Friday, February 27, 2015

End Posting Internal Medicine Examination

One more reason I like this posting : the exam was only for TWO DAYS! :D

DAY 1 - THEORY EXAMINATION

Multiple Choice Questions (15 Questions)

Here are some MCQs that were asked. See if you can answer them.

1. Causes of clubbing and coarse crepitations
A. Bronchial asthma
B. Pulmonary fibrosis
C. COPD
D. Malignant pleural effusion
E. Bronchiectasis

2. Causes of prolonged QT interval
A. Azithromycin therapy
B. Hypocalcemia
C. WPW syndrome
D. Hypothyroidism
E. Mitral valve stenosis

3. Diagnostic criteria for metabolic syndrome
A. Insulin resistance
B. BP more than 130/80
C. Low LDL
D. Low HDL
E. Proteinuria more than 1g/day

Answers

Question 1
A. False. No clubbing or creps in BA.
B. False. Fine creps in pulmonary fibrosis.
C. True. Both can be present in COPD.
D. False. Coarse creps not present in malignant PE.
E. True. Both are present in bronchiectasis.

Question 2
A. True. Many drugs can cause prolonged QT interval.
B. True. Low potassium, calcium and magnesium can cause this.
C. False. It's Romano-Ward syndrome and Jervell and Lange-Nielsen syndrome. 
D. True. Bradycardia can prolong QT interval.
E. False. MS does not cause this.

Question 3
A. True.
B. True.
C. False. Only high TG is included.
D. True.
E. False. Not included in criteria.


One Based Answer (10 Questions)

1. 29-year-old female with primary infertility, oligomenorrhea, weight gain, headache and blurring of vision. On examination, she had high BP, high RBS, hirsutism, obesity, striae, hyperpigmented area over knuckles and crease, reduced visual field, optic atrophy and expressible galactorrhea. Diagnosis?

A. Acromegaly
B. Cushing disease
C. Hypothyroidism
D. Macroprolactinoma
E. PCOS

Answer: Not sure. My bets are on macroprolactinoma and PCOS.


Extended Matching Questions (5 Questions)

The questions were on respiratory system. One of the questions:

A student of interior design presented with dyspnea and cough. Symptoms occurred only during weekdays. He started having the symptoms after he started his course. In his coursework, he needed to deal with paints.

Answer : Obviously occupational asthma.


Patient Management Problems (2 Questions)

Question 1 

Trigger 1

55-year-old woman presented with anemic symptoms. Doctor said her bone marrow was abnormal. On examination, she was pale, had petechiae and hepatomegaly.

1. Differential diagnoses?
2. Questions you want to ask to differentiate EACH of the diagnosis?
3. Expected physical findings for EACH of your diagnosis.

Trigger 2

She was diagnosed as myelodysplasia. She defaulted treatment for 2 years. Currently, peripheral blood smear showed hypochromic microcytic anemia and Auer Rod.

4. Your provisional diagnosis?
5. Further investigations you want to do.

Trigger 3

She was diagnosed as Acute Myeloid Leukaemia as a result of leukaemic transformation from Myelodysplastic Syndrome. She was treated and discharged. Two weeks later, she came with fever, dyspnea and productive cough. CXR showed consolidation with air bronchogram. Blood C&S showed MRSA. 

6. What happened to this patient?
7. Outline your management.


Question 2

Trigger 1

20-year-old man presented with generalised tonic clonic seizure for more than 10 minutes without regaining consciousness. No history of fever.

1. Differential diagnoses?
2. Questions you want to ask?
3. Immediate management in A&E.

Trigger 2

Further history revealed he had been having headache and two episodes of seizures for the last 2 months. He is an IVDU and sexually promiscuous. On examination, presence of left hemiparesis and hepatomegaly.

4. What causes his current presentation?
5. Investigations and expected results?

Trigger 3

CT brain with contrast revealed multiple ring-enhancing lesions. HIV result positive.

6. Your complete diagnosis.
7. Outline your treatment plan.

He was treated and discharged. When he came to HIV clinic for follow up, he said that he wants to get married. What is your advice to him?

