}. A 60-xear-old male patient presents witha 3. A Gb-year-old male patient presents with epigasc dscomfor, anorexia and weight loss of 6: ‘months duration. Initially these complaints were dismissed by his doctor. Later he noticed Yellow discoloration of urine and conjunctiva for the !ast two months. The jaundice is painless and progressive. There is no history of waxing and waning of symptoms. At present he complaints of generalized itching for the last 1 month. He passes clay-colored stools for the last two months. He isa recently detected diabetic. He is aheavy smoker for the last 50 years. On examination he is ill built and cachexic. The sclera is yellow orange in color (deeply Jaundiced). Scratch marks are seen in the abdomen and chest. Abdominal examination revealed a globular mass below the costal margin in the midclavicular line impinging upon the examining hand on inspiration of about 10 4.em size. The mass is visible and moving up and down with respiration. This mass is better seen than felt and better palpated by superficial palpation than deep palpation. The liver is palpable about 4 cm below the costal margin. It is firm in consistency, the edges are sharp and the surface is smooth. There is no other palpable mass in the abdomen. There is no free fluid. Digital rectal examination is normal. There is a hard mobile lymph node in the left supraclavicular area between the two heads of sternomastoid muscle. > A) What are your four points in favor of obstructive jaundice? [4] B) What is the definition of jaundice? 2 ©) What are the types of jaundice? 4] D) List four causes of obstructive jaundice (4) B) What is Courvoisier’s law? 14] F) What is the surgical treatment of gallstones? 2) lipg in the right inguinoscrotal region of 2 years duration, He also complains of dragging and aching sensation in the groin, He is a chronic smoker with bronchitis. For the last 2 years, he has difficulty in passing urine. He must get up 3-4 times every night for this purpose. There is no history of chronic constipation, abdominal pain ot vomiting. He says the swelling is present only during standing position and it will disappear as soon as he lies down. On examination, there is large pear-shaped swelling seen above the crease of the groin and medial to the pubic tubercle of 8 = 4 em size. The swelling Page 2 of 3A) Why is this a hemia? B) What is the definition of hemia? ©) What are the par nveen direct and indirect inguinal hernia? emia from femoral hernia? in children? Answer the following questions concerning intestinal obstruction (10). ‘A)-bist four cardinal features-of intestinal obstuction B) How do you differential small bowels from large bowels in 10? C) State the causes of dehydration in 10 D) Give three causes of paralytic ileus E) What is obstipation? F) Why are antibiotics given in patients with 10? THE END 4) 2] 4) ‘umference of the viscus is forming the content [2] rea ico 2 tt 4) 4] Bl GB) 2] Page 30f3\ ANSWER ALL QUESTIONS IN THE ANSWER BOOKLET PROVIDED. 3 A 40-year-old female patient presents with a painless lump in the right breast of 6 months duration, which she noticed while washing. There is no history of backache, dyspnee, pleuritic ain or jaundice. There is no family history of carcinoma breast. The patient attained menarche at the age of 13 years. Her menstrual cycles are régular. Her first child birth was at the age of 30-years. She has two children and both were breastfed. On raising her hands above her head, there is visible asymmetry of the breast (right breast is more prominent and distorted). There is retraction of the nipple on right side and it is at a higher level. Areola is normal. There is no discharge from the nipple on right side and it is at a higher level. The skin overlying the breast is normal. There is no peau d’ orange appearance or ulceration or edema. On palpation the lump is 4 «3 cm size, stony hard in consistency in the upper outer quadrant of right breast. ‘The lump is fixed to the breast. but there is no fixity to the skin or pectoral muscles, There is @ mobile, firm pectoral node palpabie in the right axilla. Supraclavicular fossa and right arm are normal. Contralateral breast, axilla. and supraclavicular fossa are normal. There is no evidence of hepatomegaly or ascites on exam the abdomen. There is no evidence of pleural effusion or consolidation on exami ‘Skull and spine are normal. Pelvic examination is ur of the diagnosis of cancer of the breast? [3] 6) C) Give four predisposing/risk factors for cancer of the breast [4] D) How will you proceed to investigate such a patient? {6} B)-What is the first investigation of choice? PI F) What is the surgical treatment of choice in this patient? 2) ‘4 days duration. 'y morning hours. This 2 few days. She felt to the right iliac 2. A 25-year-old female patient presents with history of abdomin Initially the pain started as a vague central abdominal pai pain was preceded by loss of appetite. The patient was c: nauseated and vomited once on the first day of pain. Later the pain fossa. Her pain is aggravated by moving and coughing. The married and has two children. Her mensirual cycles are regular having normal blood flow. Her last menstrual period was 6 days back. There is no history of discharge from vagina. On examination the patient looks pale. There is mild pyrexia. The tongue is.futred and there is fetor oris (halitosis). Her pulse rate is 90 per minute. Abdominal examination revealed a tender mass of 16 * 9 cm size in the right iliac fossa with overlying muscle guard andrrigidity confined to the right iliac fossa. There is no intrinsic movement for the mass and all the borders are well made out except the lateral border. The mass is intra-abdominal and intraperitoneal. There is no extension of the mass below the inguinal region. The rest of the abdomen is soft and nontender. There is no free fluid demonstrated. The bowel sounds are; normally heard. On digital rectal examination, the patient complained of pain deep in the pelvis and the mass is palpable per rectum. On vaginal examination movement of the cervix did not cause pain. Other systems are normal. Page 1 of 31. Document comprehensively how you will conduct the full clinical assessment in a systematic way and clearly list all subheading and other details. 