Beruflich Dokumente
Kultur Dokumente
Problem 1
Cellular Worlds
In viewing a specimen of animal cells through a light microscope, two first-year
veterinary medicine students, Shrinath and Peters, were intrigued by the various
compartments within the cells. Shrinath was interested in what could have been seen with
a more powerful microscope and also wondered why biochemists needed to mash up
cells in order to study their behaviour. Doesnt that kill themwouldnt they learn more
if the studied the whole cell while it was alive? he said.
OBJECTIVES
1.
Describe the ultrastructure of an animal cell.
2.
Describe the structure of the cell membrane.
3.
Describe the basic structure and properties of lipids.
4.
Relate the morphology and relative abundance of various cellular organelles
to the functions of the cell.
5.
Discuss the need for intra-cellular compartmentalisation and the basic
principles of intracellular metabolism.
6.
Discuss the different methods used in the study of cells and the
preparation of tissues.
January 7, 2008
Problem 2
Is Street Food Safe?
An article in the local newspaper recently reported unusually high numbers of cases of
diarrhoea over the last three months. An expert medical source in the newspaper report
suggested that it could be an outbreak of cholera, an intestinal infection caused by
bacteria and spread through the consumption of contaminated water and food. The article
indicated that about 10-20% of those infected would develop severe watery diarrhoea
with vomiting. This secretory diarrhoea is a result of cholera toxin binding to the
epithelial lining of the small intestine and triggering a series of events culminating in the
massive efflux of electrolytes and water into the intestinal cavity that can lead to severe
dehydration and death. Citizens were being advised to seek medical treatment promptly,
boil their drinking water and be mindful when buying food from street vendors. Public
Health Authorities were undertaking investigations and moves were being made to clamp
down on vendors who did not display valid food badges.
OBJECTIVES
1.
Review the fluid mosaic model of the plasma membrane of eukaryotic cells.
2.
Describe how water is distributed in the various body compartments.
3.
List the different types of diarrhoea and their physiological causes.
4.
Explain the mechanism of action of cholera toxin.
5.
Discuss the different types of dehydration and indicate which type cholera
causes.
6.
Describe the causes and consequences of dehydration of the fluid
compartments.
7.
Discuss the use of Darrow-Yannet diagrams.
8.
Discuss the use of epidemiology to investigate public health problems.
January 7, 2008
Problem 3
Calming the Nerve
A novel compound was being tested for its effect on a nerve preparation. Intracellular
recordings showed expected changes in membrane potentials following changes in the
ionic composition of the extracellular fluid. After application of the novel compound the
nerve no longer generated an action potential when stimulated.
OBJECTIVES
1.
Briefly describe the structure of a typical neuron.
2.
List the major anions and cations found in extracellular and intracellular fluid.
3.
Explain the processes that maintain the resting membrane potential of cells.
4.
Describe how changes in the ionic composition (Na+, K+ & Cl-) of
extracellular fluid affect the polarisation of excitable membranes.
5.
Explain how action potentials are generated in a nerve.
6.
Discuss compounds that can affect action potential generation.
January 7, 2008
Problem 4
A Chain is as Strong as its Weakest Link
Six-year-old Jennifer was taken to the doctor because her parents were worried about the
fact that she always complained of being tired and often had mild fever. Recently her
mother had noticed that her eyes looked slightly yellow. After receiving the results of the
blood test she had ordered, the doctor told her parents that one of the proteins in
Jennifers red blood cells was defective. She explained that this was caused by a gene
mutation that affected only one of the hundreds of amino acid building blocks found in a
particular protein called haemoglobin. Unfortunately, she said, this single substitution
does have a profound effect on the performance of red cells.
OBJECTIVES
1.
Discuss the histology of blood cells.
2.
Explain what is meant by the terms primary, secondary, tertiary and
quaternary structure of a protein.
3.
Explain why the primary structure of a protein is said to determine its three
dimensional structure and its function.
4.
Explain why the substitution of a single amino acid alters the shape and
biochemical function of the haemoglobin molecule.
5.
Describe the different types of point mutations and their possible effects on
protein structure and function.
6.
Discuss the role of epidemiology in identifying this patients diagnosis.
7.
Discuss the concepts of health, illness and disease.
January 7, 2008
Problem 5
Happy, Grumpy and DROOPY
A 21-year-old salesgirl complained of weakness in the shoulders and drooping eyelids.
These symptoms appeared in the evenings but disappeared after a nights rest. On and off
she also had difficulty swallowing, particularly at dinner time.
Her GP suspected a problem with either her nerves or muscles and referred her to a
neurologist. The latter performed an edrophonium test and EMG (electromyogram) to
confirm the diagnosis.
OBJECTIVES
1.
Describe the anatomy of the neuromuscular junction.
2.
Explain the process of synaptic transmission at the neuromuscular junction.
3.
Identify drugs that can block neuromuscular transmission.
4.
Briefly describe the pathophysiology and treatment of myasthenia gravis.
5.
Describe how an EMG is performed.
6.
Describe three methods that distinguish normal from abnormal tests result in
the diagnosis of this patient.
January 7, 2008
Problem 6
Their Legs Went Weak
Mr & Mrs. Singh could hardly digest the news. They had just returned from the doctors
office. He had told them that it was very likely that their son Shiva had an inherited
disorder called Muscular Dystrophy. He spent a lot of time explaining all the tests that
would have to be done to confirm the diagnosis and to determine whether it was
Duchennes Muscular Dystrophy (DMD). All poor Mr and Mrs Singh remembered was
what he had said about Shiva being unlikely to live past the age of 25.
But how did he get it? Mr. Singh asked his wife, I cant remember anyone in our
family having anything like that?
After getting over the initial shock, Mrs. Singh decided to call her niece Nalini who was a
medical student. Nalini explained that DMD was a genetic disorder that only occurred in
boys and that people with DMD did not produce a protein that was necessary for proper
muscle function. She said that Duchennes was only one of several types of muscular
dystrophies and that each type differed in the muscles affected, the age of onset, and its
rate of progress but she was not sure what caused them.
Nalini explained (as simply as she could) the different tests that were likely to be done
like a muscle biopsy, histological tests, immunohistochemistry, EMG and DNA analyses.
She knew that there had been research directed at developing techniques for replacing the
defective gene. She had read about attempts to repair the defective gene in a canine
model of DMD in golden retrievers (GRMD) but wasnt sure whether these gene
therapies were being used on humans yet.
OBJECTIVES
1.
Discuss the chromosome theory of inheritance and the genetic basis of
disease.
2.
Discuss the inheritance and genetics of DMD.
3.
Briefly describe the causes of DMD and other muscular dystrophies.
4.
Describe the organization, microscopic anatomy and ultrastructure of skeletal
muscle.
5.
Describe the structure of the actin and myosin myofilaments and their
relationship to other proteins important for muscle contraction.
6.
Discuss the role of dystrophin.
7.
Describe the different types of tests used to diagnose and characterise
muscular dystrophies.
8.
Outline the types of DNA analyses that can be used to diagnose and
characterise genetic disorders.
9.
Explain what is meant by gene therapy and give a brief account of what
progress has been made towards gene therapy for DMD.
10.
Discuss the concept of natural history and determinants of health in relation to
the diagnosis and treatment of this patient.
January 7, 2008
11.
January 7, 2008
Problem 7
HIV and Pregnancy
Charmaine, a 23 year old UWI student has just found out that she is pregnant. Only three
weeks before she learned that she was HIV positive and is barely coping. She worries that
others will find out and hasnt even told her family yet. Now she is back in Dr. Williams
office in tears. She wants to keep her baby but is worried about its health.
