MEDICINE

CARDIO
Case 11
Smurfit
65 y/o lady regular attender heart failure OPD for the past 3 yrs on a b/g of 2 aortic valve replacements and
CABG. Currently well.
Aortic valve replacements: 20 years and 3 years ago.
Heart failure also diagnosed 3 yrs ago on TOEcho.

PE: CVS precardium - what's a thrill, normal apex beat position, murmur heard in axilla - MR, types of
implantable cardiac devices (pacemaker and defibrillator) and indications, bilateral leg swelling ddx and
pathophysio -RHF due to high hydrostatic pressure, hypoalbuminemia due to high oncotic pressure, one sign
on examination to check if leg swelling due to RHF - JVP, how to differentiate JVP and artery - occludable
would be better than multiwave form esp if pt has afib.

Ques: pt was on elperenone - was asked what is the MOA : aldosterone antagonist (similar to spironolactone),
warfarin: how to monitor, what's INR, normal INR level for this patient with AVR, what meds would cause
warfarin dose to be increased and why - phenytoin increases warfarin metabolism, what med requires warfarin
dose to be reduced - NSAID. In emergency situation, how to reverse warfarin - vit K and octaplex. What's
octaplex - prothrombin complex. If elective admission, how would u manage pt with warfarin - bridging therapy

Case 17
Connolly
65yo man regular attender of cardiac opd since 2008 on b/hx of AV valve replacement in 2008. Sx just SOB.
Currently well. On warfarin.
PE-full cardio exam
Q&A
-features of AR on exam
-causes of R-R + R-F delay
-warfarin (moa,what factor warfarin affect on liver, how to monitor,what's INR,normal INR for this px,what
drugs n food interact with warfarin,what antibiotic interact with warfarin, adv n disadv warfarin vs noac, why
cant give noac for this px)
-what advice to give to this px
-follow up px (what do u assess, features on ECHO, ejection fraction in this px)
-what is ramipril, MOA (coz px was on that)

Case 18
Galway
79 years old gentleman came for elective CABG and aortic valve replacement.. Strong family history of heart
problem..

PE: full cardio exam

Q&A:
- what specific murmur to look for in patient post valve replacement
- pre-op assessment
- emergency questions on cardiac arrest
Few more questions i dont remember

Case 20
Dundalk:
Elderly c/o SOB, hx of HF dx 3/12, DM dx 3/12 ago currently on metformin, triple heart stenting 25 years ago,
lung fibrosis dx, HTN, sleep apnea., famly hx of HF and DM
Questions:
Sign of HF, lung fibrosis PFT (PEF, spirometry) abg oxygen indications, xray and CT features of lung fibrosis,
list of s/e of medications (metformin,statinsteroids), cabg vs steting in pt with multiple comorbidities.
Physical exam: cardio/resp/gi/reflexes
RESPI
Case 5
Beaumont 27/4/16
CF 36 yo came with current chest infection c/o cough productive of sputum with streaks of blood. no
aggravating factor, relieved by inhalers and nebuliser. Patient seboleh xnk bgtaw ddx haha so last2 dpt clue
she had prob since baby..hmppph ape lg CF la kan!Then basically explore CF hx since diagnosis.

P/E:anterior chest wall inspection and chest expansion, post chest percussion,auscultation-bibasal creps worst
on left lung, increase vocal resonance

QS: type of DM in cf and how to mx, bugs that grow in CF, what enzyme is in CREON and its S/E, what is on
patient's chest (portacath) and abdomen (mic-key button PEG tube), why pt had meconium ileus when she's a
baby, what is the inheritance of CF

Case 9
Smurfit
Pt 65 yo b/g RA, IPF. Sx: progressive sob on exertion, dry cough. Fatigue and recurrent chest infection (6-7
times/year). Didn't get to ask other PMHx or RF for SOB (i.e. Smoking, occupation) - not enough time to go
through history hence presenting the history was all over the place

Examination: full respiratory examination.

Q&A
- causes of chronic cough
- causes of Recurrent chest infection
- advice to give in patient with recurrent infection
- How to diagnose IPF and what do you expect the pattern to be.
- RA: what joints affected and marker for active RA
- treatment of RA as in 2016 guideline
- what are hydrochlorpquine, anti-TNF and other DMARDs and their mechanisms in treating RA. And SEs of
DMARDs
- other types of pulmonary fibrosis and how do you diagnose them.

