Download Fluid and Haemodynamics

Section 1
Fluid and Haemodynamics (no answers)
1) Systemic thromboemboli:
a)
b)
c)
d)
e)
60% arise from intracardiac thrombi
25% are of unknown origin
75% of arteriolar embolisation are in the lower limbs
20% of arteriolar embolisation are in the brain
paradoxical emboli may enter pulmonary circulation
2) Stroke cascade in sepsis is:
a)
b)
c)
d)
e)
LPS
TNF
LPS
LPS
ILI
TNF
LPS
ILI
TNF
LPS
IL6/8
ILI
IL6/8
ILI
TNF
ILI
IL6/8
TNF
IL6/8
IL6/8
3) All the following are important leucocyte adhesion molecules EXCEPT:
a)
b)
c)
d)
e)
ICAM I
VCAM I
LTB 4
P-selectin
E-selectin
4) In acute inflammation:
a)
b)
c)
d)
e)
mean capillary pressure is reduced by arteriolar dilation and opening of capillary beds
there is accumulation of extravascular fluid with specific gravity > 0.012
neutrophils usually predominate for the first 48 hours
phagocytosis may cause tissue damage
in viral infections, monocytes are the first cells to arrive
Section 2
Haemostasis, Thrombosis & Haemorrhage
1)
Regarding tissue factor/tissue thromboplastin:
a)
b)
c)
d)
e)
2)
With regard to haemostasis, all of the following are true EXCEPT:
a)
b)
c)
d)
e)
3)
brain
lower limbs
coronary vessels
renal vessels
spleen
Which is not an anti-coagulant?
a)
b)
c)
d)
e)
5)
von Willebrands factor acts as a molecular bridge between platelets and collagen
platelets bind von Willebrands factor via a glycoprotein receptor Go IIb/IIIa complex
activated platelets bind to each other using fibrinogen as bridge molecules
platelet adhesion results in release reaction and exposes surface binding sites
activated platelets accelerate activation of prothrombin 20,000 fold
Major sites of lodgement of systemic emboli include all of the following EXCEPT:
a)
b)
c)
d)
e)
4)
its production by endothelial cells can be induced by IL-1 and TNF
its production by endothelial cells can be induced by bacterial exotoxin
it activates the extrinsic clotting system
it activates factor VII
all of the above are true
thrombomodulin
protein C
protein S
anti-thrombin IH
thromboplastin
Which of the following is contained in the cytoplasmic granules of platelets?
a)
b)
c)
d)
e)
ADP
thrombin
von Willebrands factor
P-selectin
glycoprotein receptor Gp 16
6)
Functional deficiencies of all of the following prolong INR EXCEPT:
a)
b)
c)
d)
e)
7)
Regarding protein C, all of the following are true EXCEPT:
a)
b)
c)
d)
e)
8)
it inactivates factors Va and VIIIa
it is a vitamin K dependent on plasma protein
it uses protein S as a co-factor
it is activated by the thrombomodulin-thrombin complex
it stimulates conversion of plasminogen to plasmin
All of these factor sites of origin pairs are true EXCEPT:
a)
b)
c)
d)
e)
9)
fibrinogen
factor V
factor VII
factor X
factor IX
thromboxane is formed by activated platelets
protein S is synthesised by endothelial cells
prostacyclin is elaborated by platelets
endothelial cells synthesise and secrete von Willebrands factor
fibrin stabilising factor is released from platelets
The activation of protein C:
a)
b)
c)
d)
e)
is inhibited by endothelial cells
may cause intrinsic coagulation pathway inhibition
increases the activity of anti-thrombin M
is not affected by warfarin administration
stimulates the platelet secretion-release reaction
10) All of the following is released by activated platelets EXCEPT:
a)
b)
c)
d)
e)
ADP
prostacyclin
factor Va
serotonin
ionised calcium
11) Prostacyclin (PGI2):
a)
b)
c)
d)
e)
is formed by the action of lipo-oxygenase on arachidonic acid
is liberated by activated platelets
is liberated by vascular endothelial cells
enhances platelet aggregation
enhances thrombomodulin activity
12) Regarding the clotting pathways, all of the following are true EXCEPT:
a)
b)
c)
d)
e)
a prolonged APT indicates a defect in the intrinsic pathway
the intrinsic pathway is more important in vivo than the extrinsic pathway
the extrinsic pathway is initiated by tissue factor acting on factor VII
factor X is common to both pathways
deficiency of factor XII does NOT cause a bleeding tendency
13) Regarding platelets, all of the following are true EXCEPT:
a) they do not have nuclei and cannot reproduce
b) they contain actin, myosin and tropomyosin in the cytoplasm, which are all contractile
proteins
c) they are coated with glycoproteins that cause them to avoid adherence to normal
endothelium
d) contain alpha granules which are rich in ADP and Ca++
