The purpose of the ERPM examination is to assess whether a candidate can approach medical practice with the appropriate intellectual skills of enquiry, clinical reasoning, critical thinking and decision making; possessing sufficient knowledge of the basic and clinical sciences, and an understanding of the underlying principles of scientific method; and the ability to create a differential diagnosis and rationalize a treatment plan for common clinical situations prevalent in Sri Lanka.
The candidates should also be able to apply the knowledge of basic sciences to explain the aetio-pathogenesis of disease conditions. They should demonstrate an understanding of the principles of essential procedural skills and the ability to perform such procedures. They should be able to communicate with patients respecting their dignity, rights, fears and anxieties, taking into consideration the socio-economic, cultural, religious and educational background of the patients.
IN MORE SPECIFIC TERMS:
have a good knowledge of the normal and abnormal structure and function of the human body and of changes occurring during the life cycle.
have knowledge of signs and symptoms of disease, be able to take a good history, conduct an examination of the patient, order the relevant investigations, arrive at a differential diagnosis and diagnosis, and know the non-pharmacological and pharmacological management of diseases.
know to manage medical emergencies.
know about disability, rehabilitation and handicap;
know the role of the family and extended family, about inter-relationships and interactions with the society, and be aware of cultural and ethnic differences about the perception and response to illnesses;
demonstrate good communication skills e.g. breaking bad news, informing relatives of results of investigations and informing them of the patient’s condition.
Understand the concepts of patient confidentiality, privileged communication and when to breach patient confidentiality; the importance of informed consent; concept of medical negligence, civil and criminal liability.
demonstrate knowledge of medical ethics, and behave in an ethical manner.
understand the concepts of evidence based medicine
know basic statistics.
understand the concepts of self learning and lifelong learning
know about the importance of record keeping.
demonstrate ability to work as part of a team
know about doctor patient relationship, patients rights and the necessity to use a chaperone when examining adults of the opposite sex.
be able to educate patients and the public with a view to health promotion and disease prevention.
The answers are given at the end of each question in sequential order: T = true; F = false
- Characteristic features of aortic stenosis include
- pansystolic murmur at the apex
- loud second heart sound
- exertional syncope
- heaving apex beat
- early onset of symptoms
- 2. Features that support a diagnosis of infective endocarditis in a patient with fever for 2 weeks and a pansystolic murmur at the apex would include
- presence of red blood cells in urine
- linear haemorrhages under the nails
- erythema marginatum
- microcytic hypochromic anaemia
- False negative Mantoux test is known to occur in
- miliary tuberculosis
- HIV infection
- patients treated with conventional antibiotics
- infection with multi-drug resistant tuberculosis
- recent measles infection
- Elevated blood urea with normal serum creatinine is characteristically seen in
- upper gastrointestinal haemorrhage
- acute renal tubular necrosis
- Vitamin B12 deficiency
- occurs in total vegetarians
- is a known cause of peripheral neuropathy
- due to pernicious anaemia can be effectively treated with oral cyanocobalamin
- can be differentiated from folate deficiency on the blood picture
- is caused by severe hookworm infestation
- In idiopathic thrombocytopenic purpura
- splenomegaly is a characteristic feature
- low WBC count is a common finding
- ESR is usually raised
- megakaryocyte count in the bone marrow is raised
- steroid is the first line of treatment FFFTT
- A 35-year old female complains of joint pain of two months duration. The following features favour a diagnosis of rheumatoid arthritis
- arthritis affecting three or more joint areas
- involvement of the distal interphalangeal joint
- morning stiffness lasting more than 3 hours
- symmetrical arthritis
- anterior uveitis
- 8. Characteristic features of Guillain-Barre syndrome include
- lower motor neurone facial nerve palsy
- glove and stocking type sensory loss
- distal more than proximal motor weakness
- absent reflexes in limbs
- elevated CSF protein levels
- Causes of lymphocytic pleocytosis in the CSF include
- viral meningitis
- tuberculous meningitis
- partially treated pyogenic meningitis
- meningococcal meningitis
- Features of primary hypothyroidism in an adult include
- loss of scalp hair
- pericardial effusion
- macrocytic anaemia
- low serum creatinine phosphokinase (CPK) level
- In a patient who had a history of intermittent claudication – the following conditions need urgent surgical intervention to improve the limb circulation
- painful ulcer at the tip of a toe
- severe continuous pain of the affected calf requiring regular opioid analgesics
- claudication distance of 100 yards
- prominent varicose veins
- recurrent attacks of transient cerebral ischaemia (TIA)
- A 55-year old man presents with symptoms suggestive of obstructive jaundice. He has a palpable gall bladder. Following is/are likely cause/s in this patient.
