MEDICINE P4

For questions 1-4 these patients have all been found to have neck pulsations. Choose the
most appropriate clinical scenario from the list below:

A. Non-pulsation venous B. Prominent flicking’a’ waves

distention
C. Rapid ‘y’ descent D. JVP elevated to the angle of the jaw
E. Prominent pulsation ‘v’ F. JVP elevated 5cm
waves
G. Unilateral non-compressible H. Giant ‘a’ waves
pulsation

1. A 25-year old man who has severe mitral stenosis presents with swollen ankles and a
distended abdomen with right upper quadrant tenderness and pulsation on
palpitation. He is tachypnoeic and unable to lie flat.

2. A 65-year old ex smoker who presents with a 3-month history of persistent cough,
haemoptysis and left-sided chest discomfort. Examination reveals a large
supraclavicular lymph node.

3. A 45-year old man who is HIV negative complains of breathlessness and fatigue. He is
able to lie flat in bed. He was treated for TB 20 years ago. He complains of abdominal
fullness and is found to have ascites but no ankle swelling.

4. A 75-year old woman with heart block presents with episodes of light headedness.
Her pulse is 40 beats/minute but she is not in heart failure. She has refused to have a
pacemaker inserted.

5. A 48-year-old man has had a painful right wrist for 3 months. The left elbow is now
painful, and both are worse on waking up and for several hours of the morning. He is
otherwise well, except for a rash on the scalp, back and extensor aspects of his arms.
Which finding on examination would support further diagnosis?

A. Malar erythematous facial rash

B. Whitish nodule on the pinnae of the ears
C. Marked pitting of the nails
D. ‘Squaring off’ of both thumbs

6. A 35-year old woman presented with a 4-month history of increasing breathlessness

and abdominal distention. She has no history of cough or ankle swelling. Her heart
rate is 98 beats per minute, irregularly irregular. Her JVP is markedly raised and she
has minimal putting edema. The heart spun are soft, and there are no audible
murmurs. Abdominal examination reveals hepatomegaly and ascites. A lateral Chest
X-ray shows calcification. Urinalysis is normal. What is the most likely diagnosis?

A. Dilated cardiomyopathy
 B. Constrictive pericarditis
C. Restrictive cardiomyopathy
D. Nephritic syndrome

7. A 67-year old man has just been admitted with haematemesis and melaena. On
examination, he has a postural drop in blood pressure from 100/60 mmHg to70/40
mmHg. What is the most appropriate immediate management step?

A. Blood transfusion
B. Intravenous ranitidine
C. Intravenous crystalloid
D. Intravenous Vitamin K

8. A 15-year old girl has difficulty in combing her hair and climbing upstairs for 4
months. She has Gower’s sign and a papular rash over the metacarphalangeal joints.
What should be the next appropriate investigation?

A. Rheumatoid factor
B. Creatinine Kinase
C. Electromyography
D. Muscle biopsy

9. A 60-year old man complains of a chronic history of mild haemoptysis, production of

copious, foul smelling sputum and on examination there is clubbing and widespread
crackles on auscultation. The most likely diagnosis is:

A. Pulmonary tuberculosis
B. Mitral stenosis
C. Bronchiectasis
D. COPD

10. A 30-year old woman presents two weeks after recovery from a flu-like illness. She
has weak legs bilaterally with power 2/6 with reduced tone, no tendon reflexes and
absent plantar reflexes. CSF examination showed normal pressure, cell count and
glucose with a moderately increased CSF protein. The most likely diagnosis is:

A. Tuberculosis of the spine

B. Guillian Barre Syndrome
C. Brown Sequard syndrome
D. Syringomyelia

11. A coal worker consults with progressive dyspnoea and on examination of his chest
there are widespread crackles. Spirometry shows reduced FVC but a normal FEV/FVC
ratio. He has:

A. An obstructive lung condition

B. A restrictive lung condition
 C. Alpha one anti-typsin deficiency
D. Chronic obstructive pulmonary disease

12. A 28-year old woman presented to casualty, 3 days after running half a marathon.
She complained of diffuse muscle pain ad weakness, making it difficult for her to
walk and also dark urine. Urinalysis was positive for haemoglobin and her serum
creatinine(CK) was 97,342 U/L (38-176). What is the most appropriate next step to
confirm the diagnosis of rhabdomylosis?

