Smith and Pat Flashcards
(185 cards)
1
Q
Why is malnutrition common in UK hospitals?
A
- Not recognised as a clinical problem
- Increase in energy need of some medical problems
- Poor intake.
2
Q
Explain the catabolic response to trauma?
A
- Rise in catabolic hormones such as adrenalin, noradrenalin and cortisol.
- These antagonise the effect of insulin.
- These coupled with rises in cytokines will cause an increase in fatty acid oxidation, a relative decrease in glucose oxidation and an out flow of amino acids from muscle.
3
Q
Explain social factors that may lead to inadequate nutritional status in the community?
A
- Limited mobility
- Depression
- Limited cooking skills
- Recent bereavement
- Social isolation
4
Q
List 3 potential advantages of breast feeding (NB: for mother and child). [3]
A
- Correct temperature
- Decrease risk infections especially respiratory, GIT, EAR.
- Low solute load
- High bioavailability
- Easily digested
- Increase IQ?
- Decrease risk IDDM & IBD
- Decrease risk maternal breast cancer
- Promotes ‘normal’ gut flora.
5
Q
List 2 potential disadvantages of breast feeding (NB: for mother and child). [2]
A
- Transfer of environmental pollutants mum has been exposed to
- Transfer of HIV, CMV, and hepatitis.
6
Q
At what age (in months) does the World Health Organisation guidelines suggest weaning of an infant should start [2]
A
6 months
7
Q
What is the reason for the guidelines suggesting this age to start weaning [3]
A
To decrease morbidity (1 mark) and mortality (1 mark) from infections in developing counties (1 mark).
8
Q
What happens to basal metabolic rate and protein breakdown in response to critical illness? [4]
A
Increase BMR (2 marks) and increase protein breakdown (2 marks)
9
Q
What happens to nutritional intake in response to critical illness? [1]
A
It is reduced
10
Q
What is the complication of losing 40% of lean body mass and what is the usual cause? [2]
A
Death (1 mark) the usual cause is pneumonia (1 mark)
11
Q
After making your initial judgement on the basis of the history and your examination of a patient, is it absolutely necessary to measure plasma protein levels before deciding to commence nutrition therapy? Briefly explain your answer. [3]
A
- No (1 mark)
- Plasma protein levels can be useful but not necessary for decision on nutrition therapy. Low plasma proteins may be due to malnutrition but in acutely sick patients are more likely due to other factors such as liver disease, post-surgery etc (1 mark).
- Plasma proteins are affected by acute phase protein response, for example a rise in C-reactive protein will be followed by a drop in Albumin (1 mark).
12
Q
Obesity is linked to a number of diseases such as diabetes, coronary heart disease. Apart from physical illness list 3 other major social costs of obesity in adults. (3 marks)
A
- 18 million sick days
- 30,000 deaths a year resulting in 40,000 lost years of working life
- Deaths linked to obesity shorten life by 9 yrs
- Lower achievement in the work place
- Depression and increased psychological disorders
13
Q
Who, if either, would have the greater risk of heart disease: a male with a body mass index (BMI) of 25kg/m2and a waist measurement of 95cm or a male with the same BMI but with a waist measurement of 110cm? (1 mark)
A
- BMI=wt (kg)/high m2
- BMI is a method of associating health risk to body weight while controlling for height
- BMI of 25 with a waist of 110cm
14
Q
Write a short explanation of the initial consequences of insulin resistance. (2 marks)
A
Insulin resistance = abnormal carbohydrate + lipid metabolism
15
Q
How are obesity and insulin resistance linked? (4 marks)
A
- Increase in body weight is a function of increased adipocyte cell size (1)
- As adipocyte cell size increases sensitivity of the tissue to insulin falls (1) possibly due to increase TNF release from the adipocyte itself and monocytes within adipose tissue (1)
- Insulin resistant adipocytes release greater amounts of free fatty acids which relate to a decline in insulin sensitivity in muscle due to preferential oxidation of free fatty acids and a decrease need of glucose (1)
16
Q
There are a number of genetic variants which can cause abnormal metabolism of drugs used in anaesthesia. One metabolic pathway subject to genetic variants that may cause problems for anaesthetists is ester hydrolysis.
a. Name the enzyme with abnormal phenotype. (1 mark)
b. Where is this enzyme found? (1 mark)
A
a) Butyrylcholinesterase or plasma cholinesterase
b) In the plasma
17
Q
Suxamethonium is an example of a drug used in anaesthesia metabolised by this enzyme. What is this drug used for in anaesthesia? (1 mark)
A
As a muscle relaxant (or, neuromuscular blocking agent) used to paralyse patients prior to procedures such as intubation
18
Q
What happens to a patient who is homozygous for an abnormal phenotype if they are given this drug and why? (2 marks)
A
- They remain paralysed for several hours because the drug is an agonist at the motor endplate and causes a depolarising paralysis.
