GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

Internal Medicine Examination 2019 (Rotation 4 Group 3)

SBA
1. Mrs Lee a 64 year old retired nurse is admitted with abrupt onset of
neurological deficit. She is an old case of type2 diabetes mellitus &
dyslipidemia. The referring physician suspects a brainstem stroke.
Which of the following combinations of signs and symptoms would be most
likely to originate from a brainstem lesion?
A Bilateral optic neuropathy
B Cranial nerve signs with sensory and upper motor neuron signs in
all four limbs
C Horner’s syndrome with ipsilateral arm pain
D Upper motor neuron signs in both legs only

2. Mr. Charles 34 years old salesman is admitted with worsening weakness in

both legs. Over the course of 3 days he has found it increasingly difficult to
walk upstairs. In the last 12 hours he complains of feeling mildly breathless.
The referring physician finds weakness in all four limbs and cannot elicit
reflexes. There is blunting of sensation up to ankle.
Which of the following is the likely diagnosis?
A Acute transverse myelitis
B Inflammatory myopathy
C Guillain–Barre syndrome (GBS)
D Myasthenia gravis

3. Mr. Samy 18 years old student has been home from university for 3 days,
during which time he has become increasingly drowsy. He is able to be
roused but is disorientated. He has a temperature of 39°C, has marked neck
stiffness and a positive Kernig’s sign. He has developed, on-blanching rash
over his anterior chest wall. He has no focal neurological deficit.
Which of the following is most appropriate next course of action?
A Carry out a lumbar puncture.
B Arrange for a computed tomography (CT) brain scan.
C Administer Intra venous ceftriaxone
D Puncture one of the purpuric lesions for microscopic analysis.
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

4. Mr Goh a 45 years old lorry driver presents with a 6-week history of bilateral
ankle swelling. On examination his pulse was 72 beats/min, blood pressure
(BP) 126/68 mmHg, jugular venous pressure (JVP) was not elevated and
auscultation of heart and lungs was unremarkable. He had no stigmata of
chronic liver disease.
Which of the following is the most appropriate initial investigation?
A Abdominal ultrasound scan
B D-dimer
C Echocardiogram
D Urinalysis

5. Mr Hamid a 25 years old lab technician presents with visible hematuria. He

reports that he had a sore throat 2 weeks previously, but is otherwise well. His
blood pressure and renal function are both normal. Protein: creatinine ratio
was elevated (100 mg/mmol).
Which of the following is the most likely diagnosis?
A Bladder cancer
B IgA nephropathy
C Post-infectious glomerulonephritis
D Polycystic kidney disease (PKD)

6. Mrs. Ayisha a 60 years old lady was diagnosed end stage renal disease two
years ago. Since then she has been undergoing haemodialysis thrice a week.
Of late she is complaining of bone pain. She was prescribed tablet calcium
gluconate but it has not given her any relief.
Which of the following can improve her symptoms of bone pain?
A Inj erythropoietin.
B Tab calcium carbonate.
C Calcitonin.
D Tab 1,25 hydroxy cholecalciferol.

7. A 22 years old woman presents with a few weeks’ history of malaise and
weight loss. On clinical examination she has palmar hyperpigmentation.
With which investigation should she be followed up?
A Dexamethasone suppression test
B Magnetic resonance imaging (MRI) abdomen
C Thyroid function tests
D Synacthen test (ACTH ) stimulation test
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

8. Ms Surayah Begum a 26 years old office attendant seeks advice for

symptoms of weight loss, palpitations and troublesome tremor. She delivered
a baby 12 weeks ago. Her thyroid function revealed grossly reduced TSH &
raised free T4 & T3.TSH receptor antibody (TRAb) levels are not elevated.
Which of the following is the most appropriate management?
A Treat with selenium
B Consent for radioactive iodine
C Commence propranolol
D Perform ultrasound scan

9. A 72 years old man with known pituitary adenoma is admitted as an

emergency with sudden-onset headache, and visual disturbance. He is found
to have bilateral ptosis. MRI imaging shows expansion of the tumour size
secondary to hemorrhage, with invasion of the cavernous sinus.
Which of the following sets of cranial nerves (CNs) are found in the
Cavernous sinus?
A CN II and III
B CN III and IV
C CN III, IV, V and VI
D CN X, XI and XII

