Ultimate Solution (11th Edition) Numan’s Book Series Medicine B Annual 2022

ANNUAL EXAMINATION 2022

MEDICINE-B

Q1) A 30 year old female presented with loose motions containing blood and mucous for the last three
months. She has been treated by general practitioners in periphery clinics with ciprofloxacin and
metronidazole with no improvement. She reports weight loss and anorexia for the same period. There is
no family history of tuberculous contact or any gastro-intestinal malignancy. On examination she looks
pale, wasted and slight tenderness in the left lower abdomen.
a. What is the most likely diagnosis? 1
b. Mention three investigations for the definitive diagnosis? 1.5
c. Enumerate management steps 2.5
Key:
a. Dx: Inflammatory Bowel Disease (Most likely Ulcerative Colitis)
b. Ix:
 Colonoscopy with biopsy: It is diagnostic
 Stool R/E and Culture to rule out infectious cause of diarrhea
 Fecal Calprotectin: It is associated with disease activity and severity.
c. Mx Steps:
I) Detailed History
II) Relevant Examination
III) Investigations
IV) Treatment
 Medical Rx:
Remission induction
 5-Aminosalicylate
 Systemic glucocorticoids
 Immune modulator/ Biologics (Monoclonal antibodies)
 Calcium and vitamin D supplements
 Maintenance of remission
 5-Aminosalicylate
 Steroid Sparing agents (Azathioprine)
 Biologic therapy
 Surgical Rx:
 Panproctocolectomy with ileostomy
 Proctocolectomy with ileal-anal pouch anastomosis

Q2) You see a 45 year old married housewife with five kids. She complains of a year-long history of itching,
fatigue, and lethargy, unable to cope with household activities. She also has a history of spontaneous
fracture of the left neck of the femur. She has Bilirubin of 4.5mg/dl, ALT of 90/10, and Alkaline Phosphatase
of 750/ TU. Her viral serology for Hepatitis 'B' and 'C' is negative. There is no Kayser Fleischer ring on slit-
lamp examination. On examination, she is mildly pale, icteric, and has scratch marks on her extremities.
She has dry, itchy eyes and tender liver palpable one finger below the right costal margin.
a. What is the most likely diagnosis? 1
b. What investigations will you carry out to confirm the diagnosis? 2
c. How will you manage this patient? 3
Key:
a) Dx: Primary biliary cholangitis
b) Ix:
 Ultrasound abdomen
 AMA(anti-mitochondrial antibodies)
 Liver biopsy
c) Mx:
 Detailed Hx:
 Relevant Examination:
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Ultimate Solution (11th Edition) Numan’s Book Series Medicine B Annual 2022

 Ix:
 Rx:
 Ursodeoxycholic acid (1st Line)
 Obeticholic acid (2nd Line): Contraindicated in DCLD
 Liver transplantation (Refractory cases and Cirrhosis)
 For pruritis:
 Colestyramine
 Rifampicin
 Naltrexone
 Antihistamine
 Topical therapy
 For Fatigue
 Modafinil
 For Dry Eyes and Dry Mouth:
Artificial tears
Artificial saliva
Pilocarpine
 Osteopenia
 Calcium
 Bisphosphonates
 Fat-soluble vitamins replacement

Q3) A 30-year-old farmer was brought to the emergency from his field, harvesting the wheat crop. He
complains of headaches, nausea, fatigue, and weakness. He feels thirsty and anxious. On examination, he is
conscious, afebrile with tachycardia and excessive sweating. His blood pressure is 100/60mmHg. His FBC
and biochemical investigations are normal.
a. What is the diagnosis?
b. What are management steps?
Key:
a) Dx: Heat exhaustion
b) Mx Steps:
 Detailed Hx:
 Relevant Examination:
 Ix:
 Rx:
 Antipyretics are not used
 Removal from heat exposure
 Active evaporative cooling using tepid sprays and fanning ('strip-spray-fan')
 Lower fever with using cooling blankets
 More aggressive physical measure may be required:
i) Fluid losses are replaced with either through oral rehydration mixtures or intravenous isotonic
saline (5 L in first 24 hours)
ii) Ice water gastric lavage And ice pack in axilla
 Cold water immersion is the preferred method
 Stop cooling before normothermic core body temperature is achieved (such as when temperature
reaches 101.5 oF to 101.8 oF or 38.6 oC to 38.8 oC) to prevent hypothermia.

