THE UNIVERSITY OF HONG KONG

LKS FACULTY OF MEDICINE

M.B., B.S. Second Summative Examination - May 2019

Paper II: Structured Answer Questions

Date Monday, May 20, 2019

Time 9:30 am - 12:30 pm
Venue Loke Yew Hall

STUDENT'S LABEL

INSTRUCTIONS:

1. This paper consists of 30 questions. Answer ALL questions.

2. Stick your candidate number label in the "Student's Label" box on the first page of the
question paper.

3. Stick your candidate number label in the "Student's Label" box on EACH of the answer
sheets.

4. Write your answers in the spaces provided on the answer sheets. Do not write on the
question paper.

5. You are advised to spend six minutes on each question.

6. Each question carries equal marks.

7. IMPORTANT: If it is specified in a question the number of points or items that a candidate

should answer, the candidate should give only that number of points or items in their
answer. Any additional points or items in the answer will not be marked.

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Question 1

Sinusoid is a special type of blood vessel in liver.

(a) Name three types of cells lining the liver sinusoid. (3 marks)
(b) Briefly describe the functions of any two. (2 marks)

Question 2

Diagnosis of Helicobacter pylori infection can be achieved by a variety of laboratory

investigations. Name the single most appropriate approach for each of the following
scenarios.

(a) A 32-year-old lady with suspected peptic ulcer disease and Helicobacter pylori
infection who refused oesophagogastroduodenoscopy. (1 mark)
(b) A patient who has received 2 previous courses of eradication therapy for
Helicobacter pylori infection but still has persistent infection. (3 marks)
(c) A community-wide survey on the prevalence of Helicobacter pylori infection.
(1 mark)

Question 3

Colon cancer is one of the top-ranking causes of cancer mortality worldwide.

(a) What is the commonest histological subtype of colon cancer? (1 mark)

(b) Name three risk factors for colon cancer. (3 marks)
(c) Name one commonly mutated gene in colon cancer. (1 mark)

Question 4

A 35-year-old human immunodeficiency virus (HIV)-infected patient, returned from a

trip to Thailand. He presented to the Accident and Emergency Department with profuse
watery diarrhoea per day for the past 3 days, along with severe abdominal cramps,
nausea, vomiting. Upon physical examination, he was feverish (39°C). He stated that he
is allergic to beta-lactam antibiotics. If fecal leukocytes are present,

(a) Which group of antibiotics the patient should most likely be empirically given?
Name Q!!!: example of the group of antibiotics. (2 marks)
(b) What is its mechanism of action? (3 marks)

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Question 5

Observational studies show that high consumption of salted fish is positively associated
with increased risk of nasopharyngeal cancer.

(a) What type of observational study design using primary data would provide the
highest level of evidence of this association? (1 mark)
(b) Suggest two patient-oriented outcomes in observational studies relevant to patients
with nasopharyngeal cancer. (2 marks)
(c) Explain lead-time bias (1 mark) and how it may distort the evaluation of
effectiveness of cancer screening. (1 mark)

Question 6

A patient complained of a painful mass in her right popliteal fossa.

(a) What are the superomedial, superolateral, inferomedial and inferolateral

boundaries of the popliteal fossa, respectively? (4 marks)
(b) Which muscle forms part of the floor of the popliteal fossa? (1 mark)

Question 7

Type I collagen is a trimer containing two al(I) and one a2(1) chains encoded by the
COLlAl and COL2Al genes, respectively. Osteogenesis imperfecta (01) can be caused
by mutations in these two genes.

(a) If there is a mutation affecting one allele of the COLlAl gene, what proportion of
the type I collagen molecules would contain only normal type I collagen chains.
(1 mark)
(b) Bisphosphonate is used to treat patients with 01 that alters the balance of cell
activities in bone remodelling. Which cell type does it affect and what is its mode of
action? (2 marks)
(c) From the perspective of bone density and quality, why is bisphosphonate treatment
beneficial? (2 marks)

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Question 8

A 46-year-old man who was an intravenous drug user was admitted for a 5-day history of
progressive left knee pain and swelling, together with a fever up to 38°C.

(a) List two essential clinical specimens that should be collected for microbiological
investigations in this patient. (2 marks)
(b) Name one micro-organism that is most commonly associated with this infection in
this clinical setting. (2 marks)
(c) Name~ beta-lactam antibiotic that can be used for empirical treatment of this
patient. (1 mark)

Question 9

A 60-year-old retired delivery man presented to his local doctor with complaints of a 6-
month history of stiffness and pain in the right knee. He reported difficulty in walking.
There were no other joints involved and no systemic symptoms. On physical examination
he was obese. There was swelling and deformity of the right knee joint.

(a) List three changes that may be present on plain radiography of the right knee joint.
(3 marks)
(b) Explain the pathological change for any one of these changes. (1 mark)
(c) What is your most likely diagnosis? (1 mark)

Question 10

A 30-year-old man presented with head injuries in a traffic accident. His vital signs were
normal but he was unconscious. Physical examination of the pupillary responses to light
was performed.

