RUHS MO: Challenge Questions

Q51. A 40-year-old man undergoes a routine eye exam with an irregular pupil that is non-reactive to light but accommodates. What is the most likely cause of this finding?
A. Adie’s tonic pupil
B. Horner’s syndrome
C. Third nerve palsy
D. Argyll Robertson pupil
Ans:A

Challenged Correct Answer: (D) Argyll Robertson pupil

Reason for Challenge with Authoritative Reference (Khurana) & (Parson)
According to Khurana’s Comprehensive Ophthalmology, the clinical features of Argyll Robertson Pupil (ARP) are:

“Here both pupils are slightly small in size and reaction to near reflex is present but light reflex (both direct and consensual) is absent, i.e., there is light-near dissociation”
– Page 329, Khurana’s Comprehensive Ophthalmology, Edition-7th

The question clearly describes:

An irregular pupil
Non-reactive to light
Accommodation reflex present

These findings match exactly with the description of Argyll Robertson pupil in Khurana.

As per the same reference, Adie’s Tonic Pupil is described as:

“In this condition, reaction to light is absent and to near reflex is very slow and tonic. The affected pupil is larger (anisocoria). It is usually unilateral, associated with absent knee jerk and occurs more often in young women.”

– Page 329, Khurana’s Comprehensive Ophthalmology, Edition-7h

Parsons’ Diseases of the Eye (Tonic Pupil vs. ARP Description)

Reference: Parson’s diseases of EYE, (Edition-23rd),p-280

Q8. A 50 year old woman presents with heat intolerance, warm soft skin, protruding eyeball, nervousness, increased pulse rate, high plasma T4 and T3 but low plasma TSH level. She is advised to take methimazole. Which of the follow might not be the underlying cause of her clinical condition
A. Graves disease
B. Myxedema
C. Solitary toxic adenoma
D. Toxic multinodular goiter
Ans: A

Challenged Correct Answer: (B) Myxedema

Justification (from Harrison’s Principles of Internal Medicine, 21th Ed.):
The clinical picture clearly indicates hyperthyroidism & Graves’ disease accounts for 60–80% of thyrotoxicosis. (Harrison, Page no- 2938), with features including:

Exophthalmos (specific to Graves disease)
Heat intolerance, tachycardia, warm moist skin, and ↓TSH with ↑T3/T4
Methimazole is first-line treatment for Graves disease and toxic nodular goiters

Myxedema, on the other hand, is associated with severe hypothyroidism, not hyperthyroidism.
(Ref: Harrison’s Internal Medicine, 21th Ed., Endocrinology.pdf, Page-2938 : Graves’ disease accounts for 60–80% of thyrotoxicosis.

Q10. .70 year old hypertensive male discontinued his medicines. He suffered a hemorrhagic stroke involving inferior parietal lobule. Which of the following symptoms may be observed as a result of this damage?
A. Inability to recognize familiar face
B. Nonsense speech full of jargon
C. Impairment of calculation ability
D. Ignorance of stimuli on one side of the body.
Ans:D

Challenged Correct Answer: Both (C) & (D) Correct

Justification (from Harrison’s Principles of Internal Medicine, 21th Ed.):

As per Harrison’s CNS chapter, Page 3326, damage to the dominant inferior parietal lobule leads to: Acalculia, alexia, finger agnosia, and right-left confusion → These are features of Gerstmann syndrome, a classic result of inferior parietal lobule stroke.

Unilateral neglect (option D) is associated with nondominant parietal lobe involvement.

Another Reference:

Reference: Davidson’s Principles & Practice of Medicine,E-24th,p-1124