(Option A) Anal fissure: An anal fissure is a small tear or cut in the lining of the anal canal. It is a common cause of painful bleeding per rectum. The pain is usually severe, and patients may experience discomfort and fear of bowel movements due to the intensity of pain. Examination would reveal tenderness over the anal region, and sometimes, a visible tear may be seen. Anal fissures are often caused by the passage of hard stools and can be acute or chronic.

(Option B) Fistula in ano: A fistula in ano is an abnormal tunnel-like tract that develops between the anal canal or rectum and the skin surrounding the anus. While it can cause pain and bleeding, severe tenderness over the anal region is not typically associated with a fistula. Fistulas often result from an infection near the anus, such as an abscess.

(Option C) Hemorrhoids: Hemorrhoids are swollen and inflamed blood vessels in the anus and rectum that can cause bleeding, itching, and discomfort. While they can be painful, the severity of pain described in the case is more indicative of an anal fissure. Hemorrhoids are generally not associated with severe tenderness on examination.

(Option D) Peri-anal abscess: A peri-anal abscess is a collection of pus in the tissues surrounding the anus. It can cause pain, swelling, and tenderness in the anal region. While this condition may lead to painful bleeding per rectum, the severe tenderness on examination is more characteristic of an anal fissure.

Subject: Internal Medicine

System: GIT

Topic: Anorectal Disorders

(Option B) Epigastric hernia: An epigastric hernia is a type of ventral hernia that occurs in the epigastric region, which is the upper-middle part of the abdomen. It results from a defect or weakness in the abdominal wall muscles through which abdominal contents, such as fat or intestines, protrude. Epigastric hernias usually appear as small, round swellings in the midline of the abdomen, as described in the patient's presentation. The fact that it becomes more prominent when the patient raises her head and shoulders while lying supine is known as the "positive cough impulse" and is a characteristic feature of a hernia. The pain and increase in size over time are also typical features of a hernia, especially if it becomes incarcerated or strangulated.

(Option A) Abdominal wall lipoma: A lipoma is a benign tumor composed of fatty tissue. It typically presents as a soft, movable lump under the skin. However, it does not cause pain or discomfort unless it becomes very large and compresses nearby structures. In this case, the swelling is tender and painful, which is not characteristic of a lipoma.

(Option C) Paraumbilical hernia: A paraumbilical hernia is another type of ventral hernia that occurs near the umbilicus (belly button). It is more common in females and may present as a round swelling that is often reducible. However, in this case, the swelling is located between the xiphisternum and the umbilicus, which is more consistent with an epigastric hernia. The location and the positive cough impulse mentioned in the patient's presentation make an epigastric hernia a more likely diagnosis.

(Option D) Tumor of the stomach: While a stomach tumor is a possibility, it is less likely given the location of the swelling and the characteristic findings of an epigastric hernia, such as the positive cough impulse. Additionally, stomach tumors usually cause other symptoms like weight loss, changes in appetite, and gastrointestinal disturbances, which are not mentioned in the patient's presentation.

Subject: Internal Medicine

System: GIT

Topic: Abdominal Swelling and Hernias

(Option D) Digoxin with diuretic: Digoxin is a medication that can help control heart rate in patients with atrial fibrillation. It is especially useful in cases where the irregular heartbeat is causing symptoms like dyspnea. It helps to slow down the heart rate and improve cardiac output. However, digoxin is not used alone in cases of heart failure; it is often combined with a diuretic like frusemide to manage fluid overload and reduce strain on the heart.

(Option A) Injection frusemide: Frusemide, also known as furosemide, is a loop diuretic used to treat fluid retention (edema) in conditions such as congestive heart failure. While it can help reduce fluid buildup in the lungs and alleviate dyspnea, it does not address the underlying issue of atrial fibrillation.

(Option B) ACE Inhibitor: ACE (Angiotensin-Converting Enzyme) inhibitors are commonly used to treat hypertension and heart failure. While they are beneficial in some cases, they are not the primary treatment for atrial fibrillation. They may be prescribed in certain patients with atrial fibrillation who also have coexisting conditions like hypertension or heart failure.

(Option C) Nitrates: Nitrates, such as nitroglycerin, are vasodilators used primarily to treat angina (chest pain) and certain heart conditions. They do not have a direct effect on atrial fibrillation and, therefore, are not the drug of choice for this condition.

