2018 Q.P

Question 1

Risk factors for DVT

Answer 1

• Smoking
• Hyperlidpemis
• Oral contraceptives
• Immobilization
• Surgery within 3 months
• Pregnancy

Question 2

Investigation for DVT

Answer 2

1.
D-Dimer…Elevated levels suggest recent presence lysis of thrombi.

2. Ultrasonograpgy- Identify thrombi by direct visualization of venous linning

Question 3

List 3 pathological processes responsible for the formation of DVT

Answer 3

1. Venous stasis
2. Endothelial injury/damage
3. Hypercoagulation.

Question 4

Symptoms for DVT

Answer 4

1. Vague aching pain.
2. Calf swelling
3. Warmth
4. Visible veins
5. Redness
6. Mild fever

Question 5

Signs of DVT

Answer 5

1. Erythema
2. Pitting edema
3. Superficial collateral veins
4. Tenderness along tje distribution of veins.
5. • Horman’s signs

Question 6

DDx of Microcytic Anemia

Answer 6

1. Acute blood loss
2. Renal failure
3. Hypothyroidism
4. Pregnancy

Question 7

List 5 Secondary causes of HPT

Answer 7

1. Cushion’s syndrome
2. Acromegally
3. Thyroid disease
4. Chronic glomerulonephritis
5. Hyperparathyroid disease

Question 8

Baseline bedside test for MI

Answer 8

ECG

Question 9

List 2 lab investigations that will help diagnose MI

Answer 9

1. Cardiac Enzymes (Troponin)

2. FBC

Question 10

List 4 treatments that you can give at district Hospital for MI pt

Answer 10

1. Oral antiplatelet therapy
2. Nitrates
3. Anticoagulation
4. Beta-Blockers

Question 11

DDx of MI

Answer 11

1. Angina pectoris
2. Pericarditis
3. Myocarditis
4. Pulmonary Embolism

Question 12

Life-threatening complications of HPT

Answer 12

1. Ischemic heart disease
2. Hypertensive Retinopathy
3. Hypertensive Neuropathy
4. CVA
5. Heart Failure

Question 13

A 75-year-old man presents to Accident and Emergency following a week of productive cough, fever and shortness of breath. He has not had any foreign travel, however is a chronic smoker with a 15 pack/year history.

Which of the following findings is most likely to be found on examination of this patient’s chest?

Sample Clinical Questions
Lab Values
HAEM
CHEM
MISCELLANEOUS
Normal Values
The figures quoted within the themes are all standardised to the units show below. Note ranges vary between populations and age groups and it is important to always check the reference ranges.
Haematology
Haemoglobin
(M) 13.0 - 17.0 g/dL
(F) 11.5 - 15.5 g/dL
White cell count
3.0 - 10.0 x 10⁹ /L
Platelets
150 - 400 x 10⁹/L
Mean cell Haemoglobin (MCH)
27 - 33 pg
Mean cell haemoglobin concentration (MCHC)
32 - 35 g/dL
Mean cell volume (MCV)
80 - 96 fL
Neutrophils
2.0 - 7.5 x 10⁹ /L
Lymphocytes
1.5 - 4.0 x 10⁹/L
Monocytes
0.2 - 1.0 x 10⁹/L
Eosinophils
0 - 0.4 x 10⁹/L
Basophils
0 - 0.1 x 10⁹/L
Reticulocytes
25 - 100 x 10⁹/L
Packed cell volume (PCV)
(M) 0.40 - 0.54
(F) 0.37 - 0.50
Erythrocyte sedimentation rate (ESR)
< 20 mm/hr
D-dimers
< 0.5 mg/L
Coagulation screen
International normalised ratio (INR)
1.0
Activated partial thromboplastin time (APTT)
22 - 41 seconds
Prothrombin time (PT)
10 - 12 seconds
Thrombin time (TT)
9 - 15 seconds
Fibrinogen
1.5 - 4.0 g/dL
Fibrinogen degradation products
< 8 mg/mL
Factor VIII:C
50 - 150 U/dL
Bleeding time
< 10 minutes
Arterial blood gas
pH
7.35 - 7.45
PaO₂
11 - 15 kPa
PaCO₂
4.6 - 6.4 kPa
Bicarbonate
22 - 30 mmol/L
Base excess
-2 to +2 mmol/L
Question 1
A 75-year-old man presents to Accident and Emergency following a week of productive cough, fever and shortness of breath. He has not had any foreign travel, however is a chronic smoker with a 15 pack/year history.

Which of the following findings is most likely to be found on examination of this patient’s chest?

A. Hyper-resonant percussion note and tracheal deviation to the left
B. Stony dull percussion note and reduced tactile vocal fremitus

C. Increased vocal resonance and fine end inspiratory crepitations
Reduced vocal resonance and dull percussion note
D. Increased tactile vocal fremitus and dull percussion note

Answer 13

D is the correct answer. This patient has the classic symptoms of a pneumonia and the abnormality found on auscultation is indicative of a lobar pneumonia. Pneumonia presents with increased tactile vocal fremitus/ vocal resonance and dull percussion note.

Question 14

Question 2
A 69 year old woman presents following a 3 day history of shortness of breath and a productive cough. Her initial observations are HR: 104bpm, RR:31, BP:90/65, O2 sats: 96%, Temp: 38.5C.

She is admitted to hospital and treated with IV amoxicillin and clarithromycin for the past week. However, since then her fever has persisted and she has developed foul smelling sputum.

A chest x-ray is requested and an aspirate of pleural fluid is obtained. The results demonstrate a pH<7.2.

What is the most appropriate management?

A. High flow oxygen (60%)
B. Antibiotic instillation
C. Change the antibiotic regime to IV Tazocin
D. Add oral itraconazole
E. Chest drain under ultrasound guidance

Answer 14

E is the correct answer. A recurrent fever despite antibiotic treatment for a pneumonia is suggestive of an empyema. This is further supported by the pleural fluid aspirate pH reading of 7.2 which is “almost” diagnostic. Therefore, treatment of an empyema involves a chest drain under radiological guidance.

