Académique Documents
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-SBA-1-85
1. You review a 39-year-old sportsman who complains of knee pain. Arthroscopy reveals damage to the cartilage.
Which of the following stems best describes a property of hyaline cartilage?
It is avascular
Correct answer
Malabsorption of calcium
Malabsorption of vitamin D
Impaired fat absorption can lead to the formation of insoluble calcium salts in the gut. Fat and calcium are absorbed in the
proximal small intestine, so, too, is vitamin D. Although bile salts are absorbed distally, and impaired absorption can lead to a
secondary decrease in proximal fat absorption, this is unlikely to be responsible for hypocalcaemia developing so quickly. The
normal alkaline phosphatase level also mitigates against vitamin D deficiency. Hypocalcaemia would normally be expected to
stimulate parathyroid hormone secretion and cause the plasma phosphate concentration to fall (PTH is phosphaturic). Patients
with ileostomies can lose large amounts of magnesium through their stomas; hypomagnesaemia impairs PTH secretion and
can cause hypocalcaemia that is resistant to an increased provision of calcium.
4. A patient receives too many infusions after an operation resulting in a 20% increase in his blood volume.
What is the physiological process that is most likely to correct this abnormality?
Correct answer
Venous dilatation
The atria contain granulated cells that release peptides, atrial natriuretic peptide (ANP), in response to stretch. This natriuretic
agent also relaxes the peripheral vasculature and thereby opposes the actions of the sympathetic and reninangiotensin
systems.
5. In metabolic alkalosis associated with prolonged nasogastric aspiration in postoperative ileus, what is the most important
cause of the acidbase disturbance?
Hypoventilation
Increased renal bicarbonate reabsorption
Loss of gastric acid
Correct answer
Potassium depletion
Secondary aldosteronism
Loss of unbuffered gastric acid is the cause of the metabolic alkalosis seen under these circumstances if there is inadequate
replacement of the fluid lost with intravenous physiological saline. Increased renal bicarbonate reabsorption (needed to allow
adequate renal sodium reabsorption in the presence of hypochloraemia), potassium depletion (gastric secretions contain about
10 mmol/l of potassium) and secondary aldosteronism (a result of extracellular fluid loss) all help to maintain the alkalosis, but
they do not cause it. Hypoventilation is a compensatory change: on its own, hypoventilation causes carbon dioxide retention
and a respiratory acidosis.
6. An overweight 32-year-old woman presents with a short history of painless jaundice. There is no previous history of illness
and, apart from the jaundice, she has no signs of chronic liver disease. Initial investigations reveal a haemoglobin of 12.7 g/dl,
MCV 105 fl, serum bilirubin 162 mmol/l, AST 145 U/l, alkaline phosphatase 224 U/l, gamma-glutamyltransferase 200 U/l.
Which of the following is the most likely diagnosis?
Alcoholic liver disease
Correct answer
Correct answer
Hereditary spherocytosis
Infectious mononucleosis
Rotor syndrome
DubinJohnson, Rotor and Gilberts syndromes are all inherited disorders of bilirubin metabolism. However, in the first two,
there is a defect in the secretion of bilirubin from the liver and the bilirubin that accumulates in the plasma is conjugated, watersoluble and thus is excreted in the urine.
Infectious mononucleosis can cause hepatitis and jaundice but an elevated transaminase activity would be expected.
Hereditary spherocytosis is a chronic haemolytic disorder due to a defect in the red cell membrane (most frequently in spectrin,
a structural protein). It can present with a wide range of severity, from jaundice at birth to asymptomatic anaemia or jaundice in
adults, but is much less common (approximately 1:5000 in Northern Europeans) than Gilberts syndrome (approximately 1:20).
10. A 20-year-old man presents with mild jaundice following a flu-like illness. Following review by a gastroenterologist, he has
been told that a diagnosis of Gilberts syndrome is probable.
Which laboratory test is most likely to confirm this diagnosis?
Correct answer
Correct answer
12. A 42-year-old man is put on a proton-pump inhibitor to suppress symptoms of oesophagitis. The cell and membrane
biology of the gastric acid pump has which of the following features?
Correct answer
The proton pump spans the basolateral membrane of the gastric parietal cell
The H+K+-ATPase is embedded in the apical membrane. The channel is susceptible to agents that bind to cysteine residues
(particularly 813 and 822). The proton pump is the final common pathway of histamine and acetylcholine-stimulated production,
and particularly explains the enhanced efficacy of proton-pump inhibitors in comparison to H2 antagonists or acetylcholine
antagonists (eg pirenzepine).
13. A patient undergoes respiratory function tests. Which of the following are normal readings for a 70-kg man?
Correct answer
520700 l/min
56.5 litres
23 litres
500700 ml
14. Which of the following respiratory physiology tests would be consistent with a diagnosis of moderately established
cryptogenic fibrosing alveolitis?
