UNIVERSITY OF JUBA

COLLEGE OF MEDICINE

DEPARTMENT OF PATHOLOGY

4TH YEAR FINAL EXAMINATIONS IN

PATHOLOGY

OCTOBER 2015

NAME:_________________________________________________

INDEX NO. ____________________________________________

TIME: THREE (3) HOURS DATE : 7/10/2015

EXAMINERS:

External Examiner: Prof. Salvador Jaja,

Internal Examiners: Staff, Department of Pathology

INSTRUCTIONS
This examination comprises of three sections:

Section A : 60 multiple choice questions (SBQs).

Section B : 6 short notes question.

Section C: 4 problems.

All specified questions in all sections should be attempted

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SECTION A : SINGLE BEST MCQs
You are provided with a tabulated answer sheet for the MCQs.

Select ONLY the best answer

1. Presence of normal pancreatic tissue in the wall of stomach is an example of: -

A. Choristoma
B. Hamartoma
C. Low grade dysplasia
D. High grade dysplasia
E. Malignant neoplasm

2. A tumour composed of cells derived from the three germ cell layers is called: -
A. Choristoma
B. Hamartoma
C. Pleomorphic adenoma
D. Teratoma
E. Dysplasia

3. The most important criterion to differentiate a malignant neoplasm from a benign

neoplasm is: -
A. Number of mitoses
B. Degree of pleomorphism
C. Presence of a capsule
D. Rate of growth
E. Presence of metastases

4. All of the following are acquired preneoplastic conditions EXCEPT: -

A. Familial adenomatosus polyposis coli
B. Endometrial hyperplasia
C. Liver cirrhosis
D. Oral leukoplakia
E. Cervical dysplasia

5. Ebstein Barr virus (EBV) infection might cause all of the following malignant
Tumors Except: -
A. Gastric adenocarcinoma
B. Primary central nervous system lymphoma
C. Hodgkin lymphoma
D. Nasopharyngeal carcinoma
E. Burkitt lymphoma

6. All of the following are risk factors for thrombosis EXCEPT:

A. Von Willibrand factor deficiency
B. Myocardial infarction
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 C. Immobilization
D. Pregnancy
E. Antiphospholipid antibody syndrome

7. The following chemical mediators belong to the same family EXCEPT: -

A. Lipoxins
B. Prastaglandins
C. Interleukins
D. Leukotrines
E. thromboxane

8. One of the following is an example of Non- infectious type granulomatous disease;

A. Tuberculosis
B. Cat scratch disease
C. Syphilis
D. Sarcoidosis
E. leprosy
9. The following are cardinal signs of acute inflammation EXCEPT:
A. Increased temperature of the affected organ.
B. Redness
C. Swelling of the affected organ
D. Loss of function
E. Gangrene of the affected organs.
10- Gangrene is
A. Coagulative necrosis
B. Liquefactive necrosis
C. Pitting edema
D. Benign neoplasm
E. Apoptosis.

11. Which one of the following is NOT labile cell?

A. Endothelial cells
B. Epidermal cells
C. Uterine endometrial cells
D. Gastric mucosal cells
E. Urinary bladder transitional cells.

12. Atrophy is not caused by:

A. Decreased work load
B. Loss of innervations
C. Diminished blood supply
D. Hormonal stimulation
E. Aging.

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15. The most common outcome of acute inflammation is:
A. Resolution
B. Fibrosis
C. Abscess formation
D. Progression to chronic inflammation
E. Scar

16. Schistosomiasis
(a) Schistosomal polyps in the intestine can lead to intussusception
(b) Portal hypertension is a feature
(c) Pulmonary hypertension is a feature
(d) S. mansoni can caused mesangiocapillary glomerulonephritis
(e) Metrifonate and Oxamniquine are effective for all the schistosoma species
including other flukes and tapeworms

17. Complications of malaria include:

(a) Pulmonary oedema
(b) Acute renal failure
(c) Choleraic malaria
(d) DIC
(e) Burkhitts Lymphoma or Nephrotic syndrome

18. Pathologic features of extra-pulmonary TB include;

(a) Sterile pyuria
(b) Addisons disease
(c) Potts disease
(d) Scrofula
(e) Tuberculous multi-arthris

19. X-linked recessive disorders include ;

(a) Diabetes Insipidus
(b) Duchene muscular dystrophy
(c) Hemophilia A and B
(d) G6PD deficiency
(e) Thalassaemia

20. In minimal-change disease of the glomerulli:

a-The incidence is greatest between the ages of 2 and 4 years
b-Fusion of the foot processes of podocytes is seen on electron microscopy
c-A non –selective proteinuria is usual
d-Light microscopy shows crescent formation in glomerulli
e-Cells of the proximal tubules contained lipid droplets

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21. Breast carcinoma:
a-Is less common in women who give birth before the age of 18 years compared with
those who give birth after the age of 30 years
b-Is most commonly found in the lower outer quadrant of the breast
c-Has a better prognosis if positive for oestrogen receptors
d-Has a better prognosis if of a tubular , rather than ductal type
e-May be associated with microcalcification

22. The following are risk factors for formation of cholesterol stones in the
gallbladder:
a-Obesity
b-Chronic hemolytic anaemia
c-Ileal bypass
d-Alcoholic liver cirrhosis
e-Clofibrate therapy

23. The following are the features of portal hypertension

a-Ascites
b-Oesophageal varices
c-Rectal varices
d-Splenic atrophy
e-Caput medusa of the bare ara of the liver

24. Viral Hepatitis

a-Hepatitis C virus is the commonest cause of post-transfusion hepatitis
b-Hepatitis A virus infection is transmitted by both parenteral and oral routes
c-Incubation period for hepatitis A virus is 2-4 weeks
d-The infective units of hepatitis B virus are called Dane particles
e-Hepatitis B virus is an aetiological agent of Hepatocellular carcinoma.

25. Peptic duodenal ulcers

a-Are less common than gastric peptic ulcers
b- Are associated with hyposecretion of gastric acid
c- Are usually multiple
d- Are usually sited in the second and the third parts of the duodenum
e- Usually require surgical treatment

26. The following are major risk factors for the development of atherosclerosis
a- Cigarette smoking
b- Hypocholesterolaemia
c- Hypertension
d- Diabetes insipidus
e- Male or Female sex

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27- Aschoff Bodies
a- Contain fibroblasts
b- May contain Anitschokow Cells
c- Are found exclusively in the heart
d- Are always associated with active rheumatic fever
e- May contain Askanazy cells

28- Lesions of fibrinoid necrosis

a- Contain fibrin
b- Are seen in Glomerulonephritis due to SLE
c- Affect arteries in benign hypertension
d- Are seen in rheumatic fever
e- Are a cause of aneurismal dilatation of arteries

29- Mechanisms of oedema formation are :

a- Increased vascular hydrostatic pressure
b- Increased plasma colloid osmotic pressure
c- Increased interstitial colloid osmotic pressure
d- Inflammation or lymphatic obstruction
e- Decreased interstitial colloid osmotic pressure

30- Differences between Carcinoma and Sarcoma include:

a-Carcinoma is commonest in the middle and old ages while sarcoma occurs in all
age groups
b- Carcinoma grows more rapidly than Sarcomas
c- Carcinomas spread early through lymphatics
d- Most of the Carcinomas are radiosensitive while Sarcomas are radioresistant
e- Carcinoma is the tumor of connective tissues while Sarcoma is the tumor of
epithelial tissue

31- Tumors that secret ECTOPIC endocrine hormones include :

a- Small cell carcinoma of the lung
b- Medullary carcinoma of the thyroid
c- Renal cell carcinoma
d- Hepatocellular carcinoma
e- Osteosarcoma

32. The following are considered hereditary tumors:

a- Retinoblastoma
b- Wilms tumor
c- Multiple Endocrine Neoplasia
d- Familial adenomatous polyposis coli

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 e- Breast carcinoma
33. Examples of malignant tumours include:
a- Lymphoma
b- Seminoma
c- Bronchial adenoma
d- Pleomorphic adenoma
e- Melanoma

34. Myocardial Infarction (MI) can be diagnosed by:

a- Medical history
b- ECG finding
c- Cardiac Troponin I
d- Creatinine Kinase ( CK-MB)
e- ECG with narrow QRS wave

35. Bronchiectasis:
a- A prominent dilatation of bronchi and bronchioles due to elastic wall destruction
b- Productive cough with foul smelling sputum is characteristic
c- Long lasting bronchial destruction may lead to it
d- Curschman’s Spirals and Charcot-Leyden crystals are present in the mucus plugs
e- Clubbing of finger nails is common

36. Features of bronchogenic carcinoma:

a- Small cell carcinoma is the most aggressive type
b- Squamous cell and Small cell carcinomas are centrally located
c- Squamous cell carcinoma has strong association with smoking
d- Adenocarcinoma has strong association with smoking and more common in males
e- Small cell carcinoma is the most common type

37. Risk factors and features of Hepatocellular Carcinoma (HCC) include:

a- Aflatoxin
b- HBV and HCV
c- Hepatitis
d- Hepatic Cirrhosis
e- Elevated Alpha-fetoprotein

38. Necrosis is recognized by the following EXCEPT;

(a) Cellular eosinophilic staining
(b) Nuclear swelling
(c) Elevated levels of intracellular enzymes
(d) Features of inflammatory reaction
(e) Calcification seen in areas of fat necrosis

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39. Metaplasia
(a) Is an irreversible phenomenon
(b) Results from chronic irritation
(c) Smoking, a known cause
(d) Usually from columnar to transitional epithelium
(e) Involves epithelial tissue and not connective tissue

40. A 11-year old boy has had sneezing with watery eyes and running
nose for 12 days. On physical examination he has red, swollen nasal
mucosal surfaces. He has similar attacks each spring and summer. His
symptoms are most likely to be due to:
(a) Pulmonary Tuberculosis
(b) Viral common cold
(c) Type I hypersensitivity reaction
(d) Drug allergy
(e) Lobar pneumonia

41. The following are examples of suppurative inflammatory disorders

EXCEPT;
(a) Abscess
(b) Furuncle
(c) Cellulitis
(d) Bacillary dysentery
(e) Carbuncle

42. The most common cause of delayed wound healing is ;

(a) Old age
(b) Vit C deficiency
(c) Protein deficiency
(d) Length of the wound
(e) Infection

43. The following are sites of metastatic calcification EXCEPT;

(a) Mucosa of the stomach
(b) Old thrombi
(c) Renal tubules
(d) Wall of lung alveoli
(e) Wall of blood vessels

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 44. The following are factors for the development of venous
thrombosis EXCEPT;
(a) Endothelial damage
(b) Haemoconcentration
(c) Increased fibrinogen
(d) Stasis
(e) Decreased plasma protein

45. After 10 days in the hospital following a fall in which she

sustained a fracture of her trochanter, a 70 year old lady
developed left leg swelling, particularly below the knee. She
experienced pain on movement of her leg, and there is tenderness
on palpation. Which of the following complications is most likely
to occur after these days ;
(a) Gangrenous necrosis of the foot
(b) Haematoma of the foot
(c) DIC
(d) Pulmonary Thromboembolism
(e) Soft tissue sarcoma

46. Amoebiasis
(a) Can cause chronic amoebic keratitis
(b) Can cause amoebic meningoencephalitis
(c) Can cause granulomatous meningoencephalitis in immunocompromised subjects
(d) Can cause penile lesions
(e) Can cause low grade peritonitis

47.Hyper acute transplant rejection;

(a) Occurs within minutes
(b) Occurs within days
(c) Occurs in patient with previously formed antibodies
(d) Evokes an Arthus-like reaction
(e) Results in ischemic necrosis of graft

48. Sensitivity of tumors to radiotherapy depends on the following

factors, EXCEPT;
(a) Higher degree of mitotic activity in tumor cells
(b) Tissue of origin
(c) Whether the cells are labile, stable or permanent
(d) Tumors of labile cells are more sensitive to radiotherapy, while the tumors of
permanent cells are least sensitive
(e) Well differentiated tumors are more sensitive as compared to poorly differentials

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49.Teresa, 30 years old lady presented to a specialized clinic with non-
tender lymphadenopathy, low grade fever, night sweat and
generalized malaise for several months. The histological features
show the presence of cells resembling OWL eyes appearance. So ,
the best diagnosis is :
(a) Multiple myeloma
(b) Cat Scratch disease
(c) Burkhits Lymphoma
(d) Hodgkin’s Lymphoma
(e) Non-Hodgkin’s Lymphoma

