Presented by 15 Batch 1 Fhcs - Eusl

Presented by 15th Batch 1 FHCS | EUSL
Our Special Thanks goes to,
All the Prestigious academic Staff of The Faculty of Health care sciences, Eastern University, Sri
Lanka for their efforts, disseminating their very best knowledge to the students at all time.
Especially, We thank our Teachers from Human Biology Department and All the instructors
who Helped us in easing our struggle during the period of Online Education.
All Brothers & sisters of our batch for sicerely providing their support amidst their hectic
Schedule. If not for some of our Friends’ altriustic contribution, this would’ve ended
unsuccessful.
To all our seniors for Conserving their knowledge & Guiding us.

With Love,
After years of struggle and hard work to achieve our own dreams, we finally got into the University.
We were eagerly waiting to experience the life which was waiting for us in our faculty, but unfortunately
Corona had other plans. Almost 10 months of our life went sitting in front of the screen and under the roof
without even seeing the university. During this lockdown period, each and everyone had to limit
themselves to Online education. Without being able to step into the University premises, lacking the
valuable guiding of our seniors, we were unaware of the depth of our curriculum. This made us go through
so many hardships.
From the day we stepped into the Faculty premises we had to face so many challenges. The EME
aggregations & Phase 1 examination were the biggest challenges we all feared about.
Nearly 75% of our Exam papers are built up of MCQs & SEQs. So in order to pass this examinations,
having a broad idea about the pattern of Questions is vital. We believe, practising our Past Paper Questions
can yield a positive outcome in this regard.
We have designed these set of Books, compiling the Past Paper Questions. In these books, we have
segregated our Past EME & Phase I Questions along with Answers for each Modules. Through this, we hope
to ease your struggle a bit.
For most of the Questions, we have attached the Answers prepared by our Seniors. And for the
remaining ones, we’ve prepared the answers by ourselves. Especially, we took the Question Collections
prepared by 10th & 11th Batch Seniors for our reference.
So, Please accept our apologies if we have made any mistake while finding the answers.
Also we hope that all the upcoming batches will update this collection annually and continue our Effort.
Wishing you all the very best!!!

- 15th Batch Brothers & Sisters

First Edition : 15th Batch
©15th Medicine, FHCS, EUSL

All Rights Reserved
Don’t make any alterations in this Book without informing the Original Authors

Contents
RESPIRATORY SYSTEM............................................................................................................................. 9
EME QUESTIONS ........................................................................................................................................................ 9
10th Batch (EME) ...................................................................................................................................................... 9
11th Batch (EME) .................................................................................................................................................... 19
12th Batch (EME) .................................................................................................................................................... 29
13th Batch (EME) .................................................................................................................................................... 38
14th Batch (EME) .................................................................................................................................................... 43
15th Batch (EME) .................................................................................................................................................... 51
16th Batch (EME) .................................................................................................................................................... 56
PHASE 01 QUESTIONS ............................................................................................................................................. 63

8th Batch .................................................................................................................................................................. 63
9th Batch .................................................................................................................................................................. 74
10th Batch ................................................................................................................................................................ 88
11th Batch ................................................................................................................................................................ 97
12th Batch .............................................................................................................................................................. 105
13th Batch .............................................................................................................................................................. 113
14th Batch .............................................................................................................................................................. 120
15th Batch .............................................................................................................................................................. 131
CARDIOVASCULAR SYSTEM ............................................................................................................... 138

EME QUESTIONS .................................................................................................................................................... 138
10th Batch (EME) .................................................................................................................................................. 138
11th Batch (EME).................................................................................................................................................... 147
12th Batch (EME).................................................................................................................................................... 157
13th Batch (EME).................................................................................................................................................... 164
14th Batch (EME).................................................................................................................................................... 169
15th Batch (EME).................................................................................................................................................... 177
16th Batch (EME).................................................................................................................................................... 184
PHASE 1 QUESTIONS ............................................................................................................................................. 191

8th Batch ................................................................................................................................................................ 191
9th Batch ................................................................................................................................................................ 199
10th Batch .............................................................................................................................................................. 208
11th Batch .............................................................................................................................................................. 218

12th Batch .............................................................................................................................................................. 227
13th Batch .............................................................................................................................................................. 234
14th Batch .............................................................................................................................................................. 239
15th Batch .............................................................................................................................................................. 245
METABOLISM .......................................................................................................................................... 253

EME QUESTIONS .................................................................................................................................................... 253
10th Batch (EME).................................................................................................................................................... 253
11th Batch (EME) .................................................................................................................................................. 263
12th Batch (EME).................................................................................................................................................... 278
13th Batch (EME).................................................................................................................................................... 291
14th Batch (EME).................................................................................................................................................... 300
15th Batch (EME).................................................................................................................................................... 312
16th Batch (EME).................................................................................................................................................... 319
PHASE 1 QUESTIONS ............................................................................................................................................. 327

8th Batch ................................................................................................................................................................ 327
9th Batch ................................................................................................................................................................ 334
10th Batch .............................................................................................................................................................. 343
11th Batch .............................................................................................................................................................. 356
12th Batch .............................................................................................................................................................. 364
13th Batch .............................................................................................................................................................. 370
14th Batch .............................................................................................................................................................. 377
15th Batch .............................................................................................................................................................. 385
GASTROINTESTINAL SYSTEM ........................................................................................................... 395

EME QUESTIONS .................................................................................................................................................... 395
10th Batch (EME).................................................................................................................................................... 395
11th Batch (EME).................................................................................................................................................... 405
12th Batch (EME).................................................................................................................................................... 417
13th Batch (EME).................................................................................................................................................... 426
14th Batch (EME).................................................................................................................................................... 435
15th Batch (EME).................................................................................................................................................... 442
16th Batch (EME).................................................................................................................................................... 450

PHASE 1 QUESTIONS ............................................................................................................................................. 457
8th Batch ................................................................................................................................................................ 457
9th Batch ................................................................................................................................................................ 466
10th Batch .............................................................................................................................................................. 478
11th Batch .............................................................................................................................................................. 490
12th Batch ............................................................................................................................................................. 500
13th Batch .............................................................................................................................................................. 505
14th Batch .............................................................................................................................................................. 516
15th Batch .............................................................................................................................................................. 522

RESPIRATORY SYSTEM
EME QUESTIONS
10th Batch (EME) – MCQs
1. Regarding paranasal sinuses

A) They contribute to humidification of inspiratory air
B) Frontal sinus present at birth
C) Ethmoidal sinus are grown in the inferior concha
D) Maxillary sinus connects with maxilla
E) Sinus develops up to 8 years
2. Regarding development of respiratory system

A) Lung bud formation is regulated by TBX4
B) Maturation of lung already continuation to 10th years of post natal life
C) All the laryngeal muscles are derivatives of 6th laryngeal pouch
D) Mature lung has about 300million alveoli
E) Bifurcation of trachea occurs at the level of T4 vertebra
3. Regarding larynx
A) Cuneiform cartilage lies in the aryepiglottic fold
B) Movements of crico arytenoid joint facilitate the phonation
C) Free upper border of quadrilateral membrane from the vocal cord
D) Contraction of thyroarytenoid muscle tense vocal cord
E) Injury to bilateral recurrent laryngeal nerve result in hoarse of voice
4. Regarding tracheobronchial tree

A) Lies between C6 and T4
B) Contain C shaped hauling cartilage
C) Left main bronchus wider than right
D) Bifurcation occurs just left to midline
E) Left bronchus longer than right
5. total lung capacity in healthy young

A) Adult is about 2.0L
B) Adult is about 5.0L
C) In children about 4.0L
D) About 3.0L
E) About 1.0L
6. A young lady is observed with her lung volume. Her Tidal volume -800ml, Functional Residual volume - 1800ml,
Vital lung capacity - 3800 ml. The lady,
A) has obstructive airway disease
B) Restrictive lung disease
C) COPD
D) Pneumonia
E) Emphysema
7. Hypoxemia (reduction of oxygen in blood) would be seen in
A) Hypoventilation
B) Hyperventilation
C) COPD
D) Pulmonary edema
E) Ventilation-perfusion mismatch
08. Both hypoxia and hypercapnia would be seen in

A) Hyperventilation
B) Rebreathing from air bag
C) Anemia
D) Pneumonia
E)CO poisoning
9. Changes occurs in high altitude

A) Hyperventilation
B) Alkalosis
C) Shift of O2 Hb dissociation curve to right
D) Formation of 2,3 BPG
E) Secreting erythropoietin
10. Simulation of central chemo receptors occurs in

A) Hypoxia
B) Acidosis
C) hypercapnia
D) Hypoxemia
E) Hypercapnia
SBR
11. A young boy threw a peanut into air and when attempting to caught it in his mouth he inhaled it. Which is the
most likely bronchus and lung lobe that the peanut would have reached?
A) Inhaled into right main bronchus pass to right upper lobe
B) Inhaled into right main bronchus pass to medial lobe
C) Inhaled into right main bronchus pass to upper lobe
D) Inhaled into right main bronchus pass to right posterior lobe
E) Inhaled into left main bronchus pass to left lower lobe
12. A patient consist little amount of fluid in the pleural cavity. The region where the fluid occupied when he sit
sprightly
A) Apex of the lung
B) Middle mediastinum
C) Costodiapghramatic recess
D) Costomediastinal recess
E) Base of the lung

13. Intrapleural pressure in end of the normal inspiration
A) About -2mmHg
B) About -4mmHg
C) Same as atmospheric pressure
D) Same as intra thoracic pressure
E) About +4mmHg
14. Most of carbon dioxide transported as

A) Dissolve state
B) Bicarbonate ion
C) Carbheamoglobin
D) COHb
E) Carbonic acid
15. Regulatory mechanism during exercise more response to A. Partial pressure of oxygen in atrial blood
A)
B) Partial pressure of carbon dioxide in arterial blood
C) Partial pressure of oxygen in venous blood
D) Partial pressure of carbon dioxide in venous blood
E) H+ concentration in arterial blood
10th Batch EME - SEQs
01.write brief accounts on

1.1 Gross anatomy of trachea (30marks)
1.2 Pleura (35 marks)
1.3 8th intercostal space (35 marks)
02. A 60 years old patient with fibrosis of lung came with difficulty in breathing rapid respiration & central
cyanosis. His PaCO2 was 40mmHg & PaO2 was 58mmHg.Explain the physiological basis of following
features that were seen in this patient
2.1 Rapid respiration (35 marks)
2.2 Central cyanosis (35 marks)
2.3 PaO2 was 58mmHg (normal PaO2 = 100mmHg) while PaCO2 was 40mmHg (normal PaCO2 = 40mmHg)
(30 marks)
10th Batch (EME) – MCQ ANSWERS
1
A T They communicate by small apertures with nasal cavity Contribute to warming and humidifying inspired air
They are air filled cavities lined by ciliated epithelium
B F frontal sinus is the only sinus not present at the birth
CF
DT
E F Maxillary and sphenoidal present in rudimentary state at birth Rest become evident at about the 8th year
All become fully formed only in adolescence Ellis – fig.228

2
A T Respiratory diverticulum appear from outer growth of ventral wall of foregut (approximately 4 weeks) TBX4
induces formation of the bud
BT
C F cartilages & muscles – mesenchyme of 4th& 6th pharyngeal arch
Internal lining of larynx – endoderm
D F 480million
E T Tracheal bifurcation – lower border of T4
Angle of louis
3
A T Cuneiform cartilage lies in each margin of aryepiglottic fold
B T Phonation – arytenoid & vocal folds adducted
Lateral cricoarytenoid – close glottis
Posterior cricoarytenoid – only muscle abduct vocal folds
Open glottis
C F Free lower border of quadrangular ligament Form vestibular fold
D F Thyroarytenoid muscle – shorten & relax vocal ligament
E T All intrinsic muscle of larynx – recurrent laryngeal
Except cricothyroid – external laryngeal
External laryngeal nerve paralysis
Paralysis of cricothyroid muscle
Hoarse of voice
Bilateral recurrent laryngeal nerve paralysis
Can’t produce voice
4
A F Trachea – C6 – T4 lower border
Tracheobronchial tree – trachea to terminal bronchioles
B T Only trachea – C shaped (hyaline) 15-20 rings
Bronchus/tertiary bronchioles – irregular cartilaginous rings
C F Right – shorter & wider
Left – longer & narrow
D F Bifurcate in to the right of the midline
E T Left – 5cm
Right – 2.5cm
5
A F Total lung capacity – 5l approximately
BT
C
DF
EF
6
AF
BT
CF
DF
EF

7
A T reduced Ventilation →low Po2 →Hypoxic hypoxia
B F Hypocapnea
C T expiration is difficult – air is trapping alveoli Po2 in Alveoli
D T Gas exchange difficult
E T Causes of Hypoxemia
- congenital heart disease (arteriovenous shunt)
- respiratory failures – pulmonary fibrosis
- ventilation – perfusion imbalance
- pneumothorax or bronchial obstruction that limit ventilation
- abnormalities of the neural mechanism
8
A F in hyperventilation -CO2 wash out –hypercapnia
BT
C F Hb
DT
E F Hypoxia and Hypocapnia
9
AT
Reduce air barometric pressure
Po2 falls about 60mmHg
Hypoxic stimulation of chemo receptors
Hyperventilation
B T CO2 wash out
Respiratory alkalosis occur
CT
D T due to hypoxia high 2,3 BPG
E T Hypoxic stimulation> Kidney secrete Erythropoietin
10
A F Stimulate peripheral chemoreceptors
B T metabolic acidosis cause hyperventiation
C T Hypercapnia >CO2 cross BBB
H+ stimulate central chemoreceptors
D F Reduce (O2 ) in arterial blood
ET
11 A
Superior segment of the right lower lobe Common site for aspiration pneumonia abscess formation
12 C
13 D
34.7 GANONG
14 B
transport by H+ In plasma
1) Dissolved form
2) Formation of carbamino compound with Plasma protein

3) Hydration H+ buffered, HCO3- in Plasma
In RBC
1) Dissolved
2) formation of carbamino Hb
3) Hydration H+ buffer, 70% of HCO3 Enters the plasma
4) Cl- shifts in to cell
15 E
GANONG PG NO 666
The stimulus to ventilation after exercise is not
The arterial PCO2 , which is normal or low or the
Arterial PO2, which is normal or high.
But the Elevated arterial H+ concentration due to the Lactic acidemia
10th Batch EME – SEQ ANSWERS
01.
1.1
Main trunk of the tree
– Neck
– Superior mediastinum
EXTENSION
• C6 –T4
• Lower border of the cricoid cartilage (C6) and terminates by bifurcating at the level of the sternal angle of Louis
(T4/5) to form the right and left main bronchi
• Continue from larynx by attached to the lower margin of the cricoid cartilage by the cricotracheal ligament.
• Total length - 10 cm
5 cm in the neck from the cricoid cartilage to the jugular notch.
CERVICAL PART
• Course & relations
• Lies in the midline of the neck in contact with front of the oesophagus.
• Anteriorly
- isthmus of thyroid gland
- inferior thyroid veins
- sternohyoid and sternothyroid
- thyroidea ima artery - upper end of a large thymus.
• Laterally—
lobes of thyroid gland and cca
• Posteriorly—
oesophagus with RLN in the groove
THORACIC PART
• superior mediastinum relations are:
• Anteriorly—
commencement of BCA and LCCA both arising from the arch of the aorta, the left brachiocephalic(innominate) vein,
and the thymus
• Posteriorly—

oesophagus and LRLN
• Left—
arch of the aorta, LCCA and LSCA and pleura
• Right—
vagus, azygos vein and pleura
Blood Supply
• Upper two thirds - inferior thyroid arteries
• Lower third - bronchial arteries.
• Veins drain to the inferior thyroid vein.
Lymph Drainage
• drains into the pretracheal and paratracheal LNs and the deep cervical nodes.
Nerve Supply
• Sensory supply: vagi and the RLNs.
• Sympathetic nerves supply the trachealis muscle.
1.2
• Serous membrane
• Thin
• Shiny
• Slippery sheath
• Covers
• Lungs - deep into fissures by the visceral pleura
• Inner surface of thoracic cavity by the parietal pleura
• Potential space in between the pleural layers is pleural space (cavity).
Pleural cavity
• Potential space
• Closed sac
• Contains a film of fluid
• Lubricate lung surfaces
• Surface tension provides the cohesion to lungs and wall.
• Extend as pleural recess where it reflects
• Costodiaphragmatic Recesses
• Between costal and diaphragmatic pleurae.
• Fluid can accumulate when in the erect position.
• Costomediastinal Recesses
• Between costal and mediastinal pleurae.
The parietal pleurapleura

• Thicker than the visceral pleura.
• Invest the pulmonary cavities
• Thoracic wall (rib cage and vertebrae)
• Mediastinum
• Diaphragm

• A loose areolar tissue (endothoracic fascia) lines immediately the inner surface of thoracic wall.
• Consists
• costal • Mediastinal • Diaphragmatic • cervical
• Has attachment with • suprapleural membrane • fibrous pericardium (mediastinal)
The visceral pleura

• Covers the lung surfaces.
• Continuous with the parietal pleura at the hilum of the lung.
• Cuff of pleura around the lung root
• Large
• Extends down as – pulmonary ligament
• Provides a “dead space” for
• Descend of lung root during respiration.
• Expansion of pulmonary vein.
Blood supply to the parietal pleura

Arteries:
• Intercostal • Internal thoracic • Musculophrenic
Veins:
• Azygos venous system
Lymph drainage:
• Intercostal, parasternal, diaphragmatic and posterior mediastinal nodes
Blood supply to the visceral pleura

Arteries:
• Bronchial arteries
Veins:
• Bronchial veins
Lymph drainage:
• Lymphatics in lungs
Innervation to the pleura

To parietal pleura:
• Intercostal nerves
• Costovertebral pleura • Peripheral part of diaphragmatic pleura.
• Phrenic nerve
• Mediastinal pleura • Central part of diaphragmatic pleura.
To visceral pleura
• Visceral nerves (autonomic)
1.3
8th intercostal spaces lodges in between 8th and 9th ribs.
Posteriorly 8th and 9th ribs are attached to vertebrae by costotransverse joint and joints of costsl heads Anteriorly.
8th rib attaches with 7th rib,9th rib joints with 8th rib to articulate with the sternum by synovial joint ( intrchondral
joint)
Between 8th and 9th ribs and their costal cartilages

Muscle arrangement
•External intercostal muscle
Fibers run downwards, medially and forwards
After costochondral junction
Muscle is replaced by anterior intercostal membrane(external intercostal membrane)
• Internal intercostal muscle
Fibers run downwards and backwards and laterally
After angle of the rib
Muscle is replaced by posterior intercostal membrane(internal intercostal membrane)
• Innermost intercostal muscle/transversus thoracis muscle
Fibers run downwards, laterally and backwards (same direction of the internal intercostal muscle)
External intercostal muscle

o Origin-lower border of higher rib
o Insertion-outer lip of the upper border of the lower rib
Internal intercostal muscle
o Origin-floor of the costal groove of the higher rib
o Insertion-inner lip of the upper border of the lower rib
Intercostel nerves and vessels lies in the plane between intermediate and inner layers of the muscles under cover of
the lower border of the 8th rib.
Neurovascular bundle Lies in the costal groove of the 8th rib-therefore injections should always be introduced near
the upper border of the rib to protect the neurovascular bundle Arrangement.
from above downwards-vein, artery, nerve(VAN)
Mixed spinal nerves emerged from the intervertebral foramen gives off posterior ramus and the anterior ramus
passes through the intercostal space.
Posterior intercostal artery and intercostal nerve give collateral branches.
8th intercostal nerve and their collateral branches slope downwards behind the costal margin into the neurovascular
plane of the abdominal wall.
The vessels comprise,

2 anterior intercostal arteries and veins
1 posterior intercostal artery and vein
Posterior intercostal artery anastomose with upper anterior intercostal artery at the level of costochondral junction
In the 8th intercostal space
anterior intercostal artery is a branch of musculophrenic artery,posterior intercostal artery arise from descending
thoracic aorta
Posterior intercostal vein drains into azygos vein in right side and hemiazygos and accessory hemiazygos veins in left
side
lymphatics drain to
from posterior part-posterior intercostal nodes
from anterior part-anterior intercostal nodes(internal mammary nodes)
02.
2.1
Respiratory failure is a syndrome in which the respiratory system fails in one or both of its gas exchange functions
such as oxygenation and carbon dioxide elimination.
Since low arterial oxygen tension with a normal arterial CO2 tension this is Type 1 respiratory failure

Type 1 respiratory failure occurs when the respiratory system cannot adequately provide oxygen to the body,
leading to hypoxemia,
Rapid respiration is the consequence of hypoxemia
reduction of PO2 in arterial blood
Hypoxic situation must stimulate peripheral chemoreceptors if ventilation to be increased
Peripheral chemoreceptors in aortic and carotid bodies are
The main sensors for dissolved o2
In those chemoreceptors blood flow per unit of tissue is high
but they receive their O2 supply only from dissolved O2 in blood
When the partial pressure is reduced below 60mmHg
they are stimulated
Up to that level reduction of PO2 doesn’t cause significant increase in respiratory rate
when PO2 decrease
Increase of deoxyhemoglobin binds plasma H+ which brings respiratory inhibition
when PO2 reduces
due to anaerobic glycolysis
Lactic acid is formed
This causes increased [H+] in arterial blood which stimulates
Peripheral chemoreceptors
When stimulated discharge rate via buffer nerves is increased
This increase the discharge rate of respiratory center
In medulla
Respiratory rate and depth is increased
2.2
central cyanosis affects both tongue and extremities
Cyanosis is the dusky, bluish discoloration of skin and mucous membranes due to circulating deoxygenated
Hemoglobin concentration of capillary blood being more than 5g/dl
This depends on 3 main factors
- State of capillary circulation
- Total Hemoglobin concentration
_Degree of unsaturation
In lung fibrosis scar tissue formation in the lung paranchyma
So lung tissue is stiff,hard to expand normally
Decrease surface area for gas exchange
And due to fibrosis increse thickness of respiratory membrane,decrease the oxygen diffusion
Decrease PO2 in arterial blood
Since paO2 is low, So the most likely cause of cyanosis is decreased degree of saturation
When PO2 in arterial blood falls, saturation of Hemoglobin reduce
This is a consequence of hypoxic hypoxia which can be due to
Reduction of alveolar ventilation
when it exceeds a certain degree
deoxygenated Hemoglobin level reaches 5g/dl
This causes central cyanosis which is reflected as discoloration
2.3
Type 1 - (hypoxemic) respiratory failure has a PaO2 < 60 mmHg with normal or subnormal PaCO2.
In this type, the gas exchange is impaired at the level of aveolo-capillary membrane

Defect in the diffusion barrier(diffusion defect)
Lung fibrosis causes lung scarring and thickening in which fibrotic tissue blocks the movement of oxygen from inside
the tiny air sacs in the lungs into the bloodstream
This thickened, stiff lung tissue makes it more difficult for the lung to work properly. This fibrosis makes it harder
for oxygen to pass through the air sacs in the lung which in turn decreases the amount of oxygen that can passes into
the blood stream.
It leads to decrease partial pressure of oxygen.
It is called hypoxia ; however, the remaining normal lung is still sufficient to excrete the carbon dioxide being
produced by tissue metabolism.
This is possible because less functioning lung tissue is required for carbon dioxide excretion than is needed for
oxygenation of the blood.
1. Trachea
A) Commence 5cm of jugular notch
B) Transverse the thoracic inlet downwards and backwards
C) Anteromedially related to superior vena cava
D) Left vagus nerve attach to trachea
E) Is approached to tracheotomy by retracting the suprahyoid muscle
2. T/F regarding to the respiratory system

A) Lung buds appear as an out growth from the ventral wall of the foregut at 5th week
B) All the muscles of larynx are derived from 4th arch
C) Branching of bronchial tree regulated by epithelial mesenchyme interactions
D) Abnormalities in portion of the esophagus result in esophageal atresia
E) The remaining alveoli are formed during the first 10 years of post natal life
3. Which of the following is true during inspiration?

A) Intrapleural pressure is positive
B) The volume in the lung is less than the functional residual capacity (FRC)
C) Alveolar pressure equals atmospheric pressure
D) Alveolar pressure is higher than atmospheric pressure
E) Intrapleural pressure is more negative than it is during expiration
4. T/F regarding oxygen dissociation curve

A) PO2 40mmHg saturation 75%
B) 2,3 DPG increase shift to right
C) Myogloblin increase shift to right
D) CO shift ODC to left
E) Done right shift by Bohr effect
5. Regarding surfactant
A) It is a mixture of phospholipid and protein
B) Secreted by type II alveoli cells

C) Lowers surface tension in smaller alveoli
D) Permits transduction of fluids from blood into alveoli
E) Reduce lung compliance
6. Regarding gas transfer across the alveolar capillary membrane

A) Rate of transfer is proportional to partial pressure gradient across the membrane
B) Rate of transfer is inversely proportional to solubility of gas
C) O2 is perfusion limited
D) CO is diffusion limited
E) O2 diffusion capacity is higher than CO2
7. Which of following is T/F concerning type 1 respiratory failure

A) Can be caused by respiratory muscle weakness
B) CO2 retention occur in 100% O2 therapy
C) Pulmonary hypertension
D) It contributes ventricular failure
E) Mountain sickness
8. Reduction of arterial partial pressure of O2 can be caused

A) Reduced FRC
B) Connective tissue disease
C) Descending below sea level
D) Hyperventilation
E) V/Q mismatch
9. According to physiological dead space

A) It can be decrease by extension of neck
B) Is increase by salbutamol
C) Is measured by Fowler´s method
D) Is the sum of the anatomical dead space and alveolar dead space
E) Normally equals 2.5ml/kg
10. Regarding to larynx

A) Cuneiform cartilage articulate with cricoid cartilage via synovial joint
B) Contraction of lateral crycoarytenoid muscle open the vocal cords
C) Upper border of quadrangular membrane form vestibular fold
D) Injury to internal branch of laryngeal nerve affected pitch of voice
E) Size of larynx is almost same in boys and girls throughout life
SBR
11. In the apical region of lung alveolar pressure of O2 is higher ,what is the best reason for this?
A) Ventilation of apex is higher
B) Apical unit have a greater volume of FRC
C) Basal lung units are better perfuse than apical units
D) Basal units are better ventilated than apical units
E) V/Q of apical unit is greater than basal units

12. Which of the following is the most immediate physiological change in response to acute hypoxia at high
altitude
A) Increase CO
B) Pulmonary embolus
C) V/Q mismatch
D) Polycythemia
E) Raised intra cranial pressure
13. Patient with,

Expiratory volume 800ml
PEEP- 10cm per H2O
Partial pressure – 50cm per H2O
What is the approximate lung compliance?
A) 0.2 ml/cm H2O
B) 2 ml/cm H2O
C) 20 ml/cm H2O
D) 200 ml/cm H2O
E) 400 ml/cm H2O
14. A 30-year patient with pneumonia compliant painful breath of doctor suggest involvement of parietal pleura;
Which nerve supply parietal pleura?
A) Phrenic and intercostal
B) Vagus and intercostal
C) Vagus and phrenic
D) Greater splenic and intercostal
E) Phrenic and splenic phrenic
15. During dental procedure while patient in up right position, he aspirate some object and lead to aspiration
pneumonia; what is the most common sight of lung for this kind of aspiration
A) Left upper lobe
B) Right apical lower lob
C) Right posterior basal
D) Superior lingual
E) Right anterior basal segment
11th Batch (EME) - SEQs
1.
1.1 Define hypoxia? (10 marks)
1.2 Enumerate the types of hypoxia, indicating how the arterial and mixed venous values
for oxygen saturation are affected in each situation? (20 marks)
1.3 Indicate the main causes of hypoxia with special emphasis on hypoxic hypoxia? (25 marks)
1.4 Explain the major physiological consequences of hypoxemia? (45 marks)
2.
40 year- old soldier who confronted in a war had a gunshot injury in the right side chest. Suddenly
experienced severe pain in the same side. Further, he was breathless, and come in a state of shock. On examination
it was found that his trachea was deviated to left side above the jugular notch and the right lung was collapsed.
2.1 State the possible diagnosis (10 marks)
2.2 Outline the surface marking of the right lung. (15 marks)
2.3 Describe the gross anatomy of right lung. (35 marks)
2.4 Write an account on
2.4.1. Bronchopulmonary segment (20 marks)
2.4.2. Reflections of cervical pleura (20 marks)
1.
A T Commence at C6 (Last’s 12th E.) 5cm above the jugular notch 10cm long
B T Passes downward & backward behind the manubrium
C F Right brachiocephalic vein and SVC are anterolateral to trachea
D F Right side vagus nerve is in contact with trachea but Left common carotid artery and subclavian artery prevent
the left vagus from coming into contact with trachea
E By retracting infrahyoid muscle
2.
A F Appears as outgrowth from the ventral wall of the foregut at 4th week
B F Laryngeal cartilage – 4th and 6th arches Intrinsic muscles of larynx – 4th arch (except cricothyroid)
CT
D T Esophageal atretia with tracheo-esophageal fistula (langman’s pg;219-13th
E) T About 1/6 of alveolar are formed at birth
3.
A F Intrapleural is always negative
B F Quit breathing = Functional residual capacity+ Tidal volume Forced inspiration= Functional residual capacity+
Tidal volume+ Inspiratory reserve volume
CF
DF
E T Intrapleural pressure at
Normal = -2.5Hgmm
Inspiration = -6Hgmm
Strong inspiration = -30Hgmm
4.
AT
BT
CF
DT
E T At tissue level- Bhor effect (Ganong’s pg;641 25th E) At lung level Haldane effect (Ganong’s pg;642 25th E
5.
AT
Components of surfactant
1) Phospholipids a) Dipalmitoylphosphatidylcholine (DPPC) b) Phosphatidylglycerol
2) Proteins
3) Lipids
Phospholipid + protein = decrease surface tension
BT
Produce by type 2 pneumocytes
C F P = 2T/r ‫ ؞‬if P icreases r will decrease
To prevent fluctuation in the pressure decreased r , highT, to maintain P
D F No function in fluid transport
E F Increase lung compliance
6.
A T Diffusion capacity ∝ Solubility , not the pressure gradient
BF
CT
DT-
E F CO2 diffusion = 20 times than O2 diffusion
7.
AT
BF
CT
DT
ET
8.
AT
B T Connective tissue disease- emphysema
C T Breath holding high PCO2(artery) , low PO2(artery)
DF
ET
9.
A
B T Salbutamol act as beta agonist which cause bronchiolar dilatation
C T N2 washout is a test for measuring anatomical dead space in the lung during a respiratory cycle
D T Physiological dead space = Anatomical dead space + Alveolar dead space
EF
10.
A F Arachinoid cartilage is articulate with cricoid cartilage
B F Function is close the glottis
C T Last’s pg; 393 12th Edition
D F Internal laryngeal nerve supply the mucous membrane above the larynx and above the level of the vocal fold
E F Change after the puberty
BEST ANSWERS
11 C
Ventilation – base > apex (because alveoli in lung already expanded)

Perfusion – base > apex (mostly due to gravity)
answer
AF
BF
CT
DT
ET
But best answer is C due to perfusion most of O2 in alveoli diffuse into pulmonary vessels
12 C
In high altitude
immediate-Increase cardiac output,Increase respiratory rate/hyperventilation
Prolonged-Polychythemia,increase intracranial pressure
13 C
14 A
Parietal pleura
Costal- intercostal nerves
Mediastinal + diaphragmatic – phrenic nerves
15 B
Right bronchus short and vertical than the left one
11th Batch (EME) – SEQ ANSWERS
01.
1.1
Deficiency of O2 at tissue level
1.2
1. Hypoxic hypoxia
PaO2 reduced
So, SaO2 reduced
SvO2 reduced
2. Anemic hypoxia
PaO2 normal
[Hb] reduced
So, SaO2 reduced
SvO2 reduced
3. Stagnant hypoxia
PaO2 normal
Low cardiac output/perfusion
So, SaO2 normal
But SvO2 markedly reduced due to high oxygen extraction
4. Histotoxic hypoxia

PaO2 normal
So, SaO2 normal
SvO2 increases
Tissue can’t utilize the O2
1.3
0 1. Hypoxic hypoxia
Reduced arterial PO2
Causes
1. High altitude
PaO2 decrease
Hypoxic stimulation
Increased respiration
Hyperventilation leads to respiratory alkalosis
2. COPD
Emphysema
Asthma
3. Respiratory muscle paralysis
4. Restrictive lung disease
Pulmonary fibrosis
Pneumothorax
Reduced Compliance of the lung affect the respiration
5. Depression of respiratory centers
6. V/Q mismatch
Low V/Q - shunt
High V/Q - dead space
02. Anemic hypoxia

[Hb] low
PaO2 normal
*anemia
*CO poisoning (Increased Affinity of O2 so O2 release at tissue level is less)
03. Stagnant hypoxia

Due to low circulation
* low CO in heart failure
* hyper perfusion ex:- renal artery stenosis, pulmonary embolism.
04. histotoxic hypoxia

Inhibition of tissue oxidative process
*CN- poisoning
Inhibit cytochrome oxidase enzymes in ETC
Cannot use O2 in blood
1.4
Hypoxemia
Low PaO2 in blood
Occur due to hypoxic hypoxia

Stimulus - low PaO2 (below 60 mmHg in arterial blood )
Can detect via peripheral chemoreceptors
Receptor - In aortic body
Carotid body
Afferent - CN IX
CN X
Center - inform the inspiratory center in the medulla oblongata
Efferent - Phrenic nerve
Intercostal nerve
Effectors - Diaphragm
Intercostal muscles
Increased respiration by increasing respiratory rate (hyperventilation)
High PaO2
Low PCO2 ( CO2 washed )
Oxygen hemoglobin dissociation curve

Low O2 move ODC to right
Release O2 at tissue level increases
Reduced O2 level in blood
Sense chemoreceptors
Inform to cardiac regulatory center
Increased Sympathetic discharge
Increased heart rate
Increased Cardiac output (High perfusion to the tissues)
High BP ( high perfusion pressure)
Hypoxemia associated with hypercapnia
High CO2 (activate the central chemoreceptor in medulla oblongata)
Increased respiration ( highCO2 H+ cross BBB)
02.
2.1. Tension pneumothorax
2.2.
o Apex 2.5 cm above the clavicle (between junction of middle and medial 1/3rd )
o Anterior border of right lung lie within the lateral margin of sternum.
o Lower border lie horizontally around chest wall, 2 ribs higher than pleural reflection.
6th rib level – mid clavicular line
8th rib level– mid axillary line
10th rib level– lateral border of erector spinae muscle
o Hilum – behind 3rd and 4th costal cartilages and sternal margin
o Oblique fissure-line joining T3 vertebral spine and 6th rib at mid clavicular line
o Horizontal fissure - 4th costal cartilage overlies it
2.3
o Lungs are vital organs
o There are two lungs. Right and left
o Right lung- within the thoracic cavity, laterally right side

o Surrounded by visceral layer of pleura
o Has
Principle bronchus (right)
Pulmonary artery
o 02 pulmonary veins
o Surface
Mottled
Pink or gray
Crepitate to touch
o 03 surfaces
Costal- convex
Diaphragmatic- concave
Mediastinal- has impressions
o 03 borders
Anterior, posterior, inferior
o Has apex and base
o Hilum- region bronchi and pulmonary vessels
Enter or leave
Wedge shaped area
Right hilum is large
o Lung roots- both L and R lung roots similar but not identical
o In right lung root
Upper part- pulmonary artery
Below it- right bronchus
Two pulmonary veins in front and below bronchus
o Bronchus and pulmonary artery branch to upper lobe originate outside the lung
o Vagus nerve pass posterior to the lung root
o Phrenic nerve pass anterior to the lung root
o Right lung
Large and heavier than left
Shorter and wider
Anterior border relatively straight
o 03 lobes
Superior , middle , inferior o 02 fissures
Oblique- separate upper and lower lobes
Horizontal-only in right lung Separate middle lobe from upper
o Impressions on right lung
Groove for esophagus
Cardiac impression
Groove for azygous vein
Groove for IVC
Shallow groove for trachea and R. vagus
Groove for subclavian artery
Groove for brachiocephalic vein
o Blood supply
Arteries- 01 bronchial artery branch of 3rd right posterior intercostal artery
Veins- superficial bronchial veins-azygous vein
Deep system- to pulmonary vein

o Lymph drainage
To bronchopulmonary or hila nodes- to brachiocephalic nodes
o Nerve supply
Cardiac plexus ,Thoracic vagus,Sympathetic chain >autonomic nerves>yo pulmonary plexus> Pass with bronchial
vessels in to lung
2.4.1.
Bronchopulmonary segments
o 10 segments in each lung
o Therefore 10 segmental bronchi
o Roughly pyramidal in shape
o Apex toward the hilum
o Base toward the surface of the lung
o There are given same names and numbers as segmental bronchi
o Each segment separated by fibrous septa
o Each segments are separately supplied by
Single segmental bronchi
A branch of pulmonary artery (run along with segmental bronchi)
Bronchial arteries
* Pulmonary veins are tributaries which do not closely follow bronchi Tend to run in intersegmental septa
Clinical
*material aspirated by a supine comatose or anesthetized patient would tend to gravitate into superior segment of
right lower lobe
2.4.2.
Pleural reflections
o Slopes downward from sternoclavicular joint
o 2nd rib level
Meet opposite pleura , lying together or overlapping
o Pass vertically downward behind sternum
o 4th costal cartilage level
R. pleura continues vertically
L. pleura arches out and descends lateral to sternal border , halfway to apex of heart
o 6th costal cartilage level
Each turns laterally
o 8th rib level
Pass around chest wall across mid clavicular line
o 10th rib level
Mid axillary line
o 12th rib level
Lower border cross at lateral border of erecter spinae
Pass horizontally to lower border of 12th thoracic vertebrae

12th Batch (EME) - MCQs
1. Regarding pleura,
A) Parietal pleura is attached to inferior surface of the supra pleural membrane
B) Usually both pleural sacs communicate with each other
C) Supplied by vagus nerve
D) Separated from thoracic wall by endothoracic fascia
E) Fissures of the lungs are spaces
2. Lateral wall of nasal cavity,

A) Inferior conchae is the largest and broadest conchae
B) Middle meatus connect with frontal sinus
C) Naso-lacrimal duct opens into posterior part of inferior meatus
D) Drainage of maxillary sinus always accessed to inferior meatus
E) Sphenoid sinus open into superior nasal meatus
3. Vocal cord,
A) Control voice production
B) Attach between thyroid cartilage and vocal process of arytenoid cartilage
C) Blood supply than vestibular fold
D) Vocalis muscle is a tensor
E) It is tensed by Vocalis muscle
4. During normal breathing, partial pressure of,

A) PO2 high in alveoli than expiratory air
B) PCO2 in alveolar higher than expiratory air
C) Water vapor pressure in alveoli higher than room
D) CO2 in alveolar air is equal 40mmHg
E) Water vapor in alveolar air is variable
5. What changes systematic circulation,

A) pH rise
B) Increase PCO2
C) Increase PO2
D) Decrease Cl- in RBC
E) Pressure increases
6. Respiratory center,
A) Locate in hypothalamus
B) Stimulate inspiratory muscles during quite breathing
C) Stimulate expiratory muscles during quite breathing
D) Involving swallowing reflexes
E) Involving vomiting reflexes
7. Regarding surfactant,
A) Decreased in premature babies
B) Increase surface tension of fluid lining of alveolar wall
C) Increase lung compliance

D) Increase in amount when pulmonary blood flow is interrupted
E) Increase amount in fetal circulation in last week of pregnancy.
8. In high altitude at low atmospheric pressure what are increase there?

A) Pulmonary ventilation
B) Alveolar water vapor
C) Arteriolar PO2
D) Arterial PO2
E) Cerebral blood flow
9. Work of breathing is increased when,

A) Increase in compliance
B) During exercise
C) The subject lie down
D) The rate of breathing increase
E) Bronchoconstriction
10. Decompression sickness,

A) Is increased in mountings
B) Occurs when a diver ascends
C) Occurs when descending rapidly in an air craft
D) May be accompanied by air embolism
E) Due to decrease PN2
SBR
11. What is the intrapleural pressure at the beginning of inspiration?

A) 5
B) -5
C) -2.5
D) -7.5
E) 0
12. Highest CO2 % Present in,

A) Atmospheric air
B) Alveolar air
C) Dead space air
D) Expired air
E) Inspired air
13. Amount of CO2 removed from lung per 100ml of blood?

A) 10ml
B) 48ml
C) 4ml
D) 48ml
E) 52ml
14. Pleura surface marking of lungs the oblique fissure meet the axillary line,

A) At 4th rib
B) 5th rib
C) 6th rib
D) 7th rib
E) 5th costal cartilage
15. A 60-year old man is heavy smoker. His voice like hoarseness voice. His upper lobe of the left is mass.in this
features what can be affected?
A) Bronchomediastinum
B) Parasternal
C) Trachiobronchial
D) Bronchopulmonory nodes
E) Internal mammary nodes
1.
1.1. Briefly describe chemical control of respiration. (50 marks)
1.2. Explain the mechanism of hypoxia in pulmonary oedema. (50 marks)
2.
2.1. Describe course, relations and nerve supply of trachea. (25 marks)
2.2. Outline the development and congenital anomalies of trachea. (25 marks)
2.3. Write an account on
2.3.1. Hilum of left lung (25 marks)
2.3.2. Cervical pleura (25 marks)
01.
AT
B F Do not communicate
C F Supplied by parietal - mediastinal → phrenic nerve
- costal → intercostal nerve
D T Parietal pleura
EF Lined by visceral pleura
Pleural cavity is a potential space
02.
AT
BT
C F Anterior part
D F To middle meatus
E F Lie above the superior choncha
03.

A T Change the pitch
BT
C F No blood supply
DT
ET
04.
AF
BT
CT
DT
E T Depend on humidity
05.
AT
BT
CF
D T Decreased Cl- in RBC means decreased HCO3- in blood
ET
06.
AF
B T Inspiration – active
Quite expiration – passive
CF
D T Cease at mid inspiration
ET
07.
AT
B F Decreased surface tension
CT
D F Pulmonary oedema → decreased surfactant
ET
08.
AT
BT
C F After compensation. Somewhat increased
DF
E T Lead to cerebral oedema
09.
A F Increased compliance → decreased work of breathing
BT
CF
DT
E T Increased airway resistance

10.
A T High altitude
B T Scuba diving
96
C T Aerospace events
D T N2 air bubbles for
E F Due to decreased in atmospheric pressure. Which cause air bubble formation
SBR
11 C Expiration → inspiration → deep inspiration

-2.5mmHg -06mmHg -30mmHg
12 B
13 C
14 B
15 D Lymphatic plexus → bronchopulmonary → tracheobronchial
1.
1.1. Chemical regulation of respiration
Chemical changes in the blood detected by chemoreceptors
I. Peripheral chemoreceptors
Increased CO2
↓
Stimulate carotid and aortic bodies
CN Ⅸ
CN Ⅹ
To inspiratory center
Phrenic nerve
Intercostal nerve
To diaphragm and intercostal muscle
Increased the Respiratory rate

Respiratory depth
Mostly peripheral chemoreceptors sense the hypoxemia
II. Central chemoreceptors

Main respiratory regulator
Metabolism ∝ ventilation
Increased H+
in the body ; cannot directly increased the respiration. Because H+ cannot cross the blood brain barrier (BBB)
So,

H+ + HCO3- → H2CO3 → CO2+H2O
CO2 can cross the BBB.
Within the cerebro-spinal fluid,

CO2 + H2O → H2CO3 → H+ + HCO3-
↓
stimulate the central chemoreceptors in medulla oblongata
↓
increased the respiration
ex; metabolic acidosis/diabetes mellitus
increased H+ → increased respiration → hyperventilation
(‘kussmaul breathing’ – respiratory compensation)
1.2. pulmonary edema

fluid within the alveoli
I. fluid inside the alveoli reduce the surfactant concentration. Which leads to decreased lung
compliance
II. normally alveolar capillary membrane is very thin
in this condition capillary membrane thickness is increased. So O2 cannot diffuse easily into the blood
(but CO2 is ×20 times soluble than O2)
III. V/Q mismatch
asted

the cardiac output
(increased the tissue perfusion)
2.
2.1. Trachea
Cervical part
Cervical part
- esophagus
- carotid sheath
ior jugular venous arch
– in the groove between trachea and esophagus
– adherent to 2nd, 3rd , and 4th tracheal rings

– lie against lateral sides of trachea as far down as 6th ring.
Thoracic part
vertebra.
Posteriorly
Anteriorly

ommon carotid artery
Right side
(in contact with trachea, separated from right lung by pleura and arch of azygous vein)
Left side
(prevent pleura and left vagus from coming into contact with trachea
– curves backward over left bronchus

– pass upward in groove between trachea and esophagus
– branches into right and left arteries
- To the left of tracheal bifurcation in front of left bronchus
– crosses midline (in front of esophagus)
-Just below tracheal bifurcation.
Nerve supply
Afferent (including pain) fibers from vagi and recurrent laryngeal nerves
mooth muscles and blood vessels
Sympathetic fibers from upper ganglia of sympathetic trunk
2.
2.2. Abnormalities in partitioning of the esophagus and trachea by the tracheoesophageal septum

2.3.
2.3.1. Hilum of left lung
One in front and the other below the bronchus

Enclosed by a sleeve of pleura continuous below with pulmonary ligament
2.3.2. Cervical pleura

Pleura is a thin membrane of fibrous tissue surfaced by a single layer of flat cells
Lines the thoracic wall from which it is separated by endothoracic fascia
Lines the lung surface

Continuous with parietal pleura at its mediastinal layer
Cervical pleura
of the suprapleural membrane at the thoracic inlet
into the neck
Thickened connective tissue layer cover the apex of the lung

1. Vital capacity
A) It is the sum total of Tidal Volume, Inspiratory Reserve Volume, Functional Residual Volume
B) It is measured more in the supine position than in the sitting position.
C) Measuring timed vital capacity can be used to diagnose restrictive and obstructive diseases
D) It is increased in pneumothorax
E) It is decreased in restrictive disease
2. Anatomical dead space

A) Can be measured by a spirometer
B) same as physiological dead Space in healthy person
C) Increase while breathing through rubber hose.
D) Increase will increase the work of breathing
E) Is a part alveolar space.
3. Lung compliance
A) Is the change of volume per unit change of pressure
B) Increase with increased surface tension
C) Decreased with decreased surfactant
D) Is greater at apex than in the base
E) Decrease in obstructive diseases
4. Diffusion of respiratory gases

A) Oxygen have more diffusion capacity than that of carbon-dioxide
B) Diffusion rate is proportional to solubility of the gas
C) Diffusion capacity measured using CO
D) Diffusion rate is proportional to partial pressure gradient
E) Presence of a gas reduce the diffusion capacity of another gas
5. Hypoxic hypoxia results in

A) Living in the high altitude
B) Pneumothorax
C) Low hemoglobin concentration
D) Peripheral circulatory failure
E) Voluntary hyperventilation
6. Regulation of respiration
A) Increased rate of respiration is proportional to the increased PCO2 in blood.
B) Peripheral chemoreceptors are stimulated by any form of PO2 reduction in blood
C) Rhythm of the respiration is controlled by the intact vagus
D) Breathing can control when brain stem is only functioning part of the brain
E) Breath holding can be prolonged when preceded by hyperventilation
7. Acute responses in high altitude

A) Pulmonary hypertension
B) Reduce the blood viscosity
C) Increased heart rate

D) Cerebral vasoconstriction
E) Pulmonary oedema
8. Nasopharynx
A) Extends from the base of the skull to the lower surface of the soft palate
B) Receives the opening of the auditory tube in the lateral wall of it
C) Has prominent pharyngeal tonsils on the posterior wall
D) Supplied by the pharyngeal branches of the maxillary nerve
E) Closely related to the inferior carotid artery at the pharyngeal recess
9. Regarding the development of respiratory system

A) Maturation of remaining alveoli occurs during the first 10 years of postnatal life
B) Location of the lung bud along the gut tube is determined by the TBX4 gene expression
C) Abnormal dividing of tracheobronchial tree causes respiratory insufficiency.
D) All the muscles of the larynx arises from 4th pharyngeal arch
E) Insufficient secretion of surfactant in premature babies leads to death
10. Internal thoracic artery

A) It is a branch of the 1st part of subclavian artery
B) it supplies 6th intercostal space
C) It terminates at 5th rib level
D) Continue as superior epigastric artery
E) it supplies to thymus
SBR
11. Maximum air inspired in addition to Tidal volume

A) Inspiratory reserve volume
B) Inspiratory capacity
C) vital capacity
D) total lung volume
E) functional residual capacity
12. Administration of O2 rich mixture of gas is least useful in,

A) Stagnant hypoxic
B) Anemic hypoxia
C) Histotoxic hypoxia
D) Right-left shunt of blood
E) CO poisoning
13. 28-year old man has admitted to hospital due to a penetrating injury occurred in 4th costal cartilage. What
structure can be damaged in this level,
A) Right oblique fissure
B) Left oblique fissure
C) Right horizontal fissure
D) Left horizontal fissure
E) Apex of the lung

14. A 62-year old male patient expressed concern that his voice has changed over the preceding months. Imaging
reveals a growth located within the aortic arch adjacent to the left pulmonary artery. Which neural structure is
most likely being compressed to cause the changes in the patient voice,
A) Left phrenic nerve
B) Oesophageal plexus
C) Left recurrent laryngeal nerve
D) Left vagus nerve
E) Left sympathetic trunk
15. A 72-year old person come with complain of vomiting and aspiration. By a bronchoscopy that was revealed an
obstruction in right upper bronchi. What are the bronchopulmonary segments can be affected,
A) Lateral, posterior, Medial, Anterior basal
B) Apical, Anterior, Posterior
C) Posterior, Anterior, Superior, Lateral
D) Apical, Lateral, Medial, Lateral basal
E) Apical, Superior, Medial, Lateral
1.
1.1 A 51-year-old male is admitted to the hospital with severe dyspnea. Radiographic examination reveals a tension
pneumothorax. Adequate local anesthesia of the chest wall prior to insertion of a chest tube is necessary for pain
control.
1.1.1. In order to inject the local anesthetic solution, what are the layers that must be infiltrated to achieve adequate
anesthesia? (10 marks)
1.1.2. Write an account on the cervical dome of the left pleura (20 marks)
1.2 A resident of Colombo went on holiday to Horton Plains (alt. 2300 meters) in NuwaraEliya. On reaching there he
developed shortness of breath, confusion and fatigue. Two weeks later his symptoms gradually disappeared without
any medical treatment.
Explain the physiological basis of,
1.2.1. The symptoms that he developed on arrival at Horton Plains. (35 marks)
1.2.2. Disappearance of the symptoms after two weeks. (35 marks)
13th Batch (EME) – MCQs ANSWERS
1.VitalCapacity
A.False-TV+IRV+ERV
B.False-lungresistanceishigherinsupineposition
C.True -frequentlymeasuredclinicallyasanindexofpulmonaryfunction.
D.False-inpneumothoraxlungcollapseandvitalcapacitydecrease
E.True -decreaseinbothrestrictiveandobstructivediseases
2.Anatomicaldeadspace
A.False-measuredbyanalysisofthesinglebreathNitrogencurve
B.True -inhealthyindividualsanatomicalandphysiologicaldeadspacesareidentical.

C.True -tubeincreasetheairwaylength.
D.True -Airwayresistancewillincrease,thereforeWOBwillincrease
E.False-partexclusivealveolarspace.
3.Lungcompliance
A.True-changeinlungvolumeperunitchangesinairwayresistance
B.False-complianceisinverslypropotionaltosurfacetension
C.True -complianceisdirectlypropotionaltosurfactantlevel
D.False-greateratbasethanapex.
E.False-ex:emphysema
4.Diffusionofrespiratorygases
A.False-CO2has20timesmoresolubilitythanOxygen
B.True -gaseswithhighsolubilityhavehighdiffusionrate
C.True -becauseuptakeofCOisdiffusionlimited
D.True -increasedpartialpressuregradientincreasesgasdiffusion
E.False-gasesdiffuseindependently
5.HypoxicHypoxiaresultsin
A.True -normalphysiologicalprobleminhighaltitude
B.True -duetoventilation/perfusionimbalance
C.False-anemichypoxia
D.False-stagnanthypoxia
E.False-itincreasesarterialOxygenpartialpressure
6.Regulationofrespiration
A.True -increaseinpCO2inbloodincreasesventilation
B.False-stimulatedbyreductionindissolvedformofOxygeninblood.
C.True -ifVagiarecutapneusismaydevelop(Ganongfig.36-2)
D.True
E.True -becauseCarbondioxideblowoffandpCO2isinitiallyless.
7.Acuteresponseinhighaltitude
A.False-notalwaysbuthappensasadelayedeffect
B.False-asadelayedeffectbloodviscosityincreasesduetohigherythropoiesis
C.True -tosupplyadequateoxygentotissues(compensation)
D.False-asadelayedeffectcerebralvasodialationoccurs
E.False-HAPEisadelayedeffect(Ganongclinicalbox35-4)
8.Nasopharynx
A.False-extendsfromthebaseoftheskulltotheuppersurfaceofthesoftpalate,atthelevel ofCV1.
B.True -openingoftheauditorytubeliesinthelateralwallandistriangularinappearance.
C.True -prominentonlyinchildren
D.True -mucosaofnasopharynxissuppliedbypharyngealbranchofmaxillarynervethrough thepterygopalatineganglion.
E.True -internalcarotidarteryliesagainstthewallofthepharynx.
9.Regardingthedevelopmentofrespiratorysystem,
A.True -throughthecontinuousformationofnewprimitivealveoli.

B.False-locationandappearancearedependuponanincreaseinretinoicacid.
C.True -
D.False-byboth4&6pharyngealarches
E.True -IRDSdevelopsanditisacommoncauseofdeathinprematurebabies.
10.Internalthoracicartery
A.True -itisfromthefirstpartofthesubclavianartery
B.True -itgivesofftwoanteriorICarteriesineachICspace.
C.False-itterminatesatsixthrib/sixthICspacelevel.
D.True -itcontinuesassuperiorepigastricarteryandmusculophrenicarteryafterits bifucation.
E.True -itsuppliestopleura,sternum,pericardium,thymusandbreast. SingleBestanswerquestions
11.Answer-A(referganong25thedi:pages628&629)
12.Answer-C(becauseinhistotoxichypoxiacellsareunabletouptakeOxygeneventhereis enoughOxygen)
13.Answer-C(becauseontherighttheforthcostalcartilageoverliesthehorizontalfissure.)
14.Answer-C(becauseleftrecurrentlaryngealnervehooksaroundligamentumarteriosum.)
15.Answer-B(referEllisclinicalanatomy13thedi:Page.30)
1.
1.1. Skin
Superficial fascia
External intercostal muscle
Internal intercostal muscle
(To anesthetized the internal intercostal nerve)
1.2
The cervical pluera covers the apex of the lungs which extends from the root of the neck through the superior
thoracic aperture . It is a superior continuation of the costal and mediastinal parts of parietal pleura . The cervical
pleura forms a cup like dome over the apex of the left lung that reaches its summit 2 – 3 cm superior to the level of
the medial third of the clavicle , at the level of the neck of 1st rib .the cervical pleura is reinforced by a fibrous
extension of the endothoracic fascia .its called the supraplueral membrane .the membrane attaches to the internal
border of the 1strib and the transverse process of c7 vertebra .
2.
2.1 when the altitude increases the total barometric pressure decreases . Therefore po2 too decreases but the
composition of the air stays the same . Therefore it results in hypoxemia causing fatigue and dizziness . Due to
hypoxemia the chemoreceptors are stimulated resulting in hyperventilation .there fore due to hyperventilation pco2
reduces drastically resulting in respiratory alkalosis
2.2 after 3 – 4 days the compensatory mechanism are completed resulting in dissolution of the symptoms.this is
called acclimatization
Erythropoietin secretion increasing after 3 to 4 days resulting in physiological polycythemia.
Increase in number of mitochondria in cells
Increase in myoglobin
Increase in tissue cytochrome oxidase
All of the above compensations results in elevated po2 thereby compensation of hypoxemia occurs

1. The suprapleural membrane,

A) Is attached to the transverse process of C7 vertebra
B) Is related to the subclavian vessels posteriorly.
C) Is attached to the neck of the first rib.
D) It lies in the oblique plane of the thoracic inlet.
E) Damage caused by a surgical approach could cause pneumothorax in the opposite side.
2. Which of the following pharyngeal pouches and their derivatives are correctly matched
A) 1st pouch – auditory tube
B) 2nd pouch - soft palate
C) 3rd pouch- thymus
D) 4th pouch - inferior parathyroid
E) 5th pouch - superior parathyroid
3. Regarding intercostal nerves,

A) Are anterior rami of the thoracic spinal nerves.
B) Cross in front of internal thoracic artery near the sternum
C) Lie deep to the intercostal muscles
D) Supply the parietal pleura
E) Lies above the intercostal vessels in the costal groove
4. At sternal angle,
A) Arch of aorta ends
B) Trachea bifurcates
C) Azygos vein enters the superior vena cava
D) The inferior boundary of the superior mediastinum is demarcated.
E) The first rib articulates with sternum
5. Trachea,
A) Is in the midline throughout its course
B) Left vagus nerve in contact with the trachea
C) Supplied by inferior thyroid artery
D) Traverse thoracic inlet downward and backward.
E) Approach tracheostomy by retracting suprahyoid muscles
6. Tidal volume,
A) Is the amount of air that normally moves into or out of the lung with each respiration
B) The amount of air expired after maximal expiratory effort
C) Can be measured using a spirometer
D) The amount of air that enter the lung but do not participate in gas exchange
E) The amount of air in the lung after maximal expiration
7. Surfactant lining the alveoli,

A) Helps to prevent alveolar collapse.
B) Increase the work of breathing.
C) Is produced by alveolar type I cells.

D) Is a lipoprotein complex.
E) Is deficient in babies born prematurely
8. Hypoxic hypoxia is a consequence of,

A) Hypoventilation
B) Low Hb concentration
C) CO poisoning
D) Living at high altitude
E) Ventilation / perfusion mismatch
9. Regarding the breathing mechanism,

A) In normal inspiration muscular action is higher than expiration
B) Forced expiratory movement is more difficult than forced inspiratory movement
C) Intra pleural pressure is more negative in base than apex
D) Visceral & parietal pleura are held together by surface tension of pleural fluid.
E) Respiratory muscles use 25% of total O2 consumed
10. Regarding gas exchange across alveolar capillary membrane

A) Oxygen is more soluble than carbon dioxide in alveolar capillary membrane
B) Permeability of CO2 is greater than O2
C) Diffusion of CO2 is unaffected in lung fibrosis
D) Diffusion of O2 reduce in lung fibrosis.
E) Rate of the O2 diffusion increase when pulmonary blood flow increase
SBR
11. A 25-year old man with a bullet wound in the neck just above the middle of the right clavicle and 1 st rib is
admitted to an emergency department. Radiographic examination reveals collapse of right lung and tension
pneumothorax injury to which of following respiratory structures resulted by pneumothorax.
A) Costal pleura
B) Cupula
C) Right mainstem bronchus
D) Right upper lobe bronchi
E) Mediastinum parietal pleura
12. 50-year old man has a right retrosternal pain. He was examined with endoscopy and biopsy. He was diagnosed
with malignant tumor in the right main bronchus. Which lymph node will be filtered with malignant cells first?
A) Inferior tracheobronchial
B) Paratracheal
C) Broncho mediastinal trunk
D) Bronchopulmonary
E) Thoracic duct
13. Which of the following is responsible for the movement if air from alveoli to pulmonary capillaries,
A) Active transport
B) Filtration
C) Secondary active transport
D) Passive diffusion

E) Facilitated diffusion
14. Most of CO2 travel in blood,

A) Dissolve in plasma
B) Combine with plasma proteins.
C) Combine with hemoglobin
D) In bicarbonate
E) Bound to 𝐶𝑎2+
15.Spontaneous inspiration is ceased after,

A) Transection superior to the pons
B) Transection lower to the inferior medulla
C) Bilateral vagotomy
D) Denervation of peripheral chemoreceptors
E) Transection of spinal cord at the level of the first thoracic segment.
1.
1.1. Write account on the anatomy of right sixth intercostal space. (20 marks)
1.2. Draw and label the arrangement of structures in the hilum of the left lung. (10 marks)
1.3. In pneumothorax following chest wall injury inspiratory effort leads to increase intra thoracic volume more than
normal while the lung volume is reduced. Explain the mechanisms leading to,
1.3.1. Increased thoracic volume more than normal (35 marks)
1.3.2. Decrease in lung volume (35 marks)
1.
A-T
B-F subclavian vessels lie laterally over it.
C-F inner border of 1st rib
D-T
E-F Damage caused by a surgical approach could cause pneumothorax in same side
2.
A-T
B-
C-T
D-F
E-F
1st - Eustachian tube, middle ear cavity
2nd - palatine tonsils
3rd - dorsal-Inferior parathyroid

Ventral-Thymus
th
4 - dorsal-superior parathyroid
-Ventral - C cells of thyroid gland
5th
6th -larynx
3.
A-T
B-
C-T
D-T
E-F
A-
B-At back of ICS nerve lies behind the artery, At front nerve crosses in front of internal thoracic artery
C-Lies between internal intercostal and transversus thoraces
D-collateral branch supply to parietal pleura
E-lies in order from above to below: Veins, Arteries, Nerves
4.
A-F
B-T
C-T
D-T
E-F
At sternal angle:
2nd rib articulates with sternum
Aortic arch
Tracheal bifurcation
Pulmonary trunk bifurcates
Left recurrent laryngeal nerve
Azygos vein
Cardiac plexus
Thoracic duct {RATPLANT}
5.
A-T
B-F
C-T
D-T
E-F
A-
B-right vagus in contact with trachea
C-supplied by inferior thyroid and bronchial arteries
D-
E-suprahyoid muscles lie above the hyoid bone
6.
A-T

B-F
C-T
D-F
E-F
A-
B-The amount of the air expired after maximal expiratory effort is expiratory reserve volume.
C- Spirometers can measure three of four lung volumes, inspiratory reserve volume, tidal volume, expiratory reserve
volume, but cannot measure residual volume.
D-amount of air do not participate in gas exchange is called as dead space
E-amount of the air in the lung after maximal expiratory effort is called as residual volume
7.
A-T
B-F
C-F
D-T
E-T
A
B- surfactant reduces the work associated with breathing.
C-is produced by type 2 alveolar cells
D-it is a lipoprotein
E- Infant respiratory distress syndrome is caused by lack of surfactant in immature babies, because it develops
around 26-36 weeks of gestational age.
8.
A-T
B-F
C-F
D-T
E-
A-
B- anemic hypoxia
C-CO poisoning cause stagnant hypoxia
D-because partial pressure of O2 in atmosphere is reduced in high altitude
E
9.
A-T
B-
C-F
D-T
E-F
A-in normal, expiration is a passive act
B
C- At the apex of the lung, as the gravity is trying to pull downwards, there is increase in volume of pleural cavity at
the apex which means decrease in intrapleural pressure (more negative).
D-
E-

10.
A-F
B-
C-
D-
E-
A- Carbon dioxide is inherently more soluble than oxygen,
B-
C-
D-
E
11. B
12.
13. D
14. D
15. C
1.1 anatomy of right 6th intercostal space

Right 6’th intercostal space lodges in between 6’th and 7’th ribs.posteriorly 6’th and 7’th riba are attched to
vertebrae. By costotransverse joints and joints of costal heads. Anteriorly 6’th tib already attches with sternum
by costochondral joints and a primary cartilogenous joint ,6th sternocostal joint .7th rib join with 6th rib to
articulate with the sternum. 7th rib joints with sternum by a synobial joint so the 6’th intercostal space is limited
anteriorlyby common cartilaginous joint of 6th and 7th rib , in the 6th intercostal space 3 layer of muscles are
present.most outer layer is consisted of external intercostal muscles .external intercostal lie obliquely
downward attched to sharp inferior border of 6th rib and smooth upper border of 7th rib posteriorly it extend to
superior . Costotransverse ligament to costochondral junction in the front. Here they are replaced by anterior
intercostal membrane. Below it lies internal intercostal muscles which lie’s downward and backward . It lies
anteriorly to cartilogenous margin to sternum and posteriorly is replaced by posterior intercostal membrane
,which extend from the angle of the rib to the superior costotransverse ligament at the posterior limit of the
space.below it lies the inner muscular layer .anteriorly there is no transverse thoracic muscles as the transverse
thoracic is only attached to 2nd to 6th rib. Laterally in the inner wall of thorax lies subcostal muscle. Intercostal
nerve and vessels lies in the plane between intermediate and innner layer of the muscles under cover of the
lower border of 6th rib .mixed spinal nerve emerged from the intervertebral foramen gives off posterior ramus
and the anterior ramus passes through the intercostal space . Anterior ramus of 6th intercostal nerve gives off
lateral and collateral cutaneous branches. Collateral branch run along the collateral inferior border of its space
and supplies the muscles of the space . Lateral cutaneous branch pierces intercostal muscles and overlying
muscles of the wall along midaxillary line and devides into anterior and posterior branch .intercostal nerve ends
as anterior cutaneous nerve which passes anterior to internal thoracic artery and pierces intercostal muscles in
its courses 6th intercostal nerve lies below the artery and veins.
Arteries enter intercostal spaces at the back and front .6th intercostal space is supplied by a branch of descending
aorta . That branch constitute posterior intercostal artery .artery gives idd a collateral branch which passes
around the neurovascular plane . At a lower level than main trunk . Anterior intercostal artery is given by internal

thoracic artery in the 6th intercostal space in the space . There are one posterior and two anterior intercostal
veins accompanying the arteries. Anterior vein drain into internal thoracic vein. Posterior veins drain into
azygous system. Lymph vessels follow the arteries anteriorly drain into parasternal nodes and posteriorly drain
into posterior intercostal nodes
1.2) Structures in the lung hilum

1.3) in pneumothorax
Chest wall injury
Inspiratory effort leads to increase in thoracic volume more than normal while the lung volume is reduced
1.3.1) increase thoracic volume more than normal

Pneumothorax is an air filled pleural space due to some injury.normally intrapleural in the lungs is kept relatively
At the base of lung - 2.5mm hg
At the apex of lung -6 mm hg
Thoracic cavities volume is kept in a balance by the outward force by chest wall adhered to the parietal pleura and
visceral pleura attached to lung which gives the inward force.
Inspiration is an active process . It’s done with the help of chest wall muscles (external intercostal) and diaphragm.
As the chest wall is damaged the inward force to balance the outward force is lost . That injury may be a traumatic
chest injury or some open damage to the pleural seal by parietal pleura when the inspiration is done , external
intercostals increase the transverse diameter of thorax while sternum and ribs increase anteroposterior diameter.
Normally when that happens inward force by pleura takes the chest wall into normal position At expiration . But
when there is a chest injury air enters the intrapleural space, as the expiration is a passive process it has no external
intercostal muscle action and it can’t remove the air filled in the intrapleural cavity , air trapped in the intrapleural
cavity and that increase thoracic volume more than normal.
1.3.2) decreases in lung volume

Lung volume is maintained by the transmural pressure gradient between lung and intrapleural space . The
pressure in the intrapleural space is normally negative so, as the atmospheric pressure acts in the lungs. It’s
relatively positive or kept at zero . Anyhow it’s increased than the intrapleural pressure . So the lung is inflated due
to it’s attachment to pleura. Visceral pleura is attached to the lung and parietal pleura is attached to interior chest
wall. That keeps the normal lung volume it intact. When pneumothorax occurs air gets filled in the intrapleural space
. The intrapleural pressure becomes positive so the pressure gradient is lost and that results in the collapsing of lungs
. During inspiration lung pressure becomes zero to inhale o2 into the lungs . Do during inspiration positive
intrapleural pressure compress lung and reduce lung volume . More air leaks into the intrapleural space as it as a
traumatic pneumothorax . So although the pulmonary pressure increases during expiration it can’t withhold the
intrapleural pressure ,as it gets increased with every inspiratory effort. So the ling can’t be back ti its normal size and
volume . Lung is collapsed and lung volume is reduced .

1. Regarding intercostal arteries,

A) Internal thoracic artery supplies the anterior body wall as far down as the umbilicus
B) All posterior intercostal arteries arise from the descending aorta
C) They are superior to intercostal vein and intercostal nerve
D) 3rd right posterior intercostal artery is arising from right bronchial artery
E) The 1st nine anterior intercostal arteries are direct branches of the internal thoracic artery.
2. Regarding the pleura,

A) cervical pleura extends above the clavicle
B) The parietal layer is separated from the thoracic wall by the endothoracic facia
C) Parietal and visceral pleura continues to make lung root
D) Visceral pleura goes deep to inter lobal fissure
E) parietal pleura is developed by the splanchnic mesoderm
3. Regarding structures in the superior mediastinum,

A) The right brachiocephalic vein is shorter than the left
B) The vagus nerve enter the thorax posterior to the subclavian artery
C) Thoracic duct passes across the esophagus within the superior mediastinum
D)
E) The left phrenic nerve passes lateral to the aortic arch
4. Factors that determine to affect in gas exchange in human lungs include,

A) Thickness of membrane
B) Molecular weight of gases
C) solubility of gases
D) Square area of membrane
E) Pressure gradient across membrane
5. Hypoxic hypoxia is seen in,

A) High altitude
B) Left to right shunt
C) When breathing through the tracheostomy tube
D) Anemia
E) Cyanide poisoning
6. Method of transporting CO2 in blood

A) By binding with hemoglobin
B) By reacting with hemoglobin
C) Dissolving in plasma
D) By forming Bicarbonate
E) By binding with plasma protein
8. Beneficial Compensatory mechanisms during acclimatization in high altitude include,

A) hyperventilation
B) Left shift of Oxygen-hemoglobin dissociation curve
C) Polycythemia

D) Barrel chest
E) Respiratory Alkalosis
10. Lung tissue,

A) Has elastic fibers
B) Is lined throughout by ciliated epithelium
C) Is supplied by the vagus nerve.
D) Is derived lung but of foregut
E) Is firm and rigid in live human
SBR
11. Hydrostatic pressure in alveoli & plural cavity varies with the phase of respiration. What is the phase & part of
the lung which has the lowest barometric pressure?
A) Pleural cavity of basal region during inspiration
B) Apex alveoli during expiration
C) Basal alveoli during inspiration
D) Pleural cavity of basal region in mid inspiration
E) Pleural cavity of basal region during expiration
12. Respiratory rate increase during severe exercise. What is the possible explanation for the increase in
respiratory rate during exercise?
A) Stimulation of respiration by hypoxia through peripheral chemoreceptors
B) Stimulation of respiration by hypercapnia through peripheral chemoreceptors
C) Stimulation of respiration by H+ through peripheral chemoreceptors
D) Stimulation of respiration by H+ through central chemoreceptors
E) Stimulation of respiration by hypoxia through central chemoreceptors
13. Hypoxia can occur with or without hypercapnia. Which of the following condition that has hypoxia without
hypercapnia?
A) Pulmonary Fibrosis
B) Severe Asthma
C) Pulmonary Emphysema
D) Defective ventilation
E) Chronic bronchitis
14. A 62-year old male patient expressed concern that his voice has changed over the preceding months. Imaging
reveals a growth located within the aortic arch adjacent to the left pulmonary artery. Which neural structure is
most likely being compressed to cause the changes in the patient voice?
B) Esophageal plexus
D) Left vagus nerve
15. A 72-year old patient vomited and aspirated some of vomitus while under anesthesia, on bronchoscopy
examination, partially digested food is observed blocking the origin of right superior lobber bronchus. Which of
the following group of bronchopulmonary segments will be affected by this obstruction?

A) Superior, medial, lateral, medial basal
B) Apical, anterior, posterior
C) Posterior, anterior, Superior, lateral
D) Apical, lateral, medial, lateral basal
E) Apical, Superior, medial, lateral
1.
1.1. Explain the physiological basis for
1.1.1. Collapse of lung in surfactant deficiency (20 marks)
1.1.2. Cyanosis is unlikely in anemia (20 marks)
1.1.3. Intrapleural pressure is more negative in apical region than in basal region (20 marks)
1.2.
1.2.1. Write an account on hiatuses and the structures passing through the Diaphragm (25 marks)
1.2.2. List the types of hernia associated with the diaphragm (15 marks)
1. Refer on Last Pg .no 183

A.t
B.f
C.f
D.f - right bronchial artery come from third right posterior intercostal artery
E.f
2.
A.t - 2-3 cm superior to the level of the medial third of the clavicle
B.t
C.t
D.t
E.f
3.
A.t
B.f - figure on last Pg no 347
C.f
D.
E.t - refer last on pg no 195
4.
A.t
B.t
C.t
D.t

E.f - partial pressure of the gas
5.
A.t
B.f
C.t
D.f
E.f
Causes for hypoxic hypoxia
-ascend to high altitude
-decrease ventilation
-v/ q imbalance
-thickning os alveolar membrane
-right to left shunt
6.
A.t
B.f
C.t
D.t
E.t
8.
A.t due to hypoxia
B.f right shift BCS of increase 2,3 BPG
C.t
D.t
E.t
10.
A.t
B.f
C.t
D.t
E.f
11.
12.C
13.A
14.C
15.B

1.1.1.
Surfactant produce by type 2 alvelora epithelial cells.increase surfactant will reduce the surface tension.surface
tension reduction is directly proportional to concentration of the surfactant. alveolar surface tension is lower than
water- air. if there is no reduction in alveolar surface tension alveoli will be collapsed. it is explain by law of Laplace.
P=2T/R
P- collapse pressure
T - surface tension
When surfactant decrease, it leads to increase surface tension .so increase collapse pressure( law of love place )so
collapse occur.
1.1.2
Cyanosis means bluish discolouration of the skin and mucus membrane due to increase in reduced hemoglobin in
the capillary blood. Usually happen when reduced hemoglobin concentration is greater than5 g/dl in capillary blood.
In anaemia the red blood cells count decrease ,so viscosity of the blood will reduce ,so the flow rate increase .so in
anemia there are no hemoglobin to oxygenate . But cyanosis means increase reduced hemoglobin, so cyanosis can't
occur in anemia. But in polycythemia cyanosis can occur.
1.1.3.
Pleural pressure is always negative.because of the tendency of the chest wall to expand and tendency of the lungs to
recoil. it is more negative in apex of the lungs then the base of the lung. this is due to
1. Gravity
2. Pressure from the mediestinal contents
3. Pressure from the abdominal contents
These causes of pull the lungs downwards in the pleural cavity. so in Apex region the pleural space will increase so
the plural pressure is more negative in Apex.
1.2.1
Hiatus in the diagram
For the passage of structures between thorax and abdomen they are three large openings in the diaphragm and
several smaller ones.
1. Aortic opening is opposite T12 vertebra
2. Esophageal opening is opposite t10 vertebra
3. Vena caval for a man is opposite t8 vertebra
Other structures make their own smaller openings. The hemizygous vein passes through the left crush. The greater,
lesser and least splanchnic nerves pears each crush. The sympathetic trunk passes behind the medial arcuate
ligament .the subcostal nerve and vessels pass behind the lateral arcuate ligament. The left phrenic pierces the
muscle of the leftdome. The neuro vascular bundles of the 7th to the 11th intercostal spaces pass between the
digitations of the diaphragm and transverse abdominis into the neurovescular plane of the abdominal wall.
The superior epigastric vessels past between them xiphisternal and costal fibres of the diaphragm.
Extra peritoneal lymp vessels on the abdominal surface pass through the diaphragm to lymph nodes lying on its
Thoracic surface ,mainly in the posterior mediastinum.
1.2.2.
Two types of diaphragmatic hernia
1. Congenital type of hernia
2. Acquired type of hernia

Congenital type of hernia
-failure of pleuroperitoneal membrane development is most common.
-bochdalek's foramen
-morgagni's foramen-at junction of costal and xiphoid origin.
Aquired type of hernia
-sliding type
-rolling type ( paro oesophagial type )
1. Trachea
A) Commences 2 inches above jugular notch
B) Bifurcates in the middle mediastinum
C) Separated from right lung by the azygos vein
D) Has contact with right and left vagus nerves
E) Is resected at 4th and 5th cartilages during tracheostomy
2. Laryngeal inlet is formed by,

A) Vocal folds
B) Upper margin of epiglottis
C) Aryepiglottic fold
D) Inter arytenoid mucosal fold
E) Vestibular ligaments
3. Regarding lungs,
A) Lung root in middle mediastinum
B) The aortic arch impression is deeper in left lung
C) Apices are grooved by the subclavian veins
D) Lingula is an extension in the lower lobe of the left lung
E)
4. Regarding thoracic cage

A)
B) Lower rib facet articulates with its own vertebrae
C) 1st, 11th and 12th ribs articulate with their own vertebrae only
D)
E)
5. Regarding lung bud formation

A) It appears in 3rd week
B) It is an outgrowth of dorsal wall of foregut
C) Its formation is induced by TBX4 factor
D) It continuously maintains a communication with the pharynx
E) Determination of the location of lung bud is associated with the increase in retinoic acid
6. Regarding mechanism of breathing

A) There is more muscular work involved in breathing in than in breathing out in the tidal range
B) Forced expiration is greater than forced inspiration
C) Inspiration is facilitated by recoil of chest wall
D)
E)
7. Arterial hypoxemia could be seen in

A) Hypoventilation
B) Lower hemoglobin concentration
C) CO poisoning
D) Living in high altitude
E) Ventilation/Perfusion ratio mismatching
8. Regarding control of breathing

A) Increase in ventilation during exercise is proportional to rise in arterial CO2
B) Peripheral chemoreceptors are stimulated by any form of reduced oxygen content of arterial blood
C)
D) When the brain stem is isolated from the brain the respiration cease
E) Cerebral cortex controls breathing center through medullary respiratory centers
9. The blood of an anemic individual with a Hb concentration of 10mg/dL blood would be

A) Normal arterial PO2 and Normal arterial O2 content
B) Reduced arterial PO2 but normal arterial O2 content
C) Reduced arterial PO2 and have about 13mg/dL O2 content
D) Normal arterial PO2 but a reduced arterial oxygen content
E)
10. Which of the following condition can be treated by oxygen therapy?

