1. 66 years old woman recently admitted to medical ward and intubated for DKA. She was discharged well but 1 week later, she developed productive cough and fever. His temperature is 39.7 ̊C, pulse rate 90 bpm, blood pressure 135/70 and oxygen saturation is 95% under room air.

Investigation

Urea 15 mmol/L

Cretinine 150 umol/L

Hb 13.3 mg/dl

WBC 21.8 x 10 ⁹ /L

Platlet 550 x 10 ⁹ /L

Chest Xray – Consolidation over right lower zone

What the is the most likely organism cause pneumonia in this patient?

34 years old gentleman presented with history productive cough for 1 week. Chest x-ray was done noted the is pleural effusion on the right side. Pleural tapping was done and sent for investigation.

Hb 13.3 mg/dl

pleural pH 5

WBC 24.5 x 10 9 /L

Pleural Albumin 26 g/dL

Platlet 450 x 10 9 /L

Pleural LDH 1000

Albumin 30 g/dL

Serum LDH 310

What is the best diagnosis?

1. 45 years old lady, with history of uncontrolled diabetes mellitus for past 3 years presented to emergency department with history of fever and productive cough for 1 month. Further history she loss of appetite but her weight is maintain at 45 kg. On examination, she is alert conscious, her respiratory rate is 18 breath per minute, SPO2 is 95% under room air, temperature 40.5°C and her right lung is dull on percussion and reduce vocal resonance. Pleural tap was done noted pleural pH 7 and pleural LDH is 1900 u/L.

What is your best next step?

35-years-old man presented with chest pain and he was diagnosed to have myocardiac infraction. He underwent percutaneous intervention and angioplasty was done. Blood investigation was done

Urea 15 mmol/L

HDL 2.6 mmol/L

Cret 550 umol/L

LDL 3.0 mmol/L

Hb 18.0 x 10 ⁹ /L

Calcium 2.0

WBC 6.9 x x 10 ⁹ /L

Phosphate 2.2

What is the most likely predisposing factors lead to MI?

35-years-old man presented with chest pain and he was diagnosed to have myocardiac infraction. He underwent percutaneous intervention and angioplasty was done. Blood investigation was done

Urea 15 mmol/L

HDL 1.6 mmol/L

Cret 250 umol/L

LDL 5.0 mmol/L

Hb 18.0 x 10 ⁹ /L

Calcium 2.3

WBC 6.9 x x 10 ⁹ /L

Phosphate 1.4

What is the most likely underlying disease?

80 years old man was diagnosed with lung carcinoma, presented with weakness and confusion. His hydration is good, blood pressure 135/70 and oxygen saturation is 98% under room air. His blood test revealed

Hemoglobin 11.1 g/dL

Hct 36

Platelet 429 x 109 /L

WBC 5.6 x 109/ L

Creatinine 89 µmol/L

potassium 4 mmol/L,

sodium 110 mmol/L

urea 4 mmol/L

What is the best investigation to differentiate the causes of hyponatremia in this patient?

80 years old man was diagnosed with lung carcinoma, presented with diarrhea, vomiting and confusion. His hydration is fair, blood pressure 135/70 and oxygen saturation is 98% under room air. His blood test revealed

Hemoglobin 18.1 g/dL

Hct 50

Platelet 429 x 109 /L

WBC 5.6 x 109/ L

Creatinine 200 µmol/L

potassium 5 mmol/L,

sodium 150 mmol/L

urea 40 mmol/L

What is the mostly causes of confusion in this gentleman?

56 years old lady known case of diffuse large B cell Lymphoma. Currently she receives 3^rd cycles of R-CHOP chemotherapy. A week post chemo, she develops a fever associated with productive sputum. Which is the best investigation to determine next step plan of action?

35 years old lady known case of rheumatoid arthritis. 6 months ago she had flare of rheumatoid arthritis and currently she on methotrexate since then. Recently she was admitted to ward complaint of shortness of breath and reduce effort tolerance. On examination there is crepitation on bilateral lower zone. What is the most likely causes of the respiratory finding?

