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1. A  26-year-old  man  is in the  torpid shock phase  as a result  of a car accident. In blood:  3, 2 · 109/l. What  is the  leading mechanism  of leukopenia development?

Explanation

Shock is a form of stress which is accompanied by the release of stress hormones (catecholamines, cortisol). Stress-induced changes in blood leukocyte distribution may represent an adaptive response. This represents a redistribution of leukocytes from the blood to other organs such as the skin, draining sentinel lymph nodes and other compartments. Such leukocyte redistribution may enhance immune function in compartments to which immune cells traffic during stress.

2.

A 25-year-old man has spent a long time in the sun under  high air humidity.  As a result of it his body temperature rose up to 39oC . What pathological process is it?

Explanation

Hyperthermia (i.e. marked warming of core temperature) is not mediated by pyrogens and there is no resetting of the hypothalamic set point. It may be accidental or therapeutic.

3.

A   45-year-old   woman   has   breast cancer. Her left arm has symptoms of lymphatic  system insufficiency - limb edema,  lymph  node  enlargement. What form of lymphatic circulation  insufficiency is it?

Explanation

Types of lymph-circulatory insufficiency:

·        Mechanical insufficiency

·        Dynamic insufficiency

·        Insufficiency of absorption/Resorption insufficiency

Mechanical insufficiency is present where lymph flow is hindered by a mechanical factor. The mechanical factor may be of an anatomical, organic nature e.g. occlusion of lymphatics by obstructive lymphangitis, thrombosis of the lymphatics (e.g. during cancer metastasis), filariasis.

The other two types has to do with a disbalance of proteins that upsets the filtration and absorption pressures.

4. A patient underwent an extraction of a part of a CNS structures by medical indications.  As a result  of the  extraction the patient developed atony,  astasia,  intention tremor, ataxy and adiadochokinesis. Which  part  of  CNS  structure had  been extracted?

Explanation

During cerebellar lesions, there  are disturbances in posture, equilibrium and movements. Disturbances in movements: ataxia, asynergia, asthenia (weak muscle contractions with characteristically rapid onset of muscle fatigue), Dysmetria, Intention tremor, astasia (loss of the capacity for sustained tetanic contractions), nystagmus, rebound phenomenon, dysarthria, adiadochokinesis, atonia (lack or impairment of muscle tone).

5.

A tooth extraction in a patient with chronic persistent hepatitis was complicated with prolonged hemorrhage. What  is the reason for the haemorrhagic syndrome?

Explanation

Liver disease (hepatitis) may result in a number of defects in hemostasis. Except vitamin K deficiency, they may lead to the reduced synthesis of factors of coagulation. The reduced synthesis of coagulation factors may be the result of severe hepatocellular damage. There are 3 main stages in the blood coagulation cascade:

·        Formation of the thromboplastin complex

·        Transformation of prothrombin to thrombin

·        Transformation of fibrinogen to fibrin

In hepatitis, there will be reduced synthesis of thrombin and fibrin; but thrombin comes before fibrin in the coagulation cascade, therefore, decrease in thrombin production is a more correct answer in this case.

6. A patient with enteritis accompanied  by  massive  diarrhea has  low  water  rate in the extracellular space, high water rate inside  the  cells and  low blood  osmolarity. What is such disturbance of water-electrolytic  metabolism called?

Explanation

Hypoosmolar hypohydration (salt deficit) develops due to diarrhea, vomiting, sweating, adrenal insufficiency, hypokalemia, CNS lesions, salt-losing nephritis.

          Hyperosmolar hypohydration (water defcit) develops due to the loss of the fluid which lacks electrolytes e.g. in diabetes insipidus, hyperventilation.

          Isoosmolar hypohydration (isoosmotic loss): proportional volume decrease of fluids and electrolytes e.g. in blood loss, burns, diuretic therapy, especially diarrhea in cholera.

         Hypoosmolar hyperhydration (water excess) develops in acute renal failure (in the stage of anuria), Parhon’s syndrome (syndrome of inappropriate ADH secretion –SIADH).

         Hyperosmolar hyperhydration (salt excess) develops rarely e.g. in drinking salt (sea) water, infusion of hypertonic saline, adrenal hyperactivity or steroid therapy.

    Low water level extracellularly – Hypohydration

    Low blood osmolarity – Hypoosmolar

                Hypoosmolar hypohydration

7.

A  pregnant woman  was  registered in an antenatal clinic and underwent complex examination for a number of infections.  Blood  serum  contained IgM to  the  rubella  virus.  What  is this  result indicative of?

Explanation

High IgM level usually indicate an acute or primary infection because, it is the first antibody to appear in response to initial exposure to an antigen. Secondary or reinfection show an increase in IgG. IgM antibodies appear early in the course of an infection, this makes it useful in the diagnosis of infectious diseases. Demonstrating IgM antibodies in a patient’s serum indicates recent infection or in a neonate’s serum, it indicates intrauterine infection.

8. A patient with massive burns developed acute renal insufficiency characterized by a significant and rapid deceleration of glomerular filtration. What is the mechanism of its development?

Explanation

Massive burns leads to hypovolemia and decreases general blood volume in circulation. This decrease in blood volume, decrease perfusion to all organs in the body. Decrease in renal perfusion (renal blood flow) will decrease glomerular filtration rate (GFR).

9.

After  a craniocerebral trauma a patient lost the ability to execute learned purposeful movements (apraxia). The injury is most likely localized in the following region of the cerebral cortex:

Explanation

Apraxia is defined as a cognitive motor disorder in which the patient loses the ability to accurately perform learned, skilled actions. Apraxia is primarily a condition that localized to the dominant (usually left) hemisphere of the brain. In particular, lesions of supramarginal gyrus and underlying white matter of the left parietal lobe have been implicated to cause apraxia.

10.

After an immunoassay a child was diagnosed with immunodeficiency of humoral immunity. What is the reason  for the primary  immunodeficiency development in the child?

Explanation

The humoral immunity deficiency is the most frequent among primary immunodeficiency types. The genetic defects of immune system development are on the basis of primary immunodeficiency, causing various clinical symptoms. There are 36 primary immunodeficiency types according to the last international classification, which are divided into 5 groups depending on the kind of deficiency of the immune system:

·        Deficiency of humoral immunity (B-component): frequently in bacterial infections.

·        Deficiency of cellular immunity (T-component): frequently in viral infections.

·        Combined T and B – immunodeficiency: during both bacterial and viral infections.

·        Deficiency of phagocytes system.

·        Deficiency of complement system: in gram negative coccal infections.

11. In response to a change in body position from horizontal to vertical blood circulation system develops reflectory pressor  reaction. Which  of the  following is its compulsory  component?

Explanation

From horizontal (lying position) to vertical (standing position) will make all blood flow towards the lower extremities, thereby reducing venous return (blood going upwards towards the heart) in the first place. This will definitely ↓ cardiac output (C.O) → ↓blood supply to brain (this can lead to fainting). Then there is reflex vasoconstriction to increase venous return to heart, in the absence of any pathology.

12.

A child with a history of frequent angine and pharyngitis has been diagnosed with lymphadenopathy and splenomegaly. His appearance is characterised by pastosity and paleness, muscular tissue is poorly developed. Lymphocytosis is present. What  kind of diathesis is it?

 

Explanation

Abnormality of constitution, so called diathesis is characterized by pathological reactions on physiological agent. Classification of diathesis:

·        Hemorrhagic: characterized by hemorrhagic reaction to physiological factors.

·        Thymicolymphatic/Lymphohypoplastic: characterized by enlargement of lymphatic nodes, muscular atrophy, individual pale, pastous, predisposing to autoallergic disease, lymphocytosis, angina and other infectious diseases.

·        Neuroarthritic/Gouty: predisposing to arthralgia, arthritis, rheumatism, obesity, gout, psychic disease.

·        Edematic/Exudative: characterized by edema reaction to different environmental factors.

·        Asthenic: expressed in hypodynamia, hypotonia.

13. There are several groups of molecular mechanisms playing important part in pathogenesis of insult to cells which contributes to the pathology development. What processes are stimulated by proteinic damage mechanisms?

Explanation

Protein mechanism is one of the molecular mechanisms of cell injury. The protein mechanism of cell damage includes:

·        Inhibition of enzymes (reversible and irreversible)

·        Denaturation – violation of native structure of proteins

·        Proteolysis – that is carried out under the action of lysosomal enzymes.

14.

A    male    patient   has    been    diagnosed  with  gastric  ulcer.  Bacteriological examination of biopsy  material from the   affected   part   of  stomach   revealed small colonies of gram-negative, oxide reductase-positive flexibacteria  that  grew on  the  chocolate  agar  on  the  fifth  day. Which  of  the  following  microorganisms is the most likely causative agent?

Explanation

Helicobacter pylori causes gastritis and peptic ulcers. Infection with H. pylori is a risk factor for gastric carcinoma and is linked to mucosal-associated lymphoid tissue (MALT) lymphoma. It is a gram negative, flexibacteria, oxidase positive, microaerophilic, motile and the only species in the Helicobacter genus to have multiple unipolar – sheathed flagella.

image

Microaerophiles need O2 because they cannot ferment or respire anaerobically. However, they are poisoned by high concentrations of O2. They gather in the upper part of the test tube but not the very top. CO2 is essential for initial growth of H. pylori in liquid media (microaerophilic property). They produce urease, so it’s a diagnostic tool and not a necessary consideration for cultivation (culture medium).

15.

Blood   count   of  an   athlete  is  as follows:  erythrocytes  -  5, 5 · 1012/l,  Hb-180 g/l, leukocytes  - 7 · 109/l, neutrophils -64%, basophils - 0,5%, eosinophils - 0,5%, monocytes  - 8%, lymphocytes  - 27%. First of all, such results indicate the stimulation of:

Explanation

 

        Normal range

               Result

RBC (erythrocytes): Men

      4.2 – 5.2 X 1012/L

          5.5 X 1012/L     (↑)

                               Women

      3.7 – 4.7 X 1012/L

 

Hemoglobin:  Men

      135 – 165g/L

           180g/L        (↑)

                        Women

      120 – 140g/L

           

Leukocytes (WBC):

      4.0 – 9.0 X 109/L

      7 X 109/L    (normal)

    Basophils

         0 - 1%

           0.5%    (normal)

    Eosinophils

         0.5 – 5%

           0.5%    (normal)

    Neutrophils

         47 – 72%

           64%     (normal)

    Lymphocytes

         19 – 37%

           27%     (normal)

    Monocytes

           3 – 11%

            8%      (normal)

 

This results indicates erythropoiesis i.e. synthesis of RBCs.

16.

An adult man presents with systemic arterial pressure drop from 120/70  to 90/50  mmHg. This   resulted  in  reflex vasoconstriction. Vasoconstriction will be minimal in the following organ:

 

Explanation

The drop in arterial pressure (AP) will cause a reflex tachycardia, the heart increases its contractility and cardiac output. Vasoconstriction will be minimal in the heart, because the heart needs to pump more i.e. do more work. Therefore, it needs more blood supply. But vasoconstriction will be maximal in the GIT (bowels), muscles, skin due to centralization of blood flow (i.e. redistribution of blood to important organs like heart, brain)

17.

During surgical manipulations a patient has been given novocaine  injection for anesthesia. 10 minutes  later  the  patient developed paleness,  dyspnea,  hypotension. What type of allergic reaction is it?

Explanation

Considering the time (10mins) – immediate

Type I Hypersensitivity reaction (HSR); anaphylactic and atopic: free antigen cross-links IgE on presensitized (i.e. exposed to the antigen before) mast cells and basophils, triggering immediate release of vasoactive amines that act at postcapillary venules (i.e. histamine). Reaction develops rapidly after antigen exposure because of preformed antibody from first exposure. IgE is the main immunoglobulin involved in type I HSR. Type I: uses IgE and IgG4

18.

A patient with marked pneumofibrosis that developed after infiltrating pulmonary tuberculosis has been  diagnosed with respiratory failure. What is its pathogenetic type?

Explanation

Restrictive respiratory disease is the abnormal respiratory condition characterized by difficulty in inspiration. e.g. poliomyelitis, myasthenia gravis, paralysis of diaphragm, spiral cord diseases, pleural effusion, fibrosis. (lung fibrosis - pneumofibrosis) Obstructive respiratory disease is the abnormal respiratory condition characterized by difficulty in expiration. e.g. asthma, chronic bronchitis, emphysema, cystic fibrosis.
19.

Blood   plasma   of  a  healthy   man contains  several dozens of proteins.  During an illness new proteins  can originate, namely   the   protein  of  \"acute   phase\". Select such protein from the listed below:

Explanation

Acute phase reactants are factors whose serum concentrations change significantly in response to inflammation produced by the liver in both acute and chronic inflammatory states. Notably induced by IL-6 e.g. C-reactive protein, hepcidin, serum amyloid A are all upregulated; while albumin and transferring are downregulated. C-reactive protein is an opsonin, it fixes complement and facilitates phagocytosis. It is measured  clinically as a sign of ongoing inflammation.

20.

A  student failed  to  answer  all  the questions  of examination paper  correctly. As   a  result   he   blushed,   felt   hot   and lost confidence. What type of arterial hyperemia has developed in this case?

Explanation

·        Neuroparalytic arterial hyperemia is caused by damage or blockage of α-adrenoreceptors (sympathetic nervous system). It is characterized by reduction or absence (paralysis) of the sympathetic nervous system effects on the walls of the arteries and arterioles.

·        Neurotonic arterial hyperemia is caused by activation of parasympathetic nervous system; irritation of vascular dilators part of vascular center (CNS) or inhibition of vascular – constrictor part of this center (vasomotor center of CNS); M-cholinoreceptors; H2-histaminereceptors. It is characterized by predominance of the parasympathetic nervous system effects on arterial vascular walls.

After the exam parasympathetic nervous system is the dominant system. Before the exam, sympathetic nervous system is the dominant system.

21.

A patient presents with icteritiousness of skin, scleras and mucous membranes. Blood  plasma  the  total  bilirubin is increased,  stercobilin is increased in  feces,  urobilin   is  increased   in  urine. What type of jaundice  is it?

Explanation

image

Hemolytic/Prehepatic Jaundice is the type of Jaundice that occurs because of excessive destruction of RBCs resulting in ↑ blood level of free, Indirect, unconjugated bilirubin. In this condition, the excretory function of the liver is normal. But the quantity of bilirubin ↑ greatly. The liver cells cannot excrete that much excess bilirubin rapidly. Formation of Urobilinogen (stercobilin) ↑ resulting in the excretion of more amount of stercobilin in stool and urine.

Indirect; Hemolytic; Prehepatic

Mixed; Parenchymal; Hepatic

Direct; Obstructive; Mechanic; Posthepatic

Stercobilin (faeces)

        ↑↑↑

Decreases (pale faces)

Absent (clay coloured faeces)

Type of bilirubin in blood

Unconjugated

Conjugated and Unconjugated

Conjugated

·       Gilbert syndrome (familial nonhemolytic Jaundice): Autosomal recessive defect. Impaired UGT activity. Jaundice occurs with fasting, volume depletion, stress, menses.

22.

A 38-year-old  male patient has been ill with systemic lupus  erythematosus for three years. He was diagnosed with diffuse renal   affection   accompanied  by  massive  edemata and  expressive   proteinuria. What  is the  most  likely  cause  of proteinuria development?

Explanation

Type III (immune-complex): deposition of antigen-antibody complexes e.g. systemic lupus erythromatous (SLE), Arthus reaction, serum sickness, poststreptococcal glomerulonephritis etc.

Systemic lupus erythematous (SLE, Libman-sacks disease) is the classic prototype of the multisystem disease of autoimmune origin, characterized by a bewildering array of autoantibodies, particularly antinuclear antibodies. It is characterized principally by injury to the skin, joints, kidney, and serosal membranes. Antinuclear antibody is directed against several nuclear antigens and can be grouped into 4 categories:

·        Antibodies to DNA

·        Antibodies to histones

·        Antibodies to nonhistone proteins bound to RNA

·        Antibodies to nuclear antigens.

SLE is a type III hypersensitivity reaction with formation of immune complexes. It can cause diffuse proliferative glomerulonephritis seen under the light microscope as “wire loop” of capillaries and granular under the immunofluorescence microscopy.

23.

Before  a surgery a blood sample of a 30-year-old  man  has  been  typed.  Blood is Rh-positive. Standard  serums  of  such groups as 0 αβ (I), Аβ (II), Вα (III) didn’t activate  erythrocyte agglutination reaction. The group of the analyzed blood is:

Explanation

image

Blood group O(I): no antigens, therefore no agglutination.

Blood group A(II): A antigen, agglutinate with blood group B(III) and O(I).

Blood group B(III): B antigen, agglutinate with blood group A(II) and O(I).

Blood group AB(IV): A and B antigen, agglutinate with all blood groups. No antibody.

Blood group name is determined by the antigen present on RBC, but the patient has an opposite antibody. So whenever, the antibody corresponds to the antigen, there is agglutination. Since O does not have any antigen, no agglutination can occur.

24.

A  patient complains  of hydruria (7 liters per day) and polydipsia.  Examination  reveals  no  disorders of carbohydrate metabolism.  These   abnormalities  might be caused by the dysfunction  of the following endocrine gland:

Explanation

ADH (vasopressin) is produced in neurohypophysis (posterior pituitary gland). ADH causes reabsorption of free water through aquaporins in collecting ducts of kidney.

image

Diabetes insipidus (D.I.) is characterized by intense thirst and polyuria (hyperdiuresis) with inability to concentrate urine due to lack of ADH (central D.I.) or failure of response to circulating ADH (nephrogenic D.I.). in central D.I. antidiuretic hormone (ADH) is decreased; in nephrogenic D.I. ADH is normal. Therefore, the hormonal drug we can use to treat diabetes insipidus is to replace the low antidiuretic hormone (ADH) in central diabetes insipidus. So, we use ADH – a posterior pituitary hormone which increases water reabsorption in renal tubules and decrease diuresis. Its analogue desmopressin acetate can also be administered intranasally. Nephrogenic diabetes insipidus does not require hormonal replacement.

25.

A 45-year-old patient was admitted to the  cardiological  department. ECG  data: negative  P wave overlaps  QRS  complex, diastolic interval  is prolonged after extrasystole. What  type  of extrasystole is it?

Explanation

 Nodal or atrioventricular (AV) extrasystole is caused by stimulus arising from AV node. The excitation of the atria differs from normal, the impulse is transmitted retrogradely from bottom to top. The following signs are characteristic of the ECG in nodal extrasystole:

·        Premature appearance of the cardiac complex.

·        Changes in the P wave which becomes negative to show the retrograde atrial excitation (in some cases the P wave is absent on the ECG).

·        If the atria and ventricles are excited synchronously, the P wave superimposes (overlaps) the QRS complex.

26.

A  19-year-old   female   patient  has had low haemoglobin rate  of 90-95 g/l since childhood.  Blood  count  results obtained  after  hospitalisation are  as  follows: erythrocytes  -  3, 2 ·  1012/l,  Hb-   85  g/l, colour index - 0,78; leukocytes  - 5, 6 · 109/l, platelets - 210 · 109/l. Smear  examination  revealed   anisocytosis,   poikilocytosis and  target  cells. Reticulocyte rate  is 6%. Iron  therapy was ineffective.  What  blood pathology corresponds with the described clinical presentations?

Explanation

Thalassemia or target cell anemia or Cooley’s anemia is an hemoglobinopathy (abnormal hemoglobin in RBCs). Defect in α-globin chain results in α thalassemia; and point mutations in β-globin chain results in β thalassemia. It is characterized microscopically by anisocytosis, poikilocytosis, target cells and is characterized by increased hemolysis, enlargement of spleen and liver, progressive anemia with erythroblastemia (reticulocyte). It’s a microcytic, hypochromic anemia.

image

Sickle cell anemia is also a hemoglobinopathy (abnormal hemoglobin in RBCs). It results as a result of a point mutation causing a single amino acid replacement in β chain (substitution of glutamic acid with valine) to produce hemoglobin S (HbS). The condition is characterized by the presence of sickle-like erythrocytes revealed during crisis, they cause stasis, hemorrhages and infarctions.

27.

A female patient presents with endocrine dysfunction   of  follicular  cells of  the   ovarian   follicles  resulting   from an inflammation. The synthesis of the following hormone will be inhibited:

Explanation

Sexual cycles are controlled by the hypothalamus. Gonadotropin-releasing hormone (GnRH), produced by the hypothalamus acts on cells of the anterior lobe (adenohypophysis) of the pituitary gland which in turn secrete gonadotropins. These hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), stimulate and control cyclic changes in the ovary.

image

At the beginning of each ovarian cycle, 15-20 primary stage (preantral) follicles are stimulated to grow under the influence of FSH. Under normal conditions, only one of these follicles reaches full maturity and only one oocyte is discharged; the others degenerate and become atretic. FSH also stimulates maturation of follicular (granulosa) cells surrounding the oocyte. In cooperation, theca interna and granulose cells produce estrogens. As a result of this estrogen production, the uterine endometrium enters the follicular or proliferative phase. Thinning of the cervical mucus occurs to allow passage of sperm and the anterior lobe of the pituitary gland is stimulated to secrete LH. So dysfunction of follicular cells will inhibit the production of estrogen.

28.

A   32-year-old   patient  consulted   a doctor   about   the   absence   of  lactation after  parturition. Such disorder might be explained by the  deficit of the  following hormone:

Explanation

image

Prolactin is responsible for lactogenesis. Prolactin is secreted from anterior pituitary gland. It is necessary for the final preparation of mammary glands for the production and secretion of milk. Lactation means synthesis, secretion and ejection of milk.

29.

The    patient   with    complaints   of permanent thirst  applied   to  the  doctor. Hyperglycemia, polyuria  and increased concentration of 17-ketosteroids in the urine  were  revealed.  What  disease  is the most likely?

Explanation

17-ketosteroids (17-KS) are substances that are formed when the body breaks down male steroid sex hormones called androgens and other hormones released by the adrenal glands in males and females; and by the testes in males. Increased levels of 17-ketosteroids may be due to: adrenal gland problems such as tumor – cushing’s syndrome, cushing’s disease; ovarian or testicular cancer. Itsenko-cushing disease is hypercortisolism due to excess pituitary secretion of adrenocorticotropic hormone (ACTH). Excess ACTH leads to excess adrenal hormones → excess mineralocorticoids; excess sex hormones (↑17-KS); excess glucocorticoids (steroid diabetes). Steroid diabetes is a medical term referring to prolonged hyperglycemia due to glucocorticoid (cortisol) excess. Steroid diabetes → 17-KS.

30.

A  patient has  corestenoma. What  is the reason of such condition?

Explanation

Corestenoma is narrowing of the pupil i.e. miosis. Miosis (myosis) is a parasympathetic effect mediated by acetylcholine.

Muscarinic receptors belong to the class of G protein-coupled receptors under the parasympathetic nervous system. These receptors, in addition to binding Acetylcholine, it also recognizes muscarine – an alkaloid that is present in certain poisonous mushrooms. Muscarinic effects include miosis, spasm of accommodation, increasing of lacrimal, salivary, gastrointestinal, bronchial and sweat glands secretion, increase of smooth muscle tonus of internal organs, bradycardia, decreased arterial pressure. 

Sympathetic effects (acting through α or β-adrenergic receptors).

31.

A patient is 44 years old. Laboratory examination of  his  blood  revealed   that content of proteins  in plasma  was 40 g/l. What   influence   will  be  exerted on  the transcapillary water metabolism?

Explanation

Reference interval (adults): 60 – 80g/L

40g/L is low i.e. a low oncotic pressure.

Glomerular filtration rate (GFR) is inversely proportional to oncotic pressure/colloid osmotic pressure, which is exerted by plasma proteins in the glomerular capillary blood. When oncotic pressure is low, GFR increases. Reabsorption is decreased, because the low oncotic pressure is not sufficient to reabsorb water and other substances (cannot create enough pressure to reabsorb water and other substances).

32.

In allergic diseases, a dramatic increase in basophilic leukocyte number in patients’ blood is observed. This phenomenon is due to the following basophil function:

Explanation

Remember that the first contact of allergen with immune cells occurs in the immunological stage resulting in IgE bound to the surface of mast cells. Pathochemical stage of anaphylactic (Type I- allergic) reaction: now, the next exposure to the same antigen results in fixing of the antigen to mast cell-bound IgE. This process leads to mast cell degranulation with the discharge of preformed or primary mediators (histamine, heparin, serotonin etc) and synthesis of secondary mediators (prostaglandins, leukotrienes and cytokines).

33.

A patient has been admitted to the contagious isolation ward with signs of jaundice caused by hepatitis virus. Which of the symptoms given below is strictly specific for hepatocellular jaundice?

Explanation

In viral hepatitis, there is generalized liver dysfunction involving uptake and conjugation of unconjugated bilirubin, secretion of conjugated bilirubin into bile ducts, and recycling of urobilinogen. Alanine transaminase (ALT) and Aspartate transaminase (AST) are increased (↑), but ALT is higher than AST and there is a slight ↑ in alkaline phosphatase (ALP) and ɣ-glutamyltransferase (GGT).

ALT is a specific enzyme for liver necrosis; present in the cytosol. ALT>AST: viral hepatitis.

AST is present in the mitochondria. Alcohol damages mitochondria AST>ALT indicates alcoholic hepatitis

34. A patient has acute bronchitis. The fever up to 38, 5oC had lasted for a week, presently there is a decrease in temperature down to 37, 0oC. Specify the leading mechanism in the 3rd stage of fever:

Explanation

image

Stages of fever:

I. Stadium Increment (↑of temperature)

II. Stadium Fastigii (stable, but high temperature; saving of the increased temperature)

III. Stadium Decrementi (decline of temperature)

Temperature decreasing mechanisms in the 3rd stage: vasodilation of skin blood vessels (peripheral vasodilation); decrease of heat production; sweating

35.

A public utility specialist went down into a sewer well without protection and after a while lost consciousness. Ambulance doctors diagnosed him with hydrogen sulfide intoxication. What type of hypoxia developed?

Explanation

Hemic hypoxia (blood hypoxia): may be connected with hemoglobin (Hb) quantity or inhibition of its functions. It is observed during anemia of different genesis; also during poisoning with carbon monoxide, nitrates, sulfa drugs (H2S) and other substances. In this case we will observe inactivation type of hemic hypoxia with the acquired hemoglobinopathies development. Acquired hemoglobinopathies are characterized by formation of carboxyhemoglobin and methemoglobin.

36.

A child with a normal karyotype is diagnosed with cleft lip and hard palate, defects of the cardiovascular system, microcephaly. The child’s mother suffered rubella during pregnancy. This pathology in the child may be an example of:

Explanation

Genocopy is a trait that is a phenotypic copy of a genetic trait but is caused by a different genotype. A phenotype that appears identical to another phenotype but that is caused by a different genetic mechanism e.g. the cleft lip and palate is identical to patau’s syndrome (trisomy 13) but in this case the patient has a normal karyotype. Phenocopy is a phenotype that is not genetically determined but mimics one that is. It is the opposite of genocopy.

37.

A 28-year-old patient undergoing treatment in the pulmonological department has been diagnosed with pulmonary emphysema caused by splitting of alveolar septum by tissular tripsin. The disease is caused by the congenital deficiency of the following protein:

Explanation

Emphysema: permanent enlargement of all or part of the respiratory unit. Causes include smoking cigarette (most common cause) and α1-antitrypsin (AAT) deficiency. α1-antitrypsin is a protease inhibitor; also referred to as α1-proteinase inhibitor because it inhibits a wide variety of proteases (including trypsin as the name implies).

38. A patient with signs of osteoporosis and urolithiasis has been admitted to the endocrinology department.    Blood test has revealed hypercalcemia and hypophosphatemia. These changes are associated with abnormal synthesis of the following hormone:

Explanation

Parathyroid hormone: secreted by chief cells of parathyroid gland. Effects include:

↑bone resorption of Ca2+ and PO43- → ↑their plasma levels

↑kidney reabsorption of Ca2+ in distal convoluted tubule → ↑ Ca2+ plasma level

↓reabsorption of PO43- in proximal convoluted tubule → ↓ PO43- plasma levels

↑Calcitriol (vit D3) production by stimulating kidney 1α-hydroxylase in proximal convoluted tubule. It increases Ca2+ and PO43- absorption in the intestine.

image

In general, parathyroid hormone ↑ Ca2+ plasma level but ↓ PO43- plasma levels. Abnormal synthesis (↑synthesis) of parathyroid hormone can lead to hypercalcemia and hypophosphatemia.