I will congratulate him on his wedding. I will advise him to tell his future wife about his HIV status. If he wants to have intercourse, use condom. There is a risk of his children having HIV if the mother is HIV positive. I will advise him to stop taking recreational drugs and stop being sexually promiscuous. Do not forget to take his HAART and complete treatment.


DAY 2 - CLINICAL EXAMINATION

Long Case with Dr. Anis

Case : Pleural Effusion

50-year-old man presented with one day history of haemoptysis and two months history of LOA, LOW and lethargy. There was no history of fever or symptoms of TB.

On examination, patient was pale and had Grade 3 finger clubbing. Findings were confined on right lower lobe where there were reduced chest expansion, reduced TVF, stony dullness on percussion, reduced air entry and reduced VR - suggestive of right pleural effusion.

1. Your provisional diagnosis and your reasons.
Pleural effusion secondary to Lung carcinoma, Tuberculosis, Pneumonia
(say points for and points against)

2. Causes of pleural effusion.
+ Transudate (CCF, CLD, CKD)
+ Exudate (TB, Pneumonia, Lung CA, Metastasis)
+ Others : Hemorrhagic, Empyema, Chylothorax

3. Investigations.
+ CXR - see sign of infection, cavitation etc.
+ Sputum C&S - take 6 weeks for culture. Using Lowenstein Jensen medium.
+ Sputum AFB - faster result. Using Ziehl-Neelsen stain.
+ Mantoux Test - positive if more than 10mm.
+ Pleural fluid analysis - look at pH, colour, cell count, glucose, protein, LDH.
+ Bronchoscopy - see if there is any tumour or underlying abnormalities
+ Other blood tests : FBC, PT/APTT, RP, LFT, RBS, FLP etc.

4. How do you manage patient if it is confirmed to be TB?
Start anti TB right away. Total duration of treatment is 6 months : 2 months of intensive therapy using Isoniazid and Rifampicin, and another 4 months using Isoniazid, Rifampicin, Pyrazinamide and Ethambutol.

5. Side effects of anti TB?
+ Isoniazid : hepatitis, peripheral neuropathy
+ Rifampicin : hepatitis, orange discolouration of urine and tears
+ Pyrazinamide : hepatitis, gout
+ Ethambutol : optic neuritis


Short Case with Dr. Vova :)

Case : Paraparesis with sensory level up to T4 

A cachexic middle-aged man with tracheostomy, urinary catheter and TED stocking, looked tired and dehydrated. He was alert and conscious, cooperative, lying in supine position. Branula attached at dorsum of left hand with no active infusion.

Neurological examination revealed obvious muscle wasting of both lower limbs and abnormal feet position. No fasciculation noted. Both lower limbs had hypotonia, reflex 0/5 and absent reflex. No clonus. Babinski equivocal with loss of proprioception. Presence of sensory level up to T4.

I want to complete my examination by doing neurological examination of upper limbs, cranial nerve examination and cerebellar signs.

1. Do you want to check for sign of meningism?
Yes! :D

2. What are the signs?
Kernig's sign and Brudzinski's sign

3. Your provisional diagnosis?
Paraparesis secondary to Lower Motor Neuron lesion.

4. Causes of LMN?
+ Problems in spinal cord eg. TB spine, spondylolisthesis, trauma, tumour
+ Acute Transverse Myelitis
Guillain-Barre syndrome 
(points for and points against)

5. Investigations?
CT brain, CXR, CSF analysis (describe expected findings) and blood ix

6. Management?
Give high dose methylprednisolone and monitor patient. If GBS, can give IVIG.

And then Dr. Vova smiled and said, 'So that's all. Don't worry you are doing fine.'

Awww thank you doctor! Hehe.

End of Internal Medicine postinggg! :D

Wednesday, February 25, 2015

Bye Bye Internal Medicine!

So our exam had finished yesterday. Hopefully all of us will pass!

I think I am doing okay in clinical. I am not really satisfied with my theory papers though.

Especially PMPs.

The questions were on:
1. Transformation of Myelodysplastic Syndrome into Acute Myeloid Leukaemia
2. Cerebral Toxoplasmosis

Explain your treatment plan for this patient - I still remember that question.

I just read about toxoplasmosis hours before exam and yet - my brain was struggling to remember the drugs used to treat it. Arghhhhh.

