MBBS 11 YEAR 3 SUMMATIVE SAQ

2004 2008
MBBS III Summative
SAQ suggested solutions

Queenie Leung
[11.05.2009]

[Disclaimer: the author refuse to bear any responsibility on wrong answers or cyanides that may
intoxicate you]
SAQ 2004 Q.1 Medicine Endo - Cushing
A 40-year-old woman was referred for suspected Cushings syndrome.
(a) Name five classical physical signs which you will look for when examining her face, trunk and limbs. (2.5 marks)
(b) Name three complications of Cushings syndrome. (1.5 marks)
(c) Name two causes of ACTH dependent Cushings syndrome. (2 marks)
(d) What biochemical findings will confirm the diagnosis of Cushings syndrome due to an adrenal tumour? (3 marks)
(e) If she has pituitary-dependent Cushings syndrome, what abnormality will be found on the MRI of her adrenals? (1
mark)

(a) Moonface, plethora, buffalo hump, fat pads, truncal obesity, purple striae, pigmentation, thinning of skin,
proximal myopathy
(b) Osteoporosis, hypertension, diabetes mellitus, obesity, peptic ulcer, psyhosis
(c) Pituitary adenoma (Cushings disease), small cell lung carcinoma (ectopic ACTH production)
(d) Overnight and low-dose dexamethasone suppression test:
No suppression of cortisol level
Serum ACTH undetectable
(e) Bilateral adrenal hyperplasia

SAQ 2004 Q.2 Medicine Hemat Anemia

A 65-year-old man presented with shortness of breath. A full blood count showed haemoglobin: 5.5 g/dL (mean
corpuscular volume: 67 fl), white cell count: 4.5 x I0 9/L, and platelet count of 500 x I09/L. His full blood count done about
a year ago for an unrelated problem showed haemoglobin: 15.0 g/dL, white cell count: 5.2 x I09/L, and platelet count:
340 x I09/L.
(a) Give three abnormalities in the current blood count. (6 marks)
(b) Give one further blood test you consider to be most useful. (2 marks)
(c) Give the commonest cause of his haematological problem. (2 marks)

(a) Low hemoglobin, low MCV (microcytic anaemic picture), high platelet
(b) Serum iron
(c) Iron deficiency anemia due to chronic blood loss

SAQ 2004 Q.3 Medicine Nephro GN

Give a short account on the presentation and prognosis of the following glomerulonephritis:
(a) minimal change nephropathy (lipoid nephrosis) (2 marks)
(b) post-streptococcoal glomerulonephritis (2 marks)
(c) membranous nephropathy (2 marks)
(d) IgA nephropathy (2 marks)
(e) cresentic glomerulonephritis (2 marks).

(a)Minimal change nephropathy

Presentation: Nephrotic syndrome
Prognosis: Does not progress to ESRF, highly responsive to steroid and disease remits, but high relapse rate
(b)Post-streptococcal glomerulonephritis
Presentation: Acute nephritic syndrome, follows an episode of GABHS (Group A beta-hemolytic streptococcus)
infection of throat
Prognosis: Majority complete remission, seldom relapses
(c)Membranous nephropathy
Presentation: Nephrotic syndrome
Prognosis: ~1/3 remission, ~1/3 persistent proteinuria, ~1/3 ESRF
(d)IgA nephropathy
Presentation: majority microscopic hematuria of accidental finding
Prognosis: Slowly progressive to ESRF, no specific treatment available; 30% will develop ESRF in 30years
(e)Crescentic glomerulonephritis
Presentation: Acute nephritic syndrome, pulmonary hemorrhage
Prognosis: Progress to end stage renal failure within weeks if untreated
SAQ 2004 Q.4 Surgery HBP HCC
A 35-year-old man who was a chronic carrier of HBsAg developed anorexia and weight loss. A CT scan of abdomen
revealed a 12 cm tumour in the right lobe of liver.
(a) What is the MOST LIKELY diagnosis? (1 mark)
(b) What screening methods are useful for detecting such tumour at an earlier stage? (2 marks)
(c) Apart from tumours, what disease conditions are common in chronic carriers of HBsAg? (2 marks)
(d) What investigations may be useful in assessing whether the liver function of this patient is good enough for hepatic
resection? (2 marks)
(e) Name three major complications of hepatic resection in this patient. (3 marks)

(a) Hepatocellular carcinoma

(b) AFP (alpha fetoprotein) > 400ng/ml, ultrasound
(c) Chronic active hepatitis, cirrhosis and its complications (e.g. hepatic failure hepatic encephalopathy, ascites,
portal hypertension)
(d) ICG clearance (Indocyanine green) >14% at 15mins, Prothrombin Time & albumin.
(e) Biliary leakage, bleeding (from IVC/hepatic vein), infection (esp. when biliary obstruction), pleural effusion

SAQ 2004 Q.5 Surgery Acute abd

A 14-year-old girl was admitted to the ward with 1-day history of severe right lower abdominal pain.
On further questioning, the pain was found to have started in the umbilical area 2 days ago. She was pyrexial and
examination showed rebound tenderness in the right lower quadrant.
(a) Give the MOST LIKELY diagnosis for this patient. (1 mark)
(b) Suggest two other differential diagnoses. (1 mark)
(c) What are the general principles of management for patients with acute abdomen? (4 marks)
(d) Give four possible post-operative complications. (4 marks)

(a) Acute appendicitis

(b) Mesenteric adenitis, Meckels diverticulitis
(c) Assess vital signs and initiate resuscitation:
- secure airway and breathing
- IV fluid (colloid/crystalloid) given by large bore catheter to rehydrate
- NG tube suction to decompress the stomach for preparation of urgent surgery
- Empirical antibiotics after blood is taken for culture to control sepsis
- Surgical repair with peritoneal toilet (laparoscopic drainage of abscess)
(d) Wound infection, intraabdominal abscess, incisional hernia, paralytic ileus, adhesions, wound hematoma

SAQ 2004 Q.6 Surgery Ca eso

A 65-year-old gentleman was diagnosed to suffer from oesophageal cancer by a barium swallow study. Physical
examination did not yield any positive physical signs indicative of metastases.
(a) Recommend three staging investigations. (3 marks)
(b) If staging investigations show a T3NOMO disease. Name two options of treatment you can offer the patient providing
the patient is otherwise healthy. (4 marks)
(c) Name two common medical complications after oesophagectomy. (2 marks)
(d) Name a surgical complication that is likely to have its onset one week after oesophagectomy. (1 mark)

(a) Endoscopic ultrasound for tumour depth of invasion and regional lymph nodes
CT thorax for extent of disease and regional metastasis
PET scan for distant metastasis
(b) Chemoirradiation, esophagectomy
(c) Pneumonia, cardiac arrhythmia
(d) Anastomotic leaks
SAQ 2004 Q.7 Surgery Upper GIB
A 52-year-old man was admitted with an episode of vomiting fresh blood. He did not admit to any previous episodes of
haemetemesis. On further questioning he admitted to having a drink problem. On examination he was pale but his
vital signs (blood pressure and pulse) were stable. He was slightly icteric (jaundiced) with ascites. Chest and abdominal
radiographs were unremarkable. Upper endoscopic examination revealed oesophageal varices, which were banded.
(a) What is the most likely cause for his haematemesis? (2 marks)
(b) Name two non-invasive imagings you would do to confirm your suspicions. (4 marks)
(c) Name two abnormal imaging features compatible with his condition. (4 marks)

(a) Liver cirrhosis causing portal hypertension, which lead to massive bleeding from ruptured esophageal varices
(b) Ultrasound, MRI of liver
(c) Ultrasound: small nodular liver with increased echogenicity(coarsened echo texture)
MRI: Tortuous vessels (due to architectural distortion), Liver contour nodular, enlargement of segment one

SAQ 2004 Q.8 Ortho?

