Author: Renu Maurya

Synthesis Of Immunoglobulins

SYNTHESIS OF IMMUNOGLOBULINS

Q. 1

Which of the following genes involved in the synthesis of immunoglobulins are linked on a single chromosome?

 A

C gene for gamma chain and C gene for alpha chain

 B

C gene for gamma chain and C gene for kappa chain

 C

V gene for kappa chain and C gene for the epsilon chain

 D

V gene for lambda chain and C gene for kappa chain

Q. 1

Which of the following genes involved in the synthesis of immunoglobulins are linked on a single chromosome?

 A

C gene for gamma chain and C gene for alpha chain

 B

C gene for gamma chain and C gene for kappa chain

 C

V gene for kappa chain and C gene for the epsilon chain

 D

V gene for lambda chain and C gene for kappa chain

Ans. A

Explanation:

The genes for the synthesis of the entire heavy chain are present on human chromosome 14.

Of the options given above, the only genes that are present on one chromosome are for the C (constant) regions of the heavy chains.

Remember, the heavy chains determine the identity of the immunoglobulin isotypes: IgG, IgM, IgA, IgD, and IgE.

The C gene for the gamma heavy chain is on chromosome 14 and the C gene for the kappa light chain gene is on chromosome 2.

The V gene for the kappa light chain is on chromosome 2. The C gene for the epsilon heavy chain is on chromosome 14.

The V gene for the lambda light chain gene is on chromosome 22. The C gene for the kappa light chain gene is on chromosome 2.

Ref: Levinson W. (2012). Chapter 58. Cellular Basis of the Immune Response. In W. Levinson (Ed), Review of Medical Microbiology & Immunology, 12e.


Q. 2

Which of the following factors is responsible for deciding whether an antibody or immunoglobulin will remain membrane bound or get secreted?

 A

RNA Splicing

 B

Class Switching

 C

Differential RNA Processing

 D

Allelic Exclusion

Q. 2

Which of the following factors is responsible for deciding whether an antibody or immunoglobulin will remain membrane bound or get secreted?

 A

RNA Splicing

 B

Class Switching

 C

Differential RNA Processing

 D

Allelic Exclusion

Ans. C

Explanation:

Differential RNA processing decides whether an immunoglobulin will remain membrane bound or secreted.

Ref: Textbook of biochemistry by DM Vasudevan3rd edn/page 354.


Q. 3

Synthesis of an immunoglobulin in membrane bound or secretory form is determined by:

 A

One turn to two turn joining rule

 B

Class switching

 C

Differential RNA processing

 D

Allelic exclusion

Q. 3

Synthesis of an immunoglobulin in membrane bound or secretory form is determined by:

 A

One turn to two turn joining rule

 B

Class switching

 C

Differential RNA processing

 D

Allelic exclusion

Ans. C

Explanation:

C i.e. Differential RNA processing

Synthesis and diversity immunoglobin in membrane bound or secretory form is determined by differential/alternative RNA processing of heavy, Kappa and lambda light chains and immunoglobin gene rearrangements.


Q. 4

An Immunoglobulin molecule represents the following level of organized protein structure:

 A

Primary structure

 B

Secondary structure

 C

Tertiary structure

 D

Quartenary structure

Q. 4

An Immunoglobulin molecule represents the following level of organized protein structure:

 A

Primary structure

 B

Secondary structure

 C

Tertiary structure

 D

Quartenary structure

Ans. D

Explanation:

D i.e. Quartenary structure

Discription of all covalent bonds (mainly peptide and disulfide bonds) linking aminoacid residues in a linear structure refers to primary structure of protein.

Secondary structure of protein refers to description of steric relationship (spatial arrangement) between aminoacids located relatively near each other in a selected segment of main polypeptide chain, without regard to the conformation of its side chains or its relationship to other segments. Examples of secondary structures include a-helix, pleated sheet and 13 turns etc. Naturally occurring L-aminoacids can (theoretically) form either right or left handed a-helices, but extended left handed a‑

helices are theoretically less stable and have not been observed in proteinsQ.

Proline and glycine have the least tendency (proclivity) to form a-helicesQ.

Large number of charged aminoacids like aspartate (aspartic acid)Q, glutamate (glutamic acid), arginine, lysine or histidine can also disrupt a-helix by forming ionic bonds or electrostatically repelling each other.

Secondary structure is stabilized by hydrogen bonds & disulfide bonds; Cooperative hydrogen bonding in repeating secondary structures have an important role in guiding the protein folding processQ. However , location of bends (including l turns) in polypeptide chain and the direction and angle of these turns are determined by the numer & location of specific bend

producing aminoacid residues, such as Pro, Thr, Ser, and Gly. Interacting segments of polypeptide chains are held in their characteristic tertiary (3-dimensional) positions by several kinds of weak interactionsQ (mainly hydrophobic bonds,

vanderwall forces, ionic interactions) and sometimes by covalent bonds (such as disulfide cross links) between the segments. Some proteins contain 2 polypeptide chains or subunits which may be identical (homo) or different (hetero). Quarternary structure of protein refers to three dimensional arrangement of these protein subunits. Therefore, homo-or hetero-dimers

formed between 2 polypeptide chains is an example of quaternary structureQ. Similarly an immunoglobin molecule represents hetero-tetrameric quarternary structure between 4 polypeptide (2 heavy + 2 light) chains.


Q. 5

Immunoglobulins are produced by –

 A

Macrophages

 B

B-cells

 C

T-cel Is

 D

NK-cells

Q. 5

Immunoglobulins are produced by –

 A

Macrophages

 B

B-cells

 C

T-cel Is

 D

NK-cells

Ans. B

Explanation:

Ans. is ‘b’ i.e., B-cells+

  • After antigenic stimulation, B-cells form plasma cells that secret immunoglobulin.

Q. 6

The secretory component of immunoglobulin molecule is –

 A

Formed by epithelial cells of lining mucosa

 B

Formed by plasma cell

 C

Formed by epithelial cell and plasma cell

 D

Secreted by bone marrow

Q. 6

The secretory component of immunoglobulin molecule is –

 A

Formed by epithelial cells of lining mucosa

 B

Formed by plasma cell

 C

Formed by epithelial cell and plasma cell

 D

Secreted by bone marrow

Ans. A

Explanation:

Ans. is ‘a’ i.e., Formed by epithelial cells of lining mucosa



Regulation Of Gfr

Regulation Of Gfr


REGULATION OF GLOMERULAR FILTRATION RATE 

RENAL AUTOREGULATION:

  • Property of renal blood flow of being independent of mean systemic arterial pressure is referred as “Autoregulation”.
  • GFR & renal blood flow are usually autoregulated.

Need for autoregulation:

  • Relative constancy maintained for GFR & renal blood flow levels, given higher renal perfusion rate.
  • Precise control of renal excretion of water & solutes.

GFR AUTOREGULATION:

  • Well autoregulated in range of 70-180 mm/Hg systemic pressure
  • Mechanism:
  • Tubuloglomerular feedback.
  • Myogenic feedback.

1. Tubuloglomerular feedback:

Two components:

  • Afferent arteriole feedback mechanism 
  • Usually referred as “Tubuloglomerular feedback

Efferent arteriole feedback mechanism.

Factors:
1. Feedback depends on juxtaglomerular apparatus & its specialized cells.
  • 3 cells types involved:
  • Macula densa –
  • Specialized epithelium of distal tubule in close contact with afferent arteriole.
  • Juxtaglomerular cells –
  • Modified smooth muscle cells of afferent arteriole.
  • Lacis cells
  • 2. Also utilizes Na+ – Cl concentration at macula densa, controlled by renal arteriolar resistance.

Mechanism of action:

1. Afferent arteriolar feedback mechanism:

Steps:
  • ed renal arteriole pressure → low NaCl delivery to distal tubule.
  • Sensed by macula densa, signaling afferent arteriole.
  • Hence, ↓ed afferent arteriole resistance → es glomerular hydrostatic pressure→↑ed GFR.
  • Transmitter involved – Adenosine opens calcium channels
2. Efferent arteriolar feedback mechanism:
Steps:
  • ed GFR → low NaCl delivery to distal tubule, sensed by macula densa.
  • Signals Juxtaglomerular (JG) cells, secreting Renin → activates “renin-angiotensin system”→ Produces angiotensin II.
  • Results in efferent arteriole constriction → ↑es glomerular hydrostatic pressure → ↑ed GFR.
Conclusion: 
  • ed afferent & efferent arteriole resistance → ↑ed GFR
  • Both feedback mechanism GFR according to changes in arterial pressure.
  • Afferent acts directly via macula densa.
  • Efferent also acts via macula densa, yet involves Renin & angiotensin II.
Functions:
  • Ensures relative constant delivery of NaCl to distal tubule
  • Prevents spurious fluctuations renal excretions.

(Note: Tubuloglomerular mechanism & Glomerulotubular balance are different.)

