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End of Year Examination 2009 SACS

CASE 1 : Life on the Street Block ( 26 marks) The Mazibuko family lives in Katlehong on the East Rand (Ekurhuleni). Granny Agnes Mazibuko has two daughters, Fikile and Sonia. Sonia is 44 years old and lives with her boyfriend a short distance away Fikile is 27 years and has two children: a 5 year-old son Andile and baby Lerato who is 13 months old. Leratos father is Fikiles husband, Andries, who also lives with them. He is employed as an electricians assistant. Fikile brings Lerato to the local clinic with a history of a fever and frequent watery stools for the past three days. The nurse asks Fikile for Leratos Road-to-Health card, and this is what she sees: (Insert RtH card image here)

The nurse also measures Leratos length which is 71 cm (88% of median length-forage; < -2SD length-for-age). She plots this on the weight-for-length chart and finds that Leratos length is 75% of median (< -2SD weight-for-length). Lerato is apathetic and irritable. She has a temperature of 38.90C, a heart rate of 140/min, reduced skin turgor and dry oral mucosa. The nurse offers Lerato some oral rehydration solution, which she eagerly drinks. The nurse then refers Lerato to the district hospital for further management. 1a. Explain what the 3rd and 50th centiles on the Road-to-Health card represent. (2 marks) These are weight for age centiles. Expect 50% of normal children to be above or below the 50th centile at any age. 3% of normal children would be considered underweight (unless the child has followed this centile vfrom birth) b. Leratos Road-to-Health card is a valuable document. Give two reasons why the card and the observations on it are of value to Fikile (Leratos mother) and to the health professionals involved in caring for Lerato. (2 marks) Fikile has a permanent record of the childs birth history, growth, immunization development etc. Childs progress is plotted and mother can respond accordingly. Helpful for applying for grants etc. Health professional uses growth chart as a diagnostic tool. Useful for sharing information and promotes interaction. Can be used in community studies.

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MCQs 1 to 4 below consist of statements regarding the consultation between the doctor and Lerato (and her mother Fikile of course!). Each of these statements can be related one of the concepts numbered A to H below. A. B. C. D. E. F. G. H. Biomedical approach Biopsychosocial approach Facilitation Clinical reasoning Collaboration Hypothesis formulation Hypothesis testing Preventive care

For each statement in MCQ 1 to 4 below select the term from the list A to H above which most accurately refers to the process described in the statement. These are Rtype MCQs with no negative marking. Each counts 1 mark. MCQ 1 MCQ 2 mark)A MCQ 3 MCQ 4 mark) G Using the information gained during history taking and examination to make an assessment of Lerato. D or F (1 mark) Seeking only a pathophysiological explanation for Leratos condition. (1 Developing a management plan that involves Lerato and with which Fikile is comfortable. E (1 mark) Ordering selected special investigations to confirm your assessment. (1

At the regional hospital Lerato is treated for her dehydration and started on a treatment for malnutrition. When she is examined thoroughly she is also found to have a generalized non-tender lymphadenophathy and hepatosplenomegaly (liver enlarged to 3 cm below the costal; margin, spleen 1 cm enlarged). The doctor attending to Lerato does a battery of tests including an HIV test. During the pre-test counseling Fikile mentions that she had refused an HIV test in pregnancy because she was afraid. However, she agrees to a test for Lerato and receives pre-test counseling. Lerato has an HIV ELISA test that is positive. Fikile is given this result with posttest counseling and at this stage requests that she be tested too. 2a. Why was an HIV test ordered for Lerato? (1 mark)

