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Medicine Long case MBBS(Malaya) 06/11 Final Exam Data Store From Michael,same patient with Sow Cheng

A bit screwed up... =( Haiz... 1. lecturers who took u: Prof CT Tan,Prof Siti,Prof Woo,Dr Pan(External) 2. specialty: Medicine Nephrology 3. chief complaint: Nil 4. brief history: Background history of SLE diagnosed 3 years ago with lupus nephritis. Initially presented with rash,artritis,oral ulcer and progressive worsening of both lower limb and facial puffiness worsening on morning. HIstory of preterm baby and 2 miscarriage. 5. PE finding: Pedal oedema up to knee level.Multiple bruises seen on knee and forearm. 6. diagnosis: Lupus Nepritis 7. questions asked by lecturer -Proteinuria: why 24 hours urinary protein instead of urine dipstick -Does the pregnancy you want to concern related to her problem? -Her son preterm,how preterm is preterm?On how many weeks?Related to her problem? How about the miscarriage? -Does she on remission or the disease is active? -What is her current problem?(I say no active chief complaint? Is she come just for your exam sake? (She really no C/C) -Let see the patients.Show me the finding u think relevant?(Bruises,pedal oedema) -Moonface(They seem not agree)?Do you exposed probably?How about the hair loss? -Any kidney ballotable? -Go back to room.She got multiple bruises,what do you think the causes?Low platelet cause bruises like this?(He want petechaie =( ) -How you know her disease is active? HOW??? Clinically??? -Investigation you want to do?Renal profile,elaborate more on renal profile. -C3,C4.what is C3,C4? -what you will see on microscopic examination of urine? -Proteinuria detected?Mild or what?Of course more than 3+ lo... -What is nephrotic symdrome? -No management discussed...... =( Really pray hard this time...All the best to coming group... about a week ago Report

Siti Zarina Jahan. Please present your long case following this format. 1. lecturers who took u Prof KJ Goh, Prof Azad, Prof Azmi 2. specialty Medicine. 3. chief complaint vomiting 1 week 4. brief history 26 year old Malay gentleman, well untl 5 years ago when he developed vomiting 1 week. a/w low grade fever, diarrhea, lethargy, palpitation, irritability, tremor. then suddenly 1 day history of SOB, admitted, 5 days, CXR, EC and thyroid function test was done and was told to have hyperthyroidism. on medication carbimazole for 1 and half year, propanolol for 2 months and ranitidine for few weeks. currently euthyroid. has been married for 5 years but still do not have children. adopted a child, 2 and a half year. infertility still on investigation. 5. PE finding normal. no hyper/hypo/goitre/grave's. just have pigmented lesions on the foot. 6. diagnosis thyrotoxicosis secondary to grave's? or MNG. 7. questions asked by lecturer - PE: asked to demonstrate eye signs. what are the differences btween grave's and hyperthyroid signs. how do we know the disease activity. - in the room: why is the patient has vomiting? and why is it resolved after he is euthyroid? what are yr investigations. why this pt has normal T4 but low TSH. what is your management? how long is carbimazole given? propanolol? side effects of carbimazole? if pt has neutropenia what will u do? can it be given to pregnant lady? of failed 3x carbimazole, what wil u give? (radioisotope iodine) what is the mechanism? tell me about everything you know. if failed medical treatment, what will u do?--surgery. what are the complications of thyroid surgery?-thyroid storm, bleeding, recurrent laryngeal nerve injury, and parathyroid gland injured. what are the signs that you know of parathyroid deficiency?-carpopedal spasm dll. then dah.. belum loceng lagi dah kena suruh keluar.huhu. good luck kawan2 and my beloved juniors :) about a week ago Report

Huey Jiun Tan 1. Prof Ikram, Prof MTK and Prof Saw Aik 2. Medicine 3. 78 years old chinese gentleman with underlying HPT and diagnosed to have chronic kidney disease for 2 years. oher problem, gout and hyperlipideamia. 4. PE: just present the findings... no bedside examinations ( loook for complications of HTN) 5. How to grade the severity of intermittent claudication? Answer: distance claudication How is the patient's BP control? what do u think? wat is ur IX and MX ? wat usually caused CKD patient died? heart attack

Nor Fauziah lecturer who took u: a/p nortina, prof yop cheng har, prof eugene.. (all of them are so nice!!) specialty: medicine chief complaint: electively admitted for I/V antibitic.. brief history: 59 y.old malay lady, known to have bronchial asthma, hyperCmia, and BRONCHIECTASIS 5 years ago. (thanx God for give me this case...). initially presented with 1 week h/o fever chills n rigors, copious sputum, sob... keep on going here n there for m(x), finally go to tawakkal, do CT scan n confirm diagnosis.. then, for etiology, might be idioptahic.. hv TRO all 1st la.. (TB-no symptoms of TB, mantoux test was -ve , measles, congenital, blablabla).. currently on ventolin, seretide, antibiotic,acapella.. p/e:

