INTERNAL MEDICINE GROUP 5 ROTATION 4

Internal Medicine Examination 2017 (Rotation 4 Group 5)

SBA
1. A 25 years old man sustained injury to his neck in a road traffic accident. MRI shows a
right hemisection of the spinal cord at the level of C5. What is the expected clinical
finding on neurological examination of this patient?
A Paralysis of the left hand
B Absence of biceps reflex on the right side**
C Exaggeration of biceps reflex on the right side
D Absence of sensation in left hand

2. A 16 years old patient has been referred for periorbital oedema for 3 days. He has a
history of sore throat 2 weeks earlier with nausea and vomiting. A urine dipstick is
positive for protein and blood and serum creatinine and urea are mildly deranged. What
is the most likely diagnosis?
A Renal cell carcinoma
B Nephrotic syndrome
C Glomerulonephritis**
D Chronic renal failure

3. A 27 years old female notices that she is putting on weight of late with central obesity.
Her GP told her that her BP has increased when compared with last time. Her face
appeared round and there was a bruising in her arm. She has been ordered a screening
lab test. Choose the test from the following.
A Urine catecholamines
B 24-hour Urine free cortisol measurement**
C Dexamethasone suppression test
D CT scan of the abdomen.

4. A previously well 50 years old lady with a history of early menopause was referred from
orthopaedics clinic. She had bilateral Colle’s fracture after a minor fall. Which
investigation below is most appropriate?
A DEXA scan**
B Myeloma screen
C Bone scan
D Plain X rays of the pelvis
 INTERNAL MEDICINE GROUP 5 ROTATION 4

5. A 65 years old man was brought to the emergency department with a history of sudden
onset of palpitation, light headedness followed by loss of consciousness. On
examination his radial, carotid and femoral pulses could not be felt. He has a patent
airway and was breathing with O2 saturation at 90%. The doctor decided to defibrillate
the patient. What is the likely diagnosis in this patient?
A Ventricular fibrillation (VT)**
B Atrial fibrillation (AF)
C Supra ventricular tachycardia (SVT)
D Sinus tachycardia.

6. A 42 years old man is seen in the clinic with a history of fever of 3 days duration with
shortness of breath. On examination his respiratory rate is 22/min and O2 saturation is
95% on room air. Vital signs are normal. On examination of respiratory system, the
following findings are noted. Trachea is central. Bronchial breathing is heard in the right
mammary area with dullness to percussion and increased vocal resonance. What is the
diagnosis?
A Pulmonary embolism
B Right middle lobe pneumonia**
C Right sided pleural effusion
D Right lower lobe pneumonia

7. A 55 years old diabetic man has a two weeks history of worsening abdominal pain. On
examination he is found to have jaundice, abdominal distension and tenderness in the
right hypochondrium. There is a smooth hepatomegaly and shifting dullness in the
abdomen. Which of the following diagnosis fits in with the clinical scenario?
A Acute cholecystitis
B Infective hepatitis
C Budd-Chiari syndrome**
D Inflammatory bowel disease

8. A 74 years old man is admitted with left side hemiplegia. CT scan reveals right middle
cerebral artery infarct. What is the single most significant risk factor for this patient?
A Diabetes Mellitus Type 2
B Family history of stroke
C Hypertension**
D Smoking
 INTERNAL MEDICINE GROUP 5 ROTATION 4

9. A 56 years old man complains of 3-week history of malaise and shortness of breath. He
gives a history of weight loss in the last few months. On examination, he has a palpable
mass in the right lumbar region. He has no urinary symptoms but urine dipstick shows
the presence of blood. What is the most likely diagnosis?
A Pyelonephritis
B Renal cell carcinoma**
C Adrenal tumor
D Renal cyst

10. A 38 years old woman presents with double vision for three months with palpitations and
weight loss. Her appetite has remained good. On examination she has painless, raised
lesions on both shins. She also has finger clubbing. What is the most likely diagnosis?
A Pheochromocytoma
B De Quervain’s thyroiditis
C Graves’ disease**
D Thyroid storm

11. A 30 years old lady presents with photosensitive rash and multiple joint pain. Further
investigation reveals that she has SLE. Which of the following is the most appropriate
initial treatment?
A High dose prednisolone
B Azathioprine
C Cyclosporin
D Hydroxychloroquine**

12. An 80 years old man presents with acute left ventricular failure. He is a known case of
aortic stenosis. Choose from the following the appropriate clinical sign in this patient.
A Bibasal crepitations**
B Raised jugular venous pressure (JVP)
C Atrial fibrillation
D Bilateral pedal oedema

