Qs Flashcards

Question

What type of joints are present at the proximal and distal radio-ulnar joints?

Answer 1

Synovial pivot joints Allow for supination and pronation

Answer 2

Synovial condyloid joint Flexion, extension, adduction, abduction, circumduction

Answer 3

2. Gastrin

Answer 4

5. Zymogen

Answer 5

2. Emulsification

Answer 6

2. Acute pancreatitis

Answer 7

2. Stretch receptors in the rectal wall activate parasympathetic centers in the spinal cord

Answer 8

5. Third part of the duodenum

Answer 9

4. Vitamin B12

Answer 10

4. Vitamin B12

Answer 11

4. Pancreatic cancer

Answer 12

2. Abdominal ultrasound

Answer 13

1. Delayed gastric emptying

Answer 14

3. Hyponatremia One of the major functions of the intact large intestine is to absorb water and electrolytes. After colectomy, as much as 400-1000 ml of nearly isotonic ileostomy fluid may be excreted, resulting in a chronic salt and water depletion.

Answer 15

5. Multiple liver metastases

Answer 16

1. Central distribution of loops of bowel

Answer 17

3. Gastroduodenal

Answer 18

4. Sodium chloride + glucose

Answer 19

2. Cystic artery

Answer 20

1. Decreases gastrin production

Answer 21

1. Crohn's disease

Answer 22

4. Ulcerative colitis

Answer 23

1. Acute appendicitis

Answer 24

3. Jaundice

Answer 25

4. Lactose = 1 glucose + 1 galactose

Answer 26

5. Squamous cell carcinoma

Answer 27

Epidermis Dermis Hypodermis

Answer 28

3. Mast cells

Answer 29

4. Vesicle = small fluid filled

Answer 30

1. Type 1 = IgE produced specific to an antigen

Answer 31

4. Antifungal cream

Answer 32

1. Gram positive cocci = staphylococcus aureus and streptococcus pyogenes

Answer 33

Previous history of skin cancer Family history of skin cancer Fair skin (type 1 + 2 skin) Living in tropical countries for more than 1 year Working outdoors Immunosuppressive diseases or immunosuppressive treatment

Answer 34

3. Keratinocytes = SCC Melanocytes = melanoma Basal cells = BBC

Answer 35

1. Topical mupirocin

Answer 36

1. Comedones, papules, pustules and nodulocysts

Answer 37

Fingertip unit measurement (FTU)

Answer 38

``` Plaque psoriasis Guttate psoriasis Erythrodermic psoriasis Pustular psoriasis Palmoplantar psoriasis Nail psoriasis Scalp psoriasis ```

Answer 39

4. Plaque = larger raised area ``` Papule = small raised area Nodule = ? Pustule = small pus filled Plaque = larger raised area ```

Answer 40

3. Seborrheic warts

Answer 41

4. Atopic dermatitis

Answer 42

Topical steroids Topical antifungals Topical immunosuppressive Topical antibiotics

Answer 43

SCC BCC Melanoma

Answer 44

``` Protection Sensation Temperature regulation Immunity Excretion ```

Answer 45

Benign melanocytic nevus | Seborrheic keratosis

Answer 46

3. Normal pressure hydrocephalus

Answer 47

2. He has numbness over the left mandible

Answer 48

4. Numb legs and extensor plantar responses

Answer 49

2. Lesion in left temporo-parietal area

Answer 50

4. Right parietal lobe

Answer 51

1. Computerised tomography (CT) brain

Answer 52

4. Oligodendrocyte

Answer 53

3. Assessing the pupil response to light Asking the patient to screw her eyes shut = CN 7 Assessing the corneal reflex = CN 5 response to light Assessing the vestibulo ocular reflex = CN 8 Looking for nystagmus = CN 8

Answer 54

1. Asking the patient to screw her eyes shut

Answer 55

4. Assessing the vestibulo ocular reflex | 5. Looking for nystagmus

Answer 56

2. Assessing the corneal reflex

Answer 57

5. Treponema pallidum

Answer 58

5. Sustained clonus

Answer 59

3. Lateral corticothalamic tract

Answer 60

8. Dorsal column pathway Other examples: - Anterior spinothalamic tract – carries the sensory modalities of crude touch and pressure. - Lateral spinothalamic tract – carries the sensory modalities of pain and temperature. - Posterior spinocerebellar tract – Carries proprioceptive information from the lower limbs to the ipsilateral cerebellum. - Cuneocerebellar tract – Carries proprioceptive information from the upper limbs to the ipsilateral cerebellum. - Anterior spinocerebellar tract – Carries proprioceptive information from the lower limbs. The fibres decussate twice – and so terminate in the ipsilateral cerebellum. - Rostral spinocerebellar tract – Carries proprioceptive information from the upper limbs to the ipsilateral cerebellum.

Answer 61

The corticobulbar tracts arise from the lateral aspect of the primary motor cortex. They receive the same inputs as the corticospinal tracts. The fibres converge and pass through the internal capsule to the brainstem. The neurones terminate on the motor nuclei of the cranial nerves. Here, they synapse with lower motor neurones, which carry the motor signals to the muscles of the face and neck.

Answer 62

Hypertonia – an increased muscle tone Hyperreflexia – increased muscle reflexes Clonus – involuntary, rhythmic muscle contractions Babinski sign – extension of the hallux in response to blunt stimulation of the sole of the foot Muscle weakness

Answer 63

5. Heel-shin test

Answer 64

5. Unmyelinated

Answer 65

2. Left middle cerebral artery

Answer 66

5. Stepwise progression

Answer 67

2. Asking the patient to smile in order to show you his teeth

Answer 68

1. Cauda equina syndrome A condition due to damage to the bundle of nerves below the end of the spinal cord known as the cauda equina. Symptoms include: low back pain, pain that radiates down the leg, numbness around the anus, and loss of bowel or bladder control.

Answer 69

Teres Major

Answer 70

Supraspinatus

Answer 71

Long thoracic nerve

Answer 72

Acute rupture of the supraspinatus part of the rotator cuff.

Answer 73

Median nerve

Answer 74

Distal (carpal) compression of the median nerve

Answer 75

Recurrent branch of median nerve

Answer 76

part of flexor digitorum profundus.

Answer 77

Radial artery

Answer 78

Dorsal interosseous muscles

Answer 79

Pectoralis major

Answer 80

Ulnar nerve

Answer 81

Radial and axillary

Answer 82

Rupture of the tendon of the long head of the biceps

Answer 83

Flattened thenar eminence

Answer 84

Annular ligament of radius

Answer 85

Dorsal root ganglion

Answer 86

Ulnar nerve in the elbow

Answer 87

Latissimus Dorsi

Answer 88

Fracture of coracoid process

Answer 89

Loss of wrist extension leading to wrist drop

Answer 90

Inability to adduct thumb

Answer 91

Teres minor

Answer 92

Accessory nerve

Answer 93

Musculocutaneous nerve

Answer 94

E The diagnosis is open and he needs continued inpatient evaluation

Answer 95

D Amlodipine DVT, cellulitis and a ruptured Baker's cyst cause unilateral oedema, whereas bisoprolol does not cause bilateral oedema unless it has led to decompensated heart failure, which is possible, but not common.

Answer 96

E. The differential diagnosis of leg oedema is broad and includes heart failure, rectal/pelvic cancer, cellulitis, lymphatic obstruction due to cancer or to filariasis, and other causes. A full careful history and examination is always appropriate.

Answer 97

A Non-arrhythmic e.g. due to anxiety

Answer 98

E An ECG during an attack is diagnostic

Answer 99

D Painful peripheral neuropathy Alcoholic peripheral neuropathy is often painful; the clue is likely to be in the general condition of the patient (thin, recent weight loss), along with the specific clinical findings. The neuropathy should be confirmed (by EMG), and then the full range of possible causes excluded.

Answer 100

B. D-dimer The pre-test probability of a deep venous thrombosis is very high; a D-dimer in no way alters this probability and is contraindicated.

Answer 101

D Aortic stenosis The demographics, history and exam are all consistent with aortic stenosis. A normal carotid upstroke is very common in elderly patients with aortic stenosis.

Answer 102

A A benign flow murmur A flow murmur is almost universal in advanced pregnancy.

