PAEDITRICS

Case 1

A 2 year old female presented to your facility with a 3 day history of bloody diarrhoea. She
passes approximately 6 episodes of loose stools per day and vomits 4 times in a day over the
period.

On examination, he had a temperature of 38.6 deg celcius, was not pale or jaundiced. He had
sunken eyes, delayed skin recoil, lethargic. She was well perfused. Examination of other systems
was essentially normal with a normal finding on Digital Rectal Examination.

a. What is the most likely diagnosis?

b. How would you manage the patient?

c. Outline 3 possible risk factors for the diagnosis made

d. How would you counsel the caregiver of this child following discharge?

ANSWERS

a. Dysentery with severe dehydration

b. Management (management is by principles)

Detain the child
Assess airway, breathing and circulation for resuscitation
Iv canula and take blood samples for investigation
Give IV FLUIDS Ringers lactate
Give 30 mls/kg for the 1st 30 mins then 70 mls/kg for the next 2.5 hours (PLAN C)
Give iv antibiotics ciprofloxacin
Tepid sponge to control fever
Give ORS as much as child can take
Give anti-pyretics
Give zinc tablet 20 mg dly for 14 days
Reassess after 3 hours to classify type of dehydration and manage either plan A or plan B

c. Risk factors
Poor hand hygiene, poor sewage disposal and poor water sanitation

d. Improve hand hygiene

 Proper sewage disposal
Water sanitation
Counsel mother on fluid containing diet
Teach mother on how to prepare oral rehydration salt
Counsel to report back to facility if vomiting and diarrhea persist
Educate mother on danger signs of dehydration

Case 2:

A 3 day old baby was brought to your facility with yellowish discolouration of the body seen
within the first 24 hours of life. Mother initially reported to her midwife and was asked to
sunbath the baby. She later noticed the baby was unable to suckle well on the day of
presentation, with an abnormal cry and was uncosolable and reported to your facility.

On examination, baby was deeply jaundiced upto the feet, was pale. Hydration status was
good. He had a shrill cry and was irritable. Heart rate was 186bpm and a Respiratory Rate of
78cpm. No abnormal movements were seen. Examination of the other systems was normal.

a. What is your complete diagnosis for this baby?

b. How would you manage this baby?

c. Outline the 6 causes of physiologic jaundice in the newborn

d. Write a feedback to the Maternity Home where the Mother first presented

ANSWER

a. Pathological neonatal jaundice with kernicterus (abnormal crying, unable to suckle and
inconsolable crying suggest kernicterus is present) pathological is 1st day and 6th day
onwards, physiological is 2nd to 5th day
b. Managemet
Detain and counsel mother on condition
Assess airway, breathing and circulation for resuscitation
Nil per os due to possible exchange transfusion
Hydrate the child (reduce bilirubin)
Avoid breastfeeding
Refer for phototherapy

c. Causes of physiologic jaundice

Pre-hepatic – haemolysis due to high red cell mass with short life span
 Hepatic – immature liver enzymes eg glyconuric transferase and immature hepatocyte
Post hepatic - delayed in passing meconium due to delayed feeding, and delayed gut
flora
d. Jaundiced at the 1st day of life should be referred to NICU for urgent management

Case 3

A 5 year old boy presented with a 2 day history of fever, passage of cola-like urine and 3
episodes seizures within the last 24 hours.

On examination, he was febrile (Temp- 39.1 deg celcius), very pale, jaundiced and well
hydrated. He was conscious and alert. Examination of other systems was essentially normal.

a. What is your complete diagnosis for the child?

b. List 8 features of Severe Malaria
c. How would you manage this child?
d. How would you counsel the caregiver of this child following discharge?

ANSWERS

a. Severe malaria with intravascular haemolysis, severe anaemia and multiple seizures
b. Altered consciousness, severe anaemia, marked jaundice, tachypnea, sweating, oliguria,
profused vomiting, hyperpyrexia, hypoglycaemia.
c. Detain the child and reassure mother
Assess ABCD
Check the random blood sugar
Iv line and take blood samples for investigation
Tepid sponge the child
Give Intramuscular artemether
Hydrate the child with iv fluids
Give haematenics
Serial urine monitoring for haematuria
Refer for further management
d. Educate on condition, Sleeping under insecticide treated bed nets, ensure environmental
sanitation, use of personal protective clothes especially at night, adherence to
medications, eating foods which contain iron rich, review in a week

Case 4

a. Discuss the benefits of breastfeeding

b. A mother reports to you that her 2 month old baby is not receiving adequate breastmilk and so
she wants to introduce complementary feeds. How would you manage this scenario?

ANSWERS

a. Importance to mother – bond between child, maternal amenorrhoea, reduces breast

infection such as mastitis, reduces cancer
Importance to child – immuglobins to baby, protection against diseases such as diarhoea
Importance to nation – less expensive, environmental friendly, readily available
b. Mothers perspective
Is it feeding technique mother lacks
Stress
Sickness from the mother or inverted nipples
Maternal infections such as mastitis
Maternal nutrition
Babys perspective
A disease condition like kernicterus
Congenital defects
Malnourished child

CASE 5

A 3 year old female presented to your facility with a 3 day history of passage of loose
non-bloody stool associated with vomiting.
On examination, she looked very wasted with a wt/ht z-score <-3SD, with other stigmata
of severe accute malnutrition. Examination of other systems essentially normal
Retroscreen done was reactive.

1. List 10 clinical features of Severe Acute Malnutrition

2. List 8 acute complications of Severe Acute Malnutrition
3. Outline the management of any 4 of these complications
4. How would you prepare this patient for discharge?

Answers

1. Bi-pedal oedema
Severe muscle wasting
Flaking skin on the leg
Disinterested in food
Puffy face
 Brownish hair
Pallor
Sore on the oedematous part of the body
Reduced muscle bulk
2. Hypoglycaemia
Hypovolaemic shock
Xeropthalmia
Severe dehydration
Heart failure
Hypothermia
Acute kidney injury
Severe anaemia

3. HYPOGLYCAEMIA MGT
Conscious child
Oral fluids – 50 mls of 10% glucose or sucrose
That is 1 teaspoonful of sucrose in 50 mls of water for child to drink, and then you start
breastfeeding
Because of Reductive adaptation, if you give the child IV the child will get heart failure
Unconscious child
5mls/kg of 10% dextrose as bolus
Pass NG tube and start feeding with formula 75 every 2 hours
Depending on recovery, continue

INFECTION MGT
Give broad spectrum antibiotics
NB: some may come with hypothermia that is without any focus

DEHYDRATION 2°SHOCK
Resomal 5mls/kg for every 30 mins for 2 hours
Then resomal alternating with formula 75 5mls/kg every hour for 10 hrs
Reassess the child then continue or stop

SHOCK MGT
Cover with antibiotic and hydrate
Put on oxygen
Correct hypoglycaemia
Cover the patient to keep her warm
Ivf R/L 15 mls/kg/hr
Reassess the patient to avoid fluid overload
Check pulse rate, respiratory rate and ensure peripheries are warm
 Give 2nd bolus of IVF
Transfuse whole blood 10 mls/kg if anaemic
Give laxis as premedication
Switch to NG tube feeding
Rexomal 5mls/kg/hr alternating with formular 75 for 10 hrs
Monitor child every 10 minutes
Give IVF R/L with 5 % dextrose or 20 mmol/l of potassium chloride

XEROPTHALMIA MANAGEMENT
Vitamin A

4. Preparation for discharge

Discharge if weight gained is 15% more of weight admitted
If all complications have resolved
Pass the appetite test
Give Plumpes snack
Stimulate the child by singing, rubbing
Refer to appropriate people

CASE 6

1. Who is a retro exposed child

2. Who is a retro affected child
3. What is presumptive staging in Pediatric HIV
4. What is entailed in the PMTCT
5. How would you manage a retro exposed baby
6. Outline 10 complications of retroviral infection

ANSWER
1. Definition
 a child born to a mother who is HIV positive
 a child less than 18 months turns positive to HIV antibody test (retro-exposed)
 a breastfeeding child whose mother is HIV positive

NB: 18 months because in breastfeeding child has both his antibodies and her mother but if he
stops breastfeeding by 1 year, by 18 months, he has only his own antibodies

2. retro affected child is a child whose parents are sick with AIDS or dead
3. when a child less than 18 month and test positive for antibody test and starts to show
signs of the disease
4. * Primary prevention of HIV among women of child bearing age
 * Prevention of unintended pregnancies among women living with HIV
* Prevention of HIV transmission from a woman living with HIV to her infant
* Provision of appropriate treatment, care and support to women living with HIV and
their children and families.
5. Medication; Zivdovudine and Nevirapine for 12 weeks, start septrin until 12 weeks, if
positive continue, if negative then stop
Nutrition: exclusive breastfeeding for 6 months, introduce formula feeding for 12
month. Stop breastfeeding after 1 year.
Testing: early infant diagnosis 6 weeks

CASE 7

A 2 year old boy was brought to your facility with generalised bodily swelling of a week‟s
duration. This is the first of such episodes.Was associated with passage of frothy urine. No recent
history of a sore throat or skin infection.

Not associated with headaches, hematuria or passage of dark urine.

