DEPARTMENT OF GENERAL MEDICINE
8th SEMESTER I - INTERNAL ASSESSMENT EXAMINATION JULY – 2023
Date: 07.07.2023
Time: 10 am to 1 pm Max Marks: 100
Note: Answer all questions. There are 5 questions surrounding a clinical vignette borrowed from the e log books (case based online learning portfolios) of each student shared in the links below, each with a long essay question of 10 marks, short essay question of 5 and MCQ of 5 marks. Thousands of online learning portfolios of our students along with the deidentified case report data can be accessed from our dashboard here: http://medicinedepartment.Q1 Clinical Vignette :
A 45-year-old male farmer from Suryapet presents to the hospital with a chief complaint of gradually progressing joint pain involving the right knee, ankle, shoulder, elbow, wrist, and MIP joints. The pain is nonradiating and dull in nature. The patient reports a history of being asymptomatic four years ago, after which he developed joint pain that involved different joints sequentially. The patient did not experience involvement of the proximal and distal interphalangeal joints, nor the back or neck.
The patient exhibits clubbing and deformities in the fingers and knees. Additionally, he has experienced increased frequency of micturition for the past 3-4 months.
Long answer question (10 marks)
Based on the provided history, analyze the possible underlying condition, specifically related to his arthritis, and discuss the appropriate management.
Short Answer Question (SAQ - 5 marks):
Describe the clinical presentation, risk factors, and potential complications associated with rheumatoid arthritis
MCQ (NEET PG Level - 5 marks):
Based on the provided history, which of the following processes or mechanisms is most unlikely to contribute to the joint pathology in this case?
A) Synovial membrane hypertrophy and increased vascularity
B) Proliferation of osteoclasts and bone resorption
C) Upregulation of pro-inflammatory cytokines and chemokines
D) Dysregulation of T-cell-mediated immune responses
E) Deficiency in collagen synthesis and extracellular matrix remodelling
Q2 Clinical Vignette:
A 42-year-old male patient with a long history of smoking presented to the casualty with worsening dyspnea, orthopnea, and bendopnea. On examination, decreased breath sounds and prolonged expiration were noted. The patient's chest X-ray revealed hyperinflation and flattened diaphragms. Additionally, the patient complained of bilateral pedal edema (pitting type) and shortness of breath over the last two days. The patient initially noticed swelling in both legs, extending up to the shin of the tibia, and subsequently developed an ulcer on his left malleoli. He now presents with low-grade intermittent fever and generalized weakness. On examination, the patient's vital signs are within normal limits. Notably, the patient has anteroposterior and transverse chest diameters measuring 23 cm, with a prominent central pulse.
Long Answer Question (10 marks):
Discuss the management and treatment strategies for a 42-year-old male patient with chronic obstructive pulmonary disease (COPD) who presents with worsening dyspnea, orthopnea, bendopnea, bilateral pedal edema (pitting type), shortness of breath, low-grade intermittent fever, generalized weakness, and a chest X-ray revealing hyperinflation and flattened diaphragms. Provide a comprehensive approach that includes both pharmacological and non-pharmacological interventions, as well as considerations for comorbidities and patient education.
Multiple Choice Question (5 marks) :
A 42 -year-old patient with a long history of smoking presents with worsening dyspnea, orthopnea, and bendopnea. On examination, decreased breath sounds and prolonged expiration are noted. The patient's chest X-ray reveals hyperinflation and flattened diaphragms. Which of the following is the most likely underlying chronic condition contributing to these findings?
a) Restrictive lung disease
b) Pulmonary hypertension
c) Interstitial lung disease
d) Small airway disease
Answer:
d) Small airway disease
Explanation: The patient's history of smoking, along with the symptoms of worsening dyspnea, orthopnea (shortness of breath when lying flat), and bendopnea (shortness of breath when bending forward), suggest a chronic obstructive pulmonary disease (COPD), which is commonly caused by small airway disease.
The decreased breath sounds and prolonged expiration on examination indicate airflow limitation. Hyperinflation and flattened diaphragms seen on chest X-ray are characteristic findings in COPD. Hyperinflation occurs due to air trapping within the lungs, while flattened diaphragms result from the increased work of breathing associated with COPD.