A. Muscle biopsy
B. CK isoform analysis
C. Serum myoglobin
D. No further testing is required

13. A 36-year old diabetic woman is admitted with shortness of breath and pleuritic
chest pain following a 16-hour flight. The working diagnosis is of pulmonary embolus
and a CT-pulmonary angiogram is requested. What precautionary investigation
should be done before the test can go ahead?

A. Serum glucose
B. Renal function
C. Clotting profile
D. D-dimers

These patients, questions 14-17, have all presented with a palpable lump in the neck. Please
select the most appropriate diagnosis from the list below:

A. Brachial cyst B. Thyroglossal cyst

C. Thyroid nodule D. Pharyngeal pouch
E. Lymphoma F. Metastatic carcinoma
G. Cystic hygroma H. Cervical rib

14. A 20-year old woman presents with a painless lump in the midline below her chin. It
is smooth, 2cm in diameter, non-tender, fluctuant on palpation and moves upwrds on
swallowing and protrusion of the tongue.

15. A 20-year old man presents with a painless, slowly growing lump above the clavicle.
He also complains of weight loss, sweats at night and pruritus. It is firm, 3cm in
diameter and non-tender.

16. A 26- year old woman has a slowly growing smooth painless lump in the anterior
triangle of the neck. The mass is just to the left of the midline, overlying the laryngeal
cartilage and moves on swallowing.

17. A68-year old man presents with an asymptomatic slowly-growing painless lump in
the neck. Examination reveals a hard 2cm mass lying laterally in the anterior triangle
of the neck, deep to the third of the sternomastoid. He has dysphonia.
The following patients, questions 18-20, have all presented with secondary hypertension.
Choose the most appropriate diagnosis from the list:

A. Acromegaly B. Coarctation of the aorta

C. Conn’s syndrome D. Cushing’s syndrome
E. Diabetic nephropathy F. Phaeochromocytoma
G. Polyarteritis H. Polycystic kidney disease
I. Pregnancy J. Renal artery stenosis

18. An 18-year old man is found to be hypertensive during a routine medical.

Examination reveals radio-femoral delay, an ejection systolic murmur and
haemorrhages and exudates on fundoscopy.
19. A 45-year old woman presents with frequent, rapid palpitations associated with a
pounding headache, sweating and a feeling of impending doom. 24-hour
catecholamines are elevated on three occasions but TC scan of the adrenals is
normal.

20. A 46-year-old man with longstanding diabetes mellitus and coronary artery disease
develops a puffy face and ankle swelling. His BP is found to be 160/10mmHg lying
and 135/100mmHg on standing. Urinary dipstick testing is positive for protein. Blood
tests show urea of 20mmol/L and creatinine of 295umol/L.

The following patients, questions 21-24, have a vitamin deficiency. Choose the most
appropriate one from the list:

A. Folate B. Nicotinic acid

C. Vitamin C D. Vitamin D
E. Vitamin K F. Thiamine
G. Iron H. Vitamin A
I. Vitamin B12 J. Pyridoxine

21. An HIV negative patient is on treatment for pulmonary tuberculosis. He has no fixed
home. He complains of numbness and tingling of his hands and feet.

22. A 55-year-old man with long-standing chronic pancreatitis presents with epistaxis
and melaena. He has numerous bruises on his arms and shins.

23. An 80-year-old widow lives alone and presents with a rash and mild ankle swelling.
She has swollen bleeding gums, petechia on her legs and numerous bruises on her
arms and shins.