What is the chance that my baby will be infected? she asks.
Well, there have been many studies, says Dr. Williams. Without treatment,
transmission rates vary widely depending on the country. In the Caribbean it is about
28%. Most of that transmission occurs during labour and via breastfeeding. As long as
you stay relatively healthy, your placenta will help to protect the foetus against infection
during the actual pregnancy. The good news is that the risk at all stages can be
significantly reduced if we use antiviral treatment during pregnancy and delivery and for
the baby after it is born. The recommended drugs are AZT, nevirapine and 3TC - they
interfere with the replication of the viral genome.
Charmaine is so anxious about her babys health she wants to start treatment immediately,
but Dr. Williams tells her she will have to wait until after 14 weeks gestation.
OBJECTIVES
1.
Discuss the main issues that might create problems for a woman diagnosed
with HIV in the Caribbean.
2.
Discuss mother-to-child transmission of HIV and prevention strategies in
developed countries versus resource-limited settings.
3.
Describe the structure and role of a mature hemochorial placenta.
4.
List infective agents that are able to cross the placenta and are teratogenic.
5.
Review nucleic acid synthesis and replication.
6.
Explain the mechanism of action of antiretroviral drugs (with reference to the
role of reverse transcriptase in the virus genome replication).
7.
Explain why drug therapy is usually delayed until after 14 weeks gestation.
January 7, 2008
January 7, 2008
PROBLEM 2
Blood Components and Normal CBC Values
Kwame, a first-year medical student and a regular blood donor decided to use this
experience to learn something about blood. He asked the technician to obtain a suitable
sample for a CBC. He then went to the blood bank where he saw plasma being separated
from red cells. Later that afternoon, he returned to the hematology lab for his results and
was given a slip with the following values:
Hb 15g/dl; Wbc 8 x 109/l; Platelets 165 x 109/l; MCV 90 fl; Neutrophils 4.5 x 109/l;
Lymphocytes 2.5 x 109/l; Eosinophils 0.3 x 109/l; Basophils 0.6 x 109/l.
OBJECTIVES:
1. Identify normal ranges of hemoglobin by age, sex and physiology state such as
pregnancy.
2. Identify the mean corpuscular volume (MCV) as an important parameter in
indicating possible causes of low hemoglobin.
3. Describe how the cell population would appear under a microscope.
4. Briefly discuss the composition of plasma.
5. List the difference between plasma and serum.
6. Identify the components of whole blood that are available for transfusion.
7. What indications are there for blood transfusion?
8. List and explain normal CBC values.
January 7, 2008
10
PROBLEM 3
Inflammation and Wound Healing
A 12-year old secondary school student lost control of his bike and fell on the road. He
had a lacerated wound on his scalp, superficial and deep abrasions over his knees and
elbows. At casualty at the local hospital, the house officer examined the injuries and
noted the signs of acute inflammation. The wounds were cleaned with antiseptic
solutions. The patient was given a tetanus toxoid booster because he had received tetanus
toxin 10 years ago. The wound over the scalp was sutured and he was discharged.
OBJECTIVES:
1. List the various types of wound sustained by this patient.
2. Define inflammation and list the cardinal signs.
3. Describe the vascular and cellular events in the acute inflammatory response.
4. List the outcomes of acute inflammation.
5. Describe stepwise, the process of wound healing.
6. Outline various factors that influence wound healing.
7. List complications of poor wound healing.
8. List the various mild antiseptic solutions used in would cleansing.
9. Discuss the primary prevention of tetanus.
10. Discuss active and passive immunity.
January 7, 2008
11
PROBLEM 4
Transmission & Aetiology of Infection by Pyogenic Organisms
A two-year old girl was seen in the Pediatric Clinic with pustular lesions on her lower
limbs. Her mother, a graduate student, gave a history of the child being bitten by
mosquitoes. The doctor expressed concerns about organisms that are present on the skin
that may cause infection. The doctor also explained the transmission and course of
infection of pyogenic organisms. She took a sample of pus with a sterile swab and sent it
to the microbiology laboratory for Gram stain and culture. She also prescribed
antibiotics.
OBJECTIVES:
1. Discuss the aetiology of skin pustular lesions.
2. List the organisms that constitute the normal flora of the skin.
3. Discuss the transmission and pathogenesis of bacteria infection.
4. Describe the procedure of Gram stain.
5. Explain the significance of Gram stain results.
6. Outline the procedures for the culturing of bacteria.
7. Review the microbiology of staphylococci and streptococci including virulence
factors.
8. Describe the mammalian host defense mechanisms under natural barriers,
humoral mechanisms and cellular defense mechanisms.
9. Define the terms: antibiotic, bactericidal, bacteriostatic.
10. Classify antibiotics according to their mechanism of action.
January 7, 2008
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January 7, 2008
13
Problem 2
Persistent Heartburn
A 65-year-old man with a six-month history of dysphagia, heartburn, anorexia, epigastric pain
and occasional vomiting was seen at the Medical Out Patient Clinic. At the clinic on
questioning by his doctor, he admitted taking antacid drugs in an attempt to relieve his
heartburn, however, these were not effective. He also gave a history of social alcohol use,
irregular eating habits and smoking 5-10 cigarettes daily. A provisional diagnosis of peptic
ulcer was made pending further investigation. The doctor emphasized the need for lifestyle
modification for efficient management of the patient.
Objectives
1. Describe the gross anatomy and histology of the oesophagus, stomach and duodenum.
2. Explain the mechanisms and control of deglutition.
3. Define oesophagitis, list the causes and the drugs used to treat oesophagitis.
4. Describe the physiology of gastric secretions and mention the functions of the main
constituents of gastric secretions.
5. Discuss the causes and consequences of altered levels of gastric acidity.
6. Define peptic ulcer and list aggravating factors.
7. Classify drugs used in the treatment of peptic ulcer, giving one example of each class.
8. Outline the components of a healthy diet and discuss the nutritional requirements of the
elderly.
9. Is simply giving advice enough? Explain how health behaviour changes are essential for
facilitating dietary changes.
January 7, 2008
14
Problem 3
Weak William
William, a 17-year old male visited his GP complaining that he experienced early muscle
fatigue and a cramping muscle pain during strenuous exercise. He had observed that this
condition did not improve with additional exercise, with a sports drink containing
electrolytes, or with anti-inflammatory medications. His activities associated with daily
living are not affected. A blood sample taken after exercise contained very low level of
plasma lactate but plasma creatine kinase levels were elevated.
Objectives
1. Briefly explain the histology of the liver.
2. Describe the various sources of energy during short term and long term exercise.
3. Describe the pathways of glycogen breakdown and glycogen synthesis.
4. Explain the biochemical basis for glycogen storage disease.
5. Explain the central role of the liver in metabolism of nutrients.
6. Discuss the Cori cycle and its regulation.
7. Give an account of the nutritional needs and how they are met continuously from
birth to young adulthood.
January 7, 2008
15
Problem 4
A Tale of Two Gentlemen
While on call for the Medical Ward of the local hospital, final year student Eva admitted
two patients with liver problems. One was a 43-year old unmarried musician and the
other a 55-year-old businessman.
Mr. Yell OMellow, the musician had been touring the Caribbean for many years and had
fathered children in six different countries over the last 7 years. Recently he complained
of feeling weak, tired and unwell. He observed that he had a fever on and off, no
appetite, was nauseous and had dark urine. Additionally he noted some discomfort in the
right side of his abdomen. One of his friends also told him that his eyes looked yellow.