- It will eventually be metabolised, but very slowly, some will also be excreted unmetabolised and so the effect will gradually wear off spontaneously.
19
Q
Under these circumstances, what must the anaesthetist do to ensure the patient’s safety? (1 mark)
A
Ventilate the patient, and give sedation to prevent distress or panic, until the spontaneous resolution of block.
20
Q
Problems with the ester hydrolysis pathway may also be acquired. What do you think would be the implication in a patient with liver disease, or if the patient were malnourished with a low BMI? (2 marks)
A
- As butyrylcholinesterase is a plasma protein manufactured in the liver, both liver disease and malnutrition could result in low levels of butyrylcholinesterase.
- This could lead to reduced metabolism of Suxamethonium & Mivacurium with the associated problems of prolonged paralysis.
21
Q
Another genetic condition that is important to the anaesthetist is malignant hyperpyrexia or malignant hyperthermia. Briefly describe why this condition is important to the anaesthetist. (2 marks)
A
- Malignant hyperpyrexia (or malignant hyperthermia) is a potentially fatal reaction to certain anaesthetic agents including ALL the anaesthetic vapours and the depolarising muscle relaxant suxamethonium. (1 mark)
- The condition results from a massive increase in muscle metabolism stimulated by the anaesthetic agents (often likened to a “metabolic storm.”) and produces high temperatures, high oxygen consumption, metabolic acidosis, hyperkalaemia, high plasma creatinine kinase and myoglobinuria. (1 mark)
22
Q
In a patient with nasopharyngeal colonisation due to streptococcus pneumoniae, list 4 host components which initially defend against invasiveinfection. (4 marks)
A
- Secretory IgA
- Natural IgM
- Ciliae
- Defensins
- Collectins (include MBL)
- Epithelial cell tight junctions etc
- Complement-(less important)
23
Q
List 2 bacterial factors which might allow attachment or penetration of the epithelial barrier. (2 marks)
A
- Ig or complement binding proteins
* Internalisation via fibronectin binding proteins
24
Q
List 2 bacterial factors which might allow the streptococcus pneumoniaeto evade the immune response in the lung. (2 marks)
A
- Peptidoglycan cell wall
- Capsule
- Complement binding
- Ig binding
25
Which host factors might allow variation in the response? (2 marks)
(Sepsis section)
* MBL
* TNF
* HLA
* Prior exposure/level of antibody/vaccination
26
Outline 4 options for managing a patient who has lost the use of his own kidneys. (4 marks)
Which of the above options is associated with the best life expectancy and quality of life? (1 mark)
* Symptomatic / conservative management
* Peritoneal dialysis
* Haemodialysis
* Renal transplantation
Part 2: Renal transplantation
27
Identify 3 symptoms a patient with chronic renal failure may complain of. (3 marks)
* Shortness of breath
* Ankle swelling
* Itching
* Anorexia
* Nausea and vomiting
* Lethargy/tiredness
28
Identify 4 of the commonest causes of chronic renal failure in the UK. (2 marks)
* Diabetes mellitus
* Hypertension/renovascular disease
* Polycystic kidney disease
* Pyelonephritis
* Glomerulonephritis
29
During moderate intensity exercise, is PaCO2 (partial pressure of carbon dioxide in arterial blood), reduced, increased or unchanged from rest? Briefly explain your choice. (2 marks)
Unchanged – alveolar ventilation increases in precise proportion to carbon dioxide production (VCO2) so that blood gas levels are maintained constant
30
During very heavy exercise, is PaCO2 reduced, increased or unchanged from rest? Briefly explain your choice. (2 marks)
Reduced – above the AT, the increased lactic acid is initially buffered so that isocapnia is maintained. As the exercise intensity continues to increase to heavier levels, the buffering of lactic acid can’t keep pace with the increased lactic acid resulting in an accelerated ventilatory response (‘respiratory compensation’) without an associated acceleration of VCO2. Thus PaCO2 is driven down.
31
Explain the difference between ‘hyperventilation’ and the ‘hyperpnoea’ of exercise. (2 marks)
* Exercise hyperpnoea is an increase in ventilation that is appropriate for the metabolic demand (blood gases maintained) – accompanied by increase in VCO2.
* Hyperventilation is an increase in ventilation that exceeds metabolic demand – and is not associated with an increased VCO2 resulting in reduced PaCO2
32
What is the source of CO2 during aerobic and anaerobic metabolism? (2 marks)
* Aerobic = oxidation of glycogen and fatty acids.
| * Anaerobic metabolism – buffering of lactic acid
33
Describe (briefly) a graphical method for determining the anaerobic threshold during incremental exercise. (2 marks)
• Plot of VCO2 (y-axis) versus VO2 (x-axis) (v-slope method). AT is taken as the point at which the VCO2 starts to increase faster than the VO2 causing slope of plot to exceed 1.
