Internal Medicine Examination 2019 (Rotation 3 Group 4)

SBA
1. 26 y/o previously healthy woman developed rapid onset weakness of both lower
limbs a week after respiratory tract infection. On examination, she had reduced
tone in both lower limbs with grade 2/5 muscle power, diminished deep tendon
jerks in both lower limbs. There was loss of all modalities of sensation below the
nipple. She had retention of urine. Spine not tender. Diagnosis?

A Infarction of spinal cord at D4 segment

B GBS
C Epidural abscess
D Acute transverse myelitis

2. 65 y/o teacher has noted progressive weakness in holding small objects in his
hand for the last 6 months. Clinical examination show fasciculation in his right
thenar muscle and deltoids. Higher mental functions, speech, and cranial nerves
are intact. He has grade 4/5 power in all the 4 limbs. All deep tendon jerks are
exaggerated, plantars are extensors. There is no sensory or cerebellar deficit.
Bladder function is normal.

A Motor neuron disease

B Cervical spondylitis
C Muscular dystrophy
D Leprosy

3. 65 y/o hypertensive developed focal neurological deficit, recover within 5

minutes, he was evaluated by MO where it was an episode of TIA, which of the
following symptoms prompted him to consider a TIA in internal carotid circulation.

A Amaurosis fugax
B Horner syndrome
C Cortical blindness
D Lower motor neuron palsy
4. A 45 y/o woman presents to the rheumatology outpatient clinic with hx of stiff
hands and wrist of 3/12 duration. She mentions that the pain is worse in the
morning. On examination, the wrists, MTP jt and proximal interphalangeal jts are
swollen and warm. A dx of RA is suspected. Which of the following Ix is most
specific for the Dx?

A ANA
B Anti-CCP
C CRP
D X-ray hand

5. Dx of SLE

A ANA
B double strand DNA antibody
C Missed
D Missed

6. A 23-year-old woman presents to the A&E with haematuria. She finds difficulty in
walking due to pain in her knee and ankle joints. On examination, she was
afebrile & had purpuric rash at buttocks and lower limbs. What is the most likely
dx?

A HSP
B ITP
C Infective endocarditis
D Still’s disease

7. A 55 years old woman, complains of tiredness, fatigue, and weight loss in 4

months duration. On P/E: palpable spleen 10cm below the costal margin. Her
blood test revealed an elevated WBC and she is positive for Philadelphia
chromosome. She has been diagnosed as a case of Chronic Myeloid Leukaemia.
The most appropriate Tx is:

A Hydroxyurea
B Imatinib
C Myleren
D Stem cell transplant
8. 25 y/o woman, who has recently travelled from African safari, come to A&E
department, developed 7 days of fever and headache. On examination, the
temperature is 39 degree. A diagnosis of malaria is suspected. One of her family
member who accompanied her also developed high grade fever and passed out
cola coloured urine. What type of parasite will be likely seen on blood peripheral
smear.

A Plasmodium vivax
B Plasmodium ovale
C Plasmodium malariae
D Plasmodium falciparum

9. A 65 y/o man presents with a chronic hx of malaise, SOB, tingling numbness in

his feet. He feels tired on activities of daily living (ADL). On examination his Pulse
rate: 86bpm, (other vitals are normal), His HB: 6.5 g/dl, MCV is 106 fl. Blood
peripheral smear shows large RBSs, Coomb’s test is -ve. The most likely cause
of anemia is due to deficiency of:

A Hemolytic anemia
B Pernicious anemia
C Liver disease
D Folic acid deficiency

10. 36 y/o gentleman presented to clinic with fever and headache for 2 days. There
is no history of jungle trekking. However, his family ate at a roadside restaurant
before. On examination, abdomen is diffusely tender and spleen is just palpable.
Most likely diagnosis.

A Malaria
B Filariasis
C Typhus
D Typhoid fever

11. 75 y/o man admitted ED Tanjung Karang, complaint of loss of consciousness

while walking back home. Previously normal until current episode. Underlying
hypertension with history of thiazide for 3 months. Supine bp 97/73 mmHg, pulse
110, temp 36.9 degree, ecg, blood sugar and Hb normal. Likely cause of
syncope?

