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cbd91783-e901-4672-9ec1-7f58bce041da	A 74-year-old woman develops occipital headache, vomiting, and dizziness. She looks unwell, her blood pressure is 180/100 mm Hg, pulse is 70/min, and respirations are 30/min. She is unable to sit or walk because of unsteadiness. Over the next few hours, she develops a decline in her level of consciousness.For the above patient with altered level of consciousness, select the most likely diagnosis.	A 74-year-old woman develops occipital headache, vomiting, and dizziness. She looks unwell, her blood pressure is 180/100 mm Hg, pulse is 70/min, and respirations are 30/min. She is unable to sit or walk because of unsteadiness. Over the next few hours, she develops a decline in her level of consciousness.	Cerebellar hemorrhage, when mild, may present with only headache, vomiting, and ataxia of gait. Patients may complain of dizziness or vertigo. The eyes may be deviated to the side opposite the hemorrhage. Nystagmus is not common, but an ipsilateral sixth nerve palsy can occur. This is the only type of intracerebral hemorrhage that commonly benefits from surgical intervention.	cerebellar hemorrhage
17a37bf5-e78b-48f2-be15-16c1049d1427	A 40-year-old man presents with a 2-week history of recur- rent oral ulcers, genital ulcers, intermittent arthritic pain of the knees, and abdominal pain. Physical examination reveals shallow ulcerations of the mucosa of the glans penis, as well as oral aphthous ulcers and conjunctivitis. Which of the following is the most likely diagnosis?	A 40-year-old man presents with a 2-week history of recur- rent oral ulcers, genital ulcers, intermittent arthritic pain of the knees, and abdominal pain. Physical examination reveals shallow ulcerations of the mucosa of the glans penis, as well as oral aphthous ulcers and conjunctivitis.	Behget disease is a systemic vasculitis characterized by oral aphthous ulcers, genital ulceration, and ocular inflammation, with occasional involvement of the nervous, gastrointestinal, and cardiovascular systems. The mucocutaneous lesions show a non-specific vasculitis of arterioles, capillaries, and venules. The cause of the necrotizing inflammation of small blood vessels is not known, but an association with specific HLA subtypes suggests an immune basis. Herpes (choice B) does not present with arthritis.Diagnosis: Behqet disease	Behyet disease
f68d215d-20f5-4c82-a386-02445dc44ebc	A 50 years old lady presented with lump in the left breast, which has developed suddenly in weeks. Perimenstrual symptoms are present. No associated family history. On examination, the lump is well circumscribed, fluctuant, 1.5 cm oval in shape. Most likely diagnosis:	A 50 years old lady presented with lump in the left breast, which has developed suddenly in weeks. Perimenstrual symptoms are present. No associated family history. On examination, the lump is well circumscribed, fluctuant, 1.5 cm oval in shape.	Fibroadenoma - it occurs in 2nd to 3rd decade of life Galactocele - it occurs in 3rd to 4th decade of life. Breast cancer - there is no associated family history and lump has developed suddenly hence breast cancer is ruled out. Breast cyst - it occurs in 5th to 6th decade of life. Examination revealed fluctuant lesion which point towards breast cyst. - Often multiple, may be bilateral & can mimic malignancy. Typically present suddenly - Diagnosis can be confirmed by aspiration and / or ultrasound.	Breast cyst
fc4ad074-28fe-4b8f-bde1-79c50dadad98	A 1 year old child is brought to you with delayed milestones. On examination you note that the child is very fair with hypopigmented hair and blue eye. He has also got eczemas. The child was also very irritable. What is your diagnosis?	A 1 year old child is brought to you with delayed milestones. On examination you note that the child is very fair with hypopigmented hair and blue eye. He has also got eczemas. The child was also very irritable.	This child is suffering from Phenylketonuria. Here there is inability to conve phenylalanine to tyrosine due to phenylalanine hydroxylase deficiency. The decreased pigmentation in this condition is due to reduced melanin formation. The treatment is a diet low in phenylalanine with tyrosine supplementation. Delay in initiation of treatment will lead to mental retardation. Ref: Essential revision notes for MRCP by Philip A Kalra, Edition 3, Page - 322 ; Harrison, Edition 17, Page - 2470	Phenylketonuria
43746273-1b76-4c58-97ac-7de0af6fdab0	A 1-year-old boy presents with a delay in motor development. Progressive muscle weakness and blindness ensue, and the patient dies within a year. The brain at autopsy shows swollen neurons that contain numerous lysosomes filled with lipid. Which of the following is the most likely diagnosis?	A 1-year-old boy presents with a delay in motor development. Progressive muscle weakness and blindness ensue, and the patient dies within a year. The brain at autopsy shows swollen neurons that contain numerous lysosomes filled with lipid.	Tay-Sachs disease is a lethal, autosomal recessive disorder caused by an inborn deficiency of hexosaminidase A, which permits the accumulation of ganglioside GM1 in CNS neurons. The disease is fatal in infancy and early childhood. Retinal involvement increases macular transparency and is responsible for a cherry-red spot in the macula. On histologic examination, lipid droplets are seen in the cytoplasm of distended nerve cells of the CNS and peripheral nervous system. Electron microscopy reveals the lipid within lysosomes in the form of whorled "myelin figures." Swollen neurons that exhibit marked vacuolization of the perikaryon and contain lysosomes filled with lipid can also occur in other lipid-storage diseases (e.g., Gaucher disease, Niemann-Pick disease). The other diseases do not produce such neuronal changes.Diagnosis: Tay-Sachs disease	Tay-Sachs disease
aaa09f14-d097-401e-a543-a9a9e4fa9a7d	A patient was diagnosed with schizophrenia and was staed on haloperidol 5mg. On 3rd day he presented with uprolling of eyes. A complete neurological examination revealed no spasticity or any other abnormalities except uprolling of eyeballs. Visual acuity was found to be normal. What is your likely diagnosis?	A patient was diagnosed with schizophrenia and was staed on haloperidol 5mg. On 3rd day he presented with uprolling of eyes. A complete neurological examination revealed no spasticity or any other abnormalities except uprolling of eyeballs. Visual acuity was found to be normal.	* <48 hours of staing antipsychotics * M.C in======Younger black males * If a patient develops dystonia he is more prone for eps Patient considers this as an Allergic reaction , thereby may stop drugs Layryngeal dystonia is a Psychiatric emergency, should be treated with IV lorazepam TREATMENT * Diphenhydramine * Benztropine mesylate * Prophylactic anticholinergics helps Ref.Kaplon and sadock, synopsis of psychiatry, 11 th edition, pg no. 923	Acute dystonia