Or
• Plot of Ve/VO2 against workload (ventilatory equivalent for oxygen). AT is taken as the upward inflection of this plot. (Take off 1 mark if VE versus VCO2 is mentioned instead of VE verses VO2)
• Other plots they may mention include PETO2 versus time or VCO2 and VO2 against time (not easy to get it from these so give them 1 mark only)
34
Staphylococcus aureus – what kind of gram staining? [1]
Positive
35
Toxic shock syndrome host receptors [2]
MHC2 on monocytes + T-cell receptor
36
2 common diseases caused by bacteria. [2]
Pneumonia, cellulitis, septicaemia
37
Clostridium difficile – what kind of gram staining? [1]
Positive
38
Virulence factors for C. difficile. [2]
tcdb and tcda (Toxin A and B)
39
2 diseases that C. difficile causes. [2]
Pseudomembranous colitis and sepsis
40
What is volatile and non volatile acid? (2)
```
Volatile = CO2
Non-volatile = lactic acid
```
41
a) How much volatile/non volatile produced in a day (mmol)? (2)
b) pKa value (1)
c) Normal pH value (1)
```
Volatile = 13-15000 mmol/day
Non-volatile = 1500mmol/day
```
b) 6.1
c) 7.4
42
What is ratio of HCO3 to CO2 (1)
20:1
43
Define base excess or deficit (2)
Base excess: Amount of strong acid that has to be added to produce normal pH 7.4 in sample
Base excess > + 2 mmol/l: metabolic alkalosis
Base deficit: Amount of strong base to be added to produce normal pH 7.4 in sample
Base deficit more negative than - 2 mmol/l: metabolic acidosis
44
What are factors contributing to adverse drug reactions (3)
* Abnormal pharmokinetics due to genetic factors
* Abnormal pharmokinetics due to comorbid states
* Polypharmacy – multiple medications
45
What scheme is in place to report ADR? (1)
Yellow card scheme
46
What is the regulatory body for this? (1)
| To report ADR
Medicine and Healthcare products Regulatory Committee
47
What does a black upside down triangle mean? (1)
Newly licensed drug less than two years
48
What is ADR of Amiodarone, Ciclosporin?, and another one beginning with C? possible answers: Pulmonary fibrosis, Cardiac arrhythmias, Tendonitis (3)
* Amiodarone inhibits CYP450, therefore cyclosporine more abundant and less metabolized, leading to toxicity.
* Amiodarone = photosensitivity and pulmonary fibrosis
* Cyclosporine = nephrotoxicity and pancreatitis
49
What is normal BP? (1)
120/80mmHg
WELL DONE ehehehe (I totally knew this :P)
50
How do you calculate MAP and Pulse Pressure from this? (1)
* MAP = CO x Total Peripheral Resistance
* MAP = DP + 1/3PP
* Pulse Pressure = SP – DP
I KNEW THIS TOO
51
What happens to SBP/DBP in dynamic exercise and static exercise? (2 +2)
* BP increases more in static exercise and less in dynamic exercise.
* BP = TPR x CO
* TPR decreases, CO increases relatively more, therefore BP increases.
* TPR decreases because vasodilation of arterioles providing oxygen to skeletal muscle.
* CO increases to deliver oxygen to muscle to meet their demand.
* In dynamic exercise; SBP increases but DBP stays constant.
* In static, both increase.
52
From this, why should pts with Ischaemic Heart Disease not to static exercise? (3)
* IHD = lack of o2 delivery to the heart due to coronary artery disease or atherosclerosis.
* Static exercise increases both Systolic and diastolic pressures.
* Increase in BP would increase resistance, therefore, further impairing oxygen delivery leading to an MI.
53
What is the class of agents used to enhance performance by having effects on staying awake? (1)
Stimulant e.g. caffeine
54
Renal failure-mechanism for met acidosis with and without raised anion gap? (2)
* Normal anion gap: HCO3- loss (from gut or kidney)
* Anion gap > 18: added acid anion, commonly
* Lactate
* Ketoacids
55
What happens during starvation to glucose/protein/fat/energy expenditure-decrease/increase/normal? (2)
* BMR decreases.
* Glucose decreases
* Protein decreases but lesser extent than fat, only used where necessary, tried to be protected
* Fat decreases.
56
What 2 questions do you ask for assessing nutritional risk? (2)
* Have you lost weight recently?
* Has the amount you eat changed?
* GI symptoms? Vomiting? Diarrhoea?
