Immunology

Question 1

Describe the common presentations of allergy (type 1 hypersensitivity).

Answer 1

May present as atopies: Eczema, asthma, rhinitis 
Features of an allergy reaction are:
Rash
Urticaria
Wheeze
Abdominal cramps
Hypotension

plus In anaphylaxis
Angioedema
Ango animi
Laryngeal oedema

Question 2

What important factors should you ask about when taking a history investigating a possible allergy?

Answer 2

Precipitating factors
Time of year
What actually happened
Past medical history
Drug history
Any family history

Question 3

Describe the tests (and their limitations) used in the investigation of possible allergy

Answer 3

Skin prick test: Negative control used to decrease change of dermographism
Total IgE: Not allergen specific
Antigen specific IgE: Avoids dermographism, more specific
Challenge tests: Used to confirm negativity, only use in very safe environments

Question 4

Outline tests for, diagnosis and management of anaphylaxis

Answer 4

Adrenaline 0.5ml 1:1000im
Oxygen
Anti histimine
Corticosteroids

Question 5

Outline tests for, diagnosis and management of urticaria

Answer 5

Treat with antihistimines - certirizine hydrochloride

Question 6

Outline tests for, diagnosis and management of angioedema.

Answer 6

Patients should be checked for compliment protein levels

Question 7

Outline tests for, diagnosis and management of allergic rhinitis

Answer 7

Anti histimines
Intranasal corticosteroids
Local cromones

Question 8

Outline the general principles in the assessment of a patient who has taken an overdose.

Answer 8

Take a good history!

If unconscious: ABCDE

Question 9

Describe the clinical features of alcohol intoxication.

Answer 9

in-corodination
Stupor
Unconsciousness
comma
Hypoglycaemia
Hypothermia
Hypotension
Respiratory depression

Question 10

Describe the clinical features of paracetamol overdose

Answer 10

Nausea and vomiting
Tender hepatic edge
Jaundice
Hypoglycaemia
Renal failure
Hepatic encephalopathy
Coagulopathy

Question 11

List the indications and contraindications for the passage of a urethral catheter.

Answer 11

Indications
Post surgery
Monitoring in unconscious patient
Obstructed urethra
Pre surgery
Longer term for neurogenic bladder and incontenance, post surgery

Contraindications:
Pelvic trauma
Blood around meatus
Acute prostatitis

Question 12

List the alternatives for bladder drainage when urethral catheterisation is contra-indicated

Answer 12

Supra-pubic catheterisation

Ultrasound guided drainage.

Question 13

List the factors which are risks for poor wound healing 8

Answer 13

Infection
Hypoxia
Poor surgical technique
Previous radiation to the area
Sepsis
Systemic disease
Foreign body
Steroid treatment

Question 14

List what is measured in a U&E investigation

Answer 14

Sodium
Potassium
urea
Creatinine

Question 15

Given a patient’s weight, calculate the extracellular, intra-cellular and intravascular volume

Answer 15

60% of bodyweight is due to water.
2/3rds of that is intracellular
1/3rd is extracellular (25% is intravascular, meaining that 1/12 of total body water is intravascular volume.)
In women and obese patients, this figure may be 50%.

Question 16

Calculate sensible and insensible fluid and electrolyte losses in routine post-operative care

Answer 16

Sensible (urine) 1500ml/day
Non-sensible (sweat, feces, breath) 1000-1500ml/day
Sodium and potassium 0.7-1mmol/kg

Question 17

Calculate sensible and insensible fluid and electrolyte losses in a febrile patient (Temp 40C)

Answer 17

for every 1 degree celsius 10% more water is lost via insensible exit routes.

Question 18

List the main endogenous factors that affect renal control of sodium and water excretion

Answer 18

RAAS system, stimulated by:
Baroreceptors
Osmoreceptors
ADH
ANP
Hypothalamus - thirst

Question 19

List the symptoms and physical findings of dehydration 8

Answer 19

Dry mucosal surfaces
Reduced skin turgor
Dry axilla
Postural hypotension
Tachycardia
Change in consciousness
Dark urine
Sunken eyes

Question 20

List the electrolyte composition of normal saline 0.9 Crystalloid

Answer 20

154Mmol/L of Na and Cl.