Question 15

A 55 year old female presents with a three month history of dyspnoea and persistent cough.

Over the last few days her cough has progressively worsened and she is now coughing red specks. She complains that her clothes no longer fit her, and she is having to regularly wear belts. She works as a receptionist and has never smoked.

Which of the following is the single most likely diagnosis?

A. Adenocarcinoma
B. Metastasis from the breast
C. Small cell carcinoma
D. Large cell carcinoma
E. Squamous cell carcinoma

Answer 15

A is the correct answer. The patient has a history indicative of lung cancer, with dyspnoea, haemoptysis and weight loss that has progressively worsened. However, the lack of smoking history makes adenocarcinoma the most likely diagnosis

Question 16

A 25 year old male patient presents to the general practitioner with a 4 week history of an enlarging left neck mass. He reports the mass is generally painless, but he notices it is sometimes painful after he drinks alcohol. He denies any other symptoms and has no past medical history of note.

Physical examination reveals non-tender cervical lymphadenopathy. Excisional lymph node biopsy reveals large cells with bilobed nuclei and eosinophilic nucleoli.

Which of the following is a risk factor for the most likely diagnosis?

A. Middle age
B. History of Epstein-Barr virus (EBV) infection
C. African ancestry
D. Stage II (A)
E. Low socio-economic class

Answer 16

B is the correct answer. EBV is strongly associated with Hodgkin’s lymphoma. EBV antigens are found in approximately 30% of Reed-Sternberg cells.

Question 17

A 65 year old male patient presents to the general practitioner with a 1 month history of malaise, night sweats, and weight loss.

On physical examination he appears cachectic and there is conjunctival pallor. There is moderate splenomegaly. Full blood count reveals a white cell count of 5.5 x 10^9/L, a haemoglobin of 7.5 g/dL, platelet count of 88 x 10^9/L, and absolute reticulocyte count of 0.4%. Peripheral blood film reveals poikilocytes.

Which of the following is the best diagnostic investigation for the most likely diagnosis?

A. Serum protein electrophoresis
B. Serum folic acid levels
C. Serum B12 levels
D. Bone marrow aspiration
E. Bone marrow biopsy

Answer 17

E is the correct answer. The patient presents with clinical features and investigation findings suggestive of myelofibrosis, a cause of acquired pancytopenia. Marrow biopsy will reveal marrow fibrosis. The marrow may either be hyperplastic or hypoplastic, embedded in a collagenous matrix.

Question 18

An 74 year old man is being treated for chest sepsis with IV amoxicillin. His past medical history includes hypertension, for which he is on ramipril and amlodipine. He is normotensive. His blood tests come back as follows:

Na 142 (135-145)
K 5.4 (3.5-5.5)
Ur 10.4 (2.5-6.7)
Cr 203 (70-150) - baseline 120

He is initiated on IV fluids and is currently producing some concentrated urine.

What is the most appropriate next step in managing this patient?

A. Arrange dialysis
B. Stop amlodipine
C. Start furosemide
D. Stop amoxicillin
E. Stop ramipril

Answer 18

E is the correct answer.

Ramipril may worsen pre-renal AKI by reducing renal perfusion through dilation of renal arterioles. It is therefore imperative to stop it.

Question 19

A 25 year old female patient presents to the general practitioner with a 2 day history of urinary frequency and dysuria.

Physical examination reveals mild suprapubic tenderness. Vital signs are within the normal ranges.

Which of the following investigation findings is consistent with the likely diagnosis?

A. Midstream urine culture shows 20 white cells/mm^3
B. Blood culture is positive for E. coli
C. Urine dipstick reveals 2+ protein and 2+ blood
D. Midstream urine culture shows 10^5 colony forming units/mL pure growth of E. coli
E. Full blood count reveals a white cell count of 18 x 10^9/L

Answer 19

D is the correct answer. The patient’s clinical presentation is consistent with cystitis. The diagnostic test for urinary tract infection is with MC&S of midstream urine. This should show >10^4 colony forming units/mL of pure growth (10^3 is sufficient for E. coli, 10^5 is requires if the growth is mixed). Note that diagnostic confirmation of urinary tract infection is not required in women who are not pregnant presenting with the typical features of cystitis. Confirmation of urine MSU is required in children, male patients, pregnant women, recurrent/relapsing UTIs, pyelonephritis, if haematuria is present on the dipstick, and if the patient is catheterised.

Question 20

A 65 year old female patient presents to A&E with shortness of breath after a 3 day history of vomiting and diarrhoea. She has a background of chronic kidney disease.

Physical examination reveals dry mucous membranes, but is otherwise normal. An arterial blood gas is done which shows:

pH = 7.31, PaO2 13 kPa, PaCO2 3.5 kPa, normal anion gap

Which of the following is the next best step in the management of this patient?

A. Intravenous sodium bicarbonate
B. Intravenous 0.9% sodium chloride
C. High flow oxygen 15 L/min via a non-rebreathe mask
D. Low molecular weight heparin
E. Intravenous broad-spectrum antibiotics

Answer 20

B is the correct answer. This patient has a background of chronic kidney disease so is at risk of developing acute kidney injury. Hypovolaemia secondary to gastroenteritis can result in a pre-renal acute kidney injury. The acute kidney injury will cause a metabolic acidosis: the low pH is consistent with acidaemia, and the low PaCO2 indicates a metabolic cause. The metabolic acidosis will result in tachypnoea which blows off CO2, in an effort to normalise the pH (respiratory compensation). The patient is hypovolaemic and requires fluid resuscitation with intravenous 0.9% sodium chloride followed by maintenance fluids. This restore perfusion pressures and correct the pre-renal AKI.

Question 21

A 30 year old male undergoes a renal transplant for polycystic kidney disease. After 3 years he presents with pain in both hip joints and impaired mobilisation.

