Noradrenaline acts as a sympathomimetic effect via alpha as well as a beta receptor. However, they have weak ?2 action.

Natural catecholamines are Adrenaline, Noradrenaline, and Dopamine

Cough is an important defensive reflex that helps clear secretions and particulates from the airways. A complex reflex arc generates each cough.

The cough reflex begins with irritation of the cough receptors present in the epithelium of the trachea, main carina, branching points of large airways, and more distal smaller airways. These receptors are responsive to both mechanical and chemical stimuli.

Afferent pathway:
Impulses from stimulated receptors are transmitted via sensory nerve fibres of the vagus nerve (mainly) and glossopharyngeal nerve and travel to the medulla diffusely. CN 5 is also thought to contribute to the afferent limb. However, the vagus is the main nerve.

Central pathway:
The cough centre is located in the upper brain stem and pons

Efferent pathway:
Impulses from the centre travel via the vagus, phrenic nerve, and spinal motor nerves to the diaphragm, abdominal wall, and muscles.

Carbon dioxide (CO2), is a carbonic gas made up of two dissimilar atoms, namely one carbon atom and two oxygen atoms. Capnography is a technique used to measure carbon dioxide during a respiratory cycle, and it consists in calculating the concentration of the partial pressure of CO2, through the absorption of the infrared light, namely that CO2 absorbs infrared radiation at a wavelength of 4.28 µm.

End-tidal CO2 (ETCO2), referring to the level of the carbon dioxide released at the end of an exhaled breath, is required to be continuously monitored, especially in ventilated patients, as it is a sensitive and a non invasive technique that provides immediate information about ventilation, circulation, and metabolism functions. ETCO2 is normally lower than the arterial partial pressure and varies between 0.6 and 0.7 kPa.

There are two methods used to measure carbon dioxide. The sidestream capnometer method samples gases at a set flow rate (150-200 mL/min) from a sampling area through small diameter tubing, and the mainstream analyser method that uses a direct measurement of the patient exhaled CO2 by a relatively large and heavy sensors. Sidestram method allows the analysis of multiple gases and anaesthetic vapours comparing to the mainstream method that does not allow the measurement of other gases.

External carotid artery originates at the upper border of the thyroid cartilage. It ascends and lies anterior to the internal carotid arteries and posterior to the posterior belly of the digastric muscle and stylohyoid muscle.

The external carotid artery has eight important branches:
Anterior surface:
1. Superior thyroid artery (first branch)
2. Lingual artery
3. Facial artery
Medial branch
4. Ascending pharyngeal artery
Posterior branches
5. Occipital artery
6. Posterior auricular artery
Terminal branches
7. Maxillary artery
8. Superficial temporal artery

A mercury barometer can be used to determine absolute pressure. A glass tube with one closed end serves as the barometer. The open end is inserted into a mercury-filled open vessel. The mercury in the container is pushed into the tube by atmospheric pressure exerted on its surface. Absolute pressure is the distance between the tube’s meniscus and the mercury surface.

Pressure is defined as force in newtons per unit area (F) (A). 

Mass of mercury = area (A) × density (ρ) × length (L)
Pressure = ((A × ρ × L) × 9.8 m/s2)/A
Pressure = ρ × L x 9.8
Pressure is proportional to L

The numerator and denominator of the above equation, area (A), cancel out. The constants are density and the gravitational acceleration value.

The length is proportional to the applied pressure.

The middle cerebral artery is a part of the circle of Willis system of anastomosis within the brain, and the most often affected by brain pathology.

The primary function of the middle cerebral artery is providing oxygenated blood to related regions of the brain. It achieves this by giving off different branches to supply different brain regions, namely:

The cortical branches: which supplies the primary motor and somatosensory cortical areas of some parts of the face, trunk and upper limbs.

The small central branches: which supply the basal ganglia and internal capsule via the lenticulostriate vessels.

The superior division: which supplies the lateral inferior frontal lobe, including the Broca area which is responsible for production of speech, language comprehension, and writing.

The inferior division: which supplies the superior temporal gyrus, including Wernicke’s area which controls speech comprehension and language development.

When the eye is compressed or the extra-ocular muscles are tractioned, the oculocardiac reflex causes a decrease in heart rate.

