Calcium homeostasis question

Question 1 of 192
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A 54 year old lady has her serum calcium measured. Assuming her renal function
is normal, what proportion of calcium filtered at the glomerulus will be reabsorbed
by the renal tubules?
5%
15%
gathered by dr. elbarky
25%
50%
95%
Most filtered calcium is reabsorbed (95%) a rare disorder of familial hypocalcemic

calciurea may affect this proportion.
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Calcium homeostasis
Calcium ions are linked to a wide range of physiological processes. The largest
store of bodily calcium is contained within the skeleton. Calcium levels are
primarily controlled by parathyroid hormone, vitamin D and calcitonin.
Hormonal regulation of calcium
Hormone Actions
Hormone Actions
Parathyroid hormone (PTH) Increase calcium levels and

decrease phosphate levels
Increases bone resorption
Immediate action on osteoblasts to
increase ca2+ in extracellular fluid
Osteoblasts produce a protein
signaling molecule that activate
osteoclasts which cause bone
resorption
Increases renal tubular reabsorption
of calcium
Increases synthesis of 1,25(OH)2D
(active form of vitamin D) in the

kidney which increases bowel
absorption of Ca2+
Decreases renal phosphate
reabsorption
1,25-dihydroxycholecalciferol Increases plasma calcium and

(the active form of vitamin D) plasma phosphate
and gut absorption of calcium
Increases osteoclastic activity at
high levels and osteoblasts at low
levels
Increases renal phosphate
reabsorption
Calcitonin Secreted by C cells of thyroid

Inhibits intestinal calcium absorption
Inhibits osteoclast activity
Inhibits renal tubular absorption of
calcium
Both growth hormone and thyroxine also play a small role in calcium metabolism.
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Question 2 of 192
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Which of the following statements is true of glucagon?
Glucagon is produced in response to hyperglycaemia
Released by beta cells
Inhibits gluconeogenesis
Produced in response to an increase of amino acids
Composed of 2 alpha polypeptide chains linked by hydrogen bonds
Glucagon is a protein comprised of a single polypeptide chain.

Produced by alpha cells of pancreatic islets of Langerhans in response to
hypoglycaemia and amino acids.
It increases plasma glucose and ketones.
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Glucagon
Glucagon, the hormonal antagonist to insulin, is released from the alpha cells of
the Islets of Langerhans in the pancreas. It will result in an increased plasma
glucose level.
Stimulation Inhibition
Decreased plasma glucose Somatostatin
Increased catecholamines Insulin
Increased plasma amino acids Increased free fatty acids and keto acids
Sympathetic nervous system Increased urea
Acetylcholine
Cholecystokinin
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Question 3 of 192
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Which of the following is not caused by cortisol in the stress response?
Anti-inflammatory effects
Hypoglycaemia
Skeletal muscle protein breakdown

Stimulation of lipolysis
Mineralocorticoid effects
An 'anti insulin' effect occurs leading to hyperglycaemia.
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Stress response: Endocrine and metabolic changes
Surgery precipitates hormonal and metabolic changes causing the stress

response.
Stress response is associated with: substrate mobilization, muscle protein
loss, sodium and water retention, suppression of anabolic hormone
secretion, activation of the sympathetic nervous system, immunological and
haematological changes.
The hypothalamic-pituitary axis and the sympathetic nervous systems are
activated and there is a failure of the normal feedback mechanisms of
control of hormone secretion.
A summary of the hormonal changes associated with the stress response:

Increased Decreased No Change
Growth hormone Insulin Thyroid stimulating

hormone
Cortisol Testosterone Luteinizing hormone
Renin Oestrogen Follicle stimulating

hormone
Adrenocorticotrophic hormone
(ACTH)
Aldosterone
Prolactin
Antidiuretic hormone
Glucagon
Sympathetic nervous system

Stimulates catecholamine release
Causes tachycardia and hypertension
Pituitary gland
ACTH and growth hormone (GH) is stimulated by hypothalamic releasing
factors, corticotrophin releasing factor (CRF) and somatotrophin (or growth
hormone releasing factor)
Perioperative increased prolactin secretion occurs by release of inhibitory
control
Secretion of thyroid stimulating hormone (TSH), luteinizing hormone (LH)
and follicle stimulating hormone (FSH) does not change significantly
ACTH stimulates cortisol production within a few minutes of the start of
surgery. More ACTH is produced than needed to produce a maximum
adrenocortical response.
Cortisol
Significant increases within 4-6 hours of surgery (>1000 nmol litre-1).
The usual negative feedback mechanism fails and concentrations of ACTH
and cortisol remain persistently increased.
The magnitude and duration of the increase correlate with the severity of
stress and the response is not abolished by the administration of
corticosteroids.
The metabolic effects of cortisol are enhanced:
Skeletal muscle protein breakdown to provide gluconeogenic precursors and

amino acids for protein synthesis in the liver
'Anti-insulin effect'
Growth hormone
Increased secretion after surgery has a minor role
Most important for preventing muscle protein breakdown and promote
tissue repair by insulin growth factors
Alpha Endorphin
Increased
An important vasopressor and enhances haemostasis
Renin is released causing the conversion of angiotensinogen to angiotensin
I
Angiotensin II formed by ACE on angiotensin 1, which causes the secretion
of aldosterone from the adrenal cortex. This increases sodium reabsorption
at the distal convoluted tubule
Insulin
Release inhibited by stress
Occurs via the inhibition of the beta cells in the pancreas by the α2-
adrenergic inhibitory effects of catecholamines
Insulin resistance by target cells occurs later
The perioperative period is characterized by a state of functional insulin
deficiency
Thyroxine (T4) and tri-iodothyronine (T3)

Circulating concentrations are inversely correlated with sympathetic activity
and after surgery there is a reduction in thyroid hormone production, which
normalises over a few days.
Metabolic effect of endocrine response
Carbohydrate metabolism
Hyperglycaemia is a main feature of the metabolic response to surgery
Due to increase in glucose production and a reduction in glucose utilization
Catecholamines and cortisol promote glycogenolysis and gluconeogenesis
Initial failure of insulin secretion followed by insulin resistance affects the
normal responses
The proportion of the hyperglycaemic response reflects the severity of
surgery
Hyperglycaemia impairs wound healing and increase infection rates
Protein metabolism
Initially there is inhibition of protein anabolism, followed later, if the stress
response is severe, by enhanced catabolism
The amount of protein degradation is influenced by the type of surgery and
also by the nutritional status of the patient
Mainly skeletal muscle protein is affected
The amino acids released form acute phase proteins (fibrinogen, C reactive
protein, complement proteins, a2-macroglobulin, amyloid A and
ceruloplasmin) and are used for gluconeogenesis

Nutritional support has little effect on preventing catabolism
Lipid metabolism
Increased catecholamine, cortisol and glucagon secretion, and insulin deficiency,
promotes lipolysis and ketone body production.
Salt and water metabolism

ADH causes water retention, concentrated urine, and potassium loss and
may continue for 3 to 5 days after surgery
Renin causes sodium and water retention
Cytokines
Glycoproteins
Interleukins (IL) 1 to 17, interferons, and tumour necrosis factor
Synthesized by activated macrophages, fibroblasts, endothelial and glial
cells in response to tissue injury from surgery or trauma
IL-6 main cytokine associated with surgery. Peak 12 to 24 h after surgery
and increase by the degree of tissue damage Other effects of cytokines
include fever, granulocytosis, haemostasis, tissue damage limitation and
promotion of healing.
Modifying the response

Opioids suppress hypothalamic and pituitary hormone secretion
At high doses the hormonal response to pelvic and abdominal surgery is
abolished. However, such doses prolong recovery and increase the need for
postoperative ventilatory support
Spinal anaesthesia can reduce the glucose, ACTH, cortisol, GH and
epinephrine changes, although cytokine responses are unaltered
Cytokine release is reduced in less invasive surgery
Nutrition prevents the adverse effects of the stress response. Enteral
feeding improves recovery
Growth hormone and anabolic steroids may improve outcome
Normothermia decreases the metabolic response
References
Deborah Burton, Grainne Nicholson, and George Hall
Endocrine and metabolic response to surgery .
Contin Educ Anaesth Crit Care Pain (2004) 4(5): 144-147 doi:10.1093/bjaceaccp
/mkh040
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Question 4 of 192
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Which of the following statements relating to abnormal coagulation is false?
Warfarin affects the synthesis of factor 2,7,9,10
The prothrombin time is prolonged in Haemophilia A
Cholestatic jaundice can cause vitamin K deficiency

Disseminated intravascular coagulation is associated with

thrombocytopenia
Massive transfusion is associated with reduced levels of factor 5 and 8
In haemophilia A the APTT is prolonged and there is reduced levels of factor 8:C.
The bleeding time and PT are normal. Cholestatic jaundice prevents the absorption
of the fat soluble vitamin K. Massive transfusion (>10u blood or equivalent to the
blood volume of a person) puts the patient at risk of thrombocytopaenia, factor 5
and 8 deficiency.
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Abnormal coagulation
Cause Factors affected
Heparin Prevents activation factors 2,9,10,11
Warfarin Affects synthesis of factors 2,7,9,10
DIC Factors 1,2,5,8,11
Liver disease Factors 1,2,5,7,9,10,11
Interpretation blood clotting test results
Disorder APTT PT Bleeding time

Haemophilia Increased Normal Normal
von Willebrand's disease Increased Normal Increased
Vitamin K deficiency Increased Increased Normal
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Question 5 of 192
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Which of the following is not classically seen in coning resulting from raised intra
cranial pressure?
Coma
Hypotension
Unreactive mid sized pupils
Cheyne Stokes style respiratory efforts
Bradycardia
Cushings triad
Widening of the pulse pressure
Respiratory changes
Bradycardia
Due to raised ICP systemic hypertension is usually seen. Compression of the

respiratory centre will typically result in Cheyne Stokes style respiration.
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Coning
The cranial vault is a confined cavity apart from infants with a non fused
fontanelle.
Rises in ICP may be accommodated by shifts of CSF.
Once the CSF shifting has reached its capacity ICP will start to rise briskly.
The brain autoregulates its blood supply, as ICP rises the systemic
circulation will display changes to try and meet the perfusion needs of the
brain. Usually this will involve hypertension.
As ICP rises further, the brain will be compressed, cranial nerve palsies may
be seen and compression of essential centres in the brain stem will occur.
When the cardiac centre is involved bradycardia will often develop.
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Question 6 of 192
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Control of ventilation. Which statement is false?
Peripheral chemoreceptors are located in the bifurcation of the carotid

arteries and arch of the aorta
Central chemoreceptors respond to changes in O2

The respiratory centres control the rate and depth of respiration
Involuntary control of respiration is from the medulla and pons
Irritant receptors cause bronchospasm
- Central chemoreceptors: Respond to increased H+ in BRAIN INTERSTITIAL

FLUID to increase ventilation.
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Control of ventilation
Control of ventilation is coordinated by the respiratory centres,

chemoreceptors, lung receptors and muscles.
Automatic, involuntary control of respiration occurs from the medulla.
The respiratory centres control the respiratory rate and the depth of
respiration.
Respiratory centres
Medullary Inspiratory and expiratory neurones. Has ventral group
respiratory centre which controls forced voluntary expiration and the dorsal
group controls inspiration. Depressed by opiates.
Apneustic centre Lower pons

Stimulates inspiration - activates and prolongs inhalation
Overridden by pneumotaxic control to end inspiration
Pneumotaxic Upper pons, inhibits inspiration at a certain point. Fine

centre tunes the respiratory rate.
Ventillatory variables
Levels of pCO2 most important in ventilation control
Levels of O2 are less important.

Peripheral chemoreceptors: located in the bifurcation of carotid arteries and
arch of the aorta. They respond to changes in reduced pO2, increased H+
and increased pCO2 in ARTERIAL BLOOD.
Central chemoreceptors: located in the medulla. Respond to increased H+ in
BRAIN INTERSTITIAL FLUID to increase ventilation. NB the central receptors
are NOT influenced by O2 levels.
Lung receptors include:

Stretch receptors: respond to lung stretching causing a reduced respiratory
rate
Irritant receptors: respond to smoke etc causing bronchospasm
J (juxtacapillary) receptors
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Question 7 of 192
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A 52-year-old woman with a history of gastrectomy reports lethargy and a sore

tongue. Blood tests are reported as follows:
Hb 10.7 g/dl
MCV 121 fl
Plt 177 * 10^9/l

WBC 5.4 * 10^9/l
What is the most likely cause?
Vitamin B12 deficiency
Vitamin C deficiency
Iron deficiency anaemia
Anaemia of chronic disease
Vitamin E deficiency
A history of gastrectomy and a macrocytic anaemia should indicate a diagnosis of

B12 deficiency.
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Vitamin B12 deficiency
Vitamin B12 is mainly used in the body for red blood cell development and also
maintenance of the nervous system. It is absorbed after binding to intrinsic factor
(secreted from parietal cells in the stomach) and is actively absorbed in the
terminal ileum. A small amount of vitamin B12 is passively absorbed without being
bound to intrinsic factor.
Causes of vitamin B12 deficiency

pernicious anaemia
post gastrectomy
poor diet
disorders of terminal ileum (site of absorption): Crohn's, blind-loop etc
Features of vitamin B12 deficiency

macrocytic anaemia
sore tongue and mouth
neurological symptoms: e.g. Ataxia
neuropsychiatric symptoms: e.g. Mood disturbances
Management
if no neurological involvement 1 mg of IM hydroxocobalamin 3 times each
week for 2 weeks, then once every 3 months
if a patient is also deficient in folic acid then it is important to treat the B12
deficiency first to avoid precipitating subacute combined degeneration of
the cord
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Question 8 of 192
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Which of the following surgical procedures will have the greatest long term impact
on a patients calcium metabolism?
Distal gastrectomy
Cholecystectomy
Extensive small bowel resection
Sub total colectomy
Gastric banding for obesity
Calcium is mainly absorbed from the small bowel and this will have a direct long
term impact on calcium metabolism and increase the risk of osteoporosis. Gastric
banding and distal gastrectomy may affect a patients dietary choices but any
potential deleterious nutritional intake may be counteracted by administration of
calcium supplements orally. Only 10% of calcium is absorbed from the colon so
that a sub total colectomy will only have a negligible effect.
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Calcium homeostasis
Hormone Actions
Hormone Actions

resorption
of calcium

absorption of Ca2+
reabsorption

levels
reabsorption

calcium
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Question 9 of 192
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What is measured to obtain renal plasma flow?
Creatinine
Para-amino hippuric acid (PAH)
Inulin
Glucose
Protein
Renal plasma flow = (amount of PAH in urine per unit time) / (difference in PAH
concentration in the renal artery or vein)
Normal value = 660ml/min
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Renal Physiology
Overview
Each nephron is supplied with blood from an afferent arteriole that opens
onto the glomerular capillary bed.
Blood then flows to an efferent arteriole, supplying the peritubular capillaries
and medullary vasa recta.
The kidney receives up to 25% of resting cardiac output.
Control of blood flow

The kidney is able to autoregulate its blood flow between systolic pressures
of 80- 180mmHg so there is little variation in renal blood flow.
This is achieved by myogenic control of arteriolar tone, both sympathetic
input and hormonal signals (e.g. renin) are responsible.
Glomerular structure and function

Blood inside the glomerulus has considerable hydrostatic pressure.
The basement membrane has pores that will allow free diffusion of smaller
solutes, larger negatively charged molecules such as albumin are unable to
cross.
The glomerular filtration rate (GFR) is equal to the concentration of a solute
in the urine, times the volume of urine produced per minute, divided by the
plasma concentration (assuming that the solute is freely diffused e.g.
inulin).
In clinical practice creatinine is used because it is subjected to very little
proximal tubular secretion.
Although subject to variability, the typical GFR is 125ml per minute.
Glomerular filtration rate = Total volume of plasma per unit time leaving the
capillaries and entering the bowman's capsule
Renal clearance = volume plasma from which a substance is removed per
minute by the kidneys
Substances used to measure GFR have the following features:

1. Inert
2. Free filtration from the plasma at the glomerulus (not protein bound)
3. Not absorbed or secreted at the tubules
4. Plasma concentration constant during urine collection
Examples: inulin, creatinine
GFR = urine concentration (mmol/l) x urine volume (ml/min)

--------------------------------------------------------------------------
plasma concentration (mmol/l)
The clearance of a substance is dependent not only on its diffusivity across

the basement membrane but also subsequent tubular secretion and / or
reabsorption.
So glucose which is freely filtered across the basement membrane is usually
reabsorbed from tubules giving a clearance of zero.
Tubular function
Reabsorption and secretion of substances occurs in the tubules.
In the proximal tubule substrates such as glucose, amino acids and
phosphate are co-transported with sodium across the semi permeable
membrane.
Up to two thirds of filtered water is reabsorbed in the proximal tubules.
This will lead to increase in urea concentration in the distal tubule allowing
for its increased diffusion.
Substances to be secreted into the tubules are taken up from the peritubular
blood by tubular cells.
Solutes such as paraaminohippuric acid are cleared with a single passage
through the kidneys and this is why it is used to measure renal plasma flow.
Ions such as calcium and phosphate will have a tubular reabsorption that is
influenced by plasma PTH levels.
Potassium may be both secreted and re-absorbed and is co-exchanged with
sodium.
Loop of Henle
Approximately 60 litres of water containing 9000mmol sodium enters the
descending limb of the loop of Henle in 24 hours.
Loops from the juxtamedullary nephrons run deep into the medulla.
The osmolarity of fluid changes and is greatest at the tip of the papilla.
The thick ascending limb is impermeable to water, but highly permeable to
sodium and chloride ions.
This loss means that at the beginning of the thick ascending limb the fluid is
hypo osmotic compared with adjacent interstitial fluid.
In the thick ascending limb the reabsorption of sodium and chloride ions
occurs by both facilitated and passive diffusion pathways.
The loops of Henle are co-located with vasa recta, these will have similar
solute compositions to the surrounding extracellular fluid so preventing the
diffusion and subsequent removal of this hypertonic fluid.
The energy dependent reabsorption of sodium and chloride in the thick
ascending limb helps to maintain this osmotic gradient.
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Question 10 of 192
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Which of the following statements relating to alveolar ventilation is untrue?
Anatomical dead space is measured by helium dilution
Physiological dead space is increased in PE
Alveolar ventilation is defined as the volume of fresh air entering the

alveoli per minute
Anatomical dead space is increased by adrenaline
Type 2 pneumocytes in the alveoli secrete surfactant
Anatomical dead space is measured by Fowlers method.
A patient inhales 100% oxygen to empty the conducting zone gases of nitrogen
and then exhales through a mouthpiece which analyses the nitrogen concentration
at the mouth. Initially the exhaled gases contain no nitrogen as this is dead space
gas; the nitrogen concentration will increase as the alveolar gases are exhaled.
Nitrogen which is measured following the breath of 100% oxygen must then have
come only from gas exchanging areas of the lung and not dead space.
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Alveolar ventilation
Minute ventilation is the total volume of gas ventilated per minute.
MV (ml/min)= tidal volume x Respiratory rate (resps/min).
Dead space ventilation describes the volume of gas not involved in

exchange in the blood.
There are 2 types:
1. Anatomical dead space: 150mls

Volume of gas in the respiratory tree not involved in gaseous exchange:
mouth, pharynx, trachea, bronchi up to terminal bronchioles
Measured by Fowlers method
Increased by:
Standing, increased size of person, increased lung volume and drugs
causing bronchodilatation e.g. Adrenaline
2. Physiological dead space: normal 150 mls, increases in ventilation/perfusion

mismatch e.g. PE, COPD, hypotension
Volume of gas in the alveoli and anatomical dead space not involved in
gaseous exchange.
Alveolar ventilation is the volume of fresh air entering the alveoli per minute.
Alveolar ventilation = minute ventilation - Dead space volume
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Question 11 of 192
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Which of the following is associated with reduced lung compliance?
Older age
Emphysematous type COPD
Decline in pulmonary blood flow

Adopting a vertical posture
Adjusting a ventilator to maintain high lung volumes
Increased lung compliance = Older age, COPD
Lung compliance is a measure of the ease of expansion of the lungs and thorax,
determined by pulmonary volume and elasticity. A high degree of compliance
indicates a loss of elastic recoil of the lungs, as in old age or emphysema. This
increased lung compliance is due to loss of supportive tissue around the airways.
While a normal lung has a high passive elastic recoil, the sick lung has a decreased
elasticity (i.e. decreased transpulmonary pressure) which leads to increased lung
compliance.
Decreased compliance means that a greater change in pressure is needed for a

given change in volume, as in atelectasis, pulmonary fibrosis, pneumonia, or lack
of surfactant.
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Lung volumes
The diagram demonstrates lung volumes and capacities

(https://d2zgo9qer4wjf4.cloudfront.net/images_eMRCS/swb048b.png)
Image sourced from Wikipedia

(https://d2zgo9qer4wjf4.cloudfront.net
(http://en.wikipedia.org/wiki/Lung
/images_eMRCS/swb048b.png)
volumes)
Definitions
Tidal volume (TV) Is the volume of air inspired and expired during
each ventilatory cycle at rest.
It is normally 500mls in males and 340mls in
females.
Inspiratory reserve Is the maximum volume of air that can be forcibly

volume (IRV) inhaled following a normal inspiration. 3000mls.
Expiratory reserve Is the maximum volume of air that can be forcibly

volume (ERV) exhaled following a normal expiration. 1000mls.
Residual volume Is that volume of air remaining in the lungs after a

(RV) maximal expiration.
RV = FRC - ERV. 1500mls.
Functional residual Is the volume of air remaining in the lungs at the

capacity (FRC) end of a normal expiration.
FRC = RV + ERV. 2500mls.
Vital capacity (VC) Is the maximal volume of air that can be forcibly
exhaled after a maximal inspiration.
VC = TV + IRV + ERV. 4500mls in males, 3500mls
in females.
Total lung capacity Is the volume of air in the lungs at the end of a
(TLC) maximal inspiration.
TLC = FRC + TV + IRV = VC + RV. 5500-6000mls.
Forced vital The volume of air that can be maximally

capacity (FVC) forcefully exhaled.
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Question 12 of 192
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A 43 year old lady presents with urinary incontinence. At which of the following
locations is Onufs nucleus likely to be found?
Medulla oblongata
Anterior horn of L5 nerve roots

Micturition centre in the Pons
Anterior horn of S2 nerve roots
None of the above
Onufs nucleus is located in the anterior horn of S2 and is the origin of neurones to
the external urethral sphincter.
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Urinary incontinence
Involuntary passage of urine. Most cases are female (80%). It has a prevalence of
11% in those aged greater than 65 years. The commonest variants include:
Stress urinary incontinence (50%)
Urge incontinence (15%)
Mixed (35%)
Males
Males may also suffer from incontinence although it is a much rarer condition in
men. A number of anatomical factors contribute to this. Males have 2 powerful
sphincters; one at the bladder neck and the other in the urethra. Damage to the
bladder neck mechanism is a factor in causing retrograde ejaculation following
prostatectomy. The short segment of urethra passing through the urogenital
diaphragm consists of striated muscle fibres (the external urethral sphincter) and
smooth muscle capable of more sustained contraction. It is the latter mechanism
that maintains continence following prostatectomy.
Females
The sphincter complex at the level of bladder neck is poorly developed in females.
As a result the external sphincter complex is functionally more important, its
composition being similar to that of males. Innervation is via the pudendal nerve
and the neuropathy that may accompany obstetric events may compromise this
and lead to stress urinary incontinence.
Innervation
Somatic innervation to the bladder is via the pudendal, hypogastric and pelvic
nerves. Autonomic nerves travel in these nerve fibres too. Bladder filling leads to
detrusor relaxation (sympathetic) coupled with sphincter contraction. The

parasympathetic system causes detrusor contraction and sphincter relaxation.
Overall control of micturition is centrally mediated via centres in the Pons.
Stress urinary incontinence

50% of cases, especially in females.
Damage (often obstetric) to the supporting structures surrounding the
bladder may lead to urethral hypermobility.
Other cases due to sphincter dysfunction, usually from neurological
disorders (e.g. Pudendal neuropathy, multiple sclerosis).
Urethral mobility:
Pressure not transmitted appropriately to the urethra resulting in involuntary
passage of urine during episodes of raised intra-abdominal pressure.
Sphincter dysfunction:
Sphincter fails to adapt to compress urethra resulting in involuntary passage of
urine. When the sphincter completely fails there is often to continuous passage of
urine.
Urge incontinence
In these patients there is sense of urgency followed by incontinence. The detrusor
muscle in these patients is unstable and urodynamic investigation will
demonstrate overactivity of the detrusor muscle at inappropriate times (e.g.
Bladder filling). Urgency may be seen in patients with overt neurological disorders
and those without. The pathophysiology is not well understood but poor central
and peripheral co-ordination of the events surrounding bladder filling are the main
processes.
Assessment
Careful history and examination including vaginal examination for cystocele.
Bladder diary for at least 3 days
Consider flow cystometry if unclear symptomatology or surgery considered and
diagnosis is unclear.
Exclusion of other organic disease (e.g. Stones, UTI, Cancer)
Management
Conservative measures should be tried first; Stress urinary incontinence or mixed
symptoms should undergo 3 months of pelvic floor exercise. Over active bladder
should have 6 weeks of bladder retraining.
Drug therapy for women with overactive bladder should be offered oxybutynin (or
solifenacin if elderly) if conservative measures fail.
In women with detrusor instability who fail non operative therapy a trial of sacral
neuromodulation may be considered, with conversion to permanent implant if
good response. Augmentation cystoplasty is an alternative but will involve long
term intermittent self catheterisation.
In women with stress urinary incontinence a urethral sling type procedure may be
undertaken. Where cystocele is present in association with incontinence it should
be repaired particularly if it lies at the introitus.
NICE guidelines
Initial assessment urinary incontinence should be classified as stress/urge
/mixed.
At least 3/7 bladder diary if unable to classify easily.
Start conservative treatment before urodynamic studies if a diagnosis is
obvious from the history
Urodynamic studies if plans for surgery.
Stress incontinence: Pelvic floor exercises 3/12, if fails consider surgery.
Urge incontinence: Bladder training >6/52, if fails for oxybutynin
(antimuscarinic drugs) then sacral nerve stimulation.
Pelvic floor exercises offered to all women in their 1st pregnancy.
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A 12.1%
B 11.3%
C 23.1%
D 47.2%
E 6.2%
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Question 13 of 192
 
A 67 year old male is admitted to the surgical unit with acute abdominal pain. He is
found to have a right sided pneumonia. The nursing staff put him onto 15L O2 via a
non rebreathe mask. After 30 minutes the patient is found moribund, sweaty and
agitated by the nursing staff. An arterial blood gas reveals:
pH 7.15
pCO2 10.2
pO2 8
Bicarbonate 32
Base excess - 5.2
What is the most likely cause for this patients deterioration?
Acute respiratory alkalosis secondary to hyperventilation
Over administration of oxygen in a COPD patient
Metabolic acidosis secondary to severe pancreatitis
Metabolic alkalosis secondary to hypokalaemia
Acute respiratory acidosis secondary to pneumonia
This patient has an acute respiratory acidosis, however this is on a background of

chronic respiratory acidosis (due to COPD) with a compensatory metabolic
alkalosis (the elevated bicarbonate is the main clue to the chronic nature of the
respiratory acidosis). This blood gas picture is typical in a COPD patient who has
received too much oxygen; these patients lose their hypoxic drive for respiration,
therefore retain CO2 and subsequently hypoventilate leading to respiratory arrest. If
the bicarbonate was normal, then the answer would be acute respiratory acidosis
secondary to pneumonia.

Next question 
Arterial blood gas interpretation
In advanced life support training, a 5 step approach to arterial blood gas

interpretation is advocated.
1. How is the patient?
2. Is the patient hypoxaemic?

The Pa02 on air should be 10.0-13.0 kPa
3. Is the patient acidaemic (pH <7.35) or alkalaemic (pH >7.45)
4. What has happened to the PaCO2?

If there is acidaemia, an elevated PaCO2 will account for this
5. What is the bicarbonate level or base excess?

A metabolic acidosis will have a low bicarbonate level and a low base excess (< -2
mmol)
A metabolic alkalosis will have a high bicarbonate and a high base excess (> +2
mmol)
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A 8.1%
B 50.4%
C 10.3%

Question 14 of 192
 
Which of the following statements relating to low molecular weight heparins is

false?
They act via inhibition of Factor Xa
Large doses may be used prior to commencing cardiopulmonary bypass

They have a highly predictable pharmacokinetic profile
They are derivatives of unfractionated heparin
They have a molecular mass in the range of 3000-10000Da
As they are not easily reversed they are unsuitable for this purpose.
Next question 
Heparin
Causes the formation of complexes between antithrombin and activated

thrombin/factors 7,9,10,11 & 12
Advantages of low molecular weight heparin

Better bioavailability
Lower risk of bleeding
Longer half life
Little effect on APTT at prophylactic dosages
Less risk of HIT
Complications
Bleeding
Osteoporosis
Heparin induced thrombocytopenia (HIT): occurs 5-14 days after 1st
exposure
Anaphylaxis
In surgical patients that may need a rapid return to theatre, administration of

unfractionated heparin is preferred; as low molecular weight heparins have a
longer duration of action and are harder to reverse.
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Question stats
A 16.8%
B 37.9%
C 15.8%
D 14%
E 15.5%
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Question 15 of 192
 
A 43 year old lady undergoes a day case laparoscopic cholecystectomy. The

operation is more difficult than anticipated and a drain is placed to the operative
site. Whilst in recovery, the patient loses 1800ml of frank blood into the drain.
Which of the following will not occur?
Release of aldosterone via the Bainbridge reflex

Reduced urinary sodium excretion
Increase in sympathetic discharge to ventricular muscle
Fall in parasympathetic discharge to the sino atrial node
Decreased stimulation from atrial pressure receptors
The Bainbridge reflex is the increase in heart rate mediated via atrial stretch
receptors that occurs following a rapid infusion of blood. Note the question asks
which will not occur and that is why it is A and not the other options.
Next question 
Cardiac physiology
The heart has four chambers ejecting blood into both low pressure and high
pressure systems.
The pumps generate pressures of between 0-25mmHg on the right side and
0-120 mmHg on the left.
At rest diastole comprises 2/3 of the cardiac cycle.
The product of the frequency of heart rate and stroke volume combine to
give the cardiac output which is typically 5-6L per minute.
Detailed descriptions of the various waveforms are often not a feature of MRCS A
(although they are on the syllabus). However, they are a very popular topic for
surgical physiology in the MRCS B exam.
Electrical properties
Intrinsic myogenic rhythm within cardiac myocytes means that even the
denervated heart is capable of contraction.
In the normal situation the cardiac impulse is generated in the sino atrial
node in the right atrium and conveyed to the ventricles via the
atrioventricular node.
The sino atrial node is also capable of spontaneous discharge and in the
absence of background vagal tone will typically discharge around 100x per
minute. Hence the higher resting heart rate found in cardiac transplant
cases. In the SA and AV nodes the resting membrane potential is lower than
in surrounding cardiac cells and will slowly depolarise from -70mV to around
-50mV at which point an action potential is generated.

Differences in the depolarisation slopes between SA and AV nodes help to
explain why the SA node will depolarise first. The cells have a refractory
period during which they cannot be re-stimulated and this period allows for
adequate ventricular filling. In pathological tachycardic states this time
period is overridden and inadequate ventricular filling may then occur,
cardiac output falls and syncope may ensue.
Parasympathetic fibres project to the heart via the vagus and will release
acetylcholine. Sympathetic fibres release nor adrenaline and circulating adrenaline
comes from the adrenal medulla. Noradrenaline binds to β 1 receptors in the SA
node and increases the rate of pacemaker potential depolarisation.
Cardiac cycle
(http://en.wikipedia.org/wiki/Cardiac
cycle)
Mid diastole: AV valves open. Ventricles hold 80% of final volume. Outflow
valves shut. Aortic pressure is high.
Late diastole: Atria contract. Ventricles receive 20% to complete filling.

Typical end diastolic volume 130-160ml.
Early systole: AV valves shut. Ventricular pressure rises. Isovolumetric

ventricular contraction. AV Valves bulge into atria (c-wave). Aortic and
pulmonary pressure exceeded- blood is ejected. Shortening of ventricles
pulls atria downwards and drops intra atrial pressure (x-descent).
Late systole: Ventricular muscles relax and ventricular pressures drop.

Although ventricular pressure drops the aortic pressure remains constant

owing to peripheral vascular resistance and elastic property of the aorta.
Brief period of retrograde flow that occurs in aortic recoil shuts the aortic
valve. Ventricles will contain 60ml end systolic volume. The average stroke
volume is 70ml (i.e. Volume ejected).
Early diastole: All valves are closed. Isovolumetric ventricular relaxation

occurs. Pressure wave associated with closure of the aortic valve increases
aortic pressure. The pressure dip before this rise can be seen on arterial
waveforms and is called the incisura. During systole the atrial pressure
increases such that it is now above zero (v- wave). Eventually atrial pressure
exceed ventricular pressure and AV valves open - atria empty passively into
ventricles and atrial pressure falls (y -descent )
The negative atrial pressures are of clinical importance as they can allow air
embolization to occur if the neck veins are exposed to air. This patient positioning
is important in head and neck surgery to avoid this occurrence if veins are
inadvertently cut, or during CVP line insertion.
Mechanical properties
Preload = end diastolic volume
Afterload = aortic pressure
It is important to understand the principles of Laplace's law in surgery.

