Download MED 601-Paper 2 End Point Exam MBBS 3 2015

FIJI NATIONAL UNIVERSITY
Student Id_________________________
PROGRAM (YR)/COURSE:
MBBS (3)/MED 601
EXAM:
2015 MED 601 PAPER 2-END-POINT EXAM
DATE:
4/11/2015
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 sections (Scenario A-F), with several mini scenarios in each followed by a set of questions
related to the mini scenario. Understand the details in the scenarios 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.
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PART 1
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MULTIPLE CHOICE QUESTIONS
[30 MARKS]
1. (Fill in the blanks) In children, the_________fontanelle is located at the junction of sagittal and coronal
sutures and it closes at the age of_________.
A. Anterior, 18 months
B. Lamboid, 1 year
C. Mastoid, 16 months
D. Posterior, 2 years
E. Sphenoidal, 3 years
2. A 5-day old infant has an abnormally large head. A CT scan study reveals enlarged lateral and third
ventricles but a normal sized fourth ventricle. The CT study report is characteristic of :
A. Holoprosencephaly not core learning for MBBS students
B. Megacephaly
C. Meroencephaly
D. Nonobstructive hydrocephalus
E. Obstructive hydrocephalus
A 34 year old is admitted to the hospital with severe headaches, dizziness and vomiting. Imaging studies reveal
a tumour at the hypoglossal canal.
3. Which of the following muscles will most likely be affected?
A.
Genioglossus
B.
Geniohyoid
C.
Mylohyoid
D.
Palatoglossus
E.
Thyrohyoid
Physical examination of a patient reveals right pupillary constriction (Miosis) and anhydrosis (loss of sweating)
of the face. A CT scan reveals a large haematoma inferior to the Right Jugular foramen.
4. The ganglia that is affected by this hematoma is most likely to be:
A. Ciliary
B. Geniculate
C. Submandibular
D. Superior cervical
E. Trigeminal
A 7-year-old boy complains of a high fever and a painful ear. On examination his throat is red and inflamed.
5. Which of the following structures provided a pathway for the infection to spread to the inner ear?
A. Choanae
B. Eustachian tube
C. External acoustic meatus
D. Internal acoustic meatus
E. Pharyngeal recess
A 34-year-old male complains of hyperacusis (sensitivity to loud sounds).
6. An injury to which of the following nerves is most likely to be responsible for this presentation
A. Accessory
B. Facial
C. Glossopharyngeal
D. Hypoglossal
E. Vagus
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A 33-year-old woman is unconscious and admitted to Intensive Care Unit (ICU) after she fell, and hit her head.
ICU doctors performed a light reflex test.
7. This is to test the integrity of which of the following nerves
A. Maxillary and facial
B. Ophthalmic and oculomotor
C. Ophthalmic and facial
D. Optic and facial
E. Optic and oculomotor
A 48-year-old patient complains of diplopia (double vision). On neurologic examination he is unable to adduct
his left eye and lacks a corneal reflex on the left side.
8. The most likely location of the lesion resulting in this presentation is the:
A. Foramen rotundum
B. Foramen ovale
C. Inferior orbital fissure
D. Optic canal
E. Superior orbital fissure
A 35-year-old woman is hospitalized due to cavernous sinus thrombosis resulting from an infection in the
medial aspect of the face.
9. Which of the following drains the blood from the medial aspect of the face deep to the cavernous sinus
A. Basilar venous plexus
B. Frontal venous plexus
C. Parietal emissary vein
D. Pterygoid venous plexus
E. Superior ophthalmic vein
Lucy a 15-year-old girl was brought to accident & emergency with complaints of generalised itchiness,
puffiness and difficulty breathing. Lucy while swimming during their picnic was bitten by something strange.
10.
A.
B.
C.
D.
E.
The enzyme that would most likely be elevated in Lucy in response to this bite would be :
creatinine kinase
lactate dehydrogenase
serum tryptase
serum amylase
troponin
John, a chronic asthmatic, was brought to ER with severe shortness of breath.
