CoN The University of Fiji eS Umanand Prasad School of Medicine & Health Sciences Department of Clinical Sciences 2018 EINAL EXAMINATION SUPPLEME! LY PAPER IMED 301: INTERNAL MEDICINE Important Instructions to Students: 1, Read the questions, instructions carefully and answrer the questions. 2. You are allowed an extra 10 minutes reading time (during this time, you are not allowed to write with pen) and 180 minutes (3 Hours) to complete this paper. 3._ Silent, non-programmable calculators are allowed, but not supplied. 4, Write all your answers in the answer booklet provided, If you need extra sheets, please ask from the supervisor. Write your name, course code and student identification number in the answer booklet and in the attendance sheet 5. This Final Course supplementary examination Paper is worth 200 marks, contributes 40% of the total course assessments. Students must at least score 50% in this exam to pass the gourse 6. This paper contains Saat () sections A, B, and C. All questions are compulsory to answer, 7. Write all your answers legibly. The marker has the right to award zero for answers that are not legible. 8, This is a Closed Book Examination, The University views plagiarism, cheating and dishonest practice as serious offences and if found, offenders are penalized, Exami Paper Content: Section | Question | Content Marks Suggested Time a 1-50 | Multiple Choice 30 30 minutes B 31-55 | Short Answer Questions | -50~—*(| ~~ 30 minutes_—_‘| ic 56-62 | Long Answer Questions 700 100 minutes TOTAL 100 180 Minutes Page 1 of 15SECTION A — MULTIPLE CHOICE QUESTIONS (50 MARKS) ANSWER IN THE SHEET PROVIDED. CIRCLE THE CORRECT ANSWER. 1, In the treatment of hospital acquired pneumonia associated with long-term mechanical ventilation, which of the following is not a possible side effect of therapy? Leukopenia Confusion and convulsions Generalised rashes Prolonged PT poePp 2. Mycobacterium tuberculosis is a facultative anaerobe. Able to metabolize ATP in conditions without oxygen. When suppressed, which zone of the lung is most likely to find a secondary lesion in? Upper lobe of lung Middle zone of tung Hilar lymph nodes Lower zone of lungs soe 3. The only cultivable hepatitis virus is: Hav HEV Hev HEV poee 4, Morphine is contrai A. Head injury B. CopD . Acute Abdomen D. Allof the above 5. A 40 year old male with a BMI of 45 complains of frequent nocturnal awakenings and non- refreshing sleep. An overnight sleep study shows 30 obstructed breathing events per hour. His CO2 levels are normal. What is the likely diagnosis? ‘A. Moderate obstructive sleep apnoea B. Obesity hypoventilation syndrome C. Severe obstructive sleep apnoea D. Central obstructive sleep apnoea 6. The following are smoking related interstitial lung diseases EXCEPT A. Respiratory bronchiolit B. Desquamative interstitial pneumonia C. Airspace enlargement with fibrosis D. Cryptogeneic organising pneumonia Page 2 of 157. You are seeing a young previously healthy patient in the emergency room with an acute asthma attack. She {ooks very uncomfortable, she has diffuse wheezing throughout all lung fields and is requiring 50% oxygen by face mask to maintain oxygen saturations above 90%. A nurse reports that when the patient blows in her peak flow meter it reads in the normal range. What should you do next Send the patient home. She is better Repeat the peak flow several more times, Ignore the results and treat for severe asthma Get another peak flow meter goer 8. All of the following statements about beta adrenergic agonists used to treat asthma are correct EXCEPT: ‘A. Inhaled beta agonist used in clinical practice are selective for beta receptors at usual doses, but become less selective at escalating doses B. Inhaled beta agonists are functional antagonists of constriction and result in relaxation of the airway smooth muscles regardless of mechanism of constriction C._ Repeated exposure to inhaled beta agonists results in up-regulation of the beta receptors Which allows for decreased doses over time D. Long acting beta agonists are not used for acute symptoms and are not intended as first line therapy for worsening asthma 9. COPD differs from asthma in the following respects: ‘A. itis characterized by partial reversibility of obstruction at best B. Airway inflammation with many eosinophils renders COPD highly responsive to inhaled steroids C. COPD, unlike asthma is highty preventable D. Aandc 10. Tuberculosis transmission is a problem among infants in many orphanages in the developing world. The MOST EFFECTIVE way to reduce transmission of tuberculosis within an orphanage in a highly tuberculosis endemic area would be: A. Toperform a PPD test on all infants entering the orphanage B, Toisolate all infants with fever C. To require TB