2. Myogenic autoregulation:
  • ed  afferent arteriole resistance → Afferent arteriole constriction → Normal GFR.
  • Arteriole stretching opens “stretch-sensitive Ca2+ channels on arteriolar smooth muscle cells.
  • Results in Ca2+ influx →  causing constriction.
Exam Question 
 

REGULATION OF GLOMERULAR FILTRATION RATE 

  • GFR & renal blood flow are usually autoregulated by, 
  • Tubuloglomerular feedback 
  • Myogenic feedback,

1. Tubuloglomerular feedback:

  • Usually refers, Afferent arteriole feedback mechanism.
1a) Afferent arteriolar feedback mechanism:
  • Transmitter involved – Adenosine causing Ca2+ channel opening.
1b) Efferent arteriolar feedback mechanism:
  • Activates renin-angiotensin system generating angiotensin I efferent arteriole constrictioned GFR.
  • Feedback depends on juxtaglomerular apparatus & its specialized cells.

    Macula densa – Specialized epithelium of distal tubule in close contact with afferent arteriole

    Autoregulation feedback mechanism utilizes Na+ – Cl concentration at macula densa under control of renal arteriolar resistance.

2. Myogenic autoregulation:
  • Arteriole stretching opens “stretch-sensitive Ca2+ channels on arteriolar smooth muscle cells.
  • Results in Ca2+ influx → causing constriction.
Don’t Forget to Solve all the previous Year Question asked on Regulation Of Gfr

Regulation Of Gfr

REGULATION OF GFR

Q. 1

The tubuloglomerular feedback is mediated by:

 A

Sensing of Na+ concentration in the macula densa

 B

Sensing of C1+ concentration in macula densa

 C

Sensing NaCl concentration in the macula densa

 D

Opening up of voltage gated Na+ channels in afferent arteriole

Q. 1

The tubuloglomerular feedback is mediated by:

 A

Sensing of Na+ concentration in the macula densa

 B

Sensing of C1+ concentration in macula densa

 C

Sensing NaCl concentration in the macula densa

 D

Opening up of voltage gated Na+ channels in afferent arteriole

Ans. C

Explanation:

In the tubuloglomerular feedback mechanism, ATP and adenosine form a cascade of signaling molecules that adjust vascular tone to the salt concentration at the macula densa.

Ref: Reviews of Physiology, Biochemistry and Pharmacology By Frank Schweda, Volume 161, 2011, Page 21.

Q. 2

All of the following statements about angiotensin II are TRUE, EXCEPT:

 A

Autoregulation of GFR

 B

Release aldosrerone

 C

Secreted from endothelium

 D

Constriction of afferent arteriole

Q. 2

All of the following statements about angiotensin II are TRUE, EXCEPT:

 A

Autoregulation of GFR

 B

Release aldosrerone

 C

Secreted from endothelium

 D

Constriction of afferent arteriole

Ans. C

Explanation:

Angiotensinogen is the circulating protein substrate from which renin cleaves angiotensin I. It is synthesized in the liver within a few seconds to minutes after formation of angiotensin I, two additional amino acid are split from the angiotensin I to from the 8-amino acid peptide angiotensin II. This conversation occurs almost entirely in the lungs while the blood flows through the small vessels of lungs, catalyzed by an enzyme called angiotensin converting enzyme (ACE) that is present in the endothelium of the lungs vessels. 

 
FUNCTION:
Angiotensin II is an extremely powerful vasoconstrictor. Vasoconstrictor occurs intensely in the arterioles and much less so in the veins. It decrease excretion of both slowly salt and water by the kidneys. This slowly increases the extracellular fluid volume, which then increase the arterial pressure during subsequent hours and days. It exerts important actions at vascular smooth muscle, adrenal cortex, kidney, heart and brain.
 
Act directly on the zona glomerulosa of the adrenal cortex to stimulate aldosterone biosynthesis. At higher concentrations, angiotensin II also stimulates glucocorticoid biosynthesis. Angiotensin II act on the kidney to cause renal vasoconstriction, contraction of mesangial cells with a resultant decrease in GFR increase proximal tubular sodium reabsorption, and inhibit the secretion of renin. In addition to its central effects on blood pressure, angiotensin II acts on the central nervous system to stimulate drinking (dipsogenic effect ) and increase the secretion of vasopressin and adrenocorticotropic hormone (ACTH).
 
Ref: Ganong 23/e, page 670 ; Guyton 11/e, page 201-02,223-24,907

Q. 3

According to myogenic hypothesis of renal autoregulation, the afferent arterioles contract in response to stretch induced by:

 A

No release

 B

Narodrenaline release

 C

Opening of Ca2+ channels

 D

Adenosine release

Q. 3

According to myogenic hypothesis of renal autoregulation, the afferent arterioles contract in response to stretch induced by:

 A

No release

 B

Narodrenaline release

 C

Opening of Ca2+ channels

 D

Adenosine release

Ans. C

Explanation:

C i.e. Opening of Ca2+ channels


Q. 4

The tubuloglomerular feedback is mediated by:

 A

Sensing of Na+ concentration in the macula densa

 B

Sensing of Cl+ concentration in macula densa

 C

Sensing NaCl concentration in the macula densa

 D

Opening up of voltage gated Na+ channels in afferent arteriole

Q. 4

The tubuloglomerular feedback is mediated by:

 A

Sensing of Na+ concentration in the macula densa

 B

Sensing of Cl+ concentration in macula densa

 C

Sensing NaCl concentration in the macula densa

 D

Opening up of voltage gated Na+ channels in afferent arteriole

Ans. C

Explanation:

C i.e. Sensing NaC1 concentration in the macula densa

‘To perform the function of auto regulation, the kidneys have a feed back mechanism (tubuloglomerular feed back) that links changes in sodium chloride concentration at the macula densa (tubular component) with the control of renal arteriolar resistance. (glomerular component).


Q. 5

With increased flow to loop of Henle, decreased in GFR is by ‑

 A

Countercurrent exchanger

 B

Glomerulotubular balance

 C

Tubulo-glomerular feedback

 D

Countercurrent multiplier

Q. 5

With increased flow to loop of Henle, decreased in GFR is by ‑

 A

Countercurrent exchanger

 B

Glomerulotubular balance

 C

Tubulo-glomerular feedback

 D

Countercurrent multiplier

Ans. C

Explanation:

Ans. is ‘c’ i.e., Tubulo-glomerular feedback

Autoregulation of GFR

  • The GFR is normally well autoregulated in the range of 70-180 mm Hg of systemic pressure. Feedback mechanisms intrinsic to the kidney normally keep the renal blood flow and GFR relatively constant, despite marked changes in arterial blood pressure. The relative constancy of GFR and renal blood flow is referred to as autoregulation. The primary function of autoregulation in other tissues (other than kidneys) is to maintain the delivery of oxygen and nutrient at a normal level and to remove the waste products of metabolism, despite changes in arterial pressure. In the kidneys, the non-nal blood flow is much higher than that required for these functions. the major function of autoregulation in the kidney is to maintain a relatively constant GFR and to allow precise control of renal excretion of water and solutes.
  • There are two plausible hypotheses for explaining the autoregulation of GFR (i) Tubuloglomerular feedback hypothesis, and (ii) Myogenic hypothesis.

Tubulo-glomerular feedback

  • To perform the function of autoregulation, the kidneys have a feedback mechanism that links changes in sodium chloride concentration at the macula densa with the control of renal arteriolar resistance. This feedback helps to ensure a relative constant delivery of sodium chloride to the distal tubule and helps prevent spurious fluctuations in renal excretion that would otherwise occur.
  • The tubuloglomerular feedback mechanism has two components that act together to control GFR : – i) An afferent arteriolar feedback mechanism (usually this component is referred to as tubuloglomerular feedback, and ii) An efferent arteriolar feedback mechanism. These feedback mechanisms depend on the juxtaglomerular apparatus which consists of : (i) Macula densa, i.e., specialized epithelium of distal tubule where it comes in contact with afferent arteriole, (ii) Juxtaglomerular cells, i.e., modified smooth muscle cells of afferent arteriole, and iii) Lacis cells.
  1. Afferent arteriolar feedback mechanism : – Decrease in renal arteriolar pressure causes decrease in GFR and as a result low NaCI is delivered to distal tubules. This is sensed by macula densa and the signal is transmitted to afferent arterioles which causes decreased resistance of afferent arterioles. Decreased afferent arteriolar resistance increases glomerular hydrostatic pressure and therefore GFR. The transmitter involves is adenosine which causes opening of Ca*2 channels.
  2. Efferent arteriolar feedback mechanism : – Decreases GFR causes delivery of less NaCl to distal tubule, which is sensed by macula densa cells and the signal is transmitted to juxtaglomerular (JG) cells which secrete renin. As a result renin angiotensin system is activated and there is generation of angiotensin II which causes constriction of efferent arteriole. This results in increased glomerular capillary hydrostatic pressure and increased GFR.
  • Opposite occurs when there is increase arterial pressure and increased GFR. Increased NaCl is delivered to the macula densa which causes constriction of afferent arteriole and decrease,: renin by JG cells with decreased efferent arteriole resistance.
  • It would be wise to know about glomerulotubular balance, which may be confused by tubuloglomerular feedback.
  • Glomerulotubular balance : – Tubular reabsorption in proximal tubules is load-dependent, i.e., when the GFR increase, the reabsorption of the filtrate in the proximal tubule increases proportionately. It occurs because tubular reabsorption is flow-limited. Because of glomerulotubular balance, the urinary Na+ output does not increase massively when the GFR increases.

