MEDICINE OSPE

Brief .......................................................................................................................................... 3
X ray .......................................................................................................................................... 3
Skull X ray .............................................................................................................................. 3
Hereditary Haemolytic anaemia .......................................................................................... 4
Multiple osteolytic lesions/Multiple myeloma ....................................................................... 6
Chest X ray ............................................................................................................................ 7
Respiratory system ............................................................................................................. 7
CVS ...................................................................................................................................19
Abdominal X ray ....................................................................................................................19
Skeletal X ray ........................................................................................................................20
ECG ..........................................................................................................................................22
MI ..........................................................................................................................................22
Arrhythmia .............................................................................................................................26
Heart block ............................................................................................................................29
Hypertrophy ...........................................................................................................................30
Prescription writing ................................................................................................................32
Hypothyroidism......................................................................................................................32
Typhoid fever/Enteric fever ....................................................................................................33
Kala Azar...............................................................................................................................34
Malaria ..................................................................................................................................35
UTI ........................................................................................................................................37
Amoebic liver abscess ...........................................................................................................38
Instruments .............................................................................................................................39
Metered Dose Inhaler ............................................................................................................40
Feeding tube/Rylle’s tube/Nasogastric tube ...........................................................................41
Bone marrow aspiration needle .............................................................................................43
Lumbar puncture needle ........................................................................................................44
Intravenous Cannula .............................................................................................................45
Micro burette with infusion set ...............................................................................................46
Clinical problems ....................................................................................................................47
Acute leukaemia ....................................................................................................................47

1
 Aplastic anaemia ...................................................................................................................48
Obstructive jaundice with cholangitis .....................................................................................48
Iron deficiency anemia...........................................................................................................49
CLD with portal hypertension .................................................................................................50
Ruptured oesophageal varices due to CLD with portal hypertension .....................................50
Hepatic encephalopathy / Hepatic pre-coma .........................................................................51
Rheumatoid arthritis ..............................................................................................................52
Woman with fever and hepatosplenomegaly .........................................................................52
Acute viral hepatitis ...............................................................................................................53
Miscellaneous:.......................................................................................................................53
Clinical problems from Paediatrics.........................................................................................54
Acute watery diarrhoea ......................................................................................................54
Pneumonia.........................................................................................................................55
VSD and TOF ........................................................................................................................55
Data interpretation ..................................................................................................................57
Hyperkalaemia ......................................................................................................................57
Pyogenic meningitis...............................................................................................................58
Diabetic ketoacidosis .............................................................................................................59
Obstructive jaundice ..............................................................................................................60
Thyrotoxicosis .......................................................................................................................60
Photographs ............................................................................................................................61
Ring worm infection ...............................................................................................................62
Scabies .................................................................................................................................63
Psoriasis................................................................................................................................64
Acne vulgaris .........................................................................................................................66
Picture from Paediatrics: .......................................................................................................67
Xerophthalmia ....................................................................................................................67
Congenial hypothyroidism ..................................................................................................68
AGN and Nephrotic syndrome ...........................................................................................69
Growth Chart ...........................................................................................................................72

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Brief
Medicine OSPE: 10 stations; 8 from internal medicine, 2 from Pediatrics

Breakdown of the stations:

➢ X ray
➢ ECG
➢ Prescription writing
➢ Clinical problem based question
➢ Data interpretation based question
➢ Photograph
➢ Chart
o Growth chart
o Temperature chart

X ray

Skull X ray
Hereditary Hemolytic anemia ** (DU July 19, DU Jul 17,Jul 15)
Multiple osteolytic lesions **

3
Enlarged skull with enlarged pituitary fossa and erosion of anterior and posterior clinoid process

Hereditary Haemolytic anaemia

A 9-year-old boy came with the complaints of gradual pallor and history of repeated blood
transfusion since 2 years of age. On examination he had pallor and hepatosplenomegaly. X
ray of the skull was done. Study the X ray of the skull of this child and answer the
following questions

4
Mention 3 abnormalities in this x
ray
What is the most likely diagnosis?
Write down 4 clinical signs you
will look for
Mention 3 other investigations to
confirm diagnosis
Mention 1 investigation to confirm
diagnosis
Mention three principles of
treatment
Mention 4
complications/pathological
consequences of the conditions
5
1. Thinning of the outer table
2. Widening of the diploic space
3. Hair on end appearance due to thinning and
coarsening of trabeculae
Hereditary haemolytic anaemia
1. Anaemia
2. Jaundice
3. Splenomegaly
4. Mongoloid face
1. CBC
2. PBF
3. Haemoglobin Electrophoresis
…. If asked 4: write Iron Profile
….if asked 2: i. CBC with PBF, ii. Hb electrophoresis
Haemoglobin electrophoresis
1. Blood transfusion (Keep Hb >10 gm/dL)
2. Lifelong folic acid
3. Stem cell transplantation
4. Splenectomy
5. Iron chelation
1. Growth retardation
2. Splenomegaly (causing mechanical
discomfort)
3. Iron overload
 4. Extramedullary erythropoiesis leading to bone
fracture
5. Complication due to repeated blood
transfusion

Multiple osteolytic lesions/Multiple myeloma

Mention the radiological findings Multiple osteolytic lesions seen all over the skull
Mention 3 probable d/d 1. Multiple myeloma
2. Secondary metastasis to skull bone

6

Mention the most likely diagnosis
Mention 4 investigations for
diagnosis of the patient
Mention principles of treatment for
the most likely diagnosis
3. Hyperparathyroidism
4. Osteoporosis
Multiple myeloma
1. CBC (pancytopenia)
2. ESR (very high)
3. Serum protein electrophoresis
4. Bone marrow examination
5. Urine for Bens-Jones protein
1. Correction of anemia
2. Control of infection
3. Chemotherapy
4. Radiotherapy
5. Stem cell transplantation

Chest X ray

Respiratory system
Pleural effusion ** (DU Jan 19)
Pneumothorax ** (DU Jul 18, Jul 17, Jul 15)
Consolidation ** (DU Jan 17)
Tuberculosis ** (DU Oct 20)
Miliary mottling ** (DU Jan 13)
Lung abscess
Collapse (DU Nov 19)
Fibrosis (DU Nov 19)

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Pleural effusion
Mention three abnormalities in this x ray
Mention your radiological diagnosis
Mention 4 examination findings of this
patient
Mention the percussion and auscultation
findings of this patient
Enumerate 4 possible causes for this
condition
8
1. Dense homogenous opacity with
curvilinear upper margin occupying
the right middle and lower lung zones
2. Costophrenic and cardiophrenic
angles are obliterated on right side
3. Trachea is centrally placed (if
deviated, write so…)
Right sided pleural effusion
1. Inspection: restricted chest movement
on right side (affected side)
2. Palpation: trachea centrally placed,
restricted chest movement on right
side (affected side). Vocal fremitus is
diminished.
3. Percussion: dull percussion note on
right side (affected side)
4. Auscultation: diminished/absent
breath sound over right side/affected
side. Vocal resonance is diminished.
Write from above
1. Parapneumonic effusion
2. Pulmonary tuberculosis
3. Malignancy in lung
4. Pulmonary infarction
(P.S: here mention only unilateral cause,
all of them here are exudative cause)
Mention 2 atypical causes of unilateral 1. Liver abscess
right sided pleural effusion 2. Ovarian tumour (Meig’s syndrome)
What other investigations will you do to 1. Sputum smear examination
reach a diagnosis? 2. MT test and Genexpert test
3. CT scan of chest
4. Pleural fluid aspiration and study
5. Pleural biopsy
Name 3 complications of pleural effusion 1. Respiratory distress
2. Empyema (when the fluid gets
infected)
3. Iatrogenic pneumothorax (during
pleural fluid aspiration)

Left sided pleural effusion

(trachea centrally placed, but heart is shifted to the right)
Mention an atypical cause of unilateral left Acute pancreatitis
sided pleural effusion

9
Mention three abnormalities in this x ray
What is your radiological diagnosis?
Mention four probable causes of this
condition/ Mention one systemic disease
where similar radiological feature may
occur
10
1. Dense homogenous opacity with
curvilinear upper margin occupying
both right and left lower lung zones
2. Costophrenic and cardiophrenic
angles are obliterated on both sides
3. Trachea is centrally placed (if
deviated, write so…)
Bilateral pleural effusion
1. Congestive cardiac failure
2. Nephrotic syndrome
3. Liver cirrhosis
4. Hypothyroidism
5. PEM (protein energy malnutrition)
Pneumothorax