Answer 103

B. Fluid therapy is an appropriate treatment for most forms of shock when evidence of organ hypoperfusion persists. In cardiogenic shock there is a low COt and the heart will be operating on the flat part of the Frank–Starling curve. Increasing venous return is unlikely to increase cardiac output, which may stay the same or fall. Fluid therapy in these circumstances may make pulmonary oedema and hypoxia worse. Note that synthetic colloids may be a rare cause of anaphylactic shock; therefore one must be cautious about using colloids as fluid therapy in this condition as this may have been the original aetiology of anaphylaxis.

Answer 104

B. Cough lasting more that 6 weeks in the context of a normal chest X-ray is commonly due to asthma, postnasal drip or acid reflux. Empirical treatment for these conditions following on from a careful history and examination results in resolution in the majority of patients. In pulmonary fibrosis the chest X-ray may be normal, but usually either clinical or radiological signs are present.

Answer 105

D Tracheal tumour Large airway obstruction by tracheal tumour results in stridor Wheeze is result of any condition that causes narrowing of smaller airways

Answer 106

B Thoracic ultrasound Wheeze is caused by vibration of the airway wall when airway narrowing occurs. It therefore occurs in conditions that lead to narrowing of the airways. These include obstructive pulmonary diseases, which can be diagnosed using spirometry and flow volume loops. Localized obstruction to airways may be revealed by CT of the chest. Pulmonary oedema leading to diffuse airway oedema and narrowing may present with ‘cardiac wheeze’. Echocardiography may occasionally be useful in making this diagnosis.

Answer 107

D. Nephrotic syndrome Conditions such as cardiac failure, nephrotic syndrome and malnutrition typically cause transudates that are low in protein content and are caused by an imbalance between colloid oncotic pressure (which tends to hold fluid in the vascular compartment) and pressure driving fluid into the pleural space.

Answer 108

E. Most patients with primary spontaneous pneumothorax will not have a recurrence Only 30% of patients with a primary spontaneous pneumothorax will subsequently have a recurrence. After the second episode the recurrence rate rises above 50%. Pneumothorax is more reliably diagnosed by ultrasound or CT than on plain X-rays. Treatment is usually effective with either simple aspiration or narrow-bore chest drains. Air travel should be avoided for 3 months.

Answer 109

E Subcutaneous emphysema (felt as a crackling under the skin) is a sign of air leaking into the skin. It may occur in any pneumothorax and does not necessarily imply tension

Answer 110

D. Small bowel bacterial overgrowth - Lactose intolerance causes diarrhoea due to colonic fermentation - Lymphocytic colitis causes colonic diarrhoea - Pernicious anaemia results in selective deficiency of vitamin B12 Small bowel bacterial overgrowth can occur secondary to jejunal diverticulosis or small bowel motility problems (e.g. systemic sclerosis) and results in small bowel malabsorption.

Answer 111

B Pernicious anaemia

Answer 112

B A characteristic rash Dermatitis herpetiformis is a blistering rash present on the elbows and buttocks. It is now considered specific for coeliac disease. Abdominal pain and vomiting are each unusual in malabsorption, whereas steatorrhoea is non-specific and does not infer one particular cause over any other.

Answer 113

C. CT with contrast (IV and possibly lumenal) This will delineate the level of intestinal obstruction and may provide diagnostic clues as to the cause

Answer 114

C A low red cell mean cell volume This is indicative of iron deficiency and is more commonly seen in chronic intestinal blood loss rather than an acute bleed.

Answer 115

B Food bolus impaction

Answer 116

A. A bile duct stone (choledocolithiasis) will cause intermittent or persisting biliary obstruction resulting in jaundice. Other features of biliary obstruction may include pale stools, dark urine and pruritis (itching)

Answer 117

The correct answer is C. Colonic (hindgut) pain will be felt below the umbilicus. It is due to activation of pressure receptors (baroreceptors) in the wall of the colon, which accounts for its variable intensity (i.e. colicky nature). It will be exacerbated by eating despite activation of the gastro-colic reflex but will only cause vomiting if there is a significant obstruction

Answer 118

The correct answer is C. Co-amoxiclav is a recognized cause of an acute intrahepatic cholestasis similar to that seen as a consequence of using chlorpromazine-based major tranquilizers. Simvastatin is associated with an acute hepatitis but will rarely cause symptomatic jaundice. Paracetamol may cause fulminant liver failure if taken in sufficient quantitites as a deliberate act of self-harm.

Answer 119

The correct answer is A. Exudative ascites is reflected by a high protein content and should always arouse suspicion of maligancy or infection even in the setting of established chronic liver heart or renal disease.

Answer 120

The correct answer is B. Increased ADH will reduce urine output. Reduced serum sodium, hypocalcaemia and hypoglycaemia do not directly affect urine output (though hypercalcaemia and hyperglycaemia can cause polyuria). Lithium toxicity is associated with polyuria due to a nephrogenic diabetes insipidus.

Answer 121

The correct answer is D. Fluid depletion would be suggested by an increased haematocrit, a lowered JVP, postural hypotension and hypotension.

Answer 122

A Pyuria and nitrates Urinary tract infections are usually associated with pyuria and often by the presence of urinary nitrite which can be detected with dipstick tests.

Answer 123

The correct answer is A. In a patient red cell casts and proteinuria suggest a glomerular source of bleeding. Visible blood in the urine (‘macroscopic’ haematuria) only occurs in a limited number of glomerulonephritides such as IgA nephropathy but might indicate a malignancy or other structural lesion of the renal tract.

Answer 124

The correct answer is B. Pioglitazone is associated with weight gain and is used in type 2 diabetes mellitus. C and D have both been withdrawn because of adverse risk profiles.

Answer 125

The correct answer is C. Congenital adrenal hyperplasia due to 21-hydroxylase deficiency is associated with hirsutism and elevated 17-OH progesterone, whereas insulin resistance. Hyperinsulinaemia is frequently associated with PCOS. An increased LH/FSH ratio, and mild elevation of serum testosterone and androstenedione is found in patients with PCOS, but a markedly elevated testosterone (>5 mmol/L) is highly suspicious of an adrenal tumour or congenital adrenal hyperplasia.

Answer 126

D. Haemophilus influenza Toxin production is just one of the mechanisms through which bacteria can cause damage to host cells.

Answer 127

C. IgM is the first antibody type to develop and so indicates current or very recent infection. IgG is produced later and so can be used to check previous exposure or immunization.

Answer 128

B Diabetes

Answer 129

D Amphetamines/ecstasy

Answer 130

The correct answer is B. Scarlet fever is caused by group A streptococci.

Answer 131

2, T8 and T9

Answer 132

5. Upper and lower lobes separated by the oblique fissure Whereas the Right lung has 2 fissures (transverse and oblique) L lung = 2 lobes R lung = 3 lobes

Answer 133

5. There is likely to be a loss of vibration and proprioception below the lesion on the ipsilateral side DCML = fine touch (tactile sensation), vibration and proprioception. Pain and temp is via anterolateral system, specifically the lateral spinothalamic tract which eliminates 1-3.