A) Ventilatory defect
B) Hypoxia due to pathological shunting
C) Pulmonary fibrosis
D) CO poisoning
E) Anemic hypoxia
SBR
11. Suitable place to insert an aspiration syringe to drain intrapleural fluid

A) Midpoint of the intercostal space
B) Between external intercostal and internal intercostal
C) Immediately below the lower border of the rib
D) Between internal intercostal muscles and posterior intercostal membrane
E) Immediately above the rib
12. A person having tumor & pneumonia in apex of the lung. Which nerve has to be blocked using a local
anesthetic drug to relieve pain
A) Phrenic nerve
B) Intercostal nerve
C) Recurrent laryngeal nerve
D) Cardio pulmonary nerves

E) Vagus nerve
13. Arterio-venous difference in oxygen concentration is greatest in,

A) Exercise
B) Anemic hypoxia
C) CO poisoning
D) In hypoxic hypoxia
E) In histotoxic hypoxia
14. Tissue fluid is not collected in the lungs mainly because,

A) High oncotic pressure in capillaries
B) Low hydrostatic pressure in capillaries
C) Tissue pressure is low
D) Low surface tension
E)
15. CO2 is transported in the blood mostly in term of,

A) Dissolved CO2
B) Carbamino proteins
C) Bicarbonate
D) Carbonic acid
E)
16th Batch (EME) – SEQs
1.
1.1. Vital capacity was measured in a group of 15 healthy male medical students, first while seated upright and then
in supine position. The average vital capacity in upright position was 5.2 liters and in supine position 4.8 liters.
Explain the physiological basis of the above difference in the vital capacities in different postures. (60 marks)
1.2. Explain the anatomical basis of following,

1.2.1. Insertion of a central venous catheter through the left internal jugular vein may cause a chylothorax (10
marks)
1.2.2. Tumor at the apex of the lung may cause pain in the little finger and a drooping upper eyelid on the same side.
(15 marks)
1.3. Briefly describe the gross anatomy of the left main bronchus (15 marks)
01.
A. (T) - Commences in the neck below the cricoid cartilage at the level of C6 vertebra, 2 inches above the jugular
notch
B. (F) - Trachea bifurcates in the sternal angle at the lower border of the T4 vertebra

C. (T) - Separates from the right lung by the pleura and arch of the azygos vein as it hooks forwards over the right
broncus.
D. (F) Right vagus nerve contact with right side of the trachea. . On the left , left common carotid and subclavian
artery prevents the pleura and the left vagus nerve from coming into contact with trachea.
E. (F) - Resected at second and third cartilage during tracheostomy
02. Laryngeal inlet is formed by,

• Tip of the epiglottis
• Aryepiglottic fold
• Inter arytenoid fold
A. (F)
B. (T)
C. (T)
D. (T)
E. (F)
03.
A. (T) - hilum of lung is related to middle mediastinum
B. (T) - have Cardiac impression, groove of arch of aorta and descending aorta in left lung
C. (F) - subclavian artery is in Apex of lung
D. (T)
E.
04.
A.
B. (T)
C. (T)
D.
E.
Typical ribs -Two facets-upper facet articulate with lower coastal facet of vertebrae above lower rib facet articulate
with upper coastal facet of own vertebrae .
Atypical ribs-1,11,12- fst rib articulate with T1 only not contact with C7 & last two ribs articulate with own vertebrae.
(last's anatomy page 180)
05.
A. (F) - When the embryo is approximately 4 weeks old,The respiratory diverticulum (lung bud) appears
B. (F) - respiratory diverticulum (lung bud) appears as an outgrowth from the ventral wall of the foregut not from
dorsal wall
C. (T) - TBX4 induces formation of the bud and the continued growth and differentiation of the lungs.
D. (F) - The respiratory primordium maintains its communication with the pharynx through the laryngeal orifice
E. (T) - appearance and location of the lung bud are dependent upon an increase in Retinoic acid (RA) produced by
adjacent mesoderm.
06.
A. (T) – Inspiration – active,
Expiration - passive
B. (F) - Forced inspiration>Forced expiration
C. (F) - Recoil is coming from elasticity .It is helped for expiration

D.
E.
07. Hypoxemia mean , decrease in the partial pressure of Oxygen in the blood
A. (T) - Hypoventilation is breathing that is too shallow or too slow to meet the needs of the body. This causes a
buildup of carbonic acid and too little oxygen in the blood. That leads to reduce the Oxygen partial pressure.
B. (T) - Maximum amount of oxygen (97%) is transported by oxyhemoglobin.
videlicet oxygen combines with hemoglobin in blood. Then as a result of Lower hemoglobin concentration, oxygen
partial pressure become low.
C. (T) Carbon monoxide is a dangerous gas because it displaces oxygen from hemoglobin, by binding with same site
in hemoglobin for oxygen. So, oxygen transport and oxygen carrying capacity of the blood are decreased.
Then automatically Oxygen partial pressure become low
D. (T) - At high altitudes, Oxygen molecules are further apart because there is less
pressure to push them together. This effectively means there are fewer oxygen molecules in the same volume of air
as we inhale. It makes problems for ventilation. That leads to reduce the Oxygen partial pressure
in blood.
E. (T) - Ventilation perfusion ratio mismatch is a condition in which one or more areas of the lung receive oxygen but
no blood flow (Embolism) , or they receive blood flow but no oxygen ( Airway obstruction /shunt). However
both are cause to reduce the oxygen partial pressure in blood.
08.
A. (T) - Increase in Pco2 in blood increases ventilation
B. (F) - Stimulated by reduction in dissolved form of O2 in blood
C.
D.
E. (T)
09.
A. (F)
B. (F)
C. (F)
D. (T)
E.
Normal arterial Po2 and reduced arterial O2 content .( anemic hypoxia)
10.
A. (T) - The patient who has chronic obstructive pulmonary disease he can be treated by oxygen therapy
B. (F) - In this Condition Administration 100% oxygen raises the on content of Alevolar air but has only little effect on
hypoxia due to venous to arterial shunt- thisis because Venous blood does not have the opportunity to get the lung
to be oxygeraten
C. (T) - In this disease condition Oxygen therapy keeps level of oxygen in the blood above certain leve, it reduces the
breathlessness
D. (T) - Co Poisoning – is listed as form of anemic hypoxia , because the amount of hemoglobin that Carrying oxygen
is redued.CO poisoning Can be treted by hyperbaric oxygenation
E. (T) - Oxygen therophy is most effectively in hypoxia but not to all types of hypoxia. To the hypoxic hypoxia 1oo%
effective anemic hypoxia – 70%

11. (E)
Pleural drainage-just above the ribs(lower boundary of space).
Anesthetic-just below the lower border of ribs.
(last's anatomy page 183)
12. (B)
Answer: Intercostal Nerve. Intercostal Nerve block is has low risk and failure and abdominal surgery fracture , a
mastectomy or a rip fracture.
13. (A)
Answer- Exercise.
The arterio venous oxygen difference is a measure of the amount of oxygen taken up from the blood by the tissues.
During hypoxic conditions O₂ consumption at the tissue level decrease, so arterio venousOxygen difference will
decrease. In intense exercise blood flow to the tissues increases and heamoglobin dissociates more
easily, therefore the arterio Venouse oxygen difference increase during exercise.
14. (D)
Surfactant prevent pulmonary edema.
Surfactant reduces the surface tension, reduces the transpulmonary pressure and the net pressure gradient is not
very high as in systemic capillaries for fluidtransudation. Alveoli remain „moist‟ (not wet) . In the absence of
surfactant, the transpulmonary pressure will be INCREASED, and would lead to a net pressure gradient acting
outwards (about 20mmHg).
(Refer ganong page 1438) (below figure 34-12)
15. (C)
A. (F) - Carbon dioxide diffuses into blood and dissolves in the fluid of plasma. forming a simple solution. It is
about.7% of total carbon.dioxide in the blood.
B. (F) - About 30% of carbon dioxide is transported as carbamino compounds. Carbon dioxide is transported in blood
in combination with hemoglobin and plasma proteine. Carbon dioxide combines with hemoglobin to form
carbamino hemoglobin or carbhemoglobin. And it combines with plasma proteins to form carbamino proteins.
Carbamino hemoglobin and carbamino proteins are together called carbamino compounds.
C. (T) - About 63% of carbon dioxide is transported as bicarbonate. In the RBCs, carbon dioxide combines with water
to form carbonic acid. Carbonic acid is very unstable. , dissociates into bicarbonate and hydrogen ions
concentration of bicarbonate ions in the cell increases more and more. Due to high concentration, bicarbonate ions
diffuse through the cell membrane into plasma.
D. (F) - combines with the water to form carbonic acid. Transport of carbon dioxide in this form is negligible.
E.
16TH BATCH (EME) - SEQ ANSWERS
01.)
1.1) The vital capacity refers to maximum amount of air expired from the fully inflated lung or maximum
inspiratory level.
VC= TV +IRV +ERV
VC- Vital Capacity, TV- Tidal Volume. It is about 500ml , IRV- Inspiratory reserve Volume.
About 2000mland ERV -Expiratory Reserve Volume. It is about 1000ml.
Therefore the VC is about 3. 5L in a healthy person.
Physiologically the amount of VC differs with sex (female< male), slightly more in healthy body built person
&athletes. And also with the posture differ the VC.
VC is more in standing position and less in lying position. Therefore those group of people’s VC differ with different
positions because in the supine the lung difficult to increase the volume because of the pressure is made by the front
parts on both lungs. But in the upright position due to the gravity those pressure doesn’t work much and both lungs
can increase volume than in supine position. So, the amount of VC in upright 5.2L and 4.8L in supine position.
1.2 )
1.2.1) Insertion of a central venous catheter through the left internal jugular vein may cause a chylothorax
Chylothorax is a condition in which chyme is accumulated in the pleural space in chest cavity. Usually in human body
lymph is lastly collected in to the thoracic duct and in 95% of people this thoracic duct drains into left internal jugular
vein.
So when a catheter is entered through left internal jugular vein it may damage the thoracic duct and this damage
may cause the leakage of lymph from thoracic duct into the pleural space and cause chylothorax
1.2.2 ) Tumor at the apex of the lung cause may compress the sympathetic trunk and C8 Nerve. (Due to their
anatomical location)
Due to irritability of Sympathetic trunk cause drooping of eyelid (Horner's Syndrome) Little finger is supplied by C8
Dermetome, so irritation of C8 nerve due to Pulmonary Apical tumor cause pain in little finger.
1.3 ) gross anatomy of the left main bronchus -
Left main bronchus is narrower than right main bronchus. It's longer than right bronchus. It is 5cm. It runs more
horizontally . It lies inferior to the arch of aorta and anterior to the Esophagus and thoracic aorta. Left main bronchus
is divide to upper and lower lobes.

PHASE 01 QUESTIONS
8th Batch
8th Proper - MCQs
9. Which of the statements are true and false regarding diaphragm?

A) IVC opening is at 10th thoracic vertebral level
B) Left phrenic nerve passes through tendinous part of the diaphragm
C) Hemiazygos vein passes through left crus of the diaphragm
D) Sympathetic trunk passes being the lateral arcuate ligament
E) Splanchnic nerve passes through crura of the diaphragm
10. Regarding the relations of thoracic part of trachea

A) Posteriorly it is in contact with esophagus
B) On the left side it comes into contact with aorta
C) On the right side, it comes with lung
D) Anteriorly it is crossed by left brachiocephalic vein
E) Posteriorly, it is between esophagus and left laryngeal nerve
11. Anatomical features of the hilum of the left lung include the
following
A) Phrenic nerve passes in front of it
B) Vagus nerve passes behind it
C) Arch of aorta curves over it
D) It has one bronchus
E) It is at T4-T5 vertebral levels
12. Regarding intercostal spaces

A) External intercostal spaces directed downwards and backwards
B) All spaces in anterolateral aspect have paired anterior intercostal arteries
C) Upper two poster lateral surfaces are supplied by branches of subclavian artery
D) All the anterior intercostal veins drains to internal thoracic vein
E) All spaces protect the visceral organs of thorax
13. Regarding histology of alveoli

A) Goblet cells are present
B) Lymphoid follicles are present
C) Lined by simple columnar epithelium
D) Type II pneumocytes secrete surfactant
E) The epithelium consists of cilia on its surface
27. Central cyanosis seen in

A) Cardiac failure
B) Exposed to cold weather
C) Left to right shunt
D) Type I respiratory failure
E) Type II respiratory failure

28. Lung compliance
A) Measured by changes in airway pressure per unit change in lung volume
B) Low in elders than children
C) High in pulmonary emphysema
D) Low in surfactant deficiency
E) Pulmonary fibrosis does not alter
29. With regards to apex of lungs, which of the following statements is FALSE?
A) Supra pleural membrane prevent upward movement of apex
B) Malignancy of apex produces venous engorgement of arm
C) Apex of left lung is notched by brachiocephalic artery
D) Blood flow to apex is intermittent when the person is standing erect
E) Summit of the apex of lung is 2.5cm above the medial end of clavicle
30. Stagnant hypoxia is due to following conditions, EXCEPT

A) Congestive cardiac failure
B) Surgical shock
C) Pulmonary edema
D) Embolism
E) Vaso spasm
SBR
42. In hydrothorax, drainage needle inserted

A) Just above 4th rib
B) Just above 5th rib
C) Just above 6th rib
D) Just below 5th rib
E) Just below 6th rib
43. Functional residual capacity

A) Volume of air present after normal expiration
B) Residual volume
C) Physiological dead space volume
D) Forced expiratory volume at 1s
E) Forced expiratory volume in female at 2.5s
47. 50-year-old woman came to the clinic with backache, weakness, disability in breathing. Ultra sound diagnosing
conforms aneurism in the abdominal aorta in the aortic hiatus in the diaphragm. What is the most likely pair are
compressed by the aneurysm?
A) Thoracic duct and Vagus
B) Azygos and Vagus
C) Azygos vein and thoracic duct
D) Both Vagi
E) Azygos vein and esophagus
55. What is the air that the partial pressure of CO2 is increased?

A) Alveolar air of apices
B) Alveolar air at the end of the respiration
C) Alveolar air at the bases of the lungs
D) Expiratory air
E) Tissue fluid of cardiac muscle
56. In emphysema, find out the wrong statement

A) Bronchiolar obstruction occurs
B) Aeration of blood is impaired
C) Ventilation perfusion ratio is affected
D) Number of pulmonary capillaries increases
E) Pulmonary hypertension appear
8th Proper - SEQs
2.
2.1 Describe the structural arrangement of thoracic inlet with the aid of a labeled diagram (50 marks)
2.2 Compare & contrast the gross anatomy of the right & left bronchi (20 marks)
2.3 Describe briefly the surface marking of both lungs (30 marks)
5.
5.1 Describe the physiological changes that are seen during acclimatization in high altitude (50 marks)
5.2 Describe the transport of carbon dioxide in blood (50 marks)
Repeat - SEQs
1.
1.1 Describe briefly the contents of posterior mediastinum & their structural relations
1.2 Describe briefly the gross anatomy of intercostal space & add a note on its clinical significance
5.
5.1 Define the term hypoxia
5.2 State the 4 types of hypoxia with an example for each type
5.3 Describe the relationship of hypoxia & cyanosis
5.4 Explain why cyanosis,
5.4.1 Occurs in pulmonary fibrosis
5.4.2 is more prominent in polycythemia
8th Proper – MCQ ANSWERS
09)
A) F T8
B) F Muscular part of the left dome of the diaphragm
C) T
D) F Medial arcuate ligament

E) T Splanchnic nerve pierces the each crus.
10)
A) T
B) T
C) T
D) T
E) F Left recurrent laryngeal nerve is related posterio-laterally to the trachea.
11)
A) T
B) T
C) T
D) T
E) F T5 – T7
12) A) F
External intercostals – downwards and forwards Internal intercostals – downwards and backwards
B) F At the front of the intercostal space the internal thoracic artery in the upper 6 spaces and the musculophrenic
artery in the seventh, eighth and ninth spaces give off 2 anterior intercostals arteries.
C) T Upper 2 spaces are supplied by the superior intercostals artery.
This is the descending branch of the costocervical trunk. This is the descending branch of the costocervical trunk,
which comes off from the second part of the subclavian artery behind scalenus anterior.
D) F Into musculophrenic and internal thoracic veins
E) T
13)
A) F Present upto the terminal bronchioles only.
B)
C) F Simple squamous epithelium
D) T
E) F Present upto the terminal bronchioles only.
27)
A) T Cyanosis; dark and dusky bluish discoloration of the tissues appear when the reduced hemoglobin concentration
of the blood is more than 5 g/dL.
Central cyanosis is visible on the tongue (specially the underside) and lips.
B) F Peripheral cyanosis
C) F Shunting of deoxygenated venous blood into the systemic circulation takes place only in right to left shunts.
D) T Type I – hypoxia, without hypercapnea
E) T Type II – both hypoxia and hypercapnea
28)
A) F Lung compliance = Change in lung volume per unit change in airway resistance Δ𝑤 Δ𝑞
B) T Lung compliance decrease with age.
C) T Emphysema; Increased lung compliance
D) T Surfactant secreted by type II epithelial cells increases lung compliance by reducing the force of surface tension.
E) F Lung compliance decreases.

29)
A)? Gives rigidity to thoracic inlet .prevent the neck structures being puffed up and down during respiration
B)? Upper limb venous drainage to axillary vein.
C) F medial border of lung
D) F
E) T
30)
A) T In stagnant hypoxia blood flow is reduced. Adequate oxygen is not delivered to tissues. But have normal paO2
and Hb concentration
B) T Blood volume reduced
C) F Hypoxic hypoxia
D) T Obstruction of blood vessels by foreign substance. . Blood flow reduced
E) T sudden constriction of a blood vessel, reducing its diameter and flow
42) ANSWER - B
Hydrothorax – accumulation of water/fluid in the thorax
Pneumothorax – accumulation of air
Heamothorax – accumulation of blood
Pyrothorax – accumulation of pus 4th intercostal space is the space that is usually used for drainage. (Between 4th
and 5th ribs)
43) ANSWER – A
47) ANSWER - C
55) ANSWER – E
Venous PCO2 - 46 mmHg
Arterial PCO2 - 40 mmHg
56) ANSWER – D In emphysema alveolar septum is lost and capillaries are decreased.
8th Proper – SEQ ANSWERS
2)
2.1
Thoracic inlet is the upper opening of the thoracic cavity that communicate with the neck and upper extremities.
It is bounded posteriorly by the first thoracic vertebra,anteriorly by the upper margin of manubrium and lateraly by
the upper margin of the right and left first rib’
It is kidney shaped.
Direct forward and downward.
In the midline of thoracic inlet trachea lies on esophagus and may touch the jugular notch of manubrium.
The esophagus lies against the body of T1 vertebra.
In the midline of thoracic inlet wholly occupied by the esophagus,trachea and two strap muscle of
neck(sternothyroid,sternohyoid) and inferior thyroid vein.
Then right of midline brachiocephalic trunk and right brachiocephalic vein present.

On the left of midline the left common carotid artery ,left brachiocephalic vein,left recurrent laryngeal nerve and
thoracic duct present.
Laterally on each side the apex of lungs and cervical plexus project upward.
Scalaneus medias and scaleneus anterior is inserted to the superior surface of the first rib . Trunks of brachial plexus
present in scalaneus triangle.
2.2.
Right bronchus is
Shorter
Wider
More in line with trachea
Left bronchus is
Longer
Narrower
More angled with trachea
2.3.
Hilum of the each lung lies behind the third and fourth costal cartilage at sternal margin and level of T5-T7 vertibra.
Lung apex is 2.5cm above the medial margin end of clavicle.
Then the anterior margin of the right lung fall with costo-mediastinal line of pleural reflection in lateral margin of the
sternum.
Left lungs anterior border lies beyond the lateral margin of the sternum and are from forth costal cartilage to fifth
intercostal space just medial to mid clavicular line.
The lower border of the lungs lies nearly horizontal around the chestwall but 2 ribs higher than the pleural reflection.
It is in sixth rib at mid clavicular line,eight rib in mid axillary line and tenth rib in lateral border of erector spine.
In both lungs oblique fissure is a line join the spine of third rib to the sixth rib in midclaviculer line.
Horizontal fissure present in right lung .
It is horizontaly lies in the forth costal cartilage.
It meet oblique fissure in the midaxillary line.
5.
5.1. HIGH ALTITUDE
When increasing high altitude,
Composition of air stay same
Total barometric pressure falls
Partial pressure of gasses in atmosphere reduced
So partial pressure of gasses in alveoli reduced
Effect of high altitude

1) Respiratory Alkalosis
When partial pressure of gasses in alveoli reduce hypoxia occur
Stimulate peripheral chemoreceptors
Hyperventilation occur
Co2 washed away rapidly
Pco2 levels in alveoli reduced rapidly
Then reduced of o2 levels in alveoli.
H2O + CO2 H2CO3 H+ + HCO3-
H+ levels in blood decrease

pH increased & alkalosis occurs
Ventilation comes back to normal level after 4 days.
Alkalosis corrected in few days time by passing HCO3- in urine.
2) Mountain sickness
A delayed effect
Develop when 8- 24h after arrival of high altitude
Last for 4-8 days
Characterized by Headache ,Irritability ,Insomnia ,Breathlessness ,Nausea and Vomiting
Associated with cerebral oedema.
3) Cerebral oedema
Low po2 at high altitude
Arteriolar dilation
When cerebral autoregulation can’t compensate
Capillary pressure increased
Increased transduction of fluid in to brain tissue
Cerebral oedema
4) Pulmonary oedema
Pulmonary vasoconstriction due to hypoxia
Pulmonary hypertension
Hypertrophy of right heart
Pulmonary oedema
5) Diuresis
-some develop diuresis instead of mountain sickness
Methods to minimize the effects of high altitude
01) Breathing 100% o2
02) Creating an artificial atmosphere around the individual
03) Gradual ascend
ACCLIMATIZATION
“Compensatory mechanism operate over a period of time to increase altitude tolerance”
1) Hyperventilation
- A short term compensatory mechanism
- Gradually increased
-steadily increased over the next 4 days because lactic acidosis In brain
-lactic acidosis in brain caused by active transport of H+ in cerebrospinal fluid.
-Lactic acidosis cause to fall CSF PH and it increase the response to hypoxia.
-Hyperventilation cause to shift the o2 Hb dissociation curve to left.
2) Polycythemia
A long term compensatory mechanism due to hypoxia
Increase erythropoietin secretion in kidneys
Increase RBC production in bone marrow
Polycythemia
Increase Hb concentration

Secretion of erythropoietin increase rapidly and reduces gradually.
3) Increase 2-3 BPG levels

2-3 BPG bind with Hb in RBC
Reduce affinity of Hb to O2
Increase o2 delivery to tissues
This causes to shift the oxygen- hemoglobin dissociation curve to right
High altitudes o2 – Hb dissociation curve shift to the left due to alkalosis.
4) Increase number of mitochondria

- Mitochondria is the site for oxidative reaction
5) Increase number of myoglobin
- Facilitate movement of o2 into tissue.
6) Tissue content of cytochrome oxidase
Permanent human habitation in 5500 m

-Barrel- chested
- Polycythemia
- Law alveolarbPO2
- Healthy
5.2
Transport of CO2
Types of transport
(i)HCO3- in plasma -70%
(ii) Carbaminohemoglobin -20%
(iii) Dissolved co2- 10%
Gas Exchange Barrier
-thickness is 0.3 m
-alveolar capillary membrane
Pulmonary epithelium
Common basement membrane
Capillary endothelium
Exchange of CO2 & O2

-by simple diffusion
-depend on,
I. Thickness of membrane
II. Square area of membrane
III. Partial pressure gradient across membrane
IV. Solubility of gas
-co2 is more soluble in lipid bilayer
-So, CO2 easily pass across the membrane
V. Molecular weight
-not important to compare o2 & co2

8th REPEAT – SEQ ANSWERS
1.
1.1
Describe the briefly the content of posterior mediastinum and their relations (50)
space posterior to the pericardium and to the domed upper surface of the diaphragm
contains the oesophagus , thoracic aorta ,azygos , hemiazygos ,accessory hemiazygos vein ,thoracic duct and lymph
nodes
thoracic aorta commences at lower border of TV 4 , first lies left of the midline then runs to the midline and leaves
the posterior mediastinum at the level of TV 12by passing behind the diaphragm
oesophagus in the posterior mediastinum ,it is crossed anteriorly by the left main bronchus and right pulmonary
artery
thoracic duct first is posterior to the oesophagus ,firs it lies in the right side of the oesophagus and ascending behind
the oesophagus in the posterior mediastinum
on the more posterior plane the hemi azygos ,accessory hemiazygos cross the midline behind the oesophagus •
thoracic duct lies anterior to the terminal part of hemiazygos and accessory hemiazygos veins
1.2
Describe briefly the gross anatomy of inter costal space and add a note on its clinical significants
space between the two ribs
filled by the muscles of the 3 layers
outer layer
- external intercostals muscle ( chief muscle )small muscles
– serratus posterior superior , serratus posterior inferior ,levator costae
middle layer - internal intercostals muscle
Inner layer –sub costal , innermost intercostals , transverses thoracic
•Between the middle and inner layer there are inter costal nerves and vessels
Vein , artery ,nerve lie in order from above downward
•They are under cover downward projection of lower border of the rib
•Needle for pleural drainage is inserted just above the ribs ,lower border of the intercostals space To avoid damage
to neurovascular bundle
•Anaesthetic solution on an intercostals nerve inserted just below the lower border of ribs
•Collateral branches of nerve and vessels run along upper border of a rib are small and can be ignored
•Outer layer chief muscle is external intercostals

Fibres of muscle extend downward forward
Arise from sharp lower border of the rib above
Inserted in to smooth upper border of below rib
Extend posterior
- from superior costotransverse ligament anteriorly
– costochondral joint
•Middle layer consist of internal intercostals muscles
Fibres run downward backward
Arise from costal groove of the upper rib
Inserted in to upper border of below rib
It extend forward to side of the sternum

•Inner layer consist 3 group of muscles
Innermost intercostals muscle line the rib cage at the side
Sub costal are at the back
Transverses thoracic at the front
They cross more than one inter costal space
Intercostals nerve emerge from the inter vertebral foramen and given off it s posterior ramus
Pass between the internal intercostals and transverses thoracic
Intercostals nerve then gives off collateral and lateral cutaneous branches
Collateral branches lie along the inferior border of space
Lateral cutaneous branch pierce the intercostals muscles
Divide into anterior and posterior branches
Supply skin over the space
Intercostals nerves end as an anterior cutaneous branches
Anterior ramus of T1 gives off 1st intercostals nerve
Supply 1 s t inter costal space muscles
Intercostals arteries
Arteries enter from back – posterior inter costal arteries
From in front – anterior intercostals arteries
At the back upper 2 spaces supplied by branch of 2nd part of subclavian artery , superior inter costal artery
Remaining 9 spaces are supplied separate branches of descending thoracic aorta
Anterior intercostals arteries , upper 6 spaces – internal thoracic artery
7 , 8 , and 9 th spaces by musculophrenic arteries
Last 2 spaces there are no anterior intercostals arteries
Anterior inter costal arteries pass back and anastomose with posterior intercostals arteries
Venous drainage
Each space there are one posterior vein and 2 anterior inter costal veins
They accompany arteries of same name
Anterior vein drain to internal thoracic vein and musculophrenic vein • Posterior veins not regular
1st vertebral or brachiocephalic vein
2 ,3 , 4 th form single trunk , superior intercostals vein
Superior intercostals vein drained to on right side to azygos veins left side left brachiocephalic vein
Lower 8 spaces on right to azygos vein ,left side by heiazygos and accessory hemiazygous vein
Lymph drainage follow the arteries

From the front – anterior inter costal nodes
From the back – posterior inter costal nodes
5.
5.1
Define the term hypoxia
Oxygen deficiency at the tissue level
5.2
state the 4 types of hypoxia with an example for each type
1) Hypoxemia -p o2 level of the arterial blood is reduced
- Normal individual at high altitude

- Pulmonary fibrosis
-Severe asthma
2) Anemic hypoxia - p o2 level is normal - Haemoglobin concentration of the blood is reduced.
- Co poisoning
3) Ischemic (stagnant)) hypoxia - normal p o2 and haemoglobin concentration - Blood flow to a tissue is low - No
adequate o2 supply to tissue
-heart failure
4) histotoxic hypoxia - amount of o2 deliver to tissue is adequate. - Due to action of a toxic agent the tissue cannot
use the o2 that supplied to them
- CN poisoning
5.3
Explain the relationship of hypoxia and cyanosis
Hypoxia-deficiency of oxygen at the tissue level
Cyanosis-dusky bluish discoloration of the tissue due to increase deoxygenated (reduced)haemoglobin level than
5g/dl in the capillaries blood .
In hypoxia arterial p o2 level decrease
So saturation of haemoglobin by oxygen is decrease
Decrease oxygenated haemoglobin concentration in the blood
Increase the deoxygenated haemoglobin level in blood
Occur bluish discoloration in the tissue Cyanosis occur
5.4
5.4.1
Explain why cyanosis occur in pulmonary fibrosis
Hypoxia- deficiency of oxygen in the tissue level
In pulmonary fibrosis scar tissue formation in the lung parenchyma
So lung tissue is stiff, hard to expand normally
Decrease surface area for gas exchange
And due to fibrosis increase thickness of respiratory membrane, decrease the oxygen diffusion
Decrease p o2 in the arterial blood
Decrease the concentration of oxygenated haemoglobin
Increase concentration of deoxygenated haemoglobin than 5g/dl in the capillary blood
Bluish discoloration of the tissue , cyanosis occur
5.4.2
Cyanosis is more prominent in polycythemia
Cyanosis is bluish discoloration of tissue due to increase deoxygenated haemoglobin level in the capillary blood than
5g /dl
Polycythemia , increase red blood cell count than normal level in the blood
So increase haemoglobin concentration in the blood
Due to above reason increase deoxygenated haemoglobin level in the blood and cyanosis occur

9th Batch
9th Proper - MCQs
1. Rate of pulmonary and systemic gas exchange depend on

A) Thickness of the respiratory membrane
B) Molecular weight of gases
C) Surface area available for exchange in lungs
D) Partial pressure difference of gases
E) Solubility of gases
11. The superior vena cava

A) Is formed by the right anterior cardinal and right common cardinal veins
B) Is formed behind the manubrium sterni
C) Opens into the right atrium behind the 3rd costal cartilage
D) Receives the hemi azygos vein
E) Lies in the superior mediastinum
12. Regarding the inlet of the thorax

A) The lateral boundary is formed by the inner surface of the first rib and its costal cartilage
B) Manubrium sterni forms the anterior boundary
C) Posterior boundary is formed by the lower border of T4 vertebra
D) Brachiocephalic artery passes through it
E) Vertebral artery passes through it
14. Regarding functional residual capacity

A) Is the volume of air in lungs after passive expiration
B) Prevents lung fluctuations of composition of air which enter the alveoli
C) In healthy adult, it is 10 litre
D) Reduced when airflow resistance increase
E) Can be measure directly by spirometer
15. The right phrenic nerve

A) Lies in the superior mediastinum
B) Has the superior vena cava on its medial side
C) is posterior to the thoracic duct
D) Passes through the caval opening in the diaphragm
E) Supplies the fibrous pericardium
16. Regarding the bronchopulmonary segments

A) There are eight bronchopulmonary segments in each lung
B) Each segment is pyramidal in shape with the base towards the hilum
C) Each segment is supplied by a lobar bronchus
D) It is the smallest part of the lung that could be removed surgically
E) They are supplied by end arteries
17. The right lung

A) Has its inferior lobe below and behind the oblique fissure
B) Has four structures in the hilum

C) Has five bronchopulmonary segments in its lower lobe
D) Has the arch of the aorta related to its mediastinal surface
E) Is supplied by two bronchial arteries
18. Trachea
A) Is 10 cm long
B) Bifurcates at T4 Level
C) Is behind esophagus throughout
D) Bifurcate at midline
E) Commences at C3 Level
19. Following changes seen in people living in high altitude

A) Increased ventilation
B) Increased PO2 in arterial blood
C) Increased PCO2 in arterial blood
D) Increased RBC count
E) Reduced arterial PH
20. Diaphragm
A) It is completely separate the thoracic cavity from abdomen
B) Innervates from spinal segment of C3-C5
C) Has aortic opening at T10
D) Has esophageal opening at T12
E) Has an opening for IVC in central tendon
21. Which of the following statement most correctly to the anatomy of larynx?
A) It lies superior to the hyoid bone and terminate
B) It consist two single cartilage and two paired cartilage
C) Intrinsic laryngeal muscles alter size and shape of larynx
D) Extrinsic muscles move the vocal cords
E) Recurrent laryngeal nerve supply all extrinsic muscles
22. Regarding work of breath in respiration

A) More muscular effort is needed for the expiration
B) Force of expiration is higher than the force of inspiration
C) Presence of surfactant reduce the muscular effort during inspiration
D) Recoil of lung reduced the muscular effort during inspiration
E) The work of breathing is high in bronchial asthma
23. In upright position

A) Ventilation is better in the upper zone of lung
B) Perfusion is better in the lower zones of lung
C) Intra pleural pressure is more negative in lower than upper zone
D) V/Q is better in lower zone compared to upper zone
E) Compliance is better in lower zone
24. Hypocapnia
A) It may be due to hyperventilation

B) Causes dilatation of cerebral vessels
C) Decreases cardiac output
D) Depresses the vasomotor center
E) Has direct constrictor effects on peripheral vessels
SBR
42. Patient is diagnose that plural effusion. It was planned aspiration fluid from mid axillary line on right side
thoracocentesis. Which is most suitable ribs avoid right lung damage
A) 1st – 3rd rib
B) 3rd – 5th rib
C) 5th – 7th rib
D) 7th – 9th rib
E) 9th – 11th rib
43. A 68 years old male has profuse amount of fluid in the left pleural cavity due to acute pleurisy. When he sits
up in bed, where would fluid accumulate?
A) Costomediastinal recess
B) Costodiaphragmatic recess
C) Hilar reflection
D) Cardiac notch
E) Pulmonary recess
52. False statement is, in high altitude

A) Increase PaCO2
B) Increase PaO2
C) Increase erythrocyte amount
D) Increase PaH2
E) Increase amount of O2
53. Major part of CO2 transport in the blood

A) Combination with Hb
B) As HCO3-
C) As carbonic acid
D) As physical solution
E) With plasma protein
54. Chronic respiratory acidosis has following characteristic except

A) Hyperventilation
B) Increased serum HCO3- level
C) Excretion NH3 and phosphate in urine
D) pH is less than 6
E) PCO2 level is increased
55. O2 therapy will be useful in following conditions except

A) COPD
B) Anemia
C) Heart failure

D) CO poisoning
E) High altitude
59. Which of the following is the site of highest airway resistance?

A) Trachea
B) Largest bronchi
C) Medium-sized bronchi
D) Smallest bronchi
E) Alveoli
9th Proper - SEQs
1.
1.1 A 70 years old man who was a heavy cigarette smoker for nearly 50 years was diagnosed with lung cancer.
Radiologic & bronchoscopic examinations revealed a relatively small tumor in one of the tertiary bronchi of the
middle lobe right lung later the affected segment was removed & there were no evidence of metastasis of the tumor
1.1.1. Describe the gross anatomy of the right lung

1.1.2 Explain the reason for the absence of metastasis of tumor in above case
4. A patient was brought to the clinic after sustaining deep stab injury on the right chest. On the examination he was
found to have collapsed right lung, cyanosis & very low blood pressure.
Explain the physiological basis of,
4.1. Collapsed Right Lung
4.2. Cyanosis
4.3 Low blood pressure
9th Repeat - SEQs
2.
2.1 Describe the boundaries and arrangements of structures in the superior mediastinum (30 marks)
2.2 Describe the different parts origin, insertion, nerve supply & the applied anatomy of diaphragm
2.3 Enumerate the structures passing through it?
2.4 Explain common congenital anomalies of diaphragm
6. A 70-year old patient with congestive heart failure complained of breathing difficulty (dyspnoea / shortness of
breath) that was worse in supine position than in reclining position. His breathing was shallow and faster. The lips,
nail beds and tongue appeared bluish (cyanosis) pulmonary examination revealed excess of fluid in the lungs.
6.1 Explain the Physiological basis of excess fluid in lung following congestive heart failure. (30 marks)
6.2 Explain the Physiological basis of cyanosis in the above patient with pulmonary oedema. (35 marks)
6.3 Explain the Physiological mechanism of the shallow but rapid breathing seen in the above patient. (35 marks)

01) Gas exchange across alveolar capillary membrane depend on

Thickness
Square area
Solubility of gas
Molecular weight of gas
Partial pressure gradient across diffusion barrier
A) T
B) T
C) T
D) T
E) T
11)
A) T
B) F It is formed behind the right first costal cartilage by the union of right and left brachiocephalic veins
C) T
D) F Its tributaries are azygos vein, mediastinal and pericardial veins
E) T Its upper part lies in the superior mediastinum. The lower part lies in the anterior mediastinum
12) Last fig 6.9; page 347

A) T
boundaries-
• Anteriorly-costal cartilage of 1st rib and superior border of manubrium
• Posteriorly-superior surface of the body of the first thoracic vertebra
• Laterally-1st pair of ribs and its costal cartilages
B) T
C) F
D) T left and right internal thoracic artery, brachiocephalic artery, left common carotid artery, left subclavian artery,
left and right arteries are arteries pass through inlet
E) F The vertebral artery (right and left) arise from the first part of the subclavian artery. The vertebral artery enters
the foramen transversarium of the sixth cervical vertebra. It does not pass through the inlet of the thorax
14) FRC=volume of air remaining in the lungs after passive expiration.

A) T
B) T FRC prevent complete emptying of lung, prevent large fluctuations of composition of air in alveoli
C) F FRC=RV (1.3L) +ERV (1L) =2.3L
D) F airway resistance is change of pressure from alveoli to mouth divided by the change in flow rate. Bronchi and
bronchioles significantly contribute to airway resistance.
FRC increased when loss of lung elastic recoil, increased resistance to expiration, increased positive end expiratory
pressure .FRC decreased when lying supine
E) F
VC, TV, IRV, ERV can be measured directly, TLC, FRC, RV can’t measured directly
15)
A) T Nerves lying in the superior mediastinum are: phrenic, vagus and cardiac nerves, and left recurrent laryngeal
nerve

B) T The right brachiocephalic vein, superior vena cava, the pericardium over the right atrium and the inferior cava
lie on its medial side
C) F The right phrenic is not related to the thoracic duct
D) T Its terminal branches pass through the caval opening in the central tendon to supply the under surface of the
diaphragm
E) T The phrenic nerve supplies the mediastinal pleura, fibrous pericardium, parietal layer of the serous pericardium
16)
A) F There are ten bronchpulmonary segments in each lung and each of the ten bronchopulmonary segments have
ten segmental bronchi
B) F Each bronchopulmonary segment is pyramidal in shape with the base towards the lung surface and apex
towards the hilum
C) F Each segment is supplied by a segmental bronchus. Lobar bronchi supply the lobes of the lung (two lobar
bronchi in the left lung and three lobar bronchi in the right lung)
D) T It is the smallest part of the lung that could be surgically removed with minimal bleeding and damage
E) T This is important because if this artery gets blocked that part will become an infarct
17)
A) T The right lung has three lobes. The inferior lobe is below and behind the oblique fissure. The part of right lung in
front and above the oblique fissure is subdivided in to the superior lobe and middle lobe by the horizontal fissure.
The left lung has two lobes, superior and inferior, separated by the oblique fissure
B) F The right lung has five structure in the hilum, namely the two pulmonary veins, one pulmonary artery, upper
lobar bronchus and right principal bronchus. The left has four structures in the hilum, namely the two pulmonary
veins, one pulmonary artery and the left principal bronchus
C) T It has three, two and five bronchopulmonary segments in the upper, middle and lower lobes respectively
D) F The arch of the aorta is related to the mediastinal surface of the left lung. The azygos vein is related to the
mediastinal surface of the right lung
E) F It is supplied by a single bronchial artery
18)
A) T 10cm long, 2cm diameter
B) F at upper border of T5 vertebra
C) F behind oesophagus
D) F little right to midline
E) F in the neck below the cricoid cartilage at the level of C6 vertebra
19)
A) T in high altitude PO2 in atmosphere is less than at sea level. Body compensate it by increasing ventilation
B) F decreased arterial PO2 hypoxia
C) F PCO2 reduced due to hyperventilation
D) T
E) F CO2 washing out due to hyperventilation.it cause to increase PH
20)
A) F there are openings for passage of structures between thorax and abdomen
B) T motor nerve supply is from phrenic nerve (C3-C5; mainly from C4)
C) F aortic-T12 Oesophageal-T10 Vena cava- T8
D) F
E) T right to the mid line; behind 6th right costal cartilage; between middle and right leaves of central tendon

21)
A) F suspended from hyoid bone, Span between C3-C6 from laryngeal pharynx to trachea
B) F three paired-arytenoid, corniculate, cuneiform Three unpaired-thyroid, cricoid, epiglottis
C) T control shape of Rima glottis and length tension of vocal cords
D) F move the larynx superiorly and inferiorly
E) F recurrent laryngeal nerve-sensory innervation to infraglottis, motor innervation to all muscles except
cricothyroid (it innervated by superior laryngeal nerve)
22)
A) F expiration is passive, inspiration is active
B) F
C) T low compliance reduce lung recoil pressure and thereby reduce muscular effort need to inflate lungs
D) F aid expiration
E) T asthma cause narrowing of airways; increase work of breathing
23)
A) F base
B) T
C) F in upper zone
D) F better at top
E) T smaller alveoli
24)
A) T
B) F constriction. 30% reduction in blood flow
C) F increases
D) T
E) T
42) ANSWER - B
4th space is often chosen
43) ANSWER -B Costodiaphragmatic recess is the most dependent part of lung,
52) ANSWER -E Partial pressure=total pressure × percentage of gas Percentage is constant
53) ANSWER -B Dissolved in plasma as CO2-7% In plasma as HCO3—60-70% Bound to HB -20-30%
54) ANSWER - A Hyperventilation occur to compensate metabolic acidosis
55) ANSWER – C Heart failure is a condition in which heart unable to pump sufficiently
59) ANSWER – C The medium-sized bronchi actually constitute the site of highest resistance along the bronchial tree.
Although the small radii of the alveoli might predict that they would have the highest resistance, they do not
because of their parallel arrangement. In fact, early changes in resistance in the small airways may be “silent” and go
undetected because of their small overall contribution to resistance.

01.
1.1
1.1.1
Lungs are,
Vital organ of respiration
Main function is gas exchange
Are elastic & recoil organ
Separated from each other by mediastinum
Anterior border of lungs ;

o Right lung :- lies behind the lateral margin of sternum
o Left lung :- lies beyond the lateral margin of sternum & arc from 4th costal cartilage to 5th intercostal
space just medial to mid clavicular line
Lower border of lungs;
Lies horizontally & 2 ribs above than the pleural reflexion around the chest wall
Midclavicular line at 6th rib
Mid axillary line at 8th rib
At lateral border of erector spinae at 10th rib
Hilum :- -Behind 3rd,4th costal cartilage at sternal margin -Level with T5-T7
Lung has an apex & base
o Apex :- extend above root of neck Covered by cervical pleura
o Base :- concave inferior surface Opposite the apex Resting on diaphragm
Lung has 3 surfaces ;
I. Costal
II. Mediastinal
III. Diaphragmatic
Borders of lung
Has 3 borders;
I. Anterior border
II. Inferior border
III. Posterior border
Anterior border :- cardiac notch groove this border
Posterior border :- Lies in cavity at paravertebral gutter
Hilum of lung
Right hilum> left hilum
Wedge shaped area on mediastinal surfaces of each lung
Enter or exit the lung
Pulmonary ligament :- Consist of a double layer of pleura Separated by small amount of connective tissue
Root of lungs
Left Right
- crossed above by arch of aorta - crossed above by azygous vein
phrenic nerve pass down anteriorly -phrenic nerve pass down Anteriorly

phrenic nerve pass down anteriorly -phrenic nerve pass down Anteriorly
-superiorly recurrent laryngeal nerve
Lungs are attached to mediastinum by roots of lung

Consist of ;
1. Pulmonary artery
Superimost on left
2. Superior & inferior pulmonary veins
Anterior most & inferior most respectively
3. Main bronchus
Gainst & in middle of posterior boundary
4. Pulmonary plexuses of nerve
Features of left & right lungs
Right lung Left lung

Larger & heavier than left smaller & lighter
Shorter & wider longer 7 narrower
Anterior border is relatively straight Anterior border has deep cardiac notch
2 fissures One fissur
Right oblique Left oblique
Horizontal
3 lobes 2 lobes
Superior Superior
Middle Inferior
inferior
Has lingual
- Thin, tongue like process
- Extend below the cardiac notch
Impressions of left & right lungs

Right lung
Groove for oesophagus (1)
Cardiac impression (2)
Groove for azygous vein (3)
Groove for SVC (7)
Shallow groove for trachea & right vagus (4)
Groove for subclavian artery
Shallow impression for IVC (5)
Groove for brachiocephalic vein (6)
Left lung
Large cardiac impression (1)
Arch of aorta (2)
Descending aorta(3)
Small groove for subclavian artery(5)
Left brachiocephalic vein (6)

Surface marking of the fissures
Oblique fissure (in both lungs)
A line joins the spine of 3rd thoracic vertebravertebrae (posterior end of 5th rib/0 to 6th rib in midclavicular line
Iine of 5th rib
Along the vertebral border scapular of fully abducted arm
Horizontal fissure (in right lung)
Behind the 4th costal cartilage
Horizontally lies
Meets oblique fissure in mid axillary line
Blood supply By: - Bronchial artery Bronchial vein

Lymph drainage 2 lymphatic plexus superficial/ Sub pleural plexus
Deep plexus
Clinical Pleural Aspiration
Removing fluid or air from pleural cavity
Aspiration needle pass through the chest wall close to upper border of rib
It avoid the damage to neurovascular structures; course along lower border of rib
Often use 4th space in
1.1.2 Each lung lobes can be further divided into sub divisions, known as broncho pulmonary segments.
>They are separated from adjacent by connective tissue septa.
>Each are supplied by
1. Segmental bronchus.
2. Tertiary branch of bronchial artery.
>Also the pulmonary veins run independently, draining from adjacent broncho pulmonary segment.
>So as these segments are surgically resectable, when affected segment was removed, tumour doesn’t spread to
another segment.
4.0
4.1
At rest ,normally the pressure within the plural cavity is slightly less than atmospheric pressure
So, normally plural cavity is within the negative pressure
Naturally, lungs prefer to collapse in while chest wall prefers to expand out
So due to the forces which are equal in magnitude, but opposite in direction
between chest wall and lungs
lungs do not collapse
and chest does not separate out
Also, due to this opposite and equal forces, visceral plura which is attached to the lungs
And the parietal plura which is attached to the chest wall
Remain sticky with each other
In this case ,due to the deep stab injury on R/chest thoracic wall(chest) is damaged
So the expanding force of chest wall is loss
Due to the remaining opposite force of the R/lung is collapse
4.2
Bluish discoloration of skin and mucous membrane due to Increased amount of reduced Haemoglobin
Normal Hb concentration=15mg/dL

Cynosis is not present unless 05g of Hb is in deoxygenated(reduced) form in the capillary of skin
In this case, due to the collapsed lung, lung volume is reduced
So ventilator area is reduced
So Po2 in alveoli is reduced, below 100mgHg
So Po2 in blood reduced
Due to the ventilation defect
So oxygenated Hb concentration in blood reduced than it’s normal level
Deoxygenated Hb concentration in blood increased
Cyanosis occur
4.3
When blood pressure When renal blood flow is reduced
Specialized smooth muscle cell in afferent arterioles
Which act as baro receptors
And specialized kidney cells know as “macula densa” at DCT
Which act as chemoreceptors and Na+ sensors
Release a hormone called RENIN
Meanwhile liver synthezised special type of enzyme known as ANGIOTENSINOGEN Angiotensinogen is converted to
Angiotensin (decapetide) by renin
In the endothelium of pulmonary circulation system
ACE Angiotensin II (octapeptide)
Angiotensin helps to regulate the blood pressure in several ways
Mainly it constricts blood vessels (vasoconstriction)
It acts as an anterioconstrictor Increase TPR
so it increase DPB
It acts as a vasoconstrictor, Increase VR
increase EDV
increase SV
increase CO
increase BP
Also the sympathetic nerves have Ang II receptors
When Ang II binds with recptors, sympathetic nerves release Norepinephrine
Which act as a venoconstrictor and arterioconstrictor
Also zona glomeruloza cells in the adrenal gland has Ang II receptors
And when Ang II binds with its receptors ,zona glomeruloza cells release Aldosteron
2.
2.1
Wedge shaped
Anteriorly manubrium.
Posteriorly bodies of T1 to T4 vertebra.
Superiorly thoracic inlet.
Inferiorly plane of sternal angle.
Laterally two pleura.
At the thoracic inlet ,

Esophagus lies against the body of T1 vertebra.
Trachea lies on the esophagus.
Apices of lungs lies laterally
2.2
Fibro muscular sheet
Derivative of inner layer of body wall
Fibers continue with transversus abdominis from within costal margin
Completed by fibers from arcurate ligament & crura
From circumference, fibers arch upward in to domes & descend to central tendon ( at xiphisternal joint )
Right dome is higher than the left
- Ascend in full expiration
- Right 4th space ( nipple level)
- Left 5th rib
- Viewed from above, outline is kidney shaped
- Crura
- Strong tendon
- Attach to anterolateral surface of upper lumbar vertebrae
- Right crus – attach to upper 3 lumbar vertebrae
- Left crus – attach to upper 2 lumbar vertebrae
- Fibers pass vertically upward & curve forwards in to central tendon
- Median arcuate ligament - Formed by fibers from medial edge of each crus
- Lies in front of aorta at T12 level - Medial arcuate ligament - A thickening in psoas fascia - Extend from side of body
of L1 or L2 to anterior surface of transverse process of L1
- Lateral arcuate ligament
- Extend from transverse process of L1 to middle of lower margin of 12th rib
- A thickening in anterior layers of lumbar fascia
- Lies in front of quadrates lumborum
- A digitation arise from internal surface of lower 6 costal cartilage & ribs
- Interdigitate with transverse abdominis
- In front, diaphragm arise from back of xiphisternum
- Central tendon
- Frefoil shape
- Middle leaf situated fibrous pericardium ( same embryological origin)
2.3
03 large openings & several smaller ones
Aortic opening
Opposite T12, in midline, behind the median arcuate ligament
Transmit aorta
Thoracic duct
Azygos vein
Oesophageal opening
Lies – 2.5 cm left of midline
Behind 7th left coastal cartilage
Opposite T10
Lies in fibers of left crus but fibers from right crus loop around it

Attach to oesophagus about 2- -oesophageal ligament)
Passes through this
Vagal trunks
Oesophageal branch of left gastric artery
Veins & lymphatic accompany the oesophagus
A major site of portal system anastomose
Venous drainage
Caudally to portal venous system
Cranially to azygos venous system
Vena caval foreman
Lies opposite T8
Just to right of midline
Behind 6th costal cartilage
Between middle & right leaves of central tendon
( fuse firmly with adventitial wall of IVC )
Right phrenic nerve passes through this alongside IVC - Smaller openings
Hemiazygos vein
Greater , lesser & Least splanchnic nerves – through each
Sympathetic trunk – behind medial arcurate ligament
Left phrenic nerve – pierce left dome
Subcostal nerve & vessels – behind lateral arcuate ligament
Neurovascular bundles of 7th – 11th intercostal spaces
Pass between diaphragm & transversus abdominis in to abdominal wall
Superior epigastric vessels – pass between xiphisternal & costal fibers of diaphragm
2.4
Congenital diaphragmatic hernia (CDH) is a birth defect of the diaphragm.
Malformation of the diaphragm allows the abdominal organs to push into the chest cavity, hindering proper lung
formation.
CDH is a life-threatening pathology in infants and a major cause of death due to two complications: pulmonary
hypoplasia and pulmonary hypertension.
Experts disagree on the relative importance of these two conditions, with some focusing on hypoplasia, others on
hypertension.
Newborns with CDH often have severe respiratory distress which can be life-threatening unless treated
appropriately.
6.
6.1
side of the heart.

Reduce SV lead to reduce CO
So VESV increase , so back pressure increase.
According to this blood accumulation hydrostatic pressure increase in the pulmonary capillary system.
So starling forces become unbalance.
Filtration pressure gradient increase through pulmonary capillary
More blood filter to lung parenchyma
Lymph drainage is not adequate to absorb this all fluid
So excessive fluid accumulation can be seen in heart failure.

6.2
Cyanosis is the bluish color of the skin & mucus membrane
Pulmonary edema can be see in type I respiratory failure
That mean diffusion is decrease
Due to pulmonary edema gas exchange area is reduce
So less O2 soluble
Reduce Po2 due to less diffusion in to pulmonary capillary.
Then reduced oxygenated Hb concentration.
Due to the heart failure perfusion also impaired
Then deoxygenated Hb concentration goes up than normal
When it exceed 5g/dl
Bluish color appear in the skin and mucus membrane
It’s called cyanosis
6.3
Due to the congestive heart failure pulmonary edema can be occurred
So excessive fluid accumulate in the alveoli
Then alveolar surface tension become increase
So alveolar somewhat collapse
Then lung capacity get reduce
Normal negative pleural pressure can’t expand lung completely
Due to that reason shallow breathing occur.

10th Batch
10th Proper - MCQs
1. Regarding thorax
A) Internal intercostal muscle fibers run downwards and forward
B) Eighth to tenth costal cartilages directly attached to the sternum
C) the Tenth rib has one facet on its head
D) First rib flattened from above downwards
E) Twelfth rib has a subcostal grove
8. The trachea
A) Bifurcate at the level of the sternal angle
B) Is directly related to the right vagus nerve
C) Is directly related to the left subclavian artery
D) Is prevented from collapsing during inspiration by incomplete rings of
elastic cartilage
E) Lies in the median plane through its length
9. Regarding the innervation of structure of respiratory system

A) Internal laryngeal nerve supply mucosa of the infraglottic area of the larynx
B) Intercostal nerve carries somatic and autonomic fibers
C) Motor innervation of the diaphragm is purely by phrenic
D) Nasal cavity is innervated by the glossopharyngeal nerve
E) Recurrent laryngeal nerve supplies all the intrinsic muscle of the larynx
10. Lung tissue

C) Is supplied by vagus nerve
D) Is derived from lung bud in foregut
16. The diaphragm

A) Has an opening for the aorta at the level of the 10th vertebral level
B) Has a motor innervation from the 10th thoracic nerve
C) Has its left dome at a higher level than that of the right
D) Is attached to the right three lumbar vertebrae
E) Is formed in part from the dorsal mesentery
26. Peripheral chemoreceptors stimulated by

A) Hypoxia
B) Cyanide
C) Hypercapnia
D) Hydride ion
E) Carbon monoxide

27. Which of the following findings in a healthy Sri Lankan student who is in Tibet for 2 Weeks at an altitude of
5500
A) Respiratory rate of 38/min
B) Packed cell volume of 32%
C) Urinary pH of 7.45
D) Deviation of oxygen-hemoglobin dissociation curve to left
E) Barrel-shaped chest
30. Functional Residual Capacity in lung of a healthy adult

A) The volume of air in the lungs at the end of passive expiration
B) Can be measured directly using a spirometer
C) Is about 1 litre
D) Become smaller if air flow resistance increases
E) Prevents fluctuations of alveolar gas concentrations during the breathing cycle
31. With regard to mechanic factors in breathing

A) In quite breathing more muscular work is done during inspiration than during expiration
B) Forced expiration is more difficult than forced inspiration
C) Recoil of chest wall facilitate expiration
D) Intrapleural pressure is less negative during inspiration than expiration
E) Surface tension in the alveolar wall is greater during inspiration than expiration
32. Arterial hypoxia occur

A) CN poisoning
B) CO poisoning
C) Hypoventilation
D) Hb reduction
E) Shock
33. Control of breathing

A) Increase in ventilation during exercise is proportional to a rise in arterial PCO2
B) Peripheral chemoreceptors are stimulated by reduced O2 content in arterial blood
C) Afferents from airway in the vagus nerve inhibit the inspiratory center
D) Breathing can continue when the brain stem is the only functional part of the brain
E) Cerebral cortex controls breathing through medullary respiratory centers
34. Cyanosis is associated with

A) Cold temperature
B) Anemia
C) Polycythemia
D) CO poisoning
E) VSD
35. True/false
A) Highest resistance is present in bronchioles
B) β1 receptors stimulation lead to bronchodilation
C) IgA is present in the secretions of the lungs
D) In force expiration inter thoracic pressure can become positive

E) At the end of the inspiration intra alveolar pressure becomes zero
SBR
50. Most of carbon dioxide transported in blood

A) HCO3-
B) Bound to Cl
C) Dissolve in plasma
D) Carbamino form in plasma protein
E) Carbamino form in hemoglobin
51. Obstructive airway disease and restrictive lung disease both reduce
A) Vital capacity
B) FEV1
C) FEV1/VC
D) Residual volume
E) Peak expiratory flow rate
52. Correct statement regarding surfactant

A) Is secreted by type I pneumocystis
B) Reduces the fluid filtration forces in pulmonary capillaries
C) Increases surface tension during expiration
D) Deficiency causes neonatal respiratory distress syndrome
E) Synthesis is decreased by the glucocorticoids
58. A 50-year-old male with a history of chronic smoking,

Hoarse voice inability to abduct his left vocal cord had a mass in upper lobe of left lung at the hilum could have
impact the left recurrent laryngeal nerve by
A) Tracheobronchial nodes
B) Thoracic duct
C) Parasternal node
D) Bronchopulmonary nodes
E) Pulmonary nodes
59. Pain from parietal pleura transmitted by

A) Phrenic nerve and intercostal nerves
B) Vagus nerve and phrenic nerve
C) Greater splanchnic and phrenic nerve
D) Intercostal nerves and vagus nerve
E) Greater splanchnic nerves and intercostal nerves
10th Proper - SEQs
3.
3.1 Describe the gross anatomy of trachea. (30 marks)
3.2 Write an account on tracheo-esophageal fistula. (15 marks)
3.3 Outline the surface marking of pleura, lungs and their fissures. (30 marks)

3.4 Write an account on portal systemic anastomosis. (25 marks)
10th Repeat - SEQs
5. Breath holding time,

5.1 Can be prolonged if it is preceded by hyperventilation
5.2 Cannot be prolonged if it is preceded by breathing pure oxygen
Explain the physiological basis of the above experience (2× 50 marks)
1)
A) F it runs downwards & backwards.
B) F they articulate into the ribs above.
C) T Single facet for 10th thoracic vertebrae.
D) T other ribs flattened from anteroposteriorly.
E) F it is poor in 11th rib & absent in 12th rib.
8)
A) T
B) T Right side -right vagus nerve left side –left recurrent laryngeal nerve.
C) T Left subclavian artery is one of the relations of left side.
D) F It is prevented from collapsing in expiration by incomplete rings of hyaline cartilage.
E) F It slightly deviates to the right side.
9)
A) T above vocal
B) F only somatic
D) F innervated by olfactory nerve, infraorbital nerve, anterior ethmoidal nerve, anterior superior alveolar nerve
E) F except cricothyroid
10)
A) T Elastic connective tissue
B) F respiratory epithelium from anterior 3rd of nose to the beginning of respiratory bronchioles is ciliated. Rest is
simple squamous.
C) T lung is supplied by pulmonary plexus. Pulmonary plexus formed from cardiac plexus, thoracic vagus and
sympathetic chain
D) T foregut is divided into dorsal potion; esophagus and ventral portion; trachea and lung bud by the
tracheoesophageal septum.
Abnormalities in it result in tracheoesopageal fistula
E) F
16)
A) F At the level of T12
B) F Entire motor supply to the diaphragm is given by phrenic nerve.

C) F
D) T Right crus is attached to the fronts of the upper 3 lumbar vertebrae.
E)T
26)
A) T if PO2 ≤60 Hg mm
B) F peripheral chemoreceptors are triggered by, - hypoxia, hypercapnia, PH decreases
cyanide inhibits cytochrome oxidase. It doesn’t change partial pressures in blood.
C) T
D) F hydride iron (H-)
basic
PH increases
E) F CO causes anemic hypoxia.
Arterial PO2 is unchanged. [Hb] available decreases
27)
A) T Due to the hypoxic hypoxia in high attitude increase respiratory rate. After 2 weeks (after acclimatization) it
remain in high constant rate.
B) F PCV should increase than normal.
C) T
D) F Due to the increase 2, 3 BPG level reduce the affinity of Hb of O2.
E) F
30)
A) T FRC = volume of air remaining in lung after expiration of normal quite breath.
Normal quiet expiration is passive
B) F spirometer can measure; FVC, FEV 1, TV, IRV, ERV, TC.
Can’t measure; residual volume, FRC, Total lung capacity
C) F 2.5L
D) F when air flow resistance increases, expiration becomes difficult, increased FRC
lar gas remains remarkably constant. PO2 = 100
mm Hg PCO2= 40 mm Hg
31)
A) T inspiration is an active process; diaphragm and external intercostal muscles contract Expiration is a passive
process.
B) F forced inspiration uses accessory respiratory muscles; SCM, scalene, latissmus dorsi, pectoralis major, serratus
C) T in passive expiration
D) F
E) T in spherical objects like alveoli, according to law of Laplace;
P = 2T/r
reduce surface tension (T) in alveoli during expiration than during inspiration
32)
Arterial hypoxia = hypoxemia/ hypoxic hypoxia – where PO2 is decreased
Eg- ventilation defect; - pulmonary fibrosis, asthma, emphysema Diffusion defect; - fibrosis, pulmonary edema
- inhibits cytochrome oxidase

acity of O2
E) F stagnant/ischemic hypoxia
33)
A) T the gradual rise of ventilation during exercise is due to increased PO2
B) T PO2 less than 60 mm Hg
D) T vegetative breathing. Respiratory center is located in medulla

E) T voluntary system is located in cerebral cortex and sends impulses to the respiratory motor neurons via
corticospinal tracts
34)
A) T cyanosis = bluish discoloration of the skin and mucous membrane when reduce HB concentration more than
5g/dl. Eg. Cold expose, chronic lung disease, drug overdose
B) F anemia = decreased HB concentration in blood
C) T polycythemia = increased HB concentration in blood
E) F
normal VSD
35)
A) T bronchi and bronchioles significantly contribute to airway resistance, by contraction of smooth muscles.
B) F β2 receptors are present in bronchial smooth muscles.
Stimulation of these causes Broncho relaxation
C) T secretory immunoglobulins (IgA) secreted by airway epithelial cells.
D) F ganong pg. 628 fig 34.7
E) T
51) ANSWER – B
A) F
B) T
C) F
D) F
E) F Only in obstructive airway disease.
52) ANSWER – D
Surfactant doesn’t affect fluid filtration forces in pulmonary capillaries but it reduces fluid transudation into the
alveolar space.
58) ANSWER – D
Grants Pg. 45
At the hilum of lung - Broncho pulmonary/ hilar nodes

59) ANSWER – A
Mediastinal surface - phrenic
Central part of diaphragmatic-Phrenic
Costovertebral surface-intercostal nerves
Periphery of diaphragmatic surface-intercostal nerves
3.
3.1
Continuation of the larynx.
10cm long, 2cm diameter.
Commencement—C6 vertebra level, below the cricoid cartilage.
5cm above the jugular notch.
Attach to the lower margin of cricoid cartilage by cricotrachial ligament.
Termination—at upper border of T5 vertebra.
Has two parts. Cervical and thoracic part.
Cervical part.
5cm length, from lower border of cricoid cartilage to jugular notch.
Lies in the midline.
Oesophagus behind the trachea in cervical part. Recurrent laryngeal nerve in the groove between trachea and
oesophagus.
Carotid sheath each side of the trachea.
Thyroid gland,
Isthmus—adherent to 2nd, 3rd, 4th tracheal ring.
Lobes—lateral side of trachea to 6th tracheal ring.
Anterior relation—inferior thyroid vein, anterior jugular venous arch, thyroid ima artery.
Upper end of thymus.
Upper end—close to the skin.
2cm or more deep in front of jugular notch.
Pass downward and backward to enter the thorax.
Thoracic part.
5cm in length.
From jugular notch to upper border of T5 vertebra.
Lies little right to the midline.
Pass through the superior mediastinum.
Relations—oesophagus behind the trachea.
Anterior
Manubrium, sternohyoid/sternothyroid.
Remnant of thymus, inferior thyroid vein.
Left brachiocephalic vein.
Brachiocephalic trunk, left common carotid artery.
Right vagus nerve – confect with right side of vagus, hook forward over the right bronchus.
Anterolateral—right brachiocephalic vein, superior vena cava.
Left to the trachea—left common carotid artery/subclavian artery.

Left recurrent laryngeal nerve, pass upward in the groove between trachea and oesophagus.
Bifurcation of pulmonary trunk, left to the tracheal bifurcation.
Right pulmonary artery, cross midline just below the tracheal bifurcation.
Contain 15-20 C shaped hyaline cartilage rings.
Gaps between these rings filled by trachealis muscle.(smooth muscle)
Blood supply.
Arterial supply—branches of inferior thyroid artery, branches of bronchial artery.
Venous drainage—inferior thyroid vein.
Lymph drainage—pretracheal/paratracheal/inferior deep cervical lymph nodes.
Nerve supply.
Mucus membrane—vagus/recurrent laryngeal nerve.
Smooth muscle/blood vessels—sympathetic fibers. From sympathetic trunk(upper ganglia)
3.2
Tracheo-oesophageal fistula (TEF) indicates an abnormal connection between hollowed interior of above structures.
Whole respiratory tract and oesophagus are derived from the foregut. Respiratory system developed as a
diverticulum grown anteriorly from the foregut.
Normally respiratory system and GI system separate by trachea-oesophageal septum.
Failed to complete tracheo –osephageal septum, TEF occur.
There are some varieties of TEF.
Fistula with oesophageal atresia.(most common) • H type fistula.
3.3
Pleura.
Consist of 2 layers.
Parietal and visceral pleura continuous with each at the hilum of the lungs.
Parietal layer of pleura lines the thoracic wall.
Visceral layer of pleura is closely adherent to the lung surface and fissures.
Cervical pleura.
Pleura projects 2.5cm above the junction of the middle and medial 1/3 of clavicle.
Pleura does not extend above the neck of the 1st rib.
Anterior.
Costomediastinal line reflection, on the right side it extends from the sternoclavicular joint downward and medially
to the midpoint of sternal angle.
From here it continuous to the midpoint of the xiphisteranal joint.
On the left side, line follows the same course, tip to level of the 4th costal cartilage.
Then arches outwards and descends along the sternal margin up to the 5th costal cartilage.
Inferior margin.
The costodiaphragamatic reflection.
Pass laterally from the lower border of lateral margin.
Then crosses midclavicular line at 8th rib.
Then crosses midaxillary line at 10th rib.
Then crosses 12th rib at the lateral border of the erector spinae muscle.
It passes horizontally to the lower border of the T12 vertebra.
Lung.
The apex of each lung follows cervical pleura extends 2.5cm above the middle and medial 1/3 of each clavicle.

Anterior border.
Right
—follows very closely to anterior margin of pleura.
Left
—follows up to the 4th costal cartilage.
_curve laterally due to heart.
_curves downward medially to reach the 6th costal cartilage.
Lower border.
Each lung crosses the midclavicular line at the 6th rib.
Crosses the midaxillary line at the 8th rib.
Crosses the lateral border of erector spine at the 10th rib.
Ends lateral to 10th thoracic spine.
Oblique fissure—by line drawn obliquely downward and outward from spine of T5 to 6th rib in the midclavicular line.
Horizontal fissure—by line drawn horizontally along the 4th costal cartilage, this line meets oblique fissure in the
midaxillary line.
5. breath holding time

5.1. can be prolonged if it is preceded by hyperventilation
CO2 function as the main regulator in ventilation because it link respiration with metabolism
Increased CO2 in body cross the blood brain barrier
Within the CSF CO2 + H2O→ H2CO3 →H+ + HCO3-
This H+ stimulate the central chemoreceptors in medulla oblongata which stimulate the inspiratory center, increased
ventilation (Washout CO2 from the body)
During diving some people hyperventilate which cause decreased PaCO2 than normal (subnormal level).
So it takes longer time to increase and stimulate the central chemoreceptors which lead to prolonged breath holding
time
But this way lead to unconsciousness in the water which is a dangerous consequence.
5.2.
Cannot be prolonged if preceded by breathing pure oxygen
Decreased in PaO2 (below 60mmHg) Stimulate peripheral chemoreceptors in aortic body and carotid body which
stimulate inspiratory center and increase the ventilation
Increased CO2 (main regulator) stimulate central chemoreceptors in medulla oblongata and increase the respiration
in pure O2 breathing, PaO2 increase but during the breath holding
PaCO2 level increased (rapid increase due to expiration)
While PaO2 level
But increase in PaCO2 stimulate the receptors
Which stimulate inspiratory center and start respiration
So, breath holding is not prolonged than normal breath holding in pure O2 breathing
Extra;
Pure O2 in alveoli ,alveoli may collapse (O2 toxicity)

11th Batch
11th Proper - MCQs
1. Regarding parietal pleura

A) Developed from splanchno pleuric mesoderm.
B) Form the pulmonary ligament.
C) Attached to the fibrous pericardium.
D) Form the costodiaphragmatic recess.
E) On the lung surface, parietal pleura is in contact with visceral pleura.
2. The trachea,
A) Bifurcate at the level of the sternal angle.
B) Is directly related to the right vagus nerve.
C) Is directly related to the left subclavian artery.
D) Is prevented from collapsing during inspiration by incomplete rings of elastic cartilage.
E) Lies in the median plane throughout its length.
3. Vital capacity
A) Maximum volume of air expirated after a full inspiration.
B) Related to body surface area.
C) Same in male and female.
D) Decrease in obstructive air disease.
E) Measured by using peak expiratory flow meter.
4. Regarding intra pleural pressure

A) Sub atmospheric.
B) Become positive during inspiration.
C) Maintained by adhesive force of pleura.
D) Equals to intrathoracic pressure.
E) Become equal to atmospheric pressure during closed pneumothorax.
5. Hypoxemia can be seen in

A) Hypoventilation.
B) Pulmonary oedema.
C) CO Poisoning.
D) Anaemia.
E) Living in High altitude for 3 weeks.
6. Which are true statements?

A) Fail chest caused by multiple fractures of the ribs.
B) Costal angle is the weakest point.
C) Intercostal injection inserted to the inferior border of the rib.
D) All 11 posterior intercostal arteries arise from descending aorta.
E) Transverse thorasis muscle separate pluera & vessel in 1st, 2nd, 3rd space.
7. Anatomical features of the hilum of the left lung include the following
A) Phrenic nerve passes in front of it.

B) Vagus nerve passes behind it.
C) Arch of aorta curves over it.
D) It has one bronchus.
E) It is at T4-T5 vertebral levels.
8. Dissolved oxygen in plasma depends on

A) Partial pressure of oxygen.
B) Plasma pH level.
C) Partial pressure of carbon dioxide.
D) Plasma hemoglobin concentration.
E) Body temperature.
9. True or false
A) Sternal angle is at the level of the T2-T3.
B) Xiphisternal joint is secondary cartilaginous.
C) 1st and 12th ribs are easily felt.
D) The sternal angle is palpable in the obese people.
E) The 1st palpable spine is the T1.
10. Diaphragm
A) Central tendon has no bony attachment.
B) Aortic hiatus formed by median arcuate ligament.
C) Transversalis fascia extend to form the phrenoesophageal ligament.
D) Downwards projection of diaphragm increases thoracic-abdominal blood flow.
E) Phrenic nerve gives sensory supply to the periphery of the diaphragm.
12. Work of breathing increase in

A) Increased lung compliance.
B) Decrease in airway resistance.
C) Increased rate of respiration.
D) Lack of surfactant.
E) Increased tidal volume.
13. Regarding bronchopulmonary segments

A) The apex is directed toward the surface of the lungs.
B) Has a segmental venous drainage.
C) Is a separate respiratory unit.
D) Are equal in number in both lungs.
E) One segment can be removed surgically.
15. Thoracic wall

A) Has a cartilaginous wall.
B) Is cylindrical in shape.
C) Is bounded below by the 7th – 10th costal cartilages and the 11th and 12th ribs.
D) Receives its nerve supply by the brachial plexus.
E) Internal thoracic artery supply the major portion of the intercostal spaces.
16. Regarding the thoracic inlet

A) The lateral boundary is formed by the inner surface of the 1st rib and its costal cartilage.
B) Manubrium sterni forms the anterior boundary.
C) Posterior boundary is formed by the lower border of T4 vertebra.
D) Brachiocephalic artery passes through it.
E) Vertebral artery passes through it.
SBR
44. A Patient is diagnosed as plural effusion. It was planned aspiration fluid from mid axillary line on right side
thoracocentesis. Which is most suitable ribs avoid right lung damage
A) 1st – 3rd rib.
B) 3rd – 5th rib.
C) 5th – 7th rib.
D) 7th – 9th rib.
E) 9th – 11th rib.
45. Correct statement regarding surfactant

A) Is secreted by type I pneumocytes.
B) Reduces the fluid filtration forces in pulmonary capillaries.
C) Increases surface tension during expiration.
D) Deficiency causes neonatal respiratory distress syndrome.
E) Synthesis is decreased by the glucocorticoids.
46. A 56-year old man fell from a stage and admitted to the emergency department in an unconscious situation.
Tracheostomy is performed, brisk excessive arterial bleeding suddenly occur from midline incision over the
trachea. What is the most likely to be damaged?
A) Inferior thyroid branch of thyrocervical trunk.
B) Thyroid ima artery.
C) Middle thyroid vein.
D) Jugular arch connects the anterior jugular vein.
E) Cricothyroid branch of superior thyroid artery
11th Proper - SEQs
5. Explain the physiological basis dyspnea (shortness of breath) in,

5.1. Pulmonary edema
5.2. Diabetic ketoacidosis
5.3. Renal failure
5.4. Pneumothorax
01. Regarding parietal pleura

A F Parietal layer of Lateral Plate Mesoderm (Langmann page 96)
B T Pulmonary ligament is the continuity between parietal and visceral Pleura inferior to the root of the
lung
C T Mediastinal Pleura is adherent to fibrous pericardium
D T Costodiaphragmatic Recess is a narrow space formed by Costal Parietal Pleura against diaphragmatic
parietal pleura
E T Last Page 212
02. The trachea

A T Thoracic plane
B T Right Vagus contacts Trachea; The great arteries arising from Arch of Aorta prevents Left Vagus Nerve
from contacting trachea
C F Brachiocephalic trunk and Left Common Carotid Arteries contact the anterior surface of Trachea
D F Hyaline Cartilage
E F Tracheal Bifurcation is little right of the midline (Last-194)
03.Vital capacity
A T VC= IRV+TV+ERV= 3.5L
Vital capacity; refers to the maximum amount of air expired from the fully inflated lung or maximum
inspiratory level.
B T Metabolism and Oxygen Consumption increases with Body Surface Area
C F Depends on age, sex, height, mass
D T Low in both Obstructive and Restrictive lung diseases
E F Measured by spirometer: Peak Expiratory Flow meter measures PEFR(peak expiratory flow rate)
4) Regarding intra pleural pressure

A T Always subatmospheric (negative) under normal physiological conditions
BF
C F Maintained by elasticity of thoracic wall and lungs
D T Intrapleural Pressure=Intrathoracic Pressure
E F Intrapleural pressure increases above atmospheric pressure in Closed Pneumothorax (not equal)
(because air trap in the cavity)
5)Hypoxemia can be seen in

A T Hypoxic Hypoxia
B T Hypoxic Hypoxia
C F Anemic Hypoxia
D F Anemic Hypoxia, PaO2 is normal
E F Will be compensated
6)Which are true?