I'll elaborate more on the questions in my next post. 


Our happy face after finishing clinical exam yesterday evening. Dr. Che' Rosli commented on how poor our knowledge is theory-wise. He said our short case examination was good, but we need to read more on medicine.

Like for example, my friend yesterday was asked to draw Circle of Willis.

That Circle of Willis - the arteries in the brain, in case you forgot :P

I only remembered a small part of it - ACA, MCA, PCA, communicating arteries, vertebral arteries, cerebellar arteries.... wait wait I'll find the diagram 


Taken from this website

Anyway... internal medicine aside.... we still have two more postings left! Go Go!


Internal medicine is my second favourite posting - right after Psychiatry hehe

Bye bye medical, till I see you next time!

Helloooo......babieesss!! :D

Thursday, February 19, 2015

Short Case with Dr. Kuan

Patient 1

A middle-aged Indian man with unilateral ptosis and eye divergence.

1. Your differential diagnosis?
+ Partial third nerve palsy
+ Horner's syndrome
+ Myasthenia gravis
+ Congenital ptosis

2. How do you proceed with the examination?
+ First, inspect the patient's eyes. This patient has ptosis and divergence.
+ Second, check pupils. This patient's pupils are normal.
+ Then, check eye movements. Do H Test. This patient has vertical gaze palsy.
Exclude other differentials. Test anyhydrosis - put back of palms on patient's forehead. Check enophthalmos. Check fatigability - ask patient to look up and down repeatedly.

Taken from UM X'Press

3. What do you know about third nerve palsy? Taken from this website
It can be medical or surgical third nerve palsy. If pupil is spared - medical. If pupil is fixed and dilated - surgical. Classic presentation : ptosis, dilated pupil and 'down and out' pupil.

Causes of third nerve palsy
  • Diabetes (75% pupil-sparing)
  • Temporal arteritis
  • SLE
  • MS
  • Cavernous sinus thrombosis
  • Amyloid
  • Posterior communicating (PCOM) aneurysm - usually painful
  • Tumour


Patient 2

Thin build adult man on face mask, looked tired and in pain. He was on IV Tazocin and iron chelator infusion pump. No obvious Thalassemic facies noted such as frontal bossing, prominent malar eminence, malocclusion of teeth, interdigital separation of teeth, prominent maxilla. Greyish colour of skin noted. His abdomen was distended with fullness of flanks. 

Abdomen examination showed a midline splenectomy scar. Hepatomegaly present 5cm below costal margin.

Complete examination by examining thyroid, cardiovascular and peripheral neuropathy as complications of iron overload such as hypothyroidism, cardiomyopathy, hyperglycemia.

1. What should you give to patients who had undergone splenectomy?
+ Triple vaccinations - pneumococcal, meningococcal, Hib vaccine
+ Lifelong antibiotics

2. Long term advice to patients?
  • Patient education and need for blood transfusion
  • Complications of thalassemia such as iron overload causing end-organ damage, endocrinopathies, transfusion-related infection, growth retardation, osteoporosis
  • Family screening
  • Genetic counselling

3. How the trait is passed on to children?
If major marries normal, 4 out of 4 will have trait.
If minor marries normal, 2 out of 4 will have trait.
If minor marries minor, 1 out of 4 will have major!

Thats why we need genetic counselling because the disease is preventable.
  
Taken from this website

Wednesday, February 18, 2015

Short Case with Dr. Anis

Patient 1

Middle-aged man, alert and conscious, cooperative, comfortably lying on bed. Tattoos noted at both arms. There were finger clubbing, leukonychia, jaundice, pallor and hepatomegaly.