Calcitonin is secreted by parafollicular cells (C cells of the thyroid gland). It ↓bone resorption of Ca2+. It opposes actions of parathyroid hormone. But its not important in normal Ca2+ homeostasis. Calcitriol ↑ circulating Ca2+ ions as a means of enhancing intestinal absorption of calcium (NB: Calcitriol production is dependent on parathyroid hormone). Aldosterone: reabsorption of Na+, excretion of K+. Cortisol – glucocorticoid: ↑ blood pressure and gluconeogenesis; ↓ inflammatory and immune responses; ↓ bone formation (↓osteoblast activity).

39.

Pancreas is known as a mixed gland. Endocrine functions include production of insulin by beta cells. This hormone affects the metabolism of carbohydrates. What is its effect upon the activity of glycogen phosphorylase (GP) and glycogen synthase (GS)?

Explanation

krushkrok No196 (2014)

Insulin stimulates glycogen synthase by dephosphorylation. Insulin is an anabolic hormone (build up). So, it stimulates glycogen synthase to favor the synthesis of glycogen (glycogenesis) and inhibits glycogen phosphorylase used in glycogenolysis (glycogen breakdown). Glucagon and Epinephrine stimulates glycogen phosphorylase to break down glycogen to glucose and make energy available for “fight and flight” reactions.

40.

A patient complains of palpitation after stress. The pulse is 104 bpm, P-Q=0,12 seconds, there are no changes of QRS complex. What type of arrhythmia does the patient have?

Explanation

krushkrok No28 (2009)

Sinus tachycardia is the increase in discharge of impulses from the sinoatrial (SA) node, resulting in increase in heart rate (heart rate increase up to 100beats/min).ECG is normal, except for short R-R intervals .

Sinus bradycardia is the reduction in discharge of impulses from SA node resulting in decrease in heart rate. Heart rate is less than 60beats/min. Extrasystole is the premature contraction of the heart before its normal contraction. ECG is altered. Sinus arrhythmia is characterized by irregular generation of impulses and may be due to variations in the tone of the vagus nerve. ECG is altered.

41. A 30-year-old patient has undergone keratoplasty in the transplantation center, cornea has been taken from a donor, who died in a road accident. What kind of transplantation was performed?

Explanation

Allotransplantation: from an individual (donor) to another

Autotransplantation: from one part of the body to another (e.g. skin on thigh to         face).

Xenotransplantation and Heterotransplantation: from one specie to another (e.g. pig to human)

Explantation: removal of a body tissue/organ
42.

A patient has been diagnosed with ARVI. Blood serum contains immunoglobulin M. What is the stage of infection in this case?

Explanation

ARVI – Acute respiratory viral infection. High IgM level usually indicate an acute or primary infection because, it is the first antibody to appear in response to initial exposure to an antigen. Secondary or reinfection show an increase in IgG. IgM antibodies appear early in the course of an infection, this makes it useful in the diagnosis of infectious diseases. Demonstrating IgM antibodies in a patient’s serum indicates recent infection or in a neonate’s serum, it indicates intrauterine infection.

43.

Examination of a pregnant woman having   Rh-negative  blood   revealed   high  level  of  antierythrocytic  antibodies. For  its reduction she  was implanted with  her  husband’s  Rh-positive skin  graft. The   graft   was  rejected  in  two   weeks. Its  microscopic  examination revealed  circulatory disturbance, edema  and cellular infiltration  with lymphocytes,  neutrophils and macrophages predominance. What  is the most likely pathology?

Explanation

Reaction of transplant rejection resembles delayed hypersensitivity reaction. Transplant antigens induce the production of antibodies and sensibilized lymphocytes, which infiltrate the transplant. Microscopically, lymphohistiocytic infiltration is observed in the transplant. Cellular infiltration causes the disturbance of blood circulation and edema; as a result degenerations and necrosis of transplant develop. The neutrophils and macrophages appear in the transplant. Enzyme destruction of the transplant begins, which is followed by its rejection. Transplant – Graft.

This is an immune reaction against the transplant - GRAFT IMMUNITY.

44.

A 49-year old female patient has limitation  of left limbs arbitrary movements. Muscular tonus of left hand and leg is overstrained and spasmodic,  local tendon reflexes  are  strong,  pathological reflexes are  presented. What   is  the  most  likely development  mechanism   of  hypertension and hyperreflexia?

Explanation

Spasticity is probably caused by the removal of inhibitory influences exerted by the cortex (UMN) on the postural centers of the vestibular nuclei and reticular formation. Lesions in the upper motor neuron (UMN) causes hypertonia and spasticity paralysis, increased reflexes (in UMN – everything ↑).

image

Paralysis is the complete loss of strength and functions of muscle group or a limb.

45.

A concentrated solution  of sodium chloride  was intravenously injected  to an animal. This caused decreased reabsorption of sodium  ions in the renal  tubules.  It is the  result  of the  following  changes  of hormonal secretion:

Explanation

Aldosterone produced in adrenal cortex (zona glomerulosa): causes increased sodium (Na+) reabsorption; increased potassium and hydrogen ions (↑K+, H+) excretion. They increase sodium (↑Na+) channel and Na+ /K+-pump insertion in principal cells of collecting duct; enhances K+ and H+ excretion by way of principal cell K+ channels and α-intercalated cell H+ ATPases of collecting duct. Therefore, increase in aldosterone → ↑ K+ in urine (excretion) and ↓ Na+ in urine (↑ reabsorption); And decreased aldosterone → ↓ K+ excretion (↓K+ in urine) and ↓ Na+  reabsorption (i.e. ↑Na+ in urine); same effects on sweats glands too.

46.

A newborn child with pylorostenosis has often  repeating vomiting  accompanied by apathy, weakness, hypertonicity, sometimes convulsions. What   disorder form of acid-base  balance  is it?

Explanation

Acidosis is the reduction in pH (increase in H+ concentration) below normal range. pH is less than 7.35; it is produced by:

·        Increase in partial pressure of CO2 in the body.

·        Decrease in HCO3- concentration.

Alkalosis is the increase in pH (decrease in H+ concentration) above normal range. pH is greater than 7.45; it is produced by:

·        Decrease in partial pressure of CO2 in the body.

·        Increase in HCO3- concentration.

Each of these two disorders has respiratory and non-respiratory forms. The non-respiratory form is divided into metabolic and excretory(non-gaseous).

·        Respiratory acidosis is the acidosis that is caused by alveolar hypoventilation e.g. airway obstruction due to bronchitis or lung diseases (pneumonia).

·        Respiratory alkalosis is caused by alveolar hyperventilation e.g. hypoxia in high altitude.

·        Non-respiratory:

-Metabolic acidosis is characterized by excess accumulation of organic acids such as lactic acid, ketoacids and uric acid formed by normal metabolism e.g. in Diabetes mellitus or extreme/prolonged exercise.

-Excretory/Non-gaseous acidosis may develop in impaired renal H+ excretion related to increased loss of bicarbonate in urine; diarrhea causes acidosis by the loss of bicarbonate with faeces.

-Excretory/Non-gaseous alkalosis: vomiting (loss of gastric acid), increased metabolism of lactate and citrate (turns into bicarbonate and water), long-term use of thiazides and loop diuretics.

47. A   patient  with   coronary    disease has been diagnosed with myocardial hypertrophy, tachycardia and  a decrease in  minute   blood   volume.   What   is  the leading  mechanism  of cardiac  hystiocyte damage in this case?

Explanation

Coronary heart disease leads to ischemia of myocardium. Ischemia → ↓O2 → ↓mitochondrial O2 supply → ↓ATP synthesis → ↓Na+K+ ATPase pump action → ↑Intracellular Na+, Ca2+ → ↑Ca2+ load of mitochondria → uncoupling of oxidative phosphorylation → Metabolic derangement → Cell injury; also ↑Intracellular Na+, Ca2+ → ↑H2O → Acute swelling of cell → enlargement of endoplasmic reticulum → ↓protein synthesis → Metabolic derangement → Cell injury.

48. A   75-year-old-female  patient   with  complaints of  visual  impairment  has been delivered to the ophthalmologic department. Objective  examination revealed  a brain  tumor  in area  of the left optic  tract.  The  patient has a visual field defect in the following area:

Explanation

image

Lesions involving the optic tract (i.e. beyond the optic chiasm) produce loss of vision within similar areas of the visual field in both eyes (“homonymous hemianopsia”) – left optic tract – left half of both eyes. These lesions can be caused by stroke, tumor, vascular malformations, demyelinating lesions and abscesses.

49.

Autopsy of a 75-year-old  man  with a long history  of atherosclerosis revealed  a grey irregular-shaped focus of loose consistency in the right parietotemporal region of brain.  What  is the most likely cause of this process?

Explanation

The middle (medial) cerebral artery arises from the internal carotid artery and enters the lateral sulcus. There, it gives branches that supply the greater portion of the superolateral surface of the cerebral hemisphere; including the frontal, parietal, temporal lobes and the insula.

image

Anterior cerebral artery supplies the medial surface of hemisphere.

Posterior cerebral artery supplies the inferior surface of temporal lobe and the inferior and medial surfaces of the occipital lobe

Basilar artery gives the following branches: posterior cerebral arteries, anterior inferior cerebellar artery, superior cerebellar artery, pontine arteries.

            Only the middle (medial) cerebral artery supplies the right and left parietotemporal region of brain.

50. Jaundice treatment involves administration of barbiturates inducing the synthesis  of UDP-glucuronyl transferase. A medicinal  effect is caused by the production of:

Explanation

image

Crigler Najjar syndrome type II is a rare hereditary disorder and is due to a less severe defect in the bilirubin conjugation. It is believed that hepatic UDP-glucuronyltransferase that catalyzes the addition of second glucuronyl group is defective. It is treated with Phenobarbital ( a barbiturate), because it induces the action of UDP-glucuronyltransferase, thereby producing more conjugated (direct) bilirubin.

51. A 12-year-old teenager has significantly put off weight within 3 months; glucose  concentration rose  up  to  50 millimole/l. He fell into a coma. What is the main mechanism  of its development?

Explanation

Hyperosmolar coma is clinically defined by the presence of relative insulin deficiency and hyperglycemia (high glucose concentration), usually higher than 33.3mmol/L with associated elevated serum osmolality (>300mosm/kg), dehydration and stupor, progressing to coma if uncorrected, without the presence of ketosis or acidosis.

Hypoglycemic coma → ↓ glucose concentration

Ketonemic coma → ↑ ketone bodies

Lactacidemic coma → ↑ lactic acid

52.

Which  way  of  heat  emission  by  the bodies  of greenhouse workers  is the most effective   at   the   temperature  of   36oC degrees and relative humidity of 70%?

Explanation

Evaporation is a way the body dissipates heat to the environment by its evaporation via sweat or evaporation of moisture from the skin and respiratory tract mucous membranes of (“wet” heat loss). Evaporation closely related to relative humidity.

Heat Radiation is a way the surface of the human body emits heat to the environment in the form of infrared rays. The amount of heat the body radiates to the environment is proportional to the surface of radiation area and to the difference between the mean values of skin and environment temperature. The surface radiation area is the total surface area of body parts that contact the air. Elimination of heat by radiation increases with a decrease in ambient temperature and decreases with its increase. It is possible to reduce elimination of heat by radiation via reduction of the surface of radiation area (“winding oneself into a ball”). Heat radiation does not require a medium for transfer of heat. (Key words: naked or lightly clothed).

Convection is a way the body eliminates heat by means of transferring heat via moving particles of air or water. To dissipate heat by means of convection, body surface shall be airflowed at a temperature that is lower than the temperature of the skin. At that, air layer contacting with the skin warms up, decreases its density, rises and is replaced by cooler, denser air. By increasing the speed of the air flow (wind, ventilation) heat emission increases significantly as well (forced convection). Convection requires convection current; current of gases or liquids (Key words: air over exposed area of skin).

Conduction is a way the body eliminates heat by means of direct contact with another object. Heat is transferred down the temperature gradient (i.e. from the object of higher temperature to the object of lower temperature). Conduction requires contact with another object (Key words:  in water).

53.

After  transfusion of 200 ml of blood a patient presented with body temperature rise up  to 37, 9oC . Which  of the  following substances  is the  most  likely cause  of temperature rise?

Explanation

The transfused blood might contain pyrogens or its an incompatible blood that activates the immune system. Pyrogenic cytokines, principally IL-1; IL-6 and TNF-α are released into the bloodstream for transport to the hypothalamus, where they exert their action. These cytokines induce prostaglandin E2 (PGE2), which is a metabolite of arachidonic acid. It is hypothesized that when IL- 1β interacts with the endothelial cells of the blood-brain barrier in the capillaries of the organum vasculosum laminae terminalis (OVLT), which is in the third ventricle above the optic chiasm, PGE2 is released into the hypothalamus. At this point PGE2 binds to receptors in the hypothalamus to induce increase in the thermostatic set point through the second messenger cAMP. In response to the increase in its thermostatic set point, the hypothalamus initiates shivering and vasoconstriction that raise the body’s core temperature to the new set point and fever is established.

54.

As  a  result   of  continuous  starvation the glomerular filtration  rate has increased   by  20%.  The   most   probable cause of the glomerular filtration  alteration under  the mentioned conditions is:

Explanation

Starvation decreases protein synthesis because the substrates are not readily available. Decrease in protein synthesis decreases oncotic pressure and thereby increasing glomerular filtration. Net filtration pressure is the balance between hydrostatic pressure (glomerular capillary pressure) and oncotic pressure.

Net filtration pressure = Hydrostatic pressure – Oncotic pressure

Therefore, a decrease in oncotic pressure increases the filtration rate according to the degree of starvation which decreases protein synthesis.

55.

A coprological  survey revealed  light-colored  feces containing drops  of neutral fat. The most likely reason  for this condition is the disorder of:

Explanation

Obturation (obstruction, to close) of bile duct – it can be:

* Intrahepatic – blockage of intrahepatic bile ducts

* Extrahepatic – blockage of common bile duct (ductus choledochus).

Findings:

* malabsorption: bile salts do not enter the Small Intestine; no emulsification of fat.

*light coloured stool: due to lack of urobilin (which leads to lack of stercobilin).

*Jaundice (posthepatic, mechanic, obstructive): increased conjugated Bilirubin.

* Steatorrhea

The findings are specific for obstruction of bile duct and bile acid deficiency.

56. A patient has been  given high doses of hydrocortisone for a long time. This caused   atrophy  of  one   of  the   adrenal cortex zones. Which zone is it?

Explanation

The adrenal gland (suprarenal gland) has a secretory parenchymal tissue organized into cortical and medullary regions. Adrenal cortex (derived from mesoderm; steroid-secreting portion) and medulla (derived from neural crest; catecholamine-secreting portion). The adrenal cortex is divided into 3 zones on the basis of arrangement of its cells:

* Zona glomerulosa (15%): arranged in closely packed ovoid clusters; secretes aldosterone.

* Zona fasciculata (80%): large and polyhedral; arranged in long straight cords; secretes cortisol.

* Zona reticularis (5-7%): cells are arranged in anastomosing cords separated by fenestrated capillaries; secretes androgens.

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Hydrocortisone is a glucocorticoid (cortisol) and an intake of hydrocortisone will decrease endogenous production of cortisol from zona fasciculata of adrenal cortex leading to its atrophy.

57.

A 30-year-old  male patient with acute pancreatitis has been found to have a disorder   of   cavitary   protein  digestion. The reason  for such condition can be the hyposynthesis  and  hyposecretion of  the following enzyme:

Explanation

Acute pancreatitis is an autodigestion of pancreas by pancreatic enzymes (proteolytic enzymes) due to Inflammation. Therefore,

Acute pancreatitis → ↓production of pancreatic juice.

Trypsin is the most powerful proteolytic enzyme in pancreatic juice. Pepsin is secreted by chief cells in the stomach.

 
58.

Autopsy of a 73-year-old man who had been suffering from the coronary heart disease  along  with cardiac  insufficiency for a long time revealed:  nutmeg  liver, brown induration of  lungs,  cyanotic  induration of kidneys  and  spleen.  What  kind  of circulation  disorder was the  cause  of such effects?

Explanation

In general, these are signs of both right-sided cardiac insufficiency (nutmeg liver – venous congestion) and left-sided cardiac insufficiency (brown induration of lungs – venous congestion). It is Chronic because the patient has been suffering for a long time. In venous or passive hyperemia or congestion, morphologically, the sectioned surface of lungs is dark brown and the process is named brown induration of the lungs. Spleen – cyanotic induration of the spleen; liver – nutmeg liver.

59.

The minute  blood volume in a patient with transplanted heart  has increased  as a result  of physical  activity.  What  regulative mechanism  is responsible for these changes?

 

Explanation

A transplanted heart is denervated, so no nervous stimulation can increase or decrease the heart rate or cardiac output. Therefore, the only mechanism capable of increasing minute blood volume is the catecholamines (epinephrine/adrenaline; norepinephrine/noradrenaline).
60.

A  46-year-old  patient suffering  from the diffuse toxic goiter underwent resection   of   the    thyroid    gland.   After    the surgery the patient presents with appetite loss, dyspepsia,  increased neuromuscular excitement. The body weight remained unchanged. Body  temperature is normal. Which of the following has caused such a condition in this patient?

 

Explanation

One of the most common complications of thyroidectomy (resection of thyroid gland) is hypoparathyroidism because the parathyroid gland lying behind the thyroid gland capsule can be accidentally removed during the surgery by unskilled surgeons. Accidental removal of the parathyroid gland results in hypoparathyroidism.

61.

An aged man had raise of arterial pressure under  a stress. It was caused  by activation of:

Explanation

Stress activates the sympathoadrenal system and the hypothalamic-pituitary-adrenocortical (HPA) axis. Defense reactions involve catecholamine release, vagal withdrawal, cortisol secretion and activation of the renin-angiotensin system. Catecholamine release is capable of increasing the arterial pressure. Sympathoadrenal system involves the sympathetic nervous system and the adrenal glands especially increased sympathetic activity that causes increased secretion of epinephrine by the adrenal medulla and norepinephrine by the postganglionic sympathetic nerve endings.

62.

12 hours after an acute attack  of retrosternal  pain  a  patient presented a jump of aspartate aminotransferase activity in blood  serum. What pathology is this deviation  typical for?

Explanation

In laboratory diagnosis of acute myocardial infarction: Creatine kinase isoenzyme MB (CK-MB) appears within 4-8hrs, peaks at 24hrs and disappears within 1.5-3 days. Sensitivity and specificity is 95%. Reappearance of CK-MB after 3days – reinfarction. CK-MM – found in skeletal muscle and heart (not specific for heart). LDH1 – heart muscle; LDH2 – blood serum. LDH levels are also high in tissue breakdown or hemolysis. Although CK-MB is more specific and sensitive for infarction than LDH. Aspartate transaminase is not specific for heart damage alone but can still be used to diagnose myocardial infarction. But troponin test [cardiac troponins I (cTnI) and T (cTnT)] is the most sensitive and specific test for myocardial infarction.

63. ECG  of a 44-year-old  patient shows signs  of  hypertrophy  of  both   ventricles and the right atrium.  The  patient was diagnosed  with the tricuspid  valve insufficiency. What pathogenetic variant of cardiac dysfunction is usually observed in case of such insufficiency?

Explanation

Due to incomplete closure of the tricuspid valve during right ventricular systole, part of blood is regurgitated into the right atrium, where it is mixed with the normal volume of blood delivered from the venae cavae which makes the atrium become distended and hypertrophied. During diastole, a larger volume of blood is delivered into the right ventricle because the portion of blood that was regurgitated into the atrium during systole is added to the normal volume of blood delivered → ↑volume (heart overload). This causes dilatation and hypertrophy of the right ventricle. Compensation in this disease is attained by intensified work of left ventricle which leads to its hypertrophy too. The mass of the circulating blood usually increase proportionally to the degree of circulatory insufficiency. This is favored by retention of sodium chloride and water in decreased renal filtration and increased reabsorption of sodium and the increasing number of RBCs (hypoxia is attended by intensified hemopoiesis to compensate for the developing insufficiency) → ↑blood volume.

64.

Heart rate  of a 30-year-old  man under emotional stress  reached 112 bpm.  The reason   for   the   heart   rate   increase   is the altered condition of the following conducting  system of heart:

 

Explanation

The sinoatrial (SA) node is a small strip of modified cardiac muscle, situated in the superior part of lateral wall of right atrium, just below the opening of superior vena cava. The fibers of this node do not have contractile elements. SA node is called the pacemaker because the rate of production of impulse (rhythmicity) is higher in SA node than in other parts. The rate is 60-100/min and higher during tachycardia when stimulated by sympathetic effects. Atrioventricular (AV) node is 40-60/min.

During stress sympathetic nervous system produces the dominant effects in the body.

65.

Quite  often the cause of secondary immunodeficiency is an infection involvement, when the causative agents propagate directly  in the cells of immune system  and  destroy  it. The  following  diseases are characterized by:

Explanation

    Secondary immunodeficiency occurs after full development of the immune system. Chronic virus infections (e.g. infectious mononucleosis caused by Epstein-Barr virus) and HIV (human immunodeficiency virus) may cause secondary immunodeficiencies. HIV → CD4 cells; Epstein Barr virus (EBV) → B lymphocytes (B cells).

66.

A  patient has  been  diagnosed  with influenza.  His  condition  became   drastically worse after taking antipyretic drugs. His consciousness  is confused, AP is 80/50 mm  Hg,  Ps  is 140/m, body  temperature dropped down to 35, 8oC . What complication developed in this patient?

 

Explanation

His condition became worse after taking antipyretic drug. Antipyretic drugs block prostaglandin synthesis by inhibiting cyclooxygenase (COX) enzyme at the thermoregulating centers in the hypothalamus and at peripheral target sites. In case of toxicity of this drug, it can result in coma followed by cardiovascular collapse and respiratory arrest due to its CNS depressant activity. Consciousness is confused; arterial blood pressure is low and pulse rate is very high – these are clear signs of collapse.

67.

After taking poor-quality food a patient  developed repeated  episodes   of  diarrhea. On the next day he presented with decreased arterial pressure, tachycardia, extrasystole. Blood pH is 7,18. These abnormalities were caused by the development of:

Explanation

Acidosis is the reduction in pH (increase in H+ concentration) below normal range. pH is less than 7.35; it is produced by:

·        Increase in partial pressure of CO2 in the body.

·        Decrease in HCO3- concentration.

Alkalosis is the increase in pH (decrease in H+ concentration) above normal range. pH is greater than 7.45; it is produced by:

·        Decrease in partial pressure of CO2 in the body.

·        Increase in HCO3- concentration.

Each of these two disorders has respiratory and non-respiratory forms. The non-respiratory form is divided into metabolic and excretory(non-gaseous).

·        Respiratory acidosis is the acidosis that is caused by alveolar hypoventilation e.g. airway obstruction due to bronchitis or lung diseases (pneumonia).

·        Respiratory alkalosis is caused by alveolar hyperventilation e.g. hypoxia in high altitude.

·        Non-respiratory:

-Metabolic acidosis is characterized by excess accumulation of organic acids such as lactic acid, ketoacids and uric acid formed by normal metabolism e.g. in Diabetes mellitus or extreme/prolonged exercise.

-Excretory/Non-gaseous acidosis may develop in impaired renal H+ excretion related to increased loss of bicarbonate in urine; diarrhea causes acidosis by the loss of bicarbonate with faeces.

-Excretory/Non-gaseous alkalosis: vomiting (loss of gastric acid), increased metabolism of lactate and citrate (turns into bicarbonate and water), long-term use of thiazides and loop diuretics.

68.

A  male  patient has been  diagnosed with  acute  radiation disease.  Laboratory examination revealed  a considerable reduction of platelet serotonin level. The likely cause of platelet serotonin reduction is the disturbed metabolism of the following substance:

Explanation

Serotonin, also called 5-hydroxytryptamine, is synthesized and stored at several sites in the body. It can be found in the intestinal mucosa, central nervous system and in platelets. Serotonin is synthesized from tryptophan, which is hydroxylated. The product, 5-hydroxytryptophan is decarboxylated to serotonin, which is also degraded by monoamine oxidase (MAO). Serotonin has multiple physiologic roles, including pain perception, affective disorders, and regulation of sleep, temperature and blood pressure.

69.

A  45 year  old  male  died  from  disseminated tuberculosis. On  autopsy  the symptoms  of tuberculosis were confirmed by both microscopical and histological analyses. All the affected organs had epithelioid cell granulomas with caseous necrosis in the centre. What kind of hypersensitivity reaction underlies the process of granuloma development?

 

Explanation

Type IV (cell mediated, delayed): antibody-independent T-cell mediated reactions e.g. positive mantoux reaction (tuberculin test), hashimoto’s thyroiditis or transplant rejection etc.

Tuberculin (Mantoux) skin test: this test is done by intradermal injection of tuberculoprotein (tuberculin), purified protein derivative (PPD). Type IV hypersensitivity reaction.

70.

A  26  year  old  pregnant woman  is under   treatment at  an  in-patient hospital. After  a continuous attack  of vomiting she was found to have reduced volume of circulating  blood. What kind of change in general blood volume is the case?

Explanation

Polycythemic hypovolemia is a condition with a decreased amount of plasma usually characterized by appreciable concentration and increased viscosity of blood. Hematocrit is above normal. This condition is observed in connection with considerable loss of water by the organism as in diarrhea, intractable vomiting, extensive burns. Hematocrit is increased because there is no loss of erythrocytes just fluid was lost from vomiting. It can’t  be hypervolemia because there is loss of fluid from prolonged vomiting.

In simple hypovolemia: hematocrit is normal; oligocythemic hypovolemia: hematocrit is decreased.

71.

A child is pale, pastose,  muscular  tissue  is bad  developed, lymph  nodes  are enlarged.  He   often   suffers   from   angina and pharyngitis,  blood has signs of lymphocytosis.  The child is also predisposed to autoallergic diseases. What type of diathesis can be presumed in this case?

Explanation

Abnormality of constitution, so called diathesis is characterized by pathological reactions on physiological agent. Classification of diathesis:

·        Hemorrhagic: characterized by hemorrhagic reaction to physiological factors.

·        Thymicolymphatic/Lymphohypoplastic: characterized by enlargement of lymphatic nodes, muscular atrophy, individual pale, pastous, predisposing to autoallergic disease, lymphocytosis, angina and other infectious diseases.

·        Neuroarthritic/Gouty: predisposing to arthralgia, arthritis, rheumatism, obesity, gout, psychic disease.

·        Edematic/Exudative: characterized by edema reaction to different environmental factors.

·        Asthenic: expressed in hypodynamia, hypotonia.

72.

A patient with high-titer antinuclear antibodies died from progressing  renal impairment. Autopsy  revealed   mesangioproliferative glomerulonephritis and abacterial polypous  endocarditis. There was periarterial bulbar  sclerosis in spleen and  productive proliferative vasculitis  in skin. What is the most likely diagnosis?

 

Explanation

Systemic lupus erythematous (SLE, Libman-sacks disease) is the classic prototype of the multisystem disease of autoimmune origin, characterized by a bewildering array of autoantibodies, particularly antinuclear antibodies. It is characterized principally by injury to the skin, joints, kidney, and serosal membranes. Antinuclear antibody is directed against several nuclear antigens and can be grouped into 4 categories:

·        Antibodies to DNA

·        Antibodies to histones

·        Antibodies to nonhistone proteins bound to RNA

·        Antibodies to nuclear antigens.

SLE is a type III hypersensitivity reaction with formation of immune complexes. It can cause diffuse proliferative glomerulonephritis seen under the light microscope as “wire loop” of capillaries and granular under the immunofluorescence microscopy.

73.

Toxic affection  of liver results in dysfunction of protein synthesis. It is usually accompanied by the following kind of dysproteinemia:

Explanation

Liver is the primary organ of protein synthesis. In a case of dysfunction of protein synthesis, hypoproteinemia occurs. We have absolute and relative hypoproteinemia. Absolute is when there is disturbed synthesis (absolute hypoproteinemia) and in cases of increased synthesis (absolute hyperproteinemia); while relative does not have to do with synthesis but other pathologies e.g. renal lesions, in which case, there is loss of protein with urine (relative hypoproteinemia); also vomiting, diarrhea, profuse sweating can produce relative hyperproteinemia.