(a) Name three common sites of pyogenic infection of bones and joints. (1.5 marks)
(b) Name two possible sources of bacteria. (2 marks)
(c) In septic arthritis, name three important physical findings. (3 marks)
(d) Name two investigations that can confirm the diagnosis of septic arthritis. (2 marks)
(e) What is the preferred treatment for septic arthritis? (1.5 marks)

(a) Femur, knee joint, hip joint [spine!!]

(b) Hematogenous, direct inoculation, adjacent soft tissue infections [blood: needle puncture for blood taking, needle
injection by intravenous drug abuser; contiguous infective foci e.g. skin (boil)]
(c) Joint pain, swelling, increased heat (also erythema and limitation of movement)
(d) Joint aspiration (synovial fluid) for culture and microscopy
Joint X-ray
Blood culture
Increased C-Reactive Protein
(e) IV antibiotics, joint immobilization, pain relief
Surgical drainage and debridement of infected tissue
SAQ 2005 Q.1 OG
Mrs Lee, a 22-year-old woman who was diagnosed to have diabetes mellitus two years ago, got pregnant recently. She
used to take glibenclamide (daonil) for the control of her diabetes but her obstetrician advised her to stop this drug and
change to a medication E.
(a) Give two reasons why glibenclamide should be stopped. (4 marks)
(b) List two important complications of poorly controlled diabetes mellitus during the first trimester. (4 marks)
(c) What is the most appropriate medication E for Mrs Lee? (2 marks)

(a) Insulin dosage is easier to adjust by precise adjustment of the units of injection.
Insulin has better control of disease through direct action with no time lag between intake and onset of action.
Glibenclamide alone is not sufficient to control hyperglycaemia during pregnancy due to increased insulin
antagonists like human placental lactogen.
Increase risk of neonatal hypoglycaemia due to side effect of vomiting.
[not sufficient to control hyperglycemia, increased risk of maternal hypolgycemia if appetite or food intake affected
by nausea and vomiting, risk of neonatal hypoglycaemia]
(b) Teratogenicity (mainly affecting neural, skeletal and cardiac development), Miscarriage
(c) Insulin

SAQ 2005 Q.2 OG

A 42-year-old woman presented with heavy menstrual flow and dizziness for six months. She had two children and her
past health was good. Physical examination showed mild pallor (Hgb 10 g/dl) (normal range: 11.5 16.5 g/dl). Vaginal
examination was normal. In the management of this patient,
(a) suggest three appropriate investigations; (3 marks)
(b) name two non-hormonal drugs which may be useful in controlling her vaginal bleeding; (2 marks)
(c) name two hormonal therapies which may be useful in controlling her vaginal bleeding; (2 marks)
(d) name three other therapeutic options if the above measures fail to control her vaginal bleeding. (3 marks)

(a) Plevic ultrasonography, cervical smear, endometrial aspiration, hysteroscopy, thyroid function test
(b) NSAIDS (Ponstan = mefenamic acid, ibuprofen), anti-fibrinolytics (tranexamic acid)
(c) Combined Oral Contraceptive pills, progestogen
(d) Hysterectomy, endometrial ablation, progesterone-releasing Intrauterine Contraceptive Device

SAQ 2005 Q.3 Ortho

A 50-year-old woman consulted an orthopaedic surgeon with right shoulder pain which was worsen when she slept on
the right side and when she lifted her right arm.
(a) What is the most likely diagnosis? (2 marks)
(b) Name four useful equipments for physical examination of orthopaedic patients. (8 marks)

(a) Subacromial bursitis/Rotator cuff tendonitis

(b) Goniometer, tendon hammer, orange stick, cotton wool

SAQ 2005 Q.4 Medicine Resp Asthma

A 25-year-old man was admitted through the Accident & Emergency Department for an acute attack of asthma. Name
two important points in history taking (2 marks), three important physical examination findings (6 marks) and two
simple bedside tests (2 marks) that are useful in the assessment of the severity of this patients asthma.

(a) Frequency of attacks, limitation of daily activities, antecedent upper respiratory tract infection, compliance on
anti-asthmatic medications (if any), family history of atopy
(b) Cyanosis, tachypnoea, use of accessory muscles for respiration (Acute attack)
Reduced chest expansion, reduced air entry, prolonged expiration with wheezes
(c) Pulse oximeter, peak flow meter
SAQ 2005 Q.5 Medicine Endo Acromegaly
A 40-year-old woman who was previously healthy complained to her general practitioner of headache and amenorrhoea
for 12 months. She was noticed by the general practitioner to have coarse facial features on physical examination. In
addition, she had supraorbital ridges, large tongue and spade-like hands and feet. There was bitemporal hemianopia
with early optic atrophy.
(a) What is the most likely diagnosis? (1 mark)
(b) Name three investigations you would perform to confirm your diagnosis. (3 marks)
(c) Name three complications, other than the visual changes described above, that are associated with this condition. (3
marks)
(d) Name three classes of pharmaceutical agents that are currently available to treat this condition. (3 marks)

(a) Acromegaly
(b) Basal serum GH and IGF-1, oral glucose tolerance test for suppression of GH level, MRI pituitary
(c) DM, HT, carpal tunnel syndrome, OSA (Obstructive Sleep Apnea)
(d) Dopamine agonist (Bromocriptine), somatostatin receptor agonist (somatostatin), growth hormone receptor
antagonist (pevigsomant)

SAQ 2005 Q.6 Medicine Cardio HOCM

A 40-year-old previously well man presented to the emergency room with chest pain and syncope while playing football.
He had a history of intermittent resting chest pain for a few months. Family history revealed that his father died of a
sudden death at the age of 45. Physical examination showed his blood pressure was 110/60 mmHg. A grade 3/6 ejection
systolic murmur was heard over the left sternal border without radiation to neck. ECG showed left ventricular
hypertrophy.
(a) What is the most likely diagnosis? (3 marks)
(b) Name three additional physical signs that would support your diagnosis. (3 marks)
(c) Suggest two investigations that would confirm your diagnosis. (4 marks)