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Ultimate Solution (11th Edition) Numan’s Book Series Medicine B Annual 2022

Q4) A 20-year-old college student, after failing the entry test, took something with suicidal intentions. He
was brought to the emergency in a confused state with a slow pulse rate, excessive salivation, and
urination.
a. What is the most likely diagnosis? 2
b. How will you manage? 3
Key:
a) Dx: Organophosphorus Poisoning
b) Mx:
1. General:
 Decontamination of the patient
 Secure airway with vitals monitoring
 Oxygen inhalation
 Recording and Maintenance of Vitals i.e. Pulse, BP, Temperature and Respiratory rate
 Input and output record
 Resuscitate the patient
2. Specific Rx:
 Atropine: Initial dose 1 mg IV stat if no side effect then give 2 mg every 15 minutes till atropinization.
Atropinization:
 Dilated pupil
 Drying of secretion
 Dry axilla
 Heart rate More than 80/min
 Systolic Blood Pressure (SBP) more than 80 mmHG
 Chest clear with no wheeze
 Pralidoxime Mesilate:
 It is the specific antidote.
 It should not be administered without concurrent Atropine in order to prevent worsening
symptoms due to transient oxime- induced acetylcholine esterase inhibition.

Q5) A 24-year-old man presented to the outpatient department with seven days history of continuous
fever. He also reports loose stools. He denies any history of sore throat and weight loss. On examination,
he has a fever of 102 OF, with periumbilical red spots. Hb = 13 g/dL
TLC = 4000/cmm Platelets = 320,000/cmm, U/S abdomen= mild splenomegaly
Chest X-ray = Normal
a. What is the most likely diagnosis?
b. Mention three further investigations?
c. How will you manage?
Key:
a) Dx: Enteric fever
b) Further Ix:
B.A.S.U
 Fist week ------- Blood culture
 2nd week ------- Antibody/ widal test (1:160 of H and O antigen)
 3rd week -------- Stool culture
 4th week ------ Urine culture
c) Mx:
General:
 Bed rest +Antipyretics + Analgesics + Supportive Therapy
 Fluids + Electrolytes balance + Healthy diet
Specific:
 Ciprofloxacin 500 mg BD for 10 days
 Inj ceftriaxone 2 gm OD for 14 days
 Azithromycin 1 gm on day one then 500 mg OD from day 2 to 6

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Ultimate Solution (11th Edition) Numan’s Book Series Medicine B Annual 2022

 For chronic carrier

Ciprofloxacin 500mg BD for 6 weeks ± cholecystectomy.
Prevention: General safety measures + Capsular polysaccharide vaccine

Q6) A 30-year-old laborer was brought to the emergency department with four days history of fever with
chills, for the last three days, he has developed confusion and an episode of seizure. According to his wife
he hasn't experienced any bleeding. On examination, he is disoriented, has a temperature of 1030F, and has
no neck stiffness. Hb = 12 g/dL TLC = 7700/cmm Platelets = 150,000/cmm U/S abdomen= mild
splenomegaly SGPT= 65 IU/L
a. What is the most likely diagnosis?
b. Mention three further investigations?
c. How will you manage?
Key:
a) Dx: Cerebral Malaria
b) Further Ix:
 Thick & thin film:
Thick Film: For demonstration of parasite
Thin Film: For demonstration of species
 Rapid antigen detection test
 QBC (Quantitative Buffy coat) for malarial parasite
 Plasmodium Lactate Dehydrogenase (pLDH)
 CT Scan
c) Mx:
1. Anti-Malarial: Chloroquine etc.
2. Severe falciparum malaria:
• Anti-malarial (Preferably I/V)
• I/V glucose –for hypoglycemia

Q7) A 25-year-old man presented with progressive pallor, easy fatigability, and dizziness. On examination,
he has pale conjunctivae without any palpable lymphadenopathy or visceromegaly. Hb= 6 gm/dl Total
leucocyte count= 2000mm/cmm Platelets= 70 x109/L Mean corpuscular volume= 80 fL Reticulocyte
count=0.5%
a. What is the most likely diagnosis?
b. Mention two further investigations?
c. How will you manage?
Key:
a) Dx: Aplastic anemia
b) Further Ix:
 Bone marrow examination: Investigation of choice
 Peripheral Smear with reticulocytes count
c) Mx:
Supportive:
 Isolate and admit in ICU
 For Anemia  Blood transfusion
 For Infection  Antibiotics i.e. Fourth Generation Cephalosporines
 For Thrombocytopenia  Platelets infusion if the platelets count is less than 20,000 or patient is
symptomatic i.e. bleeding, bruises
Specific:
 Allogenic Bone marrow transplantation: It is curative
 Immunosuppressive Therapy: Cyclosporine + Anti Thymocytic globulins if HLA match is not
available

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Ultimate Solution (11th Edition) Numan’s Book Series Medicine B Annual 2022

Q8) A 40-year-old man presented with dizziness, ringing in the ears, and headache for the last year. He had
an episode of slurred speech and left hemiparesis six months back, which recovered within a day. On
examination, he has suffused conjunctivae, moderate splenomegaly, and no intact motor and sensory
system. Hb= 20 gm/dl Total leucocyte count= 16000mm/cmm Platelets= 500 x109/L Hematocrit= 65% X-
ray chest= Normal
a. What is the most likely diagnosis?
b. Mention two further investigations?
c. How will you manage?
Key:
a) Dx: Polycythemia Rubra Vera
b) Further 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.
 Hydroxyurea

