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

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