Medicine I - Topical Past Papers (2007-2019)

MEDICINE I – PAST QUESTIONS
(2007-2019)
(Compiled by Shahroze Ahmed, N-66,
Nishtar Medical University)
CONTENTS
SR # Unit Page #
1 Respiratory Medicine 2
2 Cardiovascular Medicine 9
3 Neurology 19
4 Stroke Medicine 23
5 Gastroenterology 25
6 Hepatology 34
7 Hematology 40
8 Rheumatology 45
1
▪ RESPIRATORY MEDICINE
Asthma
1. A 26-year-old male presents with complaints of shortness of breath and dry cough
for 2 weeks which is gradually worsening. He admits to have similar episodes every
year in spring. His father has history of atopic dermatitis. There is bilateral wheezing
in chest.
a) What is the diagnosis?
b) How will you diagnose this condition?
c) Give four treatment options to treat this patient. [Supple 2014 held in 2015]
2. An 18-year-old girl presents to emergency department with unproductive cough,

wheezy dyspnea and two previous sleepless nights. On examination, temperature is
100 F, pulse 100/min, regular and blood pressure is 125/80 mm Hg. She is mildly
cyanosed. Trachea is central. Percussion note is resonant and equal on both sides of
chest. Breath sounds are vesicular with prolonged expiration, scattered bronchi and
few crepitations on both sides. Rest of examination is normal.
a) What is the clinical diagnosis?
b) Give four investigations you would like to carry out.
c) Give brief outline of management.
d) What is the diagnostic criterion? [Annual 2011]
3. You have received a patient with known diagnosis of bronchial asthma. For the last 3
days he has been having extremely severe dyspnea. O/E he has central cyanosis and
is drowsy.
a) Name the most important test to determine the prognosis and treatment.
b) Name three most important management steps in this state.
[Supple 2008 held in 2009]
4. A middle-aged known asthmatic lady has presented with worsening attack of chest
wheeze along with increasing shortness of breath. She has been admitted to the
hospital atleast thrice in the past 3 months requiring in hospital care for 8-10 days
each. On examination, she has increased rate of respiration 35/min with active
accessory muscles of respiration, her pulse rate is 110/min and BP is 90/70 mm Hg
with a paradox of 30 mm Hg. Her FEV1/FVC is 40 and PEFR is less than 50% for her
age and height. On ABG analysis, her arterial blood oxygen on room air is 87% with a
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PaO2 of 55 mm Hg and PaCO2 of 44 mm Hg. Her blood count is normal and chest X-
ray shows hyperinflated lungs with normal markings.
b) Outline the steps of management for this patient. [Annual 2007]
COPD
1. A 60-year-old male with progressive shortness of breath and cough with
expectoration for last 6 months presented with increased symptoms, deterioration
of health status and lung function. He is smoker, febrile with blood pressure 130/85
mm Hg, pulse is 110.mini and respiratory rate is 30/min.
a) What is your diagnosis?
b) Name three triggering factors for his condition.
c) Enlist the steeps of management. [Annual 2017]
2. A 60-year-old heavy smoker for last 20 years presented to Emergency Room with
severe dyspnea, wheeze, central cyanosis and fever. Patient had past history of
tuberculosis with pleural effusion on right side, which was treated with
antituberculosis therapy, with no residual effect. Examination revealed central
cyanosis. His blood pressure was 150/90 mm Hg and breathing rate was 30
breaths/min. Chest examination revealed bilateral crepitations and wheeze.
a) Enumerate four essential investigations required in the management of this
patient.
b) What is the management of this patient?
c) What is the risk of giving higher concentration of oxygen to this patient?
Bronchiectasis
1. A 26-year-old laborer presented in OPD with history of fever, low appetite, easy
fatigability and weight loss for the past 8 weeks. He also complains of productive
cough for the last six weeks and 3 episodes of hemoptysis over the last 1 week.
There are crackles in left apical chest.
a) What is the most likely diagnosis?
b) Give two important investigations most relevant to your diagnosis.
c) How will you treat this patient? [Annual 2019]
2. A 25-year-old male presents with history of chronic cough which is productive with
occasional episodes of hemoptysis for two years. His past history is significant for
pulmonary tuberculosis when he was 10 years of age. Clinical examination reveals
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clubbing of both hands and bilateral coarse crackles. He is afebrile with ESR of 10
mm/hour.
a) What is your provisional diagnosis?
b) Write two investigations to support your diagnosis.
c) Outline the treatment options. [Annual 2016]
3. A 35-year-old male has been diagnosed as a case of pulmonary tuberculosis two

years ago. He has taken anti-tuberculous treatment for nine months. For last six
months, he is complaining of malaise, increased cough and copious sputum usually
worse in the morning brought on by change of posture. On examination, he is
tachypneic, his temperature is 101 F, pulse is 110/min and digital clubbing is present.
On auscultation, there is normal vesicular breathing with bilateral coarse
crepitations.
b) How will you confirm your diagnosis?
c) Enlist the steps of management. [Annual 2014]
4. A 40-year-old smoker presents to the OPD with cough which is productive and foul
smelling. He feels that he is able to cough out more sputum in particular posture. He
has bilateral clubbing and is febrile.
a) What is the likely diagnosis?
b) Which investigations would you advise?
c) How would you treat this patient? [Supple 2010 held in 2011]
5. A middle-aged lady has presented with repeated attacks of cough and of

breathlessness. She has been admitted to the hospital atleast thrice in the past 3
months requiring hospital care for 8-10 days each time due to purulent
expectorations ever since her childhood. On examination, she has increased
respiratory rate of 35/min with active accessory muscles of respiration. Her pulse
rate is 120/min. she has coarse crackles in the lower parts of her chest.
a) Give four specific investigations to evaluate the problem.
b) Outline the management for this patient. [Supple 2007 held in 2008]
Pneumonia
1. A 68-year-old male presents with history of fever with rigors, chest pain and purulent
sputum for last three days. He also had two episodes of hemoptysis and is confused
since morning. On examination, temperature is 104 F, pulse 120/min, BP 85/40 mm
4
Hg and R/R 36/min with bronchial breathing and coarse crepitations on left lower
chest.
a) Where this patient should be managed and why?
b) What are the four investigational markers of severity?
c) Name any four local complications of the disease if not properly treated?
2. A young male patient is referred to you from Institute of Mental Health with history
of fever, cough, productive of rusty sputum and pleuritic chest pain for last two days.
His chest radiograph shows parenchyma infiltrates.
b) What are the possible complications?
c) What are the usual organisms involved? [Supple 2017 held in 2018]
3. A 42-year-old air conditioning technician in a hotel develops high grade fever with
chills and rigors after short prodrome of aches and myalgias. On the day of
admission, he develops diarrhea and becomes mentally confused. On examination,
he is noted to have a cough with sputum production. His right chest posteriorly in
the infra-scapular area is dull on percussion and has a patch of bronchial breathing.
b) What is the drug of choice?
c) What one test would you order to confirm the etiological diagnosis?
4. A 30-year-old man, previously asymptomatic develops sudden right sided chest pain
followed by dyspnea. On examination, there is mild cyanosis and breath sounds are
diminished. On percussion, there is resonant tone on the affected side.
b) What investigations will be the most helpful to establish the diagnosis?
c) What treatment may be indicated?
d) How can this be prevented in future?
Tuberculosis
1. A 45-year-old male is admitted in the Emergency Room with persistent vomiting for
three days. He also complains of distaste of mouth and abdominal discomfort.
Physical examination revealed temperature 100 F, Pulse 110/min, BP 100/70 mm Hg,
jaundice is present. GIT examination showed tenderness in right hypochondrium. On
5
further inquiry, he reveals that he is on anti-tuberculous therapy for the last 2 weeks
for his chest problem.
a) What is the likely cause of jaundice in this patient?
b) What advice would you give him regarding his antituberculosis treatment?
c) What is DOT program? [Supple 2016 held in 2017]
2. A 40-year-old smoker presents to chest clinic with complaints of fatigue, weight loss
and fever for the last one month. He has a productive cough worse at night.
Examination reveals pulse of 110/min and BP 140/90 mm Hg. Chest examination
reveals that trachea is shifted to the left side and there is increased vocal resonance
on left apex. Bronchial breath sounds are also audible on left apex.
a) What is the most likely cause of bronchial breathing in the patient?
b) What is the likely diagnosis?
c) Name drugs you would sue to treat this patient giving one side effect of each.
3. A 25-year-old gentleman presents with symptoms of low-grade fever, cough and

pain in the right side of chest.
a) What is the possible clinical diagnosis?
b) What are the physical signs you would specifically look for on physical
examination?
c) Give a list of investigations required to make final diagnosis. [Annual 2012]
4. A 19-year-old house maid who weighs 45 kg presents with a dry irritating cough and
a low-grade fever for the last three weeks. On clinical examination, she is pale and
breathless with dullness over the right lower chest on percussion and absent breath
sounds over this dull area.
a) What are the most likely anatomical possibilities and what is the likely cause?
b) Enumerate the four most important investigations in this case.
c) Write down the prescription for this patient. [Annual 2012]
Lung Cancer
1. A fifty-year-old gentleman has been a smoker all his life. Recently his chest
symptoms of cough and sputum have worsened and he has coughed out blood-
stained sputum. In the last two weeks, he has been complaining of progressive
weakness of right arm and difficulty in speech.
a) What is the possible cause and how would you explain the development of
symptomatology?
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b) What are the physical signs to look for on neurological examination?
[Annual 2013]
2. A 55-year-old man presented with cough, fever and hemoptysis of two months
duration. He has lost 10 kg of weight. He has left smoking six months back. He had
pulmonary tuberculosis five years back which was treated with anti-tuberculous
drugs for 9 months. His chest x-ray shows an opacity in right upper zone with
blunting of right costophrenic angle.
a) Write four differential diagnoses.
b) Enumerate six investigations. [Annual 2010]
Sarcoidosis
1. A 23-year-old girl presents to Outpatient Department with complaints of gradually
progressive shortness of breath and painful nodular reddish rash over both shins.
Chest X-ray shows hilar fullness, tracheobronchial biopsy findings including large
epithelioid cells, occasional giant cells and no areas of necrosis.
a) Write down two differential diagnoses.
b) What is your treatment plan for the likely diagnosis? [Annual 2015]
Hypersensitivity Pneumonitis
1. A 35-year-old male who is fond of keeping pigeons presents with low grade fever
and dry cough for 3 months. On examination, he has clubbing and bilateral end-
inspiratory crackles and inspiratory squeaks predominantly in and around apices and
interscapular region.
b) Write down a list of proposed investigations with expected findings.
c) Write down management options. [Annual 2015]
Pulmonary Embolism
1. A 75-year gentleman sustains fracture of neck of femur and awaiting surgery in
orthopedics ward. Two days after the hospitalization he suddenly develops profuse
sweating, central chest pain and breathlessness. His pulse is 122/min, regular and his
BP is 80/50 mm Hg with cyanosis. His JVP is elevated and he has a left parasternal
heave.
a) Give three possible diagnoses.
b) What five investigations should be immediately undertaken to reach the
diagnosis.
c) Enumerate five immediate management steps. [Supple 2012 held in 2013]
7
Pulmonary Hypertension
1. A 37-year-old lady presented with progressive shortness of breath. Her cardiac
catheterization studies are as follow:
Pressure mm/Hg Saturation