(a) HOCM (Hypertrophic Obstructive CardioMyopathy)

(b) Jerky pulse, Brisk carotid upstroke, Double carotid pulse (jerky, bisferiens), normal aortic second heart sound,
murmur increase on standing and Valsalva maneuver, double apex beat
(c) Echocardiography to check thickness of ventricular muscle
Holter (24 hour ECG)
MRI

SAQ 2005 Q.7 Surgery Thyroid nodule

A 68-year-old lady presented with right cervical lymphadenopathy for 6 months. Physical examination showed a 3 cm
level III lymph node at right neck and a 2 cm hard nodule in right thyroid gland. Fine needle aspiration cytology was
suggestive of papillary thyroid carcinoma. Total thyroidectomy and right neck dissection was performed.
(a) Name three advantages of total thyroidectomy over hemithyroidectomy. (3 marks)
(b) List three poor prognostic factors in well-differentiated thyroid carcinoma. (3 marks)
(c) Name two adjuvant therapies for this patient. (2 marks)
(d) Name one biochemical parameter that can be used to monitor the disease status on follow up. (2 marks)

(a) Resect possible residual tumor on opposite lobe

Post-operative thyroglobulin monitoring for recurrence more sensitive
Avoid 2nd operation which may be dangerous due to distorted anatomy
Lower recurrence rate
Easy adjustment of thyroxine replacement dose according to the physiological status
(b) Old age, large tumour (>3cm), with distant metastasis, incomplete excision, extrathyroidal primary tumour
(c) External beam irradiation, radioactive iodine therapy
(d) Thyroglobulin
SAQ 2005 Q.8 Surgery Ca eso (see 2004 Q.6)
A 65-year-old gentleman was diagnosed to have oesophageal cancer. Physical examination did NOT yield any positive
physical signs indicative of metastases.
(a) Recommend three staging investigations. (3 marks)
(b) If staging investigations show a T3NOMO disease, name two treatments that you would offer this patient. (4 marks)
(c) Name two common medical complications following oesophagectomy. (2 marks)
(d) Name a surgical complication that may occur one week after oesophagectomy. (1 mark)

(a) Endoscopic ultrasound for tumour depth of invasion and regional lymph nodes
CT thorax for extent of disease and regional metastasis
PET scan for distant metastasis
(b) Chemoirradiation, esophagectomy
(c) Pneumonia, cardiac arrhythmia
(d) Anastomotic leak

SAQ 2005 Q.9 Surgery VAS

A 50-year-old man with atrial fibrillation presented with acute onset of right lower limb pain and paraesthesia. Physical
examination showed cold right lower limb with absent femoral and distal pulses. All other peripheral pulses were
normal.
(a) What is the most likely diagnosis? (2 marks)
(b) Name three predisposing conditions for the condition provided by you in (a). (3 marks)
(c) Name two possible treatment options. (2 marks)
After successful treatment in (c), the right lower limb pulses became palpable. However, the patient then complained of
intense pain over the right calf which was swollen.
(d) What is the likely diagnosis? (2 marks)
(e) What is the treatment of choice for the condition in (d)? (1 mark)

(a) Acute arterial insufficiency

(b) Trauma, emboli, thrombosis
(c) Anti-coagulant (heparin) in acute phase (<3hours most preferable), embolectomy
(d) Deep vein thrombosis / Compartment syndrome
(e) Anti-coagulant / Fasciotomy

SAQ 2005 Q.10 Medicine Neuro Ptosis

(a) What is ptosis? (2 marks)
(b) What muscle is involved in ptosis? (2 marks)
(c) Name three causes of ptosis. (6 marks)

(a) Drooping of upper eyelid

(b) Levator palpebrae superioris
(c) Horners syndrome, CN III palsy, Myasthenia Gravis

SAQ 2005 Q.11 Mibi? Hepat?

A 75-year-old gentleman with a history of diabetes was admitted for swinging fever, chills and right upper quadrant pain.
On examination, he had a temperature of 39.5C, abdominal right upper quadrant tenderness and an enlarged liver.
Blood tests showed mildly elevated bilirubin and leucocytosis. Ultrasonography showed a hypoechoeic lesion in the liver.

(a) What is the most likely diagnosis? (2 marks)

(b) What minimally invasive treatment would you offer the patient? (2 marks)
(c) Briefly describe how you would prepare the patient for this procedure. (4 marks)
(d) Name two agents that may be responsible for the condition in (a). (2 marks)

(a) Liver abscess

(b) USG-guided percutaneous drainage of abscess
(c) Aseptic technique, IV antibiotics, check any bleeding tendency, check and ensure no hepatic malignancy, inform
patient of the details of the procedure and get his consent
(d) Entamoeba histolytica, Klebsiella
SAQ 2005 Q.12 Ortho Spinal infection
A 30-year-old man complained of acute low back pain for 1 week. There was a history of sprained back while lifting a
heavy suitcase one week ago. He had a history of intravenous drug abuse in the past 3 years. On examination, he had a
low grade fever and there were injection marks over both groin regions. There was marked tenderness over the L4 and
L5 regions. X-rays of lumbo-sacral spine revealed destruction of the L4 lower and L5 upper vertebral end plates.
(a) What are the possible causes of his back pain? Name two. (3 marks)
(b) What investigations would you order? Name five. (5 marks)
(c) What treatments would you give? Name two. (2 marks)

(a) Tuberculosis spondylitis, acute pyogenic spondylitis, prolapsed vertebral disc causing acute spinal cord
compression
(b) Complete Blood Count for leukocytosis with differential count
Blood culture and sensitivity test for bacteremia
Inflammatory markers i.e. CRP, ESR for disease monitoring
CT-guided aspiration of spinal abscess, blood culture for microorganism
MRI spine to assess spinal cord compression
(c) IV antibiotics, drainage of abscess, surgical decompression of spinal stenosis
SAQ 2006 Q.1 Paedi
List ten interventions that have been shown to reduce mortality from major causes of death in children younger than 5
years of age globally. (10 marks)

Mothers
1) Better education for women
2) Optimization of women health before and during pregnancy
3) Promotion of breast feeding globally
4) Pre-natal diagnosis available to plan for resuscitation right after birth
Children
5) Introduction of vaccination to protect children from common diseases
6) Better nutrition provided to ensure no severe poverty or hunger shall affect a childs growth
7) Education on hand washing and hygiene to children and parents to reduce incidence of infectious diseases
Environment, society
8) Availability of clean water and sanitation as far as possible
9) Medical services being more available to everyone including the underprivileged
10) Work-family policies enabling parents to have more room to care for their child
11) Optimization of the environment for child growth

