Numan’s Book Series Medicine A Supply 2021

FINAL PROFESSIONAL MBBS

SUPPLEMENTARY EXAMINATION 2021
MEDICINE A
CHAP 4-DM
1. A 32-year-old woman who works as a Teacher comes to the emergency department with a 8-weeks
history of episodes of dizziness, nausea, and profuse sweating that resolves with eating. She is also
complaining of weight gain. She denies any chest pain or smoking. Vital signs are within normal limits.
Physical examination shows no abnormalities. While in the emergency department, she becomes dizzy,
diaphoretic and confused
a. What is most probable diagnosis 1
b. Write Immediate management 1
c. Write 3 Investigations to confirm your diagnosis 1.5
d. Outline Definitive treatment 1.5
KEY:
a) Dx:
Hypoglycemia Secondary to Insulinoma
b) Immediate Mx:
I/V Dextrose followed by Oral Carbohydrate
c) Ix:
 Best initial test: Blood Sugar (Low) + C-peptide (High)
 Most specific test: 72 hour fasting with high C-peptide + Absence of ketosis
 CT of abdomen (pancreas)
 Endoscopic Ultrasound
d) Definitive Rx:
 Laparoscopic surgical removal of Insulinoma

Chap 5-Neurology
2. A 21 year old male presented to Medical OPD with progressive writhing and jerking movements of
extremities. He also gives history of yellow sclera for last 6 weeks. On clinical examination he has
clubbing, palmar erythema and Jaundice. There is rigidity in all limbs with abnormal jerky
movements of extremities
a. What is most probable diagnosis? 1
b. Write down 5 investigations which will help in reaching diagnosis 2.5
c. Outline the management of this patient 1.5
KEY:
a) Dx: Wilson Disease
b) Five Ix:
 Serum ceruloplasmin levels: It will be <20 mg/dL.
 Serum free copper level
 24 hours Urinary copper excretion: It is increased to >100 microgram/day in Wilson’s disease
 Penicillamine challenge test
 Liver Biopsy: > 250 microgram/gram dry weight
c) Mx:
 Diet Modification:
 Diet with high protein and low copper should be given
 Avoiding foods rich in copper i.e. mushrooms, liver, ground nuts, chocolates, legumes, dried
beans, unprocessed wheat, green chilies etc.
 Drug Therapy:
 D-Penicillamine
 Zinc
 Molybdenum Ammonium tetrathiomolybdate
 Trientine
 Liver transplantation: Considered in cases of Wilson Disease with Fulminant hepatic failure or
irreversible liver damage
 Antioxidant Therapy: Alpha- Tocopherol may be useful in Wilson disease
 Recent Advances: Gene therapy is the new modality of Rx

1|Page
 Numan’s Book Series Medicine A Supply 2021

Chap 3-Endocrine
3. A 35 years old woman presents with palpitation, weight loss and disturbed sleep for last 6 months.
On examination she looks anxious with proptosis of Eyes. She has Pulse rate of 110/min regular, BP
120/80 mmHG .Thyroid gland symmetrically and diffusely enlarged with audible bruit. Systemic
examination is unremarkable.
a. What is the most likely diagnosis? 1
b. What investigations would you like to do? 2
c. What other associated condition will you look for? 1
d. What are the treatment options? 1
KEY:
a) Dx: Grave’s Disease
b) Ix:
i) TFTs:
• Serum TSH levels → Decreased. TSH is always first line
 Serum Free T3, Free T4 levels → Increased
ii) Anti TSH-R antibodies
iii) Thyroid scan (Increased uptake)
c) Associated Condition with Graves Disease:
• Graves Opthalmopathy
 Graves Dermopathy
Associated Condition with Thyrotoxicosis:
 Toxic Multinodular goiter
 Toxic Adenoma
 Hashimoto Thyroiditis
 Sub-Acute Thyroiditis
d) Rx Options:
I. Medical:
 Anti-thyroid drugs:
 Carbimazole
 Propyl thiouracil
 Beta blockers
II. Surgery: Sub-total Thyroidectomy
Best option especially in Pregnancy
III. Radioactive Iodine