fine crepitation all over the lung.. reduce vocal fremitus over left long (whole) n right lower lobe... xanthelesma noted.. otherwise, all normal diagnosis: bronchiectasis la.. ;p question ask: 1. how can u come to this diagnosis?? - patient tell me.. hehehe.. btw, history itself suggestive bronchiectasis - long standing cough, copious sputum production, recurrent chest infection... 2. other dd(x)?? - pneumonia, AEBA, but these unlikely... this patient has long history.. 3. how to confirm d(x)?? - spirometry (obstructive pattern..) CT scan, CXR... 4. let see, what this patient has... haaa CXR.. ok now interpret this CXR... features of bronchiectasis la.. cystic shadowing, blabla...;p 5. what the causes for this patient?? idiopathic maybe... other causes?? (congenital, infectious, etc) 6. how u gonna manage this patient?? - just follow what ummc did.. chest physio, acapella, prophylactic abx, dun forget acute management.. 7. acapella?? how does it help?? - help to clear secretion la... explain about pathophysio of bronchiectasis... 8. long term complication: recurent chest infection. 9. suddenly prof eugene open his mouth... let say, 5 years later this ptt come to u, what u expect to see in her ECG?? right ventricular hypertrophy! initially mentioned left, then he help me to come to answer.. thanx prof!! hehe~ 10. krrinnggggg!!!! u can go now.. thanx to all my dear prof.. u guys are so nice to me... all the best to my dear friends!! dun worry, smile always~ :)

Anis LobotoMe Examiner: Prof. Steven, Prof. April, Prof. Choy Lang (External) (Med), plus observer Dr. Koh (psychiatry) specialty : medicine ? surgery ? psychiatry ? History : Instruction : Because patient have complicated history, please List down medical, surgical, social problems. ++ Questions . Summarize. Diabetes and HPT : screening, diagnostic and monitoring of blood levels, symptoms and signs of complications especially microvascular, investigations of a Diabetic patient, monitoring of hypertension in diabetics, sexual history(dysfunction), classes of anti-diabetic drugs, criteria for Metabolic Syndrome

Poor stream urine: causes of urinary obstruction and symptoms and signs What other causes of polyuria and polydipsia ... pathophysiology ... Hyperparathyroidism : signs and symptoms of presentation, classification of causes of hyperparathyroidism, investigations of hyperparathyroidism, treatment and monitoring of hyperparathyroidism Hypercalcemia : signs and symptoms, causes of hypercalcemia, investigate hypercalcemia, why use corrected calcium, emergency treatment of hypercalcemia (how to examine multiple comorbidities?) ergh . Examination : sensation and vibration examination, demonstrate and name the term (peripheral neuropathy : glove and stockings or mononeuropathy ) Prolapsed Intervertebral Disc : interpret which level (dermatomal) ... Psychosocial aspects in this patient, Findings on Mental State Examination, possible psychiatric illnesses/psychological disturbances in this patient.

Jin Hui Ho 1. lecturers who took u Prof David Choon, Prof Chee KH, Prof Azmi, Chinese External 2. specialty Medicine 3. chief complaint 24/malay/ gentleman beta-thalassaemia major. Diagnosed since 1 year++. Monthly transfusion, pre-Hb 6. Ferritin 5000. No splenectomy. Previously on deferasirox, stop 2 years ago. Non-compliance to desferrioxamine now. Hypothyroid, delay puberty. Anaemic symptoms appear 3 weeks post trasfusion. Both parents are carrier. 1 sibling affected. 4. PE finding

slate gray hyperpigmentation skin, pallor, maxillary eminence, jaundice,very hyperactive precordium, ESM at upper left sternal edge. Splenomegaly. Tanner: PH 4, G4?? (not sure, they didn't look at it) Peripheral neuropathy-up to mid metacarpal and mid metatarsal, Glucostix- 5.7. Reflex normal, no prox myopathy. 6. diagnosis beta-thal major 7. questions asked by lecturer Why do u think he got hyperactive precordium? How do u confirm it is a spleen? =) Interpret FBC-microcytic hypochromic anaemia. Differential? How to differentiate all? What do u expect to see in PBF? If he is going to married, what will u do? screen the wife. If she also thalassemia? U want them to separate? Aiyoh..prof...I didn't say that... Patient's automomy, he decide la. Ethics involved in antenatal diagnosis? They are very nice=) Good lu

Swam Ng 1. lecturers who took u Prof Chin (external), prof Stephen J, Prof April 2. specialty Medicine 3. chief complaint Wheezing associated with productive cough for 3 days 4. brief history 48/Chinese/lady Bronchial asthma diagnosed at 3-year old. Very poor controlled. History of taking oral steroid 7 years ago ---> iatrogenic Cushing's syndrome + hypertension Secondary osteoarthritis due to MVA 25 years ago 5. PE finding Cushingoid features

Lung findings: reduced chest expansion, generalized rhonchi with prolonged expiratory phase 6. diagnosis Mild AEBA secondary to URTI with underlying uncontrolled asthma Cushing's syndrome 7. questions asked by lecturer (all asked by external examiner) - Important differential diagnosis TRO in this patient - Cause of Cushing syndrome in this patient - Complications of steroid - How steroid causes DM and leg edema - Why patient is still Cushingoid as she already stopped taking oral steroids for 7 years - Investigations for Cushing's syndrome - Control of asthma in this patient - If this patient presented to A&E with AEBA, what investigations you want to do - Signs and symptoms suggested of severe asthma - What are the drugs for asthma

