Question 1

Describe the pathway of the L and R Phrenic Nerves?

Accepted Answer

Both descend with internal jugular vein across ANT scalene muscles. R then goes to R brachiocephalic vein and SVC post to subclavian vein and passes ANT to lung root along r pericardium and right side of IVC then goes through T8. L goes l side of subclavian artery then crosses aortic arch goes over root of the lung and goes over pericardial surface then pierces the central tendon in isolation

Question 2

what are the 3 openings in the diaphragm and what structures pass through each?

Accepted Answer

T8- Vena cava - right phrenic nerve, - passes through central tendon so when intra abdo pressure rises does not get cut off. T10- oesophageal - L gastric a and 2 vagal trunks T12 - Aorta thoracic duct and azygos vein

Question 3

Where is pericardiocentesis needle inserted and why?

Accepted Answer

4th and 5th iCs left sternal border - no pleura cover heart at these ends

Question 4

what are the relations of structures in the root of the lung?

Accepted Answer

Pulmonary a = sup Pulmonary vein = inf bronchus = post (bronchial vessels immediately surround it)

Question 5

how do L lung and R lung compare in terms of size?

Accepted Answer

R lung has a higher volume, total capacity and weight despite being 5cm shorter due to liver

Question 6

How many cartilages in larynx? what level is the larynx?

Accepted Answer

9 and C3 to C6.

Question 7

where do the arytenoids attach? what shape are they? what do they do?

Accepted Answer

Attach to LAT aspect of superior border of cricoid cartilage. Are pyramidal shaped. Are essential to the controlled relaxing and tensing and positioning of the vocal cords.

Question 8

what cartilage sits ontop of the arytenoid?

Accepted Answer

cuneiform cartilage.

Question 9

what is the only bone in the body that does not attach to any other bone?

Accepted Answer

hyoid bone

Question 10

what is the free inferior margin of the quadrangular membrane ?

Accepted Answer

vestibular folds

Question 11

where do the vocal folds attach?

Accepted Answer

anteriorly at angle of thyroid cartilage and posteriorly at vocal processes of arytenoid cartilage

Question 12

what is tracheal tug? whats it indicative of?

Accepted Answer

movement of trachea and thryoid cartilage inferiorly - aneurysm at aortic arch - pushes down on left bronchus

Question 13

what is widening, blunting or discolouration of the cartilage at the carina indicate?

Accepted Answer

carcinoma of tracheobronchial lymph nodes

Question 14

how many bronchopulmonary segments in right and left lung?

Accepted Answer

Right = 10 Left = 8-10

Question 15

describe the lymphatics of the lung?

Accepted Answer

Deep plexuses - Intrinsic pulmonary lymph nodes found along lobar bronchi - hilum - bronchiopulmonary nodes- sup and inf tracheobronchial nodes (above or below carina) - R and L bronchimediastinal trunks

Question 16

Where is chest drain inserted?

Accepted Answer

4-5ICS ant to mid axillary line "safe triangle"

Question 17

What is the aetiology of pleural effusions?

Accepted Answer

transudates = PE, mitral stenosis Increased venous pressure = HF, Fluid overload, constrictive pericarditis Hypoproteinaemia = cirrhosis, nephrotic syndrome, malabsorption Exudates = Increased leakiness of capillaries due to infection, malignancy or inflammation - causes TB, pneumonia, Pe, RA, SLE, lymphoma, mesothelioma, Dresslers syndrome Chylothorax= neoplasm(lymphoma), trauma, TB, sarcoidosis, amyloidosis, cirrhosis

Question 18

Whats yellow nail syndrome?

Accepted Answer

sign of exudative pleural effusion and is 4 things yellow nails, lymphoedema, pleural effusion, bronchiectasis.

Question 19

Name 2 symptoms of pleural effusion? 6 signs?

Accepted Answer

dysopnoea, pleuritic chest pain signs - decreased expansion, strong dull percussion note, decreased breath sounds on affected side, tactile vocal fremitus and vocal resonance are decreased, tracheal deviation (away from affected side)

Question 20

what muscle controls entry to the oesophagus?

Accepted Answer

cricopharyngeus muscle - UES

Question 21

What is the circular ring of lymphatics in the pharynx called?

Accepted Answer

Waldeyers ring

Question 22

How does the cricothyroid muscle change the pitch of the voice?

Accepted Answer

changes tension in vocal folds by increasing its length

Question 23

What is the nerve supply to the muscles of the larynx?

Accepted Answer

All are supplied by recurrent laryngeal nerve except the cricothyroid which is supplied by the superior laryngeal nerve. sensory - above vocal folds = sup laryngeal nerve below = recurrent laryngeal nerve

Question 24

Where do the different paranasal sinuses drain to? What is the cavity called that recieves frontal and maxillary sinus ducts and sometimes ethmoidal air sinuses?

Accepted Answer

ethmoidal - above and below middle conchae frontal - small thin frontal nasal duct - goes inf and post - middle conchae maxillary - hole in upper post medial wall - middle conchae sphenoid air sinus - above superior conchae in sphenoethmoifal recess and cavity = infundibulum

Question 25

What structures are found in the ant, middle and post mediastinum?