1. Provisional diagnosis?
Chronic Liver Disease

2. How do you grade clubbing?
Grade 1 : fluctuation of nail bed
Grade 2 : loss of angle
Grade 3 : increase nail curvature
Grade 4 : soft tissue swelling, drumstick appearance
Grade 5 : presence of HPOA

3. Causes of fine tremor?
+ Beta agonist use
+ Hyperthyroidism
+ Anxiety
+ Senile tremor

4. Causes of flapping tremor?
+ Uremic encephalopathy
+ Carbon dioxide retention

5. Investigations?
FBC, LFT, PT/APTT, HepB/C serology, GGT, Liver US

6. Symptoms of hepatic encephalopathy?
Agitated, restless, confused, drowsy, personality change, seizure, coma

7. How do you test if patient has hepatic encephalopathy?
Ask patient to draw a 5-pointed star, he cannot join the lines together - constructional apraxia

8. How do you manage patients with hepatic encephalopathy?
  • Nil by mouth - parenteral nutrition
  • Low protein diet
  • Lactulose to clear bowel
  • Metronidazole to reduce gut flora
  • Prevention of factors that will aggravate it like trauma, bleeding, infection, constipation, surgery, alcohol, analgesic, hypokalemia
  • Patient education


Patient 2

Middle-aged man who looked tachypneic evidenced by intercostal recession and use of accessory muscles. Trachea was centrally located. Respiratory examination findings were confined to the right middle and lower zone : reduced chest expansion, absent breath sounds, reduced vocal resonance and vocal fremitus as well as stony dullness on percussion.

1. Provisional diagnosis?
Right pleural effusion

2. Causes of pleural effusion? Taken from UM X'Press
  • Transudate - cardiac failure, nephrotic syndrome, chronic liver disease
  • Exudate - malignancy, pneumonia, TB, pulmonary infarction, connective tissue disease
  • Hemorrhagic - malignancy, pulmonary embolism, trauma
  • Empyema - lung infection (pneumonia, abscess), chest trauma, thoracic surgery, subdiaphragmatic abscess
  • Chylothorax - malignancy (lymphoma), trauma
3. Investigations?
  • CXR/US - helps in finding the best site for pleural tap
  • Pleural tap and fluid analysis - protein, LDH, glucose, gram stain, Ziehl-Neelsen stain, culture/cytology, adenosine deaminase
  • Percutaneous pleural biopsy - indicated in undiagnosed pleural exudates with non-diagnostic cytology and clinical suspicion of TB or malignancy

4. How do you do Mantoux test? Taken from this website
Inject 0.1ml of purified protein derivative (PPD) intradermally. Mark the area and wait for 48h to 72h. Look if there is any induration (firm, raised, palpable). Measure it. If it is more than 10 mm, it is positive. If it is more than 15 mm, it strongly suggests active TB.

5. False positive?
+ Infection with non-TB mycobacteria
+ Previous BCG vaccination

6. False negative?
+ Recent TB infection (within 8-10 weeks of exposure)
+ Recent live-virus vaccination (eg. measles and chickenpox)
+ Very old TB infection (many years)
+ Very young age (less than 6 months old)
+ Overwhelming TB disease

7. Examples of second-line anti TB medications?
+ Ofloxacin
+ Clarithromycin
+ Minocycline

8. What are primary and secondary drug resistant TB?
Primary means the patient got infected by someone who has drug resistant TB. Secondary means the patient is on anti TB but not compliant, so he develops drug resistant TB. 

Monday, February 16, 2015

Short Case with Dr. Hasnur

Patient 1

Middle-aged man who looked lethargic, dehydrated and in pain. He was pale. Abdomen distended with fullness of flanks. Hepatosplenomegaly present.

1. Causes of hepatosplenomegaly?

Haematological
+ Myeloproliferative - Myelofibrosis, CML, PCV, essential thrombocytosis
+ Lymphoproliferative - ALL, CLL, lymphoma, myeloma
+ Haemolytic anemia

Infection
+ Infectious hepatitis
+ Infectious mononucleosis
+ Leptospirosis
+ Malaria
+ Toxoplasmosis
+ Leishmaniasis

Portal hypertension

Others 
+ Sarcoidosis
+ Amyloidosis 

2. Investigations?
FBC, FBP, LFT, AFP, VDRL/Hep B and C/HIV, Liver US, CT scan of liver


Patient 2

Middle-aged man with left hemiparesis.

