Before The Exam

Question 1

How do you work out the ESR

Answer 1

age (+10 if female)/2

Question 2

what are the sings of anaemia

Answer 2

pallor
retinal haemorrhages
cardiac failure 
systolic murmur 
bounding pulse
rapid heart rate

Question 3

what is the ferric symbol and what is the ferrous symbol

Answer 3

ferric = Fe3+
ferrous = fe2+
ferric reductase causes ferric to be converted to ferrous in the gut

Question 4

what happens if there is bundle branch block

Answer 4

• prolonged QRS

- loss of synchronic

Question 5

what does a VSD lead do

Answer 5

left to right shunting

pulmonary hypertension

Question 6

what does an ASD lead to

Answer 6

left to right shunting
pulmonary hypertension
right ventricular hypertrophy

Question 7

define megaloblastic anaemia

Answer 7

is macrocytic anaemia that results from inhibition of DNA synthesis during red blood cell production

Question 8

describe the features of pernicious anaemia and what causes it

Answer 8

• An autoimmune disorder
• Incidence is 1-2% in population > 60 years
• F > M
• Associated with fair hair, blue eyes, blood group A
• Due to an Autoantibody against parietal cells and intrinsic factor (IF)
• Leads to gastric atrophy, ↓ acid + ↓ IF secretion

Question 9

what do the lab tests show for pernicious anaemia

Answer 9

• microcytic anaemia
• hypersegemented neutrophils
• decreased serum B12

Question 10

what can long standing haemolysis cause

Answer 10

gall stones

Question 11

what is the presentation of haemolytic anaemia

Answer 11

• Pallor and signs/symptoms of anaemia
• Jaundice
• Gallstones
• Splenomegaly

Question 12

what is the difference between hereditary spherocytosis and GP6D deficiency

Answer 12

Hereditary spherocytosis is a autosomal domintant condution whereas GP6D is an a X linked condition

Question 13

what is the differnece between pituitary macroadenoma and pitutiary microadneoma

Answer 13

macroadenoma is greater than 10mm

whereas microadenoma is less than 10mm

Question 14

what does PTH do to osteoblasts

Answer 14

it inhibits osteoblasts

Question 15

what does PTH do to calcium absorption in the gut

Answer 15

• it increases calcium reabsorption from the gut but not directly, it uses vitamin D

Question 16

PTH does not….

Answer 16

facilitate phosphate reabsorption

Question 17

what are the causes of hypopituitism

Answer 17

• pituitary radiotherapy
• macro adenoma
• empty sella

Question 18

what treatment is not used in osteoporosis

Answer 18

FGF-23

Question 19

what does FGF=23 do

Answer 19

= FGF23 this is a phosphatonin - a hromone that reduces the serum phosphate levels

• it is secreted in osteocytes in response to 1,25-dihydroxyvtiamin D3
• its action is to induce phosphaturia in the kdineys by increasing renal loss of phsophate and to inhibit 1 alpha hydroxylase whcih is needed to form 1,25-dihydroxyvitamin D3

Question 20

In angina what causes an increase in oxygen demand and what can cause a decrease in oxygen supply

Answer 20

increase in oxygen demand

• hypertrophy
• stenosis
• pulmonary hypertension
• hypertension

decrease in supply

• atheroscerlosis
• severe anaemia
• regurgitation

Question 21

what is another pathway by which VWF carries out its role

Answer 21

• 2nd pathway of activation by agonists interaction on membrane surface receptors and G protein activation of phopholipase C. – further calcium release – stimulate contractile system – liberation of Arachidonic Acid and further generation of TXA2
• Flip fop of membrane charge – negative charged moieties onto outer surface – procoagulant

Question 22

what does antithrombin inhibit

Answer 22

major inhibitor of thrombin and Xa

• also inhibits VII, IX, XI

Question 23

what does protein C do in clotting

Answer 23

• serine protease
• inactivates Va and VIIIa
• Protein S
• cofactor for Activated Protein C (APC)

Question 24

what are emerging risk factors for atherosclerosis

Answer 24

• Increased Homocysteine (B6, B12 & folic acid deficiencies)
• Increase oxidant stress
• Lipoprotein (a) - (LDL + extra apolipoprotein)- more firmly retained in arterial wall
• Infection (Chlamydia pneumoniae)- inflammation of endothelium

Question 25

Name the 4 possible causes of hypertension

Answer 25

1. Overactivity of the sympathetic nervous system 2. Impaired production of nitric oxide 3. Elevated renin release 4. Reduced atrial natriuretic peptide release