Physical examination reveals painful reduction in active movement in both hip joints. Bloods reveal an eGFR >90 ml/min/1.73m^2.

Which of the following is the most likely cause?

A. Avascular necrosis
B. Rheumatoid arthritis
C. Renal osteodystrophy
D. Primary osteoarthritis
E. Osteomalacia

Answer 21

A is the correct answer. Avascular necrosis is caused by reduced blood supply to the bone. Causes to remember include corticosteroid therapy, sickle cell disease, and connective tissue disease. Systemic steroids are associated with 35% of cases of non-traumatic avascular necrosis. To prevent organ rejection, the patient requires immuno-suppressive therapy following the renal transplant so is likely to be on long-term oral steroids.

Question 22

An 8 year old boy presents to the general practitioner with a 3 week history of periorbital oedema, ankle oedema and frothy urine.

Physical examination shows significant ankle oedema to the mid-shins. Urine dipstick reveals 3+ protein.

Given the most likely syndrome, which of the following is the most likely underlying cause?

A. Minimal change disease
B. Post-streptococcal glomerulonephritis
C. Membranous nephropathy
D. Focal segmental glomerulosclerosis
E. Acute interstitial nephritis

Answer 22

A is the correct answer. This presentation is consistent with nephrotic syndrome. Minimal change disease is the most common cause of nephrotic syndrome in children. The disease is called ‘minimal change’ because renal biopsy reveals a normal appearance on light microscopy, but electron microscopy shows foot process effacement.

Question 23

A 75 year old male patient presents to the emergency department with sudden onset dizziness. He has a past medical history of type 2 diabetes and hypercholesterolaemia.

On physical examination there is loss of temperature sensation on the left half of the face. The left pupil is fixed in constriction. There is gaze nystagmus when looking to the left. His gait is unsteady and broad-based. No other abnormalities are noted.

Given the most likely diagnosis, which of the following artery is most likely involved?

A. Left posterior inferior cerebellar artery
B. Basilar artery
C. Left anterior inferior cerebellar artery
D. Right anterior inferior cerebellar artery
E. Right posterior inferior cerebellar artery

Answer 23

A the correct answer. The patient presents with features suggestive of lateral medullary syndrome (Wallenberg’s syndrome). This is caused by a stroke affecting the cranial nerve nuclei of the medulla. This form of stroke causes ataxia, dysarthria, dysphagia, ipsilateral Horner’s syndrome, ipsilateral loss of pain and temperature sensation on the face, and contralateral loss of pain and temperature sensation over the contralateral body.

Question 24

A vascular territory.

Which of the following is the most appropriate acute management for the most likely diagnosis?

A. Endovascular intervention (clot retrieval)
B. Intravenous alteplase
C. Supportive management and neuro-surgical review
D. Aspirin 300 mg orally
E. Intravenous, labetolol

Answer 24

C is the correct answer. The patient presents with features suggestive of haemorrhagic stroke. Haemorrhagic stroke should not be managed with aspirin or thrombolysis. Acute management involves neurosurgical and neuro-critical care evaluation, admission to the neurology ICU, and airway protection.

Question 25

A 65 year old male patient presents to the emergency department with sudden onset left arm and leg weakness. He has a past medical history of hypertension, osteoarthritis, and depression. Physical examination reveals left-sided hemiparesis. CT head reveals a right-sided hypo-dense region in the middle cerebral artery territory. Electrocardiogram (ECG) is normal. Given the most likely diagnosis, which of the following is the most suitable long-term pharmacological therapy? A. Warfarin with dose adjusted for target INR of 2-3, atorvastatin 80 mg once nightly B. Clopidogrel 75 mg once daily, atorvastatin 80 mg once nightly C. Aspirin 75 mg once daily, clopidogrel 75 mg once daily, atorvastatin 80 mg once every morning D. Aspirin 300 mg once daily, clopidogrel 300 mg once daily, atorvastatin 80 mg once nightly E. Aspirin 75 mg once daily, clopidogrel 75 mg once daily, Ezetimibe 20 mg once nightly

Answer 25

B is the correct answer. The patient presents with features suggestive of an ischaemic stroke, most likely secondary to small cerebral vessel atherosclerosis or carotid artery stenosis (the normal ECG make a cardio-embolic source less likely). Long-term management is with antiplatelet therapy (Clopidogrel is first line) and lipid-lowering therapy. The patient's blood pressure therapy may also need to be adjusted.

Question 26

A 65 year old male patient presents with sudden onset right-sided weakness and impaired sensation on the right side. There were no preceding symptoms. There was no loss of consciousness. By arrival to the emergency department 30 minutes later his symptoms have resolved and physical examination is normal. Blood glucose is 4.5 mmol/L. Past medical history is significant for type 2 diabetes mellitus and hyperlipidaemia. Which of the following is a risk factor for the most likely diagnosis? ``` A. Gliclazide therapy B. History of major psycho-social stressor C. Atrial fibrillation D. Vitamin D deficiency E. Family history of seizures ```

Answer 26

C is the correct answer. The presentation is consistent with a transient ischaemic attack (TIA). Atrial fibrillation increases the risk of TIA due to left atrial blood stasis and thrombus formation, with embolisation to the cerebral vessels.