screening, diagnosis and treatment of al staff members who work in the orphanage D. None of the above 11. Lobar pneumonia {s rarely caused by streptococci Involves morphological changes of red and grey hepatisation Is not usually associated with cough Is associated with immunosuppression ooepP Page 3 0f 1512. Which of the following is NOT a complication of pneumonia? A. Abscess formation 8. Emphysema C. Suppurative arthritis D. Squamous metaplasia 113. Cheyne Stokes Respiration ‘A. Is most commonly seen in patients with stroke B. Represents an obstructive type of sleep disordered breathing €. Does not correlate with the severity of heart disease/congestive heart failure D. Is a type of sleep disordered breathing resulting from instability of the respiratory control system 14, An exudative pleural effusion may be characterized by Elevated pleural fluid protein levels, Alow fluid pH ‘Abigh RBC count AandB eoe> 15. A 60 year old with COPD is admitted with a PaO2 of 40 while breathing at room air, weight gain, shortness of breath and a 4+ pedal edema, The mast likely cause of the edema is: A. Left ventricular failure 8. Low albumin due to malnutrition C._ Right ventricular failure due to hypoxic pulmonary hypertension D. Increased permeability edema 16, Total lung capacity (TLC) is determined by Strength of the inspiratory muscle Recoil pressure of the respiratory system at TLC Recoil of the chest wall at TLC AandB coe, 17. Which is the most desirable blood pressure (taken as average of 2 consecutive measurement at ‘one point in time)? A, 180/110 mmHg B. 140/80 mmbg 130/90 mmHg D. 120/80 mmHg 18. DG is a 55-year-old male with a sitting office blood pressure reading of 139/70 mmHg and 136/72 mmbg 10 minutes after the first reading. His medical history is unremarkable. The physician asked DG to return in 2 weeks for repeat blood pressure measurements. The repeat sitting blood Page 4 of 15Pressures are 138/68mmHg and 134/71mmHg, Which of the following classifies DG's blood pressure per guidelines? ‘A. Optimal blood pressure B. Stage 2 hypertension C. Pre-hypertension D. Stage 1 hypertension 19. A 35 year old obese looking man presents to the OPD, He complaints of blurred vision, and dizziness. His vitals are as follows. BP 175/100, HR 112, RR 16, Temp 37.5 degree celcius. You diagnose him of having hypertension, What would be your management? Diet control with moderate exercise Diuretic, beta blocker Beta blocker only AandB poe, 20, Tachycardia is characterized by heart rate 290 beats /min <60 beats /min >100 beats /min More than equal to 100 beats /min pae> 21, First line of treatment in acute myocardial infarction is ‘A. Heparin, morphine, nitrate, panado! 8. Morphine, aspirin, nitrates, oxygen €. Streptokinase, morphine, aspirin, oxygen D. Amoxicillin, paracetamol, oxygen, ECG 22, What is the normal PR interval in a normal ECG 120-200 milliseconds Less than 120 milliseconds 110-115 milliseconds More than 200 milliseconds poep 23. Which of the following is Not a risk factor for congestive heart failure Coronary heart disease Hypertension Congenital heart defects Nephritic syndrome oO w@> 24, Heart failure can be treated by A. Diuretic 8. Cephalosporin Page 5 of 15C. Methotrexate D. Exercise 25, Which of the following statements regarding arrhythmias are correct? ‘A. First degree heart block gives rise to an abnormally long PR interval B. Third degree heart block is indicated by an abnormally long QRS complex following P wave C. An ECG with a sawtooth pattern on the baseline indicates atrial fibrillation D. In second degree heart block some P waves are not followed by a QRS complex ‘The following questions (26 and 27) are in relation to the ECG below: 26. What is the duration of the PR interval? 120 milliseconds 250 milliseconds < 300 milliseconds > 300 millseconds poe> 27. What condition is represented by the ECG strip above? First degree heart block WPW syndrome Mobtiz type | Complete heart block soeP 28, What does the ECG below indicate A. Morbitz type | block B. Morbitz type 2 block Page 6 of 15. Complete heart block D. Acute myocardial infarction 29. A 63 year old woman presented with history of chest pain for 10 hours and profuse sweating. ECG changes showed ST elevation in leads V1-V6 and aVL with reciprocal changes of ST depression in the inferior leads. What is the most likely diagnosis? A. Acute anterior myocardial infarction B. Acute lateral wall MI €. Acute posterior wall Mi D. Septal MI 30. A 45 year old mine worker presents to your clinic, He complains of palpitations and dizziness. You order an ECG and the findings are as follows: wide QRS complex more than 120 ms. Secondary R waves in lead V1, slurred waves in lateral leads and T wave changes in septal leads. HR 57/min A basic representation