11. Which of the following would most likely be a salient microscopic feature of the pathological process in
John's asthmatic bronchus?
A. Charcot - leyden crystals
B. hypoplasia of sub mucosal glands
C. mucus plugs containing shed basement membranes
D. neutrophils - inflammatory cells appearing in sheets at low power
E. thick hyaline rose coloured line above epithelium
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Koli complains of coughing yellowish blood stained sputum for weeks, associated with weight loss, night sweats
and pleuritic chest pain.
12. As part of Koli's investigation, his sputum was sent for AFB staining. The distinctive feature of the likely
causative pathogen for Koli's is
A. curved red bacilli
B. curved pink bacilli
C. gram negative bacilli
D. gram negative capsulated rods
E. gram negative non capsulated rods
13. The most likely microscopic description of Koli's affected lung would be
A. autolysis of Epitheloid cells
B. lymphocyte as major inflammatory cells
C. curshman spirals
D. eosinophil as major inflammatory cells
E. presence of B cells
Sainimere, Koli's wife presented to Skin Clinic with the following complaints: reddish brown plaque on her
face; with apple jelly colour nodules when pressed with a glass spatula.
14. Sainimere is most likely to suffer from
A. Herpes Simplex
B. Lupus Vulgaris
C. Potts disease
D. Scrofula
E. Tinea Vulgari
15. On Koli's review a week later, he was informed that he has Pulmonary TB. He was commenced on
pyridoxine. Pyridoxine is used to:
A. alter DNA synthesis of the mycobacterium
B. alter the synthesis of the mycobacterial mycolic acid
C. counter the work of mutant mycobacterium
D. enhance reduction in intracellular acidity of the mycobacterium
E. prevent peripheral neuropathy
16. The biochemical theory that would most likely explain postpartum depression would be:
A. a decrease in production of monoamines
B. an increase in concentration of noradrenaline in the synaptic cleft
C. an increase in reuptake of monoamines
D. increased breakdown of monoamines
E. down regulation of monoamine post synaptic receptors
17. In view of the above theory of post-partum depression, the drug that would most likely be prescribed for
Esther would be:
A. Benztropine
B. Benzexhol hydrochloride
C. Imipramine
D. Largactil
E. Prochlorperazine
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18. Lemeki and his wife both suffer from Schizophrenia the likelihood that one of their children will suffer
from Schizophrenia is
A. 1 %
B. 10%
C. 25%
D. 40%
E. 50%
19. On mental status examination of Lemeki, it was noted that his speech was reduced in quantity and content.
This is termed as:
A. Alogia
B. expressive aphasia
C. flight of ideas
D. receptive aphasia
E. scanning speech
20. A chronic alcoholic is at a high risk of paracetamol poisoning due to
A. Alcohol withdrawal syndrome
B. Aminotransferase deficiency
C. Glutathione depletion
D. Low first pass effect
E. P450 isoenzyme deficiency
21. The drug that would most likely be administered to correct Paracetamol Poisoning is
A. Activated Charcoal
B. Acetyl Cysteine
C. Naloxone
D. Resonium A
E. Fuller's Earth
A 7-year-old male was brought by his mother with the complaints of painful and swollen interphalangeal joints
of both hands, a swollen painful left knee with limitation of movement and a 2-day history of loose bowel
motion with associated painful red eyes.
22. The most likely assessment for this boy would be:
A. acute rheumatic fever
B. arthralgia
C. juvenile rheumatoid arthritis
D. reactive arthritis
E. septic arthritis
An 8-year old boy was brought to Children's Outpatient Department with the history of purposeless,
involuntary movement. There was observed rhythmic movements of his hand similar to a person milking a
cow.
