PT Flashcards
Which one of the following is the effect of hyperaldosteronism?
A
Metabolic acidosis
B
Hyperkalaemia
C
Hypotension
D
Hypermagnesaemia
E
Hypokalaemia
E
Hypokalaemia
Aldosterone acts on maintaining Blood Pressure as part of the Renin-Angiotensin-Aldosterone (RAA) system.
Aldosterone acts on the DISTAL CONVOLUTED TUBULE of the nephron:
- reabsorbs Na and H2O (increase BP)
- excretes K+ and H+ ions
Hyperaldosteronism, e.g. Conn’s Syndrome, causes hypokalaemia and metabolic alkolosis.
Which one of the following is the most likely action of insulin?
A Inhibition of gluconeogenesis B Inhibition of protein synthesis C Inhibition of potassium entry into cells D Stimulation of glucagon release E Increased uptake of glucose by brain tissue
A - Inhibition of gluconeogenesis
Insulin is an ANABOLIC hormone synthesised by the islet beta-cells of the PANCREAS.
- It causes a DECREASE in BLOOD GLUCOSE by stimulating glucose STORAGE (as glycogen).
- It INHIBITS gluconeogenesis (generation of glucose from non-carbohydrate carbon substrates e.g. fats and proteins)
NB. T1DMs go into DKA (diabetic ketoacidosis) due to a complete lack of Insulin, therefore a HYPERGLYCAEMIC state due to no storage of glucose and disinhibited gluconeogenesis - resulting in breakdown of fats and formation of acidic ketones.
B - Insulin ENHANCES protein synthesis
C - Insulin causes an INTRACELLULAR K+ shift
D - Insulin and glucagon act in antagonism. Glucagon acts in low blood sugar levels and promotes glycogenolysis. Glucagon is produced by ALPHA-pancreatic islet cells.
E - glucose brain uptake is independent of insulin
A 5-month-old boy presents with a 12-h history of fever, vomiting and pain on movements of the left hip. Test results are below:
Erythrocyte sedimentation rate (ESR)
60 mm/h (3–13 mm/h)
C-reactive protein (CRP)
120 mg/l
Whole cell count (WCC)
30 × 109/l (6–18 × 109/l)
What is the most likely causative organism?
A
Group A Streptococcus
B
Enterobacteriaceae
C
Neisseria gonorrhoeae
D
Staphylococcus aureus
E
Streptococcus pneumoniae
D - Staphylococcus aureus
The neonate in this scenario likely has septic arthritis of the hip , with raised inflammatory markers, white-cell count, and a pyrexia. They likely would not be weight bearing or would hold the limb in a different position – typically flexed, abducted and externally rotated. The commonest organism causing septic arthritis is Staphylococcus aureus.
An 18-year-old man presents to Accident and Emergency with acute pain passing urine, haematuria and a dull ache over his flank. He is known to have cystinuria.
Which one of the following statements about cystinuria is correct?
A
Can be prevented with allopurinol therapy
B
Renal stones may be demonstrated by ultrasonography
C
May be caused by d-Penicillamine
D
Occur more commonly than uric acid stones
E
Tend to precipitate in alkaline urine
B - Renal stones may be demonstrated by ultrasonography
Renal stones can be detected on ultrasonography, which is particularly useful in young patients and pregnant patients when you do not want to expose them to the radiation of a computed tomography (CT) scan of the kidneys, ureters and bladder (KUB).
Cystine stones tend to precipitate in acidic urine. Alkalinisation with potassium citrate is a treatment for cystinuria.
You are treating a patient with portal hypertension and request a scan to look for a portal vein thrombosis. The radiologist reports the scan as positive and the patient is commenced initially on a treatment dose of enoxaparin.
Which one of the following would help you locate the portal vein on the scan images?
