FCPS Examinations Solved Questions

FCPS Examinations Solved Questions

' ·:,.

f.f Q.No.1. A..60 _years o,14..�an deveJ.op_ed pulmona,cy,. _embo,l�sm and was�.st_arteo, on
anticoagulants. Two weel<s after discharge from hospital h.e returned, ..:with. a h/o
haematemesis and malena.
a) Give S essential investigations.
b) Give three differential diagnoses.
c) How would you manage this patient?
;..
f
a) The_s_e_ j.nclude..
i

li' l. C_ornp}_e.te _ blood c_oilllt including platelet count.,S e vere thrombocytopenia�c.an

,,·
cause.bleeding from.upper G._l .tract.
,.-, 2. PT, APTT and INR, patient is on anti-coagulants e.g. warfain, ._which .can

I-
tgduc� prolongation of PT, INR_and hence can cause.bleeding.
I '·
3. .Rloo.� grouping �-4 ..c:rqs� .matching ..will ,. b e. ...q.rrj�d..oµt_.as .•he. [Jl.ight, need
�- uxgent.blood .transfusion.
4. f;:!e_c..fr:q_c_a,_r:_diqgi,-am; to rule out concqmitant_ myo cardial ischernia,. infarct or
,· arrh�ia.

f:.-· 5. {Jpper G.l Endoscopy wiUhelp}o look for de_finjte_r�tl-10!9.gy,.e,g "' esophag�al
varices, esopri_�geal OE _g<LStric erosi9.I.l$ lulcer.ation. or. duodenal_t,1,tc.�r.

b) These are:-
1. Anticoagul2r1t induced coagu_lopathy
2. Upp.ecgastr.ointestinaLbleed..due._to.Acid..P.eptic.4sease. .
3. Upper gastrqintestin<1,l, .ble�_ci __c!.':1��.!9. ;Portal hypertension ...(van�es 'J /
g_�tr.Q_pathy) . ____________ -· ------·- -- �--------· ·

c) These steps ctre:

� He'll be admitted in ICU.
• I.V lines will be taken.
s Nasogastric tube will be passed.
.. Anticoagulants .will be stopped.
" Ij:e'.ll be given LV vi�amin K, as an antidote to warfarin.
, LV proton pump inhibitors, omeprazolewillbe.started.(40mg,.B.D.)
" Fresh frozen plasma will_ be arranged and transfused, if. IT'1R. is
:;igt1ificamly prolonged .
J ., Haematocrit will be maintained (25-30%), by giving blood transfusion.
.,, Urgent Endoscopy 1.vill be carried out.
F urt:1er management depend on the cause. ln case of any bleeding ulcer,
,:2.utenz<!.tion or injection of epinephrine will be given. Oesoph_ageal varices will be treated
with ir,jection of scleros2.nt or by banding of the varix.

Dr. Fariha Sulton

 -:--..:r --. -
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FCPS E

a)
l-
.,
FCPS Examinations Solved

Q.No.2
.["1'J ,,",". *'T;5u'.,:*l'i*::X ]f ir r"T^o1i:*:i',p:,caysaJitr-ia a contused and
T:::g 11,S,I"r... JI: l"d iua"*i"J p,"i" for the rast 24
IHk#i"x.T.ffiyri?,f :lJ:#""; j[:,,y.1:i,-'i#il;5"tr1,i'THffi *Li:
**;i{^t::"i;yi*:Tj,::q:.:ltj;;;;;#il'l;X;'.,.IT,:'ll:-i3*?
r imm edia t*- i""".ti go ;; ;' ";;; .iJ t; J,i ff ",l'"iXiilil,"
3l&T:,"""
diagnosis ing
* the
c)Give three important steps iu
managenaeat.

