Medical MEQ 1999/2000

MEDICAL
Question 1
3 years old boy brought to A&E with signs of dehydration.
1. Patient has been vomiting with high-grade fever.
a. Give 5 questions to ask his mother
i.
Fever: duration, nature, chills/rigors?
ii.
Vomiting: duration, frequency, content of vomitus?
iii.
Any associated symptoms like abdominal pain, urinary
symptoms?
iv.
Any rashes note on the body?
v.
Any family members with similar illness?
b. Sign that you expected
i.
Signs of dehydration such as dry mucosa, decreased
skin turgor and sunken eyeball.
ii.
Fever more than 38C
iii.
Tachycardia and tachypnoea
iv.
Rashes on the body and extremities
v.
Abdominal distension or abdominal pain
c. List the investigation that you would like to do at this
stage
i.
Full blood count to look for increased white blood cell
ii.
Blood urea and electrolyte to look for imbalance sodium
and potassium.
iii.
Blood culture and sensitivity to look for type of infective
organism
iv.
Urine FEME, culture and sensitivity to look for urinary
tract infection
2. After much persuasion, parents agreed for Lumbar
puncture. Lumbar puncture showed increase protein and
decrease glucose.
a. Give 3 organism with their gram stain and appearance
which can cause meningitis
i.
Haemophilus influenzae
ii.
Streptococcus pneumoniae
iii.
Neisseria meningitidis
b. What will you tell the parents about lumbar puncture?
i.
Tell the finding of lumbar puncture
ii.
May be caused by meningitis
iii.
Tell them more about meningitis
iv.
Tell them the treatment, prognosis and complication
v.
Tell them not to worry.
c. What are the appropriate antibiotic for this patient
i.
Ampicillin + gentamicin
d. Why do you think most of the parent will refused
Lumbar puncture?
i.
Because of their false believed that Lumbar puncture
will paralysed their child or cause convulsion
3. CSF showed E. coli which sensitive to netilmycin. But
patient failed to improve his condition after 2 days of
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Medical MEQ 1999/2000

treatment. Currently presented with arched back, stiff

neck and high fever.
a. What will cause the failure of treatment?
i.
Failure of netilmycin to reach the intrathecal space.
ii.
The dosage of the drug is not enough
iii.
Drug resistant
iv.
There may be other organism as well
v.
There may be source of infection else where
b. What further investigation you want to do?
i.
Repeat CSF and blood culture and sensitivity again.
ii.
Repeat full blood count
iii.
Do urine FEME and culture and sensitivity
4. Mother was worried that patient sibling will have the
same problem
a. How do you response to this situation?
i.
Ask them to come to hospital immediately if they have
fever and signs of meningitis.
ii.
Tell the mother to give vaccine to their other children
b. Give 2 specific ways of preventing H. influenza
infection
i.
Immunization HiB
ii.
Prophylaxis antibiotic
Question 2
1. 3 years old with 1 week history of swollen face and
hands. Patients have normal development. The parent
was well.
a. 3 causes of facial puffiness
i.
Renal problem: nephrotic syndrome, nephritic syndrome
ii.
Liver problem: hypoalbuminemia
iii.
Heart problem: congestive heart failure
b. 5 question you would like ask patient
i.
Have you passing frothy urine?
ii.
Do you have sorethroat for the past few weeks?
iii.
Do you have any skin infection for the past few weeks?
iv.
Do you have any congenital heart disease?
v.
Do you passing blood during micturition?
2. Patient had history of passing frothy urine. Investigation
result given.
a. Interprete the investigation result
i.
LFT: hypoalbuminemia
ii.
Urine: proteinuria, no hematuria
b. Most likely diagnosis
i.
Nephrotic syndrome
c. Management
i.
On nephrotic chart
ii.
Strict Input/output chart
iii.
Do daily urine dipstix: to check proteinuria
iv.
Give steroid therapy
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Medical MEQ 1999/2000

(1)60mg/m2/day, in divided dose for 4 weeks

(2)40mg/m2/day, Every Other Day, for 4 weeks
3. Patient has had one relapse and currently come with
complaint of abdominal pain and high grade fever.
a. State your provisional diagnosis at this time
i.
Peritonitis secondary to nephrotic syndrome
b. How do you confirm your diagnosis
i.
Aspirate peritoneal fluid
ii.
Full blood count
iii.
Check urine for proteinuria
4. Patient is now 8 years old. He presented with relapse. He
has had 12 relapses in the past 5 years.
a. What are psychological burden of chronic illness on
patient and family?
i.
Patient
(1)He has to absence for school
(2)His school performance may reduced
ii.
Family
(1)The mother has to take care of the patient and may
neglect the other children.
(2)The mother has to bring the patient to the hospital for
every relapse.
(3)The treatment cost is a burden to the family.
b. How do you manage
i.
Give cyclophosphomide
Question 3
1. 25 years old male brought by mother to A&E with history
of abdominal pain and vomiting for 3 days prior to
admission.
a. Give 3 differential diagnosis
i.
Acute gastroenteritis
ii.
Acute appendicitis
iii.
Peptic ulcer disease
b. 2 further question you would like to ask for each of your
diagnosis above.
i.
Acute gastroenteritis
(1)Have you eating outside for the past few days?
(2)Do you have diarrhoea?
ii.
Acute appendicitis
(1)Does the pain start around the umbilicus and then
radiated to the right iliac fossa?
(2)Do you have fever?
iii.
Peptic ulcer disease
(1)Do you have gastritis before?
(2)Does the abdominal pain relieved by eating?
2. Further questioning, no history of DM, no drug overdose.
PE: revealed fruity breath, signs of dehydration. Patient
only response to painful stimuli, presence of basal
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Medical MEQ 1999/2000

