: Know the conditions that produce colicky pain.

Critique: It is important to realise the significance of different types of pain, dull aching-burning-colicky type of abdominal pain. Colicky abdominal pain is usually due to some obstructive pathology either in the bile duct, ureter or intestine. Here the pain is severe, whenever the stone moves further down and in between there is relief thereby qualifying it as a colicky pain. Pain due to pancreatitis (b) is severe and constant burning. Pain due to perforated peptic ulcer is severe, constant, most often the patient is afraid even to move, because the pain gets aggravated. Diverticulitis

(d) again is a slowly developing, persistent localised pain due to peritoneal irritation and is not colicky in type.

21. Correct Response: a

Objective: Know the clinical presentation of peritonitis.

Critique: One should be aware of the typical signs of peritonitis viz guarding, rigidity, tenderness, rebound and absent bowel sounds. Presence of peritonitis is suspected when a patient has pain guarding and rigidity and the correct response is (a). In peritonitis abdominal muscles stay contracted to protect the underlying inflamed peritoneum thereby making it guarded and rigid. Even during deep breath, talking and coughing, the rigidity persists which is a sure sign of underlying peritonitis. Because of the guarding and rigidity in the abdomen, even chest muscles do not move freely. Mobile abdominal mass (b) or presence of jaundice (c) or growth in the rectum (d) do not irritate the peritoneum unless complicated. Most often a mass can be felt in a soft abdomen. The presence of jaundice may be due to hepatitis and need not affect the peritoneum. Most of rectum is an extra peritoneal organ and a growth in the rectum need not cause any peritoneal signs.

22. Correct Response: a

Objective: Know the correct imaging technique in a patient with perforation.

Critique: The detection of free air under the diaphragm in the presence of abdominal pain indicates a perforation of hallow viscus. The x-ray film that gives indication of free air due to perforated duodenal ulcer is a up-right chest x-ray. In a properly taken chest x-ray in a up-right position both the diaphragms are well delineated and even a small amount of free air under the diaphragm can be readily picked up. As the air has a tendency to move up in erect position this is better picked up under the diaphragm. (b) and (c ) are the same and when air is below abdominal parietis this will not be seen as free air in routine x-ray. Barium swallow examination is not indicated to diagnose free air due to perforated duodenal ulcer. Where there is difficulty in diagnosis by plain x-ray a small amount of gastrograffin can be given by mouth to see leakage of the same in to the peritoneum through the perforation. This test is rarely, required to establish perforated duodenal ulcer.

23. Correct Response: a

Objective: Know the appropriate combination of tests to diagnose pancreatitis.

Critique: In choosing diagnostic tests, the combination has to be ideal in terms of cost effectiveness, direct application and easy availability. The cost effective and ideal combination of tests that will help the diagnosis of acute pancreatitis are elevation of amylase, ultrasound examination of the pancreas showing swelling, distortion pseudo cysts etc and increased bilirubin level due to inflammation around bileducts and obstruction. The correct response would be `a' because serum bilirubin, ultrasound and amylase would indicate the presence of acute pancreatitis. Flat plate of the abdomen may give some indication like calcification of pancreas and some changes in liver function tests could be seen. Routine serum alcohol level does not either indicate or rule out acute pancreatitis. Upper GI endoscopy, urinalysis, chest x-ray, ECG and upper GI series all have a place in the evaluation of acute pancreatitis. As a combination however `a' is the best response that will give cost effective diagnosis.

24. Correct Response: c

Objective: Know the ideal combination of management options in dog bite.

Critique: The role of rabies prophylaxis has to be understood thoroughly in dealing with animal bites. The patient is a 11 year old boy. Eventhough he has received childhood immunization, after the age of 10 he requires a booster dose of Tetanus Toxoid. The whereabouts of the dog is not known and we must assume that it is a rabid dog and appropriate protection against rabies has to be given. In addition, all dog bite and animal bite injuries would require appropriate wound care and antibiotics. So "c" is the best response. Other responses are deficient in one respect or the other.

25. Correct Response: d

Objective: Know the ambulatory management of hemorrhoids.

Critique: The treatment of hemorrhoids can be an office procedure under most circumstances. In treating hemorrhoids there are several options available which include a, b,c and d. Surgical hemorrhoidectomy thus will obviously require preoperative preparation, appropriate anesthesia and surgery done in ap

propriate facilities and is not desirable to do as office procedure, whereas rubber band ligation, cryo application and photocoagulation (a,b, and c) can very well be done in an office setting.

26. Correct Response: a

Objective: Know that oral contraceptives are effective treatment in primary dysmenorrhea.

Critique: This patient has clinical features consistent with primary dysmenorrhea. She has had a reasonable work up that has excluded secondary cause. For patients who fail NSAIDs a trial of oral contraceptives is warranted. Any oral contraceptive will work and no particular group is superior to the other. They are upto 90% effective. Cox2 inhibitors while having enhanced efficacy in preventing erosive gastritis are not superior to the other NSAIDs in terms of antiinflammatory properties. In a patient who has been tried on 3 different types of NSAIDs and has failed, the addition of a fourth drug is unlikely to be beneficial. Danazole is an effective therapy in patients with pre menstrual syndrome as is Leuprolideacetate. They are not indicated in patients with primary dysmenorrhea.

27. Correct Response: b

Objective: Identify the correct combination of immunization agents in a patient who is prone to tetanus.

Critique: This patient has a contaminated wound that is highly prone to tetanus. Clearly tetanus toxoid is indicated because this patient has not received any booster doses of TT as an adult. In addition, this patient would require tetanus immunoglobulin. All wounds except bite wounds are closed primarily if the patient is seen within 6-8 hours. Application of povidone iodine ointment on the suture line has not been shown to accelerate wound healing.

28. Correct Response: c

Objective: Identify mandatory vaccines for travel to certain areas in the world.

Critique: Obviously this patient requires counseling about vaccine safety and allay fears. In the rare patients who refuses to take vaccination, the only vaccination that is required by International Law for travel to certain parts of the world is yellow fever vaccine. Rabies vaccine, Hepatitis B vaccine and Japanese Encephalitis vaccine are not mandatory vaccinations.