Accepted Answer

ANT = thymus fat, lymphatics Mid = heart aorta, trachea, main bronchi, lymph nodes POST -= descending aorta, esophagus, azygous vein, thoracic duct

Question 26

Give 3 ANT 3 middle and 3 POST mediastinal masses?

Accepted Answer

ANT = thyroid gland, Thymoma(tumour of thymus associated with myasthenia gravis) and Lymphoma MID= aneurysm, bronchogenic cyst, lymphoma POST = Neurilemoma, neurofibroma and schwann cell tumour

Question 27

Name 3 things a pancoast tumour can cause?

Accepted Answer

Horners syndrome, Lower brachial plexus injury = Klumpkes palsy - claw hand, sensory loss on ulnar side. Paraesthesia to upper extremity due to compression of subclavian artery and vein.

Question 28

Give 10 symptoms of lung cancer?

Accepted Answer

cough (80%), haemoptysis (70%), Dyspnoea (60%), Chest pain (40%), Lethargy, anorexia, weight loss, wheeze, stridor, lobar collapse

Question 29

name 4 common places for lung metastasis and signs of each?

Accepted Answer

brain - headache, fits, cervical lymphadenopathy Liver - jaundice, weight loss, hepatomegaly Adrenal deposits Bone - pain pathological fractures

Question 30

what are 2 types of lung resection?

Accepted Answer

bilbectomy - remove 2 lobes of R lung Pneumonectomy - remove whole lung

Question 31

7 risk factors for TB?

Accepted Answer

Close contact with TB patients, ethnic minority groups, homeless, alcoholics, HIV, elderly, kids

Question 32

Aetiology of TB?

Accepted Answer

M. tuberculosis, M.bovis, M.Africanum spread by inhalation of infected droplets (coughing)

Question 33

describe the pathology of TB? whats a Ghon focus? Whats a Ghon complex?

Accepted Answer

1 infection - macrophages in lung engulf and carry to hilar nodes to try control infection - sometimes it spreads to distant sites via lymphatics/blood. small granulomas/tubercles form around bacteria and contain them. These may heal and bacteria eliminated - occurs in 80% of cases. Or can remain dormant as are encapsulated and then revert to active TB - 2 TB Miliary TB - is if 1 infection is not controlled and invades bloodstream Ghon focus = 1 lesion usually subpleural,- classically around fissures Ghon complex = lesion caused by TB and associated infected lymph node

Question 34

How does TB present? 18 symptoms?

Accepted Answer

general symptoms - fatigue, malaise, fever, weight loss, anorexia, pyrexia of unknown origin (PUO) pulmonary - chronic productive cough - purulent -/+ blood stained, pleural effusion, pneumonia, bronchiectasis GU- most common extrapulmonary site - sterile pyuria, epididymitis, salpingitis, Loin pain, haematuria. MSK TB - potts disease, arthritis, osteomyelitis CNS TB - meningitis Skin TB - lupus vulgaris - jelly like nodules on face or neck peritoneal TB - abdo pain, ascites pericarditis

Question 35

4 DD for Tb?

Accepted Answer

lymphoma, pneumonia, fibrotic lung disease (sarcoidosis, pneumoconiosis), diabetes

Question 36

in whom is extrapulmonary TB more common?

Accepted Answer

kids and immunocompromised

Question 37

Name 11 tests for TB?

Accepted Answer

CXR - 1 TB - pleural effusion, reactivated TB - lesion in apical lung, consolidation or cavitation of apex, millet seeds over chest (=miliary TB) normal=unlikely to be pulmonary TB. sputum - MC&S for Acid fast bacilli - bronchoscopy if can't obtain. Pleural effusion, pus, ascites, CSF, urine culture. Histology (-caseating granulomatas = hallmark) Tuberculin skin test (mantoux) to diagnose latent TB in contact tracing - may indicate immunity or vaccination. interferon gamma testing recommended if positive skin test. Bronchoscopy washout - inject saline into lungs then suck it back out.

Question 38

Tx of TB?

Accepted Answer

contact tracing and public health notification. Initial phase - 2 months on 4 drugs (rifampicin, isoniazid, pyrazinamide - hepatitis, ethambutol - can cause ocular toxicity - check vision). Then continuation phase - 4 months on 2 drugs (rifampicin, isoniazid) For latent TB - 6 months of continuation phase BCG offered to high risk individuals

Question 39

what is prevalence of MDRTB?

Accepted Answer

10%

Question 40

define pulmonary Htn?

Accepted Answer

PAP over 25 at rest or over 30mmHG on exercise

Question 41

what is atopy?

Accepted Answer

inherited predisposition to develop allergic disease

Question 42

What 2 other things do nasal polyps coexist with?

Accepted Answer

asthma and aspirin sensitivity

Question 43

Name 2 important tests that are essential in diagnosis of TB?

Accepted Answer

Auramine staining Ziehl Neelson staining - used to identify fast acid organisms(contain large amounts of mycolic acids in their walls) all 3 TB organisms are fast acid. If ziehl Neelson is + they are highly infectious

Question 44

what 3 things are common in TB?