Houseman had a splashed of blood on the face while assisting her surgeon doing laparotomy in operation theater. The anesthesia medical officer inform that that patient is hepatitis B positive. What is the next step of management she need to do?

25 years old lady was diagnosed to have Immune Thrombocytopenic Purpura and her disease was stable since 5 years ago. She presented with fever for 3 days, joint pain, headache, rashes over the trunk area. Upon admission noted patient is dehydrated, BP 98/50, Pulse rate 90 beats per minute, macular rashes and it is blanchable, otherwise other clinical examination is normal.

Her latest blood result

Hb 13.2 x 10 ⁹ /L

Alt 80 iu/L

WBC 3.9 x 10 ⁹ /L

Bilirubin 40 umol/L

Platlet 45 x 10 ⁹ /L

INR 1.03

What is the best investigation to diagnose current problem?

34 years old lady, Gravida 5 para 4 at 35 weeks of pregnancy recently complaint of unilateral leg swelling presented with shortness of breath. What is the best investigation to get her diagnosis?

47 years old gentleman has 2 days history of epigastric pain associated with nausea and vomiting. He drinks 50 units of alcohol per week. His temperature is 39.7 ̊C, pulse rate 120 bpm, blood pressure 100/50 and oxygen saturation is 90% under room air.

Investigation

Urea 15 mmol/L

Cretinine 150 umol/L

Hb 13.3 mg/dl

WBC 21.8 x 10 ⁹ /L

Platlet 550 x 10 ⁹ /L

Which is the best blood test to confirm the diagnosis?

56 years old gentleman known case of diabetes mellitus and hypertension recently discharge from the CCU for ST-elevation myocardial infraction. A week later he presented with sudden onset of left sided chest pain. His temperature is 38.9 ̊C, respiratory rate is 25 breath per minute, oxygen saturation is 94% under room air. There is bilateral crepitation of the lung and a rub can be auscultated of the left side of chest

What is the most likely diagnosis ?

48 years old gentleman presented with central chest pain, His ECG showed ST Elevation MI and he underwent primary PCI. His blood investigation as per below

Hb 20.8 mg/dl

Hct 60

Hba1c 6.4%

Urea 3.4 mmol/L

Cretinine 100 umol/L

What is the initial best investigation to diagnoses underlying problem?

A 31 year old gentleman has 24 hours of right knee pain and is unwilling to weight bear. He had a chest infection 2 weeks ago, but is otherwise healthy with no other past history of note. His temperature is 38°C, pulse rate 118 bpm, respiratory rate 24 breaths per minute and oxygen saturation 99% in air. He appears unwell and lethargic. His right knee is red and swollen, warm to touch and tender on palpation with reduced painful range of movement. The patellar tap test shows a bouncing patella.

Which is the most appropriate investigation to establish a diagnosis?

Madam X, 26 years old was diagnosed thalassemia. He received multiple blood transfusion since childhood. During the clinic checkup, she complaints that her menses is irregular. The physician notice her height is 123 cm, weight 35kg, loss of pubic hair and micromastia. Her bp 80/56, pulse rate 97 and DXT is 24 mmol/L.

What is the best blood investigation for diagnosis?

50-year-old man came for MOPD follow up for his hypertension and diabetes . He complain of on and off palpitation for the past 3 months. ECG revealed atrial fibrillation with heart rate of 80 bpm. He has history of TIA and UGIB before. He has history of on and off severe dyspepsia.

State your management at this stage.

45-year-old man, smoker presented with sudden onset of retrosternal chest pain 2 hours prior to admission associated with difficulty in breathing and profuse sweating. On examination, vital signs were normal. Cardiovascular and respiratory examination revealed no abnormality.

State the most important investigation at this stage.

