UHS final-year MBBS medicine: Paper I and Paper II syllabus

Answer: B — Community-acquired pneumonia

This is community-acquired pneumonia, defined by where it was acquired rather than by organism. Four days of fever, rigors, purulent sputum and lobar consolidation in a patient living at home with no recent admission place it in the community-acquired category, where Streptococcus pneumoniae predominates. Severity is graded with CURB-65: low severity is treated with amoxicillin alone, clarithromycin is added in moderate severity when atypical organisms are suspected, and high severity is treated with co-amoxiclav plus clarithromycin. Diabetes and smoking are risk factors, not alternative diagnoses. Tuberculosis must be weighed in Pakistan, but it typically runs over weeks with night sweats, weight loss and apical shadowing rather than a four-day lower lobe illness. Hospital-acquired pneumonia requires onset 48 hours or more after admission, excluded here, and would shift antibiotics towards Pseudomonas and resistant Gram-negative organisms. Acute bronchitis causes cough and sputum but leaves the chest X-ray clear, so the consolidation rules it out.

Answer: B — Prednisolone

This is systemic lupus erythematosus, confirmed by anti-dsDNA and anti-Smith antibodies, presenting with disabling polyarthritis and constitutional upset but without nephritis. Of the options offered, an oral corticosteroid is appropriate first treatment: prednisolone acts within days and controls the arthritis, fever and fatigue, tapered to the lowest dose that maintains control. Hydroxychloroquine is started at the same time in every lupus patient, since it reduces flares and improves survival, with a steroid-sparing agent added if steroid cannot be withdrawn. Methotrexate is useful for persistent arthritis but too slow, taking six to eight weeks, for an acute flare. Infliximab, a TNF blocker, can itself induce lupus and is contraindicated. Mycophenolate is reserved for lupus nephritis, absent here. Paracetamol treats pain without touching the inflammation.

Answer: B — Co-trimoxazole

✅ Correct: Co-trimoxazole

Co-trimoxazole (trimethoprim-sulfamethoxazole) is first line for Pneumocystis jirovecii pneumonia at every severity: the two drugs block consecutive steps of folate synthesis in the organism and achieve good lung penetration.

Everything fits: CD4 180, exertional breathlessness with dry cough, and perihilar interstitial haziness rather than consolidation.

Treat for 21 days, adding corticosteroids if PaO2 is below 70 mmHg on air or the A-a gradient exceeds 35 mmHg, because killing the organisms worsens inflammatory alveolar damage first.

❌ Why the others are wrong

Clindamycin and primaquine — second line, used in sulfa allergy or after first-line failure; check G6PD before primaquine.

Dapsone and atovaquone — each is an alternative for mild disease in sulfa-intolerant patients (dapsone with trimethoprim, or atovaquone alone), but they are not used together.

Clindamycin and dapsone — not a recognised combination for this infection.

Answer: C — Presence of autoimmune disease

✅ Correct: Presence of autoimmune disease

Everything else fits type 2 diabetes; the odd finding is treated Hashimoto's, since autoimmune disease clusters with type 1 and LADA, not type 2. An adult with autoimmune thyroid disease labelled type 2 deserves GAD/IA-2 antibodies and C-peptide, as LADA fails oral agents within months and needs insulin.

❌ Why the others are wrong

Duration of symptoms — 6 weeks of polyuria and lethargy is typical; type 2 is insidious and often symptomatic only late.

Complications at diagnosis — typical, not unusual; retinopathy is present in up to a fifth at diagnosis from years of silent hyperglycaemia.

Age — 49 is the expected band for type 2.

Answer: B — Lorazepam

This is alcohol withdrawal in a man with decompensated cirrhosis, and the principle being tested is which benzodiazepine to choose when liver function is impaired; with normal liver function chlordiazepoxide or diazepam would be the usual UK first choice. All benzodiazepines are cross-tolerant with alcohol and will suppress tremor, agitation and the risk of seizures, but lorazepam is cleared by glucuronidation rather than hepatic oxidation, so it has no active metabolites and its handling is largely unchanged in cirrhosis and in older patients. That makes it the safest agent to load and titrate against a withdrawal score in a man with established liver failure. Diazepam is effective but is oxidised to desmethyldiazepam and oxazepam, which accumulate and cause prolonged sedation if the liver is impaired. Clonazepam has a very long half-life and is an anticonvulsant of convenience rather than a withdrawal agent. Alprazolam is short-acting with a sharp offset, provokes interdose rebound anxiety and carries the highest dependence liability of the group.