10. A 24-year old Malaysian student went to one of South Eastern Asian Country
on vacations. Four days after his return to Malaysia he developed large,
watery stool. There was no blood or mucous in it. He felt bloating sensation.
On examination he was afebrile, pulse 98/min, lips mildly dry, abdomen soft &
non tender.
Which microbe is likely to be seen on examination of stool?
A Giardia lamblia
B Strongyloides stercoralis
C Vibrio cholerae.
D Entamoeba histolytica

11. A 40- year old man was diagnosed cirrhosis of liver with portal hypertension 2
years ago when he was investigated for melena. An Upper G I endoscopy had
revealed oesophageal varices. Now he has been admitted with massive
hematemesis in a peripheral hospital. Which drug can keep the variceal
bleeding under check for 24 hours While arrangement of evacuation to a GI
centre is being made?
A Octreotide.
B Propranolol.
C Vasopressin
D Norepinephrine
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

12. A young man has reported with following serology results: Hbs Ag positive,
anti HBc positive, IgM anti HBc negative & anti Hbs negative. Which one is
likely to be the correct answer?
A Immune due to natural infection
B Acutely infected
C Chronically infected
D Susceptible to infection

13. A 32-year old woman has presented with fever, malaise and skin rash on
exposure to the sun for four weeks. On examination the positive findings
include an ulcer in the mouth & alopecia areata. The joints are mildly tender.
To arrive at diagnosis the specific blood test would be
A Anti-nuclear cytoplasmic antibodies (ANCA)
B Anti- ds DNA
C C-ANCA.
D Antinuclear antibodies (ANA).

14. A 23-year-old man presents to the medical clinic with lower back and hip pain.
These have been occurring every day for the past six months. Pain and
stiffness are worse in the mornings. Recent blood tests organized by his GP
have shown a raised C-reactive protein (CRP) and erythrocyte sedimentation
rate (ESR). His GP is suspecting him of Ankylosing spondylitis. What is the
most likely complication he may have in future?
A Restrictive lung disease
B Obstructive lung disease
C Myocarditis
D Aortic stenosis

15. A 34- year old woman noted stiffness of her legs & difficulty in climbing down
the stairs for the last four weeks. She has been experiencing pain at the nape
of neck & restriction of neck movement for the same duration. On examination
the primary care physician noted that patient had symmetrical swelling of both
wrists, MCP & IP joints. She had mild ulnar deviation of hands. Neurological
examination showed brisk DTJ in all four limbs & extensor plantar response.
Which disease can explain the above?
A Reiter’s disease
B Psoriatic arthritis
C Gouty arthritis
D Rheumatoid arthritis
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

16. A 28- year old woman has been suffering from menorrhagia for the last 10
months. The gold standard investigation to prove iron deficiency anemia is
A bone marrow staining for iron stores
B serum iron level
C total serum iron binding capacity.
D serum ferritin level

17. Which one of the following is NOT a feature of metabolic syndrome?

A. Ischemic heart disease.
B. Hypertension
C. Hyperlipidemia
D. Insulin resistance

18. A 24-year old man was found to have icterus, spider nevi, ascites & firm liver
3 fingers below right costal margin. The ascitic fluid was transudate. Serum
albumin was 15gm/L, INR was 2.66. He has not undergone any surgery/blood
transfusion. Serum ceruloplasmin level was low. He consumes 350 ml of beer
thrice a week for last 4years.
Which disease can explain his illness?
A Hepatocellular carcinoma
B Wilson’s disease
C Metastasis in liver & peritoneum
D Chronic alcohol abuse

19. 19.A 26- year old man was treated for Plasmodium vivax malaria with
chloroquine. He became afebrile & felt better. Next day primaquine was
started. On the 3rd day of this therapy he felt dizzy & weak. On examination in
A&E department he looked pale, had mild jaundice & urine appeared red. His
Hb had fallen from 12 gm/dl to 10 gm in a week.
The above case scenario suggests
A primaquine induced intravascular hemolysis
B bone marrow suppression
C autoimmune hemolytic anemia
D gastric erosion due to drugs used in the treatment
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