92f241b1-5dd7-4309-be7d-575987eb3c07	A young male presents with ear discharge since three years; recently developed swelling in the neck below and behind the angle of mandible, toicollis; on the examination, the external auditory canal was filled with granulation tissue. What is the diagnosis?	A young male presents with ear discharge since three years; recently developed swelling in the neck below and behind the angle of mandible, toicollis; on the examination, the external auditory canal was filled with granulation tissue.	Bezold's abscess It can occur following acute coalescent mastoiditis when pus breaks through the thin medial side of the tip of the mastoid and presents as a swelling in the upper pa of the neck. The abscess may Lie deep to sternocleidomastoid, pushing the muscle outwards. Follow the posterior belly of digastric and present as swelling between the tip of mastoid and angle of the jaw. Present in the upper pa of the posterior triangle. Reach the parapharyngeal space. Track down along the carotid vessels. Clinical features: Onset is sudden. Pain Fever Tender swelling in the neck Toicollis The patient gives a history of purulent otorrhoea. (Ref: Textbook of diseases of ENT, PL Dhingra, 7th edition, pg no. 87)	Bezold's abscess
2c676972-bd4f-4a3c-b082-2af34b86c74c	A 30 year old female patient complains of painless hard anterior neck mass. FNAC was inconclusive. Open thyroid biopsy was performed which revealed the ﬁbrous nature of the mass, woody, non tender thyroid, mimicking carcinoma is observed. The diagnosis points towards	A 30 year old female patient complains of painless hard anterior neck mass. FNAC was inconclusive. Open thyroid biopsy was performed which revealed the ﬁbrous nature of the mass, woody, non tender thyroid, mimicking carcinoma is observed.	null	Riedel's thyroiditis
e08a75ac-3fb1-4ca9-a24c-d6798f56a3f0	A 20 year female presents with a ovarian mass 6x 6 x 6cm in size. Ultrasonography reveals solid structures in the mass. Her serum biomarkers such as AFP. fO-hCG and CA 125 are normal, however, her serum alkaline phosphatase was found to be elevated. The most likely diagnosis is	A 20 year female presents with a ovarian mass 6x 6 x 6cm in size. Ultrasonography reveals solid structures in the mass. Her serum biomarkers such as AFP. fO-hCG and CA 125 are normal, however, her serum alkaline phosphatase was found to be elevated.	null	Dysgerminoma
c2c522e9-595e-4327-a763-7eb93c7fcb88	A 68-year-old male is brought to the outpatient by his wife due to increasing forgetfulness. On taking history in details, wife repoed that for around 6 months patient is having trouble in organising the finances and paying bills, something he has done all his life. He has also become withdrawn and has decreased meeting people. The patient also behaved inappropriately with a female neighbour couple of says back, which is much against his usual nature. The patient denies having any problems and seems indifferent to his wife's concern. He has a medical history of hypeension and type 2 diabetes mellitus There is a family history of Alzheimer disease. On MMSE, score came out to be 23. Which of the following is the most likely diagnosis?	A 68-year-old male is brought to the outpatient by his wife due to increasing forgetfulness. On taking history in details, wife repoed that for around 6 months patient is having trouble in organising the finances and paying bills, something he has done all his life. He has also become withdrawn and has decreased meeting people. The patient also behaved inappropriately with a female neighbour couple of says back, which is much against his usual nature. The patient denies having any problems and seems indifferent to his wife's concern. He has a medical history of hypeension and type 2 diabetes mellitus There is a family history of Alzheimer disease. On MMSE, score came out to be 23.	The history is suggestive of executive dysfunction (trouble in organising the finances and paying bills), apathy and disinhibition (decreased socialisation and inappropriate behaviour with women), lack of insight (denies having any problem) and memory disturbances. This is suggestive of frontotemporal dementia, in which personality changes are prominent, memory disturbances appear later in frontotemporal dementia. In contrast, in alzheimers disease memory disturbances are prominent early in the disorder and personality changes later. Creutzfeldt-Jakob disease which is caused by a prion manifests with rapidly progressive dementia, myoclonus, and cerebellar dysfunction.	Frontotemporal dementia
974166b0-214b-4d84-8785-3a6ad189abd0	An alcoholic is brought to the casualty, 3 days after he quit alcohol, with the complaints of irrelevant talking. On examination, he is found to be disoriented to time, place and person. He also has visual illusions and hallucinations. There is no history of head injury. The most probable diagnosis is:	An alcoholic is brought to the casualty, 3 days after he quit alcohol, with the complaints of irrelevant talking. On examination, he is found to be disoriented to time, place and person. He also has visual illusions and hallucinations. There is no history of head injury.	This patient in the question who is a chronic alcoholic is showing features of delirium tremens, which typically appears after 3-4 days of abstinence from alcohol (24 hours to 7 days). Ref: CURRENT Diagnosis and Treatment: Emergency Medicine, 7th Edition, Chapter 37 ; CURRENT Diagnosis and Treatment: Psychiatry, 2nd Edition, Chapter 14	Delirium tremens
