Seq Medicine - A

Khyber Medical University
MBBS 4th Professional Annual Examination 2014

Short Essay Questions (SEQ)
SUBJECT: Medicine Paper A
Area / Topic: Endocrinology (Hyperthyroid)

______
Q1:
A 32 yrs old woman presented with poor sleep, weight loss despite good appetite, intermittent
diarrhea & palpitations. She felt exhausted all the time. O/E she has moderate diffuse goiter with an
audible bruit, a tremor, resting heart rate is 120/min and irregular & Blood Pressure is 150/70mm Hg.
Her eyes were prominent. Rest of the systemic examination and baseline investigations are normal.
a. What is the most likely diagnosis with justification? (1)

b. Enlist three common causes of the endocrine abnormality? (2)
c. Three treatment options with one complication of each? (2)
Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________
Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____
Dated: ___15/01/2014
Key:
Weightage
a. Hyperthyroidism due to graves’ disease (diffuse goiter plus exopthalmos). 1
b. Graves disease, toxic multinodular goiter, toxic adenoma, thyroiditis 2
c. Anti-thyroid drugs carbimazole, surgery and radioactive iodine. 2
Dated: ___15/01/2014
Area / Topic: Endocrinology (Adernal Crsis Hypocortisolism)

______
Q2:
A previously diagnosed milliary tuberculosis patient has suddenly collapsed at home. His
relatives mentioned that he has become increasingly weak with progressively increasing
darkening of his body skin. On examination his skin is deeply pigmented. His blood pressure is
60/40. Rest of organ system examination is unremarkable. Random blood sugar is 40 mg/dl.
Serum sodium 128 mEq/l.

b. 3 common causes of the hormonal abnormality? (2)
c. Name important therapeutic interventions? (2)
Dated: ___15/01/2014
Key:
Weightage
a. Adrenal crisis (Addison’s disease with crisis) 1
b. Iatrogenic, pituitary destruction, Adrenal destruction 2
c. Fluids, dextrose, steroids replacement, ATT. 2
Note: sudden withdrawal of exogenous steroids is the most common cause of Addison’s
disease. Pituitary destruction causes hypocortisolism due decreased ACTH from
pituitary gland. Adrenal destruction (from autoimmune in west and from Tuberculosis in
developing countries, HIV as an emerging issue) causes decreased steroids production.
Dated: ___15/01/2014
Area / Topic: Indective Endocarditis

______
Q3:
50 years old obese man with BMI>35, otherwise asymptomatic, is referred to you by
general practitioner for his persistently raised BP. He is smoker for last 20years, diabetic
(diagnosed 2years back) and is on metformin. His father and elder brother died of myocardial
infarction. Baseline investigations show RBS=280mg/dl, total cholesterol=300mg/dl, normal
RFTs and urine R/E.
a. Write three non-pharmacological treatment options in this particular case. (1)

b. Enlist four causes of secondary hypertension. (2)
c. 4 investigations for secondary hypertension. (2)
Dated: ___15/01/2014
Key:
Weightage
a. Smoking cessation, weight loss, salt restriction, aerobic exercises 1
b. Renal artery stenosis, polycystic kidney disease, coarctation of aorta, drugs 2
Cushing syndrome, Conn’s syndrome, thyrotoxicosis, pheochromocytoma,
c. 24 hours urinary cortisol, Thyroid function tests, ultrasound abdomen, plasma 2

aldosterone and 24 hours urinary VMA/meta-nephrine
Dated: ___15/01/2014
Area / Topic:Endocrinology (Adernal Crsis Hypocortisolism)

______
Q 4:
A 53 years old man Intra Venous Drug Abuser presented with high grade fever,
breathlessness and petechiae over body. On Examination patient has toxic look, febrile (102
F), systolic murmur over mitral area, painful nodules on finger, painless lesions on palms and
retinal hemorrhages on fundoscopy. Investigations show increased ESR, CRP, neutrophilic
leukocytosis and hematuria on urine R/E.
a. What is your most likely diagnosis & why? (1)

b. Enlist two investigations with rationale. (2)
c. Outline treatment plan for this patient. (2)
Dated: ___15/01/2014
Key:
Weightage
a. Infective endocarditis with mitral regurgitation 1
b. Blood cultures, echo (transthoracic, transesophageal) 2