a) Eollor"rlrS tJree signs.should be sought: c)

o
i 1!n:** d.ue to haemolysis *Jrial..Ur*,i
iL"li"Jl*T,:m'#t*1t".*'"r"i;'.i;"'"',#il'5l."io^",isoning
91{*il;1;ffiHH :";Tff#; ft"" lf ::?:'ffi on of lead sulphide.
c
o
These- feat*es if present *lr J,"""ejy i;ffi;"1;'11'ffi'I*'"" o

b) ftre.se ,are:
1. Ha.emoglobin with perip.leral smqar.
This wiII show red.uced haemoglobin
p1il?* (Basophilic slippliing ofRBC) with o
2. :b3ophilia.
Serum. lead.levels .}
J.
IPC't porphobilinogen deaminase 11. porphy{nogen levels will
$one. ]hs .fgnne.r -ryiff be reduced, vr-hile":"".y
be
Iauer will increase in case of
rntermittent porphyri a. acure
4. .e-I-braiato rule out concomitant
organic iesion.
c
c) o
wiil.nor be auowec to go
f:.X",*J".,i4fl:T-.:o^:1T.pi,d,*9
j*1*_,*:1*ati.1.r.,"r.aaiiii"ii"";,r,I#'.#hl back to the
,:-:*::Y::. Q-r\o-{
iHixf#H#yfi:[:*":',.i:*:Gil;t;;il;;,?iX"*i"."
chelation therapy tbr iead. poisoruo!. ror 5 days as a d:scglm
He.wi[.be rigirtcc
" hy_diated.
tUth moqitqring of intak"
l.v line wi_ltie taken
-- 4nd, normai. saline 0.9o% a)
uncl ort'p'.ri'.-
b)

Q.No.3. type-r diabetes merritus is brought

1,f.Jr.::l1g:l:l,n
1,":::,:l::,1t.."a^"onr"ioTr,.,"r;..*j;r;;;*;"H ji:li:'H,l'*:'.
one day

lf ::,f" stiffness."No
no neck *1," ;
";;tu;;;#;il:1ffi
abnormaliry in the chest
:1"f.:' :is l02oC, Pulse 96/min, BP tiO/75,
3:,_",T,:::::1.-bb:.1
sugar 6rimg[r, u.tnJ-rr,,g* and ketone bodies
j:,1*i:{i1:"1s12/hPi;;;;;r;;.ffi ifi fi]
#Y"i':
CSF

"*,;#i :Tl.T:fi"T:X:::,:l*
lVhat three diagnoses rrouid you E H.;"j ;,:I; m g/d, aft er r v
consider?^;;;;:,J
g, r rc o s e
S u gg.es t fry o inv a:; t! gation-q,,
._i..:i::;e iil lfr",. r:.f :i"n,r..-
t:."tt:n:gt ci the -:o-ct lii.^r!j, Ci:gnr..r!s

Dr Fariha Suttan
 a) I would like to consider foltowing tlree diagnoses:
1' Cerebral malaria as she has 1 day history off"r.., alter€d consciousness,
no signs
_ of meningeal irritation and hypoglycemia.
-fever,
2- viral. encephalitiq, suggested by artered consciousness, fits, raised csF
proteins, elevated cell counts on CSF examiaatiou. i
I

3- lvlqningitis, will be a suspected. diagnosis d,ue to fever, &owsiness,

raised csF ;

proteins and cell count qrith mlxture of polys and lymphocyes.

.

b) These are:
1 Giemsa stained thick and thin films will be mad.e. This may show
characteristic
.kophozoites of plasmodium falciparum, thus confirming
cerebral malaria.
2 Mzu brain may show cerebral oedema especially enhanced signals in
temporal lobes, characteristic of viral encephalitis

c) Outline treatment of the rnost.likely diagnosis.

