FCP(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain
Reg No 1955/000003/08

Final Examination for the Fellowship of the

College of Physicians of South Africa
1 September 2011
Paper 2

Principles and Practice of Medicine

(3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is
required for the one answer)

a)

b)

a)

Inflammatory disorders
i)
Write short notes on the typical clinical presentation and diagnosis of giant
cell arteritis.
ii)
Rheumatoid arthritis may result in a number of neurological complications
which are caused by nerve compression. Write short notes on these
typical neurological sequelae, their anatomic basis, and the symptoms of
such involvement. You may present your answer as a table.
(15)
You are a registrar on the general medical service. A 55-year-old divorced man
who works in a bakery is admitted into your care for management of multi-lobar
pneumonia. You decide that it would be prudent to investigate his HIV status.
i)
What legal requirements must you follow before carrying out this test?
ii)
He proves HIV positive. You contact your ICU colleagues in case he
requires mechanical ventilation and you request that the ward team
perform regular arterial blood gas estimations to monitor his condition
overnight. Have you an ethical duty to inform these colleagues of his HIV
positivity? Keep your answer to one sentence.
iii)
He has a partner with whom you are in daily contact as she is concerned
about his progress. You assume that they have a sexual as well as a
caring relationship. What is your ethical duty to this woman?
iv)
His employer contacts you; he has learned that the man has lung infection
and asks you whether his employee has tuberculosis. How would you
reply? Keep your answer to one sentence.
(15)
[30]
An 18-year-old woman who is 36-weeks pregnant presents with generalised
swelling of several weeks duration. She also complains of arthralgia affecting
both hands and a malar rash. She has fever of 38.6C, and pitting oedema +++.
The blood pressure is 135/95, and she has a soft apical systolic murmur. Urine
examination reveals protein ++++ and blood ++. Her haemoglobin is 8.2 g/dl,
white cell count 3.2 X 109/l, platelets 69 X 109/l, serum urea 17.2 mmol/l and
serum creatinine 186 mol/l.
i)
Discuss your differential diagnosis. Justify each of these diagnoses in the
light of the clinical information given.

ii)

b)

a)

b)

Describe a cost-effective plan of investigation in this patient, and explain

the value of each test in terms of the establishment of a diagnosis and the
assessment of severity.
(20)
List the extrahepatic manifestations associated with chronic hepatitis B virus and
hepatitis C virus infections respectively.
(10)
[30]
Briefly discuss the following aspects of meningococcal meningitis.
i)
Epidemiology.
ii)
Risk factors for infection.
iii)
Management of a patient with meningococcal meningitis.
(15)
A 20-year-old woman is brought to the emergency room having swallowed pills
after an argument with her family. She is slightly drowsy, hyperventilating, with a
tachycardia and her family says that she had vomited at home and complained of
tinnitus. Blood gases show a respiratory alkalosis.
i)
What is the substance ingested?
ii)
What is the reason for the hyperventilation?
iii)
How would you manage this patient?
(15)
[30]

a)
b)

Discuss the diagnostic evaluation of a patient with hypercalcaemia.

(15)
A 50-year-old woman is referred by her general practitioner as a difficult-tocontrol asthmatic. She was diagnosed with asthma 15 years previously, but,
following a mild course, the asthma had abruptly become more serious
approximately one year ago; since then she has experienced several severe
exacerbations. She also suffers from recurrent rhinosinusitis and has a one-year
history of chronic headaches. She is taking aspirin, salbutamol and budesonide
inhalers and oral theophylline.
i)
What is the most likely reason for the deterioration in her asthma over the
past year?
ii)
Describe the pathogenetic mechanism which accounts for this. A diagram
may be helpful.
iii)
Describe a cost-effective approach to the investigation and treatment of
this patient.
(15)
[30]

a)

Hypertensive emergencies.
i)
Define the term hypertensive emergency.
ii)
Briefly discuss the recognition, complications and management of
hypertensive emergencies.
(15)
A 70-year-old retired business executive presents to hospital accompanied by his
wife. She is concerned that over the past year her husband has become
progressively forgetful. He also has difficulty with simple tasks such as
completing his tax returns, grocery shopping, and payment of his accounts. He
occasionally gets lost whilst out shopping.
i)
What is the most likely diagnosis?
ii)
Briefly discuss your approach to the investigation of this patient.
(15)
[30]

b)

FCP(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain
Reg No 1955/000003/08

Final Examination for the Fellowship of the

College of Physicians of South Africa
Paper 3

2 September 2011
Principles and Practice of Medicine

(3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is
required for the one answer)

a)
b)

a)

b)

3 a)

b)

A 40-year-old obese patient with long-standing gout continues to have acute

attacks of arthritis despite being on allopurinol 300mg daily. His serum urate is
0.4 mmol/l. Discuss the long-term therapeutic management of this patient.
(15)
Discuss the cost-effective management of a patient who presents with pulmonary
hypertension of uncertain aetiology. Relate your investigation and treatment to
specific diagnostic possibilities.
(15)
[30]
A 25-year-old woman with the acquired immunodeficiency syndrome (AIDS) is
commenced on antiretroviral therapy. Three weeks later she presents with fever,
night sweats, generalised lymphadenopathy and bilateral chest infiltrates. Her
sputum subsequently tests positive for Mycobacterium tuberculosis.
i)
Discuss the differential diagnosis at the time of her most recent
presentation which should be considered prior to the sputum result
becoming available.
ii)
Name the condition which succinctly explains the essence of her most
recent deterioration.
iii)
Discuss the pathogenesis, management and prevention of this condition.
(15)
List the neurological complications of the following conditions
i)
Hypothyroidism. (No information beyond a list is required.)
ii)
Chronic alcohol abuse. For each complication of chronic alcohol abuse,
provide a brief list of its distinguishing clinical features.
(15)
[30]
A 60-year-old man has a history of a myocardial infarction 2-years previously.
This resulted in left ventricular failure which has been adequately controlled with
furosemide 40mg daily, lisinopril 10mg daily and carvedilol 12.5mg twice a day.
He now presents to the emergency room with a history of progressive dyspnoea,
orthopnoea and worsening ankle oedema for the past 2-weeks. His respiratory
rate is 24 per minute. He is in atrial fibrillation with a pulse rate of 110 bpm, and
his recumbent blood pressure is 110/60 mmHg. Bilateral basal crepitations are
present and his SaO2 is 88% on room air.
Discuss the immediate management of this patient.
(20)
Write short notes on the frailty syndrome.
(10)

[30]
4

a)
b)

a)

b)

Write short notes on the aetiology, clinical presentation and investigation of

rapidly progressive glomerulonephritis.
(20)
A 28-year-old woman is referred to you with amenorrhoea and galactorrhoea of 4
months duration and an elevated prolactin level of 120 g/l (normal range 4.8
22.3g/l)
i)
Discuss the features you would seek on history and examination.
ii)
Describe and justify the additional laboratory test you would order.
(10)
[30]
A 28-year-old woman develops jaundice in the 34th week of pregnancy
i)
What is the differential diagnosis?
ii)
Discuss a cost-effective plan of investigation, relating this to the conditions
in your differential diagnosis.
(15)
Write short notes on the haematological manifestations of inflammatory bowel
disease.
(15)
[30]