Subject: Internal Medicine

System: CVS

Topic: Atrial Fibrillation

(Option B) Pulmonary Embolism (PE): PE occurs when a blood clot (usually originating from the leg veins, called deep vein thrombosis or DVT) travels to the lungs, obstructing blood flow in the pulmonary arteries. This can lead to sudden onset dyspnea, tachycardia, and even shock due to decreased oxygenation and cardiac strain. In the given scenario, the presence of sudden onset dyspnea, sinus tachycardia on ECG, and the patient being in shock raises the suspicion of a pulmonary embolism.

(Option A) Acute respiratory distress syndrome (ARDS): ARDS is a severe lung condition characterized by rapid onset of dyspnea, low oxygen levels, and bilateral lung infiltrates on imaging. It can be caused by various factors such as pneumonia, sepsis, trauma, or inhalation of harmful substances. However, in this case, there is no mention of bilateral lung infiltrates on the physical examination or the ECG, making ARDS less likely.

(Option C) Acute Pericarditis: Acute pericarditis is inflammation of the pericardium, the membrane surrounding the heart. It can cause chest pain that worsens with breathing, a pericardial friction rub on physical examination, and characteristic ECG changes such as widespread ST-segment elevation. Since there are no new signs on the physical examination and the ECG shows sinus tachycardia without ST-segment changes, acute pericarditis is less likely.

(Option D) Septicemia: Septicemia, also known as sepsis, is a severe and life-threatening response to an infection that has spread throughout the bloodstream. It can lead to shock and multiple organ dysfunction. While septicemia can cause dyspnea, the information provided in the scenario does not indicate any signs of infection or sepsis.

Subject: Internal Medicine

System: CVS

Topic: Stroke with Dyspnea

(Option C) Sickle cell disease: Sickle cell disease is an inherited blood disorder that affects the production of hemoglobin, the protein in red blood cells that carries oxygen throughout the body. The abnormal hemoglobin can cause red blood cells to become rigid and form a crescent or sickle shape, which can block blood flow and lead to severe pain and organ damage. The chest pain in this case may have been due to a sickle cell crisis, which is a sudden and severe episode of pain caused by the blockage of blood vessels. Knee pain may also be a symptom of sickle cell disease, as the reduced blood flow can cause damage to the joints.

(Option A) Gonococcal infections: This is a sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. While it can cause joint pain and inflammation, it is not typically associated with chest pain.

(Option B) Leukemia: This is a cancer of the blood and bone marrow, which can cause a variety of symptoms depending on the type and severity of the leukemia. Chest pain and knee pain are not typical symptoms of leukemia, and it is unlikely to improve with IN fluids and oxygen alone.

(Option D) Systemic lupus erythematosus (SLE): This is an autoimmune disease that can cause a wide range of symptoms, including joint pain, chest pain, and fatigue. However, it is not typically associated with knee pain, and it would not be expected to improve quickly with IN fluids and oxygen.

Subject: Internal Medicine

System: Hematology

Topic: Hematological Disorders

(Option A) Aplastic anemia: Aplastic anemia is a condition characterized by the failure of the bone marrow to produce enough blood cells, including red blood cells (RBCs), white blood cells (WBCs), and platelets. In this condition, the bone marrow becomes hypoplastic (hypo cellularity) and is replaced by fat cells. As a result, the patient may experience fatigue, shortness of breath (due to anemia), and increased susceptibility to infections (due to low WBCs). The findings of low Hb and WCC, along with hypocellularity on bone marrow biopsy, are consistent with aplastic anemia.

(Option B) Leukemia: Leukemia is a type of cancer that affects the blood and bone marrow. It is characterized by the overproduction of immature or abnormal white blood cells. In leukemia, the bone marrow is usually hypercellular (increased cellularity) and shows an increased number of abnormal white blood cells. The patient's bone marrow biopsy showing hypo cellularity with increased fat spaces does not support the diagnosis of leukemia.

(Option C) Lymphoma: Lymphoma is a type of cancer that originates in the lymphatic system, which includes the lymph nodes and lymphoid tissues. It does not directly involve the bone marrow in the same way as aplastic anemia does. Lymphoma may cause symptoms like swollen lymph nodes, fever, and weight loss, but it is less likely to present with the combination of low Hb, low WCC, and hypocellular bone marrow.

(Option D) Iron deficiency anemia: Iron deficiency anemia is a condition characterized by a lack of iron in the body, leading to reduced production of hemoglobin and RBCs. It is one of the most common types of anemia and can cause fatigue and weakness. However, it does not explain the low WCC and the findings of hypocellularity on bone marrow biopsy. Iron deficiency anemia usually results in a hypercellular bone marrow, as the body tries to produce more RBCs in response to the lack of iron.