Anand Balakrishna From : B. Anand kumar Lecturers: Prof Rokiah, Prof Thong and Prof Chin..(fiuh..the names itself gives baseline tachy but trust me,they are super nice today,..the nicest they could eva be) Specialty: Medicine C/C: 52 y/o Malay lady who is a long standing diabetic pt presented tdy with no active complaint. HOPI: Pt was previously well when she was diagnosed to have GDM durin her first pregnancy. It was a planned and wanted pregnancy. Bookin and scanning was done and it correspond to the EDD. She was well at the beginning just with some morning sickness when she started to developed symp of '4p's around 6 month period of amenorr. Serial investgtn inludin OGTT and she was dx with GDM. Admitted and started on 2 injection regime. Nearing term,was found to have cephalopelvic disproportion and electively admitted LSCS. Post pregnancy she was on insulin for 2 years because she was breastfeedin. After that she was found to have poor glucose control and started on OHA. This pattern went on for all her 3 pregnancies and after the 3rd pregnancy, she was decided to be kept on insulin cont'..as the OHA is not helpin to control the glucose questn1.why the OHA is not helpin now ? i said the dm itself has progressed frm resistance to

insufficiency.. questn2.What are the other factor contibute to poor glcemic control now? i talked bout life style and also the fact that pt has gain more weight. questn3.What syndrome bout weight gain? i start to talk bout metabolic x.talk continously.dont stop.unless if they stop u :P continue with obstetric hx questn4.why pt has to go for LSCS? i said disproportionate CP.and maybe its macrosomic. its betta not to prolong the pregnancy as it has its own complicatn. like SIDS continue with hx questn5.why this patient has tendency for IHD?the DM status and also the high cholesterol level.. questn6.what atherosclerosis consists of? :P questn7.BMI of the pt ? :P continue with history questn8.why its importnt to know when the siblings was dx to have dm ? differentiate IDDM and NIDDM as NIDDM runs in the fmly. we also can assess the other sibling who are not really given adequate DM education..screen for others. summry.. went to see patient. questn9.elicit ankle oedema?what is the cause? i said nephropathy due to uncontrolld DM..what are the changes in renal? BM thickenin and mesangial proliferatn.. questn10.what abnormality with the face..i said it lookd like malar flush..so it could be due to.......hmmm..i ans mitral stenosis.(shit...) can i rephrase the ans,maybe its a facial flush due to premenopausal sx.(fiuh...) :P last questn11.what is the histopathology of CRF?...:P GOOD LUCK GUYS .....

Sarah Liyana 1. lecturers: Dr.Pan(external), Prof CT Tan, Dr. Subramaniam (external) 2. specialty medicine 3. chief complaint cough, 5 month

4. brief history 52 malay gentleman,cough 5 months, a/w sob, orthopnea, chronic smoker, work related to plumbum n radiation exposure, also had back pain and weakness right upper limb and lower limb 2 weeks ago, mother had colon ca, . PE finding-scar at right lower zone lateral side, percuss: dull at right lower zone, reduce breath sound at right lower zone 6. diagnosis- lung ca mets to brain and bone 7. questions asked by lecturer - pathophysiology orthopnea, given CTscan of brain and need to interpret, type of lung ca, from what cell the cancer is, how to comfirm diagnosis, differential for back pain, how to deferentiate malignant or degenerative causes...how to relate the brain ct scan finding with patient right upper and lower limb weakness about a week ago Report

Cherry Tee 1. lecturers: Prof. A.V.Chin(geriatric), Prof Fatimah Harun (Peads), external (gynae) 2. Specialty: medicine 3. chief complaint: headache for 3 days 4. brief history: 49/I/female, headache a/w vomiting, dizziness, blurring of vision, h/o Rheumatic Heart Disease at 21 y/o and had metallic valve replacement at 23 y/o. poast op on warfarin 4-5mg and INR maintained at 1.9-2.3. 5. PE finding: bruises over both arm craniotomy scar over right temporal region sternotomy scar metallic click tachypoea irregularly irregular weak pulse, normal rate increased JVP displaced apex beat

Patient said got AR and MS Bibasal crep Ascites Hepatomegaly with liver span 12cm Sacral and bilateral LL oedema 6. diagnosis: intracranial haemorrhage secondary to over warfarinization 7. questions asked by lecturer (mainly conducted by Prof Chin What other drug can be used other than warfarin? Heparin and fondaparinux Differential dx Symptom of increased ICP? Headache, vomiting,dizziness, blurring vision Earliest sign of increase ICP? Cushing reflex (papilloedema is a late sign) Is the patient had heart failure? Yes evidenced by above sx What are the indication of warfarin in this patient? Prosthetic heart valve and AF What level of INR should be maintained in patient with prosthetic heart valve replacement? 3-4 What other prosthetic heart valve available? Bioprostheses valve Interpret CT scan. Subdural haemorrhage with midline shift bell rang: external examiner ask: " how you confirm this CT scan is your patient's?" is writen there..

