Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. I'm barely responsible for compilation of various resources per my interest. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.

1. History
Taking
A CASE BASED DISCUSSION

2. Perfect happiness for student and
teacher will come with the abolition of
examinations, which are stumbling
blocks and rocks of offense in the
pathway of the true student.
- WILLIAM OSLER. “AFTER 25 YEARS” AEQUANIMITAS. 1914:202

3. Case no. 1
An 84-year-old man has central chest pain that has gradually worsened
over the last month. He finds it is made worse on exertion—
especially climbing the stairs to his flat. He has type 2 diabetes and a hiatus
hernia.
T 37.1 ° C, HR 95bpm, BP 165/95mmHg.
An ECG and a chest X-ray are both reported as ‘normal’.

4. Which is the
single most likely diagnosis?
A Angina
B Gastro-oesophageal reflux disease
C Heart failure
D Myocardial infarction
E Oesophageal spasm

5. Case no. 2
A 71-year-old man has had a central chest pain
radiating to his left arm for 1h. While an ECG is being
recorded, some observations are carried out.
T 37.1 ° C, HR 44bpm, BP 110/65mmHg, RR 22/min.

6. Which is the single most likely
occluded coronary artery?
A Left anterior descending artery (LAD)
B Left circumflex coronary artery (LCx)
C Left main coronary artery (LCA)
D Posterior descending artery (PDA)
E Right coronary artery (RCA)

7. Case no. 3
A 73-year-old woman has been short of breath for the past
3
weeks. She now needs to sleep with four pillows rather
than
two and has swollen ankles by the end of the day. She
uses a regular steroid inhaler for asthma but has never
been in hospital for any reason.

8. Which is the single most likely
diagnosis?
A Acute exacerbation of asthma
B Angina
C Cardiac failure
D Pneumonia
E Pulmonary embolus

9. Case no. 4
A 52 year old man presents with 4 days of
haemoptysis.
Over the last 2 months he has lost weight without
experiencing night sweats. He has smoked 30
cigarettes per day for 40 years and worked in
construction. He thinks it is likely that he encountered
asbestos at work but cannot recall any specific
exposure.
He returned home from holiday in Guyana 1 week ago.
What is most likely to cause the CXR findings shown
below.

10. What is the most likely diagnosis?
A. Bronchial carcinoma
B. Granulomatous polyangiitis
C. Lung abscess
D. Pulmonary and pleural tuberculosis (TB)
E. Pulmonary infarct

11. Case no. 5
A 38 year old man presents with cough
productive of blood-streaked sputum,
fever and left-sided pleuritic chest pain.
In addition he has developed troublesome
cold sores. His past medical history
includes appendicectomy. He works in a
bank.
What does his CXR show?

12. Case no. 6
A 63 year old female non-smoker presents to her family physician with a new cough. Her CXR is
abnormal with a 5-cm lesion in the right mid-zone. She has since undergone bronchoscopy at
which an endobronchial tumour was biopsied. Which is the most common histological type of lung
cancer?
A. Adenocarcinoma
B. Large cell carcinoma
C. Mesothelioma
D. Small cell carcinoma
E. Squamous carcinoma

13. Case no. 7
A 42 year old man presents with right iliac fossa pain that has progressively increased in severity over
the last few months. This is associated with weight loss and low-grade fever. Blood analysis reveals
alkaline phosphatase (ALP) of 235 U/L and γ-glutamyl transferase (GGT) of 120 U/L. Chest X-ray is
normal.
What is the most likely diagnosis?
A. Chronic appendicitis
B. Crohn’s disease
C. Human immunodeficiency virus (HIV)
D. Ileocolonic tuberculosis (TB)
E. Whipple’s disease

14. Case no. 8
A 29 year patient with type 1 diabetes on insulin with poor glycaemic control has a 6-month
history of vomiting around 1 hour following food. What is the most likely diagnosis?
A. Gastric outlet obstruction
B. Gastroparesis
C. H. pylori infection
D. Medication-induced vomiting
E. Raised intracranial pressure

15. Case no. 9
A patient with systemic lupus erythematosus (SLE) and immune thrombocytopenia (ITP) presents
with a platelet count of 5 × 10^9/L. Which of these is the most likely presenting symptom?
A. Haemarthrosis
B. Intracranial haemorrhage
C. Muscular haematoma
D. Oral mucosal bleeding
E. Retroperitoneal haematoma