e) form thromboxane helping platelet aggregation
14) Factor VIIa:
a)
b)
c)
d)
e)
is a component of the extrinsic clotting pathway
directly activates factor IX
is inhibited by protein C
its deficiency results in von Willebrands disease
is dependent on vitamin K for its synthesis
15) The mechanisms of thrombin involvement in thrombosis include all the following EXCEPT:
a)
b)
c)
d)
e)
increased P-selectin presentation on endothelial surfaces
conversion of prothrombin to thrombin
factor V and VII activation
decreased mast cell heparin release
increased platelet aggregation
16) With regard to haemostasis, all of the following are correct EXCEPT:
a)
b)
c)
d)
e)
activated protein C degrades factors Va and VIIIa
protein C is activated by thrombin in the presence of thrombomodulin
factor VIII is activated by thrombin
the primary haemostatic plug is formed by platelet aggregation due to thrombin
protein S is a co-factor for protein C
17) Stasis of blood flow results in thrombosis because:
a)
b)
c)
d)
disruption of fresh blood flow results in less dilution of activated clotting factors
disruption of fresh blood flow results in reduced inflow of inhibitors of clotting factor
it results in decreased local release of prostacyclin (PG12) and tPA
all of the above
18) In acute hypovolaemic shock, angiotensin:
a)
b)
c)
d)
e)
stimulates the central nervous system’s ischaemic response
is responsible for the reverse stress-relaxation response of the circulatory system
is not a significant factor in acute compensation
inhibits the release of vasopressin
contributes towards compensation after baroreceptor responses have been evoked
19) With regard to the in-vitro clotting of blood samples, all of the following are true EXCEPT:
a)
b)
c)
d)
e)
blood usually clots when placed in a glass tube within 4-8 minutes
clotting can be prevented by adding EDTA which chelates calcium
recalcified plasma usually clots in 2-4 minutes
the APPT is performed by adding thromboplastin to recalcified plasma
the normal APPT is 26-33 seconds
20) Vitamin K is required for the activation of:
a)
b)
c)
d)
e)
pre-kallikrein
Hageman factor
von Willebrands factor
protein C
plasminogen
21) Thrombus formation is inhibited by:
a)
b)
c)
d)
e)
von Willebrands factor
IL-1
alpha 2 – macroglobulin
TNF
endothelial cell injury
22) Most pulmonary emboli:
a)
b)
c)
d)
e)
cause centrally located pulmonary haemorrhage
cause pulmonary infarction
cause acute right heart failure
are clinically silent
lead to pulmonary hypertension
23) In normal haemostasis:
a)
b)
c)
d)
e)
factor V inhibits thrombosis
alpha 2 macroglobulin is antithrombotic
PGI2 favours platelet aggregation
platelet aggregation is inhibited by von Willebrands factor
tissue plasminogen activator is responsible for prothrombotic events
24) Normal endothelial cells decrease platelet aggregation by secreting:
a)
b)
c)
d)
e)
Interleukin-1
von Willebrands factor
prostacyclin
factor V
thromboplastin
25) Thrombosis is potentiated by all of the following EXCEPT:
a)
b)
c)
d)
e)
von Willebrands factor deficiency
protein S deficiency
antithrombin III deficiency
thrombotic thrombocytopaenia
acute leukaemia
26) Acute compensatory mechanisms in shock include all the following EXCEPT:
a)
b)
c)
d)
e)
baroreceptor reflexes
reverse stress – relaxation of vascular smooth muscle
the effects of increased aldosterone secretion
activation of the renin-angiotensin system
the central nervous system ischaemic response
27) Prothrombotic characteristics of endothelium include:
a)
b)
c)
d)
e)
plasminogen activator
prostacyclin
von Willebrands factor
thrombomodulin
heparin like molecules
Section 2
Haemostasis, Thrombosis and Haemorrhage - Answers
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
18)
19)
20)
21)
22)
23)
24)
25)
26)
27)
E
B
C
E
A
E
E
C
B
B
C
B
D
C
D
D
E
E
D
D
C
D
B
C
A
C
C
Section 3
Haemorrhage and Shock
1) The classic stages of shock include all of the following EXCEPT:
a) compensated stage which begins with mild hypotension, tachycardia, pallor and cold
extremities including septic shock
b) decompensating stage which include decline in blood pressure and rapid pulse
c) irreversible shock where all therapeutic efforts are to no avail
d) full recovery is possible, however there is a much higher mortality with patients with
cardiogenic shock
e) all of the above are stages of shock
2) Which statement regarding shock is INCORRECT?