74.

An infectious  disease unit admitted a patient with signs of jaundice  caused  by hepatitis virus. Select an indicator that  is specific only for parenchymatous jaundice:

Explanation

In viral hepatitis, there is generalized liver dysfunction involving uptake and conjugation of unconjugated bilirubin, secretion of conjugated bilirubin into bile ducts, and recycling of urobilinogen. Alanine transaminase (ALT) and Aspartate transaminase (AST) are increased (↑), but ALT is higher than AST and there is a slight ↑ in alkaline phosphatase (ALP) and ɣ-glutamyltransferase (GGT).

ALT is a specific enzyme for liver necrosis; present in the cytosol. ALT>AST: viral hepatitis.

AST is present in the mitochondria. Alcohol damages mitochondria AST>ALT indicates alcoholic hepatitis

75.

A  4 year  old  child  with  hereditary renal lesion has signs of rickets, vitamin D concentration in  blood  is normal.  What is the most probable cause of rickets development?

Explanation

Rickets results from insufficiency of vitamin D (calcitriol). Calcitriol is the active form of vitamin D.

image

Calcitriol production is dependent on the kidney’s 1-α-hydroxylase which converts 25-OHD3 to 1,25-(OH)2D3 (calcitriol). So in cases of renal lesion, there is lack of 1-α-hydroxylase which leads to a deficiency of calcitriol or impaired synthesis of calcitriol.

76. A  67 year  old  patient complains  of periodic  heart  ache, dyspnea  during  light physical activities. ECG reveals extraordinary contractions of heart ventricles. Such arrhythmia is called:

Explanation

Extrasystole is the premature contraction (an extra contraction) of the heart before its normal contraction. In other words, it is an extra contraction of the heart before its normal contraction. It is caused by an ectopic focus (discharge of an impulse from any part of the heart other than the Sinoatrial node).

Bradycardia: ↓heart rate; Tachycardia: ↑heart rate; Flutter: rapid heart contractions; Fibrillation: very rapid heart contractions. (In all this, there is no extra heart contraction, we just have faster contractions).

77. A  patient who  abuses  smoking  has chronic  bronchitis.  Biopsy of his primary bronchus  revealed  multilayer pavement epithelium.  What   pathological  process was revealed  in the bronchus?

Explanation

Metaplasia is a reversible change of one type to another type of adult epithelial or mesenchymal cells, usually in response to abnormal stimuli and often reverts back to normal on removal of stimulus. Types (2):

·        Epithelial: *Squamous metaplasia: in bronchus (chronic smokers), cervix

  *Columnar metaplasia: there is transformation to columnar epithelium.

·        Mesenchymal metaplasia: osseous and cartilaginous.

IMG_9796

Hyperplasia: ↑number of cells; Hypertrophy: ↑in size.

78.

Examination of a patient revealed II grade obesity. It is known that he consumes  a lot  of sweets  and  rich  food, has sedentary way of life. That’s why anabolic  metabolism has  the  priority  in his organism. Which of the following pathways is amphibolic?

Explanation

The citric acid cycle (kreb’s cycle, TCA cycle) is a good example of amphibolic pathway. The first reaction of the cycle in which oxaloacetate (4 carbon compound) condenses with acetate (2 carbon compound) to form citrate (6 carbon compound) is typically anabolic. The next few reactions which are intramolecular rearrangements produce Isocitrate. The following two reactions are typically catabolic. ‘COO’ is lost in each step and succinate (4 carbon compound) is produced. Amphibolic involves both catabolism and anabolism.

79.

Examination of a 42 year old patient revealed   a  tumour of  adenohypophysis. Objectively:   the  patient’s  weight  is  117 kg, he has moon-like hyperemic  face, red- blue striae  of skin distension  on his belly. Osteoporosis and muscle dystrophy are present. AP  is 210/140 mm  Hg.  What  is the most probable diagnosis?

Explanation

krushkrok No159 (2012)krushkrok No159a (2012)

Cushing Syndrome: Etiology:

INCREASE Cortisol due to a variety of causes (Glucocorticoids):

Exogenous corticosteroids: result in decrease ACTH (MCC).

Primary adrenal adenoma, hyperplasia or carcinoma (Cushing’s Syndrome).

ACTH-secreting pituitary adenoma (Cushing Disease).

Findings: Hypertension, Weight Gain, Moon Facies, Truncal Obesity, Buffalo Hump, Skin Changes (thinning striae), Osteoporosis, Hyperglycemia (Insulin resistance), Amenorrhea, Immunosuppression.

80.

Examination  of  a  child  who frequently suffers from infectious diseases revealed  that  IgG concentration in blood serum was 10 times less than normal,  IgA and  IgM  concentration was  also  significantly reduced. Analysis showed also lack of B-lymphocytes and plasmocytes.  What disease are these symptoms typical for?

Explanation

X-linked (Bruton) agammaglobulinemia: defect in Bruton’s tyrosine kinase (BTK), a tyrosine kinase gene → no B cell maturation. X-linked recessive (↑in boys). Findings: absent B cells in peripheral blood, ↓immunoglobulin of all classes (IgG, IgM, IgA). Absent/scanty lymph nodes and tonsils.

81.

A 50 year old patient has been  taking treatment thrice  for the last 6 months because  of fractures caused  by domestic accidents.   Microscopical   examination of bony tissue revealed foci of lacunar resolution, giant-cell granulomas in the tumour-like formations, cysts. Bony tissue was substituted by fibrous  connective tissue. Examination revealed  also adenoma of parathyroid gland  and  hypercalcemia. What is the most probable diagnosis?

Explanation

The main reasons for hypercalcemia are primary hyperparathyroidism (which can result from adenoma of parathyroid gland), hypervitaminosis D (calcium absorption in the intestine increases). Hypercalcemia often accompanies difficult fractures and this numerous fractures violate the equilibrium between bone construction processes, which sharply decreases and the resorption, which continues with previous speed. Reklinghausen described development of osteodystrophy as the result of bone decalcinosis at the continuous hyperparathyroidism (parathyroid adenoma). NB: parathyroid hormone → ↑bone resorption. This disease is characterized by gradual dilution and softening of bones. Metabolic osteoclasts activity increases due to the action of parathormone. Loss of bone matrix occurs and the bone becomes soft. Resorption allotments are replaced with fibrous connective tissue and zones of osteoid substance are formed.

82. As a result of a trauma a patient has developed traumatic shock that led to the following disorders:  AP is 140/90 mm Hg, Ps is 120 bpm. The patient is fussy, talkative, pale. Such state relates to the following shock phase:

Explanation

Pirogov’s stages of shock

* Erectile phase: is characterized by strong motor agitation, sweating, tremor of skeletal muscles, staggering gait, frequent urination, transient increase in blood pressure, heart rate and breath rate increases, body temperature also. Painful impulses reach CNS.

* Torpid phase: decompensation in CNS leads to deep oppression. Patient is motionless, does not answer questions or answers very silently and with long time of delay, reflexes are lowered or absent.

83.

A  5-month-old  boy  was  hospitalized  for  tonic  convulsions.  He  has  a life-time  history  of this disease.  Examination revealed  coarse  hair,  thinned and  fragile nails,  pale  and  dry  skin.  In  blood:  calcium - 1,5 millimole/l, phosphor - 1,9 millimole/l. These changes are associated with:

Explanation

Parathyroid hormone: secreted by chief cells of parathyroid gland. Effects include:

↑bone resorption of Ca2+ and PO43- → ↑their plasma levels

↑kidney reabsorption of Ca2+ in distal convoluted tubule → ↑ Ca2+ plasma level

↓reabsorption of PO43- in proximal convoluted tubule → ↓ PO43- plasma levels

↑Calcitriol (vit D3) production by stimulating kidney 1α-hydroxylase in proximal convoluted tubule. It increases Ca2+ and PO43- absorption in the intestine.

In general, parathyroid hormone ↑ Ca2+ plasma level but ↓ PO43- plasma levels.

Therefore hypoparathyroidism results in hypocalcemia and hyperphosphatemia.

84.

As a result  of a road  accident  a 26- year-old   man  is  in  the  torpid   phase  of shock.  Blood   count:   leukocytes   -  3, 2 · 109/l. What  is the  leading  mechanism  of leukopenia development?

Explanation

Shock is a form of stress which is accompanied by the release of stress hormones (catecholamines, cortisol). Stress-induced changes in blood leukocyte distribution may represent an adaptive response. This represents a redistribution of leukocytes from the blood to other organs such as the skin, draining sentinel lymph nodes and other compartments. Such leukocyte redistribution may enhance immune function in compartments to which immune cells traffic during stress.

85. Blood   test   of  a  patient  suffering from  atrophic gastritis  gave  the  following results: RBCs - 2, 0 · 1012/l, Hb- 87 g/l, colour  index  - 1,3, WBCs  - 4, 0 · 109/l, thrombocytes - 180 · 109/l. Anaemia  might have been caused by the following substance  deficiency:

Explanation

Pernicious anemia or addison’s anemia is the anemia due to deficiency of vitamin B12. It is due to atrophy of the gastric mucosa (atrophic gastritis) because of autoimmune destruction of parietal cells. The gastric atrophy results in decreased production of intrinsic factor and poor absorption of vitamin B12, which is the maturation factor for red blood cells (RBC). RBCs are larger and immature with almost normal or slightly low hemoglobin level. Synthesis of hemoglobin is almost normal in this type of anemia. So, cells are macrocytic and normochromic/hypochromic.

86.

A patient presented to a hospital  with complaints about  quick fatigability and significant  muscle  weakness.  Examination revealed  an autoimmune disease  that causes  functional   disorder  of  receptors in the  neuromuscular synapses.  This  will result  in  the  disturbed activity  of  the following mediator:

Explanation

IMG_9907 Myasthenia gravis is an autoimmune disease of neuromuscular junction caused by antibodies to cholinergic receptors. It is characterized by grave weakness of the muscle due to the inability of neuromuscular junction to transmit impulses from nerve to the muscle. It is caused due to the development of auto-antibodies (IgG auto-antibodies) against the receptors of acetylcholine. That is, the body develops antibodies against its own acetylcholine receptors. These antibodies prevent binding of acetylcholine with its receptors or destroy the receptors. So, though the acetylcholine release is normal, it cannot execute its action.
87.

A 49 year old woman  spent  a lot of time standing.  As a result of it she got leg edema.  What  is the  most  likely cause  of the edema?

 

Explanation

Where the fluid accumulates depends on the amount of excess fluid and the effects of gravity. If a person is standing, fluid accumulates in the legs and feet; if a person is lying down, fluid usually accumulates in the lower back; if the amount of fluid is large, fluid also accumulates in the abdomen.

Most water leakage occurs in capillaries or postcapillary venules which have a semipermeable membrane wall that allows water to pass freely than proteins. Increased hydrostatic pressure leads to increase filtration of water into the interstitium at the venous end of the capillary (post-capillary venule).

88. An infant has pylorospasm, weakness, hypodynamia, convulsions as a result of frequent vomiting.  What kind of acid-base disbalance is it?

Explanation

Acidosis is the reduction in pH (increase in H+ concentration) below normal range. pH is less than 7.35; it is produced by:

·        Increase in partial pressure of CO2 in the body.

·        Decrease in HCO3- concentration.

Alkalosis is the increase in pH (decrease in H+ concentration) above normal range. pH is greater than 7.45; it is produced by:

·        Decrease in partial pressure of CO2 in the body.

·        Increase in HCO3- concentration.

Each of these two disorders has respiratory and non-respiratory forms. The non-respiratory form is divided into metabolic and excretory(non-gaseous).

·        Respiratory acidosis is the acidosis that is caused by alveolar hypoventilation e.g. airway obstruction due to bronchitis or lung diseases (pneumonia).

·        Respiratory alkalosis is caused by alveolar hyperventilation e.g. hypoxia in high altitude.

·        Non-respiratory:

-Metabolic acidosis is characterized by excess accumulation of organic acids such as lactic acid, ketoacids and uric acid formed by normal metabolism e.g. in Diabetes mellitus or extreme/prolonged exercise.

-Excretory/Non-gaseous acidosis may develop in impaired renal H+ excretion related to increased loss of bicarbonate in urine; diarrhea causes acidosis by the loss of bicarbonate with faeces.

-Excretory/Non-gaseous alkalosis: vomiting (loss of gastric acid), increased metabolism of lactate and citrate (turns into bicarbonate and water), long-term use of thiazides and loop diuretics.

      It is excretory/non-gaseous alkalosis because of the frequent vomiting.

89.

Examination  of  patients with  periodontitis revealed  the interdependence between  the   rate   of  affection   of  periodontal  tissues  and  the  amount of lysozymes in saliva and gingival liquid. These results can be obtained during studying  the  following  protection system of an organism:

Explanation

Innate or non-specific resistance consist of physical and chemical barriers such as skin, gastric acid, mucus or tears, saliva as well as cells and active mechanisms such as phagocytes, natural killer cells and the complement system. They defend an organism in non-specific form/manner, responding in the same fashion, regardless of what pathogen it is. Examples of physical barriers:

·        Skin: surface is made up of dead skin cells rich in keratin, which impedes microorganisms from entering the body – mechanical barrier

·        Gastric acid is a powerful defense against invading bacteria.

·        Saliva and tears contain antibacterial enzymes such as lysozyme, which destroy the cellular walls of bacteria.

·        Mucus is another defense; coating the mucus membranes and contains IgA antibodies (a component of specific/adaptive immune system).

90. A  patient has  been  diagnosed  with acute  glomerulonephritis that  developed after   he  had  had   streptococcal  infection. It is most  likely that  the  affection  of basal  glomerular membrane is caused  by an allergic reaction of the following type:

Explanation

Acute poststreptococcal glomerulonephritis: most frequently seen in children. Occurs approximately 2 weeks after group A streptococcal infection of pharynx or skin. Resolves spontaneously. Type III hypersensitivity reaction (Immune complex). Presents with peripheral and periorbital edema, cola-coloured urine, hypertension. On immunofluorescent microscopy: granular appearance due to IgG, IgM and C3 deposition along glomerular basement membrane and mesangium. On electron microscopy: subepithelial immune complex humps. On light microscopy: glomeruli enlarged and hypercellular.
91. The patient with acute miocardial infarction was given intravenously different solutions during  8    hours with medical dropper 1500ml and oxygen  intranasally. He died because of pulmonary edema.  What caused the pulmonary edema?

Explanation

Edema commonly results from increase in hydrostatic pressure or decreased oncotic pressure. With the infusion of different solutions intravenously amounting to 1500ml within 8hours, there is an increase in hydrostatc pressure, which results in the pulmonary edema. The myocardial infarction suffered by the patient aids in the pathogenesis of the pulmonary edema. Pulmonary edema is as a result of left ventricular insufficiency i.e. the myocardial infarction is in the left ventricular myocardium. ↑hydrostatic pressure = ↑volume

92.

A 10 year old child had the mantoux tuberculin  test   administered.  48  hours later  a  papule  up  to  8 mm  in  diameter appeared  on  the   site  of  the   injection. What type of hypersensitivity reaction developed after the tuberculin injection?

Explanation

Tuberculin (Mantoux) skin test: this test is done by intradermal injection of tuberculoprotein (tuberculin), purified protein derivative (PPD). Type IV hypersensitivity reaction.

Immunization against tuberculosis is induced by injection of attenuated strains of bovine type of tubercle bacilli, Bacilli Calmette Guerin (BCG).

The Mantoux skin test should be read between 48 and 72hrs after administration. The basis of reading  is the presence or absence of induration, which may be determined by inspection and by palpation.

image

A record should also be made of formation of vesicles, bullae, lymphangitis, ulceration and necrosis at the test site. The formation of vesicles, bullae or necrosis at the test site indicates positive result. A negative mantoux result usually signifies that the individual has never been exposed to Mycobacterium tuberculosis i.e. absence of cell mediated immunity to tuberculin.

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Mantoux test is a type IV Hypersensitivity reaction (HSR), which involves macrophages,T-lymphocytes and lymphokines(cytokines). Mononuclear cells (lymphocytes,monocytes,macrophages).

93.

A  patient has  been  diagnosed  with alkaptonuria. Choose  an  enzyme  whose deficiency can be the reason for this pathology:

Explanation

image

Ochronosis (Alkaptonuria): congenital deficiency of homogentisate oxidase (homogentisic acid oxidase) in the degradative pathway of tyrosine to Fumarate → pigment-forming homogentisic acid accumulates (homogentisuria) in tissues. Autosomal recessive. Usually benign. Urine turns black on prolonged exposure to air. May have debilitating arthralgias (homogentisic acid toxic to cartilage).

94. Emotional stress  causes  activation of hormone-sensitive triglyceride  lipase in the adipocytes. What secondary mediator takes part in this process?

Explanation

The mobilization of stored fat requires the hydrolytic release of fatty acids and glycerol from their triacylglycerol (TAG) form. This process is initiated by hormone-sensitive lipase, which removes a fatty acid from carbon 1 and/or carbon 3 of the TAG. This enzyme is activated when phosphorylated by cyclic AMP (cAMP)-dependent protein kinase. cAMP is produced in the adipocyte when one of several hormones (such as epinephrine or glucagon – stress hormones) binds to receptors on the cell membrane and activates adenylyl cyclase.

95.

Blood    analysis   of   a   patient   with jaundice reveals conjugated bilirubinemia, increased concentration of bile acids. There  is no  stercobilinogen in urine. What type of jaundice  is it?

Explanation

image

Obturation (obstruction, to close) of bile duct – it can be:

* Intrahepatic – blockage of intrahepatic bile ducts

* Extrahepatic – blockage of common bile duct (ductus choledochus).

Findings:

* malabsorption: bile salts do not enter the Small Intestine; no emulsification of fat.

*light coloured stool: due to lack of urobilin (which leads to lack of stercobilin).

*Jaundice (posthepatic, mechanic, obstructive): increased conjugated Bilirubin.

* Steatorrhea

The findings are specific for obstruction of bile duct and bile acid deficiency.

Indirect; Hemolytic; Prehepatic

Mixed; Parenchymal; Hepatic

Direct; Obstructive; Mechanic; Posthepatic

Stercobilin (faeces)

        ↑↑↑

Decreases (pale faces)

Absent (clay coloured faeces)

Type of bilirubin in blood

Unconjugated

Conjugated and Unconjugated

Conjugated

96.

A disaster fighter at a nuclear power plant developed  hemorrhagic syndrome on the  background of acute  radiation disease. What is the most important factor of syndrome pathogenesis?

Explanation

Radiation disease, radiation therapy, chemotherapy or toxic chemicals can destroy megakryocytes. Megakaryocytes are responsible for the production of thrombocytes (platelets) which can lead to thrombocytopenia. Thrombocytopenia is an abnormally low level of platelets in blood, as a result of reduced platelet production in the bone marrow or excessive peripheral destruction of platelets. People with severe thrombocytopenia may have abnormal bleeding (hemorrhagic syndrome) almost anywhere in the body.

97.

A   42 year   old   patient complains of  pain  in  the   epigastral  area,   vomiting;  vomit   masses   have   the   colour   of \"coffee-grounds\", the patient also  has melena.  Anamnesis records gastric ulcer. Blood formula:  erythrocytes - 2, 8 · 1012/l,  leukocytes   - 8 · 109/l,  Hb-  90 g/l. What complication is it?

Explanation

Principal complications of peptic ulcer are perforation, penetration, hemorrhage, stenosis, malignization (cancer). Gastric hemorrhage is a very important symptom. It can be manifested by vomiting blood (hematemesis) or by black tarry stools (melena). The vomitus looks like coffee grounds. If hemorrhage is profuse (damage to a large vessel) the vomitus contains much scarlet (unaltered) blood. Hematemesis occurs in peptic ulcer, cancer and polyps, in erosive gastritis etc.

98. A  56 year  old patient suffering  from cardiac  insufficiency  has  edema   of  feet and shins, edematous skin is pale and cold. What  is the  leading  mechanism  of edema pathogenesis?

Explanation

The main symptoms of right-sided heart failure are fluid accumulation and swelling (edema) of the feet, ankles, legs, liver and abdomen.

image

Where the fluid accumulates depends on the amount of excess fluid and the effects of gravity. If a person is standing, fluid accumulates in the legs and feet; if a person is lying down, fluid usually accumulates in the lower back; if the amount of fluid is large, fluid also accumulates in the abdomen.

Most water leakage occurs in capillaries or postcapillary venules which have a semipermeable membrane wall that allows water to pass freely than proteins. In cardiac insufficiency, blood pools in the veins since the heart is not pumping effectively; this increases the hydrostatic pressure in the veins. And this increased hydrostatic pressure leads to increase filtration of water into the interstitium at the venous end of the capillary (post-capillary venule).

99.

After a serious psychoemotional stress a 48 year old patient suddenly  developed acute heart   ache  irradiating  to  the  left arm. Nitroglycerine relieved  pain after 10 minutes. What is the leading pathogenetic mechanism  of this process development?

 

Explanation

Administered nitrates → ↑ Nitrites →↑ Nitric oxide (NO) → ↑cGMP → ↑dephosphorylation of myosin chains → vascular smooth muscle relaxation. Nitroglycerin is an organic nitrates. Nitrates inhibit coronary vasoconstriction or spasm, increasing perfusion of the myocardium and thus relieving vasospastic angina. Because of this action, nitrates are effective in treating effort-induced (stress) angina. Classic, effort-induced or stable angina are experienced in such conditions as physical activity, emotional excitement or any other cause of increased cardiac workload.

100.

A   63 years   old   male   patient who had   been    suffering   from   chronic    diffuse obstructive disease, pulmonary emphysema, for 15 years died from cardiac insufficiency. Autopsy revealed nutmeg liver cirrhosis, cyanotic induration of kidneys   and   spleen,   ascites,   edemata of lower limbs. These changes of internal organs are typical for the  following  disease:

Explanation

Acute heart failure refers to sudden and rapid onset of signs and symptoms of abnormal heart functions. Chronic heart failure is characterized by the symptoms that appear slowly over a period of time and become worst gradually.

The main symptoms of right-sided heart failure are fluid accumulation and swelling (edema) in the feet, ankles, legs, liver and abdomen. Left-sided heart failure leads to fluid accumulation in the lungs, which causes shortness of breath. At first, shortness of breath occurs only during exertion, but as heart failure progresses, it occurs with less and less exertion and eventually occurs even at rest. Moist and dry rales are heard over the lungs.

She has been suffering it for 15 years – chronic         

Edema of lower limbs, ascites – Right ventricular insufficiency

101. Vitamin  A together with specific cytoreceptors penetrates through the nuclear   membranes, induces  transcription  processes  that  stimulate growth  and differentiation of cells. This biological function  is realized  by the following form of vitamin A:

Explanation

Vitamin A and retinoids play an important role in the orderly differentiation of mucus-secreting epithelium. All-trans-retinoic acid, a potent acid derivative of vitamin A, has the highest affinity for retinoic acid receptors (RARs) compared with other retinoids. Activation of RARs by their ligands causes the release of corepressor and the obligatory formation of heterodimers with another retinoid receptor, known as the retinoic X receptor (RXR). The RAR/RXR heterodimers bind to retinoic acid response elements located in the regulatory regions of genes that encode receptors for growth factors, tumor suppressor genes and secreted proteins. Through these effects, they regulate cell growth and differentiation, cell cycle control and other biologic responses.
102.

From  the group  of children  who were eating  sweet  sappy  watermelon two kids developed the  signs  of  poisoning:  rapid weakness,  dizziness,  headache, vomiting, edema,   tachycardia,  cyanosis  of  mouth, ears, tips of the fingers cyanosis. High concentration of nitrates was detected. What is the leading mechanism of the pathogenesis of the  poisoning  in the  two children?

Explanation

Oxidation of the heme component of hemoglobin to the ferric (Fe3+) state forms methemoglobin, which cannot bind O2. This oxidation may be caused by the action of certain drugs or substances containing nitrates, or endogenous products such as reactive oxygen intermediates. Furthermore a deficiency of NADH-met-hemoglobin reductase i.e. the enzyme responsible for the conversion of methemoglobin (Fe3+) to hemoglobin (Fe2+); leads to the accumulation of methemoglobin. The methemoglobinemias are characterized by “chocolate cyanosis” (a brownish-blue colouration of the skin and  membranes) and chocolate-coloured blood, as a result of the dark-coloured methemoglobin. Symptoms are related to tissue hypoxia and include anxiety, headache and dyspnea. Treatment is with methylene blue, which is oxidized as Fe3+  is reduced.

103.

HIV   has   gp41   and   gp120 on   its surface    interacts   with   target    cells   of an   organism.   Which   of   the   following human lymphocyte  antigens is gp120 complementary bound  with?

Explanation

Human immunodeficiency virus (HIV): diploid genome (2 molecules of RNA). The 3 structural genes(i.e. proteins coded for by the genes) are:

·        env (gp 120 and gp 41): formed from cleavage of gp 160 to form envelope glycoproteins. gp 120 is for attachment to host CD4+ T cell. gp 41 is for fusion and entry.

·        Gag (p24): capsid protein

·        pol: reverse transcriptase, aspartate protease, integrase.

image

ELISA/Western blot (immunoblot) tests look for antibodies to the viral proteins listed above.

Reverse transcriptase synthesizes dsDNA (ds-double stranded) from genomic RNA (mRNA); dsDNA integrates into host genome. Virus binds CD4 as well as a coreceptor, either CCR5 on macrophages (early infection) or CXCR4 on I cells (late infection).

·        Homozygous CCR5 mutation – immunity

·        Heterozygous CCR5 mutation – slower course.

104. The immunoblot detected gp120 protein in the blood serum. This protein is typical for the following disease:

Explanation

Human immunodeficiency virus (HIV): diploid genome (2 molecules of RNA). The 3 structural genes(i.e. proteins coded for by the genes) are:

·        env (gp 120 and gp 41): formed from cleavage of gp 160 to form envelope glycoproteins. gp 120 is for attachment to host CD4+ T cell. gp 41 is for fusion and entry.

·        Gag (p24): capsid protein

·        pol: reverse transcriptase, aspartate protease, integrase.

image

ELISA/Western blot (immunoblot) tests look for antibodies to the viral proteins listed above.

Reverse transcriptase synthesizes dsDNA (ds-double stranded) from genomic RNA (mRNA); dsDNA integrates into host genome. Virus binds CD4 as well as a coreceptor, either CCR5 on macrophages (early infection) or CXCR4 on I cells (late infection).

·        Homozygous CCR5 mutation – immunity

·        Heterozygous CCR5 mutation – slower course.

105.

A  man  with  a  long-term  history  of bronchial asthma died from asphyxia. Histological  examination of his lungs revealed  that  the  lumens  of bronchioles and   minor   bronchi   contained  a  lot  of mucus  with some  eosinophils.  There  was also  sclerosis  of  interalveolar septa,  dilatation of alveoli lumens. What mechanism accounts for the development of hypersensitivity reaction?

Explanation

Type I (Immediate, Anaphylaxis, Reagin): IgE (immunoglobulin E)-dependent activation of mast cells/basophils, usually accompanied by eosinophilia e.g. urticaria (hives), hay fever, asthma (wheezing), rhinitis and conjunctivitis (stuffy nose and itchy eyes; usually seasonal).

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Type I Hypersensitivity reaction (HSR); anaphylactic and atopic: free antigen cross-links IgE on presensitized (i.e. exposed to the antigen before) mast cells and basophils, triggering immediate release of vasoactive amines that act at postcapillary venules (i.e. histamine). Reaction develops rapidly after antigen exposure because of preformed antibody from first exposure. IgE is the main immunoglobulin involved in type I HSR. Type I: uses IgE and IgG4

106. A 44 year  old  woman  complains  of general weakness, heart pain, significant increase   of   body   weight.   Objectively: moon  face, hirsutism,  AP  is 165/100 mm Hg, height  - 164 cm, weight - 103 kg; the fat  is mostly  accumulated on  her  neck, thoracic   girdle,  belly.  What is the main pathogenetic mechanism  of obesity?

Explanation

krushkrok No159 (2012)krushkrok No159a (2012)

Cushing Syndrome: Etiology:

INCREASE Cortisol due to a variety of causes (Glucocorticoids):

Exogenous corticosteroids: result in decrease ACTH (MCC).

Primary adrenal adenoma, hyperplasia or carcinoma (Cushing’s Syndrome).