A T Flail chest occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a
part of the chest wall moves independently
BT
C F Needle is inserted just above the superior border of the rib to avoid damaging the intercostal nerves
and vessels
D F Upper 2 Posterior Intercostal Arteries arise from- Superior Intercostal Artery

3rd-11th posterior Intercostal
and Subcostal Arteries arise from- Descending Aorta
E F Transversus Thoracis muscle extends from Sternum to 2nd to 6th costal cartilage
7) Anatomical features of the hilum of the left lung include the following
AT
BT
CT
DT
E F Hilum of each lung lies approximately behind 3rd and 4th Costal cartilages at the sternal margin in the
level with T5-T7 verteberae
8) Dissolved oxygen in plasma depends on

AT
BT
CF
DT
ET
9) True/false
A F At T4 level
BT
C F Both ribs are difficult to palpate (Elli’s clinical anatomy)
D T Fat does not tend to accumulate in this area
E F the first spinous process that can be felt is that of C7 (Elli’s)
10) Diaphragm
AT
BT
C T Last- Page186
D T Intra-abdominal Pressure increases in diaphragm contraction, so increase venous return.
E F Motor innervation- Phrenic Nerve
Proprioceptive innervation-
Phrenic Nerve (Central region)
Lower 06 intercostal fibers (Periphery)
12) Work of breathing increase in

A F Reduces.
Compliance describes the distensibility of the lungs and chest wall and is inversely related to elastance
B F Reduces
C T Work done by the respiratory muscles increases
D T Surface tension is increased
E T Work= Pressure x Volume

13) Regarding bronchopulmonary segments
A F Wedge shape
Apex toward the hilum.
Base toward the outer surface of lung.
B F Bronchopulmonary segments are drained by intersegmental parts of the pulmonary veins that lie in the
connective tissue between and drain adjacent segments. (Moore anatomy pg;115)
C T Separated from adjacent segments by connective tissue Septa and surgically resectable individually
D T 10 segments in each lung
E T Moore anatomy pg;116
15) Thoracic wall

A F Musculo-Osseo-Cartilaginous wall
B F Domed shaped
CT
The thoracic skeleton includes 12 pairs of ribs and associated costal cartilages, 12 thoracic vertebrae
and the intervertebral (IV) discs interposed between them, and the
D F From Intercostal Nerves
E F Supplied by posterior intercostal arteries from descending thoracic aorta
16) Regarding the thoracic inlet

A T Posteriorly- Vertebra T1
Laterally- 1st pair of ribs and their costal cartilages.
Anteriorly- Superior border of the Manubrium.
BT
CF
DF
EF
Structures passing through Thoracic Inlet-
1. Trachea
2. esophagus
3. Thoracic duct
4. Apex of lung
5. Nerves (Phrenic Nerve, Vagus Nerve, Recurrent Laryngeal Nerve, Sympathetic trunk)
6. Arteries (Left and Right Common Carotid Arteries and Left Subclavian Artery)
7. Veins (Internal Jugular Vein, Brachiocephalic Vein and Subclavian Vein)
8. Lymph nodes and vessels
44)
1.As fluid accumulates inferiorly, its easier to remove the whole fluid easily
2. Risk for lung damage is reduced
3. To avoid important neurovascular structures
Answer (E)

45) Correct statement regarding surfactant
A F Type 2 Pneumocytes
B F Reduces Surface tension in lung alveoli
C F Reduces Surface tension
D T Neonatal respiratory distress syndrome can occur in premature infants because of the lack of
surfactant. The infant exhibits atelectasis (lungs collapse), difficulty re-inflating the lungs (as a result of
decreased compliance), and hypoxemia (as a result of decreased V/Q).
E F Glucocorticoids accelerate Surfactant maturation
Answer (D)
46)
Thyroidea Ima Artery
present in only 3% of individuals arises from Brachiocephalic trunk, Arch of Aorta or Right Common Carotid
Artery. It travels anterior to Trachea and enters the lower part of isthmus
Answer (B)
5.
5.1. Pulmonary edema
Excess fluid in the lungs:- causes heart failure
A. As fluid increased in the alveoli
O2 CO2 transport affected
So PaO2 in blood decrease (hypoxic hypoxia)
Decreased O2 in arterial blood stimulate peripheral chemoreceptors which increases the respiration
(hyperventilation)
B. Increased fluid in alveoli

decreased compliance in the alveoli (due to decreased concentration of surfactant)
Decreased in lung compliance
increased work of breathing So, increased respiration and increased work of breathing eventually leads to
difficulty in breathing.
5.2
In diabetes mellitus type 1 diseaese
Lack of insulin production
Cannot use glucose as ATP So, body start the ketogenesis; production of ketone bodies for energy
Increased ketone bodies
Increased acid in the body
Increased H+ concentration
This condition is called metabolic acidosis
So body start the respiratory compensation.
Increased H+ concentration

Stimulate the central chemoreceptors
Increased the respiration, so person start to hyperventilate to washed out CO2 (H+ + HCO3- H2CO3 CO2 +
H2O)
Prolonged hyperventilation
Muscles become exhausted/fatigue
Dyspnea
This condition is called as ‘Kussmaul breathing’
5.3.
Renal failure
Kidney is the major site of remove the excess H+ from the body
In renal failure,
Removal of H+ in DCT is affected. Which may lead to acidosis
So, increased in H+ in the body Stimulate the central chemoreceptors in medulla oblongata Increased the
respiration
The way of CO2 body can remove the excess H+ which cause, rapid, deep breathing
5.4. Pneumothorax
This is a collapsed lung occurs when air leaks into the pleural cavity.
In pneumothorax, Alveoli collapsed- alveolar compliance is decreased. cannot inflate the alveolar easily. So
the work of breathing increased.
Increased in work of breathing
dyspnea

12th Batch
12th Proper - MCQs
07. Regarding the intercostal tube inserting

A) Pierce all three muscle layers
B) Pierce endo thoracic fascia
C) Lateral wall is suitable site
D) Can be leads to pneumothorax
E) Mostly used 5th intercostal space at mid axillary line
08. What are the structures pierce diaphragm and enter into abdomen?
A) Greater splenic nerve
B) Azygous vein
C) Thoracic duct
D) Vagus nerve
E) esophagus
09. Superior mediastinum

A) Wedge shaped area
B) Posterior boundary is convexed towards mediastinum
C) Concavity of the arch of the aorta wholly in the superior mediastinum
D) Great arteries keep right vagus nerve and apex of the right lung away from the contracting trachea
E) Left brachiocephalic vein run above the arch of aorta to SVC
10. Phrenic nerve

A) Pass down laterally to the scalene muscles
B) Right phrenic nerve crosses the aortic arch lateral to superior intercostal nerve
C) Left phrenic nerve pierces the muscular part of the diaphragm
D) Right phrenic nerve relates medially with the brachiocephalic vein
E) Supplies the peripheral part of the diaphragmatic pleura
11. In The Right Upper Lung

A) Blood flow to the base is higher than that is to the apex
B) Ventilation-perfusion ratio is lower at apex than that is at the base
C) An area of under ventilation will result in shunting of blood to bitterly ventilated areas
D) Blood leaving an under-perfusion area is likely to have a higher PaCO2 than normal
E) Diffusion capacity of CO2 is similar to that of O2
12. True or False regarding conducting airways,

A) Main blood supply is from pulmonary arteries
B) The trachea of a normal adult is slightly deviated to right
C) Impaired ciliary action leads to obstructive lung disease
D) Airway resistance is higher during inspiration than expiration
E) Inhaled foreign particles are more likely to enter left bronchus than right
13. Left Main Bronchus

A) More vertical than right
B) Lies anterior to esophagus

C) Aorta crosses posteriorly
D) Contain circular cartilage ring
E) Divide into 3
15. Regarding paranasal sinuses

A) Maxillary sinuses not present at birth
B) Posterior ethmoidal sinuses drain to inferior meatus
C) Sphenoidal sinuses drain to superior meatus
D) Maxillary sinus pain referred to upper jaw
E) Main function is warming inhaled air
20. about functional residual capacity of lung

A) is about 1L
B) represent the volume of air remaining of lung after normal expiration
C) is a combination of tidal volume, expiratory reserve volume and residual volume
D) helps to indicate lung diseases
E) can be measure by spirometer
21. Regarding dead space,

A) About 150ml in average healthy adult.
B) Physiological dead space is measured by single breath N2 curve.
C) Increase when breathing through a tube
D) Physiological dead space is equal to anatomical dead space in healthy person
E) No gas exchanged is occurred in there
22. Regarding Intrapleural Pressure

A) It can be measured by spirometer
B) Remains constant during respiratory cycle.
C) It is sub atmospheric
D) Higher in pneumothorax than in normal
E) Higher in pulmonary emphysema than in normal.
23. Regarding surfactant

A) are produced by type II alveoli (pneumocytes)
B) reduce the surface tension
C) premature babies may have respiratory distress syndrome
D) more produced in 3rd trimester of pregnancy
E) facilitate gas exchange across respiratory membrane
24. Regarding gas diffusion across alveoli

A) Oxygen diffusion capacity is higher than CO2
B) O2 diffusion not affected in pulmonary edema
C) depend on thickness of respiratory membrane
D) is increase in increased perfusion to alveoli
E) increased when molecular weight is increased

37. In upright position in the upper portion of the lung,
A) ventilation is less than at the base
B) perfusion is more than at the base
C) ventilation perfusion ratio is higher than at the base
D) the gravity doesn't have effect on ventilation
E) reduction in the pulmonary arterial pressure can lead to physiologic dead space
SBR
43. Ligated blood supply in 3-6 posterior intercostal spaces. Which artery will be expected for supplying these
spaces?
A) Internal intercostal
B) Anterior intercostal
C) Posterior intercostal
D) Lateral thoracic
E) Musculophrenic
44. Respiratory distress syndrome occur by which cell?

A) Type I pneumocytes
B) Type II pneumocytes
C) Chief cells
D) Natural killer cells
E) Mast cells
45. Bronchial smooth muscles are supplied by,

A) Greater thoracic nerve
B) Phrenic nerve
C) Vagus nerve
D) Intercostal nerves
E) Lesser thoracic splanchnic nerve
50. Last factor affecting oxygen pass through respiratory membrane

A) Thickness of respiratory membrane
B) Alveolar temperature
C) Area of respiratory membrane
D) Oxygen pressure gradient
E) Surfactant
52. Which of the following site has the highest airway resistance?
A) Trachea
B) Alveoli
C) Bronchi
D) Respiratory bronchiole
E) Alveolar ducts
53. Major part of CO2 transport in the blood

A) Combination of Hb
B) As HCO3-

C) As carbonic acid
D) As physical solution
E) With plasma proteins
54. In the superior mediastinum,

A) The esophagus lies against the body of the first thoracic vertebra
B) The arch of the aorta lies partly in the superior and partly in the inferior mediastinum
C) the superior vena cava passes inferiorly, posterior to the left border of the sternum
D) the dead space is mainly on the left
E) the superior vena cava receives the azygos vein opposite the fifth right costal cartilage
55. Not including anatomical dead space

A) Bronchus
B) Lobar bronchus
C) Segmental bronchus
D) Respiratory bronchus
E) Terminal bronchus
12th Proper – SEQs
3. Intra plueral pressure during quite breathing is Negative. (less than the atmospheric pressure.) in pneumothorax
following chest injury the pressure become positive, the lung collapse and its volume decreases and the volume of
thoracic cage increases.
Explain the mechanism that
3.1. Keep the normal inrapleural pressure sub atmospheric.
3.2. Make the lung collapse in pneumothorax while increasing the thoracic volume.
12th Proper – MCQ ANSWER
07)
A)
B) T
C) T
D) T
E) T
08)
A) T
B) F Mainly with the right ventricle, right atrium on its right side and a narrow strip of the left ventricle
C) T
D) T
E) T
(09)
(A) T
(B) F Posterior boundary of superior mediastinum -much longer
- first 4 thoracic vertebral bodies
- concave towards the mediastinum

(C) F
•Concavity of the arch of the aorta lies in the plane of the sternal angle
•arch of the aorta lies wholly in the superior mediastinum
(D) F
(E) T
(10)
(A) F each nerve is in contact laterally with the mediastinal pleura throughout the whole of its course & nerve
passes down over the anterior scalene muscle
(B) F left phrenic nerve crosses arch of the aorta lateral to the superior intercostal vein
(C) T
(D) T
(E) F 2/3 motor to the diahragm 1/3 sensory to the diahragm
(Except for the most peripheral parts which receive intercostal afferent fibers)
(11)
(A) T
(B) F, apex has higher V/Q ratio than the base
(C) T
(D) F
(E) F
(12)
(A) F,main blood supply is bronchial artery
(B) T
(C) T
(D) T
(E) F, inhaled foreign particles are more likely to enter into the right lower lobe bronchus
(13)
(A) F, right main bronchus is more vertical than left
(B) T
(C) F, arch of the aorta curves backwards over the left bronchus
(D) T
(E) F, divide into in to 2 lobar bronchi
15) A) T
B)F ( to superior meatus and sometime to sphenoidal sinus)
C) T (via sphenoidoethmoudal recess)
D) sinus pain feel in forehead, either side of your nose , upper jaws and teeth
E) T ( warm and humidify the inspired air)
20)
A)F functional recidual capacity – 2.3L
B)T –functional residual capacity=residual volume + expiratory reserve volume
C) F
D) F can’t measure the residual volume so can’t measure functional residual capacity
E) F- can’t measure by spirometer
21) A) T
B) F measure anatomical dead space
C)T

D)T
E) F
22) A) F
B) F
C) T
D)T
E) F
23) A) T
B) T
C) T
D) T
E) F
24) A) F
B)T
C) T
D) T
E) F
37) A) T
B)F
C) T
D) F
E)T
43) B
At the front of intercostal spaces, internal thoracic artery in upper 6 & musculophrenic artery in lower 3 spaces
give off anterior intercostal arteries that pass backwards & anastomose with posterior intercostal vessels. (Last pg
184)
44) B
Respiratory distress syndrome is a breathing disorder in new born babies due to surfactant deficiency. Surfactant
is produced by type 2 pneumocytes in alveoli
45) C
(Last pg 216)

50)E
Factors affecting gas exchange through alveolar capillary membrane
 Thickness of the membrane
 Surface area of the membrane
 Diffusion coefficient of the gas
 Partial pressure difference of the gas between two side of the membrane.(partial pressure of a gas
depends on Temperature)
52) C
54)
A)T (page 190 last)
B)F the arch of aorta lies wholly in the superior mediastinum
C)F vertically downward behind the right border of sternum
D)F mainly in right side
E)F behind the sternal angles it receives azygous vein,2nd rib level
55)D
Anatomical dead space –total volume of the conducting airways from the norse or mouth down to the level of the
terminal bronchioles
12th Proper – SEQ answers
03.
3.1 keep the normal intrapleural pressure sub atmospheric.
• The lungs and the chest wall are elastic structures.
• Visceral pleura strictly adheres to the lung surface and parietal pleura strictly adhere to the chest wall.
• A thin layer of fluid is present between the lungs and the chest wall. (intrapleural space)
• Lungs slide easily on the chest wall but resist the separation.
• End of the quiet expiration the lungs tend to recoil from the chest wall.
• But it is balanced by the recoil force of the chest wall that act outwards.
• Those 02 forces (recoil force of lungs and recoil force of chest wall) are equal in value and opposite in
directions.
• So those 2 forces in equilibrium and make intrapleural pressure sub atmospheric. (- 2.5 mmHg)
• During inspiration,
 inspiratory muscles contract and increase the intrathoracic volume.
 So, the volume between 2 pleural layers is increased and leads to more pressure drop. ( -6 mmHg)
 Lungs are pulled in to more expanded position.

• At the end of the inspiration, the lung recoil begins to pull the chest back to the expiratory position and the
recoil pressure of the lungs and chest wall is balanced.
• During the expiration chest wall come to normal position and increase the intrapleural pressure.
• Strong inspiratory efforts reduce intrapleural pressure to values as low as -30mmHg.
3.2 Make the lung collapse in pneumothorax while increasing the thoracic volume
• A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall.
• Types of pneumothorax
o Closed pneumothorax – chest wall is intact, rupture of lung or visceral pleura allows air in to the pleural
space
o Open pneumothorax – air is allowed to enter pleural space from outside. Occurs when there is a large open
wound in chest wall.
o Tension pneumothorax – develops when air leak occurs from lung or through chest wall, creating a one-way
valve.
• In tension pneumothorax air continuously accumulate in pleural cavity.
• This buildup of air puts pressure on the lung.
• So, lung can’t expand and lungs are beginning to collapsed.
• Due to lung collapsing, recoil force of thoracic wall that act outward can’t be balanced.
• So, the thoracic wall begins to expand and increase the thoracic volume.

13th Batch
13th Proper - MCQs
1. Phrenic nerve
A) arise from the posterior rami of C3, C4 & C5
B) descend through the pleural cavity in thorax
C) convey sensory from mediastinal pleura
D) enter to the abdomen through caval opening
E) travel in thorax posterior to the lung root
3. Lung tissue
A) Supplied by oxygenated arterial blood by branches of aorta
B) Drain in to azygos veins
C) No lymph drainage
D) Throughout the pathway is lined by ciliated epithelium
E) Supplied by vagus nerve
11. Unilateral recurrent laryngeal nerve injury

A) para median position of the vocal codes
B) difficulty to swallowing fluid
C) normal healthy voice
D) immobility of ipsilateral vocal code
E) elevation of larynx
12. Adaptations by body in high altitude include

A) Increased RBC count
B) Decreased Hb count
C) Increased vascularity
D) Pulmonary hypertension
E) Lowering of cellular oxidative enzymes
17. Needle pass through the 9th costal cartilage towards costodiaphragmatic recess which structures pass through
the needle?
A) Endothoracic fascia
B) Innermost intercostal muscle
C) Parietal pleura
D) Serratus anterior
E) Visceral pleura
18. Diaphragm
A) pericardium attached to central tendon
B) descending occur during parturition
C) sensory supply to the periphery is phrenic nerve
D) aorta descend down through the medial arcuate ligament
E) Esophagus descend down at T8 level via esophageal hiatus

19. Pulmonary surfactant
A) glycoprotein
B) secreted by type II pneumocytes
C) increase surface tension of alveoli
D) deficiency increase lung compliance
E) prevent pulmonary oedema
20. What are correct responses?

A) Negative Intrathoracic pressure helps to expiration
B) Intrapleural pressure always negative
C) Intra pleural pressure formed by elasticity of alveoli
D) Intraalveoli pressure always same to atmospheric pressure
E) Inspiration is an active process
21. Factors providing increased respiratory rate

A) Hypoxia
B) Prolonged somatic pain
C) Sudden raise in BP
D) Anticipation of activity
E) Emotional anxiety
22. Diffusion of air is directly proportional to

A) Partial pressure gradient
B) thickness of respiratory surface
C) solubility of gas
D) molecular weight of gas
E) capillary transit time
23. T/F
A) Decreased pH increases affinity of Hb for O2
B) Hb F has high affinity for O2
C) CO bind strongly with Hb
D) Increased PCO2 releases more O2 from Hb
E) High body temperature releases more O2 from Hb
25. Regarding the surfactant?

A) A glycoprotein
B) Secreted by type ll alveoli (pneumocytes)
C) Reduction increase the lung compliance
D) Decrease amount leads to pneumonia
E) Reduction cause pulmonary oedema
SBR
44. A 39-year old patient had a retrosternal pain which radiated to his left shoulder. What is the nerve which
caused referred pain?
A) Long thoracic nerve
B) Phrenic nerve

C) Intercostal nerve
D) Intercostobrachial nerve
E) Vagus nerve
48. Due to an automobile accident manubrium-sternal joint was damaged. What’s the most probably damage
structure?
A) First rib
B) Second rib
C) Third rib
D) Fourth rib
E) Fifth rib
49. Which of the following muscle contributes most during quiet breathing
A) Intercostal
B) Diaphragm
C) Sternocleidomastoid
D) Scalene
E) Pectoralis major
50. Which one of the condition get the least benefits from oxygen therapy
A) hypoxic hypoxia
B) anaemic hypoxia
C) stagnant hypoxia
D) histotoxic hypoxia
E) CO poisoning
51. Which of the following is the strongest stimulus to medullary respiratory centre?
A) Hypoxia
B) Hypercapnia
C) Acidosis
D) Cerebral cortex
E) joints movement
13th Proper – SEQs
3. A middle aged male who sustained a rib facture on the right side following an accident was found to have
3.1. Collapsed right lung. (40 marks)
3.2. Rapid breathing. (30 marks)
3.3. Blue discoloration of skin and lips (30 marks)
Explain the physiological basis of the above observations.
5.
5.1. A young adult throws a peanut in the air and, in attempting to catch it by his mouth, inhales it.
5.1.1.What is the commonest site this peanut can lodge? (5 marks)
5.1.2.Briefly explain the reason for your answer stated in 5.1.1.? (15 marks)
5.1.3.Write an account on Broncho pulmonary segments. (30 marks)

01) phrenic nerve

A) F The phrenic nerve originates from the anterior rami of the C3 C4 C5 nerve roots.
B) F Passes over the dome of pleura and enters the thorax posterior to subclavian vein
C) T Sensory fibres from central part of diaphragm, mediastinal pleura, pericardium
D) T Right phrenic nerve passes through caval opening and left nerve pierce the muscle of the left dome Of
diaphragm.
E) F Passes anterior to lung root
03) lung tissue

A) T Usually there are three bronchial arteries. Two on the right are direct Branches of aorta.
B) T Superficial system of right hilar region and visceral pleura drains into Azygous vein
C) F Lymphatic vessels drains into broncho pulmonary nodes and then into Tracheobronchial nodes.
D) F Only up to respiratory bronchioles. Beyond that alveolar ducts have Cuboidal epithelium.
E) F Parasympathetic innervation from vagal afferent and efferent fibers.
11) Unilateral Recurrent Laryngeal nerve injury

A) T Vocal cord on the affected side take up paramedian position b/w abduction and adduction.
B) F
C )T Speech is not greatly affected because of the other cord is able to compensate.
D) T
E) F Reduced laryngeal elevation.
12) Adaptation by body in high altitude include

A) T Hypoxic stimulation causes prompt secretion of erythropoietin.
B) F
C)T As a delayed effect
D)T A delayed effect but not always occur
E) F Increase in oxidative enzymes can be seen.
17) Needle pass through the 9th costal cartilage towards costodiaphragmatic recess. Which structures pierced by the
needle?
A) T
B) T
C) T
D)F
E) F
18) Diaphragm
A) T (Last page 185) Central tendon is in separable from the fibrous pericardium.(Same Embryonic origin)
B) T (Last page 187) To increase intrabdominal pressure to facilitate delivery of baby.
C) F. Motor-Phrenic nerve (C3, C4, C5)
Proprioceptive
Central -> phrenic nerve
Periphery -> lower intercostal nerves
D) F Aorta- Behind median arcuate ligament Opposite T12 vertebra
E) F Esophageal hiatus-T10 level

19) pulmonary surfactant
A) T
B )T
C) F Decrease surface tension
D) F Compliance is directly propotional to surfactant level
E) T
20)
A) F Positive intra thoracic pressure
B) T Always sub atmospheric
C) T By both elasticity of chest wall and lungs
D) F Not always.(Refer Ganong page 628 fig.34-7)
E) T
21) Factors providing increased respiratory rate

A)T Stimulate peripheral chemoreceptors
B)T Pain results in increase flow, volume and rate of respiration
C) F
D) T
E) T
22)Diffusion of air is directly proportional to

A) T Partial pressure gradient proportional to gas diffusion
B) F Thickness of respiratory surface inversely propotional to gas diffusion
C) T Solubility proportional to gas diffusion
D) F Molecular weight inversely proportional to gas diffusion
E) F Capillary transit time inversely proportional to gas diffusion
23 T/F
A) F Decrease in pH results decrease in oxygen affinity of Hb. (Bohr effect)
B) T Hb F in infants has more oxygen affinity as adaptation for intra uterine life
C) T The affinity of Hb for CO is 210 times greater than the affinity for Oxygen
D) T
E) T Increased temperature causes decrease oxygen affinity of Hb.

25 Regarding Surfactant
A) T
B) T
C) F
D) T Causes anatomical changes commonly seen during pneumonia
E) T
44) B Retrosternal pain is mostly due to pericarditis. The pain of pericarditis Is transmitted by phrenic nerve which
originates from C3-C5. The some Nerve roots contribute for the innervation of shoulder which causes pain In
shoulder.
48)B Inferior angle of manubrium and upper lateral border of sternum have articular Facets for second costal
cartilage
50) D Because cells are unable to uptake oxygen in histotoxic hypoxia
51) C Increased Hydrogen ion concentration stimulate medullary (central) chemoreceptor
3.1 Collapsed right lung ( 40 )

Collapsed right lung
• The lungs and chest wall are elastic structures.
• The lungs slide easily on the chest wall but resist being pulled away from it.
• The lungs are stretched when they expand at birth.
• At the end of quiet expiration their tendency to recoil from the chest wall is just
• Balanced by the tendency of the chest wall to recoil in the opposite direction.
• Due to rib fracture chest wall is lost its elasticity and fracture allow atmospheric air to
• Enter into the intrapleural space.
• When air trapped in the intrapleural space the condition is called pneumothorax.
• Now in this situation recoil force of chest has lost, air exerts an additional pressure on
• Lung and lung still has its elastic recoil ability.
• Due to this condition lung recoil inwards.
• This is why right lung is collapsed in this patient
3.2 rapid breathing ( 30 )

• Due to rib fracture atmospheric air has entered into the intrapleural space and Pneumothorax results.
• As a result right lung has collapsed. And cannot expand as much as it normally does when the patient is
breathing.
• Lung volume has reduced.
• Consequently total lung capacity of the patient also reduced.
• Amount of air (oxygen ) enter in to the lung reduced.
• As a result oxygen partial pressure in alveoli reduced. (Normal value = 100mmHg)
• It results in reduced oxygen partial pressure gradient through alveolocapillary membrane.
• As gas diffusion directly propotional to the partial pressure gradient, oxygen diffusion through the
membrane reduced.
• As oxygen amount enter in to the pulmonary capillary blood is reduced, Oxygen partial pressure in the
capillary blood also reduced.

• Reduced pO2 in arterial blood results in hypoxic hypoxia. (Hypoxemia)
• Hypoxemia is a potent stimulation for peripheral chemoreceptors; Carotid bodies (mainly) and aortic
bodies.
• Stimulated carotid bodies transmit afferent nerve impulses via glossopharyngeal nerve and stimulated aortic
bodies transmit afferent nerve impulses via vagus nerve to dorsal group of respiratory neurones in medulla.
• From there efferent nerve impulses pass via the respiratory motor neurones to stimulate respiratory
muscles.
• It results in hyperventilation in the patient.
• And also anaerobic respiration of tissue cells produces lactic acid. Buffering of lactic acid may liberate more
carbondioxide. Increased carbondioxide level may also has a role in hyperventilation.
3.3 blue discoloration of skin and lips ( 30 )

• Blue discoloration of skin and lips is an indication of Cyanosis.
• Cyanosis appears when the reduced Hemoglobin concentration of the blood in the Capillaries is more than
5g/dL.
• Due to rib fracture, patient has developed pneumothorax.
• It has resulted in reduced total lung capacity.
• Amount of air (oxygen) enter into the lungs has reduced consequently.
• Oxygen partial pressure in alveoli is reduced.
• Partial pressure gradient for Oxygen through alveolocapillary membrane is reduced.
• Then Amount of oxygen enter into the pulmonary capillary is reduced.
• Therfore Oxygen saturaion of Hemoglobin in the pulmonary capillaries is reduced.
• Hemoglobin unsaturated amount increases.( normally amount of saturated Hb at the End of pulmonary
capillary is 97.5% )
• As Cyanosis depends on degree of Hb unsaturation, Cyanosis develops in this Situation.
05)
5.1.1 Lower lobe of right lung
5.1.2
• the right main bronchus is 2.5cm long and shorter, wider and more vertical than left.
• and at tracheal bifurcatiom lowest tracheal cartilage has a hook-shaped process;carina.
• Carina curves backwards between the bronchi and raises an anteroposterior Internal ridge that lies to the
left of the midline.
• Therefore foriegn bodies that inhaled are more likely to enter in to right bronchus And pass vertically down
to lower lobe of right lung
5.1.3. Write an account on bronchopulmonary segments. (30)

• Bronchopulmonary segments are the largest subdivisions of a lung lobe.
• Those are pyramidal in shape.
• Their apices are facing the lung root and their bases are at the pleural surface.
• Separated from adjacent segment by connective tissue septa.
• Each one is independently supplied by segmental bronchus and a tertiary branch of Pulmonary artery.
• Drained by intersegmental parts of pulmonary veins that lie in the connective tissue Between and drain
adjacent segment.
• The bronchopulmonary segments are given the same names and numbers as the Segmental bronchi.
• Usually there are 18 – 20 bronchopulmonary segments in both lungs. ( 10 in right and 8-10 in left.)
• These are surgically resectable.

14th Batch
14th Proper – MCQs
1. Regarding tracheobronchial tree,

A) The branches of pulmonary trunk arise in front of the lateral bronchus.
B) Carina lies to the left of mid line.
C) The left upper lobe bronchus arises outside.
D) The posterior basal segment of right lower lobe is the common site for aspiration.
E) Bronchial tree returns its own arterial supply.
2. Trachea,
A) Is crossed by the arch of aorta on left side.
B) Originates at the 5th cervical vertebral level.
C) Lines to the left of the mid line as it enters the thoracic inlet.
D) Contains cricoid cartilage as its only complete cartilaginous ring.
E) Contains skeletal muscles in its wall.
3. The right phrenic nerve,

A) Has the superior vena cava on its medial side.
B) Is posterior to the thoracic duct.
C) Passes through the caval opening in the diaphragm.
D) Supplies the fibrous pericardium.
E) Runs through the mediastinum behind the lung root.
4. Anatomical features of nasopharynx include,

A) Pharyngeal recess.
B) Pharyngeal tonsil.
C) Auditory tube.
D) Palatopharyngeal sphincter.
E) Salpingopharyngeal fold.
5. Pass through the both of superior mediastinum and posterior mediastinum?

A) Trachea.
B) Esophagus.
C) Thoracic aorta.
D) Phrenic nerve.
E) Vagus
7. Aortic opening of the diaphragm,

A) Lies anterior to the body of T10 vertebra.
B) Lies between crura of diaphragm.
C) Transmits sympathetic trunk.
D) Transmits left vagus nerve.
E) Transmits right vagus nerve.
13. Regarding the thoracic wall,

A) Costovertebral joints are synovial joints

B) Posterior serratus muscle lies on erector spinae muscle.
C) 1st sternocostal joint is a primary cartilaginous joint.
D) Neurovascular bundle lies between middle and outer muscular layer. E) External intercostal muscle lies obliquely
downward and forward.
26. Upper respiratory tract function include,

A) Humidifying inspired air.
B) Equation of inspired air.
C) Exchange of gases.
D) Secretion of surfactant.
E) Secretion of mucus.
27. Intrapleural pressure

A) Always negative.
B) Negativity is caused by the adhesion of the parietal and visceral pleura.
C) Become more negative in pneumothorax.
D) Negativity is higher in the base than the apex.
E) Surfactants reduce the intrapleural pressure.
28. Regarding functional residual capacity

A) It is about 1L.
B) If it is smaller, alveolar flow increases.
C) It can be measured using the helium dilution method.
D) It depends on fluctuation of alveolar gas concentration during the breathing cycle.
E) It can directly be measured by a spirometer.
29. Regarding the behavior of the respiratory gases,

A) Solubility of O2 is less than the solubility of CO2.
B) Arterial PO2 is higher than the PCO2.
C) O2 diffusing capacity is higher than the CO.
D) Alveolar capillary pressure gradient is 100 mmHg
E) Hyperventilation caused hypoxia is associated with hypercapnia
30. Oxygen transport mechanism.

A) Oxygen concentration in arterial blood - 15ml/dl.
B) Partial pressure oxygen in arterial - 100mmHg
C) Oxygen saturation of arterial blood is higher than pulmonary vein.
D) Partial pressure of oxygen proportional to hemoglobin concentration.
E) Methemoglobin affinity is lesser than Hb
31. Cyanosis could be seen in

A) Hypoxic hypoxia
B) Anaemic anaemia
C) Stagnant hypoxia
D) Histotoxic hypoxia
E) Exposure to severe cold
SBR

41. 33-year old male admitted to the hospital with severe traumatic injury. His BP- 89/39. Central venous line is
ordered to be placed. Which us most likely occur when subclavian central line procedure is performed?
A) Penetration of subclavian artery
B) Impalement if phrenic nerve
C) Penetration of SVC
D) Penetration of left CCA
E) Impalement of vagus nerve
42. Regarding the larynx,

A) The sub glottis is mainly formed by the cricoid cartilage.
B) In bilateral vocal cord palsy, the voice could be normal.
C) Vocal cords have a rich lymph drainage.
D) Posterior cricoarytenoid is an adductor of the vocal cord.
E) During laryngeal obstruction, the airway is accessed by splitting the thyrohyoid membrane.
43. Regarding ventilation and perfusion of lungs,

A) In upright position, ventilation in lung apex is greater than ventilation in lung base.
B) In an upright position, blood supply is greater in apex than in base.
C) In the upright position, V/Q ratio is higher in the apex than in the base.
D) In lung collapse the V/Q ratio is high.
E) In pulmonary embolism V/Q ratio is low.
45. 27-year old male undergoes a tracheostomy. During the midline incision which vein would have affected?
A) Superior thyroid vein
B) Inferior thyroid vein
C) Anterior jugular vein
D) Left brachiocephalic vein
E) Subclavian vein
46. Left superior intercostal vein drains into,

A) Accessory hemi azygos vein
B) Left brachiocephalic vein
C) Pulmonary vein
D) Superior Vena Cava
E) Right brachiocephalic vein
55. Rate of diffusion across alveolar air barrier least affected.

A) Pressure gradient
B) Cross alveolar surface area
C) Temperature on alveolar surface
D) Solubility of gases
E) Molecular weight of gases.
56. In hypoxic hypoxia

A) Oxygen carrying capacity decreased
B) Oxygen content of blood decreased
C) Hb decreased

D) PCO2 increased
E) pH decreased
57. Which one stimulates the medullary center more?

A) Arterial PCO2
B) Arterial H+
C) Arterial PO2
D) Blood pressure
E) Arterial pH
14th Proper - SEQs
1.
1.1. Each lung is invested by and enclosed in a serous pleural sac that consists of two continuous membranes: the
visceral pleura and parietal pleura
1.1.1. State the surface markings of pleura and lungs with the aid of diagram. (30 marks)
1.1.2. Explain the extension and relations of cervical dome of left pleura. (25 marks)
1.2. Draw a diagram to illustrate the surface markings of the heart on pericardium. (15 marks)
1.3. Describe the origin, relations, distribution of arch of aorta. (30 marks)
5.The following blood parameters were measured in six healthy volunteers after three weeks residence at an
altitude of 4000 meters and the average of the values are given.
a. Arterial blood pH 7.48
b. Arterial plasma bicarbonate 18 mEq/L c. Arterial PCO2 - 26 mmHg
5.1. Comment on each of the above values-normal / increased / decreased (25 marks)
5.2. Explain the physiological basis of the changes, if any (3 x 25 marks)
01)
A) The pulmonary trunk divides in front of the left main bronchus.
Left pulmonary artery spirals over the main bronchus to descend behind the lobar bronchi.
LAST P.214- FIGURE 4.29
B) F At the bifurcation the lowest tracheal cartilage has a hook- shaped process, the carina, Which curves backwards
between the bronchi and raises an anteroposterior internal ridge That lies to the left of the midline.
C) F Each main bronchus gives rise to lobar bronchi (Fig. 4.32) that supply the lobes of the lung.
The right main bronchus gives off the upper lobe bronchus outside the hilum and ends Within the hilum by dividing
into middle and lower lobe bronchi. The left main bronchus Divides within the hilum into upper and lower lobar
bronchi Left upper bronchus arise inside the lung.

D) F Material aspirated by a supine, comatose or anaesthetized patient would tend to gravitate Into the superior
segment of the right lower lobe, which is consequently a common site for Aspiration pneumonia and abscess
formation.
E) T The bronchial tree receives its own arterial supply by the bronchial arteries
02)
A) F arch of the aorta curves backwards over the left bronchus
B)F The trachea is the continuation of the larynx and commences in the neck below the cricoid Cartilage at the level
of C6 vertebra, 5 cm above the jugular notch
C) F Entering the thoracic inlet in the midline it passes downwards and backwards behind the Manubrium to
bifurcate into the two principal or main bronchi a little to the right of the Midline, level with the upper border of T5
vertebra (Fig. 4.14)
D) T The patency of the trachea as an airway, its essential function, is maintained by 15–20 Horseshoe shaped
hyaline cartilages. Cricoid cartilage is the complete ring around the Trachea.
E) F The gaps in the rings are at the back, where there is smooth muscle, mostly transverse (the Trachealis muscle).
03)
A) T The right phrenic nerve relates laterally with venous structures throughout its thoracic Course (Fig. 4.12). The
right brachiocephalic vein, the superior vena cava, the pericardium Over the right atrium, and the inferior vena cava,
lie to its medial side
B) F Thoracic duct lies posterior to esophagus also. Esophagus lies more posteriorly in Mediastinum.
C)T It reaches the undersurface of the diaphragm by passing through the central tendon Alongside the inferior vena
cava, piercing the tendon fibres that fuse with the caval wall.
D) T About two-thirds of the phrenic nerve fibres are motor to the diaphragm. The rest are Sensory to the diaphragm
(except for the most peripheral parts which receive intercostal Afferent fibres), and to the mediastinal pleura, the
fibrous pericardium, the parietal layer of Serous pericardium, and the central parts of the diaphragmatic pleura and
peritoneum.
E)F Passes in front of the lung roots.
04)
Features of nasopharynx
• Pharyngeal recess
• Pharyngeal tonsil
• Opening of auditory tube
• Salpingopharyngeal fold.
( LAST PAGE-386)
A) T
B) T
C) T
D) F
E)T
05)
A) F
B) T
C) F

D) F
E) F
CONTENTS OF SUPERIOR MEDIASTINUM
Trachea
Esophagus
Arch of aorta
Brachiocephalic trunk
Left CCA
Left subclavian artery
R/L brachiocephalic veins
Left superior intercostal vein
Upper part of superior vena cava
Cardiac plexus
Vagus nerve
Phrenic nerve
Thymus
Thoracic duct
CONTENTS OF POSTERIOR MEDIASTINUM

Esophagus
Thoracic aorta
Azygos vein
Hemiazygos vein
Accessory hemiazygos vein
Thoracic duct
Lymph nodes
07)
A) F Lies anterior to T12 vertebra
B) T Between right and left crura
C)F The sympathetic trunk passes behind the medial arcuate ligament
D) F
• T12
Aortic
Azygos vein
Thoracic duct
• T10
Esophagus
Vagus R & L
Branches of left gastric
Artery
Lymphatics
E) F LAST PAGE 185
13)A) T Last’s anatomy page 180.

B) T Small muscles of the external layer and lie on erector spinae muscle. Last’s anatomy page 181.
C) F No intercostal joint. First sternocostal joint is primary cartilaginous joint and all other sternocostal joints are
synovial.

D) F Neurovascular bundles lies between middle and inner muscular layer.
E) T Last’s anatomy page 182.
26)
A)T (nasal cavity)

B)T (nasal cavity)
C) F (alveoli and respiratory bronchioles)
D) F (alveoli)
E)T (both upper and lower)
27)
A T (normally -5cmH2O)
BT
C F(-2.5cmH2O)
D F (base = -3cmH2O ,apex= -8 cmH2O)
ET
28)
A) F (2.5L)
B) T
C)T (direct method)
D) F (lung size, lung compliance, posture)
E) F (indirectly)
29.
A) T
B)T (Po2 =95mmHg ,Pco2 =40mmHg)
C) F (at rest both same as 25Ml/min/mmHg)
D) F
E) F (hypocapnia)
30)
A)F (20 Ml/Dl)
B)F (95mmHg)
C) F (pulmonary vein =99%,arterial blood =95%, venous blood=75%)
D) T
E) T
31)A) T
B) F
C) T
D) F
E) T (due to excessive vasoconstriction)
SBR
41.B
According to relations of subclavian vein; Phrenic nerve crosses subclavian artery Anteriorly and both lie posterior to
subclavian vein but phrenic nerve is anterior Most structure.

42)A
Last’s anatomy page 393.
43)A
Alveoli at the base are expanded than alveoli at the apex at the onset of inspiration. Therefore ventilation better at
the lung base.
45)B
Inferior thyroid vein anteriorly related to trachea in cervical region.
46)B
55) C
56)B
57)A
01.
1.1 Each lung is invested by and enclosed in a serous pleural sac that consists of two Continuous Membranes: the
visceral pleura and parietal pleura
1.2 State the surface markings of pleura and lungs with the aid of diagram. (30 marks)
Plural surface marking

 The parietal pleura lines the costal walls of the thorax seen from in front its lateral surface marking is the
Horizon of the thoracic cage. It projects up to 2.5 cm above the junction of the middle and medial thirds Of
the clavicle.
 Due to the obliquity of the thoracic inlet, the pleura does not extend above the neck of the first rib, Which
lies well above the clavicle.
 Tracing the pleura now (Fig. 4.28) from behind the sternoclavicular joint, downwards behind the Sternum
and around the costodiaphragmatic gutter, there is a point to be noted at the level of each of The even-
numbered ribs.(2, 4, 6, 8, 10, 12).
 The line of pleural reflexion slopes downwards from the sternoclavicular joint to meet its fellow at the
Second rib level, that is, at the sternal angle.
 Lying together, or even overlapping, they pass vertically behind the sternum down to the fourth costal
Cartilage.
 Here the right pleura continues vertically, but the left arches out and descends lateral to the border of The
sternum, half-way to the apex of the heart.
 Each turns laterally at the sixth costal cartilage, and passing around the chest wall crosses the Midclavicular
line at the eighth rib, and the midaxillary at the tenth rib.
 This lower border crosses the Twelfth rib at the lateral border of erector spine and passes in horizontally to
the lower border of the Twelfth thoracic vertebra.
 There is thus a triangle of pleura in the costovertebral angle below the medial part of the twelfth rib, Behind
the upper pole of the kidney, a fact to be noted in incisions and wounds in this region
Lungs surface marking

 The hilum of each lung lies approximately behind the nipples and fourth costal cartilages at the sternal
Margin and level with T5-7 vertebrae.
 On upper costal walls and the supraclavicular region, the surface markings of the lungs coincide with Those
of the pleura.
 The anterior border of the right lung falls very little short of the pleura, lying within the lateral margin of The
sternum; that of the left lung in contrast curves laterally to uncover the area of superficial cardiac
 Dullness from the fourth costal cartilage out to the fifth intercostal space just medial to the midclavicular
Line.
 The lower border of the lung lies nearly horizontally around the chest wall, but two ribs higher than the
Pleural reflexion, i.e. in the midclavicular line at the sixth rib, midaxillary line at the eighth rib, and at the
Lateral border of erector spine at the tenth rib.
1.1.2 explain the extension and relations of cervical dome of left pleura. (25 marks)
It ascends above 2.5 cm from the junction of middle and medial one third of clavicle. Also cervical Dome of the lung
attached to the suprapleural membrane(sibson’s fascia) at the thoracic inlet.

1.2 Draw a diagram to illustrate the surface markings of the heart on pericardium (15 marks)
About one-third of the heart lies to the right of the midline. The right border of the heart extends from the lower
border of the right third costal cartilage to the lower border of the right sixth costal cartilage, just beyond the right
margin of the sternum and describing a slight convex curve between these points.
The inferior border passes from the right sixth costal cartilage to the apex, which is normally in the left fifth
intercostal space in the midclavicular line.
From the apex the left border extends upwards to the lower border of the left second costal cartilage about 2 cm
from the sternal margin.
These are the borders as seen in a typical radiograph of the normal heart, although the area of cardiac dullness as
determined by percussion will be smaller
1.1 Describe the origin, relations, distribution of arch of aorta. (30 Marks)
Emerging from the pericardium the ascending aorta approaches the manubrium and then at The level of the
Manubriosternal joint becomes the arch, which passes backwards over the left bronchus to reach The body of T4
Vertebra just to the left of the midline. From its upper convexity, which reaches as high as the Midpoint of the
Manubrium, arise the three great arteries for the head and upper limbs: the brachiocephalic trunk, And the left
Common carotid and left subclavian arteries. The arch is crossed on its left side by the Phrenic and vagus nerves as
they pass downwards in frontOf and behind the lung root respectively. Between them lie the sympathetic and vagus
branches To the superficial Part of the cardiac plexus. The left superior intercostal vein passes forwards across the
arch Superficial to the vagus,Deep to the phrenic, to empty into the left brachiocephalic vein. The left recurrent
laryngeal nerve

05. The following blood parameters were measured in six healthy volunteers after three Weeks Residence at an
altitude of 4000 meters and the average of the values are given.
a. Arterial blood pH 7.48
b. Arterial plasma bicarbonate 18 mEq/L
c. Arterial P CO2 – 26 mm Hg
5.1. Comment on each of the above values-normal / increased / decreased (25 marks)
a. pH is higher than the normal level. Normal pH is 7.4

b. HCO3 Level is lower than the normal level. Normal level is 24mEq/L
c. Arterial Pco2 is also lower than the normal level. The normal level is 40mmHg.
5.2. Explain the physiological basis of the changes, if any (3 x 25 marks)
When reaching a high altitude,

 The partial pressure of gasses in alveoli reduce and hypoxia occurs.
 This situation stimulate the peripheral chemoreceptors which are situated in carotid and aortic Bodies.
 Stimulation of the chemoreceptors causes hyperventilation in the body.
 Therefor CO2 washes away rapidly and so the Pco2 levels in the alveoli get reduced rapidly.
 This reduces the O2 levels in the alveoli too.
 The body is in the following equilibrium at any situation.
 H2O + CO2H2CO3 H+ +HCO3-
 Due to the falling of CO2 level in the body, the above equilibrium moves to left and provides CO2 to the
body.
 This results in reducing the H+ Level in the body and more HCO3 Is added to the body due to the Metabolic
activities in the body.
 Finally, the pH level in the body rises due to the reduction of H+ Ions and the rising of HCO3-Ions In the body,
so this causes a respiratory alkalosis condition.
 Therefor the pH value get increased when reaching a high altitude.
 But after meeting with an alkalosis condition, the body tends to compensate the condition by Various
methods.
 To keep the equilibrium of the above reaction, the ventilation becomes normal with time and
The rate of washing out CO2 get decrease.
 Within a time of 3 weeks, the renal system also start to work on the situation and it secretes More HCO3- To
urine and also reduces the H+ Secretion to urine.
 So the H+ Level in the body rises to a certain level as well as reducing the level of HCO3-In the Body
compensate the pH level in the body.
 But it takes some time to get acclimatized to the surrounding when reach in a high altitude, so
The Pco2 level and the HCO3 Levels remain lower for some time.
 The pH level remains at a high level for some time too.
 But at the time of 3 weeks, the condition of respiratory alkalosis is compensated even at this
Rate.
15th Batch
15th Proper – MCQs
3. Primary cartilaginous joint,

A) manubriosternal joint
B) sternoclavicular joint
C) costochondral joint
D) 1st sternocostal joint
E) Costotransverse joint
10. Anatomical features of nasopharynx,

A) Pharyngeal tonsil
B) Auditory tube
C) Esophagopharyngeal fold
D) Pharyngeal recess
E) Palatopharyngeal fold
34. Total lung capacity,

A) Decrease in lung fibrosis
B) Measured by spirometer
C) Increased in pulmonary emphysema
D) Greater than vital capacity
E) Measured using peak flow meter
35. Work of breathing varies with the variation in,

A) Bronchiolar tone
B) Alveolar surface tension
C) Compliance of the lung
D) Total lung capacity
E) Atmospheric pressure
36. Lung tissue

C) Is supplied Vegas nerve
D) Is derived from lung bud in foregut
37. Peripheral chemoreceptors stimulated by

A) Hydride ion
B. Hypercapnia
C. Carbon monoxide
D. Cyanide
E. Hypoxia
SBR
46. A 62-year old male patient expresses concern that his voice changed over the preceding months, imaging
showed growth located within the aortic arch, adjacent to the left pulmonary artery. Which neural structure is
most likely to be compressed which caused changes in his voice,
B) Esophageal plexus
D) Left Vagus Nerve
50. Oxygen is transported in blood in dissolved form and by binding with hemoglobin. Hypoxia is a feature in
anemia. What is the most effective way to deliver more oxygen to tissues to minimize hypoxia in anemia?
A) Increase dissolved O2 in blood
B) Increase hemoglobin in blood
C) Right shift O2 hemoglobin curve
D) Increase pulmonary ventilation
E) Increase CO
54. Hypoxia known to stimulate respiration through chemoreceptors. which of the following situation gives the
highest stimulation to respiration?
A) O2 partial pressure is about 60mmHg in arterial blood through the peripheral chemoreceptors
B) O2 partial pressure is about 60mmHg in venous blood through peripheral chemoreceptors
C) O2 partial pressure is about 60mmHg in arterial blood through central chemoreceptors
D) O2 partial pressure is about 60mmHg in venous blood through central chemoreceptors
E) O2 partial pressure is about 90mmHg in arterial blood through peripheral chemoreceptors

15th Proper - SEQs
1. Write accounts on
1.1 blood supply of the thoracic wall (40 marks)
1.2 Supra pleural membrane (25 marks)
1.3 Explain anatomical basis of following
1.3.1. External intercostal muscles are active during exercise" (15 marks)
1.3.2. "Presence of a cervical rib may cause paresthesia along the ulnar border of the forearm and small muscle
wasting in the hand” (20 marks)
5.Explain physiological basis for

5.1 ventilation perfusion ratio (V/Q) is better in the bases of the lung than in the apical region of the lung (40 marks)
5.2 hypoxia without hypercapnia (type l respiratory failure) is a feature in lung fibrosis whereas Hypoxia with
hypercapnia (type l respiratory failure) occurs in ventilator defect (30 marks)
5.3 not developing cyanosis in patients with severe anemia (30 marks)
3)
A) F
B) F
C) T
D) T
E) F
10)
A) T
B) T
C) F
D) T
E) F
34)
A) T
B) F
C) T
D) T
E) F
Residual volume can’t be measured directly by spirometer
Capacity which can’t be measured by spirometer – FRC (Expiratory reserve volume + Residual Volume)
In obstructive lung disease (Emphysema) – TLC increases
In restrictive lung disease (lung fibrosis) – TLC decreases
*TLC – Total Lung Capacity
35)
A) T
B) T

C) T
D) T
E) T
Work of breathing = To move inelastic tissue (7% viscous resistance) + To move elastic tissue in lung and chest wall
(65% elastic work) + To move air through respiratory passage (28% airway resistance)
36)
A) T
B) F - Alveolar epithelium doesn’t have cilia
C) T
D) T
E) T
37)
A) F
B) T
C) F
D) T
E) T
SBR
46) C
50) A
54) A – chemoreceptors are stimulated when the partial pressure of O2 decreases below 80mmHg
15th Proper – SEQANSWERS
01.Write accounts on,

1.1 Blood supply of the thoracic wall (40 marks)
Thoracic wall consists of intercostal spaces. Each space has
- 2 anterior intercostal arteries and veins
-1 posterior intercostal artery and vein
Posterior intercostal artery anastomose with upper anterior intercostal artery (at the level of Costochondral
junction)
- In the upper 6 spaces anterior intercostal artery is a Branch of internal thoracic artery and in the
7th-9th spaces it’s a branch of musculophrenic artery
- Anterior intercostal veins drain into internal thoracic vein (upper 6 spaces) or musculophrenic
vein(succeeding spaces)
- 1st and 2nd posterior intercostal arteries arise from superior intercostal artery and in succeeding
Spaces they arise from descending thoracic aorta
- Posterior intercostal vein drains into azygos vein in right side and hemiazygos and Accessory
Hemiazygous veins in left side
- Posterior intercostal artery gives collateral branches near the angle of the higher rib Which runs in
the upper border of lower rib – posterior intercostal artery
-also give lateral cutaneous branch (which divide into anterior and posterior branches) – which
Supply skin of lateral thoracic wall

1.2 pleural membrane (25 marks)
Page 184 – Last’s Anatomy
This is a rather dense fascial layer (Sibson’s fascia) attached to the inner border of the first rib and Costal cartilage
and the transverse process of C7 vertebra (Fig. 4.5). It is not attached to the neck of The first rib.
It has the cervical dome of the pleura attached to its undersurface, and when traced Medially it is found to thin out
and disappear into the mediastinal pleura.
It lies in the oblique plane Of the thoracic inlet, and the subclavian vessels arch upwards and laterally over it.
The membrane Gives rigidity to the thoracic inlet and prevents the neck structures being ‘puffed’ up and down
During respiration. Damage to the suprapleural membrane during surgical procedures at the root of The neck will
usually result in the development of a pneumothorax on the same side
1.2 Explain anatomical basis of following,
1.3.1 “External intercostal muscles are active during exercise” (15 marks)
There are three groups of respiratory muscles: the diaphragm, the rib cage muscles and the
Abdominal muscles. Accessory muscles of ventilation include the scalene, the sternocleidomastoid, The pectoralis
major, the trapezius, and the external intercostals.
Normal quiet expiration is brought about by elastic recoil of the elevated ribs and passive relaxation Of the
contracted diaphragm.
In deeper expiration, the abdominal muscles have an important part to Play – they contract vigorously, compress
the abdominal viscera, raise the intra‐abdominal pressure And force the relaxed diaphragm upwards.
Indeed, diaphragmatic movement accounts for Approximately 65% of air exchange whereas chest movement
accounts for the remaining 35%.
In deep and forced inspiration, additional ‘accessory muscles of respiration’ are called into play.
These are the muscles attached to the thorax that are normally used in movements of the arms and The head.
Watch an athlete at the end of a run, or observe a severely dyspneic patient – he grips his
Thighs or the table to keep his arms still, holds his head stiffly and uses pectoralis major, serratusanterior, latissimus
dorsi and sternocleidomastoid to act ‘from insertions to origins’ to increase the capacity of the thorax
1.3.2 “Presence of a cervical rib may cause paresthesia along the ulnar border of the forearm and small muscle
wasting in the hand" (20 marks)
A cervical rib is an abnormality that's present from birth. It's not usually a problem, but if it presses on nearby nerves
and blood vessels, it can cause neck pain, numbness in the arm and other symptoms.
This is known as thoracic outlet syndrome.
Thoracic outlet syndrome (TOS) is a group of disorders that occur when blood vessels or nerves in the space between
your collarbone and your first rib (thoracic outlet) are compressed.
5. Explain physiological basis for,

5.1 ventilation perfusion ratio (V/Q) is better in the bases of the lung than in the apical region of
the lung (40 marks)
Ventilation means flow of air into and out of the alveoli.
Perfusion means blood flow to the alveoli.
In the apical region, by the action of gravity the alveoli are comparatively larger than the base
region. So the ventilation to that part is lower than that to the base of lungs. Because compliance of
the alveoli in the apical region is lower than that of the basal region.
When we consider the perfusion to the apical & basal region, apical region’s perfusion is

comparatively lower than that of Basal region. Because the apical region is above the level of the
heart whereas the basal region of the lung is below the level of heart. This facilitates more perfusion
to the basal region than apical region
Though ventilation & perfusion decreases in the apex than base, net effect of changes in perfusion is High. So, V/Q is
higher in the apex than the base.
5.2 hypoxia without hypercapnia (type l respiratory failure) is a feature in lung fibrosis whereas Hypoxia with
hypercapnia (type l respiratory failure) occurs in ventilator defect (30 marks)
Hypoxia without hypercapnia (type l respiratory failure) is a feature in lung fibrosis whereas Hypoxia
With hypercapnia (type 2 respiratory failure) occurs in ventilator defect.
• Type I respiratory failure occurs because of damage to lung tissue(lung fibrosis is a lung disease
That occurs when lung tissue becomes damaged and scared.
This thickened, stiff tissue makes it More difficult for your lung to work properly. This fibrosis makes it harder for
oxygen to pass through The air sacs in the lung which in turn decreases the amount of oxygen that can passes into
the blood Stream.
It leads to decrease partial pressure of oxygen. It calls hypoxia ; however, the remaining Normal lung is still sufficient
to excrete the carbon dioxide being produced by tissue metabolism.
This is possible because less functioning lung tissue is required for carbon dioxide excretion than is Needed for
oxygenation of the blood.
• Type II respiratory failure is also known as ‘ventilatory failure’. It occurs when alveolar ventilation Is insufficient to
exhale the carbon dioxide being produced and insufficient to inhale the oxygen Inadequate ventilation is due to
reduced ventilatory effort, or inability to overcome increased Resistance to ventilation – it affects the lung as a
whole, and thus carbon dioxide Accumulates(hypercapnia) and oxygen partial pressure is decreased (hypoxia
5.3 not developing cyanosis in patients with severe anemia (30 marks)
➢ Cyanosis is dark bluish discolouration
➢ Due to concentration of deoxygenated haemoglobin in capillary blood
➢ Being higher than 5g/dl
➢ This is an effect of hypoxia
➢ Occurrence of cyanosis depends on,
➢ Total amount of Hb in blood
➢ Degree of unsaturation
➢ State of capillary circulation
➢ Anaemia is decreased [Hb] below the normal level
➢ Accepted according to age, ethnic group, gender
➢ In an anaemic patient,
➢ For a given O2 partial pressure
➢ The percentage of unsaturation does not change significantly
➢ But as the total amount of Hb level is low, the amount of deoxygenated Hb does not increase

CARDIOVASCULAR SYSTEM
EME QUESTIONS
1. Regarding fibrous pericardium

A) Completely connected to adventitia of great vessels
B) Supplied by phrenic nerve
C) Derived from septum transversum
D) lies between T5 to T8 level
E) protect heart from sudden expansion
2. Motor component of cervical plexus supply

A) longus colli
B) Geniohyoid
C) Scalenus medius
D) Sternocleidomastoid
E) Digastric muscle
3. Right coronary artery

A) Descends in the coronary sulcus
B) Have a circumflex branch
C) Directly anastomose with anterior interventricular artery
D) right coronary artery less common obstructed than left one
E) supply to the anterior two third of interventricular septum
4. Regarding heart
A) Right coronary form the posterior descending artery
B) The last part which undergoing to discharge is apex
C) SA node discharges the right atria
D) Coronary vessels lie deep to the epicardium
E) Rheumatic fever affect the endocardial region of the valve
5. Regarding left ventricle

A) More trabeculated than right
B) has anterior posterior and septal papillary muscle
C) receives blood through tricuspid valves
D) mainly supplied by right coronary artery
E) is three time thicker than right ventricle
6. Regarding the heart

A) Purkinje is the fastest conduction fibers
B) The last part of the ventricle to be activated is the apex
C) duration of action potential in ventricular muscle fibers is same as in skeletal muscle
D) T wave of ECG occurs at the beginning of absolute refractory period of right ventricle
E) it can recorded on the surface of the body

7. When erect from standing position.
A) heart rate decrease
B) cardiac out put no change
C) Pulse pressure decrease
D) Stroke volume increase
E) Preload increase
8. Which of the following correctly correlated

A) Renal stenosis - active of renin angiotensin system
B) Cushing syndrome - increase total peripheral resistance
C) Pheochromocytoma - increased total peripheral resistance
D) Thyrotoxicosis - increased cardiac output
E) Conn’s syndrome - retention of Na+
9. Cardiac output increase with increase in,

A) heart rate
B) BP
C) TPR
D) EDV
E) ESV
10. Regarding posterior triangle

A) Extended from T5 to T12
B) Has direct communication to Para pharyngeal space
C) Contain thoracic sympathetic trunk within its space
D) Consist of thoracic duct
E) Is prefers to access oesophagus at the left side
11. Regarding fetal cardiovascular system

A) 3rd arch bigger than others
B) Truncus arteriosus transfer blood from pulmonary to aorta
C) containing thyrocervical trunk in which space
D) superior vena cava persistence of the left cardinal vein
E) abnormal origin of right subclavian artery could compress oesophagus
12. With reference to regulation of blood pressure

A) Arterial blood pressure is always decreased whenever cardiac output is decreased
B) muscular exercise decrease diastolic blood pressure
C) adrenalin increase the systolic blood pressure and decrease diastolic blood pressure
D) drop blood pressure while standing due to bradycardia
E) compression of carotid sinus lead to drop atrial blood pressure
13. Regarding changes during exercises

A) Mean arterial pressure rises during isometric contraction
B) Mean arterial pressure increase during isometric contraction
C) Increase heart rate
D) Physical training increase resting stroke volume
E) Training increase end systolic volume

14. Regarding blood vessels
A) Arteries are less compliant than veins in its same size
B) Capillaries constrict in order to change peripheral resistance
C) Capillaries in all the regions are fenestrated
D) Arterioles contains more smooth muscles
E) Sympathetic innervation can lead to constriction of vein
15. Regarding right atrial pressure

A) Reduction can lead to constriction of peripheral arteries
B) Is observed in external jugular vein
C) Is elevated in right heart failure
D) With absent a wave is seen in aortic fibrosis
E) With large a wave is seen in tricuspid stenosis
SBR
16. 6-year old boy found to have a mild tumor of thymus impinging posteriorly on a blood vessel what is the most
affected blood vessel?
A) Superior vena cava
B) Arch of Aorta
C) Left common carotid artery
D) Right subclavian artery
E) Pulmonary trunk
17. the superior thyroid artery closely related to the superior laryngeal nerve
A) the vocal cord is tensed by relaxation of the cricothyroid muscle
B) Stroke volume increase
C) Heart rate decrease
D) the larynx is compressed due to the excessive collection of blood
E) cardiac out put no change
18. what is the condition with highest pulse volume ?

A) Aortic regurgitation
B) Fever
C) Thyrotoxicosis
D) Aortic valve stenosis
E) Hypertension
19. Mid diastolic murmur is a feature in ASD the reason for this murmur is turbulence
blood flow across
A) across the defect in atrial septum
B) across tricuspid
C) across mitral
D) across pulmonary
E) across aortic valves

20. Frequency of discharge of the carotid sinus baroreceptors is decreased in
A) Decreased arterial pH
B) Decrease in arterial pressure
C) Decreased O2 uptake
D) increased CO2 tension
E) Increased cardiac output
1.
1.1 Describe origin, cause, distribution and clinical significance of left phrenic nerve. (50 marks)
1.2 State the surface marking for heart valves and the best position for heart sound.
1.3 Write an account on tetralogy of Fallot
2. A middle aged female weighting 50 kg lost about 500 ml of blood in road accident. examination showed
that there was no changes in mean atrial blood pressure but her pulse rate was 106 per minute and the
skin was cold to touch. Explain the physiological basis of,
2.1 Blood pressure being normal despite blood loss. (40 marks)
2.2 Increase pulse rate (30 marks)
2.3 Cold skin (30 marks)
1)
A) T last pg. 197
B) T fibrous pericardium – by phrenic nerve
Parietal layer of serous pericardium- by phrenic nerve
Visceral layer of serous pericardium-not innervated
C) T both central tendon of diaphragm & fibrous pericardium derived from septum transversum.
D) T
E) T
2)
A) T
B) T cervical plexus are formed by anterior rami of upper 4 cervical nerves (C1-C2) refer last pg.333
C) T
D) T
E) F - posterior belly by nerve to myolohyoid
3)
A) T runs in R. Antrioventricular groove/ coronary sulcus
B) F only L. coronary has
C) F termination of R coronary A (A) L.circumflex branch
Ant. Interventricular branch (A) post. Interventrical branch
D) T most commonly affected is, A. of L. coronary A.
Anterior interventricular A. of L. Coronary A.
E) F post.1/3rd of interventricular septum supplied by post. Interventricular artery (R)
4)
A) T posterior interventricular branch also called post. Descending artery
B) F posterior aspect of L. ventricle is last to depolarize
SA node is first
C) T both atria are depolarized by SA node
D) T lie between epicardium and myocardium
E) T
5)
A) T more in left
B) F only anterior and posterior septal in right
C) F through mitral valve
D) F by L
E) T *3
6)
A) T
B) F post. Aspect of left ventricle
C) F skeletal 2-5 ms
Cardiac 200-400 ms
D) F T wave occur after platue phase (graph ganong pg. 520)
E) T electrical changes of the heart can be recorded in ECG
7)
A) F when standing due to gravity venous return decrease
SV↓ → CO↓ → baroreceptor disch. → Sympathetic → HR↑
B) T CO = SV * HR
C) T SBP  SV DBP -- >TPR
PP=SBP-DBP
D) F SV
E) F preload = ventricular EDV
VR↓ → EDV↓ → SV↓
8)
A) T renal stenosis is Narrowing of renal artery
B) T Cushing = glucorticoid excess

Glucorticoid excess → direct effect on blood vessel → TPR↑
Secretion of angiotensinogen (Ganong PG 365)
C) T pheochromocytoma = adrenal medullary tumor
Epinephrine / Norepinephrine → vasoconstrictor → TPR↑
D) T thyroxin excess → metabolic activity↑ → O2, Nutrient requirement of body→ HR↑ → CO↑
E) T aldosterone excess
9)
A) T CO ∝ SV * HR
B) F BP ∝ CO * TPR
C) F
D) T SV = EDV – ESV
E) F
10)
A) F
B) F
C) F

D) F
E) F
11)
A) T
B) F ducts arteriosum
Truncus arteriosum → roots and proximal portion aorta & pulmonary trunk
Lang. pg. 168 fig 13.9 / 13.10 12th edition
C -
D F
E T
12)
A) F BP = CO ×TPR TPR can change to compensate
B) F isotonic → TPR due to vasodilation
DBP / unchanged
Isometric → TPR due to compression of blood vessels
C) T Adrenalin / epinephrine → vasodilator → TPR↓ → DBP↓
Inotropic SV↑ → CO ↑ → SBP↑
D) F Due to venous pooling
CO↓ so, to compensate HR↑
Never bradycardia
But drop of blood pressure is possible
E) T Carotid sinus and baroreceptor → stimulate cardic inhibitory center
HR↓ → CO↓ → SBP↓
13)
A) T Isometric → TPR↑ → DBP↑
MAP = DBP + 1/3 PP
B) T
C) T Psychological initially
D) T in trained athleteS
1. larger SV
2. lower HR
3. larger heart
E) F ESV = EDV- SV
14)
A)T •Compliance = change in volume per unit change in Pressure in volume when pressure
• veins are more compliant ( largely due to their thinner walls )
B)F capillary lack OF smooth muscles . arteriole & resistant vessels
C) F liver sinusoidal
D)T Resistance vessels
E)F Veins have autonomic innervation
sympathetic stimulation → vaso constriction
15)
A) T VR↓ → SV↓ → CO↓ → to compensate TPR↑
B) F internal jugular vein
C) T Blood accumulate in R-Heart
D) F in atrial fibrillation
E) T cannon wave
16)A
17) –

18) A PP = SBP – DBP
19) A ASD –mid diastolic
Mid diastolic murmur → tricuspid & mitral stenosis, abnormal flow through normal valve
20) B. Tonicaly vagal inhibition
When decrease in arteriole pressure vagal inhibition is inhibited

1.1
x Formed mainly from anterior ramus of C4
x With contributions from anterior rami of C3 & C5 in the neck
x Descends vertically over the obliquity of scalene anterior
x Passing from its lateral to medial borders,
x Beneath the prevertebral fascia
x Lateral to the ascending inferior thyroid artery (extra)
x Passes behind subclavian vein into the mediastinum
x Below the vein, it is joined by accessory phrenic nerve (branch fro nerve to subclavius)
x Crossing anterior to the vagus enters the mediastinum
x Descends in front of the lung root
x Has mediastinal pleura as a lateral relation throughout its course
x Right phrenic nerve
x Related medially to venous structures throughout its thoracic course
x From above downwards,
x Right brachiocephalic vein
x Superior vena cava
x Pericardium over the right atrium
x Inferior vena cava
x Reaches undersurface of diaphragm passing through the central tendon
x Alongside the IVC
x Left phrenic nerve
x Related medially toarterial structures throughout its thoracic course
x From above downwards,
x Left common carotid & left subclavian arteries
x Crosses arch of aorta lateral to superior intercostal vein in front of vagus nerve
x Pericardium over left ventricle
x Towards apex of heart
x Reaches undersurface of diaphragm piercing the muscular part of diaphragm
x Just left to pericardium
x Sole motor supply to own half of diaphragm
x Sensory supply to diaphragm except peripheral part (supplied by intercostal nerves),
x Fibrous pericardium,
x Parietal layer of serous pericardium,
x Central part of diaphragmatic pleura &
x Peritoneum
x Pain from diaphragmatic irritation is referred to shoulder tip
x As sensory innervation over the shoulder & phrenic nerve
x Have same roots of origin C3, C4 & C5

1.2
All the Heart valves lies behind the Sternum
Pulmonary Valve - 3rd Costal Cartilage
 Sound – Left Sternal margin of 2nd ICS
Aortic Valve - Behind the 3rd ICS
 sound – Right Sternal margin of 2nd ICS
Mitral Valve- behind the left 4th ICS and Costal Cartilage
 sound – Apex ( 5th ICS at Midclavicular Line )
Tricuspid Valve - Midline 4th and 5th ICS
 sound - Left 5th ICS
1.3 Tetralogy of Fallot:
ow right ventricular outflow region)
2.1There is no changes in the Blood Pressure of the patient. So the Compensatory mechanism has already occurred.
Loss of Blood
Hypovolemia
EDV↓
PRELOAD ↓
STROKE VOLUME↓
Cardiac Output↓
Blood Flow ↓
Stimulation of Low Pressure Barrow Receptors

(impulses via Buffer Nerves)
NTS
Vasomotor Active Center Stimulates Stimulation of CAC Inhibition of CIC

Increase Sympathetic Discharge
Vasoconstriction
Blood Pressure won’t Change
2.2. As describes earlier (in 2.1) Sympathetic Discharge increases. This causes in increase in Heart Rate. This is called
Rapid pulse.
2.3. As describes earlier (in 2.1) Sympathetic Discharge increases. This causes Vasoconstriction. So the Cutaneous
Blood supply will be Reduced. This Results in Cold pale Skin

1. Internal features of left ventricle include

A) Fossa ovalis
B) Opening of coronary sinus
C) Opening of pulmonary vein
D) Presents of pectinate muscle in auricle
E) Rough posterior wall
2. Regarding ascending aorta

A) Takes its origin from left ventricle
B) Ascend behind sternum
C) Lies in the middle mediastinum
D) Has 2 aortic sinuses
E) End at the level of sternal angle
3. Right AV valve
A) Eversion is protected by cordae tendinae
B) Has 3 cusps
C) Also called mitral valve
D) Stenosis causes systolic murmur
E) Closes after left AV valve
4. T/F regarding Starling Law,

A) Energy relate during muscle contraction proportionate to initial fiber length
B) Is based on length tension relationship in ventricle
C) Is the mechanism that matches cardiac output to venous return
D) Left ventricle eject more volume than right ventricle during a single contraction
E) TPR induce a right and down shift in Frank–Starling curve
5. Regarding ECG which are true/false following

A) ECG is indicator of electronic changes of whole over the body at time
B) When ECG is taken all electrodes are in chest wall
C) PR interval is show atria completely depolarization
D) QRS complex represent depolarization of both ventricle
E) It can be reveal structural and functional abnormalities
6. Factors affecting CO include

A) Anxiety
B) Exercise
C) Pulmonary effusion
D) Pregnancy
E) Aortic stenosis
7. Regarding cerebral circulation

A) Regulation through local metabolic factors
B) White matter need more perfusion than grey matter.
C) Cerebral flow proportional to ICP.

D) Viscosity of blood cannot affect cerebral circulation.
E) Cushing’s reflex is cerebral ischemia secondary to high ICP.
8. Regarding heart sounds,

A) 3rd heart sound occurs during diastole.
B) 4th heart sound is heard in ventricular hypertrophy.
C) 1st heart sound is heard when mitral valve opens.
D) 2nd heart sound is heard at end of diastole.
E) Carotid pressure felt with 1st heart sound.
9. In complete heart block,

A) Fainting may occur because the atria are unable to pump blood into the ventricles
B) Ventricular fibrillation is common
C) The atrial rate is lower than the ventricular rate.
D) Fainting may occur because of prolonged periods during which the ventricles fail to contract
E) Cardiac output increased
10. Embryological structure that give rise to interatrial septum.

A) Septum primum.
B) Septum secondum.
C) Septum spurium.
D) Right valve of sinus venous
E) Membranous septum.
SBR
11. While attempting to suture the distal end of the coronary bypass onto the anterior interventricular artery, the
surgeon accidentally passed the needle to the adjacent vein. Which vein was damaged?
A) Anterior cardiac vein.
B) Great cardiac vein.
C) Oblique vein.
D) Middle cardiac vein.
E) Small cardiac vein.
12. Palpation of pulse in a patient and felt an irregularly irregular tachycardia. Which of the following is likely to
be in ECG?
A) AF
B) Sinus tachycardia
C) SVT
D) Ventricular tachycardia.
E) Ventricular fibrillation.
13. Increased radius of resistance vessels is result of an increase in,

A) Capillary blood flow.
B) Diastolic blood pressure
C) Pulmonary blood flow
D) Systolic blood pressure.
E) Viscosity of blood.

14. CO = 4L/min, HR = 100/min, Ejection fraction = 0.45
End diastolic volume=??
A) 44ml
B) 58ml
C) 75ml
D) 94ml
E) 89ml
15. Most of the drainage of thoracic body wall to superior vena cava via azygous system. But there is an exception
of left superior intercostal vein. To where this vein drainage?
A) Accessory hemi azygous vein
C) Pulmonary vein
D) Superior vena cava
1.
1.1 A 25-year old man who had tightness on the left side of chest and the pain radiate along the medical side of his
left arm and forearm. Then the symptoms disappeared with rest. He was diagnosed with angina pectoris.
1.1.1 Describe the arterial supply of the heart. (40 Marks)
1.1.2 State the reason for angina pectoris. (10 Marks)
1.1.3 State the reason for the disappearance of symptoms with rest. (10 Marks)
1.2 Write an account on,

1.2.1 Formation of aortic arches and their congenital anomalies. (20 Marks)
1.2.2 Common congenital defect in the formation of septa. (20 Marks)
02. A 30-year old gentleman underwent a routine medical. His blood pressure was recorded as 170/90mmHg. He
was advised to re-measure his blood pressure in 1 hour.
2.1 What do you understand by the following terms?

a. Systolic blood pressure (10 Marks)
b. Diastolic blood pressure (10 Marks)
c. Pulse pressure (10 Marks)
2.2 List the steps involved in measuring the blood pressure. (20 Marks)
2.3 What is “white coat Hypertension”? (20 Marks)
2.4 Briefly describe the role baroreceptors play in the control of blood pressure. (20 Marks)

1.
A) F Fossa ovalis open into right atrium
B) F Coronary sinus open into right atrium
C) F 04 pulmonary veins open into left atrium
D) F Left and right atrium contain a auricle part which have pectinate muscles
E) F Contain papillary muscles
2.
A) T Left ventricle, infundibulum forms the aorta
B) T Anteriorly sternum
C) T Present in the middle mediastinum
DF Contain 03 aortic sinuses
ET -
3.
A) T Right AV/tricuspid & mitral valves eversion is prevented by chorda tendinae
B) T
C) F Mitral valve located between left atrium and ventricle
D) F Tricuspid stenosis causes diastolic murmur Atrial contraction to empty the blood into ventricle during
ventricular diastole
E) T -
4.
A) T Starling law: energy of contraction proportion to the initial length of cardiac muscle (ganong 25th edition)
B) T
C) T Venous return↑ EDV↑ preload↑ stroke volume↑ cardiac output↑
D) F Same in both ventricles
E) T Afterload↑ so preload ↓
Cardiac output↓ venous return↓
5.
A) F Measured electronic changes of the heart
B) F 6 chest leads and 4 limb leads (one limb lead for earth)
C) F PR interval shows delay of AV node but within PR interval atria are fully depolarized
D) T –
E) T Structural: myocardial infarction Functional: abnormality in conducting system
6.
A) T –
B) T –
C) T
D) T –
E) T Because the aortic valve is not opened properly
7.
A) T CO2
B) F –
C) F Intracranial pressure is not proportional to the cerebral flow. But it is a contributing factor
D) T Factors affecting cerebral blood flow

E) T Cushing reflex
8.
A) T
B) T 4th sound
• Mostly occur in elders due to ventricular hypertrophy
C) F No valve opening can cause heart sound (normally). Only the valve closing cause heart sound
D) F 2nd heart sound- at the end of the systole
E) F After 1st heart sound
9.
A) T Atria and ventricle contract independently from each other in complete heart block. So reduction of cardiac
output can lead to fainting
B) T –
C) F SA node is fire at a high rate than other areas, so ventricles beat at a low rate
D) T Cerebral ischemia, dizziness & fainting (Stokes-Adam’s syndrome)
E) F Cardiac output will decrease, because atria can’t empty into ventricles as in a normal person
10.
A) T
B) T
C) T
D) F
E) F Membranous septum- complete the closure of interventricular foramen
Best Answers
11) B Anterior interventricular artery accompanied with great cardiac vein
12) A Irregularly irregular tachycardia(feature of atrial fibrillation)
13) A Arterioles are called as resistance vessels

Radius↑ = dilation = the resistance↓, so the capillary blood flow↑
14) E CO=SV*HR
SV=CO/HR
SV=4L/100min
Ejection fraction(EF)=SV/EDV
EDV=SV/EF
EDV=40ml/0.45=88.88ml
15) B Left superior intercostal vein → left brachiocephalic vein

1.
1.1.1) Describe the arterial supply of heart.
Right coronary artery
Run downwards in in atrioventricular groove
1. Conus artery
2. SA nodal artery
3. Right marginal artery
4. Posterior interventricular artery
5. AV nodal artery
6. Left ventricular branches
artery anastomose with termination of circumflex branch of left coronary artery
Left coronary artery
terventricular
1. Circumflex branch
Runs in atrioventricular groove
2. Left marginal artery
3. SA nodal artery
anch

4. Anterior interventricular artery
ft several ventricular branches

one is often large diagonal artery
* right coronary shorter

pply the AV node
1.1.2) State the reason for angina pectoris
vessels blood supply to some parts of heart muscles may reduce
and irritation of myocardium cause pain in this condition.
1.1.3) state the reason for the disappearance of symptoms with rest.
demand is reduced.
1.2
1.2.1) write and account on formation of aortic arches and their congenital anomalies.
- aortic arches
-
from the aortic sac
es
Derivatives of aortic arches
1. 1st aortic arch - Maxillary arteries

2. 2nd aortic arch - hyoid and stapedial arteries
3. 3rd aortic arch - common carotid and last part of internal carotid arteries
4. 4th left - arch of aorta from the left common carotid to the left subclavian arteries
5. 4th right - right subclavian artery (proximal part)
6. 6th left - left pulmonary artery and ductus arteriosus
7. 6th right - right pulmonary artery

Defects:
– narrowed aortic lumen below the origin of left subclavian artery
– by obliteration of the 4th left aortic arch
1.2.2) Common congenital defects in the formation of septa
Atrial septal defect
Ostium secondum
cell death and resorption of the septum primum or by inadequate development of the
septum secundum
Common atrium (cor triloculare biventricular)
Premature closure of the oval foramen
Ostium primum defect

Defects in formation of endocardial cushions
Due to facture of fusion of AV cushions
-ASD
-VSD
Ventricular septal defect
Combined defects
Tetralogy of Fallot:
rta arises directly above septal defect

2. 2.1)
a. systolic blood pressure:
 Maximum pressure in aorta during ventricular contraction
 Normal: 110- 120mmHg
 Depend on the cardiac output
b. Diastolic blood pressure:

 minimum pressure in aorta during ventricular relaxation
 Normal: 70-90mmHg
 Depend on the total peripheral resistance
c. pulse pressure:
 difference between systolic and diastolic blood pressure
 PP = SBP-DBP
 Normal: 40mmHg
d. Mean arterial pressure:

 average pressure in the arterial system during the cardiac cycle
 which determines the tissue perfusion
 calculated by,
 MAP= DBP+1/3PP 93mmHg
2.2) List the steps involved in measuring the blood pressure.

