20005/03/09 PMH

Station 1:
CVS: This 50 y.o. man presents with SOB.
This gentleman has rheumatoid hands with bilateral ulnar deviation at
MCPJ.
There is collapsing pulse and Corrigan sign. The apex is displaced and
thrusting. There is a loud EDM at LSB. Auscultation revealed bil basal
crepitation and there is ankle edema.
My diagnosis is AR and clinically the patient is in heart failure. The
likely cause is rheumatoid arthritis.
I think I should say it may be related to RA but more common cause of
lone
AR is degeneration or CRHD. But the examiner did not challenge for
that and
he asked me what will be the investigation and treatment in this
patient.
The final question is what is the difference of cardiac cauterization
and
TEE in assessment of valvular heart disease.

Neurology:

This 45 yo lady has progressive weakness. Please examine
lower
limbs.
There is generalized wasting of both legs without fasciculation. The
tone is normal but there is bilateral clonus. There is slightly muscular
weakness bilaterally with power of 5-/5. Bilateral heel shin test is impairment.
There is hyperreflexia and bil plantars extensor. Then the examiner ask
before you would like to perform sensation test, what else will you do.
I said I would like to see the gait. The examiner said ok. The patient
had ataxic wide base gait. The examiner asked me what are the positive
findings. I said spastic paraparesis and cerebellar signs. Then he asked me to
perform light touch test only and it seemed to be normal. The examiner said
there
was no other sensory abnormality and there were bil UML sign and
cerebellar
signs so far, what else I would like to exam. I said I would like to do
a
full neurological examination especially looked for cerebellar sign in
ULs
and nystagmus, INO and OA. He asked me what were the DDx, I told him
the DDx
of spastic paraparesis and he ask me the Ix.
After the examination another candidate told me that was a case of
spinal
cerebellar degeneration. I think it is probably a case of Friedereich
ataxia. The lady had some dysmorphic feathure, but there was not
kyphoscoliosis or bil pes cavus.
I think I will not get a high mark from this case.

Station 2: History
33/F lady in her first pregnancy is referred for abnormal TFT with
slightly
depressed TSH and slightly elevated T4.

She was a primary school teacher and got married at 23 yo. She failed
to get
pregnant since her marrige and had tried oval stimulation pills for 3
yrs.
She had some mild palpitation since 8 weeks of preg and her TFT showed
abnormal and she was put on antithyoid drugs. She didnot take the pills
at
all because she very worried about if there would be any adverse effect
on
her baby. Her job was quit stressful. There was not other symptoms
suggestive a frank thyroitoxicosis and there is not vison problem or
neck
mass.

I discussed this cases with a endocrinologist in our department after
the
exam. This should be a case to discuses about gestational thyroiditis
and
genuine Grave's disease. The former is no need to treat  but the later
should be treated. In this case it seems to the the former. I think I
was on
the right tract for my approach towards this case during the
examination.

Station 3:

Respiratory

This 50 yo gentleman presented with progressive SOB.
clubbing fingers + bilbasal end inspiratory fine crep-> fibrosising
alveolitis
Questions: possible casues, investigations, treatment

ABD: This 50 yo something lady present with chronic abd dissomfort.
bil polycytic kidneys disease with mildly pigmented skin
I didnot notice there were bil faint scars over the posterior flanks.
The
examiner asked me whether I was sure there was not scar. I said not
sure and
he asked me to see again- God, I think I failed it badly. The the
question
was what was the scars for-- I said cystectomy to debulk the polycyctic
kidney.

Station 4:
You are the medical officer working in ICU looking after Ms Lee's
father.
Mr Lee has MGN on azathioprine  and during FU 3/52 ago he was put on
allopurinol. Now complicated with severe neutropenia and pneumonia and
was
intubated in ICU.

Station 5:
Endocrine: Cushing Syn- I was very confident since I had exam it many
times
in front of you. Thank you.

Skin: systemic sclerosis
many question about complication of the disease

Joint: psoriatic arthritis

Eye: bil OA