ACTH-secreting pituitary adenoma (Cushing Disease).

Findings: Hypertension, Weight Gain, Moon Facies, Truncal Obesity, Buffalo Hump, Skin Changes (thinning striae), Osteoporosis, Hyperglycemia (Insulin resistance), Amenorrhea, Immunosuppression.

107.

A patient suffering from chronic myeloleukemia has got the following symptoms of anemia:  decreased number of erythrocytes and low haemoglobin concentration, oxyphilic and  polychromatophilic normocytes, microcytes. What is the leading pathogenetic mechanism of anemia  development?

Explanation

Chronic myeloleukemia is characterized by extensive production of blast (immature) cells in the blood. The immature cells (e.g. immature RBCs) cannot perform the normal function of a mature cell, hence the manifestation of anemia. The many blast cells constitute the majority of cells found in blood during leukemia. Therefore, as soon as cells die they are replaced by the immature ones, which are usually overproduced in leukemia.

108.

A patient with obliterating endarteritis underwent ganglionic sympathectomy. What type of arterial hyperaemia should have developed as a result of the surgery?

Explanation

·        Neuroparalytic arterial hyperemia is caused by damage or blockage of α-adrenoreceptors (sympathetic nervous system). It is characterized by reduction or absence (paralysis) of the sympathetic nervous system effects on the walls of the arteries and arterioles.

·        Neurotonic arterial hyperemia is caused by activation of parasympathetic nervous system; irritation of vascular dilators part of vascular center (CNS) or inhibition of vascular – constrictor part of this center (vasomotor center of CNS); M-cholinoreceptors; H2-histaminereceptors. It is characterized by predominance of the parasympathetic nervous system effects on arterial vascular walls.

109.

A 50  year  old  patient suffers  from essential   hypertension. After   a physical stress he  experienced muscle  weakness, breathlessness, cyanosis  of lips, skin and face. Respiration was accompanied by distinctly heard bubbling rales. What mechanism underlies the development of this syndrome?

Explanation

Acute heart failure refers to sudden and rapid onset of signs and symptoms of abnormal heart functions. Chronic heart failure is characterized by the symptoms that appear slowly over a period of time and become worst gradually.

The main symptoms of right-sided heart failure are fluid accumulation and swelling (edema) in the feet, ankles, legs, liver and abdomen. Left-sided heart failure leads to fluid accumulation in the lungs, which causes shortness of breath. At first, shortness of breath occurs only during exertion, but as heart failure progresses, it occurs with less and less exertion and eventually occurs even at rest. Moist and dry rales are heard over the lungs.

After a physical stress – sudden and rapid – ACUTE

Rales are caused by congestion of the lungs – left ventricular heart failure.

110.

After  the  traumatic tooth  extraction a  patient is  complaining   of  acute,  dull, poorly-localized pain in gingiva, body temperature rise up to 37, 5oC . The patient has been diagnosed with alveolitis. Specify the kind of pain in this patient:

 

Explanation

* Radiating pain: perceived at a site adjacent to or away from the site of origin but in the same dermatome i.e. supplied by afferent nerve fibers of one dorsal root.

* Viscera pain: organs, poorly localized, diffuse

* Protopathic pain: poorly localized pain

* Epicritic pain: well localized pain

* Phantom pain: pain from non-existent body structures (amputated limbs)

Phantom – if a leg has been amputated, the cut end heals with scar formation. The cut ends of nerve fibers are merged within the scar. If the cut end of sensory fibers are stimulated during movement of thigh, the patient feels as if the sensation is originating from non-existent leg. Sometimes the patient feels pain in non-existent limb.

111.

ECG of a patient shows prolongation of T-wave. This is caused by deceleration in ventricles of:

Explanation

krushkrok No28 (2009)

 ‘T’ wave is the final  ventricular complex and is a positive wave. It is due to the repolarization of ventricular musculature. Normal duration is 0.2sec; normal amplitude is 0.3mV.

112.

After an attack  of bronchial  asthma  a patient had  his  peripheral blood  tested. What changes can be expected?

Explanation

This is an example of type I hypersensitivity reaction considering the time taken for the symptoms (rash and itching) to manifest and the expression of eosinophilia.

Neutrophilic leukocytosis: bacterial infection

Lymphocytosis: viral and bacterial infection (e.g. whooping cough, tuberculosis)

Monocytosis: chronic inflammation (tuberculosis); autoimmune disease

Type I (Immediate, Anaphylaxis, Reagin): IgE (immunoglobulin E)-dependent activation of mast cells/basophils, usually accompanied by eosinophilia e.g. urticaria (hives), hay fever, asthma (wheezing), rhinitis and conjunctivitis (stuffy nose and itchy eyes; usually seasonal)

113.

A patient with a history of chronic glomerulonephritis presents with azotemia, oliguria, hypo- and isosthenuria, proteinuria. What is the leading factor in the pathogenesis of these symptoms   development under chronic renal failure?

 

Explanation

Chronic renal failure is the progressive, long standing and irreversible impairment of renal functions. When some of the nephrons loose their function, the unaffected nephrons can compensate for it. However, when more and more nephrons start losing their function over the months and years, then the compensatory mechanism fails and chronic renal failure manifests.

114.

Having  helped  to  eliminate consequences  of  a  failure   at  a  nuclear power  plant,  a  worker  got  an  irradiation  doze  of  500  roentgen.  He  complains of  headache, nausea,  dizziness.  What changes in leukocytes quantity can be expected 10 hours after irradiation?

Explanation

The nuclear radiation this patient was exposed to, can produce inflammatory reaction in the patient. Within the first 24hours, the first leukocyte to get into any inflammatory focus are the neutrophils, followed by the monocytes (macrophages) and then lymphocytes.

Neutrophils are the first leukocytes that cross the blood vessel wall to enter inflammatory sites. Under normal conditions, leukocytes are restricted to the center of small blood vessels, where the flow is fastest. In inflammatory sites, where the vessels are dilated, the slower blood flow allows the leukocytes to move out of the center of the blood vessel and interact with the vascular endothelium. Even in the absence of infection, monocytes migrate continuously into the tissues, where they differentiate into macrophages; meanwhile, during an inflammatory response, the induction of adhesion molecules on the endothelial cells, as well as induced changes in the adhesion molecules expressed on leukocytes recruit large numbers of circulating leukocytes, initially Neutrophils and later monocytes, into the site of an infection (inflammatory focus).

First –Neutrophils; second –monocytes and macrophages; third –lymphocytes.

115.

After severe viral hepatitis a 4 year old boy presents with vomiting,  occasional loss of consciousness, convulsions. Blood test revealed hyperammoniemia. Such condition is caused by a disorder of the following biochemical hepatic process:

Explanation

image

Hyperammonemia can be acquired (e.g. liver disease) or hereditary (e.g. urea cycle enzyme deficiencies). Acquired hyperammonemia may be a result of an acute process e.g. viral hepatitis, ischemia or hepatotoxins. As a result, the detoxification of ammonia (i.e. its conversion to urea) is severely impaired, leading to elevated levels of circulating ammonia.

116.

A child has an  acute   renal  failure. What biochemical factor found in saliva can confirm this diagnosis?

Explanation

     Kidneys excrete the unwanted waste products which are formed during metabolic activities e.g.

·        Urea: end product of amino acid metabolism

·        Uric acid: end product of nucleic acid metabolism

·        Creatinine: end product of metabolism in muscles

·        Bilirubin: end product of hemoglobin degradation

·        Products of metabolism of other substances.

Many substances both organic and inorganic are excreted in saliva also. In some pathological conditions, saliva excretes certain substances which are not found in saliva under normal conditions e.g. glucose in Diabetes mellitus. In certain conditions, some of the normal constituents of saliva are excreted in large quantities e.g. excess urea is excreted in saliva during renal failure, nephritis and excess calcium is excreted during hyperparathyroidism.

117.

A   62   year   old   woman   complains       of   frequent   pain    attacks    in   the area   of   her   chest   and   backbone, rib fractures. Her doctor suspected myeloma (plasmocytoma). What of the following laboratory characteristics will be of the greatest diagnostic importance?

Explanation

Myeloma/Plasmocytoma/Multiple Myeloma

Paraprotein, myeloma protein, M protein or spike protein is an abnormal immunoglobulin (Ig) fragment or immunoglobulin (Ig) light chain that is produced in excess by an abnormal clonal proliferation of plasma cells, typically in multiple myeloma. Monoclonal free light chains in the serum or urine are called bence jones (BJ) proteins.

Bence jones (BJ) protein: free kappa (κ) or lambda (λ) light chains that are excreted in urine associated with plasma cell malignancies (myeloma) and Waldenstrὄm macroglobulinemia. In myeloma, urinalysis for BJ protein is positive in 60-80% of cases.

118.

Parodontitis is treated with  calcium preparations and a hormone that stimulates  tooth  mineralization and inhibits tissue resorption. What hormone is it?

Explanation

Calcitonin is secreted by parafollicular cells (C cells of the thyroid gland). It ↓bone resorption of Ca2+. It opposes actions of parathyroid hormone. But its not important in normal Ca2+ homeostasis.

Parathyroid hormone: secreted by chief cells of parathyroid gland. Effects include:

↑bone resorption of Ca2+ and PO43- → ↑their plasma levels

↑kidney reabsorption of Ca2+ in distal convoluted tubule → ↑ Ca2+ plasma level

↓reabsorption of PO43- in proximal convoluted tubule → ↓ PO43- plasma levels

↑Calcitriol (vit D3) production by stimulating kidney 1α-hydroxylase in proximal convoluted tubule. It increases Ca2+ and PO43- absorption in the intestine.

In general, parathyroid hormone ↑ Ca2+ plasma level but ↓ PO43- plasma levels. Abnormal synthesis (↑synthesis) of parathyroid hormone can lead to hypercalcemia and hypophosphatemia.

119. A patient complains   about   dyspnea provoked by the physical activity.  Clinical examination revealed anaemia and presence of the paraprotein in the zone of gamma-globulins. To confirm the myeloma diagnosis it is necessary to determine the following index in the patient’s urine:

Explanation

Paraprotein, myeloma protein, M protein or spike protein is an abnormal immunoglobulin (Ig) fragment or immunoglobulin (Ig) light chain that is produced in excess by an abnormal clonal proliferation of plasma cells, typically in multiple myeloma. Monoclonal free light chains in the serum or urine are called bence jones (BJ) proteins.

Bence jones (BJ) protein: free kappa (κ) or lambda (λ) light chains that are excreted in urine associated with plasma cell malignancies (myeloma) and Waldenstrὄm macroglobulinemia. In myeloma, urinalysis for BJ protein is positive in 60-80% of cases.

120.

Vegetative abnormalities in the sleep, heat  regulation, all kinds  of metabolism, diabetes insipidus  are  developing  in the patient due  to  growth  of  the  tumour in the III ventricle  of brain. Irritation of the nucleus of what part of the brain can cause this symptoms?

Explanation

Hypothalamus is a diencephalic structure. Diencephalon: thalamus, hypothalamus, pineal body, third (3rd) ventricle. The Hypothalamus is situated just below thalamus in the ventral part of diencephalon. It is the important part of brain, concerned with homeostasis of the body. It regulates endocrine functions, metabolic activities, hunger, thirst, sleep, wakefulness, emotion, sexual functions. Lesion of hypothalamus can occur due to tumors, encephalitis and ischemia; accompanied by disturbances in carbohydrate and fat metabolisms; disturbance in sleep and sexual functions. It can also result in some clinical manifestations such as: Diabetes insipidus, dystrophia adiposogenitalis, kallmann syndrome, Laurence-Moon-Biedl syndrome, narcolepsy, cataplexy.

121. The  patient with  thymoma (thymus gland  tumour) has cyanosis, extension of subcutaneous venous  net  and  edema  of the  soft tissues  of face, neck,  upper  part of the trunk  and upper  extremities. What venous trunk is pressed with tumour?

Explanation

The superior vena cava (SVC) arises from merging left and right brachiocephalic veins posterior to the right first sternocostal joint. The SVC descends to enter the right atrium. On the left, one can distinguish the ascending aorta and on the right – the mediastinal pleura and phrenic nerve. The right pulmonary vein resides posterior to the SVC & the thymus and the right lung – anterior to it. Therefore, thymoma (thymus gland tumor) will definitely press on the SVC. The brachiocephalic veins drain the head, neck and upper limbs; hence, the manifestations.

122.

A  man  has  a  considerable decrease in diuresis  as a result  of 1,5 l blood  loss. The primary   cause of  such  diuresis  disorder is the hypersecretion of the following hormone:

Explanation

     Antidiuretic hormone (vasopressin) is secreted in response to decrease blood volume and increase plasma osmolarity. It binds to receptors on principal cells of collecting ductules causing increase number of aquaporins and increase water reabsorption which leads to decreased diuresis.

Atrial natriuretic peptide is secreted in response to increase atrial pressure. It causes increase glomerular filtration rate (GFR) and increase sodium ion filtration with no compensatory sodium ion reabsorption and water in distal nephron which leads to increase diuresis.

Parathyroid hormone is secreted in response to decrease plasma calcium ion, increase phosphate ion or decrease plasma calcitriol [1,25-(OH)2D3].

123.

A patient presents with the following motor activity disturbances: tremor, ataxia and asynergia movements, dysarthria. The disturbances are most likely to be localized in:

Explanation

During cerebellar lesions, there  are disturbances in posture, equilibrium and movements. Disturbances in movements: ataxia, asynergia, asthenia (weak muscle contractions with characteristically rapid onset of muscle fatigue), Dysmetria, Intention tremor, astasia (loss of the capacity for sustained tetanic contractions), nystagmus, rebound phenomenon, dysarthria, adiadochokinesis, atonia (lack or impairment of muscle tone).

124.

After a tourniquet application  a patient was found  to have petechial haemorrhages. The reason for it is the dysfunction of the following cells:

 

Explanation

     Thrombocyte (platelet) is involved in primary hemostasis. It’s a small cytoplasmic fragment derived from megakaryocytes. It has a life span of 8-10days. When activated by endothelial injury, it aggregates with other platelets and interacts with fibrinogen to form platelet plug. Thrombocytopenia or decrease platelet function/dysfunction results in petechiae.

Leukocytes: Neutrophils (54-62%); Lymphocytes (25-33%); Monocytes (3-7%); Eosinophils (1-3%); Basophils (0-0.75%). Neutrophils, eosinophils, basophils are granulocytes; while lymphocytes, monocytes are mononuclear cells and they are also agranulocytes. They are all responsible for defense against infections.

125.

A  child  has  abnormal  formation  of tooth  enamel and dentin  as a result of low concentration of  calcium  ions  in  blood. Such abnormalities might be caused  by deficiency of the following hormone:

Explanation

image

Parathyroid hormone: secreted by chief cells of parathyroid gland. Effects include:

↑bone resorption of Ca2+ and PO43- → ↑their plasma levels

↑kidney reabsorption of Ca2+ in distal convoluted tubule → ↑ Ca2+ plasma level

↓reabsorption of PO43- in proximal convoluted tubule → ↓ PO43- plasma levels

↑Calcitriol (vit D3) production by stimulating kidney 1α-hydroxylase in proximal convoluted tubule. It increases Ca2+ and PO43- absorption in the intestine.

In general, parathyroid hormone ↑ Ca2+ plasma level but ↓ PO43- plasma levels. Abnormal synthesis (↑synthesis) of parathyroid hormone can lead to hypercalcemia and hypophosphatemia.

Likewise, deficiency of parathormone can lead to low Ca2+ levels.

126.

A month   after surgical constriction of rabbit’s renal artery the considerable increase   of  systematic   arterial  pressure was observed.  What of the following regulation mechanisms   caused   the animal’s pressure change?

Explanation

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↓blood supply → activates renin. Renin catalyzes the conversion of angiotensinogen to angiotensin I. Angiotensin converting enzyme (ACE) converts angiotensin I → angiotensin II. Angiotensin II causes:

- vasoconstriction → ↑BP

- vasopressin (ADH) → ↑H2O reabsorption → ↑plasma volume

- aldosterone → ↑Na+ and H2O reabsorption → ↑plasma volume → ↑BP

127.

The temperature of the ambient environment is 38oC and relative air humidity is 50%. What ways of heat emission provide maintaining a constant temperature of the human body?

Explanation

Evaporation is a way the body dissipates heat to the environment by its evaporation via sweat or evaporation of moisture from the skin and respiratory tract mucous membranes of (“wet” heat loss). Evaporation closely related to relative humidity.

Heat Radiation is a way the surface of the human body emits heat to the environment in the form of infrared rays. The amount of heat the body radiates to the environment is proportional to the surface of radiation area and to the difference between the mean values of skin and environment temperature. The surface radiation area is the total surface area of body parts that contact the air. Elimination of heat by radiation increases with a decrease in ambient temperature and decreases with its increase. It is possible to reduce elimination of heat by radiation via reduction of the surface of radiation area (“winding oneself into a ball”). Heat radiation does not require a medium for transfer of heat. (Key words: naked or lightly clothed).

Convection is a way the body eliminates heat by means of transferring heat via moving particles of air or water. To dissipate heat by means of convection, body surface shall be airflowed at a temperature that is lower than the temperature of the skin. At that, air layer contacting with the skin warms up, decreases its density, rises and is replaced by cooler, denser air. By increasing the speed of the air flow (wind, ventilation) heat emission increases significantly as well (forced convection). Convection requires convection current; current of gases or liquids (Key words: air over exposed area of skin).

Conduction is a way the body eliminates heat by means of direct contact with another object. Heat is transferred down the temperature gradient (i.e. from the object of higher temperature to the object of lower temperature). Conduction requires contact with another object (Key words:  in water).

128.

A  female  patient with a tumour of pancreas has developed mechanic  jaundice resulting  from  compression of a bile-excreting duct. Which duct is compressed?

Explanation

The closest bile excreting duct to the pancreas is the common bile duct (ductus choledochus). So, in case of a tumor affecting the pancreas, this can compress the bile duct, thereby obstructing bile flow leading to mechanic, obstructive or post-hepatic jaundice.

image

Obturation (obstruction, to close) of bile duct – it can be:

* Intrahepatic – blockage of intrahepatic bile ducts

* Extrahepatic – blockage of common bile duct (ductus choledochus).

Findings:

* malabsorption: bile salts do not enter the Small Intestine; no emulsification of fat.

*light coloured stool: due to lack of urobilin (which leads to lack of stercobilin).

*Jaundice (posthepatic, mechanic, obstructive): increased conjugated Bilirubin.

* Steatorrhea

The findings are specific for obstruction of bile duct and bile acid deficiency.

129.

Chronic inflammation and transformation of the one-layer ciliated epithelium into multiple-layers flat  epithelium was revealed in the thickened mucous membrane of the bronchus bioptate of the patient with smoke abuse. Which of the processes is the most likely?

Explanation

Metaplasia is a reversible change of one type to another type of adult epithelial or mesenchymal cells, usually in response to abnormal stimuli and often reverts back to normal on removal of stimulus. Types (2):

·        Epithelial: *Squamous metaplasia: in bronchus (chronic smokers), cervix

  *Columnar metaplasia: there is transformation to columnar epithelium.

·        Mesenchymal metaplasia: osseous and cartilaginous.

IMG_9796

Hyperplasia: ↑number of cells; Hypertrophy: ↑in size.

130. An  unconscious  patient was taken  by ambulance  to  the  hospital. On objective examination  the   patient  was  found to  have  no  reflexes, periodical convulsions, irregular breathing. After  laboratory examination the patient was diagnosed with hepatic coma. Disorders of the central nervous system develop due to the accumulation of the following metabolite:

Explanation

Substances absorbed into the bloodstream from the intestine pass through the liver, where toxins are normally removed. Many of these toxins (such as ammonia) are normal breakdown products of the digestion of protein. In hepatic encephalopathy (hepatic coma), toxins are not removed because liver function is impaired. Ammonia is produced by amino acid metabolism and intestinal urease-positive bacteria. In physiological conditions, it is mostly present as ammonium (NH4+) in serum. The urea or ornithine cycle, which is fully expressed in the liver exclusively, serves to converts NH4+ to urea prior to renal excretion and to maintain low serum concentrations. In hepatic coma, when the liver cannot remove toxins and urea cycle is not functional, all this occurs:

NH3 + α-ketoglutarate → Glutamate

α-ketoglutarate is used up which leads to:

·        ↑glutamate → ↑GABA (inhibitory neurotransmitter)

·        Inhibition of citric acid cycle/tricarboxylic acid cycle; this causes impairment of ATP formation.

·        Inhibition of metabolism of amino acids (impairment of transamination reactions).

 

NH3 + Glutamate → Glutamine

Glutamine is an amide of glutamic acid which provides a non-toxic storage and transport form of ammonia (NH3). Ammonia increase synthesis of glutamine in brain. Accumulation of glutamine in brain results in elevation of osmotic pressure in nervous cells leading to brain edema.

                                   

                                    NH3 + H+ → NH4+

In blood ammonia (NH3) is represented as ammonium ion (NH4+). Accumulation of ammonium ion impairs transport of ions (Na+, K+) through cell membranes and failure of transmission of nerve impulse.

            Urea cycle takes place exclusively in the liver, so in hepatic coma, urea level is low. Glutamine toxicity in brain is dependent on increased ammonia concentration.

Bilirubin toxicity will most likely be related to increase hemolysis, which is not the case in this question. Histamine is a biogenic amine produced from the amino acid histidine.

131. A 46 year old female patient has a continuous history of progressive muscular (Duchenne’s) dystrophy. Which blood enzyme changes will be of diagnostic value in this case?

Explanation

Creatine kinase/Creatine phosphokinase is an enzyme present in striated muscles, used to generate energy. When its serum level is elevated it is often an indication of muscle damage caused by injury, muscular dystrophy or cardiac problems. Most forms of muscular dystrophy are associated with decreased creatinine excretion. Creatinine is a break down product of creatine. Normal constituent of urine but can be elevated in muscular dystrophy. 

132. A male patient has been diagnosed with acute post-streptococcal glomerulonephritis. It is most likely that the lesion of the basement membrane of renal corpuscles was caused by the following allergic reaction:

Explanation

 Acute poststreptococcal glomerulonephritis: most frequently seen in children. Occurs approximately 2 weeks after group A streptococcal infection of pharynx or skin. Resolves spontaneously. Type III hypersensitivity reaction (Immune complex). Presents with peripheral and periorbital edema, cola-coloured urine, hypertension. On immunofluorescent microscopy: granular appearance due to IgG, IgM and C3 deposition along glomerular basement membrane and mesangium. On electron microscopy: subepithelial immune complex humps. On light microscopy: glomeruli enlarged and hypercellular.

FullSizeRender (17)

Type III (immune-complex): deposition of antigen-antibody complexes e.g. systemic lupus erythromatous (SLE), Arthus reaction, serum sickness, poststreptococcal glomerulonephritis etc.

133.

A hospital  has admitted a patient complaining  of abdominal bloating, diarrhea,  flatulence   after   eating   protein foods. These signs are indicative of the impaired digestion  of proteins and  their increased  degradation. Which of the following compounds is the product of this process?

 

Explanation

Normally, protein digestion takes place in the stomach and small intestine. When this process is impaired, the  protein goes to the large intestine undigested and the gut microflora degrades/breaks down protein into ammonia, phenols, indoles and amines which have been shown to exert toxic effects in vitro and in animal models. Human studies have shown that colonic protein metabolism via the gut microflora is responsive to dietary protein as faecal ammonia and urinary phenolic compound concentrations increase in response to increased intake of protein rich foods. These gases also cause the abdominal bloating, diarrhea and flatulence mentioned in the question.

134.

A   patient   with   a   pathology   of the cardiovascular system developed edemata of the  lower  extremities. What is the mechanism  of cardiac edema development?

Explanation

The main symptoms of right-sided heart failure are fluid accumulation and swelling (edema) of the feet, ankles, legs, liver and abdomen.

image

Where the fluid accumulates depends on the amount of excess fluid and the effects of gravity. If a person is standing, fluid accumulates in the legs and feet; if a person is lying down, fluid usually accumulates in the lower back; if the amount of fluid is large, fluid also accumulates in the abdomen.

Most water leakage occurs in capillaries or postcapillary venules which have a semipermeable membrane wall that allows water to pass freely than proteins. In cardiac insufficiency, blood pools in the veins since the heart is not pumping effectively; this increases the hydrostatic pressure in the veins. And this increased hydrostatic pressure leads to increase filtration of water into the interstitium at the venous end of the capillary (post-capillary venule).

135.

A patient with extensive burns of torso skin exhibits  signs of severe  intoxication. What stage of the burn disease is this typical for?

Explanation

Intoxication – burn toxemia

The complex of typical changes in the human body developing due to the deep and severe burns is known as burn disease. There are the following stages of burn disease: burn shock, burn toxemia, burn infection, burn emaciation, outcome.

Burn toxemia is related to accumulation in the organism of toxic products of tissue decomposition and systemic expression of multiple inflammatory mediators (systemic inflammatory response syndrome).

136.

A   25-year-old   patient  consulted   a doctor  about  dysmenorrhea and infertility. Examination revealed  that  the patient was 145 cm high and had underdeveloped secondary sex characteristics, alar folds on the  neck.  Cytological  study  didn’t reveal any Barr bodies in the somatic cells. What diagnosis was made?

Explanation

These characterize Turner’s syndrome (XO). It can be complete monosomy (45,XO) or mosaicism (e.g. 45,XO/46,XX).

FullSizeRender (1)

Barr body is an inactive X-chromosome. A normal female has one barr body XX; so in turner’s syndrome, there is no barr body because the only X present is the active one (45 XO).

137.

Thermometry   revealed     that    the temperature of the  exposed  skin is by 1-1,5o   lower  than  the  temperature of  the adjacent areas covered with clothing from natural fabrics. The reason  for this is that the clothes reduce  the heat loss through:

Explanation

Convection is a way the body eliminates heat by means of transferring heat via moving particles of air or water. To dissipate heat by means of convection, body surface shall be airflowed at a temperature that is lower than the temperature of the skin. At that, air layer contacting with the skin warms up, decreases its density, rises and is replaced by cooler, denser air. By increasing the speed of the air flow (wind, ventilation) heat emission increases significantly as well (forced convection). Convection requires convection current; current of gases or liquids (Key words: air over exposed area of skin).

The areas of the skin covered with clothes has a higher temperature because the convection current does not have direct access to the skin in that area as compared to the exposed area of the skin.

Heat Radiation is a way the surface of the human body emits heat to the environment in the form of infrared rays. The amount of heat the body radiates to the environment is proportional to the surface of radiation area and to the difference between the mean values of skin and environment temperature. The surface radiation area is the total surface area of body parts that contact the air. Elimination of heat by radiation increases with a decrease in ambient temperature and decreases with its increase. It is possible to reduce elimination of heat by radiation via reduction of the surface of radiation area (“winding oneself into a ball”). Heat radiation does not require a medium for transfer of heat. (Key words: naked or lightly clothed).

Evaporation is a way the body dissipates heat to the environment by its evaporation via sweat or evaporation of moisture from the skin and respiratory tract mucous membranes of (“wet” heat loss). Evaporation closely related to relative humidity.

Conduction is a way the body eliminates heat by means of direct contact with another object. Heat is transferred down the temperature gradient (i.e. from the object of higher temperature to the object of lower temperature). Conduction requires contact with another object (Key words:  in water).

138.

The temperature in a production room is  36oC .  Relative  air  humidity   is  80%. Under these  conditions the  human  body transfers heat mainly through:

Explanation

Evaporation is a way the body dissipates heat to the environment by its evaporation via sweat or evaporation of moisture from the skin and respiratory tract mucous membranes of (“wet” heat loss). Evaporation closely related to relative humidity.

Heat Radiation is a way the surface of the human body emits heat to the environment in the form of infrared rays. The amount of heat the body radiates to the environment is proportional to the surface of radiation area and to the difference between the mean values of skin and environment temperature. The surface radiation area is the total surface area of body parts that contact the air. Elimination of heat by radiation increases with a decrease in ambient temperature and decreases with its increase. It is possible to reduce elimination of heat by radiation via reduction of the surface of radiation area (“winding oneself into a ball”). Heat radiation does not require a medium for transfer of heat. (Key words: naked or lightly clothed).