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Due to chronic ill health and signs (generalised LAD and HSM) and suggestive of chronic infection such as HIV, it must be excluded b. Leratos HIV ELISA result is positive. What does this result tell us about Leratos HIV status? (1 mark) ELISA has detected HIV antibodies. Does not distinguish between maternal and childs antibodies ie is not diagnostic of HIV infection in Lerato, despite suggestive history and signs. ELISA at this point suggests that Lerato is HIV exposed c. Why should an HIV test be ordered for Fikile? (1 mark) Leratos positive HIV ELISA suggests that Fikile is HIV +ve because most children in SA are infected vertically. Fikile needs her own HIV test to confirm this. On further testing using an HIV PCR, Lerato is found to be HIV negative. The doctor looking after Lerato explains this result and what it means to Fikile. Fikile asks, What is making my child sick then? d. Give two possible other causes for Leratos present condition that he could mention to Fikile. (1 mark) Most likely are TB or a malignancy such as leukaemia or lymphoma When the time comes to get her result, Fikile is told that she is HIV positive. She is given appropriate post-test counseling, and at this time tells the doctor that swallowing has been painful and difficult for her, for the last four weeks. On oral examination extensive white plaques with erythematous margins are noted on Fikiles hard palate, extending into the oropharynx. e. What is the most likely cause of Fikiles dysphagia (pain and difficulty in swallowing)? (1 mark) Typical of oral candidiasis with likely oesophageal extension Fikile is started on antiretroviral therapy. She has decided to keep her HIV status a secret from all including her husband and not to inform him of her treatment either. Fikile struggles to come to terms with her HIV diagnosis and often feels tired of taking her medication. On her first visit to the doctor since starting treatment (i.e. 6 months from the start of treatment) she is found to have a viral load >100,000. f. Why is Fikiles viral load so high? Give two possible reasons. (1 mark)

Probably a reflection of poor adherence to her medication that is likely from non disclosure, poor acceptance of her HIV status, associated depression and frustration. Could also be resistant to one or more of the ARVs g. You are Fikiles doctor. You decide to confirm her high viral load with a repeat test.

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Which one of the following would be the most appropriate further actions for you to take? Write an X in the block next to the answer you choose. (1 mark) a. Counsel Fikile about adherence and change her treatment to the 2nd line regimen. b. Counsel Fikile about adherence and stop all three drugs simultaneously until she has disclosed to her boyfriend. c. Counsel Fikile about adherence, continue the current regimen and plan to retest in one month. d. Stop the antiretroviral drugs in sequence, starting with those with the longest half life first. e. Suspend the antiretroviral treatment until Fikile has disclosed to someone who will offer her support. f. Take blood for resistance testing before deciding whether to change to the 2nd line regimen, whilst stepping up on adherence counseling.

The prevalence of HIV has had a major impact on population statistics in South Africa. Any population may be represented using population pyramids. The two population pyramids below represent the same population but 15 years apart.

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MidYearDejurePopulation,2007
110114 100104 9094 8084 7074 6064 5054 4044 3034 2024 1014 0 4 6000 4000 2000 0 2000 4000 6000 Male Female

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3a.

What does a population pyramid describe? (1 mark) A population pyramid is a graphical illustration that shows the distribution of various age groups in a population which normally forms the shape of a pyramid. b. What is the key difference between these two pyramids? The older population group is widening/increasing. The younger population groups are narrowing/decreasing. c. Provide two reasons that could account for this difference. Mortality declining Fertility declining. (2 marks)

(2 marks)

Fikiles son Andile is playing with his friends on a piece of open ground near their house. They disturb a stray dog which has been sleeping under a bush. The dog jumps up, barking furiously. Andile tries to calm the dog but gets bitten on his hand instead. He runs home to his Granny, crying with pain, and shows her the wound on his hand. There is a 4 cm gash on the medial side of the palm and it is bleeding. Granny decided to take Andile to hospital immediately. 4a. List the 4 commonest microorganisms (or categories of microorganisms) that you consider to be important causes of dog-bite infections. (2 marks) Gram +ve: Staphylococci, Strepococci, Corynebacteria, anaerobes Gram-ve anaerobes: Bacteroides, Fusobacterium Pasteurella: multocida, septic, canis Capnocytophaga: canimorsus, cynodegmi Rabies b. At the hospital the doctor decides to proceed with wound toilet (i.e. cleaning, irrigation, and debridement of Andiles bite wound). (1 marks) (i) Which type of hand washing technique should he practice while conducting this procedure? Standrad precautions : gloves should be worn when touching any of the fllowing: blood, body fluids, secretions, mucous membranes etc, Hands should be washed immediately after gloves are removed and between patient contact. Hand hygiene: hand washing with alcohol-based hand rubs (ii) Which other infection control precautions should he take?