Please present your long case following this format. 1. lecturers who took u: Prof CK Liam [coordinator], Prof Jessie [sweet], Prof Soffiyah [smile always] and Dr. External 2. specialty - Medical [Respi, ID, Neuro] 3. chief complaint - Fever for 2 weeks and numbness / weakness left both limbs. Hx of Hpt, IHD and chronic smoker. [arghhh... not reach any Ix or Mx] 4. brief history Fever - 2 weeks: high grade, progressive n constant, not relieved by pcm. Numbness/weakness - 40 minits, drenching of sweat, slured speech. Multiple probs with IHD, TIA..

Discharge well for 2 days and coming back due to progressive fever. 5. PE finding - UMNL [hypereflexia and hypertonia], elicit d reflex... Bilateral coarse crepitation with normal vocal resonance and vocal fremitus. There was maculopapular rash seen due to allergic to antibiotics. 6. diagnosis - Transient Ischaemic Attack - Drug Rashes - Pneumonia with PUO 7. questions asked by lecturer... - Infective endocarditis: presentation and how to diagnose? - Acute Coronary Syndrome: PTCA [asked during Past Medical Hx] - Elicit hyperreflexia - Classified the rashes, differential of rashes with pruritus. - PUO: causes... Arghhh... not reach investigation... stuck in history of PUO and PE of rashes... arghhhh.... - MHR -

Kevin Ng Rong Xiang Prof Nortina and 2 external Medicine Lupus nephritis No chief complaint history started 1989 and presented with multiple joint pain and body swelling got 10 relapses, every relapse must ask very detail and they will ask one by one and ask about your opinion for each relapse and you cannot skip the relapse history. need detail investigation too. PE: moon face and bilateral leg edema Diag: not asked Question: opinion abt every relapse like what do you think this relapse is? what is the triggering factor? what is nephrotic syndrome? should renal biosy done? can patient pregnant? why not? advice for patient? steroid issue like complications?

actually all questions very patchy and no proper answering due to time constraint. after i present history already 20minutes cos long history. no physical examination, no investigation, no management, no nothing.

last Tues

Lee Chui Yee 1. lecturers who took u - prof choy lang(med), prof kamarul(ortho), prof wan arrifin(paed) 2. specialty-medicine 3. chief complaint-scleroderma and eisenmenger's syndrome 4. brief history -scleroderma x 30years -lung fibrosis on LTOT -Raynaud's phenomenon -skin rash -renal impairment -esophageal dysmotility -vsd with eisenmenger's syndrome -hpt -allergy to chicken, prawn and cyclophosphamide

5. PE finding -everything abt scleroderma - grade 4 murmur at LSE 6. diagnosis: eisenmenger, pulm hpt, scleroderma 7. questions asked by lecturer -wat is the complication of LTOT? -wat is viagra? how does it work? wat is the 2nd mediator? -wat r the other treatment of pulmonary hpt?

-in vsd, if pt hav loud S2, wat does it mean? eisenmenger same case with Miss Karti... last Tuesday Report

Ikha Zulaikha specialty: medicine (b-thal) lecturer: prof wan azman, prof aisyah, prof eugene. chief complaint: nil HOPI: -22/m/male dx B-thal major since 2 yrs old. receive blood transfusion every months. no transfusion complication. pre hb is usually 7-8. post hb 13-14g/dl. every months will have have anaemic symptom such as reduced effort tolerance and SOB 2-3 days before go for the next blood trasfusion. have one allergic reaction post-transfusion when he was 12 years old. -family hx of consaginous marriage and father+mother both are carrier (only know their status after he was dx to have b-thal). All sibling were screened. 2nd brother also carrier. youngest brother affected. -take iron chelating agent: desferioxamine (10 hours, 4-5 times per week, 4 bottle per day) since 10 y/o and desferiopone (7 tablets per day)since last yr. no complication of iron chelating agent. he was compliant to the treatment. -complication from iron overload- poor growth - hypogonadism (small testis, penis, no axillary hair, sparse pubic hair): receive IM testosterone monthly - hypothyroidism: no symptom, accidentally dx during routine follow up and check the hormone level. on thyroxine. Lastly, social history: was feeling inferior toward friends coz shorter, no moustache or beard. feel burden towards family, not perform well in academic. never get teased by friend. smoking, no alcohol.prof really particular bout it. -got teased by friend? friend know or not? wat is his feeling? wat is his family feeling.

p/e -check abdomen. he has splenomegaly. prof ask how to differentiate spleen and kidney? enlarged inferomedially, cannot get upper border, not ballotable, moves with reps, got splenic notch and splenic rub on auscultation. -prof asked bout testis and penis and pubic and axillary hair. patient had no axillary hair, sparse pubic hair, small testis and short penis length. -how to check for pallor? conjunctiva. -comment on the face- thalasemic facies: maxillary hyperplasia, frontal bossing, gum hypertrophy.