On examination, child has anarsaca, afebrile, not jaundiced. BP within the normal range for his
age, sex and height. He weighs 15kg

1. What is your most likely diagnosis

2. What is the case definition for Nephrotic syndrome
3. List 8 secondary causes of nephrotic syndrome
4. How would you manage this patient (both mainstay of treatment as well as supportive
management)

ANSWER

1. Nephrotic syndromne
2. A triad of heavy proteinemia of 3 +, hypoalbunimea, and generalized oedema
3. Systemic lupus erythematous
Drugs eg NSAIDS
INFECTION Hep B,C
Infestation such as schistosomiasis
Ayloidosis
Chronic disease
4. Mainstay (Steroid)
 High 50 mg/m2/kg daily for 6 weeks or 20 mg/m2/kg
Maintain 40 mg/m2/kg 6 weeks alternate for 6 weeks
Supportive ( daily weighing, adequate protein diet, Low salt diet)

NB: if child urine is < 1ml/kg/hr we start diuretics

Give Penicillin V for therapeutic treatment to prevent or protect contact

CASE 8
A preterm neonate was brought to your facility in respiratory distress.
Baby‟s mother was an ANC non-attendant, as such the his gestational age could not be
ascertained from the ANC book
1. Briefly describe how you would assess this baby‟s gestational age
2. Outline 8 acute complications of Prematurity
3. Outline 8 long term complications of Prematurity
4. Discuss the management of any 4 of these complications
5. How would you prepare this infant for discharge

ANSWER
1. Dubowit score
Ballard‟s score
2. Hypothermia, hypoglycaemia, low birth weight, neonatal jaundice, neonatal sepsis,
necrotizing enterocolistis, patent ductus ateriosus, acute respiratory distress of the
premature.
3. Kernicterus, recurrent hypoglycaemia, seizures, cerebral palsy, risk of diabetes,
hypertension
4. Hypothermia
Kangaroo mother care
Skin to skin contact
Initiate breastfeeding
Keep them under incubator
Keep them under a clean clothe

5. HYPOGLYCAEMIA MGT
Conscious child
Oral fluids – 50 mls of 10% glucose or sucrose
That is 1 teaspoonful of sucrose in 50 mls of water for child to drink, and then you start
breastfeeding
Because of Reductive adaptation, if you give the child IV the child will get heart failure
Unconscious child
 5mls/kg of 10% dextrose as bolus
Pass NG tube and start feeding with formula 75 every 2 hours
Depending on recovery, continue

INFECTION MGT
Give broad spectrum antibiotics
NB: some may come with hypothermia that is without any focus

DEHYDRATION 2°SHOCK
Resomal 5mls/kg for every 30 mins for 2 hours
Then resomal alternating with formula 75 5mls/kg every hour for 10 hrs
Reassess the child then continue or stop

CASE 9

A 6 year old boy was rushed to your facility with a swollen left leg which happened about 5
hours prior to presentation. This was associated with differential warmth and redness.
Examination of the left leg also revealed 4 fang marks on the foot. There was no fever however.
The child apparently was well, helping out on the farm. He felt a sharp scratch on his foot which
later became associated with the above presentation

1. What is the most likely diagnosis?

2. Discuss the different types of Snake bite envenomation and their clinical presentation
3. How would you manage this patient?
4. Counsel the caregivers of this child on the first aid management if snakebite before
coming to the hospital

ANSWERS

1. Cellulitis of the left leg secondary to snake bike

2. myotoxins – swelling, warmth, signs of inflammation
cytotoxins - swelling, warmth, signs of inflammation
Neurotoxins – ptosis, frothy saliva, slurred speech, respiratory failure, paralysis of
skeletal muscle of skeletal muscles

3. Management
Detain the child
Assess ABC
IV Assess and take blood samples for investigation bed site clotting time
Give antibiotics
 Give antipyretics
Give anti snake venom
4. Do not tire the limb
Do not apply ice
Do not suck the affected limb

How to transport this child

Ensure the limb is immovable to prevent the spread of the venom
Do not elevate the limb so that the venom will not spread

CASE 10

A 2 year old child was rushed to your facility with drooling which started an hour prior to
presentation. Mother is a local soap maker and left the child unattended whiles making the soap.
She later came to find the child in this condition

1. What is the most likely diagnosis?

2. What other relevant history will you elicit from the mother?
3. How would you manage this patient?
4. Counsel this mother on this discharge

ANSWER

1. Caustic soda poisoning

2. Quantity ingested
Check the clothing
Intervention made at home
3. Counsel mothe r and admit
Secure IV line and take samples for investigation
Adequate hydration
Give oxygen if in distress
Give Proton pump inhibitors
Give hydrocortisone
Oral care – use Vaseline or borgella cream on lips
Give IVF
Give paracetamol
Refer after initial management
4. Keep an eye on the child
Safe keeping of container
 Counsel on medications
Counsel on complications

Contraindications of Activated charcoal

Pesticide, hydrocarbon, acid, alkali,alcohol, iron, lithium, solvent (turpentine, kerosene)
organophosphate poisoning

CASE 11

A 2 year old child was brought to your facility in respiratory distress with fever of 3 days
duration. This is associated with cough and rhinorrhea. Examination of the chest revealed
bronchial breath sounds with crackles and some rhonchi as well

1. What is your likely diagnosis?

2. What are the features that determine the severity of Bronchopneumonia
3. List 5 risk factors for Bronchopneumonia in children
4. How would you manage this patient?

ANSWER

1. Severe Bronchopneumonia with bronchiolitis

2. Tachypnea
Tachycardia
Flaring of the ala nisi
Cyanosis
Use of accessory muscles in breathin
SP02 less than 92 %
Chest in drawing
Lethargy
Reduced chest expansion
3. Exclusive breastfeeding, hand hygiene, indoor smoke, vitamin A and zinc deffficiency,
overcrowding
4. Counsel mother and admit
Ensure airway is patent
Ensure child is breathing and give humidified oxygen
Nebulize the child
Assess IV line and take blood for blood samples
Give broad spectrum antibiotics eg ceftriaxone
Control fever by tepid sponging the child
 Give antipyretics
Ensure adequate hydration by giving IVF
Monitor respiration, SPO2, pulse and temperature
Review child immunization if up-to-date
Ensure adequate feeding if stable
Refer if symptoms persist

Additional notes
Magement of Broncchiolitis
Nebulise the child with hypertonic 3% saline or salbutamol if saline unavailable
Put on oxygen
Adequate nutrition if feeding or IVF if not feeding

CASE 12

A 3 year old child was rushed to your facility with excessive salivation and drooling. Parents
reported that the child was chanced on playing with the pesticide they use on their farm so
suspect the child has consumed some of that.

1. What is your most likely diagnosis?

2. Outline the clinical features of organophosphate poisoning
3. How would you manage this child
4. Counsel the caregivers on discharge

ANSWER
1. Organophosphate poisoning
2. DUMBBELDS
Diarrhoea, urination, myosis, bronchorea, bronchospasm, emesis, lacrimation,
drooling, salivation
3. Admit child in a lateral position
Trigger referral system
Call for help and assign role
Ensure airway patency, adequate breathing by administering oxygen, and circulation
Ensure IV assess and take samples for investigation
IVF for resuscitation
Gastric lavage if within 24 hrs
Give antidote useful in treating
Atropine (muscle relaxer) and pralidoxime(to reverse muscle paralysis resulting from
organophosphate )
Monitor vitals and refer
4. Counsel on keeping eye on the child
 Safe keeping of containers
Counsel on medication
Counsel on complications

CASE 12b

Assume this child consumed kerosene………

1. Outline the clinical features of organophosphate poisoning

2. How would you manage this child
3. Counsel the caregivers on discharge

ANSWER
1. Fever, cough, respiratory distress, GI irritation, altered mental state +
DUMBBELDS
Diarrhoea, urination, myosis, bronchorea, bronchospasm, emesis, lacrimation,
drooling, salivation
2. Admit child and reassure care giver
Call for help and assign roles
Ensure airway patency,
Ensure breathing by administering oxygen
Give IVF
Keep child on nil per osgive antibiotics prophylaxis
NB: There is a risk of developing pneumonitis so there may be respiratory
symptoms. In that case antibiotic are used
3. Counsel on keeping eye on the child
Safe keeping of containers
Counsel on medication
Counsel on complications
 OBSTETRICS AND GYNAECOLOGY

DAY 1

OBS 1

A 32- year-old G3P2A presents with bleeding per vaginam at 35 weeks‟ gestation.

a. List 4 differential diagnoses of this patient‟s presentation, other than placenta previa and
abruptio placentae. 4 marks
b. What features in the history would be suggestive of placenta previa? 3 marks
c. What examination findings would be suggestive of abruptio placentae? 3 marks
d. List 3 risk factors for Abruptio placentae. 3 marks
e. List 2 supportive/ ancillary investigations you would do. 2 marks
f. Assuming that an ultrasound scan confirms the presence of a placenta previa, briefly
outline your management of this patient. 5 marks