57
What are the 4 most common diseases associated with obesity? (4)
* T2DM
* Cancer
* Arthritis
* Stroke
* Hypertension
* Coronary Artery Disease
58
Which two hormones are affected in Chronic Renal Failure? (3 marks)
Vitamin D (calcitriol) and erythropoietin
59
At which GFR does the patient start to become symptomatic? Give units. (2 marks)
80ml/min
60
What is value which oliguria? Give units. (2 marks)
Less than 300-500 ml/day
61
List three dietary restrictions for a patient with renal failure. (3 marks)
Low protein, low potassium and low phosphate
62
Give an example of a nephrotoxic agent. (1 mark)
Gentamicin, ACE inhibitors, e.g. enalapril
63
Which is obese? Give 3 reasons. (4 marks)
* High BMI > 30kg/m2
* Lowest VO2 max
* Low anaerobic threshold
* Lowest work peak
64
Which is the athlete? Give 3 reasons. (4 marks)
* High Vo2 max
* High anaerobic threshold
* High work peak
65
a) Which subject lacks the glycolytic enzyme? Justify. (2 marks)
* Anaerobic threshold would be lowest
| * Because glycolytic enzyme not present, therefore must constantly respire anaerobically
66
Streptococcus pneumoniae.
Which gram stain is this bacteria? (1 mark)
Gram positive
67
Streptococcus pneumoniae.
List two infections that it causes. (2 marks)
Pneumonia
meningitis
68
a) Give two host factors that stimulate opsonophagocytosis by binding to the pathogen? (2 marks)
* Complement (C3b) deposition on bacterial surface
* Antibody (IgG) against pneumococcal polysaccharide
* Mannose binding lectin deposition
69
List four conditions, excluding cardiac conditions, renal disease and age, where the host would be immunocompromised. (4 marks)
* HIV
* Chemotherapy
* Pregnancy
* Transplant
* Cancer
* Rheumatoid arthritis
* Systemic Lupus Erythematosus
* Malnourished
* Infection
* Iatrogenic (post-transplant)
* Trauma
* Alcoholism
* Radiotherapy
* Leukaemia
* Hyposplenism (asplenism)
* Burns
(Goodness me he's overachieving)
70
A patient has been given Ramipril and Spironolactone. Which biochemical abnormalities might you see with these two drugs? (2 marks)
Hyperkalaemia, acidosis, hyponatraemia
71
Guy with Diabetes. Name 5 classes of anti-hypertensives that have been proven to be effective in clinical trials. (4 marks)
ACEI, ARB, CCB’s, Renin antagonists, aldosterone antagonists, diuretics, e.g. thiazides, alpha blockers
72
Give the name of one trial. (1 mark)
Double-blind placebo control
73
Name the mechanism of Simvastatin and give two biochemical abnormalities you would see. (3 marks)
HMG CoA reductase inhibitor
| Liver enzyme derangements – high alkaline phosphatase, hyperkalaemia, metabolic acidosis, high CK.
74
Give two factors that would lead to Sarcopenia? (2 marks)
* Ageing
* Sedentary lifestyle
* Malnutrition (protein deficiency)
* Immobility
* Low GH/testosterone/IGF
* Low protein synthesis
75
Why do you get malnutrition in Chronic Kidney Disease? (1 mark)
Uraemia leads to decreased appetite, catabolic state.
| Uraemic symptoms may cause nausea and vomiting
76
Which condition would you see Ketogenesis in? (1 mark)
Starvation/type 1 DM
77
What would be the two main questions you would ask when beginning a nutrition assessment on a patient? (2 marks)
* Have you lost weight recently?
* Change in appetite? Has the amount you eat changed?
* GI symptoms? Vomiting? Diarrhoea?
* Change in bowel habit?
78
a) Name one volatile and one non-volatile acid produced by respiration (1)
b) Estimate the amount of each produced in mmol in a day (2)
```
Volatile = carbonic acid
Non-volatile = lactic acid
```
CO2 = 13000-15000 mmol/day
Lactate
79
Define anaerobic threshold (1)
The point at which the body just starts to become metabolically acidotic. The body can no longer effectively buffer or eliminate lactate quick enough and consequently a build up of acid occurs
Exercise intense enough to trigger anaerobic metabolism and no longer respiring aerobically.
80
What gram category is staphylococcus aureus? (1)
Positive
81
What 2 factors (I can’t remember if it was host or bacterial) are used to recognise pneumococcus (2)
HOST: TLR 2/6 and PRRs
BACTERIAL: LTA and peptidoglycan
HOST: pneumonia, sepsis and cellulitis
BACTERIAL (catalase negative): a-haemolytic, optochin sensitive
82
What is the body’s main molecule for detecting streptococcus pyogenes infections? (1)
Toll-like receptor 2 and (TLR1/6)
83
What gram stain category is C. diff? (1)
Positive
84
What are the 2 host receptors for staphylococcus aureus toxic shock toxin? (2)
MHCII and TCR
85
Name 5 classes of drugs that target the Renin-angiotensin system and explain how they affect their targets (5)
* Renin inhibitors
* ACE Inhibitor
* Angiotensin Receptor Blocker
* Mineralocorticoid antagonists
* Beta blockers
86
Patient is taking Felodipine and drinking citrus juices. Explain his symptoms of headaches and dizziness, etc. (3)
Grape fruit juice is an inhibitor of CYP450, which also metabolises felpdipine. Inhibition of CYP450 leads to an increase in levels (bioavailability) of felodipine leading to vasodilation in the brain – hypoxia in the brain causing headaches and dizziness.