question: 1)sign and symptom of hypothyroid- constipation, cold dry hand, slowness in motion, 2)how to dx hypothyroid: thyroid function test-low T4 and TSH. 3)management of b-thalasemia- i ans: - regular blood transfusion- need to take pre and post hb level, ensure received the correct leucodepleted blood, monitor the patient during transfusion if got any complication, give lasix afraid of volume overload. - iron chelating agent when serum ferritin >1000 and monitor the complication. types of chelating agent- DFP, DFX -need to monitor complication of iron overload. then prof ask how to monitor: LH,FSH and testosteron level for hypogonadism, TFT for hypothyroidism, FBS or OGTT for DM, echo for cardiomypathy, liver fuction test for liver cirrhosis. and monitor growth for effect of low growth hormone. -splenectomy if patient has hyperslpenism. then prof ask, how to know? i ans splenomegaly and thrombocytopenia. as well as low Hb.. actually 3 cell line will be low. -discuss the percentage of his offspring can get thal. then, prof gives a scenario : if he get married with normal female, what percentage of affected pregnancy and carrier?? if married with carrier, what is d percentage of affected pregnancy and carrier?- need to calculate using mandelian law. -lastly, prof ask, how do u want to help the patient. do u want to refer to any grup. I ans THALASEMIA CLUB, but all laughed! prof wan said, not club, its THALASEMIA SUPPORT GROUP. then prof ask, how it can help d pt? - pt can discuss with other thalasemic patient and the group can help him to deal with thalasemia .. prof aisyah Q: wat is the urine look like (pt had a urine sample)? i said tea color urine. but actually not.she prompt me and i ans due to iron overload, iron was passed in d urine. but i still dunno d color of d urine. i heard prof aisyah said red sumting... not sure wat. mayb red-bronze colour due to iron overload.

Zurah Hamid B thal major adult. prof wan azman, prof aisyah and prof eugene. my case and questions = ikha. plus pathophysiology of heart failure in thal and a case scenario, if patient come in with URTI, how do u manage this patient start with ix. ok guys. Goo

2 internal examiners (not sure who they are) + 2 external examiners (All of them are nice & tak garang) SLE 38 y/o/C/lady known case of sle for 22 years.no active chief complain.frequent relapses (more than 10 times) with kidney involvement. typical sle symptoms during first presentation.currently on oral pred, azathioprine, omeprazole and calcium supplement.other medication had been given previously include cyclophosphamide (stop becos she plan to conceive at that time, rituximab (costly drug and had experience febrile neutropenia during this episode),iv methylprednisolone).history of failed intrauterine insemination once,currently still has no offspring. she also has complication of steroid toxicity (cuhsingoid appearance,easy bruising,peptic ulcer disease,bilateral cataracts,fungus infection once but resolved already). PE: most signs of cushing syndrome (just mention the positive findings in the room-not being asked

to examine the patient..huhu) Ques asked : 1.How to diagnose SLE.mention all features for SLE 2.Managemnt of sle. what is the drug that normally give to sle patient but not in this patient? hydroxychloroquine. Should we consider giving her this drug?what should we check b4 start her on this drug? liver function test,renal function test, eye examination since this drug can cause central scotoma. 3.Supposely if this patient come with mood symptoms such as mania or depression.What r ur differential diagnosis? cerebral lupus,steroid induce or depression due to long term unresolved disease. 4.What are the approach for proximal myopathy?what are the differential diagnosis other than cushing syndrome. what investigation u wanna do? 5.All side effects of steroid toxicity.....how steroid can cause infection? 6.What is autoimmune disease? 7.discuss about antiphospholipid syndrome and little bit issue of sle in pregnancy. 8.Since this patient also has kidney stone-been asked about type of stone and management of kidney stone) 9. Features and complications of nephrotic syndrome 10.Suddenly caucasian examiner who sleep all the way of presentation wake up and suddenly ask approch of hyperparathyroidism... 11. caucasion examiner: what are the name of radioistope scan of hyperparathyroid gland? sestamibi scan. 12.What r the mneumonic for hypercalcaemia?

more or less these are the questions that been asked by examiners.All the best & hopefully all of us will pass this exam~ last Tuesday Report

Mohd Taufiq 1. Lecturers: Prof X (external), Prof Siti (O&G), Prof Yip (Surgery), Dr Zaharuddin