Upon examination of Mr. OMellow scleral icterus was confirmed. Eva noticed a tattoo
on his chest, an enlarged liver and tenderness over the right upper quadrant of his
abdomen in the area of his gall bladder. Results from blood analysis together with the
signs and symptoms suggested viral hepatitis.
Mr. C. Eeyo on the other hand was admitted because he was vomiting blood. He gave a
history of consuming more than 35 alcoholic drinks per week over several years.
On examination Mr. C. Eeyo was found to be agitated and somewhat disoriented. His
blood pressure was 90/40 mmHg, pulse 130 beats per minute and temperature 38 oC. His
wbc and Hct were within normal limits. Mr. Eeyos abdomen appeared tense and
distended and his liver was palpable approximately 8 cms below the right costal margin.
His sclerae were also icteric and several spider angiomata were noted on the lower
extremities. After his blood analysis was completed an emergency endoscopy was
performed which revealed oesophageal varices. The initial treatment was with
intravenous vasopressin and nitroglycerin.
Eva thought about all the other things that could go wrong with the liver, and marveled at
this multi-tasked organ.
Objectives
1. Discuss the embryology, gross anatomy and histology of the liver, gall bladder and
biliary tract.
2. Briefly describe porto-caval anastomoses.
3. Explain the physiological bases of jaundice.
4. List the biochemical abnormalities that may result from hepatic dysfunction.
January 7, 2008
16
5. Discuss the relationship between the hepatic double circulation and liver function.
6. Relate the structure of the gall bladder to its function.
7. Discuss the public health significance and prognosis of Hepatitis B & C viral
infections.
8. Explain how some of the major causes of death and disability have a nutritional
component.
January 7, 2008
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Problem 5
Hapless Harry
Several children between the ages of 5 years to 11 years old were brought to the health
centre all complaining of abdominal pain wtih several bouts of watery blood-stained
diarrhoea over the last 6-8 hours. One of them, 7 year old Harry, had fever and vomited
five times. On examination his temperture was 38.4C, skin turgor was markedly
diminished, his eyes appeared sunken and his tongue and lips were dry. His abdomen was
soft, non-tender, he had no guarding or rebound tenderness, and bowel sounds were
hyperactive. He was started on an intravenous infusion and blood was taken for CBC,
urea and electrolytes and stool tests were done. The DHV (District Health Visitor)
immediately informed the CMOH (County Medical Officer of Health) for the appropriate
public health actions.
Objectives
1. Describe the functional histology of the lower alimentary canal and associated glands.
2. Describe the changes in plasma electrolytes during chronic diarrhoea and their effects
on acid-base balance.
3. Discuss the role of the colon in water and electrolyte metabolism, and predict the
effect of any imbalances.
4. List the infectious agents associated with bloody diarrhoeal illness.
5. Define and list the differences between gastroenteritis, dysentery, diarrhoea and
enterocolitis.
6. Discuss the prevention and management of diarrhoea.
7. Explain the composition, importance, and route of administration for rehydration
therapy.
8. List the drugs used as antidiarrheal agents and briefly describe the mode of action of
diphenoxylate, loperamide, kaolin and pectin.
9. Identify ways in which foods can become contaminated.
10. Discuss the consequences of the lack of food hygiene and preventive control
measures.
11. Explain why Public Health is the responsibility of the whole society.
12. Explain how the science of Public Health is dependant on scientific knowledge of
causes of disease and how to prevent or treat, with systematic approach to identify
problems.
January 7, 2008
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January 7, 2008
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Problem 2
The Failing Heart
An executive medical examination revealed an enlargement of Mr. Deans heart.
Electrocardiogram showed Q waves in the inferior leads. Further investigations showed
abnormal cardiac enzymes. Mr. Dean explained to his doctor that in the past he had
suffered two heart attacks. The doctor made a diagnosis of heart failure arising from his
previous heart attacks. He then proceeded to discuss a treatment plan with the patient.
Objectives:
1. Describe the normal ECG tracing.
2. Give reasons for the abnormal Q waves seen in the inferior leads.
3. Describe the cardiac cycle with respect to pressure and volume changes.
4. Discuss the factors affecting normal cardiac output.
5. Using Frank Starling Law explain how the failing heart dilates to compensate
for loss of contractile power.
6. Identify drugs used to treat cardiac failure.
7. State (between digoxin and digitoxin) which of the cardiac glycosides is
preferred for treatment.
8. Explain the principal use of diuretics in treating patients with cardiac failure.
9. State the biochemical techniques used in the identification and measurement
of isoenzymes in blood and discuss the diagnostic value of these
measurements.
January 7, 2008
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Problem 3
The Designer Heart
A team of engineers has contracted a medical intern to assist them in the computer
modeling of a heart and circulatory system. The model must depict the essential
anatomical, functional and physical characteristics of the heart and great vessels. The
engineers are specifically interested in obtaining details on how the heart is able to move
blood throughout the system of blood vessels. They are also curious about the
characteristics of blood which permit it to flow, the types of flow within the system and
the ability of the mechanisms to maintain unidirectional flow. The team also intended to
obtain critical vascular flow and resistance data and cardiac pressure and volume changes
from a simulation of an exercising heart.
Objectives:
1. Discuss the gross anatomy of the heart and great vessels.
2. Review the cardiac cycle with respect to pressure and volume changes.
3. Discuss factors that affect viscosity of blood and the physiological
consequences of these changes.
4. Explain the functions of the valves in the cardiovascular system.
5. Explain the determinants of resistance in the vessels and the relationship
between flow, pressure and resistance expressed as Poisseuilles Equation.
6. Explain the physiological changes caused by exercise.
7. Discuss laminar flow as it relates to the vascular system and the determinants
of Reynolds number.
January 7, 2008
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Problem 4
Our Connected Systems
Dave is a stressed out CEO who has had uncontrolled hypertension (BP: 160/90) for the
past five (5) years. Lately he noticed puffiness around his face and ankles, and
experienced shortness of breath and fatigue. His blood pressure measurement was
190/115. His doctor had recently noticed abnormalities of his renal system. Dave has a
family history of hypertension and diabetes. Serum analysis which was requested
revealed the following results:
BUN:
Creatinine:
Hb:
80 mmol/L
110 mmol/L
8.5 mg/dL
January 7, 2008
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Problem 5
Caroni versus Tobago
A family practitioner for over 20 years in County Caroni, Dr. Gene Diet observed that a
high proportion of his male patients in the age group 45-55 had suffered from Acute
Myocardial Infarction (AMI). Most of these patients were obese, had episodes of anginal
pain and biochemical investigations often revealed hyperlipidaemia. At the same time he
found that women of similar age had very few episodes of AMI but this trend changed in
the age group 55 and over where the incidence of AMI in women equaled that of men.
During the first week after moving to work at a Primary Health Care Centre in Tobago, a
medical student asked Dr Diet for help with a research project to study causes of
morbidity in the area. The doctor was surprised to learn that the leading cause or
morbidity in men aged 45-55 was hypertension.
Women over 55 showed a similar pattern of morbidity that the doctor saw in the Caroni
patients. Dr. Diet was fascinated by these ethnic, gender and age differences in the
morbidity patterns and decided to do a detailed study with the student on the
epidemiology of cardiovascular diseases in the two regions of the country. He considered
including in the discussion of the final report a section on managed health care plans
incorporating life style, diet and medication.
Objectives:
1. Discuss the blood supply and venous and lymphatic drainage of the heart.
2. Discuss the causes of ischemic heart disease and note the influence of diet,
age, gender, life-style (stress), habits (smoking), obesity and hypertension.