Write the important radiological findings i. Increased translucency in left lung

ii. Absence of broncho-vascular
marking
iii. Trachea and mediastinum shifted
to right side
iv. Collapsed lung margin can be seen
What is the most likely diagnosis? Left Sided Pneumothorax
Write down 4 important underlying causes Primary:
when it occurs spontaneously i. Ruptured subpleural
emphysematous bulla
Secondary
i. COPD
ii. Pulmonary TB
iii. Asthma
iv. Lung abscess
v. Bronchogenic carcinoma
Write down 4 secondary causes of this (write the secondary causes from above)
condition
Mention 3 important physical sings you Inspection:
expect during percussion and auscultation of i. Restricted movement of lung of left
the chest (affected) side
Palpation
ii. Trachea apex beath shifted to the
right (opposite side)
iii. Vocal fremitus – reduced on the
(left) affected side
Percussion
i. Hyper-resonance on left (affected
side)
**if it was right sided: upper border of liver
dullness is lower than normal

11
 Auscultation
i. Breath sound: diminished/absent
on left (affected side)
ii. Vocal resonance:
diminished/absent on left (affected
side)

12
Consolidation

Write important radiological findings. i. Homogenous opacity involving

the upper zone and middle zone
of right lung field
ii. Trachea and mediastinum are
centrally placed
What is the most likely diagnosis? Right upper lobe consolidation
Mention three (3) important physical sings a. Bronchial breath sound
you expect during auscultation of the chest. b. Increased vocal resonance
c. Crepitation (during resolution stage)
d. Pleural rub (if pleurisy_
Mention the respiratory findings of this patient Inspection: restricted movement on right
upper side
Palpation: trachea, apex beat centrally; vocal
fremitus increased
Percussion note: Woody dull
Auscultation: from above
Write five (5) investigations for this patient a. CBC with ESR,
b. Sputum for Gram staining,
c. Sputum for C/S,
d. Blood for C/S,
e. Serum electrolyte,
f. Blood urea,
g. Arterial Blood Gas analysis (ABG).
Mention four (4) common complications that a. Pleural effusion
may occur b. Lung abscess
c. Septicemia

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 d. Pericarditis
e. Myocarditis
f. ARDS
g. Atrial fibrillation
h. Respiratory failure
Mention the criteria for assessment of CURB-65 score
severity of this condition C: Confusion
U: Blodd urea >7 mmol/L
R: respiratory rate >30/min
B: SBP <90 mm Hg, DBP <60 mm Hg
65: Age ≥ 65 y
Write down the treatment of community General treatment
acquired pneumonia Rest, oxygen therpy, adequate hydration,
chest physiotherapy
Antibiotic:
Uncomplicated CAP: amoxicillin 500 mg 8
hourly IV
Complicated CAP: Clarithromycin 500 mg 12
hourly + Co-Amoxiclav 1-2 gram 8 hourly

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Tuberculosis

Write down 3 important radiological findings 1. Patchy opacities involving upper

zone of right/left lung
2. Trachea and mediastinum is
centrally located
3. Costophrenic + cardio phrenic angles
are clear on both sides
4. There is no bony lesion
Write down the most common cause of such Pulmonary tuberculosis
findings in our country
Write down 3 other important laboratory 1. Sputum for acid fast bacilli
investigations to support the diagnosis 2. Mantoux text
3. Genexpert test
4. CBC, ESR

15
Write down the radiological abnormalities a. Multiple Miliary mottling involving all
zones of both lung fields
b. Trachea and mediastinum is centrally
located
c. Costophrenic + cardiophrenic angles
are clear on both sides
d. There is no bony lesion
What is the most common radiological Miliary tuberculosis
diagnosis in our country?
(if question asks only diagnosis: write
Multiple military mottling in all zones of
both lungs, most probably due to
pulmonary tuberculosis)
Write 4 differential diagnosis of this X ray / a. Miliary tuberculosis
Name one systemic disease where similar b. Sarcoidosis
radiological feature may occur c. Histoplasmosis
d. Pulmonary eosinophilia
e. Pneumoconiosis
f. Fibrosing alveolitis

16
Write down 4 other important laboratory 1. CBC, ESR
investigations to establish etiological 2. Sputum for AFB
diagnosis (other than CXR) 3. MT test
4. Biopsy of pleura, lymph node, solid
lesion in the lung
5. Genexpert/PCR test
Write down the treatment of the commonest 4FDC (HRZE) for 2 months, and 2FDC (HR)
cause for 4 months
H= Isoniazid, R = Rifampici, Z =
Pyrazinamide, E = Ethambutol

17
Collapse, Fibrosis

Write down 4 radiological abnormalities i. Homogenous opacity involving

present in this x ray whole of right lung field
ii. Trachea shifted to the right
iii. Mediastinum shifted to the right
iv. Compensatory hypertranslucency
on the left side
v. Right dome of the diaphragm is
elevated
vi. Rib crowding present on the right
side of the chest
Mention 2 differential diagnosis 1. Right lung collapse
2. Right lung fibrosis

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 3. Resection of right lung
Write 4 symptoms of this patient i. Cough
ii. Shortness of breath
iii. Chest pain
iv. Hemoptysis
v. Fever
vi. Weight loss

CVS
Cardiomegaly with oligaemic lung field
Cardiomegaly with plethoric lung field

Abdominal X ray
Pneumoperitoneum
Pancreatic stone
Gall bladder stone
Renal Stone

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Skeletal X ray
Scurvy **
Rickets ** (DU Jul 18, Jan 17)

Identify three (3) radiological abnormalities a. Widening, cupping and fraying of

metaphysis/lower end of radius and ulna
c. Increased gap between the metaphysis
and epiphysis
d. Osteopenia of radius and ulna
What is the diagnosis? Rickets
Mention three (3) findings on physical a. Bowing legs
examination. b. Knock-knee
c. Rachitic rosary
d. Harrison sulcus
e. Short stature
f. Craniotabes
g. bossing of frontal and parietal bones
h. delayed closure of anterior fontanelle

20
Write down three (3) important investigations a. S.calcium
b. S. phosphate
c. S. alkaline phosphatase
d. Parathyroid hormone level
e. Vitamin D assay

21
ECG

MI
(DU July 2019, Jan 17)

Anterior MI **
Inferior MI **
Lateral MI
Posterior MI
Anteroseptal MI

a. ST segment elevation in II, III, aVF

b. Pathological Q wave in II, III, aVF
c. T inversion in II, III, aVF
Acute ST Elevated Inferior MI

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ST elevation in V2, V3, V4
Pathological Q wave in V1, V2
Hyperacute T waves in V2, V3, V4

Hyperacute ST elevated Antero-septal MI

**here, lead V1,2,3,4 are involved, so antero-septal

If T wave was inverted (rather than being hypercute), the dx would have been Acute ST
elevated antero-septal MI

23
24
Write down the three (3) important abnormal a. ST segment elevation in II, III, aVF and V1
ECG findings to V6
b. Pathological Q wave in II, III, aVF and V1
to V6
c. T inversion in V1 to V6
What is your ECG diagnosis? Acute Anterior and Infection ST elevated
Myocardial infarction
Write five (5) investigations necessary for this a. Cardiac enzyme- Troponin I
patient b. Echocardiogram
c. CAG (Coronary Angiogram)
d. Blood sugar
e. Lipid profile
f. S. creatinine
g. S. electrolyte
h. CBC with ESR
Mention three (3) immediate complication of a. Acute Left Ventricular failure (ALVF)
this patient b. Cardiogenic shock
c. Arrhythmia/Heart
block/AF/VF/Bradycardia
d. Rupture of Papillary muscle/Rupture of
inter-ventricular
septum
e. Thromboembolism

**PS: if ECG shows inferior MI: write

“Heart block” and “Bradycardia” as 1st
complication, then the others
If ECG shows any ECG that has anterior
MI, write ALVF and Cardiogenic shock
1st,then the rest
Mention 3 immediate management for this i. Hospitalization
patient ii. Oxygen administration
iii. 300 mg clopidogrel, 300 mg
aspirin
iv. IV Morphine/pethidine

