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How Medicine Is Tested in Exams — and How to Answer Each Format

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Part 1: The Cognitive Framework Behind Medical Exam Questions

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Part 2: Types of Questions Used in Medical Exams

1. Multiple Choice Questions (MCQs)

• Single Best Answer (SBA / A-type): One stem, five options, choose the single best answer. The dominant format in USMLE Steps 1–3, PLAB, and most undergraduate finals.
• Extended Matching Questions (EMQ): A long list of options (8–15), multiple stems. Common in UK finals and MRCP.
• True/False (K-type): Each option judged independently. Being phased out in most modern exams due to poor reliability.
• Context-free MCQ: A bare factual stem ("What is the half-life of digoxin?"). Lower cognitive demand.
• Context-rich / Clinical Vignette MCQ: A patient scenario + question. The gold standard format in modern exams.

• Each question has "lures" — plausible distractors that are partially correct but lack a key defining element
• The stem contains deliberate clues embedded in patient demographics, time course, risk factors, and lab values

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2. Short Answer Questions (SAQs) / Structured Essay Questions (SEQs)

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3. Modified Essay Questions (MEQs)

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4. Objective Structured Clinical/Practical Examination (OSCE / OSPE)

• OSCE: History-taking, clinical examination, communication, procedural skills, data interpretation
• OSPE: Laboratory-based or practical skills (microscopy, specimen identification, instrument recognition)

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5. Long Case / Short Case

• Long case: 45–60 min with a real or simulated patient; then presented to examiners. Tests synthesis, communication, and clinical judgment.
• Short case: Brief focused examination of a specific system, then present findings.

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6. Oral Examinations (Viva Voce)

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7. Portfolio / Workplace-Based Assessments (WBAs)

• Mini-CEX (Clinical Evaluation Exercise): Observed clinical encounter
• DOPS (Direct Observation of Procedural Skills): Procedural competency
• CBD (Case-Based Discussion): Discussion of a patient you managed

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Part 3: How to Answer Each Format

A. Answering Clinical Vignette MCQs (SBAs) — The Six-Step Method

Step 1 — Read the Last Sentence FIRST

Step 2 — Read the Vignette and Highlight Key Data

• Age, sex, occupation, ethnicity (demographic red flags)
• Time course (acute vs. chronic is often the deciding factor)
• Chief complaint + associated symptoms
• Relevant negatives (absence of fever, no trauma history)
• Abnormal lab values / imaging findings
• Drug history and allergies

Step 3 — Visualize the Patient and Build a Differential

Step 4 — Read ALL Answer Options Before Choosing

Step 5 — Apply the Two-Step for Management/Pathophysiology Questions

1. Step 1 (internal): What is the diagnosis?
2. Step 2 (internal): Given that diagnosis, what is the correct action?

Step 6 — Strategies for Difficult Questions

• Avoid absolutes: Options with "always" or "never" are usually wrong
• If two options are opposites, one is often correct
• Eliminate clearly wrong options first, then choose between the remaining
• Set a time limit per question (~90 seconds for USMLE) — do not over-dwell; mark, move on, return
• Never change an answer unless you have a specific clinical reason — your first instinct is usually right

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B. Answering SAQs / Structured Questions

1. Read the question mark allocation — if it's worth 4 marks, write 4 distinct points
2. Use the command words as a guide:
   • List → bullet points, no explanation needed
   • Describe → brief sentences with key features
   • Explain / Discuss → mechanism + clinical relevance
   • Justify → evidence + reasoning
3. Be concise and specific — avoid vague phrases like "abnormal bloods" (say "elevated serum creatinine indicating AKI")
4. Use anatomical / pathophysiological language — markers reward precision
5. Don't pad — quality beats quantity; irrelevant content wastes your time and earns no marks

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C. Answering MEQs (Modified Essay Questions)

1. Answer each part only with information available up to that point — do not use later data to justify earlier answers
2. Be sequential — Part A (presentation) → Part B (investigations) → Part C (diagnosis) → Part D (management)
3. Show your reasoning — state why you're ordering a test or making a diagnosis
4. Update your differential as new data are revealed — this is exactly what MEQs test
5. Do not write essays for short-answer sub-parts — match depth to the marks allocated

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D. Answering OSCE Stations

• Speak aloud — examiners cannot mark what they cannot hear
• If you're stuck, say "I would normally…" to demonstrate knowledge of the correct process
• Time is tight — do not over-examine one system at the expense of the rest
• A structured approach scores marks even when knowledge is incomplete

