CGH IM Challenge Jun/2025

CGH IM Challenge Jun/2025
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Gamemaster: Dr Joel Yee
Facilitators: Gabrielle, Arthur

Let's try if this works!

Multiple Choice

Is Dr Joel Yee the most handsome consultant in CGH?

• ABSOLUTELY YES!!!!

• I pressed wrongly :(

Ok are you ready?!

Multiple Choice

A 32-year-old woman presents with a new, painless, firm breast mass noted 2 weeks ago. On exam, the mass is 2 cm, mobile, and located in the upper outer quadrant of the left breast. There is no skin dimpling or nipple discharge. No axillary lymphadenopathy is present.

What is the most appropriate next step in management?

• Reassurance and re-exam in 6 months

• Fine-needle aspiration (FNA)

• Diagnostic mammography

• Breast ultrasound

• Excisional biopsy

Explanation Slide...

- In women <30–35 years, ultrasound is the preferred initial imaging.

- Mammography is less sensitive in dense breast tissue.

- FNA or biopsy may follow depending on imaging results.

- Reassurance alone is not appropriate for a new mass.

Multiple Choice

According to CGH antibiotics guidelines, what is the antibiotic of choice for non-vertebral osteomyelitis?

• Augmentin

• Cefazolin

• Ciprofloxacin

• Clindamycin

• Vancomycin

Explanation Slide...

Cefazolin is the first-line agent for non-vertebral osteomyelitis due to its potent, bactericidal activity against MSSA and excellent bone penetration. The other options are either broader spectrum (Augmentin), reserved for Gram-negatives (ciprofloxacin), less reliable (clindamycin), or MRSA-targeted (vancomycin).

Multiple Choice

Which of the following are High Alert Medications (HAMs) in CGH?

• Phenytoin, Enoxaparin

• Phenytoin, Enoxaparin, Adrenaline

• Enoxaparin, Adrenaline, Actrapid

• All of the above

Explanation Slide...

- Refer to High Alert Medications.pdf for list of HAMs in CGH.
- Intranet > Drug Information > Medication Safety > High Alert Medications.pdf

Multiple Choice

A 28-year-old lady present with recurrent episodes of right upper quadrant abdominal pain and fever. She has had multiple episodes of cholangitis in the past. LFT shows raised ALP and GGT. MRCP was done. What is the most likely diagnosis?

• Primary sclerosing cholangitis

• Caroli disease

• Choledochal cyst

• Polycystic Liver Disease

• Hepatocellular Carcinoma

Explanation Slide...

- Caroli disease is a rare congenital disorder characterised by segmental, saccular dilatation of the intrahepatic bile ducts

- Mainly presents with cholestasis, biliary obstruction, cholangitis

- Imaging: MRCP
> Central dot sign: represents fibrovascular bundles within the dilated cystic intrahepatic ducts (typical of Caroli disease)

- Surveillance in Caroli disease and syndrome is mainly focused on the detection of cholangiocarcinoma

Multiple Choice

What is the choice of fluids during the fluid resuscitation phase of acute pancreatitis?

• Sodium chloride 0.9%

• Hartmann

• Dextrose 5% Sodium chloride 0.45%

• Dextrose 5% Sodium chloride 0.9%

• Plasmalyte

Explanation Slide...

⁃ Pathophysiology of acute pancreatitis involves premature trypsinogen activation which requires low pH
⁃ Infusion of sodium chloride risks hyperchloraemic acidosis

Multiple Choice

Which statement is FALSE about extra-fine particle ICS-containing inhalers?

• Examples of extra-fine particle ICS-containing inhalers used locally are: Fostair/Foster (Beclomethasone/Formoterol)

• Extra-fine particle ICS-containing deliver particles in size of <2µm

• Extra-fine particle inhalers result in reduced oropharyngeal deposition and greater lung deposition, hence increased potency/efficacy of the ICS delivered in extrafine formulations compared to non-extrafine formulations

• In view of reduced oropharyngeal deposition, patients do not need to rinse their mouths after every use to prevent thrush

• Fostair can be used as maintenance and reliever therapy (MART)

Explanation Slide...