5aa04ff1-94e0-42c0-b4d6-5f8b444cbb2e	A 33-yr old man presented with a slowly progressive swelling in the middle 113d of his right tibia. X-rays examination revealed multiple sharply demarcated radiolucent lesions separated by areas of dense and sclerotic bone. Microscopic examination of a biopsy specimen revealed island of epithelial cells in a fibrous stroma. Which of the following is the most probable diagnosis?	A 33-yr old man presented with a slowly progressive swelling in the middle 113d of his right tibia. X-rays examination revealed multiple sharply demarcated radiolucent lesions separated by areas of dense and sclerotic bone. Microscopic examination of a biopsy specimen revealed island of epithelial cells in a fibrous stroma.	Adamantinoma of long bone Introduction: Unusual neoplasm, almost always located in tibial shaft. Clinical features: Localized swelling and pain for several years. Age: Between 15-55 yrs. Radiological features: * An eccentric well demarcated area of destruction usually involving the anterior poion of the tibial shaft. * Slight expansion and coical thinning, with a cystic or multiloculated appearance is usual. * Periosteal Reaction is not marked. * Coical destruction on may be extensive. * Margins of tumors vary from being sharply and clearly demarcated, with slight sclerotic areas, to a hazy zone of transition of several mm, comparable to that seen in giant cell tumors. Histologically difficult to distinguish from metastatic adenocarcinoma, but component of the tumor may suggest an epithelial derivation. Although the tumor continues to grow to a slow rate, it is featured by local recurrent and eventual lung metastasis.	Adamantinoma
f8d1aab7-88d9-4a6a-982d-8f8ad20ddd8a	A 33-year-old male immigrant from Taiwan presents with increasing right upper quadrant (RUQ) pain. The pain is dull, and it does not radiate or change with eating. On examination the abdomen is soft, there is a mass in the RUQ, and no ascites is clinically detected. He has a prior history of hepatitis B. His laboratory investigations reveal hepatitis B surface antigen (HBsAg) positive, hepatitis B surface antibody (HBsAb) negative, aspartate amino transferase (AST) 60 U/L, alanine amino transferase (ALT) 72 U/L, and an elevated alpha-fetoprotein level. Which of the following is the most likely diagnosis?	A 33-year-old male immigrant from Taiwan presents with increasing right upper quadrant (RUQ) pain. The pain is dull, and it does not radiate or change with eating. On examination the abdomen is soft, there is a mass in the RUQ, and no ascites is clinically detected. He has a prior history of hepatitis B. His laboratory investigations reveal hepatitis B surface antigen (HBsAg) positive, hepatitis B surface antibody (HBsAb) negative, aspartate amino transferase (AST) 60 U/L, alanine amino transferase (ALT) 72 U/L, and an elevated alpha-fetoprotein level.	(b) Source: (Devita, pp. 533-534) Only the chronic carrier state increases HCC risk, not previous infection. The majority, but not all, of HCC associated with HBV occurs in the setting of cirrhosis (60-90%). Because the latency period of HBV infection is 35 years, before HCC supervenes, early-life infection is strongly correlated with HCC. The chronic carrier state of HBsAg in endemic areas, such as Taiwan, is associated with a relative risk of over 100 for the development of HCC. Over half the chronic carriers of HBsAg in such a population will die of cirrhosis or HCC. In Taiwan, where childhood vaccination was introduced in 1984, the death rate from childhood HCC has already declined.	hepatocellular carcinoma (HCC)
bdcb31fe-c6de-4120-ae58-4eecc6e8888c	A 5-year-old girl is brought to the physician after her parents noticed red blood in her stool. Physical examination reveals mucocutaneous pigmentation. Small bowel radiography discloses multiple, small- to medium-sized polyps that are diagnosed pathologically as hamartomas. Which of the following is the most likely diagnosis?	A 5-year-old girl is brought to the physician after her parents noticed red blood in her stool. Physical examination reveals mucocutaneous pigmentation. Small bowel radiography discloses multiple, small- to medium-sized polyps that are diagnosed pathologically as hamartomas.	Peutz-Jeghers syndrome is an autosomal dominant, hereditary disorder characterized by intestinal hamartomatous polyps and mucocutaneous melanin pigmentation, which is particularly evident on the face, buccal mucosa, hands, feet, and perianal and genital regions. The polyps seen in Peutz-Jeghers syndrome are hamartomatous, characterized by a branching network of smooth muscle fibers continuous with the muscularis mucosa that support the glandular epithelium of the polyp. Congenital teratoma (choice A) does not involve the intestine. The other choices are principally colonic polyps that derive from the luminal epithelium.Diagnosis: Gastrointestinal polyp, Peutz-Jeghers polyp	Peutz-Jeghers polyp
c3073526-26e4-4552-9050-a08cfd2af1d4	A 30-year-old woman sustained a traumatic blow to her right breast. Initially, there was a 3-cm contusion beneath the skin that resolved within 3 weeks, but she then felt a firm, painless lump that persisted below the site of the bruise 1 month later. What is the most likely diagnosis for this lump?	A 30-year-old woman sustained a traumatic blow to her right breast. Initially, there was a 3-cm contusion beneath the skin that resolved within 3 weeks, but she then felt a firm, painless lump that persisted below the site of the bruise 1 month later.	Fat necrosis is typically caused by trauma to the breast. The damaged, necrotic fat is phagocytosed by macrophages, which become lipid-laden. The lesion resolves as a collagenous scar within weeks to months. The firm scar can mammographically and grossly resemble a carcinoma. An abscess may form a palpable but painful mass lesion, and often from Staphylococcus aureus infection when localized. A fibroadenoma is a neoplasm, and tumors are not induced by trauma. Inflammatory carcinoma refers to dermal lymphatic invasion by an underlying breast carcinoma, giving a rough red-to-orange appearance to the skin. Sclerosing adenosis is a feature of fibrocystic changes, a common cause of nontraumatic breast lumps.	Fat necrosis
1dbdf7c2-95d8-41a0-9d5d-641e2666be8e	A 20 year old boy c/o hearing of voices, aggressive behavior since 2 days. He has fever since 2 days. When asked to his family, they says that he has been muttering to self and gesticulating. There is no h/o of psychiatric illness. Likely diagnosis is	A 20 year old boy c/o hearing of voices, aggressive behavior since 2 days. He has fever since 2 days. When asked to his family, they says that he has been muttering to self and gesticulating. There is no h/o of psychiatric illness.	Acute psychosis ??? [Ref: Kaplan and Saddock synopsis of Psychiatry 10/e p 516-5171We are unable to reach a conclusive diagnosis with the information provided in the question.Acute onset, presence of fever, no history of psychiatric illness suggests delirium.But, the diagnosis of delirium cannot be made definitively in the absence of disorientation.In the question there is no definite comment on orientation of the patient.May be, that suggests, the patient is not disoriented.Acute onset, presence of perceptual disturbances (hallucination and other symptoms point towards acute psychosis.But acute psychosis seems unlikely because:-- Absence of cognitive dysfunction or thought disorders.