Pathology 2014 Questions
Please note that this is from memory and so we have obviously not been able to remember all the different options in the EMQ. Also the questions that are written here are a little easier than the exam because we couldn’t remember the exact wording so just wrote the headlines – hopefully will still give you a flavour of what to expect. Just be aware that quite a few of the questions require two or three steps to figure out so the exam does actually test your understanding rather than simply your ability to memorise (it does test this too though…). Overall most people in our year would agree that it was a fair examination.
MedEd guide served as a very useful backbone to structure revision around.
Definitely worth reading around the subject and trying to understand pathology, as it will serve you well in the exam and in your future careers. (Robbins Basic Pathology is very good).
Contributions from: Rahul Ravindran, Louis Peters, Siree Wongrukmit, Khizr Nawab,
Ken Wu, and Hamish Jackson.
Immunology
Relatively tricky questions with the way they were worded – learn well – quite a few from Margaret Callan’s lectures came up [no surprises as she is deputy head of year
5]. Note – there were only six EMQs on immunology, and seven EMQs on everything else. The extra EMQ was the one on death certificates [Mike Osborne’s lecture]. Not sure if this is how it is every year…

Monitoring and diagnosing autoimmune disease (lupus, systemic sclerosis) and HIV
Some options: C3 & C4 levels, HIV test, White cell count and differential, anti-SCL-70, anti-Sm.
1.
How to monitor the activity of SLE? (C3 & C4 levels)
2.
How to monitor a patient with HIV? (WCC and differential, not HIV test…)
3.
Antibody useful to diagnose someone with systemic sclerosis? (SCL-70)

DMARDs and biologics for autoimmune disease, e.g. for Wegeners
(Cyclophosphamide), Rheumatoid Arthritis (answer was tocilizumab, despite patient not having trialed an anti-TNF e.g. Etanercept or Adalimumab beforehand which is correct according to NICE and should have been an option, and the answer), Psoriasis (Ustekinemab), Osteoporosis
(Denosumab), CGD (IFN-gamma).
Some options: cyclophosphamide, tocilizumab, ustekinemab, denosumab, IFNgamma, IFN-alpha, tacrolimus,

1.
How would you treat a patient with rheumatoid arthritis who is not responsive to methotrexate and another DMARD? (Answer was Tocilizumab, this was best fit because there were no anti-TNF medications in the list).
2.
How to treat a patient with Wegener’s Granulomatosis who has severe flare of disease? (Cyclophosphamide).
3.
A patient with osteoporosis who cannot tolerate a bisphosphonate or something. (Denosumab).
4.
How to treat chronic granulomatous disease? (IFN-gamma, I think this is the only condition treated with IFN-gamma, also learn what IFN-alpha and IFNbeta are used to treat [but they weren’t options here]).
5.
A biologic that can be used to treat psoriasis (Ustekinemab).
 Allergy treatments: h1/h2 antagonists in the options list (remember which is which), anaphylaxis, hereditary angioedema (IV C1 inhibitor), urticaria, exercise-induced urticaria.
Some options: H1 antagonist, H2 antagonist, IM adrenaline, IV adrenaline, IV C1 inhibitor, tracheostomy.
1.
A patient with some description [can’t remember details] of C1 inhibitor deficiency – she was still able to talk. (Answer – IV C1 inhibitor, and not tracheostomy!).
2.
A patient with some rash etc… after eating. (Answer – oral antihistamines – remember it is not anaphylaxis unless either airway, breathing or circulation is affected).
3.
A patient with some rash and wheeze etc… (Answer – IM adrenaline).
4.
Some kind of urticaria (Answer – H1-antagonist).
5.
Another one where the answer was H1-antagonist.

HIV question - asking about things like gp120, p24 capsid, protease inhibitor, neutralising Abs and non-neutralising Abs.
Some options: gp120, p24, CCR5, CCR7, protease.
1.
Neutralising antibodies are formed against this. (Answer – gp120).
2.
Non-neutralising antibodies are formed against this. (Answer – p24).
3.
A co-receptor required for entry. (Answer – CCR5 [CXCR4 wasn’t on the list and it can use either CCR5 or CXCR4] – it isn’t CCR7!).
4.
An enzyme that can be the target of HIV medication. (Answer – protease
[also the question was more challenging than this but can’t remember the details]).
 Immunodeficiencies - X-linked SCID with absent T cells and B cells normal,
Bare Lymphocyte syndrome with no CD4, CD40L deficiency with hyper IgM,
C7 complement deficiency for meningitis.
Some options: X-linked SCID, Bare Lymphocyte Syndrome, Hyper-IgM syndrome, C7