Chap 3-Endocrine
4. A 25-year- old female presented to medical OPD with weakness, poor appetite and abnormal menstrual
cycles for the last two years and for that she is using medicine advised by gynecologist. She is married but
having no kids for the last one and half year. She says that she has felt more irritable and anxious than
usual. Her appetite and sleep is good but she has lost some weight. She is non-smoker and drinks 10
units of alcohol per week.
On examination she is pale, pulse is 100/min, and BP is 125/85mmHg. Her proximal muscles seem a little
weak and is having fine tremors. There is a pansystolic murmur of grade 1/6 at apical area.
Investigations show HB 10.5 g/dl hypochromic microcytic, blood urea and creatinine are normal.
a. What is your diagnosis? 0.5
b. What is your other possible diagnosis? 0.5
c. What two clinical signs you will look for? 2
d. What tests you will advise to this patient? 2
KEY:
a) Dx: Hyperthyroidism
b) Other Possible Dx:
 Grave’s Disease
 Toxic Multinodular goiter
 Toxic adenoma
c) Clinical Signs:
 Heart Rate: It will be increased
 Tremors
d) Tests Advised:
i) TFTs:
 Serum Free T3, Free T4 levels → Increased
 Serum TSH levels → Decreased
ii) Thyroid autoantibodies
iii) Isotope scan of thyroid to exclude toxic nodule

2|Page
 Numan’s Book Series Medicine A Supply 2021

Chap 3-Endocrine
5. A 30- year- old female patient from Waziristan presented to medical unit with severe body ache for the
last 5 months. Four months ago she was treated in orthopedic unit for second metatarsal bone fracture.
She is having five kids with regular pregnancies.
On examination she is weak, pale. Tenderness is present over long bone. Respiratory, cardiovascular and
abdominal examination are normal. Investigations show Hb 9.2g/dl, TLC is 9000/cmm, ALT is 24 iu/l and
Alkaline phosphatase is 900 iu/L (120--300).
a. Write four investigations for diagnosis? 2
b. What is your diagnosis? 1.5
c. How you will treat this patient? 1.5
KEY:
a) Ix for Diagnosis:
 25-hydroxy Vitamin D: A level less than 12 ng/mL indicates vitamin D deficiency
 Serum Calcium/ phosphate: Low
 Imaging: Bone densitometry
 Creatine Phosphokinase (CPK): Done in case of Proximal Myopathy
 Serum PTH Levels
b) Dx: Osteomalacia
c) Rx:
 General:
 Life style changes
 Diet changes
 Counsel her for family planning
 Specific:
 Orgocalciferol 250-1000 microgram daily for 3-4 months
 After that maintenance dose of 10-20 microgram cholecalciferol daily
 Oral Calcium/ phosphate supplement

Chap -Neurology
6. A 32 year old homeless male presents to emergency department with confusional state and unsteady
gait. There is past history of drug abuse for recreational purpose. On examination patient vital signs are
normal but he is disoriented with ataxic gait. On examination of eyes there is nystagmus and limited
lateral movements of eye balls.
a. What is most probable diagnosis? 1.5
b. What is underlying cause for this clinical condition? 1
c. Write 2 differential diagnosis? 1
d. What is immediate Treatment? 1.5
KEY:
a) Dx: Wernicke Encephalopathy
Justification:
In Wernicke Encephalopathy, there is triad of
 Confusion
 Ataxia
 Ophthalmoplegia (Nystagmus)
b) Underlying cause for this clinical condition:
Thiamine (Vit B1 deficiency) due to alcohol abuse and malnutrition
c) Two D/Ds:
 Brainstem encephalitis
 Cerebellar Stroke
d) Immediate Rx:
 High dose of Thiamine I/V
 I/V Fluids
 Providing proper nutrition

