217.

A 5-year-old boy, Bilal, is brought to you by his mother who has 102 F fever for 4 days with watery eyes, runny
nose and cough. This morning, mother noticed fine rash all over the body, but more marked on the face,
forehead and extremities. She says Bilal has had complete regular vaccinations. On examination, the child is
bleary red, the throat is red, the nasal secretions are clear mucoid and the lungs are clear. The rash is
maculopapular.

A. What is your provisional diagnosis?

B. Enlist relevant questions you would ask his mother.
C. Outline your management plan in a few steps for the condition.

ANSWER
A
Most Likely Diagnosis:
Measles
B
Relevant Questions From Mother
Detailed History: To assess severity level. Ask;
 Is child taking feeds
 Any h/o seizure (febrile)
 Any h/o shortness of breath
 Any ear infection
 Any h/o cough with high grade fever
 Any h/o drowsiness, convulsions.
 Any h/o contact with a person with similar condition.
 Any immunosuppresed contact at home.
 Immunization history
 Birth +/- developmental + nutritional history.
C
Management
History: As above.
Examination:
 Vital Signs: Pulse, RR, temperature.
 GPE: Pallor, jaundice, assessment of hydration level to rule out dehydration. Is child active or
lethargic, sleepy or irritable.
 Mouth Exam: Koplick spots in oral cavity.
 Examination of rash – generalized maculopapular
 HEENT examination
 Chest: breath sounds, any signs of consolidation, chest indrawing
Laboratory Testing
 Measles IgM antibodies & IgG serology (ELISA) (serum or oral fluid samples) OR
 Isolation of measles virus RNA from respiratory specimens OR
 Salivary measles – specific IgA testing OR
 Antigen detection by fluorescent antibody or PCR techniques
Non-Pharmacological Treatment:
Discuss with mother the disease course of her child, its contagious nature and address ICE
(explain complications and signs of serious illness)
Mother’s counselling about importance of immunization and explore and reassess hat why her
child is not immunized and information that unimmunized children are at risk of developing
complications.
Treatment is supporetive.
Plenty of fluids to prevent dehydration.
Usually, it resolves in 7-10 days
 Avoid passive smoking.
If crustiness of eyes, gently clean with damp warm cloth.
Pharmacological Treatment:
Syr. Acetaminophen 10-15 mg/kg 4-6 hourly.
Vitamin A supplements (200,000 IU) for 2 days + 3rd dose 2-4 weeks apart.
Saline nasal drops if nasal congestion.
Antibiotics if there is secondary infection.
Follow-up: 1 week.
Safety Netting
If patient’s condition does not improve or develops breathing difficulty, drowsiness or persistent
high fever, take your child to A&E.
Referral of child to EPI for immunization according to his age after patient gets better.
Red Flags: Spotting Signs of Serious Illness:
Explain to mother if child condition does not improve and she observes any signs like;
o Shortness of breath
o Chest pain
o Coughing up blood
o Drowsiness
o Confusion
o Fits
To go to nearest hospital
218
Mother of an 8-year-old child is worried about rapid hair loss and a scaly rash on scalp of her child for last 2
months. On examination, his weight is 22 kg and this is the appearance

A. What is your provisional diagnosis

B. What further points in the history and examination would help to confirm your diagnosis?
C. What would you advise his mother and how would you treat the child? (mention treatment with dose and
duration)

ANSWER
A
Provisional Diagnosis:
Tenia Capitis
B
Further Points in History and Physical Examination:
History:
 Any pet animals at home (as caused by M. Canis acquired from dogs and cats)
 Is there any itching
 Is the hair loss significant (to rule out seborrheic dermatitis)
 Is there complete alopecia or patchy areas of no hair (to rule out alopecia areata)
 Any tight braiding of hair (to rule out traction alopecia)
 Does the child pull out his own hair (r/o trichotillomania)
 Extent of scaling (more in psoriasis
Examination:
o Look for typical features suggestive of scalp ringworm, for example:
o Scalp scaling.
o Patchy, irregular hair loss.
o Lymphadenopathy (postauricular and cervical).
o Itch.
o In some people, a more severe inflammatory reaction can occur, causing:
o Erythema.
o Pustules.
o Crusting.
o Pustular boggy masses (kerion).
o Permanent alopecia and scarring of hair follicles.
Itchy papules around the outer helix of the ear (a reactive phenomenon known as an id
response).
C
Advice to Mother:
 Shared items such as hats, combs, pillows, blankets, and scissors should be discarded or disinfected
(with bleach), where possible.
 Do not share towels, and frequently wash towels.
 Follow the recommendations on hygiene and treatment.
 Monitor the scalps of other children in the household; if signs of scaling or hair loss occur, they
should seek medical advice.
 If a pet with suspected infection, should assessed and treated by a vet.
Treatment:
Non-Pharmacological: As above.
Pharmacological: Recommendation is to treat with oral antifungal. Topical not to be used alone
but as an adjunct to oral.
o Oral griseofulvin for 4 to 8 weeks 20 mg/kg/day, max 500 mg for 8 weeks OR
o Terbinafine oral for 4 weeks 62.5 mg OD for 4 weeks
o Selenium sulphide or ketoconazole shampoo twice weekly.
o Use of corticosteroids though controversial, but may increase comfort to the child.
o Flucloxacillin 125 to 250 mg QID x 7 days might be given to treat secondary bacterial
infection.
Follow-up: In 4-8 weeks
o If not healed, refer
Referral:
o Refer immediately if kerion (pustular boggy mass) is suspected to dermatology.
o Refer if:
 Diagnosis is uncertain, or guidance on treatment is required.
 No response to primary care management.
 Infection is severe or extensive, or scarring.
 Infection is recurrent.
 The child is immunocompromised
Safety Netting:
o Screen and treat all contacts, whether carriers or having clinical infection
219
An 18-year-old boy visits your clinic with his mother. He has productive cough for the last 6-8 weeks. Two days
back, he had an episode of hemoptysis with a teaspoon of fresh red blood in sputum. On examination, his
temperature is 99.6 F and his weight is 48 kg