Answer 134

1. Elevated erythrocyte sedimentation rate (ESR)

Answer 135

2. Dopamine

Answer 136

1. Constriction of pupils

Answer 137

5. Look for wasting of the sternocleidomastoid muscle

Answer 138

2. There is efferent arteriole constriction | If we constrict the efferent arterioles we increase the pressure in the Bowman’s capsule; filtrate increases

Answer 139

1. Decreased osmolarity and increased volume Dilute the electrolytes in the body whilst increasing the volume

Answer 140

4. Is released in response to cellular dehydration Produced by the hypothalamus and stored in the posterior pituitary gland; it only inserts aquaporins into the collecting duct; it uses the medullary gradient to increase the reabsorption of sodium etc

Answer 141

4. Net secretion

Answer 142

3. High serum phosphate

Answer 143

4. It could be related to impaired renal function Metabolic acidosis = pH drops; metabolic is indicated by a decrease in bicarbonate / respiratory is indicated by an increase in partial pressure of carbon dioxide Rule is = in metabolic acidosis / alkalosis, the HCO / PCO drop or rise with it respectively whilst in respiratory types if the pH drops (acidosis) the PCO rises (with the HCO rising too in chronic situations) and if the pH rises (alkalosis) the PCO drops (with the HCO dropping too in chronic situations)

Answer 144

3. The subject will be excreting large amounts of ammonium ions

Answer 145

5. 128 mmol/L

Answer 146

1. Furosemide

Answer 147

2. Minimal change disease

Answer 148

2. The subject will be excreting bicarbonate ions

Answer 149

2. The subject is likely to have spent a long time at altitude

Answer 150

4. The data suggests there may be renal impairment

Answer 151

1. Acute pyelonephritis

Answer 152

4. Ultrasound of the urinary tract

Answer 153

1. Painful inability to void with a palpable or percussible bladder

Answer 154

1. Low serum calcium

Answer 155

4. Erthryopoietin

Answer 156

5. Escherichia coli

Answer 157

4. Prostatic hypertrophy

Answer 158

3. Stage 3

Answer 159

3. Bladder cancer

Answer 160

2. Calcium oxalate

Answer 161

1. Loin pain radiating to the flank and / or groin

Answer 162

4. Gentamicin

Answer 163

5. Lethargy

Answer 164

2. Secondary hypothyroidism

Answer 165

2. Hypotension

Answer 166

1. Depressed ACTH

Answer 167

4. Adrenal insufficiency

Answer 168

3. Increased phosphate excretion at the kidneys

Answer 169

5.It is relatively insignificant in terms of foetal and neonatal growth

Answer 170

3. Aldosterone

Answer 171

5. Stimulation of Na/K ATPase

Answer 172

1. Thyroid hormone

Answer 173

2. He may be able to work offshore depending on his employer and where he is going

Answer 174

5. All of the above

Answer 175

3. Biguanide (e.g metformin)

Answer 176

3. Give 200ml fresh orange juice

Answer 177

5. Liver function tests

Answer 178

1. Neutropenia

Answer 179

2. Bitemporal hemianopia

Answer 180

2. Addison’s disease

Answer 181

3. Addison’s disease

Answer 182

3. An opening for the coronary sinus = drains all the blood supplied to the heart back into the right atrium 1. A bicuspid valve leading to the right ventricle = tricuspid valve found between right atrium + right ventricle 2. An opening for the azygos vein = empties into the SVC 3. An opening for the coronary sinus = drains all the blood supplied to the heart back into the right atrium 4. An opening for the right brachiocephalic vein = stems from the SVC and goes on to form the right subclavian + right internal jugular / right external jugular 5. An oval fossa in its anterior wall = fossa ovalis is found in the right atrium of the heart

Answer 183

7. None of the above features are shared in common

Answer 184

2. 3rd Comments - 2nd pair of aortic arches = 1st / 2nd disappear early, a remnant of the 1st forms part of the maxillary artery (a branch of external carotid artery) - 3rd pair of aortic arches = constitutes the commencement of the internal carotid artery and is therefore named the carotid arch - 4th pair of aortic arches = the 4th left arch forms the right subclavian / the 4th right arch becomes the aortic arch - 5th pair of aortic arches = disappears on both sides - 6th pair of aortic arches = forms the pulmonary arteries

Answer 185

3. They have a relatively narrow lumen and strong muscular wall = narrow lumen gives them a high resistance and the strong muscular wall means they can contract or relax when the resistance needs to be changed They have a relatively wide lumen and strong muscular wall The statement is wrong - arterioles are not resistance vessels = of the arteries, arterioles are the muscular resistance arteries They only allow blood flow in one direction = all other vessels only allow blood flow in 1 direction and are classed differently

Answer 186

P-wave = atrial depolarisation QRS complex = ventricular repolarization (+ atrial repolarization) T-wave = ventricular repolarisation U-wave = last bit of the ventricular repolarisation; interventricular septum OR the papillary muscle

Answer 187

5. The semilunar valves close = second heart sound (S2 = DUB) Comments: 1. Blood enters the aortic = heart sounds are heard when valves shut 2. The atria contract = heart sounds are heard when valves shut 3. The atrioventricular valves close = first heart sound (S1 = LUB) 4. The atrioventricular valves open = heart sounds are heard when valves shut 5. The semilunar valves close = second heart sound (S2 = DUB)

Answer 188

3. Decrease preload and therefore decrease stroke volume = less time for cardiac filling; preload decreases; less stretch on the heart; smaller contractile strength; decreased stroke volume

Answer 189

3. Increase contractility and therefore increase stroke volume = beta-1-adrenoceptors are present on the cardiac muscle cells so the sympathetic activation will produce a stronger strength of contraction for any given preload / afterload = ejects more blood so the stroke volume (ml/beat) is increased

Answer 190

2. Pulmonary arterioles constrict in response to local hypoxia

Answer 191

5. All of the above

Answer 192

2. Supraventricular tachycardia Comments: 1. Atrial fibrillation = irregular palpitations 2. Supraventricular tachycardia = valsalva manoeuvre effects AV node, where the supraventricular tachycardias arise from 3. Ventricular ectopics = irregular palpitations 4. Ventricular fibrillation = leads to loss of cardiac output, collapse and death so since she is ‘usually well’ 5. Ventricular tachycardia = would be related to ventricles, valsalva manoeuvre affects AV node

Answer 193

4. Intravenous diuretic

Answer 194

2. Echocardiography

Answer 195

1. 24 hour ambulatory blood pressure recording need to confirm he suffers from genuine hypertension and not just ‘white coat hypertension’

Answer 196

3. Low molecular weight heparin - treatment of choice

Answer 197

4. Turner syndrome - all features Down syndrome = atrioventricular septal defects Noonan syndrome = pulmonary stenosis & septal defects Shprintzen syndrome = tetralogy of Fallot Williams syndrome = supravalvular aortic stenosis

Answer 198

5. Intermittent claudication = ischaemic pain resulting from the exertion of the calf muscles; increased oxygen demand cannot be met due to atherosclerosis of the supplying arteries

Answer 199

2. Down syndrome = heart atrioventricular septal defects + reduced tone 22q11 microdeletion = tetralogy of Fallot Foetal alcohol syndrome = neurological / craniofacial defects; septal defects CAN be found Multifactorial congenital heart disease Turner syndrome = coarctation of the aortic

Answer 200

2. Critical limb ischaemia = elevation of the leg causes pain; sleep Coments: Chronic venous insufficiency = venous ulcers tend not to cause severe pain Diabetic neuropathy = diabetic ulcers tend not to cause severe pain Postphlebitic syndrome = a secondary condition of deep venous thrombosis Squamous carcinoma = usually painless

Answer 201

3. Start beta blocker warfarin has no evidence of benefit

Answer 202

5 Vital Capacity (correct answer - 4600 ml; from max (5800 ml to 1200 ml [residual volume]) Comments: 1. Expiratory Reserve Volume = volume of air that can be voluntarily forcibly exhaled after normal expiration 2. Functional Residual Capacity = volume left in lungs after normal expiration (ERV + RV) 3. Residual Volume = volume of air in lungs that cannot be voluntarily expired 4. Tidal Volume = volume of air breathed in or out at rest

Answer 203

2. Lungs (correct answer; lower respiratory tract; underneath the vocal cords in the larynx)

Answer 204

2. The external intercostal and diaphragm muscles contract and thoracic volume increases (correct answer)

Answer 205

2. 6000 ml/min (correct answer) (tidal volume - dead space) x respiratory rate = alveolar ventilation (800 - 200 = 600 x 10

Answer 206

3. Compliance is greatest at the base of the lungs (correct answer) Comments: Compliance is increased in emphysema due to loss of elastic fibres)

Answer 207

1. 40 mmHg (5.3kPa) (correct answer)

Answer 208

5. Pulmonary oedema (correct answer) this is the only answer where oxygen concentration in solution (PaO2) will be reduced. The other conditions may result in significant decreases in total oxygen content (due to lack of oxygen binding to Hb or loss of Hb) but oxygen in solution in plasma will be unaffected.

Answer 209

2. Nitrous oxide is a safe sedative to use (correct answer) Nitrous oxide blunts the peripheral chemoreceptor response to falling oxygen, and as these patients are on “hypoxic drive” this effectively leaves them with no intrinsic means of controlling their ventilation.