2. What could be the predisposing risk factors for this medical condition? ‘-qWhat information will you collect in the patient family history? ° -4. What is the possible diagnosis? 5. Explain the pathophysiology of the patient medical condition? 8. What investigations will do in this patient? 9. How would you manage this patient? 10. What kind of advice will you give to him and the family about his condition? QUESTION THREE duty and inform the consaltant of your firm about Mr Phiri’s condition, he then instructs you to conduct neurological examination of the Patient. Kindly answer the following questions: 1. Take and discuss the fall neurological history 2. Discuss the full neurological examination of this patient 3. Describe how you will examine the cranial nerves from I to XII 4 Give differential diagnosis taking into account medical condition which could cause facial asymmetry : 5. What are the risk factors of this medical condition? 6. Give a brief classification of this medical condition 7. Describe and explain how you will Conduct motor examination in this patient 8. What investigations will you drder or conduct to establish the cause of the weakness? : 9. How would you manage this condition? 10. As the doctor on duty, describe how you will conduct conselling and explanation of mr Phiri’s condition to him and the family Page 2 of 3ANSWER ALL QUESTION ONE L Mrs Mathilda Phiri, a 61-year-old Mansa resident presents with a two-weeks history of easy fatigability and palpitations. She has been hypertensive for the past 15 years. She feels that over the past two weeks, her condition is getting worse and can’t now sweep her own house. She went to seek medical advice at Serenje District Hospital where you are the medical licentiate on duty. You inform the medical officer in charge about her then he instructs you to conduct clinical assessment of this patient. Kindly answer the following questions: 1. Document comprehensively the fall clinical assessment in a systematic way and clearly list all subheading and other details. 2. What kind of information would you collect in the social history related to the Patient clinical presentation? , 3. What would be the difference between the content of the history of presenting complaints and past-medical history during this patient clinical assessment? 4 What is the Summary of this patient medical problem which you will present during the post admission round? S. Using critical thinking and critical analysis, what will be your working diagnosis? 6. What is the pathophysiology of the condition the patient is suffering from? 7. The patient’s relatives ask you for explanation of what could have suddenly made her condition worse during the past two week? What factots could explain the sudden deterioration of her health? 8. The patient asks why she has been experiencing fatigue to conduct activities which were part of her normal routine, what would you tell her? 9. The patient has been complaining of palpitations, during the round the consultant ask you to define palpitations, what would you tell him? 10. Explain how you will manage this patient medical condition QUESTION TWO i Mr Peter Silungwe, a 62-year-old male, a Petauke tobacco farmer presents to Chipata General Hospital daring your clinical rotation with history of chest pain. ‘The patient recalls that a clinician préscribed some tablets to him last time he had similar pain, which he was also feeling in his left arm. He is known hypertensive for the past 10 years. The Nurse calls you as the clinician on duty. Kindly answer the following questions. Page1of 3QUESTION FOUR IV. You are ‘an Intern doctor on duty. You receive Mr. Jacob Mundia, a 42-year-old ‘male patient from Chongwe with history of flank fullness for the pact three month. He has been seen by a doctor a week prior to this visit for yellowing of eyes. His social history is significant for multiple sexual partners and alcohol consumption of locally brewed beverages for the past 10 years. Answer the following questions: 1. How would you conduct clinical assessment of this patient? 2. What features would you be looking for on physical examination? 3. What is the diagnosis? 4. What investigations would you order or conduct in this patient? 5. What examination technique are you going to use to assess the abdominal distension? 6. Which abdominal organ is likely to enlarge in this patient and give an explanation? 7. What are final complications might occur in this patient? 8. Explain what kind of changes will take place in the liver 9. How will you manage this patient medical condition? 10. How would you conduct counselling in this patient and his family? QUESTION FIVE You are a medical intern on duty. You receive John Mwansa, a 40-year-old male patient with history of cough for the past one year. He has been having shortness of breath over several months. His social history is significant for smoking 20 cigarettes per day. He works for Chilanga Cement. Answer the following questions: e Arey 9. 10. How would you conduct clinical assessment of a patient with a medical respiratory condition? What is the significance of finger clubbing on physical examination of the respiratory system? What is the diagnosis? What investigations will you conduct in this patient? ‘What are final complications might occur in this patient? Ifyou examine and find a left supraclavicular lymphadenopathy in patient, what will be your diagnosis? ‘What is the name of such lymphadenopathy and how would you describe it? IS there a connection between cigarettes smoking and this medical condition? What will be your management of this patient? i What advice will you give to the patient and his relative? ] -THE END- Page 3 of 3