LIVER
Case 4
Connolly
48 y/o gentleman fr Dub currently attending GE OPD (transferred from liver transplant clinic), presented to St.
Vincent's with constipation in a bg hx of liver transplant in 2011 followg dx of CLD
PE: full GI exam and Q&A
Q&A: if pt has LBO - investigation and mx, SBO VS LBO (hx + symptoms, PFA findings), how do u approach
pt with chest pain - hx and investigation, mx of PE

Case 23
Dundalk
px with abd pain with ascites and jaundice - CLD with backgroud alcohol intake
qna - sign n symptm cld, variceal bleed mx, medication
RHEUMATO
Case 6
Connolly 28/4/16
EO- 73 year old lady came in with acute flare of her RA. diagnosed in 1979. present with hand,
shoulder,knee,elbow pain. No erythema, swelling or stifness. limited ADL due to pain, on multiple drugs
including gold but stop due to reactions. Currently taking methotraxate once a month and tocilizumab infusion
every 6 months.

extraarticular complications: pericardial effussion, recurrent pneumonia, dry eyes only

P/E:hands exam, LL exam-hammer toe,halux valgus, ankle oedema

QS: management,extra articular manifes,s/e DMARDs,during surgery what complicates anesthetics in terms of
airway management (atlantoaxial subluxation),hw to ix atlantoaxial subluxation (xray),what xray views-lat
AP,mouth open,flexion extension of neck,wht cause ankle oedema in this case (cirrhosis due to methotraxate
& possible HF,restless leg syndrome mx (pregabalin)

Case 10
Dundalk
61 y/o lady with a b/h CREST presented with oesophageal dysmotility and heart failure. P/c: breathlessness,
leg swelling and dysphagia. Too much going on and you have to put the pieces together.

Physical exams
- hands exam for Scleroderma
- pulse
- percuss and auscultate posterior chest
- check reflex C5/6. You need to know the nerve supply coz then won't tell you what it is.
- how to examine pitting odema

Q/A
- warfarin and aspirin ( MoA, what factor does the warfarin affect on the liver, why warfarin better than aspirin
in treating A.fib)
- management of increased INR (I.e stable with INR 6 and haemodynamically unstable high INR)
- management of acute pulmonary odema
- long term management of Heart failure
- what CREST stands for
- name few scars on the abdomen and indications
- carpal tunnel syndrome (what structures go through the tunnel)

Case 21
Ms L, 36, f/u from rheumato clinic with 15 year hx of chronic back pain and hip pain, 5 year hx of neck
stiffness, 3 year hx of joint pain a/w weight loss, problem with walking.

Physical exams:
Spine, hip and foot exams

Q&A:
Ank spond
- how to diagnose
- features on xray (bamboo spine!)
- complications (10As!)
- treatment options
- s/e of steroid that u most worry about for the patient (AVN of femoral head!)
- other s/e of steroid

RA
- how to diagnose
- features of rheumatoid hands
- features on xray
- treatment options
- DMARDS examples and s/e
Case 24
Pt with multiple comorbidities, RA, DM with toe amputation, IHD with stenting, A1AT,bronchiectasis, currently
no symptoms

RENAL
Case 14
Beaumont smurfit
69yo, male. Attend eye,diabetic,renal clinic. Bg hx of Renal transplant, below knee amputation both legs,heart
bypass surgery.

Physical exam:
Abdomen
Leg
Scars

Questions:
-symptoms of hypoglycaemia (he asked for specific sympathetic symptoms) and risk factor leading to
hypoglycaemia
-explain the pt insulin treatment
-how to know rejection of transplant from palpation
-why patient diabetes can be worsen over time,what organ involve
-name all the scars u can see
-name of surgery for pt leg amputation
-landmark femoral artery,show and feel the pulse plus compare and comment
-what are the types of claudication in intermittent claudication
-why hanging leg at edge of bed release rest pain at night
(Few more but can't remember)

Case 30
Pakcik admitted with htn 220/100 bp, with background dialysis 3 years, and dx DM 30 years ago. Exam full GI
and fistula. QnA banyak pasal nephrotic and urinalysis and complication DM.