A 68-year-old farmer was admitted with nausea and general malaise . Over the last two months, he had become increasingly fatigued, breathless, anorexic and had an 8 kg weight loss. He was a smoker of 5 cigarettes per day and had drunk more alcohol than usual whilst on holiday but usually drank about 12 units of alcohol daily.On examination, he was sun-tanned, slightly confused, appeared dehydrated and had a pulse of 92 bpm regular, a temperature of 37.2oC with a blood pressure of 112/80 mmHg. He was not icteric. Cardiovascular and respiratory examination were unremarkable. He had a slight liver edge on palpation and neurological examination was normal. Investigations revealed:

Sodium 125 mmol/l

Potassium 5.6 mmol/l

Random blood glucose 3.9mmol/L

Corrected Calcium 2.73 mmol/l (NR 2.2 – 2.6)

Standard Bicarbonate 15 mmol/l

Urea 22 mmol/l

TSH 6 mU/L (NR 0.4 – 4)

Which of the following is the most likely diagnosis?

A 45 year old man presents with chronic diarrhoea and upper abdominal pains. He has had a partial gastrectomy 2 years ago due to upper GI bleeding. He is now on high dose esomeprazole regularly. A repeat OGDS now shows two small esophageal ulcers.

What is the appropriate investigation?

A 75 years old lady presented with fever and dysuria for 3 days. In ED she developed confusion and started to be agitated and shouting. She has no medical history before and not on any drugs or supplements at home. Your initial action:

An 80 years old gentleman had a fall at home and sustained a neck of femur fracture. Wich of the following must be supplemented to prevent future fall?

1. A 73-year-old man presented with a 4-month history of tiredness. He was not taking any medication.

Examination was normal.

Investigations:

serum sodium

119 mmol/L (137–144)

serum potassium

3.9 mmol/L (3.5–4.9)

serum creatinine

106 µmol/L (60–110)

serum osmolality

255 mosmol/kg (278–300)

urinary osmolality

405 mosmol/kg (100–1000)

urinary sodium

32 mmol/L

What is the most appropriate next investigation?

A 50- year-old businessman, developed sore throat and pain on swallowing, over the past 2 weeks. He also complained of fever since then. He was usually fit and well. His work required him to travel to Thailand on multiple occasions over the last 15 years. On examination, there were white plaques on the buccal mucosa, palate and oropharynx, which could be scrapped off. He also had cervical and inguinal lymphadenopathy.

Which of the following investigations would you perform next, to help identify the cause of his illness?

A 21-year-old man had an incidental finding of nephrotic range proteinuria of 0.6 g per day during a routine pre-employment check up. Urinalysis revealed 1+ protienuria, 1+ RBC and 0 leucocyte. His BP is 130/68mmHg, pulse 86/min with noticeable bilateral leg oedema up to mid shin. He has a strong family history of diabetes. His fundal examination is normal. He is not on any form of medication or supplement.

Which of the following if present will necessitate a renal biopsy?

A 36-year-old woman presents with a 2-week history of frank haemoptysis and a 5-day history of haematuria. She has no significant past medical history and is not on any medication or supplement. Her BP is 157/99mmgHg, pulse 100/min and respiratory rate of 25/min. She is noted to be febrile at 38 degree celcius. In the last 24 hours she has become increasing dyspnoeic and oliguric. Her saturation was noted to be reducing from 100% to 91% over the last one hour.

What will be the next step of action?

A 60 year old female presented with progressive increment in her creatinine for the past 6 months upon follow up in her clinic. She has diabetes and require insulin to control the disease, and hypertensive with normal blood pressure on physical examination. She denies any back pain or constitutional symptoms. However she did complains of dysuria recently.

What could be the likely cause of her worsening renal function?

1. A 35-year-old man presented with six week history of arthralgia and malaise. He also notices blotches of light purple discoloration which appeared on his thighs when he went jogging and disappeared later in the day. He was an ex-intravenous drug user. Examination revealed slightly pale man with no obvious arthropathy. He is afebrile, BP of 160/90mmHg and PR of 90 bpm. Respiratory and abdominal examination were unremarkable except liver edge slightly palpable at 2cm below the costal margin. He has pitting edema up to his ankle but obvious purple painful skin rash seen. His urinalysis revealed 4+ protein and 3+ blood.

