MEQ 1

Part 1
30 y/o mother of 2 comes in for follow-up of hypertension. Started amlodipine 5mg OD. She is a
housewife, seldom goes out, does not like to meet people. Husband works as a construction
worker. Had history of fracture in right arm. Noted bruises at left arm, patient explained that she
bumped it somewhere and refused to comment further on it.
i. 2 Differential Diagnosis and 4 history you want to ask.
ii. Investigations and reasons (2m)
Investigations came back, no abnormal results
iii. What is your diagnosis? What is your reason?
iv. How would you manage her.
Part 2
One month later she came to ED with a right arm fracture. Noted multiple bruises of different
stages at her back and arms
i. 4 further history to illicit from her?
ii. What would be your next action?
iii. 3 things to ask regarding husband.
Part 3
Husband drinks and the family has some financial problem. On building rapport, admits that
patient is being abused. Husband recently starting beating children as well.
i. What can you do for her? (4m)
ii. How do you manage her at this point?
iii. If she refuses to lodge a police report, what is your obligation? (1m)
Part 4
Found to be a victim of domestic violence. 2 months later she came back with difficulty sleeping
and having bad dreams. Also had decreased libido, feels sad, and could not perform daily
activities like she used to. Reads every part of newspaper except parts regarding domestic
abuse.
i. What is your diagnosis?
ii. Name 3 other medical complications apart from mental illness that she may develop
iii. Outline management of this patient (6m)
iv. What psychiatric co-morbidities will aggravate this condition? (3m)
Part 5
She was diagnosed with PTSD and treated. She is living in a shelter home. Lately she has been
staring at the ceiling, talks less, does not eat. She has difficulty sleeping at night. She defaulted
medical follow up, and attempts suicide by taking excess doses of lorazepam and fluoxetine that
was prescribed. This is her second attempt at suicide
i. What are the risk factors of this patient that will predict another suicide attempt? (4m)
ii. How would you manage? (4m)

MEQ 2
Part 1
A 65 year old diabetic lady for 10 years on glicazide and metformin presents with loose stools x
10 times for 3 days. History of visiting Indonesia returned 5 days ago. No blood or mucus in
the stools. Glucose levels are measured at 14 mmol/L.
i. What are your differentials (Name 2).
ii. What investigations & expected findings (Name 3, I think)
iii. What 2 immediate management would you give at this point?
Part 2
Turns out loose stools & constipation has been happening for a year now. Worse at night.
i. What are your differentials? (Name 3)
ii. Investigations.
iii. How would you manage this patient?

Part 3
Shes planned for an operation and given insulin the night before. Next morning her glucose
level is 2.6mmol/L but she feels fine.
i. What is the term used for this condition? Why?
ii. Explain the pathogenesis of her condition.
iii. Name 2 clinical tests to confirm your diagnosis.
iv. Name 2 other signs of this conditions
v. What 2 other complications that the patient may have from this condition.
Part 4
Diagnosed to have autonomic neuropathy. Given blood results that show renal failure?
Hyperkalaemia?
i. How would you manage this patient
Part 5
Patient refuses haemodialysis, despite being adequately counselled on risks and complications
(including mortality).
i. How would you now manage this patient?

MEQ 3
Part 1
20 year old man was one of a few people that was brought to the ED after the bus he was in
crashed into a ravine. Primary survey was done. At the ED, triage was done and he was send to
the Red Zone.
i. Based on the above scenario, what is the definition of triage?
ii. What is the purpose of primary survey
iii. Outline the steps you would take to perform a primary survey (5m)
After that secondary survey was done.
iv. What is the purpose of secondary survey?
Part 2
He has shortness of breath, tenderness especially over left side of chest and left upper
abdomen. His abdomen is tense. He does not have any evidence of haemo- or pneumothorax
on CXR. There is no blood at the meatus.
i. Outline your management
ii. In view of his unstable haemodynamic status, what is the best imaging modality to detect
injuries? Justify.
iii. What are the findings in your chosen imaging modality?
Part 3
Patient is now stable. Catherisation is easy but there is blood in the urine.
i. Explain why there is blood in the urine.
ii. What is the imaging modality and what are your expected findings? (6m)
Part 4
CT shows splenic injury, massive hemoperitoneum, lung contusion. Kidneys are normal.
i. Explain the pathophysiology of lung contusion
ii. Outline the principles of management for lung contusion (2m)
ABG results shows pH 7.26, pCO2 30mmHg HCO3 18, pO2 60mmHg.
iii. Given ABG - interpret the results (metabolic acidosis in picture)
Part 5
Underwent splenectomy.
i) 3 early post-operative pulmonary complications and preventive/therapeutic measures.
ii)
a. Serious infective complication and group of causative agent.
b. What early and late interventions to prevent this complication.
iii) Post-op, what component of blood will change and its implications.

