Internal Medicine

Question 1

A 23-year-old male patient who lives on the road side was admitted to a medical ward for acute febrile illness. He developed diaphoresis and palpitation hours after drug administration. On examination, his BP dropped to 80/40mmHg. What is the most appropriate next step in the management of this patient?
• a. Give IV fluid and dexamethasone
b. Reassure the patient and continue the medication
• c. Send blood culture
d. Transfuse with cross-matched blood

Answer 1

A

Question 2

A 24-year-old man came to a hospital with complaints of cough, fever and pleuritic chest pain of three days duration. He was treated with unspecified antibiotics for URTI two weeks back. On physical examination, his vital signs were unremarkable, but chest examination showed left middle lung field bronchial breath sound. What is the best initial management option for this patient?
• a. PO Augumentin plus Azithromycin
• b. PO Clarithromycin plus Doxycycline
c. PO Doxicycline plus Ciprofloxacin
• d. PO Azithromycin

Answer 2

The patient’s presentation (cough, fever, pleuritic chest pain, and bronchial breath sounds in the left middle lung field) strongly suggests community-acquired pneumonia (CAP), likely with consolidation. The best initial management involves selecting an appropriate antibiotic regimen for outpatient treatment of CAP.

The most appropriate option is:
According to STG for a patient with no comorbidities we only give azithromycin we give augumentin and azitro for the once with comorbidities
a. PO Augmentin (Amoxicillin-clavulanate) plus Azithromycin.

Rationale:
1. Coverage of Common Pathogens:
• Streptococcus pneumoniae (most common bacterial cause of CAP).
• Atypical pathogens like Mycoplasma pneumoniae and Chlamydia pneumoniae (covered by Azithromycin).
• Augmentin provides beta-lactam activity, while Azithromycin covers atypical organisms.
2. Guideline Support:
• According to IDSA and ATS guidelines for outpatient management of CAP, combination therapy with a beta-lactam (e.g., Amoxicillin-clavulanate) and a macrolide (e.g., Azithromycin) is appropriate for patients with risk factors (e.g., recent antibiotic use).

Why Not the Other Options?
• b. PO Clarithromycin plus Doxycycline:
• Dual coverage of atypicals but insufficient beta-lactam activity for S. pneumoniae.
• c. PO Doxycycline plus Ciprofloxacin:
• Ciprofloxacin has poor activity against S. pneumoniae, and dual coverage of atypicals is unnecessary.
• d. PO Azithromycin:
• Monotherapy is generally sufficient for low-risk, healthy individuals with no recent antibiotic use. However, this patient has recent antibiotic exposure, increasing the likelihood of resistant pathogens.

Next Steps:
1. Monitor for clinical improvement.
2. Educate the patient on signs of worsening symptoms (e.g., dyspnea or persistent fever).
3. Consider follow-up imaging if symptoms persist beyond treatment to assess for complications like abscess or effusion.

Question 3

A 25-year-old female patient came to a hospital with fatigue, shortness of breath and bilateral leg swelling of one month duration. She has no previously known chronic illness. Her blood pressure is 90/60 mmHg, pulse rate is 112/min, respiration rate is 18/min and temperature is 37.2 degree centigrade. She has right side pleural effusion, raised JVP, grade 2-3/6 holosystolic murmur at apex and bilateral leg swelling. Echocardiography showed left ventricular cavity diameter of 65 mm (normal value less than 54 mm) and left atrial diameter of 45 mm (normal value less than 38 mm) with ejection fraction of 30percent. What is the most likely underlying disease of the patient?
• a. Hypertrophic cardiomyopathy
Myocarditis
Dilated cardiomyopathy
Restrictive cardiomyopathy

Answer 3

A 25-year-old female patient came to a hospital with fatigue, shortness of breath and bilateral leg swelling of one month duration. She has no previously known chronic illness. Her blood pressure is 90/60 mmHg, pulse rate is 112/min, respiration rate is 18/min and temperature is 37.2 degree centigrade. She has right side pleural effusion, raised JVP, grade 2-3/6 holosystolic murmur at apex and bilateral leg swelling. Echocardiography showed left ventricular cavity diameter of 65 mm (normal value less than 54 mm) and left atrial diameter of 45 mm (normal value less than 38 mm) with ejection fraction of 30percent. What is the most likely underlying disease of the patient?
• a. Hypertrophic cardiomyopathy
Myocarditis
Dilated cardiomyopathy
Restrictive cardiomyopathy

Question 4

A 24-year-old man has been on RHZE for the last three weeks for the diagnosis of pulmonary tuberculosis. In the last two week, the patient started to complain of burning and tingling sensation in his feet. What is the most appropriate step in the management of the patient’s case?
a. Reassurance and continue anti-TB
b. Start on pyridoxine and continue anti-TB
c. Discontinue only Isonazid and start on pyridoxine plus RZE
d. Start on pyridoxine and stop all anti-TB

Answer 4

The most appropriate step in the management of this patient’s case is:

b. Start on pyridoxine and continue anti-TB

Explanation:
1. Diagnosis:
The patient is experiencing peripheral neuropathy, which is a well-known side effect of isoniazid (INH), one of the drugs in the RHZE regimen (rifampicin, isoniazid, pyrazinamide, and ethambutol).
2. Cause:
Isoniazid-induced peripheral neuropathy occurs due to interference with vitamin B6 (pyridoxine) metabolism, leading to a functional deficiency.
3. Management:
• Pyridoxine supplementation (usually 10-50 mg/day) is effective in preventing and treating this side effect.
• It is standard practice to co-administer pyridoxine with INH, especially in individuals at higher risk (e.g., malnutrition, diabetes, alcoholism, or pregnancy).
4. Why Not Other Options?:
• a. Reassurance and continue anti-TB: This would not address the underlying issue and may worsen the neuropathy.
• c. Discontinue only Isoniazid and start on pyridoxine plus RZE: Discontinuing INH is unnecessary because the neuropathy can be managed with pyridoxine.
• d. Start on pyridoxine and stop all anti-TB: Stopping the entire regimen would risk treatment failure and drug resistance.

Conclusion:

The correct approach is to start pyridoxine and continue the full RHZE regimen.

Question 5

A 25-year-old male patient came to a neurology clinic for his regular epilepsy follow-up. He has been taking the maximum dose of valproic acid, but he had six episodes of seizure in the last two months.
He claimed that he is adherent to his medication.
What is the most appropriate next step in the management of this patient?
•a. Taper Valproic acid and start regular doses of diazepam
b. Add other anti-epileptic drug with different mechanism of action
• c. Add two drugs with similar mechanisms of action
• d. Discontinue Valproic acid and start other anti-epileptic drug

Answer 5

The most appropriate next step in the management of this patient is:

b. Add another anti-epileptic drug with a different mechanism of action

Explanation:
1. Diagnosis:
The patient is experiencing drug-resistant epilepsy, defined as the failure of adequate trials of two appropriately chosen and tolerated anti-epileptic drugs (AEDs) to achieve sustained seizure freedom.
2. Current Situation:
• The patient is on the maximum dose of valproic acid but continues to have frequent seizures.
• He claims adherence, so treatment failure is likely due to insufficient seizure control with valproic acid alone.
3. Management:
• Adding a second AED with a different mechanism of action is the next step. This combination may increase the likelihood of seizure control. Examples include levetiracetam, lamotrigine, or topiramate, depending on the type of epilepsy.
• A different mechanism minimizes the risk of additive side effects while maximizing efficacy.
4. Why Not Other Options?
• a. Taper Valproic acid and start regular doses of diazepam: Diazepam is used for acute seizure management, not long-term control. Tapering valproic acid without another long-term AED risks worsening seizure control.
• c. Add two drugs with similar mechanisms of action: Using drugs with similar mechanisms increases the risk of additive side effects without significant therapeutic benefit.
• d. Discontinue Valproic acid and start another AED: Abruptly discontinuing valproic acid could provoke withdrawal seizures. Changing the AED is only considered after the failure of multiple combination strategies.

Conclusion:

The best course of action is to add a second AED with a different mechanism of action to optimize seizure control.

Question 6

A 23-year-old male patient who lives on the road side was admitted to a medical ward for acute febrile illness. He developed diaphoresis and palpitation hours after drug administration. On examination, his BP dropped to 80/40mmHg. What is the most appropriate next step in the management of this patient?
• a. Give IV fluid and dexamethasone
b. Reassure the patient and continue the medication
• c. Send blood culture
• d. Transfuse with cross-matched blood

Answer 6

The most appropriate next step in the management of this patient is:
a. Give IV fluid and dexamethasone.

Reasoning:
• The patient has hypotension (BP 80/40 mmHg) and symptoms of diaphoresis and palpitation, which could indicate an adverse drug reaction or an episode of anaphylaxis.
• Immediate management of hypotension involves IV fluid resuscitation to restore intravascular volume.
• Dexamethasone, a corticosteroid, is used to address potential hypersensitivity or allergic reactions.

Why not the other options?
• b. Reassure the patient and continue the medication: This is inappropriate in a potentially life-threatening situation like hypotension and signs of shock.
• c. Send blood culture: Blood cultures may be part of the diagnostic workup for febrile illness but are not immediately life-saving in the presence of hypotension.
• d. Transfuse with cross-matched blood: This is not indicated unless the patient has signs of severe blood loss or anemia, which is not mentioned in this scenario.

Priority: Stabilize the patient’s hemodynamics first, then investigate the underlying cause.

Question 7

A 25-year-old young man came to an emergency
OPD after having dry cough, running nose fever and headache of three days duration. He did not have history of chronic lung problems and he is not smoker. His vital signs were within the normal range except temperature of 38.4 degree centigrade, he has clear chest and normal mental status. What is the most appropriate next step in the management of this patient?
a. Do not give any medications
•b. Prescribe antibiotics
• c. Prescribe antiviral
• d. Prescribe antipyretics

Answer 7

The most appropriate next step in the management of this patient is:
d. Prescribe antipyretics.