Myogenic Autoregulation

  • Afferent arterioles constrict in response to augmented blood pressure. Arteriolar constriction restores GFR to normal levels. Possibly, stretching of arterioles leads to the opening of stretch – sensitive Ca+2 channels on arteriolar smooth muscle cells resulting in a Ca+ influx that causes the cells to contract.


Menopause

Menopause


DEFINITION:

  • Menopause is the permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity
  • The symptoms of menopause are best treated with estrogen

INCIDENCE:

  • Physiologic menopause: The normal decline in ovarian function due to ageing begins in most women between ages 45 and 55 on average 51 and result in infrequent ovulation, decreased menstrual function and eventually cessation of menstruation.
  • Pathologic menopause : The gradual or abrupt cessation of menstruation before 40 years occur idiopathically in about 5% of women in USA.
  • The incidence of carcinoma of the breast is increased in woman who Have an early menarche and late menopause

PHASES OF MENOPAUSE

The phases of menopause is usually broken down into four categories:-

  • Pre-menopause: The broad definition of pre-menopause is the time prior to menopause .Peri menopause: A period of women’s life characterized by the physiological changes associated with the end of reproduction capacity and terminating with the completion of menopause also called climacteric
  • The occurrence of menopause before the age of 40 years.
  • Menopausal phase : It is the end of menstruation . The age of menopause ranges between 45 – 55 years , average being 50 years.
  • Post-menopausal : It is defined formally as the time after which a women has experienced 12 consecutive month of amenorrhea without period.

CAUSES OF MENOPAUSE

  • Menopause occurs when the ovaries are totally depleted of eggs and no amount of stimulation from the regulating hormones can force them to work.

PHYSIOLOGICAL CHANGES

  • The lack of estrogen and progesterone causes many changes in women’s physiology that affect their health and well-being . 
  • The symptoms of menopause due to changes in the metabolism of the body.
  • Increased cholesterol level in the blood: Osteoporosis 
  • Hyperlipidemia or an increase in the level of cholesterol and lipids in the blood is common. 
  • This lead to gradual rise in the risk of heart disease and stroke after menopause.
  • Digestive system :constipation
  • Urinary system:↓ estrogen level makes tissue lining the urethra and the bladder drier, thinner and less elastic . This can lead to increased frequency of passing urine as well as an increased tendency to develop UTI.
  • Hair become dry and coarse after menopause
  • There is a decrease in skin elasticity
  • ENDOCRINE:↑ Cholestrol, ↑ Androgen,  ↑ FSH, ↑LH, ↓ estrogen,↑  Gonadotrophins 
  • GENITAL ORGANS
  • uterus become small and fibrotic
  • vaginal and cervical discharge decreases 
  • ovaries become smaller and shriveled in appearance 
  •  The vaginal mucous membrane becomes thin and loses its rugosity after the menopause
  • Decreased secretion make vagina dry
  • The fat in the labia majora and the Mons pubis decreases and pubic hair become spare
  • Voice become deeper due to thickening of vocal cords.
  • VASOMOTOR SYSTEM:Hot flashes , profuse sweating.
  • Night sweat
  • Carcinoma vulva may be Seen after menopause 
  • PSYCHOLOGICAL CHANGES :frequent headache, irritability, fatigue, depression and insomnia 
Exam Question
 
  • Gonadotrophins remain elevated after menopause for Rest of life
  • Average age range of attaining menopause is 45 – 55
  • Absence of menses for last 4 monthsin mid age women with  high serum FSH and LH level & low estradiolcan be diagnosed to have Premature menopause.
  • Carcinoma vulva may be Seen after menopause and Viral predisposition
  • There is a decrease in skin elasticity in menopause
  • Systemic vasomotor instability may be present in meopause
  • There may be an increase in FSH secretion by the pituitary gland in menopause
  • The symptoms of menopause are best treated with estrogen
  • The incidence of carcinoma of the breast is increased in woman who Have an early menarche and late menopause
  • Osteoporosis is seen in Menopause
Don’t Forget to Solve all the previous Year Question asked on Menopause

Composition Of Alveolar Air

Composition Of Alveolar Air


COMPOSITION OF ALVEOLAR AIR

  • Concentrations of gases in alveolar air differ from atmospheric air (inspired air)
  • Atmospheric air contains approximately 21% O2, 79% N2 & 0.04% of CO2.
  • Immediately after inspiration, there is no change in composition.
Factors causing difference:

1. Constant gaseous exchange process

  • Continous removal of oxygen from alveolar air into blood vessels.
  • CO2 addition to alveolar air from blood vessels.

2. Humidification:

  • Dry atmospheric air humidified by upper respiratory passages before alveolar entry.

3. Partial/slow replacement with atmospheric air:

  • Only small amount of fresh air (350 ml) added to alveolar air (2.2 L) during each inspiration.
  • Slow replacement of atmospheric air into alveolar air happens.
  • Advantages:
  • Prevents sudden changes in gas concentrations in blood.
  • Stabilizes respiratory control mechanism.
  • Prevents excessive fluctuation in tissue oxygenation, CO2 concentration, & tissue pH, 
Gaseous concentration & its partial pressure in alveoli:
1. Oxygen: 
Concentration & partial pressure controlled by, 
  • Rate of absorption of O2 into blood
  • Rate of entry of new Ointo lungs by ventilatory process.
Values:
  • Partial pressure of O2 in inspired air (Pi O2)
  • 158 mm Hg
  • Partial pressure of O2 in alveolar air (PO2)
  • 100 mm Hg
  • Calculated by “Alveolar gas equation”.
  • Partial pressure of O2 in expired air (PO2)
  • 116 mm Hg

2. Carbon-di-oxide:

  • Partial pressure of CO2 in inspired air (Pi CO2)
  • 0.3 mm Hg
  • Partial pressure of CO2 in alveolar blood (PA CO2)
  • 40 mm Hg
  • Partial pressure of CO2 in expired air (PE CO2)
  • 32 mm Hg
Exam Question
 

COMPOSITION OF ALVEOLAR AIR

Factors causing difference:

  • Constant gaseous exchange process
  • Humidification:
  • Partial/slow replacement with atmospheric air:
Gaseous concentration & its partial pressure in alveoli:
1. Oxygen:
  • Partial pressure of O2 in inspired air (Pi O2)
  • 158 mm Hg
  • Partial pressure of O2 in alveolar air (PO2)
  • 100 mm Hg
  • Calculated by “Alveolar gas equation”.
  • Partial pressure of O2 in expired air (PO2).
  • 116 mm Hg

2. Carbon-di-oxide:

  • Partial pressure of CO2 in inspired air (Pi CO2)
  • 0.3 mm Hg
  • Partial pressure of CO2 in alveolar blood (PA CO2)
  • 40 mm Hg
  • Partial pressure of CO2 in expired air (PE CO2)
  • 32 mm Hg.
Don’t Forget to Solve all the previous Year Question asked on Composition Of Alveolar Air

Composition Of Alveolar Air

COMPOSITION OF ALVEOLAR AIR

Q. 1

What is the partial pressure for oxygen in the inspired air?

 A

116 mm Hg

 B

158 mm Hg

 C

100 mm Hg

 D

0.3 mm Hg

Q. 1

What is the partial pressure for oxygen in the inspired air?

 A

116 mm Hg

 B

158 mm Hg

 C

100 mm Hg

 D

0.3 mm Hg

Ans. B

Explanation:

Partial pressure of O2 in inspired air (Pi O2) – 158 mm Hg

Gaseous concentration & its partial pressure in alveoli:
1. Oxygen: 
Concentration & partial pressure controlled by, 
  • Rate of absorption of O2 into blood
  • Rate of entry of new O2 into lungs by ventilatory process.
Values:
  • Partial pressure of O2 in inspired air (Pi O2)
    • 158 mm Hg
  • Partial pressure of O2 in alveolar air (PA O2)
    • 100 mm Hg
    • Calculated by “Alveolar gas equation”.
  • Partial pressure of O2 in expired air (PE O2)
    • 116 mm Hg

2. Carbon-di-oxide:

  • Partial pressure of CO2 in inspired air (Pi CO2)
    • 0.3 mm Hg
  • Partial pressure of CO2 in alveolar blood (PA CO2)
    • 40 mm Hg
  • Partial pressure of CO2 in expired air (PE CO2)
    • 32 mm Hg

Q. 2

What is the partial pressure for oxygen in the expired air?

