Anesthesia breathing circuits

Anesthesia breathing circuits: Bi-Directional Flow Systems:

Mapleson did a theoretical analysis of the fresh gas requirements of the semiclosed systems available at that time. It is only proper to refer to it as Mapleson systems as he gave a nomenclature as A, B, C, D and E for easy identification as per their construction. For better understanding of the functional analyses, they have been classified as:

1. Afferent reservoir system (ARS).

2. Enclosed afferent reservoir systems (EARS).

3. Efferent reservoir systems (ERS).

4. Combined systems.

The afferent limb is that part of the breathing system which delivers the fresh gas from the machine to the patient. If the reservoir is placed in this limb as in Mapleson A, B, C and Lack’s systems, they are called afferent reservoir systems (ARS).

The efferent limb is that part of the breathing system which carries expired gas from the patient and vents it to the atmosphere through the expiratory valve/port. If the reservoir is placed in this limb as in Mapleson D, E, F and Bain systems, they are called efferent reservoir systems (ERS).

Enclosed afferent reservoir system (EARS) has been described by Miller and Miller.

All of the following are suitable anaesthetic circuits for both controlled and assisted ventilation except:

a. Mapelson A
b. Mapelson B & C
c. Mapelson D
d. Mapelson E



Hint: Spontaneous (Active)--- A
        Assisted & Controlled -- D,E




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Anticentromere antibodies are most commonly associated with:

a. Diffuse cutaneous systemic sclerosis.
b. Mixed CT disease.
c. CREST syndrome.
d. Polymyositis.

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A 35 year old lady complains of dysphagia, Raynaud's phenomenon, sclerodactyly. Investigations show antinuclear antibody. The likely diagnosis is:

a. SLE.
b. Systemic sclerosis.
c. Mixed connective tissue disorder.
d. Rheumatoid arthritis.

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Most common organism associated with reactive arthritis is:

a. Staphylococcus.
b. Shigella.
c. Chlamydia.
d. Yersinia.

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All the following diseases are associated with HLA B 27 and uveitits, except:

a. Behcet's syndrome.
b. Psoriasis.
c. Ankylosing spondylitis.
d. Reiter's syndrome.




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In case of gout, preservation of urine sample is done in :

a. Normal saline.
b. Formalin.
c. Alcohol.

d. Distilled water.




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All of the following conditions are observed in Gout except:

a. Uric acid nephrolithiasis.
b. Deficiency of enzyme Xanthine oxidase.
c. Increase in serum urate concentration.
d. Renal disease involving interstitial tissues.

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A young boy presents with failure to thrive. Biochemical analysis of a duodenal aspirate after a meal reveals a deficiency of enteropeptidase. The levels of the foll digestive enzyme would be affected:

a. Amylase.
b. Pepsin.
c. Lactose.
d. Trypsin.


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Enterokinase deficiency

Congenital deficiency of this small intestine enzyme has been reported in a few children, resulting in the complete absence of pancreatic proteolytic activity; enterokinase is an essential activator of pancreatic trypsinogens.

The presentation is of infants that are ill from very early in life with severe diarrhoea and failure to thrive. Hypoproteinaemia is common in this condition and this may cause oedema. The tryptic activity in duodenal juice is missing while lipase and amylase are normal. In vitro the activity of the juice can be restored by the addition of enterokinase. The major result of this condition is malabsorption of protein although steatorrhoea has been reported.

The supplementation of the diet with pancreatic enzyme replacements restores normal digestive function.

A child presents with diarrhea and peripheral circulatory failure. The arterial pH is 7, pCO2 15 & pO2 76. Most appropriate:

a. Soda bicarb infusion.

b. Bolus of Ringer Lactate.

c. Bolus of HES.

d. 5% dextrose soln.

