Download MED 502 PAPER 2-END-POINT EXAM MBBS 2 2015

FIJI NATIONAL UNIVERSITY
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PROGRAM (YR)/COURSE:
MBBS (2)/MED 502
EXAM:
2015 MED 502 PAPER 2-END-POINT EXAM
DATE:
5/11/2015
START TIME:
2:00 PM
DURATION:
200 MINUTES (3 HOURS and 20 minutes) PLUS 10 MINUTES READING TIME
MARK ALLOCATION:
PART 1: MCQ
30 MARKS
PART 2: SHORT ANSWER QUESTIONS
130 MARKS
TOTAL:
160 MARKS
INSTRUCTIONS:

Write your student number on each sheet of the examination.

You will have ten minutes to read through the examination paper, before beginning to write your answers.
PART 1: MCQ
There are 30 Multiple Choice Questions in this section. Choose only the one best response.
Note: Each MCQ is scored 1-mark. There is no negative marking. You should attempt all questions. Each MCQ has only
one best answer. Any MCQ with two or more choices will be scored 0.
PART 2: SHORT ANSWER QUESTIONS

The Short Answer Questions section of the test contains 130 marks.

There are 6 scenarios (Scenario A-F), each followed by a set of questions related to the scenario. Understand the
details in the scenario before proceeding to answer.

Each question is followed by the number of marks, in brackets, to be scored for that question. For each question,
provide an answer in the space below the question.

Write briefly to the point, there is no need for long essays. Use diagrams if necessary to illustrate your points.

Note that, if a question asks you to “List 3 things . . . “, and you list 6, only the first three responses will be marked,
the rest is ignored.

If you need additional space for your answer, use the back of the sheet of the same question and indicate, within the
space for the answer, that you have done so.

