4th year Patho RMC sendup- 2011

MBBS III PROF. -- SPECIAL PATHOLOGY SEQs SEND UP

25th Oct 2011--CLASS OF 2009 DEPT. OF PATHOLOGY, RMC

If you have a question, raise your hand and I'll get with you.  Please do not phonate.

TOTAL MARKS: 70

TIME ALLOWED:  70 minutes.

Attempt all questions. All questions carry equal Marks.

CARDIOVASCULAR SYSTEM.

Q1.     A 14 years old male presents in the OPD with shortness of breath for one month and swelling of right knee joint for two weeks. He suffers from sore throat off and on. His ASO Titre is 800 IU/ml. The doctor suspects that he is suffering from some sort of heart problem.     (2+2+1)

    a)    What is the most likely diagnosis? What is the type of joint involvement in this condition?

   b)    What is the pathogenesis of his disease?

    c)    Name two complications which can occur in this boy.

Q1. KEY:

a)    Rheumatic heart Disease.

A migratory polyarthritis of a large joint occurs.      (1+1=2)

b) Pathogenesis of Rheumatic heart disease.

  The antibodies directed against the M protein of Group A streptococci cross react with antigens of heart.

c)  Complications:

  Mitral stenosis.

  Atrial stenosis.

  Thromboembolism.

  Heart failure.

  Arrythmias.                                                     (0.5+0.5=1)   

HAEMATOPOIETIC SYSTEM

Q2. Illustrate the pathogenesis of anemia, skeletal deformities and hemochromatosis in beta thalassemia major with the help of a flow chart.

                                                        (2+2+1)

Q2. KEY:

          Normal                                     b-thalassemia

                                              

Normal erythroblast                  Abnormal erythroblast

                                                                                  

Normal red blood cell

Hypochromic red cells with alpha globin aggregates

                                                     

                                                               

                                                                                                             

                                                                              

	Destruction of aggregate containing cells in spleen

 

                                                  

RESPIRATORY SYSTEM:

Q3.     A 25-year-old female went to a pulmonologist at the peak of spring season having severe dysponea and wheeze. Her pulmonary function tests showed decreased FEV1, serum IgE levels were elevated and blood revealed absolute eosinophilia.                      (1+2+2)

 a)   What is the most likely diagnosis?

 b)   Give four histologic findings of this disorder.

 c)    Name four chronic restrictive airway diseases.

Q3. KEY:

a)       Bronchial asthma.

b)       Histologic findings of bronchial asthma:

Occlusion of bronchi and bronchioles with mucus plugs that contain whorls of shed epithelium giving rise to Curschmann spirals.

Numerous eosinophils and Charcot-Leyden crystals.

Airway remodeling:

Thickening of basement membrane of bronchial epithelium.

Edema  and inflammatory infiltrate in the bronchial walls with prominence of eosinophils and mast cells.’Increase in size of submucosal glands.

Hypertrophy of bronchial wall muscle. 

                         (Any four 0.5 marks each= 2 marks)

c)       Four chronic restrictive airways diseases:

i)             Pneumoconiosis.

ii)            Interstitial fibrosis.

iii)           Radiation pneumonitis.

iv)           Interstitial pneumonia.

v)            Sarcoidosis.

vi)           Hypersensetivity pneumonitis.

        (Any four 0.5 marks each=2)

ORAL CAVITY AND GASTROINTESTINAL TRACT.

Q4. A 30-year-old villager presents in the gastroenterology ward with a three weeks H/O nausea, vomiting, abdominal pain and bloody stools. On sigmoidoscopy multiple polyps are distributed throughout the colon and a 2x2.5 cm mass is found in the descending colon. His liver is enlarged and nodular. X-ray chest reveals bilateral opacities.          (1+2+2)

a)        What is the likely diagnosis?

b)       Classify neoplasia of large intestine(TNM classification).

c)        Give four dietry factors predisposing to a higher incidence of this cancer.

Q4. KEY:

a) Colorectal carcinoma.     

b) TNM classification of carcinoma of the colon and rectum.

    Tumor (T).……………...………0=none evident

                                           is=in situ

                                            1=invasion of submucosa

                                            2=invasion of muscularis propria

                                            3=invasion of subserosa or nonperitonealized

 pericolic fat

                                            4=invasion of contagious structures

     Lymph Nodes (N)………….…0=none evident

                                            1=1 to 3 +ve pericolic nodes

                                            2=4 or more +ve pericolic nodes

                                            3=any +ve node along a named blood vessel

      Distant Metastasis (M)……..0= none evident

                                             1=any distant metastasis

c)   i) Excess dietry caloric intake relative to requirements

     ii)  A low content of unabsorbable vegetable fiber.

iii)   A corresponding high content of refined carbohydrates.

iv)   Intake of red meat.

v)    Decreased intake of protective micronutrients.