23. The cause of the purposeless movement is most likely caused by antibody destruction of the
A. cerebellum
B. anterior horn of the spinal cord
C. posterior horn of the spinal cord
D. red nucleus
E. caudate and sub thalamic nucleus
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24. The primary lesion found in the endocardium of patients with rheumatic heart disease are Aschoff bodies
The morphology of these bodies are:
A. anitschkow cells with Antigen-antibody complex
B. B lymphocytes and large macrophages
C. caterpillar cells due to their threadlike chromatin
D. foci of degeneration surrounded by lymphocytes
E. foci of degeneration surrounded by eosinophils
25. The most likely pathological explanation for a pansystolic murmur heard on a patient with rheumatic
heart disease is :
A. ventricular septal defect or pulmonary stenosis/ incompetence
B. aortic stenosis
C. aortic incompetence
D. mitral stenosis
E. mitral incompetence
26. Which of the following would be given as a prophylaxis for infective endocarditis in someone with mitral
stenosis (RHD) one hour before a dental procedure?
A. Amoxicillin 1g
B. Amoxicillin 500mg
C. Intravenous Benzyl Penicillin 1 mega unit
D. Intramuscular Benzathine Penicillin1.2 mega units
E. Intravenous Benzyl Penicillin 2 mega unit
27. The murmur of a large ventricular septal defect would most likely be a
A. mid systolic murmur best heard at the left lower sternal border
B. mid systolic murmur best heard at the apex radiating to axilla
C. pansystolic murmur heard at the left lower sternal border
D. pansystolic murmur best heard at the apex radiating to axilla
E. soft ejection systolic murmur best heard at the apex
28. On staining leucocytes of an anaphylactic patient reddish orange leucocytes are most probably:
A. Basophils
B. Eosinophils
C. Lymphocytes
D. Monocytes
E. Polymorphs
29. The cerebellum is connected to the rest of the brain via peduncles. The peduncle that extends from the
cerebellum to the Red nucleus of the midbrain and to the nucleus of the thalamus is the
A. Anterior cerebellar peduncle
B. Inferior cerebellar peduncle
C. Middle cerebellar peduncle
D. Posterior cerebellar peduncle
E. Superior cerebellar peduncle
30. Which of the following microscopic findings is most likely to be present in the infarcted area of the
myocardium six days following myocardial infarction?
A. Capillary proliferation and macrophages
B. Fibroblasts and collagen deposition
C. Granulomatous inflammation
D. Myofiber necrosis with neutrophils
E. Perivascular lymphocytic infiltrates
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PART 2
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SHORT ANSWER QUESTIONS
SCENARIO A
[130 marks]
[22]
Inoke a 10 year old male was brought to the Emergency Department by his uncle. He has been feeling weak
and fainted while watching TV at home.
He is a known type 1 diabetic, currently on Mixtard insulin therapy. His last dose of Mixtard was 4 hours ago.
Inoke is a thin boy who appears ill. His lips are dry and his eyes are sunken. He is breathing fast and deep. His
breath smells like fruit.
Vital Signs: Temp 37.8 ⁰C; Respiratory rate - 32 breaths /minute; Pulse - 100beats /minute; BP 95/50mmHg.
Weight - 43 kg (prior weight at school 2 months ago was 47 kg)
A1. On examination Inoke's "lips are dry and his eyes are sunken". Explain the cause and pathogenesis of these
findings.
[2]
A2. On entry into the Emergency Department Inoke was noted to have a fruity smell on his breath, which was
also observed to be "fast and deep". Explain the cause and pathogenesis of these findings.
[4]
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A3. Inoke reports being very thirsty. Describe the anatomical position of the thirst centre, and discuss 1 (one)
stimulus by which this centre is stimulated.
[4]
Mrs. King, a 57 year old, is brought by her daughter- in- law to the Emergency Department with the complaint
of dizziness, weakness and confusion since the morning. She has a foul smelling left foot ulcer that has been
slow to heal.
She is a known diabetic for 10 years. She is non -compliant with her medications, follow up and her diet.
In clinic today she is noted to have:
T 38⁰C, Heart Rate 90 beats/min BP 140/90 mmHg (lying down) & 100/50 mmHg (sitting up) - with dizziness
CBGCapillary blood glucose - HI
Urine dipstick - Glucose +++, Ketones ++
A4. Explain the pathogenesis of the foul smelling foot ulcer and the slow healing process.
