Dr.E.Boateng Attachment @the 37 Mil Hosp.&KTH Guidelines for foreign trained doctors sitting for the Ghana Medical &Dental Council Pre-Registration Examination. Do not hesitate to contact if you have any question (do not send sms ).. Good luck. 2008

INTRODUCTION Please note that this material is not from the Ghana Medical and Dental Council. One has no right to contact the council in case a question arises with respect in using this material. This material is compiled up after careful and thorough investigations as far as our environment and the need to pass the pre-registration exam is concerned. The content of this material is liable to change without prior notice hence it is to your own interest to contact the above doctor from time to time for up dates. To pass this exam is not only about what you know. Is all about following instructions, exhibiting your ability to stand pressure ,think and link ideas diversely and frustrations etc. “What you need to know before sitting for the exam, how to answer the questions, what the professors are expecting from you etc”, feel free to contact : Dr.Boateng Dr.E.Boateng,2008

Materials Standard treatment and guidelines. Remember to ask for the latest edition. You have to chew this book. A copy can be obtain at the Human resource opposite tema station. Or ask from MDC A hand book for medical emergencies: a hand book for house officers by korlebu teaching hospital medical dept. Protocol for house officers in surgery produce by Mr. Aduful-consultant surgeon -4th floor ,Korlebu TH. A hand book for house officers in paediatrics A handbook for obs & gynae by kwame Aryee,or Ten teachers A short text book of public health for the tropics Oxford handbook of clinical medicine, surgery. Dr.E.Boateng,2008

Problem solving This carry 110 marks out of 200 and it takes the greatest score. If you failed in the problem solving automatically you have failed the exam. The other way is said to be true You have to pay particular attention to investigations. Questions on management do NOT necessary require you to provide specific drug dosages such as tab paracetamol 20mg,but in broad terms such as = Analgesics .However if you know the specifics you can provide them in the exam but Remember it will go against you should you get it wrong. Look very fast than never before during the exams. Answer all questions-PARTICULARLY the short cases section. Dr.E.Boateng,2008

VIVA Don’t let fear rub you off all that you have toiled for. This part of the exam can frustrate you but grit your teeth and be a man once for a life time. Be confident and boost yourself up before you enter the room. It’s not the place to ask questions or make friends. Never crack jokes. They will laugh to let you feel bad if you dare say something wrong, so the simple rule is: Do not attempt to answer a question you are not clear with . If you don’t know ask them to change the question for you. Don’t ponder over questions. It will go against you. You try and slow the rate at which you answer your questions to beat time and avoid more questions. i.e. if you know the answer Remember most of the questions in the viva are to insult your intelligence and test your IQ . **Remember to read referral letters and notes first: to take history ,next examine patient and order for investigations. Then seek review by senior colleague. ***** Always advocate the examiner. Let them feel they know all that medicine is about even if they are wrong. You will have 18 min to face the panel. 3 min for each subject. Don’t panic when the bell is rang. Talk and talk till the bell is gone for a change over. Don’t explain anything if you are not asked to do so. Define,state,list etc. Listen carefully to the examiner to make a rightful judgment. The answers can be deduced from the scenario they give . Dr. E.Boateng,2008

Past questions Remember to read over and over again what your “forefathers” left behind. Another powerful instrument as long as passing this exam is concerned. Is now your turn to leave something behind for someone else. Don’t be a curse “forefather”. GOOD LUCK!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Dr.E.Boateng,2008

Preclinical topics Please contact for solutions to some of the questions/topics outlined below: ANATOMY: - Inguinal canal: boundries,content in males & females - femoral canal - cervical canal GENETICS: Pay attention to : -trisomes – 21=down syndrome 13= Edward syndrome 18= paten syndrome Their features, characteristics Turner’s syndrome Kleifelter’s syndrome