13. Which one of the following represents bronchial asthma?

A FEVI<80% predicted, FVC>80% predicted, FEVI:FVC <70%**
B FEVI<80% predicted, FVC<80% predicted, FEVI:FVC ~70%
C FEVI>80% predicted, FVC>80% predicted, FEVI:FVC >70%
D FEVI>80% predicted, FVC<80% predicted, FEVI:FVC >70%
 INTERNAL MEDICINE GROUP 5 ROTATION 4

14. A 44 years old male with Child’s grade C cirrhosis of liver presented with haemetemesis
from oesophageal varices. Which of the following drugs, administered intravenously
would be the most appropriate, immediate treatment?
A Omeprazole
B Octreotide (Sandostatin)**
C Propranalol
D Tranexamic acid

15. A 38 years old man is admitted with history of weakness of both lower limbs for 3 days
which is progressively worsening involving the upper limbs now with tingling sensation in
both hands. He had a bout of food poisoning 2 weeks ago. On examination his power is
3/5 in ankles and 4/5 in hips. Sensations are absent in both hands and both feet. Cranial
nerves are intact. What is the diagnosis?
A Multiple sclerosis
B Diabetic neuropathy
C Myesthenia gravis
D Guillain-Barre syndrome**

16. A 20 years old man who is recently diagnosed to have type 1 diabetes mellitus has no
complaints but wants to detect early signs of renal impairment as one of his uncles with
diabetes mellitus is on dialysis for end-stage renal disease. What is the most appropriate
investigation?
A Serum creatinine
B Serum electrolytes
C Urine dipstick for protein
D Microalbuminuria**

17. A 78 years old man is admitted with unstable angina and appropriate medications have
been started towards the ACS. He has hypertension, high LDL cholesterol is in atrial
fibrillation. What is the next step in the treatment to prevent complications?
A Cardioversion
B Digoxin
C Aspirin
D Warfarin**
 INTERNAL MEDICINE GROUP 5 ROTATION 4

18. A 52 years old woman has a three months history of copious sputum production
especially in the mornings mixed with blood and pus on and off. She is diagnosed with
bronchiectasis. Which of the following is NOT a cause of bronchiectasis?
A Cystic fibrosis
B Kartagener’s syndrome
C Bronchogenic carcinoma
D Left ventricular failure**

19. Six people wear admitted with profuse vomiting and abdominal pain 3 hours after eating
a dinner in a restaurant. They all had a mixer of dishes, rice and meat. What is the most
likely causative organism?
A E Coli
B Salmonella enteritidis
C Bacillus cereus**
D Clostridium perfringens

20. A 45 years old obese lady, a school van driver presents with sudden onset of shortness
of breath and pleuritic chest pain and blood stained sputum. On examination, her BP is
96/68 mm/Hg. Her JVP is elevated. Examination of the respiratory system is essentially
normal except tachypnea. What is the most appropriate investigation in this patient?
A Coronary angiogram
B CT pulmonary angiogram**
C Femoral venogram
D PET scan

21. A 62 years old man is seen in the clinic with a three month-history of worsening
shortness of breath and non-productive cough. On examination, he is noted to have
finger clubbing, cyanosis and bilateral basal crepitations. Choose from the list below the
correct diagnosis.
A Interstitial lung disease**
B Bilateral basal bronchiectasis
C Congestive cardiac failure
D Acute coronary syndrome

22. A 15 years old girl presents following a sore throat with chest pain, fever, and a skin
rash. Examination reveals a diastolic murmur. Her ASO titre is elevated. Which of the
following is a major criterion for the diagnosis of Rheumatic fever?
A Raised ESR
B Migratory Polyarthritis**
C Erythema nodosum
D Prolonged PR interval
 INTERNAL MEDICINE GROUP 5 ROTATION 4

23. Inability to understand conversation following a stroke in a right-handed person suggests

a lesion in
A Left frontal lobe
B Left temporal lobe**
C Left parietal lobe
D Left occipital lobe

24. A 28 years old woman, a known case of mitral valve prolapse develops fever and
malaise, one week after a dental procedure. On examination she has tachycardia,
tender vasculitic lesions on fingers. What is the appropriate investigation for a definitive
diagnosis?
A ECG
B Full blood count
C Blood cultures**
D Coronary angiogram

25. A 28 years old patient with a history of chronic bacterial sinusitis presents to the
emergency department with severe headache. He develops a generalized grand mal
seizure. Physical examination, after the seizure demonstrates high fever and neck
rigidity. Which of the following is the specific diagnostic step?
A Electro Encephalogram
B Lumbar puncture**
C CT scan brain
D Complete blood chemistry
 INTERNAL MEDICINE GROUP 5 ROTATION 4

DIGITAL OSCE

Exhibit 1

1. Name the investigation. 1

CT scan Brain

2. Give 2 findings in the picture and your diagnosis.

2
Hypodense area in the left fronto parieto occipital areas. Midline shift to the right.
Ischaemic stroke left side and cerebral oedema.