SAQ 2006 Q.2 Medicine - Neuro

(a) Name four clinical features that would indicate a frontal lobe neurological lesion. (4 marks)
(b) Name three clinical features which would indicate a temporal lobe neurological lesion. (6 marks)

(a) Disinhibition, emotional lability, reduced planning ability, expressive dysphasia (Brocas dysphasia)
(b) Amnesia, upper quadrant homonymous hemianopia, aggression, receptive dysphasia (Wernickes dysphasia)

SAQ 2006 Q.3 Ethics

A doctor is considered the patients fiduciary as well as societys gate-keeper of medical resources.
(a) Explain the exact nature of the dilemma encountered by a doctor due to his/her dual roles as fiduciary and gate-
keeper. (5 marks)
(b) What can a doctor do in order to fulfill his/her fiduciary duty and at the same time function as a gate-keeper? (3
marks)
(c) What can the hospital do to help doctors to perform their gate-keeping functions? (2 marks)

(a) As the patients fiduciary, a doctor has to advocate for the best possible treatment available regardless of its cost
to the society based on patients needs and clinical evidence. (Priniciple of equity)
As the gate-keeper, one should maximise the standard of medical care with least resources and make it available
to the majority of people. This implies that one should choose to treat majority of people with less costly treatment
instead of treating only one patient with a very costly treatment if their total costs are the same. (Utilitarian theory)
(b) Minimize treatment or investigations that are of marginal benefits to the patients
If many modalities of investigations or treatment are available with similar efficacy, choose the least costly one
Seek resolution for unacceptable shortages at hospital management level
(c) Have a set of comprehensive and up-to-date treatment guidelines for doctors to follow
Continuous evaluation and update of the guidelines based on clinical evidence
SAQ 2006 Q.4 Medicine - Rheumat
A 40-year-old woman, a heavy smoker and drinker but who was previously healthy, complained to her general
practitioner of leg swelling for six weeks. She was noticed by the general practitioner to have ankle oedema on physical
examination. In addition, urine albustix was 3+ positive. She also volunteered a recent onset of cough, shortness of
breath and weight loss.
(a) What is the most likely diagnosis? (2 marks)
(b) Name three investigations you would perform to confirm your diagnosis. (3 marks)
(c) Name three complications, other than ankle oedema, that are associated with this condition. (3 marks)
(d) Name an aetiological factor of her renal condition. (2 marks)

(a) Systemic Lupus Erythematosus

(b) Renal biopsy, serum C3/C4 level, ANA and anti-ds DNA level
(c) Pancytopenia, serositis, malar/discoid rashes
(d) Immune complex deposition

Given her smoking history, another possible diagnosis is membranous nephropathy secondary to Ca lung
(though I still hold my set of SLE answer because SLE can mimic anything)
(a) Membranous nephropathy secondary to Ca lung
(b) Chest X-Ray, bronchoscopic examination with biopsy and cytology for malignant cells, renal biopsy
(c) Haemoptysis, chest pain, skin hyperpigmentation, (Moon face, mental abnormality, diabetes, general muscle
weakness because of Cushings syndrome due to ectopic ACTH production by SCLC)
(d) Immune complex deposition causing damage

SAQ 2006 Q.5 Medicine Resp - ?Bronchiectasis

A 36-year-old woman was admitted through Accident & Emergency Department for 1-day history of haemoptysis. She
also mentioned a history of productive cough in the past 10 years. Briefly describe how you would approach the
problems of this lady from history taking (4 marks), physical examination (3 marks), and request for appropriate
investigations (3 marks).

History
Clarify what the haemoptysis means: frank haemoptysis or post-nasal drip, upper GI bleed? 1 st ever episode?
Color of the phlegm and whether there are any blood streaks
More about the long standing history of cough: progression over the years? Aggravating and relieving factors?
Amount and appearance of sputum
Associated respiratory symptoms: chest pain, dyspnoea
Constitutional symptoms: weight loss, malaise, fever, loss of appetite, night sweats
Travel, Occupation, Contact and Cluster history
Social history especially smoking history
Family history of respiratory diseases
P/E
Look for pallor, pulse rate and blood pressure for possible chronic blood loss and hypovolaemia
Central cyanosis and finger clubbing for suppurative lung diseases or lung cancer
Cervical lymph nodes for nodal metastasis or infection
Tracheal deviation, chest expansion and symmetry to localize the side of underlying pathology
Percussion for resonance, auscultate for air entry, crackles and abnormal breathing sounds
Check hepatomegaly and other systems for possible metastasis
Investigations
CBC, LRFT, Calcium
CXR, CT thorax/abdomen
Lung biopsy if indicated, sputum cytology and C/ST, AFB
SAQ 2006 Q.6 Medicine Neuro Generalized ms weakness
(a) Name two conditions that can give rise to generalised muscle weakness without sensory impairment. (5 marks)
(b) Name one investigation for each condition that you will order to help diagnose the above conditions. (5 marks)

(a) Myasthenia gravis, polymyositis, amyotrophic lateral sclerosis, hypokalaemia, DMD, SMA
(b) Tensilon test (Edrophoium test) for MG
Anti-Jo1 antibody for polymyositis
Electrophysiological studies for ALS
Check serum potassium for hypokalaemia
Check dystrophin staining of muscle biopsy for DMD
Genetic test for SMN (Survival Motor Neuron) gene for SMA

SAQ 2006 Q.7 Surgery HBP - HCC

A 45-year-old man who was a chronic hepatitis B surface antigen carrier was found to have a 3cm tumour in the right
lobe of liver on screening ultrasound examination. Computed tomography showed a tumour with arterial enhancement
and portal venous washout.
(a) What is the MOST LIKELY diagnosis? (2 marks)
(b) Apart from chronic hepatitis B infection, name two other aetiological factors for this tumour. (2 marks)
(c) Name the MOST important serum tumour marker for this tumour. (1 mark)
(d) Name three treatment options with a potential to cure. (3 marks)
(e) Name the palliative treatment that has been shown to prolong survival by meta-analysis. (2 marks)

(a) Hepatocellular carcinoma

(b) Alcohol, hepatitis C, biliary cirrhosis
(c) Alpha-Fetoprotein
(d) Surgical resection, total hepatectomy with orthotopic liver transplantation
(e) Transarterial oily chemoembolization, radiofrequency ablation

SAQ 2006 Q.8 Surgery Burns Caustic ingestion

A 45-year-old previously healthy woman swallowed some toilet cleanser liquid and was admitted to hospital. She had
caustic burn around her mouth and burn marks on the front of her chest. She complained of retrosternal chest pain.
Perforation of the oesophagus was suspected.
(a) Name three other acute complications from strong caustic ingestion. (3 marks)
(b) Name two chronic complications. (2 marks)
(c) Name three physical signs you would look for. (3 marks)
(d) List two investigations that you may perform to confirm the diagnosis of perforated oesophagus. (2 marks)