Q9) An 11-Year-old boy presented to the outdoor with an increasing generalized body swelling and facial
puffiness started two days after a sore throat. He also reports recurrent hematuria in the past. On
Examination, he has a B.P of 150/90 mmHg. Hb = 12 g/dL TLC = 9000/mmc, Platelets = 320,000/cmm,
RBS= 120mg/dl, Urea -110 mg/dl Serum creatinine=2.5 mg/dl Chest X-ray = normal Urinalysis: RBCS++,
Protein+, Red cell cast++
a. What is the most likely diagnosis?
b. How will you treat?
Key:
a) Dx: IgA Nephropathy
b) Rx:
I) Supportive Rx:
i) Anti-Proteinuric: ACE or ARBs
ii) Statins
iii) Fish Oil
iv) Dietary protein restriction to 0.8 gm/Kg/Day
II) Assess GFR and 24 Hours Urinary Protein:
1) GFR> 50 ml/Min:
i) 24 Hours protein <1 gm  Only supportive treatment
ii) 24 Hours protein >1 gm  After 6 months of supportive therapy then Steroids for 6 months or
MMF(Mycophenolate Mofetil) in case steroids contra-indicated
2) GFR=30-50 ml/Min:
Supportive Rx +/- Steroids or Mycophenolate Mofetil (MMF)
3) GFR<30 ml/Min:
Only supportive treatment
III) Control of Blood pressure

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Ultimate Solution (11th Edition) Numan’s Book Series Medicine B Annual 2022

Q10) A 30-year-old lady presented in a state of shock due to severe postpartum hemorrhage after
delivering the baby in a labor room. Her blood pressure has been restored by intravenous fluid and blood
transfusion. She has been catheterized. However, her urine output dropped to 100ml/day in two days.
Her serum creatinine rose from 0.5mg/dl at admission to 4mg/dl. Her serum potassium is 6mg/dl. Her
ultrasound revealed normal size kidneys and no retained product of conception.
a. What is the diagnosis?
b. How will you treat?
Key:
a) Dx: Acute Renal Failure (ARF) secondary to PPH
b) Rx:
I. Hospitalization & early specialist referral is advisable.
II. Emergency Measures:
 Treat Hyperkalemia
 Treat Sepsis with appropriate antibiotics, avoiding nephrotoxic drugs.
 Fluid & electrolyte balance
 Diet: With rare exceptions, Na & K restriction are appropriate
 Dialysis & Hemofiltration

Q11) A 36 year old man presented with chronic backache, which is worse in the early morning. He feels
difficulty in performing prayers. Recently he developed pain in his right heel. Recently he has received for
pain and redness in his left eye.
a. What is the most likely diagnosis?
b. Mention three relevant investigations?
c. Outline the key management steps?
Key:
a) Dx: Ankylosing Spondylitis
b) Ix:
 X-Ray Sacroiliac Joint: It is the best initial test
 MRI Spine: It is the most accurate test
 Serological tests:
• HLA-B27 positive (Not confirmatory)
• Elevated CRP
c) Mx Steps:
• Morning exercise
 Swimming is ideal exercise
 Avoidance of poor posture
• NSAIDS and analgesics: Best initial treatment
• TNF Alpha Blockers:
It is best next therapy after NSAIDs
Agents: Etanercept, Infliximab, Adalimumab, Golimumab, Cetrolizumab, Secukinumab
• Conventional DMARDs: They have no role in Ankylosing Spondylitis unless there is peripheral
Synovitis

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Ultimate Solution (11th Edition) Numan’s Book Series Medicine B Annual 2022

Q12) A 75 year old man present with generalized body aches, headache and pain in shoulder girdles for
the last one year. He uses on off analgesics for temporary relief. He has scalp pain on combing the hairs. In
the past he had sudden visual blurring without any focal neurological deficit. Clinical examination is
unremarkable except mild tenderness over the scalp.
a. What is the most likely diagnosis?
b. Mention three relevant investigations?
c. Outline the key management steps?
Key:
a) Dx: Giant cell arteritis (GCA), or temporal arteritis
b) Ix:
 Superficial Temporal artery biopsy for histopathology: It is gold standard but due to skip lesions
biopsy may be normal.
 Colour Duplex Ultrasonography
 High resolution magnetic resonance imaging (MRI)
 Positron Emission Tomography (PET) Scan
 ESR/CRP: Increased
c) Rx:
 Steroids (Prednisolone): Start on Prednisolone (1mg/kg), Review the patient in 1-2 weeks and then
reduce Prednisolone slowly
 Proton pump inhibitors (PPI)
 Bone protection in the form of Calcium/Vitamin D daily and weekly Bisphosphonate
 Aspirin: It decreases the rates of visual loss & CVA

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