c. Bed rest, antipyretics, empirical antibiotics after samples taken 2
Note: take blood samples for culture, start patient on empirical antibiotics (usually benzyl
penicillin plus gentamycin OR vancomycin plus gentamycin) and later changed according to
blood culture sensitivity reports for 4-6 weeks.
Dated: ___15/01/2014
Area/Topic: ______________________
Q5:
A 65 Years old man presented to emergency department with severe substernal

chest pain lasting for MORE than 40 minutes (not relieved by rest and nitroglycerine), profuse
sweating and pallor. Patient is smoker for last 30 years, diabetic and hypertensive (on
metformin and nefidipine) for last 20years. Labs show RBS=245mg/dl, LDL=368mg/dl and
TLC=30000 (mostly neutrophils).
a. What is your most likely diagnosis with justification? (1)

b. Write two specific and two supportive investigations? (2)
c. Outline treatment plan for this patient in hospital. (2)
Dated: ___15/01/2014
Key:
Weightage
a. Acute myocardial infarction (typical symptoms, 6 major risk factors) 1
b. ECG and cardiac markers. Echo and chest X-ray for cardiac functions 2
c. CCU care, Morphine, nitroglycerine, antiplatelet drugs for all patients.STEMI: 2
reperfusion therapy indicated (emergency PCI vs thrombolytics) NON-STEMI:
anticoagulation plus risk assessment (to plan for elective angiography and
angioplasty if high risk)
Dated: ___15/01/2014
Area/Topic: ______________________
Q 6:
A 42 yrs old female presented with 6 months history of worsening

headache with deteriorating vision in both eyes and polyuria. She is taking treatment for
carpel tunnel syndrome. She has consulted her physician for menstrual irregularities and
galactorrhea. She admitted rapid increase in the size of shoes and tight finger rings. Her BP
was 190/110 mmHg and pulse was 82/min. Her voice was husky and defects in the temporal
fields in both eyes with mild optic atrophy. Broadening of the nose and supra orbital ridges
with larger hands noticed.
1. What is the most likely Diagnosis with justification? (1)

2. Name three Investigations with expected findings? (2)
3. Name three treatment options for this woman. (2)
Dated: ___15/01/2014
Key:
Weightage
a. Acromegaly (typical features with S/S of raised intracranial pressure) 1
b. IGF (screening), oral glucose tolerance (confirmatory), MRI Pituitary 2
c. Surgery (main treatment option). Drugs and radiations (adjunctive) 2
Dated: ___15/01/2014
Area/Topic: ______________________
Q 7:
28 years old married lady has three children. She presented to the medical OPD with the
complaints of progressive headache, weight gain and depression. Examination revealed that she is
overweight, BP is 190/100 mmHg. Her skin is thin and there are bruises on the arms and legs.
Recently she was examined by ophthalmologist who found that she had bitemporal hemianopia.
The random blood sugar is 250mg%.

b. Write three causes of the hormonal abnormality? (2)
c. Four tests with rationale to confirm the diagnosis? (2)
Dated: ___15/01/2014
Key:
Weightage
a. Cushing disease: hypercortisolism features with increased intracranial pressure 1
b. Iatrogenic, adrenal neoplasms, ACTH secreting neoplasms (pituitary and ectopic) 2
c. Low dose DM suppression test (screening). 24 hours urinary cortisol 2

(confirmatory)
Serum ACTH (differentiation), high dose DM suppression, radiological tests
(Pituitary MRI, adrenal CT scan)
Dated: ___15/01/2014
Area/Topic: ______________________
Q 8:
A 28 years young man presents with on/off history of fever, sore throat, increasing
fatigability, bone pains and recently he has epistaxis and gum bleeds .O/E he looks pale, toxic, febrile
and has generalized purpuric spots on the skin, enlarged lymph nodes in the neck and enlarged
spleen. Investigations show Hb 9 gm%, TLC 78000/mm3 with 50% Blasts, platelet count 35000/mm3.
Blood urea, serum creatinine, LFTs are normal and Serial MP Smears are reported negative.
a. What is the diagnosis with justification? (1)

b. Further investigations with justification? (2)
c. Write four drugs used for chemotherapy. (2)
Dated: ___15/01/2014
Key:
Weightage
a. Acute leukemia (pancytopenia, bones infiltration, blasts on smear) 1
b. Bone marrow biopsy, blood cultures, imaging studies, CSF analysis. 2
c. Chemotherapy (ALL mainly). BMT for relapses or bad translocations. 2