Question 21

List the electrolyte composition of Hartmens/Ringer lactate. Crystalloid

Answer 21

130Mmol/L of Na, 109 of Cl, 28 of lactate, 4 of K and 1.5 of Ca.

Question 22

List the electrolyte composition of 5% dextrose in water crystalloid.

Answer 22

50g/L of glucose

Question 23

List the electrolyte composition of dextrose saline 0.18%

Answer 23

30Mmol/L of NaCl and 40g/L of glucoes

Question 24

List the electrolyte composition of albumin solution colloid

Answer 24

Available as 4% and 20% solutions.

Question 25

Define shock.

Answer 25

An acute circulatory failure with an inadequate or inappropriately distributed tissue perfusion, resulting in generalised cellular hypoxia or inability to use oxygen.

Question 26

List the types of shock 5 and their causes

Answer 26

Hypovolaemic: Haemorrhage, massive dehydration, burns Cardiogenic: Massive MI, tamponade, PE, VT/VF Septic: Infection - usually gram negative Neurogenic: Spinal injury Anaphylactic: Allergens

Question 27

Describe the effect of shock on the brain

Answer 27

Regional glucose uptake changes Reflexes reduced Cortical activity reduced Brain suffers as cannot hibernate

Question 28

Describe the effect of shock on the heart

Answer 28

The heart may cause vasodilation, resulting in hypotension.

Question 29

Describe the effect of shock on the kidneys

Answer 29

Kidneys can hibernate in deeper levels of shock but integral to the maintenance of BP

Question 30

Describe the effect of shock on the lungs

Answer 30

Still receive good oxygen perfusion However immune complexes are deposited and increased vascular permeability causes the recruitment of immune cells Result DIC and ARDS

Question 31

Describe the effect of shock on the gut

Answer 31

One of the first organs to suffer Splanchnic, autonomic nerve cause vasoconstriction, resulting in ischaemia This results in the breakdown of the gut barrier and bacteraemia.

Question 32

Describe the effect of shock on the liver

Answer 32

Reperfusion injuries

Question 33

Describe the effect of shock on the bones

Answer 33

Massive build up of lactate and reperfusion injuries, however, resistant to ischaemia for 3 hours

Question 34

List the physical findings that characterise hypovolaemic shock 8

Answer 34

``` Cold pale skin poor cap refil Oligo/anuria Confusion, drowsiness, irritability Tachycardia Normal BP but may result in hypotension Sweating Metabolic acidosis may be present with respiratory compensation. ```

Question 35

List the physical findings that characterise cardiogenic shock 5

Answer 35

``` Muffled heart sounds gallop rhythm pulsus alternans Raised JVP Basal crackles ```

Question 36

List the physical findings that characterise neurogenic shock

Answer 36

Shock with no cardiac response e.g. increase in heart rate

Question 37

List the physical findings that characterise anaphylactic shock 12

Answer 37

``` Tachycardia Warm peripheries Hypotension Peripheral oedema Pallor cyanosis Urticaria Erythema Angioedema Nausea and vomiting Abdominal cramps Diarrhoea ```

Question 38

List the physical findings that characterise septic shock 6

Answer 38

``` Warm peripheries Pyrexia and rigors nausea and vomiting coma Jaundice hypotension ```

Question 39

List physical findings that may suggest the presence of a bleeding disorder. 5

Answer 39

``` Bruises/purpura Bleeding Haematoma Haemarthrosis Liver disease ```

Question 40

List the laboratory tests that would be helpful in the diagnosis of bleeding disorders 5

Answer 40

``` FBC PTT APTT TT Correction tests ```

Question 41

List the factors that contribute to infection following a surgical procedure. 9

Answer 41

``` Length of stay in hospital Long procedure/poor surgical technique Foreign bodies Malnutrition Age Previous radiation Immunosuppression Obesity Diabetes ```

Question 42

Describe the pathological basis of fibroadenomas and how they present

Answer 42

``` Women <30 Abborations of normal breast tissue 'Breast mice' Smooth, rounded, well circumscribed lumps May be multiple of them. Not usually fixed to the chest wall ```

Question 43

Describe the pathological basis of fibroadenosis and cyts and how they present

Answer 43

Women aged 30-50 May occur simultaneously Often cyclical Feel like bubble wrap

Question 44

Describe the aetiology, morphology and pathological consequences of carcinoma of the breast

Answer 44

May be in-situ or invasive. 2 main types - ductal or lobular Most common form of cancer in women May present with rashes, discharge, mass, dimpling, skin changes, rashes, local oedema Mass feels spiky and may be tethered to underlying tissue.