1. Differential diagnoses?

Stroke
+ Ischaemic 
+ Haemorrhagic

Space-occupying lesions
+ Tumour
+ Abscess
+ Hemangioma
+ Aneurysm

2. Examples of UMN and LMN lesions

Taken from this website

3. How to test a patient with Parkinson Disease? 
Remember TRAP : Tremor, Rigidity, Akinesia, Postural instability

First, ask patient to walk to assess gait. He will have shuffling gait, reduced length of steps, reduced arm swing, stooped posture, hard to initiate movement, difficult to turn and stop abruptly. Look for masked facies.

Assess postural instability. Do pull test - pull patient backwards, ask him to resist and don't fall. He will take 4-5 steps backwards before he comes to rest.

Second, ask patient to sit down on a chair and put hands on a pillow to assess tremor. Look at pill-rolling tremor. Accentuate tremor by asking his name or ask to count from 100 backwards.

Look for other types of tremor such as resting tremor, intentional tremor (do past-pointing) and postural tremor (ask patient to lift both arms and look of there's tremor).

Check tone. Look for rigidity. Leadpipe is sustained resistance throughout whole range of motion while cogwheel is jerky resistance to passive movement. Clasp knife is rigidity that presents only at the start of passive movement, rate dependent and velocity-dependent.

Check bradykinesia. Ask patient to touch pointing finger to thumb repeatedly, play piano, grip and open grip or do foot tapping repeatedly. Look for slowness of movements.

Look for signs of Parkinson plus syndrome such as cerebellar sign (positive finger-nose test and positive Babinski in MSA) and eye sign (vertical gaze palsy in PCP).

Do glabellar tap. Tap in between eyes repeatedly. Patient will keep blinking.

Ask patient to write. Look for micrographia (small handwriting).

This video explains how to assess a patient with Parkinson. At the end of the video, look at how the neurologist does pull test and you can see the patient reacts.


Friday, February 13, 2015

Long Case with Dato' Sapari

Patient 1

Mr. B, a 51-year-old Malay man with underlying Beta-Thalassemia intermedia and hypertension, presented with four days history of generalised body rash and one day history of gum bleeding. Platelet count on admission was 1,000.

Physical examination revealed a medium build man with no Thalassemic facies. Multiple petechiae noted at upper chest with ecchymosis at right cubital fossa. There was no gum hypertrophy or hepatosplenomegaly noted.

1. Provisional diagnosis?
Idiopathic Thrombocytopenic Purpura

2. How do you diagnose ITP?
It is a process of exclusion. First, determine that there are no blood abnormalities other than thrombocytopenia, no physical signs other than bleeding. Next, secondary causes should be excluded such as leukaemia, medications (heparin, quinine), SLE, APLS, cirrhosis, HIV, hepatitis C, congenital causes and others.

3. Investigations?
FBC, FBP, PT/APTT, LFT, RP, trace old notes and check for Hb electrophoresis result, bone marrow aspiration to look for increased production of megakaryocytes

4. Management?
Admit patient, insert branula, take blood investigations, refer haematologist, give high dose steroids (oral or IV), vital signs monitoring

5. How to differentiate bleeding in platelet and coagulation disorders?
Taken from this website

6. Indications of platelet transfusion in ITP? Taken from this website
Platelet transfusions are generally ineffective in patients with ITP – the transfused platelets are rapidly removed from the patient’s circulation. They are never useful when given for prophylaxis. 

In patients with serious haemorrhage who are being simultaneously treated with definitive therapy (IV methylprednisolone or other steroid, and IVIgG), however, platelet transfusions may be life saving. In these instances the doses required are enormous. While data are very few , an initial dose of 4 units is advised, repeated if necessary.

7. Peripheral blood smear in thrombocytopenia?
Taken from this website


Patient 2

Mr. F, a 16-year-old Malay teenager with underlying Ventral Septal Defect, presented with five days history of worsening dyspnea and three days history of haemoptysis. 

He defaulted follow up at National Heart Institute (IJN) after age of 5 due to financial problems. He was well until last year when he experienced dyspnea and chest pain on exertion. He was admitted to IJN last year and defaulted again after discharge. His symptoms re-occured since one month ago and worsened for the last five days before hospital admission.

Physical examination revealed a thin build teenager, small for his age, comfortably lying on hospital bed. He had central and peripheral cyanosis. Clubbing was noted at fingers and toes. BP 100/70, HR 80, T 37, RR 20.