Gloves to prevent contamination of hands with microorganisms but not to replace the need for hand hygiene. Mask gown

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c. The doctor asks Granny and Andile where the dog bite took place, and whether they know the dog, and whether the dog was behaving strangely. Why is it important to get information about travel (geography) and unusual exposure when taking a history from a patient? ( mark) This is very important and need to have in mind the geographical distribution of microorganisms, specially rabies. Granny Agnes Mazibuko celebrated her 60th birthday last week and wanted to invite her friends to tea to celebrate with her, but did not have the money for this. She has only a few odd ironing jobs to help feed the family. She also has to look after the children as Fikile has not been well and Andries is usually out with his friends at night. Granny Agnes has been on antihypertensive medication for 16 years but she has not been to the clinic for the past two months and now she complains of a persistent headache. She is really worried about Fikile who is losing weight and Lerato who is always miserable. Andile has been behaving badly and now she worries that Andries may be spending too much money on drink and not enough on food for the family. 5. Prepare a bio-psycho-social assessment of Granny Agnes at this time. marks) Biological Assessment ( 3

Psychological Assessment

Social assessment

Sonia Mazibuko is Granny Agness older daughter aged 44. She visits the clinic and tells you (the doctor) that she was raped three days previously by her boyfriend. Sonia has not menstruated in 3 months and reports some symptoms of hot flushes. 6. Would you provide Sonia with medical management for the prevention of pregnancy? Explain your answer. (2 marks)

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Yes, you would provide X with medical management for the prevention of pregnancy? Emergency contraception is recommended for all women of reproductive age who are at risk of a pregnancy. X has come in within 5 days of the rape and is eligible to receiving emergency contraception. Although it may be suspected that she is perimenopausal, this is not confirmed. X may be pregnant or may still be at risk of falling pregnant. She should therefore receive counseling, have a pregnancy test conducted and receive appropriate management thereafter. CASE 3: CARDIOVASCULAR BLOCK ( 45 marks) Mr. Steven Carrington, a 52 year-old salesman in a hardware store, was held up in traffic and late for a meeting with the sales manager when he developed central crushing chest pain which radiated down the left arm and to the left side of his neck and jaw. The time was 08:00. For a few months now he had experienced a similar pain, but not as intense, each time he played tennis but the pain had stopped soon after he stopped playing. He had attributed the pain to his lack of fitness. When he reached his work, he decided to go ahead with his meeting, hoping that the pain would subside but at mid-morning he phoned his doctor. His doctor knew that Mr. Carrington had a number of risk factors that predisposed him to the development of a cardiovascular event, so he arranged for an ambulance to take him to hospital. On admission, his vital signs were: Blood pressure: 182/102 mm Hg Heart rate: 112 beats/minute (irregular) Respiratory: 22 breaths/minute. He had no other significant clinical signs. A 12 lead electrocardiograph recording conducted at the hospital revealed the presence of a large acute anterolateral wall myocardial infarction involving the base of the heart as well as the presence of frequent ventricular extrasystolic beats originating from the lateral wall of the ventricle. Blood tests performed at 13:00 confirmed an acute myocardial infarction. Mr. Carrington was immediately given aspirin, heparin, sub-lingual glyceryl trinitrate and morphine. Later he also received bisoprolol. As he could not afford the costs of invasive procedures, reperfusion with thrombolytic agents was attempted. An echocardiograph performed on the first day of his hospital stay revealed a normal ejection fraction. 1a. Give an anatomical explanation for the pain Mr. Carrington experienced in the arm and neck. (3 marks)