a)
b)
c)
d)
e)
cardiogenic shock has a higher mortality than neurogenic shock
“progressive” / “demonstrated” shock is usually irreversible
nephrotic syndrome is associated with loss of fluid from all fluid compartments
oliguria usually precedes diuresis
angiotensin and vasopressin levels increase within one hour
3) Shock:
a) is caused by a loss of 25% of the blood volume in a healthy individual
b) is caused primarily by cardiac failure and has a 40% mortality with modern treatment
c) is caused by sudden haemorrhage and will stimulate a maximal response from the reninangiotensin system within 10 minutes
d) is caused by endotoxins and is mediated largely by the release of ILY and TNF from
macrophages
e) will cause the “central nervous system ischaemic response” when the systolic blood
pressure is less than 80mmHg
4) The most potent vasopastic substance is:
a)
b)
c)
d)
e)
histamine
leukotriene C4
platelet activating factor
TNF-α
serotonin
5) Mediators of septic shock include all of the following EXCEPT:
a)
b)
c)
d)
e)
IL-6
C5a
PAF
catecholamines
TNF antibodies
Section 3
Haemorrhage and Shock – Answers
1)
2)
3)
4)
5)
A
B
D
B
E
Section 4
Haemodynamic disorders, thrombosis and shock
1) Hypercoagulability:
a) is most commonly caused by the factor V Leiden mutation, present in 1-2% of the
white population
b) may be caused by an inherited excess of protein C or protein S
c) can result from a congenitally reduced level of homocysteine
d) is the most frequent cause of thrombotic disease
e) may be caused by heparin-induced thrombocytopaenia
2) Regarding thrombi, which one of the following statements is NOT true?
a) arterial thrombi usually begin at the site of endothelial damage or turbulence, whereas
venous thrombi start in areas of stasis
b) arterial thrombi tend to propagate in a retrograde direction to the point of attachment
whereas venous thrombi tend to extend in the direction of blood flow
c) 30% of DVTs in the larger leg veins are asymptomatic and clinically undetectable
d) venous thrombosis commonly affects the veins of the lower extremities, with only 10%
occurring in other sites
e) activation of the fibrinolytic pathway can lead to total lysis and complete resolution of
recent thrombi
3) Regarding pulmonary emboli:
a) most are clinically detectable by a tachypnoea, dyspnoea and tachycardia
b) sudden death and/or cardiovascular collapse occur when over 40% of the pulmonary
circulation is obstructed by emboli
c) embolic obstruction of medium sized pulmonary vessels results in pulmonary infarction
and loss of respiratory capacity
d) fewer than 5% of pulmonary emboli originate outside the deep veins of the legs
e) multiple pulmonary emboli are unlikely to have a clinical effect if they occur over a
prolonged period of time
Section 4
Haemodynamic disorders, thrombosis and shock –
Answers
1)
2)
3)
E
C
D
Section 5
Haematopoietic System
1) Hereditary spherocytosis:
a)
b)
c)
d)
e)
is asymptomatic in 50% of cases
frequently presents at birth with marked jaundice
causes cholelithiasis in up to 50% of affected adults
causes massive splenic enlargement
is cured by splenectomy
2) Glucose G phosphate dehydrogenase deficiency:
a)
b)
c)
d)
e)
is X-linked
is believed to protect against malaria (plasmodium fal????)
can cause intravascular and extravascular haemolysis
rarely display the morphologic changes of chronic haemolytic anaemia
all above are true
3) Sickle cell disease:
a)
b)
c)
d)
e)
sufferers are heterozygous
frequently presents in the neonatal period
usually causes splenomegaly in adults
involves abnormal alpha-globin
causes “crew haircut” appearance on skull x-rays
4) Sickling may be precipitated by:
a)
b)
c)
d)
e)
HbA
dehydration
increased pH
HbF
co-existent alpha-thalanaemia
5) The commonest cause of death in children with sickle cell anaemia is:
a)
b)
c)
d)
e)
severe anaemia
infection by unencapsulated bacteria
vaso-occlusive complications
osteomyelitis
heart failure
6) Αlpha-thalanaemia:
a)
b)
c)
d)
e)
is more common than beta-thalanaemia
is more severe than beta-thalanaemia
can cause intrauterine death (hydrops foetalis)
is rarely asymptomatic
usually requires regular transfusions
7) Beta-thalanaemia:
a)
b)
c)
d)
e)
involves excess beta-globin production
causes spherocytes in peripheral blood ?????
