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EXTRA CLASS PRO EXAM STUDY GROUP

1.0 [SURGERY WITH MS ZETI]

A) Breast cancer (Dayahs case) :-

- Chief complaint : Patient presented with breast lump for 1 month duration
- HOPI :-
1st : Tell more about presenting complaint, HOPI (describe lump, when
noticed, how noticed, etc) & progress of the lump
2nd : Risk factors!!!*** (mention all positive and negative relevant risk
factors)
3rd : Management that had been done to the patient
- Past medical hx
- Family hx :-
1st degree relatives are parents, siblings and children-50% share DNA
What malignancy are we concern about in patient with breast lump? (FIND!)
- Social hx :-
Criteria of alcoholic (back to pasychiatry)-cuz dayah mentioned the word
alcoholic
- P/E :-
Please show me how you examine for signs of metastasis (distant metastasis)
Spine tenderness (palpate all the way from cervical to sacral)
Percuss lungs for pleural effusion (stony dullness)
Abdomen felt for hepatomegaly and ascites
- DDX (give points for and points against) :-
a) Breast cancer
b) Fibroadenoma
c) Breast abscess
d) Etc, etc
- Investigations :-
Triple assessment
i. History & PE
ii. Imaging
iii. Biopsy (trucut biopsy)

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***Ms Zetis questions along the way

o Risk factors, risk factors and RISK FACTORS! (drop dead serious)
o Definition of wide local excision? : removal of lump with rim of normal tissue
o If you did biopsy and the result came out as invasive ductal carcinoma (IDC), what to
do next?
Proceed with CT TAP for STAGING
o Option of treatment for her?
Depends on staging of the disease
If no distant metastasis what to do?
How to divide your mx? (medical and surgical)
Medical : if positive receptor status, start on hormonal therapy such as
SERM (Tamoxifen), aromatase inhibitor, etc (read about the
medications!)
Surgical : READ! From CPG :

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o Why do we do neoadjuvant therapy?
To shrink the tumor so easier to carry out the surgery
o Methods of sentinel lymph node biopsy?
Dye injection technique? (read more)
o Choice of adjuvant therapy?
Hormonal therapy
Chemotherapy
Radiotherapy
o Specific complications of mastectomy and axillary lymph node clearance?
Early Late
Infection (SSI) Lymphoedema
Bleeding (hematoma) Injury to intercostal brachial nerve
Seroma Injury to long thoracic nerve
Breast tenderness winging of scapula

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Wound breakdown
Phantom breast pain
Injury to thoracodorsal nerve
(palsy of lattisimus dorsi)

o What is the principle of sentinel lymph node biopsy?


If no cancer cells found, therefore no metastasis to axilla. Thus no need
axillary clearance

***ADDITIONAL INFO :

o Positive HER2 : Herceptin (trastuzumab)


o Staging :-

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Stage 1-2 : early
Stage 3 : locally advanced
Stage 4 : metastasis
o Malignant features in mammogram
Spiculated mass
Clustered microcalcification
Pleomorphic
Branching calcification
If scattered (possibly benign)
o Phyllodes tumor : hematogenous spread
o Difference between ultrasound and mammogram :-
a) If patient is less than 30 years old, I will choose ultrasound as modality of
choice because the breast is dense and mammogram may not be able to
visualize properly the mass (ms zeti ckp jwb mcm ni je if in exam, xyah
tambah lebih2 eventhough dr lain ajar lain. Just follow what is taught in
our level at the moment)
b) If more than 30 years old, mammogram + US (WHY? FIND OUT!)
o Lymphatic drainage of breast (refer Prof Hamids notes) :-

SUPERFICIAL SET

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DEEP SET

[Akhir kata pesanan Ms Zeti : Breast cancer is a gift


case. If you get this case you will surely pass because
you can guess already all the questions that will be
asked. Risk factors are sooo important!]