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E. Answering Long Cases / Vivas

• Present systematically: Demographics → presenting complaint → HPC → PMH → DHx → SHx → systems review → examination → investigations → diagnosis → management
• Defend your reasoning — "I believe this is X because…"
• Acknowledge uncertainty gracefully: "My differential includes X and Y; I would differentiate with Z investigation"
• Know your case deeply — examiners probe the area where you are least confident
• Viva tip: If you don't know, do not guess blindly. Say: "I'm not certain of the exact dose, but the principle would be to…"

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Part 4: High-Yield Cross-Cutting Tips for All Medical Exams

Know the Buzzwords

Understand the "Next Best Step" Logic

1. If unstable → stabilise (ABC, resuscitate) before anything else
2. If stable, undiagnosed → most specific diagnostic test
3. If diagnosed → first-line treatment per guidelines
4. If red flags present → urgent referral / imaging

Understand What "Most Likely" Means

Time Management

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Part 5: Common Mistakes to Avoid

1. Over-reading into a question — take clinical data at face value unless clearly a red herring
2. Changing answers without reason — first instinct is usually correct
3. Choosing the most invasive option — medical management before surgical; non-invasive before invasive
4. Confusing "most common" with "most likely in this scenario" — context overrides epidemiology
5. Missing the question type — distinguish "What is the diagnosis?" from "What is the next step?". The best diagnosis and the best next step are often different answers.
6. Neglecting negatives — a "no fever" or "no weight loss" in the stem is deliberate information
7. Running out of time in OSCEs — examiners cannot rescue you; practice with a timer

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Summary Table

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How Medical Exams Are Tested by Subject — and How to Answer Each Type

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UNIT 1: INTERNAL MEDICINE

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How Internal Medicine Is Tested

Question Types in Internal Medicine

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Recurring Question Themes in Internal Medicine

1. "What is the most likely diagnosis?"

1. Extract: Age, sex, time course, key symptoms, physical signs, lab abnormalities
2. Pattern-match: What unifying diagnosis explains ALL findings?
3. Use common disease thinking: common conditions are common
4. If a demographic is specified (e.g., young woman, elderly man), it is a clue

Example: "60-year-old smoker with progressive dyspnoea, barrel chest, reduced breath sounds, hyperresonance, FEV₁/FVC < 0.70" → COPD

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2. "What is the most appropriate investigation?"

• If unstable → bedside test first (ECG, glucose, O₂ sat, ABG)
• If stable + undiagnosed → most specific confirmatory test
• If diagnosis known → staging / severity test

Example: "45-year-old man with exertional chest pain radiating to the jaw" → Next investigation = 12-lead ECG (not troponin, not echo — ECG is first, fastest, bedside)

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3. "What is the next most appropriate step in management?"

1. Airway / Breathing / Circulation if there's any instability
2. Specific emergency treatment (e.g., aspirin + GTN for ACS)
3. Confirm diagnosis if not yet confirmed
4. Definitive management

Example: "Patient with suspected PE, O₂ sat 88%" → Next step = give supplemental oxygen + immediate CTPA (not anticoagulate without imaging unless imminent arrest)

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4. "What complications may occur?" / "What are the causes of X?"

• Systematic structure prevents omissions. For complications: use CVS / Resp / GI / Renal / Neuro / Haematological / Endocrine system ordering
• For causes: use a surgical sieve (VITAMIN CD: Vascular, Infective, Trauma, Autoimmune, Metabolic, Idiopathic, Neoplastic, Congenital, Drugs)

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5. Data Interpretation Questions

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Long Case / Viva Strategy in Internal Medicine

1. Demographics + chief complaint (1 sentence)
2. History of presenting complaint (chronological, 3–4 key features)
3. PMH / DHx / FHx / SHx (brief, highlight relevant positives/negatives)
4. Examination findings (positive and relevant negative)
5. Summary statement: "In summary, this is a 58-year-old hypertensive woman presenting with 3 days of progressive dyspnoea and orthopnoea, most consistent with acute decompensated heart failure"
6. Differential diagnoses (2–3, ranked)
7. Investigations you would order and WHY
8. Management plan (acute → definitive → follow-up)

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UNIT 2: PATHOLOGY

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How Pathology Is Tested

Question Types in Pathology

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Recurring Question Themes in Pathology