o She rvill be admitted in high depenCency nnit
c I.V line will be takeu.
o Naso gastric tube as well as foley catheter will be passed.
o fntat/enous quinine dihydrochloride wiil be starteb. 20 mgi kg will be given
over 4
hours, followed by lOmg/k-g, B hourly.
o Monitoring of blood sugar rvill be done 2 hourly, as infection and quinine
both can
cause hypoglycemia.
o Carefrrl monitoriag of ftuid baiance will be done.
.evideace of superadded bacterial infection
o Any will be looked for, if needed,
antibiotics r.vill be given .
Severe anemia may need. blood transfusion.
Monitoring of renal f;nctions and hepatic functions .,vill be d.one daily, as
piasmodium i?rlciparum can cause hepatic and renal failure.
.) ECG lviil be cione daily as quinine prolonged eT intemal.
a she rvill be s.,itc.hed. over..o orar quinine
"o.,rs"s
u, ,oo, as she is able to take oraliy.

?'N','4' . -A-i0--yeer-.oJd*b,usine-ss- e.xecutive-.presented with malaise.. and .yell.owish

dlsg..qloratjoSr_of_qyps from.early childhood*_Eehasjaund.ic+and.,3cm palpslle livsr-below
iight.costal margin-
tl) Gi're ;four diagnostic possibilities
b) Disc':ss the 2 imoortant in'resfig:rtions that vvill help di;iferentiate befi+.een
tlese tiiscrders.

3J il1essare:
i ' Gill:ert s-vnc'rome; due io miict cleficiency oi giucoronyi riansferase ieacins rc
,incollj useterl hyFerbiiin:binemia.
2' D':biil-joh:rscn s;,ad5e6ae due tc farrlty excrerioo of bilirubin by
hepatoc-vtes
causing ccrrj ugateC hi,perbilimbinemia.

Dr. Fariha -iultan

 -T

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FC!

a)

FCPS Examinations Solved Ouestions

:
b) &ese_efg 4

1. Tatal..ssrum--bilirubin wilh conjugatedand uncoujugated bilirubin separateiy.

P-atienL.with Gil-b-err-or-traemolytic.anaemia-will"have-uncoajugajed-lryperbilirubinemia 'io
.With. _ -D-lfb_in . jqh6o+ and ,Rotors*-syndrome.__baye conjugated
v,v.$-=l_e_---paj.i.en!.- b)
\y.p_S-rbjlin$inemia..In patien!. rvith -Gilbert.sy,ndrome-hliperbiLimbinemia increases by
faspng.
2. Pe-ryipheral blood smeaeand.reticulocyre-couat-
Fragmented.RBClsr.sPher.ocytes.-elfip3gcytes gr$ciez bodics can be seen with different
types of haemollttic.anaemi,as,..Retic coqnt is alsa elenacd xidr baemo lytic anemi a.

Q.No.S. 4_15-ySers- si( boy has- prequ-td,Eiqi! He .also complains

o{gEgpt p_airr-and-dyspoea*O_U-exe-rtion--Hi<.rcst}s diryl srfi"rahr l{'.1:ears=back Cue to-.heart
probiem.
On examination.there is.a.-systolic Extilnur.aE& i{rc'<rrqral gdgs,. exagg-erated by
v. af 54ly-4.-i_r_raneuver. d
What is the diagnosis?
N ame diagnostic rnvestigations rvith abno:ianlititc lrc torld e;pect.
How would you manage this patient?

a) Diagnr:sis-is,hlpertrophic-obsrucri.re-cdfuycp@r-
This has been discussed in detail in Q59-

