AIIMS Medicine Quiz

Quiz held at AIIMS, New Delhi for medicine residents (MD/DNB) on 20/10/19

1. AIIMS MEDICINE QUIZ 20 th October 2019 FINALS

2. Rules Total 6 rounds Each team will get 1 question per round (I-IV) Round 1,3 =A to F Round 2,4= F to A Scores at end of each round No prompting. And most important rule….

3. Quiz master’s decision is final!

4. Clinical round 1 A to F +20 points for direct question Pounce - > +10/-5 No partial points for pounce. If either wrong, -5. You may attempt parts alone (ex. attempt 1 out of 2 with risk of +5, but negative always stays -5) 1.5 min for direct question, pounce window closing after 45 sec Be patient: If direct team answers before other teams get chance to pounce, -10 for the team and the questions stands null and void.

5. Question 1 A 40-year-old male with 15-pack-year smoking history (quit 5 years ago) has presented with low-grade intermittent fever, cough and intermittent moderate hemoptysis for 2 years. He has history of associated weight loss of around 5 kgs. He has been treated on clinico-radiological basis with ATT for 1 year without improvement. He has past-history of right mastectomy for gynecomastia at age of 17 years and history of dental caries requiring tooth extraction 2 years back. Presently, he came to the emergency with a bout of massive hemoptysis which subsided with bronchial artery embolization. A subsequent bronchoscopy revealed a mucus plug and purulent discharge with yellowish granules in the right lower lobe bronchus which was suctioned. Histopathology of the mucus plug revealed gram-positive bacteria showing Splendore-Hoeppli phenomenon. What is the likely diagnosis?

6. Answer 1 Pulmonary Actinomycosis

7. Question 2 •A 52 year old man Mr A known case of major depressive disorder with poly substance abuse and poorly controlled Type 2 diabetes mellitus is found unconscious and incontinent of urine in his room and admitted •On arrival, the patient was afebrile and hemodynamically stable with a respiratory rate of 18/min-lethargic and oriented to self with dry mucous membranes •Urine toxicology screen was negative The likely diagnosis for M r. A? Value Reference Range Sodium,mmol/L 144 135-145 Potassium,mmol/L 3.6 3.3-5.0 Chloride,mmol/L 98 96-106 BUN,mg/dL 24 8-18 Creatinine,mg/dL 1.5 0.5-1.2 Glucose,mg/dL 231 70-100 Calcium, corrected,mg/dL 13.4 8.8-10.2 Magnesium,mg/dL 0.9 1.7-2.6 Phosphorus,mg/dL 2.4 2.5-4.5 Albumin,g/dL 3.4 3.5-5.0 Bicarbonate,mmol /L 34 23-28 iPTH 15 30- 85

8. Answer 2 Milk-Alkali syndrome-possibly due to Shelcal toxicity !

9. Question 3 A 63-year-old woman with a 4-year history of uncontrolled diabetes mellitus presented with an ulcerating rash, primarily on the shins, groin, and face; cheilitis; and glossitis. Her symptoms had been worsening for 4 years despite specialized wound care. In addition, she noted concurrent, severe weight loss, depression, abdominal pain, and intractable nausea. Diagnosis and finding?

10. Answer 3 Necrolytic migratory erythema due to a glucagonoma

11. Question 4 A 30-year old male with a history of alcohol abuse was admitted to the cardiac unit with progressive shortness of breath, lower extremity edema and tachycardia which had developed gradually over several days. There was no history of drug abuse or any prior cardiac events. On examination, On appearance, the patient was severely malnourished. Pulse=130/min with bounding pulses and warm extremities. BP=100/45; Respiratory rate=24/min; Pulse oximetry=98% on room air Labs revealed hyponatremia, compensated metabolic acidosis with a bicarbonate of 14 mEq /L and a lactic acidosis with lactate of 9 mmol/L. 2D Echo showed mild LV dysfunction with an EF of 50%. You have excluded sepsis(somehow). What is the diagnosis?