Reasoning:
• The patient presents with symptoms of a likely viral upper respiratory tract infection (URTI): dry cough, runny nose, fever, and headache.
• His vital signs are stable, with no evidence of bacterial infection (e.g., purulent sputum, localized chest findings, or severe systemic symptoms).
• Antipyretics like paracetamol (acetaminophen) or ibuprofen can be given to manage fever and associated discomfort.

Why not the other options?
• a. Do not give any medications: While most viral URTIs are self-limiting, symptomatic management (e.g., with antipyretics) improves patient comfort.
• b. Prescribe antibiotics: Antibiotics are not indicated for viral infections and their unnecessary use can lead to antibiotic resistance.
• c. Prescribe antiviral: Antivirals are not indicated unless there is suspicion of specific viral infections (e.g., influenza in high-risk patients) that require targeted therapy.

Additional Advice:
• Encourage adequate hydration, rest, and monitoring of symptoms.
• Advise the patient to return if symptoms worsen or new concerning signs develop (e.g., high fever, difficulty breathing).

Question 8

A 27-year-old patient came to an emergency unit complaining about nausea, vomiting, thirst, abdominal pain and shortness of breath for the last two days. On evaluation, temperature was 36.7 degree centigrade, respirations were 28/min, pulse rate was 116/min and blood pressure was 80/60mmHg. He is lethargic; however, he has no remarkable finding in other systems. His laboratory results reveal; WBC count of 4.8x103/microlitre, platelet count of 156x103/microlitre, hemoglobin level of 11.4g/dl, liver and kidney functions were normal, serum K+ 4.5mmol/L (NR; 3.5-5.5mmol/L), serum Na2+ 140mmol/L (NR; 136-146mmol/L), RBS
560mg/dl and urine analysis shows ketone +3. What is the most appropriate initial step in the management of this patient?
a. Metformin 1gm
• b. Start feeding by nasogastric tube
c. 0.9percent saline 10 ml/kg/hr

Answer 8

The most appropriate initial step in the management of this patient is:
c. 0.9% saline 10 ml/kg/hr.

Reasoning:

The patient presents with signs and symptoms consistent with diabetic ketoacidosis (DKA):
• Symptoms: Nausea, vomiting, abdominal pain, and shortness of breath (Kussmaul respirations).
• Signs: Hypotension (BP 80/60 mmHg), tachycardia (pulse 116/min), and lethargy, indicating dehydration and metabolic acidosis.
• Laboratory findings: Hyperglycemia (RBS 560 mg/dl), ketonuria (+3 ketones in urine), and normal potassium (serum K+ 4.5 mmol/L).

Initial Management:
1. Fluid Resuscitation:
• Start 0.9% normal saline at 10 ml/kg/hr to correct dehydration and improve perfusion.
• Fluids are critical to stabilize hemodynamics and dilute circulating glucose and ketones.
2. Potassium Monitoring:
• Potassium levels should be closely monitored because insulin therapy (given later) can cause hypokalemia.
3. Insulin Therapy:
• After initial fluid resuscitation, start a low-dose IV insulin infusion to address hyperglycemia and ketosis.
4. Correct Acidosis:
• Fluids and insulin are typically sufficient to resolve acidosis; bicarbonate is rarely needed.

Why not the other options?
• a. Metformin 1 gm: This is inappropriate for acute management of DKA. Metformin is used for chronic glucose control in type 2 diabetes and does not address the acute metabolic derangements of DKA.
• b. Start feeding by nasogastric tube: Feeding is not indicated in the acute phase of DKA and could exacerbate nausea and vomiting.
• d. Insulin infusion: While insulin is essential for DKA management, fluids must be administered first to avoid worsening hypotension and hypovolemia.

Key Priorities:
1. Fluid resuscitation.
2. Electrolyte monitoring and management.
3. Insulin therapy.
4. Address the underlying cause of DKA (e.g., infection, missed insulin doses).

Question 9

10 of 37 8-year-old male patient came to a health center arter noticing skin discoloration on his back for unknown duration. Five hypo-pigmented skin lesions with loss of sensation on the lesion and enlarged ulnar nerves were found during examination. What is the most likely diagnosis?
a. Leprosy
• b. Ulnar nerve neuropathy
C. Tinea corporis
• d. Pityriasis alba

Answer 9

The most likely diagnosis is:

a. Leprosy

Explanation:
• Hypopigmented lesions with loss of sensation are characteristic of leprosy (Hansen’s disease), caused by Mycobacterium leprae.
• Enlarged peripheral nerves (such as the ulnar nerve) are another hallmark feature of leprosy, as the disease primarily affects the skin and peripheral nerves.
• Tinea corporis and pityriasis alba can cause hypopigmented lesions, but they are not associated with nerve enlargement or loss of sensation.
• Ulnar nerve neuropathy could explain the enlarged ulnar nerve but would not cause the characteristic skin lesions.

Further diagnostic confirmation with a skin biopsy or slit-skin smear would be necessary.
Clinical evaluation

Physical examination — The diagnosis of leprosy should be considered in patients with skin lesions and/or enlarged nerve(s) accompanied by sensory loss. Leprosy should be suspected in the setting of the following clinical manifestations:

●Diminished sensation or loss of sensation within skin lesions
●Paresthesias (tingling or numbness in the hands or feet)
●Painless wounds or burns on the hands or feet
●Tender, enlarged peripheral nerves

Question 10

27-year-old male patient came to a medical OPD with a complaint of retrosternal chest pain of two days duration. On evaluation, his temperature is 36.5 degree centigrade, respiratory rate is 25/min, pulse rate is 92/min, and blood pressure is 100/60mmHg.
There are no remarkable findings in other systems.
Laboratory results show hemoglobin level of 12g/dl, WBC count of 5 x 103/microlitre, and platelet count of 250,000/microlitre. Cardiac biomarkers are in the normal range. Chest X-ray findings are normal. ECG shows diffuse ST-segment elevations with upward concavity in leads I, II, AVF, and v2 to v6. What is the most likely diagnosis of this patient?
• a. Acute coronary syndrome.
b. Pericarditis
• c. Pulmonary thromboembolism
d. Pneumonia

Answer 10

The most likely diagnosis is:

b. Pericarditis

Explanation:
• Diffuse ST-segment elevations with upward concavity on ECG are a hallmark of acute pericarditis. This pattern is typically seen in multiple leads and helps differentiate it from acute coronary syndrome (which usually shows localized ST elevations).
• Normal cardiac biomarkers argue against myocardial infarction (part of acute coronary syndrome).
• The absence of fever, elevated WBC, or focal findings on chest X-ray makes pneumonia less likely.
• Pulmonary thromboembolism typically presents with signs of right heart strain on ECG, hypoxia, and possible hemodynamic instability, none of which are seen here.

Other supportive findings for pericarditis could include pleuritic chest pain (worsened by lying flat and relieved by sitting up) or a pericardial rub on auscultation, though these are not mentioned in this case.

Question 11

A 30-year-old female patient comes to a medical
referral clinic complaining of bilateral recurrent pain
and swelling of her hand joints for two years. She
has no skin rash or photosensitivity. Her vital signs
are in the normal range. Musculoskeletal
examinations reveal swan neck like deformity of her
hands. What is the most likely diagnosis of the
patient?
a. Osteoarthritis
b. Reactive arthritis
C.
Gout
• d. Rheumatoid arthritis

Answer 11

The most likely diagnosis is:

d. Rheumatoid arthritis

Explanation:
• Bilateral recurrent pain and swelling of hand joints over two years strongly suggest a chronic inflammatory arthritis, which is typical of rheumatoid arthritis (RA).
• Swan neck deformity (hyperextension of the proximal interphalangeal joint and flexion of the distal interphalangeal joint) is a classic deformity associated with long-standing RA.
• Osteoarthritis typically involves the distal interphalangeal joints (Heberden’s nodes) and lacks significant inflammatory signs or deformities like swan neck.
• Reactive arthritis is usually associated with a preceding infection and often involves larger joints asymmetrically.
• Gout is characterized by acute monoarticular arthritis and does not usually cause chronic deformities like swan neck.

Further diagnostic confirmation can be made by testing for rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies.

Question 12

A 32-year-old male patient came to a hospital with
the complaints of cough and severe left side chest
pain while breathing for the last one week. His blood
pressure is 110/60 mmHg, pulse rate is 100/min,
respirations are 32/min and temperature is 38.4
degree centigrade. Respiratory system examination
showed dullness and absent air entry over the left
lower half of the lung fields. What is the most
appropriate initial investigation for the patient?
• a. Echocardiography
• b. Chest x-ray
• c. Thoracentesis
• d. Complete blood count

Answer 12

The most appropriate initial investigation is:

b. Chest X-ray

Explanation:
• The patient’s symptoms (pleuritic chest pain, fever, cough, and tachypnea) and examination findings (dullness and absent air entry) suggest a possible pleural effusion or consolidation, such as pneumonia with a parapneumonic effusion or empyema.
• A chest X-ray is the initial investigation of choice to confirm the presence of pleural effusion, determine its extent, and assess for other abnormalities like consolidation or pneumothorax.
• Thoracentesis would be the next step if pleural effusion is confirmed to determine its nature (e.g., transudate vs. exudate) and possibly guide treatment.
• Complete blood count can provide supportive information (e.g., leukocytosis suggesting infection), but it is not the primary diagnostic test.
• Echocardiography is useful if a cardiac cause (e.g., pericardial effusion) is suspected, but the clinical presentation here is more consistent with a pulmonary/pleural condition.