Q.t{o.6. A-64 years old fngf-r-gcmdaiuc{i' sfi- l*r<rc de -irt rreakness ot 6 months
,lgfptioq,.together, with--occasiolai hanba hdirctm s*ec &r saqrE ri*s pericd, Three
m-o.nrhi pri.qrlo his.adrrlission he had ilo€n. &"!rod @s 5e ftrirnrdc rql irad been ireateci as an
outpatiqnt=w-ilh..-ofal aird pareqte.al irou- I$-r;h. syry@mmrc :.oquorece=ot- du-ing this tirne
Lr.e has noticed 4rgclurnal -frgquer:c]. For ] daqq poeu' ;c B+m;tdon te Lad been oliguric-
There.,rvas ,a.past-his1o-riu-of peptic ulcqedorum"fl o fury eamoqr of n:graile rieaciaches.
On,e;<aminatio-afre l9q!9{-ua-1'reil aaa l*ss os&a SCctrC FEsgEE- !30/l?0nmHg. R/R 23
imin, a pericardial frictioa rib.rxas Frqs@
investigations:-
Fib 8.6grn /dl
:,iCHC 13ok
Chest X-ra;, shorved ed::g:d cru*m +hnrtrnu; sr'"'{ Emer iobe venous Cistension.
Urine Show'ed trace cf aIbreis. *'ffi [-I !{&sifud.
;; liscuss ii=/e ei::oid.- E i:€ sf=::l "=-;:+;:x
h) i'lan and .i:lstiry Ysui cir5ac-rs
-r f"l--.. -1^-- ;- -_i.' +:-'i-- i*'-r;<-*;.1---:-,4 *;ii
L) ,JF U tritr.) ,'r .-.! s-'-45+r-
-.'-'-^**-- -' *,*?

Dr. Fariha Snltan

 1 l

a) -Eiv-eJike.Iy'diagnoses"can..[s..
i

'
I c-hrgqlc 5-egal. failur.e-due".tod.iabetic-nephrgpa.thy,",as.he
. -' -':--r--EJ,+4 Arr giyes.history-.of.nocruria
with w.eqk4esS,and.lassitude.
2. Chionic ren+l.fatiur9_d. _"p.l9..O.bsE_tsflvs*tuopathy._(stpng./-prostatiq.,enlargemed)
tfusrs sr+cce.ct-e.d.--bv*s.ciasionar-rurnuer-p"i"-f"x;;;ii;-oliguria.
3. Q&csic*retaJ._f-ail,up_a"",io.*"rtipi" ;G;:;;J]ts..an.-elderty..s+lp,
generalized y.gqhgqs;,,lassituae.and artaemia, wi.th
- ----1:-:
Nocturil_ana pepri-".""i;;ililJ;.;L
4' ffi"t_.=6fr;E;A"i[i&
chronic renal failure.due,.to-a'algesjp,-s*e.pbrpp.-atby. as.lbEre.is..a.,lo5r.glristor"tt,,or
mieFaine-aad...IF."!Flghl.havs-takc.n-.v_a.io;,anat!"-ri".iEi
s' a"e to-qe&"is"-pxeio""p[aiir"-r".ir","ro"gperiod.
i,*]rririn-ry-,"1,1,,.rr,bgr
!r!1oarc--ren+aii,+e
p^ln..-...

b) rPlanniug.6s6j.ustifrcation.-of.diagnpsis:
. Jb.e"mest_iikely diagnosis is chr*onic_renal=fai1ure-..dgg,J-o-,ll-SAps
tub-glo-intersritiar nephritis-.He has dev"topia induced
u[controlled hypertension,_ uraemiq- pericarditis "orrrii:i#;;;f:;;;i;'il; G
and..prrlmo.rary.,"a"*u*ff" lr,
also a-naemi". T^t.r" ir ;;p;ilistoiy of aiabetes,-mlili*"*..f.rr"r,
-; haemaruria
pygri a and p as s i:e g.. s ro n"r il rd
. ;;'; ;-;;...., ;fi
fi
he-adactes for long perjod_for..which..h9, quCht,i.roiit"rr.NSAIDS-,NSAIDS
"r.
;;; ."i;ft;"
induced tubqlo-iaterstitial nephritis. is the ihira f."ai"acause.of-intrjnsic
failiiie-'Proteinuria (T;;E;p1".""a"" of.1-2-rvhitJ, renal
ceustHpF.atso supporrs
Pg.-4i+sro.is. othJ fe;il;s-;;i'ir,"r.,a.."r,it i"rir."asrr,-re.4.q.ell cast / HpF.
Blood picture may show eosinophilia_.,