Convection is a way the body eliminates heat by means of transferring heat via moving particles of air or water. To dissipate heat by means of convection, body surface shall be airflowed at a temperature that is lower than the temperature of the skin. At that, air layer contacting with the skin warms up, decreases its density, rises and is replaced by cooler, denser air. By increasing the speed of the air flow (wind, ventilation) heat emission increases significantly as well (forced convection). Convection requires convection current; current of gases or liquids (Key words: air over exposed area of skin).

Conduction is a way the body eliminates heat by means of direct contact with another object. Heat is transferred down the temperature gradient (i.e. from the object of higher temperature to the object of lower temperature). Conduction requires contact with another object (Key words:  in water).

139.

14 days after quinsy a 15-year-old  child presented with morning  facial swelling, high  blood  pressure, \"meat   slops\" urine. Immunohistological   study    of   a   renal biopsy sample revealed  deposition of immune complexes on the basement membranes of the  capillaries  and  in the glomerular mesangium.  What disease developed in the patient?

Explanation

Peritonsillar abscess also known as quinsy ( a complication of tonsillitis) caused by both aerobic and anaerobic bacteria (streptococcus, staphylococcus and haemophilus).

Acute poststreptococcal glomerulonephritis: most frequently seen in children. Occurs approximately 2 weeks after group A streptococcal infection of pharynx or skin. Resolves spontaneously. Type III hypersensitivity reaction (Immune complex). Presents with peripheral and periorbital edema, cola-coloured urine, hypertension. On immunofluorescent microscopy: granular appearance due to IgG, IgM and C3 deposition along glomerular basement membrane and mesangium. On electron microscopy: subepithelial immune complex humps. On light microscopy: glomeruli enlarged and hypercellular.
140.

A patient has normally  coloured stool including a large amount of free fatty acids. The reason  for this is a disturbance of the following process:

Explanation

A normally coloured stool indicates that there is no obstruction to bile flow, therefore, there is a normal emulsification of fat. This also indicates that there is no obstruction to pancreatic juice flow into the intestine, therefore, there will also be proper digestion (hydrolysis) of fat by pancreatic lipase. Then, the only way free fatty acid can be found in stool after emulsification and digestion is only when there is a problem with absorption by the intestinal villi.

141.

A   patient  with   lobar   pneumonia has  had  body  temperature of  39oC  with  daily  temperature  fluctuation  of  no more   than   1oC  for  9  days.  This  fever can be characterized by the following temperature curve:

Explanation

krushkrok No50 (2014)

* Febris intermittens: characterized by regular alternation of brief attacks of fever (paroxysms) with feverless periods (apyrexia). Attacks occur every 3rd day, 2nd day or everyday. Increase temperature persists for several hours, drops to normal and then rises again.

* Febris continua/persistent: elevated temperature persists at a high level, difference between morning and evening temperature does not exceed 10C.

* Febris recurrens: characterized by longer periods of pyrexia than intermittent (5-6days). Question says every 4 days.

* Febris hectic: 3-50C (difference in temperature).

* Febris remittens: difference in temperature exceeds 10C but temperature never falls to normal.

142. A male with a lesion of one of the CNS parts has asthenia, muscular dystonia, balance   disorder.  Which  CNS  part   has been affected?

Explanation

During cerebellar lesions, there  are disturbances in posture, equilibrium and movements. Disturbances in movements: ataxia, asynergia, asthenia (weak muscle contractions with characteristically rapid onset of muscle fatigue), Dysmetria, Intention tremor, astasia (loss of the capacity for sustained tetanic contractions), nystagmus, rebound phenomenon, dysarthria, adiadochokinesis, atonia (lack or impairment of muscle tone).

143. A 12-year-old  patient has been  admitted   to  a  hospital   for  hemarthrosis  of the knee joint. From early childhood he suffers from frequent bleedings. Diagnose the boy’s disease:

Explanation

Hemophilia is a genetic disorder. Its an intrinsic coagulation pathway defect. Since its genetic, it can manifest early in life (childhood). Types:

Hemophilia A: X-linked recessive; deficiency of factor VIII

Hemophilia B: X-linked recessive; deficiency of factor IX

Hemophilia C: Autosomal recessive; deficiency of factor XI

Findings: macrohemorrhage in hemophilia – hemarthroses (bleeding into joints,  such as knee), easy bruising, bleeding after trauma or surgery (e.g. dental procedures).

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          Idiopathic or Immune thrombocytopenic purpura: characterized by bleeding which results from unusually low levels of platelets, affects both and children and adults. Children often develop Idiopathic thrombocytopenic purpura after a viral infection and usually recover fully without treatment. In adults, however the disorder is often chronic.

          Hemorrhagic vasculitis is an inflammatory disorder characterized by a generalized vasculitis involving the small vessels of the skin, GI tract, kidneys, joints and rarely the lungs and CNS. It is the most common vasculitis in children. It is an immune complex HSR disease; inciting agents (antigens) include: group A β-hemolytic streptococci and other bacteria, viruses, drugs, food, insect bites.

144.

A   patient  with   jaundice   has   high total bilirubin that is mainly indirect (unconjugated), high concentration of stercobilin  in  the  stool  and  urine.   The level  of  direct  (conjugated) bilirubin   in the blood plasma is normal.  What kind of jaundice  can you think of?

Explanation

Hemolytic/Prehepatic Jaundice is the type of Jaundice that occurs because of excessive destruction of RBCs resulting in ↑ blood level of free, Indirect, unconjugated bilirubin. In this condition, the excretory function of the liver is normal. But the quantity of bilirubin ↑ greatly. The liver cells cannot excrete that much excess bilirubin rapidly. Formation of Urobilinogen (stercobilin) ↑ resulting in the excretion of more amount of stercobilin in stool and urine.

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Indirect; Hemolytic; Prehepatic

Mixed; Parenchymal; Hepatic

Direct; Obstructive; Mechanic; Posthepatic

Stercobilin (faeces)

        ↑↑↑

Decreases (pale faces)

Absent (clay coloured faeces)

Type of bilirubin in blood

Unconjugated

Conjugated and Unconjugated

Conjugated

·       Gilbert syndrome (familial nonhemolytic Jaundice): Autosomal recessive defect. Impaired UGT activity. Jaundice occurs with fasting, volume depletion, stress, menses.

·       Physiologic Jaundice of newborn: begins on day 3 of life. Caused by normal macrophage destruction of fetal RBCs containing HbF and inability of the newborn’s liver to handle excess load.

145.

A  35-year-old  male  patient has been referred by an andrologist for the genetic counselling  for  the  deviations  of  physical and mental  development. Objectively: the patient is tall, has asthenic  constitution, gynecomastia, mental retardation. Microscopy of the oral mucosa cells revealed sex chromatin (single Barr  body)  in 30% of cells. What is the most likely diagnosis?

Explanation

 Barr body is an inactive X-chromosome. So a male patient (XY) with an inactive X-chromosome must have an additional X-chromosome – XXY (Klinefelter’s syndrome). Causes :

* nondisjunction (maternal and paternal nondisjunction in meiosis I)

* Mosaicism: with the karyotype being 46, XY/47, XXY

FullSizeRender (1)

Manifestations: gynecomastia, female pattern of pubic hair distribution, no facial hair, high voice.

146.

A patient with respiratory failure  has blood   pH   of  7,35.  pCO2    test   revealed hypercapnia. Urine  pH  test  revealed  an increase in the urine acidity. What form of acid-base  imbalance is the case?

Explanation

Respiratory acidosis is caused by alveolar hypoventilation. During hypoventilation, the lungs fail to expel CO2 (hypercapnia). pH of 7.35 indicates a compensatory mechanism that keeps the pH within the normal range. (7.34-7.45 is the normal range) COMPENSATED will remain in the normal range. DECOMPENSATED will fall out of the normal range.                                                                                                         Metabolic acidosis is characterized by excess accumulation of organic acids (lactic acid, ketoacids, uric acid) in the body.                                           Respiratory alkalosis is caused by alveolar hyperventilation which causes excess loss of CO2 from the body.

147. Measurements of  the  arterial pC O2 and   pO2    during   an  attack   of  bronchial asthma  revealed  hypercapnia and hypoxemia  respectively. What kind of hypoxia occurred in this case?

Explanation

Respiratory hypoxia arises as a result of respiratory insufficiency due to alveolar hypoventilation, disturbances of lung blood supply, disturbances of gases diffusion in lungs. Alveolar hypoventilation may be due to obstructive (bronchial asthma) and restrictive violations of lungs ventilation, which can lead to hypercapnia (INCREASE  in CO2) & hypoxemia (DECREASE in O2 in blood).
148.

A 38-year-old female patient complains of general weakness, cardiac pain, increased  appetite, no menstruation. Objectively:  the  height  is 166 cm, weight 108 kg, the patient has moon-shaped face, subcutaneous fat  is deposited mainly  in the upper  body, torso  and hips. There  are also  blood-red streaks.  Ps-  62/min,  AP-160/105 mm  Hg.  Which  of the  following diseases is the described  pattern of obesity most typical for?

Explanation

krushkrok No159 (2012)krushkrok No159a (2012)

Cushing Syndrome: Etiology:

INCREASE Cortisol due to a variety of causes (Glucocorticoids):

Exogenous corticosteroids: result in decrease ACTH (Most Common Cause).

Primary adrenal adenoma, hyperplasia or carcinoma (Cushing’s Syndrome).

ACTH-secreting pituitary adenoma (Cushing Disease).

Findings: Hypertension, Weight Gain, Moon Facies, Truncal Obesity, Buffalo Hump, Skin Changes (thinning striae), Osteoporosis, Hyperglycemia (Insulin resistance), Amenorrhea, Immunosuppression.

149.

Examination of an 18-year-old girl revealed the following features: hypoplasia of the ovaries, broad shoulders, narrow pelvis, shortening of the lower extremities, \"sphinx  neck\".  Mental development is normal. The girl was diagnosed with Turner’s syndrome. What kind of chromosome abnormality is it?

Explanation

FullSizeRender (1) These characterize Turner’s syndrome (XO). It can be complete monosomy (45,XO) or mosaicism (e.g. 45,XO/46,XX).
150.

Electrophoretic  study   of   a   blood serum sample, taken from the patient with pneumonia, revealed an increase in one of the protein fractions. Specify this fraction:

Explanation

Electrophoretic study of a blood serum sample examines specific proteins in the blood called GLOBULINS. With five major fractions: -Serum Albumin, Alpha-1 Globulin, Alpha-2 Globulin, Beta-Globulin, Gamma-Globulin.

Alpha-2 Globulin is INCREASED in nephrotic syndrome.

Beta-Globulin is INCREASED in Iron Deficiency Anaemia.

 Gamma-Globulin is INCREASED in Severe Infection (pneumonia), chronic liver disease. Due to the Ig produced against the infection.

151.

A  patient  with  diabetes  developed a diabetic coma due to the acid-base imbalance. Specify the kind of this imbalance:

Explanation

During insulin deficiency, glucose cannot be utilized by the peripheral tissues for energy. So, a large amount of fat is broken down to release energy. It cause the formation of excess ketone bodies leading to acidosis. One more reason for acidosis is that the ketone bodies are excreted in combination with sodium ions through urine (ketonuria). Sodium exchanged H+, which diffuse from the renal tubules into ECF adding to acidosis.  In diabetic patients, the body produces too much acid & the kidneys are not removing the fast enough as they results in metabolic acidosis.

152. A   female    patient   has   been    diagnosed   with  cervical  erosion,   which  is a precancerous pathology. What  defense mechanism  can prevent the development of a tumor?

Explanation

NK cells are lymphocytes that are capable of destroying tumor cells without prior sensitization and thus may provide the 1st line of defense against tumor cells. After activation with IL-2 and IL-15, NK cells can lyse a wide range of human tumors, including many that seem to be non-immunogenic for T-cells. NK cells, T-cells & macrophages may collaborate in antitumor reactivity.

153.

  Autopsy   of   a   dead   patient revealed bone marrow hyperplasia of tubular and flat bones (pyoid marrow), splenomegaly (6 kg) and hepatomegaly (5 kg), enlargement of all lymph node groups. What disease are the identified changes typical for?

 

Explanation

In chronic leukemia: spleen can weigh (6-8kg); liver (5-6kg). Chronic myelogenous leukemia (CML) is characterized by hepatosplenomegaly and generalized painless lymphadenopathy; pyoid bone marrow.

154.

A 53-year-old male patient is diagnosed with Paget’s disease. The concentration of oxyproline in daily urine is sharply increased, which primarily means intensified disintegration of:

 

Explanation

Collagen, most abundant protein in human body; organizes and strengthens extracellular matrix. Collagen contains Gly-X-Y (X and Y are proline or lysine). Glycine(Gly) makes 1/3 of collagen. Oxyproline (hydroxyproline) is a major collagen amino acid which enables it to be regarded as a marker that reflects the catabolism of collagen.

Paget disease of bone (osteitis deformans): localized disorder of bone remodeling caused by increase in both osteoclastic and osteoblastic activity.

155.

Autopsy of the dead patient who died from pulmonary edema revealed a large yellow-grey nidus in the myocardium, and a fresh thrombus in the coronary artery. What is the most likely diagnosis? 

Explanation

The macro- and microscopic changes in the Myocardial Infarction (M.I.) correspond to the age of the infarct.

   * first 24hrs: No gross changes; coagulative necrosis

               * 1-3days: pallor of infracted tissue

               * 3-7days: red granulation tissue surrounds area of infarction

               * 7-10days: necrotic area is bright YELLOW

               * first 2 months: infarct is replaced by white, patchy, noncontractile scar

                  tissue.

156.

Increased HDL levels decrease the risk of atherosclerosis. What is the mechanism of HDL anti-atherogenic action?

Explanation

krushkrok No13a (2014)

High density lipoprotein (HDL) – transports cholesterol from periphery to liver. Low Density Lipoprotein (LDL) - transports cholesterol from liver to tissues.

LCAT (lecithin-cholesterol acyltransferase) – catalyzes esterification of cholesterol

Cholesterol ester transfer protein (CETP) -  mediates transfer of cholesterol esters to other lipoprotein particles.

157.

A boy referred to a genetics clinic was found to have 1 drumstick in blood neutrophils. The boy is likely to have the following syndrome:

Explanation

krushkrok No70 (2007)

Drumstick – barr body. Barr body is an inactive X-chromosome. So a boy (XY) with an inactive X-chromosome must have an additional X-chromosome – XXY (Klinefelter’s syndrome). Causes :

* nondisjunction (maternal and paternal nondisjunction in meiosis I)

* Mosaicism: with the karyotype being 46, XY/47, XXY

FullSizeRender (1)

Manifestations: gynecomastia, female pattern of pubic hair distribution, no facial hair, high voice.

158.

A drycleaner’s worker has been found to have hepatic steatosis. This pathology can be caused by the disruption of synthesis of the following substance:

Explanation

Hepatic steatosis can occur when humans are deprived of choline.

Choline + Phosphatidic acid → Phosphatidylcholine (lecithin, PC). In the liver PC can also be synthesized from phosphatidylserine (PS) and phosphatidylethanolamine (PE), when free choline levels are low, because it exports significant amounts of PC in bile and as a component of serum lipoproteins (needed for fat metabolism)

PS → PE →→→ PC. 3 methylation reactions between PE and PC. S-adenosylmethionine is the methyl group donor. If choline, phosphatidylcholine or methionine is deficient, there will be abnormal phospholipid synthesis, oxidative damage caused by mitochondrial dysfunction, lipoprotein secretion (remember, if VLDL cannot be secreted it will be accumulated & cause fatty liver degeneration as seen in hepatic steatosis). PC is also a major lipid component of lung surfactant.

159. A biochemical urine analysis has been performed for a patient with progressive muscular dystrophy. In the given case muscle disease can be confirmed by the high content of the following substance in urine:

Explanation

Creatine kinase/Creatine phosphokinase is an enzyme present in striated muscles, used to generate energy. When its serum level is elevated it is often an indication of muscle damage caused by injury, muscular dystrophy or cardiac problems. Most forms of muscular dystrophy are associated with decreased creatinine excretion. Creatinine is a break down product of creatine. Normal constituent of urine but can be elevated in muscular dystrophy. Since creatine is not a normal constituent of urine, it is more specific in this case.

160. A 41-year-old male patient has a history of recurrent attacks of heartbeats (paroxysms), profuse sweating, headaches. Examination revealed hypertension, hyperglycemia, increased basal metabolic rate, and tachycardia. These clinical presentations are typical for the following adrenal pathology:

Explanation

FullSizeRender (22)

Adrenal medulla produces catecholamines (epinephrine, norepinephrine and dopamine). Increased secretion of epinephrine & norepinephrine can result in these symptoms listed.

image

Since the patient is 41yrs old, this can be pheochromocytoma - if it is a tumor.

161. As a result of careless handling of an iron, a 34-year-old female patient has got acute pain, redness, swelling of her right index finger. A few minutes later, there appeared a blister filled with a transparent liquid of straw-yellow color. The described changes are a manifestation of the following pathological process:

Explanation

Inflammation consists of 3 stages:

* Alteration: characterized by injury of structurally-functional unit of an organ. Primary & secondary.

* Exudative: violation of microcirculation with exudation. Serous, fibrinous, purulent, decaying, hemorrhagic, combination. Serous – skin blisters, pericarditis with clear/transparent liquid(exudative inflammation).

* Proliferative: a phase of reparatory regeneration.

162.

A 43-year-old-patient has arterial hypertension caused by an increase in cardiac output and general peripheral resistance. Specify the variant of hemodynamic development of arterial hypertension in the given case:

Explanation

Eukinetic: Increase in both systolic and diastolic blood pressure.

       Hyperkinetic: Increase in systolic blood pressure.

       Hypokinetic: Increase in diastolic blood pressure.

       Cardiac output determines systolic blood pressure; peripheral resistance determines diastolic blood pressure.

163.

  Examination of a 52-year-old female patient has revealed a decrease in the amount of red blood cells and an increase in free hemoglobin in the blood plasma (hemoglobinemia). Color index is 0,85. What type of anemia is being observed in the patient?

Explanation

Increase in free hemoglobin in blood plasma is characteristic for intravascular hemolysis. It is definitely acquired since patient is 52years old. If it has an Hereditary cause, it will probably have an early onset.

164.

The processes of heat transfer in a naked person at room temperature have been studied. It was revealed that under these conditions the greatest amount of heat is transferred by:

Explanation

Heat Radiation is a way the surface of the human body emits heat to the environment in the form of infrared rays. The amount of heat the body radiates to the environment is proportional to the surface of radiation area and to the difference between the mean values of skin and environment temperature. The surface radiation area is the total surface area of body parts that contact the air. Elimination of heat by radiation increases with a decrease in ambient temperature and decreases with its increase. It is possible to reduce elimination of heat by radiation via reduction of the surface of radiation area (“winding oneself into a ball”). Heat radiation does not require a medium for transfer of heat. (Key words: naked or lightly clothed).

Convection is a way the body eliminates heat by means of transferring heat via moving particles of air or water. To dissipate heat by means of convection, body surface shall be airflowed at a temperature that is lower than the temperature of the skin. At that, air layer contacting with the skin warms up, decreases its density, rises and is replaced by cooler, denser air. By increasing the speed of the air flow (wind, ventilation) heat emission increases significantly as well (forced convection). Convection requires convection current; current of gases or liquids (Key words: air over exposed area of skin).

Evaporation is a way the body dissipates heat to the environment by its evaporation via sweat or evaporation of moisture from the skin and respiratory tract mucous membranes of (“wet” heat loss). Evaporation closely related to relative humidity.

Conduction is a way the body eliminates heat by means of direct contact with another object. Heat is transferred down the temperature gradient (i.e. from the object of higher temperature to the object of lower temperature). Conduction requires contact with another object (Key words:  in water).

165.

Urine analysis has shown high levels of protein and erythrocytes in urine. This can be caused by the following:

Explanation

When blood passes through glomerular capillaries, the plasma is filtered. All substances of plasma are filtered except the plasma proteins and plasma cells, due to their large molecular size which is larger than the slit pores present in the endothelium of capillaries. Glomerular capillary membrane, basement membrane and visceral layer of bowman capsule form the filtration membrane through which glomerular filtration occurs. So, if protein and erythrocytes are increased or present in urine, it has to do with increase in renal filter permeability.

166.

The development of both immune and allergic reactions is based upon the same mechanisms of the immune system response to an antigen. What is the main difference between the immune and allergic reactions?

Explanation

Immune reactions are directed against antigens. Allergic reactions (hypersensitivity) destroys tissue while trying to destroy the antigen leading to development of tissue lesion (tissue lesion – tissue injury). But both of them have the same mechanism.

167.

In a patient elevation of body temperature takes turns with drops down to normal levels during the day. The rise in temperature is observed periodically once in four days. Specify the type of temperature curve:

Explanation

krushkrok No50 (2014)

* Febris intermittens: characterized by regular alternation of brief attacks of fever (paroxysms) with feverless periods (apyrexia). Attacks occur every 3rd day, 2nd day or everyday. Increase temperature persists for several hours, drops to normal and then rises again.

* Febris continua/persistent: elevated temperature persists at a high level, difference between morning and evening temperature does not exceed 10C.

* Febris recurrens: characterized by longer periods of pyrexia than intermittent (5-6days). Question says every 4 days.

* Febris hectic: 3-50C (difference in temperature).

* Febris remittens: difference in temperature exceeds 10C but temperature never falls to normal.

168.

Diabetic nephropathy with uremia has developed in a patient with pancreatic diabetes. The velocity of glomerular filtration is 9 ml/min. What mechanism of a decrease in glomerular filtration velocity and chronic renal failure development is most likely in the case of this patient?

Explanation

Diabetic nephropathy results in mesangial expansion, glomerular basement membrane thickening, glomerulosclerosis by nonenzymatic glycosylation of glomerular basement membrane → increase permeability, thickening. This basically destroys the nephron, thereby reducing the number of active/normal nephrons.

Diabetics will most likely increase and not decrease the arterial pressure. Does not cause obstruction. Tissue acidosis will not necessarily affect glomerular filtration.

169.

A patient complaining of pain in the left shoulder-blade region has been diagnosed with miocardial infarction. What kind of pain does the patient have?

Explanation

* Radiating pain: perceived at a site adjacent to or away from the site of origin but in the same dermatome i.e. supplied by afferent nerve fibers of one dorsal root.

* Viscera pain: organs, poorly localized, diffuse

* Protopathic pain: poorly localized pain

* Epicritic pain: well localized pain

* Phantom pain: pain from non-existent body structures (amputated limbs)

Phantom – if a leg has been amputated, the cut end heals with scar formation. The cut ends of nerve fibers are merged within the scar. If the cut end of sensory fibers are stimulated during movement of thigh, the patient feels as if the sensation is originating from non-existent leg. Sometimes the patient feels pain in non-existent limb.

170.

A patient is diagnosed with hereditary coagulopathy that is characterised by factor VIII deficiency. Specify the phase of blood clotting during which coagulation will be disrupted in the given case:

Explanation

171.

A patient has a traumatic injury of sternocleidomastoid muscle. This has resulted in a decrease in the following value:

Explanation

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All muscles that elevate the rib cage are muscles of inspiration and those that depress the rib cage are muscles of expiration.

Muscles of inspiration:

·        Sternocleidomastoid: lift upward on the sternum.

·        Anterior serrati: lift many of the ribs.

·        Scalene: lift the first two ribs.

Muscles of expiration: Abdominal recti – pull down the lower ribs and other abdominal muscles also compress the abdominal contents upwards against the diaphragm and internal intercostals.

Normal respiration is accomplished by the movement of the diaphragm only.

172.

A 37-year-old female patient complains of headache, vertigo, troubled sleep, numbness of limbs. For the last 6 years she has been working at the gas-discharge lamp-producing factory in the lead-processing shop. Blood test findings: low hemoglobin and RBC level, serum iron concentration exceeds the norm by several times. Specify the type of anemia:

Explanation

Lead poisoning: lead inhibits Ferrochelatase and ALA dehydratase. Ferrochelatase catalyzes Protoporphyrin + Fe+ → Heme

ALA dehydratase catalyzes Aminolevulinic acid (ALA) → Porphobilinogen

FullSizeRender (6)

Therefore, Iron, Protoporphyrin and ALA will be accumulated in the body. Iron refractory anemia results from disorder of Iron inclusion in heme at decrease of enzymes activity, which catalyzes synthesis of heme.

173.

A patient with hereditary hyperammonemia due to a disorder of ornithine cycle has developed secondary orotaciduria. The increased synthesis of orotic acid is caused by an increase in the following metabolite of ornithine cycle:

Explanation

This is classic ornithine transcarbamylase deficiency. Most common urea cycle disorder. X-linked recessive. Interferes with the body’s ability to eliminate NH3.

image

Excess Carbamoyl phosphate is converted to orotic acid (part of the pyrimidine synthesis pathway).

FullSizeRender (10)

Findings: ↑Orotic acid in blood and urine, symptoms of hyperammonemia. No megaloblastic anemia as seen in orotic aciduria – that’s why it is called secondary orotiic aciduria as used in the question.

Carbamoyl phosphate + Ornithine → Citrulline (urea cycle).

Carbamoyl phosphate is involved in 2 metabolic pathways: de novo pyrimidine synthesis and urea cycle. So, if the enzyme is deficient in urea cycle, all Carbamoyl phosphate will be channeled to de novo pyrimidine synthesis producing excess orotic acid.

174. Amniocentesis revealed two sex chromatin bodies (Barr bodies) in each cell of the sample. What disease is this character typical for?

Explanation

Barr body is an inactive X-chromosome. A normal female has one barr body XX, a normal male has no barr body XY.

Trisomy XXXX (only one X is active in a female; therefore, 2 barr bodies)

KlinefelterXXY (one barr body)

Turner’s – XO (no barr body)

Down and Patau involves autosomal chromosomes and not sex chromosomes.

175.

A 49-year-old male patient with acute pancreatitis was likely to develop pancreatic necrosis, while active pancreatic proteases were absorbed into the blood stream and tissue proteins broke up. What protective factors of the body can inhibit these processes?

Explanation

α2-macroglobulin and α1-antitrypsin are protease inhibitors which can inhibit the pancreatic proteases and prevent further tissue protein breakdown. Immunoglobulin, Cryoglobulin – antibody; Ceruloplasmin – Copper; Transferrin – Iron; Haptoglobulin – hemoglobin; Interferon – released by cells in response to pathogens.

176. A patient is diagnosed with iron-deficiency sideroachrestic anemia, progression of which is characterised by skin hyperpigmentation, pigmentary cirrhosis, heart and pancreas affection. Iron level in the blood serum is increased. What disorder of iron metabolism causes this disease?

Explanation

Sideroachrestic or sideroblastic anemia: causes

Chronic alcoholism (most common cause); Vit. B6 deficiency; Lead poisoning; X-linked recessive disease. It is a defect in heme synthesis within the mitochondrial. Iron accumulates in mitochondria, producing ringed sideroblast. X-linked defect in δ-ALA synthase gene. It is classified as an Iron-overload type of anemia. This enzyme catalyzes Glycine + Succinyl-CoA → δ-ALA rate limiting step in heme synthesis. Iron cannot be used in heme synthesis since the process has been disturbed earlier with the deficiency of the enzyme, therefore, Iron is accumulated.

177.

A patient has insufficient blood supply to the kidneys, which has caused the development of pressor effect due to the constriction of arterial resistance vessels. This is the result of the vessels being greatly affected by the following substance:

Explanation

FullSizeRender (12)

↓blood supply → activates renin. Renin catalyzes the conversion of angiotensinogen to angiotensin I. Angiotensin converting enzyme (ACE) converts angiotensin I → angiotensin II. Angiotensin II causes:

- vasoconstriction → ↑BP

- vasopressin (ADH) → ↑H2O reabsorption → ↑plasma volume

- aldosterone → ↑Na+ and H2O reabsorption → ↑plasma volume → ↑BP

178.

A 16-year-old female patient has fainted after quickly changing her body position from horizontal to vertical one. Which process from the ones listed below has caused the loss of consciousness in the first place?

Explanation

From horizontal (lying position) to vertical (standing position) will make all blood flow towards the lower extremities, thereby reducing venous return (blood going upwards towards the heart) in the first place. This will definitely ↓ cardiac output (C.O) → ↓blood supply to brain (this can lead to fainting). Then there is reflex vasoconstriction to increase venous return to heart, in the absence of any pathology.

179.