Short Answer Question (5 marks):
Discuss the pathophysiological mechanisms involved in small airway disease and its impact on lung function in patients with chronic obstructive pulmonary disease (COPD). How does this contribute to the development of symptoms such as dyspnea, orthopnea, and bendopnea?
Playful version of Q 2: Statutory Warning : Traditional teachers ,students and even general public may find the playful content below offensive but it's shared below to demonstrate the future possibilities around large language models content although currently a lot more expert tweaking and guidance is needed. Currently they contain no marks.
A 42-year-old man, with legs like balloons,
Came to the doc, in search of some tunes.
His feet were swollen, oh, what a sight,
And he struggled to breathe, day and night.
For 15 days, his legs were quite full,
Pitting edema, like marshmallows in a bull.
Then came an ulcer, causing him grief,
Making the swelling worse, beyond belief.
Fever and weakness, they joined the show,
Leaving him feeling as slow as a crow.
No tummy pain or loose stools in sight,
No cough or chest pain causing a fright.
But this man's chest, oh, what a size,
Like a barrel, you couldn't believe your eyes.
With diameters equal, at 23 cm,
A clue for a condition, that's not just a gem.
Now, can you guess, this puzzle so sly,
The chronic condition, making this guy sigh?
Look for the signs, use your wit,
And solve the riddle, you clever little twit!
MCQ: Besides smoking, which lifestyle habit of this chap,
Is a known risk factor, giving his health a slap?
a) Couch potato, glued to the TV,
b) Eating junk food, unhealthy as can be,
c) A love for adventure, adrenaline in his veins,
d) Chugging energy drinks, driving him insane.
The lifestyle habit of this chap that is a known risk factor, besides smoking, is b) Eating junk food, unhealthy as can be.
Explanation: While smoking is a well-established risk factor for various health conditions, including COPD, other lifestyle habits can also contribute to poor health. In this case, the habit of eating junk food is highlighted as a risk factor.
Consuming a diet high in junk food, which is typically high in calories, unhealthy fats, added sugars, and low in nutritional value, can lead to weight gain, obesity, and various health problems. Obesity is associated with an increased risk of developing chronic diseases such as heart disease, diabetes, certain cancers, and respiratory conditions like COPD.
While options a), c), and d) (being a couch potato, having a love for adventure, and chugging energy drinks) can have their own implications for health, they are not specifically highlighted as known risk factors for the health condition mentioned in the question.
In the realm of respiratory, a mystery unfolds,
A condition causing breathlessness, as the story goes.
Worsening dyspnea, a burden to bear,
Which chronic condition might be lurking there?
a) The dragon's breath, a fire within,
b) The wheeze wizard, a dance to begin,
c) The airway rebel, causing lungs to constrict,
d) The chest conundrum, a puzzle that's picked.
Answer:
c) The airway rebel, causing lungs to constrict.
c) The airway rebel, causing lungs to constrict, is a figurative description of the characteristic airway constriction and narrowing that occurs in COPD. This narrowing of the airways, along with inflammation and mucus production, results in the symptoms of breathlessness and chronic dyspnea experienced by the patient.
Q3:
Clinical Vignette (LAQ - 10 marks):
A patient presents to the emergency department with a history of binge drinking and subsequent missed insulin dose. The patient complains of continuous vomiting and an inability to tolerate any oral intake, including water. On examination, the patient appears dehydrated and is breathing heavily. Fruity breath odor is noted. Laboratory investigations reveal hyperglycemia, ketonemia, and metabolic acidosis.
https://riddhibhalla25.
Describe the clinical presentation, risk factors, and potential complications associated with Hyperosmolar hyperglycemic state. What investigations would you consider to confirm the diagnosis? Discuss the treatment strategies for such patients.
MCQ (NEET PG Level - 5 marks):
A patient with a history of diabetes presents with continuous vomiting, dehydration, fruity breath odor, and missed insulin doses following a binge drinking episode. Laboratory investigations show hyperglycemia, ketonemia, and metabolic acidosis. Which of the following is the most likely diagnosis in this case?
A) Diabetic ketoacidosis
B) Hyperosmolar hyperglycemic state
C) Hypoglycemia
D) Alcoholic ketoacidosis
E) Gastroenteritis
Choose the best option and explain the rationale for your choice.