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It is due to cardiac referred pain. The axons of the visceral primary neurons from the myocardial region enter spinal cord segments T1 T4 and are perceived as pain from a superficial part of the body (shoulder, arm, neck) 1b. Which coronary artery is most likely to have been damaged? Explain your choice. (2 marks)

Left anterior interventricular (descending) branch of the left coronary artery and left marginal artery, a branch of the left coronary Answer MCQ 5 to 9 below in Questionmark online. (These 5 MCQs are all X type and each one counts 2 marks. The usual negative marking for X-types applies) MCQ5. Mr. Carringtons electrocardiogram recording is likely to show ST segment: (2 marks) a) elevation in lead V1. b) elevation in lead aVL. c) elevation in lead V3. d) depression in lead I. e) depression in lead aVF. MCQ 6. With respect to Mr. Carringtons arrhythmia, his electrocardiogram recording is likely to show: (2 marks) a) b) c) d) e) abnormal QRS complexes with every beat. abnormal P waves. slowly conducting ventricular electrical events. wide QRS complexes. QRS complexes with an abnormal electrical axis. (2 marks)

MCQ 7. Mr. Carringtons heart rate is likely to be attributed to: a) b) c) d) e) activation of cardiac -adrenoreceptors. the presence of frequent ventricular extra systolic beats. a decreased aortic or carotid baroreceptor firing. an increased atrio-ventricular nodal conduction. cardiogenic shock.

MCQ 8. Mr. Carringtons raised jugular venous pressure noted on the third day of his hospital visit is likely to be caused by: (2 marks) a) pulmonary hypertension.

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b) c) d) e)

an increased right ventricular wall stress. a reduced right atrial pressure. infarction of the right ventricular free wall. high output heart failure. (2 marks)

MCQ 9. Mr. Carringtons left ventricular ejection fraction is likely to: a) b) c) d) e)

be caused by an increased left ventricular wall stress. be caused by a reduced left ventricular contractility. increase in response to the acute effects of bisoprolol. decrease in response to diuretic agents. increase in response to the long-term benefits of angiotensin-converting enzyme inhibition. Explain why: a. Aspirin and not paracetamol was given (2 Marks) Aspirin is an irrevesrsible inhibitor of COX1 and only needs a low dose to exert its effect. Paracetamol has no antiplatelet action and has no benefit in this situation b. Morphine and not pethidine was given (2 Marks) Pethidine has a vagolitic action (decreases AcH activity in SA node) and would increase heart rate. Morphine has no negative inotropic action on the heart and causes a modest drop in TPR and BP c. Sublingual as opposed to oral glyceryl trinitrate was given (2 Marks) Glyceryl trinitrate is poorly absorbed after oral administration and has to be given sublingually in order to bypass first pass metabolism and inactivation in the liver.

2.

3a.
a. b. c. d. e. f.

Name 5 important cardiac complications that occur within the first two weeks of Acute myocardial infarction excluding any form of arrhythmia 5 marks)
Inlargeinfarctscardiogenicshockacutecardiacfailure Fibrinouspericarditisusuallylocalisedovertheareaofinfarction Intraventricularmuralthrombus Muralthrombusinleftatrialappendage Ruptureofpapillarymusclesuddenmitralvalveincompetencecardiacfailure Myocardialrupturefatalhaemopericardium

3b.

In this setting of acute myocardial infarction, which one complication could result in painless haematuria within the first 2 weeks following the initial infarction. Give the process by which this episode of haematuria occurs.

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Mural thrombus in ventricle and /or atrium By process of thrombo-embolisation 3c. By what process does healing take place in the area of infarction and name the two important cell types that constitute this reparative process. (1 marks)
i. Granulationtissue ii. Myofibroblastsandendothelialcells

3d.