Fostair (pMDI) and Fostair NEXThaler (DPI) have extrafine particles. (<2µm). The manufacturer states that 100 micrograms of BDP extrafine in these preparations is equivalent to 250 micrograms of BDP in a non-extrafine formulation.

Multiple Choice

A 40 year old man with no prior medical history presents to the ED after a witnessed generalised tonic-clonic seizures. He is currently alert and has no focal neurological deficits. Vitals are stable and there is no fever.

What is the most appropriate set of initial investigations to perform on admission?

• CT brain, electrolytes, inflammatory markers, CXR

• EEG, CT brain, lumbar puncture

• CT brain, ECG, serum glucose, electrolytes

• Electrolytes, liver panel, ammonia

• Serum prolactin, CT brain, ECG, troponin

Explanation Slide...

A first-ever GTCS must rapidly exclude three common precipitants: (1) an intracranial lesion needing urgent intervention—screened by a non-contrast head CT; (2) metabolic triggers such as hypoglycemia or electrolyte derangements; and (3) a primary cardiac arrhythmia that can present with convulsive syncope. Other tests in the distractor options (EEG, lumbar puncture, inflammatory markers, ammonia, serum prolactin, troponin, CXR) are either second-line or indicated only if specific red flags emerge (fever, focal deficit, encephalopathy, chest pain, liver disease).

Multiple Choice

Which set of initial blood-film findings most strongly suggests thrombotic thrombocytopenic purpura (TTP) in the Emergency Department?

• Macrocytic anaemia, leukocytosis, thrombocytosis

• Microcytic anaemia, normal platelets, elevated ferritin

• Normocytic anaemia with many schistocytes, marked thrombocytopenia, high LDH

• Haemolytic anaemia with spherocytes, prolonged PT / aPTT, low fibrinogen

• Neutropenia, thrombocytopenia, very high D-dimer

Explanation Slide...

TTP is a microangiopathic haemolytic anaemia in which widespread platelet-rich thrombi shear red cells, producing abundant schistocytes, severe thrombocytopenia and a haemolytic picture with raised LDH while coagulation times remain normal; this constellation (correct option) best fits the classic presentation described in the slide case

Multiple Choice

Which statement about inhaled corticosteroid/long-acting β₂-agonist (ICS/LABA) combination inhalers is CORRECT?

• Fluticasone/formoterol pMDI provides acute relief equal to salbutamol

• Budesonide/formoterol Turbuhaler can be used for both maintenance and reliever therapy in asthma

• Salmeterol/beclomethasone DPI is the preferred rescue inhaler during an acute attack

• Adding a LABA to ICS is contraindicated in COPD because it raises pneumonia risk unacceptably

• All DPIs require the same hand–breath coordination as a pressurised MDI

Explanation Slide...

Because formoterol has a rapid onset, the budesonide/formoterol Turbuhaler (and a few similar devices) is licensed for “single-inhaler maintenance-and-reliever therapy,” simplifying asthma regimens; fluticasone/formoterol pMDI still needs a short-acting β₂-agonist for rescue, salmeterol has too slow an onset for relief, ICS/LABA is beneficial—not contraindicated—in many COPD patients, and DPIs largely eliminate the coordination hurdle present with pMDIs.

Multiple Choice

Which test is more sensitive for diagnosing acute pancreatitis?

• Amylase

• Lipase

Explanation Slide...

⁃ Amylase has a short half-life and diagnosis may be missed if presenting >24h after onset
⁃ 20% of alcoholic pancreatitis won’t show 3x UPN rise in amylase as the parenchyma is unable to produce the enzyme

Multiple Choice

A 68-year-old man presents with recurrent light-headedness on standing. He has type 2 diabetes, well controlled. He is on ramipril, insulin, and simvastatin. On lying down, his BP is 136/78 mmHg, and standing after 3 minutes, it is 100/60 mmHg. HR remains 74 bpm. Which of the following features best suggests a neurogenic cause of orthostatic hypotension?

• A drop of more than 20 mmHg systolic BP

• HR fails to increase on standing

• Diabetes mellitus

• Use of antihypertensive medication

• Morning symptoms

Explanation Slide...

