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AC1 > Week 2 > Flashcards

Week 2 Flashcards

1
Q

Where are lymphocytes produced?

A

Lymphocytes are produced by haemopoetic stem cells in the bone marrow.

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2
Q

What happens in primary lymphoid organs? Examples of primary lymphoid organs?

A

Immature lymphocytes acquire receptors to recognise antigens.
Bone marrow, thymus

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3
Q

What happens in secondary lymphoid organs? Examples of secondary lymphoid organs?

A

Lymphocytes are exposed to and are activated in response to antigens.
Lymph nodes, spleen, Mucosa associated lymphoid tissue (MALT).

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4
Q

What are the classes of lymphocytes?

A

B Cells: these are derived from the bone marrow. Stimulated B cells will mature into plasma cells (antibody factories). The antibodies will be of one of five classes (Ig-A,D,E,G or M). The antibodies will then be secreted into the circulation (a proportion will remain bound to B cell membrane to act as the B cell receptor). Once activated, B cells will mitotically divide producing a mixture of plasma cells and memory B cells (capable of mounting a secondary immune response: more rapid, greater magnitude).

T Cells: these have effector and regulatory functions. T cells migrate from the bone marrow to the thymus, where they develop into mature T cells (or undergo apoptosis if they are self-reactive). T cells then move into the secondary lymphoid organs (lymph nodes, MALT), but are constantly circulating around.

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5
Q

What are the major classes of T cells?

A
  • T helper cells: help other cells to perform their effector functions by secreting interleukins:
    TH1 - promote a cell-mediated response
    TH2 - promote humoral immunity
    TH17 - promote acute inflammation
  • Cytotoxic T cells: kill viral and cancer cells. They require help from T helper cells to become active.
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6
Q

What are antigen presenting cells?

A

Antigen presenting cells (APCs) present antigen (normally broken down into short peptides), bound to major histocompatibilty complexes (MHCs), to lymphocytes. Contact of this MHC-peptide complex with a T cell receptor with appropriate specificity then activates the T cells.

There are two types of APCs:

Non-professional (all nucleated cells of the body): These express MHC class 1. Viral antigens, or cancer antigens would be expressed by these cells bound to MHC class I receptors, and would invoke a response by cytotoxic T cells.
Professional APC (e.g. dendritic cells, macrophages, Langerhans cells): These take in external antigen, process it and present it bound to MHC class II receptors. This promotes T helper cell response, which then activates B cells.
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7
Q

What type of lymphocytes would you find in the follicle of a lymph node?

A

B-cells

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8
Q

What type of lymphocytes would you find in the cortex/paracortex of a lymph node?

A

T-cells

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9
Q

What type of lymphocytes would you find in the medulla?

A

Plasma cells

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10
Q

How does lymph flow through the lymph node?

A
  • Lymph flows into the node, via afferent lymphatic vessels, on the convex surface of the lymph node. These are multiple, and contain valves to prevent back flow of lymph.
  • Afferent lymphatics empty into the subcapsular sinus, which is continuous with the lymphatic (cortical) sinuses,and then into the medulla.
  • Lymph flows out through medullary sinuses, to the efferent lymphatic vessel on the concave surface of the lymph node (at the hilum).
  • The lymphatic vessels and sinuses are lined with lymphatic endothelial cells.
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11
Q

What cells are present in a lymphoid follicle?

A

1) B cells
- “Centroblast” (CB) (immature B cell) - large, mitotically active cells, with round nuclei found in the darker zone of the germinal centre (closer to the medulla).
- “Centrocyte” (CC) (mature B cell) - found in the paler zone of the germinal centre, towards the lymph node capsule. These cells are of variable size, and have folded irregular nuclei. These migrate to the paler capsular zone of the germinal centre to produce “immunoblasts” (memory B cells).
- Non-proliferating B cells (in the mantle region).
2) Follicular dendritic cells (FDC)
3) Macrophages (M)

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12
Q

What cells are present in the medullary sinus?

A
  • Plasma cells (P) (and their pre-cursors, plasmablasts) are the major cell type in the medullary cords
  • ​​​​​​​the B lymphocytes complete the final stages of maturation to form plasma cells
  • plasma cells synthesise antibody that is carried by efferent lymph into the general circulation
  • plasmablasts also migrate in the efferent lymph to peripheral tissues
  • Sinus macrophages (M) are the main cell type in the medullary sinuses
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13
Q

What are the characteristic microanatomical features of the spleen?