ANSWERS
a. Placenta causes
Placenta abruption
Placenta praevia

Non placenta causes

Cervicitis
Cervical cancer
Vasa praevia
b. Features of placenta praevia
i. bright red bleeding
ii. no abdominal pain
iii. presence of fpetal movement
iv. warning or sentinel bleed

c. Findings of abruption placentae

Tenderness
Woody hard abdomen
SFH larger than expected
No malpresentation
Bleeding
Uterine contraction

d. Risk factors
Hypertension
Multiple gestation
High parity
Smoking
Oligohydramnios
Trauma

e. Supportive management
Full blood count
Bloog grouping & x-matching
Bed side clotting
Liver function test
Renal function test

f. Management
Assess ABC
Counsel on diagnosis
Admit
Monitor maternal and foetal condition
Post counseling
3 units of blood
Serial ultrasound
Bio-physical profile
Fetal kick count

g. Types of praevia
 Marginal
Lowlying
Partial
Complete

Notes: Complications on mother and baby

Anaemia
Preterm delivery
Pre maturity
IUGR
Congenital malformation
haemorrhage

OBS 2

A 29 year-old G3P0+2SA at 33 weeks‟ gestation presents to you with loss of clear fluid per
vaginam since 6AM today.

a. What is the most-likely diagnosis? 1 mark

b. What examination finding would confirm this diagnosis? 1 mark
c. Name 3 investigations that can help confirm your diagnosis. 3 marks
d. List 4 risk factors for this condition. 4 marks
e. List 3 maternal and 3 fetal complications of this condition. 6 marks
f. Briefly outline your management of this patient. 5 marks
ANSWERS

a. Preterm premature rapture of membranes

b. Examination findings
On sterile speculum examination reveals a clear fluid issuing from the cervical os
c. Investigations
Fernings test-a fluid on microscope shows a fern
Nitrizine yellow test-alkaline vagina turns blue
Red litmus turns blue

d. Risk factors for PROM

Cervical insufficiency
Previous history of PROM
MULTIPLE gestation
Polyhandraminous
Cigarette smoking
Trauma
 e. Complications
Mother
Preterm labour, chorio amnionitis, peri-tubal adhesion, sepsis
Foetus
Cord proplapse, prematurity, neonatal sepsis, neonatal respiratory distress, IUFD,
oligohandraminous

f. Management
Counsel and admit
Maternal and foetal monitoring
Give steroids to mother
Give antibiotics eg erythromycin and metronidazole
Monitor mother and foetus
Maternal monitoring – temperature <37 or pulse < 100 above suggest chorio amnionitis,
daily pad monitoring
Foetal monitoring – kick monitoring, serial ultrasound, deliver baby at 34 weeks

NOTES: before 28 weeks it is life threatening abortion

Prom – clear fluid, colourless, odourless, gushy, provoke especially by trauma, wet
underwear

GYN 1

A 19 year-old P0+1TOP presents with a 3-day history of severe lower abdominal pain, fever and
vaginal discharge.

a. What is the most-likely diagnosis? 1 mark

b. What examination findings will help you to confirm this diagnosis? 3 marks
c. List the 2 organisms most-commonly implicated in causing this condition. 2 marks
d. List 4 risk factors for this condition. 4 marks
e. List 4 indications for in-patient management of this condition. 4 marks
f. List 3 antibiotics used to manage this condition. 3 marks
g. List 3 complications of this condition. 3 marks
ANSWERS

a. Pelvic inflammatory disease

b. Examination findings for PID
Cervical motion tenderness
Adnexal tenderness
Evidence of purulent vaginal discharge from the cervix
Lower abdominal tenderness
 c. Micro- organism
Neisseria gonorrhea, chlamydia trichomatis

d. Risk factors
Multiple sexual partners
Age
Previous PID
History of STIs
Early age of coitus

e. Indications for in- patient treatment

When diagnosis is uncertain
Failure to respond to out patient treatment
Where there is peritonitis or TOA
Where ther is an implant
Immune-compromised patient

f. Antibiotics management
Doxycycline(chlamydia), metronidazole(gonorrhea),ciproflaxin,

g. Complications
Early- peritonitis, TOA, pelvic abcess, peri-hepatitis

GYN 2

A 33 year-old P0+0 presents to the Gynecology clinic with complaints of sensation of a lower
abdominal mass, associated with heavy, prolonged menstrual periods for the past 5 months. She
has also been unable to conceive for the past 2 years of marriage. A pelvic ultrasound scan done
shows the presence of multinodular uterine fibroid.

a. List 2 other differential diagnoses for menorrhagia. 2 marks

b. List 4 possible sites/locations of uterine fibroid. 2 marks
c. List 6 other symptoms that this woman may present with. 6 marks
d. List 3 supportive/ ancillary investigations you would do. 3 marks
e. List 2 surgical treatment options for her condition, and state which option would be most-
suitable for this patient. 3 marks
f. Briefly outline how you would prepare this patient for surgery. 4 marks
ANSWERS

a. PALMCOEIL
Structural causes
 Polyps, Adenomyoma, leomyomas, malignancy
Non structural
Cardiomyopathy, ovary disorders, estrogen(hormone imbalance), iathrogenic (drugs)

b. Sites of fibroid
Intramural, pendunculated, sub-serosal, sub-mucosal, parasitic

c. Symptoms
Frequency of urine, headache, LAP, anaemia, headache, dizziness, pale

d. Investigations
FBC, Blood grouping, sickling test

e. Surgical treatment
Myomectomy and total abdominal hysterectomy

f. Counseling on the risks and benefits of surgery, sign a consent forms, anaesthethic
assessment, 2 units of blood on stand-by, Nils per OS. Antibiotic regimen

DAY 2

Q1
A 23-year-old hairdresser was rushed to your clinic with sudden onset of lower abdominal pain,
dizziness and sudden collapse. Her last menstrual period was two months ago. You examined
and found she was conscious, moderately pale, BP 70/40mmhg, pulse 110bpm, abdomen was
full with generalized tenderness and rebound tenderness.
1. What is the most-likely diagnosis?
2. What quick diagnostic test would you request?
3. What treatment would you institute?
4. State three causes of bleeding in early pregnancy.

ANSWERS
1. Ruptured ectopic pregnancy
2. Urine pregnancy test
3. Iv crystalloids
Emergency laporatomy
4. Ectopic pregnancy
Molar pregnancy
Cervicitis
Abortion
Topography gestational pregnancy
Q2
A 35 year-old P6AA delivered at the labour ward 15 minutes ago and bled profusely following
the delivery of the placenta. She complains of dizziness, thirst and appears lethargic. Her blood
pressure is 70/40mmhg with a rapid, weak and thready pulse of 120bpm.

1. What is the most-likely diagnosis?

2. List 4 causes of primary PPH
3. What is the most-likely cause of PPH in the woman above?
4. List 6 risk factors for primary PPH.
5. What treatment would you institute for this patient?

ANSWER

1. Primary post-partum haemorrhage

2. Uterine atony
Retained products of conception
Infection (endo-myometritis)
Trauma
3. Uterine atony because of the parity
4. Risk factor for PPH is same as risk for uterine atony
Fetal macrosomia
Polyhydramnios
Multiple gestations
Use of oxytocin and misoprostol
Intra-amnionic infection (chorioamnionitics)
Delayed labour

5. Call for help

Assess IV line with two bore cannula

Resuscitate with IV ringers

Give oxytocin in infusion

Give misoprostol

Give haematenics

Massage the uterus(bimanual compression of the uterus)

Q3
An 18 year-old G1P0 at 34 weeks‟ gestation is referred to Agogo Presbyterian Hospital from a
peripheral facility with a BP of 160/110mmhg and urine protein 3+. She had booked at 16
weeks‟ gestation with a blood pressure of 110/60mmhg.
1. What is your diagnosis?
2. List 3 symptoms that suggest severe disease.
3. List 4 risk factors for her condition.
4. List 4 laboratory investigations you would do.
5. List 6 complications of her condition.
6. Assuming that she has a fit whilst on admission, write out your initial treatment for her.

ANSWER
1. Severe pre eclampsia
2. Headache, blurred vision, epigastric pain, oliguria, pedal oedema, retinal changes
3. Chronic HPT
Obesity
DM
Nulliparity
Extremes of maternal age (<20,>35)
4. FBC, LFT, RFT, Uric acid
5. Maternal complications
CNS – Cerebral abscess, SAH, Cortical blindness, intracranial hemorrhage
RESPIRATORY – pulmonary oedema,
CARDIOVASCULAR – Myocardial imfarction, heart failure
RENAL – AKI, ARF
GIT – ALF, Hepatic rupture
Haematology – low platelets (coagulopathy)
Fetal complications
IUGR, IUFD, preterm maturity, low birth weight,
6. Eclampsia Magement
Assess ABC
Secure IV assess
Prevent seizures by starting MG2SO4 protocol
Loading dose 14 g, 4 g IV slowly then 10g, 5 g into each buttock
Maintenance dose 5g alternating every 4 4 hour
Give anti-hypertensive such as Labetalol, Nefidipine
Monitor respiratory 12 – 16 cpm
Monitor urine output (25 mls/hr) 100 mls 4 hrly
Monitor the presence of deep tendon reflex
Refer for further management
NB = Give Dexamethasone if mothers gestation is below 32 weeks
Q4

A 32 year-old now P4AA who is 1 week postpartum presents to you with complaints of a fever,
chills and headaches. She appears unwell and her temperature is 38.6C. Her BP is 100/60mmHg
with a pulse of 110bpm.
1. What is your diagnosis?
2. List 5 questions you would ask her in your history to help you come to a conclusive
diagnosis.
3. List 5 investigations you would do.
4. Assuming that on examination of the abdomen, you could palpate a tender, bulky uterus of
20 weeks' size, what would your most-likely diagnosis be?
5. List 3 risk factors for developing the condition in the question above.

