IM

The scenario ytd is Tricuspid

regurgitation secondary to infective
endocarditis
Patient presents with a high pitched holosystolic murmur located at the left
sternal edge (left 3rd/4th ICS) which is louder on deep inspiration.

a. Patients who are at risk of this

condition?
● Elderly
● Patients with valve prostheses/
congenital heart lesions
● Intravenous drug abusers
● Immunosuppressed patients

b. Criteria to diagnose this condition :

● Modified Dukes’ Criteria

C. What is the diagnosis for this patient?

● Tricuspid regurgitation secondary to

infective endocarditis
What are the common causative organisms for patients who have :
a. Native valve - Streptococcus viridans, Streptococcus gallolyticus, Enterococcus fecalis
b. Prosthetic valve - Staphylococcus aureus, Coagulase-negative staphylococci
c. Culture-negative - HACEK group (Haemophilus, Actinobacillus, Cardiobacterium,
Eikenella, Kingella)
d. IVDA- Staphylococcus aureus
What are the investigations for a patient with IE? Empirical antibiotics for IE :
● Blood cultures (3 times from different sites) ● Ampicillin
● FBC : leukocytosis
● BUSE ● Cloxacillin
● ESR ● Gentamycin
● Liver function test
● Renal profile If allergic to penicillin, give :
● Urinalysis (Presence of RBC/red cell casts)
● ECG ● Vancomycin + Gentamycin
● Echocardiography - transthoracic echocardiogram
showing valvular vegetations
REHAB
A. What wheelchair is shown in the picture above? (2
marks)
● Tilting frame wheelchair

A. Describe 2 special functions for this wheelchair. (4

marks)
● Allow seat and back to pivot backward together;
● Maintain same hip angle throughout the tilt, thus
does not trigger spasticity

A. Which group of patients will benefit from this type of

wheelchair? (4 marks)
● For patients who are dependent for mobility due to
severe motor impairment
● patients who are unable to do independent pressure
relief or require rests or position changes throughout
the day
 A middle-aged man who was participating in a badminton tournament,
FORENSIC collapsed and died while playing a match. The arrow in the image
shows the transverse section of the left anterior descending artery
during post-mortem.

A. Describe the post-mortem findings shown by the arrow in the image

(4 marks)
There is narrowing of the left anterior descending artery by 90%
indicating it is severe occlusion. The left anterior descending artery has
an atherosclerotic plaque. There is presence of thrombus in the
artery.
B. List 3 laboratory investigations to confirm the diagnosis. (3 marks)
- Troponin
- Lipid profile
- Histopathology

C. What is the cause of death in this patient? (3 marks)

Acute myocardial infarction secondary to atherosclerotic plaque of the
left anterior descending artery
DERMATO EXAMPLE FROM DR FELIX’s HANDOUT
A. What is it?
Procedure to collect skin scales, nail or hair in a glass slides and
10% - 20% potassium hydroxide (KOH) is added to digest the keratin
materials to allow visualization of fungal elements or mites

B. How is the procedure done?

Skin scales at the edge of the lesion (for tines infection) is scraped with a
scalpel blade or glass slide and collected on the glass slide. 10-20%
KOH is added and covered with cover slip. To facilitate keratin digestion,
the glass slide can be heated up under a bunsen burner. The slide is
examined under a microscope to look for fungal hyphae, spores or
mites.

C. What condition can be diagnosed by this bedside procedure?

Fungal infection – dermatophytic infection (look for fungal
hyphae)
tinea versicolor (look for spaghetti and meatball appearance –
pseudohyphae and fungal spores)
Scabies – look for mites, scybala and eggs 0
 DERMATO
The men came in with itchy skin lesion on
groin area.
A. What is the most likely diagnosis?
Tinea cruris
B. What is the differential diagnosis?
intertrigo, contact dermatitis
C. What bedside test to be done to confirm
the diagnosis in A?
Skin scraping for KOH test
D. What result you expect to see?
branching hyphae
E. What is the treatment?
topical antifungal agent (ketoconazole)
Actuate,sharply demarcated plaque with peripheral scaling expand centrifugally and centre clear.
a)What is the bed test used?

Skin scrapping for KOH examination

b)Describe the pic above.

branching fungal hyphae

c)What is the diagnosis?

Dermatophytosis

d)What is the complication of this disease?