A

Red pulp (RP):

  • makes up bulk of the organ
  • interconnected sinuses that are tributaries of the splenic vein
  • blood cells enter the parenchyma from capillaries, squeeze through the walls of the sinuses and drain out via the splenic vein (open circulation)

White pulp (WP) (20% of mass)

  • 0.5-1mm white nodules - lymphoid aggregations (similar to the paracortex/cortex of lymph nodes).
  • T cells (mainly TH1 cells) typically form a sheath around a central artery (periarteriolar lymphoid sheath - PALS).
  • B cells form follicles, usually located in the edge of the PALS. At the follicle periphery, there is a narrow zone of small lymphocytes called the mantle zone, beyond which is a broader marginal zone of medium sized lymphocytes (which contains subsets of B cells and macrophages).
  • The perilymphoid red pulp (the red pulp around the marginal zone) contains lymphocytes migrating from the sinuses to the white pulp.
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14
Q

What are the four functions of the spleen?

A

1) Production of an immunological response against blood borne antigens
2) Removal of particulate matter and aged or defective blood cells from the circulation
3) Recycling iron back to the marrow
4) Extra-medullary haematopoesis in the fetus and during certain bone marrow diseases

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15
Q

What are the characteristic microanatomical features of the thymus?

A
  • The thymus is a lobulated organ invested by a loose collagenous capsule (C) from which interlobular septa (S) project into the substance of the organ
  • The thymic tissue is divided into two distinct zones (most obvious in childhood - as seen in this image)
    outer cortex (C)
    inner medulla (M)
  • Thymic epithelium develops into a sponge like structure containing spaces that become colonised by immature T lymphocytes derived from haematopoietic tissue
  • Cortical epithelial cells promote T cell differentiation and proliferation
  • The thymic epithelium forms sheaths around the blood vessels
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16
Q

By what 2 processes does the thymus undergo involution in the adult?

A

1) fatty infiltration - in the mature thymus islands of lymphoid tissue (L) are separated by areas of adipose tissue (A)
2) lymphocyte depletion (despite this, the thymus continues to provide a supply of mature T lymphocytes to the circulation and peripheral tissues)

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17
Q

What are the characteristic microanatomical features of the palatine tonsils?

A
  • Discrete masses of lymphoid tissue covered in stratified squamous epithelium (E)
  • Deep invaginations forming tonsillar crypts (C) allow large surface area for exposure to antigens
  • Tonsillar parenchyma contains lymphoid follicles (F) similar to those found in lymph nodes
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18
Q

What is cardiac output?

A

CO is the amount of blood which is ejected from the heart in 1 minute

CO = SV x HR

CO should be 5-6L, any less suggests some dysfunction of the heart
Ejection fraction is usually 50-70%

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19
Q

What are some causes of heart failure?

A

1) Coronary artery disease
- Post MI
- Chronic ischaemia

2) Hypertension (struggling against an after load)

3) Valvular disease
- Regurgitation of a valve = volume overload
- Stenosis of a valve = extra force needed to overcome

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20
Q

What are some causes of myocardial disease that heart failure can be secondary to?

A
  • Cardiomyopathies
  • Arrhythmias
  • Drugs (anti-arrhythmics, cytotoxics)
  • Toxins (alcohol, cocaine, mercury)
  • Endocrine (diabetes, thyroid disease, adrenal disease)
  • Nutritional (thiamine deficiency, obesity)
  • Infiltrative (sarcoidosis, amyloidosis, haemachromatosis)
  • Infective (HIV)
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21
Q

What are some causes of high output cardiac failure?

A
  • Anaemia
  • Pregnancy
  • Hyperthyroidism
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22
Q

What are some signs of reduced cardiac output?

A
  • low systolic blood pressure
  • narrow pulse pressure
  • pulsus alterans (on ECG)
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23
Q

What investigations would you do for heart failure?

A
  • ECG
  • BNP (released by ventricular myocardium when stressed)
  • Chest X-ray (alveolar oedema, Kerley B lines, cardiomegaly, upper lobe diversion, pleural effusion)
  • Special tests: echocardiogram, cardiac MRI
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24
Q

How would you acutely manage heart failure?

A
  • A-E assessment
  • oxygen
  • IV access and monitoring
  • Furosemide IV
  • Diamorphine
  • Nitrates (GTN infusion)
  • Non-invasive ventilation (NIV) eg. CPAP
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25
Q

How would you manage chronic heart failure?

