PART 1 (7 min, 13 marks)

Miss GS is a 16-year-old college student was brought by

her brother to the emergency department at 6 am. Her
brother claims that Miss GS came home in tears at 2.00
am and went straight to her room. She has allegedly
consumed 30 tablets of 500mg paracetamol.
On examination, she is conscious; her BP is 110/60
mmHg, pulse 110/min, afebrile. She is pale and
sweating excessively. Examination of the
cardiovascular, respiratory and abdomen is
unremarkable.
A. List THREE (3) immediate steps you will take:
(3 marks)
1. Take blood and urine for toxicological analysis
2. GI Tract decontamination gastric lavage
3. Administer activated charcoal via a nasogastric tube
-give NAC (the reason this answer is not accepted is because
NAC is only given AFTER the serum PCM level is established to
be in the toxic range and does not form part of the immediate
management of possible PCM poisoning)
-ABC give oxygen (EFG insert line, HIJ run in fluids)
-get patient to vomit
-give 100% in high flow mask
-ask history of any vomiting (the history and physical
examination findings have been given in the question)

-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

fulminant hepatic failure

Also useful as monitoring tool
3. Prothrombin time / INR To look for possible derangement in the
coagulation profile and potential bleeding complications.
4. RBS To rule out possible hypoglycemia
5. ABG To look for metabolic acidosis
6. Renal profile To look for evidence of acute renal failure with raised
creatinine
7. Blood/Urine for toxicology screening (accepted as an answer)
-FBC because she is pale (she is pale because she is in
distress)
-ECG to detect arrhythmia because she is tachycardic (she is
tachycardic because she is in distress)
-USG abdomen to detect liver damage (too soon and LFT does
a better job)
-pulse oximeter to check for degree of compromise in oxygen
saturation level(oximeter is NOT an investigation)
-salicylate level to check for level of toxicity (but patient
consumed PCM)
-Renal profile to look for renal impairment that impair PCM
excretion (but PCM is metabolized in the liver!)
-acetylcysteine level to identify level of toxicity (why check the
level of the antidote and not the poison?)
-urine toxic level to identify level of toxicity
-endoscopy to look for bleeding peptic ulcers (impractical)
-CXR to look for pulmonary oedema (why?)
-ECG for arrhythmia due to excessive sweating (a very unlikely

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

Question A: Describe the abnormality seen.

Answer: A large thick walled cavity with air fluid level seen in the lower zone
of left lung.

About 50% of students could identify the cavity and air fluid level.
Others seem to have seen something else which include:

1. Patchy haziness in left lung

2. Mediastinal widening
3. Ring enhancing lesion
4. Opacity with surrounding opaque ring and centre more translucent (I think
it means a cavity)
5. Left pleural effusion
6. Flattened diaphragm
7. Elongated mediastinum
8. Loss of costophrenic and cardiophrenic angles on the left (no there isnt)
9. Cannon ball lesions seen (no there arent any)

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

Question B: What is the radiological diagnosis?

Answer: Left lung abscess (those who wrote lung abscess only are given full
marks)

Most students correctly gave the radiological diagnosis. Unfortunately, quite

a number cannot differentiate between a radiological diagnosis to that of a
clinical diagnosis and ended up writing things like:
1. pulmonary tuberculosis
2. miliary tuberculosis
Other answers include lung consolidation, pleural effusion, pneumothorax.

One student wrote 3 diagnoses in one line: pleural effusion, pneumothorax

and lung abscess. The usual rule in marking exam question is that the first

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.

Question C: Name 3 underlying causes.

Answers:
Here we have to think of the possible causes of a lung abscess. It is best to
categorise them into:
1. Infective causes: Klebsiella pneumonia (those who wrote pneumonia gets
no marks), Mycobacterium tuberculosis, Entamoeba histolytica,
Actinomycosis, Histoplasmosis
2. Malignancy such as Squamous cell carcinoma (SCC being the password for
this entry; SCC is the ONLY lung Ca to cavitate, so those who wrote lung
carcinoma gets no marks) and
3. Aspiration pneumonia.

Answers from students include:

1. Immunosuppression
2. Immunosuppresives
3. Previously infected
4. Intravenous drug use
5. HIV patient
6. Smoking
7. Congestive cardiac failure
8. Renal failure
9. Liver failure
10. Diabetes mellitus
11. COAD

One student wanted to give a general answer and wrote:

viral infection, bacterial infection and fungal infection which got him no
marks.

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.

Question D: Outline the management strategy for this condition.

Answer:
The key word is here strategy, so answers like the ones below are not
acceptable for they are hardly strategies:
1. Admit into ward
2. Admit into hospital
3. Follow up at chest clinic
4. Give oxygen
5. Give oxygen with cough syrup
6. Incise and drain abscess
7. FBC, RP, LFT, RBS, UFEME etc etc (seems to be a favourite but would not
bring us any nearer to the diagnosis)
8. Do weekly CXR to look for signs of recovery (the repeated CXR might give
him lung cancer instead!)
9. Incentive spirometry (no role here)

The proper approach in outlining a strategy in dealing with a disease (any

disease for that matter) is:
1. Establish the cause: In this case, cultures and sensitivity to determine an
infective cause; BAL to establish a malignant cause as well as to biopsy any
lesions.

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!!!)

Here are some bloopers:

On General Examination:

1.There are some inai on the fingernails (Inai: henna dye)

2. The patient is round.

3. The patient is chubby.

4. The patient is a moonie.

5. The patient has round moon face with round cheeks with round eyes, with
small tiny mouth.

6. Shes got a moonie face.

7. On general infection.

8. She has fat stubby hands!

9. I am looking for greenish striae. (Gasps!)

10. She has lemon-on-stick appearance on her face.

11. She has large sausage-like fingers.

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)

13. She has facial oedema.

14. I am looking for striae in her arms.

15. There are no dilated veins (on abdomen)

16. Shes very well padded!

17. May I do the kidney?

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?)

