Medicine

Block examination

Instructions

This is a 3 hour examination.

There are 6 questions, each worth 20 marks. Each question is also subdivided into
subsections, and the number of marks for each subsection is given in brackets.

You should write your answer in the space provided. If there is not enough room you
may write on the back of the page, but it must be clear to which section of the
question your answer corresponds. No marks will be given for answers if the writing
is not clear, or if it is not clear to which question or subsection the writing is referring.

All questions must be answered.

You are free to leave early if you wish, except you must not leave during the last 10
minutes (to ensure those who are striving to finish are not disturbed).

Please ensure you write your student number at the bottom of this page, and also
ensure no page is detached from this booklet – there should be 12 pages (including
this page).

YOUR STUDENT NUMBER___________________

1
Question 1

A 45 year old woman has had increasing shortness of breath on exertion for about 2
months. Her daughter has asthma, and she has tried her daughter’s asthma spray with
no benefit.

a) LIST THE MOST IMPORTANT QUESTIONS TO ASK HER TO DISTINGUISH

WHETHER HER SHORTNESS OF BREATH IS CAUSED BY A CARDIAC
PROBLEM OR A RESPIRATORY PROBLEM (5 marks)

b) LIST THE MOST IMPORTANT FEATURES YOU WOULD LOOK FOR ON

PHYSICAL EXAMINATION TO DISTINGUISH WHETHER HER SHORTNESS
OF BREATH IS CAUSED BY A CARDIAC PROBLEM OR A RESPIRATORY
PROBLEM (5 marks)

c) LIST THE INVESTIGATIONS WHICH WOULD HELP DETERMINE THE

CAUSE OF THE PATIENT’S SHORTNESS OF BREATH. (FOR EACH
INVESTIGATION, GIVE THE REASON WHY IT WOULD HELP) (5 marks)

d) DESCRIBE WHAT IS MEANT BY THE DIAGNOSIS OF COR PULMONALE.

HOW WOULD YOU DETERMINE FROM THE HISTORY, PHYSICAL
EXAMINATION AND INVESTIGATIONS THAT THIS PATIENT HAS COR
PULMONALE? (5 marks)

Question 2

A 20 year old medical student complains of a severe headache.

a) WHAT ARE THE CLINICAL FEATURES WHICH WOULD HELP YOU

DISTINGUISH BETWEEN MIGRAINE, A CEREBRAL TUMOUR, A
SUBARACHNOID HAEMORRHAGE, MENINGITIS, AND ANXIETY CAUSED
BY AN UPCOMING BLOCK EXAM IN MEDICINE AS THE CAUSE OF THE
HEADACHE? (10 marks).

b) WHAT INVESTIGATIONS MIGHT HELP YOU? (GIVE YOUR REASONS

FOR EACH INVESTIGATION). (5 marks)

c) IF YOU HAVE MADE THE DIAGNOSIS OF MIGRAINE AS THE CAUSE OF

THE STUDENT’S HEADACHE, OUTLINE YOUR TREATMENT – INCLUDE A
DESCRIPTION OF ANY ADVERSE EFFECTS THAT MIGHT BE CAUSED BY
YOUR TREATMENT. (5 marks)

2
Question 3

A 50 year old Indian Fijian man developed a severely painful knee joint over 24
hours.

a) WHAT ARE THE CLINICAL FEATURES THAT WOULD HELP YOU

DISTINGUISH BETWEEN GOUT, SEPTIC ARTHRITIS AND REACTIVE
ARTHRITIS AS THE MOST LIKELY DIAGNOSIS? (5 marks)

b) YOU DECIDE TO TREAT THE PAIN WITH A NON-STEROIDAL

ANTIINFLAMMATORY DRUG (NSAID). DESCRIBE THE MECHANISM OF
ACTION OF THIS DRUG GROUP, AND THE IMPORTANT ADVERSE
EFFECTS THAT MIGHT OCCUR. (5 marks)

c) IF THE DIAGNOSIS IS GOUT, WHAT CHANGES WOULD YOU SEE IN THE

SYNOVIAL FLUID OBTAINED FROM JOINT ASPIRATION? (5 marks)

d) IF THE DIAGNOSIS IS GOUT, WHAT LONG TERM MANAGEMENT

WOULD YOU PUT IN PLACE TO TRY TO PREVENT RECURRENT
ATTACKS? (5 marks)

Question 4

A 40 year old Fijian man has had epigastric pain for some years.

a) DESCRIBE THE CLINICAL FEATURES THAT WOULD ENABLE YOU TO

DISTINGUISH BETWEEN CHRONIC OESOPHAGEAL REFLUX, A
DUODENAL ULCER, GALLSTONES AND CHRONIC PANCREATITIS AS THE
CAUSE OF HIS PAIN. (5 marks)

b) IF HE IS ALSO FOUND TO HAVE A Hb OF 7.5 (NR 13-15) AND MCV OF 60

(NR 82-96), LIST THE POSSIBLE EXPLANATIONS FOR THE ANAEMIA,
GIVING THE MECHANISM IN EACH CASE. (5 marks)

c) IF GASTROSCOPY REVEALS A DUODENAL ULCER, DESCRIBE YOUR

THERAPY OF THE ULCER.(5 marks)

d) DESCRIBE HOW YOU WOULD INVESTIGATE AND MANAGE THE

ANAEMIA (5 marks)

3
Question 5

A 35 year old Fijian woman is admitted to hospital with a fever, cough, pleuritic chest
pain, and shortness of breath.

a) WHAT PHYSICAL SIGNS WOULD MAKE YOU SUSPECT PNEUMONIA AS

THE CAUSE OF HER ILLNESS? (4 marks)

b) WHAT INVESTIGATIONS WOULD YOU PERFORM TO CONFIRM THE

DIAGNOSIS OF PNEUMONIA? (GIVE YOUR REASONS FOR EACH
INVESTIGATION). (3 marks)

c) HOW WOULD YOU DETERMINE WHETHER THE PNEUMONIA WAS

MILD, MODERATE OR SEVERE PNEUMONIA? (5 marks)

d) IF YOU HAVE ASSESSED THE PNEUMONIA AS BEING MILD, HOW

WOULD YOU TREAT THE PATIENT? (4 marks)

e) IF YOU HAVE ASSESSED THE PNEUMONIA AS BEING SEVERE, HOW

WOULD YOU TREAT THE PATIENT? (4 marks)

Question 6

A 40 YO woman presents to you with a 5 day history of nausea, tiredness, right

upper quadrant discomfort and jaundice.
Liver function tests showed the following results:

Total Bilirubin 105 umol/l (N: 10.2-29)

D. Bilirubin 85 umol/l (N: 0-6)
Alkaline Phosphatase 115 U/L (N: 36-92)
AST 1115 U/L (N <65 U/L)
ALT 764 U/L (N <70 U/L)
T. Protein 65gm/L (N: 64-83)
Albumin 36gm/L (N: 35-50)

a) EXPLAIN THE MOST LIKELY UNDERLYING LIVER PATHOLOGY

RESPONSIBLE FOR THIS WOMAN’S JAUNDICE? (4 marks)

b) WHAT ARE THE POSSIBLE CAUSES OF THIS CLINICAL PICTURE?

(4marks)

c) HOW WOULD YOU INVESTIGATE THIS PATIENT FURTHER? (4marks)

d) HOW WOULD YOU DETERMINE THE SEVERITY OF THIS PATIENT’S

LIVER DISEASE? (4 marks)

e) WHAT ARE THE IMPORTANT LINES OF MANAGEMENT THAT YOU

SHOULD CONSIDER? (4 marks)