Question 13

P Flag question
A 33-year-old woman came to a clinic with
complaints of decreased urine output and foamy
urine of one week duration. On physical examination,
a blood pressure of 150/90 mmg, peri orbital
edema and malar rash were noted. Investigation
results show a urine analysis blood of +2, protein of
+3 and many RBC cast, 24-hour urine protein of 2.5g
and serum creatinine of 1.3mg/dl. What is the most
likely cause of the patient’s condition?
• a. Lupus nephritis
• b. Post streptococcus glomerulonephritis
c. IgA nephropathy
• d. Focal segmental glomerulosclerosis
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Answer 13

The most likely cause of the patient’s condition is:

a. Lupus nephritis

Explanation:
• The patient’s malar rash, peri-orbital edema, and hypertension suggest an underlying systemic autoimmune condition, most likely systemic lupus erythematosus (SLE).
• Urinalysis findings of proteinuria (+3), hematuria (RBC casts), and a 24-hour urine protein of 2.5 g indicate significant renal involvement, consistent with lupus nephritis.
• Serum creatinine elevation further supports renal dysfunction.

Why not the other options?
• Post-streptococcal glomerulonephritis (PSGN): Typically occurs after a streptococcal infection and is more common in children. It usually presents with low complement levels (especially C3). No history of recent infection is noted here.
• IgA nephropathy: Usually presents with episodic gross hematuria, often following an upper respiratory infection, but it lacks systemic symptoms like malar rash.
• Focal segmental glomerulosclerosis (FSGS): Characterized by nephrotic syndrome (heavy proteinuria >3.5 g/day) without significant hematuria or systemic symptoms like rash.

Next Steps:
• Confirm the diagnosis with ANA, anti-dsDNA, and complement levels (C3, C4).
• A renal biopsy may be necessary to classify the lupus nephritis and guide treatment.

Question 14

A 35-year-old female patient came to a hospital with
anterior neck swelling of five years duration. Since
the last three month, she has started to experience
palpitation and has a history of hot intolerance with
no history of bone pain, cough or yellowish
discoloration of the eye. On examination, her pulse
rate is 110/min, blood pressure is 120/70mmHg,
and there is lid lag and lid retraction. On thyroid
examination, there is diffusely enlarged thyroid
measuring of 4*3cm,the lower border is reachable.
She is investigated with thyroid function test and the
results show that TSH is 0.3micro unit/mL(Normal;
0.5-5 micro unit/mL), Total T4 is 180
nmol/L(Normal; 55-150 nmol/L), Total T3 is 5
nmol/L(Normal; 1.5-3.5 nmol/L). What is the most
likely diagnosis of the patient?
• a. Toxic multinodular goiter
• b. Toxic Adenoma
• c. Graves’ disease
• d. Follicular neoplasm
7 : 3 9 巴
Doctor of Medicine Model

Answer 14

The most likely diagnosis is:

c. Graves’ disease

Explanation:
• Thyroid findings: Diffusely enlarged thyroid with no nodules suggests a condition involving the entire gland, such as Graves’ disease.
• Symptoms: Palpitations, heat intolerance, and lid lag/lid retraction are classic features of hyperthyroidism, which is most commonly caused by Graves’ disease.
• Thyroid function test results: Suppressed TSH (0.3 µU/mL) with elevated T4 and T3 confirms primary hyperthyroidism.
• Examination findings: Lid lag and lid retraction are often seen in Graves’ disease due to orbital inflammation (thyroid eye disease).

Why not the other options?
• Toxic multinodular goiter (TMNG): Typically presents with an irregularly enlarged thyroid with multiple nodules, which is not described here.
• Toxic adenoma: Characterized by a single hyperfunctioning nodule, which is not consistent with a diffusely enlarged thyroid.
• Follicular neoplasm: Usually presents as a solitary thyroid nodule and does not cause hyperthyroidism or systemic symptoms.

Next Steps:
• Confirm the diagnosis with thyroid-stimulating immunoglobulins (TSI) or TRAb (TSH receptor antibodies).
• Consider a thyroid ultrasound and radioactive iodine uptake (RAIU) test to differentiate Graves’ disease from other causes of hyperthyroidism.

Question 15

A 35-year-old woman presented with complaints of
foul smelling greasy diarrhea, fatigability and weight
loss. On examination, she is emaciated and has pale
conjunctiva. Laboratory is notable for hemoglobin
level of 8.5g/dl with MCV of 105fL. What is the most
likely nutrient deficiency the patient has?
• a. Iron
• b. Cobalamin
• c. Copper
• d. Phosphorus

Answer 15

The most likely nutrient deficiency is:

b. Cobalamin (Vitamin B12)

Explanation:
• Foul-smelling, greasy diarrhea and weight loss suggest malabsorption, likely due to a condition such as celiac disease or small intestinal bacterial overgrowth (SIBO), which can impair the absorption of vitamin B12.
• Macrocytic anemia (MCV of 105 fL) is characteristic of vitamin B12 or folate deficiency. Given the malabsorption symptoms, vitamin B12 deficiency is more likely.
• Fatigability and emaciation further support a nutrient deficiency, with vitamin B12 deficiency commonly leading to neurological symptoms over time if untreated.

Why not the other options?
• Iron: Iron deficiency causes microcytic anemia (low MCV), which is not seen here.
• Copper: Copper deficiency typically causes anemia and neutropenia but is much rarer and does not typically present with diarrhea.
• Phosphorus: Phosphorus deficiency is not associated with anemia or the symptoms described.

Next Steps:
• Confirm with serum vitamin B12 levels.
• Test for underlying causes of malabsorption, such as anti-tissue transglutaminase antibodies for celiac disease or a stool test for fat malabsorption.

Question 16

A 35-year-old male patient came to an emergency
OPD complaining of high grade fever, headache and
neck pain of three days duration. He has been
admitted to a private hospital for three days taking
unidentified medications but had no improvement.
His temperature is 38.2 degree centigrade, pulse
rate is 100/min and respirations are 24/min. On
neurologic evaluation, he has neck stiffness and
kerning sign is positive. Laboratory studies show;
WBC count of 16.3x103/mm3, platelet count of
480x103/mm3, hemoglobin level of 14g/dl, there are
450 cells in CSF of which 75percent are neutrophils
and he is positive for HIV. What is the most
appropriate empiric management for the patient?
a. Ceftazidime and Metronidazole
• b. Ceftriaxone, Prednisolone and
Chloramphenicol
• c. Ceftriaxone, Vancomycin and Ampicillin
• d. Cefipime and Dexamethasone

Answer 16

The most appropriate empiric management is:

c. Ceftriaxone, Vancomycin, and Ampicillin

Explanation:

This patient has acute bacterial meningitis, likely due to his immunocompromised status (HIV-positive) and clinical findings of fever, headache, neck stiffness, positive Kernig’s sign, and CSF analysis showing neutrophilic pleocytosis (450 cells, 75% neutrophils).
• Ceftriaxone: Covers Streptococcus pneumoniae and Neisseria meningitidis, the most common causes of bacterial meningitis in adults.
• Vancomycin: Added to cover drug-resistant S. pneumoniae.
• Ampicillin: Included due to the patient’s HIV status, which places him at higher risk for Listeria monocytogenes.

Why not the other options?
• a. Ceftazidime and Metronidazole: These are not first-line agents for bacterial meningitis. Ceftazidime primarily covers Pseudomonas, and metronidazole targets anaerobes, which are uncommon in meningitis.
• b. Ceftriaxone, Prednisolone, and Chloramphenicol: Chloramphenicol is used in resource-limited settings but is not preferred due to resistance concerns. Prednisolone is not recommended; dexamethasone is the steroid of choice.
• d. Cefepime and Dexamethasone: Cefepime is used for broad-spectrum Gram-negative coverage (e.g., in nosocomial meningitis) but is not optimal for community-acquired bacterial meningitis.

Additional Considerations:
• Dexamethasone: Should be administered before or with the first dose of antibiotics to reduce inflammation in pneumococcal meningitis.
• Blood cultures and CSF cultures should be obtained before starting antibiotics, if possible.

Question 17

A 38-year-old daily laborer from Humera presents
with complaints of fatigue, abdominal swelling and
early satiety for the past six months. On physical
examination, he is wasted, has pale conjunctiva and
splenomegaly. His hemoglobin level is 9 g/di, WBC
count is 3000/mm3 and platelet count is
100000/mm3. His splenic aspirate microscopy
revealed amastigote. PITC non-reactive (NR;
Hemoglobin 13.3-16.2g/dl, WBC count 3.54-9.06 x
103/mm3, platelet count 165-415 × 103/mm3).
What is the first line drug for the management of
this patent?
• a. amphotercin B + paramomycin
b. miltefosine+amphotercin B
c. amphotercin B + sodiumstibulogluconate
• d. sodium stibulgluconate +paramomycin

Answer 17

The first-line drug for the management of this patient is:

d. Sodium stibogluconate + paromomycin

Explanation:

This patient has visceral leishmaniasis (kala-azar), as evidenced by:
• Clinical symptoms: Fatigue, abdominal swelling (splenomegaly), early satiety, and wasting.
• Laboratory findings: Pancytopenia (anemia, leukopenia, thrombocytopenia) and identification of amastigotes in splenic aspirate.
• Geographical context: Humera, a region endemic to leishmaniasis.

First-line treatment:
• Sodium stibogluconate + paromomycin is the recommended first-line therapy for visceral leishmaniasis in many endemic regions, including East Africa.
• This combination is highly effective, reduces the duration of treatment, and minimizes resistance.