EMBRYOLOGY Pay attention to : Birth Defects Neural tube defects: spina bifida, microanenchaphaly, anenchaphaly (+ their intrauterine/pre-natal diagnosis) = do amniocenteses **elevated levels of alpha feto protein in amniotic fluid.** Down syndrome –prenatal diagnosis = low level of alpha feto protein in maternal blood Respiratory Distress – in neonates & premature babies - causes + role of surfactant deficiency: Dr .E.Boateng,2008

surfactant deficiency Diagnosis of lung maturation prenatally= Ans: Amniotic fluid examination for splingomyelin ratio i.e. leathin/ splingomyelin ratio > 2 = adequate amount of surfactant, hence adequate lung maturation. FETAL BLOOD CIRCULATION & HEMODYNAMIC CHANGES THAT OCCURS AFTER BIRTH & STRUCTURAL CHANGES eg: Ductus arteriosus Foramen ovale=fossa ovale Umbilical vessels Patent ductus arteriosus,early conservative management =INDOMETHACIN. Dr .E.Boateng,2008

PHARMACOLOGY Definition of pharmacology, pharmacokinetics; pharmacodynamic; clinical trials General pharmacological principles Receptor mechanisms Dr .E.Boateng,2008

CONGENITAL HEART DISEASE -VSD, ASD,TOF Read all you can about this topic. PHYSIOLOGY=general physiological principles -osmosis -diffusion, perfusion permeability Shock Dr .E.Boateng,2008

MICROBIOLOGY Definitions of: -immunological principles: Primary immunity secondary immunity acquired immunity innate immunity active immunity passive immunity gram + & gram –ve organisms vaccination Dr .E.Boateng,2008

VACCINATION Pay attention to terminology in this section Vaccination schedules –pay attention to this - very very important HIV/AIDS:WHO classifications or stages. Test ,Medications. Dr .E.Boateng,2008

PATHOLOGY General pathological principles inflammation-features; -pain, redness, oedema, heat, hyperemia, Necrosis(types)= coagulation, colliquative ***based on my own observation, it’s found out that the preclinical topics cut across the MCQs** Dr .E.Boateng,2008

clinical PUBLIC HEALTH/PRIMARY HEALTH CARE & DELIVERY: Public health features *very importantly* in the entire examination. Biostatistics: i. SENSITIVITY- of a test is its ability to identify individuals with the disease or condition. S= true positive(TP)/TP + False Negative(FN) ii. SPECIFICITY - of a test is defined as its ability to defined those who do not have the disease. SP=FN/FN +TP

VITAL STATISTICS Birth rate Infant mortality rate Neonatal mortality rate Maternal mortality rate Under five mortality rate Incidence – occurrence of new cases Incidence rate= incidence /tot pop @ risk X 1000 Prevalence = number of existing cases at a given point in time in a given population Dr.E.Boateng,2008

VITAL STATISTICS Epidemiology + its method( cohort or prospective study, case control study or retrospective) Epidemiology= study of human population with respect to size, density, distribution and structure. Methods: i. cohort study ii.case control study Read about the methods** Endemic = the constant presence of a disease within a given geographical area. Epidemic = occurrence of disease in excess of normal expectancy Accuracy = t he degree of veracity Reliability= consistency and repeatability of a set of measurement

PREVENTIONS(primary,2ndary,tertiary): Primary prevention: health education health promotion prophylaxis

- prompt /adequate treatment Secondary prevention 2ndary prevention: - early diagnosis - prompt /adequate treatment

Tertiary prevention Involves rehabilitation. **1.prevention of susceptible host, 2.elimination of vectors 3.interruption of route of transmission 1,2,3 conforms to the levels of preventions discussed above respectively. Dr. Boateng,2008

quiz In an outbreak of cholera what will you do as a doctor?? Very high yield important question!!!! Ans: think around the level of prevention we just discussed and answer it yourself. If fumbling you can contact for help. Don’t pass by this question. you will regret. Define: Notifiable disease Infectious disease Communicable disease Contagious diseases Dr. Boateng,2008

Define and give examples Zoo noses Ornithoses Very high yield – obligatory topic to learn thoroughly: -life cycle of malaria parasite -life cycle of schistosomiasis ankylostoma & others Helminthes Note clearly – the group of worms that inhabit the lungs as part of their life cycle Group of worm that pass through the liver in their life cycle Onchocerciases Filarial worms Dr. Boateng,2008

quizzzzzzzzz Cold chain Malnutrition Guinea worm Refuse disposal KVIP & pit latrine Birds Immigration & types Can road traffic accident(RTA) be considered as EPIDEMIC? The Ans is YES. You should be able to explain based on the definition given previously. Dr. E.Boateng,2008