Question 27

A 22 year old male patient presents to the emergency department after suffering a head strike during a boxing match. He lost consciousness for 15 seconds then regained a normal level of consciousness. On arrival to the emergency department he reports a mild headache but is otherwise well. Within the next 2 hours his headache worsens and consciousness level declines. Which of the following CT head findings is consistent with the most likely diagnosis? A. Crescent-shaped homogeneously hyper-dense extra-axial collection adjacent to the left frontoparietal convexity B. Irregular hypo-dense lesion within the left temporal white matter, with irregular enhancement of the margins C. Hyper-attenuating material pooling within the occipital horns of the lateral ventricles D. Cortical hypo-density associated with loss of grey-white matter differentiation in the vascular territory of the middle cerebral artery E. Lentiform-shaped heterogenous hyper-dense extra-axial collection adjacent to the left squamous temporal bone

Answer 27

E is the correct answer. The patient presents with a clinical presentation consistent with an extradural haematoma (in particular the lucid interval followed by deterioration)

Question 28

An 82 year old man being investigated for weight loss by his GP is found to have an abnormal blood count revealing a lymphocytosis of 25.8 x10^9/L (and low-normal haemoglobin and platelets). Liver and renal function are normal and the blood film shows a lymphocytosis with an abundance of smudge cells. Aside from the weight loss he reports only occasional night sweats on direct questioning. On closer examination, the GP finds subtle cervical lymphadenopathy bilaterally and 2 finger breadths hepatosplenomegaly. He has not traveled recently and there is no family history of blood disorders. What is the single best diagnostic investigation? A. EBV serology and viral PCR B. Bone marrow biopsy and immuno-phenotyping. C. Chest X-ray and mycobacterial sputum culture D. HIV test E. Excision lymph node biopsy

Answer 28

B is the correct answer. The working diagnosis here must be chronic lymphocytic leukaemia presenting with indolent symptoms and lymphocytosis in an elderly man. Smudge cells are a pathognomonic features of CLL on a blood film. Bone marrow biopsy with immuno-phenotyping will confirm the diagnosis.

Question 29

An 80 year old female complains of progressive tiredness over the past 5 months. She denies any history of anaemia, no black stools, no fresh blood per rectum. She maintained a good appetite although has lost 8 kg of weight during this time frame. Bloodwork reveals a pancytopenia, normal renal function and otherwise normal biochemistry profile. What is the next appropriate step and management? ``` A. Lymph node biopsy B. Blood film C. Thyroid function tests D. Bone marrow biopsy E. Urine Bence Jones protein ```

Answer 29

B. The peripheral film can tell lots of important information regarding a pancytopenia. Nutritional deficiencies such as iron, B12 or folate will all be apparent on a film alongside rouleaux formations for multiple myeloma. Blasts and other immature cells may suggest malignancy or a primary bone marrow disorder such as myelofibrosis. The differential for pancytopenia can be wide but the film can help pinpoint the aetiology and the next stage of tests.

Question 30

A 70-year-old man with a diagnosis of Chronic Obstructive Pulmonary Disease which is normally managed by a Symbicort inhaler, is admitted following a 5-week history of gradual shortness of breath and confusion. His observations are: HR 110bpm, RR 27, BP 100/70, Temp 37.0C, and O2 saturations of 82%. The patient is started on nebulized bronchodilators and oxygen, and after 20mins a further arterial blood gas is performed with the results as follows: pH 7.29 PaO2 7.7 PaCO2 8 HCO3- 27 Which is the next best step in the management of the patient? ``` A. Doxapram B. IV Hydrocortisone C. Oral Amoxicillin 500mg/8 hourly D. IV aminophylline E. Non-invasive Ventilation (NIV) ```

Answer 30

E is the correct answer. The ABG shows an uncompensated type 2 Respiratory Failure as PaO2 <8 and PaCO2 >6. Due to the PH <7.35 we would consider Non-invasive ventilation since the PaCO2 is rising.

Question 31

A 55 year old male patient came to the emergency department with a complaint of breathlessness for the past 2 hours. This is the 3rd episode in the last 3 weeks. On examination the patient is using his accessory muscles to breathe. The vitals are: blood pressure 140/88mmHg, pulse rate 110bpm. Respirationa 30bpm, temperature 37.6C. On auscultation his chest is silent. a) List 7 additional findings (not listed above) in his medical history (subjective data) that will support a diagnosis of an acute asthma attack.

Answer 31

1. Wheeze 2. Cough 3. Chest tightness 4. Eczema 5. Hayfever 6. Famil Hx of asthma 7. Symptoms worse at night, early morning, with cold or stress.

Question 32

A 20 year old male patient brought by an ambulance to the emergency department with a history of a circumcision performed one week ago at a circumcision school. He presents with fever and shallow breathing. A clinical associate on duty makes an assessment of Septic shock. a) List 3 additional findings (not mentioned above) on physical examination (objective data) to support the diagnosis of Septic shock

Answer 32

1. Tachycardia 2. Cold peripheries 3. Weak pulse 4. Hypotension

Question 33

A patient is being placed under general anesthesia. Following the induction with propofol, the anesthetist attempts to intubate the patient. The doctor accidentally touches the patient's vocal cords with the endotracheal tube. The patient starts excessively making it impossible to intubate the patient. a) Explain why the patient starts to cough during the attempted intubation?

Answer 33

Irritation of the vocal cord by the endotracheal tube stimulates the cough Reflexes as the body attempts to remove the foreign body.

Question 34

A 42 year old patient is diagnosed with gout after his first attack. He is referred to the clinical associate by the primary health care nurse for treatment and education. List 2 non-drug management steps and explain why each step is recommended to help manage the patient's medical condition.

Answer 34

1. Rest & immobilize- To help reduce the pain and avoid aggravating the pain. 2. Educate the patient about the importance of alcohol cessation & other symptoms.

Question 35

A 42 year old patient is diagnosed with gout after his first attack. He is referred to the clinical associate by the primary health care nurse for treatment and education. List 2 drug management steps and explain why each step is recommended to help manage the patient's medical condition.

Answer 35

1. Ibruprofen oral, 400mg/kg- To help relieve pain and reduce inflammation. 2. Prednisone oral, 40mg/daily, 5 days- It helps reduce inflammation

Question 36

A 45 year old male patient started TB treatment a month ago. He is HIV negative and his TB symptoms have improved. However today, at the district hospital OPD, he complains that the anti-TB medication is affecting him adversely. On examination his sclerae appears Dark yellow bilaterally. a) Describe the next most important management steps for this patient.