This were his initial investigations:

Hemoglobin 11.1 g/dL

Platelet 429 x 109 /L

WBC 5.6 x 109/ L

Creatinine 205 µmol/L

potassium 4 mmol/L

sodium 145 mmol/L

urea 10 mmol/L

Albumin 25

Normal liver function test

What could be the best next investigation of choice?

A 40-year-old man presents to the neurology clinic complaining of severe headaches for the past 6 months. He has been having severe headaches occurring several times a day for a couple of hours (often worse at night) which then settle after a few weeks and recur again. The pain is predominantly around the eye and his eye feels full and he notices it watering and his eye appears red. There is no visual disturbance.

What is the most likely diagnosis?

A 45-year-old female with a known history of migraine presents with a severe throbbing headache. On examination, she is confused and there is evidence of a 4/5 power on left side with brisk reflexes. She has recently been unwell with sinusitis. A non enhanced CT is performed and shows no significant findings.

Which of the following is the most likely diagnosis?

A 30 year-old man has presented to his GP with visual blurring. Previously you have noticed he has had attendances with paraesthesia in his leg and weakness in his hand. These all resolved fully on their own. On examination you note he is unable to adduct her right eye and has nystagmus on abducting his left. He has prolonged visual evoked potentials. An MRI brain is performed and showed white matter lesions.

What is the most likely diagnosis?

1. A 37‐yr‐old woman was admitted with massive haemoptysis. She had a long history of polyarteritis nodosa. During the 3 months before the admission she suffered from frequent episodes of coughing. Chest radiography revealed opacities in the left lung.

On examination she was afebrile. Pulse rate 120/min, respiratory rate 38/min, blood pressure 80/52mmHg. SPO2 86% on room air.

Which of the following is the best immediate management for this patient?

A 64-year-old lady presented to the emergency department after being found collapsed at home. She gave a preceding history of one day of diarrhoea.

On examination she was afebrile. Pulse rate 110/min, respiratory rate 32/min, blood pressure 100/70mmHg. SPO2 94% on room air. On examination of respiratory system, there was reduced chest expansion, stony dullness with reduced breath sounds over right side of lung. Chest radiograph showed moderate right sided pleural effusion. Pleural tap was done at emergency department which revealed cloudy effusion.

Which one of the investigations would help to distinguish the cause of pleural effusion?

63 year-old woman presents complaining of hands and wrist pain for 2 years. The pain was bilateral, particularly painful on movement and associated with morning stiffness lasting about 15 minutes. On examination of the hands, she has bony enlargement with tenderness in multiple distal interphalangeal joints (DIP) and proximal interphalangeal joints (PIP). The other metacarpophalangeal joints and the wrist are normal. There is no synovitis.

What is the diagnosis?

30 years old gentleman who is a chronic smoker presented with epigastric discomfort, associated with acid and water brash for the past 3 months. He had not had any constitutional symptoms. He is 1.72meter and weight 90kg. Physical examination is unremarkable.

What would be the best approach for this gentleman for long term remission?

42 years old lady complain of hand stiffness and joint pain for the past 6 months. Physical examination had noted Z-deformities of the thumbs, associated with hyperextension of the right 4^th proximal interphalangeal joint and flexion over the same distal interphalangeal joint with pitting nail changes.

What is the most likely diagnosis for this patient?

60 years old gentleman presented with epigastric discomfort associated with water brash and acid brash. He had no loss of appetite, no loss of weight. He had a brother who had had an operation done a year back for stomach malignancy.

Which of the following would be the best treatment for him?

A 50 year old gentleman was recently admitted for acute myocardial infarction, and was started in a list of medications below. 1 month later, he noticed erythematous well defined scaly plaques appeared on his scalp and extensor areas of his elbows and knees. His nails have developed onycholysis.

which medication lead to the current problem?