Here are the explanations for the questions provided (aka answer key):
LAQ (10 marks):
Based on the patient's history of binge drinking, missed insulin dose, continuous vomiting, inability to tolerate oral intake, dehydration, fruity breath odor, laboratory findings of hyperglycemia, ketonemia, and metabolic acidosis, the possible underlying condition is diabetic ketoacidosis (DKA). DKA is a life-threatening complication of diabetes mellitus, characterized by inadequate insulin levels, resulting in the production of ketones and subsequent metabolic acidosis. The patient requires immediate medical intervention, including intravenous fluid resuscitation, insulin administration, electrolyte management, and identification and treatment of any underlying precipitating factors.
SAQ (5 marks):
Complications of HHS may include cerebral edema, acute kidney injury, electrolyte imbalances, and cardiac arrhythmias. Investigations to confirm the diagnosis of HHS include ...
Treatment strategies for HHS involve fluid resuscitation, insulin administration, electrolyte replacement, and management of any underlying precipitating factors.
MCQ (5 marks):
The correct answer is A) Diabetic ketoacidosis. The patient's history of diabetes, binge drinking, missed insulin doses, continuous vomiting, dehydration, fruity breath odor, and laboratory findings of hyperglycemia, ketonemia, and metabolic acidosis are characteristic of diabetic ketoacidosis (DKA). DKA is a severe complication of diabetes mellitus, characterized by inadequate insulin levels leading to the production of ketones, metabolic acidosis, and electrolyte disturbances. The fruity breath odor is due to the presence of acetone, a ketone, in the breath. Prompt recognition and treatment of DKA are essential to prevent life-threatening complications.
Please note that the explanations provided here are general and simplified for the purpose of this response. In clinical practice, a thorough evaluation and consideration of individual patient factors are essential for accurate diagnosis and management.
Q4:
Clinical Vignette:
A 38-year-old male patient presented to the clinic with sudden onset high-grade fever, associated with chills and rigors. The fever is relieved by taking medication and has no aggravating factors. Additionally, the patient complains of pricking type of pain in the right side of the chest for the past 7 days, which worsens during deep inspiration.
On examination, the patient appears mildly tachypneic with decreased breath sounds on the right side of the chest. Auscultation reveals dullness to percussion and decreased tactile fremitus over the right lower lung fields. No murmurs or abnormal heart sounds are detected.
Question 1 (LAQ 10 marks):
Based on the clinical presentation and physical examination findings provided, what is the most likely morphologic or anatomico pathologic diagnosis for this patient (for example is it consolidation, mass lesion, collapse fibrosis etc)?
Describe the possible etiologies associated with this condition.
Question 2 ( SAQ 5 marks):
Which specific findings on the chest X-ray would support the diagnosis mentioned in question 1? Explain how these findings are related to the underlying condition.
MCQ (5 marks):
Which of the following modalities would be least useful to confirm the diagnosis in this patient?
A) Abdominal ultrasound
B) Chest X-ray
C) CT scan of the chest
D) Echocardiography
E) Pulmonary function tests
Answer Key with explanation :
Question 1 (10 marks):
Based on the clinical presentation and physical examination findings provided, what is the most likely morphologic or anatomico pathologic diagnosis for this patient (for example is it consolidation, mass lesion, collapse fibrosis etc)?
Answer:
The most likely
morphologic or anatomico pathologic diagnosis for
this patient is pleural effusion. Pleural effusion refers to the accumulation of fluid in the pleural space, which is the space between the two layers of the pleura that surround the lungs. In this case, the patient's symptoms of sudden onset high-grade fever, associated with chills and rigors, along with chest pain that worsens during deep inspiration, are suggestive of pleural inflammation (due to various possible etiologies such as infection, immune mediated, neoplastic) and the subsequent development of pleural effusion.
The pathophysiology of pleural effusion involves an imbalance between fluid production and reabsorption within the pleural space. It can be caused by various factors, including infections (such as pneumonia or tuberculosis), malignancies, congestive heart failure, liver or kidney disease, and inflammatory conditions. In this case, the patient's symptoms of fever and localized chest pain, along with the decreased breath sounds, dullness to percussion, and decreased tactile fremitus on examination, are indicative of a pleural effusion on the right side possibly due to infective pneumonia.
Complications associated with pleural effusion include lung collapse (atelectasis) due to the pressure exerted by the accumulated fluid, impaired breathing and reduced lung function, and potential infection (empyema) if the effusion becomes infected.