Answer 36

- Stop the hepatotoxic drug and replace it with a hepato friendly second line drug. - Treat the Jaundice

Question 37

A 6 month old girl is brought to the clinic by her mother who is worried about her cough. The mother reports that the girl has been less active than usual for 3 days. The girl has runny nose, decreased appetite, worsening cough and weakness. On examination she looks sick. The vitals are: Pulse rate 160bpm, respiratory 60bpm, temp 38.8C. On exam no chest in drawing. Auscultation reveals reduced breath sounds with defuse Expiratory wheeze. a) State 3 general and/or supportive non-drug measures which should be taken in the management of the child.

Answer 37

1. Cool the child with damp luke warm cloth 2. Ensure hydration = IV or oral 3. Encourage feeding, preferably breast feeding

Question 38

A 6 month old girl is brought to the clinic by her mother who is worried about her cough. The mother reports that the girl has been less active than usual for 3 days. The girl has runny nose, decreased appetite, worsening cough and weakness. On examination she looks sick. The vitals are: Pulse rate 160bpm, respiratory 60bpm, temp 38.8C. On exam no chest in drawing. Auscultation reveals reduced breath sounds with defuse Expiratory wheeze. B) Complete the table below for the most appropriate pharmacological treatment to be prescribed for this girl. State 2 drugs with Drug name, drug class, and drug mechanism of action.

Answer 38

1. Drug name: Paracetamol Drug class: Analgesia & pyretic Mechanism of Action of drug: Acts to aliviate pain. 2. Drug name: Amoxicillin Drug class: Antibiotics Mechanism of Action of drug: Weakness and destroys the bacterial cell wall, causing lysis or death.

Question 39

Caroline, a 12 year old girl is brought to the clinic by her mother with a Skin rash on the face and trunk. She complains of a fever for 3 days. Her 10 year old sister had similar symptoms 2 weeks ago. On examination the maculopapular is distributed all over the skin. The lesions are in successive crops, some papules are appearing while earlier crops begin to crust over. a) State the most likely causative agent for this illness? B) Describe 3 important points of advice to give to the mother to keep the lesions protected from secondary bacterial infections. c) Describe 3 ways to prevent the spread of this illness to other siblings in the house.

Answer 39

a) Varicella zoster B) 1. Ensure adequate hydration and keep lesions clean 2. Cut fingernails short and discourage scratching 3. Ensure compliance of treatment C) 1. Isolate the child from other siblings 2. Wash and disinfect linen and clothes 3. Ensure vaccination to those who have not received vaccination and are less than 6 years old.

Question 40

A 6 month old male baby is brought by his mother with a complaint of slow growth and development. He is the third born and has 2 older female siblings. The mother states that her son is not developing at a the same pace as his siblings did at his age. She became concerned because the boy cannot sit upright without support. He cannot reach out for objects and grasp them. He is not interested in the environment and he does not laugh. Complete the table below to describe 3 relevant History taking questions to ask the parents and explain why you are asking each question

Answer 40

1. Relevant question to ask on history: Was the child born a premature/ low birth weight? Explanation/Reasons for asking this question: premature babies do not always grow and develop as well and fast like full term babies do. 2.Relevant question to ask on history: Ask for symptoms like body wasting, swelling, etc. Explanation/Reasons for asking this question: To help rule out malnutrition 3.Relevant question to ask on history: What is the clinical Explanation/Reasons for asking this question

Question 41

Thabile Chabangu's epilepsy is not controlled on Sodium Valproate (epilim). She is 22 years old. (a) Apart from adhering to the correct drug treatment, which other measures can you advise to minimize the likelihood of her having more seizures? List three (3):

Answer 41

1. The adverse effect of alcohol on seizures, 2. Good sleep hygiene, 3.Family planning is important in women of child-bearing potential as anticonvulsants, are all potentially teratogenic. Note that there are important drug-drug interactions between hormonal contraceptives (except DMPA) and several anticonvulsant medicines (carbamazepine, phenom barbital, phenytoin).

Question 42

Thabile Chabangu's epilepsy is not controlled on Sodium Valproate (epilim). She is 22 years old. (b) Several other issues should also be discussed with every patient diagnosed with Epilepsy. Describe four (4) issues you would address in your further health education for Thabile. (4 marks)

Answer 42

1. Patients with uncontrolled seizures should avoid driving and operating machinery until they have been seizure free for one year. 2. The effect of missing a dose of medication. 3. Discontinuing the medication without advice of a doctor, and 4. Record dates and, if possible, times of seizures in a seizure diary. Present seizure diary at each consultation for assessment of therapy.

Question 43

A 52-year-old man is admitted to the district hospital complaining of productive cough and shortness of breath for four (4) months. His symptoms have gradually worsened over the last three (3) months. He also complains of losing weight. He is not on medication and has smoked 15 cigarettes a day for past 20 years. HIV status is unknown. List the four (4) relevant hypotheses based on the history given. ( 4 marks).

Answer 43

1. Chronic Obstructive Pulmonary Disease 2. Pulmonary TB 3. Bronchiectasis 4. Lung cancer

Question 44

A 52-year-old woman, known DM type II and hypertensive patient who has been on treatment for more than five (5) years. She came to OPD for her blood results to be reviewed. What are the optimal treatment target levels of fasting blood sugar, random blood sugar, HBA1C, and blood pressure for this patient?