Case 31
Chronic kidney dz come for dialysis. Got many transplant rejection since 2000. Pstu bnyk hal pt tu, xsempat
smpai social n family hx pon :( Kene tnye why transplanted kidney xwork after 6years of working fine. I
answerd bantai chronic rjection n pt ade comorbidities.
Physical exam cvs n abdomen. Plus describe how to examine inguinal hernia (nk buat physical exm tpi
examiner suruh describe je) Ade temporary ileostomy juge. Asked abt complictn n define HOStoma.
Lgi kne tnye pt with abdo pain what Ix. Sempat listkan smpai imaging je.
Examiner2 tu mcm xtau2 sgt pasal timeline exam (sbb 1st student kot) so die start tnye2 wktu minit presenting
hx. Jadinye agak jumping here and there la.

NEURO
Case 16
Smurfit
68yo man b/hx of hemorrhagic stroke n afib. Had stroke june last year. Had 3 episodes of IHD in the past
+3stents. Currently attending beaumont for follow up n st joseph hospital for rehab. On warfarin
PE-upper limb neuro
Q&A
-stroke posture,power grading,reflex root,dermatome
-GCS
-follow up stroke px in opd what to do
-px hx of stroke came in to a+e with sudden SOB what do you most worry about?=PE
-PE(investigation n mx, what ecg changes for PE,what do you look for in ctpa),actually ada lg soalan tp dh xigt
sorry
ENDOCRINE
Case 22
Connolly
pt attending opd for 1.t2dm 2.incisional hernia 3.angina
T2dm dx 6mths ago and still got polyuria n nocturia. 6wks ago buat eye check smue normal. Xpernah buat
footcheck.
Hernia recurrent. Repair 5 yrs ago. Background hx heavy work.
Angina 20 yrs ago tpi skrg ade pnd n orthopnea n dyspnoea n leg swelling. Heart stent last yr.
Q&A: hernia (types,repair pkai mesh ape smue...serius goreng, mane lgi common- die nk dgr most inguinal tpi
femoral lgi bnyk kt female, but inguinal still most common). And y femoral lgi bahaya. I said sbb higher risk of
strangulation. He ask y, I said sbb position. Krik2 smue diam.
Medicine kne tnye psl hypertension nk pkai drug ape. Drug combination. And MOA ace inh and b blocker. And
diabetes beza type 1 n 2
sx pasal small bowel n large bowel obstruction beza

Case 28
Stable type II DM female patient attending endocrinology OPD
Currently well, most recent complication being recurrent osteomyelitis
Then asked for opening statement
Then physical exam (don't forget to wash hands!)
-describe what can u see on the foot (charcot joint, ulcer)
-what else? (Jenguk sole ade callus)
-what jt abN is that? (pes cavus, valgus hallux, hammertoe)
- what else? (A few toes was dressed-why? Igtkn sbb ulcer, amputation ke rupanye sbb as protection from
abrasion or friction wearing tight footwear luls)
-what other exams u wanna do (vascular-pulse n cap refill, sensory-vibration, poprioception, soft touch)
-what sensory abN is that
Q&a
-summarize 3 most important complaints from the history
-who else should be involved in this pt care
-from the hx, why pt like in this presentation would fall
-ddx of periph neuropathy
-if pt female, c/o sensation of spider crawling on legs what's ur dx
-wht is the one prognostic indicator of periph neuropathy progression
There were a few more qxs asked, x igt
Examiners and pt were supernice, hoping they're the same with the markings though!