             (0.5+0.5+0.5+0.5=2)

Q5. A 26 year old male has recurrent attacks of bloody mucoid diarrhea with abdominal cramps, which are relieved on defecation. Each episode lasts for 5-6 days followed by symptom free periods of 4-5 months. Colonoscopy shows pancolitis extending from rectum to the splenic flexure.       (1+3+1)

a)            What is the diagnosis?

b)           What features will a colonoscopic biopsy show?

c)            What is the role of intestinal flora in the pathogenesis?

Q5. KEY:

a) Diagnosis: Ulcerative colitis

b) Histologic features:

Ulceration of mucosa

Inflammation limited to mucosa

Pseudopolyps

Crypt abscesses: Neutrophil aggregates in lamina propria

Mild lymphoid reaction

Mild to severe fibrosis

Mild serositis

c) Role of intestinal flora:

        IBD is caused by a strong immune response against gut flora.

        Microbes may exacerbate immune reaction by providing antigens, inducing

        costimulators and cytokines, all of which contribute to T cell activation.

        Reducing intestinal flora has a beneficial role in IBD.

        The hunt for a specific microbe has been fruitless.

HEPATOBILIARY SYSTEM.

Q6. A 1-month old infant presenting with jaundice is diagnosed with extraheptic biliary atresia.                      (3+2)

a)     What are the major histological features on the liver biopsy?

b)     Which two enzymes are likely to be raised in this condition?

Q6. KEY:

a)   Liver biopsy:

Cholestasis is the key finding

Accumulation of bile pigment within hepatic parenchyma

Bile plugs form in bile canaliculi, rupture of canaliculi leads to extravasation of bile which is taken up by Kupffer cells

Accumulation of bile in hepatocytes leads to feathery degeneration and eventually to dissolution of hepatocytes

Ductular proliferation in portal areas

Portal tract edema, periductular neutrophil infiltrates

Unrelieved obstruction leads to portal tract fibrosis

b)    Enzymes:

Serum alkaline phosphatase

g- glutamyl transpeptidase

URINARY SYSTEM.

Q7. Clinical pyelonephritis is most commonly caused by ‘ascending infection’. Give the five major steps in its pathogenesis.                                            (5)

Q7. KEY:

·         Colonization of distal urethra and introitus, role of bacterial adhesions and fimbriae

·         From urethra to bladder, through urethral catheterization or instrumentation. Commoner in females in absence of these procedures. ? Shorter urethra, trauma during coitus, no antibacterial properties in vaginal fluid, hormonal changes

·         Multiplication in bladder: Obstruction to urine outflow or bladder dysfunction promote stasis allows multiplication

·         Vesicoureteral reflux: Incompetence of VU valve allows retrograde flow of urine, especially during micturition and permits bacteria to ascend into ureter. Congenitally absent or short intravesical portion of urethra

·         Intrarenal reflux: VU reflux further propels the urine into renal pelvis and deep into renal parenchyma. Most common at poles.

MALE GENITAL SYSTEM

Q8. A male presented in OPD with a right testicular mass.               (2+3)

a)    What three serum markers would you order in a patient with a testicular

     mass?

b)   What is the value of serum markers in the context of testicular tumors?

Q8. KEY:

a)  Serum markers for testicular germ cell tumors:

   AFP

   HCG

   LDH

b)  Value of markers:

• In evaluation of testicular masses
• In staging of testicular GCTs, a persistently raised AFP after orchidectomy indicates stage II disease, even if lymph nodes do not appear enlarged
• In assessing tumor burden: LDH is related to tumor mass and is an independent prognostic marker for GCTs
• In monitoring response to therapy: serial measurements of AFP and HCG, rapid fall indicates eradication. Recurrence can be predicted

FEMALE GENITAL SYSTEM:

Q9. A 45-year-old female patient develops a peanut sized nodule in an old midline laparotomy scar, which becomes painful during menstrual period. The excised nodule consists of normal-looking endometrial tissue with glands and stroma.                                                        (1+3+1)

a)       What is the diagnosis?

b)       Give three theories of pathogenesis of such lesions.

c)       List two important sites for this process other than the abdominal wall.