RA (mean) 17 78%
RV 90/30 78%
PA 110/50 78%
LA (mean) 30 95%
LV 118/5 95%
Aorta 115/80
a) What is diagnosis?
b) Enumerate four physical signs.
c) What complications are noted from above data? [Annual 2010]
Pneumothorax
1. A 35-year-old thin male non-smoker, history of sudden onset of right sided pleuritic
chest pain and shortness of breath. On examination, BP 120/80 mm Hg, pulse
90/min, no cyanosis. Respiratory examination reveals hyper-resonant percussion
note and reduced breath sounds on right side of the chest. Trachea is central.
a) What is the most likely diagnosis and its etiology?
b) What are the others types of this illness?
c) Discuss the guidelines of managing such illness. [Annual 2018]
2. Write short note on tension pneumothorax. [Annual 2013]
Miscellaneous
1. An 18-year-old college student who weighs 49 kg develops fever, dry cough and pain
over the right lateral chest on coughing. On examination, he is febrile with an
appropriate tachycardia. He has decreased movements of the right lower chest with
dull percussion note and absent breath sounds.
a) Give two most likely possibilities.
b) Enumerate 5 most important investigations.
c) Write a prescription for this young boy.
8
2. A 25-year-old poultry farm worker presents to you with persistent cough and
episodic dyspnea. He complains of frequent attacks of runny nose. His symptoms
often worsen at night, when he wakes up coughing but is often unable to bring up
any sputum. He claims that ever so often. He becomes totally asymptomatic and is
able to play cricket on his Sunday holidays. His investigations show:
Hb 13.7 gm%, ESR 27 mm, TLC 7500/mm3, Polys 68% Lymphocyte 22% Monocytes
2% Eosinophils 8%, Pulmonary function show FEV/FVC: 0.63
How would you manage this patient? [Annual 2009]
▪ CARDIOVASCULAR MEDICINE
Risk of Cardiovascular Disease
1. A 53-year-old bank executive comes for routine checkup. He has sedentary lifestyle
and smokes on cigar daily. Although asymptomatic, he is worried about his heart
because of positive family history. He is 5.5 inches tall and weighs 85 kg, his waist
measures 42 inches and sitting BP was recorded as 150/95 after five minutes rest in
the clinic.
a) What points in the history & physical examination are relevant to the CVS risk?
b) What investigations should be done to determine his total risk of developing
cardiovascular disease?
c) What medication may be indicated to reduce the risk of CVS disease?
[Annual 2008]
Heart Failure
1. A 60-year-old diabetic female presents with gradually increasing breathlessness on
exertion. According to her, she becomes breathless while changing her clothes and
also gives history of breathlessness during sleep which improves with sitting.
a) What six clinical examination findings you will try to look for confirming your
provisional diagnosis?
b) What two drug groups must be used in this patient for improvement?
c) What are the two treatment options for patients who do not improve with
maximal lifestyle modification and drug treatment? [Supple 2019 held in 2020]
2. A 58-year-old hypertensive male presents with severe dyspnea. He gives history of

severe central chest pain occurring in the morning associated with sweating and
later followed by breathlessness. On examination, there are bilateral crepitations up
to mid-chest.
9
a) What investigations are required? Justify it.
b) How you are going to manage this patient? [Annual 2019]
3. A 50-year-old man, a known case of ischemic heart disease and Diabetes Mellitus
seen in ER with acute history of shortness of breath & profuse sweating. On
examination, his BP is 170/110 mm Hg, sinus tachycardia, rate is 120/min, his JVP is
not raised and bilateral fine crepitations are present up to mid zone of chest.
b) What investigations are required in ER?
c) Outline the management. [Supple 2016 held in 2017]
4. A 65-year-old diabetic for 35 years presents with shortness of breath and orthopnea.
He has got previous history of shortness of breath. On examination, pulse is
100/min, blood pressure is 160/100 mm Hg, respiration rate is 24/min, temperature
is 95 F, pedal edema is present. JVP is raised and fine basal crackles on the base of
both lungs are present. Apex beat is also displaced and S3 is audible on auscultation.
b) What investigations should be advised for this patient?
c) Enlist five drugs to be given in this patient. [Annual 2015]
5. A poorly controlled hypertensive patient has come with progressive dyspnea on

exertion. On examination, there is 3rd heart sound and few basal crepitations.
a) What is the most likely cause of his symptoms?
b) How will you confirm the diagnosis?
c) Name four drugs which may be useful for him. [Supple 2008 held in 2009]
6. A fifty-year-old person presents in the emergency wad with severe dyspnea. On

physical examination, his pulse is 110/min regular. Lying down BP 110/70 mm Hg. His
chest is full of fine crepitations without any wheeze. Percussion note is dull on both
bases. Heart sounds are normal except gallop without any murmur. His
investigations are as follows: Hb 13.5 gm%, Creatinine 1.1 mg/dl, Ejection fraction
30%. How would you manage this patient? [Supple 2008 held in 2009]
Angina Pectoris
1. A 50-year-old hypertensive male presents with pain behind the breastbone occurring
on exertion with radiation to the left arm. What are the three most likely diagnoses?
Name three stress tests which can be used to reach a final diagnosis.
10
2. A 50-year-old male smoker presents with pain behind the breastbone. On further
inquiry, he has radiation of pain towards the jaw and left arm with the pain occurring
only on exertion and relieved by taking rest. He has insignificant past history of any
disease and the detailed physical examination is normal.
a) What can be the six most likely causes of breastbone pain?
b) What three investigations can help in confirming the diagnosis and what lifestyle
advice will you give? [Annual 2019]
3. A 50-year-old male smoker and diabetic complaining of precordial chest pain usually
precipitated by stress or exertion and relieved by rest, lasts for 5-10 minutes seen in
OPD department for consultation.
CBC: Hb 16 gm/dl, WBC 9x10^9, Platelets 450x10^9. His resting ECG is normal.
b) What further investigations are required?
c) Enlist the various groups of pharmacological drugs used in his management and
other treatment modalities. [Annual 2018]
4. A 40-year-old female presented in A&E department with central chest pain which
would usually come at rest. It bothers her intermittently for last one year. You did an
EKG which shows ST segment elevation in precordial leads. You requested for a
cardiac enzyme panel which turned out to be normal. Meanwhile she was given
aspirin and sublingual nitroglycerin to which she responded with improvement in her
chest pain.
b) How would you confirm the diagnosis?
c) How will you treat this patient? [Supple 2017 held in 2018]
Acute Coronary Syndrome

1. A 58-year-old hypertensive male presents with severe dyspnea. He gives history of
severe central chest pain occurring in the morning associated with sweating and
later followed by breathlessness. On examination, there are bilateral crepitations up
to mid-chest.
a) What investigations are required? Justify it.
b) How you are going to manage this patient? [Annual 2019]
2. A 50-year-old male presented in the emergency with severe central constricting

chest pain radiating to left arm and lower jaw. There is associated profuse sweating.
11
His blood pressure is 90/60 mm Hg. Pulse is 90/min regular. His ECG shows ST
segment elevation in leads II, III and aVF.
b) Which coronary artery is involved?
c) What are other acute coronary syndromes?
d) Enlist the main steps of treatment. [Annual 2017]
3. A 55-year-old smoker presented to emergency room with a complain of severe

central chest pain along with sweating and vomiting. On examination, his BP is
160/100 mm Hg and the pulse is 100/min regular. His chest is clear. His father had
died a sudden death at the age of 40 years. ECG showed ST segment elevation in
leads V1-V6.
b) What are the risk factors in this patient?
c) How will you manage this patient in Emergency Room? [Annual 2016]
4. A 60-year-old jeweler develops severe retrosternal chest pain with profuse sweating
at 6 am on a cold winter morning. On presentation at 8 am in the emergency, his
pulse rate was 110/min with BP of 150/100 mm Hg and a fourth heart sound is heard
in the left parasternal area without any other significant clinical finding.
a) Give three possible diagnoses in the order of the priority.
b) What four investigations should be done immediately?
c) Enumerate four most important management steps that you will take in the 1st
hour of hospitalization. [Annual 2012]
5. A 50-year-old male known diabetic complained of pain in the epigastrium radiating

to the back along with syncopial attack. He had one episode of vomiting and gave
history of similar attack on week back as well. His pulse is 75/min, regular and good
volume. BP on admission was 160/100 mm Hg. His ECG strip show ST elevation in II,
III and aVF leads along with prolonged PR interval.
b) Outline the acute management plan of this patient. [Supple 2007 held in 2008]
6. A 58-year-old male smoker complained of pain in the epigastrium radiating to the

back accompanied by pallor and cold sweats. He had one episode of vomiting and
gave history of similar attack of pain, though of lesser duration while walking back
from his work one day. His BP on admission was 160/100 mm Hg and ECG showed ST
elevation in I, aVL, V4, V6.
12
b) Enlist the acute management of this patient.
c) Enlist four common complications of condition along with their management.
[Annual 2007]
Hypertension
1. A 45-year-old male non-smoker seen in OPD, who has been first time diagnosed as a
case of hypertension. His blood pressure 160/100 mm Hg, pulse 80/min regular, JVP
is not raised, CVS normal first and second heart sounds, no gallop, chest is normal on
percussion and auscultation. There is no family history of diabetes mellitus,
hypertension and dyslipidemia.
a) What are the various pharmacological steps in controlling his BP according to UK
hypertension guidelines?
b) If this patient is above age of 55, what will be main difference of treatment?
c) What basic routine tests are required while patient is on treatment?
[Annual 2018]
2. An 18-year-old asymptomatic cade is found to have a blood pressure of 180/110 mm

Hg on a routine medical examination. His pulse rate is 74/min, regular and has no
other significant clinical findings.
a) Give four most likely causes of hypertension.
b) Enumerate four most useful investigations in this case.
c) Give two bedside clinical signs to evaluate target organ involvement/damage in
this case. [Annual 2012]
3. Give four surgical remediable causes of hypertension.