results in ineffective erythropoiesis
is manifest at birth in severe cases
is a cause of primary haemochromatosis
8) Paroxysmal nocturnal haemoglobinuria:
a)
b)
c)
d)
e)
is a congenital hereditary condition
affects white cell, platelet and red cell function
is rarely fatal
is not associated with aplastic anaemia
causes paroxysmal and nocturnal intravascular haemolysis in more than 75% cases
9) Immune haemolytic anaemia of warm antibody type includes:
a)
b)
c)
d)
e)
systemic lupus erythematosus
syphilis
mycoplasma pneumoniae
measles
mumps
10) Causes of folic acid deficiency include:
a)
b)
c)
d)
e)
ileac resection
anticonvulsant
pernicious anaemia
vegetarianism
????? infection with fish tapeworm
Section 5
Haematopoietic System – Answers
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
C
E
E
B
B
C
C
B
A
B
Section 6
Leucopoenia, Leukocytosis, spleen, blood group
1) The normal spleen:
a)
b)
c)
d)
e)
stores >50% body platelets
stores 30-40ml of red blood cells
is frequently the site of primary disease
is an important primary organ of the immune system
has a periarteriolar sheath of β lymphocytes
2) Splenomegaly in adults can be caused by all EXCEPT:
a)
b)
c)
d)
e)
amyloidosis
Epstein-Barr virus
multiple myeloma
rheumatoid arthritis
sickle cell anaemia
3) Patients with polycythaemia veins:
a)
b)
c)
d)
e)
frequently have splenomegaly in the early stages
usually have a haematocrit of ≥ 60%
are all hypertensive
have normal levels of erythropoietin (serum)
usually present with thrombotic episodes
4) The most common site of multiple myeloma lesions is:
a)
b)
c)
d)
e)
vertebral column
skull
pelvis
femur
clavicle
5) Severe infections tend to occur when the neutrophil count drops below:
a)
b)
c)
d)
e)
100 cells/mm3 blood
500 cells/mm3 blood
1000 cells/mm3 blood
1500 cells/mm3 blood
3000 cells/mm3 blood
6) Basophilic leukocytosis is seen in:
a)
b)
c)
d)
e)
severe burns
periphagus
inflammatory bowel disease
myeloproliferative disease
non Hodgkin lymphomas
7) The life-span of a neutrophil in the circulation is:
a)
b)
c)
d)
e)
6-7 hours
12-24 hours
24-45 hours
4-5 days
none of the above
8) Blood transfusion reaction is an example of a:
a)
b)
c)
d)
e)
type I hypersensitivity reaction
type II hypersensitivity reaction
type III hypersensitivity reaction
type IV hypersensitivity reaction
(rather embarrassing monumental cock-up)
9) Regarding rhesus blood groups:
a)
b)
c)
d)
e)
rhesus antibodies are innate
there are three types of rhesus factors
rhesus ‘D’ is the mast prevalent and antigenic rhesasta
most Caucasians are “rhesus negative”
maximal antibody response occurs 2-4 weeks after initial exposure
10) Type O blood:
a)
b)
c)
d)
e)
can be safely transfused into anyone
contains anti A and anti B antigens at birth
red cells have O, A and B antigens on their surface
is the commonest blood type in Caucasians
show maximal anti-A and anti-B titres in 20-30 year old
Section 6
Leucopoenia, leukocytosis, spleen, blood groups –
Answers
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
B
E
B
A
B
D
A
B
C
D
D
Section 7
1) In acute infection which cytokine is responsible for the leukocytosis?
a)
b)
c)
d)
e)
IL-1
IL-2
IL-4
IL-5
IFN-X
2) Which of the following conditions would a barophitic leukocytosis be most likely in?
