Medical MEQ 1999/2000

MEDICAL Question 1 3 years old boy brought to A&E with signs of dehydration. 1. Patient has been vomiting with high-grade fever. a. Give 5 questions to as his mother i. Fever: duration, nature, chills/rigors? ii. Vomiting: duration, re!uenc", content o vomitus? iii. #n" associated s"m$toms li%e a&dominal $ain, urinar" s"m$toms? iv. #n" rashes note on the &od"? v. #n" amil" mem&ers 'ith similar illness? b. !ign that you e"#e$ted i. (igns o deh"dration such as dr" mucosa, decreased s%in turgor and sun%en e"e&all. ii. Fever more than )*+ iii. ,ach"cardia and tach"$noea iv. -ashes on the &od" and e.tremities v. #&dominal distension or a&dominal $ain $. %ist the investigation that you would li e to do at this stage i. Full &lood count to loo% or increased 'hite &lood cell ii. /lood urea and electrol"te to loo% or im&alance sodium and $otassium. iii. /lood culture and sensitivit" to loo% or t"$e o in ective organism iv. 0rine FEME, culture and sensitivit" to loo% or urinar" tract in ection &. After mu$h #ersuasion' #arents agreed for %umbar #un$ture. %umbar #un$ture showed in$rease #rotein and de$rease glu$ose. a. Give 3 organism with their gram stain and appearance which can cause meningitis i. Haemophilus influenzae ii. Streptococcus pneumoniae iii. Neisseria meningitidis b. (hat will you tell the #arent)s about lumbar #un$ture* i. ,ell the inding o lum&ar $uncture ii. Ma" &e caused &" meningitis iii. ,ell them more a&out meningitis iv. ,ell them the treatment, $rognosis and com$lication v. ,ell them not to 'orr". $. (hat are the a##ro#riate antibioti$ for this #atient i. #m$icillin 1 gentamicin d. (hy do you thin most of the #arent will refused %umbar #un$ture* i. /ecause o their alse &elieved that 2um&ar $uncture 'ill $aral"sed their child or cause convulsion 3. +!, showed E. $oli whi$h sensitive to netilmy$in. -ut #atient failed to im#rove his $ondition after & days of treatment. +urrently #resented with ar$hed ba$ ' stiff ne$ and high fever. a. (hat will $ause the failure of treatment* i. Failure o netilm"cin to reach the intrathecal s$ace.
3200) 4567 45678( 65,E(

Medical MEQ 1999/2000

ii. ,he dosage o the drug is not enough iii. 9rug resistant iv. ,here ma" &e other organism as 'ell v. ,here ma" &e source o in ection else 'here b. (hat further investigation you want to do* i. -e$eat +(F and &lood culture and sensitivit" again. ii. -e$eat ull &lood count iii. 9o urine FEME and culture and sensitivit" .. /other was worried that #atient sibling will have the same #roblem a. 0ow do you res#onse to this situation* i. #s% them to come to hos$ital immediatel" i the" have ever and signs o meningitis. ii. ,ell the mother to give vaccine to their other children b. Give & s#e$ifi$ ways of #reventing 0. influen1a infe$tion i. :mmuni;ation <i/ ii. =ro$h"la.is anti&iotic Question 2 1. 3 years old with 1 wee history of swollen fa$e and hands. Patients have normal develo#ment. 2he #arent was well. a. 3 $auses of fa$ial #uffiness i. -enal $ro&lem: ne$hrotic s"ndrome, ne$hritic s"ndrome ii. 2iver $ro&lem: h"$oal&uminemia iii. <eart $ro&lem: congestive heart ailure b. 5 question you would li e as #atient i. <ave "ou $assing roth" urine? ii. 9o "ou have sorethroat or the $ast e' 'ee%s? iii. 9o "ou have an" s%in in ection or the $ast e' 'ee%s? iv. 9o "ou have an" congenital heart disease? v. 9o "ou $assing &lood during micturition? &. Patient had history of #assing frothy urine. 3nvestigation result given. a. 3nter#rete the investigation result i. %,24 hy#oalbuminemia ii. 5rine4 #roteinuria' no hematuria b. /ost li ely diagnosis i. 6e$hrotic s"ndrome $. /anagement i. 5n ne$hrotic chart ii. (trict :n$ut/out$ut chart iii. 9o dail" urine di$sti.: to chec% $roteinuria iv. 7ive steroid thera$" >1? @0mg/m2/da", in divided dose or A 'ee%s >2? A0mg/m2/da", Ever" 5ther 9a", or A 'ee%s 3. Patient has had one rela#se and $urrently $ome with $om#laint of abdominal #ain and high grade fever. a. !tate your #rovisional diagnosis at this time i. =eritonitis secondar" to ne$hrotic s"ndrome b. 0ow do you $onfirm your diagnosis i. #s$irate $eritoneal luid
3200) 4567 45678( 65,E(