deficiency, X-linked lymphoproliferative disorder, C1q deficiency…
1.
A 6-month old boy with severe failure to thrive and recurrent infections etc… his T cells were undetectable and B cells were normal. (Answer – X-linked
SCID – this one confused me a little as I thought B cells require T cell help to become activated, but checked Dr Callan’s slides and it says B cells can be normal).
2.
Someone with three previous episodes of meningococcal meningitis. (Answer
– C7 deficiency – this is to check that you know that deficiency of any components of the terminal complement pathway (C5-9 – forming membrane attack complex) can predispose to infection from encapsulated organisms).
3.
Someone with normal CD8 levels but absent CD4. (Answer – Bare
Lymphocyte Syndrome [type 1 and 2 exist, but more common to have type 2 with absent CD4 compared to type 1 with absent CD8).
4.
Someone with lots of IgM but low levels of IgG, IgA etc… (Answer – CD40L deficiency – this is hyper-IgM but this wasn’t on the option list so they wanted you to know the mechanism and put this down).

Vaccines - which one to avoid in immunodeficiency - yellow fever. Which one for asplenic patients repeated every five years - pneumovax. Which one is part of the routine schedule but avoid in immunodeficiency - MMR. Which one against viral haemagglutinin - influenza.
Make sure you learn the list of live attenuated vaccines, killed vaccines etc…
Live attenuated: small yellow typhoid chicken MMR boy (BCG, oral polio, yellow fever) [yes I know yellow fever is there twice!].
Small – Smallpox
Yellow – Yellow Fever
Typhoid – Typhoid…
Chicken – Chickenpox
MMR
B – BCG
O – Oral polio
Y – Yellow fever

Death certificate question - deadly. There will always be 1 Q from the human tissue act/law/death certificates/coroner lecture - learn it as it is guaranteed to screw most people…All of them had cardiac arrest, T2DM and malignancy.
1 was PE then cardiac arrest, 2 was brain tumour and coning, 3 was STEMI.

Haematology
Quite an easy section… spent a lot of time learning the material on Barbara Bain’s slides that she said you don’t need to know (obviously when someone writes this you don’t believe it); however, she seemed to be telling the truth.
1. Causes of thrombocytosis – there was a little bit of clinical history and blood results for each patient (all had raised platelets ranging from around 450 to 1100) and you had to select the most likely cause. The answers were: infection, ET, CML, iron deficiency, SLE. The point of this question is to realise that a ‘raised value’ has lots of different causes and you should be able to recognise platelets going up with a pneumonia (to around 450 – patient was feeling feverish and unwell) compared with essential thrombocythaemia (around 1100 – patient had routine bloods done before an operation and no symptoms) – the histories did help quite a lot too though.
2. Such an easy question on haematological cancers. The questions were each about
4-5 sentences, but all ended with a convenient buzzword such as smear cells, Auer rods, (9,22) mutation so it was very straightforward. Myelofibrosis as well I think.
3. Transfusion reactions – you MUST memorise the flowchart on transfusion reactions, both for this exam as well as real life. Bacterial contamination – patient had a high fever, anaphylaxis due to IgA def (Already transfused once before --> sensitised), one history had a patient who had recently been involved in some kind of trauma and had been transfused with O negative blood. He lost consciousness or something a few minutes after the transfusion and the answer was haemorrhage with a splenic haemorrhage after a stab wound rather than ABO incompatibility
(because O negative blood).
4. Clotting - Warfarin monitoring, given the condition and current INR, had to know recommendations - AF/DVT 2-3, prosthetic valve 3-4, options were either to increase the dose, decrease the dose or keep the same (lots of other options were available like FFP but they were filler, but know when to use them as well).
5. Clotting in pregnancy

One question the woman had a clot but so did her father and sister  familial  ATIII deficiency.

Recurrent miscarriage – anti-phospholipid syndrome.

TTP (aka HELLP) for pregnant woman with seizures and schistocytes but TTP because of fever & neuro symptoms etc… so not DIC (tricky Q).

DIC for another obvious septic person, leading to consumption of factors.
 Gestational Thrombocytopenia in a pregnant woman.
6. Easy Q - normal Hb with positive sickle solubility test (Sickle trait), low Hb with positive sickle test (Sickle disease), African man with haemolysis after anti-malarials
(G6PD deficiency), older man with polychromasia and spherocytes (Spherocytosis).