1. "Describe the pathogenesis / pathophysiology of X"

1. Initiating event / etiology (genetic, infective, chemical, ischaemic, immune)
2. Cell/tissue-level response (injury → cell death type: apoptosis vs. necrosis)
3. Molecular mediators (cytokines, growth factors, enzymes)
4. Morphological changes (what you see microscopically and grossly)
5. Progression / complications
6. Clinical consequence

Example: "Describe the pathogenesis of atherosclerosis" → Endothelial injury (hypertension, hyperlipidaemia) → LDL oxidation → monocyte recruitment → foam cell formation → fatty streak → fibrous plaque → complication (rupture → thrombosis → MI/stroke)

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2. "What are the microscopic/histological features of X?"

1. Architecture (pattern of tissue arrangement)
2. Cellularity (hypercellular? sparse?)
3. Cell type (what cells are present: epithelial, inflammatory, stromal)
4. Nuclear features (size, pleomorphism, chromatin, mitoses)
5. Cytoplasm (granules, vacuoles, inclusions)
6. Stroma / matrix (fibrosis, necrosis, calcification)
7. Special stain results if applicable

Know the key stain–condition pairs:

• Congo red + apple-green birefringence → Amyloid
• PAS stain → Glycogen / fungi
• Ziehl-Neelsen (ZN) → AFB / TB
• Prussian blue → Haemosiderin / iron
• Masson's trichrome → Collagen / fibrosis
• Silver stain → Fungi / spirochetes / reticulin

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3. "Classify / list the types of X"

• State the classification principle first (e.g., benign vs. malignant; primary vs. secondary; acute vs. chronic)
• List with brief distinguishing features of each
• Use the examiner-expected classification (Robbins-based language is standard worldwide)

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4. Practical / Spot Diagnosis (Histology/Gross Slide)

1. Tissue type (epithelium, gland, stroma)
2. Low-power pattern (what does the architecture look like overall?)
3. High-power features (cell detail, nuclear atypia, mitoses)
4. Diagnosis

1. Organ identified
2. Describe the lesion: size, shape, colour, texture, margins, cut surface
3. Name the pathological process
4. Likely diagnosis

Example script: "This is a section of colon showing an infiltrative ulcerated lesion with raised irregular edges. Microscopically there are malignant glands invading through the muscularis propria with desmoplastic stroma. This is consistent with a moderately differentiated adenocarcinoma of the colon."

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5. Neoplasia Questions — the Most Tested Topic

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UNIT 3: SURGERY

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How Surgery Is Tested

Question Types in Surgery

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Recurring Question Themes in Surgery

1. "What is the diagnosis?" (Surgical Scenario)

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2. "What investigations would you order?"

1. Bedside: Vitals, urine dipstick, pregnancy test (if female), ECG
2. Blood tests: FBC, U&E, LFTs, amylase/lipase, coagulation, group & save, blood cultures
3. Imaging: Plain X-ray (erect CXR / AXR) → Ultrasound → CT (with contrast) → MRI/endoscopy as indicated
4. Special investigations: Biopsy, angiography, laparoscopy for diagnostic uncertainty

Always justify each test: "CT abdomen/pelvis with IV contrast to identify the level and cause of obstruction and assess for ischaemia"

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3. "What is the management?" (Surgical Cases)

IMMEDIATE → RESUSCITATION → SPECIFIC INTERVENTION → DEFINITIVE SURGERY → POST-OP

1. Resuscitation (ABCDE): Airway, IV access, fluid resuscitation, oxygen, catheter, NGT if needed
2. Monitoring: Vitals, fluid balance, urine output (target ≥0.5 ml/kg/hr)
3. Analgesia and anti-emetics
4. Specific medical management (e.g., antibiotics for peritonitis, heparin for DVT)
5. Operative intervention: Name the operation, timing (emergency vs. elective), approach (open vs. laparoscopic)
6. Post-operative care: VTE prophylaxis, wound care, drain management, diet progression, rehabilitation

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4. Surgical Complications Questions

• General (apply to any operation): Haemorrhage, infection, DVT/PE, pain, anaesthetic risk, scarring
• Specific (organ/operation-specific): e.g., recurrent laryngeal nerve injury in thyroidectomy; bile duct injury in cholecystectomy; anastomotic leak in bowel surgery

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5. OSCE Surgical Examination — How to Present Findings

"On inspection, the abdomen is mildly distended with no visible peristalsis or scars. On palpation, there is tenderness in the right iliac fossa with guarding and rebound tenderness at McBurney's point. Rovsing's sign is positive. Bowel sounds are reduced. In summary, the clinical findings are consistent with acute appendicitis, and I would like to confirm with bloods and imaging."