- The lack of compensatory tachycardia despite hypotension is the key feature pointing to neurogenic orthostatic hypotension (e.g. autonomic neuropathy). Other causes like dehydration or medications usually cause reflex tachycardia.

- A BP drop alone doesn't distinguish neurogenic vs non-neurogenic.

- DM and antihypertensives are risk factors but not diagnostic.

Multiple Choice

Which of the following condition is caused by the larvae of the Echinococcus granulosus tapeworm?

• Caroli Disease

• Cystadenocarcinoma

• Cystadenoma

• Hydatid Cyst

Explanation Slide...

Hydatid cysts are caused by the cyst-like larvae of the Echinococcus granulosus tapeworm. Patients are largely asymptomatic, but may present with complications of mass effect, rupture etc. First line treatment is with albendazole.

Multiple Choice

Which of the following NOT required in the treatment of SIADH?

• Treating underlying aetiology

• Fluid restriction

• Increasing porridge intake

• Sodium tablets

• Increasing protein intake

Explanation Slide...

Porridge has a VERY high fluid content. Part of fluid restriction is to reduce porridge consumption (if possible do without porridge!)

Multiple Choice

A young lady presents to the ED for an episode of LOC with jerking of limbs. Which feature is the least useful to differentiate a seizure from a syncope?

• Serum lactate

• Location of tongue bite

• Urinary incontinence

• Prolonged confusion post LOC

• Head version

Explanation Slide...

Urinary incontinence is a poor discriminator between seizure and syncope because it occurs commonly in both conditions, whereas several other bedside clues are far more telling: a markedly elevated serum lactate obtained within 1–2 hours of the event strongly supports a recent generalised tonic-clonic seizure; a fresh lateral tongue bite and forced head-or-eye deviation (“versive” movement) are highly specific for epileptic activity; and post-ictal confusion lasting more than about 30 seconds is typical of seizure, while rapid recovery is usual after syncope.

Multiple Choice

Your team wants to start continuous IV isotonic bicarbonate drip 1.5L/day for a patient. Which is the most suitable order?

• Sodium bicarbonate 8.4% (1mmol/mL) Injection - IV Intermittent 75 mL, Q24H In Final Volume Dextrose 5% Infusion 1500 mL Infuse Over 24 hour, Run at 62.5 mL/hr

• Sodium bicarbonate 8.4% (1mmol/mL) Injection - IV Intermittent 500 mL, Q8H Run Undiluted Infuse Over 8 hour, Run at 62.5 mL/hr

• Sodium bicarbonate 8.4% (1mmol/mL) Injection - IV Intermittent 75 mL, Q8H In Final Volume Dextrose 5% Infusion 500 mL Infuse Over 4 hour, Run at 125 mL/hr

• Sodium bicarbonate 8.4% (1mmol/mL) Injection - IV Intermittent 75 mL, Q8H In Final Volume Dextrose 5% Infusion 500 mL Infuse Over 8 hour, Run at 62.5 mL/hr

Explanation Slide...

- For option A, 75ml of Sodium bicarbonate 8.4% (1mmol/mL) Injection is diluted in 1500ml D5, hence is not isotonic.
- For option B, hypertonic bicarbonate (undiluted) was ordered, which translates to 1500 mmol of bicarbonate (overdose).
- For option C, every 500ml of isotonic bicarbonate drip is run over 4 hours, hence is not a continous drip.

Multiple Choice

Which of these are differentials for Charcot arthropathy?

(i) Cellulitis

(ii) DVT

(iii) Gout

(iv) Recurrent osteomyelitis

• Cellulitis

• DVT

• Gout

• Recurrent osteomyelitis

• All of the above

Explanation Slide...

Acute Charcot arthropathy presents with erythema, warmth, swelling and pain—features that overlap with cellulitis, DVT, gout and recurrent osteomyelitis. Distinguishing factors include imaging (X-ray/ MRI), Doppler studies, joint aspiration (for crystals), and bone biopsy or probe-to-bone testing when osteomyelitis is suspected.

Multiple Choice

Does pressure overload or volume overload lead to (A) hypertrophy or (B) dilatation?

• hypertrophy

• dilatation

Explanation Slide...