Name 2 important intra-cardiac complications that can follow some months after the infarct has healed. (2 marks)
a. Congestivecardiacfailuredependentonthesizeoftheinfarct b. Ischaemicmitralincompetence Ventricularaneurysmformation

Mr Carringtons atherosclerotic cardiovascular disease is a complex problem involving lipid deposition, pressure, flow forces, carbohydrate tolerance and thrombogenesis. Risk factors for cardiovascular diseases have been identified through epidemiological research. These have been classified into 4 major contributor groups with examples of risk factors in each of these 4 major groups. 4a. Name the 4 major contributor (risk factor) groups
MajorModifiableRiskFactors OtherModifiableRiskFactors NonModifiableRiskFactors NovelRiskFactors

(2 marks)

4b.

Provide any 8 examples of risk factors that could be present in Mr Carrington (4 marks) (Studentcanlistanyeightexamplesfromthelistbelow)
MajorModifiableRiskFactors 1) HighBloodPressure 2) AbnormalBloodLipids 3) Tobaccouse 4) Physicalinactivity 5) Obesity 6) Unhealthydiet 7) Diabetesmellitus

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OtherModifiableRiskFactors 1) LowSocioeconomicstatus 2) Mentalillhealth(depression) 3) Psychosocialstress 4) Heavyalcoholuse 5) Useofcertainmedication 6) Lipoproteins NonModifiableRiskFactors 1) Age 2) HereditaryorFamilyHistory 3) Gender 4) Ethnicity

When Mr Carrington arrived in hospital he was anxious and kept asking the intern about whether he was going to die soon and who would look after his family. The intern reassured him that everything would be fine. That night the intern starts to worry about the accuracy of what he had told Mr Carrington and decides to do an evidence-based search to find out what the prognosis is for Mr Carrington. He find the following study:

Important factors for the 10-year mortality rate in patients with acute chest pain or other symptoms consistent with acute myocardial infarction. Herlitz J, Karlson BW, Lindqvist J, Sjolin M. Division of Cardiology, Sahlgrenska University Hospital, Goteborg, Sweden. OBJECTIVE: Our purpose was to describe the mortality rate and mode of death over 10 years and factors associated with death among patients admitted to the emergency department with acute chest pain or other symptoms consistent with acute myocardial infarction (AMI). METHODS: All patients who came to the emergency department at Sahlgrenska University Hospital in Goteborg, Sweden, with acute chest pain or other symptoms consistent with AMI during a 21-month period were studied. All patients, with the exception of the 8 who died in the emergency department, are included in the analyses. On the basis of history, clinical examination, and an electrocardiogram (ECG) recorded on admission, all patients were classified by the physician on duty in the emergency department into one of the following four categories (1) Obvious myocardial infarction; (2) Strongly suspected myocardial infarction; (3) Vague suspicion of myocardial infarction; (4) No suspected myocardial infarction. The mode of death was judged from medical records, autopsy reports, and death certificates.

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RESULTS: In all, 5362 patients were registered, for whom information on 10-year mortality was available in 5158 (96.2%). Overall, there were 2126 deaths (41.2%). Patients with a final diagnosis of confirmed AMI had a 10-year mortality rate of 66.5% compared with 36.6% for patients with no confirmed AMI (P < .0001). Fifty-two percent of patients were 65 years old. An independent predictor of death registered on admission to hospital during the subsequent 10 years was male sex (relative risk 1.38, 95% confidence interval 1.25-1.52). Other independent predictors were age >65 years, a pathologic initial ECG, symptoms of congestive heart failure, a history of previous myocardial infarction, hypertension, diabetes and current smoking. In multivariate analysis a history of smoking was a strong independent predictor of death. Development of AMI during the first 3 days after hospital admission was an independent predictor of death (relative risk 1.63, 95% CI 1.43-1.86). CONCLUSION: For patients admitted to the emergency department with acute chest pain or other symptoms consistent with AMI, several predictors based on clinical history and clinical presentation are related to the 10-year prognosis. However, whether the patients have an AMI during the subsequent days will independently influence the longterm prognosis from observations on admission.

Answer MCQs 10 to 17 below in Questionmark online. (These 8 MCQs are all A type and each one counts 1 mark. There is no negative marking.) MCQ 10. What type of study design was used? a) Case review b) Case-Control c) Cohort d) Cross-sectional study e) Randomised controlled trial (1 mark)

MCQ 11. How similar (homogenous) were patients with respect to prognostic risk at the start of this study? (1 mark) a) Very similar as all had acute chest pain b) Mostly similar as most had acute chest pain c) Somewhat similar as they all had chest symptoms d) Non-homogenous (dissimilar) because even patients with vague symptoms resembling myocardial infarction were included MCQ 12. Was follow-up sufficiently complete? a) b) c) d) (1 mark)

Yes, a 96.2% follow up rate after 10 years is excellent Yes, a 96.2% follow up rate after 10 years is satisfactory No, overall there were 2126 deaths (41.2%) No, patients with a confirmed AMI had a 10-year mortality rate of 66.5%

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e) No, patients with no confirmed AMI had a 10-year mortality rate of 36.6% MCQ 13. What was the main outcome measure used in this study? a) Acute myocardial infection (AMI) b) Symptoms consistent with AMI c) Both AMI and symptoms consistent with AMI d) An electrocardiogram (ECG) e) Death (1 mark)

MCQ 14 Development of AMI during the first 3 days after hospital admission was an independent predictor of death (relative risk 1.63, 95% CI 1.43-1.86). The relative risk of 1.63 in the above statement means: (1 mark) a) Patients with symptoms of AMI were 1.63 times more likely to develop AMI within 3 days b) Patients with AMI were 1.63 times more likely to die within 3 days c) Patients with AMI were 1.63 times more likely to die within 10 years d) Patients with acute chest pain or other symptoms consistent with AMI were 1.63 times more likely to die within 3 days e) Patients with acute chest pain or other symptoms consistent with AMI who developed definite AMI within 3 days were 1.63 times more likely to die in the next 10 years MCQ 15. Based on the abstract, which one of the following individuals presenting to an emergency department in Sweden with acute chest pain or other symptoms consistent with AMI is most likely die in the next ten years: (1 mark) a) A 34 year old female non-smoker b) A 34 year old female diabetic c) A 54 year old male hypertensive d) A 68 year old male smoker e) A 72 year old female non-smoker MCQ 16. An independent predictor of death registered on admission to hospital during the subsequent 10 years was male sex (relative risk 1.38, 95% confidence interval 1.25-1.52) Statistically, was male sex a significant independent predictor of death?(1 mark) a) Yes, since the relative risk was 1.38 b) Yes, since the 95% confidence interval exceeded 1 c) No, since the relative risk was 1.38 d) No, since the 95% confidence interval was less than 2 e) Significance cannot be determined from the data provided

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MCQ 17.

Are the results likely to be generalisable to Mr Carrington? (1 mark) a) Yes, he is a Swedish male with acute chest pain b) Yes, he is a white male with acute chest pain c) No, he is a male with acute chest pain d) No, he is not Swedish e) No, his acute chest pain is atypical

MEQ 3

Mr Henry Johnson is a 57-year old who has smoked 30 cigarettes a day for over 30 years. He was brought to the local clinic in Kuruman in the Northern Cape by his daughter. She was coming anyway with her two young children and her pregnant sister in law. He has been increasingly short of breath and has had chest pain and tiredness for a while. He coughs a lot, but has always coughed in the morning on waking. He describes coughing until he is blue in the face. He cannot walk far before becoming short of breath. 1. Describe the stimulus and subsequent mechanism for coughing. (2 marks)

2.a List six health services the family could expect to find at the local clinic.(3 marks) b. Name four advantages of attending the local clinic rather than going to the district hospital. (2 marks) Mr Williams is referred to the district hospital for investigations to provide a proper diagnosis. Lab investigations showed: Ref range Haemoglobin concentration: 18.8 14.3-18.3 g.dl-1 PaO2 6.9 9.0-11.1 kPa PaCO2 5.6 3.9-4.9 kPa pH 7.34 7.37-7.43 3. Explain the haemoglobin concentration. (1 mark)