3. Discuss the biochemistry of plasma lipoproteins and the risks associated with
an abnormal lipid profile.
4. List the drug groups used in the treatment of hypercholesterolemia and
identify members of each group.
5. Discuss the incidence and prevalence of ischaemic heart disease and
hypertension in the Caribbean in relation to associated risk factors.
6. Describe the process (identifying tasks) used to undertake research.
7. Discuss the factors which influence what people eat (economic, social, ethnic,
religious, educational).
January 7, 2008
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Problem 6
Surviving on Water
A 22-year old American marine was part of the military force sent to the Middle East
during the Gulf crisis. This was the first time he was posted to the sandy desert working
at temperatures around 49C (120oF).
Two days after his arrival, he was admitted to the sick room as he felt unusually tired and
fatigued. He complained of intense thirst and muscle cramps and had intermittent fainting
spells. He was infrequently passing small amounts of highly colored urine and
subsequently collapsed
The examining physician found his skin was hot and flushed, his eyeballs were soft and
sunken, and the rectal temperature was 41C (106F). He had rapid shallow breathing and
his blood pressure was 80/60 mmHg. He was diagnosed as having heat stroke. His
colleague was not affected as he regularly drank plenty of water to which a pinch of salt
was added.
Objectives:
1. Describe the gross anatomy and histology of the kidney.
2. Explain the mechanism of urine concentration.
3. Describe the transport processes in the kidney which are involved in the
maintenance of water and electrolyte balance.
4. Describe the different fluid compartments and distribution of electrolytes.
5. Discuss factors which regulate body water.
6. Explain the regulation of body temperature.
7. Discuss the effects of dehydration on cardiac and renal functions.
January 7, 2008
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Laboratory Values
Haemoglobin (g/dl)
14.5
PaO2 (mm Hg)
48
PaCO2 (mm Hg)
69
O2 saturation (%)
78
HCO334
Based on the above data the pulmonologist recommended a full assessment to include
measurement of airway resistance (R AW), lung compliance (CL), total lung capacity (TLC)
functional residual capacity (FRC) and residual volume (RV). The results are given in the table
below
Residual Volume (RV)
1.8 L
Functional Residual capacity
3.0 L
Airway resistance RAW
3.2 cm H2O/l/sec
Lung compliance (CL)
0.35 L/sec/cm H2O
OBJECTIVES:
1.
2.
3.
4.
5.
6.
7.
8.
Describe the anatomy of the nasal cavity, paranasal air sinuses and nasopharynx.
Draw a spirogram indicating lung volumes and capacities and factors affecting them.
Describe the physiological significance of the RV.
Discuss the physiological mechano-concepts involved in breathing and respiration (movement
of air into and out of the lung; RAW; forces generated by the respiratory muscles to move the
air, CL, surface tension and the defense system of the respiratory system).
Compare the values of the patient with normal values.
Describe the common symptoms and signs associated with respiratory disease.
Discuss the pharmacology of drugs used in the treatment of cough (suppressants,
expectorants and mucolytics).
Discuss the pharmacology of:
drugs used as bronchodilators (salbutamol, theophylline, adrenaline and ipratropium)
drugs used as prophylactic treatment of asthma (sodium cromoglycate) and
glucocorticoids.
January 7, 2008
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Change
75 mm Hg
36 mm Hg
97%
62 mm Hg
35 mm Hg
90%
OBJECTIVES:
1. Describe the anatomy of the lower respiratory tract and the right and left lungs (To include
arterial supply, venous and lymphatic drainage of the lungs, bronchial tree and innervation).
2. Discuss the aetiopathology of the restrictive pulmonary disease.
3. Distinguish between obstructive and restrictive diseases and describe the various laboratory
methods used to assess ventilatory function.
4. Discuss factors affecting the diffusing capacity of the lungs
5. Outline the major immune defenses in the upper and lower respiratory tract.
January 7, 2008
26
On recovery she learnt that the difference between weight loss and death is only a small
concentration change in dinitrophenol, making the drug dangerous. She agreed to do further
studies on blockers of the electron transport chain, their sites of action and to analyse the effect
of the blockers on the chemiosmotic theory.
OBJECTIVES:
1. List the components of the electron transport chain, and describe their organisation and
function.
2. Explain the term uncoupler and list the common inhibitors and uncouplers of the electron
transport chain, indicating their site of action.
3. Discuss oxidative phosphorylation with emphasis on the chemiosmotic theory.
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PROBLEM 2
Back Stabbing For Real
James was rushed to the hospital after he was stabbed in the back. The examining doctor
noted that below James navel, he did not respond to pain and temperature on his left
side, or proprioception on his right side. James was referred to a neurosurgeon for
appropriate management.
Objectives
1. Describe ascending (sensory) neuronal tracts in the spinal cord and brain.
2. Describe the segmental innervations of the body and dermatomes.
3. Determine the level of spinal cord lesion based on the presenting neurological
symptoms and signs.
4. Relate segments of the spinal cord to vertebral levels.
5. Discuss the possibility of recovery of sensation.
January 7, 2008
31
PROBLEM 3
To Transmit Or Not To Transmit?
Epilepsy is a syndrome that arises when the excitatory neurotransmitter, glutamate,
stimulates neurons to start firing wildly and uncontrollably, sometimes resulting in
seizures or loss of consciousness. In a recent study, a team of scientists induced epilepsy
in rats and found to their great surprise that there was an increase in abnormal glial cells
in the cerebral cortex. One of the roles of normal glial cells is to mop up excess glutamate
but the abnormal glial cells produced increased amounts of glutamate.
Current treatments of epilepsy are aimed at slowing down brain function to reduce the
neuronal firing, but these have unwelcome side effects, such as drowsiness due to their
action on the reticular activating system. Researchers used the rat models to analyse three
GABAmimetic drugs commonly used to treat epilepsy. They found that in addition to
slowing neural firing, the drugs reduced the type of chemical signaling that causes
astrocytes to release glutamate. This may contribute to why the drugs work, the
scientists suggested.
Objectives
1. List the types of glial cells in the central nervous system and their functions;
indicate which one of them is affected in the scenario above.
2. Classify glutamate receptors.
3. Briefly describe the general structure and mechanisms of action of ionotropic and
metabotropic receptors.
4. List the types and causes of epilepsy in humans and discuss their underlying
mechanisms.
5. Discuss the role of GABAmimetic drugs in the treatment of epilepsy.
6. Discuss the management of epilepsy.
7. Discuss the role of the Reticular Activating System in consciousness.
January 7, 2008
32
PROBLEM 4
Proteins Slow the Progress of Parkinson's Disease
Researchers claim to have slowed the progress of Parkinsons disease in rats by injecting
two proteins into a part of the brain that has been implicated in Parkinsons disease. The
proteins prevented the brain cell loss associated with the disease.
Until now, most therapies have concentrated on replenishing the neurotransmitter, but
that does not stop the brain cell loss and so have had limited success. Now, working in
rats, a team of scientists have succeeded in halting brain cell death in the vital brain
region. The researchers used a genetically engineered virus to transfer the genes for the
two proteins Sonic Hedgehog and Gli-1 to the brain cells of a group of adult rats
referred to as Group I. One week after the proteins had been injected, a drug that induces
Parkinsons disease was given to the rats, as well as to a second group of rats that had not
received the proteins referred to as Group 2.
Four weeks later, the Group 2 rats had lost 80% of neurons in the vital brain region.
Whereas the Group I rats had only suffered 20% - 30% brain cell loss in the same region.