Correct answer
Correct answer
Correct answer
Correct answer
Correct answer
The first 12 branches of the bronchial tree are collectively known as the conducting zone
The equilibration of gases takes about 2.5 s in the resting lung
Only about 0.15% of oxygen is carried in solution in the plasma
Carbon dioxide is less water-soluble than oxygen
Gas exchange can occur in the final seven branches of the bronchoalveolar tree (the respiratory zone). The first 16 branches of
the bronchial tree are collectively known as the conducting zone. The equilibration of gases takes about 0.25 s in the resting
lung. Only about 1.5% of oxygen is carried in solution in the plasma. Carbon dioxide is more water-soluble than oxygen,
between 5 and 10% of and this is the predominant method of carriage of CO2 is carried in dissolved form.
19. Which one of the following is MOST likely to increase during exercise?
Stroke volume
Diastolic pressure
Venous compliance
During exercise, increased oxygen consumption and increased venous return to the heart result in an increase in cardiac
output and an increase in blood flow to both skeletal muscle and coronary circulation, when oxygen utilization is greatest. The
increase in cardiac output is due to an increase in both heart rate and stroke volume. Syst
20. Which one of the following is higher at the apex of the lung than at the base when a person is standing?
V/Q ratio
Correct answer
Ventilation
PaCO2
Compliance
Blood flow
The alveoli at the apex of the lung are larger than those at the base so their compliance is less. Because of the reduced
compliance, less inspired gas goes to the apex than to the base. Also, because the apex is above the heart level, less blood
flows through the apex than through the base. However, the reduction in air flow is less than the reduction in blood flow, so that
the V/Q ratio at the top of the lung is greater than it is at the bottom. The increased V/Q ratio at the apex makes PaCO2 lower
and PaO2 higher at the apex than they are at the base
21. A 56-year-old woman sustains a myocardial infarction. ST elevation and Q waves are present in leads V4V6, I and AVL.
Which of the following aspects of the heart is most likely to have been involved in the infarct?
Anterior
Anterolateral
Correct answer
Anteroseptal
Inferior
Lateral
This combination suggests an anterolateral infarct. Purely anterior infarcts tend to involve the chest leads only (typically V2V5),
anteroseptal V1V3, lateral infarcts chest leads only (I, II, AVL) and inferior infarcts II, III and AVF.
22. High titres of antithyroid microsomal and antithyroglobulin antibodies would suggest which of the following diagnoses in a
patient presenting with a complaint of tiredness?
Single best answer - choose ONE true option only
Hashimotos thyroiditis
Correct answer
Reidels thyroiditis
Graves disease
Hypoparathyroidism
Idiopathic hypothyroidism
This finding in Hashimotos thyroiditis is characteristic, but lower titres can occur in Reidels thyroiditis and Graves disease.
High titres of these antibodies in euthyroid individuals indicate the possibility of future thyroid failure, but this may be many
years away; hence the need for thyroid function tests every 12 years in such individuals.
23. An elderly man with a history of prostatism presents with acute retention of urine. His serum creatinine concentration is 520
mmol/l.
Which of the following additional abnormal serum biochemistry test results is most suggestive of a chronic component to his
renal failure?
Single best answer - choose ONE true option only
Hyperkalaemia
Hyperuricaemia
Hypocalcaemia
Correct answer
Hyponatraemia
Low serum bicarbonate concentration
Hyperkalaemia and hyperuricaemia (due to decreased excretion), hyponatraemia (due mainly to continued water intake with
decreased ability to excrete it) and metabolic acidosis occur in both acute and chronic renal failure. The presence of
hypocalcaemia in renal failure suggests that this is, at least in part, of longstanding, and is due to decreased renal synthesis of
calcitriol (1,25-dihydroxycholecalciferol).
24. A 71-year-old man with known chronic obstructive pulmonary disease is admitted to A&E with severe shortness of breath.
Blood gas analysis shows: arterial [H+] 55 nmol/l (pH 7.26), p(CO2) 9.4 kPa, p(O2) 9.1 kPa, derived [HCO3] 31 mmol/l.
Which of the following types of acidbase disturbance is most likely?
Correct answer
Goblet cells
Kupffer cells
Peptic cells
Chief cells
Correct answer
Parietal cells
Goblet cells are mucus-secreting cells, widely distributed throughout epithelial surfaces, but especially dense in the
gastrointestinal and respiratory tracts.
Kupffer cells have phagocytic properties and are found in the liver. They participate in the removal of ageing erythrocytes and
other particulate debris.
The gastric mucosa contains many cell subtypes, including acid-secreting cells (also known as parietal or oxyntic cells), pepsin
secreting cells (also known as peptic, chief or zymogenic cells) and G-cells (gastrin-secreting cells). Peptic cells synthesise and
secrete the proteolytic enzyme, pepsin. Parietal cells actively secrete hydrochloric acid into the gastric lumen, accounting for
the acidic environment encountered in the stomach. However parietal cells are also involved in the secretion of the
glycoprotein, intrinsic factor.
Intrinsic factor plays a pivotal role in the absorption of vitamin B12 from the terminal ileum. Autoimmune damage to parietal
cells leads to a lack of intrinsic factor and hydrochloric acid, leading to vitamin B12 deficiency and achlorhydria. This is known
as pernicious anaemia. Pernicious anaemia is associated with a 3-fold increase in gastric cancer risk.
