CVSR Written Exam Qs Flashcards
A 16-year-old girl in a distressed state is brought to the emergency department by her parents at 00:30am. Her breathing is rapid and shallow and she has an audible expiratory wheeze. On examination, her lips and tongue have a bluish tinge. As it is impossible to obtain an oral temperature because of her shortness of breath, an aural temperature is taken, and is 38°C. The girl’s parents say that she suffered from ‘wheezy bronchitis’ in her pre-school years and that she has some wheezing after vigorous sport and often wakes during the night with a wheeze and cough.
a) Briefly explain the pathophysiological basis of her bluish lips/tongue? (2 marks)
Disease of heart or lungs→blood leaving the left heart is not well oxygenated → Abnormal amount of deoxygenated haemoglobin (‘blue’) in superficial blood vessels→bluish tinge (centrally–in part of body with good circulation, such as tongue)
A 16-year-old girl in a distressed state is brought to the emergency department by her parents at 00:30am. Her breathing is rapid and shallow and she has an audible expiratory wheeze. On examination, her lips and tongue have a bluish tinge. As it is impossible to obtain an oral temperature because of her shortness of breath, an aural temperature is taken, and is 38°C. The girl’s parents say that she suffered from ‘wheezy bronchitis’ in her pre-school years and that she has some wheezing after vigorous sport and often wakes during the night with a wheeze and cough.
b) What is the most likely diagnosis for this girl’s condition? (1 mark)
c) Briefly explain the physiological basis of the wheeze that was heard, and why wheezing is louder in expiration. (2 marks)
d) Name three (3) different types of triggers which may have precipitated this attack. From the information provided, which one is the most likely trigger (give reasons for your choice). (5 marks)
a) Disease of heart or lungs→blood leaving the left heart is not well oxygenated → Abnormal amount of deoxygenated haemoglobin (‘blue’) in superficial blood vessels→bluish tinge (centrally–in part of body with good circulation, such as tongue)
B) Asthma
c) Wheeze–a continuous whistling noise during breathing that is heard in narrowed airways—in this case due to bronchoconstriction. When the lungs recoil in expiration, the lung mass exerts a further narrowing effect on airways.
d) Any three of
Infection OR Environmental–New allergen, cold air OR Emotion OR Non adherence or change to usual medication OR Exercise
MOST LIKELY: infectionas patient is febrile—temp 38°C
A 16-year-old girl in a distressed state is brought to the emergency department by her parents at 00:30am. Her breathing is rapid and shallow and she has an audible expiratory wheeze. On examination, her lips and tongue have a bluish tinge. As it is impossible to obtain an oral temperature because of her shortness of breath, an aural temperature is taken, and is 38°C. The girl’s parents say that she suffered from ‘wheezy bronchitis’ in her pre-school years and that she has some wheezing after vigorous sport and often wakes during the night with a wheeze and cough.
e) What is the relevance of a personal and family history of allergy? (2 marks)
f) Name two (2) pharmacological classes of drugs which should be used to manage her condition after discharge from hospital. For EACH class, briefly explain its role in management (i.e. what does it do?). (4 marks)
g) Briefly describe two (2) strategies that you would use to develop good communication and rapport with this adolescent girl? (4 marks)
e) Past history childhood wheeze/bronchitis/nocturnal cough/wheeze PLUS personal or family history of atopy OR exposure to environmental allergens →↑likelihood of asthma
f) Any two of:
Beta agonists or Beta 2 agonists (short or long acting)—relax bronchial smooth muscle →relief of bronchospasm (reliever)
Corticosteroids—prophylaxis: inhibit production of inflammatory mediators →control of inflammation (preventer)
Anticholinergics—block acetylcholine mediated bronchial smooth muscle constriction →relief of bronchospasm
g) Any two of:
Active listening, Positive body language/non verbal communication
Use of language that adolescents relate to
Talk to her and not just her parents
When she is better, offer her the opportunity for communication (without parents)
A 47 year old man presents to you with a 2 month history of a productive cough with blood-stained sputum, as well as general malaise and lethargy.
a) Name three (3) likely causes of this presentation. (3 marks)
b) What are three (3) questions you would ask to obtain further information about his illness? (3 marks)
c) Name two (2) initial investigations you would request, giving reasons for your choices. (4 marks)
a) Bronchitis, Tuberculosis, Bronchial Carcinoma, Pneumonia (but usually more acute)
b) Any three of;
Other respiratory symptoms (e.g. wheeze, cough, chest pain)?
fever?
purulent sputum?
a smoker?
exposure to infective respiratory illness specifically TB?
other environmental exposures?
past medical history etc etc etc
C) Blood picture/examination: Hb, WCC for infection/ ?Chronic blood loss
Sputum: colour for inflammation (can be infection or allergy), micro and culture for pneumonia, Special tests for TB (Ziehl Nielson stain for acid-fast bacilli)
Imaging: CXR for lesions such as opacities (Carcinoma) or TB focus
A 47 year old man presents to you with a 2 month history of a productive cough with blood-stained sputum, as well as general malaise and lethargy.