Obstetrics + Gynaecology Antenatal care Signs and symptoms of pregnancy Abortion definition +types: expulsion of the fetus before the 28th week of pregnancy is termed as abortion. types: spontaneous; -threaten - incomplete -complete -inevitable - missed induced; - therapeutic -criminal Dr. Boateng,2008

Obs + gynae APH= antepartum haemorrhage PPH=post partum haemorrhage PIH = pregnancy induce hypertension i.e. pre – eclampsia= high BP+ proteinuria + oedema eclampsia= pre eclampsia + fit Contraception Emergency contraception + indications Rh –incompatibility Anaemia in pregnancy Multiple pregnancies Polyhydramnios Oligohydramnios Dr Boateng, 2008

Obs + gynae Ectopic pregnancies Cervical cerclage in cervical incompetence Placental insufficiency Birth injuries: -caput succedaneum -cephalhaematoma -Erb’s palsy(involves C5-C6) -Klumpke’s palsy(involves C7-C8 +Th1) Menstarl cycle- physiology, phases, hormones involved, the axes= hypothalamo –pituitary –ovarian axis

quiz How would you diagnose pregnancy? Ans: A. clinically - symptoms=morning sickness,amenorrhia,breast engorgement etc -signs= linear nigra,bluish discoloration of the vulva + vagina, FHS etc B . By investigation: UPT,USG,Beta HCG etc Dr. E.Boateng,2008

quiz Fibroid = definition,causes,management. Do you know Ghana is the country that started the treatment of eclampsia with magnesium sulphate and one of the best countries when it comes to the management of hypertension? Pre eclampsia, eclampsia. Signs, symptoms ,diagnosis, management. Compare and contrast abruptio placenta ,placenta praevia and vasa praevia. Dysmenorrheal .definition, types and treatment. A pregnant woman in your office .What tests will you do and why? GOOD LUCK!!!!!!!!!!!!!!!!!!!!!!!!!!!! Dr.Boateng,2008

MDC feb ,2008. obs+gynae 50 year old female presented with abdominal distension. Give 6 causes A 25 yr old hypertensive pregnant woman bleeding per vagina at 30 week .10 causes. Diagnose Unconscious after successful delivery.10 causes? A 29 yr old female has just missed her period and started bleeding p/v. Causes. How will you manage her? For answers feel free to contact Dr. Boateng, 2008

paediatrics - vitamins Neonatology : - breast feeding.*read all you can about this topic* -formation of breast milk Types of breast milk= 1. colostrums 2.mature breast milk Breast milk composition i.e.= - carbohydrate 6.7 - protein 1.25 (casein,lactoglobulin,lactalbumin) - lipid 3.5 - water 87 -mineral (Na, ca, K,Cl) - vitamins Dr. E. Boateng,2008

Breast feeding Advantages of breast milk = -mother child bond is assured -contraceptive effect -prevent breast cancer -antiviral/bacterial effect etc Weaning- programme or schedule Cow milk( formula feeds) - advantages Disadvantages Their composition i.e. constituents as above. !!!this topic features quite prominently !!!!! Dr. Boateng ,2008

Respiratory distress syndrome(RDS) RDS :causes ,signs, symptoms Neonatal jaundice Neonatal sepsis Neonatal tetanus Failure to thrive Congenital heart disease Otitis media Cerebral palsy Malaria + complication Pharyngitis Tonsillitis Anaemia Diarrhea + complication Meningitis diagnosis = lumbar puncture. Note CSF changes Signs of meningitis = neck stiffness, kerning's +ve,brudzenski +ve and others Dr. Boateng , 2008

Febrile convulsion Definition + causes What would you do at the emergency dept. when a child is brought in convulsing?? Ans: - 1st take RBS=random blood sugar -next tipped with water if temperature is high -if unconscious evaluate the level of consciousness with Blantyre coma scale Next of paramouncy is =control of convulsion with anticonvulsants and the drug of choice is DIAZEPAM per rectum/ IV Take history from mother, Examine the child thoroughly Order for investigation Seek review by senior colleague as and when necessary. Dr. Boateng,2008