1. Inspection findings
2. Palpation findings (superficial then deep; note tenderness, masses, organomegaly)
3. Percussion findings
4. Auscultation
5. Summary statement with diagnosis
6. Offer further examination / investigation

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6. Anatomy-Based Viva Questions (Surgery)

• State the structure's position/location first
• Give boundaries or relations in a systematic order (anterior → posterior → medial → lateral → superior → inferior)
• Then give clinical relevance (what happens if it's injured? why does it matter surgically?)

A good anatomy answer is NEVER just a list — it ends with: "This is clinically important because..."

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UNIT 4: PAEDIATRICS

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How Paediatrics Is Tested

Question Types in Paediatrics

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Recurring Question Themes in Paediatrics

1. Age Is Always a Clue

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2. "What is the diagnosis?" in Paediatrics

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3. Developmental Assessment Questions

1. State the child's chronological age
2. State what the child CAN do (achievements)
3. Identify the DOMAIN in which the child is delayed
4. Suggest a probable aetiology (vision/hearing problem? neurological? environmental?)
5. State what investigation/referral is needed

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4. "What is the management?" in Paediatrics

• Weight-based dosing: Always state dose in mg/kg (e.g., paracetamol 15 mg/kg QDS; amoxicillin 25 mg/kg TDS)
• Fluid resuscitation in children: 10–20 ml/kg bolus of 0.9% NaCl (NOT 500 ml like adults)
• Normal vital sign ranges change with age — know paediatric ranges (a HR of 120 in a neonate is normal; in an adult it means tachycardia)
• Always include parents: Management of a child involves parent education, consent, and safety-netting

1. ABCDE stabilisation (if acutely unwell)
2. Weight-appropriate fluids/medications
3. Specific treatment (name drug + dose + route + duration)
4. Monitoring parameters (O2 sat, RR, HR, urine output)
5. Escalation criteria (when to call for senior help)
6. Parent education and discharge advice
7. Follow-up / immunisation review / community referral

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5. OSCE in Paediatrics — Unique Challenges

• Open question to parent first: "Tell me what's been happening with [child's name]"
• Note discrepancy between parent's account and child's behaviour
• ALWAYS ask: Birth history, developmental history, immunisation status, family history, school performance
• Safeguarding: If the history doesn't match the injury, or there are unexplained injuries, state: "I have safeguarding concerns which I would escalate to my senior and the paediatric safeguarding team"

• Approach gently — introduce yourself to the child by name first
• Examine least painful areas first, most painful last
• Use distraction (toy, phone)
• Narrate your findings to the examiner throughout

1. Plot weight, height, and head circumference on appropriate centile chart
2. Identify if the child is above / below normal centiles
3. Note centile crossing (crossing 2 centile lines = significant concern)
4. State: "This child's weight has crossed two centile lines downward between 6 months and 12 months, consistent with failure to thrive"
5. Offer differential: organic (malabsorption, cardiac, chronic infection) vs. non-organic (psychosocial, neglect)

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Cross-Subject Principles That Apply to All Units

The Universal Answer Framework for Any Clinical Question

DIAGNOSIS → INVESTIGATIONS → MANAGEMENT → COMPLICATIONS → PROGNOSIS

The "Worst First" Principle

• Always mention and exclude the most life-threatening diagnosis first, even if it is less likely
• Examiners reward safety-conscious reasoning

"The most important diagnosis to exclude is X because it is immediately life-threatening. Once excluded, the most likely diagnosis is Y."

Command Word Decoder

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Subject-by-Subject Quick Reference Card

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How to Answer Internal Medicine Exam Questions and Score Well

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Part 1: The Five Question Types in Internal Medicine

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TYPE 1: MCQ / SINGLE BEST ANSWER (SBA)

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What These Questions Look Like

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▸ DIAGNOSIS QUESTION

A 68-year-old man presents with a 3-day history of progressive dyspnoea, orthopnoea, and ankle swelling. He has a background of hypertension and had a myocardial infarction 5 years ago. On examination his JVP is elevated, he has bibasal crackles, and pitting oedema to the knees. His chest X-ray shows cardiomegaly and bilateral perihilar shadowing.