A 30-year-old female presents with several months of pruritic dry scaly skin between the toes and over the lateral aspects of the foot. More recently she developed blisters on the plantar aspect of the foot beneath the toes. She also has an underlying history of poorly controlled diabetes and is on insulin.

Which diagnosis is MOST likely?

A 36-year-old male presents with two years of hypopigmented macules on his upper chest and back which are occasionally itchy. You perform a potassium hydroxide (KOH) exam which demonstrates the characteristic short, cigar-butt hyphae which is referred to as the “spaghetti and meatballs” appearance. What is your diagnosis?

A 17-year-old woman with a medical history of mild intermittent asthma presents to your clinic in last visit with several days of cough, fever, malaise, and myalgias. She notes that her symptoms started 3 days earlier with a headache and fatigue. She just touched down from pilgrim yesterday and none of them in the group having a similar symptoms. She did not receive a flu shot this year or prior to visit Mecca. Which of the following medication treatment plans is the best option for this patient?

40. A 32-year-old female is seen in the emergency department for acute shortness of breath. A helical CT shows no evidence of pulmonary embolus, but incidental note is made of dilatation of the ascending aorta to 4.3 cm. Further history she always has recurrence painful multiple oral ulcers and genital ulcer especially at vulva area.

Which the best diagnosis fit with these problem

A 42-year-old man with AIDS and a CD4+ lymphocyte count of 23, presents with shortness of breath and fatigue in the absence of fevers. On examination, he appears chronically ill with pale conjunctiva. Hb 6.7 mg/dl and Hematocrit is 16%. Mean corpuscular volume is 84. Red cell distribution width is normal. Bilirubin, lactose dehydrogenase, and haptoglobin are all within normal limits. Reticulocyte count is zero. White blood cell count is 4.3 x 10 ⁹ /L, with an absolute neutrophil count of 2.5 x 10 ⁹ /L, and Platelet count is 105 x 10 ⁹ /L.

Which is the best investigation for diagnosis?

40. 56 years old lady was diagnosed diffuse large b cell lymphoma. She develops fever post Day 13 of allogenic bone marrow transplant. The medical officer started her on Iv Tazosin 4.5g QID and Iv Amikacin 15mg/kg/day as her ANC was very low 0.6 x 10 ⁹ /L. Day 3 of antibiotic patient was well and fever was subsided but she develops generalize maculopapular rash and diarrhea more than 4 times on that day. Repeat blood showed (Mmed part 2)

Urea 3.8 mmol/L

Bilirubin 89 umol/L

Cret 56 umol/L

ALT 56 iU/L

Hb 10.0 x 10 ⁹ /L

ALP 80 iU/L

WBC 0.9 x x 10 ⁹ /L

Albumin 31 g/dL

What is the best next step of management?

56 years old gentleman presented to emergency department with fever and shortness of breath. On examination, he looks lethargic, dry, apathy, coarse skin and overweight. His GCS 10/15, temperature is 35°C, BP 100/80 with heart rate of 50 bpm. On auscultation his lung reduce air entry on right lower zone.

Urea 19.8 mmol/L

Bilirubin 19 umol/L

Cret 56 umol/L

ALT 30 iU/L

Hb 10.0 x 10 ⁹ /L

ALP 20 iU/L

WBC 6.9 x x 10 ⁹ /L

Albumin 25 g/dL

CRP 25.0 mg/dL

Na 132 mmol/L

Ca 2.8 mmol/L

K 5.5 mmol/L

What is the best next step of management?

78 years old man recently discharged from the ward due to diabetic ketoacidosis, presented to emergency department with history of 3 days of fever and shortness of breath. Upon examination, His Temperature is 39.5°C, respiratory rate is 25 breath per minute, and his right lung increase vocal resonance with coarse crepitation. He has been treated with IV Rocephim, after 3 days of treatment his condition worsening and he was intubated and send to ICU.

Hemoglobin 11.0 g/dL

White cell count 28 x 10x9/l (predominantly neutrophils)

Platelet 120 x 10x9/l

Blood culture No Growth

What is the best next step of management?