4. A 17-year-old boy presents with BP of 190/110 mm Hg.

a) How will you investigate him for secondary hypertension?
b) Enumerate four classes of antihypertensive drugs. [Annual 2010]
5. A 35-year-old male comes to you with frequent occipital headache. Both his parents
were hypertensive and have died. O/E his BP is 170/150 mm Hg. Rest of examination
is normal.
a) Name five investigations to rule out a secondary cause.
b) Enlist lifestyle changes this patient should follow.
c) Enlist five classes of antihypertensive drugs. [Annual 2008]
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Rheumatic Fever/Rheumatic Heart Disease
1. A 15-year-old boy presented with 1 week history of sore throat followed by joint
pains mainly involving large joints in migratory sequence. His mother also noticed a
macular rash with clear center on his trunk. On examination, his pulse is 80/min
regular, BP is 110/70 mm Hg and a short mid-diastolic murmur is heard on
auscultation.
b) Enlist the criteria to diagnose this illness.
c) Outline the medical treatment. [Supple 2016 held in 2017]
2. A 14-year-old girl presented with complaints of joint pain and swelling which first
involved the left elbow and then involving the right knee joint over a period of 14
days (migratory). She also complained of slight shortness of breath on exertion.
There is history of sore throat infection 3 weeks back. Her vitals are following: Pulse
110/min, BP 110/80 mm Hg, temperature 102 F and respiratory rate 18/min. JVP is
not raised, no pedal edema is present. Auscultation reveals a soft mid-diastolic
murmur at mitral area.
b) What investigations should be advised in this case?
c) List down causes of diastolic murmur at apex. [Annual 2015]
3. A 12-year-old boy presents with complaints of joint pain with swellings in the left
elbow and then the right knee joint over a period of 10 days. He also complains of
mild breathlessness while playing. There is history of sore throat infection 3 weeks
back. His vitals are: Pulse 110/min, BP 110/80 mm Hg, Temperature 102 F,
respiratory rate 18/min. JVP is not raised. No pedal edema is present. Auscultation
reveals a soft mid-diastolic murmur at mitral area.
b) What investigations should be advised in this case?
c) Write down steps of management. [Annual 2014]
4. An 18-year-old girl presents with a history of weakness of right half of her body for 6
hours. Examination reveals irregularly irregular pulse. She has history of joint pains
and fever off and on.
b) What is the likely cause of her joint pains?
c) How can fever be prevented in the future? [Supple 2010 held in 2011]
14
5. A 12-year-old boy is brought to you with swollen and painful right knee joint. Few
days earlier he had similar swelling of the left wrist joint which is improving. Rest of
the physical examination including CNS, CVS and skin is unremarkable.
b) What criteria are applied to establish the diagnosis?
c) What may be chronic complications of this disease?
d) How can you prevent it in future? [Annual 2008]
6. A 16-year-old young girl from a village gave history of low-grade fever of four weeks
duration with weakness, breathlessness, palpitations and joint swelling. On
examination, she looks sick, has temperature 100.5 F, her pulse is 102/min, irregular,
BP 100/60 mm Hg and cardiac auscultation reveals Grade 3 diastolic murmur at
cardiac apex. She has small nodules along the extensor surface of the shin and arm
and painful tender swelling of the right and left knee joints. Chest X-ray shows
cardiomegaly.
b) How you confirm the diagnosis? [Supple 2007 held in 2008]
Mitral Valve Disease

1. A 23-year-old married female with a single child, presented in cardiology clinic with
complaints of shortness of breath. She is diagnosed case of rheumatic heart disease
and receiving prophylaxis with benzathine penicillin. She is on digoxin and diuretic
therapy. On examination, she has a pansystolic murmur at apical area radiating to
axilla.
a) What is the valvular lesion?
b) What investigations will you advise?
c) What is the treatment of choice in this patient? [Supple 2014 held in 2015]
2. A 28-year-old pregnant female in her third trimester is brought to the medical

emergency markedly short of breath and having hemoptysis. Her pulse is 102/min,
regular and small volume, BP 90/60, neck veins distended with prominent ‘a’ wave,
apex beat in left 6th intercostal space in midaxillary line, her first and second heart
sounds are prominent. There is faint long diastolic murmur increasing in intensity
towards the ed. She also has bilateral basal crackles.
a) What is the complete clinical diagnosis?
b) Give four findings likely to be seen on her chest x-ray?
c) What four treatment options are available for such a lesion?
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Aortic Valve Disease
1. A 46-year-old man with progressive dyspnea with exertion is found to have
tachycardia with a large volume pulse. Early diastolic murmur at the base of the
heart and a BP of 140/50 mm Hg.
a) What three peripheral signs will you look for in cardiovascular system/
b) What is the most likely diagnosis? [Annual 2016]
2. A 65-year-old diabetic and hypertensive male patient presents with complaints of

chest pain which occurs on exertion and is associated with feeling of shortness of
breath. Pain is relieved at rest. He also gives history of several episodes of giddiness
while working. On examination, apex beat is in 5th intercostal space in anterior
axillary line. An ejection systolic murmur of grade III is present in aortic area with
radiation towards the carotids. ECG shows left ventricular hypertrophy and cardiac
enzymes are normal.
b) Enumerate two important investigations that you will order in this patient.
c) What is the management of choice in this patient? [Annual 2013]
Infective Endocarditis
1. A 20-year-old male diagnosed as Rheumatic Heart Disease developed high grade
fever. On examination, vitals are pulse 120/min, temperature 103 F, respiratory rate
22/min and BP 130/80 mm Hg. Patient looks toxic and tachypneic. There are macular
reddish lesions on the palmer surface of the hands. Abdominal examination shows
splenomegaly. Auscultation reveals a mid-diastolic murmur in mitral area.
b) What are the investigations of choice?
c) Write down management. [Annual 2014]
2. A 16-year-old young girl from a remote village gives history of low-grade fever of 3
weeks duration with weight loss, weakness, breathlessness and palpitations. On
examination, she looks sick, has temperature of 100.5 F, her pulse is 102/min
irregular. BP 100/60 mm Hg and cardiac auscultation received grade 3 diastolic
murmur at cardiac apex. She has mild splenomegaly as well. Chest x-ray shows
straight left border only.
b) How will you confirm the diagnosis? [Supple 2013 held in 2014]
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3. A 22-year-old female who underwent an aortic wall replacement some 10 years ago
for rheumatic heart disease now presents with low grade fever for the last six weeks
which partially responds to antibiotics and antipyretics.
a) Enumerate three clinical findings that will help to reach the diagnosis.
b) Give five most relevant investigations.
c) List two most important steps in the management of this lady.
4. A 10-year-old boy has fever for last three months. He also has pain in left
hypochondrium. His examination shows a diastolic murmur in the precordium and
soft tender spleen.
a) What is the likely diagnosis and why?
b) How will you manage her? [Annual 2009]
Cardiomyopathy
1. A 20-year-old male presented with complaints of exertional chest pain and dyspnea
on walking. He has no previous history of cardiac disease. His father had a heart
condition and died. His pulse is 100/min, jerky in character, BP 100/60 mm Hg and
respiratory rate 20/min. Double apical impulse is palpable which is not displaced.
There is a short systolic murmur at base of heart and a pansystolic murmur at apical
area. S4 is also audible. Rest of systemic examination is normal.
b) What investigations will you advise?
c) Write down any two worse prognostic factors in this condition.
Pericardial Diseases
1. A 50-year-old hypertensive male patient presents with pain behind the breastbone
occurring on exertion with radiation to the left arm. After few days the patient’s pain
becomes constant which increases on bending forward and coughing. He also
develops low grade fever. On auscultation of precordium, three is systolic additional
sound. What is now the most likely diagnosis? What two medicines can be used for
the relief of pain? [Supple 2019 held in 2020]
2. A patient presented with slow onset of progressive dyspnea, fatigue and weakness.
On examination, you find mild ankle edema and soft hepatomegaly with ascites. An
echo was done which revealed pericardial constriction.
a) What is the characteristic sign in JVP?
17
b) Enumerate a few causes. [Supple 2017 held in 2018]
3. A 20-year-old boy had fever, central dull chest pain which worsened on deep
breathing and improved on leaning forward. He also had progressive dyspnea for the
last one month. There were no joint symptoms. On examination, his temperature
was 38.5 C, pulse 130/min and BP 110/70 mm Hg. Apex beat was not palpable. On
auscultation, heart sound was soft and a rough scratchy sound was audible all over
the precordium. The respiratory exam was normal. X-ray chest showed enlarged
globular shadows.
a) What is the most likely clinical diagnosis?
b) Enumerate three investigations of this patient.
c) What is the management, if patient develops raised JVP, pulsus paradoxus and
hypotension? [Supple 2015 held in 2016]
4. A 57-year-old man being managed conservatively for chronic renal failure with urea
of 245 mg/dl and creatinine of 4.5 mg/dl, develops sharp sub-sternal chest pain for
two days. He is not obviously dyspneic. His pulse is 90/min regular and of small
volume becoming even smaller during inspiration. BP 105/75 mm Hg, distended neck
veins, apex beat could not be localized and he has very faint heart sounds. Chest is
clear on auscultation.
b) What is the single most useful investigation?
c) What is required for the long-term relief of his problem? [Annual 2011]
Miscellaneous
1. A 50-year-old man was admitted with left sided chest pain of one hour duration 48
hours ago. On admission, his blood pressure was 130/80 mm Hg and CVS
examination was normal. ECG showed ST segment elevation. Myocardial Infarction
and Q waves in anterior chest lead. On 7th day of admission while going to
washroom, he developed sudden severe dyspnea. On examination, his blood
pressure was 110/80 mm Hg. Jugular Venous Pressure (JVP) was raised. On
auscultation of the heart, a new pansystolic murmur was heard over the precordium.
Chest examination revealed bilateral basal crepitations.
a) Enumerate three causes of pansystolic murmur in this patient.
b) Enumerate the steps of management of acute pulmonary edema.
18
2. Write short notes on:
a) ECG changes in acute anterior inferior myocardial infarction.
b) Use of B-blockers in medicine [Annual 2013]
3. A 14-year-old presented at OPD with fever, cough and left lower chest pain of three
days duration. Clinical examination shows temperature 100 F, pulse 100/min, BP
160/110 mm Hg. A radio-femoral delay in pulse was noted. Respiratory system
examination showed trachea central, percussion note dull and bronchial breathing at
left lower chest.
a) What is the clinical diagnosis?
b) How will you convince the parents that their boy will need operation in future?
▪ NEUROLOGY
Migraine
1. A 25-year-old lady one year history of episodic unilateral throbbing headache,
associated with nausea, vomiting and photophobia. There is a family history of
similar headaches. On examination, BP 120/80 mm Hg, pulse 80/min, no
neurological physical signs. Fundoscopy is normal. On investigations:
CBC: Hb 12.5 gm/dl, WBC 7x109, Platelets 235, ESR 20, contrast CT scan of head is
normal.
a) What is the most likely diagnosis and four precipitating factors of this type of
headache?
b) How will you manage her headache? [Annual 2018]
Trigeminal Neuralgia
1. A 50-year-old man presents to his physician with complaints of electric shock like
pain on right side of the face. It is usually triggered in the morning by shaving. Pain
does not occur at night.
b) What treatment options are available? [Supple 2006 held in 2007]
Third Nerve Palsy

1. A 46-year-old hypertensive, non-diabetic female reports to medical OPD with one
month history of pain in and around the right eye as well as the adjoining part of the
head. For the last two weeks, she is also complaining of double vision. On
19
examination, she has ptosis of the right eye along with fixed dilated right pupil.
External ocular movements in the left are normal and full while her right eye is facing
downwards and outwards and only abduction and some inward rotation (intorsion)
is possible. On shining light in the right eye, the left pupil constricts but the right fails
to constrict.
a) What is the neurological lesion?
b) What might be causing this neurological lesion?
c) What one investigation may help to confirm the diagnosis?
Epilepsy
1. Parents of 15-year-old girl brought her in emergency immediately after she had an
episode of fall while she was dressing for school and the mother observed the jerk
movements of all her body along with passage of urine. This was her second episode.
This whole episode lasted for 2-3 minutes and the girl has no memory of the event.
a) What do you call this episode?
b) What two investigations you will order initially?
c) What metabolic disorders can cause such kind of symptoms? [Annual 2019]
2. A 63-year-old female comes with history of single episode of lip smacking associated
with excessive blinking and staring in space with no response to verbal commands
from attendants. After this episode she remained drowsy for almost one hour and
then became normal. No previous history of such attacks. She is smoker and had an
attack of right-sided weakness one month back. On her previous CT scan done at
that time there is a large hypodense area on left side in middle cerebral artery
distribution territory.
a) What is the comprehensive diagnosis?
b) Will you start treatment for this episode and why?
c) If you decide to treat then what is the 1st line and 2nd line drugs for this kind of
episode. Give one name of each.
d) Name three factors in daily life which can trigger the recurrence of these
episodes. [Annual 2017]
3. A 28-year-old man gets up in the morning and embarrassed to find that he has wet
his bed during sleep. When he went to brush his teeth, he found that his tongue is
sore.
a) What is your most likely diagnosis?
b) What is your differential diagnosis?
20
c) Outline plan of management. [Annual 2007]
Parkinsonism
1. A 70-year-old man presents with a stepwise loss of intellectual function. Prior
episode had been associated with unilateral weakness and difficulty in swallowing.
Unilateral Babinski sign is positive on neurological examination. There is increased
tone in lower limbs and he has a mask like face.
b) Write down reversible causes of this condition. [Annual 2015]
2. A 72-year-old retired police officer presented with increased difficulty in walking and
falls. On examination, he is hemodynamically stable and has generalized truncal
rigidity with normal deep tendon reflexes and intact sensations.
b) Give three causes of this clinical condition.
c) Enumerate three most important steps in the management of this case.
3. A 70-year-old retired banker presents to OPD with the history of tremors of the right
hand and increased difficulty in walking. He has progressively become physically
incapacitated over the past 18 months.
a) Give most likely diagnosis with three other possibilities.
b) What is the single most pathogenic explanation for this disorder?
c) Give four most appropriate treatment options. [Annual 2012]
Amyotrophic Lateral Sclerosis