A Addisonian crisis
B Sepsis
C Myocardial infarction
D Drug induced
12. 30 y/o male developed sudden onset fever, pleuritic chest pain, cough with rusty
sputum. Pt had showed rapid shallow breathing and looked ill. PE will show all
except

A Restricted hemi thorax movement

B Dull percussion sound
C Bronchial breathing
D Decreased vocal fremitus

13. The most likely cause of superior vena cava obstruction

A Bronchogenic CA
B Mesothelioma
C Thymoma
D Apical pulmonary bullae

14. Unequal consolidation on a CXR can be caused by all except

A Pulmonary edema
B Pulmonary hemorrhage
C Pneumonia
D Pulmonary infarction

15. 34 y/o teacher was being treated with anti-tubercular drugs. Six weeks later
complained of pain and swelling of the right ankle. Aspiration of joint fluid showed
needle like crystal. Serum uric acid raised. The consultant asked his house
officer to discontinue the offending drugs. Which drugs that have been stopped?

A Isoniazid
B Rifampicin
C Ethambutol
D Pyrazinamide

16. 26 y/o obese young man given T. Metformin for newly diagnosed DM. He is
asked to come for follow up. He claim good complaint. But wake up to void urine
3-4 at night. What is the indicator to check for his control?

A Fasting and post prandial glucose

B HbA1c
C Serum glucagon
D Serum insulin
17. What is true regarding leptospirosis

A Acquire by airborne
B Mostly effect lungs
C Detect easily by culture
D Its is zoonotic disease

18. 45 y/o male presented with dizziness, headache diagnosed with systemic
hypertension, the following are true except:

A Left ventricular hypertension is best detected by CXR

B Poor control of hypertension may result in hemorrhagic stroke
C Coarctation of aorta is a secondary cause of hypertension
D Phoechromocytoma may present with hypertensive emergency

19. A 26 y/o lady complained of weakness and LOW of 5 months duration. She
denied fever and cough. On exam, she appeared wasted had pigmentation of
oral mucosa. Her supine BP was 90/70 mmHg and after 2 mins standing it fell
down to 70/50. Her Hb 5.6 mmol/L. She should be investigated for:

A Thyrotoxicosis
B Addison disease
C HIV
D DM

20. A 50 y/o woman has been brought with complaint of feeling low. The daughter
feels that her mother has gained weight since she saw her last about a year ago.
Clinical examination is essentially normal except for delayed relaxation of ankle
jerks. She should be excluded for:

A Depression
B Cushing syndrome
C Hypothyroidism
D Perimenopausal syndrome
21. 66 y/o man had undergone right hip replacement. He had given injection
enoxaparin 24h before surgery and continued daily thereafter. He had to be
injected pethidine twice a day to relieve his pain. On 4 th day post operative day,
he was noted to be drowsy. The pt developed seizure in the evening.
Neurological check up did not reveal any abnormality. CT brain showed mild
cerebral atrophy. ECG showed ST depression of 1mm in lead 2,3, aVF. CXR,
FBC,LFT, urea and creatinine were normal. Blood sugar level was 11 mmol/L.
Serum electrolyte, sodium 120 mmol/l, potassium 4mmol/l. his neurological
problem can be explained due to effect of:

A Enoxaparin
B Pethidine
C ECG changes
D Hyponatremia

22. 30 y/o lady came to the ED complaining of sudden onset SOB. She had returned
to Malaysia after 10 days holiday in America. She had no past hx of diabetes or
hypertension. She had 2 prev episodes of spontaneous abortion. She is a non
smoker and does not abuse drugs. Physical examination revealed that she is
tachypneic and breathless with SpO2 of 92% on room air. The lung were clear to
auscultate and there was no murmur. The right thigh appeared swollen and
slightly tender. What is the most definitive investigation?

A ECG
B CXR
C CTPA
D Echocardiogram

23. 35 y/o female diagnosed with hypertension few months back. Control suboptimal.
Investigation: urea 5.6mmol/l, potassium 2.1mmo/l, creatinine 96mmo/l, sodium
146mmol/l. Dx:

A Conns syndrome
B Coarctation aorta
C Renal artery stenosis
D Renal tubular necrosis
24. Mr. Sevaraju been undergoing regular hemodialysis last 4 years. Which
parameters will not improve with hemodialysis?

A CCF
B Hyperkalemia
C Anemia
D Uremic encephalopathy

25. 45 y/o man complained of intermittent hematuria of two years duration. On

examination he had hypertension; bilateral lump was felt in the abdomen. One
year ago, he had experienced very severe headache for which contrast CT
angiogram for brain was done which showed berry’s aneurysm in the circle of
Willis in relation to left carotid artery. The likely cause of his hypertensive is

A Bilateral hydronephrosis
B Renal artery stenosis
C Abdominal aneurysm
D Polycystic kidney disease

26. A 65 y/o man is seen in the clinic complaining of tiredness and lethargy. He has
lost 8 kg of weight over a 4 months period with normal appetite and bowel habits.
His abdominal examination and per rectal examination are normal. His FBC
reveals Hb of 9.2. The same was 14 one year ago. His MCV is 70Fl. What is the
most appropriate management.