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2.0 [MEDICINE WITH DR ARIF]

A) Lung cancer (Faras case) :-

- C/C
Mr A, with underlying lung cancer stage 4 since 2 years ago presented with
shortness of breath on the day of admission.

- Dr Arifs comments
1. For HOPI :-
1st : start with presenting complaint (tell more about the SOB, started
when, what was he doing during that time, etc mcm biasa rule out
semua differentials for SOB. Dont just focus on the lung cancer!)
Then baru cerita about the diagnosis of the lung cancer
a. How many times admitted?
b. What chemo was he started on? How many cycles already
received?
c. Last follow up?
d. How many more session to go?
e. Risk factors?
f. How long has the patient been on morphine? How long has
been constipated? (because patient dpt current SOB time dia
tgh defecate)
Recently, the patient presented with lump at the back of left shoulder
which his doctor said possible to be bone metastasis then tell more
about the lump (ni ayat dr)
2. O/e : conclusion of the lung finding? (reduced air entry on left lung, reduced
left lung expansion, dullness on percussion, and reduced vocal resonance)
left lung collapse
- From the c/c which is SOB, try to rule out the differentials (other causes of deterioration in
lung cancer) :-
i. Infection (pneumonia)
ii. Recurrent lung cancer
iii. Pleural effusion
iv. Pulmonary embolism

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Akhir kata pesanan Dr Arif

I. Janganlah percaya bulat-bulat cakap patient. Kalau rasa tak logic


takyah cakap.
Mcm patient ni ckp dia stage 4 tp dia cerita dr ckp tumor dia kt lung je
and did not go to other place.
Habis tu kalau aku suruh korang makan taik, korang makanlah?
Dah Dr Arif suruh. Makanlah korang taik tu, dengan penuh
berselera, waktu buka puasa.
Ouch.
II. Jgnlah sebab dah tau dia ada lung cancer kau nak cerita semua
pasal lung cancer dia taknak rule out ddx lain. Jgn tamak sgt semua
benda psl lung cancer kau nak sumbat dlm HOPI.
III. Patient got sudden onset of SOB while defecate.
Kau ni pun, time terberak tu jgk kau nak cerita. Ni satu soalan je
aku nak tanya. Dia berjaya berak ke tak?

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3.0 [PAEDS WITH DR MAZIDAH]

A) Thalassemia (Syahmis case) :-

- 3 year 5 month old


- Underlying thalassemia intermedia, came for blood transfusion
- Initial presentation : at 1 year old, pallor, less active and became easily fatigue
- Hb at diagnosis : 4.6 g/dL
- Post-transfusion : 12 g/dL
- Currently on 4-weekly blood transfusion
- Currently
Pre-transfusion Hb : 7.9-9 g/dL (not good )
Post-transfusion Hb : 12-14 g/dL
Iron level : 1,100 started on iron chelator Esjade. Now iron level 1, 400 (on
3 tabs Esjade)
- Family hx : mom has beta thalassemia intermedia, dad has thalassemia trait
- 1st ENT follow up at 2 y 8 m all normal

***Dr Mazidahs comments


In HOPI :-
When patient required titration of medication, tell why.
State the compliant of patient (the iron level continued to increased
despite being compliant)
Presenting symptom DURATION?
When give a timeline, mention age of patient. Eg. last December when
patient was 1 year old
Time HOPI, has to rule out other ddx of anemia in children. Eg. apart
from easily fatigue, patient did not present with other symptoms such
as bla bla bla.
Tell about the complications of iron chelators (mention all)
Initial C/C :-
Dont too narrow to thalassemia
Give further history to rule out other causes of pallor in paeds

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DDX of anemia in 1 year old? (CLASSIFY!! REFER SUNFLOWER)
Tell what happen along the way of follow up

***For thalassemia case


i. Initial symptom & rule out other ddx
ii. Progress
iii. Current status
HOPI :-
Include G6PD history (normal G6PD status during birth)
Mother had anemia in pregnancy? (baseline Hb during pregnancy? If asked
but mother couldnt remember mention jgk so nmpk kita tnye)

****Thalassemia needs a booster of Hep B every now and then (depends on antibody
level-dr need to do serology)READ ABOUT THIS!

