MEQ Answers

Part 1 : A patient is presented with fasting glucose level 8.0 mmol/L.

a. State four causes of hyperglycemia besides diabetes mellitus. [ 2 m ]

Cushing’s syndrome, acromegaly, pheochromocytoma, hyperthyroidism
b. State the investigations you would carry out to rule out the causes mentioned above. [ 4 m ]
Cushing’s syndrome – dexamethasone test
Acromegaly – insulin like growth factor-1 measurement
Pheochromocytoma – 24 hour urinary collection for catecholamines and metanephrines
Hyperthyroidism – high serum T4 and low TSH
c. Describe the structure of insulin. [ 2 m ]
Made up of 52 amino acids. Two polypeptide chains linked by disulphide bonds.
d. Describe the mechanism of action of insulin. [ 3 m ]
Insulin binds to receptor on surface of target cell membrane. Insulin receptor consists of alpha
subunit which binds insulin and beta subunit which has tyrosine kinase activity and
autophosphorylation site. Tyrosine kinase phosphorylates a network of intracellular proteins ( insulin
receptor substrate ).

Part 2 : On physical examination, the patient has coarse facial features and prognathism. His stature is
taller than the average man of his age.

a. State two possible causes for the disorder in this case. [ 2 m ]

Pituitary adenoma; ectopic GHRH secretion
b. Describe the regulation of growth hormone in our body. [ 2 m ]
GH secretion is stimulated by GHRH, inhibited by somatostatin.

Part 3 : After a few days, the patient develops paraesthesia and numbness on the palmar surface of lateral
three and a half fingers.

a. Explain the condition in this patient. [ 2 m ]

The patient develops carpal tunnel syndrome as a result of abnormal growth of bones around the
hand and wrist. Median nerve is compressed leading to paraesthesia and numbness on the palmar
surface of lateral three and a half fingers.
b. List all the components which make up the carpal tunnel. [ 3 m ]
Median nerve, four tendons of flexor digitorum profundus, four tendons of flexor digitorum
superficialis and one flexor pollicis longus.

1. Part I : A patient is presented with polydipsia and polyuria.

a. State two disorders which are associated with this patient’s presentation. [ 1 m ]
Diabetes mellitus, diabetes insipidus
b. State the criteria for diagnosis of diabetes mellitus. [ 2 m ]
Fasting plasma glucose ≥ 126 mg/dL ( 7.0 mmol/L ) or two hour plasma glucose ≥ 200 mg/dL ( 11.1
mmol/L ) with classical symptoms of polydipsia, polydipsia and polyphagia
c. State three differences between type I and type II diabetes mellitus. [ 3 m ]
DM I – autoimmune destruction of beta cells, associated with HLA, weight loss is common, diabetic
ketoacidosis is common, non ketotic hyperosmolar coma is rare
DM II – insulin resistance, no association with HLA, weight loss is rare, diabetic ketoacidosis is rare,
non ketotic hyperosmolar coma is common

Part II : After a few months, the patient complaints of passing foamy urine.

a. State the five stages of diabetic nephropathy. [ 3 m ]

Stage I – hyperfunction and hypertrophy, stage II – silent stage, stage III – incipient stage, stage IV –
overt diabetic nephropathy, stage V – uremic
b. Describe the pathophysiology of diabetic nephropathy. [ 3 m ]
 Hyperglycemia causes glycosylation of glomerular proteins which leads to mesangial proliferation,
matrix expansion and vascular endothelial damage. Thickening of glomerular basement membrane
and diffuse mesangial sclerosis are present.
c. State two characteristic feature of diabetic nephropathy under microscope. [ 2 m ]
Kimmelstiel Wilson lesions and hyaline arteriosclerosis of afferent and efferent arterioles.

