DEPARTMENT OF GENERAL MEDICINE
INTERNAL ASSESSMENT EXAM FOR 1st and 2nd YEAR PG STUDENTS
Answer all questions Max Marks: 60
Time: 2pm to 4pm Date: 01.02.2020
There are in total ‘3’ questions. The 3 long questions are 20 marks each
with two parts of 10 marks, one specifically related to the case and the other more general as per tradition. The paper is designed to be answered by you in a blended offline and online format. Most of the real patient data presented here is due to our hardworking interns who have obtained signed informed consent from patients and then captured deidentified history and images. It has been shared nearly unchanged with minimal editing.
Q1. A 50 year old man with progressive abdominal pain with vomiting since last 3 months and tenderness in the paraumbilical region with no history suggestive of sepsis. On CT abdomen, patient was found to have a large cystic lesion in right hypochondrium possibly arising as a sequelae of pancreatic inflammation. Patient was admitted and put on injection taxim and injection tramadol for last 7 days.
a) Please check out the CT images of the abdomen (also check radspa and discuss with the Radiology PGs for the entire set of images)
and write the answers to the following:
Where is the cyst anatomically located in relation to the pancreas? Is it in the greater sac or lesser sac or both? If in greater sac is it communicating with the pancreatic duct? Why is it not causing pancreatic ascites? What would be the disadvantages of an external drainage in such a situation? If planning internal drainage given the CT findings what would be the disadvantages of a cystogastrostomy vs cystojejunostomy? (3 marks)
and write the answers to the following:
Where is the cyst anatomically located in relation to the pancreas? Is it in the greater sac or lesser sac or both? If in greater sac is it communicating with the pancreatic duct? Why is it not causing pancreatic ascites? What would be the disadvantages of an external drainage in such a situation? If planning internal drainage given the CT findings what would be the disadvantages of a cystogastrostomy vs cystojejunostomy? (3 marks)
b) Is there a role of antibiotics in Pseudocyst without any evidence of sepsis? Please substantiate with evidence from review of literature (3 marks)
c) What is the role of aspiration in management of an infected Pseudocyst?
Please substantiate with evidence from review of literature (2 marks)
d) What is the role of prophylactic antibiotics in intestinal obstruction?
Please substantiate with evidence from review of literature (2 marks)
Short note: Peritoneal relations with pancreas. (3 marks)
Pancreatic pseudocyst (3 marks)
ERCP and pancreatic duct (2 marks)
Role of pancreatic necrosectomy (2 marks)
Q2. A 55yr old male patient with diabetes since 7 yrs presented with c/o vomitings since 1 day(20 episodes non projectile and bilious) with right sided weakness and headache since 1 day .3 yrs back he had right sided weakness ,squint and weak memory for which he was admitted in a pvt hospital and diagnosed as acute cva for which he used allopathic medication for 2 months and ayurvedic medication for 3 yrs .he was asymptomatic for those 3 yrs but 1 week ago on 27/01/2020 he had 20 episodes of vomitings,non projectile and bilious, and a grbs of 300+ (tested at home with a glucometer )and developed slurred speech for which he was immediately taken to an rmp and given iv fluids overnight and referred to our hospital in the morning.patient consumes alcohol occassionally and consumes chewable tobbacco since 30yrs. (History taken by intern)
- Please examine the clinical images of his neurological findings during this admission and answer the following questions:
Higher mental functions: MMSE15
Cranial nerve examination: Inability to adduct the left eyeball with visible nystagmus in the right eye ball. Bilateral partial abduction of eyeballs. Absent sensations over left half of face.
Very prominent slurring of speech with marked scanning of each syllable and inability to pronounce jointed words (yuktaksharas).
Bilateral motor weakness of upper and lower limbs with lower limbs grade 3 minus and upper limb 4 minus. The right sided power is lesser than the left side.
What is the cranial nerve finding depicted above suggestive of in terms of anatomical localization?
If the etiology is vascular then which vessels are likely involved?
What could be the localization for his dementia? What information will help you to localize it further? (3)
- Please go through the cranial MR images of the patient and comment on which cerebral territories are involved. (3)
- What is the role of MR angio in further diagnosis? Will you advice it for this patient? (2)
- What is the role of cerebral vessel stenting in this patient? Please review the literature on its evidence and share it in the PICO format.(2)
Short notes:
- Weber’s syndrome (Neurology) (2)
- Cerebrovascular disease etiologies (2)
- Aspirin and stains in CVD prevention: evidence in PICO format (3)
- Multiple infarct dementia (3)
Q3. 40 yrs female had h/o productive cough & cold for 10 days, three days after she went to a temple in chervugattu. In 3 days,she developed fever associated with headache and body pains.then she was admitted in govt. Hsptl, Nalgonda and stayed there for 5 days.after 3 days of hsptl stay in govt.hsptl,she had feeling of nausea and later vomitings. Then she went to a private hospital in Nalgonda and from there she was referred to our hospital. (History by intern)
Her hospital fever chart showed high grade spikes (figure below)
Her hospital fever chart showed high grade spikes (figure below)
On examination she has severe tachypnoea and crepitations over chest (right more than left) and her Spo2 reveals severe hypoxemia on room air with persistent hypoxia even on 100% oxygen.
