SEVENTH

YEAR
GETWAY

LCH
SBMJ, HCC

SBMJ | LUSAKA
Table of Contents
INTERNAL MEDICINE........................................................................................................... 3
OBSTETRICS AND GYNECOLOGY ................................................................................. 59
PEADIATRICS ........................................................................................................................ 69
SURGERY................................................................................................................................. 73

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INTERNAL MEDICINE
OSCE.

1. HX Taking of a 23year old who presents with a heart failure. With

atrial fibrillation
Introduce and confirm details
Get permission
What has brought them to the hospital
Review cardiovascular symptoms in full
Review respiratory symptoms in full
Review past medical hx… HTN
History of sore throat in the past
History of thyrotoxicosis
Drug history also ask on injection e.g benzathyne penicillin monthly
Surgical history
Social history - alcohol

2. Three differential dx – RHD

Thyrotocicosis
HTN
a) Three investigations – CXR, ECG, ECHO
b) Management
Rate
Rhythm
anticoagulants

3. Lower limb examination

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4. What were your positive findings
a. Localise the lesion
b. One investigation you would request for

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 5. X- ray. what were the findings

Almost complete opacification of the left hemithorax, with a meniscus

laterally. The trachea is markedly pushed to the right, due to mass effect.

a. Differential diagnosis – PTB

b. Other investigations – Fluid aspiration for analysis, biopsy, CT –

Scan, HIV test
c. Management – TB (intensive phase 4HRZE x 2months, then
continuation phase RIFNAH/ INH x 4months) if patient is HIV
positive and TLD, then Double the dose of DTG.
6. A 56-year-old Asian man presents with jaundice and ascites. Lab
results showed elevated AST and ALT.
a. What are the lab abnormalities? Elevated AST, Elevated ALT
b. Diagnosis: Liver Cirrhosis secondary to hepatitis
c. Other investigations
d. Management
7. Do a general examination patient with pellagra – defenciency of B3
(Niacin)
a. Describe the lesions
b. Differential diagnosis
c. Investigations
d. Management
8. Urinalysis
a. Record the positive findings
b. Diagnosis

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 c. Differential diagnosis
9. CSF analysis – TB meningitis
GBS
CRYPTOCOCAL MENINGITIS
10. GIT EXAMINATION – ASCITIS – SAAG
11. PLEURAL TAPING PROCEDURE
12. LUMBER PUNCTURE PROCEDURE
13. ASCITIC TAP PROCEDURE
14. DKA URINALYSIS FINDINGS/
a. Other investigations
b. Management
15. CT –SCAN – SAH
ISCHEAMIC/ HEAMORRGAGIC STROKE
CMV
NEUROCYSTORISIS
16. A 60-year-old male a known retroviral disease patient for 5
years from maramba presented to Dr Simon Beda Mwale at
Livingstone Central Hospital medical department. He presented to the
Medical department on a wheel chair paralysed for 3 weeks. He also
presented with a CT Scan.

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 a. Describe the lesion?
Ring enhanced leison
b. At what CD4 is this patient predisposed to this condition?
Less than 100
c. Whats your diagnosis?
toxoplasmosis
d. What further investigations can you do to confirm the
diagnosis?
Serum TAT, PCR, IgG, IGM, Hemagglutination test,
e. How do you manage?
Cotrimozaxale and Prednisolone
f. Complications
Retinochondritis, cataract,
g. Differential diagnosis?
CNS TB (TBM), shyphilis, CMV, brain abcess, histoplasmosis,

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17. Identify the following slides

\
a. Which organism is in the above slides?
Entamoeba Histolytic

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 b. What disease does it cause? Amebiasis
c. Complications of amebiasis ? fulminant or necrotising colitis, toxic
Mega Colon, ameboma, Retrovaginal fistula, amobic liver abcess,
bowel perforation, stricture, intussusception, empyema.
d.
risk factors
returning traveler, visitor from another country, or those on monoclonal antibody
therapy directed against IgE such as omalizumab
Investigations
Entamoeba histolytica was detected by stool polymerase chain reaction, and E.
histolytica antibody was positive (ELISA), LAMP (especially in amoebic liver),
endoscopy, histology

Management

18. A patient presented with a febrile illness after travelling to

Lusaka. Investigations were done and under the microscope the
following was seen.

a. What do you see on the slides above? Malaria Trophosoite

b. What’s the diagnosis? Malaria
c. What are the species of the above diagnosis?

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 Malaria, falciparum, vivax, ovale, knowlesi,
d. What stage is shown in the slides above?
Trophosoites
e. What are the 10 complications of malaria?
CNS – Prostration, Cerebral Malaria (Coma, Seizures)
Metabolic – Hypoglycemia, metabolic acidosis
Resp – Tachypnoea, ARDS, Pulmonary Edema
Hematological –Severe Aneamia (due to
hemolysis,dyserythropoiesis), DIC, Bleeding (Retinal Heamorage)
Renal –Heamoglobinuria (Blackwater fever), Oligouria, Uraemia
ATN)
GIT/Liver – Diarrhoea, Jaundice, splenic rapture (splenomegaly)
General – Shock, Hypotension
f. What is the management of severe malaria?
Iv atesunate 2.4m/kg (0, 12, 24, 48) then switch to atemeter
lumefantrin
g. What are the complications of quinine? Hypoglycaemia
h.
19. A patient presented with a febrile illness after travelling to
china then to Italy then France and back home to Lusaka.
Investigations were done and under the microscope the following was
seen.

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11
a. What’s diagnosis? Coronavirus (Covid – 19)
b. What is the cause of coronavirus? SARS – COV 2
c. What type of a virus is SARS – COV 2? RNA virus
d. What family is SAR – COV 2?
e. What is the pathogenesis?
f. What investigation is used to confirm the diagnosis? RT – PCR
g. What other investigation is used to support your diagnosis? CT-
Scan chest
h. What findings do you expect to find on CT-scan chest?
Consolidation, hazy patchy appearance and ground glass

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 i. What are the signs and symptoms of COVID – 19?
j. What are the complications of COVID – 19?
k. What is the management of COVID – 19?
20. A 7-year-old presented to Dr Hastings Lungu, at Livingstone
Central Hospital with history of passing blood in urine. He says the
blood in his urine is prominent close to when he is about finish his
urination and he experiences pain when passing urine and feels there
is something inside. He also gives a history of playing in the nearby
swamps in Maramba compound Livingstone.

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 a. What is the most likely diagnosis?
b. How many species are common?
c. What is the confirmatory diagnosis?
d. After laboratory investigations identify the following species?
e.

21. Identify the sides below:

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22. Identify the CT Scan below

CMV

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Owls appearance - CMV
23. Identify the CT-Scan below
24. A patient presented to Dr Simon Beda Mwale Jr in the
emergency room with the following signs.

OPISTOTONUS POSITION

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 AMPUTATED FINGER RISUS SARDONICUS
a. What signs do you see on the picture below?
b. What is your diagnosis? Tetanus infection
c. Risk factors?
d. What other departments in the following is this patient is to be
referred to? Opthamology
Nephrologist
Cardiologist
Maxillofacial
ENT
Interventional Radiologist – PE
Anesthetises
e. What investigations would you order for this patient?
Serum
25. A 34 years old patient, a known retroviral disease reactive
patient for 10 years presented with a fever, headache, neck
stiffness. Dr innocent Motshabi the intern on call made a diagnosis of
meningitis clinically.
a. What next test is Dr Motshabi going to request for? Lumbar
puncture
b. What tests were ordered to analyse the fluid?
CSF CRAG, CSF TAT, CSF gene xpert, CSF GLU, WCC, RCC,
Gram stain, Protein, India ink
c. What are the layers that you go through?
d. What are the indications for the test in (a)
e. What are the contraindications for the test in (a)

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 f. After results were obtained show that India ink was positive.
Thus, Dr Motshabi started managing the patient for
cryptoccoal meningitis. What are the poor prognostic factors in
a patient with crpytococal meningitis?
g. Dr Motshabi initiated the Cryptoccoal meninigitis WHO
protocol. How do you manage this type meningitis?
h.
26. A patient presented with a cough.

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19
27. Ct scan

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28. Salmonella

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22
23
29. Shigella

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25
30. Ecoli

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27
28
31. Candida

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30
31
32. Sickle cell disease

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Theory

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Question 1.
Mr Mwale 42-years-old, businessman, normotensive, nondiabetic,
nonsmoker, hailing from Livingstone presented with fever for 2 months,
which is low grade, highest recorded temperature is 102° F. There is no
history of chill and rigor or profuse sweating. The patient complains of loss
of appetite and substantial loss of weight for the last … months. There is
no history of diarrhoea, vomiting, urinary abnormality, cough, haemoptysis,
skin rash, oral ulcer, joint pain, hematemesis, melena, history of travel to
malaria endemic zones, IV drug abuse, needle prick injury. He denies
unprotected sexual exposure. He was treated by local doctors, but no
improvement. There is no family history of any illness.
General examination
The patient is ill and emaciated.
He is moderately anemic.
No cyanosis, jaundice, edema, clubbing, koilonychia or leukonychia.
No lymphadenopathy or thyromegaly.
Pulse: 120/min.
BP: 90/70 mm Hg.
Temperature: 100ºF.
CVS: No abnormality.
Respiratory system: No abnormality.
Nervous system: No neck rigidity, Kernig’s sign
Gastrointestinal system: Tongue is coated with angular stomatitis. No
organomegaly.
Musculoskeletal system: No spinal tenderness, no gibbus, no other
abnormality.
Examination of other systems reveals no abnormalities.
a. What is your diagnosis?
b. What is the commonest cause of the above?
c. What investigations would you do?
d. What is your definition of the above diagnosis?
e. How do you classify the above diagnosis in (a)?
f. What are the causes of the above diagnosis?
g. What drugs can cause the above diagnosis?
h. What history would you elicit from the above to confirm your diagnosis?
i. What physical findings would you look for in the above diagnosis?

Question 2.
Mr Beda Mwale Jr a 45 years old male a known cardiac patient presented
with heart palpitations to Livingstone Central Hospital. On review in cardiac
clinic the Doctor Alefa Phir ordered an ECG for the

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patient.

a) Interpret the ECG findings above?

