Phase IV Exams

MEQ
January 9, 2012

Question Specialty
1 Anaesthesia
2 Obstetrics and Gynaecology
3 Ophthalmology
4 Psychiatric Medicine
5 Psychiatric Medicine
6 Obstetrics and Gynaecology
7 Emergency Medicine
8 Emergency Medicine
9 Forensic Medicine

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 QUESTION ONE

A 70-year-old man had an uneventful laparotomy done for a perforated peptic ulcer. Four how-s
after arriving back in the ward, he was noted to be more tachypnoeic. He was a heavy smoker
with a history of chronic obstructive airwa)( disease.

Part 1 o(9
State FOUR likely causes for his tachypnoea. (4 marks)

The pulse oximeter reading showed an oxygen saturation of 88%.

Pa~t2 o(9
Does the pulse oximeter compares the absorption spectra of .total hemoglobin and oxygenated
oxygenated hemoglobil1 OR oxygenated hemoglobin and deG>xygeneated hemoglobin? (1 ·tnark)

Pat·t 3 o(9
His pulse oximeter reading showed an oxygen saturation of"88%. What would you expect ltis
P_a 02 to be, assuming a normal oxygen -dissociation curve? {2tlia:rks)
a. 20 - 40 mmHg
b. 40 - 60 mml g
c. 60 - 80 mmHg
d. 80 - 100 mml-lg
e. 100 -120 mmHg

Part 4 o[9
How would you administer oxygen to this patient? (2 marks)

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Part 5 o(9
You are handed 2 masks to choose from by the staff nurse. What is the difference between mask
A and mask B? (2 marks)

The arterial blood gas taken when he was breathing room air showed the following:
pH 7.27 (normal range 7.36 -7.44)
PaC02 40 mmHg (normal range 35- 45 mmHg)
p02 50 mmHg (normal range 75-100 mmHg)
Standard Bicarbonate 17 mmol/L (normal range 22-28 mmol/L)
Base Excess -3.5 (normal range -3 to 3)

Part 6 o(9
Give your interpretation of the blood gas results (2 marks)

Part 7 o(9
What is the likely contribution of his smoking history to his hypoxaemia? (2 marks)

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92 - - - - - - - -""""'1'=-- - - - - - -

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Lo~--------50----B+
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Parli>l Prossurt ol Oxyfcft DluolRd In Blood
(PaOZJ

Part 8 o[9
State any THREE factors that can jnfluence the position of this oxygen-haemoglobin dissociation
curve. (3 marks)

Part 9 o(9
How would this patient' s smoking history affect his oxygen-haemoglobin dissociation curve? (2
marks)

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 QUESTlON TWO

Madam MR is a 40-ye-ar-old in her first pregnancy after 5 years of marriage. She presented at
the antenatal clinic for booking on 27.5.20 11 . She gave her LMP to be 2.12.201 0. Her cycles
are always regular. She bas no past history of any serious medical illness. She is the third of 5
siblings and her eldest brother is a diabetic. She is otherwise asymptomatic.
Examination revealed her to be·a healthy lady. Her weight was 50 kg. Her height was 145 em.
She was not pale. BP was 120/70 mm ofHg. The thyroid breasts, heart and lungs were normal.
The uterine size corresponded to 25 weeks' gestation. Fetus was in longitudinal lie with cephalic
presentation. Fetal heart tones were regular at 144 bpm.

Part 1 o[6
Identify THREE problems from the presenting scenario related to this visit in Madam MR. (3
marks)

Part 2 of6
Besides the routine antenatal screening, suggest TWO relevant investigations with reasons that
you would li~e to do at this stage. (4 marks)
 Madam MR. is a 40-year-old in her first pregnancy after 5. years ofmaniage. She presented at
the antenatal clinic for booking on 27.5.2011. She gave her LMP to be 2.12.2010. Her cycles
are always regular. She has no past history of any serious medical illness. be is the third of 5
siblings and her eldest brother is a diabetic. She is otheiWise asymptomatic.

Examination revealed her to be a healthy lady. Hetweight was 50 kg. Her height was 145 em.
She was not pale. BP was 120/70 mm ofHg. The thyroid, breasts, heart and lungs were normal.
The uterine size corresponded to 25 weeks' gestation. Fetus was in longitudinal lie with cephalic
presentation. Fetal heart tones were regular at 144 bpm.

