MEQ 1

TRIGGER 1

A 24 years old Chinese female came to you complaining of easy fatigability and drooping of the eyelid especially in the evening. There is no fever and the patient work as a tailor

1) List 5 further questions you would like to ask the patient2) List 5 physical signs you would like to look for

TRIGGER 2

24 years old Chinese female – easy fatigability and drooping of the eyelid especially in the evening. Physical examination reveals she had bilateral ptosis and diploplia. There are weakness over both upper and lower limb with MRC grading of 3/5 but the reflexes, sensations and coordination were intact. Other physical examination is unremarkable.

1) Explain the grading used in MRC2) List 5 investigations you would like to order

TRIGGER 3

24 years old Chinese female – easy fatigability and drooping of the eyelid especially in the evening. Physical examination reveals she had bilateral ptosis and diploplia. There are weakness over both upper and lower limbs with MRC grading of 3/5

Investigations results are as follows

i) Tensilon test – positiveii) Plasma thyroxine – normaliii) Serum acetylcholine receptor antibodies – positiveiv) Anti-striated muscle antibody – positivev) CT of chest – reveals widened mediastinum vi) ANA and rheumatoid factor – negative

1) What is Tensilon test?2) What is your provisional diagnosis3) What does the CT scan findings consistent with4) Plan your management

MEQ 5

TRIGGER 1

A 58 years old Malay female complains of bilateral lower limb swelling for the past 4 days. She was a known case of Diabetes Mellitus type 2 which was diagnosed 2 years ago and on oral metformin and sulfonylureas. She also has been inactive since 1 year ago following the fracture of right femur due to motor vehicle accident.

1. List 5 further questions you would like to ask the patient2. What is the mode of action of metformin and sulfonylureas?3. List 5 physical signs you would like to look for

TRIGGER 2

Further questioning reveals that the patient was oliguria associated with pruritus and drowsiness. Physical examinationsWeight – 98kgHeight – 160 cm

Other findingsObese patient with facial puffiness, ascites and bilateral lower limbs pitting oedema up to the level of knee. Conjunctiva was pale. Bilateral basal crepitations with cardiomegaly can be found upon examining the chest. Homan‘s test and Moses test was negative

1. List 5 investigations you would like to order2. State 3 substances that may leads to pruritus

TRIGGER 3

Investigations results are as follows

FBC – Hb; 9.2 g/dL, WCC; 5x109

BUSE – Na – 135, K – 3.2, Mg – 0.2, Se Creatinine – 250 µmol/LRandom blood glucose – 11.2 mmol/L, HbA1c – 9.0 %ECG – normalCXR – Mild bilateral pleural effusion with cardiomegalyDoppler ultrasound of bilateral lower limbs – normal

1. State the Cockroft-Gault formula and calculate for this patient2. What is your diagnosis

Explain the treatment plan (discuss on principles of haemodialysis)

TRIGGER 1

A 16 years old Chinese female was admitted with history of heavy menstrual flow since 2 years ago. She came with complaint of lethargy and palpitation for 2 days duration

1) List 5 further questions you would like to ask the patient and justify2) List 5 physical signs you would like to elicit from the patient and reasons

TRIGGER 2

Further questioning reveals that she had regular menstrual cycle and no history of easily bleeding such as unexplained bruising and epistaxis. No history of dysmenorrhoea. Physical examinations reveal that the patient was lethargic-looking, pallor and pulse rate was 130 beats per minute. Per abdomen examination was unremarkable

1) List 5 investigations you would like to order and why

TRIGGER 3

FBC – Hb - 7.0 g/dL, WCC – 8.0 x 109/L, Platelet – 200GSH – O positiveBUSE/Cr – Normal findingsLFT – No findingsUPT –veThyroid function test - NormalUltrasound of uterus – Normal findingsCXR – No cardiac enlargementECG – No findings

She was planned for blood transfusion

1) What is your provisional diagnosis2) Outline your plan of your management3) Based on the FBC results, how much blood you would like to transfuse to the patient4) State 4 complications of blood transfusion

3.