50. The best blood product for treating patients with deficiencies of
multiple coagulation factors who are actively bleeding is ;
(a) Whole blood
(b) Cryoprecipitate
(c) Packed RBCs
(d) Granulocytes
(e) Fresh Frozen Plasma

51.A 44-year old male alcoholic presents with fever and a productive
cough with copious amounts of foul-smelling purulent sputum.
Physical examination finds that changing the position of this
individual produces paroxysms of coughing. Which one of the
following is most likely responsible for this patients signs and
symptoms?
(a) Esophageal cancer
(b) Esophageal reflux
(c) Myocardial Infarction
(d) Pulmonary abscess
(e) Pulmonary infarction

52.A 49-year old female taking ibuprofen for increasing joint pain in
her hands presents with increasing pain in he midsternal area.
Endoscopy reveals multiple , scattered, punctuate hemorrhagic
areas in her gastric mucosa. Biopsies from one of these
hemorrhagic lesions reveal mucosal erosions with edema and
hemorrhages. No mucosal ulceration is seen. What is the best
diagnosis ?
(a) Active chronic gastritis
(b) Acute gastritis
(c) Chronic gastritis

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 (d) Autoimmune gastritis
(e) Peptic Ulcer Disease

53.Which of the following cells has the most significant role in the
pathogenesis of Rheumatoid arthritis
(a) CD 4 T-helper
(b) CD 8 T-cells
(c) NK-cells
(d) Mast cells
(e) Neutrophils

54.The combination of severe acute flank pain and microscopic

Haematuria is suggestive of;
(a) Cholelithiasis
(b) Renal tumor
(c) Urolithiasis
(d) Urinary bladder stone
(e) Adrenal tumor

55.A 22-year old male presents with a testicular mass, which is

resected and diagnosed as being a yolk sac tumour. Which one of
the listed substances is most likely to be increased in this patients
serum as a result of being secreted from the cells of the tumour?
(a) Acid Phosphatase
(b) Alpha-Fetoprotein ( AFP )
(c) Alkaline Phosphatase
(d) Beta-human chorionic gonadotrophin ( B-hCG )
(e) Prostate-specific antigen ( PSA )
56.A 49-year old man smokes two packs of cigarettes a day presents
with a lung mass on x-ray and recent weight gain. Lab examination
shows hyponatraemia with hyperosmolar urine. The patient
probably has ;
(a) Renal failure
(b) Pituitary failure
(c) Conn’s Syndrome
(d) Cardiac failure
(e) Inappropriate ADH Syndrome

57. Meningiomas:
a-Account for 15 -20% of primary intracranial tumors.
b-Are thought to arise from the arachnoid granulations
c-Are usually malignant
d-Microscopically, often show psammonia bodies and whorl formation
e-Are common in Lindau’s disease

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 58. The features of osteoporosis include:
a-Decreased incidence of bony fractures
b-An association with Cushing’s syndrome
c-A lack of active vitamin D
d-Reduction in the mineralization of bone
e-Thinning of cortical bone

59. Squamous cell carcinoma of the skin

a-Was a common tumour of early radiologists
b-Arises most commonly on the face, the back of the hands and the pinna of the ears
c-Is radiosensitive
d-Is associated with exposure to soot
e-May arise at the edges of long- standing ulcers

60. The following are correct concerning calcium disorders:

a-Multiple myloma or prolonged immobilization can cause hypercalcaemia
b-High calcium levels can predispose to renal s
c-In hypocalcaemia, tingling sensation, tetany and cardiac arrhyttunias are recognized
features.
d-The cause of hypocalcaemia can be due to hypoparathyroidism
e-Cataracts is a complication of hypocalcaemia

SECTION B: SHORT NOTES

1. OUTLINETHE CAUSES OF CELL INJURY, AND DISCUSS BRIEFLY

THE BIOCHEMICAL MECHANISMS THAT ARE INVOLVED IN CELL
INJURY.

Here is an outline of some common causes of cell injury:

1. Physical Agents:
- Mechanical trauma: Blunt force, lacerations, fractures.
- Thermal injury: Heat or cold exposure.
- Radiation: Ionizing radiation, ultraviolet radiation.

2. Chemical Agents:
- Drugs and toxins: Medications, environmental toxins, alcohol, heavy
metals.
- Chemical irritants: Acids, alkalis, corrosive substances.

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 - Endogenous metabolites: Accumulation of substances like bilirubin or
uric acid.

3. Infectious Agents:
- Bacteria, viruses, fungi, parasites.
- Microbial toxins or byproducts.

4. Immunological Reactions:
- Autoimmune diseases: Autoantibodies targeting self-tissues.
- Hypersensitivity reactions: Allergies, immune complex-mediated
diseases.

5. Genetic Factors:
- Inherited genetic abnormalities: Mutations affecting cellular function or
metabolism.
- Genetic predisposition to certain diseases or conditions.

Now, let's briefly discuss the biochemical mechanisms involved in cell

injury:

1. ATP Depletion: Cellular injury often leads to a decrease in ATP

production or increased ATP consumption. Without sufficient ATP, cellular
functions, such as ion pumping and maintaining membrane integrity, are
compromised.

2. Mitochondrial Dysfunction: Mitochondrial damage can occur, leading to

reduced oxidative phosphorylation and increased production of reactive
oxygen species (ROS). This can further exacerbate cellular injury.

3. Generation of Reactive Oxygen Species (ROS): ROS, including free

radicals like superoxide and hydroxyl radicals, can be generated during
cellular injury. These reactive molecules can damage cellular components,
including proteins, lipids, and DNA.

4. Calcium Homeostasis Disruption: Increased intracellular calcium levels

can activate variousenzymes, leading to cellular damage. Excessive calcium
influx can disrupt membrane integrity, activate proteases, and impair
mitochondrial function.

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5. Oxidative Stress: The imbalance between the production of ROS and the
antioxidant defense system can lead to oxidative stress. This can result in
damage to lipids, proteins, and DNA.

6. Membrane Damage: Cell injury can cause disruption of the plasma

membrane, leading to loss of cellular contents and influx of damaging
substances.

7. Protein Misfolding and Aggregation: Cellular stress can result in

misfolding and aggregation of proteins, leading to cellular dysfunction and
impaired protein home

2. URINALYSIS

Urinalysis is a diagnostic test that examines the physical and chemical

properties of urine. It involves analyzing a urine sample to assess various
components, such as:

1. Color: Urine color can range from pale yellow to dark amber, and
abnormal colors may indicate certain health conditions.

2. Appearance: The clarity or turbidity of urine can provide insights into

the presence of substances like bacteria, blood, or mucus.

3. Specific gravity: This measurement indicates the concentration of solutes

in the urine and can help assess kidney function.

4. pH level: Urine pH indicates the acidity or alkalinity of the urine, which

can be influenced by diet and certain medical conditions.

5. Protein: The presence of protein in urine (proteinuria) can indicate kidney

damage or other underlying conditions.

6. Glucose: Elevated levels of glucose in urine (glycosuria) may indicate

diabetes or other metabolic disorders.

7. Ketones: The presence of ketones in urine can indicate abnormal

metabolism, such as in uncontrolled diabetes or certain dietary conditions.

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8. Blood: The presence of blood in urine (hematuria) can suggest various
conditions, including urinary tract infections, kidney stones, or kidney
disease.

9. Nitrites and leukocyte esterase: These can indicate the presence of

urinary tract infections caused by bacteria.

10. Microscopic examination: This involves examining the urine sample

under a microscope to identify the presence of red blood cells, white blood
cells, bacteria, or other cellular elements.

3. (A) DEFINE NEOPLASM AND DISCUSS THE PATHWAYS OF IT’S

SPREAD.

(a) A neoplasm is an abnormal growth of cells that forms a mass or tumor.

It is commonly referred to as a tumor, which can be benign or malignant. Neoplasms
occur due to uncontrolled cell division and can arise from various tissues in the body.
Benign neoplasms are non-cancerous and tend to grow slowly without invading nearby
tissues or spreading to other parts of the body.
Malignant neoplasms, also known as cancerous tumors, have the potential to invade
nearby tissues, spread to distant sites, and cause significant damage to the body.

The pathways of neoplastic spread include:

1. Local invasion: Malignant neoplasms can invade nearby tissues and organs by
infiltrating into surrounding structures. This occurs as cancer cells grow and penetrate the
surrounding tissue, destroying normal tissue architecture and function.

2. Lymphatic spread: Many cancers have the ability to spread through the lymphatic
system. Cancer cells can enter lymphatic vessels near the primary tumor, travel through
lymph nodes, and form new tumors in distant lymph nodes. This is a common pathway
for the spread of breast cancer, melanoma, and certain other malignancies.

3. Hematogenous spread: Some cancers spread through the bloodstream. Cancer cells
can invade blood vessels and enter the circulation, allowing them to travel to distant
organs and tissues. This is often how metastatic tumors are formed in organs such as the
liver, lungs, bones, and brain.

4. Transcoelomic spread: Certain cancers can spread within body cavities lined with
serous membranes, such as the peritoneal or pleural cavity. Cancer cells can shed into the
fluid within these cavities and establish new tumors on the surfaces of organs within the
cavity. This is seen in cancers like ovarian cancer and mesothelioma.

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 (B) SHOCK: DEFINITION, TYPES AND COMPLICATIONS

(b) Shock is a life-threatening medical condition characterized by

inadequate blood flow and oxygen delivery to the body's organs and
tissues. It can result from various factors that disrupt the body's
normal circulation and compromise adequate tissue perfusion.

There are several types of shock, including:

1. Hypovolemic shock: This occurs when there is a significant loss of

blood volume or fluid, such as from severe bleeding, dehydration, or
fluid loss due to burns. It leads to decreased circulating blood volume,
reduced cardiac output, and inadequate tissue perfusion.

2. Cardiogenic shock: This type of shock is caused by a severe

dysfunction of the heart, leading to inadequate pumping of blood. It
can result from conditions such as myocardial infarction (heart
attack), heart failure, or severe arrhythmias.

3. Distributive shock: This type of shock is characterized by

abnormal distribution of blood flow within the body, often due to
vasodilation and increased vascular capacity. The most common
forms of distributive shock are:

a. Septic shock: Caused by a severe infection (sepsis) that triggers

widespread inflammation and vasodilation.

b. Anaphylactic shock: Caused by a severe allergic reaction that

leads to a rapid release of histamine and other mediators, causing
widespread vasodilation and smooth muscle contraction.

c. Neurogenic shock: Caused by spinal cord injuries or severe

central nervous system disorders that result in loss of sympathetic
nervous system control over blood vessel tone and heart rate.

4. Obstructive shock: This occurs when there is a mechanical

obstruction that prevents adequate blood flow, leading to decreased
cardiac output. Examples include pulmonary embolism (blockage of
pulmonary artery), tension pneumothorax (accumulation of air in the

16
pleural space), or cardiac tamponade (compression of the heart by
fluid or blood in the pericardial sac).

Complications of shock can varydepending on the type and

severity. They may include:

- Organ dysfunction or failure: Inadequate blood flow and oxygen

supply can lead to organ damage or failure, particularly in vital organs
such as the heart, liver, kidneys, and lungs.

- Acute respiratory distress syndrome (ARDS): Severe shock can

cause lung injury, leading to the development of ARDS, which
impairs oxygen exchange in the lungs.

- Disseminated intravascular coagulation (DIC): In some cases of

severe shock, the body's coagulation system becomes dysregulated,
resulting in excessive bleeding in some

4. (A) THE COMPONENTS AND SIGNIFICANCE OF LIVER FUNCTION

TESTS IN A DECOMPENSATED CHRONIC LIVER DISEASE DUE TO
HBV INFECTION.
Liver function tests (LFTs) are a group of blood tests that provide
information about the overall liver function and help assess liver
health. In the context of decompensated chronic liver disease due to
HBV infection, LFTs are essential for monitoring the severity of liver
damage and guiding treatment decisions. The components and
significance of LFTs in this condition include:

1. Alanine Aminotransferase (ALT): ALT is an enzyme primarily

found in liver cells. Elevated ALT levels indicate liver inflammation
and damage. In chronic HBV infection, persistent elevation of ALT
suggests ongoing liver injury and inflammation.