2. Specialty: Medicine 3. Chief Complaint: Productive cough 5 years ago 4. Brief history: 59 y/o Malay lady, housewife, history of childhood asthma, c/o productive cough, fever, a/w SOB and wheezing. Initially under Hosp Seremban f/up. In 2007, went to private hosp, investigations were done n diagnosis was made.. condition remain stable however in 2009 another exacerbation occur, went to UMMC, CT scan n CXR was performed and diagnosis was given. Since then she is under UMMC f/up every 4 months. Last year, she had 4 admissions to hosptal due to exacerbation. This time, came in for cyclical antibiotic.. PM hx- dyslipidaemia Drug hx-MDI Ventrolin and Seretide, statin n a/b 5. PE finding: Pf. X notice i did not hand rub( before n after seeing pt). He said u(me) should hand rub..... iv fortum???, no clubbing, no tremor, no cyanosis, lymph node (xcheck), trachea xdeviated (but in CXR trachea deviated, inspiratory coarse crepitation and occasional ronchi (from middle to lower zone), i mentioned present of pleural effusion (actually no pleural effusion), bcoz i think present stony dull. 6. Diagnosis: Bronchiectasis (pt told me), when presenting hx, i did mentioned a diagnosis had been made, Prof X ask me " do u know the diagnosis? I anwred " yes, bronchiectasis, pt told me" Pf. X " it's an medical term, does pt really told u?" yes, pt really told me".. They are not asking about differential 7. Questions asked by lecturer: Pf. X a) what the diagnosis? (already mentioned above) b) this pt require a/b for rest of life,, why?? c) what do u do if u see pt came to the hosp? d) what investigation u would do? He give me cxr Ring lesion.. What is it imply? e) what cause bronchiectasis? I mentioned a1 antitrypsin def, then he ask what is a1at def? f) how would u manage her? (actually he asked a lot of questions, but can remember all) He finished... Bell not rang yet He asked prof yip n pro siti, anything they want to ask Prof Yip continued a) let say, pt go for operation for perforated peptic ulcer, what is ur concern? b) what assesment do u do before surgery? Lung function( spirometry)

c) what parameter u look in spirometry? (FEV1 and FVC) last Tuesday Report

Chew Kee Seang 1. Prof Philip Poi, Prof Cheach (UKM neonatologist) , another external 2. specialty: medicine 3. chief complaint: exam 4. brief history History of recurrent MI for2 times in 3 months period, presented last year. Now having CCF symptoms orthopnoea, leg swelling, reduced effort tolerance. I start off presenting a symptoms history on MI last year and how he progressed to CCF with the typical symptoms. Accessed the ADL. 15 years ago diagnosed DM, presented with 3P and weight loss. poorly controlled, changed to basal bolus insulin after MI, good control. Multiple episodes of hypoglycemia. Many complication of DM: recurrent abscess on skin, frothy urine with proteinuria, bilateral cataract but no retinopathy, bilateral numbness up to mid shin, no diabetic foot ulcer before as he was educated on foot examination, no unilateral body weakness, no bilateral leg pain on exertion. on metformin hypertension 5 years diagnosed after screening. has multiple episodes of postural hypotension. hyperchol 4 years. Spine TB 8 years ago, presented with sudden onset severe back pain asso numbness of LL and shooting pain. then had multiple spine surgeries and bed bound for 1 year. subsequently recover, regain full function but still have residual pain BPH 1 year. on xatral (alfuzosin) and symptoms were relieved. fracture right tibia 20 years ago with ORIF and treated. mild deformity. strong family history od DM hpt chol. brother died at 54 due to MI, father died at 74 due to

MI. mother got stroke. drug history a long list.... metformin, insulinatard and actrapid, perindopril, lasix, spironolactone, bisoprolol, plavix, aspirin, vactarel, xatral. no allery NO smoke, no alcohol, married, sedentery lifestyle, diet: high fat high salt. thats all.

5. PE finding: raised JVP (must show prof philip), displaced apex, loud P2. typical DM leg changes (diabetic dermopathy, atrophy skin, shiny, loss of hair, no dorsalis pedis pulse, no ulcer. sensation lost up to mid shin. SLR SST positive at 30 degrees.

6. diagnosis CCF secondary to MI. with.....

7. questions asked by lecturer (prof philip) why patient has recurrent MI? what is so special about atherosclerosis in THIS patient? do u think surgery better? how to access pre op fitness? what is lung function test? RINGgg........

(prof cheah) what is the management of MI? like that la......kin join

Hadi Anuar 1. lecturers who took u : Prof Rokiah Ismail (main) Prof Hani & External Examiner 2. specialty : Medicine 3. chief complaint : no active chief complain came for exam 4. brief history : 33 y.o Chinese man presented to UMMC 14 years ago (1997) with high fever &

progressive bilateral leg swelling. Referred to GP multiple times, treated with Ab and PCM but fever kept coming back. Developed progressive bilateral leg swelling over 3 days, referred to Assunta Hospital. Multiple ix done, diagnosed to have SLE. Switched to UMMC due to logistics. Started on high dose oral prednisolone since then. Not compliance to meds due to acne, proximal myopathy. Relapse nephrotic in 1998, renal biopsy done -> GN 2nd to lupus nephritis. remained normotensive. started on cyclophosphamide for 1 year. didnt develop s/e. again not compliance, relapsed 2nd time in 1999. remained asymptomatic till 2008 where he developed AVN of left femur 2nd to steroid in 2008, left hip arthroscopy done to repair with bone graft. other symptoms of SLE during 1998-1999: alopecia, malar rash, photosensitivity,mild arthralgia. others were not present.