- carcinoma of the head of the Pancreas
- Gall stones
- Cholangiocarcinoma of the common hepatic dust
- uncomplicated choledochal cyst
- periampullary carcinoma
- 3. Regarding mid palmar space infections
- elevation of the hand delays the healing process
- mobilization of fingers should be delayed till infection is completely settled
- antibiotics are best administered orally in the initial management
- swelling of the dorsum of the hand is common.
- when the hand is splinted the metacarpophalangeal joint should be maintained in extension
- A 21-year old girl presents with a clinically solitary thyroid nodule, 2 cm in diameter. Features that indicate the possibility of malignancy in this nodule include
- cold nodule rather than a hot nodule in the Tc isotope scan
- history of exposure to ionizing radiation.
- presence of enlarged ipsilateral cervical lymph nodes
- recent voice change E. markedly reduced TSH levels.
- Saturation of oxygen (SaO2) measured by the pulse oxymeter
- gives a value of 70% in a healthy adult male breathing room air
- is affected by anaemia
- is unaffected by vasoconstriction
- is altered in old age
- can be increased over 100% by giving hyperbaric oxygen.
- An arterial blood gas report of a patient is as follows:
pH – 7.21 (7.45 – 7.55)
pCO2 – 4 kPa (4.6 – 5.6)
pO2 – 13.3 kPa (10-13)
HCO3 – 11.5 mmol/l
This is compatible with :
- diabetic ketoacidosis
- gangrenous bowel
- pulmonary embolism
- tension pneumothorax
- An 84-year old male is brought with acute retention of urine of 24 hours duration. He has a tender distended bladder extending up to the umbilicus. Attempted catheterization with a size 16 Foley catheter fails. In the immediate management of this patient
- Oral paracetamol should be administered to relieve the pain
- abdominal x ray should be performed urgently to exclude a bladder calculus
- supra pubic puncture should be performed
- intravenous infusion of 1 liter normal saline will facilitate urine flow
- intravenous frusemide will relieve the retention of urine
- 8. The following are true/false regarding head injury
- surgery is not indicated in most skull fractures
- drainage of cerebrospinal fluid from the ear is an indication for emergency surgery
- loss of consciousness after direct trauma to head is an indication for a skull x ray
- compound fractures of skull can occur without external injury
- rising blood pressure and bradycardia indicates raised intracranial pressure
- In upper gastrointestinal endoscopy
- spraying the throat with lignocaine reduces the risk of aspiration
- varices are usually seen in the lower oesophagus
- “J manoeuvre” is used to visualize the fundus of the stomach.
- first part of the duodenum is the ideal site for biopsy to detect Helicobacter pylori
- risk of oesophageal perforation is high in the presence of strictures
- The following are premalignant lesions
- adenomatous colorectal polyps
- duct ectasia affecting the breast
- intestinal metaplasia in the lower oesophagus
- hyperplastic polyp in the colon
- colonic angiodysplasia
OBSTETRICS AND GYNAECOLOGY
- During the antenatal period
- an intrauterine pregnancy is recognized by transvaginal ultrasound scan at six weeks of amenorrhoea
- the uterine fundus is palpable at the symphysis pubis at 14 weeks of amenorrhoea
- maternal perception of fetal movements first occur between 18-20 weeks
- VDRL test is done as a diagnostic test for syphilis
- maternal serum triple test is offered to exclude Trisomy 21
- Anaemia complicating pregnancy
- is a risk factor for intra-uterine growth retardation (IUGR)
- is defined if the haemoglobin is below 9 g%
- in Sri Lanka is predominantly due to iron deficiency.