12. Answer 4 Wet beri-beri Thiamine deficiency

13. Question 5 62 years old male, known diabetic and hypertensive for past 20 years presented with acute onset altered sensorium with altered behaviour and difficulty recognizing relatives. He was admitted and worked up. Routine evaluation including MRI brain, CSF were normal. Serum ammonia was 305. CT portography done. What is the diagnosis? What specific intervention can be offered for this indication?

14. Answer 5 Hepatic encephalopathy secondary to portosystemic shunting (Type B HE) Blocking the leino -renal shunt

15. Question 6 A 40 year old lady, diabetic and hypertensive for 10 years, controlled on therapy presented to EM with recurrent vomiting for 3 days. No history of fever, diarrhea or food intake from outside, no one else in family is symptomatic. EM evaluation showed normal vitals, electrolytes and was discharged after symptomatic treatment with ondansetron and IV fluids. Lady returned to EM two days later with acute painless loss of vision in both eyes and tetraparesis For suspected illness MRI was done which showed the changes shown What is the clinical diagnoses and next investigation?

16. Answer 6 Diagnosis-NMO/NMOSD Investigation- anti-AQP4 antibody

17. Audience question • The fight for the creation of a drug against this virus began in 1929 and only finally saw the light of day when it was approved by the FDA on 1 May 2019. It has been injected to >8 lakh school children across the globe. • The problem arose with the drug in those who had never been infected with a type of this virus previously and resulted in disastrous cytokine storm upon subsequent infection • What is the drug?

18. Clinical Round 2 F to A +20 points for direct question Pounce - > +10/-5 No partial points for pounce. If either wrong, -5. You may attempt parts alone (ex. attempt 1 out of 2 with risk of +5, but negative always stays -5) 1.5 min for direct question, pounce window closing after 45 sec Be patient: If direct team answers before other teams get chance to pounce, -10 for the team and the questions stands null and void.

19. Question 1 A 76 years old male, prior smoker presents with recurrent episodes of angina and syncope. On evaluation he’s found to have a Hb of 5.4. On detailed questioning, he gives a history of episodes of melena interspersed between syncopal attacks, ongoing for the past 1 year. A colonoscopy is performed that shows characteristic vascular lesions. What’s the diagnosis? Explain the pathophysiology behind it.

20. Answer 1 Heyde’s Syndrome. (Colonic angiod ysplasia shown) Pathophysiology-Acquired Von Willebrand Factor defect due to mechanical breakdown by aortic stenosis. Shear stress.

21. Question 2 An athletic 40 year old man with no significant medical history presented with complaint of episodes of palpitations. He had no cardiovascular risk factors and no family history of sudden cardiac death or cardiomyopathy. On examination in the OPD, pulse was 45 beats/min, respiratory rate of 12/min and blood pressure of 135/62. Physical examination showed a discrete pansystolic murmur at the lower sternal border, which increases with inspiration. His baseline ECGs and ECG during an episode of palpitation while in the hospital were recorded. E CHO showed a normal LV ejection fraction, no valvular heart disease and apical dyskinesia of the right ventricle. Diagnosis?

22. Answer 2 Arrhythmogenic right ventricular dysplasia(ARVD) First ECG shows incomplete right bundle branch block and inverted T waves in right precordial leads, QRS prolongation and epsilon wave Second ECG shows a broad QRS tachycardia with AV dissociation and LBBB morphology-an RVOT VT ECG findings Epsilon wave (most specific finding, seen in 30% of patients) T wave inversion in V1-3 (85% of patients) Prolonged S-wave upstroke of 55ms in V1-3 (95% of patients)

23. Question 3 A 57-year old man with a 10 year history of type 2 diabetes presented to the emergency room with light-headedness. He had been on metformin and empagliflozin for the last 6 months and last HbA1C value was 5.7 one month back. He was currently on a low carbohydrate diet and had been NPO that day for an outpatient dental procedure. The episode of lightheadedness began 1 hour prior and was associated with nausea and tachypnea. A friend checked his capillary blood glucose at the time and reports it to be 122 mg/dL Pulse 98/min; BP 130/66; RR 26/min; SpO2 99% on RA Explain his current condition. VBG parameter Value pH 7.25 Bicarbonate(meq/L) 10 Anion gap(meq/L) 23 K+(mEq/L) 4.9 Ketonemia +++

