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A 32-year-old male is admitted to Kamuzu Central Hospital in Lilongwe with high-grade fever, altered mental status (GCS 11/15), scleral icterus, and passage of dark cola-coloured urine. A peripheral blood film demonstrates Plasmodium falciparum ring forms with 8% parasitaemia. According to the Malawi Standard Treatment Guidelines (MSTG) and WHO recommendations, what is the first-line treatment for this patient?

Internal Medicine

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Question

A 40-year-old male presents to a district hospital outpatient department with a 4-week history of productive cough, evening fevers, profuse night sweats, and marked weight loss. Sputum testing by GeneXpert MTB/RIF detects Mycobacterium tuberculosis with no rifampicin resistance. What is the standard first-line treatment regimen for this patient under the Malawi National Tuberculosis Programme?

Internal Medicine

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Question

A 35-year-old female living with HIV on standard first-line antiretroviral therapy (Tenofovir/Lamivudine/Dolutegravir - TLD) is diagnosed with active pulmonary tuberculosis and initiated on 2RHZE. Rifampicin is a potent inducer of hepatic CYP3A4 and UGT1A1 enzymes, markedly reducing dolutegravir plasma concentrations. According to Malawian National HIV and TB Guidelines, how should her antiretroviral regimen be adjusted during anti-TB treatment?

Internal Medicine

Question · Hard

Question

A 22-year-old female with type 1 diabetes presents to the casualty department with severe nausea, recurrent vomiting, deep sighing (Kussmaul) respiration, and sweet acetone breath. Blood glucose is 26 mmol/L, urine ketones are 4+, and arterial blood gas reveals pH 7.16, HCO3 9 mmol/L, with serum potassium of 4.4 mmol/L. Following initial intravenous fluid resuscitation with 0.9% normal saline, what is the initial insulin protocol?

Internal Medicine

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Question

A 68-year-old male presents with right-sided pleuritic chest pain, productive cough with rust-coloured sputum, and fever for 3 days. Physical examination reveals bronchial breathing and dullness at the right lung base. Vital signs: blood pressure 86/52 mmHg, pulse 112/min, respiratory rate 34/min, temperature 38.9°C. Blood urea is 8.8 mmol/L, and he is disoriented to time and place. What is his CURB-65 pneumonia severity score and the appropriate level of care?

Internal Medicine

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Question

A 62-year-old female with long-standing poorly controlled hypertension presents to casualty in severe respiratory distress, orthopnea, and pink frothy sputum. Examination reveals bilateral coarse lung crackles extending halfway up the lung fields, elevated jugular venous pressure (JVP +6 cm), and blood pressure of 185/105 mmHg. Oxygen saturation is 84% on room air. What is the immediate pharmacological intervention?

Internal Medicine

Question · Easy

Question

A 34-year-old male with newly diagnosed advanced HIV infection (CD4 count 22 cells/mm³) was initiated on 2RHZE for pulmonary tuberculosis 3 weeks ago. Two weeks after starting anti-TB treatment, he was initiated on TLD antiretroviral therapy. He now returns with recurrent high fevers, massive enlargement of right cervical lymph nodes, and worsening cough. Repeat sputum GeneXpert confirms sensitive M. tuberculosis, and blood cultures are negative. What is the diagnosis and correct clinical management?

Internal Medicine

Question · Hard

Question

A 25-year-old female diagnosed with Systemic Lupus Erythematosus (SLE) presents with new bilateral lower extremity edema, facial puffiness, and a blood pressure of 155/95 mmHg. Urinalysis demonstrates 3+ proteinuria, microscopic hematuria with dysmorphic red cells, and red blood cell casts. Serum creatinine is 165 µmol/L (baseline 65 µmol/L), anti-dsDNA titre is strongly positive, and serum C3 and C4 complement levels are markedly decreased. What is the essential definitive investigation required to classify renal involvement and direct immunosuppressive therapy?

Internal Medicine

Question · Hard

Question

A 31-year-old male with advanced HIV disease and a CD4 count of 65 cells/mm³ presents with progressive exertional dyspnea, dry non-productive cough, and low-grade fever for 3 weeks. Examination reveals tachypnea and marked exertional desaturation from 93% at rest to 78% on room air following 30 seconds of walking. Chest radiograph demonstrates diffuse bilateral perihilar ground-glass interstitial infiltrates. Arterial blood gas on room air shows a PaO2 of 56 mmHg. In addition to high-dose oral or IV Co-trimoxazole, what adjunctive medication must be started immediately to reduce mortality?