Answer 44

1. Fasting blood sugar: 4-7.1 mmol/L 2. Random blood sugar: <12 mmol/L 3. HBA1C: < 6.5% 4. Blood pressure: 140/70 mmHg- 150/80 mmHg

Question 45

A 55-year-old female came to OPD referred from the clinic with the diagnosis of hypertension. Her BP values remains 150/95mmHg in several occasions. Mention four (4) invesgation you consider important complete the assessment of the patient current condition. Explain in each case why it is important. (4 marks)

Answer 45

1. Bloods: U&E, protein:creatinine ratio. 2. ECG: check for LVF on ECG. 3. Urine dip (blood and proteinuria) 4. CXR: to assess presence of LV hypertrophy

Question 46

A 20-year-old female, known with Asthma presents with shortness of breath, Wheezing and cough. The ClinA makes an assessment of moderate acute asthma. 1. In view of the current COVID-19 pandemic, what is the next most appropriate pharmacological management of this patient. (2 marks) 2. List 4 clinical features of acute severe asthma. (4 marks)

Answer 46

1. Give Salbutamol, MDI, 200mcg 2. °Shortness of breath ° Slient chest ° Confusion/ altered mental state ° Loss of consciousness

Question 47

A 54 year old female, known with Type 2 Diabetes mellitus presents with a 2-day history of Polyuria, Polydipsia, and progressive body weakness. On examination, the patient is severely dehydrated and drowsy. BP=146/88mmHg; PR=116 beats/min; RR=20 breath/min. Urinalysis: Glucose 3+, protein 1+, ketones Nil. 1.What is the most likely clinical assessment?

Answer 47

1. Hyperosmolar hyperglycemic state

Question 48

A 17-year-old male student presents to OPD with a history of severe headache, fever and confusion. The ClinA on duty makes a provisional diagnosis of Bacterial Meningitis 1. Outline the 4 features from CSF analysis that support the diagnosis of Bacterial meningitis. (4 marks)

Answer 48

1. Appearance-Turbid 2. WBC, Polymorphs- High 3. Protein-High 4. Glucose- Low

Question 49

Mention the causative organism and way of transmission of Typhoid Fever. (2marks)

Answer 49

1. Salmonella Typhi | 2. Fecal-Oral route

Question 50

What are the typhoid fever general measures

Answer 50

1. Transfusion is indicated for severe haemorrhage. 2. Replace fluid and electrolytes. 3. Contact isolation during acute phase of illness.

Question 51

What is the Medicine treatment for Typhoid Fever

Answer 51

Antibiotic Therapy There is increasing resistance to ciprofloxacin in South Africa and it is important to send specimens for culture and sensitivity prior to commencing antibiotic therapy. Total duration of antibiotic therapy: 10 days. Ceftriaxone, IV, 2 g 12 hourly. LoEII [33] Follow with oral therapy as soon as patient can swallow and the temperature is <37.8°C for 24 hours, based on culture sensitivity results: Ciprofloxacin, oral, 500 mg 12 hourly. LoEIII Stool cultures must be repeated at weekly intervals after convalescence to ensure that a carrier state has not developed. Two consecutive negative stool cultures are required to exclude carrier state. This is of vital importance in food handlers, who must not be permitted to return to work until stools are negative. Chronic carriers: (Z22.0) Ciprofloxacin, oral, 500 mg 12 hourly for 6 weeks (if sensitive to ciprofloxacin). Advise strict hand washing. Avoid food preparation for others during severe illness.

Question 52

A 40 year old male admitted with acute asthma is being discharged home on his routine Salbutamol inhaler and beclomethasone inhaler. 1. What class of drug is Salbutamol? (1 mark) 2. Mention 2 mode of action of Salbutamol. (2marks)

Answer 52

1. Selective Beta-2 stimulant Agonist 2. ° Reduces bronchospasm ° Smooth muscle relaxation

Question 53

List 2 possible side effects of Beclomethasone inhaler. (2 marks)

Answer 53

1. Oral candidasis | 2. Hoarseness

Question 54

Name the specific treatment (antidote) for an overdose of the following drugs. (5 marks) 1. Paracetamol 2. Opioid 3. Organophosphate 4. Benzodiazepine 5. Isoniazid

Answer 54

1. Paracetamol- N-acyticysteine 2. Opioid- Naloxon 3. Organophosphate-Atropine 4. Benzodiazepine- Flumazenil 5. Isoniazid- Pyridoxine

Question 55

A 28-year old male presents with Generalized tonic-clonic seizure that has been on-going for about 10 mins. An assessment of Status epilepticus was made, and a parenteral benzodiazepine was administered. 1. List 2 examples of benzodiazepine that could be administered, including doses and route of administration. (3 marks)

Answer 55

1. Lorazepam IM/IV/oral 4mg | 2. Diazepam IV/oral 10mg

Question 56

Mention the mechanism of action of benzodiazepine. (2 marks)

Answer 56

° Potentiate the action of GABA, which is an inhibitory neurotransmitter

Question 57

Mention 2 mechanism of action of Magnesium Sulphate. (4 marks)

Answer 57

1. Exerts a depressant effect on the CNS and acts peripherally to produce vasodilation. 2. It causes direct inhibition of action potential in myometrial muscle cells.

Question 58

A 4 year old girl is brought to the hospital by her mother with a history of history of high fever, nasal discharge and skin rash for two days. The mother reports that the child had received polio zero and BCG vaccine only at birth. A clinical assessment of Measles was made 1. Outline 4 other symptoms and 4 signs of Measles.

Answer 58

Symptoms 1. Cough 2. Coryza 3. Red and itch eye 4. Photophobia Signs 1. Conjunctivitis 2. High temperature 4. Koplik spot 5. Mucopapular rash 6. Mouth ulcer

Question 59

Describe the characteristics appearance (progression and morphology) of skin rash in measles (4 marks)

Answer 59

Koplik spot: it usually begins as flat red spots that appear on the face Read????

Question 60

Complications of Measles

Answer 60

1. Pneumonia 2. Encephalitis 3. Feeding difficulties 4. Croup 5. Severe diarrhea 6. Otitis media

Question 60

Complications of Measles

Answer 60

1. Pneumonia 2. Encephalitis 3. Feeding difficulties 4. Croup 5. Severe diarrhea 6. Otitis media

Question 61

How to prevent spread of Measles among other children in the community?