ANSWER
1. Postpartum pyrexia
2. Mode of delivery
Prolong labour
PPROM
Several repeated vaginal examination
Instrumental delivery
Perineal lacerations
3. FBC(White cell count, neutrophils,), Urine blood C/S, Endocervical swab(puerperal),
chest X-ray,
4. Endometriosis (infection of the endometriosis
5. Prolong labour
Culture and sensitivity
Instrumental delivery

DAY 3

Q1
1. List 4 causes of vaginal discharge in 22-year-old P0.
2. A 26 year P1A presents with a greyish, fishy-smelling vaginal discharge. What is the
most-likely cause?
3. List 4 criteria used to confirm the diagnosis in Q4 above.
4. A 21-year-old P0 complains of a thick creamy vaginal discharge associated with vulval
itching. What is the most-likely cause of her vaginal discharge?
5. What test can be used to confirm the diagnosis in Q6 above?
6. List 3 drugs that can be used to treat the diagnosis in Q6 above.
ANSWER
1. Causes of vaginal dischages in reproductive age – bacteria vaginitis, vaginal
candidiasis, PID, Trachomiasis, physiologic discharge
2. Bacteria vaginosis
3. AMSTL CRITERIA
 A grey homogenious vaginal discharge adhere to vaginal wall
 Vagina PH more than 4.5
 Clue cell on microscopy: vaginal epithelial cell covered with bacteria
 Positive amine test (release of fishy odour from the vagina)
Treatment is with metronidazole and clindamycin
4. Vulvo vaginal candidiasis
5. High vaginal swab for microscopy
6. Clotrimazole, fluconazole

Q2
A 65 year-old P8 (all by SVD at home), who is 15 years post-menopausal, presents with a 1-year
history of the sensation of a mass in her vagina. The mass increases in size when she coughs and
she has to reduce it to be able to empty her bladder. For the past 2 months, the mass has
protruded out of her vagina and she thus reports for management.

1. What is your most-likely diagnosis?

2. List 5 risk factors for her condition.
3. List 5 supportive/ ancillary investigations you would do before her definitive
management.
4. Name one surgical procedure that can be used to definitively manage her
condition.
5. List 3 complications of the surgical procedure above.
ANSWER
1. Pelvic organ prolapse
2. History of prolong labour
Multiparity
Constipation
Delivery by home (unskilled attendant)
Menopause
3. Blood grouping, FBC, RFT, URINE R/E, Chest X-ray, ECG
4. Trans-vaginal hysterectomy
5. Intra-operative – injury to bladder, uterus and rectum, haemorrhage
Immediate operative – acute retention of urine, DVT, infection(surgical site infection)

Q3
A 28year old Madam A.K G8P5(1D) + 2SA presents to the Antenatal Clinic (ANC) with
complaint of dizziness and palpitations. She is currently 36weeks pregnant. Her Hb is 7.6g/dl
 1. List 6 causes of anemia in pregnancy?
2. List 6 complications of anaemia in pregnancy.
3. List 6 laboratory investigations done at the booking ANC visit.
4. What interventions are put in place to prevent malaria in pregnant women at
ANC.
5. Describe the Intermittent Preventive Therapy for Malaria regimen.
6. List 2 contraindications to the administration of SP to the pregnant women.

ANSWER
1.*Disorders of decreased production – nutrition deficiency(iron, folate and vit B deficiency)
*Increased destruction of RBC – Haemolysis (G6PD, Sickling), Thalassaemia, Intravascular
causes
*disorders characterized by increase loss of blood – Haemorrhagic disorders , Acute blood
loss(APH, Worm infestation, Upper and lower GI bleeding)

2. Maternal Complication – Postpartum hemorrhage, heart failure, respiratory

distress
FETAL Complication – IUFD, IUGR, Low birth weight, birth asphyxia, fetal
distress
3. Full blood count, G6PD, Urine R/E, Stool R/E, Blood grouping, BF for MPS,
HIV test, VDRL
4. Treated bed nets
Encourage to keep environment clean
To use mosquito repellent
Wear long sleeves clothes or things to cover their body
Intermittent preventive
5. 1st dose at 16th week and every 4 weeks till delivery. It is a directly observed
therapy fixed tablet of Sulphadoxine pyrimethamine
6. G6PD defects, allergies to sulfur containing drugs

Q4

You are called to the labour ward to attend to a new born, delivered at 32 weeks‟ gestation. She
weighed 1.9kg. Your initial impressions are prematurity and low birth weight. After your initial
assessment, you record the following vital signs. Temperature= 34.8C, Heart rate=160beats per
minute, respiratory rate = 60 cycles per minute
1.Which problem of prematurity and low birth weight do you identify in this baby?
2. Outline 3 measures to address this problem at the primary healthcare level.
3.Name 2 leading causes of neonatal mortality in Ghana.
ANSWER

1. Hypothermia (Respiratory distress syndrome)

2. Kangaroo mother care
Skin to skin contact
Dry baby very well after delivery
Baby should be clothed and cover well
Initiate breastfeeding

3. Birth asphyxia, prematurity, neonatal jaundices, neonatal sepsis

DAY 4

Q1
A 20 year-old G2P0+1TOP presents to the clinic having missed her menses for the past 2
months. She subsequently started bleeding per vaginam after taking some over the counter
medication about a week ago and currently appears ill and is febrile, with a temperature of 38C.

1. What is your most-likely diagnosis?

2. Which examination findings would support your diagnosis?
3. List 4 investigations you would do to confirm your diagnosis and aid your management.
4. List 3 complications of this condition.
5. Briefly outline your management of this patient.
ANSWER
1. Septic abortion
2. Sterile speculum examination with offensive discharge of products of conception with
fluids in the posterior fornices and clots of blood
Abdominal tenderness
3. Blood grouping and cross matching, pelvic USG, FBC, clotting screen, Blood culture,
Urine culture
4. Infertility, septic shock, peritonitis, acute renal failure, uterine damage, ARDS,
5. Resuscitation with IV Crystalloids
Iv broad spectrum antibiotics
Administer analgesia and antipyretics
Take blood for investigation (FBC)

Q2
A 60 year-old P4AA, who is 12 years post-menopausal, presents with a week‟s history of
bleeding per vaginam.
 1. List 4 differential diagnosis of postmenopausal bleeding.
2. Name one physical exam you would carry out.
3. List 4 investigations you would do to confirm your diagnosis and aid your
management.
ANSWER

1. Endometrial cancer, vulval cancer, atrophic vaginitis, endometrial polyps

2. Sterile speculum examination (atrophic vaginitis) or bi-manual pelvic examination
3. Pelvic ultrasound, FBC, BG & X matching, LFT, Pap smear, cervical biopsy(specialist)

Q3
A 26year old G3P1A + 1SA is admitted to the labour ward with complaint of lower abdominal
pain, waist pain and having seen show. Her cervix is 5 cm dilated on vaginal examination with
intact membranes. She has 3 contractions in 10 minutes, each lasting 40 seconds.

1.What is your diagnosis?

2.What tool would you use to monitor her?
3.List 2 complications associated with the first stage of this labour.
4.List 2 complications associated with the second stage of labour.
5.How is the third stage of labour actively managed?

ANSWER
1. Active phase of first stage of labour
2. Partograph
3. Maternal
Cephalo pelvic disproportion, prolong labour, poor progress of labour
Foetal
Foetal distress, foetal death
4. injury to the genital tract, prolong 2nd stage of labour, maternal exulsion, brachial
plexus injury, shoulder dystocia,
5. palpate abdomen to exclude other foetus
Give 10 units IM oxytocin within 1 minute of delivery of the baby after exclusion of
another baby by abdominal palpation.
Deliver placenta by controlled cord traction.
Massage uterus to maintain contraction.
Repeat uterine massage every 15 minutes for 2 hours.
Inspect for the completeness of the placenta.
Examine the perineum and vagina for any laceration or tear. If present repair.
Estimate volume of blood loss.
Q4

A 36-year-old G6 P5AA (with 1 previous CS 1 year 6 months ago) at 39 weeks‟ gestation

presents to the labour ward with a complaint of severe intermittent lower abdominal pain. Whilst
you are still taking her history, she complains of the sudden onset of dizziness and becomes
restless. Her extremities are cold, conjunctivae appear pale and BP is 70/40mmhg with a pulse of
130bpm, weak and thread. Her abdomen appears grossly distended with easily palpable fetal
parts. The fetal heart tones cannot be heard on auscultation.
1.What is your diagnosis?
2.List 3 other clinical signs that this condition can present with.
3.List 4 risk factors for this condition.
4.What would be your initial management steps?

