CR2 EOY2 (+ 7Qs at the end)

Question 1

which ligament connect the hyoid bone and thyroid? - what is this covered by?

which ligament connects the cricoid and thyroid cartilage?

where does ithe internal laryngeal nerve and superior laryngeal artery enter larnyx?

Answer 1

Hyoid bone and thyroid are joined by thyrohyoid ligament, covered by a thyrohyoid membrane.

Internal laryngeal nerve and superior laryngeal artery come through this ligament/membrane

Between the cricoid and thyroid cartilages: Crico-thyroid ligament

Question 2

Answer 2

Question 3

which nerve controls most of the muscles of larynx? - which muscle does it not innervate?

Answer 3

most motor to muscles controlled by the recurrent laryngeal nerve - PHONATION
sensory innervation to area below vocal cords

doesnt innervate motor control for cricothyroid (comes from superior laryngeal nerve)

Question 4

The larynx lies in which vertebral layers? [1]

Answer 4

C3-C6

Question 5

What does the cricoid cartilage attach to:
Anteriorly?
Posteriorly?

Answer 5

Anteriorly: Cricothyroid membrane
Posteriorly: Inferior horns of thyroid cartilage + paired arytenoid cartilages

Question 6

The vocal cords attach posteriorly to which of the following?

Cricoid cartilage
Cuneiform cartilage
Epiglottis
Arytenoid cartilage
Thyroid cartilage

Answer 6

The vocal cords attach posteriorly to which of the following?

Cricoid cartilage
Cuneiform cartilage
Epiglottis
Arytenoid cartilages
Thyroid cartilage

Question 7

What is the sensory innervation to all muscles below the vocal cords? [1]
What is the sensory innervation to all muscles above the vocal cords? [1]

What is the motor innervation to all muscles of the larynx except for the cricothryroid? [1]

What is the motor innervation for the cricothryroid? [1]

Answer 7

What is the sensory innervation to all muscles below the vocal cords? [1]
Recurrent laryngeal nerve

What is the sensory innervation to all muscles above the vocal cords? [1]
Internal laryngeal nerve

What is the motor innervation to all muscles of the larynx except for the cricothryroid? [1]
Recurrent laryngeal nerve

What is the motor innervation for the cricothryroid? [1]
External laryngeal nerve

Question 8

What are the effects of superior, internal and external branch palsies? [A&B]

Answer 8

A: reduced gag reflex
B: reduced range of pitch

Question 9

Palsy to which nerve causes reduced gag reflex?

Superior laryngeal nerve, external branch
Superior laryngeal nerve, internal branch
Recurrent layngeal nerve, bilateral damage
Recurrent layngeal nerve, unilateral damage

Answer 9

Palsy to which nerve causes reduced gag reflex?

Superior laryngeal nerve, internal branch

Question 10

Palsy to which nerve causes reduced range of pitch?

Superior laryngeal nerve, external branch
Superior laryngeal nerve, internal branch
Recurrent layngeal nerve, bilateral damage
Recurrent layngeal nerve, unilateral damage

Answer 10

Palsy to which nerve causes reduced range of pitch?

Superior laryngeal nerve, external branch
Superior laryngeal nerve, internal branch
Recurrent layngeal nerve, bilateral damage
Recurrent layngeal nerve, unilateral damage

Question 11

Palsy to which nerve causes horseness of voice?

Superior laryngeal nerve, external branch
Superior laryngeal nerve, internal branch
Recurrent layngeal nerve, bilateral damage
Recurrent layngeal nerve, unilateral damage

Answer 11

Palsy to which nerve causes horseness of voice?

Superior laryngeal nerve, external branch
Superior laryngeal nerve, internal branch
Recurrent layngeal nerve, bilateral damage
Recurrent layngeal nerve, unilateral damage

Question 12

Palsy to which nerve causes loss of phonation?

Superior laryngeal nerve, external branch
Superior laryngeal nerve, internal branch
Recurrent layngeal nerve, bilateral damage
Recurrent layngeal nerve, unilateral damage

Answer 12

Palsy to which nerve causes loss of phonation?

Superior laryngeal nerve, external branch
Superior laryngeal nerve, internal branch
Recurrent layngeal nerve, bilateral damage
Recurrent layngeal nerve, unilateral damage

Question 13

How do you calculate forced vital capacity? [1]

Answer 13

Forced vital capacity (maximum volume of air air forcibly exhaled out of your lungs after a deep full breath) = Inspiratory reserve volime + tidal volume + expiratory reserve volume

Question 14

Explain what DCLO measures [1]

How do you calculate DCLO? [1]

What is a normal DLCO value? [1]

Answer 14

DCLO: a measurement to assess the ability of the lungs to transfer gas from inspired air to the bloodstream. Carbon monoxide has a high affinity for hemoglobin, and it follows the same pathway as that of oxygen to finally bind with hemoglobin. Inhaled carbon monoxide is used for this test due to its high affinity for hemoglobin (200-250 times that of oxygen).

above 75 % of predicted value

Question 15

Why is DCLO raised in asthma Ptx?