Cardiovascular examination showed no raised JVP. Apex beat was heaving and displaced. Left parasternal heave was felt. Palpable thrill felt at tricuspid area with pansystolic murmur heard. It was moderate in intensity, grade 4/5, not accentuated by inspiration or expiration. Loud P2 was heard at pulmonary area.

1. Provisional diagnosis?
Pulmonary hypertension due to large VSD

2. Differential diagnoses?

  • Complex cyanotic congenital heart disease (CCCHD) eg. 
  • Eisenmenger + endocarditis (causing clubbing)
  • CCCHD + pulmonary hypertension + pneumonia (causing haemoptysis)

3. What is Eisenmenger's syndrome?
It's a condition whereby a large left-to-right shunt (VSD/ASD/PDA) causing severe pulmonary vascular disease and pulmonary hypertension > leading to reversal of the direction of shunting > cyanosis

Taken from UM X'Press

4. Complications of Eisenmenger's?

  • Hyperviscosity symptoms (headache, dizziness, visual disturbance) - due to polycythemia
  • Hemoptysis - due to pulmonary infarction or rupture of pulmonary arterioles or arteries
  • Cerebral infarction - due to paradoxical embolism and venous thrombosis
  • Cerebral abscess
  • Syncope - due to reduced cardiac output and atrial fibrillation
  • Right heart failure
  • Sudden death (cardiac arrhythmia)

5. Investigations?

  • FBC - polycythemia
  • ECG - right ventricular hypertrophy, atrial fibrillation
  • CXR - prominent central pulmonary arteries, reduced markings ("pruning") of peripheral vessels
  • ECHO - shunt, increased right ventricular pressure
  • Cardiac catheterization with pulmonary vasodilator (oxygen or nitric oxide) - assess reversibility of pulmonary hypertension (reversibility suggests benefit from surgical repair of defect)

6. Management?

  • Patient and family education on current condition, complications, recurrence in future if not treated, advice on drug usage, seek treatment of infection or hemoptysis occur, need to refer to IJN for cardiac surgery
  • Reduce pulmonary pressure by giving calcium channel blocker (Diltiazem) or PDE5 inhibitor (Viagra, Cialis, Levitra) or epoprostenol (pulmonary vasodilator)
  • Venesection to relieve hyperviscosity symptoms  

Thursday, February 12, 2015

Short Case with Prof. Yousof

Patient 1

59-year-old Indian man, alert and conscious, cooperative, comfortably lying in supine position. He had Dupuytren's contracture, scleral jaundice and pedal edema.

On abdomen examination, there were presence of spider naevi, gynaecomastia, ascites and hepatomegaly. No other stigmata of CLD noted.

1. Provisional diagnosis?
Chronic Liver Disease

2. Possible causes of CLD?
  • Viral - Hepatitis B or C, CMV, EBV
  • Toxic - Alcoholic, Drug-induced eg. methotrexate
  • Metabolic - Non-alcoholic fatty liver disease, Wilson's disease, haemochromatosis
  • Autoimmune - Primary Biliary Cirrhosis, Primary Sclerosing Cholangitis
  • Others - Right heart failure

3. Complications? Remember HEPATIK
  • HEpatic encephalopathy
  • Portal hypertension (variceal and rectal bleeding)
  • Ascites
  • Tumor (hepatoma)
  • Infection (spontaneous bacterial peritonitis)
  • Kidney failure (hepatorenal syndrome) 

4. Investigations?
LFT, PT/APTT, AFP, Viral serology, Liver US, Abdominocentesis, OGDS, CXR

5. Management?
  • Give diuretic for symptomatic relief
  • Reduce risk of portal hypertension by giving beta-blocker
  • Prevention of hepatic encephalopathy 


Patient 2

Patient with right homonymous hemianopia.

How do you test patient's eyes?

Cranial nerve 2 (optic)
  • Visual acuity using Snellen chart
  • Colour vision using Ishihara plates
  • Visual field
  • Pupillary reflex
  • Accomodation
  • Funduscopy

Cranial nerve 3, 4, 6 (oculomotor, trochlear, abducens)
  • Eye movements - H Test

Complete examination of cranial nerves at this website.