Irregular R-R Interval
Absent p waves
b) What is your diagnosis of the ECG findings above?
Atrial fibrillation
c) What is Atrial Fibrillation?
It is an arrhythmia where atria beat rapidly, chaotically and ineffectively,
while the ventricles respond at irregular intervals, producing irregularly
irregular pulse. Any conditions causing raised atrial pressure, increased
atrial muscle mass, atrial fibrosis, inflammation and infiltration of the
atrium can cause atrial fibrillation.
The atria usually fire impulse at the rate of 350 to 600/minute, ventricles
respond at irregular intervals usually at the rate of 100 to 140/minute.
Many of the atrial impulse reach the AV node in the refractory period. So,
not all are conducted.
d) How do you classify the above diagnosis given in (b)?
Paroxysmal < 7 days
Persistent > 7 days
Longstanding persistent >12 months
Permanent – Failed medical treatment
e) What is the pathophysiology of the above?
Automatic focus – pulmonary vein
Multiple wavelet theory
f) What are the causes of the above?
Chronic rheumatic heart disease with valvular lesions, commonly mitral
stenosis

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Coronary artery disease (commonly acute MI)
Thyrotoxicosis
Hypertension
Lone atrial fibrillation (idiopathic in 10% cases)
Others: ASD, chronic constrictive pericarditis, acute pericarditis,
cardiomyopathy, myocarditis, sick sinus syndrome, coronary bypass surgery,
vulvular surgery, acute chest infection (pneumonia), thoracic surgery,
electrolyte imbalance (hypokalemia, hyponatremia), alcohol, pulmonary
embolism.
Hemodynamic states
Atrial ischemia
Inflammation
Non-cardiovascular respiratory
Endocrine disorders
Neurogenic disorders
Advancing age
g) Give 5 physical findings in your above diagnosis (b)?
Irregular – irregularly pulse,
Head and neck
Exothalmus, carotid bruit, thyromegaly, cyanosis
Pulmonary findings – rales, pleural effusion
Abdomen – ascites, hepatomegaly
Lower extremities – clubbing, cyanosis
Neurologic – increased reflexes
h) How do you manage the above?
Rate – beta blockers, non – dehydropyridines calcium channel blocker
(verapamil, diltiazem, nefedipine), Beta blockers (Esmolo, propranolol,
atenolol, metoprolol), digoxin, amiodarone
Rhythm control – Electrical cardioversion, flecanide, propafenone,
deflitilide, amiodarone, satolol, Ablation (Catheter based, Surgical, hybrid)
Anticoagulants – heparin, Dabigatran, Rivaroxaban, Apixaban, Endoxban

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 i) Classification of the medications used in the above are named after?

j) How do you classify the above medications and give examples in each
class?
k) List five complications of the above?
Pulmoray embolism, stoke, renal failure
l) What is the role of anti-coagulant in atrial fibrillation?
Usually, warfarin is given who are at risk of stroke. Target INR is 2 to 3.
It reduces stroke in 2/3rd cases. Aspirin reduces stroke in 1/5th cases.
Anticoagulation is indicated in patient with atrial fibrillation having risk
factors for thromboembolism.
m) Assessment of risk of thromboembolism in atrial fibrillation—CHADS
score:
Congestive cardiac failure (1 point)
Hypertension (1 point)
Age > 75 (1 point)
Diabetes mellitus (1 point)
Stroke or transient ischemic attack (2 points).
In CHADS score:
Score 0 has a stroke risk of 1.9% per year.
Score 6 correlates with 18.2% stroke risk per year.
For prevention:
The patient with score 0 should get aspirin only
The patient with score 1 should get warfarin or aspirin
The patient with score 2 or more should get warfarin

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Question 3
Mrs M. Mwale a 50-year-old woman, presents to Livingstone Central
Hospital after an acute condition. While in the Emergency Room Dr
Hastings Lungu an Intern Doctor orders an emergency ECG after an
assessment.

a) Interpret the following?

ST Elevation in leads V2, V3,
b) What is your diagnosis in the above?
ST – ELEVATION MI
c) What is the pathophysiology of? myocardial infarction, reperfusion
injury, plaque
d) What are the types of the above (b)? NON STEMI AND STEMI
e) What syndrome is associated the above (b)? Acute coronary syndrome
f) What are the risk factors of the above (b)
g) What are your findings on physical examination?
HR – INCREASED
BP – ELEVATED
RR- INCRESED
TEMP- ELEVATED
NECK VEINS – DISTENDED
HEART - DISPLACED APLICAL BASE, MURMUR
ABDOMEN – HEPATOJUGULAR REFLEX POSITIVE, PULSATILE
ABDOMINAL MASS
h) What are the specific investigations you would do to confirm (b)?
Cardiac biomarkers – troponin I AND T, CK, CK MB, Myoglobin, BNP
i) What are the treatment options?

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 j) What is used in the stratification of patients with the above
condition?
Killip classification
Class 1 - no signs of heart failure
Class 2 - rales, crackles, elevated jvp
Class 3 – with frank acute pulmonary edema
Class 4 – cardiogenic shock, hypotension, impared mental illness, cyanosis

Question 4

1. Hospital female ward with body hotness which does not stop. She had
the history of; cough, asthma treated with corticosteroids at times.
On examination, the fever was above 38 degrees Celsius for some
time.
a) Define fever of unknown cause?

A fever of 38.3oC on several occasions, persisting for at least for 3 weeks,

diagnosis is not made after more than 2 outpatient visits or 3 days in the
hospital with no obvious source despite investigations
b) Give 5 noninfectious causes of fever of unknown origin.

Malignancy – lymphoma, myloma, Carcinoma (renal cell) of kidney, liver,

colon, stomach, pancreas
SLE.
Giant cell arteritis.
Vasculitic disorders, e.g. PAN and rheumatoid disease with vasculitis.
Polymyalgia rheumatica.
Adult Still's disease.
Polymyositis

c) Infectious causes?

Tuberculosis.
Abscess (amoebic or pyogenic liver abscess, subphrenic or at any site).
Infective endocarditis.
Urinary tract infection, (especially prostatitis).
Dental infection.
Sinusitis.
Cholecystitis or cholangitis.
Bone and joint infections.
Malaria, brucellosis, toxoplasmosis.
Viral infections (CMV, HIV).

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Fungal infections.
d) The patient was PANCA positive. What is your diagnosis?

Churge Strauss syndrome (Eson

e) C – ANCA

Wegners granulamatosis
Microscopic polyangitis
Polyarthritis nodosa

f) What other investigations are you going to do?

FBC/DC – Eosinophilia
ESR/CRP - ELEVATED
CXR – Pulmonary infiltrates or opacities which are bilateral
ECG – cardiac manifestations
G- endoscopy -
RFT – Elevated
Urine MCS – red blood cell cast
Urinalysis – proteinuria
IgE – elevated
RF – positive
ANCA - positive
PNS XRy – sinusitis,
Histology – small necrotizing granuloma in the lungs on biopsy, kidney, skin,
muscle, nerve
g) What is the management of patient you have diagnosed in (c)?

Induction phase
Glucorticoids – e.g prednisolone
Used only if there is steroid resistant - Cytotoxic drugs –
cyclophosphamide, monoclonal antibodies – rituximab,
Maintainance
Methotrexate
Azathioprine
Prognosis – 5 years’ survival rate without treatment
On treatment – 90%
Complications
Cardiac failure
Renal failure
Status asthmatics
Cerebral hemorrhage
Gi bleeding

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 2. Tyson Wamunyima presented to Dr. Lungu Hastings at the Livingstone
Central Hospital with the history of; vomiting, diarrhea and fainting.
He also has the history of excessive nose bleeding after being injured
with a hoe at a farm. On examination; he is drowsy, temp of 35.1,
BP of 89/55mmHg, and his radial pulse was weak or not appreciated.
After touching his hands and legs they were cold.
a) What is the diagnostic criteria of this condition?
Criteria for shock –
Blood pressure – systolic < 90mmhg or MAP of <65
HR– tachycardia
Mental status- altered
Serum lactate – Altered (>2mmol/l)
Base (HC03) – Altered
Urine output - <0.5ml/kg/hr
Central venous pressure -
Central weigh pressure -
b) What are the types of shock?

Distributive shock – anaphylactic, septic

Obstructive – neurogenic, Cardiac tamponade, tension pneumonia
thorax
Hypovolemic shock – Burns, diarrhea, vomiting
Cardiogenic shock – MI,
c) What other clinical pointers are you going to look for in this
patient with the history of vomiting?

Low GCS
Cool peripheries
Pallor
Tachycardia
Slow capillaries refill
Tachypnea
Oliguria
d) What information are you going to look for the cause of shock?

What type of diarrhoea, consistency bloody non bloody, duration

e) What is the management approach?

Identify and treat underlying cause

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 Raise the legs
Give a fluid bolus of 20m/kg/bwt
ABCDE
Insert tubes – urinary catheter, central line, IV lines (collect
bloods) – give 3 boluses in the first hour, if no improvement after
an hour.
START IV ANTIBIOTICS
START INNOTROPIC DRUGS – E.g. Dopamine
f) Define shock index? Beside assessment of HR/SBP (0.5 – 0.7)
g) Modified shock index: HR/MAP (STEMI)
h) What MAP is required to achieved adequate renal perfusion?
65
i) How do you know that the patient is out of shock?
Urine output
Central weigh pressure
MAP
Lactate dehydrogenase level
Central venous pressure
Shock index
Question 5
3. Mr. Shapeela Spedding, a handsome young man aged 27 presented to
Dr. Mukumbuta Talama Nawa at Livingstone Central Hospital with
altered levels on consciousness and left sided hemiparesis. His blood
pressure was 220/140mmHg and the chest x ray showed
cardiomegaly. The Echo findings also revealed left atrial ventricular
dysfunction.
a) What is your diagnosis? Acute ischemic stroke secondary to
severe hypertension
b) From the history what are the risk factors of the above
condition?

Modifiable
Alcohol
Smoking
Drugs - NSAIDS
Non-modifiable
Age
Endocrine disorder – conns, pheochromcytom, hyperthyroidism,
Renal – RAS disorders
Family history

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 c) What are the complications of the other types of the
condition you have diagnosed?

Renal failure
Hemolytic
Aortic dissection
Acute coronary syndrome

d) How would manage the management of the patient with

Ischemic stroke?

Admit to HDU
Continue antihypertensive
Start IV tissue plasminogen activator – altapsae,
Maintain on low dose aspirin, if patient is allergic to aspirin clopedegril
Labetalol and Nicardipine
e) What are the physical findings would look for to help with
your diagnosis?

Carotid brite
Nuerological deficits – Hemiparesis, facial droop
Height , weight, = BMI to
Pulse
Bp
Fundoscopy
Abdominal apron – visceral megaly, ascites
Apex beat
Lower limb edema
f) Does the patient above have a hypertensive emergency?

Yes
g) What are the other investigations you would order?

h) What are your findings on peripheral blood smear?

Fragmented rbc
i) List four medications you would use to manage your BP?
Sodium nitroprusside, labetalol, clevidipine, fenoldopam
Question 6

4. Mr. Pipeline Zulu a 32-year-old man with acquired immunodeficiency

syndrome (AIDS) presents to Dr. Beda Malume Mwale at LCH OPD

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 with complaints of worsening of headache, fever and stiff neck. A
Lumbar puncture is performed with the help of Dr. Motshabi Innocent
and the csf findings are as follows: elevated opening pressure,
protein level of 400, reduced glucose level of 30, and White blood
count of 700 with lymphocytes of 50. A special staining of the spinal
fluid reveals a budding yeast.
a) What is your diagnosis? Cryptoccoccao meningitis
b) What microorganism causes this disease and what is its
morphology?
Cryptococcoal neoformins, morphology – spherical encapsulated
(mucious) non mycelied
c) How is the organism transmitted and how does it cause illness?

Pigeon drop-ins, soil, feaces via inhalation of spores via respiratory system
d) Apart from Indian ink reveling a budding yeast, what are the
other investigation which Dr. Beda will do from cerebra spinal
fluid?

CSF CRAG, PCR, CSF TAT, GENE XPERT,

e) Give the laboratory serological findings for this organism?

Latex agglutination which detects polysaccharide antigen

f) What are the poor prognostic factors?

Low CD4, Low WCC of LESS than 20, high csf Cryptococci titer (>1:1024),
Low BMI, positive India ink, high pressure CSF between 20 – 22, GCS of
less than 8 (Alter mental status), hyponatremia, positive cultures from
extra meningeal sites.
g) What is the most appropriate treatment of this condition?

