2008 Internal Medicine past paper

(I) Definitions (5 marks each)

1. Respiratory Failure:
-It caused by any condition that affects the lungs ability to maintain arterial oxygenation or carbon
dioxide (CO2) elimination. A condition in which gas exchange deteriorates below the usual level, so
that arterial oxygen tension (PaO2) decreases, with or without an abnormal rise in arterial carbon
dioxide tension (PaCO2).
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2. Hospital acquired pneumonia (HAP):
-Also called nosocomial pneumonia:
It is an infection of the lung parenchyma that was neither present nor incubating at the time of
hospital admission
Colonization of the upper respiratory tract with potentially pathogenic organisms, including gram-
negative bacilli and S. aureus, commonly occurs in hospitalized patients. The prevalence of
colonization is proportional to the duration of hospitalization and the severity of underlying illness.
HAP causes inflammation of the distal lung, terminal airways, alveolar spaces and interstitium. The
causes of HAP are allergies or pathogenic and physiochemical factors (radiation, chlorine, sulfur
dioxide).
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3. Acute coronary syndrome:
-ACS refers to any group of symptoms attributed to obstruction of the coronary arteries. The most
common symptom prompting diagnosis of ACS is chest pain, often radiating of the left arm or angle
of the jaw, pressure-like in character, and associated with nausea and sweating. Acute coronary
syndrome usually occurs as a result of one of three problems: ST elevation myocardial
infarction (30%), non ST elevation myocardial infarction (25%), or unstable angina (38%). It is the
result of an imbalance between myocardial oxygen supply and demand
-The term ACS covers a group of clinical syndromes that includes:
1) Angina pectoris
2) Myocardial infarction
3) Sudden death
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4. COPD:
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state
characterized by airflow limitation that is not fully reversible. The airflow limitation is usually
progressive and is associated with an abnormal inflammatory response of the lungs to noxious
particles or gases, primarily caused by cigarette smoking. COPD also produces significant systemic
consequences.
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5. Angina:
-Angina is a syndrome where myocardial oxygen requirement is greater than its supply. There is
chest pain due to ischemia of the heart muscle, due to obstruction of the coronary arteries. Coronary
artery disease occurs because of atherosclerosis of the coronary arteries and is the main cause of
angina.
-Angina classifications:
1. Stable angina (classic angina)
2. Prinzmentals angina
3. Unstable angina
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(II) Single choice answer: (3 marks each)

1. Chlamydia pneumonia is the most common pathogenic microorganism of?

a) Pulmonary candidiasis
b) Viral pneumonia
c) Staphylococcus pneumonia
d) Staphylococcus pneumonia
e) Mycoplasmal pneumonia
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2. Which one is not the symptom of the pulmonary tuberculosis?
a) Cough
b) Edema
c) Hemoptysis
d) Fever
e) Expectoration
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3. The golden standard to diagnosis respiratory failure is?
a) Cyanosis and dyspnea
b) PaCO2 > 50mmHg and PaO2 < 60mmHg
c) Change of the respiratory rhythm, rate and intensity
d) Mucous hyperemia, edema and change of consciousness
e) acid-base disorders
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4. The following are risk factors of the atherosclerosis except?
a) Gerontism
b) Smoking
c) Oligiria
d) Hypertension
e) Diabetes
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5. Which measure we should take first to a cardiac arrest patient?
a) ECG
b) -blockers
c) Digitalis
d) Cardiopulmonary resuscitation
e) Surgical operation
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(III) Short answer questions (6 marks each)