(a) What is the name of the reflex? (1 mark)

(b) How does a lesion in the following structures affect the reflexive responses on his
left eye?
(i) Right oculomotor nerve (2 marks)
(ii) Left optic nerve (2 marks)

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Question 11

Facial expressions play important roles in non-verbal communication.

(Source: Moore, Keith L., and Arthur F. Dalley. Clinically oriented anatomy. Philadelphia:
Lippincott Williams & Wilkins. 7th Ed. 2017)

(a) Analyse the images. For each case name the main muscle involved in making such
facial expression. (2 marks)
(b) Which nerve innervates all muscles responsible for facial expression? (1 mark)
(c) Explain why a tumour located in the parotid gland can produce unilateral facial
paralysis. (2 marks)

Question 12

A 36-year-old woman is admitted with fever, headache, confusion and abnormal

behaviour for 5 days. Cerebrospinal fluid (CSF) examination showed elevated white cells
(predominantly lymphocytes) with moderately elevated CSF protein and normal glucose
levels. A diagnosis of herpes encephalitis is suspected.

(a) What is the investigation of choice to confirm the aetiology? (1 mark)

(b) What is the antiviral therapy of choice for this patient? For how long? (2 marks)
(c) Name two routes by which the herpes simplex virus gets into the central nervous
system to cause encephalitis. (2 marks)

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Question 13

Smell is a special sense for chemical detection.

(a) How is a particular quality of smell of a chemical encoded by olfactory receptor

cells? (2 marks)
(b) Briefly describe the potential effects of sympathetic nerve stimulation on the
responses of olfactory receptor cells to odorants?(2 marks)
(c) Name the structure within the olfactory bulb to which the axon of the olfactory
receptor cell projects. (1 mark)

Question 14

A 39-year-old woman presented with a 1-year history of progressive weight gain and
constipation. She also complained of cold intolerance, amenorrhoea, and development of
a deep, croaky voice. Physical examination showed that she had a low core body
temperature at 36°C, and a pulse of 60/minute. A diffuse swelling was noted in front of
her neck.

(a) What is the most likely diagnosis? (1 mark)

(b) Explain why this patient developed a deep, croaky voice. (1 mark)
(c) Explain why this patient suffered from amenorrhoea. (3 marks)

Question 15

Insulin decreases blood glucose.

(a) Name the cell type in the pancreas which produces insulin. (1 mark)
(b) What is the most important regulatory factor for the control of insulin release?
(1 mark)
(c) Explain how insulin deficiency leads to glucosuria. (2 marks)
(d) Name .Q.!!!: non-pancreatic hormone that can increase blood glucose level. (1 mark)

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Question 16

A 35-year-old female presented with a painless right breast mass and swollen axillary
lymph nodes with rapid progressive enlargement.

(a) What was the most likely cause of her swollen axillary lymph nodes? (1 mark)
(b) She received treatment for her condition and years later returned to your clinic with
a swollen right arm. What treatment did she receive and why? (2 marks)
(c) List two possibilities for her swollen right arm. (2 marks)

Question 17

Red cell metabolism serves to protect these cells from intracellular oxidation.

(a) Name two sources of hydrogen peroxide that contribute to oxidative stress in
erythrocytes. (2 marks)
(b) Apart from supplying energy to support erythrocyte function, glucose also serves to
mitigate oxidative stress in these cells. Briefly explain how. (2 marks)
(c) Name Q!!£ form of anaemia that can result from oxidative damage of erythrocytes.
(1 mark)

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Question 18

This is the peripheral blood film of a SO-year-old man who presented with shortness of
breath (Figure 1 and Figure 2).

(a) List one salient abnormality seen in the peripheral blood film. (1 mark)
(b) What is the haematological diagnosis of the patient? (1 mark)
(c) What is the next step of investigation to confirm the diagnosis? (1 mark)
(d) Name one non-haematological clinical manifestation of the condition you named in
part (b). (1 mark)
(e) Why is the patient having shortness of breath? (1 mark)

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Question 19

Leucovorin is used in combination with other chemotherapic drugs to either enhance the
effectiveness (e.g. fluoruracil) or as a chemoprotectant (e.g. methotrexate). Explain the
respective mechanisms for leucovorin's actions in chemotherapy. (5 marks)

Question 20

Mary, 25-year-old, received three doses of human papillomavirus (HPV) vaccine in her
teenage. She learnt from internet sources that HPV vaccine could induce T cell immunity
for protection against cervical cancer. Her elder sister never had any HPV vaccination
and was recently diagnosed with cervical cancer.

(a) For effective vaccination protection, more than 1 dose of vaccine is recommended.
Give one immunological explanation for this recommendation. (1 mark)
(b) Can the transfer of T cells from Mary to her sister be a possible anticancer treatment
option? (1 mark). Explain your answer with the key immunological concepts
involved. (3 marks)

Question 21

A 55-year-old female smoker suffered from right breast cancer, presented with an orange-
peel appearance of the skin. She then had right radical mastectomy, chemotherapy and
radiotherapy for breast cancer.