c) Managemert
{-oqg,yt_t!-r.,theirj-ustifications:
' Hq-yd! be admitted in the.lard
e .I.V line will be taken.
' $e4al replacement therapy in the form of diarysis ylr be arranged. Regardless
o{,89 .ievel of creatinine and serum potussiu*, *-".;;;*ty;;";;;";;
pericarditis and fluid overload.
' There.after intake output moriitoring wiil be clone..
" Echocardiogram witl be done to check. for cardiac
tamponade or ,pericardial
effirsion' Pericardiocentesis will be planned. i".^"
or.ii.,rical deterioration.
" Controi of brood.pressure is imporrant in adciirion t"
antihypertensive like calcium channel blockers
di.r;;r-;" *,iii.'r,r..
diuretics.
*a .rprr"-rrockers along
wirh
o i{e i'q anaemic too' Improvement in haer:roglobin levels will
rveakness' ivloreover it will red.uce the fluil orr..iood. -H"
help to imprcve his
rviil be started on s/c
erlthropoietin on weekly basis. intraveno*s iron wi[
be given if required.
I Protein-restricted diet will be given. Phosphate binders
("ca caruonate or acetate)
rvill be given in case of hyperphosphatemia.

Dr. Irariha Sultan

.,:.:.1:,..:';i.:li.,J]:...-'.:-.-.-..:.-i==:-:=-.'j

FCPSi.

a)

FCPS Examinations Solved

e.No.7. i\.previously healthy 30 years old.young gentleman .!vas found to have to

hiv_e-raise.a aif- (twi"" normal) during routine investigations. Repeated LFT's showed
pe5sistgnt raised AI-T (around twice normal)'
^ a)
!l!3!.are tle five possible causes fqr his'raised ALT?
b) Name five investigatious that you.would a{vise'
.j Wnrt precaution would you tell him before a final diagnosis is reached.
b)
a) Thg Iive possible causes of his raised ALT are:-
1. Chronic viral hePatitis.
2. 1Vjlg9-4];,.disease,
3. Al-c.qioiic livsrdiseas"e.
4. Autoimmuse hePatitis.
" 5. Non-alcoholic steato hepatitis CNASH)-

b)' It-rs-sq.tgy"stigationsinclude:
IgM
t. Vi.^i i"iof.gy;.aati I{CV antibodies-and HB-sAg along with.Anti HBc and
a-N.]
{sS.9lIjF"edie-s' respiq
Z- ffid;f iFi's wiil be done to iook for AST, alkaline Phosphatase and Reverse of pad
of alcohql liv-er disease along with'raised gamma-
+ff : AST ratio,lvtric.h-is,typical Onrr
GT. I
Fq,! ANA Sng Adi-LKM anti-bodies for autpimmune hepatitis' T
-4. g1i'*o""a abdomen to look at ihe hepatic echotexture, size and width of biliaLry
i
Ciiunn.ts, portal vdin or any evidencq.qf splenomegaly orascites.
5. Liver biopsy, to look at ihe degree of inflammation, fibrosis and characteristic ThLI
histopathlogical changes of the underlying disorder'
i
c) The patient rvill be advised to discontinue alcohol if he is taking it. Q.Nd
q If h6 is obese then he will be aclvised to reduce weight' cgg
. He.will bE asked to.avoid hepatotoxic drugs' lost!il
Use of disposable sterilized syring"s and screening of btood.betbre -transfusion
wiil Labfl
"
be advised for the future-
. Screening of the other family members'*ill be done'