 A

116 mm Hg

 B

158 mm Hg

 C

100 mm Hg

 D

0.3 mm Hg

Q. 2

What is the partial pressure for oxygen in the expired air?

 A

116 mm Hg

 B

158 mm Hg

 C

100 mm Hg

 D

0.3 mm Hg

Ans. A

Explanation:

Partial pressure of O2 in expired air (PE O2) – 116 mm Hg

Gaseous concentration & its partial pressure in alveoli:
1. Oxygen: 
Concentration & partial pressure controlled by, 
  • Rate of absorption of O2 into blood
  • Rate of entry of new O2 into lungs by ventilatory process.
Values:
  • Partial pressure of O2 in inspired air (Pi O2)
    • 158 mm Hg
  • Partial pressure of O2 in alveolar air (PA O2)
    • 100 mm Hg
    • Calculated by “Alveolar gas equation”.
  • Partial pressure of O2 in expired air (PE O2)
    • 116 mm Hg

Q. 3

What is the partial pressure for oxygen in the alveolar air?

 A

116 mm Hg

 B

158 mm Hg

 C

100 mm Hg

 D

0.3 mm Hg

Q. 3

What is the partial pressure for oxygen in the alveolar air?

 A

116 mm Hg

 B

158 mm Hg

 C

100 mm Hg

 D

0.3 mm Hg

Ans. C

Explanation:

Partial pressure of O2 in alveolar air (PA O2) – 100 mm Hg.

Gaseous concentration & its partial pressure in alveoli:
1. Oxygen: 
Concentration & partial pressure controlled by, 
  • Rate of absorption of O2 into blood
  • Rate of entry of new O2 into lungs by ventilatory process.
Values:
  • Partial pressure of O2 in inspired air (Pi O2)
    • 158 mm Hg
  • Partial pressure of O2 in alveolar air (PA O2)
    • 100 mm Hg
    • Calculated by “Alveolar gas equation”.
  • Partial pressure of O2 in expired air (PE O2)
    • 116 mm Hg

Q. 4

What is the partial pressure for carbon-di-oxide in the alveolar blood?

 A

0.3 mm Hg

 B

40 mm Hg

 C

32 mm Hg

 D

158 mm Hg

Q. 4

What is the partial pressure for carbon-di-oxide in the alveolar blood?

 A

0.3 mm Hg

 B

40 mm Hg

 C

32 mm Hg

 D

158 mm Hg

Ans. B

Explanation:

Partial pressure of CO2 in alveolar blood (PA CO2) – 40 mm Hg.

Carbon-di-oxide:

  • Partial pressure of CO2 in inspired air (Pi CO2)
    • 0.3 mm Hg
  • Partial pressure of CO2 in alveolar blood (PA CO2)
    • 40 mm Hg
  • Partial pressure of CO2 in expired air (PE CO2)
    • 32 mm Hg

Q. 5

What is the partial pressure for carbon-di-oxide in the inspired air?

 A

0.3 mm Hg

 B

158 mm Hg

 C

100 mm Hg

 D

32 mm Hg

Q. 5

What is the partial pressure for carbon-di-oxide in the inspired air?

 A

0.3 mm Hg

 B

158 mm Hg

 C

100 mm Hg

 D

32 mm Hg

Ans. A

Explanation:

Partial pressure of CO2 in inspired air (Pi CO2) – 0.3 mm Hg

Carbon-di-oxide:

  • Partial pressure of CO2 in inspired air (Pi CO2)
    • 0.3 mm Hg
  • Partial pressure of CO2 in alveolar blood (PA CO2)
    • 40 mm Hg
  • Partial pressure of CO2 in expired air (PE CO2)
    • 32 mm Hg.

Q. 6

What is the partial pressure for carbon-di-oxide in the expired air?

 A

0.3 mm Hg

 B

158 mm Hg

 C

40 mm Hg

 D

32 mm Hg

Q. 6

What is the partial pressure for carbon-di-oxide in the expired air?

 A

0.3 mm Hg

 B

158 mm Hg

 C

40 mm Hg

 D

32 mm Hg

Ans. D

Explanation:

Partial pressure of CO2 in expired air (PE CO2) – 32 mm Hg

Carbon-di-oxide:

  • Partial pressure of CO2 in inspired air (Pi CO2)
    • 0.3 mm Hg
  • Partial pressure of CO2 in alveolar blood (PA CO2)
    • 40 mm Hg
  • Partial pressure of CO2 in expired air (PE CO2)
    • 32 mm Hg.


Menorrhagia

Menorrhagia


DEFINITION:

  • A complaint of heavy cyclical menstrual blood loss over several consecutive menstrual cycles in a woman of reproductive years, or more objectively, a total menstrual blood loss of more than 80 ml per menstruation.

CLASSIFICATION:

Primary 

  •  Idiopathic / DUB 
  • Ovulatory
  •  Non-ovulatory

Secondary 

  • Uterine and ovarian pathologies
  • Systemic diseases 
  • Iatrogenic causes

ETIOLOGY:

TYPES CAUSES
General Causes
  • Blood dyscrasia:
  • Leukaemia
  • Severe anaemia
  • Coagulopathy:Thyroid dysfunction
  • Thrombocytopenic purpura
  • Coagulation disorders are seen in 20% adolescents
  •  Von Willebrand’s disease.
  • Genital TB
  • Intersitial myoma(Inhibit uterine contraction)
Pelvic Causes
  • PID, pelvic adhesions
  • Uterine fibroids, endometrial hyperplasia
  • Adenomyosis
  • Feminizing tumour or the ovary
  • Endometriosis,Pelvic congestion, varicose veins in the pelvis
  • Retroverted uterus
Contraceptive Use
  • IUCD
  • Post-tubal sterilization
  • Progestogen-only pills
Hormonal/AUB
  • Ovulatory—irregular ripening or irregular shedding
  • Anovulatory—Resting endometrium – 80%
  • Metropathia haemorrhagica

INVESTIGATIONS:

  • Complete haemogram.
  • Bleeding time and clotting time.
  • Thyroid profile as indicated.
  • Pelvic sonography—sonosalpingography.
  • Diagnostic hysteroscopy.
  • Diagnostic laparoscopy.
  • Endometrial study by ultrasound and curettage.
  • Sonosalpingography can delineate a submucous fibroid clearly.
  • Pelvic angiography is required when the cause of menorrhagiais not detected by other means. This shows varicosity and arteriovenous fistula.

MANAGEMENT:

                                          YOUNG WOMEN       OLDER WOMEN
 Contraception not desirable

Contraception desired

  • Combined OCPs
  • Progestogens and other hormones
  • Mirena
  

Rule out cancer &uterine pathology

Progestogens

Ethamsylate, NSAIDs

Estrogen

Tranexamic for 3–4 months

GnRH 3–4 months

 Effective  Fails  Normal uterus (DUB) Uterine pathology 
 

Continue for 6–9 months

Minimal invasive surgery

Hysterectomy with conservation of ovaries

 Progestogens and others

 ↓No response 

Hysterectomy  with removal of ovaries after 50 years

 Surgery
  • Removal of an intrauterine contraceptive device if medical therapy fails.
  • Myomectomy/hysterectomy for uterine fibroids.
  • Wedge resection/hysterectomy for adenomyosis of the uterus.
  • Dilatation and curettage with blood transfusion  is the primary treatment of puberty menorrhagia with low Hb%
  • Laparoscopic lysis of adhesions for chronic PID.
  • Multipara, hypertensive woman with menorrhagia should be treated with MIRENA
  • Electrocautery or laser vaporization of endometriosis and drainage of chocolate cysts in pelvic endometriosis.
  • Hysterectomy with or without removal of the adnexa according to the age and the individual needs of the patient.
  • In patients suffering from bleeding disorders, a haematologist’s opinion should be sought.
  • Uterine artery embolization in varicose vessels.
  •  Von Willebrand’s disease; intravenous desmopressin
Exam Question
 
  • Myomectomy is specifically indicated in an infertiie woman or woman desirous of bearing child and wishing to retain her uterus in severe menorrhagia
  • Fundal myomas commonly present as Menorrhagia
  • Intersitial myomas predispose to menorrhagia by Inhibiting uterine contractility
  • Puberty menorrhagia is treated by Progesterone, estrogen & GnRH analogues
  • Female presenting with dysmenorrhoea & menorrhagia most probably has Endometriosis & Fibroid
  • A woman is said to be have menorrhagia if the menstrual blood loss is more than 80 ml
  • Hysterectomy is the definitive treatment of adenomyosis
  • NSAID’s, Norethesterone & Tranexamic acid are indicated in menorrhagia
  • Dilatation and curettage with blood transfusion  is the primary treatment of puberty menorrhagia with low Hb%
  • Commonest condition associated with menorrhagia is Fibroid
  • Retroverted uterus causes menorrhagia
  • Puberty menorrhagia associated with anovulatory bleeding
  • Puberty menorrhagia Routine screening for bleeding disorder is done
  • Hematinics & Hormone therapy is the treatment of choice for Puberty menorrhagia 
  • A patient comes to you with history of frequent cycles with heavy bleeding. This condition is called Polymenorrhagia
  • Multipara, hypertensive woman with menorrhagia should be treated with MIRENA
  • Adenomyosis  presents with menorrhagia, dysmenorrhia, and an enlarged uterus
  • lUCD of choice in women with menorrhagia Progesterone containing IUCD
Don’t Forget to Solve all the previous Year Question asked on Menorrhagia

Menorrhagia

Menorrhagia

Q. 1

Sucheta, a 29 year old nulliparous women com­plains of severe menorrhagia and lower abdomi­nal pain since 3 months. On examination there was a 14 weeks size uterus with fundal fibroid.