20. A 22- year old man reported to the primary care physician for painful ulcers in
the mouth. The medical officer noted raised, wavy, hairy white lines on side of
tongue & thrush on the soft palate. He had multiple apthous ulcers over gums
& soft palate. On leading question patient admitted that he is promiscuous &
does not practice safe sex.
The patient should be investigated for?
A Secondary syphilis
B Kaposi’s sarcoma
C HIV
D Oral cancer

21. A 30-year old patient has been suffering from chronic productive cough &
dyspnea on exertion. On examination he had grade 2 clubbing of fingers &
auscultation of chest revealed coarse crackles over left upper axillary
region.
The likely diagnosis is
A pleural effusion
B bronchiectasis
C COPD
D interstitial lung disease (ILD)

22. A 65 years old male presented with painful blisters distributed along left
thoracic dermatome for the past 3 days. Which one is specific drug to treat
this disease?
A Iitraconazole
B Acyclovir
C Prednisolone
D Cloxacillin

23. A 48 -year old man reported to medical OPD for lethargy & general weakness
of 3 months duration. He had undergone partial gastrectomy 4 years ago for
gastric carcinoma. He was administered chemo& radiotherapy at that time.
On examination he looked pale. Both ankle jerks were absent.
Which one is the most likely cause of his anemia?
A Recurrence of gastric carcinoma
B Bone marrow suppression due to chemo & radiotherapy
C Vitamin B12 deficiency
D Folic acid defeciency
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

24. A 33 years old male presented with red plaques with white scales over both
elbows and knees involving <10% of BSA.
Which one of the following is the most likely drug to treat her skin lesion?
A PUVA therapy
B Oral methotrexate
C Topical steroids
D Oral steroids

25. A 58 years old man was treated for acute myocardial infarction in HKL 4
weeks ago. For the last 2 weeks he has been breathless on exertion. On
examination a soft a pan systolic murmur is heard over precordium which
increases during expiration accompanied by soft first heart sound. JVP is not
raised.
Which one of following is the most likely diagnosis?
A Ventricular septal defect
B Pulmonary regurgitation
C Tricuspid regurgitation
D Mitral regurgitation

26. A 48 years old foreign worker was admitted in GH KL with difficulty in

breathing for the last 2 months. He has had no significant past illness. On
examination he had central cyanosis and clubbing of fingers. Prominent V
waves were seen in the neck, ejection systolic murmur in pulmonary area and
pan systolic murmur in left lower sternal edge. X-ray chest showed prominent
pulmonary artery. ECG showed partial right bundle branch block.
The likely diagnosis is
A Eisenmenger complex due to reversal of ASD shunt
B Congenital pulmonary stenosis
C Fallot’s tetralogy
D Transposition of Great Arteries

27. A 68 years old man is admitted with breathlessness & chest discomfort of
6hours duration. The underlying cause is aortic stenosis
Which sign is most likely to be present on clinical examination of this patient?
A Collapsing pulse
B Raised JVP
C Palpable thrill in mitral area
D Crackles over both lung bases
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

28. 43-years woman complaints of cough & low-grade fever for three months. On
examination, there is multiple erythematous tender swelling over shin of both
legs & pink rash over tip of her nose. She has enlarged cervical lymph nodes
which are soft & non tender. Histopathology of biopsied lymph node shows
non caseating granuloma.
The likely diagnosis is
A Tuberculosis
B HIV
C Sarcoidosis
D Hodgkin lymphoma

29. A 56 years old heavy smoker was admitted in HKL for acute exacerbation of
COPD. He had fever & change in the color of septum. His blood count
showed leukocytosis with predominance of neutrophils. X-ray chest showed
ill-defined opacity in lower zone.
The most likely microbe to cause the lung infection seems
A Staphylococcal aureus
B Mycoplasma pneumoneae
C Legionella pneumophilla
D Hemophylus influenzae

30. A 54 years old gentleman was treated for pulmonary tuberculosis one year
ago. Now, he has cough & hemoptysis of 1 week. Sputum examination shows
aspergilus fumigatus.No AFB seen. The most appropriate drug treatment is
A Azithromycin
B Oflaxacin
C Amphotericin B
D Cotrimoxozole