3|Page
 Numan’s Book Series Medicine A Supply 2021

Chap 2-Respiratory Disease

7. A 60-years-old woman presented to orthopedic OPD with fracture of neck of femur after a fall from roof.
She was operated next day. On 20th post-operative day, she suddenly developed chest pain, dyspnea
and tachycardia. Her pulse was 120/min/regular and BP 100/70 with SaO2 78%. Her chest was clear on
auscultation. X Ray Chest was unremarkable. Doppler U/S showed DVT left lower limb up to femoral
vein.
a. What is the diagnosis? 1.5
b. Write 3 investigations 1.5
c. How would you manage? 2
KEY:
a) Dx: Pulmonary Embolism (PE) secondary to DVT
b) Ix:
• Duplex and Doppler U/S of legs: It is the investigation of choice in patients with suspected Deep
Venous Thrombosis to confirm source of emboli
• CT Pulmonary Angiography: It is the investigation of choice and diagnostic (Gold standard)
 ECG: Sinus tachycardia, Right bundle branch block with right ventricular strain pattern
c) Mx:
Emergency Rx:
 Oxygen inhalation if hypoxemic
 Dissolution of thrombus: Streptokinase 1.5 million Units or alteplase 100mg by peripheral I/V
infusion if patient is in state of shock.
 Analgesia: Morphine (5-10mg I/V)
 I/V fluids: (To raise the filling pressure)
Long term management:
 Prevention of further thrombi: LMWH/ Warfarin/ Novel anticoagulant (Rivaroxaban)
 Anti-coagulation for 3-6 months: For recurrent Pulmonary Embolism, lifelong anticoagulation.
 Insertion of vena caval filter
Surgery:
Rarely necessary may be employed in severe cases of acute massive embolism

Chap 4- Hematological Disease (Medicine B)

8. A 45-years-old man presented to medical OPD with complaints of easy fatigability, headache, visual
disturbances, tinnitus and occasional nasal and gums bleeding. He also gets pruritus after taking bath
on hot water. On clinical examination, he was plethoric. He had mild splenomegaly. Investigations
showed Hb. 18 gm/dl, TLC was 15000/ul, platelets 500000/ul. He had 25 packed years.
a. What is the diagnosis? 1.5
b. Enlist 3 investigations? 1.5
c. How would you manage? 2
KEY:
a) Dx: Polycythemia Rubra Vera
b) Ix:
 PCR for JAK-2 Mutation
 Bone Marrow Biopsy
 Red cell mass index
 Erythropoietin Level
c) Mx:
• Venesection: It is the Rx of choice. Keep hematocrit below 45%
• Low dose aspirin
 Rouxolitinib
• Anagrelide
• Radioactive phosphorus 32.

Chap 2-Respiratory Disease

9. A 30 –year- old male came to medical OPD with left sided chest pain, cough, hemoptysis and fever for
the last two days. On examination his temp is 102 F, respiratory rate is 20/min, pulse 100/min and there
is coarse crypts on left side of the chest in upper zone.
a. Name three investigations? 1.5
b. What is your diagnosis? 1.5
c. Name four complications of this disease? 2
KEY:
a) Ix:

4|Page
 Numan’s Book Series Medicine A Supply 2021

 Chest X-Ray: Consolidation signs in left upper zone

 Full Blood Count (FBC): TLC will be raised
 Sputum Analysis: Gram Staining and Bacterial C/S
b) Dx:
Community Acquired Pneumonia
c) Cx:
 Hemoptysis
 Lung Abscess
 Empyema
 Respiratory failure
 ARDS

