DESK NO: ____________________

MATRIC NO: _________________

1. 65 year old presented for renewal of her prescriptions. She reports a history of
hypertension and has osteoarthritis in both knees. Her current medications are amlodipine
10 mg once daily, metoprolol 50 mg twice daily and hydrochlorothiazide 12.5 mg daily. On
examination, her seated blood pressure, using an appropriately sized cuff, is 164/88 mmHg
in the right arm and 140/86 mmHg in the left arm with no postural drop.

1a. Define resistant hypertension. (2 mark)

Answer
Unable to reach traget BP despite 3 hypertensives including a diuretic
1b. You have been asked to take further history from Iniah. What is your aim (3 marks)
of history taking in this patient?
Answer
To establish
 the presence of end-organ damage (eg retinopathy, cardiac failure,
proteinuria, reduced eGFR, CKD)
 cardiovascular risk
 the presence of clinical features suggestive of secondary hypertension,
e.g. chronic kidney disease (CKD), obstructive sleep apnoea and rare
causes such as phaeochromocytoma, Cushing’s syndrome,
hypothyroidism and aortic coarctation.

1c. Which arm blood pressure recording should be used to guide Iniah’s (2 marks)
medical management? Give one reason.
Answer
Right arm - diagnosis and management should always be guided by the
readings from the arm with the higher measurement
1d. What is Iniah’s target blood pressure? (1 mark)
Primary Care Medicine Rotation 4A and B- Year 5 End of Posting Examination

Answer
Iniah’s blood pressure target is <130/85 mmHg as she has CKD with
microalbuminuria.

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Primary Care Medicine Rotation 4A and B- Year 5 End of Posting Examination

She was first diagnosed 5 years ago and reports good compliance with her medication. She
is an ex-smoker (30 pack years), drinks 1–2 glasses of red wine with her evening meal, does
not exercise regularly because of her knees and eats a lot of processed foods.
Her father was diagnosed with type 2 diabetes at 48 years of age and had a myocardial
infarction at 52 years of age.

On examination, there is silver wiring of her retinal vessels in both eyes, heart rate of 54
beats per minute, body mass index (BMI) of 31 kg/m2 and waist circumference of 95 cm.
Iniah states that she has had some blood tests performed one year ago but does not have
the results with her.

1e. How would you further investigate Iniah? (5 mark)

Answer
• sodium
• potassium
• urea
• creatinine
• eGFR
• serum albumin concentration
• FSL
• FBC
• Plasma aldosterone-to-renin ratio are normal.
• urinalysis
• UACR
• ECG

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Primary Care Medicine Rotation 4A and B- Year 5 End of Posting Examination

Iniah’s blood tests reveal:

• sodium 136 mmol/L (reference range 135–150)
• potassium 3.8 mmol/L (3.5–5.0)
• urea 12.6 mmol/L
• creatinine 146 μmol/L (70–110)
• eGFR 38 mL/min/1.73 m2
• serum albumin concentration 38 g/L (32–40)
• total cholesterol 5.8 mmol/L
• HDL cholesterol 1.8 mmol/L
• LDL cholesterol 3.6 mmol/L
• triglycerides 1.6 mmol/L.

Her full blood count, the remainder of her biochemistry and her plasma aldosterone-to-
renin ratio are normal.

A urinalysis reveals 10 x 106/L red and white cells and a UACR of 22 mg/mmol (<5.0
mg/mmol).

Her ECG shows evidence of left ventricular hypertrophy. Records obtained from Iniah’s
previous GP showed that 2 years ago her serum creatinine was 125 mmol/L and eGFR was
40 mL/min/1.73 m2.
1f. What is your diagnosis? (2 marks)

Answer
CKD with microalbuminuria.

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Primary Care Medicine Rotation 4A and B- Year 5 End of Posting Examination

Question 2
78 year old Tony is a widower and lives alone. He has been brought to see you today because of
altered behavior noticed by his son. He used to be compliant to medication but not in the last 5
months and always says he is too tired to bother leaving the house. He used to eat a healthy diet but
now eats canned food and buns only. His children want him to go and stay with them, which he says
makes him feel like a child.

He has always been socially active till 6 months ago when his wife died suddenly. His two children
don’t live with him and are concerned for his health.

He has hypertension and hypercholesterolemia but does not have any any known psychiatric
illnesses. He had an acute myocardial infarction (AMI) 1 month previously. His recovery was
complicated by pneumonia and delirium. Tony has become anxious and fears that he will not
survive the next attack. His discharge medications included aspirin, atenolol, perindopril,
atorvastatin and esomeprazole.

He has have put on 6 kg over the last 5 months and does little physical exercise. He has never
smoked.

2a. What is your working diagnosis? (2 marks)

Answer
 Major Depressive Disorder

2b. Give THREE differential diagnoses (3 marks)

Answer
 Depression due to a general medical condition or medication
 Delirium
 Dementia

2c. Name THREE investigations you would request to exclude differential (6 marks)
diagnoses. Give reasons.

Answers
 Mid-stream urine for microscopy and culture to rule out (TRO) UTI
 chest X-ray TRO Pneumonia
 blood tests TRO electrolyte disturbance
 and electrocardiograph (ECG) TRO arrhythmia.
 Vitamin B 12 deficiency

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Primary Care Medicine Rotation 4A and B- Year 5 End of Posting Examination

You diagnose a Major Depressive Disorder and commence escitalopram. You request relevant
investigations to exclude medical causes of his symptoms. You also refer Tony to an inpatient
cardiac rehabilitation program. When you review him 1 month later his mental and physical
health are both much improved.

2d. Name 4 side effects should you monitor Tony for? (4 marks)
Answer
SSRIs - anorexia, nausea, diarrhoea and dizziness, hyponatraemia, postural
hypotension and falls, reduced bone density and fractures, bleeding (especially
gastrointestinal) and ECG changes

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Primary Care Medicine Rotation 4A and B- Year 5 End of Posting Examination

SHORT ESSAY QUESTIONS 20 MINUTES

Question 3 (SEQ)

a. Describe FIVE symptoms and signs in the diagnosis of asthma. (5 marks)

Any 5 of the following:

i. Frequent cough, especially at night.
ii. Dry cough
iii. Chest tightness
iv. Losing your breath easily/shortness of breath.
v. Feeling very tired or weak when exercising.
vi. Wheezing or coughing after exercise.
vii. Easily upset, grouchy, or moody
viii. Low peak flow reading < 300cc
ix. Abnormal spirometer test.
x. These signs include wheezing, a runny nose or swollen nasal passages, and
allergic skin conditions (such as eczema).

b. Describe 3 methods of investigations in the diagnosis of asthma.

(3 marks)
i. CXR
ii. Peak flow meter reading
iii. Spirometer reading
iv. Allergen test

c. Name 4 important symptoms and signs of microcytic hypochromic anaemia

(iron deficiency anaemia)?
i. Tiredness and loss of stamina
ii. Dizziness
(4 marks)
iii. Muscular aches and cramps
iv. Fainting attacks
v. Loss of memory
vi. Pallor
vii. Spoon shaped nails

d. In the laboratory test what 3 indices which will confirm microcytic hypochromic
anaemia(iron deficiency anaemia)? (3 marks)
i. Low haemoglobin < 11.5 mg/dL for females and 13.5mg/dL for males
ii. Low RBC < 6.0 for females and 6.5 for males
iii. Low MCV < 27 pg
iv. Low MCH < 77 fl
v. Low serum Iron Binding Capacity
vi. (Low MCHC) 30-36 g/dL
vii.

EPX – PCM - 2015/2016 MBBS Program MAHSA University