UHS PMDC STEP 2 SEPTEMBER 19 2015

SOLVED SEQ PAPER

A small gift from my side for step 2
students(Fawad Khattak)
Q 1 A 16 years old girl is admitted in the emergency with severe
abdominal pain and vomiting.On examination she is
dehydrated,pulse is 110/min,regular.Her respiratory rate is
32/min.Blood pressure is 100/80 mm Hg,lying position.Urgent
surgical consult is ordered.Blood sugar done on glucometer at
bedside shows a blood sugar level of 450 mg/dl.
a)which most important investigations will you order immediately(4)
b)what is the diagnosis?(1)
c)which steps in treatment will you carry out in first few hours(5)
answers a) 1)serum ketone bodies 2)serum electrolytes(K specially) 3)RFTS
b)Diabetic ketoacidosis
c)correct electrolyte imbalance(K replacement),insulin infusion ,correct
dehydration by giving fluids.and lastly general supportive care(vital signs
monitoring)
Q 2 A 20 year old girl is admitted in the emergency with worsening
dyspnea for the last few days.She has had a similar episode 2 years
back but since then has been well.Her only medication was
occasional use of salbutamol inhaler.On examination she has a resp
rate of 30/min,Blood pressure 130/80 mmHg.Pulse is 120/min
regular.Chest exam reveals bilateral wheeze.
a)what is ur clinical diagnosis?(2)
b)which investigations wil you order immediately(2)
c)how would you manage her in emergency(6)
Answers a)Bronchial asthma
b)1)chest Xray,2)abgs,3)PFTs,4)IgE.5)esinophills

c)1)stabilize her by structured approach of ABC.2)give her O2 3)give beta 2

agonists(salbutamol) 4)theophyline 5)follow up and check the patient
condition and treat accordingly
Q 3 A 40 year old man presents to the OPD with recurrent epigastric
burning for the last one year.It is worse at night and empty
stomach.There is history of occasional vomiting .Bowel habits are
normal.He smokes occasionally but there is no history of NSAID
intake
a)which investigations would you advise to this patient?(4)
b)what is the clinical diagnosis?(1)
c)how would you treat this patient?(5)
Answers a)1)x ray abdomen2),endoscopy,3)h pylori test.4)u/s abdomen,5)ct
abdomen
b)duodenal ulcer
c)1)PPIs eg omeprazole 2)h2 blockers eg ranitdine 3) triple therapy for h
pylori 4)sucralfate 5)advise on good hygiene and avoid spicy food and also
avoid smoking 6) surgery if indicated(highly selective vagotomy)7)follow up
Q 4 Asad ,a 31 years old bus driver has come to you for assessment
of episodes of sudden unconsciousness.After taking a detailed
history and relevant investigations you diagnose him to be suffering
from epilepsy.You advise him to take medicine and refrain from
work.He promises to take medicine but requests you that he cannot
take leave from work,since he 4 children and he is the only bread
earner of the family.Also he has taken loan and if the repayments
are not done on monthly basis he would lose his house.And lastly ,if
he does not go to work even for 2 days then he will lose his job and
the only thing he knows dring.
a)How would you proceed in such a situation?(5)
b)Name few situations where breaches of confidentiality can be
made and justified(5)
Answers a)Advise and convince him about the dangers of epilepsy while you
are driving.advise him to leave his job and try his best to find another job

.and if the patient did not convince after your full struggle of counselling
then leave the decision on patient(autonomy).
b)1)when patient authorizes to do so 2)when it is in best interest of patient in
case of child abuse,rape. 3)when court order 4)when it is in best interest of
community eg contagious disease 5)when the information to be shared with
health professionals 6)For reaseach purpose only as anonymous
Q 5 A 55 years old general practitioner receiving NSAIDS for
osteoarthritis for the last five years presented with sudden severe
pain in epigastrium.On examination his pulse is 124/minute and
abdomen is tense and tender.
a)what is the most likely diagnosis?(2)
b)discuss the management plan (8)
Answers a)perforated peptic ulcer
b)1)stabilize the patient by structured approach of ABC 2)shift to surgical
ICU.3)after stabilizing,do X ray abdomen and u/s and ct abdomen. 4)do
endoscopy if indicated 5)laparotomy for confirmation of diagnosis and
treatment.6)lavage the peritoneum with normal saline 7)do repair of the
affected part of stomach or duodenum with omentum patch 8)follow up and
advise on general good care
Q 6 A 30 years old female in surgical OPD with complain of
palpitations for past six months.On examination there is 2 cm
swelling in front of neck .
a)what is the most probable diagnosis?(2)
b)Give the management plan of this patient.(8)
Answers a)Hyperthyroidism
b)1)check TFTS 2)TSH 3)Thyroid scintigraphy 4)antithyroid drugs eg
carbimazole,methimazole etc 5)beta blockers for palpitations
6)thyroidectomy if indicated,options for thyroidectomy are total
thyroidectomy,subtotal thyroidectomy,near total thyroidectomy.
Q 7 A 20 years old college girl is diagnosed to have acute
appendicitis and operation is planned .