ANSWER
1. Uterine rupture 2° hemorrhagic shock
2. Cold extremities, tachycardia, hypotension, absence FH, generalized tenderness with
guarding, abdomen does not move with respiration, bleeding per vaginum
3. Previous C/S, previous myomectomy, previous chorion ectopic gestation, grand
multiparity, previous ruptured uterus, augmentation
4. Initial management
Call for help, Assess ABC, IV assess and take blood for investigations, Resuscitate
with IV fluids
Definitive management
Done at the highest level
 INTERNAL MEDICINE

COACHING COURSE PREPARATION QUESTIONS

INTERNAL MEDICINE ( MARCH 2021)

DAY 1

1. A 64 y.o man, known hypertensive and diabetic for 12 yrs was found one morning on the
floor with reduced level of consciousness.

a. Give 3 differential diagnoses you will entertain

b. List 4 investigations you will request
c. On further assessment, you realized he could not move his right upper and right lower
limbs. What is the most likely diagnosis now?
d. How will you manage this patient based on your response in “c”?
e. What advice will you give this patient on discharge?

ANSWERS

a. Diabetic ketoacidosis, hypoglycaemia, head injury, hpt encephalopathy, CVA

b. RBS, Urine R/E, RDT for malaria parasite, CT scan of the head
c. Cardiovascular accident with right hemi plaegia
d. Detain the patient,
Assess ABCDE for resuscitation
Make patient comfortable in bed
Elevate head and pass NG tube
Give anti diabetics and anti-hypertensive to control BP and sugar
Give statins and aspirin if no haemorrhage
4 hourly vitals monitoring
Physiotherapy
Identify and treat ongoing infection
Regular turning in bed to prevent bed sores
DVT prevention with TED stockings
e. Counsel patient on drug adherence
Counsel patient on good nutrition
Counsel patient on exercise
Counsel patient on smoke cessation

2. A 42 y.o is admitted for an asthmatic attack

a. provide 3 differential diagnoses

b. What information would you like to ask in the history?
c. give 3 signs likely to be present in this patient
 d. list 3 investigations you will request
e. give your initial management for her asthmatic attach
f. what features will you use to assess the severity of her attack

ANSWER

a. bronchitis, pneumonia, tuberculosis, pneumothorax, COPD, ARDS, foreign body

aspiration, interstitial lung disease
b. allergens, family history of asthma, drug history, timing of onset with its
frequency, any known triggers, associated fever, associated eczema, social history
on occupation and pest
c. tachycardia, tachypnea, pulsus paradoxical, inability to complete full sentence,
use of accessory muscles in breathing, reduced air entry bilateral, audible wheeze
bilateral
d. FBC, Chest X-ray, spirometry, PEFR, Pulximetry
e. MANAGEMENT
Assess ABC and resuscitate
Nurse upright and give oxygen
Nebulise salbutamol
Iv hydrocortisone
Treat infections
Monitor SPO2
f. Respiratory rate, inability to complete full sentence, cyanosis,heart rate, level of
consciousness, blood pressure

3. A 26 y.o sexually active woman presents to your consulting room with 5 days of dysuria
and lower abdominal pains.

a. what is your diagnosis

b. list 3 possible likely micro-organisms causing this presentation
c. What investigations will you carry out?
d. How will you manage her condition
e. list 3 complications if poorly treated

ANSWER
a. urinary tract infection
b. chlamydia trachomatis, Neisseria gonorrhea and Escherichia coli
c. Urinalysis, UPT, FBC, Pelvic ultrasound
d. Oral antibiotics eg ciprofloxacin, cefuroxime, nitrofurantoin,
Analgesics eg paracetamol
Adequate hydration
e. Sepsis, pyelonephritis, recurrence UTI, preterm labour if pregnant, AKI

4. 16 y.o boy presents with 5 day hx of fever, and abdominal pains

 a. What are your differential diagnoses (list 3)?
b. request 4 lab tests
c. On further questioning, you are told he had diarrhea last week but now has
constipation. What is the most likely diagnosis?
d. what treatment will you offer
e. list 4 complications of this disease
f. what preventive practices will you advise

ANSWER
a. malaria, enteric fever, appendicitis, acute cholecystitis, gastroenteritis, acute hepatitis
b. RDT for malaria parasite, FBC, Hepatitis, Abdominal USG, Stool R/E, Blood culture
is gold standard
c. Enteric fever
d. Oral antibiotics like ciprofloxacin
Analgesics eg paracetamol
e. Bowel perforations, cholecystitis, sepsis, osteomyelitis, septic arthritis, septic shock
f. Practice regular handwashing before eating
Ensure good sanitation
Avoid improper disposal of waste
Provision of potable water
Identify and treat food vendors who are carriers
Food should be covered and warm

INTERNAL MEDICINE

DAY 2

1. An 18-year-old student has been experiencing recurrent generalized severe bone pains
since childhood.
a) What is your most likely diagnosis?
b) List 4 investigations you will request
c) Give 4 factors likely to precipitate this episode
d) Mention 3 examples of other acute episodes she is likely to experience
e) How will you treat this episode?

ANSWER
a. Sickle cell with bone crises (vaso occlusive crises)
b. FBC, Blood grouping and cross matching, BF for MPS, ESR, Chest X-RAY, Urine
R/E, Blood C/S
c. Extremes of weather, hypoxia, infection, dehydration, acidosis, alcohol intoxication,
emotional stress.
 d. Acute chest syndrome, priapism, mesenteric ischaemia, stroke, anaemic crises
(hemolytic, sequestration, aplastic anaemia)
e. Adequate hydration with iv fluids (3 L)
Pain control with IV morphine, NSAIDs, paracetamol
Treat ongoing infection including malaria
Monitor pain and level of hydration
Give folic acid, prophylactic penicillin V when stable
Referral to consider hydroxyurea therapy

Complications of hydroxyurea
Bone marrow suppression, calculi

Acute chest syndrome – oxygen therapy, consider chest X – ray, start early antibiotics
Anaemic crises- transfuse with blood
Haemolytic crises – serial urine collection also do G6PD investigation
Sequestration crises – monitor spleen and liver

2. 49yr old man presents with 6 months of jaundice and abdominal distention.
a) What is the most likely diagnosis?
b) List 4 other stigmata of this disease
c) List 4 investigations you will like to request
d) What treatment steps will you undertake?
e) Mention 4 complications of his condition in “a”?

ANSWER

a. Chronic liver diseases (alcoholic liver disease)

b. Bi-pedal piting edema, hepato-splenomegaly, ascites, flfapping tremors, jaundice,
spider naevi, caput medusa, dupuryten contractures, leuconychia, clubbing
c. FBC, Hep B & C, LFT, BUE & Cr, Abdominal USG
d. Encourage good nutrition
e. Stop alcohol
f. Oral glucose, thymine and zinc supplementation
g. Upper GI bleeding, spontaneous bacterial peritonitis, hypoglycaemia,
coagulopathy

NB: Differentials of tremors – Parkinson disease, thyroid toxicosis,

alcoholwithdrawal
3. 43 year old woman presents with fever and altered mental state. There were whitish
plaques on her tongue
a) Give 3 differential diagnoses you will entertain
b) What 4 investigations will you request?
c) Outline your management for this patient
d) What measures will you undertake to prevent a recurrence of this presentation
e) List 3 other common infections peculiar to this group of patients

ANSWERS
a. HIV infection with cerebral toxoplasmosis, cerebral abscess, cerebral tuberculosis,
diabetes mellitus, oral candidiasis, CNS lymphoma, CNS cyptoccossuc, CNS
cystercercosis,
b. FBC, BF for MPS, Urine R/E, CD4 count, Chest X-ray, Head CT Scan, HIV Screen,
RBS.
c. Admit
Assess ABC
Nurse in a prop up position
IVF hydration
Iv antibiotics broad spectrum
Pass NG tube
Educate relatives
d. Adherence to medications
Counseling
e. Pneumocystis jiroveci, extrapulmonary tuberculosis, cytomegaly virus, disseminated
herpes zoster, cryptococcal meningitis, oral/esophageal candidiasis

4. 18 yr. old boy presents with altered mental state. You noticed he has fruity odour in his
breath.
a) What diagnosis will you entertain?
b) What 2 bedside tests will you perform to confirm your diagnosis?
c) What factors can precipitate this episode (List 4)
d) How will you manage this patient?
e) Give 4 long term complications of the underlying disease

ANSWERS

a. DKA
b. RBS, Urine dipstick, RDT for malaria parasite
c. Not adhering to medication
Dehydration
Infection
Stress
Inadequate medication
d. Aggressive hydration with IV fluids N/S
2 hr RBS monitoring
Start soluble insulin as per Albert regimen
Give potassium as soon as urine output
 Treat ongoing infection
e. Complications
Macro vascular – Stroke, coronary artery disease, peripheral vascular disease,
diabetic foot ulcer
Micro vascular – retinopathy, nephropathy, neuropathy

DAY 3

1. A 38 year old man, who came to you with a long standing history of anemia, has recently
noticed bipedal swelling.

a. What 2 most likely diagnoses will you consider?

b. what questions will you like to ask this patient?
c. What 4 investigations will you carry out?
d. A month later, he presents with dyspnea. Further assessment found he has a high
blood pressure.
What will be your diagnosis now?
e. What initial treatment will you institute for him?