Induction
Premedication before giving drugs – IV
One week (amphotericin B deoxycholate (1mg/kg/day) and flucytocine
(100mg/kg/day) divided in four days per day) followed by one week
fluconazole (1200mg/day)
Repeat LP after 2 weeks
Maintenance
Fluconazole 600mg
Continuation
Fluconazole 200mg

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Question 7
5. A 46-year-old man presents with itching of the skin after taking a
cold bath. He says he usually has such episodes occasionally which
resolves spontaneously and has never seen a doctor for this itchiness.
He presents to the department of internal medicine Dr David Zimba
orders a full blood, results were as follows:

a. What are the abnormalities in the full blood count?

Hb highly elevated
High heamatocrit
Mcv – low

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 Rbc – highly elevated
Wcc – slightly low
b. What is your diagnosis?

Polycethemia rubra vera

c. What other things would minic the blood picture above?

Dehydration, obesity, malignancy – chronic myeloi leukemia, COPD, high

altitude
d. What other investigations would you do?

ESR elevated, SPO2, PBS, Bone Marrow aspiration, erythropoietin levels,

genetic test – JAK 2
e. What is the pathophysiology of your above diagnosis (b)?

Mutation in the JAK 2

f. What are the complications of the diagnosis in (b)

Pulmonary hypertension, thrombus formation, malignancy transformation,

stroke
g. What is the management of the above (b)

Phlebotomy
Question 8
Mr Mweene a 48 years old, shopkeeper, normotensive, nondiabetic, smoker,
hailing from Livingstone, presented with frequent attack of cough with
profuse expectoration of mucoid sputum for 6 years. Cough is present
throughout the day and night, more marked in the morning and also on
exposure to cold and dust. It is progressively increasing day by day. He
also complains of difficulty in breathing, more marked during moderate to
severe exertion, relieved by taking rest. His breathlessness is progressively
increasing. There is no history of chest pain, hemoptysis, paroxysmal
nocturnal dyspnea. He does not give any history of fever, swelling of the
ankle or weight loss. His bowel and bladder habits are normal. He was
admitted in the hospital 4 times with severe breathlessness in the last 3
years. He smokes 30 sticks a day for last 35 years. He used to take
tablet aminophylline, salbutamol, ketotifen frequently. Sometimes, he used
to take different types of inhalers. There is no history of such illness in
the family.
Dr Nawa Mukumbuta ordered ABGs on admission.
Results as below
PH – 7.0 (7.35 – 7.45)
HCO3 – 12 (22 – 26)
P02 – 50 (70 – 100)

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 PCO2 – 55 (35 – 45)
a. Interpret the ABGs?

PH – LOW
HCO3 – LOW
PCO2 - HIGH
b. What is your diagnosis?

COPD
c. What type of respiratory failure is this?

Type 2 respiratory failure (blue blott)

d. What are the differentials of (b)

PE
Pulmoray edema
Pneumonia
Gbs
Severe asthma
e. What investigations would you order?

CxR – hyperinflation, increased bronchovascular markings

Spirometry – low FEV
Fbc/dc – polycythemia
CT – bronchial wall thickening, bullae
ECG – Right axis deviation
CSF – rule GBS
f. What are the risk factors?

Dusty (air pollution), cystic fibrosis, alpha antitrypsin, smoking

g. Complications

Heart failure, cor pulmonale, malnutrition, secondary polycythaemia,

infection
h. Management
ABCDE
Reverse hypoxia or prevent –
Supplemental O2, saturations greater than 90
Medications – loop diuretics – frusemide
Nitrites lower the preload and after load – eg nitroglycerine
Morphine iv
Inotropes – dopamine
Bronchodilators – sulbutalmol
Anticholinergics – atropine

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 Corticosteroids – hydrocortisone
Xanthines – aminophylline

i. What is the prognosis of (b)

50 %

Question 9
Mrs. M. Mwale, 32 years old, housewife, normotensive, nondiabetic,
hailing from Livingstone, presented with the complaints of excessive
sweating and heat intolerance for 5 months. She prefers and feels
comfortable in cold environment. She also noticed significant loss of
weight inspite of her good appetite. She feels very hungry and takes
more food, also experiences palpitation, even at rest which is more
marked on exertion. She also complains of insomnia, irritability and
restlessness for the last 3 months. The patient also complains of
occasional loose stool, 3 to 4 times per day, which is not associated with
mucus or blood and not related to intake of any food or milk. There is
no history of fever, excessive thirst, polyuria or abdominal or chest
pain. There is no such illness in her family. Her menstruation was
regular. But for the last few months she is amenorrhoic. There is no
history of taking drugs that may cause these symptoms. There is no
family history of similar illness.
Dr Joe Mwanza orders thyroid tests; results below
TSH – 0.1umol/l

a. What is your diagnosis?

Greaves disease
b. What is the pathophysiology?

Autoimmune response in which there is hypersecretion of thyroid circulating

immunoglobulins
c. What further tests would you do and give what are the
expected results?

TSH receptor IGG antibodies – may be present

Thyroid scan - homogenous uptake
T3 AND T4 – high
u/s – homogenous
FBC/dc – leucocytosis
ESR – elevated

48
 d. What is the management and give the precautions for each
modality of treatment?

Medical – carbimazole causes agranulocytosis (repeated FBC/DC

weekly)
Surgical – thyroidectomy- causes bleeding (uthyroid)
Radioactive iodine – crosses placenta (pregnancy test)
e. What is the pathophysiology of opthalmopalthy?

It is immunologically mediated. Within the orbit, there is cytokine-

mediated proliferation of fibroblast, which secretes hydrophilic
glycosaminoglycans.
The following changes occur in ophthalmopathy:
• Excessive interstitial fluid and infiltration of chronic inflammatory
cells in the orbit (lymphocytes,plasma cells and mast cells)
• Swelling and edema of extraocular muscles
• increased retrobulbar pressure and eyeball is pushed forward
(proptosis). In severe cases, optic nerve compression may occur.

f. What is pretibial myxedema?

In this condition, there is firm, nodular, thickened or plaque-like lesion,

pink or brown, giving a peau d’orange appearance. It is due to the
deposition of mucopolysaccharide in the dermis. Usually, present in the shin
of legs up to the dorsum of foot (but may occur in any part of the body,
especially at pressure point). It may be pruritic and hyperpigmented. It is
present only in Graves’ disease in 10% cases, almost always associated with
ophthalmopathy and is not a manifestation of hypothyroidism (pretibial
myxedema is a misnomer). Occasionally, pretibial myxedema develops after
treatment of hyperthyroidism, especially with radioiodine therapy.
Treatment is rarely necessary. Local injection of triamcinolone or ointment
betamethasone may be helpful.

Question 10
A 52-year-old man presented to with a cardiac condition. On clinical
examination, he was noted to have a blood pressure of 167/50. A diastolic
murmur is detected in the second intercostal space, right sternal border.

a) What can you observe about the blood pressure?

Wide pulse pressure (difference between systolic and diastolic pressure –
20-40 mmHg)

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 b) What is your diagnosis?
Aortic regurgitation
Dx – thyrotoxicosis
Severe anaemia (Fe)
Pregnancy
Thiamine deficiency (wet beriberi)
Arteriovenous fistula in a patient – pda
Volume depletion
Sympathetic overdrive
Aortic stiffening
c) List 5 other peripheral findings in (a)
Corrigan’s sign – carotid pulsation
De musset’s sign – head nodding with each heart beat
Quincke’s sign – capillary pulsation in the nail bed
Du roziez’s sign- in the groin which compresses the femoral artery 2cm
proximal to the stethoscope gives a systolic murmur the 2cm distal gives
diastolic murmur.
Treaube’s – pistol shot sign over femoral arteries
Austin flint murmur – due to flattering of anterior mitral valve cusp caused
by regurgitant string

d) List the other valvuvular cardiac lesions found with the

following findings.

i. Austin Flint Murmur – found Aortic Regurgitation

ii. Carey coombs murmur – RHD it’s a diastolic murmur, on
mitral valve (mitral valvulitis)
iii. A diastolic murmur with an opening snap in the 5th
intercostal space mid clavicular?
Mitral stenosis

Question 11
A 63-year-old goes to her GP complaining of extreme tiredness. She has
been increasingly fatigued over the past year., but in recent weeks she has
become breathless on excertion and light-headed and complained of
headaches. Her feet have become numb, and she has started to become
unsteady on her feet. She has had no significant previous medical illnesses.
She is a non-smoker and drinks about 15 units of alcohol per week. She is
taking no regular medications.
Examination

50
Her conjuctivae are pale, and sclera are yellow. Her temperature is
37.80c. Her pulse rate is 96bpm and regular, and blood pressure is 142/72
mmHg. Examination of her cardiovascular, respiratory and abdominal
systems is normal. She has a symmetrical distal weakness affecting her
arms and legs. Knee and ankle jerks absent, and she has extensor plantor
responses. She has sensory loss in a glove and stocking distribution with a
particularly severe loss of joint position sense.
Laboratory results
HB 4.2g/dl
MCV 114 fl (80 – 99)
WCC 3.3 x 109/l
Plt 102 x 109/l
Na 136 mmol/l
K 4.4mmol/l
Urea 5.2 mmol/l
Cr 92 mmol/l
a) What abnormalities can you see in the results?
Low Hb
Low WCC
Low PLT
High MCV
Pancytopenia
b) List 4 causes of the abnormalities seen in the results?
Excessive alcohol consumption
Hypothyroidism
Chronic liver disease
Vitamin B12 deficiency
Certain drugs – azathioprine, methotrexate, zidovudine,
phenytoin
Primary acquired sideroblastic anaemia and mylodysplatic

c) What is the most likely diagnosis in the scenario above?

Vitamin B12 Deficiency secondary to chronic alcoholism
d) List 4 other investigations can do to confirm your diagnosis?
List findings
Peripheral smear (Hyper segmented neutrophils)
Serum B12 (LOW)
Serum Folate levels (low)
Antibodies against Intrinsic Factor or Parietal Cells (positive in
pernicious anaemia)
Schillings Test (positive)

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 e) What complication has occurred in the patient above?
Subacute combined degeneration of the spinal cord
f) How do you treat this condition?
Vitamin B12 injections 1000iu/daily for one week, then 1000iu
weekly for a month, the 1000iu monthly till levels normalise (or
indefinitely for pernicious anaemia)
Question 12
A 20-year-old man presents to LCH complaining of painless swelling of both
legs, which he first noted approximately 2 months ago. The swelling started
at the ankles, but now his legs, thighs and genitals are swollen. His face is
puffy in the mornings on getting up. His weight is up by 10 kg over the
previous 3 months. He has noticed that his urine appears frothy in the
toilet.
On examination, there is anasarca and bruising on the forearms and around
the eyes. There are no signs of chronic liver disease. His pulse rate is
72bpm and regular. Blood pressure is 166/78 mmhg. His JVP is raised at
5cm. The rest of the examination is unremarkable. Urinalysis shows 3+
proteinuria.

His laboratory workup shows the following

Hb 10.7g/dl
McV 95
WCC 4.7 x 109/l
PLT 176 x 109/l
Na 138mmol/l
K 4.9mmol/l
Urea 7.4 mmol/l
Cr 112umol/l
Albumin 16g/l
Cholesterol 15.2mmol/l

b) List any three abnormalities in the above results?

