SCENARIO 1

A 20-year-old student consulted her family doctor for her recurrent episodes of troublesome cough, tightness of chest & wheezing especially in the middle of the night for more than three months. She also noticed that her symptoms came back whenever she hugged and pat her pet.

1. a) In inspiration there is an increase in the diameter of the thoracic cavity. i. State the muscle that increases the vertical diameter. Diaphragm ii. State the type of movement that increase the antero-posterior diameter of the thoracic cavity. Pump-handle movement b) State the muscle that is fixed on the first rib. Scalenus anterior muscles c) State the muscle that is involved in forced expiration. Abdominal muscles d) In asthma, the normal histological features of the bronchiole are likely to be changed. Briefly describe four histological features of a normal bronchiole. Simple columnar ciliated with occasional goblet cells, no cartilage, no gland; prominent layer of smooth muscles (Answer to respiratory or terminal bronchiole are also acceptable)

2. In a patient with severe asthma, the breathing rate will be decreased. Briefly explain the expected acid-base changes in her body. In asthma, there is respiratory acidosis due to hypoventilation. Compensation by renal mechanism by generating and retaining more HCO3+ to adds up alkali reserve. Excretion of titrable acids and NH4+ is elevated.

3. a) Briefly describe the effect of asthma on ventilation-perfusion ratio. A lower V/Q ratio

COMPILED BY: ISMAHANI AR SPECIAL THANKS: FATIN SHAMSUDDIN

MBBS YEAR 1 (2012/2013)

b) Explain the possible cause that lead to this ventilation-perfusion ratio. Impairs pulmonary gas exchange and low arterial partial pressure of oxygen (paO2). The alveoli of the lung are perfuse with blood as normal, but ventilation (supply of the air) fails to supply the perfuse region causes the blood supply leaving the lung to have lower levels of O2 and higher levels of CO2 and normal gas exchange does not occur

4. a) Name the parasite and the disease by cat that causes asthma-like symptoms in man. Parasite: Toxocara catis Disease : Visceral Larvae Migrans b) Briefly describe the pathogenesis of the disease. Infective L2 stage larvae hatch in small intestine & penetrates gut wall, goes into the circulation and are carried to different organs. Somatic migration of Toxocara larva causes mechanical damage, necrosis and provokes vigorous host inflammatory reactions. Excretory-secretory antigens secreted by migrating larvae consists of enzymes & circular proteins together with the metabolic wastes released by larvae during migration will provoke inflammatory reactions (eosinophils) reactions to remove them

5. a) Comment on the level of serum IgE in this patient. IgE level will be elevated in allergic asthma whereas it will be normal in non-allergic asthma b) State what is expected to seen in a pap stain of the respiratory lavage from this patient. Curscmann spirals

6. The patient was treated with a short acting bronchodilator. State two short acting bronchodilators with the mechanism of action and two adverse effects. Drugs: Terbutaline & Salbutamol Mechanism of action: They act on 2 receptor to produce bronchodilation Adverse effects: Tremors, tachycardia & hypokalaemia

COMPILED BY: ISMAHANI AR SPECIAL THANKS: FATIN SHAMSUDDIN

MBBS YEAR 1 (2012/2013)

SCENARIO 2
A 23-year-old man had a high fever with chills, cough with rusty sputum and pleuritic pain in the right side of the chest for three days. On examination of the chest, there was reduced chest movement. He was diagnosed to have pneumonia.

1. a) State two types of pariental pleura with their nerve supply. i. Cervical & costal pleura: Intercostal nerve ii. Mediastinal pleura: Phrenic pleura iii. Diaphragmatic pleura: central part Phrenic nerve; peripheral part Intercostal pleura b) Briefly describe the surface marking of the inferior margin of the pleura. Midclavicular line at the level of 8th rib; Midaxillary line at the level of 10th rib; adjacent to vertebral column at the level of 12th rib

2. Explain the mechanism of voluntary expiration. In mechanism of voluntary exhale, the major muscles involved are internal intercostal and abdominal wall muscles (internal and external obliques & rectus abdominis). The internal intercostal muscles lower and constrict the rib cage to decrease thoracic volume. The abdominal wall muscles cause constriction of the abdomen, forcing the abdomen to push against the diaphragm, shoving it back upward into the thorax.

