Internal Med End of Posting Exam
*some info might be lost or incomplete due to my severely short term memory
*
1) An elderly woman came in with severe pain in the gum, tongue and cheek. It is aggravated by touching the lips and moving the tongue. MRI was done and was normal. On physical examination, everything was normal.
a) what cranial nerve is involved?
correct answer: duh, this is so easy, trigeminal nerve
b) what is your diagnosis?
stupid answer by me: diabetic neuropathy - mononeuritis multiplex
correct answer: trigeminal neuralgia
c) why is MRI done?
correct answer: to rule out intracranial pathology - compression, tumor..bla bla
d) what drugs can be used to treat the symptoms?
correct answer: phenytoin, carbamazepine, tricyclic
e) what is the complication of surgery to treat this problem?
stupid answer by me: weakness in mastication muscle. Patient may have difficulty chewing and talking
correct answer: facial anesthesia, numbness
2) A 45 year old man came in with drowsiness and confusion. He had bone pain since 2 months ago. He had abdominal pain 2 days ago and was having constipation, vomiting. On examination, he is very dehydrated. His investigation was:
Na - low
K - low
urea - high
Cl - normal
Ca - high
creat - normal
Hb - low
a) what abnormality in the investigation can be attributed to all his signs and symptoms?
correct answer: hypercalcemia
b) what is the differential diagnosis?
correct answer: multiple myeloma, primary parathyroidism, malignancy, sarcoidosis...bla bla
c) what other investigation will u do?
correct answer: chest, skull, vetebra X-ray, parathyroid hormone level, bla bla....
d) how would u manage this patient? (3 steps)
correct answer: rehydrate! bisphosphonates, correct other electrolytes
3) a 25 old lady presented with high BP (180/110). Also had muscle spasm and polyuria. Her renal profile was:
Na - high
K - low
others - normal
a) what is your diagnosis?
correct answer: primary hyperaldosteronism - conn's syndrome
b) explain why she got muscle weakness? (hell, why not in history one?)
correct answer: secondary to hypokalemia
c) explain why she got polyuria?
stupid answer by me: because of hypernatremia resulting in increase in osmolality, therefore decrease in ADH. (muahaha...cock till the max)
correct answer: diabetes insipidus secondary to hypokalemia
d) what is the primary pathology in her?
correct answer: adrenal adenoma
e) what other causes of hypokalemia? (3 causes)
correct answer: vomiting, diuretics, polyps, bla bla...
4) A 20 year old lady presented with fever and sudden onset of left sided hemiparesis. On examination, she got pansystolic murmur at the apex and the murmur radiate to the axilla.
a) what is your diagnosis?
correct answer: infective endocarditis with mitral regurgitation
b) why she has left sided hemiparesis?
correct answer: septic emboli to the brain
c) what other investigation? (list 4)
correct answer: CT brain, echocardiogram, blood culture, FBC, bla bla
d) how would u treat this patient?
correct answer: I.V antibiotic for 4 weeks. Refer cardiothoracic surgeon for underlying structural heart problem (if any). Physio for her hemiparesis. Anti pyretic for her fever. bla bla....
5) a 45 year old man complaining of lethargy and unwell for 2 months. This is his investigation that he did 1 week ago in a private lab
Liver function test
Total protein - normal
albumin - normal
bilirubin - normal
ALP - normal
ALT - high (120)
prothrombin time - normal
Hep B serology
HbsAg - reactive
HbsAb - non reactive
HbeAg - non reactive
HbeAb - reactive
a) interpret the LFT
correct answer: ALT is raised showing hepatocellular damage. Liver synthesis function however is normal
b) comment on his Hep B serology
correct answer: HbsAg positive showing infection with hep B virus. This is a picture of chronic infection (HbeAb +ve but HbeAg -ve) of the pre core mutation (what the f***??? never heard of it) strain. bla bla... couldn't comprehend. In view of the chronicity, there might be a superinfection of other hepatitis virus that cause his current symptoms. Dr James said this is postgrad level. This make me feel a lot better don't know how to do the whole question 
c) what history are u going to ask further?
correct answer: sexual history, history of blood transfusion, IVDU.
d) what other blood test will u do to confirm your diagnosis?
correct answer: Hep B DNA. Serology for other hepatitis virus like Hep A and C.
6) a 18 year old boy presented with history of lethargy, fever and night sweats of recent onset. He is also pale and have hepatosplenomegaly on examination. This is his peripheral blood film picture:
White cell count: high
neutrophil: 5%
lymphocyte: 20%
blast: 70%
Hb: low
Platelets: low
a) what is your diagnosis?
stupid answer by me: tembak, ALL (acute lymphocytic leukemia)
correct answer: acute leukemia
b) what is the classification of leukemia?
stupid answer by me: classify according to French, American, British (FAB) classification. Was so proud that i knew it...
correct answer: lymphoid and myeloid (what the f***?????!!!! piss me off!!!)
c) the patient's neutrophil alkaline phosphetase is 10. what is the significant? (Prof Cheong always like to give a number without normal range. How the f*** i know this is low or high?)
correct answer: this is low suggestive of Acute myeloid leukemia (yeah right, tembak 1 over 2 also can get wrong...sigh...)
d) how would u manage this patient?
correct answer: chemo, supportive, counselling, bla bla...
As for my clinical exam, i got Prof Cheong for examiner and my case is a 50 year old Malay lady presented with dysphagia + odynophagia for 5 months. Final diagnosis: Oroesophageal oral candidiasis secondary to HIV+ve. Didn't do very well, he only asked me until investigation. Somemore the only investigation i get to said was full blood count only and he said my exam is over, i still got a lot to say! Kok Fang said this is bad prognosis for me. However, he said i clear pass, so no worry lo...
15 comments:
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regarding the hepatitis question (5b). HbeAb tells tat the hepB is NOT infective. chronicity is the presence of HBsAg of >6months.. not mer??
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Ya. that's by defination. Another one marker for chronicity is HbcAb (igG) and is usually associated with HbeAg and HbeAb. (from Davidson) I didn't really know what Dr. James was talking about seriously. I didn't know how to do the whole question...ha. Any idea from anyone?
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