25
Arrhythmia
Atrial Fibrillation **(DU Oct 20, May 19, Jul 18, Jan 13)
Supra ventricular tachycardia (SVT) **
Ventricular Tachycardia
Ventricular fibrillation

Write down 4 important abnormal ECG 1. P wave absent

findings 2. R-R interval irregular (irregular rhythm)
3. Fibrillatory “f” waves present
4. Heart rate is 104 beats per minute

(here, 18 QRS complexes seen in the 10 seconds

recorded activity on ECG paper. 18 in 10 seconds,
so 18x6=104 in 60 seconds)
What is the most likely diagnosis Atrial fibrillation
Mention 4 important causes of this ECG 1. Mitral valvular heart disease (esp. mitral
change stenosis)
2. Ischemic heart disease
3. Thyrotoxicosis
4. Hypertension
5. Lone atrial fibrillation
6. Atrial septal defect
7. Myocarditis
8. Cardiomyopathy
9. Acute pericarditis
10. Thoracic surgery

26
Mention 4 important physical signs of the
patient
Write down 2 important complications of
this case
1. Pulse: irregularly irregular
2. BP: maybe hypertensive
3. JVP: absence of A wave
4. Examination of precordium: pulse deficit
present, valvular abnormality maybe
present
5. Thyroid gland status: gland maybe
enlarged
1. Systemic and pulmonary embolism leading
to: Cerebrovascular disease (stroke),
Peripheral vascular disease, Mesenteric
ischemia, Pulmonary embolism
2. Heart failure

Or…like this

1. Cerebro vascular disease

2. Peripheral vascular disease
3. Mesenteric ischemia
4. Pulmonary embolism
5. Heart failure
Write down the specific treatment in 1. Control of heart rate: Beta blocker,
symptomatic patient Calcium channel blocker (verapamil)
2. Restore + maintain sinus rhythm: DC
conversion, Beta blocker
3. Treatment of the underlying cause
4. Prophylaxis against thromboembolism:
warfarin, aspirin
What other investigations will you 1. Echocardiogram
suggest? (not DU) 2. Thyroid function test
3. Exercise tolerance test

27
Write down 4 important ECG findings 1. Heart rate is 150 bits per minute
(tachycardia)
2. P wave absent
3. R-R interval same/rhythm is regular
4. Narrow QRS complexes
What is your diagnosis? Supraventricular tachycardia
Mention 4 physiological and 2 pathological Physiological:
causes of this 1. Anxiety
2. Tea
3. Coffee
4. Alcohol

Pathological:
1. Ischemic heart disease
2. Thyrotoxicosis
3. Drug toxicity: Digoxin
What are the clinical presentation of this 1. Palpitation
2. Breathlessness
3. Dizziness
4. Syncope
Mention 2 non pharmacological and 2 Non pharmacological
pharmacological approaches to treatment 1. Carotid sinus massage
2. Direct cardioversion (DC shock)
3. Valsalva manoeuvre

Pharmacological:
1. IV adenosine
2. IV verapamil
3. Beta blocker

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Heart block
1st degree Heart block **
2nd degree heart block
Complete heart block ** (DU 19)

Write 4 important abnormal ECG findings i. PR interval variable

ii. PP interval fixed
iii. RR interval fixed
iv. Heart rate: 42 beats per minute
(bradycardia)
What is your ECG diagnosis? Complete heart block
Write down 4 clinical signs you will look for i. Bradycardia
this case ii. High volume pulse
iii. Wide pulse pressure
iv. Cannon wave in neck
v. Variable intensity of 1st heart
sound
Mention 4 important cause of this ECG i. Acute myocardial infarction
change ii. Drugs: beta blocker
iii. Cardiomyopathy
iv. Myocarditis
v. Endocarditis (infective…)
vi. Idiopathic fibrosis
vii. Collagen disease (SLE, RA)
Mention the definitive treatment of this i. Temporary pacemaker followed by
condition Permanent pacemaker
Mention one important complication of this i. Cardiac arrest
condition

29
Hypertrophy
Left ventricular hypertrophy (LVH) **
LVH with strain ** (DU Jan 19, Jul 15)

Write down 3 important abnormal ECG 1. Rhythm is regular

findings 2. Heart rate: 75 beats/min (count whatever
is during the exam)
3. S in V1 + R in V6 > 35 mm (here, 50 mm)
4. T inversion in v5 and v6
What is your ECG diagnosis? Left Ventricular Hypertrophy with strain

**if there is no T inversion, the Dx will be only

LVH
Mention 4 important causes of this ECG a. Hypertrophic obstructive cardiomyopathy
change b. Systemic hypertension
c. Aortic stenosis and regurgitation
d. Mitral regurgitation

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 e. Coarctation of aorta
f. Patent ductus arteriosus
Mention 2 different D/D 1. Hypertrophic cardiomyopathy
2. Subendocardial MI
What are the clinical findings on palpation 1. Apex bit shifted
of precordium 2. Heaving type of apex beat (lifts finger and
the force is sustained)
Complication of LVF 1. Left ventricular failure
How will you manage the case 1. Hospitalization
2. Propped up position
3. Inj.Frusemide
4. Inj. Morphine
5. ACE inhibitor
6. Beta blocker

31
Prescription writing
Enteric fever ** (DU Jan 19, Jul 10)
Tuberculosis ** (DU July 19, Jan 17)
UTI ** (DU Jul 18, Jul 17)
Hypothyroidism ** (DU Oct 20, May 19)
Malaria ** (DU Jul 15)
Amoebic liver abscess (DU Nov 19)
Kala azar (DU Jan 13)
Intestinal Amoebiasis
Acute viral hepatitis

Hypothyroidism
Write down a prescription for a 35 year old woman who has been suffering from primary
hypothyroidism
Name (0.5)….Age (0.5)… Sex: Female…Age….35 years…… Weight: ……Date
…………………..
Diagnosis: Primary Hypothryoidism Rx:

Investigation: 1. Tab Thyroxine 50 micrograms

1. Serum TSH 1+0+0 before breakfast for 3 weeks
2. Serum T3, T4 (once daily before breakfast for 3
3. Serum lipid profile weeks), then:
4. ECG 2. Tab Thyroxine 100 micrograms
1+0+0 before breakfast for 3 weeks,
then
3. Tab. Thyroxine 150 micrograms
1+0+0 before breakfast, lifelong

Advice:
1. Take medicine regularly according to
prescription
2. Consult doctor with the investigation
reports after 6 weeks

Doctors name:……..
Registration number:…….
Doctor’s signature:……..

32
Typhoid fever/Enteric fever
Write down a prescription for a 35 year old woman who has been suffering from typhoid
fever (only 1 drug to be prescribed)
Name (0.5)….Age (0.5)… Sex: Female…Age….35 years…… Weight: ……Date
…………………..
Diagnosis: enteric fever Rx

Investigations: 1. Cap. Cefixim 400 mg

1. Blood culture 1+0+1 after meal for 14 days
2. Widal test (1 tablet, 12 hourly, for 14 days after
3. CBC with ESR meal)
2. Tab Paracetamol 500 mg
In full stomach in case of fever
(don’t write this if only 1 drug is to be
prescribed. In that case write in
advice)

Advice:
1. Tepid sponging and Paracetamol
tablet if temperature is high
2. Take plenty of water
3. Follow normal diet

Doctors name:……..
Registration number:…….
Doctor’s signature:……..

33
Kala Azar
A 30 year old woman (weight 45 kg) is diagnosed as a case of Kala-azar. Write down a
prescription for her with an oral drug
Name (0.5)….Age (0.5)… Sex: Female…Age….30 years…… Weight: 45 kg…Date
…………………..
Rx
Diagnosis: Kala Azar
1. Cap. Miltefosine 50 gm
Investigations: 1+0+1 after meal, for 28 days
1. CBC (1 capsule 12 hourly after meal for 28
2. ICT for Kala Azar days)
3. Bone Marrow Biopsy for LD body 2. Tab. Paracetamol 500 gm
1+1+1+1 after meal for 5 days
(1 tabley 6 hourly after meal for 5
days)

Advice:
1. Follow normal diet
2. Complete the course of medicine
3. Meet the doctor again after 28 days

Doctors name:……..
Registration number:…….
Doctor’s signature:……..