a)
b)
c)
d)
e)
bacterial infection
asthma
myeloproliferative conditions
parasitic infection
myelodysplastic conditions
3) Neutropenia associated with ineffective granulopoiesis include:
a)
b)
c)
d)
e)
hypersplenism
aplastic anaemia
alkylating agents (CXT)
SLE
vitamin B12 deficiency
4) Lead poisoning leads to a:
a)
b)
c)
d)
e)
megaloblastic anaemia
haemolytic anaemia
microcytic anaemia
hypodromic anaemia
aplastic anaemia
5) Acute cold agglutinin haemolytic anaemia is seen in:
a)
b)
c)
d)
e)
SLE
lymphoma
leukaemia
mycoplasma infection
paroxysmal cold haemoglobinuria
Section 7
Answers
1)
2)
3)
4)
5)
A
C
E
B
D
Section 8
Haematology
1) Monocytosis is seen in:
a)
b)
c)
d)
e)
burns
non-Hodgkin lymphoma
chronic myelogenous leukaemia
inflammatory bowel diseases
hay fever
2) Mycoplasmal infections can cause:
a)
b)
c)
d)
e)
megaloblastic anaemia
aplastic anaemia
warm antibody haemolytic anaemia
cold agglutinin immune haemolytic anaemia
cold haemolysis haemolytic anaemia
3) Sickle cell disease:
a)
b)
c)
d)
e)
is seen in heterozygotes for Hbs
if severe, is present at birth
splenomegaly is a late sign
painful bone crises are extremely common in children
is a type of intravascular haemolytic anaemia
4) Folic acid deficiency is seen in:
a)
b)
c)
d)
e)
vegetarianism
gastrectomy
disseminated cancer
fish tapeworm infection
ileitis
5) Regarding pernicious anaemia:
a)
b)
c)
d)
e)
it is an important cause of folic acid deficiency
intrinsic factor is secreted by chief cells in stomach
it is usually diagnosed in adolescence
intrinsic factor complexes with vitamin B12 in the stomach
it is associated with myelin degeneration of dorsal and lateral tract
Section 8
Haematology – Answers
1)
2)
3)
4)
5)
D
D
D
C
E
Section 9
Endocrine
1) Which is the most common pituitary adenoma?
a)
b)
c)
d)
e)
non-functioning adenoma
growth hormone adenoma
prolactin cell adenoma
ACTH cell adenoma
mixed growth hormone – prolactin adenoma
2) Regarding Hashimoto thyroiditis:
a)
b)
c)
d)
e)
women are five times more frequently affected than men
some cases are HLA-B8 associated
caused primarily by a B cell defect
antibodies are directed against the iodine transporter
presents as a symmetric, diffuse, painful enlargement of the thyroid, usually with
hypothyroidism
3) Which feature is most frequently seen in Cushing syndrome?
a)
b)
c)
d)
e)
osteoporosis
moon faces
weakness and fatigability
hypertension
central obesity
4) Which is NOT an example of secondary hyperaldosteronism?
a)
b)
c)
d)
e)
congestive heart failure
Conn syndrome
renal artery stenosis
hypoalbuminaemia
pregnancy
5) Which is the most common cause of Addison’s disease?
a)
b)
c)
d)
e)
autoimmune adrenalitis
tuberculosis
metastatic cancer
acute haemorrhagic necrosis
drug-induced – of ACTH
Section 9
Endocrine – Answers
1)
2)
3)
4)
5)
C
D
E
B
A
Section 10
Haematopoietic System
1) Regarding pernicious anaemia:
a)
b)
c)
d)
e)
it is more common among Mediterranean and Chinese people
atrophic gastritis with failure of IF production is characteristic
tapeworm infestation may sometimes be a cause
becomes more rare in advancing age groups
failure of terminal ileal receptor sites for IF is a common cause
2) Regarding B12 deficiency:
a)
b)
c)
d)
e)
dietary deficiency may deplete normal reserves after several weeks
failure of B12 protein R splitting in elderly people may be a cause
pepsin is not normally involved in the process of B12 absorption
without IF, there can be no B12 absorption at all
anaemia and spinal degeneration can be reversed with folate
Section 10
Haematopoietic System - Answers
1)
2)
B
B
Section 11
1) Which primary tumour is not responsible for ectopic ACTH production?
a)
b)
c)
d)
islet cell tumours of the pancreas
carcinoid tumours
ductal cancer in the site of the breast
small cell cancer of the lung
2) With respect to adrenocortical insufficiency, which is TRUE?