SURGERY
ABDOMEN
Case 1
48 y/o F admitted in Oct following one day hx of vomiting and diarrhea following 2 weeks hx of headache,
nausea, constipation and lethargy
Dx: diverticulitis
PE+Q&A: classification of diverticulitis complication and what are the stages (hincheys), in A&E pt very sick
with suspected diverticulitis how would u investigate (bla bla key is do not do colonoscopy straight do CT in
fear of perforation), examine scar - laparoscopic scar (how many scars and why), examine patient's hernial
orifices?, test cranial nerve 7 (why did u asked for change in taste sensation and increased sensitivity to loud
voices), do Weber's test, palpate pt's liver and spleen (causes of hepatosplenomegaly- one of my answer was
acromegaly-what GI complication acromegaly pt can get), test c5 c6 reflexes (what muscle group are u
testing), why did u asked for eye symptoms in hx (IBD extraarticular), what eye symptoms can they get, skin
symptoms they can get, why did u asked pt's travel hx (GE), what microorgs cause GE (bac, viral, parasites),
how do u treat giardiasis, if pt has been on Abs and present with distended abd and very sick what's ur dx
(Cdiff), how do u dx it and how do u treat, will u give the pt Ab?
If u suspect GI malignancy, what other test on PE (LN-troisier's sign), any other signs on abdomen for GI
malignancy (trosseau sign of malignany-thrombophlebitis migrans, sister mary joseph nodules)
Case 2
70ish lady BIBA complaing of LIF pain b/h sjogren and lupus (dia xbagi tahu dia ada diverticulitis)
LIF pain started suddenly and become constant. Radiate to the back.. Progressively getting worse after a/w
nausea and vomitting.. Getting worse when flexed her hip.. few hours later pain become generalised and the
abdomen was hard and tender to touch.
Of note: patient on warfarin for recurrent DVT
Dx: diverticulitis complicated by psoas abscess..
Q&A: who's at high risk for DVT, therapeutic dose for LMWH, whats sjogren, how to dx lupus,list me
medication for RA, mx of diverticulitis based on hincheys classifiction, what is psoas abscess, what bugs can
grow in them, what antibiotic can we give, how do we manage abscess.. What could cause psoas abscess.

Case 7
Smurfit
68 yo lady attending beaumont hospital for regular stoma check up post subtotal colectomy due to UC dx in
2007. Presented in 2007 with 2 months hx of diarrhoea and constipation a/w LIF pain. Had surgery on the
same presentation due to resistant to meds and 2 episodes of adhesion a few yrs after surgery.
PE- GI exam + extraintestinal manifestation for IBD
Q&A- medical tx for UC, effect of biologic agent in rx of UC, mx flare up of UC, work up for thyroid nodule, mx
of thyroid storm, s/e carbimazole, ddx for abdo distention with fever n chill, mx of toxic megacolon and pleural
effusion.

Case 8
Drogheda
21 yo gentlement presented 1/52 ago with 2/7 hx of fever and rigors a/w RIF pain with b/g hx of lap
appendicectomy 2/52 ago.
Dx-abscess (complication appendicectomy)
PE- GI exam n elicit psoas sign.
Q&A- risk factor of abscess formation post appendicectomy, possible location for abscess post
appendicectomy and it presentations, ddx for RIF pain, risk factor for infection post ops, how to manage pt with
fever post ops.

Case 12
Drogheda
73 y/o gentleman transferred from Navan hosp with 7/52 hx of coffee ground vomiting on a b/g hx of gastric ca
diagnosed june 2015. Had gastrectomy but tumor not removed and receiving chemo.

PE: GI - hands, eyes, abdo. What would u see in hands for this pt's presentation - koilonychia, pallor of palmar
creases, eyes conjunctiva pallor, abdo - scars midline laparotomy and paramedian due to gastrectomy. What
other signs on abdo would u see in this pt - no idea what he wants ?sister mary joseph nodule. Demonstrate
hepatomegaly.

Ques: vomiting electrolyte abnormalities - hypokalemic, hypochloremic metabolic alkalosis, investigation done
in ED for the pt. complications of gastric ca. then prof gillen asked if pt presented with distended tense abdo,
likely cause - ascites. Why would pt have ascites - portal hypertension?
On laporoscopy/endoscopy (cant remember what he said, i zoned out a second lol) what would u see at
anastomosis site - omental plug came out from my mouth. then he asked what do u call an omental plug filled
with fluid and cant remember what else he mentioned - dunno. Then asked something about peritoneum
involvement - dunnooo.
Case 13
Connolly-opd
Pc: a 39 year old gentleman from dublin is currently attending general surgery clinic under the care of mr ikram
for follow up of hartmann's surgery 2 months ago after presented with lower abdominal pain assoc with
constipation and blood in stool on the b/g of previous appendectomy and fhx of polyps and gallstone. Hpc:
presented to emergency 2 months ago c/o lower abd pain, crampy pain, sudden onset, no radiation, initially
rated 3/10 which progressed to 12/10 for less than 24H, needed to keep still, nothing made it worse.. Assoc
sx: constipation, fever, night sweats, trace of blood in stool.. -ve sx: no diarrhoea, weight loss, tenesmus. After
admission, managed with abx for 3 days but no improvement, had emergency hartmann's surgrry on day 4 of
surgery.. Post op was uneventful..
PE: GI exam