Answer 15

Expiration is decreased, so air is trapped in the lungs.

Have a lot of blood vessel recruitment

Question 16

Name 3 & explain 3 excercise tests

Answer 16

Assess pre-operative fitness/fitness state/extent of breathlessness/benefit of oxygen therapy

Question 17

Briefly explain how the immediate energy system works
Enzyme name? [1]

Answer 17

Decomposition of phosphocreatine releases high amounts of energy which can generate ATP. This energy transfer occurs within a fraction of a second

Enzyme: creatine kinase

Question 18

How do you calculate VO2? [1]
What is the name of the equation? [1]

Answer 18

Fick equation:

VO2 = Q x (CaO2-CvO2)

Qis thecardiac outputof the heart (blood flow to muscle)
CaO2is the arterial oxygen content
CvO2is the venous oxygen content
(CaO2– CvO2) is also known as thearteriovenous oxygen difference.

Question 19

What is VO2 max?

When do you reach VO2 max?

Answer 19

VO2 max: is the highest peak oxygen uptake that an individual can obtain during dynamic exercise using large muscle groups during a few minutes performed under normal conditions at sea level

VO2 max is reached when: O2 consumption remains at steady state despite and increase in workload

Question 20

Explain how increase muscle blood flow occurs during exercise [Local control & Systemic control?]

I.e. which molecules are the mediators of local vasodilation [7] and what conditions does this occur at [1]

Name the two ways that systemic regulation of vasodilation occurs [2]

Answer 20

Regional muscle vasodilation achieved by:

Local control:
* Vasoactive substrates and products of muscle metabolism (CO2, Lactate, K+)
* Muscle hypoxia
* Vasoactive mediators released by the endothelium (Nitric Oxide, ATP, Adenosine and prostaglandins)

Systemic regulation:
* Adrenergic receptor activation (β2R –> Vasodilation)

AND

Vasoconstriction of other vascular beds which redirects blood flow

Question 21

Explain how cardiac output is increased during exercise? [2]

What is relationship between HR and SV as they both increase? [1]

Answer 21

Achieved by increasing HR and SV.
- HR increase due to: more adrenaline on B1 adrenoreceptors AND decrease parasympathetic NS.
- SV: increase preload, decrease afterload, and increase contractility

However! SV starts to drop after a while: as HR increases, diastolic time decreases, so get reduced blood out.

Question 22

What are the increases in sympathetic outflow that occur due to exercise that contribute to increased skeletal and cardiac muscle blood flow ? [3]

What are the local responses that occur due to exercise? [1]

Answer 22

Sympathetic:
- Increase HR: increased CO
- Constriction of aterioles (splachnic and renal)
- Constrictio of veins: increase in venous return

Local response:
- Increase in vasodilator metabolites: decrease in SVR

AND

Decreased parasympathetic output

Question 23

If during exercise SVR / Total peripheral resistance decreases, how come systolic BP increases? [1]

Answer 23

SVR reduces, but SV and MAP increases. CO increases in greater magnitude than TPR decreases

Question 24

What is resting CO like in atheletes vs non atheletes? Explain your answer

Answer 24

Resting CO in athletes is identical to non-athletes due an increased resting stroke volume and a compensatory bradycardia. They have a increased resting end diastolic volume (EDV) and therefore SV.

Question 25

How do blood gas differences in arteries / veins effect oxygen diffusion in exercise?

Answer 25

Get increased difference in AV gradient: drives oyxgen diffusion into cells

Question 26

What happens to the levels of paO2 in arterial blood during high levels of exercise?

Answer 26

At high levelss of exercise the paO2 in the arterial blood declines slightly

Question 27

During exercise, changes in autonomic factors (inhibition of parasympathetic and increase in sympathetic) are controlled by WHAT?

Answer 27

Central command: area in brain that mediates autonomic responses (increase in sympathetic / decrease in parasympathetic) to exercise.

Happens at same time as brain tells muscles to move: e.g. The increase in heart rate, even within the first beat, is proportional to the force developed

Once begun, chemical and metabolic tweaks to the system: chemoreceptors, baroreceptors

Question 28

How is resp. response regulated when initiating exercise?