Part III : The patient develops into chronic renal failure after few years with complications of renal
osteodystrophy.

a. State the benchmark for diagnosis of chronic renal failure. [ 1 m ]

Glomerular filtration rate less than 60 mL/min/1.73 m2 for 3 or more months.
b. Explain the pathogenesis of osteomalacia in this patient. [ 3 m ]
Osteolamacia is incomplete mineralization of the bone. Decreased renal conversion of calcidiol ( 25-
hydroxycholecalciferol ) to the calcitriol ( 1,25-dihydroxycholecalciferol ) by alpha 1 hydroxylase.
Vitamin D is required for calcium absoprtiona dn mineralization of the bone.
c. State two clinical presentations of rickets in children. [ 2 m ]
Craniotabes, rachitis rosary, genu valgum, genu varum, saber shin deformity, Harrison’s groove

2. Part I : A patient with history of sickle cell anemia presented with fatigue, bone pain and skin ulceration.
a. Describe the pathogenesis of sickle cell anemia. [ 3 m ]
Sickle-cell anaemia is caused by a point mutation in the β-globin chain of haemoglobin, causing the
amino acid glutamic acid to be replaced with the less polar amino acid valine at the sixth position.
The β-globin gene is found on the short arm of chromosome 11. Deoxygenation of HbS leads to
distortion of the shape of RBCs. RBCs unable to pass through capillaries resulting in vessel
occlusion and ischaemia.
b. Describe three features you would observe in peripheral blood smear of this patient. [ 3 m ]
Sickle shaped RBCs, target cells, Howell Jolly bodies

Part II : The patient develops osteomyelitis as complication.

a. Name the most possible causative microorganism for this osteomyelitis. [ 1 m ]

Salmonella spp
b. Describe briefly the pathogenesis and course of osteomyelitis. [ 4 m ]
Compression of vasculature by pyogenic exudates – ischemic necrosis of bone and marrow –
necrotic bone ( sequestrum ) – subperiosteal abscess – sinus draining though skin – new bone
formation ( involucrum ) – Brodie abscess

Part III : Most of the indigenous inhabitants of Sub-Saharan Africa carry the sickle cell trait and they are
resistant to malaria.

a. Name four malaria species. [ 2 m ]

Plasmodium ovale, Plasmodium vivax, Plasmodium falciparum, Plasmodium malariae
b. Describe briefly the life cycle of malaria species in the human body. [ 5 m ]
Sporozoite - schizont ( exoerythrocytic ) - merozoite - trophozoite - schizont ( erythrocytic ) -
merozoite - gametocyte
c. Describe the treatment for malaria. [ 2 m ]
First line therapy – Chloroquine; quinine plus doxycycline; atovaquone-proguanil
Multidrug resistant – mefloquine
 3. Part I : A young male complains of bloody diarrhoea, cramping abdominal pain, fever and weight loss.

a. State three investigations for this patient. [ 3m ]

Stool culture to exclude infectious causes, sigmoidoscopy, CT colonoscopy, double contrast barium
enema
b. Name three microorganisms which can cause bloody diarrhoea. [ 3m ]
Shigella, salmonella, campylobacter, entamoeba histolytica, clostridium difficile, yersinia, E.coli
c. Name the main three branches of celiac trunk. [ 3m ]
Left gastric artery, common hepatic artery, splenic artery

Part II : The diagnosis of ulcerative colitis is confirmed in this patient. He also develops low back pain with
morning stiffness recently.

a. State four causes of low back pain. [ 2m ]

Ankylosing spondylitis, compressive fracture due to osteoporosis, spinal disc herniation, bone tumour
b. State two other extraintestinal manifestations of ulcerative colitis. [ 2m ]
Migratory polyarthritis, primary sclerosing cholangitis, pyoderma gangrenosum, erythema nodosum
c. Describe two changes you would observe in X ray of the spine for this patient. [ 2m ]
Bamboo spine appearance, pseudowidening from subchondral erosions, followed by sclerosis or later
narrowing and eventually fusion in the sacroiliac joints.