It states that for hollow organs with a circular cross section, the total
circumferential wall tension depends upon the circumference of the wall,
multiplied by the thickness of the wall and on the wall tension.
The total luminal pressure depends upon the cross sectional area of the
lumen and the transmural pressure. Transmural pressure is the internal
pressure minus external pressure and at equilibrium the total pressure must
counterbalance each other.
In terms of cardiac physiology the law explains that the rise in ventricular
pressure that occurs during the ejection phase is due to physical change in
heart size. It also explains why a dilated diseased heart will have impaired
systolic function.
Starlings law
Increase in end diastolic volume will produce larger stroke volume.
This occurs up to a point beyond which cardiac fibres are excessively
stretched and stroke volume will fall once more. It is important for the
regulation of cardiac output in cardiac transplant patients who need to
increase their cardiac output.
Baroreceptor reflexes
Baroreceptors located in aortic arch and carotid sinus.
Aortic baroreceptor impulses travel via the vagus and from the carotid via
the glossopharyngeal nerve.
They are stimulated by arterial stretch.
Even at normal blood pressures they are tonically active.
Increase in baroreceptor discharge causes:
*Increased parasympathetic discharge to the SA node.

*Decreased sympathetic discharge to ventricular muscle causing decreased
contractility and fall in stroke volume.
*Decreased sympathetic discharge to venous system causing increased
compliance.
*Decreased peripheral arterial vascular resistance
Atrial stretch receptors

Located in atria at junction between pulmonary veins and vena cava.
Stimulated by atrial stretch and are thus low pressure sensors.
Increased blood volume will cause increased parasympathetic activity.
Very rapid infusion of blood will result in increase in heart rate mediated via
atrial receptors: the Bainbridge reflex.
Decreases in receptor stimulation results in increased sympathetic activity
this will decrease renal blood flow-decreases GFR-decreases urinary sodium
excretion-renin secretion by juxtaglomerular apparatus-Increase in
angiotensin II.
Increased atrial stretch will also result in increased release of atrial
natriuretic peptide.
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Question stats
A 39.4%
B 9.8%
C 9%
D 14.4%
E 27.3%
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Question 16 of 192
 
Which one of the following is least associated with thrombocytopenia?
Heparin therapy
Rheumatoid arthritis
Infectious mononucleosis
Liver disease
Pregnancy
Rheumatoid arthritis, unlike systemic lupus erythematous, is generally associated

with a thrombocytosis. In some cases of Felty's syndrome thrombocytopaenia may
be seen secondary to hypersplenism. This however represents a small percentage
of patients with rheumatoid arthritis.
Next question 
Thrombocytopenia
Causes of severe thrombocytopenia

ITP
DIC
TTP
haematological malignancy
Causes of moderate thrombocytopenia

heparin induced thrombocytopenia (HIT)
drug-induced (e.g. quinine, diuretics, sulphonamides, aspirin, thiazides)
alcohol
liver disease
hypersplenism
viral infection (EBV, HIV, hepatitis)
pregnancy
SLE/antiphospholipid syndrome
vitamin B12 deficiency
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Question stats
A 11.2%
B 35.1%
C 14.6%
D 10.4%
E 28.7%
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Question 17 of 192
 
Which of the following statements relating to the pharmacology of warfarin is

untrue?
Interferes with clotting factors 2,7,9 and 10
It may not be clinically effective for up to 72 hours

The half life of warfarin is 40 hours
Warfarin has a large volume of distribution
It is metabolized in the liver
Factors 2,7,9,10 affected
Warfarin interferes with fibrin formation by affecting carboxylation of glutamic acid

residues in factors 2,7,9 and 10. Factor 2 has the longest half life of approximately
60 hours, therefore it can take up to 3 days for warfarin to be fully effective.
Warfarin has a small volume of distribution as it is protein bound.
Next question 
Warfarin
Warfarin is an oral anticoagulant which inhibits the reduction of vitamin K to its

active hydroquinone form, which in turn acts as a cofactor in the formation of
clotting factor II, VII, IX and X (mnemonic = 1972) and protein C
Factors that may potentiate warfarin

Liver disease
P450 enzyme inhibitors, e.g.: amiodarone, ciprofloxacin
Cranberry juice
Drugs which displace warfarin from plasma albumin, e.g. NSAIDs
Inhibit platelet function: NSAIDs
Side-effects
Haemorrhage
Teratogenic
Skin necrosis: when warfarin is first started biosynthesis of protein C is
reduced. This results in a temporary procoagulant state after initially
starting warfarin, normally avoided by concurrent heparin administration.
Thrombosis may occur in venules leading to skin necrosis.
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Question stats
A 9.4%
B 12.2%
C 26%
D 43.3%
E 9.1%
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Question 18 of 192
 
Which of the following drugs is least likely to cause syndrome of inappropriate anti
diuretic hormone release?
Haloperidol
Carbamazepine
Amitriptylline
Cyclophosphamide
Methotrexate
Drugs causing SIADH: ABCD
A nalgesics: opioids, NSAIDs

B arbiturates
C yclophosphamide/ Chlorpromazine/ Carbamazepine
D iuretic (thiazides)
Next question 
Hyponatraemia
This is commonly tested in the MRCS (despite most surgeons automatically

seeking medical advice if this occurs!). The most common cause in surgery is the
over administration of 5% dextrose.
Hyponatraemia may be caused by water excess or sodium depletion. Causes of

pseudohyponatraemia include hyperlipidaemia (increase in serum volume) or a
taking blood from a drip arm. Urinary sodium and osmolarity levels aid making a
diagnosis.
Classification
Urinary sodium > 20 Sodium depletion, renal loss Mnemonic:

mmol/l Patient often Syndrome of
hypovolaemic INAPPropriate Anti-
Diuretics (thiazides) Diuretic Hormone:
Addison's In creased
Diuretic stage of renal Na (sodium)
failure PP (urine)
SIADH (serum osmolality
low, urine osmolality high,
urine Na high)
Patient often euvolaemic
Urinary sodium < 20 Sodium depletion, extra-renal

mmol/l loss
Diarrhoea, vomiting,
sweating
Burns, adenoma of
rectum (if villous lesion
and large)
Water excess Secondary

(patient often hyperaldosteronism: CCF,
hypervolaemic and cirrhosis
oedematous) Reduced GFR: renal
failure
IV dextrose, psychogenic
polydipsia
Management
Symptomatic Hyponatremia :
Acute hyponatraemia with Na <120: immediate therapy. Central Pontine

Myelinolisis, may occur from overly rapid correction of serum sodium. Aim to
correct until the Na is > 125 at a rate of 1 mEq/h. Normal saline with frusemide is
an alternative method.
The sodium requirement can be calculated as follows :
(125 - serum sodium) x 0.6 x body weight = required mEq of sodium

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Question stats
A 14.4%
B 14.9%
C 17.4%
D 13.9%
E 39.4%
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Question 19 of 192
 
Which of the following substances related to thyroid function has its effects
mediated by a nuclear receptor?
Triiodothyronine
Thyroxine
Thyroglobulin
Thyroid stimulating hormone
Thyroxin binding globulin
T3 binds to a receptor on chromatin to induce protein synthesis.
Next question 
Thyroid hormones
Hormones of the thyroid gland
Triiodothyronine Major hormone active in target cells

T3
Thyroxine T4 Most prevalent form in plasma, less biologically active

than T3
Calcitonin Lowers plasma calcium
Synthesis and secretion of thyroid hormones

Thyroid actively concentrates iodide to twenty five times the plasma
concentration.
Iodide is oxidised by peroxidase in the follicular cells to atomic iodine which
then iodinates tyrosine residues contained in thyroglobulin.
Iodinated tyrosine residues in thyroglobulin undergo coupling to either T3 or
T4.
Process is stimulated by TSH, which stimulates secretion of thyroid
hormones.
The normal thyroid has approximately 3 month reserves of thyroid
hormones.
LATS and Graves disease

In Graves disease patients develop IgG antibodies to the TSH receptors on the
thyroid gland. This results in chronic and long term stimulation of the gland with
release of thyroid hormones. The typically situation is raised thyroid hormones and
low TSH. Thyroid receptor autoantibodies should be checked in individuals
presenting with hyperthyroidism as they are present in up to 85% cases.
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Question stats
A 34%
B 15.7%
C 17.5%
D 22.9%
E 10%
34% of users answered this question correctly
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Question 20 of 192
 
The blood - brain barrier is not highly permeable to which of the following?
Carbon dioxide
Barbituates
Glucose
Oxygen
Hydrogen ions
The blood brain barrier is relatively impermeable to highly dissociated compounds.
Next question 
Cerebrospinal fluid
The CSF fills the space between the arachnoid mater and pia mater (covering
surface of the brain). The total volume of CSF in the brain is approximately 150ml.
Approximately 500 ml is produced by the ependymal cells in the choroid plexus
(70%), or blood vessels (30%). It is reabsorbed via the arachnoid granulations
which project into the venous sinuses.
Circulation
1. Lateral ventricles (via foramen of Munro)
2. 3rd ventricle
3. Cerebral aqueduct (aqueduct of Sylvius)
4. 4th ventricle (via foramina of Magendie and Luschka)
5. Subarachnoid space
6. Reabsorbed into the venous system via arachnoid granulations into superior
sagittal sinus
Composition
Glucose: 50-80mg/dl
Protein: 15-40 mg/dl
Red blood cells: Nil
White blood cells: 0-3 cells/ mm3
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Question stats
A 15.6%
B 14.7%
C 14.1%
D 8.9%
E 46.7%
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Question 22 of 192
 
Which of the following arterial blood gas results would fit with chronic respiratory
acidosis with a compensatory metabolic alkalosis?
pH 7.36, PaCO2 7.3, PO2 8.9 (FiO2 40%), Bicarbonate 30.2, Base excess
+5.3
pH 7.32, PCO2 3.8, PaO2 22.2 (FiO2 40%), Bicarbonate 19.1, Base excess
-7.9
pH 7.14, PaCO2 7.4, PaO2 8.9 (FiO2 40%), Bicarbonate 14 mmol, Base
excess -10.6
pH 7.57, PaCO2 3.5, Pa O2 24.5 (FiO2 85%), Bicarbonate 23.5, Base excess
+1.8 mmol
pH 7.19, pCO2 10.2, pO2 16 (FiO2 85%), Bicarbonate 23.8, Base excess -2.2
mmol
Next question 




mmol)
mmol)
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Question stats
A 57.9%
B 10.1%
C 9.2%
D 7.2%
E 15.6%
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Question 21 of 192
 
A 73 year old man has an arterial line in situ. On studying the trace the incisura can
be seen. What is the physiological event which accounts for this process?
Atrial repolarisation
Mitral valve closure

Ventricular repolarisation
Elastic recoil of the aorta
Tricuspid valve closure
It is the temporary rise in aortic pressure occurring as a result of elastic recoil. its
the same thing as the dicrotic notch.
Next question 
Cardiac physiology
pressure systems.
Cardiac cycle
cycle)




systolic function.
Starlings law

compliance.

angiotensin II.
Next question 
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Question stats
A 11.4%
B 13.1%
C 11.8%
D 53.2%
E 10.6%

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Question 23 of 192
 
A 44 year old man receives a large volume transfusion of whole blood. The whole
blood is two weeks old. Which of the following best describes its handling of
oxygen?
It will have a low affinity for oxygen
Its affinity for oxygen is unchanged

It will more readily release oxygen in metabolically active tissues than

fresh blood
The release of oxygen in metabolically active tissues will be the same as

fresh blood
It will have an increased affinity for oxygen
Stored blood has less 2,3 DPG and therefore has a higher affinity for oxygen, this
reduces its ability to release it at metabolising tissues.
Next question 
Oxygen Transport
Oxygen transport
Almost all oxygen is transported within erythrocytes. It has limited solubility and
only 1% is carried as solution. Therefore the amount of oxygen transported will
depend upon haemoglobin concentration and its degree of saturation.
Haemoglobin
Globular protein composed of 4 subunits. Haem consists of a protoporphyrin ring
surrounding an iron atom in its ferrous state. The iron can form two additional
bonds; one with oxygen and the other with a polypeptide chain. There are two
alpha and two beta subunits to this polypeptide chain in an adult and together
these form globin. Globin cannot bind oxygen but is able to bind to carbon dioxide
and hydrogen ions, the beta chains are able to bind to 2,3 diphosphoglycerate. The
oxygenation of haemoglobin is a reversible reaction. The molecular shape of
haemoglobin is such that binding of one oxygen molecule facilitates the binding of
subsequent molecules.
Oxygen dissociation curve

The oxygen dissociation curve describes the relationship between the
percentage of saturated haemoglobin and partial pressure of oxygen in the
blood. It is not affected by haemoglobin concentration.
Chronic anaemia causes 2, 3 DPG levels to increase, hence shifting the
curve to the right
Haldane effect
Shifts to left = for given oxygen tension there is increased saturation of Hb
with oxygen i.e. Decreased oxygen delivery to tissues
Bohr effect
Shifts to right = for given oxygen tension there is reduced saturation of Hb
with oxygen i.e. Enhanced oxygen delivery to tissues
(http://en.wikipedia.org/wiki/Oxygen (https://d2zgo9qer4wjf4.cloudfront.net
%E2%80%93haemoglobin dissociation /images_eMRCS/swb038b.png)
curve)
Shifts to Left = Lower oxygen delivery Shifts to Right = Raised oxygen
HbF, methaemoglobin, delivery
carboxyhaemoglobin raised [H+] (acidic)
low [H+] (alkali) raised pCO2
low pCO2 raised 2,3-DPG*
low 2,3-DPG raised temperature
low temperature
*2,3-diphosphoglycerate
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Question stats
A 25.9%
B 14%
C 13.2%
D 7.6%
E 39.3%
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Question 24 of 192
 
A 43 year old presents to the urology clinic complaining of impotence. Which of

the following will occur in response to increased penile parasympathetic
stimulation?
Detumescence
Ejaculation
Erection
Vasospasm of the penile branches of the pudendal artery
Contraction of the smooth muscle in the epididymis and vas deferens
Memory aid for erection

p=parasympathetic=points
s=sympathetic=shoots
Parasympathetic stimulation causes erection. Sympathetic stimulation will

produce ejaculation, detumescence and vasospasm of the pudendal artery. It will
also cause contraction of the smooth muscle in the epididymis and vas to convey
the ejaculate.
Next question 
Penile erection
Physiology of erection
Autonomic Sympathetic nerves originate from T11-L2 and
parasympathetic nerves from S2-4 join to form pelvic
plexus.
Parasympathetic discharge causes erection, sympathetic
discharge causes ejaculation and detumescence.
Somatic Supplied by dorsal penile and pudendal nerves. Efferent signals

nerves are relayed from Onufs nucleus (S2-4) to innervate
ischiocavernosus and bulbocavernosus muscles.
Autonomic discharge to the penis will trigger the veno-occlusive mechanism which
triggers the flow of arterial blood into the penile sinusoidal spaces. As the inflow
increases the increased volume in this space will secondarily lead to compression
of the subtunical venous plexus with reduced venous return. During the
detumesence phase the arteriolar constriction will reduce arterial inflow and
thereby allow venous return to normalise.
Priapism
Prolonged unwanted erection, in the absence of sexual desire, lasting more than 4
hours.
Classification of priapism
Low flow Due to veno-occlusion (high intracavernosal pressures).

priapism Most common type
Often painful
Often low cavernosal flow
If present for >4 hours requires emergency treatment
High flow Due to unregulated arterial blood flow.

priapism Usually presents as semi rigid painless erection
Recurrent Typically seen in sickle cell disease, most commonly of

priapism high flow type.
Causes
Intracavernosal drug therapies (e.g. for erectile dysfunction>
Blood disorders such as leukaemia and sickle cell disease
Neurogenic disorders such as spinal cord transection
Trauma to penis resulting in arterio-venous malformations
Tests
Exclude sickle cell/ leukaemia
Consider blood sampling from cavernosa to determine whether high or low
flow (low flow is often hypoxic)
Management
Ice packs/ cold showers
If due to low flow then blood may be aspirated from copora or try
intracavernosal alpha adrenergic agonists.
Delayed therapy of low flow priapism may result in erectile dysfunction.
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A 8.8%
B 14.4%
C 60.8%
D 7.6%
E 8.4%
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Question 25 of 192
 
A 28 year old man undergoes a completion right hemicolectomy for treatment of a

5cm appendiceal carcinoid. As part of his follow up he is due to undergo 24 hour
urine collection for 5-HIAA. Which of the following causes an elevated 5-HIAA in a
24-hour urine collection?
Naproxen
Oranges
Flucloxacillin
Amiodarone
Beef
It is important to be aware of what can falsely elevate 5-HIAA to avoid diagnosing

carcinoid syndrome incorrectly. These include:
Food: spinach, cheese, wine, caffeine, tomatoes

Drugs: Naproxen, Monoamine oxidase inhibitors
Recent surgery
Next question 
Carcinoid syndrome
Carcinoid tumours secrete serotonin

Originate in neuroendocrine cells mainly in the intestine (midgut-distal
ileum/appendix)
Can occur in the rectum, bronchi
Hormonal symptoms mainly occur when disease spreads outside the bowel
Clinical features
Onset: insidious over many years
Flushing face
Palpitations
Pulmonary valve stenosis and tricuspid regurgitation causing dyspnoea
Asthma
Severe diarrhoea (secretory, persists despite fasting)
Investigation
5-HIAA in a 24-hour urine collection
Somatostatin receptor scintigraphy
CT scan
Blood testing for chromogranin A
Treatment
Octreotide
Surgical removal
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Question stats
A 32.8%
B 16%
C 9.7%
D 24%
E 17.5%
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Question 26 of 192
 
Which is the least likely to cause hyperuricaemia?
Severe psoriasis
Lesch-Nyhan syndrome
Amiodarone
Diabetic ketoacidosis
Alcohol
Mnemonic of the drugs causing hyperuricaemia as a result of reduced

excretion of urate
'Can't leap'
C iclosporin
A lcohol
N icotinic acid
T hiazides
L oop diuretics
E thambutol
A spirin
P yrazinamide
Decreased tubular secretion of urate occurs in patients with acidosis (eg, diabetic
ketoacidosis, ethanol or salicylate intoxication, starvation ketosis). The organic
acids that accumulate in these conditions compete with urate for tubular
secretion.

Next question 
Hyperuricaemia
Increased levels of uric acid may be seen secondary to either increased cell
turnover or reduced renal excretion of uric acid. Hyperuricaemia may be
found in asymptomatic patients who have not experienced attacks of gout
Hyperuricaemia may be associated with hyperlipidaemia and hypertension.

It may also be seen in conjunction with the metabolic syndrome
Increased synthesis
Lesch-Nyhan disease
Myeloproliferative disorders
Diet rich in purines
Exercise
Psoriasis
Cytotoxics
Decreased excretion
Drugs: low-dose aspirin, diuretics, pyrazinamide
Pre-eclampsia
Alcohol
Renal failure
Lead
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Question stats
A 17%
B 13.9%
C 39.4%
D 19%
E 10.7%
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Question 27 of 192
 
Approximately what proportion of basal salivary secretions are provided by the

submandibular glands?
10%
70%
40%
90%
20%
Although they are small, the submandibular glands provide the bulk of salivary
secretions and contribute 70%, the sublingual glands provide 5% and the remainder
from the parotid. During food consumption the contribution of the parotid
secretions is greater.
Next question 
Submandibular gland
Relations of the submandibular gland
Superficial Platysma, deep fascia and mandible

Submandibular lymph nodes
Facial vein (facial artery near mandible)
Marginal mandibular nerve
Cervical branch of the facial nerve
Deep Facial artery (inferior to the mandible)
Mylohyoid muscle
Sub mandibular duct
Hyoglossus muscle
Lingual nerve
Submandibular ganglion
Hypoglossal nerve
Submandibular duct (Wharton's duct)

Opens lateral to the lingual frenulum on the anterior floor of mouth.
5 cm length
Lingual nerve wraps around Wharton's duct. As the duct passes forwards it
crosses medial to the nerve to lie above it and then crosses back, lateral to
it, to reach a position below the nerve.
Innervation
Sympathetic innervation- Derived from superior cervical ganglion
Parasympathetic innervation- Submandibular ganglion via lingual nerve
Arterial supply
Branch of the facial artery. The facial artery passes through the gland to groove its
deep surface. It then emerges onto the face by passing between the gland and the
mandible.
Venous drainage
Anterior facial vein (lies deep to the Marginal Mandibular nerve)
Lymphatic drainage
Deep cervical and jugular chains of nodes
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A 9.1%
B 45.4%
C 17.5%
D 11.5%
E 16.5%
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Question 28 of 192
 
Which of the following changes are not typically seen in established dehydration?
Rising haematocrit
Urinary sodium <20mmol/ litre
Metabolic acidosis
Decreased serum urea to creatinine ratio
Hypernatraemia
Diagnosing dehydration can be complicated, laboratory features include:

Hypernatraemia
Rising haematocrit
Metabolic acidosis
Rising lactate
Increased serum urea to creatinine ratio
Urinary sodium <20 mmol/litre
Urine osmolality approaching 1200mosmol/kg
Next question 
Pre operative fluid management
Fluid management has been described in the British Consensus guidelines on IV

fluid therapy for Adult Surgical patients (GIFTASUP) and by NICE (CG174
December 2013 updated May 2017)
The Recommendations include:

Use Ringer's lactate or Hartmann's when a crystalloid is needed for
resuscitation or replacement of fluids. Avoid 0.9% N. Saline (due to risk of
hyperchloraemic acidosis) unless patient vomiting or has gastric drainage.
Use 4%/0.18% dextrose saline or 5% dextrose in maintenance fluids. It
should not be used in resuscitation or as replacement fluids.
Adult maintenance fluid requirements are: Na 50-100 mmol/day and K 40-80
mmol/day in 1.5-2.5L fluid per day.
Patients for elective surgery should NOT be nil by mouth for >2 hours
(unless has disorder of gastric emptying).
Patients for elective surgery should be given carbohydrate rich drinks 2-3h
before. Ideally this should form part of a normal pre op plan to facilitate
recovery.
Avoid mechanical bowel preparation.
If bowel prep is used, simultaneous administration of Hartmann's or Ringer's
lactate should be considered.
Excessive fluid losses from vomiting should be treated with a crystalloid
with potassium replacement. 0.9% N. Saline should be given if there is
hypochloraemia. Otherwise Hartmann's or Ringer lactate should be given for

diarrhoea/ileostomy/ileus/obstruction. Hartmann's should also be given in
sodium losses secondary to diuretics.
High risk patients should receive fluids and inotropes.
An attempt should be made to detect pre or operative hypovolaemia using
flow based measurements. If this is not available, then clinical evaluation is
needed i.e. JVP, pulse volume etc.
In Blood loss or infection causing hypovolaemia should be treated with a
balanced crystalloid or colloid (or until blood available in blood loss). A
critically ill patient is unable to excrete Na or H20 leading to a 5% risk of
interstitial oedema. Therefore 5% dextrose as well as colloid should be
given.
If patients need IV fluid resuscitation, use crystalloids that contain sodium in
the range 130-154 mmol/l, with a bolus of 500 ml over less than 15 minutes
(NICE Guidance CG 174).
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Question stats
A 9.2%
B 18.3%
C 15.1%
D 44.5%
E 12.9%
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External links
The British Association for Parenteral and Enteral Nutrition

(BAPEN) (http://www.bapen.org.uk/pdfs/bapen_pubs  
/giftasup.pdf)
British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical
Patients
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Question 29 of 192
 
Which of the following best accounts for the action of PTH in increasing serum
calcium levels?
Activation of vitamin D to increase absorption of calcium from the small

intestine.
Direct stimulation of osteoclasts to absorb bone with release of calcium.

Stimulation of phosphate absorption at the distal convoluted tubule of the

kidney.
Decreased porosity of the vessels at Bowmans capsule to calcium.
Vasospasm of the afferent renal arteriole thereby reducing GFR and

calcium urinary loss.
PTH increases the activity of 1-α-hydroxylase enzyme, which converts 25-

hydroxycholecalciferol to 1,25-dihydroxycholecalciferol, the active form of vitamin
D.
Osteoclasts do not have a PTH receptor and effects are mediated via osteoblasts.
Next question 
Parathyroid hormone
Parathyroid hormone is secreted by the chief cells of the parathyroid glands. It acts
to increase serum calcium concentration by stimulation of the PTH receptors in
the kidney and bone. PTH has a plasma half life of 4 minutes.
Effects of PTH
Bone Binds to osteoblasts which signal to osteoclasts to cause

resorption of bone and release calcium.
Kidney Active reabsorption of calcium and magnesium from the distal
convoluted tubule. Decreases reabsorption of phosphate.
Intestine via Increases intestinal calcium absorption by increasing activated

kidney vitamin D. Activated vitamin D increases calcium absorption.
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Question stats
A 46.8%
B 32.1%
C 9%
D 6.4%
E 5.7%
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Question 30 of 192
 
Which of the following cell types is least likely to be found in a wound 1 week
following injury?
Macrophages
Fibroblasts
Myofibroblasts
Endothelial cells
Neutrophils
Myofibroblasts are differentiated fibroblasts, in which the cytoskeleton contains

actin filaments. These cell types facilitate wound contracture and are the hallmark
of a mature wound. They are almost never found in wounds less than 1 month old.
Remember the question asks about the cell type asks about which cells are least
likely to be found.
Next question 
Phases of wound healing
Phase Key features Cells Timeframe
Haemostasis Vasospasm in Erythrocytes and Seconds/

adjacent vessels platelets Minutes
Platelet plug
formation and
generation of fibrin
rich clot
Inflammation Neutrophils migrate Neutrophils, Days
into wound (function fibroblasts and
impaired in diabetes). macrophages
Growth factors
released, including
basic fibroblast
growth factor and
vascular endothelial
growth factor.
Fibroblasts replicate
within the adjacent
matrix and migrate
into wound.
Macrophages and
fibroblasts couple
matrix regeneration
and clot substitution.
Regeneration Platelet derived Fibroblasts, Weeks

growth factor and endothelial cells,
transformation growth macrophages
factors stimulate
fibroblasts and
epithelial cells.
Fibroblasts produce a
collagen network.
Angiogenesis occurs
and wound resembles
granulation tissue.
Remodelling Longest phase of the Myofibroblasts 6 weeks to

healing process and 1 year
may last up to one
year (or longer).
During this phase
fibroblasts become
differentiated
(myofibroblasts) and
these facilitate wound
contraction.
Collagen fibres are
remodelled.
Microvessels regress
leaving a pale scar.
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Question stats
A 10.7%
B 12.9%
C 42.9%
D 10%
E 23.5%
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Question 31 of 192
 
What is the half life of insulin in the circulation of a normal healthy adult?
Less than 30 minutes
Between 1 and 2 hours

Over 6 hours
Insulin is degraded by enzymes in the circulation. It typically has a half life of less
than 30 minutes. Abnormalities of the clearance of insulin may occur in type 2
diabetes.
Next question 
Insulin
Insulin is a peptide hormone, produced by beta cells of the pancreas, and is central
to regulating carbohydrate and fat metabolism in the body. Insulin causes cells in
the liver, skeletal muscles, and fat tissue to absorb glucose from the blood. In the
liver and skeletal muscles, glucose is stored as glycogen, and in fat cells
(adipocytes) it is stored as triglycerides.
Structure
The human insulin protein is composed of 51 amino acids, and has a molecular
weight of 5808 Da. It is a dimer of an A-chain and a B-chain, which are linked
together by disulfide bonds.
Synthesis
Pro-insulin is formed by the rough endoplasmic reticulum in pancreatic beta cells.
Then pro-insulin is cleaved to form insulin and C-peptide. Insulin is stored in
secretory granules and released in response to Ca2+.
Function
Secreted in response to hyperglycaemia
Glucose utilisation and glycogen synthesis
Inhibits lipolysis
Reduces muscle protein loss
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A 47.5%
B 19.9%
C 13.7%
D 10.4%
E 8.6%
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Question 32 of 192
 
Which of the following is responsible for the release and synthesis of calcitonin?
Parathyroid glands
Anterior pituitary
Thyroid gland
Posterior pituitary
Adrenal glands
Calcitonin has the opposite effect of PTH and is released from the thyroid gland.
Next question 
Calcium homeostasis
Hormone Actions
Hormone Actions

resorption
of calcium

absorption of Ca2+
reabsorption

levels
reabsorption

calcium
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Question stats
A 25.5%
B 6.8%
C 54.3%
D 7%
E 6.4%
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Question 33 of 192
 
Which main group of receptors does dobutamine bind to?
α-1
α-2
ß-1
ß-2
D-1
Dobutamine is a sympathomimetic with both alpha- and beta-agonist properties; it

displays a considerable selectivity for beta1-cardiac receptors.
Next question 
Inotropes and cardiovascular receptors
Inotropes are a class of drugs which work primarily by increasing cardiac output.
They should be distinguished from vasoconstrictor drugs which are used
specifically when the primary problem is peripheral vasodilatation.
Catecholamine type agents are commonly used and work by increasing cAMP
levels by adenylate cyclase stimulation. This in turn intracellular calcium ion
mobilisation and thus the force of contraction. Adrenaline works as a beta
adrenergic receptor agonist at lower doses and an alpha receptor agonist at higher
doses. Dopamine causes dopamine receptor mediated renal and mesenteric
vascular dilatation and beta 1 receptor agonism at higher doses. This results in
increased cardiac output. Since both heart rate and blood pressure are raised,
there is less overall myocardial ischaemia. Dobutamine is a predominantly beta 1
receptor agonist with weak beta 2 and alpha receptor agonist properties.
Noradrenaline is a catecholamine type agent and predominantly acts as an alpha
receptor agonist and serves as a peripheral vasoconstrictor.
Phosphodiesterase inhibitors such as milrinone act specifically on the cardiac

phosphodiesterase and increase cardiac output.
Inotrope Cardiovascular receptor action
Adrenaline α-1, α-2, β-1, β-2
Noradrenaline α-1,( α-2), (β-1), (β-2)
Dobutamine β-1, (β 2)
Dopamine (α-1), (α-2), (β-1), D-1,D-2

Minor receptor effects in brackets
Effects of receptor binding
α-1, α-2 vasoconstriction
β-1 increased cardiac contractility and HR
β-2 vasodilatation
D-1 renal and spleen vasodilatation
D-2 inhibits release of noradrenaline
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A 12.2%
B 10.5%
C 40.4%

Question 34 of 192
 
A 43 year old man has recurrent episodes of dyspepsia and treatment is

commenced with oral antacids. Which of the substances listed below is released
in response to increased serum gastrin levels and decreases intra gastric pH?
Cholecystokinin
Histamine
Somatostatin
Insulin
Vasoactive intestinal peptide
Remember that a low pH value indicates an acidic solution. Solutions of less

than 7 (i.e. 1) have more free hydrogen ions than solutions of pH 10.
Histamine is released from enterochromaffin cells in the stomach mucosa which

stimulates acid secretion. It is usually released in response to increased serum
gastrin levels. Histamine blockers (e.g. cimetidine) were extremely popular
treatments until the advent of proton pump inhibitors.
Next question 
Gastric secretions
A working knowledge of gastric secretions is important for surgery because peptic

ulcers are common, surgeons frequently prescribe anti secretory drugs and
because there are still patients around who will have undergone acid lowering
procedures (Vagotomy) in the past.
Gastric acid
Is produced by the parietal cells in the stomach
pH of gastric acid is around 2 with acidity being maintained by the H+/K+
ATP ase pump. As part of the process bicarbonate ions will be secreted into
the surrounding vessels.
Sodium and chloride ions are actively secreted from the parietal cell into the
canaliculus. This sets up a negative potential across the membrane and as a
result sodium and potassium ions diffuse across into the canaliculus.
Carbonic anhydrase forms carbonic acid which dissociates and the
hydrogen ions formed by dissociation leave the cell via the H+/K+ antiporter
pump. At the same time sodium ions are actively absorbed. This leaves
hydrogen and chloride ions in the canaliculus these mix and are secreted
into the lumen of the oxyntic gland.
This is illustrated diagrammatically below:
(https://d2zgo9qer4wjf4.cloudfront.net/images_eMRCS/swb028b.jpg)
(http://en.wikipedia.org/wiki/Gastric
/images_eMRCS/swb028b.jpg)
acid)
Phases of gastric acid secretion

There are 3 phases of gastric secretion:
1. Cephalic phase (smell / taste of food)
30% acid produced
Vagal cholinergic stimulation causing secretion of HCL and gastrin release
from G cells
2. Gastric phase (distension of stomach )

60% acid produced
Stomach distension/low H+/peptides causes Gastrin release
3. Intestinal phase (food in duodenum)

10% acid produced
High acidity/distension/hypertonic solutions in the duodenum inhibits
gastric acid secretion via enterogastrones (CCK, secretin) and neural

reflexes.
Regulation of gastric acid production

Factors increasing production include:
Vagal nerve stimulation
Gastrin release
Histamine release (indirectly following gastrin release) from
enterchromaffin like cells
Factors decreasing production include:

Somatostatin (inhibits histamine release)
Cholecystokinin
Secretin
The diagram below illustrates some of the factors involved in regulating gastric
acid secretion and the relevant associated pharmacology
acid)
Below is a brief summary of the major hormones involved in food digestion:
Source Stimulus Actions
Gastrin G cells in Distension of Increase HCL, pepsinogen

antrum of stomach, and IF secretion, increases
the extrinsic nerves gastric motility, trophic effect
stomach Inhibited by: low on gastric mucosa
antral pH,
somatostatin
CCK I cells in Partially Increases secretion of

upper digested enzyme-rich fluid from
small proteins and pancreas, contraction of
intestine triglycerides gallbladder and relaxation of
sphincter of Oddi, decreases
gastric emptying, trophic
effect on pancreatic acinar
cells, induces satiety
Secretin S cells in Acidic chyme, Increases secretion of

upper fatty acids bicarbonate-rich fluid from
small pancreas and hepatic duct
intestine cells, decreases gastric acid
secretion, trophic effect on
pancreatic acinar cells
VIP Small Neural Stimulates secretion by

intestine, pancreas and intestines,
pancreas inhibits acid and pepsinogen
secretion
Somatostatin D cells in Fat, bile salts Decreases acid and pepsin

the and glucose in secretion, decreases gastrin
pancreas the intestinal secretion, decreases
and lumen pancreatic enzyme secretion,
stomach decreases insulin and
glucagon secretion
inhibits trophic effects of
gastrin, stimulates gastric
mucous production
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Question stats
A 20.6%
B 37.6%
C 23.8%
D 7.9%
E 10%
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Question 35 of 192
 
A 22 year old man suffers a blunt head injury. He is drowsy and has a GCS of 7 on
admission. Which of the following is the major determinant of cerebral blood flow
in this situation?
Systemic blood pressure
Mean arterial pressure

Intra cranial pressure
Hypoxaemia
Acidosis
Hypoxaemia and acidosis may both affect cerebral blood flow. However, in the
traumatic situation increases in intracranial pressure are far more likely to occur
especially when GCS is low. This will adversely affect cerebral blood flow.
Next question 
Cerebral blood flow
CNS autoregulates its own blood supply

Factors affecting the cerebral pressure include; systemic carbon dioxide
levels, CNS metabolism, CNS trauma, CNS pressure
The PaCO2 is the most potent mediator
Acidosis and hypoxaemia will increase cerebral blood flow but to a lesser
degree
Intra cranial pressure may increase in patients with head injuries and this
can result in impaired blood flow
Intra cerebral pressure is governed by Monroe-Kelly Doctrine which
considers brain as closed box, changes in pressure are offset by loss of CSF.
When this is no longer possible ICP rises
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Question stats
A 6.5%
B 21.7%
C 50.4%
D 10.8%
E 10.5%
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Question 36 of 192
 
A surgeon is considering using lignocaine as local anasthesia for a minor

procedure. Which of the following best accounts for its actions?
Blockade of neuronal acetylcholine receptors
Blockade of neuronal nicotinic receptors

Blockade of neuronal sodium channels
Blockade of neuronal potassium channels
Blockade of neuronal calcium channels
Lignocaine blocks sodium channels. They will typically be activated first, hence the
pain some patients experience on administration.
Next question 
Local anaesthetic agents
Lidocaine
An amide
Local anaesthetic and a less commonly used antiarrhythmic (affects Na
channels in the axon)
Hepatic metabolism, protein bound, renally excreted
Toxicity: due to IV or excess administration. Increased risk if liver
dysfunction or low protein states. Note acidosis causes lidocaine to detach
from protein binding.
Drug interactions: Beta blockers, ciprofloxacin, phenytoin
Features of toxicity: Initial CNS over activity then depression as lidocaine
initially blocks inhibitory pathways then blocks both inhibitory and activating
pathways. Cardiac arrhythmias.
Increased doses may be used when combined with adrenaline to limit
systemic absorption.
Cocaine
Pure cocaine is a salt, usually cocaine hydrochloride. It is supplied for local
anaesthetic purposes as a paste.
It is supplied for clinical use in concentrations of 4 and 10%. It may be
applied topically to the nasal mucosa. It has a rapid onset of action and has
the additional advantage of causing marked vasoconstriction.
It is lipophillic and will readily cross the blood brain barrier. Its systemic
effects also include cardiac arrhythmias and tachycardia.
Apart from its limited use in ENT surgery it is otherwise used rarely in
mainstream surgical practice.
Bupivacaine
Bupivacaine binds to the intracellular portion of sodium channels and blocks
sodium influx into nerve cells, which prevents depolarization.
It has a much longer duration of action than lignocaine and this is of use in
that it may be used for topical wound infiltration at the conclusion of
surgical procedures with long duration analgesic effect.
It is cardiotoxic and is therefore contra indicated in regional blockage in
case the tourniquet fails.
Levobupivacaine (Chirocaine) is less cardiotoxic and causes less
vasodilation.
Prilocaine
Similar mechanism of action to other local anaesthetic agents. However, it
is far less cardiotoxic and is therefore the agent of choice for intravenous
regional anaesthesia e.g. Biers Block.
All local anaesthetic agents dissociate in tissues and this contributes to their
therapeutic effect. The dissociation constant shifts in tissues that are acidic e.g.
where an abscess is present, and this reduces the efficacy.
Doses of local anaesthetics
Agent Dose plain Dose with adrenaline
Lignocaine 3mg/Kg 7mg/Kg
Bupivacaine 2mg/Kg 2mg/Kg
Prilocaine 6mg/Kg 9mg/Kg
These are a guide only as actual doses depend on site of administration, tissue
vascularity and co-morbidities.
Maximum total local anaesthetic doses
Lignocaine 1% plain - 3mg/ Kg - 200mg (20ml)
Lignocaine 1% with 1 in 200,000 adrenaline - 7mg/Kg - 500mg (50ml)
Bupivacaine 0.5% - 2mg/kg- 150mg (30ml)
Maximum doses are based on ideal body weight
Effects of adrenaline
Adrenaline may be added to local anaesthetic drugs. It prolongs the duration of
action at the site of injection and permits usage of higher doses (see above). It is
contra indicated in patients taking MAOI's or tricyclic antidepressants. The toxicity
of bupivacaine is related to protein binding and addition of adrenaline to this drug
does not permit increases in the total dose of bupivacaine, in contrast to the
situation with lignocaine.
References
An excellent review is provided by:
French J and Sharp L. Local Anaesthetics. Ann R Coll Surg Engl 2012; 94: 76-80.
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Question stats
A 16.1%
B 8.4%
C 58.7%
D 8%
E 8.9%


Question 37 of 192
 
A 25 year old man undergoes an appendicetomy for appendicitis. The appendix is

submitted for histopathological evaluation. Which of the following is most likely to
be identified microscopically?
Macrophages
Neutrophils
Fibroblasts
Lymphocytes
Stem cells
Neutrophil polymorphs are the cell type most commonly encountered in acute
inflammation.
Next question 
Acute inflammation
Inflammation is the reaction of the tissue elements to injury. Vascular changes

occur, resulting in the generation of a protein rich exudate. So long as the injury
does not totally destroy the existing tissue architecture, the episode may resolve
with restoration of original tissue architecture.
Vascular changes
Vasodilation occurs and persists throughout the inflammatory phase.
Inflammatory cells exit the circulation at the site of injury.
The equilibrium that balances Starlings forces within capillary beds is
disrupted and a protein rich exudate will form as the vessel walls also
become more permeable to proteins.
The high fibrinogen content of the fluid may form a fibrin clot. This has
several important immunomodulatory functions.
Sequelae
Resolution Typically occurs with minimal initial injury

Stimulus removed and normal tissue
architecture results
Organisation Delayed removal of exudate

Tissues undergo organisation and usually
fibrosis
Suppuration Typically formation of an abscess or an

empyema
Sequestration of large quantities of dead

neutrophils
Progression to chronic Coupled inflammatory and reparative

inflammation activities
Usually occurs when initial infection or
suppuration has been inadequately managed
Causes
Infections e.g. Viruses, exotoxins or endotoxins released by bacteria
Chemical agents
Physical agents e.g. Trauma
Hypersensitivity reactions
Tissue necrosis
Presence of neutrophil polymorphs is a histological diagnostic feature of acute

inflammation
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A 17.1%
B 58.3%
C 6%
D 13%
E 5.7%

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Question 38 of 192
 
A 23 year old man is undergoing an inguinal hernia repair under local anaesthesia.
The surgeon encounters a bleeding site which he manages with diathermy. About
a minute or so later the patient complains that he is able to feel the burning pain of
the heat at the operative site. Which of the following nerve fibres is responsible for
the transmission of this signal?
A α fibres
A β fibres
B fibres
C fibres
None of the above
Slow transmission of mechanothermal stimuli is transmitted via C fibres.

A γ fibres transmit information relating to motor proprioception, A β fibres transmit
touch and pressure and B fibres are autonomic fibres.
Next question 
Pain - neuronal transmission
Somatic pain
Peripheral nociceptors are innervated by either small myelinated fibres (A-
delta) fibres or by unmyelinated C fibres.
The A gamma fibres register high intensity mechanical stimuli. The C fibres
usually register high intensity mechanothermal stimuli.
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Question stats
A 15.4%
B 14.2%
C 9.3%
D 54.7%
E 6.4%
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Question 39 of 192
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In a 70 Kg male, what proportion of total body fluid will be contributed by plasma?
50%
5%
35%
65%
25%
70 Kg male = 42 L water (60% of total body weight)
Next question 
Fluid compartment physiology
Body fluid compartments comprise intracellular and extracellular compartments.

The latter includes interstitial fluid, plasma and transcellular fluid.
Typical figures are based on the 70 Kg male.
Body fluid volumes
Compartment Volume in litres Percentage of total volume
Intracellular 28 L 60-65%
Extracellular 14 L 35-40%
Plasma 3L 5%
Interstitial 10 L 24%
Transcellular 1L 3%
Figures are approximate
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Question stats
A 8.4%
B 41.8%
C 16.1%
D 17.7%
E 16%
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Question 40 of 192
 
Which of the following hormones is mainly responsible for sodium - potassium

exchange in the salivary ducts?
Vasopressin
Angiotensin I
Aldosterone
Somatostatin
Cholecystokinin
Aldosterone is responsible for regulating ion exchange in salivary glands. It acts on

a sodium / potassium ion exchange pump.It is a mineralocorticoid hormone
derived from the zona glomerulosa of the adrenal gland.
Next question 
Parotid gland
Anatomy of the parotid gland
Location Overlying the mandibular ramus; anterior and inferior to

the ear.
Salivary duct Crosses the masseter, pierces the buccinator and drains
adjacent to the 2nd upper molar tooth (Stensen's duct).
Structures Facial nerve (Mnemonic: The Zebra Buggered My
passing through Cat; Temporal Zygomatic, Buccal, Mandibular,
the gland Cervical)
External carotid artery
Retromandibular vein
Auriculotemporal nerve
Relations Anterior: masseter, medial pterygoid, superficial

temporal and maxillary artery, facial nerve,
stylomandibular ligament
Posterior: posterior belly digastric muscle,
sternocleidomastoid, stylohyoid, internal carotid
artery, mastoid process, styloid process
Arterial supply Branches of external carotid artery
Venous drainage Retromandibular vein
Lymphatic Deep cervical nodes

drainage
Nerve innervation Parasympathetic-Secretomotor

Sympathetic-Superior cervical ganglion
Sensory- Greater auricular nerve
Parasympathetic stimulation produces a water rich, serous saliva. Sympathetic

stimulation leads to the production of a low volume, enzyme-rich saliva.
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Question stats
A 9.3%
B 6.8%
C 40.9%
D 25.3%
E 17.6%
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Question 41 of 192
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What are the most likely effects of the release of vasopressin from the pituitary?
Vasoconstriction of the afferent glomerular arteriole
Increased permeability of the mesangial cells to glucose
Reduced permeability of the inner medullary portion of the collecting duct

to urea
Increased secretion of aldosterone from the macula densa
Increased water permeability of the distal tubule cells of the kidney
ADH (vasopressin) results in the insertion of aquaporin channels in apical

membrane of the distal tubule and collecting ducts.
Next question 
Renal Physiology
Overview

cross.
inulin).


1. Inert

--------------------------------------------------------------------------

reabsorption.
Tubular function
membrane.
sodium.
Loop of Henle

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Question stats
A 24.6%
B 5.3%
C 10.4%
D 14.4%
E 45.3%

Question 42 of 192
 
A 25 year old man is undergoing respiratory spirometry. He takes a maximal

inspiration and maximally exhales. Which of the following measurements will best
illustrate this process?
Functional residual capacity
Vital capacity
Inspiratory capacity
Maximum voluntary ventilation
Tidal volume
The maximum voluntary ventilation is the maximal ventilation over the course of 1
minute.
Next question 
Lung volumes

volumes)
Definitions
females.




in females.

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Question stats
A 11.6%
B 54.1%
C 7.7%
D 13.5%
E 13.1%
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Question 43 of 192
 
Which of the following is the main site of dehydroepiandrosterone release?
Posterior pituitary
Zona reticularis of the adrenal gland
Zona glomerulosa of the adrenal gland

Juxtaglomerular apparatus of the kidney
Zona fasciculata of the adrenal gland
Adrenal cortex mnemonic: GFR - ACD
DHEA possesses some androgenic activity and is almost exclusively released from
the adrenal gland.
Next question 
Renin-angiotensin-aldosterone system
Adrenal cortex (mnemonic GFR - ACD)

Zona glomerulosa (on outside): mineralocorticoids, mainly aldosterone
Zona fasciculata (middle): glucocorticoids, mainly cortisol
Zona reticularis (on inside): androgens, mainly dehydroepiandrosterone
(DHEA)
Renin
Released by JGA cells in kidney in response to reduced renal perfusion, low
sodium
Hydrolyses angiotensinogen to form angiotensin I
Factors stimulating renin secretion

Low BP
Hyponatraemia
Sympathetic nerve stimulation
Catecholamines
Erect posture
Angiotensin
ACE in lung converts angiotensin I → angiotensin II
Vasoconstriction leads to raised BP
Stimulates thirst
Stimulates aldosterone and ADH release
Aldosterone
Released by the zona glomerulosa in response to raised angiotensin II,
potassium, and ACTH levels
Causes retention of Na+ in exchange for K+/H+ in distal tubule
(http://en.wikipedia.org/wiki/Renin%E2%80
%93angiotensin system)
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Question stats
A 7%
B 52.1%
C 17.6%
D 8.6%
E 14.8%
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Question 44 of 192
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A 63 year old female is referred to the surgical clinic with an iron deficiency
anaemia. Her past medical history includes a left hemi colectomy but no other co-
morbidities. At what site is most dietary iron absorbed?
Stomach
Duodenum
Proximal ileum
Distal ileum
Colon
Iron is best absorbed from the proximal small bowel (duodenum and jejunum) in
the Fe 2+ state. Iron is transported across the small bowel mucosa by a divalent
membrane transporter protein (hence the improved absorption of Fe 2+). The
intestinal cells typically store the bound iron as ferritin. Cells requiring iron will
typically then absorb the complex as needed.
Next question 
Iron metabolism
Absorption Duodenum and upper jejunum
About 10% of dietary iron absorbed
Fe2+ (ferrous iron) much better absorbed than Fe3+ (ferric
iron)
Ferrous iron is oxidized to form ferric iron, which is
combined with apoferritin to form ferritin
Absorption is regulated according to body's need
Increased by vitamin C, gastric acid
Transport In plasma as Fe3+ bound to transferrin
Distribution
Storage in body
Ferritin (or haemosiderin) in bone marrow
Total body iron 4g

Excretion Lost via intestinal tract following desquamation
Haemoglobin 70%
Ferritin and haemosiderin 25%
Myoglobin 4%
Plasma iron 0.1%
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Question stats
A 9.7%
B 39.1%
C 19.8%
D 22.9%
E 8.5%

Question 45 of 192
 
A 56 year old man has long standing chronic pancreatitis and develops pancreatic
insufficiency. Which of the following will be absorbed normally?
Fat
Protein
Folic acid
Vitamin B12
None of the above
Pancreatic lipase is required for digestion of fat, Proteases facilitate protein and
B12 absorption. Folate digestion is independent of the pancreas.
Next question 
Pancreas exocrine physiology
Composition of pancreatic secretions

Pancreatic secretions are usually 1000-1500ml per 24 hours and have a pH of 8.
Secretion Source Substances secreted
Trypsinogen
Procarboxylase
Enzymic Acinar cells
Amylase
Elastase
Sodium
Bicarbonate
Water
Ductal and
Aqueous Potassium
Centroacinar cells
Chloride
NB: Sodium and potassium reflect their plasma levels;
chloride and bicarbonate vary with flow rate
Regulation
The cephalic and gastric phases (neuronal and physical) are less important in
regulating the pancreatic secretions. The effect of digested material in the small
bowel stimulates CCK release and ACh which stimulate acinar and ductal cells. Of
these CCK is the most potent stimulus. In the case of the ductal cells these are
potently stimulated by secretin which is released by the S cells of the duodenum.
This results in an increase in bicarbonate.
Enzyme activation
Trypsinogen is converted via enterokinase to active trypsin in the duodenum.
Trypsin then activates the other inactive enzymes
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Question stats
A 9.4%
B 10%
C 32.1%
D 40.3%
E 8.3%
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Question 46 of 192
 
Which vitamin is involved in the formation of collagen?
Vitamin A
Vitamin B
Vitamin C
Vitamin D
Vitamin E
Vitamin C is needed for the hydroxylation of proline during collagen synthesis.
Next question 
Collagen
Collagen is one of the most important structural proteins within the extracellular
matrix, collagen together with components such as elastin and
glycosaminoglycans determine the properties of all tissues.
Composed of 3 polypeptide strands that are woven into a helix, usually a
combination of glycine with either proline or hydroxyproline plus another
amino acid
Numerous hydrogen bonds exist within molecule to provide additional
strength
Many sub types but commonest sub type is I (90% of bodily collagen),
tissues with increased levels of flexibility have increased levels of type III
collagen
Vitamin c is important in establishing cross links
Synthesised by fibroblasts
Collagen Diseases
Disorders of collagen range from relatively common, acquired defects (typically
aging), through to rarer congenital disorders. The latter are exemplified by
conditions such as osteogenesis imperfecta and Ehlers Danlos syndromes.
Osteogenesis imperfecta:
-8 Subtypes
-Defect of type I collagen
-In type I the collagen is normal quality but insufficient quantity
-Type II- poor quantity and quality
-Type III- Collagen poorly formed, normal quantity
-Type IV- Sufficient quantity but poor quality
Patients have bones which fracture easily, loose joint and multiple other defects
depending upon which sub type they suffer from.
Ehlers Danlos:
-Multiple sub types
-Abnormality of types 1 and 3 collagen
-Patients have features of hypermobility.
-Individuals are prone to joint dislocations and pelvic organ prolapse. In addition to
many other diseases related to connective tissue defects.
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Question stats
A 11.5%
B 6.1%
C 59.4%
D 8.8%
E 14.1%


Question 47 of 192
 
A 28 year old man is shot in the abdomen and haemorrhages. Which of the
following substances will produce vasoconstriction in response to this process?
Renin
Angiotensin I
Angiotensin II
Aldosterone
None of the above
Renin does not cause vasoconstriction. Angiotensin I is biologically inactive.

Aldosterone will increase blood pressure but does not have direct vasospastic
effects.
Next question 
Shock
Shock occurs when there is insufficient tissue perfusion.

The pathophysiology of shock is an important surgical topic and may be
divided into the following aetiological groups:
Septic
Haemorrhagic
Neurogenic
Cardiogenic
Anaphylactic
Septic shock
Septic shock is a major problem and those patients with severe sepsis have a
mortality rate in excess of 40%. In those who are admitted to intensive care
mortality ranges from 6% with no organ failure to 65% in those with 4 organ failure.
Sepsis is defined as an infection that triggers a particular Systemic Inflammatory

Response Syndrome (SIRS). This is characterised by body temperature outside 36
oC - 38 o C, HR >90 beats/min, respiratory rate >20/min, WBC count >12,000/mm 3
or < 4,000/mm3, altered mental state or hyperglycaemia (in absence of diabetes).
Patients with infections and two or more elements of SIRS meet the diagnostic
criteria for sepsis. Those with organ failure have severe sepsis and those with
refractory hypotension -septic shock.
During the septic process there is marked activation of the immune system with
extensive cytokine release. This may be coupled with or triggered by systemic
circulation of bacterial toxins. These all cause endothelial cell damage and
neutrophil adhesion. The overall hallmarks are thus those of excessive
inflammation, coagulation and fibrinolytic suppression.
The surviving sepsis campaign (2012) highlights the following key areas for
attention:
Prompt administration of antibiotics to cover all likely pathogens coupled
with a rigorous search for the source of infection.
Haemodynamic stabilisation. Many patients are hypovolaemic and require
aggressive fluid administration. Aim for CVP 8-12 cm H2O, MAP >65mmHg.
Modulation of the septic response. This includes manoeuvres to counteract
the changes and includes measures such as tight glycaemic control. The
routine use of steroids is not advised.
In surgical patients, the main groups with septic shock include those with
anastomotic leaks, abscesses and extensive superficial infections such as
necrotising fasciitis. When performing surgery the aim should be to undertake the
minimum necessary to restore physiology. These patients do not fare well with
prolonged surgery. Definitive surgery can be more safely undertaken when
physiology is restored and clotting in particular has been normalised.
Haemorrhagic shock
The average adult blood volume comprises 7% of body weight. Thus in the 70 Kg
adult this will equate to 5 litres. This changes in children (8-9% body weight) and is
slightly lower in the elderly.
The table below outlines the 4 major classes of haemorrhagic shock and their
associated physiological sequelae:
Parameter Class I Class II Class III Class IV
Blood loss ml <750ml 750-1500ml 1500-2000ml >2000ml

Blood loss % <15% 15-30% 30-40% >40%
Pulse rate <100 >100 >120 >140
Blood pressure Normal Normal Decreased Decreased
Respiratory rate 14-20 20-30 30-40 >35
Urine output >30ml 20-30ml 5-15ml <5ml
Symptoms Normal Anxious Confused Lethargic

Decreasing blood pressure during haemorrhagic shock causes organ

hypoperfusion and relative myocardial ischaemia. The cardiac index gives a
numerical value for tissue oxygen delivery and is given by the equation: Cardiac
index= Cardiac output/ body surface area. Where Hb is haemoglobin
concentration in blood and SaO2 the saturation and PaO2 the partial pressure of
oxygen. Detailed knowledge of this equation is required for the MRCS Viva but not
for part A, although you should understand the principle.
In patients suffering from trauma the most likely cause of shock is haemorrhage.
However, the following may also be the cause or occur concomitantly:
Tension pneumothorax
Spinal cord injury
Myocardial contusion
Cardiac tamponade
When assessing trauma patients it is worth remembering that in order to generate

a palpable femoral pulse an arterial pressure of >65mmHg is required.
Once bleeding is controlled and circulating volume normalised the levels of

transfusion should be to maintain a Hb of 7-8 in those with no risk factors for
tissue hypoxia and Hb 10 for those who have such risk factors.
Neurogenic shock
This occurs most often following a spinal cord transection, usually at a high level.
There is resultant interruption of the autonomic nervous system. The result is
either decreased sympathetic tone or increased parasympathetic tone, the effect
of which is a decrease in peripheral vascular resistance mediated by marked
vasodilation.
This results in decreased preload and thus decreased cardiac output (Starlings
law). There is decreased peripheral tissue perfusion and shock is thus produced. In
contrast with many other types of shock peripheral vasoconstrictors are used to
return vascular tone to normal.
Cardiogenic shock
In medical patients the main cause is ischaemic heart disease. In the traumatic
setting direct myocardial trauma or contusion is more likely. Evidence of ECG
changes and overlying sternal fractures or contusions should raise the suspicion
of injury. Treatment is largely supportive and transthoracic echocardiography
should be used to determine evidence of pericardial fluid or direct myocardial
injury. The measurement of troponin levels in trauma patients may be undertaken
but they are less useful in delineating the extent of myocardial trauma than
following MI.
When cardiac injury is of a blunt nature and is associated with cardiogenic shock
the right side of the heart is the most likely site of injury with chamber and or valve
rupture. These patients require surgery to repair these defects and will require
cardiopulmonary bypass to achieve this. Some may require intra aortic balloon
pump as a bridge to surgery.
Anaphylactic shock
Anaphylaxis may be defined as a severe, life-threatening, generalised or systemic
hypersensitivity reaction.
Anaphylaxis is one of the few times when you would not have time to look up the
dose of a medication. The Resuscitation Council guidelines on anaphylaxis have
recently been updated. Adrenaline is by far the most important drug in anaphylaxis
and should be given as soon as possible. The recommended doses for adrenaline,
hydrocortisone and chlorpheniramine are as follows:
Adrenaline Hydrocortisone Chlorpheniramine
< 6 months 150 mcg (0.15ml 1 25 mg 250 mcg/kg

in 1,000)
6 months - 6 150 mcg (0.15ml 1 50 mg 2.5 mg

years in 1,000)
6-12 years 300 mcg (0.3ml 1 in 100 mg 5 mg

1,000)
Adult and child 500 mcg (0.5ml 1 in 200 mg 10 mg

12 years 1,000)
Adrenaline can be repeated every 5 minutes if necessary. The best site for IM
injection is the anterolateral aspect of the middle third of the thigh.
Common identified causes of anaphylaxis

food (e.g. Nuts) - the most common cause in children
drugs
venom (e.g. Wasp sting)
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Question stats
A 14.4%
B 9.3%
C 52.8%
D 15.1%
E 8.3%
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Question 48 of 192
 
A 73 year old lady is admitted for a laparoscopic cholecystectomy. During her pre-
operative assessment it is noted that she is receiving furosemide for the treatment
of hypertension. Where is the site of action of this diuretic?
Proximal convoluted tubule
Descending limb of the loop of Henle

Ascending limb of the loop of Henle
Distal convoluted tubule
Collecting ducts
Action of furosemide = ascending limb of the loop of Henle
Furosemide and bumetanide are loop diuretics that act by inhibiting the Na-K-Cl
cotransporter in the thick ascending limb of the loop of Henle, reducing the
absorption of NaCl.
Next question 
Diuretic agents
The diuretic drugs are divided into three major classes, which are distinguished
according to the site at which they impair sodium reabsorption: loop diuretics in
the thick ascending loop of Henle, thiazide type diuretics in the distal tubule and
connecting segment; and potassium sparing diuretics in the aldosterone -
sensitive principal cells in the cortical collecting tubule.
In the kidney, sodium is reabsorbed through Na+/ K+ ATPase pumps located on the
basolateral membrane. These pumps return reabsorbed sodium to the circulation
and maintain low intracellular sodium levels. This latter effect ensures a constant
concentration gradient.
Physiological effects of commonly used diuretics
Carrier or Percentage of
channel filtered sodium
Site of action Diuretic inhibited excreted
Ascending limb of Frusemide Na+/K+ 2Cl - Up to 25%

loop of Henle carrier
Distal tubule and Thiazides Na+Cl- carrier Between 3 and 5%

connecting
segment
Cortical collecting Spironolactone Na+/K+ ATP Between 1 and 2%

tubule ase pump
Next question 
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Question stats
A 11.6%
B 17.9%
C 48.2%
D 13.3%
E 8.9%
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Question 49 of 192
 
Which of the following blood gas results would fit with metabolic acidosis with a
compensatory respiratory alkalosis?
pH 7.36, PaCO2 7.3, PO2 8.9 (FiO2 40%), Bicarbonate 30.2, Base excess
+5.3
excess -10.6
+1.8 mmol
-7.9
mmol
Next question 




mmol)
mmol)
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Question stats
A 11.3%
B 14.8%
C 8.2%
D 56.1%
E 9.6%
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Question 50 of 192
 
Which of the following is not well absorbed following a gastrectomy?
Vitamin c
Zinc
Vitamin B12
Copper
Molybdenum
Vitamin B12. The others are unaffected
Post gastrectomy syndrome

Rapid emptying of food from stomach into the duodenum: diarrhoea,
abdominal pain, hypoglycaemia
Complications: Vitamin B12 and iron malabsorption, osteoporosis
Treatment: High protein, low carbohydrate diet. Replace B12/Fe/Ca
Next question 
Gastric emptying
The stomach serves both a mechanical and immunological function. Solid
and liquid are retained in the stomach during which time repeated peristaltic
activity against a closed pyloric sphincter will cause fragmentation of food
bolus material. Contact with gastric acid will help to neutralise any
pathogens present.
The amount of time material spends in the stomach is related to its
composition and volume. For example a glass of water will empty more
quickly than a large meal. The presence of amino acids and fat will all serve
to delay gastric emptying.
Controlling factors
Neuronal stimulation of the stomach is mediated via the vagus and the
parasympathetic nervous system will tend to favor an increase in gastric motility. It
is for this reason that individuals who have undergone truncal vagotomy will tend
to routinely require either a pyloroplasty or gastro-enterostomy as they would

otherwise have delayed gastric emptying.
The following hormonal factors are all involved:
Delay emptying Increase emptying
Gastric inhibitory peptide Gastrin
Cholecystokinin
Enteroglucagon
Diseases affecting gastric emptying

All diseases that affect gastric emptying may result in bacterial overgrowth,
retained food and eventually the formation of bezoars that may occlude the
pylorus and make gastric emptying even worse. Fermentation of food may cause
dyspepsia, reflux and foul smelling belches of gas.
Iatrogenic
Gastric surgery can have profound effects on gastric emptying. As stated above
any procedure that disrupts the vagus can cause delayed emptying. Whilst this is
particularly true of vagotomy, this operation is now rarely performed. Surgeons are
divided on the importance of vagal disruption that occurs during an
oesophagectomy, some will routinely perform a pyloroplasty and others will not.
When a distal gastrectomy is performed, the type of anastomosis performed will

impact on emptying. When a gastro-enterostomy is constructed, a posterior,
retrocolic gastroenterostomy will empty better than an anterior one.
Diabetic gastroparesis
This is predominantly due to neuropathy affecting the vagus nerve. The stomach
empties poorly and patients may have episodes of repeated and protracted
vomiting. Diagnosis is made by upper GI endoscopy and contrast studies, in some
cases a radio nucleotide scan is needed to demonstrate the abnormality more
clearly. In treating these conditions, drugs such as metoclopramide will be less
effective as they exert their effect via the vagus nerve. One of the few prokinetic
drugs that do not work in this way is the antibiotic erythromycin.
Malignancies
Obviously a distal gastric cancer may obstruct the pylorus and delay emptying. In
addition, malignancies of the pancreas may cause extrinsic compression of the
duodenum and delay emptying. Treatment in these cases is by gastric
decompression using a wide bore nasogastric tube and insertion of a stent or, if
that is not possible, by a surgical gastroenterostomy. As a general rule
gastroenterostomies constructed for bypass of malignancy are usually placed on

the anterior wall of the stomach (in spite of the fact that they empty less well). A
Roux en Y bypass may also be undertaken, but the increased number of
anastomoses for this, in malignant disease that is being palliated, is probably not
justified.
Congenital Hypertrophic Pyloric Stenosis

This is typically a disease of infancy. Most babies will present around 6 weeks of
age with projectile non bile stained vomiting. It has an incidence of 2.4 per 1000
live births and is more common in males. Diagnosis is usually made by careful
history and examination and a mass may be palpable in the epigastrium (often
cited seldom felt!). The most important diagnostic test is an ultrasound that
usually demonstrates the hypertrophied pylorus. Blood tests may reveal a
hypochloraemic metabolic alkalosis if the vomiting is long standing. Once the
diagnosis is made the infant is resuscitated and a pyloromyotomy is performed
(either open or laparoscopically). Once treated there are no long term sequelae.
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A 8.7%
B 11.5%
C 67.7%
D 5.8%
E 6.4%
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Question 51 of 192
 
Which of the following best accounts for the mechanism of action of

glucocorticoids?
Binding of cell wall receptors and intracellular tyrosine kinase activation
Binding of intracellular receptors that migrate to the nucleus to then affect

gene transcription
Activation of transmembrane tyrosine kinase systems to affect

intranuclear gene transcription
Induces post translational modification of intracellular proteins
Direct binding of inflammatory cells inducing apoptosis
Glucocorticoids exert their effects by binding intracellular receptors that are then
transported to the nucleus where they affect gene transcription. There are some
questions in the MRCS now that seem to test common pharmacology and so we
have decided to include this. A detailed knowledge of the mechanisms by which
these effects occur is not needed.
Next question 
Corticosteroids
Synthesised from cholesterol within the adrenal cortex

Bind to specific intracellular glucocorticoid receptors located on the nucleus
Effects of glucocorticoids
Metabolic
Decreased uptake and utilisation of glucose, increased gluconeogenesis and
hyperglycaemia
Increased protein catabolism
Permissive effect on lipolytic hormones
Regulatory actions
Has a negative feedback action on the hypothalamus causing reduced release of
endogenous glucocorticoids
Within the CVS they cause decreased vasodilation and decreased fluid exudation
They decrease osteoblastic activity and increase osteoclastic activity
Decrease acute and chronic inflammation (decrease in influx and activity of
leukocytes), decreased clonal expansion of B and T lymphocytes.
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Question stats
A 17.3%
B 45.3%
C 19.9%
D 8.4%
E 9.1%
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Question 52 of 192
 
A healthy man has a blood pressure of 120/80 mmHg and an intra cranial pressure
of 17 mmHg. What is the approximate cerebral perfusion pressure?
103 mmHg
63 mmHg
83 mmHg
91 mmHg
76 mmHg
Cerebral perfusion pressure= Mean arterial pressure - intra cranial pressure
The mean arterial pressure can be calculated as:

MAP= Diastolic pressure+ 0.333(Systolic pressure- Diastolic pressure)
In this situation the MAP = 93.
The ICP is subtracted from this value; 93 - 17 = 76
Next question 
Cerebral perfusion pressure
The cerebral perfusion pressure (CPP) is defined as being the net pressure
gradient causing blood flow to the brain. The CPP is tightly autoregulated to
maximise cerebral perfusion. A sharp rise in CPP may result in a rising ICP, a fall in
CPP may result in cerebral ischaemia. It may be calculated by the following
equation:
CPP= Mean arterial pressure - Intra cranial pressure