Microbiology
Hate this topic as there is a lot of memorizing but I guess you need to know this as a doctor!
1. Infections in neonates and childhood – Listeria, GBS, E. Coli, and toxoplasmosis – learn everything about these as it is both in path and specialties so almost guaranteed to be assessed.
2. Travel - HAV, Malaria, Cutaneous leishmania, V. Cholera (rice water), Swimming pool/Fish tank granuloma (Mycobacteruim marinum)
3. GI - how to investigate with different histories - vomiting and diarrhoea - rotavirus, C. diff (Toxin ELISA rather than culture),Diarrhoea after barbecue -
Salmonella/Shigella (culture)
4. Neurological - easy one with meningitis in patients of different ages and described gram staining (Neisseria meningitides, strep pneumoniae in a smoker, e coli in neonate) - gave you the very limited history, and then microscopic appearance to make the diagnosis (Ie, Gram +ve bacilli - listeria monocytogenes)
5. Infections in pregnancy - toxoplasmosis - flagellate protozoan that can cross placenta, syphilis - STI that can cross placenta in third trimester, Listeria - in food,
GBS- part of normal commensals that can cause sepsis, C. trachomatis - STI that can cause neonatal conjunctivitis (N. gonnorrhoea wasn't an option).
6. UTI - most common UTI - E. coli. Common in young women- E.coli again? blackboard has said Candida? Staph sapprophyticus? What suggests contamination - epithelial cells on microscopy. What suggests coliform organisms - nitrites. Associated with stones - Proteus (Struvite stones).
7. Skin infections - Clostridium perfringens - gas gangrene. Strep pyogenes for leg cellulitis, then again for a child with erysipelas (facial lesion). Leishmania for an
Afganistani soldier with skin lesion.

Histopathology
Quite straightforward.
1. Breast - fibroadenoma, ductal papilloma, invasive ductal carcinoma, Paget's disease of the nipple.
2. Endocrine - cushingoid - only option that fitted was adrenal tumour, thyroid cancers associated with ret mutation (medullary). what is Type 2 DM associated with? Amyloid or IHD. Thyroid - Medullary carcinoma (Calcitonin staining), Cystic lesion with papillary architecture and clear cytoplasm (Papillary carcinoma).
3. Gynae - difference between type 1 (Oestrogen related) and type 2 (Older women with atrophic endometriosis) endometrial cancer was the only tricky one here.
4. Liver - copper high and affects basal ganglia - Wilson’s, ANA and lymphoctic infiltrate on boipsy - Autoimmune, guy with portal HTN - alcoholic cirrhosis, PBC.
5. Colon - what on surveillance would be an indication for colectomy in UC?
(Dysplastic polyps) What would you see on histology in crohns? (Granulomas), Guy with continuous colonic lesion (UC)
6. Neurological (v. easy) Sub-arachnoid, sub-dural, variant CJD (obvious history - young omnivore who had psychiatric symptoms then motor symptoms), histology of alzheimer's (plaques)
7. Resp - mesothelioma with weight loss etc, EAA with occupational, small cell with smoker and SIADH.
Nothing on renal, or nitty gritty of bone tumours.

Chemical Pathology
You must understand this section well, as the harder questions are impossible to figure out if you just memorise it. Try reading ‘Clinical Chemistry’ by Bangert [one of the recommended textbooks].
1. Question on deficiencies - Four B
12
deficiencies in a row(!):
1) Vegan lady.
2) Someone 'lacking intrinsic factor’.
3) Woman with hypothyroidism, T1DM, adrenal failure (polyendocrinopathies – autoimmune and is hinting towards pernicious anaemia).
4) Crohn’s – B
12
deficiency [as terminal ileum required to absorb and this is commonly affected in Crohn’s].
Make sure you really know the details of folate vs. B12 deficiency.
Fifth one was simple vitamin D deficiency with low calcium, low phosphate, high PTH and high ALP [this is secondary hyperparathyroidism in response to the low calcium].
2. LFTs - all quite straightforward - had a raised ALP here isolated that was Paget’s so be careful - doesn’t necessarily have to be liver if the title of the EMQ is liver.
(Sounds obvious but in the exam you start to double guess yourself). Others were gallstones, alcoholic liver disease.
3. Enzymes - rate-limiting enzyme in haem synthesis? (ALA synthase), deficiency leads to high urate (HGPRT), Presents with hyperkalaemia? (CAH), How to diagnose B
Thal trait (HbA2), Mumps (Amylase), Enzymes raised in Rhabdo (CK)
4. Calcium question - just had numbers and you had to choose answers. osteomalacia, osteoporosis (normal biochem), primary hyperparathyroidism (raised calcium, NORMAL PTH in this question [it is inappropriately normal]), malignancy
(raised calcium and PTH was <1 i.e. appropriately suppressed), hypoparathyroidism
(low calcium and PTH was in the normal range [but you expect it to be high]).
5. Question that had a stem with just numbers (a little like one of the blackboard quizzes) - the potassium you would see in untreated DKA (raised), calculate osmolarity, calculate anion gap, what would bicarbonate be in pyloric stenosis (40), what value would you see in IGT.
6. Diabetes question - two cases of T1DM (DKA), one case of T2DM in HONK, OGTT results (patient had IGT), and Conns (quite hard to differentiate from the Diabetes
Insipidus), all giving nothing but serum electrolyte values.