Common Rules In Medicine

In dealing with non specific and complex symptoms, apply the following rule/guide while making your diagnosis:

No.1

1. Common presentations of a common disease.
2. Rare presentations of a common disease.
3. Common presentations of a rare disease.
4. Rare presentations of a rare disease.

No.2

Consider the following aspects while making your diagnosis:
Biological-Pschological-Social-Environment-Spiritual approach.

No.3

What are the possible events may have taken place before, during and after a disease. Preventive phase, Acute Phase and rehabilitative phase.

No.4
Consider partially treated or symptoms arising from side effects of treatment.

No.5
For elderly, consider presentations of aging process! (giants of geriatrics!)

Family Medicine Practice MCQ (True False)

1. A 50 year old man is seen at the health clinic complaining of tiredness and abdominal distension of 4 weeks duration. He has 20 year history of alcohol consumption. On examination, presence of hepatomegaly and shifting dullness is positive.

Which of the following statements are true:

A. He is most likely suffers from alcoholic hepatitis.
B. Enlarge parotid gland is an associated finding.
C. Serum alpha feto protein level assists in the diagnosis.
D. If a liver bruit is audible in auscultation a provisional diagnosis is alcoholic liver cirhossis.
E. Per rectal bleed is a common finding.

F T T F (Liver bruit is a feature of hepatocellular carcinoma) F(Portal hypertension most often associated with bleeding esophageal varices. Per-rectal bleeding may indicate other colorectal pathology)

2. A 14 year old college student presents with fever, productive cough and mild dyspnea of 3 days duration. On examination presence of crepitations on the lower zone of his right lung.

A. Clubbing of the finger is an expected physical finding.
B. Presence of multiple blistering “target” skin lesion on the trunk indicate the diagnosis of chickenpox pneumonia.
C. If presence of macular rash on the trunk he can be reassured it is viral upper respiratory tract infection.
D. Penicillin is indicated if the sputum gram stain shows gram positive diplococci.
E. If the chest radiograph shows a cavitating lung lesion, Mycoplasma pneumonia is the mostlikely diagnosis.

F (Too acute for clubbing to develop) F (Target lesion is a characteristic feature of Mycoplasma infection) F (The clinical features suggest lower respiratory tract infection rather than URTI) T F (Pulmonary Tuberculosis)


3. A 35 year old house wife presents with palpitation and tiredness. Her serum thyroid function test results are as follow:

TSH 2.0 (0.15-3.5 mU/L)
Free T4 12 (0-30 pmol/L)
T3 3.0 nmol/L (1.0-2.6 )
Tyroid Binding Globulin 40 ( 15-30 mg/L)

The above findings are consistent with:

A. primary hyperthyroidism
B. subclinical hyperthyroidism
C. pregnancy
D. subacute thyroiditis
E. T3 thyroidtoxicosis

F F T F F ( TSH will be low in primary hyperthyroidism, T3 and T4 thyroitoxicosis, TBG is elevated in pregnancy can give a false positive high levels for T3 and T4. Measurement of Free T4 is normal )


4. A 30 year old foreign worker presents with multiple small lumps at the lateral aspect of his neck. On examination, there is a cheesy serous discharge seen and some of the lumps are matted together.

A. Chest radiograph is a mandatory investigation.
B. His ESR is expected to be raised.
C. Infected branchial cyst is the commonest diagnosis.
D. Cloxacillin is the drug of choice.
E. A cutaneous biopsy of the lump is indicated.

T T F F F ( The clinical diagnosis here is Tuberculous lymphadenitis)

5. The following features on the hands and fingers are known to occur in a patient who has 10-year history of rheumatoid arthritis.

A. Swan neck deformity
B. Carpal tunnel syndrome
C. Tenosynovitis
D. Palmar eryhthema
E. Bouchard’s nodes

T T T T F (Osteoarthritis)

6. A 25 year old housewife who has 3 previous episodes of first trimester spontaneous abortion. Now she is at 8th week period of amenorrhea.

A. Glucose tolerance test is indicated.
B. Speculum examination for cervical incompetence.
C. Lupus anticoagulant test.
D. Anticardiolipin antibody titer.
E. Transvaginal ultrasound.

T F (usually occur in 2nd trimester) T T F (transvaginal USG is used for investigating an ectopic pregnancy or ovarian cyst)

7. A 50 year old woman presents with sudden onset of blurring of vision and ocular pain. On examination the conjunctiva is injected surrounding the cornea and the anterior chamber is cloudy.