Slightly low HB
Very low albumin
High cholesterol
Heavy proteinuria
c) What is the possible diagnosis?
Nephrotic Syndrome
Dx – diabetic nephropathy

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 Chronic glomerulonephritis
Iga nephropathy
Sickle cell nephropathy
d) List 4 histological types in diagnosis (ii)
Minimal change
Focal segmental glomerulosclerosis
Membranous nephropathy
Membranoproliferative
e) What 2 additional investigations would like to aid in the
diagnosis and give a reason why?
Renal biopsy – to confirm histologic type
Renal US – checking size, CMD
Autoimmune screen – r/o autoimmune eg lupus
Clotting profile – usually in a procoagulant state due to loss of
antithrombin 3 and protein c/s

f) List 3 treatment modalities for above condition

Diuretics – loops e.g furosemide high dose to reduce oedema
Reduce fluids to 1L/day and reduce salt intake
Steroids in case of minimal change
Treat underlying cause
Anti-hypertensives e.g. enalapril
Supportive – High protein diet

Question 13
a) A 55 years old male patient with lethargy and confusion for 3
days. He has no prior history of similar presentation. He is a
known type 2 diabetes patient well controlled on an oral
hypoglycemic agent for 3 years.
On examination he appears lethargic, disoriented in time and
place. His blood pressure, pulse, temperature and peripheral
saturation of oxygen are all normal. The rest of the systemic
examination was unremarkable.
Laboratory investigations shows the following
RBS – 6.5 mmol/l WCC 6.5 X 109/L
HB – 14g/dl Na 121 mmol/l
PLT – 179 X 109/L cr 102 mmol/l
K – 4.2 mmol/l serum osmolarity 264 mosm/kg
Albumin – 30g/l
II. What abnormalities can you see in above results.

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 Low sodium
Low Serum osmolaraity
III. What is the most likely diagnosis?
SIADH (syndrome of inappropriate antidiuretic hormone)
IV. What could be the cause of the condition from the clinical
scenario given?
Oral hyperglycaemic agents such as tolbutamide
V. What are the other 2 causes of the condition?
CNS – Cns lupus, brain abscess, cavernous sinous thrombosis,
delirium tremens, epilepsy, GBS, Head trauma, Wernickie
encephalopathy
RESP – lung cancer, mesothelioma, bronchiolitis, acute
respiratory failure, aspergillosis, asthma, atelectasis, cystic
fibrosis, emphysema, pneumonia, TB,
GIT – adrenocorticortical ca, ca cervix, prostate ca, ureter
GUT – ca colon, ca pancreas, ca duodenum
VI. What test(s) would help you confirm the diagnosis and what
would you see
Urine sodium high (>40mmols/l)
Urine osmolality (>100 mmol/l)
High plasma vasopressin levels
Abnormal water load test
I. What are the ways of treating the patient above?
Water restriction
Loop diuretics – furesmide
Hypertonic saline (with caution)
Vasopressin V2 antagonist – conivaptan, statvactan
II. Complications
Cerebral edema
Non cardiogenic pulmonary edema
Central pontine myelinolysis

Narrow pulse pressure – less than 25% of systolic value

- Causes – Aortic stenosis
§ Congestic cardiac failure
§ Cardiogenic shock
§ Cardiac tamponade
Question 14
A 30-year-old male presented with

54
 a. Interpret the x-ray above
Bilateral peri – hilar lymphadenopathy
Question 15
Interpret the xray

ground glass appearance

Question 16

55
ischemic stroke

Question 17.
Mr Zulu 55-year-old male trader from Kafue Market, a known Diabetic
Mellitus and Hypertensive patient with good control of both conditions. He
lives with his wife and two children with a flushable toilet, with water
supply said to his home said to be poor. Last week he is said to have had
boom in his business as he had transacted with South African business man
from Pretoria who is said to have bought all his products from his shop. He

56
is said to have not even gone for work the following day as all his products
had elapsed in his shop.

A week later according to his wife he is said to have had a fever and a
drug cough with flu. Two days later he presents to you at Shikoswe Clinic in
Kafue, in a comatose state, unresponsive, with a weak pulse, respiratory
rate of 30 bpm, saturations 80%.
After laboratory investigations, the following microorganism isolated.

a. What in history would you inquire from the wife?

b. What are your expected physical examination findings?
c. What is the confirmatory investigation?
d. List other investigations you would request for and expected findings
of those investigations?
e. What type of a microorganism was isolated?
f. What family does this microorganism come from?
g. What is your diagnosis?
h. What causes (f)
i. What is your differential diagnosis?
j. What routes is (f) spread?
k. What is the pathophysiology of (f)?
l. What is the incubation period of a patient with (f)
m. What are the complications of (f)?
n. What is the natural reservoir of the isolated microorganism?

57
 o. What thought to have transmitted (f) to humans?
p. What public health measures would you implement?
q. What are the poor prognostic factors in this patient?
r. How do you manage the patient above?

Question 18
A 60 year man presents to your hospital with central chest pain. A
diagnosis of myocardial infarction is made and the patient is sent to south
Africa for an operation which is successful. After 2 months he presents
again with central chest pain and difficulties in breathing.

a. What are the ECG findings?

b. What is the diagnosis now?
c. What procedure was done in south Africa?
d. What is the confirmatory investigation?
e. What is the management?

Question 19
Sarcoidosis
Investigations
Management

Question 20
Organophosphate poisoning
Signs and symptoms
Confirmatory investigation
Other investigation
Management

Question 21
TLD
Advantages of deltagravir

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OBSTETRICS AND GYNECOLOGY
OSCE
1. HX Taking abdominal pain

2. Pre- eclampsia counselling

3. Abdominal examination

4. Mva

5. Instruments
Forceps – riglers

6. Drugs
a. RPR in pregnancy - Benzathine penicillin 2.4 mu IM weekly for
3 weeks
b. Hyperprolactinaemia bromocriptine -
c. Drugs of choice in PROM
d. Bacterial Vaginosis -
e. Cervical Ripening at term – 25umg
f. Erythromycin – 250mg qid po
g. Magnesium sulphate
h. Benzathynpencilin -
7. VIA

8. CONTRACEPTIVES
a) MIRENA
b) COC
c) LOOP
d) MINI PILL
e) EMERGENCY CONTRACEPTIVES

9. PARTOGRAPH
10. SEMEN ANALYSIS
11. PICTURE OF HYSTERECTOMY
12. HORMONAL PROFILE

59
 13. HELLP SYNDROME RESULTS
14. CTG RESULTS – FETAL DISTRESS (DEFINATIONS OF
ACCELERATION, DECELARATION, VARIABLITY)
15. WRITE A FULL PRESCRIPTION OF A PATIENT WHO HAS
BEEN SEXUALLY ASSAULTED
16. Dilutions of sodium hypochlorite
17.

Theory
A 19 year old first year student from Kafue Institute, who recently had
got into a relationship with a third year student at the same institution.
Presents to the Kafue district Hospital with a history of having had not
seen her menses for 2 months, and says has never used a family planning
pill. She also presents with vaginal bleeding, lower abdominal pain, with
fever and chills. She also tells the clinician that she has not been able to
shower with her friends as there is bad smell that does not go away after
bathing from her vagina.
a. What other history are you going to inquire from the patient?
b. What are your expected findings on physical examination?
c. What is the diagnosis?
d. What is the definition of (C)
e. List the other types of (C)
f. List the investigations you would request for?
g. How do you manage the patient above?
h. The auntie the patient who is the bedsitter tells you she has not
been able conceive as when she gets pregnant in the second
trimester, this has happened in three of her previous pregnancies.
She says clots and parts usually come off her vagina without any
pain.
a. What is the diagnosis
b. List on investigation you would request for to confirm your
diagnosis, also what is your expected finding
c. What is the management?

Question 1
A 27-year-old woman, who is 30 weeks’ gestation in her first pregnancy, is
admitted from home with a history of painful contractions. Outline the
management of this problem.

60
Question 2
Outline the principal features that one would include in a consent form to
women who are considering sterilization in an outpatient appointment.
Question 3
A 20-year-old woman has had an episode of amenorrhoea lasting for 6
weeks and 5 days, having had a previous regular 28-day cycle. She
presents with right iliac fossa pain and light vaginal bleeding. She has had a
previous history of chlamydia but no other medical illnesses, and is not
taking any medication. On examination, she is in pain and distressed. The
patient’s pulse is 89 beats per minute, she had a blood pressure of
120/70mmHg.Abdominal examination and vaginal examination exhibited
tenderness in the right iliac fossa with guarding. She was also tender in the
right adnexum on vaginal examination. Urinary pregnancy test was positive.
What are the possible differential diagnoses and what investigations would
you perform and why?

Question 4
Outline the different strategies for the management of a single 4 cm
ovarian cyst in the pre-menopausal, pregnant and postmenopausal woman.

Question 5
A 40-year-old patient presents with a history of ovarian cysts in the past.
She is admitted with acute abdominal pain after 2 weeks of pelvic
discomfort and urinary frequency. On examination, there is a mass palpable
arising out of the pelvis. What is the differential diagnosis? What are the
salient features in the history and examination, and how would you
investigate the patient?

Question 6
A 65-year-old woman presents in clinic with a single episode of
postmenopausal bleeding. Write short notes on the investigation and
management of such a patient.

Question 7
A 35-year-old woman presents with a 2-year history of involuntary loss of
urine on exercise and coughing. Write short notes on the salient features in
her history and examination. What investigations would you arrange and
why?

Question 8

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Mirriam Nyambe a primigravida aged 24 with a gestation age of 34 weeks a
referral from Mahat Maghandi to Livingstone Central Hospital for further
management and evaluation of high blood pressure of 142/92 mmHg. On
examination; urinalysis shows 2+. Based on this results she has been
admitted by Dr. Talama Nawa.
a. What is your diagnosis?
b. Define a condition in a?
c. What are the pointers to your diagnosis?

After a day during reviews with the consultant Dr. Bupili. It was discovered
that her BP was 162/112 mmHg and proteinuria of 3+
d. What is your diagnosis?
e. What are your clinical pointers to your diagnosis?
f. What is your management of the above condition?

Question 9
Lindiwe Banda aged 27 with the gestation age of 28 weeks is a known
diabetes mellitus patient. She has come to see Dr. Mwale Beda at
Livingstone Central Hospital.
a. Outline the management of this patient during prenatal?
b. Outline the management of this patient during postnatal?

Question 10
Janet Lungu aged 34 with 24 weeks of gestation, reported to casualty at
Livingstone central hospital. She reported to Dr. Ashiola Temitope that her
pregnant was not increasing in size and she could not feel any fetal
movements.
a. What is your diagnosis?
b. Which investigations are you going to do?
c. What will be the management of this patient?
d. Define (a) spalding sign (b) Braxton Hicks

Question 11
Pumbuness Hamagamba aged 19, a female student from David Livingstone
School of Education (DALISE) came to see Dr. Musonda Chongo at
Livingstone Central Hospital. She came towards family planning that she
does not want to get pregnant since she is still at college and at the same
time she does not want to deny sexual intercourse (pipeline) to her loving
Sugar Daddy Mr. Kafwambila Donga who gives her tuition fees. So she
wants natural family planning not others
a. Explain to her how family planning works
b. State the family methods you would advise her?

