A 60-year-old man presents to the outpatient department with cough and dyspnea on exertion for 2 years which has become worse recently with increasing shortness of breath. The cough is productive with small amount of mucoid sputum. He has no hemoptysis, chest pain or leg swelling. The patient has a 40-pack-year smoking history. The temperature is 37.2° C (99° F), blood pressure 140/80 mm Hg, pulse 80/min and respirations 20/min. A chest x-ray reveals prominent bronchovascular markings with diaphragmatic flattening.
a)What clinical information would you like to take from the patient for further
b)Mention the investigations with reasons.
c)Mention 3 complications of this condition you will look for
d)Give a management plan for this patient.

i) Mention the causes of errors in clinical reasoning with examples.
ii) How can we reduce errors in clinical reasoning?

b)Mention briefly types of prenatal genetic testings with their indications and examples.

c)A 70-year-old man, a known case of diabetes mellitus, presents to you with 5-day history of high rise of temperature with loin pain and burning sensation during micturition. His CBC shows leukocytosis, urine culture and sensitivity shows profuse growth of E.coli. Antibiogram shows sensitivity to gentamicin and amikacin with all other drugs showing resistant. His serum creatinine is 1.7 mg/dl.
1)What will be your concem in managing UTI in this patient?
ii) Mention the factors to consider when balancing benefits and harms of drug therapy.

d)A 55-year-old woman has been suffering from T2DM for 10 years with reasonable glycemic control. For the last 6 months she has been suffering from burning pain and tingling sensation of both the lower limbs especially at night.
i) Mention further clinical information you want to get from the patient about her complaints.
ii) Briefly mention pharmacological management of this condition.

e)A 65-year-old male man, farmer by occupation, presented with history of fever, cough and breathless for 1 month. For the last 7 days he developed a pustular swelling of right ankle with discharge. His right knee was also swollen. Despite getting; antibiotics his condition deteriorated with high rise of temperature, BP 90/50 pulse 130 beat/min.

i)What further clinical information will you look for to reach to the diagnosis?
ii) Mention 3 investigations to reach to the diagnosis.
iii) How will you manage this case?

a)A 35-year-old man admitted to medicine ward with the complaints of severe abdominal pain, nausea, vomiting and lethargy. On examination his vitals were normal. Investigations showed serum lipase 1000 u/L and serum calcium 12.0 mg/dl.
i) What clinical information would you look for to support your diagnosis? ii) Mention the relevant investigations with interpretations

b) A 30-year-old woman presents with history of extreme weakness and profuse sweating. She has been suffering from fever for 4 days. She is having unusual P/V bleeding for 2 days. Her BP 80/65 mmHg and pulse 110/min. Laboratory blood report shows Hb 10gm/dl, CBC 3.5×10/L, platelet 70x109/L and HCT 32%.
1) What is the most likely diagnosis?
ii) Give a plan of management of this patient.
c) A 55-year-old man, a known case of 12 DM with HbA1C 9.2%, was on oral hypoglycemic agents has presented with disorientation for one day. His BP 100/60 and, pulse 80/min, His blood sugar 44 mmol/L, serum Na 136mmol/L, K 3.7 mmol/L, CH-109 mmol/L with HCO3 23 mmol/L..
i) Mention further investigations with interpretations.
ii) Give the principles of management of this case.

d)A 36-year-old woman presented with the complaints of dizziness and frequent syncopal attacks for last 2 years. She also gave history of right upper limb pain and weakness while doing works using upper limbs.
What further clinical information you will gather from the patient to reach the diagnosis?
ii) Mention the investigation with interpretations to substantiate your diagnosis.
e) A 36-year-old HIV positive man is being admitted under your care. During blood drawing a nursing staff got needle prick injury with the contaminated needle.
How will you evaluate the attending nurse?
How will you manage this needle prick injured nurse?
iii) Mention the preventive measure to be adopted to avoid such complication.

a)A 40-year-old man has brought to the emergency department with the complaints of severe respiratory distress, flushed face and erythematous skin rash all over the body. The attendant of the patient informed that he was given an IM injection one hour before onset of these symptoms.

 i) Mention the immediate management of this patient.
ii) Mention the principles of further prevention of such event.

b)A 45-year-old man presented with the complaints of weakness of left side of the body for 2 hours. He is a known case of hypertension for last 5 years with history of taking irregular antihypertensive drugs. On examination his blood pressure is 200/110 mmHg. Immediate CT head showed normal imaging.
How will you manage his hypertension? What will be the target BP in this patient? ii) Mention the specific treatment for this patient.

c) A 30-year-old man has presented with high rise of temperature for 3 days with deteriorating level of consciousness. On examination his BP 85/50 mmHg, pulse 130/min with stiff neck and positive Kerning's sign. His skin shows diffuse maculopapular progressing to purpura and blistering lesions. Blood examination showed total WBC count 16x109/L with neutrophil 88%, lymphocyte 10%, eosinophil-1% and basophil-1%,

What is the most likely diagnosis?
ii) Mention single investigation to substantiate your diagnosis.
iii) Give immediate management to this patient.

d) A 30-year-old man attended the outpatient clinic for evaluation of his low back pain. He stated
that he has low back pain for last 1 year for which there is no apparent history of trauma but the pain used to aggravate on rest and he feels better on taking Naproxen 500 mg twice daily. On query he gave the history of recurrent painful red eyes for the preceding 5 years and every time he had to consult with an ophthalmologist on emergency basis.
i) How will you evaluate him clinically?
ii) Mention the principles of treatment for this patient

e) A 30-year-old woman admitted in medicine ward with history of fall followed by loss of consciousness. On query she gave history of such type of presentation twice during the preceding 1 year.
i) What further clinical information would you like to gather to reach a diagnosis? 

ii) How would you manage the patient? 

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