Development :-
3 y/o : for language igt coloursss
Cth ayat : regarding developemental history, he is appropriate to his age
whereby for gross motor he is able to ______, fine motor able to _______,
speech _______ and social _________
Past medical hx :-
His 1st hospitalisation was during point of diagnosis
Any hospitalisation due to febrile illness? (or hospitalised for recurrent febrile
illness?) They are prone to get sepsis and die!
Currently patient is on Esjade (compliance and monitoring!!) patient is
compliant and monitored by mother
Any adverse or allergic reaction during blood transfusion?
Family hx :- any genetic counselling given?
Impact of illness :- currently patient is coping well with the disease
Summary :-
MA, a 3 year old boy with underlying transfusion-dependent thalassemia
diagnosed since 1 year old whereby he presented with _______. Patient is
currently asymptomatic of thalassemia but has underlying iron overload with
symptoms of _________.

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P/E :-
i. General (thalassemic facies such as frontal bossing, maxillary overgrowth &
tooth overriding)
ii. Growth chart
iii. Vital signs
iv. Next, yg hands, eyes, mouth tu semua
v. Abdomen : patient had hepatosplenomegaly whereby liver & spleen are
____cm palpable below the costal margin
vi. Other systemic examination were normal whereby for CVS no sign of heart
failure, respiratory ______.
Diagnosis :-
Provisional diagnosis
Beta-thalassemia :-
Pallor (duration?)
Lethargic for 2 months
Poor oral intake for 7 months
Differential diagnosis
Iron deficiency anemia :-
Minimal iron-rich diet given to child (eg. green leafy veggies,
red meat)
Pallor
Easily fatigue
Leukemia :-
Time of presentation at 1 y/o
s/s of anemia
points against : no bruises, not febrile
Bagilah lagi ddx lain

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***Drs questions

o If youre the managing doctor and see patient for the 1st presentation, what work up to
do? :-
FBC (TRO other ddx) :-
a. Hb (microcytic hypochromic anemia)
b. WCC (low/markedly high hyperleukocytosis in leukemia)
c. Platelets (look at other cell lines ; WCC & platelets)
d. RDW
e. Reticulocytes count
f. Mentzer index (read!)
Peripheral blood film :-
a. Presence of blast cells
b. Hemolysed RBCs
c. Features of microcytic hypochromic RBCs
d. Target cells/nucleated RBCs
Iron work up :-
a. Serum iron (if low, rule out IDA)
b. Ferritin level
c. Transferring
d. TIBC
Hb electrophoresis :-
a. Low HbA
b. High HbF
c. High HbA2 (kot?)
Prior to transfusion (if patient needs transfusion) :-
a. Viral screening (Hep B & C, VDRL)
b. Group cross match
HLA phenotyping (to look at minor blood antigens) mesti kena bagi blood
yg match. Kalau tak, pt produce antibody & susahlah for future transfusion.
o How would you manage the patient then :-
Gradually transfuse the patient for few days until I reach Hb of 12 g/dL
Prescribe with medications like folic acid, vitamins
If febrile, give antipyretic or may need antibiotic

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Assess on compliant and side effects
Counsel parents : patient may need regular transfusion which can cause long-
term complications such as infection, iron overload.
Above 10 y/o : check endocrine, growth, MRI (refer protocol!)
Since mom complaint patient had reduced oral intake, may need fluid full
maintenance, strict i/o charting.
Genetic counselling
Family screening

[Akhir kata pesanan Dr Mazidah :- dont forget to read


about DM, CP and hepato too. Dont forget to practise
your timing. Teach others what you have learned because
the outcome will be umphh!]