2. Aspartate Aminotransferase (AST): AST is an enzyme found in

various tissues, including the liver. Elevated AST levels can indicate
liver damage, but they are less specific to the liver compared to ALT.
AST levels may also be elevated in conditions affecting other organs,
such as the heart or muscles.

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3. Bilirubin: Bilirubin is a yellow pigment produced from the
breakdown of red blood cells. Increased levels of bilirubin can
indicate impaired liver function, typically seen as jaundice (yellowing
of the skin and eyes). In decompensated chronic liver disease,
elevated bilirubin suggests liver dysfunction and impaired bilirubin
processing.

4. Albumin: Albumin is a protein produced by the liver. Reduced

levels of albumin in the blood can indicate severe liver damage or
impaired synthetic function of the liver. Low albumin levels may
contribute to fluid accumulation (ascites) and other complications in
decompensated chronic liver disease.

5. Prothrombin Time (PT) and International Normalized Ratio

(INR): PT and INR are measures of blood clotting ability. In liver
disease, the liver's ability to produce clotting factors is compromised.
Consequently, prolonged PT and increased INR values suggest
impaired liver synthetic function and an increased risk of bleeding.

6. Gamma-Glutamyl Transferase (GGT):GGT is an enzyme found

in liver cells and bile ducts. Elevated GGT levels can indicate liver
damage or obstruction of the bile ducts. In chronic liver disease due to
HBV infection, elevated GGT levels may suggest ongoing liver injury
or cholestasis (impaired bile flow).

(b) Classification and laboratory diagnosis of Leukaemias

Leukemia is a group of cancers that affect the blood-forming tissues,

particularly the bone marrow and blood. Laboratory diagnosis of
leukemias involves various tests that help classify and identify the
specific type of leukemia. The classification and laboratory diagnosis
of leukemias typically include the following:

1. Blood Tests: A complete blood count (CBC) measures the levels of

red blood cells, white blood cells, and platelets in the blood.
Abnormalities in these cell types can indicate leukemia. Additionally,
peripheral blood smear examination allows the identification of
abnormal blood cells, such as immature or abnormal-looking white
blood cells.

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2. Bone Marrow Aspiration and Biopsy: These procedures involve
the extraction of a small sample of bone marrow from the hipbone or
sternum. The samples are examined under a microscope to evaluate
the cellular composition of the bone marrow and identify abnormal
cells. Bone marrow examination helps classify the leukemia and
determine the percentage of blasts (immature cells) present, which is
crucial for diagnosis.

3. Immunophenotyping: Immunophenotyping is performed using

flow cytometry, a technique that uses specific antibodies to label and
identify cell surface markers. By analyzing the expression pattern of
these markers, immunophenotyping helps determine the lineage and
maturity of the leukemic cells. It aids in distinguishing between
different types of leukemia, such as acute lymphoblastic leukemia
(ALL) and acute myeloid leukemia (AML).

4. Cytogenetic Analysis: Cytogenetic analysis involves studying the

chromosomes of leukemic cells. It helps identify specific
chromosomal abnormalities, such as translocations, deletions, or
duplications, which are characteristic of certain types of leukemia. For
example, the Philadelphia chromosome (resulting from a translocation
between chromosomes 9 and 22) is associated with chronic myeloid
leukemia (CML).

5. Molecular Testing: Molecular testing involves the detection of

specific genetic mutations or alterations in leukemic cells. Polymerase
chain reaction (PCR) and other molecular techniques are used to
identify mutations that have diagnostic or prognostic significance. For
instance, the presence of BCR-ABL1 fusion gene (resulting from the
Philadelphia chromosome) is diagnostic of CML.

6. Lumbar Puncture: In some cases of leukemia, particularly ALL, a

lumbar puncture (spinal tap) may be performed. Cerebrospinal fluid
(CSF) is collected through a needle inserted into the spinal canal. CSF
examination helps determine if leukemic cells have spread to the
central nervous system.
5. (A) LABORATORY APPROACH OF CHEST INFECTIONS
When evaluating chest infections, a laboratory approach is often used
to aid in diagnosis and guide treatment. The laboratory tests
commonly employed in the assessment of chest infections include:
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1. Complete Blood Count (CBC): A CBC measures the levels of red
blood cells, white blood cells, and platelets in the blood. An elevated
white blood cell count, specifically an increase in neutrophils (a type
of white blood cell), can indicate an infection.

2. Sputum Culture and Gram Stain: A sputum sample may be

collected and analyzed to identify the presence of bacteria, fungi, or
other microorganisms causing the infection. A Gram stain is often
performed on the sputum sample to give preliminary information
about the type of bacteria present (Gram-positive or Gram-negative)
and their characteristics.

3. Blood Cultures: Blood cultures are collected to detect the presence

of bacteria or fungi in the bloodstream. This is particularly important
in cases of severe chest infections or suspected pneumonia that may
have spread beyond the lungs.

4. Respiratory Viral Panel: A respiratory viral panel is a multiplex

polymerase chain reaction (PCR) test that can detect the presence of
multiple respiratory viruses, including influenza, respiratory syncytial
virus (RSV), rhinovirus, and others. Viral infections can cause chest
infections and are especially common during certain seasons.

5. Serology: Serological tests can help identify specific antibodies

produced in response to certain infections. For example, serology may
be used to detect antibodies to Mycoplasma pneumoniae, Legionella
pneumophila, or other atypical bacteria associated with chest
infections.

6. Imaging Studies: While not a laboratory test, imaging studies such

as chest X-rays or computed tomography (CT) scans are commonly
used to visualize the lungs and identify areas of infection, such as
consolidation or infiltrates.

(B) COMPLICATIONS OF BLOOD TRANSFUSION

(b) Complications of blood transfusion can occur, although they are
relatively rare due to advanced screening and safety measures. Some
potential complications include:

20
1. Allergic reactions: Allergic reactions can range from mild to
severe. Mild reactions may include hives, itching, or rash, while
severe reactions can cause anaphylaxis, a life-threatening allergic
response characterized by difficulty breathing, low blood pressure,
and swelling of the throat.

2. Febrile non-hemolytic reactions: These reactions are

characterized by a sudden onset of fever during or after a transfusion.
They are usually benign but can cause discomfort and may be
accompanied by chills, headache, and muscle pain.

3. Acute hemolytic reaction: This is a severe and potentially life-

threatening reaction caused by the transfusion of incompatible blood.
It occurs when the recipient's immune system attacks and destroys the
donor red blood cells. Symptoms can include fever, chills, flank pain,
chest pain, shortness of breath, dark urine, and rapid heartbeat.

4. Transfusion-related acute lung injury (TRALI): TRALI is a rare

but serious complication characterized by acute respiratory distress
shortly after a blood transfusion. It is thought to be caused by an
immune response triggered by donor antibodies, leading to
inflammation in the lungs. Symptoms include shortness of breath, low
oxygen levels, and fluid buildup in the lungs.

5. Transfusion-associated circulatory overload (TACO): TACO

occurs when a large volume of blood is transfused too quickly,
overwhelming the recipient's circulatory system. This can lead to fluid
overload, causing symptoms such as shortness of breath, cough, and
swelling.

6. Infections: While blood banks follow strict protocols to ensure the

safety of donated blood, there is still a small risk of transmitting
infections, such as bacterial or viral infections. Screening tests are
performed to minimize this risk, but there is still a possibility of rare
or emerging infectious agents escaping detection.

7. Iron overload: Repeated blood transfusions, especially in

individuals with conditions like thalassemia or sickle cell disease, can
lead to iron overload in the body. Excess iron can accumulate in
organs and tissues, causing damage over time.
21
 6. DIAGNOSTIC CRITERIA FOR INFECTIVE ENDOCARDITIS

The diagnosis of infective endocarditis (IE) involves a combination of

clinical criteria, laboratory tests, and imaging studies. To make a definitive
diagnosis of infective endocarditis, one of the following combinations of
criteria must be met:

Definite Infective Endocarditis:

1. Pathological Criteria:
- Microorganisms detected by culture or histological examination in a
vegetation, embolized intracardiac mass, or an intracardiac abscess specimen
- Microorganisms detected by culture of blood samples (at least two
positive blood cultures), typically showing typical microorganisms
consistent with infective endocarditis, such as viridans group streptococci,
Staphylococcus aureus, or enterococci. Alternatively, persistently positive
blood cultures, defined as two positive cultures of blood samples drawn >12
hours apart, or all of three or a majority of four or more separate cultures of
blood samples, with first and last drawn at least 1 hour apart.

2. Clinical Criteria:
- Evidence of endocardial involvement, such as valvular destruction,
abscess, or new valvular regurgitation, detected by imaging studies (e.g.,
echocardiography).

Possible Infective Endocarditis:

1. One major criterion and one minor criterion, or

2. Three minor criteria.

Major Criteria for Infective Endocarditis:

1. Positive blood cultures consistent with infective endocarditis (typical

microorganisms, as mentioned above).
2. Evidence of endocardial involvement, as detected by echocardiography
(valvular dehiscence, abscess, vegetation).

Minor Criteria for Infective Endocarditis:

22
1. Predisposing heart condition or intravenous drug use.
2. Fever ≥ 38.0°C (100.4°F).
3. Vascular phenomena (e.g., arterial emboli, Janeway lesions).
4. Immunological phenomena (e.g., glomerulonephritis, Osler's nodes).
5.Microbiological evidence that does not meet major criteria or serological
evidence of active infection with an organism consistent with infective
endocarditis.

SECTION C : CLINICAL PROBLEM SOLVING

1. A LATE TEENAGE PRESENTED TO THE CASUALTY WITH SEVERE

CENTRAL ABDOMINAL PAIN AND VOMITING. HE WAS CONFUSED AND
DROWSY. THE PARENTS ADMITTED THAT SHE LOST WEIGHT RECENTLY
AND ALSO HE USED TO COMPLAIN OF DRY MOUTH.

O/E: HE WAS DEHYDRATED AND LOOKED IN PAIN.

PR=100/MIN, BP=90/60
CVS NOT RELEVANT, CNS ALSO NOT SIGNIFICANT.

ABDOMEN=TENDERNESS AROUND THE UMBILICUS.

IN THE CASUALTY THE DIAGNOSIS OF ACUTE PANCREATITIS WAS
MADE AND THE PATIENT REFERRED TO THE SURGICAL UNIT.
LAB. INVESTIGATIONS: NA =125MEQ/L, K =5.8MEQ/L,
UREA=60MG/DL(15-45) , CREATININE=2.0MG/DL (0.7-1.3) ,
HCO3=14MEQ/L ( 20-30), AMYLASE = 500U/L( 70- 300 ).
IN VIEW OF THESE RESULTS, URINE ANALYSIS WAS DONE AFTER
ADMISSION AND THE FINDINGS SEEN CHANGED THE COURSE OF
MANAGEMENT.
(A) WHAT DO YOU THINK IS THE NEW DIAGNOSIS?
(B) WHAT FURTHER TEST WOULD YOU DO?
(C ) HOW WOULD YOU MANAGE THIS CASE ?
(D) MENTION ONLY FIVE COMPLICATIONS DUE TO THIS CONDITION.
(a) Based on the provided information and laboratory findings, the new
diagnosis could be diabetic ketoacidosis (DKA).
(b) Further tests that could be done to confirm the diagnosis and assess the
severity of DKA include:
- Blood glucose level
- Arterial blood gas analysis

23
 - Serum ketone levels
- Complete blood count
- Electrolyte panel

(c) The management of this case would likely involve the following
steps:
1. Fluid resuscitation: Intravenous fluids, such as normal saline, would be
administered to correct dehydration and restore circulating volume.
2. Insulin therapy: Insulin would be initiated and administered
intravenously to reduce blood glucose levels and promote the entry of
glucose into cells.
3. Electrolyte correction: Abnormal electrolyte levels, such as low
sodium and high potassium, would be addressed through appropriate
interventions, such as electrolyte replacement.
4. Acid-base balance: Correction of the acidosis would be achieved
through insulin therapy and intravenous administration of bicarbonate if
severe acidosis is present.
5. Identification and treatment of underlying cause: The underlying
cause of DKA (such as uncontrolled diabetes) would be investigated and
managed accordingly.