24. Answer 3 Euglycemic diabetic keto-acidosis due to empagliflozin

25. Question 4 A 21-year-old medical student presents to you with history of high-grade fever with chills for 3 weeks and cough with streaky hemoptysis for 2 weeks. There are no other localizing symptoms. He gives history of travel to hills with his friends during the summer break when he used recreational drugs. He has smoked 1 packet of cigarettes a day for the past 2 years. His past-history is significant for surgery for acute appendicitis 3 years back. During the present illness he has been treated with Cefixime, Azithromycin and Ceftriaxone without relief in fever. His blood culture is positive for Staphylococcus aureus. What should be the next investigation?

26. Answer 4 A 2D Echocardiography He seems to have developed an unfortunate complication from his vices!

27. Question 5 35 year lady, fatigue, loss of weight CBC – TLC: 65000/cmm, Platelet: 25000/cmm PBS – Blasts 71% Bone Marrow – Blasts 96% Cytochemistry shows Myeloperoxidase – ve, Sudan Black B – ve, combined chloracetate esterase – ve. Cytogenetics is t(9;22), FISH s/o BCR-ABL translocation What are the two possible diagnosis? Common BCR-ABL variants in each? Drug of choice in both scenarios?

28. Answer 5 CML- lymphoid BC or PH positive ALL P190- ALL, p210-CML Dasatanib in both

29. Question 6 A 32 year old male has migraine with aura. He developed left sided hemiparesis. Family history revealed father and grandfather suffering from migraine and dementia. For suspected acute stroke MRI is done and showed the image on the right. Your consultant asks you to get a skin biopsy. What is the likely clinical diagnosis? What is the underlying genetic abnormality?

30. Answer 6 Clinical diagnosis-CADASIL Underlying abnormality-Mutation of NOTCH 3 Next investigation-Skin Biopsy

31. Name the maneuver shown in the image used to improve visualization of the larynx during endotracheal intubation, but not intended to prevent regurgitation. Audience question

32. Trivia A to F +20 points for direct question Pounce - > +10/-5 No partial points for pounce. If either wrong, -5. You may attempt parts alone (ex. attempt 1 out of 2 with risk of +5, but negative always stays -5) 1.5 min for direct question, pounce window closing after 45 sec Be patient: If direct team answers before other teams get chance to pounce, -10 for the team and the questions stands null and void.

33. Question 1 What did Dr Thomas Latta of Edinburgh do for the first time ever, which has since become a standard of care during patient resuscitation?

34. Answer 1 Intravenous fluid resuscitation

35. Question 2 In 1937, after the Japanese invasion of China, the communist General Zhu De requested Jawaharlal Nehru to send Indian physicians to China. Netaji Subhash Chandra Bose, the President of the Indian National Congress, made arrangements to send a team of volunteer doctors and an ambulance by collecting a fund of Rs 22,000 on the All-Indian China Day and China Fund days on July 7-9. ___________________ was one of five Indian physicians dispatched to China to provide medical assistance during the Second Sino-Japanese War in 1938. Besides being known for his dedication and perseverance, he has also been regarded as an example for Sino-Indian friendship and collaboration.

36. Answer 2 Dr Dwarkanath Kotnis

37. Question 3 This picture represents the 10,000 th mile of the national cycle network in Britain and is part of the National Cycle Route 11. It stretches from Addenbrooke’s Hospital, Cambridge to the nearby village of Great Shelford. It is a dedication to the 1994 discovery made by  Professor Michael Stratton and Dr Richard Wooster (Institute of Cancer Research, UK). Which discovery?

38. Question 4 In 1832, Dr. B described a 50 year old man suffering from a ‘heat of the blood’, intense sweating and oppression of the chest. The patient had a pale and puffy countenance with eyes like those of a ‘cray fish’ likely due to a blood dyscrasia. He described 2 more patients with thickened lower legs consisting of a ‘plastic brawn’ not being impressible and not releasing fluid by puncture. From his observations, he described pregnancy as the most suitable cure and associated it with the Merseburger triad. Name the disease.

