Internal Medicine Examination 2019 (Rotation 2 Group 5)

1. 58 years old man complains of difficulty to maintain balance while walking

on slopes for 6 mo. On examination, he has a mild stooping posture, takes
time to get up from chair and when he walks the arm swing is less on the
left side. His muscle power, DTJ and planter response are normal. Ocular
movements are full. He is on some medication which he can’t remember.
Possibly he is suffering from
A. Old stroke
B. Progressive supranuclear palsy (PSP)
C. Parkinson disease (PD)
D. Multiple sclerosis

2. One of the following suggest TIA in internal carotid circulation:

A. Amaurosis fugax (Blindness in one eye)
B. Horner’s syndrome
C. Cortical blindness
D. Difficulty in swallowing

3. 32 y/o school teacher was found to exhibit odd behaviour. While talking to
her friend she suddenly started staring at the ceiling, followed by chewing
movements, licking of her lips and swallowing. Then she abruptly got up,
adjusted her spectacles, walked up to the door then came back and sat in
the chair. Whole episode lasted less than a minute. Patient has no
recollection of the even. It appears she had an attack of
A. Conversion reaction (hysterical reaction)
B. Complex partial seizure
C. Hypoglycaemia
D. TIA

4. 65 y/o gentleman was evaluated for cough and haemoptysis of 2/52

duration. He has been smoking 25 sticks of cigarettes per day for 40 years.
On examination of chest, patient has right supraclavicular fossa was
bulging. He had bronchial breathing and crackles in the same region.
Trachea was central. He was afebrile. The right pupil was small & there
was mild ptosis. The likely dx is?
A. PTB
B. Bronchiectasis
C. Wagener’s granulomatosis
D. Pancoast tumour
5. Which of the following is true for the dx of Legionella Pneumophilia?
A. PCR for Legionella DNA
B. Grows rapidly in culture
C. Acute and convalescent antibodies are not helpful
D. The microbe is seen in ZN-stain.

6. Miss Hema went to Jafina, Sri Lanka to visit her grandmother during
summer vacation. She stayed there for 3 weeks. 2/52 after her return to
M’sia she started getting nocturnal dry cough & breathlessness. On
examination, she had extensive bilateral rhonchi all over the chest. Her
CXR showed fine sand like particles in all the zones. Her Total WBC was
17,000 per mm3, Poly: 45%, Lympho: 30%, and Eosi: 25%. The likely dx is:
A. bronchial asthma
B. Missed
C. Missed
D. Missed
E. Missed

7. 29 y/o lady have SOB on lying flat and relieved upon sitting. She has been
running low grade fever for about 2 weeks. Her gynecologist had
prescribed her with oral contraceptive pills for irregular menses, which she
has been taking for the last 6 months. On examination, temperature 38°C,
BP 120/ 76 mmHg, pulse 80 bpm, respiratory rate 18 breaths/min.
Auscultation of back of chest is essentially normal. On auscultation of the
front of chest, abnormal finding has been noted. The likely finding is:
A. Pleural effusion secondary to pulmonary thromboembolism
B. Pericardial friction rub
C. Missed
D. Bronchial breathing and crepitus

8. A 54 years old man was brought to the A&e department in an unconscious

state with continuous jerking of his limbs & frothing from his mouth for the
last 15 minutes. In the morning, he had complained of severe headache
and dizziness. On examination in the casualty, his BP was 250/140 mmHg,
neck was soft, and he was confused. There was no focal motor deficit. A
CT scan of brain was reported normal. Which parenteral antihypertensive
drug will you administer to lower his bp?
A. Sodium Nitroprusside
B. Glyceryl Trinitrate
C. Labetalol
D. Phenoxybenzamine

9. Missed
10. 58 years old man presented with increased bowel movement, lose weight
despite good appetite. PE shows pulse 110, irregularly irregular, BP 150/80.
Investigation plasma glucose 6 mmol/L,TSH 0.8, serum catecholamine and
renal profile normal. Chest xray and ultrasound abdomen normal. What is
the likely diagnosis?
A. Diabetes mellitus
B. Phaechromocytoma
C. Missed
D. Thyrotoxicosis

11 to 15: Missed

16. 31 y/o woman present hx of fever for last 1 week. She also have rash over
sun exposed area. On examination, she has alopecia areata and ulcer in
the mouth. What is the most likely diagnosis?
A. Systemic Lupus Erythematosus
B. Missed
C. Missed
D. Missed

17. 22-year-old university boy was investigated and was found to have HBsAg.
Screening blood test; ALT, ALT is normal. Which shows active proliferation
of the virus?
A. HbsAg
B. HbeAg
C. Hbe – Ab
D. Anti - Hbc

25. Patient diagnosed with malaria, treated with chloroquine and was well, he
was later started on 5 days course of Primaquine, developed mild jaundice,
and Hb dropped from 12 to 10g/dl. What’s the cause ?
A. Intravascular hemolysis due to G6PD
B. Intravascular hemolysis due to malaria parasite itself
C. Caused by side effect of primaquine itself
D. Missed
26. A 26 yo man reported to the primary care physician for painful ulcers in
mouth and gums. The MO noted raised, wavy, hairy white lines on side of
the tongue and thrush on the soft palate. He had multiple aphthous ulcer
over gums and soft palate. On further questioning, he admitted that he is
promiscuous and does not practice safe sex. Patient should be
investigated for:
A. Gonorrhoea
B. Secondary syphilis
C. HIV
D. Lymphogranuloma inguinale