Question 2 ( SAQ 5 marks):
Which specific findings on the chest X-ray would support the diagnosis mentioned in question 1? Explain how these findings are related to the underlying condition.
Answer:
On the chest X-ray, specific findings that would support the diagnosis of pleural effusion include the following:
1. Blunting of the costophrenic angle: Pleural effusion typically results in the accumulation of fluid at the base of the lungs, causing the angle between the diaphragm and the chest wall (costophrenic angle) to appear blunted or obscured on the X-ray image.
2. Increased opacity in the affected hemithorax: The presence of fluid in the pleural space causes increased density and opacity on the affected side of the chest X-ray. This opacity can extend upwards and may obscure the diaphragm.
3. Shift of mediastinal structures: In large pleural effusions, there can be a mediastinal shift towards the unaffected side due to the accumulated fluid exerting pressure on the lung, pushing it away from the affected side.
These findings are related to the underlying condition of pleural effusion by demonstrating the presence of fluid in the pleural space, resulting in radiographic changes such as blunting of the costophrenic angle, increased opacity, and possible mediastinal shift.
MCQ (5 marks - NEET PG level):
Which of the following imaging modalities would be most useful to confirm the diagnosis in this patient?
A) Abdominal ultrasound
B) Chest X-ray
C) CT scan of the chest
D) Echocardiography
E) Pulmonary function tests
We had already tweaked this original LLM generated question above
Answer:
C) CT scan of the chest
While a chest X-ray is helpful in identifying radiographic signs of pleural effusion, a CT scan of the chest would be the most useful imaging modality to confirm the diagnosis in this patient. CT scan provides more detailed information about the size, location, and characteristics of the pleural effusion, as well as any associated lung parenchymal abnormalities or potential underlying causes. It can help differentiate between transudative and exudative effusions, guide management decisions, and detect other concurrent pulmonary abnormalities or complications.
Rejoinder from question paper setter to demonstrate challenges in achieving equipoise (equipoise is a term often used to determine the need for an intervention and I suppose we are treating the questions here as a social cognitive ontologic intervention with all it's ramifications in driving the next generation of doctors ) :
Now the rejoinder :
Above MCQ is an unsubstantiated opinion of the LLM to which we may politely disagree and depending on how much time we can spare to review the scientific epidemiologic literature, we can tweak it toward optimal current knowledge. Currently the LLM is behaving like an opinionated expert fed with a good diet of Wikipedia in it's recent past and it does need scientific epidemiologic support to substantiate it's opinions but then this space too keeps evolving daily hence the challenge to develop XAI systems, which current AI LLMs inspite of their explanatory answer keys are not till they can incorporate epidemiologic references to substantiate their claims (in the answer key).
Here's a step by step guide by one of our students on how to start a DIY approach to using an AI LLM to generate such questions and we hope the audience shall be able to tweak those with a suitable prof or facilitator who can guide them around the pitfalls: https://tellashruthi159.
Q5:
To demonstrate how much way off the mark the LLM can be and to enable you to learn how to tweak those I share below a raw version it spitted out after the prompt :
Pancreatitis
Apologies for the misunderstanding. Here's an updated clinical vignette without explicitly mentioning pancreatitis:
Clinical Vignette (LAQ - 10 marks):
A 26-year-old male car driver presents to the emergency department at 1 am with sudden-onset severe epigastric pain radiating to the back. He reports 4-5 episodes of bilious vomiting and a loss of appetite with unintentional weight loss over the past few months. The patient has a history of chronic alcohol abuse (8-10 drinks/day for 5 years) and had a similar episode of abdominal pain 12 years ago. On examination, he appears distressed, with tenderness and guarding in the epigastric area. Bowel sounds are diminished.
Investigations reveal an elevation in serum amylase and lipase levels. Abdominal ultrasound shows evidence of inflammation in the retroperitoneal area. The patient's liver enzymes (ALT and AST) are within normal limits.
Based on the provided history and investigation findings, analyze the possible underlying condition and discuss the appropriate management.
Short Answer Question (SAQ - 5 marks):
1. Discuss the clinical presentation, risk factors, and potential complications associated with the condition most likely responsible for the patient's symptoms. What investigations would you consider to confirm the diagnosis? Interpret the significance of the elevated serum amylase and lipase levels in this context.