(d) Complications associated with diabetic ketoacidosis include:

1. Cerebral edema: Swelling of the brain, which can lead to neurological
complications and potential brain injury.
2. Hypoglycemia: Occurs when blood glucose levels drop too rapidly
during treatment.
3. Hypokalemia: Low potassium levels in the blood, which can lead to
cardiac arrhythmias.
4. Acute respiratory distress syndrome (ARDS): Severe lung
inflammation that can cause breathing difficulties.
5. Acute kidney injury: Impaired kidney function due to the effects of
DKA on renal perfusion and function.

2. A YOUNG MAN, 24 YEARS OLD CAME TO YOUR CLINIC WITH RED

URINE.
(A) WHAT ARE THE POSSIBLE CAUSES?
(B) HOW WOULD YOU APPROACH THIS CASE?
(a) Possible causes of red urine in a young man include:

24
1. Hematuria: The presence of red blood cells in the urine, which can
indicate various underlying conditions. Causes of hematuria can include
urinary tract infections, kidney stones, bladder or kidney infections, urinary
tract trauma or injury, certain medications, strenuous exercise, or kidney
diseases such as glomerulonephritis or polycystic kidney disease.

2. Exercise-induced hematuria: Strenuous exercise, such as long-distance

running, can cause temporary blood in the urine due to the breakdown of red
blood cells during intense physical activity.

3. Urinary tract infection (UTI): Infections in the urinary tract, such as

cystitis (bladder infection) or urethritis (infection of the urethra), can cause
red or pink urine.

4. Kidney stones: The presence of kidney stones can lead to blood in the
urine, along with symptoms such as pain in the lower back or abdomen.

5. Medications: Certain medications, such as certain antibiotics, laxatives,

or anticoagulants, may cause urine discoloration.

(b) In approaching this case, the following steps can be taken:

1. Medical history: Obtain a detailed medical history, including any recent

illnesses, injuries, medications, or known medical conditions.

2. Physical examination: Perform a physical examination to assess vital

signs and look for any signs of trauma, infection, or other abnormalities.

3. Urinalysis: Collect a urine sample to perform a urinalysis, which can help

determine the presence of red blood cells, white blood cells, and other
abnormalities.

4. Additional tests: Depending on the findings of the urinalysis, further

tests may be required, such as a urine culture to check for infection, imaging
studies (such as ultrasound or CT scan) to evaluate the urinary tract or
kidneys, or blood tests to assess kidney function and rule out systemic
causes.

5. Referral if necessary: Based on the evaluation, referra to a urologist or

nephrologist may be required for further evaluation and management.
25
3. MAJDA, 22YEARS OLD TEACHER PRESENTED TO THE HEALTH FACILITY
WITH BLEEDING PER NOSE AND EXCESSIVE MENSTRUATION
( MENORRHAGIA ).
LAB INVESTIGATIONS:
HB= 10GM/DL
PLATELETS COUNT= 250,000/MM3
PROTHROMBIN TIME ( PT )= 13 SEC ( CONTROL =13 SEC )
PARTIAL THROMBOPLASTIN TIME = 60 SEC ( CONTROL = 35 SEC )
BLEEDING TIME = 15 MIN ( CONTROL = 3-8 MIN. )
I. COMMENT ON THE RESULTS
II. WHAT IS THE MOST LIKELY DIAGNOSIS?
III. EXPLAIN THE CAUSE OF THE PROLONGED BLEEDING TIME ?

Based on the provided lab investigations, the results suggest that Majda has
a bleeding disorder. The specific diagnosis is likely von Willebrand disease
(vWD), which is a common inherited bleeding disorder characterized by a
deficiency or dysfunction of von Willebrand factor (vWF), a protein
involved in clotting.

Interpreting the lab results:

1. Hemoglobin (Hb) level of 10 g/dL: This indicates that Majda has

anemia, which can be caused by the chronic blood loss associated with
excessive menstruation.

2. Platelet count of 250,000/mm3: The platelet count appears to be within

the normal range, indicating that thrombocytopenia (low platelet count) is
not the cause of the bleeding.

3. Prothrombin time (PT) of 13 seconds (control = 13 seconds): The PT is

within the normal range, suggesting normal function of the extrinsic
pathway of the coagulation cascade.

4. Partial thromboplastin time (PTT) of 60 seconds (control = 35

seconds): The prolonged PTT indicates a defect in the intrinsic pathway of
the coagulation cascade, which is commonly seen in vWD.

26
5. Bleeding time of 15 minutes (control = 3-8 minutes): The prolonged
bleeding time further supports the presence of a bleeding disorder, and in the
context of Majda's other symptoms, it is consistent with vWD.

Explanation for the prolonged bleeding time:

1. The prolonged bleeding time is primarily caused by a deficiency or

dysfunction of vWF in von Willebrand disease.

2. vWF plays a crucial role in platelet adhesion and aggregation, which are
necessary for normal blood clot formation and hemostasis.

3. In vWD, the impaired vWF function leads to defective platelet adhesion

and aggregation, resulting in prolonged bleeding time.

It's important for Majda to be further evaluated by a healthcare professional,

preferably a hematologist, to confirm the diagnosis and determine the
specific type and severity of von Willebrand disease. Treatment options,
such as desmopressin (DDAVP) or replacement therapy with vWF
concentrate, can be considered to manage the bleeding symptoms associated
with vWD.

4. NYANDENG, 46 YEARS OLD WOMAN, PRESENTED WITH YELLOWISH

SCLERA, ITCHING OF THE BODY AND PALE STOOL.
(A) WHAT IS YOUR CLINICAL DIAGNOSIS ?
(B) HOW WOULD YOU INVESTIGATE THIS CASE?
(C) WHAT ARE THE POSSIBLE CAUSES?
ITS KNOWN THAT THIS OLD LADY WAS MULTIPAROUS AND OBESE, AND
THAT SHE HAD ATTACKS OF RIGHT HYPOCHONDRIAL COLICKY PAIN
AGGRAVATED BY FATTY MEAL.
(D) WHAT IS THE POSSIBLE DIAGNOSIS?
(E) HOW WOULD YOU CONFIRM IT?
(F) WHAT ARE THE COMPLICATIONS OF THIS DISEASE?

(a) Based on the presented symptoms, the clinical diagnosis for Nyandeng is likely
jaundice or icterus.

(b) To investigate this case, the following diagnostic tests and investigations can be
considered:

27
1. Blood tests: A comprehensive metabolic panel (CMP) can be performed to assess liver
function, including liver enzymes (such as alanine transaminase (ALT) and aspartate
transaminase (AST)), bilirubin levels (total, direct, and indirect), and markers of liver
function (such as albumin and prothrombin time).

2. Complete blood count (CBC): This can help assess for anemia or other blood
abnormalities.

3. Viral serology: Tests for viral hepatitis (such as hepatitis A, B, and C) may be
conducted to rule out viral causes of jaundice.

4. Imaging studies: Abdominal ultrasound or other imaging modalities may be used to

evaluate the liver, gallbladder, and bile ducts for any structural abnormalities or
obstruction.

(c) Possible causes of the presented symptoms include:

1. Hepatitis: Infection or inflammation of the liver, commonly caused by viral hepatitis

(such as hepatitis A, B, or C).

2. Obstructive jaundice: Blockage or obstruction of the bile ducts, which can be caused
by gallstones, tumors, or strictures.

3. Liver diseases: Conditions such as alcoholic liver disease, non-alcoholic fatty liver
disease (NAFLD), cirrhosis, or liver cancer can also present with jaundice.

4. Other causes: Certain medications, autoimmune disorders, hemolytic disorders (such

as hemolytic anemia), or genetic conditions (such as Gilbert's syndrome) can also lead to
jaundice.

(d) Based on the additional information provided about right hypochondrial colicky pain
aggravated by fatty meal, a possible diagnosis is gallstone disease or cholelithiasis.

(e) To confirm the diagnosis of gallstone disease, further investigations may include:

1. Abdominal ultrasound: This can help visualize the gallbladder and identify the
presence of gallstones.

2. Endoscopic retrograde cholangiopancreatography (ERCP): This procedure allows

for direct visualization of the bile ducts and can help detect any stones or blockages.

(f) Complications of gallstone disease can include:

1. Cholecystitis: Inflammation of the gallbladder often caused by gallstones.

28
2. Biliary Colic: This is a common symptom of gallstone disease. Biliary colic occurs
when a gallstone temporarily blocks the bile duct, causing intense pain in the upper
abdomen and right shoulder.

3. Cholecystitis: Gallstones can cause inflammation of the gallbladder, known as

cholecystitis. It occurs when a gallstone blocks the cystic duct, leading to infection and
inflammation of the gallbladder.

4. Choledocholithiasis: Gallstones can migrate from the gallbladder and become lodged
in the common bile duct, causing choledocholithiasis.

5. Cholangitis: When the common bile duct becomes blocked by gallstones, it can lead
to a bacterial infection in the bile ducts known as cholangitis.

6. Gallstone Pancreatitis: In some cases, a gallstone can travel from the gallbladder and
lodge in the pancreatic duct, causing inflammation of the pancreas (pancreatitis)

7. Gallbladder Empyema or Gangrene: Prolonged obstruction of the cystic duct by

gallstones can lead to the accumulation of infected fluid or even the death of gallbladder
tissues, resulting in gallbladder empyema or gangrene.

UNIVERSITY OF JUBA
SCHOOL OF MEDICINE
DEPARTMENT OF PATHOLOGY
FOURTH YEAR FINAL EXAMINATION
OCTOBER 2022
SECTION A: MULTIPLE CHOICE QUESTIONS

1. An irritant acting on the tissue may cause:

A) Degeneration
B) Nicrosis
C) Inflammation
D) Cellular proliferation
E) All of the above
2. Fibrin is present in excess in:
A. Lobar pneumonia
B. Diphtheria
C. Abscess
D. Catarrhal rhinitis
E. Small pox
3. Acute inflammation is characterized by the following except:
A. Short duration
B. Marked vascular reaction

29
C. Presence of lymphocytes
D. Acute onset
E. Presence of fibrin threads
4. Pus is characterized by the following except:
A. Thick consistency
B. Clot on standing
C. Presence of bacteria
D. Alkaline reaction
E. Presence of RBCs
5. The following occur in membranous inflammation except:
A. Marked toxaemia
B presence of pseudomembrane
C. Affect mucous surfaces
D. Cloudy swelling of the kidney
E. Septicemia
6. Cellulitis is:
A. Localized suppuration
B. Necrotizing inflammation
C. Caused by streptococcus
D. All the above
E. Non of the above
7. The abscess is lined by:
A. Hyperaemic zone
B. Fibrous wall
C. Pyogenic membrane
D. Necrotic tissue
E. Granulation tissue
8. Granulation tissue is characterized by the following except:
A. Red colour
B. Sensitive to touch
C. Granular surface
D. Moist surface
E. Bleeds on touch
9. A surgical wound heals by:
A. Regeneration
B. Primary intention
C. Secondary intention
D. Granulation tissue
E. Non of the above
10. The most common cause of delayed wound healing is:
A. Old age
B. Vitamin C deficiency
C. Protein deficiency
D. Length of the wound
E. Infection
11. Amyloid Degeneration affect the following organs except:

30
A. Brain
B. Liver
C. Kidney
D. Spleen
E. Adrenal
12. Site of metastatic calcification include:
A. Mucosa of stomach
B. Old thrombi
C. Renal tubules
D. Wall of lung alveoli
E. Wall of blood vessels
13. Examples of metabolic disturbance of melatonin pigment include:
A. Cholasma
B. Albinism
C. Benign melanoma
D. Melanosis coli
E. Tattooing
14. Caseation Nicrosis is caused by:
A. Anoxemia
B. Bacterial toxins
C. Hypersensitivity
D. Chemical agents
E. Excess heat
15. Compound granular corpuscles are:
A. Microphages distended with hemosiderin
B. Microglia distended with fats
C. Giant cells in Tuberculosis
D. Plasma cells showing hyalinosis
E. Non of the above
16. Thrombosis is more common in:
A. Arteries
B. Veins
C. Right Auricle
D. Capillaries
E. Left Auricle
17. Thrombophlebitis is:
A. Venous thrombosis
B. Thrombosis in inflamed vein
C. Thrombosis in inflamed artery
D. Thrombosis in a vein due to blood stagnation
E. Non of the above
18. An example of generalized oedema
A. Cardiac
B. Nutritional
C. Renal
D. All of the above