The results of this study were submitted to the journal Brain Research for publication.
Reviews were favorable and though one referee suggested that a third group of rats be
analysed to improve the reliability of the results.
Objectives
1. Name the region of the brain in which the scientists injected the proteins.
2. Draw a diagram to illustrate the direct & indirect pathways in the basal ganglia;
indicate the neurotransmitters involved in the pathways.
3. Describe the synthesis of the neurotransmitter that mammalian brain cells
manufacture to prevent progression of Parkinsons disease; indicate the ratelimiting enzyme.
4. Describe all the receptors for the transmitter (identified in 3) and possible second
& third messenger systems for the transmitter.
5. Discuss the use of genetically engineered virus vectors for gene transfer.
6. Discuss the role of the third groups of rats in improving the reliability of the
research.
January 7, 2008
33
PROBLEM 5
Memory Loss in Mice & Humans
A group of scientists discovered that injecting fragments of the protein beta-amyloid from
human patients with Alzheimers dementia into the brains of a group of mice caused the
animals to forget chores they had just been taught. When further electrophysiological
experiments were done, both long-term potentiation and long-term depression were found
to be compromised.
Objectives
1. Describe the gross anatomy, histology and embryology of the human cerebral
cortex.
2. List the pathological features that would be expected to develop in the brain of the
mice.
3. Describe the common classifications of learning.
4. Describe the common classifications of memory.
5. List neurotransmitters and brain regions associated with memory and learning.
6. Compare (and contrast) long-term potentiation and long-term depression.
January 7, 2008
34
PROBLEM 6
Upper or Lower????
Mr. Jones, a 63 year old Afro-Trinidadian man awakes one morning with weakness on his
right side. He also complains of difficulty seeing and has slurred speech. He is rushed to
the accident and emergency department where he is examined. Findings include a history
of hypertension, right-sided hemiparesis (equally in the arm and leg) with diminished
pinprick and two point discrimination of his right side. His muscle tone on the right is
reduced and so are his tendon reflexes.
Six months later when Mr. Jones is seen in the out-patient clinic he is walking with a limp
and has little functionality of his right arm. However tendon reflexes on his right side are
now increased and he has a positive Babinski sign and increased muscle tone on the right
side.
Objectives
1. List the components of the neurological examination and briefly describe how
they are assessed.
2. Describe the arterial supply to the brain indicating which artery/arteries could
have been blocked to cause the stroke in the above patients. (The use of a diagram
is recommended).
3. Describe the ascending pathways for pain and two-point discrimination.
4. Describe the primary descending motor pathways.
5. Explain the physiological basis for: (i) a simple stretch reflex (ii) the primitive
reflexes.
6. Compare and contrast upper and lower motor neuron lesions.
January 7, 2008
35
PROBLEM 7
Hearing Loss Is More Than The Ears
Mrs. Johnson, a 70 year old retired music teacher, has been experiencing a gradual loss in
hearing over the last 10 years. Even with her hearing aid turned to full volume, she can't
make sense of speech, especially when two or more persons speak at the same time
during a conversation.
Audiometric testing showed sensory-neural deafness and a PET scan revealed that there
was less than normal activity in the midbrain. The scan also showed that fewer nerve
fibers infiltrated the midbrain and that there were lower levels of calcium entering and
leaving the nerve cells.
The specialist explained, much to Mrs. Johnson's disappointment, that a cochlear implant
was unlikely to improve her hearing. He further advised Mrs. Johnson's daughter that her
mother would benefit from persons speaking more slowly to her and engaging her in a
polite conversation where people take turns.
Objectives
1.
2.
3.
4.
5.
6.
List the common causes of hearing loss in the different age groups.
Describe the anatomy of the ear.
Describe transduction of sound in inner ear.
Describe the auditory pathways.
Describe the processing of hearing & speech in the CNS.
Describe how polite conversation improves Mrs. Johnsons understanding of
speech.
7. Describe the various tests for hearing.
8. Explain how hearing aids & cochlear implants work.
January 7, 2008
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OBJECTIVES:
1.
2.
3.
4.
5.
6.
7.
January 7, 2008
37
1.
2.
3.
4.
5.
6.
7.
Describe the embryology, gross anatomy, and histology of the adrenal gland.
Describe the physiological actions of glucocorticoids.
Describe the pharmacological actions of glucocorticoids.
Discuss the aetiology and pathophysiology of hypersecretion of glucocorticoids.
Discuss the tests used to assess adrenal cortical function.
Discuss the complications of steroid use.
Discuss the pathophysiology of adrenal failure.
January 7, 2008
38
1.
2.
3.
4.
5.
6.
7.
Describe the embryology, gross anatomy and histology of the endocrine pancreas.
Describe the pathophysiology of the different types of diabetes mellitus.
Discuss methods used in the diagnosis of diabetes mellitus.
Describe hormonal control of blood glucose levels in patients with NIDDM.
Describe strategies for the prevention and management of Type II diabetes.
Classify and describe the hypoglycemic drugs available for the treatment of Type
II diabetes.
Classify insulin preparations as short, medium and long acting and identify
sources of insulin preparations.
January 7, 2008
39
1.
2.
3.
4.
5.
6.
7.
Describe the embryology, gross anatomy and histology of the male reproductive
system.
Discuss the process of spermatogenesis and the maturation and storage of
spermatozoa.
Discuss the physiology of erections.
Discuss the physiology of ejaculations.
Define the composition and functions of seminal fluid.
Discuss the causes of male infertility and reduced libido.
Describe the parameters used in evaluating production and quality of semen.
January 7, 2008
40
1.
2.
3.
4.
5.
6.
Describe the embryology, gross anatomy and histology of the female reproductive
system including the placenta.
Discuss the causes of amenorrhea.
Identify the major physical and hormonal changes associated with pregnancy.
Outline the principles underlying tests used in the diagnosis of pregnancy.
Discuss the hormones involved in breast development and lactation.
Discuss the merits of breast feeding.
January 7, 2008
41
1.
2.
3.
4.
5.
6.
Discuss the factors underlying the onset of puberty in males and females and
menopause in females.
Describe the physiology (including regulation) of puberty in males and females.
Discuss the physiology and management of climacteric changes.
Classify oestrogens (natural and synthetic) and recognize their use in hormone
replacement therapy.
Discuss the controversy surrounding hormone replacement therapy.
Describe the psychological factors associated with the onset of puberty or
menopause.
January 7, 2008
42
January 7, 2008
43
Problem 2
The Young Scientist
John a curious second-year medical student was performing a series of experiments upon
a nerve-muscle (skeletal) preparation. He noted that when he stimulated the nerve once,
the muscle would twitch. But if he increased the frequency of stimulation, a point would
be reached when the muscle would stop twitching and remain contracted. John wondered
if this was what occurred during muscle 'cramps' and whether it was in any way related to
a reduction in muscle ATP with repeated stimulation. He also was not sure about the
differences between the skeletal muscle fibres of different colour and wanted to test
whether the same thing would occur in smooth muscle because he vaguely remembered
someone telling him that smooth muscles cannot undergo tetanus.
In another series of experiments John observed that if he added acetylcholine to the bath,
without stimulating the muscle, the preparation would contract. This even occurred when
he sectioned the nerve. However contraction was greatly reduced if the concentration of
calcium in the bath was lower than normal.
OBJECTIVES:
1. Describe the histology and ultrastructure of skeletal muscle and contrast muscle
fibre types, their distribution and innervation. Describe the functional histology of
the neuromuscular junction.
2. Describe the mechanism of skeletal muscle contraction and functional roles of
slow and fast twitch muscle fibres. Explain the role of acetylcholine and calcium
in muscle contraction.