1. A 58-year-old male presented with progressive weakness of all four limbs. His
examination revealed some wasting and power grade 3 in lower limbs and grade 2 in
upper limbs. Fasciculations were noted on thigh muscles during examination. His
tendon reflexes were brisk. The higher mental functions, cranial nerves and sensory
system was normal on examination.
a) What are the different variants of this condition?
b) What are the treatment options? [Supple 2017 held in 2018]
Multiple Sclerosis
1. A 22-year-old female consulted an ophthalmologist for sudden onset of vision loss in
left eye. Six months ago, she had weakness of right arm and staggering gait which
improved over two months. Two years ago, she felt numbness in limbs and was
21
thought to be functional as no neurological deficit was detected at that time. On
examination, ophthalmologist noticed afferent pupillary defect and intra-nuclear
ophthalmoplegia. Neurologist also found positive Lhermitte’s sign & ataxia.
b) What investigations would be helpful?
c) How would you treat her? [Annual 2009]
Meningitis
1. A 35-year-old male presents with complaints of high-grade fever, neck pain and
headache for two days and altered sensorium for 2 hours. On examination, his BP is
100/60 mm Hg, pulse is 120/min, temp is 103 F. GCS is 12/15 and neck is rigid. There
is no focal deficit. Rest of systemic examination is normal.
b) Write down important investigations to confirm diagnosis.
c) Write down empirical treatment for suspected condition.
2. A young man aged 18 has developed low grade fever and severe headaches for the
last two weeks. On examination, he has neck rigidity.
a) How will you further investigate this patient?
b) Which of these investigations is most crucial in diagnosis? Give a sample of
diagnosis. [Annual 2013]
Guillain-Barre Syndrome
1. A 25-year-old man presented with rapidly progressive paralysis of all four limbs over
days. Examination reveals hypotonia, grade 0/5 power and absent reflexes in all four
limbs. His sensations were normal. CSF examination shows:
Opening pressure 13 cm of water

Cell count 07 (all lymphocytes)
Protein 175 mg/dl
Sugar 70 mg/dl
Gram stain and ZN stain Negative
Blood glucose 105 mg/dl

b) How will you confirm this diagnosis?
22
c) How will you manage the case? [Annual 2010]
2. A 15-year boy is brought to you with progressive weakness of both lower limbs over
a period of 7 days. He was previously normal except mild flu prior to present
condition. On examination, boy is fully alert and febrile. GPE does not reveal any
abnormality except undescended testis on one side. Power in upper limbs is 5/5
whereas in lower limbs is 2/5. Deep tendon reflexes were absent in lower limbs.
b) What investigations are helpful to confirm the diagnosis?
c) What complications can prove fatal and how can you manage them?
[Annual 2008]
Extradural Hematoma
1. Mr. X is known case of valvular heart disease and is taking oral anticoagulants for the
past three months. He fell from motor cycle two days back with an injury to the right
eye and transient loss of consciousness. He developed gradual loss of consciousness
since last night. On examination, he has deeply hemorrhage and dilated pupil of the
right eye. He has generalized hypotonia with an extensor plantar reflex on the left
side.
b) Give four relevant investigations.
▪ STROKE MEDICINE
CVA Infarction
1. A 28-year-old female, a known case of Rheumatic Heart Disease, on regular
prophylactic monthly injections of Benzathine Penicillin presented in ER with sudden
onset of weakness in right half of the body. On examination, her pulse is irregularly
irregular, rate 130/min, BP 120/80 mm Hg and mild diastolic murmur at mitral area.
a) What is the comprehensive diagnosis?
2. A 20-year-old girl who is a known patient of mitral stenosis is admitted in emergency

room with history of sudden weakness of right half of body. On examination, he is
conscious, having irregularly irregular pulse. Her BP is 110/70 mm Hg, and signs of
23
upper motor neuron lesion on right side are present. CT scan reveals hypodense area
in left parietal region.
a) What is the probable diagnosis?
b) What single most important investigation is needed and why?
c) Give four steps of management. [Annual 2014]
3. A 45-year-old painter while painting had a mild headache. His painting brush
suddenly dropped from his hand followed by weakness of right upper and lower
limbs. On examination, pulse is 70/min, blood pressure is 130/80 mm Hg. There is
drooping of left upper eye lid. Left pupil is dilated and not reacting to light. Power in
right upper limb is 3/5 and right lower limb is 4/5. Tendon reflexes are brisk on right
upper and right lower limb and right plantar reflex is extensor.
b) Give two investigations to confirm diagnosis.
c) What would be the likely best treatment? [Annual 2011]
4. A 23-year-old male presents with complete flaccid paralysis of right side. On

examination, his pulse is irregularly irregular. On auscultation of the heart, there is
faint murmur.
a) What do you think is the most likely cause of paralysis?
b) Name one definitive test to confirm the neurological problem.
c) Name one definitive test to establish heart problem.
d) How could you prevent stroke in patients with such heart disease?
Miscellaneous
1. A 63-year-old female is brought by her attendants with complaints of abnormal
behavior, screaming and abnormal limb movements occurring last night. There is no
previous history of similar attacks in past. However, she is smoker and has had an
attack of right-sided weakness 1 month back from which she is almost completely
recovered. On her previous CT scan done at the time there is a large hypodense area
on left anterior cerebral artery distribution.
a) What is the comprehensive diagnosis? Will you start treatment for this episode
and why?
b) What is the first line drug? [Supple 2019 held in 2020]
24
▪ GASTROENTEROLOGY
Hematemesis
1. A 38-year-old barber presents to the emergency with hematemesis. On examination,
he is pale with pulse rate 110/min and a BP of 90/60.
a) What are the four most likely causes of his condition?
b) Enumerate the four most important procedures in the management of this
patient.
c) Write down most important investigations in this case. [Annual 2012]
Abdominal Pain
1. A 35-year-old person presents with history of persistent pain in upper abdomen for
the past two months. There is no history of previous illness and he denies taking any
medicines. His father died of a tumor in the abdomen in his mid-40. On examination,
he is pale and has tenderness in the epigastrium.
a) What are the differential diagnoses? Name atleast four conditions.
b) Name atleast three specific investigations to confirm the diagnosis.
[Annual 2007]
Gastro-esophageal Reflux Disease (GERD)

1. A 55-year-old male presents with two months history of retrosternal pain and reflux
of food contents sometimes reaching to the pharynx whenever he bends forward
during prayers. He also has night time attacks of cough and wheeze. The physical
examination is unremarkable.
a) What is the most likely diagnosis? What are three treatment options available
which should be used initially?
b) What lifestyle advice you will give? [Supple 2019 held in 2020]
2. A 44-year-old male, who is morbidly obese, presents with complaints of heart burn
and indigestion. He also experiences water brash. An endoscopy is performed and a
Hiatus Hernia is found.
a) What are the two types of Hiatus Hernia?
b) Write any four complications associated with Gastro-esophageal Reflux Disease?
c) Enlist the treatment options. [Supple 2016 held in 2017]
25
3. A middle-aged lady has presented with severe burning sensation behind the sternum
along with regurgitation and feeling of stickiness of food at the level of xiphisternum.
On examination, she is an obese lady with normal physical examination.
b) Name atleast three specific tests to confirm the diagnosis.
c) How will you manage the patient? [Supple 2007 held in 2008]
Achalasia
1. A 45-year-old female presents in an OPD with complaints of difficulty in swallowing
for solids and liquids for the last 1 year. This is accompanied by nocturnal coughing
and vomiting undigested food taken 2 to 3 days ago.
b) Name the investigations you may like to carry out in tis patient. [Annual 2019]
2. A 26-year-old female presents with a complaint of difficulty swallowing which has

worsened gradually over time for last one year. She gives history of feeling as if food
gets stuck in her mid-chest. She notices that swallowing difficulty is worse for liquids
and by standing and moving around after eating. She has had a 15-pound weight loss
and reports occasional regurgitation of undigested food after eating.
b) How will you confirm it?
c) Give brief treatment options. [Annual 2013]
Esophageal Carcinoma
1. A 55-year-old heavy smoker presents with progressive dysphagia to solids and a
significant weight loss over the last three months. On examination, he is pale and
emaciated with no other detectable clinical abnormalities.
a) Give two most likely possibilities of this clinical condition.
b) Write down three most useful investigations for this case.
c) Enumerate two most important steps in the management of this case.
2. A 75-year-old man is brought to you with progressive difficulty in swallowing

especially solids. He gives history of chronic retrosternal pain, preceding dysphagia.
On examination, the man looks emaciated and pale.
a) Name three possible diagnoses.
b) Name three investigations.
c) What will be the long-term management? [Supple 2008 held in 2009]
26
Peptic Ulcer Disease
1. A 55-year-old male presents with two days history of burning in epigastrium with
nausea and vomiting. He had passed a black tarry foul smelling stool this morning
and is worried. He gives history of intake of some medication for his joint pain. The
physical examination is unremarkable.
a) What is the most likely diagnosis and what is the cause? Enumerate four other
probable causative factors for such presentation.
b) What can be the two differentials?
c) What investigations are available for diagnosis of a bacterial infection causing
these symptoms and what four drugs you will use for the treatment?
[Annual 2019]
2. A 35-year-old male seen in emergency department with 2 days history of coffee

