Department of Medicine

Medical Unit – I
Holy Family Hospital, Rawalpindi

3RD YEAR END BLOCK

January 2020
MARK DISTRIBUTION OF END BLOCK EXAMINATION OF 3RD YEAR
MBBS

End Block Exam: 70 Marks

Internal Assessment: 30 Marks

Total Marks: 100 Marks

End Block Exam Marks Time

Stations Distribution Allocation
MCQs 20 15mins
History taking 10 04 mins
Shot case 10 04 mins
(Respiration)
Shot case (GIT) 10 04 mins
Shot case (CNS) 10 04 mins
Shot case (CVS) 10 04 mins
INTERNAL ASSESSMENT TOTAL MAKS 30

Histories Attendance 10 Mini Clinical

marks Examination
10 marks
10 marks

If 05 >75% 10marks 75 - 100% 10 marks

histories
witten:10
marks

If less than 60-75% 7 marks 50%-75% 7.5 marks

05 histories
written: 0
marks <60% 0 marks <50% 0 marks
Station 1:History Taking Skills
Total Marks: 10

Total Time: 4mins

This 35 years old male presented with history of fever. Kindly take
focused history.

Keep in mind the time constraints.

Key for Station 1:
• Duration of fever. ( 1 mark)
• Onset , severity ( low grade , high grade ) , character (
intermittent , remittent, undulant , continued ), diurnal
variation, relieving factors. ( 2 marks)
• Associated symptoms to rule out causes ( headache, neck
stiffness, sore throat , sinusitis , earache , cough , vomiting ,
diarrhea , burning micturition , lumbar pain , joint pains ,
myalgias , rash ) associated anorexia, weight loss. ( 3 marks )
• Personal history / socioeconomic history (occupation, dietary
habits, cow milk intake, personal hygiene, supply of
contaminated water). ( 1 mark )
• Family history (for tuberculosis, dengue fever, contagious viral
illnesses). ( 1 mark )
• Travel history (yellow fever, STDs, AIDs). ( 1 mark)
• Animal contact / birds contact history (anthrax, psittacosis ). (
1 mark )
Station 2: Respiratory System Examination:
Total Marks : 10
Total time: 4 mins

PART A: MARKS: 05

Fulfill the following tasks:

1. Palpation of the trachea.

2. Demonstrate palpation, percussion, vocal fremitus, and
percussion of the back of the chest.
PART B: MARKS:05

1. What are the 3 causes of bronchial breathing?

2. Explain the examination findings on inspection, palpation,
percussion, and auscultation in a patient who presents with right
lower lobar pneumonia?
Key for Station 2:
PART A:
Introduction to the patient, consent before the examination.(1mark)
Use of hand sanitizer before the examination.(0.5mark)
Proper exposure, explanation of the procedure, and accuracy of the
procedure (2.5marks)
Has developed rapport with the patient, showed empathy, is grateful at
the end of examination and has properly covered the patient.(1 mark)

PART B:

1. Consolidation, Collapse with patent bronchus , above a pleural

effusion and localized fibrosis (2marks)
2. Inspection: reduced chest movements on the affected side
Palpation: reduced chest expansion on the affected side
Vocal fremitus: increased
Percussion: dull or impaired
Auscultation: bronchial breathing on the affected side with
increased vocal resonance (3marks)
Station 3: Cardiovascular System Examination
Total marks: 10
Total Time: 4min

Part AMarks: 05
Fulfill the following tasks:

Q1) Localize the apex beat

Q2) Point out cardiac areas of auscultation

Q3) Measure the JVP

Part B Marks: 05
Answer the following question.

Q4) Describe apex beat in Mitral stenosis and Mitral regurgitation

Q5) Causes of raised JVP
Key for Station 3:

Part A
Introduction to patient, consent, proper exposure and position the
patient at 45°. (1 marks)
Use of hand sanitizer before the examination.(0.5 marks)

Palpate and localize apex beat in relation to sternal angle. Auscultates

all cardiac areas. Uses scale to measure JVP properly and abdomino
jugular reflux to confirm it. (2.5 marks)
Has developed rapport with the patient, showed empathy, is grateful
at the end of examination and has properly covered the patient. (1
marks)
Part B
1. In mitral stenosis apex beat is not displaced and is tapping in
character. In Mitral regurgitation apex beat is displaced and
diffuse in character (2.5 marks)
2. Congestive cardiac failure
Pericardial effusion
Cardiac tamponade
Fluid overload.(2.5 marks)
Station 4: Central Nervous System
Examination:

Total marks: 10
Total time: 4min

Part AMarks: 05
Fulfill the following tasks:

1) How will you examine power of lower limbs

2) Demonstrate examination of 3rd cranial nerve

3) Demonstrate cerebellar signs

Part B Marks: 05
Answer the following question.

