MBBS PBL Problems Yr 1-4

7/23/2019 MBBS PBL Problems Yr 1-4

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MDSC 1001 Environment and Health

Problem 1

Cellular Worlds

In viewing a specimen of animal cells through a light microscope, two first-yearveterinary medicine students, Shrinath and Peters, were intrigued by the various

compartments within the cells. Shrinath was interested in what could have been seen with

a more powerful microscope and also wondered why biochemists needed to mash upcells in order to study their behaviour. Doesnt that !ill them"wouldnt they learn more

if the studied the whole cell while it was alive# he said.

OBJECT!ES

$. Describe the ultrastructure of an animal cell.

%. Describe the structure of the cell membrane.

&. Describe the basic structure and properties of lipids.

'. (elate the morphology and relative abundance of various cellular organellesto the functions of the cell.

). Discuss the need for intra-cellular compartmentalisation and the basicprinciples of intracellular metabolism.

"# Dis$uss the di%%erent methods used in the stud& o% $ells and the

're'aration o% tissues#

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2/79

Problem (

s Street )ood Sa%e*

n article in the local newspaper recently reported unusually high numbers of cases of

diarrhoea over the last three months. n e/pert medical source in the newspaper report

suggested that it could be an outbrea! of cholera, an intestinal infection caused bybacteria and spread through the consumption of contaminated water and food. 0he article

indicated that about $-%1 of those infected would develop severe watery diarrhoea

with vomiting. 0his secretory diarrhoea is a result of cholera to/in binding to theepithelial lining of the small intestine and triggering a series of events culminating in the

massive efflu/ of electrolytes and water into the intestinal cavity that can lead to severe

dehydration and death. 2iti3ens were being advised to see! medical treatment promptly,boil their drin!ing water and be mindful when buying food from street vendors. Public

4ealth uthorities were underta!ing investigations and moves were being made to clamp

down on vendors who did not display valid food badges.

OBJECT!ES$. (eview the fluid mosaic model of the plasma membrane of eu!aryotic cells.

%. Describe how water is distributed in the various body compartments.&. 5ist the different types of diarrhoea and their physiological causes.

'. 6/plain the mechanism of action of cholera to/in.

). Discuss the different types of dehydration and indicate which type choleracauses.

7. Describe the causes and conse8uences of dehydration of the fluid

compartments.

+. Discuss the use of Darrow-9annet diagrams.. Discuss the use of epidemiology to investigate public health problems.

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3/79

Problem +

Calmin, the -erve

novel compound was being tested for its effect on a nerve preparation. Intracellular

recordings showed e/pected changes in membrane potentials following changes in the

ionic composition of the e/tracellular fluid. fter application of the novel compound thenerve no longer generated an action potential when stimulated.

OBJECT!ES

$. :riefly describe the structure of a typical neuron.

%. 5ist the ma;or anions and cations found in e/tracellular and intracellular fluid.

&. 6/plain the processes that maintain the resting membrane potential of cells.'. Describe how changes in the ionic composition , ?> @ 2l-A of

e/tracellular fluid affect the polarisation of e/citable membranes.

). 6/plain how action potentials are generated in a nerve.

7. Discuss compounds that can affect action potential generation.

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4/79

Problem .

/ Chain is as Stron, as its Weaest in

Si/-year-old *ennifer was ta!en to the doctor because her parents were worried about the

fact that she always complained of being tired and often had mild fever. (ecently her

mother had noticed that her eyes loo!ed slightly yellow. fter receiving the results of theblood test she had ordered, the doctor told her parents that one of the proteins in

*ennifers red blood cells was defective. She e/plained that this was caused by a gene

mutation that affected only one of the hundreds of amino acid building bloc!s found in aparticular protein called haemoglobin. Bnfortunately, she said, this single substitution

does have a profound effect on the performance of red cells.

OBJECT!ES

$. Discuss the histology of blood cells.

%. 6/plain what is meant by the terms primary, secondary, tertiary and

8uaternary structure of a protein.

&. 6/plain why the primary structure of a protein is said to determine its threedimensional structure and its function.

'. 6/plain why the substitution of a single amino acid alters the shape andbiochemical function of the haemoglobin molecule.

). Describe the different types of point mutations and their possible effects on

protein structure and function.7. Discuss the role of epidemiology in identifying this patients diagnosis.

+. Discuss the concepts of health, illness and disease.

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5/79

Problem 2

Ha''&3 4rum'&55 and D6OOP7

%$-year-old salesgirl complained of wea!ness in the shoulders and drooping eyelids.

0hese symptoms appeared in the evenings but disappeared after a nights rest. Cn and off

she also had difficulty swallowing, particularly at dinner time.

4er P suspected a problem with either her nerves or muscles and referred her to a

neurologist. 0he latter performed an edrophonium test and 6E


6/79

Problem "

Their e,s Went Wea5

Er @ Ers. Singh could hardly digest the news. 0hey had ;ust returned from the doctors

office. 4e had told them that it was very li!ely that their son Shiva had an inherited

disorder called Euscular Dystrophy. 4e spent a lot of time e/plaining all the tests thatwould have to be done to confirm the diagnosis and to determine whether it was

Duchennes Euscular Dystrophy


7/79

$$. 2ontrast the epidemiological triangle and web of causation in identifying

the cause of this disease.

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8/79

Problem 8

H! and Pre,nan$&

2harmaine, a %& year old BGI student has ;ust found out that she is pregnant. Cnly three

wee!s before she learned that she was 4IH positive and is barely coping. She worries that

others will find out and hasnt even told her family yet. =ow she is bac! in Dr. Gilliamsoffice in tears. She wants to !eep her baby but is worried about its health.

Ghat is the chance that my baby will be infected# she as!s.

Gell, there have been many studies, says Dr. Gilliams. Githout treatment,

transmission rates vary widely depending on the country. In the 2aribbean it is about%1. Eost of that transmission occurs during labour and via breastfeeding. s long as

you stay relatively healthy, your placenta will help to protect the foetus against infection

during the actual pregnancy. 0he good news is that the ris! at all stages can be

significantly reduced if we use antiviral treatment during pregnancy and delivery and for

the baby after it is born. 0he recommended drugs are 0, nevirapine and &02 - theyinterfere with the replication of the viral genome.

2harmaine is so an/ious about her babys health she wants to start treatment immediately,

but Dr. Gilliams tells her she will have to wait until after $' wee!s gestation.

OBJECT!ES

$. Discuss the main issues that might create problems for a woman diagnosed

with 4IH in the 2aribbean.

%. Discuss mother-to-child transmission of 4IH and prevention strategies indeveloped countries versus resource-limited settings.

&. Describe the structure and role of a mature hemochorial placenta.

'. 5ist infective agents that are able to cross the placenta and are teratogenic.). (eview nucleic acid synthesis and replication.

7. 6/plain the mechanism of action of antiretroviral drugs


9/79

MDSC 100( Basi$ Para$lini$al S$ien$es

P6OBEM 1

Tests Per%ormed in Chemi$al Patholo,& aborator&

Ers. Sandy was offered a position with 0he Bniversity of the Gest Indies and wasre8uired to submit a 2ertificate of Eedical Jitness. 4er general practitioner filled out a

laboratory form re8uesting a biochemical profile, haematological profile, urine analysis,

4IH screen and a test for the 4epatitis : virus. Ers. Sandy was pu33led, as she did not

understand the meanings of these medical terms. She, however, went to the laboratorydepartment of the 6ric Gilliams Eedical Sciences 2omple/ and in8uired as to the type of

biological specimen re8uired for the tests.

OBJECT!ES9

$. Discuss the important items of information re8uired on a laboratory re8uest form.%. 5ist the different biochemical investigations done in a 2hemical Pathology

5aboratory.

&. Discuss the different types of biological specimens needed for investigations donein a chemical pathology laboratory.

'. Describe three


10/79

P6OBEM (

Blood Com'onents and -ormal CBC !alues

?wame, a first-year medical student and a regular blood donor decided to use thise/perience to learn something about blood. 4e as!ed the technician to obtain a suitable

sample for a 2:2. 4e then went to the blood ban! where he saw plasma being separatedfrom red cells. 5ater that afternoon, he returned to the hematology lab for his results and

was given a slip with the following valuesK

4b $)gLdlM Gbc / $FLlM Platelets $7) / $FLlM E2H F flM =eutrophils '.) / $FLlM5ymphocytes %.) / $FLlM 6osinophils .& / $FLlM :asophils .7 / $FLl.

OBJECT!ES9

$. Identify normal ranges of hemoglobin by age, se/ and physiology state such as

pregnancy.%. Identify the mean corpuscular volume


11/79

P6OBEM +

n%lammation and Wound Healin,

$%-year old secondary school student lost control of his bi!e and fell on the road. 4ehad a lacerated wound on his scalp, superficial and deep abrasions over his !nees and

elbows. t casualty at the local hospital, the house officer e/amined the in;uries andnoted the signs of acute inflammation. 0he wounds were cleaned with antiseptic

solutions. 0he patient was given a tetanus to/oid booster because he had received tetanus

to/in $ years ago. 0he wound over the scalp was sutured and he was discharged.