MED 601
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A5. On further history, she states that she feels dizzy when she stands up suddenly. Explain the likely
mechanism for this problem.
[1 ½]
A6. Outline an acute management and investigation plan for Mrs. King’s conditions.
[3]
A7. List the 4 (four) levels of prevention and give an example of each prevention for diabetes
[4]
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SCENARIO B
[21]
Maika is a 35 year old man, who was diagnosed with hypertension when he suffered a mild stroke 3 months
ago. His blood pressure is 160/100 mmHg in clinic today. He complains of blurred vision. He is a heavy smoker
with a strong family history of cardiovascular disease.
B1. Maika’s Hypertension could be of primary or secondary causes. List 4(four) secondary causes of
hypertension?
[2]
B2.Maika's blurred vision was attributed to "end organ damage" by his doctor. Explain two ways in which
hypertension causes end organ damage?
[3]
B3. Maika's mother had hypertension and died of stroke. Her physician was unsure whether she had a cerebral
haemorrhage or an ischemic stroke.
Explain how hypertension can lead to a haemorrhagic or ischaemic stroke?
[3]
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B4. Maika had a mild stroke 3 months ago. His computerised tomography (CT) scan result was consistent with
a "lacunar infarct" Explain what is meant by lacunar infarcts and their pathogenesis.
[3]
Alice is a 50-year-old female who is a known type 2 diabetic for past 5 years. On review this morning she is
complaining of generalised swelling of her body, breathlessness when she exerts herself, and tiring easily.
She is advised that she has chronic renal failure as a complication of her type 2 diabetes mellitus.
Investigations are as follows:
• Sodium: 137 mmol/l (normal range-135-145)
• Calcium: 1.6 mmol/l (normal range-2.1-2.6)
• e-GFR - 25 ml/min
Potassium: 5.9 mmol/l (normal range-3.5-5.0)
Phosphate: 2.4 mmol/l (normal range-0.64-1.5)
B5. Alice developed acute pyelonephritis. E.coli was isolated from her urine and she was commenced on
Gentamicin. State and explain whether Gentamicin should be given to Alice and why?
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B6. Alice used to take Tab Glipizide and Tab Metformin for her Type 2 Diabetes Mellitus. In view of her
Chronic Renal failure complete the table below and decide whether to continue with the current regimen of
oral hypoglycaemic
[4]
Oral hypoglycaemic
half life
Class of Hypoglycaemic
Mechanism of elimination
Glipizide
Metformin
B7. After Day 10 of admission, Alice's Renal Function tests continued to worsen and an intervention plan of
Chronic Ambulatory Peritoneal Dialysis [CAPD] is suggested. Explain how CAPD works and 2 (two) problems
commonly encountered during the use of a CAPD.
[3]
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SCENARIO C
[24]
William a 4 year old boy was brought to the health centre by his mother, complaining of fever, cough and red
eyes for a few days. He also developed a skin rash which started from his neck and face yesterday.
This morning the rash has spread over the rest of his body.
C1. The attending nurse thought that William had chicken Pox but the Doctor decided that it was measles.
What are the distinguishing features between Chicken Pox and Measles?
[3]
C2. While being pregnant with William, his mother received tetanus during her antenatal clinic. Explain why
this is important and explain what type of immunity is produced in both the mother and the infant.
[2]
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C3. William is born at a time where he should have been vaccinated with a measles vaccine. Why is William
having measles? Explain four (4) possible mechanisms that could make William more prone to developing this
infection.
[2]
C4. Ilisapeta is originally from Kiribati and had requested to take William to Kiribati so he can have lots of fish
to help in his healing. Explain why William should not take this trip to Tarawa (the capital of Kiribati) in terms
of nutrients that are needed for healing.
[1]
Ben a 19-year-old man is seen in the outpatients department complaining of fever, headache, muscle pain, and
weakness for the past three days. This morning he had a nosebleed.