34
Malaria
A 30-year-male presented to you with a history of fever for 5 days. He had a history of travel
to Rangamati 26 days ago. His blood picture shows malarial parasite (Plasmodium
falciparum). Write down a prescription for this patient.
Name (0.5)….Age (0.5)… Sex: Male…Age: 30 years…… …….…Date …………………..
Chief complaints: Rx
1. Fever for 5 days
2. History of travelling to Rangamati 26 1. Tab Co-Artem (Artemether 20 mg+
days ago Lumefantrine 120 mg combination)
4 tablets at a time, on 6 occasions
Diagnosis: Falciparum Malaria each (total 24 tablets), at 0, 8, 24, 36,
Investigation: 48, 60 hours
Presence of malarial parasite (P. falciparum)
2. Tab Primaquin 0.25 mg/Kg once only,
on 1st day of the treatment

Advice:
1. Complete the course of treatment
adequately
2. Plenty of fluid
3. Rest
4. Cold sponging
5. Report immediately if symptoms like
jaundice, inadequate/dark urination,
drowsiness etc. develop.

Doctors name:……..
Registration number:…….
Doctor’s signature:……..

(**here weight of patient is not given, if wt is

given, write according to that the dose of
primaquine)

35
Tuberculosis
A 45 year-old-male (weight-45kg) diagnosed as a case of smear +ve pulmonary
tuberculosis. He is on oral hypoglycaemic agent and his postprandial blood sugar is
15mmol/L. You have decided to give Category-1 anti-tubercular therapy.
Write down a prescription for him.

A 35 year old male (weight-45 kg) diagnosed as a case of smear +ve pulmonary
tuberculosis. You are asked to prescribe Category-1 anti tubercular therapy. Write down a
prescription for him.
Name (0.5)….Age (0.5)… Sex: Male…45 years…… Weight: 45 kg…Date …………………..
Chief complaints: Rx
1. Cough and low grade fever for 1
month 1. Tab 4FDC
2. Anorexia and weight loss for same (containing Isoniazid, Rifampicin 150
duration mg, Pyrazinamide 400 mg,
Ethambutol 275 mg)
Examination findings: 3+0+0, three tablets, once daily,
before meal, for 2 months; then:
Diagnosis: Pulmonary tuberculosis 2. Tab 2FDC
(containing Isoniazid 75 mg,
Investigations: Rifampicin 150 mg)
1. Sputum for AFB 3+0+0, three tablets, once daily,
2. X ray Chest PA view before meal, for 4 months
3. MT test 3. Tab Pyridoxin 20 mg
1+0+0, once daily for 6 months

Advice:
1. Don’t discontinue drug without
consultation of physician
2. There maybe orange discoloration of
the urine, stool, sweat but it is
harmless
3. Report immediately if you have
jaundice, visual disturbance, or any
other problem
4. Follow up 2 months later

Doctors name:……..
Registration number:…….
Doctor’s signature:……..

36
UTI
Write down a prescription for a 30 year old pregnant female who has been suffering from
uncomplicated urinary tract infection.
(Only one drug is to be prescribed)
Name (0.5)……………….. Age (0.5)……30 years…Sex: female ………Date (0.5)……………
Chief complaints: Rx

Examination findings: Cap. Cefixime 200 mg

1 capsule twice daily, 12 hourly
Diagnosis: Uncomplicated Urinary tract 1+0+1, for 7 days
infection
Advice: (any 2)
Investigations: i. Take plenty of fluid
ii. Regular complete emptying of
bladder
iii. Emptying of bladder before and
after sexual intercourse

Doctors name:……..
Registration number:…….
Doctor’s signature:……..

37
Amoebic liver abscess
A 35 year old man diagnosed as a case of amoebic liver abscess from clinical and
laboratory investigations. Write down a prescription using one effective drug
Name (0.5)………………..Age (0.5)……35 years…Sex: male ………Date (0.5)…………
Chief complaints: Rx:

Examination findings: Tab Metronidazol 400 mg

2 tablets, Three times daily
Diagnosis: Amoebic liver abscess 2+2+2, for 5 days

Investigations: Advice: (any 2)

1. Regular intake of drugs
2. Drinking safe water
3. Don’t take uncooked food

Doctors name:……..
Registration number:…….
Doctor’s signature:……..

38
Instruments
AMBU Bag **
Lumbar Puncture needle ** (DU Nov 19, Jan 19, Jul 18, Jul 17, Jul 15)
Bone marrow aspiration needle ** (DU May 19, Jan 19, Jul 18, Jan 13)
Cannula (DU July 19)
Microburette with infusion set (DU Nov 19)
Infusion fluid
(Cholera Saline **
Normal Saline **
DNS **
Baby Saline **
Junior Saline
Electro-dex-10)
Nasogastric tube/Feeding tube ** (DU Oct 20, Jul 19, Jul 15)
MUAC Tape **
Metered dose inhaler (DU Oct 20)Jan 17)
Nebulizer
Peak flow meter

39
Metered Dose Inhaler

Identify the instrument Metered dose Inhaler (MDI)

Write down 2 important diseases where this a. Bronchial asthma
device can be used b. Chronic Obstructive Pulmonary Disease
Write down 4 important drugs which can be a. Salbutamol (SABA)
used through this device b. Salmeterol (LABA)
c. Steroid /Fluticasone/ Budesonide/
Beclomethasone
d. Ipratropium bromide (LAMA)
e. Na cromoglycate
Mention its parts (not DU) 1. Mouth piece with cap
2. Canister
3. Actuator
4. Nozzle
Mention the advantages of inhaler over oral 1. Direct application at site of action
therapy 2. Rapid onset of action
3. Lower systemic side effects

40
Feeding tube/Rylle’s tube/Nasogastric tube
Identify the supplied instrument
Mention 4 indications of its use
State one special indication of using this
instrument in case of children
Mention 2 contraindications of its use
Mention 2 complications
41
Nasogastric tube/Ryle’s tube
a. Nasogastric feeding
b. Stomach wash/Gastric lavage
c. Nasogastric suction
d. Deflation of stomach in intestinal
obstruction/acute abdomen
e. Nasogastric medication
f. Collection of gastric juice for analysis
Feed preterm very LBW baby unable to suck
breast milk/spoon feed
a. Corrosive poisoning/Kerosene
poisoning
b. Patient with coma
c. Nasal obstruction
d. Choanal atresia
e. Oesophageal fistula
f. Trachea-oesophageal fistula
1. Injury to nose, pharynx, esophagus
2. Perforation of nose, pharynx,
oesophagus
3. Aspiration pneumonia
4. Violent cough
5. Infection
How will you measure the length to be
introduced?
Mention 3 measures that can confirm the
correct position of the instrument after
introduction
42
Measure the length from tragus/ear lobule to
ear to the alae nasi/tip of nose to the
xiphisternum
a. Syringing and aspiration of the
stomach content
b. Auscultation of the abdomen after
providing air through the tube
c. Bubble appears in water when it
enters the lungs
d. Violent coughing of the patient when
the tube enters the airway
Bone marrow aspiration needle
Identify the instrument
Mention its parts
Write down 4 important indications of
using this instrument
Write down the common site of
introduction of this instrument
Write down the contraindications of using
this instrument
Write down one/two complication of using
this instrument.
43
Bone marrow aspiration needle
1. Trocar with knob
2. Cannula
3. Adjustable guard
1. Hematological disease: Leukaemia,
Lymphoma, Idiopathic thrombocytopenic
purpura
2. Infectious disease: Kala Azar
3. Storage disease: Gaucher disease
4. Bone marrow transplantation
Children <2 years: medial aspect of upper end
of tibia
Children >2 years: posterior iliac crest
1. Local skin infection
2. Known case of Haemophilia
3. Patient on anticoagulant therapy
4. Bone disorders: Osteomyelitis
1. Local suction pain
2. Introduction of infection
3. Haemorrhage
4. Shock
Lumbar puncture needle