What is the most likely diagnosis?

• A. Community-acquired pneumonia
• B. Pulmonary embolism
• C. Decompensated heart failure
• D. Bilateral pleural effusions due to malignancy
• E. Exacerbation of COPD

• The combination of JVP elevation + bibasal crackles + bilateral ankle oedema + CXR showing cardiomegaly and perihilar shadowing = the classic tetrad of decompensated heart failure
• Prior MI (ischaemic aetiology) + hypertension (risk factor) supports the diagnosis
• Option A lacks the cardiac features and oedema
• Option B would not typically show bilateral perihilar shadowing or ankle oedema
• Option E lacks the cardiac signs; COPD causes hyperinflation, not cardiomegaly

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▸ INVESTIGATION QUESTION

A 55-year-old woman with known atrial fibrillation presents acutely confused and dysarthric. Her symptoms started 1 hour ago. She is on warfarin with an INR of 1.8. Neurological examination reveals right facial droop and right-sided weakness.

What is the single most important immediate investigation?

• A. MRI brain with diffusion-weighted imaging
• B. Carotid Doppler ultrasound
• C. Non-contrast CT brain
• D. Echocardiogram
• E. Coagulation screen

• The priority is to distinguish ischaemic stroke from haemorrhagic stroke — because treatment (thrombolysis/anticoagulation) is dangerous if there is haemorrhage
• Non-contrast CT is fast, available, and sufficient to exclude haemorrhage — that is all you need right now
• MRI-DWI is more sensitive but takes longer and is not the immediate priority
• Carotid Doppler, echo, and coag screen are all important but come AFTER the CT

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▸ MANAGEMENT QUESTION

A 72-year-old man with type 2 diabetes and stage 3 CKD (eGFR 35) presents with a fasting glucose of 14 mmol/L and HbA1c of 82 mmol/mol. He is currently on metformin 1g BD and gliclazide 80mg OD. His BP is 148/92 and his ACR is 45 mg/mmol.

Which of the following is the most appropriate next step in his management?

• A. Increase gliclazide to 160mg OD
• B. Add insulin
• C. Add an SGLT-2 inhibitor
• D. Stop metformin immediately
• E. Add a GLP-1 receptor agonist

• SGLT-2 inhibitors (e.g., empagliflozin, dapagliflozin) are now first-line add-on agents in T2DM with CKD because of proven cardiorenal protection (EMPA-REG, CREDENCE, DAPA-CKD trials)
• His eGFR 35 is above the threshold to initiate (≥20) and ACR elevation makes him a priority
• Metformin should be reviewed at eGFR <30 but does not need to be stopped now at eGFR 35
• Gliclazide increase risks hypoglycaemia without cardiorenal benefit
• Insulin and GLP-1 are valid escalations but not the most appropriate next step given available evidence

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▸ "NEXT BEST STEP" (Most Dangerous Question Type)

A 45-year-old man presents with sudden onset severe crushing central chest pain radiating to his left arm, diaphoresis, and nausea for 40 minutes. His ECG shows 3mm ST elevation in leads II, III, and aVF with reciprocal changes in I and aVL. His BP is 88/60 and HR is 110.

What is the single most appropriate immediate action?

• A. Administer IV morphine and GTN infusion
• B. Give aspirin 300mg and activate the catheter lab
• C. Perform urgent echocardiogram
• D. Administer IV fluids 500ml and reassess
• E. Give thrombolysis immediately

• This is an inferior STEMI (ST elevation in II, III, aVF)
• The patient is haemodynamically compromised (BP 88/60) — this suggests right ventricular involvement (inferior MI + hypotension = RV MI until proven otherwise)
• Primary PCI is the treatment of choice and must be activated immediately
• Aspirin 300mg loading dose is the first pharmacological step
• IV fluids are given for RV MI hypotension but only AFTER diagnosis — not before catheter lab activation
• Option D is dangerous alone because fluids without knowing RV involvement could harm
• Thrombolysis is only given when PCI is unavailable within guideline windows

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The SBA Method — 6 Steps to Every MCQ