Part III : After a few years, the patient develops complications from the ulcerative colitis.

d. State two complications for ulcerative colitis. [ 2m ]

Toxic megacolon, colon carcinoma
e. State three differences between ulcerative colitis and Crohn disease. [ 3m ]

Ulcerative colitis Crohn's disease

Involves colon and rectum Involves terminal ileum and colon
Pancolitis Skip lesions
Loss of haustration String sign
Mucosal and submucal inflammation Transmural inflammation
No granuloma Non caseating granuloma
Crypt abscess and pseudopolyps
present Cobblestone appearance; creeping fat

4. Part I : Patient is presented with sudden onset of tenderness, warmth and swelling in his toes. Serum uric
acid is found to be elevated in this patient.

a. State the provisional diagnosis for this patient. [ 1m ]

Gout
b. State the investigations you would carry out to confirm the diagnosis. [ 2m ]
Examination of aspirated synovial fluid, X ray of the toes
c. State three causes for the disorder. [ 3m ]
Hypoxanthine-guanine phosphoribosyltransferase deficiency ( Lesch-Nyhan syndrome ),
myeloproliferative and lymphoproliferative disorders, renal insufficiency
d. Describe two pathways for synthesis of nucleotides from purine. [ 4m ]
De novo pathway ( amidophosphoribosyltransferase ) and salvage pathway ( hypoxanthine guanine
phosphoribosyltransferase )
Part II : The diagnosis of acute gout has been made in this case.

a. Outline the treatment and management for this patient with the goals of
i. termination of acute attack [ 2m ] NSAID, colchicine
ii. lowering of serum uric acid [ 2m ] allopurinol, probenecid
b. State four features of synovial joint. [ 2m ]
Synovial fluid, synovial cavity, synovial capsule, reinforcing ligament

Part III : Patient develops complication from untreated chronic gout after a few years. He experiences loin
pain radiating to the groin with nausea and vomiting.

a. State the most likely complication of untreated chronic gout in this case. [ 1m ]
Uric acid stone formation
b. Describe struvite stone and its formation. [ 3m ]
Magnesium ammonium phosphate stone, associated with chronic UTI with gram negative bacteria / urea
splitting bacteria ( Pseudomonas, Proteus, Klebsiella ), alkaline urine, nidus for UTI

5. Part I : A 47 year old man presents to the emergency department after experiencing substernal chest pain.
The pain is worsened with inspiration and is relived only when he leans forward.

a. State four causes of chest pain. [ 2m ]

Myocardial infarction, pericarditis, angina, pulmonary embolism, aortic dissection, tension
pneumothorax, pneumonia, gastro esophageal reflux disease
b. State three investigations you would carry out for this patient. [ 3m ]
Chest X ray, ECG, serum cardiac marker
c. Name the branches of right coronary artery and the areas supplied by each branch. [ 3m ]
Posterior interventricular / descending artery ( posterior right and left ventricles, posterior 1/3 part of IV
septum ), right marginal artery ( right ventricle and apex ), nodal artery ( SA and AV nodes )

Part II : Cardiac examination reveals a friction rub. An ECG and chest X ray are done for this patient.

a. State the provisional diagnosis. [ 1m ]

Acute pericarditis
b. Describe the findings you would expect in the
i. ECG [ 2m ] diffuse ST elevation with PR depression
ii. Chest X ray [ 1m ] cardiomegaly due to pericardial effusion
c. Explain cardiac tamponade. What is Beck triad ? [ 4m ]
Accumulation of pericardial fluid prevents diastolic filling of the heart resulting in reduced cardiac
output. Beck’s triad – increased JVP, hypotension, diminished heart sound

Part III : The patient had a myocardial infarction two weeks earlier.

a. State your final diagnosis for this case. [ 1m ]

Dressler’s syndrome
b. State three other complications of myocardial infarction. [ 3m ]
Arrhythmia, cardiogenic shock, ventricular free wall rupture, papillary muscle rupture, ventricular
aneurysm, thromboembolism