87
What class of drug is felodipine? (1)
Calcium channel blocker – dyhyropiridine
88
3 dietary restrictions for someone with kidney failure (3)
Low potassium, low phosphate, low protein, fluid restriction, salt not over recommended 6g per day
89
Describe how acute kidney failure/tubular necrosis happens?
Low blood pressure, low intravascular volume, low perfusion of the kidney = low nutrient and oxygen supply – ischaemia and necrosis
Renal artery stenosis, hypovalaemia, hypoperfusion, hypoxia
90
Other than physical illness, list and quantify 3 social costs of obesity (3)
* Special equipment requirement
* Depression
* llness – days off work cost to economy
* Time and money in to weight loss management.
• Income loss by premature deaths
* Absenteeism
* Income loss from decreased productivity
* Depression and increased psychological disorders
91
3 features on ECG of hyperkalaemia (3 marks)
Tented t waves, absent p waves, broad qrs complex, bradycardia
92
How does posterior pituitary control water balance? (2 marks)
High osmolality of blood/low volume/BP = ADH release = aquaporin 2 in collecting duct = reabsorption of water.
93
2 types of acid the body produces (2 marks)
Carbonic, lactate, HCl,
94
What is factitious hyponatraemia. Give an example (2 marks)
Hyperosmolality not due to sodium which causes an increase in water in the blood leading to relative fall in sodium e.g. high glucose
95
Give a condition where metabolic acid is produced. Name the acid (1 mark)
Type I DM – ketoacidosis
96
Which layer of the heart is the most susceptible to myocardial ischaemia (sub-epicardial/ mid-layer/ sub-endocardial)? (1 mark)
Innermost – sub endocardial
97
What symptom does a patient complain for myocardial ischaemia? When does it happen (1 mark)
Angina on exertion
98
Orientation of mid-layer of cardiomyocyte in-relation to longitudinal axis (1 mark)
Perpendicular
| AV septal defect
99
Flow of blood (1 mark)
a) Between the ventricles (left to right or vice versa)
100
Pulmonary blood flow (1 mark
Increased
101
Pulmonary artery pressure (1 mark)
a) Increased
Coarctation of aorta
102
Why in that place (1 mark)
Ductus arteriosis
103
Impact on blood pressure measurement (1 mark)
a) High in upper limbs and lower in lower limb
104
What would be seen on X-ray (1 mark)
a) Dilation of aorta followed by constriction
105
Grapefruit juice and how does it affect statin. What would you expect to see? (2 marks)
Inhibit cyp450 – increase in statin, drop in cholesterol with more side effects such as myalgia, constipation, dizziness, headaches, heartburn, nausea
106
2 measurements to be made and state frequencies of measurement (2 marks)
CK and LFT
107
Medical indications of statin (1 mark)
High cholesterol – high LDL and low HDL
108
Phase 1,2,3,4 trial aims (4 marks?)
a. Phase 1 – dose range, tolerability and safety on small number of healthy subjects
b. Phase 2 = efficacy, safety and optimum dose and POC
c. Phase 3 = long term safety and effectiveness (vs placebo)
d. Phase 4 = long term safety, side effects, yellow card scheme, pharmacoeconomic, QOL, marketing.
109
2 common trial designs (2 marks)
Parallel and crossover
110
Committee approval required. Which 2 committees? (1 mark)
MHRA, EMEA, FDA
111
Gram positive pneumococcus factor for recognition (1 mark)
Pneumolysin TLR4
112
Other bacterial factor for recognition (1 mark)
LTA peptidoglycan
113
2 defence mechanisms for recognition of bacteria (2 marks)
Complement/antibodies, dendrites
114
Function of TNF/ IL8/ iNOS/ Tissue factor (4 marks)
a. TNF – recruitment and activation of macrophages
b. IL8 – recruits neutrophils and monocytes
c. iNOS – synthesis of NO causing vasodilation
d. Tissue factor -
115
a) 2 bacteria causes acute meningiditis in adult (2 marks)
Streptococcus pneumonia and Neisseria meningitides
116
Energy expenditure in obese c.f. normal (1 mark)
Increased
117
Leptin level in obese cf normal (1 mark)
Higher – more adipose
118
2 advantages for eating oily fish (2 marks)
Reduces LDL and increases HDL, reduces platelet activity
119
2 questions to ask in nutritional assessment (2 marks)
Weight loss? Appetite?