20. Id like to do a physical on her hirsutism!

21. She is (*pause*) FAT!

22. I would like to palpate the abdomen for ovarian mass/ascites/enlarged

adrenals.

On how to investigate a suspected Cushings:

1. I want to do a 24 hour serum cortisol (I think the patient would be

exsanguinated by then).

2. 24 hours serum urine cortisol (patient must be passing out blood)

3. 24 hours serum dexamathasone level

4. thyroid function test

5. 24 hours blood VMA test

6. X-ray of the brain to look for enlarged pituitary (MRI is far better)

7. FBC, Renal profile, LFT etc etc.

Personally I think it was a very good station because it discriminates students

who have seen a patient with Cushings from those who havent. For those
who havent, do try to look up a patient who has this condition, and
remember all the features that are practically synonymous with Cushings;
you know, things like alopecia, moon facies, acne, hirsutism, plethora, buffalo
hump, proximal myopathy (remember the lower limbs!!!), thin skin, bruisings,
central obesity, fungal infection on skin, cataract, osteoporosis, just to name
a few.

Thurs, 210208 @ 1700

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.

I am going to write in no particular order.

On Introduction and General Examination:

1. He is well built and not obese. (Isnt that contradictory?)

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!)

4. The hands is worm. (I think its warm)

5. Saya nak check dadah. (Translated: I want to look for drugs)

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)

8. There is no evidence of splinter hemorrhage and all the other stuff-la.

(Actually we dont give marks for all the other stuff).

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)

On Examination of the Precordium

1. Encik boleh baring ke atas? (Translated: Sir, can you lie up there?)

2. There is no visible palpations. (I think the student meant pulsations)

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!)

7. There are no spider naevi. (Oops! wrong system!)

8. Almost all the students could locate the apex but failed to talk about its
character!!! (Why, why, why???)

9. Encik boleh terbalik? (Translated: Sir, can you flip over?)

10. Only one student checked the brachial and carotid arteries. You determine
the character of a pulse by checking the large arteries.

On Diagnosis:

1. There is a systolic murmur in the mitral area. The diagnosis is Mitral

Stenosis! (Wrong! MS presents with mid-diastolic murmur in the mitral area.)

2. There is a systolic murmur in the mitral area. The diagnosis is Aortic

Regurgitation. (Wrong! AR presents with early diastolic murmur in aortic area)

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)

4. Rheumatoid heart disease. (There is no such disease).

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:

Describe the abnormality seen in the film (3 marks)

Note: if 3 marks are allocated to the question, then generally 3 findings would
be expected.

Answers:

1. This is a CT abdomen cutting from liver downwards. (Actually the question

already said this is a CT abdomen! There is no need to repeat it and
describing it as a CT film is NOT an abnormality!)

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)

4. Absence of large colon. (Good grief!)

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)

6. Hypodense lesion in kidney. (Umthats the medulla of the kidney)

7. Ascites seen. (Nope, no ascites seen)

8. Rib erosions seen. (Nope again, none there)

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)

10. Shrunken liver! (opposite of above!)

Question 2:

Based on the CT abdomen and lab result, what is the diagnosis? (1 mark)

Note: remember, the diagnosis MUST be based on the 2 findings given.

Answers:

1. Hepatitis A! (Gaargh!!!)

2. Hepatitis B & D! (Double Gaargh!!!)

3. Stomach Carcinoma!

4. Acute hepatitis B. (The lab result and history suggest chronicity, how can it
be acute then?)

5. Newly diagnosed Hepatitis B. (Aiyo! Same as above. Furthermore, how do

you expect a 70 year old woman to newly get hepatitis B? I know its likely
but common things being common ya.)

6. Acute/Chronic hepatitis B. (Very undecisive this one)

Question 3:

List THREE (3) etiological causes for the diagnosis. (3 marks)

Anwers:

1. Having sex with an infected partner. (I really cringe at the thought of a 70

year old having sex with an infected partner; which is not to say it cant
happen; it can, but less likely la)

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)

3. Smoking. (Good grief!!)

4. HIV. (Double good grief!!)

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????)

7. Chronic alcoho. (Yup, the l was missing!)

8. A lot of students wrote Hepatitis B or Hepatitis C or Hepatitis B & C.

(Time again, Ive reminded students to be precise in thier words. We are
doctors or going to be doctors. Our words must be precise and convey the
exact meaning we want. We cannot do a VK Lingam when it comes to our
words. We cant say things like I think its a cancer, looks like a cancer,
maybe a cancer, etc etc. There is a big difference between ACUTE and
CHRONIC hepatitis B or C infection. The former do not cause hepatocellular
carcinoma while the latter do when cirrhosis has set in. Thankfully, we agreed
to mark HBV and HCV correct, regardless)

9. Pyrazinamide consumption. (Definitely has something against anti-TB)

Question 4:

Name THREE (3) management options for this patient. (3 marks)

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?)

3. Radiotherapy. (Wrong answer. Ive hardly know of any use of radiotherapy

for lesions in the liver)

4. Multivitamins! (*fainted*)

5. Hepatoprotective treatment like Jetepar (*double fainted*)

6. Followups! (*triple fainted*!!! Followup till she dies?!)

7. Good hydration. (I dont think I can faint anymore)

8. Resection of the stomach!!! (But the liver is involved wor!)

9. H. pylori eradication. (Okay, perhaps, I can just faint one more time)

10. Chemoradiotherapy. (this guy is either undecisive or very diplomatic)

11. Tepid sponging for fever! (But no where was fever mentioned!!!)