1.Palpatory
2.Auscultatory Use sphygmomanometer

1. wrap the BP cuff around the upper arm and keep it at the heart level
2. inflate the cuff while feeling the radial pulse
3. at one point it won’t feel (SBP)
4. keep the stethoscope bell at the brachial artery just below the cuff
5. inflate the cuff above SBP/100mmHg
6. slowly release the pressure At one point you will hear a sound – SBP Then at one point sounds
disappear – DBP These are the “sounds of Korotkoff”
2.3) what is “white coat hypertension”

COP↑ SBP ↑
TPR ↑ DBP ↑
Emotions increase the cardiac output and peripheral resistance
↑the SBP and DBP
so some hypertensive patients have higher BP at doctor’s office than at home

2.4) Briefly describe the role Baroreceptors play in the control of blood pressure.
Normal: BP 120/90mmHg
Increasing or decreasing of blood pressure regulated by our body via various mechanisms

1. Regarding myocardial contractility,

A) Increases with increasing heart rate
B) Increase with increasing force of contraction
C) Decrease with sympathetic stimulus
D) Decrease with parasympathetic stimulus
E) Thyroxin depressed
2. What can occur when a healthy man changing the body from supine position to standing position?
A) Increase in stroke volume
B) Decrease pulse rate
C) Decrease end diastolic volume
D) Increase in cardiac output
E) Increase in peripheral resistant
3. What are the changes that occur in high altitude?

A) Increase blood pressure
B) Cardiac output increases
C) Stroke volume increases
D) Heart rate increases
E) Enlarge ventricle
4. Signs of hypovolemic shock,

a. Blood pressure is reduce
b. Heart rate is reduce
c. Warm skin
d. Clammy (moist) skin
e. Cyanosis
5. Regarding the pulse pressure,

A) Blood entering to aorta initiates pulse wave
B) Difference between systolic and diastolic pressure
C) Increase in increasing the systolic and diastolic pressure
D) Decrease in decreasing the systolic and diastolic pressure
E) Increase when the peripheral resistance increase
6. Regarding pulmonary and systemic circulation,

A) Lowers resistant
B) Lower pressure
C) Lowers cardiac output
D) Raise resistance
E) Raise pressure
7. Mechanical events occur in normal adult cardiac cycle,

A) Left ventricle eject more volume in one beat than right ventricle
B) Mitral valve opens when the left atrial pressure exceeds left ventricular pressure
C) During strenuous work in a healthy subject left ventricular end diastolic volume may be twice its volume at rest

D) Pulmonary valve opens when right ventricular pressure 20-25mmHg
E) During diastole left ventricular pressure is about 70mmHg
8. Left ventricle,
A) Forms the apex of heart
B) Forms the diaphragmatic surface of the heart
C) Has anterior and posterior papillary muscles
D) Mainly supply by left coronary artery
E) Wall is thinner than right ventricle
9. Regarding development of the heart,

A) Septum secondum completely divide the atria
B) Septum spurium contribute to form the atrial
C) Pulmonary artery develop from the right horn of sinus venosus
D) Arise from the truncus arteriosus to pharyngeal arches in 4th week
E) Smooth part of left atrium develop from left horn of sinus venosus
10. Regarding the arterial development, structures of embryo develop into adult structures including,
A) Right 4th aortic arch – right internal carotid artery
B) 5th aortic arch – subclavian artery
C) 2nd aortic arch – maxillary artery
D) Left umbilical artery – median umbilical ligament
E) Left vitelline vein – inferior mesenteric artery
SBR
11. Best way to measure ventricular function?

A) Blood pressure
B) Electrocardiogram
C) Echocardiography
D) Chest X ray
E) Angiogram
12. Which organ has the highest blood supply at 100g/ml blood flow?
A) Brain
B) Liver
C) Kidney
D) Heart muscle
E) Skeletal muscle
13. Cardiac muscles differ from the skeleton muscles in that?

A)
B) Cardiac muscle fibers are multinucleated
C) Function as syncytium
D) It can be tetanized by high frequency stimulus
E) Its oxygen extraction is very low

14. A 60-year old man admits hospital with chest pain because of myocardial infraction. The infraction is behind
sternum. What is the most common can occurring vessel?
A) Anterior interventricular
B) Circumflex artery
C) Right marginal artery
D) Posterior interventricular artery
E) Right coronary artery
15. Left superior intercostal valve drain into,

A) Accessory hemiazygous vein
B) Azygous vein
C) Left brachiocephalic vein
D) Left subclavian vein
E) Superior vena cava
1. A healthy young adult male standing in attention in a parade on a hot sunny day fainted and fell down. On
examination following observations were made.
1.1 Blood pressure – 80/60
1.2 Pulse rate – 90 per minutes
1.3 Skin was cold and clammy
1.4 Regained consciousness spontaneously after about three minutes.
Explain the physiological basis of the above observation mentioned from 1.1 to 1.4 (4*25=100 marks)
2.
2.1 List 4 valves of the heart. (10 marks)
2.2 Describe the structures of those valves. (30 marks)
2.3 State the surface marking of heart valves and heart sounds. (20 marks)
2.4
2.4.1 List 10 embryonic structures that became adult structure in the development of
venous system. (15 marks)
2.4.2 Describe three common congenital abnormalities associated with the ventricular
septum formation. (25 marks)
01
A) T
B) T
C) F sym - contractility in ventricle and atria
D) T
E) T
02
A) F Venous pooling

B) F As a compensation HR increases
C) T
D) F
E) T After the compensation, initially low BP
03
A) T increase in ICP - cerebral edema
B) T
C) T
D) T
E) T
04
A) T Both SBP and DBP
B) F
C) F
D) T
E) F
05
A) T
B) T
C) F
D) F
E) F TPR - DBP only so decrease PP
06
A) T
B) T
C) F
D) F
E) F
07
A) F Same COP
B) T After IVVR
C) T increase venous return to heart
D) F 10
E) F During systole 80 120
08
A) T
B) T 2/3 of diaphragmatic surface
C) T
D) T
E) F ×3 thicker
09

A) F
B) T
C) F
D) F
E) T
10
A) F 3 rd arch
B) F 5 th one do not form/disappear
C) F 1 st arch
D) F Median umbilical ligament- urachus
E) F
11) C
12) C
13) C
14) A
15) C
1.1

So in this person
SBP × DBP
So BP = 80/60 mmHg
Leads to shock (distributive)
1.2
1.3

1.4
2.
2.1
• Ductus arteriosus – ligamentum arteriosum
• Ductus venosus – ligamentum venosum
• Left umbilical vein – ligamentum teres hepatis
*Anastomosis between –
• L/ brachiocephalic vein - Anterior cardinal veins
• R/ common cardinal vein - SVC
+
Proximal portion of R/ anterior cardinal vein
*anastomosis between
• Sub cardinal veins - L/ renal vein
• L/cardinal distal portion - L/gonadal vein
• R/sub cardinal – renal segment of IVC
*Anastomosis between sacrocardinal veins
• R/sacrocardinal vein – sacrocardinal segment of IVC

1. Regarding anatomy of the Heart,

A) AV node is located in the poster inferior region of interventricular septum.
B) Diaphragmatic surface is mainly formed by left ventricle
C) Mitral valve prolapse during blood flow is avoided by fibrous skeleton
D) Right auricle has pectinate muscle
E) Right border extend between SVC and IVC
2. Regarding mediastinum,
A) It is a serous covering of the body cavity
B) Esophagus is a content of superior mediastinum
C) It extends posteriorly from T1 to T12.
D) Right recurrent laryngeal nerve lies in superior mediastinum
E) Internal thoracic vessels are contained in anterior mediastinum
3. The veins drain in to Right brachiocephalic veins include

A) Vertebral vein
B) Inferior thyroid vein
C) Middle thyroid vein
D) External jugular vein
E) Internal thoracic vein
4. In fetal circulation, what are the places that mixing of deoxygenated and oxygenated blood take place
A) Left atrium
B) Left ventricle
C) Right atrium
D) Right ventricle
E) Liver
5. Hypovolemic shock is accompanied by

A) Low blood pressure
B) Warm extremity
C) Reduced pulse rate
D) Increased respiratory rate
E) Cyanosis
6. Vasomotor center (Rostral ventro lateral medulla) is stimulated by

A) Carotid and aortic chemoreceptors
B) Carotid and aortic baroreceptors
C) Pain pathway
D) Brain stem reticular formation
E) Increased body temperature
7. ventricular ejection fraction

A) Is the fraction of blood ejected by ventricle from the volume of ventricle
B) Is an index of myocardial contractility
C) Normal value is about 90%

D) Reduced in aortic stenosis
E) Not changed during exercises
8. When a normal person changes from lying down position to erect position, there is an increase in his
A) Systolic blood pressure
B) Heart rate
C) Venous return
D) Diastolic blood pressure
E) Stroke volume
9. Regarding cardiac muscle fibers,

A) The action potential is similar to the action potential of neuron
B) The mechanical response is similar to that of the skeletal muscle fibers
C) Its behavior as a syncytium is due to its branched nation
D) SA node is a specialized cardiac muscle
E) It can be tetanized by high frequency stimulations
10. According to the cardiac cycle,

A) Resting time of cardiac cycle is 0.3s
B) Maximum right ventricular pressure is 25mmHg
C) Lowest right ventricular pressure is about 10mmHg
D) First heart sound is produced in early systole
E) Ventricular volume is lower in end of the systole
SBR
11. Major contribution to blood viscosity is due to,

A) Electrolytes
B) Plasma proteins
C) Red blood cells
D) White blood cells
E) Platelets
12. Resistance to blood flow is highest in,

A) Aorta
B) Artery
C) Arterioles
D) Capillaries
E) Veins
13. Which structure has largest blood volume at rest

A) Chambers of heart
B) Pulmonary circulation
C) Systemic veins
D) Aorta
E) Capillaries

14. A two day old baby is diagnosed with transposition of the great arteries.which of the following
structures must be remain patent to prolong the life of the baby until it would be surgically
connected
A) Ductus arteriosus
B) Umbilical artery
C) Umbilical vein
D) Foramen ovalle
E) Ductus venosus
15. A 62-year old patient come with a complain of dysphagia and swelling of legs. Radiography revealed a tumor
in the thoracic part of the oesophagus. The mass is compressing a posterior mediastinal structure .obstruction in
what structure is leaded to edema in lower extremities
A) Thoracic aorta
B) Thoracic duct
C) IVC
D) Aortic aneurism
E) SVC
1.
1.1 48-year old male is diagnosed to have nearly total blockage of the posterior descending interventricular artery.
1.1.1 Briefly describe the venous drainage of the heart? (20 marks)
1.1.2 He is waiting for coronary bypass surgery. State the cardiac vein that is most susceptible to injury during the
procedure. (10 marks)
1.2 In a professional long distant runner, the blood pressure is 110/70 mmHg and average resting heart rate is 62
beats per minute. The rise in blood pressure and heart rate during exercise is much less and they return to normal
sooner than in a sedentary person in engaged in similar exercise. Briefly describe,
1.2.1 The adaptive changes in the heart during physical training (35 marks)
1.2.2 Contribution of the above changes to the efficiency of the cardiac pump (35 marks)
1
A False Posteroinferior region of interatrial septum subendocardially
B True
C True
D True Fibrous skeleton and chorda tendinae support to the atriovetricular valves.
E True
2
A False The space between two pleural sacs
B True
C False Superior mediastinum-: 1st rib – T4
Inferior mediastinum-: Anterior T4 – T9
Middle T4 – T9

Posterior T4 – T12
D False
 Left recurrent laryngeal nerve- hook around the ligamentum arteriosum & passing up on the right side of the
aortic arch.( at T4 level)
 Right recurrent laryngeal nerve- Hook around the right subclavian artery.
3
A True 1st intercostal vein also drain
B True
C False To internal jugular vein
D False To right subclavian vein
E True
04
A False Mix with blood returning from lung
B False
C False Returning from head and limbs
D True
E True Small amount returning from the portal system
Inferior vena cava – deoxygenated blood from lower parts and kidneys
Entrance of the ductus arteriosus in to descending aorta.
05
A True
B False
C False
D True Acidosis- Reduced O2 carrying capacity Stagnant hypoxia
E True Little cyanosis can be occur. (ganong)
06
A True
B False
C True
D True
E False Direct vasodilator effect
07 ventricular ejection fraction

A True From EDV 65%
B True
C False 65%
D True
E True SV increased only in Isotonic Exercises & EDV also elevated due to vasoconstriction
08
A False
B True
C False
D True Sympathetic stimulation

E False
09
A False
B False Cardiac Muscles can’t be tetanized
C False Intercalated discs are a network of cardiomyocytes connected that enable the rapid transmission of electrical
impulses through the network, enabling syncytium to act in a coordinated contraction of myocardium
D True
E False
10
A False 0.4 diastole
B True
C True
D True Ventricular systole- isovolumetric contraction
E True
11 C Blood viscosity is mainly depend on RBC count
12 C
13 C
14 A
15 B Thoracic duct related posteriorly to esophagus in posterior mediastinum
13th Batch (EME) – SEQ ANSWER
1.1.1) Heart consist 3 major veins,

 Coronary sinus
 Anterior cardiac vein
 Venae cordis minimae
Coronary sinus-: is a wide vessel that lie in posterior part of atrioventricular groove. Opening of vessel located at its
right side end & it drain in to right atrium. Has five tributaries,
1. Great cardiac vein-mainly receiving blood from left ventricle and enter the sinus at its left side end.
2. Middle cardiac vein- opening near to the termination of sinus.
3. Small cardiac vein- open near to the termination of sinus
4. Posterior vein of the left ventricle
5. Oblique vein of the left atrium- open into the sinus at its left side end
Anterior cardiac vein-: collection of veins that run across the surface of right ventricle & open in to right atrium.
Venae cordis minimae-: collection of small veins located within walls of all 4 chambers & they directly open in to
corresponding chambers.
1.1.2) Middle cardiac vein
1.2.1) Hypertrophy of cardiac myocyte occur & due to that ventricular wall thickness get elevated. So
 Size of heart is enlarged

 Stroke volume raised
 End systolic volume raised
Due to the elevation of stroke volume during rest, the resting heart rate become lower without affecting the cardiac
out output at rest. Time that needed to heart rate to become normal after the exercise reduced ( Heart rate
recovery time ↓ )
1.2.2) During the exercise, the demand for O2 & nutrients (Glucose & FA ) in skeletal muscles elevated. Heart has to
pump more blood to circulation to keep the skeletal muscle perfusion in a proper range. In exercise muscular
contraction & action of thoracic pump keep the venous return to heart in a greater volume. Therefor
Preload elevated
Increase in force of ventricular Contraction needs to keep a higher ventricular ejection. For that need, Heart adapt by
hypotrophy of myocytes, That result greater contractile force. Hypotrophy is physiologically capillary density to
muscle also elevated. Due to this adaptation, stroke volume in exercising as well as resting become elevated. With
high stroke volume, the heart rate can remain in low value to keep normal cardiac output in resting.
Due to high End Systolic Volume heart can pump more blood during exercising by rising its stroke volume & then end
Systolic Volume get reduced. So heart rate will not be elevated as in a sedimentary person.
Lower heart rate allow heart to till properly during Diastole & that facilitated ejection of proper amount of blood into
circulation. Lower heart rate facilitated proper blood supply to heart muscles as well.
(subendocardial portion of left ventricle receive its arterial blood supply only during Diastole. So in tachycardia, time
period period for diastole reduced & risk to have ischemic conditions in those areas is reduced)
1. Select the true statements regarding the fibrous skeleton

A) It provides the passageway for the AV bundle of conducting system.
B) It forms the electrical discontinuity between the atria and ventricles.
C) It provides attachments to cups of the semilunar valves of the heart.
D) It prevents the prolapse of the tricuspid valve.
E) It is attached to the muscular part of the interventricular septum.
2. Select the true statements with reference to normal ECG

A) The QRS complex is produced by depolarization of ventricles.
B) The aortic valve is closed at the time of the P wave.
C) The second heart sound occurs at about the same time as the QRS complex.
D) The Q-T interval is an approximate indication of the duration of ventricular systole.
E) The first heart sound occurs at about the same time as P wave.
3. Select the true statements regarding the electrical properties of the heart muscle
A) Rate of pace-maker potentials is highest in the S-A node.

B) Duration of action potential is shorter than that of skeletal muscle.
C) Spread of action potential is faster than in skeletal muscle.
D) Gap junctions have high electrical resistance.
E) Refractory period is longer than the contraction phase.
4. Select the true statements regarding the cardiac output

A) It is greater in supine position than in standing position.
B) It is defined as the volume of blood ejected by both ventricles in one minute.
C) The cardiac output of the left ventricle is greater than the cardiac output of the right ventricle
D) It increases during fever.
E) It is greater during inspiration than during expiration.
5. What are the changes occurring when a normal 50kg woman loses one liter of blood?
A) Immediately after hemorrhage her hematocrit is decreased.
B) Iron absorption from the intestine increases.
C) Heart rate is likely to be more than 100 beats per minute.
D) Reticulocyte count in the blood decreases.
E) Her blood volume is depleted by about 30%.
6. Select the true statements regarding the arch of the aorta

A) It commences at the level of the sternal angle.
B) It might develop coarctation.
C) It is encircled by the right recurrent laryngeal nerve.
D) Generally, the right common carotid artery arises from the arch.
E) It has a connection with the pulmonary artery via ligamentum arteriosum.
7. Select the true statements regarding the arterial pulse

A) Pulse strength reflects stroke volume.
B) It is caused by blood flow in the arteries.
C) Pulse wave travels faster than blood flow.
D) Pulse wave travels faster in children than in elderly people.
E) It is "thready" in circulatory shock.
8. Select the true statements regarding the thoracic sympathetic trunk

A) Each ganglion receives a preganglionic white ramus from the anterior ramus of its corresponding spinal nerve
B) The first thoracic ganglion is preserved intact during upper thoracic ganglionectomy.
C) The greater splanchnic nerve is formed by branches from the second to sixth ganglia.
D) It gives post-ganglionic fibers to the thoracic viscera.
E) It lies anterior to the costovertebral pleura.
9. Select the true statements regarding the left coronary artery

A) Its blood flow reduction causes angina.
B) It supplies the sinoatrial node in 40% of cases.
C) It is usually shorter than the right coronary artery.
D) It passes posterior to the left auricle.
E) It gives off the posterior interventricular artery in a left dominant circulation
10. Select the true statements regarding diaphragm

A) The left phrenic nerve pierces the diaphragm with the inferior vena cava.
B) A congenital Bochdalek hernia occurs posteriorly.
C) It is attached to the upper three lumbar vertebrae on the left.
D) The esophagus passes through it at the level of T8.
E) It is attached to the Xiphoid.
11. Which of the following structures contribute to form the interventricular septum?
A) Septum spurium
B) Anterior endocardial cushion
C) Floor of primitive ventricles
D) Sinus venosus
E) Conus septum
12. Which of the following cardiovascular changes occur when a healthy person changes from supine to standing
position?
A) Blood flow to the apices of the lung decreases.
B) Veins in the lower limbs constrict.
C) Venous return increases.
D) Heart rate is higher than in supine position.
E) Cerebral blood flow decreases.
13. Select the true statements regarding the cardiac cycle

A) Duration of a cardiac cycle at rest in a normal adult is 0.8 milliseconds.
B) Systole takes longer than diastole.
C) Semilunar valves remain closed during late diastole.
D) Left ventricle ejects more blood than right ventricle.
E) Coronary blood flow is greater during systole than during diastole.
14. Select the true statements regarding the heart

A) Fossa ovalis present in the anterior wall of the right atrium.
B) SA node lies deep to the epicardium.
C) Lymph from the heart reaches the tracheobronchial lymph nodes.
D) Compression to the sterno-costal surface by the sternum might injure the right ventricle.
E) Purkinje fibers of right ventricle traverse the septo-marginal trabeculae.
15. Select the true statements regarding the contractile properties of cardiac muscle
A) Catecholamines have positive inotropic effect on contraction.
B) Tetanic contraction is produced when stimulated at high frequency.
C) Hyperkalemia prolongs the diastolic time.
D) Isometric and isotonic contractions are seen in cardiac muscle.
E) Myocardial contractility increases with increasing strength of the stimulus.
SBR
16. Which of the following is the fastest response in restoring normal blood pressure after hemorrhage?
A) Baroreceptor reflex
B) ADH
C) Chemoreceptor reflex

D) Reduced capillary filtration
E) Aldosterone
17. A 48-year old male patient is scheduled to have a coronary arterial bypass because of chronic angina. Coronary
arteriography reveals nearly total blockage of the posterior descending interventricular artery, In exposing this
artery to perform the bypass procedure, which accompanying vessel is most susceptible to injury?
A) Middle cardiac vein
B) Coronary sinus
C) Anterior cardiac vein
D) Small cardiac vein
E) Great cardiac vein
18. Which of the following factor leads to increases in cerebral blood flow markedly?
A) With increasing arterial PCO2
B) Under reflex vasomotor control of cerebral vessels
C) In systemic hypertension
D) During elevated intracranial pressure
E) With increasing arterial PO2
19. Which of the following structures contains the largest fraction of blood volume
A) Systemic Veins
B) Pulmonary vessels
C) Systemic Arteries
D) Heart chambers
E) Capillaries
20. An emergency tracheostomy needs to be done in a 2-month-old infant. Which of the following structures will
be most commonly at high risk of injury during the procedure?
A) Left subclavian artery
B) Left vagus nerve
D) Left brachiocephalic vein
E) Left phrenic nerve
1.
1.1 Define the term "circulatory shock". (10 Marks)
1.2 Hemorrhagic shock is often accompanied by,

1.2.1. Hypotension
1.2.2. Tachycardia
1.2.3 Cold, pale and clammy skin
Explain the physiological mechanisms underlying the above changes. (3 x 30 Marks)
2.
2.1 Write an account on origin, course and tributaries of azygos system of veins. (30 Marks)

2.2. Describe the formation of interventricular septum and state 4 congenital anomalies associated with its
development. (20 Marks)
2.3 Blood pressure measurements were made in a healthy medical student at rest and during moderate exercise in a
treadmill. His BP at rest was 116/76 mmHg and at the end of a 10 minute exercise it was 168/68 mmHg.
Explain the physiological mechanisms leading to,
2.3.1 Increased systolic pressure (30 Marks)
2.3.2 Reduced diastolic pressure (20 Marks)
01
A- T because increasing strength of stimulus = discharge of SA node.
B- F all contractions are isometric or isovolumetric (no change in volume or length than tone/tension/pressure.
(Refer starling law of the heart).
C- T that’s why in hyperkalemic patients, their heart stops in diastole, eventually.
D- Despite the strength of stimulus or intensity nothing can result in tetany.
E- T (refer Ganong)
02
C is the answer since the veins containing most of the total blood volume they’re called as capacitance vessels. Large
diameter enables them to acquire this characteristic.
03
A- F
B- T
C- F in the right
D- F pierces the diaphragm at T10 level via esophageal hiatus
E- F Hernia occurs anteriorly.
04
All statements are true.
05
A- F output by both ventricle is equal.
B- T increase venous return leads to increased end diastolic volume which results in increased cardiac output.
(Venous return increases due to the increased negative pressure during inspiration hence the compression of veins
and facilitated venous return.)
C- F by either right or left ventricle not two ventricles.
D- T increased SA node discharge due to increase in temperature by pyrogens. Hence results in accelerated
contractility and more cardiac output.
E- T in venous return is greater in supine position than standing position due to the pulling effect of gravity.
06
A- T
B- T

C- F
D- T
E- F
07 A is the answer, an increased arterial PCO2 is the main factor dilates the coronary blood vessels and increases the
flow in a marked level. Refer Ganong page 582.
08
A- F
B- T
C- T
D- F
E- T
09
B is the answer middles cardiac vein goes along with posterior descending
interventricular artery
10
A- T P wave denotes the atrial contraction so during the contraction prior to that both aortic and pulmonary valves
close.
B- F the second heart sound DUB refers to the closure of aortic and pulmonary valves. That occurs in late systole or
early diastole. And QRS complex denotes the ventricular contraction. So, before the contraction the valves should’ve
been closed.
C- T theory
D- T theory
E- F Atrial systole begins after the P wave. 1st heart sound is heard in early systole or late diastole. So, it’s unlikely to
be correlated.
11
A- T theory
B- F because the sarcoplasmic system more inclusive in skeletal muscles than cardiac muscle.
C- F AP duration is longer than cardiac muscle.
D- F less electric resistance since allowing to form a syncytium.
E- T that’s why heart muscle can’t be tetanized.
12
A- F
B- F refer Langman embryology.
C- F
D- F
E- T
13
A- T containment of particular blood volume reflects the strength of pulse waves.
B- T during circulatory shock in an example like severe hemorrhages will result in reduction in total blood volume
hence the weaken pulse due to reduced distension via containment of blood.

C- F in elder people unlike young or children walls of arteries loses elastic nature so speed of pulse wave is higher
due to less resistant to travel via distension and recoil of arterial walls.
D- T pulse wave reaches a distal point before blood comes there.
E- F its actually caused by distension of aortic walls and that particular distension spreads as the wave to the distant
part of arteries. ( during diastole extra blood is kept in aorta to maintain the diastolic pressure and preventing it to
reach zero)
14
A- T occurs in children with turner’s syndrome.
B- F left common carotid artery.
C- T at T4 level
D- F left recurrent laryngeal nerve encircles Infront of ligamentum arteriosus.
E- T theory
15
A- F there’s no changes in veins of lower limb. Actually, the venous return is aided by contraction of muscles.
B- F venous return reduces due to the effects of gravity which causes pooling of blood in lower part of the body.
C- T total cardiac output reduces so sometimes sudden erection from supine position results in vertigo or syncope
due to reduced perfusion to brain.
D- ?
E- T reduction blood pressure in the sense of reduced cardiac output compensated by increasing heart rate by
cardiovascular regulation. Low pressure sensed by baroreceptors and inhibitory impulse to cardiac inhibitory
center at medulla oblongata is sent. Then reduction in the intensity of cardiac inhibitory signal will result in increased
SA node activity and discharge hence the increased heart rate in a progressive way.
16 B is the answer. Location of susceptible organs of injury varies within adults and children
14th Batch (EME) – SEQ ANSERS
1 1.1.Define the circulatory shock
Circulatory shock is inadequate perfusion with relatively inadequate cardiac output.that may be
hypovolumic,cardiogenic,distributive or obstructive type of shock because of any type of above reasons
tissue doesn’t get enough oxygen to fulfill it’s need for proper function
1.2.haemorrage shock is often accompanied by
1.2.1.hypertension
1.2.2.tachycardia
1.2.3.cold,pale, clammy skin

Haemorrhage shock is a condition occurs due to the ascending of blood volume circulatory.this may due to
haemorrage or huge blood loss .that decrease the bloodb volume in the system and result in hypovolumic
shock.
Due to blood loss huge blood volume decreases when there is a blood loss mostly isotonic fluid loss occurs.
Anyhow it decreases end diastolic volume decreases that decreases stroke volume. Cardiac output=stroke
volume* heart rate .so cardiac output also decreases.due to this condition blood flow decreases ,it will
decrease the baroreceptor discharge due to the activation of vasomotor area in the brainstem is less.
Baroreceptor are located in carotid sinus and aortic arch.suppressed activation of vasomotor area increase
sympathetic activity which results in vasoconstriction increase the total peripheral resistance that increase
the end diastolic blood pressure. That result in hypertension sympathetic innervation act on receptoa in
heart and increase heart rate result in tachycardia . Due to increased sympathetic activity sweat secretion
from sweat gland is increased,that cause clammy skin,as vasoconstriction occur blood supply to cutaneous
structure is decreased ,so cold and skin can be Observed
Loss of Blood
Hypovolemia
EDV↓
PRELOAD ↓
STROKE VOLUME↓
Cardiac Output↓
Blood Flow ↓
Stimulation of Low Pressure Barrow Receptors

(impulses via Buffer Nerves)
NTS
Vasomotor Active Center Stimulates Stimulation of CAC Inhibition of CIC

Increase Sympathetic Discharge
Heart Rate Vasocontriction Sweating
Tachycardia TPR↑ Blood supply to Skin↓ Clammy

Skin
Hypertension Cold Clammy Skin
1. The thymus,
A) Lies in the anterior mediastinum
B) Involutes after puberty
C) It is supplied by inferior thyroid artery
D) It lies anterior to the left brachiocephalic vein
E) Has lymphoid follicles
2. The left atrium,

A) Forms the major part of the left border of the heart
B) Lies behind to the right atrium
C) Has oblique sinus posterior to it
D) lies anterior to the esophagus
E) Consist of Sinoatrial node in its wall
3. Ligaments that have fetal vessels of origin includes,

A) Ligamentum arteriosum
B) Ligamentum teres
C) Ligamentum venosum
D) Median Umbilical ligaments
E) Gastroparesis ligaments
4. The Azygos vein,

A) Formed by conjoined right subcostal vein and right ascending lumbar vein
B) Arches over the root of the left lung
C) Receives superior intercostal vein
D) Azygos vein directly drain into right atrium
E) Passes through esophageal hiatus

5. Flow of lymph from lower limb,
A) Increases during supine position than standing
B) Increases during exercise
C) Increase in increase of venous pressure
D) Increase in peristalsis of the lymphatics
E) Is increased by massaging
6. Regarding veins in the circulatory system,

A) They serve as blood receiver during emergencies
B) They are fully distended at rest conditions
C) Their capacity is less than that of the arteries
D) They are controlled by sympathetic nerves
E) They have more elastic tissue in their wall than corresponding arteries
7. Following factors have direct impact on blood pressure,

A) Blood Volume
B) Elasticity of walls
C) Gravitational force
D) Serum electrolyte concentration
E) Capillary permeability
8. Compare to the systemic circulation, the pulmonary circulation

A) Has lower blood volume
B) Has lower resistance
C) Has lower oncotic pressure
D) Hypoxia causes constriction of Arteries
E) Higher hydrostatic pressure
9. Regarding baroreceptor reflex,

A) It has the afferent fibers through cervical nerves
B) Stretching of the artery stimulate the receptors
C) Baroreceptors located in aortic and carotid body's
D) Respond for short term regulation of arterial blood
E) Baroreceptor reflex is faster than the hormonal regulation
10. ECG is use to evaluate,

A) Cardiac rhythm
B) Integrity of conducting system
C) Mechanical efficiency of heart chambers
D) Abnormalities of the heart valves
E) Coronary circulation
SBR
11. A 6-year old boy is found to have a mid-line tumor of the thymus impinging posteriorly on blood vessel. The
blood vessel most likely to be affected would be?
A) Superior vena cava
B) Arch of aorta

D) Right brachiocephalic vein
E) Right pulmonary vein
12. 47 age man admit emergency department due to severe dysphagia and edema at the lower limb. Barium
sulfate swallow imaging procedure reveals esophageal constriction, mostly likely cause of severe edema of lower
limb is,
A) Thoracic aorta constriction
B) Thoracic duct blockage
C) Obstruction in inferior vena cava
D) Aortic aneurism
E) Femoral artery disease
13. Which of the following offer lease resistance to blood flow,

A) Arteries
B) Arterioles
C) Capillary
D) Venules
E) Veins
14. Which of the following has the greatest effect on total peripheral resistance?
A) Hematocrit
B) Plasma protein Concentration
C) Blood volume
D) Plasma osmolality
E) Sympathetic tone
15. Which of the following serum electrolyte in high concentration has greatest effect on cardiac function,
A) Sodium
B) Potassium
C) Bicarbonate
D) Magnesium
E) Chlorine
1.
1.1 Resting blood pressure and heart rate were measured in a group of healthy youngsters after regular intense
physical training and in a sedentary control group. The mean value for blood pressure was 116/76 mmHg and the
heart rate were 58 bpm in the trained group. In the sedentary control group mean values were found to be
118/80mmHg and 70 bpm.
Explain the physiological mechanisms maintaining a normal blood pressure in the trained group despite a
significantly low resting heart rate. (60 marks)
1.2 A 48-year old male patient is scheduled to have a coronary arterial bypass because of chronic angina. Coronary
arteriography reveals nearly total blockage of the posterior descending interventricular artery.
1.2.1 In exposing this artery (posterior descending interventricular) to perform the bypass procedure, which
accompanying vessel would be most susceptible to injury? (05 marks)

1.2.2 Describe origin, branches and supply of the right coronary artery. (15 marks)
1.2.3 Tabulate/List all the embryonic aortic arches and the derivatives of the respective arch. (20 marks)
01)
A. T
B. T
C. T
D. T
Components of anterior mediastinum
Thymus remnant
Sternopericardial ligaments
Lymph nodes
Branches of interval thoracic
Rference. (last )
The lymphatic component decreases with age being replaced with fat and fibrous tissue
blood supply : inferior thyroid artery
Internal thoracic artery
Left brachiocephlic vein lies posterior to thymus since it has a long course than right brachiocephlic vein
02)
A. F (major part is formed by L/ventricle)
B. T
C. T
D. T
E. F(SA node is situated subepicardially in the wall of the R/atrium.
03)
A. T
B. T
C. T
D. F
E. F
ligamentum arteriosus
Left umbilical vein
Ductus venosum
Embryonic uracus
( But the medial umbilical ligament is a remenant of umblical arteries )
04)
A. T
B. F( arches forward over the root of the R/lung)
C. T
D. F (ends in the SVC)

E. F (posterior to the oesophagus)
05)
A. F
B. T
C. T
D. F
E. T
During standing due to the contraction of muscles of lower limb the lymphatic return is increased .
During exercise due to increased muscle contraction the associated lymphatic return is increased
Due to increase in venous pressure the suction effect of high velocity flow of blood in the veins in which the
lymphatics terminate increases lymph flow
Peristaltic movement is not realated to increase but is realated to movement of direct of lymph flow
Massaging increases lymph return
06)
A. T
B. F
A. F(at rest, 50% of circulating blood volume is in the systemic circulation, 12% in the heart cavities, 18% is in
the low pressure pulmonary circulation, 8% in the arteries, 1% in the arterioles and 5% is in the capillaries - -
ganong pg 574)
C. T
D. F
07)
A. T
B. T
C. T
D. F
E. F
1. Blood volume is usually associated with stroke volume and cardiac output so directly affects BP
2. Elasticity of walls affects vessel diameter
3. Gravitational force affects BP directly (see image below)
4. Serum concentrations affects the blood osmalarity thereby affecting bp so it’s indirect
5. Capillary permeability affects blood osmolarity thereby affecting bp

08)
A.T ( at rest, 50% of circulating blood volume is in the systemic circulation, 12% in the heart cavities, 18% is
in the low pressure pulmonary circulation, 8% in the arteries, 1% in the arterioles and 5% is in the capillaries
- - ganong pg 574)
B. T
C. F
D. T
E. F (arterial system – high pressure system
Systemic veins, pulmonary circulation, heart chambers other than the L/ventricle – low pressure system -
- ganong pg 575)
09)
A. T
B. F
C. F
D. T
E. T
The afferent fibers of baroreceptor reflex are through glossopharyngeal and vagus nerve
Baroreceptors are stimulated by distention of the structures they are located so they discharge at a higher rate when
the pressure on these structures rise
Baroreceptors are located in carotid sinus and aortic arch and walls of right and left atria
It’s a reflex for short term regulation so it’s fast
10)
A. T
B. T
C. F (electrical activity of heart)
D. F (The echocardiogram is the most common test to diagnose a problem with the heart valves. echocardiogram uses
sound waves to create a picture of the heart valves and chambers. ECG is used to check abnormal heart
rhythm)

E. (The most widely used invasive method for assessing the coronary collateral circulation is contrast angiography.
Myocardial infarction, ischemia, occluded artery can be identified by using ECG)
SBR
11. answer – arch of aorta
12) Ans- B
Thoracic duct blockage causes difficulties to drain lymphatics from the lower limb which causes edem in lower limb
13) answer- veins

Veins are called capacitance vessels – normally veins are partially collapsed al large amount of blood can be ad ded
to venous system before the pressure in the system increases drastically
Arterioles and small arteries have high resiatance therefore they are called resistance vessels
14) Ans - E
Blood vessels diameter has an greater effect on peripheral resistance. Diameter is inversely proportional to
resistance. Sympathetic tone leads to the construction of blood vessels causes reduction in the diameter which leads
to the greater peripheral resistance
15) Answer- Pottasium

K is the major electrolyte in cardiac function
Na in nerve functions
1.1
In trained individuals the cardiac fibers undergo modifying and causes cardiac hypertrophy thereby increasing the
cardiac contractility and by the starting law it heart it increases the stroke volume drastically
Therefore the heart rate is not increased to increase cardiac output to suffice the need of increased blood flow to
satisfy metabolic needs of muscles undergoing strenuous work during exercise .
But in untrained individuals the increase in sympathetic discharge increases both cardiac contractility and heart rate
.the increase in heart rate is very high. Therefore stroke volume increases moderately .
1.2.1) Middle cardiac vein

1.2.2)
Origin & course
 Arise from the anterior aortic sinus
 Then passes between the R/auricle and the infundibulum of the R/ventricle
 Then runs downward in the inter ventricular groove
 After that turns backwards at the inferior border of the heart and runs posteriorly
Branches & supply
I. Conus artery – pass upwards & medially on the front of the conus (infundibulum) of the R/ventricle. It
frequently anastomoses with the similar branch of L/coronary artery.
II. SA nodal artery – runs backwards between the R ventricle and the aorta. Forms the vascular ring around
the termination of the SVC. It supplies 60%of the heart
III. R/marginal artery – supplies the R/border of the heart
IV. Posterior inter ventricular branch / posterior inter ventricular artery – passes along the inter
ventricular groove towards the apex.
V. AV nodal artery
VI. One or more L/ventricular artery
VII. Remaining and much smaller R/coronary artery – anastomoses with the termination of the circumflex
branch of the L/coronary artery.
1.2.3)
I. 1st aortic arch – disappears -a small portion; piece of maxillary artry
II. 2nd aortic arch – disappears – small portions ; hyoid and stapedial
III. 3rd aortic arch – has the same development on the right and left side contribute to initial portion of the
internal carotid artery.
IV. 4th aortic arch – has ultimate fate different on the right and left side..
•on the left forms a part of the arch of the aorta between left common carotid and left subclavian artery. •
on the right – it forms the proximal segment of the right subclavian artery
V. 5th aortic arch- is transient and soon obliterates
VI. 6th aortic arch – pulmonary arch - - gives off a branch on each side that grows toward the developing lung
bud on the right side.
 the proximal part transforms into the right branch of the pulmonary artery, the distal part disappears
• on the left side, the distal part persists as the ductus arteriosus during intrauterine life.
• the proximal part gives rise to the left branch of the pulmonary artery.
1. Ductus arteriosus,
A) Connects the left pulmonary vein to the aortic arch
B) Functionally closed shunt after the birth
C) Persist in the post ductal type of the coarctation of the aorta
D) Represents the distal portion of the left 6th aortic arch
E) Shunts blood from the pulmonary trunk to aorta during fetal life
2. Regarding internal thoracic artery,

A) Arises from the second part of the subclavian artery
B) Supplies to the breast

C) It lies between the external and internal intercostal muscles
D) It lies in the posterior mediastinum
E) The superior epigastric artery is a terminal branch
3. Regarding the heart,

A) A heart is formed by smooth and rough portions
B) Left ventricle lies posterior to the right ventricle
C) Mitral valve is tricuspid
D) No muscular continuity from left atrium to left ventricle
E) The papillary muscle and the chordae tendinea anchor the aortic valve
4. Regarding descending aorta,

A) Commence at T4 level
B) Gives rise to a pair of subcostal arteries above the diaphragm
C) It is isolated and coarctation occur at the level of aortic hiatus
D) It supplies lower 9 posterior intercostal arteries
E) Passes the aortic hiatus at the level of T10
5. Regarding events of cardiac cycle in normal individuals

A) During diastole ventricular pressure is about 70mmHg
B) During strenuous work in a healthy subject left ventricular and diastolic volume may be twice as much as at rest
C) Mitral valve opens when the left atrial pressure exceeds the left ventricular pressure
D) Pulmonary valves open when the right ventricle pressure reaches 20-25mmHg
E) The left ventricle ejects more blood than the right ventricle
6. When a normal person lies down

A) Blood flow to the apices of lung increases
B) Blood supply to the brain is high
C) Heart rate rise more than when standing
D) There is constriction of lower limbs
E) Venous return is immediately increased
7. About blood flow to different parts of the body

A) Blood flow to brain varies with arterial blood pressure
B) Blood flow to the kidney is more than its oxygen consumption
C) Blood flow to myocardium is greater during diastole than systole
8. Following moderate blood loss (500ml),

A) Arterial blood pressure may be maintained as normal
B) Blood flow to brain is maintained by cerebral vasoconstriction
C) Osmoreceptors in hypothalamus get triggered
D)
E) Skin vessels constricted
9. A slow heart rate is a recognized feature in,

A) A trained young athlete
B) Sleep apnea
C) Heart block

D) Hypoxia
E) Hypothyroidism
10. Which factors in arterioles are higher than aorta

A) Flow of blood
B) Muscle:Elastic ratio
C) Resistance to blood flow
D) Velocity of blood
E) Cross sectional area
SBR
11. 2 day born female baby, pulmonary stenosis, Ventricular septal defect, Hypertrophy of right ventricle
A) Atrioventricular septal defect
B) Defect of aortic pulmonary septum
C) Endocardial cushion effect
D) Superior malalignment of the sub pulmonary infundibulum
E)
12. Pulse pressure is mostly depended on,

A) Cardiac output, Assuming a constant stroke volume
B) Heart rate, Assuming a constant stroke volume
C) Mean arterial pressure, Assuming a constant peripheral resistance
D) Stroke volume, Assuming a constant cardiac output
E) TPR, Assuming a constant arterial pressure
13. SA node is the normal pace maker of the heart because,

A) It can be depolarized many times spontaneously
B) Is a modified myocardium
C)
D)
E) It is the origin of the conducting system
14. Two patients were admitted to the emergency department and they were diagnosed with shock. One had
septicemia and the other one had cardiac tamponade. What is the change in central venous pressure compared to
a healthy person?
in Septicemia in Cardiac Tamponade
A) Increase Increase
B) Decrease Decrease
C) Increase Decrease
D) Decrease Increase
E) Decrease no change
15. The SA node is failing. Where can we place a pace maker to prevent fatal arrythmias
A) Right atrium
B) Left ventricle
C) Left atrium
D) Right Ventricle
E) SVC
1. A 60-yearold woman was admitted to hospital complaining of difficulty in breathing when lying down. Recently,
she had been treated for anteroseptal myocardial infarction and found to have ventricular septal defect during the
investigation. In this admission her blood pressure was 90/60 mmHg and the jugular venous pressure was elevated.
Ejection fraction was 40%.
1.1 Name the cardiac dysfunction in this patient (05 marks)
1.2 Briefly describe the coronary arterial supply of the heart (30 marks)
1.3 Briefly describe the formation of interventricular septum and list 3 congenital anomalies associated with its
formation (20 marks)
1.4 Give the physiological basis for observation in the above patient
1.4.1 Difficulty in breathing (15 marks)
1.4.2 Ejection fraction of 40% (20 marks)
1.4.3 Elevated jugular venous pressure (10 marks)
1.
A.f
B.t
C.f
D.t proximal portion of 6 th left aortic arch represents left pulmonary artery
Et
Refer on last Pg no.193
2.
A.f from 1st part ( last Pg no 184)
B.t
C.f
D.f
E.t
Musculophrenic and superior epigastric arteries are terminal branch of internal thoracic artery.
3.
A
B.t
C.f
D.t
E.t
4.
A.t lower border of t4 vertebra

B.t last Pg no 276
C.t
D.t
E.f
5.
A.f
Bf
C.t
D.t
E.f
6.
A.t
B.t
C.f
D.f
E.f
7.
A.t
B.t table 33.1 on ganong
C.t
D.
E.
8.
A.t
B.
C.t
D.
E.t
9.
A.t
B.f
C.t
D.f
E.t
10.
A.fArterioles are high resistance vessels
B.t Aorta contain large amount of elastic fibers
C.t
D.fAverage velocity is high in aorta
E.t cross area of aorta - 4.5
Cross area of arterioles - 400

SBR
11.
12.c
13.A
14.A
15.D
1.
1.1
Congestive cardiac failure
1.2
Heart is supplied by two coronary arteries; right and left.
Right coronary artery which is smaller arise from the anterior aortic sinus at the root of the ascending aorta
It passes forwards and emerges between the pulmonary trunk/infundibulum & right auricle Here it gives off SA
nodal, right atrial & conus branches
Then it runs downwards backward in the right anterior atrioventricular sulcus
To junction between right and inferior border
It winds around the inferior border and enters the diaphragmatic surface
Where it runs in the right posterior atrioventricular groove backwards and to the left Just before the turn it gives off
right marginal artery
It reaches posterior interventricular groove
Gives off posterior interventricular artery terminates by anastomosing with the circumflex branch of left coronary
artery
It also gives off AV nodal artery
Left coronary artery which is larger arises from the left posterior aortic sinus
It passes forward & to the left and emerges between the pulmonary trunk and the left auricle
Here it gives off left atrial and conus branches
It also gives an anterior interventricular branch(left anterior descending artery)
And continues as circumflex artery runs in the left anterior atrioventricular groove towards the left.
It winds around the left border of the heart and gives off diagonal artery
Then it continues in the left posterior atrioventricular groove ends by anastomosing with terminal branches of right
coronary artery
Anterior interventricular artery runs in the anterior interventricular groove Towards the apex & anastomoses with
the posterior interventricular artery
Right coronary artery supplies

 Right atrium
 Most of the right ventricle
 Left ventricle near posterior interventricular groove
 Posterior part of interventricular septum
 Whole of conducting system except for a part of left branch of the AV bundle
Left coronary artery supplies,

 Left atrium
 Most of the left ventricle
 Right ventricle - a small area near anterior interventricular groove
 Part of the left branch of the AV bundle
 Anterior part of the interventricular septum

1.3
By the end of the fourth week, the two primitive ventricles begin to expand.
This is accomplished by continuous growth of the myocardium on the outside and continuous diverticulation and
trabecula formation on the inside.
The medial walls of the expanding ventricles become apposed and gradually merge, forming the muscular
interventricular septum..
Sometimes, the two walls do not merge completely, and a more or less deep apical cleft between the two ventricles
appears. The space between the free rim of the muscular ventricular septum and the fused endocardial cushions
permits communication between the two ventricles.
The interventricular foramen, above the muscular portion of the interventricular septum, shrinks on completion of
the conus septum.. During further development, outgrowth of tissue from the anterior (inferior) endocardial cushion
along the top of the muscular interventricular septum closes the foramen.
This tissue fuses with the abutting parts ofthe conus septum.
Complete closure ofthe interventricular foramen forms the membranous part ofthe interventricular septum
1.4
1.4.1
In left Ventricular failure, VEDV is decreased
Left ventricular hypertrophy
Increased left atrial pressure
Increased pulmonary venous pressure(Due to starling forces, Pulmonary edema)
Increased pulmonary capillary pressure
Ventilation-perfusion mismatch
Increased work of breathing
Results in difficulty in breathing
1.4.2
Ejection fraction is the Fraction of total ventricular volume pumped out per beat during systole
Ejection fraction = Stroke Volume (SV) / End Diastolic Volume (EDV)
EF = 70 / 120 = 0.65
In order for the ejection fraction to change significantly the stroke volume must increase or decrease relative to EDV.
The SV is dependent on preload, afterload and myocardial contractility.
The preload doesn’t significantly affect the EF
This is because according to the Frank – Starling law, change in EDV, changes the SV in a directly proportional
manner, thereby having no significant effect on the ratio.
Since the changes in myocardial contractility can change the stroke volume, independent of the initial length of the
muscle fibre EDV doesn’t change.
Therefore increase in the myocardial contractility directly increases the EF by increasing the SV and vice versa
In congestive cardiac failure, myocardial contractility is decreased
So stroke volume decreases without any changes in EDV.
So ejection fraction will decrease.
1.4.3
JVP manifests due to pressure changes in the right atrium and the venous system
In left Ventricular failure, VEDV is decreased
Left ventricular hypertrophy
High LV filling pressure
Increased left atrial pressure
Increased pulmonary venous pressure(Due to starling forces, Pulmonary edema
increased right atrial pressure,
Results in elevated JVP

PHASE 1 QUESTIONS
8th Batch
8th Proper - MCQs
1. The AV bundle
A) Is developed from the ectoderm
B) Lies in the atrio-ventricular septum
C) Is part of the conducting system of the heart
D) Bridges the atrial and ventricular muscles anatomically
E) Divides into two branches which end in the subendocardial plexus
2. Right atrium
A) Has an auricle Superolaterally
B) Contain crista terminalis on its external surface
C) It is superior to central tendon of diaphragm
D) Contain opening of coronary sinus near their opening of SVC
E) Has anterior endocardial fold guarding the IVC
4. Regarding the development of heart

A) Conducting system develops from the sinus venosus
B) Primitive embryonic ventricle will develop into right ventricle
C) VSD occurs because of incomplete formation of the inter-ventricular septum
D) Primitive heart tube forms 21st day after fertilization
E) One of the condition of Fallot's teratology is left ventricular enlargement occurs
5) Which of the statements are true or false regarding the development of aortic arch?
A) Communicating 3rd and 6th aortic arch persists as ductus arteriosus
B) Left subclavian artery develops from the 5th aortic arch
C) Maxillary artery develops from first aortic arch
D) Left side of the 4th aortic arch gives rise to arch of aorta, left common
carotid and left subclavian arteries
E) Fifth arches never form completely
6) Thoracic aorta
A) Lies in midline throughout its course
B) Begins at upper border of 4th thoracic vertebra
C) lies posterior to esophagus at its termination
D) Has azygos vein lying posterior to it
E) Gives 12 pairs of posterior interosseous arteries
19) Regarding cardiac output

A) Increases when a person stands up from the lying down position
B) is high in patients with hyperthyroidism
C) Is increased by parasympathetic stimulation
D) Is largely determined by the end diastolic volume
E) Does not increase in response to muscular exercise in transplanted heart

25) Tachycardia is a feature in
A) Acute blood loss
B) Atrial fibrillation
C) Obstructive jaundice
D) Sinus arrhythmias
E) Ventricular extra systole
26) Total peripheral resistance

A) Decrease during blood loss
B) Increase than normal in polycythemia
C) Increase when adrenaline administered
D) Reduce when ACE inhibitors are given
E) Increases when Aldosterone is secreted
45) The person’s ECG with has no P wave has QRS and normal T wave. This person’s pace maker located
A) SA node
B) AV node
C) Bundle of his
D) Purkinje system
E) Ventricular muscle
51) 50-year old patient came with history of tachycardia and low pulse pressure (70/55 mmHg) . What is the most
likely condition?
A) Aortic stenosis
B) Fever
C) Heart block
D) Hypovolemic shock
E) Isotonic muscular exercises
52) 52-year old male came with a history of chest pain. It was found that the second heart sound is widely split
and do not alter while respiration. There was a mid-diastolic murmur in precordium. This complication is due to
A) ASD
B) Mitral stenosis
C) PDA
D) Tricuspid stenosis
E) VSD
53) There are CVS changes during muscular exercises. Changes that seen in isometric exercise but not in isotonic
exercise
A) Increase in cardiac output
B) Increase in force of contraction
C) Increase in heart rate
D) Increase in systolic blood pressure
E) Increase in total peripheral resistance

8th Proper - SEQs
1.
1.1. Draw a diagram to illustrate surface marking of the heart on precordium (15 marks)
1.2. Describe the pericardium of heart (35 marks)
1.3. Describe the components of the conductive system of the heart (30 marks)
1.4. Explain the innervation of the heart (20 marks)
4.0.
4.1. Define the tern shock (10 marks)
4.2. State three different types of shock (15 marks)
4.3. Describe the compensatory mechanisms that occur after acute loss of one liter of blood from a healthy adult (75
marks)
8th Repeat - SEQs
2.
2.1 Describe briefly macroscopic view of interior of the right atrium (40 marks)
2.2.1 Conducting system of the heart (20 marks)
2.2.2 Anatomical location of the heart. (20 marks)
2.2.3 Fibrous pericardium (20 marks)
4.
4.1 State the starling low of the heart (10 marks)
4.2 Explain the concept of contractility using the starling low of the heart (30 marks)
4.3 Describe the cardiovascular changes that occur when a person standing up from lying down position. (30 marks)
4.4 Explain why 𝛽 blockers are given to treat hypertension. (30 marks)
1)
A) F Most of conduction pathway – mesoderm
SA node – neural crest cells
B) F Inter ventricular septum
C) T
D) F functionally (physiologically)
E) T
2)
A) F Superiomedially
B) F Crista terminalis is a vertical ridge of heart muscle projected into the cavity of the right atrium.
Externally is a small groove; the sulcus terminalis between the superior vena cava and the right auricle.
C) T
D) F Coronary sinus opening is just to the left of the IVC opening and also between the fossa ovalis and above septal
cusp.
E) T

5)
A) F Distal part of the left 6th arch
B) F The 4th on the right contributes to the subclavian artery, on the left to the arch of aorta.
C) T Part of the first arch.
D) F The 4th on the right contributes to the subclavian artery, on the left to the arch of aorta.
E) T The fifth disappears entirely.
6)
A) F First left to the midline
B) F Lower border of T4
C) T
D) F
Posterior relations;
E) F 9 pairs of intercostal – 3-11
19)
A) F CO = SV × HR
When person stands up from lying down venous return to the heart is decreased, thus decreasing the SV.
The CO may decrease due to the decrease in SV or kept constant by the compensating mechanisms by increasing the
HR.
B) T Cardiac output is increased by the direct action of thyroid hormones as well as by circulating catecholamine
(which are increased during hyperthyroidism)
C) F Parasympathetic stimulation on heart decreases the heart rate and atrial contractility.
D) T SV is determined by the EDV
E) F Even the heart is denervated, during muscular exercise the level of circulating catecholamine is increased and
they act on the heart to increase the CO.
25)
A) T Due to the hemorrhage blood volume is reduced, to compensate the loss heart rate is increased.
B) T Atrial fibrillation is an irregular and often rapid heart rate.
C) F
D) T Sinus arrhythmia; a normal phenomenon where heart rate accelerates during inspiration and decelerates during
expiration.
E) T Purkinji initiate another heartbeat.
26)
A) F
Blood loss → Blood volume decreases → DBP decreases to compensate vasoconstriction → TPR increases
B) T Polycythemia; Increased hematocrit
Viscosity is increased.

C) T
Adrenalin sympathetic stimulation vasodilatation in liver and skeletal muscles and
vasoconstriction in the rest TPR increases
D) T
ACE inhibitors inhibit conversion of angiotensin I to angiotensin II vasoconstrictor
activity of angiotensin II is lost TPR reduces
E) F
Aldosterone causes Na+ and water retention increase blood volume vasodilatation
TPR decreases
45) ANSWER – B
No P wave suggests that there is no depolarization of the atria by SA node.
51) ANSWER – D
52) ANSWER – A
In ASD there is a left to right shunt of blood through the septal defect and it increases the EDV of the right ventricle
independent of respiration causing a fixed split.
53) ANSWER – E
1.1
1.2
Fibrous pericardium
• A fibrous ,single layered and is the outer most layer.
• At the base of the heart adherent to central tendon.
• Laterally adherent to mediastinal plura.
• At the roots of great vessels adherent to their adventitia.
• Anteriorly connect to sternum by weak sternopericardial ligaments.

Serous pericardium
• It is embryoligically a lining of body cavities.
• So a mesothelium consist of 2 layers
• Which a parietal and visceral layer
• It has 2 sinus
1) transvers sinus
•Above heart between arteries*aorta and pulmonary trunk+ and veins *SVC,L.atrium+
2) oblique sinus
• Between the left atrium and fibrous pericardium.
• Bounded by IVC and 4 pulmonary veins
Nerve suppy
• Phrenic nerve-fibrous pericadium+parietal layer
• No innervation-visceral layer
• Conducting system of the heart consist of - si - -atrioventricular
- -sub endocardial purkinje fibers • SA and AV nodes are
specialized type of cardiac muscle. • Impulses are conducted to the AV node by atrial cardiac muscle fibers.
• The AV node ,bundle,branches and subendocardial fibers form one continuous mass.
• SA node
• Pace maker of heart.
It is subepicardialy situated in the wall of the right atrium,just below the superior vena cava at the top of the sulcus
terminalis
• It has no microscopic or palpable.
• AV node
• Small mass of specialized myocardial cells.
• It is subendocardialy situated in the right atrium on the interatrial septem.
• Above the attachment of the septal cusp of the tricuspid valve
• To left of the opening of the coronary sinus.
• AV bundle
• From AV node the AV bundle runs along the inferior border of the membranous part of the interventricular
septum.
• Divide into right and left branches.
• The bundle is the only way of conducting the contractile impulse from atria to ventricle.
• The right bundle runs subendocardial on the right side of the septum.
• And reach the anterior papillary muscle and anterior wall of the ventricle and it’s purkinje fibers spread out
beneath endocardium.
• The left bundle reaches to left ventricle and rest of the ventricular wall.
2.
2.1 briefly describe macroscopic view of interior of the right atrium (40)
• Elongated chamber lies between the superior vena cava and inferior vena cava
• Crista terminalis is produced by projection into the cavity of the right atrium by sulcus terminalis
• Interior of the right atrium is smooth to the right of the crista terminalis

• Between the crista terminalis and blind extremity of the auricle the myocardium ,there is a series of horizontal
ridges , the pectinate muscle
• This is rough area
• There are openings for inferior vena cava , superior vena cava, for coronary sinus
• Inter atrial septum forms the posterior wall of the right atrium
• Toward the lower part of the posterior wall is a shallow depression ,fossa ovalis crescentic upper margin of the
fossa ovalis is called limbus
2.2 write an account on
2.2.1 Conducting system of the heart

• Consists of the sinuatrial node , atrioventricular node ,atrioventricular bundle (bundle of his) Right and left limbs
or branches of the his subendocardial purkinje fibers
• Specialized type of cardiac muscle fibres
• Impulses are conducted to the AV nodes by atrial cardiac muscle fibres
• The AV node , bundle ,branches ,subendocardial fibres forms one continues mass of conduction tissue
• SA node pacemaker of the heart
• Subepicardially
• Situated in the wall of the right atrium , just below the SVC , at the top of the sulcus terminalis
• AV node is subendocardially situated in the right atrium on the interatrial septum ,above the attachment of the
septal cusp of the tricuspid valve , to the left of the opening of the coronary sinus
• From the AV node , the AV bundle runs along the inferior border of the membranous part of the interventricular
septum
• It divide in to 2 branches
• Right and left branches
• Right branch runs at first within the muscle of the septum ,become subendocardial on the right side of the septum
• It continues in to the septomarginal trabecula to reach the anterior papillary muscle
• Anterior wall of the ventricle
• It s purkinji fibers then spread beneath the endocardium
• Left branch reach the septal endocardium of the left ventricle ,rapidly breakdown into the branches and spread
into the subendocardially over the septum and ventricular wall
2.2.2Anatomical location of heart (20)

• Lies obliquely in the thorax ,middle mediastinum
• Long axis is downward and to the left to the apex
• Lies behind the posterior surface of the sternum
• One third of the heart lies to the right of the midline
• 2/3 of the heart lies to the left of the midline
• Right border of the heart extend from the lower border of the right 3 rd costal cartilage to lower border of the
right sixth costal cartilage , just beyond the right margin of the sternum
• Inferior border passes from the right sixth costal cartilage to the apex (left 5th intercostals space
• From apex left border extend upward to the lower border of the left second costal cartilage about 2 cm from the
sterna margin
2.2.3 Fibrous pericardium (20)

• outer single layered fibrous sac
• enclosed heart and the root of the great vessel
• fusing with the adventitia of the great vessel

• overlies the central tendon of the diaphragm , both are inseparably blend
• both are derived from septum transversum
• phrenic nerve lies on the surface of the fibrous pericardium
• mediastinal pleura is adherent to it
• fibrous pericardium connect with the posterior surface of the sternum by weak sternopericardial ligament
• blood supply -internal thoracic artery
• venous drainage in to azygos vein
• nerve supply – phrenic nerve
4. 4 .1 state the starling low of the heart (10)

• within the normal physiological level power of myocardical contraction is proportional to the initial length of the
cardiac muscle fibres • initial length of the cardiac muscle fibres proportional to the end diastolic volume
4 .2 state the concept of contractility using the starling low of the heart (30)
• Within the physiological limit power of myocardial contraction is proportional to initial length of the cardiac
muscle fibres • Initial length of the cardiac muscle is proportional to ventricular end diastolic volume • So
ventricular end diastolic volume is proportional to the power of myocardial contraction
• myocardial contractility is property of the myocardium • It depend on the ventricular end diastolic volume •
VEDV is increased • Myocardial contractility is increased • So stroke volume is increased • Cardiac output is
increased • So stroke volume is depend on the myocardial contractility
4.3 Describe the cardiovascular changes that occur when a person standing from lying down position (30)
• In lying down position gravitational force are similar on the thorax abdomen and legs because these compartments
lies in the same horizontal plane
• When person standing from lying down gravitation force is variable in the above compartments.
• Due to effect of gravity the venous return is decreased
• Ventricular end diastolic volume is decreased
• According to the starling low of the heart power of contraction is proportional to initial length of cardiac muscle
fibres
• Initial length of cardiac muscle is proportional to ventricular end diastolic volume
• So force of cardiac muscle contraction is proportional to VEDV
• In this condition VEDV is increased
• Increase power of contraction of cardiac muscles
• Increase myocardial contractility
• Increase stroke volume
• cardiac output = stroke volume x heart rate
• Increase cardiac output
• Blood pressure = cardiac output x total peripheral resistance
• So blood pressure is increased
4.4Explain why beta blockers are given to treat hypertension

• Hypertension ,sustained elevation of the systemic arterial blood pressure
• Blood pressure = cardiac output x total peripheral resistance
• Hypertension can occur due to increase of cardiac output or total peripheral resistance
• Sympathetic discharges , epinephrine (noradrenalin) acts on the beta 1 receptors on the SA node , AV node ,His
purkinji fibres and atria and ventricular contractile tissue
So increase heart rate
• Increase rate of transmission in the cardiac connective tissue

• Increase force of ventricular contraction ,stroke volume is increased
• Due to above reason s cardiac output is increased
• So blood pressure is increased than normal level
• So hypertension occur
• Beta blocker act on the beta 1 receptor in the heart and block the action of the epinephrine and reduce the blood
pressure by decrease the heart rate and myocardial contractility
9th Batch
9th Proper - MCQs
2) Regarding surface marking of the heart

A) The apex lies in the 4th intercostal space at mid clavicular line
B) The mitral valve lies in left of the sternum in 4th intercostal space
C)The pulmonary valves lie left of the sternum in upper border of 3rd intercostal space
D)The tricuspid valve lies behind right of the sternum at 4th intercostal cartilage level
E) The aortic valve lies behind right of the sternum at 2nd intercostal space
5) Sinus tachycardia has been seen in

A) Hypovolemic shock
B) With vagal stimulus
C) During emotion
D) In thyrotoxicosis
E) In essential hypertension
11) The superior vena cava

A) Is formed by the right anterior cardinal and right common cardinal veins
B) Is formed behind the manubrium sterni
C)Opens into the right atrium behind the 3rd costal cartilage
D)receives the hemi azygos vein
E) lies in the superior mediastinum
Best response
44) A 35-year old man met an automobile accident and had a deep penetrating wound middle of the sternum
between 4th and 5th costal cartilage which of the chamber likely to be damaged
A) Right atrium
B) Right ventricle
C) Right auricle
D) Left atrium
E) Left ventricle
45)When administering surgery to distal coronary bypass to anterior interventricular artery, needle accidently
pass to nearby vein. Which vein may get damaged,
A) Great cardiac vein
B) Coronary sinus
C) Great cardiac vein
D) Middle cardiac vein
E) Small cardiac vein
56) What are the features that shock is compensated

A) Tachycardia
B) decrease pulse pressure
C) Sweating
D) Rapid respiration
E) Acidosis
57) Heart block can be diagnosed by

A) bradycardia
B) prolonged PR interval ECG
C) bifid and broad P wave
D) tall P wave in V5 lead
E) large Q wave
58) The SA node impulses are more than the 230 but the normal heart rate is not 230
A) AV node impulses transmission is slower than SA node
B) there is a delay in conduction to bundle of his
C) the muscles are specialized myocardial cells
D) they act as an electrical syncytium
E) there is no conduction between atria and ventricle
60) The following measurements were obtained in a male patient:

central venous pressure : 10 mmHg
Heart rate : 70 beats/min
Pulmonary vein [O2] = 0.24ML O2/mI
Pulmonary artery [O2] = 0.16ml O2/ml
Whole body O2 consumption : 500ml/min
What is this patient’s cardiac output?

A)1.65 L/min
B)4.55 L/min
C)5.00 L/min
D)6.25 L/min
E)8.00 L/min
9th Proper - SEQs
01 explain physiological basis for,

1.1 split of second heart sound during expiration (30 marks)
1.2 Ejection systolic murmur in aortic stenosis (25 marks)
1.3 Increase in cardiac output during muscular exercise. (45 marks)
02.
2.1 Describe atrial supply of the heart and its clinical significance. (40 marks)

9th Repeat - SEQs
1.
1.1 Describe briefly the internal anatomy of the left ventricle. (40 marks)
1.2 Write a brief account on,
1.2.1 Fibrous pericardium. (25 marks)
1.2.2 Embryological development and defects of interatrial septum. (35 marks)
2. A 70-year old patient with congestive heart failure complained of breathing difficulty (dyspnoea / shortness of
breath) that was worse in supine position than in reclining position. His breathing was shallow and faster. The lips,
nail beds and tongue appeared bluish (cyanosis) pulmonary examination revealed excess of fluid in the lungs.
2.1 Explain the Physiological basis of excess fluid in lung following congestive heart failure. (30 marks)
2.2 Explain the Physiological basis of cyanosis in the above patient with pulmonary oedema. (35 marks)
2.3 Explain the Physiological mechanism of the shallow but rapid breathing seen in the above patient. (35 marks)
02)
A) F In 5th (left) intercostal space at MCL
B) T mitral valve is left to midline of sternum opposite 4th left intercostal space and costal cartilage
C) T
D) F behind midline of lower sternum
E) F behind left border of sternum at level of intercostal space
05)
Sinus tachycardia is a sinus rhythm with an elevated rate of impulses greater than 100bpm. Causes are strenuous
exercise, fever, fear, stress, anxiety, anaemia and hyperthyroidism
A) T immediately occur to maintain the cardiac output
B) F parasympathetic cause to bradycardia
C) T
D) T
E) T
11)
A) T
B) F It is formed behind the right first costal cartilage by the union of right and left brachiocephalic veins
C) T
D) F Its tributaries are azygos vein, mediastinal and pericardial veins

E) T Its upper part lies in the superior mediastinum. The lower part lies in the anterior mediastinum
44) ANSWER -B
Right side of ventral wall of heart must damaged.it is formed mainly by right ventricle; Right margin lies just beyond
the right margin of sternum. That right marginal part of ventral wall made by right atrium. When middle of sternum
damaged RV is most vulnerable.
45) ANSWER -A

Great cardiac vein passes along the inter ventricular sulcus with the anterior inter ventricular coronary artery
56) ANSWER – E
Acidosis is not a compensatory mechanism
57) ANSWER – B
First degree-prolonged PR interval in ECG
58) ANSWER – A
60) ANSWER – D
Cardiac output is calculated by the Fick principle if whole body oxygen (O2) consumption and [O2] in the pulmonary
artery and pulmonary vein are measured. Mixed venous blood could substitute for a pulmonary artery sample, and
peripheral arterial blood could substitute for a pulmonary vein sample. Central venous pressure and heart rate are
not needed for this calculation.
1.0
1.1
- due to the sudden closure of the semilunar valves
- at the end of the ventricular systole.
- 2nd heart sound occur.
- as when semilunar valves closed. They bulge backward and towards the ventricles.
- inspiration means the inhalation of air into the lungs.
- in inspiration, the negative intra thoracic pressure increases.
-this sucks the blood into the great veins.
- specially to the IVC.
- so, this increases the venous return to the RA. ( right atrium)
- so, RV, EDV increases
-meanwhile, during inspiration, the pulmanory capillaries expand and accommodate more blood
- so, pulmanory venous return (VR) decrease.
- so, LV,EDV decreases.
-due to the arrival of excessive amount of blood to the RF rather than LA.
-during inspiration,
-RV, EDV is higher than LV.
-So, ejection phase of RV is longer during inspiration.
- so during inspiration , aortic valve closes slightly before the pulmonary valve.
-so splitting of the heart sound is heard during inspiration.
-in the expiration, no negative intrathoracic pressure grows.
-so, pulmonary and aortic valves close at the same time

- so ejection phases are similar during expiration.
- so during expiration, splitting of 2nd heart sound is not heard well.
1.2
- murmurs are sounds generated in heart due to the turbulence in blood flow.
- This is due to either when large blood volume goes through the normal orifice.
- or when normal blood volume goes through stenosed orifice.
-Murmurs are 02 types systolic and diastolic.
-Murmurs heard during systole are known as “systolic murmurs”
- most systolic murmurs are physiological not associated with cardiac diseases.
-Systolic murmurs can be mid systolic and pansystolic .
-Mid systolic murmurs begins shortly after the 1st sound, and it becomes peak in middle of systole.
-During ventricular ejection, semilunar valves open and blood eject so rapidly to aorta and pulmanory trunk.
-Hense, during L1 ventricular ejection, aortic valve opens and blood eject so rapidly to aorta.
-in aortic stenosis, blood enters through small fibrous aortic opening.
- and it causes more resistance to ejacuation of blood.
From LV to aorta
-so during the mid systolic a murmur can be heard due to stenosed aortic valve.
1.3
- 02 types of muscular exercises.
- isotonic and isometric
-isotonic muscular exercises- no alteration in tension during exercise
e.g.- walking (any dynamic exercise)
-isometric muscular exercise-no alteration in length during exercise
e.g.- weight lifting (static exercise)
-CO =SV*HR CO=cardiac output
SV=stroke volume
HR=heart rate
-during muscular exercise, active muscles increase utilization of O2
-and also CO2 production increase
-so,at venous end PO2 decrease below 40mmHg
-and PCO2 increase over 46mmHg
-however,in moderate exercises ,arterial end PH ,PO2,PCO2 remain constant
-but in vigorus exercises ,as more lactic acid and other metabolites (H+,K+)accumulate,
-release more CO2
-chemoreceptors at CNS are sensitive to PCO2 at arterial side respiratory center stimulate and ventilation occur
-also at onset of exercise there is abrupt increase in ventilation due to psychic stimuli
-propioceptive impulse from joints muscles and tendons
-propioceptions → ascending tract → CNS * has collateral connection with the respiratory center
-so during early exercise ventilation increases due to tidal volume
-during late exercise ventilation increases due to increase of respiratory rate
-this is known as thoracic pump (increasing depth of respiration)
-moreover ,increase the pumping action of the muscles, muscle pump increase
-due to vasodilation in contracting muscles, peripheral resistance decrease
-so capillary pressure increase
-hence blood mobilizes more to the visceral organ
-due to above 4 reasons, venous return increases

-so, venous pressure rises
↓
Diastolic inflow is greater
↓
Ventricular EDV increase
↓
Ventricular muscle get stretch
-according to Frank-Starling mechanism,
Energy of contraction is propotional to the initial length of the cardiac muscle fiber
-powerful muscle contraction occur
-stroke volume increase in 50%,162 ml /beat
-heart rate increases due to,
tory catecholamine
-so HR increases via 270%

-so CO ↑ 5L 30L/min
02.
2.1
-By Right and Left coronary arteries and their branches.
-Arises from Right &Left aorta sinus.
-Runs in coronary groove (arterio ventricular groove)
-Embeded in deep to the epicardum.
- Supply vasa vasorum to aorta.
• Distribution – o Right atrium

o Right ventricle except a small area near the anterior IV groove.
o Left ventricle near posterior ventricular groove.

o Posterior 1/3 of the intervent. Septum.
o Whole conducting system except a part of left bundle branch.
• Distribution – o Left atrium

o Left ventricle except for a small area near posterior IV groove.
o Right ventricle – small area near anterior IV groove
o A part of the bundle branch of the AV node.
o Anterior 2/3 of IV septum.
•however, endocardium and subendocardium get O2 & nutrients by diffusion and microvasculature directly from
the chambers of heart.
•Although anastomoses occur between the termination of the right and left coronary arteries , these are usually
inefficient .
•so thrombosis in these vessels leads to a myocardial infarction.
1.0
1.1 describe the gross anatomy of the interior of left ventricle?
• The wall of the cavity is 3times thicker than the right ventricle
• The trabeculae carneae are well developed
• There are two papillary muscles
• Anterior ,posterior the anterior beign larger
• Both are connected by chorda tendineae to each valve cusp
• The interventricular septum bulgs forwards in to the
• Cavity of the right ventricle • So that cross section of the left ventricle is circular
• The upper and right end of the septal wall is
• Smooth ,thinner and more fibrous
• This is the membranous part of the septum

• Between the membranous part and the anterior cusp
• Of the mitral valve is the aortic vestibule
• Which leads up to the aortiorifice
• The aortic orifice guarded by the aortic valve
• At the entrance to the ascending aorta
• It lies at a lower level than the pulmonary orifice
• It has 3 semilunar cusps
• In the adult heart these cusps in
• Anterior,left posterior,and right posterior position
1.2
1.2.1 Fibrous pericardium
• Tough external layer

• Single layer of fibrous sac
• Extension TV 5 to TV 8
• Conical shape,tough,and inelastic fibrous sac
• Apex – toward the great blood vessels
• Base-toward the diaphragm
• Enclose the heart and great vessels
• By fusing with adventitia of vessels
• Fuse superiorly
• Tunica adventitia of great vessels
• Pretracheal layer of deep cervical fascia
• Broad base inseparably bleand with
• Central tendon of diaphragm
• By pericardiophrenic ligament
• Connect to back of sternum
• By weak sternopericardial ligament
• Functions
• Holds the heart in place inside the fibrous sac
• Forms the barrier against the infection • Protect the heart from sudden over filling
• Limit the heart motion
• Separation from the surrounding tissue of mediastinum
• Maintainces of low transmural pressure
1.2.2
• At the end of the fourth week, a sickle-shaped crest grows from the roof of the common atrium into the lumen.
• This crest is the first portion of the septum primum.
• The two limbs of this septum extend toward the endocardial cushions in the atrioventricular canal.
• The opening between the lower rim of the septum primum and the endocardial cushions is the ostium primum .
• With further development, extensions of the superior and inferior endocardial cushions grow along the edge of the
septum primum, closing the ostium primum .
•Before closure is complete, however, cell death produces perforations in the upper portion of the septum
primum.
• Coalescence of these perforations forms the ostium secundum, ensuring free blood fl ow from the right to the left
primitive atrium .