- due to iron deficiency is treated with parenteral iron when close to term
- is associated with preterm labour
- In preterm labour
- Fibronectin test is used to identify patients at risk
- a potential cause is bacterial vaginosis
- a vaginal swab is taken for E.coli culture
- nifidipine is use for tocolysis
- vacuum delivery is recommended
- The perinatal management options of Rh D Negative alloimmunization are
- examination of maternal blood for rising levels of IgG
- ultrasound examination for fetal hydrops
- Predisolone to the mother
- delivery at 40 weeks
- The following are compatible with a diagnosis of severe preeclampsia
- right hypochondrial pain
- pulmonary oedema
- elevated alkaline transferase
- The correct statements regarding contraception are
- failure rate is expressed as a percentage
- in selecting a method patient’s parity has to be considered
- mitral valve prolapse is a contraindication for use of the combined oral contraceptive pill
- Depo-Provera will induce amenorrhoea
- Copper T 380 intrauterine device needs to be changed every 3 years
- The causes for acute pelvic pain and signs of hypovolaemia are
- ruptured tubal pregnancy
- torsion of an ovarian cyst
- ruptured corpus luteum cyst
- Uterine fibromyomas are
- most commonly found in postmenopausal women
- associated with hydronephrosis
- considered as a predisposing factor for malprestations
- presented with acute abdominal pain due to calcification
- treated with Tamoxifen
- 9. The causes of menorrhagia include
- pelvic inflammatory disease
- Ashermann syndrome
- chronic cervicitis
- retroversion of uterus
- A woman presenting with post menopausal bleeding to a district hospital
- needs speculum examination
- needs referral for endometrial evaluation
- is treated with progestogens for three months
- requires transfer for urgent hysterectomy
- requires hormone replacement therapy if the pelvic examination is normal
- 1. Causes of neonatal jaundice on the fourth day of life include
- physiological jaundice
- breast milk jaundice
- congenital spherocytosis
- Effective therapeutic modalities of management of a child with diabetic ketoacidosis include
- intravenous insulin infusion
- correction of acidosis at the onset of rehydration
- correction of hypokalaemia
- intravenous antibiotics
- oral metformin
- In a child with excessive bleeding after a tooth extraction , a prolonged APTT (activated partial thromboplastin time )and a normal bleeding time is compatible with a diagnosis of
- Factor VIII deficiency
- Factor IX deficiency
- Von Willebrand disease
- Glanzeman Disease
- Idiopathic thrombocytopaenic purpura
- Following anticonvulsants and their side effects are correctly paired
- Carbamazepine – hepatotoxicity
- Vigabatrin – eye toxicity
- Phenytoin – ataxia
- Phenobarbitone – hyperactivity
- Sodium valproate – erythema multiforme
- 5. In a child with encephalopathy a diagnosis of Reye syndrome is suggested by
- a rapidly enlarging liver
- deep jaundice
- high serum ammonia
- focal neurological signs
- In nephrotic syndrome in children
- The commonest histological type is minimal change
- The congenital type has a good prognosis
- renal vein thrombosis is a known complication
- spontaneous peritonitis is commonly due to E-coli
- abdominal pain is a sign of gut ischemia
- In post streptococcal acute glomerular nephritis
- There is a significant risk of chronic renal failure
- Serum complement (C3) is low
- Microscopic haematuria is a feature
- Anti-hypertensive drugs should be started prophylactically
- Follow up of the patient is not necessary
- In measles
- Koplik spots are pathognomonic
- pneumonia is a serious complication
- non reactivity to Mantoux test occurs following an infection, due to immune suppression
- the rash typically occurs on the fifth day of the illness
- There is significant lymp node enlargement in the posterior cervical region
- In congenital rubella syndrome
- the risk of congenital infection significantly higher during the first trimester
- atrio-septal defect is the commonest heart lesion
- Congenital cataract is a common finding
- Hydrocephalus is a known complication
- Virus is excreted in the urine of the baby for a long period