Answer 61

1. Isolate pt in a separate room 2. All entering the room to wear mask, gloves and gown. 3. Measles vaccine

Question 62

What measures should be taken in order to prevent Bacterial meningitis in a community? (4 marks)

Answer 62

1. Haemophilus influenzae type b (Hib) vaccine 2. Prophylaxis (antibiotics) 3. Keep Your Distance From Infected People 4. Do not share personal item's 5. Wash Your Hands Vigorously

Question 63

What measures should be taken in order to prevent Community acquired pneumonia in the community? (5 marks)

Answer 63

1. Practice good hygiene 2. Pneumococcal vaccines 3. Smoking cessation 4. Coughing or sneezing into a tissue or into your elbow or sleeve 5. Taking good care of medical conditions (like asthma, diabetes, or heart disease)

Question 64

List the anti-TB medication for intensive phase (2marks)

Answer 64

1. Rifampicin 2. Isoniazid 3. Pyrazinamide 4. Ethambutol

Question 65

A. List 5 baseline investigations and anthropometric measurements to be performed prior to initiating anti-TB. (5 marks) B. How is response to treatment monitored in the patient (tests including intervals) (3 marks)

Answer 65

1. Weight (BMI) 2. Fingerprick test 3. HIV test 4. CXR 5. FBC B. 1. 1 spot sputum for smear microscopy: week 7 2. Gradual weight gain

Question 66

Two months later the patient on anti-TB medication presented with burning sensation, numbness, and tingling sensations on his feet. Assuming this is an adverse reaction. 1. What is the most likely offending anti-TB drug causing this adverse reaction? 2. What is the treatment used to prevent the adverse reaction? (including Dose, Route, Frequency) (4 marks)

Answer 66

1. Isoniazid | 2. Pyridoxine, oral, 25mg, daily

Question 67

A 52-year-old woman known to have type 2 diabetes mellitus, with good glycaemic control, has presented for her monthly follow-up visit. On examination; BP=158/96mmHg (on the right arm) and 152/98mmHg (on the left arm). Review of her medical record revealed that her blood pressure was 148/92mmHg on her last visit 4 weeks ago 1. What is the initial drug of choice to start the patient on? (2 marks) 2. What is the target control blood pressure level for the patient in this scenario? (2marks) On the next follow up visit, it is noted that the target control blood pressure is not achieved. The patient reports excellent adherence both non-drug and drug management 3. What is the drug that has to be added? (Dose, Route, Frequency). (2 marks)

Answer 67

1. Metformin, oral, 500mg, twice daily 2. 140/90mmHg 3. Enalapril, oral, 5mg 12 hourly

Question 68

A 32 year old male comes for a review after8 weeks of intensive phase treatment for PTB. The monitoring smear performed one week before came positive for mycobacterium tuberculosis. 1. Mention 4 critical steps you need to perform in the further management of this patient. (4 marks)

Answer 68

1. Check adherence and refer for increased increased support if needed 2. Send 1 spot sputum specimen for LPA^1 3. Continue intensive phase 4. Check LPA^1 result after 1 week

Question 69

A 27-year-old female, HIV positive still not on treatment came to casualty. She reported some small white spot in oral mucosa that looks like "grains of salt"5 days ago. Two days ago she started with high fever and running nose. On the examination her body shows disseminated erythematous and flat rash covering her neck, trunk, arms, legs and feet. She also reported her nephew had a similar condition 2 weeks ago when she visited him 1. What is her more probable diagnosis? 2. How is the condition transmitted?

Answer 69

1. Measles 2.

Question 70

A 18 year old sexual active female visits OPD complaining of lower abdominal pain and vaginal discharge, what. What are the treatment of choice for her condition? State the drugs, doses, frequencies and ways of administration of each of them. (3marks)

Answer 70

1. Metronidazole, oral, 2g, stat 2. Azithromycin, oral, 1 g, stat 3. Ceftriaxone, IM, 250mg, stat

Question 71

Mention 6 DDx of Chicken Pox (3 marks)

Answer 71

1. Measles 2. Herpes simplex 3. Atypical herpes zoster 4. Urticaria 5. Rubella 6. Kawasaki disease

Question 72

A 56-year-old man is admitted to the district hospital complaining of productive cough and shortness of breath for the past 3 months. His symptoms have gradually worsened over the last 3 months. He also complains of losing weight. He is not on medication and has smoked 15 cigarettes a day for the past 20 years. HIV status is unknown. 1. List the 4 relevant hypothesis based on the history given (2marks)

Answer 72

1. COPD 2. Bronchitis 3. Pulmonary TB 4. Asthma

Question 73

A 49-year-old female came to OPD complaining of joint pain and swelling on her hands, she also refers malaise and hand stiffness especially in the morning and gets slightly better 1 to 2 hours later. 1. What is the probable diagnosis for this patient (1)? Give 2 supportive evidences. (2 marks)

Answer 73

1. Rheumatoid arthritis-early morning stiffness, bilateral (pain on both hands).

Question 74

Define MDR and XDR tuberculosis?

Answer 74

MDR- Resistance to Rifampicin and isoniazide XDR- Resistance to rifampicin, isoniazide, plus resistance to fluoroquinoles and an injectable medicine e.g. Kanamycin

Question 75

A 55-year-old man newly diagnosed with diabetes came to OPD for treatment initiation. BMI=30.5, BP=128/86mmHg. No other significant findings during the examination. No proteinuria or nitrates in the urine dipstick, BS= 13.2 mmol/L. 1. What is the drug of selection for the patient treatment? State drugs, doses, and frequency, and ways of administration. (2marks)

Answer 75

Metformin, oral, 500mg, 12 hourly

Question 76

A 18-year-old student presents to casualty following ingestion of unknown quantity of some tablets. Activated charcoal is being prepared for administration by the nurse. 1. List 3 scenarios where activated charcoal will be of no value or is contraindicated. (3marks)

Answer 76

1. Organophosphate poisoning 2. Paraffin injection 3. Injection of corrosive agents

Question 77

A 50-year-old female diabetic patient presents to a district hospital from a local clinic with a random glucose value of 20.0mmol/L and blood pressure of 180/110mmHg. Her current prescription is for Metformin 850mg twice daily, glimepiride 1mg once daily, and no other medication. A. List 2 Acute and 2 Chronic complications of diabetes mellitus and one specific physical examination technique used to detect each examination. B. List 5 investigations that are most appropriate to order and the reason for each.