OBJECT!ES9

$. 5ist the various types of wound sustained by this patient.%. Define inflammation and list the cardinal signs.

&. Describe the vascular and cellular events in the acute inflammatory response.

'. 5ist the outcomes of acute inflammation.). Describe stepwise, the process of wound healing.

7. Cutline various factors that influence wound healing.

+. 5ist complications of poor wound healing.. 5ist the various mild antiseptic solutions used in would cleansing.

F. Discuss the primary prevention of tetanus.

$. Discuss active and passive immunity.

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12/79

P6OBEM .

Transmission : /etiolo,& o% n%e$tion b& P&o,eni$ Or,anisms

two-year old girl was seen in the Pediatric 2linic with pustular lesions on her lowerlimbs. 4er mother, a graduate student, gave a history of the child being bitten by

mos8uitoes. 0he doctor e/pressed concerns about organisms that are present on the s!inthat may cause infection. 0he doctor also e/plained the transmission and course of

infection of pyogenic organisms. She too! a sample of pus with a sterile swab and sent it

to the microbiology laboratory for ram stain and culture. She also prescribed

antibiotics.

OBJECT!ES9

$. Discuss the aetiology of s!in pustular lesions.

%. 5ist the organisms that constitute the normal flora of the s!in.

&. Discuss the transmission and pathogenesis of bacteria infection.'. Describe the procedure of ram stain.

). 6/plain the significance of ram stain results.

7. Cutline the procedures for the culturing of bacteria.+. (eview the microbiology of staphylococci and streptococci including virulence

factors.

. Describe the mammalian host defense mechanisms under natural barriers,

humoral mechanisms and cellular defense mechanisms.F. Define the termsK antibiotic, bactericidal, bacteriostatic.

$. 2lassify antibiotics according to their mechanism of action.

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13/79

MDSC 1101 Di,estion and Metabolism

Problem 1

One Smart Cooie

Cne day while Sonny Smart was the intern on duty at the regional hospital, two female patients

were admitted to the nutrition ward for weight loss.

0he severe weight loss suffered by :eatrice, a poor elderly woman, was occasioned by the fact

that she had very few teeth, and thus was unable to ensure proper diet. She admitted during

history ta!ing that for many years she had neglected to brush her teeth, and when she did she

used ba!ing soda.

In the bed ne/t to :eatrice was ?elly, a %$ year old aspiring model. ?elly was always

overweight as a child, and now as an adult, fed up of hearing what was good for her, she decidedto embar! upon a self-administrated weight loss programme.

Cn admission ?elly appeared apathetic and unnaturally thin. 6/amination revealed bulging

eyes, pallor and a rapid pulse. 4er tongue was smooth and inflamed and the corners of her

mouth were hypopigmented. She had dermatitis, brittle, easily pluc!able hair, areas of petechiae

and evidence of poor wound healing. 4er body mass inde/ was $).

Dr Smart invited the hospital nutritionistLdietitian to have consultations with both :eatrice and

?elly, and they were slowly started on proper diets.

Ob;e$tives

$. Describe the gross anatomy of the buccal cavity with special reference to the tongue, its

muscles, innervations, blood supply, and lymphatic drainage.

%. Describe the embryology, histology, and gross anatomy of the salivary glands.

&. Describe the eruption of the teeth and discuss their functions.

'. (eview the concept of recommended daily allowances


14/79

Problem (

Persistent Heartburn

7)-year-old man with a si/-month history of dysphagia, heartburn, anore/ia, epigastric pain

and occasional vomiting was seen at the Eedical Cut Patient 2linic. t the clinic on

8uestioning by his doctor, he admitted ta!ing antacid drugs in an attempt to relieve his

heartburn, however, these were not effective. 4e also gave a history of social alcohol use,

irregular eating habits and smo!ing )-$ cigarettes daily. provisional diagnosis of peptic

ulcer was made pending further investigation. 0he doctor emphasi3ed the need for lifestyle

modification for efficient management of the patient.

Ob;e$tives

$. Describe the gross anatomy and histology of the oesophagus, stomach and duodenum.

%. 6/plain the mechanisms and control of deglutition.

&. Define oesophagitis, list the causes and the drugs used to treat oesophagitis.

'. Describe the physiology of gastric secretions and mention the functions of the main

constituents of gastric secretions.

). Discuss the causes and conse8uences of altered levels of gastric acidity.

7. Define peptic ulcer and list aggravating factors.

+. 2lassify drugs used in the treatment of peptic ulcer, giving one e/ample of each class.

. Cutline the components of a healthy diet and discuss the nutritional re8uirements of the

elderly.

F. Is simply giving advice enough# 6/plain how health behaviour changes are essential for

facilitating dietary changes.

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15/79

Problem +

Wea William

Gilliam, a $+-year old male visited his P complaining that he e/perienced early muscle

fatigue and a cramping muscle pain during strenuous e/ercise. 4e had observed that this

condition did not improve with additional e/ercise, with a sports drin! containing

electrolytes, or with anti-inflammatory medications. 4is activities associated with daily

living are not affected. blood sample ta!en after e/ercise contained very low level of

plasma lactate but plasma creatine !inase levels were elevated.

Ob;e$tives

$. :riefly e/plain the histology of the liver.

%. Describe the various sources of energy during short term and long term e/ercise.

&. Describe the pathways of glycogen brea!down and glycogen synthesis.

'. 6/plain the biochemical basis for glycogen storage disease.

). 6/plain the central role of the liver in metabolism of nutrients.

7. Discuss the 2ori cycle and its regulation.

+. ive an account of the nutritional needs and how they are met continuously from

birth to young adulthood.

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16/79

Problem .

/ Tale o% T


17/79

). Discuss the relationship between the hepatic double circulation and liver function.

7. (elate the structure of the gall bladder to its function.

+. Discuss the public health significance and prognosis of 4epatitis : @ 2 viral

infections.

. 6/plain how some of the ma;or causes of death and disability have a nutritional

component.

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18/79

Problem 2

Ha'less Harr&

Several children between the ages of ) years to $$ years old were brought to the health

centre all complaining of abdominal pain wtih several bouts of watery blood-stained

diarrhoea over the last 7- hours. Cne of them, + year old 4arry, had fever and vomited

five times. Cn e/amination his temperture was &.'O2, s!in turgor was mar!edly

diminished, his eyes appeared sun!en and his tongue and lips were dry. 4is abdomen was

soft, non-tender, he had no guarding or rebound tenderness, and bowel sounds were

hyperactive. 4e was started on an intravenous infusion and blood was ta!en for 2:2,

urea and electrolytes and stool tests were done. 0he D4H


19/79

MDSC 110( Cardiovas$ular and 6enal

Problem 1

And the Beat goes on

systolic murmur was detected in *oan when she was ten years old. 4owever her mothercould not !eep regular appointments with the doctor because of her inability to pay for

transportation.

Ghen appointments were !ept, the doctor recorded a progressive increase in the atrial

beat rate and a decrease in the ventricular beat rate over the course of the last ten years.0he doctor differentiated this murmur from the diastolic murmur of rheumatic fever.

=ow at $F years of age, *oans atrial beat was + bpm and the ventricular rate was 7)bpm. 4er stro!e volume obtained by echocardiography was larger than normal.

Cne day, when *oan was out shopping, she suddenly collapsed and was rushed to hospitalwhere she received an i.m. in;ection of 8uinidine. Bnfortunately she died. 0he family wasdistraught and was advised to see! counseling.

Ob;e$tives9

$. Describe the gross anatomy of the heart.

%. Describe the innervation and the conducting system of the heart.

&. Describe normal heart sounds.'. 6/plain the physiological basis of heart murmurs.

). Describe conduction of the cardiac impulse and the abnormalities of

conduction.

7. 5ist drugs that are used in the treatment of cardiac arrhythmias.+. 2lassify them according to Haughn Gilliam 2lassification.

. Discuss the epidemiology and impact of congenital lesions of the

cardiovascular system.F. Discuss the familys response to Nloss as in the situation of death.

$. Discuss relevant issues in child health surveillance.

*anuary +, % $F


20/79

Problem (

The Failing Heart

n e/ecutive medical e/amination revealed an enlargement of Er. Deans heart.

6lectrocardiogram showed waves in the inferior leads. Jurther investigations showed

abnormal cardiac en3ymes. Er. Dean e/plained to his doctor that in the past he hadsuffered two heart attac!s. 0he doctor made a diagnosis of heart failure arising from hisprevious heart attac!s. 4e then proceeded to discuss a treatment plan with the patient.

Ob;e$tives9

$. Describe the normal 62 tracing.

%. ive reasons for the abnormal waves seen in the inferior leads.

&. Describe the cardiac cycle with respect to pressure and volume changes.'. Discuss the factors affecting normal cardiac output.

). Bsing Jran! Starling 5aw e/plain how the failing heart dilates to compensate

for loss of contractile power.