31
E. Non of the above
19. Arterial thrombosis is caused by the following except:
A. Atherom
B. Aneurysm
C. Hypertension
D. Polyarteritis
E. Thromboangiitis obliterans
20. Non-pitting oedema is present in:
A. Congestive heart failure
B. Nephrotic syndrome
C. Acute diffuse glomerulonephritis
D. Filariasis
E. Liver disease
21. Secondary shock is caused by:
A. Severe hemorrhage
B. Extensive burns
C. Surgical operation
D. Crush injury
E. All of the above
22. Pathological lesions in streptococcal septicemia include:
A. Red staining of the intime of the vessels
B. Focal necrosis in the liver
C. Acute splenic swelling
D. Subacute bacterial endocarditis
E. Petechial haemorrhage in the skin
23. Cellular antibodies are produced by:
A. B-lympocytes
B. T- lymphocytes
C. Plasma cells
D. Macrophages
E. Mast cells
24. The following are features in delayed HSR except:
A. Presence of circulating anybodies
B. Long duration
C. No chemical mediator
D. Inhibited by corticosteroids
E. No passive transportation of the sensitivity state
25. Severe necrosis is bilharzial reaction is caused by:
A. Dead worms
B. Living worms
C. Bilharzial ova
D. Cercaria
E. All of the above
26. The following are the primary sites of tuberculosis:
A. Tonsils
B. Tongue

32
C. Lung
D. Skin
E. Intestine
27. The common fate for Ghon's focus is:
A. Fibrosis
B. Blood spread
C. Bronchial spread
D. Direct spread to the pleura
E. Non of the above
28. Tuberculous ulcers in the intestine are characterized by the following except:
A. Occurs in the terminal ileum
B. Undermined edge
C. Yellow soft floor
D. Parallel to the long axis of the intestine
E. It's healing may lead to chronic intestinal obstruction
29. The CSF in Tuberculous meningitis shows large number of:
A. Epithelioid cell
B. Lymphocytes
C. Plasma cells
D. Tubercle bacilli
E. Langhan's giant cell
30. Syphilitic aortitis affects:
A. The intima
B. The media
C. The adventitia
D. Coronary orifices
E. All of the above
31. In Tabes Dorsalis progressive degeneration affect:
A. Posterior columns
B. Posterior nerve roots
C. Cranial nerves
D. All of the above
E. Non of the above
32. The commonest site for actinomycosis is:
A. Angle of the mandible
B. Skin
C. Lung
D. Intestine
E. Liver
33. Causes of rickets do not include:
A. Vitamin C deficiency
B. Calcium deficiency
C. Phosphorus deficiency
D. Chronic Renal disease
E. Coeliac disease
34. Hormonal hyperplasia occur in:

33
A. Thyroid
B. Breast
C. Prostate
D. Kidney
E. Endometrium
35. New growth of tissue which does not obey general rules of the body is called:
A. Neoplasia
B. Aplasia
C.Anaplasia
D. Hyperplasia
E. Non of the above
36. Which is not true for neoplasia:
A. Independent of a stimulus
B. Has a useful function
C. Not limited
D. Cells abnormal in shape
E. Cells abnormal in pattern
37. The most important factor in prognosis in malignant tumours is:
A. Size of the tumour
B. Histological grading
C. Distant metastasis
D. Age of the patient
E. Site of the tumour
38. Which of the following is not a locally malignant tumour:
A. Basal cell carcinoma
B. Osteoclastoma
C. Transitional cell carcinoma
D. Adamantinoma
E. Astrocytoma grade ll
39. Which of the following is precancerous lesion:
A. Urinary bilharziasis
B. Portal cirrhosis
C. Lupus vulgaris
D. Varicose ulcers
E. All of the above
40. The following are examples of radioresponsive tumours except:
A. Malignant melanoma
B. Squamous cell carcinoma
C. Basal cell carcinoma
D. Breast carcinoma
E. Adenocarcinoma
41. A 39 year old woman gives birth to a term infant with a right transverse palmar
crease low set ears, oblique palpebral fissures, and a heart murmur. The infant
survives to childhood and exhibits only mild mental retardation, which of the
following chromosomal abnormalities is most likely to be present in the somatic cells
of this child?

34
A. Haploidy
B. Monosomy
C. Mosaicism
D. Tetraploidy
E. Triploidy
42. A 35 year old man has a history of mild infections of the upper respiratory tract.
He also has had diarrhoea for most of his life, although it was not severe enough to
cause malabsorption and weight loss. After an episode of trauma with blood loss, he
receives blood transfusion and has an anaphylactic reaction. Which of the following
underlying conditions best explains these findings?

A. Severe combined immunodeficiency

B. HIV infection
C. DI-George Syndrome
D. Wiskott-Aldrich Syndrome
E. Selective IgA deficiency

43. A 47 year old man has felt increasingly tired and weak for the past 6 months. On
physical examination, he appears pale. Laboratory studies show Hb of 10.7g/dl,
PCV of 32.1%, Thrombocytes of 155,000/mm3, and WBCC of 167,500/mm3. The
peripheral blood smear shows a predominance of mature and immature
neutrophilic cells, Cytogenetic studies of cells obtained through the bone marrow
aspiration shows a t(9.22) translocation, which has resulted in formation of a hybrid
gene, causing potent tyrosine kinase activity, which of the following genes was
translocated from the chromosome 9?
A. P53
B. RB
C. NF 1
D. K-RAS
E. C-ABL
44. A 44 year old woman sees her physician because she feels lumps in the right
axilla. The physician notice right axilla lymphadenopathy on physical examination
the nodes are painless and firm. Which of the following is the most likely diagnosis
A. Ductus carcinoma of the breast
B. Acute mastitis with breast abscess
C. Leiomyosarcoma of the uterus
D. Cerebral glioblastoma multiforme
E. Squamous dysplasia of the larynx

45. A 24 year old woman has had bloody diarrhoea for the past 4 days. On physical
examination she has a temperature of 38.3oC and appearance of the rectum and
descending colon on colonoscopy shows haemorrhagic mucosa. The patient is
treated with antibiotics but develop a chronic arthritis after the diarrhoea has
resolved. HLA typing is done and she is found to be HLA-B27 positive. Which of the
following organisms is most likely to be identify in her diarrhoeal stool.

35
A. Vibrio cholera
B. Shigella flexneri
C. Entamoeba histolytica
D. Salmonella typhi
E. Helicobacter pylori

46. A 45 year old man experiences crushing substernal chest pain after arriving at
work one morning. Over the next 4 hours, the pain persist and begin to radiate to
his left arm. He becomes diaphoretic and sort of breath but waits until the end of his
8 hours to go to the hospital. An evaluated serum value of which of the following
laboratory test would be most useful for diagnosis of this patient on admission to the
hospital?

A. Lipase
B. AST
C. CK-MB fraction
D. ALT
E. LDH-1 and C-reactive protein

47. A 55 year old lady present with increasing malaise and dyspnoea on exception.
He admitted a history of rectal bleeding for 6 months. Colonoscopy revealed colonic
ulcerated mass. Laboratory investigation shows Hb of 6g/dl, TWBCC of
11,000/mm3, Thrombocytes 500,000/mm3. Peripheral blood picture shows
microcytic hypochromic picture with poikilocytes and discrepant RBCs and iron
serum parameters. Which of the following is appropriate diagnosis?

A. Anemia of the chronic disease

B. Mylophthistic
C. Iron deficiency anemia
D. Aplastic anemia
E. Megaloblastic anemia

48. A 50 year old man has a history of chronic alcoholism. He is found in a

stuporous condition after 3 days of binge drinking. On physical examination his
temperature is 39.2oC. A few crackles are heard on auscultation of the right lung
base. A chest radiography shows a 3cm lesions with an air fluid level in the right
lower lobe. Which of the following organisms are most likely to be detected in
broncho-alveolar lavage fluid?

A. Staphylococcus aureus and bacteriodes fragile

B. Mycobacterium tuberculosis and aspergillus fumigatu
C. Nocardia asteroid and actinomyces Israelii
D. Cytomegalovirus and pneumocytis carinii
E. Cryptococcus neoformans and candida albicans

36
49. A 52 year old woman has had an increasingly severe cough productive of
yellowish sputum for several days. On physical examination, her temperature is 38.9
deg.C, and diffuse crackles in the left lower lung. A chest radiography shows left
lower lung consolidation. Laboratory studies show a WBC count of 11,990/mm3
with 72% segmented neutrophils, 8% band, 16% lymphocytes, and 4% monocytes.
Which of the following pathogens is most likely to be cultured from the patient's
sputum?

A. Mycoplasma pneumonia
B. Streptococcus pneumonia
C. Legionella pneumonia
D. Cryptococcus neoformans
E. Pneumocytis carinii

50. A 55 year old woman notices a lump on the right side of her face that has
become larger over the past year. On physical examination, a 3 to 4 cm firm, mobile,
painless mass is palpable in the region of the parotid gland. The oral mucosa
appears normal. The does not complain of difficult in chewing food or talking.
Which of the following conditions is most likely to account for these findings?

A. Sialolithiasis
B. Pleomorphic adenoma
C. Sjogren syndrome
D. Mucoepidermoid carcinoma
E. Malignant lymphoma

51. One of the following is benign tumour:

A. Neuroblastoma
B. Retinoblastoma
C. Papilloma
D. Seminoma
E. Hepatoma
52. Metastatic effects of malignant tumours include:
A. Iron deficiency anemia
B. Tumor cachexia
C. Cushing syndrome
D. Neuropathy
E. Acanthosis nigricans
53. Right sided heart failure is caused by:
A. Thyrotoxicosis
B. Systemic hypertension
C. Pulmonary embolism
D. Coartation of the aorta
E. Aortic stenosis
54. Rheumatic fever is:
A. Is caused by staph aureus

37
B. Due to invasion of organism to the heart
C. Diagnosed by swap culture
D. Associated with skin nodules
E. Associated with recent infection of the throat
55. Intrinsic asthma:
A. Usually starts in childhood
B. Commonly associated with chronic bronchitis
C. Allergens involved include house dust and pollen
D. Skin tests are usually positive
E. Family history is positive
56. Causes of type ll respiratory failure include:
A. Emphysema
B. Acute attack of bronchial asthma
C. Pulmonary oedema
D. Sarcoidosis
E. Pneumonia
57. Functional obstruction of the esophagus is caused by:
A. Ghon's disease
B. Reflux esophagitis
C. Mediastinal tumors
D. Chagas disease
E. Foreign material
58. Causes of unconjugated hyperbilirubinemia include:
A. Gilbert disease
B. Liver cirrhosis
C. Hepatitis
D. Biliary atresia
E. Dibin_Johnson syndrome
59. Acute lymphoblastic leukemia:
A. Affect adults more than children
B. May present with sternal tenderness
C. Males have better prognosis than females
D. Most cases are of T-cell origin
E. Is not curable
60. Primary pulmonary tuberculosis:
A. Patients usually present with hemoptysis
B. Mainly affect the lung apex
C. Characterized by the Gron's complex
D. Is characterized by cavitation
E. Is mainly a disease of adults.

SECTION B: SHORT NOTES QUESTIONS

1. (A) NECROSIS

38
Necrosis is a type of cell death characterized by the premature and irreversible
destruction of cells or tissues within a living organism. It occurs as a result of various
factors, including injury, infection, toxins, lack of oxygen (ischemia), or certain diseases.

Key points about necrosis include:

1. Mechanisms of necrosis: Necrosis can occur through different mechanisms, such as

I. ischemia,
II. physical trauma,
III.exposure to toxins or
IV. radiation, or
V. severe infection.
These factors disrupt normal cellular processes, leading to cell swelling, membrane
rupture, and leakage of cellular contents into the surrounding tissue.

2. Types of necrosis: Different types of necrosis can occur based on the specific
characteristics of the affected tissue. Some common types include
I. coagulative necrosis,
II. liquefactive necrosis,
III. caseous necrosis,
IV. fat necrosis, and
V. gangrenous necrosis.

3. Inflammatory response: Necrosis typically triggers an inflammatory response. The

release of cellular debris and molecules can stimulate an immune response, leading to
inflammation, infiltration of immune cells, and tissue damage.

4. Consequences and implications: Necrosis can have serious consequences depending

on the extent and location of tissue damage. It can lead to the loss of organ function,
impaired healing, and potential complications or secondary infections. In some cases,
necrotic tissue may need to be removed surgically.

5. Diagnostic significance: Recognizing the presence of necrosis is important for

diagnosing and evaluating various conditions, such as ischemic injuries, infections,
tumors, or autoimmune diseases. Imaging techniques, laboratory tests, and microscopic
examination of affected tissues help in identifying necrotic areas.