Question 26

How do you work out blood pressure

Answer 26

Blood pressure P = Cardiac output x SVR

Question 27

what causes the Link between obesity and primary hypertension

Answer 27

1) - Obese individuals have high levels of leptin but often have a decreased sensitivity to leptin and thus their ‘ponderostat’ control is set too high. - The high levels of leptin produce overstimulation of the sympathetic nervous system, especially the supply to the kidney. - This may directly stimulate excess renin release. 2) - Obesity is associated with hyperinsulinaemia and insulin resistance. - hyperinsulinaemia can damaging endothelial walls and decrease nitric oxide production, thus increasing SVR and inducing hypertension

Question 28

what investigations initially should you do for pulmonary embolism

Answer 28

1. ECG – sinus tachycardia, right heart strain, T-wave inversion on anterior leads. 2. CXR – often normal, focal oligaemia, peripheral wedge shaped density above diaphragm, small pleural effusion 3. Arterial blood gases – often hypoxia, low CO2, but may be normal

Question 29

what are the causes of dilated cardiomyopathy

Answer 29

- idiopathic - familial Inflammatory - infectious (especially viral) - non infectious - connective tissue disorders - permpartum cardiomyopathy - Sarcodosis Toxic - chronic alcohol consumption - chemotherapeutic agents metabolic - hypothyroidism - chronic hypocalcameia neuromuscular - muscular or myotonic dystrophy

Question 30

what are the signs and symptoms of dilated cardiomyopathy

Answer 30

- Decreased cardiac output – tiredness and fatigue - Pulmonary oedema – Dyspnoea/Crackles - Ascites and peripheral oedema (in legs, ankles) - Enlarged heart – leftward displacement of apical beat and possibly a third heart sound (indicates poor systolic function) - Mitral regurgitation – regurgitation of blood back into the left atrium - Palpitations – this is caused by arrhythmias

Question 31

what are the symptoms of hypertrophic cardiomyopathy

Answer 31

There is wide variation in the symptoms of HCM, with some people having few or no symptoms, to people who have very severe symptoms • Palpitations – caused by arrhythmias. • Chest pain – reduced oxygen levels getting to the heart. • Dizziness or fainting – reduced oxygen levels or blood flow to the brain. • Breathlessness (or dyspnoea) – pulmonary oedema, making it harder to breathe.

Question 32

what are signs and symptoms of restrictive cardiomyopathy

Answer 32

* Decreased cardiac output - fatigue (tiredness) * Systemic congestion * Jugular venous distension * Peripheral oedema * Arrhythmias - Palpitations * Possible conduction block * Signs of congestive heart failure may also be present e.g. pulmonary crackles etc.

Question 33

describe the T cell response to asthma

Answer 33

- Dendritic cell causes activation of TH2 cell - TH2 cells are activated : there Central role is Release inflammatory mediators: - interleukin-4 (IL-4) and IL-13 = Stimulates B cells to synthesize IgE - IL-5 = Eosinophil activation - IL-9 = mast cell proliferation – this causes an increased histamine production and further activation of mast cells

Question 34

How is COPD caused

Answer 34

- Cigarette smoke (major risk factor) = irritates & activates epithelial cells & macrophages → inflammatory mediators Macrophages release CXCL8 = chemokine = attracts neutrophils Epithelial cells release CXCL9 & CXCL10 = chemokine = attracts T helper 1 (TH1) cells and type 1 cytotoxic T (TC1) cells TC1 & neutrophils → Proteases (e.g. metalloproteinase 9 (MMP9)leads to = elastin degradation Neutrophil elastase leads to = mucus hypersecretion. Epithelial cells & macrophages → transforming growth factor-β (TGFβ) = stimulates fibroblast proliferation = fibrosis in the small airways

Question 35

what are the clinical signs of COPD

Answer 35

- Shortness of breath - Chronic cough - Phlegm - Wheezing - Chest tightness - Respiratory infection

Question 36

what are the symptoms of idiopathic pulmonary fibrosis

Answer 36

- - difficult to distinguish - Extertional dyspneoa - Clubbing - Dry cough

Question 37

how to you diagnose sarcoidosis

Answer 37

- Info from the patient and Clinicoradiographic data: - Bilateral hilar adenopathy on the chest radiograph - Lofgren syndrome (erythema nodosum skin rash + bilateral hilar adenopathy on chest radiograph +/- fever and arthritis) - Diagnosis possible versus idiopathic granulomas – for example one organ has granulomas if there is more than one granuloma then diagnosis is more likely

Question 38

what are the major symptoms of a common cold

Answer 38

Rhinorrhoea (excess mucus filling in the nasal cavity) and nasal obstruction (mucosal lining) – major symptoms

Question 39

name the categories for the centor score for pharyngitis

Answer 39

- Tonsillar exudate - Tender anterior cervical lymphadenopathy or lymphadenitis - History of fever greater than 38 degrees - No cough