- Pressure overload in stenosis > chamber behind valve will be subject to higher stress > more pressure required to force blood through stenosis valve > heart compensates with hypertrophy

- Volume overload as regurgitant blood > heart will dilate to accommodate the increased volume of blood > dilatation

Multiple Choice

When teaching a patient to use a dry-powder inhaler (DPI), which of the following steps is essential for correct drug delivery?

• Exhale fully into the mouthpiece before inhaling

• Inhale slowly and gently after activation

• Keep the device horizontal and inhale forcefully and deeply

• Shake the inhaler vigorously before each dose

• Press the canister at the start of inspiration

Explanation Slide...

DPIs rely on the patient’s inspiratory effort to de-aggregate the powder; holding the device level and taking a rapid, deep breath generates the turbulent flow needed to disperse drug particles, whereas shaking or canister actuation apply only to pMDIs, and exhaling into the mouthpiece risks moisture clumping the powder.

Multiple Choice

A 65-year-old male, post op day 7 right hemicolectomy, complicated by ileus, receiving total parenteral nutrition via a central venous catheter in surgical intensive care unit. He is persistently spiking fevers, despite being on day 7 of IV meropenem. Blood cultures grow Candida glabrata.

What is the most appropriate initial intervention?

• Start oral fluconazole

• Remove CVC

• Observe

• Repeat cultures in 48 hours

• Exploratory laparotomy

Explanation Slide...

- Risk scoring: Candida score
- Other risk factors:
> Recent intra-abdominal surgery
> Prolonged hospitalization / ICU stay
> Prior exposure to broad spectrum abx
- Candida glabrata associated with antifungal resistance – first line treatment is with echinocandin i.e. anidulafungin

Multiple Choice

Which of the following is most suggestive of iron-deficiency anemia rather than thalassemia trait?

• Low MCV

• Low MCH

• High RDW

• Inappropriately normal retic count

• Basophilic stippling on blood film

Explanation Slide...

High RDW is the only finding that distinguishes iron‐deficiency anemia from thalassemia trait—iron deficiency produces a mix of normal and microcytic cells (elevating RDW), whereas thalassemia trait yields uniformly small cells with a normal RDW. Low MCV, low MCH and an inappropriately normal reticulocyte count occur in both conditions, and basophilic stippling is actually seen in thalassemia (and other dyserythropoietic states), not in pure iron deficiency.

Multiple Choice

Which of the following drugs are most strongly associated with SJS/TEN?

• Cefazolin

• Vancomycin

• Allopurinol

• Omeprazole

• Olanzapine

Explanation Slide...

Allopurinol is the single most frequent culprit in SJS/TEN, accounting for around 17 % of cases in large case–control series; the other drugs listed have only rare or much lower associations with these severe reactions

Multiple Choice

Which of the following is not part of the criteria to diagnose SIADH?

• Serum Osm > 275 mOsm/kg

• Urine Osm > 100 mOsm/kg

• Urine Na > 30 mmol/L

• Absence of severe hypothyroidism or hypocortisolism

• Absence of diuretic use

Explanation Slide...

SIADH is defined by hypotonic hyponatremia, so serum osmolality must be low (< 275), not high.

All of the other options are part of the diagnostic criteria:


- Urine Osmolality > 100 (failure to maximally dilute urine)

- Urine Na > 30 (reflects ongoing natriuresis)

- Absence of severe hypothyroidism or hypocortisolism (exclude other causes of hyponatraemia)

- No recent diuretic use (diuretics can mimic SIADH)

Multiple Choice

In a patient strongly suspected of having TTP, what is the single most important first therapeutic intervention?

• High-dose intravenous immunoglobulin

• Empirical broad-spectrum antibiotics

• Urgent plasma exchange with fresh-frozen plasma replacement

• Prophylactic platelet transfusion to raise the count above 50

• High-dose oral folic acid supplementation

Explanation Slide...

Mortality from TTP falls dramatically when plasma exchange is started promptly; exchanging 1-to-1.5 plasma volumes removes ultra-large vWF multimers and replenishes ADAMTS13, and it must not be delayed even though blood is often drawn for ADAMTS13 assays beforehand

Multiple Choice

A 58-year-old woman is diagnosed with invasive ductal carcinoma of the breast. Tumor immunohistochemistry is positive for estrogen receptor (ER), progesterone receptor (PR), and negative for HER2. She has no evidence of metastatic disease.