Identify the instrument Lumbar puncture needle

Mention its parts i. Trocar
ii. Cannula
Write down 4 important indications i. Meningitis
of using this instrument ii. Encephalitis
iii. Sub-arachnoid hemorrhage
iv. Guillain Barre Syndrome
v. Multiple sclerosis
vi. Spinal anaesthesia
vii. Intra-thecal injection
(the last 2 are therapeutic indications, the rest are
diagnostic)
Mention the common site of Between the L3 and L4 vertebra
introduction of this instrument (in
adults)
Write down the contraindication of i. Papilledema/evidence of raised Intra-cranial
using this instrument pressure
ii. Local infection
iii. Local bed sore
iv. Coagulation disorder
v. Thrombocytopenia (<1 lac/cubic mm)
Mention 1/2 complication of using i. Herniation/coning
this instrument ii. Introduction of infection
iii. Post Lumbar puncture headache
iv. Bleeding
v. CSF leakage
vi. Injury to IV disc

44
Intravenous Cannula

Identify the instrument Intravenous cannula

Mention the parts 1. Trocar
2. Cannula proper
3. Protective cap
What is its size (please write according to the color provided)

Yellow: 24 gauge
Blue: 22 gauge
Pink: 20 gauge
Green: 18 gauge
Grey: 16 gauge
Brown: 14 gauge
Write down 4 (four) important 1. Administration of Intra venous fluid
indications of using this instrument 2. Blood transfusion
3. Intravenous medication
4. Parenteral nutrition
What are the advantages of using this 1. Can be kept in situ for a longer time
instrument 2. Patient doesn’t need to be pricked multiple
times to administer medication
3. Blood sample can be collected without
needing to prick multiples times
4. Less risk of thrombosis in vein
Write down 2 (two) complications of 1. Hematoma formation
using this instrument 2. Embolization
3. Thrombophlebitis
4. Ascending infection
Mention 2 (two) infections which may be 1. Staphylococcus epidermidis (coagulase -ve
introduced by using this instrument staphylococci)
2. Candida albicans (Immunocompromised
patients)

45
Micro burette with infusion set
Mention the name of this instrument
Write down 2 indications of its use in child
Name 1 advantage of its use in child
46
Microburette with infusion set
i. To give IV fluid in children
ii. For giving medication in children
i. Less chance of fluid overload
ii. Small volume of fluid can be given
iii. Antibiotics can be given slowly
Clinical problems
Acute leukaemia (DU Oct 20, May 19)
Aplastic anaemia (DU Nov 19)
IDA (DU Jul 18, Jan 13)
Fever with hepatosplenomegaly (DU July 19, Jan 17)
Obstructive jaundice (DU Oct 20)
CLD (DU July 19, Jan 13)
Hepatic encephalopathy (DU Nov 19)
Acute viral hepatitis (DU Jan 19, Jul 17)
Rheumatoid arthritis (DU Jan 19, Jul 17, Jul 15)

Acute leukaemia
A 25-year-old man presented with high grade fever for 3 weeks and glum bleeding for 2
weeks. On examination he was severely anemic and having generalized lymphadenopathy
and sternal tenderness.
What is your clinical diagnosis? Acute leukaemia
Mention 3 other important physical sign you 1. Bony tenderness
look for in favour of your diagnosis 2. Hepatomegaly
3. Splenomegaly
4. Purpura
Write down 3 important investigations 1. CBC with ESR
2. Peripheral blood film
3. Bone marrow study
Write down the principles of management for 1. Blood transfusion (to correct anemia)
him 2. Platelet transfusion
3. Antibiotic: Correction of infection/fever
4. Chemotherapy
5. Hematopoietic stem cell
transplantation (Bone marrow
transplantation
6. Allopurinol: to prevent hyperuricemia

47
Aplastic anaemia
A 25 year old man, tannery worker presented with progressive generalized weakness, fever,
purpuric rash and bleeding for 1 month. He was found to be severely anaemic, but there was
no bony tenderness or organomegaly.
What is the most likely diagnosis? Aplastic anaemia
Suggest 3 investigations to support your i. CBC with ESR
diagnosis ii. Peripheral blood film
iii. Bone marrow examination
Write down 4 different treatment options in i. Blood transfusion
management of this case ii. Bone marrow/stem cell transplant
iii. Immune-suppressants
iv. Bone marrow stimulants
v. Antibiotics/antiviral/antifungal
Name 2 differential diagnosis of this condition i. Aplastic anaemia
ii. Subleukemic acute leukaemia

Obstructive jaundice with cholangitis

A 50 year old man presented with abdominal pain, pale coloration of stool and generalized
itching for 1 month. One examination he was deeply icteric and temperature was 100 degree
F
What is the most likely diagnosis? Obstructive jaundice with cholangitis
Mention 5 investigations you will advice in a. Serum Bilirubin
this case? b. Serum ALP
c. USG of whole abdomen
d. CT scan of Hepatobiliary
system/abdomen
e. MRCP
f. CBC with ESR
g. ERCP
Write down 4 underlying causes of this a. Choledocholithiasis
condition b. Ca head of pancreas
c. Cholangiocarcinoma
d. Periampullary carcinoma
e. Biliary stricture
f. Biliary ascariasis
g. Intrahepatic cholestasis
h. Compression by lymph node

48
Iron deficiency anemia
A 30-yr-old female presented with generalized weakness and pallor. On clinical examination,
she had moderate anemia and koilonychia
Alternate scenario: A 35 year-old woman presented with progressive generalized weakness
and palpitation for 3 months. She had H/O menorrhagia for 5 months. On examination, she
had koilonychia, anemia and no organomegaly
What is the likely diagnosis?
Mention 3(three) points in favour of your
diagnosis in this scenario
Mention 3 investigations to confirm your
clinical diagnosis
Write 3 (three) investigations to confirm your
diagnosis with findings
Name the oral drug with duration of treatment
Write down the 3 common causes of the
above condition in Bangladesh
49
Iron deficiency anaemia
1. Anemia/Pallor
2. Koilonychia
3. Glossitis, angular cheilosis
4. (If present) history of menorrhagia
1. CBC with ESR
2. Peripheral blood film
3. Serum Iron Studies
4. Bone marrow study (write last if asks
4)
1. CBC with ESR: low Hb%, low RBC
count, MCV low, MCH and MCHC low
2. Peripheral blood film: microcytic
hypochromic RBC, anisocytosis,
poikilocytosis, pencil cells
3. Serum Iron Studies
Serum Ferritin, Serum Iron, %
saturation of transferring receptor:
reduced; TIBC: increased
Ferrous Sulphate for 3-6 months
1. Hookworm infestation
2. Repeated pregnancy/childbirth
3. Reduced dietary intake
4. Menstrual loss
5. Chronic peptic ulcer disease
CLD with portal hypertension
A 50-year-old male presents in emergency with massive hematemesis and melaena. On
examination, he was found to be jaundice, gynecomastia and spider naevi
What is the most likely diagnosis? Chronic Liver Disease with Portal
Hypertension
What is the likely source of bleeding? Ruptured oesophageal varices
Mention 3 (three) signs you may get on 1. Flapping tremor
examination of hand of this patient. 2. Leukonychia
3. Palmar erythema
4. Clubbing
5. Dupuytren’s contracture
Mention 6 (six) investigations necessary for 1. Upper GIT endoscopy (write this if
him scenario has bleeding, otherwise
don’t write it)
2. Serum Prothrombin Time
3. Serum ALT
4. Serum Bilirubin
5. USG of whole abdomen
6. Viral Markers for Hepatitis B and E
7. Liver Biopsy

Ruptured oesophageal varices due to CLD with portal

hypertension
A 40 yrs old male presented in Emergency room with haematemesis and melaena. On
examination, he had leuconychia, spiders in his chest and splenomegaly
What is the likely cause of haematemesis Ruptured oesophageal varices due to CLD
and melaena with portal hypertension
Mention one investigation to confirm your Upper GIT Endoscopy
clinical diagnosis
Mention 3 important investigations to assess 1. Haemoglobin percentage
prognosis 2. Serum Bilirubin
3. Serum Prothrombin Time
4. Serum ALT
Mention 5 emergency steps to be taken for 1. Resuscitation with wide bore IV
his management access, IV fluid and emergency blood
transfusion
2. Vasopressor agents: Terlipressin,
Octreotide
3. Upper GIT endoscopy
4. Endoscopic Band ligation of varices
5. Balloon tamponade
6. Trans-jugular intra hepatic porto-
systemic shunt (TIPSS)