SEQ
1. Write a short note on hyperkalemia based on the following heading
a. Aetiologies (2m)
b. Clinical features (2m)
c. Investigations (2m)
d. Treatments (4m)

2. A 26 years old man is a drug abuser for the last 2 years. 3 days ago he
was admitted in acute medical ward on suspicion of respiratory and
cardiac complications associated with iv drug abuse
a. Respiratory signs and symptoms (2m)
b. CVS signs and symptoms (2m)
c. Investigation for lung infections (2m)
d. Diagnostic investigation for the cardiac lesion (2m)
e. Treatment for cardiac lesion you want to suggest as a HO (2m)
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

3. Write a short note on Rheumatoid Arthritis based on the following heading

a. Pathophysiology (2.5m)
b. Diagnostic Criteria (ANA) (2.5m)
c. Differential Diagnosis (2.5m)
d. Treatment (2.5m)

4. Write a short note on Chronic Kidney Disease based on the following

heading
a. 4 etiopathology (2m)
b. Classification according to GFR (2m)
c. Clinical features (2m)
d. Renal replacement Therapy (2m)
e. Treatment for anemia and bone related disease in CKD (2m)
MEQ
MEQ 1
SECTION A
A 56 years old man came with progressive non painful abdominal enlargement for 2
months duration.
1. Give 3 differential diagnosis
2. 7 points for focused history

SECTION B
On further history he had jaundice for 3 weeks. He was treated last year for
hematemesis. He consumed 180ml whiskey thrice daily for past 10 years. On
examination he has jaundice, duputyren contracture, spider angioma, gynaecomatia.
Abdomen is distended, flank full, umbilicus flattened. The abdominal veins are
prominent. Tenderness of the abdomen upon palpation, liver and spleen are not
palpable.
1. State the diagnosis
2. Give 4 investigations with interpretations for his condition.

SECTION C
Diagnosis consistent with liver cirrhosis and portal hypertension. OGDS shown
esophageal varices.
1. 4 complications of liver cirrhosis
2. Management of hepatic encephalopathy.
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

MEQ 2
SECTION A
32 y/o woman while watching TV, suddenly loss power at the Right Upper & Lower
Limbs in a matter of 2-5 minutes to such extent that she was not able to move
fingers & toes, & her mouth was pulled to the other side. She had problem in
speaking.

1. Clinical impression
2. Further history that you will elicit from this patient to know extend of
neuro deficit.
3. List 2 findings on General Physical Examination

SECTION B
On examination she had irregularly irregular pulse, BP: 180/90 mmHg. She
understood conversation but spoke few meaningful words. She had Right hemiplegia
with hypotonia, grade 0/5 power, extensor plantar response. Heart and lungs were
normal.

1. Significance irregularly irregular pulse in this patient. Elaborate.

2. Interpretation of speech function in this patient.
3. What is the explanation of hypotonia and reduced DTJ with extensor
plantar response
4. List 2 Ddx of acute hemiplegia
5. List 1 Investigation to confirm diagnosis in this patient

SECTION C
Urgent CT brain was done. It was reported as normal.
1. Discuss how will you manage this patient
2. What advice you will give on discharge to the patient and attendant?
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

DIGITAL OSCE
EXHIBIT 1 (LEFT ISCHEMIC STROKE)
Picture of a CT scan of the brain of a 60 years old lady.

1. State 2 abnormalities
2. What is the diagnosis
3. Area affected
4. What are the signs seen in this patient
5. List the risk factors of the disease.

STATION 2 (PTB)
This is a chest x-ray of 34 years old patient who complaint of fever and
hemoptysis for 3 weeks

1. Describe 2 abnormalities
2. Diagnosis
3. 4 investigations to confirm diagnosis
4. Write 4 drugs with 1 complication each
5. 1 complication
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

STATION 3 (ANTERIOR NSTEMI)

This is the ECG of 66 years old 66 years old man with chest pain

1. Abnormal findings
2. Diagnosis
3. 3 specific investigations performed
4. 6 treatments

STATION 4 (UC)
A 24 years old lady has been having recurrent loose motion and discomfort in
the left lower abdomen for the last 5 years. She has been passing blood and
mucus in the stool. She has loss of weight. A colonoscopy was done by
gastroenterologist. One of the views is shown.