120
GI index definition (1 mark)
A measure of how quickly blood sugar rises after eating a particular food
121
Why low GI food beneficial for diabetics (1 mark)
Stops high peak of glucose, better control of glucose as lower level of insulin levels needed.
122
2 differences between metabolism in starvation and chronic illness (2 marks)
Starvation – metabolism goes down, protein metabolism stays the same
Chronic illness – metabolism goes up, protein metabolism increases
123
Name three drugs that cause hyperkalemia (3marks)
* Sprinolactone,
* Ramipril
* Enalopril
124
Name three hormones that control water balance (3marks)
* ADH
* Aldosterone
* Renin
125
What is pseudohyponatermia (2marks)
A low serum sodium concentration resulting from volume displacement by massive hyperlipidemia or hyperproteinemia, or by hyperglycemia.
126
Dye is injected into the veins on the arm, how long before it reaches:
a. The right ventricle (1mark)
b. Evenly diffused throughout the body (1mark)
a) 10s
| b) 30s
127
Once it has been injected (the dye in arm) you will see a few peaks in a graph showing the concentration in the RV but then it eventually levels off-why does this happen (2marks)
Leading flow – rest diluted and dispersed throughout body
128
Name three conditions cause a murmur on the sternal side at diastole (3marks)
* Valve stenosis
* Atrial septal defect
* Arrhythmia
129
What are three clinical disadvantages of a CMR (Cardiac MRI) (3marks)
* Expensive
* Time-consuming
* Not suitable for patients with metal implants (pacemakers common in cardiac patients)
130
Name four host factors that prevent streptococcus pneumonia from penetrating the mucosal layer? (4marks)
* Lysozymes
* Anti-microbial peptides
* ?
* ?
131
Three bacterial factors that help streptococcus pneumonia evade the immune system (3marks)
* Capsule/flagella
* Type 4 pili
* ?
132
A 66year old man has recently suffered an MI. He was given Clopidogrel, however he says it isn’t effective. He gets a second opinion on the dosage he was given and was told that the drug may not be working as effectively in him as it does in other patients.
a) What reasons may have led to the doctor telling him that the drug isn’t as effective in him as it is in other people? (2marks)
Allele – genes – pharmacogenomics – different metabolisms
133
What are two side effects of Clopidogrel? (2marks)
* Easy bruising
| * Longer prothrombin time
134
Give four ways to ensure good prescribing (4marks)
* Check patient details
* Check dosage
* Check allergies
* Check drug interactions
135
Name 2 ways to manage the diet of CKD patient about to undergo dialysis (2)
Phosphate binders, lower fluid intake etc.
136
Explain four ways in which cancer can lead to malnutrition in a lung cancer patient, along with their mechanism of action (4)
* Iatrogenic causes (decreased intake)
* Inadequate symptom control (loss of appetite, nausea and vomiting)
* Tumour site (obstruction of colon = constipation?)
* Increased metabolic rate (intake mismatched with use)
* Cancer cachexia
* Odynophagia due to radiotherapy (cancer cachexia lecture)
137
What is the gold standard for diagnosing food allergy (1)
Food elimination and reintroduction (exclusion diet)
138
List 2 lifestyle changes you would advise an obese patient to lose weight (2)
Increase physical activity, decreased fat intake
139
Two immediate tests you would order to diagnose MI (2)
Troponin
| ECG
140
2 drugs you would give immediately which have been shown to be prognostically beneficial (2 marks
Clopidogrel
| Aspirin
141
Leaves with impaired left systolic function. In addition to the drugs you mentioned above, what 2 classes of drugs could you give to this patient on discharge (2)
Beta blocker and ace inhibitors, spironolactone
142
Explain the term "surrogate marker" (2)
True substitute to a clinically meaningful endpoint
143
Name 2 advantages of using a surrogate marker (2)
Shows if drug is clinically useful, allows the identity of an endpoint in disease eg Alzheimer’s
144
Patient with MRSA infection due to central line or something
Name 2 bacterial factors that can be recognised by the host (2)
LTA
| Peptidoglycan
145
Name one soluble host factor that acts as a chemoattractant/attracts neutrophils (1)
IL8
146
Name one soluble host factor that causes local vasodilation (1)
NO
147
List three ways in which this bacteria can evade the host immune system (3)
1. Anti-neutrophil (PVL)
2. Anti-opsonisin (IgG binding protein)
3. Inhibit phagolysozyme activity (TB)
148
Explain the strategies a doctor would use to treat this infection. Of this, name 2 drugs (3)
* Vancomycin and clindamycin.
* Isolation of patient.