A. A foreign body injury must be excluded.
B. Measurement of intraocular pressure is mandatory.
C. Undiagnosed diabetes mellitus is a common cause.
D. Stage IV hypertensive retinopathy is the most likely cause.
E. Topical analgesic is contraindicated.

T T F F T (The clinical features are suggestive of Acute Angle Closure Glaucoma)

8. A 65 year old man with past history of benign prostatic hypertrophy treated by transurethral resection of prostate 3 years ago now presents with newly onset of hesitancy and terminal dribbling of 3 weeks duration. The following management plans are appropriate.

A. Urine analysis for microscopic hematuria.
B. Intravenous pyelogram
C. Micturating cystogram
D. Assessment of prostatic specific antigen levels
E. Refer him to urologist for a cystoscopy.

T F F T T ( New onset symptoms of prostatism in an elderly warrants further investigation to exclude Prostatic cancer or bladder cancer)

9. A new diagnostic instrument named ZZZ is invented for the purpose of investigating a disease MMM. The sensitivity of ZZZ is 85%, Specificity is 30% and the positive predictive value is 60%.
Which of the following statements are true?

A. ZZZ is useful as a diagnostic confirmatory instrument.
B. ZZZ has a role in screening of disease MMM.
C. If an asymptomatic person is tested positive by DIM, the chances that he is suffering from the disease MMM is 85%.
D. The false positive result is as high as 70%.
E. The positive predictive value of ZZZ will increase if the prevalence of disease MMM in the community is higher.

F (Low specificity is not good as diagnostic test) T F (Positive predictive value 60% means If an asymptomatic person is tested positive by DIM, the chances that he is suffering from the disease AAA is 60%.) T T

10. The following pedigree shows the mode of inheritance of a genetic disease.



Which of the following diseases are represented by the above pedigree?
A. Beta Thallasemia major
B. G6 PD deficiency
C. Cystic fibrosis
D. Hemophilia A
E. Familial Hypophosphatemia rickets

F T F T F (The mode of inheritance shown here is X-linked recessive)

Family Medicine MCQ (Single Best Answer)

1. A 35-year-old school teacher who is asymptomatic consults his family doctor for the following blood tests. He had Hepatitis B vaccination 10 years ago.

Hepatitis B surface antigen NEGATIVE
Hepatitis B “core” antigen NEGATIVE
Hepatitis B antibody POSITIVE ( Titer: 8 i.u./L)

Which of the following statement is correct?

A. He has good immunity against hepatitis B infection
B. He has chronic hepatitis B
C. He has acute hepatitis B infection.
D. He acquired hepatitis B from vertical transmission.
E. He should be advised for booster dose of hepatitis

2. A 30 year-old housewife presents with chronic persistent diarrheas for 6 weeks. Which of the following symptoms would MOST suggestive of a pathological cause of her diarrhea?

A. More than 3 episodes of diarrhea per day.
B. Having a sensation of active bowel movement
C. Nocturnal diarrhea with 2-3 episodes after sleep.
D. Abdominal pain
E. Similar episodes 2 years ago

3. A 20 year old college student was treated for bronchopneumonia two weeks ago. On follow up, his blood test shows the following results:

Haemoglobin 10.3 (13-14 g/d L)
White blood count 8,000 (4,000-11,000/dL)
Platelets 160,000 (150,000-400,000/dL)
Reticulocytes 10%
Agglunitation POSITIVE

The above results are consistent with:

A. Drug induced hemolysis
B. Acute Infectious mononucleosis
C. Partially treated pneumonia
D. Mycoplasma induced hemolysis
E. Aplastic anemia

4. A 75-year-old Right-handed patient suffers a thrombotic stroke. He understands what is being said to him but he has difficulty in finding words to speak. He is also confused about left and right. The lesion in his brain is MOST likely situated at:

A. Left frontal lobe
B. Right frontal lobe
C. Left parietal lobe
D. Left temporal lobe
E. Right temporal lobe


5. A 50 year old man with history of diabetes mellitus presents to his family doctor with a complaint of itchiness at both the armpits. On examination, both his axilla regions are erythematous, shinny and satellites lesions are seen.
The MOST likely diagnosis is:

A. Pityriasis versicolour
B. Necrobiosis lipodica diabeticurum
C. Impetigo
D. Cutaneous candidiasis
E. Atopic eczema

6. A 20 year old college student presents with nocturnal cough and chest tightness. Occasionally he also complains of audible wheeze after exercise.
Which of the following will BEST confirm your clinical diagnosis?