6. Part I : A 50 year old woman is presented with 1-month history of productive cough with yellow sputum.
She has had several periods of cough lasting 4 to 6 consecutive months each year for the past 5 years. She
has been smoking for the past 30 years.

a. State your provisional diagnosis. Give the reasons from the history to support your diagnosis. [ 2m ]
Chronic bronchitis. Persistent productive cough for at least three consecutive months in at least two
consecutive years.
 b. State the abnormalities you would expect on pulmonary function test of this patient. [ 3m ]
Reduced FEV1, reduced FVC, reduced FEV1/ FVC ratio
c. Describe the pathogenesis of this disorder. [ 3m ]
Hypersecretion of mucus in airway with hypertrophy of submucosal glands in trachea and bronchi;
increase in goblet cells and size of mucous glands; Reid index – increased ratio between mucous gland
and bronchial wall; narrowing of bronchioles by goblet cells metaplasia, mucus plugging, inflammation,
fibrosis

Part II : Her jugular venous pressure is elevated and there is pitting edema noted up to her knees.

d. What complication of this condition do the patient’s enlarged neck veins, hepatomegaly and edema
suggest ? [ 3m ]
Cor pulmonale. Right heart failure due to chronic pulmonary hypertension leads to systemic congestion.
e. State two other causes of elevated jugular venous pressure. [ 2m ]
Pericardial effusion, superior vena cava syndrome, cardiac tamponade, constrictive pericarditis
f. State all the segments of right lower lobe of the lung. [ 3m ]
Superior, medial basal, lateral basal, anterior basal and posterior basal.

Part III : Antibiotics and ipratropium bromide are given for this patient as treatment.

g. State three differences between emphysema and chronic bronchitis. [ 3m ]

h. State the mechanism of action of ipratropium bromide and state two side effects. [ 3m ]
Non-selective muscarinic antagonist; dry mouth, glaucoma, mydriasis, hypotension, palpitations, urinary
retention, tachycardia, constipation, bronchospasm,

Pink puffer ( emphysema ) Blue bloater ( chronic bronchitis )

Fighter Non fighter
( overventilate to maintain normal blood gases ) ( unable to compensate by increasing ventilation )
Thin ( weight loss due to difficulty in eating ) Obese
Small sputum volume Large sputum volume
Rarely edematous Often edematous
Purse breathing ( prevent airway collapse )
Non cyanotic Cyanotic ( ventilation perfusion mismatch )
Barrel chest ( hyperinflation ) dramatic Barrel chest may be present
Increased total lung capacity Normal total lung capacity
Decreased diffusing capacity Normal diffusing capacity
Normal blood gases Hypercapnea and hypoxemia ( pulmonary hypertension )
There is proportionate loss of ventilation and There is disproportionate loss of ventilation and
perfusion perfusion
Dyspnea with use of accesory muscles Less respiratory distress
Cor pulmonale in advanced cases Cor pulmonale is frequent
Polycythemia in advanced cases Polycythemia is frequent
Loss of elastic tissue, airways often collapse during Excessive bronchial secretion and airflow obstruction
expiration ( air trapping )
Hyperresonant on percussion Increased resonance on percussion
Decreased breath sounds Decreased breath sounds w wheezing
7. Part I : A 27 year old man complains of blood in his urine over the past week.

a. State four causes of hematuria. [ 2m ]

Kidney stone, nephritic syndrome, UTI, bladder carcinoma, renal cell carcinoma
b. State three investigations you would carry out for this patient. [ 3m ]
Urine analysis, renal ultrasound, intravenous pyelogram, kidney ureter bladder X ray
c. State three sites where constriction of ureter occur. [ 3m ]
Ureteropelvic junction, crosses common iliac vessels at pelvic brim, and when it pierces bladder wall.