of the EC6 is given above. What is the most likely diagnosis? A. LBBB B. RBBB C._RBBB, acute inferior Ml and sinus bradycardia D. Sinus bradycardia 31. ASS year old man presents with asymptomatic first degree AV block with PR interval of 225, milliseconds. What would be your line of treatment? ‘A. Refer for pace-maker B. Start on beta blockers €. Notreatment at the moment but call for regular reviews D. Immediate surgery 32. A 62 year old male presents to emergency department with complaints of profuse sweating, retro-sternal chest pain radiating to his jaw and between the scapular. His ECG shows no changes in ST segment and his cardiac enzymes are within normal ranges. What would be your most likely diagnosis? A. Acute gastritis B. Unstable angina c. STEMI D._NSTEMI 33, A 19-year-old college student presents to your office for evaluation of episodes of chest pain and shortness of breath. She has no medical problems. She does not smoke, drink alcohol, or use illicit drugs. She is on the dean’s list and is studying electrical engineering. On auscultation of her heart, you hear a mid-systolic click at the apex. What is her most likely diagnosis? ‘A. Bicuspid Aortic valve B. Pulmonary hypertension C. Mitral valve prolapsed D. Mitral stenosis Page 7 of 1534, 38-year-old file clerk presents to your office for evaluation of fatigue. She has a 20-pack-a year history of smoking and had rheumatic heart fever in childhood. On auscultation of her heart, the S2, sound is widely split; that is, it persists throughout the respiratory cycle. What is the most likely cause of the widely split $2? A. Physiological cause B. Pulmonary stenosis, €. Atrial septal defect, D. Left bundle branch block 35. A S2-year-old computer analyst presents to the office for a checkup. He is doing well except that, he has noticed increasing shortness of breath with physical exertion, so he has cut down on his recreational activities. On auscultation of the heart, you hear a blowing, medium-pitched pansystolic murmur at the apex. It radiates to the left axilla and does not change with inspiration. ‘This murmur is most likely: A. Mitral regurgitation B. Tricuspid regurgitation C. Ventricular septal defect D. Aortic stenosis 36. Which of the following is NOT true regarding dengue fever? ‘A. Is spread by vector Aedes Aegypti B, Has an incubation period of 2-3 weeks C. Is caused by a flavivirus D. Characteristically causes severe myalgias, 37. A.35 year old woman presented shocked with one week history of sore throat and fever. Her blood pressure was 80 mmHg systolic, temperature of 39.5 degree celcius, and pulse of 130/min. she was mildly jaundiced and had macular erythematous rash that blanched on pressure. She was oliguric and had biochemical evidence of renal failure. Her creatine kinase was twice the upper timit of normal. The differential dose would include all EXCEPT: A. Leptospirosis B. Toxic shock syndrome C. Myocardial infarction D. Dengue fever 38, Vivax Malaria ‘A. May be complicated by anemia 8. Maybe complicated by jaundice C. Is sensitive to chloroquine D. Allofthe above 39. Which of the following regarding Leptospirosis is FALSE ‘A. Usually causes a self limiting disease B. Causes jaundice Page 8 of 1540, 1. 42. 43, 4s. 46, C. Causes meningitis D. Is caused by Gram positive bacili The sexual cycle of Plasmodium is completed in ‘A. The gut of the mosquito B, RBC C. Liver tissue D. The salivary gland of the mosquito The most common of the human infecting malarial par A. Plasmodium ovale B. Plasmodium vivax Plasmodium falciparum D. Plasmodium malariae ‘What are the signs and symptoms of leptospirosis? A. Flu like symptoms with nausea, vomiting, conjunctivitis and pharyngitis, calf tenderness 8, Jaundice and palor Rashes and diarrhea, calf tenderness D. None of the above Which form of leptospirosis is known as Weil's disease? A. icteric 8. Anicteric . Both D. None of the above Concerning HIV infection in pregnancy, which of the following statement is correct: ‘A. Pregnancy approximately doubles the rate of progression to AIDS B. The rate of vertical transmission of HIV is greater than 50% C. Perinatal administration of zidovudine to the mother reduces vertical transmission and breast feeding increases vertical transmission D. Transmission of HIV to the neonate is confirmed if the neonate is HIV antibody positive Which of the following is not a recognized feature of infective endocarditis? ‘A. Erythema marginatum B. Roth spots and osler’s nodes C. Splenomegaly D. Proteinuria Which of the following is not a risk factor for developing rheumatic fever? ‘A. Exposure to streptococcus Group A B. Recurrent sore throat ._ Streptococcus induced glomerulonephritis. D. Congenital heart disease Page 9 of 1547, Rice water stool is seen in