A Reassurance
B hematinics
C Urgent endoscopy
D Follow up

27. A known case of ulcerative colitis came with fever, abdominal pain, diarrhea. On
examination, is pale and toxic looking, abdomen is distended and tender. There
is fresh blood on per rectal exam. Hb is 12, CRP is 22. Which following
complications has he developed?

A Intestinal obstruction
B Toxic megacolon
C Mild flare of UC
D Perforated peptic ulcer
28. 65 y/o male present with jaundice for 3 weeks. He had hx of pale stool and tea
coloured urine. On examination, abdomen soft non tender, a non-tender palpable
mass felt at right upper quadrant. What are most likely causes?

A Cholelithiasis
B Gall bladder Ca
C Pancreatic Ca
D Hepatocellular Ca

29. 23 y/o man come to clinic with red plaques with white scales. What is the nail
changes that is pathognomonic?

A Pitting nail
B Oncychomycosis
C Beaus line
D Oil drop sign

30. An athlete presented with tenia pedis and hypopigmented skin lesion on the
back. Dx?

A Ptyriasis vesicolor
B Psoriasis
C Leprosy
D Eczema
SHORT ESSAY QUESTIONS (SEQ)

1) A 26 years old man is a drug abuser for the last 2 years. 3 days ago he was admitted
in acute medical ward on suspicion of respiratory and cardiac complication associated
with IV drug abuse.
A) RSP signs and symptoms
B) CVS signs and symptoms
C) Investigation for lung infection with expected findings
D) Diagnostic investigation for CVS
E) Treatment for cardiac lesion

2) Write a short essay on rheumatoid arthritis (RA) under the following headings.
A) Pathophysiology
B) Diagnostic criteria (ARA)
C) List and elaborate 4 systemic manifestations of RA.
D) Differential diagnoses of RA.
E) Treatment of RA.

3) A 26 years old male sowed paddy in his field. During many days of work, he had
sustained some abrasion on his feet which covered with mud and rain water up to his
ankle. He did not bother because no pain. 10 day later he develops fever which
continue to persist for more than 2weeks despite taking paracetamol.
A) List 4 differential diagnosis of fever more than 10 days duration in the above
scenario.
B)Discuss in brief the etiopathogenesis of leptospirosis.
C)Expected finding on GE and PE.
D)Mention 2 diagnostic tests of leptospirosis.
E) Treatment of leptospirosis.

4) A 56 year old woman has been complaining of aches & pain in her limbs & spine.
The treating physician suspected osteoporosis. Write about this disease under the
following headings.
A) What are the differences between osteoporosis and rickets/osteomalacia. Write in a
table form.
B) Aetiopathogenesis of osteoporosis
C) Investigations of osteoporosis.
D) Treatment of osteoporosis.
MEQ
2) 30+ y/o lady given birth vaginally 10 days ago to healthy baby. She developed
chest pain and SOB.

A.4 differential dx for this

B. Further hx to confirm your differentials

2b) BP is 100/70, pulse rate is 90, prickling pain, 4/10, not worsen on deep
inspiration. No orthopnea. Calf tenderness.
C. What dx?
D. 4 investigations and interpretation
E.

2c. Doppler showed DVT, CT Pulmonary angiogram confirm pulmonary

thromboembolism.
F. Standard tx for PTE
G. One drug to prevent? And what side effect
H. How to monitor that side effect.
I. What other 2 modalities of treatment?

OSCE
OSCE 1 Kayser-Fleischer Ring

1. Describe the picture.

2. What’s the name of this sign.
3. The underlying disease.
4. How’s this form?
5. What are the specific organs to check.
6. Treatment
OSCE 2 Pleural effusion

1) 2 abnormalities seen in x ray.

2) diagnosis
3) causes
4) other investigations

OSCE 3. Rheumatoid arthritis

1. Identify the deformities.

2. Diagnosis.
3. Investigations.
4. Treatment.
OSCE 4. MICROCYSTIC HYPOCHROMIC ANEMIA

1. Identify the blood film.

2. Diagnosis.
3. Causes of the diagnosis.

OSCE 5.

1. Interpret the ECG.

2. Diagnosis.
3. Investigations.
4. Management.
 OSCE 6. Acromegaly

1. Diagnosis
2. Radiology test
3. Blood test
4. Eye sign
5. Management (medical& surgical)

INTERACTIVE OSCE
• Counsel asthma patient
• Trigeminal nerve examination