STEP 1 → Read the LAST SENTENCE first (the actual question)
STEP 2 → Read the vignette with purpose — what do I need to answer THIS question?
STEP 3 → Extract: Age / Sex / Time course / Key symptoms / Key signs / Abnormal investigations
STEP 4 → Form your OWN answer BEFORE reading the options
STEP 5 → Match your answer to the option closest to what you thought
STEP 6 → If unsure: eliminate, then choose; avoid "always/never"; if two options are opposites, one is likely correct

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TYPE 2: SHORT ANSWER QUESTIONS (SAQs)

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What These Questions Look Like

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▸ DIRECT SAQ — Causes / List

Question: List SIX causes of macrocytic anaemia. (6 marks)

• Write six distinct causes — one per line, labelled
• Do not explain unless asked ("List" = no explanation needed)
• Organise to show you know the classification

Answer:
1. Vitamin B12 deficiency (e.g., pernicious anaemia, malabsorption)
2. Folate deficiency (poor intake, malabsorption, increased demand e.g. pregnancy)
3. Hypothyroidism
4. Alcohol excess / liver disease
5. Myelodysplastic syndrome
6. Drugs — hydroxyurea, methotrexate, azathioprine (anti-metabolites)

• Writing "anaemia of chronic disease" (that causes microcytic/normocytic, not macrocytic)
• Listing subtypes of the same cause as separate answers
• Adding explanation when not asked — wastes time

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▸ DIRECT SAQ — Investigations

Question: A 35-year-old woman presents with fatigue, weight loss, palpitations, heat intolerance, and a smooth goitre. What investigations would you perform? (5 marks)

Answer:
1. Thyroid function tests (TFTs): TSH (suppressed in hyperthyroidism), free T4, free T3
2. Thyroid antibodies: TSH receptor antibodies (positive in Graves' disease)
3. Full blood count and ESR (baseline; exclude concurrent anaemia)
4. Thyroid ultrasound: assess goitre characteristics, exclude nodules
5. Radioactive iodine uptake scan (if USS shows nodular disease or diagnosis uncertain)

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▸ SCENARIO-BASED SAQ — Management

Question: A 60-year-old man with known cirrhosis presents with haematemesis. He is pale, diaphoretic, and his BP is 90/60, HR 118. Outline your immediate management. (8 marks)

Answer:
A – Airway: Position patient, assess for vomiting/aspiration risk; consider anaesthetic review
B – Breathing: Apply high-flow O₂ via non-rebreather mask; monitor O₂ saturation
C – Circulation:
   - 2 large-bore IV cannulae (14–16G)
   - Urgent bloods: FBC, U&E, LFTs, coagulation (INR), group & crossmatch, blood cultures
   - IV fluid resuscitation: 500ml 0.9% NaCl bolus and reassess
   - Target systolic BP >90 mmHg; transfuse pRBC if Hb <70 g/L (or <80 in ACS)
   - Blood products: FFP and platelets if coagulopathic (likely in cirrhosis)
D – Disability: GCS, blood glucose
Specific:
   - IV terlipressin (vasoconstrictor — reduces portal pressure in suspected variceal bleed)
   - IV ceftriaxone 1g OD (antibiotic prophylaxis — reduces mortality in cirrhotic bleeds)
   - Insert NGT after stabilisation only if needed
   - Urgent endoscopy (OGD) within 12 hours of resuscitation for diagnosis + treatment
     (band ligation for varices; adrenaline injection / clips for peptic ulcer)
   - Keep NBM, catheterise (monitor urine output ≥0.5 ml/kg/hr)
   - Alert senior / GI/surgical team early

• ABCDE structure (even partial credit per step)
• Named drug + route (IV not just "give terlipressin")
• Specific thresholds (transfuse at Hb <70)
• Mentioning endoscopy — this is the definitive step, often forgotten

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▸ SCENARIO SAQ — Interpretation

Question: Interpret this ABG: pH 7.28, PaCO₂ 28, HCO₃ 12, PaO₂ 88, on room air. What is the likely underlying cause in a patient with polyuria and polydipsia? (4 marks)

Step 1 — pH: 7.28 → ACIDOSIS
Step 2 — PaCO₂: 28 (low) → respiratory component is ALKALOTIC (not causing the acidosis)
Step 3 — HCO₃: 12 (low) → metabolic component is ACIDOTIC → PRIMARY METABOLIC ACIDOSIS
Step 4 — Compensation: Expected PaCO₂ = (1.5 × HCO₃) + 8 ± 2 = (1.5 × 12) + 8 = 26
           Actual PaCO₂ is 28 → appropriate respiratory compensation
Step 5 — Anion gap: Not given full electrolytes here, but in context:

Answer:
Metabolic acidosis with appropriate respiratory compensation. In a patient with polyuria and polydipsia, this is consistent with DIABETIC KETOACIDOSIS (DKA), which causes a HIGH ANION GAP metabolic acidosis (accumulation of ketoacids).

