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🩺 4th Year MBBS Internal Medicine Practical Exam — Complete Study Guide

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1. EXAM STRUCTURE OVERVIEW

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2. LONG CASE — The Most Important Component

Format

1. Spend 45–60 min with the patient alone
2. Take a full history and examine the patient
3. 10 min to organize your thoughts
4. Present to two examiners for 20–25 min

Opening Statement (Critical — Memorize a Template)

"Mr. X is a 55-year-old male, presented with [chief complaint] for [duration], on a background of [key comorbidities]. He is currently [hemodynamically stable/in distress]."

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Most Common Long Case Topics

Cardiovascular

• Heart Failure — Ask for: orthopnoea, PND, ankle swelling, NYHA class; aetiology (IHD, valvular, cardiomyopathy)
• Hypertension — Complications (IHD, stroke, CKD, retinopathy), secondary causes, antihypertensive history
• Ischaemic Heart Disease — Risk factors (DM, HTN, dyslipidaemia, smoking), angina vs ACS, echo/angio findings

Respiratory

• COPD — Smoking history, exacerbation frequency, spirometry, current inhalers, cor pulmonale signs
• Bronchial Asthma — Triggers, diurnal variation, steroid use, hospital admissions
• Pleural Effusion — TB vs malignancy vs CCF; Light's criteria; LDH, protein

Endocrine

• Diabetes Mellitus — Type, duration, glycaemic control (HbA1c), complications (retinopathy, nephropathy, neuropathy, PVD), hypoglycaemic episodes
• Thyroid Disease — Hypo vs hyperthyroidism; Graves' disease features; TFTs, medications

Gastroenterology

• Chronic Liver Disease / Cirrhosis — Aetiology (hepatitis B/C, alcohol, NAFLD), portal hypertension, Child-Pugh scoring
• Jaundice — Pre-hepatic / hepatic / post-hepatic differentiation

Haematology

• Anaemia — Iron deficiency vs B12/folate vs haemolytic vs aplastic; dietary history, bleeding history
• Lymphoma / CML / CLL — B symptoms, lymphadenopathy, organomegaly

Renal

• Chronic Kidney Disease — Aetiology, staging (GFR), complications (anaemia, HTN, hyperK+), dialysis status
• Nephrotic / Nephritic Syndrome

Neurology

• Stroke — NIHSS, time of onset, type (ischaemic/haemorrhagic), risk factors, rehabilitation
• Epilepsy — Seizure type, frequency, medications, driving advice

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Long Case Presentation Structure

1. Introductory Statement — Age, sex, chief complaint, key background
2. History of Presenting Complaint — Onset, duration, progression, severity, associated symptoms
3. Past Medical History — Previous episodes, comorbidities
4. Drug History — Current medications, compliance, allergies
5. Family & Social History — Occupation, smoking, alcohol, marital status
6. Systemic Review — CVS, respiratory, GI, CNS, urological, musculoskeletal
7. Examination Findings — General, vitals, system-specific (positive AND relevant negative findings)
8. Summary — "In summary, this is a [age/sex] with [diagnosis] complicated by [complications], currently managed with [treatment]"
9. Differential Diagnosis — 2–3 differentials with reasoning
10. Investigations — What you would request and why
11. Management Plan — Pharmacological + non-pharmacological

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3. SHORT CASE — Spot Diagnosis + Focused Exam

How to Perform

• Always introduce yourself, wash hands, expose properly
• Describe findings as you go or present at the end
• Give a one-line diagnosis: "This patient has signs consistent with mitral stenosis, as evidenced by..."

Common Short Case Scenarios

Cardiovascular

• Mitral stenosis / regurgitation — auscultate, describe murmur (timing, location, radiation, character)
• Aortic stenosis / regurgitation
• Atrial fibrillation — pulse, JVP, precordial exam
• Signs of heart failure — JVP raised, bibasal crackles, peripheral oedema

Respiratory

• Consolidation, pleural effusion, pneumothorax — classical percussion/auscultation findings
• COPD — barrel chest, hyperinflation, pursed lip breathing
• Clubbing — list causes by system (respiratory, cardiac, GI, hepatic)

