Professional Documents
Culture Documents
-fluid therapy
-charcoal activation (how exactly does one activate charcoal?)
-Fullers earth (wrong treatment for PCM poisoning)
-detoxify carbon
-maintain ABC (once again, I must stress that ABC is not
acceptable as an aswer)
-NAC
-nasogastric tube
-naltrexone for opioid ingestion (the patient ingested PCM)
-administer beta blocker
-explore reason and take history from patient on why take PCM
-assess mental state
-assess suicidal risk
-take proper history on the substance and amount ingested
-acquire more history and physical examination
-put in 2 intravenous cannula and run intravenous fluids on
her (the patient would then be quite wet)
-admit her (this answer DOES NOT GET YOU ANY MARKS so
please stop writing such answers)
-ask what else she had consumed
-psychiatric evaluation
B. List FIVE (5) important investigations and ONE (1)
reason for each of the investigation that will help in the
management of this patient. (10 marks)
1. Serial Plasma PCM level To establish level of plasma PCM to guide
therapy
2. LFT To check AST/ALT levels indicating hepatitis and potential
scenario)
-USG hepatobiliary system to look for areas of hepatic necrosis
or damage
-LFT to look for extension of liver damage (where would it
extend to?)
-serum acetylcholinesterase levels to look for co-ingestion of
organophosphates(though technically this is not wrong,
however, the history clearly states that only PCM was found
with the patient. It is important to follow the case and manage
as such)
-fecal occult blood for evidence of GI bleed (we do not expect a
patient to BO in an acute setting and a nasogastric tube would
reveal GI bleed a lot faster than the other end)
-LFT to look for history of excessive PCM intake (not sure when
LFT became part of history taking)
-TFT to look for hyperparathyroidism
-UPT as pregnancy may be affected by PCM poisoning or social
issues regarding teenage unwanted pregnancy (in an acute
setting, the mothers life takes precedence over that of the
foetus, assuming there is one and social issues come much
much later, assuming the mother and child survives)
-salicylate level to look for toxic level (there wont be toxic
level as the patient clearly did not ingest it!)
-LFT to see if liver is failing
About 50% of students could identify the cavity and air fluid level.
Others seem to have seen something else which include:
One student thought the lungs are rather heavy for the student wrote:
there is heaviness seen in both side of lungs, perihilar heaviness indicative of
hilar lymph nodes
answer will be considered when asked for ONE answer and the others will be
discarded. Unfortunately, lung abscess was not considered.
Some students may get angry and cry foul but think about it, if this rule is not
in place, what is there to prevent a student from writing everything under the
sky on one line in the hope that at least one of the answer would turn out to
be correct. That is not the way of a future thinking doctor, for we will then
produce doctors who will order every investigation under the sun and hope to
hit something to get a diagnosis.
Another wanted to cover all the bases and gave SEVEN instead of THREE
answers:
lung abscess, tuberculosis, bronchogenic carcinoma, lung carcinoma,
bronchiectasis, penumonia and COPD !!!
Usually in this scenario, the first 3 answers will be marked while the rest will
be discarded. Thankfully for this student, TB and Bronchogenic Ca (which is
SCC) fell within the first 3 answers.
2. Once the cause is established, then the management should include one of
two:
a. medical therapy such as systemic antibiotics, for at least 4-6 weeks in
bacterial abscess, anti=TB, anti-fungal where applicable; postural drainage as
well as chest physiotherapy.
b. surgical therapy such as lobar resection if possible or surgical drainage
(not really a therapy of choice ~ fortunately hardly any student ventured into
the surgical realm; which is NOT a good thing as this means the students
mind is compartmentalised into disciplines. I mean, if this has been perceived
as an O&G case, then some people might consider a caesarean section for
the abscess!!!)
On General Examination:
5. The patient has round moon face with round cheeks with round eyes, with
small tiny mouth.
7. On general infection.
12. I am looking for oral ulcers because steroids can cause oral ulcers (but
actually one of the treatment for oral ulcers is steroid! Corticosteroids cause
oral candidiasis)
18. Saya nak examine awak. (I think the malay word is periksa)
19. Boleh buka perut sikit? (Translated: Can you open your stomach a little?)
6. X-ray of the brain to look for enlarged pituitary (MRI is far better)
This was the scenario today: A patient who complains of lethary and
breathlessness. The task: to examine the cardiovascular system after which
the examiner will asks a few questions. Time given: 10 min.