3. Describe a muscle twitch. Explain how contraction occurs in skeletal and smooth
muscles and note their differences.
4. Define the term tetanus and explain how it comes about.
5. Discuss the different sources of fuel for skeletal (fast and slow twitch fibres) and
smooth muscles.
6. Discuss the effects of oxygen debt and ATP depletion on muscle function.
7. Discuss the possible biochemical basis and pathophysiology of muscle cramps
and their management.
January 7, 2008
44
Problem 3
A Carnival Dancer
Mr. Green, a 37-year-old Trinidadian taxi driver was complaining to his family doctor
about lower back pain, which began just after the last carnival. On questioning he told
the doctor that he and his friends had a lot of fun participating in recent carnival
activities. Mr. Greens dancing apparently involved excessive movements of his trunk,
which led to his lower back problem.
On examination of his back, the doctor noticed moderate tenderness of the lower
paravertebral muscles and movements of the lumbar spine were painful and limited.
Radiographic study revealed a spina bifida occulta of the 1st sacral vertebra, while an
isotope scan of the lumbar vertebrae was normal. A muscle relaxant was prescribed.
Mr. Greens father often suffered with lower backbone problems because he had a
slipping lumbar vertebra and Mr. Green wondered if he could have a similar problem
with his own vertebra, which might lead to his present condition.
OBJECTIVES:
1. Describe the gross anatomy and embryology of the vertebral column with special
emphasis on its articulations, mobility and stability.
2. Discuss common congenital abnormalities of the vertebral column, their
manifestations and complications.
3. Describe the gross anatomy of the muscles of the back and movements they
produce.
4. Discuss the effect of extreme movements on the vertebral column.
5. Contrast the factors which can cause lower back pain.
6. Discuss the diagnostic tools for backbone problems.
7. Name groups of common muscle relaxants and describe the use of
benzodiazepines to provide muscle relaxation.
January 7, 2008
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Problem 4
Spoilt Concert
Ms. T., a beautiful middle-aged famous Trinidadian singer, was invited to New York in
January to give a concert. On the way from the airport to her hotel she could not avoid
the blast of the chilling wind on her face and neck. The next morning she looked in the
mirror and was shocked because her face looked crooked. While she was able to move
her head and neck freely, she could not close her left eye; and on drinking, water dribbled
from the left corner of her mouth.
She recalled a similar problem in the past when the dentist, treating her teeth, blocked a
nerve in her mouth by an anaesthetic. At that time all symptoms disappeared on the same
day. However, on this occasion the specialist to whom she was referred, explained after
examination of her face and radiographs of her skull that she could have a nerve
compression in the small opening of the skull also known as Bells palsy and her new
condition would require a more prolonged period of treatment. Since her concert was
scheduled for the same evening, the singer had to cancel it.
OBJECTIVES:
1. Describe the gross anatomy of the skull and the individual cranial bones.
2. Describe the gross anatomy of the muscles of the head and neck and explain their
actions.
3. Explain the procedure of inferior alveolar nerve block and anatomical reasons for
the possibility of facial nerve block during that procedure.
4. Discuss the pathophysiology of facial paralysis (Bells palsy), its manifestation
and diagnosis.
5. Discuss a negative effect of facial paralysis on other organs of the head.
January 7, 2008
46
Problem 5
Clicos Marathon & Unexpected Problems
Mr. Thomson, a young marathon competitor from Jamaica was preparing himself for
international and regional races. In order to improve his speed during the last part of the
race he began weight training. While training one day he noticed that straining to lift
heavy weight could be very tiring and rapidly produce muscle fatigue even though his
arm muscles were not moving.
He arrived in Trinidad to take part in a marathon competition, sponsored by CLICO, and
on his way from Piarco airport was involved in a car accident in which he sustained an
injury of his right shoulder with traumatic dislocation of the humeral head, closed
fracture of the surgical neck (confirmed on radiographs) and deep lacerated wound in the
right posterior triangle of the neck. He was treated in the department of surgery at Mount
Hope. His blood sample was sent to clinical laboratory for calcium and alkaline
phosphate determination. After repair, the lacerated wound and bone fracture were healed
within a normal period of time due to proper deposition of collagen.
However, six months after the surgical correction the injured glenohumeral joint still had
significant limitation of movement which was associated with postoperative scars and
deficiency of the synovial fluid and its components in the cavity of this joint.
OBJECTIVES:
1. Describe the gross anatomy of the glenohumeral joint and the muscles acting on
it.
2. Identify potential areas of weakness of the glenohumeral joint and the structures
that maintain its stability.
3. Describe the muscular triangles of the neck and their contents.
4. Review the functions of collagen including its role in the process of wound
healing.
5. List the different types of glycosaminoglycans with their composition, site of
occurrence and functions.
6. Explain the clinical importance of serum calcium and alkaline phosphatase levels.
7. Discuss the length-tension relationship and other biophysical relationships in
muscles.
8. Briefly describe the physiological changes the body undergoes during exercise.
January 7, 2008
47
Problem 6
Unhappy Triad
Mr. F., a popular 22-year-old forward of the National Soccer Team of Trinidad and
Tobago has missed several matches due to a right knee problem, known as a runners
knee. In the ensuing games he was very successful and contributed many goals toward
the teams victory. At his last game he was tackled by the defender while running and
dribbling the ball. The defenders shoulder hit his left knee from the side when his foot
was firmly planted on the ground. He felt a severe pain and fell. As a result of left knee
injury he was taken by ambulance to the Port of Spain General Hospital where Unhappy
triad was diagnosed. Recovery after surgical treatment was prolonged and complicated,
resulting in residual instability of the knee joint, associated with improper locking and
unlocking mechanisms. His teammates wondered if he would ever be able to play with
the team again.
OBJECTIVES:
1. Describe the gross anatomy of the knee joint and the muscles acting on it.
2. Explain the locking and unlocking mechanism of the knee joint.
3. Discuss common knee injuries.
4. Describe the pathophysiology of chondromalacia patellae (runners knee) and its
management.
5. Define the term: Unhappy triad. Describe its etiopathogenesis, diagnosis,
management, complications.
6. Discuss factors leading to the instability of the knee joint.
January 7, 2008
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Problem 7
Defective Gene
Johnny, a 5-year-old boy, was brought to the doctor by his mother. She was extremely
worried and very concerned about the way Johnny walked and his generalized muscular
weakness. She explained to the doctor that his condition had been getting progressively
worse during the past three years.
The doctor observed an exaggeration of the lumbar lordosis when Johnny was standing,
and a waddling gait when he walked. Almost all his muscle groups were poorly
developed with exception of his calf muscles, which looked excessively large. He also
observed that Johnny had a tendency to stand and walk on the front of his feet with his
heels off the ground. Apart from muscle hypertrophy of legs, the ankle joints and bones
forming them did not have any lesions.
Further enquiries by the doctor revealed that Johnnys older brother did not have any
health problems, but his cousin had a congenital anomaly known as a clubfoot.
Tests of individual Johnnys muscles and muscle groups demonstrated a consistent
pattern of weakness. Blood test revealed an increased level (50 times) of a serum creatine
kinase (SCK). Electromyography showed low electrical activity of the tested muscles. A
muscle biopsy was ordered for analysis of the gene and its protein, dystrophin.
OBJECTIVES:
1. Describe the gross anatomy of the ankle joint and the muscles of the leg acting on
it.
2. Describe the development of the lower limbs and their common congenital
anomalies.