5. PE finding stretch mark due to previous ascites, scar on left flank due to arthroscopy. not cushingoid. protein 3+. 6. diagnosis SLE with lupus nephritis. 7. questions asked by lecturer epidemiology of SLE in Malaysia, ethnic group, ratio female:male common presentation of SLE - in comparison to this patient? why do u think his presentation is unusual? Side effects of prolonged use of steroid? does he has features of cushing's? would you send him to ophthalmologist (cataract)? how would you monitor this patient on daycare basis (BP, proteinuria, glucosuria)? how would you persuade him to be compliant? Prognosis of this patient? (RF) what is the normal function of kidneys? (erythropoietin, hemostasis, toxic excretion, blood pressure) how would you advice him?(ESRF-->hemodialysis, needs fistula) if ur in remote area and this patient presents with severe acidosis? (peritoneal dialysis) how do you perform peritoneal dialysis? what fluid do u use? Role of renal transplant in this patient? (no point transplant, develop antibody) bedside: show me ur positive findings. how do u elicit prox myopathy? does he has any features of cushing's? last Tuesday Report

Peng Loon Cheah Same as kee seang's case lo.. 1. lecturers who took u: Prof Philip Poi, Prof Cheah Fook Zhoe (External UKM), Dr. Wong (not sure from where.. um?) 2. specialty: Medicine 3. chief complaint: Came for exam. Last admission 8 months ago with chest pain. (MI) 4. brief history: - Last year two episodes of typical MI symtoms, done angioplasty and discharged with aspirin and clopidogrel. Had acute pulmonary edema, some ascites, no leg edema. Dunno got CCF or not, but i clerked as MI. - 18 year history of DM with complications - 4 year history of hpt - 8 year history of TB spine - BPH on Xatral - previous distal tibia fracture 5. PE finding Same as kee seang's oso lo.. I found JVP oni 3 cm (which is wrong lo >.<) 6. diagnosis Myocardial Infarction with all those chronic probs lo.. Not asked for diagnosis also. 7. questions asked by lecturer a) What important physical findings u found? Me: BP normal. Checked for postural hypotension. (Yay he's happy :P) b) What is considered significant for postural hypo? (>20mmHg systolic) c) I said JVP only 3 cm.. not raised.. he said sure? Ok.. straight to see patient. d) Show to elicit JVP. First try still point to the 3cm point, then he ask to look again then found a higher point lo.. e) How you confirm its a JVP? What is normal JVP? Me: Not palpable and slightly enhanced by hepatojug reflux. (Prof: What slightly? Either got or dun have..... of cos say got lo) f) What else in CVS? (This one really SWT) Me: Apex not displaced Prof: Where's the apex? I pointed lo below the nipple 5th ICS, then i said okla.. displaced 1 cm) Then prof go feel high up in the axilla (above the nipple line weyh) then ask me feel.. i can't feel oso finally he put one finger there ask me feel. So finally i felt. Then prof said.. hmm interesting.. this patient has two apex beats.. (hopefully that means i'm not screwed la..) g) What are the causes of displaced apex beat? What is definition of apex beat?

h) What bruit would u expect to hear? Me: Carotid bruit? U mean murmur ah? (Prof: Of cos la.. aren't murmurs bruits?) Me: ok.. mitral regurg due to dilatation i) Show the loss of hair on the shin, peripheral neuropathy. j) What else u look for in the legs? (already covered ulcers, fungal infections in web spaces.. dunno what else d) His answer is callouses h) Did u feel dorsalis pedis pulses? OOPS FORGOT OMG.. then feel in front of him.. left leg got, right leg absent. Posterior tibial present. Tell me how diabetes causes peripheral neuropathy. (Dunno.. can guess? he said ok.. so i said hyperglycaemia causing myelin and schwann cell damage.. he said yea.. but HOW? I said due to osmolarity imbalances.. then he said i'm going further off track.. nvm d) i) Did u check urine? Yup.. got trace protein oni.. the rest normal. OK back to room j) He has trace protein, so what's a better way to quantify it? Me: 24 hour urine? (what else?), uFEME (talking nonsense d.. wrong oso of cos), microalbuminnuria (YES YES all nodding head) k) How u test for microalbuminuria? Me: ERR.. order oni lo.. (all laugh..sarcastically say just tick in the form oni right? then prof philip say actually is dipstick oni) l) Does he have hypoglycaemic attacks? (OMGGG forgot to ask again.. sorry prof. Prof: say sorry to patient, not me) m) Ok.. he actually has morning hypoglycaemia. How u want to manage? Me: Err.. assess the prev. night management. maybe ask him to take snacks before sleeping. Prof: Anything else? (I dun dare to lower insulin.. scared cannot and its a serious mistake then straight fail.. so just stone there lo..) So u mean u only give snacks and dun do anything else? Me: Erm.. yeah i think so.. and monitor lo.. Prof: U give him insulin and he got morning hypo u still dun wan change ah?? (SO strong hint d so i say YAYAYA WANT TO LOWER INSULIN) =.=" n) Ok.. so he has proteinuria, what medication u wanna give? (ACE-I) o) Why? (Proven to reduce proteinuria and progression to renal failure gua) p) Why ACEI can reduce proteinuria? (Dunno.. stone few seconds..) q) What are the side effects of ACEI? (transient rise in creatinine and CI in bilat renal artery stenosis) r) Ok.. Why got transient rise in creatinine? (Dunno.. just studies show oni.. stone there again) Prof: Its related to afferent and efferent vessels. Me: Err.. maybe reduce blood flow to afferent vessels? Prof: A- or E- fferent? ( I said A-fferent).. Then he said ok nvm.. u can go now.. (wrong lo i guess) last Wednesday Report