50
Hepatic encephalopathy / Hepatic pre-coma
A 50-year-old known case of cirrhosis of liver presents with disorientation for 2 days. On
examination he has flapping tremor with bilateral plantar extensor response. Answer the
following questions.
What is the most likely diagnosis? Hepatic encephalopathy / Hepatic pre-
coma
Mention 6 investigations necessary for him i. Serum bilirubin
ii. Prothrombin time
iii. Serum albumin
iv. USG of whole abdomen
v. Renal function test (S.
creatinine/BUN)
vi. Serum electrolyte
vii. EEG
viii. Arterial blood ammonia
ix. Arterial blood gas analysis
Write down six important management steps i. Hospitalization
for him ii. Identify and remove precipitating
factors, if any
iii. Maintain nutrition and fluid
iv. Correct electrolyte imbalance
v. Reduce ammonia (NH3) load
vi. Treat constipation by laxatives
vii. Treat infection If present
viii. Stop diuretic

51
Rheumatoid arthritis
A 25-year-female presented with polyarthritis involving small and large joints of both upper
and lower limbs for 1 year. She gave H/O morning stiffness for 2 hours

Alternate scenario: : A 35-year-female presented with polyarthritis involving small and large
joints of both upper and lower limbs for 1 year. She gave H/O morning stiffness for 1 hour
What is your clinical diagnosis? Rheumatoid arthritis
Mention 3 deformities which may be found in i. Swan neck deformity
the hand ii. Boutonniere deformity
iii. Z deformity
iv. Ulnar deviation
v. Dorsal subluxation
vi. Triggering of finger
Write 4 important investigations used to i. ESR
support your diagnosis ii. CRP
iii. RA test
iv. Anti CCP Antibody
v. Xray hand/involved joint.
What are the groups of drugs used in this i. Analgesic/NSAID: Ibuprofen/ Naproxen
condition? ii. DMRD (disease modifying anti-rheumatic
Mention 4 groups of drugs with example from agents: Methotrexate/Sulfasalazine/
each group Hydroxychloroquine
iii. Biologics: Adalimumab/ Infliximab
iv. Steroid: Hydrocortisone

Woman with fever and hepatosplenomegaly

A 35 year old female presented with fever for 3 months. On examination she had
hepatosplenomegaly.
Write down 4 important d/d a. Kala-azar,
b. Malaria,
c. Chronic myeloid leukaemia (CML)
d. Lymphoma
Mention 4 other important physical signs you a. Bleeding manifestation/ purpura/gum
will look for bleeding,
b. Anaemia,
c. Jaundice,
d. Lymphadenopathy,
e. Bony tenderness.
Write down 5 investigations to reach a a. CBC with ESR
diagnosis b. PBF
c. Bone marrow
d. Rk39/ DAT/ Serology for kala-azar
e. Splenic puncture/ Splenic puncture for LD
bodies
f. CXR

52
Acute viral hepatitis
A 30-year-female presented with the complaints of malaise for 10 days followed by profound
anorexia, vomiting and upper abdominal discomfort with high color urine for 5 days
What is your clinical diagnosis Acute viral hepatitis
Write 4 important physical signs you may get a. Jaundice
in this case b. Tender+ hepatomegaly
c. Flapping tremor
d. Level of consciousness/Orientation
f. Bilateral plantar extensor
g. Fever
Write 4 important investigations you will do in a. Serum bilirubin
this case b. ALT
c. Prothrombin time
d. Viral markers
e. Ultrasonography of hepatobiliary system
Write down one important acute complication Acute fulminant hepatic failure/Hepatic
encephalopathy
Write 4 d/d i. Acute liver failure
ii. Chronic liver disease
iii. Cholestatic/obstructive jaundice
iv. Relapsing hepatitis
How will you treat this case i. Rest
ii. Normal diet
iii. Avoid hepatotoxic drugs
iv. Treatment of complication

Miscellaneous:
45 y/o female, fever for 2 months, abdominal examination reveals hepatosplenomegaly **

50 y/o male presented to emergency department with massive hematemesis and melaena. On
examination patient has jaundice, gynecomastia and spider naevi. **

Patient with progressive pallor and fever for 1 month. On examination patient has bony
tenderness and hepatosplenomegaly. **

Female with recurrent pregnancies, menorrhagia and progressive weakness. On examination

she has anemia and koilonychia.

5 days fever, unconscious for 2 days. On examination neck rigidity was present, Kerning’s sign
was present. **
25 year old female present with weight loss, diarrhoea, palpitation, excessive sweating **

Hypothyroidism

DKA

53
Clinical problems from Paediatrics
VSD**
Tetralogy of fallot **

Acute watery diarrhoea with severe dehydration (DU July 19), Some dehydration (DU Oct
20)
Pneumonia (DU Jan 13)

Acute watery diarrhoea

A 10 month old child weighing 7 kg has been suffering from acute watery diarrhoea for 3
days. On examination the baby was irritable and drinking eagerly.
What is his dehydration status? Some dehydration
Mention the name of fluid to correct the child Oral Rehydration Salt Solution (ORS
solution)
Calculate the amount of fluid required and The formula is: 75 mL/Kg of ORS
duration of correction administered orally over 4 hours

75x7 = 525 mL ORS fluid to be drunk in 4

hours

A 10 month old child weighing 7 kg has been suffering from acute watery diarrhoea for 3
days. On examination the baby was lethargic and drinking poorly.
What is his dehydration status? Severe dehydration
Mention the name of fluid to correct the child Cholera saline
Calculate the amount of fluid required and Formula: 100 mL/Kg; 30 mL/kg in 1 hour,
duration of correction then 70 mL/kg in 5 hours

7x30 = 210 mL Cholera saline IV in 1st 1 hour

7x70 = 490 mL Cholera saline IV in next 5
hours

A 10 months old child, weighing 7 kg has been suffering from acute watery diarrhea for 3
days. On examination, the baby is lethargic and drinking poorly
What is your interpretation? Acute watery diarrhoea with severe
dehydration
Mention the name of fluids will you select to Cholera Saline (1st choice), Ringer’s solution
manage the child.
How will you measure the amount of fluid Formula: 100 mL/Kg; 30 mL/kg in 1 hour,
required for rehydration? then 70 mL/kg in 5 hours

7x30 = 210 mL Cholera saline IV in 1st 1

hour
7x70 = 490 mL Cholera saline IV in next 5
hours
Mention the duration of rehydration in this 6 hours total
case. 210 mL in 1st hour
490 mL in next 5 hours

54
Pneumonia
A 6 month old baby, weighing 5.5kg came with complaints of cough. His respiratory rate was
60 breaths per minute
What is your probable diagnosis?
Name 3 investigations that you will do
Outline principles of management of this
disease
Severe pneumonia
1. Chest x ray
2. CBC for WBC count
3. Blood culture
4. Aspirate from sputum/cough: gram
staining and culture sensitivity
1. Antibiotic: Ampicillin, Gentamicin
2. Oxygen therapy
3. Antipyretic: for fever
4. Bronchodilator: if there is wheeze
5. Warm water to soothe throat
6. Encourage breast feeding

VSD and TOF

Child with recurrent respiratory tract infection, isn’t growing well, poor breastfeeding, cyanosis
absent

Dx: Ventricular septal defect

Sign:
1. Tachycardia
2. Tachypnoea
3. Thrill present in tricuspid area
4. Harsh, loud pansystolic murmur at lower left sternal border

Inv:

1. Chest x ray (increased pulmonary vascular marking)

2. ECG: Left ventricular hypertrophy
3. Echocardiography
4. CBC with ESR: raised WBC (recurrent infection)

Treatment
1. High calorie diet
2. Diuretics
3. ACE inhibitor
4. Transcatheter device closure
5. Surgical closure of shunt

55
Child with cyanosis, clubbing, squatting when cyanosis, failure to thrive, poor feeding

Dx: Cyanotic congenital heart disease most probably Tetralogy of Fallot

Components:
1. Sub-pulmonary/Pulmonary stenosis
2. Right ventricular hypertrophy
3. Ventricular septal defect
4. Overriding of aorta

Clinical features
1. Cyanosis, clubbing
2. Tachycardia, tachypnoea
3. Left parasternal heave
4. Ejection systolic murmur at pulmonary area radiating to left side of the neck (murmur
of Pulmonary stenosis)

Investigation:
1. Chest x ray: boot shaped heart, decreased pulmonary vascular marking
2. ECH: right ventricular hypertrophy
3. Echocardiography
4. CBC: raised RBC (due to cyanosis)