24. A 12-year-old boy presents with a cough. His parents are vegetarian for religious
reasons. The GP thinks that his chest is abnormally shaped and the child has bowing
of the legs.
25. A 40-year-old woman presented with left sided chest pain of sudden onset. The pain
was worse on coughing and taking a deep breath. Which of the following clinical
features would support a diagnosis of pulmonary embolus?

A. Body mass index <25kg/m2

B. Fever of 38.5°C
C. Peripheral cyanosis
D. Sinus bradycardia
E. Pleural friction rub

26. A 28-year-old man is suspected of having had a sub-arachnoid haemorrhage after

presenting with a sudden onset of a severe headache. The following sign is definitive
in confirming the diagnosis:

A. Severe stiffness on neck flexion

B. Negative Kernig's sign
C. Neck pain on lateral flexion
D. Negative Brudzinski's sign
E. Positive Lhermitte's sign

27. A 35-yeasinourished wi was found lying unconscious along the roadside. He looked
malnourished with nicotine stained fingers, parolid fullness, bilateral Dupuytren's
contractures and several spider naevi. His temperature was 36.8°C, RR-24/min, BP-
100/60mmHg. His Glasgow coma scale was 5/15, with no neck stiffness. The pupils
were equal and reactive to light. What is the next best step in the management of
this patient?

A. Immediate CT scan of the brain

B. Urgent liver function tests
C. Finger prick glucose test
D. Lumbar puncture
E. Immediate intubation

28. A 45-year-old man presents to his general practioner 4 weeks after returning from a
holiday in Thailand complaining of a painless ulcer on his penis for the past week. He
has no abnormal discharge or rashes. What is the likely aetiological agent
responsible for his symptoms?

A. Herpes simplex virus

B. Treponema pallidum
C. Trichomonas vaginalis
D. Neisseria gonorrhoea
 E. Candida albicans

29. A 56-year-old man presents to the clinic complaining of dysuria, frequency and
urinary urgency for 3 days. He has also been experiencing a sensation of incomplete
bladder emptying, decreased force of his urinary stream, hesitancy and dribbling
over the preceding 6 months. What is the likeliest underlying cause for his current
presentation?

A. Prostate cancer
B. Acute bacterial prostatitis
C. Benign prostatic hypertrophy
D. Carcinoma of the bladder
E. Urethral stricture

30. An HIV positive patient presents with a dry cough and breathlessness on mindra.
exertion. He is not obviously cyanosed TOil suspect Pneumocystis jroved pneumonia.
Which one of the following would support the diagnosis?

A. Use of cotrimoxazole prophylaxis

B. Normal chest examination
C. Wheeziness on auscultation
D. Bilateral pleural effusions
E. High fever of 40°C

31. A 35-year-old woman presents with joint pain and swelling, painless most ulcers and
symptoms of anaemia for three months. Urinalysis is abnormal with 14 of blood and
protein. Results show an ESR of 105mm/hr. What is the likely cause for these mouth
ulcers?

A. Aphthous ulcers
B. Herpetic stomatitis
C. Lupus erythematosus
D. Behcet's disease
E. Bullous pemphigoid

32. A 30-year-old woman delivered her 2nd child months ago. She developed shortness
of breath 6weeks post-delivery which progressively became worse, She can no
longer do her household chores. She has orthopnoea, paroxysmal nocturnal
dyspnoea and a dry cough.
One of these would be a rather unexpected sign to find on examination:

A. bilateral pedal oedema

B. normal jugular venous pulse
 C. tender hepatomegaly
D. bilateral basal crepitations
E. pericardial friction rub

33. A 59-year-old man complains of vague periumbilical abdominal pain which radiates
to the back for the past 6 months. He has lost about 15kg in the 6months. The wife
noticed yellowing of his eyes and he has been feeling itchy all over his body. Which
of these is the most likely cause of his symptoms?