6. Contrasting with apoptosis: Necrosis is distinct from apoptosis, which is a

programmed and controlled form of cell death. Unlike necrosis, apoptosis is a regulated
process that plays a fundamental role in normal development, tissue homeostasis, and
removal of damaged or unnecessary cells.

7. Treatment and management: Treatment of necrosis involves addressing the

underlying cause, promoting tissue healing, and managing complications. This may
include surgical intervention, antibiotics for infection, supportive therapy, and addressing
any systemic conditions contributing to necrosis.

39
 (B) PULMONARY EMBOLISM

Pulmonary embolism (PE) is a serious medical condition characterized by the blockage

of one or more arteries in the lungs. It occurs when a blood clot, usually originating from
the deep veins of the legs (deep vein thrombosis or DVT), travels through the
bloodstream and lodges in the blood vessels of the lungs.

Common signs and symptoms of pulmonary embolism include:

1. Sudden onset of shortness of breath: Breathlessness that occurs suddenly and is not
related to exertion or known respiratory conditions is a common symptom of pulmonary
embolism. It may be accompanied by a rapid or irregular heartbeat.

2. Chest pain: Chest pain can range from sharp and stabbing to a dull ache. It may
worsen with deep breaths, coughing, or movement. The pain may be localized or spread
to the arm, shoulder, neck, jaw, or back.

3. Cough: Coughing, sometimes with blood-tinged sputum, may occur in pulmonary

embolism. However, not everyone with PE experiences coughing.

4. Other symptoms: Additional symptoms may include lightheadedness, dizziness,

fainting, excessive sweating, anxiety, and a sense of impending doom.

If pulmonary embolism is suspected, prompt medical attention is crucial. Diagnostic

tests that are commonly used to confirm the diagnosis of PE include:

1. Imaging tests: Computed tomography pulmonary angiography (CTPA) or ventilation-

perfusion (V/Q) scan can help visualize the blood vessels in the lungs and identify any
blockages.

2. Doppler ultrasound: This test may be performed to detect the presence of deep vein
thrombosis (DVT) in the legs, which is a common cause of pulmonary embolism.

3. Blood tests: D-dimer blood test is commonly used as a screening tool to assess the
likelihood of a pulmonary embolism. Elevated levels may indicate the presence of a
blood clot, but further testing is required for a definitive diagnosis.

The treatment of pulmonary embolism typically involves the use of anticoagulant

medications to prevent further clot formation and allow the body to dissolve the existing
clot.

2. (A) HOW MICROBES INVADE IMMUNE SYSTEM

Microbes can invade the immune system through various mechanisms. Here are a few
ways in which microbes can breach the immune system's defenses:

40
1. Direct Invasion: Some microbes have mechanisms to directly invade and breach
physical barriers of the immune system. For example, certain bacteria can produce
enzymes that break down the protective layers of the skin or mucous membranes,
allowing them to enter and infect tissues.

2. Phagocytosis Evasion: Phagocytes, such as macrophages and neutrophils, are immune

cells that engulf and destroy invading microbes. However, some pathogens have evolved
strategies to evade phagocytosis. They can produce proteins or capsules that interfere
with phagocyte recognition or inhibit the killing mechanisms of phagocytes.

3. Intracellular Survival: Some microbes can invade host cells and survive inside them.
By residing within cells, they can evade direct immune surveillance and attack. For
example, certain bacteria like Mycobacterium tuberculosis can survive within immune
cells called macrophages.

4. Antigenic Variation: Microbes can undergo antigenic variation, which means they
change the proteins or surface molecules they express. This allows them to evade
recognition by the immune system, as the immune cells may be primed to target specific
antigens. By altering their surface molecules, the microbes can escape immune detection
and continue causing infection.

5. Immune Suppression: Some microbes have developed mechanisms to suppress or

evade the immune response. They can produce molecules that dampen the activity of
immune cells or interfere with signaling pathways involved in immune activation. This
can weaken the immune response and allow the microbes to persist and cause infection.

It's important to note that the immune system is highly complex and has evolved
numerous mechanisms to detect and eliminate invading microbes.

(B) CLINICAL EFFECTS AND LABORATORY DIAGNOSIS OF TUMORS

Clinical effects of tumors can vary depending on the type, location, size, and stage of the
tumor. Some common clinical effects of tumors include:

1. Local Symptoms: Tumors can cause local symptoms related to their location. For
example,
A. a brain tumor may cause
i. headaches,
ii. seizures, or
iii. neurological deficits.
B. A breast tumor may present as
i. a palpable lump or
ii. changes in breast appearance.
C. Local symptoms can also include
i. pain,

41
 ii. functional impairment, or
iii. obstruction of nearby structures.

2. Systemic Symptoms: Tumors can produce systemic effects that affect the whole body.
These can include
i. weight loss,
ii. fatigue,
iii. loss of appetite,
iv. night sweats, and
v. generalized weakness.
Systemic symptoms may be caused by the release of hormones or other substances by the
tumor or by the body's immune response to the tumor.

3. Paraneoplastic Syndromes: Some tumors can produce hormone-like substances or

induce immune reactions that cause symptoms in distant organs that are not directly
affected by the tumor. These are called paraneoplastic syndromes. Examples include
ectopic hormone production leading to hypercalcemia (elevated blood calcium levels)
or Cushing's syndrome (excessive cortisol production).

Laboratory diagnosis of tumors involves various tests and procedures that are used
to identify and characterize the presence of tumors. These can include:

1. Imaging Studies: Imaging techniques such as X-rays, computed tomography (CT),

magnetic resonance imaging (MRI), ultrasound, or positron emission tomography (PET)
scans can help visualize tumors and determine their size, location, and extent of spread.

2. Biopsy: A biopsy is the removal of a small piece of tissue from a suspected tumor for
examination under a microscope. It allows for the identification of tumor type, grade, and
other characteristics. Biopsies can be obtained through various techniques, including
needle biopsy, surgical biopsy, or endoscopic biopsy.

3. Blood Tests: Blood tests may be used to detect specific tumor markers, which are
substances produced by tumors or released into the bloodstream in response to the
presence of a tumor. Examples include prostate-specific antigen (PSA) for prostate
cancer or carcinoembryonic antigen (CEA) for certain types of cancers.

4. Molecular and Genetic Testing: Molecular and genetic tests can analyze the DNA or
RNA of tumor cells to identify specific genetic mutations or alterations. These tests can
help determine prognosis, guide treatment decisions, and identify targeted therapies.

5. Staging and Grading: Staging involves determining the extent of tumor spread, while
grading assesses the aggress

3. (A) COMPLICATIONS OF MYOCARDIAL INFARCTION

Complications of myocardial infarction can include:

42
1. Heart failure: Damage to the heart muscle can weaken its pumping ability, leading to
heart failure.

2. Arrhythmias: Abnormal heart rhythms, such as ventricular tachycardia or ventricular

fibrillation, can occur after a heart attack.

3. Cardiogenic shock: In severe cases, the heart may be unable to pump enough blood to
meet the body's needs, leading to cardiogenic shock.

4. Pericarditis: Inflammation of the pericardium, the sac surrounding the heart, can
occur after a heart attack.

5. Ventricular septal defect (VSD): A hole can develop in the septum, the wall
separating the heart's ventricles.

6. Papillary muscle dysfunction or rupture: Damage to the papillary muscles that

control the heart valves can lead to valve dysfunction or rupture.

7. Thromboembolism: Blood clots can form in the heart and travel to other parts of the
body, causing blockages.

It's important to note that these are potential complications and not every individual will
experience all of them. Prompt medical attention and appropriate treatment can help
reduce the risk of complications following a myocardial infarction.

(B) CAUSES AND CLASSIFICATION OF GLOMERULONEPHRITIS

Causes of glomerulonephritis include:

1. Immune system disorders: Certain immune system disorders, such as systemic lupus
erythematosus (SLE) or Goodpasture's syndrome, can cause glomerulonephritis.

2. Infections: Infections caused by viruses, bacteria, or parasites, such as streptococcal

infections (post-streptococcal glomerulonephritis) or hepatitis B and C, can lead to
glomerulonephritis.

3. Vasculitis: Conditions that cause inflammation of blood vessels, such as

granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA), can affect
the glomeruli.

4. Genetic factors: Certain genetic disorders, such as Alport syndrome or Fabry disease,
can result in glomerulonephritis.

43
5. Medications and toxins: Some medications, including nonsteroidal anti-inflammatory
drugs (NSAIDs), certain antibiotics, and certain toxins or chemicals, can damage the
glomeruli and cause glomerulonephritis.

Classification of glomerulonephritis can be based on various factors, such as the

underlying cause, clinical presentation, and histopathological findings. The
classification systems commonly used include:

1. Primary glomerulonephritis: This refers to glomerulonephritis that occurs without

any underlying systemic disease or known cause.

2. Secondary glomerulonephritis: This type occurs as a result of an underlying

condition or disease, such as SLE, vasculitis, or infections.

3. Acute glomerulonephritis: This is characterized by a sudden onset of symptoms and

inflammation in the glomeruli. It is often associated with infections, such as streptococcal
infections.

4. Chronic glomerulonephritis: This type develops slowly over a period of time and can
lead to progressive kidney damage and renal failure.

5. Histopathological classification: This classification system is based on the

examination of kidney tissue under a microscope and identifies specific patterns of
glomerular injury, such as minimal change disease, focal segmental glomerulosclerosis,
membranous nephropathy, or IgA nephropathy.

It's important to note that glomerulonephritis is a complex condition, and the causes and
classifications may vary depending on the individual case. A proper diagnosis and
evaluation by a healthcare professional are necessary for accurate identification and
treatment.

4. (A) AETIOLOGY AND CLINICAL MANIFESTATIONS, DIAGNOSIS AND MONITORING OF

DIABETES MELLITUS

Diabetes mellitus is a chronic metabolic disorder characterized by elevated blood sugar

levels (hyperglycemia) due to insufficient insulin production or impaired insulin function.
There are different types of diabetes, including type 1 diabetes, type 2 diabetes, and
gestational diabetes. Here's an overview of the etiology, clinical manifestations,
diagnosis, and monitoring of diabetes mellitus:

(A) ETIOLOGY:
1. Type 1 Diabetes: It is an autoimmune condition where the immune system mistakenly
attacks and destroys the insulin-producing beta cells in the pancreas. The exact cause is
unknown, but genetic and environmental factors are thought to play a role.

44
2. Type 2 Diabetes: This is the most common form of diabetes and is characterized by
insulin resistance, where the body's cells become less responsive to insulin. Genetic
factors, obesity, sedentary lifestyle, and poor diet are often contributing factors.

3. Gestational Diabetes: This type of diabetes occurs during pregnancy and is usually
temporary. Hormonal changes during pregnancy can lead to insulin resistance, resulting
in elevated blood sugar levels.

CLINICAL MANIFESTATIONS:
Common clinical manifestations of diabetes mellitus include:
- Excessive thirst (polydipsia) and increased urination (polyuria)
- Unexplained weight loss
- Fatigue and weakness
- Blurred vision
- Slow wound healing
- Recurrent infections, such as urinary tract infections or yeast infections

DIAGNOSIS:
The diagnosis of diabetes mellitus is generally based on the following criteria:
1. Fasting Plasma Glucose (FPG): A fasting blood sugar level equal to or higher than
126 mg/dL (7.0 mmol/L) on two separate occasions indicates diabetes.
2. Oral Glucose Tolerance Test (OGTT): A blood sugar level equal to or higher than
200 mg/dL (11.1 mmol/L) two hours after consuming a glucose-rich drink indicates
diabetes.
3. Glycated Hemoglobin (HbA1c): An HbA1c level of 6.5% or higher indicates
diabetes.HbA1c reflects average blood sugar levels over the past two to three months.

MONITORING:
Once diagnosed, people with diabetes need ongoing monitoring to manage their condition
effectively. Monitoring may include:

1. Regular blood sugar testing: This helps individuals track their blood sugar levels and
adjust their treatment accordingly.

2. HbA1c testing: This test provides a measure of average blood sugar levels over time
and is typically done every three to six months.

3. Lipid profile: This is a blood test that measures various types of cholesterol and
triglycerides in the blood. Diabetes is associated with an increased risk of cardiovascular
disease, and monitoring lipid levels can help manage this risk.
4. Blood pressure monitoring: High blood pressure (hypertension) often coexists with
diabetes and can increase the risk of complications. Regular blood pressure checks are
important to manage and control hypertension effectively.