• When the lumen of the right atrium expands as a result of incorporation of the sinus horn, a new crescent-shaped
fold appears.
• This new fold, the septum secundum , never forms a complete partition in the atrial cavity .
• Its anterior limb extends downward to the septum in the atrioventricular canal. When the left venous valve and
the septum spurium fuse with the right side of the septum secundum, the free concave edge of the septum
secundum begins to overlap the ostium secundum .
• The opening left by the septum secundum is called the oval foramen (foramen ovale). When the upper part of the
septum primum gradually disappears, the remaining part becomes the valve of the oval foramen.
• The passage between the two atrial cavities consists of an obliquely elongated cleft through which blood from
the right atrium flows to the left side .
• After birth, when lung circulation begins and pressure in the left atrium increases, the valve of the oval foramen is
pressed against the septum secundum, obliterating the oval foramen and separating the right and left atria.
• In about 20% of cases, fusion of the septum primum and septum secundum is incomplete, and a narrow oblique
cleft remains between the two atria.
• This condition is called probe patency of the oval foramen; it does not allow intracardiac shunting of blood.
2.
2.1
• In a congestive heart failure the heart is not able to pump efficiently
• More and more blood accumulate in the left side of the heart.
• Reduce SV lead to reduce CO
• So VESV increase , so back pressure increase.
• According to this blood accumulation hydrostatic pressure increase in the pulmonary capillary system.
• So starling forces become unbalance.
• Filtration pressure gradient increase through pulmonary capillary
• More blood filter to lung parenchyma
• Lymph drainage is not adequate to absorb this all fluid
• So excessive fluid accumulation can be seen in heart failure.
2.2
• Cyanosis is the bluish color of the skin & mucus membrane
• Pulmonary edema can be see in type I respiratory failure
• That mean diffusion is decrease
• Due to pulmonary edema gas exchange area is reduce
• So less O2 soluble • Reduce Po2 due to less diffusion in to pulmonary capillary. • Then reduced oxygenated Hb
concentration. • Due to the heart failure perfusion also impaired • Then deoxygenated Hb concentration goes up
than normal • When it exceed 5g/dl • Bluish color appear in the skin and mucus membrane • It’s called cyanosis
2.3
• Due to the congestive heart failure pulmonary edema can be occurred
• So excessive fluid accumulate in the alveoli
• Then alveolar surface tension become increase
• So alveolar somewhat collapse
• Then lung capacity get reduce
• Normal negative pleural pressure can’t expand lung completely
• Due to that reason shallow breathing occur.

10th Batch
10th Proper - MCQs
2. Internal features of right atria include

A) Opening for pulmonary vein
B) Opening for coronary sinus
C) Presence of pectinate muscle in the anterior wall
D) Rough posterior wall
E) Fossa ovalis
3. Regarding arch of the aorta

A) It commences and ends at the Sternal angle
B) It is circled by the left recurrent laryngeal nerve
C) It is joined to the pulmonary artery by ligamentum arteriosum
D) It leaves impression on the right lung
E) It is the persistent of the 3rd aortic arch
4. Regarding veins
A) Veins more than arteries
B) Has internal elastic lamina but no external elastic lamina
C) No valves in visceral vein
D) Anastomosis with arteries in viscera
E) Venae comitantes more in lower leg part
5. Left coronary artery

A) Originate from anterior sinus
B) Lie in both anterior & posterior interventriculer grooves
C) Spasm cause ischemic pain called angina
D) Supplies right atrium
E) It supplies anterior surface of both ventricles
6. Closed/ obliterated
A) Foramen ovale remains as crista terminalis
B) Ductus arteriosus remains as ligamentum arteriosus
C) Ductus venosus remains as ligamentum venosus
D) Umbilical artery remains as median umbilical ligament
E) Umbilical vein remains as medial umbilical ligament
11. Branches of descending thoracic aorta are

A) Musculophrenic artery
B) Superior intercostal artery
C) Bronchial arteries
D) Internal thoracic artery
E) Superior phrenic artery
21. Increase in myocardial contractility

A) Adrenaline

B) Noradrenalin
C) Increase heart rate
D) Increase end diastolic volume
E) Digoxin
22. During left ventricular isovolumetric ventricular contraction which are the correct statements
A) Aortic pressure exceeds left ventricular pressure
B) Left ventricular pressure remain unchanged while the ventricular blood volume is increased
C) Mitral valve open
D) No blood flow to left atrium
E) Coronary blood flow is higher
23. Second heart sound

A) Occur with the QRS complex of the ECG
B) Split is better heard during inspiration than expiration
C) Split is fixed in ASD
D) Is louder in pulmonary hypertension
E) is absent in aortic regurgitation
24. The jugular venous pulse/ pressure

A) Represents change in the left atrial pressure
B) ‘C’ wave coincides with isovolumetric ventricular relaxation
C) ‘V’ wave is prominent in severe dehydration
D) Is reduced during inspiration
E) Is measured in the internal jugular vein
28. When a normal person lies down

A) Heart rate is more than when standing
B) Venous return increases
C) Cerebral blood flow is more than when standing
D) Blood flow to apex of lung increases
E) There is reflex vasoconstriction of lower limb veins
29. Regarding regional blood circulation

A) Blood flow to atrium is highest at systole
B) Blood flow to myocardium increase during systole than diastole
C) Blood flow to kidney highly related with oxygen requirement
D) Voluntary hyperventilation increase blood supply to the brain
E) Increased blood flow to the skeletal muscle associated with electrical metabolites
SBR
41. When compressed the sternocostal surface of the heart by sternum, which part of the heart may get damage
A) Apex of the heart
B) Base of the heart
C) Left atrium
D) Left ventricle
E) Right ventricle

43. The pericardium
A) Is supplied by the arteries which are derived from descending thoracic aorta
B) Has an oblique sinus behind the right atrium
C) Cavity of it is filled with air
D) Forms a transverse sinus posterior to the superior vena cava
E) Is not attached to the diaphragm
44. 40-year old women came to the clinic with systolic murmur and slow raising pulse pressures. What is the
possible condition?
A) Aortic stenosis
B) Atherosclerosis
C) Heart failure
D) Hypertension
E) Coarctation of Aorta
49. The blood vessel responsible for creation of the resistance to blood flow in peripheral circulation
A) Aorta
B) Large artery
C) Arterioles
D) Capillaries
E) Vein
10th Proper - SEQs
1. A 45-year old man who suffered from myocardial infarction was admitted to the hospital for coronary bypass
surgery. The surgeon used a patient’s vein and reversed it for bypass surgery.
1.1 State how myocardial infarction is caused? (10 marks)
1.2 Describe the course and distribution of the coronary circulation of heart (50 marks)
1.3 Name the vein that was taken for by pass and state the reason for reversing it for bypass. (20marks)
1.4 Write an account on superior mediastinum. (20 marks)
5.
5.1 Describe the pressure changes in cardiac chambers and mechanical events of the heart during cardiac cycle. (60
marks)
5.2 Draw a labelled diagram to illustrate the pressure changes in jugular vein during cardiac cycle and explain the
reasons for those changes. (40 marks)
2)
A) F Pulmonary vein – LA
IVC – RA
B) T Coronary sinus drains coronary venous blood into RA. Above the septal cusp of tricuspid valve to the
left of IVC opening.

C) T Pectinate muscle – series of horizontal ridges like a teeth of a comb. – represent true auricular
chamber of embryonic heart. – Rough area
Between crista terminalis and blind extremity of auricle.

D) F Posterior wall is smooth. Produced by incorporation of right horn of sinus venosus.
E) T Shallow depression represents primary septum of fetal heart
3)
A) T structures pass through angle of Louis / sternal angle
pulmonary trunk
cle
B) T Hooks around ligamnetum arteriosum (last pg. 192) Right
C) T Obliterated remnants of fetal.

Ductus arteriosus; shunt oxygenated blood from
Pulmonary artery into aorta bypassing the lungs.
D) F Grants pg. 36, 37
Right lung → arch of azygous vein
Left lung → arch of aorta
E) F
1st arch → maxillary artery
2nd arch → stapedial artery
3rd arch → common carotid, part of internal artery
4th arch → right – subclavian artery, brachiocephalic
Left – arch of aorta, left subclavian
5th arch - --
6th arch → pulmonary artery
5)
A) F It arises from the left posterior aortic sinus
B) T
C) T
D) F it supplies the left atrium
E) T Greater part of the left ventricle

6)
A) F Foramen ovale --fossa ovalis
Crista terminalis --- junction between sinus venosus and heart in the developing embryo
B) T ductus arteriosus ---shunt oxygenated blood from pulmonary artery to aorta
C) T ductus venosus--- direct communication between left umbilical vein and right hepatocardiac canal
bypass the sinusoidal plexus of the liver.
D) F Median umbilical ligament ----obliterated remnants of fetal urachus.
Medial umbilical ligament----umbilical artery
E) F obliterated remnants of left umbilical vein---ligamentum teres
11)
A) F branches of descending thoracic aorta –
1. 9 pairs of posterior intercostal arteries
2. 1 pair of subcostal arteries
3. Bronchial arteries
4. Esophageal vessels
5. Pericardial branches
6. Phrenic branches
Musculophrenic artery → 1 terminal branch of internal thoracic artery
C) T
D) F 1st part of subclavian artery
E) T thoracic → superior phrenic
Abdominal → inferior phrenic
21) A) T ↑ myocardial contractility ↑ inotrophic effect

↑ Affects SV {preload and afterload}
- increased by;
1. Sympathetic nerve stimulation
2. Circulating catecholamine ; norepinephrine and epinephrine
3. Xanthene, digitalis, glucagon, theophylline, digoxin
- decreased by;
1. Hypoxia, hypercapnia
2. Acidosis
3. Vagal stimulation
4. Loss of myocardium
5. Drugs
B) T
C) F ↑HR ---chronotrophic effect
D) T ↑EDV---- ↑preload --- ↑myocardial contractility
E) T
22)
A) T isovolumetric ventricular contraction

- At the start of ventricular systole, ventricular muscles shorten relatively little with all the valves closed. -
- lasts about 0.05s

- Until the pressure is left ventricle exceeds the pressure in the aorta
B) F pressure ↑ sharply, blood volume is constant
C) F mitral valve open at the end of the isovolumetric ventricular r elaxation
E) F during systole when ventricular muscles contract coronary vessels compress and Constrict.
Coronary supply takes place in diastole
23)
A) F Ganong. Pg. 541 fig. 30.3
B) T
C) T pathological splitting/ flixed splitting in ASD, VSD. Split is heard throughout inspiration and expiration.
D) T the 2nd heart sound is louder in pulmonary hypertension
E) F 2nd heard sound is heard during the closure of aortic and pulmonary valves. Even if the aortic valve is
dysfunctional pulmonary valve closure is heard as DUB.
24)
A) F Right
B) F Cusp bulging in isovolumetric ventricular contraction.
C) F V wave represents the venous return, when the A/V valves are closed.
D) T Inspiration → negative intra thoracic pressure → ↓ venous pressure + sqeezes blood towards the
heart.
E) T

28)
cts equally all over the body ↑ VR → ↑SV → ↑CO → to maintain CO,
HR should ↓ or maintain at normal level, it never increase
B) T
C) T when standing heart has to pump blood against gravity. But when lying down gravity acts qually.
D) T gravity
E) F vasoconstriction→ TPR↑ → ↑ VR} don’t take place
29)
A) T
B) T
C) F Medulla oxygen requirement is high, blood flow low
Cortex oxygen requirement is low, blood flow high
D) F
E) T
41) ANSWER - E
Sternocostal surface consists mainly of right ventricle. Also consists right atrium and narrow strip of left
ventricle.
43) ANSWER – A
A) Is supplied by branches from internal thoracic, musculophrenic arteries and descending thoracic aorta.
B) It lies between the left atrium and the parietal pericardium.
C) Pericardial cavity filled with serous fluid
D) It is bounded by anteriorly ascending aorta and pulmonary trunk, posteriorly by the Superior vena
cava and inferiorly left atrium.
E) Base of the pericardium is inseparably blended with the central tendon of the diaphragm.
44) ANSWER – A
Ejection systolic murmur } in aortic stenosis
Slow rising pulse
49) ANSWER – C
Ganong pg. 575 fig. 31.24
1.
1.1. Death of segment of heart muscle, due to loss of its blood supply.
1.2.
• Arterial supply
• By two coronary arteries and their branches.
o Right coronary Artery.
o Left coronary artery.
• Each coronary artery is the main source of supply to its same atrium and ventricle.
• But it also supply opposite side chambers.
• Veins drains from the myocardium do not have names that corresponding to arteries.
• Right coronary artery.
• Arise from anterior aortic sinus.
• Pass down between the right auricle and infundibulum of right ventricle. • In the atrioventricular groove / coronary
sulcus.
• Anastomose with circumflex artery of left coronary artery.
• Supply → anterior 2/3 of interventricular septum. Supply branches to both atrium and ventricle.
• Branches
o Right conus artery.
Highest branch of right coronary artery.
o SA nodal artery.
g around the termination of SA node.supply SA node in about 60% of heart.
o Right marginal artery—pass obliquely down over front of the ventricle.
o Posterior interventricular artery.
Anastomose with anterior interventricular artery.
• AV nodal artery.
• Left ventricular artery.
o Left coronary artery.
auricleand right ventricular infundibulum.
• Circumflex artery.
• Anterior interventricular artery.
o Circumflex artery.
• Left marginal artery.

o Anterior intervenricular artery
ntricular groove.
• Three anastomose in the heart.

o Termination of right and left coronary arteries in atrioventicular groove.
o Posterior interventricular artery and anterior interventricular artery.
o Right conus and left conus artery.
• Veins of the heart.

• Coronary sinus and five normal tributaries.
• Five normal tributaries
o Great cardiac vein.
o Middle cardiac vein.
o Small cardiac vein.
o Posterior vein of the left ventricle.
o Oblique vein of the left atrium
• Anterior cardiac vein opens into right atrium.
• Venae cordis minimae opens directly into specific chamber. Most frequent in the right atrium. • Coronary sinus
receives most of the heart`s blood.
• Coronary sinus is a wide vessel.
• Lies posterior part of the atrio-ventricular groove.
• Opens at it`s right end into the posterior wall of the right atrium.
1.3. Great saphenous vein

• Reason—superficially located • —can easily obtain contain valves: - reversing.
1.4
• Wedge shaped
• Anteriorly manubrium.
• Posteriorly bodies of T1 to T4 vertebra.
• Superiorly thoracic inlet.
• Inferiorly plane of sternal angle.
• Laterally two pleura.
• At the thoracic inlet ,
• Esophagus lies against the body of T1 vertebra.
• Trachea lies on the esophagus.
• Apices of lungs lies laterally.
• Below the thoracic inlet trachea slopes back and the manubrium slops forward.
• Brachiocephalic trunk, left brachiocephalic vein, thymus lies in the above space.
• Concavity of the arch of the aorta lies in the plane of the sternal angle.
• Arch of the aorta lies completely in the superior mediastinum.
• Arch over the beginning of the left bronchus and bifurcation of the pulmonary trunk.
• Brachiocephalic trunk begins as a midline branch from the arch.
• Ascends in front of the trachea.
• Left common carotid artery, left subclavian artery pass upward on the left side of the trachea. • On the right side
there is no structure to separate the trachea from the right vagus and apex of right lung.
• Veins enter to the superior mediastinum. 1. Right brachiocephalic vein. 2. Left brachiocephalic vein.
• Brachiocephalic vein lies in front of the arteries and asymmetrical.
• Right brachiocephalic vein lies more vertically left brachiocephalic vein cross the superior mediastinum.
• Confluence of brachiocephalic veins produce superior vena cava behind the right edge of the sternum.
• Right phrenic nerve descends in contact with the lateral aspect of the right brachiocephalic vein and superior vena
cava.
5.
5.1
• Cardiac cycle has 5 events.
o Ventricular filling.(VF)

o Atrial systole.(AS)
o Isovolumetric ventricular contraction.(IVVC)
o Ventricular ejection.(VE)
o Isovolumetric ventricular relaxation.(IVVR)
• In ventricular filling, phase.

o Tricuspid and mitral valves are opened.
o Aortic and pulmonary valves are closed.
o Blood flow into the heart throughout the diastole, filling the atria and ventricles. o Rate of ventricular filling
decreased, when ventricles are distended.
o 70% of ventricular filling occur passively during diastole.
• In atrial systole, phase.

o Contraction of atria.
o Due to that filling addition 30% blood in to the ventricles.
• Isovolumetric ventricular phase.

o Beginning of V.S the tricuspid and mitral valves are closed.
o Due to ventricular presser higher than atrial presser.
o Aortic valve, pulmonary valves are closed.
o Isovolumetric ventricular contraction occur.
o Ventricular muscle contraction.
o Intraventicular presser increase. o Ventricular presser increase than presser in the aorta and pulmonary artery.
• Left ventricle presser—80mmHg
• Right ventricle—10mmHg o Aortic and pulmonary valves open.
o During IVVC, due to increase presser in the ventricle, AV valves bulge into atria.
• Ventricular ejection phase.

o Blood pumped into the aorta and pulmonary artery through aortic valve and pulmonary valves.
o From left ventricle and R.Ventricle respectively.
o Rapid ejection at first
o Then slow ejection phase.
• Aortic and pulmonary > left and right ventricular presser Valve presser
• Aortic and pulmonary valve closed.
• IVVR phase.
o Mitral and tricuspid valves closed.
o Right and left ventricles are closed chambers.
o Presser drop rapidly.
o Atrial presser > ventricular presser.
o Tricuspid and mitral valves opens.
o New cardiac cycle start.

5.2
• a wave.
o Due to regurgitation of blood into the veins during atrial systole.
• c wave.
o Bulging of tricuspid valve to right atrium during lsovolumetric ventricular contraction.
• x descend o due to relaxation of atria and pulling of valves during ventricular ejection.
• v wave.
o Due to atrial filling before AV valves opens.
• Y descend.
o Due to ventricular filling when AV valves open.
11th Batch
11th Proper - MCQs
11) Which of the following are derived from fetal vessels?

A. Ligamentum teres.
B. Gastrosplenic ligament.
C. Ligamentum venosum.
D. Medial umbilical ligament.
E. Median umbilical ligament.
14) Regarding thoracic aorta,

A. Becomes abdominal aorta at T10 level.
B. Begins at T4 level.
C. Gives inferior phrenic artery.
D. Gives 11 pairs of intercostal arteries.
E. Bifurcate at L4 leveL
15) Thoracic wall

A. Has a cartilaginous wall.

B. Is cylindrical in shape.
C. Is bounded below by the 7th – 10th costal cartilages and the 11th and 12th ribs.
D. Receives its nerve supply by the brachial plexus.
E. Internal thoracic artery supply the major portion of the intercostal spaces.
16) Regarding the thoracic inlet

A. The lateral boundary is formed by the inner surface of the 1st rib and its costal cartilage.
B. Manubrium sterni forms the anterior boundary.
C. Posterior boundary is formed by the lower border of T4 vertebra.
D. Brachiocephalic artery passes through it.
E. Vertebral artery passes through it.
17) Regular exercise in healthy adult leads to

A. Increased systolic pressure in rest.
B. Increased stroke volume in rest.
C. Increased resting heart rate.
D. Increased ventricular size.
E. Increased ejection fraction.
18) Regarding arterial arches

A. Pulmonary arteries are derived from 4th arch.
B. The connection between 4th arch and 6th arch on right side is not disappeared.
C. Arterial arches derive from truncus arteriosus.
D. External carotid artery derives from 3rd aortic arch.
E. Blood from pulmonary trunk goes via 3rd and 6th arch arteries.
19) Regarding peripheral circulation which are true

A. Coronary circulation gets 5% of the cardiac output.
B. Renal vessels are constricted by catecholamines.
C. Peripheral vasodilatation can be seen in cardiogenic shock.
D. Increased PaCO2 dilates cerebral blood vessels.
E. Blood flow to intestine increase in exercise.
20) Regarding the Development of the heart

A. The rough part of the right atrium is developed from the sinus venosus.
B. In Fallot's tetralogy, due to the unequal division of the truncus arteriosus, large pulmonary trunk is formed.
C. Osteum secondum defect is found high up is the inter atrial wall.
D. Membranous part of the interventricular septum is developed by the proliferation of atrioventricular cushion.
E. In fetal life, blood from the SVC is directly shunted through foramen ovale to the left atrium.
21) The right atrium

A. Has an auricle superolaterally.
B. Contain crista terminalis on its external surface.
C. Contain opening of coronary sinus near their opening of SVC.
D. It is superior to central tendon of diaphragm.
E. Has anterior endocardial fold guarding the IVC

SBR
48) A 6-year old boy was undergoing a cardiac catheterization. The doctor noticed that the contrast medium was
found in left pulmonary artery soon after it left Aortic arch. Which of the following would be the most suitable
diagnosis?
A. Atrial septal Defect.
B. Patent ductus arteriosus.
C. Patent ductus venosus.
D. Mitral stenosis.
E. Ventricular septal defect.
49) A 52-year old male came with a history of chest pain. It was found that the 2nd heart sound is widely split and
do not alter while respiration. There was a mid diastolic murmur in precordium. This complication is due to
A. ASD (atrial septal defect)
B. Mitral stenosis.
C. Aortic regurgitation.
D. Tricuspid stenosis.
E. VSD (ventricular septal defect).
55) During which interval on ECG does the mitral valve close?
A. A
B. B
C. C
D. D
E. E
56) Which one shows Prominent pace maker potential

A. Ventricular myocardium.
B. Atrial myocardium.
C. Bundle of His.
D. AV node.
E. SA node.
57) A 64-year old woman recently had myocardial infarction at the apex of the heart. In this condition what is the
artery that can occluded due to arthrosclerosis
A. Right coronary artery.
B. Marginal artery.
C. Posterior interventricular artery.
D. Anterior interventricular artery.
E. Circumflex artery of left coronary artery.
58) Which of the following organs has the highest A-V O2 difference under normal resting conditions
A. Brain.
B. Heart.
C. Skeletal muscle.
D. Kidney.
E. Liver.

11th Proper - SEQs
1.
1.1.
1.1.1. Describe briefly the anatomy of heart valves. (40 Marks)
1.1.2. Outline the surface markings of heart valves. (20 Marks)
1.1.3. State the auscultation point of heart valves. (10 Marks)
1.2. Describe the extension, course and relations of thoracic duct. (30 Marks)
6. While working in the estate a worker was stung by wasps. Following features were developed after the sting.
Explain their physiological basis.
6.1. His face and lips were swollen. (25 Marks)
6.2. He started to wheeze. (25 Marks)
6.3. He became unconscious. (25 Marks)
6.4. His pulse was very feeble. (25 Marks)
11th Proper – MCQ ANWERS
11.
A. True Ligamentum teres-Umbilical Vein
B .False Part of Greater Omentum- Developed from Dorsal Mesogastrium
C .True Ligamentum venosum-Ductus Venosum
D. True Medial umbilical ligament-Umbilical Arteries
E. False Median umbilical ligament-Urachus
14)
A. False T12 level
B. True Continues from Arch of Aorta
C. False Inferior Phrenic Artery is given by Abdominal Aorta
Thoracic Aorta gives –
i. 09 pairs of Posterior Intercostal Arteries
ii. Pair of Subcostal Artery
iii. Bronchial Arteries
iv. Esophageal Arteries
v. Superior Phrenic Artery
D. False 09 pairs of Posterior Intercostal Arteries
E. False Abdominal aorta bifurcate at L4 level.
15)
A .False Musculo-Osseo-Cartilaginous wall
B. False Domed shaped
C. True The thoracic skeleton includes 12 pairs of ribs and associated costal cartilages, 12 thoracic
Vertebrae and the intervertebral (IV) discs interposed between them, and the sternum
D. False From Intercostal Nerves
E. False Supplied by posterior intercostal arteries from descending thoracic aorta

16)
A .True Posteriorly- Vertebra T1
Laterally- 1st pair of ribs and their costal cartilages.
Anteriorly- Superior border of the Manubrium.
B. True
C. False
D. False Structures passing through Thoracic Inlet1. Trachea
2. esophagus
3. Thoracic duct
4. Apex of lung
5. Nerves (Phrenic Nerve, Vagus Nerve, Recurrent
Laryngeal Nerve, Sympathetic trunk)
6. Arteries (Left and Right Common Carotid Arteries and Left
Subclavian Artery)
7. Veins (Internal Jugular Vein, Brachiocephalic Vein and
Subclavian Vein)
8. Lymph nodes and vessels
E. False
17)
A. False Reduces Systolic Pressure at rest
B .True
C. False Reduces Heart Rate
D. True Natural physical adaptation of the body to deal with the high pressures and large amounts
of blood during exercise
E. True Both Systolic Volume and End Diastolic Volume increase
18)
A. False Pulmonary Arteries are derived from 6th Arch; 4th Arch formsOn Left-Part of Arch of Aorta, Left Common
Carotid Artery and Left Subclavian ArteryOn Right- Proximal segment of Right Subclavian Artery
B .False Persists as Ligamentum Arteriosum in Left side; Disappears on Right Side
C .True From Aortic Sac(most distal part of Truncus Arteriosus)
D. True ECA sprouts from 3rd Aortic Arch
E. False 4th and 6th arches have connection (ductus arteriosus) Not the 3rd and 4th arches
19)
A .True
B. True Example- During Exercising
C .False Sympathetic activity leads to vasoconstriction
D. True Carbon dioxide is the main regulator of Cerebral blood flow
E. False Blood from GIT is diverted to muscles
20)
A. False Smooth pat- sinus venosus
Rough part- original heart tube
B. False Unequal division of Conus resulting from anterior displacement of Conotruncal Septum
C. True
D. True

E. False From IVC
21)
A. False Superomedially
B. False Crista Terminalis- Interior surface
Sulcus Terminalis- Exterior Surface
C. False Medial and above IVC Opening
D. True
E. False Has small, crescenteric ridge (Remnants of Valve of IVC)
48)
A PDA is a condition where there is a persistent communication between the Descending
Aorta and the Pulmonary Artery that results from failure of normal physiologic closure of
the fetal Ductus Arteriosus
Answer (B)
49)
Mid diastolic murmur is caused by Mitral/Tricuspid Stenosis or Aortic/Pulmonary Regurgitation or ASD
Fixed Splitting of 2nd heart sound- (A fixed split S2 occurs when there is always a delay in the closure of the pulmonic
valve and there is no further delay with inspiration)- ASD
VSD- Pan systolic Murmur
Answer (A)
55)
Answer (C)
56).
Answer (E)
57)
a branchch of Left Coronary Artery which supplies Apex of the heart by anastomosing with Posterior Interventricular
Artery. It is the cardiac vessel most often affected by disease.
Answer (D)
58)
Answer (B)
1.
1.1.
1.1.1. Describe the anatomy of heart valves
There are 04 valves

 Tricuspid
 Mitral
 Aortic
 Pulmonary

01.tricuspid valve
 Guard right atrioventricular orifice

 Has 03 orifices
o Anterior
o Posterior
o Septal
 Attached by their bases to fibrous atrioventricular ring.
 Open position lies against sternocostal, diaphragmatic and septal wall of ventricle
 Appear to be subdivided. But no complete additional leaflets.
 Edges and ventricular surfaces are attached to chordae tendinae, which diverge from papillary muscles.
 There are anterior, inferior and septal papillary muscles, each connected to more than one cusp.
02.mitral valve (bicuspid)
 Guard left AV orifice.

 Has 02 cusps – anterior, posterior
 Bases are attached to fibrous atrioventricular ring.
 Anterior cusp is thicker and more rigid than posterior cusp.
 Anterior cusp lies between mitral and aortic orifices.
 So, lies between in flow and out flow tracts of left ventricle.
 02 papillary muscles (anterior and posterior) are connected by chordae tendinae to each valve cusp.
 In posterior cusp chordae tendinae attached to both margins and ventricular surface.
 In anterior cusp chord is only attached to margins.Because blood passes across both surfaces of cusps.
 Cusps of mitral and tricuspid valves
 Flat
 Free edges separated
 Attachment of marginal chordae prevent eversion of free edges into atrium.
 Centrally attached chordae limit amount of ballooning of cusps towards atrium.
03.pulmonary valve
 As semilunar cusps
 Right and left anterior
 Posterior
 Attached at junction of infundibulum and the commencement of pulmonary trunk.
04.aortic valve
 Guard aortic orifice an entrance of ascending aorta.

 Lies lower level than pulmonary orifice to its right, more obliquely placed.
 03 semilunar cusps.
o Anterior
o Left posterior
o Right posterior
 Cusps of pulmonary and aortic valves are cup shaped.
 Free edges contain central fibrous nodule.
 During ventricular systole, bulge of aortic sinus above cusps prevent them from becoming flattened
against wall of sinus.


 Microscopically,
o Heart valve composed of core of collagenous
o Fibrous tissue covered by vascular endothelium
1.1.2. Outline surface marking of heart valves
 All valves lie behind the sternum.

 Tricuspid valve – behind the midline of lower sternum
 Mitral valve – overlap tricuspid, lies higher and to left opposite 4th left intercostal space and costal
cartilage
 Aortic – behind left border of sternum at level of 3rd intercostal space.
 Pulmonary – behind left border of sternum at level of 3rd costal cartilage.
1.1.3. State the auscultation points of the heart valves
 Aortic valve – at right sternal margin in 2nd intercostal space

 Pulmonary valve – left sternal margin, 2nd intercostal space
 Mitral valve – at apex of heart, 6th intercostal space in left midclavicular line
 Tricuspid valve – over its surface, left 4th intercostal space near the sternal margin.
1.2. Describe the extension, course and relations of thoracic duct.
 Commences at upper end of cisterna chyli

 Level of T12 vertebral body, between aorta and azygous vein
 Passes upward with these structures between crura of the diaphragm
 Lies against right side of esophagus
 At T5 vertebral level inclines to left and passes behind esophagus
 In superior mediastinum lies to left of esophagus on a posterior plane Passes vertically upward
 At root of neck arches forward and to left crosses over the dome of pleura and left subclavian artery
 Enter where left internal jugular and subclavian veins join
 May divide into two or three separate branches all open at angle between these two veins
 Thoracic duct has several valves
Relations:
 Posteriorly
 Right aortic intercostal arteries
 Terminal parts of hemiazygous and accessory hemiazygous veins
 Anteriorly
 Arch of aorta (at superior mediastinum)
 Left subclavian artery
 Carotid sheath and contents (at root of neck)
 Duct receive lymph from

a) At thorax - posterior mediastinal nodes
i. Left intercostal nodes
ii. Left bronchomediastinal trunk
b) At neck - left jugular and left subclavian lymph trunks
 Carry lymph from all body except from right upper limb and right halves of thorax and head and neck

6.
6.1.
Bee sting release histamine
 Histamine increased the vessel wall permeability.
 Normally at arterial end; filtration Venular end; reabsorption -Remaining fluid enter into the
lymphatic vessels.
 When increased vessel permeability, increased the fluid filtration. This leads to increased the
interstitial fluid in that area. Localized edema occur.
 Lips, face are more prone to become swollen in allergic conditions.
6.2.
Increased histamine production by mast cells which line the respiratory mucosa.
Increased in histamine
1. Increased the mucus secretion
↓
Accumulation of mucus in bronchus
↓
Narrow the diameter of the airway
2. Bronchoconstriction
↓
Narrow the diameter
3. Laryngospasm
 Decreased in airway diameter, increases the airway resistance.
 Air flow through a narrow space produces sounds(wheezing)
6.3.
Bee sting release histamine causes a generalized vasodilation (anaphylactic shock)
Vasodilation
↓
Venous pooling
↓
Decreased venous return
↓
Decreased ventricular end diastolic volume (VEDV)
↓
Decreased stroke volume
↓
Decreased cardiac output
↓
Decreased blood pressure
↓
Decreased blood supply to the brain
↓
Patient become unconscious
6.4.
Decreased cardiac output leads to decreased systolic blood pressure
Which is sensed by aortic and carotid sinuses baroreceptors.
To compensate,
 Stimulate the cardiac stimulatory area

 Inhibit the cardiac inhibitory area
 Stimulate the vasomotor area
Sympathetic discharge to the heart
↓
Increased the heart rate
 Which cause the rapid pulse
 But still his blood volume is less, which cause a thready pulse (feeble pulse
12th Batch
12th Proper - MCQs
1. Regarding heart valves,

A) The cusps of tricuspid and mitral valves are cup shaped
B) Competence of pulmonary and aortic valves is a passive phenomenon
C) All the valves of the heart lie behind the sternum
D) The tricuspid valve overlies mitral valve
E) Valves of the heart are composed of a core of collagenous fibrous tissue
2. About aorta
A) Forms aortic sinuses immediately above aortic orifice
B) Ascending part lies behind the infundibulum of the right ventricle
C) Fibrous pericardium is blended with wall of the ascending part
D) Arch is turned to descending aorta at upper border of T4 vertebra.
E) Descending part lies lest to the midline at the beginning
3. Left brachiocephalic vein

A) Has valves
B) Posterior to left sternoclavicular joint
C) Susceptible to injury during tracheostomy
D) Lies lateral to arch of aorta
E) Receive accessory hemi azygos vein
6. When the cholinergic vagal fibers to SA node are stimulated

A) The membrane becomes hyperpolarized
B) The slope of prepotential decreased
C) K+ conduction of cell membranes of nodal tissues decreased
D) Heart rate increases
E) Opening of Ca2+ channels become slow
14. Branches of thoracic aorta

A) Posterior intercostal artery
B) Esophageal artery
C) Supply to main bronchus
D) Superior phrenic arteries
E) Inferior phrenic arteries

18. About ventricular ejection
A) Ventricular pressure exceeds the aortic and pulmonary arterial pressure
B) Is rapid at first and then slows down later
C) At last stage, momentum keeps the blood flowing
D) Ventricular muscles initially shorten relatively little
E) Blood ejected by each ventricle is about 70-90 ml
19. In subclavian catheterization following structures are pierced

A) skin
B) superficial fascia
C) platysma
D) clavicular head of pectoralis major
E) subclavius muscle
25. Ventricular ejection fraction

A) is the fraction of blood ejected by ventricle.
B) is an index of myocardial contractility
C) normal value is about 50%
D) reduced in aortic stenosis
E) not change during exercise
30. Thoracic duct,

A) continuation of cisterna chyli
B) runs through middle mediastinum
C) drains into commencement of right brachiocephalic vein
D) present valve
E) ascend through the aortic opening
32. coronary sinus

A) Located on posterior aspect of coronary sulcus
B) Develops from left horn of sinus venosus
C) Has a valve in its openings
D) Opens into rough part of right atrium
E) begins as the continuation of small cardiac vein
33. Left coronary artery,

A) originate from anterior sinus
B) lie in both anterior & posterior interventricular grooves
C) spasm cause ischemic pain called angina
D) supplies right atrium
E) supplies anterior surface of both ventricles
34. The jugular venous pulse,

A) represents change in the left atrial pressure
B) "c" wave coincides with isovolumetric ventricular relaxation
C) "v" wave is prominent in severe dehydration
D) is reduced during inspiration

E) is measure in the internal jugular vein
36. Regarding pericardium,

A) fibrous pericardium blends with central tendon
B) phrenic nerve supplies both fibrous and serous pericardium
C) muscular phrenic artery supplies visceral layer of pericardium
D) fibrous pericardium originates from septum transversum
E) pericardial cavity is a potential space
46. Veins,
A) Contain most of the blood volume
B) Have a sympathetic vasoconstrictor innervation
C) Receive nutrition from vasa vasorum arising in front of their lumen
D) Respond to distension by contraction of their smooth muscle
E) Undergo smooth muscle hypertrophy when exposed to high pressure through an arterio-venous fistula
57. Which one has highest firing rate?

A) SA node
B) AV node
C) Myocardium
D) Bundle of his
E) Purkinje fibers
58. What is associated with atherosclerosis?

A) Decrease in total peripheral resistance
B) Decrease in arterial compliance
C) Increase pulse pressure
D) Widening of blood vessel lumen
E) low blood cholesterol
59. High resistance in,

A) Aorta
B) Arterioles
C) Capillaries
D) Venules
E) Inferior vena cava
12th Proper - SEQs
1..
1.1. Describe the blood supply of the Right and Left ventricles. (35 marks)
1.2. Briefly describe the gross anatomy of Superior Vena Cava (20 marks)
1.3. Write accounts on,
1.3.1. The relations cervical dome of Left Pleura (15 marks)

1.3.2. Embryonic development of Interventricular septum and the Congenital defects associated its formation. (30
marks)

2. The Blood flow of resting skeletal muscle is about 2-3 ml/100g/min. There is nearly 30 fold increase during
Strenuous Rhythmic Exercise. Neural an Hormonal mechanisms are responsible for changes during exercise.
Briefly describe,
2.1. The neural mechanisms operative in this situation. (50 marks)
2.2. The Hormonal mechanisms operative in this situation. (50 marks)
1.
a)False flat
b)True
c)True
d)False (page no.202 last, 12th edition)
e)True
2.
a)True (page no.203 last, 12th edition)
b)True
c)True
d)False lower border of T4
e)True
3)
6)
A) True
B) True
C) false
D) false
E) true
14) Branches from the thoracic aorta include the bronchial arteries, the mediastinal arteries, the esophageal arteries,
the pericardial arteries, and the superior phrenic artery.
a) True
b)True
c)True
d)True
e) False ( branch of abdominal aorta)
18)
a)-True when the ventricular pressure increased more than aortic and pulmonary arterial pressure ventricular
ejection occur
b) – True when the ventrical eject blood to the aorta and pulmonary artery its pressure increased so the pressure
gradient between ventrical and aorta or pulmonary artery. So the ventricular ejection rapid at first then slow down
later

C) – True the pressure in the aorta can exceed that of the left ventricle but for a short period of momentum keep
the blood moving
d) – True ventricular muscles initially shorten relatively little
e) – True amount of blood ejected at rest-70 ml
19)
a) – True
b) – True
C) – True
d) – True
e) – True
25)
a- True
b-True
c-Flase normal range is 65%
d-
e- true EDV and stroke volume both increased
30)
A – False
B – False posterior mediastinum
C – False it drains into point of confluence of left internal jugular and subclavian veins
D – True thoracic duct has several valves
E – True transmit aorta with azygous vein, thoracic duct
32.
A) Coronary sinus is a wide vessel located at posterior part of atrioventricular groove/coronary sulcus (true)
B) Oblique vein of the left atrium & coronary sinus are developed from the left horn of the sinus venosus. (true)
C) The valve of the coronary sinus (Thebesian valve) is a semicircular fold of the lining membrane of the right atrium,
at the orifice of the coronary sinus. (true)
D) To right of crista terminalis, it is smooth & crista terminalis runs between IVC & SVC openings. Coronary sinus
opening is located in front of IVC opening. (false)
E) Great cardiac vein Middle cardiac vein Small cardiac vein Tributaries of coronary sinus (true) Posterior vein of left
ventricle Oblique vein of left atrium
33.
A) Left coronary artery originates from left posterior aortic sinus. (false)
B) Normally, posterior interventricular artery is given off by right coronary artery and anterior interventricular artery
is given off by left coronary artery. But in 10% of left dominant, posterior interventricular artery is replaced by a
branch of circumflex artery. In them, at both anterior and posterior grooves are occupied by branches of left
coronary artery. (true)
C) Anterior interventricular branch is mostly affected by spasms. (true)
D) Arteries of right and left sides supply respective sides mostly and opposite sides to some extent. (true)
E) Arteries of right and left sides supply respective sides mostly and opposite sides to some extent. (true)

34.
A) Jugular venous pulse is about pressure changes inside right atrium. (false)
B) C wave is due to rise in atrial pressure due to bulging of tricuspid valve to right atrium, during isovolumetric
contraction. (false)
C) V wave is due to quick rise in atrial pressure before opening of tricuspid valve, during diastole. With hypovolemia
& dehydration, Jugular venous pressure can be reduced, so as V wave. (false)
D) During inspiration, all wave patterns of Jugular Venous pressure is increased due to reduced intrathoracic
pressure. This is also important in describing Kussmaul’s sign. (false)
E) (true)
36).
A. True
B. False - fibrous only
C. True
D. True
E. True
46) answer A
57) answer A
58)
59)answer B
1
1.1
• The heart is supplied by the two coronary arteries and their branches.
• Each coronary artery is the main source of supply to its same side atrium and ventricle, but also supplies the
opposite side chambers to some extent.
Right coronary artery
• Running downwards in the atrioventricular groove the right coronary artery turns backwards at the inferior
border of the heart and runs posteriorly.
• It gives off branches to both atrium and ventricle.
• One of the highest branches is the conus artery which passes upwards and medially on the front of the
conus (infundibulum) of the right ventricle.
• It frequently anastomoses with a similar branch from the left coronary artery to form an anastomosis
around the origin of the pulmonary trunk.
• . At the sharp (acute) inferior border the right marginal artery passes to the left along the right ventricle,
although it often has a much higher origin and passes obliquely down over the front of the ventricle.
• On the diaphragmatic surface of the heart the posterior interventricular branch—also called the posterior
descending artery—is given off.
• This large vessel passes along the interventricular groove towards the apex of the heart.
• Having given off one or more left ventricular (right posterolateral) branches, the remaining and much
smaller right coronary artery anastomoses with the termination of the circumflex branch of the left coronary
artery to a varying extent.

Left coronary artery
• it divides into its two terminal (circumflex and anterior interventricular) branches .
• The circumflex branch continues round the left margin to the back of the heart in the atrioventricular
groove, giving off various ventricular and atrial branches and anastomosing variably with the end of the right
coronary.
• One large left marginal artery frequently runs down the rounded (obtuse) left border of the heart.
• The anterior interventricular artery is the cardiac vessel most often affected by disease.
• It runs down in the interventricular groove to anastomose under the apex with the posterior
interventricular branch of the right coronary.
• Near its origin it gives a conus branch and further towards the left several ventricular branches.
• One is often large; this diagonal artery may arise separately from the left coronary trunk, which then ends
by trifurcation
1.2 SVC
• This vessel commences at the lower border of the first right costal cartilage by confluence of the two
brachiocephalic veins .
• It passes vertically downwards behind the right border of the sternum and, piercing the pericardium at the
level of the second costal cartilage,
• enters the upper border of the right atrium at the lower border of the third right costal cartilage.
• Behind the sternal angle it receives the azygos vein, which has arched forwards over the root of the right
lung.
• There are no valves in the superior vena cava, the brachiocephalic veins or the azygos system of veins.
1.3
inferior margin:
• manubrium
• 1st left costal cartilage
• First left rib
• 1st thoracic vertibra
Deep:
• Left Visceral parietal pleura
Medially:
• thyroid
• Trachea
• Oesophagus
• Great vessels
Superiorly:
• Left suprapleural membrane
Posterosuperiorly:
• Neck of left first rib
1.3.2
• By the end of the fourth week,the two primitive ventricles begin to expand.
• This is accomplished by continuous growth of the myocardium on the outside and
continuous diverticulation and trabecula formation on the inside

• . The medial walls of the expanding ventricles become apposed and gradually merge,
forming the muscular interventricular septum .
• Sometimes the two walls do not merge completely, and a more or less deep apical cleft
between the two ventricles appears.
• The space between the free rim of the muscular ventricular septum and the fused
endocardial cushions permits communication between the two ventricles.
• The interventricular foramen, above the muscular portion of the interventricular septum,
shrinks on completion of the conus septum .
• During further development, outgrowth of tissue from the inferior endocardial cushion
along the top of the muscular interventricular septum closes the foramen .
• This tissue fuses with the abutting parts of the conus septum. Complete closure of the
interventricular foramen forms the membranous part of the interventricular septum.
Ventricular septal defect
• Involving the membranous or muscular portion of the septum are the most common
congenital cardiac malformation
• Most occur in the muscular region of the septum and resolve as the child grows.
• . Although it may be found as an isolated lesion, VSD is often associated with
abnormalities in partitioning of the conotruncal region.
• Depending on the size of the opening,blood carried by the pulmonary artery may be 1.2
to 1.7 times as abundant as that carried by the aorta.
• Occasionally the defect is not restricted to the membranous part but also involves the
muscular part of the septum
13th Batch
13th Proper - MCQs
13. Pulmonary artery,

A) supply oxygenated blood into lungs
B) completely covered by fibrous pericardium
C) connected by ligamentum arteriosum with descending aorta
D) Derived from sinus venosus of embryonic heart
E) termination divide into two commencement of arch of aorta
24. Regarding normal heart sound

A) this is caused by turbulent blood flow through the valves
B) first heart sound is occurred due to closure of aortic valve
C) second heart sound occurs at end of ventricular systole
D) first heart sound can be heard at the beginning of isovolumetric contraction
E) 3rd heart sound during early diastole
30. Thromboxane A2,

A) Has a very short half life
B) An active metabolite of PGE2
C) Major prostaglandin produced in the cell
D) Does not contain a ring structure
E) Synthesized from the intermediate PGE2
SBR
41. A 45-year old man is diagnosed to have a total blockage in circumflex artery near to origin from left coronary
artery.
Which of the following vein must be protected during bypass procedure?
A) Anterior cardiac vein
B) Great cardiac vein
C) Middle cardiac artery
D) Posterior cardiac artery
E) Small cardiac artery
42. A 42 yrs. old child was admitted to the pediatric clinic with severe dyspnoea. ECG reveals cardiac arrhythmia
and right ventricular hypertrophy. Angiogram revealed PDA. What is the embryonic origin of ductus arteriosus?
A) Right 5th pharyngeal arch
B) Right 6th pharyngeal arch
C) left 4th pharyngeal arch
D) left 6th pharyngeal arch
E) left 5th pharyngeal arch
43. 50-year old patient came with history of tachycardia and low pulse pressure (70/55 mmHg) . What is the most
likely condition?
A) Aortic stenosis
B) Fever
C) Heart block
D) Hypovolemic shock
E) Isotonic muscular exercises
52. Which of the following cause greatest increase in cardiac output?

A) Adrenalin
B) Noradrenalin
C) Thyroxin
D) Glucagon
E) Angiotensin
53. What is the most affected pressure for tissue perfusion?

A) Systolic pressure
B) Diastolic pressure
C) jugular venous pressure
D) pulse pressure
E) Mean arterial pressure
54. Which would be the main function of the cutaneous circulation?

A) giving color to the skin
B) temperature regulation
C) transportation of vitamin D
D) nutritive function
E) blood reservoir

13th Proper - SEQs
4. Circulatory shock following severe hemorrhage is accompanied by,

4.1. Dizziness
4.2. Tachycardia
4.3. Thread pulse
4.4. Cyanosis
Explain the physiological basis of above observations. (4*25 marks)
5.
5.2. Describe the structure of the right atrium. (30marks)
5.3. Outline the origin, extent ad surface making of brachiocephalic vein (20marks)
13 )
A- False Deoxygenated blood to lungs
B- True
C- True Left pulmonary artery connects with descending aorta
D- False Derived from Truncus Arteiosus
E- True
24)
A. False Turbulent flow through valves is not normal
B. False Due to closure of AV valves
C. True
2nd heart sound is due to semilunar valve closure after ventricular systole
D. True Isovolumetric contraction occurs as soon as AV valves close
E .True
Heard about one third of the way through diastole. Heard due to vibrations setup by inrush of blood
41)
Answer B
Great cardiac vein accompanies the anterior interventricular and
circumflex arteries to enter the left end of coronary sinus
42)
Answer D
Distal part of left 6th pharyngeal arch persist as ductus arteriosus and
proximal part gives rise to left branch of pulmonary artery
43)
Answer A
Narrowing of aorta>>>>>CO reduced>>>>SBP reduced>>>>>Pulse pressure reduced>>>>Baroreceptor
stimulation>>>.Sympathetic activity>>>>Tachycardia
In aortic stenosis, both SBP & DBP falls, but the fall in SBP is more
Striking

52)
Answer A
contraction of heart
oreceptors
>>>>Reflex bradycardia>>>>> COP reduced
so DBP reduced>>>>>pulse pressure is widened but baroreceptor stimulation is insufficient>>>>>

no reflex bradycardia>>>>>>COP rises
53 )
Answer E
54)
Answer B
Cutaneous circulation ensures heat exchange between body and
environment. It is the main effector organ for human thermoregulation
and has high vasodilatory reserve capacity in response to metabolic,
thermal and pharmacological stimuli.
4.1.
Shock is defined as inadequate tissue perfusion with a relatively or absolutely inadequate cardiac output.
↓
Severe hemorrhage
↓
Reduced blood volume
↓
Reduced venous return
↓
Reduced end diastolic volume
↓
Reduced stroke volume
↓
Reduced cardiac output
↓
Reduced blood flow and reduced blood pressure
↓
Low blood flow to brain due to reduced blood pressure
↓
Dizziness
4.2.
Reduced cardiac output
↓
Reduced baroreceptor discharge due to low blood flow and pressure
↓

Stimulation of sympathetic activity and inhibition of parasympathetic(vagal) activity
↓
Sympathetic input to SA node increases heart rate(tachycardia)
4.3.
Increased sympathetic activity
↓
Vasoconstriction
↓
Increased total peripheral resistance
↓
Increased diastolic blood pressure
↓
(Systolic blood pressure is reduced due to reduced cardiac output)
↓
Reduced pulse pressure(Pulse pressure= SBP-DBP)
↓
Thready pulse
4.4.
Cyanosis is bluish discoloration of skin/mucosa due to rise in reduced hemoglobin n blood. If reduced hemoglobin
level increases more than 5g/100 ml of blood, then cyanosis occurs.
Due to hypovolemic shock, blood is shunted from skin to internal organs Blood flow to skin is reduced
The amount of oxyhemoglobin level decreases and reduced hemoglobin level rises than 5g/100 ml of blood as gas
exchange takes place
Cyanosis occurs
5.2. Describe the structure of the right atrium
 The right atrium forms the right border of the heart and it receives SVC, IVC and coronary sinus.
 It has the right auricle (a muscular pouch which increases the capacity of the atrium)
 Interior of right atrium has smooth thin posterior wall which receives IVC and rough muscular anterior wall
containing pectinate muscle with irregular ridges.
 Sulcus terminalis is a shallow groove in between SVC and right auricle
 Crista terminalis is inside the atrium which separates the rough and smooth regions
 Interatrial septum separate the two atria and it forms the posterior wall above the opening of coronary sinus
and it also contains fossa ovale as a shallow depressio
5.3. Outline the origin, extent and surface marking of brachiocephalic vein
Brachiocephalic vein is formed posterior to the sternoclavicular joint by the union of internal jugular and subclavian
veins.
Left brachiocephalic vein runs diagonally and overlies the 3 branches of arch of aorta
At the inferior border of the first right costal cartilage, brachiocephalic veins unite to form SVC
Tributaries
 Right brachiocephalic vein-
internal jugular vein
subclavian vein
vertebral, inferior thyroid and internal thoracic vein
Receives right lymphatic duct
 Left brachiocephalic vein-

Internal jugular vein
Subclavian vein
Vertebral, inferior thyroid and internal thoracic vein
Left superior intercostal vein and large thymic vein
Receives thoracic duct
14th Batch
14th Proper - MCQs
6. In the fetal circulation, mixing of oxygenated and deoxygenated blood occurs in the,
A) Left atrium.
B) Left ventricle.
C) Right atrium.
D) Right ventricle.
E) Liver.

14. Origins from aortic arch

A) Carotid arteries.
B) Inferior mesenteric artery (IMA)
C) Pulmonary artery.
D) Right subclavian.
E) Coronary artery.
15. Regarding the venous drainage of the heart,

A) Coronary sinus opens to the posterior wall of right atrium.
B) Great cardiac vein accompanies the circumflex artery.
C) Anterior cardiac vein drains into the coronary sinus.
D) Right marginal vein directly drains into right atrium.
E) Venae cordis minimae are most abundant in left ventricle.
30. Oxygen transport mechanism.

A) Oxygen concentration in arterial blood - 15ml/dl.
B) Partial pressure oxygen in arterial - 100mmHg
C) Oxygen saturation of arterial blood is higher than pulmonary vein.
D) Partial pressure of oxygen proportional to hemoglobin concentration.
E) Methemoglobin affinity is lesser than Hb

32. Ejection fraction,
A) Is the percentage of stroke volume from end diastolic volume
B) Normal value is about 75%
C) Not changed during exercises
D) Is an index of myocardial contractility
E) Reduced in aortic stenosis
33. Factors regulating cutaneous blood flow

A) Sympathetic nerves
B) Parasympathetic nerves
C) Somatic nerves
D) Metabolites
E) Temperature
34. Hypovolemic shock characterized by

A) Reduced blood pressure
B) Reduced pulse rate
C) Shallow and rapid respiration
D) Warm extremities
E) Cyanosis
35. Vascular resistance is determined by

A) Length of blood vessels
B) Viscosity of blood
C) The way blood flow through a vessel
D) Diameter of blood vessel
E) Blood pressure
36. Regarding functions of veins,

A) It has larger volume
B) More elastic tissue content
C) Has sympathetic control
D) Act as blood reservoir
E) has greater resistance to blood flow
SBR
41. 33-year old male admitted to the hospital with severe traumatic injury. His BP - 89/39. Central venous line is
ordered to be placed. Which is most likely occur when subclavian central line procedure
performed?
A) Penetration of subclavian artery
B) Impalement if phrenic nerve
C) Penetration of SVC
D) Penetration of left CCA
E) Impalement of vagus nerve

44. 62-year old male admitted to emergency department. Echo reveals that there are pulmonary regurgitation and
aortic stenosis. Angiography reveals that upper part of anterior ventricular free wall occluded. What artery is
occluded in here?
A) Circumflex artery
B) Anterior interventricular artery
C) Posterior interventricular artery
D) Artery of conus
E) Acute marginal branch of the coronary artery
46. Left superior intercostal vein drains into,

A) Accessory hemi azygos vein
C) Pulmonary vein
D) Superior Vena Cava
47. At lower esophageal level which vein has the anastomotic connection with left gastric vein?
A) Azygos venous system
B) Inferior vena cava
C) Superior vena cava
D) Brachiocephalic vein
E) Right gastric vein
58. Which of the following contributes most of changing the resistance to blood flow.
A) Change in length of vessels
B) Change In radius of arterioles
C) Change Radius in veins
D) Change the viscosity of blood
E) Change in Hematocrit
59. Tissue perfusion depends on which pressure?

C) Mean arterial pressure
D) Pulse pressure
E) Jugular venous pressure
60. Which of the flowing organ receive the largest share of cardiac output when person rest
D) Pulse pressure
14th Proper - SEQs
1.
1.2 Draw a diagram to illustrate the surface markings of the heart on pericardium (15 marks)

1.3. Describe the origin, relations, distribution of arch of aorta.
6. A healthy student while standing in attention in the school parade on a hot and humid day fainted and fell on the
ground. He had rapid feeble pulse. About two minutes later he regained consciousness and stood up on his own.
Explain the physiological basis of:
6.1. Rapid but feeble pulse before regaining consciousness (50 marks)
6.2. Regaining consciousness immediately without any assistance (50 marks)
06)
A- True Ganong Page616 – figure 33-17 & 33-18
B- Mixing occur in
• Liver (ductus venosus)
• Inferior vena cava
• Right atrium
• Left atrium
C- True
D-
E –True
07)
A- False Lies anterior to T12 vertebra
B- True Between right and left crura
C- False The sympathetic trunk passes behind the medial arcuate ligament.
D- False
E- False LAST PAGE 185
14.
A –False Left common carotid artery is a branch of the aortic arch but right common carotid artery is a branch of
brachiocephalic trunk.
B- False Branch of abdominal aorta.
C- False Origins from pulmonary trunk.
D- False Origins from brachiocephalic trunk
E- False Origins from ascending aorta.
15.
A- True Last’s anatomy page 205.
B- True Last’s anatomy page 205.
C –False Anterior cardiac veins open into the right atrium.
D- True Last’s anatomy page 206.
E- False Venae cordis minimae are most frequent in the right atrium
30.
a- False (20 Ml/Dl)
b- False (95mmHg)
c- False (pulmonary vein =99%,arterial blood =95%, venous blood=75%)
d- True

e -True
32.
a -True
b- False (65%)
c- False (normally increase)
d -True
e- True
33.
a- True (vasoconstriction)
b –True (vasodialation)
c- False
d- True
e- True
34.
a- True (hypotension)
b- False (rapid and thread pulse)
c –True (rapid respiration)
d- False (cold)
e- True
35.
a –True (directly proportional)
b- True
c- False
d- True
e- False
36.
a -True (vena commitance)
b -False
c- True (sparer sympathetic innervation)
d -True ( store 64% of blood volume under low pressure)
e- False
41.
Answer B
According to relations of subclavian vein; Phrenic nerve crosses subclavian artery
anteriorly and both lie posterior to subclavian vein but phrenic nerve is anterior
most structure
44.
Answer B
According to course of anterior interventricular artery.
46. answer B
47.

Answer A
this is a site where a portal/systemic anastomosis occurs between the esophageal branches
of left gastric vein and esophageal branches of the azygos venous system
58) answer B
59) answer C
60)answer E
1.2 Draw a diagram to illustrate the surface markings of the heart on pericardium
About one-third of the heart lies to the right of the midline. The right border of the heart extends from
the lower border of the right third costal cartilage to the lower border of the right sixth costal cartilage,
just beyond the right margin of the sternum and describing a slight convex curve between these points.
The inferior border passes from the right sixth costal cartilage to the apex, which is normally in the left
fifth intercostal space in the midclavicular line. From the apex the left border extends upwards to the
lower border of the left second costal cartilage about 2 cm from the sternal margin. These are the
borders as seen in a typical radiograph of the normal heart, although the area of cardiac dullness as
determined by percussion will be smaller
1.3 Describe the origin, relations, distribution of arch of aorta.
Emerging from the pericardium the ascending aorta approaches the manubrium and then at the level of the
manubriosternal joint becomes the arch, which passes backwards over the left bronchus to reach the body of T4
vertebra just to the left of the midline. From its upper convexity, which reaches as high as the midpoint of the
manubrium, arise the three great arteries for the head and upper limbs: the brachiocephalic trunk,
and the left common carotid and left subclavian arteries. The arch is crossed on its left side by the phrenic and vagus
nerves as they pass downwards in front of and behind the lung root respectively. Between them lie the sympathetic
and vagus branches to the superficial part of the cardiac plexus.
The left superior intercostal vein passes forwards across the arch superficial to the vagus,
deep to the phrenic, to empty into the left brachiocephalic vein. The left recurrent laryngeal nerve
hooks around the ligamentum arteriosum to pass upwards on the right side of the arch of the
aorta, in the groove between the trachea and esophagus. The pulmonary trunk bifurcates into
right and left pulmonary arteries in the concavity of the arch. On the right side of the arch lie the trachea and
esophagus
6.1. Rapid but feeble pulse before regaining consciousness

According to above scenario the person standing for long time and due to gravity blood pooling in
legs and abdomen.
Therefore , venous return to right heart reduced.
Basically cardiac output depend on stroke volume as well as heart rate.
Stroke volume depend on mainly 3 factors ; preload , afterload and cardiac contractility .
Preload means degree to which myocardium is stretched before it contracts.
Ventricular end diastolic volume is the volume of blood in the ventricle just prior to the contraction
depend mainly on venous return via superior and inferior vena cava.
As above mentioned venous end diastolic volume is reduced .Therefore stroke volume and cardiac
output are reduced .

Due to low cardiac output blood pressure also reduced ( BP = CO ×TPR).
Due to this low blood pressure baroreceptors locate in carotid sinus and arch of the aorta less distended
and therefore less discharged
Impulses are carried via cranial nerve nine and ten to nucleus of tractus soliterius in medulla oblongata .
It less stimulates cardiac inhibitory center and less inhibits vasomotor center.
Net effect is decrease parasympathetic discharge and increase sympathetic discharge.
Therefore increase in norepinephrine and concentration .
Norepinephrine act on B receptors on SA node and cause reflex tachycardia (rapid pulse ).
Inhibition of vagus will inhibit the muscarinic receptors in n SA node also result in tachycardia (rapid
pulse).
Due to venous pooling , stroke volume reduce and lead to feeble pulse.
6.2. Regaining consciousness immediately without any assistance

As mentioned above cardiac output and then blood pressure are reduced .
Therefore vital organs brain and heart did not receive sufficient blood supply cause unconscious .
As mentioned in 1 st part , sympathetic discharge is increased.
Due to increased sympathetic stimulation there is generalized arteriolar vasoconstriction occur.
Generalized vasoconstriction spare the arterioles in heart and blood vessels.
This will ensure blood flow to heart and brain.
Vasoconstriction occur in the splanchnic circulation as well.
This will result in diversion of blood flow from viscera to vital organ such as brain and heart via systemic
circulation .
Stimulation of sympathetic system result in venoconstriction as well.
Venoconstriction results increased in venous return due to reduction in venous pooling .
And also this person fell on ground and effect of gravity also clear off and further increase venous
return .
Increased venous return elevate the stroke volume and then cardiac output. With proper cardiac output
and above mention redistribution of blood to brain , person regained consciousnes
15th Batch
15th Proper - MCQs
1. Regarding surface markings of the neck,

A) Hard palate is lies at the C2 level
B) Hyoid bone lies at the C3 level
C) Larynx ends at C4
D) Pulsation of carotid artery is felt at the level of C6
E) Mandibular margin is between C2 and C3
4. The left atrium,

A) Forms the major part of the left border of the heart
B) Lies behind the right atrium
C) has the oblique sinus posterior to it
D) lies anterior to esophagus
E) Receive the 4 pulmonary veins

6. The atrioventricular bundle,
A) Forms the conduction system of the heart
B) Formed by nervous tissue
C) Atria ventricular bundle branches into 2 branches in the atria ventricular septum
D) Terminal branches of the bundle branch lies sub endocranially
9. Regarding borders of the heart,

A) Ascending aorta and pulmonary trunk emerge from superior border
B) apex contributes to inferior border
C) left border is formed by left atrium
D) left border is more vertical than right border
E) right border extends between IVC and SVC
17. Inferior vena cava derived from,

A) Right subcarinal vein
B) Left Sacro cardinal vein
C) Right hepato cardiac canal
D) Left umbilical vein
E) Right Sacro cardinal vein
28. Events which occur during isovolumetric contraction of the Left Ventricle,
A) Left ventricular pressure is greater than aortic pressure
B) Coronary blood flow is lower than that during the diastole
C) Pressure remains same while the volume of left ventricle increase
D) Mitral valve is open
E) There is no blood coming to right atrium
29. Factors altered in liver cirrhosis,

A) Capillary osmotic pressure
B) Capillary hydrostatic pressure
C) Filtration coefficient
D) Intestinal colloid osmotic pressure
E) Interstitial hydrostatic pressure
30. Causes of secondary hypertension

A) Coarctation of aorta
B) ADH section
C) Pheochromocytoma
D) Fatty liver
E) Conn's syndrome
31. True or false with reference to normal ECG?

A) aortic valve is closed at the time of P wave
B) QRS complex is produced by depolarization of ventricles
C) the 1st heart sound occurs at about the same time as P wave
D) the Q-T interval is an approximate indication of duration of ventricular systole
E) the 2nd heart sound occurs at about the same time as QRS complex

32. Which causes an increase in myocardial contractility
A) Adrenaline
B) noradrenalin
C) increase heart rate
D) increases end diastolic volume
E) dioxin
45. During cardiac contraction of age 6-year old child the radiologist notes that the contrast medium released into
arch of aorta is visible immediately in left pulmonary artery. What is the most likely explanation for this finding?
A) Patent ductus arteriosus
B) Patent ductus venosus
C) Patency of the oval foramen
D) Aortic aneurysm
E) Hypertrophy of ventricle
49. A 69-year old female is admitted to the hospital with intense left chest pain. ECG reveals hypokinetic
ventricular septal muscle, myocardial infarction in the anterior 2/3 of interventricular septum and left
atrioventricular wall. The patient's ECG also exhibited left bundle branch block. Which of the following artery is
most likely damaged?
A) Circumflex artery
B) Proximal right coronary artery
C) Proximal left coronary artery
D) Proximal left atrioventricular artery
E) Posterior interventricular artery
51. From following answers, which has the greater contribution to peripheral resistance?
A) Aorta
B) Arteriole
C) Venule
D) Vein
E) Capillary
52. Which of the following has the highest impact on perfusion of the tissues?
A) systolic pressure
D) Pulse pressure
15th Proper - SEQs
6. A young adult was disoriented and in a state of confusion after a minor road accident resulting in mild
hemorrhage. On examination his blood pressure was found to be 80/60 mmHg and a pulse rate of 110/min but
feeble pulse.
Explain the physiological basis of
6.1 disorientation and state of confusion following hemorrhage (25 marks)
6.2 low blood pressure (25 marks)

6.3 tachycardia (25 marks)
6.4 feeble pulse (25 marks)
01)
a- false
b- true
c- false
d- true
e- true
04)
a- false major part is formed by left ventricle
b- true
c- true
d-true
e-true
06)
a- true
b-false muscle mass
c-false interventricular septum
d- true
09)
a- true
b-true
c- false formed by left ventricle and left atrium
d- false right border is more vertical, left border is rounded
e- true
17)
a- true forms renal segment of IVC
b- false forms hemiazygos vein
c- true forms hepatocardiac portion of IVC
d- false disappears after birth
e- true forms sacrocardinal segment of IVC
28)
a-false when the pressure exceeds the aortic pressure ventricular ejection occurs
b- true
c- false volume remains unchanged while pressure increases
d- false mitral valve is closed
e- false
29)
a- true protein amount in capillary changed
b- false there’s no change in hydrostatic pressure due to liver chirrhosis
c- false

d-
e-
30)
a- true
b- true
c- true
d- false
e-true secondary hypertension causes - conns , cushing disease , adrenal hyperplasia, phenochromocytoma,
acromegaly, thyrotocsicossis , caoartation of aorta , chronic renal failure, kidney disease
31)
a- true
p wave atrial depolarization , qrs complex ventricular depolarization , t wave ventricular repolarization ,
s1 sound – closure of mitral valve and tricuspid valve ( beginning of ventricular systole )
s2 sound- closure of aortic and pulmonary valve ( end of ventricular systole)
b- true
c- false
d- true time from the start of the Q wave to the end of the T wave represent time taken for ventricular
depolarization and repolarization .
effectively the period of ventricular systole from ventricular isovolumetric contraction to isovolumetric relaxation
e- false
32)
a- true
b-true
c-true
d-true
e- true
increased contractility - sympathetic , catecholamines

positive ionotropic agents (dopamine)
digitalis( digoxin)
xanthine – caffeine , theophylline
force frequency relationship
decreased contractility – parasympathetic
hypoxia , hypercapnia
acidosis
pharmacological agents (barbiturates , quinidine , procainamide)
loss of myocardium
intrinsic depression – heart failure
vagal stimulation
45) answer A
49) answer D
51) answer B
52) answer C

6.1 disorientation and state of confusion following hemorrhage

• Acute blood loss causes a fall in central venous pressure and cardiac filling
• Reduced cardiac output
• Reduced organ perfusion
• Body try to compensate the blood supply to brain through sympathetic activation
• Systemic vasoconstriction increases
• Systemic vascular resistance increase
• Sympathetic activation has little direct influence on brain
• Cardiac output is redistributed from less important organs to the brain
• Even if the compensatory mechanism occurs
• Blood supply to the brain is decreased and slow than normal since low blood volume and low
blood pressure
• Hypoperfusion of brain
• Brain cells do not get the nutrients and oxygen they need if blood flow to the brain is reduced.
This can prevent them from working correctly.
• Results in confusion and disorientation
6.2 low blood pressure

This person’s road accident leads to a mild hemorrhage (blood loss). Loss of blood volume leads to reduced venous
return. It will lead to decreased end diastolic volume. It will lead to reduced contractility. It will lead to decreased
stroke volume. Decreased stroke volume leads to decrease in cardiac output. Decreased CO leads to decreased
blood pressure.
6.3 tachycardia
➢ Tachycardia-Rapid beating of the heart, usually defined as greater than 100 beats per minute.
➢ The reduction in blood volume during acute blood loss causes a fall in central venous pressure and cardiac filling.
➢ This leads to reduced cardiac output and organ perfusion through the Frank-Starling mechanism, and reduced
arterial pressure.
➢ Tachycardia is a compensatory mechanism in blood loss to compensate the cardiac output by increase the heart
rate ( cardiac output=heart rate×stroke volume)
➢ It is acheived through activation of sympathetic system
1) The body can quickly sense a fall in blood pressure through its arterial and cardiopulmonary baroreceptors, and
then activate the sympathetic adrenergic system to stimulate the heart (increase heart rate and contractility) and
constrict blood vessels (increase systemic vascular resistance).
2) Reduced organ blood flow caused by vasoconstriction and reduced arterial pressure leads to systemic acidosis
that is sensed by chemoreceptors. The chemoreceptor reflex further activates the sympathetic adrenergic system,
reinforcing the baroreceptor reflex.
❖ Increased sympathetic discharge
❖ Elevated catecholamine level in blood acts on the beta 1 adrenergic receptors in the heart
❖ Increases the impulse generating rate of the SA node and the conduction velocity of heart
❖ The heart rate increases
❖ Results in Tachycardia
6.4 feeble pulse

- Thready feeble (low volume) pulse
There are high pressure baroreceptors on carotid sinus and aortic arch.
Low pressure baroreceptors on atrial wall at the opening of SVC, IVC and pulmonary veins and in

pulmonary circulation.
They send afferents to the NTS via buffer nerves.
NTS usually inhibits VMC (sympathetic stimulator); Excites CIC (parasympathetic stimulator).
During hypovolemic shock, due to low blood volume, the discharge rate of low pressure
baroreceptors is decreased.
Low pressure causes decreased discharge rate of high pressure baroreceptors.
Due to their action the inhibition of VMC is taken off and sympathetic discharge increases.
Stimulation of CIC is taken off and parasympathetic discharge decreases.
Increased sympathetic discharge acts on β1 receptors of the SA node and increases its discharge rate
and heart rate increases.
But, the circulating blood volume is low.
So, the pulse is rapid but thready. So it is feeble pulse.
*NTS - Nucleus Tractus Solitarius

*VMC – VasoMotor Centre
*CIC – Cardiac Inhibitory Centre

METABOLISM
EME QUESTIONS
1. Following mechanism regulate the metabolic process,

A) Allosterically
B) Cell Signaling
C) Covalent Modification
D) Feedback Inhibition
E) Protein Synthesis
2. Regarding fatty acid synthesis,

A) Occurs in mitochondria
B) NADPH spared
C) Catalyzed by Fattyacid synthase
D) Is activated by glucagon
E) Require specific enzyme found in RER and MC
3. Regarding purine synthesis,

A) Purines are not synthesized initially as free bases.
B) Dietary purines are broken up by salvage pathway
C) Committed step of purine synthesis uses 5- phosphoribosyl-1-pyrophosphate.
D) PRPP is a donor of Ribose Phosphate group
E) Ribo nucleotides are end product of de novo purine synthesis
4. Oxidation of odd chain FA produce,

A) Aceto acetyl CoA
B) Malonoyl CoA
C) Succinyl Coa
D) Propionyl Co A
E) Hydroxybutaryl ACP
5. Regarding pyrimidine synthesis,

A) Increased availability of carbamoyl phosphate promotes pyrimidine synthesis
B) 5- fluorouracil is called suicide inhibitor of thymidylate synthase.
C) All enzyme involved in pyrimidine biosynthesis are cytosolic.
D) Pyrimidine synthesis reqiures glutamine and aspartate
E) dUTPase prevent erroneous incorporation of uracil into DNA
6. A medical student is in intensive study without food for 24 hours. The main fuel for brain comes from,
A) Breakdown of glycogen in muscles
B) Ketone bodies from the liver
C) Gluconeogenesis in the liver
D) Beta oxidation of fatty acids
E) Glycolysis

7. Aminotransferases,
A) Make an alpha ketoacids from alpha amino acid
B) use tetrahydrofolate as carrier of amino groups
C) Reactions are highly reversible
D) use ATP
E) Levels in serum are uses as a clinical measure of tissue damage
8. Essential for glycogen synthesis

A) Glucogan
B) Glycogen synthase
C) Glycogenin
D) NADH
E) UDP glucose
9. Regarding the heme,

A) Haem synthesis occurs in the liver
B) Lead poisoning inhibits heme synthesis
C) Drug like phenobarbitone stimulates heme synthesis
D) Haem forms part of active site of peroxidase and catalase
E) Haem synthesis requires Succinyl CoA and Alanine
10. Complex IV in the ETC,

A) Accept electrons from reduced Co Enzyme Q
B) Is inhibited by carbon monoxide
C) Utilize molecular O2 as electron acceptor.
D) Is capable of pumping electron from inner mitochondrial membrane
E) Produces H2O
SBR
11. An 18-year old cricketer was found with 109°F hyperthermia. Which of the complex of electron
transport chain is responsible for this phenomenon?
A) ATP synthase
B) Complex I
C) Complex II
D) Complex III
E) Complex IV
12. Hydroxilation of poly unsaturated fatty acid produce,

A) Alpha linoleic acid
B) Cis fatty acid
C) Trans fatty acid
D) Beta linolenic acid
E) Alpha linolenic acid
13. Which helps transport of fatty acid from cytosol to mitochondria in oxidation of fatty acid
A) Carnitine
B) Carnitine phosphate

C) Creatinine
D) Fatty acyl synthase
E) Albumin
14. 4-year old child present to a pediatric clinic with megaloblastic anemia and failure to thrive. Blood bio
chemistry reveals orotic aciduria, enzyme measurements reveals deficiency of pyrimidine biosynthesis enzyme
orotate phosporibosyl transferase and abnormally high activity of the enzyme aspartate trans carbonylase. Which
of the following treatment will reverse all symptoms,
A) Blood transfusion
B) Oral uridine
C) Oral thymidine
D) Dietary supplements
E) Sulfonomides
15) Which one is correct with urea formation,

A) 2 Nitrogen atoms are incorporated into urea enter cycle as ammonia and alanine
B) Urea is formed directly by the hydrolysis of ornithine
C) ATP is required for the cleavage of arginosuccinate to arginine
D) Urea formation increases in a diet full of protein
E) Urea cycle takes place exclusively in the cytosol.
1.
1.1 Briefly describe the functions of two main glucose oxidation pathways. (40 marks)
1.2 Outline the Cori cycle with its significance in human body. (20 marks)
1.3 Briefly explain the biochemical basis of regulatory enzyme deficiencies lead to haemolytic anaemia
with common examples.
2.
2.1 Explain the biochemical basis of the treatment of chronic gout with allopurinol. (40 marks)
2.2 Write the short notes on the followings
a. Phenylketonuria (30 marks)
b. Synthesis and Transport of ammonia (30 marks)

10th Batch (EME) – MCQ Answers

8.

1.1 Briefly describe the functions of two main glucose oxidation pathways. (40 marks)
I.The Major Pathway for Energy Production

A) Glycolysis – Produce Pyruvate under Aerobic Condition
Produce Lactate under anaerobic Condition
B)Kreb’s Cucle – Under aerobic condition, Pyruvate convert to active acetatefor oxidation through Kreb cycle
II. Minor Pathway for synthesis of other Derivatives

HMP Pathway – Production of NADPH and Pentose
Uronic Acid pathway – Uronic acid Production
1.2 Outline the Cori cycle with its significance in human body. (20 marks)
Cori cycle is made considering the lactate produced by red blood cells and skeletal muscle cells.

1.3 Briefly explain the biochemical basis of regulatory enzyme deficiencies lead to haemolytic anaemia with common
examples.
Glucose-6-phosphate dehydrogenase deficiency causes haemolytic anaemia.
• Mutations present in some populations causes a deficiency in glucose 6-phosphate dehydrogenase, with
consequent impairment of NADPH production.
• Detoxification of H2O2 is inhibited, and cellular damage results - lipid peroxidation leads to erythrocyte membrane
breakdown and hemolytic anemia.
2.
2.1 Explain the biochemical basis of the treatment of chronic gout with allopurinol. (40 marks)
• Allopurinol is a structural analog of hypoxanthine
• Inhibits UA synthesis
• Allopurinol oxidizes to oxipurinol, a long lived inhibitor of XO
• Increased accumulation of hypoxanthine and xanthine, more soluble than UA
• Prevent crystal formation and inflammatory response

2.2 Write the short notes on the followings
a. Phenylketonuria (30 marks)
• Deficiency of Phenyl Alanin Hydroxylase

• ↑*Phe+ tissues,plasma,urine
• ↑Phenyl lactate, Phenyl acetate, Phenylpyruvate
• Cause-mental retardation
-failure to talk and walk
-seizers hyperactivity tremor
-microcephaly
-failure to grow
-hypopigmentation because high [Phe] competitively inhibit hydroxylation of Tryosine by tryosinase
Treatment
- *Phe+ ↓ diet
- Tyrosine supplied in diet
Maternal PKU
- PKU mother *Phe+↑
- Cause microcephaly, mental retardation, congenital heart abnormalities in foetus
Laboratory diagnosis
1. Blood phenylalanine
2. Guthrie test
3. Ferric chloride test – blue green colour

b. Synthesis and Transport of ammonia (30 marks)
Transport of NH3
Because of its toxicity NH3 is transported in blood as Gln.