ANSWER
a. CLD, CKD, Heart failure secondary anaemia, CHF
b. Orthopnoea, PND, family history of HPT, Sickle cell, dizziness, early morning
puffiness, oliguria, SHX (alcohol history)
c. FBC, FBS, Abdominal USG, Urine R/E, BUE & Cr, Abdominal Ultrasound
d. Chronic kidney disease because of anaemia, elevated BP with pulmonary oedema
e. Admit
Give oxygen in a prop up position
Monitor vitals and SPO2
Pass urethral catheter
Give diuretics (IV furosemide)
Control BP
Arrange for haemotransfusion depending on the lab

NB: The cause of anaemia in young men is chronic kidney disease and in the
elderly is malignancy

2. 47 year old man started experiencing severe pains in his right big toe in the night after he
and his friends enjoyed some bottles of beer earlier on.

a. what is the most likely diagnosis

b. mention 3 risk factors of this condition
c. list 4 investigations you will request
d. how will you manage this patient
 ANSWER

a. Gout due to alcohol

b. HPT, Diabetes, CKD, Obesity, high protein diet, hyperuricaemia, alcohol
c. FBC, Urea and creatinine, Seum uric acid, X-ray of the right toe, FBS, Lipid
profile, joint aspiration for analysis
d. Ice pack application
Give NSAIDs
Give prednisolone
Adequate hydration
Joint aspiration for relieve
Giv allopurinol after attack
Lifestyle modification

Differentials: septic arthritis, pseudo gout

3. 40 year old woman has been experiencing recurrent abdominal pains worse after meals

a. provide 3 differential diagnosis you will entertain

b. what important questions will you ask this patient
c. what investigations will you request(list 4)
d. what treatment will you provide for the most likely diagnosis

ANSWER
a. PUD
Cholelithiasis
Pancreatitis
Gastric cancer
b. Nature of pain, associated with any foods, timing of pains, other associated
symptoms, alcohol intake, frequent use of NSAID
c. FBC, ESR, H-pylori(serology), Abdominal USG, SERUM Amylase/Lipase, upper
GI endoscopy
d. Triple therapy because H-pylori is the commonest cause of the ulcer
Amoxicillin + metronidazole for 7 – 14 days
Omeprazole for 4 – 8 weeks
Antacids

4. A young healthy-looking couple presented their pre-marital screening test results to seek
your opinion. The only abnormal result was a positive Hepatitis B test for the man.

a. list 4 follow up investigations you will like to request for the man
b. give 3 ways in which hepatitis B is transmitted
c. give 2 complications of chronic hepatitis B
d. what advice will you give the couple
ANSWER

a. Hepatitis B viral profile, Viral load, LFT, KFT

b. Unprotected sexual intercourse with an infected person
Sharing needle or sharp instrument or toothbrush with an infected person
Contact with infected blood or blood products
Transfusion of infected blood
Mother to child during labour
c. Liver cirrhosis, liver failure, hepatocellular carcinoma/hepatoma, Upper GI
bleeding, Hepatic encephalopathy
d. Woman to be vaccinated as soon as possible
Couple to use barrier protection until woman has completed vaccination schedule
Man to attend regular review to monitor state of infection

DAY 4

1. 32 year old presents with 3 days of fever, cough and throat pains. Earlier in the week, he
visited his cousin who also had similar symptoms.

a. give 2 differential diagnosis

b. Which questions will you ask this patient?
c. give 4 laboratory investigations
d. how will you manage this case

ANSWER

a. pharyngitis, epiglottis, tonsillitis, COVID-19, Common cold, infectious

mononucleosis,
b. productive cough
Nature of sputum
Associated chest pains, dyspnea, dysphagia
Has the cousin been diagnosed?
Presence of underlying condition
Any medication
c. FBC, Throat swab for C/S, Nasopharyngeal, oropharyngeal for Covid 19, ESR, BF
for MPs, Sputum for C/S
d. Analgesics and antiryretics
Broad spectrum antibiotics and change depending on lab results
 Adequate oral rehydration
Encourage good nutrition
Antiseptic gargle
Isolate if confirmed to be corona virus

2. A boarding school student present with a day of pruritic vesicular skin rashes around his
trunk and arms after experiencing fever and chills for 2 days.

a. What is your most likely diagnosis?

b. Give 3 ways in which this condition is transmitted?
c. What treatment will you provide?
d. Give 2 complications that may occur with this condition.
ANSWER

a. Chicken pox
b. Direct contact with infected person
Respiratory droplets
Mother to child transmission
c. Antihistamine
Antipyretic
Calamine lotion
Stay away from school until all lesions have crusted
d. Immediate: secondary bacteria infection, pneumonia, encephalitis
Long term: herpes zoster,neuralgia, ramsay hunt (facial nerve palsy), neuralgic

3. A 45 year old farmer presents with difficulty in opening the mouth, neck rigidity and
fever of a week duration.

a. What 2 most likely differentials will you entertain?

b. how will you clinically differentiate these 2 conditions stated in (A)
c. List 3 investigations
d. What is the causative organism for your most likely diagnosis?
e. How will you manage this patient?

ANSWER
a. Tetanus
Meningitis
b. Reduced level of consciousness but intact in tetanus
Rigidity can be generalized in tetanus but limited to the neck in meningitis
Rigidity induced by stimulation in tetanus unlike in meningitis
Opisthotonus, trismus, sardonic smile but Kernig and brudzinsky sign in meningitis
c. FBC, CSF for gram stain and C/S, Blood C/S, wound swab for C/S
d. Clostridium tetani
e. Admit to quiet dark room, avoid noise and frequent touching
Ensure ABC
Start antibiotics (metronidazole)
 Give muscle relaxant like Diazepam or phenorbibartone
Adequate hydration
Give anti-tetanus serum or Anti tetanus immunoglobin or tetanus toxoid vaccine

4. 68 year old man presents with a 3 day history of cough, fever and chest pains.
a. What is your most likely diagnosis?
b. give 3 signs likely to be present on examination
c. How will you assess the severity of this condition?
d. list 4 investigations you would request
e. how will you treat this patient

ANSWER

a. pneumonia
b. assymetric chest movement
reduced chest expansion
increased tactile fremitus
dull percussion note
reduced breath sounds
crackles
bronchial breath sounds
wheezes
c. FBC, ESR, Blood C/S, Sputum gram stain, culture and sensitivity
d. CURB 65
e. Treat on OPD if less severe
Give empirical antibiotics coamoxiclav, azithromycin
Give antipyretics
Change antibiotics when culture results indicates

SURPRISED QUESTIONS

48 year old HPT is rushed in because of a sudden onset of severe chest pains radiating to the jaw
and breathlessness over the past hour

a. what is the most likely diagnosis

b. give four risk factors for this condition
c. list four investigation
d. how will you manage
ANSWER

a. acute coronary syndrome/MI

b. HPT, Diabetes, obesity, hyperlipidemia
 c. ECG, Lipid profile, Echocardiogram, Cardiac enzymes, FBC, FBS
d. Admit
Put on oxygen
Give morphine, aspirin, statins and sublingual nitroglycerin
Monitor oxygen saturation and vitals
Control any risk factors like HPT, DM
e. Stop smoking
Healthy lifestyle (diet, exercise)
Moderate alcohol
Adherence to medication and follow up

A 27 year old man presents to your consulting room with passage of bloody urine of a
week duration
a. Provide 3 differentials
b. What will you elicit from the history
c. What lab investigations will you request
d. How will you manage this patient
ANSWER

a. Urinary schistomiasis, urethral trauma, prostitis, cystitis, recent urethral

instrumentation, bladder cancer when old, kidney stones, ureter stone
b. Associated symptoms like fever
Any recent pelvic trauma
Any recent catheterization
First time of occurrence
Contact with water bodies
Community where disease is prevalent
c. Urological scan, FBC
d. Praziquantel
Adequate hydration
Treat anaemia if any
 SURGERY

CASE 1

45 years old man, who had received only a dose of tetanus toxoid two years ago sustained a deep
wound with a blunt hoe on the left thigh whilst weeding his goat farm. He bled and continued to
bleed profusely and was carried to a health facility within two hours of the injury, doppy. His
blood pressure was 70/30 mm of hg, pulse of 120 beats per minute, pale with cold clammy skin.

1) What is wound?

2) What type of wound was sustained?

3) List four other types of wound

4) What is shock in surgery?

5) What type of shoch did the patient come with into the health facility?

6) How would you prevent tetanus in this patient?

7) What will be your emergency management of this case?

ANSWERS

1. Wound is a disruption of cellular and anatomical continuity due to loss or destruction of

tissue by accidental or surgical trauma, physical or chemical agents
2. Laceration
3. Punctured wound
Abrasions
Lacerations
Contusion
Incised wound
4. A state of systemic hypofusion owning to a reduction in either cardiac output or effective
circulatory volume resulting in inadequate perfusion with oxygen and nutrient and
inability to remove the end product of metabolic waste and lactic acid.
5. Haemorrhagic shock
6. Give a shot of tetanus immuglobin if not available tetanus serum
Then complete the tetanus toxoid
7. Detain and call for help
Ensure airway is patent
Ensure patient is breathing
Put in 2 large bore cannula into a vein
Take blood for investigation (eg blood grouping)
 Infuse with crystalloids eg N/S
Monitor vitals eg pulse, BP, Urine output, Capillary refill time, warm extreties
Definite treatment
Suture and give anti biotics

NB: golden period is 6 hours duration when a person sustains a wound. You can suture
but after the 6 hours you clean and cover and wait for 72 hours if wound is not infected,
then you suture.

