Internal Medicine Examination 2019 (Rotation 5 Group 2)

Single Best Answer (SBA)

1. Mr. Ali suffers from 2 asthmatic attacks per month. His spirometry shown FEV1 of 85%.
He has no daytime or night time symptoms. What is the best way to treat him?
A. Allergen avoidance alone
B. Allergen avoidance and “as needed” used of salbutamol inhalers
C. Salbutamol inhalers daily with an inhaled corticosteroid
D. A 10 days course of oral steroid followed by daily salbutamol

2. Mrs. Mariam is a 35 years old patient who is going to be treated for active tuberculosis.
She wears soft contact lenses. Before starting treatment, you advice her to stop using
the contact lenses because they may get red-orange discoloration. Which one of the
drugs prescribed is the likely cause of this discoloration?
A. Isoniazid
B. Pyrazinamide
C. Ethambutol
D. Rifampicin

3. Mr. Lim is a 45 years old male, presents with cough and fever. His chest x-ray reveals a
consolidation on the right lung. Which of the following findings is NOT suggestive of
consolidation?
A. Dullness to percussion over the involved area of the chest
B. Crepitation over the involved area of the chest
C. Bronchial breath sounds over the involved area of the chest
D. Decreased tactile fremitus over the involved area of the chest

4. Mrs. Khatija a 23 years old woman presents with a 6 months history of increasing neck
swelling and discomfort on swallowing. On examination, she has a smooth diffuse
symmetrical goiter. Thyroid function test are normal and thyroid antibody levels are
undetectable. Ultrasound shows a diffuse and symmetrical echogenic pattern, with no
significant nodularity. Which of the following is correct in this scenario?
A. Radioactive iodine treatment should be used to shrink the gland
B. Pretibial myxedema will be noted on her legs
C. The goiter may enlarge during pregnancy
D. There is high risk of malignancy

5. Mr. Chin 43 years old man presents to his family physician with a 1-month history of
weight gain and difficulty climbing stairs. On clinical examination, he is found to have a
blood pressure of 182/85 mmHg, abdominal striae and bruising on his arms. An
overnight dexamethasone test reveals a morning serum cortisol level of 153nmol/l
(5.55μg/dl). Hich of the following would be an appropriate test investigation?
A. 24-hour urine free cortisol
B. ACTH estimation
C. High dose dexamethasone suppression test
D. CT adrenals
6. Mr. Abdullah a 58 years old gentleman felt sudden weakness of the left side of the body
while shopping in the mall. He is brought to A&E department within an hour. On
examination, he is fully conscious, pulse 80 beats per min regular, BP 170/90 mmHg. He
has complete ptosis of right eye and inability to lookup & adduct his eye towards nose.
Right pupil is dilated & does not constrict on direct & consensual light reflex. He has
paralysis of the left lower face, left upper & lower limb. CT scan of the brain, done soon
after arrival has been reported normal. What is most likely site of the lesion in the brain in
this patient?
A. Right internal capsule
B. Right midbrain
C. Right pons
D. Right thalamus

7. Miss Suhana a 36 years old teacher presented with 6 weeks of intermittent diplopia,
improved by closing one eye. The physicians has checked a variety of blood tests – all
are normal except high antibody titre to the acetylcholine receptor (AChR). Which of the
following is the next most relevant test?
A. Antibody to muscle-specific kinase (MuSK)
B. CT chest
C. Electromyography (EMG)
D. Tensilon test

8. Mr. Nikmat a 46 years old businessman felt tingling & numbness on waking up in the
morning & weakness of both lower limbs. Two days later the symptoms worsened. He
reports to his family physician who notes that his vital are normal. Lower limbs are
hypotonic, with grade 3/5 power, however, both upper limbs have 4/5 power, all deep
tendon jerk (DTJ) are absent. He has blunted sensation below both wrist & ankle. He
also has weakness of both orbicularis oculi. Which of the following is the most likely
diagnosis?
A. Infarction of cervical cord
B. Acute transverse myelitis
C. Gullian-Barre syndrome
D. Myasthenia gravis

9. A 78 years old woman with osteoarthritis and long term indomethacin therapy presents
as an emergency with a short history of dizziness and passage of black tarry stools over
2 days. Clinically, she has signs of anemia, tachycardia and hypotension. Her
hemoglobin is 5.5g/dl and her urea is 21 mmol/l (ref range <9mmol/l) with a normal
creatinine. What is the most likely diagnosis?
A. She has acute on chronic renal failure due to long term NSAID therapy
B. She has suffered a silent myocardial infarction causing hypertension
C. She has had acute lower GI bleeding from NSIAD-induced ulcer
D. She has had acute upper GI bleeding from NSIAD-induced ulcer
10. A patient with inflammatory bowel disease is commenced on azathioprine for
maintenance immunosuppression. He should undergo regular screening test to pick up
all effects of medication. Which one of the following is the appropriate advice to the
patient?
A. The patient requires an annual chest x-ray and hepatitis serology
B. To get serum amylase estimation within 1 week of staring this medication
C. The patient requires regular blood analysis to test liver and bone marrow
function
D. The patient should not conceive whilst on this medication