7. Identify drugs used to treat cardiac failure.+. State


21/79

Problem +

The Designer Heart

team of engineers has contracted a medical intern to assist them in the computer

modeling of a heart and circulatory system. 0he model must depict the essential

anatomical, functional and physical characteristics of the heart and great vessels. 0heengineers are specifically interested in obtaining details on how the heart is able to move

blood throughout the system of blood vessels. 0hey are also curious about the

characteristics of blood which permit it to flow, the types of flow within the system andthe ability of the mechanisms to maintain unidirectional flow. 0he team also intended to

obtain critical vascular flow and resistance data and cardiac pressure and volume changes

from a simulation of an e/ercising heart.

Ob;e$tives9

$. Discuss the gross anatomy of the heart and great vessels.

%. (eview the cardiac cycle with respect to pressure and volume changes.

&. Discuss factors that affect viscosity of blood and the physiologicalconse8uences of these changes.

'. 6/plain the functions of the valves in the cardiovascular system.). 6/plain the determinants of resistance in the vessels and the relationship

between flow, pressure and resistance e/pressed as Poisseuilles 68uation.

7. 6/plain the physiological changes caused by e/ercise.+. Discuss laminar flow as it relates to the vascular system and the determinants

of (eynolds number.

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22/79

Problem .

Our Connected Systems

Dave is a stressed out 26C who has had uncontrolled hypertension 9 $.F) mmolL5

Brinalysis revealed proteinuria.

Ob;e$tives9$. Describe the factors that regulate blood pressure in the short term.

%. Discuss the epidemiology of hypertensive disease including the role oflifestyle and how it affects the prevalence of hypertensive disease.

&. Describe the pathophysiology of hypertensive disease.

'. Discuss the anatomy of the !idney.). Describe the histology of the filtration membrane.

7. 5ist the functions of the !idney.

+. 5ist the functional tests of the !idney.. Describe the factors that regulate blood pressure in the medium to long term.

F. Describe the role of the !idney in erythropoeisis.

$. Describe the role of the !idney in the aetiology of chronic anaemia.$$. Describe the role of the !idney in the regulation of calcium metabolism.$%. 5ist the drugs used in the treatment of hypertension and describe the

mechanisms and sites of action.

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23/79

Problem 2

Caroni versus Tobago

family practitioner for over % years in 2ounty 2aroni, Dr. ene Diet observed that a

high proportion of his male patients in the age group ')-)) had suffered from cute

Eyocardial Infarction


24/79

Problem "

Surviving on Water

%%-year old merican marine was part of the military force sent to the Eiddle 6ast

during the ulf crisis. 0his was the first time he was posted to the sandy desert wor!ing

at temperatures around 'FO2


25/79

MDSC (001 6es'iration

PROBLEM 1: FACTORY WOES

Hilda Raucher is a 54-year old, 170 cm cement industry worker, who has worked in the kilnsection of the plant for the past 30 years. he complained of shortness of !reath, which she

claimed was e"acer!ated !y the often-dusty workin# en$ironment. %pon &uestionin# sheadmitted to !ein# a chain smoker and that she fati#ues easily, e$en with li#ht e"ertion. he hadde$eloped chronic sinusitis and a persistent cou#h. 'n e"amination the doctor found #eneralisedhyper-resonance on percussion, prolon#ed e"piratory phase in her !reathin#, !ilateral e"piratorywhee(es and coarse crackles o$er the ri#ht lower (one on auscultation and increased antero-posterior chest diameter. Her nail !eds were cyanotic and she had moderate pittin# oedema ofthe ankles. He concluded that the patient)s pro!lems could !e related to her occupation andlifestyle and referred her to the pulmonary function la!oratory for simple spirometry and !lood #asmeasurements. he was #i$en appropriate treatment for the cou#h.

Her pulmonary function assessment and la!oratory findin#s were as follows*

Pulmonary Function Tests Laboratory alues

+redicted $ital capacity +/ 4. Haemo#lo!in #2dl/ 14.5orced $ital capacity / 3. +a' mm H#/ 4

+eak e"piratory flow rate 300 l2min +a'mm H#/ 6

1.0 .4 'saturation 8/ 7

H'3- 34

9ased on the a!o$e data the pulmonolo#ist recommended a full assessment to includemeasurement of airway resistance R:;/, lun# compliance /, total lun# capacity R:;> forces #enerated !y the respiratory muscles to mo$e theair, , surface tension and the defense system of the respiratory system/.

5. ompare the $alues of the patient with normal $alues.. =escri!e the common symptoms and si#ns associated with respiratory disease.7. =iscuss the pharmacolo#y of dru#s used in the treatment of cou#h suppressants,

e"pectorants and mucolytics/.. =iscuss the pharmacolo#y of*

dru#s used as !ronchodilators sal!utamol, theophylline, adrenaline and ipratropium/

dru#s used as prophylactic treatment of asthma sodium cromo#lycate/ and

#lucocorticoids.

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26/79

PROBLEM #: MORE T$A% A BLOC&E' BRO%C$(S

?r. e$rin Restrictor, a 1-year-old retired welder consulted his physician !ecause he wase"periencin# shortness of !reath durin# e"ertion and was cou#hin# up !lood haemoptysis/ forthree weeks. He had recently e"perienced mild chest pain in the upper part of his thora" on theri#ht side and noticed a remarka!le hoarseness of his $oice.

"amination re$ealed diminished !reath sounds in the upper lo!e of the ri#ht lun# and fine rales,particularly at the !ase of the left lun#. :n o!scuration of the hilum of the ri#ht lun# !y a masssu##esti$e of a tumor/ was detected on the chest radio#raph, in addition to fine diffuse mottlin#of the left lun#. : !ronchoscopy and mediastinoscopy with a !iopsy were ordered for this patient.

=urin# endoscopy of the !ronchial tree, a #rowth o!structin# the ori#in of the ri#ht superior lo!ar!ronchus was o!ser$ed and the !iopsy material o!tained from this !ronchus and the ri#httracheo!ronchial lymph nodes showed the presence of mali#nant tumor cells.


27/79

PROBLEM ,: -T$E P(MP "S 'OW%.

?s. enus '!esino is a 36 year old unmarried doctor, who wei#hs 110k#. he is 150 cm tall. he

has tried most of the slimmin# dru#s without much success. he recently stum!led upon the fact

that some 50 years a#o , 4 dinitrophenol was #i$en as a dru# to help patients lose wei#ht. he

self administered the dru#, with near fatal conse&uences.

'n reco$ery she learnt that the difference !etween wei#ht loss and death is only a smallconcentration chan#e in dinitrophenol, makin# the dru# dan#erous. he a#reed to do furtherstudies on !lockers of the electron transport chain, their sites of action and to analyse the effectof the !lockers on the chemiosmotic theory.

OB!ECT"ES:

1. ist the components of the electron transport chain, and descri!e their or#anisation andfunction.

. "plain the term Auncoupler) and list the common inhi!itors and uncouplers of the electrontransport chain, indicatin# their site of action.

3. =iscuss o"idati$e phosphorylation with emphasis on the chemiosmotic theory.

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28/79

PROBLEM /: CREEP"%0 '"STRESS

: 3-year old, semiconscious man is !rou#ht into the emer#ency room followin# an automo!ileaccident. He is tachypnoeic and cyanotic. +hysical e"amination re$eals a small laceration andflailin# on the ri#ht lower anterolateral thoracic wall.


29/79

PROBLEM : ALPS $YPE

=on it decided to cele!rate his 1st!irthday !y @oinin# a mountain clim!in# e"pedition to thewiss :lps. =on is in e"cellent condition> he runs 5 miles daily and plays s&uash and soccer on are#ular !asis. =on underwent a complete medical e"amination, includin# !lood #asmeasurements !efore the clim!. His +a'was 100 mm H# and all other parameters were within

the ran#e of normal.


30/79

MDSC (00( -euros$ien$es and Behaviour

P6OBEM 1

:orn Gith a 5ump

male infant was born with a large midline mass in the lumbar region of the bac! that

was covered with a membranous sac. Githin a few days the mass grew larger andulcerated leading to fluid lea!age from the mass. 0he infant was ta!en to the hospital

where the attending physician detected bilateral neurological deficits in the lower limbs.

n E(I also revealed partial herniation of the medulla oblongata and the cerebellum

through the foramen magnum. 0he doctor informed the mother that her child wassuffering from a congenital abnormality.

Objectives

$. Describe the formation, circulation, drainage, constituents and functions ofcerebro-spinal fluid


31/79

P6OBEM (

:ac! Stabbing Jor (eal

*ames was rushed to the hospital after he was stabbed in the bac!. 0he e/amining doctor

noted that below *ames navel, he did not respond to pain and temperature on his leftside, or proprioception on his right side. *ames was referred to a neurosurgeon for

appropriate management.

Objectives

$. Describe ascending


32/79

P6OBEM +

0o 0ransmit Cr =ot 0o 0ransmit#

6pilepsy is a syndrome that arises when the e/citatory neurotransmitter, glutamate,

stimulates neurons to start firing wildly and uncontrollably, sometimes resulting insei3ures or loss of consciousness. In a recent study, a team of scientists induced epilepsy

in rats and found to their great surprise that there was an increase in abnormal glial cells

in the cerebral corte/. Cne of the roles of normal glial cells is to mop up e/cess glutamate

but the abnormal glial cells produced increased amounts of glutamate.