39. Answer 4 Graves ’ disease

40. Question 5 In the Middle Ages, treatment for X included hot baths, sweating, bloodletting and enemas. Thomas Graham is said to be the father of Y His ideas were implemented in animals for the first time by Abel who used Collodion membranes with the help of hirudin from leeches to carry out “Y”. In 1945, Kolffbrought out the rotating drum version of “Y” and managed to treat the first patient with X using Y. However, it was difficult to use on patients until Brescia-Cimino came out with their innovation, “Z” that allowed patients to use Y for many years with a lower rate of infections. Name ”Y” and “Z”.

41. Answer 5 Y : Hemodialysis Z : AV fistula

42. Question 6 Despite being the youngest in the group, he was chosen as the first author in a seminal publication of May 13, 1932, a decision that would have far reaching implications. He went on to have an exceptionally good practice, with patients including president D Eisenhower. He always however lamented the time his work took from his family, as encapsulated in this quote. "It has been my misfortune (or perhaps my fortune) to spend most of my professional life as a student of constipation and diarrhea. Sometimes I could wish to have chosen ear, nose and throat as a specialty rather than the tail end of the human anatomy...". Who are we talking about?

43. Answer 6 Burbill B Crohn

44. Audience Q Middle aged smoker presented with hoarseness of voice x 1 month. ENT evaluation shows no growth in larynx but decreased movement of one sided vocal cords. CXR shown. What is this clinical syndrome known as?

45. Connect F to A Each question has a set for four images, which have something in common. The common thing can be anything, a diagnosis, drug, syndrome, test etc. Total points are +20= 10 for the connect and 10 for explanation (including all images) In some cases, explaining 3 out of 4 images may suffice. 2 mins for connect and 1 min pounce window. Pounce marks are +10: +5 for connect and + 5 for explanantion and -5 if either is wrong. You may attempt only the connect as well.

46. Question1

47. Answer Frontal lobotomy

48. Question 2

49. Answer Crohns’ disease

50. Question 3

51. Answer Digoxin

52. Question 4

53. Answer Immunotherapy Allison and Honjo- nobel prize William cooley- father of immunotherapy RCC and melanoma- immunotherapy first line, revolutionized management

54. Question 5

55. Answer Amyloidosis

56. Question 6 Pulmonologists love stethoscope . WOULD YOU PREFER A BLACK STETHOSCOPE OR A YELLOW STETHOSCOPE?

57. René Laennec

58. Audience Q What is he planning to do with this tube?

59. Endotracheal intubation in elephant surgery

60. Systems Selection Each team, starting from the lowest scoring team, will get to choose a topic of their own, from the tiles given. Each topic will have a set of 3 questions arranged in the order of increasing difficulty. The score of the questions will be +20,+30, +40 for questions 1 to 3 respectively (no part points).2 min per question, 1 min pounce window. If a team cannot answer a question, they can skip the question with no loss of points and proceed further to the next question. However, if a team answers a question incorrectly, the points for the whole round will be scrapped. Pounce for each question carries +10 for right answer and -10 for wrong answer (no part points) and pounce window for 1 minute. If any team answers a question incorrectly, the remaining questions (if any) of that title shall be open to pounce for all the teams. (including the team who chose the round)

61. Systems selection Sea waves in my heart You take my breath away To the lumen and beyond Not what you thought Malignant friends Let’s get hormonal

62. Systems 1 Sea Waves in my heart

63. Q1 A 20/M presented with the following ECG. The astute cardiologist noticed that this is not the garden variety PSVT and is infact the simultaneous presence a culprit and it’s facililtator .

64. He explains to you interventional procedures that can be used for management of the culprit, ‘A’, and for the facilitator, ‘B’ (not necessarily in this case). Identify.

65. AF with aberrant pathway (WPW). A= PVI and B= RFA

66. Q2 An intern brought the ECG of a patient from the emergency while you’re at cardio ward. You panic and activate the cath lab. The intern asks you to help localize the territory leaving you red faced. What is the localization?