Answer 210

4. When perfusion exceeds ventilation in L/min (correct answer) A pulmonary shunt is a pathological condition which results when the alveoli of the lungs are perfused with blood as normal, but ventilation (the supply of air) fails to supply the perfused region. In other words, the ventilation/perfusion ratio (the ratio of air reaching the alveoli to blood perfusing them) is zero.

Answer 211

5. Running a marathon (correct answer) increase in body temperature, CO2 and lactic acid production shifts curve to the right making oxygen extraction in peripheral tissues easier and therefore increases oxygen delivery. Comments: 1. Hypothermia decrease in body temperature shifts curve to the left making it difficult to offload oxygen to peripheral tissues. 2. Presence of foetal haemoglobin higher affinity for oxygen than adult haemoglobin so curve would shift to the left. 3. Respiratory alkalosis decrease in [H+] pulls CO2 equilibrium to the right, reducing PCO2 so shifts haemoglobin binding curve to the left. 4. Voluntary hyperventilation decreases PCO2 so would shift curve to the left.

Answer 212

5. Serum calcium (correct answer) Squamous cell lung cancer associated with hypercalcaemia due to parathyroid hormone related protein. Symptoms in this case classic for hypercalcaemia. Comments: 1. Bronchoscopy Peripheral lesion can’t be accessed and tissue diagnosis known already 2. Chest x-ray Known lung cancer and this would add nothing further 3. Mediastinoscopy Cancer diagnosis known 4. Sputum cytology cancer diagnosis known and would add nothing further

Answer 213

3. Fine needle aspiration (FNA) lymph node Comments: 1. Bronchoscopy Peripheral lesion may not be accessible 2. CT thorax Ultimately a pathological diagnosis is needed 3. Fine needle aspiration (FNA) lymph node (correct answer) A sample is needed for pathology to give a tissue diagnosis for cancer type. This offers an easily accessible option for this 4. Lung function tests Would only be used for suspected airway obstruction 5. Sputum cytology Unlikely to yield a diagnosis

Answer 214

4. Nebulised beta-2 agonist (correct answer) Comments: Answer isn't 1. because she needs more aggressive treatment than normal inhaler as she is hypoxic and hypercapnic

Answer 215

3. Empyema thoracis (correct answer)

Answer 216

4. Poor sleep hygiene (correct answer) Change in sleep pattern indicates a behavioral aspect to his lack of sleep

Answer 217

5. Pseudomonas aeruginosa

Answer 218

5. Streptococcus pneumoniae

Answer 219

4. pH 7.22, PaO2 7.8 kPa, PaCO2 8.6 kPa, on air Exhaustion and decreased ventilation leads to hypercapnia, hypoxia and acidosis

Answer 220

3. Inhaled corticosteroids and inhaled beta-2-agonist (correct answer) Nighttime symptoms indicates need for inhaled corticosteroid

Answer 221

4. Primary pneumothorax (correct answer) Should always be considered in sudden onset pain with shortness of breath in previously healthy person

Answer 222

Anterior ethmoid artery

Answer 223

Acute mastoiditis

Answer 224

Left sensorineural hearing loss

Answer 225

Pseudomonas Aeruginosa

Answer 226

Medullary thyroid cancer

Answer 227

Taste sensation to the anterior 2/3 of the tongue

Answer 228

Metastases in their neck

Answer 229

CT of the neck and chest

Answer 230

Recurrent laryngeal nerve

Answer 231

Sloping sensorineural hearing loss with hearing worse in higher frequencies

Answer 232

Influx of Na+ ions

Answer 233

Leaky K+ Channels

Answer 234

Occurs after T wave and is caused by the last part of ventricular repolarising (septum or pap muscles)

Answer 235

Pulmonary arteries constrict in hypoxic conditions

Answer 236

- Increases in systemic filling pressure - Contraction of smooth muscle surrounding the veins - Increased rate and depth of respiration - Rhytmic contraction of skeletal muscle

Answer 237

ACEi | Beta-blockers

Answer 238

Supraventricular tachycardia

Answer 239

Increases vagal tone and the effect at AV.

Answer 240

IV Diuretics

Answer 241

PND Elevated JVP Lung crackles peripheral oedema

Answer 242

TPR primarily controlled of noradrenaline on alpha 1 -adrenorecpetors

Answer 243

Decrease preload and therefore decrease stroke volume

Answer 244

Increase contractility and therefore increase stroke volume

Answer 245

GTN Beta-blockers CCBs Ivabradine

Answer 246

Anticoagulation | Warfarin is TERATOGENIC in first trimester = Low molecular weight hep

Answer 247

Shprintzen syndrome

Answer 248

Antihypertensives (beta blockers) Prophylactic aortic root surgery Lifestyle advice

Answer 249

Aortic stenosis Mitral regurgitation Aortic sclerosis

Answer 250

Heard louest at the apex and radiates to the axilla, pan systolic murmur, maximal on expiration

Answer 251

Pulse waveform | Low output pulse, radiates to carotid

Answer 252

A. latitude of patient's home country cassava is associated with a multi-nodular goitre as they contain thiocyanate

Answer 253

C. acute extradural haemorrhage there is a lucid interval

Answer 254

B. chronic subdural haematoma

Answer 255

E. absence seizures

Answer 256

C. complex partial seizure with secondary generalization

Answer 257

A. hypertension

Answer 258

F. serum prolactin - may be caused by a prolactinoma

Answer 259

C. CN IX - the glossopharyngeal nerve.

Answer 260

b. anti-voltage-gated-calcium-channel receptor antibodies

Answer 261

B. Tremor - This is an extra-pyramidal sign such as in parkinsons which affects the substantia nigra (part of the basal ganglia that is aka the extra-pyramidal system of the body)

Answer 262

f. diazepam

Answer 263

D. wide based gait

Answer 264

a shuffling gait is characteristic of parkinson's

Answer 265

b. high-stepping gait

Answer 266

C. stamping gait

Answer 267

D. cervical sympathetic ganglion

Answer 268

B - E1V1M1

Answer 269

E - hemisensory neglect

Answer 270

E - Wernicke's encephalopathy

Answer 271

a. Sprigelian herniation

Answer 272

B - substantia nigra

Answer 273

b. Huntington’s disease

Answer 274

d. Internal Carotid artery

Answer 275

E. Hypercapnia

Answer 276

C. choroid plexus

Answer 277

B. voltage gated sodium channels

Answer 278

A. blurring of vision

Answer 279

B. CUB (combined Ultrasound/biochemical) screening

Answer 280

A. Anticholinergic medication

Answer 281

C. Oblique Lie

Answer 282

A. Ramipril

Answer 283

B. Placental Abruption (concealed)

Answer 284

A. All Rhesus negative women

Answer 285

C. Diagnostic Laparoscopy

Answer 286

C. Luteinizing hormone

Answer 287

B, Endometrial Cancer

Answer 288

E. Vaginal examination to assess the cervical dilatation

Answer 289

B. Entonox

Answer 290

C. Normal physiological change in pregnancy

Answer 291

D. Histology

Answer 292

C. They need good diabetic control before contraception to help prevent anomalies in the baby

Answer 293

C. Oestrogen

Answer 294

C. HPV 16 and 18 immunisation

Answer 295

D. The screening target population are registered with a GP practice and are aged between 50 and 70 years.

Answer 296

A. Emergency Copper Intrauterine Device

Answer 297

D. Proteinuria

Answer 298

B. In the supine position the pressure of the gravid uterus on the IVC causes a reduction in the venous return to the heart with a possible 25% reduction in the cardiac output.

Answer 299

All women planning a pregnancy should be advised to take 400mcg folate periconceptually and up until 12 weeks gestation to prevent megaloblastic anaemia. B. Because the expansion in plasma volume is greater than the increase in red cell mass there is a fall in haemoglobin concentration, haematocrit and red cell count.