A pathology report states that caseating granulomatous inflammation is present.
d) What is a caseating granuloma and what is the significance of this granulomatous inflammation (in your answer explain how this finding affects your diagnosis and what the most likely causative agent is). What is the most common route of transmission for this infective agent? (4 marks)
e) Name two (2) public health consequences of your diagnosis, and briefly explain how you would deal with these issues. (6 marks)
d) A granuloma is a chronic inflammatory lesion containing epithelioid histiocytes, giant cells and lymphocytes.
It is called a caseating granuloma when it has a central area of necrotic material (of a cheesy nature– caseation).
Suggests TB caused by Mycobacterium tuberculosis–airborne transmission.
e) Contact tracing: TB is spread from person to person and effective tracing of close contacts can help to limit spread of disease and identify diseased individuals at an early stage. Screen all close family members or others who share the same kitchen or bathroom as infected person, occasionally close school or work contacts. Screening of ‘well’ involves a tuberculin test and CXR.
OR
Prevention: Vaccination with BCG for tuberculin negative individuals, although it is becoming less costeffective to administer this vaccine. Depends on where you are in world.
OR
Follow-up of TB patients: See regularly for duration of chemotherapy and again after 3 months to check for relapse. Patients with multi drug resistant TB should be followed for at least 1 year after treatment completed.
OR
Chemoprophylaxis: for patients with any CXR changes compatible with previous TB, and who are about to go long-term treatment that has immunosuppressive effect.
Faye is 75 years old woman having treatment for high blood pressure. When she was initially diagnosed her BP was 154/99 mmHg.
a) Name three (3) different classes of drug that could be used to treat Faye’s hypertension. Include in your answer an explanation of the mode of action of each. (9 marks)
Diuretic
Reduces blood volume and thereby venous return. Reduced venous return decreases ventricular stretch and via frank-starling relationship reduces force of contraction. Stroke volume and hence cardiac output are reduced lowering mean arterial
BP.
Ca++ channel blocker
Main effect - reduces vasoconstriction by blocking receptor mediated entry of Ca++ that normally mediates smooth muscle contraction - thereby reducing peripheral resistance and reducing mean arterial BP. Some effect on heart to reduce force of contraction / stroke volume and hence CO. Some action on heart to reduce pacemaker activity and slow heart rate.
ACE inhibitor
Inhibits enzyme mediated conversion of inactive peptide angiotensin I to angiotensin II. It therefore reduces circulating levels of ang II and reduces ang II- mediated effects that normally serve to raise BP – vasoconstriction (peripheral resistance), stimulation of thirst, re-absorption of water in kidneys (direct), stimulation of aldosterone (re-absorption of water in kidneys) raising blood volume.
Angiotensin receptor antagonist
Similar effects to ACE inhibitor by blocking the action of ang II on its receptors.
Aldosterone antagonist
Blocks aldosterone and reduces sodium and water re-absorption by the kidney
Alpha antagonist / Alpha2 agonist (centrally-acting)
Block the action of adrenaline and noradrenaline on alpha adrenoreceptors in arterioles and therefore reduce peripheral resistance, lowering mean arterial BP.
Direct vasodilator
Acts presynaptically to inhibit release of noradrenaline. Action in the brainstem (medulla oblongata) results in reduced sympathetic nervous tone – slowing heart rate and force of contraction, reducing vasoconstriction. Mode of action not clear – relaxes blood vessels and reduces peripheral vasoconstriction.
Faye is 75 years old woman having treatment for high blood pressure. When she was initially diagnosed her BP was 154/99 mmHg.
Hypertension is one of many risk factors for coronary heart disease.
b) In addition to hypertension: Name one (1) risk factor for coronary heart disease that is regarded as modifiable and one (1) risk factor that is not-modifiable. (2 marks)
Faye has been suffering chest pain for over 24 h and is admitted to hospital with a suspected myocardial infarction. Coronary angiography shows total blockage of a single vessel.
c) According to research, which particular vessel is the single most common vessel to be blocked leading to a myocardial infarction? (1 mark)
An infarct is confirmed from low wall motion by echocardiography. On the basis of the location of the infarct, Faye is deemed to be at high risk of developing a left ventricular thrombus and is prescribed anticoagulant therapy as a preventative treatment for stroke.
d) What is the location of an acute myocardial infarction associated with the greatest incidence of left ventricular thrombus formation? (1 mark)
b) Modifiable risk factors:
Smoking, high salt intake, obesity, diabetes, high blood cholesterol (total or LDL), sedentary lifestyle.
