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1. Describe the role and fate of nasal prominences in the development of the face. (2%)
2. Describe the role and fate of maxillary prominences in the development of the face. (2%)
The merger of medial nasal prominences forms the intermaxillary segment consisting of the four
incisor teeth, the philtrum of the upper lip and the primary palate.
4. List the four elements of phonation and briefly describe them. (4%)
MCQ (T/F)
A. The nasolacrimal duct drains into inferior meatus in the lateral wall of the nasal cavity.
B. Medial nasal prominences merge with each other to form intermaxiallary segment which gives rise to
secondary palate.
C. The maxillary prominences give rise to lower lip and lower jaw.
D. The frontonasal prominence forms the forehead and the dorsum and the apex of the nose.
E. Each lateral nasal prominence is separated from the maxillary prominences by nasolacrimal groove.
Answers: T F F T T
Medial nasal prominences merge with each other to form intermaxiallary segment which gives rise to
primary palate.
The maxillary prominences give rise to upper lip and upper jaw.
Answers: T T F F T
The fissure between the vestibular folds is called rima vestibule.
The vocal cord acts as vibrators to determine the pitch of the voice.
Respiratory tree
1. Goblet cells are present in these portions of the respiratory tract (State TRUE or FALSE).
a. Respiratory bronchioles
b. Small bronchi
c. Terminal bronchioles
d. Alveoli
e. Trachea
f. Nasopharynx
g. Larynx
FTFFTTT
a. Continuation of the larynx at the level of the 6th cervical vertebra and ends at about the
level of the 6th thoracic vertebra by dividing into the left and right main bronchi.
4. What is a broncho-pulmonary segment and how many of these segments are present in one lung?
ANS : TFFTTTF
Mechanics of Respiration 2
a) Give the definition of the following and its numerical value at rest.*** ( we are not required to
memorize resting values... i think, no one should need to memorize this)
(Given that atmospheric pressure is 760 mmHg)
i) Intra-alveolar pressure
Ans: Pressure in the pleural space between the visceral and pleural membrane. 756mmHg
ii) decreased
Ans: pulmonary venous pressure increases, lung remains unventilated for a long time, fibrosis of the lung
Ans: It arises because the attractive forces between the adjacent molecules of water are much stronger
than those between the water and the gas.
iii) Pulmonary surfactant is manufactured from fatty acids from 2 places. Name them.***(very vague,
candidate will not know whether you're asking for 2 places where pulmonary surfactant is produced or
where fatty acids are manufactured. Even after seeing the answer i'm not sure what the question is
supposed to mean)
Ans: Lowers the surface tension, promotes the stability of the alveoli, keeps the alveoli dry, prevents the
transudations of fluid
Ans: DCCCD
e) In assessing expiratory airway resistance, FEV1/ FVC is assessed. State whether there is an increase or
a decrease in the following as compared to that of a normal person.
Ans: The volume of gas that enters the respiratory passage where there is no gas exchange per breath
The volume of gas that enters unperfused alveoli per breath
The volume of gas that enters the lungs that is not subject to gas exchange ( i would prefer the
formula alveolar dead space + anatomical dead space
Volume of air inspired or expired per minute
Volume of air that reaches the alveoli per minute
c) State whether it is the upper or lower zones of the lungs for the following.
Better ventilated
Subjected to greater distending pressure
More compliant
Less negative intrapleural pressure
(in comparison to the other zone)
2. how does the normal flora of the respi tract interfere with the colonization of pathogens? Give 2
methods.
Occupies receptor sites, competition for nutrients, secretion of metabolic toxins, cross reacting antibody
production stimulated.
3. List 2 factors that may impair the defenses of the respi tract.
Air pollution, alcohol, bacterial/viral infections, immunosuppression, respi tract diseases (asthma,
emphysema, cystic fibrosis)
Ig A
Drugs used for cough
To prevent foreign material from entering the lower respi tract, to clear foreign material and excessive
secretions from the lower respi tract.
2. Antitussives are cough suppressants - increasing the threshold of the cough centre in the brainstem.
Give an example of an antitussive and its main use.