Approximate time guide is 1 minute and 15 seconds of exam time for each mark.
MED 502
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PART 1
MULTIPLE CHOICE
[30 MARKS]
SCENARIO 1
Henry, a 49-year-old man, who is a longtime alcoholic presents to the emergency room with hematemesis. His wife
says that his stools float on the toilet water and are difficult to flush. Ten years ago he was admitted for alcoholic
hepatitis.
His prothrombin time (PT) is prolonged.
[Use the above scenario for Items 1-5]
1. Which of the following represents the most likely cause of Henry’s hematemesis?
A. Duodenal ulcer disease
B. Esophageal ulceration
C. Esophageal varices
D. Gastritis
E. Mallory Weiss tear
2. Which vessel is most likely to be involved in Henry’s bleeding?
A. Azygos vein
B. Coronary vein
C. Gastroduodenal artery
D. Middle colic artery
E. Short gastric artery
3. What is the gold standard for diagnosing Henry’s hematemesis?
A. Barium swallow
B. Colonoscopy
C. Plain abdominal X-ray
D. CT (computed tomography) scan abdomen
E. Upper Gastrointestinal endoscopy
4. Which of the following explains Henry’s floating stool?
A. Biliary obstruction
B. Decreased synthesis of bile salts
C. Increase in his dietary fat intake
D. Inflammatory bowel disease
E. Insufficient production of pancreatic lipase and colipase
5. Henry’s prolonged PT is the result of a malabsoption of which of the following micronutrients?
A. Iodine
B. Potassium
C. Vitamin B₁₂
D. Vitamin E
E. Vitamin K
MED 502
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SCENARIO 2
Milika, a 48-year old woman, complains of intermittent right upper quadrant pain, jaundice and pruritis over the
last three months.
On examination, she is febrile and tender in the right upper quadrant. Her serum creatinine is elevated whilst her
hepatitis serology results are still pending.
[Use the above scenario for Items 6-10.]
6. Which pathological condition best explains Milika’s symptoms?
A. Acute appendicitis
B. Acute bowel obstruction
C. Acute cholangitis
D. Acute gastritis
E. Acute hepatitis
7. Which of the following radiological examination modalities is the most cost effective and suitable to
investigate Milika's condition?
A. Barium swallow
B. CT- scan
C. Erect abdominal X-ray
D. Gastrograffin anterocolisis
E. Ultrasound scan
8. Which antibiotics will be appropriate to use for Milika, given her raised serum creatinine?
A. IV Ceftriaxone
B. IV Cloxacillin
C. IV Gentamicin
D. Oral ciprofloxacin
E. Oral amoxicillin
9. Milika would be at risk of developing hepatocellular carcinoma if her hepatitis serology is positive for
which of the following?
A. Hepatitis A
B. Hepatitis B
C. Hepatitis D
D. Hepatitis E
E. Hepatitis G
The medical student accidently pricked himself when discarding the needles and syringes used to collect Milika’s
blood. He is worried he might get infected with hepatitis B. He has just completed his hepatitis B vaccine series and is
advised by his superiors to have a blood test.
10. On reviewing the medical student’s laboratory studies (assuming he has no prior exposure to hepatitis B),
you expect:
A. Antibody against both hepatitis B surface and hepatitis B core antigen
B. Antibody against hepatitis B surface antigen (anti-HBS) alone
C. Antibody against hepatitis B core antigen (anti-HBC )
D. Antibody against hepatitis E antigen
E. Positive test for hepatitis B surface antigen
MED 502
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SCENARIO 3
Nikil, a 10-year-old boy, is brought by his parents to the Children’s Outpatient Department with edematous face,
ankles and oliguria. His blood pressure (BP) is slightly raised; urine shows no marked hematuria, and a dipstick
protein of 3+.
His doctor suspects a kidney disease of either Nephrotic or Nephritic syndrome and needs to do further tests on
Nikil.
His blood and urine are collected for further investigations. A 24-hour urine collection for protein measurement is
also done.
[Use the above scenario for Items 11-15]
11. Which of the following is the cause of edema in Nephrotic syndrome?
A. Decreased synthesis of albumin
B. Decreased urine output resulting in fluid overload
C. Low dietary intake of protein
D. Marked proteinuria
E. Water intoxication
12. Which of the following is the most likely cause of Nikhil’s proteinuria?
A. Increased quantity of serum proteins
B. Raised blood pressure
C. Dysfunction of glomerular filtration barrier
D. Urinary tract infection
E. Low reabsorption at proximal convoluted tubule
13. Which of the following urinalysis results would help confirm Nephritic syndrome?
A. Microscopic white blood cells
B. Presence of creatinine in urine
C. Microscopic red blood cells with dysmorphic features
D. Urine culture positive for E.coli
E. Proteinuria of more than 3.5g/24 hours
Nikil had an upper respiratory tract infection ten days ago.
14. If he had Nephritic Syndrome, the laboratory test that would help determine its cause is:
A. Erythrocyte Sedimentation Rate
B. Antistreptolysin O antibody level
C. Blood culture
D. Full blood count
E. Throat swab
His initial compliment C₃ is noted to be very low.
15. When should his C₃ complement level be repeated, in order to help exclude the other causes of Nephritic
syndrome?
A. In 4 weeks
B. In 8 weeks
C. In 10 weeks
D. In 12 weeks
E. In 16 weeks
MED 502
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SCENARIO 4