26. Splenectomy increases susceptibility to which of the following organisms?
Streptococcus pyogenes
Schistosoma haematobium
Bacteroides fragilis
Neisseria meningitidis
Correct answer
Staphylococcus aureus
The spleen plays an important role in the removal of dead and dying erythrocytes and in the defence against microbes.
Removal of the spleen (splenectomy) leaves the host susceptible to a wide array of pathogens, but especially to encapsulated
organisms.
Certain bacteria have evolved ways of evading the human immune system. One way is through the production of a slimy
capsule on the outside of the bacterial cell wall. Such a capsule resists phagocytosis and ingestion by macrophages and
neutrophils. This allows them not only to escape direct destruction by phagocytes, but also to avoid stimulating T-cell
responses through the presentation of bacterial peptides by macrophages. The only way that such organisms can be defeated
is by making them more palatable by coating their capsular polysaccharide surfaces in opsonising antibody.
The production of antibody against capsular polysaccharide primarily occurs through T-cell independent mechanisms. The
spleen plays a central role in both the initiation of the antibody response and the phagocytosis of opsonised encapsulated
bacteria from the bloodstream. This helps to explain why the asplenic individuals are most susceptible to infection from
encapsulated organisms, notably Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus) and
Haemophilus influenzae.
The risk of acquiring such infections is reduced by immunising individuals against such organisms and by placing patients on
prophylactic penicillin, in most cases for the rest of their lives. In addition, asplenic individuals should be advised to wear a
MedicAlert bracelet to warn other health care professionals of their condition.
27. Cardiac output is decreased:
Correct answer
Stimulation of the sympathetic nervous system results in a rise in heart rate and stroke volume and therefore cardiac output
increases. Cutting the vagus nerves to the heart results in an increase in heart rate because of the abolition of vagal tone and
therefore cardiac output increases.
If the end diastolic volume of the heart (pre-load) is increased, under normal physiological circumstances, cardiac output is
increased by the Frank-Starling mechanism. The exception is in the failing heart where the Law of LaPlace becomes more
important and cardiac output actually falls.
Arterial blood pressure is homeostatically regulated through the action of baroreceptors, principally located in the carotid sinus
and the wall of the aortic arch. If the carotid sinus pressure is reduced, the baroreceptors become inactive and lose their
inhibitory effect on the vasomotor centre in the brainstem. The result is activation of the sympathetic nervous system. This
produces a rise in heart rate, stroke volume, mean systemic filling pressure and venous return, leading to an increase in
cardiac output and return of the mean arterial blood pressure to its original value.
Cardiac output falls when one stands up due to the pooling of blood on the venous side of the circulation, which has a large
capacitance. Stepping out of a hot bath exacerbates this pooling effect because superficial cutaneous veins dilate in response
to heat, increasing their capacitance even further. Under normal circumstances, activation of the baroreceptor reflex
compensates to some degree, preventing syncope. However, in the elderly, or in patients on anti-hypertensives, inadequate
compensation from the baroreceptor reflex may result in a vasovogal syncope, or othostatic hypotension.
28. Flow through a vessel or lumen is:
Correct answer
The Hagen-Poiseuille law states that the flow through a vessel is:
Directly proportional to the pressure head of flow
Directly proportional to the fourth power of radius
Inversely proportional to the viscosity
Inversely proportional to the length of the tube
The radius of the tube is therefore the most important determinant of flow through a blood vessel. Thus, doubling the radius of
the tube will lead to a 16-fold increase in flow at a constant pressure gradient. The implications of this are several fold.
First, owing to the fourth power effect on resistance and flow, active changes in radius constitute an extremely powerful
mechanism for regulating both the local blood flow to a tissue and central arterial pressure. The arterioles are the main
resistance vessels of the circulation and their radius can be actively controlled by the tension of smooth muscle within its wall.
Second, in terms of intravenous fluid replacement in hospital, flow is greater through a peripheral cannula than through central
lines. The reason is that peripheral lines are short and wide (and therefore of lower resistance and higher flow) compared to
central lines, which are long and possess a narrow lumen. A peripheral line is therefore preferential to a central line when
urgent fluid resuscitation, or blood, is required.
29. In a lung function test, the functional residual capacity:
Correct answer
Is that volume of air that remains in the lung after forced expiration
Spirometry traces are easy to understand if you remember the following two rules:
1. There are 4 lung volumes and 5 capacities that you need to remember.
2. A capacity is made up of 2 or more lung volumes
The 4 lung volumes are:
Tidal volume = volume of air inspired or expired with each normal breath in quiet breathing; approximately 500mls. Residual
volume = that volume of air that remains in the lung after forced expiration. Inspiratory reserve volume = extra volume of air
that can be inspired over and above the normal tidal volume. Expiratory reserve volume = extra volume of air that can be
expired by forceful expiration after the end of a normal tidal expiration.