colored vomiting & epigastric pain. There is history of NSAIDs for his chronic lower
back pain. Patient is non-alcoholic. On examination, he is pale, epigastric tenderness,
no hepatosplenomegaly. Upper GI endoscopy shows small duodenal ulcer on the
posterior wall. Serology for H. pylori is positive.
a) What other invasive/non-invasive tests to confirm that he is suffering from H.
pylori infection?
b) Write down a standard non-bismuth H. pylori eradication triple therapy
prescription for this patient. [Annual 2018]
3. A 45-year-old obese male gave history of periodic epigastric pain radiating to the
back particularly 2-4 hours after meals and occasionally at bed time. There was no
history of smoking or use of NSAIDs. However, he is fond of eating junk food. On
examination, there is no history of Diabetes Mellitus, Hypertension and Ischemic
Heart Disease. His BP is 120/80 mm Hg, pulse is 80/min which is regular and there is
no hepatomegaly. Lab investigations showed CBC 10x10^9/L, Hb 13.5 g/dL and
platelets are 234x10^9/L. His liver function tests (LFTs) are: ALT 85 IU, AST 75 IU, ALP
140 IU. BUN and Serum Creatinine levels are normal.
a) What is the most likely diagnosis? List two other possibilities.
b) What further investigations are required to confirm the diagnosis and its
etiology?
c) Outline the management of your most likely diagnosis. [Annual 2016]
4. A 50-year-old obese woman is taking drug for painful osteoarthritis for last two
years. For last one week, she was complaining of upper abdominal pain and vomited
27
blackish material on the day of admission. On examination, she was not looking pale,
her pulse and blood pressure were normal. Her liver was normal and spleen was not
enlarged.
a) What is the most likely cause of hematemesis in this patient?
b) Enumerate three investigations required in this patient.
c) What is the drug treatment for duodenal ulcer? [Supple 2015 held in 2016]
5. A 40-year-old male with history of recurrent epigastric pain that occurs after meal
presents in medical emergency with massive hematemesis. His blood pressure is
90/60 mm Hg. He has tachycardia and sweating. There is no history of chronic liver
disease.
b) Give important steps of management. [Annual 2014]
6. A 50-year-old executive presented with history of episodic epigastric pain for the last
many years with remission. His upper GI endoscopy shows an ulcerated lesion on the
lesser curvature of the stomach.
a) List three investigations to detect possible etiologic factor.
b) How would you treat him?
c) How would you like to follow up the patient? [Supple 2013 held in 2014]
7. A 70-year-old lady helping her grandson in green grocery shop attended medical
outpatient department with complaints of nausea, abdominal distension and
vomiting in which she had noticed food eaten 24 hours previously. On examination,
she was dehydrated and succussion splash was elicited 4 hours after food intake. On
investigations Hb 10 gm/dl, ESR 10 mm 1st hour, serum sodium 145 mEq/L, serum
potassium 2.5 mEq/L, serum bicarbonate 32 mEq/L, serum chloride 90 mEq/L.
a) What is the clinical diagnosis and associated biochemical abnormality?
b) Give two investigations to confirm the diagnosis and help in management.
c) Give an outline of management. [Annual 2011]
8. A 60-year-old woman presents in the emergency with massive hematemesis. She has
history of pain in her knee joints for which she is seeing her orthopedic surgeon who
has prescribed her some painkillers. She is pale and tender in her epigastrium.
b) What immediate treatment should be started? [Supple 2010 held in 2011]
28
9. A 28-year-old woman has chronic dyspepsia. There is no history of NASIDs intake.
She has been treated with omeprazole which gave her temporary relief. On
examination, there is mild pallor and epigastric tenderness. Blood culture
examination revealed mild hypochromic microcytic anemia. Stool was positive for
occult blood. Upper GI endoscopy showed an ulcer in the first part of duodenum.
a) What do you think may be the cause of her ulcer?
b) How will you confirm the diagnosis?
c) How will you manage her? [Supple 2008 held in 2009]
Celiac Disease
1. A fourteen-year-old boy presented with iron deficiency anemia. During examination,
you notice finger clubbing and a rash on the dorsum of elbows about which he
reported to be intensely pruritic. He also looked slightly smaller as compared to his
older siblings.
a) Which tests will help you make a diagnosis?
b) What is the treatment?
c) What is the associated skin condition called?
[Supple 2017 held din 2018]
2. A 19-year-old boy has a long history of weight loss, abdominal distension, bloating,
recurrent anemia and diarrhea, calcium is low. A small bowel biopsy reveals blunting
and flattening of villi.
b) What laboratory investigations you order?
c) What are the long-term complications of the disease?
d) What is the treatment plan? [Annual 2017]
3. A 1-year-old pale looking boy of small height presented with frequent bulky diarrhea
for the last 10 years. There was no history of abdominal pain or fever. His
hemoglobin was 8 g/dL with microcytic and macrocytic picture of RBCs. His serum
vitamin D level was low.
b) What is the cause of small height, anemia in this patient?
c) Enumerate two blood tests for the diagnosis of this patient.
4. A 45-year-old male presents with complaints of chronic diarrhea for last 3 months.
Stools are bulky, difficult to flush and don’t contain any bleed. There is history of
29
generalized bodyaches and difficulty to climb stairs and stand from sitting position.
On examination, he is markedly pale with koilonychia present.
a) What are the differential diagnoses?
b) There is an itchy vesicular rash over extensor surface of elbows and legs. What is
the reason for this rash in this patient? [Annual 2015]
5. A 45-year-old male presents with complaints of chronic diarrhea for last 3 months.
Stools are bulky and difficult to flush but do not contain any blood. There is history of
generalized bodyaches and difficulty to go upstairs and standing from sitting
position. On examination, he is markedly pale and has koilonychia. What are your
differential diagnoses? Give any four
What is the cause of proximal muscle weakness in this case and how would you treat
it? [Supple 2014 held in 2015]
6. A young person has presented with chronic diarrhea for the past three months. He
passes three to six bulky motions without mucus or blood. He passes motions usually
every time he eats or drinks. The food contents can be recognized in the stool
sample. On examination, he is pale and has evidence of loss of muscle mass. There is
itchy erythematous papulovesicular rash on the lower limb extremities. Abdomen
distended with loud bowel sounds.
Laboratory evaluation show Hb 10 gm/ dL, MCV 66 fL, MCH 55 pg/L, ferritin 5 ng/ml
& albumin 3 gm/dl, stool examination is normal except for undigested food particles
and start molecules.
a) What is the most likely diagnosis & differential diagnoses?
b) Outlie the steps to reach the diagnosis. [Supple 2013 held in 2014]
7. A 15-year-old unmarried female is on maintenance L-thyroxine 50 ugm 3 tablets

daily. On follow-up, she complains of tiredness, easy fatigue, abdominal distension,
loose stool 2-3 times/day since previous 5 months and normal menstrual periods. On
examination, conjunctivae are little pale. Physical examination shows no other
abnormality. Her Hb is 9 gm/dL. Blood film shows microcytic hypochromic RBCs, T4
and TSH normal, serum iron is low and total iron binding capacity is high.
a) What two investigations are required to reach the diagnosis?
c) How will you treat this patient? [Annual 2011]
30
Inflammatory Bowel Disease
1. A 28-year-old female 6 months history of chronic diarrhea associated with lower
abdominal crampy pain & fever. The stool contains mucus and blood. On
examination, she is pale, mild tenderness all over the abdomen, no
hepatosplenomegaly.
Investigations: Hb 9.5 mg/dL, TLC 15000, Platelets 550, ESR 75, Serum Albumin 2.5
g/dL, LFTs: Total Bilirubin 1 mg/dL, AST 70 IU/L, ALT 65 IU/L, ALP 240 IU/L.
Ultrasound Abdomen was normal.
b) List the features of severe disease.
c) Name various groups of pharmacological drugs used and outline the
management of this illness. [Annual 2018]
2. A 35-year-old female presented with 3 months history of bloody diarrhea with lower
abdominal crampy pain. She also gives history of fever, weight loss and occasional
large joint pains.
b) Enlist four other diseases causing chronic diarrhea.
c) Outline the management of such patient.
3. A 30-year-old man presents with diarrhea for 5 days. Stools are mixed with fresh
blood and mucus. Frequency of stools I 9-11/day with fever and abdominal
distension. He says that he has similar episodes of diarrhea, although of less intensity
in the last six months. On examination, he is pale, dehydrated and has toxic look. His
BP is 110/70 mm Hg, pulse is 110/min and temperature is 102 F. His lab reports show
Hb 7 g/dl, ESR 80 mm in 1st hour. WBC 14 x 10^9/L
b) How will you manage him? [Annual 2014]
4. A 24-year-old policeman presents with bloody diarrhea accompanied by colic for the
last two months along with low grade fever and some weight loss. His clinical
examination reveals clubbing, pallor and deep tenderness over the left lower
abdomen.
a) Give four most likely possibilities of this clinical condition.
b) Enumerate four most important investigations for this gentleman.
c) Write down the three most appropriate therapeutic options. [Annual 2012]
31
5. A 55-year-old man presented with history of diarrhea containing blood and
abdominal pain for three months. He also reports low grade fever and weight loss.
Examination revealed a temperature of 99 F and some abdominal tenderness.
a) Enumerate four differential diagnoses.
b) How will you investigate the case? [Annual 2010]
6. A 43-year-old woman presents to you with 27 days history of watery, bloody

diarrhea mixed with mucus. Her diarrhea has not responded to previous medication
of ciprofloxacin & metronidazole by her primary physician. She is weak and
exhausted and is passing 10-12 stools during the day and night. She has severe
tenesmus and has lost her appetite. Physical examination is unremarkable except
left hypochondriac tenderness. Fever is 100 F. Her investigations show ESR: 62 mm,
Hb 10.2 gm%, SGPT 58, Albumin 2.9 gm & sigmoidoscopic examination revealed
inflamed friable mucosa. Biopsy examination showed crypt abscess formation. How
would you manage this patient? [Annual 2009]
Irritable Bowel Syndrome

1. A 47-year-old female presents with recurrent abdominal pain and fullness associated
with increased number of stools. Her pain improves after defecation and the
symptoms worsen whenever she has some issues with her husband.
b) What alarm features (any six) you must ask her before starting her treatment?
c) Name any two medicines used to decrease her stool frequency.
2. A 23-year-old male of normal built presents with complaints of crampy abdominal

pain relieved by defecation which is associated with loose stools along with mucus
but not blood, 3 to 4 episodes per day. There is no history of fever, travelling or any
restaurant food intake. He reported that similar episodes have occurred over past 6
months which last for 7 to 10 days and resolved spontaneously. There is no
abdominal tenderness, mass or visceromegaly. Rest of systemic examination is
normal.
b) What relevant investigations you can advise?
c) Give four treatment options. [Supple 2014 held in 2015]
32
3. A 35-year-old woman comes with history of chronic diarrhea and lower abdominal
discomfort which is relieved by defecation. Occasionally she had noticed some
mucus but never blood in the stool.
b) Name three most relevant investigations.
c) How will you treat this case? [Annual 2008]
Pseudomembranous Colitis
1. A 45-year-old male presents in medical OPD with high grade fever, abdominal
cramps and loose stools containing blood for 2 days. He gave history of dysuria for
which he has been on tablet Ciprofloxacin 500 mg twice a day for 12 weeks. On
examination, he is markedly dehydrated, pale, toxic and febrile and has diffuse
abdominal tenderness but no visceromegaly.
b) How will you confirm diagnosis?
c) Write down two treatment options. [Annual 2015]
Carcinoid Tumor
1. A 52-year-old man is admitted for the workup of chronic recurrent diarrhea of about
six months duration in addition to the watery diarrhea. He also has recurrent
wheezing of the chest for which inhalers have been prescribed. He is noted to have a
bluish red rash over the face and necklace area. He also complains of pain right
hypochondrium on ultrasound examination. His liver is found to have multiple
rounded space occupying lesions.
a) What is the likely cause of his clinical features?
b) What one investigation will help confirm?
c) Give treatment. [Supple 2011 held in 2012]
Miscellaneous
1. A 32-year-old housewife complains of excessive dysphagia, pain epigastrium and
intermittent vomiting for the past three years. She has been treated with antacids,
H2 receptor blockers and various PPIs on many occasions with temporary relief. Her
clinical examination is unrevealing except for deep tenderness in the epigastrium.
a) Give three possible causes of her clinical condition.
b) Enumerate three most important investigations to reach the diagnosis.
c) Write down three most important steps in the management of this case.
33
▪ HEPATOLOGY
Jaundice
1. A 15-year-old girl presented with jaundice. Her total serum bilirubin is 3.9 mg/dl,
serum ALT 191 IU/L, serum AST 191 IU/L, ALP 105 IU/L.
a) Give two differential diagnoses.
b) Write five investigations to confirm the diagnosis. [Annual 2010]
Hepatic Encephalopathy
1. A 55-year-old known cirrhotic presents with ill health for the last one week and now
with apathy, lack of concentration, confusion and drowsiness. On examination, there
are flapping tremors and inability to draw objects like star and inability to perform
simple mental arithmetic tasks.
b) Enlist the six factors which precipitate this condition.
c) What are the principles of management? [Annual 2017]
Variceal Bleeding
1. A 33-year-old female presents with blood in the vomitus. On examination, she is pale
with palmar erythema and had positive fluid thrill on abdominal examination.
a) What six emergency management steps you will do? Give reason for each.
b) After stabilization, what treatment you will advise to prevent recurrence of the
same complication? [Supple 2019 held in 2020]
Acute Hepatitis/Acute Liver Failure