crepitation, decreased breath sound and increased vocal

resonance.
a. 4 investigation and reason.
i.
Chest X-ray: to look for consolidation, pleural effusion
ii.
Liver function test: to look for liver impairment, bilirubin
iii.
Hepatitis A, B and C screening
iv.
Full blood count: to look for increased white blood cell
b. Investigation result
i.
ABG: pH
ii.
RBS:
iii.
Urine: ketone
iv.
CXR: showed pleural effusion in left lung
c. Interpret the result
i.
ABG: patient has metabolic acidosis
ii.
RBS: patient has hyperglycaemia
iii.
Urine: the is ketonuria
iv.
CXR: the is pleural effusion in left lung
v.
Conclusion: patient has diabetic ketoacidosis
d. What would you like to do this patient
i.
Start DKA regimen
ii.
To rehydrate the patient
(1)Give normal saline 0.9% first
(2)Check to blood glucose level, if RBS <15mmol/L, change
normal saline 0.9% to dextrose 5%.
iii.
Give potassium
iv.
Give insulin therapy
3. Patient was rehydrated and given DKA regime. But blood
glucose level still high.
a. What are the causes of failure of treatment
i.
b. What will be your management
Question 4
1. 66 years old hypertensive male presented with history of
cough which had been prescribed with ampicillin 1 week
ago. Patient currently presented with SOB, PND and
orthopnoes for last few days.
a. What could be the cause of his SOB
i.
Left ventricular failure
ii.
Pneumonia
iii.
Pleural effusion
2. PE finding: spleen 8cm below left costal margin
a. Cause of splenomegaly
i.
Portal hypertension due to congestive heart failure
ii.
Hematological causes such as leukemia, myeloma,
myelofibrosis
iii.
Infective causes such as malaria, typhoid
b. What investigation would you like to do

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Medical MEQ 1999/2000

i.

Full blood picture to look for leucocytosis, anemia,

thrombocytopenia
ii.
Blood smear
iii.
Sputum, Blood culture and sensitivity to look for
infective organism
iv.
Chest X-ray to look for consolidation, cardiomegaly,
pleural effusion
c. Blood film revealed
i.
What further investigation
ii.
What are the mostly likely diagnosis
iii.
How to confirm it
(1)Bone marrow aspiration
3. Bone marrow shows myelofibrosis. Patient was treated
with regular blood transfusion. 2 years later he presented
with history of bleeding and petechiae.
a. Possible cause of this
i.
Thrombocytopenia due to myelofibrosis
ii.
Dengue hemorrhagic fever
iii.
Idiopathic thrombocytopenia purpura
b. How do you treat
i.
Transfuse fresh frozen plasma
Question 5
1. 18 years old girl previously a shy girl, presented with
history of 2 weeks while at training college, excessive
active. She always gave mini lectures to friends and
became extrovert and out going. She also started to wear
bright clothes.
a. 3 differential diagnosis
i.
Acute Mania
ii.
Bipolar disorder
iii.
Schizophrenia
b. Give further question
i.
Do you have decreased need of sleep?
ii.
How do you spend your money?
iii.
Do you have increased libido?
iv.
Do you have feel that you are important person?
v.
Do you have many plans to do?
vi.
Do you feel sad?
2. Patient has increase ideas. She said she can become
lecturer as she very clever and good at teaching. She also
made many plans on how to improve ministry of
education. She has decrease need for sleep (only 1-2
hours a night) but still very active next day.
a. What is your provisional diagnosis?
i.
Acute mania episode
b. Give 3 symptomatology in this patient
i.
Grandiosity
ii.
Increased in goal directed activity
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Medical MEQ 1999/2000

iii.
Talkative
3. MSE revealed gradiose ideation, pressure of speech
a. What is your management of this patient?
i.
Admit this patient
ii.
Give mood stabilized: lithium. Monitor serum lithium
level
4. Patient was started on lithium.
a. What 2 initial investigation do you want to do to this
patient
i.
Thyroid function test
ii.
Renal function test
b. Give 4 side effect of lithium
i.
Hypothyroidism
ii.
Tremor
iii.
Weight gain
iv.
Nausea and vomiting
c. What do you think regarding this patient prognosis and
give your reasons
i.
Poor because
(1)Early onset
(2)Not married yet

2003 YONG YONGS NOTES