- Absence of H/o psychiatric illness or substance abuse disorders.Psychotic disorders cannot be diagnosed only in the presence of perceptual disturbances. Some disorder in cognitive dysfunction or thought disorders is also required.May be this is a case of acute transient psychosis- These disorders do not give the classical manifestations of psychotic disorders.- They are characterized by the predominance of perceptual disturbances, and they do not fulfil the criteria of psychotic disorders.Acute and Transient Psychotic disordersA large number of psychiatrists especially from the developing countries like India, repoed that many patients developed an acute psychotic disorder that neither followed the course of schizophrenia nor resembled mood disorders in the clinical picture and usually had a better prognosis than schizophrenia.Acute and transient psychosis as a descriptive entity was recognized only with the advent of 1CD-10 in 1992. Where it is included under psychotic disorder.- The key features that characterize the disorder are an -- acute within (2 weeks) onset in all the cases presence of typical syndrome which are described as rapidly changing variables, polymorphic states and typical schizophrenic symptoms evidence ,for associated acute stress in a substantial number of cases and complete recovery in most cases within 2-3 months.A pa from these criteria ICD-10 also provides diagnostic guide- lines which include- Not meeting the criteria for manic or depressive episodes although the affective symptoms may be prominent - Absence of organic causation although perplexity confusion and inattention may he present. - Absence of obvious intoxication by drugs or alcohol.It is evident that ICD 10 intends to "clearly differentiate" the concept of acute transient psychosis .from those of affective psychosis, organic psychosis and drug induced psychosis.This is the point which is creating doubt in our minds.The ICD wants to clearly differentiate it from organic psychosis.- The boy presents with "fever" therefore the organic cause for the psychosis cannot be ruled out. - May be the psychosis is due to fever (some C.N.S. infection)- If fever had not been mentioned the diagnosis would have been clear. But the presence of fever prevents us from diagnosing this as acute transient psychosis.- The correct option would have been "organic psychosis" or "psychosis due to general medical condition". - Acute psychosis cannot be diagnosed without addressing the organic basis of the disease.Four subtypes of acute transient psychosis are described in ICD 10 -Acute polymorphic psychotic disorder without symptoms of schizo- phrenia - Acute polymorphic psychotic disorders with symptoms (?f schizo- phrenia - Acute schizophrenia like psychotic disorder- Acute predominantly delusional psychotic disorderOverall, duration of total episode should not exceed 3 months and that .for schizophrenic symptoms should not exceed 1 month. There is provision for change of diagnosis to schizophrenia.	Acute psychosis
9dbfe50d-9f1b-40f7-9d22-086482e85b07	A child is taken to a pediatrician because his mother notices that his eyes appear very puffy. The mother said that the boy's eyes appeared normal two days ago, and pa of what caused her concern was that her child seemed to be rapidly becoming ill. On physical examination, the boy is noted to have generalized edema. No hypeension or jaundice is noted. Blood urea nitrogen and serum creatinine are within normal limits. A urine sample is collected, and the nurse notices that the top of the urine has a small amount of foam at the top. Urinalysis is negative for glucose, red cells, white cells, casts, crystals, and bacteria. A 24-hr-urine specimen is collected, which demonstrates proteinuria of 55 mg/h/m2. Which of the following is the most likely diagnosis?	A child is taken to a pediatrician because his mother notices that his eyes appear very puffy. The mother said that the boy's eyes appeared normal two days ago, and pa of what caused her concern was that her child seemed to be rapidly becoming ill. On physical examination, the boy is noted to have generalized edema. No hypeension or jaundice is noted. Blood urea nitrogen and serum creatinine are within normal limits. A urine sample is collected, and the nurse notices that the top of the urine has a small amount of foam at the top. Urinalysis is negative for glucose, red cells, white cells, casts, crystals, and bacteria. A 24-hr-urine specimen is collected, which demonstrates proteinuria of 55 mg/h/m2.	Proteinuria greater than 40 mg/h/m2 in a child or 3.5 g/d/1.73 m2 in an adult produces nephrotic syndrome, which is characterized by generalized edema, often most noticeable in the face. The condition develops when large amounts of protein are spilled through the glomeruli into the duct system of the kidneys. In contrast, nephritic syndrome is accompanied by lower levels of proteinuria, together with microscopic or macroscopic hematuria (red cells and blood in urine). Acute and chronic renal failure are characterized by rising serum levels of BUN and creatinine. The findings seen do not suggest lower urinary tract disease, which is typically due to a lower urinary tract infection (which would show bacteria and white cells), calculi (crystals would likely be present), or tumor (which would show abnormal bladder epithelial cells).	Nephrotic syndrome
f8ba7301-121a-479d-9340-514301b354d5	A 40 year old female reports of sudden bouts of anxiety which would occur anytime and associated with sweating, palpitation, derealization, and feeling of going crazy. These episodes would last for 20 -25 minutes. So much so that she fears of having these episodes in future. All routine investigations are normal. What is the diagnosis?	A 40 year old female reports of sudden bouts of anxiety which would occur anytime and associated with sweating, palpitation, derealization, and feeling of going crazy. These episodes would last for 20 -25 minutes. So much so that she fears of having these episodes in future. All routine investigations are normal.	Ans. C. Panic disorderPanic attack: acute intense attack of anxiety accompanied by feelings of impending doom.Symptoms during panic attack usually involve* Sudden onset of palpitations, Sweating, Trembling or shaking,* Shortness of breath, Feelings of choking, Chest pain,* Nausea/abdominal distress, Feeling dizzy, unsteady,* Chills or heat sensations,* Paresthesias, derealization or depersonalization.* Fear of losing control or "going crazy or fear of dying.Recurrent panic attacks is Panic disorder	Panic disorder