A. What is your provisional diagnosis?

B. What further points in his history would help to confirm your diagnosis?
C. What investigation would you do initially to confirm your diagnosis?
D. Write a prescription for this patient assuming the diagnosis is confirmed.

ANSWER
A
Provisional Diagnosis
Pulmonary tuberculosis
B
Further Points in History?
 Productive cough 6 to 8 weeks along with recent episode of haemoptysis along with low grade fever
are the clues of the pulmonary T.B.
 But for the confirmation of my diagnosis i also ask some more questions from the patient and take
the detailed history as
o ask about the details of cough its onset,association aggravating and relieving factors
associations such as vomiting, nausea, headache, weight loss, weakness, shortness of breath,
chest pain.
o ask about the haemoptysis its quantity,nature as it is copious or not any gum bleeding or mouth
infection
o history of fever (by the formula of SOCRATES) severity onset characteristics association timing
exacerbating relieving factors
o Past medical history
o Ask the complete family history personal history any other family members having the same
problem or not ,is he taking some medicines or on vaccinations or any other therapy
o Socioeconomic history
 Any contact of person with similar symptoms
 Any immunosuppressed contacts
 Way of living
 H/O personal hygiene, ventilation at home.
C
Investigations
 CBC ESR (PT APTT for the coagulation profile as it might be disturbed in some hemorrhagic fevers
like in congo & Ebola fevers Rarely in Pak & Saudia)
 Order a fresh chest X ray PA view with at inspiration.
 then sputum for AFB smear (3 consecutive samples sent in early morning)
 tuberculin skin test (TST) by Mantoux test, heaf secreaning or by time screening
 if pt can afford and easily accessible then advise Gene expert for T.B( if still in suspicion)
 Interferon gamma release Assay (IGRA)
D
Prescription:
As in question this is mentioned that write a prescription so no need to tell the non pharmacological
measures
Just write that with the instructions of DOTs therapy and preventive instructions i ll give
P E St R I (pastry)
P. pyrazinamide 25mg / kg
E. Ethambutol 2.0mg / kg
St. Streptomycin 1.5 mg/kg
R. Rifampicin 1.0 mg /kg
I. Isoniazid 0.5 Mg/kg
That must b initial phase threapy for 8 weeks then
3 drug threapy for 18 months having R.I.P (rest in peace )
R. Rifampicin
I. Isoniazid
P. Pyrazinamide
Also add vit B6 continuly from day 1 till 6 months threapy.

PRESCRIPTION
Name: XYZ Date: DD/MM/YEAR
AGE: 18 years Diagnosis:
Weight: 48 kg
Calculated Dose
INH (Isoniazid) 300 mg 1+0+0 240 mg
Rifampicin 450 mg 1+0+0 480 mg
Ethambutol 400 mg 2+0+0 720 mg
PZA (pyrazinamide) 500 mg 2+0+0 960 mg
Pyridoxine 50 mg 1+0+0

Explain all possible side effects of above medicines to patient’s mother. If any one of the side effects
appear, then bring patient to clinic or nearest hospital.
220.
A mother brings her 18-year-old son in your clinic with symptoms of irritability, insomnia, nightmares and
flashbacks. His symptoms started 6-7 months back after he was kidnapped for ransom and later on released.

A. Enlist four points you would like to explore in the history.

B. What is the most probable diagnosis?
C. Enlist your management plan.

ANSWER
A
Points in History:
1) Having recurrent nightmares
2) Avoiding people, places, situations that remind you of trauma
3) Having difficult sleep
4) Having difficult time remembering important points of traumatic event.
5) Frequently upsetting thoughts/memories
6) Any drug history – alcohol etc.

B
Most Probable Diagnosis:
Posttraumatic stress disorder (PTSD)

C
Management:
Non-Pharmacological
Reassure the patient
Explore ideas and concerns
CBT
Eye movement desensitization and reprocessing (EMDR)
Pharmacological
Antidepressant – SSRI, SNRI (some benefit)

Referral: If symptoms become severe.

221.
A 44-year-old married lady presents to your clinic complaining of heavy menstrual cycle.

A. What further relevant questions in history do you want to ask?

B. What relevant examination you will perform in this patient?
C. List the investigations that you would do in the patient
D. Enlist your management plan.