Chemotherapy remission induction, consolidation and maintenance
(Vincristine, prednisone, daunorubicine, asparaginase, methotrexate)
Dated: ___15/01/2014
Area/Topic: ______________________
Q 9:
A twenty five years old lady with three children came to the medical OPD. She complains of
weakness, lethargy and easy fatigability. She looks pale, liver, spleen and lymph nodes are not
palpable. Hb 7.6 gm%, TLC 5600/mm3, neutrophils 80%, lymphocytes 20%. MCV= 68, MCH 20,
platelets 500000//mm3.
a. a. What is the most likely diagnosis and why? (1)

b. b. Four questions in History to find out the cause? (2)
c. c. Four causes of microcytic hypochromic anemia? (2)
Dated: ___15/01/2014
Key:
Weightage
a. Microcytic Hypochromic anemia (most likely iron deficiency) 1
b. Nutritional, menorrhagia, NSAIDs, family history (thalassemia minor) 2
c. Iron deficiency, chronic disease, thalassemia, sideroblastic, lead poisoning 2
Dated: ___15/01/2014
Area/Topic: ______________________
Q 10:
A sixty years old female with history of auto immune hypothyroidism presented
with weakness. She is also complaining of tingling in her fingers & toes. On examination she is pale
and has loss of vibration and position sense in her feet. Her Hb is 9 gm/dl, TLC, DLC, platelet count,
serum folate, LFTs, RFTs and TFTs normal (taking thyroxin 200 microgram per day). There is no history
of diarrhea or any surgery in the past. Her MCV is 120.

b. Write one possible complications of the disease? (2)
c. Three investigations with rationale to confirm the Diagnosis? (3)
Dated: ___15/01/2014
Key:
Weightage
a. Pernicious anemia (anemia with neurological feature and autoimmune 1
association)
b. Increased risk of gastric carcinoma. Subacute combined degeneration of 2
spinal cord
c. Blood smear (oval macrocytes, hypersegmented neutrophils). 3

Serum homocysteine and methylmalonic acid levels increased
Serum vitamin B12 levels decreased (folate normal)
Antibodies screening for pernicious anemia
Dated: ___15/01/2014

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Khyber Medical University

MBBS 4th Professional Annual Examination 2014

Area / Topic: Endocrinology (Hyperthyroid)

a. What is the most likely diagnosis with justification? (1)

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

Area / Topic: Endocrinology (Adernal Crsis Hypocortisolism)

a. What is the most likely diagnosis with justification? (1)

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

Area / Topic: Indective Endocarditis

a. Write three non-pharmacological treatment options in this particular case. (1)

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

c. 24 hours urinary cortisol, Thyroid function tests, ultrasound abdomen, plasma 2

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

Area / Topic:Endocrinology (Adernal Crsis Hypocortisolism)

a. What is your most likely diagnosis & why? (1)

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

b. Blood cultures, echo (transthoracic, transesophageal) 2

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

A 65 Years old man presented to emergency department with severe substernal

a. What is your most likely diagnosis with justification? (1)

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

A 42 yrs old female presented with 6 months history of worsening

1. What is the most likely Diagnosis with justification? (1)

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

a. What is the most likely diagnosis with justification? (1)

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

b. Iatrogenic, adrenal neoplasms, ACTH secreting neoplasms (pituitary and ectopic) 2

c. Low dose DM suppression test (screening). 24 hours urinary cortisol 2

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

a. What is the diagnosis with justification? (1)

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

c. Chemotherapy (ALL mainly). BMT for relapses or bad translocations. 2

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

a. a. What is the most likely diagnosis and why? (1)

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

a. What is the most likely diagnosis with justification? (1)

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

c. Blood smear (oval macrocytes, hypersegmented neutrophils). 3

Name: ____ AP. Dr. Muhammad Adnan Bashir Signature: ________________________

Department: _____Medicine Paper A Institute: _Jinnah Medical College Peshawar ____

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________

Name: AP. Dr. Muhammad Adnan Bashir Signature: ____________________