A 53-year-old male patient complains of acute pain in the right hypochondrium. Objective examination revealed scleral icterus. Laboratory tests revealed increased ALT activity, and stercobilin was not detected in the stool. What disease is characterized by these symptoms?

Explanation

Liver is found in the right hypochondrium; sclera icterus is specific for jaundice; Absence of stercobilin in stool – blockage of bile duct. These symptoms indicate obstructive , mechanic, posthepatic jaundice.

image

image

Cholelithiasis – gallstones which can obstruct bile flow → absence of stercobilin. Hemolytic jaundice → presence of stercobilin in stool.

Obturation (obstruction, to close) of bile duct – it can be:

* Intrahepatic – blockage of intrahepatic bile ducts

* Extrahepatic – blockage of common bile duct (ductus choledochus).

Findings:

* malabsorption: bile salts do not enter the Small Intestine; no emulsification of fat.

*light coloured stool: due to lack of urobilin (which leads to lack of stercobilin).

*Jaundice (posthepatic, mechanic, obstructive): increased conjugated Bilirubin.

* Steatorrhea

The findings are specific for obstruction of bile duct and bile acid deficiency.

180.

Experimental stimulation of the sympathetic nerve branches that innervate the heart caused an increase in force of heart contractions because the membrane of typical cardiomyocytes permitted an increase in:

Explanation

IMG_9907

When a muscle is excited (stimulated) by the impulses passing through neuromuscular junction, action potential is generated which spreads over sarcolemma (plasma membrane of muscles). When the action potential reaches the cisternae of ‘L’ tubules, Ca2+ stored in the cisternae are released into the sarcoplasm (cytoplasm of muscles). The Ca2+ moves towards the actin filaments to produce the contraction. Therefore, it is Ca2+ entry into the sarcoplasm.

181.

According to the results of glucose tolerance test, the patient has no disorder of carbohydrate tolerance. Despite that, glucose is detected in the patients’ urine (5 mmol/l). The patient has been diagnosed with renal diabetes. What renal changes cause glucosuria in this case?

Explanation

Food substances like glucose, amino acids, acetoacetate ions and vitamins are completely reabsorbed from renal tubules and do not appear in urine under normal conditions. These substances can appear in urine, only if their concentration in plasma is abnormally high (for glucose above 10mmol/L – renal threshold) or in renal diseases when reabsorption is affected. Since glucose is 5mmol/L, then it has to be a problem with decreased reabsorption of glucose.

182.

Parents of 5-year-old child report him o have frequent colds that develop into pneumonias, presence of purulent rashes on the skin. Laboratory tests have revealed the following: absence of immunoglobulins of any type, and naked cells are absent from the lymph nodes punctate. What kind of immune disorder is it?

Explanation

X-linked (Bruton) agammaglobulinemia: defect in Bruton’s tyrosine kinase (BTK), a tyrosine kinase gene → no B cell maturation. X-linked recessive (↑in boys). Findings: absent B cells in peripheral blood, ↓immunoglobulin of all classes. Absent/scanty lymph nodes and tonsils.

183.

A 3-year-old child has continuous fever, lymph nodes are enlarged, the amount of lymphocytes in blood is significantly increased. Enzyme-linked immunosorbent assay (ELISA) revealed antigen of Epstein-Barr virus. What diagnosis can be made based on the information given above?

Explanation

Anti-Epstein-Barr nuclear antigen antibody is specific and highly sensitive test or laboratory finding for Infectious mononucleosis. Epstein Barr virus (EBV) is a herpes virus and causative agent of Infectious mononucleosis, also called kissing disease.

image

Associated with Burkitt lymphoma (a neoplasia but no neoplastic lymphocytes mentioned in the question).

184.

A patient intending to undergo a gender reassignment surgery has been admitted to a specialised clinic. In the course of examination both male and female gonades have been revealed, with male structure of external genitals. What kind of genital maldevelopment has the patient?

Explanation

Hermaphroditism refers to ambiguous sexual differentiation due to development disorders during embryonic period. 2 types: true and false (pseudo). True hermaphroditism is a rare-type state featuring presence of both female and male gonads in an organism. Pseudohermaphroditism is more common and further divided into male and female. Male: male gonads, 46XY but external genitals are intersexual or resemble female. Female: female gonads, 46XX but external genitals resemble those in males.
185. An 18-year-old male has been diagnosed with Marfan syndrome. Examination revealed a developmental disorder of connective tissue and eye lens structure, abnormalities of the cardiovascular system, arachnodactylia. What genetic phenomenon has caused the development of this disease?

Explanation

* Pleiotropy: one gene contributes to multiple phenotypic effects → disorder of connective tissue and eye lens structure, abnormalities of CNS, arachnodactylia. Marfan is FBN1 gene mutation on chromosome 15; Marfan is one gene defect causing all this phenotypic defects.

* Codominance: both alleles contribute to the phenotype of the heterozygote. e.g. blood group AB

* Incomplete dominance: intermediate inheritance. Red + White → Pink

* Multiple allelism e.g. ABO blood type

186.

In case of alkaptonuria, homogentisic acid is excreted in urine in large amounts. The development of this disease is associated with a disorder of metabolism of the following amino acid:

Explanation

image

Ochronosis (Alkaptonuria): congenital deficiency of homogentisate oxidase (homogentisic acid oxidase) in the degradative pathway of tyrosine to Fumarate → pigment-forming homogentisic acid accumulates (homogentisuria) in tissues. Autosomal recessive. Usually benign. Urine turns black on prolonged exposure to air. May have debilitating arthralgias (homogentisic acid toxic to cartilage).

Phenylalanine → Tyrosine →→→ Homogentisic acid → Maleylacetoacetic acid

187.

When studying the signs of pulmonary ventilation, reduction of forced expiratory volume has been detected. What is the likely cause of this phenomenon?

Explanation

Forced expiratory volume (FEV) is the volume of air, which can be expired forcefully in a given unit of time. It is very much decreased in obstructive diseases like asthma and emphysema.

188.

A 55-year-old patient with a characteristic rash, fever, dizziness has been admitted to a hospital. He has been provisionally diagnosed with typhus. No similar cases have been reported. In his youth (15 years old) the patient suffered typhus in a boarding school. What disease is it?

Explanation

Epidemic typhus (human body louse) – Rickettsia prowazekii, can remain latent and reactivate months or years in an infected patient, with symptoms similar to or even identical to the original attack of typhus, including a rash that starts centrally and spreads out, sparing palms and soles. This delayed relapse of epidemic typhus – Brill’s disease.

189. X-ray examination of a patient allowed to diagnose a tumor in the superior lobe of the right lung. There is a probability of metastases spread to the following lymph nodes:

Explanation

The dominant lymphatic drainage from the right upper lobe flowed into the superior mediastinal nodes. The sternal or parasternal nodes is one of the superior mediastinal nodes.
190.

In the course of an experiment adenohypophysis of an animal has been removed. The resulting atrophy of thyroid gland and adrenal cortex has been caused by deficiency of the following hormone:

Explanation

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6 hormones are secreted by anterior pituitary/adenohypophysis: GH; TSH; ACTH; FSH; LH and Prolactin. They are responsible for the growth and secretory activity of their target glands. The first 5 hormones (Prolactin not included) are called tropic hormones.

191.

Degenerative changes in posterior and lateral columns of spinal cord (funicular myelosis) caused by methylmalonic acid accumulation occur in patients with B12-deficiency anemia. This results in synthesis disruption of the following substance:

 

Explanation

imageimage

Funicular myelosis: Vit B12 deficiency – subacute combined degeneration – demyelination of dorsal columns (posterior), lateral corticospinal tracts and spinocerebellar tracts.

IMG_9833

Fatty acids →→ Methylmalonyl-CoA → Succinyl-CoA → TCA cycle, myelin synthesis, Heme

192. Patients with erythropoietic porphyria (Gunther’s disease) have teeth that fluoresce with bright red color when subjected to ultraviolet radiation; their skin is light-sensitive, urine is red-colored. What enzyme can cause this disease, when it is deficient?

Explanation

Erythropoietic porphyria (Gunther’s disease): This disorder is due to a defect in the enzyme Uroporphyrinogen III cosynthase. It is characterized by:

* It is a rare congenital disorder caused by autosomal recessive mode of inheritance, mostly confined to erythropoietic tissues.

* The individuals excrete Uroporphyrinogen I and Coproporphyrinogen I which oxidize respectively to Uroporphyrin I and Coproporphyrin I (red pigments).

* The patients are photosensitive (itching and burning of skin when exposed to visible light) due to the abnormal porphyrins that accumulate. Porphyrins are accumulated in the teeth, bones and an increases amount are seen in the plasma, bone marrow, faeces, RBCs and urine.

* Increased hemolysis is also observed in the individuals affected by this disorder.

193.

A female patient saught medical-genetic consultation. Physical examination revealed pterygium colli deformity (webbed neck), broad chest, underdeveloped breasts. Study of buccal epithelium cells revealed no X-chromatin in the nuclei. This indicates that the patient has the following syndrome:

Explanation

krushkrok No105 (2014)FullSizeRender (1)

These characterize Turner’s syndrome (XO). It can be complete monosomy (45,XO) or mosaicism (e.g. 45,XO/46,XX). Klinefelter is related to males. The rest are not related to sex chromosomes, but they are autosomoes.

194. During blood transfusion a patient has developed intravascular erythrocyte hemolysis. What kind of hypersensitivity does the patient have?

Explanation

* Type I: Allergic and atopic disorders (e.g. rhinitis, hay fever, asthma); Anaphylaxis. Presentation – immediate, anaphylactic, atopic

* Type II: Acute hemolytic transfusion reactions, autoimmune hemolytic anemia, Erythroblastosis fetalis, Goodpasture syndrome, Graves disease, Myasthenia gravis. Disease tends to be specific to tissue or site where antigen is found.

* Type III: Arthus reaction; SLE; serum sickness. Can be associated with vasculitis and systemic manifestations.

* Type IV: Contact dermatitis, Graft-versus-host disease, multiple sclerosis. Response is delayed and does not involve antibodies (vs. Type I, II, III)

195.

Examination of a 56-year-old female patient with a history of type 1 diabetes revealed a disorder of protein metabolism that is manifested by aminoacidemia in the laboratory blood test values, and clinically by the delayed wound healing and decreased synthesis of antibodies. Which of the following mechanisms causes the development of aminoacidemia?

Explanation

Type I diabetes: lack of insulin. Normally, insulin stimulates storage of lipids, proteins and glycogen. But in the absence of insulin, glucagon and epinephrine stimulates use fuel reserves through hepatic glycogenolysis, hepatic gluconeogenesis, adipose release of free fatty acids (FFA). ↑in glucagon and epinephrine → ↑protein degradation (muscle) → ↑amino acid → aminoacidemia. Protein degradation = proteolysis.
196.

For biochemical diagnostics of myocardial infarction it is necessary to measure activity of a number of enzymes and their isoenzymes. What enzymatic test is considered to be the best to prove or disprove the diagnosis of infarction in the early period after the chest pain is detected?

Explanation

In laboratory diagnosis of acute myocardial infarction: Creatine kinase isoenzyme MB (CK-MB) appears within 4-8hrs, peaks at 24hrs and disappears within 1.5-3 days. Sensitivity and specificity is 95%.

IMG_9910

Reappearance of CK-MB after 3days – reinfarction. CK-MM – found in skeletal muscle and heart (not specific for heart). LDH1 – heart muscle; LDH2 – blood serum. LDH levels are also high in tissue breakdown or hemolysis. Although CK-MB is more specific and sensitive for infarction than LDH. Aspartate transaminase is not specific for heart damage alone but can still be used to diagnose myocardial infarction. But troponin test [cardiac troponins I (cTnI) and T (cTnT)] is the most sensitive and specific test for myocardial infarction.

197.

Due to the use of poor-quality measles vaccine for preventive vaccination, a 1-year-old child has developed an autoimmune renal injury. The urine was found to contain macromolecular proteins. What process of urine formation has been disturbed?

Explanation

When blood passes through glomerular capillaries, the plasma is filtered. All substances of plasma are filtered except the plasma proteins and plasma cells, due to their large molecular size which is larger than the slit pores present in the endothelium of capillaries. Glomerular capillary membrane, basement membrane and visceral layer of bowman capsule form the filtration membrane through which glomerular filtration occurs. So, if protein and erythrocytes are increased or present in urine, it has to do with increase in renal filter permeability (filtration permeability).
198. As a result of a road accident a 37-year-old female victim developed urinary incontinence. What segments of the spinal cord had been damaged?

Explanation

Urinary incontinence – involuntary urination. In general, parasympathetic stimulation is anabolic, promoting normal function and conserving energy. The sacral part of parasympathetic system resides within the S2-S4 sacral segments of the spinal cord.

IMG_9908

They inhibit contraction of internal sphincter of bladder, contracts detrusor muscle of the bladder wall causing urination (voluntary). Lesion to this segment of spinal cord (S2-S4) causes involuntary urination.

199. In the course of puncture biopsy of transplanted kidney the following has been revealed: diffuse infiltration of stroma by lymphocytes and plasmocytes and necrotic arteritis. What pathological process has developed in the transplant?

Explanation

A biopsy of the transplanted organ can confirm that it is being rejected. The laboratory pathologist generally seeks 3 main histological signs:

* Infiltrating T cells, perhaps accompanied by infiltrating plasma cells, eosinophils and neutrophils.

* Structural compromise of tissue anatomy.

* Injury to blood vessels.

Rejection is an adaptive immune response. Therefore, immune rejection.

200. A female patient, having visited the factory premises with lots of dust in the air for the first time, has got cough and burning pain in the throat. What respiratory receptors, when irritated, cause this kind of reaction?

Explanation

Irritant receptors are located in the bronchi and bronchioles of lungs and are stimulated by irritant chemical agents such as ammonia, sulfur dioxide and some other small particles like dust, smoke etc. These receptors send afferent impulses to respiratory centers via vagal nerve fibers. Stimulation of irritant receptors produces reflex hyperventilation along with bronchospasm. J receptors are stimulated during pulmonary congestion, pulmonary edema, over-inflation of lungs. Stretch receptors are the receptors which give response to stretch of the tissues – Hering-Breuer reflex is initiated by the stimulation of stretch receptors of air passage. Proprioceptors of respiratory muscles are the receptors which give response to change in the position of body. Thermoreceptors are cutaneous receptors, which give response to change in the environmental temperature.

201. A newborn baby has numerous hemorrhages. Blood coagulation tests reveal increased prothrombin time. The child is most likely to have a disorder of the following biochemical process:

Explanation

Prothrombin time (PT) evaluates the extrinsic coagulation system down to the formation of the fibrin clot.

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Factors that are evaluated include factor VII, X, V, II, and I. PT is increased when a factor level is 30% - 40% of normal. Vitamin K-dependent factors include factor II, VII, IX and X; protein C and S.

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Vitamin K is activated in the liver by epoxide reductase. Activated vitamin K ɣ-carboxylates each of the vitamin K-dependent factors. Carboxylated factors are now able to bind calcium, which are essential for interaction between the coagulation factors and platelet membranes.

Warfarin inhibits the enzyme vitamin K epoxide reductase. Neonates lack enteric bacteria which produce vitamin K.

202.

A 67-year-old male patient consumes eggs, pork fat, butter, milk and meat. Blood test results: cholesterol - 12,3 mmol/l, total lipids - 8,2 g/l, increased low-density lipoprotein fraction (LDL). What type of hyperlipoproteinemia is observed in the patient?

Explanation

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Type IIa (familial hyperlipoproteinemia: ↑LDL and cholesterol. Autosomal dominant; due to absent or defective LDL receptors.

Type I:  ↑chylomicrons, triacylglycerol (TAG), cholesterol. Autosomal recessive; due to lipoprotein lipase deficiency or altered apolipoprotein C-II.

Type IV: ↑very low density lipoprotein (VLDL) and TAG. Autosomal dominant; due to hepatic overproduction of VLDL.

Type IIb: similar to Type IIa, except that VLDL is also increased and VLDL is normal for IIa.

203.

The resuscitation unit has admitted a patient in grave condition. It is known that he had mistakenly taken sodium fluoride which blocks cytochrome oxidase. What type of hypoxia developed in the patient?

Explanation

Tissue or histotoxic hypoxia is the type of hypoxia produced by the inability of tissues to utilize O2 which results from tissue poisoning. These poisonous substances destroy the cellular oxidative enzymes and there is a complete paralysis of cytochrome oxidase system.

Hemic hypoxia: connected with hemoglobin (Hb) quantity or inhibition of its functions. Cardiovascular or circulatory hypoxia arises during the disturbance of blood circulation due to heart and vessels pathology. Hypoxic hypoxia develops during the decrease of barometric pressure that is accompanied with decrease of pO2. Respiratory hypoxia arises as a result of respiratory insufficiency due to alveolar hypoventilation, disturbances of lungs blood supply, disturbances of gases diffusion in lungs.

204.

On the fifth day after the acute blood loss a patient has been diagnosed with hypochromic anemia. What is the main mechanism of hypochromia development?

Explanation

Acute hemorrhage refers to sudden loss of a large quantity of blood as in the case of accident. Within about 24 hours after the hemorrhage, the plasma portion of blood is replaced. However the replacement of RBCs does not occur quickly and it takes at least 4-6 weeks. On the 5-7th day (regenerative or bone marrow period). There is appearance of some immature forms of RBC (i.e. normoblast, reticulocyte) with decreased hemoglobin and colour index (hypochromia).
205.

A patient has severe blood loss caused by an injury. What kind of dehydration will be observed in this particular case?

Explanation

Dehydration (hypohydration, hypohydria, exicosis): in dehydration, the extracellular fluid (ECF) and sodium ions are lost.

*Isoosmolar dehydration: based on proportional volume decrease of fluids and electrolytes e.g. acute renal failure (stage of polyuria), blood loss, burns etc.

*Hypoosmolar dehydration (salt deficit) develops due to diarrhea, vomiting, sweating, adrenal insufficiency etc.

*Hyperosmolar dehydration (water deficit) develops due to the loss of the fluid which lacks electrolytes e.g. in diabetes insipidus, hyperventilation

206.

A 30-year-old patient has dyspnea fits, mostly at night. He has been diagnosed with bronchial asthma. What type of allergic reaction according to the Gell-Coombs classification is most likely in this case?

Explanation

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Type I (Immediate, Anaphylaxis, Reagin): IgE (immunoglobulin E)-dependent activation of mast cells/basophils, usually accompanied by eosinophilia e.g. urticaria (hives), hay fever, asthma (wheezing), rhinitis and conjunctivitis (stuffy nose and itchy eyes; usually seasonal)

Type II (cytotoxic): antibody dependent reactions e.g. Goodpasture syndrome, Myasthenia gravis, Graves disease, ABO hemolytic disease of newborn etc.

Type III (immune-complex): deposition of antigen-antibody complexes e.g. systemic lupus erythromatous (SLE), Arthus reaction, serum sickness, poststreptococcal glomerulonephritis etc.

Type IV (cell mediated, delayed): antibody-independent T-cell mediated reactions e.g. positive mantoux reaction (tuberculin test), hashimoto’s thyroiditis or transplant rejection etc.

207.

After a road accident a victim has tachycardia, arterial blood pressure 130/90 mm Hg, tachypnoe, the skin is pale and dry, excitation of central nervous system is observed. What shock stage is the patient most likely in?

Explanation

Pirogov’s stages of shock

* Erectile phase: is characterized by strong motor agitation, sweating, tremor of skeletal muscles, staggering gait, frequent urination, transient increase in blood pressure, heart rate and breath rate increases, body temperature also. Painful impulses reach CNS.

* Torpid phase: decompensation in CNS leads to deep oppression. Patient is motionless, does not answer questions or answers very silently and with long time of delay, reflexes are lowered or absent.

208. Autopsy has revealed shrunken kidneys weighing 50 mg, with fine-grained surface and uniformly thinned substance. Microscopic investigation has shown the thickening of arteriole walls due to accumulation of homogeneous anhistic pink-coloured masses in them. Glomerules were undersized, sclerotic, with atrophied tubules. What disease are these changes characteristic of?

Explanation

Primary shrunken kidney is a renal form of essential hypertension. It is characterized by chronic arteriolosclerotic nephrosclerosis. Macroscopically, both kidneys are affected equally and are reduced in size and weight. The surface of the kidney is finely granular. The cut surface shows firm kidney and narrowed cortex. Microscopically, there is variable degree of atrophy of parenchyma; these include glomerular shrinkage, deposition of collagen in Bowman’s space, periglomerular fibrosis.

Secondary shrinkage of kidneys is found in chronic glomerulonephritis.

209.

A patient operated on complicated appendicitis has the following changes of blood count: erythrocytes - 4, 0 · 1012/l,  Нb - 120 g/l, color index - 0,9, leukocytes - 18 · 109/l,  basophils - 0,   eosinophils  -  0,   myelocytes  -   0,   juvenile  -  0,  stab neutrophils - 20, segmentonuclear neutrophils - 53, lymphocytes - 21, monocytes - 5. How is such nuclear shift of leukocytic formula called?

Explanation

Neutrophilic leukocytosis: increase in neutrophil count. Depending on the proportion between the mature and premature forms of neutrophils, two types of the nuclear shift may be distinguished: to the left, when there is an elevated content of immature forms of neutrophilic granulocytes (myelocytes, metamyelocytes, bands) in the blood; And to the right, when the mature neutrophils with a large number of segments (5 – 6) prevail against a background of younger cells disappearing. The nuclear shift may be subdivided into: regenerative, hyperregenerative, degenerative and regenerative-degenerative shifts.

Degenerative shift is characterized by increasing in band's number and appearance of a large number of destructive changed segmented forms (nuclear pyknosis, toxic granularity and cytoplasm vacuolization). This indicates the inhibition of granulocytopoiesis and may occur in the severe course of infectious diseases and in endogenous intoxication.

 Neutrophils: Stab (band): 1-6%                        (20%)↑

                                    Segmented: 47-72%         (53%) normal

                                    Myelocyte: - 0

                                    Metamyelocyte: 0-1%      Juvenile forms (0)

Since there is an elevated content of Stab (band) form of neutrophils, then it is a degenerative left shift.

210.

A  child  was born  with  cleft  palate. Examination revealed  aorta  defects  and reduced  number    of   T-lymphocytes   in blood.  What  immunodeficient syndrome is it?

 

Explanation

DiGeorge’s syndrome results from a congenital malformation affecting the 3rd and 4th pharyngeal pouches. These structures give rise to the thymus, parathyroid glands and portions of lips, ears and the aortic arch. It is the most common disorder of cell mediated immunity. The thymus is usually rudimentary and T cells are deficient or absent in the circulation. Most of these infants have additional developmental defects affecting the face, ears, lips heart and great vessels. All of these disorders are part of a spectrum called 22q deletion syndrome because they result from a deletion on the long arm of chromosome 22 (22q11). It represents the most severe example of a collection of disorders that also includes velocardiofacial syndrome (VCFS) and conotruncal anomalies face syndrome.

211. A  20 year  old  patient complains  of general weakness, dizziness, quick fatigability.  Blood   analysis  results:  Hb-  80 g/l. Microscopical  examination results: erythrocytes are  of  modified  form.  This condition might be caused by:

Explanation

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Sickle cell hemoglobin (HbS) point mutation causes a single amino acid replacement in β chain of hemoglobin (substitution of glutamic acid with valine). Pathogenesis of sickle cell anemia: low O2, high altitude or acidosis precipitates sickling – modified shape (deoxygenated HbS polymerizes) → anemia and vaso-occlusive disease. Clinical findings include: dizziness, general weakness, fatigue, “crew-cut” on skull X-ray due to marrow expansion from increased erythropoiesis (this is also seen in thalassemia)  etc. Sickle cells are crescent-shaped RBCs.

212.

Examination of a patient admitted to the surgical department with symptoms of acute  appendicitis revealed  the following changes in the white blood cells: the total count of leukocytes  is 16 · 109/l. Leukocyte formula:  basophils  - 0, eosinophils  - 2%, juvenile  forms  - 2%,  stabnuclear - 8%, segmentonuclear   -   59%,    lymphocytes -  25%,  monocytes-   4%.  The  described changes can be classified as:

Explanation

Neutrophilic leukocytosis: increase in neutrophil count. Depending on the proportion between the mature and premature forms of neutrophils, two types of the nuclear shift may be distinguished: to the left, when there is an elevated content of immature forms of neutrophilic granulocytes (myelocytes, metamyelocytes, bands) in the blood; And to the right, when the mature neutrophils with a large number of segments (5 – 6) prevail against a background of younger cells disappearing. The nuclear shift may be subdivided into: regenerative, hyperregenerative, degenerative and regenerative-degenerative shifts.

Regenerative shift develops against a background of mild general leukocytosis, accompanied with elevated content of bands and metamyelocytes (immature forms). This shift results from the reactive leukopoiesis (granulocytopoiesis) activation and is common in suppurative septic processes.

Neutrophils: Stab (band): 1-6%             (8%)↑

                                    Segmented: 47-72%         (59%) normal

                                    Myelocyte: -

                                    Metamyelocyte: 0-1%      Juvenile forms (2%)↑

Since there is an elevated content of immature forms of neutrophils, then it is a regenerative left shift.

213.

ECG  of a patient shows such alterations: P -wave is normal,  P − Q-interval is short,  ventricular QRST   complex  is wide, R-wave  is double-peak or two-phase. What form of arrhythmia is it?

Explanation

Patients with a history of palpitations and a pre-excited ECG have a syndrome known as Wolff-Parkinson-White (WPW) syndrome. Accessory fibers are most commonly situated on the left but may occur anywhere around the atrioventricular (AV) groove. The most common accessory pathways, known as kent bundles, are in the free wall or septum. Mahaim fibers are atrio-fascicular or nodo-fascicular fibers entering the ventricular myocardium in the region of the right bundle branch. If the accessory pathway conducts from the atrium to the ventricle during sinus rhythm, the electrical impulse can conduct quickly over this abnormal connection to depolarize part of the ventricles abnormally (pre-excitation). image A pre-excited ECG is characterized by a short PQ interval and a wide QRS complex that begins as a slurred part known as the δ wave (delta wave).
214.

A female  patient suffering  from bronchial  asthma  had  got a viral infection  that  provoked status  asthmaticus with fatal  outcome.  Histological  examination of lungs revealed  spasm and edema  of bronchioles, apparent infiltration  of their walls with  lymphocytes,  eosinophils   and other   leukocytes;   labrocyte   degranulation.  What  mechanism  of hypersensitivity underlies the described  alterations?

Explanation

Type I (Immediate, Anaphylaxis, Reagin): IgE (immunoglobulin E)-dependent activation of mast cells/basophils, usually accompanied by eosinophilia e.g. urticaria (hives), hay fever, asthma (wheezing), rhinitis and conjunctivitis (stuffy nose and itchy eyes; usually seasonal).

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Type I Hypersensitivity reaction (HSR); anaphylactic and atopic: free antigen cross-links IgE on presensitized (i.e. exposed to the antigen before) mast cells and basophils, triggering immediate release of vasoactive amines that act at postcapillary venules (i.e. histamine). Reaction develops rapidly after antigen exposure because of preformed antibody from first exposure. IgE is the main immunoglobulin involved in type I HSR. Type I: uses IgE and IgG4

215.

A patient was admitted to the infectious department. His symptoms:  dry skin, decreased  skin  turgor,   rice-water  stool. The  patient was diagnosed with cholera. What  disorder  of  water-electrolytic balance  is most often  observed in this disease?

Explanation

Isoosmolar hypohydration (isoosmotic loss): proportional volume decrease of fluids and electrolytes e.g. in blood loss, burns, diuretic therapy, especially diarrhea in cholera.

Hypoosmolar hypohydration (salt deficit) develops due to diarrhea, vomiting, sweating, adrenal insufficiency, hypokalemia, CNS lesions, salt-losing nephritis.

          Hyperosmolar hypohydration (water defcit) develops due to the loss of the fluid which lacks electrolytes e.g. in diabetes insipidus, hyperventilation.

         Hypoosmolar hyperhydration (water excess) develops in acute renal failure (in the stage of anuria), Parhon’s syndrome (syndrome of inappropriate ADH secretion –SIADH).

         Hyperosmolar hyperhydration (salt excess) develops rarely e.g. in drinking salt (sea) water, infusion of hypertonic saline, adrenal hyperactivity or steroid therapy.

216.