Hospital staff suspects an outbreak of dengue.
Ben is very weak, feels dizzy with painful eyes. He recalls that this is similar to what he experienced 2 years ago.
Blood results:
Tourniquet test: Positive
FBC: Hb14 gm/dL; PCV: 50%; WBC 5,800 /mm3; Platelets 80,000/mm3
Bleeding time: 7 minutes
PT: 14 seconds (control 13 sec); PTT: 32 seconds (control 34 sec)
Dengue rapid cassette test: Positive He was later admitted to Acute Medical Ward.
C5. Explain the clinical significance of the following information from Ben's history and his blood results.
[2 ½]
Fact
"…..had a nose bleed"
Clinical significance
"....similar to what I
experienced 2 years ago."
Platelets 80,000/mm³
PCV 50 %
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C6. Would you recommend Vitamin K for Ben? Explain the basis for this recommendation.
[1 ½]
C7. Explain how the risks and the severity of an outbreak of dengue fever in the Pacific, can vary according to
the serotype of the virus and the length of time since a previous outbreak.
[3]
C8. Which vector transmits dengue? Explain whether it is a biological or a mechanical vector of dengue virus,
and explain the difference between these two.
[2]
C9. What is transovarial transmission? Does it occur in dengue? Explain how transovarian transmission may
impact on control of vector-borne disease.
[2]
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Elena a 9 year old, after returning from the Solomon Islands was brought into emergency department with a
history of fever, lethargy and passing black urine for the past week. She was rushed into ER this morning
because it has been difficult to wake her up. On examination Elena is difficult to wake and her temperature is
40⁰C. Elena's blood film demonstrated Plasmodium falciparum rings.
C10. What is wrong with Elena? Explain the pathogenesis of this condition.
[2]
C11. On examination of Elena there was an enlarged spleen and her blood results are as follows
FBC - Hb 5.0 gm/dL, PCV 20 %, WBC 5, 400 - 45% N, 55% L, and platelets-250, 000/mm³. Explain the
pathophysiology of the haemoglobin count in this result.
[2]
C12. Why is Elena passing black urine?
[1]
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SCENARIO D
[22]
Olivia a 30 year old G3P2 presents to Antenatal Clinic for booking at 12 weeks gestation. On examination, she
is noted to have moth eaten alopecia of her eyebrows.
Booking bloods were as follows:
Hb 11.0 g/l ; O +; VDRL 1: 128 dilutions, TPHA: REACTIVE; HepBsAg - POSITIVE. HIV - negative
Intracevical swab isolated N.gonorhoea
D1. Explain the clinical significance of Olivia's "moth eaten alopecia" of her eye brows
[1]
D2. In view of her serology results, state the infections she has, and what are the risks of these infections to the
fetus, and for each infection state the mode of transmission.
[4 ½]
Investigation
infection
mode of
transmission
Risks to fetus
Intracevical swab isolated
N.gonorhoea
TPHA :
REACTIVE
HepBsAg:
POSITIVE
D3. With reference to Olivia's serology results: VDRL 1: 128, TPHA – Reactive; Outline a treatment plan for
Olivia?
[3]
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D4. Baby of Olivia is born with risks of developing high risk infectious conditions. Explain how you will treat
and investigate Olivia's baby in view of Olivia's serology status - TPHA reactive and HepBsAg positive.
[3 ½]
Risks
Plan of management
Olivia has had 5 partners . She has also been treated for Gonorrhea while still in high school .She was
counseled on the high chance of an Ectopic pregnancy and HIV infection.
D5. Explain the pathogenesis of an Ectopic Pregnancy in view of Olivia's sexual history?
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D6. As part of Post Test counselling, List 4 (four) important issues that will need to be discussed with Olivia
now that her HIV test is negative?
[2]
D7. Explain the life cycle of human immunodeficiency virus from infection of the initial cell to the infection of
other cells?
[3]
D8. There are 2 antiretroviral drugs that are used in Fiji to treat HIV infections. Explain the mechanism of
action of each of the antiretroviral?