The ophthalmic division of the trigeminal nerve provides the afferent limb. This synapses with the vagus nerve’s visceral motor nucleus in the brainstem. The efferent signal is carried by the vagus nerve to the heart, where increased parasympathetic tone reduces sinoatrial node output and slows heart rate.

The most common symptom is sinus bradycardia, but junctional rhythm and asystole can also occur.

In patients with an intact hypothalamic-pituitary axis, serial TSH measurements are used to determine the adequacy of treatment with thyroid hormones . changes in TSH levels becoming apparent after approximately eight weeks of therapy with thyroid hormone replacement. Change in T3/T4 levels are seen before changes in TSH .

In patients taking thyroid replacement therapy, the most frequent reason for persistent elevation of serum TSH is poor compliance. Patients who do not regularly take their L-thyroxine try and catch up just before a visit to a clinician for blood test.

Tissue-level unresponsiveness to thyroid hormone is caused by mutation in the gene controlling a receptor for T3 and is rare.

Reduced responsiveness of target tissues to thyroid hormone aka resistance to thyroid hormones (rTH) occurs when there is a mutation in the thyroid hormone receptor ? gene. It is a rare autosomal dominant inherited syndrome of reduced end-organ responsiveness to thyroid hormone and has two types:

Generalised resistance (GrTH)
Pituitary resistance (PrTH)

Patients with rTH have normal or slightly elevated serum thyroid stimulating hormone (TSH) level, elevated serum free thyroxine (FT4) and free triiodothyronine (FT3) concentrations.

Drugs that increase metabolism of thyroxine include:

Warfarin
Rifampin
Phenytoin
Phenobarbital
St John’s Wort
Carbamazepine

These drugs lower circulating thyroid hormones and would be associated with a raised TSH but low T3/T4.

There are different classes of electrical equipment that can be classified in the table below:

Class 1 – provides basic protection only. It must be connected to earth and insulated from the mains supply

Class II – provides double insulation for all equipment. It does not require an earth.

Class III – uses safety extra low voltage (SELV) which does not exceed 24 V AC. There is no risk of gross electrocution but risk of microshock exists.

Type B – All of above with low leakage currents (0.5mA for Class IB, 0.1 mA for Class IIB)

Type BF – Same as with other equipment but has ‘floating circuit’ which means that the equipment applied to patient is isolated from all its other parts.

Type CF – Class I or II equipment with ‘floating circuits’ that is considered to be safe for direct connection with the heart. There are extremely low leakage currents (0.05mA for Class I CF and 0.01mA for Class II CF)

For this patient, his forced expiratory volume in 1 second (FEV1) will decrease at the same rate as a non-smoker.

There is a notable, but slow, decline in FEV1 when an individual reaches the age of 26. An average reduction of 30 mls every year in non-smokers, while a more significant reduction of 50-70 mls is observed in approximately 20% of smokers.

Considering the age of the patient, individuals who begin smoking cessation by the age of 60 are far less likely to achieve normal FEV1 levels, even in the next five years. It is expected that their FEV1 will be approximately 14% less than their peers of the same age.

The area described in the question is supplied by the intercostobrachial nerve, which provides sensory innervation to the portions of the axilla, tail of the breast, lateral chest wall and medial side of the arm.

It is a common for it to be ‘missed’ during administration of local anaesthesia because of its very superficial anatomic course. It may be anesthetized by giving an analgesia from the upper border of the biceps at the anterior axillary fold, to the margin of the triceps by the axillary floor.

Malignant hyperthermia (MH) is a autosomal dominant inherited medical condition which predisposes affected individuals to a clinical syndrome of hypermetabolism which involves abnormal ryanodine receptors in skeletal muscle causing a deregulation of calcium in muscle.

It is a life threatening condition requiring immediate medical intervention. It often lies dormant until triggered in susceptible individuals mostly by volatile inhaled anaesthetic agents and succinylcholine which is a muscle relaxant.

The signs and symptoms of MH are related to this hypermetabolism, which includes an increase in carbon dioxide production, metabolic and respiratory acidosis, accelerated oxygen consumption, heat production, activation of the sympathetic nervous system, hyperkalaemia, disseminated intravascular coagulation (DIC), and multiple organ dysfunction and failure.

Early signs of MH to look out for in patients includes an uptick in end-tidal carbon dioxide (even with increasing minute ventilation), tachycardia, muscle rigidity, tachypnoea, and hyperkalaemia. Later signs include fever, myoglobinuria, and multiple organ failure.