(a) Acute Respiratory Distress Syndrome, airway obstruction due to tissue edema, peritonitis, shock, arrhythmia, pleural
effusion, chemical burns
(b) Stenosis, fistula, death
(c) Stridor, tachypnoea, tachycardia
(d) Oesophagogastroduodenoscopy (acute phase, CI if perforation already evident)
Chest x-ray for gas within mediastinum, water soluble contrast gastrograffin for study of perforation

SAQ 2006 Q.9 ENT

(a) Where does acoustic neuroma usually arise from? (2 marks)
(b) Name four common associated clinical symptoms. (8 marks)

(a) Schwann cells of the vestibular nerve at cerebellopontine angle

(b) Ipsilateral sensorineural hearing loss, vertigo, tinnitus, cerebellar ataxia postural instability, nystagmus (**not
facial palsy since slow-growing)
SAQ 2006 Q.10 Medicine Haemat DVT / Surgery VAS DVT
A 63-year-old man presented to the Accident and Emergency Department complaining of pain and swelling of the right
leg for 2 days.
(a) Ankle oedema is classified as pitting and non-pitting.
(i) List three underlying causes of pitting ankle oedema. (3 marks)
(ii) List one underlying cause of non-pitting ankle oedema. (1 mark)
Physical examination showed the right calf was cyanosed, swollen, warm and tender. There were dilated veins noted
over the right shin which did not empty on elevation of the right lower limb. The left lower limb looked normal.
(b) What is the clinical diagnosis? (2 marks)
(c) Name one investigation that should be performed to confirm the diagnosis. (2 marks)
(d) Name one potentially fatal complication that may arise from this condition. (2 marks)

(a) (i) congestive heart failure, nephrotic syndrome, cirrhosis (ii) lymphoedema, pretibial myxoedema
(b) Deep vein thrombosis
(c) Duplex Doppler ultrasound
(d) Pulmonary embolism

SAQ 2006 Q.11 Fam Med

Mrs Ho is a 38-year-old professional singer who has just flown home from a beach holiday with discomfort in her left ear.
She complains of pain and a blocked sensation in that ear. She comes to see you because you are her husbands doctor.
(a) Name two possible reasons for consultation. (2 marks)
(b) List four possible diagnoses and explain how you could confirm each one (by history, physical examination or
investigation). (6 marks)
(c) How might this case illustrate the principle of family medicine in providing comprehensive medical care? (2 marks)

(a) Due to unresolved, agonizing pain

Persistence of symptoms exceed her threshold of tolerance and anxiety
(b) Acute otitis externa (ear discharge, by otoscopic examination)
Acute otitis media (associated hearing loss, by otoscopic examation, tuning fork test, pure tone audiogram, and
tympanometry)
Carcinoma of ear canal (ask about onset, duration and progression of symptoms, otoscopic examination)
Acute labyrinthitis (associated hearing abnormalities, tinnitus, vertigo)
(c) Address patients concerns on physical and psychosocial aspect, trying to help as far as possible
Acknowledge patients ideas, concerns and expectations such that one can give appropriate and satisfactory
management with building up of a trusting doctor-patient relationship to foster a basis for
SAQ 2006 Q.12 Paedi
A 4-year-old girl was referred to the child assessment centre for suspected developmental delay. The table below shows
part of her developmental profile.
(a) What is her developmental age? Is she having global or isolated developmental delay? (4 marks)
(b) What are the important items to be included in your history-taking? Name six. Explain why you think each of these
items is important. (6 marks)

Result
Tasks (=pass; x = fail)
1. tell personal particulars
full name x
age x
sex x
2. Building Blocks
tower of 23
tower of 67
tower of 89 X
bridge X
3. Colours
Match 4 colours X
Sort 4 colours X
4. Pencil and paper
Scribble (straight/circular)
Imitate vertical stroke X
Imitate horizontal stroke x
Copy O X
5. walking
Without help
Backward in imitation
On tiptoes X
On heels X
On straight line (not heel to toe) X
6. Managed stairs
Up Down
2 ft step, with rail 2 ft step, with rail
1 ft step, with rail 2 ft step, with rail X
1 ft step, alone 2 ft step, with rail or alone X
(a) Her developmental age is around 2 years
old in all aspects of development. She has global developmental delay (as by definition, presence of more than or
equal to 2 delay in the above aspects in a child less than 5 years old can be regarded as having GDD).
(b)
i) Prematurity premature babies are more likely to suffer from cerebral damage and therefore prone to have GDD.
Also we need to correct the chronological age to compare with the developmental age.
ii) Intrauterine growth restriction risk factors, like alcohol or smoking in antenatal period this is also a risk factor for
babies to have neuronal underdevelopment leading to GDD
iii) Events during labour, like difficulty delivery or evidence of asphyxiation prone to cerebral palsy and therefore
GDD
iv) Gestational diabetes known teratogenicity to fetus especially in early stage of pregnancy, causing neural
maldevelopment
v) Previous abnormal movements or posture of the girl may suggest GDD due to CNS pathology
vi) Neonatal screening whether she has undergone neonatal screening in Hong Kong as hypothyroidism can lead to
underdevelopment of the brain
SAQ 2007 Q.1 Medicine Nephro - Gn
An 18-year-old student with good past health presents with severe ankle swelling and facial puffiness over 1 week.
Physical examination shows no pallor, bilateral pitting ankle oedema, and blood pressure reading at 115/78 mmHg.
Urine examination shows 4+ proteinuria by dip stix, without any cells.
(a) What is the most likely histological diagnosis if this patient undergoes a renal biopsy? (4 marks)
(b) List two additional differential diagnoses. (6 marks)

(a) Minimal Change Nephropathy

(b) Focal segmental glomerulosclerosis
membranous glomerulonephritis

SAQ 2007 Q.2 Medicine Neuro

(a) List five clinical signs that can be associated with a brainstem lesion. (5 marks)
(b) List five clinical signs associated with a cerebellar disorder. (5 marks)

(a) Irregular respiration, impaired consciousness, facial palsy, hearing loss, bulbar palsy-aspiration, dysphagia,
dysarthria, vertical nystagmus
(b) Truncal ataxia, dysmetria, horizontal nystagmus, dysdiadochokinesia, intention tremor

SAQ 2007 Q.3 Medicine Hepat HBV infection

Discuss the prevention of hepatitis B infection. (10 marks)