11. A 20 years old student with no significant past medical history presents with 1-week
history of acute lethargy and jaundice 2 weeks after returning from a week long holiday
in Myanmar. His ALT is found to over 10 000 U/l. which of the following is the most likely
diagnosis?
A. Alcoholic hepatitis
B. Hepatitis B virus
C. Hepatitis C virus
D. Hepatitis E virus

12. A 55 years old man presents to his GP with a 2 weeks history of pain in his hands. The
pain is particularly more in his right hand. On examination, brown discoloration of the
nails with onycholysis is noted. His DIPJ are tender on palpation. Which one of the
following is the most likely diagnosis?
A. Rheumatoid arthritis
B. Psoriatic arthritis
C. Gouty arthritis

13. Mr. Rohan a 30 years old clerk, present to his GP with a week history of painful, swollen
left knee and a painful right heel. He has been experiencing burning pain while urinating
for the past 2 weeks. His eyes have become red and it’s itchy but no discharge. Which
one of the following is the most likely diagnosis?
A. Septic arthritis
B. Gout
C. Ankylosing spondylitis
D. Reactive arthritis

14. Umaya, a 34 years old Afro-Caribbean woman living in Wangsa Maju, has been admitted
to KPJ Sentosa Hospital for investigation of increasing shortness of breath for 3 months.
She noticed redness on her face and itching on sun exposure areas. She has been
suffering from recurrent mouth ulcers. SLE is suspected. Which of the following auto-
antibody is most specific for the presumed diagnosis?
A. Anti-nuclear antibody
B. Rheumatoid factor
C. Anti-double stranded DNA antibody
D. Anti-centromere antibody

15. Prognostic factor of RA

A. Marginal erosion of bone
B. Rheumatoid factor
C. Increased ESR
D. CRP
16. A 47 years old teacher complaints of difficulty in maintaining her concentration at work.
She states that over the last 4 months she feels increasingly tired and has noticed a
tingling sensation in her finger. Examination shows a positive Babinski’s sign and absent
ankle reflexes. A blood test reveals this following: Hb 10g/Dl, MCV 103 fL. Which of the
following is the most likely diagnosis?
A. Hypothyroidism
B. Vitamin B12 deficiency
C. Folic acid deficiency
D. Chronic liver disease

17. A 23 years old college student presents in his GP complaining of shortness of breath
after exercise, she denies any coughing or wheezing. On examination you notice mild
pallor & brittle nails. Her blood investigation result are given below: Hb 12g/dl, MCV 70
fL. Serum iron & ferritin are within normal reference range. Hb electrophoresis shows
increased HbA2. Which of the following is the most likely diagnosis?
A. α thalassemia trait
B. anemia of chronic disease
C. β thalassemia trait
D. Hemoglobin H disease

18. A 65 years old present to outpatient department about lack of energy in the last 2 weeks.
He mentions he has been feeling excessively tired and has suffered from fevers
unresponsive to PCM. He has noticed bleeding to his gums. A blood film shows Auer
rods, hypo granular neutrophils that stains with Sudan black B. Which one of the
following is the most likely diagnosis?
A. Acute lymphoblastic leukemia
B. Afibrinogenemia
C. Disseminated intravascular coagulation
D. Acute myeloid leukemia

19. A 45 years old man is seen in the cardiology clinic for worsening shortness of breath. He
is known case of mitral regurgitation on follow up for the past 10 years. Which of the
following statement is true regarding mitral regurgitation?
A. It is associated with loud first heart sound
B. There is reversed splitting of the second heart sound
C. It is associated with third heart sound
D. Symptoms usually present early in the course of the disease

20. A 75 years old man has 2 episodes of loss of consciousness. Further investigation
reveals he has sick sinus rhythm (sino atrial disease). Which of the following is true
about this condition?
A. It is not associated with systemic embolization
B. It is associated with both sinus bradycardia and tachycardia
C. Ventricular arrythmia is common
D. Anti-arrhythmic drug is the management of choice
21. You see a 54-years old in the ward. He is admitted for dyspnea and orthopnea. The apex
is displaced and there is significant cardiomegaly on chest radiography. A provisional
diagnosis is dilated cardiomyopathy is made. With regards to this condition, which one of
the following is INCORRECT statement?
A. Pericardial effusion
B. Gallop rhythm
C. Clinical improvement following thiamine administration
D. Mural thrombus formation