45
5. Kidney function tests: Diabetes can affect kidney function over time. Regular
monitoring of kidney function, including measuring blood creatinine levels and
estimating glomerular filtration rate (eGFR), helps assess kidney health.

6. Eye examinations: Regular eye exams, including dilated eye examinations, are
essential as diabetes can increase the risk of eye problems such as diabetic retinopathy.

7. Foot examinations: Regular foot exams are important to detect any signs of nerve
damage or poor circulation, which are common complications of diabetes. Checking for
foot ulcers, infections, and other foot-related issues is crucial.

5. (A) CSF CIRCULATION, COMPOSITION AND CLINICAL CORRELATION

Cerebrospinal fluid (CSF) is a clear, colorless fluid that surrounds the brain and spinal
cord.
It plays crucial roles in protecting and nourishing the central nervous system (CNS). The
circulation, composition, and clinical correlation of CSF are as follows:

CSF CIRCULATION:
1. Production: CSF is primarily produced by the choroid plexus, which is located within
the ventricles of the brain. The choroid plexus secretes CSF into the ventricles.

2. Flow: CSF flows through the ventricular system, which includes

A. the lateral ventricles,

 Foramina of Monro

B. third ventricle,
 Cerebral aqueduct

C. cerebral aqueduct, and

 Foramina luschka on both sides
 Foramina magendie

D. fourth ventricle.
From the fourth ventricle, CSF can exit the ventricular system into the subarachnoid
space that surrounds the brain and spinal cord.

3. Absorption: CSF is absorbed into the bloodstream through structures called arachnoid
granulations, which are located in the dural sinuses. The arachnoid granulations allow
CSF to be reabsorbed, maintaining the balance of CSF production and absorption.

CSF COMPOSITION:
The composition of cerebrospinal fluid (CSF) can vary slightly depending on factors like
age and health status. Here are the normal ranges for some key components of CSF:

46
1. Pressure: The normal CSF pressure is typically between (50-200mmH2O) when
measured in the lumbar region.

2. G-glubulin: 3%-12% of the total protein

3. Cell Count: The normal CSF cell count is typically less than 5 white blood cells
(WBCs) per microliter (µL) in adults and less than 10 WBCs/µL in neonates and infants.

4. Protein: The normal protein concentration in CSF is generally (15-60 mg/dl or 0.15-
0.45g/dl) in adults and less than 100 mg/dL in neonates.

5. Glucose: The normal glucose concentration in CSF is approximately 60-70% of the

blood glucose level. Thus, a rough range would be around 50-80 milligrams per deciliter
(mg/dL).

6. Lactate: The normal lactate concentration in CSF is typically less than 2.5 millimoles
per liter (mmol/L) or less than 22.5 milligrams per deciliter (mg/dL).

CLINICAL CORRELATION:
The clinical correlation of cerebrospinal fluid (CSF) involves analyzing CSF findings to
aid in the diagnosis and management of various neurological conditions. Here are some
examples:

1. Lumbar Puncture: CSF analysis is commonly performed through a procedure called

lumbar puncture or spinal tap. It involves collecting a sample of CSF from the
subarachnoid space in the lower back. CSF analysis can aid in diagnosing various
neurological conditions, such as meningitis, encephalitis, and multiple sclerosis.

2. CNS Infections: Changes in CSF composition, such as increased white blood cell
count and presence of specific bacteria or viruses, can indicate CNS infections like
bacterial meningitis or viral encephalitis.

3. Subarachnoid Hemorrhage: Blood in the CSF can be a sign of subarachnoid

hemorrhage, typically caused by a ruptured cerebral aneurys

4. Meningitis and Encephalitis: CSF analysis is crucial in diagnosing and distinguishing

between different types of meningitis (inflammation of the meninges) and encephalitis
(inflammation of the brain). In bacterial meningitis, the CSF may show increased white
blood cell count (mainly neutrophils), elevated protein levels, and decreased glucose
levels. Viral meningitis and encephalitis typically present with increased lymphocytes in
the CSF.

5. Neurosyphilis: CSF analysis plays a vital role in diagnosing and monitoring

neurosyphilis, which is the involvement of the central nervous system in syphilis
infection. CSF examination may reveal elevated white blood cell count, increased protein

47
levels, and the presence of specific antibodies (such as Treponema pallidum antibodies)
indicating an active infection.

6. Multiple Sclerosis (MS): CSF analysis can be supportive in diagnosing MS, an

autoimmune disorder affecting the central nervous system. The presence of oligoclonal
bands (abnormal bands of immunoglobulins) in the CSF, along with other clinical and
imaging findings, can support the diagnosis of MS.

7. Guillain-Barré Syndrome (GBS): In GBS, an autoimmune condition affecting

peripheral nerves, CSF analysis often shows elevated protein levels without a significant
increase in white blood cells. This finding, known as albuminocytologic dissociation, can
help support the diagnosis of GBS.

(B) COMPLICATIONS AND LABORATORY DIAGNOSIS OF HEMOLYTIC ANAEMIA

Hemolytic anemia is a condition characterized by the accelerated destruction of red

blood cells, leading to a decreased lifespan of these cells. There are several causes of
hemolytic anemia, including immune-mediated reactions, inherited disorders, infections,
medications.
The complications and laboratory diagnosis of hemolytic anemia can vary
depending on the specific cause.

COMPLICATIONS OF HEMOLYTIC ANEMIA MAY INCLUDE:

1. Anemia-related symptoms: These can include fatigue, weakness, shortness of breath,

pale skin, dizziness, and rapid heart rate.

2. Gallstones: The breakdown of red blood cells releases a substance called bilirubin,
which can increase the risk of gallstone formation.

3. Enlarged spleen: The spleen may become enlarged as it works to remove damaged
red blood cells from circulation.

4. Iron overload: In some cases, excessive breakdown of red blood cells can lead to
increased absorption of iron, resulting in iron overload.

LABORATORY DIAGNOSIS OF HEMOLYTIC ANEMIA TYPICALLY INVOLVES THE

FOLLOWING TESTS:

1. Complete blood count (CBC): This test measures the levels of red blood cells, white
blood cells, and platelets, and can provide information about the severity of anemia.

2. Reticulocyte count: Reticulocytes are immature red blood cells. An elevated

reticulocyte count indicates increased production of red blood cells in response to their
accelerated destruction.

48
3. Blood smear examination: A microscopic examination of a blood smear can help
identify abnormal red blood cells, such as fragmented cells (schistocytes) or cells with
specific features seen in certain types of hemolytic anemia.

4. Direct Coombs test: This test detects the presence of antibodies or complement
proteins on the surface of red blood cells, indicating immune-mediated hemolysis.

5. Indirect Coombs test: This test detects antibodies in the blood that may be causing
destruction of red bloodcells.

6. Other specialized tests: Depending on the suspected cause of hemolytic anemia,

additional tests such as hemoglobin electrophoresis, enzyme assays, or genetic testing
may be performed.

6. PATHOGENESIS OF SEPTIC SHOCK

Septic shock is a life-threatening condition that occurs when an infection leads to a

systemic inflammatory response throughout the body.
Here is a simplified overview of the pathogenesis:

1. Infection: The process begins with the presence of an infection, typically caused by
bacteria, but it can also be caused by viruses, fungi, or other pathogens. The infection can
originate from various sources, such as the respiratory tract, urinary tract, or wounds.

2. Immune response: The immune system recognizes the infection and initiates an
immune response. Immune cells, particularly macrophages, release pro-inflammatory
cytokines (such as tumor necrosis factor-alpha, interleukin-1, and interleukin-6) to
combat the infection.

3. Inflammatory cascade: The release of pro-inflammatory cytokines triggers a cascade

of events, leading to the activation of other immune cells and the production of more
cytokines. This cascade amplifies the systemic inflammatory response, causing
widespread inflammation throughout the body.

4. Vasodilation: The inflammatory mediators cause blood vessels to dilate, resulting in

increased blood flow to affected tissues. However, this dilation leads to a drop in blood
pressure and impaired blood flow to vital organs.

5. Endothelial dysfunction: The inflammatory mediators damage the endothelial lining

of blood vessels. This damage disrupts the normal regulation of vascular tone and
permeability and leads to leakage of fluid from blood vessels into the surrounding tissues.

6. Microvascular dysfunction: The dysfunction of the microvasculature, including

capillaries and small blood vessels, further impairs blood flow and oxygen delivery to
tissues. Microclots may form, contributing to tissue injury.

49
7. Organ dysfunction: The combination of hypotension, impaired blood flow, and tissue
hypoxia can lead to multiple organ dysfunction syndrome (MODS). Organs commonly
affected include the lungs, liver, kidneys, and heart, among others.

8. Coagulation abnormalities: In septic shock, there is often a dysregulation of the

clotting system, leading to disseminated intravascular coagulation (DIC). This can result
in both excessive clotting and increased bleeding tendencies.

9. Metabolic abnormalities: Septic shock can also lead to metabolic imbalances, such as
lactic acidosis, due to tissue hypoxia and impaired cellular metabolism.

SECTION C: PATHOLOGICAL PROBLEM SOLVING

1. A 70 YEAR OLD LADY PRESENTED WITH LOW BACK PAIN, LETHARGY, MALAISE,
FEVER AND WEIGHT LOSS. ON EXAMINATION, SHE WAS PALE BUT NOT JAUNDICED.
ESR WAS HIGH I.E 65MM/HR. THERE WAS HYPERCALCEMIA AND ANEMIA X-RAY OF
THE LUMBER SPINE SHOWS MULTIPLE PUNCHED OUT LYTIC LESSONS WHICH ARE
ALSO EVIDENT IN BOTH I NOMINATE BONES.
(A). WHAT ARE THE DIFFERENTIAL DIAGNOSIS?
(B). WHAT FURTHER INVESTIGATIONS WOULD YOU CARRY?
(C). EXPLAIN THE CAUSE OF HYPERGLYCEMIA AND ANEMIA.
(D). THE PATHOLOGIST ADVICE YOU TO DO PLASMA PROTEINS ELECTROPHORESIS.
DEFINE THE TERM ELECTROPHORESIS AND WHAT THE FINDING THAT IS CONSISTENT
WITH THIS CONDITION IS
(E). WHAT IS THE DEFINITIVE DIAGNOSIS?

(A) The differential diagnoses based on the given clinical presentation and findings
include:

1. Multiple myeloma: This is a malignancy of plasma cells which can cause bone
lesions, anemia, hypercalcemia, and elevated ESR.
2. Metastatic cancer: Cancer that has spread to the bone can cause similar symptoms
and findings.

3. Lymphoma: Lymphoma can also involve the bones and present with similar
symptoms.

4. Osteoporotic fractures: Osteoporosis-related fractures can cause back pain, but they
would not typically explain the other symptoms.

5. Chronic Infection: Infections such as tuberculosis can cause constitutional symptoms,

elevated ESR, and weight loss. However, the presence of bone lesions would be less
common in this scenario.

(B) Further investigations that would be appropriate in this case include:

50
1. Serum protein electrophoresis: This test can help identify abnormal protein bands
and diagnose multiple myeloma or other plasma cell disorders.

2. Urine Protein Electrophoresis: This can detect abnormal proteins in the urine, such
as Bence Jones proteins, which are associated with multiple myeloma.

3. Bone marrow biopsy: This procedure can help confirm the presence of abnormal
plasma cells and determine the extent of bone marrow involvement.

4. Imaging studies: Additional imaging, such as a skeletal survey or MRI, may be

performed to assess the extent of bone lesions and identify any other sites of
involvement.

5. Complete blood count (CBC) with peripheral smear: This can provide information
on the severity and characteristics of the anemia.

(C) The cause of hypercalcemia and anemia in this case can be explained as follows:

1. Hypercalcemia: In multiple myeloma, abnormal plasma cells produce substances that

stimulate the breakdown of bone, leading to the release of calcium into the bloodstream.

2. Anemia: Multiple myeloma can cause anemia through various mechanisms, including
direct infiltration of the bone marrow by abnormal plasma cells, impaired production of
red blood cells, and increased destruction of red blood cells.