Following trauma, the CPP has to be carefully controlled and the may require
invasive monitoring of the ICP and MAP.
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Question stats
A 17.5%
B 15.9%
C 16.9%
D 10.5%
E 39.2%
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Question 53 of 192
 
Which of the following statements related to the coagulation cascade is true?
The intrinsic pathway is the main pathway in coagulation
Heparin inhibits the activation of Factor 8
The activation of factor 8 is the point when the intrinsic and the extrinsic
pathways meet
Tissue factor released by damaged tissue initiates the extrinsic pathway
Thrombin converts plasminogen to plasmin
The extrinsic pathway is the main path of coagulation. Heparin inhibits the
activation of factors 2,9,10,11. The activation of factor 10 is when both pathways
meet. Thrombin converts fibrinogen to fibrin. During fibrinolysis plasminogen is
converted to plasmin to break down fibrin.
Next question 
Coagulation cascade
Two pathways lead to fibrin formation
Intrinsic pathway (components already present in the blood)

Minor role in clotting
Subendothelial damage e.g. collagen
Formation of the primary complex on collagen by high-molecular-weight
kininogen (HMWK), prekallikrein, and Factor 12
Prekallikrein is converted to kallikrein and Factor 12 becomes activated
Factor 12 activates Factor 11
Factor 11 activates Factor 9, which with its co-factor Factor 8a form the
tenase complex which activates Factor 10
Extrinsic pathway (needs tissue factor released by damaged tissue)

Tissue damage
Factor 7 binds to Tissue factor

This complex activates Factor 9
Activated Factor 9 works with Factor 8 to activate Factor 10
Common pathway
Activated Factor 10 causes the conversion of prothrombin to thrombin
Thrombin hydrolyses fibrinogen peptide bonds to form fibrin and also
activates factor 13 to form links between fibrin molecules
Fibrinolysis
Plasminogen is converted to plasmin to facilitate clot resorption
(http://en.wikipedia.org
/wiki/Coagulation)
Clotting pathway Clotting parameters affected Factors affected
Intrinsic pathway Increased APTT Factors 8,9,11,12
Extrinsic pathway Increased PT Factor 7
Common pathway Increased APTT & PT Factors 2,5,10
Vitamin K dependent Factors 2,7,9,10
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Question stats
A 12.6%
B 10.2%
C 13.8%
D 47.3%
E 16.1%
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Question 54 of 192
 
The pressure within the pleural space is negative with respect to atmospheric
pressure, except for which of the following?
At the end of inspiration
When taking a deep breath

If the patient is intubated with an endotracheal tube
During a Valsalva manoeuvre
At the end of expiration
During a Valsalva manoeuvre, the intra pleural pressure rises owing to extrinsic
compression.
Next question 
Pleural pressure
Pleural pressure is the pressure surrounding the lung, within the pleural space.
During quiet breathing, the pleural pressure is negative; that is, it is below
atmospheric pressure.
The pleura is a thin membrane which invests the lungs and lines the walls of the
thoracic cavity. During development the lungs grow into the pleural sacs until they
are completely surrounded by them. The side of the pleura that covers the lung is
referred to as the visceral pleura and the side of the pleura which covers the chest
wall is called the parietal pleura. These two sides are continuous and meet at the
hilum of the lung. The two faces of the pleural membranes are directly opposed to
one another, and the entire potential space within the pleura contains only a few
milliliters of serous pleural fluid.
The size of the lung is determined by the difference between the alveolar pressure
and the pleural pressure, or the transpulmonary pressure. The bigger the
difference, the bigger the lung. As a result of gravity, in an upright individual the
pleural pressure at the base of the lung base is greater (less negative) than at its
apex; when the individual lies on his back, the pleural pressure becomes greatest
along his back. Since alveolar pressure is uniform throughout the lung, the top of
the lung generally experiences a greater transpulmonary pressure and is therefore
more expanded and less compliant than the bottom of the lung.
During active expiration, the abdominal muscles are contracted to force up the
diaphragm and the resulting pleural pressure can become positive. Positive pleural
pressure may temporarily collapse the bronchi and cause limitation of air flow.
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Question stats
A 18%
B 7.8%
C 12.8%
D 45.8%
E 15.5%
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Question 55 of 192
 
Which of the blood gas results listed below is most likely to fit with a patient who
has acute respiratory acidosis?
+1.8 mmol
mmol
excess -10.6
pH 7.36, PaCO2 7.3, PO2 8.9 (FiO2 40%), Bicarbonate 30.2, Base excess 5.3
-7.9
Next question 




mmol)
mmol)
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Question stats
A 6.5%
B 55%
C 22.7%
D 8.1%
E 7.8%
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Question 56 of 192
 
A patient has an arterial blood gas sample taken and the following result is
obtained:
pH 7.48
pO2 10.1
Bicarbonate 30
pCO2 4.5
Chloride 10meq
Respiratory alkalosis
Metabolic alkalosis
Type 1 respiratory failure
Metabolic acidosis with normal anion gap
Metabolic acidosis with increased anion gap
This would be a typical result of prolonged vomiting.
Next question 
Disorders of acid - base balance
Disorders of acid- base balance are often covered in the MRCS part A.
The acid-base normogram below shows how the various disorders may be
categorised
(http://en.wikipedia.org/wiki/Acid-base
homeostasis)
Metabolic acidosis
This is the most common surgical acid - base disorder.
Reduction in plasma bicarbonate levels.
Two mechanisms:
1. Gain of strong acid (e.g. diabetic ketoacidosis)

2. Loss of base (e.g. from bowel in diarrhoea)
- Classified according to the anion gap, this can be calculated by:
(Na+ + K+) - (Cl- + HCO3-).
- If a question supplies the chloride level then this is often a clue that the anion gap
should be calculated. The normal range = 10-18 mmol/L
Normal anion gap ( = hyperchloraemic metabolic acidosis)

Gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
Renal tubular acidosis
Drugs: e.g. acetazolamide
Ammonium chloride injection
Addison's disease
Raised anion gap

Lactate: shock, hypoxia
Ketones: diabetic ketoacidosis, alcohol
Urate: renal failure
Acid poisoning: salicylates, methanol
Metabolic acidosis secondary to high lactate levels may be subdivided into two
types:
Lactic acidosis type A: (Perfusion disorders e.g.shock, hypoxia, burns)
Lactic acidosis type B: (Metabolic e.g. metformin toxicity)
Metabolic alkalosis
Usually caused by a rise in plasma bicarbonate levels.
Rise of bicarbonate above 24 mmol/L will typically result in renal excretion
of excess bicarbonate.
Caused by a loss of hydrogen ions or a gain of bicarbonate. It is due mainly
to problems of the kidney or gastrointestinal tract
Causes
Vomiting / aspiration (e.g. Peptic ulcer leading to pyloric stenosis,
nasogastric suction)
Diuretics
Liquorice, carbenoxolone
Hypokalaemia
Primary hyperaldosteronism
Cushing's syndrome
Bartter's syndrome
Congenital adrenal hyperplasia
Mechanism of metabolic alkalosis

Activation of renin-angiotensin II-aldosterone (RAA) system is a key factor
Aldosterone causes reabsorption of Na+ in exchange for H+ in the distal
convoluted tubule
ECF depletion (vomiting, diuretics) → Na+ and Cl- loss → activation of RAA
system → raised aldosterone levels
In hypokalaemia, K+ shift from cells → ECF, alkalosis is caused by shift of H+
into cells to maintain neutrality
Respiratory acidosis
Rise in carbon dioxide levels usually as a result of alveolar hypoventilation
Renal compensation may occur leading to Compensated respiratory acidosis
Causes
COPD
Decompensation in other respiratory conditions e.g. Life-threatening asthma
/ pulmonary oedema
Sedative drugs: benzodiazepines, opiate overdose
Hyperventilation resulting in excess loss of carbon dioxide
This will result in increasing pH
Causes
Psychogenic: anxiety leading to hyperventilation
Hypoxia causing a subsequent hyperventilation: pulmonary embolism, high
altitude
Early salicylate poisoning*
CNS stimulation: stroke, subarachnoid haemorrhage, encephalitis
Pregnancy
*Salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis.

Early stimulation of the respiratory centre leads to a respiratory alkalosis whilst
later the direct acid effects of salicylates (combined with acute renal failure) may
lead to an acidosis
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Question stats
A 15.5%
B 62.3%
C 8.6%
D 6.7%
E 6.9%


Question 57 of 192
 
Which of the following substances is released from the sympathetic nervous

system to stimulate the adrenal medulla?
Noradrenaline
Acetyl choline
Substance P
Tyrosine
Arginine
In the autonomic nervous system, noradrenaline is the commonly used

neurotransmitter. However, in the adrenal medulla, Acetylcholine is released to
stimulate adrenaline release.
Next question 
Adrenal physiology
Adrenal medulla
The chromaffin cells of the adrenal medulla secrete the catecholamines
noradrenaline and adrenaline. The medulla is innervated by the splanchnic nerves;
the preganglionic sympathetic fibres secrete acetylcholine causing the chromaffin
cells to secrete their contents by exocytosis.
Phaeochromocytomas are derived from these cells and will secrete both
adrenaline and nor adrenaline.
Adrenal cortex
Three histologically distinct zones are recognised:
Image sourced from (https://d2zgo9qer4wjf4.cloudfront.net/images_eMRCS
Wikipedia () /swb215b.png)
Zone Location Hormone Secreted
Zona glomerulosa Outer zone Aldosterone
Zona fasiculata Middle zone Glucocorticoids
Zona reticularis Inner zone Androgens
The glucocorticoids and aldosterone are mostly bound to plasma proteins in the
circulation. Glucocorticoids are inactivated and excreted by the liver.
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Question stats
A 29.5%
B 47.4%
C 9.2%
D 7.8%
E 6%
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Question 58 of 192
 
A 65 year old man is admitted for a below knee amputation. He is taking digoxin.
Clinically the patient has an irregularly irregular pulse. What would you expect to
see when you examine the jugular venous pressure?
Absent y waves
Slow y descent
Cannon waves
Steep y descent
Absent a waves
Jugular venous pressure
Absent a waves = Atrial fibrillation

Large a waves = Any cause of right ventricular hypertrophy, tricuspid stenosis
Cannon waves (extra large a waves) = Complete heart block
Prominent v waves = Tricuspid regurgitation
Slow y descent = Tricuspid stenosis, right atrial myxoma
Steep y descent = Right ventricular failure, constrictive pericarditis, tricuspid
regurgitation
This patient has atrial fibrillation and is most likely to have absent a waves.
Next question 
As well as providing information on right atrial pressure, the jugular vein waveform
may provide clues to underlying valvular disease. A non-pulsatile JVP is seen in
superior vena caval obstruction. Kussmaul's sign describes a paradoxical rise in
JVP during inspiration seen in constrictive pericarditis
'a' wave = atrial contraction

large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis,
pulmonary hypertension
absent if in atrial fibrillation
Cannon 'a' waves

caused by atrial contractions against a closed tricuspid valve
are seen in complete heart block, ventricular tachycardia/ectopics, nodal
rhythm, single chamber ventricular pacing
'c' wave
closure of tricuspid valve
not normally visible
'v' wave
due to passive filling of blood into the atrium against a closed tricuspid
valve
giant v waves in tricuspid regurgitation
'x' descent = fall in atrial pressure during ventricular systole
'y' descent = opening of tricuspid valve
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Question stats
A 11.5%
B 9.8%
C 17%
D 7.4%
E 54.4%
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Question 59 of 192
 
Which of the following is not secreted by the parietal cells?
Hydrochloric acid
Mucus
Magnesium
Intrinsic factor
Calcium
Chief of Pepsi cola = Chief cells secrete PEPSInogen
Parietal cells: secrete HCl, Ca, Na, Mg and intrinsic factor

Chief cells: secrete pepsinogen
Surface mucosal cells: secrete mucus and bicarbonate
Next question 
Gastric secretions

Gastric acid

acid)


30% acid produced
from G cells

60% acid produced

10% acid produced
reflexes.


Gastrin release

Cholecystokinin
Secretin
acid)

antral pH,
somatostatin




secretion

glucagon secretion
mucous production
Next question 
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Question stats
A 11.1%
B 45.8%
C 14.5%
D 11%
E 17.6%
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Question 60 of 192
 
Which of the following is not an effect of somatostatin?
It stimulates pancreatic acinar cells to release lipase
It decreases gastric acid secretion
It decreases gastrin release

It decreases pepsin secretion
It decreases glucagon release
It inhibits pancreatic enzyme secretion.
Next question 
Gastric secretions

Gastric acid

acid)


30% acid produced
from G cells

60% acid produced
10% acid produced
reflexes.

Gastrin release

Cholecystokinin
Secretin
acid)


antral pH,
somatostatin




secretion

glucagon secretion
mucous production
Next question 

          
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Question stats
A 57.2%
B 9.3%
C 8.2%
D 9.4%
E 15.9%
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Question 61 of 192
 
Which of the following is not a feature of normal cerebrospinal fluid?
It has a pressure of between 10 and 15 mmHg.
It usually contains a small amount of glucose.
It may normally contain up to 5 red blood cells per mm3.

It may normally contain up to 3 white blood cells per mm3.
None of the above
It should not contain red blood cells.
Next question 
Cerebrospinal fluid
Circulation
2. 3rd ventricle
sagittal sinus
Composition
Glucose: 50-80mg/dl
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Question stats
A 7.5%
B 12.5%
C 57.5%
D 13.8%
E 8.7%
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Question 62 of 192
 
Which of the following is responsible for the rapid depolarisation phase of the
myocardial action potential?
Rapid sodium influx
Rapid sodium efflux

Slow efflux of calcium
Efflux of potassium
Rapid calcium influx
Next question 
Electrical activity of the heart
Myocardial action potential
Phase Description Mechanism
0 Rapid Rapid sodium influx

depolarisation These channels automatically deactivate after
a few ms
1 Early repolarisation Efflux of potassium
2 Plateau Slow influx of calcium
3 Final repolarisation Efflux of potassium

Phase Description Mechanism
4 Restoration of ionic Resting potential is restored by Na+/K+ ATPase

concentrations There is slow entry of Na+ into the cell
decreasing the potential difference until the
threshold potential is reached, triggering a new
action potential
NB cardiac muscle remains contracted 10-15 times longer than skeletal muscle
Conduction velocity
Atrial Spreads along ordinary atrial myocardial fibres at 1 m/sec

conduction
AV node 0.05 m/sec

conduction
Ventricular Purkinje fibres are of large diameter and achieve velocities of

conduction 2-4 m/sec (this allows a rapid and coordinated contraction of
the ventricles
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Question stats
A 51.8%
B 13.6%
C 6%
D 11.2%
E 17.5%


Question 63 of 192
 
Which one of the following cells secretes the majority of tumour necrosis factor in
humans?
Neutrophils
Macrophages
Natural killer cells
Killer-T cells
Helper-T cells
Next question 
Tumour necrosis factor
Tumour necrosis factor (TNF) is a pro-inflammatory cytokine with multiple roles in

the immune system
TNF is secreted mainly by macrophages and has a number of effects on the

immune system, acting mainly in a paracrine fashion:
activates macrophages and neutrophils
acts as costimulator for T cell activation
key mediator of bodies response to Gram negative septicaemia
similar properties to IL-1
anti-tumour effect (e.g. phospholipase activation)
TNF-alpha binds to both the p55 and p75 receptor. These receptors can induce
apoptosis. It also cause activation of NFkB
Endothelial effects include increase expression of selectins and increased
production of platelet activating factor, IL-1 and prostaglandins
TNF promotes the proliferation of fibroblasts and their production of protease and
collagenase. It is thought fragments of receptors act as binding points in serum
Systemic effects include pyrexia, increased acute phase proteins and disordered
metabolism leading to cachexia
TNF is important in the pathogenesis of rheumatoid arthritis - TNF blockers (e.g.

infliximab, etanercept) are now licensed for treatment of severe rheumatoid
Next question 
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Question stats
A 12.7%
B 41.2%
C 23.4%
D 13.8%
E 8.9%
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Question 64 of 192
 
Where are the arterial baroreceptors located?
Carotid sinus and aortic arch
Carotid sinus only
Superior vena cava

External carotid artery
None of the above
They lie in the carotid sinus and aortic arch.
Next question 
Cardiac physiology
pressure systems.

Cardiac cycle
cycle)





systolic function.
Starlings law

compliance.

angiotensin II.
Next question 
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Question stats
A 74%
B 10.6%
C 5.1%
D 5%
E 5.3%

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Question 65 of 192
 
A 47 year old lady is diagnosed as suffering from a phaeochromocytoma. From

which of the following amino acids are catecholamines primarily derived?
Aspartime
Glutamine
Arginine
Tyrosine
Alanine
Catecholamine hormones are derived from tyrosine, it is modified by a DOPA

decarboxylase enzyme to become dopamine and thereafter via two further
enzymic modifications to noradrenaline and finally adrenaline.
Next question 
Adrenal physiology
Adrenal medulla
Adrenal cortex
Next question 
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Question stats
A 6.8%
B 14.7%
C 14.8%
D 51.7%
E 12%
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
Question 66 of 192
 
Adult lung volumes. Which statement is false?
In restrictive lung disease the FEV1/FVC ratio is increased
Residual volume is increased in emphysema
Functional residual capacity is measured by helium dilution test

The tidal volume is approximately 340mls in females
The vital capacity is increased in Guillain Barre syndrome
FEV1/FVC is normal or >80% in restrictive lung disease such as pulmonary

fibrosis. The ratio is reduced in obstructive airways disease.
The functional residual capacity, residual volume and the total lung capacity
cannot be measured with spirometry. They can only be measured by helium
dilution.
The vital capacity is reduced in:
1. Pulmonary fibrosis/infiltration/oedema/effusions
2. Weak respiratory muscles e.g. MG, GBS, myopathies
3. Skeletal abnormalities e.g. chest wall abnormalities
Next question 
Lung volumes

volumes)
Definitions
females.




in females.

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Question stats
A 15.2%
B 8%
C 18.6%
D 9.7%
E 48.5%
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Question 67 of 192
 
What is the most significant event to contribute to wound healing immediately

following injury?
Neutrophil activation
Platelet degranulation
Endothelial cell proliferation
Migration of tissue macrophages
Proliferation of wound bed fibroblasts
Many of these events contribute to healing. However, platelet degranulation is the

earliest phase and results in haemostasis, the main event in then allowing the
release of cytokines to attract other cells types to the wound and co-ordinate
healing.
Next question 

Platelet plug
formation and
rich clot
impaired in diabetes). macrophages
Growth factors
released, including
basic fibroblast
growth factor and
growth factor.
within the adjacent
matrix and migrate
into wound.
Macrophages and
fibroblasts couple
matrix regeneration

factors stimulate
fibroblasts and
epithelial cells.
collagen network.
Angiogenesis occurs
and wound resembles
granulation tissue.

may last up to one
year (or longer).
During this phase
fibroblasts become
differentiated
contraction.
Collagen fibres are
remodelled.
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Question stats
A 24.7%
B 39.9%
C 15%
D 10.5%
E 9.8%
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Question 68 of 192
 
Which receptor does noradrenaline mainly bind to?
α 1 receptors
α 2 receptors
β 1 receptors
β 2 receptors
G receptors
Noradrenaline is the precursor of adrenaline. It is a powerful α 1 stimulant

(although it will increase myocardial contractility). Infusions will produce
vasoconstriction and an increase in total peripheral resistance. It is the inotrope of
choice in septic shock.
Next question 
Inotropes and cardiovascular receptors
Inotropes are a class of drugs which work primarily by increasing cardiac output.
They should be distinguished from vasoconstrictor drugs which are used
specifically when the primary problem is peripheral vasodilatation.
Catecholamine type agents are commonly used and work by increasing cAMP
levels by adenylate cyclase stimulation. This in turn intracellular calcium ion
mobilisation and thus the force of contraction. Adrenaline works as a beta
adrenergic receptor agonist at lower doses and an alpha receptor agonist at higher
doses. Dopamine causes dopamine receptor mediated renal and mesenteric
vascular dilatation and beta 1 receptor agonism at higher doses. This results in
increased cardiac output. Since both heart rate and blood pressure are raised,
there is less overall myocardial ischaemia. Dobutamine is a predominantly beta 1
receptor agonist with weak beta 2 and alpha receptor agonist properties.
Noradrenaline is a catecholamine type agent and predominantly acts as an alpha
receptor agonist and serves as a peripheral vasoconstrictor.
Phosphodiesterase inhibitors such as milrinone act specifically on the cardiac

phosphodiesterase and increase cardiac output.
Inotrope Cardiovascular receptor action
Adrenaline α-1, α-2, β-1, β-2
Noradrenaline α-1,( α-2), (β-1), (β-2)
Dobutamine β-1, (β 2)
Dopamine (α-1), (α-2), (β-1), D-1,D-2
Minor receptor effects in brackets
Effects of receptor binding
α-1, α-2 vasoconstriction
β-1 increased cardiac contractility and HR
β-2 vasodilatation
D-1 renal and spleen vasodilatation
D-2 inhibits release of noradrenaline
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A 49.1%

Question 69 of 192
 
Where does spironolactone act in the kidney?
Glomerulus
Proximal convoluted tubule
Descending limb of the loop of Henle

Ascending limb of the loop of Henle
Distal convoluted tubule
Next question 
Potassium sparing diuretics
Potassium-sparing diuretics may be divided into the epithelial sodium channel

blockers (amiloride and triamterene) and aldosterone antagonists (spironolactone
and eplerenone).
{Amiloride} is a weak diuretic which blocks the epithelial sodium channel in the
distal convoluted tubule.
Usually given with thiazides or loop diuretics as an alternative to potassium

supplementation.
{Spironolactone} is an aldosterone antagonist which acts act in the distal

convoluted tubule.
Indications
ascites: patients with cirrhosis develop a secondary hyperaldosteronism.
Relatively large doses such as 100 or 200mg are often used
heart failure
nephrotic syndrome
Conn's syndrome
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Question stats
A 5.9%
B 13%
C 9.2%
D 12.4%
E 59.5%
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Question 70 of 192
 
A man is admitted after a period of prolonged self, induced starvation. Naso

gastric feeding is planned. Which of the following is least likely to occur?
Hypokalaemia
Increased risk of cardiac arrhythmias

His haemoglobin will have decreased affinity for oxygen
Hypophosphataemia
Hypoalbuminaemia
The process of starvation may lower DPG levels, in practice this is unlikely to occur
early as it is generated during glycolysis. Altered metabolism in starvation may be
more acidotic and this would also tend to impair oxygen carriage.
Next question 
Nutrition - Refeeding syndrome
Refeeding syndrome describes the metabolic abnormalities which occur on

feeding a person following a period of starvation. The metabolic consequences
include:
Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
Abnormal fluid balance
These abnormalities can lead to organ failure.
Re-feeding problems
If patient not eaten for > 5 days, aim to re-feed at < 50% energy and protein levels
High risk for re-feeding problems
If one or more of the following:
BMI < 16 kg/m2
Unintentional weight loss >15% over 3-6 months
Little nutritional intake > 10 days
Hypokalaemia, Hypophosphataemia or hypomagnesaemia prior to feeding
(unless high)
If two or more of the following:

BMI < 18.5 kg/m2
Unintentional weight loss > 10% over 3-6 months
History of: alcohol abuse, drug therapy including insulin, chemotherapy,
diuretics and antacids
Prescription
Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days
Start immediately before and during feeding: oral thiamine 200-300mg/day,
vitamin B co strong 1 tds and supplements
Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium
(0.2-0.4 mmol/kg/day)
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Question stats
A 11.4%
B 9.4%
C 58.2%
D 9.2%
E 11.8%

Question 71 of 192
 
Which of the following statements are not typically true in hypokalaemia?
It may occur as a result of mechanical bowel preparation
Chronic vomiting may increase renal potassium losses
It may be associated with aciduria

It may cause hyponatraemia
It often accompanies acidosis
Potassium depletion occurs either through the gastrointestinal tract or the kidney.
Chronic vomiting in itself is less prone to induce potassium loss than diarrhoea as
gastric secretions contain less potassium than those in the lower GI tract. If
vomiting produces a metabolic alkalosis then renal potassium wasting may occur
as potassium is excreted in preference to hydrogen ions. The converse may occur
in potassium depletion resulting in acid urine.
Hypokalemia is very commonly associated with metabolic alkalosis. This is due to

2 factors: 1) the common causes of metabolic alkalosis (vomiting, diuretics)
directly induce H+ and K loss (via aldosterone) and thus also cause hypokalemia
and 2) hypokalemia is a very important cause of metabolic alkalosis by three
mechanisms. The initial effect is by causing a transcellular shift in which K leaves
and H+ enters the cells, thereby raising the extracellular pH. The second effect is
by causing a transcellular shift in the cells of the proximal tubules resulting in an
intracellular acidosis, which promotes ammonium production and excretion.
Thirdly, in the presence of hypokalemia, hydrogen secretion in the proximal and
distal tubules increases. This leads to further reabsorption of HCO3-. The net
effect is an increase in the net acid excretion.
Next question 
Hypokalaemia
Potassium and hydrogen can be thought of as competitors. Hyperkalaemia tends

to be associated with acidosis because as potassium levels rise fewer hydrogen
ions can enter the cells
Hypokalaemia with alkalosis

Vomiting
Diuretics
Cushing's syndrome
Conn's syndrome (primary hyperaldosteronism)
Hypokalaemia with acidosis

Diarrhoea

Acetazolamide
Partially treated diabetic ketoacidosis
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Question stats
A 7%
B 16.2%
C 12.9%
D 22.5%
E 41.4%
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Question 72 of 192
 
A 16 year old girl develops pyelonephritis and is admitted in a state of septic

shock. Which of the following is not typically seen in this condition?
Increased cardiac output
Increased systemic vascular resistance

Oliguria may occur
Systemic cytokine release
Tachycardia
Cardiogenic Shock:
e.g. MI, valve abnormality
increased SVR (vasoconstriction in response to low BP)

increased HR (sympathetic response)
decreased cardiac output
decreased blood pressure
Hypovolaemic shock:
blood volume depletion
e.g. haemorrhage, vomiting, diarrhoea, dehydration, third-space losses during
major operations
increased SVR
increased HR
Septic shock:
occurs when the peripheral vascular dilatation causes a fall in SVR
similar response may occur in anaphylactic shock, neurogenic shock
reduced SVR
increased HR
normal/increased cardiac output
The SVR is reduced in sepsis and for this reason a vasopressor such as
noradrenaline may be used if hypotension and oliguria remain a concern despite
administration of adequate amounts of intravenous fluids.
Next question 
Shock

Septic
Haemorrhagic
Neurogenic
Cardiogenic
Anaphylactic
Septic shock


attention:
Haemorrhagic shock
Blood loss % <15% 15-30% 30-40% >40%
Pulse rate <100 >100 >120 >140


Spinal cord injury
Cardiac tamponade


Neurogenic shock
vasodilation.
Cardiogenic shock

following MI.
Anaphylactic shock

in 1,000)

years in 1,000)

1,000)

12 years 1,000)

drugs
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Question stats
A 15.8%
B 66.8%
C 5.7%
D 6.2%
E 5.5%
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Question 73 of 192
 
A 45 year old man is undergoing a small bowel resection. The anaesthetist decides
to administer an intravenous fluid which is electrolyte rich. Which of the following
most closely matches this requirement?
Dextrose / Saline
Pentastarch
Gelofusine
Hartmans
5% Dextrose with added potassium 20mmol/ L
Hartmans solution is the most electrolyte rich. However, both pentastarch and
gelofusine have more macromolecules.
Next question 
Intra operative fluid management

Composition of commonly used intravenous fluids mmol-1
Na K Cl Bicarbonate Lactate
Plasma 137-147 4-5.5 95-105 22-25 -
0.9% Saline 153 - 153 - -
Dextrose / saline 30.6 - 30.6 - -
Hartmans 130 4 110 - 28
Recommendations for intra operative fluid management

The latest set of NICE guidelines produced in 2013 relating to intravenous fluids
did not specifically address the requirements of intra operative fluid
administration. The reason for this is that administration of fluids in this specific
situation does not lend itself to rigid algorithms.
With the introduction of enhanced recovery programmes 10 years ago there was
an increasing emphasis of the concept of fluid restriction. Historically, patients
received very large volumes of saline rich solutions peri-operatively. Clearing the
sodium load of a single litre of saline may take up to 36 hours or more. This can
have deleterious effects on the tissues including the development of oedema. This
results in poor perfusion, increased risk of ileus and wound breakdown. A tailored
approach to fluid administration is now practiced and far greater usage is made of
cardiac output monitors in providing goal directed fluid therapy.
References
British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical
Patients
GIFTASUP (2009) Revised May 2011.
Frost P. Intravenous fluid therapy in adult inpatients. BMJ 2015 (350): 31-34.
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Question stats
A 7.5%
B 5.5%
C 5.9%
D 72.3%
E 8.8%

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Question 74 of 192
 
A 17 year old lady with long standing anorexia nervosa is due to undergo excision
of a lipoma. Which of the following nutritional deficiencies is most likely to be
implicated in poor collagen formation as the wound heals?
Deficiency of copper
Deficiency of iron
Deficiency of ascorbic acid
Deficiency of phosphate
None of the above
Vitamin C is involved in the cross linkage of collagen and impaired wound healing
is well described in cases of vitamin C deficiency.
Next question 
Collagen
Collagen is one of the most important structural proteins within the extracellular
matrix, collagen together with components such as elastin and
glycosaminoglycans determine the properties of all tissues.
Composed of 3 polypeptide strands that are woven into a helix, usually a
combination of glycine with either proline or hydroxyproline plus another
amino acid
Numerous hydrogen bonds exist within molecule to provide additional
strength
Many sub types but commonest sub type is I (90% of bodily collagen),
tissues with increased levels of flexibility have increased levels of type III
collagen
Vitamin c is important in establishing cross links
Synthesised by fibroblasts
Collagen Diseases
Disorders of collagen range from relatively common, acquired defects (typically
aging), through to rarer congenital disorders. The latter are exemplified by
conditions such as osteogenesis imperfecta and Ehlers Danlos syndromes.
Osteogenesis imperfecta:
-8 Subtypes
-Defect of type I collagen
-In type I the collagen is normal quality but insufficient quantity
-Type II- poor quantity and quality
-Type III- Collagen poorly formed, normal quantity
-Type IV- Sufficient quantity but poor quality
Patients have bones which fracture easily, loose joint and multiple other defects
depending upon which sub type they suffer from.
Ehlers Danlos:
-Multiple sub types
-Abnormality of types 1 and 3 collagen
-Patients have features of hypermobility.
-Individuals are prone to joint dislocations and pelvic organ prolapse. In addition to
many other diseases related to connective tissue defects.
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Question stats
A 7.6%
B 7.5%
C 69.7%
D 7.8%
E 7.5%

Question 75 of 192
 
A 69 year old man has been living in sheltered accommodation for many months,
with inadequate nutrition notices that his night vision is becoming impaired.
Deficiency of which vitamin is responsible?
Vitamin B3
Vitamin A
Vitamin C
Vitamin B12
Vitamin E
Loss of vitamin A will result in impair rhodopsin synthesis and results in poor night
vision.
Next question 
Vitamin deficiency
Vitamin Effect of deficiency
A Night blindness
Epithelial atrophy
Infections
B1 Beriberi
B2 Dermatitis and photosensitivity
B3 Pellagra
B12 Pernicious anaemia
C Poor wound healing

Impaired collagen synthesis
D Rickets (Children)
Osteomalacia (Adults)
K Clotting disorders
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Question stats
A 5.9%
B 77.1%
C 6%
D 4.5%
E 6.6%
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Question 76 of 192
 
Which of the following statements relating the fluid physiology of a physiologically

normal 70 Kg adult male is false?
He will have more water per unit of body weight than a female of similar
weight
Plasma will comprise 25% of his body weight

Interstitial fluid will account for up to 24% of body water
Approximately 65% of total body water is intracellular
60% of his body weight is composed of water
The 60-40-20 rule:

60% total body weight is water
40% of total body weight is intracellular fluids
20% of body weight is extracellular fluids
Plasma typically accounts for 4-6% of body weight in healthy individuals.

Males typically have more water per unit weight than females, as females have a
higher fat content.
Next question 
Fluid compartment physiology
Body fluid compartments comprise intracellular and extracellular compartments.

The latter includes interstitial fluid, plasma and transcellular fluid.
Typical figures are based on the 70 Kg male.
Body fluid volumes
Intracellular 28 L 60-65%
Extracellular 14 L 35-40%
Plasma 3L 5%
Interstitial 10 L 24%
Transcellular 1L 3%
Figures are approximate

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Question stats
A 17.3%
B 49.4%
C 12.4%
D 11.1%
E 9.9%
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Question 77 of 192
 
Which of the following statements relating to blood transfusions in surgical

patients is false?
Packed red cells typically have a haematocrit of between 55 and 75%
Clotting factor activity in whole blood decreases in samples stored for

longer than 7 days
After 3 weeks of storage blood has a pH of 6.9
Gamma irradiated blood products are not required routinely
Patients should be transfused to achieve a target haemoglobin of 10 g/dl

and a haematocrit of 30%
Patients can generally be managed without transfusion as long as the Hb is 7 or

greater. The exact level depends upon patient factors such as co-morbidities. Old
blood functions less effectively and should not be used during massive
transfusions.
Next question 
Blood products
Whole blood fractions
Fraction Key points
Packed red cells Used for transfusion in chronic anaemia and cases where
infusion of large volumes of fluid may result in
cardiovascular compromise. Product obtained by
centrifugation of whole blood.
Platelet rich Usually administered to patients who are
plasma thrombocytopaenic and are bleeding or require surgery. It is
obtained by low speed centrifugation.
Platelet Prepared by high speed centrifugation and administered to

concentrate patients with thrombocytopaenia.
Fresh frozen Prepared from single units of blood.

plasma Contains clotting factors, albumin and
immunoglobulin.
Unit is usually 200 to 250ml.
Usually used in correcting clotting deficiencies in
patients with hepatic synthetic failure who are due to
undergo surgery.
Usual dose is 12-15ml/Kg-1.