Sickle cell disease Signs + symptoms Crisis : 1. VOC= vaso oclusive crisis(pain + mild jaundice) 2. Haemolytic crisis( 1 + anaemia+severe jaundice) 3. Aplastic crisis( severe anaemia) 4. Sequestration crisis( hepatosplenomegaly ) Complications: sc dactylitis, osteomyelitis,swelling of the hand + feet, priapism, spleenic infarction, brain infarction-stroke, heart failure etc Management: - relief Pain with analgesics - rehydrate with IVF -Blood transfusion if indicated - oxygen if hypoxic - cover infection = antimalaria or Rx for precipitants Dr. Boateng ,2008

Ca Burkits lymphoma – the most common malignancy in children in the tropics Hodgkin's lymphoma Typhoid fever(enteric fever):drug of choice in Ghana now is ciprofloxacin according to sensitivity. Chloramphenicol is used at regions where salmonella is sensitive to it

GMDC , Feb 2008.paediatrics Neonatal jaudice.Causes,2 most important test to do, treatment. -causes: -physiological if >1d old but <6d old -neonatal sepsis -blood, Rh incompatibility -hypothyroidism Obstructive jaundice -galactosaemia etc Investigation: -SBR,comb test of child -blood group of mother and child, blood culture etc write as many as you can Treatment : -phototherapy - exchange transfusion. Dr. Boateng, 2008

GMDC , Feb 2008. paediatrics A mother presented with asthmatic child. What will you ask the mother? Immediate management of this child? Ans: -diurnal variation in PEF -Exercise tolerance -sleep disturbances -other atopic diseases -the home(esp. bed rooms, sitting room etc) -medication etc Treatment: -give humidified oxygen -nebulized salbutamol -IVF if necessary. Dr. Boateng,2008

GMDC , Feb 2008. paediatrics Ans: A child looks dull as compare to his friends during sports activities and squat during family walks. Diagnosis. What other signs will you find? Ans: Diagnose: congenital heart disease( Tetralogy of fallot) Other signs: pansystolic murmur, cyanosis, failure to thrive etc. **do well and read about all the topics discussed above. Your viva ,mcq, problem solving will be from these topics** Red typed means answer /s to the asked question but you are encouraged to read more about the said topics. The answers were provided to guide you as to how to answer the questions. Never write notes/essay!!!!!!! Dr. Boateng,2008

Surgery Fluid & electrolyte balance = daily fluid requirements in the tropics. Check this up from Archampong & Jaja’s Book on surgery Blood transfusion & transfusion reactions The acute abdomen Acute appendicitis Acute cholecystitis Pancreatitis Intestinal obstruction: causes: - hernia(*strangulated) - adhesion and band - vulvulus - intussusceptions - constipation/ faecal compaction - intestinal worms - malignancy - PUD( peptic ulcer disease) Typhoid perforation **HIGH YIELD** note differential from appendicitis .Pay attention to the history of preceding fever. Upper & lower GI bleeding. Causes ,management. Hernia- classification Surgical jaundice Haemorrhoids

Surgery Wound +wound healing. Classification Urinary retention . Note causes + management Haematuria . Note cause and management Haematemesis . Note causes and management. Refer to GI bleeding. Burns classification(the rule of 9’s) Buruli ulcer Postoperative care Dr. Boateng , 2008

Gmdc ,Feb. 2008.surgery Haematuria. Cause? How would you manage any 1 of the causes? A boy presented at the emergency dept. with swollen elbow after a fall on hand outstretched. Diagnose , management, give 4 early and late complications. Fracture of the tibia and fibular. Give 4 early and late complications. How would you manage it? A 70 yr old woman unable to stand after a fall. Her right leg is shorten. Diagnose? How would you manage her. Give 6 early and late complications. Dr. Boateng, 2008

Medicine Heart failure Congestive heart failure Oedema( chf, nephrotic, liver, malnutrition) Bacterial endocarditis ACE inhibitors – side effect Hypertension Cardiac murmurs Malaria + its complications such as cerebral malaria DVT/PE Cellulitis DKA Shock TB Pneumonia Aphasia Addisonian crisis Acute renal failure Poisoning and intoxication Bites and stings Dr. Boateng, 2008

Medicine Anaphylactic reactions and shock Brown – Sequad syndrome: Partial cord lesion. Features: - loss of pain and temperature below specific dermatome levels - loss of proprioception and discrimination to touch - limb weakness Causes of hepatosplenomegaly Sickle cell crisis Status asthmaticus Status epilepticus Pneumothorax Consolidation Pleural effusion Dr. Boateng, 2008.