ANSWER
A
History Questions:
1) Age
2) Area of residence (Afro-Caribbean are at increased risk of fibroids)
3) Presenting complaint, i.e., menorrhagia (duration of complaint)
4) Menstrual history: Age of menarche, duration of cycle, regular/irregular cycles, number of
sanitary towels, LMP, postcoital/intermenstrual bleeding, passing any clots, dysmenorrhoea
5) Gynaecological History:
a. Vaginal discharge
b. History of Pap smear if any
6) Obstetrical history: Parity, abortions, any complications.
7) Associated Symptoms
a. Feeling tired (anaemia)
b. Urinary symptoms (large fibroid)
c. Bowel symptoms (large fibroid)
d. History of hirsuitism
8) History of contraception
9) Any history of bleeding dicharge
10) Thyroid problem
11) Personal or family history of endometrial or cervical cancer.
B
Examination:
Vital Signs: BP (hypotension), pulse (tachycardia), Temp, RR
GPE: Pallor, dehydration
Systemic:
1) Abdominal examination for hepatic/renal
2) Pelvic examination for cervical erosions, polyp, fibroids.
3) Thyroid examination
C
List of Investigations:
1) Pregnancy Test: To rule out pregnancy.
2) CBC for anaemia
3) LFTs, TFTs, serum prolactin
4) Clotting profile to know any bleeding diathesis.
5) Pelvic ultrasound
6) Serum testosterone if there is any history of hirsuitism/virilization
C
Management Plan:
History: Age, area, menstrual, gynae, obs history with associated symptoms
Examination:
1) GPE: Pallor, dehydration
2) Systemic:
a. Pelvic examination
b. Abdominal examination
 c. Thyroid examination
Investigations:
CBC, LFTs, TFTs, serum prolactin, pregnancy test, USG abdomen
Treatment Plan: Tranexemic acid can be added.
1) Iron therapy: Tablet ferrous sulphate 190/300 one PO OD
2) NSAIDs, i.e., diclofenac sodium 25 mg 1 PO OD. It can be combined with PPIs to reduce gastric
problem.
3) Combined OCPs, i.e., Diane 35. I will explain how to use Diane -35.
a. Start at 5th day of menstrual cycle and use it with _____.
b. Take tablet daily for 21 days
c. 7 days gap days or you can take iron in 7 days and wait for periods.
4) For further management, gynae referral will be done. Management includes
a. Medroxyprogesterone Injection
b. LNG – IOS
c. Danazol
d. GnRH
5) If refractory to medical treatment, surgical intervention may be done, i.e.,
a. D&C
b. Endometrial ablation
c. Hysterectomy
222.
A 5-year-old girl presents with weakness and anorexia for the last one year. She also tells you that sometimes
she passes small white worms in her stool. On examination, she is pale. Rest of history and examination are
normal.

A. Write two cost effective investigations?

B. What advice would you give to the mother? (Also mention medications with dose and duration)
C. How will you prevent this condition in future?

ANSWER
A
Cost-Effective Investigations:
1) Blood – CBC (anaemia)
2) Tape test/Scotch Test
3) Stool D/R
B
Advise to Mother:
1) Regular handwashing
2) Routine household cleaning
3) Frequent changing of clothes, towels and bed liners
4) Discuss about complications of untreated pinworms like weight loss, bedwetting, diarrhea, UTI,
possibly appendicitis
5) Medications:
a. Mebendazole (Vermox) 100 mg tab or 100 mg in 5 ml suspension (once in a single dose
or twice each day for 3 days OR
b. Albendazole 400 mg PO OD x 2 doses 2 weeks apart
c. Iron 6 m/kg/day for six months for anaemia
d. Vitamins – Syr. B complex, vitamin A, vitamin D
C
Prevention:
1) Remind kids to wash their hands often especially after using toilet, after playing outside and
before eating.
2) Make sure your kid showers by bath every day.
3) Keep kids’ fingernails short and clean
4) Tell kids not to scratch around their bottom or bite nails.
5) Wash your kids’ shirt and trousers every few days.
6) Keep hygiene
7) Entire household be treated regardless of symptoms.
223.
A 28-year-old man is brought to your clinic with history of burns 2 hours back as his clothes caught fire. On
examination, he appears in pain. He has redness and blisters on whole of left arm and chest.

A. What other points are required in history based on given information?

B. How would you assess for the extent of burn injury?
C. Enlist initial management plan of the patient.

ANSWER
A
History Points:
1) Exact Mechanism
a. Type of burn agent (scald, flame, electrical, chemical)
b. How did it come into contact
c. Is there risk of concomitant injuries.
d. Is there risk of inhalational injuries.
e. What first aid performed
f. Has any treatment started.
2) Exact Timings
a. When did injury occur
b. Duration of cooling applied
c. Duration of energy source exposure to patient.
3) Exact Injury:
a. What was liquid boiling/recently boiled
b. Domestic/Industrial
4) Suspicion of non-accidental injury
B
Assessment of Extent of Injury:
1) Cause, size, thickness of burn
2) Rule of nines to estimate extent of burn
3) Appearance:
a. Partial thickness burns – red, painful, blistered.
b. Full thickness burns – painless, white/grey
4) Always consider non-accidental injury in children
C
Management:
1) Remove clothing from affected area
2) Place patient under cold running water for > 10 minutes until pain relieved
3) Do not burst blisters
4) Prescribe analgesia
5) Refer all but the smallest (< 5%) partial thickness burns for assessment in A&E
6) Referral if inhaled smoke.
7) IF MANAGING BURN IN COMMUNITY
a. Check tetanus immunity – given immunization +/- prophylaxis
b. Apply silver sulfadiazine cream/paraffin impregnated gauze and non-adherent dressings
+ review every 1-2 days.
c. Cover burns on hand with silver sulfadiazine, place in plastic bag, elevate hand,
encourage finger movement.
d. Referral: If not healed in 10-12 days.
224.
A 30-year-old banker presents with fresh bleeding per rectum with hard stools for the last one week. The blood
is small in amount and there is severe rectal pain at the time of defecation. He mostly eats outside and loves
fast food.