It should not be used as first line therapy for
hypovolaemia.
Cryoprecipitate Formed from supernatant of FFP.

Rich source of Factor VIII and fibrinogen.
Allows large concentration of factor VIII to be
administered in small volume.
SAG-Mannitol Removal of all plasma from a blood unit and substitution

Blood with:
Sodium chloride
Adenine
Anhydrous glucose
Mannitol
Up to 4 units of SAG M Blood may be administered.

Thereafter whole blood is preferred. After 8 units, clotting
factors and platelets should be considered.
Cell saver devices

These collect patients own blood lost during surgery and then re-infuse it. There
are two main types:
Those which wash the blood cells prior to re-infusion. These are more
expensive to purchase and more complicated to operate. However, they
reduce the risk of re-infusing contaminated blood back into the patient.
Those which do not wash the blood prior to re-infusion.
Their main advantage is that they avoid the use of infusion of blood from donors
into patients and this may reduce risk of blood borne infection. It may be
acceptable to Jehovah's witnesses. It is contraindicated in malignant disease for
risk of facilitating disease dissemination.
Blood products used in warfarin reversal
In some surgical patients the use of warfarin can pose specific problems and may
require the use of specialised blood products
Immediate or urgent surgery in patients taking warfarin(1) (2):
1. Stop warfarin
2. Vitamin K (reversal within 4-24 hours)

-IV takes 4-6h to work (at least 5mg)
-Oral can take 24 hours to be clinically effective
3. Fresh frozen plasma

Used less commonly now as 1st line warfarin reversal
-30ml/kg-1
-Need to give at least 1L fluid in 70kg person (therefore not appropriate in fluid
overload)
-Need blood group
-Only use if human prothrombin complex is not available
4. Human Prothrombin Complex (reversal within 1 hour)

-Bereplex 50 u/kg
-Rapid action but factor 6 short half life, therefore give with vitamin K
References
1. Dentali, F., C. Marchesi, et al. (2011). 'Safety of prothrombin complex
concentrates for rapid anticoagulation reversal of vitamin K antagonists. A meta-
analysis.' Thromb Haemost 106(3): 429-438.
2. http://www.transfusionguidelines.org/docs/pdfs/bbt-03warfarin-reversal-
flowchart-2006.pdf
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Question stats
A 11.3%
B 11.7%
C 17%
D 13.4%
E 46.6%
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Question 79 of 192
 
The acute phase response to injury does not typically include:
Pyrexia
Decreased albumin
Hepatic sequestration of cations

Increased transferrin
Increased serum amyloid A
The acute phase response includes:
Acute phase proteins

Reduction of transport proteins (albumin, transferrin)
Hepatic sequestration cations
Pyrexia
Neutrophil leucocytosis
Increased muscle proteolysis
Changes in vascular permeability
Next question 

response.

hormone

hormone
(ACTH)
Aldosterone
Prolactin
Glucagon

Pituitary gland
control
Cortisol
corticosteroids.

Growth hormone
Alpha Endorphin
Increased
I
Insulin
deficiency

normal responses
surgery
Protein metabolism

Lipid metabolism

Cytokines
Glycoproteins

References
/mkh040
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Question stats
A 8.2%
B 25%
C 13.8%
D 34.8%
E 18.2%
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Question 80 of 192
 
Which of the following mechanisms best accounts for the release of adrenaline?
Release from the adrenal medulla in response to increased angiotensin 1

levels
Release from the zona fasiculata from the adrenal gland in response to
increased sympathetic discharge
Release from the adrenal medulla in response to increased noradrenaline

levels
Release from the adrenal medulla in response to sympathetic stimulation

from the splanchnic nerves
None of the above
The adrenal gland releases adrenaline in response to increased sympathetic

discharge from preganglionic sympathetic fibres of the splanchnic nerves. These
cause the chromafin cells of the medulla to release adrenaline (which is
preformed) by exocytosis.
Next question 
Adrenaline
Fight or Flight response
- Catecholamine (phenylalanine and tyrosine)

- Neurotransmitter and hormone
- Released by the adrenal glands
- Effects on α 1 and 2, β 1 and 2 receptors
- Effect on β 2 receptors in skeletal muscle vessels-causing vasodilation
- Increase cardiac output and total peripheral resistance
- Vasoconstriction in the skin and kidneys causing a narrow pulse pressure
Actions
α adrenergic receptors:
Inhibits insulin secretion by the pancreas
Stimulates glycogenolysis in the liver and muscle
Stimulates glycolysis in muscle
β adrenergic receptors:
Stimulates glucagon secretion in the pancreas
Stimulates ACTH
Stimulates lipolysis by adipose tissue
Next question 
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Question stats
A 7.5%
B 11.8%
C 10%
D 63%
E 7.7%
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Question 81 of 192
 
A 43 year old lady is admitted with cholestasis secondary to a stone impacted at

the level of the ampulla of vater. Which of the following tests is most likely to be
predictive of bleeding diathesis at the time of ERCP in this particular case?
Bleeding time
Prothrombin time
APTT
Platelet count
Factor I levels
PT: Vitamin K dependent factors 2, 7, 9, 10

APTT: Factors 8, 9, 11, 12
Jaundice will impair the production of vitamin K dependent clotting factors. This is
most accurately tested by measuring the prothrombin time. APTT can be affected
by vitamin K deficiency (due to factor 9 deficiency), however this occurs to a lesser
extent and is normally associated with severe liver disease. The bleeding time is a
measure of platelet function.
Next question 


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Question stats
A 13.3%
B 50.5%
C 23.1%
D 8.3%
E 4.9%
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
Question 82 of 192
 
Which of the following hormonal agents will increase secretions of water and
electrolytes in pancreatic juice?
Secretin
Aldosterone
Somatostatin
Cholecystokinin
Adrenaline
Secretin causes secretion of water and electrolytes

Cholecystokinin causes enzyme secretion
While secretin will typically increase electrolyte and water volume of secretions,
the enzyme content is increased by cholecystokinin. Somatostatin will decrease
the volume of secretions. Aldosterone will tend to conserve electrolytes.
Next question 

Trypsinogen
Procarboxylase
Amylase
Elastase
Sodium
Bicarbonate
Water
Ductal and
Aqueous Potassium
Centroacinar cells
Chloride
Regulation
Enzyme activation
Next question 
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Question stats
A 49.7%
B 9.5%
C 10.2%
D 24.9%
E 5.8%
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Question 83 of 192
 
A 73 year old lady is diagnosed with hyperaldosteronism. From which of the

following structures is aldosterone released?
Zona fasciculata of the adrenal gland
Juxtaglomerular apparatus of the kidney

Zona reticularis of the adrenal gland
Adrenal medulla
Zona glomerulosa of the adrenal cortex
Aldosterone serves to conserve sodium and water. It is produced in the zona

glomerulosa of the adrenal cortex.
Next question 
Aldosterone
Aldosterone is secreted by the zona glomerulosa of the adrenal cortex. It is a

mineralocorticoid hormone. Secretion is regulated by the renin- angiotensin
system, and by plasma levels of sodium and potassium. Aldosterone conserves
sodium by stimulating the reabsorption of sodium in the distal nephron in
exchange for potassium. Lack of aldosterone release will result in hyperkalaemia
and hyponatraemia.
Next question 
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Question stats
A 12.3%
B 6.9%
C 9.1%
D 6.2%
E 65.5%
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Question 84 of 192
 
Which of the following inhibits gastric acid secretion?
Histamine
Nausea
Calcium
Parasympathetic vagal stimulation
Gastrin
Nausea inhibits gastric secretion via higher cerebral activity and sympathetic
innervation.
Next question 
Gastric secretions

Gastric acid

acid)


30% acid produced
from G cells

60% acid produced
10% acid produced
reflexes.

Gastrin release

Cholecystokinin
Secretin
acid)


antral pH,
somatostatin




secretion

glucagon secretion
mucous production
Next question 

          
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Question stats
A 10.3%
B 42.2%
C 21.4%
D 14.4%
E 11.8%
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Question 85 of 192
 
A 22 year old man is undergoing a daycase excision of a sebaceous cyst. He is

needle phobic and as the surgeon approaches with the needle the patient begins
to hyperventilate. He soon develops circumoral parasthesia and muscular
twitching. Which of the following is the most likely explanation for this event?
Temporal lobe epilepsy

Reduction in ionised calcium levels
Increase in ionised calcium levels
Fall in serum PTH levels
Rise in serum PTH levels
50% of plasma calcium is ionised. Hyperventilation will induce a state of alkalosis

which will lower ionised plasma calcium levels.
Next question 
Calcium homeostasis
Hormone Actions
Hormone Actions

resorption
of calcium

absorption of Ca2+
reabsorption

levels
reabsorption

calcium
Next question 

          
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Question stats
A 7.7%
B 59%
C 20.9%
D 6.6%
E 5.8%
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Question 86 of 192
 
Which of the following statements relating to gastric acid secretions are untrue?
In parietal cells carbonic anhydrase generates hydrogen ions which are

then actively secreted
The cephalic phase is abolished following truncal vagotomy

The intestinal phase accounts for 60% of gastric acid produced
Histamine acts in a paracrine manner on H2 receptors
H2 receptor antagonists will not completely abolish gastric acid

production
The intestinal phase of gastric acid secretion accounts for only 10% of gastric acid
produced.
Next question 
Gastric secretions

Gastric acid

acid)


30% acid produced
from G cells

60% acid produced

10% acid produced
reflexes.

Gastrin release


Cholecystokinin
Secretin
acid)


antral pH,
somatostatin




secretion

glucagon secretion
mucous production
Next question 

          
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Question stats
A 10.7%
B 17%
C 50.7%
D 10.4%
E 11.2%
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Question 87 of 192
 
Which of the following stimulates gastric acid secretion?
Cholecystokinin
Gastric inhibitory peptide
Secretin
Histamine
Somatostatin
Gastrin: From G cells: stimulates gastric acid production
Pepsin: Digestion of protein, secretion occurs simultaneously with gastrin
Secretin: From mucosal cells in the duodenum and jejunum: inhibits gastric acid,
stimulates bile and pancreatic juice production
Gastric inhibitory peptide: (produced in response to fatty acids) inhibits gastrin

release and acid secretion from parietal cells
Cholecystokinin: From mucosal cells in the duodenum and jejunum (produced in

response to fatty acids) inhibits acid secretion from parietal cells, causes
gallbladder contraction and relaxation of sphincter of Oddi
Somatostatin: From D cells
Next question 
Hormonal control of gastric acid secretion


the extrinsic nerves Next
gastric motility, question
trophic 
effect
antral pH,
somatostatin
   upper
  digested
   enzyme-rich
 fluid from
 
Save my notes gastric emptying, trophic

Question stats cells, induces satiety

A upper 11.5%
fatty acids bicarbonate-rich fluid from
B small 5.4% pancreas and hepatic duct
C 19.2%
D 58.7% pancreatic acinar cells
E 5.3%
secretion
Somatostatin D cells in Search

Fat, eMRCS
bile salts Decreases acid and pepsin
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glucagon secretion
 Open MRCS Part A textbook (../review/textbook.php) inhibits trophic effects of
mucous production
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Question 88 of 192
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A 34 year old lady develops septic shock and features of the systemic
inflammatory response syndrome as a complication of cholangitis. Which of the
following is not a typical feature of this condition?
Body temperature less than 36oC or greater than 38oC
Respiratory rate >20

Lactate <4 mmol/L
High levels of tumour necrosis factor α
WCC >12,000 mm3
Septic shock will typically result in end organ hypoperfusion and as a result lactate
levels will often be high. In the surviving sepsis campaign it is suggested that
elevated lactate levels are an independent indicator for vasopressor support in
patient with sepsis. The WCC may be paradoxically low in severe sepsis, although
it is most often elevated.
Next question 
Shock

Septic
Haemorrhagic
Neurogenic
Cardiogenic
Anaphylactic
Septic shock

attention:
Haemorrhagic shock
Blood loss % <15% 15-30% 30-40% >40%
Pulse rate <100 >100 >120 >140


Spinal cord injury
Cardiac tamponade


Neurogenic shock
vasodilation.
Cardiogenic shock
following MI.
Anaphylactic shock

in 1,000)

years in 1,000)

1,000)

12 years 1,000)
drugs
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Question stats
A 6.6%
B 5.5%
C 56.4%
D 26.1%
E 5.4%
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Question 89 of 192
 
Release of somatostatin from the pancreas will result in which of the following?
Decrease in pancreatic exocrine secretions
Contraction of the gallbladder
Increase in the rate of gastric emptying

Increased synthesis of growth hormone
Increased insulin release
Octreotide reduces exocrine pancreatic secretions so is used to treat high output

pancreatic fistulae (though parenteral feeding is most effective). Other uses
include variceal bleeding and treatment of acromegaly.
Inhibits growth hormone and insulin release (when released from pancreas).
Somatostatin is also released by the hypothalamus causing a negative feedback
response on growth hormone.
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Somatostatin
Somatostatin is produced in the D cells of the pancreatic islets. It is also produced

in the gut (enterochromaffin cells) and is found in brain tissue. Those substances
that stimulate insulin release will also induce somatostatin secretion. It is an
inhibitor of growth hormone, it also delays gastric emptying and reduces gastrin
secretion.
It reduces pancreatic exocrine secretions and may be used therapeutically to treat
pancreatic fistulae.
Somatostatinomas are rare pancreatic endocrine tumours and will result in the
clinical manifestations of diabetes mellitus, gallstones and steatorrhoea.
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Question stats
A 49.1%
B 14.6%
C 17.6%
D 8.9%
E 9.8%
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Question 90 of 192
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Which of the following is least likely to be associated with hypercalcaemia?
Thiazides
Antacids
Coeliac disease
Sarcoidosis
Zolinger-Ellison syndrome
Mnemonic for the causes of hypercalcaemia:
CHIMPANZEES
C alcium supplementation
H yperparathyroidism
I atrogentic (Drugs: Thiazides)
M ilk Alkali syndrome
P aget disease of the bone
A cromegaly and Addison's Disease
N eoplasia
Z olinger-Ellison Syndrome (MEN Type I)
E xcessive Vitamin D
E xcessive Vitamin A
S arcoidosis
Patients with coeliac disease tend to develop hypocalcaemia due to malabsorption

of calcium by the bowel.
Next question 
Hypercalcaemia
Main causes
Malignancy (most common cause in hospital in-patients)
Primary hyperparathyroidism (commonest cause in non hospitalised
patients)
Less common
Sarcoidosis (extrarenal synthesis of calcitriol )
Thiazides, lithium
Immobilisation
Pagets disease
Vitamin A/D toxicity
Thyrotoxicosis
MEN
Milk alkali syndrome
Clinical features
Stones, bones, abdominal groans, and psychic moans
High serum calcium levels result in decreased neuronal excitability. Therefore
sluggish reflexes, muscle weakness and constipation may occur.
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Question stats
A 13.4%
B 18.3%
C 43.7%
D 8.1%
E 16.5%


Question 91 of 192
 
Which one of the following would cause a rise in the carbon monoxide transfer
factor (TLCO)?
Emphysema
Pulmonary embolism
Pulmonary haemorrhage
Pneumonia
Pulmonary fibrosis
Transfer factor
raised: asthma, haemorrhage, left-to-right shunts, polycythaemia
low: everything else
Where alveolar haemorrhage occurs the TLCO tends to increase due to the
enhanced uptake of carbon monoxide by intra-alveolar haemoglobin.
Next question 
Transfer factor
The transfer factor describes the rate at which a gas will diffuse from alveoli into
blood. Carbon monoxide is used to test the rate of diffusion. Results may be given
as the total gas transfer (TLCO) or that corrected for lung volume (transfer
coefficient, KCO)
Causes of a raised TLCO Causes of a lower TLCO
asthma pulmonary
pulmonary haemorrhage (Wegener's, fibrosis
Goodpasture's) pneumonia
left-to-right cardiac shunts pulmonary emboli
polycythaemia pulmonary
hyperkinetic states oedema
male gender, exercise emphysema
anaemia
low cardiac
output
KCO also tends to increase with age. Some conditions may cause an increased
KCO with a normal or reduced TLCO
pneumonectomy/lobectomy
scoliosis/kyphosis
neuromuscular weakness
ankylosis of costovertebral joints e.g. ankylosing spondylitis
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Question stats
A 29.3%
B 14.8%
C 33.9%
D 7.6%
E 14.4%


Question 92 of 192
 
Which of the following does not cause a normal anion gap acidosis?
Pancreatic fistula
Acetazolamide
Uraemia
Ureteric diversion
Normal Gap Acidosis: HARDUP
H - Hyperalimentation/hyperventilation
A - Acetazolamide
R - Renal tubular acidosis
D - Diarrhoea
U - Ureteral diversion
P - Pancreatic fistula/parenteral saline
Uraemia will typically cause a high anion gap acidosis. It is one of the unmeasured
anions.
Next question 
categorised
homeostasis)
Metabolic acidosis
Two mechanisms:

(Na+ + K+) - (Cl- + HCO3-).

Addison's disease
Raised anion gap

types:
Metabolic alkalosis

Causes
Diuretics
Hypokalaemia
Cushing's syndrome
Bartter's syndrome

convoluted tubule
Causes
COPD
/ pulmonary oedema
Causes
altitude
Pregnancy

lead to an acidosis
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Question stats
A 12.3%
B 17.1%
C 43.3%
D 10.8%
E 16.5%


Question 93 of 192
 
An arterial blood gas sample is taken and the following results obtained;
PaO2 8kPa
PaCO2 4kPa
pH 7.4
With which of the following are these values most consistent?

Compensated metabolic alkalosis
Pulmonary atelectasis
Alveolar hypoventilation
Residing at 4500M for 48 hours
LAD occlusion
The patient has low oxygen tension and low carbon dioxide. The pH is normal so
there is compensation for a long standing condition in which oxygenation is
reduced. There is neither alkalosis, nor hypoventilation as the carbon dioxide is
low. At very high altitude, the low oxygen tension can exceed the anaerobic
threshold and carbon dioxide levels increase.
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mmol)
mmol)
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Question stats
A 16%
B 18%
C 18.9%
D 41%
E 6.1%
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Question 94 of 192
 
Which of the following is not a characteristic of the proximal convoluted tubule in

the kidney?
Up to 95% of filtered amino acids will be reabsorbed at this site
It is a risk of damage in a patient with compartment syndrome due to a

tibial fracture
It is responsible for absorbing more than 50% of filtered water
Its secretory function is most effective at low systolic blood pressures

(typically less than 100mmHg)
Glucose is reabsorbed by a process of facilitated diffusion
The proximal convoluted tubule may undergo necrosis in situations such as

compartment syndrome. It is responsible for reabsorbing up to two thirds of
filtered water. Low systolic blood pressures (below the renal autoregulatory range)
are a risk factor for acute tubular necrosis. Within the autoregulatory range the
absolute value of systolic BP has little effect.
Next question 
Renal Physiology
Overview

cross.
inulin).

1. Inert

--------------------------------------------------------------------------

reabsorption.
Tubular function
membrane.
sodium.
Loop of Henle
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Question stats
A 10%
B 12.5%
C 18.4%
D 45.1%
E 14%
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Question 95 of 192
 
At which of the following sites is the most water absorbed?
Right colon
Left colon
Stomach
Jejunum
Duodenum
Water absorption in the gastrointestinal tract predominantly occurs in the small

bowel (jejunum and ileum). The colon is an important site of water absorption,
however, its overall contribution is relatively small. The importance of the colonic
component to water absorption may increase following extensive small bowel
resections.
Next question 
Water absorption
During a 24 hours period the average person will ingest up to 2000ml of liquid
orally. In addition a further 8000ml of fluid will enter the small bowel as
gastrointestinal secretions. Intestinal water absorption is a passive process and is
related to solute load. In the jejunum the active absorption of glucose and amino
acids will create a concentration gradient that water will flow across. In the ileum
most water is absorbed by a process of facilitated diffusion (with sodium).
Approximately 150ml of water enters the colon daily, most is absorbed, the colon
can adapt to, and increase this amount following resection.
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Question stats
A 24.5%
B 23%
C 5%
D 38.7%
E 8.8%
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Question 96 of 192
 
A 39 year old lady has recurrent attacks of biliary colic. What is the approximate
volume of bile to enter the duodenum per 24 hours?
500 mL
50 mL
100 mL
2000 mL
150 mL
Between 500 mL and 1.5 L of bile enters the small bowel daily. Most bile salts are
recycled by the enterohepatic circulation. When the gallbladder contracts the
lumenal pressure is approximately 25cm water, which is why biliary colic may be
so painful.
Next question 
Bile
Bile is produced at a rate of between 500ml and 1500mL per day. Bile is composed
of bile salts, bicarbonate, cholesterol, steroids and water. There are three main
factors regulating bile flow; hepatic secretion, gall bladder contraction and
sphincter of oddi resistance. Bile salts are absorbed in the terminal ileum (and
recycled to the liver). Over 90% of all bile salts are recycled in this way, such that
the total pool of bile salts is recycled up to six times a day.
Primary bile salts

Cholate and chenodeoxycholate.
Secondary bile salts

Formed by bacterial action on primary bile salts. These are deoxycholate and
lithocholate. Of these deoxycholate is reabsorbed, whilst lithocholate is insoluble
and excreted.
Pathophysiology of gallstones
Bile salts have a detergent action. They aggregate to form micelles and these have
a lipid centre in which fats may be transported. Excessive quantities of cholesterol
cannot be transported in this way and will tend to precipitate, resulting in the
formation of cholesterol rich gallstones.
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Question stats
A 53.1%
B 7.8%
C 7.3%
D 15.2%
E 16.6%
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Question 97 of 192
 
A 24 year old man is involved in a road traffic accident. His right leg is trapped for
6 hours whilst he is moved. On examination his foot is insensate and a dorsalis
pedis pulse is only weakly felt. Which of the biochemical abnormalities listed
below is most likely to be present?
Alkalosis
Hypercalcaemia
Hypocalcaemia
Hyperkalaemia
Hyponatraemia
In this scenario the patient will have a compartment syndrome, delayed diagnosis
and muscle death. The effect of muscle death will result in the release of
potassium. It is also highly likely that there will be a degree of renal impairment,
the result of which is that the serum potassium is likely to be high.
Next question 
Hyperkalaemia
Plasma potassium levels are regulated by a number of factors including

aldosterone, acid-base balance and insulin levels.
Metabolic acidosis is associated with hyperkalaemia as hydrogen and
potassium ions compete with each other for exchange with sodium ions
across cell membranes and in the distal tubule.
ECG changes seen in hyperkalaemia include tall-tented T waves, small P
waves, widened QRS leading to a sinusoidal pattern and asystole
Causes of hyperkalaemia
Acute renal failure
Drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor
blockers, spironolactone, ciclosporin, heparin**
Metabolic acidosis
Addison's
Tissue necrosis/rhabdomylosis: burns, trauma
Massive blood transfusion
Foods that are high in potassium

Salt substitutes (i.e. Contain potassium rather than sodium)
Bananas, oranges, kiwi fruit, avocado, spinach, tomatoes
*beta-blockers interfere with potassium transport into cells and can potentially
cause hyperkalaemia in renal failure patients - remember beta-agonists, e.g.
Salbutamol, are sometimes used as emergency treatment
**both unfractionated and low-molecular weight heparin can cause hyperkalaemia.

This is thought to be caused by inhibition of aldosterone secretion
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Question stats
A 6.1%
B 7.3%
C 6.1%
D 72.7%
E 7.8%


Question 98 of 192
 
A 55-year-old man with a history of type 2 diabetes mellitus, bipolar disorder and
chronic obstructive pulmonary disease has bloods taken during a pre operative
assessment of an inguinal hernia repair:
Na+ 125 mmol/l
K+ 3.8 mmol/l
Bicarbonate 24 mmol/l
Urea 3.7 mmol/l
Creatinine 92 µmol/l
Due to his smoking history a chest x-ray is ordered which is reported as normal.
The Consultant asks you what is the most likely cause for the hyponatraemia?
Metformin
Lithium
Carbamazepine
Sodium valproate
Pioglitazone
SIADH - drug causes: carbamazepine, sulfonylureas, SSRIs, tricyclics
Lithium can cause diabetes insipidus but this is generally associated with a high
sodium. Lithium only tends to cause raised antidiuretic hormone levels following a
severe overdosage.

Next question 
syndrome of inappropriate antidiuretic hormone (SIADH):

causes
Malignancy
especially small cell lung cancer
also: pancreas, prostate
Neurological
stroke
subarachnoid haemorrhage
subdural haemorrhage
meningitis/encephalitis/abscess
Infections
tuberculosis
pneumonia
Drugs
sulfonylureas
SSRIs, tricyclics
carbamazepine
vincristine
cyclophosphamide
Other causes
positive end-expiratory pressure (PEEP)
porphyrias
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Question stats
A 11%
B 32.9%
C 34.8%
D 14.2%
E 7.1%
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Question 99 of 192
 
A 45 year old man sustains a closed head injury. He is initially alert, however, his
level of consciousness deteriorates on arrival at hospital. An intra cranial pressure
monitor is inserted. What is the normal intracranial pressure?
35 - 45mm Hg
45 - 55mm Hg
<15mm Hg
25 - 35mm Hg
25 - 30 mm Hg
The normal intracranial pressure is between 7 and 15 mm Hg. The brain can
accommodate increases up to 24 mm Hg, thereafter clinical features will become
evident.
Next question 
Applied neurophysiology
Pressure within the cranium is governed by the Monroe-Kelly doctrine. This

considers the skull as a closed box. Increases in mass can be
accommodated by loss of CSF. Once a critical point is reached (usually 100-
120ml of CSF lost) there can be no further compensation and ICP rises
sharply. The next step is that pressure will begin to equate with MAP and
neuronal death will occur. Herniation will also accompany this process.
The CNS can autoregulate its own blood supply. Vaso constriction and
dilatation of the cerebral blood vessels is the primary method by which this
occurs. Extremes of blood pressure can exceed this capacity resulting in
risk of stroke. Other metabolic factors such as hypercapnia will also cause
vasodilation, which is of importance in ventilating head injured patients.
The brain can only metabolise glucose, when glucose levels fall,
consciousness will be impaired.
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Question stats
A 8.6%
B 6.6%
C 62.6%
D 11.4%
E 10.8%
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Question 78 of 192
 
A 73 year old man presents to pre operative clinic for an elective total hip
replacement. He is on furosemide for hypertension. His investigations reveal to the
following results:
Na 120
Urine Na 10 (low)
Serum osmolality 280 (normal)

Hypotonic hypovolaemic hyponatraemia
Hypertonic hypovolaemic hyponatraemia
Syndrome of inappropriate ADH secretion
Over administration of 5% dextrose
Glomerulonephritis
The blood results reflect extra-renal sodium loss. The body is trying to preserve the
sodium by not allowing any sodium into the urine (hence the low Na in the urine).
Note with renal sodium loss the Urinary sodium is high.
Next question 
Hyponatraemia


diagnosis.
Classification

failure PP (urine)

urine Na high)

mmol/l loss
sweating
Burns, adenoma of
and large)

failure
polydipsia
Management


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Question stats
A 43.8%
B 11.8%
C 24.6%
D 14.6%
E 5.2%
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Question 100 of 192
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Which substance can be used to achieve the most accurate measurement of the
glomerular filtration rate?
Glucose
Protein
Inulin
Creatinine
Para-amino hippuric acid
Creatinine declines with age due to decline in renal function and muscle mass.
Glucose, protein (amino acids) and PAH are reabsorbed by the kidney.
Next question 
Renal Physiology
Overview

cross.
inulin).


1. Inert

--------------------------------------------------------------------------

reabsorption.
Tubular function
membrane.
sodium.
Loop of Henle

Next question 
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Question stats
A 4.9%
B 5.2%
C 61.2%
D 11.5%
E 17.3%

Question 101 of 192
 
Which of the following statements relating to cerebrospinal fluid is untrue?
The choroid plexus is only present in the lateral ventricles
Total CSF volume is 100-150ml
CSF pressure is usually 10-15mmHg

The cerebral aqueduct connects the third and fourth ventricles
The foramen of Luschka are paired and lie laterally in the fourth ventricle
The choroid plexus lies in all ventricles.
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Cerebrospinal fluid
Circulation
2. 3rd ventricle
sagittal sinus
Composition
Glucose: 50-80mg/dl
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A 56.4%
B 8.3%
C 8.5%
D 10.1%
E 16.7%
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Question 102 of 192
 
A 74-year-old woman with thyroid cancer is admitted due to shortness of breath.

What is the best investigation to assess for possible compression of the upper
airways?
Arterial blood gases
Forced vital capacity

Transfer factor
Peak expiratory flow rate
Flow volume loop
Flow volume loop is the investigation of choice for upper airway compression.
Next question 
Flow volume loop
A normal flow volume loop is often described as a 'triangle on top of a semi circle'
Flow volume loops are the most suitable way of assessing compression of the
upper airway
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A 10.1%
B 13.7%
C 8.2%
D 29.8%
E 38.3%
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Question 103 of 192
 
Which of the following drugs does not cause pseudohaematuria?
Rifampicin
Quinine
Noradrenaline
Levodopa
Phenytoin
Rifampicin, phenytoin, levodopa, methyldopa, and quinine all cause

pseudohaematuria.
Next question 
Haematuria
Causes of haematuria
Trauma Injury to renal tract

Renal trauma commonly due to blunt injury
(others penetrating injuries)
Ureter trauma rare: iatrogenic
Bladder trauma: due to RTA or pelvic fractures
Infection Remember TB
Malignancy Renal cell carcinoma (remember paraneoplastic
syndromes): painful or painless
Urothelial malignancies: 90% are transitional cell

carcinoma, can occur anywhere along the urinary
tract. Painless haematuria.
Squamous cell carcinoma and adenocarcinoma:
rare bladder tumours
Prostate cancer
Penile cancers: SCC
Renal disease Glomerulonephritis
Stones Microscopic haematuria common

Structural Benign prostatic hyperplasia (BPH) causes

abnormalities haematuria due to hypervascularity of the
prostate gland
Cystic renal lesions e.g. polycystic kidney disease
Vascular malformations
Renal vein thrombosis due to renal cell carcinoma
Coagulopathy Causes bleeding of underlying lesions
Drugs Cause tubular necrosis or interstitial nephritis:

aminoglycosides, chemotherapy
Interstitial nephritis: penicillin, sulphonamides,
and NSAIDs
Anticoagulants
Benign Exercise
Gynaecological Endometriosis: flank pain, dysuria, and

haematuria that is cyclical
Iatrogenic Catheterisation
Radiotherapy; cystitis, severe haemorrhage,
bladder necrosis
Pseudohaematuria For example following consumption of beetroot
References
Http://bestpractice.bmj.com/best-practice/monograph/316/overview
/aetiology.html
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A 7.8%
B 8.1%
C 61.6%
D 12.6%
E 9.8%
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Question 104 of 192
 
A 19 year old man is attacked outside a club and beaten with a baseball bat. He
sustains a blow to the right side of his head. He is brought to the emergency
department and a policy of observation is adopted. His glasgow coma score
deteriorates and he becomes comatose. Which of the following haemodynamic
parameters is most likely to be present?
Hypertension and bradycardia

Hypotension and tachycardia
Hypotension and bradycardia
Hypertension and tachycardia
Normotension and bradycardia
Hypertension and bradycardia are seen prior to coning. The brain autoregulates its
blood supply by controlling systemic blood pressure.
Next question 
Head injury
Patients who suffer head injuries should be managed according to ATLS principles
and extra cranial injuries should be managed alongside cranial trauma. Inadequate
cardiac output will compromise CNS perfusion irrespective of the nature of the
cranial injury.
Types of traumatic brain injury

Bleeding into the space between the dura mater and the skull. Often
results from acceleration-deceleration trauma or a blow to the side of the
head. The majority of extradural haematomas occur in the temporal
region where skull fractures cause a rupture of the middle meningeal
Extradural artery.
haematoma
Features
Raised intracranial pressure
Some patients may exhibit a lucid interval
Bleeding into the outermost meningeal layer. Most commonly occur

around the frontal and parietal lobes. May be either acute or chronic.
Subdural
haematoma Risk factors include old age and alcoholism.
Slower onset of symptoms than a extradural haematoma.