To prevent hepatitis B infection, we have to know more about the infectious source and the route of transmission.
And by reducing the infectious source and preventing transmission, hepatitis B infection can be prevented effectively.
Around 10% of Hong Kong population are chronic hepatitis B carriers. They are undoubtedly the major pool of
infectious source. Majority of them acquire the disease from their mother vertically or during infancy horizontally from
parents or siblings. If the infection is acquired after 6 years old, chances of developing viral chronicity is low as our
immune system is able to clear the virus effectively. Therefore we need to prevent being infected especially during early
times of our life.
There are two ways to prevent hepatitis B infection: to avoid contact and become immunized before exposure to
the virus. Hepatitis B is mainly transmitted by blood and much less likely, by sexual contact. Therefore careful handling
of blood-containing materials including needles, syringes and sharps is essential. All medical professionals must follow
the standard guidelines in handling patients specimen to avoid needle prick injury with contaminated blood. If,
unfortunately, a non-immunized person got such injury, they can go and receive 2 doses of intramuscular
immunoglobulin injection as soon as possible, which may protect them from getting the infection at a 75% success rate.
Active immunization with recombinant DNA yeast vaccine [subunuit vaccine without complete viral particle] for all
unimmunized individuals is definitely preferred for protection against hepatitis B infection as this vaccine has 95%
immunogenicity and once anti-HBsAg antibody develops, protection is 100% lifelong. Vaccination should be commenced
as early as when the babies are born, at 0, 1 and 6 months. For infants of HBsAg positive mothers, they may receive
HBIG and vaccine simultaneously to minimize their chances of getting the infection and become chronic carriers in the
future.

SAQ 2007 Q.4 Surgery Ca eso (See 2004 Q.6, 2005 Q.8)
A 63-year-old gentleman is diagnosed to be suffering from oesophageal cancer by a barium swallow study. Physical
examination does not yield any positive physical signs indicative of metastases.
(a) Name four staging investigations that you will recommend. (4 marks)
(b) If staging investigations show a T3NOMO disease, what options of treatment can you offer the patient providing he is
otherwise healthy? (3 marks)
(c) Name two most common MEDICAL complications after oesophagectomy. (2 marks)
(d) Name one SURGICAL complication that is likely to have its onset one week after oesophagectomy. (1 mark)
(a) Endoscopic ultrasound for tumour depth of invasion and regional lymph nodes
CT thorax for extent of disease and regional metastasis
Bronchoscopy for invasion to trachea
PET scan for distant metastasis
(b) Chemoirradiation, esophagectomy
(c) Pneumonia, cardiac arrhythmia
(d) Anastomotic leaks
SAQ 2007 Q.5 Surgery HBP HCC (See 2004 Q.4)
A 35-year-old gentleman who was a chronic carrier of HBsAg developed anorexia and weight loss. A CT scan of abdomen
revealed a 12 cm tumour in the right lobe of liver.
(a) What is the most likely pathological diagnosis? (1 mark)
(b) Name two screening methods that are useful for detecting such tumour at an earlier stage. (2 marks)
(c) Apart from tumours, list two conditions that are common in chronic carriers of HBsAg? (2 marks)
(d) Name two investigations that may be useful in assessing whether the liver function of this patient is good enough for
hepatic resection. (2 marks)
(e) Name three major complications of hepatic resection in this patient. (3 marks)
(a) Hepatocellular carcinoma
(b) AFP (alpha fetoprotein) > 400ng/ml, ultrasound
(c) Cirrhosis and its complications, hepatic failure (e.g. hepatic encephalopathy), ascites, portal hypertension
(d) ICG clearance (Indocyanine green) >14% at 15mins, Prothrombin Time & albumin.
(e) Biliary leakage, bleeding (from IVC/hepatic vein), infection (esp. when biliary obstruction), pleural effusion

SAQ 2007 Q.6 ENT

Regarding rhinitis:
(a) What is the commonest allergen for allergic rhinitis in Hong Kong? (1 mark)
(b) What are the two distinguishing clinical features between allergic rhinitis and chronic sinusitis? (2 marks)
(c) What is the investigation of choice for identification of allergen of allergic rhinitis? (1 mark)
(d) What are the two groups of first line drugs for the treatment of allergic rhinitis? (2 marks)
(e) Describe four important principles of functional endoscopic sinus surgery for the treatment of sinusitis. (4 marks)
(a) Dust mites > cockroaches > Pets fur
(b) Allergic rhinitis: clear nasal discharge, no facial pain
Chronic sinusitis: purulent nasal discharge, facial pain
(c) Skin-prick test
(d) Antihistamines, steroid nasal sprays
(e) To preserve as much normal tissue as possible
To allow microdebridement of polyps or lesions without damaging the important brain structures
To hasten recovery by improving drainage
To improve efficacy of the surgery by using a 3D-real time feedback

SAQ 2007 Q.7 Surgery

A 50-year-old man presented to the Accident and Emergency Department, complaining of difficulty in breathing for 1
week. He was previously healthy. On examination, the patient looked plethoric. The head, neck and both upper limbs
appeared swollen and there were dilated veins over the upper chest and neck.
(a) What is the clinical diagnosis? (2 marks)
(b) Give one benign cause of the diagnosis. (2 marks)
(c) Give one malignant cause of the diagnosis. (2 marks)
Chest X-ray showed widened superior mediastinum.
(d) What are the four boundaries of the mediastinum? (4 marks)
(i) Anteriorly
(ii) Posteriorly
(iii) Right side
(iv) Left side
(a) Superior vena cava obstruction
(b) TB granuloma/ retrosternal goiter
(c) Lymphoma affecting mediastinal lymph node/ bronchogenic carcinoma with mediastinal node infiltration
(d) (i) sternum
(ii) vertebral bodies (T1 T12)
(iii) right mediastinal pleura
(iv) left mediastinal pleura
SAQ 2007 Q.8 Com Med
Table 1 below shows the attributable risks due to non-accidental deaths for NO 2 and SO2 when the concentration of each
pollutant is reduced by 10 g/m3 10 years after a government intervention Table 1 Estimated attributable risk for NO2
and SO2 for a 10 g/m3 reduction
NO2 only SO2 only NO2 + SO2 combined
Relative risk 1.006 1.011 1.017
The total number of deaths due to all non-
Attributable risk 0.6% 1.1% A accidental causes in Hong Kong in the year
Estimated number 1996 is 32 000.
of death avoidable (a) Compute the value for A, the attributable
X Y Z
after the risk for NO2 and SO2 combined in Table 1. (2
intervention marks)
(b) What is the assumption you have made in
calculating the combined attributable risks? (2 marks)
(c) Compute the values for X, Y and Z in Table 1. (3 marks)
(d) Under what situation can one use excess risk in lieu of attributable risk for calculating the number of deaths
avoidable? (3 marks)
[Attributable risk = (RR-1)/ RR x 100%] [excess risk = (RR-1) x 100%]
(a) 1.71% [1.67%]
(b) Assuming there is no intermediate risk factor relationship between NO2 and SO2 or vice versa. (i.e. not a
confounder) [the two variables are independent of each other.]
Assume they exhibit a multiplicative effect on risk outcome
(c) X: 192 Y: 352 Z: 535
(d) When relative risk itself is close to one such that excess risk and attributable risk are similar.