Calculate plasma osmolality:

Na-125, Glu- 108, BUN- 140

a. 300

b. 306

c. 312

d. 318

PIP, DIP & 1st MCP joint involvement and sparing of wrist is a feature of:

1. Rheumatoid arthritis
2. Pseudogout
3. Psoriatic arthropathy
4. Osteoarthritis.

A 35 year old male develops involvements of PIP, DIP and MCP joints with sparing of wrist and carpometacarpal joints. The probable diagnosis is:

1. Psoriatic arthropathy.
2. Osteoarthritis.
3. Rheumatoid arthritis.
4. Pseudo gout.

Normal anion gap- FUSED CARS

In patients with a normal anion gap the drop in HCO₃⁻ is compensated for almost completely by an increase in Cl⁻ and hence is also known as hyperchloremic acidosis.

The HCO₃⁻ lost is replaced by a chloride anion, and thus there is a normal anion gap.

FUSED CARS 


Fistula (pancreatic)
Uretogastric conduits
Saline administration
Endocrine (hyperparathyroidism)
Diarrhea


Carbonic anhydrase inhibitors (acetazolamide)
Ammonium chloride
Renal tubular acidosis
Spironolactone

High anion gap Acidosis

A CAT PILES MUD:

Alcohol abuse

Carbon monoxide or Cyanide
Aspirin
Toluene

Paraldehyde/ Polyethylene glycol
Iron/ Isoniazid
Lactic acidosis
Ethylene glycol
Starvation

Methanol
Uremia
Diabetic ketoacidosis.

Anion Gap

The anion gap is the difference in the measured cations and the measured anions in serum, plasma, or urine.

It is calculated by subtracting the serum concentrations of chloride and bicarbonate(anions) from the concentrations of sodium plus potassium (cations):

= ( [Na⁺] + [K⁺] ) − ( [Cl⁻] + [HCO₃⁻] )

The average anion gap for healthy adults is  8 -12 mEq/L.

Plasma osmolality

Normal human reference range of osmolality in plasma is about 275-299 milli-osmoles per kilogram.

To calculate plasma osmolarity use the following equation :

• = 2 x Na⁺ + Glucose +  BUN 
                                   18            2.8
  
  where [Glucose] and [BUN] are measured in mg/dL.

Simplifications are sometimes used:

• = 2[Na⁺] + [Glucose]/20 + BUN/3 - 2

Although more than 400 blood groups have been identified, the ABO blood system remains the most important in clinical medicine because:

1. It was the first blood group system to be discovered.
2. It has four different blood group A, B, AB, O.
3. ABO antigens are present in most body tissues and fluids.
4. ABO antibodies are invariably present in plasma when persons RBC lack the corresponding antigen.

Oxygen dependent killing is done through:

1. NADPH oxidase.
2. Superoxide dismutase.
3. Catalase.
4. Glutathione reductase.

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Tomatoes can save you from high cholesterol

Want to be free of high cholesterol and blood pressure (BP)? Tomatoes can be a way out for you!

Tomatoes may be an effective alternative to drugs in lowering cholesterol and BP and in preventing heart disease.

A bright red pigment called lycopene found in tomatoes and to a lesser extent in watermelon, guava, papaya and pink grapefruit has antioxidant properties that are vital to good health.

Karin Ried and her colleague Peter Fakler from the University of Adelaide are the first to summarise the effect of lycopene on cholesterol and blood pressure (BP), analysing the collective results of 14 studies over the last 55 years.

"Our study suggests that if more than 25 milligrams of lycopene is taken daily, it can reduce LPD (bad) cholesterol by up to 10 per cent," says Ried, reports the journal Maturitas.

Tomatoes have high levels of lycopene, with half a litre of tomato juice taken daily, or 50 grams of tomato paste, providing protection against heart disease, according to an Adelaide statement.

"That's comparable to the effect of low doses of medication commonly prescribed for people with slightly elevated cholesterol, but without the side effects of these drugs, which can include muscle pain and weakness and nerve damage," says Ried.

Lycopene is better absorbed in processed and cooked tomatoes or tomato paste rather than fresh tomatoes. As a supplement, lycopene is available in soft gelatine capsules or tablets.

"Research shows that high lycopene consumption has been associated with a decreased risk of cardiovascular disease, including hardened arteries, heart attacks and strokes," she adds. 