She had Oral Glucose Tolerance Test done. The result was as follows:
Fasting Blood Sugar 8.5 mmol/L (Normal4-6.7 mmol/L)
Two Hour Post Prandial Blood Sugar 19.3 mmol!L (Normal <7.8 mmol/L)

Part 3 6[6
Wl1at do the findings indicate? (2 marks)

Part 4 o(6
What would be your management at this stage? (6 marks)

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 Madam MR is a 40-year-old in her first pregnancy after 5 years of marriage. She presented at
the antenatal clinic for booking on 27.5.2011. She gave her LMP to be 2.12.2010. Her cycles
are always regular. She has no past history of any serious medical illness. She is the third of 5
siblings and her eldest brother is a diabetic. She is otherwise asymptomatic.

Examination revealed her to be a healthy lady. Her weight was 50 kg. Her height was 145 em.
She was not pale. BP was 120/70 mm Hg. The thyroid, breasts, heart and lungs were normal.
The uterine size corresponded to 25 weeks' gestation. Fetus was in longitudinal lie with cephalic
presentation. Fetal heart tones were regular at 144 bpm.

She was sent for Oral Glucose Tolerance Test and the results were as follows:
Fasting Blood Sugar 8.5 mmol/1 (4-6.7 mmol/1)
Two Hour Post Prandial Blood Sugar 19.3 mmol/1 (<7.8 mmol/1)

She was admitted to the antenatal ward for stabilization of the diabetes. Blood sugar
profiles were done. She was started on Insulin therapy. After a week, her diabetes was
controlled with 16 units actrapid insulin three times daily and monotard 8 units two times a
day.

Ultrasound showed no obvious structural abnormality. Fetal parameters were within

range for dates. Liquor volume was normal.

Part 5 o[6
How would you monitor her fetus? (4 marks)

Part 6 o[6
When would you like to deliver the baby assuming her diabetes is well controlled? (1 mark)

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 QUESTION THREE

A 50-year-old lady presented to Accident and Emergency department with a 3 hour history of
headache and blurred vision. She has a history of diabetes mellitus for 15 years and hypertension
for 15 years. Her diabetes and hypertension are controlled with medications.

Part I o[6
Give FOUR possible differential diagnoses for her symptoms that you would consider at this
point. (4 marks)

Part 2 o[6
Give FOUR additional aspects in the history that would help you ascertain the etiology (4
marks)

On examination, she is alert but obviously in distress. Her vitals are as follows: Temperature
36.8 C, respiratory rate 18/min, heart rate 88/min, and blood pressure 220/150 mm ofHg. Her
first and second heart sounds are well heard over the precordium. Lung auscultation is normal.
Ophthalmic examination reveals the following findings:
Visual acuity: 6/12 right, 6/18 left
Pupils are equal and reactive to light
There is no relative afferent pupillary reflex
Anterior segment examination is normal and the intraocular pressures are 15mmHg right
and 17 mmHg left.

Part 3 o[6
These are the fundus photographs of the patient. Describe FOUR key findings. (4 marks)

Right Eye Left Eye

Part 4 o[6
What is your principal diagnosis? (2 marks)

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 On examinati0n, she is alert but obviously in distress. Her ~tals are as follows: Temperature
36.8 C, respiratory Rate 18/min, heatt rate 88/min, and blood pressure 220/150 mm of Hg. Her
first and second heart sounds are well heard over the precordium. Lung auscultation· is normal.
Ophthalmic examination reveals the following findings:
Visual acuity: 6112 right, 6/18 left
Pupils are equal and reactive to light
There is· no relative afferent p~1pi llary reflex
Anterior segment examination is normal and the intraocular pressures are 1SmmHg right
and 17 mmHg left.

Part 5 o(6
Wliat are TWO other acute complications she is at risk of? (2 marks)

Part 6o(6
Outline the principles of management of hypettensive crisis in this patient. (4 marks)

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 QUESTION FOUR

You are the resident in the medical department. You are asked to carry out a pre-admission
assessment of a 35-year-old man who has a known history of excessive alcohol consumption. He
has been referred by his GP for management of alcohol withdrawal. According to his wife, he
has been drinking a bottle of Chinese wine every day for the last 3 years. His wife also says that
he has been drinking particularly heavily over the past 2 months and over this time has eaten
only occasional meals.