a)While selecting a more appropriate incision what should be the

surgeon selection criteria based on anatomical facts?(4)
b)Enumerate with precision the structures incised and /or retracted
to reach inflamed appendix in retrocaecal position.(6)
Answers a)incision selection criteria=best exposure of appendix Mc burney
point,gridiron incision is made at right angle to a line joining the anterior
superior iliac supine to the umbilicus,mcburney,s point is located at the
junction of medial 2/4 and lateral 1/3 of line from umbilicus to anterior
superior iliac spine.
b)Structures incised=1)skin 2)subcutaneous tissue 3)fascia scarpa 4)external
oblique apponeurosis 5)internal oblique and transverses abdominus muscle
fibers are splited and retracted,peritoneum is opened 6)appendicular
vessesls ligated,mesoappendix ligated.7)gentle traction of caecum.
Q 8 you are asked to see a 22 year old primigravida in the antenatal
clinic at 33 weeks of gestation with blood pressure of 170/120 mm
Hg.She does not have any prior history of hypertension.On
examination she has puffy face with ankle edema.
a)what will be ur delivery plan?(2)
b)what tests will you carry out?(5)
c)what immediate steps will you take?(3)
Answers a)plan is to deliver the child as soon as possible because the
definitive treatment/cure is to deliver the child.vaginal delivery is preferable.
b) 1)urine protein(albumin) 2)urine r/e 3)rfts 4)lfts
c) stabilize the patient by ABC structured approach.give hydrlazine i/v for
hypertension.check vitals and monitor it.give steroids before 24 hour
delivery.follow up
Q 9 A 28 year old para 1 abortion 4 presents in her 6th pregnancy
with 12 weeks pregnancy.All of her previous miscarriages were
around 14-16 weeks gestation and suddenly started with painless
dilatation of cervix.She is quite apprehensive and has been told
about the stitch to prevent loss of pregnancy.
a)How will you evaluate her regarding suitability for cerclage?(2.5)

b)how will you apply cerclage if considered appropriate?(5)

c)When will the cerclage stitch be removed and what will be the
mode of delivery?(2.5)
Answers a) A cervical cerclage is a minor surgical procedure in which the
opening to the uterus (the cervix) is stitched closed in order to prevent a
miscarriage or premature birth,and it is done from 12 to 14 weeks of
pregnancy.
Cerclage can be performed if a woman has one or more of the following risk
factors:

a previous preterm delivery

previous trauma or surgery to the cervix

early rupture of membranes ("breaking water")

hormonal influences

abnormalities of the uterus or cervix

exposure as a fetus to diethylstilbestrol (DES), a synthetic hormone

that was used in the mid-twentieth century to treat recurrent
miscarriages.

As all the risk factors are there in this patient so this patient is
suitable for cerclage.
b) Cervical cerclage can be done through the vagina (transvaginal cervical cerclage) or,
less commonly, through the abdomen.(Mcdonald cerclage and shirodkar cerclage)
c) Typically, the stitches are removed at around week 37 of pregnancy.vaginal delivery
will be the mode of delivery otherwise C section if vaginal delivery is contraindicated