A. pancreatic tumour
B. chronic hepatitis B
C. gallstones
D. liver cirrhosis
E. haemolytic anaemia

34. A 35-year-old man presents with a severe headache for 2 weeks with concomitant
nausea and vomiting. Pulse is 60 beats/minute, BP 150/90mmHg and he is pyrexial
with mild pallor and enlarged cervical lymph nodes. A lumbar puncture is carried out.
The opening pressure is 22cm of water. CSF is clear and colourless and results show

Glucose 2.1mmol/L
Protein 1.1g/L(100-400mg/L)
Globulin Positive
Cell Count 114 cells/hpf (60% lymphocytes)
Blood glucose (random) 6.0 mmol/L

What is the most likely diagnosis?

A. Tuberculous meningitis
B. Cryptococcal meningitis
C. Primary CNS lymphoma
D. Intracerebral tumour

35. A 93-year old female patient is admitted with acute onset of confusion, generalised
body weakness and urinary incontinence. She was previously well, with no chronic ill
health and independently mobile. She has been on thyroxine 100 ug daily for man
for a benign thyroid nodule. She lives with her maid/housekeeper who preparesher
meals and looks after home.

Her FBC and urea, K, Na and creatinine are normal. The rest of her blood results are
as follows:
Total protein 51 g/l
Albumin 27 g/l
Corrected calcium 1.99 mmol/l
 phosphate 2 1 mmol/l
Magnesium 0 5 mmol/l
TSH is normal

Which of the following is the most likely cause of these biochemical abnormalities?
A. Chronic malnutrition
B. Hypoparathyroidism
C. Vitamin D deficiency
D. Severe osteoporosis
E. Thyroxine treatment

36. A 76-year-old smoker presented with muscle weakness and haemoptysis. He has a
night supraclavicular node and is found to be clubbed.
Investigations showed.
Sodium 143 mmol/L
Potassium 2.8 mmolL
Urea 3.7 mmol/L.
Bicarbonate 34 mmol/L

What is the most likely underlying diagnosis?

A. Pulmonary tuberculosis
B. Chronic obstructive airways disease
C. Squamous carcinoma bronchus
D. Alveolar cell carcinoma

37. 24 hours after a laparotomy a 60 year old man had a urine output of 12ml per hour.
He had been previously well and there was no significant past medical history and no
symptoms to suggest urinary outflow tract obstruction. These were the results:

Sodium 135mmol/L
Potassium 6.0mmo/L
Urea 16mmol/L
Creatinine 100 umol/L
Blood glucose 4mmol/L
Urine osmolality 700mosmol
Urine sodium 10mmol/L

What is the most appropriate initial management for him?

A. Rapid iv rehydration
B. Acute peritoneal dialysis
C. Suprapubic catheterization
D. Strict fluid restriction
E. immediate haemodialysis
 38. A middle-aged man presents with increasing thirst, polyuria and polydipsia. He is
otherwise well and takes no regular medication. His blood glucose level is normal.
His serum calcium and renal function are normal. He undergoes a water deprivation
test.
TIME SERUM Na SERUM OSM URINE VOL URINE OSM
Baseline 138 280 350 50
60 140 285 150 200
120 141 290 50 300
180 143 295 0 350
240 145 298 50 600
OSM = OSMOLALITY in mmol/L, urine vol in mls

The most likely diagnosis is;

A. Central diabetes insipidus

B. Psychogenic polydipsia
C. Diabetes mellitus
D. Nephrogenic diabetes insipidus
E. Sjogren's syndrome

39. A 90-year-old man is brought in to Casualty with acute confusion, He is

haemodynamically stable and looks well hydrated. He is febrile. Results of blood
tests show:
Serum Na 115 mmol/L.
Serum Osmolality 245mmol/L
Urinary Sodium 50mmol/L
Urinary Osmolality High

What is the best treatment option for him?

