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Part 2 : On physical examination, the patient has coarse facial features and prognathism. His stature is
taller than the average man of his age.
Part 3 : After a few days, the patient develops paraesthesia and numbness on the palmar surface of lateral
three and a half fingers.
Part II : After a few months, the patient complaints of passing foamy urine.
Part III : The patient develops into chronic renal failure after few years with complications of renal
osteodystrophy.
2. Part I : A patient with history of sickle cell anemia presented with fatigue, bone pain and skin ulceration.
a. Describe the pathogenesis of sickle cell anemia. [ 3 m ]
Sickle-cell anaemia is caused by a point mutation in the β-globin chain of haemoglobin, causing the
amino acid glutamic acid to be replaced with the less polar amino acid valine at the sixth position.
The β-globin gene is found on the short arm of chromosome 11. Deoxygenation of HbS leads to
distortion of the shape of RBCs. RBCs unable to pass through capillaries resulting in vessel
occlusion and ischaemia.
b. Describe three features you would observe in peripheral blood smear of this patient. [ 3 m ]
Sickle shaped RBCs, target cells, Howell Jolly bodies
Part III : Most of the indigenous inhabitants of Sub-Saharan Africa carry the sickle cell trait and they are
resistant to malaria.
Part II : The diagnosis of ulcerative colitis is confirmed in this patient. He also develops low back pain with
morning stiffness recently.
Part III : After a few years, the patient develops complications from the ulcerative colitis.
4. Part I : Patient is presented with sudden onset of tenderness, warmth and swelling in his toes. Serum uric
acid is found to be elevated in this patient.
a. Outline the treatment and management for this patient with the goals of
i. termination of acute attack [ 2m ] NSAID, colchicine
ii. lowering of serum uric acid [ 2m ] allopurinol, probenecid
b. State four features of synovial joint. [ 2m ]
Synovial fluid, synovial cavity, synovial capsule, reinforcing ligament
Part III : Patient develops complication from untreated chronic gout after a few years. He experiences loin
pain radiating to the groin with nausea and vomiting.
a. State the most likely complication of untreated chronic gout in this case. [ 1m ]
Uric acid stone formation
b. Describe struvite stone and its formation. [ 3m ]
Magnesium ammonium phosphate stone, associated with chronic UTI with gram negative bacteria / urea
splitting bacteria ( Pseudomonas, Proteus, Klebsiella ), alkaline urine, nidus for UTI
5. Part I : A 47 year old man presents to the emergency department after experiencing substernal chest pain.
The pain is worsened with inspiration and is relived only when he leans forward.
Part II : Cardiac examination reveals a friction rub. An ECG and chest X ray are done for this patient.
Part III : The patient had a myocardial infarction two weeks earlier.
6. Part I : A 50 year old woman is presented with 1-month history of productive cough with yellow sputum.
She has had several periods of cough lasting 4 to 6 consecutive months each year for the past 5 years. She
has been smoking for the past 30 years.
a. State your provisional diagnosis. Give the reasons from the history to support your diagnosis. [ 2m ]
Chronic bronchitis. Persistent productive cough for at least three consecutive months in at least two
consecutive years.
b. State the abnormalities you would expect on pulmonary function test of this patient. [ 3m ]
Reduced FEV1, reduced FVC, reduced FEV1/ FVC ratio
c. Describe the pathogenesis of this disorder. [ 3m ]
Hypersecretion of mucus in airway with hypertrophy of submucosal glands in trachea and bronchi;
increase in goblet cells and size of mucous glands; Reid index – increased ratio between mucous gland
and bronchial wall; narrowing of bronchioles by goblet cells metaplasia, mucus plugging, inflammation,
fibrosis
Part II : Her jugular venous pressure is elevated and there is pitting edema noted up to her knees.
d. What complication of this condition do the patient’s enlarged neck veins, hepatomegaly and edema
suggest ? [ 3m ]
Cor pulmonale. Right heart failure due to chronic pulmonary hypertension leads to systemic congestion.
e. State two other causes of elevated jugular venous pressure. [ 2m ]
Pericardial effusion, superior vena cava syndrome, cardiac tamponade, constrictive pericarditis
f. State all the segments of right lower lobe of the lung. [ 3m ]
Superior, medial basal, lateral basal, anterior basal and posterior basal.
Part III : Antibiotics and ipratropium bromide are given for this patient as treatment.
Part II : Ultrasound shows massively enlarged kidneys bilaterally. The surface of both kidneys is covered with
well circumscribed cysts.
Part III : After a few years, the patient is presented with sudden, severe headache described as the worst
headache his life.
8. Part I : A 30 year old patient is admitted into the hospital with severe epigastric pain radiating to the back.
Pain is relieved by leaning forward. He also complains of nausea and vomiting.
a. State two possible causes of severe epigastric pain radiating to the back. [ 2m ]
Acute pancreatitis, penetrating peptic ulcer, aortic dissection
b. Define acute abdomen. [ 1m ]
Any serious acute intra-abdominal condition attended by pain, tenderness, and muscular rigidity and for
which emergency surgery must be considered.
c. State three indications for endoscopic retrograde cholangiopancreatography ( ERCP ). [ 3m ]
Gallstone, pancreatic head tumour, cholangiocarcinoma, obstructive jaundice, Endoscopic
sphincterotomy, dilation of strictures in primary sclerosing cholangitis, chronic pancreatitis
Part II : Physical examination shows guarding and presence of rebound tenderness in the epigastric region.
Cullen and Grey Turner signs are positive.
Part III : The patient develops dyspnea, tachypnea and cyanosis after several days. Bilateral fine inspiratory
crackles are heard upon auscultation of the chest. He is diagnosed with adult respiratory distress syndrome.
g. State the four criteria for diagnosis of adult respiratory distress syndrome. [ 4m ]
Acute respiratory failure, diffuse bilateral infiltrates on chest radiography, absence of left atrial
hypertension and hypoxemia
h. Describe the clinical course of adult respiratory distress syndrome. [ 3m ]
Exudative – fibroproliferative – fibrosis
9. Part I : A 25 year old patient is presented with fever, chills, headache and nuchal rigidity. He also
complains on photophobia and vomiting.
Part II : Blood culture of the patient shows encapsulated gram-negative diplococcus. Petechial rash is
found to be present in this patient. Persistent bleeding occurs at the skin puncture sites for intravenous
injection. The patient has developed disseminated intravascular coagulation.
Part III : The coagulation profile of the patient confirmed the diagnosis and appropriate treatment is given
promptly.
10. Part I : A 30 year old female is presented with amenorrhoea for the past three months. Diagnosis of
pregnancy is ruled out in this patient.
Part II : The patient has been having palpitations and weight loss despite increase in appetite. A thyroid
function test is carried out.
i. State the probable diagnosis and the findings you would obtain in the thyroid function test. [ 3m ]
Hyperthyroidism. High serum free T4 and free T3, low serum TSH
ii. State the investigation to be carried out in this patient to rule out malignancy. [ 1m ]
Fine needle aspiration cytology of the thyroid gland
iii. Explain the pathogenesis of palpitations, weight loss and amenorrhoea in this patient. [ 3m ]
Palpitations – increased sensitivity to catecholamines. Weight loss – increased basal metabolic rate.
Amenorrhoea – high TH stimulates production of sex hormone binding globulin, resulting in low free
sex hormones
Part III : The diagnosis of hyperthyroidism has been made. Anti thyroid drug therapy is given.
iii. State two organs which are not affected by thyroid hormones. [ 1m ]
Testes, brain, spleen, uterus and thyroid gland.
By wehloong