Answer 300

E. This is her 4th pregnancy and she had 2 previous early pregnancy losses

Answer 301

D. Inevitable miscarriage

Answer 302

A. Clomiphene

Answer 303

``` Ectopic pregnancy Miscarriage Urinary tract infection Appendicitis Molar pregnancy Ovarian cyst ```

Answer 304

Ectopic Pregnancy

Answer 305

``` Headache Blurring of Vision/Visual disturbances Epigastric Pain Reduced fetal movement Nausea and vomiting ```

Answer 306

FBC U and E's urate LFTs Ultrasound - growth scan

Answer 307

``` Call for help - senior obstetrician Check airway - maintain check breathing Check BP, PR PP IV access Control seizure, magnesium sulphate Treat BP ```

Answer 308

B. Biting insects

Answer 309

H. Skin contact

Answer 310

A. Infection

Answer 311

E. Human herpesvirus type 8

Answer 312

F. Human papilloma virus

Answer 313

B. Helicobacter pylori

Answer 314

F. Monofunctional alkylation of DNA and protein

Answer 315

H. Topoisomerase inhibition

Answer 316

A. Bifunctional alkylation of DNA and proteins

Answer 317

H. Neutrophils

Answer 318

F. Mast cells

Answer 319

A. Basophils

Answer 320

D. Glandular fever

Answer 321

H. Rubella

Answer 322

J. Trosier's sign

Answer 323

H. Toxoplasma

Answer 324

C. Entamoeba histolytica

Answer 325

J. Trypanosoma

Answer 326

C. Influenza vaccine

Answer 327

F. Pertussis vaccine

Answer 328

J. The 5-in-1 vaccine (diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type B)

Answer 329

C. Cervical cancer

Answer 330

A. Bladder cancer

Answer 331

F. Ovarian cancer

Answer 332

C. Pulmonary embolism An Abdominal Aortic Aneurysm can rupture due to dilation of the vessel walls and the pressure of the blood passing through, consequently local thrombosis, femoral artery embolism and calcification of the walls are also likely. Pulmonary embolism is a rare result of an AAA.

Answer 333

D. Necrosis Cardinal signs of acute inflammation are erythema, heat, swelling, pain and loss of function. Necrosis occurs in chronic inflammation.

Answer 334

E. The resulting exudate is rich in protein. In acute inflammation there is a cellular and vascular response, which causes the cardinal signs of acute inflammation, as a result of the cellular response exudates rich in protein is made from the destruction of microbes.

Answer 335

E. Vasodilation is caused by histamine release from mast cells. In acute inflammation vasodilatation is caused by histamine and nitric oxide.

Answer 336

D. Raised protein Meningococcal meningitis, the CSF would be cloudy, purulent due to increased neutrophils, increased protein levels and decreased glucose.

Answer 337

D. If the drug targets an enzyme, production of a structurally different enzyme may allow resistance to occur. Bacteria can acquire resistance to antimicrobial agents. This mainly occurs from genes that encode for bacterial enzymes that block the effect of the antibiotic; these genes are normally found in the plasmids, allowing resistance to be transferred from bacterium to bacterium. Other methods of resistance include, prevention of the drug entering the bacteria, enzyme inactivation, alteration of the antibiotic target site and efflux resistance where the antibiotic is pumped out of the bacteria.

Answer 338

E. Usually caused by tuberculosis Caseous necrosis is where there is a complete loss of normal tissue architecture, replaced by amorphous, granular and eosinophilic tissue. There are varying amounts of fat giving a cheese like appearance. It is seen in tuberculosis.

Answer 339

C. Collagen

Answer 340

E. Not seen in the hands Seen in severe respiratory failure, cardiac causes including shunts, oxygen partial pressure may be normal but most often is not. Someone who has central cyanosis in their hands might look cyanosed as well because their blood is deoxygenated and all of their blood is deoxygenated at all sites

Answer 341

E. Neoplasia - Neoplasia describes autonomously growing tissue. - Dysplasia is disordered cell development. - Hyperplasia is an increase number of cells. - Hypertrophy is an increase in tissue or organ size. - Metaplasia is the change from one cell type to another

Answer 342

D. Streptococcus pneumoniae

Answer 343

E. Predominantly interstitial changes in the lungs on the CT scan

Answer 344

B. Is more likely to respond to aromatase inhibitor

Answer 345

E. Staphylococcus aureus

Answer 346

E. RNA is transcribed using viral polymerase into a positive sense strand. This conversion is required to generate viral RNA that can be used as an mRNA in order to make viral proteins.

Answer 347

B. Fluconazole

Answer 348

C. G2 phase

Answer 349

D. The production of clonal memory cells

Answer 350

C. Live vaccines produce higher levels of antibody

Answer 351

E. Psoriasis

Answer 352

B. Heterosexual sex

Answer 353

C. Ergosterol

Answer 354

D. Production of telomerase to prevent chromosome shortening

Answer 355

D. Skin tethering

Answer 356

A. Stratum basale

Answer 357

The prostatic urethra is commonly obstructed by benign hyperplasia

Answer 358

Seminal vesicles The openings of the ureters are found in the upper two corners of the trigone.

Answer 359

At the base, it has a different cell type make up.

Answer 360

F. Raised serum potassium levels The amount of potassium (K+) in the blood determines the excitability of nerve and muscle cells, including the heart muscle or myocardium. When potassium levels in the blood rise, this reduces the electrical potential and can lead to potentially fatal abnormal heart rhythms. High serum potassium levels also called hyperkalemia can be life threatening and requires immediate therapy. There are several conditions that can significantly affect serum potassium levels and cause them to rise, but renal failure is the most common.

Answer 361

B. Raised blood renin level

Answer 362

I. Reduced serum erythropoietin levels

Answer 363

E. Efferent arteriole * Angiotensin II constricts the artery leading to increased BP. In the kidney Angiotensin II constricts both the afferent and efferent arterioles, but preferentially increases efferent resistance. At least 2 factors may contribute to this response: * The efferent arteriole has a smaller diameter in the basal state; as a result, further constriction at this site will produce a greater increase in resistance than at afferent arteriole. * Angiotensin II stimulates the release of the vasodilator NO from the afferent arteriole, thereby minimizing constriction at this site.

Answer 364

J. Thick ascending loop of Henle Furosemide is a loop diuretic. It inhibits water reabsorption in the nephron by blocking the sodium-potassium-chloride cotransporter in the thick ascending limb of the loop of Henle. This is achieved through competitive inhibition at the chloride binding site on the cotransporter, thus preventing the transport of sodium from the lumen of the loop of Henle into the basolateral interstitium.

Answer 365

J. Thick ascending loop of Henle About 85 to 90% of the filtered bicarbonate is reabsorbed in the proximal tubule and the rest is reabsorbed by the intercalated cells of the distal tubule and collecting ducts.

Answer 366

C. Gentamicin

Answer 367

F. Methyl penicillin

Answer 368

E. Lithium

Answer 369

B. Escherichia coli

Answer 370

E. Pseudomonas aeruginosa

Answer 371

B. A decrease in the concentration of plasma protein As the rate is defined by volume of urine x urine flow/ plasma protein concentration. A decrease in plasma protein will increase GFR.

Answer 372

E. Proximal Convoluted Tubule

Answer 373

A. Clearance volume

Answer 374

D. An abnormality of the basement membrane of the glomerulus An abnormality of the basement membrane of the glomerulus would be found as, oedema of the ankles and face and protein in the urine suggests nephrotic syndrome. The basement membrane is a key component of the filtration barrier (the endothelial cell layer, the basement membrane and the podocytes (epithelial cells).

Answer 375

C. Glomerulonephritis In Glomerulonephritis there may be haematuria and/or proteinuria. However proteinuria is strongly suggestive of a glomerular pathology. A bladder tumour typically produces isolated haematuria (often, but not always, visible), stones usually produce pain (colic) if they are in the ureter or present with infection. Retroperitoneal fibrosis produces renal obstruction at the level of the ureters and progressive renal failure.

Answer 376

C. Hyaline casts Hyaline Casts are seen in normal urine, these are found in healthy individuals who maybe dehydrated or who do vigorous exercise. They are formed from excess (Tamm-Horsfall) protein in the nephrons.

Answer 377

E. Trimethoprim

Answer 378

B. Nitrites in the urine

Answer 379

A. Benign hyperplasia of the prostate gland Benign prostatic hyperplasia is the commonest cause of bladder outflow obstruction leading to renal failure in men. Posterior urethral valves are seen in young boys. Bladder cancer is more likely to cause obstruction at the level of the vesico-ureteric junction, in which case the bladder would be empty.

Answer 380