SAQ 2007 Q.9 ?Radi

A 7-year-old boy who was previously well presents to the Accident and Emergency Department with a history of fever
and increasing abdominal pain for 2 days. He does not have a history of vomiting or diarrhoea. You are the house officer
in the admission ward. Physical examination reveals diffuse abdominal tenderness and guarding in the right lower
quadrant. His temperature is 39C. Blood tests show a white cell count of 2x10 9/l.
(a) What is the most likely diagnosis? (2 marks)
(b) Name the most appropriate imaging modality and give three reasons for selecting this modality. (4 marks)
(c) Name three possible findings on imaging for this diagnosis. (3 marks)
(d) Name an alternative imaging modality which may be used, especially in an obese child. (1 mark)
(a) Acute appendicitis
(b) Ultrasound
- non-invasive
- no irradiation
- excellent for soft tissue organs
- safe, portable and quick
(c) Fecolith obstructing the appendix
acoustic shadow behind the fecolith
grossly distended appendix
thickened appendiceal wall
(d) Magnetic Resonance Imaging

SAQ 2007 Q.10 Ethics

List five negative medical-social implications of Assisted Reproductive Technologies (ART) using In Vitro Fertilization &
Embryo Transfer. (10 marks)

1) Erosion of human dignity

2) Medicalisation of the human reproductive process
3) Commercialization of the human reproductive process
4) Eugenic potentials as pre-implantation diagnosis is available
5) Surplus embryos may be used for research purposes which is highly unethical
6) Resource allocation and social injustice
SAQ 2008 Q.1 TB clerkship
Tuberculosis (TB) represents an important health problem worldwide.
(a) List five principles of WHO DOTS Strategy for TB control and prevention. (5 marks)
(b) Name two areas in the world with a TB incidence greater than 300 per 100,000 population. (2 marks)
(c) The practice of BCG vaccination varies between different countries. List two population subgroups that are
vaccinated in Hong Kong. (2 marks)
(d) Name the other infectious disease that is world-wide associated with tuberculosis. (1 mark)

(a) Political commitment with increased and sustained financing

Case detection with quality-assured bacteriology
Effective drug supply and management system
Standardised treatment with supervision and patient support
Monitoring and evaluation system and impact assessment
(b) China, Africa
(c) All newborns in Hong Kong. All immigrated children less than 15 years old who have never been vaccinated before.
(d) HIV

SAQ 2008 Q.2 Surgery Lower abd pain

A 25-year-old female patient presented with a history of right lower quadrant pain for 2 days associated with one
episode of vomiting. On clinical examination, the abdomen was soft, with tenderness at the right lower quadrant. No
mass was palpable and bowel sounds were present.
(a) List differential diagnoses. (5 marks)
(b) Name three investigations that would help in arriving at the diagnosis. (3 marks)
(c) What is the most likely diagnosis? (1 mark)
(d) What is the most appropriate treatment? (1 mark)

(a) Ectopic pregnancy

Acute appendicitis
Diverticulitis
Intestinal obstruction
Ureteric calculi with urinary tract infection
(b) Ultrasound, pregnancy test, abdominal X-Ray
(c) Acute appendicitis
(d) Laparoscopic resection with IV antibiotics if there is sepsis

SAQ 2008 Q.3 Medicine Neuro - MG

(a) Name five specific clinical features (specific symptoms or signs) likely to be present in a patient with moderately
severe generalised myasthenia gravis. (5 marks)
(b) Name two associated disorders which are associated with myasthenia gravis. (2 marks)
(c) What three investigations would help you confirm the diagnosis of myasthenia gravis? (3 marks)

(a) Diplopia, ptosis, dysphonia, dysphagia, respiratory distress, generalized ms weakness, fatigue worst till the end of
day
(b) Thymoma or thymic hyperplasia, Graves disease
(c) Tensilon test using edrophonium injection
Serum anti-AChR antibody level/ Anti-MuSK Ab (Anti-muscle specific receptor tyrosine kinase)
Electromyogram
(d) Specific tx: anti-cholinesterase, thymectomy, immunotherapy
SAQ 2008 Q.4 Medicine Endo Pituitary prolactinoma
A 30-year-old woman presented with galactorrhoea and amenorrhoea for 6 months and was diagnosed to have a
prolactin-producing pituitary macroadenoma. Her menstruation resumed after starting on bromocriptine and she
became pregnant. She stopped the medication but did not return for follow-up until three months later when she woke
up with complete ptosis of the right eye.
(a) What is the neurological deficit causing her right eye ptosis? (1 mark)
(b) What other abnormal findings are likely to be present on eye examination? (5 marks)
(C) How can these eye changes be related to her pituitary macroadenoma? (2 marks)
(d) What medical treatment can potentially reverse her eye changes? (2 marks)

(a) Acute oculomotor nerve palsy

(b) Pupil dilatation (mydriasis), eye in a down and out position, papilloedema, optic atrophy, bitemporal hemianopia
(c) Mydriasis, ptosis and abnormal eye position can be explained by acute III palsy due to lateral extension of pituitary
macroadenoma. Papilloedema is due to increased intracranial pressure from mass effect of the tumour. Optic
atrophy and visual field defect is due to compression on optic chiasma by the tumour.
(d) Use dopamine analogues such as bromocriptine to shrink the tumour and reverse the pressure effect.

SAQ 2008 Q.5 Medicine infective endocarditis

A 40-year-old man consults your clinic for progressive breathlessness and weight loss for 2 months. He also complains of
low grade temperature and painful nodules over his fingers. Physical examination shows early fluctuance over the right
knee and tender nodules over finger pulp. There is a grade 3/6 early diastolic murmur over left sternal border. Urine
analysis shows non-haemolysed blood on dip test 3+.
(a) What is the most likely diagnosis? (3 marks)
(b) Name three additional physical signs that would support your diagnosis. (3 marks)
(c) Briefly outline investigations to confirm your diagnosis. (4 marks)

(a) subacute infective endocarditis

(b) Splinter hemorrhage, finger clubbing, Roths spot
(c) - blood x CBC, C/ST, ESR, serological markers (RF, Ig, complements, immune complex) 3 venous blood cultures
(each taken at diff sites and separated by at least half an hr): persistent bacteremia showing typical organisms (e.g. S.
viridians, S. aureus)
- urine x R/M, C/ST
- CXR, echo evidence of endocardial involvement e.g. moving masses, abscess, prosthetic valve dehiscence

