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MedTutor is an online tutoring site for medical students and young doctors in Internal Medicine. Write to MedTutor at: <moc.liamg|todikiwrotutdem#moc.liamg|todikiwrotutdem>.

August to December 2015

1

A sample of the questions asked to students in the final examination at the end of Semester 10 in August 2015.

  1. A patient has cirrhosis liver. But the liver is enlarged and palpable. Is this possible?
  2. What will be the abnormalities seen, if any, in the LFT of patients with cirrhosis?
  3. What are the tumour markers relevant to patients with cirrhosis liver?
  4. What is the biochemical abnormality that leads to hepatic encephalopathy?
  5. What kind of antibiotics are used in patients with hepatic encephalopathy?
  6. What can be done to limit upper GI bleeding (before endoscopy is done) in patients with cirrhosis liver?
  7. When one lower limb is shorter than the other, how do you know if the shortening is due to a problem above or below the greater trochanter?
  8. How can you demonstrate the presence or absence of fixed flexion deformity of the hip?
  9. Why should the knee be examined in patients with long standing hip joint problems?
  10. How do you test the motor function of the sciatic nerve in a patient who has pain in the lower limb?
  11. What is the significance when an abdominal mass becomes more prominent on tensing the abdominal wall?
  12. What is the criteria for saying that a stroke is a lacunar stroke?
  13. Some strokes can be caused by space occupying lesions in the brain. Explain how that happens.
  14. When you are faced with an elevated serum creatinine in a patient, how do you go about determining whether it represents acute kidney injury or chronic kidney disease?
  15. What precautions will you observe when treating diabetes in patients with chronic renal failure?
  16. Why do some people with inferior wall myocardial infarctions have a transient period of hypotension?
  17. When will you prescribe thiamine to a patient with congestive cardiac failure?
  18. What is the rationale of prescribing spironolactone to a patient with congestive cardiac failure?
  19. How do you diagnose diabetes mellitus?
  20. What is the risk of prescribing high doses of inhaled corticosteroids?
  21. When is the ideal time for surgical closure of atrial septal defect?
  22. Why does pulmonary hypertension develop in patients with atrial septal defect?

2

A 59 year old woman presented to the hospital with these investigations. Your task is to analyse these results and discuss the various things that might be wrong with her.

Item Patient's value unit of measurement normal value/range
Blood urea 26.8 mmol/L 2.8 - 7.8
Serum creatinine 773 umol/L 61 -124
Serum sodium 138 mmol/L 135 -148
Serum potassium 4.9 mmol/L 3.5 - 5.1
Serum chloride 107 mmol/L 93 - 108
Total serum protein 62 Gram/L 60 -83
Serum Albumin 36 Gram/L 35 - 48
Serum Globulin 27 Gram/L 28 - 36
Total Bilirubin 5.8 umol/L 0 -25
Alk. Phosphatase 120 U/L 36 -92
Alanine transaminase (ALT) 15 U/L < 40
Total Cholesterol 3.8 mmol/L < 5.7
Triglycerides 2.1 mmol/L 0.4 -1.8
HDL C 1.0 mmol/L > 1.7
LDL C 1.9 mmol/L < 3.3
Serum Calcium 1.95 mmol/L 2.2 - 2.65
Serum Phosphate 1.82 mmol/L 0.81 - 1.45
Fasting plasma glucose 4.2 mmol/L 3.9 - 6.6
HbA1c 6.9 % <7
24 hours urine protein 7.6 Grams Less than 150mg
Urine examination SG 1.010 protein 5G/L glucose + nitrite nil

Urine WBC: 5 to 10 / HPF (500/uL; normal less than 10/uL)
Urine RBC: 1 to 3 / HPF ; (50/uL; normal less than 5/uL)


3

For discussion:

  1. The discharge diagnosis is: "Chronic liver disease with thrombocytopenia". How are these two things linked?
  2. From clinical notes: "The patient has fluid overload. His x-ray chest shows congestive pattern and cardiomegaly." What exactly are we dealing with here?
  3. A woman has hypertension and a serum creatinine of 171umol/L. What do you think may be the cause of the hypertension?
  4. An 85 year old man has CKD. His fasting plasma glucose is 5.3mmol/L. Is it possible that he has diabetes?
  5. The renal profile of a patient: Blood urea 14.3mmol/L; Serum creatinine 156umol/L; Serum Na 140mmol/L; Serum K 3.2mmol/L. Question: Why is the K low when the urea and creatinine are raised?
  6. A 69 year old man has COPD and was diagnosed recently as having decompensated CCF. His ECHO showed LVEF of 60 percent. What are we dealing with here?
  7. How do you treat a patient who has chronic renal failure?
  8. What are the advantages and disadvantages of using Frusemide in chronic renal failure?

Dr Velayudhan Menon, MD
Clinical Associate Professor of Medicine
International Medical University, Malaysia

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