Q 7) A 20 year old girl undergoes a road traffic accident and is brought to the emergency half an hour later with pelvic pain and lower abdominal distension.
Vitals- Pulse 130/min
BP is 96/46.
X ray - Pelvic fracture with fracture of shaft of Left femur.
She undergoes immediate resuscitation with 9 units PRBC over 2 days and later operative stabalization of fracture.
At the time of discharge she develops jaundice with total bilirubin 6mg%, direct 2.5mg%m , serum alkaline phosphatase 135 IU/l.
What is the most likely cause of this hyperbilirubinemia?
a) Decreased excretion of bilirubin in bile
b) Decreased conjugation of bile
c) Over production of bilirubin
d) Intrahepatic cholestasis
Q 8 ) A 40 year old male comes to you with diagnosis of Acute diverticulitis.
He was managed with NPO regime, IV cephalosporin and metronidazole.
He says that pain in left lower quadrant has decreased but present. There is no diarrhea now. You have advised a CT scan now. Which of the following features now would now prompt you to advise elective surgery?
a) Family history
b) 2nd episode of severe pain
c) Abscess on CT
d) Low grade leukocytosis
Q9) A 40 years old man comes for the evaluation of dysphagia. He has had eating difficulty for the past 5 years with difficulty in swallowing both solids and liquids. He says that it is easier for him to swallow while standing.There is h history of regurgitation and 5 kg weight loss in the last 6 months.
He does not smoke and does not consume alcohol.On examination his vital signs are normal, cardiovascular examination is normal and muscle strength is 5 / 5 in all extremities. Barium esophagogram shows dilated esophagus with smooth tapering . Which of the following is the most likely diagnosis?
b) Carcinoma Esophagus
c) Plummer Vinson syndrome
d) Zenker Diverticulum
Q10) A 40 year old lady presents with fever, chills, pain abdomen and nausea of 2 days duration. She is a non alcoholic and does not take any other drugs. Pain has been progressively increasing since 2 days and is slightly relieved with pain killers. Her Pulse is 110/min, Temp 101.5 degrees, BP 90/60 and appear confused. She is icteric and has tenderness and guarding in right upper quadrant.
Total Bilirubin 7.1 mg%
Direct - 6 mg%
Alkaline phosphatase 860 IU/l
GGTP- 567 IU/L
Amylase 60 U/L
SGOT - 124 IU/L
SGPT - 223 IU/L
TLC 17,900 cu mm
Further work up is most likely to reveal
a) Dilated Common bile duct
b) Inflamed pancreas with free fluid
c) Elevated ascitic fluid cell count
d) Altered dilation and narrowing of ducts in liver
Answer to USMLE Practise Questions
In massive blood transfusion, there is excessive breakdown of RBCs with production of bilirubin. This leads to indirect hyperbilirubinemia as seen in this case.
This is a case of diverticulitis in a young male. A 2nd attack at this young age would certainly require elective surgery in the form of colectomy. Family history has nothing to do in this setting. Abscess is a complication of diverticulitis that has to be managed with percutaneous drainage/surgery
Hinchey classifcation is commonly used to describe the severity of diverticular disease complicated by perforation and is an additional tool that may be used to guide overall management:
Stage I: Small, confned pericolonic or mesenteric abscess
Stage II: Larger, walled-oﬀ pelvic abscess
Stage III: Generalized purulent peritonitis
Stage IV: Generalized fecal peritonitis
Low grade leukocytosis means continuous disease process and require urgent surgery
9) a Achalasia
Achalasia cardia is a disorder of oesophagus in which there is chronic dysphagia to solids and liquids with associated regurgitation, heartburn and weight loss.
In this case the chances of malignancy are less because age of the patient is 40 years, symptoms have been there for a long time the weight loss is not significant.
Other symptoms of Achalasia include chest pain and heart burn/
In Plummer Vinson syndrome dysphagia is for solids but not liquids
Zenker diverticulum presents in more than 60 years of age and has dysphagia , halitosis and fullness of throat
First Aid Q&A for the USMLE Step 1, Third Edition (First Aid USMLE)
10) a Dilated Common bile duct
This patient has acute cholangitis and ultrasound abdomen is likely to show dilated CBD. Cholangitis presnt with Charcot's triad ie Pain , Fever, Jaundice.
Reynauld's pentad include altered mental status and hypotension in addition to three signs mentioned above. Most common causes of Cholangitis are gall stones, malignancy and stenosis
This patient is unlikely to have acute cholecystitis because of the high serum bilirubin. She does not have SBP (Spontaneous bacterial peritonitis) because it usually follows ascites which is absent in this case.
Normal amylase rules out acute pancreatitis.
Primary sclerosing cholangitis has a long standing course, although it can have recurrent attacks of cholangitis but in this case the symptoms have presented for only 2 days.