1. A young boy presented to you in emergency with history of anorexia, nausea and
vomiting for last three days. Her mother noted that his eyes look slightly yellow and
he was lethargic. You get his liver chemistry which reveal serum bilirubin to be 12
mg/dl and ALT 4500 IU.
a) What are the possible causes of these abnormal blood findings?
b) How will you treat this patient?
c) What is the treatment of one deadly complication of this condition?
[Suppled 2017 held in 2018]
2. A previously healthy 25-year-old pregnant female is admitted with 2 weeks history of

loss of appetite, fever, nausea, vomiting, upper abdominal pain and yellow
discoloration of the skin. Over the course of admission, she has become confused
34
and delirious with development of ecchymoses on the skin. Her bilirubin was 7
mg/dl, serum transaminases were more than 1000 U/L. Alkaline Phosphatase is
mildly elevated with prolonged prothrombin time.
a) Enumerate two viral and two non-viral causes of her illness.
b) Enumerate four essential investigations required in the management of acute
liver failure. [Supple 2015 held in 2016]
Viral Hepatitis
1. A 15-year-old boy presented with 5 days history of anorexia, nausea, vomiting and
pain in right hypochondrium. The symptoms started after his return from a hill
station. On examination, temperature is 99 F, mild icterus + and tender
hepatomegaly. Investigations revealed:
CBC: TLC 3500 cells/mm3, Hb 13.5 g/dl, platelets 220x10^9/L, LFTs: Total Bilirubin
2.3 mg/dl, ALT 3000 IU/L, AST 2795 IU/L, ALP 195 IU/L.
a) What is the diagnosis and the most likely etiologic agent?
b) How can you prevent this disease?
c) How will you treat him and what is the outcome? [Annual 2016]
2. A 20-year-old student presents in the emergency with history of vomiting for one
day. He usually eats out and has felt a bad taste in his mouth for a few days. He also
lost desire to smoke.
a) What is likely diagnosis?
b) What investigations would you perform?
c) What is the prognosis? [Supple 2010 held in 2011]
3. A young girl is brought to you with fever, anorexia and upper abdominal discomfort
for last three days. On examination, there is no definite jaundice but there is
tenderness in right upper quadrant of abdomen. Lab tests show normal CBC,
bilirubin 1.9 gm/dl and SGPT 2500 IU/L.
b) Name one screening test for each of the four main etiologies of her problem.
c) How will you treat her? [Supple 2008 held in 2009]
4. A medical student gets a needle prick injury while drawing blood from a patient
suffering cirrhosis of liver. Earlier patient had received a full course of interferon for
hepatitis C and was vaccinated for Hepatitis B.
a) What is the risk to the student?
b) How would you manage the patient? [Annual 2008]
35
5. A 40-year-old dentist presented with a five months H/O weight loss. He had recently
become jaundiced. Blood results show ALT 400 IU/L, ALP 165 IU/L, Bilirubin 80
umol/L, albumin 3.2 g/L (3.4-4.2 g/L), alpha fetoprotein 4 ng/L, serum ferritin 150
ug/L, (15-250), HBsAg positive, HBeAg positive.
b) Which three tests will you perform?
c) What is the management? [Supple 2007 held in 2008]
Pyogenic Liver Abscess

1. A 28-year-old male, a known case of Diabetes Mellitus, presented with 3 days history
of high-grade fever with rigors and chills. On examination, he is jaundiced with
tender right hypochondrium and epigastric area. Investigations showed TLC 20,000
with 90% neutrophils, LFTs: Total Bilirubin 2.5 mg/dL, ALT 60 IU/L, AST 45 IU/L, ALP
480 IU/L (Normal Value <200 IU).
c) What is the treatment? [Supple 2016 held in 2017]
2. A 52-year-old diabetic male presents in ER with high grade fever and abdominal pain
for last 4 to 5 days. On examination, he has high fever of 102 F, RR 24/min, BP
130/80 mm Hg and pulse 110/min. Abdominal examination reveals severe
tenderness in right hypochondrium and a palpable liver. Labs show leukocytosis and
deranged LFTs.
b) Enlist two investigations that you will carry out in this patient.
c) What is the treatment? [Annual 2014]
Non-Alcoholic Fatty Liver Disease

1. A 40-year-old male seen in outpatient department with pain in right hypochondrium.
On examination, hepatomegaly without any other stigmata of chronic liver disease.
Investigations: Total Bilirubin 1.5 mg/dL, ALT 175 IU/L, AST 185 IU/L, ALP 180 IU/L,
Fasting lipid profile: triglycerides 450 mg/dL, T. Cholesterol 240 mg/dL, HbsAg/Anti-
HCV negative.
a) What is the most likely diagnosis, and two principal causes?
b) List different options of treatment. [Annual 2018]
36
2. A 23-year-old boy who is morbidly obese, non-alcoholic, presents for his annual
medical checkup. His SGPT is 200 IU/L and random blood sugar is 134 mg/dL. Viral
serology panel is negative. There is no history of liver disease in family. Ultrasound
shows fatty liver changes.
b) Write down the investigations to make definite diagnosis.
c) Write down four treatment options. [Annual 2015]
Hepatocellular Carcinoma
1. A 65-year-old farmer with no history of alcohol intake presents with pain in the right
hypochondrium radiating to the right shoulder along with weight loss of seven kgs
over the past two months. He was treated with ribavirin tablets and injection
interferon five years ago for his hepatitis.
a) Give two most likely diagnoses in this case.
b) Give four most appropriate investigations.
c) Give two appropriate treatment options for him. [Annual 2012]
Primary Biliary Cirrhosis

1. A 42-year-old female presents with pruritus for 6 months. She has noticed
progressive disabling fatigue and a 7 kg weight loss. She is on levothyroxine for
hypothyroidism. She is mildly icteric and has spider angiomas on her body. On
palpation, a nodular liver edge 2 cm below the costal margin is found. CBC shows Hb
8 g/dl, TLLC 8600/mm3, platelets count 165000/mm3, ESR 45 mm in 1st hour, Urea
38 mg/dl, creatinine 0.7 mg/dl, SGPT 78 IU/L (10-50 IU/L), SGOT 74 IU/L (10-50 IU/L),
Alkaline phosphatase 378 IU/L (40-125 IU/L) and serum cholesterol 290 mg/dl.
Ultrasonography shows echo pattern changes of liver parenchyma.
b) How will you confirm it?
c) Discuss briefly your treatment options. [Annual 2014]
2. A 52-year-old lady is admitted with vertebral collapse and her x-ray show bone
rarefaction. She gives history of progressively worsening generalized itching for the
last seven years and has recently developed mild jaundice. She looks fatigued with
scratch marks on the body. She has bilateral xanthelasmas and her spleen is
palpable. Liver Is palpable and firm. The bilirubin is 4 mg/dl, ALT 345 IU/L, AST raised
and ALP 1578 IU/L. USG abdomen does not show dilatation of intra or extra hepatic
bile ducts.
37
b) What may be the cause of her vertebral collapse?
c) What serological investigations will help to establish a diagnosis?
3. A 25-year-old primigravida developed jaundice in the early third trimester of

pregnancy with dark urine, pale stool and pruritis worse at night involving the entire
body. She also fees nauseated with upper abdominal pain. On examination, she is
afebrile and apart from icterus physical blood tests showed:
Serum bilirubin: 4 mg/dl
Serum ALT: 110 U/L
Serum AST: 100 U/L
ALP: 240 U/L
PT: 20 seconds
a) What investigations you would like to carry out?
c) What two medications are indicated in treatment and prevention of complication
of her illness? [Annual 2010]
4. A forty-year-old female presented with history of fatigue, generalized pruritus,

yellowish discoloration of sclera, xanthelasmas on eyelids and 4 cm enlarged liver.
Lab test shows serum bilirubin 6.5 mg/dl, ALP 700 IU/L and anti-mitochondrial
antibodies are positive.
b) What complications can occur in this condition?
c) How will you treat her? [Annual 2009]
5. A middle-aged lady has presented with pain RUQ with fever and jaundice. On
examination, she is healthy looking with yellowness of eyeball. There are marks of
itching on the trunk. Her liver is 3 cm enlarged with sharp and regular edge. An USG
of upper abdomen shows dilated biliary channels.
a) What is the differential diagnosis? Name atleast four conditions.
b) Enlist atleast three specific investigations you will order to confirm the diagnosis.
[Annual 2007]
Hemochromatosis
1. A 58-year-old male presents with complaints of abdominal distension which is
worsening for two weeks now. He has history of diabetes for which he is taking
insulin twice daily. He is taking paracetamol three times a day for his knee arthritis.
38
His abdomen is protuberant with full flans, everted umbilicus and fluid thrill. No
viscera are palpable, skin is pigmented and knee joints have crepitus but no swelling
or redness. Viral serology for hepatitis is negative.
a) Give your diagnosis.
b) How will you confirm your diagnosis?
c) What dietary precautions should be taken to prevent progression of his illness?
Cholecystitis
1. A woman aged fifty has recurrent attacks of pain in the right hypochondrium. On
examination, she is jaundiced and is tender in the right hypochondrium.
a) How will you investigate this patient?
b) How will you manage this case both in the short term and long term?
[Annual 2013]
Cholangitis
1. A middle-aged lady has presented with severe pain in the right upper quadrant of
the abdomen along with fever and jaundice. On examination, she is a febrile sick
looking lady with yellowness of eyeballs and tenderness in her abdomen especially in
RUQ. There are marks of itching on the trunk. Her liver is 3 cm enlarged with sharp
and regular edge. An USG of upper abdomen shows dilated biliary channels along
with echogenic rounded shadows in the lumen and similar shadows in the lumen of
gallbladder.
b) How will you treat this patient? [Supple 2007 held in 2008]
Miscellaneous
1. A 25-year primigravida in her last trimester of pregnancy presents with anorexia,
fever and intractable vomiting. On examination, she is dehydrated, jaundiced and
fever of 101 F.
a) Give three most likely possibilities of her clinical condition.
b) Write down three most important investigations for this case.
39
▪ HEMATOLOGY
Splenomegaly
1. A boy aged 16 has been complaining of ill health and shortness of breath of recent
onset. On physical examination, he is markedly anemia and spleen is grossly
enlarged to a level below the umbilicus.
a) Give a list of possibilities.
b) Make a list of investigations which would help in diagnosis. [Annual 2013]
Hypochromic Microcytic Anemia

