PGET Punjab (UHS): Paper II format, table of specifications and merit

Answer: A — Check bedside blood glucose level

No treatment can be chosen for a drowsy diabetic until glucose is known, since the two possibilities demand opposite interventions. Poor intake with vomiting on insulin or a sulfonylurea makes hypoglycaemia as likely as a hyperglycaemic crisis, and giving insulin or saline to a hypoglycaemic patient wastes the minutes that matter and risks neuroglycopenic injury. A capillary glucose takes seconds and needs no laboratory, which is why glucose follows airway, breathing and circulation. IV insulin is dangerous until hyperglycaemia and potassium are confirmed. Normal saline is correct in ketoacidosis or a hyperosmolar state, but only once diagnosed. Bicarbonate is not indicated except at pH below 6.9. Oxygen is given if hypoxaemic, but addresses neither cause of coma.

Answer: C — Alpha-1 antitrypsin deficiency

The differential is cirrhosis with no alcohol history, and emphysema appearing unusually early. Alpha-1 antitrypsin deficiency unifies both: the abnormal Z protein polymerises within hepatocytes, producing periodic acid-Schiff-positive diastase-resistant globules and cirrhosis, while the low circulating antiprotease leaves neutrophil elastase unopposed in the lung, giving basal panacinar emphysema that smoking accelerates dramatically. One disease accounts for both organs, unlike any other option. Alcoholic liver disease is excluded by the history. Non-alcoholic fatty liver disease explains the cirrhosis but nothing in the lung. Chronic hepatitis C is likewise confined to the liver. Wilson disease presents younger with Kayser-Fleischer rings, low caeruloplasmin and neuropsychiatric features. Confirmation requires phenotyping or genotyping for the PiZZ allele.

Answer: D — Perform urgent percutaneous coronary intervention

This is an inferior STEMI, with elevation in II, III and aVF indicating right coronary occlusion in most patients. The only treatment that alters outcome is reopening the artery: primary PCI within 120 minutes of first contact beats fibrinolysis, and where a catheter lab is unreachable, as in much of Pakistan, thrombolysis is given immediately and the patient transferred. The bradycardia and borderline pressure fit right coronary occlusion with vagal activation or right ventricular involvement, so nitrates are avoided. IV beta-blockade would be harmful with a pulse of 58 and systolic 95. Cardiac enzymes take hours and must never delay reperfusion when the ECG is diagnostic. A statin is secondary prevention. Heparin alone does not dissolve established thrombus.

Answer: C — Diabetic foot

This is a neuropathic diabetic foot ulcer, read from its site, sensation and pulses. Long-standing hyperglycaemia damages nerve fibres, so vibration and pinprick are lost; the foot no longer registers pressure, callus builds over pressure points, and unfelt trauma breaks the skin, giving a punched-out, painless ulcer. Warm skin with palpable pulses confirms intact perfusion and a neuropathic, not ischaemic, mechanism. Peripheral arterial disease gives a painful ulcer on the toes with a cold, pulseless foot. A venous ulcer sits above the medial malleolus, shallow with sloping edges and haemosiderin staining. A pressure ulcer arises over a bony prominence in an immobile patient. Cellulitis is spreading erythema rather than an ulcer, though it may complicate this one.

Answer: C — Group B Streptococcus

This is bacterial meningitis in a fifteen-day-old, shown by the bulging fontanelle, poor feeding and lethargy with CSF showing high protein, low glucose and neutrophil pleocytosis. In the first month of life the organisms come from the maternal genital tract, and group B Streptococcus is commonest; late-onset disease presents in the second to fourth week exactly like this, with meningitis and shock. Escherichia coli is the second commonest neonatal pathogen, particularly in preterm infants and without intrapartum prophylaxis, but ranks below group B Streptococcus. Listeria is uncommon yet important enough that ampicillin stays in the empirical regimen. Neisseria meningitidis and Streptococcus pneumoniae matter only after about three months, once maternal antibody has waned. Empirical treatment is ampicillin with a third-generation cephalosporin or gentamicin.