67. A2 High lateral MI. Localization: D1>>LCX occlusion ST elevation primarily localized to leads I and aVL is referred to as a high lateral STEMI. It is usually associated with reciprocal ST depression and T wave inversion in the inferior leads. Sometimes referred to as the South African Flag sign

68. Q3. Identify the waveform in aortic pressure curve and the characteristic finding on LVOT gradient curves (20+20) Aortic pressure waveform LV to Aorta pressure gradient

69. Spike and dome pulse wave The brockenbrough – braunwald – morrow sign

70. Systems 2 You take my breath away

71. Q1 • A 73-year-old man is being considered for liberation from mechanical ventilation. He was initially admitted to the ICU for community acquired pneumonia and sepsis. He has comorbid heart failure (LVEF = 35%), COPD, hypertension and diabetes mellitus. The patient is given a spontaneous breathing trial for 1 hour with PEEP of 5 cm H2O and an inspiratory augmentation of 7 cm H2O. At the end of this trial, the patient has a HR – 80/min, RR – 16/min, BP – 100/60 mmHg, SpO2 – 96% on fiO2 – 30% and the patient is generating tidal volume of approximately 320 mL. What is the rapid shallow breathing index?

72. A1 16/0.32 = 50

73. Q2 Match the following 1.Lymphangioleiomyomatosis (LAM) 2.Burt-Hogg-Dube Syndome 3.Pulmonary Langerhans Cell Histiocytosis 4.Lymphoid Interstitial Pneumonia A.Bronchoalveolar lavage fluid CD1a + cells > 5% B.Serum Vascular Endothelial Growth Factor-D level > 800 pg /mL C.Folliculin (FLCN) gene variants D.Systemic rheumatic diseases

74. A2 B C A D

75. Q3 • A 62-year-old female with history of chronic alcohol use is admitted to your ICU with history of black colored stools for the past 3 days and hematemesis for 1 day. She has not had anything to eat for the past 1 day. At admission, her vitals are HR – 110/min, BP – 100/60 mmHg, RR – 20/min, SpO2 – 100% on O2 @ 2 L/min. Examination reveals scratch marks, evidence of presence of bed bugs. An ECG demonstrates tachycardia but not ischemia. Chest X-Ray shows no acute event. Echocardiography reveals normal left ventricular function. • Assuming a cardiac output of 10 L/min, what is the delivered Oxygen per minute? Value WBC 21500/μL Hb 2.1g/dL Platelet 198000/μL Sodium 145 mmol/L Potassium 3.9 mmol/L Creatinine 1.13 mg/dL Lactate 17.0 mmol/L

76. A3 280 mL/min =10L/minx(1.34x2.2x1 ml/dL) =100x2.1x1.34

77. Systems 3 To the lumen and beyond!

78. Q1 A 58/M with no prior comorbidities, BMI 24kg/m2 presents with drunken gait and aggressive behavior. Complete metabolic profile including electrolytes, liver panel were normal. Toxin screen was negative. Previously charged twice with drunk driving with similar symptoms- breathalyzer tested positive for high levels of alcohol on both occasions. Based on this history, blood alcohol levels were tested, and were 250mg/dl (elevated). Patient repeatedly denied alcohol consumption and family members confirm him being a teetolatter ===. What is the diagnosis What is the pathogen involved?

79. A1 Autobrewery syndrome Saccharomyces cerevisae

80. Q2 A 34 years old housewife, resident of Kota, Rajasthan presented with chronic small bowel type diarrhea with 8-10 stools per day associatedwith weight loss of over 10 kg over 6 month. She had iron deficiency anaemia on investigations, with Hb-8.3 and anti tTgAb negative. A duodenal biopsy was done, that showed markedvillous atrophy with increase in IEL- 100/100 hpf , crypt hyperplasia and diffusechronic inflammatory infiltrate. IHC was positive in those cells for CD3 and CD8. No strictures were found on CT enterography . PET CT enterography was done that showed the following finding. Serum electrophoresis and immunofixation are also shown. What is the diagnosis?

81. Q2

82. A2 IPSID Alpha heavy chain disease with plasmacytoid infiltration in the jejunum

83. Q3 A 50 years old male presents with dull aching epigastric pain. He is subsequently evaluated and is found to have lesion in the pancreas on CT. MRCP and Side viewing endoscopy and EUS-FNA are performed. Diagnostic aspiration from the lesion shows high CEA and high amylase values.