Codeine, dextromethorphan, pholcodine. Used for dry unproductive cough to minimize damage to the
respi tract, and allow healing of surgery or wounds to the abdomen and eyes
Mucolytics break the disulphide bonds in mucus glycoprotein, reducing the viscosity to allow easier
expectoration. Acetylcysteine, methylcysteine, carbocysteine.
By irritating the bronchial mucosa, they increase amount and fluidity of secretions and promote productive
cough.
5. Oxymetazoline is a topical decongestant used in the treatment of rhinorrhea of the common cold and
allergies. How does it work?
Decongestants are sympathomimetics that activate alpha-1-adrenergic receptors on blood vessels, causing
vasoconstriction which causes bronchodilation
Hemoglobin and Gas transport
b. What are the physiological advantages of the Bohr effect in oxygen transport? (2marks)
In the lungs where the pH is highest, the oxygen-hemoglobin curve shifts to the
left indicating that Hb has a higher affinity for oxygen. This favours oxygen
uptake by Hb in the lungs.
In peripheral tissues where acid metabolites (e.g lactic acid) are produced, pH
is lower. The curve shifts o the right indicating a decreased affinity of Hb for
oxygen. Oxygen is therefore released rapidly in the periphery.
HbF has γ-globin chains which lack some of he positively charged amino
Acids found in the β-chains that are responsible for binding 2,3-BPG.
*The amount of CO2 transported in the blood is markedly influenced by the degree
of oxygenation of the blood. This is the HALDANE EFFECT.
g. Why are O2, H+ (hydrogen ion), CO2 and 2,3-BPG collectively called allosteric
effectors? (1mark)***
A 54 year old man went to see his family doctor complaining of difficulty in swallowing which started 2
months ago and had gotten worse over the past 1 month. He cannot eat solid foods now only semi-solid
and liquid foods. He also complained of severe pain associated with his difficulty in swallowing. His voice
has been persistently hoarse for the past 1 month. On further inquiry, he claimed to have lost weight over
the past 1 month. However, he did not suffer from cough or hemoptysis. He smokes 20 cigarettes a day for
the past 30 years. He also drinks alcohol, about 7 pints of beer a week.
Laryngeal carcinoma.
*Cough is the most common symptom of a bronchogenic carcinoma. Its absence in this case would
probably be more indicative of laryngeal carcinoma than bronchogenic/lung cancer.
b. Name two groups of this carcinoma that respond well to voice saving surgery. (2marks)***
d. Which pattern of nasopharyngeal carcinoma shows the strongest association with EBV?
(1mk)***
Undifferentiated carcinoma.
e. What is the treatment of choice for this type of Nasopharyngeal carcinoma (NPC)? (1mark)
Radiotherapy.
f. Where do reactive nodules/ vocal cord polyps usually develop? Which group of
individuals are most at risk of developing them? (2marks)
They are focal protrusions of the mucosa associated with inflammation, allergy,
Mucoviscidosis/ cystic fibrosis.
*They are not true neoplasms. Histologically, a nasal polyp appears to have an
edematous mucosa with loose stroma and lots of inflammatory cells (mostly
eosinophils).
Allergic Rhinitis & Anti- asthmatic drugs.
1. A 12 year old boy visited a clinic complaining of a runny nose and sneezing that occurs, according
to his mother, especially when he plays with the family dog. Upon further questioning, it is
discovered that he has had this problem for a few years now and has been to see doctors at other
clinics before who told his mother that he is suffering from allergic rhinitis.
Initiated by a hypersensitivity reaction to allergens (pollens, fungi, animal allergens, dust mites). It
is an immunoglobulin – mediated immune reaction. Also known as Hay fever.
c) If you were the doctor at the clinic, what would be your advice to this boy and his mother?
(2marks)
Advice : Stay away from situations that would lead the boy to be exposed to allergens as well
making sure conditions at home are as dust free as possible.
certain types of asthma do not require the presence of common allergens (pollen) to occur.