Gmdc feb.2008.medicine Dr.Boateng, 2008 Compare and contrast malaria and Typhoid fever. Which one will you Rx first based on incubation period. Write your regime. In a tabular form compare CCF, nephritic, liver, adult malnutrition oedema TB + management (it’s preamble and you have to deduce it.) CCF. managent. (it’s preamble and you have to deduce it.) Dr.Boateng, 2008

how to answer the questions The questions in this exams are set or asked vaguely in the viva and in the problem solving. Understanding the principles in answering such questions is the key. We take example 1. You enter the room , sit before the panel and you are asked ‘ACUTE ABDOMEN’. it looks simple, Right? I tell you just a single word you’ll say can fail you but knowing the single word to say will pass you. In such vague questions the single word is DIFFERENCIALS/causes of acute abdomen in order of importance. The answer is differential diagnosis. Just list them. Then after commence on management if time permits you to do so. Which will include: Resuscitation - Analgesics half strength(to avoid diminishing of the pain before the review by resident or consultant) , IVF, History, examination Order for investigation Seek review by consultant or resident. And Go according to their instructions. QUESTN: 1. Kidney and Splenic mass 2. pleural effusion **answer 1= clinical signs to differentiate between the two. *Answer 2= clinical signs** look for them. These are some of the questions I had in the viva. Dr. Boateng, 2008

Example 2 Unconscious patient? Your approach in such cases is ‘causes/differentials. You can use the mnemonics below (hide seeds)list them. don’t explain : H - hypogycaemia I - infections D - diabetic + its complications E- epilepsy S - stroke E - encephalitis E – electrolytes disturbance D- drugs s –subarachnoid bleed/ space occupying lesion Your next step is management / resuscitation: -check ABC( airway, breathing and circulation) Next ‘check RBS (random blood sugar) very important and correct deficits Secure IV access ,infuse/transfuse or give oxygen as and when needed Access level of consciousness with GCS( Glasgow coma scale) Monitor urine output by catheterization Take history, examination, order for investigation Seek review by resident / consultant./rule out possible cause and treat. The above is a question I had in the viva. You may be the next. Dr. Boateng, 2008

VIVA prominent questions VIVA prominent questions. have these on your finger tips & you’ll be 80% via the exam medicine OBS/ GYNAE surgery paediatrics Public health 1.Diabetic + comp eg DKA 2.DVT 3.Cellulitis 4.Pneumonia 5. TB 6.GI bleeding 7.Hypertension 8.PUD 9.Splen & kidney mass 10.Unconscious patient 11.stroke/ CVA 12.Status epilepticus 13.Dehydration + signs 14. CCF 15.CHD 16.Oedema 17.Malnutrition 18. Malaria 19. Typhoid 20. Dyspnea 21.Astma 22.Endocarditis 23.Pericarditis 24.STD’s 25.Upper/lower motor neuron lesion 26.hypo/hyperthyroidism PPH APH Abruptio placenta Placenta Praevia Vasa praevia Post partum pyrexia Abortion Ectopic pregnancy PIH PID Diagnosis of pregnancy Labour PROM Infertility Fibroids Shoulder dystosia Ca cervix Anaemia in pregnancy 1.Fractures 2.Acute abdomen 3.Haematuria 4.BPH 5.Urinary retention 6.Appendicitis 7.Goo(gastric outlet obstruction) 8.Hernia 9.DVT 10. Cellulitis 11.Tetanus 12.Gasgan grene 13.Jaundice pt 14.Haemorrhoids 15.Fissura in ani 16 .intestinal obstruction 17.GI bleeding 18.Rectal prolapse 19.colle’s fracture 20 orthopaedics 21 .RIF mass(right iliac fossa mass) 1.Neonatal jaundice 2. Convulsion 3.Meningitis 4.Dehydration +signs 5.SCD 6.CHD 7.Pneumonia 8.Immunization + schedule 9.Otitis media 10.Cerebral palsy 11.Neonatal sepsis 12.malaria/cerebral malaria 13.RDS 14.Measles 15.Chicken pox 16.Malnutrition Read the ‘juju ‘+ the already discussed questions.

