MD2 2016 Recall Exam

QUESTION 1 (20 marks)

A 67 year old female patient presents to her GP for a repeat prescription for antihypertensives. She is currently treated with perindopril and amlodipine (5mg). The GP measures her BP to be 156/90, with a regular pulse at 88bpm. She repeats the BP measurement 5 minutes later to find BP at 170/110 with a regular pulse rate of 95 bpm. The patient also has a visible neck mass on the left lobe. The patient reports this has been present for around 1 year but isn’t too worried about it and is vague on the details. Aside from this, she has an otherwise normal cardiovascular examination and no peripheral oedema. On examination, the neck mass is diffusely enlarged on the left side and moves with swallowing.

  1. List 8 things you may ask on further history in relation to her suspected thyroid condition (4 marks)

  1. List 8 things on further history you might ask for in relation to the thyroid mass? (4 marks)

  1. List 4 things on further examination you might look for in relation to the suspected thyroid condition? (2 marks)

  1. What are 4 further examination findings you would look for in regards to the thyroid mass, and what do they tell you? (4 marks)

Exam finding

Meaning

  1. What are the 4 most important investigations to perform on this lady with suspected thyroid problems with a brief explanation of their importance? (4 marks)

  1. How would you manage this patient’s hypertension? (2 marks)

QUESTION 2 (20 marks)

72M male presents with RUQ and epigastric pain. He states he has no chest pain. He has a past medical history of hypertension, diabetes and AF. His vitals were HR 110, BP 90, RR 20, temperature 38.2.  

  1. Name FOUR (4) things from the history given that put him at increased risk of it being a cardiac cause for pain and name TWO (2) investigations you could do to rule out a cardiac cause (4 marks)

  1. What are THREE (3) features on examination other than those already described that would suggest he’s critically unwell? (3 marks)

  1. Interpret the ABG and explain why the patient may have these results. (3 marks)

Patient

Reference

Patient

Reference

Pao2

80

80-100

Lactate

6.1

0.3-0.8

pH

7.32

7.35-7.45

Na+

143

135-145

CO2

32

35-45

K+

5.5

3.5-5

HCO3

17

22-28

Cl-

106

96-106

Base excess

-7

(-3 - +3)

Creatinine

105

60-100

The surgical registrar sees the patient and books him in for a laparoscopic cholecystectomy for gangrenous cholecystitis.

  1. Why is it important that he has urgent surgery? (2 marks)

  1. What are 3 things that are important to ask on history prior to surgery? (3 marks)

The theatre will be available in 30 minutes.

  1. How will you manage the patient whilst waiting to go to theatre? (5 marks)

QUESTION 3 (20 marks)

A 24 year old female presents with a 24hr history of epistaxis and a rash on her ankles and mouth. She reports having a one week history of fatigue and exertional dyspnoea. On examination, she appears pale with pale conjunctiva and a petechial rash. Her BP is 100/60 when lying, and drops to 85/50 when standing. She has a temperature of 38.7C.
 

  1. Name three differential diagnoses for this presentation and for each give ONE additional feature on history and ONE on exam that would support the DDx. (9 marks)

Differential

History

Exam

  1. List four findings on FBE and blood film that would support a diagnosis of acute leukaemia (4 marks)

Her coagulation studies come back as follows:

Platelets

5

APTT

Increased

INR

4.2

Fibrinogen

0.1

  1. What is the above coagulation disorder called? (1 mark)

This is the patient’s blood film showing APML:

  1. What are TWO features on the above blood film giving the diagnosis? (2 marks)

  1. What are the main things you would do in the emergency management of this patient? (4 marks)

QUESTION 4 (20 marks)

A 46 year old woman presents with 24 hours of constant left iliac fossa pain.

  1. List THREE (3) causes of lower left iliac pain along with TWO findings on history and TWO findings on examination for each differential diagnosis. (9 marks)

DDx

History

Examination

1.

1.
2.

1.
2.

2.

1.
2.

1.
2.

3.

1.
2.

1.
2.

The following is the woman’s CT scan: Shows acute diverticulitis with small adjacent collection and pocket of free gas

  1. What are the distinct findings on the above CT? (2 marks)

  1. What is the diagnosis? (1 mark)

  1. Explain the pathophysiology of the diagnosis mentioned in c). (6 marks)

  1. What are the important steps in the immediate management of this patient? (2 marks)

QUESTION 5 (20 marks)

A 28 year old man came into the GP overwhelmed because of ‘lots of blood’ in his urine. He had just come back from Singapore 3 days ago where he had a flu like illness (sore throat, fever) . He went to the doctor there who said he had “early pneumonia” and gave him some medications (antibiotics and anti-inflammatory). He is still taking the medications now. He had no dysuria and no urgency. On examination, his chest is now clear.

  1. Name EIGHT things you would ask to clarify on history & their significance. (4 marks)

Feature on history

Significance

  1. Name three pathological processes that may be causing this man’s symptoms (3 marks)

  1. Name 6 investigations you would perform, and explain how they help to determine the diagnosis. (3 marks)

Investigation

Significance

  1. This man has a probability of developing chronic kidney disease. Name FIVE (5) investigation results used in the diagnosis of chronic kidney disease. (5 marks)

QUESTION 6 (20 marks)

A 40 year old man presents to the ED with 24 hours of headache. It is suspected that he has acute bacterial meningitis.

  1. List TWO further features of the headache, THREE further features on history and THREE clinical signs consistent with acute bacterial meningitis (8 marks).

Further features of headache

1.
2.

Further features on history:

1.

2.

3.

Clinical signs

1.

2.

3.

  1. List TWO clinical signs of raised ICP (2 marks).

They decided to do a CT before proceeding onto lumbar puncture to rule out any causes of raised ICP.

  1. Name TWO drug classes (specific drug names not needed) important in the immediate management of bacterial meningitis (2 marks).

  1. When should these two drugs be given? (indicate with a cross on a timeline below) (1 mark):

|---Presentation-----clinical assessment-----CT scan-----CT results-----LP-----LP results---|

  1. Fill in the following table with CSF findings for bacterial and viral meningitis (normal values are provided) (5 marks).

Bacterial meningitis

Viral meningitis

Normal

Appearance

Clear

Number of white cells (use greater than X, less than Y, between X and Y)

0-5 is normal

Main type of cell

Protein (use greater than X, less than Y, between X and Y)

< 3

Glucose (low, normal, high)

>60% of serum glucose

  1. What are the TWO most likely causative agents of bacterial meningitis in this patient (2 marks)?