Q.No-8- A thirty six year old man presents with a long history of low grade
fever, sinus
5 years'
discharge on many occasions, haemoptvsis and difhculty in
breathing since about
He had received broad' spectnrr.n antibioiics and a full course of ATT' w'ithout benefit'
on examination' temperature 99.6oF, resp rate 24 per minule, B.P 110/70 mmHg and and
pulse 100/min. Nasai septal perforation with bridged nose' Coarse crepitations gelloviin$
breathing over mid.thora-x posteriorly. on presentation, patient 1t"6
bronchial
investigations. Urine D/R- alburnin r-r-, RBC- pienqv' pus ceiis - nii:
CBC mita anemia, ESR- 88mm t" hour'
-waiie.l caviiies..ip.each lung in inici zoilcs.
Chest x-ray reveaied trvo big thick
:r) Narne ihe 'i lab iave.stigafions and ius{iry ho';v these'+itl help you to reacti
aE a ppro pria-ie dagaosis air<i s u irscq ut;r t rr i :r tr ag+ ::i ei.i i-

Dr Fariha Sulten
 a) Foliowing 4 lab investigations are required to reach
I a diagnosis.

[-fl:j"11l "^fTlit ,T:: y.i:""\]9nnlic. "r,;il;-.; antibodies herp in

vessei- vasc"ri,ii i,,"r"ii'iJ,ln';;_;ffi;,*:iffi:;:
*:.*:::::t'-:l_:TI1 g;;;-;'";;:";:;fi lL "rr'i*Ifrl
microscopic po tyangitis and wegen".,,
+:::"*T-::,:lb-'_.,.?lla,rrierr,siecinty6rwe;#;;;;*1t,.rr#li
2. Transthoracic lung bi has the lgld.Jt'll show characteristic
3::::lt".j::*:j^ of i-@Girh"*
granulomatous inflammilion, ;,: vascuritis,
inflammation.
and acute/chronic
Renal biopsy will demonstrate segmental necrotizing glomerurbnephritis
1
4' S/creatinine and blood *"., -to demonstrate renar insufficiency.. once
proteinr:ria and haematuria develops, firrther
renal deterioration is quite rapid.
b) Planagement:
o He'll be admitted in the ward
o He'Il be
:E:g oral,
cyclophosphefmide_
steroids, prednisolone, lmg/kg along with
C,v-ctgphosphamide_ will be con-ti-niicd_fo,r_*1_sp_e-{1s
and &en it.r,vill b." r
least 12 - 15 rnonths t
o Ntrd-wEiIE, Tenal-6nction will be continuously monitored and acute
renal failure will be treated rvith dialysis

Q'No'9' A 42 years old lady, diabetie for the last 8 months recentiy developed
respiratory tract infection and since last 2 days *os
re"ting-g."Jr.r weakness as the day
passed' she also comprained of doubre vision, nasar
speech ;"; r;;;;ffi;;;""a
are ";;J
on examination, all her craniar nerves are intact an. reflexes
brisk.
a) What is ihe diagnosis?
t b) lVhat test will you carry out to confirrn?
r c) 'V-tlat nrill be your rranagemeut?
l n She is suflering frorn myasthenia grasis.
r
This has been discussed in detail iae51.
t
I
I
t
a.I',io.}.0- $__2d_ 1.ears old
. aches house .vife r.vith-p4{q4ry-.infertility with.3-.ysars
ge-n-e-ralized F,ro
and pains,.backashe and poryur*,.uJsi;r'si. Li poor
r appetite anci had.
B-p was normar and there w.as no sweliing itloirrtr. srr.
i
ffi.Tlt. rrua a.waddring gait.
B-l_o_-o.d_E-S_R 4-4:no
I
-"!BC
6-0Cllcmm
Platelers 13-;000/cmm
Hb. 9.7 gdl
s3fl
q.-.,.ulrio*
!.84 nmolii. AI: 2.12-2.65)
Al--b-wutn + )!/L
Inorg- Phosphate f .i5 mmol/L fC.8-i.45 mmoVL)

