Portfolio-based questions asked to final year medical students during the examination held in February 2014
1. An 82 year old man has COPD. He presents to the hospital with an acute exacerbation. On examination he is febrile, tachypnoeic, and tachycardic; rhonchi are heard in both lungs. Crepitations are heard in the bases of both lungs. He is suspected to have community acquired pneumonia.
a. When will you suspect the diagnosis of COPD in a patient?
b. How will you confirm the diagnosis of COPD?
c. What will you suspect when a patient with breathlessness has crepitations in the bases of both lungs?
d. What are the usual causative organisms of community acquired pneumonia?
e. What are the usual antibiotics used empirically for the treatment of community acquired pneumonia?
2. A 61 year old man with ischemic heart disease presented with breathlessness to the hospital. He is diagnosed to have congestive cardiac failure. He is prescribed bisoprolol (along with other drugs) at the time of discharge.
a. What should you be aware of when prescribing beta blockers to patients with congestive heart failure?
b. When will you prescribe digoxin to patients with congestive cardiac failure?
c. Name the various drugs that are useful for the treatment of congestive cardiac failure.
d. What is the significance of a cardiac apex beat that is in the 6th intercostal space lateral to the mid clavicular line?
3. A 47 year old man presented with sudden onset of chest pain. He is subsequently diagnosed to have a non-ST elevation myocardial infarction (NSTEMI).
a. How is the treatment of STEMI different from NSTEMI?
b. What are the complications that can arise from infusion of Streptokinase?
c. What is the difference between stable angina and unstable angina?
d. What is the significance of a loud pulmonary second sound in a patient with coronary artery disease?
e. In what way is fondaparinux different from enoxaparin?
4. A 38 year old woman with a long history of Type 1 diabetes presented with anemia, breathlessness and swelling of both legs. Her haemoglobin was 6.7gm/dL and her urea and creatinine were very high. She also had hyperkalemia. Her random plasma glucose was 2.6mmol/L. Her ECG did not show any ischemic changes.
a. What is the cause of her heart failure?
b. What are the reasons for anemia in patients with renal failure?
c. How should patients with Type 1 diabetes be treated for control of blood sugar?
d. Suggest reasons why she has hypoglycaemia.
e. Suggest reasons for her breathlessness.
5. A 55 year old man with diabetes developed chest pain. His ECG showed ST segment elevation in the chest leads and he was referred to hospital. When he arrived in hospital a few hours later, his ECG showed only T wave inversion in the same chest leads. His cardiac enzymes were elevated and he was diagnosed and treated as NSTEMI.
a. Suggest a reason why the ST segment was elevated initially.
b. How is Streptokinase administered to patients with STEMI?
c. What auscultatory findings will you expect in patients with chest pain due to pericarditis?
6. A 65 year old man with IHD presented with shortness of breath and leg swelling. He was diagnosed to have congestive cardiac failure. The x-ray chest showed cardiomegaly and the ECG showed only left axis deviation. His blood pressure was normal and he was not a diabetic.
a. Can the left axis deviation in the ECG be due to ischemic heart disease?
b. How do you diagnose diabetes mellitus?
c. In a patient with cardiomegaly on x-ray chest, what will make you suspect pericardial effusion?
7. A 49 year old man presented with chronic cough, shortness of breath and hemoptysis. He was noted to have clubbing of his fingers and toes and signs of a large pleural effusion on the right side. The trachea was noted to be normal in position.
a. How do you begin the process of finding the cause of a pleural effusion?
b. Why is the trachea not deviated to the opposite side as expected?
c. What clinical features help to differentiate a pleural effusion from a pneumothorax?
d. How is the diagnosis of a tuberculous pleural effusion made?
e. How is tuberculosis treated?
8. A 40 year old man with diabetes presented with chest pain. He is a smoker. His ECG showed deep symmetrical T wave inversions in the chest leads V1 to V4. His serum triglycerides were 5.31mmol/L. The cardiac enzymes were not elevated. His random plasma glucose was 8.9mmol/L. He was diagnosed as having Wellen’s syndrome.
a. What is the significance of making a diagnosis of Wellen’s syndrome?
b. What are the clinically relevant issues related to a very high serum triglyceride level?
c. Can a random plasma glucose value be used to diagnose diabetes?
d. Why is cigarette smoking addictive?
9. A 63 year old man with hypertension presented with acute chest pain. This was diagnosed as unstable angina. His LDL cholesterol was 4.5mmol/L. He had diabetes and hypertension.
a. How do you distinguish between unstable angina and myocardial infarction in a patient with chest pain?
b. When will you suspect aortic dissection in a patient with chest pain?
c. What are the parameters that define “good diabetic control”?
d. What is the significance of a LDL cholesterol value more than 4.9mmol/L?
e. Is there any role for exercise stress testing in patients diagnosed to have unstable angina?
10. A 35 year old woman with nephrotic syndrome presented with bilateral leg swelling, fever, abdominal pain, nausea and vomiting. Her urine showed proteinuria with plenty of red cells and white cells. She was later diagnosed to have urinary infection and a relapse of nephrotic syndrome.
a. How is the diagnosis of nephrotic syndrome made?
b. What is the usual organism that causes uncomplicated urinary infection in women?
c. What must you do before prescribing antibiotics in a patient with recurrent urinary infection?
11. A 60 year old woman with diabetes, hypertension and chronic kidney disease is admitted because of severe bradycardia (heart rate 28/min) and hypotension. On investigations, she is noted to have hyperkalemia.
a. What is the usual cause of hypotension in patients?
b. Can bradycardia cause hypotension?
c. How does the ECG help in evaluating the cause of bradycardia?
d. What are the ECG findings of hyperkalemia?
e. What are the indications for immediate dialysis in patients with chronic kidney disease?