2urrent treatments of epilepsy are aimed at slowing down brain function to reduce the

neuronal firing, but these have unwelcome side effects, such as drowsiness due to theiraction on the reticular activating system. (esearchers used the rat models to analyse three

N:mimetic drugs commonly used to treat epilepsy. 0hey found that in addition to

slowing neural firing, the drugs reduced the type of chemical signaling that causesastrocytes to release glutamate. 0his may contribute to why the drugs wor!, the

scientists suggested.

Objectives

$. 5ist the types of glial cells in the central nervous system and their functionsMindicate which one of them is affected in the scenario above.

%. 2lassify glutamate receptors.

&. :riefly describe the general structure and mechanisms of action of ionotropic andmetabotropic receptors.

'. 5ist the types and causes of epilepsy in humans and discuss their underlying

mechanisms.). Discuss the role of N:mimetic drugs in the treatment of epilepsy.

7. Discuss the management of epilepsy.

+. Discuss the role of the (eticular ctivating System in consciousness.

*anuary +, % &%


33/79

P6OBEM .

Proteins Slow the Progress of Par!insonQs Disease

(esearchers claim to have slowed the progress of Par!insons disease in rats by in;ectingtwo proteins into a part of the brain that has been implicated in Par!insons disease. 0he

proteins prevented the brain cell loss associated with the disease.

Bntil now, most therapies have concentrated on replenishing the neurotransmitter, but

that does not stop the brain cell loss and so have had limited success. =ow, wor!ing in

rats, a team of scientists have succeeded in halting brain cell death in the vital brainregion. 0he researchers used a genetically engineered virus to transfer the genes for the

two proteins R Sonic 4edgehog and li-$ R to the brain cells of a group of adult rats R

referred to as roup I. Cne wee! after the proteins had been in;ected, a drug that inducesPar!insons disease was given to the rats, as well as to a second group of rats that had not

received the proteins R referred to as roup %.

Jour wee!s later, the roup % rats had lost 1 of neurons in the vital brain region.

Ghereas the roup I rats had only suffered %1 - &1 brain cell loss in the same region.

0he results of this study were submitted to the ;ournal N:rain (esearch for publication.

(eviews were favorable and though one referee suggested that a third group of rats be

analysed to improve the reliability of the results.

Objectives

$. =ame the region of the brain in which the scientists in;ected the proteins.

%. Draw a diagram to illustrate the direct @ indirect pathways in the basal gangliaM

indicate the neurotransmitters involved in the pathways.&. Describe the synthesis of the neurotransmitter that mammalian brain cells

manufacture to prevent progression of Par!insons diseaseM indicate the rate-

limiting en3yme.

'. Describe all the receptors for the transmitter


34/79

P6OBEM 2

Eemory 5oss in Eice @ 4umans

group of scientists discovered that in;ecting fragments of the protein beta-amyloid fromhuman patients with l3heimers dementia into the brains of a group of mice caused the

animals to forget chores they had ;ust been taught. Ghen further electrophysiologicale/periments were done, both long-term potentiation and long-term depression were found

to be compromised.

Objectives

$. Describe the gross anatomy, histology and embryology of the human cerebralcorte/.

%. 5ist the pathological features that would be e/pected to develop in the brain of the

mice.&. Describe the common classifications of learning.

'. Describe the common classifications of memory.

). 5ist neurotransmitters and brain regions associated with memory and learning.7. 2ompare


35/79

P6OBEM "

Bpper or 5ower####

Er. *ones, a 7& year old fro-0rinidadian man awa!es one morning with wea!ness on hisright side. 4e also complains of difficulty seeing and has slurred speech. 4e is rushed to

the accident and emergency department where he is e/amined. Jindings include a historyof hypertension, right-sided hemiparesis


36/79

P6OBEM 8

4earing 5oss Is Eore 0han 0he 6ars

Ers. *ohnson, a + year old retired music teacher, has been e/periencing a gradual loss inhearing over the last $ years. 6ven with her hearing aid turned to full volume, she canQt

ma!e sense of speech, especially when two or more persons spea! at the same timeduring a conversation.

udiometric testing showed sensory-neural deafness and a P60 scan revealed that there

was less than normal activity in the midbrain. 0he scan also showed that fewer nervefibers infiltrated the midbrain and that there were lower levels of calcium entering and

leaving the nerve cells.

0he specialist e/plained, much to Ers. *ohnsonQs disappointment, that a cochlear implant

was unli!ely to improve her hearing. 4e further advised Ers. *ohnsonQs daughter that her

mother would benefit from persons spea!ing more slowly to her and engaging her in apolite conversation where people ta!e turns.

Objectives

$. 5ist the common causes of hearing loss in the different age groups.

%. Describe the anatomy of the ear.

&. Describe transduction of sound in inner ear.'. Describe the auditory pathways.

). Describe the processing of hearing @ speech in the 2=S.

7. Describe how polite conversation improves Ers. *ohnsons understanding ofspeech.

+. Describe the various tests for hearing.

. 6/plain how hearing aids @ cochlear implants wor!.

*anuary +, % &7


37/79

MDSC (101 Endo$rine and 6e'rodu$tion

roblem ! " H#$%& A'D H#O&ACT()(T#

?enny was small for his age. lthough he was %% years old he loo!ed li!e a boy of $$.

4e was not very active and was mentally challenged. ?ennys doctor had previouslyindicated that ?enny was a thyroid dwarf.

?ennys &-year-old tutor, who had developed normally, also appeared to have a thyroid

problem. She had ;ust visited her physician and informed him that she was losing weightalthough she was eating incessantly. She complained of muscle wea!ness, and fatigue

during e/ercise. She had also developed irregular menstrual periods, and her s!in was

often warm and moist.

medical e/amination by her doctor revealed that her thyroid gland was enlarged.

5aboratory tests indicated high levels of total serum 0', free 0'and low levels of serum

0S4.

OBJECT!ES9

$. Describe the embryology, anatomy and histology of the anterior pituitary.

%. Describe the embryology, anatomy and histology of the thyroid gland.

&. Describe the synthesis, storage and release


38/79

roblem * & TOO +,CH ST$%O(D

nne, a 7-year-old woman who had suffered from chronic arthritis for years, had been

treated over the past year with ) mgLday of prednisolone, which she had been obtaining

over the counter at the local drug store. She had observed recently that her s!in hadbecome 8uite thin and easily bruised, and her best friend teased her about her moon face.

4er arms and legs always felt e/tremely wea!, and an -ray revealed osteoporosis.

Cne day while crossing the pavement she slipped and fell and sustained a fracture of the

femur and after admission to hospital she was scheduled for surgery. :lood tests revealed

elevated levels of glucose. nne omitted to tell the doctor that she had been ta!ingprednisolone and the medication was not given in hospital after admission. During the

operation, which was done three days later, her blood pressure suddenly fell to L) mm

4g and the doctors had great difficulty maintaining the blood pressure. Post-operatively,

the doctors discovered that nne had been ta!ing a steroid prior to her admission and

they suggested that this could have affected her adrenal gland function.

OBJECT!ES9

$. Describe the embryology, gross anatomy, and histology of the adrenal gland.

%. Describe the physiological actions of glucocorticoids.

&. Describe the pharmacological actions of glucocorticoids.

'. Discuss the aetiology and pathophysiology of hypersecretion of glucocorticoids.

). Discuss the tests used to assess adrenal cortical function.

7. Discuss the complications of steroid use.

+. Discuss the pathophysiology of adrenal failure.

*anuary +, % &


39/79

roblem - & D(AB$T$S A'#O'$

group of third year medical students decided to underta!e a study of their classmates

for their 2ommunity 4ealth class pro;ect, to determine the number with the potential for

developing non-insulin-dependent diabetes mellitus


40/79

roblem . & T%#('/ TO F(00 TH$ )O(D

fifty-two year old male lawyer whose first marriage had remained childless after ten

years was recently re-married to a young woman who was an/ious to start a family. 4e

noticed very early in his marriage that he was having difficulty with micturition and hadto get up fre8uently at night to void his bladder. 4e consulted his doctor, who, on

e/amination ofhis prostate gland, found it to be enlarged and tender. 0he doctor also

re8uested a semen sample for analysis as well as blood samples for serum JS4L54 andandrogen estimation. 0he lawyer sought advice on the potential influence of his current

problem on his past and future fertility, as well as his libido and ability to have erections.

OBJECT!ES9

$. Describe the embryology, gross anatomy and histology of the male reproductive

system.

%. Discuss the process of spermatogenesis and the maturation and storage of

spermato3oa.

&. Discuss the physiology of erections.

'. Discuss the physiology of e;aculations.

). Define the composition and functions of seminal fluid.

7. Discuss the causes of male infertility and reduced libido.

+. Describe the parameters used in evaluating production and 8uality of semen.