A. Chest radiograph
B. Peak flow monitoring for diurnal variability
C. Trial of inhaled beta-2 agonist
D. Trial of inhaled steroid
E. Spirometry

7. A 30-year-old man presents with a 12-month history of headaches. He describes it as severe and sudden onset around his right supraorbital and temporal region associated with watery eyes and a blocked nose. The attacks last about 1-2 hours, occurring daily for a week. He experiences this phenomenon every 3-4 months. In between the attacks he is asymptomatic.
The history of this patient suggest a diagnosis of:

A. Tension headache
B. Chronic glaucoma
C. Migraine
D. Trigeminal neuralgia
E. Cluster headache

8. A 30-year-old asymptomatic worker visits his family doctor for pre-employment assessment. He has a sister who is diagnosed with chronic anemia. This is his blood test results.

Hemoglobin 9.5 (13-18 g/d L)
White cell count 5,000 (4,000-11,000 /dL)
Platelets 160,000 (150,000-400,000 /dL))
Serum Ferritin 35 (12-200 µg/L)

Periphral Blood film: Hypochromic, microcytic, anisocytosis with some target cells.

The MOST appropriate next line of investigation is:

A. Request for Serum Iron level
B. Request for Serum Folate level
C. Hemoglobin electrophoresis
D. Upper GIT endoscopy
E. Lower GIT endoscopy


9. A 25 year old primigravida at 20 weeks of her pregnancy is found to have Bacteriuria caused by E.coli on urine test. She is asymptomatic. Which of these is the most appropriate plan of management.

A. Reassurance without treatment.
B. Repeat urine test at term
C. Commence with antibiotic treatment
D. Delay treatment until after delivery
E. Ultrasonography of her kidneys


10. A 25-year-old female presents with generalize malaise, lethargy and intermittent low grade fever for 6 month duration. On examination she is pale and erythematous rash is presence on her face and neck. The following are some tests done at the clinic:

Urine analysis:
Protein ++ Red blood cell: ++ White blood cell: +

ESR 110 (<20 mm/hr )
Creatinine 250 (60-130 umol/L)
Na: 140 (135-145 mmol/L)
K: 5.5 (3.5-4.5mmol/L)

What is the MOST likely cause of her problems?

A. Renal calculi
B. Infective endocarditis
C. Chronic pyelonephritis
D. Systemic lupus erythematosus
E. Chronic rheumatic heart disease

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Answer: 1(E) 2(C) 3(D) 4(C) 5(D) 6(B) 7(E) 8(C) 9(C) 10(D)

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Educational Publications

The following publications is available free on line at the Malaysia Academy of Family Physician website. http://ejournal.afpm.org.my/

(Click on the title below can link directly to the website)

Urinary tract infections in pregnancy. Loh Keng Yin, Sivalingam Nalliah[Abstract] [PDF]

A man with chronic cough. Loh Keng Yin. [PDF]

Interpreting hepatitis B serology. Loh Keng Yin, Kew Siang Tong [PDF]

The association of lunar phases and mental illness: fact or myth? Loh Keng Yin [PDF]

Hepatitis B infection: what the primary care doctors should know. Loh Keng Yin, Kew Siang Tong [HTML] [PDF

Is there a role for aspirin in primary prevention of ischaemic heart disease in hypertensive patients? [HTML] Loh Keng Yin, Chan Soo Chin [PDF]

Conjunctivitis: viral or bacterial? Antibiotic or no antibiotic? [PDF]

A housewife with recurrent pelvic pain.[PDF]

Meditation for physical, mental and spiritual health Keng Yin LOH.

Clinical quiz: Test Your Knowledge

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An 18 year old college student presents with sudden onset of skin rash 2 weeks after an episode of viral pharyngitis. (Figure 2) His has no bleeding tendency. His platlet count is 100x10 9/L. Other parameters are all normal.

Figure 2

Photo copyright Dr. Loh K Y

1. What is the most likely diagnosis?

2. What is the pathogenesis of this condition?

3. What is the prognosis?

++++++++++++++++++++++++++++++++++++++++++++++++++++

Answer:

1. Idiopathic thrombocytopenia purpura

2. Presence of auto antibody directed against platelet membrane or antigen antibody complex adhere to platelet causing premature removal or destruction of the platelets.

3. ITP following an episode of URTI has a good prognosis and usually self limiting. Majority of the patients recover without serious complications.

MCQ

1. The following is/are true about visual acuity test:

A. Snellan chart should be placed at a distance of 6 feet from the patient.
B. A normal acuity is designated as 6/6.
C. If a patient has a visual acuity of 6/60 of the best corrected eye, he is legally blind.
D. Industrial blindness is defined as a vision “counting fingers” of the best corrected eye.
E. No perception to light is also known as total blindness.