a)
b)
c)
d)
e)
Addison’s disease is commonly caused by infiltrative disease such as ????ser
hyperpigmentation is not seen in this condition
Na+ and K+ losses result in hypokalaemia and hyponatraemia
resolution is normal with adequate cortisol replacement
acute Waterhouse–Fridericksen syndrome responds well to appropriate steroid
replacement
3) In the anterior pituitary, which is TRUE?
a) somatotrophs make up the major cell component
b) thyrotrophs produce TSH and lipotropin
c) stimulation is via axons from the ??? supraoptic and paroventricular nuclei in the
hypothalamus
d) tumours of the pituitary are normally recognised by the mass effects with the cranium
4) Hypothyroidism, which is TRUE?
a)
b)
c)
d)
is uncommonly caused by autoimmune destruction of the thyroid
may result in elevated TSH levels detectable by blood test
can cause gynaecomastia and amenorrhoea
commonest cause in region with adequate iodine is drug induced
5) Parathyroid hormone:
a) is secreted by the action PTH release protein
b) commonest cause of secretion is primary hyperplasia
c) over activity causes bone, kidney, gastrointestinal and central nervous system
symptoms
d) parathyroid levels are low in primary hyperparathyroidism
6) The commonest cause of hypothyroidism in iodine sufficient areas of the world is:
a)
b)
c)
d)
e)
Hashimoto thyroiditis
developmental lack of thyroid parenchyma
developmental deficiency of enzymes of thyroid hormone syndrome
due to antithyroid medications
radiation damage to thyroid gland
7) Regarding pituitary, which is TRUE?
a)
b)
c)
d)
e)
50% of the pituitary gland is adenohypophysis
posterior pituitary derives from Ratrike’s pouch
corticotrophs and thyrotrophs are acidophilic cells
the commonest type of pituitary adenoma is prolactin secreting adenomas
non-functional adenoma are usually microadenomas
8) Regarding prolactin, which is TRUE?
a)
b)
c)
d)
level decreases in hypothyroidism and renal failure
level decreases by use of reserpine
level decreases by neuroleptics
non prolactin secreting adenomas can increase the pituitary prolactin secretion by stalk
effect
e) prolactin levels decrease by use of oestrogens
9) Which is false regarding null cell adenomas?
a)
b)
c)
d)
e)
null cell adenomas contribute to 20% of pituitary adenomas
they do not produce hormones
they can cause pituitary apoplexy
they contain large numbers of secreting granules
they cause hypothyroidism by destruction of normal pituitary cells
Section 11
Answers
1)
2)
3)
4)
5)
6)
7)
8)
9)
C
D
A
B
C
A
D
D
D
Section 12
Haemostasis, Thrombosis and Embolism
1) Concerning thromboembolism:
a)
b)
c)
d)
e)
the majority of pulmonary emboli arise from deep calf vein and popliteal thrombosis
about 40% of pulmonary emboli are clinically silent
pulmonary hypertension is a common sequelae in pulmonary embolism
cardiomyopathy is the commonest cause of systemic emboli
the risk of renal infarction from thromboembolus is approximately equivalent to the risk
of cerebral infarction
2) Concerning thrombi:
a)
b)
c)
d)
arterial thrombi propagate in a retrograde direction (against flow)
increased levels of protein C and S are risk factors for thrombi
“lines of Zahn” are more prominent in venous than arterial thrombi
deep venous thrombosis occurs in the following order of frequency: deep calf,
popliteal, femoral, iliac
e) femoral artery thrombi are rarely occlusive
3) Which of the following deficiency syndromes will predispose a patient to a bleeding
disorder?
a)
b)
c)
d)
e)
protein C deficiency
protein S deficiency
factor XII (Hageman factor) deficiency
vitamin C deficiency
PGI2 deficiency
4) Of all hospitalised deaths, what percentage are wholly or largely due to pulmonary
embolus?
a)
b)
c)
d)
e)
5%
10%
20%
50%
75%
5) Which statement regarding tests in bleeding diseases is INCORRECT?
a)
b)
c)
d)
e)
clotting time is prolonged in thrombocytopaenia
partial thromboplastin time detects changes in the intrinsic pathway
Hess’ test is a measure of capillary fragility
prothrombin time detects changes in the extrinsic pathway
bleeding time is affected by the degree of hyperanaemia of the skin
6) Regarding thrombus formation, which of the following is INCORRECT?
a)
b)
c)
d)
e)
platelets aggregate when there is a decrease in intraplatelet levels of cyclic AMP
primary haemostatic plug is formed due to the release of ADP
platelet adhesion requires von Willebrands factor
protein C deficiency increases the tendency to thrombus formation
fibrin predominates in a pale thrombus
7) Which clotting factor is NOT synthesised by the liver?