(D) Electrophoresis is a laboratory technique used to separate and analyze charged

particles, such as proteins, based on their size and charge. In this case, plasma protein
electrophoresis can help identify abnormal protein bands (M-proteins) characteristic of
multiple myeloma. The presence of a monoclonal (or M) spike in the electrophoresis
pattern would be consistent with this condition.

(E) The definitive diagnosis in this case is most likely multiple myeloma. This is
supported by the clinical presentation, laboratory findings (elevated ESR, hypercalcemia,
anemia), characteristic bone lesions on X-ray, and the presence of abnormal protein
bands (M-proteins) on plasma protein electrophoresis. However, further investigations,
such as bone marrow biopsy, would be needed to confirm

2. YOSEFO PRESENTED TO THE CASUALTY WITH SEVERE CENTRAL ABDOMINAL PAIN

AND VOMITING. HE WAS CONFUSED AND DROWSY. THE PARENTS ADMITTED THAT HE
LOST WEIGHT RECENTLY AND ALSO HE USED TO COMPLAIN OF DRY MOUTH.
O/E: HE WAS DEHYDRATED AND LOOKED IN PAIN.
PR=100/MIN, BP=90/60
CVS NOT RELEVANT. CNS ALSO NOT SIGNIFICANT. ABDOMEN=TENDERNESS AROUND
THE UMBILICUS.

51
IN THE CASUALTY THE DIAGNOSIS OF ACUTE PANCREATITIS WAS MADE AND THE
PATIENT REFERRED TO THE SURGICAL UNIT.
LAB. INVESTIGATIONS: NA =125MEQ/L, K= 5.8MEQ/L, UREA=80MG/DL(15-45),
CREATININE=2.0MG/DL(0.7-1.3), HCO3=14MEQ)L(20-30), AMYLASE=500U/L(70-300).
IN VEIW OF THIS RESULTS, URINE ANALYSIS WAS DONE AFTER ADMISSION AND THE
FINDINGS SEEN CHANGE THE COURSE OF MANAGEMENT.

(A). WHAT DO YOU THINK IS THE NEW DIAGNOSIS?

(B). WHAT FURTHER TEST WOULD YOU DO?
(C). HOW WOULD YOU MANAGE THIS CASE?

(A) Based on the new findings in the urine analysis, the new diagnosis is likely Diabetic
Ketoacidosis (DKA).

(B) Further tests that would be appropriate in this case include:

1. Blood glucose level: It is important to determine the blood glucose level to confirm
and monitor the severity of hyperglycemia.
2. Arterial blood gas (ABG) analysis: This can provide information about the acid-base
status, including the presence of metabolic acidosis.
3. Ketone bodies: Measurement of ketone bodies (beta-hydroxybutyrate and/or urine
ketones) can confirm the presence of ketosis.

(C) The management of this case would involve the following steps:

1. Fluid resuscitation: Intravenous fluids, typically isotonic saline, are administered to

correct dehydration and restore circulating volume.
2. Insulin therapy: Regular insulin is administered through intravenous infusion to lower
blood glucose levels and promote glucose utilization.
3. Electrolyte management: Abnormal electrolyte levels, such as low sodium and high
potassium, should be corrected as needed.
4. Correction of acidosis: Intravenous sodium bicarbonate may be administered to
correct severe metabolic acidosis, although cautious use is necessary.
5. Monitoring and support: The patient's vital signs, blood glucose levels, electrolytes,
and acid-base status should be closely monitored. Supportive care, including appropriate
pain control and antiemetic medications, should be provided.
6. Identification and treatment of underlying cause: In this case, the underlying cause
of DKA would likely be poorly controlled diabetes. Therefore, long-term management of
diabetes, including insulin therapy and lifestyle modifications, should be initiated or
optimized.

It is important to note that the management of DKA requires close medical supervision
and should ideally be carried out in an intensive care setting or under the guidance of an
experienced healthcare professional.

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3. TAHA, 60 YEAR MALE, WHO IS A HEAVY SMOKER, PRESENTED TO THE CLINIC WITH
HAEMOPTYSIS FOR FOUR MONTHS.
ON EXAMINATION THE PATIENT WAS FEBRILE, NOT JAUNDICE OR CYANOSED. HE HAS
PTOSIS AND FINGER CLUBBING, CHEST EXAMINATION REVEALED NO SIGNS APART
FROM MILD WHEEZE. OTHER SYSTEMS WERE UNBREAKABLE.
(A). WHAT ARE THE DIFFERENTIAL DIAGNOSIS
(B). EXPLAIN THE PATHOGENESIS OF PTOSIS
(C). MENTIONED TWO (2) IMPORTANT INVESTIGATIONS THAT WOULD HELP YOU IN
REACHING A DEFINITIVE DIAGNOSIS
(D). WHAT IS THE MOST LIKELY DIAGNOSIS?
(E). MENTION 4 COMPLICATIONS OF THIS CONDITION.

(A) The differential diagnoses based on the given clinical presentation include:

1. Lung cancer: Hemoptysis, history of heavy smoking, and the presence of finger
clubbing are suggestive of lung malignancy.
2. Tuberculosis: Chronic, persistent hemoptysis can be a symptom of active pulmonary
tuberculosis.
3. Bronchiectasis: The presence of chronic cough, wheezing, and finger clubbing may
indicate bronchiectasis, which can lead to hemoptysis.
4. Chronic bronchitis: Hemoptysis can be a manifestation of chronic bronchitis,
especially in heavy smokers.
5. Pulmonary embolism: Although less likely based on the given information,
pulmonary embolism can rarely present with hemoptysis.

(B) The pathogenesis of ptosis (drooping of the eyelid) can vary depending on the
underlying cause. However, in this case, with the presence of ptosis and finger clubbing,
it is most likely related to lung cancer. Ptosis can result from the involvement of the
sympathetic nerves that innervate the eyelid, which can be affected by the tumor or
metastasis in the lung.

(C) Two important investigations that would help in reaching a definitive diagnosis
are:

1. Chest X-ray or CT scan: Imaging studies of the chest can help identify any
abnormalities, such as lung masses, nodules, or lymphadenopathy, which can indicate the
presence of lung cancer or other lung diseases.
2. Sputum cytology: Examination of sputum samples for the presence of cancer cells can
provide a definitive diagnosis of lung cancer.

(D) Based on the given history, clinical findings, and risk factors, the most likely
diagnosis is LUNG CANCER. However, further investigations are needed to confirm the
diagnosis.

(E) Four complications of lung cancer include:

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1. Metastasis: Lung cancer can spread to other organs, such as the liver, bones, brain, or
adrenal glands, leading to secondary tumors and related complications.
2. Pleural effusion: Lung cancer can cause an accumulation of fluid in the pleural space,
leading to pleural effusion, which can cause chest pain and breathing difficulties.
3. Superior vena cava syndrome: Tumors located in the upper part of the lungs can
compress the superior vena cava, leading to symptoms such as facial swelling, neck
swelling, and difficulty in breathing.
4. Hemoptysis: Lung cancer can result in bleeding from the airways, leading to coughing
up blood (hemoptysis).

4. A 45 YEAR OLD WOMAN, MRS SARAH, PRESENTED TO THE ACCIDENT AND

EMERGENCY DEPARTMENT WITH MANIFESTATIONS OF HYPERTENSION. THE
SPECIALIST IN THE UNIT ADVISED TO HANDLE AND MANAGE THIS CASE.
(A). HOW WOULD YOU INVESTIGATION THIS CONDITION?
(B). WHAT ARE PREDISPOSING FACTORS TO HYPERTENSION?
(C). DISCUSS BRIEFLY THE PATHOLOGICAL CHANGES WHICH OCCUR IN THE HEART ,
BLOOD VESSELS AND THE KIDNEY
(D). WHAT ARE THE COMPLICATIONS OF THIS CONDITION?

(A) INVESTIGATIONS THAT CAN BE CONDUCTED TO EVALUATE AND INVESTIGATE

HYPERTENSION INCLUDE:

1. Blood pressure measurement: The initial and crucial step is to accurately measure
the patient's blood pressure multiple times to confirm the diagnosis of hypertension.
2. Blood tests: Blood tests can help assess renal function, blood glucose levels, lipid
profile, and electrolyte levels, which may provide insights into underlying causes or
associated conditions.
3. Urinalysis: Urine analysis can detect proteinuria or hematuria, which may indicate
kidney involvement or damage.
4. Electrocardiogram (ECG): An ECG can identify any abnormalities in cardiac
electrical activity and detect left ventricular hypertrophy, a common consequence of
chronic hypertension.
5. Echocardiogram: This imaging test uses sound waves to assess the structure and
function of the heart, helping to identify any hypertensive heart disease or complications.
6. Imaging studies: Additional imaging studies such as Doppler ultrasound, computed
tomography (CT), or magnetic resonance imaging (MRI) may be performed to assess
blood vessel health, identify potential blockages, or evaluate target organ damage.

(B) PREDISPOSING FACTORS TO HYPERTENSION INCLUDE:

1. Age: The risk of developing hypertension increases with age.

2. Family history: Having a family history of hypertension can increase the likelihood of
developing the condition.
3. Obesity: Excess body weight, especially around the waist, is a significant risk factor
for hypertension.

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4. Unhealthy lifestyle: Factors such as physical inactivity, excessive salt intake, low
potassium intake, excessive alcohol consumption, and smoking can contribute to the
development of hypertension.
5. Chronic conditions: Chronic conditions such as diabetes, kidney disease, and sleep
apnea can predispose individuals to hypertension.
6. Stress: Chronic stress or high levels of stress can contribute to the development of
hypertension.

(C) PATHOLOGICAL CHANGES THAT OCCUR IN THE HEART, BLOOD VESSELS, AND THE
KIDNEYS DUE TO CHRONIC HYPERTENSION INCLUDE:

Heart: Chronic hypertension can lead to left ventricular hypertrophy (thickening of the
heart muscle), impaired diastolic function, and ultimately heart failure.

Blood vessels: Prolonged hypertension causes structural changes in blood vessels,

leading to endothelial dysfunction, increased stiffness (arteriosclerosis), and the
development of atherosclerosis (plaque buildup). These changes can contribute to the risk
of coronary artery disease, stroke, and peripheral artery disease.

Kidneys: The kidneys play a crucial role in blood pressure regulation. Chronic
hypertension can damage the blood vessels in the kidneys, leading to renal artery sten

(D) COMPLICATIONS OF HYPERTENSION CAN AFFECT VARIOUS ORGANS AND SYSTEMS

IN THE BODY. SOME COMMON COMPLICATIONS INCLUDE:

1. Cardiovascular disease: Hypertension significantly increases the risk of developing

heart diseases such as coronary artery disease, heart attack (myocardial infarction), heart
failure, and abnormal heart rhythms (arrhythmias). It can also lead to the development of
hypertensive heart disease, characterized by left ventricular hypertrophy and impaired
cardiac function.

2. Stroke: Hypertension is a leading cause of ischemic strokes, which occur when blood
flow to the brain is blocked or reduced. Chronic high blood pressure can weaken blood
vessels in the brain, making them more susceptible to rupture and causing hemorrhagic
strokes.

3. Kidney damage: Prolonged hypertension can damage the blood vessels in the kidneys,
leading to chronic kidney disease and an increased risk of kidney failure. Hypertension-
related kidney damage is known as hypertensive nephropathy.

4. Eye complications: Hypertension can affect the blood vessels in the eyes, leading to
retinopathy. Retinopathy can cause vision loss or impairment and, in severe cases, can
result in blindness.

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5. Peripheral arterial disease: Hypertension can contribute to the development of
peripheral artery disease, which involves the narrowing or blockage of blood vessels in
the legs and arms. This condition can cause pain, numbness, and impaired circulation.

6. Aneurysm: Chronic high blood pressure can weaken the walls of blood vessels,
forming aneurysms. Aneurysms are abnormal bulges in the blood vessels and can occur
in various locations, such as the aorta (aortic aneurysm) or the brain (cerebral aneurysm).
If an aneurysm ruptures, it can lead to life-threatening bleeding.

7. Cognitive decline and dementia: There is evidence suggesting a link between

hypertension and an increased risk of cognitive decline, vascular dementia, and
Alzheimer's disease.

8. Metabolic syndrome: Hypertension is frequently associated with other metabolic

abnormalities, including obesity, high cholesterol, and insulin resistance, collectively
known as metabolic syndrome. These conditions increase the risk of cardiovascular
disease and type 2 diabetes.

PATHOLOGICAL PROBLEM SOLVING

1.

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