A
It arises at the union of the splenic and inferior mesenteric veins
B
It lies directly anterior to the aorta
C
It lies in the free edge of the lesser omentum
D
It lies in front of the hepatic artery at the porta hepatis
E
It receives the ligamentum teres at its right branch
C
It lies in the free edge of the lesser omentum
The portal vein is formed by the confluence of the splenic and superior mesenteric veins, at the level of L1.
(the inferior mesenteric vein usually joins the splenic vein as seen in the image below).
Following its formation, the portal vein runs in the free edge of the lesser omentum (hepatoduodenal ligament).
The portal vein is posterior to the hepatic artery proper and the common bile duct, with the artery medial to the duct.
The portal vein is anterior to the inferior vena cava.
NB. The ligamentum teres (hepatis) is the free edge of the falciform ligament. It contains the obliterated umbilical vein and paraumbilical veins
Which one of the following is the most important physiological function of the lymphatic system?
A
To transport fluid and proteins away from the interstitium to the blood
B
To concentrate proteins in the lymph
C
To remove particulate materials from the interstitium
D
To transport antigenic materials to lymph nodes
E
To create negative pressure in the free interstitial fluid
A
To transport fluid and proteins away from the interstitium to the blood
In the absence of a lymphatic system, the interstitial fluid protein concentration would increase greatly, causing widespread extracellular oedema.
NB. think of radiation therapy damaging the axillary lymphatics, causing peripheral unilateral oedema.
C
To remove particulate materials from the interstitium
This is a function of the lymphatic system, but not the most important.
B
To concentrate proteins in the lymph
This is a function of the lymphatic system, but not the most important.
D
To transport antigenic materials to lymph nodes
This is a function of the lymphatic system, but not the most important.
E
To create negative pressure in the free interstitial fluid
This is a function of the lymphatic system, but not the most important.
ANATOMY - DRAW THE CARPAL BONES
Which one of the following bones is contained within the proximal row?
A
Capitate
B
Hamate
C
Scaphoid
D
Trapezium
E
Trapezoid
C
Scaphoid
Proximal row: (lateral) Scaphoid Lunate Triquetrium Pisiform (medial)
Distal row: (lateral) TrapezIUM TrapezOID Capitate Hamate (Medial)
Which one of the following occurs in dehydration?
A
Approximately 15% of the glomerular filtrate is reabsorbed in the proximal renal tubule
B
Fluid in the distal convoluted tubule is hypertonic with respect to plasma
C
Interstitial fluid in the medulla of the kidney is hypotonic
D
Renal blood flow will increase
E
Urine output may decrease to around 600 ml/24 h
E
Urine output may decrease to around 600 ml/24 h
Dehydration and hypotension Dehydration leads to splanchnic and visceral vasoconstriction, causing hypoperfusion. A fall in renal blood flow can cause a decrease in the urine output and it can be as low as 500 ml/24 h.
- 70% of the glomerular filtrate is reabsorbed in the proximal renal tubule.
- The fluid is hypotonic compared with plasma in the distal convoluted tubule.
- The fluid in the medulla of the kidney is hypertonic.
- Dehydration leads to decreased intravascular volume and so renal perfusion falls.
The secretion of antidiuretic hormone (ADH) leading to increased water reabsorption is another mechanism by which oliguria occurs. The loops of Henle of the juxtamedullary nephrons dip deeply into the medullary pyramids before draining into the distal convoluted tubules in the cortex. There is a graded increase in the osmolality at the tips of the papillae (around 1200 mOsm/l approximately equal to four times that of plasma).
Granuloma is seen in which one of the following conditions?
A
Syphilis
B
Typhoid
C
Cholera
D
Amoebiasis
E
Shigellosis
A
Syphilis
A granuloma is a collection of macrophages, giant-cells as a nidus of chronic inflammation. The centre may necrotise to form caseation - an example is TUBERCULOSIS.
Examples of granulomatous conditions:
- Tertiary syphilis
- sarcoidosis
- Crohn’s and Wegener’s granulomatosis.
Typhoid fever is predominantly caused by Salmonella enterica and classically presents with fever, malaise, diffuse abdominal pain and constipation. It does not result in granuloma formation.