A 5 year old child is ill with measles. Blood  analysis  revealed  increase  of total number   of  leukocytes   up  to  13 · 109/l. Leukogram:  basophils   -  0,  eosinophils - 1,  myelocytes  - 0,  juvenile  neutrophils - 0, band  neutrophils  - 2, segmented neutrophils - 41, lymphocytes  - 28, monocytes  - 28. Name this phenomenon:

Explanation

        Normal range

RBC (erythrocytes): Men

      4.2 – 5.2 X 1012/L

                                    Women

      3.7 – 4.7 X 1012/L

Hemoglobin:  Men

      135 – 165g/L

                        Women

      120 – 140g/L

Leukocytes (WBC):

      4.0 – 9.0 X 109/L

    Basophils

         0 - 1%

    Eosinophils

         0.5 – 5%

    Neutrophils

         47 – 72%

    Lymphocytes

         19 – 37%

    Monocytes

           3 – 11%

Monocyte is 28%, therefore it is monocytosis i.e. ↑monocyte count. Increase in total number of leukocytes is in the monocyte fraction. Agranulocytes include lymphocyte and monocyte.

217. Cardinal symptoms  of primary hyperparathyroidism are osteoporosis and renal lesion along with development of urolithiasis.  What substance  makes up the basis of these calculi in this disease?

Explanation

Urolithiasis or formation of urinary calculi at any level of the urinary tract is a common condition. There are 4 main types of urinary calculi, namely:

·        Calcium stones: are the most common comprising 75% of all urinary calculi. They may be pure stones of calcium oxalate (50%) or calcium phosphate (5%) or mixture of calcium oxalate.

·        Mixed (struvite) stones: about 15% of urinary calculi are made of magnesium-ammonium-calcium phosphate often called struvite. “Staghorn stone”

·        Uric acid stones: can be seen in gout, Lesch-Nyhan syndrome (hyperuricemia).

·        Cystine stones: seen in cases like cystinuria.

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NB: hyperparathyroidism → ↑Ca2+ concentration in blood.

218.

A 15 year old girl has pale skin, glossitis, gingivitis. Blood  count:  erythrocytes - 3, 3 cot 1012/l, hemoglobin - 70 g/l, colour index  - 0,5. Examination of blood  smear revealed  hypochromia, microcytosis,  poikilocytosis. What type of anemia  is it?

Explanation

Microscopically, iron deficiency anemia is characterized by hypochromia (red cells are pale) and smaller than nomal (microcytic); chlorosis (pale-greenish colouration of skin).

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There is alopecia, koilonychias, atrophies of the tongue and gastric mucosa (atrophic glossitis and atrophic gastritis). Plummer-Vinson triad: hypochromic microcytic anemia, atrophic glossitis and esophageal webs.

B12 –folic acid deficiency: megaloblastic macrocytic anemia

Sickle cell anemia: sickled shaped or modified shaped erythrocytes

Hemolytic anemia: in chronic conditions, its manifestations are very similar to iron deficiency anemia.

Thalassemia: target cell, anisocytosis, poikilocytosis.

219. A patient with obliterating atherosclerosis underwent sympathectomy of femoral  artery  in the region of femoral trigone.  What  type  of arterial hyperemia was induced  by the operation?

Explanation

·        Neuroparalytic arterial hyperemia is caused by damage or blockage of α-adrenoreceptors (sympathetic nervous system). It is characterized by reduction or absence (paralysis) of the sympathetic nervous system effects on the walls of the arteries and arterioles.

·        Neurotonic arterial hyperemia is caused by activation of parasympathetic nervous system; irritation of vascular dilators part of vascular center (CNS) or inhibition of vascular – constrictor part of this center (vasomotor center of CNS); M-cholinoreceptors; H2-histaminereceptors. It is characterized by predominance of the parasympathetic nervous system effects on arterial vascular walls.

220.

Dietary  intake  of a 30 year old nursing woman  contains  1000 mg of calcium, 1300 mg of phosphorus and 20 mg of iron per day. It is necessary  to change  content of these mineral substances  in the following way:


Explanation

221.

Lungs of a preterm infant have areas of  atelectasis (pulmonary collapse).  The main cause is:

Explanation

Atelectasis refers to partial or complete collapse of the lungs. Its major cause is deficiency or inactivation of surfactant. It causes collapse of lungs due to increased surface tension, which leads to respiratory distress syndrome. Other causes include obstruction of a bronchus or a bronchiole; presence of air (pneumothorax), fluid (hydrothorax), blood (hemothorax) or pus (pyothorax) in the pleural space.

222. A female patient underwent liver transplantation. 1,5 month  after it her condition became worse because of reaction of transplant rejection. What  factor  of immune  system plays the  leading  part  in this reaction?

Explanation

Cytotoxic T cells destroy cancer cells, transplanted cells, such as those of transplanted heart or kidney or any other cells, which are foreign bodies. They destroy even the body’s own tissues which are affected by the foreign bodies, particularly the viruses.

     Helper T cells (CD4 cells) activate all the other T cells and B cells.

     B cells – plasma cells – antibodies: major defense against bacterial infections.

     Natural killer (NK) cells: destroy viruses, malignant cells and prevents development of cancerous tumors.

    Interleukin are cytokines produced by leukocytes to act on other leukocytes e.g. IL-1, IL-2, IL-3, IL-12 etc.

223. A patient has delayed conduction of excitement through the atrioventricular node. What changes of  ECG will be observed?

Explanation

image

P-Q or P-R interval is the interval between the onset of ‘P’ wave and onset of ‘Q’ wave. This interval signifies the atrial depolarization and conduction of impulses through the AV node.

krushkrok No28 (2009)

Short isoelectric (zero voltage) period after the end of ‘P’ wave represents the time taken for the passage of depolarization within the AV node. Normal duration of P-Q interval is 0.18s and varies between 0.12 and 0.20s. If it is more than 0.20s, it signifies a delay in the conduction of impulse, usually, the delay occurs in the AV node. It is prolonged in bradycardia and Atrioventricular (AV) heart block i.e. delay in conduction of impulse through the AV node.

224.

Voluntary breath-holding caused increase   of  respiration  depth   and frequency.   The   main  factor   stimulating these changes of external  respiration is:

 

Explanation

Central chemoreceptors are responsible for 70 – 80% of increased ventilation through chemical regulatory mechanism. Main stimulant for central chemoreceptors is the increased hydrogen ion concentration. However, if H+ concentration increases in blood, it cannot cross the blood-brain barrier and blood-cerebrospinal fluid barrier. On the other hand, if CO2 increases in the blood, it can easily cross the blood-brain barrier and blood-CSF barrier and enter the interstitial fluid of brain or the CSF. There, the CO2 combines with water to form carbonic acid. Since carbonic acid (H2CO3) is unstable, it immediately dissociates into H+ and bicarbonate ion. 

Then H+ stimulates the central chemoreceptors. From chemoreceptors, the excitatory impulses are sent to dorsal respiratory group of neurons, resulting in increased ventilation (increased rate and force of breathing). Lack of O2 does not have significant effect on the central chemoreceptors, except that it generally depresses the overall function of brain.

225.

A  patient with skin mycosis has disorder   of  cellular   immunity. The most typical characteristic of it is reduction of the following index:

Explanation

Cellular immunity or T-cell immunity involves majorly the T cells. 

B-lymphocytes differentiates into plasma cells which then produce antibodies or immunoglobulins (IgG, IgE …). They participate more in humoral immunity.

Immunodeficiency disorders is a good soil for opportunistic pathogenic infections (e.g. skin mycosis). Therefore, a disorder of cellular immunity indicates a reduction in T-lymphocyte count.

226. A  47 year  old  man  with  myocardium infarction  was admitted to the  cardiological department. What changes of cellular  composition of peripheral blood are induced by necrotic changes in the myocardium?

Explanation

The necrotic changes is an invitation for an inflammatory reaction.

Neutrophils are the first leukocytes that cross the blood vessel wall to enter inflammatory sites. Under normal conditions, leukocytes are restricted to the center of small blood vessels, where the flow is fastest. In inflammatory sites, where the vessels are dilated, the slower blood flow allows the leukocytes to move out of the center of the blood vessel and interact with the vascular endothelium. Even in the absence of infection, monocytes migrate continuously into the tissues, where they differentiate into macrophages; meanwhile, during an inflammatory response, the induction of adhesion molecules on the endothelial cells, as well as induced changes in the adhesion molecules expressed on leukocytes recruit large numbers of circulating leukocytes, initially Neutrophils and later monocytes, into the site of an infection (inflammatory focus).
227.

Examination of  a  pregnant woman revealed  twice as much  concentration of fibrinogen  in blood plasma. What ESR can this woman have?

Explanation

Normal erythrocyte sedimentation rate (ESR): men: 2 – 10mm/h

                                                                               Women: 2 – 15mm/h

Products of inflammation (e.g. fibrinogen) coat RBCs and cause aggregation. The denser RBC aggregates, fall at a faster rate within a pipette tube. Therefore, an increase in fibrinogen (2x increase) should produce a proportional increase in ESR.

40 – 50mm/h is the only option higher than the normal range.

↑ESR: most anemias, infections, inflammation (e.g. temporal arteritis), cancer (e.g. multiple myeloma), pregnancy, autoimmune disorders (e.g. SLE)

↓ESR: sickle cell anemia (altered shape), polycythemia (↑RBCs “dilute” aggregation factors), microcytosis, hypofibrinogenemia

228.

Introduction of a big dose of histamine to an experimental animal caused abrupt drop of arterial pressure as a result of:

Explanation

Histamine is one of the most important inflammatory mediators. Histamine is synthesized and secreted from tissue basophils, thrombocytes, endothelium and smooth muscle cells. Activation of H1-receptors leads to bronchospasm, activation of chemotaxis and lymphocytotoxicity, generation of lipid mediators, increase of vessels permeability and dilatation of resistance vessels (arterioles). Increase in vessels permeability leads to the formation or accumulation of exudates i.e. the escape of fluid, proteins and blood cells from the vascular system into the interstitial tissue or body cavities (i.e. edema). Edema denotes an excess of fluid in the interstitial tissue or serous cavities. It can be either an exudate or a transudate. An exudate is an inflammatory extravascular fluid that has a high protein content, specific gravity and many cells.

229.

Patients who  suffer  from  severe  diabetes  and don’t receive insulin have metabolic acidosis. This is caused by increased  concentration of the  following metabolites:

Explanation

When the rate of formation of ketone bodies is greater than the rate of their use, their levels begin to rise in blood (ketonemia) and eventually in the urine (ketonuria). These two conditions are seen most often in cases of uncontrolled type I diabetes mellitus. In such individuals, high fatty acid degradation produces excessive amounts of acetyl CoA. It also depletes the NAD+ pool and increases the NADH pool, which slows the citric acid cycle. This forces the excess acetyl CoA into the ketone body pathway. An elevation of the ketone body concentration in  the blood results in metabolic acidosis.
230.

A man weighs 80 kg, after long physical activity his circulating blood volume is reduced down  to 5,4 l, hematocrit makes up  50%,  whole  blood  protein is 80 g/l. These  blood  characteristics are  determined first of all by:

 

Explanation

Normal hematocrit is approximately 45%. After a long physical activity, his circulating blood volume is reduced as a result of profuse sweating which can also produce relative hyperproteinemia (in the absence of any pathology). This decrease in blood liquid compartment has caused a relative increase in blood cells, increasing the hematocrit to 50% i.e. decrease in blood liquid compartment → ↑blood concentration → ↑hematocrit. Hematocrit is the percentage of cells present in plasma. In this case, no increase in plasma cell synthesis but a reduction in blood liquid compartment (through sweat) leads to an increase in the plasma cell percentage relative to the liquid component.
231.

A couple had a child with Down’s disease. Mother is 42 years old. This disease is most probably  caused  by the following impairment of prenatal development:

Explanation

The normal and pathologic development and growth can be divided into the following stages:

·        Progenesis: characterized by gametogenesis i.e. formation and maturation of gametes. This stage occurs before the fertilization of the ovum. Pathology of gametogenesis is called gametopathy.

·        Development after fertilization is called kymatogenesis. This intrauterine phase can be divided into:

-         Blastogenesis: from day 1 – 15 of gestation. Pathology of blastogenesis is called blastopathy.

-         Embryogenesis: from day 16 to the end of the 3rd month (75th day). Pathology of embryogenesis is called embryopathy.

-         Fetogenesis: from the 4th month of gestation to delivery (from 76th -280th day). Pathology of fetogenesis is called fetopathy.

     Gametopathy is an injury of formation and maturation of the gametes during ovo- and spermatogenesis until fertilization. The most frequent is trisomy 21 (Down’s syndrome); trisomy 13 (Patau’s syndrome), trisomy 18 (Edward’s syndrome), Klinefelter’s syndrome (XXY), Turner’s syndrome (XO).

232.

A patient suffering from pheochromocytoma complains of thirst, dry mouth, hunger. Blood test for  sugar revealed hyperglycemia. What type of hyperglycemia is it?

Explanation

Pheochromocytoma is the most common tumor of the adrenal medulla in adults. Most tumors secrete epinephrine, norepinephrine and dopamine which can cause episodic hypertension.

FullSizeRender (22)

There is increase catecholamines and metanephrines in urine and plasma. Epinephrine stimulates glycogen phosphorylase (rate-limiting enzyme in glycogenolysis i.e. breakdown of glycogen to glucose). This results in hyperglycemia (increase glucose conc. in blood).

krushkrok No196 (2014)

There is also pronounced sympathetic effects throughout the body like dry mouth.

233.

A patient was stung by a bee. Examination  revealed  that his left hand was hot, pink, edematic,  there  was a big red blister on  the  site of sting.  What  is the  leading mechanism  of edema development?

Explanation

Bee sting can initiate an inflammatory process, which leads to the release of biogenic amines and other important inflammatory mediators. Histamine is one of the most important inflammatory mediators. Histamine is synthesized and secreted from tissue basophils, thrombocytes, endothelium and smooth muscle cells. Activation of H1-receptors leads to bronchospasm, activation of chemotaxis and lymphocytotoxicity, generation of lipid mediators, increase of vessels permeability and dilatation of resistance vessels (arterioles). Increase in vessels permeability leads to the formation or accumulation of exudates i.e. the escape of fluid, proteins and blood cells from the vascular system into the interstitial tissue or body cavities (i.e. edema). Edema denotes an excess of fluid in the interstitial tissue or serous cavities. It can be either an exudate or a transudate. An exudate is an inflammatory extravascular fluid that has a high protein content, specific gravity and many cells.

234.

During  hypersensitivity test a patient got subcutaneous injection  of an antigen which  caused  reddening of skin,  edema, pain as a result  of histamine action.  This biogenic amine  is generated as a result of transformation of the  following  histidine amino acid:

Explanation

image

Certain amino acids undergo decarboxylation that means the removal of their α-carboxyl group resulting in liberation of CO2 and formation of biogenic amines. Biogenic amines are physiologically active substances such as hormones, neurotransmitters etc. decarboxylation of amino acids:

·        Tryptophan → Niacin → NAD+/NADP+

          Tryptophan → Serotonin →Melatonin

·        Histidine → Histamine

·        Glutamine → GABA

Glutamine → Glutathione

235. A  patient staggers  and  walks astraddle. He  has  hypomyotonia of arm and leg muscles, staccato  speech.  In what brain section is this affection localized?

Explanation

During cerebellar lesions, there  are disturbances in posture, equilibrium and movements. Disturbances in movements: Speech disorders, ataxia, asynergia, asthenia (weak muscle contractions with characteristically rapid onset of muscle fatigue), Dysmetria, Intention tremor, astasia (loss of the capacity for sustained tetanic contractions), nystagmus, rebound phenomenon, dysarthria, adiadochokinesis, atonia (lack or impairment of muscle tone).

NB: Scanned or staccato speech is as a result of cerebellar disorders; while monotonus speech is as a result of parkinson's disease.

236.

Hepatitis has led to the development of hepatic  failure. Mechanism  of edemata formation is activated by the impairment of the following liver function:

Explanation

Hepatitis is inflammation of the liver. The liver is the main site of protein synthesis i.e. synthesis of albumin, globulin, fibrinogen etc., which are necessary to maintain plasma oncotic pressure. In a situation of hepatic failure, there is decrease of protein synthesis which results in decreased oncotic pressure and then, edema. Therefore, an impairment of protein synthetic function of liver leads to the formation of edema.

237.

Two hours after an exam a student had a blood count done and it was revealed that he had  leukocytosis without significant leukogram modifications. What is the most probable mechanism  of leukocytosis  development?

Explanation

Any form of stress is accompanied by the release of stress hormones (catecholamines, cortisol). Stress-induced changes in blood leukocyte distribution may represent an adaptive response. This represents a redistribution of leukocytes from the blood to other organs such as the skin, draining sentinel lymph nodes and other compartments. Such leukocyte redistribution may enhance immune function in compartments to which immune cells traffic during stress.

238. A patient ill with thrombophlebitis of his lower limbs had chest pain, blood spitting, progressing  respiratory insufficiency that  led to his death.  Autopsy diagnosed multiple lung infarctions. What is the most probable cause of their development?

Explanation

Pulmonary embolism is the most common and fatal form of venous thromboembolism in which there is occlusion of pulmonary arterial tree by thromboemboli. Pulmonary emboli are more common in hospitalized or bedridden patients. The majority of emboli arise from the deep veins of the lower extremities; most of the fatal ones arise from the ileofemoral veins. Consequences of thromboembolism include pulmonary infarction in which pyramidal segments (or ‘triangular’ segments) of hemorrhagic infarction are seen at the periphery of the lung. Detachment of thrombi from the thrombophlebitis site in the lower limbs produces a thromboembolus that flows through venous drainage into the large veins draining into the right side of the heart and then to the pulmonary circulation where they embolize.

239.

Examination of a man who had been working  hard  under  higher  temperature of the environment revealed abnormal quantity of blood  plasma  proteins. What phenomenon is the case?

Explanation

Liver is the primary organ of protein synthesis. In a case of dysfunction of protein synthesis, hypoproteinemia occurs. We have absolute and relative hypoproteinemia. Absolute is when there is disturbed synthesis (absolute hypoproteinemia) and in cases of increased synthesis (absolute hyperproteinemia); while relative does not have to do with synthesis but other pathologies e.g. renal lesions, in which case, there is loss of protein with urine (relative hypoproteinemia); also vomiting, diarrhea, profuse sweating can produce relative hyperproteinemia.

It is Relative because it does not have to do with synthesis. The man must have lost a lot of fluid through sweat, thereby decreasing the fluid content of the body and creating a relative hyperproteinemia. Decrease blood volume (liquid component alone) → ↑concentration of blood.

240. A  62  year   old  patient  who  previously  worked  as stoker  was admitted to a hospital  with complaints  about  general weakness,  abrupt weight loss, hoarse  voice, dyspnea, dry cough. Laryngoscopy revealed  a tumour in the pharynx that invaded  vocal cords  and  epiglottis.  What is the most probable cause of tumour development?

Explanation

Polycyclic aromatic hydrocarbons (PAH) or simply polycyclic hydrocarbons may be released during the combustion of fossil fuels, particularly when coal and gas are burnt at high temperatures (e.g. in steel foundries) and are present in tar and soot (Pott identified soot as the cause of scrotal cancers in chimney sweeps in 1775). Polycyclic hydrocarbons are among the most potent carcinogens and industrial exposures have been implicated in the development of lung, respiratory tract and bladder cancer. NB: a stoker is a person who tends a furnace specifically of a steam boiler, on a ship, locomotive etc.

241. A patient staying in the pulmonological department was diagnosed  with pulmonary emphysema accompanied by reduced elasticity of pulmonary tissue. What type of respiration is observed?

Explanation

Lung emphysema is characterized by increased airiness of the lungs due to overdistended or destroyed alveoli. The patient mainly complains of dyspnoea, which at the onset of the disease may only develop during exercise but later it occurs at rest. Dyspnea increases in cold seasons, in chills and exacerbations of bronchitis; it is especially pronounced during attacks of cough. Dyspnea is usually of an expiratory type: a healthy person expires air with ease whereas the patient with emphysema presses it out from the chest with an effort.

242. A 35 year old man consulted  a dentist  about   reduced  density   of  dental   tissue,  high  fragility  of  teeth  during  eating  solid  food.   This  patient  suffers  the most probably from the deficiency of the following mineral element:

Explanation

Calcium (above 98%) and phosphorus (about 86%) are mainly fixed in bones and teeth, from where they can be mobilized in case of immediate organism needs. The role of calcium in the organism consists in the participation in bone and teeth construction, transmission of nervous stimulation, blood clotting, regulation of membranes permeability, muscle contraction etc. Therefore, a deficiency of Ca2+ → ↓density of teeth and ↑fragility.

243.

A patient has a decreased vasopressin synthesis  that  causes  polyuria   and  as  a result  of it evident  organism  dehydration.  What  is the  mechanism   of  polyuria development?

Explanation

image 

Antidiuretic hormone (vasopressin) is secreted in response to decrease blood volume and increase plasma osmolarity. It binds to receptors on principal cells of collecting ductules causing increase number of aquaporins and increase water reabsorption which leads to decreased diuresis.

↓vasopressin → ↓H2O reabsorption → polyuria

244.

A   30   year   old   woman   has   face edemata. Examination revealed  proteinuria (5,87 g/l), hypoproteinemia, dysproteinemia, hyperlipidemia. What condition is  the  set  of  these  symptoms typical for?

Explanation

Nephrotic syndrome is characterized by massive proteinuria (>3.5g/day) with hyperlipidemia, hypoalbuminemia (hypo- and dysproteinemia), edema etc. It may be primary (direct podocyte damage) or secondary (podocyte damage from systemic process e.g. diabetes). For example – focal segmental glomerulosclerosis, minimal change disease, membranous nephropathy, amyloidosis, diabetic glomerulonephropathy.

245.

A 42 year  old woman  with neuralgia of  trifacial  nerve  complains  about   periodical  reddening of the  right  part  of her face and neck, sense of warmth gush, increased   skin  sensitivity.   These   effects can  be  explained by  the  following  type of arterial hyperemia:

Explanation

·        Neuroparalytic arterial hyperemia is caused by damage or blockage of α-adrenoreceptors (sympathetic nervous system). It is characterized by reduction or absence (paralysis) of the sympathetic nervous system effects on the walls of the arteries and arterioles.

·        Neurotonic arterial hyperemia is caused by activation of parasympathetic nervous system; irritation of vascular dilators part of vascular center (CNS) or inhibition of vascular – constrictor part of this center (vasomotor center of CNS); M-cholinoreceptors; H2-histaminereceptors. It is characterized by predominance of the parasympathetic nervous system effects on arterial vascular walls. Trifacial nerve (Trigeminal nerve CNV), a cranial nerve. Parasympathetic system is craniosacral i.e. it has cranial and sacral segments.

246.

Inflammatory processes cause synthesis of protein of acute phase in an organism. What substances  stimulate their synthesis?

Explanation

IL-1 is produced by macrophages, endothelium, keratinocytes, microglia, B-lymphocytes, fibroblasts, dendritic cells. Pro-inflammatory effects depend on IL-1, also induction of adhesive molecules, endopyrogenic activity, reason of prodromal syndrome, trigger of the reaction of an acute phase of inflammation and induction of synthesis of acute phase reactants, the main mediator of the immune reaction to alien substances, stimulator of stress.

247.

A 25 year old Palestinian woman complains of weakness, dizziness, dyspnea. In anamnesis: periodically exacerbating anemia. In blood: Hb  - 60 g/l, erythrocytes - 2, 5 · 1012/l, reticulocytes -  35o/oo, anisocytosis and poikilocytosis of erythrocytes, a lot of target cells and polychromatophils. What type of anemia is it?

Explanation

Thalassemia or target cell anemia or Cooley’s anemia is an hemoglobinopathy (abnormal hemoglobin in RBCs). Defect in α-globin chain results in α thalassemia; and point mutations in β-globin chain results in β thalassemia. It is characterized microscopically by anisocytosis, poikilocytosis, target cells and is characterized by increased hemolysis, enlargement of spleen and liver, progressive anemia with erythroblastemia (reticulocyte). It’s a microcytic, hypochromic anemia.

image

Sickle cell anemia is also a hemoglobinopathy (abnormal hemoglobin in RBCs). It results as a result of a point mutation causing a single amino acid replacement in β chain (substitution of glutamic acid with valine) to produce hemoglobin S (HbS). The condition is characterized by the presence of sickle-like erythrocytes revealed during crisis, they cause stasis, hemorrhages and infarctions.

248.

A  17 year  old  boy  fell  seriously  ill, the  body temperature rose up to 38, 5oC , there  appeared cough,  rhinitis,  lacrimation,  nasal  discharges.  What  inflammation is it?

Explanation

Catarrhal inflammation is one of the morphologic patterns in acute inflammation. In this type, a surface inflammation is associated with greatly increased secretion of clear mucus (nasal discharges). Rhinitis is inflammation of mucous lining of the nose.

249.

48 hours  after  tuberculine test (Mantoux test)  a child  had  a  papule  10 mm in diameter on the spot of tuberculine injection.  What hypersensitivity mechanism underlies these changes?

Explanation

Mantoux test is a type IV Hypersensitivity reaction (HSR), which involves macrophages,T-lymphocytes and lymphokines(cytokines). Mononuclear cells (lymphocytes,monocytes,macrophages). FullSizeRender (7)

The Mantoux skin test should be read between 48 and 72hrs after administration. The basis of reading  is the presence or absence of induration, which may be determined by inspection and by palpation. A record should also be made of formation of vesicles, bullae, lymphangitis, ulceration and necrosis at the test site. The formation of vesicles, bullae or necrosis at the test site indicates positive result. A negative mantoux result usually signifies that the individual has never been exposed to Mycobacterium tuberculosis i.e. absence of cell mediated immunity to tuberculin.

image

Type IV (cell mediated, delayed): antibody-independent T-cell mediated reactions e.g. positive mantoux reaction (tuberculin test), hashimoto’s thyroiditis or transplant rejection etc.

250. A patient suffering from periodical attacks  caused  by inhalation of different flavoring  substances  was diagnosed  with atopic bronchial asthma. IgE level was increased.  This is typical  for the  following type of reactions:

Explanation

Type I Hypersensitivity reaction (HSR); anaphylactic and atopic: free antigen cross-links IgE on presensitized (i.e. exposed to the antigen before) mast cells and basophils, triggering immediate release of vasoactive amines that act at postcapillary venules (i.e. histamine). Reaction develops rapidly after antigen exposure because of preformed antibody from first exposure. IgE is the main immunoglobulin involved in type I HSR. Type I: uses IgE and IgG4

251. A   34   year   old   woman    was   diagnosed with hereditary microspherocytic hemolytic anemia (Minkowsky-Shauffard disease). What mechanism caused haemolysis of erythrocytes?

Explanation

Hemolytic anemia: according to the mechanisms of the development, they are divided into 3 groups namely:

·        Erythrocytic membrane structure (membranopathy)

·        Erythrocytic enzyme activity (enzymopathy)

·        Structure or rate of hemoglobin synthesis (hemoglobinopathy)

    Membranopathies are characterized by disorders of protein or lipid components of the erythrocytic membrane structure. Membranopathies caused by the disorders of protein structure includes:

o   Hereditary spherocytosis (Minkowsky-shauffard disease)

o   Hereditary elliptocytosis (ovalocytosis)

o   Hereditary pyropoikilocytosis

o   Hereditary and acquired stomatocytosis

     In addition, the membrane defect leads to a loss of both potassium and water, which produces cellular dehydration and results in erythrocyte damage (electrolytic osmotic).

252.

ECG  of a patient shows prolongation of T-wave. This is caused  by deceleration in ventricles of:

Explanation

krushkrok No28 (2009)

‘T’ wave is the final  ventricular complex and is a positive wave. It is due to the repolarization of ventricular musculature. Normal duration is 0.2sec; normal amplitude is 0.3mV.

253.

A   patient  who   has   been   abusing tobacco  smoking  for a long time  has got cough  accompanied  by  excretion of  viscous mucus; weakness  after minor physical stress, pale  skin. The  patient has also lost  12,0 kg of body  weight.  Endoscopic examination of biopsy material his illness was diagnosed  as squamous cell carcinoma.  Name  a pathological process  that preceded formation of the tumour:

Explanation

Metaplasia is a reversible change of one type to another type of adult epithelial or mesenchymal cells, usually in response to abnormal stimuli and often reverts back to normal on removal of stimulus. Types (2):

·        Epithelial: *Squamous metaplasia: in bronchus (chronic smokers), cervix

                          *Columnar metaplasia: there is transformation to columnar epithelium.