A. Hypertonic saline
B. Normal saline
C. Fluid restriction
D. oral salt supplement
E. Hypotonic saline

40. An 80-year-old woman sustained a fall five weeks ago. She became confused on the
day of admission and has a left hemiparesis with an upgoing plantar response. What
is the most likely diagnosis?

A. Subarachnoid haemorrhage
B. Subdural haematoma
C. Cerebrovascular thrombosis
D. Lacunar infarct
41. A 45-year-old truck driver presents to casualty with a 7-week history of a truncal rash
and a dry cough. He has been on the same antiretroviral regimen for 7 years and is
adamant that he is compliant with medication even when he is travelling. On
examination he has lesions on the foot and the gums. What is the most appropriate
investigation plan in his management?

A. Swab a lesion for microscopy and culture

B. Check HIV viral load and CD4
C. HIV genotype resistance testing
D. Sputum for AAFB and chest x-ray
E. Perform therapeutic drug levels in blood

42. A 13-year-old girl from Gokwe was admitted with symptoms of tiredness and
exercise breathlessness. Her blood film is shown. Clinically there is mild jaundice and
mild hepatomegaly but no splenomegaly. What is the mainstay of her long-term
therapy?

A. Ferrous sulphate
B. Hydroxyurea
C. Antimalarial prophylaxis
D. Daily imatinib
E. Low dose aspirin

43. A 71-year-old hypertensive woman presents with recurrence of a short history of

pain, redness and swelling of the finger. The joint x-ray is shown. What is the most
important management in her long-term care?

A. Dietary manipulation
B. Low dose short-course prednisolone
C. Oral allopurinol
D. Strict alcohol avoidance
E. Desferrioxamine

44. The EGG shown is taken from a 65-year-old woman who was found in a coma in her
home: She lives alone and has become rather reclusive lately. Results show normal
glucose, haemoglobin 11.8g/dL, MCV 100fL. What is the key blood test required to
confirm the likely diagnosis?

A. Thyroid stimulating hormone

B. Urea and electrolytes
C. Blood alcohol level
D. Peripheral blood film
45. This 65-year-old man was referred by the optometrist where he had his eyes tested
recently. He was diagnosed and treated for lung cancer 2 years ago. He admits to
having had headaches recently and his wife says that his memory is not what it 'used
to be. A metastatic lesion is suspected. What is the site of the lesion demonstrated
by the perimetry shown in this slide?

A. Optic chiasm
B. Lateral geniculate body
C. Left optic nerve
D. Occipital lobe visual cortex
E. Right temporal lobe

46. This 40-year-old woman with a history of rheumatic heart disease and atrial
fibrillation presents with a history of sudden collapse and left sided weakness.She
was taking warfarin, frusemide, enalapril and digoxin. What is the next appropriate
step in her management?

A. Intramuscular vitamin K
B. Fresh frozen plasma infusion
C. Systemic dexamethasone
D. Intravenous mannitol

47. This 60-year-old patient presents with symptoms of anemia and severe backache. Hb
is 8.5g/dL, MCV 89fL, WCC and platelets are normal, urea 15mmol/L, creatinine
250pmol/L, alkaline phosphatase 95iu/L. What investigation is most likely to be
diagnostic?

A. PA and lateral chest X-ray

B. Renal ultrasound scan
C. Urine microscopy & culture
D. Plasma C-reactive protein
E. Plasma protein electrophoresis

48. A 48-year old hypertensive man, HIV positive on ART, with a recent CD4 count or
452cells/ml, presents with 5 days of fever, malaise, low back pain, and constipation.
The onset was gradual, and he was able to continue working until yesterday. He
denies dysuria or frequency, though he admits to some hesitancy for at least one
year. He is adherent to medications. He lives in Harare on a property with well water
and works as a painter. Examination reveals temperature 39.6°C, BP 173/92mmg.
pulse 82beats/min, respiratory rate 12breaths/min. He is alert and there is bilateral
renal angle tenderness. Results show urinalysis: pH 7.4, specific gravity 1.012,
protein 2+, leucocytes 1+, nitrate trace, ketones trace, 10-30 WBC; WCC 8.7 x 10°L,
normal creatinine. Blood cultures show Gram negative rods after 24 hrs. incubation.
Which of the following is the most likely diagnosis?
 A. Pyelonephritis
B. Epidural abscess
C. Diverticulitis
D. Enteric fever
E. Prostatitis