fce59ebf-c07e-4ffc-9c94-c93da3164977	Vasanti, a 25-year-old-girl, presents with complaints of fever and weakness. On examination there is splenomegaly of 3 cm below the costal margin.Hb is 8 gm/dL, TLC is 3,000/mm3 , platelet count is 80,000 mm3. Which of the following is the least likely diagnosis -	Vasanti, a 25-year-old-girl, presents with complaints of fever and weakness. On examination there is splenomegaly of 3 cm below the costal margin.Hb is 8 gm/dL, TLC is 3,000/mm3 , platelet count is 80,000 mm3.	null	Aplastic anemia
68ff9908-2480-44a0-b76d-a50dd05032f9	A 60-year-old man with diabetes acutely develops double vision and discomfort in his left eye. On examination, there is ptosis of the left eyelid, the eye is rotated down and out, and the pupil is 3 mm and reactive to light. The right eye is normal. Which of the following is the most likely diagnosis?	A 60-year-old man with diabetes acutely develops double vision and discomfort in his left eye. On examination, there is ptosis of the left eyelid, the eye is rotated down and out, and the pupil is 3 mm and reactive to light. The right eye is normal.	Third nerve palsy can result in ptosis of the eyelid. There is also loss of the ability to open the eye, and the eyeball is deviated outward and slightly downward. With complete lesions, the pupil is dilated, does not react to light, and loses the power of accommodation. In diabetes, the pupil is often spared. The sixth cranial nerve can also be affected by diabetes, but this is much less common.	third nerve palsy
f360e887-b066-4a7d-9231-c516a7ed6532	48 year old male reported with the chief complaint of ulcer on the gums and on general examination headache, fever and malaise was observed. On oral examination, sharply punched out crater-like erosions of the interdental papillae of sudden onset were noted. The patient also complained of bad breath. Diagnosis is	48 year old male reported with the chief complaint of ulcer on the gums and on general examination headache, fever and malaise was observed. On oral examination, sharply punched out crater-like erosions of the interdental papillae of sudden onset were noted. The patient also complained of bad breath.	null	ANUG
f0e1adc0-eeb7-43ed-b013-27f0a855961f	A 23-year-old woman is noticed to have irregular pupils on routine examination. She has 1 large pupil, which has minimal response to light stimulation, but it does respond to accommodation. The eye movements are normal and she experiences no double vision.For the above patient with a pupillary abnormality, select the most likely diagnosis.	A 23-year-old woman is noticed to have irregular pupils on routine examination. She has 1 large pupil, which has minimal response to light stimulation, but it does respond to accommodation. The eye movements are normal and she experiences no double vision.	The tonic pupil (Holmes-Adie syndrome) is caused by a parasympathetic lesion at or distal to the ciliary ganglion. The pupil is large and usually unilateral, with absent response to light. A bright room, by causing constriction of the normal pupil, accentuates the anisocoria. The tonic pupil can be associated with Shy-Drager syndrome, amyloidosis, or diabetes. However, it is most commonly seen in otherwise healthy young women.	tonic pupils (Holmes-Adie syndrome)
7c2228ca-b770-4cd6-b018-66056347cfb9	A 20 year old boy c/o hearing of voices, aggressive behavior since 2 days. He has fever since 2 days. When asked to his family, they say that he has been muttering to self and gesticulating. There is no of psychiatric illness. Likely diagnosis is:	A 20 year old boy c/o hearing of voices, aggressive behavior since 2 days. He has fever since 2 days. When asked to his family, they say that he has been muttering to self and gesticulating. There is no of psychiatric illness.	B i.e. Acute psychosis- Delusions or hallucinations (suchas hearing voices in this case) with grossly disorganized speech and behavior (such as muttering to self, gesticulation, aggressiveness in this case) of acute onset with normal cognition & consciousness indicate the diagnosis of acute psychosis (i.e. psychosis of acute onset). This acute psychosis may be d/t psychotic disorder d/t general medical condition (such as high fever as in this case) or d/t brief psychotic disorder (DSMIVTR), or d/t acute and transient psychotic disorder (ICD-10). So here the term acute psychosis is used to depict the clinical picture not the cause of that clinical picture.Delirium can also present acute onset disorganized behavior (agitation) and speech (incoherent) with delusions or hallucinations but the delusions are poorly elaborated & transient, the course of disease is fluctuant (eg sun downing). And characteristically there is clouding of (disturbance in) consciousnesss (i.e. reduced clarity of awareness of the environment) and disorientation (change in cognition) in delirium. Just like psychosis clinical picture of delirium may also be d/t various reasons such as general medical condition / substance intoxication/ withdrawal.- Dementia is a chronic slow/insiduous process presenting with decrement in intellectual abilities (such as sho & long term memory, judgement, abstract thinking, impulse control, personal care and personality)Q.- Delusional disorder presents with nonbizarre delusions (involving situations that occur in real life) of at least 1 months durationQ. Apa from the impact of delusion (s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre (i.e. criteria. A of schizophrenia has never been met). However, tactile or olfactory hallucinations may be present if they are related to delusional theme.	Acute psychosis
a29bb139-1b53-463c-b01d-8c6404f7f06d	30 year old patient with pain in right hypochondrium for 5 days with soft and tender liver and intercostal tenderness. He complains of catch in breath on inspiration and has a non productive cough. On examination the lung fields are clear, patient looks pale and emaciated. Probable diagnosis is	30 year old patient with pain in right hypochondrium for 5 days with soft and tender liver and intercostal tenderness. He complains of catch in breath on inspiration and has a non productive cough. On examination the lung fields are clear, patient looks pale and emaciated.	Ans. (a) Ameobic liver abscessRef:Manipal Manual of surgery, 4th ed./521Refer to the above explanationHydatid cystUsually clinically silentEnlarged liver with smooth surface and is non tender.Pyogenic liver abscessMultiple abscess leading to spiky fever and enlarged liver.Hepatic adenomaPresents in young women on OCP and is solitary. Liver enlargement may or may not be seen.	Amoebic liver abscess