- In childhood obesity
- The best method to define obesity is with the Body Mass Index (BMI)
- insulin dependent diabetes mellitus is a well known complication
- During assessment measurement of the bone age and height is very important
- The incidence is increasing rapidly in developing countries
- There is a positive family history invariably
- Prevalence of a disease is increased by
- longer duration of the disease
- high case fatality rate
- increase in incidence
- improved cure rate
- better diagnostic facilities
- Anthropometric measures that can be used in a one-year old child include:
- mid upper arm circumference
- head circumference
- chest circumference
- The following statements are true regarding case control studies
- it is an analytical study design
- suitable to study rare diseases
- can assess multiple risk factors of a disease
- relative risk is calculated as a measure of association
- recall bias is a limitation
- 4. Surveillance of dengue is carried out to
- predict epidemics
- study the disease trend
- identify risk factors
- evaluate control programmes
- set control programme priorities
- In Sri Lanka
- malaria is endemic in the North Central Province
- chicken pox is a common source epidemic
- measles vaccination is a secondary prevention measure
- non-communicable disease is the leading cause of death
- post-exposure prophylaxis is a rabies control strategy
- Occupational hearing loss:
- occurs from exposure to noise levels over 85 decibels during a working life time
- can be prevented by limiting the time of exposure
- can be detected early by performing periodic audiometric examinations
- starts at frequencies around 40 Hz
- can be reversed by removing the worker from the noisy environment
- The following statements are true of demographic indicators:
- The total fertility rate gives information on the average number of children born to a couple during their reproductive period.
- The infant mortality rate is an indicator of the health status of a population.
- Knowledge of the crude death rate and the crude birth rate will enable the calculation of the growth rate of a population.
- A neonatal death is defined as the death of an infant occurring in the first week of life.
- The majority of infant deaths in Sri Lanka occur in the neonatal period.
- 8. The following statements are true of contraceptive methods:
- The CuT 380A intrauterine device gives protection for 10 years after insertion
- Menstrual irregularities are a common side effect experienced by users of injectable DMPA.
- Traditional methods of family planning are included in the computation of the contraceptive prevalence rate (CPR).
- Oral contraceptives are contraindicated in women with migraine.
- The most popular method of contraception in Sri Lanka is the use of the intra-uterine device.
- 9. The following statements are true regarding notification of communicable diseases in Sri Lanka
- A fever of more than seven days duration is notifiable
- HIV/AIDS is now included in the list of notifiable diseases
- Medical practitioners in the private sector are not legally bound to notify
- An outpatient diagnosed to have typhoid fever should be notified
- Suspected cases should be notified before confirmation of the diagnosis
- 10. The following statements are true regarding tuberculosis:
- In Sri Lanka anti-tuberculous drugs are administered to adult contacts who are Mantoux positive
- BCG vaccination is given to infants at birth
- BCG vaccine is administered subcutaneously
- HIV infected persons are more susceptible to tuberculosis
- In a patient diagnosed with active tuberculosis, anti-tuberculous drugs should be administered for a minimum period of 6 months
- 1. The following are features of apoptosis:
- Hydropic swelling of the affected cell
- Inflammatory reaction in the surrounding tissue
- Chromatin condensation at the periphery of nucleus.
- Formation of apoptotic bodies
- Death of a large area of a tissue
- 2. A 50-year old male with a history of intermittent claudication was admitted to the casualty ward with a blackish, pulseless , cold, right foot. The following statements are true:
- This is an example of secondary gangrene.