Tough NEET PG Entrance Exam Level Question on Pathology (Anatomy):
1. A 26-year-old male patient with a history of chronic alcohol abuse presents with severe epigastric pain radiating to the back, along with vomiting and weight loss. On examination, abdominal tenderness and guarding are noted. Which specific type of necrosis is commonly associated with the affected organ in this condition? Describe the microscopic features and possible complications of this type of necrosis.
Sure! Here's a multiple-choice question (MCQ) for NEET PG level about pancreatitis:
MCQ (NEET PG Level - 5 marks):
A 45-year-old male presents with severe epigastric pain radiating to the back, accompanied by vomiting and weight loss. On examination, tenderness and guarding are noted in the upper abdomen. Serum amylase and lipase levels are elevated, and abdominal ultrasound reveals inflammation in the retroperitoneal area. Which of the following mechanisms is most likely involved in the pathogenesis of the patient's condition?
A) Increased activation of pancreatic proteolytic enzymes
B) Impaired insulin production and secretion
C) Autoimmune destruction of pancreatic acinar cells
D) Defective gallbladder contractility
E) Obstruction of the pancreatic ducts by gallstones
Choose the best option and explain the rationale for your choice.
Key
Certainly! Here are the explanations for the questions provided:
LAQ (10 marks):
Based on the patient's history and symptoms, along with the examination findings, the possible underlying condition is pancreatitis. Pancreatitis is inflammation of the pancreas, which can cause severe epigastric pain radiating to the back, vomiting, weight loss, and tenderness on examination. The patient's history of chronic alcohol abuse, previous episode of abdominal pain, and elevated serum amylase and lipase levels support this diagnosis. Abdominal ultrasound findings indicating inflammation in the retroperitoneal area further strengthen the suspicion of pancreatitis. The appropriate management for pancreatitis includes supportive care, pain management, fluid resuscitation, and identification and management of underlying causes.
SAQ (5 marks):
The most likely underlying condition in this patient is pancreatitis. Pancreatitis is characterized by severe epigastric pain radiating to the back, vomiting, weight loss, and tenderness on examination. The risk factors associated with pancreatitis include chronic alcohol abuse, gallstones, and elevated serum amylase and lipase levels. Complications of pancreatitis may include pancreatic pseudocysts, abscess formation, pancreatic necrosis, and systemic complications such as respiratory failure or sepsis. Investigations that can confirm the diagnosis of pancreatitis include serum amylase and lipase levels, abdominal ultrasound, and imaging modalities like computed tomography (CT) scan.
MCQ (5 marks):
The correct answer is A) Increased activation of pancreatic proteolytic enzymes. Pancreatitis involves the activation of pancreatic proteolytic enzymes, particularly trypsin, within the pancreas, resulting in autodigestion and tissue damage. This activation can be triggered by various factors such as alcohol, gallstones, or other underlying etiologies. The release of activated enzymes leads to inflammation, cellular injury, and subsequent clinical manifestations of pancreatitis.
Please note that the explanations provided here are general and simplified for the purpose of this response. In clinical practice, a thorough evaluation and consideration of individual patient factors are essential for accurate diagnosis and management.
Above was a raw version and I hope the audience can spot the errors and ambiguities and learn to tweak it according to their own learning ecosystem requirements and stance. The above question paper is not being given to students for any exam but is shared with a world wide audience to gain more active learning insights into the nature of human and AI collaboration, translational patient centered research, how to preserve human doctor competences in optimally resolving individual patient clinical complexity and not having to make them memorized protocol driven automatons using quickly generalized and simplified rules of thumb doling out average interventions with marginal effect sizes rather than precision medicine to meet individual patient requirements. Finally we need to further the field of medical cognition demonstrating positive correlations between learning outcomes of medical students and doctors with patient illness outcomes.
Some of our recent work in this direction below :
Understanding clinical complexity in organ and organizational systems: Challenges local and global
Integrated case-based clinical approach in understanding pathways, complexities, pitfalls and challenges in neurodegenerative disorders
Developing a Case-Based Blended Learning Ecosystem to Optimize Precision Medicine: Reducing Overdiagnosis and Overtreatment
Translational research project to hold all current projects in Medicine department : creating a dynamic user driven ontology toward improved medical cognition
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