A

Lifestyle:

  • Stop smoking
  • Reduce alcohol
  • Fluid restriction
  • Salt restriction
  • Regular weighing
  • Cardiac rehabilitation

Medical:

  • ACEi
  • Beta blockers
  • Diuretics
  • Treat underlying cause (eg. arrhythmias)

Surgical:

  • Cardiac resynchronisation
  • Treat underlying cause eg. valvular disease, ischaemic heart disease
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26
Q

What is the purpose of a psychiatric history?

A
  • Gather information on psychological and physical symptoms
  • Understand the impact of symptoms on the patient’s life
  • Understand the context of the patient’s problems from a psychological and social point of view
  • Contributes to risk assessment
  • Contributes to formulation
  • Provides a therapeutic intervention
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27
Q

What is the purpose of a Mental State Examination (MSE)?

A
  • Your observation of the patient’s mental experiences and behaviours at that period in time
  • Structured description of signs and symptoms
28
Q

What is the structure of an MSE?

A
  • Appearance and behaviour
  • Speech
  • Mood and affect
  • Thought: Form, Content
  • Perception
  • Cognition
  • Insight
29
Q

What are some ways to describe thought disorder?

A
  • Circumstantial thinking
  • Flight of ideas
  • Tangentiality
  • Loosening of associations (knight’s move thinking/derailment)
  • Word salad
  • Neologisms (words created by patient)
  • Thought blocking
30
Q

Define delusions

A

a false and firmly held belief that is out of keeping with the patient’s educational, cultural and social background. It is held with unshakable conviction and cannot be altered by rational argument

31
Q

Define overvalued idea

A

non-delusional, non-obsessional belief that nevertheless preoccupies the patient and dominates their thinking. Plausible belief arrived at logically but held with undue importance and causes distress to patient or those around them. No major abnormality in reasoning. Not viewed as abnormal by the patient.

32
Q

Define obsessive thoughts

A

recurrent, intrusive unpleasant thought. The patient knows that the thought makes no sense and struggles to resist it

33
Q

What is thought insertion?

A

belief that thoughts are being implanted in one’s head by an external agency

34
Q

What is thought withdrawal?

A

belief that thoughts or ideas are being extracted from one’s head by an external agency

35
Q

What is thought broadcast?

A

belief that one’s thoughts are being broadcast so that everyone knows what one is thinking

36
Q

Define hallucination

A

sensory perception in the absence of an external stimulus, which the patient believes is a real perception

37
Q

What is the criteria for diagnosing Major Depressive Disorder according to DSM-V

A

Need 5 out of 9 symptoms:

  • Depressed mood
  • Decreased interest/pleasure
  • Weight loss/gain
  • Inability to sleep or oversleeping
  • Psychomotor agitation or impairment
  • Fatigue
  • Feelings of worthlessness/guilt
  • Decreased concentration
  • Thoughts of death or suicidality
38
Q

What screening tool is used in primary care to monitor the severity of depression and response to treatment?

A

PHQ-9
If answer to first two questions is positive, go on to complete the rest of the questionnaire
- little interest or pleasure in doing things?
- feeling down, depressed or hopeless?

39
Q

What are the 5 classes of antidepressants?

A

1) Selective serotonin reuptake inhibitors (SSRIs)
2) Serotonin/norepinephrine reuptake inhibitors (SNRIs)
3) Tricyclic antidepressants (TCAs)
4) Monoamine oxidase inhibitors (MAOIs)
5) Atypical antidepressants

40
Q

Which amino acid is serotonin synthesised from?

A

Tryptophan

41
Q

Which amino acid is noradrenaline synthesised from?

A

Tyrosine

42
Q

What are the advantages of advanced care planning (ACP)?

A

1) Planning ahead allows for care to be accessed safely, at the right time and with continuity of delivery
2) Can avoid the conflicts and tensions that arise between doctors, patients and relatives during emotionally fraught times
3) Can help in determining right course of action if capacity is lost

43
Q

What should the ACP discussion include?

A

1) The patient’s wishes, preferences or fears in relation to future treatment or care
2) The feelings, beliefs or values influencing the patient’s preferences and decisions
3) Family members, or others close to the patient or any legal proxies that the patient would like to be involved in decisions about their care.
4) Interventions that may be considered or undertaken in an emergency, such as CPR.
Especially important if a patient has a condition where they may lose capacity in the future.