84. What is the diagnosis?

85. A3 MD-IPMN

86. Systems 4 Not what you thought!

87. Q1 A 34 year old woman presented to the emergency department 2 days ago withcomplaints of severe, sudden onset headache and diplopia for 2 hours. An emergent non-contrast CT scan (NCCT) of the head was performed that revealed a subarachnoid hemorrhage. A lumbar puncture was also performed which revealed a grossly bloody tap with 20-30 RBC’s per high power field and an opening pressure of 20 cmH2O on lying on the side. She was admitted and conservatively managed by IV propranolol and IV mannitol. On the 3rd day of admission she developed sudden onset severe occipital headache, worse than the episode for which she was admitted. Another emergent NCCT of the head was performed which did not reveal any significant changes. A lumbar puncture revealed an opening pressure of 14 cmH2O and a xanthochromic tap. What is the drug of choice for the patient’s symptoms?

88. A1 Nimodipine , not any calcium channel blocker. Diagnosis: Reactive vasospasm post Sub-Arachnoid Hemorrhage.

89. Q2 A 12 year old child was brought on wheelchair for both upper and lower limb weakness. Which classical sign given by an Indian neurologist is shown in the images?

90. A2 Pradhan’s Valley sign. Atrophied posterior axillary fold with hypertrophy of deltoid and infraspinatus muscle.

91. Q3 76 years old lady diabetic, hypertensive, hypothyroid with CKD 5 on maintenance hemodialysis presented to EM with increased sleepiness, decreased oral intake and intermittent non responsiveness. EM evaluation showed sodium of 109meq and dehydration. 3% NS was provided to rapidly correct the sodium deficit. Her sensorium improved over 24 hours but while discharging the patient she developed tremors and mutism. Repeat sodium value of 135meq lead to readmission. NCCT head didn’t show any infarct, bleed or pontine changes. MRI brain was done but showed no pontine changes. What is the likely cause for her current altered sensorium? What are the most common sites to look for this pathology?

92. A3 Extrapontine myelinosis . Cerebellum, lateral geniculate body, external capsule, hippocampus.

93. Systems 5 Malignant friends

94. Q1 A 35 year old male presented with one month history of generalized weakness and 10 day history of petechial rash. On evaluation he was found to have a HB of 9g/dl, TLC of 2400/mm3 and Platelet count of 32000. A peripheral Smear was done picture of which is shown What is the likely diagnosis? What is the characteristic molecular abnormality associated with this condition?

95. Answer APML PML-RARA

96. Q2 A 2 year and 8 month old boy is brought to the emergency department with complaints of involuntary, rapid eye movements in various directions and an inability to walk since the past 3 days. The parents also give a history of moderate fevers (documented as 99-100ºF), weight loss, anorexia, generalized malaise and worsening ataxia since the past 2 months. On examination the child is irritable, his vitals are: BP – 124/80 mm Hg; pulse rate – 130/min, regular; respiratory rate – 22/min; temperature 100ºF. A few rhythmic involuntary twitching of the upper limbs is noted. Further examination failed to reveal anything significant.

97. A Contrast Enhanced CT Scan of the chest and abdomen is shown What is the diagnosis? Which mutation is associated with universally poor prognosis in this tumor?

98. A2 Neuroblastoma . Opsoclonus-myoclonus syndrome. N-myc

99. Q3 A 65 year old man presents to the medicine OPD with complaints of dizziness, difficulty in speaking, difficulty swallowing food at dinnertime and a ‘wobbly gait’ since the past 1 month. He also gives a history of weakness in his arms and legs as the day progresses which improves with some activity. He has 50 pack year smoking history. On examination his vitals are stable. On neurological examination there is horizontal nystagmus bilaterally, he has an ataxic gait and demonstrates past pointing on a finger nose test. Muscle bulk, tone and power are normal in all 4 limbs with normal sensory exam. His CBC reveals mild anemia, leukopenia and leuko-erythroblastic blood picture on PS itself. MRI Brain, CECT chest and Pathology findings from CT guided biopsy are shown

100. Sagittal T1 shows marked diffuse cerebellar atrophy with no atrophy of the cerebral cortex, midbrain, pons, or medulla. B B PET scan showed multiple skeletal lytic lesions What is the most likely complete diagnosis? Name the phenomenon on HPE seen in this tumor For bonus +10 points, next investigation based on provided information?