Usually occurs spontaneously in the context of a ruptured cerebral

Subarachnoid
aneurysm, but may be seen in association with other injuries when a
haemorrhage
patient has sustained a traumatic brain injury.
Pathophysiology
Primary brain injury may be focal (contusion/ haematoma) or diffuse
(diffuse axonal injury)
Diffuse axonal injury occurs as a result of mechanical shearing following
deceleration, causing disruption and tearing of axons
Intra-cranial haematomas can be extradural, subdural or intracerebral, while
contusions may occur adjacent to (coup) or contralateral (contre-coup) to
the side of impact
Secondary brain injury occurs when cerebral oedema, ischaemia, infection,
tonsillar or tentorial herniation exacerbates the original injury. The normal
cerebral auto regulatory processes are disrupted following trauma rendering
the brain more susceptible to blood flow changes and hypoxia
The Cushings reflex (hypertension and bradycardia) often occurs late and is
usually a pre terminal event
Management
Where there is life threatening rising ICP such as in extra dural haematoma
and whilst theatre is prepared or transfer arranged use of IV mannitol/
frusemide may be required.
Diffuse cerebral oedema may require decompressive craniotomy
Exploratory Burr Holes have little management in modern practice except
where scanning may be unavailable and to thus facilitate creation of formal
craniotomy flap
Depressed skull fractures that are open require formal surgical reduction
and debridement, closed injuries may be managed non operatively if there is
minimal displacement.
ICP monitoring is appropriate in those who have GCS 3-8 and normal CT
scan.
ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT
scan.
Hyponatraemia is most likely to be due to syndrome of inappropriate ADH
secretion.
Minimum of cerebral perfusion pressure of 70mmHg in adults.
Minimum cerebral perfusion pressure of between 40 and 70 mmHg in
children.
Interpretation of pupillary findings in head injuries
Pupil size Light response Interpretation
Unilaterally Sluggish or fixed 3rd nerve compression secondary to

dilated tentorial herniation
Bilaterally dilated Sluggish or fixed Poor CNS perfusion

Bilateral 3rd nerve palsy
Unilaterally Cross reactive Optic nerve injury

dilated or equal (Marcus - Gunn)
Bilaterally May be difficult to Opiates

constricted assess Pontine lesions
Metabolic encephalopathy
Unilaterally Preserved Sympathetic pathway disruption

constricted
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Question stats
A 66.9%
B 9.4%
C 11.5%

Question 105 of 192
 
An elderly lady who presented with weight loss and malabsorption was found to
have amyloid of the small bowel. On presentation she was found to have
osteomalacia and was hypocalcaemic. Over the past seven days she has received
total parenteral nutrition with adequate calcium replacement. Despite this she
remained hypocalcaemic. Deficiency of which of the following electrolytes is most
likely to account for this process?
Magnesium
Potassium
Sodium
Phosphate
None of the above
Patients with malabsorption may develop magnesium deficiency, although her

TPN feeds may have contained magnesium it may not have been sufficient to
correct her losses. Sodium, phosphate and potassium would not have this effect
on serum calcium.
Next question 
Combined deficiency of magnesium and calcium
Magnesium is required for both PTH secretion and its action on target tissues.
Hypomagnesaemia may both cause hypocalcaemia and render patients
unresponsive to treatment with calcium and vitamin D supplementation.
Magnesium is the fourth most abundant cation in the body. The body contains
1000mmol, with half contained in bone and the remainder in muscle, soft tissues
and extracellular fluid. There is no one specific hormonal control of magnesium
and various hormones including PTH and aldosterone affect the renal handling of
magnesium.
Magnesium and calcium interact at a cellular level also and as a result decreased
magnesium will tend to affect the permeability of cellular membranes to calcium,
resulting in hyperexcitability.
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Question stats
A 55.6%
B 6.7%
C 5.4%
D 26.8%
E 5.5%
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Question 106 of 192
 
Which of the following drugs does not interfere with the laboratory analysis of
serum cortisol levels?
Dexamethasone
Prednisolone
Hydrocortisone IV
Hydrocortisone PO
Hydrocortisone IM
Prednisolone and it's metabolites can chemically mimic cortisol in radio-

immunoassay techniques of laboratory analysis.
Dexamethasone can be given as glucorticoid replacement during testing for

addisons or adrenal insufficiency as it does not interfere with cortisol levels. For
example, if you have a patient with polymyalgia rheumatica and they are on long
term prednisolone, you can replace the prednisolone with dexamethasone to
undertake a short synacthen test.
Next question 
Cortisol
Glucocorticoid
Released by zona fasiculata of the adrenal gland
90% protein bound; 10% active
Circadian rhythm: High in the mornings
Negative feedback via ACTH
Actions
Glycogenolysis
Gluconeogenesis
Protein catabolism
Lipolysis
Stress response
Anti-inflammatory
Decrease protein in bones
Increase gastric acid

Increases neutrophils/platelets/red blood cells
Inhibits fibroblastic activity
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Question stats
A 43%
B 20%
C 7.7%
D 16.7%
E 12.5%
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Question 107 of 192
 
A 55 year old male is diagnosed with carcinoma of the head of the pancreas. He
reports that his stool sticks to the commode and will not flush away. Loss of which
of the following enzymes is most likely to be responsible for this problem?
Lipase
Amylase
Trypsin
Elastase
None of the above
Loss of lipase is one of the key features in the development of steatorrhoea which
typically consists of pale and offensive stools that are difficult to flush away.
Next question 
Pancreatic cancer
Adenocarcinoma
Risk factors: Smoking, diabetes, adenoma, familial adenomatous polyposis
Mainly occur in the head of the pancreas (70%)
Spread locally and metastasizes to the liver
Carcinoma of the pancreas should be differentiated from other
periampullary tumours with better prognosis
Clinical features
Weight loss
Painless jaundice
Epigastric discomfort (pain usually due to invasion of the coeliac plexus is a
late feature)
Pancreatitis
Trousseau's sign: migratory superficial thrombophlebitis
Investigations
USS: May miss small lesions
CT Scanning (pancreatic protocol). If unresectable on CT then no further
staging needed
PET/CT for those with operable disease on CT alone
ERCP/ MRI for bile duct assessment
Staging laparoscopy to exclude peritoneal disease
Management
Head of pancreas: Whipple's resection (SE dumping and ulcers). Newer

techniques include pylorus preservation and SMA/ SMV resection
Carcinoma body and tail: poor prognosis, distal pancreatectomy, if operable
Usually adjuvent chemotherapy for resectable disease
ERCP and stent for jaundice and palliation
Surgical bypass may be needed for duodenal obstruction
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Question stats
A 65.9%
B 8%
C 8.3%
D 11.8%
E 6%


Question 108 of 192
 
Which of the following substances related to thyroid function has its secretion
inhibited by increased plasma T3 and T4?
T3
T4
Thyroglobulin
Thyroid stimulating hormone
TSH release is inhibited by negative feedback.
Next question 
Thyroid hormones

T3

than T3

concentration.
T4.
hormones.
hormones.

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Question stats
A 4.8%
B 4.6%
C 6.6%
D 5.5%
E 78.4%
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Question 110 of 192
 
Which one of the following is associated with increased lung compliance?
Kyphosis
Pulmonary oedema
Emphysema
Pulmonary fibrosis
Pneumonectomy
Next question 
Respiratory physiology: lung compliance
Lung compliance is defined as change in lung volume per unit change in airway
pressure
Causes of increased compliance

age
emphysema - this is due to loss alveolar walls and associated elastic tissue
Causes of decreased compliance

pulmonary oedema
pulmonary fibrosis
pneumonectomy
kyphosis
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Question stats
A 9%
B 6.2%
C 65%
D 10%
E 9.8%
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Question 109 of 192
 
Which of the following areas is predominantly concerned with thermoregulation?
Hypothalamus
Anterior pituitary
Cerebellum
Brain stem
Temporal lobe
The hypothalamus is primarily concerned with thermoregulation. It may relay to the

cerebral cortex to induce behavioural adaptation to facilitate the thermoregulatory
process.
Next question 
Thermoregulation
The hypothalamus is the main centre for thermoregulation. Peripheral and

central thermoreceptors relay to this region.
Central thermoreceptors play the main role in maintenance of core
temperature.
Hypothalamus may initiate involuntary motor responses to raise body
temperature (e.g.shivering). It will also stimulate the sympathetic nervous
system to produce peripheral vasoconstriction and release of adrenaline
from the adrenal medulla.
Heat loss is governed by behavioural responses and by autonomic
responses including peripheral vasodilation.
Heat loss can be maintained within the thermoneutral zone (25 to 30
degrees) although the absolute value depends upon atmospheric humidity.
Sepsis results in the release of cytokines that reset the thermoregulatory
centre resulting in fever.
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Question stats
A 73.9%
B 5.5%
C 5.3%
D 10.1%
E 5.3%
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Question 111 of 192
 
Which of the following is not a major function of the spleen in adults?
Iron reutilisation
Storage of platelets
Storage of monocytes
Haematopoeisis in haematological disorders
Storage red blood cells
The reservoir function of the spleen is less marked in humans than other animals
(e.g. pigs) and in normal individuals it can sequester between 5 and 10% of the red
cell mass. The other stated processes are major splenic functions and this
accounts for the answer provided.
Next question 
Spleen
The spleen is located in the left upper quadrant of the abdomen and its size can
vary depending upon the amount of blood it contains. The typical adult spleen is
12.5cm long and 7.5cm wide. The usual weight of the adult spleen is 150g.
The exact position of the spleen can vary with respiratory activity, posture and the
state of surrounding viscera. It usually lies obliquely with its long axis aligned to
the 9th, 10th and 11th ribs. It is separated from these ribs by both diaphragm and
pleural cavity. The normal spleen is not palpable.
The shape of the spleen is influenced by the state of the colon and stomach.
Gastric distension will cause the spleen to resemble the shape of an orange
segment. Colonic distension will cause it to become more tetrahedral.
The spleen is almost entirely covered by peritoneum, which adheres firmly to its
capsule. Recesses of the greater sac separate it from the stomach and kidney. It
develops from the upper dorsal mesogastrium, remaining connected to the
posterior abdominal wall and stomach by two folds of peritoneum; the lienorenal
ligament and gastrosplenic ligament. The lienorenal ligament is derived from
peritoneum where the wall of the general peritoneum meets the omental bursa
between the left kidney and spleen; the splenic vessels lie in its layers. The
gastrosplenic ligament also has two layers, formed by the meeting of the walls of
the greater sac and omental bursa between spleen and stomach, the short gastric
and left gastroepiploic branches of the splenic artery pass in its layers. Laterally,
the spleen is in contact with the phrenicocolic ligament.
Relations
Superiorly Diaphragm
Anteriorly Gastric impression
Posteriorly Kidney
Inferiorly Colon
Tail of pancreas and splenic vessels (splenic artery divides here, branches pass
Hilum
to the white pulp transporting plasma)
Contents
White Immune function. Contains central trabecular artery. The germinal centres are
pulp supplied by arterioles called penicilliary radicles.
Red
Filters abnormal red blood cells.
pulp
Function
Filtration of abnormal blood cells and foreign bodies such as bacteria.
Immunity: IgM. Production of properdin, and tuftsin which help target fungi
and bacteria for phagocytosis.
Haematopoiesis: up to 5th month gestation or in haematological disorders.
Pooling: storage of 40% platelets.
Iron reutilisation
Storage monocytes
Disorders of the spleen

Massive splenomegaly
Myelofibrosis
Chronic myeloid leukaemia
Visceral leishmaniasis (kala-azar)
Malaria
Gaucher's syndrome
Other causes (as above plus)
Portal hypertension e.g. secondary to cirrhosis
Lymphoproliferative disease e.g. CLL, Hodgkin's
Haemolytic anaemia
Infection: hepatitis, glandular fever
Infective endocarditis
Sickle-cell*, thalassaemia
Rheumatoid arthritis (Felty's syndrome)
*the majority of adult patients with sickle-cell will have an atrophied spleen due to
repeated infarction
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Question stats
A 16.4%
B 12.7%
C 12.1%
D 20.7%
E 38.1%
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
Question 112 of 192
 
A 55 year old man undergoes a laparotomy and repair of incisional hernia. Which
of the following hormones is least likely to be released in increased quantities
following the procedure?
Insulin
ACTH
Glucocorticoids
Aldosterone
Growth hormone
Insulin and thyroxine are often have reduced levels of secretion in the post
operative period. This, coupled with increased glucocorticoid release may cause
difficulty in management of diabetes in individuals with insulin resistance.
Next question 

response.

hormone

hormone
(ACTH)
Aldosterone
Prolactin
Glucagon

Pituitary gland
control
Cortisol
corticosteroids.

Growth hormone

Alpha Endorphin
Increased
I
Insulin
deficiency

normal responses
surgery
Protein metabolism

Lipid metabolism

Cytokines
Glycoproteins

References
/mkh040
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Question stats
A 64.3%
B 7.2%
C 8.8%
D 8%
E 11.7%
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Question 113 of 192
 
Which of the following stimulates prolactin release or action?
Leutinising hormone
Dopamine
Thyrotropin releasing hormone

Oestrogen
Follicle stimulating hormone
TRH stimulates prolactin release. Dopamine suppresses the release of prolactin.
Next question 
Prolactin
Prolactin is a peptide hormone released from the anterior pituitary. It is under tonic
dopamine inhibition, thyrotropin releasing hormone has a stimulatory effect on
release. Prolactin release stimulates milk production but also reduces gonadal
activity. It decreases GnRH pulsatility at the hypothalamic level and to a lesser
extent, blocks the action of LH on the ovary or testis.
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Question stats
A 17%
B 29.1%
C 31.5%
D 13.6%
E 8.9%
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Question 114 of 192
 
Which one of the following reduces the secretion of renin?
Erect posture
Adrenaline
Hyponatraemia
Hypotension
Beta-blockers
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Renin
Renin is secreted by juxtaglomerular cells and hydrolyses angiotensinogen to

produce angiotensin I

Hypotension causing reduced renal perfusion
Hyponatraemia
Catecholamines
Erect posture
Factors reducing renin secretion

Drugs: beta-blockers, NSAIDs
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Question stats
A 11.4%
B 23.4%
C 11.4%
D 7.3%
E 46.4%
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Question 115 of 192
 
A 22 year old lady receives intravenous morphine for acute abdominal pain. Which
of the following best accounts for its analgesic properties?
Binding to δ opioid receptors in the brainstem
Binding to δ opioid receptors at peripheral nerve sites

Binding to β opioid receptors within the CNS
Binding to α opioid receptors within the CNS
Binding to µ opioid receptors within the CNS
4 Types of opioid receptor:

δ (located in CNS)- Accounts for analgesic and antidepressant effects
k (mainly CNS)- analgesic and dissociative effects
µ (central and peripheral) - causes analgesia, miosis, decreased gut
motility
Nociceptin receptor (CNS)- Affect of appetite and tolerance to µ
agonists.
Next question 
Morphine
Strong opiate analgesic. It is a pro- type narcotic drug and its effects mediated via
the 4 types of opioid receptor. Its clinical effects stem from binding to these
receptor sites within the CNS and gastrointestinal tract. Unwanted side effects
include nausea, constipation, respiratory depression and, if used long term,
addiction .
It may be administered orally or intravenously. It can be reversed with naloxone.
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Question stats
A 8%
B 7.5%
C 6.2%
D 6%
E 72.3%
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Question 116 of 192
 
A 77 year old man presents to pre operative clinic for a total knee replacement. He
is on furosemide for hypertension. He is known to have multiple myeloma. He is
found to have the following test results:
Na 120
Serum osmolality 280 (normal)
Urine osmolality normal

Urine Na normal
Pseudohyponatraemia
Syndrome of inappropriate ADH secretion (SIADH)
Hypotonic hypovolaemic hyponatraemia
Psychogenic polydipsia
Hypertonic hypovolaemic hyponatraemia
Hyperlipidaemia and multiple myeloma are known to cause a

pseudohyponatraemia, this is due to raised protein.
Next question 
Hyponatraemia

diagnosis.
Classification

failure PP (urine)
urine Na high)

mmol/l loss
sweating
Burns, adenoma of
and large)

failure
polydipsia
Management

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Question stats
A 48.6%
B 21.4%
C 15.3%
D 7%
E 7.8%
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Question 117 of 192
 
A homeless 42 year old male had an emergency inguinal hernia repair 24 hours
previously. He has a BMI of 15. He has been put on a feeding regime of 35
kcal/kg/day with no additional medications. The nursing staff contact you as he
has become confused and unsteady. On examination the patient is disorientated
to place, has diplopia and nystagmus. What is the most likely diagnosis?
Cerebellar stroke
Acute dystonic reaction
Cerebrovascular accident
Parkinsonism
Wernickes encephalopathy
Triad of Wernicke encephalopathy:

Acute confusion
Ataxia
Ophthalmoplegia
This patient has received a carbohydrate rich diet without any thiamine or vitamin
B co strong replacement. This has led to Wernickes encephalopathy, which
classically presents with confusion, ataxia and ophthalmoplegia. Characteristically
it is associated with chronic alcoholism, however it is also known to occur post
bariatric surgery.
Next question 

include:
Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
Re-feeding problems

BMI < 16 kg/m2

(unless high)

BMI < 18.5 kg/m2
Prescription
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Question stats
A 9.3%
B 15.2%
C 7.2%
D 5.5%
E 62.8%

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Question 118 of 192
 
A patient has an arterial blood gas sample which provides the following result:
pH 7.20
pO2 7.5
Bicarbonate 22
pCO2 8.1
Chloride 10meq
Type II respiratory failure
Metabolic alkalosis
Type I respiratory failure
This is a sign of acute type 2 respiratory failure (non compensated). This is the
result of carbon dioxide retention.
Next question 
categorised
homeostasis)
Metabolic acidosis
Two mechanisms:

(Na+ + K+) - (Cl- + HCO3-).

Addison's disease
Raised anion gap

types:
Metabolic alkalosis
Causes
Diuretics
Hypokalaemia
Cushing's syndrome
Bartter's syndrome

convoluted tubule
Causes
COPD
/ pulmonary oedema
Causes
altitude
Pregnancy

lead to an acidosis
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Question stats
A 59.9%
B 12.5%
C 5.1%
D 17.8%
E 4.8%


Question 119 of 192
 
The oxygen-haemoglobin dissociation curve is shifted to the left in:
With decreased 2,3-DPG in transfused red cells
Sudden move to high altitude

Pyrexia
Haemolytic anaemia
S shaped curve
The curve is shifted to the left when there is a decreased oxygen requirement by
the tissue. This includes:
1. Hypothermia
2. Alkalosis
3. Reduced levels of DPG:
DPG is found in erythrocytes and is reduced in non exercising muscles, i.e.
when there is reduced glycolysis.
4. Polycythaemia
Next question 
Oxygen Transport
Oxygen transport
Haemoglobin

curve to the right
Haldane effect
Bohr effect
curve)

low temperature
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Question stats
A 59.5%
B 10%
C 14.3%
D 7.8%
E 8.4%

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Question 120 of 192
 
A 72-year-old woman is admitted to the acute surgical unit with profuse vomiting.
Admission bloods show the following:
Na+ 131 mmol/l
K+ 2.2 mmol/l
Urea 3.1 mmol/l

Creatinine 56 micro mol/l
Glucose 4.3 mmol/l
Which one of the following ECG features is most likely to be seen?
Short PR interval
Short QT interval
Flattened P waves
J waves
U waves
Hypokalaemia - U waves on ECG
J waves are seen in hypothermia whilst delta waves are associated with Wolff
Parkinson White syndrome.
Next question 
ECG features in hypokalemia
U waves
Small or absent T waves (occasionally inversion)
Prolonged PR interval
ST depression
Long QT interval
One registered user suggests the following rhyme!

In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT!
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A 9.6%
B 12.9%
C 18.8%
D 9.9%
E 48.8%
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Question 121 of 192
 
A 23 year old man has a routine ECG performed. Which part of the tracing obtained
represents atrial repolarisation?
P wave
T wave
Q-T Interval
P-R interval
None of the above
The process of atrial repolarisation is generally not visible on the ECG strip. It
occurs during the QRS complex.
Next question 
The normal ECG

Image sourced from Wikipedia (https://d2zgo9qer4wjf4.cloudfront.net

P wave
(http://en.wikipedia.org/wiki/ECG) /images_eMRCS/swb110b.png)
Represents the wave of depolarization that spreads from the SA node
throughout the atria
Lasts 0.08 to 0.1 seconds (80-100 ms)
The isoelectric period after the P wave represents the time in which the
impulse is traveling within the AV node
P-R interval
Time from the onset of the P wave to the beginning of the QRS complex
Ranges from 0.12 to 0.20 seconds in duration
Represents the time between the onset of atrial depolarization and the
onset of ventricular depolarization
QRS complex
Represents ventricular depolarization
Duration of the QRS complex is normally 0.06 to 0.1 seconds
ST segment
Isoelectric period following the QRS
Represents period which the entire ventricle is depolarized and roughly
corresponds to the plateau phase of the ventricular action potential
T wave
Represents ventricular repolarization and is longer in duration than
depolarization
A small positive U wave may follow the T wave which represents the last
remnants of ventricular repolarization.
Q-T interval
Represents the time for both ventricular depolarization and repolarization to
occur, and therefore roughly estimates the duration of an average ventricular
action potential.
Interval ranges from 0.2 to 0.4 seconds depending upon heart rate.
At high heart rates, ventricular action potentials shorten in duration, which
decreases the Q-T interval. Therefore the Q-T interval is expressed as a
'corrected Q-T (QTc)' by taking the Q-T interval and dividing it by the square
root of the R-R interval (interval between ventricular depolarizations). This
allows an assessment of the Q-T interval that is independent of heart rate.
Normal corrected Q-Tc interval is less than 0.44 seconds.
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Question stats
A 11.5%
B 13.2%
C 12.9%
D 20.7%
E 41.8%
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Question 122 of 192
 
Which one of the following serum proteins is most likely to increase in a patient
with severe sepsis?
Transferrin
Transthyretin
Ferritin
Albumin
Cortisol binding protein
Ferritin can be markedly increased during acute illness. The other parameters tend
to decrease during an acute phase response.
Next question 

CRP
procalcitonin
ferritin
fibrinogen
alpha-1 antitrypsin
caeruloplasmin
serum amyloid A
haptoglobin
complement
During the acute phase response the liver decreases the production of other
proteins (sometimes referred to as negative acute phase proteins). Examples
include:
albumin
transthyretin (formerly known as prealbumin)
transferrin
retinol binding protein
cortisol binding protein
Levels of CRP are commonly measured in acutely unwell patients. CRP is a protein
synthesised in the liver and binds to phosphocholine in bacterial cells and on those
cells undergoing apoptosis. In binding to these cells it is then able to activate the
complement system. CRP levels are known to rise in patients following surgery.
However, levels of greater than 150 at 48 hours post operatively are suggestive of
evolving complications.
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Question stats
A 17.5%
B 7%
C 57.2%
D 6.7%
E 11.7%
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Question 123 of 192
 
Which part of the jugular venous waveform is associated with the closure of the
tricuspid valve?
a wave
c wave
x descent
y descent
v wave
JVP: C wave - closure of the tricuspid valve
The c wave of the jugular venous waveform is associated with the closure of the
tricuspid valve.
Next question 

As well as providing information on right atrial pressure, the jugular vein waveform
may provide clues to underlying valvular disease. A non-pulsatile JVP is seen in
superior vena caval obstruction. Kussmaul's sign describes a paradoxical rise in
JVP during inspiration seen in constrictive pericarditis
'a' wave = atrial contraction

large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis,
pulmonary hypertension
absent if in atrial fibrillation
Cannon 'a' waves

caused by atrial contractions against a closed tricuspid valve
are seen in complete heart block, ventricular tachycardia/ectopics, nodal
rhythm, single chamber ventricular pacing
'c' wave
closure of tricuspid valve
not normally visible
'v' wave
due to passive filling of blood into the atrium against a closed tricuspid
valve
giant v waves in tricuspid regurgitation
'x' descent = fall in atrial pressure during ventricular systole
'y' descent = opening of tricuspid valve
Next question 
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Question stats
A 10.6%
B 48.6%
C 10.8%
D 15.3%
E 14.7%
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Question 124 of 192
 
Which of the following is not an effect of cholecystokinin?
It causes gallbladder contraction
It increases the rate of gastric emptying
It relaxes the sphincter of oddi

It stimulates pancreatic acinar cells
It has a trophic effect on pancreatic acinar cells
It decreases the rate of gastric emptying.
Next question 
Gastric secretions

Gastric acid

acid)


30% acid produced
from G cells

60% acid produced
10% acid produced
reflexes.

Gastrin release

Cholecystokinin
Secretin
acid)


antral pH,
somatostatin




secretion

glucagon secretion
mucous production
Next question 

          
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Question stats
A 6.3%
B 48.7%
C 8.1%
D 10.1%
E 26.7%
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Question 125 of 192
 
A 24 year old man is injured in a road traffic accident. He becomes oliguric and his
renal function deteriorates. Which of the options below would favor acute tubular
necrosis over pre renal uraemia?
No response to intravenous fluids
Urinary sodium < 20mmol/L

Bland coloured urinary sediment
Increased urine specific gravity
None of the above
In acute tubular necrosis there is no response to intravenous fluids because the

damage occurs from within the renal system rather than as a result of volume
depletion.
Next question 
Acute renal failure: Pre renal failure vs. acute tubular necrosis
Prerenal uraemia - kidneys retain sodium to preserve volume
Pre-renal uraemia Acute tubular necrosis
Urine sodium < 20 mmol/L > 30 mmol/L
Fractional sodium excretion* < 1% > 1%
Fractional urea excretion** < 35% >35%

Pre-renal uraemia Acute tubular necrosis
Urine:plasma osmolality > 1.5 < 1.1
Urine:plasma urea > 10:1 < 8:1
Specific gravity > 1020 < 1010
Urine 'bland' sediment brown granular casts
Response to fluid challenge Yes No
*fractional sodium excretion = (urine sodium/plasma sodium) / (urine

creatinine/plasma creatinine) x 100
**fractional urea excretion = (urine urea /blood urea ) / (urine creatinine/plasma

creatinine) x 100
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Question stats
A 50.3%
B 15.1%
C 11.5%
D 16.7%
E 6.4%
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
Question 126 of 192
 
Which statement about peristalsis is true?
Longitudinal smooth muscle propels the food bolus through the

oesophagus
Secondary peristalsis occurs when there is no food bolus in the

oesophagus
Food transfer from the oesophagus to the stomach is 4 seconds
Circular smooth muscle is not involved in peristalsis
Peristalsis only occurs in the oesophagus
Next question 
Peristalsis
Circular smooth muscle contracts behind the food bolus and longitudinal
smooth muscle propels the food through the oesophagus
Primary peristalsis spontaneously moves the food from the oesophagus
into the stomach (9 seconds)
Secondary peristalsis occurs when food, which doesn't enter the stomach,
stimulates stretch receptors to cause peristalsis
In the small intestine each peristalsis waves slows to a few seconds and
causes mixture of chyme
In the colon three main types of peristaltic activity are recognised (see
below)
Colonic peristalsis
Segmentation Localised contractions in which the bolus is
contractions subjected to local forces to maximise mucosal
absorption
Antiperistaltic Localised reverse peristaltic waves to slow entry

contractions towards into colon and maximise absorption
ileum
Mass movements Waves migratory peristaltic waves along the entire

colon to empty the organ prior to the next ingestion
of food bolus
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Question stats
A 51.4%
B 17.9%
C 16.5%
D 7.3%
E 6.8%
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Question 127 of 192
 
What is the main component of colloid in the thyroid gland?
T3
Thyroglobulin
T4
TSH
It is a high molecular weight protein that acts as a storage form of thyroid

hormones.
Next question 
Thyroid hormones

T3

than T3

concentration.
T4.
hormones.
hormones.

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          
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Question stats
A 12.4%
B 62.4%
C 9%
D 11.2%
E 5.1%
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Question 128 of 192
 
Which of the following is least likely to cause a prolonged prothrombin time?
Cholestatic jaundice
Disseminated intravascular coagulation
Prolonged antibiotic treatment

Liver disease
Acquired factor 12 deficiency
Vitamin K deficiency results from cholestatic jaundice and prolonged antibiotic

therapy. Acquired factor 12 deficiency causes prolonged APTT.
Next question 

Next question 
          
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Question stats
A 10.3%
B 11.2%
C 27.6%
D 9.8%
E 41%
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Question 129 of 192
 
A 73 year old female is referred to the surgical clinic with an iron deficiency
anaemia. As part of the diagnostic work up the doctor requests a serum ferritin
level. Which of the conditions listed is most likely to lead to a falsely elevated
result?
Locally perforated sigmoid colonic adenocarcinoma

Colonic angiodysplasia
Dieulafoy lesion of the stomach
Transitional cell carcinoma of the bladder
Endometrial adenocarcinoma
A locally perforated colonic tumour will typically cause an intense inflammatory

response and if peritonitis is not present clinically then at the very least a localised
abscess. This inflammatory process is the most likely (from the list) to falsely
raise the serum ferritin level. Angiodysplasia and dieulafoy lesions are mucosal
arteriovenous malformations and unlikely to result in considerable inflammatory
activity.
Next question 
Ferritin
Ferritin is an intracellular protein that binds iron and stores it to be released in a

controlled fashion at sites where iron is required. Because iron and ferritin are
bound the total body ferritin levels may be decreased in cases of iron deficiency
anaemia. Measurement of serum ferritin levels can be useful in determining
whether an apparently low haemoglobin and microcytosis is truly caused by an
iron deficiency state.
Ferritin is an acute phase protein and may be synthesised in increased quantities
in situations where inflammatory activity is ongoing. Falsely elevated results may
therefore be encountered clinically and need to be taken in context of the clinical
picture and full blood count results.
Next question 
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Question stats
A 42.1%
B 14.2%
C 25.4%
D 9.3%
E 9%
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Question 130 of 192
 
A 48 year old man undergoes a right hemicolectomy for a large caecal polyp. In the
immediate post operative period which of the physiological processes described
below is least likely to occur?
Glycogenolysis
Increased production of acute phase proteins

Increased cortisol production
Bronchoconstriction
Release of nitric oxide by vessels
Next question 
Response to surgery

Noradrenaline from sympathetic nerves and adrenaline from adrenal
medulla
Blood diverted from skin and visceral organs; bronchodilatation, reduced
intestinal motility, increased glucagon and glycogenolysis, insulin reduced
Heart rate and myocardial contractility are increased
Acute phase response

TNF-α, IL-1, IL-2, IL-6, interferon and prostaglandins are released
Excess cytokines may cause SIRS
Cytokines increase the release of acute phase proteins
Endocrine response
Hypothalamus, pituitary, adrenal axis
Increases ACTH and cortisol production:
increases protein breakdown

increases blood glucose levels
Aldosterone increases sodium re-absorption
Vasopressin increases water re-absorption and causes vasoconstriction
Vascular endothelium
Nitric oxide produces vasodilatation
Platelet activating factor enhances the cytokine response
Prostaglandins produce vasodilatation and induce platelet aggregation
Next question 
          
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Question stats
A 10.8%
B 7.6%
C 8.9%
D 55.9%
E 16.8%
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Question 131 of 192
 
Which of the following is the equivalent of cardiac preload?
End diastolic volume
Stroke volume
Systemic vascular resistance

Mean arterial pressure
Peak systolic arterial pressure
Preload is the same as end diastolic volume. When it is increased slightly there is
an associated increase in cardiac output (Frank Starling principle). When it is
markedly increased e.g. over 250ml then cardiac output falls.
Next question 
Cardiac physiology
pressure systems.
Cardiac cycle
cycle)




systolic function.
Starlings law

compliance.

angiotensin II.
Next question 
          
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Question stats
A 64.7%
B 12.3%
C 9.8%
D 6.8%
E 6.3%

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Question 132 of 192
 
A 33 year old female is admitted for varicose vein surgery. She is fit and well. After
the procedure she is persistently bleeding. She is known to have menorrhagia.
Investigations show a prolonged bleeding time and increased APTT. She has a
normal PT and platelet count. What is the most likely cause?
Anti phospholipid syndrome

Haemophilia
Factor V Leiden deficiency
von Willebrands disease
Protein C and S deficiency
Bleeding post operatively, epistaxis and menorrhagia may indicate a diagnosis of

vWD. Haemoarthroses are rare. The bleeding time is usually normal in haemophilia
(X-linked) and vitamin K deficiency.
Next question 
Most common inherited bleeding disorder

All vWD is caused by mutations in the gene for von Willebrand factor. von
Willebrand factor is an adhesive glycoprotein that is secreted by
endothelium and megakaryocytes
von Willebrand factor promotes platelet adhesion to damaged endothelium
and other platelets. It is also involved in the transport and stabilization of
factor VIII
There are 7 subtypes of von Willebrand disease. The commonest is type I
(autosomal dominant) which accounts for 80% of cases, type 2vWD
(autosomal dominant or recessive) accounts for 15% of cases
There is a significant spectrum of severity ranging from spontaneous
bleeding and epistaxis through to troublesome excessive bleeding following
minor procedures
The test that is most typically diagnostic is the bleeding time
Treatments include administration of tranexamic acid for minor cases
undergoing minor procedures. More significant bleeding or more significant
procedures respond well to DDAVP. This is most effective in type I, less
effective in type 2 and contraindicated in type 2B. Patients with type 3
disease do not respond to DDAVP as they lack the ability to secrete vWF
Individuals who cannot have DDAVP or in whom it is contra indicated usually
receive factor VIII concentrates containing vWF
Next question 
          
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Question stats
A 14.5%
B 19.4%
C 10.3%
D 49.3%
E 6.6%
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Question 133 of 192
 
A 43 year old man has a nasogastric tube inserted. The nurse takes a small
aspirate of the fluid from the stomach and tests the pH of the aspirate. What is the
normal intragastric pH?
0.5
2
The intragastric pH is usually 2. Administration of proton pump inhibitors can

result in almost complete abolition of acidity
Next question 
Gastric secretions

Gastric acid

acid)


30% acid produced
from G cells

60% acid produced

10% acid produced
reflexes.

