CPC question MBBS batch 09/14

CPC 2014

Encik Ahmad a 72yo gentleman has had bilateral knee pain for the past one year. Otherwise, he is ADL independent and well. He was then presented with a history of reduced mobility, not eating and not drinking for the past 3 days. He has been hypertensive for the past 20 years.

He is on hydrochlorothiazide ___mg, amlodipine 5mg and takes celecoxib occasionally.

On admission, he was pale, skin turgor was reduced and his tongue was dry. His vital signs were T:37.2C RR:30bpm HR:107bpm BP:147/94mmHg. His oxygen saturation was 93% in room air. He had intercostal recessions and crepitations on right lung on auscultation. The doctors noticed that he was not moving his left upper and lower limbs. He was drowsy and not obeying commands. His tendon reflexes were normal. Plantar reflex was equivocal on left side and downgoing on right side.

Blood investigations :

Na 116   K 3.5   Cl 77   Urea 16   Creat 178   Anion gap 23   Total CO2 and RPG with normal range

Hb 9   MCH 70   TWB 10  Plt 100

serum osmo 260  urine osmo 840  urine sodium 32

CT brain n Xray thorax were done.

He was treated with intravenous dextrose saline, IV Ceftriaxone and oxygen 3L/min with nasal canulae. However his condition deteriorated and became more confused.

On day 5, his condition was deteriorating and doctors decided that he may need ventilation support. Counselling was done with the family members regarding the probabilty of putting him on mechanical ventilation. His family the brought up that he has said to them some time a go that up until now he has been healthy and lived a happy life. If one day he falls sick and needs life support, he does not want to go through that. Doctors then treated him conservatively continuing his antibiotics and oxygen supplementation.

On day 6, he became more confused, didn’t know he was in hospital and thought that the nurse was intruder in his house.He was only orderedfor iv fluid and antibiotics, not for intubation, mechanical ventilation, and cpr. He developed respiratory arrest and died. His serum Legionella antibody titre results were 1:64. His urine Legionella pneumophila came back positive.

Questions

1 Discuss Encik Ahmad’s medical problems on admission (25m)

2 What other investigations would you have ordered on admission and state your reasons (20m)

3 Comment on his Xray thorax (4m)

4 Comment on his CT Brain (4m)

5 Comment on the treatment and state what constitutes the appropriate treatment (20m)

6 Discuss the ethical issue in this case and discuss (5m)

7 Comment on the results of his serum Legionella antibody and urine Legionella pneumophila (4m)

8 If an autopsy was to be carried out, state the gross and microscopic findings of the lungs and kidneys (10m)

9 Fill in the death certificate (8m)

By Ili Syazana

END

-Unlucky student

OSCE questions for MBBS 09/14

OSCE 2014 #prayhardallpass

1. Prescription

Scenario: Mr. Rizal bin Mohammad (RN: ) 50 years old with history of DM, HPT, and hypercholesterolemia. On examination and ix , BP =130/80, HbA1c 6.3% . He is on Metformin 500mg two times per day, Perindopril 2mg morning once, Simvastatin 20mg on night. Please write a prescription to him until next follow up in 1 months.

2. Cannula insertion 

Scenario: You as a housemen in ward need to do IV cannulation to a patient with Crohn’s disease who need IV saline infusion. Please do this procedure and treat this manikin as real patient. Question by doctor: What is the name of the vein? 2. Give me two complications that may arise from this procedure.

3. ABG interpretation

Findings : Metabolic acidosis with partial respiratory compensation

a) What is your interpretation

b) Calculate the anion gap

c) What causes for such anion gap

4. Insulin injection

Scenario: This patient have DM Type 2 on two OAD, Metformin and Gliclazide. HbA1c 9% .You want to start him on insulin insultard 6unit on night.

Please demonstrate/educate patient on how to use novopen 4.

5. Radio Imaging –

a) Congestive cardiac failure (Calculate cardiothoracic ratio, 2 findings on film: blunted costophrenic angle, what is your dx)

b) Perforated bowel (Gas under bilateral diaphragm, pneumoperitoneum)

6. Anterior shoulder dislocation. Given Right shoulder xray.

1) Give me your diagnosis.

2) Perform neurovascular examination for this patient.

3) what is your management.