Abdominal

• Hepatomegaly / splenomegaly / hepatosplenomegaly
• Ascites — shifting dullness, fluid thrill
• Renal mass — ballotable, moves with respiration

Neurological

• Upper vs lower motor neurone lesion
• Cerebellar signs — DANISH (Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonia)
• Parkinson's disease — rigidity, tremor, bradykinesia, shuffling gait
• Peripheral neuropathy — glove and stocking distribution

Hands / Peripheral

• Rheumatoid arthritis hands
• Thyroid status — examine thyroid, eye signs, hands
• Anaemia — pallor, koilonychia, angular stomatitis

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4. VIVA VOCE — Common Questions

Cardiovascular Viva

• "What are the causes of atrial fibrillation?"
• "How do you classify heart failure? (NYHA)"
• "What are the indications for anticoagulation in AF?" (CHA₂DS₂-VASc score)
• "Differentiate cardiac tamponade from constrictive pericarditis"

Respiratory Viva

• "What is Gold staging in COPD?"
• "How do you differentiate TB from lung cancer on CXR?"
• "What are Light's criteria for exudate?"
• "Causes and management of haemoptysis"

Endocrine Viva

• "How is diabetes diagnosed?" (fasting glucose ≥7.0 mmol/L, HbA1c ≥48 mmol/mol)
• "What are the complications of long-term steroid use?"
• "Causes of hypoglycaemia in a diabetic patient"
• "Differentiate Graves' disease from toxic multinodular goitre"

Haematology Viva

• "Classify anaemia by MCV (microcytic, normocytic, macrocytic)"
• "What is the peripheral blood film in iron deficiency anaemia?"
• "How do you manage a patient with sickle cell crisis?"

Renal/GI Viva

• "Stages of CKD and their GFR ranges"
• "Causes of raised unconjugated vs conjugated bilirubin"
• "Child-Pugh scoring in liver cirrhosis"

Pharmacology (Very Commonly Asked)

• Drug of choice for each condition
• Side effects: metformin, warfarin, ACE inhibitors, digoxin, lithium, steroids
• Contraindications: beta-blockers in asthma, NSAIDs in CKD
• Antidotes: naloxone (opioids), N-acetylcysteine (paracetamol), protamine (heparin)

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5. OSPE / OSCE STATIONS

Data Interpretation

• ECG reading: normal sinus rhythm, AF, LBBB/RBBB, STEMI (ST elevation in leads), LVH
• CXR reading: cardiomegaly, pleural effusion, consolidation, pneumothorax, hilar adenopathy
• ABG interpretation: respiratory/metabolic acidosis/alkalosis, compensation
• Blood results: FBC, LFTs, U&E, TFTs — identify the abnormality and link to diagnosis

Procedural / Practical Stations

• Measure blood pressure correctly
• Demonstrate inhaler technique
• ECG lead placement
• Urine dipstick interpretation
• Calculate BMI or GFR (CKD-EPI)

History Taking (Mini)

• Take a focused history for chest pain / breathlessness / jaundice
• Identify red flags

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6. HIGH-YIELD TOPICS TO MASTER (Most Frequent in Exams)

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7. STUDY STRATEGY

3–4 Weeks Before the Exam

• Study long case templates system by system — know the history framework for each condition cold
• Practice presenting out loud (time yourself — 5 min for presentation)
• Do ward rounds actively: examine patients, present cases to your resident/registrar

1–2 Weeks Before

• Focus on short case clinical signs — practice bedside examination daily
• Memorize key diagnostic criteria and classifications (NYHA, GOLD, Child-Pugh, CKD staging, CHA₂DS₂-VASc)
• Drill ECG and CXR interpretation — do 10 a day

Final Week

• Review common drug side effects and mechanisms
• Practice answering viva questions aloud with a partner
• Go over your "never miss" red flags for each system

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8. GOLDEN TIPS FOR THE DAY

• Long case: Build rapport with your patient — they may give you useful extra history; ask open then closed questions
• Examination: Narrate your positive AND significant negative findings; examiners reward systematic approach
• Viva: If you don't know, say "I would look that up / discuss with my senior" — never fabricate; think aloud
• Presentation: Use connective tissue phrases: "Consistent with... supported by... which explains the..."
• OSPE: Read the question stem twice before answering — they love catching students who answer a different question