101. A3

102. Systems 6 Let’s get hormonal

103. Question 1 A 37 year old male presented with complaints of fever for six weeks with 4 weeks of mild left mandibular pain. He was suspected to have a dental abscess and managed with intravenous antibiotics. On examination, his height was 150 cm. A radiograph of his hand and lab reports are shown. What congenital condition does he have? Parameter Lab Value Sodium 135 mmol/L Potassium 4.6 mmol/L Calcium 9.5 mg/dL Phosphate 3 gm/dL iPTH 50 pg/mL OT/PT 18/16 IU/L

104. Answer 1 Pseudo-pseudo-hypoparathyroidism (AHO).

105. Q2 A 45 year old lady not on any treatment, prescribed or OTC presented with unexpected weight gain and puffiness over her whole body for 1 year. She was found to be hypertensive and diabetic nearly simultaneously 6 months ago poorly controlled on usual therapy. She first presented to the endocrinologist when her dermatologist noticed ugly purple striae and suspected Cushing’s disease. Her post-low dose DEX morning cortisol was elevated following which her serum ACTH levels were found to be high. MRI Brain showed a pituitary tumor and a high dose DEX found suppression of levels. Your suggestion of a brain surgery scared the patient and she insisted on further confirming that the pituitary tumor is the source of the increased ACTH before proceeding. Name an invasive investigation you can perform to confirm the source to be pituitary?

106. A2 Inferior petrosal sinus sampling

107. Q3 A 41 year old woman presented with a slowly enlarging neck mass. Her medical history was notable for rosacea for which she was on allopurinol for gout, calcium and Vitamin D for osteoporosis, minocycline, amiodarone and had a family history of non-Hodgkin lymphoma. Thyroid examination revealed a 1 cm right sided nodule. FNAC showed the characteristic features of papillary thyroid carcinoma for which she underwent a total thyroidectomy. Intra-operatively, the thyroid was grossly black in appearance. Histopathology revealed a 1 cm classic type of papillary thyroid carcinoma with surrounding benign follicular cells showing coarse black pigment granules. •What is the reason for this appearance of the thyroid?

108. Minocycline: brings out the goth in you

109. Audience Q What did the nymph Ondine do to her husband when he committed adultery and what does that have to do with Medicine?

110. Answer Ondine’s curse-congenital central hypoventilation syndrome Ondine’s husband has promised his every waking breath to her. Hence, after his heinous act, she cursed with with the inability to breathe if he fell asleep

111. Rapid Fire Round will start from team with lowest score till now and then 2nd last until the highest scoring team Each team will choose one of the available sets with 7 questions of nearly equal difficulty including 1 image. +10 per question, no negatives 60 seconds on the clock Passed questions to be answered only at the end of the 7 questions. First word out on the mic is the final answer. No second guessing. Don’t wait for the questions to be read out loud. Answer!

112. Choose wisely Set 1 Set 2 Set 3 Set 4 Set 5 Set 6

113. Rapid Fire set 1

114. Set1 Q1. Six Food Elimination diet is characteristically prescribed for what disease? Q2. HLA testing in epileptics before carbamazepine is not useful in Indians because of very low prevalence in Indian population. True or false? Q3. Drug of choice for recurrence of giant cell tumor of bone? Q4. 3rd D in DDDR pacemaker stands for? Q5. Which delicacy encountered at a sushi bar contains tetradotoxin which may block sodium channels and land you on a ventilator? Q6. What comes early in Albright’s and late in Kallman’s ?

115. Q7. Identify the disease

116. Answers Eosinophilic enteritis False Denosumab Dual response to pacing Puffer fish Puberty PSP

117. Rapid Fire set 2

118. Set 2 Q1. What relatively new Hepatitis B drug has been shown to have lower risk of osteopenia and renal dysfunction? Q2. EPS finding of demyelinating neuropathy? Q3. Recently approved immunotherapy for triple negative breast cancer? Q4. NOACs are now the anticoagulant of choice in bioprosthetic valves. True or false? Q5. What natural antiseptic in tears and saliva did Alexander Fleming discover prior to his discovery of antibiotics? Q6. Patiromer , Z irconium silicate, T enapanor and V everimerare potential new treatment modalities for which condition?