(a) List Q!!£ arterial branch supplying the right breast. (1 mark)
(b) Where does the lymph from the right medial quadrants of the breast drain into
(specific lymph nodes)? (1 mark)
(c) List two explanations for the orange-peel appearance of the skin in breast cancer.
(2 marks)
(d) Do lymphatics of the breast communicate with those in the anterior abdominal
wall? (1 mark)

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Question 22

Diabetic ketoacidosis is a complication that is often associated with Type I but not Type
II diabetes.

(a) What are the two common biochemical species that directly cause a change of blood
pH in the event of diabetic ketoacidosis? (2 marks)
(b) Give two reasons why these compounds are formed in large quantities in
uncontrolled Type I diabetes. (2 marks)
(c) Name .!!!!!:. other glucose-derived biochemical species that cause diabetic
complications in Type I and Type II diabetes. (1 mark)

Question 23

A 36-year-old woman who had undergone total thyroidectomy and the pathology showed
a thyroid cancer nodule measuring 3 cm with a clear resection margin.

(a) What are the two commonest histologic types of thyroid cancer? (2 marks)
(b) Radioactive therapy is recommended as post-operative treatment. Please name the
radioisotope used. (1 mark)
(c) If she has a recent computed tomography with injection of iodinated contrast before
the radioactive therapy, what will be the effect on the cellular uptake of the
radioactive therapy in the thyroid remnant? (1 mark)
(d) She is put on thyroxine 75 micrograms daily after the radioactive therapy. She
remains clinically euthyroid with good compliance to thyroxine. Her latest serum
thyroxine (T4) and thyroid stimulating hormone (TSH) was 15.1 pmol/L (normal: 9
- 19 pmol/L) and 2.3 mIU/L (normal 0.35 - 4.94 mIU/L). How should her thyroxine
dosage be adjusted? (1 mark)

Question 24

In a population with adequate coverage of cervical cytology screening, the incidence and
mortality of cervical cancer is usually reduced. List five factors which underlie the success
of cervical cytology screening. (5 marks)

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Question 25

A 60-year-old woman with type II diabetes is not sensitive to the anti-diabetic drug
metformin. The doctor suggests her to take anti-diabetic drugs which can enhance insulin
secretion.

(a) Name two types of anti-diabetic drugs which can enhance insulin secretion in p cells.
(2 marks)
(b) Describe the mechanisms whereby these drugs enhance insulin secretion. (2 marks)
(c) Explain why some insulin secretagogues cause weight gain. (1 mark)

Question 26

A 42-year-old woman presented with longstanding tingling and numbness of her hands
and fingers, and intermittent leg cramps. Her past medical history involved a radiation
therapy to the neck for thyroid cancer 2 years ago. On physical examination, the doctor
found that she was positive for Chvostek and Trousseau signs.

(a) What could be the likely diagnosis of this patient? (2 marks)

(b) Name one normal physiological function of the hormone involved in the disorder of
this patient. (1 mark)
(c) What is a positive Chvostek sign? (1 mark)
(d) What is a positive Trousseau sign? (1 mark)

Question 27

An artificial intelligence (AI) algorithm has been developed which can identify those
patients in the last year of life. The Hospital Authority (HA) is under increasing pressure
to save money and it is increasingly aware that patients in the last year of life are an
extremely costly cohort in terms of hospital resource utilisation. The HA decides that any
patients identified using the algorithm will be approached to discuss advance care
planning and do-not-attempt cardiopulmonary resuscitation (DNACPR).

(a) What are the ethical implications of adopting such a model? Explain your answer
with reference to the 4 principles. (4 marks)
(b) What are your views on the introduction of such AI? Justify your position. (1 mark)

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•

Question 28

A 40-year-old man has been engaging in extramarital bisexual activities and is now
human immunodeficiency virus (HIV) positive. He tells you that he will not tell his wife
about his HIV status. His wife has also been your patient for a number of years.

(a) What is the ethical dilemma? (2 marks)

(b) What would you do? (3 marks)

Question 29

A third year medical student is planning to do a research study comparing the effect of
measles vaccine versus placebo in preventing measles in children. The outcome of the
study is the episode of measles within one year after intervention. Sample size required
for the study is 120.

(a) What type of study is the gold standard for testing a new vaccine? (1 mark)
(b) Are placebo controlled trials ethical? Justify your answer. (2 marks)
(c) You are a member of the independent institutional review board. Would you
approve this study? Justify your answer. (2 marks)

Question 30

You are covering a busy medical ward overnight and you are informed by a nurse that by
accident a patient has been given the wrong dose of insulin. Instead of administering 35
units of insulin the patient has received 55 units. The patient's blood glucose is reading
1.0 mmol/1.

(a) What kind of medical error is this? (1 mark)

(b) What would you do? (4 marks)

- End of Paper -

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