Secondary bacterial infection

Psychosocial impact
DERMATO 41 y/old male with hypopigmentation. Test
was done. And the finding is like pic below

A. What is the bedside test done?

skin scraping for KOH test

B. Describe the pic.

Mixture of pseudohyphae & spores

(spaghetti & meatball appearance)

C. What is your diagnosis?

Tinea versicolor caused by Malassezia

furfur

D. How do you manage the patient?

topical antifungal agent (ketoconazole)

 1) Describe the picture
GYNAE #1 - Excessive hair growth on cheek extending to chin and neck
- hyperpigmentation (dark, thick velvety skin) on the posterior
neck indicating acanthosis nigricans

2) What is the diagnosis

- Polycystic ovarian syndrome

3) List four long term complications

1. Infertility issue
2. Endocrine - Diabetes Mellitus, metabolic syndrome
3. Malignancy - breast carcinoma, endometrial carcinoma
4. Cardiovascular - Hypertension, cardiovascular disease

4) What are the 4 hormones that can be raised in this

condition? ( 2 marks)
a.DHEAS (dehydroepiandrosterone sulfate)
b.Serum testosterone
c.LH (Luteinizing hormone)
d.Anti-mullerian hormone
GYNAE #2
1. What are 4 other symptoms that this patient can present
with? (2 marks)
a.Acne
b.Acanthosis nigricans
c.Amenorrhea/ infertility
d.Oily skin
Alopecia, deepening of voice, breast atrophy

2. List four management if she does not wish to conceive

-Lifestyle modification – weight reduction, diet, exercise
- low dose COCP pills to control menstrual irregularities
-anti-androgen (spironolactone, finasteride) to control
hyperandrogenism
- metformin to help in weight reduction
- Benzoyl peroxide for acne
-anti-obesity medications or bariatric surgery to treat
comorbidities
 A. Name the instrument above. (2 marks)
SURGERY Triple-lumen / three way indwelling Foley catheter

OR describe the tube shown in the picture.

Flexible tube made up of latex rubber, at the proximal end, there is 2 fenestration.
Immediate just proximal to it, there is a filled up balloon. At the distal part, there are
3 lumens.

B. Name and state the function of the ports A, B and C. (3 marks)

A- Balloon channel (balloon inflation)
B- Drainage channel (urine drainage)
C- Third channel (facilitate continuous bladder irrigation / medicine instillation)

C. What are the indications for its use in a surgical ward? (3 marks)
- Acute urinary retention
- Bedridden patient
- Intermittent decompression for neurogenic bladder
- Used for drainage after bladder or upper urinary tract surgeries to add
continuous irrigation capabilities.
- Continuous irrigation catheters are used to help remove tissue chips, blood clots and
other debris from the bladder after surgery.

D. What are the early and late complications of using this instrument? (2 marks)
Early: Urethral trauma, false passage creation, bladder spasms.
Late: Urethral stricture, infection, bladder laxity
 Name the device. Metered dose inhaler

Medication that can be given via the device. Salbutamol,

fluticasone

Name a common disease where this device is advised.

Bronchial asthma/ chronic obstructive pulmonary disease

Counsel on the use of the device.

Side effect
B2 agonist: hand tremor,
headache,dry mouth,
palpitations
Inhaled corticosteroids: oral
thrush, sore throat
*i think if under FamMed will ask these only la
● Shake the inhaler. Remove the cap.
● When ready, breathe out gently and seal lips properly
over the mouthpiece.
● Incline the head backwards slightly. While pressing
down on the canister, simultaneously begin a slow
deep inspiration.
● Remove the mouthpiece and hold breath for 10
seconds. Repeat if another puff is necessary.
Ortho 1. Describe. Reduced intervertebral disc space, end
plate sclerosis, osteophytes, spondylolisthesis (didnt
see properly which level but i think is L5/S1)

2. Diagnosis? Anterior spondylolisthesis, state the

level

3. Complication? Nerve Root Compression causing

neurological deficits (numbness, sciatica pain, etc)

4. What imaging to look for complication? MRI lumbar

spine, lateral view

4. Management?
- Non-operative: NSAIDs, activity modification,
physiotherapy, lumbar bracing
- Operative: Spinal decompression and fusion
 Not this exact picture, and not sure of DX, but going with spastic bilateral
PAEDS (quadriplegic) cerebral palsy based on this diagram from textbook
Findings (this is from revision):