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SAQ Scoring Rules

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TYPE 3: MODIFIED ESSAY QUESTION (MEQ)

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What These Questions Look Like

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▸ FULL MEQ EXAMPLE (Internal Medicine)

Part A: Mrs. RK, a 52-year-old teacher, presents to the outpatient clinic with a 6-week history of progressive dyspnoea on exertion, mild ankle swelling, and fatigue. She has a history of hypertension managed with amlodipine. On examination: BP 158/96, HR 96 bpm, RR 18, O₂ sat 94% on room air. JVP is raised at 4cm. Chest reveals bibasal dullness with reduced breath sounds at both bases. Heart sounds: S1 S2 + S3 gallop.

i) What is your working diagnosis? (2 marks) ii) List THREE clinical signs that support your diagnosis. (3 marks)

i) Congestive cardiac failure (heart failure with reduced or preserved ejection fraction)

ii)
1. Raised JVP (4cm above sternal angle) — elevated venous pressure from right heart failure
2. Bibasal dullness + reduced breath sounds — bilateral pleural effusions (transudates from raised hydrostatic pressure)
3. Third heart sound (S3 gallop) — indicates rapid ventricular filling; hallmark of dilated/failing ventricle

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Part B: You order investigations. Results: Hb 11.2 g/dL, Na 134, K 4.1, Creatinine 102, BNP 1850 pg/mL, ECG: sinus tachycardia, LVH voltage criteria. CXR: cardiomegaly, bilateral perihilar haziness, Kerley B lines, upper lobe diversion.

i) Interpret the BNP result. (1 mark) ii) List THREE CXR findings supporting your diagnosis. (3 marks) iii) What further investigation would you request to confirm and guide management? (2 marks)

i) BNP 1850 pg/mL is markedly elevated (normal <100 pg/mL); this confirms significant ventricular wall stress consistent with heart failure. It also has prognostic value — the higher the BNP, the worse the prognosis.

ii)
1. Cardiomegaly — cardiac shadow >50% of thoracic diameter on PA film
2. Kerley B lines — horizontal lines at periphery indicating interstitial oedema (lymphatic engorgement)
3. Upper lobe diversion — redistribution of blood flow to upper zones due to elevated LVEDP

iii)
- Transthoracic echocardiogram (TTE): gold standard to assess ejection fraction, wall motion, valve function, and determine HFrEF vs. HFpEF — this directly guides management (e.g., ACE-inhibitor/beta-blocker for HFrEF)

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Part C: Echo shows LVEF 30%, dilated LV, no significant valvular disease. She is commenced on treatment.

i) List the THREE cornerstone drugs for this patient's condition with evidence base. (6 marks) ii) What monitoring is required after starting these medications? (3 marks)

i)
1. ACE inhibitor (e.g., ramipril) — reduces mortality in HFrEF by blocking neurohormonal activation; proven in SOLVD, CONSENSUS trials (start low, titrate up)

2. Beta-blocker (e.g., carvedilol, bisoprolol, metoprolol succinate) — reduces mortality and hospitalisation; proven in MERIT-HF, COPERNICUS trials; start only when euvolaemic (not in acute decompensation)

3. Mineralocorticoid receptor antagonist/MRA (e.g., spironolactone or eplerenone) — reduces mortality when added to ACEI + BB; proven in RALES and EMPHASIS-HF trials; use if K⁺ < 5.0 and eGFR > 30

Bonus: SGLT-2 inhibitor (dapagliflozin/empagliflozin) — now class IA recommendation; DAPA-HF and EMPEROR-Reduced trials showed mortality + hospitalisation benefit

ii)
1. Renal function + electrolytes (U&E) at 1–2 weeks after starting ACEI/MRA and after each dose increase — risk of hyperkalaemia and AKI
2. BP monitoring — risk of hypotension especially with ACEI + BB combination
3. Repeat BNP/NT-proBNP at 3 months — guide response to therapy and assess prognostic trajectory

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How to Excel in MEQs

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TYPE 4: LONG CASE / SHORT CASE

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What the Long Case Looks Like

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The Winning Presentation Structure

"Mr. A is a 64-year-old retired engineer presenting with a 3-month history of progressive exertional dyspnoea and bilateral leg swelling, in the context of known hypertension and diabetes mellitus."