Accepted Answer

weight loss, fever and night sweats

Question 45

does lung cancer have a higher incidence in men?

Accepted Answer

yes

Question 46

where does the superior laryngeal nerve branch from?

Accepted Answer

from main trunk of vagus and supplies general sensation to superior vocal fold tissue, cricothyroid and inf constrictor muscles

Question 47

describe the path of the recurrent laryngeal nerve?

Accepted Answer

R RLN branches from vagus at T1-T2 travels lost and inf to subclavian artery then ascends in neck between trachea and eosophagus behind right common carotid artery. L RLN - branches from L vagus in thorax travels inf and post to aortic arch and ascends in neck between trachea and esophagus

Question 48

give 10 causes of haemoptysis?

Accepted Answer

bronchiectasis, TB, pneumonia, PE, bronchial carcinoma, met from breast, melanoma, aspergilloma/invasive fungal disease, lung abscess and heart failure.

Question 49

4 causes of massive haemoptysis?

Accepted Answer

bronchiectasis, TB, aspergilloma, tumours, abscess

Question 50

If CXR is clear, small haemoptysis and increasing SOB and low sats what would u do?

Accepted Answer

V/Q scan for PE (ctpa is more appropiate if suspect pe)

Question 51

What are 5 causes of dementia?

Accepted Answer

Alzheimers disease = commonest cause in over 35 years Vascular dementia (cumulative effects of many small strokes) = 25% of dementia - 2nd most common cause Lewy body dementia = 3 rd commonest cause Frontotemporal (pick's) dementia - 5% Others - alcohol, repeated head trauma, pellegra, Huntingtons, parkinsons - 5%

Question 52

investigations in dementia? 12 ?

Accepted Answer

FBC, ESR, U+E, Ca, LFT, TSH, B12/Folate, Syphilis serology, CT/MRI, ECG, CSF, HIV test.

Question 53

What the features of vascular dementia?

Accepted Answer

pathological emotionism - more stressed when cant perform tasks - extremes of emotion. Sudden onset, stepwise deterioration - rapid deterioration followed by periods of gradual improvement.

Question 54

what are the features of lewy body dementia?

Accepted Answer

fluctuating cognitive impairment (dyspraxia and dysexecutive problems) detailed visual hallucinations and later parkinsonism. If it can't be work out what it is as its an usual case of dementia then its DLB. abnormalities of attention and arousal - falling asleep suddenly. Delusions.

Question 55

Do u have intact long term memory with korsakoff's ?

Accepted Answer

yes but can't remember anything thereafter

Question 56

What 2 tests do you do with alzheimers?

Accepted Answer

MRI - investigation of choice to exclude other cerebral pathology HMPAO SPECT - differentiate Alzheimers from other dementias.

Question 57

How does Alzheimers present?

Accepted Answer

Early - Memory lapses, forgetting names/places, difficulty finding words, inability to remember recent events. As progresses - difficulties with language, apraxia, confusion, problems planning. Later - wandering disorientation, apathy, aggression, agitation, incontinence, hallucinations, delusions.

Question 58

Describe the management of Alzheimers?

Accepted Answer

conservative - memory enhancement strategies - notes, lists cognitive stimulation programmes, cognitive behavioural therapy, exercise, animal assisted therapy, therapeutic music. Pharmacological - in all mild- moderate - Acetylcholinesterase inhibitors - Rivastigmine, donepezil - start low go slow. NMDA antagonist - Memantine - moderate to severe alzheimers. BP control

Question 59

How many years beforehand can changes in CSF amyloid beta be seen? And CSF tau protein and brain atrophy?

Accepted Answer

25 years before onset 15 years before onset

Question 60

What is an example of reversible dementia?

Accepted Answer

normal pressure hydrocephalus - rare - impaired drainage of CSF. - accumulates in cerebral ventricles - but CSF pressure remains the same. Key symptoms are ataxic gait, insidious memory impairment, urinary incontinence.

Question 61

What is HMPAO spect?

Accepted Answer

Is a form of cerebral blood flow SPECT. Blood flow abnormalities indictate different types of dementia.

Question 62

What is aphasia ? How do u test the 2 different types?

Accepted Answer

Also called dysphasia - is complete or partial defect in language and communication. Receptive aphasia - touch your R ear with your L hand. Expressive aphasia - listen to spontaneous speech for hesistancy and word finding difficulties -- Test naming abilities

Question 63

Describe the pathophysiology in neurodegenerative disease?

Accepted Answer

1. Normally expressed protein is not folded properly - non functional - hydrophobic molecules that are normally buried in the centre of the protein are now on the surface- strong tendency to stick to cell membranes and form clumps or aggregates - Amyloid deposits - Leads to cell neuron death. misfolding occurs spotaneously throughout life and when mutations occur

Question 64

Name 2 physiological protective mechanisms against misfolded proteins?

Accepted Answer

chaperone proteins - bind to and encourage misfolded proteins to fold correctly. Ubiquitination reaction.

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