Question 45

List the risk factors for carcinoma of the breast 8

Answer 45

``` Female gender Obesity HRT OCP Early menarche/late menopause age Nulliparity Not breast feeding for long enough ```

Question 46

Describe the diagnostic approach used in the diagnosis of a breast lump

Answer 46

Triple assessment: History and physical assessment Mammography and USS Biopsy

Question 47

What noises may be heard during an obstructed airway?

Answer 47

Stridor - Anaphylaxis | Gargles

Question 48

Specify a definition of pain

Answer 48

Pain is an unpleasant sensory and/or emotional experience associated with actual or perceived tissue damage.

Question 49

Describe the adverse physiological effects of pain

Answer 49

Trouble sleeping, coughing, moving around, breathing | depression

Question 50

Describe the WHO pain ladder

Answer 50

Mild to moderate pain - non-opoids NSAIDs and paracetamol Moderate to severe pain - mild opiods e.g. codeine Severe pain - Strong opiods e.g. morphine

Question 51

Describe the WHO (World Health Organisation) checklist in patients undergoing electric surgical procedures

Answer 51

Patient wristband must be compared to consent form constantly. Involves a kit check and an anaesthetics check as well as a sign in and out.

Question 52

Outline the causes of post-operative nausea and vomiting

Answer 52

More common in females, young people, those who do not smoke. Due to: Analgesics and anaesthetics used

Question 53

Describe the typical presenting symptoms and signs of a patient presenting with single regional pain resulting from an overusage/strain injury

Answer 53

Localised pain that occurs with movement. Pain doesn't get worse over time. Usually only occurs over a certain range of movements Patient can usually recall when injury occurred May be associated with local inflammation and tenderness. No systemic features.

Question 54

Differentiate between back pain arising from MSK structures from referred pain arising from other organs or systems

Answer 54

MSK pain usually in lumbar region, whereas organ pain usually thoracic region. MSK pain is usually associated with exercise. MSK pain usually short and self limiting whereas organ may be chronic and progressive MSK pain may also have a sudden onset, recurrent and relieved by rest unlike organ pain. ``` Risk factors: Age Female gender Other chronic illnesses Dissatisfaction with job Poor rating of self health Poor posture Pregnancy ```

Question 55

Describe the typical presenting symptoms and signs of a patient presenting with joint inflammation and/or joint damage and link with systemic disease.

Answer 55

Inflammation presents with: swelling, redness, warmth Stiffness that lasts longer than 15 minutes in the morning suggests inflammation. Inflammatory pain is generally worse with rest and gets better with exercise. Sepsis, inflammatory arthritis and gout present as inflammatory joint pain.

Question 56

Describe the symptoms 4 and signs 6of osteoarthritis and specify the relative prevalence of knee, hip and hand osteoarthritis.

Answer 56

``` Hip and knee OA affect 25% and 40% of the population. Symptoms include: Pain on exercise, relieved after Joint gelling Joint instability Loss of function ``` ``` Signs: Decreased motility Swelling Bony swelling Crepitus on movement Joint effusion Muscle wasting ```

Question 57

Describe the symptoms, signs and pattern of joint involvement in rheumatoid arthritis

Answer 57

Pain and stiffness in the small joints of the hands and feet. Patient feels tired and unwell Pain is worse in the morning and may get better throughout the day. May improve slightly upon exercise

Question 58

What is osteoarthritis?

Answer 58

A decrease in bone density, leading to an increased risk of bone fractures.

Question 59

What are the symptoms of osteoarthritis?

Answer 59

``` Usually asymptomatic until fracture occurs May have Kyphosis Decreased height Abnormal protuberance Spinal tenderness ```

Question 60

What are the risk factors for osteoporosis? 10

Answer 60

``` Hyperparathyroidism Oestrogen deficiency Vitamin D deficiency Steroid use Smoking Alcohol abuse Being white Chronic renal/liver failure Previous fracture Myeloma ```