- Gross oedema of the area is a feature.
- Affected area appears well demarcated from the normal area.
- Septicaemia is a common complication.
- Venous obstruction is the most likely cause.
- Fat embolism syndrome
- manifests within 12 hours of injury
- peticheal rash is a feature
- is associated with microinfarcts of brain
- can complicate air embolism
- may be definitely diagnosed in paraffin embedded sections.
- The following statements are true regarding leprosy
- Spread of the disease occurs following close contact with a tuberculoid leprosy patient.
- Lepra bacilli are easily demonstrable in lepromatous leprosy.
- Leonine (Lion like) facies is a characterisic feature of tuberuculoid leprosy.
- Claw hand is a complication observed is tuberculoid leprosy.
- Humoral immunity plays an important the role during the healing process.
- The following statements ate true regarding cellular adaptive mechanisms:
- Metaplasia is when a fully differentiated mature tissue changes to undifferentiated tissue.
- Hyperplasia of cardiac muscle is seen around a site of myocardial Infarction.
- Atrophic tissue functions at a lower metabolic rate.
- Removal of a diseased kidney leads to compensatory hypertrophy of the remaining kidney.
- Both hypertrophy & hyperplasia occurs in the uterine smooth muscle during pregnancy.
- 6. The following statements are true regarding dystrophic calcification
- Deposition of calcium salts occur is normal tissues.
- The serum calcium levels are usually normal.
- Phlebolith is an example.
- Demonstrable as blue purple deposits in a H & E section.
- Is a common finding is long standing multinodular goitre.
- 7. Regarding wound healing
- Deep burns involving the skin heals by primary union
- Macrophages play an important role
- Fibrosis occurs within the first 72 hours of healing
- Rapid in a facial wound
- Irradiation is a promoting factor
- Chronic venous congestion
- occurs in hypovolaemic shock
- produces a nutmeg pattern in the liver
- is a cause of generalized oedema
- of the lungs is seen in tricuspid valve stenosis
- of the lungs leads to the formation of heart failure cells
- 9. Infarction
- is defined as necrosis of tissue due to loss of blood supply
- of cardiac muscle heals by regeneration of surrounding cells
- is not usually accompanied by an inflammatory reaction
- Release of intracytoplasmic enzymes from infarcted tissue is helpful in the diagnosis
- of brain appears as a fluid filled cyst after one month
- The following are features of pulmonary tuberculosis:
- Caseation occurs in both primary and post primary tuberculosis
- Haematogenous spread of tubercle bacilli produces miliary tuberculosis
- Haemorrhagic pleural effusion is a presenting feature
- Primary complex includes the apical cavity and enlarged hilar lymph nodes
- Primary pulmonary tuberculosis leads to bronchiectasis of the middle lobe in some cases.