119. Q7. Role of the following in refractory pleural effusion?

120. Answers TAF Decreased velocity and latency. AP normal or decreased Atezolizumab True Lysozyme CKD. N ot hyperkalemia For causing pleurodeisis

121. Rapid Fire set 3

122. Set 3 Q1. Which disease has been found to be associated with malignancy risk including T cell type of small intestinal lymphoma? Q2. ABCD2 score is used for? Q3.  Which new class of biologicals and small molecules has the highest propensity for zoster reactivation? Q4. FDA issued black box warning for which treatment of recurrent C. Difficile infection due to risk of transmission of MDR organisms? Q5. The International Society of Human and Animal Mycology criteria and the Rosenberg criteria are used for diagnosis of which condition? Q6. The saline-stimulated copeptin test is used in the diagnostic evaluation of which endocrine disorder?

123. Q7. EEG diagnosis

124. Answers Celiac disease TIA JAK inhibitors Fecal microbiome transplant ABPA Diabetes insipidus Absence seizures

125. Rapid Fire set 4

126. Set 4 Q1. What system is used to classify esophageal motility disorders? Q2. Route of administration of tensilon in testing for myaesthenia gravis? Q3. PCSK9 full form? Q4. Which heavy metal is known to accumulate in the lens of smokers? Q5. Treatment of choice for radiation induced carotid stenosis with 80% occlusion? Q6. Which is the first nanobody approved by FDA for therapeutics?

127. Q7. The labelled points are related to which disease ?

128. Chicago Intravenous Proprotein convertase subtilisin/ kexin type 9 Cadmium Stenting Caplacizumab Fibromyalgia

129. Rapid Fire set 5

130. Set 5 Q1. New FDA approved drug for cardiac amyloidosis Q2. Expand SUNCT. Q3. Maddrey’s score is used for prognosticating what disease? Q5. The Nasal NO and the high-speed video microscopy tests are employed for the diagnosis of which etiology of bronchiectasis? Q. Name the test used for gram negative bacterial sepsis that utilises the blood of horseshoe crabs. Q Name the disease associated with ZnT8, IA-2 and GAD-65 antibodies

131. Q7. 28 female. Identify underlying disease.

132. Tafamidis Short lasting unilateral neuralgia with conjunctival tearing Acute alcoholic hepatitis Ciliary dyskinesia Limulus amebolysate T1DM Takayasu arteritis

133. Rapid Fire set 6

134. Set 6 Q 1. Wet, whacky, wobbly is classical triad of? Q 2 . What is the delivery of radioactive therapeutic isotopes such as Iridium-192 using a bronchoscope to a central airway tumor known as? Q3. The Framingham, Fridericia and Hodges formula are used as alternatives for correction of which parameter? Q4. The Modified Faine’s criteria is used for the diagnosis of which disease? Q5. Poisoning by Hottentota tamulus may be managed with prazosin. So which animal am I talking about? Q6. Name the metal whose excess causes a granulomatous disease mimicking sarcoidosis

135. Q7. Identify the tiny biliary lesions

136. NPH Brachytherapy QTc Leptospirosis Scorpion bite Berylliosis Von meyenburg Complexes (biliary microhamartoma )

137. Thanks!

138. Q30 A 32-year-old woman presents with nausea and RUQ dull pain of 5 days duration post laparoscopic cholecystectomy for symptomatic gallstones. On exam, she is febrile with RUQ tenderness. An abdominal ultrasound shows moderate perihepatic and peripancreatic fluid. An ERCP is performed and the in-procedure cholangiogram is shown What will be your next step? AST Total bilirubin Direct bilirubin Creatinine 30 U/L 4.1 mg/dL 1.9 mg/dL 0.9 mg/dL WBC ALP ALT Amylase 11,000/μ L 280 U/L 26 U/L 40 IU/L

139. Place a stent while in ERCP. Post choleycystectomy biliary leak.