Medical MEQ 1999/2000

ii. Full &lood count iii. +hec% urine or $roteinuria .. Patient is now 6 years old. 0e #resented with rela#se. 0e has had 1& rela#ses in the #ast 5 years. a. (hat are #sy$hologi$al burden of $hroni$ illness on #atient and family* i. =atient >1? <e has to a&sence or school >2? <is school $er ormance ma" reduced ii. Famil" >1? ,he mother has to ta%e care o the $atient and ma" neglect the other children. >2? ,he mother has to &ring the $atient to the hos$ital or ever" rela$se. >)? ,he treatment cost is a &urden to the amil". b. 0ow do you manage i. 7ive c"clo$hos$homide Question 3 1. &5 years old male brought by mother to A&E with history of abdominal #ain and vomiting for 3 days #rior to admission. a. Give 3 differential diagnosis i. #cute gastroenteritis ii. #cute a$$endicitis iii. =e$tic ulcer disease &. 2 urther !uestion "ou 'ould li%e to as% or each o "our diagnosis a&ove. i. #cute gastroenteritis >1? <ave "ou eating outside or the $ast e' da"s? >2? 9o "ou have diarrhoea? ii. #cute a$$endicitis >1? 9oes the $ain start around the um&ilicus and then radiated to the right iliac ossa? >2? 9o "ou have ever? iii. =e$tic ulcer disease >1? 9o "ou have gastritis &e ore? >2? 9oes the a&dominal $ain relieved &" eating? &. ,urther questioning' no history of 7/' no drug overdose. PE4 revealed fruity breath' signs of dehydration. Patient only res#onse to #ainful stimuli' #resen$e of basal $re#itation' de$reased breath sound and in$reased vo$al resonan$e. a. . investigation and reason. i. +hest BCra": to loo% or consolidation, $leural e usion ii. 2iver unction test: to loo% or liver im$airment, &iliru&in iii. <e$atitis #, / and + screening iv. Full &lood count: to loo% or increased 'hite &lood cell b. 3nvestigation result i. A-G4 #0 ii. 8-!4 iii. 5rine4 etone
3200) 4567 45678( 65,E(

Medical MEQ 1999/2000

iv. +984 showed #leural effusion in left lung $. 3nter#ret the result i. #/7: $atient has meta&olic acidosis ii. -/(: $atient has h"$ergl"caemia iii. 0rine: the is %etonuria iv. +B-: the is $leural e usion in le t lung v. +onclusion: $atient has dia&etic %etoacidosis d. (hat would you li e to do this #atient i. (tart 9D# regimen ii. ,o reh"drate the $atient >1? 7ive normal saline 0.9E irst >2? +hec% to &lood glucose level, i -/( F1Gmmol/2, change normal saline 0.9E to de.trose GE. iii. 7ive $otassium iv. 7ive insulin thera$" 3. Patient was rehydrated and given 7:A regime. -ut blood glu$ose level still high. a. (hat are the $auses of failure of treatment i. b. (hat will be your management Question 4 1. ;; years old hy#ertensive male #resented with history of $ough whi$h had been #res$ribed with am#i$illin 1 wee ago. Patient $urrently #resented with !<-' P=7 and ortho#noes for last few days. a. (hat $ould be the $ause of his !<i. 2e t ventricular ailure ii. =neumonia iii. =leural e usion &. PE finding4 s#leen 6$m below left $ostal margin a. +ause of s#lenomegaly i. =ortal h"$ertension due to congestive heart ailure ii. <ematological causes such as leu%emia, m"eloma, m"elo i&rosis iii. :n ective causes such as malaria, t"$hoid b. (hat investigation would you li e to do i. Full &lood $icture to loo% or leucoc"tosis, anemia, throm&oc"to$enia ii. /lood smear iii. ($utum, /lood culture and sensitivit" to loo% or in ective organism iv. +hest BCra" to loo% or consolidation, cardiomegal", $leural e usion $. -lood film revealed > i. (hat further investigation ii. (hat are the mostly li ely diagnosis iii. 0ow to $onfirm it >1? /one marro' as$iration

3200) 4567 45678( 65,E(

Medical MEQ 1999/2000

3. -one marrow shows myelofibrosis. Patient was treated with regular blood transfusion. & years later he #resented with history of bleeding and #ete$hiae. a. Possible $ause of this i. ,hrom&oc"to$enia due to m"elo i&rosis ii. 9engue hemorrhagic ever iii. :dio$athic throm&oc"to$enia $ur$ura b. 0ow do you treat i. ,rans use resh ro;en $lasma Question 5 1. 16 years old girl #reviously a shy girl' #resented with history of & wee s while at training $ollege' e"$essive a$tive. !he always gave mini le$tures to friends and be$ame e"trovert and out going. !he also started to wear bright $lothes. a. 3 differential diagnosis i. #cute Mania ii. /i$olar disorder iii. (chi;o$hrenia b. Give further question i. 9o "ou have decreased need o slee$? ii. <o' do "ou s$end "our mone"? iii. 9o "ou have increased li&ido? iv. 9o "ou have eel that "ou are im$ortant $erson? v. 9o "ou have man" $lans to do? vi. 9o "ou eel sad? &. Patient has in$rease ideas. !he said she $an be$ome le$turer as she very $lever and good at tea$hing. !he also made many #lans on how to im#rove ministry of edu$ation. !he has de$rease need for slee# ?only 1-& hours a night@ but still very a$tive ne"t day. a. (hat is your #rovisional diagnosis* i. #cute mania e$isode b. Give 3 sym#tomatology in this #atient i. 7randiosit" ii. :ncreased in goal directed activit" iii. ,al%ative 3. /!E revealed gradiose ideation' #ressure of s#ee$h a. (hat is your management of this #atient* i. #dmit this $atient ii. 7ive mood sta&ili;ed: lithium. Monitor serum lithium level .. Patient was started on lithium. a. (hat & initial investigation do you want to do to this #atient i. ,h"roid unction test ii. -enal unction test b. Give . side effe$t of lithium i. <"$oth"roidism ii. ,remor iii. Height gain iv. 6ausea and vomiting

3200) 4567 45678( 65,E(

Medical MEQ 1999/2000

$. (hat do you thin regarding this #atient #rognosis and give your reasons i. Poor be$ause >1? Earl" onset >2? 6ot married "et

3200) 4567 45678( 65,E(