Why not the other options?
• a. Amphotericin B + paromomycin: Liposomal amphotericin B is an alternative but more commonly used in regions with high resistance to antimonials or in immunocompromised patients (e.g., HIV-positive).
• b. Miltefosine + amphotericin B: Miltefosine is used in certain regions but is not the first-line therapy in East Africa due to cost and availability.
• c. Amphotericin B + sodium stibogluconate: Effective but associated with higher toxicity and not routinely used as the first-line therapy.

Next Steps:
• Monitor for side effects during treatment, such as cardiotoxicity (with sodium stibogluconate) and nephrotoxicity (with amphotericin B).
• Assess response to treatment with clinical improvement and follow-up splenic aspirate, if necessary.

Question 18

A 40-year-old female patient came to an OPD with
the complaint of amenorrhea of three months
duration. She also had frequent abortion for which
she visited many private clinics and did not get cure.
She also complained hot intolerance and significant
weight loss. Her pulse rate is 120/min. On
examination, she has lid lag and exophthalmia,
diffused anterior neck swelling which moves with
respiration, and thickened skin over the dorsum of
the foot and pre-tibial region. What is the most likely
explanation for these findings?
O a. Hashimotos thyroiditis
• b. Secondary thyrotoxicosis
• c. Subacute thyroiditis
• d. Graves’ disease

Answer 18

The most likely explanation for these findings is:

d. Graves’ disease

Explanation:
• Symptoms: Amenorrhea, hot intolerance, significant weight loss, and tachycardia (pulse rate 120/min) are consistent with hyperthyroidism.
• Signs: Lid lag, exophthalmos, diffusely enlarged thyroid (goiter), and pre-tibial myxedema (thickened skin) are classic features of Graves’ disease, an autoimmune condition and the most common cause of hyperthyroidism.
• Frequent abortions: Hyperthyroidism can lead to menstrual irregularities and pregnancy complications, including miscarriages.

Why not the other options?
• a. Hashimoto’s thyroiditis: Typically causes hypothyroidism and is associated with features like fatigue, cold intolerance, and weight gain, not hyperthyroidism or exophthalmos.
• b. Secondary thyrotoxicosis: Caused by TSH-secreting pituitary adenomas, which are rare and usually do not cause exophthalmos or pre-tibial myxedema.
• c. Subacute thyroiditis: Causes a painful thyroid and transient hyperthyroidism but does not present with exophthalmos or pre-tibial myxedema.

Next Steps:
• Confirm diagnosis with TSH, free T4, and T3 levels.
• Check TSH receptor antibodies (TRAb) to confirm Graves’ disease.
• Consider a thyroid ultrasound or radioactive iodine uptake (RAIU) scan to evaluate gland activity.

Question 19

A 41-year-old man came to a hospital with a three
weeks history of generalized body swelling that
started from the legs and progressed to the whole
body. He also has shortness of breath at rest and
orthopnea of three pillows equivalent. On
examination, his blood pressure is 130/80 mmHg,
pulse rate is 120/min, respirations are 32/min,
temperature is 35.8 degree centigrade, he has
bilateral basal fine crepitation and S3 gallop, and
TVLS is 14cm. Investigation showed Creatinine level
of 2.1 mg/dl. What is the best initial treatment for
the patient?
a. Enalapril
• b. Metoprolol
• c. Hydrochlothizide
• d. Furosemide

Answer 19

The best initial treatment for the patient is:

d. Furosemide

Explanation:

The patient presents with signs and symptoms of congestive heart failure (CHF), including:
• Generalized body swelling (edema) starting from the legs, which suggests fluid retention.
• Shortness of breath and orthopnea (difficulty breathing while lying down), indicating pulmonary congestion.
• Bilateral basal fine crepitation and S3 gallop, which are clinical signs of heart failure.
• Elevated creatinine level (2.1 mg/dL), indicating some degree of renal impairment, which is common in heart failure due to poor perfusion or volume overload.

Furosemide is a loop diuretic used to manage fluid overload in heart failure by promoting renal excretion of sodium and water, thus reducing edema and alleviating symptoms like shortness of breath and orthopnea.

Why not the other options?
• a. Enalapril: An ACE inhibitor that helps with long-term management of heart failure by improving symptoms and outcomes, but it’s not the initial treatment in an acute setting where fluid overload needs to be addressed first.
• b. Metoprolol: A beta-blocker that is important in chronic heart failure management but should not be started in the acute setting of fluid overload without first stabilizing the patient.
• c. Hydrochlorothiazide: A thiazide diuretic, which is less potent than furosemide and typically used for mild fluid retention. In this patient with significant fluid overload and heart failure, a loop diuretic like furosemide is more appropriate.

Next Steps:
• Monitor renal function closely after initiating diuretics.
• Consider ACE inhibitors, beta-blockers, and aldosterone antagonists once the patient is stable and volume status is improved.
• Consider echocardiography to evaluate left ventricular function and determine the cause of heart failure.

Question 20

A 55-year-old man came to an OPD with progressive
left side chest pain. The pain starts while performing
activities and improves during resting. He has
smoked about 20 pack years. Physical examination
showed normal system findings, but his blood
pressure is 140/90 mmHg. What is the most likely
cause of the patient’s chest pain?
• a. Subacute pericarditis
b. Atherosclerotic coronary artery disease
c. Chronic pulmonary thromboembolism
• d. Obstructive valve disease

Answer 20

The most likely cause of the patient’s chest pain is:

b. Atherosclerotic coronary artery disease

Explanation:
• Chest pain that is progressive, worsens with activity, and improves with rest is highly suggestive of angina, particularly stable angina related to coronary artery disease (CAD).
• The patient’s smoking history (20 pack years) is a major risk factor for atherosclerosis and CAD.
• Elevated blood pressure (140/90 mmHg) is another risk factor for cardiovascular disease.

Why not the other options?
• a. Subacute pericarditis: This condition causes chest pain that is usually sharp and worsens with inspiration or coughing, and may improve when sitting forward. It is not typically related to activity or rest.
• c. Chronic pulmonary thromboembolism: This condition can cause dyspnea and right heart failure but is less likely to present with chest pain that is activity-dependent.
• d. Obstructive valve disease: This can cause chest pain but is more likely to be associated with symptoms of heart failure (dyspnea, fatigue) or syncope, not activity-induced chest pain.

Next Steps:
• The patient should undergo ECG, stress testing, or coronary angiography to evaluate for coronary artery disease.
• Management may include lifestyle changes, antiplatelet therapy, and possibly statins, depending on the severity of the disease.

Question 21

A 60-year-old female known diabetic patient on
follow-up was found to have hypertension. She is
not symptomatic, but her blood pressure was in the
hypertensive range for several months. She is taking
ant-diabetic medications properly and her glycemic
control is good. Currently, her blood pressure is
160/100 mm Hg. Laboratory investigation showed
protein +2 in the urine otherwise normal. What is the
preferred drug to start for blood pressure control?
• a. Amilodipine
• b. Hydrochrothiazide
• c. Atenolol
O d. Enalapril

Answer 21

The preferred drug to start for blood pressure control in this patient is:

d. Enalapril

Explanation:

This patient has hypertension and proteinuria, which is suggestive of diabetic nephropathy. The use of an ACE inhibitor like Enalapril is preferred because:
• ACE inhibitors (such as Enalapril) help lower blood pressure and provide renal protection, especially in patients with diabetes and proteinuria.
• They reduce glomerular hypertension and proteinuria, slowing the progression of kidney damage, which is particularly important in diabetic nephropathy.
• ACE inhibitors are also beneficial in patients with diabetic kidney disease (with or without hypertension), as they reduce both blood pressure and albuminuria.

Why not the other options?
• a. Amlodipine: A calcium channel blocker that is effective for blood pressure control, but it does not have the same protective effect on the kidneys as ACE inhibitors in patients with diabetes and proteinuria.
• b. Hydrochlorothiazide: A thiazide diuretic can help lower blood pressure, but it may not provide the renal protective benefits seen with ACE inhibitors. Additionally, it can worsen electrolyte imbalances and is not as protective against diabetic kidney disease.
• c. Atenolol: A beta-blocker can be used to control blood pressure but is not the preferred agent for diabetic nephropathy. It does not provide the same renal benefits as ACE inhibitors in this context.

Next Steps:
• Start Enalapril at an appropriate dose, monitor renal function (creatinine, potassium), and check for blood pressure response.
• Consider adding other agents if blood pressure control is inadequate.
• Continue monitoring proteinuria as a marker of kidney function.

Question 22

A 55-year-old man came to an outpatient clinic with
a complaint of intermittent epigastric burning pain
which is worsened by taking food and awakes him
from sleep for the last two months. He has no
weight loss and any history of drug intake. Physical
examination shows mild epigastric tenderness.
Laboratory studies show hemoglobin level of
10.5g/dl, WBC count of 7500/mm3 and positive
stool helicobacter antigen. Upper Gl endoscopy
s h o w s d u o d e n a l ulcer. What is the b e s t
management for the patient?
• a. Start on H2 blocker
• b. Start on PPI +Clarithromycin
+Metronidazole
O c. Start on proton pump inhibitor
• d. Start on H2 blocker +Clarithromycin
+Metronidazole

Answer 22

The best management for the patient is:

b. Start on PPI + Clarithromycin + Metronidazole

Explanation:

The patient presents with symptoms suggestive of peptic ulcer disease (PUD), specifically a duodenal ulcer, which is confirmed by upper gastrointestinal endoscopy. The positive stool Helicobacter pylori antigen suggests that the ulcer is likely caused by an H. pylori infection.