An Rh -ve woman became pregnant with Rh +ve fetus. Within few days after birth, the infant developed jaundice, ascites, hepatomegaly and edema. The likely substances deposited in skin and sclera in jaundice are given below. Which is the best possible answer?

1. Biliverdiin.
2. Conjugated and unconjugated bilirubin.
3. Unconjugated bilirubin.
4. Conjugated bilirubin.

MHCs

MHC-I associated with CD8
and
MHC-II associated with CD4

( Remember I x 8 = II x 4 )"

Sickle cell trait patients do not have manifestations of sickle cell disease because:

1. 50% HbS is required for occurrence of sickling.
2. HbA prevents sickling.
3. 50% sickles.
4. HbA prevents polymerization of HbS.

Reticulocytosis is seen in all except:

1. PNH
2. Hemolysis
3. Nutritional anemia.
4. Dyserythropoietic syndrome.

Causes of reticulocytosis

Which one of the following statements about Hemoglobin S is not true:

1. HbS differs from HbA by the substitution of Val for Glu in position 6 of the beta chain.
2. One altered peptide of HbS migrates faster towards the cathode than the corresponding peptide of HbA.
3. Binding of HbS to the deoxygenated HbA can extend the polymer and cause sickling of the red blood cells.
4. Lowering the concentration of deoxygenated HbS can prevent sickling.

The pathogenesis of hypochromic anemia in lead poisoning is due to:

1. Inhibition of enzymes involved in heme synthesis.
2. Binding of lead to transferrin inhibiting the transport of iron.
3. Binding of lead to cell membrane of erythroid precursors.
4. Binding of lead to ferritin inhibiting their breakdown into hemosiderin.

Which of the following surface glycoproteins is most often expressed in human hematopoetic stem cell

1. CD 22
2. CD 40
3. CD 15
4. CD 34

Ulnar Nerve

Ulnar nerve is the branch of the medial cord of brachial plexus with root value C8 and T1. 


it supplies flexor carpi ulnaris and the medial half of flexor digitorium profundus in forearm.


 In the hand through its superficial branch it supplies palmaris brevis and digital branches to the volar side of the little finger and medial half of ring finger. 


The deep branch supplies the hypothenar, the dorsal and palmar interossei, two medial lumbricals and the adductor pollicis muscles of the hand.

Hemophilia with rheumatoid arthritis, analgesic of choice:

1. Ibuprofen.
2. Aspirin.
3. Acetaminophen.
4. Phenylbutazone.

The following are rheumatoid disease modifying drugs except:

1. Chloroquine.
2. Gold.
3. Penicillamine.
4. BAL.

Disease-modifying_antirheumatic_drug

A 45 year old coal mine worker presents with cutaneous nodules, joint pain and occasional cough with dyspnea. His chest radiograph shows multiple, small nodules in bilateral lung fields. Some of the nodules show cavitation and specks of calcification. Most likely these features are diagnostic of:

1. Sjogren's syndrome
2. Caplan's syndrome
3. Silicosis
4. Wegener's granulomatosis.

Type of anemia seen in Rheumatoid arthritis is :

a. Microcytic hypochromic

b. Macrocytic hypochromic

c. Normocytic hypochromic

d. Normocytic normochromic.

False positive rheumatoid factor can be associated with all except:

1. Inflammatory bowel disease.
2. HbsAg
3. VDRL
4. Coombs test.

Which of the following is true regarding Rheumatoid arthritis?

1. Typically involves small and large joints symmetrically but spares the cervical spine.
2. Causes pleural effusion with low sugar.
3. Pulmonary nodules are absent.
4. Enthesopathy prominent.

A patient with Hb-6gm%, TLC 1200, platelet 60000, MCV 12 fl, what is the diagnosis?

1. Aplastic anemia.
2. Megaloblastic anemia.
3. PNH.
4. Myelofibrosis.

A 30 yrs old female, RBC count 4.5 million, MCV 55fl, TLC 8000, no history of blood transfusion. What is the likely diagnosis?