4) Describe the difference between upper and lower motor neuron

lesion?
Key for Station 4:
Introduction to the patient, consent, proper exposure (1 marks)Use of
hand sanitizer before the examination.(0.5 marks)
proper explanation of procedure ,check power in all muscle
groups of lower limb and is able to grade the power.
For oculomotor nerve performs extra ocular movements, light
reflex, accommodation reflex.
For cerebellum elicits all signs (2.5marks)
Has developed rapport with the patient, is grateful at end of
examination
and has properly covered the patient (1marks)

Part B(5 marks)

UMN lesions LMN lesions

Side of body Contralateral Ipsilateral
Type of paralysis Spastic Flaccid
Muscle tone Hypertonia Hypotonia
Deep reflexes Exaggerated Absent
Superficial reflexes Lost Preserved
Muscle wasting Not significant Marked
Fasciculations Absent Present
Babinski sign Positive Negative
Rigidity Clasp knife type Flaccid
Clonus Present Absent
Station 5: GASTROINTESTINAL SYSTEM

Examination:
Total Marks: 10
Total Time: 4min

Part A Marks: 05
Kindly fulfill the following tasks.
1) Inspection of abdomen
2) Palpate for liver and spleen
3) Check for shifting dullness
Part B Marks: 05
Answer the following questions.
1) Causes of hepatomegaly.
2) Causes of ascites.
Key for Station 5:

Part A
Introduction to the patient, consent, proper exposure.(1 mark)
Use of hand sanitizer before examination. (0.5marks)
Explanation of procedure, accuracy of procedure e.g
gently place hand, look for tenderness and palpate for liver
& spleen. Palpate spleen with all of 3 methods.(2.5 marks)
Has developed rapport with the patient, showed
empathy, is grateful at the end of examination and has
properly covered the patient.(1marks)
Part B
1) Acute viral hepatitis,
Hepatocellular carcinoma
Congestive hepatomegaly
Glycogen Storage diseases (2.5 marks)
2) Liver cirrhosis
Nephrotic syndrome
Tuberculosis,
Heart failure (2.5 marks)
 3rd Year MCQS
Total Marks: 20
Total Time: 15min

1) Peripheral cyanosis can be seen at all of the followings except

a. Hands
b. Feet
c. Ears
d. Lips.

2) All of the following are causes of clubbing except.

a. Lung cancer
b. Inflammatory bowel disease.
c. Chronic obstructive pulmonary disease (COPD)
d. Cyanotic heart disease.

3) JVP is raised in all of the following except

a. Pulmonary embolism
b. Pericardial effusion
c. Superior vena cava obstruction
d. Inferior vena cava obstruction.

4) In mitral stenosis
a. S1 is loud
b. S1 is soft
c. S2 is loud
d. S2 is soft.
5) Murmur of aortic stenosis is best heard in
a. Supine position
b. Left lateral position
c. Right lateral position
d. Sitting and leaning forward.

6) Tidal percussion is to
a. Map the lower border of liver
b. Map the diaphragmatic movement during respiration
c. Map the border of spleen
d. Map the lateral border of heart.

7) Which of the following is true about the assessment of arm reflexes?

a. The root value of biceps reflex is C5, C6
b. If no reflex is elicited when you tap a tendon, it is documented as
absent
c. Thetricep tendon is struck in the anterior cubital fossa.
d. Brisk finger jerk signifies LMN lesion.
8) Bronchial breathing is characterized by
a. Inspiratory component louder and longer with a gap between
expiration and inspiration
b. Expiratory component louder and longer with a gap between
inspiration and expiration
c. Both inspiratory and expiratory component are equal with a gap
between expiration and inspiration
d. Both inspiratory and expiratory components are equal with no gap
betweenexpiration and inspiration.
9) A palpable left parasternal impulse suggests which abnormality
a. Right ventricular hypertrophy
b. Aortic stenosis
c. Aortic regurgitation
d. Left ventricular hypertrophy.
10) Which of the following features is suggestive that a pulsating in the
neck is arterial?
a. Waggling of ear lobe
b. Positive hepato jugular reflex
c. No variation with posture
d. Pressing the root of neck reduces the impulse.

11) Irregular canon waves are seen in

a. Complete heart block
b. Supra ventricular tachycardia
c. Heart failure
d. Cardiac temponade.

12) Cause of fixed splitting of S2

a. ASD
b. Hypertension
c. Aortic stenosis
d. Aortic regurgitation

13) Trachea will be shifted to left

a. Left sided massive pleural
b. Right sided collapse
c. Right sided massive pleural effusion
d. Left sided pneumothorax

14) When assessing a patient for juglar vein distention, you should
position him
a) Sitting upright
b) Lying flat on his back
c) Lying on back with the head of his bed elevated to 45 degree
d) Lying on his left side
15) You are auscultating for heart sounds in a child and hear an S3. You
assess the sound to be
a. Normal finding
b. Probable sign of heart failure
c. Possible sign of atrial septal defect
d. Probable sign of mitral stenosis.

16) For auscultation of base of heart, auscultation should be done at

a. Mitral area
b. Aortic and pulmonary
areas
c. Tricuspid area
d. Epigastrium

17) Irregularly irregular pulse is a feature of

a. Atrial fibrillation
b. Sinusarrythmias
c. Ventricular ectopics
d. Atrial ectopics

18) When listening to heart sounds, you can best hear S1 at

a. Base
b. Apex
c. Aortic
d. 2nd intercostal space to the right of sternum

19) Which of the following is not the cause of massive splenomegaly?

a. Myelofibrosis
b. Enteric fever
c. Chronic malaria
d. Leishmaniasis
20) The hooking maneuver of Middleton is used to palpate which organ
a. Liver
b. Kidney
c. Spleen
d. Gallbladder
MCQs KEY
1. D
2. C
3. D
4. A
5. D
6. B
7. A
8. C
9. A
10. C
11. A
12. A
13. C
14. C
15. A
16. B
17. A
18. B
19. B
20. C
RESULT OF 3rd
YEAR END
BLOCK
EXAMINATION