The treatment of choice is :

 A

Myomectomy

 B

GnRH analogues

 C

Hystrectomy

 D

Wait and watch

Q. 1

Sucheta, a 29 year old nulliparous women com­plains of severe menorrhagia and lower abdomi­nal pain since 3 months. On examination there was a 14 weeks size uterus with fundal fibroid.

The treatment of choice is :

 A

Myomectomy

 B

GnRH analogues

 C

Hystrectomy

 D

Wait and watch

Ans. A

Explanation:

Ans. is a i.e. Myomectomy  

First lets see whether we would like to go for medical management or surgical intervention. The patient is presenting with :

  •  Severe menorrhagia°
  • Chronic lower abdomen pain°
  • Size of fihroici = 14 weekca

These 3 indications are strong enough for surgical intervention. Other indications for surgical Management are :

  • Acute pain in abdomen as in Torsion of pedunculated fibroid or prolapsing submucosal fibroid°
  • Pressure symptoms like constipation°
  • Dysuria°
  • Infertilty (when other causes of infertility have been ruled out) and habitual abortion caused by submucous fibroid.°

Now comes the question – whether Myomectomy or hysterectomy should be done.

Indication of Myomectomy : Myomectomy is specifically indicated in an infertiie woman or woman desirous of bearing child and wishing to retain her uterus.

Since, our patient, Sucheta is just 29 years and Nulliparous – Myomectomy should be done.


Q. 2

Fundal myomas commonly present as :

 A

Inversion of uterus

 B

Dysmenorrhoea

 C

Urinary retention

 D

Menorrhagia

Q. 2

Fundal myomas commonly present as :

 A

Inversion of uterus

 B

Dysmenorrhoea

 C

Urinary retention

 D

Menorrhagia

Ans. D

Explanation:

Ans. is d i.e. Menorrhagia

I know many of you might be thinking – Inversion of uterus is the correct option. It is correct that.

Inversion of uterus occurs in a fundal submucous fibroid polyp when it is being extruded. But chronic inversion of the uterus as such is a rare entity. Most common symptom of fundal fibroid like other fibroids is menstrual irregularity­menorrhagia.

The Bottom line is :

  • Most common fibroid causing inversion of uterus is fundal submucous firboid.°
  • But most common symptom of fundal submucous fibroid is menorrhagia.°



Q. 3

Intersitial myomas predispose to menorrhagia by:

 A

Inhibiting uterine contractility

 B

Degeneration

 C

Erosion of endometrial mucosa

 D

Mechanism not known

Q. 3

Intersitial myomas predispose to menorrhagia by:

 A

Inhibiting uterine contractility

 B

Degeneration

 C

Erosion of endometrial mucosa

 D

Mechanism not known

Ans. A

Explanation:

Inhibiting uterine contractility


Q. 4

A 30 year old, para two, with two live children has menorrhagia for 2 years. She was ligated 4 years back. On investigation she is found to have a 2 cm X 2 cm submucous myoma. What will be the best management option for her :

 A

Total abdominal hysterectomy

 B

Danazol 400mg twice daily for 3 months

 C

Gn RH analogues

 D

Hysteroscopic myoma resection

Q. 4

A 30 year old, para two, with two live children has menorrhagia for 2 years. She was ligated 4 years back. On investigation she is found to have a 2 cm X 2 cm submucous myoma. What will be the best management option for her :

 A

Total abdominal hysterectomy

 B

Danazol 400mg twice daily for 3 months

 C

Gn RH analogues

 D

Hysteroscopic myoma resection

Ans. A

Explanation:

Total abdominal hysterectomy


Q. 5

Puberty menorrhagia is treated by :

 A

Progesterone

 B

Progesterone and estrogen

 C

GnRH analogues

 D

All

Q. 5

Puberty menorrhagia is treated by :

 A

Progesterone

 B

Progesterone and estrogen

 C

GnRH analogues

 D

All

Ans. D

Explanation:

Ans. is a, b and c i.e. Progesterone; Progesterone & estrogen; and GnRH analogues 

Most common cause of puberty menorrhagia is Anovulatory cycles – so the girl should be managed initially with

–   Explanation                             – Reassurance                                – Mefenamic acid &

–    Psychological support           – Correction of anaemia                   tranexemic acid

  • In refractory cases: potent progesterone eg. Medroxy progesterone acetate is given until bleeding stops.
  • Progesterone and oral contraceptive pills both are used during episodes of bleeding and later to regularize and control menstrual bleeding.
  • Oestrogen therapy alone yields very good results but is not recommended due to its high dose and side effects and is reserved only for emergency situations.
  • Danazol is contraindicated in young girls as it causes hirsutism.
  • In case hormone therapy fails, curettage of endometrium ican be done to rule out genital TB, (seen in 4% of these young girls) or presence of intrauterine clots.

Use of GnRH analogues :

“For adolescent patients with coagulopathies or malignancy requiring chemotherapy, long term therapeutic amenorrhea with menstrual suppression using GnRH analogues can be achieved.” 

Other therapies :

  • Desmopressin – synthetic analogue of vasopressin is given in case of Von Willebrand disease.
  • In patients not responding to medical therapy – Mirena IUCD is inserted. It causes thining of the endometrium.
  • Rarely when uterine arterio venus aneurysm exists, embolisation of uterine artery is done

Q. 6

A 45 year old female presenting with dysmenorrhoea & menorrhagia most probably has :

 A

DUB

 B

Endometriosis

 C

Fibroid

 D

B and C both

Q. 6

A 45 year old female presenting with dysmenorrhoea & menorrhagia most probably has :

 A

DUB

 B

Endometriosis

 C

Fibroid

 D

B and C both

Ans. D

Explanation:

Ans. is d i.e. Endometriosis; and Fibroid (Most probably)

Well friends, here we will have to weigh each option one by one.

Option “a”  DUB              

  • Especially metropathia hemorrhagica is seen in age group 40 – 45 years which coincides with the age of the patient given in the question.
  • But in DUB (as 80% cases are due to anovulatory bleeding) pain is characteristically absent. Bleeding is always painless and acyclical and continues for 2 – 8 days. In about half the cases it is preceded by a short period of amenorrhea (Metropathia Haemorrhagica).

So, option “a” is ruled out.

Option “b” : Endometriosis

Dysmenorrhea (Secondary and Progressive in nature) and menstrual irregularities including menorrhagia are specifically seen in endometriosis.    

As far as age is concerned.

“Active endometriosis is seen most commonly between the ages of 30 and 40 years. It can however occur at any time between the menarche and the menopause, even before the age of 20 years.”

Option “c”         Fibroid

  • Age group : Seen in women of child bearing age group. Seen in 40% of women above the age of 40 years.
  • Fibroids most commonly cause symptoms between the ages of 35 and 45 years. (So age is consistent with the patients age).
  • Fibroid uterus causes menorrhagia and dysmenorrhea so, the possibility of fibroid is high. 

Option “d” : Endometrial carcinoma

  • It is not a case of endometrial Ca because, endometrial Ca is common in 55 – 60 years 
  • Patient presents with irregular and heavy cycles.

The lower abdominal pain in advanced stage is due to parametrial involvement. (Not dysmenorrhea) .


Q. 7

Which of the following is not indicated in menorrhagia :

 A

NSAID’s

 B

Clomiphene

 C

Norethesterone

 D

Tranexamic acid

Q. 7

Which of the following is not indicated in menorrhagia :

 A

NSAID’s

 B

Clomiphene

 C

Norethesterone

 D

Tranexamic acid

Ans. B

Explanation:

Ans. is b i.e. Clomiphene

Clomiphene is mainly indicated in anovulatory infertility and PCOD.