1. Iron deficiency anemia.
2. Thalassemia major
3. Thalassemia minor
4. Megaloblastic anemia.

Microangiopathic hemolytic anemia is seen in all of the following diseases except:

1. Antiphospholipid antibody syndrome.
2. Thrombotic thrombocytopenic purpura.
3. Microscopic polyangitis.
4. Metallic cardiac valves.

Which of the following complications is likely to result after several units of blood have been transferred?

1. Metabolic alkalosis.
2. Metabolic acidosis.
3. Respiratory alkalosis.
4. Respiratory acidosis.

Autoimmune hemolytic anemia is seen in:

1. ALL
2. AML
3. CLL
4. CML

A 40 yrs old male had undergone splenectomy 20 years ago. Peripheral blood smear examination would show the presence of:

1. Dohle bodies.
2. Hypersegmented neutrophils.
3. Spherocytes.
4. Howell-Jolly bodies.

The primary defect which leads to sickle cell anemia is:

1. An abnormality inn porphyrin part of hemoglobin.
2. Replacement of glutamate by valine in beta chain of HbA.
3. A nonsense mutation in the beta chain of HbA.
4. Substitution of valine by glutamate in the alpha chain of HbA.

A couple with a family history of beta thalassemia major in a distant relative, has come for counselling. The husband has HbA2 of 4.8% and the wife has HbA2 of 2.3%. The risk of having a child with beta thalassemia major is:

1. 50%
2. 25%
3. 5%
4. 0%

The following protein defects can cause hereditary spherocytosis except:

1. Ankyrin
2. Palladin
3. Glycophorin C
4. Anion transport protein

The following statement is not true about sotalol:

1. It is a non-selective beta blocker.
2. It prolongs action potential duration throughout the heart.
3. It is excreted through bile following hepatic metabolism.
4. Polymorhpic ventricular tachycardia is a common side-effect.

Which of the following statements about hydralazine is NOT true?

1. It causes direct relaxation of the blood vessels.
2. It causes dilatation of both arteries and veins.
3. Postural hypotension is not a common problem.
4. It increases plasma renin activity.

Which of the following does not result in the release of NO?

1. Fenoldopam.
2. Hydralazine.
3. Nitroprusside.
4. Nitroglycerine.

True about fibrates are all except

1. Drug of choice fro Type III hyperlipoproteinemia and severe hypertriglyceridemia.
2. Activate PPAR to stimulate LPL.
3. Absorbed good on empty stomach and absorption is delayed by fatty meals.
4. Side effect are rash, urticaria, myalgia and impotence.

Coronary steal phenomenon is seen with

1. Dipyridamole.
2. Dilitiazem.
3. Propanolol.
4. Verapamil.

All are used for treatment of pulmonary hypertension except

1. Endothelin receptor antagonists.
2. Phosphodiesterase antagonists.
3. Calcium channel blockers.
4. Beta blockers.

Angiotensin II causes all except

1. Stimulates release of ADH
2. Increases thirst.
3. Vasodilation
4. Stimulates aldosterone release.

Which type of amyloidosis is caused by the mutation of the transthyretin protein?

1. Familial Mediterranean Fever.
2. Familial amyloidotic polyneuropathy
3. Dialysis associated amyloidosis.
4. Prion protein asso amyloidosis.

Amyloidosis

Mixed lymphocyte culture is used to identify:

1. MHC class I antigen.
2. MHC class II antigen.
3. B lymphocytes.
4. T helper cells.

A young lady presented with bilateral nodular lesions on shins. She was also found to have bilateral hilar lymphadenopathy on chest X-ray. Mantoux test reveals induration of 5 mm. Skin biopsy would reveal:

1. Non caseating granuloma
2. Vasculitis
3. Caseating granuloma
4. Malignant cells

Which of the following chemical mediators of inflammation is an example of a C-X-C or alpha chemokine?

1. Lipoxin LXA 4
2. Interleukin IL-8
3. Interleukin IL-6
4. Monocyte Chemo attractant Protein MCP-1

Chemokine

CD 95 has a major role in:

1. Apoptosis
2. Cell necrosis
3. Interferon activation
4. Proteolysis.

Fas_receptor