Asthma leads to reversible bronchoconstriction of the airways.
Little or no shedding of airway epithelium in rhinitis
Inhalled allergen interacts with IgE that is bound to the surface of mast cells interspersed among
the epithelial cells of the bronchial mucosa. The mast cells degranulate and release mediators that
produce the effects characteristic of asthma.
The body of a 20 year old woman was brought to the forensics department. Upon autopsy of the body, the
coroner’s report states that she died due to an asthmatic attack.
b) State 3 probable morphological features that the coroner has most likely seen in the lungs to have come
to the conclusion that he did. (3marks)
Curshmann spirals, Charcot – leyden crystals, thick mucous plugs occluding bronchi and bronchioles,
hypertrophy of bronchial smooth muscle.
c) Match the conditions below that contraindicate the usage of the drugs in the table. The conditions may
be used once, more than once or not at all. (3marks)
A - Diabetes
B - Children
C – Female patients
Drug Contraindications
Salbutamol A
Theophylline B
Prednisolone A
e) List 2 side effects of the usage of glucocorticoids in the treatment of asthma. (2marks)
(Just about everything you can think of =P) Tuberculosis, pneumonia, influenza, chronic bronchitis,
asthma, chronic airway obstruction, emphysema, lung cancer
IHD, Hypertension, Cerebrovascular diseases, pulmonary heart disease, atherosclerosis, aortic aneurysm,
(any other cvs disease you can think of)
Low birth weight, respiratory distress syndrome, sudden infant death syndrome.
4.What is ETS? What is its significance with reference to respiratory disease? (4 marks)
ETS is Environmental Tobacco Smoke. It contains the same carcinogens which are present in tobacco
smoke. Prolonged exposure to ETS increases risks of developing lung cancer,
asthma, bronchitis, pneumonia. It causes eye and nasal irritation. Children are the most adversely affected.
1.What are possible allergic sensitizers in occupational rhinitis and laryngitis? Name three. (3 marks)
dusts and mites, fungi from flour; dusts from animal feed and grain; chemicals in adhesives; latex on
granules on latex gloves; pollen and mold spores; proteins from lab animals
2.What size of particles cause pneumoconioses? What happens to bigger particles? (4 marks)***
Particles up to 1 micron reach the alveoli - these are ingested by macrophages and are either cleared by
lymphatics or cause fibrosis. Bigger particles get trapped in the mucus in the upper airways.
3.The severity of lung disease caused by dust is dependent on what factors? (3 marks)
nature and properties of the dust, amount of dust retained in the lung (inhaled dose and duration of
exposure), individual reactivity of the dust
4.What are the pathologic changes seen in a lung affected by pneumoconiosis? (4 marks)
destruction of alveoli and capillaries, with fibrotic replacement fibrous cysts seen, giving a honeycomb
appearance, fibrotic thickening of respiratory bronchioles, alveolar ducts and alveoli, fibrotic thickening
and calcification of the pleura, plaques, bronchogenic carcinoma
5.What kind of granulomas, if present, are most commonly found in pneumoconioses? (1 mark)
Question 1
Define and give 2 examples each for obstructive and restrictive lung diseases.
Obstructive: ↑resistance to airflow due to partial/complete obstruction at any level of the bronchial tree.
E.g. chronic bronchitis, emphysema, asthma, bronchiectasis, bronchiolitis obliterans.
Restrictive: ↓expansion of lung parenchyma with ↓total lung capacity. E.g. Kyphoscoliosis, pleural
disease, poliomyelitis, obesity,ARDS, pneumoconiosis, sarcoidosis, extrinsic allergic alveolitis,
cryptogenic fibrosing alveolitis, lymphangitis carcinomatosis.
Question 2
Define chronic bronchitis, emphysema, asthma and bronchiectasis.
Chronic bronchitis : cough productive of sputum most days in at least 3 consecutive months for at least
2-3 consecutive years.