E. Ultrasound It will demonstrate hydronephrosis in post renal kidney failure. It is therefore the imaging modality of choice in this situation.

Answer 381

D. A Xenobiotic is a substance, typically a synthetic chemical that is foreign to the body or to an ecological system.

Answer 382

B. basic pH aids clearance of acidic drugs Urine pH is critical to if a substance is easily passed into it. Acidic pH aids basic drugs to be excreted, and vica versa.

Answer 383

B. The distal tubule Thiazide diuretics inhibit the sodium-chloride transporter in the distal tubule. This transporter reabsorbs about 5% of filtered sodium, and so thiazides are less powerful than loop diuretics.

Answer 384

E. The proximal tubule

Answer 385

E. Structural abnormality of the urinary tract Recurrent urinary tract infection in a child suggests an underlying cause. The commonest cause would be a structural abnormality of the urinary tract such as vesicoureteric reflux or a duplex system with incomplete drainage. Ascending urinary tract infection occurs when a lower urinary tract infection results in an infection of the kidney (not the other way around). Females can get recurrent UTIs from GI organisms due to the close anatomical relation of ureter and anus. Immunoglobulin deficiency is rare. Urinary tract infection is more likely to lead to bloodstream infection rather than the other way round.

Answer 386

C. Inulin clearance Inulin is the most accurate substance to measure because it is a small, inert polysaccharide molecule that readily passes through the glomeruli into the urine without being reabsorbed by the renal tubules. The steps involved in this measurement, however, are quite involved; consequently, inulin is seldom used in clinical testing, although it is used in research. Creatinine clearance is the more common procedure used to assess renal function.

Answer 387

B. The genitofemoral nerve (branch of lumbar plexus arising within substance of psoas major from union of L1 and L2 spinal nerves)

Answer 388

B. Inferior mesentreic artery

Answer 389

E. Efferent arteriolar vasodilation Inhibition of ACE by ACE inhibitors such as captopril, leads to inhibition of the conversion of angiotensin 1 to angiotensin II. However in addition ACE inactivates Bradykinin, which is a potent vasodilator. Therefore inhibition of ACE leads to elevated bradykinin levels, and vasodilatation.

Answer 390

A. Calcium oxalate

Answer 391

C. Intermediate mesoderm

Answer 392

C. Disruption Amniotic Bands are an example of disruptive congenital defects. Disruption is a destructive process which alters normal structures after their formation.

Answer 393

K. Teratogenesis Rubella is an example of an environmental agent that causes a maternal infection resulting in foetal damage. It is therefore, teratogenesis. A teratogen is an environmental agent that causes abnormalities of form or function in an exposed embryo or foetus. To produce a malformation a teratogen must be present in sufficient amounts at appropriate time in a genetically susceptible individual

Answer 394

G. Sequence Pierre Robin Syndrome is an example of a sequence defect this when there is a pattern of multiple anomalies that occurs when a single primary defect occurs early and produces a cascade of 2º and 3º errors in morphogenesis.

Answer 395

B. Creatine kinase

Answer 396

G. Prolactin

Answer 397

D. Glucose Free glucose on whole blood may be broken down by glycolysis carried out by the cells in the blood. Inclusion of an inhibitor of glycolysis (typically fluoride, to inhibit enolase) prevents breakdown of free glucose.

Answer 398

D. Suicide The leading cause of maternal mortality after birth is suicide and then post-partum haemorrhage. However the commonest cause of direct (i.e. related directly to pregnancy) maternal death is thromboembolism. The most common indirect cause is cardiac disease. Both currently outnumber suicide but in the past suicide has been higher. The list is quite different in developing countries when sepsis, haemorrhage and obstructed labour would be common.

Answer 399

B. Cardiac output increases. Blood glucose rises by a process of hypervolemia. In order to satisfy this need, there is cardiac remodelling, thus maintaining blood pressure.

Answer 400

B. Blood flow across the foramen ovale is from right to left. In the developing foetus the blood flows from the right to the left of the heart through the foramen ovale, until changes occur at birth, this is to prevent blood entering the right ventricle and therefore the under developed lungs. The liver is avoided by the ductus venosus. The ductus arteriosus diverts blood from the pulmonary artery to the aorta.

Answer 401

C. Pulmonary artery to Aorta Ductus arteriosus is a temporary fetal structure that shunts blood from the pulmonary arteries to the aorta, in order to avoid circulating blood through the lungs, which are inactive in the womb.

Answer 402

B. Ductus arteriosus The ligamentum arteriosum (Latin: arterial ligament) is a small ligament that is the remnant of the ductus arteriosus formed within three weeks after birth. In conjunction with the other fetal shunts, the foramen ovale and ductus arteriosus, it plays a critical role in preferentially shunting oxygenated blood to the fetal brain. It is a part of fetal circulation.

Answer 403

D. Placenta to inferior vena cava The ductus venosus shunts a portion of the left umbilical vein blood flow directly to the inferior vena cava. Thus, it allows oxygenated blood from the placenta to bypass the liver. In conjunction with the other fetal shunts, the foramen ovale and ductus arteriosus, it plays a critical role in preferentially shunting oxygenated blood to the fetal brain. It is a part of fetal circulation.

Answer 404

Liver (ductus venosus) | Lungs (ductus arteriosus, foramen ovale)

Answer 405

E. Surfactant works by reducing surface tension within the lung alveoli.

Answer 406

C. The mechanism is not known. Oxytocin is released by positive feedback and key in the events of labour but it is unknown what triggers its release. Naturally, labour does not require the stimulation by the beta-adrenoreceptors in the uterine muscles. During labour there are abrupt falls in the oestrogen but it does not initiate labour

Answer 407

B. Before 24 weeks

Answer 408

C. Discuss the findings with the local social services team. because the history the mum gives does not match the signs a child has.

Answer 409

A. Ampullary-isthmic junction The UTJ is the junction between the oviduct and uterus, through which the blastocyst passes, signifying end of cleavage development. The AIJ is the region where fertilization typically occurs. The fimbriae are the finger-like projections that pick up the ovulated oocyte, the uterus is the organ which supports post implantation development and the ostium is the opening of the oviduct through which the ovulated oocyte is passed.

Answer 410

B. Capacitation - Ejaculation is not required as sperm can be collected from manual extraction from the testis. - However, for normal fertilization a sperm must be capacitated (i.e. have become activated and undergone acrosome reaction) in order to penetrate the cumulus and the zona pellucida. Although binding to the epithelia of the oviduct is observed there is no evidence that this is required for successful fertilization. - Decondensation describes the process occurring to the sperm nuclear material after fertilization and binding to the ZP proteins on the zona pellucida is a key early event in the fertilization process.

Answer 411

E. Zona reaction - The Acrosome reaction describes a process prior to fertilization when the enzymes responsible for digesting through the cumulus are released. - The zona reaction, or block to polyspermy (zona hardening) is the process mediated by the cortical granule release, altering the protein structures on the zone responsible for sperm binding. - Cumulus expansion refers to the mucification and expansion of the granulosa-derived cells that accompany the oocyte after ovulation. While the cumulus plays a role in reducing sperm transit to the egg, it does not specifically prevent polyspermy. - Sperm selection, mediated by binding to the oviduct, reduces the numbers of sperm in the vicinity of the egg, but again does not directly prevent polyspermy. - Capacitation describes the process by which sperm become able to fertilise and oocyte.

Answer 412

A. Acrosome reaction

Answer 413

C. Cumulus expansion While the cumulus plays a role in reducing sperm transit to the egg, it does not specifically prevent polyspermy.

Answer 414

C. Blastocyst

Answer 415

A. Ectoderm - The inner cell mass cells are the cells of the blastocyst that will differentiate into epiblast and hypoblast. In turn, these will differentiate into the 3 key cell types of Endoderm and Ectoderm – both of which contribute to the foetus. - The syncytiotrophoblast derives from the trophectoderm and is the multinucleated cell population that mediates implantation and production of progestogens. - The hypoblast is a derivative of the inner cell mass.

Answer 416