Dr. Fariha Su[tan

:.r1ffi--.i

FCPSI

a)

a):
Alkatinc-Fhpsphetessl3S-8-U&-GN;*6-5.-*06) !9im6
Urine analysis : Norrral. gXgSPLpr-+SgP!9!e9. l-
' ,Ger-i[Ld$-.Ieti"{4iefe-pplvis,. pdghrts.lp..rptit" a44.rarefactiqr-}vith a lvtic lesion
iq-Ug-irf-e.nsr-.Bu-bisr-aJnus a:
Fqne-s_"Sggp-*;M9j?hqtls-b--oesilsssle.
al 'W[i? melaUolic bone disease is she likety to have? 3-I
I

Ui Wtrat further investigatioDs you would like to carry out?

c) Mention briefly the manirgemeut.
t
L1
a) with.secondary- hyperparathyroiciism. 5.,
Thg_pSgsl.-likei:r.-diagnosis is Osteomalacia i
1gg.,1q-ry.-"-4g.iirm,.r.gl.s-sd.. ilorsanic.phosphate,raised-alkall$s..Phospbatase.and combination 5-r
lytic lesions, in the bone suggeststhe''liagnosis'
"+.ilg;oiiil I

I
b) f.sl-1-q...ying in1rgliealil5lp.wi!!*bq*equircd:- I
;--s-esug-83liJsy,-els'bv*ir-ersEsq4:sal;-9[l]],9'iacrea5qd'
olle,vsisrv.ill.he-dEteqmiqed-iihese will be low'
" -S-e$SIE;i- O,(2i.-OUsigqlficaqt.'uc-mineralized'osteoid' MATUi
" E qS-F&P-!-Y-,.-Ylil show
fSWiS.f."_"eE pririar-y-"r+felulrty, thre to uaderlying disorder
" iq in".F.qtigate
qrs*i" utl"s-t)"- ih-... ari --asgte€!{ negullicles'of GnRH
CeAfi-;g*oo",, .

ilGei; so her FSH, LH are likely^to' b+lsw-normal'

wiih sudan siaining for fat globules to mle, out underlying
" $tgol,-cie
mg|4-b;qrption.
SSzulf-t-.-UfS+, .ctgqti.ti+",. as 5qngt..failure ca+ cause -both.osteomalacia and
' qecondary [yp grp ary!hg-o.1.9r,o,",

c)
' BrieflY:maqageulent:
rthe *itf U* fiven calcium and vitarnin D replacement. Vit..D Ceficiency will be
rre*,.ecl y,.iif, orit ergoCalcifeiql,(D.z),,50,000 I.U os.ce''*:eekly for--6-- 12 ino-ntip,,{gllor'''ed b7
10.00I-U"daily.
q;lg|g11j.gpigcem"tt.*.with.-eilher.'-'ealpiqrp carb-onate"or-'citr-ate will be carried out'
C-oititGn- oi trypocatcemia & hypovitaminosis D will tend to correct secondary
Q-NoJ:
fryperpar_altryib
- iaism and hypelphosphatemia. ;entral r

A4gqY.te e1p-o;ure io suniight wili !e advised'

' acrmal-
' Treatment of underlying cause,rvill be done' o-.ier ia
:nyocri
::.SDirii I
Q.No.11. A.40 years olil laciy presenteC in OPD ','vith history of generalized vreai<ness'
crupdm
gr^a" and easy fatigabiliV of 4 years. She also reports of decrease in appetite,
tl* fever
insists a) S{
iig*Fr"urr, loss of weight -*'ith constant nausea over the past 16 rnontix' She aiso b) sr
to black o'/er the body sparring
ihat her sk-in colour'r* tui, which have receotly changeci
hgncls and feet. Her past family l-ristor;r is insigniiicanr:'
r/inl signs remirerarure 99o8. p,rise
gi;n".in. g,p gSl:O rniniiS, iespiratori' :ateZ?/min'-t)a:\<
o;'er the boC'r. es?eciaii'r c"'ei irie eibc''vs and sKlo
br,lr,*r,.u fig**nirtinn is -oreser,i;,ll
p'<?1'1in?:.ir'r' iq
aaau=a=. F.-,,-l 9f thr' e !inir-.el ;r:rnrai'

Dr. Fariha Sultan

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