In vitro muscle contracture test (IVCT) is the standard for determining individual susceptibility to MH. It is conducted by measuring the force of muscle contraction after exposing the patient’s muscle sample to halothane and caffeine., the sample is normally taken from the vastus medialis or lateralis under regional anaesthesia.

The deep inguinal ring lies approximately 1.5-2cm above the midpoint of the inguinal ligament, the halfway point between the anterior superior iliac spine and the pubic tubercle, next to the epigastric vessels.

It is an important point in determining the nature of an inguinal hernia (direct or indirect). The patient is asked to cough after the hernia is reduced, with pressure applied to the deep inguinal ring. The hernia reappearing indicates it is direct, moving through the posterior wall of the inguinal canal.

Inferior and lateral to the pubic tubercle is the normal anatomical position of the neck of a femoral hernia.

Superior and medial to the pubic tubercle is the site of the superficial inguinal ring, and the normal anatomical position of the neck of an inguinal hernia.

The mid-inguinal point is located halways between the pubic symphysis and the anterior superior iliac spine. It is the surface marking for taking the femoral pulse.

The upper limb venous drainage is divided into superficial and deep. The superficial veins are accessible to draw blood for investigations. The cephalic, basilic, and median cubital veins are superficial veins.

The median cubital vein connects the cephalic vein and basilic vein. It is located anteriorly in the antecubital fossa and is preferred for venepuncture due to its palpability and ease of access.

The basilic vein and cephalic vein are the primary veins that drain the upper limb. They begin as the dorsal venous arch. The basilic vein originates from the ulnar side, while the cephalic vein originates from the radial side of the dorsal arch of the upper limb.

When using dry soda lime for VOCs, very high amounts of carbon monoxide may be produced, regardless of the inhalational anaesthetic agent used. The carbon monoxide produced is sufficient enough to cause cytotoxic and anaemic hypoxia. To prevent this, soda lime canisters are shaken well to even out the packing of granules. This can help to evenly distribute gas flow for proper CO2 absorption and ventilation.

Compound A is formed when dry soda lime, or soda lime in high temperature, reacts with the inhalational anaesthetic Sevoflurane. Animal studies have shown renal toxicity in rats, but renal adverse effects in humans are yet to be observed.

When monitors are not employed with VOCs, deleterious effects are not for certain. However, monitors not employed with vaporiser inside the circuit (VIC) can lead to significant adverse events.

The femoral triangle is a wedge-shaped area found within the superomedial aspect of the anterior thigh. It is a passageway for structures to leave and enter the anterior thigh.

Superior: Inguinal ligament
Medial: Adductor longus
Lateral: Sartorius
Floor: Iliopsoas, adductor longus and pectineus

The contents include: (medial to lateral)
Femoral vein
Femoral artery-pulse palpated at the mid inguinal point
Femoral nerve
Deep and superficial inguinal lymph nodes
Lateral cutaneous nerve
Great saphenous vein
Femoral branch of the genitofemoral nerve

The posterior pituitary and the hypothalamus are connected by the pituitary stalk. It contains in the pituitary sella and has the optic chiasm and hypothalamus as superior relations.

The anterior pituitary produces thyroid-stimulating hormone (TSH), luteinising hormone (LH) and follicle-stimulating hormone (FSH) . These hormones are Glycoproteins and share a common alpha subunit with unique beta subunits.

The secretion of pituitary hormones are pulsatile. Examples are LH, adrenocorticotropic hormone (ACTH) and growth hormone (GH).

Spirometry measures the total volume of air that can be forced out in one maximum breath, that is the total lung capacity (TLC), to maximal expiration, that is the residual volume (RV).

It is conducted using a spirometer which is capable of measuring lung volumes using techniques of dilution.

During spirometry, the following measurements can be determined:
Forced vital capacity (FVC)/vital capacity (VC): The maximum volume of air exhaled in one single forced breathe.
Forced expiratory volume in one second (FEV1)
FEV1/FVC ratio
Peak expiratory flow (PEF): the maximum amount of air flow exhaled in one blow.
Forced expiratory flow (mid expiratory flow): the flow at 25%, 50% and 75% of FVC
Inspiratory vital capacity (IVC): The maximum volume of air inhaled after a full total expiration.

Anatomical dead space is measured using a single breath nitrogen washout called the Fowler’s method.