* IV immunoglobulins
149
Name 3 drugs that cause hyperkalemia (3)
ACEI
ARBs
K sparing diuretics
150
The lack of which hormone causes hyperkalemia (1)
Aldosterone
151
Explain how thiazide diuretics work (2)
Block Na/Cl transported in DCT
152
Describe the biochemical abnormalities you would see in SIADH (2)
Hyponatraemia
blood osmolality less than 285 mmol/l
high urine osmolality
153
Name 2 instances you would see dilated pulmonary arteries (2)
Sepis, PE
154
List 2 investigations to assess myocardial viability (2)
Stress echocardiogram
MRI and MPI
ECG
155
Patient injected with contrast agent in left arm vein. Which chamber and/or vessels which you see the highest concentration in after [3]
a. 8-10 seconds:
b. 20 seconds:
c. 60 seconds:
a) Pulmonary artery
b) Aorta
c) Rest of body
156
When does the forward flow peak in the left mainstem coronary artery occur and why? (1) - sorry couldnt remember the exact wording!
Diastole, valves shut and blood pushed into coronary arteries.
157
Patient who is diabetic, he's already on metformin, gliclazide and BP-lowering pills comes in with sepsis, i.e. he has low BP, high HR, fever, chest x-ray 1 which is associated with the first 3 q's showed pulmonary consolidation in the right lung, i.e. he has pneumonia, his had acidosis with a ph7.1, a low pO2 (assumed due to pneumonia so poor ventilation) and a normal range c02 (type 1 RF). Also he had a base excess in the minus - i.e. he had metabolic acidosis
Comment on what has happened etc, include the acid-base results in your answer.
He has sepsis, describe what has happened to cause these symptoms
- i put systemic inflam response causing vasodilation and fluid extravasation causing low bp and reflex tachy etc metabolic acidosis due to low BP and organ hypoperfusion causing lactic acidosis etc without any compensation due to the problems with ventilation due to pneumonia. blah blah blah sepsis and all that jazz
158
What initial management would be given and what changes may you have to make to his meds? (diabetic patient)
Put on 02, give antibiotics, give some insulin as he's diabetic, his low BP is the problem so take him off BP lowering meds and give fluids/colloids
159
From the diabetic patient case:
What likely pathogens are likely to have caused this and what about him may make him more vulnerable?
Diabetic so immunocompromised and all the likely pathogens
160
On the 3rd night he seems to be getting better, CRP is improving but suddenly becomes acutely short of breath and troponin is raised, an x-ray shows a big mess which i am pretty sure is pulmonary oedema, which seems likely as they gave him a diuretic too
a) What has happened and what do you think about its management?
I assume he had heart failure he was given furosemide, which is good but maybe give him and ace-I to stop it happeneing again and again, wasn't certain about this part
161
Complete the missing substrates and enzymes in the pathway. [3]
(Angiotensin system)
Angiotensinogen Angiotensin I Angiotensin II
Enzymes are renin and ACE
162
What are the 2 principle actions of angiotensin II? [2]
* Vasoconstriction
| * Stimulates aldosterone secretion leading to sodium reabsorption and potassium excretion
163
Which elements of this pathway can be targeted in order to reduce the activity of the renin-angiotensin system? [3]
* ACE inhibition
* Angiotensin I receptor antagonism
* Direct renin inhibition
164
Describe 2 ECG changes associated with hyperkalaemia. [2]
* Tall t waves
* Small p waves
* Broad QRS
* bradycardia
165
What is the Gram staining characteristic of Staphylococcus aureus? [1]
Gram positive
166
List the major host receptor that the host used to recognise Staphylococcus aureus. [1]
Toll-like receptor 2
167
List 2 invasive infections that are most commonly caused by Staphylococcus aureus? [2]
* Most deep abscess (pyomyositis, renal abscess, brain abscess)
* Acute bacterial endocarditis
* Osteomyelitis
168
Staphylococcus aureus can cause toxic shock syndrome. List the 2 main host receptors for the TSST-1 superantigen toxin. [2]
* HLA class II (or MHC II)
| * TCR (variable beta chain)
169
What is the Gram staining characteristic for Clostridium difficile? [1]
Gram postitive
170
List 2 major disease syndromes caused by Clostridium difficile. [2]
* Antibiotic associated diarrhoea
* Pseudomembranous colitis
* Bowel perforation
* Toxic megacolon
171
Name one virulence factor produced by Clostridium difficile that causes disease? [1]
Toxin A
Toxin B
Binary toxin
172
What's a major risk factor for Clostridium difficile? [1]
Antibiotics
173
A 62 year old man presents with a week’s history of palpitations and shortness of breath. His ECG shows atrial fibrillation.