44
Q

What are the three ways in which a patient may express their wishes for the future?

A

1) Advance requests for treatment (not technically a ‘decision’)
2) Advance refusals of treatment
3) Decisions about cardiopulmonary resuscitation (CPR)

45
Q

When can an Advance Refusal of Treatment be legally binding?

A

If:

  • It is valid
  • It is clearly applicable to the patient’s current circumstances
46
Q

What makes an Advance Refusal valid?

A
  • The patient was an adult when the decision was made
  • The patient had capacity to make the decision at the time it was made
  • The patient was not subject to undue influence in making the decision
  • The patient made the decision on the basis of adequate information
47
Q

When is an Advance Refusal not valid?

A
  • The person has withdrawn the advance decision since making it
  • Since making the decision, the person has created a Lasting Power of Attorney for health and welfare, giving someone else the authority to refuse or consent to the treatment in question
  • The person has done anything that is clearly inconsistent with the advance decision remaining their fixed decision
48
Q

What must advance refusals of life-sustaining treatment be?

A
  • Written
  • Signed by the person making it
  • Witnessed
  • Specify that the treatment is potentially life sustaining/acknowledge that death could result from the refusal
49
Q

What does ReSPECT stand for?

A

Recommended Summary Plan for Emergency Care and Treatment

50
Q

What are the three stages of the developmental process?

A

Passive reception –> Perception –> Conception

51
Q

According to Piaget, what is a schema?

A

A cohesive, repeatable action sequence possessing component actions that are tightly interconnected and governed by a core meaning

52
Q

What are the two processes by which a child builds up knowledge?

A

1) Assimilation: An existing schema works well for a new situation, so the knowledge attached to the new situation is assimilated into the existing schema
2) Accommodation: No existing schema fits the new situation, so a schema must be altered to accommodate the new information.

53
Q

What are the Piaget stages?

A

1) Sensorimotor 0-2 y object permanence
2) Pre-operational 2-7 y egocentric
3) Concrete operations 7-11 y conservation of number
4) Formal operations 11+ y abstract thinking

54
Q

What are the superior and inferior boundaries of the neck?

A

Superior boundary = inferior border of the mandible and around the base of the skull; around the pericraniocervical line

Inferior boundary = manubrium, clavicle and a line passing from the acromion to the spinous process of C7

55
Q

What are the boundaries of the anterior triangle of neck?

A 
Medial = midline (median sagittal plane)
Lateral = sternocleidomastoid (anterior border)
Superior = inferior margin of mandible
56
Q

Name the suprahyoid muscles, and their innervation. What is the function of suprahyoid muscles?

A

Suprahyoid muscles elevate the hyoid

  • Digastric anterior belly CN Vc
  • Mylohyoid CN Vc
  • Digastric posterior belly CN VII
  • Stylohyoid CN VII
57
Q

Name the infrahyoid muscles, and their innervation. What is the function of suprahyoid muscles?

A 
Infrahyoid muscles depress the hyoid
- Omohyoid (superior & inferior bellies)
- Sternohyoid
- Thyrohyoid
- Sternothyroid
Innervated by the ansa cervicalis (C1-3)
58
Q

What are the borders of the submandibular triangle?

A
  • Mandible

- Digastric

59
Q

What are the borders of the carotid triangle?

A
  • SCM
  • Superior belly of omohyoid
  • Posterior belly of digastric
60
Q

What are the borders of the muscular triangle?

A
  • SCM
  • Superior border of omohyoid
  • Midline
61
Q

What are the borders of the submental triangle?

A
  • Hyoid bone
  • Anterior belly of digastric
  • Midline
62
Q

How can the posterior triangle be subdivided?

A

By the inferior belly of omohyoid into occipital triangle and omoclavicular (supraclavicular triangle)

63
Q

What forms the floor of the posterior triangle?

A

Prevertebral fascia overlying splenius capitus, levator scapulae and scalenus (anterior, medius and posterior)

64
Q

What nerves pass through the posterior triangle?

A
  • Accessory nerve
  • Brachial plexus
  • Phrenic nerve
65
Q

Which muscles and bones from from the first pharyngeal arch and what is its neural supply

A

CN V
Mastication muscles, mylohyoid, anterior belly digastric, tensor tympani, tensor veli palatini

Malleus, incus, spine of sphenoid and sphenomandibular ligament, maxilla, zygoma and mandible

AC1 (9 decks)

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