*anuary +, % '


41/79

roblem 1 " A+$'O%%H$A A'D2O% %$/'A'C#

*ane, a %)-year-old woman, who had been having her normal %-day menstrual cycle

since the age of $& years, presented with a history of amenorrhea for three months.

urine test ruled out the possibility of a pregnancy. She also reported that her mother haddied in an automobile accident four months ago. 0he young woman wondered which of

her ovarian functions were disrupted, and how the disruptions affected the rest of her

reproductive system. 0he doctor ordered laboratory tests for the estimation of serumconcentrations of JS4, 54, prolactin and the ovarian se/ steroids before any medication

could be contemplated.

6vita, a twenty-one year old actress had also missed her last three periods. She had

gained some weight and noticed slight tenderness in her breasts. 4er doctor performed a

urine pregnancy test and diagnosed that she was pregnant. She wondered about the

processes that had occurred in her body following intercourse, as well as, the changes that

were ta!ing place in her. Since it was her first pregnancy, her doctor advised her aboutregular antenatal care as an ad;unct for an uneventful parturition. She was also given

literature about lactation and the merits of breast-feeding.

OBJECT!ES9

$. Describe the embryology, gross anatomy and histology of the female reproductive

system including the placenta.

%. Discuss the causes of amenorrhea.

&. Identify the ma;or physical and hormonal changes associated with pregnancy.

'. Cutline the principles underlying tests used in the diagnosis of pregnancy.

). Discuss the hormones involved in breast development and lactation.

7. Discuss the merits of breast feeding.

*anuary +, % '$


42/79

roblem 3 " TH$ A0HA A'D O+$/A OF F$%T(0(T#

:rigit was turning into a well-developed thirteen year old girl who was somewhat

embarrassed by the initiation of menses and her breast development, which was

becoming a source of attention from some of the young boys in the neighbourhood. 4erown attitude to the opposite se/ was beginning to shift noticeably. Some of the boys

were also ;ust beginning to manifest growth spurts, facial hair growth and a deepening of

their voices. :rigit wondered what was causing the changes in her body, as well as, thechanges in the young boys.

In contrast, :rigitQs )&-year-old grandmother was e/periencing irregular menses,e/cessive sweating at night and fre8uent mood swings. 4er doctor discussed the pros

and cons of hormone replacement therapy with her.

OBJECT!ES9

$. Discuss the factors underlying the onset of puberty in males and females and

menopause in females.

%. Describe the physiology


43/79

MDSC (10( Mus$les3 Bones and Joints

Problem 1

5emon Day

Devin was a member of a crew which was going to re-enact 2olumbuss ;ourney acrossthe tlantic in a replica of the Santa Earia. s he was about to board the ship, his wife

ail-nn ;o!ed that she hoped he had pac!ed some lemons because she wanted him to

come bac! with all his teeth. 4e !new she was referring to a disease which used to afflictsailors on long voyages, causing their s!in to become spotted and their gums to bleed.

4e remembered reading one description which referred to the sailors losing all their

strength and not being able to stand on their feet. 4e later as!ed the ships coo! if theyhad lemons on board. 0he coo! replied that they didnt have lemons but they had plenty

of other fresh fruit on board.

Devin realised that he did not !now why lemon ;uice prevented the disease or if other

fruit would do the same ;ob. 4e thought of his cousin =avin who had complained aboutthe difficulties in getting fresh fruit for his family


44/79

Problem (

0he 9oung Scientist

*ohn a curious second-year medical student was performing a series of e/periments upon

a nerve-muscle


45/79

Problem +

2arnival Dancer

Er. reen, a &+-year-old 0rinidadian ta/i driver was complaining to his family doctor

about lower bac! pain, which began ;ust after the last carnival. Cn 8uestioning he told

the doctor that he and his friends had a lot of fun participating in recent carnivalactivities. Er. reens dancing apparently involved e/cessive movements of his trun!,

which led to his lower bac! problem.

Cn e/amination of his bac!, the doctor noticed moderate tenderness of the lower

paravertebral muscles and movements of the lumbar spine were painful and limited.

(adiographic study revealed a spina bifida occulta of the $stsacral vertebra, while anisotope scan of the lumbar vertebrae was normal. muscle rela/ant was prescribed.

Er. reens father often suffered with lower bac!bone problems because he had a

slipping lumbar vertebra and Er. reen wondered if he could have a similar problem

with his own vertebra, which might lead to his present condition.

OBJECT!ES9

$. Describe the gross anatomy and embryology of the vertebral column with special

emphasis on its articulations, mobility and stability.%. Discuss common congenital abnormalities of the vertebral column, their

manifestations and complications.

&. Describe the gross anatomy of the muscles of the bac! and movements they

produce.'. Discuss the effect of e/treme movements on the vertebral column.

). 2ontrast the factors which can cause lower bac! pain.

7. Discuss the diagnostic tools for bac!bone problems.+. =ame groups of common muscle rela/ants and describe the use of

ben3odia3epines to provide muscle rela/ation.

*anuary +, % ')


46/79

Problem .

Spoilt 2oncert

Es. 0., a beautiful middle-aged famous 0rinidadian singer, was invited to =ew 9or! in

*anuary to give a concert. Cn the way from the airport to her hotel she could not avoid

the blast of the chilling wind on her face and nec!. 0he ne/t morning she loo!ed in themirror and was shoc!ed because her face loo!ed croo!ed. Ghile she was able to move

her head and nec! freely, she could not close her left eyeM and on drin!ing, water dribbled

from the left corner of her mouth.

She recalled a similar problem in the past when the dentist, treating her teeth, bloc!ed a

nerve in her mouth by an anaesthetic. t that time all symptoms disappeared on the sameday. 4owever, on this occasion the specialist to whom she was referred, e/plained after

e/amination of her face and radiographs of her s!ull that she could have a nerve

compression in the small opening of the s!ull also !nown as :ells palsy and her new

condition would re8uire a more prolonged period of treatment. Since her concert was

scheduled for the same evening, the singer had to cancel it.

OBJECT!ES9

$. Describe the gross anatomy of the s!ull and the individual cranial bones.

%. Describe the gross anatomy of the muscles of the head and nec! and e/plain theiractions.

&. 6/plain the procedure of inferior alveolar nerve bloc! and anatomical reasons for

the possibility of facial nerve bloc! during that procedure.

'. Discuss the pathophysiology of facial paralysis


47/79

Problem 2

2licos Earathon @ Bne/pected Problems

Er. 0homson, a young marathon competitor from *amaica was preparing himself for

international and regional races. In order to improve his speed during the last part of the

race he began weight training. Ghile training one day he noticed that straining to liftheavy weight could be very tiring and rapidly produce muscle fatigue even though his

arm muscles were not moving.

4e arrived in 0rinidad to ta!e part in a marathon competition, sponsored by 25I2C, and

on his way from Piarco airport was involved in a car accident in which he sustained an

in;ury of his right shoulder with traumatic dislocation of the humeral head, closedfracture of the surgical nec!


48/79

Problem "

Bnhappy 0riad

Er. J., a popular %%-year-old forward of the =ational Soccer 0eam of 0rinidad and

0obago has missed several matches due to a right !nee problem, !nown as a runners

!nee. In the ensuing games he was very successful and contributed many goals towardthe teams victory. t his last game he was tac!led by the defender while running and

dribbling the ball. 0he defenders shoulder hit his left !nee from the side when his foot

was firmly planted on the ground. 4e felt a severe pain and fell. s a result of left !neein;ury he was ta!en by ambulance to the Port of Spain eneral 4ospital where Bnhappy

triad was diagnosed. (ecovery after surgical treatment was prolonged and complicated,

resulting in residual instability of the !nee ;oint, associated with improper loc!ing andunloc!ing mechanisms. 4is teammates wondered if he would ever be able to play with

the team again.

OBJECT!ES9$. Describe the gross anatomy of the !nee ;oint and the muscles acting on it.

%. 6/plain the loc!ing and unloc!ing mechanism of the !nee ;oint.&. Discuss common !nee in;uries.

'. Describe the pathophysiology of chondromalacia patellae


49/79

Problem 8

Defective ene

*ohnny, a )-year-old boy, was brought to the doctor by his mother. She was e/tremely

worried and very concerned about the way *ohnny wal!ed and his generali3ed muscular

wea!ness. She e/plained to the doctor that his condition had been getting progressivelyworse during the past three years.

0he doctor observed an e/aggeration of the lumbar lordosis when *ohnny was standing,and a waddling gait when he wal!ed. lmost all his muscle groups were poorly

developed with e/ception of his calf muscles, which loo!ed e/cessively large. 4e also

observed that *ohnny had a tendency to stand and wal! on the front of his feet with hisheels off the ground. part from muscle hypertrophy of legs, the an!le ;oints and bones

forming them did not have any lesions.

Jurther en8uiries by the doctor revealed that *ohnnys older brother did not have any

health problems, but his cousin had a congenital anomaly !nown as a clubfoot.