Medical management of menorrhagia :

  • NSAID’s or prostaglandin synthetase inhibitors
  • Hormones : — Progesterones  — Combined OCP

— Danazol  — Gestrinone, GnRH agonist

— Mifepristone (In Menorrhagia due to fibroids)

  • Antifibrinolytic drugs : Act by inhibiting plasminogen activators, reducing the accelerated fibrinolytic activity found in menorrhagic women.e.g. : Tranexamic acid
  • Ethamsylate : Acts by decreasing capillary fragility.
  • GnRH agonist : They induce down regulation of pituitary with an initial agonist phase followed by down regulation causing hypoestrogenism which results in amenorrhea in 90% cases.
  • SERM-Ormeloxiphene:lt is an antagonist to uterine and breast tissue by its antiestrogenic effects and agonist to bone and CVS.
  • Seasonale-It is a new drug with estrogen & progesterone combined.lt is given daily for 84 days & a gap of 6 days is given after that during which menstruation occurs.



Q. 8

Which one of the following is the primary treatment of puberty menorrhagia in a 16 years old girl with 3 gm% Hb ?

 A

Dilatation and curettage with blood transfusion

 B

Danazol with blood transfusion

 C

Progestogen with blood transfusion

 D

A combination of estrogen and progesterone with blood transfusion

Q. 8

Which one of the following is the primary treatment of puberty menorrhagia in a 16 years old girl with 3 gm% Hb ?

 A

Dilatation and curettage with blood transfusion

 B

Danazol with blood transfusion

 C

Progestogen with blood transfusion

 D

A combination of estrogen and progesterone with blood transfusion

Ans. D

Explanation:

Ans. is d i.e. A combination of estrogen and progesterone with blood transfusion  

Management of Puberty Menorrhagia

Since, it is not mentioned in the question, whether the girl is having severe bleeding / moderate bleeding and I.V. conjugated estrogen with blood transfusion is not given in the options, combination of Estrogen and Progesterone is the next best option.

The girl has Hb = 3 gm%. So, blood transfusion should be done.


Q. 9

Commonest condition associated with menorrhagia is :

 A

Adenomyosis

 B

Fibroid

 C

Granulosa cell tumour

 D

Polycystic ovary 

Q. 9

Commonest condition associated with menorrhagia is :

 A

Adenomyosis

 B

Fibroid

 C

Granulosa cell tumour

 D

Polycystic ovary 

Ans. B

Explanation:

Fibroid


Q. 10

In perimenopausal women with menorrhagia we rule out all carcinoma except :

 A

Ovary

 B

Uterus

 C

Fallopian tube

 D

Endometrium

Q. 10

In perimenopausal women with menorrhagia we rule out all carcinoma except :

 A

Ovary

 B

Uterus

 C

Fallopian tube

 D

Endometrium

Ans. A

Explanation:

Ovary


Q. 11

Which of the following IUD is used for patients with menorrhagia :

 A

CuT 250

 B

Multiload

 C

Nova T

 D

Progestasert (Levonorgestrel)

Q. 11

Which of the following IUD is used for patients with menorrhagia :

 A

CuT 250

 B

Multiload

 C

Nova T

 D

Progestasert (Levonorgestrel)

Ans. D

Explanation:

Progestasert (Levonorgestrel)


Q. 12

Which is true regarding retroverted uterus :

 A

Causes menorrhagia

 

 B

Associated with endometriosis

 C

It is a cause of infertility

 D

All

Q. 12

Which is true regarding retroverted uterus :

 A

Causes menorrhagia

 

 B

Associated with endometriosis

 C

It is a cause of infertility

 D

All

Ans. D

Explanation:

Ans. is a, b and c i.e. Associated with endometriosis; It is a cause of infertility; Causes menorrhagia; and Associated with PID

The usual position of the uterus is one of anteversion and anteflexion, in which the body of the uterus is bent forward at its junction with cervix.

Retroversion is a condition in which axis of cervix is directed upward and backward (instead of forward).

Causes

  • Seen in 20% of patients                                      Mobile retroversion               Fixed retroversion
  • Retroversion can never be                                  • Prolapse                              • PID

congenital (it is always developmental)                        • Puerperium                          • Pelvic tumors

malformation as the uterus is without                           • Fibroid                                   • Chocolate cyst of ovary

version and flexion at birth.                                          • Ovarian cyst                          • Pelvic endometriosis

                                                                                      (pushes uterus backward)

Symptoms :

  • Mobile retroversion is usually symptomless, main disadvantage being increased risk of perforation of the uterus at the time of instrumentation.

Symptoms which can be seen are :

  • Spasmodic dysmenorrhea°
  • Pelvic congestion syndrome causing :

– Congestive dysmenorrhea

–        Polymenorrhagia

–        Premenstrual low backache

–    Dyspareunia (it is the most specific and genuine complain in case of retroversion)

–        Leucorrhoea

  • Infertility as cervix is directed forward away from the seminal pool and the ejaculation of semen directly into the external os.
  • Abortion : can cause abortion between 10th to 14th week.

Treatment :

  • If retroversion is mobile no treatment is required.
  • In patient complaining of dyspareunia backache with retroverted uterus Hodge pessary may be used to keep uterus in anteverted position.
  • Surgical management : – Modified Gilliams operation

Plication of round ligament°

Baldy webster open9tion°


Q. 13

All are true about in puberty menorrhagia Except:

 A

Associated with anovulatory bleeding

 B

Endometrial biopsy confirms diagnosis

 C

Routine screening for bleeding disorder is done

 D

Hematinics & Hormone therapy is the treatment of choice

Q. 13

All are true about in puberty menorrhagia Except:

 A

Associated with anovulatory bleeding

 B

Endometrial biopsy confirms diagnosis

 C

Routine screening for bleeding disorder is done

 D

Hematinics & Hormone therapy is the treatment of choice

Ans. B

Explanation:

Endometrial biopsy confirms diagnosis REF: Novak’s gynecology 13′ edition – page 152

Causes of mennorhagia in adoloscese

  • Anovulatory bleeding
  • Pregnancy-related Bleeding
  • Exogenous Hormones
  • Hematologic Abnormalities
  • Infections
  • Anatomic Causes Obstructive or partially obstructive genital anomalies typically present during adolescence. mUllerian abnormalities, such as obstructing longitudinal vaginal septa or uterus didelphisolycystic ovarian syndrome

Diagnosis

  • Any adolescent with abnormal bleeding should undergo sensitive pregnancy testing, regardless of whether she states that she has had intercourse.
  • Laboratory Testing In addition to a pregnancy test, laboratory testing should include a complete blood count with platelets, coagulation studies, and bleeding time.
  • Thyroid studies also may be appropriate. A complete pelvic examination is appropriate if the patient has been sexually active, is having severe pain, or an anomaly is suspected.
  • Cultures for gonorrhea and testing for chlamydia infection are appropriate if the patient has been sexually active. Some young teens who have a history that is classic for anovulation, who deny sexual activity, and who agree to return for follow-up evaluation may be managed with a limited gynecologic examination and pelvic ultrasonography
  • Imaging Studies If the pregnancy test is positive, pelvic imaging using ultrasonography may be necessary to confirm a viable intrauterine pregnancy and rule out a spontaneous abortion or ectopic pregnancy. If a pelvic mass is suspected on examination, or if the examination is inadequate (more likely to be the case in an adolescent than an older woman) and additional information is required, pelvic ultrasonography may be helpful

Management

  • Management of bleeding abnormalities related to pregnancy, thyroid dysfunction, hepatic abnormalities, hematologic abnormalities, or androgen excess syndromes should be directed to treating the underlying condition. Oral contraceptives can be extremely helpful in managing androgen excess syndromes. After specific diagnoses have been ruled out by appropriate laboratory testing, anovulation or dysfunctional bleeding becomes the diagnosis of exclusion.

Q. 14

A woman is said to be have menorrhagia if the menstrual blood loss is MORE than:

 A

20 ml

 B

40 ml

 C

60 ml

 D

80 ml

Q. 14

A woman is said to be have menorrhagia if the menstrual blood loss is MORE than:

 A

20 ml

 B

40 ml

 C

60 ml

 D

80 ml

Ans. D

Explanation:

Menorrhagia is defined as loss more than 80 ml of blood per cycle and frequently producing anemia. Predictors of menorrhagia includes bleeding resulting in iron deficiency anemia or a need of transfusion, passage of clots more than 1 inch diameter and changing pad or tampon more than hourly. 
  • Normal menstrual bleeding last for an average of 5 days with a mean blood loss of 40 ml.
  • Menorrhagia is defined as bleeding between periods.
  • Polymenorrhea is defined as bleeding that occurs more often than every 21 days.
  • Oligomenorrhea is defined as bleeding that occur less frequently than every 35 days.
Ref: Konkle B. (2012). Chapter 58. Bleeding and Thrombosis. In D.L. Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), Harrison’s Principles of Internal Medicine, 18e.

Q. 15

32 year old lady presented with menorrhagia and dysmenorrhea. What is the definitive treatment of adenomyosis?

 A

Mifepristone

 B

Oral progestins

 C

Hysterectomy

 D

Conservative resection

Q. 15

32 year old lady presented with menorrhagia and dysmenorrhea. What is the definitive treatment of adenomyosis?