ea5f1823-e6eb-443b-a8ba-fd006d951f58	A 38-year-old gentleman repos of decreased hearing in the right ear for the last two years. On testing with a 512 Hz tuning fork, the Rinne&;s test without masking is negative in the right ear and positive on the left ear. With Weber&;s test, the tone is perceived as louder in the right ear. The most likely diagnosis in the patient is	A 38-year-old gentleman repos of decreased hearing in the right ear for the last two years. On testing with a 512 Hz tuning fork, the Rinne&;s test without masking is negative in the right ear and positive on the left ear. With Weber&;s test, the tone is perceived as louder in the right ear.	The characteristics of conductive hearing loss are: 1. Negative Rinne test, i.e. BC > AC. 2. Weber lateralized to poorer ear. 3. Normal absolute bone conduction. 4. Low frequencies affected more. 5. Audiometry shows bone conduction better than air conduction with air-bone gap. Greater the air-bone gap, more is the conductive loss 6. Loss is not more than 60 dB. 7. Speech discrimination is good. Ref: Dhingra 7e pg 31.	Right conductive hearing loss
5def7c8a-7647-4298-8a56-63a1be239920	Ramkali bai, a 35-year-old female presented with a one-year history of menstrual irregularity and galactorrhoea. She also had off and on headache, her examination revealed bitemporal superior quadrantanopia. Her fundus examination showed primary optic atrophy. Which of the following is a most likely diagnosis in this case -	Ramkali bai, a 35-year-old female presented with a one-year history of menstrual irregularity and galactorrhoea. She also had off and on headache, her examination revealed bitemporal superior quadrantanopia. Her fundus examination showed primary optic atrophy.	A 35 year old woman complaining of amenorrhoea — galactorrhoea syndrome along with visual field defects confirms the diagnosis of pituitary macrodenoma (prolactinoma) Amenorrhoea and galactorrhoea results due to increased secretion of prolactin. Headache and visual field defects are seen due to mass effect of the tumours on the optic nerve. Now, the closest d/d of prolactinoma i.e. craniopharyngioma Bimodal age of incidence with one peak in childhood and the other in old age at 60 years. These tumours are suprasellar in location and the symptoms are produced due to mass effect of tumour either on the pituitary or optic chiasm. (It does not secrete any hormone) "Craniopharyngioma will never produce the Amenorrhoea galactorrhoea syndrome. Craniopharyngioma does not secrete any hormone."	Pituitary macroadenoma
ddb2fe1c-105e-4ccf-a740-fe383571d102	A 30 year old male was brought for evaluation. The history revealed that the patients 3 year old son died, 5 months back after being hit by a car. At the time of accident, patient was standing nearby and witnessed the accident. For last 5 months, he has been having symptoms of sadness of mood, crying spells, feelings of wohlessness, poor sleep and poor appetite. He has twice thought of killing himself but stopped at the end moment. He has not been attending the office of last 5 months. What is the likely diagnosis:	A 30 year old male was brought for evaluation. The history revealed that the patients 3 year old son died, 5 months back after being hit by a car. At the time of accident, patient was standing nearby and witnessed the accident. For last 5 months, he has been having symptoms of sadness of mood, crying spells, feelings of wohlessness, poor sleep and poor appetite. He has twice thought of killing himself but stopped at the end moment. He has not been attending the office of last 5 months.	Depression: A major depressive disorder occurs without a history of a manic, mixed, or hypomanic episode. A major depressive episode must last at least 2 weeks DIAGNOSIS: Major Depressive Disorder The DSM-5 diagnostic criteria for major depression Sadness of mood Diminished interest in pleasure Significant weight loss or gain more than 5% in a month Crying spells Feeling of wohlessness Poor sleep (Insomnia or hypersomnia) Suicidal thoughts Psychomotor retardation Fatigue or loss of energy. Five or more of these symptoms present for 2 weeks or more or either depressed mood or loss of interest or pleasure.	Major depression
e4ba25b1-2be8-4d30-b095-c3ddc931cc4c	A 26 year old third_gravida mother delivered a male baby weighing 4-2 kg at 37 weeks of gestation through an emergency caesarean section, for obstructed labour. The child developed respiratory distress one hour after bih. He was kept nil per orally (NPO) and given intravenous fluids. He maintained oxygen saturation on room air. No antibiotics were given. Chest radiograph revealed fluid in interlobar fissure. Respiratory distress settled by 24 hours of life. What is the most likely diagnosis ?	A 26 year old third_gravida mother delivered a male baby weighing 4-2 kg at 37 weeks of gestation through an emergency caesarean section, for obstructed labour. The child developed respiratory distress one hour after bih. He was kept nil per orally (NPO) and given intravenous fluids. He maintained oxygen saturation on room air. No antibiotics were given. Chest radiograph revealed fluid in interlobar fissure. Respiratory distress settled by 24 hours of life.	Ans. is 'a' i.e., Transient tachypnea of newborn o Respiratory distress, which resolves within 24 hours without any respiratory suppo and fluid in interlobar fissure on chest X-ray suggest the diagnosis of TTN.	Transient tachypnea of the newborn
ec6babf8-6e3e-49af-aa46-c746a914850b	An 8 years old child has left sided flank pain and mental retardation. On ultrasound, a hyperechoic lesion in the right kidney and multiple lesions in the liver are noted. CT examination of the abdomen revealed -50 to -80 HU density of these lesions. The most probable diagnosis is:	An 8 years old child has left sided flank pain and mental retardation. On ultrasound, a hyperechoic lesion in the right kidney and multiple lesions in the liver are noted. CT examination of the abdomen revealed -50 to -80 HU density of these lesions.	Answer- A (Tuberous sclerosis)AML is a benign clonal neoplasm consisting of varying amounts of mature adipose tissue, smooth muscle and thick-walled vessels.	Tuberous sclerosis