High solubility
Gln uncharged- can cross membranes
High N content
Glutamine synthetase reaction

Glutamine synthetase
NH4 + Glutamate Glutamine
ADP
Glutamine (Gln)
• Major method of detoxifying NH3 in brain.
• Also produced in liver, kidney and muscle.
• Hydrolyzed in kidney to liberate NH3.
↑In metabolic acidosis
↓In metabolic alkalosis

1. Anabolic reaction,
A) Bio synthetic
B) Divergent
C) Energy required
D) Enzyme dependent
E) Oxidative
2. Enzymes involving in TCA cycle,

A) Glutaminase
B) Fumarase
C) Glutamate dehydrogenase
D) PEP Carboxykinase
E) Pyruvate Carboxylase
3. Glutamate,
A) Fix NH3 by an ATP using reaction
B) most abundant neurotransmitter in brain
C) can be produced from glucose
D) does not cross blood brain barrier
E) synthesized from glutamine using glutaminase
4. A 15-year old boy who was diabetic type 1, He felt unconscious by giving Insulin, after that he was given with
glucagon,
A) Activate protein kinase A
B) Using cAMP
C) Phosphorylase kinase
D) Phosphorylating glycogen phosphorylase
E) Utilizing G-Protein depend signal transduction pathway
5. Which is/are following required for purine synthesis,

A) Alanine
B) CO2
C) Glutamine
D) NH3
E) Ribose 5 phosphate
6. Amino transferase,
A) Are highly reversible
B) Can make alpha keto acid from an alpha amino acid
C) The level in the serum are used as a clinical measurement of tissue damage
D) Use ATP
E) Requires THF as a carrier
7. What are the complications of chronic alcoholism?

A) Fatty liver
B) Confusion

C) Coma
D) Low NADPH/NADP+ ratio
E) Suppression of TCA cycle
8. Beta oxidation of fatty acid,

A) Generate ATP only if acetyl CoA is subsequently oxidize
B) controlled primarily by allosteric effects
C) occurs by repeated sequence of 4 reactions
D) use NADP+
E) only use even chain saturated fatty acids as substrates
9. Regarding reactions of xenobiotic metabolism,

A) after phase 2 most of compacts are rendered non toxic
B) conjugation is main event in phase 1
C) Cytochrome P450 is major enzyme in phase 2
D) most of the reactions take place in the liver
E) the polarity of xenobiotic increase upon conjugation
10. Regarding eicosanoids,

A) Aspirin induce prostaglandins production by inhibiting cyclooxygenase
B) Leukotriene E4 promotes vasodilation and muscle contraction
C) Prostacyclin promotes vasodilation and platelets aggregation
D) Prostaglandin
E) they are originated from 25C unsaturated fatty acids
11. A 4-year old boy of a first degree consanguineous couple was noted by the pa rents to have darkening of urine
to an almost black color when it was left standing. He has a normal sibling and there are no other medical
problems. Growth and development to date are normal. Which of the following is most likely to be elevated in the
patient?
A) Methymalonate
B) Homogentisate
C) Phenylpyruvate
D) alpha ketoisovalerate
E) Homocysteine
12. A 5-year old boy presented with abnormal movements, seizures and hypotonia. His lactate pyruvate and
ketone body (keto acidosis) level was high and diagnosed as pyruvate carboxylase enzyme deficiency. Which of
the following is made by above enzyme,
A) Aspartate
B) alpha ketoglutarate
C) Malate
D) Oxaloacetate
E) Pyruvate
13. 50-year old lady was admitted to the hospital with deficiency of Acyl CoA transferase deficiency.
What is the possible state?
A) Decreased mature HDL
B) Reduced ability to store cholesterol in cell

C) inability to form cholesterol esters in plasma
D) High nascent HDL level
E) High level of cholesteryl esters in chylomicrons
14. 56-year diabetic patient with end stage renal disease receive a kidney from his son. His nephrologist is
concerned for the possibility of transplant reject and puts the patient on mycophenolic acid that inhibit which of
the following enzyme in the synthesis of nucleotides,
A) Adenylosuccinate synthetase
B) Adenylsuccinate synthetase
C) IMP dehydrogenase
D) PRPP synthetase
E) Nucleotides reductase
15. During prolonged starvation,

A) Fatty acid produces at high rate in plasma by action of lipoprotein lipase enzyme on chylomicrons
B) Liver gluconeogenesis increase
C) Muscle increase use of ketone bodies
D) The amount of circulating TAG will be low
E) store fatty acid release from adipose tissue into plasma as VLDL
1.
1.1. Describe the biochemical basis of the followings;
1.1.1 Gouty arthritis due to high consumption of fructose diet. (15 Marks)
1.1.2 Cataract formation in hyperglycemia.
1.2. Briefly describe the glycogenolytic pathway with its regulation. (40 Marks)
1.3. Write the short notes on synthetic inhibitors of purine biosynthesis. (30 Marks)
2.
2.1. Briefly describe the role of folic acid in amino acid metabolism. (30 Marks)
2.2. Briefly describe the regulation of lipid metabolism. (40 Marks)
2.3. Briefly describe the role of liver, adipose tissue, skeletal muscle and brain in fed state. (30 Marks)

11th Batch (EME) – MCQ Answers


1) Regarding hexokinase and glucokinase,

A) Hexokinase is isozyme
B) Glukokinase acts as the sensor for glucose in regulating blood glucose level
C) Directly inhibited by glucose-6-phospate
D) Insulin up-regulates the production of these enzyme
E) They phosphorylate fructose
2) Converting Acetyl CoA to pyruvate,

A) Is reversible
B) Involve the participation of lipoic acid
C) Activated when PDH complex phosphorylated
D) Occurs in the cytoplasm
E) Depend on co enzyme biotin
3) Regarding gluconeogenesis,
A) It can use carbon skeletons derived from certain amino acids
B) It is the simple reversal of glycolysis
C) Requires Vitamin B12
D) Involves in glucose 6-phosphate
E) It use metabolic energy
4) Regarding glycogen synthesis,

A) cAMP induce the phosphorylation of the glycogen synthase
B) cAMP level elevated by stimuli from epinephrine via adenylyl cyclase
C) NADPH are produced
D) It occurs in the ER
E) Phosphorylate kinase is activated by phosphorylation
5) Regarding xenobiotics,
A) Cytochrome P450 enzyme use phase 1 reaction
B) Metabolism occurs in Kidney
C) Enalapril is activated in phase 1 reactions
D) In phase 1, active compounds are converted into inactive form
E) Conjugation reactions can occur independently
6) State T/F,
A) FA synthesis requires CO2
B) Beta oxidation occurs in mitochondrial matrix
C) Endogenous FA is assembled in chylomicron
D) Ketone Bodies generate from Acetyl CoA utilize by liver
E) Linoleic acid synthesize in human
7) Regarding Purine bio synthesis,

A) Ribose phosphate assembled in synthesis
B) ATP is not required

C) Requires glycine
D) Requires phosphoribosyl pyrophosphate
E) Requires Vitamin B12
8) True or False,
A) Increased gluconeogenesis from amino acids causes decrease in urea formation
B) Cysteine is an essential amino acid in a diet devoid of methionine
C) Glutaminase in renal cells increase in acidosis
D) In the presence of adequate dietary source of tyrosine, phenylalanine is not a essential amino acid
E) Ornithine and Citrulline are not found in tissue protein
9) Regarding well fed state,

A) Acetyl CoA elevated
B) Hepatic fructose 2, 6-bisphosphate level is elevated
C) Insulin stimulate glucose transport into the hepatocyte
D) Gluconeogenesis occur in the interval between two meals
E) Synthesis is glucokinase is enhanced
10) State True or False,

A) Active form of methionine donate methyl group for synthesis creatine
B) Homocystinuria is an inherited defect in cysteine catabolism
C) In urea cycle, NH4, CO2, aspartate consumption
D) Liver mitochondria have special carrier for ornithine and citrulline
E)
SBR
11. A 42-year old male patient undergoing radiation therapy for prostate cancer develops severe pain in the
metatarsophalangeal joint of his right big toe. MSU crystals are detected by polarized light microscopy in fluid
obtained from this joint by arthocentasis. This patient’s pain is directly caused by the overproduction of which of
the following metabolic pathway?
A) De novo purine bio synthesis
B) Pyramidine synthesis
C) Purine degradation
D) Purine salvage
E) Pyrimidine degradation
12. 12-year old boy was characterized with white color skin and hair, red eyes, what is the enzyme deficient in this
appearance?
A) Dihydrofolate reductase
B) Homogenstic oxidase
C) NADPH oxidase
D) Phenylalanine hydroxylase
E) Tyrosinase
13. Which one is the most common alpha amino group accepter of transamination?
A) Acetoacetate
B) Aspartate

C) Oxaloacetate
D) Pyruvate
E) Alpha ketoglutarate
14. What happened when glucose 6-phosphatase is deficient?

A) Increased glycogen accumulation in skeletal muscle
B) Decrease glycogen accumulation in skeletal muscle
C) Hyperglycemia
D) Increased glycogenesis
E) Increased hepatic glycogen accumulation
15. A 4-year old boy of a first degree consanguineous couple was noted by the parents to have darkening of urine
to an almost black color when it was left standing. He was a normal sibling and there are no other medical
problems. Growth and development to date are normal. Which of the following is most likely to be elevated in the
patient?
A) Homogentisate
B) Homocystine
C) Alpha keto iso valerate
D) Methylmalonate
E) Phenylpyruvate
1.
1.1. Briefly explain the biochemical basis of followings occur in alcoholism;
1.1.1 hypoglycaemia
1.1.2 lactic acidosis (20 marks)
1.2 Outline the disorders of galactose metabolism. (25 marks)

1.3. Briefly describe the functions of pentose phosphate pathway. (35 marks)
1.4. Outline the biochemical basis of Lesch-Nyhan syndrome (20 marks)
2.
2.1 Explain how triglycerides are synthesized. (30 marks)
2.2. Write the role of liver in fasting. (40 marks)
2.3. Explain the routes of ammonia disposal via

2.3.1. Glutamate
2.3.2. Glutamine



1. PhosphoFructoKinase-1 enzyme,
A) Is cytosolic enzyme
B) It produce ATP
C) Activated when glucose is abundant
D) Inhibited by fructose 2,6-bisphosphate
E) Involve in rate limiting step of gluconeogenesis
2. Contributing molecules of purine ring include,

A) Asparagine
B) CO2
C) Cysteine
D) Glycine
E) N10-Formyletetrahydrofolate
3. Regarding xenobiotic metabolism,

A) Conjugation reactions occur in phase 1
B) It happens in kidney
C) Facilitate elimination of toxic substances
D) It makes substances water insoluble
E) NADPH required for phase 1 reactions.
4. Regarding Fructose Metabolism,

A) Excess uptake of Fructose diet causes production of more ATP
B) Fructokinase has low Km for fructose
C) Fructose transporters are insulin dependent
D) Hyperuricemia can be seen in Hereditary Fructose intolerance
E) Rate of Fructose metabolism is more Rapid than glycolysis
5. Nitrogen of urea ultimately formed by,

A) Ammonia
B) Aspartate
C) Fumarate
D) Glucose
E) Ornithine
6. Glutamate,
A) Can fix NH3, is a ATP dependent reaction
B) Can form glutamine by glutamate dehydrogenase
C) Utilize to funnel nitrogen in to OAA
D) Is one of the nitrogen carrier in blood under normal conditions
E) Is the precursor of the ornithine

A) CO2 is used as a substrate
B) It is activated by glucagon

C) Occurs in the cytoplasm
D) Malonyl CoA converted in to acetyl CoA in mitochondrial matrix
E) It requires multi functional enzyme complex
8. Regarding Eicosanoids,
A) Aspirin inhibits cyclooxygenase pathway
B) It is synthesized from 18 carbon polyunsaturated fatty acids
C) Leukotriens synthesized in lipoxygenase pathway
D) Prostanoid include prostaglandins, prostacyclins and leukotriens
E) Thromboxane produced by platelets
9. TAG molecules stored in adipose tissue represent the major reserve of substrate providing energy during
prolonged fast. During such a fast,
A) Free fatty acids are produced at high rate in the plasma by the action of lipoprotein lipase in the chylomicron
B) Glycerol produced by the degradation of TAG is an important direct energy source for adipocytes
C) Hormone sensitive lipase is phosphorylated by cAMP dependent protein kinase A
D) Circulating chylomicrons and VLDL levels become low.
E) Fatty acid released from adipose tissue to the circulating albumin
10. Pentose phosphate pathway

A) Produce 36 ATP for one glucose molecule
B) Start from glucose-6-phosphate
C) Occurs in the cytoplasm
D) Produce deoxyribose
E) Regulated by glucose-6-phosphate dehydrogenase enzyme
SBR
11. A 4-year old boy of a first degree consanguineous couple was noted by the parents to have darkening of urine
to an almost black colour when it was left standing. He has a normal sibling and there are no other medical
problem. Growth and development to date are normal. Which of the following is most likely to be elevated in
patient?
A) Methylmalonate
B) Homogentisate
C) Phenylpyruvate
D) α ketoisovalerate
E) Homocystine
12. 23-year old female was diagnose with genetic disorder due to deficiency in enzyme Acetyl CoA : cholesterol
acyl transferase enzyme. This enzyme deficiency would result in,
A) Decrease in mature LDL level
B) Decreased ability to store cholesteryl esters in cytoplasm in cells
C) Inability to form cholesteryl esters in plasma
D) Increase in nascent HDL level in plasma
E) Increase in cholesteryl esters content in chylomicrone

13. 65-year old man has chronic alcoholism. He present with slurred speech, loss of muscle coordination,
abdominal pain. Examination done about him has reported that he has developed hypoglycemia and
hyperketonemia. Which of the following will most probably be the cause for development of hypoglycemia,
A) Decreased NADH level
B) Increased TCA cycle
C) Increased reduction of OAA in to Malate
D) Thymine deficiency
E) Increased Fatty acid oxidation
14. Which of the following status is true about Pyrimidines?

A) CPS – 1 is the main regulatory enzyme
B) Methotrexate decrease synthesis of Pyrimidines nucleotide monophosphate
C) Orotic aciduria is a pathology of Pyrimidine degradation
D) Pyrimidines synthesis depend on PRPP
15. Hypoglycemia caused by Glycogen storage disease type 1a is more severe and type b is mild. Which enzyme
deficient in type 1a glycogen storage disease?
A) Glucokinase
B) Glucose-6-phosphatase
C) Glycogen synthase
D) Liver phosphorylase
E) Pyruvate carboxylase
1.
1.1 Briefly describe how glycolysis and gluconeogenesis are reciprocally regulated. (40 marks)
1.2 Outline the biochemical basis of the disorder caused by Adenosine deamainase deficiency. (20 marks)
1.3 Explain why Sulphonamaids do not interfere with human nucleic acid synthesis. (15 marks)
1.4 State the functions of NADPH with examples. (25 marks)
2. Briefly describe the followings,

2.1 Beta Oxidation pathway of parmitic acid (40 marks)
2.2 Transamination (40 marks)
2.3 Role of liver and brain in fed state (20 marks)
01
AT
B F Utilize ATP
CT
D F Fructose -1,6-bisphosphate is an allosteric activator
ET

02
AF
• CO2
• ATP
• N10 formyltetrahydrofolate
BT
CF
DF
ET
03
AF
B F Main site is the LIver
CT
D F Make hydrophobic substances water soluble
E T NADPH used for the actions of NADPH Cytochrome P 450 Reductase in Phase -1 reactions
04
A F Excess fructose uptake causes for elevated phosphorylation and formed fructose 1 phosphate accumulated
resulting reduction of available Pi. That leads to reduction of ATP synthesis
B T Fructokinase - low Km Glucokinase
- high Km
C F GLUT – 5 is insulin independent
D T Hereditary Fructose Intolerance causes elevated degradation of purine nucleotides that results high Uric acid
production.( hyperuricemia)
ET
05
AT
BT
CF
DF
EF
06
A T Action of Glutamine synthetase needs ATP and NH3 and it convert Glutamate in to Glutamine
B F Glutamate dehydrogenase convert Glutamate in to Alpha keto gluterate and NH3
C T During the action of Aspartate aminotransferase
DF
Nitrogen carriers : - Glutamine
Alanine
EF
07
A T CO2 or HCO3- used for the action of acetyl co A carboxylase
B F Activated by Insulin ( ACETYL CO A Carboxylase)
CT
DF

E T Fatty acid synthase is a multifunctional enzyme complex
08
A T ASPIRINE inhibit COX-1 & COX-2
B F Synthesized from 20 C polyunsaturated fatty acids.( ex:Arachidonic acid)
C TArachidonic acid Lipoxygenase → Leukotriens
D T Prostanoids : - Prostaglandin , Prostacyclin , Thromboxanes , Leukotriens
ET
9
A F Chylomicrons are postprandial lipoproteins available in blood after a meal and not during prolonged fast
B F Glycerol is sent to liver to be coverted to glycerol-3-phosphate by glycerol kinase which is exclusive to liver.
C T epinephrine activates cAMP dependant protein kinase A and phosphorylates HSL
D T During fasting chylomicrons and VLDL decrease and in fed state they increase in blood
E T FA require a transporter in blood and albumin acts as a transporter of fatty acids
10
A F No ATP is directly produced or consumed in the pathway
36 ATP is produced in by one glucose molecule during cellular respiration
BT
C T As it occurs in cytoplasm, this pathway also occur in RBC
D F this pathway produces ribose-5-phosphate from ribulose-5-phosphate in oxidative phase and does not produce
deoxyribose sugar
E T Glucose-6-phosphate dehydrogenase is the rate imiting step which converts glusoce6phosphate to 6-
phosphogluconolactone
11 B
Alkoptonuria is caused due to deficiency of homogenistic acid oxidase resulting inaccumulation 0f homogenistic acid
which is an intermediate in degradative pathway of tyrosine
12 C
when cholesterol is not required immediately, it is esterified by this enzyme. cholesterol recieves a FA from fatty acyl
CoA producing a cholesteryl ester
13 C
Due to increased production of NADH by alcohol metbolism, OAA to malate conversion which is a NADH requiring
step occurs making OAA unavailable to be used in gluconeogenesis
14 D
PRPP is the ribose 5 phosphate donor to orotate to form orotidine-5monophosphate(OMP)
15B
glucose-6-phosphate is converted to glucose by glucose-6-phosphatase. Type 1a is due to glucose-6-phosphatase
deficiency

01)
1.1) Glycolysis is the ATP synthesis by the substrate phosphorylation of glucose.
GNG is the synthesis of glucose by non-carbohydrate components.it utilizes ATP.
Glycolysis has three irreversible reactions that has to be bypassed by alternative steps to synthesis glucose in GNG.
several regulatory captors maintain one of the two pathways according to the energy level and
substrate level in tissues.
1. Action of glucose phosphorylation
• In well fed state, the insulin high → gene expression of Glucokinase is high → glucose phosphorylation and
glycolytic pathway facilitated. Low ATP level allosterically activate the reaction
• In fasting state, Glucagon is high → glucose phosphorylation is inhibited and glucose -6-phosphate
conversion in to free glucose is facilitated.
2. PFK-1
• In well fed state, the insulin high → kinase action of PFK-2 activated. Fructose -2, 6-biphosphate
production increased.it allosteric ally activates action of PFK-1.
•And high AMP and low ATP also facilitate above action and glycolysis facilitated.
•In fasting state, Glucagon is high → phosphatase action of PFK-2 activated. Fructose -2, 6-biphosphate
production inhibited.
allosterically activate action of PFK-1 is absent.it facilitate the action of Fructose 1-6 bisphosphatase.
• And high ATP amount due to FA oxidation in fasting also inhibit the PFK-1 action.
•GNG facilitated.
3. PK
• In well fed state, the insulin high → cAMP production low.
Protein Kinase action low.PK phosphorylation inhibited.
Dephosphorylated PK increased and it is active form. Action of pyruvate kinase and glycolysis facilitated.
• In fasting, high glucagon increase cAMP level and result phosphorylated PK. It is inactive.it facilitate entry
of PEP in to GNG.
1.2) Adenosine deaminase

adenosine Inosine
Deficiency of Adenosine deaminase causes to accumulation of Adenosine and then they converted in to deoxyribo
neucleotide or in to riboneucleotide by salvage pathways. Catalyze by Adenosine Kinase.
If dATP production as deoxyriboneucleotides is elevated , that leads to high amount of dATP.

dATP inhibit action of riboneucleotide reductase.reduction of riboneucleotides in to deoxyriboneucleotides is
inhibited.DNA synthesisi inhibited.low DNA causes to reduction of cell division. That enzyme found in large amount
in lymphocytes.
T, B lymphocytes and NK cells proliferation reduced. Causes to immune system dysfunction.
1.3)
In purine synthesis , synthesis of IMP required the presence of N10 Tetrahydrofolate And folic acid synthesis
required to make Tetrahydrofolate.
-Sulphonamides are structural analogues of Para Amino Benzine Acid (PABA)
-PABA involved in synthesis of Folic Acids.therfor , they can inhibit the synthesis of Folic Acid and inhibt synthesis of
neucleic acid in cell which synthesis Folic acid.

But human cells do not contain enzymes for synthesis of folic acid.therefor Sulphonamides cannot act in human cells
and they cannot inhibit neucleic acid synthesis in human cells.
1.4) * Act as reducing agent in reductive biosynthesis of

• Cholesterol
• Fatty Acids
• Steroid hormones
* Preventing cellular damages from the Reactive Oxygen Species.
* Act as reducing agent in detoxification of xenobiotics from Cytochrome p 450 Monooxygenase system.
- Enzyme complex found in smooth endoplasmic reticulum. They hydroxylate xenobioics and make them more water
soluble .then they can be excreted via urine.
* Act as a substrate for the production of NO by the reaction that catalyzed by NO synthase.
NO act as neurotransmitter, a vasodilator, prevents platelet aggregation
2)2.1)
This is the major pathway for catabolism of saturated fatty acids which occur in mitochondria.
2 carbon units are removed from carboxyl end of fatty acyl CoA producing acetyl CoA, NADH, and FADH2.
Transport of fatty acid chain to mitochondrial matrix.

At first, fatty acid is incorporated with CoA to form fatty acyl CoA by fatty acyl CoA synthetase which is an outer
mitochondrial enzyme.
CoA derivative is impermeable through inner mitochondrial membrane, so transport occurs via a special transporter.
Acyl group is transferred from CoA to carnitine by carnitine palmitoyltransferase 1, an enzyme in outer
mitochondrial membrane. This reaction forms an acylcarnitine an regenerates free CoA.
Acylcarnitine is transported to mitochondrial matrix in exchange for free carnitine by carnitine acylcarnitine
translocase

Carnitine palmitolyltransferase 2 is an inner mitochondrial enzyme which catalyzes the transfer of the acyl group
from carnitine to CoA regenerating free carnitine.
Beta oxidation
For palmitic acid, above cycle is repeated for 7 times until the whole chain is converted
to acetyl CoA.
The yield from one palmitic acid molecule is 8 acetyl CoA molecules, 7 NADH, 7 FADH, from which
131 ATP is generated. As activation of fatty acid requires 2 ATP, the net yield is 129 ATP.
Regulation
• CPT-1 is inhibited by malanoyl CoA.
As acetyl CoA:CoA ratio increases, thiolase reaction decreases
2.2)
Transamination is the process which transfers the alpha amino group of an amino acid to alpha ketoglutarate
producing an alpha keto acid and glutamate.
This process is catalysed by enzymes called aminotransferases which are found in cytosol and mitochondria.
All amino acids except lysine and threonine undergo transamination.
Aminotransferases
Each aminotransferase is specific for one or few amino group donors. Two important aminotransferases are alanine
aminotransferase (ALT) and aspartate aminotransferase (AST).
All aminotransferases require the coenzyme pyridoxal phosphate(vitamin B6 derivative).

ALT:
catalyzes the transfer of the amino group of alanine to alpha ketoglutarate forming pyruvate and glutamate.
AST:
catalyzes the transfer of the amino group of aspartate to alpha ketoglutarate forming oxaloacetate
and gutamate.
These enzymes are intracellular enzymes with low levels found in plasma. Elevated levels indicate damage to cells
rich in theses enzymes.
AST and ALT levels increase in hepatic diseases. ALT is more specific than AST for liver disease. These enzymes are
also elevated in non hepatic diseases that cause damage to cardiac or skeletal muscle.
2.3)
Liver in fed state
In fed state liver is rich in glucose which is absorbed by GIT.
Carbohydrate metabolism:
• Increased glucose phophorylation occurs due to elevated glucose levels in hepatocyte.
• Increased glycogenesis occurs by conversion of glucose-6-phosphate to glycogen by glycogen synthase activation
• Pentose phosphate pathway activity is increased
• Glycolysis is increased
• Glucose production is decreased by inhibition of gluconeogenesis and glycogenolysis.
Fat metabolism:
• Fatty acid synthesis and TAG synthesis are increrased
Amino acid metabolism:

• Amino acid degradation is increased and protein synthesis is increased
Brain in fed state

Brain exclusively uses glucose during fed state

1. Select the true statements regarding the events that occur in the liver during fasting,
A) Activation of a tyrosine kinase.
B) Activation of glycogen phosphorylase.
C) Synthesis of Malonyl-CoA.
D) Activation of a Gs protein.
E) Phosphorylation of hormone-sensitive lipase.
2. Select the true statements regarding the synthesis of 5-phosphoribosyl-1-pyrophosphate (PRPP),

A) It is inhibited by purine ribonucleotides.
B) It occurs primarily in the cytosol of liver.
C) It is the committed step of purine synthesis.
D) It is catalyzed by PRPP carboxylase.
E) It is activated by inorganic phosphate.
3. Select the true statements regarding the fructose metabolism,

A) Hexokinase needs, high concentration of intracellular fructose for phosphorylation.
B) Hereditary aldolase B enzyme deficiency causes fructose intolerance.
C) Insulin is needed for fructose transport in cells.
D) Fructokinase has low Vmax for fructose.
E) The rate of fructose metabolism is higher than glycolysis.
4. Select the true statements,

A) Resting muscle uses glycogen as its major fuel source during fasting.
B) Skeletal muscle and liver use fatty acids as their major fuel during fasting.
C) Chylomicrons enter the blood within 1 to 2 hours after ingestion of a meal.
D) During prolonged fasting two-third of the energy is supplied by ketone bodies.
E) Increase in insulin /glucagon level results in the inhibition of acetyl CoA carboxylase.
5. Select the true statements regarding the pyrimidine synthesis,

A) Requires glycine as a carbon donor.
B) Carbamoyl phosphate synthetase II is the regulatory enzyme of it.
C) The parent product is uridine monophosphate (UMP).
D) It has a shorter pathway than for purines.
E) The pathway starts with ribose 5 phosphate.
6. Select the true statements regarding the glucose 6 Phosphate dehydrogenase (G6PD),
A) NADPH is a potent competitive inhibitor of the enzyme.
B) It is involved in the production of ATP.
C) Its deficiency results in hemolysis due to oxidative stress.
D) It converts 6-phosphogluconolactone to 6-phosphogluconate.
E) It is the rate-limiting enzyme of pentose phosphate pathway.
7. Select the true statements regarding the well-fed state,

A) Acetyl CoA is elevated.
B) Insulin stimulates the transport of glucose into hepatocytes.
C) Hepatic fructose 2,6-bisphosphate is elevated.

D) Most enzymes that are regulated by covalent modification is in the phosphorylated state.
E) The synthesis of glucokinase is enhanced.
8. Select the true statements regarding the glycogenesis,

A) It requires Vitamin B6 as the coenzyme.
B) It is stimulated by glucose 6-phosphate.
C) It is an endergonic pathway.
D) It produces glucose-1-phosphate as the final product.
E) It occurs in the mitochondrial matrix.
9. Select the true statements regarding the hexokinase enzyme,

A) It has a high affinity for glucose even in low blood glucose concentration.
B) It is strongly inhibited by glucose 6 phosphate.
C) It is a multi-enzyme complex.
D) It is mainly found in the liver.
E) It is able to phosphorylate hexoses.
10. Select the true statements regarding the fatty acid synthesis,
A) It supplies ATP for gluconeogenesis.
B) It is activated by insulin.
C) It requires a multi-enzyme complex.
D) CO2 is used for biosynthesis.
E) Malonyl CoA converted to Acetyl CoA in cytosol.

A) Homogentisate accumulates in albinism.
B) Methionine and its metabolites are elevated in homocystinuria.
C) Individuals deficient in cystathionine β-synthase exhibits ectopia lentis.
D) Patients with Maple syrup urine disease excrete urine with musty odor.
E) Phenylketonuria patients show hypopigmentation in skin, hair, and eyes.
12. Select the true statements regarding the aminotransferases,

A) They are highly reversible.
B) They use ATP.
C) Their levels in serum are used as a clinical measure of tissue damage.
D) They use tetrahydrofolate as a carrier of amino groups.
E) They can make an α-ketoacid from an α-amino acid.
13. Select the true statements regarding the classic galactosemia,

A) It occurs due to hereditary galactokinase deficiency.
B) It can be managed by reducing lactose diet.
C) It causes the accumulation of galactitol in lens causes cataract.
D) Antenatal diagnosis is possible by chorionic villus sampling.
E) It is an autosomal recessive disorder.

A) The biosynthesis of cholesterol in the liver is enhanced by dietary cholesterol intake.
B) Unsaturation at the 9th carbon of palmitic acid is possible in human.

C) Carnitine acyl carrier system is inhibited by long-chain fatty acids.
D) In Niemann-Pick disease, sphingomyelin is found in highest concentration.
E) Heart muscles utilize fatty acids in preference to glucose.
15. Select the TRUE statements regarding the urea synthesis

A) All the reactions take place in mitochondria.
B) The second N atom is derived from aspartate.
C) The enzyme ornithine transcarbamylase is connected with the formation of citrulline from ornithine.
D) The ornithine formation from arginine is the rate-limiting step.
E) 2 moles of ATP are utilized.
SBR
16. A 45-year-old man who has a mild heart attack is placed on diet and mevastatin therapy to reduce her
cholesterol. This drug is effective due to direct inhibition of which of the following?
A) Medium chain Acyl-CoA dehydrogenase (MCAD)
B) HMG-CoA synthase.
C) HMG-CoA reductase.
D) Carnitine acyltransferase 1 (CAT-1)
E) Citrate lyase
17. A newborn infant presents with lethargy, and a blood test indicates hyperammonemia. In addition,
hypercitrullinemia is also found. The most likely enzymatic defect is,
A) N-acetylglutamate synthase
B) Argininosuccinate lyase
C) Carbamoyl-phosphate synthetase I
D) Arginase
E) Argininosuccinate synthetase
18. UDP-Galactose is a donor of galactose units in a number of synthetic pathways, except the synthesis of,
A) Lactose
B) Glycoproteins
C) Glycolipids
D) Glycosaminoglycans (GAGs)
E) Glycogen
19. Which of the following enzymes does not involved in alcohol metabolism?
A) Enolase
B) Catalase
C) Cytochrome P450 (CYP2E1)
D) Alcohol dehydrogenase (ADH)
E) Aldehyde dehydrogenase (ALDH)
20. A clinical procedure whereby a sterile needle and syringe are used to drain fluid from a joint known as,
A) Lumbar puncture
B) Phlebotomy
C) Amniocentesis
D) Paracentesis
E) Arthrocentesis

1.
1.1 Briefly describe the hormonal regulation of glycogen metabolic pathways during fasting state. (30 marks)
1.2 State the importance of glycolysis and gluconeogenesis. (20 marks)
1.3 Briefly explain why ethanol used as antidote for methanol poisoning. (10 marks)
1.4 Outline the biochemical basis of the following conditions in relation to altered nucleotide metabolism
1.4.1 Gouty arthritis. (20 marks)
1.4.2 Severe combined immune deficiency (SCID). (20 marks)
2.
2.1
2.1.1 Describe the metabolism of phenyl alanine. (15 marks)
2.1.2 Add a note inborn errors associated with it. (15 marks)
2.2 Discuss ketone bodies under the following topics

2.2.1 Composition (5 marks)
2.2.2 Synthesis (20 marks)
2.2.3 Utilization (15 marks)
2.3.m Describe the biochemical action of insulin in metabolism of,

2.3.1 Carbohydrate (15 marks)
2.3.2 Lipid (10 marks)
2.3.3 Protein (5 marks)
01 A- F
B- T phosphorylates glycogen and yields glucose.
C- F FA synthesis is inhibited FA breakdown occurs. (Malonyl-CoA is an intermediate of FA synthesis)
D- T glucagon acts via a G-protein complex.
E- F hormone sensitive lipase is activated instead of shutdown.
02
A- T theory
B- T theory
C- F formation of 5-phosphoribosylamine is the committed step.
D- F PRPP synthetase is the related enzyme.
E- T theory
03
A- T high Km and low Vmax for fructose nature shown by hexokinase.
B- T accumulation of fructose-1-phosphate without a negative feed back mechanism will result in fructose
intolerance.
C- F insulin is only needed for glucose.

D- F it has high Vmax.
E- T since having a bypass for fructokinase enzyme’s step and results in accelerated production of intermediates for
pay-off phase of glycolysis.
04
A- F glycogen is not easily used for energy during fasting.
B- T
C- T theory
D- T body organs adapts for usage of ketone bodies in preference to glucose.
E- F insulin is an anabolic hormone. So, it rather activates acetyl Co-A carboxylase than inhibition.
05
A- F glycine is a nitrogen atom donor.
B- T theory
C- T theory
D- T
E- F first the ring structure is formed then the ribose is added.
06
A- T theory-feedback inhibition.
B- F neither ATP formed nor consumed.
C- T lack of the enzyme results in collapse of antioxidant system and hence results in damage of cell membrane due
to the unopposed effect of free radicals.
D- F conversion of glucose-6-phosphate to 6-phosphoglucanolactone.
E- T theory
07
A- F need of glucose rather than need of Energy. So, breakdown of glucose isn’t favored. So low level of Acetyl CoA.
B- F insulin has no effect on liver by facilitating transport of GLUT-4 transporters unlike in other cells. But in liver it
induces the transcription glucokinase enzyme.
C- T intracellular signal of glucose abundance.
D- F main hormone at action during well-fed state is insulin. It rather dephosphorylates the enzymes in
phosphorylated state.
E- T by the action of insulin.
08
A- F glycogenesis requires vitB6 as the coenzyme for glycogen phosphorylase.
B- T theory
C- T theory
D- F theory
E- F theory
09
A- T low Km high Vmax
B- T theory
C- F
D- F mainly in cells other than liver.
E- T glucose, fructose, galactose can be phosphorylated.

10
A- F irrelevant fact
B- T theory
C- T theory
D- T CO2 is provided in the form of acetyl Co-A
E- F the opposite reaction occurs.
11
A- F theoretically tyrosinase enzyme deficiency results in albinism. So unconverted tyrosine accumulates.
B- T theory
C- T theory
D- F
E- T Alkapton bodies
12
A- T theory
B- F
C- T for MI and liver disease.
D- F
E- F
13
A- F
B- T
C- T
D- T
E- T
14
A- F actually inhibits
B- T
C- T
D- T
E- T
15
A- F some reactions occur in cytosol as well.
B- T
C- T
D- F
E- F 3moles of ATP
16 C
17 E
18 E UDP-Glucose is the donor for glycogen synthesis

19 A enolase is an enzyme of glycolysis
20 E
1)1.1 Hormonal regulation of glycogen metabolism during fasting state
1)1.1 Hormonal regulation of glycogen metabolism during fasting state
During fasting stage blood glucose level is low. As the brain only uses glucose as its energy source ,glucosee should
be increased in circulation. During fasting glucagon and epinephrine is more dominant. Glucagonn and epinephrine
are bound to G-protein coupled receptors on the cell membrane. Activation of G-protein converts ATP to CAMP.
CAMP activates protein kinase A
protein kinase A
glycogen synthase glycogen

(active)
synthase (inactive)
protein phosphatase I
Protein kinase A phosphorylates glycogen synthase. Glycogen synthase is inactive at the phosphorylated
stage.So,little or no glycogen synthesis during fasting.
Protein kinase
CO2glycogen glycogen phosporylase

phosphorylase (inactive) (active)
protein phosphatase I
Protein kinase A, phosphorylates glycogen phosphorylases glycogen phosphorylase is active in phosphorylated

state.So,fasting results in increased glycogenolysis.
1.2 Importance of glycolysis and gluconeogenesis

Glycolysis is the process which supplies a pyruvate for further energy yielding pathways such as TCA cycle.It is an
aerobic process and erythrocytes use glycolysis to produce its required energy. IT liberates 2 ATP as energy .IT
provides important intermediates such as Dihydroacetone phosphate can give glycerol 3 –P which is used in
lipogenesis
3 phosphoglycerate which is used to synthesise serine

Pyruvate used to alanine synthesis

Gluconeogenesis meets the needs of the body for glucose and maintains glucose homeostasis, when carbohydrates
not available sufficient amounts,Some tissues such as brain,RBC,lens,cornea and kidney medulla requires continuous
supply of energy. As glycogen store starts depleting, gluconeogenesis takes place which ensure the continuous
supply of glucose to brain and other tissues. It is used to clear the products of metabolism of other tissues.
Ex lactase, produced by aerobic respiration glycerol
Propionyl –CoA produced by oxygenation of odd chain fatty acids and carbon skeleton of some amino acids.
1.3 Why ethanol used as antidote to methanol poisoning?

alcohol alcohol
dehydrogenase dehydrogenase
methanol formaldehyde
formic acid
H2O CO2
Formic acid is poisonous to the body. It causes metabolic acidosis, and optic injury. During methanol poisoning
ethanol is given as an antidote. Ethanol works as a substrate to alcohol dehydrogenase enzyme with methanol. So,
behalf of methanol ethanol is metabolised and make less harmful intermediates in the body.
alcohol
dehydrogenasepr
ethanol acetaldehyde H2O
So, its end products and intermediates are less harmful, and it can be used as an antidote
1.4 Gouty arthritis normal uric acid male 3-7mg/dl female 2-5mg/dl . Disorder purine nucleotide metabolism due to
excessive production of uric acid
Gout can be resulted due to,

 Increased PRPP synthase
 Increased glutamyl amidotransferase
 HGPRT deficiency
 Glucose –6-phosphatase deficiency
 Increased activity of glutathione reductase
Due to above causes purine degradation is increased. Increased uric acid production .That uric acid crystals or
monosodium urate is precipitated in the joints. That results in gouty arthritis.
Results in
▫ renal stones (urate crystals)
▫ hyperurecemia
1.4.2 severe combined immune deficiency (SCID)
Severe combined immune deficiency is resulted due to deficiency of adenosine deaminase (ADA)enzyme. It may be
autosomal recessive of X-linked recessive disorders.
5'
ribonucleotide
APRT
Adenosine AMP adenosine
PRPP PP2 adenosinedeaminase(ADA)
IMP
Deficiency of ADA or decreased activity of them adenine salvage pathway is altered.So,adenosine and deoxy
adenosine are increased .Adenosine monophosphate and deoxyadenosine mono phosphates are increased.AMP are
converted into ATP .So ,ATP in the clls increases .Increased ATP binds with ribonucleotide reductase and activates
with dAMP are converted to deoxy ATP and as dATP is increased,it decreases the ribonucleotide reductase activity
.So ,the activity of ribonucleotide reductase is suppressed.So, the production of other deoxy ribo nucleotides are
inhibited and decreases.That decreases DNA synthesis.Both humoral and cell mediated immunity is suppressed due
to decreased proliferation of T and B lymphocytes.
2)2.1.1 Metabolism of phenylalanine

Phenylalanine is an essential aminoacid. It converts to tyrosine by phenyl alanine hydroxylase with the help of O2,
H2O and BH4.Tyrosine is non-essential amino acid. If phenylalanine is present

BH4 is a coenzyme for phenylalanine hydroxylase.BH2 is reduced to BH4 by dihydrobiopterine reductase (DHPR)
Formed fumarate can be used in gluconeogenesis and TCA cycle. Acetoacetate is led to fat synthesis.Tyrosine is led
through various separate pathways to produce melanin,dopamin, catecholamines and thyroid hormones.
2.1.2 Inborn errors associated with it

 Phenylketonuria
Autosomal recessive defect in phenylalanine hydroxylase
phenylalanine hydroxylase
phenyl alanine tyrosin
e
BH4 BH2
BH2 reductase
NADP NADPH
Mousy odor in urine due to phenylalanine breaksdown metabolites.

Mental retardation failure to walk and talk ,growth failures seizures and tremors.
Affect on pigmentation due to low melanine production
 Alkaptonuria
 Dark color urine
 Defect in homogenisate oxidase
 Homogenisate is increased in the body .That excess homogenisate is converted into alkapton,which is
deposited in connective tissue,bones and various tissues(ochrosis)
 Tyrosinemia
 Increased tyrosine in blood
 Mainly due to deficiency in tyrosinaminase
2.2 ketone bodies

i) 2.2.1 composition
ii) 2.2.2 synthesis
iii) 2.2.3utilisation
Ketone bodies are used as energy compunds .ketone bodies are acetone,acetoacetate and β hydroxybutarate.
Normal ketone body level in blood is <1mg/dl.Ketone bodies synthesised in mitochondria of hepatocytes .High level
of acetyl CoA leads to ketogenesis.

 Utilisation
Produced acetone is more volatile .So,it is not metabolised in the body.Exhaled through lungs.Utilisation of β-
hydroxybutarate is in extrahepatic tissue.No utilisation in live and RBC.ketone bodies are used in fasting as a energy
compound mainly in CNS.
β-hydroxybutarate transported into blood through SLCI6AG transported.It is transported dissolving in blood to
effector sites. In the brain it crosses blood brain barrier through MCT-1 and MCT-2.In other tissues it simply passes
through CM.
2.3 biochemical action of insulin in metabolism of

™ 2.3.1 carbohydrates
™ 2.3.2 lipids
™ 2.3.3 protein
2.3.1 Insulin promotes carbohydrate storage in 3 tissues; in liver and muscles it increases glycogen synthesis, in
muscle and adipose tissue increases glucose uptake by more GLUT-4. Insulin inhibits gluconeogenesis and
glycogenolysis. Pancreatic β cells contain GLUT-2 transporters and have glucokinase activity and thus can
phosphorylate glucose in amount s proportional to its actual concentration in blood. Ingestion of carbohydrate rich
meals lead to a rise in blood glucose, which increases insulin secretion and decrease glycogen secretion.
Insulin increases the glucose uptake into cells by GLUT-4 action in muscles. It increases glucose uptake in the liver
and insulin inactivates glycogen phosphorylase by dephosphorylating it. That inhibits glycogenolysis. Insulin
increases the activity of glucokinase in liver to increases glucose trapping in cells. It increases glycogenesis by

dephosphorylating glycogen synthase which is active in dephosphorylated stage. It activates PFK-1which is the rate
limiting step of glycolysis by dephosphorylating it to increase glycolysis process.
During well fed state,
o Insulin/glucagon is high
o Insulin activates phosphodiesterase
Phosphodiesterase
ATP 5'AMP CAMP
inhibits gluconeogenesis
by covalent modification glycogen synthase
No phosphorylation
(active)
glygogen phosphorylase
PFK-1
(inactive)
Active
2.3.2 Insulin inhibits the action of hormone –sensitive lipase that decreases the hydrolysis of triglycerides stored in
adipose tissue. Insulin promotes glucose transport through the cell membrane into the fat cells. some of this glucose
is then used to synthesize minute amounts fatty acids but forms large amounts of α-glycerol phosphate to form
more fat stores by synthesising triglycerides.
Increased insulin/glycogen ratio dephosphorylates HMG- CoA reductase and activate increase cholesterol synthesis.
2.3.3
Insulin promotes protein synthesis and storage. Insulin stimulates transport of many amino acids into the cells. It
increases the translation of m-RNA thus forming more proteins. Over a long time of high insulin expression is
occurred. Insulin inhibits the catabolism of proteins

1. Regarding metabolism in the human body,

A) Can be regulated by controlling gene expression of enzymes
B) It helps in conversion of food to energy to run cellular processes
C) It accumulate the metabolic wastes in body
D)
E) They are non-compartmentalized
2. Regarding the role of glucagon on gluconeogenesis,

A) acts through G protein coupled receptors
B) Increase the level of Fructose-2,6 biphosphate
C) Increase the transcription of phosphoenolpyruvate kinase
D) Inhibit the conversion of pyruvate kinase to active
E) Promote mobilization of amino acid from muscle protein
3. Pentose phosphate pathway,

A) Helps in detoxification processes in liver
B) is a catabolic process
C) Occur in Endoplasmic reticulum
D) Rapidly dividing cells require more ribose-5-P than NADPH
E) Producing more Ribose 5 phosphate than NADPH in hyper replicating cell
4. The Phase 1 reactions of xenobiotic metabolism,

A) Convert lipophilic compounds to hydrophilic compounds
B) occurs through conjugation reaction
C) occurs mainly through cytochrome P450 dependent monooxygenase system
D) happens mainly in kidney
E) needed NADPH and O2
5. Phosphoribosylamine synthesis,
A) happens in mitochondria
B) is activated by intracellular concentration of PRPP
C) is catalyzed by glutamine; PRPP amido transferase
D) is inhibited by high amount of AMP
E) is the committed step of purine degradation
6. Regarding transamination,
A) Ammonia are either consumed or biosynthesis
B) Require Biotin
C) The amino group accepter is keto acid
D) All amino acid can undergo transamination
E) Transamination function both aa catabolism and anabolism
7. Organs involved in glucose metabolism,

A) Brain
B) Liver
C) Pancreas

D) Muscle
E) Adipocytes
8. Cholesterol,
A) Synthesis is inhibited by aspirin
B) is synthesized from Acetyl CoA in mammals
C) is more polar than cholesterol ester
D) Rich in coconut oil
E) Has very short life
9. In phenylketonuria,
A) Enzyme phenylalanine hydroxylase deficient
B) Melanie formation is increased
C) Transmission is autosomal dominant
D) A diet low in phenylalanine recommended
E) Phenylpyruvate is excreted in urine
10. Prostaglandins are,

A) Cyclic fatty acids
B) Stored in tissues
C) Synthesized only in prostate gland
D) 18C
E) involved in inflammatory response
SBR
11. Which of the following enzyme is considered as defect in galactosemia?

A) Gactase
B)
C) Glucokinase
D) Phosphoglucomutase
E) Hexokinase
12. In liver, the accumulation of which of the following metabolites, reduce the inhibitory of ATP in
Phosphofructokinase?
A) Acetyl Co-A
B) Citrate
C) Fructose-1,6 bisphosphate
D) Fructose 2,6 bisphosphate
E) Glucose -6-phosphate
13. The action of which enzyme inhibited by chemotrophic agent during DNA synthesis,
A) CTP synthetase
B) DHF reductase
C) Dehydratase
D) ribonuclease reductase
E) thymidylate synthase

14. In prolonged starvation the main energy source of brain is
A) Ketonbodies
B) Fructose
C) Fatty acid
D) Glucose
E) Amino acid
15. A newborn infant presents with hyperammonemia and hyper citrullinemia, the most likely enzymatic defect is,
A) N-acetyl glutamate synthetase
B) Arginase
C) Arginosuccinate synthase
D) Arginosuccinate lyase
E) Carbamoyl phosphate synthetase I
1.1 Explain the followings,

a. Biochemical consequences of chronic alcoholism. (30 Marks)
b. State Purine salvage pathway and the disorders related to it. (30 Marks)
1.2 Briefly explain Regulation of Fatty acid synthesis (25 Marks)
1.3 A patient was diagnosed as having alkaptonuria

a. Name the defective enzyme (02 Marks)
b. State the changes in urine, on standing, in such patients. Why? (10 Marks)
c. What is ochronosis? (03 Marks)
01)
A T
B T
C T
D –
E F Metabolic compartmentation refers to the differential localization or nonhomogeneous
distribution of biochemical pathways within the cell and is founded in the differential localization of the
enzymes involved.Many metabolic pathways are highly compartmentalized, for example, between different
subcellular organelles. In all eukaryotic cells, compartmentation of metabolism within organelles
concentrates enzymes and metabolites and also separates them, as a means of controlling reactions.
02) A T
B F glucagon causes elevated cAMP and increased level of active protein kinase A. Increased protein
kinase A leads to active fructose 2,6 biphosphatase via phosphorylation of PFK2/FBP2. So, fructose 2,6
biphosphatase converts fructose 2,6 biphosphate into fructose 6 phosphate which leads to decreased level
of fructose 2,6 biphosphate.
C F glucagon, cortisol increase transcription of the gene for PEP carboxykinase. Not PEP kinase.

D T page No.122. In Lippincott
E T. Decreased insulin (increased glucagon )levels favor mobilization of aminoacids from muscle
protein to provide carbon skeleton for gluconeogenesis (page 122)
03)
A. T via NADPH formation.
B. F
C. F In cytosol
D. T For DNA synthesis
E. T
4)
A. F oxidation, reduction, hydrolysis happen in phase I. In phase II, solubility in water is increased via
conjugation process.
B. F
C. T
D. F in liver
E. T O2 is needed for cytochrome P450 system fuctions. Page 149.
05)
A.F in cytosol.
B.T inhibitors- AMP, GMP , Activators- PRPP
C.T
D.T
E. F committed step of purine synthesis.
6)
A. F
B. F pyridoxal phosphate( vit B6). Biotin involves in carboxylation reactions.
C. T mostly alpha ketoglutarate.
D. F except lysine,threonine
E. T
7)
A. T glycolysis
B. T glycolysis,ppp, gluconeogenesis, glycogenolysis
C. T insulin, glucagon secretion
D. T glycolysis, gluconeogenesis, glycogenolysis
E. T glycolysis, ppp
8)
A. F Aspirin inhibits cyclooxygenase
B. T carbon atoms from Acetyl coA, Reducing equivalent from NADPH.
C. T cholesterol ester is more hydrophobic.
D. F cholesterol is an animal sterol. Coconut oil has saturated, monounsaturated and linoleic acid E. F
(not sure)

09)
A. T deficiency of phenylalanine hydroxylase and Tetrahydrobiopterine.
B. F here,tyrosine can’t be formed. So, melanine can’t be formed from tyrosine.
C. F Autosomal recessive
D. T As there is an accumulation of phenylalanine.
E. T phenylpyruvate,phenylacetate,phenyllactate are formed and excreted in urine. They give urine a
characteristic musty odor.
10)
A. T(not sure) prostaglandin comes from oxidation and cyclization of Arachidonic acid which comes
from dietery linoleic acid.
B. F not stored
C. F synthesized in almost all tissues.
D. F 20C(one of the eicosanoids)
E. T
Best response
11) A galactokinase, galactose 1 phosphate uridylyltransferase deficiency leads to galactose
accumulation in blood.
12) D Fructose2,6 biphosphate is the most potent activator of PFK 1 and is able to activate the enzyme
even when ATP levels are high.
13) B Chemotrophic agent refers to anticancer drug. So, methotrexate is an anticancer drug and it
inhibits DHF reductase.
14) A For brain, early days of fasting- glucose(maintained by liver’s gluconeogenesis), prolonged
fasting(2-3 weeks)- Ketone bodies.
15) C (urea cycle)+ there is chart in mahinthan maam’s lecturenotes.
1)
1.1)
A. Alcohol(ethanol) is metabolized in the liver by two oxidation reactions. Ethanol is first converted to
acetaldehyde by alcohol dehydrogenase. Acetaldehyde is subsequently oxidized to acetate by aldehyde
dehydrogenase.The metabolism of alcohol (by both dehydrogenases) involves the consumption of NAD+ &
consequently a high NADH/NAD+ ratio.This is mostly responsible for the metabolic alterations observed in
alcoholism.they are,
01. Pyruvate-> lactate
02. Oxaloacetate -> malate
03. 1,3 bisphosphoglycerate-> glyceraldehyde 3 phosphate.

High concentration of NADH favors the conversion of pyruvate to lactate which may lead to lactic acidosis.
Deficiency of pyruvate leads to inadequate formation of oxaloacetate. This results in depression of
gluconeogenesis leading to hypoglycemia. Reduced oxaloacetate, decreased pyruvate &high NADH cause
suppression of TCA cycle. Acetyl CoA is accumulated, which favors ketogenesis. Increased level of acetyl CoA
causes increased fatty acid synthesis; but fatty acid is not oxidized as NAD+ is low. Fat is accumulated in liver,
resulting in fatty liver.Accumulated toxic effect of acetaldehyde leads to cellular death & replacement by
fibrous tissue. Fibrosis of liver is called Cirrhosis. When liver functions are reduced hepatic coma results.
B.
Purines that result from the normal turnover of cellular nucleic acids, or the small amount that is obtained
from the diet and not degraded, can be converted to nucleoside triphosphates and used by the body. This is
referred to as the salvage pathway for purines. Salvage is particularly important in the brain. The significance
of salvage pathway are Save the fuel, Some tissues and organs such as brain and bone marrow are only
capable of synthesizing nucleotides by salvage pathway. Both enzymes use PRPP as the source of the ribose 5-
phosphate group. The release of pyrophosphate and its subsequent hydrolysis by pyrophosphatase makes
these reactions irreversible. Adenosine is the only purine nucleoside to be salvaged. It is phosphorylated to
AMP by adenosine kinase. (Use the equations to get full marks)
Lesch-Nyhan syndrome: This is a rare, X-linked recessive disorder associated with a virtually complete
deficiency of HGPRT. The deficiency results in an inability to salvage hypoxanthine or guanine, from which
excessive amounts of uric acid, the end product of purine degradation, are then produced. In addition, the lack
of this salvage pathway causes increased PRPP levels and decreased IMP and GMP levels. As a result, GPAT
(the regulated step in purine synthesis) has excess substrate and decreased inhibitors available, and de novo
purine synthesis is increased. The combination of decreased purine reutilization and increased purine
synthesis results in increased degradation of purines and the production of large amounts of uric acid, making
HGPRT deficiency an inherited cause of hyperuricemia. In patients with Lesch-Nyhan syndrome, the
hyperuricemia frequently results in the formation of uric acid stones in the kidneys (urolithiasis) and the
deposition of urate crystals in the joints (gouty arthritis) and soft tissues. In addition, the syndrome is
characterized by motor dysfunction, cognitive deficits, and behavioral disturbances that include self-mutilation
(for example, biting of lips and fingers.)
1.2.
A. Short-term regulation of acetyl CoA carboxylase.
a. By allosteric regulation
Large enzyme exists as inactive protomers (dimer), which can assemble into active filaments (dimer to
polymer).
• Promoted by citrate
• Inhibited by fatty acyl CoA
b. By reversible phosphorylation
• Glucagon stimulates phosphorylation (via cAMP) and thus inactivation of the liver enzyme.
• Adrenalin (epinephrine / norepinephrine) stimulates phosphorylation and inactivation in adipose
tissue
• Insulin activates enzyme by dephosphorylation. Also stimulates glucose uptake & conversion to
Pyruvate & its conversion to acetyl CoA.
B. Long-term regulation of acetyl CoA carboxylase

• High carbohydrate or fat free diet increases synthesis of acetyl CoA carboxylase and fatty acid
synthase which promote FA formation.
• A low-calorie diet or Fasting or high fat diet decreases FA synthesis by reducing synthesis of above
enzymes. (Use the equations to get full marks)

1.3.
A. Homogentisic acid oxidase.
B. Urine sample color changes to black. Bcoz, the urine contains elevated levels of HA, which oxidized
to a dark pigment on standing.
C. Deposition of black pigment in cartilage and collagenous tissue is called ochronosis.

1. Regarding the fructose metabolism,

A) Fructose transporters are insulin dependent
B)
C) Hereditary fructose intolerance is occurred due to deficiency of fructose kinase
D)
E) Sorbitol dehydrogenase found in kidney
2. Causes for hyperuricemia,

A) Decreased level of HGPRT enzyme
B) Increased level of ADA enzyme
C) High turnover of nucleic acid
D) Inhibition of xanthine oxidase
E) Unusually high PRPP
3. Cytochrome P450,
A)
B) Uses Cu ion as a cofactor
C)
D)
E)
4. The direct/indirect inhibitors of glutamate dehydrogenase,

A) AMP
B) Glucose 1-phosphate
C) Epinephrine
D) Insulin
E) Inorganic phosphate
5. Regarding purine synthesis

A)
B)
C) Pentose phosphate pathway supplies ribose-5-phosphate for purine synthesis
D)
E) AMP and GMP control their respective synthesis from IMP by a feedback mechanism
6. Regarding Glutamate dehydrogenase,

A) It purposes to fix nitrogen for Amino acid synthesis
B) It is oxidizing NADH into NAD+ & H+
C) It is inhibited by high concentration of ATP or GTP
D)
E) Oxidation reactions produce H2O2 as a byproduct
7. Disorder of methionine,
A) Cystathionuria
B) Homocystinurea
C) Alkaptonuria

D) Histidinemia
E) Maple syrup urine disease
8. Bile acid contain,

A) Taurocholatel
B) Glycocholate
C) Dihydrocholic acid
D) Glycoprotein
E) Lecithin
9. Fatty acid synthesis

A) Occur in mitochondria matrix
B) Requires NADPH
C) Is catalyzed by fatty acid synthase
D) Is activated by glucagon
E) It requires specific enzymes in endoplasmic reticulum and mitochondria
10. True/False,
A) Chylomicrons released to blood 1 - 2 hours after the ingested meal
B) Resting muscle uses glycogen as its major fuel source during fasting.
C) During prolonged fasting 2/3 of the energy is supplied by ketone bodies
D) Increased insulin/glucagon inhibits Acetyl Co A carboxylase
E) Skeletal muscles and liver uses fatty acid as major fuel in fasting
SBR
11. A 34-year old male has shortness of breath after having treatment of antibiotic. After 4 days of therapy
hematuria on going. Hemoglobin concentration decreased to 7.4g/dL. Bilirubin increased to 4.3mg/dL. Marginal
elevation of LDH also seen. What is the most probable reason?
A) Pyruvate dehydrogenase deficiency
B) Glucose 6 Phosphate dehydrogenase deficiency
C) PhosphoFructoKinase 1
D) Glycogen storage disease
E) Galactocemia
12.
13. A newborn infant presents with hyperammonemia and hypercitrullinemia. The most likely enzymatic defect is,
A) N-acetyl glutamate synthetase
B) Arginase
C) Arginosuccinate synthase
D) Arginosuccinate lyase
E) Carbamoyl Phosphate Synthetase-1
14. In prolonged starvation the main energy source of brain is,

A) Ketone bodies
B) Fructose
C) Fatty acids

D) Glucose
E) Amino acid
15. Carnitine Palmitoyl Transferase-1 is allosterically inhibited by,

A) Citrate
B) Oxaloacetate
C) Acetyl-CoA
D) Malonyl-CoA
E) Carbamoyl Phosphate Synthetase-1
1.
1.1 Briefly describe the regulation of Gluconeogenesis (30 marks)
1.2 Briefly explain how alcohol is metabolized in the body (25 marks)
1.3 State three complications of chronic alcoholism (15 marks)
1.4 A 46-year old male presented to the emergency department with severe right toe pain. The patient did not have
any trauma to the toe and no previous history of such pain in other join. The right big toe was swollen, warm, red
and tender. Synovial (joint) fluid was obtained and revealed rod- or needle-shaped crystals.
1.4.1 What is the most likely diagnosis? (05 marks)
1.4.2 Give the reasons for the diagnosis? (05 marks)
1.4.3 What is the biochemical basis for the above condition? (10 marks)
1.4.4 State the probable treatment on the biochemical basis. (10 marks)
2.
2.1 A 5-month old female infant was hospitalized. A diagnosis of classic phenylketonuria (PKU) was made,
2.1.1 Name the defective enzyme of classic phenylketonuria. (05 marks)
2.1.2 Briefly describe the characteristics of PKU? (30 marks)
2.1.3 Name diagnostic test for PKU. (05 marks)
2.1.4 What is the probable treatment? (10 marks)
2.2 Compare fatty acid breakdown and synthesis (30 marks)
2.3 Briefly describe the role of liver and adipose tissue in starvation. (20 marks)
01
A. F – Fructose transport in cells is not insulin dependent
B.
C. F – Deficiency of Aldolase – B
D.
E. F – Found in ovaries, seminal vesicles and liver

02
A. T
B. T
C. T
D. F
E. T
04
A. F GH is inhibited by ATP, GTP
GH is stimulated by ADP, GDP, Leu and other aa
B.
C.
D.
E.
05
A.
B.
C. T
D.
E. T
06
A.
B. F
C. T
D.
E. F
07
A. F
B. T
C. F absence of homogentisate oxidase
D. F defect of branched chain dehydrogenase
E. F
08 The major components of the bile acid pool are cholic and chenodeoxycholic acid with lesser amounts
deoxycholic and lithocholic acid and minor amounts of ursodeoxycholic acid.
A. T
B. T
C. F
D. F
E. F
09
A. F Oxidation occurs in mitochondria. Synthesis occurs in cytosol. (Liver and lactating mammary glands)
B. F NADPH is formed from 1st stage of fatty acid biosynthesis
C. T 3rd stage of fatty acid biosynthesis reactions are catalyzed by fatty acid synthase complex
D. F Glucagon stimulates phosphorylation (via cAMP) and thus inactivation of the liver enzyme

E. F
10
A.
B. During a fast, maintenance of blood glucose levels initially relies on glycogen stores in the liver and
skeletal muscle.
C. T ketone bodies provide the brain with an alternative source of energy, amounting to nearly 2/3 of the
brain's energy needs during periods of prolonged fasting and starvation. In prolonged starvation ¾ or 75% of
brain fuel needs are met by acetoacetate
D. T Acetyl coA carboxylase enzyme converts acetyl CO-A to malonyl coA. Insulin activates enzyme by
dephosphorylation. Also stimulates glucose uptake & conversion to Pyruvate & its conversion to acetyl CO-A
which is then converted to malonyl- CoA
E. During a fast, maintenance of blood glucose levels initially relies on glycogen stores in the liver and
skeletal muscle. 18 – 20 hours period of fasting is enough to use glucose storage as a fuel. Upon depletion of
glycogen, fatty acids are the major fuel source which is converted into ketone bodies
11
Answer B
G6PD helps red blood cells work. It also protects them from substances in the blood that could harm them.
In people with G6PD deficiency, either the red blood cells do not make enough G6PD or what they do make
doesn't work as it should. Without enough G6PD to protect them, the red blood cells break apart.
Degradation of RBC causes reduced Haemoglobin and haematuria.
13
Answer C
Due to arginosuccinate synthetase deficiency the conversion of citrulline to arginosuccinate is inhibited
leading to accumulation of citrulline and due to defective urea cycle results in consequent hyperammonia.
14
Answer A
15
Answer D
1.1 Briefly describe the regulation of Gluconeogenesis (30 marks)
Substrate availability
(Ala, glycerol, lactate)
Energy state
↑ATP / AMP
•Gluconeogenesis stimulated
•PK inhibited
•PEP guided to form glucose

•PFK 1 is inhibited
•F 1,6 Bisphosphatase activated
↓ATP/AMP
•Gluconeogenesis Inhibited
•PK activated
•PFK 1 activated
•F-1,6- bisphosphatase inhibited (01)
ADP ↑
•Pyruvate Carboxylase and PEP Carboxykinase inhibited
Allosteric regulation
Acetyl CoA activates PC
AMP & F-2,6 BP inhibit fructose-1,6-bisphosphatase
Citrate activates Fructose 1,6 Bisphosphatase
F-2,6 Bisphosphate inhibits Fructose 1,6 – Bisphosphate
Covalent Modification
Glucagon,
Phosphorylate Pyruvate Kinase and inactivates it
Phosphorylate PFK 2 and inactivate it. So F 2,6 Bisphosphate level is reduced
Induction & repression

Glucagon induces- F 1,6 BPase - PEPCK - G6phosphatase
Glucagon represses - GK - PFK 1 - PK
1.2 Briefly explain how alcohol is metabolized in the body (25 marks)
•Alcohol is not handled by your body in the same way as food nutrients, like carbohydrates, proteins and fats.
•This is partly because your body doesn't have anywhere to store it.
• If you didn't metabolize it quickly, it would just build up, causing damage to your cells and tissues.
After alcohol is swallowed,

↓
it is absorbed primarily from the small intestine into the veins that collect blood from the stomach and bowels and
from the portal vein, which leads to the liver.
↓
From there it is carried to the liver, where it is exposed to enzymes and metabolized
• The primary enzymes involved are,

alcohol dehydrogenase (ADH)
aldehyde dehydrogenase (ALDH)
cytochrome P450 (CYP2E1)
catalase
Alcohol is readily absorbed by the Stomach & Intestine

Major fraction of the alcohol is oxidized in Liver.
Alcohol gets oxidized in the liver by ADH to Acetaldehyde.
Acetaldehyde is further oxidized to Acetate by a Mitochondrial NAD+ dependent enzyme.

The Acetate is then converted to Acetyl CoA.
MEOS
It is another mechanism of detoxification of Alcohol.
It is Ctochrome P450 dependent & is inducible.
Ethanol can be oxidized in Liver microsomes to Acetaldehyde by mixed function oxidase.
The electron donors are ethanol and NADPH by which O2 is reduced to Water
1.3 State three complications of chronic alcoholism (15 marks)

•High concentration of NADH favors the conversion of pyruvate to lactate which may lead to lactic acidosis.
•Deficiency of pyruvate leads to inadequate formation of oxaloacetate. This results in depression of gluconeogenesis
leading to hypoglycemia.
•Reduced oxaloacetate, decreased pyruvate &high NADH cause suppression of TCA cycle. Acetyl CoA is accumulated,
which favors ketogenesis. Increased level of acetyl CoA causes increased fatty acid synthesis; but fatty acid is not
oxidized as NAD+ is low. Fat is accumulated in liver, resulting in fatty liver.
•Accumulated toxic effect of acetaldehyde leads to cellular death & replacement by fibrous tissue. Fibrosis of liver is
called Cirrhosis. When liver functions are reduced hepatic coma results.
1.4 A 46-year old male presented to the emergency department with severe right toe pain. The patient did not have
any trauma to the toe and no previous history of such pain in other join. The right big toe was swollen, warm, red
and tender. Synovial (joint) fluid was obtained and revealed rod- or needle-shaped crystals.
Gout
1.4.2 Give the reasons for the diagnosis? (05 marks)

Synovial (joint) fluid was obtained and revealed rod- or needle-shaped crystals.
1.4.3 What is the biochemical basis for the above condition? (10 marks)
A disorder due to high levels of uric acid in blood (Hyperuricaemia)
• Occurs as a result of either

1) Overproduction of uric acid
Less common (Mutation in the gene for X linked PRPP synthetase --→ increased UA production
(LyschNyhansyndrome)
2) Under excretion of uric acid ->90%
oPrimary – inherited
o Secondary – lactic acidosis (lactate increases renalreabsorption, decrease uric acid excretion)
Drugs (Thiazide diuretics)
Exposure to lead
• Hyperuricaemia can lead to deposition of monosodium urate(MSU) crystals in the joints
• Inflammatory response to the crystals causing acute and then progressive chronic gouty arthritis
1.4.4 State the probable treatment on the biochemical basis. (10 marks)
• Allopurinol is a structural analog of hypoxanthine
• Inhibits UA synthesis
• Allopurinol oxidizes to oxipurinol, a long lived inhibitor of XO
• Increased accumulation of hypoxanthine and xanthine, more soluble than UA
• Prevent crystal formation and inflammatory response
2.
2.1 A 5-month old female infant was hospitalized. A diagnosis of classic phenylketonuria (PKU) was made,
2.1.1 Name the defective enzyme of classic phenylketonuria. (05 marks)
Phenylalanine Hydroxylase
2.1.2 Briefly describe the characteristics of PKU? (30 marks)

• ↑*Phe+ tissues,plasma,urine
• ↑Phenyl lactate, Phenyl acetate, Phenylpyruvate
• Cause -mental retardation
-failure to talk and walk
-seizers hyperactivity tremor
-microcephaly
-failure to grow
-hypopigmentation because high [Phe] competitively inhibit hydroxylation of Tryosine by tryosinase
2.1.3 Name diagnostic test for PKU. (05 marks)

1. Blood phenylalanine
2. Guthrie test
3. Ferric chloride test – blue green colour
2.1.4 What is the probable treatment? (10 marks)

- *Phe+ ↓ diet
- Tyrosine supplied in diet

PHASE 1 QUESTIONS
8th Batch
8th Proper - MCQs
1. Regarding cellular respiration

A) NAD+ converted into NADH in both glycolysis and Kreb’s cycle
B) Absence of NAD+ lead to defective glycolysis
C) ATP is produced in glycolysis
D) ATP is produced in oxidative phosphorylation
E) Lactic acid converted into pyruvate
2. Cancer cells are dependent on glycolysis for their energy needs. True regarding cancer cells,
A) Fructose-2,6-biphosphate will be low
B) PEP carboxykinase will be active
C) Glucose-6-phosphatase will be active
D) PFK-2 will be active
E) Pyruvate will be converted to OAA in the mitochondrial matrix
3. Regarding galactosemia,
A) Deficiency of Galactose-1-phosphate
B) Galactose kinase deficiency
C) Genetic disorder
D) Occurs due to deficiency of aldolase enzyme
E) It causes severe damage to liver function
4. The oxidative phosphorylation of intact mitochondria is blocked by,

A) Puromycin
B) Oligomycin
C) Streptomycin
D) Erythromycin
E) Dicumarol
5. Odd chain fatty acid degradation leads to the production of

A) Acetyl Co A
B) Malonyl Co A
C) Acetoacetyl Co A
D) Propinyl Co A
E) β hydroxybutarate
6. Amino acid transferases,

A) Make a α-ketoacid from α-amino acid
B) Use pyridoxal phosphate as a carrier of amino group
C) Catalyze reversible reactions
D) Use ATP
E) Serum levels are used as a clinical measure of specific tissue damage

7. Lecithin; Cholesterol acyl transferase
A) Substrates are lecithin and free cholesterol
B) Modifies cholesterol and pack them into lipid membranes
C) is primarily active in skeletal muscles
D) Require Apo AІ as co-factor
E) Transported in circulation bound to HDL
8. Complex IV in electron transport chain

A) Accept electrons from reduced Co enzyme Q
C) Utilize molecular O2 as an electron acceptor
D) is capable of pumping electron from inner mitochondrial membrane
E) Produces H2O
9. A new born is brought to your clinic by his parents tell that their baby is lethargy, vomiting. If you suspected
that the baby has hyper ammonia. Which of the following screen to suspection?
A) Arginosuccinate synthase
B) Carbonyl phosphate synthatase I
C) Ornithine transcarbomyl
D) Glutamate dehydrogenase
E) Carbonyl phosphate synthatase II
10. Which deficiency leads to phenylketonuria?

A) Phenylalanine carboxylase
B) Phenylalanine hydroxylase
C) Phenylalanine dehydroxylase
D) Alanine aminotransferase
E) Glutathione reductase
11. PRPP is a substance for which of the following enzymes?

A) Ribonucleotide synthase
B) Thymidylate synthase
C) Uridine kinase
D) Carbonyl phosphate transferase II
E) Hypoxanthin Guanine Phosphoryposyl Transferase – HGPRT
19. Familial hypercholesterolemia

A) Reduced plasma lipoprotein lipase levels
B) Reduce liver Apo C-II production
C) Increase CVS diseases
D) Increase plasma triglycerol level
E) Reduce plasma VLDL level
SBR
41. Which is the enzyme that is used in reversal of glycolysis that is used for the gluconeogenesis?
A) Pyruvate kinase
B) Phosphoglucuralase

C) Phosphofructokinase
D) Aldolase
E) Glucose 6 phosphate
8th Proper - SEQs
1. A 19-year- old girl presented with history of muscle weakness and poor exercise intolerance. She was
confirmed of having carnitine deficiency after biochemical investigations.
1.1.Explain the biochemical Basis of the muscle weakness and poor exercise intolerance that she presented
with (35 marks)
1.2 Explain how the deficiency of glucose 6 phosphate dehydrogenase may lead to increased excretion of
urobiliogen (40 marks)
1.3 Briefly describe the biochemical abnormalities of alkaptonuria (25 marks)
2. Short notes on,

a) Regulation of cholesterol biosynthesis (40 marks)
b) TCA cycle (35 marks)
8th Repeat - SEQs
1.
1.1 Describe the process of ketogenesis (15 marks)
1.2 How ketone bodies are utilized (15 marks)
1.3 Explain the biochemical basis of the following,
1.3.1. severe diabetics mellitus leads to ketoacidosis (30 marks)
1)
A) T Substrate phosphorylation.
B) T
C) T 𝐺𝑙𝑢𝑐𝑜𝑠𝑒 2𝐴𝑇𝑃 + 2𝑁𝐴𝐷𝐻 + 2 𝑝𝑦𝑟𝑢𝑣𝑎𝑡𝑒
D) T 32 ATP from oxidative phosphorylation.
E) T 𝑃𝑦𝑟𝑢𝑣𝑎𝑡𝑒𝐿𝑎𝑐𝑡𝑎𝑡𝑎𝑒 𝑑𝑒𝑕𝑦𝑑𝑟𝑜𝑔𝑒𝑛𝑎𝑠𝑒→ 𝐿𝑎𝑐𝑡𝑖𝑐 𝑎𝑐𝑖𝑑
2)
A) F Fructose 2, 6-bisphosphate allosterically activate glycolysis
B) F Enzyme in gluconeogenesis.
C) F Found only in hepatocytes.
D) T Lippincott pg. 100 - fig. 8.17
E) F Reaction takes place in gluconeogenesis.
3)
A) T

B) F
C) T Autosomal recessive disease.
D) F Lippincott pg. 141 – fig. 12.5
E) T
4)
A) F Protein synthesis inhibitor.
B) T Prevent oxidative phosphorylation by inhibiting ATP Synthase (complex V)
C) F Antibiotic against bacterial infection.
D) F Antibiotic against bacterial infection.
E) F Anticoagulant.
5)
A) T Lippincott pg. 195 – fig. 16.20
B) F
C) F
D) T
E) F
6)
A) T Transamination. Lippincott pg.250/251 - fig. 19.8/19.9
B) T
C) T
D) F
E) T Lippincott pg.251 - fig. 19.10
7)
A) T also known as phosphatidylcholine – sterol O- aceyltransferase.
B) T
C) T Secreted and produced in liver, active in peripheral tissues.
D) T
E) T Enzyme is synthesized and secreted by liver. Bind to nascent HDL. Activated by Apo A1
8)
A) F From cytochrome c
B) T CN, CO, H2S, NaN3
C) T
D) F Protons are pumped from complex I, III and IV
E) T
9)
A) T Defective urea cycle causes accumulation of NH3 –hyperammonia.
B) T
C) T
D) F
E) F Enzyme in pyrimidine synthesis.