Part 1 o(7
What are the FOUR (4) questions of the CAGE questionnaire that is used to assess alcohol
dependence? (4 marks)

Part 2 o(7
His wife mentions that he feels annoyed when she criticizes his drinking. He needs to drink
Chinese wine first thing in the morning to calm his nerves. What is your diagnosis? (1 mark)

Part 3 o(7
When you see the patient, he displays confusion, agitation and sweating. Name FOUR (4) other
signs or symptoms you would look for to support your most likely diagnosis. (4 marks)

Part 4 o(7
You have completed the assessment and conducted a physical examination. He appears
malnourished. You are charting initial medication.
What are the TWO (2) MOST IMPORTANT medications that you would prescribe for this
patient? Please indicate the route of administration and the reason for prescribing them. (6
marks)

Part 5 o(7
You send off a Full Blood Count to the laboratory. What is the MOST CHARACTERISTIC
abnormality you would expect to see in the full blood count in this patient? Give ONE answer
only. (1 mark)

Part 6 o(7
You send off a Liver Function Test to the laboratory. What is the MOST CHARACTERISTIC
abnormality you would expect to see in the liver function test in someone with this history of
ACUTE alcohol ingestion? Give ONE answer only. (1 mark)

Part 7 o(7
He has stayed in the hospital for one week and he no longer has withdrawal symptoms. He would
like to quit alcohol. Name THREE (3) psychosocial interventions that would help him to quit
alcoholism. (3 marks)

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 QUESTION FIVE

You are the resident in the renal team. You are asked to see a 50-year-old woman on the renal
ward who has been admitted for non-adherence to her dialysis regime. Her family informs you
that she has a history of psychiatric illness; but unable to specify the nature of the illness. Now
she says she does not wish to continue her dialysis. She wishes to try 'natural therapy'.

Part 1 o[8
What is the most important thing you would like to assess before you accede to her request? (1
mark)

Part 2 o[8
You have decided to assess her mental capacity. What are the main elements of mental capacity
that this patient would need to demonstrate? List FOUR (4) main elements. (4 marks)

Part 3 o[8
The patient believes that the devil is going to harm her through dialysis. Should you support her
decision to decline dialysis? Please give a reason. (2 marks)

Part 4 o[8
Should you exclude non- psychiatric causes for her delusion? Explain your answer. (2 marks)

Part 5 o[8
What are FOUR psychiatric illnesses that you would like to consider? (4 marks)

Part 6 o[8
You are the resident in the renal team. You are asked to see a 50-year-old woman on the renal
ward who has been admitted for non-adherence to her dialysis regime. Her family informs you
that she has a history of psychiatric illness; but unable to specify the nature of the illness. Now
she says she does not wish to continue her dialysis. She wishes to try 'natural therapy'.

The patient appears to be calm but she is preoccupied with her delusion. Please name ONE
psychiatric medication which you would order to treat her delusion. Please indicate the route of
administration. (2 marks)

Part 7 o[8
Name ONE psychiatric medication that you will not prescribe in this patient. Please state your
reason. (2 marks)

Part 8 o[8
You have observed this patient in the ward for 2 weeks. She cannot remember the name ofher
children. Name THREE (3) MOST IMPORTANT COGNITNE DOMAINS which you would
assess. (3 marks)

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 QUESTION SIX

A 28-year-old nulliparous sexually active lady presents with amenorrhea of 6 months' duration.
She had menarche at 12 years and has been having periods every 2-3 months since then but has
not taken any treatment for this problem. Her urine pregnancy test is negative and the GP has
already done a thyroid function test which is normal. She is currently not on any regular
medication.

Part I o(8
Give THREE common medical conditions that can explain her situation (3 marks)

Part 2 o(8
Give FOUR additional relevant questions you need to ask to ascertain the etiology. (4 marks)

The patient reports that she has gained 10 kg in the last 1 year but has no undue mental or
physical stress. She does not suffer from headaches.

Part 3 o(8
Give THREE relevant physical findings that you would look for. (3 marks)

Part 4 o(8
What is the most likely diagnosis? (1 mark)

Part 5 o(8
Name THREE most relevant hormonal assays that you would like to do for her. (3 marks)

Part 6 o(8
What is the most appropriate imaging study you would like to do for her? (1 mark)

Part 7 o(8
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 State TWO important treatment options for her condition. (2 marks)

Part 8 o(8
Name THREE (3) diseases that may be associated with her condition (3 marks)

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 QUESTION SEVEN

You are the doctor working in the Emergency Department. A 75-year-old man is brought in by
his anxious family after a fall. He woke up in the morning and fell down on the way to the toilet.
He has a history of hypertension and ischemic heart disease. He has a history of stroke about 5 -
years ago. His current medications include aspirin and atenolol.