62
Question 12
Mrs. Rakelo Malisopo age 38 presents to Dr. D. Zimba with the history of
weight loss, per vaginal bleeding and postcoital bleeding. Her husband
complains that he does enjoy sexual intercourse because of vaginal bleeding.
The scan showed the features of hydronephrosis.
a. What is your diagnosis?
b. Give the invasive stages of the diagnosis you have made?
c. What is the stage which the patient has presented with?
d. How would you manage the patient?
e. What organisms causes the above condition?
f. List 4 WHO classification of the condition you have diagnosed?
g. Who you screen for the condition you have mentioned?

Question 1
A 26-year-old woman presents in clinic at 30 weeks’ gestation. The
community midwife has referred her because she is ‘large for dates’. Dr
Innocent Motshabi an intern doctor order for an ultrasound scan has
demonstrated polyhydramnios. Discuss the possible causes of polyhydramnios
in this pregnancy.

Question 2
A promiscuous girl from 25-year-old lady from Dambwa North was referred
from Mahati Mahgandi. At Livingstone Central Hospital while being attended
to by Dr S. Mwale presented with a history of occasional fevers, lower
abdominal pain, which was associated with vaginal discharge for 2months.
a. what is the diagnosis in the above patient?
b. What investigations would you order for the patient above?
c. What are the physical findings on examination?
d. What is the gold standard investigation?
e. What are the risk factors for the above condition?
f. What organism are implicated in the above condition?
g. How do you classify the above condition?
h. How do you manage the above patient?
i. What are the complications of the above condition?

Question 3
Mrs James a prime gravida at 26 weeks is referred from libuyu clinic for
high Blood pressure and proteinuria of 3+. Dr David Zimba is the doctor on

63
call and admits the patient and informs his senior Dr Hansingo about the
patient.
a. What is the diagnosis in the above?
b. What investigations did Dr Zimba order on the patient?
c. Why did Dr Zimba admit the patient and where did he admit the
patient?
d. What are the risk factors associated with this condition?
e. How do you manage this condition?
f. What are complications associated with the above condition?
g. While admitted the patient became unresponsive, what complication
did the patient develop?
h. How do you manage the above complication (g)?
i. How do monitor drug toxicity of the above condition?

Question 4
A 28-year-old woman a known retroviral disease patient was referred to
Obstetrics and Gynaecology clinic by Dr Joe Mwanza for further evaluation
of intermenstrual and postcoital bleeding, and vaginal watery discharge.
a. Before referring the patient to obstetrics and gynaecology clinic Dr
Mwanza ordered investigating, list three investigations he ordered
for?
b. After being seen in obstetrics and Gynaecology clinic by the
consultant Dr Chammbwa admitted the patient, why was the patient
admitted?
c. After being admitted to the ward Dr Chaambwa order further tests,
list three tests that were ordered?
d. After tests results had come back it was confirmed it was a
malignancy, list the types of malignancy and which of them has a poor
prognosis?
e. List some of the benign lesions?
f. How do you stage the malignancy above?
g. What are the treatment options for the above?
h. How often should a person be screened, in relation to this
malignancy?
i. What are the risk factors associated with this malignancy?
j. How do you manage the above malignancy?
k. How do you manage the benign lesions you listed in (e)?
l. What are the preventive measures you can put in place for this
malignancy?

64
Question 5
A 13-year-old girl is pregnant and comes seeking help from an intern Dr
Mukumbuta Nawa in obstetrics clinic regarding her pregnancy. She is 12
weeks pregnant by date. She plans to have tubal ligation after delivery as
she regrets being pregnant so early in life
a. Describe the antenatal investigations you would advise her at this
time and their importance (5 marks)
b. How would you describe focussed antenatal to her? 5 marks
c. What are the complications of teenage pregnancy? 5marks
d. what counselling would give her regarding tubal ligation? 5marks

Question 6
A 24-year-old woman with poorly controlled insulin-dependent diabetes was
referred from Maramba clinic by a clinical officer, she is planning to start
a family. In clinic at Livingstone central hospital, she meets with Dr
Musonda Chongo an intern doctor, outline the advice specific to her
condition that you would give regarding pregnancy.
She should be advised that poor glucose control in pregnancy increases the
risk of congenital anomalies and also increases the risk of miscarriage.
However, with good control, these risks are substantially reduced.
She should be advised that she will require hospital care and that this will
take the form of a joint clinic with an obstetrician, diabetic physician,
diabetic nurses and dieticians.
The aim of treatment is to maintain the blood glucose levels as near normal
as possible. Insulin requirements go up during pregnancy and these will
require careful monitoring. She should monitor her own blood glucose levels
and have blood taken for haemoglobin A1c to monitor long-term control.
She is at increased risk of both diabetic ketoacidosis and hypoglycaemia,
and should be educated about the signs and symptoms of both.
It should be explained that an ultrasound scan at approximately 20 weeks’
gestation would examine for structural anomalies especially cardiac and
neural tube defects.
There is also a risk that both diabetic nephropathy and retinopathy will
worsen with pregnancy; however, these complications usually improve
postdelivery. There is an increased risk of pre-eclampsia, which will require
regular monitoring of blood pressure and urine.
There is also an increased risk of polyhydramnios, which is associated with
an increase in premature delivery. Poor control is associated with
macrosomia and an increased rate of shoulder dystocia. The unexplained
stillbirth rate is increased after 36 weeks and careful fetal monitoring will
be necessary.

65
Question 7
A 24-year-old woman consults Dr Temitope Ashola in the Obstetrics and
Gynaecology clinic at Livingstone Central Hospital in her second pregnancy
and she is concerned that her blood group is rhesus negative.
a. What information would you give her regarding the use of anti-D
immunoglobulin at this time? (2marks)
b. What investigations would you order at this time? (2marks)
c. Define immune hydrops (1 mark)
d. List 4 causes of non-immune hydrops (2marks)
e. Give 3 reasons for decrease in complications due to rhesus iso-
immunisation (3marks)

Question 8
A woman presents at 30 weeks’ gestation with complaints of vaginal draining
and Dr Temitope Ashola admits her to ward 3, at Livingstone Central
Hospital.

a. What information would you ask for in the history that would
influence your management? (2marks)
b. How would you confirm the diagnosis? (1mark)
c. What drugs would you prescribe and why? (3marks)
d. What information would ask for from the ward nurse that would
influence the management of the patient? (2marks)
e. List complications of draining ( 2marks)

Question 9
A gravida 5 para 4 presents with a scan confirming intrauterine fetal death
(IUFD) at 34 weeks gestation
a. What features on X-Ray would suggest intrauterine fetal death? (2
marks)
b. What investigations would you do? (2 marks)
c. What advice would you give her regarding when to delivery her?(3
marks)
d. Following delivery, what information would you learn from examining
the placenta regarding the possible cause of the IUFD? ( 3 marks)
e. What complications are associated with IUFD?

Question 10

66
A woman presents to having been told that she is pregnant with twins as
confirmed by scan.
a. Describe Hellin's Law as it relates to multiple pregnancy (1 mark)
b. Describe the types of twins and risk factors (2marks)
c. What complications can arise antenatally? (2marks)
d. You decide on vaginal delivery. What preparations will you do? (2
marks)
e. In a vaginal delivery, how would you manage the delivery of the
second twin? (3 marks)
f. What sign was seen on ultrasound?

Question 11
A pregnant woman delivered 1 week ago by caesarean section after a
prolonged labour associated with dystocia. She is now complaining of lower
abdominal pain
associated with fever and rigors.
a. Define puerperal pyrexia (1 mark)
b. List 5 possible causes of fever in this case (3 marks)
c. List investigations you would request for in the above patient?
d. Mention 4 risk factors for puerperal sepsis after the caesarean
section (2 marks)
e. Describe how you would conduct a vaginal delivery when confronted
with shoulder dystocia (4 marks)
f. Imagine the patient above had delivered vaginally and presented with
a fever after 8 days. What are some of the possible diagnosis,
investigations and treatment?

Question 12
You suspect polycystic ovarian disease (PCO) in your infertile patient.
a. Mention 3 other clinical criteria associated with the condition (3
marks)
b. Mention 3 abnormal findings in the hormonal profile of this patient.
(3 marks)
c. Mention 4 late complications of this condition (2 marks)
d. describe the treatment options for her hirsutism (2 marks)

Question 13
A 26 years old primigravida presents with prolonged second stage of labour
a. What are the 3 possible causes of this condition (2 marks)

67
b. what are the possible complications of this condition (3 marks
c. Discuss how you will proceed to manage this patient? (5 marks)

Question 14
A patient is seen in the antenatal clinic at 37-weeks’ gestation and you
diagnose placental
abruptio
a. What are the possible causes of this condition? (2 marks)
b. How will you make the diagnosis (2 marks)
c. What are the complications of the condition (2 marks)
d. Briefly describe how you will manage this patient? (4 marks)

question 15
Mrs Kafwamfwa who gave birth 2 days ago. During your round one the
nurses and family members reports to you to say Mrs Kafwamfwa has
display some weird behaviour since giving birth. Dr Hastings Lungu an Intern
Doctor is asked Discuss the possible psychiatric sequelae of pregnancy and
how they might be treated with the husband and family members.

Question 15
A patient whose presents with a history of headache, fever of 38 degree
and dry cough.
a) Give five differentials
b) She gives you a hx of travelling to itezhi itezhi and was not sleeping
under a treated mosquito. Among your differential what is your
definite diagnosis
c) How do you manage
d) She comes back 2 weeks with severe headache and irrelevant talking
what is your diagnosis
e) What investigations would you do to confirm diagnosis?
f) Effects on the fetus?
g) Management

Question 16
A woman who comes to you with history of bleeding, with clots, but despite
having these complaints she has a regular menstrual cycle of 28 days. On
examination, she has mass in the lower abdomen which is non-tender. She’s
has been married for 7 years but has not managed to conceive for the past
5 years with no success.
a. Give three differentials

68
 b. After examination, the os is closed, PV bleeding which is not a lot
and an irregular mass. What’s your diagnosis?
c. What investigations are you going to do?
d. How are you going to manage?
e. Degenerative changes in fibroids?
f. Complications of fibroids?
g. Types of fibroids
Question 3
A female who 33 weeks pregnant. Spotting, which was not enough,
pregnancy test positive, nausea, vomiting

a Diagnosis and justify

b What clinical features in the clinical scenario to support your
diagnosis
c What prophylactic drug can you give for life
d What is the long-term complication?
Question 4
A 24 year primegraviade of 37 weeks pregnant, with a bp of 146/92 hmg,
with proteinuria of 300g. she came in with complaints of epigastric pain.
Where mmt was given, and felt much better.

a) What is your diagnosis?

b) How are you going to manage?
Question 5
A primegravide 14 weeks pregnant. Tetanus. Explain the schedule to give
tetanus. Effects of tetanus in pregnancy. Management

PEADIATRICS
OSCE
1. STATION ONE – X-RAY SHOWING CARDIOMEGALY

Question 1.