 A

Mifepristone

 B

Oral progestins

 C

Hysterectomy

 D

Conservative resection

Ans. C

Explanation:

Hysterectomy is the definitive treatment and as with other conditions, the type of surgical procedure depends on uterine size and associated uterine or abdominopelvic pathology.

Endometrial ablation or resection using hysteroscopy has been used to successfully treat dysmenorrhea and menorrhagia caused by adenomyosis.

Ref: Hoffman B.L., Schorge J.O., Schaffer J.I., Halvorson L.M., Bradshaw K.D., Cunningham F.G., Calver L.E. (2012). Chapter 9. Pelvic Mass. In B.L. Hoffman, J.O. Schorge, J.I. Schaffer, L.M. Halvorson, K.D. Bradshaw, F.G. Cunningham, L.E. Calver (Eds), Williams Gynecology, 2e.


Q. 16

A 27 year old nulliparous woman complains of severe menorrhagia and lower abdominal pain since 4 months. On examination there is a 9 wks size uterus with fundal fibroid. The treatment of choice is:

 A

Myomectomy

 B

GnRh analogues

 C

Hysterectomy

 D

Wait and watch

Q. 16

A 27 year old nulliparous woman complains of severe menorrhagia and lower abdominal pain since 4 months. On examination there is a 9 wks size uterus with fundal fibroid. The treatment of choice is:

 A

Myomectomy

 B

GnRh analogues

 C

Hysterectomy

 D

Wait and watch

Ans. A

Explanation:

Resection of tumors is an option for symptomatic women who desire future childbearing or for those who decline hysterectomy.

This can be performed laparoscopically, hysteroscopically, or via laparotomy incision, and each is described in detail in the surgical atlas.

Myomectomy usually improves pain, infertility, or bleeding.

Menorrhagia improves in approximately 70 to 80 percent of patients following tumor removal.

Ref: Hoffman B.L., Schorge J.O., Schaffer J.I., Halvorson L.M., Bradshaw K.D., Cunningham F.G., Calver L.E. (2012). Chapter 9. Pelvic Mass. In B.L. Hoffman, J.O. Schorge, J.I. Schaffer, L.M. Halvorson, K.D. Bradshaw, F.G. Cunningham, L.E. Calver (Eds), Williams Gynecology, 2e.


Q. 17

Which of the following is not indicated in menorrhagia:

 A

NSAID’s

 B

Clomiphene

 C

Norethesterone

 D

Tranexamic acid

Q. 17

Which of the following is not indicated in menorrhagia:

 A

NSAID’s

 B

Clomiphene

 C

Norethesterone

 D

Tranexamic acid

Ans. B

Explanation:

The chief use of clomiphene citrate is in sterility due to failure of ovulation.

Ref: Essentials of Medical Pharmacology By K D Tripathi, 6th Edition, Page 303 ; Reproductive Endocrinology for The MRCOG and Beyond By Adam H. Balen, 2007, Page 60 ; Textbook of Gynaecology By Shaw, Soutter, Stanton, 2nd Edition, Page 435 ; Shaw’s Textbook of Gynaecology, 12th Edition, Page 242


Q. 18

A patient comes to you with history of frequent cycles with heavy bleeding. This condition is called:

 A

Menorrhagia

 B

Polymenorrhea

 C

Polymenorrhagia

 D

Metrorrhagia

Q. 18

A patient comes to you with history of frequent cycles with heavy bleeding. This condition is called:

 A

Menorrhagia

 B

Polymenorrhea

 C

Polymenorrhagia

 D

Metrorrhagia

Ans. C

Explanation:

Menorrhagia  –  regular cycles with prolonged or heavy bleeding

  • Polymenorrhea  –  frequent cycle with normal bleeding
  • Polymenorrhagia  –  frequent cycles with heavy bleeding
  • Menorrhagia  –  Inter menstrual bleeding
Also know
  • Normal cycle   –    21 – 35 days ( frequency)
  • Normal duration   –     2 – 8 days 
  • Normal volume  –    15 – 80 ml
 
Ref: Essentials of Gynaecology by Lakshmi Seshadri, Edition 1, page – 105.

Q. 19

Which of the following treatments for menorrhagia is NOT supported by evidence?

 A

Tranexamic acid

 B

Ethamsylate

 C

Combined OCP

 D

Norethindrone

Q. 19

Which of the following treatments for menorrhagia is NOT supported by evidence?

 A

Tranexamic acid

 B

Ethamsylate

 C

Combined OCP

 D

Norethindrone

Ans. B

Explanation:

Etamsylate does not have a clinical role in the treatment of menorrhagia.
Its effectiveness varies in randomized trials, and ranges from no reduction in flow to a 50-percent decrease.
 
Medical Treatment of Menorrhagia:
 
Acute Treatment
  • Premarin
  • Combination oral contraceptive pills (COCs)
Chronic Treatment
  • Mefenamic acid
  • Naproxen
  • Ibuprofen
  • Flurbiprofen
  • Meclofenamate
  • COCs
  • Tranexamic acid
  • Norethindrone
  • Danazol
  • GnRH agonists
  • LNG-IUS
Ref: Hoffman B.L., Schorge J.O., Schaffer J.I., Halvorson L.M., Bradshaw K.D., Cunningham F.G., Calver L.E. (2012). Chapter 8. Abnormal Uterine Bleeding. In B.L. Hoffman, J.O. Schorge, J.I. Schaffer, L.M. Halvorson, K.D. Bradshaw, F.G. Cunningham, L.E. Calver (Eds), Williams Gynecology, 2e.

Q. 20

A 48 years old female suffering from severe menorrhagia (DUB) underwent hysterectomy. She wishes to take hormone replacement therapy. Physical examination and breast are normal but X-ray shows osteoporosis. The treatment of choice is:

 A

Progesterone

 B

Estrogen progesterone

 C

Estrogen

 D

None

Q. 20

A 48 years old female suffering from severe menorrhagia (DUB) underwent hysterectomy. She wishes to take hormone replacement therapy. Physical examination and breast are normal but X-ray shows osteoporosis. The treatment of choice is:

 A

Progesterone

 B

Estrogen progesterone

 C

Estrogen

 D

None

Ans. C

Explanation:

Osteoporosis in this patient is due to estrogen deficiency. Estrogens are efficacious when administered orally or transdermally.

Various types of estrogens (conjugated equine estrogens, estradiol, estrone, esterified estrogens, ethinyl estradiol, and mestranol) reduce bone turnover, prevent bone loss, and induce small increases in bone mass of the spine, hip, and total body.

The effects of estrogen are seen in women with natural or surgical menopause and in late postmenopausal women with or without established osteoporosis.

Ref: Lindsay R., Cosman F. (2012). Chapter 354. Osteoporosis. In D.L. Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), Harrison’s Principles of Internal Medicine, 18e.


Q. 21

A 30 yr old multipara, hypertensive woman complaints of menorrhagia. Which is best treatment for her?

 A

Combined pills

 B

MIRENA

 C

Hysterectomy

 D

Transcervical resection of endometrium

Q. 21

A 30 yr old multipara, hypertensive woman complaints of menorrhagia. Which is best treatment for her?

 A

Combined pills

 B

MIRENA

 C

Hysterectomy

 D

Transcervical resection of endometrium

Ans. B

Explanation:

MIRENA is a levonorgestrel containing IUD particularly in elderly parous women assuming that they have no history of PID, ectopic pregnancy, leukemia, sickle cell disease or valvular heart disease.

In this patient MIRENA is the best treatment for her.

It is an effective alternative to hysterectomy to reduce heavy vaginal bleeding.

IUD is not indicated for young nulliparous women due to the potential for dysmenorrhea and high risk of STD.

Combined OCP is a well accepted and safe method of contraception for teens.


Q. 22

The true regarding adenomyosis is:

 A

More common in nullipara

 B

Progestins are the agents of choice for medical management

 C

Presents with menorrhagia, dysmenorrhia, and an enlarged uterus

 D

More common in young women

Q. 22

The true regarding adenomyosis is:

 A

More common in nullipara

 B

Progestins are the agents of choice for medical management

 C

Presents with menorrhagia, dysmenorrhia, and an enlarged uterus

 D

More common in young women

Ans. C

Explanation:

Adenomyosis is a condition characterized by the presence of ectopic glandular tissue found in muscle.

It usually refers to ectopic endometrial tissue (the inner lining of the uterus) within the myometrium (the thick, muscular layer of the uterus).

The condition is typically found in women between the ages of 35 and 50. Patients with adenomyosis can have dysmenorrhea & menorrhagia. In adenomyosis, basal endometrium penetrates into hyperplastic myometrial fibers.