The first-line treatment for H. pylori-associated peptic ulcers involves triple therapy, which typically includes:
• Proton pump inhibitor (PPI): Reduces gastric acid secretion, promoting ulcer healing and providing symptomatic relief.
• Clarithromycin: An antibiotic that targets H. pylori.
• Metronidazole: An alternative antibiotic for H. pylori eradication, particularly in areas with high resistance to clarithromycin.

Why not the other options?
• a. Start on H2 blocker: H2 blockers can reduce stomach acid, but they are less effective than PPIs and do not address the underlying H. pylori infection.
• c. Start on proton pump inhibitor: While a PPI is appropriate for ulcer healing and symptom relief, H. pylori eradication requires antibiotic therapy as well, which is not provided by PPI alone.
• d. Start on H2 blocker + Clarithromycin + Metronidazole: This is not the preferred combination. While it includes the correct antibiotics, H2 blockers are less effective than PPIs in reducing gastric acid and promoting ulcer healing.

Next Steps:
• Confirm eradication: After completing the triple therapy (PPI, clarithromycin, metronidazole), re-test for H. pylori (preferably with a stool antigen test or urea breath test) to confirm eradication.
• Consider maintenance therapy with a PPI if the patient has complications like severe symptoms or if there is a history of ulcer recurrence., you can change metronidazole by amoxicillin

Question 23

A 38-year-old female patient, who is on treatment for
Crohn’s disease for two years, came to a medical
referral clinic complaining about weakness,
palpitation, forgetfulness and headache of two
months duration. On evaluation, she has tachycardia
and absent deep tendon reflexes and position and
vibration sensation. Her blood cell count shows
WBC of 3.8x103/microlitre, platelet of
350x103/microlitre, and hemoglobin of 8.0g/dL. On
examination of peripheral blood smear, there are
three neutrophils with seven lobes. What is the most
appropriate initial management for this patient?
• a. Prednisolone
• b. Cyanocobalamine
• c. Iron sulfate
• d. Immunotherapy

Answer 23

The most appropriate initial management for this patient is:

b. Cyanocobalamin

Explanation:

The patient presents with symptoms that are indicative of vitamin B12 deficiency, which is commonly seen in patients with Crohn’s disease, particularly those with ileal involvement or those who have undergone intestinal resection. The key signs and symptoms include:
• Weakness, palpitations, forgetfulness, and headache, which may be attributed to anemia and neurological manifestations of B12 deficiency.
• Tachycardia and absent deep tendon reflexes and loss of position and vibration sensation suggest neurological involvement, which can occur with B12 deficiency (peripheral neuropathy).
• Blood findings: The patient has anemia (hemoglobin of 8.0g/dL) and neutrophils with hypersegmentation (7 lobes), which is a classic sign of megaloblastic anemia due to vitamin B12 deficiency.
• WBC count of 3.8 x 10^3/μL indicates mild leukopenia, which is consistent with B12 deficiency.

Vitamin B12 is essential for red blood cell production and nervous system function. In Crohn’s disease, particularly with ileal involvement or bowel resections, B12 malabsorption is common.

Why not the other options?
• a. Prednisolone: While steroids are used to manage flare-ups of Crohn’s disease, they do not address the underlying B12 deficiency and would not help resolve the patient’s current symptoms.
• c. Iron sulfate: While this is used for iron deficiency anemia, the patient’s symptoms and blood findings are more consistent with megaloblastic anemia (due to B12 deficiency) rather than iron deficiency.
• d. Immunotherapy: This is not relevant for vitamin B12 deficiency or for treating the current symptoms, which are due to a nutritional deficiency rather than active inflammation or immune-mediated disease.

Next Steps:
• Cyanocobalamin (B12) should be administered, typically through intramuscular injection or oral supplementation, depending on the severity of deficiency and the patient’s ability to absorb it.
• Follow-up with monitoring of B12 levels and neurological symptoms to assess response to treatment.
• If the patient has had intestinal surgery or malabsorption, long-term supplementation may be necessary.

Question 24

A 48-year-old female patient was admitted to a
medical ICU with the diagnosis of NYHA Class-IV
Stage-C CHF secondary to chronic rheumatic
valvular heart disease. The physicians and nurses in
the ICU were unable to secure IV line. Where is the
most appropriate site for IV access in the patient?
a. Saphenous vein cut down
• b. Intraouseus route
• c. Scalp vein
• d. Jugular vein cut down
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Answer 24

The most appropriate site for IV access in this patient is:

d. Jugular vein cut down

Explanation:

In critically ill patients, especially those with severe heart failure (NYHA Class-IV Stage-C CHF), IV access may be difficult due to peripheral venous collapse or difficulty in securing a peripheral line. When standard IV access is not possible, more central veins or alternative access methods are considered. The jugular vein is an appropriate choice for central venous access because:
• It is a large, easily accessible vein with relatively predictable anatomy.
• The cut down technique involves making a small incision over the vein to gain direct access, which is useful when standard venous access techniques (e.g., peripheral IV or central venous catheter placement) fail.

Why not the other options?
• a. Saphenous vein cut down: The saphenous vein is typically used for lower extremity access in emergency situations, but it is not commonly the first choice for central access in critically ill patients due to the difficulty of performing a cut down and the potential for complications.
• b. Intraosseous route: The intraosseous route is used for emergency access in pediatric or adult patients when no other options are available (e.g., in cases of trauma or cardiac arrest), but it is generally considered a last resort, and not the best first-line option for this scenario.
• c. Scalp vein: Scalp veins are typically used in infants or small children for IV access. In an adult patient, the jugular vein would be a more appropriate choice for central venous access.

Next Steps:
• Once access is achieved (e.g., via the jugular vein cut down), ensure appropriate monitoring and management of the patient’s CHF symptoms, including diuretics, inotropes, and other supportive measures.
• Consider the need for longer-term access (e.g., for medications or nutrition) and choose the best approach based on the patient’s condition.

Question 25

A 49-year-old man came with one day history of
severe shortness of breath, cough and confusion.
He is a known asthmatic patient with irregular
follow-up and not adherent to medications. On
examination, his blood pressure is 140/90 mmHg,
respirations are 40/min and SPO2 is 70percent at
room air. The patient was admitted with emergency
treatment protocol. What is the best initial treatment
for this patient?
a. Long acting beta agonists
• b. Systemic steroids
• c. Short acting beta agonists
• d. Magnesium sulphate

Answer 25

The best initial treatment for this patient with severe shortness of breath, cough, and confusion, who is a known asthmatic in acute distress, is:

c. Short acting beta agonists

Explanation:

This patient is likely experiencing a severe asthma exacerbation or asthma attack, as evidenced by:
• Severe shortness of breath,
• Respiratory distress (high respiratory rate of 40/min),
• Low oxygen saturation (SpO2 of 70%), and
• Confusion, which can be a sign of hypoxia.

The first-line treatment for an acute asthma exacerbation involves the following:
• Short-acting beta agonists (SABA) (e.g., albuterol), which are bronchodilators that rapidly relieve bronchospasm and improve airflow. They work quickly to dilate the airways and relieve symptoms of wheezing, shortness of breath, and cough.

Why not the other options?
• a. Long acting beta agonists (LABAs): LABAs are used for maintenance therapy in asthma and are not suitable for acute exacerbations. They take longer to act and do not provide rapid relief in emergency situations.
• b. Systemic steroids: Systemic steroids (e.g., prednisone) are often used in moderate to severe asthma exacerbations to reduce airway inflammation, but they are not the first step in treatment. They are typically used after the initial relief of bronchospasm with SABA therapy.
• d. Magnesium sulfate: Magnesium sulfate may be used in cases of severe asthma exacerbations if the patient does not respond to initial treatments, as it can help relax the smooth muscle of the airways. However, it is not the first-line therapy and would typically be considered after SABA and steroids.

Initial Treatment Sequence:
1. Administer short-acting beta agonists (SABA) via nebulizer or inhaler to rapidly relieve bronchospasm.
2. Systemic steroids should be started shortly after to reduce inflammation.
3. Consider additional treatments like magnesium sulfate if the patient does not respond adequately to the initial therapies.

Key Takeaway:

The best initial treatment for acute asthma exacerbation involves short-acting beta agonists (SABA) to relieve bronchospasm, followed by systemic steroids to reduce inflammation.

Question 26

A 50-year-old female patient presents with a
complaint of cough of two years duration. The
cough is productive of small tenacious whitish
sputum that is present in most days of the week.
She also complains of occasional chest tightness,
exertional dyspnea, fatigue and loss of appetite of
same duration. She has no history of cigarette
smoking. She uses wood for cooking. Physical
examination shows scattered wheezing over chest
fields. Chest x-ray shows hyper inflated lungs with
flattening of diaphragm. What is the most likely
diagnosis of this patient?
• a. Bronchiectasis
• b. COPD
• c. Obliterative bronchiolitis
• d. Bronchial asthma

Answer 26

The most likely diagnosis for this patient is:

b. COPD (Chronic Obstructive Pulmonary Disease)

Explanation:

This patient presents with symptoms that are highly suggestive of COPD, particularly:
• Chronic cough: The patient has a productive cough of two years duration with tenacious whitish sputum, which is characteristic of the chronic bronchitis component of COPD.
• Exertional dyspnea and fatigue: These are common symptoms of COPD as airflow limitation progressively worsens.
• Chest tightness: This can also occur in COPD, particularly in the presence of bronchospasm.
• History of wood smoke exposure: This is a significant risk factor for COPD, especially in individuals who do not smoke but are exposed to indoor air pollution from cooking with wood or biomass fuels.

Additionally, the chest x-ray showing hyperinflated lungs and flattening of the diaphragm further supports the diagnosis of COPD, particularly the emphysema component, which is common in advanced stages.