Kejal Udani from kejal : BTW, my lecturers were : Prof CK Liam, Prof Jessie Bruyne, dr sofea, and an observer who asked a lot of questions... long case : indian lady with fibroid, pesented with a fall in bathrom ?anaemia ?? underlying asthma, and Diabetes Qs : d(X), why, how can u treat? when is HIFU better over myomectomy? i guess when its ONE large one.. side effects of UAE? post emboisation syndrome...not sure wat exactly.. why fobroid sudenly painful ? - degeneration? ischeamic necrosis? how to optimise b4 opt ? Lung function test, ecg, echo, insulin sliding scle if need wat type of anaemia ? IDA why ? storage depleted.. ix : serum ferrittin she appeared pale, guess her HB ? i dunno, just said 8g/L which medications : COC, tranexamic acid and NSAIDS

Norazwa Ramli 1.Prof siti(o&g),prof yip(surg), prof ?(external med) 2.specialty:medicine 3.History: no current complain. background hx of mitral stenosis n valvular replacement done twice.1st on 1986 (bioprotheses),2005 (metal valve).last adm last month (feb2011) due to AF with heart failure.currently NYHA classification is stage 2 to 3.no other co morbit. on warfarin(anticoagulation), digoxin(rate control),atenolol(B-blocker), lasix(diuretic), sloking(K+ supplement). 4.PE:AF+tachycardic(100bpm) ---> not well control AF cardiomegaly + pedal oedema up to shin --->not complete recovery of HF no pleura effusion,no hepatomegaly,no raise in JVP 5.Diagnosis:AF in HF 6.Question:

a.what happen during the 1st adm?what is the probable diagnosis? b.what happen on 2nd adm? c.why u say her NYHA classifation is 2 to 3?tell all the stage in NYHA d.do u think her heart prob is well control? e.what could be the valve abnormality for the valve replacement? f.what type of valve she had been replace with? g.why she was on warfarin?desired INR?how frequent to check the INR? wat u advise u should tel the patient?what precaution u should tale on her. h.explain why she was given the current medication.what other drug u can give to control the heart rate? i.how to treat HF in acute state? ji.if she come to u now what do u want to do? k.interprate ECG l.echo show her ejection fraction is low, what do u want to give her to improve her ejection fraction?

Chuan Chun Lim Lec: Prof Phillip (Med), Prof Nik(PCM), Prof Thambi (Paeds Surgery) All questions by Prof Phillip Main Problem: TIA and polycythaemia,5 years ago Currently no C/O. Came for exam purpose. HPT 5 years. When i presented my hx, Prof Phillip asked 1. What CT scan findings of the brain you expect to see if patient come into A&E? 2. Why the Doc changed Aspirin to ticlopidine in polycythaemia? Zzz Then Prof said it was a high tech question. I only figured it out be4 i sleep... 3. For Aspirin, how many percent of patient will have GI problems? PE (they mainly want to see the skills) Show power, reflex, clonus, visual field. Only have hyperreflexia. Others they want to see the skills. Discussion

1. Tell me about polycythameia? How many type? 2. Show me the FBC result, interpret. All cell line raised. 3. What is this condition called? I became thought block. Zzz myelo.....dysplasia. No!! then i said myelo.......proliferative d/o. They accepted the answer. 4. What is hydroxyurea? Anti-metabolite...... 5. What is perindopril? ACE-I....... 6. What is ticlopidine? Antiplatelet...... Patient came to your clinic. How would you check for polycythamia? Conjunctival plethora. What else? I keep talking hand, bla bla all rubbish then they said cyanosis. Why polycythamia patient will have cyanosis? I keep talking rubbish again until i said hypervicosity, blood stasis, and then only they let me go. Zzz,, serious thought block when they throwed me the Q !! really screwed up!!!! on Friday Report

Kamariah Ahmat 1. lecturers who took u - prof ida, prof ong, external 2. specialty- medicine 3. chief complaint - 63/malay gentleman c/o left sided weakness 4. brief history - background history of hpt for 20 years, dm for 10 years and asthma presented with a c/o left sided weakness..sudden onset on 2006..admitted for 20 days..non-compliance to medication 5. PE finding - left hemiplegia- flexion contrature, grade 4/5, hypertonia, hyperreflexia, upgoing plantar, sensory intact 6. diagnosis - left sided stroke 7. questions asked by lecturer a) question related histry - why patient not compliance to medication b) why this patient have flexion contracture c) imagine u're a doctor in-charge at ane, patient presented like that, what do you want to do n why? d) what is the severity of his stroke?..i'm not sure what she want

e) what d difference with anterior and posterior artery circulation stroke presentation? f) she want me to describe ct scan...but bell ringgggg... on Sunday Report