CASE 2

A 26 years old young woman found a lump in her left breast during self-examination. The lump
was painless, firm and mobile. No enlarged lymph nodes were detected in both axilla. There was
no nipple discharge. She is very worried as a friend had recently died of cancer of the breat after
a protracted illness.

1. List four causes of lump in the breast in this age group?

2. If you are asked to choose between ultrasound of the breast and mammography, which
one will you select for this patient and why?
3. You referred this patient to the district hospital where there is a surgeon. What specific
procedure will be done to exclude or comfirm a benign lesion of the breast?

ANSWERS
1. BREAST FIBROADENOMA
Left Breast cyst
Left breast lipoma
Cancer of the breast
Traumatic fat necrosis of the breast
Antibioma(hard cyst)
Left breast abscess
2. Ultrasound due to
Age – breast is less dense below 35 years
Radiation – does not radiate into the body
3. Excisional breast biopsy

CASE 3

A 35 years old man is diagnosed as a case of generalized peritonitis from typhoid ileal
perforation after prodromal illness of fever, headache and diarhoea of two weeks.
1. What will be the probable abdominal signs if this patient was examined?
 2. What may be the probable finding if erect x-ray of the abdomen, including the lower
zones of the chest was taken?
3. List six relevant laboratory investigations which will be requested for this patient and
why?
4. What will be the pre-operative preparation of this patient?
5. List five indicators that will be monitored to find out if the patient is adequately
resuscitated for surgery

ANSWERS

1. INSPECTION : distension of the abdomen, abdomen does not move with

respiration
Light palpation : generalized abdominal tenderness
Deep palpation – rebound tenderness, guarding
Percussion – tympanic due to gas in the abdominal wall
Auscultation – reduced or absent bowel sounds
DRE
2. Gas under the diaphragm
3. Full blood count – to rule out anaemia, haematocrit
Blood grouping and cross matchingfor possible blood transfusion if anaemic
Fasting blood glucose – to check for hypoglycaemia
Sickling test – to manage adequately if present
BUE & Cr – to know the electrolyte level
Hepatitis B surface antigen – to now type of anaesthesia to give as halothane
causes hepatic failure due to it ability to damage liver cells
4. Pass NG tube to compress the GIT
Put in 2 large bore canulla
Urethral catheter to monitor urine output and ensure bladder is empty
5. Pulse, BP, Respiration rate, oxygen saturation, state of hydration, temperature

CASE 4

A 40 years old male farmer reported at a health centre with a left groin swelling he had noticed
for the past six months. The swelling stands out prominently when he stands up, increasing in
size when he coughs. The swlling disappears when he lies on his back. Further eamination
showed that, the swelling which slightly goes into the scrotum actually passes over the inguinal
ligament

• Formulate a complete diagnosis for this patient‟s condition.

 • List four complications that may arise for which reason you will suggest surgery to the
patient.

• List four basic yet relevant laboratory investigations which may be requested for the
patient as he is being investigated for surgery and explain why the choice of those
investigations.

ANSWERS

1. Left reducible inguinoscrotal hernia

2. Rapture
Obstruction
strangulation
Incarceration
Irreducibility
3. Full blood count – to rule out anaemia, haematocrit
Blood grouping and cross matchingfor possible blood transfusion if anaemic
Fasting blood glucose – to check for hypoglycaemia
Sickling test – to manage adequately if present
BUE & Cr – to know the electrolyte levelHepatitis B surface antigen – to now
type of anaesthesia to give as halothane causes hepatic failure due to it ability to
damage liver cells

CASE 5

A 35 years old woman presents with anterior neck swelling of five years duration. She has no
problems with respect to this swelling but is seeking for surgical help for cosmetic reasons.

1. List four conditions that can give rise to an anterior neck swelling.
2. After history taking and clinical examination, it was decided to operate the case as a
goitre. List five relevant laboratory investigations that would be requested for this patient
and why the choice of those laboratory tests?
3. List two imaging modalities, commonly available in district hospitals in ghana, which
will be requested for this patient and why?
4. List four complications which may occur at operation to remove the cause of the goitre?

ANSWERS
1. Anterior neck lipoma
Goiter
Thyroid abscess
Thyroglossal cyst
2. Thyroid function test – to rule out hypo and hyper thyroidism
 Full blood count – to rule out anaemia, haematocrit
Blood grouping and cross matchingfor possible blood transfusion if anaemic
Fasting blood glucose – to check for hypoglycaemia
Sickling test – to manage adequately if present
BUE & Cr – to know the electrolyte level
Hepatitis B surface antigen – to know type of anaesthesia to give as halothane
causes hepatic failure due to it ability to damage liver cells
3. USG of the neck
AP X ray of the neck
4. Bleeding
Damage to the trachea
Trans esophageal fistula
Vocal cord paralysis
Damage to the para-thyroid gland
Hypocalcaemia

CASE 6

• A young man presents with painless enlargement of the scrotum on the right side. The
physician assistant who saw the patient has got a differential diagnoses of a left hdrocoele
and left inguinoscrotal hernia
1. What is a hernia?
2. What is a hydrocoele?
3. How would you clinically distinquish between a hydrocoele and an inguinoscrotal
hernia?
4. What imaging modality may provide evidence to support a hydrocoele
5. List three complications that can occur in a hydrocoele.

ANSWERS

1. A hernia is a protrusion of an intra-abdominal viscous through a defect in the abdominal

wall
2. Hydrocele is collection of fluid around the testes in the tunica vaginalis
3. Hydrocele and hernia
Hydrocele Hernia
You can go above the swelling You cannot go above swelling
Cough impulse is absent Cough impulse is present
Trans illumination No trans illumination

4. Ultrasound scan of the scrotum

 5. Infection
6. Rupture
7. Scrotal haematoma

CASE 7
• Repair of groin hernias using synthetic mesh is a common operation the world over.
1. List four complications associated with hernia mesh repair.
2. Why and how would you recomment the use of antibiotics in a cold case hernia repair
using mesh?

ANSWERS

1. Infection
Mesh migration
Chronic pain
Recurrent hernia
Serumal formation
Rejection
Haematoma repair
Feeling of mass after operation
2. In cold case hernia repair we do not give antibiotics but in mesh repair we give to
prevent infection since we are introducing a foreign material to the body

CASE 8

• A man who has been suferring from peptic ulcer disease is given a provisional diagnosis
of „‟acute abdomen‟‟, ? Acute excercebation of peptic ulcer disease ?? Perforated peptic
ulcer. The emergency team immediately started to work on this patient who was in severe
pains.

1. What is acute abdomen?

2. Why is it that, in cases of acute abdomen, it is recommended that an electrocardiogram is

done as part of the investigations?

3. List ten conditions that may present as acute abdomen but for which, surgery is
contraindicated?

4. List four causes of acute abdomen that can lead into generalized peritonitis.

ANSWERS
1. Acute abdomen is a sudden onset of severe abdominal pain which may or may not
require surgical intervention
2. Because some conditions in the chest or heart may be referred to the abdomen example
MI and pneumonia
3. Sickle cell occlusive crises
Pneumonia
Pyenophretis
Severe malaria
Diabetic keto acidosis
Gastroenteritis
Myocardial imfarction
Typhoid fever
Acute hepatitis
4. Perforated peptic ulfer
Peptic duodenal ulcer
Ruptured appendicitis
Strangulated intestinal obstruction
Cholicystitis

CASE 9
A 65 years old man is brought into the casualty for not being able to urinate for the past
five hours. He is in severe pain and calling for help to have his problem solved
1. List four common causes of acute retention of urine in males in this age group.
2. What two imaging modalities, easily available in a district hospital in ghana, may assist
in finding the cause of the urinary retention?
3. How would it be confirmed that, this is or is not a case of cancer of the prostate?
4. What would be done to provide immediate relief for the patient if possible?
5. What if the intended remedy failed, what would be the diagnosis?