Which of the following is NOT appropriate adjuvant therapy?

• Trastuzumab

• Tamoxifen

• Aromatase inhibitor

• Chemotherapy only

• Radiation therapy only

Explanation Slide...

- Postmenopausal women with ER+/PR+ breast cancer benefit most from aromatase inhibitors (e.g., letrozole, anastrozole).

- Tamoxifen is used in premenopausal women.

- Trastuzumab is for HER2+ tumors.
- Chemotherapy may be added depending on stage but is not the sole indicated therapy here.

Multiple Choice

A 76-year-old woman with Parkinson's disease presents with recurrent dizziness and near-syncope on standing. BP measurements show: Supine: 140/84 mmHg After 3 minutes standing: 100/62 mmHg HR: 70 bpm (unchanged) She is already on low-dose midodrine 2.5 mg TDS and non-pharmacological measures (e.g. compression stockings, hydration). Symptoms persist. What is the most appropriate next step in management?

• Add fludrocortisone

• Start bisoprolol

• Discontinue midodrine

• Switch to carbidopa-levodopa

• Prescribe meclizine

Explanation Slide...

- Fludrocortisone is a mineralocorticoid that helps expand plasma volume and raise BP, often used in combination with midodrine for refractory neurogenic orthostatic hypotension.

- Bisoprolol may worsen symptoms by blunting compensatory HR.

- Meclizine is for vertigo, not orthostatic hypotension.

Multiple Choice

60-year-old lady, background of poorly controlled type 2 diabetes mellitus, recent HbA1c 13%, presents with facial pain, nasal congestion. She was discharged one week ago with diabetic ketoacidosis.

What is the most likely diagnosis?

• Aspergillosis

• Chronic rhinosinusitis

• Pre-septal cellulitis

• Rocky Mountain Spotted Fever

• Mucormycosis

Explanation Slide...

- Risk factors:

> Diabetes mellitus, particularly with ketoacidosis

> Immunocompromised host
> Treatment with deferoxamine / iron overload
> Traumas / burns
> Malnutrition

- Presentation: black necrotic eschar on nasal mucosa, palate

 > May present with rhino-orbital-cerebral syndrome (eye swelling, cranial nerve palsies, altered mental status)

- Refer EYE, ENT, MRI face

- Treat with IV Liposomal amphotericin, surgical debridement

Multiple Choice

Which of the following is the most potent topical steroid?

• Mometasone cream 0.1%

• Betamethasone valerate 0.1% cream

• Betamethasone dipropionate 0.05% ointment

• Hydrocortisone 1% cream

• Betamethasone cream 0.05%

Explanation Slide...

Betamethasone dipropionate 0.05% ointment is a Class I (super-potent) topical corticosteroid, making it the strongest option listed. Mometasone furoate 0.1% is Class III–IV (potent–medium), betamethasone valerate 0.1% is Class V (medium), and hydrocortisone 1% is Class VII (low potency)

Multiple Choice

An elderly lady presents in your clinic complaining of involuntary leakage of urine whenever she sneezes or coughs. She does not have urge symptoms. Which of the following is not a treatment option for her type of urinary incontinence?

• Kegel exercises

• Vaginal pessaries

• Duloxetine

• Solifenacin

• Midurethral sling surgery

Explanation Slide...

Solifenacin is indicated for overactive bladder, not stress urinary incontinence

Multiple Choice

Which physical sign is NOT classically associated with chronic aortic regurgitation?

• Corrigan carotid pulse

• Quincke capillary pulsations in the nail bed

• Kussmaul sign (paradoxical rise in JVP on inspiration)

• De Musset rhythmic head bobbing

• Duroziez femoral “to-and-fro” murmur

Explanation Slide...

Corrigan, Quincke, De Musset and Duroziez signs all reflect the wide pulse pressure and bounding peripheral pulses of severe aortic regurgitation, whereas Kussmaul sign relates to impaired right-ventricular filling (e.g., constrictive pericarditis) and is unrelated to AR