Cholera is caused by Vibrio cholera and presents with profuse diarrhoea as a result of enterotoxin formation that promotes secretion of fluid and electrolytes into the small intestine.
Amoebiasis is caused by Entamoeba histolytica a parasite that causes proteolysis and tissue lysis. It can induce apoptosis and present with dysentery with the potential to involve other organs.
Shigella infection induces acute inflammation accompanied by polymorphonuclear cell infiltration resulting in destruction of the colonic mucosa.
ANATOMY - DRAW THE LOWER LIMB ARTERIAL SUPPLY
Which branch of the femoral artery supplies the femoral neck and may result in avascular necrosis of the femoral head if damaged?
A
Deep circumflex iliac artery
B
Profunda femoris artery
C
Anterior branch of the obturator artery
D
Posterior branch of the obturator artery
E
Inferior epigastric artery
B
Profunda femoris artery
The profunda femoris artery (deep femoral artery) arises from the posterolateral aspect of the common femoral artery.
Its main branches are the medial and lateral circumflex arteries, which supply the femoral head via retinacular arteries that travel in the joint capsule.
If damaged, ischaemia and avascular necrosis of the femoral head may result.
- The deep circumflex iliac artery arises from the external iliac artery. It is responsible for arterial supply of the iliacus.
- The anterior branch of the obturator artery supplies the pectineus, obturator externus, adductor muscles and gracilis. It is not involved in supplying the femoral head or neck.
- The posterior branch of the obturator artery supplies some of the deep gluteal muscles.
- The inferior epigastric artery arises from the external iliac artery and primarily supplies the anterior abdominal wall. It is not involved in supplying the femur.
NB. The surface marking of the femoral artery is the mid-inguinal point [half-way between pubic symphysis and anterior superior iliac spine (ASIS)]. This is just medial to the deep inguinal ligament.
The DEEP INGUINAL ring lies at the MIDPOINT of the inguinal ligament (MOIL), (half-way between PUBIC TUBERCLE and ASIS).
The femoral artery is subcutaneous in the femoral triangle, separated from skin by the fascia lata.
A 19-year-old woman presents to her GP with anxiety, sweating, heat intolerance, weight loss and a tremor. Blood tests reveal Graves’ disease.
Which one of the following options concerning Graves’ disease is correct?
A
Carbimazole is drug of choice for treatment throughout pregnancy
B
Has equal sex incidence
C
In children has a high relapse rate when treated with antithyroid drugs
D
Is due to immunoglobulin M (IgM) thyroid-stimulating antibodies
E
Is a form of toxic multinodular goitre
C
In children has a high relapse rate when treated with antithyroid drugs
About half of the children with Graves’ disease treated with antithyroid drug therapy have a complete remission, but up to 1 in 3 children suffer a relapse. Features that increase the risk of relapse include a large goitre, a high radioactive iodine uptake and a high thyroid-stimulating immunoglobulin titre.
- In Graves’ disease the thyroid-stimulating auto-immunoglobulins are of the IgG class, which bind the thyroid-stimulating hormone receptor, mimic the function of thyroid-stimulating hormone leading to thyroid hyperplasia and an overproduction of thyroid hormones.
- Therefore, propylthiouracil is the medication of choice to treat Graves’ disease during the first trimester of pregnancy.
Propylthiouracil inhibits the production of thyroid hormones by inhibiting the enzyme thyroperoxidase.
Following the first trimester, carbimazole use can resume for the remainder of the pregnancy, as propylthiouracil is associated with hepatotoxicity. - Hyperthyroidism caused by Graves’ disease is more common in women, 7:1.
- Graves’ disease the antibodies stimulating the thyroid-stimulating hormone receptor lead to hyperplasia of the thyroid follicular cells of the thyroid gland leading to a toxic diffuse goitre.
Which one of the following features suggests an aggressive malignant melanoma?