Chest X-ray reveals progression from non specific hilar infiltrates to batwing appearance and her WBC counts show a trend of 7000-11000.
The next day’s chest X ray (image link) reveals bilateral moderate pleural effusion with loss of the previous alveolar opacities
Chest X-ray reveals progression from non specific hilar infiltrates to batwing appearance and her WBC counts show a trend of 7000-11000.
The next day’s chest X ray (image link) reveals bilateral moderate pleural effusion with loss of the previous alveolar opacities
What is your morphological and etiological differential diagnosis for this patient? (2)
How would you proceed to manage this patient if you suspect that there could be an infectious etiology? (6)
How would you prevent contagion? (2)
Short notes: (2x5)
- SARs, MERs and Wuhan Corona virus
- ARDS infectious etiologies
- Anatomical relations between alveoli and pleura
- Disaster responsiveness
- Malaria ARDS: incidence, epidemiology and management
This comment has been removed by the author.
ReplyDeleteThis comment has been removed by the author.
ReplyDeleteTreatment of pseudopancreatic cyst comprises two aspects: supportive care or medical management and definitive care or surgical drainage.
ReplyDeleteIntravenous fluids, analgesics, and antiemetics are the basic requirements
Weber's syndrome, also known as superior alternating hemiplegia, is a form of stroke characterized by the presence of an ipsilateral oculomotor nerve palsy and contralateral hemiparesis or hemiplegia
Treatment of pseudopancreatic cyst comprises two aspects: supportive care or medical management and definitive care or surgical drainage.
ReplyDelete....pca territory infarct involving right cerebellum
Intravenous fluids, analgesics, and antiemetics are the basic requirements
Weber's syndrome, also known as superior alternating hemiplegia, is a form of stroke characterized by the presence of an ipsilateral oculomotor nerve palsy and contralateral hemiparesis or hemiplegia
There is a multitude of etiologies that can lead to a stroke. Some of the most common risk factors include hypertension, diabetes mellitus, hypercholesterolemia, physical inactivity, obesity, genetics, and smoking. Cerebral emboli commonly originate from the heart, especially in patients with preexisting heart arrhythmias (atrial fibrillation), valvular disease, structural defects (atrial and ventricular septal defects) and chronic rheumatic heart disease. Emboli may lodge in areas of preexisting stenosis.[3] Alcohol intake has a J-shaped relationship with ischemic stroke. Mild to moderate drinking carries a slightly lower risk of ischemic stroke yet heavier drinking increases the risk drastically. Alcohol intake increases the risk of hemorrhagic stroke in a near linear relationship.
Strokes that occur in small vessels(lacunar infarcts) are most commonly caused by chronic, uncontrolled hypertension resulting in the pathological entity of lipohyalinosis and arteriolosclerosis. These strokes occur in the basal ganglia, internal capsule, thalamus, and pons. Uncontrolled hypertension in these areas can also lead to hypertensive intracerebral hemorrhages (ICH).[4]
About 15% of all strokes are classified as hemorrhagic, with the etiology being the most commonly uncontrolled hypertension. Other causes of hemorrhagic strokes include cerebral amyloid angiopathy, a disease in which amyloid plaques deposit in small and medium vessels, which causes vessels to become rigid and more vulnerable to tears. Deposition can occur anywhere, but they occur most commonly on the surfaces of the frontal and parietal lobes. The structural integrity of vessels is another important consideration in hemorrhagic stroke etiology, with aneurysms, arteriovenous malformations, cavernous malformations, capillary telangiectasias, venous angiomas, and vasculitis being more common reasons for stroke.[5]
SARS (Severe Acute Respiratory Syndrome)
ReplyDeleteCause
SARS coronavirus (SARS-CoV) – virus identified in 2003. SARS-CoV is thought to be an animal virus from an as-yet-uncertain animal reservoir, perhaps bats, that spread to other animals (civet cats) and first infected humans in the Guangdong province of southern China in 2002.
Transmission
An epidemic of SARS affected 26 countries and resulted in more than 8000 cases in 2003. Since then, a small number of cases have occurred as a result of laboratory accidents or, possibly, through animal-to-human transmission (Guangdong, China).