a) List 2 ECG features which are often present in atrial fibrillation. [2]
* Absent p-waves
* Irregularly irregular beat
* Narrow QRS complex tachycardia
* Absent isoelectric baseline
* Fibrillatory waves
174
List 2 further relevant investigations for atrial fibrillation. For each investigation, indicate the type of abnormality that is being sought. [6]
* Bloods – thyroid function (exclude hyperthyroidism, thyrotoxicosis), U&Es (exclude electrolyte disturbance as a cause), FBC (infection), CRP (infection), BNP (measure of heart failure)
* Chest X ray – pulmonary oedema/cardiomegaly/pneumonia/left atrial dilatation
* Transthoracic echocardiogram – to assess LV function, LA size and valves
* Coronary angiogram, or non-invasive ischaemia testing (exercise ECG, stress echo, myocardial perfusion scan, CT coronary angiogram) to exclude IHD as a cause for his AF, as strong risk factor profile
* 24 hour tape/Holter monitor: to assess rate control for AF/burden/exclude significant pauses
175
Name 2 classes of medication that may be of benefit in the treatment of AF in this patient, giving a reason for each. [2]
* Anticoagulation to reduce thromboembolic/stroke risk – e.g. warfarin/aspirin/novel anticoagulant (dabigatran, rivaroxaban)
* Anti-arrhythmic to provide rate or rhythm control – e.g. Beta blocker/calcium channel blocker/digoxin/amiodarone/flecainide/propafenone/dronedarone etc.
176
Name the lipoprotein particles that:
a. Carry lipid from the liver to the periphery. [1]
b. Carry cholesterol back to the liver. [1]
a) VLDL
| b) HDL
177
What is the best way to reduce the risk of developing Type 2 Diabetes? [1]
* Weight loss (reduce BMI)
| * Maintain ideal BMI
178
List 4 consequences of not complying with a gluten free diet in those with coeliac disease. [2]
* Osteoporosis
* Low bone mineral density
* Weak bones
* Osteopaenia
* Anaemia
* Iron/B12/folate deficiency
* Cancer
* Depression/low mood
* Diarrhoea
* Constipation
* Abdominal pain
* Bloating
* Nausea Weight loss
179
List 4 factors that contribute to malnutrition in surgical, trauma and critically ill patients. [2]
* Increased metabolic rate
* Increased protein breakdown
* Poor oral intake
* GI symptoms (nausea, vomiting, diarrhoea, malabsorption, ileus)
* Wound exudate, which is high in protein content
* Fasting for procedures
180
How many portions of oily fish would you advise patients to eat each week, after a MI, to reduce their risk of further heart disease? [1]
2-3 portions per week
181
Give an example of an important change seen in body composition during ageing and state the clinical implication. [2]
* Decreased muscle mass – affects muscles strength, respiratory function, heart function, mobility and overall independence
* Decreased fat mass (reduced energy store)
* Decreased bone mineral density (weaker bones predisposing to fractures)
182
A 64 year old man with a history of coronary artery disease presents with heart failure.
a) List some of the other common causes of HF (15%)
* Hypertension
* Cardiomyopathies
* Valvular disease
* Congenital heart disease
* Anaemia, thyotoxicosis
183
Describe some of the investigations you would carry out to confirm diagnosis of HF (40%)
* CXR: cardiomegaly (present in >50% HF patients), upper lobe diversion, pleural effusions, Septal/Kerley B lines
* ECG: not diagnostic but may help with aetiology (Q waves suggest ischaemia)
* Blood tests: BMP and pro-BNP (values above 400pg/ml (BNP) or 2000pg/ml (pro-BNP) are diagnostic (other test included troponin T, serum electrolytes, fasting blood glucose, complete blood count)
* Echocardiography: left ventricular ejection fraction, measures of stiffness (can detect ventricular sizes, valvular heart disease)
* Cardiac MRI, coronary angiogram, cardiopulmonary exercise test
184
Discuss how the renal system is involved and how it can be targeted for the treatment of HF (15%)
* Reduced perfusion pressure in the glomeruli increased renin production, increased Na+ reabsorption
* RAAS system – Angiotensin II vasoconstriction & cardiomegaly, aldosterone – increase Na+ and water reabsorption
185
The patient is sent home with pharmalogical interventions and recommended to follow a DASH or Mediterranean diet
a) Describe and evaluate the DASH diet and Mediterranean diets (30%)
* Foods that are low in sodium, rich in fruits and vegetables and low fat dairy
* DASH study (2001) found that those at the lowest sodium intake saw reductions in systolic BP ranging from 7-14mmHg. Not just seen in hypertensive but also normotensive individuals.
* PURE study (2014) also showed the benefit of reduced salt intake
* Mediterranean diet comprises an abundance of plant foods (fruits, vegetables, cereal, beans, nuts and seeds), olive oil, more omega-3 fats, fish, wine, pasta & bread low consumption of red meat
* Benefits first described in the seven-countries study and also shown in the Lyon diet heart study (1999) and the PREDIMED study (2013)