0ests of individual *ohnnys muscles and muscle groups demonstrated a consistentpattern of wea!ness. :lood test revealed an increased level


50/79

MDSC ++10 Patholo,& and Mi$robiolo,&@Pharma$olo,&@Publi$ Health and

Primar& Care

Problem 1# Chest Pain

n obese, dyslipidaemic, hypertensive male complained of a si/-month history of avague precordial aching sensation which e/tended into his left shoulder and down the

inside of his left arm. It occurred particularly at times of e/ertion and occasionally at

night. 4owever, he did not see! medical attention until the pain became more severe,

persistent and was accompanied by shortness of breath. Ghen seen in 2asualty, the

patient appeared to be an/ious and restless with cool diaphoretic s!in. 4is pulse was

regular and somewhat thready, at FLminute. 4eart sounds were distant. :P $L$

mm.4g, (esp. rate %'Lmin. Cn e/amination of the chest, inspiratory rales were heard at

the lung bases. n electrocardiogram obtained in casualty showed deep waves with S0

segment elevation. :lood was collected for biochemical investigations. diagnosis of

acute myocardial infarction was made.

OBJECT!ES9

$. Discuss the epidemiological pattern of ischaemic heart disease and its primary,

secondary and tertiary prevention.%. 5ist the differences between angina pectoris and myocardial infarction including

the meaning of the terms stable and unstable angina.

&. Discuss the pathogenesis of acute myocardial infarction including predisposingfactors.

'. Cutline the time dependent gross and microscopic findings seen in acute

myocardial infarction.). 5ist the complications of acute myocardial infarction and e/plain the pathogenesis

of each.

7. Discuss the lipid profile of a patient with heart disease.

+. 5ist the biochemical mar!ers used to diagnose myocardial infarction and e/plainthe time dependent relationship of biochemical mar!ers to myocardial infarction.

. Discuss the management of the patient with an acute myocardial infarction and

e/plain the rationale for all drugs used.F. In a patient who has had a myocardial infarction, describe the use of thrombolytic

and anti-platelet agents.

$. 5ist the drugs used for the treatment of angina and describe their mechanisms of

action and side effects.

*anuary +, % )


51/79

Tutor4s /uidelines5

Students should be able to discuss the use of thrombolytic drugs and anti-platelets

drugs in acute myocardial infarction based on their pharmacological mechanism of

action.

Cb;. & - 0hese predisposing factors should include age, male se/, obesity, smo!ing,

low 4D5 and high 5D5.

*anuary +, % )$


52/79

Problem (# Pneumonia

%+-year-old man presented to the emergency room complaining of fever and cough.

0wo days previously, he noted the onset of wea!ness and malaise, which forced him to go

to bed earlier than usual. 0he ne/t morning he had a sha!ing chill that lasted $) minutes.

Cne hour later his temperature was &F.'T2. Several hours later he noted the onset of right

lower chest pain, which was aggravated by ta!ing a deep breath and by coughing. 0hat

evening his cough became productive of brown-coloured sputum. ll the symptoms had

progressed by the time he arrived at the emergency room.

Physical e/amination revealed an acutely ill young man with :P $%L, pulse rate

$%Lminute, respiratory rate of &%Lminute and temperature of &F.'T2. 4is lips and nail

beds were cyanotic. 0here was increased vocal fremitus, dullness and rales over the right

lateral chest.

ram stain of the sputum showed many polymorphonuclear leu!ocytes and gram-

positive diplococci. 2hest /-ray showed consolidation of right lower lobe. 0wenty-four

hours after the administration of appropriate antimicrobial therapy, the patient became

afebrile. 4e eventually made a complete recovery.

OBJECT!ES9

$. Discuss the etiology and classification of pneumonia.%. Discuss the structures and mechanisms present in the respiratory system that

protect against infection.

&. Ghat populations are at ris! for pneumonia and what preventative measures areavailable#

'. Describe the pathogenesis of pneumonia.

). Describe the gross and microscopic features of the classic stages of evolution oflobar pneumonia, bronchopneumonia and primary atypical pneumonia.

7. Describe the complications of pneumonia.

+. Describe the haematological findings in a case of pneumonia.. Cutline the biochemical test that constitutes blood gases.

F. Describe acid-base balance during hypoventilation and hyperventilation.

$. Discuss respiratory acidosis and al!alosis.

$$. Discuss the role of the plain chest radiograph in the diagnosis of pneumonia andother chest infections.

$%. Describe the ma;or side effects of penicillins and describe the diagnosis and

treatment of hypersensitivity reactions.$&. Discuss microbial resistance to the U-lactam antibiotics.

$'. Identify U-lactamase resistant penicillins


53/79

Problem +# / Case o% Joint Pain

&-year-old female complained of painful wrists and palms for the past & months. She

also admitted to her physician that she was e/periencing stiffness in her hands onmornings, and that her pain was e/acerbated when she sewed. She was an upholsterer and

her ability to do her ;ob was being compromised.

Cn e/amination, the wrists and metacarpophalangeal ;oints of both hands were swollen

and tender. 0here were no deformities, nodules or vasculitic lesions. :lood was ta!en for

measurements of 2:2, 2-reactive protein, rheumatoid factor, =J and dsD=.

She was diagnosed as possible autoimmune disease and was prescribed non-steroidal

anti-inflammatory drugs. 0his medication proved only partially effective and after two

months her !nees and an!les were similarly affected, so she was referred to a

rheumatologist.

OBJECT!ES9

$. 2lassify common ;oint disorders.%. Define autoimmunity and the factors predisposing to the development of

autoimmune disease.

&. Discuss the immunological tests used to diagnose and monitor rheumatoid

arthritis


54/79

Problem .# Prison n%e$tions

77-year-old prisoner was sent to the doctor for persistent cough and difficulty in

breathing. few wee!s earlier he was alarmed when bright red blood came up in one of

his coughing bouts. 4e had been in prison for the past year and lately was not !eeping

well, had lost some weight, suffered spells of diarrhoea for no apparent reason and was

generally wea!.

Cn physical e/amination, his :P was $&L, pulse rate was $$Lminute, respiratory rate

was %7Lminute and his temperature was &V2. Eovement of the chest wall was slightly

reduced on the right side. 4is chest radiograph showed a lesion suggestive of a cavity in

the right infra-clavicular area. 4e had a positive tuberculin s!in test. Serological tests

proved that he was positive for 4IH antibodies.

OBJECT!ES9

$. 2ontrast the morphological features of primary and secondary


55/79

Problem 2# &m'hadeno'ath&

&-year-old female who has not yet started a family, presented to her P complaining

of painless, persistent swellings in the nec!. She did not admit to fever, night sweats or

weight loss and she had no ris! behaviour for 4IH.

Cn e/amination, the only significant finding was bilateral 'cm nodes in the lower

cervical regionM there was no hepatosplenomegaly. 4er :P was $$L+, and her weight

)!g.

Cn investigation her chest /-ray was normal. Eantou/ test, 4IH and HD(5 screens were

negative. 5ymph node biopsy showed nodular sclerosing 4odg!ins disease, and she

subse8uently had a whole body 20 scan that confirmed the presence of cervical

lymphadenopathy only.

She was counselled about her diagnosis


56/79

Problem "# Si$le Cell Disease@Chroni$ 6enal )ailure

PG is a )%-year-old mother of three with sic!le cell disease. She has attended clinic since

childhood. She first became aware of her disorder when she missed sitting her end-of-

year test in standard three. 0he previous wee!end the family had gone to Earacas beach

and after she came out of the water, she felt a bit cold but was having too good a time to

complain.

0he following day she had generali3ed body pains that did not respond to paracetamol

syrup. 0wo days later she developed a cough and fever. 4er ne/t memory of the event

was being in hospital attached to a needle and a bag of fluid. Eany doctors were around

the bed and she remembered hearing the words chest infection.

Since that first admission, she has had numerous hospital admissions for chest problems

and has been on prolonged bed rest for ulcers on the right an!le.

She now has three grown up children, all of whom are well. She was transfused during

her last pregnancy. 4er daughter in the BS is pregnant and would li!e to !now if her

baby will have sic!le cell disease.

(esults of blood tests done at her last clinic visitK

Hb.8: WBC !18< ? !@2l:

7latelets -!1 ? !@2l: urea -1mg2dl: creatinine -8-mg2l: 18!mmol208

Total bilirubin 38@1mg2dl indirect .81-mg2dl direct !81*mg2dl

4er blood pressure was :P $'LF.

She is presently on erythropoietin and folic acid and has been given a chronic renal

failure diet by the dietitian.

OBJECT!ES9

$. rrange the problems encountered by persons with sic!le cell disease on an age

chart from birth to the 7th decade. Include the psychosocial problem that may be

prevalent at each range.%. Discuss the chest infections to which the sic!le cell disease patient is susceptible.

&. Ghat might you e/pect to find in a sic!le cell patient who died of acute chestsyndrome#

'. 2reate a chec!list of the complications of blood transfusion under the following

headings.

- immunologic- microbiological

- immediate

- delayed

*anuary +, % )7


57/79

). 5ist the effects of sic!le cell disease on the spleen along with the immunological

and clinical se8uences.

7. 5ist the common underlying causes of systemic emboli3ation and infarction.+. Describe the patho-physiological se8uence of events that most commonly result in

pulmonary infarction.

. (eview the physiologic functions of the !idney and the role of erythropoietin in

the management of chronic renal failure.