1. What is the classification for mitral stenosis according the mitral orifice area?
Answer:
-Mitral stenosis is heart valve disease which is progressive and lifelong. It may be asymptomatic for
up to 20 years. It occurs due to the thickening of the leaflets of the mitral valve (normal valve area 4
~6 cm2) due to thickening and shortening of the chordae tendinae fibers. Severe stenosis (valve area
< 1 cm2) leads to right heart failure due to severe pulmonary venous congestion.
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2. Please write down the symptoms of bronchiectasis.
Answer:
1) Daily cough productive of muco-purulent phlegm.
2) Chronic productive cough due to accumulation of pus in dilated bronchi (usually worse in the
morning).
3) Intermittent hemoptysis.
4) Can be slight or massive and is often recurrent.
5) Usually associated with purulent sputum purulence.
6) Recurrent lung infections.
7) Shortness of breath.
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3. Please describe the conduction system within the adult heart.
Answer:
-There are 3 steps:
1) Depolarization starts in the sinoatrial node (SA node) & spreads through the atria and then through
the atrio-ventricular node (AV node).
2) Depolarization then spreads through the bundle of His and then to left and right bundle (Purkinje
fibers) of braches to reach the ventricular muscle.
3) Repolarization spreads from epicardium to endocardium.
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4. What are the clinical manifestations of obstructive sleep apnea syndrome (OSAS)?
Answer:
-In OSAS, suffocation may occur for a long time causing frequent overturning or sudden sitting up
of a person and may even cause coma if cyanosis occurs during sleep.
-Recurrent hypoxemia and hypercapnia during sleep can cause a wide range of symptoms such as:
1) Snoring.
2) Palpitation.
3) Chest tightness.
4) Precordial discomfort.
5) Sweating.
6) Poor sleep quality.
7) Daytime sleepiness.
8) Dozing off.
-Hypoxia due to OSAS can also lead to:
1) High blood pressure
2) Vagus nerve bradycardia
3) Myocardial ischemia
4) Excitement
5) Arrhythmia
6) Sudden death
7) Brain damage
8) Dizziness
9) Memory loss
10) Unresponsiveness
11) Irritability
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5. Please write down the treatment of asthma?
Answer:
-There are 5 steps:
1) Rapid-acting 2-agonist whenever necessary.
2) Low-dose inhaled ICS or leukotriene modifier.
3) Low-dose inhaled ICS +long-acting 2-agonist, medium-or-high-dose ICS, low-dose inhaled ICS
+leukotriene modifier, low-dose
inhaled ICS +sustained release theophylline.
4) Medium or high dose ICS plus: A) Long-acting 2-agonist, B) Leukotriene modifier, C) Sustained
release theophylline.
5) Oral glucocorticosteroid or anti-IgE treatment.
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(IV) Case studies (6 marks each)

First case study:

-A male patient who is 55 years old has a history of hypertension and diabetes for two years. The BP
of patient is normal under the control of anti-hypertensive drugs, but the blood sugar cant be
controlled very well. Patient has activities related chest pain accidentally, which can be released
within 5min by taking a break or nitroglycerin. Recently the patient complains chest pain happened
more frequently, the symptoms as similar as previous. This morning the chest pain with sweat,
nausea and vomiting seriously, cannot be reserved by taking nitroglycerin. EKG shows ST segment
elevation in the leads II, III and aVF.

1) What is the most likely diagnose of the patient?

Answer:
-The patient suffering from STEMI (ST elevation myocardial infarction)

2) What are the differential diagnoses?

Answer:
-Atherosclerosis
-Pericarditis
-Plueritis
3) What are the most important therapy for this patient in the initial stage?
Answer:
-Treat the patient with mona regimen:

M Morphine (for pain management)

O Oxygen (to prevent tissue damage)
N Nitroglycerine preferred sublingually (Vasodilator to increase coronary blood flow)
A Antiplatelet drugs such as aspirin or clopidogrel
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Second case study:
-A 40 year male has recurrently suffered from severe headache, palpitations, in 8 weeks and has not
been treated. Recently he measured his BP 3 times in different time and his BP are 220/126mmHg
and 140/95mmHg

1) Please write down the most important for diagnosis and treatment?
Answer:
-The patient might be suffering from accelerated hypertension, the best managed with
antihypertensive drugs such as:
A) Diuretics (Furosemide or Indapamide).
B) Adrenergic receptor antagonist (-blockers such as atenolol, propranolol, metoprolol).
C) Adrenergic receptor agonist (clonidine, methyl dopa).
D) Calcium channel blockers (Nifedipine or Verapamil).
E) Renin inhibitors (Aliskiren).
F) ACE inhibitors (Enapril or Ramipril).

2) What is your first choice to reduce his BP before operation?

Answer:
-Administration of best loop diuretics like Furosemide, Indapamide
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Third case study:
-A patient with low-grade fever and weight loss has poor excursion on the right side of the chest with
decreased fremitus, flatness to percussion, and decreased breath sounds all on the right. The trachea
is deviated to the left.

1) What will be most likely the diagnosis? Why?

Answer:
-The patient suffering from lung cancer with tumor on the right side which blocking right bronchus.
Differential Diagnosis:
A) Pulmonary Tuberculosis.
B) Pulmonary Infection.
C) Benign Lung Tumors.
D) Mediastinal Lymphoma.
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