A. What is the most likely diagnosis?

B. What clinical examination will you perform to confirm your diagnosis?
C. Enlist four steps of pharmacological plan.
D. Enlist three steps of non-pharmacological plan.

ANSWER
A
Most Likely Diagnosis:
Anal fissure with constipation
B
Clinical Examination:
Vital Signs: Pulse, BP, respiratory rate, temperature
GPE: Look for anaemia, jaundice, dehydration, skin rash, thyroid, cyanosis, clubbing, height, weight, etc.
Abdominal Examination: Inspection, palpation (tenderness/distension, visceromegaly) and bowel
sounds
Rectal Examination: Do not attempt as it is painful due to muscle spasm (DRE)
 On inspection, anal mucosa is torn – usually on posterior aspect of anal canal.
 The fissure is often visible as a sentinel pile (bunched up mucosa over the base of tear)
C
Steps of Pharmacological Plan:
Stool softener (isphagol husk) 2 tablespoons in 1 glass of warm water BD
0.4% nitroglycerine ointment BD
Syr. Lactulose 30 ml HS
Analgesic suppositories
o 5% lidocaine ointment
o OTC haemorrhoid preparations if nitroglycerine not available.
o 2% topical diltiazem (third lin)
Follow up in 1 week.
If these interventions fail, refer to surgeon.
D
Steps of Non-Pharmacological Plan:
Reassure the patient
Increase fluid intake to 8-10 glasses of water per day.
Exercise
High fiber diet
Sitz bath
Increase fruits and vegetables in diet.
225.
A 55-year-old man, hypertensive for last 2 years, presents to your clinic with a 3-month history of
breathlessness. He does not report any chest pain. He is currently on atenolol. His BP is 180/100 mmHg, pulse
is 90/min and there are bilateral crepts at lung bases.

A. What is the most likely diagnosis?

B. List the investigations you would order.
C. What medications you would like to add for his current condition?
D. What two non-pharmacological measures you would advise this patient.

ANSWER
A
Likely Diagnosis:
Heart failure (pulmonary edema)
B
Investigations:
1) Full blood count
2) U&E
3) BNP (brain natriuretic peptide)
4) Chest x-ray (to see cardiomegaly, cardiothoracic ratio > 50%, pleural effusion, Kerley’s B lines,
bats wing shadowing
5) ECG: May indicate ischemic MI or ventricular hypertrophy
6) Echocardiography: Key investigation.
a. May indicate MI or any valvular heart disease
b. Can confirm presence/absence of LV dysfunction
C
Medicines to Add
1) ACE inhibitor, i.e. perindopril 10 mg 1 PO OD
2) Diuretics, i.e. furosemide 40 mg PO OD (to reduce pulmonary edema)
D
Non-Pharmacological
1) Eat less salt, i.e. < 6 g/day
2) Encourage exercise, i.e., moderate to intense exercie at least 3-4 days a week.
3) DASH diet.
4) Optimize weight.
226.
A 45-year-old gentleman presents for his annual checkup. He is a smoker and his labs are as follows:
 Fasting blood sugar 116 mg/dl
 Total cholesterol 210 mg/dl
 Serum creatinine 80 mg/dl
Urine D/R
 Glucose Nil
 Proteins Nil
 Bacterias Few
 Leukocytes 2-4/HPF
On examination, his BMI is 32 kg/m2, BP is 140/94 mmHg and his waist circumference is 102 cm.

A. List down the risk factors for cardiovascular disease in this case.
B. What further investigations would you need to manage his condition and why?
C. What is the non-pharmacological management of this patient?

ANSWER
A
Risk Factors for CVD:
1) Smoker
2) Age 45 years
3) High cholesterol (>130), i.e. 210
4) FBS: 116 (normal 80-100)
5) BMI: 32 (normal 18-25)
6) BP: 140/94 (First-stage hypertension)
7) Waist circumference: 102 cm (obesity)
B
Further Investigations:
1) FBC – to rule out anaemia (in chronic renal insufficiency)
2) Chest x-ray PA view (to see any pathology in heart)
3) RBC, HbA1c (to rule out diabetes)
4) Thyroid profile
5) Serum electrolytes, to see level of Na and K, Ca (to exclude renal damage secondary cause such
as aldosteronism)
6) Renal ultrasound (to rule renal artery stenosis)
7) Urinary free cholesterol, reninin, aldosterone (secondary causes of HTN)
8) ECG + echocardiography (LV hypertrophy)
9) Serum triglycerides
10) Total Lipid profile – To check HDL, LDL, cholesterol, triglycerides level, so as hyperlipidaemia
might be managed accordingly.
C
Non-Pharmacological Management:
1) Smoking cessation.
2) Reduce salt (<2.4 g/day)
3) Blood pressure monitoring at home.
4) Mediterranean diet, i.e. low fat diet. Reduce intake of saturated fats
5) Increase exercise, i.e. encourage minimum of moderate to intense 3-4 times weekly.
6) Weight reduction to achieve BMI of 18-24.
7) Diet rich in fruits and vegetables. Avoid whole grains in diet
227.
A 35-year-old female presents with dysphagia to solid foods since the last 2 months. On examination, her BMI is
18 kg/m2. She brings reports of her hemoglobin. Hb is 8 gm/dL with MCV of 60. Her menstrual cycles are
normal.