2. Saya nak tengok awak punya jantung. (Translated: I want to see your
heart)
3. Encik, saya nak bukak baju ya. (Translated: Sir, I want to take off my
clothes!)
6.Ongeneralexaminationthepatientiscomfortablelyingin45degreesupinenotinr
espiratory
distressnopallorcyanosisjaundiceclubbingcapillaryrefillinlessthan2secs..(the
bullet train is back! It reminded me of another bullet train in another exam
last year.) Slow down la
7. The hands are pink, er, no, pale, er.. no, pink, er..no, pale..or pink?
(very indecisive this one)
9. One student took 4 minutes just to do the general examination and had to
be rushed through the rest of the examination! (Pace yourself guys)
10. Since there might be lack of time, I want to start with the hands first.
(There should not be any lack of time, the time given is usually adequate. You
will miss a lot of findings and marks if you skip the General Examination)
1. Encik boleh baring ke atas? (Translated: Sir, can you lie up there?)
3. Now, I shall elicit thrills. (The patient was about to get excited!)
4. Tarik nafas, lepas, lepastu, pegang! (Take a deep breath, release, then
hold. I think its a direct translation from Englilsh)
5. I will percuss the JVP now. (Quite painful on the neck, I think)
6. Id like to count the pulse rate, but lets assume its about 60-70 per min!!!
(Do not assume in exams, just do it!)
8. Almost all the students could locate the apex but failed to talk about its
character!!! (Why, why, why???)
10. Only one student checked the brachial and carotid arteries. You determine
the character of a pulse by checking the large arteries.
On Diagnosis:
3. Its ventricular septal defect. (Again wrong, as it would be quite unusual for
the patient (about 25 years old) to live with a VSD and not develop
Eisenmenger Syndrome where we will find cyanosis and clubbing)
The scenario is that of a 70 year old lady who presents with 3 months history
of anorexia, weight loss and upper abdominal discomfort.
A CT scan of the abdomen similar to the one below was shown. Some lab
results were shown as well, which shows elevated alpha-fetoprotein, normal
CEA and HBsAb non reactive.
Question 1:
Note: if 3 marks are allocated to the question, then generally 3 findings would
be expected.
Answers:
2. Liver cannaliculi are seen and distorted. (I dont think a CT scan can pick
up cannaniculi)
3. Abnormal bowels are seen. (Im a bit flabbergasted as the obvious lesion is
in the liver and vaguely describing the bowels as abnormal does not earn
marks)
5. The liver does not take up contrast. (It is the abnormal lesions that pick up
MORE contrast than normal tissue, hence the diagnostic value of contrasted
CT. Btw, the question did not mention if the film is a contrasted one or not)
9. Enlarged liver. (It is not absolutely an abnormal finding and furthermore its
probably hard to gauge the size based on the given film ~ not the one above,
the one in the exam is much smaller in size)
Question 2:
Based on the CT abdomen and lab result, what is the diagnosis? (1 mark)
Answers:
1. Hepatitis A! (Gaargh!!!)
3. Stomach Carcinoma!
4. Acute hepatitis B. (The lab result and history suggest chronicity, how can it
be acute then?)
Question 3:
Anwers:
2. Hepatitis infection. (For some reasons, a lot of students wrote this! There is
no such thing as hepatitis infection. Its probably viral hepatitis infection
that they meant)
5. Primary Biliary Cirrhosis. (The patient is probably the first and only patient
still alive with PBC at 70 years of age, in this world)
6. Oral Contraceptive Pill. (And the reason a 70 year old woman takes it
is????)
Question 4:
Answers:
1. Chemo. (Dont be lazy. It does not take long to write the full word
chemotherapy)
2. Surgery. (Again, another vague answer. What kind of surgery and where?)
4. Multivitamins! (*fainted*)
9. H. pylori eradication. (Okay, perhaps, I can just faint one more time)
11. Tepid sponging for fever! (But no where was fever mentioned!!!)