F. 6/plain the types of anaemia e/pected as a result of deficiency of folic acid anderythropoietin.

$. Describe a Nchronic renal failure diet.

$$. Ghat support systems are available to help the chronically ill patient to cope#

Tutor4s guidelines5 +a;e re6erence to the Society o6 (nherited +edical Blood

Disorders8

*anuary +, % )+


58/79

Problem 8# /$ute &m'hoblasti$ euaemia

5*, an -year-old boy, presented with a four-wee! history of fatigue and pallor, a one-

wee! history of bac! pain and a one-day history of a low-grade fever


59/79

$. Ghat are the roles of the primary care physician in prevention and screening for

cancer#

$$. Ghat resources are available to help in the management of patients withleu!aemia#

*anuary +, % )F


60/79

Problem A# /utoimmune Haemol&ti$ /naemia@S&stemi$ u'us Er&thematosus

Eavis is a '-year-old 6ast Indian who at age & noticed sudden onset of tiredness

associated with yellow eyes.

Cn 8uestioning, she gave a history of pains in multiple ;oints and e/treme tiredness. 0he

significant findings on e/amination were icterus, pallor and a palpable spleen 7cm below

the left costal margin.

4er 2:2 showed the followingK

Hb 2#0 ,@d MC! 10(%l WBC " 10@ Platelets 1.2 10@

She was referred from her P to haematology clinic.

blood film showed raised reticulocytes and spherocytes. 4er direct 2oombs test was

positive. Jurther investigations showed her to have a positive =J. Brine showed

moderate proteinuria and hematuria.

OBJECT!ES9

$. 5ist the causes of ;aundice under the headingsK- pre-hepatic

- hepatic

- post-hepatic%. Bse a systems approach to identify the important autoimmune diseases that affect

the various organ systems.

&. 2lassify autoimmune haemolytic anaemias.

'. Cutline the importance of the direct and indirect 2oombs test in the evaluation ofhaemolytic states.

). (eview the causes of macrocytic anaemia and the relevant findings on blood film

e/amination.7. Describe the clinical manifestations of S56.

+. Describe the laboratory diagnosis of S56.

. Describe the morphological changes in the !idney in a patient with S56.

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Problem # ntra$ranial Bleed

)-year-old salesman was admitted to the Priority 2are Jacility. 4e was accompanied

by his wife who said he had complained of a severe headache that developed while

straining at stool about $ hours before. 0his was followed by a sudden loss of

consciousness. She also told the doctor that her husband had suffered with high blood

pressure for the past $% years and had been ta!ing his anti-hypertensive drugs Non and

off. She could not remember the last time he had visited the family physician to chec!

his blood pressure.

Cn e/amination, the patient was drowsy, confused and breathing heavily. 0here was nec!

stiffness. :P W $+L$$ mm 4g, Pulse Lmin. 0emperature was normal and apart from

the elevated blood pressure the 2HS e/am showed an enlarged heart. :ilateral retinal

haemorrhages were seen on ophthalmoscopic e/amination. lumbar puncture was

performed in P2J and the 2SJ showed /anthochromia. 20 scan was then ordered andrevealed subarachnoid haemorrhage in the basal cisterns. ruptured aneurysm was

suspected. 5aboratory investigationsK 4b W $&.)gLdl, G:2 W $ / $FLl, platelets W % /

$FLl, P0 and P00 R normal.

0he patient was admitted to the ward and treatment started with analgesics and anti-

hypertensives including a calcium channel antagonist. referral was sent to the

neurosurgeon but the patients condition 8uic!ly deteriorated and he became comatose

before he could be seen. 4e died shortly afterward. utopsy confirmed a ruptured berry

aneurysm in the 2ircle of Gillis. :leeding from the aneurysm e/tended in the sub;acentcerebral corte/ and brain stem. 0he heart and !idney showed pathological changes

consistent with long-standing hypertension.

OBJECT!ES9

$. Define aneurysm and discuss the morphological classification of aneurysms.

%. Discuss the pathogenesis of berry aneurysms and describe the morphologicalfeatures of berry aneurysms.

&. 5ist the common ages and sites of occurrence of berry aneurysms and discuss

the clinical significance.

'. Discuss the laboratory investigations of a patient with suspected intracranialhaemorrhage and hypertension.

). Describe the morphological features of hypertensive cerebrovascular diseaseincluding intracerebral haemorrhage.

7. Describe the morphological changes in the heart and !idneys in hypertension.

+. Describe the circulation of 2SJ.

. Discuss normal and abnormal constituents of 2SJ and the conditionsassociated with them.

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F. 5ist causes of /anthochromia.

$. 5ist precautions ta!en when doing a lumbar puncture.

$$. Discuss the medico-legal implications of sudden death.

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Problem 10# D&s'ha,ia

Jor the past four years it, a )7-year-old businessman of $)%cm height and weighing

F!g was under self-medication with antacids for water brash and heartburn. year ago

he had been to a P because the symptoms persisted and he was e/periencing

odynophagia on drin!ing grapefruit ;uice. 4e was prescribed Nantac and advised by the

doctor about stress management related to his busy lifestyle.

Presently, he complains of dysphagia and feels food is stic!ing in his chest. 0he P

referred him to a gastroenterologist who advised him to undergo gastroesophagoscopy.

Cn en8uiry he was found to be a smo!er and admits to heavy daily consumption of

alcohol.

2:2 was done and revealed a decreased 4b with a microcytic picture on the blood

film.0he following findings were noted upon endoscopyK

aA :arretts changes in the lower third of the oesophagus with ulceration.

bA =odular growth at the oesophago-gastric ;unction.

biopsy was ta!en from the growth for histological evaluation.

Bpon receipt of the histopathology report, treatment protocol was discussed with the

patient.

OBJECT!ES9

$. Describe the gross and microscopic anatomy of oesophagus and the gastro-

oesophageal ;unction.%. 5ist the causes of heartburn and dysphagia.

&. Discuss the aetio-pathogenesis of gastro oesophageal reflu/ disease and describe

the morphology, complications and management of reflu/ esophagitis.

'. Describe the morphological changes associated with :arretts oesophagus.). Describe the epidemiology, ris! factors, aetio pathogenesis, morphology, spread,

staging and management of oesophageal cancer.

7. 5ist and describe some common tests for gastrointestinal function test e.g.Schilling test, D-/ylose absorption test, :reath test for 4. pylori.

+. 6/plain the significance of stool e/aminations.. Describe the test for faecal occult blood.F. (eview possible causes of microcytic anaemia.

$. Describe the process of smo!ing cessation.

$$. Discuss the primary care approach to the patient with dysphagia.$%. Discuss the drugs used in the treatment of C(D.


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Tutor4s guidelines5 Brie6ly discuss obesity and its relevance to this case8

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Problem 11# /$etamino'hen Toi$it&

(E, a &7-year-old man with a history of alcohol dependence was brought by his brother

to the emergency room. 4e had gone to visit (E and found him drun!. bottle of

acetaminophen


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0utors guidelinesK Students need to !now how to define a unit of alcohol for different

alcoholic drin!s and the upper limit of consumption for men and women.

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Problem 1(# The Cas$adura Hunter

&-year-old man presented to the 2ouva 4ealth 2entre with a four-day history of fever,

yellow eyes, headache, myalgia and nausea. 4e had been swimming in the 2aroni (iver

in an attempt to catch cascadura $% and ) days previously. 4e had always been fit and

well.

Cn e/amination, he was haemodynamically stable, pyre/ial


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Problem 1+# 4lomerular Disease@=rine /nal&sis

F-year-old previously healthy boy presented with puffiness of face and swelling of

e/tremities of four days duration. 4is mother mentioned that he recovered from the

NHirus a few wee!s ago. Cn physical e/amination, he was afebrile. 4eart rate W F%Lmin.,

(( W %%Lmin. and :P W $L7 mm 4g. 4e had &> pitting oedema of feet. bdomen was

soft and normal on palpitation. Brinalysis revealed '> proteins and had no rbcs or pus

cells. :lood results were as followsK Serum albumin - $.gLd5

4e was treated with prednisolone for si/ wee!s and re-evaluation showed proteinuria and

:P was $&LF mm 4g. 4is parents were advised that he should have a renal biopsy.

OBJECT!ES9

$. 5ist the organ systems associated with peripheral oedema.

%. Describe the diagnostic criteria for nephrotic syndrome.&. 2ompare nephritic syndrome with nephrotic syndrome.

'. 5ist the causes of nephrotic syndrome.

). Describe the aetio-pathogenesis and pathology of nephrotic syndrome inchildhood.

7. Cutline the indications and contraindications for renal biopsy.

+. Discuss the complications of nephrotic syndrome.. Describe the management and prognosis of this patient.

F. 6/plain the procedure for doing a %'-hour urine collection and list the error

sources.

$. 6/plain urine analysis under the following headingsK urine microscopy, dipstic!

analysis.$$. 6/plain the sources of interference when doing a dipstic! analysis.

Tutor4s guidelines5

Diagnostic criteria include urine, blood and clinical findings.

=ephrotic Syndrome R to describe morphology of !idney in each of the common

causes listed above


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Problem 1.# =rinar& Tra$t n%e$tion3 Thrombo$&to'enia3 Prostate Can$er

is a )F-year-old company director, who presented to his P with a three-day history

of painful urination and a one-day history of rigors and fever. digital rectal e/amination

revealed an enlarged nodular prostate. 4e had been ta!ing ranitidine for heartburn.