·        Mesenchymal metaplasia: osseous and cartilaginous.

IMG_9796

Hyperplasia: ↑number of cells; Hypertrophy: ↑in size.

254.

A 46 year  old woman  suffering  from chololithiasis developed jaundice.  Her urine  became  dark-yellow  and  feces became  colourless. Blood serum will have the highest concentration of the following substance:

Explanation

Cholelithiasis is obstruction of bile duct by a stone.

Obturation (obstruction, to close) of bile duct – it can be:

* Intrahepatic – blockage of intrahepatic bile ducts

* Extrahepatic – blockage of common bile duct (ductus choledochus).

Findings:

* malabsorption: bile salts do not enter the Small Intestine; no emulsification of fat.

*light coloured stool: due to lack of urobilin (which leads to lack of stercobilin).

*Jaundice (posthepatic, mechanic, obstructive): increased conjugated Bilirubin.

* Steatorrhea

image

The findings are specific for obstruction of bile duct and bile acid deficiency.

Indirect; Hemolytic; Prehepatic

Mixed; Parenchymal; Hepatic

Direct; Obstructive; Mechanic; Posthepatic

Stercobilin (faeces)

        ↑↑↑

Decreases (pale faces)

Absent (clay coloured faeces)

Type of bilirubin in blood

Unconjugated

Conjugated and Unconjugated

Conjugated

255.

A full-term newborn  child has yellowish skin and mucous  membranes. This might be probably caused by temporary deficiency of the following enzyme:

Explanation

In the hepatocyte, the solubility of unconjugated bilirubin is increased (i.e. it is made soluble) by the addition of two molecules of glucuronic acid to produce conjugated bilirubin. This process is reffered to as conjugation. This reaction is catalyzed by Uridine diphosphate (UDP) glucuronyltransferase – UGT.

image

Varying degrees of deficiency of this enzyme result in Crigler-Najjar I & II and Gilbert syndrome; with Crigler-Najjar I being the most severe deficiency.

Deficiency of UGT inhibits conjugation and therefore increase unconjugated bilirubin in serum (Jaundice).

256. A  patient  is  ill  with  diabetes  mellitus  accompanied  by  hyperglycemia  on an  empty  stomach  (7,2 millimole/l).  The hyperglycemia  rate   can  be  retrospectively estimated (over  the  last  4-8 weeks before   the  examination) on  the  ground of the rate  of the following blood  plasma protein:

Explanation

One of the laboratory tests for diabetes mellitus is the level of glycosylated hemoglobin. Glycosylated hemoglobin test (HbA1C, glycohemoglobin) are proteins with glucose bound to them by nonenzymatic way. They precisely represent the extent of impairment of the carbohydrate metabolism and serve as the basic index of quality of compensation of diabetes mellitus. The level of HbA1C is determined by the method of chromatography using special laboratory equipment. Level of HbA1C shows an average blood concentration during the previous 2 - 3 months. Normal level of HbA1C is 4 – 6%. [4 – 8 weeks (1-2months)]

257.

A  12-year-old  patient was found  to have  blood  serum  cholesterol at the  rate of  25 mmol/l.  The  boy  has  a  history  of hereditary familial hypercholesterolemia, which is caused by the impaired  synthesis of the following protein receptors:

Explanation

image

Type IIa (familial hyperlipoproteinemia: ↑LDL and cholesterol. Autosomal dominant; due to absent or defective LDL receptors.

Type I:  ↑chylomicrons, triacylglycerol (TAG), cholesterol. Autosomal recessive; due to lipoprotein lipase deficiency or altered apolipoprotein C-II.

Type IV: ↑very low density lipoprotein (VLDL) and TAG. Autosomal dominant; due to hepatic overproduction of VLDL.

Type IIb: similar to Type IIa, except that VLDL is also increased and VLDL is normal for IIa.

258. A female patient complains of vision impairment. On examination she was found to have obesity, fasting hyperglycemia. What  complication of diabetes can cause vision impairment?

Explanation

Microangiopathy is a chronic complication of diabetes mellitus (fasting hyperglycemia) affecting small blood vessels and manifested as retinopathy (vision impairment), nephropathy, neuropathy. Macroangiopathy affects larger vessels causing symptoms such as gangrene, ulceration, transient ischemic attack.
259. A  3-year-old  child  had  eaten  some strawberries. Soon  he  developed a  rash and itching. What was found in the child’s leukogram?

Explanation

This is an example of type I hypersensitivity reaction considering the time taken for the symptoms (rash and itching) to manifest and the expression of eosinophilia.

Neutrophilic leukocytosis: bacterial infection

Lymphocytosis: viral and bacterial infection (e.g. whooping cough, tuberculosis)

Monocytosis: chronic inflammation (tuberculosis); autoimmune disease

260.

A patient underwent a course of treatment for atherosclerosis. Laboratory tests revealed an increase in the anti-atherogenic lipoprotein fraction in the blood  plasma.  The  treatment efficacy  is confirmed by the increase in:

Explanation

High density lipoprotein (HDL): is the antiatherogenic lipoprotein fraction (nicknamed the ‘good lipoprotein’).

Low density lipoprotein (LDL): is the proatherogenic lipoprotein fraction (nicknamed the ‘bad lipoprotein’)

krushkrok No13a (2014)

High density lipoprotein (HDL) – transports cholesterol from periphery to liver. Low Density Lipoprotein (LDL) - transports cholesterol from liver to tissues.

LCAT (lecithin-cholesterol acyltransferase) – catalyzes esterification of cholesterol

Cholesterol ester transfer protein (CETP) -  mediates transfer of cholesterol esters to other lipoprotein particles.

261.

A   patient  complains   that   at   the bare   mention  of  the  tragic  events   that once  occurred in his life he  experiences tachycardia, dyspnea  and  an  abrupt rise in blood  pressure. What  structures of the CNS are responsible for these cardiorespiratory  reactions in this patient?

 

Explanation

Cerebral cortex is responsible for the memory, attention, consciousness and all higher nervous system functions. The cardiorespiratory reaction in the patient is because he is able to store and remember the tragic event. The cerebral cortex also has extensive connections with the subcortical structures responsible for short and long term memories.

262. A  patient with  constant headaches, pain in the occipital region, tinnitus, dizziness has been  admitted to the cardiology department. Objectively: AP- 180/110 mm Hg, heart  rate - 95/min. Radiographically, there   is  a  stenosis  of  one  of  the  renal arteries. Hypertensive condition in this patient has been  caused by the activation of the following system:

Explanation

FullSizeRender (12)

The main stimulator of renin release from juxtaglomerular cell is decrease blood flow in afferent arteriole. Stenosis of renal artery → ↓blood flow to afferent arteriole thereby stimulating renin release and set up the renin-angiotensin-aldosterone system (RAAS).

263.

As a result of a home injury, a patient suffered a significant blood loss, which led to  a fall in blood  pressure. Rapid  blood pressure recovery  after  the  blood  loss is provided  by the following hormones:

Explanation

Adrenaline is an adrenomimetic; α1 – mediates peripheral vasoconstriction →↑blood pressure. Activation of β1-adrenoreceptors by adrenaline results in increased cardiac output and heart rate.

Vasopressin → ↓diuresis; ↑H2O reabsorption → ↑blood volume

Aldosterone is a steroid hormone and cannot produce the same level of increase in blood pressure as adrenaline and vasopressin combined.

264. A  patient with  extensive  myocardial infarction  has developed heart  failure. What pathogenetic mechanism  contributed  to the development of heart  failure in the patient?

Explanation

Extensive myocardial infarction: extensive necrosis of myocardial cells. The pathogenesis of the heart failure is definitely the fact that there are less active/alive myocardial cells that can contract and pump blood effectively. No information about blood volume, so we can’t talk about the other options.

265. A  30-year-old  female  exhibits  signs of virilism (growth  of body  hair,  balding temples, menstrual disorders). This condition can be caused by the overproduction of the following hormone:

Explanation

These symptoms indicates an increase in male sex hormones. This can probably be a pathology of the adrenals or ovaries in a female, which leads to increase production of testosterone (the only male sex hormone in the options)

266.

On allergological  examination a patient has been diagnosed with pollinosis. Specific desensitization can be performed by:

Explanation

Desensitization therapy in atopic individuals involves repeated injection of increasingly greater amounts of allergen, resulting in production of IgG antibodies that attach to allergens and prevent them from binding to mast cells.

267. After  the prolonged vomiting a pregnant 26-year-old  woman  was  found to have  the  reduced volume  of circulating blood.  What  change  in the total  blood volume can be the case?

Explanation

Polycythemic hypovolemia is a condition with a decreased amount of plasma usually characterized by appreciable concentration and increased viscosity of blood. Hematocrit is above normal. This condition is observed in connection with considerable loss of water by the organism as in diarrhea, intractable vomiting, extensive burns. Hematocrit is increased because there is no loss of erythrocytes just fluid was lost from vomiting. It can’t  be hypervolemia because there is loss of fluid from prolonged vomiting.

In simple hypovolemia: hematocrit is normal; oligocythemic hypovolemia: hematocrit is decreased.

268.

Due  to the blockage  of the common bile duct (which was radiographically confirmed),  the  biliary  flow to  the duodenum was stopped. We should expect the impairment of:

Explanation

Obturation (obstruction, to close) of bile duct – it can be:

* Intrahepatic – blockage of intrahepatic bile ducts

* Extrahepatic – blockage of common bile duct (ductus choledochus).

Findings:

* malabsorption: bile salts do not enter the Small Intestine; no emulsification of fat.

*light coloured stool: due to lack of urobilin (which leads to lack of stercobilin).

*Jaundice (posthepatic, mechanic, obstructive): increased conjugated Bilirubin.

* Steatorrhea

The findings are specific for obstruction of bile duct and bile acid deficiency.

269. In a car accident  a man  got injured and  lost a lot of blood.  What  changes  in peripheral blood  are most likely to occur on the 2nd day after the injury?

Explanation

Pathogenesis of acute posthemorrhagic anemia consists of 3 periods: reflex vascular period; hydremic period (2-3days) and regenerative (bone-marrow) period. During the hydremic period after 2-3days: there is compensation of circulating plasma volume: diminishing/decrease of excretion by kidneys; increase transport of interstitial fluid and lymph into the lumen of blood vessels. This will cause a relative decrease in erythrocytes (erythropenia) and hemoglobin [but colour index (C.I.) is near norm] because the fluid component of blood have been replaced by the 2nd day but the cellular components are yet to be replaced because erythropoiesis will take a longer time.

270.

A   22-year-old    woman   ate   some seafood.  5 hours  later  the  trunk  and  the distal  parts   of  limbs  got  covered   with small itchy  papules  which  were  partially fused  together. After   one  day,  the  rash disappeared spontaneously. Specify the hypersensitivity mechanism  underlying these changes:

Explanation

It is anaphylactic because of the relatively short time it took to manifest the symptoms. It is local because, it affects just the trunk and distal part of limb. Systemic will have systemic effects like anxiety, loss of consciousness, shock, difficulty in breathing.

Type I Hypersensitivity reaction (HSR); anaphylactic and atopic: free antigen cross-links IgE on presensitized (i.e. exposed to the antigen before) mast cells and basophils, triggering immediate release of vasoactive amines that act at postcapillary venules (i.e. histamine). Reaction develops rapidly after antigen exposure because of preformed antibody from first exposure. IgE is the main immunoglobulin involved in type I HSR. Type I: uses IgE and IgG4

271.

10 days  after  having  quinsy  caused by   beta-hemolytic  streptococcus   a   6-year-old child exhibited symptoms of glomerulonephritis. What  mechanism   of glomerular lesion  is  most  likely  in  this case?

Explanation

Peritonsillar abscess also known as quinsy ( a complication of tonsillitis) caused by both aerobic and anaerobic bacteria (streptococcus, staphylococcus and haemophilus).

Acute poststreptococcal glomerulonephritis: most frequently seen in children. Occurs approximately 2 weeks after group A streptococcal infection of pharynx or skin. Resolves spontaneously. Type III hypersensitivity reaction (Immune complex). Presents with peripheral and periorbital edema, cola-coloured urine, hypertension. On immunofluorescent microscopy: granular appearance due to IgG, IgM and C3 deposition along glomerular basement membrane and mesangium. On electron microscopy: subepithelial immune complex humps. On light microscopy: glomeruli enlarged and hypercellular.
272.

What  condition may  develop  15-30 minutes after re-administration of the antigen as a result of the increased level of antibodies, mainly IgE, that are adsorbed on the  surface  of target  cells, namely  tissue basophils (mast cells) and blood basophils?

Explanation

Type I Hypersensitivity reaction (HSR); anaphylactic and atopic: free antigen cross-links IgE on presensitized (i.e. exposed to the antigen before) mast cells and basophils, triggering immediate release of vasoactive amines that act at postcapillary venules (i.e. histamine).

FullSizeRender (17)

Reaction develops rapidly after antigen exposure because of preformed antibody from first exposure. IgE is the main immunoglobulin involved in type I HSR. Type I: uses IgE and IgG4

Type I (Immediate, Anaphylaxis, Reagin): IgE (immunoglobulin E)-dependent activation of mast cells/basophils, usually accompanied by eosinophilia e.g. urticaria (hives), hay fever, asthma (wheezing), rhinitis and conjunctivitis (stuffy nose and itchy eyes; usually seasonal)

273. In   our   country,   routine  preventive  vaccinations against  poliomyelitis involve  using  live vaccine  that  is administered  orally.  What  immunoglobulins are responsible for the  development of local post-vaccination immunity in this case?

Explanation

Vaccine is a substance that is introduced into the body to prevent the disease produced by certain pathogens. Vaccine consists of dead pathogens or live but attenuated (artificially weakened) organisms. The vaccine induces immunity against the pathogen, either by production of antibodies or by activation of T-lymphocytes. Mature B cells express IgM and IgD on their surfaces. They may differentiate in germinal centers of lymph nodes by isotype switching into plasma cells that secrete IgA, IgE, IgG. IgA prevents attachment of bacteria and viruses to mucous membranes; it has 2 isotypes – a monomer (in circulation) and a dimer (when secreted- secretory). Crosses epithelial cells by transcytosis. It is the most produced antibody overall, but has lower serum concentrations. Released into secretions (tears, saliva, mucus) and breast milk. Based on the localization of secretory IgA, it is responsible for local immunity. And all other Immunoglobulins, since they are found in serum, they are responsible for systemic immunity.

274. Deficiency  of  linoleic  and  linolenic acids   in   the   body   leads   to   the   skin damage,  hair  loss, delayed  wound  healing,  thrombocytopenia, low  resistance to infections.  These  changes  are  most likely to be caused by the impaired synthesis of the following substances:

Explanation

Two fatty acids are dietary essentials in humans – linoleic acid and α-linolenic acid (long chain polyunsaturated fatty acids). They are required for fluidity of membrane structure and synthesis of eicosanoids. A deficiency of essential fatty acid is characterized by scaly dermatitis, hair loss and poor wound healing. Essential fatty acid deficiency however is rare. Linoleic acid is the precursor of arachidonic acid, the substrate for prostaglandin synthesis. Arachidonic acid becomes essential if linoleic acid is deficient in the diet.

275.

A  child  cut  his leg with  a piece  of glass while playing and was brought  to the clinic for the  injection  of tetanus toxoid. In   order   to   prevent  the   development of anaphylactic shock the serum was administered by Bezredka method.  What mechanism  underlies this method of desensitization of the body?

Explanation

Desensitization as a method of treating allergic diseases is used, in particular, to prevent serum anaphylaxis from repeated injections of serum preparations (e.g. tetanus toxoid), in accordance with the method proposed in 1907 by the Russian scientist A. M. bezredka. The method consists in injecting small concentrations of the preparation (toxoid antigen) that produce the sensitization, as a result, a state of anti-anaphylaxis arises (i.e. desensitization). Owing to this, the next injection of the reacting dose of the allergen does not produce anaphylaxis. The small concentrations injected are below threshold concentrations inducing complete and sustained deprivation of releasability (ability to release inflammatory mediators from activated mast cells having IgE attached to them already) without triggering degranulation. Basophil desensitization is regulated by their surface IgE levels.

Desensitization therapy in atopic individuals involves repeated injections of increasingly greater amounts of allergens, resulting in production of IgG antibodies that attach to allergens and prevent them from binding to mast cells.

276.

6 hours after the myocardial  infarction a patient was found  to have  elevated level  of lactate  dehydrogenase in blood. What  isoenzyme  should  be  expected in this case?

Explanation

Lactate dehydrogenase (LDH) is an enzyme in cardiac cells which can serve as a marker for injured myocardial cells as it leaks out of damaged cell membranes into the bloodstream. It catalyzes the conversion of pyruvate to lactate (a reversible reaction). It has five (5) isoenzymes (isoenzymes catalyze same reaction), but only LDH1 is found in the myocardium.

LDH1 – heart, RBCs and brain; LDH2- reticuloendothelial system; LDH3- lungs; LDH4- kidneys, placenta and pancreas; LDH5- liver and striated muscle.

277.

ECG of a patient displays an abnormally long R wave (up to 0,18s). This is caused by a decrease in the conduction velocity of the following heart structures:

Explanation

QRS complex on an ECG graph is also called the initial ventricular complex. Q wave is a small negative wave. It is continued as the tall R wave which is a positive wave. R wave is followed by a small negative wave – S wave. QRS complex is due to depolarization of ventricular musculature.

krushkrok No28 (2009)

Q wave is due to the depolarization of basal portion of interventricular septum. R wave is due to the depolarization of apical portion of interventricular septum and apical portion of ventricular muscle. S wave is due to the depolarization of basal portion of ventricular muscle near the atrioventricular ring. The Q wave may be absent on an ECG. The R wave corresponds to almost complete excitation of both ventricles. It is the highest wave of the ventricular complex.

278.

Analysis  of  the  ECG   revealed   the missing of several PQRST  cycles. The remaining waves and  complexes  are  not changed. Specify the type of arrhythmia:

 

Explanation

Sinoatrial (SA) block is the failure of impulse transmission from SA node to AV node. It is also called sinus block. It is characterized by periodic missing of the heart beat and pulse beat. The ECG shows periodic missing of the heart complex (neither P-wave nor the QRST complex are recorded); the length of diastole doubles.

279.

A  19-year-old   male  was  found   to have  an  elevated level  of  potassium   in the  secondary urine.  These  changes  might have  been  caused  by the  increase  in the following hormone level:

Explanation

Aldosterone produced in adrenal cortex (zona glomerulosa): causes increased sodium (Na+) reabsorption; increased potassium and hydrogen ions (↑K+, H+) excretion. They increase sodium (↑Na+) channel and Na+ /K+-pump insertion in principal cells of collecting duct; enhances K+ and H+ excretion by way of principal cell K+ channels and α-intercalated cell H+ ATPases of collecting duct. Therefore, increase in aldosterone → ↑ K+ in urine (excretion) and ↓ Na+ in urine (↑ reabsorption); And decreased aldosterone → ↓ K+ excretion (↓K+ in urine) and ↓ Na+  reabsorption (i.e. ↑Na+ in urine); same effects on sweats glands too.

280.

Diseases  of  the  respiratory  system and  circulatory  disorders  impair  the transport  of   oxygen,   thus   leading   to hypoxia.  Under these  conditions the energy metabolism is carried  out by anaerobic glycolysis. As a result, the following substance  is generated and accumulated in blood:

Explanation

Lactate, formed by the action of lactate dehydrogenase (converting pyruvate to lactate) is the final product of anaerobic glycolysis in eukaryotic cells. In organs or cells that are poorly vascularized and/or lack mitochondria, formation of lactate is the major fate of pyruvate as seen in lens, cornea of the eye, kidney medulla, testes, leukocytes and red blood cells.

Aerobic glycolysis progresses to citric acid cycle from pyruvate. The cycle occurs totally in the mitochondria.

281.

During   the   intravenous  transfusion  of  the   saline   the   patient’s   condition  deteriorated dramatically, and  the patient died  from  asphyxiation. Autopsy revealed  acute  venous  congestion of internal  organs   with   the   dramatic  right heart  dilatation. When the right ventricle     was    punctured   underwater, the bubbles escaped. What pathological process occurred in the patient?

Explanation

Embolism is occlusion of a vessel by material traveling in the circulation.

* Gas embolism: two main forms of gas embolism are air embolism and decompression sickness. Air embolism is usually due to accidental pumping of air into the venous circulation during intravenous (IV) injection or transfusion ( bubble – air escaped).

* Fat/Adipose embolism: obstruction of arterioles and capillaries by fat globules constitutes fat embolism. It may occur following severe fracture trauma to bones, inflammation of bones and soft tissues, fatty liver

* Thromboembolism: a detached thrombus or part of thrombus which may arise in the arterial or venous circulation.

Tissue embolism: fragments of tissue.

282.

Inherited diseases, such as mucopolysaccharidoses,   are   manifested in  metabolic disorders   of  connective tissue, bone  and  joint  pathologies. The  sign of this disease  is the excessive urinary excretion of the following substance:

Explanation

The Mucopolysaccharidoses are hereditary disorders that are clinically progressive. They are characterized by accumulation of glycosaminoglycans in various tissues, causing varied symptoms such as skeletal and extracellular matrix deformities and mental retardation. Mucopolysaccharidoses are caused by a deficiency of any one of the lysosomal hydrolases normally involved in the degradation of heparin sulfate and/or dermatan sulfate. This results in the presence of oligosaccharides in the urine because of incomplete lysosomal degradation of glycosaminoglycans.

283. Hemoglobin catabolism results in release of iron which is transported to the bone marrow by a certain   transfer protein and used again for the synthesis of hemoglobin. Specify this transfer protein:

Explanation

Transferrin is the binding protein of iron and is synthesized in the liver. Iron bound to transferrin is the serum iron. Absorbed Iron is either stored in the cytoplasm as mucosal ferritin or binds to plasma transferrin and transported to the erythroid precursors in the bone marrow.
284.

Enzymatic  jaundices  are accompanied  by  abnormal activity  of  UDP-glucuronyl   transferase. What  compound is accumulated in blood  serum  in case of these pathologies?

Explanation

In the hepatocyte, the solubility of unconjugated bilirubin is increased (i.e. it is made soluble) by the addition of two molecules of glucuronic acid to produce conjugated bilirubin. This process is reffered to as conjugation. This reaction is catalyzed by Uridine diphosphate (UDP) glucuronyltransferase – UGT. Varying degrees of deficiency of this enzyme result in Crigler-Najjar I & II and Gilbert syndrome; with Crigler-Najjar I being the most severe deficiency.

image

Deficiency of UGT inhibits conjugation and therefore increase unconjugated bilirubin in serum (Jaundice).

285. A 35-year-old  male developed acute heart  failure  while running  for a long time. What  changes  in the ionic composition can be observed  in the cardiac muscle?

Explanation

Increase in cardiac workload can cause imbalances in oxygen (O2) supply and demand to the heart itself. Blood supply to the heart occurs during diastole. Increase heart rate (↑HR) → ↓diastolic period → ischemia in myocardium. Ischemia, hypoxia, heart failure are associated with disruptions in intracellular Na+ and Ca+ concentration homeostasis of myocardial cells. A decrease efflux or increase influx of Na+ may cause cellular Na+ overload. Na+ overload is followed by an ↑influx of calcium (Ca2+) through Na+-Ca2+ exchanger. Failure to maintain the homeostasis of Na+ and Ca+ leads to electrical instability (arrhythmias), mechanical dysfunction (reduced contractility and ↑ diastolic tension) and mitochondrial dysfunction. These events increase ATP hydrolysis and decrease ATP formation and if left uncorrected, they cause cell injury and death → acute heart failure.

286. A  23-year-old  patient has  been  admitted to a hospital with a craniocerebral injury. The patient is in a grave condition. Respiration is characterized by prolonged convulsive inspiration followed by a short expiration. What  kind  of respiration is it typical for?

Explanation

APNEUSTIC: Prolonged, gasping inspiration followed by an insufficient or brief expiration. E.g damage to brainstem, ketamine.

KUSSMAUL: Vigorous inhalation and active exhalation with forced contraction of expiratory muscles. E.g in diabetic ketoacidosis.

CHEYNE-STOKES: Cyclic breathing pattern which regular change in frequency (at time faster & followed by a gradual decrease) that results in a temporary stop in breathing (apnea). E.g heart failures,strokes.

BIOT: periods of apnea interchanging with periods of resumption of breathing without significant changes in the amplitude of respiratory movements. E.g damage to pons due to stroke or trauma.

GASPING: forced,convulsive breath.

287. At  the  end  of  the  working  day  a worker  of a hot work shop has been delivered to a hospital. The patient complains of a headache, dizziness, nausea,  general weakness. Objectively: the patient is conscious, his skin is hyperemic, dry, hot to the touch. Heart rate is of 130/min. Respiration  is rapid,  superficial.  What  disorder of thermoregulation is most likely to have occurred in this patient?

Explanation

The patient was in a hot workshop, there is definitely a transfer of heat from the environment to the patient. Compensatory mechanisms in the patient should work to increase heat transfer from the patient back to the environment (heat emission), to avoid accumulating excessive heat. The patient was hyperemic (vasodilation –normal), dry (i.e. not sweating) and hot to touch (if there was evaporation of sweat, it would have cooled the skin temperature). In the absence of sweating, it therefore means that there is reduced heat transfer from the patient’s body back into the surrounding.

NB: the question is concerned about heat transfer from the patient to the surrounding.

288.

A  patient got  a  gunshot   wound  of hip which damaged the sciatic nerve. Any impact on the affected limb causes severe, excruciating  pain.   What   mechanism   of pain is most likely in this case?

Explanation

Causalgia is a rare pain syndrome related to partial peripheral nerve injuries. The peripheral nervous system encompass  nerves that extend from the CNS of the brain & spinal cord to serve limb & organs. The gunshot wound damged a peripheral nerves (sciatic nerve) from spinal cord supplying the lower limb.
289.

A 3-year-old boy with pronounced hemorrhagic syndrome  doesn’t have anti-hemophilic  globulin  A  (factor   VIII)   in the  blood  plasma.  Hemostasis has  been impaired  at the following stage:

Explanation

FullSizeRender In the intrinsic (internal) coagulation system: Four component complex is formed (Factor VIII, IXa, Phospholipid and Calcium)- this complex activates Factor X in the final common pathway. Therefore, deficiency of factor VIII will impair the Intrinsic coagulation system (Internal mechanism  of prothrombinase activation).
290.

The  cellular  composition of exudate largely  depends on the  etiological  factor of inflammation. What leukocytes  are the first to get into the focus of inflammation caused by pyogenic bacteria?

 

Explanation

Neutrophils are the first leukocytes that cross the blood vessel wall to enter inflammatory sites. Under normal conditions, leukocytes are restricted to the center of small blood vessels, where the flow is fastest. In inflammatory sites, where the vessels are dilated, the slower blood flow allows the leukocytes to move out of the center of the blood vessel and interact with the vascular endothelium. Even in the absence of infection, monocytes migrate continuously into the tissues, where they differentiate into macrophages; meanwhile, during an inflammatory response, the induction of adhesion molecules on the endothelial cells, as well as induced changes in the adhesion molecules expressed on leukocytes recruit large numbers of circulating leukocytes, initially Neutrophils and later monocytes, into the site of an infection (inflammatory focus).

First –Neutrophils; second –monocytes and macrophages; third –lymphocytes.

291. A  patient with bronchial  asthma  has developed acute respiratory failure. What kind  of respiratory failure  occurs  in this case?

Explanation

krushkrok No50 (2009) Obstructive respiratory disease is the abnormal respiratory condition characterized by difficulty in expiration. e.g. asthma, chronic bronchitis, emphysema, cystic fibrosis.  Forced expiratory volume (FEV) is the volume of air, which can be expired forcefully in a given unit of time. It is very much decreased in obstructive diseases like asthma and emphysema.   Restrictive respiratory disease is the abnormal respiratory condition characterized by difficulty in inspiration. e.g. poliomyelitis, myasthenia gravis, paralysis of diaphragm, spiral cord diseases, pleural effusion, fibrosis (lung fibrosis-pneumofibrosis)