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4.0 [PSYCHIATRY WITH PROF SYED]

A) Generalized anxiety disorder (Naddys case) :-

- C/C : Neck stiffness for 6 months duration


- Since mother in law came to stay with him
- Associated with generalized headache
- Feels tired in the morning
- No depressive symptoms, no manic symptom
- No underlying medical conditions

***Prof Syeds comments

C/C : patient came with neck stiffness due to underlying conflicts (ni kena ckp
kalau tak examiner direct kan kita ke soalan medicine!)
Patients symptoms
Panicky :-
- Onset?
- Triggering factors?
- Symptoms (all panic symptoms) feels like having heart attack
Neck pain (SOCRATES)
No past history of medical problem
Was he ever investigated during first presentation? If yes, what? And results?
Any medications given to him in ED or OPD? Did the medication relieved his pain?
***3 types of impairment to include in HOPI!! :-
a. Social (interaction with people)
b. Work (patient cant work)
c. Psychological (has anxiety and depression?)
Mention the medications he is on currently for the anxiety (compliant to medications
and follow up?)
Family history (if relevant can put in HOPI) :-
Mom and dads age, any medical problem?
Patient not talking to mother for 3 years
Mom has underlying anxiety

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Siblings?
Closer to mom or dad? Closer to which sibling?
Personal history :-
The relevant
Sexual history
We want to know what kind of person he is? (talkative? Outgoing? Shy?)
In school was he a prefect? Active socially or not active?
Any problem with police? Smoking? Alcohol?
Cth ayat : in average, hes a person that can get along with people and ________.
Past medical history
Past psychiatry
P/E :-
If have time, check vital signs such as the pulse, BP, etc (if not, say if I have
time I would do .....)
Cooperative, moderate build
MSE :-
Appearance & behaviour
Mood : how is he feeling? (patient said he had brain fog. What is
meant by that? What he meant by thought block?)
***Thought block is more related to schizo. It means they
suddenly not answer question and jump to other topic.
Affect : what we observe
Speech
Thought
Perceptual (acute anxiety can get derealisation)
Cognition
Insight :-
He must know why he had the problem
Good insight if : able to mention some contributory factors,
compliant to medications.
Diagnosis :-
GAD (give all points for, the mnemonic WATCHERS)
Panic disorder
Substance-induced anxiety (eg of medications smoke)

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Anxiety due to other medical illness
Somatisation disorder (MUST HAS MULTIPLE SYMPTOMS! SATU JE
TAK BOLEH)
a. Abdominal upset?
b. MSK?
c. Genitourinary?
Hypochondriasis
Delusional disorder (rasa neck symptom, pastu rasa dia ada cancer)
Management :-
Treat as inpatient or outpatient?
Investigations (investigate 1st to know the general status) :-
Haematological studies
FBC
ESR
BUSE
UFEME
LFT before start medications
Urine toxicology
DXT
Endocrine study (TFT, if remote possibility of
phaeochromocytoma, investigate too)
Imaging
Cervical Xray
If needed, CT
ECG
Treatment :-
Biopsychosocial
Biologically (anxiolytic such as alprazolam ; SSRI such as sertraline)
Education : explain about illness
Psychosocial (relaxation technique, muscle relaxing technique)
Cth ayat Prof :-
- 1st Ill go with pharmacotherapy. Since patient responded well to
alprazolam and sertraline, Ill continue with the medications but
remind the patient of the risk of dependency

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- 1st line is always SSRI! (other SSRI that I can prescribe are _____)
- Anxiolytics (eg. Lorazepam, Clonazepam) mention about the
danger (since Im prescribing benzodiazepine, I would advice about
the side effect of sedation and for patient to be careful)
- Psychosocial therapy (marital therapy, family therapy call family
members)
- Education : importance of compliant, watch out for early signs of
relapse
Patient has good prognosis. Why?
a. Looking for help
b. Good help-seeking behaviour
Difference between derealisation & depersonalization
Derealisation (usually in acute anxiety Depersonalization
state)
Realized changes to something around Something change to their body (telinga
them (mcm nmpk awan tsunami, nmpk sebelah kecik sebelah besar)
tiang kecik besar)