Note: This Scenario is 100% same as Q11 Annual 2021

10. A 50 years old woman presented with exertional shortness of breath, dry cough and skin rash on
lower limbs for last 6 months. His brother was suffering from Pulmonary Tuberculosis 5years ago with
whom she met once 2 years back. On examination Pulse is 80/min. temperature 98. 6F. Lower limb shows
tender erythematous lesion on shins. Chest was clear on auscultation. Investigation showed HB
13gm/dl, TLC 7000/cmm, ESR 40 mm/hour, S. calcium 11mg/dl. Chest x ray showed bilateral hilar
lymphadenopathy.
a. What is the diagnosis? 2
b. How will you investigate? 1
c. What are the stages of this disease? 1
d. How will you treat this patient? 1
a. Dx: Sarcoidosis
b) Ix:
 High Resolution CT Scan (HRCT) chest: Shows characteristic appearance of Reticulo-nodular opacities
 Endobronchial biopsy via Bronchoscopy: It shows histological features of Sarcoidosis
 Raised serum ACE levels
 Tissue Biopsy (Lung , Lymph Nodes shows histological features of Sarcoidosis)
c) Stages of this Diseases:
 Stage 0: With a normal appearance at chest radiography
 Stage 1: With lymphadenopathy only
 Stage 2: With lymphadenopathy and parenchymal lung disease
 Stage 3: With parenchymal lung disease only
 Stage 4: With pulmonary fibrosis
d) Rx:
 Bed rest
 NSAIDS
 Steroids
11. A 33 years old woman working as BUS crew presented with arthralgia and high grade fever. She relates
these symptoms to menses. On systemic review she gave history of vaginal discharge a week ago before
menses. On examination she has tender extensor tendon of thumb, right wrist joint and
erythematous rash is noted on feet. Investigations showed TLC 16000/cmm and CRP 200 mg.
a. What is the cause of this condition? 1
b. How will you investigate this patient? 1
c. What others associated pathogen will suspect in this case? 1
d. What is the treatment? 2
KEY:
a) Cause of this Condition: Neisseria Gonorrhea
Diagnosis: Disseminated Gonococcal infection (DGI)

b) Ix:
 Blood culture (2sets): But may be negative
 Synovial fluid analysis (Joint aspiration)
 Urethral, cervical, pharyngeal or rectal cultures
 Nucleic Acid Amplification Tests
 Recommend HIV and Syphilis screen
 Recurrent DGI: Check terminal complement activity
c) Others associated pathogen suspected in this case:
Chlamydia trachomatis
d) Rx:
 IV Ceftriaxone 1g/day for 7 to 14 days, switch to PO Cefixime when clinically improved
5|Page
 Numan’s Book Series Medicine A Supply 2021

 Joint drainage for purulent arthritis

 Empirically Azithromycin (single 1gram dose) or Doxycycline for 7 days for concomitant chlamydia
infection
 Treat sexual partner

12. A 56 year old male presents to emergency department with confusional state, sweating and high body
temperature. According to his wife he was recently started on some antipsychotics for his recent
psychiatric illness. On examination patient is irritable, confused with BP 0f 130/80 mm Hg and Heart rate
of 110/min. His temperature is 102 degree Fahrenheit and there is rigidity in all 4 limbs. There are no
signs of Meningism.
a) What is most probable diagnosis? 1.5
b) Write 4 investigations that will help in confirming Diagnosis? 2
c) Outline 3 steps of management? 1.5

KEY:
a) Dx:
Neuroleptic malignant syndrome
(Note: It is a rare, but serious complication of Anti-Psychotic medications)
b) Ix:
 Creatinine Phosphokinase (CPK): Elevated
 Serum Electrolytes: Potassium level will be elevated
 Full Blood Count (FBC): WBC will be raised
c) Steps of Mx:
 Stop antipsychotic medications
 Admit to Intensive care unit (ICU)
 Adequate Hydration
 Anti-Pyretic: To reduce Hyperthermia
 Dantrolene
 Dopamine agonists i.e. Bromocriptine, Cabergoline
Note: Mortality is 20% without treatment and 5% with treatment

6|Page