3. Understand the principles behind electromyography and how it can be used to aid
the clinical diagnosis of muscular disorders.
4. Discuss the aetio-pathogenesis of Duchennes muscular dystrophy (DMD), its
clinical manifestations and diagnosis.
5. Describe the structure, the location, the attachment of dystrophin to the
cytoskeleton of the muscle fibre and its role in muscular dystrophy.
6. Explain the reason for the high level of the creatine kinase in a blood serum in
patients with DMD.
7. Discuss the mode of inheritance of DMD.
January 7, 2008
49
Chest Pain
Discuss the epidemiological pattern of ischaemic heart disease and its primary,
secondary and tertiary prevention.
List the differences between angina pectoris and myocardial infarction including
the meaning of the terms stable and unstable angina.
Discuss the pathogenesis of acute myocardial infarction including predisposing
factors.
Outline the time dependent gross and microscopic findings seen in acute
myocardial infarction.
List the complications of acute myocardial infarction and explain the pathogenesis
of each.
Discuss the lipid profile of a patient with heart disease.
List the biochemical markers used to diagnose myocardial infarction and explain
the time dependent relationship of biochemical markers to myocardial infarction.
Discuss the management of the patient with an acute myocardial infarction and
explain the rationale for all drugs used.
In a patient who has had a myocardial infarction, describe the use of thrombolytic
and anti-platelet agents.
List the drugs used for the treatment of angina and describe their mechanisms of
action and side effects.
January 7, 2008
50
Tutors Guidelines:
Students should be able to discuss the use of thrombolytic drugs and anti-platelets
drugs in acute myocardial infarction based on their pharmacological mechanism of
action.
Obj. 3 - These predisposing factors should include age, male sex, obesity, smoking,
low HDL and high LDL.
January 7, 2008
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Problem 2.
Pneumonia
A 27-year-old man presented to the emergency room complaining of fever and cough.
Two days previously, he noted the onset of weakness and malaise, which forced him to go
to bed earlier than usual. The next morning he had a shaking chill that lasted 15 minutes.
One hour later his temperature was 39.4C. Several hours later he noted the onset of right
lower chest pain, which was aggravated by taking a deep breath and by coughing. That
evening his cough became productive of brown-coloured sputum. All the symptoms had
progressed by the time he arrived at the emergency room.
Physical examination revealed an acutely ill young man with BP 120/80, pulse rate
120/minute, respiratory rate of 32/minute and temperature of 39.4C. His lips and nail
beds were cyanotic. There was increased vocal fremitus, dullness and rales over the right
lateral chest.
Gram stain of the sputum showed many polymorphonuclear leukocytes and grampositive diplococci. Chest x-ray showed consolidation of right lower lobe. Twenty-four
hours after the administration of appropriate antimicrobial therapy, the patient became
afebrile. He eventually made a complete recovery.
OBJECTIVES:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
January 7, 2008
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Problem 3.
A 30-year-old female complained of painful wrists and palms for the past 3 months. She
also admitted to her physician that she was experiencing stiffness in her hands on
mornings, and that her pain was exacerbated when she sewed. She was an upholsterer and
her ability to do her job was being compromised.
On examination, the wrists and metacarpophalangeal joints of both hands were swollen
and tender. There were no deformities, nodules or vasculitic lesions. Blood was taken for
measurements of CBC, C-reactive protein, rheumatoid factor, ANF and dsDNA.
She was diagnosed as possible autoimmune disease and was prescribed non-steroidal
anti-inflammatory drugs. This medication proved only partially effective and after two
months her knees and ankles were similarly affected, so she was referred to a
rheumatologist.
OBJECTIVES:
1.
2.
3.
4.
5.
6.
7.
8.
9.
January 7, 2008
53
Problem 4.
Prison Infections
A 66-year-old prisoner was sent to the doctor for persistent cough and difficulty in
breathing. A few weeks earlier he was alarmed when bright red blood came up in one of
his coughing bouts. He had been in prison for the past year and lately was not keeping
well, had lost some weight, suffered spells of diarrhoea for no apparent reason and was
generally weak.
On physical examination, his BP was 130/80, pulse rate was 110/minute, respiratory rate
was 26/minute and his temperature was 38C. Movement of the chest wall was slightly
reduced on the right side. His chest radiograph showed a lesion suggestive of a cavity in
the right infra-clavicular area. He had a positive tuberculin skin test. Serological tests
proved that he was positive for HIV antibodies.
OBJECTIVES:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
January 7, 2008
54
Problem 5.
Lymphadenopathy
A 30-year-old female who has not yet started a family, presented to her GP complaining
of painless, persistent swellings in the neck. She did not admit to fever, night sweats or
weight loss and she had no risk behaviour for HIV.
On examination, the only significant finding was bilateral 4cm nodes in the lower
cervical region; there was no hepatosplenomegaly. Her BP was 110/70, and her weight
50kg.
On investigation her chest x-ray was normal. Mantoux test, HIV and VDRL screens were
negative. Lymph node biopsy showed nodular sclerosing Hodgkins disease, and she
subsequently had a whole body CT scan that confirmed the presence of cervical
lymphadenopathy only.
She was counselled about her diagnosis (Stage IIA Hodgkins lymphoma) and treatment:
combination chemotherapy with chlorambucil, vincristine, procarbazine and
prednisolone. She was concerned about prospects of having children after treatment with
these drugs.
After four courses of this treatment, she had gained 10kg and her BP was 140/100 with a
fasting blood glucose of 11.1mmol/l.
OBJECTIVES:
1.
2.
you
3.
4.
5.
6.
of
7.
8.
January 7, 2008
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56
5.
List the effects of sickle cell disease on the spleen along with the immunological
and clinical sequences.
6.
List the common underlying causes of systemic embolization and infarction.
7.
Describe the patho-physiological sequence of events that most commonly result in
pulmonary infarction.
8.
Review the physiologic functions of the kidney and the role of erythropoietin in
the management of chronic renal failure.
9.
Explain the types of anaemia expected as a result of deficiency of folic acid and
erythropoietin.
10.
Describe a chronic renal failure diet.
11.
What support systems are available to help the chronically ill patient to cope?
Tutors guidelines: Make reference to the Society of Inherited Medical Blood
Disorders.
January 7, 2008
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Treatment Days
vincristine
prednisone
1, 8, 15, 22
1-28
L-asparaginase
daunorubicin
58
10.
What are the roles of the primary care physician in prevention and screening for
cancer?
11.
What resources are available to help in the management of patients with
leukaemia?
January 7, 2008
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January 7, 2008
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9.
10.
11.
January 7, 2008
62
Describe the gross and microscopic anatomy of oesophagus and the gastrooesophageal junction.
2.
List the causes of heartburn and dysphagia.
3.
Discuss the aetio-pathogenesis of gastro oesophageal reflux disease and describe
the
morphology, complications and management of reflux esophagitis.
4.
Describe the morphological changes associated with Barretts oesophagus.
5.
Describe the epidemiology, risk factors, aetio pathogenesis, morphology, spread,
staging and management of oesophageal cancer.
6.
List and describe some common tests for gastrointestinal function test e.g.
Schilling test, D-xylose absorption test, Breath test for H. pylori.
7.
Explain the significance of stool examinations.
8.
Describe the test for faecal occult blood.
9.
Review possible causes of microcytic anaemia.
10.
Describe the process of smoking cessation.
11.
Discuss the primary care approach to the patient with dysphagia.
12.
Discuss the drugs used in the treatment of GORD. (e.g. H2 antagonists,
cimetidine,
proton-pump inhibitors e.g.omeprazole, sucralfate, antacids).