22. A 45 years old man presented with a 6 weeks history of bilateral ankle swelling. On
examination his pulse is 722 bpm, BP 126/68 mmHg, JVP is not elevated and
auscultation of heart and lungs is remarkable. He has 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

23. A 25 years old man presents with visible hematuria. He reports that he had a sore throat
2 weeks previously, but is otherwise well. His BP and renal function are both normal.
Protein: creatinine ratio is elevated (100mg/mmol). Which one of the following is the
most likely diagnosis?
A. Post streptococcal glomerulonephritis
B. IgA nephropathy
C. PCKD
D. Renal calculus

24. A 60 years old with a long-standing stage 4 chronic kidney disease presents with vague
bony pain. Blood test reveals eGFR 17ml/min/1.73m2; calcium 2.92 mmol/l (normal 2.1
to 2.6 mmol/l); phosphate 1.82 mmol/l (normal 0.8-1.4 mmol/l); PTH is elevated & ALP is
470 IU/L (range: 40-125 IU/L). which one of the following is the most likely diagnosis?
A. Excess vitamin D consumption
B. Primary hyperparathyroidism
C. Secondary hyperparathyroidism
D. Tertiary hyperparathyroidism

25. ..

26. A 57 years old women with history of 5 years diet-controlled diabetes. She is struggling
to make further changes in her lifestyle. Her HbA1c is above target. Which is the best
choice for first line treatment?
A. Biguanide (metformin)
B. DDF-4 inhibitor (sitagliptin)
C. Insulin
D. Sulfonylureas (gliclazide)
27. A 30 years old housewife presents with fever of 2 days duration, she has no premorbid
illness. She has headache, abdominal pain and loose stools. Her BP is 120/80 mmHg,
pulse 90 bpm and CRT <2 seconds. You suspect she has dengue.
A. Diclofenac should be prescribed to relieve the fever and body ache
B. Dengue combo test is not helpful at this stage as is still too early in the course of
the illness
C. She can be safely managed as an outpatient as she has no warning sign
D. Close monitoring is needed as she has dengue with warning signs

28. A 22 years old male student is admitted via the medical outpatient clinic for fever, body
ache and myalgia. He is icteric. Which one of the following is the correct statement
regarding leptospirosis?
A. Splenomegaly is a common finding
B. Metronidazole is the antibiotic of choice
C. The diagnosis can be made by preferring the MAT (microscopic
agglutination test)
D. Liver failure is common

29. A 25 years old presented with 14 hypopigmented patches over her extremities for the
past 2 years. She complained of decrease sensation over the patches. Which one of the
WHO treatment guidelines should be followed?
A. 6 months treatment with dapsone daily and rifampicin once monthly
B. 6 months with dapsone and rifampicin daily
C. 12 months with dapsone and clofazimine daily and rifampicin once monthly
D. 12 months with dapsone and clofazimine and rifampicin daily

30. ..
MEQ
1. TB Meningitis
A 30 years old man has presented with headache and low-grade fever of 10
days, vomiting and drowsiness of 2 days duration. He was found HIV positive 5
years ago when investigated for recurrent herpes zoster in different
dermatomes. One examination he appeared drowsy, temperature 100
oF,pulse 56 (regular) and BP 140/76 mmHg. He had neck stiffness.

a. List 2 provisional dx. (1 mark)

Cryptococcal Meningitis, TB Meningitis
b. How to you explain headache, vomiting, drowsiness?
Raised ICP
c. General examination findings.
Drowsy, unconscious, febrile, lymphadenopathy, raised bp, tachycardia
d. CSF
Appearance – clear
Pressure- high more than 200 mm Hg
WBC increased predominant lymphocytes
Glucose decreased
Protein increased
e. 2 stains to be done
India ink (cryptococcal neoformans)
Ziehl neelsen stain (mycobacterium TB)
f. Anti TB doses and duration
Isoniazid 5mg/kg
Rifampicin 10mg/kg
Ethambutol 15mg/kg
Pyrazinamide 20mg/kg
Intensive 2 months, maintenance phase 10 months
Total for one years
g. Complications
Hydrocephalus
Stroke
Cranial nerve palsy
Seizures
2. DKA secondary with UTI
a. History
Illness begins with fever, dysuria, pain in flank
History of upper abdominal pain with vomiting
Any stressful situation
Stopped using insulin
b. General examination
Sign of dehydration
Tachycardia
Tachypnea
Low bp
High temperature
Fruity smell in breathe

c. Provisional diagnosis
Diabetic ketoacidosis with severe dehydration precipitated by UTI
d. 4 blood tests
ABG low pH <7.34
Low serum bicarbonate <15mmol/L
Ketone bodies in blood
Plasma glucose more than 14mmol/L
2 urine test
Glycosuria
Acetone and ketone bodies
e. Management
Correct dehydration
Correct hypokalemia
Correct hyperglycemia
Treat UTI
f. Complications of aggressive mx of dka
Cerebral edema
Hypoglycemia
3. Pulmonary embolism
30+ y/o lady given birth vaginally 5 days ago to healthy baby. She developed
chest pain and SOB.