Residual volume and total lung capacity are both measured using the body plethysmograph or helium dilution

The functional residual capacity is usually measured using a nitrogen washout or the helium dilution technique.

A prospective randomised double blind controlled trial against cyclizine in multiple centres is the most likely to change your practice.

Case controlled studies are efficient in identifying an association between a drug treatment and outcome and are usually conducted retrospectively. They are generally less valued than prospective randomised trials. They cannot generate incidence data, are subject to bias, have difficult selection of controls and can be made more difficult if note keeping is not reliable.

The gold standard in intervention-based studies is randomised controlled double blind trials. Its features are:

Treating all intervention groups identically
Reduction of bias by random allocation to intervention groups
Patients and researchers unaware of which treatment was given until at completion of study
Patients analysed within the group to which they were allocated, and
Analysis focused on estimating the size of the difference in predefined outcomes between intervention groups.

New healthcare interventions should be evaluated through properly designed randomised controlled trials (though there are some potential ethical disadvantages)

Conducting trials in multiple centres is an accepted way of evaluating a new drug as it may be the only way of recruiting sufficient number of patients within a reasonable time frame to satisfy the objectives of the trial. Type II statistical errors will occur if a small numbers of patients is used in study group.

The ileocolic artery is the terminal branch of the superior mesenteric artery. It supplies:
1. terminal ileum
2. proximal right colon
3. cecum
4. appendix (via its branch of the appendicular artery)

As veins accompany arteries in the mesentery and are lined by lymphatics, high ligation is the norm in cancer resections—the ileocolic artery branches off the SMA near the duodenum.

Gentamicin is a broad-spectrum antibiotic whose mechanism of action involves inhibition of protein synthesis by binding to 30s ribosomes. Its major adverse effect is nephrotoxicity and ototoxicity

Aminoglycoside bind to 30s subunit of ribosome causing misreading of mRNA

Tetracyclines inhibit protein synthesis through reversible binding to bacterial 30s ribosomal subunits, which prevent binding of new incoming amino acids (aminoacyl-tRNA) and thus interfere with peptide growth.

Chloramphenicol binds to the 50s subunit and inhibits peptidyl transferase

Clindamycin binds to the 50s ribosomal subunit of bacteria and disrupts protein synthesis by interfering with the transpeptidation reaction, which thereby inhibits early chain elongation.

Chronic obstructive pulmonary disease (COPD) is an obstructive, inflammatory lung condition. It encompasses symptoms of emphysema, chronic bronchitis and asthma.

Inhaling high dose steroids are prescribed to treat COPD. They are effective at reducing symptoms and improving lung function. They also work to reduce the number of hospitalisations by decreasing the number of acute exacerbation events. Despite providing effective symptom relief, it cannot slow down the decline of FEV1 as COPD is an irreversible condition.

COPD reduces the FEV1 measurements, as well as the FEV1/FVC ratio.

Breathlessness is a major COPD symptom and can occur at any point in the disease progression, including at an FEV1 >50%.

FEV1 is used in COPD staging, and it is classed as follows:
>80%: Mild or stage I
50 – 79%: Moderate or stage II
30 – 49%: Severe or stage III
<30%: Very severe or stage IV
Patients with mild COPD are usually able to manage their condition on their own, however once the disease progresses to moderate, more GP visits are required, with those in the severe category requiring frequent hospitalisation.

Asthma is correlated to an increase in transfer factor. COPD (emphysema) is correlated to a decreased transfer factor.

COPD predisposes to eventual pulmonary hypertension as a result of an increase in pulmonary vascular resistance.

In first order kinetics the rate of elimination is proportional to plasma concentration.

Rate of elimination is described by the following equation:

C = C0. e^-kt

Where:
C=drug concentration,
C0= drug concentration at time zero (extrapolated),
k = rate constant and
t = time.

The initial concentration of this drug is 12 mcg/ml therefore:

The plasma concentration will have halved to 6 mcg/ml at 2 hours.
The plasma concentration will have halved to 3 mcg/ml at 4 hours and
The plasma concentration will have halved to 1.5 mcg/ml t 6 hours.

The total body water content of a 70kg man is (70 × 0.6) = 42 litres. For a woman, the calculation is (70 × 0.55) = 38.5 litres.

For a man, it is subdivided into:

Extracellular fluid (ECF) = 14L (1/3)
Intracellular fluid (ICF) = 28L (2/3).