F T T F T

2. When assessing a 60 year old patient with recent onset of headache,

A. A history of ataxia indicates cluster headache.
B. Unilateral papilloedema is of no significant.
C. Newly prescribed antihypertensive must be excluded.
D. Fortification of spectra indicates local ocular problem.
E. Bitemporal hemianopia warrants a brain imaging study.

F F T F T

3. A 10 year old boy presents with history of high grade fever of 5 days duration.

A. Presence of conjunctivitis and rhinitis suggest the diagnosis of measles.
B. A negative result of Anti Dengue IgM antibody excludes the diagnosis of dengue fever.
C. Migratory joint pain highly suggestive of Kawasaki disease.
D. Typhoid fever is not likely at this age.
E. First degree heart block in the ECG is a normal finding at this age.

T F F F F

4. The following findings on auscultation may be a normal finding.

A. A grade 2/6 diastolic murmur.
B. A short and soft grade 2/6 systolic murmur.
C. A third heart sound in a pregnant mother.
D. A continuous murmur at the back of the patient.
E. A splitting of second heart sound during deep inspiration.

F T T F T


5. A 6 year old boy presents with sorethroat for two days.

A. Majority of the cases (>90%) are due to Group A Beta hemolytic streptococcus infection.
B. Unable to swallow and drooling of saliva warrants urgent admission.
C. Presence of submental lymphadenopathy indicates bacteria pharyngitis.
D. Exudative tonsillitis and cervical lympadenopathy are suggestive of infectious mononucleosis.
E. Penicillin should be prescribed without delay if fever is above 38 degrees Celsius.


F T F T F

Multiple Choice Question

Section A: True / False

1. A 50 year old hypertensive patient presents with chest pain.

A. If there is a fall in blood pressure detected during exercise, it is a sign of severe coronary artery disease.
B. If the pain occurs at rest without a rise in cardiac enzyme, it indicates coronary artery spasm.
C. Presence of ankle edema invariable indicates congestive cardiac failure.
D. A normal ECG exclude an acute myocardial infarct.
E. Presence of T wave inversion in lead V3- V6 in his ECG indicates the urgency for intravenous thrombolytic therapy.

Answer: T T F (can be side effects of Calcium Channel Blocker) F (ECG can be normal in first 6 hours) F (Can be due to hypertensive strain pattern)

2. The following statement(s) is/are true about classical dengue fever.

A. it presents with cervical lympadenopathy
B. it is transmitted by Anopheles mosquito.
C. it is commonly produces acute DIVC.
D. it causes hepatitis
E. it is associated with high mortality in majority of the cases.

Answer: F (lympadenopathy is NOT a feature of dengue), F (Aedes sp) , F (DIVC occurs in Dengue heamorrhagic fever) , T , F ( classical dengue fever has low mortality rate)

3. An 18-year-old college female student presents with recurrent headache, chest tightness, fainting spells and perioral numbness. Physical examination does not reveal any significant findings. Her thyroid function test and cardiac assessment are also normal. The following statements are correct:

A. She may be hyperventilating
B. Underlying anxiety disorder must be excluded.
C. Substance abuse is a differential diagnosis.
D. Assessing her serum calcium level during the symptoms is useful in assisting the
diagnosis.
E. She needs a cranial CT scan.

Answer: T T T T F

4. The following condition(s) cause(s) painful visual loss.

A. central retinal artery occlusion
B. optic neuritis
C. retinal detachment
D. 3rd cranial nerve palsy
E. temporal arteritis

Answer: F T F F T

5. Which of the following etiological agent and its association(s) is/are correct:

A. Group A beta-hemolytic Streptococcus: Acute rheumatic fever
B. Enterobius vermicularis: pruritus ani
C. Helicobacter pylori: gastric lymphoma
D. Necator americanus: B-12 deficiency
E. Mallasezia furfur: scalp seborrheic

Answer: T T T F (iron deficiency anemia) T

6. A 50 year old man presented with persistent cough for 3 months associated with scanty sputum. His sputum culture for bacteria gave negative results. His chest radiograph showed a cavitating lung lesion at the right upper zone. The following differential diagnoses are likely:

A. Invasive Aspergillosis
B. Pneumocystis carinii pneumonia
C. Squamous cell lung cancer
D. Pulmonary tuberculosis
E. mesiothelioma

Answer: T F T T F

7. A 25 year old mother with a history of narcotic addiction was managed with methadone during the pregnancy. Which of the following features are consistent with the diagnosis of narcotic withdrawal in her newborn?