A
Amelanotic lesions
B
Located on the arm
C
Flat lesions
D
Low mitotic rate
E
Satellite lesions
E - Satelite lesions
Satelite lesions are areas of tumour located away from but WITHIN 2cm of the primary site.
A 55-year-old obese diabetic man is admitted with leg cellulitis. He soon becomes more unwell and complains of increased pain. His cellulitis spreads, his Glasgow Coma Scale (GCS) level drops and he becomes hemodynamically unstable requiring inotropic support to maintain his blood pressure, urine output and cerebral perfusion.
Where should his care be managed?
A
Acute medical ward
B
Acute surgical ward
C
Coronary care ward
D
High dependency unit (HDU)
E
Intensive care unit
E - Intensive care unit
ICU care (Level 3) is indicated for TWO of MORE reversible organ failures, OR the requirement for Intubation. This patient has Cerebral hypoperfusion, Hypotension, and Renal impairment (THREE)
HDU is Level 2 care, and is indicated in SINGLE agent/organ support, unless advanced respiratory support (e.g. Intubation) is required.
ANATOMY - DRAW CALOT’S TRIANGLE and its CONTENTS
A surgical registrar is performing his third solo laparoscopic cholecystectomy in a 47-year-old woman. When attempting to dissect out Calot’s triangle to identify the cystic artery great difficulty is experienced as the anatomy appears aberrant.
What proportion of patients have anomalies of the gall-bladder and biliary tree?
A
<1%
B
25%
C
50%
D
75%
E
>90%
C
50%
Calot’s triangle, also known as the cystohepatic or hepatobiliary triangle is an anatomic space that is of great relevance when performing a laparoscopic cholecystectomy.
- (medial) Common Hepatic Duct
- (lateral) Cystic duct
- (superiorly) Free edge of Liver
- The cystic artery runs within
Anomalies of the gall-bladder or biliary tree are found within 50% of subjects and are important during surgery:
- Anomalous ducts in around 12% – around 85% of which are found (and occasionally injured) within Calot’s triangle.
- Anomalous gall-bladder development – rarely agenesis of the gall-bladder (around 0.02%), more commonly multiple gall bladders around (1 in 3800), or other anomalies such as the gall-bladder opening directly into the side of the common bile duct ie the cystic duct is absent.
- Variation in the blood vessel arrangement supplying the gall-bladder eg in 25% of people the right hepatic artery crosses in front of the common hepatic duct instead of behind it.
A 78-year-old man undergoes a very prolonged transurethral resection of prostate (TURP). He becomes unwell on the ward post-operatively.
Which one of the following options may occur?
A
Bradycardia
B
Hyperglycaemia
C
Hypernatraemia
D
Increased osmolality of the plasma
E
Increased total body sodium
A - Bradycardia
There is a risk of TURP syndrome with prolonged surgery, caused by the glycine irrigation fluid used peri-op.
- dilutional hyponatraemia
- fluid overload (causing HYPERtension and reflex bradycardia)
- glycine toxicity
ANATOMY- DRAW THE PERITONEAL CAVITY
You are admitting a young man who has presented with 1 week of severe abdominal pain following a binge drinking session on holiday. A diagnosis of acute pancreatitis is made.
Which one of the following are correct regarding complications of acute pancreatitis?
A
Gastrointestinal haemorrhage with resultant haematemesis and melaena is usually the result of rupture of the posterior duodenal artery due to stress
B
Hypocalcaemia is relatively common and is caused by fat saponification
C
Pancreatic pseudocysts are formed in the greater sac of the abdomen
D
Relative hypoxia in acute pancreatitis is due to multiple sub-clinical pulmonary emboli due to hypercoagulability
E
Splenic rupture is a common complication
B - Hypocalcaemia is relatively common and is caused by fat saponification
Acute pancreatitis is caused by the PANCREATIC ACINI releasing excess pancreatic enzymes. This causes both localised and systemic damage.