Answer 77

Acute complications: 1. Diabetic ketoacidosis (DKA)- Acetone breathe and Kussmaul breathing 2. Hyperosmolar hyperglycaemic state(HHS)- Assess the degree of Dehydration Chronic complications: 1. Diabetic Neuropathy- Diabetic foot exam, 2. Diabetic Retinopathy- Fundoscopy 1. HBA1c- to see how the treatment is working 2. Ophthalmoscopy- to check retinopathy 3. Urine dipstick- to check for nephropathy 4. eGFR- Renal impairment 5. Chest X-ray- for complications such as heart failure.

Question 78

A 55-year-old male patient presents to a district hospital with a referral from his local clinic as his BP was found to be elevated on three separate occasions. The BP was, measured as 162/98mmHg, 165/100mmHg then 162/99mmHg. Today his pulse is 96bpm and regular. On examination, there is no pedal oedema. No abnormality was noted on the CVS exam. On chest examination, good air entry was noted bilaterally and there were no additional breath sounds. On abdomen exam, neither masses nor organomegaly was noted. List the anti-hypertensive drug(s) which according to the South African Primary Healthcare clinical guideline should be started today include the drug name, drug class and describe the mechanism action of each drug.

Answer 78

1. Hydrochlorothiazide- Thiazide 2. Enalapril- ACE inhibitors 3. Amlodipine- Long acting calcium channel blocker

Question 79

Explain briefly the pathogenesis of Rheumatic fever? (3 marks)

Answer 79

The major implied mechanism is molecular mimicry: ° Humoral and cellular response to streptococcal antigens as a result of infection. ° Cross-reaction with human proteins that share some structural similarity with bacterial antigens.

Question 80

A 36-year old male IA admitted with headache and confusion. On examination GCS=12/15 and there is positive meningeal signs. He is HIV positive and the CSF was positive for Indian Ink. 1. What is the most probable diagnosis? (2marks) 2. Mention the 2 most adequate pharmacological drug for this patient? (2marks)

Answer 80

1. Cryptococcal meningitis 2. Amphoteracin B, slow IV infusion, 1mg/kg/day in 5% Dextrose over 4 hours for 14 daus And Fluconazole, oral, 1200mg daily for 14 days

Question 81

Causes of CKD

Answer 81

1. Diabetes mellitus Uncontrolled hyperglycemia causes glucose to stick to the artery walls= damage blood supply to kidneys 2. Hypertension High pressure on artery walls= damage blood supply to nephrons. 3. Acute kidney injury 4. Polycystic kidney disease 5. Nephrotoxic drugs 6. Age related decline

Question 82

Risk factors for CKD

Answer 82

1. Diabetes 2. Hypertension 3. Old age 4. Smoking 5. Use of Nephrotoxic drugs

Question 83

What are the Contra-indication of Metformin

Answer 83

1. Renal impairment i.e. eGFR <30 mL/minute, 2. Uncontrolled congestive cardiac failure, 3. Severe liver disease, 4. Patients with significant respiratory compromise, or 5. Peri-operative cases.

Question 84

Insulin Therapy In Type 2 Diabetes | Indications for insulin therapy:

Answer 84

1. Inability to control blood glucose pharmacologically, i.e. combination/substitution insulin therapy. 2. Temporary use for major stress, e.g. surgery, medical illness. 3. Severe kidney or liver disease. Pregnancy.

Question 85

What investigations would you perform in a CCF patient?

Answer 85

Blood tests: o FBC looking for any anemia o U&Es looking for evidence of hypoalbuminemia, renal failure, electrolyte disturbance o LFTs looking for evidence of liver congestion o TFTs 2. ECG looking for arrhythmias, left ventricular hypertrophy and ischaemic changes 3. CXR- cardiomegaly, Kerley B lines, bats wing, pleural effusion

Question 86

What are the features of digoxin toxicity?

Answer 86

* Arrhythmia * Nausea * Vomiting * Confusion * Yellow vision (xanthopsia)

Question 87

Stage 2 HIV/AIDS

Answer 87

• Unexplained persistent enlarged liver and/ or spleen • Papular pruritic eruptions • Seborrheic dermatitis • Extensive human papilloma infection • Extensive molluscum contagiosum • Fungal nail infections • Recurrent oral ulcerations • Linear gingival erythema • Angular cheilitis • Unexplained persistent enlarged parotid • Herpes zoster • Recurrent or chronic respirato-y tract infections (sinusitis, ear infection, otorrhoea, sinus-itis, tonsillitis)

Question 88

STAGE 3 HIV

Answer 88

• Unexplained Moderate Malnutrition not adequately responding to standard therapy • Oral thrush (outside neonatal period) • Oral hairy leucoplakia • Acute necrotising ulcerative gingivitis/ periodontitis • The following conditions if unexplained and if not re-sponding to standard treatment: - Diarrhoea for 14 days or more - Fever for one month or more - Anaemia (Hb <8 g/dL) for one month or more - Neutropaenia (< 500/mm3) for one month - Thrombocytopaenia (platelets <50,000/mm3) for one month or more • Recurrent severe bacterial pneumonia • Pulmonary TB • TB lymphadenopathy • Chronic HIV-associated lung disease, including bronchiectasis • Symptomatic Lymphoid Interstitial Pneumonitis

Question 89

Stage 4 HIV

Answer 89

• Unexplained severe wasting or Severe Malnutrition not adequately responding to standard therapy. • Oesophageal thrush • Herpes simplex ulceration for one month or more • Severe multiple or recurrent bacterial infections, two or more episodes in a year (not including pneumonia) • Pneumocystis pneumonia (PCP/ PJP) • Kaposi sarcoma • Extrapulmonary TB