The 5 lung capacities are:
Functional residual capacity = that volume of air that remains in the lung at the end of quiet expiration. Equal to the sum of the
residual volume and the expiratory reserve volume. Inspiratory capacity = inspiratory reserve volume + tidal volume Expiratory
capacity = expiratory reserve volume + tidal volume Vital capacity = inspiratory reserve volume + tidal volume + expiratory
reserve volume (or total lung capacity residual volume) Total lung capacity = vital capacity + residual volume
The residual volume (and therefore functional residual capacity and total lung capacity) cannot be measured directly by
spirometry. They are measured by either whole body plethysmography, or by using the helium dilution or nitrogen washout
techniques.
30. Lung compliance:
Correct answer
Testosterone
Oxytocin
TSH
Correct answer
CRH
ADH
The pituitary gland (hypophysis) is the conductor of the endocrine orchestra. It is divided into both an anterior part and posterior
part. The anterior pituitary (adenohypophysis or pars distalis) secretes 6 hormones namely:
FSH/LH: Reproduction
ACTH: Stress response
TSH: Basal metabolic rate
GH: Growth
Prolactin: Lactation
The posterior pituitary (neurohypophysis or pars nervosa) secretes only 2 hormones:
ADH (vasopressin): Osmotic regulation
Oxytocin: Milk ejection and labour
Testosterone is produced from Leydig cells in the testis and from the adrenal glands. CRH is produced by the median
eminence of the hypothalamus.
32. The Haemoglobin Oxygen-Dissociation Curve is shifted to the left by:
An increase in pCO2
A fall in pH
10
A rise in temperature
An increase in 2,3-DPG
Correct answer
Fetal haemoglobin
The haemoglobin oxygen dissociation curve is sigmoidal in shape which reflects the underlying biochemical properties of
haemoglobin. The significance of the sigmoidal curve is that haemoglobin becomes highly saturated at high oxygen partial
pressures (and is therefore highly efficient at collecting oxygen), and releases a significant amount of oxygen at pressures
which are fairly low, but not extremely so (with the result that haemoglobin is highly effective at supplying oxygen where it is
needed).
The effect of things that shift the curve to the right (raised CO2, lowered pH, increased temperature, increase in 2,3-DPG) is to
increase oxygen availability in the tissues. The effect of CO2/H+ on O2 carriage is known as the Bohr shift or effect. This is
exactly what is needed in metabolising tissues; release of acids or CO2 thus liberates O2 to fulfil the metabolic needs of the
tissue. Do not confuse this with the effect of changes in O2 on CO2 carriage which is called the Haldane effect.
A shift of the oxygen dissociation curve to the left is characteristic of fetal haemoglobin. When compared with adult
haemoglobin, it is composed of 2 alpha and 2 gamma chains, instead of the usual 2 alpha and 2 beta chains of adult
haemoglobin. This arrangement assists in the transfer of oxygen across the placenta from the maternal to the fetal circulation.
The corollary of this is that fetal tissue oxygen levels have to be low to permit the release of oxygen from the haemoglobin.
33. Which of the following cells is cytotoxic?
CD4 T-cells
CD8 T-cells
Correct answer
B cells
TH1 cells
TH2 cells
Lymphocytes can be divided into two main subtypes T cells and B cells.
B cells (or plasma cells) secrete antibodies.
T cells can be divided into two further subtypes CD4 T-cells and CD8 T-cells. CD4 (helper) T-cells can recognise antigen only
in the context of MHC Class II, whereas CD8 (cytotoxic) T-cells recognise cell-bound antigens only in association with Class I
MHC. This is known as MHC restriction.
CD4 and CD8 T-cells perform distinct but somewhat overlapping functions. The CD4 helper T-cell can be viewed as a master
regulator. By secreting cytokines (soluble factors that mediate communication between cells), CD4 helper T-cells influence the
function of virtually all other cells of the immune system including other T-cells, B-cells, macrophages and natural killer cells.
The central role of CD4 cells is tragically illustrated by the HIV virus which cripples the immune system by selective destruction
of this T-cell subset. In recent years two functionally different populations of CD4 helper T-cells have been recognised TH1
cells and TH2 cells, each characterised by the cytokines that they produce. In general, TH1 cells facilitate cell-mediated
immunity, whereas TH2 cells promote humoral-mediated immunity.
CD8 cytotoxic T-cells mediate their functions primarily by acting as cytotoxic cells (i.e. they are T-cells that kill other cells). They
are important in the host defence against cytosolic pathogens. Two principal mechanisms of cytotoxicity have been discovered
perforin-granzyme-dependent killing and Fas-Fas ligand dependent killing.
34. A 3-week-old baby exhibits projectile vomiting shortly after feeding and failure to thrive. On examination an olive-shaped
mass is palpable in the right upper quadrant of the abdomen. A clinical diagnosis of pyloric stenosis is made. What biochemical
laboratory features would support the diagnosis?
Correct answer
11
Fluid loss stimulates renal sodium reabsorption, but sodium can only be reabsorbed either with chloride, or in exchange for
hydrogen and potassium ions (to maintain electroneutrality). Gastric juice has a high concentration of chloride and patients
losing gastric secretions become hypochloraemic. This means that less sodium than normal can be reabsorbed with chloride.