Part II : Ultrasound shows massively enlarged kidneys bilaterally. The surface of both kidneys is covered with
well circumscribed cysts.

d. State the provisional diagnosis. [ 1m ]

Adult polycystic kidney disease
e. Describe micturition reflex. [ 3m ]
Filling of bladder raises the intravesical pressure. Stretch receptors are stimulated. Cortical inhibition is
removed. Pelvis floor muscle is relaxed. Contraction of detrusor muscle of the bladder occurs. Intra-
abdominal pressure is increased by contracting abdominal muscles. Internal and external urethral
sphincters are relaxed. Urine in the urethra is emptied by gravity in females and by the contraction of
bulbocavernosus muscle in males.
f. Describe the development of nephron. [ 2m ]
Epithelial-Mesenchyme Interaction. Signals released from the ureteric bud induce the differentiation of
the metanephrogenic blastema into nephron.

Part III : After a few years, the patient is presented with sudden, severe headache described as the worst
headache his life.

g. Explain the patient’s condition. [ 2m ]

Subarachnoid hemorrhage due to rupture of a berry aneurysm of the circle of Willis.
h. State the arteries which form the circle of Willis. [ 3m ]
Anterior communicating, anterior cerebral, internal carotid, posterior communicating and posterior
cerebral artery.
i. State the significance of circle of Willis. [ 1m ]
If one part of the circle becomes blocked or narrowed or one of the arteries supplying the circle is blocked
or narrowed, blood flow from the other blood vessels can often preserve the cerebral perfusion well
enough to avoid the symptoms of ischemia.

8. Part I : A 30 year old patient is admitted into the hospital with severe epigastric pain radiating to the back.
Pain is relieved by leaning forward. He also complains of nausea and vomiting.

a. State two possible causes of severe epigastric pain radiating to the back. [ 2m ]
Acute pancreatitis, penetrating peptic ulcer, aortic dissection
b. Define acute abdomen. [ 1m ]
Any serious acute intra-abdominal condition attended by pain, tenderness, and muscular rigidity and for
which emergency surgery must be considered.
c. State three indications for endoscopic retrograde cholangiopancreatography ( ERCP ). [ 3m ]
Gallstone, pancreatic head tumour, cholangiocarcinoma, obstructive jaundice, Endoscopic
sphincterotomy, dilation of strictures in primary sclerosing cholangitis, chronic pancreatitis

Part II : Physical examination shows guarding and presence of rebound tenderness in the epigastric region.
Cullen and Grey Turner signs are positive.

d. State three laboratory findings to support your diagnosis. [ 3m ]

Elevated amylase and lipase levels, leucocytosis
e. State four causes of the disorder. [ 2m ]
Gallstone, alcoholism, mumps, hypercalcemia, scorpion bite, pancreatic tumour
f. State two complications of the disorder. [ 2m ]
Pancreatic pseudocyst, abscess formation, bile duct obstruction, DIC, ARDS

Part III : The patient develops dyspnea, tachypnea and cyanosis after several days. Bilateral fine inspiratory
crackles are heard upon auscultation of the chest. He is diagnosed with adult respiratory distress syndrome.

g. State the four criteria for diagnosis of adult respiratory distress syndrome. [ 4m ]
Acute respiratory failure, diffuse bilateral infiltrates on chest radiography, absence of left atrial
hypertension and hypoxemia
h. Describe the clinical course of adult respiratory distress syndrome. [ 3m ]
Exudative – fibroproliferative – fibrosis

9. Part I : A 25 year old patient is presented with fever, chills, headache and nuchal rigidity. He also
complains on photophobia and vomiting.

a. What is meningism ? State two causes of meningism. [ 3m ]

Meningism is the triad of nuchal rigidity, photophobia and headache. Meningitis, subarachnoid
hemorrhages, encephalitis
b. State two investigations you would carry out for this patient. [ 2m ]
CSF analysis, blood culture, complete blood count, latex agglutination test to detect specific bacterial
antigens
c. Name two bacteria which commonly cause meningitis in young adults. [ 2m ]
Streptococcus pneumoniae, Nesseria meningitidis