56
Data interpretation
Meningitis ** (DU July 19, Jul 17, Jan 13)

DKA ** (DU Nov 19, May 19, Jul 18, Jan 17, Jul 15, Jan 13)

Hypoglycemic Coma (DU Jan 19)

Hyperkalemia (DU Oct 20, DU Jan 18)

Acute leukaemia **

Hypothyroidism **

Hyperthyroidism ** (DU Jan 16)

Obstructive jaundice (DU May 19, Jul 18, Jan 17, Jul 15)

Hyperkalaemia
Study the blood report of a 65 year old man containing Na 135 mmol/L, K 6.9 mmol/K, HCO3:
20 mmol/L. Answer the following questions
What is your biochemical diagnosis?
Mention 4 possible causes
Mention 4 principles of treatment of this case
Hyperkalaemia
1. Renal failure
2. Metabolic acidosis
3. Drugs: Spironolactone, ACE inhibitor,
ARB
4. Muscle injury/Crush injury
5. Haemolysis
1. Correct the causative factor
2. Stabilize cell membrane potential: IV
Calcium Gluconate
3. Shift K+ into cells: IV Insulin with
Glucose
4. Remove K_ from the body: Dialysis
5. Loop diuretics: Frusemide

57
Pyogenic meningitis
A 10 month old boy is admitted with high fever and recurrent
convulsions. The finding of his CSF study is as follows:
Colour- Hazy
Cells- 560/mm3
(Polymorph-95%, Lymphocyte-5%)
Protein- 125 mg/dl Glucose- 26 mg/dl Chloride- 98 mg/dl

Alternate scenario: A 10-month-old girl presented with fever for 3 days followed by convulsion
for 2 days. On examination, she had neck stiffness and bulged fontanelle.
Her CSF study showed the following findings :
Color-hazy,Protein-138 mg/dl, Cells-2000/cumm, 96% Neutrophil
What do you think about the probable Pyogenic/Bacterial meningitis
diagnosis?
Write down 2 important physical signs 1. Neck rigidity
2. Kernig’s sign
3. Brudzinski’s sign
Name 2 important organisms responsible for (10 months: infant)
this i. Haemophillus infleunzae
ii. Neisseria meningitidis
iii. Streptococcus pneumoniae
Name 2 important complications if not treated i. Hydrocephalus
properly ii. Cranial nerve palsy
iii. Cerebral palsy
iv. Focal neurological deficit
v. Epilepsy
Name 4 important principles of treatment. 1. Anti-convulsant (Per rectal Diazepam)
2. Antibiotic (Injection Ceftriaxone)
3. Anti-pyretic (Paracetamol)
4. Corticosteroid (IV Hydrocortisone)
Write down the name of 2 drugs you will start 1. Per rectal Diazepam
empirically to initiate therapy 2. Injection Ceftriaxone

58
Diabetic ketoacidosis
A 18-year-old known diabetic boy who was on insulin for 6 months, presented to emergency
department in a semiconscious state. On query his mother told that he has fever for 1 week
and has missed insulin doses. His reports showed
RBS: 33 mmol/L, Urine for ketone body: Present.
Serum electrolyte: Na: 128 mmol/L, K: 5.3 mmol/L, Cl: 99 mmol/L, CO2: 14 mmol/L

Alternate scenario: A 20-year-old male, known diabetic, presented to emergency department

in semiconscious state. On query, his attendant told that he had a fever for 1 week and
missed insulin doses. Now his blood sugar is 32 mmol/L, Urine for ketone body is present
What is your clinical diagnosis? Diabetic ketoacidosis
Write down 4/5/6 additional important signs i. Dehydration
you may get. ii. Air hunger/kussmaul’s breathing
iii. Characteristic fruity odor
iv. Hypotension
v. Tachycardia
vi. Hypothermia
vii. Cold extremity
Mention 4/5/6 most important additional i. CBC + ESR
investigations for monitoring this patient ii. Serum electrolyte
iii. Arterial blood gas analysis
iv. Serum creatinine
v. Urine RME/CS
vi. ECG
vii. Chest X ray
Write down the outline of 4 management i. Control of blood sugar by short
steps/4 principles of management acting insulin
ii. Maintenance of fluid balance by
normal saline
iii. Electrolyte correction and
potassium replacement
iv. Administration of antibiotic for
control of infection
Mention complications of this disease i. Cerebral edema
ii. Acute respiratory distress
syndrome
iii. DIC
iv. Thromboembolism
v. Acute circulatory failure

59
Obstructive jaundice
A 50-year-male presented with blood report showing S. bilirubin 25mg/dl, SGPT 60 U/L,
Alkaline phosphatase- 1200 U/L. Prothrombin time- Patient: 20 sec, Control: 12 sec
What is your clinical diagnosis? Obstructive jaundice
Mention 3/4 important clinical history you will a. Generalized Itching
take to reach a diagnosis b. Pale colored stool
c. Abdominal pain
d. Progressively increasing deep Jaundice
e. Fever
Write 2 other important investigations you will a. USG of whole abdomen
do in this case b. CT scan of Hepatobiliary system/abdomen
c. MRCP
d. ERCP
(don’t say S bilirubin, SGPT, PT as they are
already mentioned in the stem. If not
mentioned, write them.)
Mention 4/6 important causes of this a. Choledocholithiasis
condition b. Ca head of pancreas
c. Cholangiocarcinoma
d. Periampullary carcinoma
e. Biliary stricture
f. Biliary ascariasis
g. Intrahepatic cholestasis
h. Compression by lymph node

Thyrotoxicosis
A 35-year-old male presented to you with following investigation report
S. TSH: 0.002 mU/L, T3: 10nmol/L and T4: 480 nmol/L.
(Normal value—S. TSH: 0.34-6.2 mU/L, T3: 1.2-3 nmol/L and T4: 51-142 nmol/L.
What is the most likely diagnosis? Hyperthyroidism/Thyrotoxicosis
Write 5 important physical signs you will look a. Anxious face/staring look,
for b. Warm sweaty hands,
c. Tremor/fine tremor,
d. Pulse-tachycardia/irregularly irregular
e. Lid retraction,
f. Lid lag,
g. Goiter/thyromegaly,
h. Exophthalmos,
i. Reflex exaggerated,
j. Proximal myopathy.
Write 3 other important investigations you a. Radioiodine uptake
can do in this case b. Thyroid scan
c. USG of thyroid gland
d. Antithyroid antibody/TRAb
e. ECG

60
 Mention modalities of treatment a. Anti-thyroid drugs Carbimazole/
Propylthiouracil
b. Radioiodine therapy
c. Thyroid surgery
d. Beta blocker drug: for symptom control

Photographs
Acne vulgaris (DU Nov 19)
Tineasis /Ring worm infection ** (DU Oct 20, July 19)
Scabies ** (DU May 19, Jul 18, Jul 17, Jul 15)
Herpes Zoster/Shingles **
Herpes labialis
Psoriasis (DU Jan 19, Jan 17)

61
Ring worm infection

What is your possible diagnosis? Tineasis/Tinea corporis/Ringworm infection

Mention some points in favour of your 1. Erythematous lesion
diagnosis 2. Ring shaped lesion
3. Scaly
4. Well defined edge
5. Central clearing
What is the causative organism? 1. Trichophyton
2. Epidermophyton
3. Microsporum
Give 2 differential diagnosis 1. Eczema
2. Psoriasis
Mention 2/3 local and 2 systemic drugs Local drug:
which are used for this condition 1. Econazole
2. Miconazole
3. Clotrimazole

Systemic drug
1. Fluconazole
2. Itraconazole
3. Terbinafine
Write down the possible factors in causation 1. Hot, humid climate
of this disease 2. Overcrowded area
3. Poor personal hygiene
4. Immunocompromised condition

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Scabies
Describe the lesion from the given picture
What is the most likely diagnosis?
Mention 2 points in favour of your diagnosis.
Name the causative organism.
Mention 2/3 topical and 1 systemic drug used
in this condition.
Write down 1 local and 1 systemic
complications in this condition.
What advice will you give to the patient?
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Multiple erythematous, excoriated papules,
vesicles, pustules involving he fingar, dorsal
aspect of hand and interdigital space and
writst
Scabies with complication/Infected
scabies
i. Papule, Pustule
ii. Interdigital/web space involvement
iii. Eczematization
Sarcoptes scabiei hominis
i. Topical- 25% Benzyl benzoate
lotion/5% Permethrin/ 10% Crotamiton
ii. Systemic- Ivermectin
i. Local- secondary bacterial infection
/Eczematisation
ii. Systemic-AGN/Post-streptococcal
glomerulonephritis
i. Avoid contact with others
ii. Maintain personal hygiene
iii. Family members should be
treated
iv. Application of drugs according to
prescription
Psoriasis