A. List 2 differentials for her dysphagia.

B. What 3 investigations would you advise?
C. List 2 important points of management.

ANSWER
A
Differential Diagnosis:
1) Neuromuscular Diseases:
a. Achalasia
b. Parkinson’s disease
c. CVA
d. Diffuse esophageal spasm
e. Medication induced
2) Obstructive Lesion:
a. Esophageal CA
b. Esophageal webs (Plummer Vinson Syndrome)
c. Substernal thyroid
d. Mediastinal mass (anterior)
B
Investigations
1) Barium swallow studies and fluoroscopic evaluation: It will show esophageal lesions uch as
webs, strictures.
2) Serum Iron Studies: To see decreased levels of iron, ferrritin, and increased levels of total iron
binding capacity to see the cause of anaemia
3) Upon specialist/consultant advice:
a. Haemoglobin electrophoresis
b. Fiberoptic endoscopy
c. Oesophageal manometry
d. CT scan of neck, chest, abdomen
C
Management:
Management is on outpatient basis.
1) Educate the patient regarding the disease and treat anaemia by giving iron supplements and
also its underlying cause if there is any.
2) For further management, refer to gastroenterologist (for causative treatment for dilatation)
228.
A 55-year-old post menopausal woman (para 6+2) presents with history of urinary incontinence on sneezing-
coughing. She has no comorbids. Her weight is 80 kg height is 160 cm

A. List the most likely diagnosis.

B. List two investigations that would help in your diagnosis.
C. List 3 points of your management.

ANSWER
A
Diagnosis:
Stress incontinence
B
Investigations:
a) Urinalysis
b) Empty supine stress test to detect intrinsic urethral sphincter dysfunction
c) Cough stress test
d) Postvoid residual measurement to measure postvoidal urine volume by ultrasound
e) Creating images of bladder as it functions
f) To be ordered by specialist:
a. Cystoscopy
b. Urodynamics
C
Management:
History:
1) Detailed history of incontinence
a. Duration
b. Sudden urgency, nocturia
c. Voiding difficulty
d. Constant passive leakage
e. Postvoid dribbling
f. Life activities affected
2) Associated symptoms – fever, constipation, burning micturition, lowr back pain, nausea,
vomiting
3) Comorbids – HTN, DM, hypo/hyperthyroidism, kidney issues, IHD
4) Past medical history – UTI, PID, CVA, etc.
5) Past surgical history – spinal surgery, pelvic surgery
6) Gynaecological/obstetrical history
7) Drug history – anxiolytics, diuretics, etc.
8) Lifestyle – exercise, diet, etc.
9) Family history – Ca, HTN, etc.
10) Psychological history – depression, anxiety.
Physical Examination:
1) Vital Signs: BP, pulse, RR, temperature.
2) GPE: Anaemia, jaundice, thyroid, lymphadenopathy
3) Abdominal examination: Ascites, organomegaly
4) Pelvic Examination – prolapse, tenderness, etc.

Non-Pharmacological:
Reassurance
Diet: Cut back caffeine and alcohol (as can irritate bladder). Add fiber, fruits and vegetables.
Bladder training – schedule for toileting if mixed incontinence.
Lose weight
 Kegel exercise/pelvic floor exercise
Exercise like walking 30 to 90 minutes 5-7 times per week (increase tim of slow walking)
Pharmacological:
Anticholinergics, i.e.,
o Oxybutynin
o Tolterodine
o Mirabegron
o Alpha blockers
o Topical estrogen
Devices:
o Urethral insert
o Vaginal pessaries
If it is not corrected with pharmacological, behavioral therapies, then interventional therapies and
surgery can be done (to improve closure of sphincter or support bladder neck).
Referral:
If prolapse
If cause unknown
If symptoms become worsened.
Follow-up:
In 4-6 weeks
Required long-term follow-ups up to 12 to 24 months.
229.
A 58-year-old businessman who has had a myocardial infarction followed by angioplasty presents to you 6
weeks after the event. He is still at bed rest and feels low and agitated. He has quit smoking after the heart
attack. He is on bisoprolol, aspirin, enalapril, atorvastatin. He does not have any cardiac symptoms now.