However, it appears that the defence of extracellular fluid volume takes precedence over acid-base homeostasis and further
sodium reabsorption occurs in exchange for hydrogen ions (perpetuating the alkalosis) and potassium ions (leading to
potassium depletion). This explains the apparently paradoxical finding of acidic urine in patients with pyloric stenosis.
Potassium is also lost in the gastric juice and thus patients frequently become potassium-depleted and yet are losing
potassium in their urine.
35. Normal Cerebrospinal fluid (CSF):
Correct answer
The GFR is the main factor determining the rate of urine production
GFR can be measured by para-aminohippuric acid (PAH)
The normal GFR is 50mls/min
Inulin clearance can be used to estimate GFR
Correct answer
Somatostatin
Gastrin
Correct answer
12
Secretin
The glossopharyngeal nerve
Cholecystokinin
Gastric acid is stimulated by 3 factors:
Acetylcholine: From parasympathetic neurones of the vagus nerve that innervate parietal cells directly.
Gastrin: produced by pyloric G-cells.
Histamine: Produced by mast cells. This stimulates the parietal cells directly and also potentiates parietal cell stimulation by
gastrin and neuronal stimulation. H2 blockers such as ranitidine are therefore an effective way of reducing acid secretion.
Gastric acid is inhibited by 3 factors:
Somatostatin
Secretin
Cholecystokinin
There are 3 classic phases of gastric acid secretion:
Cephalic (preparatory) phase [significant]: Results in the production of gastric acid before food actually enters the stomach.
Triggered by the sight, smell, thought and taste of food acting via the vagus nerve.
Gastric phase [most significant]: Initiated by the presence of food in the stomach, particularly protein rich food.
Intestinal phase [least significant]: The presence of amino acids and food in the duodenum stimulate acid production.
38. Carbon dioxide is principally transported in the blood in the form of:
Bicarbonate
Carbaminohaemoglobin
Carbonic anhydrase
Magnesium influx
Potassium influx
Calcium influx
Correct answer
Chloride efflux
Sodium influx
The most important source of activator calcium in cardiac muscle remains its release from the sarcoplasmic reticulum. Calcium
however also enters from the extracellular space during the plateau phase of the action potential. This calcium entry provides
the stimulus that induces calcium release from the sarcoplasmic reticulum (calcium induced calcium release).
The result is that tension generated in cardiac, but not in skeletal, muscle is profoundly influenced both by extracellular calcium
levels and factors that affect the magnitude of the inward calcium current. This is of practical value in two key clinical situations;
13
in heart failure where digoxin is utilised to increase cardiac contractility (by increasing the intracellular calcium concentration)
and in hyperkalaemia where calcium gluconate is used to stabilise the myocardium.
The plateau phase of the action potential in cardiac muscle (principally due to calcium influx) maintains the membrane at a
depolarised potential for as long as 500ms. The result is that the cell membrane is refractory throughout most of the
mechanical response, largely due to the inactivation of fast sodium channels. This prevents tetany upon repetitive stimulation
which would be detrimental to cardiac output. Furthermore, the prolonged refractory period in cardiac muscle allows the
impulse that originates in the sino-atrial node to propagate throughout the entire myocardium just once, thereby preventing reentry arrhythmias.
40. The ejection fraction is defined as:
Correct answer
Duodenum
Jejenum
Ileum
Correct answer
Colon
Caecum
90-95% of the bile salts are absorbed from the small intestine and then excreted again from the liver; most are absorbed from
the terminal ileum. This is known as the enterohepatic circulation. The entire pool recycles twice per meal and approximately 68x per day.
Disruption of the enterohepatic circulation, either by terminal ileal resection or through a diseased terminal ileum (e.g. Crohns
disease), results in decreased fat absorption and cholesterol gallstone formation. The latter is believed to result because bile
salts normally make cholesterol more water-soluble through the formation of cholesterol micelles. Loss of reuptake also results
in the presence of bile salts in colonic contents, which alters colonic bacterial growth and stool consistency.
42. The cardiovascular effects of raised intracranial pressure include:
decreased blood pressure, decreased heart rate, decreased cerebral perfusion pressure
decreased blood pressure, increased heart rate, decreased cerebral perfusion pressure
increased blood pressure, increased heart rate, decreased cerebral perfusion pressure
increased blood pressure, decreasd heart rate, decreased cerebral perfusion pressure
Correct answer
decreased blood pressure, increased heart rate HR, increased cerebral perfusion pressure
The important relationship between the cerebral perfusion, mean arterial blood pressure and intracranial pressure is as follows:
CPP = MABP ICP, where CPP = cerebral perfusion pressure
MABP = mean arterial blood pressure
ICP = intracranial pressure
14
It stems from the fact that the adult brain is enclosed in a rigid, incompressible box, with the result that the volume inside it
must remain constant (Monroe-Kelly doctrine). A rise in intracranial pressure therefore decreases cerebral perfusion pressure
(and hence cerebral blood flow).