3. List 4 neurological finding you expect in this patient?

2
Hemiplegia right side. UMN facial palsy – Rt side, hemi anopia, hemianaesthesis.

4. Name 2 complications associated with the diagnosis,

2
Altered consciousness, cerebral coning, hydrocephalus, aspiration pneumonia,
bed sores, muscle contractures, seizures etc

5. Write 3 strategies in the management.

3
Control BP if high, cerebral resuscitation, nil by mouth, RT feeding / PEG tube
feeding, nursing care to prevent bed sore, physio therapy, occupational therapy.
 INTERNAL MEDICINE GROUP 5 ROTATION 4

Exhibit 2

1. Spot the abnormality. 2

Ptosis of the left eye

2. Identify the cranial nerve affected here. Mention the side?

2
3rd cranial nerve. Left side

3. What abnormality do you expect in the pupil?

2
Dilated pupil. Direct and consensual pupillary reflex absent on the affected side.

4. Mention FOUR abnormalities that you expect in the eye and its movements?
4
Divergent squint, Absence of adduction, depression and elevation of the eye ball.
 INTERNAL MEDICINE GROUP 5 ROTATION 4

Exhibit 3

1. List 3 abnormalities seen in this picture?

3
Swan-neck deformity, ulnar deviation of the hand, swelling of the wrist and MCP
joint

2. What is your diagnosis? 2

Rheumatoid arthritis
3. Give 3 diagnostic criteria of the underlying disease. 3
• Morning stiffness >1 hr and > 6 weeks
• Arthritis of 3 or more joints
• Arthritis of hand joints
• Symmetric arthritis
• Rheumatoid nodules
• Positive Rheumatoid factor and positive anti CCP Ab.
• Radiographic changes

4. List 2 disease modifying drugs. 2

Sulphasalazine, mesalazine, hydroxy chloroquine, methotrexate
 INTERNAL MEDICINE GROUP 5 ROTATION 4

Exhibit 4

1. What is the ECG diagnosis?

2
AF

2. List TWO drugs used for rate control and ONE drug for rhythm control.
3
Beta blockers (Bisoprolol, Carvedilol, Metoprolol, atenolol, digoxin)
Amiodarone, Flecainide

3. List 2 complications of this condition. 2

Cardiac failure, embolism (Stroke, mesenteric, limbs etc),

4. Name the criteria used for anticoagulation in this condition.

1
CHADS 2, CHAD VA2 SC

5. Name the blood investigation used to monitor oral anticoagulation therapy.

2
PT, INR.
 INTERNAL MEDICINE GROUP 5 ROTATION 4

Exhibit 5

1. Give two findings in the displayed image. 2

Non-homogenous opacity in the right upper zone.
Air bronchogram seen.

2. What is the diagnosis? 1

Right upper lobe pneumonia

3. Write THREE clinical signs that you would elicit in this patient.
3
Reduced air entry, reduced chest movement, dullness (woody), bronchial breath
sounds, pleural rub, crepitations.

4. Name the admission criteria used to assess the severity of this condition.
1
CURB 65

5. Give THREE complications associated with this diagnosis. 3

Respiratory failure, sepsis, lung abscess, pleural effusion/empyema, cardiac
arrhythmia (AF)
 INTERNAL MEDICINE GROUP 5 ROTATION 4

A 56 year old man with a history of hypertension and

diabetes for 15 years presented with lethargy, reduced urine
output and anaemia. His blood parameters are as follows.
• Urea 60 mmol/L (2.5 - 7.5)
• Creatinine 1500 mmol/L (58 - 110)
• Potassium 6.4 mmol/L (3.6 - 5.0)
• Calcium (Corrected) 2.0 mmol/L (2.10 - 2.55)
• Phosphate 3.2 mmol/L (0.8 - 1.45)
• eGFR 10 ml/minute/1.73 m2

Exhibit 6

1. What is the diagnosis? 2

ESRD

2. Write 4 causes of the above diagnosis .

2
DM, HPT, Glomerulonephritis, renal calculus, amyloidosis, autoimmune diseases,
drug toxicity (analgesic nephropathy), AD adult polycystic kidney disease.