A. What activities can be resumed by this time?

B. What could be the current cause of his symptoms?
C. How would you manage this patient?

ANSWER (Post MI Depression)

A
Activities to Resume Now:
1) He could resume his work by now if it is a sedentary business.
2) He could start walking 2 miles/day by now
3) He can resume sexual activity now.
4) He can start driving 4 weeks post angioplasty
5) He can travel by air after two weeks of MI.
B
Current Causes of Symptoms:
1) Lack of social support (prolonged isolation)
2) Marital status (being single)
3) Major life events like loss in business, being in debt, being in a divorce process, moving of
business, retiring from business, death of a loved one.
4) Substance abuse (drugs and alcohol)
5) Medications (beta-blockers, sedatives, steroids)
C
Management:
1) Psychosocial therapies like CBT (cognitive behavioural therapy)
2) Selective serotonin reuptake inhibitors (SSRIs) are preferred over TCAs (tricyclic antidepressants)
because SSRIs do not share the adverse cardiac effects of TCAs.
230.
An 18-year-old female presents with seasonal nasal blockage, throat irritation, watery rhinorrhoea and frequent
sneezing since the last 2 years. These episodes occur 2-3 times a year, when the season changes and last for
about a month

A. What is the most likely diagnosis?

B. What clinical examination findings would you look for?
C. Enlist your management plan for her.

ANSWER
A
Most Likely Diagnosis:
Seasonal allergic rhinitis
B
Clinical Examination Findings:
1. General Exam: Mouth versus nose breathing
2. Eyes: Swollen (periorbital), red conjunctiva, dark areas under eyes (allergic shiners)
3. Nose:
a. Horizontal nasal crease showing repeated rubbing with hand/palm
b. Nasal mucosa: red, swollen, mucosa of turbinate may be pale.
c. Thin, watery secretion
d. Rule out nasal polyp
e. Presence of nasal discharge blocking nares
4. Throat: Erythema, postnasal drip, any evidence of infection
5. Chest: Signs and symptoms suggestive of atopic disease, i.e., asthma (wheeze, rhonchi)
6. Skin: Signs of eczema (atopic) support diagnosis of allergic rhinitis
C
Management Plan:
1) History: Seasonal, watery rhinorrhoea, nasal blockage, frequent sneezing
2) Examination:
a. Vitals: BP, pulse, RR, temperature
b. GPE: Anaemia, jaundice, dehydration, lymph nodes, skin rash
c. Nose: Nasal discharge
d. Chest: May be any evidence of rhonchi
e. Skin: Any ectopic rash
3) Non-Pharmacologic:
a. Avoidance of allergens, i.e., dust, mite, pollens, smoking
b. Patient education about allergy
c. Nasal irrigation
4) Pharmacologic
a. Intranasal antihistamines, i.e., xylometazoline nasal spray 2 puffs BD (to relieve nasal
blockage) for 3 days
b. Intranasal corticosteroids as first line if moderate symptoms, i.e. mometasone nasal
spray 2 puffs OD
c. In severe cases, both intranasal steroids and oral/nasal antihistamines
5) Prevention
a. Allergen avoidance
b. Nasal irrigation
c. Probiotics
d. Herbal preparation
231.
A 32-year-old woman presents with a nodule in the anterior neck for the last 3 months. On examination, the
nodule is 3-4 cm, non-tender, in central area of neck and moves on swallowing.

A. List 5 relevant questions in history related to the presentation?

B. What 2 initial investigations would you order?
C. What investigation would confirm your diagnosis?

ANSWER
A
History Points:
1) Details of swelling/nodule
a. When noticed
b. Increase/decrease in size with time
c. Pain during swelling
d. Shortness of breath
e. Cold intolerance
f. History of tremors
2) Associated Symptoms: Fever, shortness of breath, stridor, pain, chest pain, change in voice, blurred
vision, tremors, constipation/diarrhea, menstrual problems, sweating, weight loss/increase, etc.
3) Comorbids: HTN, IHD, CVA, DM, asthma
4) Past medical history: Hypo/hyperthyroidism, TB
5) Lifestyle: Drug history, diet, family history of thyroid problems, exercise level.
B
Initial Investigations:
 USG neck
 Thyroid function tests (TSH, T3, T4)
 FBS, RBC, HbA1c
 Serum free testosterone (screening for PCOS)
C
Confirmatory Tests to Make Diagnosis
 Thyroid profile with TPO antibodies
 Thyroid antibodies
 Thyroid ultrasound
 CXR
 Refer to specialist for:
o Fine needle aspiration
o CT scan of thyroid
o Thyroid scan with low dose radioactive iodine
232.
A 40-year-old male, smoker, gets a screening checkup as his father died at the age of 40-year due to an MI. His
BMI is 29 kg/m2, BP is 140/90 mmHg.
His blood reports are as follows:
Hb: 17.2 mg/dL
Cholesterol 236 mg/dL
Triglycerides: 402 mg/dL
HDL: 28 mg/dL
LDL: 128 mg/dL
FBS: 102 mg/dL
Urine report: normal
Serum creatinine 1.2 mg/dL