In raised intracranial pressure, as the brainstem becomes compressed, local neuronal activity causes a rise in sympathetic
vasomotor drive and thus a rise in blood pressure. This is known as the Cushings reflex. This elevated blood pressure evokes
a bradycardia via the baroreceptor reflex. The Cushings reflex helps to maintain cerebral blood flow and protect the vital
centres of the brain from loss of nutrition if the intracranial pressure rises high enough to compress the cerebral arteries.
43. Aldosterone is secreted from the:
Liver
Zona glomerulosa of the adrenal cortex
Correct answer
Juxtaglomerular apparatus
Adrenal medulla
Zona fasciculata of the adrenal cortex
The adrenal gland comprises an outer cortex and an inner medulla, which represent two developmentally and functionally
independent endocrine glands within the same anatomical structure. The adrenal medulla secretes adrenaline (70%) and
noradrenaline (30%). The adrenal cortex consists of 3 layers, or zones. The layers from the surface inwards may be
remembered by the mnemonic GFR:
G = Zona glomerulosa (secretes aldosterone)
F = Zona fasciculata (secretes cortisol and sex steroids)
R = Zona reticularis (secretes cortisol and sex steroids)
Aldosterone is a steroid hormone that facilitates the reabsorption of sodium and water and the excretion of potassium and
hydrogen ions from the distal convoluted tubule and collecting ducts. Conns syndrome is characterised by increased
aldosterone secretion from the adrenal glands.
44. Which of the following gastrointestinal fluids is richest in potassium?
Salivary
Correct answer
Pancreatic
Gastric
Bile
Small bowel
In man about 1-1.5 litres of saliva are secreted each day. Secretion is an active process. The two-stage hypothesis of salivation
states that a primary secretion is first formed by secretory end-pieces (that resembles an ultrafiltrate of plasma), which is then
modified as it flows along the duct system. Na+ and Cl- are absorbed and K+ and HCO3- are secreted as saliva flows along the
ductal system. In addition, the ducts have a low water permeability.
The final saliva is hypotonic with respect to plasma and contains a higher potassium concentration than any other
gastrointestinal secretion of the body. Any abnormal state in which saliva is lost to the exterior of the body for long periods can
lead to a serious depletion of potassium, leading in occasional circumstances to serious hypokalaemia and paralysis.
45. In the respiratory system, physiological shunt?
Correct answer
15
element of pulmonary alveolar capillary blood that has passed through non or poorly aerated alveoli. Therefore physiological
shunt is always at least as great as or greater than the anatomical shunt.
There is always a normal anatomical shunt even in the young healthy adult.
The difference in carbon dioxide tension between arterial and mixed venous blood is a little less than 1 kPa, and therefore even
a 50% shunt only increases arterial carbon dioxide tension by about 0.5 kPa. A 50% shunt would reduce arterial oxygen
tension from 13.5kPa to below 9 kPa.
The physiological dead space results primarily in a failure to remove carbon dioxide from alveolar gas, i.e. a rise in arterial
carbon dioxide tension if ventilation not increased.
The breathing of pure oxygen cannot eliminate the anatomical right to left portion of the physiological shunt.
46. The action potential of skeletal muscle?
Correct answer
Correct answer
Brain
Heart
Skin
Liver
Kidneys
Organ
Kidneys
Heart
Liver
Brain
Correct answer
16
Skin
12.8
Correct answer
If the patient blood group is AB, his serum will have anti A and anti B antibodies
Naturally occurring anti A and anti B antibodies are usually IgG
Red blood cells are the only carrier of the antigen A,B and H
The presence of the D antigen makes the subject rhesus positive
Correct answer
Correct answer
Bilateral vagotomy
Bilateral vagotomy combined with transection of the brain stem at the superior border of pons
17
Plasma pH increases
The plasma level of free fatty acids decreases
Hypoglycemia
The plasma level of non protein nitrogen decreases
Correct answer
Plasma glycerol increases
There is usually acidosis (pH decreases). Lipolysis increases leading to increase in fatty acids and glycerol.
There is hyperglycemia and an increased level of non protein nitrogen.
54. Vasopressin (ADH)
Correct answer
Correct answer
Is decreased by hypercapnia
Is decreased by hypoxia
Is mainly controlled by sympathetic and parasympathetic activity
Is decreased by isoflurane in general anaesthesia
18
Cerebral blood flow accounts for about 15% of the cardiac output. Hypoxia and hypercapnia increase the CBF. An autonomic
mechanism seems to be unimportant. Isoflurane increases CBF.
57. With respect to vomiting which of the following statements is the best answer?
Correct answer
Growth hormone
Testosterone
T4
Insulin
Correct answer
Vasopressin
Growth is stimulated by growth hormone which stimulates IGF-I secretion, androgens and estrogens initially stimulate the
growth, they then ultimately terminate the growth by causing the epiphysis to fuse to the long bones. Thyroid hormones have a
permissive effect to the action of growth hormone possibly via somatomedines. Insulin promotes growth as it has an anabolic
effect on protein metabolism. Vasopressin has no effect on growth.
59. Nociception (pain)
Correct answer
Cholesterol
Correct answer
Albumin
RT3
Iodide
Thyroid binding globulin (TBG)
Thyroid hormone lowers circulating cholesterol level. The plasma cholesterol level drops before the metabolic rate rises.