- (localised) Partial - Complete pancreatic necrosis
(systemic) : - fat necrosis and saponification, leading to fatty acids binding to calcium, resulting in hypocalcaemia.
- Increase in vascular permeability - third spacing into peritoneal cavity
NB - Psuedocysts are enzyme rich collections, formed in the LESSER SAC following acute/chronic pancreatitis.
A 68-year-old man who had been feeling unwell and pyrexial for 10 days was seen in the Emergency Department. He described dull pain on palpation of his left lower back. He had burning dysuria. A full blood count revealed an elevated white blood cell count with a left shift.
Which one of the following urinalysis findings would be most diagnostic for his renal condition?
A
Hyaline casts
B
Oval fat bodies
C
Proteinuria
D
Renal tubular epithelial cells
E
White blood cell casts
E - White blood cell casts
White blood cell casts indicate an INFLAMMATORY process within the kidney e.g. glomerulonephritis and tubulointerstitial nephritis.
Tubulointerstitial nephritis is a PRIMARY injury to the renal tubules and intersitium, resulting in decreased renal function.
Common causes of tubulointerstitial nephritis:
- Infection (pyelonephritis)
- allergic reactions
- Toxins/medication reactions (NSAIDS, phenytoin, penicillins e.t.c.)
Which one of the following statements on glomerular filtration is correct?
A
ADH acts on the proximal tubule
B
Allows the passage of glucose into the ultrafiltrate in the normal individual
C
Depends on venous return
D
Is normally governed by the blood pressure
E
Usually takes place at 24 ml/min
B - Allows the passage of glucose into the ultrafiltrate in the normal individual
Glucose is able to cross the glomerular basement membrane into the ultrafiltrate. In normal individuals it is then actively reabsorbed.
If the glucose concentration of the serum, and consequently the ultrafiltrate is too high, then the mechanism is overwhelmed and glycosuria occurs (as occurs in diabetes mellitus).
A
ADH acts upon the collecting ducts to increase the permeability to water. This increases water reabsorption.
C
The glomerular filtration rate is dependent on the rate of glomerular (arterial) blood flow, which is governed by the tone of BOTH the afferent and efferent arterioles.
D
The filtration rate is kept constant over a range of blood pressures by autoregulation. It is kept constant by the tone of the afferent and efferent arterioles.
E
In the normal individual the glomerular filtration rate is kept fairly constant at 120 ml/min.
How much oxygen is normally carried in the blood?
A
2ml O2/100ml blood
B
5ml o2/100ml blood
C
10ml o2/100ml blood
D
20ml o2/100ml blood
E
30ml o2/100ml blood
D - 20ml oxygen/100ml blood
A 34-year-old woman undergoes a caesarean section because of fetal distress. On review, she complains of not opening her bowels. You suspect she has developed an ileus.
Which one of the following is true regarding her prolactin levels?
A
Secretion is increased by dopamine
B
Secretion is under hypothalamic control
C
Secretion would be lower as she has undergone surgery
D
Secretion would be lower than normal because of her pregnancy
E
Secretion would be reduced due to the stress response
B - Secretion is under hypothalamic control
Prolactin secretion is from the LACTOTROPH CELLS of the ANTERIOR pituitary gland - under the control of the hypothalamus.
-Dopamine INHIBITS prolactin secretion
A 24-year-old footballer presents with a swollen painful knee. On examination he is noted to have significant joint effusion and a positive Lachman’s test.
Which component of the knee joint has been injured?
A
Anterior cruciate ligament
B
Lateral collateral ligament
C
Medial collateral ligament
D
Patellar tendon
E
Posterior cruciate ligament
A - Anterior cruciate ligament
High impact sports that involve rapid changes of direction or direct lower limb trauma are often associated with ACL rupture.
It originates from the Medial Aspect of the LATERAL femoral condyle, and inserts into the Intercondyloid Tibial Eminence.
Lachman’s test:
- knee flexed to 20-30 degrees
- postive if Tibia can be pulled ANTERIORLY
B
The lateral collateral ligament can be injured when there is a varus force to the knee – a force on the medial aspect of the knee.