A.4 differential dx for this

Acute myocardial infarction
Pulmonary embolism
Dissection aorta
Pericarditis

B. Further hx to confirm your differentials

Noticed any swelling or pain at one of lower limb
Breathlessness more than chest pain (pain out of proportion)
Marfan syndrome? Do you feel you are taller than your other siblings?
Any chest pain previously? Did you see a doctor?

2b) BP is 100/70, pulse rate is 90, prickling pain, 4/10, not worsen on deep
inspiration. No orthopnea. Calf tenderness.
D. What dx?
Pulmonary embolism
D. 4 investigations and interpretation
D dimer
CT Angiogram to see the blockage of pulmonary artery
Ultrasound of calf vein
Chest x ray

2c. Doppler showed DVT, CT Pulmonary angiogram confirm pulmonary

thromboembolism.
E. Standard tx for PTE
Low molecular weight heparin
Along with warfarin
F. One drug to prevent? And what side effect
Warfarin side effect bleeding tendency
G. How to monitor that side effect.
Monitor INR
H. How to prevent recurrent Pulmonary embolism?
Vena cava filter
SEQ
1. HEPATIC ENCEPHALOPATHY
a. CNS findings
b. Pathophysiology
c. Investigation
d. Treatment

2. PNEUMONIA
a. Types and classifications
b. Signs and symptoms
c. Diagnosis
d. Type of antibiotics
e. Complications

3. OSTEOPOROSIS
a. Definition & Pathophysiology
b. 4 risk factors in women
c. Differences between osteoporosis and osteomalacia

4. RHEUMATOID ARTHRITIS
a. Pathophysiology
b. Diagnostic criteria
c. Diagnostic investigation
d. Treatment
e. Manifestations & complications:
i. CNS (2)
ii. CVS (1)
iii. RSP (1)

Interactive OSCE
1. Female pt with hyperthyroid symptoms treated with carbimazole for 3 months come for
follow up.
a) Examine thyroid (general and systemic examination)
b) Based on examination, state the current condition of patient
(hypo/eu/hyperthyroidism

2. Patient with COPD

a) counsel about COPD
b) how to manage (pharmacological and non-pharmacological)
c) risk of cigarette smoking
Digital Osce
1. Lung carcinoma- Right sided consolidation/ patchy opacity
a. Describe the abnormalities of the lung
b. i. Diagnosis
ii. Differential Diagnosis
c. List 3 definitive investigation
d. Management

2.

a. List the abnormalities in the ECG

prolonged PR interval in lead…..
T inversion in lead V1 – V3
b. What is your diagnosis based on the ECG?
Anteroseptal myocardial ischemia with heart block
c. Investigations and their expected findings
d. Management in ICU. List the 6 drugs
3.

A B

a. Describe pic A and Pic B

podagra and tophi
b. Diagnostic investigation
c. Not sure
d. Treatment for acute and long term
Acute- NSAIDs.. Diclofenac, ibuprofen
Long term.. Allopurinol and colchicine

4.

a. List 2 abnormalities seen in scan

grossly enlarged bilateral kidney
cystic kidney lesion
b. State your diagnosis
PCKD
c. Mode of inheritance
vertical transmission.. Autosomal dominant and very lil autosomal recessive
d. List 4 common manifestations of this disease
Palpable painless lump, raised BP, hematuria, CKD features….
e. List 1 common CNS associated with this disease
Berrys anuerysm
5.

Hx chronic loose stool for 5 years. No blood in the stool

a.Describe histology
loss of villous and hyperplasia of the villi
b. Dx- Celiac disease
c. Ix
d. Name the skin lesion found in this patient.
Dermato lesion (Dermatitis herpiticus)
e. What dietary advice would you give ???

6.

A middle age women’s pic with history of lack of interest told by the husband
a.Describe 2 abnormalities
b. DX- hypothyroidism
c. 2 test (one to confirm and another to exclude the other cause
d. treatment, dosage and duration
7. Pic of peripheral blood smear given
Came with history of fever for 10days
a. What is the diagnosis
b. List 2 abdominal finding
c. List 4 clinical features
d. write a prescription for the patient(drug, duration and dose)
nucleated RBc – Malaria

8.

loo

jbebfubqvu