69
A ten-year-old male presents to your clinic with history of malaise, fever,
and pallor for 3 weeks. 7 seven days later he had a cut on the knee (left)
which took time to stop bleeding. Has no history of rash.
a. What is your diagnosis?
Haemophilia
b. Investigations
Fbc/dc
Clotting studies
Activated partial thromboplastin time – usually prolonged ( 25-45SEC)
Bleeding time, prothrombin time (12-16SEC) and platelet time – normal
Von willebrands factor assay
Dna based diagnosis
c. Management
Prevention of bleeding
Avoid trauma, contact sports, Asprin and other nsaids, Im, educated
Hepatitis A and B
Fresh plasma
Immunisations – pnemococcoal
Cryoprecipitate
Desmopressin
Antifibronolytics – tranexamic acid
Gene therapy
Prednisolone – hemathrosis and haematuria
d. In your diagnosis is (a) which one is known as Christmas disease -
haemophilia B
e. What are the variants of this condition?
Hemophila a (8)
Hemophila b (9)
Hempilia c (11)
f. How is this condition acquired?
Autosomal x linked recessive
g. Commonest type – hemophilia A
h. Complications –
Infections
Hematrosis
Intracranial breathing
Compartment syndrome
g. which syndrome is associated with hemopilia in females- turners syndrom

Question 2

70
 A woman who gave birth at 37 weeks gestation baby with a weight of
2.5kg, head circumference of 31 cm presents to you with history of fever,
jaundice and history of not passing stools for 72 hours. When you ask
mother, mother says baby looks like father, mother says no. the baby has
a flat occiput and umbilical hernia.
a. What is your diagnosis?
Early onset neonatal sepsis downs syndrome
b. Pointers to your diagnosis?
Small brachycephalic head (flat occiput)
Umbilical hernia
Not opening bowels (git pathology – duodenal atresia, hirsprungs
disease, imperforate anus)
Sepsis – fever, jaundice, hx of

c. Risk factors
Advanced maternal age >35 years
Previous down syndrome baby
Torches infection
Genetics

d. Management
Management
Muilt displinarnary
Sepsis
Antibiotics
Supportive treatment
Hypothermia
Hypoglycaemia
O2
Monitoring and treating apnea
Infusion of NS if perfusion is poor
Adjunt therapy
Exchange transfusion
IV immunoglobulin 250mg/kg/day
Transfusion of fresh frozen plasma
immunaisations
e. When an abdominal xray was done, it showed a double bubble sign as
a reason for not passing stool – what is your diagnosis? Deudenal
atresia
f. What cytogenetic factors?
Non disjunctional

71
 Moisiac
translocation
g. What is the fertility of female?
15-30%
h. What is the fertility of males?
unknown

Question 3
A 10-year-old male adolescent named Joe is brought to your office with a
long-standing
history of joint swelling. The swelling was first noticed at the age of 11
years old when
the child began to cruise. The swelling first started with the ankle joints
and other
joints. The parents never sought medical attention because it would resolve
spontaneously. He has never bled from the nose or stool. Lately, it is
particularly the left
elbow joint that swells even without history of trauma according to parents.
On physical
examination, you notice deformity of left elbow joint.
a) What is the most likely diagnosis? Haemophilia
b) Briefly explain the pathophysiology behind this condition?
Autosomal x linked recessive where there is deficiency of factor 8 and 9
c) What investigations you would do in this child? Mention the expected
results in line with your diagnosis

Fbc/dc
Clotting studies
Activated partial thromboplastin time – usually prolonged ( 25-45SEC)
Bleeding time, prothrombin time (12-16SEC) and platelet time – normal
Von willebrands factor assay
Dna based diagnosis

d) What name is given to joints like joes left elbow joint that swell up even
in
absence of trauma? hemathrosis
e) What is the treatment for this condition when the child presents with
swelling? prednisolone

72
SURGERY
OSCE
1. ATLS
ABCDE
2. HX TAKING OF INTESTIANAL OBSTRUCTION, INVESTGATIONS,
MANAGEMENT, COMPLICATIONS
3. POST OP REVIEW, ANIMAL BITE, TYPES OF VENOM,
4. EXTERNAL FIXATIORS
TYPES
INDICATIONS
COMPLICATIONS
5. CT – SCAN – HEAMORAGE
6. COLOSTOMY – CARE (MANAGEMENT)
7.

Theory
4. An elderly security guard presents with long distended tortuous varicose veins from the
left groin to the medial side of the left ankle. He has a bulging swelling at the left sapheno-
femoral junction which is compressible and shows evidence of cough impulse.
4.1 what is this bulging swelling called? Saphena varix (2)

73
4.2 what local problem of the sapheno-femoral junction has led to the above? Due to
long standing due to his occupation (2)
4.3 name the clinical test you would do to support your above answer? Brodie
Trendelenburg test (2)
Vein is emptied by elevating the limb and a tourniquet is tied just below the saphenofemoral
junction (or using thumb, saphenofemoral junction is occluded). Patient is asked to stand
quickly. When tourniquet or thumb is released, rapid filling from above signifies
saphenoemoral incompetence
4.4 how is the above type of varicose veins usually treated?
Conservative compressive stockings, unna boots, diosmin
Medical calcium debosilate, diosmin, toxerutin, sclerotherapy
Surgical – stripping and ligation
4.5 what is the local underlying cause of non-healing varicose vein ulcer? Nutritional,
underlying medical condition like DM, immunosuppression HIV (2)
3. A young man of 25 years of age with a wound on the right calf region heavily
covered with soil. He was injured while trying to yoke his oxen in the kraal.
3.1 How should the would be managed operatively in the theater? Copius wound
irrigation and adequate debridement2)
3.2 what prophylactic immunisation is indicated and how would you administer it?
Immunization: Tetanus Toxoid administration:0.5ml im stat(2)
3.3 what position is the leg nursed on the ward? Limb should be elevated (2)
3.4 how will you locally manage the wound on a daily basis? Daily wound cleaning (2)
3.5 After three weeks the wound is clean and granulating. What phase of wound healing
is this? Prolifatory ...(2)
3.6 Give the phases of wound healing and give essential details of what happens in each
phase?
Phase 1 : HEMOSTASTIS PHASE – body activated the emergency clotting system (platelets
aggregates with collagen with thrombin ) mesh clot formations (objective to stop bleeding)
Phase 2: Inflammatory or defensive phase – destroying bacteria and removing debris
essentially wound bed. Neutrophils destroy debris (4-6 days) associated with cardinal signs
of inflations
Phase 3: proliferative phase – feeling the wound, contraction of wound margins, granulation
tissue will form (4 – 24 days)
Phase 4: maturation - collagen new tissue slowly gains strength and remodels matures (21
days – 2 years)
10)

4. A Zambian lad of 17 years of age presents to casualty with severe pain of the penis.
Shortly prior to his presentation, he gives history of self-stimulation described by himself as
vigorous masturbation which resulted in a ‘pop’ sound with immediate severe pain and
swelling.
4.1 what is your diagnosis? Penile Fracture (2)
4.2 Among the layers of tissues in the penis which layer is injured leading to ‘pop’ sound
Tunica Albiginea 2)
4.3 What is the deep fascia of the penile shaft called? Buck’s fascia (2)

74
4.4 Name the structures /tissues of the penis responsible for tumescence? Corpora
cavernous (male) female (bulb vestibule) (2)
4.5 In the event that this adolescent patient gave a false history and it so happened that
he had been attacked by an irate prostitute that he had failed to pay and sustained anterior
urethral injury. What would be your management of urethral injury?
4.6 Give the two anatomical classification of urethral injury Depending on site of
rupture:
1. Rupture of the membranous urethra.
2. Rupture of the bulbous urethra.
II. Depending on circumference of the urethral wall involved:
1. Complete.
2. Incomplete.
III. Depending on the thickness of the urethra involved:
1. Total.
2. Partial
(2)
4.7 What investigation would you do before attempting to catheterize an injured
urethra?urethralgram (2)
4.8 What finding in the above investigation 4.7 would be a contraindication for
catheterization?..........................................................................................................................
.............................................................................................(2)
3. A young man of 25 years of age with a wound on the right calf region heavily
covered with soil. He was injured while trying to yoke his oxen in the kraal.
3.1 How should the would be managed operatively in the theater?
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………… (2)
3.2 what prophylactic immunisation is indicated and how would you administer it?
Immunization:…………………………………………………………………………administration:……………………
…………………………………………………. (2)
3.3 what position is the leg nursed on the
ward?.................................................................................(2)
3.4 how will you locally manage the wound on a daily
basis?...........................................................................................................................................
....................................................................................................................................................
......(2)
3.5 After three weeks the wound is clean and granulating. What phase of wound healing
is
this?.............................................................................................................................................
........................................................................(2)
3.6 Give the phases of wound healing and and give essential details of what happens in
each
phase?.........................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................

75
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
.......................................................................................(10)

4. A Zambian lad of 17 years of age presents to casualty with severe pain of the penis.
Shortly prior to his presentation, he gives history of self stimulation described by himself as
vigorous masturbation which resulted in a ‘pop’ sound with immediate severe pain and
swelling.
4.1 what is your
diagnosis?................................................................................................(2)
4.2 Among the layers of tissues in the penis which layer is injured leading to ‘pop’
sound……………………………………………………………………………………………………………..(2)
4.3 What is the deep fascia of the penile shaft
called?...................................................................................................................................(2)
4.4 Name the structures /tissues of the penis responsible for
tumescence………………………………………………………………………………………………………………..............
.............................................................................(2)
4.5 In the event that this adolescent patient gave a false history and it so happened that
he had been attacked by an irate prostitute that he had failed to pay and sustained anterior
urethral injury. What would be your management of urethral
injury?.........................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....(6)
4.6 Give the two anatomical classification of urethral
injury………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………(2)

76
4.7 What investigation would you do before attempting to catheterize an injured
urethra?........................................................................................................(2)
4.8 What finding in the above investigation 4.7 would be a contraindication for
catheterization?..........................................................................................................................
.............................................................................................(2)
[18/12, 06:20] Dr. Lungu Hastings: 1. A 37 year old man comes to casualty with history of
fighting with the wife at home. She stabbed him with a kitchen knife to his upper chest and
bite him on the scrotum and penile shaft leaving him with a de-gloving wound on the penis.
He is restless and in obvious respiratory distress. He has reduced air entry on the left but the
percussion note is tympanic over the upper lung zone on the same side, becoming dull over
the mid and lower lung zones. His neck veins are distended, heart sounds muffled and B/P is
80/40mmHg.
1.1 what is your diagnosis?
1.2 outline your management.
1.3 what is Beck's triad.(3)
1.4 what diagnosis do you make using becks
triad?....................................................................................................................................(1)
1.5 what are you likely to see on the chest X-rays .(4)
1.6 classify his wounds in terms of
contamination……………………………………………………………………………………………………….1
1.7 what are the other classes of wounds other than seen in this man?
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………….(3)
1.8 The penile wound develops pus on day 3. what is the likely microbiology microscopy
result ?......................................................................................................................................
(1)

Question 2. A 33 year old man comes to casualty with history of severe adominal pain .
He has had a bad cough for the last 5days. He has elevated temperature of 400 C, he is
tachypnoeic at 38resp/minute, and saturations are low on room air 76%. On chest
auscultation he has no air entry on the left mid and lower lung zones although he has some
air entry in the upper zone. FBC shows elevated white blood cells and mildly elevated ESR.
2.1 What is your diagnosis?
(3)…………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
…………..
2.2 You do a chest X-Ray and it shows a whitish opacity on the right mid and lower lung
shadow with no meniscus. What are the most likely differentials for this X-Ray finding? Give
3.
....................................................................................................................................................
...........................................................................................................(3)
2.3 You decide to do a laparotomy and its negative lap. Give 6 differentials for a negative
lap…………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………

77
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
……………………………………………….(6)
2.4 What is ESR, explain why it is raised this way in this
patient……………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………(3)
2.5 The anesthetist was consulted before taking the patient to surgery. He was worried
about the ASA grade. What is ASA
grading?......................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
..............................................................................................................................................
[18/12, 06:20] Dr. Lungu Hastings: 3. A young man of 25 years of age with a wound on the
right calf region heavily covered with soil. He was injured while trying to yoke his oxen in the
kraal.
3.1 How should the would be managed operatively in the theater?
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………… (2)
3.2 what prophylactic immunisation is indicated and how would you administer it?
Immunization:…………………………………………………………………………administration:……………………
…………………………………………………. (2)
3.3 what position is the leg nursed on the
ward?.................................................................................(2)
3.4 how will you locally manage the wound on a daily
basis?...........................................................................................................................................
....................................................................................................................................................
......(2)
3.5 After three weeks the wound is clean and granulating. What phase of wound healing
is
this?.............................................................................................................................................
........................................................................(2)
3.6 Give the phases of wound healing and and give essential details of what happens in
each
phase?.........................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................