Part II : Blood culture of the patient shows encapsulated gram-negative diplococcus. Petechial rash is
found to be present in this patient. Persistent bleeding occurs at the skin puncture sites for intravenous
injection. The patient has developed disseminated intravascular coagulation.

d. Describe the pathophysiology of disseminated intravascular coagulation in this patient. [ 3m ]

Tissue factor is released in response to exposure to endotoxin produced by gram negative bacteria. Upon
activation, tissue factor binds with coagulation factors and trigger both the intrinsic and the extrinsic
pathways of coagulation. Clotting factors are consumed in the development of multiple clots, which
contributes to the bleeding seen with DIC.

e. State four other causes of disseminated intravascular coagulation. [ 2m ]

Carcinomas of lung, pancreas, prostate and stomach, abruptio placentae, retained dead fetus, amniotic
fluid embolism, massive tissue injury ( trauma, burns, extensive surgery ), liver disease, snake bite, acute
intravascular hemolysis, vasculitis, aortic aneurysm

f. Define primary and secondary phase of hemostasis. [ 2m ]

Primary phase – involves blood vessel and platelet; secondary phase – involves coagulation factors

Part III : The coagulation profile of the patient confirmed the diagnosis and appropriate treatment is given
promptly.

g. State the findings you would expect in the following [ 3m ]

- Fibrin degradation products ( D dimers ) – high
- Partial thromboplastin time (PTT) – prolonged
- Platelet count – low
- Prothrombin time (PT) – prolonged
- Bleeding time – prolonged
- Serum fibrinogen – low
h. State another condition when D dimers test is ordered. [ 1m ]
Deep vein thrombosis, pulmonary embolism

i. Suggest two treatment and management for this patient. [ 2m ]

Platelet concentrate for thrombocytopenia / cryoprecipitate replace fibrinogen and factor VIII / fresh
frozen plasma to increase levels of other clotting factors

10. Part I : A 30 year old female is presented with amenorrhoea for the past three months. Diagnosis of
pregnancy is ruled out in this patient.

i. Define anovulatory amenorrhoea. [ 1m ]

Absence of menstruation and ovulation.

ii. State three causes of anovulatory amenorrhoea. [ 3 m ]

Kallmann syndrome, hyperprolactinemia, hypopituitarism due to Sheehan's syndrome, gonadal
dysgenesis, hypothyroidism, hyperthyroidism, Cushing syndrome, polycystic ovary syndrome (
PCOS )

iii. Outline the process in oogenesis. [ 3m ]

Oogonium → primary oocyte → secondary oocyte ( after ovulation ) → ovum ( after fertilization )
→ zygote

Part II : The patient has been having palpitations and weight loss despite increase in appetite. A thyroid
function test is carried out.

i. State the probable diagnosis and the findings you would obtain in the thyroid function test. [ 3m ]
Hyperthyroidism. High serum free T4 and free T3, low serum TSH

ii. State the investigation to be carried out in this patient to rule out malignancy. [ 1m ]
Fine needle aspiration cytology of the thyroid gland

iii. Explain the pathogenesis of palpitations, weight loss and amenorrhoea in this patient. [ 3m ]
Palpitations – increased sensitivity to catecholamines. Weight loss – increased basal metabolic rate.
Amenorrhoea – high TH stimulates production of sex hormone binding globulin, resulting in low free
sex hormones

Part III : The diagnosis of hyperthyroidism has been made. Anti thyroid drug therapy is given.

i. Name one antithyroid drug and describe its mechanism of action. [ 1m ]

Propylthiouracil by inhibiting thyroperoxidase in the iodination of thyroglobulin ( organification )
and coupling process

ii. Outline the synthesis of thyroid hormone. [ 4m ]

Iodide trapping – oxidation to iodine – iodination of tyrosine / organification - coupling of MIT and
DIT

iii. State two organs which are not affected by thyroid hormones. [ 1m ]
Testes, brain, spleen, uterus and thyroid gland.

By wehloong