Not-modifiable risk factors:
Age, family history, male gender
c) Left anterior descending coronary artery (interventricular artery)
d) Anterior infarction [Apical stasis occurs with anterior infarction]. The apex farthest from the inflow and outflowareas—the areas with the highest blood flow velocities. Severe apical wall motion abnormalities, and aneurysm, precede thrombus formation in acute infarction. (Anterior infarction - >30% , Inferior infarct - <5%)
Epidemiology from the Framingham heart study shows several factors to be associated with an increased risk of stroke.
e) Aside from left ventricular thrombus formation arising from coronary heart disease and myocardial infarction name two (2) other factors commonly associated with a high risk of stroke and describe the basis of the risk for each. (4 marks)
Faye was prescribed an oral anticoagulant.
f) Name the two (2) classes of oral anticoagulants and give an example (apart from ceasing administration) of how the effects of these drugs can be antagonized in the event of excessive bleeding. (3 marks)
e) Hypertension:
Haemorrhagic stroke due to high pressure in cerebral blood vessels Atrial fibrillation: Ischaemic stroke due to thrombus formation in left atrium and clot travelling to cerebral circulation.
Heart failure:
Ischaemic stroke due to low blood pressure and cerebral under-perfusion, also stasis of blood within the heart might lead to thrombus formation
f) Drug class 1: Coumarins
Drug class 2: Indanediones
Example of antagonism of drug action: Actions are antagonized by administration of Vit K
A 50-year-old woman is found at routine screening by her GP to have a sustained blood pressure (BP) of 180/110 mmHg at rest. She has normal renal function and is considered most likely to have essential (primary) hypertension.
a) Describe essential and secondary hypertension and the difference between them. (2 marks)
b) Name two (2) factors that could lead to an inappropriate diagnosis of hypertension. (2 marks)
c) List four (4) other risk factors for ischaemic heart disease (besides hypertension) that should be inquired about in this patient? (4 marks)
a) Essential: primary elevation of BP, cause not known
Secondary: BP elevation is result of a specific and potentially treatable cause
b) Patient not at rest for at least 10 mins prior to measurement OR not sitting for measurement Diagnosis made on only one reading OR Different equipment used every time OR Faulty equipment used OR wrong cuff size OR inaccurate measurement by the person taking BP OR Emotional distress, anxiety e.g. White coat hypertension OR BP elevated due to pain OR Elevated BP due to drug that leads to hypertension OR Elevated BP due to high licorice consumption etc (only 2 of these)
c) Race, family history, diet, smoking, hyperlipidaemia, diabetes, sedentary lifestyle etc (note: already know her age and gender, so any other 4)
d) Name one (1) sign (detected on physical examination) you would look for as evidence of arterial disease, and explain the physiological mechanism of this sign. (3 marks)
One example: atherosclerosis in carotid→carotid narrowing →turbulent flow→carotid bruit (in other vessels too, e.g. femoral, renal arteries)
e) Name one (1) organ or site in the body that can be affected by long-term untreated hypertension, and briefly explain how it is affected by prolonged high blood pressure. (2 marks)
One example: Hypertension→changes in large arteries→loss of arterial compliance→mechanical stresses (this detail not needed: interacting with low growth factors endothelial dysfunction)→atheroma in large arteries→coronary artery disease
f) What are two (2) drug CLASSES that could have been used to treat this woman’s hypertension, and very briefly explain, the mechanism of action of each. (6 marks)
Diuretics: increase salt excretion by the kidneys→↑excretion water→↓blood volume
Beta blockers: attenuate effects of sympathetic nervous and renin-angiotensin systems Angiotensin
Converting Enzyme (ACE) inhibitors—block conversion of Ang I to Ang II, to reduce Ang II potent vasoconstriction, stimulation of thirst, stimulation of aldosterone release (water retention)
Angiotensin receptor antagonists: selectively block the receptors for Ang II to prevent Ang II mediated vasoconstriction, thirst stimulation, aldosterone release
Calcium channel blockers: cause arteriolar dilatation, + reduce force of cardiac contraction
g) What is one (1) reason why patients may not adhere to treatment with an antihypertensive medication? (1 mark)
Experiences side effects,
Worried about side effects
Too busy to take the time to take regime,
Regime too complex
May feel well, so not feel the need to take the drugs