Transmission of SARS-CoV is primarily from person to person. It appears to have occurred mainly during the second week of illness, which corresponds to the peak of virus excretion in respiratory secretions and stool, and when cases with severe disease start to deteriorate clinically. Most cases of human-to-human transmission occurred in the health care setting, in the absence of adequate infection control precautions. Implementation of appropriate infection control practices brought the global outbreak to an end.
Nature of the disease
Symptoms are influenza-like and include fever, malaise, myalgia, headache, diarrhoea, and shivering (rigors). No individual symptom or cluster of symptoms has proved to be specific for a diagnosis of SARS. Although fever is the most frequently reported symptom, it is sometimes absent on initial measurement, especially in elderly and immunosuppressed patients.
Cough (initially dry), shortness of breath, and diarrhoea are present in the first and/or second week of illness. Severe cases often evolve rapidly, progressing to respiratory distress and requiring intensive care.
Geographical distribution
The distribution is based on the 2002–2003 epidemic. The disease appeared in November 2002 in the Guangdong province of southern China. This area is considered as a potential zone of re-emergence of SARS-CoV.
Other countries/areas in which chains of human-to-human transmission occurred after early importation of cases were Toronto in Canada, Hong Kong Special Administrative Region of China, Chinese Taipei, Singapore, and Hanoi in Viet Nam.
Risk for travellers
Currently, no areas of the world are reporting transmission of SARS. Since the end of the global epidemic in July 2003, SARS has reappeared four times – three times from laboratory accidents (Singapore and Chinese Taipei), and once in southern China where the source of infection remains undetermined although there is circumstantial evidence of animal-to-human transmission.
Should SARS re-emerge in epidemic form, WHO will provide guidance on the risk of travel to affected areas. Travellers should stay informed about current travel recommendations. However, even during the height of the 2003 epidemic, the overall risk of SARS-CoV transmission to travellers was low.
Prophylaxis
None. Experimental vaccines are under development.
Precautions
Follow any travel recommendations and health advice issued by WHO.
We did a trial run now with Dr Rashmita and Dr Ajit and it's possible that directly posting to the blog can sometimes cause errors and the message may not go through. So as a back up please also send it to my email address shared above.
ReplyDeleteThose students who were absent in the exam hall, please ensure that you complete your answers and post it online by Monday 👍
ReplyDeleteFew of you have shared your handwritten versions and while the only original content in them is your handwriting which we appreciate, it's much more easier for us to assess and share if we can get those in a typed version.
ReplyDeleteI know all of you love your handwriting practice but at least once in two weeks you can have some typing practice too. 👍
Thanks to those who have begun uploading your answers online and or shared them in email.
ReplyDeleteCan you paste the question before your answers as otherwise it's difficult to sort them out and also difficult to guage which questions you have left out especially if you have done your own numbering (for example you may have used 1,2,3...for a, b, c...in the original question?
Please share the reference link when you share generic information such as in short notes.
For example when you share the short note below:
"Pancreatic pseudocyst:
Pancreatic pseudocysts can be described as fluid-filled cavities arising from the pancreas and surrounded by a wall of fibrous or inflammatory tissue, but lacking an epithelial cover.
Most common after chronic pancreatitis than acute pancreatitis..." we realize this is text book knowledge but it would be nice to have a reference to the text book with page numbers along with an online link to it.
Please check below an example on how text book information is cited and referenced:
"Example: Chapter in an Edited Book
In-Text Citation (Quotation):
(Stewart, 2007, p. 102)
References:
Stewart, B. (2007). Chapter title... "Pancreatic pseudocyst" In J. Jaimeson, T. Bannerman, & S. Wong (Eds.), Pancreatic disorders (pp. 97-105). Toronto, Canada: university Press." (Online link)
The above was just an example to also make you learn to cite references as it will become important for you all to write papers (once you begin working on projects that can run parallel to your thesis). 👍
The above reference example was modified with apologies from this link https://rdc.libguides.com/c.php?g=342399&p=2686962
ReplyDeleteOther than the above there can be some scope for originality too in your online submitted answer paper if you can add to the questions around the patients, add to the history and clinical findings and add more questions around the diagnostic and therapeutic uncertainties in these three patients.
ReplyDeleteLastly we are looking forward to your submitting some different patients with different medical issues in a similar question format that will if good enough become automatically be selected for the next fortnightly exam.
Once we make this a regular project and publish and share it with the university there may be enough traction for them to adopt this methodology even for the finals 👍
Assessor's inputs on the answers in general (hoping not to sound too patronizing):
ReplyDeleteA large volume of copy paste that will be construed as plagiarism when shared online. However this is a transition phase where our students are learning to realize how copy pasting from memory (aka paraphrasing in one's own words after internalizing) is not the same as copy pasting directly from one online location to another although both are similar in some ways. We shall be able to quickly grow out of this phase I am sure with a little more persistence.