1. Describe 2 abnormal finding

2. What is the diagnosis
3. Which area will be affected in GI tract
4. Other similar diagnosis
5. 4 extraintestinal manifestation
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

STATION 5 (PCKD)
This is picture of CT scan abdomen of the patient who presented with
recurrent attacks of pain flanks.

1. List 2 abnormalities seen in scan

2. State your diagnosis
3. Mode of inheritance
4. List 4 common manifestations of this disease
5. List 1 common CNS associated with this disease

STATION 6 (CUSHING SYNDROME)

This lady came with complaint of gaining 20kg weight in one year and easy
bruising of the skin. She also complained of difficulty in getting up from low
chair. This is the photograph of the abdomen.

1. State 2 abnormalities
2. Give 2 abnormalities upon general physical examination
3. What is the diagnosis
4. 3 investigations to diagnose
5. 3 biochemical abnormalities
6. 3 etiologies
7. Treatment
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

STATION 7 (RHEUMATOID ARTHRITIES)

This is a photograph of patient’s hand

1. List 4 abnormalities
2. What is the diagnosis
3. List 4 ARA Criteria
4. 2 Disease Modifying Drugs

STATION 8 (CELLULITIS AND TINEA PEDIS)

Picture A shows 40 years old male with painful swelling on left foot for 3 days.
Picture B shows the lesion between the toe web space.

1. Describe the skin lesion in Picture A and B

2. What is the diagnosis of Picture A
3. What is the diagnosis of Picture B
4. Investigation for diagnosed Picture B
5. Name one topical and one systemic drug for Picture B
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

INTERACTIVE OSCE
SETTING- CHEST OPD
CLINICAL DATA- A- 30 year old patient, known case of asthma for 10 years, came
to see you for his asthma. He gets up every night due to asthma and had missed
work several days in a month. He uses salbutamol almost every day.
TASK FOR THE CANDIDATE
Counsel him under the following issues:
A) Explain to him his level of asthma control.
B) How will you manage his asthma?
C) Explain the non-pharmacological management of asthma.
D) Advise patient on written asthma action plan.

ITEM MARKS SCORE

Bed side manners: 1
Greeting, introduction, explain and consent. (0.25/response)
Say thanks
Explain his level of asthma control: Well 2
controlled, partly controlled and uncontrolled, using
day time symptoms, night awakening, reliever use
and limitation of activity
How will you manage his asthma: Use of 2
moderate to high dose of asthma with SABA PRN,
if not controlled to add LABA/ICS with SABA (step
wise treatment)

Non pharmacological management of asthma:

1. Smoking cessation
2
2. Vaccination
3. Breathing exercise
4. Weight loss, caffeine intake
Explain about written asthma plan based on
PFM reading:
1. Green: Maintain same medication
2. Yellow: Continue maintenance and increase 3
reliever every 20 minutes for an hour
3. Red: Have used more than 8 puffs of reliever a
day and still not better. Take rescue
prednisolone and go to hospital
 GROUP 3 ROTATION 4 INTERNAL MEDICINE POSTING

10
TOTAL SCORE
Comment (Weakness & strength)

Overall Performance:

CASE SCENARIO
“A 38 years old gentleman presented to the hospital with pain and tingling sensation
over the right cheek for the last 3 months.”
Action undertaken by the student/Tasks Marks Students
S.N performed allotted score
o.
1. Introduces himself & Takes permission to 0.25
2. examine to the patient about tests he is going
Explains 0.25
examine
to do the patient
3. Cleans his hand with antiseptic soln. 0.25
.
4. Thanks the patient at the end of examination. 0.25
5. Tests sensory function in 3 divisions of 5th CN
a Ophthalmic 1
b Maxillary 1
c Mandibular 1
6. Tests 3 sets of muscles supplied by 5th CN
a Temporalis 1
b Masseter 1
c Pterygoids 1
7. Checks for Corneal reflex 1
8. Checks for jaw jerk 1
10. What is your diagnosis? 1
Total marks 10

TASK TO BE PERFORMED BY THE CANDIDATE

Do the appropriate clinical examination.
State your diagnosis at the end of examination
Time - 5 minutes