0he P made a diagnosis of acute urinary tract infection and prostatic enlargement for

further evaluation and prescribed cotrimo/a3ole empirically. Ghen he returned one wee!

later for review, he noticed bruising on the arms, legs and inside the mouth. :lood was

ta!en for relevant investigations. 0he results wereK

Hb 12,@dl3 WBC "#2 10@l3 'latelets + 10@l#

4e was admitted to hospital and the haematologist, who was called, ordered the

following investigationsK =J, PS, bone marrow aspirate.

0he =J was normal, the PS was elevated and the marrow showed plentiful

mega!aryocytes with normal erythropoiesis and myelopoiesis.

diagnosis of drug-induced, immune mediated peripheral destruction of platelets was

made. 0his was thought to be due to cotrimo/a3ole. 0he patient was treated with

intravenous immunoglobulin and steroids. Cne wee! later his results wereK

Hb 1.#2,@dl3 WBC 1"#" 10@l3 'latelets ++1 10@l

Steroids were tailed off. 4e had a needle biopsy of the prostate two wee!s later and wasdiagnosed as having prostatic adenocarcinoma, leason score 7.

OBJECT!ES9

$. (eview the structure of the normal bone marrow.

%. Identify the causes of low platelets under the headingsK

- Production failure- Increased consumptionLutili3ation

- Peripheral destruction.

&. (eview the mechanisms of immune mediated hypersensitivity disorders


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F. Discuss the ris! factors and epidemiology of cancer of the prostate.

$. Discuss the role of the PS in the diagnosis and treatment of prostate cancer.

$$. Describe the morphology and grading of carcinoma of the prostate.$%. Discuss the staging of prostate cancer.

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Problem 12# Ovarian Mass

&'-year-old female, who was seen by her physician for unrelated complaints, was

found on routine pelvic e/amination to have a palpable left ovarian mass. Past medical

history and family history were unremar!able e/cept that her mother had died of breast

cancer. 0he remainder of the physical e/amination was unremar!able, as was the routine

haematological wor!-up. 0umour mar!ers including 42, and a-fetoprotein were

negative but cancer antigen $%)


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Problem 1"# Breast um'

)-year-old accounts cler! visited her family physician after feeling a small, irregular,

painless lump in her right breast. She had been on hormone replacement therapy for two

years. Cn 8uestioning she revealed that her mother had died of breast cancer at age 7

and that she was worried about her increased ris!. She had never had a mammogram. Cn

e/amination, the doctor found a firm to hard, irregular, mobile mass in the lower outer

8uadrant of the breast. 4e referred her to a general surgeon who performed a fine needle

aspirate of the lump in his office and told her to return in two days for the result. Ghen

she returned, the surgeon reported that the pathologists report described the presence of

malignant cells in the aspirate. n open biopsy of the lump was scheduled a wee! later.

diagnosis of infiltrating duct carcinoma-rade $ was made on histology. 0he tumour

was %.cm in diameter. Joci of duct carcinoma in-situ were seen ad;acent to the invasive

tumour. In addition, there was fibrocystic change and sclerosing adenosis with ductepithelosis in the surrounding breast. 0he tumour was estrogen receptor positive and

46(-% negative. fter e/tensive discussion with the breast surgeon, a modified radical

mastectomy with a/illary node clearance was performed. =o residual tumour was found

in the breast and $% a/illary lymph nodes were negative for metastatic disease.

0he patient was treated with 0amo/ifen postoperatively and $ months later is currently

free of disease.

OBJECT!ES9

$. Discuss the factors that increase a womans ris! of developing breast cancer.

%. Discuss the current recommendations for the screening of breast cancer.&. Describe the gross and microscopic features of benign breast diseases including

proliferative and non-proliferative fibrocystic change.

'. 6/plain the relationship between the different !inds of benign breast disease and

the subse8uent ris! of developing carcinoma.). 6/plain what is meant by carcinoma in-situ and describe the recognised types that

occur in the breast.

7. Describe the morphology of infiltrating lobular carcinoma and the four commonsubtypes of infiltrating duct carcinoma.

+. 6/plain how primary tumour si3e, lymph node status, oestrogen and progesteronereceptor status, 46(-% receptor status and histological grade help predict survival


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$$. 5ist drugs used in the treatment of breast cancer relating to cytoto/ic

chemotherapy and hormone receptor positive drugs.

$%. 6/plain the different mechanisms of action of the hormonal therapies oftamo/ifen and anastro3ole.

$&. Discuss the role of 4erceptin


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Problem 18# Cervi$al Tumour

Es. H. 6. a '&-year-old, visited her local health centre where the nurse as!ed her whethershe had ever had a Pap smear. She replied that she had never had one and after a brief

e/planation by the nurse, she agreed to have one done that day, mainly because she had

recently noted a bloodstained vaginal discharge. Cn further en8uiry, she had four childrenby three different partners and all pregnancies had been uncomplicated.

0he nurse too! the Pap smear in the clinic and told her to return in three wee!s for theresult.

6/foliated cervical cells were also sent for assessment of 4PH status. Cn her return, Es.

H.6. was advised by the medical officer that her Pap smear report showed abnormal cells.She was then given a referral letter to the ynaecology Cut-patients 2linic at the Et.

4ope Gomens 4ospital for further investigation. Some wee!s later, a colposcopic loop

biopsy of her cervi/ was ta!en and sent to the histopathology laboratory.

0he histology report showed invasive s8uamous carcinoma of the cervi/, which e/tendedto the margin of the biopsy specimen. radical hysterectomy was later performed and

her tumour was staged II:.

$. Discuss the epidemiology of and ris! factors for cancer of the cervi/.%. Discuss the pathogenesis of cervical cancer as it relates to !nown ris! factors.

&. Discuss the role of the immune system in protection against oncogenic viruses

such as 4PH.

'. Cutline the principle of one method of detecting viral nuclei acids in cervicalcells.

). Describe the pre-cancerous s8uamous lesions of the cervi/ using the standard

classifications of these lesions.7. Discuss efficacy of the Pap smear as a screening test for cervical pre-cancer and

outline the re8uirements for ta!ing a satisfactory smear.

+. Cutline the reporting systems used for cervical smears.. (eview the criteria for appraisal of a screening program.

F. Describe the gross and microscopic features of the common forms of invasive

cervical cancer.$. Describe the staging of cervical cancer.

$$. Discuss the basic principles of chemotherapy in cancer treatment.

$%. Discuss the most appropriate antineoplastic agents for the management of this

cervical cancer patient.$&. Discuss the role of combined chemotherapy.

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Tutor4s guidelines5 Students should summarise criteria 6or a77raising 7racticability:

e66icacy and a77ro7riateness o6 screening 7rograms using Wilson4s criteria8Problem

1A# Diabetes mellitus 1F

'-year-old diabetic woman is hospitalised because of an ear infection. 0hree months

previously she noticed the onset of redness, swelling, and drainage from her left ear. Shehad been treated by her family physician with medication, which failed to halt the

progress of her condition. In the wee! prior to admission there had been increasing pain

and swelling and daily fever.

Cn e/amination, she appeared acutely ill with a temperature of &.FT2. 0here was a

considerable amount of drainage from the ear and granulation tissue was observed on the

floor of the e/ternal auditory canal. ram-negative rods and a few gram-positive cocci in

clumps were noted on ram stained smear of the drainage fluid.

4er :P was F)L7 mm 4g, pulse $$%Lmin. She had cold e/tremities, deep sighing

respiration


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$. Discuss the various classes of drugs used in the treatment of 0ype II diabetes

mellitus.

$$. Ghat are the indications for the use of insulin in diabetes mellitus#

Tutor4s /uidelines5

Diabetes $ and % should be covered in two wee!s.

=oteK Diabetic !etosis presents more often in insulin dependants.

*anuary +, % +7


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Problem 1# Diabetes (F

In spite of oral and topical antibiotics the '-year-old diabetic woman continued to have

high temperatures


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Problem (0# 4oitre

DD, a 'F-year old woman presented to clinic with a year long history of feeling

increasingly hot, with diarrhoea, and an increased appetite, but with weight loss of over

%)lbs


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'. 2ompare and contrast the pathogenic mechanisms and clinical features of raves

disease, 4ashimotos thyroiditis, and primary my/odema.

). 6/plain the difference between hyperthyoidism and 0&-to/icosis.7. Discuss thyroid function tests.

+. Describe the morphological changes in the thyroid gland in raves disease.

. Cutline the changes present in tissues such as heart, s!eletal muscle and s!in inraves disease.

F. Discuss the synthesis of thyroid hormones and the sites of action of antithyroid

drugs.$. 5ist the drugs used in the treatment of hyperthyroidism and indicate their sites of

actionM list their associated to/icities.

$$. 6/plain the role of beta bloc!ers in raves Disease.

Tutor4s guidelines5 $m7hasie negative 6eedbac; mechanisms8

Documents

MBBS PBL Problems Yr 1-4