Why not the other options?
• a. Bronchiectasis: This condition typically presents with a persistent cough and copious sputum production, often with a history of recurrent respiratory infections. However, bronchiectasis is less likely in the absence of a history of infections or significant inflammation causing airway dilation.
• c. Obliterative bronchiolitis: This is a rare form of small airway disease that is associated with exposure to inhaled toxic agents or organ transplantation. It is less likely in this case because the patient’s symptoms and chest x-ray findings are more consistent with COPD.
• d. Bronchial asthma: Although asthma can present with wheezing and cough, it typically occurs in younger individuals, with a history of episodic symptoms and reversible airway obstruction. This patient has chronic symptoms lasting for two years, making asthma less likely. The absence of a clear pattern of asthma triggers and the physical exam and radiologic findings are more consistent with COPD.

Key Takeaway:

Given the patient’s chronic cough, exertional dyspnea, history of wood smoke exposure, and chest x-ray findings of hyperinflated lungs, COPD (likely a combination of chronic bronchitis and emphysema) is the most likely diagnosis.

Question 27

A 54-year-old man came to a hospital with a
compliant of vomiting of coffee ground matter of
five hours duration. He has long standing epigastric
pain, easy fatigability and dark tarry stool. At
presentation, his blood pressure is 85/60mmHg and
pulse rate is 120/min. His abdominal examination
did not reveal remarkable finding. His laboratory
findings show WBC count of 4.3X103/mm3, platelet
count of 178x103 and hemoglobin level of 7g/dl.
What is the most appropriate initial management for
the patient?
• a. Resuscitate and prepare for emergency
laparatomy
• b. Secure IV line and send for upper GI
endoscopy immediately
• c. Resuscitate with double IV line and prepare
cross matched blood
• d. Put him on maintenance fluid and do NG

Answer 27

The most appropriate initial management for this patient is:

c. Resuscitate with double IV line and prepare cross-matched blood

Explanation:

This patient presents with signs of gastrointestinal (GI) bleeding, which is supported by:
• Vomiting of coffee ground matter (suggestive of upper GI bleeding),
• Dark tarry stool (indicating melena, which typically occurs due to digested blood from the upper GI tract),
• Low hemoglobin level (7 g/dL, indicating significant blood loss),
• Hypotension (85/60 mmHg) and tachycardia (120/min), which suggest hypovolemic shock due to blood loss.

The most critical initial steps are:
1. Resuscitation: The patient needs immediate volume resuscitation to stabilize his blood pressure and improve tissue perfusion. This can be achieved by administering IV fluids (normal saline or Ringer’s lactate) and cross-matched blood if needed.
2. Secure IV access: Double IV lines should be established to ensure that there is adequate access for fluid resuscitation and blood transfusion if necessary.
3. Prepare for potential blood transfusion: Given the low hemoglobin and clinical signs of shock, blood transfusion may be required. Cross-matched blood should be prepared in case transfusion becomes necessary.

After initial resuscitation, the patient should be evaluated further for the source of bleeding, likely through upper GI endoscopy, but this is not the first step in management. The priority is to stabilize the patient before diagnostic procedures.

Why not the other options?
• a. Resuscitate and prepare for emergency laparotomy: While this may be needed if the bleeding is from a surgical cause (like perforation or massive hemorrhage that requires surgical intervention), it is not the first-line approach in this scenario. The priority is stabilization, and an emergency laparotomy is typically not the initial step unless there is a clear surgical emergency.
• b. Secure IV line and send for upper GI endoscopy immediately: While upper GI endoscopy is important to identify the source of bleeding, it should not be done immediately before resuscitation. The patient is in hypovolemic shock, and the first priority is to stabilize the patient with IV fluids and blood transfusion, if necessary, before any diagnostic procedures.
• d. Put him on maintenance fluid and do NG: Nasogastric (NG) tube placement can be helpful in assessing the volume and type of bleeding (e.g., presence of blood), but the priority here is aggressive resuscitation and stabilization. Maintenance fluids are not sufficient in this setting, as the patient needs immediate resuscitation with large volumes of IV fluids and potential blood transfusion.

Key Takeaway:

For a patient with upper GI bleeding and hypovolemic shock, the immediate priority is to resuscitate with IV fluids, establish double IV access, and prepare for blood transfusion if necessary. Diagnostic procedures, like upper GI endoscopy, should follow after the patient is stabilized.

Question 28

A 55-year-old diabetic patient was brought to a
medical emergency OPD after sudden loss of
consciousness while he was on bed two days ago.
On evaluation; his temperature was 36.0 degree
centigrade, pulse rate was 77/min, respirations were
23/min, and blood pressure was 160/100mmHg. On
neurologic examination, the power on the left upper
and lower extremity was 0/5 and GCS was 15/15.
What is the most appropriate next step in the
patient’s care?
• a. Do brain CT
• b. Do brain MRI
• c. Start Atrovastatin
• d. Start Asprin

Answer 28

The most appropriate next step in the patient’s care is:

a. Do brain CT

Explanation:

The patient has a sudden loss of consciousness and a neurologic deficit (left-sided weakness with 0/5 power on the left upper and lower extremities), which raises concern for an acute cerebrovascular event, such as a stroke.

Given that the patient has:
• A history of diabetes (which is a risk factor for stroke),
• Sudden loss of consciousness,
• Unilateral weakness (hemiparesis), and
• Elevated blood pressure (160/100 mmHg, which may be indicative of an ischemic or hemorrhagic stroke),

It is crucial to rapidly assess the type of stroke (ischemic or hemorrhagic) to determine the appropriate treatment.

Brain CT:
• CT of the brain is the initial imaging modality of choice in the acute setting (within the first few hours) because it can quickly distinguish between ischemic and hemorrhagic stroke. A CT scan is more readily available and faster than MRI in the emergency setting.
• In hemorrhagic stroke, a CT scan will quickly reveal bleeding, whereas, in ischemic stroke, it may take several hours for changes to appear, but it is still useful to rule out hemorrhage.

Why not the other options?
• b. Do brain MRI: While MRI is superior in detecting ischemic strokes, especially in the early stages, it is not the first-line test in the emergency setting. CT is quicker and more readily available, making it the preferred initial imaging study.
• c. Start Atorvastatin: While statins like atorvastatin may be beneficial in the long-term management of cardiovascular risk and prevention of further strokes, they are not the first intervention for a patient with acute stroke. Immediate evaluation with brain imaging is the priority.
• d. Start Aspirin: Aspirin is commonly used for ischemic stroke to prevent further clot formation, but it should not be given in the case of a hemorrhagic stroke, as it can worsen bleeding. The first step is to determine the type of stroke using brain CT before initiating antiplatelet therapy.

Key Takeaway:

In a patient with a suspected acute stroke, brain CT is the most appropriate initial step to determine the presence of hemorrhagic stroke or ischemic stroke. Only after determining the type of stroke can appropriate treatment, including medications like aspirin or interventions like thrombolysis, be considered.

Question 29

A 55-year-old female patient came to an emergency
OPD with complaints of shortness of breath and
right side chest pain of two days duration. Her
temperature is 36.8 degree centigrade, respirations
are 28/min, pulse rate is 104/min, and blood
pressure is 80/50 mmHg. Cardio-respiratory
examination shows that the lower posterior chest is
dull to percussion and JVP is raised. CT angiography
shows pulmonary artery thrombosis. What is the
most effective management of this patient?
O a. IV fibrinolytic therapy
• b. Systemic glucocorticoids
• c. High dose Furosemide
• d. Oral anti-platelet

Answer 29

The most effective management for this patient is:

a. IV fibrinolytic therapy

Explanation:

The patient’s presentation with:
• Shortness of breath,
• Right-sided chest pain,
• Hypotension (80/50 mmHg),
• Raised JVP (jugular venous pressure),
• Dullness to percussion (which may suggest pleural effusion),
• And a CT angiography showing pulmonary artery thrombosis, indicates a diagnosis of massive pulmonary embolism (PE).

In massive pulmonary embolism, there is a high-risk for cardiovascular collapse, and the primary treatment goal is to rapidly resolve the obstruction in the pulmonary vasculature to restore normal circulation and prevent hemodynamic collapse.

Management of Massive Pulmonary Embolism:
• IV fibrinolytic therapy (also called thrombolytics, e.g., alteplase) is the first-line treatment for massive PE with hemodynamic instability (i.e., shock or hypotension). Fibrinolytics help dissolve the clot rapidly, improving pulmonary circulation and hemodynamics.

Why not the other options?
• b. Systemic glucocorticoids: While glucocorticoids can be used for inflammatory conditions (such as asthma or autoimmune disorders), they have no role in managing pulmonary embolism. PE is a thrombotic event, not an inflammatory condition requiring steroids.
• c. High-dose Furosemide: Although furosemide (a loop diuretic) can be used to manage fluid overload and symptoms of heart failure or pulmonary edema, it does not address the underlying cause of pulmonary embolism, which is a clot in the pulmonary arteries. Furosemide would not be effective in managing the acute thromboembolic event.
• d. Oral anti-platelet: While antiplatelet drugs (like aspirin) are useful for prevention of thrombotic events (such as myocardial infarction), they are not effective in treating acute pulmonary embolism. Pulmonary embolism is primarily treated with anticoagulation (such as heparin), and in cases of massive PE, fibrinolytics are the most appropriate therapy.

Key Takeaway:

For a patient with massive pulmonary embolism with hemodynamic instability (hypotension, raised JVP, tachypnea), the most effective treatment is IV fibrinolytic therapy to rapidly dissolve the thrombus and restore circulation.