Internal Medicine

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Question

An 18-month-old child is brought to the Nutrition Rehabilitation Unit (NRU) with generalised bilateral pitting oedema (+++), apathy, generalised muscle wasting and extensive 'flaky-paint' dermatosis, diagnostic of severe acute malnutrition (kwashiorkor) with complications requiring inpatient care. According to the WHO protocol used in Malawian NRUs, which therapeutic feed must be used during the initial stabilisation phase (Phase 1)?

Pediatrics Child Health

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Question

A term male neonate is born via spontaneous vaginal delivery in the labour ward. Immediately following delivery, the baby is placed on a warm dry cloth. At 30 seconds after birth, the neonate remains completely limp, cyanotic, and apneic with a heart rate of 70 beats/min despite thorough drying, suctioning of thick meconium from the mouth, and gentle tactile stimulation. According to the Helping Babies Breathe (HBB) and Neonatal Resuscitation Program (NRP) algorithms, what is the immediate action within the 'Golden Minute'?

Pediatrics Child Health

Question · Easy

Question

A 15-month-old boy weighing 10 kg is brought to a rural health centre in Machinga with a 2-day history of frequent watery diarrhoea. Physical examination shows sunken eyes, irritability, and dry tongue, but the child drinks eagerly when offered a cup; skin pinch on the abdomen retracts in 1.5 seconds. He is classified as having acute diarrhoea with 'Some Dehydration' (IMCI Plan B). What is the prescribed volume of Oral Rehydration Salts (ORS) solution to be administered over the initial 4-hour rehydration period, and what micronutrient must be co-prescribed?

Pediatrics Child Health

Question · Easy

Question

A 3-year-old girl is admitted to the paediatric intensive care unit in Blantyre with severe Plasmodium falciparum malaria. Neurological assessment using the Blantyre Coma Scale (BCS) reveals: eye movements: fails to watch or follow face (score 0); best motor response: localizes painful stimulus (score 2); best verbal response: only emits inappropriate groans to pain (score 1). What is her total Blantyre Coma Scale score, and what clinical score threshold defines cerebral malaria in children?

Pediatrics Child Health

Question · Hard

Question

A previously healthy 20-month-old boy is brought to casualty having experienced a single generalized tonic-clonic convulsion lasting 3 minutes during an acute febrile episode (axillary temperature 39.2°C) caused by acute otitis media. In the clinic, he is alert, interactive, has no neck stiffness or focal neurological deficits, and the convulsion has fully resolved. Which classification applies, and what is the primary management?

Pediatrics Child Health

Question · Easy

Question

A 5-month-old infant presents during the rainy season with a 3-day history of low-grade fever, clear rhinorrhea, followed by tachypnea (respiratory rate 62/min), widespread expiratory wheeze, and mild subcostal retractions. Oxygen saturation is 94% on room air, and chest radiograph shows bilateral hyperinflation with flattened diaphragms and no focal consolidation. What is the cornerstone of clinical management for acute viral bronchiolitis?

Pediatrics Child Health

Question · Medium

Question

An 18-month-old child presents with high fever, bulging anterior fontanelle, vomiting, marked irritability, and neck stiffness. A lumbar puncture yields turbid, cloudy cerebrospinal fluid (CSF). Analysis reveals a leukocyte count of 3,200 /mm³ (90% neutrophils), elevated protein at 2.8 g/L, and CSF-to-blood glucose ratio of 0.12 (marked hypoglycorrhachia). Gram stain demonstrates Gram-positive, lancet-shaped diplococci. What is the most likely causative organism and the indicated empirical antibiotic therapy?

Pediatrics Child Health

Question · Medium

Question

A 2-year-old child weighing 12 kg presents with severe pneumonia, cold hands and feet, a capillary refill time of 5 seconds, a weak fast radial pulse (175 beats/min) and lethargy, meeting WHO criteria for shock. The child has NO severe acute malnutrition and no blood loss. According to WHO's 2025 guideline on fluid management of acutely ill children, what initial intravenous fluid approach is recommended?