Therefore, unlike functional layer, basal layer does not undergo typical cyclic changes with menstrual cycle. Ref: Current Obstetrics and Gynecology By Gita Ganguly Mukherjee, Sudip Chakravarty, Bhaskar Pal, et al, Jaypee Brothers, Medical Publishers, 2007, Page 274


Q. 23

The coagulation profile in a 13-year old girl with Menorrhagia having von Willebrands disease is ‑

 A

Isolated prolonged PTT with a normal PT

 B

Isolated prolonged PT with a normal PTT

 C

Prolongation of both PT and PTT

 D

Prolongation of thrombin time

Q. 23

The coagulation profile in a 13-year old girl with Menorrhagia having von Willebrands disease is ‑

 A

Isolated prolonged PTT with a normal PT

 B

Isolated prolonged PT with a normal PTT

 C

Prolongation of both PT and PTT

 D

Prolongation of thrombin time

Ans. A

Explanation:

Ans. is ‘a’ i.e., Isolated prolonged PTT with a normal PT

Von Willebrand’s factor acts as a plasma carrier of factor VIII and circulates in the blood as factor VIII-VWF complex. Its deficiency therefore impairs the intrinsic pathway of coagulation and prolongs the PTT as the intrinsic pathway of coagulation remains unimpaired, PT is not altered.

i) Bleeding time

  • It is a not a test for coagulation rather it tests the ability of the vessels to vasoconstrict and the platelets to form a hemostatic plug.

o It is the time taken for a standardized skin puncture to stop bleeding.

o Normal reference value is between 2-9 minutes.

  • Prolongation generally indicates the defect in platelet number or function.

ii) Prothrombin time (PT)

o This assay tests the extrinsic and common coagulation pathway.

  • So, a prolonged PT can result from deficiency of factor V, VII, X, prothrombin or fibrinogen.

iii) Partial thromboplastin time (PTT)

o This assay tests the intrinsic and common coagulation pathways.

  • So, a prolonged PTT. Can results from the deficiency of factor V, VIII, IX, X, XI, XII, prothrombin or fibrinogen.

iv) Thrombin time

  • It is the time taken for clotting to occur when thrombin is added to the plasma.

o It tests the conversion of fibrinogen to fibrin and depends on adequate fibrinogen level.

o Prolonged thrombin time results from decreased level of fibrinogen.


Q. 24

What is thelUCD of choice in women with menorrhagia?

 A

Lippe’s loop

 B

Copper-T 200

 C

Copper-T 3 8 OA

 D

Progesterone containing IUCD

Q. 24

What is thelUCD of choice in women with menorrhagia?

 A

Lippe’s loop

 B

Copper-T 200

 C

Copper-T 3 8 OA

 D

Progesterone containing IUCD

Ans. D

Explanation:

Ans. is ‘d’ i.e., Progesterone containing IUCD 


Q. 25

A 43-year-old woman presented with mild pelvic discomfort, menorrhagia and irregular menstruation for recent 6 months. Physical examination found a firm, non-tender lower abdominal mass arising from the pelvis. Laboratory investigations were unremarkable. Cervical smear did not reveal any malignant cells or atypia. A KUB was performed as an initial investigation.What can be the possible diagnosis?

 

 A

Bladder Carcinoma

 B

Bladder Stones

 C

Endometrial Carcinoma

 D

Uterine Fibroid

Q. 25

A 43-year-old woman presented with mild pelvic discomfort, menorrhagia and irregular menstruation for recent 6 months. Physical examination found a firm, non-tender lower abdominal mass arising from the pelvis. Laboratory investigations were unremarkable. Cervical smear did not reveal any malignant cells or atypia. A KUB was performed as an initial investigation.What can be the possible diagnosis?

 

 A

Bladder Carcinoma

 B

Bladder Stones

 C

Endometrial Carcinoma

 D

Uterine Fibroid

Ans. D

Explanation:

Ans:D.)Uterine Fibroid.

Image shows:KUB shows a large calcified mass in the pelvis (arrows), which is typical for a large calcified fibroid.

UTERINE FIBROID

  • Uterine leiomyoma, also known as uterine fibroid, is benign and the most common gynaecological neoplasm.
  • When they are symptomatic, their usual presentations include: suprapubic mass, pain or menorrhagia.
  • A leiomyoma may undergo calcification as it degenerates, and become visible on plain radiograph.
  • The diagnosis is usually made on ultrasound . On USG, it appears as a well-defined hypoechoic mass in the myometrium of the uterus.

Other differentials of pelvic calcification in a female include dermoid , bladder stones  and phleboliths.



Measurement Of Renal Blood Flow

Measurement Of Renal Blood Flow


MEASUREMENT OF RENAL BLOOD FLOW

  • Renal cortical blood flow is about 5 mL/g of kidney tissue/min (v/s in brain – 0.5 mL/g/min).
  • Yet, low oxygen consumption. 
  • Arteriovenous oxygen difference:
  • In both kidneys – only 14 mL/L of blood.
  • In brain – 62 mL/L.
  • In heart – 114 mL/L.

Renal Plasma & Blood flow:

  • Total renal blood flow (RBF) is approximately 1.1 – 1.3 Lit/min.
  • i.e., 22-25% of cardiac output.
  • Renal blood flow (RBF) is closely related to renal plasma flow (RPF).
  • Renal plasma flow (RPF) – Volume of plasma delivered to kidney per unit time.
Measurement of RPF & RBF:
  • Using Para-aminohipporic acid (PAH)
  • PAH clearance used as a measure for calculating RPF.
Rationale behind:
  • Measurement of RPF should utilize substance with following properties, 
  • Substance should pass freely across glomerular membrane.
  • Be secreted by tubules.
  • Must be completely cleared off by kidney.
  • PAH closely satisfies these criteria.
Portions not secreting PAH:
  • Renal medulla.
  • Perineal fat.
  • Renal capsule.
  • Pelvis & calyces.

IMPORTANT METRICS:

1. Measure of Effective Renal Plasma Flow (ERPF):

  • Is through PAH clearance 
  • In normal adult is about 625 ml/minute

2. Extraction ratio of PAH:

  • 0.9.
  • I.e., Only 90% PAH excreted in single urinary passage via kidney.
  • Remaining 10% RPF is underestimated.
  • Due to lack of PAH secretion in certain renal areas.
  • Hence, Actual RPF is 10 % more than ERPF.
  • Actual RPF calculated by,
  • ERP/(extraction ratio) = 625/0.9
  • i.e., 690 ml/minute
Conclusion:
  • PAH clearance – Measure for ERPF.
  • Actual RPF is 10% more than PAH renal clearance/ERPF.

4. Measure of Renal Blood Flow (RBF):

  • Parameters required:
  • RPF & hematocrit.
  • Renal blood flow – 1273 mL/min.
Exam Question
 

MEASUREMENT OF RENAL BLOOD FLOW

Renal Plasma & Blood flow:

  • Total renal blood flow (RBF) is approximately 1.1 – 1.3 Lit/min
  • i.e., 22-25% of cardiac output
Measurement of RPF & RBF:
  • PAH clearance used as a measure for calculating renal plasma flow.

IMPORTANT METRICS:

1. Measure of Effective Renal Plasma Flow (ERPF):

  • Is through PAH clearance 
  • In normal adult is about 625 ml/minute

2. Extraction ratio of PAH – 0.9

3. Actual RPF – 10 % more than ERPF.

  • 690 ml/minute.
Don’t Forget to Solve all the previous Year Question asked on Measurement Of Renal Blood Flow

Measurement Of Renal Blood Flow

MEASUREMENT OF RENAL BLOOD FLOW

Q. 1

How much of blood flows through the kidneys?

 A

1-1.5 L/min

 B

1.5-2 L/min

 C

2-2.5L/min

 D

2.5-3 L/min

Q. 1

How much of blood flows through the kidneys?

 A

1-1.5 L/min

 B

1.5-2 L/min

 C

2-2.5L/min

 D

2.5-3 L/min

Ans. A

Explanation:

1-1.5 L/min.

  • The total renal blood flow (RBF) is approximately 1.1-1.3 Lit/min.
  • i.e.,22-25% of cardiac output.

Q. 2

Two substances that can probably be used to determine filtration fraction are

 A

Insulin and mannitol

 B

Urea & diodrast

 C

PAH and phenol red

 D

Inulin and PAH

Q. 2

Two substances that can probably be used to determine filtration fraction are

 A

Insulin and mannitol

 B

Urea & diodrast

 C

PAH and phenol red

 D

Inulin and PAH

Ans. D

Explanation:

Inulin and PAH.

  • Filtration fraction – GFR/renal plasma flow.
  • Again, GFR is measured by inulin and renal plasma flow is measured by PAH.

Q. 3

In humans, effective renal blood flow is

 A

425

 B

525

 C

625

 D

725

Q. 3

In humans, effective renal blood flow is

 A

425

 B

525

 C

625

 D

725

Ans. C

Explanation:

625

Measure of Effective Renal Plasma Flow (ERPF):

  • Is through PAH clearance 
  • In normal adult is about 625 ml/minute
  • However, PAH underestimates the effective renal plasma flow by about 10%.
  • Therefore, actual renal plasma flow is about 700 ml/min.


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