49. A 12-year-old girl is admitted for acute bacterial meningitis and dies on the second
hospital day. Three days later, her 17-year-old brother is admitted directly to
another medical ward, also with meningitis. Gram stain of CSF obtained from the
brother shows Gram negative intracellular diplococci. Which of the following
individuals who had contact with the brother should receive post exposure
prophylaxis?
A. A pregnant student nurse working in the ward who took the patient's vital signs
B. The two-year-old niece who lives in the patient's home
C. Any patient sitting beside him in the Casualty waiting area
D. All staff who took a history and did a physical examination prior to initiation of
antibiotics
E. The brother's girlfriend who last saw him two weeks ago.

50. A 32-year-old woman is seen at a rural antenatal clinic. During her first pregnancy
five years ago she was told that she had a heart murmur, but she not return for
follow-up care. She gets slightly breathless on getting onto the examination couch,
signs include a low volume pulse 92 beats/minute, BP 105/75mmHg, sustained
displaced apex but no elevated JVP or peripheral oedema. She is not pale or
cyanosed and there are no signs to suggest infective endocarditis. ECG shows
marked left ventricular hypertrophy and a strain pattern. What is the likely clinical
abnormality?

A. Hypertrophic obstructive cardiomyopathy

B. Mitral stenosis
C. Aortic stenosis
D. Ventricular septal defect
E. Eisenmenger syndrome

51. A 61-year-old man is admitted with some breathlessness and obvious abdominal
distension. Pulse 96 beats/minute, BP 100/70mmg, respiratory rate 28 breaths/min.
He has ascites. Paracentesis shows:

Ascitic white cell count 210 leucocytes/ML, 35% polymorphonuclear cells

Ascitic albumin 12g/L
Ascitic protein 20g/L
Serum albumin 26g/L
Peritoneal cultures awaited.
Which of the following is the most likely diagnosis?
A. Heart failure
B. Tuberculosis
C. Carcinomatosis
D. Chylous ascites
E. Bacterial peritonitis

52. A 35-year old pregnant woman is referred to the outpatients' clinic at 26 weeks
gestation because of mild jaundice, a 1-month history of intense prunitus and
fatigue. She has no other medical problems and is not on any medication. On
examination, she is fully orientated. Her pulse rate is 72beats/min, and blood
pressure is 110/85 mmHg. She has mild jaundice and obvious scratch marks on the
arms, chest, and legs.

Liver function tests:

Bilirubin 102umol/L
AST 175 TU/L
ALT 137 lU/L
ALP 350 IU/L
GGT 52 lU/L
Albumin 33g/L
INR 1.01

Abdominal ultrasound is normal with a 26-week gravid uterus. There is no free

abdominal fluid and no organomegaly. Which of the following is the most likely
diagnosis?
A. Intrahepatic cholestasis of pregnancy
B. HELP (haemolysis, elevated liver enzymes, low platelets) syndrome
C. Hyperemesis gravidarum
D. Acute fatty liver of pregnancy
E. Acute cholecystitis

53. A 19-year-old man presents with a 2-day history of frank haematuria after having
been unwell with what he thought was a flu-like illness. He had a similar episode
about a year ago. There is no family history of renal disease. These are his results:
BFAT IgG positive
Sodium 135mmol/L
Potassium 4.5mmol/L
Bicarbonate 20mmol/L
Urea 23mmol/L
Creatinine 400m/L
 Urinalysis: haematuria+++ and proteinuria +, no bacterial growth, no schistosoma
ova.
Cholesterol level 4.5mmol/L
Triglycerides 2.5mmolL

Which of the following is the most likely cause of his haematuria?