Part 1 o(9
What are the important preceding symptoms which would indicate a medical cause for fall?
Name THREE. (3 marks)

You are the doctor working in the Emergency Department. A 75-year-old man is brought in by
his anxious family after a fall. He woke up in the morning, felt giddy and fell down on the way to
the toilet. He has a history of hypertension and ischemic heart disease. He has a history of stroke
about 5 -years ago. His current medications include aspirin and atenolol.

On questioning, the family mentions that he felt giddy on the way to toilet. There is no
chest pain, one-sided weakness, or blurring of vision.

On examination, his temperature is 36.5 C; pulse rate is 88/min, and supine blood pressure
is 168/90 mm of Hg. He complains ofleft hip pain. His lower limbs are shown below.

Part 2 o(9
Briefly describe the abnormalities in this picture. (2 marks)

Part 3 o(9
What radiologiga.l inyestigations would you order? Name TWO. (2 marks)
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Part4 o(9
A pelvic AP x-ray and left lateral hip x-rays are taken. What is the key abnormality shown in the
x-ray? (2 marks)

When you speak to his family, they mention that he has been complaining of weakness and
giddiness that is worse whenever he stands up. His blood pressures in the EMD are 168/90
mmHg (supine), 101/60 mmHg (standing).

Part 5 o(9
What is this blood pressure change called? (1 mark)

Part 6 o(9
You diagnosed the patient to have postural hypotension. What are the possible causes in this
patient? Name TWO. (2 marks)

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In the Emergency Department, the patient passes motion. The following picture shows a
sample of the patient's stools.

Part 7 o(9
What are the possible causes for this particular type of stool in this patient? Name TWO (2
marks)

Part 8 o(9
What blood investigations would you order in this patient? Explain briefly the reasons. Name
THREE. (3 marks)

Part 9 o(9
You have decided to admit the patient. List THREE important subsequent management
interventions. (3 marks)

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 QUESTION EIGHT

A 32-year-old driver was brought into the Emergency Department by the paramedics following a
car-crash. On arrival, he reeked of digested alcohol mixed with vomitus. He opened his eyes to
call, was not able to give his name but went on blabbering about the party that was "out of this
world". He was punching his fists into the face of the nurse.

Part 1 o(9
What is his Glasgow Coma Scale (GCS) score? Specify the score for each component. (4 marks)

Part 2 o(9
Name one important and immediate bedside point of care test (POCT) that should be done. (1
mark)

A 32-year-old driver was brought into the Emergency Department by the paramedics following a
car-crash. On arrival, he reeked of digested alcohol mixed with vomitus. He opened his eyes to
call, was not able to give his name but went on blabbering about the party that was "out of this
world". He was punching his fists into the face of the nurse. His GCS is 13.
His capillary blood glucose is 6.5 mmol/L.
When his shirt was removed, you notice these red marks on his chest.

Part 3 o(9
What is this sign? (1 mark)

Part 4 o(9
What is tl<re ·significance
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Refer to X-Ray below:

Part 7 o(9
A chest x-ray was done. What are TWO important diagnoses in this x-ray? (2 marks)

Part 8 o(9
What is the immediate, life-saving procedure that should be done to treat the condition seen
before insetiing the chest tube? (1 mark)

Part 9 o(9

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You have decided to perform needle decompression thoracostomy in this patient. Identify the
two important landmarks for the procedure. (1 marks)

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 QUESTION 9

An 8-year-old male was admitted to hospital with fractures of the right 3rd and 4th
metacarpals, together with bruises and abrasions on the face, chest and limbs. Both his
height and body weight were below the respective third percentiles for his age. According
to his care-givers, he was injured when he jumped down from a table a few days ago. His
injuries were treated conservatively. After he was discharged prematurely on his care-
givers' insistence and against medical advice, he was "lost to follow-up", but was re-
admitted 6 months later in an unconscious state. A CT scan of the head then revealed the
presence of a right-sided, acute subdural haematoma. The patient underwent emergency
neurosurgery, but died on the 7th post-operative day.

Part 1 o(4
Discuss the significance of the injuries in relation to the circumstances of the patient's
death. (6 marks)

Part 2 o(4
Explain why his death was reportable to the coroner, in respect of the Coroner's Act 2010.
(4 marks)

Part 3 o(4
Indicate the significant pathological features which might be revealed by a coroner's
autopsy (6 marks)

Part 4 o(4
List the ancillary investigations which are likely to be useful in this case. (4 marks)

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