10)
A) F
B) T
C) F
D) F
E) F
11)
A) T
B) F Lippincott pg. 304 – fig.22.23
C) F
D) F Lippincott pg. 303 – fig.22.21
E) T Lippincott pg. 296 – fig.22.10
19)
A) F Type I hyperlipoproteineamia.
B) F Type I hyperlipoproteineamia.
C) T
D) F increase VLDL
E) F
41) ANSWER – D
Pyruvate kinase – glycolysis
Phosphoglucuralase –
Phosphofructokinase – glycolysis
Aldolase – both glycolysis and gluconeogenesis
Glucose 6 phosphatase - gluconeogenesis
1.1 A 19 years old girl presented with history of muscle weakness and poor exercise intolerance .she was conform of
having carnitine deficiency after biochemical investigation .explain the biochemical basis the muscle weakness
and poor exercise intolerance that she present with
from cytosole in to the mitochondrial matrix
hich converted in the cytosole to its co-A derivative by thiokinase
must be transport cross the inner
mitochondrial membrane
-A
e group is transferred from Co-A to carnitine by CAT-I forms acyl carnitine
CAT-II .then release carnitine and form acyl
co-A
-II is inner mitochondrial membrane enzyme
e carnitine enter into the inter membranous space by translocation
–meat product ,diet ,lysine,methionine
fatty acids as fuel

is caused by defect membrane transporter that prevent uptake of carnitine by cardiac
and skeletal muscle and kidney
I. Strick vegetarian
II. Increased carnitine demand
III. CAT I enzyme defect
IV. Poor reabsorption of carnitine by kidney
Symptoms
I. Hypoglycemia
-A level goes up it stimulate pyruvate carboxylase enzyme which catalyze production of OAA from
pyruvate
g chain fatty acid in matrixto produce acetyl co-A through bita

oxidation pathway
II. accumulation of long chain fatty acid in plasma

III. hypoketonemia
IV. muscle fatigue
1.2 Explain how deficiency of glucose 6 phosphate dehydrogenase may lead to increased excreation of urobilinogn
he pentose phosphate pathway
enzyme synthesis well
the reduced glutathione pool

form H2O2
insoluble masses called Heinz body
ne
↓
These RBC are hemolysis in the liver and spleen by reticulo-endothelial cells
↓
Hemolytic anaemia
↓
RBC breakdown to heme and globulin
↓
Globulin reutilized but heme breakdown to biliverdine and Fe+2
↓
Fe+2 reutilize biliverdin converted to bilirubin in macrophages
↓
In the digestive system bilirubin is secreted in the bile to the duodenum
↓
These bilirubin converted into urobilinogen by bacteria in the gut
↓

Due to increased hemolysis the conversion of heme to urobilinogen also increased
↓
Urobilinogen excretion also increased
1.3 Breifly describe the biochemical abnormalities of alkaptonuria
ay of thyrosine
I. Homogentisic aciduria
II. Large joint artheritis
III. Deposition of black pigment
-diets with low levels of phenyalanine and tyrosine
8th Repeat – SEQ ANSWERS
1.1 Ketogenesis
acid oxidation and by glycolysis

releasing one coA and reaction is catalized by
thiolase
-hydroxy-3-methylglutaryl coA (HMG-coA) by using acetyl group from
another acetyl coA
-coA synthase
-coA convert to acetoacetate by releasing acetyl coA
dered as ketone bodies

-hydroxy butarate dehydrogenase by using NADH convert
to 3-hydroxybutarate
1.1 How keton bodies are utilized
ues
-hydroxybutarate considered as ketone bidies
protein to transport
portant energy compound in fasting

1.2 Serve diabetics mellitus leads to keto acidosis
the rate of there use
ise in the blood(ketonemia)
ketone bodies may be as high

s is a fruity ordor on the breath therefore each ketone body loses a
proton as it circulates in the blood which lower than PH
dehydration
in a decreased volume of plasma can cause sever
acidosis(ketoacidosis)
and excessive ethanol consumption
9th Batch
9th Proper - MCQs
1. Pyruvate,
A) Precursors of gluconeogenesis
B) Oxidatively decarboxylated to OAA
C) Is product of threonine catabolism
D) Dehydrogenase enzyme defect cause lactic acidosis
E) Is transported in to mitochondrion by proton antiporter
2. Regarding oxidative phosphorylation

A) Occur in mitochondria and cytosol
B) F0 & F1 has open channel for H+
C) Inhibited by amobarbitol drugs
D) Some drugs block the electron enter to the respiratory chain
E) Oxygen is the final electron donor
3. Gluconeogenesis,
A) Occur in skeleton muscles
B) Is received of glycolysis
C) Is stimulated by glucocorticoids
D) Require NADPH
E) Is increase by increase action of PEP carboxylase
4. Patient suffering from G-6-P dehydrogenation deficiency

A) Increase risk of having Wernicke korsakof syndrome
B) Increase cellular concentration of 6-phosphogluconate
C) Decrease amount of oxidize glutathione
D) Hemolysis following to antimalarial drug
E) Decrease level of NADPH in RBC
5. True/False,
A) Alkaptonuria is due to deficiency of phenylalanine hydroxylase
B) Hartnup disease is due to deficiency of homogensitic acid oxidase
C) Homocystinuria is due to deficiency of cystothionine B synthase
D) Phenylketonuria is due to deficiency of dihydropteridine reductase
E) Maple syrup urine disease is due to deficiency of branched chain alpha keto acid dehydrogenase
6. Regarding the nucleotide metabolism,

A) Nucleotide in food are not utilize by human body
B) Purine nucleotide are degraded to uric acid which serves as a natural
antioxidant in the living system
C) Pyrimidine synthesis requires CPS I enzyme
D) In orotic aciduria administration of uridine results in improvement of the anemia
E) Methotrexate inhibits pyrimidine bio synthesis
7. Ketone bodies,
A) Are synthesis in liver
B) Normally absent in blood
C) Are utilized by RBC in energy
D) Synthesis depend on NADH:NAD+ ratio
E) Disturb the HCO3- buffer system in blood
10. Apolipoprotein B-100 component of,

A) Chylomicron
B) HDL
C) IDL
D) LDL
E) VLDL
11. LDL,
A) Transport cholesterol from the peripheral cells to the liver
B) Contain Apo protein B48
C) Give milky appearance to the plasma
D) In an electric field moves faster than other lipoprotein
E) Contain more phospholipid than other lipoprotein
20. Pentose phosphate pathway

A) Occur in all cells
B) Occur in both cytoplasm & mitochondria
C) Is the main product of the NADPH
D) is important for energy production
E) When it is interrupted, it may effect to phagocyte bacteria
SBR
41. Which of the following is false regarding the beta oxidation & fatty acid synthesis,
A) LPS 11 inhibited by Malonyl CoA
B) Leptin is inhibited by fatty acid synthesis
C) Fatty acid synthesis used NADPH
D) Palmityl inhibit fatty acid synthesis

E) Body synthesis saturated fatty acid
43. A 42-year-lold male patient undergoing radiation therapy for prostate cancer develops severe pain in the
metatarsal phalangeal joint of his right big toe. Monosodium urate crystals are detected by polarized light
microscopy in fluid obtained from this joint by arthrocentesis. Uric acid crystals are present in his urine. This
patient’s pain is directly caused by the overproduction of the end product of which of the following metabolic
pathways?
A) De novo pyrimidine biosynthesis
B) Pyrimidine degradation
C) De novo purine biosynthesis
D) Purine salvage
E) Purine degradation
44. A medical student continuously studying without taking any meal for 24 hour during this main source of
energy for him is,
A) Ketone body from liver
B) Glycogen degradation of muscle
C) Beta oxidation
D) Gluconeogenesis
E) Fatty acid from adipose tissue
45. Conjugated hyperbilirubinemia is seen in,

A) Hemolytic jaundice
B) Neonatal jaundice
C) Crigler-Najjar syndrome
D) Gilbert syndrome
E) Post hepatic jaundice
9th Proper - SEQs

1.
1.1 What are “anaplerotic reaction” (10 marks)
1.2 List 3 anaplerotic reaction (20 marks)
1.3 “Fats burn in fire of carbohydrate” briefly explain the biochemical basis for this statement
(35 marks)
1.4 Describe the integration between urea cycle and TCA cycle (35 marks)
2.
2.1 Describe the chylomicron metabolism (30 marks)
9th Repeat – SEQs
1.
1.1 Explain the chemiosmotic theory with necessary diagrams. (35 marks)
1.2 Outline the importance of HMP shunt pathway. (25 marks)
1.3 Briefly outline the step of beta-oxidation of palmitic acid and state how the pathway is regulated. (40 marks)

1)
A) T Precursor of gluconeogenesis
B) F By carboxylation
𝑃𝑦𝑟𝑢𝑣𝑎𝑡𝑒→ 𝑂𝐴𝐴 by 𝑃y 𝑟𝑢𝑣𝑎𝑡𝑒 𝑐𝑎𝑟𝑏𝑜𝑥𝑦𝑙𝑎𝑠𝑒
C) T Lippincott pg. 261 fig. 20.1
D) T
𝑃𝑦𝑟𝑢𝑣𝑎𝑡𝑒𝑃𝐷𝐻 𝑐𝑜𝑚𝑝𝑙𝑒𝑥→ 𝐴𝑐𝑒𝑡𝑦𝑙 𝑐o 𝐴
Deficiency of action of PDH complex shifts pyruvate into lactic acid and cause lactic acidosis.
E) F
Pyruvate transported across the inner mitochondrial membrane by pyruvate translocase which is a proton
symporter.
2)
A) F Oxidative phosphorylation; synthesis of ATP by the energy produced as electrons are transported down
the ETC Takes place only in mitochondria (in all tissues that contain mitochondria)
B) T Complex V (Lippincott pg. 78)
C) T Amorbarbital = amytal → blocks complex I
D) T Amytal, rotenone → Complex I
Antimycin A → Complex II
CN-, CO, H2S, NaN3→ Complex IV
E) F O2 is the final electron acceptor.
3)
A) F During an overnight fast
90% of gluconeogenesis occurs in liver
10% of gluconeogenesis occurs in kidneys
B) F Not a simple reversal of glycolysis. 3 irreversible reactions of glycolysis
C) T
D) F
E) F PEP caboxykinase
4)
A) F G6PD deficiency > hemolytic anemia + neonatal jaundice
Thiamine deficiency > wernike-korsakoff syndrome
B) F Pentose phosphate pathway won’t proceed forward.
C) F G6PD deficiency > reduced NADPH + reduced concentration of reduced glutathione
D) T Oxidant drugs (AAA) – are precipitating factors of G6PD deficiency and produce hemolytic anemia
1. Antibiotics
2. Antimalarials
3. Antipyretics
E) T
5)
A) F Alkaptonuria > deficiency in homogenestic acid oxidase
B) F Hartnup disease > defect in transport of tryptophan
C) T Homocysteinuria > defect in enzyme cystathione B-synthase

D) F Phenylketonuria > deficiency of phenylalanine hydroxylase
E) T Marple syrup urine disease > deficiency of BCKD (branched chain α-ketoacid dehydrogenase)
6)
A) F Enzymes > nucleotidases/nucleosides/ nucleases
B) F Excretory product of nucleotide catabolism
C) F CPS I in urea cycle. Pyrimidine synthesis requires CPS II (Lippincott fig. 22.20 pg.302)
D) T
E) F Purine synthesis inhibitor; folic acid analogues. (Lippincott pg.294 fig. 22.7)
7)
A) T
B) F Transport via blood
C) F In RBC energy generated only by glycolysis
ketogenesis increase
E) T
10)
A) F Apo B-48 > chylomicron
Apo B-100 > LDL, IDL, VLDL
Apo A-1 > HDL
B) F
C) T
D) T
E) T
11)
A) F HDL > transport cholesterol from peripheral cells to liver
LDL > transport cholesterol from liver to peripheral cells
B) F
C) F Milky appearance is given by chylomicrons
D) F Lippincott pg. 228 – fig. 18.15
E) F Lippincott pg. 232 – fig. 18.19
41) ANSWER – A
CPS-II is an enzyme in pyrimidine synthesis.
Activated by PRPP and inhibited by UTP.
43) ANSWER – E
The patient’s pain is caused by gout, resulting from an
inflammatory response to the crystallization of excess uric acid in his joints. Radiation therapy caused cell death,
with degradation of nucleic acids and their constituent purines. Uric acid, the end product of purine degradation, is a
relatively insoluble compound that can cause gout and kidney stones. Pyrimidine metabolism is not associated with
uric acid production. Overproduction of purines can indirectly result in hyperuricemia. Purine salvage decreases uric
acid production.

44) ANSWER – D
During the first 10-18 hrs of a fast glucose is given by Glycogenolysis. After that it is taken up by gluconeogenesis.
45) ANSWER – E
1)1.1 a. Anaplerotic reaction are replenishment of intermediates of TCA cycle that are remove to serve as
biosynthetic precursors.it maintain concentration of intermediates almost constant.
1.2 “fat burn in the fire of carbohydrates” means fat can only be oxidized in the presence of carbohydrates.
Acetyl CoA is the major production of fatty acid β oxidation. This acetyl CoA is completely oxidized by entering TCA
cycle.
Acetyl Co A
OAA Citrate
Citrate synthase
So that, acetyl CoA can enter the TCA cycle only in presence of OAA. Pyruvate is mainly used for anaplerotic reaction
to replenish OAA which is removed as biosynthetic precursor.
OAA is also formed by the transamination of aspartate.
But aspartate also uses formation of pyrimidine, purine and urea.
So, concentration of OAA is mainly maintained by the pyruvate.
Pyruvate is mainly formed by the glycolysis.
So without carbohydrates pyruvate cannot form and replenishment of TCA cycle intermediates are impaired.
Therefore TCA cycle blocked and acetyl CoA cannot be oxidized.
So that carbohydrates are important for fat metabolism.
1.3

Aspartate participates in urea cycle for condensation with citrulline to form argino succinate.
In the subsequent reaction, argino succinate undergoes a lytic reaction to form arginine and Fumarate.
Fumarate forms the link between TCA cycle.
Fumarate can be recycled to forms OAA, through intermediate formation of malate that can be transaminated to
form asparate, to get reutrilized in the urea cycle.
3)3.1
•Chylomicrons are assembled in intestinal mucosal cells and carry dietary (exogenous) TAG, cholesterol, fat-soluble
vitamins, and cholesteryl esters to the peripheral tissues .
•Apo B-48 is unique apolipoprotein to chylomicrons.
•Assembly of the apolipoproteins and lipid into chylomicrons requires microsomal triglyceride transfer protein which
loads apo B-48 with lipid.
•This occurs before transition from the ER to Glogi, where the particles are packed in secretory vesicles.
•These fuse with the plasma membrane releasing the lipoproteins, which then enter the lymphatic system and,
ultimately, the blood.
•The particle released by the intestinal mucosal cell is called a “nascent” chylomicron because it is functionally
incomplete.
•When it reaches the plasma, the particle is rapidly modified, receiving apolipoproteins E and C. •The latter includes
apo C-II, which is necessary for the activation of lipoprotein lipase (LPL), the enzyme that degrades the TAG
contained in the chylomicron.
•The source of these apolipoproteins is circulating HDL.
•LPL is an extracellular enzyme that is anchored by heparan sulfate to the capillary walls of most tissues, but
predominantly those of adipose tissue and cardiac and skeletal muscle.
•Adult liver does not have this enzyme.
•It plays some role in TAG degradation in chylomirons .
•LPL, activated by apo C-II on circulating lipoprotein particles, hydrolyzes the TAG contained in these particles to
yield fatty acids and glycerol.
•The fatty acids are stored (by the adipose) or used for energy (by the muscle).
•If they are not immediately taken up by a cell, the long-chain fatty acids are transported by serum albumin until
their uptake does occur.
•The glycerol is used by the liver(in lipid synthesis or gluconeogenesis).
•LPL is synthesized by adipose tissue and by cardiac and skeletal muscle.
•As the chylomicron circulates, and more than 90% of the TAG in its core is degraded by LPL, the particle decreases
in size and increases in density.
•Apo C (but not apo E) are returned to HDL.
•The remaining particle, called a “remnant,” is
rapidly removed from the circulation by the liver,
whose cell membranes contain lipoprotein
receptors that recognize apo E .
•Chylomicron remnants bind to these receptors
and are taken into the hepatocytes by endocytosis.
•The endocytosed vesicle then fuses with a
lysosome, and the apolipoproteins, cholesteryl
esters, and other components of the remnant are
hydrolytically degraded, releasing amino acids,
free cholesterol, and fatty acids. The receptor is
recycled.

9thRepeat – SEQ ANSWERS
1.
1.1. Explain the chemiosmotic theory with necessary diagrams.(35 marks)
electrons derived from different fuels of the body flow to O2 and finally produce ATP.
-v each contain part of ETC these complexes accept or donate electrons to relatively mobile electron
carries COQ and cytochrome C.
– soluble Quinone.
Complex i
nase complex. The free proton plus the hydride ion carried by NADH are transfer to NADH
dehydrogenase.
ugh passing FMN, Fes. As eelectrone flows energy loss it used to

pump protons to across inner mc membrane from matrix to inter membranous space.
in this process no proton produce.
C the in to cytochrome a+a3 (complex iv) as electrons flow protons pumped across inner mc membrane at complex
iii and iv.
and bound to free protons forming H2O
1.2. Outline the importance of HMP shunt pathway (25marks)
carbon sugars and reducing equivalents.

NADPH and
CO2.

depend on NADPH for fatly acid synthesis. Because NADPH is high energy molecule.
ts ovens placenta and adrenal cortex NADPH used to biosynthesis of steroid
hormone. In red blood cells require NADPH to keep glutathione reduced.
tathione has no protective properties. Cells regenerate reduced glutathione via glutathione reductase
enzyme reducing equalent is NADPH. RBC totally depend on PPP for NADPH because they don’t have any alternative
pathway for product NADPH, RBC.
y use NADPH to maintain integrity of membrane.
oxygen into substrates.

ones in steroidogenic tissue.
compounds more water soluble.

– bile acid synthesis hydroxylation of cholecala
kidney used this to hydroxylyze the hydroxyl cholecakiferol
ed
mechanism. NADPH oxidized by NADPH oxidase and reduced O2 to super oxides used to respiratory blast.
No used as – vasodilator factor

Neurotransmitter
Platelet aggregation
Macrophage function
hucleorite and acid.
1.3. Briefly outline the steps of beta oxidation of palmitic acid and state how the pathway regulate.
Major pathway for catabolism of saturated fatty acids.
ed from COOH end of FA.
brane without carnitinl shuttle
carnitine acyl transferase
ii.
Now FA can undergo β oxygenation.

artons at carboxy end.
cleavage.

COA molecules.
as coenzyme.
MCOA racemase.
Succinyl COA enter to TCA cycle.

Acetyl COA oxidais via TCA cycle and NADH2 and FADH2 produce in 1st two steps
under go ETC and produce ATP
So in ꞵ oxidation of FA finaly
FADH2 produce 2 ATP
NADH produce 3 ATP
Acetyl COA one molecule – 12 ATP
10th Batch
10th Proper - MCQs
1. Regarding glycolysis,
A) Insulin inhibits the conversion of glucose to pyruvate
B) Phosphokinase is the key regulatory enzyme catalyzing the committed step
C) Sodium fluoride specifically inhibits the enolase enzyme
D) High level of ATP and citrate inhibit glycolysis
E) Conversion of 2-phosphoglycerate to phosphoenoylpyruvate is called substrate level phosphorylation
3. Gluconeogenesis,
A) Is the energy requiring process
B) Is the entirely reversed process of glycolysis
C) Maintain the glucose level in fasting state
D) Occurs exclusively in cytosol
E) Is regulated by insulin
4. Regarding glycogen synthase,

A) Wants primer for its function
B) Can’t synthesis glycogen from free glucose
C) Dephosphorylated form is active form
D) Add glucose to alpha chain glucose
E) Rate limiting enzyme in glycogenolysis
5. Role of glutamate,
A) Glutamine can be converted in to glutamate by glutamate dehydrogenase
B) Glutamate and OAA are important pair in the nitrogen metabolism
C) Ammonia is actively fixed to glutamate
D) Glutamine and glutamate are important ammonia carrier in the blood
E) Glutamate is a precursor of ornithine: intermediate of urea cycle
6. Concerning the HMP shunt,
A) Occurs in cytosol
B) Is the only source of NADPH for fatty acid synthesis
C) Activity is high in skeletal muscle
D) When fatty acid synthesis is increased more than nucleic acid synthesis the activity of the non-oxidative part of
the HMP shunt is increased
E) Activity of Trans aldolase is impaired in beri beri
8. Regarding amino acids,

A) Both leucine and lysine are purely ketogenic
B) Proline is an essential amino acid synthesized from glutamine
C) Excretion of alanine and glycine are increased in Maple Syrup diabetic disease
D) Carbon skeleton of glucogenic and ketogenic amino acids enter TCA cycle for Oxidation
E) Deficiency of phenylalanine hydroxylase causes accumulation of phenylalanine in plasma
9. Insulin directly stimulates the following enzyme/activity in adipocyte,

A) Fatty acyl Co-A synthetase
B) Glucose uptake
C) Glucose 6 phosphatase
D) Hormone sensitive lipase
E) Secretion of lipoprotein lipase
10. Desaturation of fatty acids in humans,

A) Introduces cis double bonds primarily
B) First double bond is introduced at the methyl end
C) Catalyzed by NADPH and cytochrome system
D) Only after palmitate is converted into stearic acid
E) Primarily in mitochondria

A) Adenosine is the only nucleoside to be salvaged
B) PRPP is an activated pentose
C) Occurs primarily in the liver
D) It is inhibited by purine nucleotides
E) Formation of PRPP is a committed step in the de novo purine synthesis
12. The atoms in the pyrimidine ring,

A) Aspartate
B) CO2
C) Glutamine
D) Glycine
E) N10 formyl tetrahydrofolate
SBR
41. False statements regarding VLDL,
A) Is synthesized in liver
B) Is increased in blood when insulin gets deficient
C) High dense than chylomicrons.

D) Can be converted to HDL in circulation
E) Is a precursor of LDL
44. A new born infant came to the clinic with lethargy and hyperammonemia, in addition to hypercitrullemia.
What is the enzyme to be affected?
A) Arginosuccinate lyase
B) Arginase
C) Arginosuccinate synthestase
D) Carbomylphosphate synthetase
E) Glutamate dehydrogenase
10th Proper - SEQs
1.
1.1 Outline the mechanism of oxidative phosphorylation. (20 marks)
1.2 Briefly describe the biochemical basis of Lesch-Nyhan syndrome. (20 marks)
1.3 Glycolysis and gluconeogenesis are effectively two sides of the same coin. Briefly explain the statement by using
the pathways. (35 marks)
1.4 Outline regulation of fatty acid metabolism. (25 marks)
2. A 30-year old diabetes presented with vomiting and abdominal pain for two days. She was drowsy and her
breathing was deep and rapid. There was a distinctive smell from her breath. She has been diagnosed with diabetic
keto acidosis.
2.1 Explain the biochemical basis behind the development of diabetic keto acidosis in this patient. (45 marks)
10th Repeat - SEQs
3.
3.1
3.1.1 Briefly describe the glycogen synthetic pathway and its regulation. (40 marks)
3.1.2 Outline the functions of pentose phosphate pathway. (30 marks)
3.1.3 HGPRT deficiency may give rise to hyperuricemia. State the biochemical basis. (30 marks)
3.2. Write an account on,

3.1.1 Jaundice
3.2.2. Alkaptonuria
1)
A) F Insulin decrease blood glucose.
B) F PFK 1 is the key regulatory enzyme.
C) T Enolase needs Mg2+. It is inhibited by F-

D) T Allosteric inhibition
E) F 2 phosphoglycerate →PEP is called dehydration
2)
A) F α-ketoglutarate dehydrogenase complex need 5 co-enzymes;
1. Thiamine pyrophosphate (TPP)
2. Lipoic acid
3. NAD+ (niacin/B3)
4. FAD+ (riboflavin/B2)
5. Co-enzyme A (pantothenic acid/B5)
B) T
C) T
D) F
E) T
3)
A) T Gluconeogenesis; production of glucose from non-carbohydrate precursors.-is an active process, require
4ATP and 2GTP
B) F Not the reversal of glycolysis. 3 non-reversible steps of glycolysis are circumvented by 4 alternate reactions.
They are unique to gluconeogenesis.
C) T Tissues such as RBC, brain, testis, cornea of the eye, exercising
muscles and kidney medulla require continuous glucose supply.
Glycogenolysis; supply glucose only for 10-18hrs.
Gluconeogenesis; when glycogen stores are diminished during an overnight fast.
D) F takes place both in mitochondria and cytosol in liver and kidney.

E) F Regulated primarily by glucagon and gluconeogenic substrates.Glucagon;
1. Reduce level of fructose 2, 6-Bisphosphate.
2. Covalent modification of enzyme activity.
3. Enzyme synthesis.
4)
A) T Cannot initiate synthesis using free glucose. Require a primer; Glycogenin or an already existing glycogen
fragment.
B) T UDP-Glucose to Glycogen
C) T Lippincott pg.132- fig.11.10
D) T Because it forms (1-4) α bonds
E) F Rate limiting step in glycogenesis.In glycogenolysis it is Glycogen Phosphorylase.
5)
A) F 𝐺𝑙𝑢𝑡𝑎𝑚𝑖𝑛𝑒→ 𝐺𝑙𝑢𝑡𝑎𝑚𝑎𝑡𝑒 + 𝑁𝐻3 by 𝑔𝑙𝑢𝑡𝑎𝑚𝑖𝑛𝑎𝑠𝑒
𝐺𝑙𝑢𝑡𝑎𝑚𝑎𝑡𝑒→ 𝛼 𝑘𝑒𝑡𝑜𝑔𝑙𝑢𝑡𝑎𝑟𝑎𝑡𝑒 + 𝑁𝐴𝐷𝑃𝐻 By. 𝑔𝑙𝑢𝑡𝑎𝑚𝑎𝑡𝑒 𝑑𝑒𝑕𝑦𝑑𝑟𝑜𝑔𝑒𝑛𝑎𝑠𝑒
B) T In transamination,
OAA + Glutamat
AST/PLP
Aspartate. + α-ketoglutarate

C) T 𝐺𝑙𝑢𝑡𝑎𝑚𝑎𝑡𝑒 + 𝑁𝐻3→ 𝐺𝑙𝑢𝑡𝑎𝑚𝑖𝑛𝑒
by. 𝑔𝑙𝑢𝑡𝑎𝑚𝑖𝑛𝑒 𝑠𝑦𝑛𝑡𝑕𝑒𝑡𝑎𝑠𝑒
D) F Only glutamine is transported in blood. (Lippincott pg. 253 – fig. 19.13)
E) T N for the urea molecule are supplied from
1. Free ammonia
2. Aspartate (Glutamate is the immediate precursor of both N through oxidative deamination.)
6)
A) T
B) F
C) F
D) F
E) F
7)
A) T
B) T
C) T
D) F
E) F
8)
A) F Leucine only.
B) F Proline non-essential (α-KG → Glu → Proline)
C) F Branched chain amino acids are excreted (Ile, Val, Leu)
D) T
E) T
9)
A) F It is an enzyme in beta oxidation of fatty acids. Beta oxidation takes during fasting state.
Insulin is secreted in fed state/ absorptive state.
B) T Glut- 4 in adipose tissues in an insulin sensitive channel
C) F 𝐺𝑙𝑢𝑐𝑜𝑠𝑒 6 𝑝𝑕𝑜𝑠𝑝𝑕𝑎𝑡𝑒→ 𝐺𝑙𝑢𝑐𝑜𝑠𝑒 By 𝑔𝑙𝑢𝑐𝑜𝑠𝑒 6 𝑝𝑕𝑜𝑠𝑝𝑕𝑎𝑡𝑎𝑠𝑒
Present only in the liver.
D) F
𝐷𝑖𝑎𝑐𝑦𝑙𝑔𝑙𝑦𝑐𝑒𝑟𝑜𝑙→ 𝑀𝑜𝑛𝑜𝑎𝑐𝑦𝑙𝑔𝑙𝑦𝑐𝑒𝑟𝑜𝑙 + 𝐹𝐴 By 𝑕𝑜𝑟𝑚𝑜𝑛𝑒 𝑠𝑒𝑛𝑠𝑖𝑡𝑖𝑣𝑒 𝑙𝑖𝑝𝑎𝑠𝑒
Stimulated by Glucagon/Epinephrine
E) T LPL is an extracellular enzyme in adipose tissue stimulated by insulin.

𝐶𝑕𝑦𝑙𝑜𝑚𝑖𝑐𝑟𝑜𝑛→ 𝐺𝑙𝑦𝑐𝑒𝑟𝑜𝑙 + 𝐹𝐴 by 𝐿𝑃𝐿
10)
A) T
B) F
First double bond is introduced between carbons 9 and 10. Humans have only carbon 9, 6, 5 and 4 desaturases. But
lack the ability to form bonds from C10 to ω end. (ω end=methyl end)
C) F Require O2, NADH, Cytochrome b5 and FAD-linked reductase.
D) T

Palmitate 16:0 is the end product of de-novo synthesis of fattyacids. First double bond is inserted producing
Oleic Acid 18:1(9)
Therefore palmitate has to be converted to Stearic acid 18:0
before being desaturated.
E) F
Only in SER
11)
A)T alvage pathway for purines; purines that result from normal cell turnover of cellular nucleic acids / diet and
not degraded can be converted to nucleoside triphosphates and used by the body.

Nucleotides salvaged
𝐻𝑦𝑝𝑜𝑥𝑎𝑛𝑡𝑕𝑖𝑛𝑒→ 𝐼𝑀𝑃 by 𝐻𝐺𝑃𝑅𝑇
𝐺𝑢𝑎𝑛𝑖𝑛𝑒→ 𝐺𝑀𝑃 by 𝐻𝐺𝑃𝑅𝑇
𝐴𝑑𝑒𝑛𝑖𝑛𝑒→ 𝐴𝑀𝑃 by 𝐴𝑃𝑅𝑇
*Adenosine is the only purine nucleoside to be salvaged.
B) T PRPP= Phosphoribosyl pyro phosphate. (Ribose is a pentose sugar)
C) T Purine ring is synthesized primarily in the liver.

D) T 𝑅𝑖𝑏𝑜𝑠𝑒 5 − 𝑃𝑕𝑜𝑠𝑝𝑕𝑎𝑡𝑒→ 𝑃𝑅𝑃𝑃 by 𝑃𝑅𝑃𝑃 𝑆𝑦𝑛𝑡𝑕𝑒𝑡𝑎𝑠𝑒
* PRPP Synthetase is inhibited by purine ribonucleotides.
E) F Not the committed step because PRPP is used in other pathways.
Committed step;
𝑃𝑅𝑃𝑃→ 5− 𝑝𝑕𝑜𝑠𝑝𝑕𝑜𝑟𝑖𝑏𝑜𝑠𝑦𝑙𝑎𝑚𝑖𝑛𝑒 By 𝐺𝑙𝑢𝑡𝑎𝑚𝑖𝑛𝑒: 𝑃𝑕𝑜𝑠𝑝𝑕𝑜𝑟𝑖𝑏𝑜𝑠𝑦𝑙 𝑝𝑦𝑟𝑜𝑝𝑕𝑜𝑠𝑝𝑕𝑎𝑡𝑒 𝑎𝑚𝑖𝑑𝑜𝑡𝑟𝑎𝑠𝑛𝑓𝑒𝑟𝑎𝑠𝑒
12)
A) T
B) T
C) T
D) F
E) F
41) ANSWER – D
A) T Incooperating endogenous TAG.
B) T Low insulin → low LDL activity → reduce uptake
C) T Density
CM<VLDL<LDL<HDL
D) F HDL produced in liver & intestine
E) T VLDL→IDL→LDL
44) ANSWER – C
Refer Lippincott pg. 254 – fig. 19.14
𝐶𝑖𝑡𝑟𝑢𝑙𝑙𝑖𝑛→ 𝐴𝑟𝑔𝑖𝑜𝑠𝑢𝑐𝑐𝑖𝑛ate by 𝐴𝑟𝑔𝑖𝑛𝑜𝑠𝑢𝑐𝑐𝑖𝑛𝑎𝑡𝑒 𝑠𝑦𝑛𝑡𝑕𝑎𝑠𝑒
10th PROPER – SEQ ANSWERS
2.

2.1.
Oxidative phosphorylation
erated by transport of electron by electron transport chain.
se contain F0 domain and a F1 domain.

-enter the matrix through proton channels in F0 domain.
d ADP and Pi and release ATP.
2.2.
Lesch – Nyhan syndrome
- Nyhan syndrome occur due to diffeciency of HGPRT Enzyme which involve in salvage pathway.
- Nyhan syndrome is a rare , X linked, recessive disorder.
r guanine.
PP) and decreased inhibitors.
2.3.
Glycolysis and gluconeogenesis

a simple reversal of glycolysis.
e can see they are effectively 2 sides of the same coin.
2.4. Regulation of fatty acid synthesis

A. Short-term regulation of acetyl CoA carboxylase.
c. By allosteric regulation
Large enzyme exists as inactive protomers (dimer), which can assemble into active filaments (dimer to
polymer).
• Promoted by citrate
• Inhibited by fatty acyl CoA
d. By reversible phosphorylation
• Glucagon stimulates phosphorylation (via cAMP) and thus inactivation of the liver enzyme.
• Adrenalin (epinephrine / norepinephrine) stimulates phosphorylation and inactivation in adipose
tissue

• Insulin activates enzyme by dephosphorylation. Also stimulates glucose uptake & conversion to
Pyruvate & its conversion to acetyl CoA.
B. Long-term regulation of acetyl CoA carboxylase

• High carbohydrate or fat free diet increases synthesis of acetyl CoA carboxylase and fatty acid
synthase which promote FA formation.
• A low-calorie diet or Fasting or high fat diet decreases FA synthesis by reducing synthesis of above
enzymes. (Use the equations to get full marks)
Regulation of β oxidation of FA.

-1 of conitine shuttle.
not degraded.
↑ → Co A requiring thiolase reaction decrese.
2.1

Therefore without enough insulin, glucose cannot enter into the cells
ipase and hormone sensitive lipasenormally.
etone body synthesis because OAA is used for gluconeogenesis and decreased NAD+/NADH
ratio.
etoacidosis, vomiting and abdominal pain occur in this patient.
- hydroxybutyrate
- hydroxyl butyrate transport in to peripheral tissues via blood.
energy source)
10th Repeat – SEQ ANSWERS
-Glycogenesis IS The synthesis of glycogen from α D glucose.

-An energy consuming pathway
Requires
Glycogenin,
Glycogen synthase,
 Glycogen-branching enzyme
 UDP-glucose
 Pyrophosphorylase

Glycogen synthase is the key regulatory enzyme
• Glucose activation
Glucose→ Glucose-1-P
UDP-Glucose Phyrophospharylase
Glucose-1-P + UTP UDP-Glucose (activated form) + PPi
PPi + H2O → 2Pi
Therefore all reactions producing PPi are shifted to right & almost irreversible
• Initiation of glycogen synthesis Glycogen synthase needs a primer to initiate synthesis.

-Protein called glycogenin
-Glycogen fragment
• Chain elongation
Glycogen Synthase
(Glycogen)n + UDP-Glucose (Glycogen)n+1 + UDP
Glucose is added to non-reducing ends.- α-1→4-glycosidic bonds
ATP + UDP → UTP + ADP
So, for each α added 1 ATP is consumed
• Branching
Branching enzyme cuts a string of glycogen (8-10 glycosyl units) from the growing end and grafts onto the 6th C
atom of a glucose residue in the chain. –α-1→6-glycosidic bonds Further elongation by glycogen synthase.
01. Hormonal regulation

 Fed state - ↑Insulin
 Fasting state- ↑Glucagon
02. Allosteric regulation

In fed state, Glycogenesis↑
Glycogenolysis↓
In fasting state, Glycogenesis↓
Gluconeogenesis↑

3.2) Outline the functions of pentose phosphate pathway.
i. Production of ribose-5-pospate
Need for nucleotide metabolism of all cells.
ii. NADPH production
Provide reduction potential for,
• fatty acid synthesis In liver placenta and lactating mammary glands.
• reduction of oxidants/ H2O2
In G6PD deficiency,
Due to lack of NADPH,
RBC undergo hemolysis producing hemolytic anemia due to damage from oxidants.
• Cytochrome P450 monooxygenase system.
R-H + O2+NADPH + H + → R-OH + H2O + NADP+ P450 Enzymes
• Phagocytosis by WBC
• NO synthesis
NO cause : Vasodilation, Neurotransmitter, Bactericidal action, Prevent platelets Aggregation
3.3) Hypoxanthine-guanine phosphoribosyl transferase(HGPRT) deficiency may give rise to hyperuricemia, state the
biochemical basis.
Deficiency in HGPRT Causes,
Increased PRPP level
Decreased IMP, GMP level
As a consequence,
Increased purine denovo synthesis
Due to increased substrate level
(PRPP) and decreased inhibitors (IMP, GMP)
PRPP ---------------------------------------------------------------------------> Phosphoribosyl amine

Glutamine : PRPP amidotransferase
IMP,GMP (-) ( + )PRPP
So reduced purine salvage and increased purine synthesis

So increased purine degradation which increase uric acid formation
Hyperuricemia occur
Gouty arthritis (urate crystal deposition)
Also associated with motor dysfunction, self-mutilation
4.1) Biochemical basis of Jaundice.
Normal: UCB – 0.7mg/dl

CB – 0.2mg/dl
Total – 1mg/dl
So if it’s more than 2mg/dl show jaundice
1.Prehepatic/hemolytic
Increase in hemolysis cause increase in UCB
CB level normal

2.Hepatic
Uptake/conjugation impaired
Which lead to increase UCB/CB levels
Ex: Dubin johnson syndrome
3.post hepatic
Obstruction of bile flow (cholestasis)
Which increase CB cause pale stool and dark Urine
Can identify by yellow coloration in sclera, mucus membrane etc.
4.2) Alkaptonuria
 Rare metabolic disease
 Deficiency of homogentisic acid oxidase
 Which cause accumulation of homogentisic acid (defect in tyrosine metabolism)
o Homogentisic aciduria → dark pigment on standing
o Large joint arthritis o Black ochronosis pigmentation of cartilage and collagenous tissue
 Usually asymptomatic until age 40
 Dark color dippers- indicate disease in infants
 Treatment: diets low in protein especially phenylalanine and tyrosine

11th Batch
11th Proper - MCQs
24. Regarding metabolism in different tissues,

A) Glucose is the major source of energy for exercising muscle under anaerobic condition.
B) Erythrocytes are glucose dependent.
C) Muscles cannot utilize ketone bodies.
D) Brain develops the ability to utilize ketone bodies after an overnight fasting.
E) Adipose tissue provides the major source of energy for the body during prolonged starvation.
25. During fasting,

A) Stimulate G protein.
B) Stimulate tyrosine kinase.
C) Stimulate glycogen phosphorylase.
D) Phosphorylation of hormonal sensitive lipase.
E) Stimulate of Malonyl CoA.
26. Regarding pyruvate dehydrogenase and alpha ketoglutarate dehydrogenase,

A) Are multi enzyme complex found in TCA.
B) Their action results in formation of a product which contains coenzyme A.
C) They are not present in RBC.
D) NADPH is product of their action.
E) They are mitochondrial enzymes.
27. The rate of lipolysis increase in Diabetes Mellitus due to,

A) Activation of hormone sensitive lipases.
B) Formation of more glycerol phosphate in adipocytes.
C) Increased activity of LPL.
D) Increased blood Glucose level.
E) Ketone body formation.
28. In oxidation of fatty acids

A) Short chain fatty acids pass directly into mitochondria without involvement of carnitine.
B) Long chain fatty acids are activated to acetyl CoA on outer mitochondrial membrane.
C) Acyl CoA synthetase is found both inside and outside the mitochondria.
D) Increased oxidation is seen in well-fed state and diabetes mellitus.
E) Beta oxidation involves successive cleavage and release of Acetyl CoA.
29. Synthetic inhibitors of purine degradation

A) Atorvastatin.
B) Metformin.
C) Mycophenolic acid.
D) Sulfonamides.
E) Methotrexate.
30. Regarding xanthine oxidase (XO) in purine degradation

A) Allopurinol inhibits the XO activity.
B) Convert GMP into its nucleoside guanosine.

C) Convert hypoxanthine into xanthine.
D) Convert IMP into its nucleoside inosine.
E) Convert xanthine into uric acid.
SBR
50. Which is the enzyme catalyse the rate limiting step of pyrimidine synthesis allosterically inhibited by citidine
tri phosphate(CTP/Citoline)
A) Aspartate transcarbamoylase.
B) Hypoxanthine guanine phosphoribosyl transferase. (HGPT)
C) Phosphoribosyl pyrophosphate synthetase.
D) Thymidine synthase.
E) Xanthine oxidase.
51. A patient was given allopurinol as a drug to treat his gouty arthritis. Which of the following enzyme is inhibited
by the drug Allopurinol?
A) Xanthine oxidase.
B) PRPP synthetase.
C) Adenosine deaminase.
D) Dihydrooratase.
E) Ribonucleotide reductase
52. A new born baby has milky white skin, white hair and red appearing eyes. What is the enzyme defect?
A) NADH oxidase.
B) Phenyl alanine hydroxylase.
C) Tyrosinase.
D) Homogenestic acid oxidase.
E) Cystathione beta synthase.
53. A young lady who had a heart attack had been prescribed Mevastatin to reduce her Serum Cholesterol level.
Which of the following enzyme is inhibited by the drug?
A) Carnitine Palmitoyltransferase-1. (CAT-1)
B) Medium Chain Ketoacyl CoA Thiolase. (MCAT)
C) Citrate Lyase.
D) HMG CoA Synthase.
E) HMG CoA Reductase.
11th Proper - SEQs
3.
3.1 Briefly describe the biochemical basis for the followings.
3.1.1 Hereditary pyruvate kinase deficiency leads to hemolytic anemia. (15 Marks)
3.1.2. The effect of hyperglycemia on sorbitol metabolism. (15 Marks)
3.2
3.2.1 State the biochemical consequences of alcohol metabolism in the body. (15 Marks)
3.2.2 Explain the biochemical basis for development of hyperuricemia in hypoxanthine-guanine
phoshoribosyltransferase deficiency (HGPRT) (25 Marks)
3.3 Explain the biochemical basis of “excess dietary protein consumed is more likely to appear as body
fat rather than body protein”.

11th Repeat - SEQs
3.
3.1 A 55-year old man suffers from liver cirrhosis. His blood test showed hyperammonemia. Explain the biochemical
basis of this condition.
3.2 Briefly write an account on beta oxidation of a saturated fatty acid.
3.3 Mention three pathways which are increased during starvation.
3.4 Outline the role of allopurinol in treatment of gouty arthritis.
5.
5.2.1 Sulfonamides do not interfere with human nucleic acid synthesis.
5.2.2 Cataract acidosis in alcoholics.
6.
6.1 Briefly describe the regulation of fatty acid synthesis
6.2 Describe the transport of ammonia to the liver.
6.3 Briefly explain the regulation of glycogen metabolism.
24) Regarding metabolism in different tissues

A) T
B) T Only glycolysis can occur in RBC due to lack of mitochondria
C) F Can be utilized
D) F Ketone bodies will be utilized after a few days
E) T
25) During fasting
A) T Glucagon acts on GPCR
B) F Insulin receptor
C) T Glycogen Phosphorylase gets phosphorylated and becomes active
D) T HSL is phosphorylated and activated
E) F Malonyl CoA inhibits Carnitine shuttle
26) Regarding pyruvate dehydrogenase and alpha ketoglutarate dehydrogenase

A) F PK is not part of TCA cycle; But it supplies substrates for the cycle
B) T PyruvateAcetyl CoA; Alpha KetoglutarateSuccinyl CoA
C) T TCA cycle doesn’t occur in RBC due to lack of mitochondria
D) F NADH is produced
E) T TCA Cycle occurs in mitochondria
27) The rate of lipolysis increase in Diabetes Mellitus due to,

A) T HSL is inhibited by Insulin. Insulin is Relatively or Absolutely low in Diabetes Mellitus. Thus HSL causes TAG
breakdown (Lipolysis) in adipocytes
B) F Glycerol Phosphate is formed due to TAG breakdown in adipocytes by HSL. It’s a result of lipolysis, not the
cause of lipolysis
C) F LPL activity is reduced, Hence VLDL and Chylomicron levels in plasma increases (Hypertriacylglycerolemia)

D) F Hyperglycemia may not itself lead to lipolysis, as the mechanisms that control Hyperglycemia is inactive in
Diabetes Mellitus
E) F It’s a result of lipolysis, not the cause of lipolysis
28) In oxidation of fatty acids

A) T LCFA needs Carnitine shuttle to cross Mitochondrial Membrane. Shorter chain Fatty acids don’t need
Carnitine Shuttle
B) F LCFA is activated by CoA into Fatty Acyl CoA by Long Chain Fatty Acyl CoA Synthase (Thiokinase- an enzyme of
outer mitochondrial membrane)
C) In Outer Mitochondrial Membrane
D) F Not seen in well fed state
E) T
29. Synthetic inhibitors of purine degradation

A) F Inhibits Cholesterol Synthesis by competitively inhibiting HMG CoA Reductase, Thus used to treat
Hypercholesterolemia
B) F Decreases Hepatic Gluconeogenesis, thus used to treat Diabetes Mellitus
C) F Reversible Inhibitor of IMP dehydrogenase (Inhibits Purine Synthesis). Thus seprieves rapidly proliferating T
and B cells of key components of Nucleic acids and used as an immune suppressant to prevent graft rejection 48
D) F Structural Analog of PABA that competitively inhibits bacterial synthesis of Folic acid which is needed in Purine
synthesis as a coenzyme
E) F Inhibits the reduction of Dihydrofolate to Tetrahydrofolate, catalyzed by Dihydrofolate Reductase and reduces
the amount of Tetrahydrofolate available for use in Purine synthesis. Thus they slow down DNA replication in
mammalian cells and used to control rapidly growing cells in Cancer
30) Regarding xanthine oxidase (xo) in purine degradation

A) T Allopurinol is a structural analog of Hypoxanthine
B) F 5’-Nucleotidase
C) T
D) F 5’-Nucleotidase
E) T
50) Answer (C)
51) Answer (A)
52) Answer (C) Albuminisum
53) Answer (E) Statin drugs are competitive inhibitors of HMG-CoA reductase, the rate-limiting enzyme of B
cholesterol biosynthesis

3.1.1
In Glycolysis,
Pyruvate Kinase
Glucose →→→→→→ 2PEP 2Pyruvate
RBC,
Totally depend on glycolysis to produce energy due to lack of mitochondria.
In pyruvate kinase enzyme deficiency
 Decrease ATP levels, so RBC cannot survive
 Increase hemolysis of RBC to remove unwanted RBC leads to hemolytic anemia.
3.1.2
-aldose reductase reduce glucose to sorbitol.

-found in lens, retina, schwann cells, kidney, placenta, red blood cells, cells of ovaries and seminal vesicles.
- Sorbitol dehydrogenase that can oxidize sorbitol to produce Fructose.
-found in Liver, ovaries, sperms and seminal vesicles cells
-Aldose reductase has low affinity to glucose. but when the glucose concentration is high conversion to sorbitol
occurs.
In Hyperglycemia
↑Glucose in the cells, an adequate NADPH Supply leads to ↑Sorbitol Production.
Sorbitol is an osmotically active particle which cannot cross the cell membrane.
Accumulated Sorbitol Trapped inside the cell.
Is exacerbated when Sorbitol Dehydrogenase low or absent (Retina, Lens, Nerve, Kidney)
As a result, Sorbitol accumulates, causing strong osmotic effects, Cell swelling as a result of water retention.
Cataract formation, Peripheral Neuropathy, Nephropathy and Retinopathy in Diabates.

3.2.1
The metabolism of alcohol involves the consumption of NAD+ and consequently a high NADH/NAD+ ratio.
Increase NADH/NAD+ ratio cause many metabolic changes,
Lactic Acidosis
Suppression of TCA cycle
Suppression of gluconeogenesis - Hypoglycemia
Increase in acetyl Co A → increases Fatty Acid Synthesis → Fat is accumulated in liver lead to Fatty Liver.
Consequences of Ethanol Metabolism

• The result of the altered NADH/NAD+ ratio that is the consequence of both the ADH and ALDH catalyzed reaction;
• acetaldehyde forms adducts with proteins, nucleic acids and other compounds resulting in impaired activity of the
affected compounds.
• oxygen deficits (i.e., hypoxia) in the liver and the formation of highly reactive oxygen-containing molecules (i.e.,
reactive oxygen species, ROS) that can damage other cell components.
• Reduce NADPH
• tissue damage; fetal damage; impairment of other metabolic processes; cancer; and medication interactions.
3.2.2
HGPRT deficiency cause

Increase PRPP level
Decrease IMP & GMP level

As a consequence,
So,
 decrease purine salvage
 increase purine synthesis
because of this, increase purine degradation

↓
increase production of uric acid
↓
hyperuricemia
gouty arthritis (deposition of urate crystals in joints)
Lesh- Nyhan syndrome
1.2. Protein cannot store in our body
(these Carbon Skeleton can enter into 7 differen Intermediates)

↓

12th Batch
12th Proper - MCQs
27. Glycogen metabolism,

A)Glucose is the only fuel which can be oxidized under anaerobic condition.
B)Glycogenesis and glycogenolysis are controlled reciprocally.
C)Muscle glycogen level isn't altered during fasting because glucagon doesn't have effect on muscle
D)Glycogen phosphorylase is the rate limiting enzyme of glycogenolysis.
E)Glycogen synthase is stimulated allosterically by glucose 6 phosphate
28. Glucose-6-phosphate dehydrogenase,

A) Deficiency causes a drug induced hemolytic anemia.
B) Has low affinity to NADP than NAD.
C) Is activated by ATP.
D) Activity is high in adipose tissue.
E) RBC totally depends on pentose phosphate pathway for NADP

A) It’s a cytosolic process
B) takes place primarily in liver
C) AMP activated protein kinase dephosphorylates & activates Acetyl co A carboxylase
D) Acetyl co A carboxylase enzyme catalyze conversion of Acetyl CoA to Malonyl CoA
E) Needs ATP, NADPH
39. regarding fatty acid synthesis

A) ACC enzyme is the enzyme regulated step
B) ATP produce
C) CO2 is one of substrate
D) Malonyl CoA convert in to Acetyl CoA
E) Insulin stimulate the fatty acid synthesis
40. prolong starvation give substrate for gluconeogenesis in,

A) Adipose tissue
B) Brain
C) Liver
D) Pancreas
E) Muscle
SBR
48. Not included in oxidative phase of pentose phosphate pathway,
A) 6-phosphogluconate
B) Glucose-6-phosphate dehydrogenase
C) Glucose-6-phosphate
D) Lactonase
E) Transketolase
49. Degradation of fatty acids may not include,

A) Malonyl CoA

B) Propionyl CoA
C) Acetyl CoA
D) Succinyl CoA
E) HMG CoA
51. Which enzyme is inhibited by anisate in glycolysis?

A) Glyceraldihyde-3-phosphate
B) Hexokinase
C) Lactate dehydrogenase
D) Phosphofructokinase
E) Pyruvate kinase
12th Proper - SEQs
5.
5.2.1 Explain why failure of gluconeogenesis is usually fatal.
5.2.2 Explain the biochemical basis of hyperuricemia seen in high fructose diet consumption.
5.2.3. State the role of NADPH in red blood cells.
6.
6.1. A 30-years-old man has been fasting for religious reasons for several days.
6.1.1 Name the substance that his brain could utilize as a source of energy.
6.1.2 Briefly explain the synthesis of above substance during above condition.
6.1.3 Outline how these substance are utilized by the brain as a source of energy.
6.2. Briefly explain the following stating the biochemical basis.

6.2.1. Hepatic metabolism of glucose increases after a meal containing carbohydrates.
6.2.1. Albinism
6.2.3. Orotic aciduria
28)
A–T
B – F High NADPH : NADP ratio inhibit enzyme activity
C–F
D – T important in lactating mammary glands, liver, adipose tissue
E – F for NADPH
35)
A. T
B. T
C. F
D. T
E. T

39)
A) T Rate limiting step
Acetyl co A Melanoyl co A
Acetyl co A carboxylase (ACC)
B) F
C) T (Required CO2 & ATP)
D) F
E) T
40)
A) T
B) F
C) T
D) T
E) T
49)answer A
51)answer E
5.2.1 Explain why failure of gluconeogenesis is usually fatal.

 Gluconeogenesis The synthesis of glucose from noncarbohydrate precursors (e.g., lactate , pyruvate,
glycerol, citric acid cycle intermediates & amino acids)
 Glucose is the major fuel source for the Brain, Nervous system, Testes, Erythrocytes (RBC), Kidney, medulla,
Lens & cornea of the eye, Exercising muscle.
 During fasting, starvation or intense exercise glucose must be replaced by gluconeogenesis
 Thus gluconeogenesis in the liver and kidney helps to maintain the glucose level in the blood
 So that brain and muscle can extract sufficient glucose to meet their metabolic demands.
 therefore FAILURE OF GNG USUALLY FATAL
5.2.2 Explain the biochemical basis of hyperuricemia seen in high fructose diet consumption.
Biochemical basis of gout & hyperuricemia due to high fructose diet & hereditary enzyme deficiency.

5.2.3
NADPH is formed via pentose phosphate pathway which is the sole source for red blood cells. It is required for
maintenance of G-SH pool which helps to maintain reduced states of sulfhydryl groups in haemoglobin. It prevents
oxidation of membrane proteins and formation of heinz bodies. Then it prevents haemolytic anemia
(6)
6.1.1 ketone bodies
6.1.2
Brain use ketone bodies which spare glucose and it is important during prolonged fasting
During fasting liver is flooded with fatty acid mobilized from adipose tissue
As a result elevated hepatic acetyl coA produced by fatty acid oxidation inhibits pyruvate dehydrogenase
and activate pyruvate carboxylase
OAA produced is used by liver for gluconeogenesis rather than for TCA cycle. Therefore acetyl coA is
channelled into ketone body synthesis
HMG coA synthase is the rate limiting step in synthesis of ketone bodies
Ketone bodies are acetoacetate, 3-hydroxy butyrate, acetone
Acetoacetate and 3-hydroxy butyrate are transported into peripheral tissues by blood
Acetone is volatile, biologically nonmetabolized compound which is released in breath

6.2.3
Ketone bodies are produced by the liver mitochondria which are soluble in aqueous solution therefore do
not need to be incorporated into lipoproteins. They are transported into brain
3- Hydroxyl butyrate is oxidized to acetoacetate by 3-hydroxybutyrate dehydrogenase producing NADH
Acetoacetate is then provided with a coA molecule taken from succinyl coA by succinyl coA : acetoacetste
coA transferase (thiophorase)
This reaction is reversible, but acetoacetyl coA is actively removed by its conversion to two acetyl coAs.
This pulls reaction forward.
Brain efficiently oxidize acetoacetate and 3-htdroxybutyrate
6) Briefly explain the following stating the biochemical basis

I. Hepatic metabolism of glucose increases after a meal containing carbohydrate.
Meal containing carbohydrate leads to increased blood glucose concentration in portal circulation. That
much of glucose shouldn’t be entered into systemic circulation directly. So, liver has to decrease the
glucose amount, that enters to blood. For that liver has many mechanisms.
 Increased intake of glucose
 Increased glycolysis
 Increased glycogenosis
 Increased pentose phosphate pathway
Increased intake of glucose
Liver expresses the glucose transporter GLUT-2. It is insulin independent glucose transporter. It enters such
a big amount of glucose.
Increased glycolysis
In liver parenchymal cells and beta cells of pancreas contain glucokinase enzyme (hexokinase D), which
phosphorylates glucose.
glucokinase hexokinase
Found in liver Found in most tissues
Lower km Higher km
Higher affinity Lower affinity
Lower glucose concentration is needed for Higher glucose concentration is needed
half saturation for half saturation
Lower Vmax Higher Vmax
So glucokinase enzyme phosphorylates more amount of glucose than hexokinase.

Furthermore, high insulin to glucagon ratio increases
 conversion of glucose into acetyl Co. A
 enzymatic reactions of PK and PDH
acetyl Co. A is the building block of Fatty acids. As much as acetyl Co. A is used, glycolysis also increases
Increased glycogenesis
By activation of glycogen synthase. It can be done by dephosphorylation and increased availability of
glucose-6-phosphate. Glucose-6-phosphate is an allosteric activator.

Increased pentose phosphate pathway
Increases availability of glucose-6-phosphate and increased demand for NADPH for lipogenesis increases
pentose phosphate pathway.
II. Orotic aciduria

Orotate phosphoribosyl transferase and OMP decarboxylase are separate domains of a single polypeptide-
UMP synthase
Low activity of orotidine phosphate decarboxylases and orotate phosphoribosyl transferase result in poor
growth, megaloblastic anemia, and the excretion of large amounts of orotate in the urine
Administration of uridine results in improvement of the anemia and decreased excretion of orotate
III. Albinism
Defect in tyrosinase metabolism.
Deficiency in the production of melanin
Melanin can be partially or fully absent from skin, hair and eyes.
The characteristics are
 Hypopigmentation
 Vision defect
 Photophobia
 Increased risk for skin cancer
It can be inherited as
 autosomal recessive/ primary mode
 Autosomal dominant
 X- linked
Complete albinism or tyrosinase negative oculocutaneous albinism results from deficiency of Cu requiring
tyrosinase, characterized by total absence of melanin

13th Batch
13th Proper - MCQs
30. Thromboxane A2,

A) Has a very short half life
B) An active metabolite of PGE2
C) Major prostaglandin produced in the cell
D) Does not contain a ring structure
E) Synthesized from the intermediate PGE2
31. Pyruvate Carboxylase,

A) Has biotin as a prosthetic group
B) Is found in muscle
C) Is allosterically activated by Acetyl CoA
D) Catalyze the reaction that conversion of pyruvate to OAA
E) Is found within mitochondria
32. Regarding HMP Shunt,

A) Active in resting cells
B) Glucose is oxidized to CO2 and H2O
C) It increase NADPH/NADP+ Ratio
D) NADP is the Co enzyme for transketolase
E) Pathway gives rise to glucose-6-phosphate for the synthesis of glucuronic acid
33. Glucokinase,
A) Phosphorylates only glucose
B) Is present in most tissues
C) Decreased in diabetes mellitus
D) Has higher Km for glucose than hexokinase
E) Is allosterically inhibited by glucose and phosphate
34. Complex IV in electron transport chain,

A) Accept electrons from reduced Co enzyme Q
C) Utilize molecular O2 as an electron acceptor
D) is capable of pumping electron from inner mitochondrial membrane
E) Produces H2O
35. Pass alpha ketoglutarate as obligatory intermediate,

A) Glutamine
B) Glycine
C) Histidine
D) Lysine
E) Methionine
36. True/False,
A) High cholesterol content increase cholesterol synthesis

B) Carnitine acyl protein inhibited by long chain fatty acid
C) Lipids are homogenous in nature
D) Niemann-Pick is related with glycosphingolipids
E) Human can insert double bond in 9th carbon of palmitic acid
37. True about prostaglandins

A) has a short half life
B) is group part based on numbers of double bond
C) inhibited by aspirin
D) Synthesis from Acetyl CoA in human body
E) stored at the site of origin
38. True/False,
A) Chylomicrons released to blood 1-2 hours after the ingested meal
B) During prolonged fasting 2/3 of energy is supplied by ketone body
C) Increased insulin/glucagon inhibits acetyl Co A carboxylase
D) Resting muscles uses glycogen as major fuel in fasting
E) Skeletal muscles and liver uses fatty acid as major fuel in fasting
39. Functions of Xenobiotic metabolism

A) Detoxification
B) Metabolic activation
C) Convert hydrophilic to lipophilic
D) Eliminate polar metabolites
E) Facilitate reabsorption of metabolites kidney
40. Elements of pyrimidine base ring

A) Glutamine
B) CO2
C) N5-formyltetragydrofolate
D) Aspartate
E) Glycine
SBR
56. A 2-year old boy has been diagnose with Zellweger syndrome a disorder caused by malformation of
peroxisome. Which fatty acid oxidation is impaired due to this defect?
A) Bran chain fatty acid
B) Cyclic fatty acid
C) Palmitic acid
D) Unsaturated fatty acid
E) Very long fatty acid
57. A patient present with complains of his urine turning black after exposure to the air. Which of the following
amino acid degradative pathway is defective?
A) Arginine
B) Cysteine
C) Methionine

D) Isoleucine
E) Phenylalanine
58. Pyruvate is least likely to be to synthesis,

A) Acetyl Co-A
B) Branch chain Amino acid
C) Ethanol
D) Lactate
E) Purine nucleotide
59. Odd chain fatty acid degradation leads to the production of,
A) Acetyl Co A
B) Malonyl Co A
C) Acetoacetyl Co A
D) Propinyl Co A
E) β-hydroxybutarate
60. A child with severe combined immune deficiency (SCID) cannot fight infections due to,
A) Deficiency of plasma cells
B) Deficiency of B and T cells
C) Gouty arthritis
D) Porphyria
E) Deficiency of plasma lipoproteins
13th Proper - SEQs
1.
1.1. A 35-year old man presents with severe pain in his legs upon walking. He is diagnosed with
atherosclerotic plaques in the arteries of his legs. High level of cholesterol and low density
lipoprotein (LDL) contribute to atherosclerosis.
1.1.1 State how LDLs formed. (15 marks)
1.1.2 Briefly describe the biochemical basis of atherosclerosis. (25 marks)
1.2 Outline the fate of fatty acids in the fed state. (20 marks)
1.3 Explain how the integrity of RBC membrane is maintained in response to oxidative stress.
(25marks)
1.4 State the biochemical basis of fatty liver in a chronic alcoholic patient. (15 marks)
2.
2.1 Describe the mechanism of action of methotrexate in relation to nucleotide synthesis. (30marks)
2.2 Describe the oxidative deamination of amino acids. (20 marks)

30)
A)T
B ) F Is an active metabolite of PGH2
C)
D)F
Contain a ring structure.
E ) F Synthesised from intrmediates of PGH2
31)
A) T
B) F Only found in tissues which performing gluconeogenesis
C) T
High acetyl coA/ coA ratio allosterically activate Pyruvate Carboxylase
D) T
E) T
32 )
A) T
B) F. Glucose oxidised in to CO2 and water in aerobic respiration
C) T
D) F TPP act as a coenzyme foe Transketolases action
E) F
Pathway synthesis Fructose-6- phosphate and Glyceraldeyhde -3-phosphate
33. Glucokinase
A) T
B) F Present in pancreatic beta cells, liver parenchymal cells
C) T
In insulin dependent diabetes mellitus , due to destruction of pancreatic beta cells, the amount of Glucokinase
present in body will be decreased
D) T
E) F
Not inhibited directly by Glucose-6-phosphate but , indirectly
inhibited by Fructose -6-phosphate
34. Complex IV in ETC

A) F Receive electrons from reduced Cytochrome c
B) T Inhibited by Azide , CO and Cyanide
C) T
D) T
E) T
35. Alpha keto glutaarte

A) T
- OAA
- Alphaketoglutaarte
- Pyruvate
- Acetyl co A
- Succinyl co A
B) F
C) T
D) F
E) F
36.
A) F
B) F Carnitine acyl proteins inhibited by Malonyl co A
C) F
D) F Niemann- pick disease related with sphingomyelin
E) T
37. Prostaglandin
A) T
B) T
C) T
D) F Synthesised from Arachidonic acid
E) F
Eicosanoids are local hormones that produced locally and rapidle metabolised in to inactive compounds.
38.
A) T
B) F
During prolonged fast, gluconeogenesis occurs and ketone bodies are spared to be used by the brain
C) F
in the presence of insulin ACC is dephosphorylated and active
D) F
resting muscles use FA as major fuel during fasting while exercising muscle initially uses creatine phosphate and its
glycogen stores.
E) F FA is major fuel for skeletal muscle but not for liver
39. About Xenobiotics metabolism

A) T
B) T
C) F
makes lipophilic to hydrophilic
D) F eliminates non polar metabolites by converting them to polar metabolites
E) F kidney facilitates elimination of metabolites and not reabsorption
40. About pyrimidine base ring

A)T
B)T
C)F
D)T
E)F
SBR
56)
E
VLCFA<=22 carbons undergo beta oxidation in peroxisomes. The shortended fatty acid chain is transferred to
mitochondria for further shortening.
57)
E

Alkaptonuria is due to deficiency of homogenistic acid oxidase resulting in acculmuation of homogenistic acid , an
intermediate of tyrosine degradation.
Tyrosine is produced by phenylalanine
58) E
• pyruvate to acetyl coA(transfer of pyruvate to mitochondria for TCA cycle
• pyruvate to lactate(anaerobic respiration)
• pyruvate to ethanol(fermentation)
• degradation of branched chain amino acids produce succinyl CoA which is in turn converted to pyruvate
• pyruvate is not involved in purine nucleotide synthesis
59) D
Even chain degradation forms acetyl CoA
Odd chain degradation forms propionoyl CoA
60) B
caused due to adenosine deaminase deficiency
1.1.1.
VLDL are produced in the liver and released as nascent particles containing apo B-100. They obtain apo C-II and apo
E from HDL. VLDL are composed predominantly of endogenous TAG and their function is to carry lipid from liver to
peripheral tissues. TAG is degraded by LPL and it gets more denser, so VLDL is converted to LDL.
1.1.2.
Normally, when there are high cholesterol levels in blood, synthesis of new LDL receptor protein is reduced by
decreasing expression of LDL receptor gene, limiting entry of LDL to cells. In addition to these highly regulated
receptors, macrophages possess a scavenger receptor activity by receptors called scavenger receptor class A. This
receptor is not downregulated.
 In response to endothelial injury, monocytes adhere to endothelial cells, move to intima and converted to
macrophages.
 These macrophages consume excess modified (oxidized) LDL which are formed by Reactive oxygen species.
 Consumption of modified LDL is by low affinity nonspecific and non-regulated scavenger receptors and as a
result, macrophages are converted to foam cells.
 Foam cells accumulate releasing growth factors and cytokines that stimulate the migration of smooth
muscle cells from media to intima. There smooth muscle cells proliferate, produce collagen and take up lipid
becoming foam cells. Foam cells participate in the formation of atherosclerotic plaque
1.2. In liver, fatty acid synthesis is increased due to availability of substrates acetyl CoA and NADPH during
fed state, activation of acetyl CoA carboxylase (ACC) which is the regulatory enzyme of fatty acid de novo
synthesis. ACC produces malonyl CoA which in turn inhibits carnitine palmitoyl transferase I (CPT-I) of fatty
acid oxidation. Thus, TAG synthesis is favored due to presence of FA
In adipose tissue,
after a diet, FA are released by action of LPL on chylomicrons. Action of insulin inactivates HSL thereby
inhibiting lipolysis. FA is therefore stored as TAG in adipose tissue.
1.3.
 Glucose utilised under aerobic conditions in mitochondrias and ETC use these molecular oxygen as an
elctron acceptor synthesising Water.
 In partial reduction of molecular oxygen , Reactive oxygen Species formed and they are harmful to the
body cells because they have ability of damaging Unsaturated fatty acid in red blood cell membranes and
results hemolysis..
 Body cells including RBC , prevent this oxidative damage by reducing them.the unbalance between the
production and reduction of ROS results the condition called oxidative stress.reduction of ROS in RBC done
through reduced glutathione and this pathway require produce NADPH in HMP shunt .
1.4. State the biochemical basis of fatty liver in a chronic alcoholic patient.
 These recation leads to increase NADH/NAD+ ratio within hepatocytes.

 That causes reduction of rate of TCA cycle and accumulation of Acetyl Co A.
 In cytosol , Dihydroxyacetone phosphate reduced in to Glycerol-3-phosphate
 These changes leads to increase in formation of fatty acids and they converted in to TAG
 TAG storage in liver cells increased and that results fatty liver.
2.1. Describe the mechanism of action of methotrexate in relation to nucleotide synthesis

 Methotrexate is an anti cancer drug.acts by reducing the proliferation of cancer cells by redcuing the synthesis of
DNA.
 For that , the formation of nucleotides need to be reduced.
 Methotrexate is a structural analogue of Folic Acid .
 Folic acid converted in to N10 formyltetrahydrofolate by the action of dihydrofolate reductase.
 N10 formyltetrahydrofolate is essential for conversion of Phosphoribosylamine pyrophosphate in to IMP.

 Inhibition of dihydrofolate reductase.by the action of Methotrexate causes reduction of N10-
formyltetrahydrofolate and that causes reduction in formation of IMP. That causes the reduction in nucleotide
synthesis.DNA formation reduced and cancer cell proliferation reduced.
2.2. Describe the oxidative deamination of amino acids. (20 marks)

Glutamate is the only amino acid that undergoes oxidative deamination. The ammonia group is liberated as free
ammonia. This process occurs in liver and kidney. The enzyme involved in this process is Glutamate dehydrogenase
which is a mitochondrial enzyme which uses either NAD+ or NADPH as its coenzyme.
This reaction is reversible and the direction depends on relative concentrations of glutamate, alpha
ketoglutarate, and ammonia and the ratio of oxidized coenzymes GTP is an allosteric inhibitor whereas ADP is an
activator of GDH enzyme.
14th Batch
14th Proper - MCQs
16. Regarding glycogen synthesis,

A) Glycogen phosphorylase is the key enzyme.
B) Protein phosphatase activates glycogen synthase.
C) Gycogenin acts as a primer.
D) Beta D glucose is the main component of glycogen.
E) Liver stores glycogen than skeletal muscle.
17. Regarding the role of glucagon on gluconeogenesis,

A) Acts through G protein coupled receptors.
B) Increases the level of fructose-2,6-bisphosphate.
C) Increases the transcription of phosphoenolpyruvate carboxy kinase.
D) Inhibits the conversion of pyruvate kinase to inactive form.
E) Promotes mobilization of amino acids from muscle protein.
18. Regarding pyrimidine metabolism,

A) Dihydrofolate reductase need for dihydrofolate convert into dTMP.

B) Fluorouracil is competitive inhibitor of thyamidylate synthesis.
C) Vitamin B1 responsible for folate trap.
D) Methotrexate prevent remethylation of dUMP.
E) Thymidylate synthase use N5-N10 methelene THF as the source of methyl group.
19. True/False,
A) Absorption of Amino acids occurs mostly by active transport.
B) Glutamate is temporary storage and major transport of NH3
C) Protein turnover is a continuous process.
D) Tyrosine metabolism contain melatonin and serotonin.
E) Phenylketonuria patients show hypopigmentation in hair, skin and eyes.
20. Synthetic inhibitors of purine synthesis,

A) Atorvastatin
B) Metformin
C) Mycophenolic acid
D) Sulfonamides
E) Methotrexate
21. True/False,
A) Adipose tissue rich in glycerol kinase.
B) Eicosanoids have 20 carbons
C) Long chain fatty acid transport across the inner mitochondria membrane by carnitine.
D) VLDL production increase fatty liver patient.
E) Fatty acid synthesis occurs in mitochondria matrix.
22. Cholesterol,
A) High in coconut oil.
B) Have a short half life.
C) Polar than cholesterol esters.
D) Synthesized by acetyl CoA by mammals.
E) Inhibits synthesis by Aspirin.
23. During starvation which of the following increase in blood / tissue,

A) Epinephrine.
B) Glucagon.
C) Glycogen.
D) Insulin.
E) Ketone bodies.
24. Regarding pentose phosphate pathway,

A) Involve in detoxification in liver.
B) It is a catabolic pathway.
C) Produce ribose 5 phosphate than NADPH in rapidly dividing cells.
D) Produce intermediates for glycolysis.
E) Occurs in endoplasmic reticulum.

25. Regarding phase 1 reactions in xenobiotic metabolism,
A) Conjugation occurs in here.
B) Mainly occurs in P450 mono oxygenase system.
C) Needs NADPH and O2.
D) Convert lipophilic subjects to hydrophilic substances.
E) Primarily occurs in kidney
SBR
48. A new born baby has milky white skin, white hair and red appearing eyes. What is the enzyme defect?
A) NADH Oxidase
B) Phenylalanine hydroxylase
C) Tyrosinase
D) Homogenestic acid oxidase
E) Cystathionine beta synthase
49. Regarding carbohydrate metabolism,

A) Fluoride ions inhibit glycolysis.
B) PFK1 is inhibited by alanine.
C) Gluconeogenesis occurs at all cells in the body except RBCs
D) Cori cycle occurs in resting muscle
E) Its possible to make glucose from acetyl CoA, if CoA levels are high
50. Milk appearance in lymph after take lipid rich food?

A) Branched chain FA
B) Cholesterol
C) Chylomicrons
D) Unsaturated FA
E) VLDL
51. Which organ most important in glucose homeostasis,

A) Heart
B) Liver
C) Lysosome
D) Skeletal Muscle
E) Spleen
14th Proper - SEQs
3. A patient was diagnosed as having alkaptonuria.

3.1
3.1.1 Name the causative factor. (05 marks)
3.1.2 Mention three (03) characteristic symptoms in such patients. (15 marks)
3.1.3. What dietary advice you would give this patient? (05 marks)
3.2 Briefly describe the regulation of fatty acid synthesis. (25 marks)

3.3. Explain how ketone bodies spare muscle protein during prolonged fasting. (25 marks)
3.4. Dietary lipids are fundamental nutrients for human health.

3.4.1 What are the primary products of lipid digestion? (08 marks)
3.4.2 State the role of bile salts in the absorption of dietary lipids. (12 marks)
3.4.3 List two causes for lipid malabsorption/steatorrhea. (05 marks)
14th Repeat - SEQs
3.
3.1. Briefly describe on,
3.1.1 Diagnostic importance of transaminases. (15 marks)
3.1.2 Briefly describe the regulation of cholesterol biosynthesis. (30 marks)
3.2. Briefly explain the metabolic changes occur in skeletal muscle during fed state. (30 marks)
3.3. Briefly describe the pentose phosphate pathway with regard to

3.3.1 Regulation (10 marks)
3.3.2 Functions (15 marks)
4.
4.1. Write short notes on,
4.1.1 Disorders of purine metabolism (30 marks)
4.1.2 Importance of xenobiotic metabolism. (20 marks)
16)
A) F Glycogen synthase is the key enzyme.
B) T Protein phosphatase remove the phosphate group covalently attach to glycogen synthase and activate the
enzyme.
C) T Lippincott page 126, 127.
D) F Alpha glucose is the main component glycogen.
E) F Approximately 400g – muscles , 100g - liver
17)
A) T Lippincott page 122
B) F Decrease the level of fructose 2,6 – bisphosphate .
C) T Lippincott page 122 ; induction of enzyme synthesis.
D) F As a result of covalent modification of enzyme activity; via elevation of cyclic AMP and cAMP dependent protein
kinase A activity , stimulate the conversion of hepatic
E) T Glycogen is a catabolic hormone.
18)
A) F dihydrofolate reductase is needed to convert dUMP into dTMP. DHF get converted into THF during the
reaction.
B) T
C) F B12 is the vitamin needed for folateliver
D) F Methotrexate prevents the methylation of dUMP into tUMP.

E) T
19)
A) T Most of the amino acids are getting absorbed into the enterocytes via sodium-dependent secondary active
transport by solute carrier proteins.
B) T Glutamine, the amide of glutamate provides the nontoxic storage and transport form of urea.
C) T
D) F The precursor of melatonin and serotonin is tryptophan.
E) T
20) Synthetic inhibitors of purine synthesis are,

A) F
B) F
C) T Reversible, inhibitor of inosine monophosphate dehydrogenase(IMP dehydrogenase)
D) T A structural analog of PABA.
E) T A folic acid analog.
21)
A) F Glycerol kinase is only found in liver.
B) T Eicosanoids are polyunsaturated fatty acids with 20 carbons.
C) T
D) F Nonalcoholic fatty liver occurs in conditions in which there is an imbalance between the TAG synthesis and the
secretion of VLDL.
E F FA synthesis is a cytosolic process.
22)
A) F
B) F Cholesterol declines at an exponential rate with a half-life ranging from 58 to 75 days.
C) T
D) T
E) F
23)
A) T Epinephrine, glucagon hormones are increasing during starvation.
B) T
C) F Increases in fed state.
D) F Increases in fed state.
E) T Ketone body level too increases during fasting.
24)
A) T NADPH helps in detoxification process in body.
B) F
C) T Produce ribose-5-phosphate needed for the nucleotide synthesis.
D) T Pentose phosphate pathway produce NADPH, Ribose-5-phophate and intermediates of glycolysis
E) F Occurs in cytosol.
25.
a) T Oxidation, reduction and hydrolysis reactions occur in this phase.
b) T
c) T
d) T
e) F Primarily occurs in liver.
SBR
48) C

Albinism
49) A
inhibits enolase enzyme in glycolysis pathway
50) C
51) B
3.1.1. Name the causative factor.

accumulation of Homogentisic acid due deficiency of homogentisic acid oxidase.
3.1.2. Mention three (03) characteristic symptoms in such patients.
3.1.3. What dietary advice you would give this patient?

Limit the dietary intake of phenylalanine and tyrosine by reducing consumption of Soyabean, fish, meat, cheese.
3.2. Briefly describe the regulation of fatty acid synthesis.

• Fatty acid synthesis is one o cytosolic process which occurs during well fed state.
• Mainly it occurs in the liver hepatocyte.
• Also it occurs in adipocytes and lactating mammary gland.
• In this process fatty acids are synthesized by using acetyl co-A.
• Regulation of fatty acid synthesis either can be short term or long term.
• In short term regulation it is more focused on it’s rate limiting step.
• This short term regulation can be 2 ways as,
1. Allosteric regulation
2. Covalent modification
• The rate limiting step of whole process is as follow.
• Biotin acts as the coenzyme.

• Citrate activate this enzyme accelerating the rate of the enzyme.
• Excessive accumulation of long chain fatty acids leads to reduce the rate of the reaction by feedback inhibition.
• Adequate amount of ATP also accelerate the rate of reaction.
• All of these are considered as allosteric regulation.
• Insulin , glucagon and epinephrine are important in covalent regulation.
• Insulin activates the acetyl co-A carboxylase enzyme through protein phosphatase.
• Glucagon and epinephrine inhibit the reaction by converting activated acetyl co-A carboxylase enzyme to the
inactive form by AMP depended protein kinase.
• Regarding long term regulation , high carbohydrate low fat diet increase the rate of fatty acid synthesis while
during at fasting or high fat ,low carbohydrate die the process is inhibited.

3.3. Explain how ketone bodies spare muscle protein during prolonged fasting.
• Most of our body process depend on energy.
• For the purpose of energy production cellular respiration occurs.
• Generally mostly used substrate for cellular respiration glucose.
• But there are other substrates like fatty acids, amino acids can participate this too.
• During the fasting period there are inadequate amount of glucose for the cellular respiration.
• Generally adipose tissue in our body has considerably large amount of fat deposition in
the form of TAG.
• During fasting they convert into fatty acids by lipase enzyme.
• These newly formed fatty acids transport to the liver.
• Within the hepatocyte these FA convert to fatty acyl co-A
• These fatty acyl co-A and other acetyl co-A convert into acetoacetyl co-A and finally using these acetoacetyl co-A
ketone bodies are formed in hepatocytes.
• This overall process is known as ketogenesis.
• There are 3 main ketone bodies as acetone , 3-hydroxybutyrate and acetone.
• But acetone is functionally inactive.
• These ketone bodies are then transport o periphery high energy needed areas like muscles.