A. List his known risk factors for heart disease.

B. What advice would you give? List 4.
C. What medication would prescribe?

ANSWER
A
Risk Factors for Heart Disease:
1) Positive family history of coronary artery disease.
2) Smoking
3) Overweight + obesity; BM 29 kg/m2.
4) High cholesterol 236 mg/dL (should be > 130 mg/dL)
5) HDL 23 mg/dL (should be > 35 mg/dL)
6) Stress or depression as his father’s early death with MI.
B
Advice for Patient:
1) Patient Education: Counseling and motivation of patient’s health lifestyle modification,
education and information about risks and complications
2) Smoking: Goal should be for complete cessation of smoking. Provide counselling, nicotine
replacement, bupropion.
3) Physical Activity: Encourage minimum of 30-40 minutes of moderate intensity 3-4 times weekly
physical activitiy (walking, jogging, swimming)
4) Weight Management: Ideal BMI 18.5 to 25 kg/m2. Start intensive diet and appropriate physical
activity intervention. Advise a diet rich in fruits and vegetables and low in saturated fats.
5) Lipid Management:
a. Primary goals:
i. LDL < 100 mg/dL
ii. HDL > 35 mg/dL
iii. Triglycerides 200 mg/dL
b. Advise patient, he may need medication, physical activity + diet control to achieve the
goal.
C
Medications to Prescribe:
a) Tablet atorvastatin 20 mg OD at night after food. Educate patient about possible side effects
and follow up after three months to check lipid profile and LFTs.
b) Tablet Fenofibrate 145 mg OD
c) Omega-3 fatty acids (fish oils)
233.
A mother brings her 4-year-old daughter with chronic constipation since the last 6 months. The child passes a
stool every 3-4 days which is hard and difficult to pass. She drinks 3-4 glasses of milk in the day. She has to use
glycerin suppositories occasionally to relieve her symptoms. The child’s height and weight are on the 25 th
centile for age.

A. List 3 likely causes of her constipation.

B. List 2 investigations you would order.
C. How you manage this patient?

ANSWER
A
Likely Causes of Constipation:
1) Idiopathic constipation
2) Hirschsprung’s disease
3) Coeliac disease
4) Hypothyroidism
5) Anorectal abnormalities
6) Neurological conditions
7) Abdominal tumours
8) Unhealthy/poor diet
B
Investigations to Order:
1) Blood – CBC (anaemia, infection)
2) Thyroid profile – very rare
3) Abdominal radiograph
4) Stool D/R, Culture and sensitivity.
5) Abdomino-pelvic ultrasound
C
Management:
History:
1) Ask about abnormal stool pattern (< 3 stools per week)
a. Hard, large, or rabbit-dropping stool
b. Overflow soiling (> 1 year)
c. Any worm in stool
2) Associated symptoms with defecation
a. Distress/anal pain
b. Bleeding with stool
c. Straining.
d. Poor appetite
e. Abdominal pain improves after stool passed
f. Posture indicating retaining stools
3) H/o previous constipation/anal fissure
4) Birth/developmental/immunization history
5) Family history – constipation, etc.
6) Socioeconomic history (diet, hygiene, any recent travel history, any stress for the child)
Examination:
i) Vitals: Pulse, RR, temperature
ii) GPE: Anaemia, jaundice, lymphadenopathy, height, weight.
iii) Abdominal Examination: Distension, tenderness, bowel sounds.
iv) DRE (if possible)
Non-Pharmacological: Diagnose if serious underlying causes have been excluded.
Educate mother for causes and reasons of constipation
Advise about balanced healthy diet like more fiber rich fruits + vegetables
 Advise adequate fluid intake
Train child for proper toilet habits
Promote physical activity regularly to stimulate normal bowel function.
Sometimes get so wrapped up in play that they ignore the urge to have bowel movement, so
remind your child.
Pharmacological:
Macrogols – First-line drug laxative dose according to response.
Lactulose – if macrogols not sufficient.
Stimulant laxatives: If above not tolerated.
o Sodium picosulfate
o Bisacodyl
o Senna
Continue medication for several weeks after regular bowel habit has been established. In
addition to medication, advise about balanced diet and adequate fluid intake.
Follow up after 2 weeks
Refer for specialist assessment:
o If constipation not improved
o If one of the following serious underlying cause
 Delay in passing meconium since birth
 Abnormal appearance of anus
 Ribbon like stool
 New leg weakness, deformity/neuromuscular signs
 Asymmetrical gluteal muscles
 Abdominal distension with vomiting
234.
A 56-year-old female presents with bilateral knee pain for the last 1 year. It aggravates on exertion and climbing
stairs.

A. What risk factors would you explore in this patient for this disease?
B. What knee x-ray findings would you be expecting?
C. How would you manage this patient?

ANSWER (bilateral knee OA)