78
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
.......................................................................................(10)

4. A Zambian lad of 17 years of age presents to casualty with severe pain of the penis.
Shortly prior to his presentation, he gives history of self stimulation described by himself as
vigorous masturbation which resulted in a ‘pop’ sound with immediate severe pain and
swelling.
4.1 what is your
diagnosis?................................................................................................(2)
4.2 Among the layers of tissues in the penis which layer is injured leading to ‘pop’
sound……………………………………………………………………………………………………………..(2)
4.3 What is the deep fascia of the penile shaft
called?...................................................................................................................................(2)
4.4 Name the structures /tissues of the penis responsible for
tumescence………………………………………………………………………………………………………………..............
.............................................................................(2)
4.5 In the event that this adolescent patient gave a false history and it so happened that
he had been attacked by an irate prostitute that he had failed to pay and sustained anterior
urethral injury. What would be your management of urethral
injury?.........................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....(6)
4.6 Give the two anatomical classification of urethral
injury………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………(2)
4.7 What investigation would you do before attempting to catheterize an injured
urethra?........................................................................................................(2)

79
4.8 What finding in the above investigation 4.7 would be a contraindication for
catheterization?..........................................................................................................................
.............................................................................................(2)

past paper
1. Which of the following statements are true?
A .Cells change from aerobic to anaerobic metabolism when perfusion to
tissues is reduced. T
B The product of aerobic respiration is lactic acid. F
C The product of anaerobic respiration is carbon dioxide. F
D The accumulation of lactic acid in the blood produces systemic
respiratory acidosis.f
E Lack of oxygen and glucose in the cell will eventually lead to failure of
sodium/ potassium pumps in the cell membrane and intracellular
organelles. T
2. Which of the following statements regarding hypovolaemic shock are
true?
A It is associated with high cardiac output. F
B The vascular resistance is high. T
C The venous pressure is low. T
D The mixed venous saturation is high.F
E The base deficit is low. F

3.Which of the following statements about ischaemia-reperfusion syndrome

is correct?
A This refers to the cellular injury because of the direct effects of
tissue hypoxia. F
B It is seen after the normal circulation is restored to the tissues
following an episode of hypoperfusion. T
C The increased sodium load can lead to myocardial depression.F
D This is influenced by the duration and extent of tissue hypoperfusion.
T
E It usually does not cause death. F
4.In which of the following cases might tachycardia accompany shock?
A Hypovolaemia due to gastrointestinal (GI) bleeds T
B Patients on alpha-blockers T
C Patients with implanted pacemakers F
D Fit young adults with normal pulse rate of 50/min F
E Cardiogenic shock. F
5.Which of the following regarding blood pressure in shock are false?
A Elderly patients who are normally hypertensive may present with a
‘normal’ blood pressure. F

80
 B Children and fit young adults are able to maintain blood pressure until
the final stages of shock.F
C Hypotension is one of the first signs of shock. T
D Beta-blockers may prevent a tachycardic response. T
E Blood pressure is increased by reduction in stroke volume and
peripheral vasoconstriction. F

6.Which of the following statements about compensated shock are false?

A The preload is preserved by the cardiovascular and endocrinal
compensatory responses. F
B Tachycardia and cool peripheries may be the only clinical signs. F
C The perfusion to the skin, muscle and GI tract is increased. T
D Systemic respiratory acidosis is seen. T
E Patients with occult hypoperfusion for more than 12 hours have a
significantly higher mortality rate.F
7.About Natural barriers to infection . Which of the following is a natural
barrier to infection?
A Intact epithelial surface T
B High gastric pHF
C AntibodiesT
D Antibiotics F
E Macrophages. T
8. Host resistance to infection , Which of the following is a cause of
reduced host resistance to infection?
A Malnutrition T
B Heart failure F
C Cancer T
D AIDS T
E Systemic sclerosis. F
9.Risk factors for wound infection , Which of the following is a risk factor
for wound infection?
A Poor perfusion T
B Use of skin clips for wound closure. F
C Poor surgical technique T
D Not using prophylactic antibiotics F
E Uraemia. T
10.About Secondary infections , Which of the following is a cause of
secondary (or exogenous) infection?
A Poor hand-washing technique
B Community
C Perforated diverticular disease

81
 D Anastomotic leak
E Inadequate air filtration in the theatre.

11.Which of the following statements about surgical site infections (SSIs)

are true?
A Infection in the musculofascial tissues is known as deep SSI.
B The patient may have systemic signs in a minor SSI.
C Infection causing delay in hospital discharge is a major SSI.
D The differentiation between major and minor SSIs is not important.
E Surveillance for surgical site infection should be done for a year after
implanted joint surgery.
12.Which of the following statements regarding abscesses are true?
A Staphylococcus aureus is one of the most common causative organisms.
B The abscess wall is composed of epithelium.
C Most wound-site abscesses occur before the patient is discharged
from the hospital.
D Antibiotics are indicated if there is evidence of cellulitis.
E Actinomyces can cause a chronic abscess.

13 Which of the following statements about inguinoscrotal swellings are

false?
A A hydrocele is a patent processus vaginalis as is a hernia.
B Hernia is always indirect.
C Hernia can be direct or indirect.
D In incarcerated hernia, reduction should be attempted by taxis
followed by operation 24 h later.
E A hydrocele always needs an operation.
14. Which of the following are true for undescended testis?
A. Orchidopexy in a subdartos pouch is the treatment of choice.
B. The operation is recommended at the age of 2 years.
C. When a testis is impalpable and therefore intra-abdominal, laparotomy
should be done.
D. Laparoscopy is the gold standard procedure for an intra-abdominal
testis.
E. Orchidopexy reduces the chance of malignancy.

82
15. Which of the following statements are true with regard to acute
scrotal pain?
A Acute testicular pain can be from torsion of the testis, torsion of the
hydatid of Morgagni or acute epididymitis.
B Pain of testicular torsion may originate in the groin or suprapubic area.
C Doppler ultrasound should be done in suspected testicular torsion.
D Incarcerated hernia may cause similar symptoms.
E In case of any doubt, exploration of the scrotum must be carried out.

16.What is the operation for congenital hypertrophic pyloric stenosis

called?
A Hartmann
B Whipple
C Heller
D Ramstedt
E Ivor-Lewis

17. Which of the following are true of preoperative patient preparation?

A. It includes a thorough history-taking and medical examination.
B. The patient’s medical state is optimized
C. CIt is to anticipate and plan for management of perioperative problems.
D. Good communication is required.
E. It involves taking informed consent.

18. Which of the following statements regarding preoperative investigations

are true?
A. Chest X-ray is routinely requested in all patients over 60
years old.
B. A ventricular ejection fraction of less than 35 per cent
indicates a high risk of cardiac complications.
C. A body mass index (BMI) <15 is associated with significant
hospital mortality.
D. ECG is usually required in patients above 65 years.
E. HIV testing requires patient consent.

19. Which of the following statements regarding preoperative management

of specific medical problems are true?

83
 A. Patients with a diastolic pressure above 95 mmHg should have their
elective operations postponed.
B. Elective surgery should be delayed until at least 1 year after a
myocardial infarction (MI).
C. There is no need to control tachyarrhythmias preoperatively.
D. Preoperative transfusion should be considered if the Hb level <10 g/dL.
E. In patients with malnutrition, preoperative nutrition therapy should be
started 2 weeks prior to surgery.

20. Which of the following is a problem associated with surgery in obese

patients?
A. Myocardial infarction
B. B Aspiration
C. C Deep vein thrombosis (DVT)/embolism
D. D Pressure sore
E. E Pain control.

21. Which of the following is a problem associated with surgery in the

jaundiced patient?
A. Clotting disorders
B. Hepatorenal syndrome
C. Infection
D. Poor wound healing
E. Myocardial infarction.

22. Which of the following is a surgical risk in a diabetic patient?

A. Infection
B. Myocardial infarction
C. Pressure sore
D. Poor wound healing
E. Pain control.

23. Which of the following is a risk factor for thrombosis?

A. Young age
B. Pregnancy
C. Smoking
D. Trauma
E. Malignancy. Consent for surgery

84
24. Regarding consent for surgery, which of the following are true?
A. A Children below the age of 16 years cannot give consent.
B. A social worker can give consent for a child under a care order.
C. All minor complications with an incidence above 1 per cent should
be discussed. D
D. Consent is not required for life-saving surgery in a competent
patient.
E. Two senior doctors need to sign the form explaining reasons for
the actions if an adult is deemed not competent to consent.

25. Initial stage of clinical union of bone is equivalent to:

A. Soft callus formation
B. Woven bone
C. Hematoma formation
D. Calcification only
E. Remodeling

26. Which term causes a spiral fracture:

A. Compression
B. Bending
C. Twisting
D. Tension
E. Not one of them

27. Earliest sign of compartment syndrome is:

A. Pallor distally
B. Numbness
C. Pain
D. Parasthesia
E. All of these

85
28. In an injury with multiple fractures most important is:
A. Airway maintenance
B. Blood transfusion
C. Intravenous fluids
D. ORIF
E. MUA

29. Involucrum means:

A. Fragment of dead bone
B. Hole formed in the bone during the formation of sinus
C. Osteomyelitis of spine
D. Periostal new bone formation around necrotic sequester
E. Fibrous tissue

30. Brodie’s abscess usually involves:

A. Short bones
B. Long bones
C. Pelvic bones
D. Skull bones
E. Flat bones

31. Commonest cause of acute septic arthritis in neonates and infants up to

6 months of age:
A. H. Influenza
B. Salmonella
C. Staphylococcus
D. Pseudomonas
E. Streptococcus

32. Acute septic arthritis is associated with all except:

86
 A. May be caused by a penetrating wound
B. May be caused by a open fracture involving a joint
C. May be due to blood borne infection
D. Tends to end with the formation of a fibrous ankylosis
E. Pathological dislocation of joint

33. Which of the following causes para vertebral abscess:

A. Brucella
B. Tuberculosis
C. Kala-azar
D. Typhoid
E. Salmonella

34. Duration of continuation phase treatment of TB joints:

A. 4 months
B. 6 months
C. 9 months
D. 12 months
E. 18 months

35. Benign bone tumors are:

A. Osteoid osteoma
B. Osteohondroma
C. Multiple myeloma
D. Chondroblastoma
E. Chondromyxoid fibroma

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36. Fatigue fracture is treated by:
A. Rest
B. Cast
C. MUA
D. Internal fixation
E. External fixation
37.A patient with obstructive jaundice due to a stone in the common bile duct
had a failed ERCP.He became febrile and collapses 48 hour later. Which of the
following is/are correct regarding immediate management?
A) Oxygen via face mask.
B) Intravenous Fluids.
C) Intravenous Cloxacillin.
D) Intramuscular Vitamin K.
E) Emergency Cholecystectomy

38. In patients with Acute Cholecystitis

A) Gall stones are always present.
B) Diagnosis is confirmed by a CT scan.
C) Pericholecystic abscess is the most common complication.
D) Presence of Jaundice invariably implies a stone in CBD.
E) Emergency cholecystectomy is contraindicated.