Subject: Internal Medicine

System: Hematology

Topic: Anemia and Bone Marrow Disorders

(Option A) Virus: Viral infections can lead to symptoms like fever and drowsiness. The CSF examination showing increased lymphocytes, normal protein, and glucose levels is suggestive of viral meningitis. Viruses that can cause viral meningitis include enteroviruses (such as coxsackievirus and echovirus), herpes simplex virus, and mumps virus.

(Option B) Bacteria: Bacterial infections can also cause similar symptoms, but bacterial meningitis often presents with a different CSF profile. Bacterial meningitis typically results in increased white blood cells (neutrophils), elevated protein levels, and decreased glucose levels in the CSF.

(Option C) Tuberculosis (TB): Tuberculosis can lead to a condition known as tuberculous meningitis. However, in this case, the CSF profile would usually show elevated lymphocytes, elevated protein levels, and decreased glucose levels, rather than the described combination of increased lymphocytes, normal protein, and glucose levels.

(Option D) Fungus: Fungal infections of the central nervous system can cause symptoms similar to viral and bacterial infections. However, the CSF profile in fungal meningitis often includes elevated lymphocytes, elevated protein levels, and sometimes decreased glucose levels, depending on the fungal pathogen.

Subject: Internal Medicine

System: Infectious Disease

Topic:  Viral Meningitis

(Option D) Ulnar nerve: Cellulitis is a bacterial skin infection that can cause redness, pain, and swelling. The ulnar nerve provides sensory innervation to the little finger (pinky) and the medial aspect of the hand, along with the ulnar side of the ring finger. It also supplies motor innervation to some of the muscles of the hand. Given the patient's symptoms of loss of sensation in the little finger and medial aspect of the hand, the ulnar nerve is the most likely nerve involved in this case of forearm cellulitis.

(Option A) Intercostobrachial nerve: The intercostobrachial nerve is a branch of the second intercostal nerve and provides sensory innervation to the skin of the axilla (armpit) and upper medial aspect of the arm. It is not involved in the forearm area, so this is not the correct option for the patient's symptoms.

(Option B) Median nerve: The median nerve supplies sensory innervation to the palmar side of the thumb, index finger, middle finger, and half of the ring finger. It does not provide sensory innervation to the little finger or the medial aspect of the hand. Therefore, the median nerve is not the most likely nerve involved in this case.

(Option C) Radial nerve: The radial nerve innervates the extensor muscles of the arm, forearm, and hand, and it provides sensory innervation to the dorsal (back) side of the hand and forearm. It does not supply the little finger or the medial aspect of the hand, so the radial nerve is not the most likely nerve involved.

Subject: Internal Medicine

System: Nervous System

Topic: Peripheral Nervous System Disorders

(Option B) Cluster headache: Cluster headaches are characterized by severe, unilateral (one-sided) headache pain, typically around or behind one eye. The pain is often described as excruciating and may be accompanied by redness, tearing of the eye, and nasal congestion. Cluster headaches tend to occur in episodic clusters, with frequent attacks over a period of weeks to months, followed by periods of remission. The fact that the patient has a history of similar episodes that resolved spontaneously suggests a pattern consistent with cluster headaches.

(Option A) Brain tumor: While brain tumors can cause headaches, they typically present with other symptoms as well, such as seizures, neurological deficits, or changes in mental status. The patient's history of previous episodes resolving spontaneously makes a brain tumor less likely.

(Option C) Intracranial hemorrhage: Intracranial hemorrhage refers to bleeding within the skull, which can cause severe headaches. However, other neurological symptoms, such as changes in consciousness, focal weakness, or seizures, are usually present as well. The absence of these symptoms and the patient's history of similar episodes make intracranial hemorrhage less likely.

(Option D) Migraine: Migraines are recurrent headaches that can be accompanied by various symptoms, including sensitivity to light and sound, nausea, and visual disturbances (aura). While migraines can cause intense pain and unilateral symptoms, the sudden onset of a severe headache accompanied by a red-shot eye is more characteristic of a cluster headache.

Subject: Internal Medicine

System: Nervous System

Topic: Primary Headaches

(Option C) Membranous glomerulonephritis: Membranous glomerulonephritis is a type of glomerular disease characterized by thickening of the glomerular basement membrane due to immune complex deposition. It often presents with nephrotic syndrome, which includes proteinuria, edema, and hypoalbuminemia (low levels of albumin in the blood). The symptoms described in the case, including marked lower extremity edema, periorbital swelling, and significant proteinuria, are consistent with membranous glomerulonephritis. Therefore, this is the most likely diagnosis.