Q9. KEY:

a)  Diagnosis: Endometriosis

b)  Theories:

• Regurgitation/implantation theory: Retrograde menstruation through fallopian tubes common even in normal women, implantation in peritoneal cavity
• The metaplastic theory: Endometrium could arise directly from coelomic epithelium
• The vascular or lymphatic dissemination theory: Dissemination through pelvic veins or lymphatics can explain endometriosis in lungs and lymph nodes

c)   Common sites of implantation:

• Ovaries
• Uterine ligaments
• Rectovaginal septum
• Pelvic peritoneum

          Laparotomy scar

DISEASES OF BREAST:

Q10. A 68 year old lady has presented with a painless mass in upper outer quadrant of left breast. A pathologist is grading a breast tumor according to the Scarff-Bloom-Richardson system.                         (3+2)

  a)     Which three morphological features will he assess in this system?

  b)     What is the significance of ER/PR and Her 2-neu status in a breast CA?

Q10. KEY:

a)    Nuclear grade

       Tubule form

       Mitotic rate                                      

b)

·         ER/PR status: Positive tumors have a slightly better prognosis than negative ones. Most valuable in predicting response to therapy, if both positive 80% tumors respond, if one positive, 40% and if both negative less than 10%

·         Her 2-neu: over-expressed in 20% of breast carcinomas. Positive tumors have poorer prognosis, targeted therapy to her 2 neu receptor is effective in these patients                                 (1+1)

ENDOCRINOLOGY.

Q11. The patient presented with mass in front of neck, throidectomy was done and specimen was sent for histopathology. While examining H & E sections from the thyroidectomy specimen, a pathologist notices a lesion having a follicular pattern of growth.                            (3+2)

  a)     What is the differential diagnosis for such lesions?

  b)     List two nuclear features diagnostic for papillary carcinoma of

          thyroid.

Q11. KEY:

a)   Thyroid lesions with a follicular architecture

·         Non neoplastic

o   Hyperplastic nodule in goiter

·         Neoplastic

o   Follicular adenoma

o   Follicular carcinoma

o   Follicular variant of papillary carcinoma

b)

·         Optically clear, empty nuclei (orphan Annie)

·         Intranucler inclusions (pseudo-inclusion)

·         Nuclear grooves

MUSCULOSKELETAL SYSTEM AND BONES & JOINTS.

Q12. A 19 year old male presented in OPD with swelling in left knee for last 6 months which is associated with pain. He complaints of shortness of breath for the last one month. X-Ray of the knee shows ill-defined lesion in metaphyseal region of distal femur with elevated periosteum. X-Ray chest shows multiple coin-shaped opacities.                             (1+2+2)

a)    What is the diagnosis?

b)   Explain the classic radiologic finding associated with this condition.

c)    Give its microscopic features.

Q12. KEY:

a)    Osteosarcoma

b)   Codman triangle

Tumor elevates the periosteum to form the codman’s triangle, which is formed by the angle between the elevated periosteum and the surface of the involved bone.

c)    Hallmark is “formation of osteod” by malignant mesenchymal cells. This is seen in the form of islands of primitive bony trabeculae hugged by a rim of malignant osteoblasts.

CENTRAL NERVOUS SYSTEM.

Q13. A 60-year-old man presented to his primary care physician with complaints of headache and weakness in his left arm over the past several weeks. The day before his appointment, he experienced two episodes of uncontrollable shaking in his left arm and leg, accompanied by development of weakness in his left leg. On physical examination, he was found to have mild papilledema, decreased strength in his left arm and leg, and brisk deep tendon reflexes on the left side of his body compared to the right. A CT scan of his head revealed a ring-enhancing mass in the right frontal region.                       (2+2+1)

  a)   What is the most likely diagnosis?

  b)   Give any TWO histological patterns of the lesion.

  c)   What is the most common site of the lesion?

Q13. KEY:

a)  Astrocytoma

b)    i) Fibrillary Astrocytoma

      ii) Pilocytic Astrocytoma

     iii) Pleomorphic Astrocytoma

     iv) Glioblastoma Multiforme

c)  Cerebral Hemispheres

CLINICAL CHEMISTRY.

Q14. List 2 laboratory tests each for the evaluation of hepatocyte integrity, biliary excretory function and hepatocyte function.                    (2+1½+1½)

Q14. KEY:

       hepatocyte integrity………………..AST

                                                     ALT

                                                     LDH

       biliary excretory function………….serum bilirubin

                                                      urine bilirubin

                                                      serum bile acids

                                                      serum alkaline phosphatase

                                                      serum GGT

       hepatocyte function………………….seum albumin

                                                      PT

                                                      Serum ammonia

                                                      aminopyrine breath test

This exam is not intended to be especially difficult.  Be prepared for somewhat more challenging exams in the future.

Paper setters: Prof. Dr. Abbas Hayat, Dr.Aiman Aijaz

                                                          GOOD LUCK

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