Question 40

name the categories for the FeverPain score for pharnygitis

Answer 40

- If the person has fever above 38 degrees - Purulence - Attend within 3 days or less - Severly inflamed tonsils - No cough or coryza

Question 41

what are the signs of hypovalemic shock

Answer 41

- confusion / anxiety, - cold - clammy skin (sympathetic nervous system turns of taps to the skin), - low BP, - high heart rate, - slow capillary refill, - greyish pallor, - oliguria, - absent bowel sounds. - Reduction in blood flow to the kidney – not the first line of defence

Question 42

what are the symptoms of patients with cardiogenic shock

Answer 42

present with the constellation of symptoms of acute cardiac ischemia - chest pain - shortness of breath - diaphoresis - nausea - vomiting Patients experiencing cardiogenic shock also may present with pulmonary edema, acute circulatory collapse, and presyncopal or syncopal symptoms.

Question 43

what are the signs of cardiogenic shock

Answer 43

ECG shows the pattern of AMI or acute coronary insufficiency Systolic BP < 80 mm Hg * Pulse rate is 100 per min or faster The urinary output is low, 30 ml or less per hour There are clinical signs of peripheral circulatory collapse

Question 44

what are the symptoms of septic (distributive shock)

Answer 44

- low BP - tachycardia - fever - this could be absent in elderly or immunosuppressed patients - chills - rigors - fatigue - malaise - nausea - vomiting - difficulty breathing - anxiety - confusion

Question 45

what are the signs of obstructive shock

Answer 45

- tachycardia and anxiety of hypovolemic shock are present. - chest pain - breath sounds are absent on the affected hemiothorax - the trachea deviates away from the affected side. - A pulmonary embolism* (PE) can cause obstructive shock.

Question 46

what are the clinical symptoms of hypovolaemic shock

Answer 46

* Tachycardia, * Pale, Shut down * Sweaty, Clammy * Oliguria * Confusion

Question 47

what are the symptoms of sepsis

Answer 47

- Temp > 38oC or < 36oC - HR > 90 bpm - RR > 20 bpm or PaCO2 < 32 mmHg - WBC > 12 x 109/L, or >10% band form

