Question 1: Describe the physical examination of the cardiovascular system?

( 6 marks)

Question 2: Describe the abnormal sign shown ?

Question 3: Give TWO differential diagnoses.

Question 4: List TWO important investigations in this case ( 2 marks)

Station 1 : Internal Medicine

A 75-year-old man is brought to hospital with an episode of dizziness. He still feels

unwell when he is seen 30 min after the onset. He was well until the last 6 months,
since when he has had some falls, irregularly. On some occasions he lost
consciousness and is unsure how long he has been unconscious. On a few occasions
he has fallen, grazing his knees, and on others he has felt dizzy and has had to sit
down but has not lost consciousness.

These episodes usually happened on exertion, but once or twice they have occurred
while sitting down. He recovers over 10–15 min after each episode. He lives alone
and most of the episodes have not been witnessed. Once his granddaughter was with
him when he blacked out. Worried, she called an ambulance. He looked so pale and
still that she thought that he had died. He was taken to hospital, by which time he had
recovered completely and was discharged and told that he had a normal
electrocardiogram (ECG) and chest X-ray.

There is no history of chest pain or palpitations. He has had gout and some urinary
frequency. A diagnosis of benign prostatic hypertrophy has been made for which he is
on no treatment. He takes ibuprofen occasionally for the gout. He stopped smoking 5
years ago. He drinks 5–10 units of alcohol weekly. The dizziness and blackouts have
not been associated with alcohol. There is no relevant family history. He used to work
as an electrician.

Question 1: Describe the physical examination of the cardiovascular system? ( 6 marks)

Greet the patient

Introduce himself/herself
Ask for the patient’s name
Ask for the patient’s age
Courteous with the patient
Explain to the patient what procedure to be done throughout the exam
Techniques of Examination)
General examination
 Wash hands using alcohol lotion (provided)
 Observe patient’s general condition
 Examination of the hand
 Pulses
- Radial
- Water-hammer pulse or collapsing pulse
 - Carotid pulse
Inspection & Positioning the patient

 Appropriate position for examination (45º propped up).

 Adequate exposure (expose the chest until waist)
 Inspection from the end of bed
 Look for raised JVP
 Feel the JVP
Palpation)
 Apex beat:
 - Locate apex beat
 Thrills at the mitral, tricuspid, pulmonary and aortic region
 Left parasternal heave at the left parasternal region
 Check for sacral edema
 Check for pedal edema
 Examine for peripheral pulses (stop student after posterior tibial
pulses, omit popliteal pulses)
Auscultation
 Auscultate the mitral region with the bell, follow by
 Turning patient to the left side and ask patient to exhale and hold
his/her breath
 Auscultate mitral, tricuspid, pulmonary and aortic regions with
diaphragm
 Palpate either carotid or radial pulses during auscultation
 Auscultate both carotid pulses for bruit with diaphragm
 Auscultate in sitting position
 pulmonary region in full inspiration
 aortic region in full expiration
 Auscultate lung bases for basal crepitation
Upon completion of above examination
 Student to suggest to do BP measurement
 Thank the patient for cooperation & wash hands

Examiner :
The Bp is 96/64 mmHg
pulse rate : 33/min, regular.
There are no heart murmurs.

Question 2: Describe the abnormal sign shown ?

The jugular venous pressure is raised (1)
Patient has pallor of the conjunctiva (1)

Question 3: Give TWO differential diagnoses.

Neurological causes :
Epilepsy
Transient ischemic attacks

Vascular causes :
Arrhythmias (pallor present)
Postural hypotension (pallor present)

Additional : interpret this ECG.

Answer : 3rd degree heart block / complete heart block. No relation between P and QRS
complex caused by Stokes-Adams attack

Question 4: List TWO important investigations in this case ( 2 marks)

ECG (1)
Chest X-ray (1)
Cardiac enzymes troponin and CK-MB

Station 2 : Internal Medicine

A 19-year-old boy has a history of repeated chest infections. He had problems with a cough
and sputum production in the first 2 years of life and was labelled as bronchitic. Over the next
14 years he was often ‘chesty’ and had spent 4–5 weeks a year away from school. Over the
past 2 years he has developed more problems and was admitted to hospital on three occasions
with cough and purulent sputum. On the first two occasions, Haemophilus influenzaewas
grown on culture of the sputum, and on the last occasion 2 months previously Pseudomonas
aeruginosawas isolated from the sputum at the time of admission to hospital. He is still
coughing up sputum. Although he has largely recovered from the infection, his mother is
worried and asked for a further sputum to be sent off. The report has come back from the
microbiology laboratory showing that there is a scanty growth of Pseudomonason culture of
the sputum.
There is no family history of any chest disease. Routine questioning shows that his appetite is
reasonable, micturition is normal and his bowels tend to be irregular.

Question 1: Describe the physical examination of the respiratory system? ( 6 marks)

Build rapport
 Greet the patient
 Student introduces himself/herself
 Ask for the patient’s name
 Ask for the patient’s age
 Courteous to the patient
 Explain to the patient the steps of examination as he/she goes along
Techniques of Examination
 (General examination)
 Wash hands using hand rub
 Put patient in correct position sitting up at 45º for examination
 Expose the chest adequately
 Observe patient’s general condition
 Examine patient’s hands for cyanosis
 Examine patient’s hands for clubbing
 Examine for flapping tremor
 Check respiratory rate
 Examine for conjunctival pallor
 Examine for jaundice
 Examine for central cyanosis
 Examine neck lymph nodes (examine from behind patient)
Inspection of chest
 Inspect from end of bed
 Examine chest wall for scars/deformity/dilated veins
Palpation
 Examine tracheal position
 Perform chest wall expansion
 Perform tactile fremitus
Percussion
 Perform lung percussion systematically comparing both sides
Auscultation
 Auscultate all lung fields systematically comparing both sides
 Examine vocal resonance of lungs
 Upon completion of above examination
 Thank the patient at end of examination
 Clean hands using hand rub

On examination he is thin, weighing 48 kg and 1.6 m (5 ft 6 in) tall.

•The only finding in the chest is of a few inspiratory crackles over the upper zones of both
lungs. Cardiovascular and abdominal examination is normal.
Question 2: Describe the abnormal sign shown in this x-ray?

- abnormal shadowing throughout both lungs, more marked in both upper lobes with some
ring shadows and tubular shadows representing thickened bronchial walls.
These findings would be compatible with a diagnosis of bronchiectasis.
The pulmonary arteries are prominent, suggesting a degree of pulmonary hypertension.

Question 3: Give TWO differential diagnoses.

- Bronchiectasis
- asthma
- cystic fibrosis
- agammaglobulinaemia
- immotile cilia
- tuberculosis
- allergic bronchopulmonary aspergillosis associated with asthma

Question 4: List TWO important investigations in this case ( 2 marks)

- Sweat test to diagnose CF (>60mmol/L)

- High resolution CT for bronchiectasis
- CFTR gene testing