27. Missed

28. Patient on isoniazid and develop peripheral neuropathy. What other

medication need to give?
A. Folic acid
B. Ascorbic acid
C. Riboflavin
D. Pyridoxine

29. Missed
30. Missed
Modified Essay Questions
MEQ 1
Section A
A 30 years old man has presented with headache and low-grade fever of 10
days, vomiting and drowsiness of 2 days duration. He was found HIV positive 5
years ago when investigated for recurrent herpes zoster in different
dermatomes. One examination he appeared drowsy, temperature 100oF,
pulse 56 (regular) and BP 140/76 mmHg. He had neck stiffness.
a. List 2 provisional dx. (1 mark)
b. Missed
c. Name 2 additional signs of meningeal irritation (1 mark)
d. List 2 findings on general examination in this patient that may give clue
to the etiologies of the ddx you have entertained (1 mark)
Section B
Stem continues: …Neurological examination revealed bilateral 6th CN palsy
and papilledema. There was no motor sensory or cerebellar deficit. The house
officer planed an urgent CT scan of brain, followed by LP for CSF examination.
e. Write the expected abnormalities in the CSF pertaining to the
differential dx you have entertained in this patient under following
headings:
i. Pressure and appearance: _________ (1 mark)
ii. WBC count: _____per mm3 (1 mark)
iii. Glucose: ___________ (0.5 mark)
iv. Proteins: ___________ (0.5 mark)

f. Name 2 stains that you will use on the CSF that may disclose the
possible etiologist in this case.
Section C
Stem continues: … The CSF examination was consistent with the findings of
cryptococcal meningitis. Additional Ix showed that his Hb was 8 gm/dl, WBC
was within normal limits but there was lymphocytopenia. CD-4 positive T-cell
count was 150/mm3. His blood sugar, LFT, and renal profiles were essentially
normal. CXR was essentially normal & Mantoux’s test was negative.
g. Mention the drugs and dosages that you will prescribe to this patient.
MEQ 2
Section A
A 58 years old man was brought to the A&E department with central chest pain
of 1-hour duration. He was diagnosed to be suffering from coronary artery
disease 6 months ago.
a. List 4 ddx of central chest pain (arising from different organs). (2 marks)
b. List 6 points in the hx that will suggest the site of origin of chest pain and
mention relevant risk factors associated with it. (3 marks)
Section B
Stem continues: … The intensity of the pain was 8/10. It radiated to his left
shoulder and did not response to 2 tabs of GTN. Soon he developed
palpitation and breathlessness. He vomited once and was sweating. He has
been smoking 20 sticks per day for last 25 years. He suffered from DM and
HTN and dyslipidemia. There was no history of dyspepsia or GERDS. He did
not suffer from DVT of legs. His father died at the age of 75 years due to MVA.
c. What findings do you expect to find on general and CVS examination in
this patient? (3 marks)
d. List 3 Ix with expected results that will help you in establishing the dx in
this patient. (1.5 marks)
e. Write your complete dx. (0.5 mark)
Section C
Stem continues: …
On examination, the pulse was 120 bpm, regular rhythm, BP 160/100 mmHg.
He had orthopnea. Cardiac apex was heaving and in 6th left ICS. He had gallop
rhythm, but no murmur. There was bilateral crepitation over both lung bases.
ECG showed ST elevated MI. Cardiac markers, Trop T and CKMB were raised.
CXR showed haziness in both lung fields. Diagnosis of STEMI with left
ventricular failure. Risk factors: HTN, DM, Dyslipidemia, Smoking
f. How you will manage this patient? Write the dosages of drug where
required. (4 marks)
g. What advice will you give at the time of discharge? (1 mark)
MEQ 3
Section A
A 40 years old previously healthy man has developed fever, cough, and right
sided chest pain of one-week duration.
a. List SIX points in the hx that will help you to arrive at differential dx.
(4 marks)
Others Missed.
Short Essay Questions
SEQ 1
A 24 years old IVDU has developed high fever of 7 days duration. Write under
the following headings:
a. A. List 2 organs most likely to be affected in this patient. (1 mark)
b. List 2 microbes that may damage the organs mentioned above. (1
mark)
c. Enumerate the symptoms pertaining to the 2 organs mentioned in
above. (2m marks)
Digital OSCE
Exhibit 1

*for illustration purpose only

A 36 years old lady woke up in the early hours of the morning with severe
excruciating headache. Her photograph is displayed.
a. Why is she unable to open her right eye? Name the muscle and its
nerve supply. (1 mark)
- Due to paralysis of levator palpebral superior muscle supplied by 3rd
CN
b. State the abnormality that you will observe when eyelid is lifted. (1
mark)
-Right eye will be squinted, looking down and outwards.
Exhibit 2

*Exact picture

*Comparison: PTB *Comparison: Pancoast tumor

Exhibit 3

*Exact picture *Comparison: Spl. Hemorrhage

Exhibit 4

*Exact picture

Exhibit 5

*Exact picture *Comparison: Pityriasis Alba

Exhibit 6

*Exact picture

*Comparison: Megaloblastic Anaemia

Exhibit 7

*Exact picture *Comparison: PCK

Exhibit 8

*Exact picture

*Comparison: A.Fib
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