D. Seek advice from a GP - Current guidance is that for all couples who are unsuccessful in becoming pregnant after one year of regular unprotected intercourse that they should seek advice from the GP. - Earlier advice was that for women under 35, they should attempt to become pregnant for two year before seeking advice, but this is no longer accurate. It would be early to seek advice from a fertility clinic directly at this stage, and undertaking IVF with clinical investigation would not be recommended. - Requesting a semen evaluation would not immediately be necessary as there is little indication of male infertility, although this would likely be undertaken if further investigations are carried out.

Answer 417

B. Maternal age - Although there is evidence for declining fertility with advanced paternal age, functional spermatozoa can be produced throughout the male lifetime. Sperm counts are declining, but still, in the general population, remain sufficiently buoyant for healthy fertility. - Ovulatory dysfunction and endometriosis are relatively common specific causes of infertility, however the biggest cause of infertility is the decline in fertility with maternal age, which is linked to follicular (oocyte) reserve, and declines rapidly beyond the age of 35.

Answer 418

C. Formation of the primary villi - Fertilisation and early preimplantation development is nourished by internal embryonic reserves and oviduct cell secretions. - The implanted conceptus relies on histotrophic support from surrounding tissue until the formation of the primary villi establishes heamotrophic support. - Reduction of the chorionic villi and completion of the villus tree describe completion of the development of the villus structure.

Answer 419

D. Mesoderm - The ectoderm contributes to the amnion - The endoderm to the yolk sac - The trophoblast to the chorion - The hypoblast to the endoderm - The mesoderm contributes to all structures of the placenta.

Answer 420

B. Oestradiol - Progesterone and pregnenolone are produced by the placenta from the precursor cholesterol. - In order to make oestradiol, progesterone must be converted into 17a-hydroxy-pregnenolone-sulphate which requires the foetal adrenals. Somatomammotropin is synthesized by the placenta directly.

Answer 421

C. To ensure financial obligations are met in terms of balancing income

Answer 422

D. Size of current family

Answer 423

C. Immuno-reactive trypsin

Answer 424

A. Scrutinises public spending on behalf of parliament and reports on the economic, efficient and effective use of public money by government bodies

Answer 425

E. Tell the national reporting and learning system

Answer 426

A. Choice of dose

Answer 427

C. The local authority

Answer 428

E. Prolactin by the anterior pituitary gland

Answer 429

D. 2 years

Answer 430

E. Type II diabetes

Answer 431

D. Transposition of the great arteries

Answer 432

H. Phenytoin

Answer 433

F. Lamotrigine

Answer 434

D. Ethosuximide

Answer 435

B. Facial nerve lower motor neurone

Answer 436

A. Abducens nerve

Answer 437

H. Trigeminal nerve

Answer 438

B. Lateral spinothalamic tracts The VIII cranial nerve (vestibulcochlear) is responsible for balance and hearing, the saccule, semicircular canals and visual cues are all important in the maintenance of balance. The lateral spinothalamic tracts transmit pain sensation, they are therefore not required in balance maintenance.

Answer 439

A. The oculomotor nerve - Pupil dilation is controlled by the oculomotor nerve. - The ophthalmic division of the trigeminal nerve supplies sensation around the eye.

Answer 440

B. Cribriform plate

Answer 441

D. Leaves the skull through the stylomastoid foramen The facial nerve supplies the posterior belly of the digastric muscle, contains taste fibres from the anterior two-thirds of the tongue, innervates muscles of the face (motor), and supplies parasympathetic innervation to the submandibular and sublingual glands

Answer 442

B. The ossicles are united by means of the synovial joints. The middle ear isn’t drained by the auditory tube just communicates with the nasopharynx. The chorda tympani crosses the inner surface of the tympanic membrane. The oval window is closed by the stapes and the tensor tympani is supplied by the trigeminal nerve.

Answer 443

A. Cauda equina Cauda equine syndrome involves cord compression and produces bilateral symptoms both sensory sacrum, perineum and motors defect to the lower limbs.

Answer 444

B. Right hypoglossal nerve Lesions to this nerve are commonly extracranial it is purely motor to the tongue

Answer 445

D. Substantia nigra A lesion in substantia nigra would create Parkindsonian symptoms

Answer 446

B. Impaired vibration sense in the feet Subacute combined degeneration of the cord is caused by a vit B12 deficiency causing degeneration of the posterior columns of the cord, causing an impaired vibration sense in the feet Absent ankle jerks and upgoing plantars combined motor and sensory loss.

Answer 447

C. Berry aneurysm A subarachnoid Haemorrhage is primarily caused by berry aneurysm, which occur in relation to the circle of Willis. There is an association with adult polycystic kidney syndrome but most are idiopathic.

Answer 448

E. Vestibular nerve damage A, B and D Blocked Eustachian tube, earwax and otitis media (middle ear infection) are more likely to cause conductive hearing loss, and bone conduction would be louder than air conduction. Vestibular nerve damage would cause vertigo (dizziness) as it affects the sense of balance, not hearing. Hair cells in the cochlea that displace in response to sound are easily damaged by prolonged exposure to loud noise.

Answer 449

B. Ciliary

Answer 450

Rumbling, mid diastolic, loud S1 | Early diastolic opening snap

Answer 451

H. Whooping cough 90% of cases occur in below the age of 5. Incubation period 7-10 days. Symptoms similar to upper respiratory tract infection with a cough & nasal discharge; >90% of cultures from respiratory secretions positive for B. pertussis. Cough becomes acute with paroxysms of coughing-with classic inspiratory whoop; paroxysms often followed by vomiting.

Answer 452

G. Lobar pneumonia S. pneumonia commonest pathogen causing lower respiratory tract infection (60-75% of cases) in all age groups. Lobar pneumonia affects lung parenchyma causing whole areas of lung consolidation; the consolidation results in bronchial breathing. Chest X-ray shows a distinct area of shadowing. Other features include dry cough and purulent sputum, pleuritic pain, rigors and sometimes pleural effusion.

Answer 453

D. Broncho pneumonia Patchy shadowing = broncho rather than lobar pneumonia Bronco pneumonia affects lung parenchyma (mainly alveoli) in a patchy fashion. Causes breathlessness, chest pain, cough and sputum, with lung crackles; chest X-ray shows patchy shadowing.

Answer 454

H. Verapamil 4. Verapamil belongs to the Class IV antiarrhythmic drugs that are calcium antagonists (they block the voltage-sensitive calcium channels) and slow conduction (action potential upstroke) in the SA and AV nodes.

Answer 455

E. Digoxin Digoxin is a cardiac glycoside. It acts to cause a cardiac slowing and reduced rate of conduction through the AV node (by increasing vagal outflow) and increases the force of contraction. Acts via inhibition of the Na+/K+ pump. The increased intracellular Na+ slows extrusion of Ca2+ via the Na+/ Ca2+ exchanger decreasing Ca2+ extrusion and thus increased Ca2+ is stored in the SR and available on release. Digoxin is used to slow the ventricular rate in rapid persistent atrial fibrillation. Also used in patients with heart failure who remain symptomatic despite optimal treatment.

Answer 456

D. Atenolol (betablocker) Atenolol is a Class II antiarrhythmic β1-selective-Adrenoceptor antagonist. It diminishes the Phase 4 depolarisation, thus suppressing automaticity, prolonging AV conduction and decreasing heart rate and contractility. Class II drugs are useful in the treatment of tachyarrhythmias caused by increased sympathetic activity. It is also used for atrial flutter and fibrillation and for AV-nodal re-entrant tachycardia.

Answer 457

D. Dobutamine • Dobutamine is a predominantly β1 adrenoceptor agonist and α1 selective activity with some weak β2 activity. It is used to treat acute but potentially reversible heart failure (cardiogenic shock or septic shock) for its β1 inotropic effect in increasing heart contractility and cardiac output.

Answer 458

H. Spironolactone • Spironolactone is an aldosterone antagonist used to treat chronic heart failure acting in the collecting ducts to increase sodium and water excretion. The decrease in fluid volume helps relieve the pulmonary oedema and the symptoms of heart failure.

Answer 459

I. Verapamil • Verapamil worsens cardiac failure by having a negative inotropic effect from blocking calcium channels. It acts on the L-type calcium channels. It is therefore contraindicated in heart failure.

Answer 460

