i am posting the intermediate paper in the subject of medicine for January 2008. please participate and answer these:
January 2008 Examination
Subject: Medicine
1. A 30 year old female presented with 1 month history of high grade fever with right periorbital swelling and proptosis. She has a history of cough with hemoptysis of same duration. On examination, chemosis of conjunctivae with periorbital swelling, right sided coarse crepitations were noted. Investigations revealed right sided infiltrate and small cavity on xray chest. ESR 85mm / hr, xray PNS showed haziness in right maxillary sinus.
a. What is the differential diagnosis?
b. What 5 further investigations would you do?
c. How will you manage this lady?
2. A young farmer working in the field at night has a sharp prick on his left big toe. Early in the morning he feels difficulty in breathing and is brought to the medical emergency. There is ptosis right eye. He cannot cough forcefully. He also had swelling at the site of the prick and bruises on both legs. His Hb is 13mg/dl, TLC 4.5 X 109 / L, platelet 215 X109 / L and normal urine analysis.
a. What is the most likely diagnosis?
b. What immediate treatment is required?
c. How would you investigate further?
3. A 16 year old school boy presents in the medical OPD with history of recurrent watery diarrhea since 3 years. He gives a history of bluish red flushing over face and neck during the episode of diarrhea. On examination, his pulse is 80bpm, regular BP 110/80mmHg, cyanosis and clubbing negative, JVP raised, 3/6 pansystolic murmur at left lower sterna border which increases on inspiration. Liver is palpable and tender.
a. What is the likely diagnosis?
b. Give investigations which will help in diagnosis.
c. How will you manage this case?
4. A 40 years old salesman with a 12 days history of fever, cough and watery diarrhea has received a one week course of antibiotic therapy but has not improved. On examination, he has sunken eyes, ankle edema, a temperature of 103F, pulse 110bpm, and coarse crackles over right anterior chest wall. Sputum reveals large number of neutrophils but Grams stain shows no organisms.
a. What is the most likely diagnosis? Give reasons for making that diagnosis.
b. What investigations are required to confirm the diagnosis? Justify your investigations.
c. How will you manage this case?
5. A 22 year old medical student presents with anemia. She gives a history of excessive menstrual blood loss over previous one year. There is no pain abdomen, hemetemesis or melena. Her mother has been treated for anemia most of her life. Other than pallor, there are no significant physical signs. Hb is 8g/dL, microcytosis & hypochromic, TLC 8.5X109 / L, platelets 380X109 / L, Normal PT and APTT, and stool negative for occult blood and ova or worms.
a. List three important investigations giving the likely benefit from each.
b. Mention the treatment for underlying cause / causes.
6. A 23 year old laboratory technician became unwell with a sore throat, cervical lymphadenopathy and low grade pyrexia and was started on amoxicillin, but three days later he noticed dark colored urine and was referred to a physician. On examination, he had some small lymph nodes in the anterior cervical triangle. There was tenderness in both loins but no hepatosplenomegaly. BP was 175/100mmHg, no dependent edema and normal fundoscopy.
a. What is the most likely diagnosis?
b. What two other conditions will be considered in the differential diagnosis?
c. What investigations will you carry out? Justify each.
7. A 50 year old lady comes to OPD with complaint of burning and numbness in the right hand and forearm. She had burnt her hand twice while cooking without even noticing. She denied any history of diabetes, neck pain or trauma. Examination showed normal cranial nerves and weak right arm distal muscles along with wasting and absent jerks and dissociated sensory loss.
a. What is your diagnosis? Give three differential diagnoses.
b. What relevant investigations will you request?
c. Give the management plan
8. A 35 year old man who is suffering from insulin dependent diabetes mellitus and chronic hepatitis due to HCV presents to you for evaluation of his diabetic control.
a. Enlist the parameters of diabetic control that you will check in this patient.
b. What are the principles of dietary advice that you will give to this patient?
c. How will you calculate his protein requirements if he develops hepatic encephalopathy at a later stage?
9. A 26 year old laborer is brought to the emergency with 3 days history of persistent precordial pain. He has no significant past medical history. He is a non-smoker. Pulse 106bpm, BP 120/90mmHg, Temperature 99.8F, and normal systemic examination. ECG shows normal sinus rhythm with ST elevation in the precordial leads. Serum AST 36 U/L, CK 92U/L, CKMB 14 U/L, chest xray shows a cardio-thoracic ratio of 15.5 / 28.
a. What is the diagnosis?
b. How will you confirm the diagnosis?
c. Mention the management.
10. A 23 year old medical student presents with history of fever for the last 4 weeks, and gives a history of easy fatigability, weight loss and lack of appetite. For the last one week she started to have productive cough and now she presented in the emergency with hemoptysis. On examination, she is anemic, mild throat congestion, chest examination showed few crepts heard over left apex. GIT: no visceromegaly. Hb is 9 g/dL, TLC 6.7 X 109 / L, N 64%, L 32% and ESR 80 mm/ hr.
a. What is the probable diagnosis?
b. Give three investigations to support your diagnosis.
c. How will you manage this case?
aoa guys,
I am now posting the IM paper for the month of June 2008. Please participate.