A 28-year-old woman with previous history of having a baby with Down’s syndrome is now 12-weeks pregnant.
[Use the above scenario for Items 16-18.]
16. As she is concerned about recurrence, which of the following would you suggest to her?
A. Amniocentesis
B. Obstetric ultrasound
C. Chorionic villus sampling
D. Fetal blood sampling
E. Wait till 18 weeks for detailed ultrasound and amniocentesis
17. Which of the following is assessed in ultrasound screening for Down syndrome during pregnancy?
A. Heart defect
B. Femur length
C. Head circumference
D. Nuchal thickness
E. Palmar crease
18. The commonest mechanism of genetic abnormality in a case of Down syndrome is:
A. Nondysjunction in maternal gamete
B. Nondysjunction in paternal gamete
C. Translocation to any autosome
D. Translocation to chromosome 14
E. Trisomy of X-chromosome
19. A patient has a muscular weakness. His parents and sister do not have weakness, but his mother’s brother
has weakness. You suspect Duchenne’s muscular dystrophy. This is an example of:
A. Autosomal dominant inheritance
B. Autosomal recessive inheritance
C. Semi-dominant inheritance
D. X-linked dominant inheritance
E. X-linked recessive inheritance
20. Both the parents are affected with albinism, but have a normal child. Which of the following terms best
describes this situation?
A. Allelic heterogeneity
B. Incomplete penetrance
C. Locus heterogeneity
D. New mutation
E. Variable expressivity
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SCENARIO 5
Jenny, a 25-year-old woman, was bumped by a car while crossing the road. She is brought to the Emergency
Department in a semi-comatose state and bleeding profusely from an open wound on her left leg. She is suspected
to have multiple injuries.
On neurological assessment: she opens her eyes to pain, flexes her arms in response to pain, and she is making
incomprehensible sounds.
She is hypotensive, tachypnoeic and tachycardic.
[Use the above scenario for Items 21-25.]
21. The first treatment priority in patients with multiple injuries is:
A. Airway maintenance
B. Bleeding control
C. Circulatory volume restoration
D. Reduction of dislocation
E. Splinting of fractures
22. What is Jenny’s Glasgow Coma Scale?
A. 5
B. 7
C. 9
D. 11
E. 13
23. The safest method to stop the bleeding in Jenny before she arrives in hospital is:
A. Direct pressure on wound
B. Elevation of leg
C. Ligation of bleeding vessel
D. Pressure over femoral artery in groin
E. Use of tourniquet
24. Jenny is suspected to have hypovolemic shock, which cannula size would be ideal for infusion?
A. 18G
B. 20G
C. 22G
D. 24G
E. 26G
25. She is to be infused rapidly with intravenous normal saline. How many milli-equivalents per liter (mEq/L)
of chloride are contained in this solution?
A. 150mEq/L
B. 152mEq/L
C. 154mEq/L
D. 156mEq/L
E. 158mEq/L
MED 502
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SCENARIO 6
Annie, a 16-year-old female secondary student is seeking contraception. A relevant history and physical
examination will be conducted.
[Use the above scenario for Items 26-30.]
26. Which of the following ethical issues should one consider when attending to Annie?
A. Confidentiality
B. Her religious beliefs
C. Parental consent
D. She is below 21
E. The doctor’s beliefs on contraception
27. Annie was wearing revealing clothes, and while talking to the doctor she comes up very close and starts
asking him personal questions in a seductive tone. What should be the appropriate response by the doctor?
A. Ask her to put on a gown
B. Call in a nurse
C. Ignore her seduction
D. Refer her to another doctor
E. Refuse to examine her
28. She is told about oral contraceptives and explained that the major cause of unplanned pregnancies in
women using it is:
A. Breakthrough bleeding at mid-cycle
B. Development of antibodies
C. Gastrointestinal malabsorption
D. High frequency of intercourse
E. Incorrect use of contraceptives
29. Which of the following is an absolute contraindication to the use of combined oral contraceptive pills?
A. History of thromboembolism
B. Mild essential hypertension
C. Seizure disorders
D. Tension headache
E. Varicose veins
30. In addition to effective contraception, health benefits for women taking oral contraceptives include a
decreased incidence of which of the following?
A. Benign breast disease
B. Cervical cancer
C. Hypertension
D. Liver cancer
E. Pelvic inflammatory
END OF MCQ SECTION
MED 502
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PART 2
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SHORT ANSWER QUESTIONS
SCENARIO A
[130 MARKS]
[23 MARKS]
Maria, a 56 year old woman, is unable to move the right side of her body for the past two days. She seems to
understand what people say to her. She tries to answer questions with great effort, as she has difficulty in choosing
the correct words to communicate.
In view of her presentation it was thought that Maria had a stroke.
A1. Name the labelled branches of the circle of Willis.
Branches
label
a
b
c
f
g
h
[3]
Name of artery
A2. Which cerebral artery is most likely to have been affected in Maria? Justify your answer.
[3]
A3. Explain what each of these terms means, and what the cause would be, ie, where the lesion would be, for each
of them: expressive aphasia, receptive aphasia and dysarthria .
[3]