H. Staphylococcus aureus • In general, Staph. Aureus causes pneumonia only after a preceding influenza viral illness. The infection commences in the bronchi, leading to patchy areas of consolidation in one or more lobes, which break down to form abscesses. Infection with this bacterium is often seen in intravenous drug abusers and patients with central catheters being used for parenteral nutrition. The infected puncture site is the source of the Staph. Aureus.

Answer 461

B • Haemophilus influenzae is divided into typeable or nontypeable strains based on the presence or absence of a polysaccharide capsule. Nontypeable Haemophilus influenzae is a bacterium that is present in the nasopharynx of most healthy adults and in this situation it appears to be a commensal. It may also spread down to the lower respiratory tract and in these locations it has been well recognized to be associated with inflammation and disease. In this context it is no longer a commensal and becomes an important respiratory pathogen associated with a range of common conditions including bronchitis, bronchiectasis, pneumonia, and particularly chronic obstructive pulmonary disease.

Answer 462

F. It is an opportunistic infection that accounts for 50% of the cases of pneumonia in these patients. Infection is associated with a high fever, breathlessness and a dry cough.

Answer 463

A. Atrial flutter Digoxin blocks the exchange of intracellular Na+ for extracellular K+ by inhibiting the Na+/K+-ATPase in the cell membrane; this leads to an increases intracellular Ca2+ and causing positive inotropic effect. In addition, digoxin stimulates the vagus and increases vagal tone, which slows the heart down in atrial fibrillation and flutter.

Answer 464

A. Cardiac arrhythmias Angiotensin converting enzyme inhibitors are useful for diabetic nephropathy, hypertension, left ventricular failure, prophylaxis of ischaemic heart disease as they prevent the formation of angiotensin II which is causes vasoconstriction. They would have no effect in cardiac arrhythmias.

Answer 465

A. Has a negative inotropic effect on the heart The principle action of calcium channel blockers is its negative inotropic effect on the heart. Interfere with inward displacement of calcium ions through slow channels (L-type channels) of active cell membranes. Different preparations have different principal sites of action either cardiac or peripheral (vasculature).

Answer 466

B. Metastatic carcinoma Canon ball lesions in all lung fields are indicative of metastatic cancer. Typical sites for the primary tumour includes kidney, prostate, breast, bone GI tract, cervix or ovary. Multiple lesions are characteristic of secondaries. Miliary TB the snow storm pattern is often seen. Sarcoidosis and bronchial carcinoma may show hilar prominence due to hilar lymphadenopathy.

Answer 467

A. The atria are fibrillating An irregular pulse with absent P waves in indicative of atrial fibrillation. Nodal rhythms still see P waves but are dissociated. SA node sinus rhythm may not be regular in a number of conditions affecting downstream conduction. Problem with bundle of His heart block; this can give rise to right or left bundle block. Idioventricular rhythm heart block; if there is complete heart block no P waves from the atria are conducted to the ventricles. The rate is 30-45 bpm and the QRS complexes are wide (>0.12sec) with a wide and bizarre configuration. Cells of the His-Purkinje system can take over and act as the heart’s pacemaker.

Answer 468

E. Increased end-diastolic volume Increasing the cardiac pre-load due to an increased blood volume will cause an increased end-diastolic volume. According to starling’s law this should increase the force of contraction but may not in the failing heart.

Answer 469

B. Legionella pneumophilia The symptoms of L. pneumophilia are often vague with malaise, headache, myalgia, fever with rigors and a pyrexia up to 400C. The hyponatraemia distinguishes L. pneumophilia infection from other pneumonias.

Answer 470

C. Damage to the phrenic nerve Damage to the phrenic nerve can be recognised by its permanent elevation and a paradoxical breathing pattern in which the anterior abdominal wall moves inwardly during inspiration and outwardly with forced expiration. Phrenic nerve palsy has many causes, and can be caused by lesions anywhere along the course of the phrenic nerve, as it travels from the neck, to pierce the diaphragm adjacent to the pericardium.The other options are incorrectA. A pneumonthorax of this size would cause some collapse of the lung and a minimal amount of elevation of the diaphragm in this case, but some diaphragmatic movement on breathing would be seen with the ultrasound.B. A congenital deformity of the diaphragm often leads to rupture of the diaphragm and herniation of the diaphragm which would be clearly evident on the radiograph.D. A consolidation of the lower lobes will reveal dullness on percussion, but will often obscure the crisp contour of the adjacent hemi-diaphragm. So this is unlikely to cause a hemi-diaphragm.E. As the name suggests, it is confined to the anterior mediastinum , that portion of the mediastinum anterior to the pericardium and below the level of the

Answer 471

E. Receives lymph from the pelvis and abdomen Receives lymph from the pelvis and abdomenThe other options are incorrect.The thoracic duct drains lymph from the left side of the head, neck, the upper left limb and from the lower limbs, pelvic cavity and abdominal cavity. The right lymphatic duct collects lymph from the right jugular trunk, which drains the right side of the head and neck; the right subclavian trunk, which drains the upper extremity; and the right bronchomediastinal trunk, which drains the right side of the thorax, right lung, right side of the heart and part of the liver.The thoracic duct usually empties into the venous system near the union of the left internal jugular and subclavian veins; the left venous angle.The thoracic duct enters the thoracic cavity through the aortic hiatus and ascends to the right of the midline in the posterior mediastinum between the aorta and azygos vein, posterior to the oesophagus.The thoracic duct is posterior to the oesophagus.

Answer 472

B. Theophylline has a very narrow therapeutic index So not much of a range between a therapeutic and toxic dose; thus monitoring of plasma theophylline is required, which is measured after 5 days of starting treatment. Start with low dose.

Answer 473

A. First dose hypotension ACE inhibitors have an important side effect of first dose hypotension especially in those on high dose diuretics or dehydration or on dialysis.

Answer 474

E. Troponin 1 Cardiac troponins: troponin C (TnC) and troponin I(TnI) ) are biological markers of cardiac muscle necrosis, and are now used for diagnosing MI. Highly sensitive tests now exist for both TnC and TnI, allowing results to be obtained within 4 hours of presentation to A&E. Lactic dehydrogenase (LDH) activity is widespread in the body and an increase in LDH is not specific to diagnose an MI and is no longer used.

Answer 475

Gentamicin Gentamicin is an antibiotic that can be given via injection or intravenous. It is part of the aminoglycoside family of antibiotics, which work via either preventing the growth of bacteria, or inducing bacterial death. It therefore does not work to prevent colds, or flu infections. It is typically used for serious gram negative bacterial infections which are difficult to treat with other antibiotics. However, it may also cause some serious side effects, including damage to your kidneys and the cochlea in the inner ear, which controls hearing and balance. The clearance of Gentamicin depends on both your kidney function and body weight.

Answer 476

Methyl penicillin Methyl penicillin is more commonly known as Penicillin V and is less effective than Penicillin G against gram-negative bacteria, but shows similar activity against gram positive bacteria. However it is more acid stable than Penicillin G and therefore can be given orally. Probenecid blocks the proximal tube secretion of penicillin by the kidney and therefore increases the penicillin plasma concentration.

Answer 477

B Glomerular filtration rate (GFR) is a test used to check how well the kidneys are working. Specifically, it estimates how much blood filtered through the glomeruli into Bowman’s space each minute. As the rate is defined by volume of urine x urine flow/ plasma protein concentration a decrease in plasma protein will increase GFR.

Answer 478

F. Monofunctional alkylation of DNA and protein

Answer 479

H. Topoisomerase inhibition

Answer 480

A. Bifunctional alkylation of DNA and protein

Answer 481

A. Basophils

Answer 482

H. Neutrophils

Answer 483

H. Rubella

Answer 484

J. Troisier's sign

Answer 485

Inhibits nucleuic acid synthesis

Answer 486

Inhibits protein synthesis

Answer 487

Membranous glomerulopathy Focal segmental glomeruloscleoris Diabetic nephropathy SLE Amyloidosis

Answer 488

Minimal change nephropathy | Focal segmental glomerulosclerosis

Answer 489

Haemolytic uraemic syndrome Henoch-schonlein purpura (IgA vasculitis) Post-streptococcal GN

Answer 490

Goodpasture's ANCA-associated vasculitis Primary or secondary mesangiocapillary GN SLE