Answer 28

Central command:generates autonomic signals: increase stimulation in excercising skeletal muscle, increase in resp muscles.

• Happens before CO2 / 02 changes = why there’s a need for neuronal changes driving this

CO2 chemoreception contributes to driving ventilation

Question 29

Clara cells have which three functions? [3]

Answer 29

• They produce one of the components of surfactant.
• They act as stem cells, i.e. they are able to divide,
  differentiate and replace other damaged cell types.
• They contain enzyme systems which can detoxify noxious substances

Question 30

What would DCLO be expected to be in COPD & asthma patients?

DCLO reduced in COPD & asthma patients
DCLO reduced in COPD but raised in asthma patients
DCLO reduced in asthma but raised in COPD patients
DCLO raised in COPD and asthma patients

Answer 30

What would DCLO be expected to be in COPD & asthma patients?

DCLO reduced in COPD & asthma patients
DCLO reduced in COPD but raised in asthma patients

Low KCO: seen in COPD with emphysema due to alveolar destruction (usually normal in chronic bronchitis) with an obstructive pattern on PFT.

DCLO reduced in asthma but raised in COPD patients
DCLO raised in COPD and asthma patients

Question 31

A 69-year-old male presents with pleuritic chest pain and shortness of breath. He is normally fit and well. On examination, he is alert, orientated and conversing with you. He is febrile (38.4) and tachycardic (105bpm) but other observations are within normal limits. A chest x-ray demonstrates left lower zone consolidation.

Blood tests are as follows:

Urea: 8mmol/L
Creatinine: 115 µmol/l
WCC: 13 10^9/l
Hb: 130 g/l
An ECG is performed showing sinus rhythm with some ventricular ectopics.

A diagnosis of community-acquired pneumonia is made.

What is this patient’s CURB-65 score?

3
2
4
1
5

Answer 31

2

CURB-65 is a scoring system used to grade the severity of pneumonia:

Confusion
Urea > 7
Respiratory rate ≥ 30
Blood pressure <90mmHg systolic or ≤60mmHg diastolic
Aged ≥ 65 years old

Question 32

Which of the following is the correct name for the piece of equipment shown in the image?

Nasal cannulae
Venturi mask
Nasopharyngeal airway
Reservoir mask
Hudson mask

Answer 32

Which of the following is the correct name for the piece of equipment shown in the image?

Nasal cannulae
Venturi mask
Nasopharyngeal airway
Reservoir mask
Hudson mask

Question 33

Which of the following treatments of pneumonia causes toxic optic neuropathy?

Rifampicin
Isoniazid
Ethambutol
Pyrazinamide

Answer 33

Which of the following treatments of pneumonia causes toxic optic neuropathy?

Rifampicin
Isoniazid
Ethambutol
Pyrazinamide

Question 34

An 82-year-old lady presents to the hospital with a fever and confusion.

A CXR is performed showing a right-sided basal pneumonia. Her blood tests reveal a urea of 12mmol/L. Her observations are shown below:

Oxygen saturation 94% on air
Heart rate 120 bpm
Blood pressure 110/57 mmHg
Respiratory rate 28 breaths per minute
Temperature 38.1oC
What is her CURB 65 score?

2
3
5
4
1

Answer 34

An 82-year-old lady presents to the hospital with a fever and confusion.

A CXR is performed showing a right-sided basal pneumonia. Her blood tests reveal a urea of 12mmol/L. Her observations are shown below:

Oxygen saturation 94% on air
Heart rate 120 bpm
Blood pressure 110/57 mmHg
Respiratory rate 28 breaths per minute
Temperature 38.1oC
What is her CURB 65 score?

2
3
5
4
1
She would score for confusion, urea, diastolic blood pressure and age, bringing her total score to 4.

Question 35

A 36-year-old Norwegian female presents with a 4-month history of gradually progressive shortness of breath, a non-productive cough and fatigue. She also reports painful red lesions on her shins. She has no significant medical/surgical history and is on no regular medications. She has no family history of note. She is a non-smoker and non-drinker. She is married and works as a classroom assistant. Her review of systems is otherwise unremarkable.

She is afebrile and her vital signs are within normal limits. Respiratory examination is normal. On inspection of the lower limbs, there are tender erythematous nodules on the anterior aspects of her lower legs bilaterally.

Given the most likely underlying diagnosis, what is the most likely cause of the skin lesions on her lower limbs?