A. Travelers diarrhea 8. Cholera i C. Typhoid D. Gastroenteritis 48, ASO year old man Is diagnosed to have a community acquired MRSA (CA-MRSA) infection. Which of the following clinical feature is consistent with such a diagnosis? A. Positive culture for MRSA after 48 hours hospitalization | 8. The patient presents in out-patient setting C. The patient has an indwelling catheter D. The patient tested negative for MRSA infection within the last one year 49, Tuberculosis is an example of A. Pandemic 8. Prodemic C. Endemic D. Epidemic 50. Vancomycin is A. Aninfectious ase B. Avirus C. Anantibiotic D. Anantiviral Page 10 of 15SECTION B © SHORT ANSWER QUESTIONS (10 Marks Each) TOTAL 50 MARKS 51. Briefly write the differences between asthma and COPD 52. Enumerate the major and minor criteria (modified Jone’s criteria) for diagnosis of rheumatic heart disease 53. Write the classification of hypertension and give an example of each of the following class of drug (ACEI, diuretic, Beta blocker, calcium channel blocker) 54, Write the sequence of events that leads to myocardial infarction 55, Draw, label and write the normal time intervals for a NORMAL ECG SECTION C — LONG ANSWER QUESTIONS (TOTAL: 100 marks): ANSWER ALL QUESTIONS. 56. Define and classify heart Failure. Discuss the clinical assessment of heart failure with investigations and management of congestive heart failure. (15 MARKS) 57. Describe in detail the causes, clinical features and management of Pneumonia (15 MARKS) 58, Elaborate of clinical features, complications, investigations and management of Maiaria. (15 MARKS) 59. CASE A A 40 year old Indian male presented to the emergency department of Lautoka Hospital. He complained of chest pain and palpitations. He also informed that he has been feeling dizzy recently. He is a smoker (10 cigarettes per day). He consumes alcohol occasionally. He is married and has 3 children, He lives in a farming settlement and works at a local supermarket as a security guard. He also complained of fatigue, shortness of breath and exercise intolerance. He does not have any co-morbidities. ‘The vitals recorded were as follows: BP 90/60 mmHg RR increased. HR ~ bradycardiac RBS—normal A blood sample was sent for cardiac markers which came negative and all markers were within normal range. His FBC and UECr was unremarkable. His ECG was taken is given below. |. What is your preliminary diagnosis? (4 Marks) Nl, Justify your diagnosis with ECG finding to support it. (10 Marks) I, How would you manage this case? (6 marks) Page 11 of 15T1071 a8ed vase) 10} 99360. Case B ‘A 66-year-old male complaining of chest pain is brought to the emergency room by ambulance. The pain began six hours ago and has become more severe over the past hour prompting him to call emergency services. He describes the pain as retro-sternal, pressure-like, and non-radiating. He endorses some mild dyspnea and nausea accompanying the pain. He has also noted intermittent palpitations since last evening. He has a past medical history of hypertension (not currently under treatment) and tobacco use of ‘one pack per day of cigarettes for the past 47 years. Vital signs on arrival to the emergency room show a blood pressure of 160/100 mmHg, a heart rate of $2 beats per minute, and a respiratory rate of 18 per minute. His physical exam is unremarkable, He reports no allergies and no medication use. Question A: You initially suspect this patient is suffering an acute coronary syndrome. Which of the following symptoms would NOT typically be consistent with this diagnosis? (5) A. pressure-like chest pain 8. Palpitations . Dyspnea D. Nausea Question B: What is the most likely diagnosis and what ECG evidence is there to support your answer (10}. Page 13 of 15S140 pT 98ed @ FSW) 40} 99361. Write the signs and symptoms of leptospirosis and differentiate between the icteric and anicteric phases of this disease. Also mention the treatment of leptospirosis with dosages. (10) 62. Write down ONE generic name for the class of me Corticosteroid — prednisone _ (10 marks) - % mark each ine mentioned below: Example 1. Penicil 2. Cephatosporin: 3. Macrolide: 4, Fluroquinolones: 5. Sulfonamides: 6. Aminoglycosides: 7. Loop Diuretic: 8 ACE inhibitors 9. Anglotensin Il eceptor Blockers: 10. Thiazide diuretics: 11, Calcium Channel blockers: 12. Beta Blockers: 13. Sulfonylureas: 14. Biguanid 15. NSAID: 16. Antipyretic: 17. Short acting beta Agonist: 18. Long acting beta Agonis 19. Benzodiazepines: 20. Xanthines: Page 15 of 15= 3 & 2 . 7 z 7 5 < MULTIPLE CHOICE ANSWER SHEET 6 The Uni UMANAND PRASAD SCHOOL OF MEDICINE & HEALTH SCIENCES INTERNAL MEDICINE (IMED301) ~ SUPPLEMENTARY EXAM - 2018 NAME: 26 7 28 29 30 31 32 36 7 38 39 a1 42 47 48 49 50 10 Fry 2 4 15 16 v7 18 19 20 21 2 2B 24 25