Q.1 A 60 year old housewife married for 30 years had a long history of ill health with 'anaemia' and 'bone pains' and a number of operations had been performed in the past to correct valgus deformities of her knees. Recent x-rays of her hips and knees showed a reduction in bone density, a fissure fracture of the right patella and marked bowing of the pelvic bones and femora. She also complained of diarrhoea, 4-5 times a day for last many years. She complains of weight loss of 8 kg alongwith leg cramps and tingling in her feet and hands. There was a past history of pulmonary tuberculosis treated with streptomycin, para-amino salicylic acid and isoniazid. The drug history included paracetamol, ibuprofen and a herbal 'tonic'. On examination, she appeared to be of short stature (height 150 cms) with pallor, angular stomatitis and wide-spread bony tenderness and proximal muscle weakness, abdominal examination was normal. Investigations showed haemoglobin of 9.9 gms/dl and MCV of 102 fl. Blood film showed target cells, macrocytes and Howell-Jolly bodies. Albumin was 24 gms/I; globulin 34 gms/I; corrected calcium 3.5 mg; bilirubin 2 mg%; alkaline phosphatase 200 IU/I; AST 20 IU/L; ALT 19 IU/L and gamma GT 14 IU/L. Faecal fat was 28 mmol/day (3 day collection)
a) What is the most likely diagnosis? Please justify.
b) How may this be confirmed? Give reasons.
c) What is the most feared long term complication of the disease?
Give small account of the condition.
Q. 2. A young male presented with six weeks history of low grade fever along with night sweats and progressive weight loss. On examination he is pale. His cervical lymph nodes are enlarged on either side. They are firm and discrete. His spleen is 4 cm below costal margin and there are scratch marks on his skin. His neck veins are engorged along with visible veins on his chest
a) What is the most likely clinical diagnosis?
b) What is the cause of engorged neck veins and how will you confirm this?
c) Enlist six investigations you would like to carry out with justification.
d) Briefly describe four components of his treatment.
Q.3. A 20 years old girl living in a refugee camp was brought to a local hospital in a state of collapse with a history of malaise and lethargy for two days
Associated -with vomiting. On the day of admission, she complained of headache and weakness. She had become confused and disoriented. Examination showed BP 90/60 mmHg, pulse -120-bpm. Neck was stiff but there was no focal deficit. Dusky red rash was seen on the pages
. Investigations revealed WCC21x109/I, platelets 17x109/1, sodium 137 mmol/l, PT 21 sec (control: 14 sec).
a) What is the diagnosis?
b) What complication has occurred?
c) Highlight important steps in management of this girl.
d) What prophylaxis would you suggest for the hospital staff in closed contact and for the other people in refugee camp?
Q.4. A 50 years old male presented with abrupt onset difficulty in swallowing to both liquids and solids. He complains of vertigo and is unable to walk. On examination his speech is slurred. BP 160/110, right pupil is constricted.
a) What is you clinical diagnosis and where is the Pathology
?
I
b) What two sensory abnormalities you expect to find in him?
c) What two additional neurological abnormalities you expect to find on examination of eyes?
d) How will you confirm your diagnosis?
Q. 5. A 44 years old man on treatment for a chronic kidney problem complains of dizzi spells. His BP is 110/60 mmHg lying and 80/50 on standing. He has pitting edema of sacrum and both ankles. Investigations reveal urine protein +++, serum sodium 126 mmol/L, potassium 4.6 mmol/L, urea 5.0 mmol/L.
a) Is his sodium depleted or over loaded?
b) What drug is responsible for this electrolyte abnormality in him?
c) What treatment would be effective for his edema and postural hypotension?
Q.6 A 20 years old lady with 34 weeks pregnancy reports with fever, headache and rash of four days duration. Over the last twelve hours, she has become increasingly short of breath.
On examination she had wide spread vesicular rash with some crusted lesions. On examination, she is tachypnoeic with bilateral course crepitation on chest auscultation.
a) What is the diagnosis?
b) What complication has occurred?
c) Which two investigations will you like to perform?
d) Name four essential steps in her management.
e) If no improvement occurs, what next step will you consider?
Q.7 A 26 years old male has been having low backache, worse in the morning, and pain in his left knee. This has progressed over the last five months, and more recently he had developed sore eyes. Both his father and grandfather had suffered from backache starting in their youth.
a) What is the most likely diagnosis?
b) What four treatment options are available?
c) Enlist three musculoskeletal complications.
Q.8. While climbing to his third floor office, a slim 24 years old clerk develops acute localized ft le upper chest pain along with a bout of cough. Shortly thereafter he develops relentless progressive dyspnea.
a) What is the diagnosis?
b) What three clinical signs will you look for?
c) What single investigation is mandatory?
d) What is the immediate therapeutic procedure you would like to carry out? What is the next treatment option?
Q.9. A 22 year old foot baller presented with history of recent Onset chest and shortness of breath on exertion during, last three months. During this period he had three episodes of syncope. On examination his pulse is 68/min and BP 140/90 mmHg. There is left ventricular heave on palpation of precardium alongwith systolic thrill at left lower sternal border, On the same area, there is systolic murmur a increases on Valsalva
a) What is clinical diagnosis?
b) Enlist three abnormalities you will expect in ECG and echocardiography separately.
c) Briefly discuss three treatment options.
Q.10. A 25 years old woman became unwell with fever,sore throat and dysphagia. On examination, she has a temperature of 38C and fine tremors in her hands. Her thyroid is mildly enlarged and tender. Investigations show Hb 14 g/dl, WBC 6X10 9/l, ESR 65, T4 190 nmol/L, 99Tc-isotope scan shows no uptake.
a) What is diagnosis?
b) How would you treat her?
c) What is the prognosis?
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