• Onset, duration, progression
• Associated symptoms (what else is going on)
• Relevant negatives (what is NOT there — equally important)
• Precipitating / relieving factors

"His dyspnoea is now limiting him to 50 metres on flat ground (NYHA Class III). He reports orthopnoea (sleeps on 3 pillows) and two episodes of paroxysmal nocturnal dyspnoea in the past month. He denies chest pain, haemoptysis, or fever."

"Hypertension — diagnosed 10 years ago, treated with amlodipine; poorly controlled. Type 2 DM — 8 years, on metformin and gliclazide. No previous cardiac history or hospitalisations."

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Examination Findings — How to Present

"On general inspection, Mr. A is comfortable at rest but mildly breathless on minimal exertion. He has peripheral cyanosis and pitting oedema to the mid-shin bilaterally. JVP is elevated at 5cm with a prominent v-wave. The apex beat is displaced to the 6th intercostal space, anterior axillary line — consistent with cardiomegaly. Heart sounds S1 and S2 are present with an audible S3 gallop at the apex. Chest auscultation reveals fine bibasal crackles to the mid-zones. There is dullness to percussion at both bases."

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The Summary Statement — Most Important Part

1. Concise (2–3 sentences max)
2. Diagnostic
3. Confident

"In summary, Mr. A is a 64-year-old man with longstanding hypertension and diabetes presenting with progressive biventricular heart failure, most likely of hypertensive aetiology given his chronically uncontrolled blood pressure and absence of ischaemic features. His NYHA class III functional impairment with clinical, biochemical, and radiological signs of congestion warrants urgent echocardiography and optimisation of medical therapy."

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Viva Questions After the Long Case — What Examiners Ask and How to Answer

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PART 2: HIGH-YIELD INTERNAL MEDICINE TOPICS

and How Questions Are Asked About Each

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The Most Commonly Tested Conditions — Question Style and Answer Template

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1. CHEST PAIN / ACS

• "What is the diagnosis?" — ST elevation in V1–V4 → anterior STEMI
• "What do you do immediately?" — Activate cath lab; aspirin + P2Y12 inhibitor + anticoagulant
• "What complication has occurred?" — New pan-systolic murmur post-MI → ventricular septal defect or mitral regurgitation (papillary muscle rupture)

• Troponin rise = myocardial injury (NOT always MI — also myocarditis, PE, sepsis)
• Reciprocal ST depression = confirms true ST elevation
• New LBBB in chest pain = treat as STEMI

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2. DYSPNOEA / RESPIRATORY

• "Spirometry shows FEV₁/FVC 0.64, FEV₁ 55% predicted. What diagnosis?" → Obstructive (COPD or asthma)
• "FEV₁/FVC 0.82, FEV₁ 60% predicted?" → Restrictive (pulmonary fibrosis, sarcoidosis)
• "What is the most appropriate long-term oxygen therapy criterion?" → PaO₂ <7.3 kPa at rest on 2 separate occasions

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3. ALTERED CONSCIOUSNESS / NEUROLOGY

1. Most likely diagnosis: Bacterial meningitis
2. Do NOT delay treatment for LP — give IV ceftriaxone immediately if LP will be delayed >1 hour
3. Give dexamethasone before first dose of antibiotics (reduces inflammation, improves outcomes)
4. CT head first only if: focal neurological deficit, immunocompromised, papilloedema, seizure, GCS <13

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4. ELECTROLYTES / METABOLIC

• Hyponatraemia (low serum Na)
• Serum hypo-osmolality (<275 mOsm/kg)
• Inappropriately concentrated urine (>100 mOsm/kg)
• Elevated urinary sodium (>20 mmol/L)
• Euvolaemia (no oedema, no dehydration)
• Exclude: hypothyroidism, hypoadrenalism

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5. JAUNDICE / LIVER

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PART 3: MASTER RULES FOR SCORING WELL

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The Examiner's Mindset

The 10 Rules That Consistently Separate High Scorers

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Common Mistakes That Drop Marks

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Quick Reference: What to Write First for Each Question Type

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