a)
b)
c)
d)
e)
IX
VII
IV
II
V
8) Regarding disseminated intravascular coagulation, which of the following statements is
INCORRECT?
a)
b)
c)
d)
e)
it involves the development of numerous microthrombi
it is often a primary disorder
it involves active fibrinolysis
it is associated with increased FDPs
it involves consumption of platelets and clotting factors
9) Which of the following is NOT found in alpha-granules of platelets?
a)
b)
c)
d)
e)
fibrinogen
platelet derived growth factor
ADP
platelet factor IV
fibronectin
10) Regarding the clotting cascade, which of the following is INCORRECT?
a) formation of “prothrombin activator” is the rate limiting factor
b) intrinsic pathway is more rapid than extrinsic pathway
c) enough thrombin can be generated by clotting of 1ml of blood to coagulate all the
fibrinogen in 3000mls of blood
d) proteins C and S are reaction accelerators
e) C’1 inactivator neutralises some activated clotting factors
11) Which statement regarding embolism is INCORRECT?
a)
b)
c)
d)
e)
amniotic fluid embolism has about 85% mortality
gas embolism may lead to ischaemic necrosis of bone
about 99% of emboli are thrombotic in origin
most systemic thrombotic arise from valvular lesions
free fatty acids induce toxic injury to micro-vessels in fat embolism syndrome
12) Regarding anti-thrombin III, which statement is INCORRECT?
a)
b)
c)
d)
e)
it combines with the inactivates most serine proteases
anti-thrombin III deficiency usually presents in late adolescence or early adult life
its action is enhanced by both exogenous and endogenous heparin
it blocks the action of IIa on I
it is a beta globulin
13) Which statement regarding platelets is INCORRECT?
a)
b)
c)
d)
e)
PGI2 promotes platelet aggregation
they have a life span of about 10 days
degranulation leads to activation of platelet factor III
they cannot synthesise cyclo-oxygenase
they carry class 1 MHC antigens
14) Which clotting factor is NOT vitamin K dependent?
a)
b)
c)
d)
e)
II
IX
X
V
VII
15) Which of the following is NOT found in dense bodies of platelets?
a)
b)
c)
d)
e)
factor IV
histamine
adrenaline
beta-thromboglobulin
serotonin
16) The control mechanisms of coagulation (anticoagulant) include all of the following
EXCEPT:
a)
b)
c)
d)
e)
the depletion of clotting factors
the clearance of activated factors
stasis and turbulence of blood flow
the inhibition of activated proteases
fibrinolysis
17) Anti-thrombotic factors include all of the following EXCEPT:
a)
b)
c)
d)
e)
thrombomodulin
protein C
anti-thrombin III
von Willebrands factor
tissue plasminogen activator
18) Which of the following is the most important natural constraint to coagulation?
a)
b)
c)
d)
e)
protein C
anti-thrombin III
protein S
endogenous heparin
endogenous tPA
19) Regarding the fibrinolytic system, which of the following is INCORRECT?
a)
b)
c)
d)
e)
urokinase-like plasminogen activators (uPA) activate plasminogen in the fluid phase
alpha-one-antitrypsin inhibits action of plasmin
interleukin-1 inhibits synthesis of tPA-inhibitors
tissue-type plasminogen activators (tPA) are mainly synthesised in endothelial cells
small amounts of plasmin are formed in the blood all the time
20) Which of the following is NOT a platelet agonist (ie, does NOT induce platelet
aggregation)?
a)
b)
c)
d)
e)
ADP
nitric oxide
thrombin
adrenaline
thromboxane A2
21) Thrombosis is potentiated by all of the following EXCEPT:
a)
b)
c)
d)
e)
von Willebrands factor deficiency
protein S deficiency
antithrombin III deficiency
thrombotic thrombocytopaenia
acute leukaemia
22) Prothrombotic characteristics of endothelium include?