- The following are true regarding abdominal injuries:
- they are the commonest cause of death in road traffic accidents
- subcapsular liver ruptures causes sudden collapse
- a stab injury of the gall bladder is categorized as “fatal in the ordinary course of nature”
- ascites is a common complication
- effects of a blast wave are commonly seen in the liver and the kidney
- In a death due to multiple rifled fire arm injuries
- a full body x-ray is warranted at the autopsy
- range of firing is best estimated with test-firing
- exit wounds on the skull shows inner beveling
- tattooing indications intermediate range of shooting
- a scene visit is done only if the ballistic specialist is available
- When completing a Medico-Legal Examination Form (MLEF)
- a fracture of a milk tooth is categorized as non-grievous
- the medical officer’s short signature is placed in the relevant cage
- the JMO relies upon the patient’s history in filling the alcohol status
- when a patient claims that he has lost consciousness, the category of hurt is “endangering life”
- a large extradural hemorrhage is categorized as fatal in the ordinary course of nature
- 4. In electrocution
- the “joule burn” can be caused after death
- the endogenous thermal burn produces the crocodile skin lesion
- the exit wound is rarely found
- “arc eye” is a complication
- death could result due to asphyxia
- A mason had fallen off a 20 ft height. The following injuries are likely to be found at the autopsy: A. grazed abrasions on the limbs
- lacerations of the liver
- “sparrow foot” cut injuries on the face
- a depressed fracture on the occipital region
- tramline contusions on the back of the chest
- In sexual offences:
- evidence of injuries of restraint indicate lack of consent
- the finding of a fresh laceration in the posterior region of the hymen indicates there has been recent penetration of the vagina
- the presence of spermatozoa in the vagina is required to prove a charge of rape
- injuries in parasexual regions are not seen
- consenting sexual intercourse is not considered rape when the child is 15 years
- 7. In a putrefied body, the following are useful for identification:
- The presence of natural disease
- The facial features
- The presence of surgical scars
- The type of clothing worn and its contents
- The presence of tattoos
- Common injuries seen in victims of torture include:
- tram-line contusions
- intramuscular contusions of the gluteal region
- depressed skull fracture with extradural haemorrhage
- falanga (blunt injuries to the soles)
- fractures of the long bones in the lower limbs
- In burn injuries
- heat haematomas are seen in the subdural space
- pugilistic attitude (flexed posture) is a common finding in charred bodies
- heat fractures of the skull are usually blow-out fractures
- flexion seen in the fingers indicate cadaveric spasm.
- heat ruptures of the skin do not bleed
- The following statements are true regarding manual strangulation of the neck:
- Petechial haemorrhages may be found in the eyes
- Death could occur due to vagal inhibition
- Cerebral ischaemia is a known consequence
- Intimal tears of the carotid artery are commonly seen
- Hyoid bone fractures are not seen
List of persons (in alphabetical order) who contributed towards the compiling of these guidelines for students preparing for the ERPM examination
Dr Nilukshi Abeysinghe – Senior Lecturer in Forensic Medicine, Faculty of Medicine, University of Colombo
Dr Deepika Attygalle – Consultant Community Physician, Family Health Bureau, Ministry of Healthcare and Nutrition
Dr A.P. de Silva, Senior Lecturer, Department of Medicine, Faculty of Medicine, University of Kelaniya.
Prof. Mohan de Silva – Professor of Surgery, Faculty of Medical Sciences, University of Sri Jayawardenepura
Prof Nilanthi de Silva, Head, Medical Education Centre, Faculty of Medicine, University of Kelaniya.
Dr Lalindra Gunaratne, Senior Lecturer in Pathology, Faculty of Medicine, University of Colombo.
Dr Nalika Gunawardene – Senior Lecturer in Community Medicine, Faculty of Medicine, University of Colombo
Dr H.M.S.S.D. Herath – Consultant Community Physician, Assistant Registrar, Sri Lanka Medical Council.
Prof. Jayantha Jayawardana – Professor of Obstetrics & Gynaecology, and Dean, Faculty of Medical Sciences, University of Sri Jayawardenepura
Prof. Lalitha Mendis – Emeritus Professor University of Colombo and President, Sri Lanka Medical Council
Dr Nihal Nonis – Consultant Physician and Registrar, Sri Lanka Medical Council
Dr Niranthi Perera – Senior Lecturer in Pathology, Faculty of Medicine, University of Colombo
Dr Gominda Ponnamperuma, Lecturer in Medical Education, Faculty of Medicine, University of Colombo
Prof. A.P. Premawardena, Head and Professor, Department of Medicine, Faculty of Medicine, University of Kelaniya.
Prof. M. P. Senanayake, Professor in Paediatrics, Faculty of Medicine, University of Colombo
Prof. A.R. Wickremasinghe, Dean and Professor of Public Health, Faculty of Medicine, University of Kelaniya.
Dr S.S. Williams, Senior Lecturer and Head, Department of Psychiatry, Faculty of Medicine, University of Kelaniya.