1. A 23-year-old primigravida has been found to have mild anemia during routine
antenatal examination. Her husband, who is his first cousin, also has mild anemia.
Blood tests of the patient show Hb 10.6 gm/dl with hypochromic microcytic picture.
a) Name two major causes of this type of anemia.
b) What further investigations should be performed to determine the cause of
anemia?
c) What are the possible risks to the baby?
d) How could you prevent any serious complications in this baby?
Megaloblastic Anemia
1. A 32-year-old female presents with lethargy, malaise and paresthesia of hands and
feet. On examination, she is pale with smooth tongue and angular cheilitis. On
examination, the patient has absent ankle jerks also.
a) What is the most likely diagnosis? What initial investigation you will require and
what abnormalities you will find in this?
b) What other neurological complications can occur? [Annual 2019]
2. A sixty-year-old female presented with weakness and shortness of breath on

exertion. She is diabetic and has mild depression. Her examination reveals an
edentulous (lacking teeth) patient with moderate degree of mucosal pallor. You
request for her routine tests which reveal that she has a hemoglobin of 6.5 g/dl with
MCV of 124 fL. The blood film also shows that the cells are megaloblastic. Her renal
function was normal.
a) How will you differentiae the two causes of megaloblastic anemia?
b) Which micronutrient will you replace first if you are not clear as to what is the
cause of this anemia? [Supple 2017 held in 2018]
40
3. A 20-year-old girl presented with complaints of shortness of breath, easy fatigability
and joint pains. On examination, she is pale, mildly icteric and has small
splenomegaly. Investigations showed: Hb 8.5 g/dl, MCV 105, T. Bilirubin 2.5 mg/dl,
Conjugated 0.5 mg/dl, Unconjugated 2 mg/dl.
a) What is the most likely cause of her anemia?
c) What are the four causes of this type of anemia? [Supple 2016 held in 2017]
4. A 23-year-old non-diabetic presents with history of paresthesia in arms and legs. On

examination, he is markedly pale and has a beefy red tongue. He has got loss of
touch, pain, proprioception and vibration in a glove and stocking distribution. His
plantars are down going and ankle reflexes are diminished with preserved other
deep reflexes. There are big patches of vitiligo on his trunks and limbs.
a) What is the cause of these symptoms?
b) How will you treat this patient?
c) What is significance of vitiligo in this patient? [Supple 2014 held in 2015]
5. A 25-year-old female presents in medical outpatient with generalized body

weakness, easy fatigability and paresthesia of hands and feet for 3 weeks. On
examination, bald tongue and angular cheilosis are present. On investigations, Hb
7.8 mg/dl, MCV 120 Fl, peripheral blood film shows oval macrocytes and
poikilocytosis.
b) Enlist three other causes of raised MCV. [Annual 2014]
6. A 58-year-old lady is complaining of easy fatigue, breathlessness as well as numbness

and pins and needles in her feet and legs. She also says that immediately after taking
meals, she develops nausea, bloating, sweating and palpitations. In her past medical
history, it is noted that she underwent partial gastrectomy, seven years ago. Her Hb
is 8.8 mg/dl and MCV 104 fL. She is negative for H. pylori.
a) What may be the cause of her anemia?
b) How would you explain her post-prandial symptoms?
c) What is the explanation of her numbness and pins and needles?
7. A 45-year-old lady presented with progressive shortness of breath for last six
months. Lab data shows: Hb 3.8 g/dl, TLC 3000/mm3, Platelets 4500/mm3, MCV 112
Fl, PCV 0.15, Retics 3%
41
c) What is the treatment? [Annual 2010]
Leukemias
1. A 50-year-old man presented to OPD with weakness, shortness of breath, weight
loss and fever for the last one month. On examination, he was pale looking with no
lymphadenopathy. His spleen was moderately enlarged. His Hb was 7 g/dl, TLC
80000/mm3, neutrophil 70%, lymphocytes 15%, platelet count was also raised.
a) What is the most likely diagnosis? Give two other causes of large spleen.
b) What chromosomal abnormality is present in this disease?
c) What is the drug treatment and curative treatment of this patient?
2. An 8-year-old girl presented with extreme pallor, gum bleed, purpura,

lymphadenopathy and hepatosplenomegaly. She consults her physician who
referred her to a tertiary care facility here investigations were carried out. Only a
week later, she was ill again with fever, severe headache and extreme lethargy.
b) Write down the investigation plan.
c) Enumerate treatment options. [Annual 2015]
Multiple Myeloma
1. A 70-year-old male 3 months history of fever, bone pains in back & ribs, weight loss
and recurrent urinary tract infections. On examination, she is pale, temperature 101
F, tenderness in the bilateral flank areas, no hepatosplenomegaly.
Investigations: Hb 7.5 g/dl, platelets 540, TLC 15000, EESR 110 mg Hg in 1st hour,
blood urea 120 mg/dl, serum creatinine 3 mg/dl, serum calcium 12 mg/dl, serum uric
acid 10 mg/dl, total protein 11 g/dl with albumin 3 g and globulin 8 g.
b) What are the four investigations to confirm your diagnosis?
c) Give four reasons of renal involvement in this patient. [Annual 2018]
2. A 50-year-old male presented with 6 months history of weakness, malaise and back
pain. He has been suffering recurrent urinary tract infections and respiratory tract
infections in the recent past.
42
Investigations showed Hb 8.5 g/dl, TLC 3.5X10^9/L, Platelets 70x10^9/L and ESR 120
mm/hr. Urine complete examination showed proteinuria ++, RBC +++, blood urea
120 mg/dl, serum creatinine 3 mg/dl, LFTs are: total bilirubin 2 mg/dl, ALT 35 U/L,
AST 30 U/L, Alkaline Phosphatase 460 U/L, serum calcium 12 mg/dl, uric acid 9
mg/dl, total protein 10 g/dl, albumin 4 g/dl and globulin 6 g/dl.
b) Give four reasons of renal failure in such patients.
c) Give four investigations to confirm your diagnosis.
d) Name two drugs used in this illness. [Annual 2016]
3. A 65-year-old man presents with low grade fever for six weeks. He also complains of
bone pains, weakness and early fatigue. His work-up reveals an ESR of 112 mm fall in
first hour, Hb 10.2 g/dl, normal TLC, DLC and platelets. His serum calcium was found
to be elevated with a normal alkaline phosphatase. X-rays reveal multiple round to
oval lytic lesions in his bones.
b) What three investigations will help make a diagnosis?
c) What three specific therapies may be helpful? [Supple 2011 held in 2012]
Aplastic Anemia
1. A 28-year-old boy presents with shortness of breath, pallor and bleed from gums and
nose. On investigations, his Hb is 7 g/dl, platelet count 12000 and TLC is 12x10^9/L
and absolute neutrophil count < 0.5x10^9/L. Bone marrow is hypocellular and he is
diagnosed as a case of aplastic anemia.
a) How you assess the severity of aplastic anemia in this patient?
b) How will you manage this patient?
c) Into which conditions aplastic anemia can evolve? [Annual 2017]
2. A 15-year-old boy is brought to you with fever, pallor and dyspnea. On examination,
there is marked pallor but no hepatosplenomegaly and lymphadenopathy.
Hb 6.5 g/dl, TLC 1800/mm3, DLC Polys 20% Lymphocytes 78% Monocytes 2%
Eosinophils 0% Basophils 0% Platelets 25000/mm3, no blast cells or other premature
cells on smear.
b) What investigations will be most helpful in establishing diagnosis?
c) How will you treat this case? [Annual 2008]
43
Platelet Disorders
1. A 25-year-old girl presented with 3 months H/O bleeding gums, menorrhagia,
bruising in skin without significant trauma. On physical examination, there is no
palpable lymphadenopathy or splenomegaly. She does not complain of joint pain or
skin rash or loss of hair. Her blood picture shows microcytic hypochromic anemia,
normal TLC without any immature cells. Bone marrow examination showed normal
trilineage cell lines without any evidence of neoplasm. Megakaryocytes were
however increased in number. How would you manage her? [Annual 2009]
2. A middle-aged female has history of easy bruising and bleeding from the gums for
past three months. On examination, she has multiple small red spots which do not
blanch on pressure, investigations reveal increased bleeding time with normal PT,
platelet count is 50000/mm3.
b) How will you investigate this patient? [Supple 2007 held in 2008]
3. A 29-year-old woman presents to her gynecologist with menorrhagia. Her doctor

noticed her to have purpura over the forearms. Blood complete examination is
normal except a low platelet count.
b) What immediate treatment can you start?
c) What do you expect the bone marrow to show on examination?
d) What is the short term and long-term treatment? [Supple 2010 held in 2011]
Coagulation Disorders
1. A young boy of 12 years is referred by the dentist for persistent bleeding after tooth
extraction. There is previous history of increased bleeding from minor cuts in the
past few years. Investigations reveal increased bleeding time and aPTT. Platelet
count is normal.
b) How will you treat this boy? [Annual 2007]
Venous Thromboembolic Disease

1. A 52-year-old female presents with swelling of left leg, this started a week back and
is associated with pain on walking. On examination, the leg is swollen with slightly
raised temperature and dilated superficial veins. However, there is no tenderness.
44
There is pain in calf on dorsiflexion of the foot. She had a pelvic surgery two weeks
back,
a) What is the most likely diagnosis? What pharmacological treatment options can
be used to prevent such complications to occur? Name any six.
b) What three treatment options you will use and what should be the minimum
duration of treatment of this patient? [Supple 2019 held in 2020]
Miscellaneous
1. A 62-year-old retired accountant presents with excessive tiredness, visual discomfort
and dull pain in the left upper abdomen. On physical examination, he is plethoric
with congested conjunctiva and has an 8 cm palpable spleen.
a) Give three most likely possibilities for this gentleman’s clinical condition.
b) Give three most appropriate investigations to reach the proper diagnosis.
c) Write down three most important steps in treatment of this case.
▪ RHEUMATOLOGY
Systemic Lupus Erythematosus (SLE)
1. A 28-year-old female presents with swelling and bluish discoloration of fingers on
exposure to cold. Her investigations show Hb of 8 gm/dL, TLC 3000/mm3, Polys 80%
Lympho 20%, Platelets 90,000/mm3, with ANA and Anti dsDNA antibodies strongly
+ve.
a) What clinical signs you will look in this patient to reach the final diagnosis (enlist
any six of them)?
b) After a few days, she developed sudden weakness f right half of body. Her CT
scan shows area of infarction. While on echocardiography performed as routine
shows vegetation on the mitral valve. Her blood samples were taken for culture
and sensitivity but no growth was obtained on 3 cultures taken 1-2 hours apart.
What complication she has developed? Name two drugs which should be started.
2. A 25-year-old female presents with pain and swelling of small joints of hand along
with rash on the face, which becomes itchy and red when she goes outside. She has
no history of morning stiffness and oral ulcers.
b) What investigations will you carry out to confirm your diagnosis?
45
c) After a few days she developed chest pain which becomes aggravated on bending
forward. On auscultation there is a scratchy sound heart at precordium that
aggravates on pressing the bell of the stethoscope. How you are going to
manage? [Annual 2019]
3. A young woman seen in OPD with 6 months history of fever, arthralgia, weight loss
and photosensitivity rash. On examination, she is pale, blood pressure 150/110 mm
Hg, butterfly erythematous rash over the face, periorbital puffiness and bilateral
pitting edema. No clinical evidence of arthritis. Investigations: Hb 10.5 mg/dL, ESR
90, Platelets 130. Urine examination shows proteinuria and RBC casts. Chest X-ray
shows cardiomegaly. ANA positive, RA Factor negative. Renal biopsy shows
membranoproliferative glomerulonephritis. The clinical diagnosis of SLE was made.
a) Write down the criteria to diagnose this illness.
b) Discuss this patient’s management. [Annual 2018]
4. A 32-year-old female gives history of painless swelling of the fingers and on exposure
to cold. On examination, she has butterfly rash on her cheeks along with redness of
eye around the limbs. Her ESR is 100 mm with hemoglobin of 8.5 mg/dL,
normochromic normocytic picture and 1200 WBC/mm3.
b) List four appropriate investigations.
c) Enlist four systemic complications. [Supple 2007 held in 2008]
Systemic Sclerosis (Scleroderma)