39. Regarding patients with pancreatic cancer

A) Cancer arising from tail of the gland is usually curable with distal
pancreatectomy.
B) Maturity onset diabetes is not uncommon.
C) They often present with palpable Gall Bladder.
D) Peri ampullary cancers have better prognosis.
E) They can be treated palliatively with Whipples (Pancreatico-duodenectomy
and gastrointestinal bypass) procedure.

40. Causes of painful fresh bleeding per-rectum include,

A) Thrombosed external haemorrhoids
B) Polyp in the lower rectum
C) Angiodysplasia
D) Anal fissure
E) Peri-anal abscess

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41 The causes of a newborn not passing meconium within 48 hours of birth
include

A) Ileal atresia.
B) Infantile pyloric stenosis.
C) Hirschsprung disease.
D) Hypothyroidism.
E) Necrotizing entero-colitis.

42. Ureteric stones

A) Are sometimes asymptomatic.
B) Cause pain free windows between episodes of ureteric colic.
C) Are almost always accompanied by hematuria.
D)Aremostly radioopaque?
E) Sometimes necessitate urgent intervention.
43. Which of the following statements are correct regarding the management
of a ten year old boy who presents with an acutely painful scrotum?

A) Initial antibiotic therapy and analgesia should be considered if pain has been
there for less than two hours.
B) A normal Duplex scan of the scrotum reliably excludes the necessity for
surgery.
C) Patient should be fasting for solids for six hours prior to surgery, if needed.
D) Surgery is unlikely to salvage the affected testis if the presentation is after
12 hours.
E) If found to be due to torsion of the testis, contra lateral testis should be
fixed.

44. Which of the following are true regarding a 65 year- old man presenting
with frank haematuria?
A) Presence of pain excludes the possibility of malignancy.
B) Initial haematuria is likely to be of prostatic origin.
C) An elevated PSA during acute symptoms confirms the diagnosis of prostate
cancer.
D) Presence of thread like clots suggests bleeding from the upper urinary
tract.
E) A normal CT urogram excludes bladder carcinoma.

45 Which of the following are true regarding the upper urinary tract trauma?
A) Absence of frank haematuria excludes renal injury.
B) Unexplained hypotension is a presenting feature.

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C) Majority need surgical exploration.
D) Polycystic kidneys are less likely to get injured.
E) Angioembolization is a treatment option.

46. Which of the following are true regarding carcinoma of the prostate?
A) Most of the prostatic cancers present with obstructive symptoms.
B) Erectile dysfunction is a recognized presentation.
C) Trans rectal ultrasound and biopsy is the gold standard in confirming the
diagnosis.
D) PSA level over 10 nanograms/ml confirms metastatic disease.
E) Radical prostatectomy is of value in locally advanced disease.

47 Which of the following are true regarding Urethral strictures?

A) Instrumentation is the most common cause for anterior strictures.
B) Water can' perineum is a complication.
C) Falling astride injury leads to strictures of the prostatic urethra.
D) Repeated dilatation is an accepted management option in experienced hands.
E) In Optical urethrotomy , the incision is made at 6'O clock position

48. Which of the following are correct regarding scrotal lumps?

A) Varicoceles almost always lead to infertility.
B) Testicular tumours are associated with large hydroceles.
C) Torsion of testis does not present after 18 years.
D) Sebaceous cysts are more common in scrotum than in rest of the body.
E) Hydroceles are always transilluminant.

49. Which of the following are true regarding varicoceles?

A) It is more common on the right side.
B) It is the most common correctable cause of male infertility.
C) Failure to disappear in supine position is a sinister feature.
D) Ultrasound scan is required before surgery.
E) Minimally invasive techniques are among the treatment options.

50. In head injuries the signs of an expanding intracranial lesion include.

A) Deteriorating level of consciousness.
B) Rising pulse rate.
C) Falling blood pressure.
D) Small pupils.
E) 6th Nerve palsy

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MARKING KEY FOR SGY 710 JULY 2019
A B C D E A B C D E
1 T F F F T 26 T T F T T
2 F T T F F 27 F F F T F
3 F T F T F 28 T F F F F
4 T T F F F 29 F F F T F
5 F F T F T 30 F T F F F
6 F F T T F 31 F F T F F
7 T F T F T 32 F F F T F
8 T F T T F 33 F T F F F
9 T F T F T 34 F F T F F
10 T F F T T 35 T T F T T
11 T F T F T 36 F T F F F
12 T F F T T 37 T T F F F
13 F F T F T 38 F F T F F
14 T T F T F 39 F T T T F
15 T T F T T 40 F T T T F
16 F F F T F 41 T F T T F
17 T T T T T 42 T T T T T
18 F T T T T 43 F F F T T
19 T F F F T 44 F T F T F
20 T T T T F 45 F T F F T
21 T T T T F 46 F T T F F
22 T T T T F 47 F T F T F
23 F T T T T 48 F F F T F
24 F T T T F 49 F T T T T
25 F T F F F 50 T F F F T

A 28-year-old female sex worker with two kids from two different men.
Who usually leaves her home every day at 21hrs at finds herself in

91
different night clubs in Kafue looking for wealthy clients. On night after
leaving early she left her 5-year-old child to finish up with the cooking of
Nshima as she rushed for client in Kafue Town. While trying to finish up
with the cooking with her younger sister the pot which was filled with
boiling porridge fell on her younger sister. This was the presentation at the
local clinic.

a. Look at the patient below and state the type of injury it?
b. What methods are used to assess the percentage of burns and
what percentage does this patient have?
c. What is the most accurate way of assessing burns?
d. How to do you classify burns and what class does this patient
belong to?
e. How are going to manage this patient?
f. Tell us how you are going to administer fluid therapy in this
patient?
g. What are the complications of burns?
h. What is the criteria for admitting patients with burns?
i. when do you give blood?
j. After being admitted this patient had a fever how do you approach
this?
k. After one week on being admitted the patient lost weight, what
could have caused it?
l. After admitting the patient your senior on duty decided to add a
proton pump inhibitor as part of management what was the reason
behind?
m. what are the different methods for treating burns?
n. If at a later stage, you decided to skin graft the patient, state the
types of grafting?
o. What is the pathophysiology?

PEADIATRICS
1. A 16 year old presents to you with history of body hotness, BP OF
150/94 mmhg, urinalysis results shows – Nitrates +, Hematuria +,
Protenuria 1+.

a) Diagnosis
Acute glomerulonephritis with Urinary tract infection
What are the other investigations
Urea and creatine, us, threat swab, asot, anadsa,

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 Management
Supportive
Restrict fluid intake
Restrict salt
Diet
Weight monitoring daily
Diuretic – frusemide
Htn – AcEI
ANTIBiotics – benzyil penicillin, cepalosporn, erythromycin

2. A baby with steven johnsons syndrome come to your clinic.

Define – SJS
Type IV (subtype C) hypersensitivity reaction that typically involves
the skin and mucous membranes characterised by BSA <10%.
Risk factors
DRUGS – co-trimoxazol, cephalosporis, NSAIDS, NVP,
CARBAMAZPINE, ALLOPURINOL
INFECTIONS – BACTERIAL – TB, SYHILIS
FUNGAL – HISTOPLASMOSIS,
COCCIDIOMYCOSIS
VIRAL – MUMPS, HIV, MEASLES, INFLUENZA
IMMUNIZATIONS – SMALLPOX, MEASLES, DIPTHERIA-
PERTUSIS-TETANUS (DPT), BACCILUS CALMETE GUERIN (BCG),
MEASLES-MUMPS-RUBELLA (MMR)
OTHERS – GRAFT VS HOST DISEASE, IBD, RADIATION THERAPY

CLINCAL FEATURES
PURPURITIC PAPULES, OR PLAQUES, BLISTERS

MANAGEMENT
Supportive
Iv fluids
Isolate the patient –
Wound care
Ophthalmology
Nutritional support
With drawl of offending agent – eg drugs

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 A 10 year old male adolesct named Joe is brought to your office with
longstanding hx of joint swelling. The swelling was first noticed at the
age of 1 year when the child began to cruise. The swelling first
started with the ankle joints other joints. The parents never brought
medical attention

OSCE
What is this?
Phototherapy machine
What is the wavelength?
430 – 490nm
indication
unconjugated bilirubin
Pathophysiology of phototherapy?
Three mechanisims
1. Structural isomerisation – (reversible)
2. Structural configuration – (irreversible)
3. Photoxidation -
How you put a baby for phototherapy?

Distance?
20 – 45cm
complications
hyperthermia, dehydration, watery diarrhoea, hypocalcaemia, retinal
damage, bronze baby syndrome, potential genetic syndrome, mutations,
station 2
resuscitation

94
95
96
97
98
99
 ANSWERS
1. B (Maternal breast cancer)
2. A (Shouldn’t wait for autopsy)
3. A (Heamolytic anaemia)
4. C (Neural crest cells)
5. D (Downs Syndrome)
6. B (50%)
7. B (hypothyroidism)
8. B (messenger RNA)
9. C (bacterial DNA separate from chromosome)
10. B (DNA)
11. D (low Calcium and high phosphate)
12. C (Radiologically)
13. D
14. D
15. D
Section B
1.
A. false b. true C. true d. false

Question 3.
Mrs M. Mwale a vegetable farmer for 5 years, who sprays regularly her
vegetables. Has two children a 3-year-old and a 10 years old and is
currently pregnant, while at antenatal she was given iron tablets. After a
day of business, she gets home and finds two of her children unconscious.
A 10 lying on the floor with saliva coming out, with excessive sweating, with
a bottle of coca cola on the floor which had earlier contained one of the
chemicals used to spray the vegetables by her workers. A 3 year who was
also lying unconscious with a packed of iron tablets empty. On presentation,
the doctor on call Dr Temitope Ashola admits the patients.
a) What is the diagnosis in the 10 years old patient?
b) What are the signs and symptoms of your above diagnosis?
c) How do you manage your patient in a giving dosages and frequency in
a
d) What is the pathophysiology for your diagnosis in a
e) What investigations would you order in a
f) What is the diagnosis in the 3-year-old paitent?
g) What predisposed the 3 years old child?
h) How many tables make a toxic dose in 3 years old?
i) What is the pathophysiology of your diagnosis in f

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j) What are the signs and symptoms of your diagnosis in f
k) How many stages are involved in your diagnosis in f
l) What are the complications of your diagnosis in f
m) What investigations would you do ( f)
n) How do you manage the patient in f
o) What are the complications?
p) At what point in your management would you involve a paediatric
nephrologist and why in f?

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