1.

A 65yo man presents with painless hematuria, IVU is normal, prostate is mildly enlarged with
mild frequency. What is the most appropriate next step?

a. US Abdomen
b. Flexible cystoscopy
c. MRI
d. Nuclear imaging
e. PSA

Ans. The key is B. Flexible cystoscopy. [Painless hematuria in an elderly (here 65 years old man)
indicates carcinoma bladder for which flexible cystoscopy is done. Here BEP is not advanced to
cause hemorrhage. There is mild enlargement of prostate and mild symptoms of prostration and
hemorrhage is unlikely at this initial stage of BEP which makes Bladder cancer as the likely cause
of painless hematuria. It is also less likely to be prostate cancer as symptoms of prostration are
mild (indicates disease is not advanced) and no constitutional or other features suggesting
cancer and moreover bleeding in cancer prostate is much more less common].

2. A 74yo smoker presented to his GP with cough and SOB. Exam revealed pigmentation of the
oral mucosa and also over the palms and soles. Tests show that he is diabetic and hypokalemic.
What is the most probable dx?

a. Pseudocushing syndrome

b. Conns disease

c. Ectopic ACTH

d. Cushings disease

e. Hypothyroidism

Ans. The key is C. Ectopic ACTH. [The patient is smoker and probably developed squamous cell lung
cancer which is working as a tumour producing ectopic ACTH causing pigmentation. Resulting raised
cortisole is leading to diabetes and hypokalemia].

3. A 44yo woman has lost weight over 12 months. She has also noticed episodes where her heart
beats rapidly and strongly. She has a regular pulse rate of 90bpm. Her ECG shows sinus rhythm.
What is the most appropriate inv to be done?

a. Thyroid antibodies
b. TFT
c. ECG
d. Echocardiogram
e. Plasma glucose

Ans. The key is B. TFT. [The patient has paroxysmal atrial fibrillation That is why there is no
arrhythmia in between attacks. From the given option TFT is the appropriate test as
thyrotoxycosis is a leading cause of paroxysmal atrial fibrillation and this ladies weight loss also
makes thyrotoxycosis as the probable cause here]

4. A 79yo anorexic male complains of thirst and fatigue. He has symptoms of frequency,
urgency and terminal dribbling. His urea and creatinine levels are high. His serum calcium is 1.9
and he is anemic. His BP is 165/95 mmHg. What is the most probable dx?

a. BPH
b. Prostate carcinoma
c. Chronic pyelonephritis
d. Benign nephrosclerosis

Ans. The key is B. Prostate Carcinoma. Explanation for Question no. 4: First to say in this case
(almost all features goes in favour of prostatic carcinoma like- frequency, urgency and terminal
dribbling are features of prostatism; Age, anorexia and anaemia are constitutional features of
carcinoma prostate and it would be accurate presentation if it was hypercalcaemia. But given
calcium level is of hypocalcaemic level and it is the main cause of discrepancy of this question).
Renal failure can be an association of malignant disease and can cause high BP. Thirst is a
feature of hypercalcaemia (here may be erroneously calcium level is given in hypocalcaemic
level ; probably a bad recall). Prostate biopsy is the confirmatory diagnosis and others like PSA
is suggestive. ***There are some suggestion that Renal Failure may be the cause of
hypocalcemia.