PAST QUESTIONS 1.A Whiteman presented with Haematuria. He had swam in lake bosomtwe 4 months ago & lake volta.What is your diagnose? in which lake did he acquire the disease & your treatment. 2.PUD 3. A child presents with Hb of 4 g/dl. Looks pale & feverish. What is the most important thing to do? 4.A child presents with abdominal pain. Differential diagnose? 5.Signs of dehydration 6.Typhoid fever 7.Acute epiglottitis 8. Meningitis: causes , signs and symptoms, management 9. the unconscious child : causes, general management 10. contraindication of lumbar puncture 11.subphrenic abscess, management

PAST QUESTIONS 12. complication of pregnancy with IUCD in sito 13.A woman come to you with IUCD in sito and want to keep her pregnancy ,what would you do? 14. after 24hrs gastrectomy a patient comes with difficulty in breathing.Diagnose,Treatment. 15. menopause, climacteric: signs & symptoms. Treatment. 16. A farmer presented with tremor & spasm of muscles after receiving a minor injury. What would be your diagnose and management? 17. signs of meningeal irritation 18. Maternal care 19. shoulder dystocia & management 20. uterovaginal prolapse 21. distribution of iron in pregnancy 22.Diagnose of pregnancy 23. Antenatal care 24. Anaemia : signs & symptoms 25. lower & upper motor neuron lesions 26. posterior motor neuron lesions & cerebella syndrome

PAST QUESTIONS 27. indications for blood transfusion 28. complications of sickle cell disease 29.cardiomyopathy 30. Ectopic pregnancy 31. septic abortion ,management 32. dysmenorrheal: signs & symptoms 33.post partum pyrexia 34. an elderly person complains of headaches ,dizziness and unable to stand on the feet. On examination BP is high .What is the diagnosis and where will the lesion be? What other signs will you find in in the physical examination? 35.differentiate b/n peripheral and central motor neuron lesion 36. treatment of TB 37. causes of PPH 38.A girl presented with bone pain. The sister was recently transfused .Diagnose and treatment? 39.Burns: classifications, signs n symptoms 40. Pneumothorax, pleural effusion,empyema, lobar consolidation in pneumonia 41. gas gangrene, management 42. Anaemia in Pregnancy

PAST QUESTIONS 43. Monteux test negative. Give 3 conditions to show negativity? 44.Goo:causes, problems ,Treatment 45.Mention 10 characteristics of febrile convulsion 46. differential diagnosis of a mass in the LIF 47.Demography 48.a Patient started experiencing numbness & tickling of the arm after subtotal thyroidectomy.What is the possible cause and management? 49. differential diagnosis of a mass in the RIF 50. Acute abdomen 51.New born: screening, Average 52.complications of radiotherapy in Cervix Ca. Treatment 51. hyperemesis Gravidium 52.major cause of maternal mortality in Ghana 53. A pregnant woman undergoing radiotherapy. Which organ of the fetus would be affected. 54.Emergency contraceptive + types 55.Ectopic pregnancy 56.what is your diagnosis & management of a woman who delivered 2 days ago & presented with fever, general weakness and offensive vaginal discharge 57.Painless ulcer on the penis: diagnose & treatment 58. painful ulcer on the penis 59.clinical features of chronic renal failure 60.A child comes with painful limb. Give differential diagnose 61.Failure to thrive. Give causes 62.pre operation preparation of the jaundiced patient.

Addendum Wishing you the best of luck!!!! Contact me for answers and further explanations to some of the problems outlined here. 90% of the questions will come from the cases discussed above. Be prudent. Dr.E.Boateng +233-249856723 doc_ boat1@yahoo.com Stay blessed.

Solutions to the past questions