What is the most likely diagnosis Psoriasis

Mention three (3) points in favour of your a. Erythematous plaque
diagnosis b. White/silvery scale
c. Well defined edge/margin
d. lesion on extensor surfaces
Write five (5) common sites of involvement of a. Elbow
this type of lesion b. Knee
c. Lower back
d. Scalp
e. Nail
f. Natal cleft
g. Sub-mammary area
h. Axillary folds
Mention two (2) topical and two (2) systemic Topical:
drugs used in this a. Topical steroid
condition. b. Topical Vitamin D analogue (Calcitriol)
c. Topical Salicylic acid ointment
d. UV phototherapy

Systemic
a. Retinoid/Vitamin A
b. Methotrexate
c. Cyclosporin
d. PUVA (Psoralen and UVA)
Mention two (2) drugs which may exacerbate (BALAAN)
this condition
a. Beta blocker
b. Anti malarial
c. Lithium

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 d. Alcohol
e. ACE inhibitor
f. NSAID
What may be the DDs? 1. Dermatomyositis
2. Seborrheic dermatitis
3. Pityriasis rosea
4. Lichen planus
What are the treatment modalities? 1. General measure: explanation,
identify + avoid triggers
2. Topical drug
3. Systemic drug

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Acne vulgaris

What is the most likely diagnosis? Acne vulgaris

Mention 2 points in favour of your diagnosis i. Commedone
ii. Papule
iii. Pustule
iv. Site of distribution – cheeks
Write 2 local and 2 systemic drugs which are Local drugs
used for this condition i. Erythromycin
ii. Clindamycin
iii. Retinoid
iv. Benzyl peroxide
v. Salicylic acid
Systemic drugs
i. Tetracycline
ii. Doxycycline
iii. Azithromycin
iv. Clindamycin
Mention the sites where acne occurs i. Face
predominantly ii. Shoulders
iii. Upper chest and back
Write down the possible factors in the i. Infection with Propionibacterium
causation of this disease acne
ii. Increased sebum excretion
iii. Occlusion and blockage of
sebaceous gland duct
iv. Idiopathic
v. Multifactorial

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Picture from Paediatrics:
AGN ** (DU Jan 19)
Nephrotic syndrome ** (DU Jul 14, Jan 14, Jul 13)
Xerophthalmia/Bitot’s spot (DU Jan 17)
Congenital hypothyroidism (DU Nov 19)

Xerophthalmia

What is the name of the condition of the eye Bitot’s sport/Xerophthalmia

visible in the photograph?
What is the most likely cause of this Vitamin A deficiency
condition?
Write down the WHO Staging of this XN- Night blindness
condition XIA- Bitot’s spot
XIB- Conjunctival Xerosis
XII- Corneal Xerosis
XIIIA- Keratomalacia ˂1/3rd of the corneal
surface
XIIIB- Keratomalacia ˃1/3rd of the corneal
surface
XS- Corneal scar
XF- Xerophthalmic fundus
Mention the specific treatment. Vitamin A, three doses on day 1, day 2 and
day 14

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Congenial hypothyroidism

Mention three abnormal findings in this i. Coarse facies

photograph ii. Dull looking
iii. Low anterior hairline
iv. Tongue protruded
What is the most probable diagnosis? Congenital hypothyroidism
Write down 1 investigation to confirm the i. TSH
diagnosis ii. Serum T3
iii. Serum T4

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AGN and Nephrotic syndrome
This image is taken from a 6 years old child presented with puffiness of the face, scanty high
colored urine and history of skin infection 10 days back
What is your provisional diagnosis?
Name 4 important investigations with findings
that will help to reach the diagnosis
Name 3 important complications that may
develop in this disease
Mention the principles of treatment of this
disease
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Acute Glomerulonephritis
1. Urine RME: RBC, RBC cast,
proteinuria
2. Spot urine protein creatinine ratio:
0.2-2
3. Bedside heat coagulation test:
proteinuria present
4. Blood for C3: reduced
5. Streptodornase (antiDNase): raised if
due to streptococcal skin infection
6. Serum urea
7. Serum creatinine
8. Serum electrolytes
9. ASO titre: raised if due to
streptococcal sore throat
1. Acute left ventricular failure
2. Acute kidney injury
3. Hypertensive encephalopathy
1. Diet: Protein and K+ restriction
2. Diuretics: Frusemide
3. Antihypertensive: Labetalol,
Nifedipine
4. Treatment of complications
A 5 years old boy admitted with swelling of whole body and scanty micturition for 15 days. His
blood pressure was 90/60 mm Hg and bedside urine albumin was 4+
What is your most probable diagnosis?
What are your d/ds
What other investigation findings do you
suspect?/Mention 5 other investigations with
findings
Outline 5 principles of management
70
Nephrotic syndrome
1. Acute glomerulonephritis
2. Congestive cardiac failure
3. Protein energy malnutrition
4. CLD/liver cirrhosis
1. Urine RME: proteinuria, granular
cast, hyaline cast
2. Spot urine protein creatinine ratio:
>2
3. Serum albumin: <25 gm/L (<2.5
g/dL)
4. Serum cholesterol: >200 mg/dL
5. Serum urea
6. Serum creatinine
1. Specific:
(1) oral corticosteroid
60 mg/m2 everyday for 6 weeks,
followed by 40 mg/m2 every
alternate day for 6 weeks
2. Supportive:
(2) Diet: Protein supplementation
(3) Antibiotic: for infection
(4) Heparin: for thrombo-embolism
(5) Diuretics: frusemide
(6) treatment of complication
What may the complications if this remains 1. Pneumonia
untreated 2. UTI
3. Diarrhoea/ GIT infection
4. Stroke/hemiplegia

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Growth Chart
A child of 2 years of age with 7 kg weight. Plot the weight for age on growth chart

Calculate the expected weight for age and interpret it

Ans:

Weight for age = (child’s weight/Expected weight)x 100% = (7/12.2)x100 % = 57.4 %

According to Gomez classification: Weight for age <60% = Severe malnutrition

So, this child is suffering from severe malnutrition

(find out the expected weight from the point that crosses between the child’s age and the 50th
percentile weight for that age)

Gomez classification:
91-110%: normal nutrtion
76-90: mild malnutrition
61-75: moderate malnutrition
<60%: severe malnurtirion

Mention 2 other procedures to interpret it according to interpret it

Ans:

1. WHO classification based on Z score

2. Welcome classification
Mention 5 important complications of this child

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Ans:
1. Hypoglycemia
2. Hypothermia
3. Dehydration
4. Electrolyte imbalance
5. Infection
6. Anaemia
7. Congestive cardiac failure
8. Bleeding
9. Sudden infant death syndrome (SIDS)

A 3-year-old girl weighing 9 mg with cough and respiratory distress for 5 days. Her height was
85 cm. Plot and calculate her weight for heigh z score and classify it according to WHO.

Her weight for height Z score in -2.63

According to WHO, she is suffering form Moderate acute malnutrition (between -2 to -3)

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***please note:

For calculating SD, please note the lowest percentile the given chart has
Some chart has 3rd percentile as the lowest (WHO), some have 5th percentile as the lowest
(CDC)

Formula for 3 percentile (WHO charts):

value at 50th centile – value at 3rd centile
SD = 2

Formula for 5th percentile (CDC charts):

value at 50th centile – value at 5th centile
SD = 1.8

After finding out the SD:

Example of a CDC chart:

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A 6 month old male infant with 6 kg weight. Plot it on growth chart. Calculate the weight for
age z score and interpret it according to WHO

Weight for age Z score: -2.53

So, the child has moderate acute malnutrition

A 6 month old male infant with 6 kg weight. Plot it on growth chart. Calculate the weight for
age z score and interpret it according to WHO (same question with CDC chart)

75
76
Weight for age Z score: -2.43
So, the child has moderate acute malnutrition

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