LAMU

FINAL 5TH MEDICAL EXAMS- TIME 3 HOURS

23rd November, 2015

PAPER 2

COMPUTER NUMBER.

INSTRUCTIONS:

There are Ten (10) scenarios/short notes question, answer all. All questions carry equal
marks. Answer should be brief, clearly written in point form.

This paper consists of 6 pages.

PLEASE ANSWER EACH QUESTION ON A DIFFERENT BOOKLET

 1. Mr. Mabvuto sakala is a 76 year old male that arrives in AMEU at Levy Mwanawasa General
Hospital in an ambulance. As an intern doctor on duty, he is brought in your consultation room.
He complains of shortness of breath for a week which seems to have gotten worse today. He
complains of also of a persistent dry cough especially at night.

He is known to be Diabetic Mellitus and Hypertensive on Losartan 5omg, Amlodipine 10mg and insulin
therapy. He has no known drug allergies.

On assessment- Vitals BP 218/110 mmHg, RR 36, Temp 37.7, Sa O2 95 (Room Oxygen), he has difficult in
talking, unable to lie flat ( prefers sitting upright), dusky nail beds, skin cool and moist with ankle edema
JVP is 10cm; Apex beat in the 6th intercostal space anterior axillary line with a tachycardia and occasional
ectopics. Rales noted right middle lobe and lower lobes bilaterally.

The following ar investigation done on the patient-Lab values: Na 135 K 3.9 Hb 12.5 Create 220mol/l
CXR- Bilateral pulmonary congestion with enlarged cardiac shadow
12 Lead EKG-Sinus tachycardia with occasional PVCS, Old Anterior MI

From the patients chief complaint and your initial assessment, what is the patients primary problem?
(4 marks)

Describe the pathophysiology of CHF (congestive heart failure). (6 marks)

What are the signs and symptoms of heart failure in this patient? (2 marks)

What factors contribute to the patients heart failure? (4 marks)

What pharmacologic agents are used to improve cardiac performance in patients with CHF? (4 marks)
You have been asked to evaluate a patient in the Dept. of obstetrics and gynecology. The
consultation reads: very urgent, come and manage our patient with suspected acute renal
failure

You find that she is 26 yrs of age. She had given birth 10 hours earlier by Spontaneous Vaginal
delivery to a mildly asphyxiated baby. She has not passed urine since delivery. The Antenatal
card shows she had no medical or gynecological problems. Urinalysis was done twice during
antenatal and was reported normal.

The midwife tells you that the labour was very hectic and patient was difficult during
delivery and hence bled a lot.

Examination:

Drowsy, pulse 142/min, Blood pressure 85/55, respiratory rate 29/min

CVS- tachycardia, no murmurs, no gallop. RS clear lung fields. GIT normal.
There no active bleeding per vagina and uterus well contracted.
Urinalysis: pH = 5.5 ; specific gravity >1030, Amino acids= trace; glucose= trace; casts
present; Hemoglobin, RBC, Albumin, White blood cells, nitrites= all negative.

Glucometer random blood sugar = 6, Urea = 26

Urgent bedside Ultrasound shows normal kidneys

What assessment needs to be done on this patient? (4 marks)

Analyse the findings (6 marks)

Plan your full management (10 marks)

A male patient 45 years old was admitted yesterday to ICU with severe chest pain. He is a
known diabetic and hypertensive patient for more than 10 years.

Diagnosis of admitting doctor was unstable angina.

Doctor on call was informed that patient suddenly changed his condition after a short episode of
breathlessness (though in the morning he appeared to be stable, pain free and not on ventilation).
The nurses reported the absence of pulse and recordable BP.

On the monitor attached to the patient the fine oscillations seen.

Questions:

What condition is this? (4 marks)

What is your immediate action? (3 marks)

If the monitor still shows oscillations and pulse is absent on the carotid arteries what do you do
next? (4 marks)

What is the possible diagnosis? (6 marks)

How would you manage in post-resuscitation period? (3 marks)

A 20 year old male patient presents to admission ward after being found unconscious at home.
The friend accompanying him says that he is a known diabetic on injections that are kept in the
fridge and that he has been unwell the past 4 days with a febrile illness and is not sure whether he
was getting his injections or not.
Examination: unconscious (GCS 8/14), moderately wasted, no generalized lymphadenopathy,
dehydrated, febrile and has Kussmauls respiration.

You are the attending officer in AMEU.

Please, fully manage him (all the facilities are there i.e. labs etc.).