7. GCS assessment. Ahmad Ali lives at taman medan, pj involved in MVA. Please assess GCS on him.

On examination: (Eye opening on voice, confused/disoriented verbal response, able to obey commands)

Question by doctor: 1) Two screening x-rays 2) Is a CT Brain needed? Yes or No

8. This pt has low mood for 6 months. Please assess depressive symptoms.

9. Otomycosis. (Aspergillus niger) 3 Findings.  3 complaints. Management.

10. Tracheostomy (Change of trachy tube, perform on mannequin)

11. Papilloedema (Grade 4 hypertensive retinopathy)  4 Findings. 2 possible causes. 2 other clinical exam.

12. Paediatric vital signs and fluid balance chart:

pt c/o headache and facial swelling

Findings : high BP,pain score fluctuating, weight 20kg, total urine output 600ml, input 1000ml

2 problems, calculate urine output and comment, one drug to give

13. Papanicolaou smear:

Exhibit A : Cytobrush

Exhibit B : Ayre’s spatula

Name Exhibit A & B, Gynaecological indication, 5 risks factor for gynae malignancy, 1 prevention

14. Defibrillation for pulseless VT (perform on mannequin)

15. Visual field Examination (Perform on patient)

Findings : Right homonymous hemianopia

16. Right tension pneumothorax. Pt with SOB, hypotension and severe right chest pain.

a) What is the dx?

b) 3 clinical signs

c) Immediate treatment?

d) Explain how you perform the procedure

-END-

-Unlucky Student

Collections of Cases with Q&A Clinical Exam Final MBBS Batch 08/13

LONG CASE MBBS 0813 

SHORT CASE MBBS 0813 

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-Unlucky Student

Collections of questions for final year MBBS Exam batch 09/14 (Theory paper 1)

Paper 1 Theory

Each questions 25 marks

1. Obstetric – g5p4 29 weeks POG diagnosed with placenta previa Type 2  and booking Hb was 12g/dL and Blood group Rhesus negative.

-Ask relevant history (5m)

-Presented with mild pv bleed.

-Give your management plan. (9m)

Discharge at 33 weeks POG due to stop bleeding and the placenta “migrated” to upper uterus.

Presented again at 36wk with pv bleed and appeared to be pale.

-Give three differential diagnosis. (3m)

Blood result showed low haemoglobin level 7g/dl, normal platelet count, normal INR and aPTT.

-Outline your management plan. (8m)

2. Paediatric – Macrosomic baby 4.5kg, spontaneous delivery, 30yo primid mother.Apgar 1st min-1, 5th min-3

-Ask 5 irelevant history(antenatal, intrapartum) (5m)

-Developed seizure for 10 minutes and aborted with medication.

Given reult of ABG after 40 mins

-Intepret the ABG: decompensated metabolic acidosis (2m)

-What is the possible cause of seizure? (2m)

-Give two important investigations to rule out other causes of the seizure (2m)

Baby develop epilepsy and treated with antiepileptic.

At 4 month of age during follow up, seizure frequency increase,global developmental delay, failure to thrive.

-List 4 problems from the above information. (4m)

-What 3 other steps to evaluate (through Hx and PE) (6m)

-Give your management plan. (4m)

3. PCM – 11-year-old girl, Headache and body ache, upper abdominal pain with vomiting. face flushed. No sorethroat runny nose or cough. Concentrated urine, but no dysuria. Haematocrit increases（0.45）, Platelet(100) and WBC decrease(3).

-Give 3 differential diagnoses. (3m)

-interpret the lab result

examination showed pt’s face flushed and tender liver 2cm from costal margin.

-what is your provisional diagnosis, give reasons why. (4m)

-outline your management.

her parents refused to admission.

-how would you respond.(4m)

4. Surgery – Breast lump. 3cm X 3cm. No palpable lymph node. Not fixed to skin and muscle.

-Give 6 risk factors of breast cancer. (6m)

She was sent for mammogram and trucut biopsy.

-give 3 features suggestive of malignancy on mammogram (3m)

-What is her clinical stage of breast cancer.

-why is it mportant to stage patient.

She had wide local excision and sentinel node biopsy.

-what are the 5 pathological finding that determines her prognosis (5m)

-outline your management.

5. Psychiatry – 30-year-old lady, brought by friend because she threatened to jump off a building. In the A&E, she looked confused and talking to herself.

-What is your immediate management. (4m)

She has been staying in her own rom for past 1 months, talking about suicide and sometimes seen talking to herself.

-What are the 5 things you want to ask in history (5m)

-Give 3 differentials. (3m)

Further history : she has been hearing voices talking about her. Her mood is normal. She believes people are trying to pass her a message through their actions. She saw some bird nest outside her windows and believe it’s a sign 2014 is the year earth is destroyed. That’s why she wants to kill herself.

-State your provisional dx and reasons. (4m)

-Outline your management for her.

Her employer called wanting to know why is she absent from work.

-How would you respond. (4m)

6. Ortho – Lady had an accident, car driver, anterior collision by a van, knee hit on dashboard, dashboard injury, hip sustained injury.

Presented with left intenal rotated hip with shorted limb

-Outline the initial management of the patient

-Based on information provided, What is the likely diagnosis?

-Describe the picture shown (adducted, internally rotated, partially flexed left hip)

-Describe the radiograph (head of femur out of acetabulum, located above it)

-What is the management for the hip problem in the A&E.

-What is the common manoeuvre used to treat the above hip problem. Describe briefly.

-What are 4 complications related to this hip injury.

END 🙂

-Unlucky Student