3. Write TWO additional investigations to establish the diagnosis? 2

U/S KUB, CT scan abdomen, MRI abdomen, renal biopsy

4. Name one life-threatening electrolyte abnormality seen in this lab result. What is the
urgent treatment required for this. 2
Hyperkalemia.
Calcium gluconate/chloride, Insulin and glucose, haemodialysis,

5. Give 2 treatment options for this patient.

2
Renal replacement therapy, (HD, CAPD, renal transplant), Correction of anaemia,
control of hypertension, maintaining electrolyte balance, phosphate binders (Cal
carbonate)
 INTERNAL MEDICINE GROUP 5 ROTATION 4

Exhibit 7

1) What is this procedure? 1

LP

2) Mention 4 indications. 4
• CSF infection- Meningitis, Encephalitis, CNS syphilis
• Subarachnoid haemorrhage
• Evaluation and diagnosis of demyelinating or inflammatory CNS
processes- Multiple sclerosis,sarcoidosis,GBS, Paraneoplastic syndromes
• Spinal anaesthesia
• Chemotherapy
• Treatment of idiopathic intracranial hypertension

3) Mention 3 contraindications. 3
• Increased ICP due to cerebral mass- brain tumor, abcesses, hemorrhage,
epidural/ subdural hematoma
• Bleeding diathesis, Focal neurological signs without CT, Skin infection
near site

4) Mention 2 normal findings from the sample obtained. 2

• Pressure: 5-25 cm H2O, Appearance: Clear (crystal clear), Protein: 0.18-0.45
g/L, Glucose: 2.5-3.5 mmol/L (CSF: serum ratio 0.6 or>60% of bl glucose)
• White cell count: 0-4 x 106/L, Microbiology: sterile
• Red cell count: 0-4 x 106/L
 INTERNAL MEDICINE GROUP 5 ROTATION 4

Exhibit 8
1. Name the procedure being done.
2
Pleurocentesis or chest tube insertion on the left side

2. List 2 conditions for which it is done. 2

• Pleural effusion, pneumothorax, hemothorax, chylothorax, hydro-
pneumothorax

3. How is this tube connected outside? 2

• Under-water-seal drainage

4. List 2 complications that may be associated with this procedure. 2

• Infection, pneumothorax, bleeding, surgical emphysema, pulmonary
oedema.

5. Describe the safe triangle.

2
• Latissimus dorsi, pectoralis major, horizontal line from nipple and below
the axilla.
 INTERNAL MEDICINE GROUP 5 ROTATION 4

INTERACTIVE OSCE
STATION 1
A 46 years old patient is diagnosed with type 2 diabetes mellitus. Counsel the patient under the
following headings.
1. Diabetes and its complications.
2. Diet and life style modification
3. Glycaemic, lipid and BP targets.
ITEM MARKS SCORE
Student should explain to the patient about diabetes &
its complications (Retinopathy, Nephropathy,
2
Neuropathy, Cardiomyopathy & Foot care) importance
of keeping the diabetes under control
1. Healthy eating
to achieve and maintain weight goals (BMI < 25)
2
(Weight loss of 5-10% in 6 months for obese patients)
Carbohydrate (50-60% energy)
Protein (15-20%)
Fat (25-30%)
High fibre diet
to attain individualized sugar, BP and lipid goals

2. Physical activity
>150 min/week moderate-intensity aerobic activity
spread over 3 days/wk. (max 2 consecutive days
2
without exercise)
Reduce sedentary time = max 90 min sitting

Glycaemic targets:

HbA1C (<6.5%) 1
Fasting blood sugar (4.4-6.1 mmol/L)
Non-fasting (4.4-8.0)

Lipids: Triglycerides (<1.7 mmol/L) 1

HDL (>1.1)
LDL (<2.6)

BP: 130/80 mm/Hg (normal renal function) 1

125/75 (renal impairment)
Professionalism –Introduction, permission, Interaction,
motivation, dress, grooming and thanks 1

TOTAL SCORE
10
Comment (Weakness & strength)

Overall Performance:

Pass / Fail
Station 2
 INTERNAL MEDICINE GROUP 5 ROTATION 4

PEAK FLOW METER

A 35 years old female is admitted with acute attack of asthma. The peak flow rate is checked to
assess the severity of the attack.
A. Demonstrate the use of peak flow meter.
B. Explain its use before and after treatment.
C. Counsel the patient on asthma management and follow up.
ITEM MARKS SCORE
Student should explain to the patient about PEAK FLOW
METER its parts. 1

Explain its use before and after treatment. (>12% reversibility in 1

asthma)
Student should be able to demonstrate how to use PEAK flow
meter 2

Explain how frequently it can be used and how to maintain the

1
instrument.
Importance of ASTHMA Education and how to keep asthma
under control to prevent complications like Respiratory failure 2

Communication Skill, Discussion & follow up.

2
Professionalism –Introduction, permission, Interaction,
motivation, dress, grooming and thanks 1

TOTAL SCORE
10
Comment (Weakness & strength)

Overall Performance: