2010 MBBS Year 2 Summative Examination

Minicases

Case 1 (4 sections in total)

Section 1
Mrs Lee, a 39-year-old lady, presented to the gynaecologist with heavy vaginal bleeding. The
bleeding was still going on after 12 days and more than 10 sanitary pads were needed in one day, all
of which were quite heavily soaked. Mrs Lee felt tired and experienced dizzy spells. Palpitation
occurred at times. Her past health was good.

Upon further questioning, Mrs Lee admitted that she had been having regular but heavy
menstruations. Each period used to last for 7 to 8 days. There was mild dysmenorrhoea but not
necessitating analgesia. She thought that the previous menstruations were quite normal.

1. List 2 abnormalities in this patient. (4 marks)

2. List 4 characteristics of normal menstruations. (8 marks)
3. List 2 possible causes for the vaginal bleeding. (4 marks)

Section 2
On physical examination, Mrs Lee appeared to be pale. The uterus was found to be enlarged. The
cervix and vagina were normal, so as the adnexae. Pelvic ultrasound showed an anteverted uterus
with multiple spherical intramyometrial nodules. The diameter ranged from 3cm to 10cm.

4. Describe the normal position of the uterus. (4 marks). What is the anatomical structure that
sustains the proper position of the uterus? (2 marks)
5. What is pelvic fascia condensation (PFC)? (2 marks). List 3 examples. (6 marks)
6. What are the 2 primary supports of the uterus? (4 marks) What is their respective innervation?
(6 marks)

Section 3
A complete blood count was performed and the results were as follows:

White blood cell count (WBC): normal

Red blood cell count (RBC): low
Hemogobin concentration (HBC): low
Hematocrit/ Packed cell volume (PCV): low
Mean cell volume (MCV): low
Mean cell hemoglobin (MCH): low
Mean cell hemoglobin concentration (MCHC): low
Red cell distribution width (RDW): high
Platelet count (PLT): high

7. What is your interpretation of the results of the complete blood count? (2 marks)
8. What is your diagnosis from the results of the complete blood count? (2 marks)
9. List 4 of the findings that are considered AYTPICAL for thalassmia trait. (8 marks)
10. List 5 abnormalities that will be seen in peripheral blood smear. (10 marks)
11. List 4 biochemical tests done on the blood sample to confirm your diagnosis. Include also the
expected result of each test. (12 marks)

Section 4
Hysterectomy was performed. Sections of nodules showed interlacing bundles of spindle shaped
smooth muscle fiber with no sign of necrosis or atypia. Mitotic activity was less than 2 per 10 high
power field.

12. Based on the histological findings described, suggest a likely diagnosis.

13. Give an alternative diagnosis if endometrial glands and stroma are found.
14. List 2 common malignant tumors arising from the uterus. For EACH of them, list 2 risk factors.
15. If malignancy was not likely and the patient wanted to preserve her uterus, list 4 possible
treatment options.

End of case 1

Case 2 (3 sections in total)

Section 1
A 60-year-old man was brought to Accident and Emergency Department of Queen Mary Hospital
because of sustaining a right femoral neck and a right distal forearm fracture during a fall from the
top of a ladder. His right lower limb was markedly externally rotated and shortened due to muscle
pull. During history taking, he said he had experienced bone pain for 5 years and had history of
kidney stone. His blood pressure was 185/100 mmHg. He also complained of muscle weakness and
polyuria.

1. What endocrine disorder was the patient suffering from? (3 marks)

2. Based on your answer in question 1, explain on the physiological basis for a) muscle weakness
b) hypertension c) polyuria. (9 marks)
3. What other endocrine disorder could also cause hypertension, muscle weakness and polyuria? (3
marks)
4. Name 3 other clinical features that could be found in this patient. (6 marks)
5. Name 4 muscles that laterally rotate the thigh. (8 marks)
Section 2
He was suspected to be suffering from primary hyperparathyroidism and was sent for X-ray
examination. Some chemical tests were done on his blood.

6. Besides bone fracture, suggest 2 other features that might be found in his X-ray. (4 marks) name
the disorder. (2 marks)
7. What 2 biochemical tests should be done and what is the expected result for EACH of them? (6
marks)
8. Suggest 2 immediate treatments to alleviate his current symptoms. (4 marks)
9. What is the treatment option for primary hyperparathyroidism? (5 marks)

Section 3
He was found to suffer from osteitis fibrosa cystica which resulted in weakening of the bones.
Blood ionized calcium was 1.8 mmol/L (normal range: 1.07 – 1.33), serum PTH level was 20
pmol/L (normal range: 1.2 – 5.6). He was given fluid replacement and i.v. pamidronate. He was
later sent for parathyroidectomy.

10. What is the cause of primary hyperparathyroidism in this patient? (4 marks)

11. What is the embryonic origin of parathyroid gland? (4 marks)
12. What cells types could be found in parathyroid gland? (4 marks) Which cell type is responsible
for secreting parathormone? (2 marks)
13. List 3 other endocrine disorders that may lead to bone fracture. (6 marks) Give an explanation
for EACH of them. (12 marks)
14. What are the differences between the above endocrine disorders and primary parathyroidism in
a) bone b) serum calcium level c) serum parathormone level? (12 marks)

He was scheduled for surgery which involved manipulative reduction and internal fixation of the
bones. 6 days later, the patient developed wound infection on the right thigh. A swab of the wound
was taken by the microbiologist. Smear of the culture showed Gram positive cocci in clusters and
numerous neutrophils. A culture of the swab was also performed.

15. Which organism is likely to be seen in the culture? (3 marks)

16. Which class of antibiotic cold you use for empirical treatment? (3 marks)

End of case 2

Case 3 (4 sections in total)

(This is a long case and I did not have enough time to copy all the information. But I still managed
to jot down the questions which you might be able to answer even without knowing the details.)
Section 1
An unmarried 50-year-old man presented with progressive swelling over the left upper neck region
for the past 6 months. The swelling did not show redness or tenderness upon palpation. He also
experienced pain along the lower jaw area with frequent drooling of saliva. He was unable to
whistle. The patient was a taxi driver and consulted the doctor upon pressure from his friends.

1. List 4 main problems in this patient.

2. Give an explanation for EACH of the above problems.
3. List 2 possible hypothesis.
4. Suggest 2 reasons why the patient delayed medical consultation.

Section 2
On physical examination, a 4cm non-tender mass was found at left upper neck region extending
both to the preauricular and postauricular regions. Left cervical lymph nodes were palpable at level
III. Saliva was drooled on left side. Examination on the heart and lungs revealed unremarkable
findings. Abdomen was not tender and no mass was palpable. (…)

5. List 6 investigations that you would like to perform on this patient.

6. Explain the rationale behind EACH of the suggested investigations.
7. The patient was given beta-blocker. List 3 other classes of drugs for treating hypertension.
8. Explain the mechanism for EACH of the above class of drugs.
9. The patient was given glibenclamide (sulfonylurea). List 3 other anti-diabetic drugs.
10. Explain the mechanism for any 3 of the above drugs.
11. Suggest a major side effect for 1 of the above drugs.

Section 3
(…) Histological studies of the lymph node biopsy revealed malignant cells with glandular tissues
and foci of squamous cell differentiation.

12. Explain the mechanism of salivary secretion.

13. List 3 controls of salivary secretions.
14. What is your diagnosis?
15. What is the difference in clinical manifestation between central and peripheral facial nerve
palsy?
16. Based on the histological diagnosis, what is the likely type of parotid gland tumor? (should be
mucoepidermoid carcinoma)
17. What would the treatment option?
18. List 2 possible morbidies arising from the above treatment.
Section 4
(…) (I remembered it says surgery was done to remove the parotid gland tumor together with
radical resection of the affected cervical lymph nodes. The patient was on chemotherapy and
somehow got a stroke and went into coma.)

19. Describe the innervation of parotid gland. (3 marks)

20. Describe the lymphatic drainage of parotid gland. (3 marks)
21. Describe the formation of carotid sheath. List 4 anatomical structures that could be found in it.
22. What are the 4 subdivisions of anterior triangle? For EACH of them, suggest 1 anatomical
structure that could found inside.
23. (This is a question asking about advance care planning. You need to name this procedure, state
its goals, content and advantages)
24. (This is a question asking about advance directive. You need to name this document and suggest
3 conditions that would trigger its implementation).
25. (It says the patient was not married and his next of kin would be his father and brother. If the
doctor wanted to terminate the treatment on him, which 2 persons could be the legal proxy for
this patient under Hong Kong laws and which 2 procedures would be required)

End of case 3