Questions
1. ddx: diverticulitis, ibd, bowel obstruction 2nd to adhesion
2. Mgmt of suspecred perforated diverticulitis in a&e
3. Hinchey classification
4. Post hartmann complication
5. What should we advise patient after hartmann's surgery to prevent recurrent of disease
6. Ix before reversal of hartmann & when will we do the reversal
7. IBD medical mgmt

Case 15
Connolly hospital
48yo,male, referred by liver team to GI team for constipation. Associated symptoms nausea,vomiting,abd pain.
Had colonoscopy. Bg hx liver transplant and hernia repair.

PE: Abdomen

Q&A
- what could you see on examination pt with CLD and demonstrate it
- tell me about hernia
- why femoral hernia tend to strangulate
- investigations if pt comes to a&e with constipation
- what would you see on PFA of bowel obstruction(small and large bowel)
- what else could u ask to differentiate bowel obstruction and constipation (flatus,they ask coz I forgot to ask
this in my hx T.T)
- tell me about immunosuppression
- why patient on immunosuppression
- tell me about rejection and how it happens
- and they ask about protocol use for either immunosuppression or rejection (could not remember which one
coz I dunno any of it)

Case 29
Aku dpt chrons dz dx 23 years ago. Chronic abdo pain, currently treated with medication. Misleading sikit, sbb
dia ckp recent issue is RIF pain, after aku dah tnya srcopsara baru dia ckp pain tu sbb pcos, pastu bru dia ckp
ada LIF pain gak chronic due chrons. Soalan pasal aetiology, site of lesion, macro and micro finding,
investigation, mgt, uc vs chrons. Surveillance for chrons, mgt of fistula, lol second examiner tnya pasal
dermato (erythema nodosum, psoriasis, eczema) haha
BREAST
Case 3
Smurfit Beaumont
62 y/o lady attending breast OPD dxd with breast CA (invasive ductal CA) came in for chemoradiotherapy TX
following lumpectomy last year
Of note, pt is stable with no complications
PE: breast exam, LNs, what other exam u want to do
Q&A: present case, tx options in breast ca pt, gene involved, any other ddx for hysterectomy, investigations for
HTN and expected ECG findings, definition and aetiology of malignant HTN, SEs of Ca channel blocker and
ACE-I

Case 19
Smurfit:
Lady with hx of mastectomy and silicon implants on left breast. Right breast augmentation. And revised silicon
reconstruction with LD flap. Hx of IVF.
Questions: mostly everything abt breast cancer in the surgery book ie triple assessment, signs, complications
of chemo, types and physcial/radiological findings, meds etc
Emergency questions was same woman (on chemo tx) present acutely unwell to a&e - list all diff dx,
investigations PE, signs, dx and well's score.

Physical: full breast exam

VASCULAR
Case 25
Opd pvd, all questions relating to pvd and it's management as well as the bridging therapy for a surgical
intervention. Patient had a midline sternotomy scar for cabg and a left long saphenous vein extraction for it as
well with a scar for it.

Case 26
AAA evar repair. Lots of questions: RF, benefit open vs evar, a fib, emergency AAA rupture etc etc. I spoke a
bit faster than usual prob that prone to more time for Q
Also my pt was on those in patient surg gown. Always ask if is in pt or OPD. Cos they usually wear those for
the purpose of the exam

Case 27
Beaumont ward: Prof Leahy + Prof Alice stanton (what a "pleasant" surprise selak langsir nampak diorg kan)
Diabetic foot..
My history was not greatly done..should have done better.. Should focus more on glycemic contro which i tak
tanya pun patient tu. boleh pulak tengah dekt HPC nurse kacau nak take off iv line dri patient masyaAllahhhh..
Why now?? examination Vascular and neuro..
-tak boleh rasa pulse dia weyh!! Kaki dia swollen-

Question: causes of peripheral neuropathy in diabetes, why ABPI high in diabetes (calcified vessel jawapan
dia, bukan atherosclerotic vessel).. What other investigation apart from ABPI? Toe pressure (not FOOT
PRESSURE-tersilap jawab).. Management of diabetic ulcer.. who else nak involve ni selain endocrinologist..
Vascular surgeon!!!