Pediatrics Child Health

Question · Hard

Question

A 10-month-old infant with known uncorrected Tetralogy of Fallot becomes intensely cyanotic, tachypneic, and irritable while crying vigorously during blood sampling. The previously loud, harsh systolic ejection murmur over the left sternal border becomes faint and barely audible. What is the immediate physical maneuver and physiological rationale for managing this hypercyanotic ('tet') spell?

Pediatrics Child Health

Question · Hard

Question

A 4-year-old boy presents with progressive bilateral periorbital puffiness on waking, generalised abdominal distension, and marked pitting lower-limb oedema for 10 days. Blood pressure is normal (90/60 mmHg). Urinalysis reveals 4+ proteinuria with no hematuria. Serum albumin is 18 g/L (severe hypoalbuminemia) and serum total cholesterol is markedly elevated at 8.5 mmol/L. In this age group, what is the most likely histological diagnosis and the standard first-line therapy?

Pediatrics Child Health

Question · Medium

Question

A 7-year-old girl is brought to the clinic with dark, smoky 'coca-cola' coloured urine, facial periorbital edema, and headache. She had an untreated purulent impetigo skin infection 3 weeks ago. Examination reveals blood pressure of 135/90 mmHg (elevated for age). Urinalysis shows 2+ protein, microscopic hematuria with dysmorphic red blood cells and red blood cell casts. Which laboratory finding provides strong confirmatory evidence of Acute Post-Streptococcal Glomerulonephritis (APSGN)?

Pediatrics Child Health

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Question

An 11-month-old comatose child admitted with severe pneumonia and severe acute malnutrition is tested for point-of-care blood glucose upon arrival. According to WHO and Malawian guidelines for the inpatient management of severely malnourished children, what is the defined blood glucose cutoff for hypoglycemia in children with SAM, and what is the immediate treatment for an unconscious patient?

Pediatrics Child Health

Question · Hard

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A 28-year-old woman at 34 weeks gestation presents to the antenatal clinic for a routine evaluation. She reports new persistent frontal headache and epigastric discomfort. Her blood pressure is 165/112 mmHg on two measurements taken 15 minutes apart. Urinalysis demonstrates 3+ proteinuria. Serum biochemistry reveals platelets of 78,000 /µL, and serum transaminases (AST/ALT) are more than three times the upper limit of normal. What is the definitive obstetrical diagnosis?

Obstetrics Gynecology

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Question

Ten minutes following the spontaneous vaginal delivery of a 4.1 kg infant and the placenta, a 30-year-old para 4 mother is observed to have torrential vaginal bleeding. The uterus is palpated 4 cm above the umbilicus and feels soft, flaccid, and boggy. Blood loss is estimated at 800 mL. In managing primary postpartum haemorrhage (PPH) due to uterine atony under Malawian protocols, which uterotonic agent is strictly contraindicated if the mother has pre-existing hypertension or pre-eclampsia?

Obstetrics Gynecology

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A 22-year-old primigravida in active labour at 4 cm cervical dilatation has her progress monitored using the WHO modified partograph. Over the subsequent 6 hours, repeat vaginal examinations demonstrate that cervical dilatation has progressed from 4 cm to only 5 cm, and the plotting line has crossed to the right of the 4-hour 'Action Line'. Uterine contractions have weakened to 2 per 10 minutes lasting 20 seconds. What is the clinical interpretation and appropriate management?

Obstetrics Gynecology

Question · Medium

Question

A 27-year-old female presents to casualty with a 6-week history of amenorrhea, followed by sudden, severe tearing lower abdominal pain, vomiting, and collapse. On examination, she is pale, cold, and diaphoretic with a pulse of 128 beats/min and blood pressure of 76/40 mmHg. Abdominal examination demonstrates generalized rigidity and marked rebound tenderness. Bimanual pelvic examination reveals exquisite cervical motion tenderness and a full, boggy pouch of Douglas. Urine pregnancy test is positive. What is the immediate definitive management?

Obstetrics Gynecology

Question · Hard

Question

A 32-year-old gravida 3 para 2 woman at 32 weeks gestation presents with sudden, painless, bright-red vaginal bleeding that soaked her clothes while resting. Uterine palpation reveals a soft, non-tender, relaxed uterus with normal resting tone. The fetal heart rate is 142 beats/min with good variability. What essential clinical rule must be strictly observed in managing this patient?

Obstetrics Gynecology

Question · Easy

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