1. A 45-year-old female gives a long history of numbness followed by pins and needles
in her hands especially in winters and upon washing her face or hands. She is unable
to fully extend her fingers because of light and inflexible skin of her fingers which
also appear shiny and without skin creases. Her nose is rather beaked, she is also
unable to open her mouth fully as it has grown smaller.
b) Describe three other findings in this case.
c) Describe serological tests which may be helpful in establishing the diagnosis.
2. A 40-year-old female complains of progressive tightness of skin of hands and face

with stiffness in the movement of fingers. She gave history of fingers turning cold
and blue during winter for las 10 years. Investigations revealed normal blood count,
46
raised ESR, positive anti-nuclear antibody (ANA) and negative rheumatoid factor. Her
uric acid was normal.
b) Enumerate one complication of this disease in GIT, pulmonary and renal system.
c) What medication is useful in the management of the renal complication in this
patient? [Supple 2015 held in 2016]
Rheumatoid Arthritis
1. A 25-year-old female presented to the OPD with complaints of multiple symmetrical
joint swellings and pain since last 2 months. She also complained of morning
stiffness for 1-2 hours.
a) What is the most probable diagnosis?
b) How will you investigate this patient?
c) How will you treat her? [Supple 2016 held in 2017]
2. A 42-year-old female presented with complaints of pain with swelling of small joints
of hands and feet for 3 months. Her labs show CBC: Hb 10 g/dL, TLC 6200/mm3,
Platelets count 165000/mm3 and ESR 75 mm in 1st hour and CRP 96.
b) What serological investigation should be advised?
c) What are the radiological findings expected on x-ray hand? [Annual 2014]
3. A woman in her mid-thirties started having stiffness of both hands on waking up in

the morning. This was followed by swelling of small joints of the hands.
a) Enlist possible causes.
b) How will you investigate this patient?
c) Enlist drugs used in this condition.
d) What are pulmonary complications of rheumatoid arthritis?
4. A 42-year-old housewife complains of low-grade fever and pain in the proximal

interphalangeal joints of both hands over the past 6 months. She has taken many
pain killers and antipyretics with some temporary relief.
a) Give three most likely diagnoses of her clinical condition.
b) Enumerate three most important investigations for this case.
c) Write down three appropriate treatment steps. [Supple 2012 held in 2013]
47
5. A 60-year-old man with rheumatoid arthritis has Hb of 8 g/dL. What are the possible
causes of his anemia? [Supple 2010 held in 2011]
6. A 32-year-old banker presents with 2 months history of fatigue with generalized

rashes and pain. For last couple of months, he feels very stiff in the morning and
finds it difficult to button up his shirt. On physical examination, he looks tired, he is
unable to extend or flex his fingers fully, both his knees are swollen, warm and
tender. He has no genital warts, or skin rash or scaly lesions but his right elbow
shows normal colored cystic/firm lesions near the olecranon process. His laboratory
investigations showed: Hb 12.3 g/dL, ESR 93 mm, SGPT 46, Uric acid 4.5, ANA
negative, Ca++ 9.05 mg
b) How will you manage this case? [Annual 2009]
7. A 32-year-old female complains of early morning stiffness of small joints of hands

and feet for the last six months. There are no urinary complaints but she has small
nodules near both elbows.
a) What is the most probable diagnosis?
b) List four specific investigations.
c) List four systemic complications of this condition. [Annual 2007]
Osteoarthritis
1. A 64-year-old man comes to you for the evaluation of knee pain. He tells you that he
had right knee pain for many years but recently it has gotten worse. He denies
constitutional symptoms and other joint pain except for his left second and third
DIPs. He has noticed stiffness in the morning. On examination, you hear crepitations
as you move his right knee but there is no evidence of swelling, warmth or erythema
of the knee. Laboratory testing is unremarkable.
b) How will you investigate the patient?
c) Give treatment plan. [Supple 2009 held in 2010]
Gouty Arthritis
1. A 34-year-old male presents with complaints of sudden onset pain in right knee joint
which is unbearable keeping him from doing any of his activities. He is a known
hypertensive, taking Lisinopril 10 mg twice a day, amlodipine 10 mg twice a day and
hydrochlorothiazide 25 mg in the morning. Right knee joint is swollen, red and
tender and all movements are restricted due to severe pain.
48
b) Give three differential diagnoses.
c) What is the most likely cause of this acute attack in this patient?
2. A 50-year-old politician who is being treated for hypertension presents to the

emergency at 3 am with an excruciating pain in his left big toe which on examination
is swollen, tender and has painful restriction of interphalangeal and
metatarsophalangeal joints. His BP is 150/100 mm Hg without any other clinically
detectable abnormalities.
b) Give four most important investigations in this case.
c) Enumerate the four most important steps in the management of this case.
[Annual 2012]
3. A 50-year-old lady on second post-operative day following hysterectomy developed

acute pain in left knee joint. On examination, left knee joint was swollen, hot and
tender.
a) Give three differential diagnoses in this patient for complaints of her left knee
joint.
b) Give three important investigations with interpretation of results to reach the
Septic Arthritis
1. A 50-year-old lady on second post-operative day following hysterectomy developed
acute pain in left knee joint. On examination, left knee joint was swollen, hot and
tender.
a) Give three differential diagnoses in this patient for complaints of her left knee
joint.
b) Give three important investigations with interpretation of results to reach the
Ankylosing Spondylitis
1. An 18-year-old boy presents with low backache that radiates to the buttocks and
back of thigh. There is associated stiffness that persists for more than half an hour.
Pain is worse at night and after inactivity and is relieved by activity. On
investigations, ESR and CRP are raised. ANA and rheumatoid factors are normal.
49
b) Name three investigations for the condition.
c) Name the three extra-articular manifestations of the disease.
d) What is the risk of transmission of disease from the patients to their children?
[Annual 2017]
Miscellaneous
1. A 20-year-old lady presented with polyarthralgia and fever for 3 months duration.
For last one week, she is complaining of edema feet and shortness of breath.
Examination reveals BP 140/100 mm Hg, pedal edema, raised JVP, heart examination
is normal, bilaterally reduced breath sounds at bases of the lungs, there is two
finger-breadth enlarged liver & ascites present in the abdomen.
a) What is the differential diagnosis?
b) Enumerate the investigations for this case. [Annual 2010]
2. A 35-year-old woman complains of pain and stiffness of both hands especially in the
morning. Blood test shows Hb 12 g/dl and ESR 65 mm in 1st hour. Rheumatoid factor
and ANA tests are negative.
b) What treatment may be indicated to relieve her symptoms?
c) What treatment may be indicated to stop further progression of disease?
50

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MEDICINE I – PAST QUESTIONS

2. An 18-year-old girl presents to emergency department with unproductive cough,

3. A 35-year-old male has been diagnosed as a case of pulmonary tuberculosis two

5. A middle-aged lady has presented with repeated attacks of cough and of

3. A 25-year-old gentleman presents with symptoms of low-grade fever, cough and

Pressure mm/Hg Saturation

2. Write short note on tension pneumothorax. [Annual 2013]

2. A 58-year-old hypertensive male presents with severe dyspnea. He gives history of

5. A poorly controlled hypertensive patient has come with progressive dyspnea on

6. A fifty-year-old person presents in the emergency wad with severe dyspnea. On

Acute Coronary Syndrome

2. A 50-year-old male presented in the emergency with severe central constricting

3. A 55-year-old smoker presented to emergency room with a complain of severe

5. A 50-year-old male known diabetic complained of pain in the epigastrium radiating

6. A 58-year-old male smoker complained of pain in the epigastrium radiating to the

2. An 18-year-old asymptomatic cade is found to have a blood pressure of 180/110 mm

3. Give four surgical remediable causes of hypertension.

4. A 17-year-old boy presents with BP of 190/110 mm Hg.

Mitral Valve Disease

2. A 28-year-old pregnant female in her third trimester is brought to the medical

2. A 65-year-old diabetic and hypertensive male patient presents with complaints of

Third Nerve Palsy

Amyotrophic Lateral Sclerosis

Opening pressure 13 cm of water

a) What is the likely diagnosis?

2. A 20-year-old girl who is a known patient of mitral stenosis is admitted in emergency

4. A 23-year-old male presents with complete flaccid paralysis of right side. On

Gastro-esophageal Reflux Disease (GERD)

2. A 26-year-old female presents with a complaint of difficulty swallowing which has

2. A 75-year-old man is brought to you with progressive difficulty in swallowing

2. A 35-year-old male seen in emergency department with 2 days history of coffee

7. A 15-year-old unmarried female is on maintenance L-thyroxine 50 ugm 3 tablets

6. A 43-year-old woman presents to you with 27 days history of watery, bloody

Irritable Bowel Syndrome

2. A 23-year-old male of normal built presents with complaints of crampy abdominal

Acute Hepatitis/Acute Liver Failure

2. A previously healthy 25-year-old pregnant female is admitted with 2 weeks history of

Pyogenic Liver Abscess

Non-Alcoholic Fatty Liver Disease

Primary Biliary Cirrhosis

3. A 25-year-old primigravida developed jaundice in the early third trimester of

4. A forty-year-old female presented with history of fatigue, generalized pruritus,

Hypochromic Microcytic Anemia

2. A sixty-year-old female presented with weakness and shortness of breath on

4. A 23-year-old non-diabetic presents with history of paresthesia in arms and legs. On

5. A 25-year-old female presents in medical outpatient with generalized body

6. A 58-year-old lady is complaining of easy fatigue, breathlessness as well as numbness

2. An 8-year-old girl presented with extreme pallor, gum bleed, purpura,

3. A 29-year-old woman presents to her gynecologist with menorrhagia. Her doctor

Venous Thromboembolic Disease

Systemic Sclerosis (Scleroderma)

2. A 40-year-old female complains of progressive tightness of skin of hands and face

3. A woman in her mid-thirties started having stiffness of both hands on waking up in

4. A 42-year-old housewife complains of low-grade fever and pain in the proximal

6. A 32-year-old banker presents with 2 months history of fatigue with generalized

7. A 32-year-old female complains of early morning stiffness of small joints of hands

2. A 50-year-old politician who is being treated for hypertension presents to the

3. A 50-year-old lady on second post-operative day following hysterectomy developed

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