19
61. The symptoms of dumping syndrome in patients with intestinal short circuits such as anastomosis of the jejunum to the
stomach are caused by?
Hypoglycemia
Hyperglycemia
There are two types of dumping syndromes resulting from rapid gastric emptying;
Early dumping which manifests by dizziness, sweating and palpitations within 5-45 minutes after eating. Late dumping occurs
2-4 hours after eating and is due to rebound hypoglycemia, small meals and glucose help to improve symptoms
62. With regard to CO2 transported in the blood, most of the CO2 is
Dissolved in plasma
In the form of carbamino compounds formed from plasma proteins
In the form of carbamino compounds formed from haemoglobin
Bound to Chloride
Correct answer
In the form of HCO3Carbon dioxide is transported in three main ways:
Carbamino compounds between CO2 and proteins. Most of these reactions are with the globin portion of haemoglobin,
accounting for 20-30% of the transported CO2.
Dissolved CO2 accounts for about 10% of the transported CO2.
HCO3- accounts for about 60-70% of the transported CO2.
63. Pepsin is secreted from which cells of the stomach?
Parietal cells
Chief cells
Correct answer
G cells
Mucous cells
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There are many types of cells located within the gastric glands;
Parietal cells secrete HCl and intrinsic factor Chief cells secrete pepsinogen, the precursor of pepsin G cells secrete the
hormone gastrin Mucous cells secrete mucous
64. Vitamin K is involved in carboxylation of glutamic acid residues of the following clotting factors EXCEPT for?
Single best answer question choose ONE correct option only
XI
Correct answer
Prothrombin
VII
IX
X
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Decreased pCO2
Decreased levels of 2,3 DPG
Presence of fetal haemoglobin
Increased pH
Correct answer
Increased temperature
The oxygen dissociation curve is a sigmoid shape; a shift to the right enables haemoglobin to give up oxygen more readily at a
given pO2. This occurs where temperature rises, PCO2 rises and pH falls. Levels of 2,3, DPG rise in conditions causing chronic
hypoxia, such as airway obstruction or living at high altitude, and also cause a right shift of the curve hence B is false. The
increased affinity of fetal haemoglobin for oxygen (i.e. a left shift of the curve) facilitates oxygen transport across the placenta
hence C is false.
66. Concerning the salivary glands
Correct answer
Cholecystokinin
Correct answer
Gastrin
Insulin
Secretin
Somatostatin
Cholecystokinin secretion from the duodenal and jejunal mucosa is stimulated by the presence of fatty acids, amino acids and
peptides in the lumen of the duodenum and jejunum. As well as causing contraction of the gall bladder and relaxation of the
sphincter of Oddi, it stimulates release of pancreatic enzymes, and increases the secretin mediated secretion of HC03- by
pancreatic duct cells. Its release is inhibited by somatostatin.
68. Which of the following hormones is secreted by the kidney in response to sympathetic nervous stimulation?
Aldosterone
Angiotensin I
Angiotensin II
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Erythropoetin
Correct answer
Renin
Renin is produced by the juxtaglomerular apparatus of the kidney in response to hypovolaemia, via 3 mechanisms:
1. increased catecholamine levels secondary to sympathetic stimulation from arterial receptors
2. direct effect of hyponatraemia on the juxtaglomerular apparatus
3. reduction of renal perfusion pressure via afferent arteriolar baroreceptors
Renin acts to cleave angiotensin I from angiotensinogen produced in the liver. Angiotensin converting enzyme is present in
many tissues, especially the lungs, and converts angiotensin I to angiotensin II. Angiotensin II is a powerful vasoconstrictor,
causing vasoconstriction of renal arteries, as well as a positive inotropic effect on the heart. It also causes release of ADH and
adrenaline. Along with aldosterone, whose release is also stimulated, Angiotensin II conserves Na+ and H2O in the gut.
Aldosterone acts to conserve Na+ and H2O in the distal renal tubule and collecting ducts. These mechanisms combine to
restore the plasma volume in hypovolaemia.
Erythropoetin is released by the kidney in response to hypoxia and high levels of the products of red cell breakdown, and
increases the rate of red cell production.
69. Aldosterone causes the following effect
Correct answer
Adrenaline
Tracheostomy
Correct answer
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Bronchial carcinoma
Mitral regurgitation
Correct answer
Pneumonia
Tuberculosis
Tricuspid regurgitation
An effusion with less than 3g of protein per 100ml is a transudate. Other biochemical characteristics of a transudate include
LDH < 200 iU/l, WCC < 1000/ml, glucose <3 mmol/l. Transudative effusions are most commonly due to factors such as
decompensated liver failure and left ventricular failure. Malignancy and infection are causes of an exudative pleural effusion.
Pulmonary embolism can cause either an exudative or transudative effusion, although the former is more common.
In this question, B is more likely than E to be associated with left ventricular failure, and therefore a pleural effusion. Tricuspid
regurgitation is usually functional and secondary to an enlarged right ventricle in right ventricular failure, and causes a pulsatile
liver, peripheral oedema and ascites.