[2]
Antiretroviral
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HIV life cycle affected -mechanism of action
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SCENARIO E
[20]
Susan a 30 year old G4P2 Ab-1, Ectopic - 1 presents to the Gynae Clinic with complaints of post coital
bleeding, with low abdominal pain and foul smelling discharge
Gynae hx- 2 children, Menarche 11, was treated for an STI (Per Vaginal discharge) - at the age of 16 yrs. of
age.
E1. Outline and describe 4 (four) tests that should ideally be done on Susan and explain why?
[2]
Susan returns after 6 weeks her Pap smear results shows CIN III.
E2. Describe the histological change in CIN III and explain the histological change under the Bethesda
classification.
[3]
E3. While on this review Susan was counseled to have a colposcopy and a cone biopsy. Susan was told that the
Cone biopsy procedure is diagnostic as well as therapeutic. Explain how can cone biopsy procedure for Susan
be therapeutic.
[2]
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E4. In view of the multistep theory of carcinogenesis, name 4 (four) risk factors that will put the cervical
epithelial cells at risk of HPV infection and hence commence the initial process of INITIATION.
[2]
E5. Explain the process of Initiation in the theory of carcinogenesis in relation to Ca Cervix
[3]
E6. List 3 ways in which colposcopy help in diagnosing cervical dysplasia-
[3]
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Lavlyn a G0P0 presents to the Breast Clinic with a painful left breast lump, which has become more red and
painful over the last 2 weeks.
Drugs: No history of Contraceptive use
E7. On the lateral surface of the breast is a 5 cm area of redness with a "peau d 'orange" appearance. Explain
the pathogenesis of this finding.
[2]
E8. Explain what the BRCA gene is, and its relation to breast cancer.
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SCENARIO F
[21]
Asinate, a 73 year old woman, is brought to the General Outpatient Department (GOPD by her daughter-inlaw, with knee and back pain which has been progressively worsening over the past 2 years. The pain is
exacerbated by exertion but now persists at rest and she reports some swelling of the knees after walking long
distances.
She has notices some bumps on her fingers and experiences some brief morning stiffness as well.
At times she hears slight crackle sounds when she walks.
On examination:
Hands and knees - notable swelling on her hands and knees, joints of her feet are normal
F1 .What is Asinate's most likely diagnosis? Give three reasons from the information given to support your
answer.
[3]
F2. Asinate thinks she is getting old. Discuss the 2 theories of ageing.
[2]
F3. On examination of Asinate's knees there is notable crepitus heard and a decrease in the range of motion.
Explain the mechanism underlying these findings
[2]
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F4. Asinate's knee is aspirated and the aspirate reveals a high protein level. In view of the pathogenesis of
Asinate's condition explain the mechanism of this high level of protein in the knee.
[2]
F5. Asinate was sent for an X-ray of her knee which showed "narrowing of the joint space, obvious bone spikes
and reduced bone density". Explain the basis for each finding on the X-ray.
[2]
Isimeli is seen in the General Outpatients Department (GOPD) with the complaint of severe right toe pain,
stiffness, and swelling .It is suspected that he is suffering from gouty arthritis.
F6. Briefly describe the pathogenesis of gouty arthritis
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F7. Colchicine may be used in treating an episode of acute gout. Explain its mechanism of action.
[2]
F8. Allopurinol may be used in the long-term treatment of someone who has recurrent attacks of gouty
arthritis. Explain its mechanism of action.
[2]
F9. Amaan a 60 year old man presents for a routine blood pressure check - He asked why is it important to
have an annual BP check at this age. Explain the mechanism of the increase in blood pressure which occurs
with ageing?
[2]
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FIJI NATIONAL UNIVERSITY
Student Id_________________________
F10. On further interview, Amaan says that he has just had an operative procedure cancelled due to his age
and poor lung function. Explain the normal changes that occur to the vital capacity with ageing?
[2]
.
MED 601
END-POINT EXAMINATION-PAPER 2, 2015
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