- Bilateral hand fisting, flexion of elbows, spasticity posture of upper limbs

Additional:

● What other findings do you expect? Scissoring of legs from excessive adduction of hips,
poor head control, low central tone
● Complications of spasticity: muscle contractures, limb deformities, pressure sores,
degenerative joint disease
● MX of spasticity: physical therapy (cooling & heating of muscles, stretching, orthosis),
electrical therapy (functional nerve stimulation, transcutaneous electrical nerve
stimulation), intramuscular botulinum, intrathecal/enteral baclofen
● DX: Spastic bilateral (quadriplegic) cerebral palsy
● Possible causes:
○ Antenatal - Congenital infections, genetic syndromes,
○ Perinatal - HIE, periventricular leukomalacia
○ Postnatal - hyperbilirubinaemia (kernicterus), hypoglycaemia,
meningitis/encephalitis
● Associated abnormalities/comorbidities? Seizures, microcephaly, moderate-to-severe
intellectual impairment, learning difficulties, feeding difficulties, problems with
speech/vision/hearing, increased risk of hip subluxation and dislocation and scoliosis
● Approach to MX? Multidisciplinary approach - dietitian, specialist health visitor, social
worker, psychologist, paediatrician, physiotherapist, speech & language therapist,
occupational therapist, physiotherapist
 Not this exact picture, and not sure of DX, but going with GLAUCOMA based on
OPHTHAL this past year question
Findings (this is from revision):

- Disc oedema, engorged veins, missing optic cup

Additional:

1. This is the (Left) eye.

2. The optic disc appears (oedematous?), CD ratio is (0.8)
3. The venules/veins are (dilated), The arterioles and arteries are present but
(attenuated)
4. The CD ratio makes the patient a (glaucoma) suspect.
5. What are the 2 investigations to be done to help in diagnosis? - Applanation
tonography, gonioscopy
6. The provisional diagnosis is (open angle glaucoma)

7. MX?

Medication:
1. PG analogs - latanoprost (Xalatan) [increase uveoscleral outflow]
2. B-blocker - timolol (decreased aqueous production)
3. Miotics - Pilocarpine (increase trabecular outflow)
4. Carbonic anhydrase inhibitors (acetazolamide) [decrease aqueous
production]
Surgery: Trabeculotomy (only in congenital glaucoma, answer should be
trabeculectomy)
 Alternative: PAPILLOEDEMA (due to increased intracranial pressure)
OPHTHAL Findings (this is from revision):

- Disc oedema, engorged veins, missing optic cup

Additional:

● In papilloedema, optic disc swelling is usually bilateral

● History
○ Can be asymptomatic, but SX include systemic (headaches -
positional, worse in mornings), pulsatile tinnitus & visual
(transient visual obscuration)
○ Rule out causes: meningitis, SOL hypertension
● MX - treat underlying cause, symptomatic relief,
○ Osmotic diuretics, (e.g., urea, mannitol, glycerol) and loop
diuretics (e.g., furosemide, ethacrynic acid) are first-line
pharmacologic agents used to lower elevated ICP.
● IX
○ Check BP to rule out malignant hypertension
○ Urgent CT brain to r/o SOL
○ To exclude other causes: B scan ultrasonography, fluorescein
angiography, optical coherence tomography (OCT)
A worker in a metal factory presented to ENT clinic with hearing loss. An audiogram was performed for the patient.

A. What is the nature of the loss in this audiogram above?

(conductive, sensorineural, or mixed)? (2 marks)
This is a sensorineural hearing loss
The AB gap is less than 15 dB and the bone conduction
thresholds more than 20 dB
B. What is the possible cause for this hearing loss? (2 marks)
Noise-induced hearing loss
C. What are the methods of prevention for hearing loss in this
patient? (6 marks)
- Substitution - Replacement of old equipment with
quieter new models
- Engineering - Modifications of the noise source
(Fitting mufflers to air exhaust nozzles);
Modifications of the noise path (Placing sound-
blocking enclosures around equipment);
Modifications of the receiver (Constructing an
enclosure around the employee’s workstation)
- Administration control - Adherence to equipment
maintenance programmes related to noise control;
Make changes in employee work schedules to
reduce noise doses by limiting exposure time
- PPE - Earplugs, Earmuffs, Semi-aural devices
SBA- Surgery