ANSWERS
1. Prostrate cancer
BPH
Bladder cancer
Bladder neck stenosis
Bladder calculi
2. USG for BPH and stone in bladder
Plain X-ray of the pelvic
Prostate Specific Antigen can confirm BPH and prostatitis
3. Incisional biopsy
4. Pass urethral catheter under aseptic technique
 5. Urethral stricture

CASE 10

Five years ago, this ten years old boy had typhoid peritonitis for which he was operated
upon and had very stormy recovery. He had presented several times to the emergency
department and expectant treatment had worked for him. Picture of his abdomen is on the
next slide

Picture of the abdomen of the boy referred to earlier

1. What is the provisional diagnosis for this case?
2. List four complains that this boy will tell the medical practitioner seeing him?
3. List five things, relevant to the patients diagnosis that the examining practitioner will
find on abdominal examination.
4. What imaging modality will be done to get information to support the diagnosis?
5. What will be the initial management of this patient, the same thing he had
successfully gone through in the past for previous attacks
6. Clinically, what will tell the practitioner that the attack has been relieved?
7. List five complications that could occur with the attack if this boy had not sought help
from an adequately equipped (in terms of personnel, equipment and know how) health
facility

ANSWERS
1. Intestinal obstruction 2° intraabdominal adhesion
2. Colicky abdominal pain
Constipation
 Abdomianal distension
Vomiting
3. Inspection – abdominal distension, abdomen moves with respiration, surgical scars
Light palpation – mild tenderness
Deep palpation – no rebound tenderness
Percussion – tympanic
Auscultstion – Hyperactive sounds,
DRE – no stools
4. Plain abdominal X-ray
5. Pass NG tube for decompensation of gas and fluid
Drip and suck
6. Reduced colicky abdominal pain
Passage of stools
Passage of flatus
Normal bowel sound
7. Hypovolaemic shock
Gangrene of the bowel
Generalized peritonitis

CASE 11

A 26 years old young woman reports to the clinic with sudden onset of severe abdominal
pain. The attending physician assistant on taking full history and done examination and
had querried acute abdomen. He now has informed the only doctor he is working with
who can do laparotomy.
1. What is acute abdomen?
2. What is a „‟surgical abdomen‟‟?
3. List five gynaecological causes of acute abdomen.
4. What one imaging modality, available in most district hospitals in ghana could be used to
help in the diagnosis in this case?

ANSWER
1. Acute abdomen is the sudden onset of severe abdominal pain which may or may
not require surgical intervention
2. Surgical abdomen is the onset of severe abdominal pain which require surgical
intervention
3. Ovarian torsion
Ruptured ectopic
Acute salpingitis
 Ruptured ovarian cyst
Ruptured ovarian follicles
4. Abdomino pelvic ultrasound

CASE 12

A 24 years old university student is involved in road traffic accident and suffers fracture
of his right femur bone with a gaping wound on that thigh and a piece of bone showing
through the wound. He has been brought to the district hospital, doppy (gcs=12/15) with
blood pressure of 80/?30mm of hg, pulse of 120 beats per minute, thready with cold
clammy skin. The team intends to resusscitate and stabilize him and transport him to the
regional hospital situated 100 km from the district hospital.

1. What is a fracture?

2. What is a compound fracture?

3. List four immediate complications of a fracture

4. What is shock in surgery?

5. In which type of shock is this patient?

6. What will be your emergency management of this patient?

7. How would you manage the fracture and wound of this patient before referral?

ANSWER

1. Fracture is a break in the continuity of a bone

2. Compound fracture is a break in the continuity of a bone which can communicate with
the external environment
3. Infection
Haemorrhage
Compartment syndrome
Nerve and vessel damage
4. Shock is a state of systemic hypoperfusion owning to a reduction in either cardiac output
or effective circulatory volume resulting in inadequate perfusion with oxygen and
nutrient and inability to remove the end product of metabolic waste (lactic acid)
5. Haemorrhagic shock
6. Detain and call for help
Ensure airway is patent
Ensure patient is breathing
Put in 2 large bore cannula into a vein
 Take blood for investigation (eg blood grouping)
Infuse with crystalloids eg N/S
Monitor vitals eg pulse, BP, Urine output, Capillary refill time, warm extreties
Give antibiotics

7. Immobilize and splint bone

Give analgesics
Clean the wound and apply sterile dressing
Give tetanus prophylaxis
Give broad spectrum antibiotics

CASE 13
• A male farmer had a tree he was cutting fall on his thigh. He was rescued after three
hours by a nadmo team after great difficulty and rushed to a mission hospital nearby. The
receiving hospital are worried about this patient, however, they found, he had a femur
fracture on the thigh which had now become very boggy and swollen.

1. How would damage to a blood vessel in the affected lower limb be comfirmed or
excluded
2. How would damage to a nerve in the affected lower limb be comfirmed or excluded
3. How would damage to muscle in the affected lower limb be comfirmed or excluded

ANSWER
1. Absence of dorsalis pedis pulse
Absence of sensation
Absence of movement

CASE 14
A woman steps on a rusty nail and got cut by this nail on the left foot. Little attention was
paid to the injury. Three days after, there was severe thrombing pain of the left foot
associated with fever. The foot was swollen, warm, tender with the wound exuding pus.
Examintion of the left groin revealed tender and enlarged lymph nodes. The husband is
worried.
1. What is your full diagnosis?
2. This woman has never been immunized against tetanus. How would you prevent tetanus
in this patient?
3. What is cellulitis?
4. What organisms are normally responsible for cellulitis?
5. How would this patient be managed?
6. List four complications that may occur in cellulitis.
7. List four basic and relevant laboratory investigations that would be requested in the
management of the patient and why those tests.

ANSWERS
1. Cellulitis of the left foot 2° punctured wound
2. Administer human immunoglobin tetanus and if not available anti tetanus serum
Initiate active tetanus toxoid
3. Cellulitis is the inflammation of the subcutaneous connective tissues
4. Strptoccoccus aureus
Streptococcus pyogenes
5. Rest and elevate the wound
Start antibiotics
Give analgesics
Clean and treat wound
Take blood for culture and sensitivity
6. Septicaemia
Abscess formation
Ulcerations
Amputation
7. Full blood count – to check if patient is anaemic
Blood culture and sensitivity – to know sensitive antimicrobial
Fasting blood sugar – to check for DM
X-ray of the left foot
 PUBLIC HEALTH QUESTIONS

1. The total population of the combination TB Patients, mothers, Neonates, and infants in
Yamfo is 12,000 as collected by the epidemiologist. The information below is also
collected about Yamfo in the same the year 2020:

– Total average population = 40,000

– Total number females = 30000
– Total number of people working at the Gold Mining Company = 800
– Total number of live births = 4000
– Total number of deaths = 400
– Total number of deaths before the age of 28 days = 50
– Total number of infant deaths = 200
– Number of women who died from pregnancy related causes = 160
– New cases of tuberculosis = 100
– All cases of tuberculosis = 300
– Deaths from tuberculosis = 60

Based on the above information calculate the following.

a. The incidence rate of tuberculosis -

b. The period prevalence rate of tuberculosis.

c. The case fatality rate of tuberculosis.

d. The Neonatal mortality rate.

e. The infant mortality rate.

f. The maternal mortality rate

ANSWERS

a. The incidence rate of tuberculosis = =

b. The period prevalence rate of tuberculosis = =

c. The case fatality rate of tuberculosis = =

d. The Neonatal mortality rate = =

e. The infant mortality rate = =

f. The maternal mortality rate = =

 NB: If women in fertility age is not given, then we assume each women gives birth to one
child which then becomes total number of lives birth

2. As an occupational health expert in insecticide spray manufacturing company in Ghana

a. What will „duty of care‟ mean in the workplace? -

b. Name the four categories of costs of workplace injuries to the organisation.

c. Mention the five (5) principles of health and safety?
d. With an example each, name the five (5) groups of hazards found in workplaces.

ANSWER
a. The legal obligation of one person towards others regarding his safety and security

b. Tour examples should center on these three that is Human , Social and organisational.
Human resource or labour force cost
Financial cost
Productivity cost
Property cost
c. Personal protection

Tools protection
Environmental protection
Customers and co workers protection
Adequate security
d. Chemical hazards eg explosives

Biological hazards eg infection by bacteria

Mechanical hazard eg injury by a machine
Physical hazard eg needle prick
Workload hazard eg stress
Psychological hazard eg

3 a. There is an outbreak of skin disease in your locality. As a public health officer, how will you
help community members prevent cross-infection of skin disease in five ways
 b. State four(4) duties expected to be performed at the port under disease
surveillance/control.

C. State four (4) roles of public health in promoting mental health in a community

d.How will you ensure each of the above in locality.

ANSWER

a. Wearing of clean clothes

Ensure proper hygiene

Health education on skin disease
Isolation of contacts

b. Inspection of vaccine certificate

Ensure proper documentation of regulations and laws of the land

Pure medical inspection of of humans, baggages, containers and animals
Any suspected baggages could be ceased and further checks done on them
c. Avoiding stigmatisation of mental health patients

Regular counselling
Mental health sentinel programmes
Organising durbars on mental health education
d. Communication, radio, posters, durbars, newspapers

4.As the head of a Public Health Institution in a culturally diverse district with many public
health concerns,

a. Mention any (3) Ethical Principles would you consider in pursuance of your job?

b. State any 3 exceptions to ethical principles in public health

ANSWER
a. Address the fundamental cause of diseases in the community
Ensure the rights of the individual in the community
 Ensure equitable access of health care
b. Rights of privacy is denied
When the health of the community is at stake against the health of the individual
Confidentiality is denied

Expanded program of immunization, Reproductive and child health, Nutrition as well as Safe
water and good waste disposal are among the core functions of the District Primary Health Care
Unit.
State four (4) activities under ANY TWO of the above functions for C and D respectively

c. . Expanded program on immunisation

 Do growth monitoring and promotion
 Treatment of minor illness
 counselling

d. Safe water and good waste disposal

 boiling water and cooling it before use
 provision of proper waste disposal before
 recycling of waste materials