A
Risk Factors:
1) Obesity
2) Previous injuries or trauma
3) Athletic activity or physical exercise
4) Older age (more than 45 years)
5) Female sex
6) Certain occupations that place repetitive stress on joints
7) Genetics
8) Bone deformities
9) Abnormal mechanical loading of joints
a. Instability
b. Poor muscle function
c. Post-meniscectomy
d. Occupation
B
Knee X-ray Findings:
1) Presence of marginal osteophytes
2) Joint space narrowing
3) Effusion
4) Subchondral sclerosis and cysts
5) Joint erosions (altered shape of femoral condyles + tibial plateau
6) Synovial thickening
7)
C
Management:
History:
1) Detailed history of pain (duration, frequency, nature of pain, onset, is any other joint
involvement).
2) Aggravating factors
3) Relieving factors (such as painkillers, rest, etc.)
4) Associated symptoms
a. Fever, headaches, weight loss, swelling of joints, stiffness of joints, difficulty in motion,
etc., affecting activities
5) Gynaecological history:
a. History of menstrual cycles
b. History of menopause
c. Any past fibroid history
6) Drug history/past surgical history
7) Family history
8) Socioeconomic history – occupation, diet, weight, exercise
9) Comorbids – HTN, IHD, DM, etc.
Physical Examination:
1) Vital Signs: BP, pulse, RR, temperature
 2) GPE: Anaemia, jaundice, cyanosis, clubbing, lymphadopathy
3) Hands – Heberden’s/Bouchard’s nodes. Temperature, color, texture.
4) Knee Examination: Temperature, colour, texture, swelling, crepitus on movement, limited range
of motion, tenderness.
5) Others: Gait, joint deformity, weakness of muscle, surrounding joints.
Investigations:
1) X-ray knee joint (AP/lateral view)
2) Blood – CBC, RBS
Non-pharmacological Interventions:
1) Patient education
a. Warm up before exercise
b. Try low impact exercises
c. Get support, like shoe inserts
d. Walk downhills
e. Avoid sleeping on your side
2) Weight loss – healthy diet
3) Exercise – light walk/cycling, preferably walk.
4) Physical therapy
5) Occupational therapy
6) Unloading in knee joints, use walking stick
7) Cushioned insoles/shoes
8) Seek and treat depression and anxiety in the patient.
Pharmacological Treatment:
1) Nonsteroidal anti-inflammatory drugs (NSAIDs), such as Brufen (ibuprofen). Omeprazole 20 mg
OD if patient on oral NSAIDs
2) Acetaminophen (paracetamol)
3) Corticosteroid shots are used in cases of severe inflammation
4) Low dose amitriptyline 10 to 75 mg (pain causing disturbed sleep)
5) Other modalities may be tried such as strontium ranelate.
6) Follow-up after 4 weeks
7) Referral:
a. To rheumatology if coexists with psoriasis.
b. To orthopedics if signs and symptoms worsen
c. To chiropodist for foot care and insoles
d. To physiotherapist for exercises
e. To orthopedic surgery for modalities such as knee replacement or cartilage grafting, etc.
235.
A 25-year-old university student presents with 1 week history of productive cough, low grade fever, nausea and
mild shortness of breath.
On examination, there are crepitations in right lower zone with few rhonchi.

A. What is the most likely diagnosis?

B. What two investigations would you order?
C. Enlist 5 steps of your management plan.

ANSWER
A
Most Likely Diagnosis:
Pneumonia
B
Investigations:
 FBC (increased TLC)
 Chest x-ray PA view (infiltrates in lung bases/cavitation
 Blood culture to confirm organism causing pneumonia
 Sputum for microscopy and culture
 CRP
C
Management Steps:
1. Oxygen: To maintain O2 saturation PaO2 > 8.0, saturation > 94%
2. IV fluids: To prevent hypotension in case of shock/dehydration.
3. Antibiotics:
a. Co-Amoxiclav 1.2 g/8h
b. Clarithromycin 500 mg/12H
c. If penicillin allergic use ciprofloxacin
4. Analgesia: Paracetamol 1 g/6h (if pleurisy)
5. Follow-up: At 6 weeks with chest x-ray and CRP
236.
A 10-year-old child from a poor socio-economic background attends your clinic with his mother who says that he
has some rashes between the web of his fingers, legs and elbows with a lot of itching at night for the last two
months. There are 3 other children in the family.

A. What are the two most likely diagnoses?

B. How will you manage this child?
C. What preventive advice will you give to the mother?
D. What advice will you give the mother for future prevention of this problem?

ANSWER
A
Likely Diagnoses:
1) Scabies
2) Contact dermatitis
B
Management:
History: Ask more questions like;
a) complete brief history, especially any skin disease history and recent infections
b) relevant aggravating & relieving factors
c) associations with fevers, rashes, boils, blisters, etc.
d) family history; any other person in family ill or likely to be having same or relevant disease
e) complete thorough examination of child along with groin examination
Investigations:
 Order CBC as pt belong to poor family background so might b having low Hb levels and having
any other worm infestation then seen by eosinophils. Also check wbc for any other infection for
safe side
Non-Pharmacological:
a) EDUCATION: Educate the pt. and his family his mother about the disease and its course its spread
to other family members.
b) avoid direct contact sleeping with other children of the family until get complete application of
medicine at leats 2 times in a week.
c) all close contact people other brothers and sisters need same treatment prophylacticaly
d) proper washing of clothing bedding etc
Pharmacological:
Local
o Melathion or Permethrin 5% lotion or cream. Should be applied completely on whole
body for 8 to 10 hours then wash. It’s one time measure but can be repeated after 5 to
7 days or accordingly.
o NOTE: itching of scabies may persist until 1 to 2 week, although infection settled down
o 25% benzyl benzoate lotion
o Crotamiton with sulphur lotion
o Crotamiton cream
Oral: Single dose of ivermectin 200 mcg/kg. May be repeated
If secondary infection, oral antibiotics.
For itching, antihistamines
Treat all household members simultaneously, lotion or cream should be applied on the whole
body of infants and below the collar line in other patients.
Safety Netting: Tell the patient to come again in two weeks or if something unusual happens.
C
Preventive Advice:
1) Avoid direct contact
2) Avoid bed sharing
D
Advice for Future Prevention:
1) Educate mother regarding disease
2) Improve hygienic conditions.
3) Improve cleanliness of the house and also of the household members.