16. Case no. 10
A 40 year old male smoker presents with weight loss and blood tests suggesting biochemical
primary hyperthyroidism. Which of the following features would suggest that the hyperthyroidism
is due to Graves’ disease?
A. Eyelid retraction
B. Gynaecomastia
C. Lack of orbitopathy
D. Male gender
E. Palpable smooth goitre with bruit

17. Get the patient in a good light. Use your five senses. We
miss more by not seeing than we do by not knowing.
Always examine the back. Observe, record, tabulate,
communicate.
WILLIAM OSLER

18. Case no. 11
A 23 year old man develops toxicity after deliberately ingesting an OPC insecticide. Clinical
features include headache, vomiting, diarrhoea, hypersalivation, abdominal pain,
tachycardia, muscle weakness, fasciculation and reduced ventilation due to respiratory
muscle involvement. Which one of the following is an example of a cholinergic (muscarinic)
effect?
A. Fasciculation
B. Mydriasis
C. Respiratory muscle paralysis
D. Salivation
E. Tachycardia

19. Case no. 12
An 18 year old male presented to hospital after a deliberate overdose involving unknown substances. At
presentation there was a high concentration of paracetamol in the blood. Over the subsequent 3 days
he developed worsening abnormalities of liver function (elevated bilirubin and alanine
transaminase), clotting (raised international normalised ratio) and renal function (elevated creatinine)
and episodes of hypoglycaemia. All the features below are consistent with paracetamol overdose,
except one. Which feature is most likely to be caused by another substance?
A. Acute kidney injury
B. Early unconsciousness
C. Elevated international normalised ratio
D. Hypoglycaemia
E. Liver failure

20. Case no. 13
A 32 year old farmer presents to your hospital with a history of working in a rice paddy and being
bitten by something, not seen. He appears unwell and has swelling around the bite on his foot,
with two bite marks that are bleeding. What is a key test that might help you determine the type of
snake and need for antivenom?
A. 20-Minute whole-blood clotting test (20WBCT)
B. Arterial blood gas
C. Blood pressure
D. Extended coagulation studies
E. Serum electrolytes

21. Case no. 13(cont.)
Considering the previous patient given the particular circumstances of this bite, and that testing
showed a coagulopathy, which of the following venomous animals would be most likely as a cause
for his bite?
A. Cobra
B. Indian red scorpion
C. Krait
D. Russell’s viper
E. Saw-scaled viper

22. Russell’s viper

23. Case no. 13(cont.)
Our patient is clearly envenomed and needs antivenom urgently. In giving him antivenom, which is
the most important drug to have available?
A. Adrenaline (epinephrine)
B. Antihistamine
C. Dopamine
D. Hydrocortisone
E. Prazosin

24. Case no. 13
The patient has now developed a low urine output, despite adequate IV fluids. In this small rural
hospital setting, what test might best help in deciding that acute kidney injury and renal failure is
occurring?
A. Dipstick test for proteinuria
B. Measure serum creatinine level
C. None of the above
D. Renal biopsy
E. Renal ultrasound

25. Antivenoms recommended
Krait Cobra Russell’s Viper
Neurotoxicity
Less local envenoming
Ground bite
Obscure Fang marks
Nephro, myo-toxicity
Neurotoxicity
Local envenoming ++
Nephro, myo, neuro-toxicity,
coagulopathy
Currently available antivenoms not recommended for
the bites of:
Green pit viper
Sea Snake
Do not give antivenom for local envenoming alone, except for cobra and Russell’s viper bites
when indicated

26. DO NOT DO THE FOLLOWING!!
Do not apply tourniquets/ligature
Do not cut, or prick with needles or use any topical cream
Do not go to any traditional healer or ozha
Do not provide anything by mouth
Do not cauterize by using chemicals.
Do not apply herbal medicines, stones, seeds, saliva, potassium permanganate solution or cow-dung and
mud.
Do not apply alcohol
Do not give NSAID, Antihistamine, sedative, steroids
Do not delay to reach hospital
Do not cut wound
Do not apply ice

27. Pressure Bandage with
Immobilization(PBI)

28. The practice of medicine is an art, not a
trade; a calling, not a business; a calling
in which your heart will be exercised
equally with your head. Often the best
part of your work will have nothing to do
with potions and powders, but with the
exercise of an influence of the strong
upon the weak, of the righteous upon the
wicked, of the wise upon the foolish.
-William Osler. Aequanimitas ‘The Master-word in medicine.’