Question 30

A 62-year-old man, who is a known HIV patient on
AZT/3TC/EFV for the last two years with a good
drug adherence, came to an adult OPD with
complaints of headache and recurrent seizure of
three weeks duration. Previously he was
asymptomatic. His CD4 count was 400/microlitre
six months back and currently it is 100/microlitre.
What is the most likely explanation for his current
problem?
• a. Acute stroke
• b. Treatment failure
• c. Drug side effects
d. IRIS

Answer 30

B

Question 31

A 65-year-old, a known DM patient on metformin for
last six years, presented with complaint of facial
swelling for the last six weeks. He was diagnosed
with Diabetic retinopathy before. Vital signs are in
the normal range except his blood pressure is
150/95mmHg. He had periorbital and leg edema. On
investigation, urinalysis albumin +4 blood +1, Cr-
2.5mg/dl, 24 hour urine protein of 3.2g and HgA1c
8percent. What is the most appropriate
management of this patient?
• a. Start on Furosemide
• b. Start on steroid
• c. Start on antibiotic
O d. Start on Enalapril

Answer 31

The answer is ACE inhibitor
In this patient, with periorbital and leg edema and a serum creatinine of 2.5 mg/dL, there may be signs of fluid overload, which can be seen in the context of diabetic nephropathy with renal impairment. Fluid overload can result from the kidneys’ reduced ability to excrete excess fluid, leading to edema and potential heart failure if left untreated.

Management of Fluid Overload:

The treatment of fluid overload includes:
1. Diuretics:
• Furosemide (a loop diuretic) is commonly used to treat fluid overload and edema. It helps the kidneys eliminate excess sodium and water. In patients with renal impairment, the dose may need to be adjusted carefully.
• Thiazide diuretics (e.g., Hydrochlorothiazide) may be used as adjuncts in combination with loop diuretics if necessary, especially if there is significant fluid retention.
2. Fluid Restriction:
• In some cases, especially with severe fluid overload, fluid intake may need to be restricted to prevent further accumulation of fluids.
3. ACE Inhibitors or ARBs:
• While these agents (e.g., Enalapril) are primarily used to reduce proteinuria and control blood pressure, they may also have a mild diuretic effect, but they are not a substitute for specific diuretics.
4. Electrolyte Monitoring:
• It’s important to closely monitor serum electrolytes (especially potassium levels) when using diuretics, as they can lead to imbalances like hypokalemia (from furosemide) or hyperkalemia (if ACE inhibitors are used in combination with other medications).

Initial Management:

Given the patient’s edema and renal impairment, initial management should focus on fluid removal while also addressing the underlying diabetic nephropathy. The patient can be managed with:
1. Furosemide (loop diuretic): This would help to manage fluid overload and reduce edema.
2. Enalapril (ACE inhibitor): For proteinuria, blood pressure control, and nephroprotection.
3. Close monitoring of renal function and electrolytes: Since the patient has renal impairment, monitoring renal function (creatinine, BUN) and electrolytes is crucial during diuretic therapy.

In summary, while Enalapril is important for managing the underlying nephropathy and proteinuria, furosemide would be the first-line therapy to address the fluid overload in this patient.

Question 32

A nurse working at a hospital sustained needle stick
injury while carrying order for the patient with
chronic liver disease with positive for hepatitis B
surface antigen. The nurse had no history of liver
disease and serology for hepatitis B is negative.
What is the best management for this scenario?
• a. Do anti-HBs level and treat accordingly
• b. Reassurance and no treatment
• c. Give single dose of HBIG and single dose of
HBV vaccine
• d. Give single dose of HBIG and full course of
HBV vaccine

Answer 32

The best management for this scenario is:

d. Give single dose of HBIG and full course of HBV vaccine.

This is the recommended post-exposure prophylaxis for a healthcare worker who has sustained a needlestick injury from a patient who is positive for hepatitis B surface antigen (HBsAg) and has a negative hepatitis B serology (i.e., the nurse is not immune).

Rationale:
• Hepatitis B Immunoglobulin (HBIG): A single dose of HBIG provides immediate passive immunity to protect against potential infection from the needlestick injury.
• HBV Vaccination: The nurse should also receive a full course of the hepatitis B vaccine (usually 3 doses over 6 months) as active immunization to ensure long-term protection. Even though the nurse’s baseline serology is negative, the vaccination will help in case of any future exposures.

The combination of HBIG and HBV vaccine is the standard and most effective approach for post-exposure prophylaxis in this situation.

Question 33

A five-year-old male child is brought to a hospital
with complaints of failure to use his left hip joint and
pain of 10 days duration. Physical examination
elicited a temperature of 38.9 degree centigrade,
pulse rate of 112/min and slightly swollen right hip
joint. He had also tender and restricted passive and
active movements. The X-ray and ultrasound
findings are normal. What is the most appropriate
initial step in the management of this child?
O a. IV antibiotics and open joint biopsy
• b. IV antibiotics and follow change with ESR
• c. IV antibiotics and joint fluid gram stain and
c u l t u r e
• d. IV antibiotics and do CRP

Answer 33

Stg -cloxacilin +culture so C

Question 34

A known diabetic patient for the last 15 years came
to a regular OPD with the complaint of left calf pain
of two months duration. The pain was aggravated
during walking and relieved during rest. What is the
most likely diagnosis of the patient?
• a. Diabetic neuropathy
• b. Deep vein thrombosis
• c. Varicose vein
• d. Peripheral arterial disease

Answer 34

The most likely diagnosis for this patient is:

d. Peripheral arterial disease (PAD)

Rationale:
• Peripheral arterial disease (PAD) is a common complication of diabetes and typically presents with claudication (pain in the calf or thigh that is exacerbated by walking and relieved by rest). The pain is due to reduced blood flow to the muscles during activity, causing ischemia.

Why the other options are less likely:
• a. Diabetic neuropathy: This typically causes numbness, tingling, or burning pain in the feet and lower legs, not intermittent pain with exertion.
• b. Deep vein thrombosis (DVT): DVT usually presents with swelling, redness, and tenderness in the affected leg, not pain specifically related to walking and rest.
• c. Varicose veins: Varicose veins can cause aching or heavy feeling in the legs, but they are not typically associated with pain that is relieved by rest during walking, as in PAD.

Thus, the pattern of pain aggravated by walking and relieved by rest is characteristic of Peripheral arterial disease.

Question 35

A physician was evaluating a CLD patient who is on
propranolol and has had endoscopic band ligation
one month back for primary prophylaxis of variceal
bleeding. His blood pressure is 100/60mmHg and
pulse rate is 92/min. On laboratory investigation,
Hemoglobin level is 12.5g/dl and platelet count is
135,000/mm3. What clinical parameter is needed to
optimize the propranolol dose?
a. Platelet count
b. Hemoglobin
c. Pulse rate
• d. Blood pressure

Answer 35

The correct answer is c. Pulse rate.

Rationale:

Propranolol is a non-selective beta-blocker that is commonly used in patients with chronic liver disease (CLD) and varices for primary prophylaxis of variceal bleeding. The goal of propranolol therapy is to reduce portal pressure by decreasing the heart rate and reducing cardiac output.
• Pulse rate is the most important clinical parameter to monitor when adjusting the propranolol dose. The target heart rate for propranolol therapy is typically between 55-60 beats per minute (bpm), as this has been shown to be effective in reducing the risk of variceal bleeding without causing excessive side effects.

Why the other options are less relevant:
• Platelet count: While platelet count is an important marker for liver function and bleeding risk, it does not directly guide propranolol dosing.
• Hemoglobin: This is important for evaluating anemia or bleeding, but it does not directly influence the dosing of propranolol.
• Blood pressure: While hypotension could be a concern with beta-blockers, the dose of propranolol is primarily titrated based on the heart rate. Blood pressure should be monitored but is not the primary parameter for optimizing the propranolol dose in this case.

Thus, pulse rate is the key clinical parameter for titrating the propranolol dose.

Question 36

A 56-year-old male patient came t o ART clinic with complaints of productive cough, night sweat and loss of appetite.
He had been taking HAART (TDF + 3TC + DTG) for the past two years. On examination, he has erythematous tongue.
Ait entry has decreased in left posterior chest. On investigation, the viral load is 2400 copies/ml, What is the most
appropriate next step in the management of this patient?
e s t i o n
© a. Repeat viral load after a month
• b. Switch to 2nd or 3rd line ART regimen
Enhanced adherence support for 3 months
• d. Discontinue HAART

Answer 36

The most appropriate next step is:

c. Enhanced adherence support for 3 months

Explanation:

This patient on HAART (TDF + 3TC + DTG) presents with symptoms suggestive of opportunistic infection (productive cough, night sweats, loss of appetite) and has a detectable viral load of 2400 copies/mL, indicating possible virological failure or suboptimal adherence. However, switching the regimen immediately is not recommended without addressing adherence first.
1. Viral load threshold:
• A viral load >200 copies/mL suggests poor control, and the first step is to evaluate and improve adherence to therapy.
2. Enhanced adherence support:
• Patients with detectable viral loads should undergo enhanced adherence counseling for at least 3 months.
• Adherence issues are a common cause of virological failure, especially in patients with low-to-moderate viral load elevation like this.
3. Further steps after 3 months:
• Repeat the viral load test after adherence support.
• If the viral load remains elevated (>1000 copies/mL), evaluate for drug resistance and consider switching to a second-line or third-line regimen.

Other options:
• a. Repeat viral load after a month: Inadequate without addressing adherence, as the underlying issue may persist.
• b. Switch to 2nd or 3rd line ART regimen: Premature without confirming treatment failure after adherence support and resistance testing.
• d. Discontinue HAART: Discontinuing ART is not appropriate, as it would worsen the patient’s condition and increase the risk of opportunistic infections.

Additional considerations:
• Investigate for tuberculosis (TB) given the respiratory symptoms and night sweats. Sputum testing and chest imaging are recommended.
• Treat the erythematous tongue, possibly indicating oral candidiasis, with antifungal therapy.