3dc7cfae-f1fa-4b38-9b68-c95eebbad9ff	An 8 year old child has shown of lack of interest in studies for last 6 months. He has frequent quarrels with his parents and has frequent headaches as anexcuse to avoid school. What would be the most appropriate clinical diagnosis in this patient?	An 8 year old child has shown of lack of interest in studies for last 6 months. He has frequent quarrels with his parents and has frequent headaches as anexcuse to avoid school.	Since the person in the question is showing a hostile behavior which is impairing his academic activities for the last 6 months, the most appropriate next step would be to rule out Oppositional defiant disorder.Oppositional defiant disorder is a recurrent pattern of negativistic, hostile or defiant behavior that lasts longer than 6 months and creates disturbances in at least one of the domains of child functioning including social, academic or occupational impairment. The symptoms of this disorder is usually evident around 6-8 years. Ref: Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 9th Edition, Page 3586, 3580.	Rule out an oppositional defiant disorder
2a8e61f3-085c-4603-b331-de0078d6e5f9	A 12-year-old boy had a gradually progressive plaque on a buttock for the last 3 years. The plaque was 15 cm in diameter, annular in shape, with crusting and induration at the periphery and scarring at the centre. The most likely diagnosis –	A 12-year-old boy had a gradually progressive plaque on a buttock for the last 3 years. The plaque was 15 cm in diameter, annular in shape, with crusting and induration at the periphery and scarring at the centre.	This boy has Annular plaque On buttock Crusting at periphery Scarring at centre These suggest the diagnosis of lupus vulgaris. Annular lesions When the lesions of a skin disease are arranged in ring shape, they are called annular lesions.	Lupus vulgaris
31117f1b-6870-4655-bd34-9f166f70b54f	A 52-year-old alcoholic notices a skin rash on his chest, and also has symptoms of diarrhea and abdominal pain. On examination, he has a scaly and pigmented rash on the sun-exposed areas of his skin, the abdomen is soft, and his short-term memory is impaired. He has dermatitis, diarrhea, and dementia syndrome.For the patient with vitamin deficiency or excess, select the most likely diagnosis	A 52-year-old alcoholic notices a skin rash on his chest, and also has symptoms of diarrhea and abdominal pain. On examination, he has a scaly and pigmented rash on the sun-exposed areas of his skin, the abdomen is soft, and his short-term memory is impaired. He has dermatitis, diarrhea, and dementia syndrome.	Diarrhea, dementia, and dermatitis are the classic triad for pellagra (niacin deficiency). The diagnosis is based on clinical suspicion and response to therapy, and can be confirmed by demonstrating low levels of the urinary metabolites 2-methylnicotinamide and 2-pyridone. Small doses of niacin (10 mg/day) with adequate dietary tryptophan will cure pellagra secondary to nutritional deficiency.	niacin
d93522e3-8ae1-451e-a688-daec2e5dfe08	A 19-year-old man presents to the clinic complaining of early fatigue and muscle cramps while playing sports. He is fine when walking or doing less intense levels of work. On physical examination, he appears well and the vital signs are normal. Muscle bulk, tone and strength in the proximal muscles are normal. There is no muscle fatigue with repetitive arm grip exercises. After an exercise stress test, his serum creatine kinase (CK) is elevated and lactate level is normal. Which of the following is the most likely diagnosis?	A 19-year-old man presents to the clinic complaining of early fatigue and muscle cramps while playing sports. He is fine when walking or doing less intense levels of work. On physical examination, he appears well and the vital signs are normal. Muscle bulk, tone and strength in the proximal muscles are normal. There is no muscle fatigue with repetitive arm grip exercises. After an exercise stress test, his serum creatine kinase (CK) is elevated and lactate level is normal.	There are many types of glycogen storage diseases, each caused by a different enzymatic abnormality. The best-known types of glycogen storage disease are those that have hepatic hypoglycemic pathophysiology (eg, von Gierke disease) or those that have muscle energy pathophysiology (McArdle disease). InMcArdle' symptoms usually develop in adulthood, and it is marked by cramps and muscle injury with strenuous exercise, but not with usual activities. Gaucher and Tay-Sachs disease are lysosomal storage diseases.	McArdle disease (glycogen storage disease)
25f981b1-3ecc-43c0-a40e-89937631579b	A 50 years old patient presented to the skin OPD with erythematous scaly plaques over trunk and extremities for last l0 years. Lesions are occasionally itchy. There is history of remission and relapse with exacerbation during winters. Most likely diagnosis is?	A 50 years old patient presented to the skin OPD with erythematous scaly plaques over trunk and extremities for last l0 years. Lesions are occasionally itchy. There is history of remission and relapse with exacerbation during winters.	Ans: B. Psoriasis vulgaris(Ref: Neena Khanna 4'h/e p. 40-48; Roxburg lVh/e p. 128-42; Venkataram 1"'/e p. 491)Psoriasis (psoriasis vulgaris):Psoriasis is chronic dermatosis characterized by unpredictable course of remission and relapse and presence of well defined silvery white scaly papules and plaques on erythematous base.Aggravated in winter.Lesions are mildly pruritic or non-pruritic.	Psoriasis vulgaris
a157f6a4-4f0b-4c11-82a9-effbebbba58d	1729. A 28 yr old female presented with malaise and generalised weakness since 6 month. Her appetite Is reduced and she has giddiness and palpitations on and off. There was no organomegaly. Laboratory Study showed normochromic to hypochromic anaemia and MCV-80. What Is the diagnosis	1729. A 28 yr old female presented with malaise and generalised weakness since 6 month. Her appetite Is reduced and she has giddiness and palpitations on and off. There was no organomegaly. Laboratory Study showed normochromic to hypochromic anaemia and MCV-80.	<p> Iron deficiency anemia is much more common in women between the age of 20 & 45 yrs than in men.The onset of this anemia is generally slow .The usual symptoms are weakness ,fatigue ,palpitations ,dyspnoea on exeion & pallor of skin, sclera & mucous membrane.</p><p>Also MCV will be less than 80fl in iron deficiency anemia .</p><p>Reference :Harsh mohan textbook of pathology sixth edition pg no 298.</p>	Iron deficiency anaemia