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On physical examination: Maria’s blood pressure is 160/100mmHg and her muscle tone is increased in her right
upper and lower extremity.
A4. Briefly describe two (2) ways by which hypertension increases Maria’s risk of stroke.
[2]
A5. What is the explanation for the increase in tone?
[2]
A6. List two (2) modifiable and two (2) non-modifiable risks factors for stroke.
[2]
Modifiable
Non-modifiable
A brain CT(computed tomography) scan shows that Maria has a large hypodense area of the brain, confirming the
suspicion of stroke.
A7. Describe what “hypodensity” appears like on a CT scan, compared with normal brain substance. Explain what
is happening in the brain to cause the hypodense appearance.
[2]
A8. Is the CT scan finding above more likely to indicate an ischaemic or a haemorrhagic stroke? Explain your
answer.
[2]
MED 502
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Maria is admitted to hospital for treatment and close observation. A week later she is discharged.
On physical examination, she has regained some slight movement in her right leg.
A9. Explain why someone who has had a stroke may recover some function following the acute episode.
[1]
A10. List three (3) long term complications of stroke and how each can be prevented.
[3]
MED 502
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SCENARIO B
[24 MARKS]
Nitesh, a 58 year old carpenter, is seen in the out-patient department (OPD) with a complaint of difficulty passing
his urine since early this morning. He has had symptoms of hesitancy, occasional urgency, and dribbling for at
least a year.
Several days ago, he was seen in the OPD with a complaint of diarrhoea, and his folder shows he was given an antidiarrhoeal medication, one that contains atropine, an anticholinergic agent.
His doctor suspects benign prostatic hyperplasia(BPH)
B1. Explain the pathogenesis of benign prostatic hyperplasia (BPH) as men become older.
[3]
B2. Explain the mechanism of action of atropine in treating diarrhoea.
[2]
B3. Explain why a medication like atropine should be used cautiously in BPH patients like Nitesh.
[3]
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B4. Which anatomical zone of the prostate is more likely to be involved in BPH and prostatic cancers?
[2]
Anatomical zone of the prostate involved
BPH
Prostate cancers
Investigations include checking his Prostate Specific Antigen (PSA) level.
B5. What is the reason for performing this investigation? Explain your answer.
[1]
The ‘cut-off’ level for the PSA test is generally accepted to be 4 ng/ml, in other words, a level above 4 is a ‘positive’
test.
B6. If the cut-off level were reduced to 3 ng/ml, explain how this would affect the sensitivity and specificity of the
PSA for diagnosing cancer.
[3]
Nitesh also had a urine culture done to investigate the possibility of a urinary tract infection.
B7. Which organism is likely to cause an infection of the urinary tract? What is their source?
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B8. Which culture media is most commonly used to culture a urine specimen? Explain whether this culture media
is ‘selective’ or not, whether this media is ‘differential’ or not, and what these terms mean.
[3]
B9. Explain what is meant by ‘significant bacteriuria’? Explain the standard which is used to determine
‘significance’. Explain why it is necessary to use this standard.
[2]
Nitesh’s urine culture is negative. He is treated for his micturition difficulty with Prazosin.
B10. Explain how Prazosin works in treating benign enlargement of the prostate.
[2]
Nitesh is counselled on the option of surgery.
B11. Briefly describe two (2) surgical procedures which may be done for benign enlargement of the prostate.
[2]
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SCENARIO C
[23 MARKS]
Lisa, a 37-year-old woman, comes to clinic with complaints of palpitations and weight loss over the past several
months. She says she feels warm even when others do not and has noticed a swelling in front of her neck.
On physical examination, her pulse is 112/minute; her blood pressure is 140/50 mm Hg.
C1. Describe the borders of the anterior triangle of the neck.
[3]
Investigations of Lisa’s serum hormone levels reveal the following:
Free T3 (Triiodothyronine): 30 picomoles / litre
[Normal level 3-8 picomoles / litre]
Free T4 (Thyroxine) : 110 picomoles / litre
[Normal 12-26 picomoles/litre]
TSH (Thyroid stimulating hormone) : < 0.1 mU/litre
[Normal 2-10 mU / litre]
C2. What is Lisa’s likely diagnosis based on the results of the investigation?
Explain your answer.
[2]
C3. List four (4) possible causes of Lisa’s likely diagnosis.
[2]
C4. Given her diagnosis above, explain the basis for Lisa’s feeling warm while others do not.
[1]
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C5. Explain the basis for Lisa’s loss of weight over the last several months.
[1]
C6. Explain why her pulse rate is 112 per minute.
[2]
C7. Explain the physiological basis for her blood pressure reading of 140/50mmHg.
[3]
On eye examination, Lisa has ‘lid-lag’.
C8. Describe how we test for lid-lag. Explain the mechanism which gives rise to this physical sign (include nerve
innervation).
[3]
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C9. List two (2) types of medications recommended for the treatment of Lisa’s condition. Briefly explain the
mechanism of action of each medication.