A. Benign familial haematuria
B. IgA nephropathy
C. HIV nephropathy
D. Hereditary nephritis

54. A 41-year old woman presents with a 4-month history of progressively worsening
exertional dysproea, She is a former smoker (20 packyear history overweight and
being treated for systemic sclerosis. Her pulmonary function tests are as follows:

Measured % of predicted
FEV1(L) 1.9 71
FVC(L) 2.4 75
FRC(L) 2.2 79
RV(L) 1.6 92
TLC(L) 3.9 83
TLco(mmol/min/kPa) 4.51 50
Kco(mmol/min/kPa/L) 1.43 76

Which of the following is the most likely cause of this patient's symptoms?
A. Chronic bronchitis
B. Emphysema
C. Interstitial lung disease
D. Cor pulmonale

55. A 36-year-old HIV positive man who was recently started on TB medications
disseminated miliary tuberculosis presents with abdominal pain, vomiting and
continued loss of weight. His investigations reveal: Sodium 120mmol/L, potasium
5.8mmol/L, urea 15mmol/L and creatinine 170mmol/L. The TB therapy is continued,
but what else should he be given?

A. Ceftriaxone
B. Hydrocortisone
C. Vitamin B12
D. Calcium gluconate
56. A 24-year-old woman presented with a year's history of increasing blurred vision and
lately has had disturbed nights because of having to get up to pass urine.She has lost
weight recently and is feeling generally weak and tired. She is found to have
cataracts on examination and impaired visual acuity.

What test is critical to making the diagnosis?

A. Corrected serum calcium

B. Blood glucose level
C. Thyroid function tests
D. Parathormone levels

57. A 60-year-old man comes for review two weeks after being discharged from hospital
for acute pancreatitis. He is noted to have a history of chronic back pain and limb
pain, and had previously had a bone marrow examination for suspected'cancer
which was normal. He reports polyuria and polydipsia and is dehydrated on
examination. The following tests were done a day before the current presentation:
Na 137mmolL, K 3.6mmol/L, urea 15.2 mmol/L, creatinine 136 mol/L, HbA1c5.6%

Which of the following tests is likely to lead to the correct diagnosis?

A. Lateral and AP skull X-rays

B. Corrected serum calcium
C. Fasting blood sugar
D. Serum and urine osmolality
E. Urine protein electrophoresis

58. A 23-year-old man who has recently started an intense physical exercise programme,
comes to hospital complaining of persistently sore muscles. His parents became
concerned when they noticed that his upper arms appeared to be swollen. When
questioned further, he denies taking any medications, and adds that he has been
passing small amounts of very concentrated urine.Investigations reveal Na
140mmol/L, K 5.9, urea 20mmol/L, creatinine 374 mol/L, CPK 21450 iu/L, and
urinalysis shows 2+ blood and trace of protein.

Which of the following treatment modalities is most appropriate?

A. Rapid saline infusion

B. Immediate anticoagulation
C. Furosemide bolus
D. Intravenous steroids
E. Bicarbonate infusion
59. A 68-year old woman is referred for evaluation of symptomatic anaemia. On
examination, she is pale and has mild splenomegaly. Her full blood count shows:
WCC 3. 5 x 109/L Hb, 7.6g/dL, MCV 113fL, PLT 135 x 109/L, peripheral film shows
pancytopenia and macrocytic red cells. Vitamin B12 levels 350 pgm/ml (150 - 800),
folate levels normal. The bone marrow shows reduced granulopoieisis,
erythropoiesis and thrombopoiesis with maturation arrest. There are no
granulomata and no bone marrow infiltration.

Which of the following diagnoses is most consistent with this clinical picture?
A. Hypothyroidism
B. Chronic alcohol use
C. Myelodysplastic syndrome
D. Chronic myeloid leukaemia
E. Mycobacterial TB infection