Gastrin release


Cholecystokinin
Secretin
acid)


antral pH,
somatostatin




secretion

glucagon secretion
mucous production
Next question 

          
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Question stats
A 7.1%
B 60.1%
C 15.6%
D 9.3%
E 8%
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
Question 134 of 192
 
A 54-year-old woman is admitted to the Surgical Admissions Unit with abdominal

pain. Blood tests taken on admission show the following:
Magnesium 0.40 mmol/l (normal value 0.7-1.0 mmol/l)
Which one of the following factors is most likely to be responsible for this result?
Excessive resuscitation with intravenous saline
Digoxin therapy
Diarrhoea
Hypothermia
Rhabdomyolysis
Next question 
Hypomagnasaemia
Cause of low magnesium

Diuretics
Total parenteral nutrition
Diarrhoea
Alcohol
Hypokalaemia, hypocalcaemia
Features
Paraesthesia
Tetany
Seizures
Arrhythmias
Decreased PTH secretion → hypocalcaemia
ECG features similar to those of hypokalaemia
Exacerbates digoxin toxicity
Next question 

          
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Question stats
A 14.5%
B 16.6%
C 55.3%
D 5.8%
E 7.9%
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Question 135 of 192
 
Which of the following is not linked to excess glucocorticoids?
Osteonecrosis
Osteoporosis
Hypokalaemia
Hyponatraemia
Growth retardation in children
There are many adverse effects associated with excess glucocorticoids. Thinning
of the skin, osteonecrosis and osteoporosis are all common. Steroids are
associated with retention of sodium and water. Potassium loss may occur and
hypokalaemic alkalosis has been reported.
Next question 
Cortisol
Glucocorticoid
Actions
Glycogenolysis
Gluconeogenesis
Protein catabolism
Lipolysis
Stress response
Anti-inflammatory
Next question 
          
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Question stats
A 19%
B 7.8%
C 22.8%
D 39.5%
E 11%
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Question 136 of 192
 
A 25-year-old man who has been morbidly obese for the past five years is reviewed
in the surgical bariatric clinic. In this patient, release of which of the following
hormones would increase appetite?
Leptin
Thyroxine
Adiponectin
Ghrelin
Serotonin
Obesity hormones
leptin decreases appetite
ghrelin increases appetite
Whilst thyroxine can increase appetite it does not fit with the clinical picture being
described.
Next question 
Obesity: physiology
Leptin
Leptin is thought to play a key role in the regulation of body weight. It is produced
by adipose tissue and acts on satiety centres in the hypothalamus and decreases
appetite. More adipose tissue (e.g. in obesity) results in high leptin levels.
Leptin stimulates the release of melanocyte-stimulating hormone (MSH) and

corticotrophin-releasing hormone (CRH). Low levels of leptin stimulates the
release of neuropeptide Y (NPY)
Ghrelin
Where as leptin induces satiety, ghrelin stimulates hunger. It is produced mainly by
the fundus of the stomach and the pancreas. Ghrelin levels increase before meals
and decrease after meals
Next question 

          
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Question stats
A 24%
B 11.4%
C 7%
D 49.6%
E 8.1%
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Question 137 of 192
 
Which of the following drugs causes hyperkalaemia?
Heparin
Ciprofloxacin
Salbutamol
Levothyroxine
Codeine phosphate
Both unfractionated and low-molecular weight heparin can cause hyperkalaemia.

This is thought to be caused by inhibition of aldosterone secretion. Salbutamol is a
recognised treatment for hyperkalaemia.
Next question 
Hyperkalaemia

Acute renal failure
Metabolic acidosis
Addison's


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          
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Question stats
A 44.3%
B 15.6%
C 17.1%
D 13.1%
E 9.8%
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
Question 138 of 192
 
A 39 year old lady undergoes a laparoscopic cholecystectomy as a daycase. The

operation is more difficult than anticipated and the surgeon places a drain to the
liver bed. In recovery 1.5 litres of blood is seen to enter the drain. Which of the
following substances is the first to be released in this situation?
Angiotensinogen
Renin
Angiotensin I
Angiotensin II
Aldosterone
The decrease in blood pressure will be sensed by the juxtaglomerular cells in the
kidney. This will cause renin secretion.
Next question 
Shock

Septic
Haemorrhagic
Neurogenic
Cardiogenic
Anaphylactic
Septic shock


attention:
Haemorrhagic shock

Blood loss % <15% 15-30% 30-40% >40%
Pulse rate <100 >100 >120 >140


Spinal cord injury
Cardiac tamponade


Neurogenic shock
vasodilation.
Cardiogenic shock
following MI.
Anaphylactic shock

in 1,000)

years in 1,000)

1,000)

12 years 1,000)
drugs
Next question 
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Question stats
A 7.5%
B 70.5%
C 6.4%
D 6.9%
E 8.7%
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Question 139 of 192
 
Which of the following statements relating to the regulation of renal blood flow is
untrue?
In a healthy 70Kg male, the glomerular filtration rate will be the same at a
systolic blood pressure of 120mmHg as a systolic blood pressure of 95
mmHg
Over 90% of the blood supply to the kidney is distributed to the cortex
The kidney receives approximately 25% of the total cardiac output at rest
A decrease in renal perfusion pressure will cause the juxtaglomerular cells

to secrete renin
Systolic blood pressures of less than 65mmHg will cause the mesangial
cells to secrete aldosterone
The kidney autoregulates its blood supply over a range of systolic blood pressures.
Drop in arterial pressure is sensed by the juxtaglomerular cells and renin is
released leading to the activation of the renin-angiontensin system. Mesangial
cells are contractile cells that are located in the tubule and have no direct
endocrine function.
Next question 
Renal Physiology
Overview

cross.

inulin).

1. Inert

--------------------------------------------------------------------------

reabsorption.
Tubular function
membrane.
sodium.
Loop of Henle

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          
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Question stats
A 11.3%
B 20.8%
C 11.5%
D 9%
E 47.3%
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11
12
13

Question 140 of 192
 
Which of the following features does not put a patient at risk of refeeding
syndrome?
BMI < 16 kg/m2
Alcohol abuse
Thyrotoxicosis
Chemotherapy
Diuretics
Diuretics increase the risk of re-feeding syndrome through a process of increasing

the risk of depletion of key electrolytes.
Next question 

include:
Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
Re-feeding problems
BMI < 16 kg/m2
(unless high)

BMI < 18.5 kg/m2
Prescription
Next question 
          
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Question stats
A 8.3%
B 7.3%
C 34.3%
D 13.3%
E 36.8%
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11
12

Question 146 of 192
 
A 34 year old man presents with a peptic ulcer. Which of the following is
responsible for the release of gastric acid?
Chief cells
Parietal cells
Brunners Glands
G Cells
None of the above
Parietal cells are responsible for the release of gastric acid. Brunners glands are
found in the duodenum.
Next question 
Gastric secretions

Gastric acid

acid)


30% acid produced
from G cells

60% acid produced

10% acid produced
reflexes.

Gastrin release

Cholecystokinin
Secretin
acid)


antral pH,
somatostatin




secretion

glucagon secretion
mucous production
Next question 

          
Save my notes
Question stats
A 17.1%
B 60.2%
C 5.3%
D 12.3%
E 5.1%
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
Question 141 of 192
 
Intra cranial pressure is governed by the principles of the Monroe-Kellie doctrine.

To which of the following does this concept not apply?
A 2 month old child
A 2 year old child

A 5 year old child
A 10 year old child
An adult
The Monroe-Kelly Doctrine assumes that the cranial cavity is a rigid box. In children
with non fused fontanells this is not the case.
Next question 

Next question 
          
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Question stats
A 73.3%
B 6.4%
C 4.8%
D 5.6%
E 9.9%
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Question 142 of 192
 
A 52 year old man develops septic shock following a Hartmans procedure for
perforated diverticular disease. He is started on an adrenaline infusion. Which of
the following is least likely to occur?
Peripheral vasoconstriction
Coronary artery vasospasm

Gluconeogenesis
Lipolysis
Tachycardia
It's cardiac effects are mediated via β 1 receptors. The coronary arteries which
have β 2 receptors are unaffected.
Next question 
Adrenaline
Fight or Flight response
- Catecholamine (phenylalanine and tyrosine)

- Neurotransmitter and hormone
- Released by the adrenal glands
- Effects on α 1 and 2, β 1 and 2 receptors
- Effect on β 2 receptors in skeletal muscle vessels-causing vasodilation
- Increase cardiac output and total peripheral resistance
- Vasoconstriction in the skin and kidneys causing a narrow pulse pressure
Actions
α adrenergic receptors:
Inhibits insulin secretion by the pancreas
Stimulates glycogenolysis in the liver and muscle
Stimulates glycolysis in muscle
β adrenergic receptors:
Stimulates glucagon secretion in the pancreas
Stimulates ACTH
Stimulates lipolysis by adipose tissue
Next question 
          
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Question stats
A 11.3%
B 46.9%
C 20%
D 15.1%
E 6.7%
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Question 143 of 192
 
Which of the following does not cause hyperkalaemia?
Haemolysis
Burns
Familial periodic paralysis

Type 4 renal tubular acidosis
Severe malnutrition
'Machine' - Causes of Increased Serum K+
M - Medications - ACE inhibitors, NSAIDS

A - Acidosis - Metabolic and respiratory
C - Cellular destruction - Burns, traumatic injury
H - Hypoaldosteronism, haemolysis
I - Intake - Excessive
N - Nephrons, renal failure
E - Excretion - Impaired
Familial periodic paralysis has subtypes associated with hyper and hypokalaemia.
Next question 
Hyperkalaemia

Acute renal failure
Metabolic acidosis
Addison's


Next question 
          
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Question stats
A 7%
B 8.3%
C 21%
D 13.3%
E 50.5%
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14
15

Question 144 of 192
 
Which of these substances is not released from the islets of Langerhans?
Pancreatic polypeptide
Glucagon
Secretin
Somatostatin
Insulin
Secretin is released from mucosal cells in the duodenum and jejunum.
Next question 
Pancreas endocrine physiology
Hormones released from the islets of Langerhans
Beta cells Insulin (70% of total secretions)
Alpha cells Glucagon
Delta cells Somatostatin
F cells Pancreatic polypeptide
Next question 
          
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Question stats
A 14.8%
B 11%
C 45.6%
D 19.5%
E 9.1%
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Question 145 of 192
 
Which of the following does not lead to relaxation of the lower oesophageal
sphincter?
Metoclopramide
Botulinum toxin type A

Nicotine
Alcohol
Theophylline
Metoclopramide acts directly on the smooth muscle of the LOS to cause it to

contract.
Theophylline is a phosphodiesterase inhibitor (mimics action of prostaglandin E1)
which causes relaxation of the LOS.
Next question 
Peristalsis
Circular smooth muscle contracts behind the food bolus and longitudinal
smooth muscle propels the food through the oesophagus
Primary peristalsis spontaneously moves the food from the oesophagus
into the stomach (9 seconds)
Secondary peristalsis occurs when food, which doesn't enter the stomach,
stimulates stretch receptors to cause peristalsis
In the small intestine each peristalsis waves slows to a few seconds and
causes mixture of chyme
In the colon three main types of peristaltic activity are recognised (see
below)
Colonic peristalsis
Segmentation Localised contractions in which the bolus is

contractions subjected to local forces to maximise mucosal
absorption
Antiperistaltic Localised reverse peristaltic waves to slow entry

contractions towards into colon and maximise absorption
ileum
Mass movements Waves migratory peristaltic waves along the entire

colon to empty the organ prior to the next ingestion
of food bolus
Next question 
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Question stats
A 47.1%
B 13.5%
C 12.9%
D 11.2%
E 15.3%
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
Question 151 of 192
 
Which of the following will increase the volume of pancreatic exocrine secretions?
Octreotide
Cholecystokinin
Aldosterone
Adrenaline
None of the above
Cholecystokinin will often increase the volume of pancreatic secretions.
Next question 

Trypsinogen
Procarboxylase
Amylase
Elastase
Sodium
Bicarbonate
Water
Ductal and
Aqueous Potassium
Centroacinar cells
Chloride
Regulation
Enzyme activation
Next question 
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Question stats
A 13.1%
B 62.8%
C 8.8%
D 7.7%
E 7.6%
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Question 147 of 192
 
A 43 year old lady is diagnosed with primary hyperparathyroidism. Her serum PTH
levels are elevated. An endocrine surgeon performs a parathyroidectomy. How
long will it take for the serum PTH levels to fall if the functioning adenoma has
been successfully removed?
6 hours
24 hours
2 hours
1 hour
10 minutes
PTH has a very short half life usually less than 10 minutes. Therefore a
demonstrable drop in serum PTH should be identified within 10 minutes of
removing the adenoma. This is useful clinically since it is possible to check the
serum PTH intraoperatively prior to skin closure and explore the other glands if
levels fail to fall.
Next question 
Calcium homeostasis
Hormone Actions
Hormone Actions

resorption
of calcium

absorption of Ca2+
reabsorption

levels
reabsorption

calcium
Next question 

          
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Question stats
A 21.7%
B 13.7%
C 9.7%
D 10.8%
E 44.2%
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
Question 148 of 192
 
Which of the following inhibits the secretion of insulin?
Adrenaline
Lipids
Gastrin
Arginine
Vagal cholinergic activity
Inhibition of insulin release:
Alpha adrenergic drugs

Beta blockers
Sympathetic nerves
Next question 
Insulin
Structure
Synthesis
Function
Inhibits lipolysis
Next question 
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Question stats
A 49.5%
B 17.1%
C 12.8%
D 8.7%
E 11.9%
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Question 149 of 192
 
Which opioid receptor does morphine attach to?
mu
alpha
sigma
beta
kappa
Pethidine and other conventional opioids attach to this receptor.
Next question 
Opioids
- Combine to specific opiate receptors in the CNS (periaqueductal grey matter,

limbic system, substantia gelatinosa)
- Morphine attaches to mu1 receptors
Next question 
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Question stats
A 68.9%
B 8.1%
C 7.3%
D 7.1%
E 8.7%
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Question 150 of 192
 
Where is the majority of iron found in the body?
Bone
Haemoglobin
Ferritin and haemosiderin

Myoglobin
Plasma iron
Approximately 70% of body iron is found bound to haemoglobin.
Next question 
Iron metabolism
Absorption Duodenum and upper jejunum

About 10% of dietary iron absorbed
Fe2+ (ferrous iron) much better absorbed than Fe3+ (ferric
iron)
Ferrous iron is oxidized to form ferric iron, which is
combined with apoferritin to form ferritin
Absorption is regulated according to body's need
Increased by vitamin C, gastric acid
Decreased by proton pump inhibitors, tetracycline, gastric
achlorhydria, tannin (found in tea)
Transport In plasma as Fe3+ bound to transferrin

Storage Ferritin (or haemosiderin) in bone marrow
Excretion Lost via intestinal tract following desquamation
Distribution in body
Total body iron 4g
Haemoglobin 70%
Ferritin and haemosiderin 25%
Myoglobin 4%
Plasma iron 0.1%
Next question 
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Question stats
A 6.9%
B 53%
C 22.7%
D 11%
E 6.5%
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
Question 152 of 192
 
Which of the following does not cause an increased anion gap acidosis?
Uraemia
Paraldehyde
Diabetic ketoacidosis
Ethylene glycol
Acetazolamide
Causes of increased anion acidosis: MUDPILES
M - Methanol
U - Uraemia
D - DKA/AKA
P - Paraldehyde/phenformin
I - Iron/INH
L - Lactic acidosis
E - Ethylene glycol
S - Salicylates
Next question 
categorised
homeostasis)
Metabolic acidosis
Two mechanisms:

(Na+ + K+) - (Cl- + HCO3-).

Addison's disease
Raised anion gap

types:
Metabolic alkalosis

Causes
Diuretics
Hypokalaemia
Cushing's syndrome
Bartter's syndrome

convoluted tubule
Causes
COPD
/ pulmonary oedema
Causes
altitude
Pregnancy

lead to an acidosis
Next question 
          
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Question stats
A 17.7%
B 13.9%
C 11.2%
D 13.1%
E 44%


Question 153 of 192
 
Which of the following statements about blood clotting is untrue?
Platelet adhesion to disrupted endothelium is dependent upon von

Willebrand factor
Protein C is a vitamin K dependent substance

The bleeding time provides an assessment of platelet function
The prothrombin time tests the extrinsic system
Administration of aprotinin during liver transplantation surgery prolongs

survival
Although aprotinin reduces fibrinolysis and thus bleeding, it is associated with

increased risk of death and was withdrawn in 2007. Protein C is dependent upon
vitamin K and this may paradoxically increase the risk of thrombosis during the
early phases of warfarin treatment.
Next question 
Coagulation cascade
Two pathways lead to fibrin formation
Intrinsic pathway (components already present in the blood)

Minor role in clotting
Subendothelial damage e.g. collagen
Formation of the primary complex on collagen by high-molecular-weight
kininogen (HMWK), prekallikrein, and Factor 12
Prekallikrein is converted to kallikrein and Factor 12 becomes activated
Factor 12 activates Factor 11
Factor 11 activates Factor 9, which with its co-factor Factor 8a form the
tenase complex which activates Factor 10
Extrinsic pathway (needs tissue factor released by damaged tissue)

Tissue damage
Factor 7 binds to Tissue factor
This complex activates Factor 9
Activated Factor 9 works with Factor 8 to activate Factor 10
Common pathway
Activated Factor 10 causes the conversion of prothrombin to thrombin
Thrombin hydrolyses fibrinogen peptide bonds to form fibrin and also
activates factor 13 to form links between fibrin molecules
Fibrinolysis
Plasminogen is converted to plasmin to facilitate clot resorption
(http://en.wikipedia.org
/wiki/Coagulation)
Clotting pathway Clotting parameters affected Factors affected
Intrinsic pathway Increased APTT Factors 8,9,11,12
Extrinsic pathway Increased PT Factor 7
Common pathway Increased APTT & PT Factors 2,5,10
Vitamin K dependent Factors 2,7,9,10

Next question 
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Question stats
A 11.6%
B 18.4%
C 14.1%
D 17.7%
E 38.2%
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
Question 154 of 192
 
Which of the substances below is derived primarily from the zona reticularis of the
adrenal gland?
Mineralocorticoid hormones
Glucocorticoid hormones
Sex hormones
FSH
Vasopressin
Next question 
Adrenal physiology
Adrenal medulla
Adrenal cortex
Next question 
          
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Question stats
A 10.2%
B 10.8%
C 67.1%
D 5.5%
E 6.4%
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11
12
13

Question 155 of 192
 
A patient is seen in clinic complaining of abdominal pain. Routine bloods show:
Na+ 142 mmol/l
K+ 4.0 mmol/l
Chloride 104 mmol/l

Bicarbonate 19 mmol/l
Urea 7.0 mmol/l
Creatinine 112 µmol/l
What is the anion gap?
4 mmol/L
14 mmol/L
20 mmol/L
21 mmol/L
23 mmol/L
The anion gap may be calculated by using (sodium + potassium) - (bicarbonate +

chloride)
= (142 + 4.0) - (104 + 19) = 23 mmol/L
Next question 
Anion gap
The anion gap is calculated by:
(sodium + potassium) - (bicarbonate + chloride)
A normal anion gap is 8-14 mmol/L
It is useful to consider in patients with a metabolic acidosis:
Causes of a normal anion gap or hyperchloraemic metabolic acidosis

gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
renal tubular acidosis
drugs: e.g. acetazolamide
ammonium chloride injection
Addison's disease
Causes of a raised anion gap metabolic acidosis

lactate: shock, hypoxia
ketones: diabetic ketoacidosis, alcohol
urate: renal failure
acid poisoning: salicylates, methanol
Next question 
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Question stats
A 7.4%
B 9.4%
C 8.5%
D 11.1%
E 63.6%


Question 156 of 192
 
A 48 year old woman suffers blunt trauma to the head and develops respiratory
compromise. As a result she develops hypercapnia. Which of the following effects
is most likely to ensue?
Cerebral vasoconstriction
Cerebral vasodilation
Cerebral blood flow will remain unchanged
Shunting of blood to peripheral tissues will occur in preference to CNS

perfusion
None of the above
Hypercapnia will tend to produce cerebral vasodilation. This is of considerable

importance in patients with cranial trauma as it may increase intracranial pressure.
Next question 

Next question 
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Question stats
A 19.7%
B 53.9%
C 11.8%
D 8.6%
E 6%
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Question 157 of 192
 
The Cori cycle is important in lactate metabolism in the septic surgical patient. It is
used to describe a pathway in which glucose is metabolised anaerobically to
lactate in one tissue and the lactate is converted back to glucose in another. Which
one of the following relies on this cycle to meet all of its energy needs?
Hepatocyte
Leucocyte
Erythrocyte
Pneumocyte
Goblet cells
Erythrocytes lack a mitochondria and therefore they generate energy via glycolytic
pathways only. All the other cell types have mitochondria and will therefore use the
Krebs cycle unless true anaerobic conditions prevail.
Next question 
Cellular metabolism
Circulating glucose enters the cell, subsequently a glycolytic process results

in the generation of ATP and pyruvate
In the presence of oxygen, the pyruvate from the glycolytic process then
enters the Krebs cycle
When oxygen is limited or absent, pyruvate enters an anaerobic pathway. In
these reactions, pyruvate can be converted into lactic acid. In addition to
generating an additional ATP, this pathway serves to keep the pyruvate
concentration low so glycolysis continues, and it oxidizes NADH into the
NAD+ needed by glycolysis. In this reaction, lactic acid replaces oxygen as
the final electron acceptor. Anaerobic respiration occurs in most cells of the
body when oxygen is limited or mitochondria are absent or nonfunctional.
For example, because erythrocytes (red blood cells) lack mitochondria, they
must produce their ATP from anaerobic respiration. This is an effective
pathway of ATP production for short periods of time, ranging from seconds
to a few minutes. The lactic acid produced diffuses into the plasma and is
carried to the liver, where it is converted back into pyruvate or glucose via
the Cori cycle
In the presence of oxygen, pyruvate can enter the Krebs cycle where
additional energy is extracted as electrons are transferred from the pyruvate
to the receptors NAD+, GDP, and FAD, with carbon dioxide being a by
product. The NADH and FADH2 pass electrons on to the electron transport
chain, which uses the transferred energy to produce ATP. As the terminal
step in the electron transport chain, oxygen is the terminal electron acceptor
and creates water inside the mitochondria.
The oxidative pathways eventually yield a total of 36 ATP molecules and are
therefore far better at generating energy than anaerobic pathways.
Next question 
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Question stats
A 35.5%
B 6.9%
C 45.3%
D 5.4%
E 6.9%
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Question 158 of 192
 
A 53 year old man is on the intensive care unit following an emergency abdominal
aortic aneurysm repair. He develops abdominal pain and diarrhoea and is
profoundly unwell. His abdomen has no features of peritonism. Which of the
following arterial blood gas pictures is most likely to be present?
pH 7.45, pO2 10.1, pCO2 3.2, Base excess 0, Lactate 0

pH 7.35, pO2 8.0, pCO2 5.2, Base excess 2, Lactate 1
pH 7.20, pO2 9.0, pCO2 3.5, Base excess -10, Lactate 8
pH 7.29, pO2 8.9, pCO2 5.9, Base excess -4, Lactate 3
pH 7.30, pO2 9.2 pCO2 4.8, Base excess -2, lactate 1
This man is likely to have a metabolic acidosis secondary to a mesenteric infarct.
Next question 
categorised
homeostasis)
Metabolic acidosis
Two mechanisms:

(Na+ + K+) - (Cl- + HCO3-).

Addison's disease
Raised anion gap

types:
Metabolic alkalosis
Causes
Diuretics
Hypokalaemia
Cushing's syndrome
Bartter's syndrome

convoluted tubule
Causes
COPD
/ pulmonary oedema
Causes
altitude
Pregnancy

lead to an acidosis
Next question 
          
Save my notes
Question stats
A 9.9%
B 8.6%
C 57.3%
D 15.1%
E 9%
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
Question 159 of 192
 
Which of these fluids is not an intravenous colloid?
Gelofusine
Dextran 40
Human albumin solution

Hydroxyethyl starch
Bicarbonate 8.4%
Bicarbonate is a crystalloid.
Next question 
Pre operative fluid management
Fluid management has been described in the British Consensus guidelines on IV

fluid therapy for Adult Surgical patients (GIFTASUP) and by NICE (CG174
December 2013 updated May 2017)
The Recommendations include:

Use Ringer's lactate or Hartmann's when a crystalloid is needed for
resuscitation or replacement of fluids. Avoid 0.9% N. Saline (due to risk of
hyperchloraemic acidosis) unless patient vomiting or has gastric drainage.
Use 4%/0.18% dextrose saline or 5% dextrose in maintenance fluids. It
should not be used in resuscitation or as replacement fluids.
Adult maintenance fluid requirements are: Na 50-100 mmol/day and K 40-80
mmol/day in 1.5-2.5L fluid per day.
Patients for elective surgery should NOT be nil by mouth for >2 hours
(unless has disorder of gastric emptying).
Patients for elective surgery should be given carbohydrate rich drinks 2-3h
before. Ideally this should form part of a normal pre op plan to facilitate
recovery.
Avoid mechanical bowel preparation.
If bowel prep is used, simultaneous administration of Hartmann's or Ringer's
lactate should be considered.
Excessive fluid losses from vomiting should be treated with a crystalloid
with potassium replacement. 0.9% N. Saline should be given if there is
hypochloraemia. Otherwise Hartmann's or Ringer lactate should be given for
diarrhoea/ileostomy/ileus/obstruction. Hartmann's should also be given in
sodium losses secondary to diuretics.
High risk patients should receive fluids and inotropes.
An attempt should be made to detect pre or operative hypovolaemia using
flow based measurements. If this is not available, then clinical evaluation is
needed i.e. JVP, pulse volume etc.
In Blood loss or infection causing hypovolaemia should be treated with a

balanced crystalloid or colloid (or until blood available in blood loss). A
critically ill patient is unable to excrete Na or H20 leading to a 5% risk of
interstitial oedema. Therefore 5% dextrose as well as colloid should be
given.
If patients need IV fluid resuscitation, use crystalloids that contain sodium in
the range 130-154 mmol/l, with a bolus of 500 ml over less than 15 minutes
(NICE Guidance CG 174).
Next question 
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Question stats
A 8%
B 11.7%
C 8.9%
D 7.9%
E 63.6%


Question 160 of 192
 
Cortisol is predominantly produced by which of the following?
Zona fasciculata of the adrenal
Zona glomerulosa of the adrenal
Zona reticularis of the adrenal

Adrenal medulla
Posterior lobe of the pituitary
Relative Glucocorticoid activity:
Hydrocortisone = 1
Prednisolone = 4
Dexamethasone = 25
Cortisol is produced by the zona fasciculata of the adrenal gland.
Next question 
Cortisol
Glucocorticoid
Actions
Glycogenolysis
Gluconeogenesis
Protein catabolism
Lipolysis
Stress response
Anti-inflammatory
Next question 
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Question stats
A 60.8%
B 17.1%
C 9.7%
D 7.6%
E 4.8%
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Question 161 of 192
 
A 34 year old male donates a unit of blood. It is stored at 4 oC. After 72 hours
which of the following clotting factors will be most affected?
Factor IV
Factor II
Factor VIII
Factor IX
Factor XI
Factors V and VIII are sensitive to temperature which is the reason why FFP is
frozen soon after collection.
Next question 
Blood products
Whole blood fractions
Fraction Key points
Packed red cells Used for transfusion in chronic anaemia and cases where
infusion of large volumes of fluid may result in
cardiovascular compromise. Product obtained by
centrifugation of whole blood.
Platelet rich Usually administered to patients who are

plasma thrombocytopaenic and are bleeding or require surgery. It is
obtained by low speed centrifugation.
Platelet Prepared by high speed centrifugation and administered to
concentrate patients with thrombocytopaenia.
Fresh frozen Prepared from single units of blood.

plasma Contains clotting factors, albumin and
immunoglobulin.
Unit is usually 200 to 250ml.
Usually used in correcting clotting deficiencies in
patients with hepatic synthetic failure who are due to
undergo surgery.
Usual dose is 12-15ml/Kg-1.
It should not be used as first line therapy for
hypovolaemia.
Cryoprecipitate Formed from supernatant of FFP.

Rich source of Factor VIII and fibrinogen.
Allows large concentration of factor VIII to be
administered in small volume.
SAG-Mannitol Removal of all plasma from a blood unit and substitution

Blood with:
Sodium chloride
Adenine
Anhydrous glucose
Mannitol
Up to 4 units of SAG M Blood may be administered.

Thereafter whole blood is preferred. After 8 units, clotting
factors and platelets should be considered.
Cell saver devices

These collect patients own blood lost during surgery and then re-infuse it. There
are two main types:
Those which wash the blood cells prior to re-infusion. These are more
expensive to purchase and more complicated to operate. However, they
reduce the risk of re-infusing contaminated blood back into the patient.
Those which do not wash the blood prior to re-infusion.
Their main advantage is that they avoid the use of infusion of blood from donors
into patients and this may reduce risk of blood borne infection. It may be
acceptable to Jehovah's witnesses. It is contraindicated in malignant disease for
risk of facilitating disease dissemination.
Blood products used in warfarin reversal

In some surgical patients the use of warfarin can pose specific problems and may
require the use of specialised blood products
Immediate or urgent surgery in patients taking warfarin(1) (2):
1. Stop warfarin
2. Vitamin K (reversal within 4-24 hours)

-IV takes 4-6h to work (at least 5mg)
-Oral can take 24 hours to be clinically effective
3. Fresh frozen plasma

Used less commonly now as 1st line warfarin reversal
-30ml/kg-1
-Need to give at least 1L fluid in 70kg person (therefore not appropriate in fluid
overload)
-Need blood group
-Only use if human prothrombin complex is not available
4. Human Prothrombin Complex (reversal within 1 hour)

-Bereplex 50 u/kg
-Rapid action but factor 6 short half life, therefore give with vitamin K
References
1. Dentali, F., C. Marchesi, et al. (2011). 'Safety of prothrombin complex
concentrates for rapid anticoagulation reversal of vitamin K antagonists. A meta-
analysis.' Thromb Haemost 106(3): 429-438.
2. http://www.transfusionguidelines.org/docs/pdfs/bbt-03warfarin-reversal-
flowchart-2006.pdf
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Question stats
A 39.6%
B 14%
C 29.9%

Question 162 of 192
 
A 23 year old man presents with blunt abdominal trauma and a splenic bleed is
suspected. He is commenced on an infusion of tranexamic acid. Which of the
following best describes its mechanism of action?
Inhibition of plasmin
Inhibition of thrombin
Inhibition of factor II
Inhibition of factor Xa
Activation of factor VIII
Tranexamic acid inhibits plasmin and this prevents fibrin degradation.
Next question 
Tranexamic acid
Tranexamic acid is a synthetic derivative of lysine. Its primary mode of action is as

an anti fibrinolytic that competitively inhibits the conversion of plasminogen to
plasmin. Plasmin degrades fibrin and therefore rendering plasmin inactive slows
this process.
The role of tranexamic acid in trauma was investigated in the CRASH 2 trial and
has been shown to be of benefit in bleeding trauma when administered in the first
3 hours.
Next question 
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Question stats
A 43.9%
B 20.1%
C 7.1%
D 11.8%
E 17.2%
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Question 163 of 192
 
A 44 year old lady presents with jaundice. Following a minor ward based surgical
procedure she develops troublesome and persistent bleeding. Deficiency of which
of the vitamins listed below is responsible?
Vitamin C
Vitamin K
Vitamin D
Vitamin B
Vitamin A
Patients who are jaundiced usually have impaired absorption of vitamin K. This
can result in loss of the vitamin K dependent clotting factors and troublesome
bleeding.
Next question 
Vitamin deficiency
A Night blindness
Epithelial atrophy
Infections
B1 Beriberi

B3 Pellagra

Next question 
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Question stats
A 7.6%
B 77.5%
C 5.2%
D 5.3%
E 4.4%
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Question 164 of 192
 
A 34 year old lady has just undergone a parathyroidectomy for primary

hyperparathyroidism. The operation is difficult and all 4 glands were explored. The
wound was clean and dry at the conclusion of the procedure and a suction drain
inserted. On the ward she becomes irritable and develops stridor. On examination,
her neck is soft and the drain empty. Which of the following treatments should be
tried initially?
Administration of intravenous calcium gluconate
Administration of intravenous lorazepam
Removal of the skin closure on the ward
Direct laryngoscopy
Administration of calcichew D3 orally
Exploration of the parathyroid glands may result in impairment of the blood supply.
Serum PTH levels can fall quickly and features of hypocalcaemia may ensue, these
include neuromuscular irritability and laryngospasm. Prompt administration of
intravenous calcium gluconate can be lifesaving. The absence of any neck swelling
and no blood in the drain would go against a contained haematoma in the neck
(which should be managed by removal of skin closure).
Next question 
Calcium homeostasis

Hormone Actions

resorption
of calcium

absorption of Ca2+
reabsorption

levels
reabsorption

calcium
Next question 

          
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Question stats
A 49.6%
B 6.2%
C 23.3%
D 14.6%
E 6.3%
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Question 165 of 192
 
What is the approximate volume of pancreatic secretions in a 24 hour period?
100ml
200ml
500ml
1500ml
3000ml
Typically the pancreas secretes between 1000 and 1500ml per day.
Next question 

Trypsinogen
Procarboxylase
Amylase
Elastase
Sodium
Bicarbonate
Water
Ductal and
Aqueous Potassium
Centroacinar cells
Chloride
Regulation
Enzyme activation
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A 7.3%
B 10.2%
C 20.7%
D 54.8%
E 6.9%
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Question 166 of 192
 
A patient loses 1.6L of fresh blood from their abdominal drain. Which of the
following will not decrease?
Cardiac output
Renin secretion
Firing of carotid baroreceptors
Firing of aortic baroreceptors
Blood pressure
Renin secretion will increase as systemic hypotension will cause impairment of

renal blood flow. Although the kidney can autoregulate its own blood flow over a
range of systemic blood pressures a loss of 1.6 L will usually produce an increase
in renin secretion.
Next question 
Shock

Septic
Haemorrhagic
Neurogenic
Cardiogenic
Anaphylactic
Septic shock


attention:
Haemorrhagic shock

Blood loss % <15% 15-30% 30-40% >40%
Pulse rate <100 >100 >120 >140


Spinal cord injury
Cardiac tamponade


Neurogenic shock
vasodilation.
Cardiogenic shock
following MI.
Anaphylactic shock

in 1,000)

years in 1,000)

1,000)

12 years 1,000)
drugs
Next question 
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Question stats
A 11.6%
B 61.1%
C 9.6%
D 9%
E 8.8%
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Question 167 of 192
 
What is the typical stroke volume in a resting 70 Kg man?
10ml
150ml
125ml
45ml
70ml
Stroke volumes range from 55-100ml.
Next question 
Stroke volume-Cardiac physiology
The stroke volume equates to the volume of blood ejected from the ventricle
during each cycle of cardiac contraction. The volumes for both ventricles are
typically equal and equate roughly to 70ml for a 70Kg man. It is calculated by
subtracting the end systolic volume from the end diastolic volume.
Factors affecting stroke volume

Cardiac size
Contractility
Preload
Afterload
Next question 
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Question stats
A 6%
B 16.3%
C 19.6%
D 7.5%
E 50.7%
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Question 168 of 192
 
Secretions from which of the following will contain the highest levels of
potassium?
Rectum
Small bowel
Gallbladder
Pancreas
Stomach
The rectum has the potential to generate secretions rich in potassium. This is the
rationale behind administration of resins for hyperkalaemia and the development
of hypokalaemia in patients with villous adenoma of the rectum.
Next question 
Potassium secretion -GI tract
Potassium secretions
Salivary glands Variable may be up to 60mmol/L
Stomach 10 mmol/L
Bile 5 mmol/L
Pancreas 4-5 mmol/L
Small bowel 10 mmol/L

Rectum 30 mmol/L
The above table provides average figures only and the exact composition varies
depending upon the existence of disease, serum aldosterone levels and serum pH.
A key point to remember for the exam is that gastric potassium secretions are low.
Hypokalaemia may occur in vomiting, usually as a result of renal wasting of
potassium, not because of potassium loss in vomit.
Next question 
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A 37%
B 25.6%
C 7.2%
D 16.8%
E 13.4%
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Question 169 of 192
 
Which of the following does not decrease the functional residual capacity?
Obesity
Pulmonary fibrosis
Muscle relaxants
Laparoscopic surgery
Upright position
Increased FRC:
Erect position
Emphysema
Asthma
Decreased FRC:
Pulmonary fibrosis
Laparoscopic surgery
Obesity
Abdominal swelling
Muscle relaxants
When the patient is upright the diaphragm and abdominal organs put less pressure
on the lung bases, allowing for an increase in the functional residual capacity
(FRC). Other causes of increased FRC include:
Emphysema
Asthma
In addition to those listed above, causes of reduced FRC include:

Abdominal swelling
Pulmonary oedema
Reduced muscle tone of the diaphragm
Age
Next question 
Lung volumes

volumes)
Definitions
females.



in females.