[3]
Lisa eventually undergoes surgery to remove part of the thyroid gland.
The report of the histopathological section of the thyroid lobe shows a nodule “composed of follicular elements”.
C10. What is a thyroid follicle? Briefly describe its makeup and appearance.
The following morning, the surgeon noticed that Lisa had a hoarse voice.
C11. What is the possible reason for this new symptom?
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SCENARIO D
[20 MARKS]
Wati, a 28-year-old woman on high dose prednisone medication for an autoimmune disease, comes for follow-upvisit complaining of easy bruising, weakness, and obesity. Examination reveals Wati has moon facie, a bufflo
hump, and thin limbs with centripedal obesity. There is purple striae on her lower abdomen, proximal muscle
weakness and BP of 150/100 mmHg.
Her doctor suspects that her new formed symptoms and signs are the side-effects of her prednisone medication.
.
D1.What is the common term used to describe the side-effects of prednisone that Wati’s doctor is referring to? [2]
D2. List three (3) different etiologies of this condition and state which is the commonest.
[4]
D3. Describe the pathophysiology of her weight gain and its distinctive features.
[2]
D4. Explain the easy bruising and purple striae found on this woman.
[2]
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D5. Explain the pathophysiology of her blood pressure reading (150/100 mmHg).
[2]
D6. Lists four (4) complications of this disorder if left untreated.
[2]
D7. Describe the connection of the anterior and posterior pituitary gland with the hypothalamus, on the basis of
their embryological origin.
[4]
D8. Explain the neuronal and hormonal control exerted by the hypothalamus on the anterior and posterior
pituitary.
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SCENARIO E
[20 MARKS]
Olivia, a 15 year old girl, is brought to the clinic by her mother. She has not had a monthly period yet, though all of
her friends have.
E1. History-taking involves questions regarding thelarche and adrenarche. Define each of these terms.
[2]
E2. If Olivia has thelarche and adrenarche but still has not had menses, what might be the problem?
[2]
E3. What sign would one look for if delayed puberty is suspected in a boy?
[1]
E4. What is the role of the hypothalamus and pituitary in the onset of puberty? Briefly describe what happens. [2]
One hypothesis entertained for delay of puberty is malnutrition.
E5. Explain how this might affect the onset of menstruation.
[1]
Olivia is suspected to have Turner syndrome, a condition in which the patient has gonadal dysgenesis (a term
which means failure of the gonads to develop).
E6. What impact might this have on signs of puberty?
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E7. What hormone profile of the hypothalamic-pituitary-ovarian axis would you expect in Olivia’s case?
[2]
E8. What effect would Olivia’s endocrine condition have on her expected growth spurt?
Explain.
[2]
To get Olivia to have menstrual bleed she is treated with oestrogen for 3 weeks and progesterone for 1 week.
E9. What histological changes could occur in the uterus as a result of this regimen.
[2]
Turner syndrome is a genetic disorder in which cells lack an X chromosome.
E10. Explain how Olivia’s condition can be confirmed.
[2]
Patients with Turner syndrome should undergo screening for coarctation of the aorta, a congenital narrowing of
the thoracic aorta.
E11. Explain the most significant sign that would be present in coarctation of the aorta. Explain the mechanism of
the sign.
[2]
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SCENARIO F
[20 MARKS]
Ioana, a 35-year-old woman who is G5P3 is seen for her antenatal clinic booking visit. Her last normal period was
10 weeks ago.
F1. What does G5 P3 mean?
[2]
F2. Explain what happens to the oestrogens and progesterones level following fertilisation of the ovum.
[3]
Ioana returns for an antenatal clinic visit at about 32 weeks gestation. Her blood pressure (BP) is checked.
F3. Briefly describe how two (2) physiological changes in a pregnant woman would affect BP.
[3]
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F4. Ioana's haemoglobin is checked, and is found to be lower than it was during her booking visit. Her mean cell
volume (MCV) is unchanged. Explain the most likely reason for the decrease in haemoglobin value.
[2]
Several months later, Ioana arrives at the hospital with labour pains.
F5. Explain how the relative changes in oestrogen and progesterone levels lead to the onset of labour.
[2]
The nurse performs a vaginal examination every four hours. Besides checking the dilatation of the cervix, the
nurse locates the ischial spines.
F6. Explain what the nurse uses this landmark for during labour.
[1]
F7. Briefly describe the three (3) stages of labour. Which of these stages normally lasts the longest?
[3]
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Ioana, managed to deliver her baby normally and started breastfeeding soon after.
F8. While breast-feeding, Ioana complains of cramping in her abdomen. Explain the physiology of this, and the
advantage.
[2]
F9. If Ioana wishes to use a hormonal method of contraception while breastfeeding, which contraceptive should be
recommended? Explain the reason for your choice.
[2]
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