Emphysema : ↑beyond the normal size of airspaces distal to terminal bronchiole due to destruction of
alveoli
Asthma : chronic inflammatory disease of the airways causing ↑in airway hyperresponsiveness. This
leads to recurrent, reversible episodes of wheezing, breathlessness, chest tightness and coughing.
Bronchiectasis : permanent dilation of bronchi and bronchioles caused by destruction of muscle and
elastic supporting tissue, secondary to persisting infection/obstruction
Question 3
a. Describe the pathogenesis of ARDS
Injury to alveolar epithelium and alveolar capillary endothelium->leaky lung capillary bed->exudates
pours into interstitium, then alveolar spaces->fibrosis
Hypersensitivity reaction (type III & IV) to inhaled organic antigens->formation of circulating immune
complexes->non-caseating granulomas.
Question 4
a. What is pneumoconiosis?
Diffuse, usually fibrotic lung reaction to inhaled inorganic Ags.
Question 5
Airway obstruction, loss of alveolar surface area, ventilation-perfusion mismatch, reduced respiratory
drive.
Question 1
Partnership with HIV – HIV weakens the immune system making it easier for (re)infection to occur. Also
there are multidrug resistant strains.
Poor socioeconomic status, occupation – health care workers/miners, smoking, alcoholics, predisposing
medical conditions, geographical (↑in wet, cold climates like UK)
Question 2
Question 3
inhaled bacteria->upper part of lower lobe/lower part of upper lobe->macrophages phagocytose bacteria
and become epitheloids->granuloma surrounded by lymphocytes and fibroblasts->necrosis of epitheloids-
>caseation. Some epitheloids become giant cells.
c. What causes the ‘coin lesions’ in the X-rays of patients with postprimary TB?
TB granuloma becomes liquefied->contents of granuloma coughed out leaving behind a cavity, which is
seen on X-ray as coin lesion.
Question 4
Usually to organs with high O2 tension e.g. kidneys, ends of long bones, brain, meninges, lungs, lymph
nodes, spleen, vertebra
Occurs when large numbers of TB bacilli are released into bloodstream->pulmonary venous return to
heart->numerous small tubercles are scattered throughout body.
Question 5
Tuberculin test, sputum smear, CSF for meninges, FNAC of LN, biopsy of LN
Bacillus Calmette-Guerin (BCG) vaccine protects against disseminated & miliary TB. DOTs, multidrug
therapy
Isoniazid (INH), Ethambutol (EMB), Rifampicin (RIF), Pyrazinamide (PZA), Streptomycin (SM)
Anti-TB Drugs
1. Explain the mechanism of action of rifampicin, & give one possible side effect. (3 marks)
2. Give 3 other example of 1st-line anti-TB drugs other than rifampicin. (3 marks)
3. What are the indications for the usage of 2nd-line anti-TB drugs? (2 marks)
3. What are the laboratory tests that can be performed to confirm a diagnosis of a patient that is suspected
of having pneumonia? (3 marks)
4. What are the unique microscopic morphology of a pneumocystis pneumonia, & what is the stain used?
(3 marks)
- “cotton candy” exudates, septa thickened by oedema, minimal mononuclear infiltrate in intra-alveolar
spaces.
- silver/ GIEMSA stains.
Control of Breathing
(a) Inspiratory center – responsible for basic rhythm of respiration, caused by its intrinsic periodic firing.
- initiates inspiratory ramp signals.
2. Explain how does increased PCO2 in the blood stimulates the central chemoreceptors. (2 marks)
- Increase PCO2, CO2 enters brain and cerebral spinal fluid (blood brain barrier impermeable to H+ ions).
- CO2 then hydrated into H2CO3, which then dissociates into H+ ions, which stimulates the central
chemoreceptors.
Malnutrition, low birth weight, poor housing and over crowding, indoor air pollution, outdoor air
pollution, environmental tobacco smoke, educational level of mother.
2. a) What is pneumonia and state the most common bacteria that cause pneumonia. (3 marks)
Pneumonia is an inflammatory process affecting alveoli and airways leading to consolidation of lung
parenchyma secondary to bacterial, viral or fungal infection. Streptococcus pneumonia.