C
The medial collateral ligament can be injured when a valgus force is applied to the knee. The valgus stress test can be used to assess for this. The medial collateral ligament is adherent to the medial meniscus, which can easily be damaged at the same time.
The McMurray’s test may be positive if there is meniscal involvement in the injury.
D
Patella tendon injury usually arises from a jumping or explosive load on the knee. There is a ‘popping’ noise heard at the time of injury.
Patients are unable to straight leg raise if it has been torn.
E
Posterior cruciate ligament injury can be diagnosed with the posterior drawer test. The classical description of how this injury is sustained is the knee hitting the dashboard of a car – essentially, a direct blow to a flexed knee.
During a carotid endarterectomy, the surgeon damages a nerve. Post-operatively the patient has a drooping lip.
Which nerve was damaged?
A
Greater auricular nerve
B
Hypoglossal nerve
C
Marginal mandibular nerve
D
Glossopharyngeal
E
Vagus nerve
C - Marginal mandibular nerve
The marginal mandibular nerve is a branch of the facial nerve and supplies muscles to the lower lip and chin.
All the above nerves, as well as the glossopharyngeal nerve, may be damaged during carotid endarterectomy.
Patients must therefore be informed of possible postoperative complications including difficulty moving their tongue, the presence of a drooping lip, hoarseness, numbness around the jaw and ear lobe, and difficulty swallowing. Most of these are due to a neuropraxia from retraction as opposed to the nerves being accidentally divided and usually settle with time.
A
Damage to the greater auricular nerve would produce paraesthesiaesthesia/numbness around the ear lobe.
This nerve arises from the cervical plexus and passes along the posterior border of the sternocleidomastoid. It then passes into the deep fascia to the parotid gland below the platysma muscle.
B
Damage to the hypoglossal nerve would cause tongue muscle wasting and deviation of the tongue towards the affected side.
D
Damage to the glossopharyngeal would most commonly produce a loss of taste in the posterior third of the tongue.
E
Damage to the vagus nerve would produce a plethora of pathology given the multitude of functions including autonomic functions and parasympathetic supply to the cardiovascular, respiratory and gastrointestinal system.
A 43-year-old man has developed sclerosing cholangitis and iron deficiency anaemia secondary to chronic bloody diarrhoea. They undergo colonoscopy as an outpatient.
A colonic biopsy would be most likely to show which one of the following?
A
Colonic adenocarcinoma
B
Diverticulitis
C
Granulomatous inflammation
D
Pseudopolyps
E
Villous adenoma
D - Pseudopolyps
Pseudopolyps are a classic finding of ulcerative colitis.
This diagnosis is suggested by presence of sclerosing cholangitis (an extra-intestinal manifestation) along with the bloody diarrhoea in the scenario above.
C
Granulomatous inflammation suggests Crohn’s disease, however, Crohn’s is not classically associated with sclerosing cholangitis.
B
Diverticulitis presents typically with left iliac fossa tenderness, bloody diarrhoea, and fever.
E
A villous adenoma is a non-malignant polyp that is most commonly found within the colon. They can result in diarrhoea, typically not bloody diarrhoea though. They have considerable potential to develop into malignant adenocarcinoma.
A young man, who is training for a marathon, was admitted to the Emergency Department after passing dark brown coloured urine. The urine dipstick test for blood was positive but no red blood cells were seen on urine sediment microscopy.
Which one of the following conditions is most likely to be associated with these findings?
A
Myoglobinuria
B
Post-streptococcal glomerulonephritis
C
Renal infarction
D
Renal papillary necrosis
E
Ureteric lithiasis
A - Myoglobinuria
Myoglobinuria is the presence of myoglobin in the urine, usually associated with rhabdomyolysis or muscle destruction. Trauma, including electrical injuries and burns, vascular problems, excessive exercise, venoms and certain drugs can destroy or damage the muscle, releasing myoglobin into the circulation and so to the kidneys.
