Ophthalmology clinical
Case one
The first request was slit-lamp examination. The patient was a 64 year
old man. Slit-lamp examination showed a right corneal graft. The graft
was sutured with a combined interrupted and continuous suture techniques.
The graft and the donor cornea were clear and there were no signs of rejection.
I then looked at the recipient cornea for clues to the graft but there
were no evidence of any stromal dystrophy and the patient was phakic. On
the other eye, the cornea was thickened and the endothelium showed guttatae.
I made a diagnosis of Fuch's endothelial dystrophy.
The examiner wanted to know the indication for removal of corneal graft
suture. I mentioned infection, presence of neovascularization around the
suture and excessive astigmatism.
The second examiner asked me the advantages and disadvantages of using
a small graft vs a large graft. I mentioned increased astigmatism with
small graft but decreased risk of rejection as it is away from the limbus
compared with a large graft.
Case two.
The second patient was a 80 year old woman. The examiner wanted me
to perform the ocular motility examination. I noted the patient wore a
pair of high hypermetropic glasses and mentioned that I would like to know
if there were prisms in the glasses. The examiner told me that there were
no prisms incorporated.
I began the examination by looking at the corneal reflexes with a torch
light. The patient had a small right esotropia. Ocular movement revealed
poor right abduction. I diagnosed right lateral rectus palsy. The examiner
asked me to repeat the test but all that I could find was poor abduction.
The examiner then demonstrated to me the presence of palpebral narrowing
when the right eye adducted and also a small upshooting of the right eye
on adduction. The diagnosis was Duane's syndrome. It did not occur to me
that a 80 year old woman would have Duane's syndrome. "Patients with Duane's
syndrome do grow old !" was the response from the examiner.
I was a bit disheartened after this case.
Case three
This was examination with a indirect ophthalmoscopy with a 20D lens.
Unfortunately, the pupils were poorly dilated. I mentioned these to the
examiner and was asked to proceed anyway. The discs appeared normal but
there were some exudates in the macula in both eyes. I made a diagnosis
of diabetic maculopathy. The examiner then asked me about the definition
of clinically significant macular oedema
Case four
This was a slit-lamp case. The patient was about 40 years old and I
was asked to examine the anterior segments. The pupils were not dilated.
There was a right pseudoexfoliation syndrome and some iris transillumination
and pigments on the endothelium. The left eye was normal.
The examiner questioned me on the difficulty that I would anticipate
if the patient were to require surgery. I mentioned poor pupil dilatation
and weak zonules leading to zonulysis during cataract surgery.
Case five
The last case was also a slit lamp examination. The patient was a young
girl. There was a right disciform scar with some anterior chamber activity.
Before I was asked any questions the bell went.
Neurology clinical
Case one
I was asked to observe the patient. He was undresses to the waist and
had right hemiplegic posture with the elbow and the wrist in flexion. I
gave the finding and suggested that the patient may have cerebrovascular
accident involving the motor cortex of the left hemisphere.
The examiner then asked me what else I would like to examine. I mentioned
upper limb examination and cardiovascular examination including the blood
pressure. It turned out that he wanted me to perform visual field examination.
I was expecting to find a right homonymous hemianopia but my examination
showed normal visual field.
Case two
The examiner told me that this patient had a right VA of 6/18 and left
VA of 6/12. I was then asked to perform another visual field examination.
I noted that the patient had a right superior field defect and a left inferior
field defect. The findings suggested a bilateral altitudinal field loss.
I was asked about the diagnosis and gave ischaemic optic neuropathy as
the answer. The examiner then asked me to look into the patient's fundi
with a direct ophthalmoscope. I noted both discs were pale
Case three
The patient was in hospital gown and had a head bandage. He had an
obvious right complete ptosis. I was asked to perform the ocular motility
examination. The patient had a pure right third nerve palsy. I gave a diagnosis
of posterior communicating aneurysm. The examiner then asked me the complication
of intracerebral aneurysm and the ocular signs associated with subarachnoid
haemorrhage
Case four
I was asked to perform a complete cranial nerve examination on this
patient. She had an obvious left seventh nerve palsy. During the examination,
I also discovered that she had a left sixth nerve palsy, poor left corneal
sensation and decreased hearing in her left ear.
I gave a diagnosis of cerebellopontine angle lesions. The examiner
then asked me the different types of nystagmus one may get with such lesions