Q 10 A 10 days old baby presented with escessive crying and

vomiting over last 2 days .He was born following full term
pregnancy but needed some resuscitation at birth and kept at
nursery for 2 days only.On examination pulse is 140/min,temp 96 F

and respiratory rate 40/min.he looks pale and has bulging

fontanellae.
a)what are your 2 differential diagnosis?(2)
b)what 4 investigations you will ask in this baby?(4)
c)Mention first four steps of management?(4)
Answers a)1)meningitis 2)hydrocephalus 3)neonatal sepsis
b) 1)LP 2)Csf examination 3)ct head 4)blood culture 5)cbc
c)1)confirm diagnosis by history,examination and above
investigation,2)stabilize the baby 3)proper antibiotics 4)temp regulation and
vital monitoring 5)follow up
Q 11 A one year old baby is brought in pediatric OPD as he is not
thriving well and has recurrent loose motions.He has been on
diluted cow milk since birth.On examination his weight is 5
kg,length 68 cm,hair are light and sparse.He is looking pale and has
oedema of hans and feet.
a)what is ur clinical diagnosis?(2)
b)what investigations you will ask in this baby?(4)
c)Describe your 5 steps of management?(4)
Answers a)kwashiorkor
b)1)cbc 2)serum albumin 3)fecal microscopy 4)blood smear 5)electrolytes
6)blood sugar 7)chest x ray 8)skin test for tb
c)1)treat hypoglycemia 2)treat hypothermia 3)treat and prevent dehydration
and restore electrolyte balance 4)start feeding child 5)treat infection
6)immunization 7) treat vitamin deficiency8)treat shock and heart failure
Q12 An eight years old girl is suffering from right sided hearing
loss ,nasal obstruction and occasional otalgia.Examination shows
she is mouth breather and carries dull looking tympanic
membrane.Her audiological assessment shows conductive hearing
loss and type B tympano curve.
a)what is the most probable diagnosis?(2)

b)Any other investigation you will like to do?(2)

c)Discuss the medical and surgical options for this patient.(6)
Answers a)otitis media with adenoiditis
b)1)examination of adenoids 2)ct scan 3)tympanometry 4)culture of
discharge if any
c)Medical=1)antibiotics eg amoxicillin for 10 days 2)nasal decongestants
3)oral decongestants 4)aural toilet 5)analgesics 6)good ear
health.surgical=1)adenoidectomy 2)myringotomy 3)myringoplasty
Q 13 A six weeks old baby is brought to you with the symptoms of
watering and discharge of the right eye since birth.
a)what is the commonest cause of this condition?(1)
b)which clinical test /method would help you in the confirmation of
the diagnosis?
c)what is treatment for the next 6-8 months?(2+2+2)
d)what is the treatment after 1 year of age?(2)
Answers a)congenital nasolacrimal duct obstruction
b)regurgitation test
c)1)massaging 2)syringing 3)antibiotics 4)self resolution(wait and see)
d)Dacrocystorhinostomy
Q 14 Mr A is 25 years old .He works in a factory .The owner of
factory snubs him on his laziness,increased heart rate,difficulty in
falling asleep.Later he started hearing voices of different people
talking to him.These voices are derogatory in nature and he has no
control over them.He also becomes suspicious that people are
against him and will harm him .He was very much convinced about it
and confines himself in his house.There is no remarkable finding in
rest of history except that he started using charas a few months
back.
a)Enlist different psychopathological phenomenon.(4)
b)Enlist three differential diagnosis.(4)

c)What questions you will ask to elicit hallucination.(2)

Answers a) Here laziness, increased heart rate, and difficulty falling asleep
indicates depression, auditory hallucinations, percecutory delusion
b)1)schizophrenia 2)bipolar disorder 3)major deprresive disorder 4)anxiety
disorder 5)personality disorder 6)delusion
c)1)do hallucinations are auditory? 2)do hallucinations are visual?3)do
hallucinations are tactile? 4)do hallucinations are gustatory(of taste)? 5)do
hallucinations olfactory(of smell)?
Q 15)A 28 year old soldier presents with an itchy rash.He is itchy in
his finger webs,writs and groin.There is evidence of excoriation in
these areas.H e has been living in the barracks for the past six
moths where other soldiers were hving similar complaints.
a)what is the most likely diagnosis?(4)
b)Enumerate the treatment methods(6)
Answers a)scabies
b)1)general hygiene care 2)wash and clean all the blankets and badsheets
with hot water or chlorhexidine 3)antihistamine for itching 4)permithrin
lotion/cream for neck to toe to all the family members and take a bath after
24 hour of applying cream/lotion of permithrin