Question 48

what are the clinical signs for ischemic myocardial injury

Answer 48

``` – Chest pain – 4th heart sound – Low grade fever – Leucocytosis and raised inflammatory markers (ESR, CRP) – Troponin leak ```

Question 49

what is the drug treatment for an NSTEMI

Answer 49

- Aspirin and ticagrelor - ± GP IIb/IIIa inhibitor - Fondaparinux (factor Xa inhibitor) - Anti-ischaemic drugs (BB, nitrates) - Angiography ± PCI within 24-96 hrs

Question 50

how do you work out - vital capacity - end respiratory volume - total lung capacity - inspiratory capacity - functional residual volume - expiratory reserve volume

Answer 50

- vital capacity = is calculated by adding the inspiratory reserve volume, the tidal volume and the expiratory reserve volume (IRV + VT + ERV) - end respiratory volume = measured, total lung capacity (TLC) - total lung capacity = is calculated by adding the inspiratory reserve volume, the tidal volume, the expiratory reserve volume and the residual volume (IRV + VT + ERV + RV) - inspiratory capacity = is calculated by adding the tidal volume and the inspiratory reserve volume (VT + IRV) - functional residual volume = FRC) is calculated by adding the expiratory reserve volume and the residual volume (ERV + RV) - expiratory reserve volume = (ERV) is a measured value and cannot be calculated

Question 51

what are the clinical findings of aortic stenosis

Answer 51

- dyspnoea - increase in diastolic pressure in stiff non-compliant LV * Angina - increase in O2 demand of hypertrophied LV, thickened aortic valve as the ventricles have to generate more pressure to push blood through the valve thus is hypertrophied and it needs oxygen which the coronary cannot deliver, patietns are often quite old as have coronary disease so reduced oxygen levels * Syncope - either paroxysmal ventricular arrhythmias or exertional cerebral hypoperfusion, if you have aortic stenosis and you black out this is a serious sign, due to hypotension heart cannot increase blood around body * LVF - contractile failure as ventricle dilates * Sudden death - ventricular arrhythmias

Question 52

what are the signs of aortic stenosis

Answer 52

Slow rising carotid pulse S4 ± ejection click Ejection systolic murmur

Question 53

what are the clinical signs of aortic regurgitation

Answer 53

* Rapidly rising carotid pulse - vigorous ejection of volume loaded LV * Early diastolic murmur - aortic backflow (left sternal edge) * Ejection murmur - turbulent ejection from volume loaded LV (left sternal edge)

Question 54

what are the symptoms of mitral stenosis

Answer 54

Dyspnoea, orthopnoea - increased left atrial pressure RV failure- passive consequence of increased left atrial pressure and reactive pulmonary vasoconstriction Palpitations atrial fibrillation Systemic emboli - static blood within dilated fibrillating left atrium predisposes to thrombosis

Question 55

what are the signs of mitral stenosis

Answer 55

Pulse - AF Auscultation (heart)- loud S1, opening snap, mid-diastolic rumble, ± pre-systolic murmur (SR only) Volume overload - increased JVP, basal creps, ankle oedema

Question 56

what are the signs of mitral regurgitation

Answer 56

Pulse - SR/AF Auscultation (heart) - Pansystolic murmur S3 Volume overload -increased JVP, basal creps, ankle oedema

Question 57

what are the signs of lacunar strokes

Answer 57

- Well defined deficits are present but cortical infarct signs (such as aphasia, neglect, and visual field defects) are always absent

Question 58

how do you treat atrial fibrillation thus lowering the risk of stroke

Answer 58

Give Aspirin for healthy patients < 65 years Give Warfarin for patients > 65 years or having other stroke risk factors

Question 59

describe hypersensitivity type 1

Answer 59

- Mast cell activation. - Release of mediators: Histamine, leukotrienes (& prostaglandins). - IgE mediated

Question 60

describe the differnet types of hypersenstivity

Answer 60

type 1 - IgE and mast cells - allergies, astham type 2 - IgG and IgM and complement, graves, rheumatic fever type 3 - IgG - complement - neutrophils - e.g. lupus type 4 - t cells - e..g tb, hasmitos thyroditis, coeliacs type 5 - autoimmune, IgG, IgM - graves and myansthesia gravis

Question 61

what are the common causes of type 1 respiratory failure

Answer 61

 Ventilation/Perfusion (V/Q) mismatch  Shunting of blood across lungs  Poor gas exchange (alveoli filled with fluid eg in pneumonia)  Decreased minute ventilation (MV) relative to demand  Increased dead space ventilation (less gas to alveoli)

Question 62

name 4 things that can happen when NO is impaired

Answer 62

1. Vasoconstriction (e.g., coronary vasospasm, elevated systemic vascular resistance, hypertension) 2. Thrombosis due to platelet aggregation and adhesion to vascular endothelium 3. Inflammation due to upregulation of leukocyte and endothelial adhesion molecules 4. Vascular hypertrophy and stenosis

Question 63

what is the VO2

Answer 63

the rate of oxygen uptake by skeletal muscle

Question 64

How do you work out MCV

Answer 64

haematocrit/ red cell count

Question 65

Why is vitamin C given in order to help iron absorption

Answer 65

Iron can only be absorbed as the ferrous ion (1 mark). Vitamin C is a reducing agent and will reduce dietary ferric iron to ferrous iron to improve absorption (1 mark)

Question 66

what can cause a D dimer test other than a clot

Answer 66

Increased fibrin formation may be caused by VTE but also by cancer, infection, inflammation, post-op, pregnancy ( 1 mark)

Question 67

PE symtpoms

Answer 67

= chest pain pleuripotic - dyspnea - shortness of breath

Question 68

what is a tuberculin

Answer 68

Tuberculin is the name given to purified protein derivative (1/2 mark) (PPD) extracts of Mycobacterium tuberculosis, M. bovis, or M. avium (1/2 mark any one)

Question 69

2) Name two consequences of hyperthyroidism on glucose metabolism. [2 marks]

Answer 69

Hyperthyroidism leads to Insulin resistance [1], mainly associated with increased hepatic gluconeogenesis [1].

Question 70

Explain why the thyroid gland is enlarged in Hashimoto thyroiditis

Answer 70

Thyroid enlargement is induced by an inflammatory infiltrate of immunocytes that replace the parenchyma and subsequent fibrosis [1]

Question 71

explain how an insulin stress test works

Answer 71

(i) Growth hormone levels are pulsatile and almost undetectable for most of the day and so growth hormone levels are measured by their response to stimulation [1 mark] (ii) Gold standard is insulin-induced hypoglycaemia [1 mark] Blood is taken for growth hormone, cortisol and glucose and then fast-acting insulin is injected intravenously. Blood is taken again for growth hormone, cortisol and glucose after 30, 45, 60, 90 and 120 minutes. [1mark]

Question 72

What is NSILA and which hormone accounts for it? [2 marks]

Answer 72

NSILA: nonsuppressible insulin-like activity. [1 mark] | The insulin-like biological effects of IGFs accounts for NSILA [1 mark]

Question 73

Left sided heart failure causes...

Answer 73

Pulmonary oedema whereas right sided heart failure causes peripherla oedema