GAD is more of duration (tak kisah sgt yg free-floating anxiety and the anxiety cant
be pinned to one specific issue tu. Prof said if more than 6 months terus je ckp GAD)

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B) Schizophrenia (Myzas case) :-

- C/C : brought to ED due to aggressive behaviour for 2 days prior to admission (if has
underlying psychiatric disorder put with underlying psychiatric disease dont
mention straightaway the diagnosis the patient had) dont hv to mention with
no known medical illness
- Patient had auditory hallucination, persecutory delusion (people are going after him)
for 4 months duration
- Mother said was temperamental since childhood
- Had history of drug use 5 years ago. Stopped 6 months ago. No withdrawal symptom

****Prof Syeds comments


o Your DDX? :-
a. Schizophrenia :-
Young age
Strong paranoid delusion
Cannabis is a triggering factor
Bizarre hallucination
(for the paranoid delusion and hallucination, look at the strangeness &
bizarreness)
b. Drug-induced psychotic disorder (but in this patient unlikely because Prof
said, drug-induced is more of an acute onset)
c. Depressive disorder with psychosis
d. Schizoaffective (has both depressive and psychotic disorder)
o So in this patient what do you think is the likely diagnosis?
Schizophrenia because of the bizarreness of the delusion and hallucination.
o We asked Prof, yg patient had temperamental since childhood is it considered as
prodromal for schizo?
No because illness means you are initially well then at one point of time you
become sick. Temperamental is more of personality based on how the patient
was brought up. Thats why important to ask about relationship with family.
o Ask about crying spells and guilty feeling TRO depressive disorder

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o Depression can be divided into
Mild Reacting to environment only got social
withdrawal, loss interest and crying spells
Moderate -
Severe Has suicidal attempt, psychosis

****ADDITIONAL INFO BY PROF (IMPORTANT!)

Common cases in Pro :-


a. Anxiety disorder
b. OCD
c. Depression
d. PTSD
e. Schizo
f. Bipolar disorder in remission
Child case ada tak prof?
No lah, because its a sub specialty case. Tapi kalau keluar pun they will ask
you features of autism mcm tu je
For OCD, just remember 4 things :-
a. Obsession with washing (cleanliness)
b. Obsession with checking
c. Obsession with doubting (ambik wudu byk kali)
d. Obsession with hoarding (keep all things even yg dah xleh guna)
For OCD, you must prove there is presence of obsession (thinking about it all the
time), ritual of compulsion, and distress**** (if no distress, its obsessive
personality not disorder)
OCD can lead to depression and suicide!! (soalan past pro)
ECT usually has 2 main indications :-
a. Mania/schizo/depression with suicidal
b. Early intervention for aggressiveness

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****If patient tu dah byk kali relapse and dtg for pro with no active complaint :-
For C/C and HOPI, always go for the latet one. Cth latest admission was due
to relapse 2 months ago, you should start from there. Ceritalah apa yg trigger
dia relapse time tu, what medication given bla bla.

In past psychiatric hx : baru cerita how many admissions patient had and what
was the initial presentation.

For PTSD case you must show that the patient had :-
a. MUST GET THE TRIGGERING FACTOR! assault, trauma, saw a
situation that is traumatic (last time ada your senior dpt case PTSD patient
tu ada symptom depression with history kena slash dgn parang. Tp your
senior directed to MDD je. Penat kami bagi hint psl trauma tu. So make
sure you know the triggering factor)
b. Signs and symptoms (anxiety, depression, flashbacks)
c. Having dreams about the traumatic event
d. Avoid situation (avoidance)
e. Worry about the same thing

[Akhir kata pesanan Prof Syed : Psychiatry is very easy.


Most important is that you can get the chief complaint,
the signs and symptoms and the medications. Yang lain
tu you goreng jelah. I wont be your examiner this year.
Tapi doktor lain semua baik-baik. Never get your
medication wrong! Wrong choice of drug or wrong
group can lead to failure]

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