a)
b)
c)
d)
e)
plasminogen activator
prostacyclin
von Willebrands factor
thrombomodulin
heparin-like molecules
23) Hageman factor activates the:
a)
b)
c)
d)
e)
complement system
kinin system
fibrinolytic system
coagulation system
all of the above
Section 12
Haemostasis, Thrombosis and Embolism - Answers
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
18)
19)
20)
21)
22)
23)
E
A
E
B
A
E
C
B
C
B
D
E
A
D
D
C
D
B
C
B
A
C
E
Viva Answer
BLOOD GROUPS
There are more than 30 groups of commonly occurring antigens on RBC,
The two groups of greatest clinical significance are:
1 ABO
2 Rhesus
ABO
Possible blood groups; O, A, B, AB
Inherited antigens on RBC surface:
Gp O
no surface antigens
Gp A
A surface antigens
Gp B
B surface antigens
Gp AB
A and B surface antigens
(O,O)
(AA or AO)
(BB or BO)
(AB)
Do not possess antibodies at birth – but exposed AB antigens in food, or bacteria etc and develop
antibodies spontaneously in early life
Gp O → A and B antibodies
Gp A → B antibodies
Gp B → A antibodies
Gp AB → no antibodies
Anti A antibody levels are two times higher than anti B levels.
Antibody levels decline with time (peak at 10 years)
ABO Transfusion Reaction
Antigen transfused
RBC



Antibody serum
recipient
Type II hypersensitivity rx????
Red cell clumping. Small red cell plugs in circulation
Complement activation → lysis of RBC
Opsonisation → phagocytosis (neutrophils and macrophages)
Rhesus
Six Rh factors; C, D, E, c, d, e
Inherit one of each type of factor; C or c and D or d and E or e
D is widely prevalent and most antigenic
Anaemia
Definition:
Reduction in circulating red cell mass below normal limits for individual’s age and gender
Classification
Acute versus chronic
Mechanism: Blood loss (acute/chronic)
hereditary
intrinsic
Increased RBC destruction
acquired
extrinsic
stem cell abnormality
Impaired RBC production
maturation abnormality
By RBC appearance RBC size : micro / normo / macrocytic
RBC pigmentation : hypo/normochrome
Classification by mechanism
1
Blood loss;
acute :
chronic:
2
Increased RBC destruction; Haemolytic anaemias
Intrinsic: hereditary: RBC membrane disorder,
eg Hereditary spherolytosis
RBC enzyme deficiency,
eg GGPD
Disorder RBC synthesis,
eg deficient globulin thalassaemia
eg abnormal globin sickle cell
acquired:
3
trauma, haemorrhage
GIT bleeding, menorrhazia
RBC membrane defect,
eg paroxysmal nocturnal haemoglobinuria
Impaired RBC production
Stem cell disturbance : aplastic anaemia, anaemia of CRF,
Problem with RBC maturation : defective DNA synthesis: ↓B12, folate
defective Hb synthesis : ↓iron
TOPIC
Haematology
Haematology
QUESTION
ESSENTIAL KNOWLEDGE
Discuss
Rhesus
blood Rhesus antigens are antigens occurring on RBCs that are
group and its importance
known to induce clinically significant immunologic disease
via type II hypersensitivity /X. The other common group of
antigens being the ABO group.
6 factors - C, D, E, c, d, e (inherent of each).
- antigen D (Rh+) is widely prevalent and most antigenic
- exposure of Rh- mother to Rh+ blood from foetus →
development of antibodies over 2-4 weeks
Classify the haemolytic Anaemia is decreased oxygen transport capacity of blood
anaemias
secondary to deficiency in RBCs.
Males - Hb < 135gm/ml,
Females – Hb < 120gm/ml
Haemolytic anaemia is increased rate of destruction of
RBCs, characterised by
1 shortened life span of RBCs
2 accumulation of products of HB catabolism
3 marked increased erythropoiesis
Classification (various methods)
1 Extravascular haemolysis (spleen)
2 Intravascular haemolysis
Extravascular haemolysis
- injured or less deformable RBCs
- hereditary sphenocytosis
- sickle cell anaemia
- G6PD deficiency
Intravascular haemolysis
- normal RBCs damaged by mechanical injury (eg
mechanical heart valves, thrombi in microcirculation)
- complement fixation (transfusion of mismatched blood)
- exogenous toxic factors (falcipam and clostridin)
- immune haemolytic anaemias
1
warm antibody type (lymphoma, leukaemia, dwas,
SLE)
2
cold agglutinin type (mycoplasma, EBV, lymphoma)
3
cold haemolysis (paroxysmal cold haemoglobinuria)
NOTES
Subsequent exposure (eg snd
pregnancy) causes serious type
II hypersensitivity /X
→
erythroblastosis
foetalis (jaundice, anaemia
and hepatosplenomegaly)