3. a) State one opportunistic respiratory pathogen that causes pneumonia under the following group of organism. VIRUS BACTERIUM FUNGUS Human cytomegalovirus, etc Streptococcus pneumonia, etc Pneumocytis jiroveci, etc

b) Influenza A virus causes primary pneumonia. Briefly explain the possible reasons for the need for annual boost of vaccination against influenza. Antigenic shift based on reassortment of RNA segments and antigenic drift based on mutations in the RNA genome

4. a) Describe the morphological features of the following acute bacterial pneumonia classification. i. Bronchopneumonia A patchy distribution of inflammation that generally involves more than one lobe

COMPILED BY: ISMAHANI AR SPECIAL THANKS: FATIN SHAMSUDDIN

MBBS YEAR 1 (2012/2013)

ii.

Lobar pneumonia Air spaces of part or all of a lobe are homogeneously filled with an exudate that can be visualized on radiographs as a lobar or segmental consolidation

b) State four complications that can occur following acute bacterial pneumonia. i. Organization (fibrous scarring) ii. Lung abscess iii. Bronchiectasis iv. Empyema (pus in the pleura cavity)

5. Amoxycillin and clavulinic acid combination is used in pneumonia. a) State two advantages of this drug combination. Amoxycillin is susceptible to penicillinase producing organisms while clavulinic acid is penicilinase inhibitors. Combination of this two drugs enhances the activity of amoxicillin. b) State two respiratory fluoroquinolones that are used in pneumonia. Moxifloxacin, levofloxacin, gemifloxacin

SCENARIO 3
A 54-year-old heavy smoker complained of cough productive of blood streaked sputum for three weeks. On examination, he had bilateral clubbing of the fingers, a hard right supraclavicular lymph node and collapse of the right upper lobe. He was diagnosed to have bronchogenic carcinoma.

1. In bronchogenic asthma carcinoma, the affected segments of the lung can be removed independently. a) Define bronchopulmonary segment. Portion of the lung supplied by tertiary bronchus which has its own segmental artery, segmental nerve and lymphatics (veins is interseqmental) b) State the effect of the nerves on the following structures. TYPE OF NERVE Sympathetic fibres Parasympathetic fibres EFFECT ON BRONCHI Bronchodilation Bronchoconstriction EFFECT ON BLOOD VESSELS Vasoconstriction Vasodilation

COMPILED BY: ISMAHANI AR SPECIAL THANKS: FATIN SHAMSUDDIN

MBBS YEAR 1 (2012/2013)

c) Briefly describe the surface anatomy of the oblique fissure of the lung. Begins at 3rd thoracic vertebral spine, follows the 6th rib and ends at 6th costochondral junction where it meets the inferior border of the lung

2. This patients gas exchange across the respiratory membrane may be affected. a) Based on Ficks Law of Diffusion of Gases, describe briefly three factors that affect the rate of gas diffusion across the respiratory membrane. i. Thickness of respiratory membrane (alveolar-capillary membrane) ii. Surface area of the respiratory membrane, 70 m2 in normal adult iii. Diffusion coefficient: solubility in water, molecular weight, carbon dioxide diffuses 20 times as rapidly as oxygen iv. Pressure difference across the respiratory membrane b) Explain briefly the following: i. External respiration Diffusion of O2 from the alveoli to blood; CO2 from blood to alveoli ii. Internal respiration Diffusion of O2 from blood to tissues; CO2 from tissue to blood

3. a) Briefly describe the modes of spread of bronchogenic carcinoma. Direct spread to nearby structures. Distant spread via blood stream (vascular & hematogenous) to bone, brain & liver. b) Briefly describe two local effects of bronchogenic carcinoma. Pressure onto nearby structures such as pleura and pericardium, recurrent larygngeal to cause hoarseness, oesophagus to cause dysphagia, superior vena cava and phrenic nerve to cause diaphragm paralysis

4. Opioid antitussives are used to suppress cough. State one centrally-acting opioids cough suppressant with two adverse effects of it. Drugs: Codeine/Phocodeine Adverse effect: Sedation, habituation, respiratory centre depression

5. List two possible chemical carcinogens in this patient i. Polyaromatic hydrocarbon ii. Arsenic

COMPILED BY: ISMAHANI AR SPECIAL THANKS: FATIN SHAMSUDDIN

MBBS YEAR 1 (2012/2013)