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A 10.2%
B 11.2%
C 16.6%
D 9.3%
E 52.8%
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
Question 170 of 192
 
An otherwise fit 30 year old male donates 500ml of blood. Which of the processes
outlined below is most likely to occur?
Oliguria
Activation of the renin angiotensin system

Sweating
Fall in mean arterial pressure
Tachypnoea
The loss of 500ml (assuming a 70 Kg male) will usually be sufficient to activate

the renin angiotensin system. It is unlikely that it would cause any other
physiological disturbance.
Next question 
Bleeding
The initial response to bleeding, even if of relatively small volume is generalised

splanchnic vasoconstriction mediated by activation of the sympathetic nervous
system. This process of vasoconstriction is usually sufficient to maintain renal
perfusion and cardiac output if the volume of blood lost is small. Over the
following hours the circulating fluid volume is restored and normal
haemodynamics resume. Loss of greater volumes of blood will typically result in
activation in the renin angiotensin system (see diagram below).
(http://en.wikipedia.org/wiki/Renin%E2%80
%93angiotensin system)
Where the source of bleeding ceases these physiological measures will restore
circulating volume. Ongoing bleeding will result in haemorrhagic shock.
Blood loss is typically quantified by the degree of shock produced as outlined
below:
Blood loss % <15% 15-30% 30-40% >40%
Pulse rate <100 >100 >120 >140
Next question 
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Question stats
A 8%
B 65%
C 9.1%
D 9.5%
E 8.4%

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Question 171 of 192
 
Which of the following haemodynamic changes is not seen in hypovolaemic

shock?
Decreased cardiac output
Increased heart rate

Reduced left ventricle filling pressures
Reduced blood pressure
Reduced systemic vascular resistance

Cardiogenic Shock:
e.g. MI, valve abnormality
increased SVR (vasoconstriction in response to low BP)

increased HR (sympathetic response)
Hypovolaemic shock:
blood volume depletion
e.g. haemorrhage, vomiting, diarrhoea, dehydration, third-space losses during
major operations
increased SVR
increased HR
Septic shock:
occurs when the peripheral vascular dilatation causes a fall in SVR
similar response may occur in anaphylactic shock, neurogenic shock
reduced SVR
increased HR
normal/increased cardiac output
SVR will typically increase
Next question 
Shock

Septic
Haemorrhagic
Neurogenic
Cardiogenic
Anaphylactic
Septic shock

attention:
Haemorrhagic shock
Blood loss % <15% 15-30% 30-40% >40%
Pulse rate <100 >100 >120 >140


Spinal cord injury
Cardiac tamponade


Neurogenic shock
vasodilation.
Cardiogenic shock
following MI.
Anaphylactic shock

in 1,000)

years in 1,000)

1,000)

12 years 1,000)

drugs
Next question 

          
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Question stats
A 10.9%
B 7%
C 9.8%
D 6.4%
E 65.9%
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Question 172 of 192
 
Which of the following does not stimulate insulin release?
Gastrin
Atenolol
Protein
Secretin
Vagal cholinergic action
Beta blockers inhibit the release of insulin.
Stimulation of insulin release:
Glucose
Amino acid
Vagal cholinergic
Secretin/Gastrin/CCK
Fatty acids
Beta adrenergic drugs
Next question 
Insulin
Structure
Synthesis
Function
Inhibits lipolysis
Next question 
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Question stats
A 11.9%
B 51.8%
C 12.8%
D 13.5%
E 9.9%
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Question 173 of 192
 
A 32 year old man has a glomerular filtration rate of 110ml / minute at a systolic
blood pressure of 120/80. If his blood pressure were to fall to 100/70 what would
glomerular filtration rate be?
110ml / minute
100ml/ minute
55ml/ minute
25ml/ minute
75ml/ minute
The proposed drop in blood pressure falls within the range within which the kidney
autoregulates its blood supply. GFR will therefore remain unchanged.
Next question 
Renal Physiology
Overview


cross.
inulin).

1. Inert

--------------------------------------------------------------------------

reabsorption.
Tubular function
membrane.
sodium.
Loop of Henle
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Question stats
A 57.9%
B 16.1%
C 8%
D 6.4%
E 11.5%

Question 174 of 192
 
A 23 year old man has taken an opiate overdose. Of the following structures, which
will be most affected by opiates to produce a reduction in respiratory rate?
Carotid chemoreceptors
Central chemoreceptors
Medullary respiratory centre
Pneumotaxic centre
Juxtacapillary (J) receptors
Opiates typically affect the medullary respiratory centre to depress respiratory

activity.
Next question 
Control of ventilation
Control of ventilation is coordinated by the respiratory centres,

chemoreceptors, lung receptors and muscles.
Automatic, involuntary control of respiration occurs from the medulla.
The respiratory centres control the respiratory rate and the depth of
respiration.
Respiratory centres
Medullary Inspiratory and expiratory neurones. Has ventral group

respiratory centre which controls forced voluntary expiration and the dorsal
group controls inspiration. Depressed by opiates.
Apneustic centre Lower pons
Stimulates inspiration - activates and prolongs inhalation
Overridden by pneumotaxic control to end inspiration
Pneumotaxic Upper pons, inhibits inspiration at a certain point. Fine

centre tunes the respiratory rate.
Ventillatory variables
Levels of pCO2 most important in ventilation control
Levels of O2 are less important.
Peripheral chemoreceptors: located in the bifurcation of carotid arteries and
arch of the aorta. They respond to changes in reduced pO2, increased H+
and increased pCO2 in ARTERIAL BLOOD.
Central chemoreceptors: located in the medulla. Respond to increased H+ in

BRAIN INTERSTITIAL FLUID to increase ventilation. NB the central receptors
are NOT influenced by O2 levels.
Lung receptors include:

Stretch receptors: respond to lung stretching causing a reduced respiratory
rate
Irritant receptors: respond to smoke etc causing bronchospasm
J (juxtacapillary) receptors
Next question 
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Question stats
A 9.8%
B 34.6%
C 21.3%
D 14.8%
E 19.6%

Question 175 of 192
 
What is the substrate of renin?
Aldosterone
Angiotensinogen
Angiotensin converting enzyme

Angiotensin I
Angiotensin II
Renin hydrolyses angiotensinogen to form angiotensin I.

Next question 
Renin
Renin is secreted by juxtaglomerular cells and hydrolyses angiotensinogen to

produce angiotensin I

Hypotension causing reduced renal perfusion
Hyponatraemia
Catecholamines
Erect posture
Factors reducing renin secretion

Drugs: beta-blockers, NSAIDs
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Question stats
A 9.9%
B 49.4%
C 10.4%
D 19.4%
E 10.9%
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Question 176 of 192
 
Which of the following physiological changes do not occur following

tracheostomy?
Alveolar ventilation is increased.
Anatomical dead space is reduced by 50%.

Work of breathing is increased.
Proportion of ciliated epithelial cells in the trachea may decrease.
Splinting of the larynx may lead to swallowing difficulties.
Work of breathing is decreased which is one of the reasons it is a popular option

for weaning ventilated patients. Humidified air in this setting helps to reduce the
viscosity of mucous that forms.
Next question 
Trachea
Trachea
Location C6 vertebra to the upper border of T5 vertebra

(bifurcation)
Arterial and venous Inferior thyroid arteries and the thyroid venous
supply plexus.
Nerve Branches of vagus, sympathetic and the recurrent

nerves
Relations in the neck
Anterior(Superior to Isthmus of the thyroid gland

inferior) Inferior thyroid veins
Arteria thyroidea ima (when that vessel
exists)
Sternothyroid
Sternohyoid
Cervical fascia
Anastomosing branches between the
anterior jugular veins
Posterior Oesophagus.
Laterally Common carotid arteries

Right and left lobes of the thyroid gland

Inferior thyroid arteries
Recurrent laryngeal nerves
Relations in the thorax
Anterior
Manubrium, the remains of the thymus, the aortic arch, left common carotid
arteries, and the deep cardiac plexus
Lateral
In the superior mediastinum, on the right side is the pleura and right vagus;
on its left side are the left recurrent nerve, the aortic arch, and the left
common carotid and subclavian arteries.
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Question stats
A 13.8%
B 16.8%
C 50.7%
D 10.6%
E 8.2%
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
Question 177 of 192
 
A 45 year old man undergoes a sub total colectomy and formation of end
ileostomy. What is the most likely sodium content per litre of ileostomy fluid?
120 mmol
60 mmol
20 mmol
210 mmol
180 mmol
Investigators in the 1960's dehydrated and measured the sodium content of

ileostomy effluent and determined this concentration. Not an experiment many
would care to repeat!
Next question 
Gastrointestinal secretions
Up to 7 litres of gastrointestinal secretions enter the lumen of the GI tract in a 24

hour period. The absorptive function of the small bowel is such that by the time a
formed stool is created, it will contain, on average 200ml water.
The common secretions together with their approximate volumes are
demonstrated below:
Origin of Volume in ml / Na + K+ Cl-

secretion 24 hour period mmol/L mmol/L mmol/L HCO3
Salivary glands 1500 10 26 10 30

Origin of Volume in ml / Na + K+ Cl-
secretion 24 hour period mmol/L mmol/L mmol/L HCO3
Stomach 1500 60 10 130
Duodenum 100-2000 140 80 80
Pancreas 1000 140 5 70 115
Bile 50-800 145 5 100 35
Jejunum/ileum 3000 140 10 104 30
Colon 100 60 30 40
The regulation of these secretions is dependent upon location. In the salivary

glands a complex interaction of flow rate governed by the autonomic nervous
system. The exact composition of sodium and potassium is regulated by
aldosterone. In the stomach hormones such as gastrin play a role and feedback is
both endocrine and neurologically mediated (vagus). In the duodenum CCK is
released in response to duodenal distension and this causes contraction of the
gallbladder and release of bile.
Pancreatic secretions are affected by somatostatin. The secretions in the small

bowel are affected by the osmolality of the lumenal contents. This is in part due to
the tightness of cellular junctions and in this regard the jejunum is more permeable
than the ileum. The practical implication of this is that if an individual has an
extensive intestinal resection and a high output, proximally sited stoma then
administration of hypotonic rather than isotonic solutions will result in worsening
of electrolyte disturbances as electrolyte rich secretions will enter the jejunum.
In some individuals a colectomy or similar procedure results in formation of an end

or loop ileostomy. Ileostomies typically lose between 500 and 1000ml over a 24
hour period and patients with high output ileostomies can rapidly become
dehydrated. Ileostomy effluent typically contains 126mmol/L of sodium and
22mmol/L of potassium. Knowledge of this fluid composition should guide fluid
prescribing in replacing losses.
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Question stats
A 47.5%
B 15.4%
C 8%
D 11%
E 18.2%
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Question 178 of 192
 
The oxygen-haemoglobin dissociation curve is shifted to the right in which of the

following scenarios?
Hypothermia
Low altitude
Decreased 2,3-DPG in transfused red cells
Chronic iron deficiency anaemia
Mnemonic to remember causes of right shift of the oxygen dissociation

curve:
CADET face RIGHT
C O2
A cidosis
2,3-DPG
E xercise
T emperature
The curve is shifted to the right when there is an increased oxygen requirement by
the tissue. This includes:
Increased temperature
Acidosis
Increased DPG:
DPG is found in erythrocytes and is increased during glycolysis. It binds to the Hb

molecule, thereby releasing oxygen to tissues. DPG is increased in conditions
associated with poor oxygen delivery to tissues, such as anaemia and high
altitude.

Next question 
Oxygen Transport
Oxygen transport
Haemoglobin


curve to the right
Haldane effect
Bohr effect
curve)

low temperature
Next question 
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Question stats
A 10.2%
B 15.4%
C 17.4%
D 22.5%
E 34.5%

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Question 179 of 192
 
An over enthusiastic medical student decides to ask you questions about ECGs.
Rather than admitting your dwindling knowledge on this topic, you bravely attempt
to answer her questions! One question is what component of the ECG represents
ventricular repolarization?
QRS complex
Q-T interval
P wave
T wave
S-T segment
The T wave represents ventricular repolarization. The common sense approach to

remembering this, is to acknowledge that ventricular repolarization is the last
phase of cardiac contraction and should therefore correspond the the last part of
the QRS complex.
Next question 
The normal ECG


P wave
P-R interval
QRS complex
ST segment
T wave
depolarization
Q-T interval
action potential.
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A 11.9%
B 8.2%
C 6.5%
D 58.1%
E 15.3%
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Question 180 of 192
 
A 56 year old male presents to the acute surgical take with severe abdominal pain.
He is normally fit and well. He has no malignancy. The biochemistry laboratory
contacts the ward urgently, his corrected calcium result is 3.6 mmol/l. What is the
medication of choice to treat this abnormality?
IV Pamidronate
Oral Alendronate
Dexamethasone
Vitamin D
Resonium salts
IV Pamidronate is the drug of choice as it most effective and has long lasting
effects. Calcitonin would need to be given with another agent, to ensure that the
hypercalcaemia is treated once its short term effects wear off. IV zoledronate is
preferred in scenarios associated with malignancy.
Next question 
Management of hypercalcaemia
Free Ca is affected by pH (increased in acidosis) and plasma albumin

concentration
ECG changes include: Shortening of QTc interval
Urgent management is indicated if:
Calcium > 3.5 mmol/l

Reduced consciousness
Severe abdominal pain
Pre renal failure
Management:
Airway Breathing Circulation
Intravenous fluid resuscitation with 3-6L of 0.9% Normal saline in 24 hours
Concurrent administration of calcitonin will also help lower calcium levels
Medical therapy (usually if Corrected calcium >3.0mmol/l)
Bisphosphonates
Analogues of pryrophosphate
Prevent osteoclast attachment to bone matrix and interfere with osteoclast

activity
Inhibit bone resorption.
Agents
Drug Side effects Notes
IV
pyrexia, leucopaenia Most potent agent
Pamidronate
response lasts 30 Used for malignancy associated

IV Zoledronate
days hypercalcaemia
Calcitonin
Quickest onset of action however short duration (tachyphylaxis) therefore
only given with a second agent.
Prednisolone
May be given in hypercalcaemia related to sarcoidosis, myeloma or vitamin
D intoxication.
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A 60.4%
B 9.7%
C 8.6%
D 10.1%
E 11.3%

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Question 181 of 192
 
Which of the conditions listed below is most likely to account for the following
arterial blood gas result:
pH 7.49
pO2 8.5
Bicarbonate 22
pCO2 2.4
Chloride 12meq
Metabolic alkalosis
Metabolic acidosis
Type II respiratory failure
The hyperventilation results in decreased carbon dioxide levels, causing a

respiratory alkalosis (non compensated).
Next question 
categorised
homeostasis)
Metabolic acidosis
Two mechanisms:

(Na+ + K+) - (Cl- + HCO3-).

Addison's disease
Raised anion gap

types:
Metabolic alkalosis
Causes
Diuretics
Hypokalaemia
Cushing's syndrome
Bartter's syndrome

convoluted tubule
Causes
COPD
/ pulmonary oedema
Causes
altitude
Pregnancy

lead to an acidosis
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Question stats
A 67.8%
B 11.9%
C 5.9%
D 8.2%
E 6.2%


Question 182 of 192
 
A 34 year old man receives morphine following an appendicectomy. He develops

constipation as a result. Which of the following best accounts for this process?
Stimulation of DOPA receptors
Inhibition of DOPA receptors

Stimulation of Mu receptors
Stimulation of serotonin release
Inhibition of serotonin release
4 Types of opioid receptor:

δ (located in CNS)- Accounts for analgesic and antidepressant effects
k (mainly CNS)- analgesic and dissociative effects
µ (central and peripheral) - causes analgesia, miosis, decreased gut
motility
Nociceptin receptor (CNS)- Affect of appetite and tolerance to µ
agonists.
Constipation is a common side effect of morphine treatment and stimulation of

Mu receptors accounts for this process.
Next question 
Morphine
Strong opiate analgesic. It is a pro- type narcotic drug and its effects mediated via
the 4 types of opioid receptor. Its clinical effects stem from binding to these
receptor sites within the CNS and gastrointestinal tract. Unwanted side effects
include nausea, constipation, respiratory depression and, if used long term,
addiction .
It may be administered orally or intravenously. It can be reversed with naloxone.
Next question 
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A 9.4%
B 14.1%
C 59.6%
D 7.5%
E 9.4%
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Question 183 of 192
 
A 28 year old man undergoes an ileocaecal resection to treat terminal ileal Crohns
disease. Post operatively he attends the clinic and complains of diarrhoea. His
CRP is within normal limits and small bowel enteroclysis shows no focal changes.
Which of the following interventions is most likely to be beneficial?
5 ASA drugs
Azathioprine
Pulsed methylprednisolone
Infliximab
Oral cholestyramine
The question is about high output diarrhoea following terminal ileal resection
and the most likely cause is malabsorption of bile salts. The administration of
cholestyramine (bile salt binding agent) will counter this and thats why its the
correct answer.
Malabsorption of bile salts is a common cause of diarrhoea following ileal

resection. A normal small bowel study and CRP effectively excludes active Crohns
disease and therefore immunomodulator drugs are not appropriate.
Next question 
Ileum
Anatomical overview
The terminal ileum comprises 20% of the ileum and has a diameter that is smaller
than that of the jejunum (typically 2cm at the ileocaecal valve). The ileum is
attached to the abdominal wall by a mesentery that contains more fat than that of
the jejunum. The blood supply of the ileum is derived from branches of the
superior mesenteric artery, the vascular arcades of the ileum are more densely
packed than those of the jejunum. The wall of the ileum contains Peyers patches
which are aggregations of lymphoid tissue.
Function
The main function of the terminal ileum is absorption of vitamin B12 and bile salts.
The neuroendocrine cells in the wall of the ileum may secrete hormones. In
surgical patients, resection of the terminal ileum is a common procedure for
conditions such as terminal ileal Crohns disease. Where a significant proportion of
the ileum is removed, patients are at increased risk of bile salt malabsorption with
the development of bile salt diarrhoea and increased risk of gallstones. The lack of
vitamin B12 may pre-dispose to macrocytic anaemia.
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A 15%
B 12.7%
C 11.1%
D 15.3%
E 45.9%
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Question 184 of 192
 
What is the main event involved in the neovascularization of the immature wound
bed following surgery?
Endothelial cell proliferation
Fibroblast proliferation
Macrophage migration
Neutrophil accumulation
Granulocyte degradation
Angiogenesis is a key event in wound healing and occurs as a result of endothelial

cell proliferation.
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Platelet plug
formation and
rich clot
macrophages
impaired in diabetes).
Growth factors
released, including
basic fibroblast
growth factor and
growth factor.
within the adjacent
matrix and migrate
into wound.
Macrophages and
fibroblasts couple
matrix regeneration

factors stimulate
fibroblasts and
epithelial cells.
collagen network.
Angiogenesis occurs
and wound resembles
granulation tissue.

may last up to one
year (or longer).
During this phase
fibroblasts become
differentiated
contraction.
Collagen fibres are
remodelled.
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A 53.3%
B 21.4%
C 10%
D 9.1%
E 6.3%
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Question 185 of 192
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There is decreased secretion of which one of the following hormones in response

to major surgery:
Insulin
Cortisol
Renin
Anti diuretic hormone
Prolactin
Endocrine parameters reduced in stress response:

Insulin
Testosterone
Oestrogen
Insulin is often released in decreased quantities following surgery.
Next question 

response.

hormone

hormone
(ACTH)
Aldosterone
Prolactin
Glucagon

Pituitary gland
control
Cortisol
corticosteroids.

Growth hormone
Alpha Endorphin
Increased
I
Insulin
deficiency

normal responses
surgery
Protein metabolism

Lipid metabolism

Cytokines
Glycoproteins

References
/mkh040
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A 54.3%
B 11%
C 9.3%
D 11%
E 14.5%
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Question 186 of 192
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A 23 year old is stabbed in the groin and develops hypovolaemic shock. What is
the most likely finding on analysis of his urine?
Decreased specific gravity
Increased specific gravity

Increased urinary glucose
Increased urinary protein
Increased red blood cells in the urine
Hypovolaemic shock is likely to compromise renal blood flow especially if blood

pressure falls below the range at which the kidney is able to autoregulate its blood
flow. The result of this will be an increase of the specific gravity as water retention
occurs in an attempt to maintain circulating volume.
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Renal Physiology
Overview


cross.
inulin).


1. Inert

--------------------------------------------------------------------------

reabsorption.
Tubular function
membrane.
sodium.
Loop of Henle

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A 14.7%
B 55.2%
C 6.5%
D 8.1%
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Question 187 of 192
 
A 43 year old lady is recovering on the intensive care unit following a Whipples
procedure. She has a central venous line in situ. Which of the following will lead to
the y descent on the waveform trace ?
Ventricular contraction
Emptying of the right atrium

Emptying of the right ventricle
Opening of the pulmonary valve
Cardiac tamponade
JVP
3 Upward deflections and 2 downward deflections
Upward deflections
a wave = atrial contraction
c wave = ventricular contraction
v wave = atrial venous filling
Downward deflections
x wave = atrium relaxes and tricuspid valve moves down
y wave = ventricular filling
The y descent represents the emptying of the atrium and the filling of the right
ventricle.
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Cardiac physiology
pressure systems.
Cardiac cycle
cycle)






systolic function.
Starlings law

compliance.

angiotensin II.
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B 47%
C 22.3%
D 12.7%
E 6.7%
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Question 188 of 192
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A 45 year old male has alcoholic cirrhosis and decompensated liver failure, which
of the following clotting factors is least likely to be affected?
Factor V
Factor VII
Factor IX
Factor VIII
Factor XI
Factor VIII is synthesised in the endothelial cells of the liver rather than the liver
itself and therefore is less prone to the effects of hepatic dysfunction.
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C 8.9%
D 42.7%
E 12.8%
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Question 189 of 192
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Which part of the ECG represents atrial depolarization?
P wave
Q wave
T wave
QRS complex
P-R interval
The P wave represents atrial depolarization. Note that atrial repolarization is

obscured within the QRS complex.
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The normal ECG


P wave
P-R interval
QRS complex
ST segment
T wave
depolarization
Q-T interval
action potential.
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C 8.7%
D 8.6%
E 8.8%
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Question 190 of 192
 
von Willebrand factor is involved in the stabilization of which of the clotting factors
listed below?
Factor VII
Factor VIII
Factor V
Anti thrombin III
Factor Xa
vWF stabilizes factor VIII
If you answered this incorrectly check you did not select factor VII by mistake!
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Most common inherited bleeding disorder

All vWD is caused by mutations in the gene for von Willebrand factor. von
Willebrand factor is an adhesive glycoprotein that is secreted by
endothelium and megakaryocytes
von Willebrand factor promotes platelet adhesion to damaged endothelium
and other platelets. It is also involved in the transport and stabilization of
factor VIII
There are 7 subtypes of von Willebrand disease. The commonest is type I
(autosomal dominant) which accounts for 80% of cases, type 2vWD
(autosomal dominant or recessive) accounts for 15% of cases
There is a significant spectrum of severity ranging from spontaneous
bleeding and epistaxis through to troublesome excessive bleeding following
minor procedures
The test that is most typically diagnostic is the bleeding time
Treatments include administration of tranexamic acid for minor cases
undergoing minor procedures. More significant bleeding or more significant
procedures respond well to DDAVP. This is most effective in type I, less
effective in type 2 and contraindicated in type 2B. Patients with type 3
disease do not respond to DDAVP as they lack the ability to secrete vWF
Individuals who cannot have DDAVP or in whom it is contra indicated usually
receive factor VIII concentrates containing vWF
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C 10.8%
D 7.6%
E 10.3%
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Question 191 of 192
 
Deficiency of which vitamin is most likely to explain the presentation of a 3 year

old child with Rickets?
Vitamin C
Vitamin B3
Vitamin D
Vitamin A
Vitamin E
Vitamin D is needed to help mineralise bone. When this is deficient, mineralisation

is inadequate and deformities may result.
Next question 
Vitamin deficiency
A Night blindness
Epithelial atrophy
Infections
B1 Beriberi
B3 Pellagra

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B 6.4%
C 70.9%
D 5.4%
E 5.1%
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Question 192 of 192
Which of the following drugs increases the rate of gastric emptying in the
vagotomised stomach?
Ondansetron
Metoclopramide
Cyclizine
Erythromycin
Chloramphenicol
Vagotomy seriously compromises gastric emptying which is why either a

pyloroplasty or gastro-enterostomy is routinely performed at the same time.
Chloramphenicol has no effect on gastric emptying. Ondansetron slows gastric

emptying slightly. Metoclopramide increases the rate of gastric emptying but its
effects are mediated via the vagus nerve. Erythromycin enhances gastric emptying
by acting via the motilin receptor in the gut.
Gastric emptying
The stomach serves both a mechanical and immunological function. Solid

and liquid are retained in the stomach during which time repeated peristaltic
activity against a closed pyloric sphincter will cause fragmentation of food
bolus material. Contact with gastric acid will help to neutralise any
pathogens present.
The amount of time material spends in the stomach is related to its
composition and volume. For example a glass of water will empty more
quickly than a large meal. The presence of amino acids and fat will all serve
to delay gastric emptying.
Controlling factors
Neuronal stimulation of the stomach is mediated via the vagus and the
parasympathetic nervous system will tend to favor an increase in gastric motility. It
is for this reason that individuals who have undergone truncal vagotomy will tend
to routinely require either a pyloroplasty or gastro-enterostomy as they would
otherwise have delayed gastric emptying.
The following hormonal factors are all involved:
Delay emptying Increase emptying
Gastric inhibitory peptide Gastrin

Cholecystokinin
Enteroglucagon
Diseases affecting gastric emptying

All diseases that affect gastric emptying may result in bacterial overgrowth,
retained food and eventually the formation of bezoars that may occlude the
pylorus and make gastric emptying even worse. Fermentation of food may cause
dyspepsia, reflux and foul smelling belches of gas.
Iatrogenic
Gastric surgery can have profound effects on gastric emptying. As stated above
any procedure that disrupts the vagus can cause delayed emptying. Whilst this is
particularly true of vagotomy, this operation is now rarely performed. Surgeons are
divided on the importance of vagal disruption that occurs during an
oesophagectomy, some will routinely perform a pyloroplasty and others will not.
When a distal gastrectomy is performed, the type of anastomosis performed will

impact on emptying. When a gastro-enterostomy is constructed, a posterior,
retrocolic gastroenterostomy will empty better than an anterior one.
Diabetic gastroparesis
This is predominantly due to neuropathy affecting the vagus nerve. The stomach
empties poorly and patients may have episodes of repeated and protracted
vomiting. Diagnosis is made by upper GI endoscopy and contrast studies, in some
cases a radio nucleotide scan is needed to demonstrate the abnormality more
clearly. In treating these conditions, drugs such as metoclopramide will be less
effective as they exert their effect via the vagus nerve. One of the few prokinetic
drugs that do not work in this way is the antibiotic erythromycin.
Malignancies
Obviously a distal gastric cancer may obstruct the pylorus and delay emptying. In
addition, malignancies of the pancreas may cause extrinsic compression of the
duodenum and delay emptying. Treatment in these cases is by gastric
decompression using a wide bore nasogastric tube and insertion of a stent or, if
that is not possible, by a surgical gastroenterostomy. As a general rule
gastroenterostomies constructed for bypass of malignancy are usually placed on
the anterior wall of the stomach (in spite of the fact that they empty less well). A
Roux en Y bypass may also be undertaken, but the increased number of
anastomoses for this, in malignant disease that is being palliated, is probably not
justified.
Congenital Hypertrophic Pyloric Stenosis

This is typically a disease of infancy. Most babies will present around 6 weeks of
age with projectile non bile stained vomiting. It has an incidence of 2.4 per 1000
live births and is more common in males. Diagnosis is usually made by careful
history and examination and a mass may be palpable in the epigastrium (often
cited seldom felt!). The most important diagnostic test is an ultrasound that
usually demonstrates the hypertrophied pylorus. Blood tests may reveal a
hypochloraemic metabolic alkalosis if the vomiting is long standing. Once the
diagnosis is made the infant is resuscitated and a pyloromyotomy is performed
(either open or laparoscopically). Once treated there are no long term sequelae.
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D 53.7%
E 3.7%

Calcium homeostasis question

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Calcium homeostasis question

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Question 1 of 192

Most filtered calcium is reabsorbed (95%) a rare disorder of familial hypocalcemic

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Hormonal regulation of calcium

Parathyroid hormone (PTH) Increase calcium levels and

(active form of vitamin D) in the

1,25-dihydroxycholecalciferol Increases plasma calcium and

Calcitonin Secreted by C cells of thyroid

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 Open MRCS Part A textbook (../review/textbook.php)

Which of the following statements is true of glucagon?

Glucagon is produced in response to hyperglycaemia

Released by beta cells

Produced in response to an increase of amino acids

Composed of 2 alpha polypeptide chains linked by hydrogen bonds

Glucagon is a protein comprised of a single polypeptide chain.

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Decreased plasma glucose Somatostatin

Increased catecholamines Insulin

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 Open MRCS Part A textbook (../review/textbook.php)

Which of the following is not caused by cortisol in the stress response?

Skeletal muscle protein breakdown

An 'anti insulin' effect occurs leading to hyperglycaemia.

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Stress response: Endocrine and metabolic changes

Surgery precipitates hormonal and metabolic changes causing the stress

A summary of the hormonal changes associated with the stress response:

Growth hormone Insulin Thyroid stimulating

Cortisol Testosterone Luteinizing hormone

Renin Oestrogen Follicle stimulating

Sympathetic nervous system

Skeletal muscle protein breakdown to provide gluconeogenic precursors and

Thyroxine (T4) and tri-iodothyronine (T3)

Metabolic effect of endocrine response

ceruloplasmin) and are used for gluconeogenesis

Salt and water metabolism

Modifying the response

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 Open MRCS Part A textbook (../review/textbook.php)

Which of the following statements relating to abnormal coagulation is false?

Warfarin affects the synthesis of factor 2,7,9,10

The prothrombin time is prolonged in Haemophilia A

Cholestatic jaundice can cause vitamin K deficiency

Disseminated intravascular coagulation is associated with

Massive transfusion is associated with reduced levels of factor 5 and 8

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Heparin Prevents activation factors 2,9,10,11

Warfarin Affects synthesis of factors 2,7,9,10

DIC Factors 1,2,5,8,11

Liver disease Factors 1,2,5,7,9,10,11

Interpretation blood clotting test results

Disorder APTT PT Bleeding time

Haemophilia Increased Normal Normal

von Willebrand's disease Increased Normal Increased

Vitamin K deficiency Increased Increased Normal