January 7, 2008
63
Tutors guidelines: Briefly discuss obesity and its relevance to this case.
January 7, 2008
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January 7, 2008
65
Tutors guidelines: Students need to know how to define a unit of alcohol for different
alcoholic drinks and the upper limit of consumption for men and women.
January 7, 2008
66
Tutors guidelines: Students should discuss the pharmacology of dobutamine vis a vis
dopamine.
January 7, 2008
67
Problem 13.
A 9-year-old previously healthy boy presented with puffiness of face and swelling of
extremities of four days duration. His mother mentioned that he recovered from the
Virus a few weeks ago. On physical examination, he was afebrile. Heart rate = 92/min.,
RR = 22/min. and BP = 100/60 mm Hg. He had 3+ pitting oedema of feet. Abdomen was
soft and normal on palpitation. Urinalysis revealed 4+ proteins and had no rbcs or pus
cells. Blood results were as follows: Serum albumin - 1.8g/dL
He was treated with prednisolone for six weeks and re-evaluation showed proteinuria and
BP was 130/90 mm Hg. His parents were advised that he should have a renal biopsy.
OBJECTIVES:
1.
List the organ systems associated with peripheral oedema.
2.
Describe the diagnostic criteria for nephrotic syndrome.
3.
Compare nephritic syndrome with nephrotic syndrome.
4.
List the causes of nephrotic syndrome.
5.
Describe the aetio-pathogenesis and pathology of nephrotic syndrome in
childhood.
6.
Outline the indications and contraindications for renal biopsy.
7.
Discuss the complications of nephrotic syndrome.
8.
Describe the management and prognosis of this patient.
9.
Explain the procedure for doing a 24-hour urine collection and list the error
sources.
10.
Explain urine analysis under the following headings: urine microscopy, dipstick
analysis.
11.
Explain the sources of interference when doing a dipstick analysis.
Tutors guidelines:
Diagnostic criteria include urine, blood and clinical findings.
Nephrotic Syndrome to describe morphology of kidney in each of the common
causes listed above (Obj.5).
January 7, 2008
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9.
10.
11.
12.
January 7, 2008
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January 7, 2008
71
Discuss the factors that increase a womans risk of developing breast cancer.
Discuss the current recommendations for the screening of breast cancer.
Describe the gross and microscopic features of benign breast diseases including
proliferative and non-proliferative fibrocystic change.
Explain the relationship between the different kinds of benign breast disease and
subsequent risk of developing carcinoma.
Explain what is meant by carcinoma in-situ and describe the recognised types that
occur in the breast.
Describe the morphology of infiltrating lobular carcinoma and the four common
subtypes of infiltrating duct carcinoma.
Explain how primary tumour size, lymph node status, oestrogen and progesterone
receptor status, HER-2 receptor status and histological grade help predict survival
assist management) in breast cancer.
Describe the staging of breast cancer.
Discuss CA27-29 and CA15-3 with respect to the diagnosis and management of
breast carcinoma.
Discuss the advantages and disadvantages of hormone replacement therapy
January 7, 2008
72
11.
List drugs used in the treatment of breast cancer relating to cytotoxic
chemotherapy and hormone receptor positive drugs.
12.
Explain the different mechanisms of action of the hormonal therapies of
tamoxifen
and anastrozole.
13.
Discuss the role of Herceptin (including its major toxicity) as a monoclonal
antibody
in treating breast cancer.
Tutors guidelines:
Classify biochemical tumour markers giving examples of these. Please stress the
various types of tumour markers.
January 7, 2008
73
Problem 17.
Cervical Tumour
Ms. V. E. a 43-year-old, visited her local health centre where the nurse asked her whether
she had ever had a Pap smear. She replied that she had never had one and after a brief
explanation by the nurse, she agreed to have one done that day, mainly because she had
recently noted a bloodstained vaginal discharge. On further enquiry, she had four children
by three different partners and all pregnancies had been uncomplicated.
The nurse took the Pap smear in the clinic and told her to return in three weeks for the
result.
Exfoliated cervical cells were also sent for assessment of HPV status. On her return, Ms.
V.E. was advised by the medical officer that her Pap smear report showed abnormal cells.
She was then given a referral letter to the Gynaecology Out-patients Clinic at the Mt.
Hope Womens Hospital for further investigation. Some weeks later, a colposcopic loop
biopsy of her cervix was taken and sent to the histopathology laboratory.
The histology report showed invasive squamous carcinoma of the cervix, which extended
to the margin of the biopsy specimen. A radical hysterectomy was later performed and
her tumour was staged IIB.
1.
2.
3.
Discuss the epidemiology of and risk factors for cancer of the cervix.
Discuss the pathogenesis of cervical cancer as it relates to known risk factors.
Discuss the role of the immune system in protection against oncogenic viruses
such as HPV.
Outline the principle of one method of detecting viral nuclei acids in cervical
4.
cells.
5.
Describe the pre-cancerous squamous lesions of the cervix using the standard
classifications of these lesions.
6.
Discuss efficacy of the Pap smear as a screening test for cervical pre-cancer and
outline the requirements for taking a satisfactory smear.
7.
Outline the reporting systems used for cervical smears.
8.
Review the criteria for appraisal of a screening program.
9.
Describe the gross and microscopic features of the common forms of invasive
cervical cancer.
10.
Describe the staging of cervical cancer.
11.
Discuss the basic principles of chemotherapy in cancer treatment.
12.
Discuss the most appropriate antineoplastic agents for the management of this
cervical cancer patient.
13.
Discuss the role of combined chemotherapy.
January 7, 2008
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130mmol/L
5.8mmol/L
5mmol/L
18mmol/L
140mol/L
32 mmol/L
ABG
pH7.05
PCO2 2.0kPa
OBJECTIVES:
1.
2.
3.
4.
5.
What are the epidemiological features of diabetes mellitus? List the risk factors.
Compare the pathogenesis of NIDDM and IDDM.
Explain diabetic keto-acidosis as a complication of diabetes mellitus.
Explain the difference between diabetes mellitus and diabetes insipidus.
Describe the source(s) of ketone bodies during starvation and in poorly controlled
diabetes.
6.
Discuss the biochemical findings shown above.
7.
Outline the biochemical complications of longstanding diabetes mellitus.
8.
Describe the pathologic changes that can occur in kidney, eyes and cardiovascular
system in longstanding diabetes mellitus.
9.
Discuss the monitoring and control of the diabetic patient in a primary care
setting;
emphasising preventive strategies e.g. foot care.
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10.
11.
Discuss the various classes of drugs used in the treatment of Type II diabetes
mellitus.
What are the indications for the use of insulin in diabetes mellitus?
Tutors Guidelines:
Diabetes 1 and 2 should be covered in two weeks.
Note: Diabetic ketosis presents more often in insulin dependants.
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January 7, 2008
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4. Compare and contrast the pathogenic mechanisms and clinical features of Graves
disease, Hashimotos thyroiditis, and primary myxodema.
5. Explain the difference between hyperthyoidism and T3-toxicosis.
6. Discuss thyroid function tests.
7. Describe the morphological changes in the thyroid gland in Graves disease.
8. Outline the changes present in tissues such as heart, skeletal muscle and skin in
Graves disease.
9. Discuss the synthesis of thyroid hormones and the sites of action of antithyroid
drugs.
10. List the drugs used in the treatment of hyperthyroidism and indicate their sites of
action; list their associated toxicities.
11. Explain the role of beta blockers in Graves Disease.
Tutors guidelines: Emphasize negative feedback mechanisms.
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