(b) Name three risk factors for the above bacteria (3 marks)
old people, post viral infection, impaired immune system-malnutrition, diabetes mellitus, rheumatoid
arthritis, renal disease, leukaemia, alcoholics, cirrhosis.
3. (a) Why women and children are the most people who has chronic respiratory disease. (3 marks)
***
This is due to indoor air pollution. Air pollution indoor is 1000 times more easily affecting the
lungs than outdoor due to biomass fuel used in cooking and heating. They are those who stay in
house relatively longer than men do, who are the breadwinner in the family.
(b) Name two diseases that caused by ambient air pollution. (2 marks)***
Ambient air pollution is outdoor air pollution. Bronchitis, emphysema, pneumonia, COPD, lung
cancer, Asthma, acute respiratory disease.
It is pertaining to indoor air pollution where air pollution released indoor is 1000 times more likely
to reach people's lung.
4. Name three primary prevention methods to reduce the incident of lung cancer caused by tobacco
smoking. (3 marks)
Health promotion by preventing non-smokers from addiction to nicotine, aimed primarily at children <
10. create smoke free environment, increase cigarette prices.
Pulmonary adjustment to various activities
1. (a) What are the differences between physiological stresses in exercises and in high altitude? (3
marks)
(b) Why does the fractional concentration of Oxygen does not change in high altitude? (4
marks)***
The fractional concentration of O2 is not changed because the amount of oxygen is still the same
in high altitudes. That means, the fraction of oxygen in the world is 21percent and it still stays true
even in high altitude where people have difficulty in breathing. The difference is because of the
pressure, po2. It differs according to the level form the sea. Hence, in high altitude, the pressure is
lower than at the sea level. Hence, PO2 in high altitude is lower.
(d) How is the Oxygen delivery to the tissues increase in exercise? (2 marks)
(e) Why does the pulmonary blood flow increases in exercise? (2 marks)
Systemic Pulmonary
high pressure system low pressure system
Arteries – oxygenated blood arteries – deoxygenated blood
veins – deoxygenated blood veins – oxygenated blood
well developed smooth muscle in vessel walls poorly developed smooth muscle in vessel walls
tissue fluid formation NO tissue fluid formation
neural and humoral regulation regulated by hypoxia and gravity
gravity effects negligible affected by gravity.
Gas exchange, nutrient supply to the alveolar ducts and alveoli, a filter to trap thrombi and other emboli,
angiotensin converting enzyme (ACE) released by the pulmonary capillaries.
Anastomoses between the bronchial capillaries and pulmonary capillaries and veins.
Blood flow from the coronary arteries into the chambers of the left heart.
Blood passing through non-ventilated areas of the lung.
5. Give 2 possible symptoms you might come across in a patient with pulmonary hypertension.
Ans: - The thoracic cage stops but the internal viscera still moves on impact. The
internal viscera then stops suddenly.
- This causes the hollow viscera to tear away from its fixation, and spills its
contents into the body’s cavity
b) A man was admitted into the A & E department for a deep stab wound located 2cm above his left
nipple.
iii. Based on chest X-rays, it was found that the man had trapped air in his thorax.
What would his treatment be? (1m)
Flail chest –A
Splenic rupture –B
Cardiac temponade –C
Tension pneumothorax –D
Diaphragmatic rupture –E
Hyperventilation & Mass Sociogenic Illness (MSI)
(Source: Hyperventilation & Mass Sociogenic Illness (MSI) lecture, PJ: ?)
QUESTION 8 (10m):
b) It is discovered that MSI outbreaks share several characteristics. State at least 4 characteristics of
MSI. (4m)
3. CNS 4. CVS
- Dizziness - Tachycardia
- Feeling faint - Palpitations
- Headache
- Blurred vision
Ans: - She must breathe quietly into a small paperbag for about 5 minutes
(the “brown paper-bag treatment”)
[NOTE: This treatment is used during violent hyperventilating attacks. The ‘brown paper-bag
treatment’ is done to increase the carbon dioxide levels in her blood.]