4 a. List the components of the blood gas barrier (in the correct order) from the alveolar lumen to the vascular lumen in sequence. (2 marks) b. List the three components of the respiratory portion of the respiratory tract. (1 marks) 5 a. Based on the results above, explain whether Mr Williams has a ventilation or diffusion defect or both producing his hypoxia. (3 marks)

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b. How would the results listed above explain the tiredness and shortness of breath experienced by Mr Williams? (1 mark)

The results of Mr Williams lung function tests are as follows: ( ) ( ) ( ) ( ) ( ) Measured 3.2 1.6 5.7 3.7 2.5 Predicted 4.4 3.5 5.5 2.8 1.1 Give reasons for your (3 mark) b. Explain the: i. TLC ii. RV 7a. Explain how smoking causes the lung disease of Mr Williams. (2 marks) (2 marks) (2 marks)

FVC FEV1 TLC FRC RV

6a. Does Mr Williams have obstructive lung disease? answer.

b. List four other diseases which are caused or significantly exacerbated by smoking. (2 marks) On radiograph of the chest granulomas were observed in the lung parenchyma. A lung biopsy was performed and the pathologists report came back as: the histological features in the biopsy were consistent with a diagnosis of tuberculous infection. 8 a. Define granuloma. ( mark)

b. What two histological features in the biopsy would have been noted in the section examined by the pathologist which would have allowed him to make the diagnosis of tuberculous infection. (1 mark) c. Apart from TB there are occupational infectious causes of granuloma in the lungs. Name two such conditions produced by the thermophilic bacteria. (1 mark)

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d. Name one important non-infectious granulomatous disease which affects the lungs. ( mark) After the diagnosis of TB is confirmed Mr Williams is placed on the standard new patient regimen of rifampicin, isoniazid, ethambutol and pyrazinamide. 9a. Complete the table below regarding this treatment: Drug Rifampicin Mechanism of action (3 marks) Side effects (other than GIT effects) a. b Pyrazinamide a. b.

b. List four drugs which will be used if Mr Williams develops multi-drug resistant (MDR) TB. (2 marks) 10. List three issues in his community / social management that you, as the doctor, must attend to for both diseases affecting Mr Williams, (3 marks) Total 38 marks CASE 4A : RENAL BLOCK (6 marks) A 53 year old male who lives alone, was found seriously ill in bed on a hot summers day by a concerned neighbour. He was admitted with a diagnosis of a stroke. Clinically, in addition to the neurological features of a stroke, he was found to be dehydrated and oliguric. LABORATORY RESULTS Results Serum Sodium 147 Potassium 3.5 Chloride 110 Total Carbon dioxide 22 Urea 26

Units mmol/L mmol/L mmol/L mmol/L mmol/L

Reference Range 135 -145 3.3 - 4.8 98 -108 23 - 33 2.6 - 8.0

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Creatinine Osmolality(measured) Urine Na Creatinine Osmolality

200 330 < 10 7.7 529

mol/L mmol/kg mmol/L mmol/L mmol/Kg

80 - 115 275 - 295

1a.

What are the possible mechanisms for this patients hydration status? (1 mark)

Dehydration from inadequate fluid intake and other losses eg sweating. Intake not balanced with output.

1b.

Using the above biochemical findings and/or relevant indices, determine the patients renal status. If impaired, is it pre-renal failure or acute kidney failure? Show your workings. (4 marks)
(4 marks) prerenal uraemia spot urine Na <10 mmol/L FENa <1% U:P osmolality > 1.3 U:P urea > 14 U:P creatinine > 14 Plasma urea: creat > 70 acute kidney failure > 20 mmol/L >1 < 1.3 < 14 < 14

1c.