Necrobiosis lipoidica
Pyoderma gangrenosum
Acanthosis nigricans
Erythema multiforme
Erythema nodosum

Answer 35

Erythema nodosum

The most likely underlying diagnosis is sarcoidosis, given this patient’s Scandinavian ancestry, age, female gender and constellation of non-specific symptoms and signs. Erythema nodosum (painful, blue-red nodules most commonly affecting the shins) is associated with sarcoidosis. Other causes of erythema nodosum include TB, streptococci and certain drugs (eg. sulfonamides, dapsone, COCP).

Question 36

A 78-year-old male presents for evaluation of unexplained weight gain in the last few days. For the past four months, the patient reports drenching night sweats and dysphagia with an associated unexplained weight loss. However, he now has rapid weight gain and is concerned because he feels like he is “blowing up like a balloon.” His vital signs reveal a temperature of 38.5 degrees Celcius, a pulse of 60/min, blood pressure of 140/90/min, and respirations of 15/min. On physical examination, generalized lymphadenopathy is noted. The left supraclavicular node is distinctly palpable. Based on the patient’s findings, what pattern of edema would be seen?

A. Entire right side and left leg
B. Entire left side and right leg
C. Left arm only
D. Right arm only

Answer 36

A 78-year-old male presents for evaluation of unexplained weight gain in the last few days. For the past four months, the patient reports drenching night sweats and dysphagia with an associated unexplained weight loss. However, he now has rapid weight gain and is concerned because he feels like he is “blowing up like a balloon.” His vital signs reveal a temperature of 38.5 degrees Celcius, a pulse of 60/min, blood pressure of 140/90/min, and respirations of 15/min. On physical examination, generalized lymphadenopathy is noted. The left supraclavicular node is distinctly palpable. Based on the patient’s findings, what pattern of edema would be seen?

A. Entire right side and left leg
B. Entire left side and right leg
C. Left arm only
D. Right arm only

Question 37

Which of the following is not part of Weldeyer ring?

Pharyngeal
Tubal
Lingual
Tonsular
Palatine

Answer 37

Which of the following is not part of Weldeyer ring?

Pharyngeal
Tubal
Lingual
Tonsular
Palatine

Question 38

A 12-year-old male presents to the emergency department with a chief-complaint of wheezing, flushing, and a full-body rash after consuming a brownie at school. The patient has a history of peanut allergy and was not aware that peanut butter was one of the ingredients in the brownie. What is the patient currently experiencing?

A. Type I hypersensitivity reaction that involves IgG, IgM, and sometimes IgA antibodies.
B. Type II hypersensitivity reaction that involves immunoglobulin E antibodies.
C. Type I hypersensitivity reaction that involves immunoglobulin E antibodies.
D. Type IV hypersensitivity reaction that involves IgG, IgM, and sometimes IgA antibodies.

Answer 38

A 12-year-old male presents to the emergency department with a chief-complaint of wheezing, flushing, and a full-body rash after consuming a brownie at school. The patient has a history of peanut allergy and was not aware that peanut butter was one of the ingredients in the brownie. What is the patient currently experiencing?

A. Type I hypersensitivity reaction that involves IgG, IgM, and sometimes IgA antibodies.
B. Type II hypersensitivity reaction that involves immunoglobulin E antibodies.
C. Type I hypersensitivity reaction that involves immunoglobulin E antibodies.
D. Type IV hypersensitivity reaction that involves IgG, IgM, and sometimes IgA antibodies.

Question 39

An 18-year-old female underwent endotracheal intubation for an emergent appendectomy. Post-procedure, the patient developed aphonia. Which of the following represents the site of injury of the most likely nerve involved?

A. At the level of the oropharynx
B. Between the cricoid and thyroid cartilage
C. At the level of the epiglottic fold
D. In between the thyroid and parathyroid gland

Answer 39

An 18-year-old female underwent endotracheal intubation for an emergent appendectomy. Post-procedure, the patient developed aphonia. Which of the following represents the site of injury of the most likely nerve involved?

A. At the level of the oropharynx
B. Between the cricoid and thyroid cartilage : RLN
C. At the level of the epiglottic fold
D. In between the thyroid and parathyroid gland

Question 40

This would cause which type of shock?

Hypovolaemic
Cardiogenic
Distributive
Obstructive

Answer 40

This would cause which type of shock?

Hypovolaemic
Cardiogenic
Distributive loss of sympathetic tone and thus unopposed parasympathetic response driven by the vagus nerve. Consequently, patients suffer from instability in blood pressure,
Obstructive

Question 41

Which is not a good indicator of shock?

• Reduced urine output
• Reduced pH
• Reduced BP
• Confusion

Answer 41

Which is not a good indicator of shock?

• Reduced urine output
• Reduced pH
  - Reduced BP: retained till the end via comp. mechanisms
• Confusion