(Option A) Diabetic nephropathy: Diabetic nephropathy is a common complication of diabetes mellitus and is characterized by proteinuria, high blood pressure, and progressive kidney damage. However, in this case, there is no mention of a history of diabetes or elevated blood glucose levels, so this is an unlikely diagnosis.

(Option B) Membranoproliferative glomerulonephritis: Membranoproliferative glomerulonephritis is a type of glomerulonephritis characterized by immune complex deposition and inflammation in the glomeruli. It typically presents with hematuria (blood in urine) and low levels of proteinuria. In this case, the urine dipstick is negative for blood and positive for protein, and the proteinuria is quite high (6 grams per day), making membranoproliferative glomerulonephritis less likely.

(Option D) Minimal change disease: Minimal change disease is another type of glomerular disease that primarily affects children. It is characterized by the absence of visible changes in the glomeruli under a microscope. It typically presents with nephrotic syndrome and often has a rapid response to corticosteroid therapy. The age of the patient (41 years old) and the absence of mention of any response to corticosteroids make minimal change disease less likely.

(Option E) Berger disease (IgA nephropathy): Berger disease is a type of glomerulonephritis caused by the deposition of immunoglobulin A (IgA) in the glomeruli. It commonly presents with episodes of gross hematuria (visible blood in the urine) following upper respiratory or gastrointestinal infections. In this case, there is no mention of hematuria or a history of recent infections, so Berger disease is less likely.

Subject: Internal Medicine

System: Renal System

Topic:  Glomerular Diseases

(Option D) Pneumothorax: A pneumothorax occurs when air or gas enters the pleural space, resulting in lung collapse. It typically presents with sudden-onset severe breathlessness and chest pain. The absence of raised JVP (jugular venous pressure) and normal heart sounds are consistent with a pneumothorax. The physical exertion of carrying a load upstairs could have contributed to the development of a pneumothorax.

(Option A) Acute aortic dissection: Acute aortic dissection is a serious condition in which there is a tear in the inner lining of the aorta, causing blood to flow between the layers of the aortic wall. It usually presents with sudden, severe, tearing chest pain that radiates to the back. This condition is less likely because the described chest pain is localized to the right side and not tearing in nature.

(Option B) Acute pulmonary embolism: Acute pulmonary embolism occurs when a blood clot (usually from the deep veins of the legs) travels to the lungs, obstructing the pulmonary arteries. It can cause symptoms such as sudden-onset shortness of breath, chest pain (which may be pleuritic), and sometimes an increased heart rate. While acute pulmonary embolism is a possibility, the absence of pleuritic chest pain and the localized right-sided pain make it less likely.

(Option C) Oesophagitis: Oesophagitis refers to the inflammation of the esophagus, often caused by acid reflux from the stomach. It can cause symptoms such as heartburn, difficulty swallowing, and retrosternal chest pain. However, the sudden-onset severe breathlessness described in this case is not characteristic of oesophagitis.

Subject: Internal Medicine

System: Respiratory System

Topic: Respiratory Conditions

(Option C) Rheumatoid arthritis: Rheumatoid arthritis (RA) is an autoimmune disease where the immune system attacks the synovium, which is the lining of the membranes that surround the joints. This leads to joint inflammation, pain, swelling, and stiffness. RA typically affects small joints, including those in the hands and feet. The symptoms of morning stiffness lasting for more than an hour are classic for RA. It is more common in females and often presents in the age group mentioned in the question.

(Option A) Osteoarthritis: Osteoarthritis is a type of arthritis that occurs due to wear and tear of the joints over time. It typically affects weight-bearing joints such as knees, hips, and spine. While it can also affect the hands, it usually presents with pain and stiffness that worsen with activity and improve with rest. It is less likely in this case since morning stiffness lasting for more than an hour is not typical for osteoarthritis.

(Option B) Psoriatic arthritis: Psoriatic arthritis is a type of inflammatory arthritis that can occur in individuals with psoriasis, a skin condition. It usually affects the joints on one side of the body and can involve the fingers and toes. However, the given symptoms of bilateral joint involvement and prolonged morning stiffness are more characteristic of rheumatoid arthritis.

(Option D) Septic arthritis: Septic arthritis occurs when a joint becomes infected, usually by bacteria. It can cause joint pain, swelling, and decreased range of motion. However, septic arthritis is usually acute in onset, and the patient would typically have other signs of infection like fever and chills. Given the chronicity of the symptoms in this case, septic arthritis is less likely.

Subject: Internal Medicine

System: Rheumatology

Topic: Rheumatoid Arthritis in Hand Joints