Why is it important to differentiate between pre-renal failure and (intrinsic) renal failure? (1 mark)

Management is different prerenal uraemia replace fluids AKF manage the kidney failure be careful not to fluid overload, arrange for dialysis

CASE 4B: 9 marks A 21 year old medical student, who is a known Type 1 diabetic patient, was admitted to hospital after collapsing whilst attending a ward round. LABORATORY RESULTS Admission Plasma sample Sodium Potassium 138 6.4

8 hours after admission 143 2.7

Units mmol/L mmol/L

Reference Range 136 - 145 mmol/L 3.2 - 4.8 mmol/L

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Chloride Total Carbon dioxide Urea Creatinine Glucose Urine dipstick (on admission) 2a.

100 10 18.9 290

113 18 13.0 180

mmol/L mmol/L mmol/L mol/L mmol/L

98 -113 23 - 29 2.1 - 7.1 80 - 115 3.0 - 5.5

mmol/L mmol/L mmol/L mol/L mmol/L

23.8 12.9 Glucose 4+, Ketones 2+

What diagnosis does the admission results indicate?

(1 mark)

Diabetic Ketoacidosis

2b.

Which 4 results lead you to this diagnosis?

(2 marks)

Raised plasma glucose, low bicarbonate, ketones in urine, high anion gap in a known TIDM patient

2c. i.

Explain: the high admission plasma potassium result (assuming there were no pre-analytical factors involved) (1 mark)

Insulin deficiency affects action of the Na-K pump, hyperosmolality of ECFC with solvent drag

ii. 2d.

the low plasma potassium results 8 hours later

(1 mark)

Patient received insulin (and fluids) which corrected above mentioned factors

What is the patients acid - base status on admission? Describe the mechanisms responsible. (3 marks)

High anion gap metabolic acidosis. Insulin deficiency glucose cannot enter cells for glycolysis and ATP production fatty acids are used as an alternative fuel oxidation ketone and H ion production buffering of H by the ECF bicarbonate buffer depletion of the bicarbonate unbuffered H ions lower the pH

2e.

Why were the urea and creatinine results elevated on admission and lower 8 hours later? (1 mark)

Patient was dehydrated due to loss of fluid (osmotic diuresis) decreased GFR prerenal uraemia received fluids in hospital improved the GFR

(Total marks: 15)

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CASE 5 : HAEMATOLOGY

(21 marks)

Lindiwe Selebi is 35 years old. She presents to her doctor complaining of easy bruising and on specific questioning also mentions that her last period was unusually heavy. Her FBC shows a platelet of 5x10^9/l (normal 170 420). 1. Describe 4 changes that occur in a platelet when it is activated. Flip-flop of the membrane Shape change from discoid to spiny Rearrangement of GPIIbIIIa Granule release Others acceptable: release of arachidonic acid etc. (4 marks)

A diagnosis of ITP (Idiopathic/immune Thrombocytopenic Purpura) is made. 2a. Briefly outline the mechanism of thrombocytopenia in this disorder. (3 marks) Autoantibodies attach to platelet surface recognized and removed by splenic macrophages 2b. What would you see in the bone marrow that would reassure you that this is the correct diagnosis? (1 mark) Increased numbers of normal megakaryocytes

She fails to respond completely to therapy and her platelet count remain below 50x10^9/l. She continues to bruise easily and her periods are very heavy. After 6 months she begins to feel very tired and has marked pallor. 3a. Give 2 signs of severe anaemia to be found on examination of the CARDIOVASCULAR system. (1 mark) Bounding pulse, tachycardia, flow murmur etc. (1 mark)

3b. Why should the doctor suspect iron deficiency anaemia? Chronic blood loss leading to decreased iron stores 3c 3d.

Give 2 findings on iron studies which would confirm iron deficiency. (2 marks) Reduced ferritin and increased transferrin levels Draw and label the red cell features which would be seen in the peripheral blood in iron deficiency. (3 marks) Targets, pencils, hypochromic microcytic reds

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End of Year Examination 2009 SACS

3e. Fe3+

Draw a flow diagram to show the absorption pathway of inorganic dietary iron. (6 marks) 2+ Fe duodenum DMT1 on enterocyte Passes to base of enterocyte Ferroportin Transferrin