SAQ 2008 Q.6 Surgery Carotid stenosis

A 75-year-old lady presented with repeated episodes of transient blindness affecting her left eye. Duplex scan of the
carotid artery was performed and showed 90% stenosis of the left internal carotid artery.
(a) Discuss two medical treatments for this patient. (2 marks)
(b) Is left carotid endarterectomy indicated in this patient? (1 mark)
(c) Can carotid endarterectomy be performed under loco-regional anaesthesia? (1 mark)
(d) Discuss the complications associated with carotid endarterectomy. (3 marks)
(e) What is the alternative surgical treatment to carotid endarterectomy? (1 marks)
(I) Name two situations where the option in (e) would be a preferred option. (2 marks)

(a) Anti-platelet agent like aspirin or clopidogrel to prevent platelet plug formation which further aggravate the stenosis
Lipid lowering drugs like statins or fibrates to prevent further atherosclerosis
(b) Yes
(c) Yes
(d) Stroke, as microthrombi may be flushed upwards causing cerebral ischaemia after patency of the artery is restored.
Also, during the operation, the artery will be clamped and may cause cerebral ischaemia.
There may be cranial nerve damage as the carotid artery is in close proximity to glossopharyngeal nerve, vagus
nerve and hypoglossal nerve.
Reperfusion may lead to cerebral oedema as previously accumulated metabolites will lead to vasodilation and
increased endothelial permeability, for which sudden reperfusion will lead to acute cerebral oedema.
(e) Angioplasty with stenting
(f) When the patient is medically unfit for surgery. When the site of stenosis is higher up rather than at bifurcation of
common carotid artery.
SAQ 2008 Q.7 ENT unilateral lower motor neuron facial palsy, parotid gland tumor
A 40-year-old woman suddenly noticed right lower facial nerve palsy.
(a) Name three likely diagnoses. (3 marks)
(b) Name one predisposing factor for one of the conditions provided by you in part (a). (1 mark)
(c) Name one investigation for this patient. (1 mark)
(d) The patient while waiting for investigation was noticed to have a right parotid swelling. What is the likely diagnosis?
(1 mark)
(e) The patient was noted to have adenoid cystic carcinoma of the parotid gland. Name four clinical characteristics of
this malignant tumour. (4 marks)

(a) Bells palsy

Ramsay Hunt syndrome
Acoustic neuroma
(b) Previous viral URTI for Bells palsy
(c) Electroneurogram
(d) Parotid gland tumour
(e) Low-grade, slowly growing, early metastasis but patients can survive a long time with it, high recurrence rate

SAQ 2008 Q.8 ENT - NPC

Regarding nasopharyngeal carcinoma:
(a) Name three epidemiological characteristics pertaining to Hong Kong. (3 marks)
(b) Name two early and three late clinical features. (5 marks)
(c) Name one serological test useful for the diagnosis of this condition. (2 marks)

(a) Southeast China population, positive family history of NPC, infected with EBV, nitrosamine containing diet
(b) Early: enlarged neck lymph node, otitis media with effusion [blood stained phlegm, otitis media with effusion]
Late: epistaxis, blood streaks in phlegm, stertor, referred otalgia [nasal obstruction, diplopia, enlarged cervical LN]
(c) Antibody against EBV

SAQ 2008 Q.9 Medicine - Neuro

A 55-year-old man presents with bilateral lower limb weakness for 2 days. He has back pain that radiates around the
chest at the level of the nipples for 1 month and has taken some analgesics himself.
(a) List two other neurological symptoms that should be asked in history. (2 marks)
(b) List five clinical features to look out for on physical examination of the motor system of the lower limbs. (5 marks)
(c) What is the dermatome corresponding to the level of the nipples? (1 mark)
(d) What is the likely clinical diagnosis? (2 mark)
(a) Numbness, paresthesia [numbness, incontinence]
(b) Muscle fasciculations, muscle atrophy, muscle tone, muscle power, deep tendon reflexes, plantar response, clonus
[spasticity, sustained clonus, Babinskis sign, hyperreflexia, abnormal gait due to weakness???]
(c) T4
(d) Transverse myelitis
(Acute T4 cord compression due to tumour/TB granuloma?)

SAQ 2008 Q.10 Mibi? Hepat? (See 2005 Q.11

A 75-year-old gentleman with a history of diabetes was admitted for swinging fever, chills and right upper quadrant pain.
On examination, he had a temperature of 39.5C, abdominal right upper quadrant tenderness and an enlarged liver.
Blood tests showed mildly elevated bilirubin and leucocytosis. Ultrasonography showed a hypoechoic lesion in the liver.
(a) What is the most likely diagnosis? (2 marks)
(b) What minimally invasive treatment would you offer the patient? (2 marks)
(c) Briefly describe how you would prepare the patient for this procedure. (4 marks)
(d) Name two agents that may be responsible for the condition in (a). (2 marks)

(a) Liver abscess

(b) Percutaneous drainage of the abscess under ultrasound guidance
(c) informed consent, prior investigations to rule out bleeding tendency and hepatic malignancy, IV antibiotics,
sedation, aseptic technique
(d) Entamoeba histolytica, Klebsiella
SAQ 2008 Q.11 Medicine Haemat DVT/ Surgery VAS - DVT
Mrs. Lee is a 45-year-old woman who has just arrived back in Hong Kong a week ago after visiting her son in Vancouver.
She presents to you with a painful left lower leg, which has been getting progressively more swollen since coming back.
She does not recall injuring her leg, but is now having difficulty walking due to calf pain.
(a) What serious diagnosis must be excluded? (1 mark)
(b) What are the risk factors for this condition? Name eight. (4 marks)
(c) What are four physical signs you would like to look for or elicit? (4 marks)
(d) List one initial investigation you would like to carry out to help confirm the diagnosis. (1 mark)

(a) Acute arterial occlusion of left leg/ DVT

(b) dehydration, use of oral contraceptives, pregnancy, (smoking, hyperlipidaemia, diabetes mellitus)
pelvic surgery, orthopaedic surgery, pelvic mass/ tumor
prolonged immobilization of lower limb
congenital deficiency of protein C/ S/ ATIII
(c) Pitting oedema, gangrenous change of the limb, peripheral pulses, temperature of the limb/ swelling, tenderness,
warmth, Homans sign
(d) Duplex Doppler ultrasound

SAQ 2008 Q.12 Ethics

In the allocation of scarce medical resources e.g. ICU beds to competing patients, briefly discuss the three most ethically
acceptable and two least ethically acceptable criteria for prioritization of patients. (10 marks)

3 Most ethically acceptable

1) Patients need triage system
determine whose condition is more sinister and urgent that requires ICU care
2) Potential benefits from ICU care
determine who will get maximal benefit from getting the care, trying to maximise the benefits to most patients
3) Age of the patient and life expectancy
those who are expected to have a longer life expectancy should be allocated the ICU beds. Those who shall die with
the disease due to limited life span may not get the care

2 Least ethically acceptable

1) Ability to pay
those who can pay for the service can get the service first social injustice
2) Social status
those in a higher socioeconomic status and being more important to the society should be prioritized for ICU care