The ECF volume is further divided into:

Interstitial fluid = 10.5 litres
Plasma = 3 litres
Transcellular fluid (CSF/synovial fluid) = 0.5 litres.

Directly measured fluid compartments:

Heavy water (deuterium) can be used to measure total body water content, which is freely distributed.
Albumin labelled with a radioactive isotope or using a dye called Evans blue can be used to measure Plasma volume . They do not diffuse into red blood cells.
Radiolabelled (Cr-51) red blood cells can be used to measure total erythrocyte volume.
Inulin as the tracer can be used to measure ECF volume as it circulate freely in the interstitial and plasma volumes.

Indirectly measured fluid compartments:

Total blood volume can be calculated with the level of haematocrit and the volume of total circulating red blood cells.
ICF volume can be calculated by subtracting ECF volume from total blood volume.

The first line of defence against acid-base disorder is buffering. The blood mainly utilizes bicarbonate ion (HCO3-) for its buffering capacity (total of 53%, plasma and red blood cells combined).

Strong acids, when acted upon by a buffer, release H+, which then combines to HCO3- and forms carbonic acid (H2CO3). When acted upon by the enzyme carbonic anhydrase, H2CO3 dissociates into H2O and CO.

The rest are the percentage of utilization for the following buffers:
Haemoglobin (by RBCs) – 35%
Plasma proteins (by plasma) – 7%
Organic phosphates (by RBCs) – 3%
Inorganic phosphates (by plasma) – 2%

The shaft of the humerus has two prominent features:
1. Deltoid tuberosity – attachment for the deltoid muscle
2. Radial or spiral groove – The radial nerve and profunda brachii artery lie in the groove

Mid-shaft fractures of the humerus usually occur after a direct blow to the upper arm, which can occur after a fall or RTAs. The most important clinical significance of a mid-shaft humeral fracture is an injury to the radial nerve. The radial nerve originates from the brachial plexus and has roots of C5-T1. It crosses the spiral groove on the posterior side of the shaft of the humerus.
On examination, the patient may have a wrist drop, loss or weakness of finger extension, and decreased or absent sensation to the posterior forearm, digits 1 to 3, and the radial half of the fourth digit.

The following parts of the humerus are in direct contact with the indicated
nerves:
Surgical neck: axillary nerve.
Radial groove: radial nerve.
Distal end of humerus: median nerve.
Medial epicondyle: ulnar nerve.

The basilar artery is a large vessel that is formed by the union of the vertebral arteries at the junction of the medulla and pons. It lies in the pontine cistern and follows a shallow groove on the ventral pontine surface, extending to the upper border of the pons.

The basilar artery then bifurcates into the two posterior cerebral arteries that form part of the Circle of Willis.

The intercostal nerves arise from the ventral rami of the first 11 thoracic spinal nerves. they course along the costal groove on the lower margin of the rib.

The twelfth intercoastal nerve is called the subcostal nerve. This is because it is below the 12th rib.

Each intercostal nerve is connected to a ganglion of the sympathetic trunk from which it carries preganglionic and postganglionic fibres that innervate blood vessels, sweat glands, and muscles.

The lateral and medial pectoral nerves innervates pectoralis major muscle.

Skeletal muscle blood flow is in the range of 1-4 ml/min per 100 g when at rest. Blood flow can reach 50-100 ml/min per 100 g during exercise. With maximal vasodilation, blood flow can increase 20 to 50 times.

The adrenal medulla releases catecholamines and increases neural sympathetic activity during exercise. Normally, alpha-1 and alpha-2 would cause vasoconstriction in the muscle groups being used, but vasodilatory metabolites override these effects, resulting in a so-called functional sympathectomy. Local hypoxia and hypercarbia, nitric oxide, K+ ions, adenosine, and lactate are some of the stimuli that cause vasodilation.

However, the splanchnic and cutaneous circulations, which supply inactive muscles, vasoconstrict.

Sympathetic cholinergic innervation of skeletal muscle arteries is found in some species (such as cats and dogs, but not humans). Vasodilation is induced by stimulating smooth muscle beta-2 adrenoreceptors, but at rest, the alpha-adrenoreceptor effects of adrenaline and noradrenaline predominate. During exercise, the skeletal muscle pump promotes venous emptying, but it does not necessarily increase blood flow.