73. A parathyroid adenoma will be most likely to cause
23
Correct answer
Deep inspiration
Correct answer
Forced expiration
Hypovolaemia
Positive pressure ventilation
Tension pneumothorax
Blood returns to the heart from the lower limbs via the action of the calf muscle pumps, valves in the veins of the leg, and the
effect of negative intra-thoracic pressure generated during inspiration. Anything causing the intra thoracic pressure to become
less negative will decrease the venous return to the right atrium. Tension pneumothorax, positive pressure ventilation and
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forced expiration all cause this effect, and therefore reduce the venous return. Although hypovolaemia may cause
vasoconstriction in an attempt to increase venous return, it is unlikely to increase above normal levels.
78. The largest contribution to systemic vascular resistance (SVR) is made by the
Aortic valve
Great arteries
Arterioles
Correct answer
Venules
Great veins
The capillaries and arterioles each account for around 25% of the SVR. The large surface area of the capillaries, as well as the
low flow and pressure drop through the capillary beds is vital to their function in exchange of gases and nutrients. The
arterioles have abundant smooth muscle in their walls, and flow is regulated to a large degree by the sympathetic nervous
system. They therefore exert a great deal of control over the flow through the capillary beds, as well as which capillary beds are
open at a given time.
79. What is the half life of free triiodothyronine (T3) in the blood?
1 minute
1 hour
1 day
Correct answer
1 week
1 month
Most of the T3 and thyroxine (T4) are carried in plasma bound to thyroxine binding globulin, and are inactive in this state. Only
1% of T3 and 0.05% of T4 is free. T3is the active hormone, and is formed from the intracellular deiodination of T4 by type 2
deiodinase. The half life of T4 is 1 week, and of T3 1 day, suggesting that T4 acts as a source of T3, rather than an active
hormone in its own right.
80. Which of the following metabolic effects is most likely to be caused by thyroid hormone?
Correct answer
Decreased lipolysis
Decreased expression of adrenergic receptors
Decreased oxygen uptake in the mitochondria
Thyroid hormone has widespread metabolic effects.
Increased glycogenolysis in the liver, increased glucose absorption in the gut and increased insulin breakdown all tend to
increase blood glucose. The glycogenolytic effects of catecholamines are also potentiated. These effects can make the
diagnosis and management of diabetes in thyrotoxicosis difficult.
There is an overall lipolytic effect, with decreased serum cholesterol seen in thyrotoxicosis, and an increase in hypothyroidism.
There is an increased expression of -adrenergic receptors in many tissues including skeletal and cardiac muscle. There is a
positive inotropic effect with increased cardiac output and heart rate.
A raised metabolic rate and increased heat production are due to increased oxygen uptake and ATP production in the
mitochondria.
There are also effects on bone, with an overall breakdown of bone, sometimes leading to hypercalcaemia. Increased serum 2,3
DPG leads to a right shift of the haemoglobin dissociation curve. Thyroid hormones are also essential for fetal development,
with deficiency leading to cretinism. The fetus produces its own hormone from 18 weeks of gestation.
81. Which of the following is the most important direct stimulus to respiration?
25
Correct answer
Bradycardia
Correct answer
Hypotension
Tachycardia
Tachypnoea
Venous ulceration
The cranium is a fixed volume containing blood, CSF and brain tissue in equilibrium. Increases in one component can be
compensated by a decrease in the other components without increasing intracranial pressure (the Monroe-Kellie doctrine).
Beyond a certain point, this compensation is insufficient, and raised intracranial pressure results (greater than 10-15mmHg).
The effects of raised intracranial pressure are hydrocephalus, cerebral ischaemia (due to decreased cerebral perfusion
pressure) and systemic effects. The systemic effects include hypertension, bradycardia, slowed respiration and gastric
ulceration (Cushings ulcer). These are thought to be due to autonomic dysregulation resulting from hypothalamic compression.
83. Insulin levels are not increased by which of the following?
Single best answer question choose ONE correct option only
Amino acids
-adrenergic stimulation
Hypokalaemia
Correct answer
Correct answer
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Hyperkalaemia
Hypermagnesaemia
Hypocalcaemia
Hypokalaemia
Correct answer
Hypomagnesaemia
Cardiac effects of hypokalaemia are usually minimal until plasma potassium levels are less than 3 mmol/l. Hypokalaemia leads
to sagging of the ST segment, depression of the T-wave and elevation of the U-wave. With marked hypokalaemia, the T-wave
become progressively smaller and the U-wave becomes increasingly larger. Sometimes, a flat or positive T-wave merges with
a positive U-wave, which can be confused with qT prolongation. Hypokalemia can also cause premature ventricular and atrial
contractions, ventricular and atrial tachyarrhythmias and second- or third-degree atrioventricular block. Such arrhythmias
become more severe with increasingly severe hypokalaemia; eventually, ventricular fibrillation can occur. Patients with
significant pre-existing heart disease and/or those receiving digoxin are at risk of cardiac conduction abnormalities, even with
mild hypokalaemia.
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