Answer in Bullet form (20 marks)

A 65 year-old man presents with a 6-week history of cough, progressive shortness of breath and
10kg weight loss. He has a 50-pack year smoking history and his family doctors orders a chest x-
ray and blood work.

The CXR shows a left lower lobe mass. His physical is normal. He is otherwise healthy, and takes
no regular medication-

List 4 differentials for above patient (8marks)

How would you further investigate this man, in order to get a pathologist diagnosis- list 5 (5
marks)

If it is Bronchogenic carcinoma, what addition tests are required to properly stage this patient-
list 7 (7 marks)

Mrs. Banda is a 27 year old woman (unemployed) who was referred from VCT center after
testing HIV positive 3 weeks ago. Her husband recently died from cryptococcal menin
goencephalitis; during his hospitalization he tested positive for HIV, causing her to pursue
testing.

Her medical history has been unremarkable except being diagnosed with extra pulmonary TB 4
months ago. She declined HIV test at the time of TB diagnosis.

She is allergic to trimethoprim/sulfamethoxazole which causes a diffuse erythematous rash.

Her physical examination is notable for a thin, well developed woman with no acute distress.
HEENT exam reveals candida on the tongue and buccal mucosa. Heart, lung and abdomen
examinations are normal.

Her laboratory test

Hb11.7mg/dl. Platelets 167,000, HIV positive, CD4 410/ul.

For this patient, what evidence (history, physical examination, and/or laboratory data), support
beginning antiretroviral therapy (ART) (4marks)
Do you identify any barriers to good ARV adherence? List 3. What would you recommend to
address these barriers? (6 marks)

What antiretroviral medication would initiate? (4 marks)

What toxicities could be associated with the anti-retroviral therapy you chose? 2 for each (6
marks)

Mr. Saili is a 74 year old man who presents to your consultation room with his wife complaining
of shortness of breath and fever. His wife did bring records from his last physician that he has
Chronic Obstructive Pulmonary Disease (COPD). After evaluation you make a diagnosis of acute
exacerbation in COPD.

What is the mechanism of airflow limitation in COPD? (4 marks)

What is the role of inflammatory mechanisms in COPD? (4 marks)

What are the organism commonly associated with exacerbation of COPD? (4 marks)

What investigation would you order? (4 marks)

How would you treat an acute exacerbation? (4 marks)

A 20 year old young lady comes to the hospital complaining of fevers and oral ulcers for a week.
She reports having had fevers in the recent past. She says she has no urinary symptoms. She
feels tired and has no cardiac symptoms. She has also noticed that her hair is thinning out. The
registrar suspects she has a connective tissue disease.

What else would you want to probe for in the history? (5marks)

The patient is noted to have a rash on her face that looks like a butterfly pattern and she also
has joint tenderness in the hands. Your registrar further suggests that this could be Systemic
Lupus Erythematosus (SLE). List the manifestations used in the criteria to make a diagnosis of
SLE. (5marks)

List the investigations you would do in this patient (6marks)

What drugs can you use in a patient with SLE? (4marks)

A 40 year old HIV negative male patient presents to AMEU with four days of jaundice, upper
abdominal pain, nausea, vomiting, and headache.
He is a patient on sputum positive PTB on treatment for 6 weeks. He is currently on Rifampicin,
Isoniazid, Ethambutol and Pyrazinamide. The patient has no other pertinent past medical
history and uses no other medications.

On physical examination, he is alert and oriented with the following vital signs: blood pressure
113/62 mmHg; heart rate 88 beats/ minute; respiratory rate 14 breaths/ minute; pulse
oximetry 100% on room air; temperature 37.1 degrees Celsius. His skin is jaundiced, but
without ecchymoses or petechiae. Eye examination reveals scleral icterus.

Cardiovascular and pulmonary findings are unremarkable. His abdomen is soft, but diffusely
tender to palpation without any organomegaly, rebound, guarding, or rigidity.

Initial pertinent laboratory results include: AST > 2600 IU/L; ALT > 2600 IU/L; total bilirubin > 20
mg/dl; INR 3.7.

What is the primary problem with this patient? (2 marks)

How would you investigate this patient? List 4 important investigations ( 4 marks)

How does Isoniazid (INH) cause hepatotoxity? (6 marks)

How would you manage this patient if it was purely due to INH? (8 marks)

Write short notes;

Diagnosis of Myocardial infarction (5 marks)

Mechanism of diarrhea in Cholera (5 marks)

Symptoms, signs and diagnosis of organophosphate poisoning (5 marks)

Treatment of organophosphate poisoning (5 marks)