de231299-c4b5-4980-88ca-3dd828085789	A patient with primary Sjogren syndrome treated with tear replacement for symptomatic relief notes continued parotid swelling for the last 3 months. She also has enlarged posterior cervical lymph nodes. Evaluation shows leukopenia and low C4 complement levels. What is the most likely diagnosis?	A patient with primary Sjogren syndrome treated with tear replacement for symptomatic relief notes continued parotid swelling for the last 3 months. She also has enlarged posterior cervical lymph nodes. Evaluation shows leukopenia and low C4 complement levels.	Lymphoma is well known to develop specifically in the late stage of Sjogren syndrome. Common manifestations include: Persistent parotid gland enlargement Purpura Leukopenia Cryoglobulinemia Low C4 complement levels. - Most of the lymphomas are extranodal, marginal zone B cell, and low grade. Low-grade lymphomas may be detected incidentally during a labial biopsy. - Moality is higher in patients with concurrent B symptoms (fevers, night sweats, and weight loss), a lymph node mass >7 cm, and a high or intermediate histologic grade.	Lymphoma
93871c68-7564-4ba5-aa49-a23221c122c9	A 10 year old boy has a fracture of femur. biochemical evaluation revealed Hb 11.5 gm/dl and ESR 18 mm 1st hour. Serum calcium 12.8 mg/dL, serum phosphorus 2.3 mg/dL, alkaline phosphate 28 KA units and blood urea 32 mg/dl. Which of the following is the most probable diagnosis in his case –	A 10 year old boy has a fracture of femur. biochemical evaluation revealed Hb 11.5 gm/dl and ESR 18 mm 1st hour. Serum calcium 12.8 mg/dL, serum phosphorus 2.3 mg/dL, alkaline phosphate 28 KA units and blood urea 32 mg/dl.	You can solve the question just looking at calcium value. Amongst the given options only hyperparathyroidism causes hypercalcemia. The patient in question has an increased serum Ca', decreased serum phosphorus and increased values of alkaline phosphatase, all of which characterize hyperparathyroidism.	Hyperparathyroidism
50f67ace-0c4b-435b-89bc-e827d452a3d2	A 6 year old boy has been complaining of headache, ignoring to see the objects on the side for 4 months. On Examination, he is not mentally retarded, his grades at school are good & visual acuity is diminished in both the eyes, visual chaing showed significant field defect. CT scan of the head showed suprasellar mass with calcification. Which of the following is the most probable diagnosis?	A 6 year old boy has been complaining of headache, ignoring to see the objects on the side for 4 months. On Examination, he is not mentally retarded, his grades at school are good & visual acuity is diminished in both the eyes, visual chaing showed significant field defect. CT scan of the head showed suprasellar mass with calcification.	B i.e. Craniopharyngioma	Craniopharyngioma
b3b8f17f-25ac-4f83-9434-0efb1f1621b8	An 11-year-old boy was brought to the pediatric OPD with multiple abscesses over his face, chest, and back. The child has a history of recurrentrespiratory infections. On examination, he has atopic excoriating skin and multiple cold abscesses on his back. What is the most probable diagnosis?	An 11-year-old boy was brought to the pediatric OPD with multiple abscesses over his face, chest, and back. The child has a history of recurrentrespiratory infections. On examination, he has atopic excoriating skin and multiple cold abscesses on his back.	From the above clinical history and examination, the most probable diagnosis is Hyper IgE syndrome (Job's syndrome). It is an autosomal dominant primary immunodeficiency disease caused by a mutation of STAT3 gene. Neutrophils do not generate an immune response, probably due to a defect in chemotaxis. Patients present with recurrent staphylococcal skin abscesses, recurrent lung infections (pneumatoceles), eczema, eosinophilia and high serum levels of lgE. Reference: Ananthanarayan and Paniker&;s Textbook of Microbiology Tenth edition	Hyper IgE syndrome
37e100e7-52d2-4744-aa7a-daa3992d56e0	A 19 year old young girl with previous history of repeated pain over medial canthus and chronic use of nasal decongestants, presented with abrupt onset of fever with chills & rigor, diplopia on lateral gaze, moderate proptosis & chemosis. On examination optic disc is congested. Most likely diagnosis is:	A 19 year old young girl with previous history of repeated pain over medial canthus and chronic use of nasal decongestants, presented with abrupt onset of fever with chills & rigor, diplopia on lateral gaze, moderate proptosis & chemosis. On examination optic disc is congested.	Patient is suffering from cavernous venous thrombosis, as a complication of chronic ethmoidal sinusitis. The facial veins make clinically impoant connections with the cavernous sinus through the superior ophthalmic veins. Cavernous sinus thrombosis usually results from infections in the orbit, nasal sinuses, and superior pa of the face. Think Detail: Cavernous sinus: is located on the side of the body of sphenoid. The cavernous sinuses consist of extradural venous plexuses surrounded by a dural fold. Structures Within its cavity Internal carotid aery Abducent nerve Carotid sympathetic plexus Lateral wall Oculomotor nerve Trochlear nerve Opthalmic division of trigeminal nerve Maxillary division of trigeminal nerve Tributaries: Anteriorly Opthalmic veins (connects with the facial vein) Posteriorly Superior petrosal sinus (connects with transverse sinus) Inferior petrosal sinus (conncets with internal juglar vein) Medially Anterior and posterior intercavernos sinuses (connects the two cavernous sinuses) Superiorly Superficial middle cerebral vein (from latwral surface of the brain) Cerebrsl veins from inferior surface of brain Cavernous sinus thrombosis (CST) is a late complication of facial or paranasal sinus infection, resulting in thrombosis of the cavernous sinus and inflammation of its surrounding anatomic structures, including cranial nerves. Clinical features: Infection of the cavernous sinus is characterized by sepsis, orbital pain, chemosis, proptosis, and ophthalmoplegia. Cavernous sinus thrombosis results in paresis of cranial nerves III, IV, and VI and the opthalmic and maxillary divisions of the cranial nerve V. The diagnosis is based primarily on clinical data. CT and MR imaging can provide diagnostic information.Treatment is with broad spectrum antibiotics and should be staed early .This has high moality. Cavernous sinus syndrome: is characterized by multiple cranial neuropathies. The clinical presentation includes impairment of ocular motor nerves, Horner's syndrome, and sensory loss of the first or second divisions of the trigeminal nerve in various combinations. The pupil may be involved or spared or may appear spared with concomitant oculosympathetic and parasympathetic involvement. Ref: 1) Comprehensive opthalmology,by AK Khurana,4th Edition, Page 384-389; 2) Parsons ' Diseases of the Eye, 20th Edition, Page 456-459;	Cavernous sinus thrombosis