Under ideal situations myoglobin will be filtered and excreted with the urine, but if too much myoglobin is released into the circulation it can overwhelm the kidneys. This can cause casts to form (solid masses of myoglobin) which can occlude the renal filtration system, leading to acute tubular necrosis and acute kidney injury. Patients who have undergone severe rhabdomyolysis (eg crush injury victims) should receive high volumes of IV fluids in an aim to prevent cast formation.
B
Post-streptococcal glomerulonephritis
While this can be seen in younger patients there is no preceding history of streptococcal illness such as a sore throat in this case history.
C
Renal infarction
Renal infarction is rare and in a young man it would be unlikely as it is most commonly due to thromboemboli.
D
Renal papillary necrosis
Papillary necrosis is most commonly caused by analgesic nephropathy (caused by excessive ingestion of simples analgesics such as NSAIDs and paracetamol). These patients can sometimes present with renal colic, as the necrotic tissue can obstruct ureteric drainage.
E
Ureteric lithiasis
Renal stones would present with renal colic and the presence of microscopic haematuria that would include red blood cells.
DRAW THE JVP WAVE
A 75-year-old man with known diverticular disease presents to the Emergency Department with left iliac fossa pain. He is not sure why, but he takes warfarin. His observations show a temperature of 38.2°C, heart rate 124 beats/min, respiratory rate 20 breaths/min and blood pressure 114/74 mmHg. On examination he is found to have an irregularly irregular pulse.
Which one of the following would be found on a jugular venous pressure (JVP) wave for this patient?
A
Normal waveform
B
Large a-wave
C
Absent a-wave
D
Absent p-wave
E
Slow y-descent
C - Absent a-wave
The a-wave on a JVP waveform corresponds to right atrial contraction and would be absent in patients with atrial fibrillation.
A
Normal waveform
- a-peak: atrial contraction
- x-descent: atrial relaxation
- c-peak: tricuspid valve Bulge during ventricular contraction
- x1-descent: tricuspid valve moving Downwards during ventricular contraction
- v-peak: passive atrial filling
- y-descent: tricuspid valve opening before atrial contraction. Ventricle starts to fill.
B
Large a-waves occur when there is resistance to emptying of the right atrium for example in tricuspid stenosis.
D
Absent p-wave
The JVP waveform does not include a p-wave. This would be the finding on an ECG in a patient with atrial fibrillation.
E
The y-descent represents ventricular filling and this would be slow in tricuspid stenosis.
A 47-year-old man presents to the hospital with a 2-month history of night sweats and weight loss. Blood culture grows a Haemophilus species from two different peripheral venous samples. On examination a pan-systolic murmur is present. Increasingly there are signs of left heart strain.
What procedure may this patient ultimately require if his condition deteriorates further?
A
Trans-catheter aortic valve implantation
B
Mitral valvuloplasty
C
Mechanical aortic valve replacement
D
Biological aortic valve replacement
E
Mechanical mitral valve replacement
E - Mechanical mitral valve replacement
This patient is likely to have mitral regurgitation secondary to infective endocarditis. Given his age, mechanical valve replacement is the better choice as it has better lifespan, but does have a higher risk of thromboembolism.
In devising a suitable screening test for malignant cancer, which of the following would be most useful?
A
The natural history of the disease should not be known
B
The test should have high sensitivity
C
The test should have low specificity
D
The tumour should be of anaplastic type
E
The tumour should have a short latent phase
B - The test should have high sensitivity
Preconditions for a good screening test include:
•the disease must be an important health problem
•there should be an accepted treatment
•facilities for diagnosis and treatment must be available
•there should be a latent stage
•the screening test should have both high sensitivity and specificity
•the test should be acceptable to the population
•the natural history of the disease should be adequately understood
•there should be an agreed policy on which patients should be treated
•diagnosis and treatment should be relatively cost effective
•the screening should be an ongoing process.