A. increased tone
B. poor feeding
C. sound sleep
D. tachypnoea and nasal flaring
E. regurgitation of feeds

Answer: F (Hypotonia), T , F (Irritable), T, T

8. Which of these diseases in Malaysia must be notified to the health authority upon making the diagnosis?

A. Measles
B. Infectious mononucleosis
C. Mumps
D. Pertussis
E. Leprosy

Answer: T, F, F, T, T

9. A 20 year old healthy young man visited his family doctor for pre-employment health examination. His blood test shows:

Hepatitis B surface antigen NEGATIVE

Anti Hep B antibody POSITIVE ( Titer: 200 iu/ml)

Which of the following statement(s) is/are correct.

A. He has persistent hepatitis B infection
B. He is a chronic hepatitis carrier
C. He is having acute hepatitis B infection
D. He is encourage to get a hepatitis B vaccination

E. He has adequate levels of protective antibody.

Answer: F, F, F, F, T ( Antibody Levels above 100 iu/ml is adequate)

10. In managing a 60 year old man diagnosed with community acquired pneumonia, you would consider hospital admission for him if:

A. His oxygen saturation on pulse oximeter is below 90%.

B. His blood urea levels is 15 mmol/l.

C. He has underlying diabetes mellitus with random blood sugar of 15 mmol/l.

D. He has poor urine output.

E. He is staying alone without family support.

Answer: T T T T T

Section B Single Best Answer

1. Which of the following measures taken is proven in reducing the incidence of hepatitis A transmission:

A. Proper food hygiene
B. Hepatitis A vaccination
C. Avoiding sea food
D. Avoid close contact
E. Use of surgical face mask

Answer: B

2. A 8-year-old boy presented with history grade fever and rash. He also complained of severe ankle pain followed by knee pain and elbow pain after 48 hours. Which of the following is the most likely diagnosis?

A. Kawasaki disease.

B. Juvenile chronic arthritis

C. Leptospirosis

D. Acute rheumatic fever

E. Septic arthritis

Answer: D

3. A 10-month-old infant is expected to perform the following:

A. Use words with meanings
B. Pick up a marble with his thumb and index finger.
C. Stand without support.
D. Walk up a staircase.
E. Arranging 3 cubes tower.

Answer: B

4. A 40-year-old housewife from the remote village presents with history of fever of 39.5 degrees Centigrade, profuse sweating, abdominal discomfort and constipation for 3 days duration. Her blood pressure 100/60mmHg and pulse is 70 beats per minute. Her white cells counts showed leucopenia. The most likely diagnosis is:

A. Dengue fever
B. Hepatitis
C. Acute rheumatic fever.
D. Malaria
E. Typhoid fever

Answer: E

5. Vertical transmission of infectious disease from mother to baby has been recognized to occur in which of the following infection :
A. Measles
B. Helicobacter pylori
C. Hepatitis A
D. Varicella virus
E. Candida albicans

Answer: D

6. The most sensitive measurement for nutritional index of a child is:

A. Head circumference

B. Height

C. Heamoglobin

D. Serum protein

E. Weight

Answer: E

7. A 10-month-old baby presents with high grade fever, cough, rhinitis and conjunctivitis. Three days later he has generalized macular rash on the body. He is most likely suffering from:

A. Rubella
B. Measles
C. Chicken pox
D. Molluscum contagiosum
E. Streptococcal pneumonia

Answer: B

8. A 60 year old diabetic patient presents with sudden onset of visual loss which she describes as “something like a curtain coming down slowly blocking my vision”. She is suffering from:

A. Diabetic cataract
B. Rubeotic glaucoma
C. Proliferative diabetic retinopathy
D. Acute optic neuritis
E. Retinal detachment

Answer: E

9. A 30 year old factory worker experienced sudden onset of pain and redness of his right eye while hammering on a piece of metal plate. He felt intense pain when he tried to open his eyes. The most likely cause is:

A. Chemical conjunctivitis

B. Acute glaucoma

C. Optic neuritis

D. Foreign body at the cornea

E. Lens dislocation

Answer: D

10. A 45-year-old house wife presents with 3 months history of progressive bilateral pain and stiffness of all the small joints of both hands. The most likely diagnosis is:

A. Osteoarthritis

B. Psoriatic arthropathy

C. Rheumatoid arthritis

D. Scleroderma

E. Reactive arthritis

Answer: C