MEQ 4
Part 1
2 year old boy, high fever for 6 days. Generalised maculopapular rash. Eyes red but no
discharge. Lips red, dry and cracked. Injected throat. Cervical lymph nodes enlarged. Dengue
IgM negative.
i. 3 differentials and 2 clinical signs for each. (3m)
ii. 3 investigations you would do and expected findings. (3m)
Part 2
Patient develops swelling and redness of his legs and hands. Laboratory findings showed raised
TWC (85% neutrophil predominant), Dengue IgM negative, Monospot negative, measles
antibody negative.
i. Interpret findings. (2m)
ii. Diagnosis and supporting reasons. (5m)
Part 3
Diagnosed as having Kawasaki disease based on fever, polymorphic exanthem,
mucocutaneous involvement, cervical lymphadenopathy and peripheral involvement.
i. 4 other clinical signs of Kawasakis disease.
ii. Pathophysiology of Kawasakis disease.
iii. What is 1 important imaging to perform and the expected finding.

Part 4
Patient had coronary artery dilatation and aneurysm.
i. Name 2 drugs used to treat Kawasaki disease and how they work. (2m)
ii. Name 2 other cardiac complications. (2m)
Part 5
Treated with IV IgG. Echo showed dilated coronary vessel.
i. Parents refused to give consent for IVIG. What are the ethical issues involved and how
would you manage the situation.
ii. Long-term management plan. (4m)
iii. Parents want to have another child but is worried that the same may occur. What do you
tell them. (3m)

MEQ 5
Part 1
40 year old G3P2 at 8 weeks complained of morning sickness and PV bleeding for 3 days. First
child was delivered by caesarean section and she had post-partum haemorrhage after the birth
of the second child.
On examination, uterus was 8 weeks size, os was closed and there was stale blood in the
vagina. There is mild tenderness over the abdomen, but examination of pouch of douglas and
adnexa are normal.
i. 4 history you would ask
ii. What is the provisional diagnosis
iii. 4 investigations you would do and reasons why
iv. How would you manage her current presentation
Part 2
She was diagnosed with threatened miscarriage. Had history of caesarean section for first
pregnancy and PPH for second pregnancy. Presented at 37 weeks, leaking liquor, CTG showed
late deceleration. Current baby is in breech presentation. Fetal parts not engaged. Fetal heart
rate is between 100-180bpm. Amniotic fluid is measured at 1.2cm.
i. 3 causes for the fetal distress
ii. How would you manage her at this point?
iii. What actions would you take during the perioperative period to reduce maternal
morbidity?
Part 3
Diagnosed with cord prolapse. She went in for caesarean section. She has uterine atony and
bleeds about 2.4 litres of blood.
1) What are her 4 risk factors for PPH.
2) 4 measures to manage uterine atony and conserve the uterus.
3) How would you manage her.
4) How do you take her consent for hysterectomy.
Part 4
Patients agrees to the hysterectomy. Later, she comes in with inability to control her bladder and
urinary incontinence.
1) 4 differential diagnoses
2) 4 investigations to diagnose each
3) What is her most likely diagnosis? Explain how did this occur in her.
Part 5
Diagnosed with vesicovaginal fistula.
During the follow-up, noted that she had poor sleep, fatigue, low mood, low libido, reduced
concentration. She has been taking sleeping tablets once nightly. Her GP does some
investigations. Her FSH is in the pre-menopausal stage.
i. What is the most likely diagnosis? Explain why.
ii. How do you evaluate the severity of her disease.

iii. How do you manage her?

MEQ 6
Part 1
60 year old female presented with cough with expectorant, she complains of malaise, sternal
pain. Went to a general practitioner and was given antibiotics and treated as having an upper
respiratory tract infection. However, malaise and sternal pain was still there. Chest radiograph
done showed normal lung fields.
Hb 10g/dL
WBC 4 x10^9/L
Plt 200 x 10^9/L
K+ 5.9mmol/L
Urea 25 mmol/L
Creatinine 450 umol/L
Corrected calcium 3+ (raised)
i. What is your diagnosis?
ii. Interpret the findings
iii. List 4 investigations and expected findings
iv. How would you manage her initially
Part 2
Patient is diagnosed as multiple myeloma. Came in for followup.
Hb 6 g/dL
WBC 3 x 10^9/L
Plt 20 x 10^9/L
Reticulocyte 0.5%
i. Interpret the results and explain the reasons why. (2m)
ii. Explain the pathophsyiology of the haematological findings
iii. How would you manage her condition
Part 3
Pt comes in complaining of left chest pain from mid axillary to anterior and left hip pain. There
is paradoxical chest movement over the left side, and crepitations felt over the left chest wall.
There are Emergency chest, abdominal & pelvic x-ray are ordered.
i. What are your expected findings on chest radiography (3m)
ii. Name 1 investigation you would do and the expected finding.
iii. What is the lung complication that could arise from this condition.
Suddenly there was hyperinflation was noted on the left chest and drop in blood pressure.
iv. Name your immediate management for this condition
Part 4
Patient is unable to move her leg, and was unable to sit or stand up.
i. What is your most likely diagnosis?
ii. 3 physical signs you would find in this patient
iii. Name 2 findings you expect to see on radiography of the pelvis.
iv. Investigation for her condition
v. How would you manage her condition
Part 5

Patient was diagnosed with neck of femur fracture and a total hip replacement was done. Came
in again for mid thorax pain radiating to the anterior chest. Numbness below nipple line,
weakness over both lower limbs. Acute urinary retention.
i. What is the possible diagnosis?
ii. 3 other physical signs you would find on neurological examination of the lower limbs?
iii. 2 findings on PR examination
iv. 2 radiographic investigations and the expected findings
v. Name 1 surgical procedure you would do for the patient.