Question 37

50-year-oid male patient has come t o a hospital with progressive dysphagia since eight months which is associated
with significant weight loss. Currently, he swallows liquids with difficulty. On examination, he is emaciated and his
vital signs are all in normal tange. Barium swallow shows distal esophageal narrowing with shouldering. What is the
most likely diagnosis?
D a . Gastro esophageel vetlux disease
Esophageal cancel
Esophagea stricture
d A c h a l a s i a

Answer 37

The most likely diagnosis is:

b. Esophageal cancer

Explanation:

The patient’s symptoms and barium swallow findings strongly suggest esophageal cancer:
1. Progressive dysphagia:
• Initially for solids and later for liquids indicates a mechanical obstruction, commonly seen in esophageal cancer.
2. Significant weight loss:
• Suggests a malignant process causing both difficulty swallowing and systemic effects.
3. Barium swallow findings:
• Distal esophageal narrowing with shouldering is a classic finding in esophageal cancer, indicating an irregular mass causing obstruction.

Other options:
• a. Gastroesophageal reflux disease (GERD):
• GERD can cause dysphagia but usually does not lead to progressive symptoms or significant weight loss.
• Barium swallow would typically show reflux, not the characteristic narrowing and shouldering.
• c. Esophageal stricture:
• Strictures from GERD or other causes (e.g., caustic injury) usually cause non-progressive dysphagia.
• Barium swallow would show a smooth narrowing without shouldering.
• d. Achalasia:
• Achalasia causes dysphagia for solids and liquids from the onset, not progressively worsening dysphagia.
• Barium swallow typically shows a bird’s beak appearance at the lower esophageal sphincter.

Next Steps:
• Perform an upper endoscopy with biopsy to confirm the diagnosis.
• Staging with CT or PET scans to evaluate the extent of the disease.

Question 38

A 55-year-old male patient, who is a known diabetic taking Metformin and Liraglutide, has come to a clinic for check
up. His blood pressure is 135/84mmHg, waist circumference is 102cm and BMI is 29kg/m2, An investigation result
shows FBS of 110mg/dl, HbA1C of 6,2 percent and LDL of 110mg/dl. What is the best cardiovascular risk reduction
m e a s u r e t o b e taken in this case?
O a. Enalapril
© b. Add Insuln
O c. Rusovastatin
C d. ASA

Answer 38

The best cardiovascular risk reduction measure to be taken in this case is:

c. Rosuvastatin

Explanation:

This patient has multiple cardiovascular risk factors, including:
1. Diabetes (even with controlled HbA1C, he remains at increased risk).
2. Hypertension (although not severely elevated).
3. Obesity (BMI 29 kg/m², waist circumference >102 cm).
4. Elevated LDL (110 mg/dL).

Why Rosuvastatin?
• LDL management is crucial: For diabetic patients, the recommended LDL target is <70 mg/dL for high-risk individuals or at least <100 mg/dL.
• Statins (e.g., Rosuvastatin or Atorvastatin) are first-line therapies to lower LDL cholesterol and significantly reduce cardiovascular events in diabetic patients.
• Rosuvastatin is particularly effective in lowering LDL and stabilizing plaques.

Other options:
• a. Enalapril: Not indicated unless the patient has hypertension >140/90 mmHg, proteinuria, or evidence of diabetic nephropathy.
• b. Add Insulin: Unnecessary, as the patient has good glycemic control with HbA1C of 6.2% on Metformin and Liraglutide.
• d. ASA (Aspirin): Recommended for secondary prevention or very high-risk patients. This patient is not yet in the secondary prevention category (no prior CV events).

Key Cardiovascular Risk Reduction Steps:
1. Start a statin (e.g., Rosuvastatin 10–20 mg daily).
2. Continue managing diabetes and weight with lifestyle changes and current medications.
3. Monitor blood pressure and glycemic control regularly.
4. Consider low-dose aspirin if future cardiovascular risk increases.

Question 39

A 25-year-old male patient came t o a medical OPD with complaints of shortness of breath, palpitation and
generalized body swelling for two weeks. Evaluation result show, temperature 36,4 degree centigrade, respiratory
rate of 28/min, pulse rate of 98/min, and blood pressure of 100/60mmHg. There is a diastolic murmur at the apex.
Echocardiography shows LVEF of 35 percent, MVA of 1.5 cm2, mitral valve leaflets are shortened and thickened. What
is the most likely underlying cause of this patient’s illness?
O a. Atherosclerosis
• b. Rheumatic heart disease
• c. Carcinoid tumour
• d. Dilated cardiomyopathy

Answer 39

The most likely underlying cause of this patient’s illness is:

b. Rheumatic heart disease

Explanation:

The patient’s presentation is consistent with mitral stenosis (MS), most likely secondary to rheumatic heart disease (RHD):
1. Key findings suggestive of mitral stenosis:
• Diastolic murmur at the apex: A classic finding in MS, caused by turbulent blood flow across a narrowed mitral valve during diastole.
• Mitral valve area (MVA) of 1.5 cm²: Indicates moderate mitral stenosis (normal MVA is 4–6 cm²).
• Thickened and shortened mitral valve leaflets: Typical echocardiographic finding in RHD-related MS.
2. Signs of heart failure:
• Left ventricular ejection fraction (LVEF) of 35% indicates systolic dysfunction, possibly due to chronic volume overload or sequelae of mitral stenosis.
• Symptoms of dyspnea, palpitation, and generalized swelling (suggesting pulmonary congestion and right-sided heart failure).
3. RHD as the most common cause of MS:
• RHD is the primary cause of mitral stenosis, especially in younger patients from regions where rheumatic fever remains prevalent.

Other options:
• a. Atherosclerosis:
• Atherosclerosis does not cause mitral valve thickening or stenosis. It is associated with coronary artery disease.
• c. Carcinoid tumor:
• Carcinoid syndrome affects right-sided heart valves (e.g., tricuspid and pulmonary valves), not the mitral valve.
• d. Dilated cardiomyopathy:
• Can cause systolic dysfunction and heart failure but does not explain the diastolic murmur, mitral valve thickening, or stenosis.

Conclusion:

The most likely cause of this patient’s mitral stenosis and subsequent heart failure is rheumatic heart disease.

Question 40

22-year-old patient, who sustained a car accident by a high speed moving car while she was crossing the road, was.
brought t o a n emergency room. Upon arrival, she was unconscious and there was significant secretion and bleeding
from the mouth as well a s an open sucking wound over left anterior chest. What is the most appropriate initial
management for this patient?
• a . Suck o u t the secretion
• b. Insert chest tube
• c. Apply three way dressing
• d. Putting her on Oxygen

Answer 40

The most appropriate initial management for this patient is:

c. Apply three-way dressing

Explanation:

The patient has a sucking chest wound, which is a type of open pneumothorax. This condition causes air to flow into the pleural cavity with each breath, leading to a collapsed lung and respiratory distress. Immediate management focuses on:
1. Sealing the sucking chest wound:
• A three-way (occlusive) dressing is applied to temporarily seal the wound. This dressing allows air to escape from the pleural cavity (preventing tension pneumothorax) while stopping further air entry.
2. Further steps after stabilization:
• Once the wound is sealed, definitive management includes placing a chest tube to re-expand the lung.

Why not the other options?
• a. Suck out the secretion:
• Clearing the airway is essential, but the priority in this case is addressing the life-threatening sucking chest wound. Suction can be done after stabilizing the chest wound.
• b. Insert chest tube:
• While a chest tube is necessary, it is not the initial step. Air entry through the wound must be controlled first with a three-way dressing.
• d. Putting her on oxygen:
• Administering oxygen is supportive but not the initial priority. The sucking chest wound must be addressed immediately to restore proper lung function.

Conclusion:

The initial priority is to control the sucking chest wound with a three-way dressing to stabilize the patient, followed by further interventions such as chest tube placement and suctioning as needed.

Question 41

A 27-year-old female patient came to a medical OPD with complaints of reddish discoloration of skin, which is
exacerbated by exposure t o sun light and arthralgia of two years duration. On examination, there is a slightly raised
erythematous rash o n her cheeks, chest and arms. Her hand joints are tender and swollen. A laboratory result shows
Hgb level of 8.1g/d), WBC count of 4.1X10,000/micro litter and platelet count of 126,000/micro litter. What is the
most specific antibody associated with this disease?
© a. Rheumatoid factor
• b. Anti-dsDNA
O c. Anti-Ro
• d. Antihistone

Answer 41

The most specific antibody associated with this disease is:

b. Anti-dsDNA

Explanation:

The patient has symptoms suggestive of systemic lupus erythematosus (SLE):
1. Key clinical features:
• Photosensitivity: Reddish discoloration of the skin exacerbated by sunlight.
• Malar rash: Raised erythematous rash on her cheeks.
• Arthralgia/arthritis: Symmetrical joint pain and swelling, commonly seen in SLE.
2. Laboratory findings:
• Anemia, leukopenia, and thrombocytopenia: Common in SLE due to autoimmune destruction or bone marrow suppression.
3. Anti-dsDNA antibody:
• Highly specific for SLE (although not the most sensitive).
• Associated with disease activity, particularly lupus nephritis.

Why not the other options?
• a. Rheumatoid factor:
• Seen in rheumatoid arthritis, not specific to SLE.
• c. Anti-Ro (SSA):
• Associated with subacute cutaneous lupus erythematosus, Sjögren’s syndrome, and neonatal lupus but is less specific for SLE.
• d. Antihistone:
• Commonly seen in drug-induced lupus, not in systemic lupus erythematosus.

Conclusion:

The presence of anti-dsDNA antibodies is the most specific finding for systemic lupus erythematosus (SLE) in this patient.