• There are thiophorase enzyme and using this enzyme ketone bodies converted int acetyl co-A which is a substrate
for TCA cycle.
• Then TCA cycle and ETC occurs.
• This process called as ketolysis.
• When this ketolysis occurs in muscles during energy production the need to muscle proteins such as myosin , actin
to be participate in energy production is prevented.
• These adequate amount of energy for muscle contraction is taken from keolysis.
• This is known as muscle protein sparing effect of ketone bodies during fasting.
3.4.1. What are the primary products of lipid digestion

• Mono acyl glycerol
• Fatty acids
3.4.2. State the role of bile salts in absoprtion of diatery lipids.

• Bile production occurs in liver.
• Bile is important in lipid digestion and therefor it plays a vital role in case of absorption of lipids.
• Bile salts mainly consist of phospholipids, cholesterol, conjugated bilirubin, electrolytes and water.
• From the liver to the duodenum bile salts are transmitted through common bile duct which opens to the major
duodenal papilae through oddi's sphincter.
• Examples are,
• Diatery lipid digestion has 3 parts as,
▪ Processing
▪ Emulsification
▪ Digestion
• Bile salts are needed to the emulsification as these bile salts can act as ditergents.
• Through emulsification large fat droplets convert into small fat droplets.
• By this the surface area which the lipase enzymes (lipid digesting enzymes ) can act on increases. And leads to the
elevation of rate of fat digestion.
• This emulsification step occurs in duodenum.
• By this bile salts are important in fat absorption.
3.4.3. List two causes for lipid malabsorption/steatorrhea. (05 marks)

• Chronic or acute pancreatitis
• Common bile duct obstruction
• Cystic fibrosis
• Celiac disease
• Damage to the intestine
• Surgical removal of intestine
04.
4.1
4.1.1. Outline the disorders of galactose metabolism.
• Galactose is a monosaccharide.
• The dietary source of galactose is lactose. Which are rich in milk and dairy products.
• Also certain amount of galactose can be taken from the lysosomal degradation of glycolipids.
• Galactokinase is the enzyme which is important for the galactose metabolism.
• When this enzyme becomes deficient it leads to the excessive amount of galactose accumulation in body causing
galactosemia, galactoseurea.

• Galactose is converted into galactose 1 phosphate by galactokinase.
• There is another enzyme called aldose reductase which converts galactose into galactitol.
• Galactitol is osmotically very active component.
• When galactokinase enzyme is deficient there are more galactitol formation occurs specially in kidneys, retina,
lens, nerve tissues, seminal vesicles and ovaries.
• Due to Their high osmotic activity excessive accumulation leads to elevation of oxidative stress.
• Cataract formation in lens occurs.
• At the same time micro vascular diseases such as retinopathy, neuropathy, nephropathy occurs.
• Another disorder relate to galactose metabolism is classic galactosemia.
• Both classic galactosemia and galactokinase deficiency are rare autosomal recessive diseases.
• Classic galactosemia occurs due to the deficiency of galactose - l – phosphate uridylytranseferase.
• By this galactose - l - phosphate is convert into UDP galactose.
• Therefore excessive accumulation of galactose - l - phosphate occurs in body causing symptoms such as
galatosemia, galactoseuria.
• Also this enzyme deficiency indirectly increase galactitol formation by tending more aldose reductase actions on
galactose.
• Therefore cataract formation, retinopathy, neuropathy, nephropathy are also seen.
• The treatment for above mentioned 2 galactose metabolism related disease is limiting the dietary intake.
4.1.2. Briefly explain the biochemical basis of the mechanism of action of sulfonamides in bacterial infection.
• in case of formation of folic acid initially para-aminobenzoic acid (PABA) is used.
• Folic acid are needed for the synthesis of both purines and pyrimidines.
• Sulfonamide is a drug which is used to treat bacterial infections.
• Sulfonamide is a PABA analog substrate.
• Therefore it acts as competitive antagonist in bacterial cells.
• Purine and Pyrimidines synthesis of such bacterial cells are inhibited.
• The growth of such microberial cells has prevented.
• But there is no effect to nucleic acid synthesis in human bodies by sulfonamides.
• The reason is there is no folic acid synthesis in human body.
• Human body takes folic acids which are needed for purine and pyrimidine synthesis from outside.
• Therefore sulfonamides are used to treat bacterial infections in human body.
15th Batch
15th Proper - MCQs
18. Urea,
A) is metabolically inactive in liver
B) is hydrolyzed to NH3 and CO2 by human uricemia enzyme
C) is the principle nitrogenous compound in urine
D) level in blood is increased in kidney disease.
E) output in urine is not affected by diet

19. Disorder of methionine,
A) Cystathioninuria
B) Alkaptonuria
C) Histidinemia
D) Maple Syrup Urine Disease
E) Propynyl CoA carboxylase
20. HMG CoA reductase,

A) Decrease in diabetes mellitus
B) Decrease in fasting
C) Increase by bile acids/salts
D) Regulate cholesterol synthesis
E) Need NADPH/H+
22. Events happen during Fed state,

A) Activation of Acetyl CoA carboxylase in liver cells
B) Activation of Fructose 2,6-bisphosphatase in liver cells
C) Increased hormone sensitive lipase in adipose tissue
D) Increase in insulin level
E) Increased level of Malonyl CoA in liver
24. Regarding alcohol metabolism,

A) Alcohol dehydrogenase is an isoenzyme
B) Excess alcohol consumption increases the gene expression of cytochrome P450
C) Excess chronic intake causes lactic acidosis
D) NADPH act as an electron acceptor in alcohol oxidation
E) Oxidation of alcohol leads to free radical formation

A) adenosine is the only nucleoside to be salvaged.
B) PRPP is an activated pentose
C) occurs primarily in the liver
D) it is inhibited by purine nucleotides
E) It occurs all over the body
26. Regarding digestion and absorption of protein,

A) Amino acids are absorbed via Na+ co-transport mechanism
B) Amina acids transported across the apical membrane via facilitated diffusion into circulation
C) Chemical digestion begins in stomach
E) Pepsin break polypeptide into Amino acids
27. Hyperuricemia is seen in,

A) Decreased level of HGPRT enzyme
B) Increased level of ADA enzyme
C) High turnover of nucleic acids
D) Inhibition of xanthine oxidase
E) Unusually high PRPP

SBR
56. The most severe complication in uncontrolled diabetes mellitus,

A) Hyperuricemia
B) Hyperglycemia
C) Hyponatremia
E) Persistent hyperglycemia
57. In Maple syrup urine disease, accumulating compound is?

A) Branched chain alpha keto acid
B) Homocysteine
C) Homogentisic acid
D) Methyl Malonyl CoA
E) Phenyl alanine
59. Which of the following is correct regarding glycogenesis?

A) is an exergonic pathway
B) occurs in mitochondrial matrix
C) produces glucose-1-phosphate as the final product
D) requires Vitamin B6 as the coenzyme
E) stimulated by glucose-6-phosphate
60. The major control of de novo pyrimidine synthesis in man is,

A) availability of N-acetyl glutamate
B) competitive inhibitor of CPS11
C) feedback inhibition
E) substrate availability was
15th Proper - SEQs
3.
3.1 A 3-year old female child, brought to the emergency treatment unit following several episodes of vomiting and
fatigue. History and clinical examination revealed her
episodes mainly occurring after ingestion of fruits. Investigations revealed random blood glucose- 42 mg/dL,
hyperuricemia, and positive reducing sugars in urine.

3.1.2 State the cause for the above condition (05 marks)
3.1.3 State the biochemical basis of the symptoms mentioned above (20 marks)
3.2 Explain how aspirin reduces the risk of a heart attack (30 marks)
3.3 With the aid of a diagram, show the major metabolic pathways in the skeletal muscle
during fasting (15 marks)

3.4 Briefly describe "phenylketonuria" (25 marks)
4.
4.1 Purines are essential components of DNA and RNA.
4.1.1 State the sources of atoms of purine ring (10 marks)
4.1.2 Outline the regulation of purine synthesis with significance (15 marks)
4.2 Briefly discuss the significance of HMP pathway (25 marks)
18.
A)
B) F - Bacterial urease enzyme
C) T
D) T
E) F
19.
A) T
B) F - Tyrosine- homogentisate oxidase deficiency
C) F
D) F - Valine, isoleucine, leucine - branched chain dehydrogenase deficiency
E) F
20.
A) T
B) T
C) F
D) T
E) T
21.
A) T
B) F - present in pancreatic beta cells, liver parenchymal cells
C) T - diabetes mellitus causes destruction of pancreatic beta cells and decrease glucokinase level
D) T
E) F - not inhibited directly by Glucose-6-phosphate. But, indirectly inhibited by Fructose-6-
phosphate
22.
A) T
B) T
C) F
D) T
E) T
23.
A) T
B) T
C) T
D) F - Synthesized from arachidonic acid
E) F - Eicosanoids are local hormones that produced locally and rapidly metabolized into inactive
compounds
24.
A) T
B) T
C) T
D) T
E) T
25.
A) F
B) T
C) T
D) T
E) F
[Erythrocytes, polymorphonuclear leukocytes and brain cannot produce purines]
26.
A) T
B) T
C) T
D)
E) F
27.
A) T
B) T
C) T
D) F
E) T
SBR
56. E
57. A
58. D
UDP-galactose used to synthesis of Lactose, Glycolipid, Glycoprotein & Glycosaminoglycans (GAG)
59. E
60. A

3.1.1. What is the most likely diagnosis?

Hereditary Fructose intolerance (HFI)
3.1.2. State the cause for the above condition

Absence of aldolase B enzyme leads to intracellular trapping of fructose-1-phosphate.
3.1.3. State the biochemical basis of the symptoms mentioned above (20 marks)
These symptoms appear after when baby consuming fruits containing sucrose or fructose. High fructose diets and
hereditary enzyme deficiency causes to these symptoms. In the fructose metabolism 1 St reaction, phosphorylation
of fructose into fructose-1-phosphate is rapid, while aldolase B reaction is slow. Accumulation of fructose-1-
phosphate in the liver with decrease in intracellular Pi leads to "sequestered of phosphate ". So, lower production of
ATP and high ADP, AMP increasing catabolism of ADP,AMP.
As. ATP falls, AMP rises. The AMP is degraded to IMP, insoine, respectively xanthin,e hypoxanthine and finally Uric
acid by the presence of xanthine oxidase enzyme. This leads to hyperuricemia. The decresed availability of hepatic
ATP decreases gluconeogenesis causing hypoglycemia and vomiting. Decresed random blood glucose level than his
normal value 70- 110 mg/dl proves this hypoglycemia condition. Falling of ATP production and protein synthesis
leads muscle fatigue.
Diagnosis of HFI can be made on basis of fructose in urine. Sucrose is a non reducing sugar and
fructose is a reducing sugar. This gives positive reaction in benedict test of urine after sucrose
cleaves into glucose and fructose.
3.2 Explain how aspirin reduces the risk of a heart attack
 Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, fever, and/or inflammation,
and as an antithrombotic.
 Aspirin is also used long-term to help prevent further heart attacks, ischemic strokes, and blood clots in
people at high risk.
 Aspirin has been shown to be helpful when used daily to lower the risk of heart attack, clot-related strokes
and other blood flow problems in patients who have cardiovascular disease or who have already had a heart
attack or stroke. Many medical professionals prescribe aspirin for these uses.
 Aspirin is a blood thinner. It makes it difficult for the platelets in blood to form clots. This can help reduce the
risk of a heart attack and limit the severity of one that occurs.
 Aspirin slows the blood's clotting action by reducing the clumping of platelets.
 Platelets are cells that clump together and help to form blood clots. Aspirin keeps platelets from clumping
together, thus helping to prevent or reduce blood clots. Most heart attacks and strokes are caused by blood
clots.
 Aspirin reduces the risk for atherothrombosis through the inhibition of platelet function (through COX-1
inhibition) and has been used widely for the prevention of CVD events, particularly for secondary
prevention.
Mechanism of Action
Aspirin is a non-selective irreversible inhibitor of Cyclooxygenase enzyme.
Once Cyclooxygenase enzyme is inhibited endothelial cells can readily produce it as endothelial cells have a nucleus.
Platelets do not have nucleus. So, they cannot produce Cyclooxygenase enzyme.
So, concentration of prostacyclin increases with time.
So that aspirin act as vasodilator.
In platelets, the COX-1 enzyme produces thromboxane A2, a powerful promoter of platelet
aggregation.
Thus, aspirin, by irreversibly inactivating COX-1, thereby blocking the generation of thromboxane A2, derives a
potential antiplatelet effect.
3.3 With the aid of a diagram, show the major metabolic pathways in the skeletal muscle during fasting
Carbohydrate metabolism
● Glucose transport into skeletal myocytes via insulin-sensitive GLUT-4 and subsequent glucose metabolism are
decreased because circulating insulin levels are low.
● Therefore, the glucose from hepatic gluconeogenesis is unavailable to muscle and adipose.
Lipid metabolism
● Early in fasting, muscle uses FA from adipose tissue and ketone bodies from the liver as fuels.
● In prolonged fasting, muscle decreases its use of ketone bodies (thus sparing them for the brain) and oxidizes FA
almost exclusively.
● Epinephrine signaling increases LPL expression in muscle cells, allowing cells to take up additional FA from VLDL
triglycerides in the fasting state.
Protein metabolism
● During the first few days of fasting, there is a rapid breakdown of muscle protein (e.g., glycolytic enzymes),
providing amino acids that are used by the liver for gluconeogenesis.
● Because muscle does not have glucagon receptors, muscle proteolysis is initiated by a fall in insulin and sustained
by a rise in glucocorticoids.
● In the second week of fasting, the rate of muscle proteolysis decreases, paralleling a decline in the need for
glucose as a fuel for the brain, which has begun using ketone bodies as a source of energy. not developing cyanosis
in patients with severe anemia
3.4 Briefly describe "Phenylketonuria"

Phenylketonuria is caused by absence or deficiency of phenylalanine hydroxilase.
It is an autosomal recessive disease.
So, phenylalanine accumulates in all over body fluid. So patient presents with high concentration of phenylalanine in
plasma as well as in urine.
Excess amount of phenylalanine is converted to phenylpyruvate.
Patients may have defects in myalination of nerves and low brain weight. They may have mental retardation.
Patients will present with hypopigmentation and musty oder urine.
The life expectancy is drastically shortened.
4.1.1 State the sources of atoms of purine ring

CO2
N10-formyl THF
Aspartate
Glutamine
Glycine
4.1.2 Outline the regulation of purine synthesis with significance
Purine synthesis occurs in cytosol. It has 11 steps. 1st step is activation of pentose sugar. And the 2nd step is the
committed step of the pathway. So, this step is regulated by GPAT enzyme (glutamine phosphoribosyl
pyrophosphate amidotransferase). PRPP stimulate this enzyme and AMP, GMP inhibit the enzyme.
This enzyme’s Km is far bigger than the substrate concentration of PRPP. So, if any tiny changes happen in the
concentration of PRPP the purine synthesis will be multiplied.
This happens in the Lesch-Nyhan syndrome. In this case they are lack of HGPRT enzyme which synthesis purine via
salvage pathway. So, concentration of PRPP will be high and it multiple the purine synthesis. Eventually, it leads to
overproduction of urea.

4.2. Briefly discuss the significance of HMP pathway
HMP shunt is also known as Pentose phosphate pathway. While glycolysis pathway occurs to produce energy by
cellular respiration there is another alternative branch of glycolysis to produce sugars which is needed to DNA and
RNA synthesis.
HMP shunt pathway begins with glycolytic intermediate Glucose-6 phosphate (G6P). The end products of the
pathway are glyceraldehyde-3P and fructose-6P. These two end products are already intermediates of glycolytic
pathway. No ATP is consumed or produced in this pathway. The pathway yield NADPH (which used in anabolic
reactions requiring electrons) and Ribose-5-P (which is used in nucleotide synthesis). HMP shunt occurs in the
cytosol in 2 phases
1. Oxidative phase – irreversible , reaction produce NADPH
2. Non-oxidative phase - reversible, reaction produce ribose-5-P
Demand for NADPH are,
• Biosynthetic pathways like fatty acid synthesis, Cholesterol synthesis, steroid hormone synthesis
• Detoxification in liver (cytochrome p450)

Xenobiotics are hydroxylate by using NADPH ,through this pathway cytochrome p450 detoxify drugs by
oxidation
• Hydrogen Peroxide reduction

Reduction of oxygen molecule in a series of one electron steps yield superoxide, Hydrogen peroxide, hydroxyl radical
& water. The intermediate form called as reactive oxygen species, this cause serious chemical damage to DNA,
protein and cause cell death. It cause cancer and inflammatory disease & cell aging.
Reduced glutathione as an antioxidant in RBC - reduced glutathione protect the RBC from free redicals. To
Regenerate reduced glutathione(GSH) from it’s oxidized (GS-SG) need NADPH.
• Generation of superoxide (neutrophils) -

In phagocytic cells microorganism is phagocytosed by lysosomal enzyme. NADPH oxidase in tyhese cells convert
molecular oxygen in to superoxide, superoxide plus chloride ions are converted in to hydrochlorous acid that kills
bacteria
• Hydrogen peroxide reduction
• Synthesis of nitric oxide -

L arginine converted in to L citrulline by using NADPH and produce NO gas, NO (nitric oxide) has lot of function in
human body
- Smooth muscle relaxation blood vessel dilation
- Prevent platelet aggregation
- Acts as a neurotransmitter
- Mediate tumour & bacteriocidal actions of macrophages
Glucose-6-P dehydrogenase enzyme deficiency (G6PD deficiency) leads to heamolytic anemia. Lak of NADPH leads
increasing the demage to the RBC membrane by free radicals.

GASTROINTESTINAL SYSTEM
EME QUESTIONS
1. Regarding anatomy of salivary gland,

A) External carotid artery is embedded deep inside the parotid gland
B) Parotid duct is palpable on the clenched masseter
C) Submandibular gland has large deep part and small superficial part
D) Parotid duct opens in mucosa against 2nd molar teeth
E) Parotid gland has its own tough capsule
2. Regarding Inguinal Canal,

A) Oblique intermuscular slit
B) Deep inguinal ring lie just above the middle of the inguinal ligament
C) Has 3 coverings
D) Ilioinguinal nerve pass through the deep inguinal Ring
E) Hernia sac of direct inguinal hernia pass lateral to inferior epigastric artery
3. Regarding oral cavity and tongue,

A) Floor of the oral cavity is formed by the dorsum of the tongue
B) Intrinsic muscles have not attachment with bony parts
C) Tongue is drain into jugular omohyoid lymph nodes
D) Roof of the oral cavity is roughened by ridges
E) Muscle of soft palate is exclusively innervated by vagus
4. Contents of gastric juice,

A) Pepsinogen
B) Trypsinogen
C) Rennin
D) Lipase
E) Secretin
5. Defecation reflex,
A) Is mediated at L2, L3 level
B) Mediated by parasympathetic nerve.
C) Affected by mid spinal injury
D) Detention of colon induce desire to defecate
E) is Absent in babies
6. Regarding digestion,
A) Amylase
B) The emulsification decrease the surface area of the hydrophobic lipid droplets
C) The conjugated bile salts act as detergent
D) Pancreatic PhosphoLipase A2 require bile salts for optimum activity
E) CCK decrease gastric motility

7. 1st part of duodenum,
A) Intraperitoneal
B) Is derivatives from midgut
C) Minor duodenal papilla
D) Has hepatoduodenal Colonic content
E) Has hepatoduodenal ligament proximal
8. Spleen,
A) lies deep to the 9th, 10th, 11th ribs
B) Reserve as a blood reservoir
C) Is a retroperitoneal organ
D) Extend downward and medially when enlarge
E) Is covered anteriorly by fundus of stomach
9. True/False,
A) Ulcer in the posterior aspect of the duodenum will damage the gastro duodenal artery
B) Stretching of phrenoesophageal ligament involved in sliding hiatal hernia Perforated gastric ulcer might cause of
portal vein
C) Perforated gastric ulcer might cause of portal vein
D) Pain of the appendix commence at peri umbilical region
E) Valvula common in less mobile ascending colon
10. Regarding development of gastro intestinal tract,

A) Spleen derived from fore gut
B) Ventral mesentery extend from esophagus to cloaca
C) Rotation of stomach tack place anti clockwise
D) Is due to stretching of phrenico - oesophageal ligament
E) Volvulus cause due to Meckel’s diverticulum
SBR
11. Most powerful stimulus for the release of secretin is,

A) Products of protein synthesis
B) Histamine
C) HCl
D) CCK
E) Vagal stimulation
12. Which of the following has the highest pH?

A) Gastric juice
B) Pancreatic juice
C) Gistamine
D) Saliva
E) CCK
13. Following enzymes are elevated in liver disease. Except,

A) Alanine transaminase
B) Aspartate transaminase

C) G-Glutamyltransferase
D) Alkaline phosphatase
E) Amino glutamine transpeptidase
14. Regarding peptic ulcer in posterior wall of stomach,

A) Obstruction of hepatic portal vein
B) Obstruction of superior mesenteric artery
C) Obstruction of the bile duct
D) Obstruction of portal vein
E) Obstruction of inferior mesenteric vein
15. Lower part of the anal canal draining in to which group,

A) Superficial inguinal nodes
B) Pre rectal lymph nodes
C) Para rectal lymph nodes
D) Sacral lymph nodes
E) Internal iliac nodes
1.
1.1 Explain the physiological basis of the following,
1.1.1.Diarrhea in lactose intolerance
1.1.2.Pale, greasy and bulky stools in bile duct obstruction (60 marks)
1.2 Briefly describe the classification of liver function test with examples. (40 marks)
2.
2.1 A 60 year old female patient was admitted to ward with severe dysphagia (difficult to swallowing).
She was diagnosed with carcinoma at the gastro esophageal junction.
2.1.1 State the reason for dysphagia in this patient. (05 marks)
2.1.2 Describe the gross and microscopic anatomy of the oesophagus (40 marks)
2.2 A posterior gastric ulcer might result in severe hemorrhage in the peritoneal cavity.
2.2.1 State the structures that form the stomach bed. (20 marks)
2.2.2 Explain the anatomical basis of above condition. (10 marks)
2.3 List five features of large intestine that can be distinguished from small intestine.
(10 marks)
2.4 Outline the blood supply of the large intestine. (15 marks)

1.
A T & Its terminal branches
BT
CF
D T 2ND Upper molar tooth
EF
2.
AT
BT
C F Testis and spermatic cord which run through the canal has 03 covering
DF
E F medial
3.
A F Mylohyoid muscle
BT
CT
DF
E T Except tensor veli palatine by medial pterygoid nerve (CN 5)
4.
AT
BF
CT
DF
EF
5.
A F Sacral level
BT
CF
DF
E F Present higher control is less
6.
A-
B F Increase
CT
28
DT
E T Potent inhibitor of gastric emptying
7.
A F 2.5cm intra 2.5cm retro
BF

CF
DF
E T In proximal part
8.
AT
BT
CF
D F Downward and forward
EF
9.
AT
BT
C F Perforated peptic ulcer cause fistula in duodenum and portal vein
DT
E F Common in mobile parts
10.
AF
BF
CF
D - Phrenoesophageal stretching Cause hernia
ET
SBR
11 C
12 A
13 D
14 E
15 E
01.
1.1.1
 in humans intestine there is an enzyme called lactase, to digest lactose in dairy products.
 Intestinal lactase activity is high at birth, then declines to low levels during childhood and adulthood.
 The low lactase levels are associated with intolerance to milk.
 When such individuals ingest dairy products, they are unable to digest lactose sufficiently.
 Therefore cannot absorb lactose.
 Unabsorbed osmoles that are subsequently digested by colonic bacteria.
 This osmotic ally active particle causes fluid influx in the lumen of gut.
 Causes diarrhea.
1.1.2.
 Bile secreted by liver and stored in gall bladder.
 Released via bile duct.
 Bile acids contained therein are responsible for the emulsification of fat preparatory to its
Digestion and absorption in the small intestine.
 When there is an obstruction in bile duct bile cannot released into the intestine.
 So fat cannot digested and absorbed.
 Fat will excreted with stools it will give greasy and bulky appearance to stools.
 Also the reason of the color of the stools is the bile pigments - bilirubin and biliverdin.
 If there is no bile, stools will appear in pale color.
1.2.
LFT are classified as:
 Liver protein test:

o Albumin levels.
o Globulin levels.
o Albumin to globulin ratio.
o Prothrombin time.
 Liver enzyme test:

o Alkaline phosphatase(ALP)
o Alanine aminotransferase (ALT)
o Aspartate aminotransferase (AST)
Bilirubin tests:
Bilirubin
 A by-product of red blood cell breakdown

 It is the yellowish pigment observed in jaundice
 High bilirubin levels are observed in:
o Gallstones, acute and chronic hepatitis
1. Serum bilirubin levels

o Normal: 0.2 – 0.8 mg/dL
o Unconjugated (indirect): 0.2 – 0.7 mg/dL
o Conjugated (direct): 0.2 – 0.4 mg/dL
2. Urobilinogen(UBG) and bile salts

 Most UBG is metabolized in the large intestine but a fraction is excreted in urine (less than 4 mg/day)
 Normally bile salts are NOT present in urine
 Obstruction in the biliary passages causes:
o Leakage of bile slats into circulation
o Excretion in urine
 Sensitive indicator of
o Hepatocellular dysfunction
o Alcoholic liver damage
Liver protein tests:
1. Serum Albumin
2. Serum Globulin
3. Albumin to globulin (A/G) ratio
4. Prothrombin time
Liver enzyme tests:
1. Alkaline phosphatase (ALP)

2. Alanine aminotransferase (ALT)
3. Aspartate aminotransferase (AST)
4. Gamma-glutamyl transferase (GGT)
02]
2.1
2.1.1.
 Carcinoma will block the gasroesophgeal junction.
 Therefore food cannot go from esophagus to stomach.
 Food will accumulate in lower esophagus.
 Therefore patient cannot swallow.
2.1.2.
 muscular tube
 25 cm long
 begins at the lower border of the cricoid cartilage (at C6 )
 passes through the diaphragm at T10
 ends in the abdomen at the cardiac orifice of the stomach at T11
 commences in the midline in front of the prevertebral fascia
 then inclines slightly to the left
 then inclines slightly to the left
 passes downwards through the superior mediastinum
 At T5 vertebra the oesophagus returns to the midline
 at T7 it deviates again to the left
 pass in front of the descending thoracic aorta and pierce the diaphragm 2.5 cm to the left of the midline
 Here fibres from the right crus of the diaphragm sweep around the oesophageal opening
 Relation
Cervical part
 Anterior:
 Thyroid gland.
 Trachea
 Posterior:
 CV6 & CV7
 Prevertebral fascia

 Lateral:
 Carotid sheath and its contents
 Lobes of the thyroid gland.
 Recurrent laryngeal nerve.
 Cervical pleura at the root of the neck.
 Left:
 Thoracic duct
 Subclavian artery
Thoracic part
In superior mediastinum
 Anterior:
 Trachea
 Left bronchus
 Posterior:
 Bodies of the T1-T4 vertebrae.
 Thoracic duct lies on the left side of the esophagus
 Azygos vein and its tributaries
 Right:
 Pleura
 Azygos vein
 Left lateral
 Terminal part of the arch of the aorta.
 Left subclavian artery
 Thoracic duct
 Left recurrent laryngeal nerve
 Left pleura
In posterior mediastinum
 Anterior:
 Pericardium
 Diaphragm
 Posterior:
 Thoracic vertebrae (TV5 – TV10)
 Descending aorta
 Azygos venous system
 Right:
 Thoracic duct
 Encircled by nerve plexus (right and left vagi)
 Normally esophagus has 3 constrictions
I. Cervical constriction
 upper esophageal sphincter
 pharyngoesophageal junction
 approximately 15 cm from the incisor teeth
 by the cricopharyngeus muscle.
II. Thoracic (broncho-aortic) constriction:

 arch of the aorta (22.5 cm from the incisor teeth)
 main bronchus (27.5 cm from the incisor teeth)
III. Diaphragmatic constriction:

 esophageal hiatus of the diaphragm
 approximately 40 cm from the incisor teeth.
Blood supply
Arterial supply:
• Inferior thyroid artery – upper part
• Esophageal branches from to middle part
• Thoracic aorta
• Bronchial arteries
• Left gastric artery – lower part
Venous drainage:
• Upper part -> brachiocephalic vein
• Middle part -> azygos venous system
• Lower part -> left gastric vein -> portal vein
Venous drainage
From per-esophageal lymph plexus into
• Supraclavicular LNs
• Posterior mediastinal LNs
• Coeliac LNs
Nerve supply
Motor:
Upper part:
 Recurrent laryngeal nerve (Nuc.Ambiguous)
 Sympathetic nerves (mid.cer.Gan) -> Inf.Thy.Arteries.
Middle part:
 Thoracic sympathetics
 Greater splanchnics
 Vagus from esophageal plexus
Lower part:
 Vagus from esophageal plexus ( Dorsal Motor Nucleus)
 Secretory motor:
 vagi
Sensory:
 Through vagi and sympathetics.
Microscopic
Wall:
 Mucosa:
-Non-keratinized stratified squamous.
-Longitudinal folds.
 Submucosa: mucous glands.
 Internal circular
 external longitudinal layers of muscle
 Proximal third - voluntary striated muscle
 Distal third - smooth muscle

 middle third - both types of muscles.
 No serosa except abdominal part.
2.2
2.2.1.
2.2.2.
 The splenic artery that arises from coeliac trunk passes behind the posterior wall of stomach to supply the
spleen.
 When there is an ulcer in posterior stomach wall ,ulcer will erode posterior wall and damage the splenic
artery
 Therefore splenic artery bleeds into the peritoneal cavity.
2.3.
 Appendices epiploicae
 Tinea coli
 Sacculations
 Mesocolone
2.4.
Caecum
• SMA -> Ileocolic artery -> Anterior & Posterior (large) caecal arteries.
• Anterior & posterior caecalveins -> SMV -> Portal vein
Colon
• SMA –> RIM -> As colon & proximal 2/3 of Transverse colon.
• IMA -> left colic and sigmoid arteries -> distal Transverse colon, Descending colon & Sigmoid colon.
• Tributaries -> SMV or IMV -> Portal vein.
• Portosysytemic anastomosis between As. colon & Ds. Colon in posterior abdominal wall.

1. The abdominal esophagus,

A) Enter the abdomen between the right and left cruse of the diaphragm
B) Is enveloped by the peritoneum.
C) Is closely related to both the anterior and posterior gastric nerve
D) Is closely related to the left lobe of the liver
E) Is surrounded by an external esophageal sphincter.
2. The stomach,
A) has complete peritoneal covering.
B) Completely covered the lesser sac anteriorly.
C) Is solely supplied by branches of coeliac trunk.
D) Epithelium is always simple columnar in type.
E) Lymph drained in to coeliac lymph nodes.
3. The common bile duct,

A) Descends behind the portal vein.
B) Accompanies the gastro-duodenal artery.
C) Opens in the second part of the duodenum.
D) Is surrounded by the lymph nodes at the porta hepatis.
E) Lies in the right side of the hepatic artery in the lesser omentum.
4. A patient with Zollinger-Ellison syndrome would be expected to have which of the following changes?
A) Decreased serum gastrin level
B) Increased serum Insulin level.
C) Increased absorption of dilatory lipids.
D) Decreased parietal cell mass.
E) Peptic ulcer disease.
5. The Secretion of which of the following substances is inhibited by low pH,

A( Secretin.
B) Gastrin.
C) Cholecystokinin (CCK).
D) Vasoactive Intestinal Peptide.
E) Gastric Inhibitory Factor.
6. Relations of 1st part of the Duodenum are,

A) Anteriorly – Gall Bladder.
B) Posteriorly – Gastro duodenal artery.
C) Inferiorly – Head of pancreas.
D) Superiorly – Epiploic foramen.
E) Medially – Bile duct.
7. Meckel’s diverticulum,
A) Arise from mesentery of ileum.
B) May contain gastric mucosa, Liver or pancreatic tissue lead to ulceration.
C) Remnant of the vitellointestinal duct.

D) 2 feet distal to the ileocecal junction.
E) Normally contributes no pain.
8. Which of the following factor/ factors inhibit the gastric emptying,

A) CCK
B) Motilin
C) Pregnancy
D) Secretin
E) VIP
9. Regarding gastrin secretion,

A) Amylase
B) It has pH 1.5 – 3.5
C) It is high in Zollinger Ellison syndrome
D) It is most contributed by cephalic phase of secretion.
E) Parietal cells secrete gastric acid.
10. Amylase,
A) action is facilitated by gastric acid.
B) enzyme responsible for protein digestion.
C) found in saliva.
D) release increased in acute pancreatitis in blood.
E) release is stimulated by CCK.
SBR
11. A surgery was done to ligate the splenic artery from its origin. Which one of the following would least likely to
be effected?
A) body of pancreas.
B) body of stomach.
C) duodenum.
D) body of the stomach.
E) tail of the pancreas.
12. 60-year old male admitted to hospital due to carcinoma in lower GI tract. Biopsies were taken from para
rectal, internal iliac and superficial inguinal lymph nodes. Metastatic cells were present only in superficial inguinal
group of lymph nodes. Which of the following area is associated with the carcinoma?
A) upper 3rd of the rectum.
B) upper 1/3 of anal canal.
C) upper 2/3 of rectum.
D) Lower 1/3 of anal canal.
E) Lower part of the Sigmoid colon.
13. A young patient present with steatorrhea after resection of ilium for bowel injury. What is the physiological
basis of above condition?
A) failure to digestion of triglycerides.
B) Due to lipase over secretion.
C) Malabsorption of fat soluble vitamins.

D) failure to form micelles in the gut.
E) increase liver bile pool.
14. What is the most correctly matching surgical incision for the abdominal viscera?
A) Right subcostal incision – Duodenum
B) Right Pfannenstiel incision – Stomach
C) Gridiron incision - Appendix
D) Left subcostal incision – Left Kidney
E) Midline incision – Urinary bladder.
15. A low PT time occur in persons,

A) after taking blood thinning medicine.
B) severe liver diseases.
C) vitamin K deficiency.
D) inherent blood disorder.
E) take birth control pills.
1.
1.1. Briefly describe the secretion of saliva and its regulation. (40 Marks)

1.2.1 Enterohepatic circulation of bile salts. (20 Marks)
1.2.2 Physiological consequences of ileum. (20 Marks)
1.3. Outline the test based on the excretory function of liver. (20 Marks)
2..
2.1 Outline the relation and blood supply of
2.1.1 Head of pancreas
2.1.2 Neck of pancreas
2.1.3 Body of pancreas

2.2.1 Blood supply and lymphatic drainage of stomach
2.2.2 Sphincters of anal canal
1.
A F Aorta enter to the abdomen In between cruse of diaphragm. For oesophagus have a separate opening in the
muscular part of the diaphragm.
B F Abdominal oesophagus have a peritoneal covering but it is not applicable to thoracic part. (do not cover
completely- Last’s pg249 12th E)
CF

D T Visceral surface of the liver has an impression of oesophagus
E T Crura of the diaphragm function as the external oesophageal sphincter.
02.
A T By lesser and greater omentum.
B F Cover the part of lesser sac anteriorly
C T Coeliac trunk- supply the derivatives of the foregut
D T Gastric mucosa- simple columnar cells
ET
3.
A F In front of right edge of portal vein. Hepatic artery on its left.
B T Retroduodenal part accompany the gastroduodenal artery.
C T Posteromedial wall of duodenum at major duodenal papilla. 10cm from pylorus
DT
E T Hepatic artery on its left
4.
A F Zollinger-Ellison syndrome Gastrin secreting tumor High secretion of gastric acid
Damage the mucosa Ulcer
B T Pancreatic tumor
C F Malabsorption – steatorrhea
DF-
ET–
5.
A F Acid in duodenum cause to increase secretion of secretin
B T Low pH- inhibit gastrin secretion by negative feedback mechanism
C F Acid in duodenum increase secretion of CCK
D
E
6.
AT
BT
CT
DT
EF
7.
A F Arise from antimesenteric border of ileum. 40-60cm from ileocecal junction.
BT-

C T (Langmann’s pg245)
D T 60cm from ileocecal junction/ 02 feet
E T Usually no symptoms
8.
AT
B
C
D
E
9.
A F Content
- HCl
- pepsinogen and HCO3-
B T pH 1.5-3.5
C T Zollinger-Ellison syndrome- gastrin secreting tumor
D F Cephalic phase – input from higher centers Most prominent secretion occur in gastric phase by
direct contact of meal Activate stretch receptors Provoke vagovagal response
E T Parietal cells - HCl
10.
A F Salivary alpha amylase activity stopped in stomach due to low pH
BF Salivary alpha amylase
Starch maltose
Pancreatic alpha amylase maltotrrose
alpha-limit dextrins
CT-
D T Acute pancreatits – hormones released into GI tract.
serum amylase test in bile duct obstruction
E T Secretion of pancreatic juice rich in enzymes
SBR
11 C Coeliac trunk
Duodenum – foregut and midgut derivatives, so get

blood from both coeliac trunk and superior mesenteric artery.
12 D
13 E Ileal resection
– enterohepatic circulation

14 C
15 E Prothrombin time – extrinsic pathway of clotting cascade

B. liver is the major site for clotting factor synthesis
C. vitamin K – need for gema carboxylation of 2,7,9,10 clotting factors
01)
1.1. Briefly describe the secretion of saliva and its regulation
– hypotonic, Alkaline, PH 6-7
1.2. Write account on

1.2.1. Enterohepatic circulation of bile salts
Cholesterol metabolism
↓
Bile salts
(Cholic acid, chenodeoxycholic acid)
↓
Via bile duct enter into the gut

↓
Within the gut they are converted into secondary bile salt by Conjugation of glycine and to urine
↓
As it reaches the ilium 95% of these bile salt reabsorbed into portal circulation and reenter to the liver
Only a small percentage leave via feces
→ steatorrhea
1.2.2. Physiological consequences of ilium

A. Steatorrea
B. B12 deficiency
-B12 intrinsic factor absorption occur at ileum
crocytic megaloblastic anemia
1.3. Outline the test based on the excretory function of liver

- 0.7mg/dl
- 0.2-0.3mg/dl
-1mg/dl
irubin > 2mg/dl → Jaundice
– UCB ↑
– UCB ↑ / CB ↑
– CB ↑
B. Urine bilirubin
-bile duct obstruction
C. Urine urobillinogen
ease in when there’s obstruction to bile flow
D. Urine bile salt
02)
2.1. Outline the relation and blood supply of
2.1.1. Head of pancreas

ric vessels.
Anterior relations
Posterior relations
Blood supply – Superior and inferior pancreaticoduodenal artery and vein
2.1.2Neck of the pancreas
Anterior relations
Posterior relations
SMV joins the splenic vein to form the hepatic portal vein
Transvers mesocolon is attached towards the lower border.
Blood supply – Pancreatic branches of splenic artery
Venus drainage – Pancreatic veins

2.1.3. Body of pancreas
aorta and L2 vertebra posterior to the omental bursa

Slopes upward across
Superior border
at the origin of the coeliac trunk
Inferior border
Posterior surface
vein
Transvers mesocolon is attached along the anterior border
Lies behind the lesser sac
Blood supply – Pancreatic branch of splenic artery
Mainly –>Arteria pancreatica magna
Venus drainage – Pancreaic veins -> Splenic vein.
2.2. Write an account on

2.2.1. Blood supply and venous drainage of stomach

– uppermost part of greater curvature
Supplied by short gastric arteries from splenic artery in gastrosplenic ligament
Rest of greater curvature – left and right gastroepiploic arteries
They are anastomose with each other, between two layers of greater omentum.
y
2.1.3. Sphincters of anal canal.
1. External anal sphincter

2. Internal anal sphincter
External anal sphincter
I. Deep part
II. Superficial part
III. Subcutaneous part
ation

– anococcygeal ligament
External sphincter
Iliococcygeus and pubococcygeus components
Overlying superior fascia of pelvic diaphragm
I. Transvers perineal and

II. bulbospongious muscles at perineal body
rs
Internal anal sphincter
Outer longitudinal layer of rectal muscle

↓
Become fibroelastic
↓
Together with striated muscle fibers of puborectalis
↓
From conjoint longitudinal coat
↓
Runs down between two sphincters
Lower part of external sphincter

ome reach fat of ischioanal fossa
Perineal skin
Particularly the pectinate line

1. Function of saliva,
A) Helping perception of taste
B) Heavy metal excretion
C) Nucleotide digestion
D) Peptone formation
E) Excretion of Na+
2. Functions of large intestine,

A) Reabsorption of water and electrolytes
B) Secrete HCO3-
C) Reabsorption of bile salts
D) Reabsorption of Vitamin B12
E) Production of Vitamin K
3. Inter maxillary segment form the,

A) Philtrum of the upper lip
B) Hard palate
C) Tongue
D) Gum
E) Soft palate
4. Regarding common bile duct,

A) It commence at the intra hepatic tissue
B) Runs through the margin of the lesser omentum
C) Cystic duct join with common hepatic duct by acute angle in the left side
D) Is related anteriorly to right branch of the hepatic artery
E) Could be injured during arterial ligature in cholecystectomy
5. Rectum,
A) is anterior to the analcoxygeal ligament
B) Middle part of the Rectum is fully covered by peritoneum
C) Rectum is the terminal part of the Pelvic cavity
D) It does not contain longitudinal muscle fibers in muscularis externa
E) In rectal examination, semilunar vesicles are palpable
6. Pharynx,
A) Made up of smooth muscles
B) Extend from C1-C6
C) Lies posterior to the airway
D) Sensory innervation by CN 5, 9, 10
E) Can be injured in piriform recess
7. Regarding pancreas,
A) Accessory pancreatic duct drains uncinate process
B) Body lies on transpyloric plane
C) Hepatopancreatic ampulla obstruction cause reflex of bile into pancreatic duct

D) It is an intraperitoneal organ
E) Pancreatic head tumor cause extra hepatic obstruction of biliary tract
8. Appendix,
A) Base lies in Mcburney’s point
B) Retrocecal posteriorly
C) Has taenia coli
D) Open in to the posterior medial wall of the cecum
E) Swallowing and pain in the periumbilical region during appendicitis
9. Regarding spleen,
A) covered by mesentery
B) Is a readily palpable organ
C) Has red pulp for defense function
D) 9th, 10th, 11th rib level
E) Helps in digestion and absorption of carbohydrates
10. Degradation of carbohydrates,

A) Amylase hydrolase alpha 1-6 glycolytic bonds
B) Deficiency of disaccharides cause to diarrhea
C) Fructose utilize Na+ dependent monosaccharide transporter for absorption
D) Its digestion decrease in stomach due to increase of acidity
E) Ileum absorbed monosaccharides as bulk
SBR
11. Cephalic phase of gastric secretions is mediated by,

A) Vagus
B) Glossopharyngeal
C) Phrenic
D) Hypogastric
E) Accessory nerve
12. What is the organ that absorb more fat?

A) Stomach
B) Duodenum
C) Jejunum
D) Ilium
E) Colon
13. A 45-year old women admitted to hospital with acutely painful abdomen. Examination reveals, penetration of
fundus region of stomach by an ulcer result in infraabdominal bleeding. Which one is the most likely source of
bleeding?
A) Common hepatic artery
B) Left gastric artery
C) Left gastroepiploic artery
D) Short gastric artery
E) Splenic artery

14. In normal person without any liver damage, the consumption of high alcohol what can be elevate in plasma?
A) Alanine aminotransferase
B) Aspartate aminotransferase
C) Gamma glutamine transferase
D) Alkaline phosphate
E) Lactate dehydrogenase
15. What are the branches that anastomose in lower part of the esophagus?
A) Left gastric and azygous
B) left gastric hemiazygos
C) right gastric azygous
D) Superior epigastric and inferior epigastric
E) Superior epigastric and azygous
1. People who have undergone gastrectomy often complain of

1.1 Reduced tolerance for large meals
1.2 Light headedness after eating
1.3 Diarrhea
1.4 Anemia after several months
Explain the physiological basis of the above symptoms. (4*20 Marks)
1.5 Explain the difference between the blood supply, nerve supply and lymphatic drainage of anal canal and the
state underlying reason for the above differences. (20 Marks)
2.
2.1. Tumor of the 3rd part of the duodenum causes compression to an artery.
2.1.1 State the relations of 3rd part of the duodenum. (15 Marks)
2.1.2 Name the artery being compressed. (10 Marks)
2.1.3 Describe the course, origin and distribution of the artery. (30 Marks)
2.2 Outline the nerve supply of the stomach. (15 Marks)

2.3.1 Extension, course and relations of parotid duct (15 Marks)
2.3.2 Surface markings of the liver and gall bladder (15 Marks)
01.
AT
BT
CF
DT
ET

02.
AT
BT
CF
D T Mainly in ileum
E T Bacterial flora
03.
A T By lateral component ( upper jaw component-4 incisors , palatal component-primary palate) ( pg:278 Langman)
BF
CF
DF
EF
04.
AF
BT
C F Right side mainly
D F Common hepatic duct
ET
05.
AT
B F Only the front
CT
DF
E F Normal seminal vesicles not palpable (prostate can be palpable)
06.
AF
B F Base of skull to C6
C F Nasopharynx - part of the airway
DT
ET
07.
AT
BT
CT
DF
ET
08.
AT
BT
CF
D F Posteromedial wall

E T T10 referred pain
09.
AT
BF
CF
DT
EF
10.
AF
B T Ex: lactose intolerance
C F GLUT-5 ( independent from Na+)
DT
EF
BEST ANSWERS
11 A
12 D Enterohepatic circulation
13 E
14 C GGT - used as a marker of alcohol abuse
15 A
01. people who have undergone gastrectomy often complain of

1.1 reduced tolerance for large meals
1.2 light headedness after eating
o Removal of the stomach.
o Main function is store the meals for about 2 hours and do a gastric emptying.
als.
to tissue (hypoglycemia).
o Weakness.
o Dizziness (lack of glucose to brain).

1.3
↓
Osmotically active particles cause movement of water into the gut.
↓
Leads to diarrhea
1.4
o Secrete intrinsic factor.
o Deficient intrinsic factor cause decreased/no B12 absorption.
o Macrocytic megaloblastic anemia.

o CNS malformation.
(Because B12 needed for nucleotide metabolism)
1.5
o Upper end – superior rectal artery.
o Lower end – inferior rectal.
o Upper end - drain via superior rectal and inferior mesenteric to portal system.
o Lower end – inferior and middle rectal veins into internal iliac to systemic circulation.
o Upper end – lymph of rectum.

o Lowe end – superficial inguinal.
o Inferior rectal branch of pudendal nerve.

o External anal sphincter.
o Sensory to 1-2cm above pectineal line.
o Autonomic fibers – internal anal sphincter.
o Upper end of anal canal.
o Afferents from upper end carried by both sympathetic and parasympathetic nerves.
o Upper part (2/3).

ed from endoderm of the hind gut.
o Lower part (1/3).
o So anal canal has a two different embryological origins.

o Which lead to difference in,

– columnar epithelium.
– stratified squamous.
(02)
2.1.
2.1.1. Relations of third part of duodenum
-anteriorly
-posteriorly
Right gonadal vessels
-superiorly
-inferiorly
2.1.2. Abdominal aorta

2.1.3. Course -
ic aorta becomes abdominal aorta by passing behind the median arcuate ligament and between the
crura at T12 level
common iliac arteries.
-relations
-surface markings
o a point 1-2cm below and left of normally umbilicus
-branches
- first branches from abdominal aorta

Slope upwards over the cruras of diaphragm
Supply diaphragm
Give small supra renal branches
- between inferior phrenic and renal branches
Right-passes behind IVC, Left- passes behind posterior wall of Lesser sac
- arise at a right angle at L2 level
Left shorter than right
Both approach hilum of each kidney and divided into segmental Branches
- similar origin in both sexes

Testicular and gonadal arteries
Above the origin of IMA
- 4 pairs
Leave the aorta opposite the bodies of upper 4 vertebrae
- a small posterior branch leaves aorta little above the bifurcation.
Anastomose with lateral sacral arteries and give blood supply to rectum
2.2.Nerve supply of stomach

- along with arterial branches- innervates the stomach
1. Anterior vagal trunk (mainly left vagus)

Lies in contact with esophageal wall (mcq)
1/2 hepatic branches
Several gastric branches to fundus and body
Anterior nerve of lartaget( great anterior gastric nerve) -runs down in lesser Omentum
- subdivided like cow's foot
- supply antrum + pylorus
2. Posterior vagal trunk (mainly right vagus)
Not in contact with posterior surface of the esophagus

Supply to antrum but not to pylorus
2.3.1. Parotid duct( of stensen)
f masseter
ne of cheek opposite the second upper molar tooth
2.3.2.
- upper margin at the level of xiphisternal joint
Left it reaches 5th intercostal space , 7-9cm from midline
On the right to the 5th rib
Right border extends 7-11 in the mid axillary line
Lately at the right costal margin
2. Gall bladder- fundus touches the parietal peritoneum of anterior abdominal wall
At the tip of the right 9th costal cartilage
Where the transpyloric plane crosses the costal margin at the lateral border of right rectus sheath.

1. Regarding gastric function,

A) Gastric contents of average meal emptying after about 30 minutes
B) Gastric secretion is increased by sympathetic nervous system
C) Intra gastric pressure will increased with increased amount of contents
D) Gastric secretion is increased by histamine
E) Gastric motility is inhibited by enterogastrone
2. Which of the following functions are exclusively done by liver,

A) Synthesis of prothrombin
B) Break down of red blood cells
C) Conversion of glucose to glycogen
D) Secretion of bile salts
E) Synthesis of gamma Globulin .
3. Inferior mesentery artery,

A) Continue as superior rectal artery at the apex of the sigmoid colon
B) Supplies more distance of the gut than the superior mesenteric artery
C) It lies anterior to the horizontal part of the duodenum
D) Origins from abdominal aorta at the 4th lumbar vertebral level
E) Supplies anal cannel
4. Regarding stomach,
A) Fundus of the stomach in contact with left dome of the diaphragm
B) Hyloid region lies at the level of 1st lumbar vertebra
C) Pain arise from stomach can be felt in umbilical region
D) Perforated ulcers of posterior wall leads to erosion of gastro duodenal artery
E) Venous drainage is via the superior mesenteric vein
5. Head of the pancreas,

A) Is firmly attach to descending path of the duodenum
B) Fix to the posterior abdominal wall
C) Retro peritoneal organ
D) Lies anterior to the bile duct
E) Lies in the stomach bed
6. Regarding peritoneal reflection of the liver,

A) Bare area of the liver lies between right and left triangular ligaments
B) Coronary ligament continue as falciform ligament
C) Inferior vena cava form a border of the bare area
D) Lesser omentum is reflect around structure of porta hepatis
E) Bare area is in contact with right colic flexure
7. Regarding the anatomy of tongue,

A) Anterior 2/3 and the posterior 1/3 is divided by sulcus terminalis
B) Blood supply is directly by the external carotid artery
C) Lymphatic of the root of the tongue drain in to lower part of the deep cervical nods

D) Nerve supply to anterior 2/3 is derivated from facial nerve
E) All intrinsic muscles are innervated by 12th cranial nerve
8. derivatives of the caudal limb of the foregut,

A) Ileum
B) Jejunum
C) Transverse colon
D) Sigmoid colon
E) Appendix
9. Regarding rectum,
A) Recto anal junction is related to puborectalis
B) Upper 1/3 of rectum is totally invested by peritoneum
C) The pararectal lymph nodes lies in the mesorectum
D) Denonvillier’s fascia lies below the recto vesicle pouch
E) There are two rectal folds of on right side
10. Which is true regarding digestion and absorption of carbohydrates,

A) Gastric contents entering the duodenum are neutralized by bicarbonate
B) Final digestion of disaccharide occur in mucosal layer of ileum
C) Congenital deficiency of sucrose isomaltase results in sucrose intolerance
D) Galactose is absorbed to enterocytes by facilitated diffusion
E) Lactose intolerance can be treated by reducing intakes of dietary food
SBR
11. 21-year old boy came to the hospital with retroperitoneal infection , which of the following can
be infected?
A) Appendix
B) Descending colon
C) Jejunum
D) Stomach
E) Transverse colon
12. Regarding hepatic blood flow,

A) it is about 25% of total CO (Cardiac Output)
B) Hepatic arterial blood flow is same as the hepatic venous blood flow
C) Hepatic blood flow increases during exercise
D) Portal vein blood contains all the absorbed contents of the intestine
E) Portal venous blood and arterial blood mix in the liver sinusoids
13. Where the Vitamin B12 absorption take place mostly,

A) Stomach
B) Duodenum
C) Jejunum
D) Ileum
E) Descending colon

14. A 45-year old male was admitted to the hospital with groin pain and a palpable mass just superior to the
inguinal ligament. The patient was diagnosed with an inguinal hernia and a surgical repair was performed. During
the operation the surgeon found a loop of intestine passing through the deep inguinal ring. Which of the following
hernia was that,
A) Direct inguinal
B) Umbilical
C) Femoral
D) Lumbar
E) Indirect inguinal
15. An obese 45-year old female patient with an elevated temperature come to the physician complaining on
nausea and intermittent acute pain in the right upper quadrant of the abdomen. During past two days she has 24
hours history of jaundice and a history of gall stones. What is the structure that has obstructed by gall stones,
A) Right hepatic duct
B) Pancreatic duct
C) Left hepatic duct
D) Cystic duct
E) Common bile duct
1.
1.1 Outline the blood supply of small intestine (30 marks)
1.2 Briefly describe the development of stomach (20 marks)
1.3 Briefly describe,

1.3.1 The role of bile salts in the digestion and absorption of fat (20 marks)
1.3.2 Metabolic disturbances owning to chronic obstruction of bile duct and their physiological basis. (30 marks)
1 Regarding gastric function

A True After consuming a typical solid meal there is a log time of 20 to 30 minutes which
there is minimal gastric emptying
B False Physiologic regulation gastric secretion
❖ Cephalic phase (20%) – stimulatory sight, smell, taste of food though of food, chewing, swallowing stress
Vagus nerve -> parasympathetic control of the heart, lung and digestive tract
❖ Gastric phase (70%) – stimulatory presence of food in stomach
❖ Vagus
❖ Gastrin
❖ Stretch
❖ Intestinal phase – inhibitory (meal left the stomach)
❖ CCK
Intestinal influences are the reflex and hormonal feedback effects on gastric secretion initiated from
mucosa of the small intestine

C True When food enters the stomach, the fundus and upper portion of the body relax
and accommodate the food with little if any increase in pressure
D True ❖ Histamine, gastrine stimulates the gastric secretion
❖ Histamine stimulates the parietal cells to secret HCl
❖ Prostaglandin inhibitory effect on acid secretion
E True Gastric motility regulated by
❖ Myogenic
❖ Neural
❖ Humoral
Enterogastrone is any hormone secreted by the mucosa of duodenum in lower gastro intestinal tract in response to
dietary lipids that inhibits the caudal motion of the contents of chyme
2. Function of liver
A True ❖ Formation of bile salts – Na & K salt of bile acids
❖ Synthesis of plasma protein – Albumin, clotting factor, hormones binding protein, Acute phase protein
❖ Metabolism of – glucose & other sugars, Amino acids, Lipids (fatty acids, cholesterol, lipoprotein), fat
soluble vitamins, water soluble vitamins, heme
❖ inactivation of – hormones, toxins, drugs
❖ Removal of bacteria from portal veins – phagocytosis by Kupfer cells
B True
C True
D True Bile secretion occur in the liver
E True Most of the globulin synthesis in the liver
3. Inferior mesentery artery

A True
B True
C False
D False
☺ Arise from the front of the aorta, behind the 3rd part of the duodenum.
Opposite L3 vertebra at the level of umbilicus, 3 or 4 cm above the aortic bifurcation
☺ Then obliquely down to the pelvic brim, beneath the peritoneal floor of left infracolic compartment give
of left colic, sigmoidal artery
☺ It crosses the pelvic brim at the bifurcation of left common iliac vessels over the sacroiliac joint
☺ Beyond the pelvic brim it continues in the root of the sigmoid mesocolon as the superior rectal artery
E True Supply large intestine from the distal transverse colon to the upper part of the anal canal
Branches of IMA
❖ Superior rectal artery
❖ Left colic artery
❖ Sigmoidal artery
4. Stomach
A True Stomach has 4 main regions
1. Cardia
2. Fundus
3. Body

4. Pyloric
Fundus
the left dome of the diaphragm
– between the esophagus and the funders

B True Pyloric region
nal
– 9th costal cartilage and the L1 vertebra

C False Visceral referred pain from a gastric ulcer is referred to epigastric region because the stomach is supplied by
pain afferent that reach the T7 &T8 Spinal sensory ganglia & spinal cord segment through the greater
splanchnic nerve
(Moore – page 257 figure 82.12 picture)
D False Acute ulcer along the anterior part of first part of duodenum usually perforate,
where those on posterior aspect tend to cause bleeding as they erode into gastroduodenal artery In the
stomach, erosion the splenic artery
E True Splenic vein joins the superior mesenteric vein and then form hepatic portal vein
5. pancreas
A True
B True
C True
D True
E False
❖ Divided into head, neck, body, tail
❖ Length 15cm
❖ Lies – retroperitoneally
❖ Lies posterior to the stomach between duodenum on the right and the spleen on the left
Head of the pancreas
m to the right of the superior mesenteric vessels
the level of L2 vertebra
Organs found in the posterior abdominal wall

➢ 2nd and 3rd part of duodenum
➢ Pancreas
➢ Kidney
➢ Supra renal glands
➢ Ureter
Stomach bed
➢ Left crus & dome of diaphragm
➢ Splenic artery
➢ Body of pancreas

➢ Transverse mesocolon
➢ Upper part of left kidney
➢ Left supra renal gland
➢ Spleen
➢ Left colic flexure
6.
A False
Bare area
peritoneal
-> Glisson’s capsule (fibrous capsule)
B True
C True IVC -> base of the bare area
D True Lesser omentum has 2 layers
These join together ascend as a double fold to porta hepatis

E False ❖ Bare area contacts with diaphragm
❖ Right colic flexure -> right lobe of liver (visceral surface)
7 Tongue
A True
-> the junction of the oral and pharyngeal parts of the tongue
-> anterior 2/3
-> posterior 1/3
B False
❖ Lingual artery
❖ Small contributions from -> tonsillar branch of the facial artery & ascending pharyngeal artery
C True Lymph drainage
❖ Tip -> submental / directly to deep cervical nodes
❖ Rest of the anterior part
▪ Marginal -> ipsilateral submandibular and / or sometimes directly deep cervical nodes
▪ Central -> deep cervical nodes (either side)
❖ Posterior part -> bilaterally to deep cervical nodes
D False ➢ All tongue muscles -> hypoglossal nerve
▪ (except palatoglossal) -> pharyngeal plexus (CN XI, CN X)
➢ Proprioceptive impulse -> lingual nerve (CN V)
➢ Sensory supply of mucus membrane of anterior 2/3 (not the region of vallate papillae) -> lingual nerve
➢ Taste sensation -> chorda tympany (CN VII)
➢ Posterior 1/3 -> lingual – tonsillar branch of glossopharyngeal nerve (include vallate papillae)
E True Palatoglossus -> extrinsic

8. development
A False
B False
C False
D False
E False
9 Rectum
A True The recto-anal junction is slung forwards by the U loop of the puborectalis, which merges with the top of the
external sphincter of the anal canal, forming a palpable ledge (the anorectal ring) on rectal examination.
B True
➢ Superior 1/3
➢ Anterior surface covered by peritoneum Covered by Peritoneum
➢ Lateral sides
-> only anterior peritoneal covering
-> no peritoneum
C True
❖ Lymphoid follicles in the mucus membrane -> epicolic nodes
❖ Pararectal nodes -> mesorectum
❖ Lower rectum -> internal colic nodes, nodes in the hollow of the sacrum.
D False
• Rectogenital septum – rectovesical fascia of Denovilliers
• This fascia connects to the floor of the rectovesical pouch above and to the apex of the prostate below
E
10 Digestion and absorption of carbohydrates

A True
Immediately neutralized by alkalic bile / pancreatic juice mixture injected into the intestinal lumen via the voter
papilla
B True Enzymes in brush border of small intestine wall
C True Affected child typically experience stomach clamps, bloating. Excess gas production and diarrhea
D False
• Galactose – secondary active transport
• Fructose – facilitated diffusion
E True
11.B

13. D
14. E
15. E
1.1
Blood supply of small intestine is mainly done by pancreaticoduodenal arteries. The part of small intestine which is
proximal to the entrance of bile duct is supplied by the Superior pancreaticoduodenal artery, which arises from the
coeliac trunk. And the remaining part of the small intestine is supplied by the inferior pancreaticoduodenal artery,
arising from the superior mesenteric artery.
In addition to this, first 2cm of the small intestine is also supplied by,
-hepatic artery
-gastroduodenal artery
-supraduodenal artery
-right gastric artery
-right gastroepiploic artery
Venous drainage occurs into the tributaries of portal vein and superior mesenteric vein.
Lymph drainage is done by the channels which accompany superior and inferior pancreaticoduodenal vessels. And
they drain into coeliac and superior mesenteric nodes. Nerve supply is done by coeliac and superior mesenteric
plexus.
1.2
Stomach At fourth week begins as a fusiform dilation in foregut.
Rotations
I. 90: Clock wise in longitudinal axis
•Left side become anterior =>
Left vagal fibers – Anterior vagal trunk
•Right side become posterior =>
Right vagal fibers – Posterior vagal trunk

II. In antero posterior axis
•Pylorus => to right & upwards
•Cardia => to left & downwards
Rotation of stomach causes changes in mesogastrium.

1.Around Longitudinal axis
Pulls dorsal mesogastrium to the left
↓
Formation of vacuoles and fusion of them
↓
Lesser Sac
2.Around Antero –Posterior axis

Bulging down of dorsal mesogastrium as Greater Omentum
Growth Difference
Posterior wall > Anterior wall
- Greater curvature => to the left
- Lesser curvature => to the right
1.3
1.3.1.
The bile salts have number of important actions. They reduce the surface tension and, in conjugation with
phospholipids and mono glyceraldehydes, they are responsible for emulsification of fat. This action creates a much
larger surface area for the action of lipase in the small intestine. Provides an alkaline fluid in the duodenum to
neutralize the acidic pH of the chyme that comes from the stomach and facilitate lipase enzyme’s activities. These
actions are preparatory to fat digestion and absorption.
1.3.2
In this condition, conjugated bilirubin fail to enter into the gut. So, they get trapped in the bile duct, flow back into
the Liver. Build up of conjugated bilirubin in the liver leads to destruction of hepatocytes.
Liver is the major site where various plasma proteins are synthesized. This includes mainly Albumin & the clotting
factors. So, when the hepatocytes get damaged, it leads to deficiency of Plasma proteins like Albumin & clotting
factors.
If clotting factors’ deficiency occur, that affects both the intrinsic and extrinsic pathways of clot formation. So, it
results in delayed clotting after an injury.
Albumin is quantitatively the lost significant and accounts for the majority of plasma oncotic pressure. So, deficiency
for Albumin, reduces the plasma oncotic pressure, leading to edema.
Another important role of liver is, Ammonia metabolism and its Excretion. The liver is critical for ammonia handling
in the body. Ammonia levels must be carefully controlled, because it is toxic to the central nervous system. If
hepatocytes get damaged, Ammonia metabolism & excretion will also be affected. And this will result in ammonia
leaking into the blood. This ammonia will eventually cross the BBB (Blood Brain Barrier) and cause mental state
changes.
Liver also plays a significant role in glucose buffering. Under the above condition, glucose buffer function of liver gets
impaired and hypoglycemia is commonly resulted.
Liver is the main site of detoxification. Without the proper function of liver, detoxification and excretion of harmful
drugs are disturbed.

1. The esophagus,
A) Is crossed anteriorly by the left main bronchus.
B) Passes through the diaphragm with the left phrenic nerve.
C) Has a blood supply from the inferior thyroid artery.
D) Is drained by right gastric vein.
E) Can be easily accessible through right thorax.
2. Liver,
A) Hepatocytes are derived from septum transversum.
B) Caudate lobe contains the 2nd liver segment.
C) Bile canaliculi start from the space of Disse.
D) Upper border of the liver is at the level of 3rd costal cartilage.
E) Bleeding to the liver is prevented by compressing the anterior border of lesser omentum.
3. Coeliac trunk,
A) Supplies the entire foregut.
B) Arises below the arcuate ligament.
C) Gives branches behind the peritoneum of lesser sac.
D) Anastomoses with the superior mesenteric artery by the superior pancreaticoduodenal artery.
E) Right hepatic artery is a direct branch.
4. Gall bladder,
A) Abundant in smooth muscles.
B) Neck is at the transpyloric plane.
C) Palpable in normal persons.
D) Epithelium has goblet cells.
E) Has spiral valve and Hartsmann’s pouch at the neck.
5. Sigmoid colon,
A) Is a retroperitoneal organ.
B) Arises from mid gut.
C) Has few appendices epiploicae.
D) Extends from descending colon at pelvic brim.
E) Sacculated by taeniae coli.
6. Rectus abdominis muscle,

A) Arises from the pubic crest and pubic symphysis.
B) Has an attachment to the 9th rib.
C) Enclosed with aponeurosis of external oblique muscle between umbilicus and costal margin.
D) Has a tendinous intersection of the level of umbilicus.
E) Is supplied by iliohypogastric nerve.
7. Regarding saliva,
A) It is isotonic with plasma.
B) It has both neuronal and hormonal contributions.
C) It initiates protein digestion.

D) Sympathetic stimulation increases its mucous content.
E) Buffers in saliva help to maintain oral pH at 7.
8. The peritoneum,
A) Gives origin for spleen.
B) Extend between the stomach and the liver as ligamentum teres.
C) Extends into thorax as phreno – esophageal ligament through esophageal hiatus.
D) Extend into pelvic cavity up to anorectal junction.
E) Become broad ligament on either side of the uterus in pelvic cavity.
9. Regarding intestinal motility.

A) Forward propulsion of food is brought about by segmental movement.
B) Extrinsic innervation is essential for the motility of small intestine.
C) Reverse peristalsis can be seen in vomiting.
D) Intestinal motility is inhibited by sympathetic stimulation.
E) Voluntary control of defecation is lost in spinal injury.
10. Fecal fat excretion can be seen

A) After a resection of stomach.
B) After a resection of terminal ileum.
C) In chronic pancreatitis.
D) In xerostomia.
E) In Zollinger Ellison syndrome.
SBR
11) A patient with history of gall stone presented with features of obstructive jaundice. What is most likely site at
which a gall stone maybe lodged in
A) Cystic duct
B) Hartmann’s pouch
C) Common bile duct
D) Pancreatic duct
E) Left hepatic duct
12. 44 years old patient admitted to emergency department having excessive vomiting and diarrhea. Radiograph
images show a part of the bowel has been compressed by abdominal aorta and superior mesenteric artery. Which
of the following has been compressed in the above scenario?
A) Second part of duodenum
B) Transverse colon
C) Third part of duodenum
D) First part of duodenum
E) Jejunum
13. Which of the following has a diagnostic marker which is more specific for bone diseases,
A) Alanine aminotransferase
B) Alanine phosphatase
C) Aspartate aminotransferase
D) γ- glutamyltransferase

E) Prothrombin
14. Which of the following inhibit the gastric acid secretion

A) Histamine
B) ACh
C) Gastrin
D) Somatostatin
E) CCK
15. Absorption of largest volume of gastro intestinal secretions occurs in,

A) Stomach
B) Duodenum
C) Jejunum
D) Ileum
E) Colon
1. Write brief accounts on the following,

1.1 Relations of pancreas (25 marks)
1.2 Differences between ileum and jejunum (25 marks)
1.3 Internal and external features of anal canal (30 marks)
1.4 Development of stomach (20 marks)
2.
2.1 Outline the digestion and absorption of dietary lipids. (20 marks)
2.2 A patient undergoing gastrectomy (partial removal of stomach) could develop,

2.2.1 Diarrhea following large meals (30 marks)
2.2.2 Pernicious and iron deficiency anemia after about 18-24 months (50marks)
Explain the physiological basis of the above consequences following the gastrectomy.
01
A- T- left main bronchus is anterior relation to esophagus
B- F – passes through the diaphragm with vagus
C- T
D
E- F deviated to left thorax
02
A- T
B- T
C- T
D- F at the level of 7th costal cartilage.

E- T hepatic artery behind the lesser omentum.
03
A- T
B- T
C- T
D- T
E- F is a branch of common hepatic artery.
04
A- T it’s a muscular membranous sac.
B- F fundus of gallbladder lies at transpyloric plane
C- F
D- F don’t have goblet cells
E- T
05
A- F it’s an intraperitoneal organ
B- T
C- F has abundant appendices epiploicae
D- T continuation of descending colon.
E- T
06
A- T
B- F 5-7 rib
C- T
D- F above the level of umbilicus.
E- F supplied by subcostal & intercoastal nerve.
07
A- F saliva is a hypotonic solution
B- T
C- F it initiates carbs digestion.
D- T sympathetic system inhibits the digestive activity.
E- T
08
A- T
B- F lesser omentum
C
D- T
E- T
09
A- T
B- F it can be regulated by hormonal action.
C- T food is moved in a reverse manner (reverse peristalsis)

D- T
E- T
10
A- F
B- T
C- T
D- F
E- F
11 Answer B
12 Answer C superior mesenteric artery passes above the 3rd part of duodenum
13 Answer E
14 Answer D
15 Answer C
.1 Relation of pancreas
Head
Head of the pancreas is moulded into the c shaped con cavity of duodenum
Posteriorly -inferior venacava
R/L renal veins at the level of L2
Terminal part of bile duct
Aorta (uncinate process)
Anteriorly. Transverse mesocolon
Superior mesenteric vein and artery
Neck
Posteriorly
Commencement of portal vein
Splenic vein
At lower margin superior mesenteric vein and transverse mesocolon
Body
Posteriorly
 -left renal vein
 Aorta
 Left crus of diaphragm
 Left psoas muscle
 Lower part of left suprarenal gland
 Hilum of the left kidney
Superiorly

 Coeliac trunk joins aorta
 Splenic vein
Inferiorly
 Superior mesenteric artery
Medially
 Anterior surface of leftkidney
 Splenic vein ,artery and lymphatics within the two layer of splenorenal ligament
Laterally
 Hilum of spleen
From gbe head uncinate process is formed downward over the aprta medially pancreatic duct passes to the 1st part if
duodenum joined with biliary duct before opening through sphincter of
.2 difference between ileum and Jejunum
1.3) internal and external features of anal canal .
Tenia coli appendices epiploicae and sacculations are absent in the analcanl . Analcanal extends from anorectal
junction opening of anus .
Anal canal has 3 parts. Upper part is approximately 15 mm long which is lined be columnar epithelium. Proximally
simple columnar epithelium is present . Distally stratified columnar epithelium is present . It is called mucosal part .
It has vertical mucosal tolds with radicals of superior rectal vein . At the lower part mucosal part ,transverse mucosal
folds are preset . Valves of morgagni. Anal sinuses are present above those transverse folds . Anal glands are opened
through ducts into anal sinuses . Pectinate line below the anal sinuses .
2nd part is covered by non keratinized stratified squamous epithelium. It doesn’t have mucosal folds. Bluish pink in
colour due to present of venous plexus. It is called as transitional zone . It extends from pectineal line to white line of
hilton to anal orifice .anal canal has two sphincters is the thickening part of inner circular layer if git . External anal
sphincter is made up of skeletal muscles. It has 3 parts as dup part, superficial part and subcutaneous part .
Subcutaneous part is not attached to any structure, superficial part is attached to perineal bodyand anococcygeal
raphe . Deep part doesn’t have any body attachment . Longitudinal fibres of git have fibrous attachment to
puborectalils muscle . Those fibroelastic muscle tissue mase by abive 2 passes below and pierces subcutaneous anal
sphincter to attach to the perianal septum and skin . It is called as conjoined longitudinal cord. Fascial fibres from the

junctionod 2nd and 3 rd part of anal canal makes perianal septum with its attachment to the fascia of pudendal canal
. Anal inter muscular septum is also present in this level . Anorectal ring is formed by internal anal sphincter and dup
part of external anal sphincter ishioanal fossa is present laterally to anal canal above the perianal septum . Below
the perianal fascia lies the perianal fossa . Within the ischioanal fossa large fat globules are present while in the
perianal fossa small fat lobules are present
.3 development of stomach
Stomach is a derivative of foregut at the distal part if primitive gut a fusiform dialatation is formed. During 4th to
5th week. As the liver developed in the dorsal mesogastrium developing stomach in the midline of the body
moves to the left side . It undergoes 90 degree rotation . Ventral aspect lies on the right side and dorsal aspect
becomes left aspect .previously right and left vagus nerves laid with the stomach . With the rotation of stomach
vagus nerve location are also moves to the dorsal side left vagus nerve lies on the stomach so right vagus
becomes the dorsal vagal trunk while left vagus become the anterior vagal trunk . Lesser curvature is formed in
the right side by buldging of lower aspect of stomach to right side and bit superiorly . Greater curvature is alsi
formed, at the same time ventral mesogastrium is decided into 2 parts as lesser omentum and falciform
ligament and corinal ligament . Dorsal mesogastrium form splenogastric ligament and splenorenal ligament
3 factor are affected ti the adult position of stomach
 Rapid enlargement of liver
 Omental bursa shifting ti left
 Rotation by rapid growth of posterior aspect if stomach than anterior aspect
Curvature are formed because of this . Posterior aspect which later becomes left aspect become i rapidly
lengthening than anterior aspect which later form Right aspect . concave end of stomach moves to left and
slightly downward while the pyloric end become slightly upward .
2)2.1 digestion and absorption of dietary lipids
3 enzymes are important to digest dietary TAG. They are lingual lipase ,gastric lipase and pancreatic lipase .
When the lipid food enter the oral cavity lingual lipase start the lipid digestion.
Most digestion occurs in the duodenum by the pancreatic lipase secretion To assist the lipid digestion . Bile salt are
important for emulsification process . It breaks down larger fat droplets into smallen ones.
Fatty acids and monolglycerides freely diffuses into the cell . Other fatty acids which can’t be freely absorbed. Gets
aggregated with cholesterol bileslat and other lipid. Soluble practicles to form micelles to get absorbed into the cell .
Golgi apparatus inside the enteric cell aggregates the organizes the fat molecules into chylomicron . They are
exported as chylomicron from the cell by exocytosis . It enters the lymphatic vessels . Inside the intestinal villus .
Eventually it passes through
Lymphatics and enters the lymphatic trunks (thoracic duct and right lymphatic duct ) to open into boood vessels to
pass chylomicrons into blood
2.2 patient undergoing gastrectomy

2.2.1 diarrhea following large meals
When a meal is taken the food particles undergo mechanical and chemical digestion (to small extend ) inside the
mouth and then passes through the esophagus to the stomach . Stomach stored food to continue its further
digestion and breakdown it can store food for 1-2 hours in it . When a large meal is taken , the food amount is much
higher than the amount the intestinal enzymes can digest at one.
So normally the intestinal enzymes can digest at once. So normally stomach stores the food and produced chyme is
squirted in to the 1st part of duodenum in small amount . So the intestinal enzyme can digest the food particles
easily. And absorb them when the gastrectomy is done ,the storage organ is absent. So the large meals passes
directly from esophagus to the duodenum . The amount of food is much larger than the small intestinal can digest.so
the nutrients can’t be fully absorbedred into-the body . Because of that various osmotically active molecules are
present in the substance passes through the intestine . That absorbs water from the intestinal cells into the lumen of
intestine according to a osmotic gradient . That increase the fluidity of the fecal substance and diarrhea occurs .
Following large meals . And as the amount of material is large , large intestine can’t properly absorb water in It so,
diarrhea is present
2.2.1) pernicious and iron deficiency anemia after about 18-24 months
Stomach secretes HCl and intrinsic factor In the stomach . HCl is secreted by parietal cells,while intrinsic factors is
secret by chief cells in the stomach .
Pernicious anemia occurs due to absence of vitamin b12 primarily , vit b12 is important for erythrocytes maturation .
When vitamin B12 is deficient Rbc production is altered and that results in decreased RBC count . Vit B12 is
absorbed in large intestine . Vit B12 can’t be absorbed alone . In the stomach vitamin B12 is bound with intrinsic
factor . Then that complex is passes to large intestine to be absorbed . When gastrectomy is done , gastric secretion
are absent , Intrinsic factor is absent. Without intrinsic factor VitB12 can’t be absorbed in large intestine. Vit B12 is
deficient in the body but the body has B12 stores which can be released during Vitamin B12 deficiency. That stores
are sufficie to 1 ½- 2 years . When the vitamin B12 stores are depleted the symptoms of vitamin B12 deficiency is
presented pernicious anemia can be seen . Iron is a micromolecule which is important to produce hemoglobin being
a component of heme . Iron in the food is mostly in ferrous ion form . But to be absorbed in to the body ferrous
must be converted into ferric ion . Afyer gastrectomy hcl sectetion also absent so this conversion never happens so
iron cant be absorbed . Ferric iron deficiency occurs. But iron is stored in the liver as ferritin . It frees fe3+ into
blood in a deficiency. That stores can be enough from 6 months to 3 years . Normally 1 to 2 years , when the ferritin
stores are depleted symptoms can be seen . Iron deficiency anemia is resulted due to decreased RBC production
1. Abdominal esophagus,
A) is 2cm in length.
B) makes impression on the right lobe of the liver.
C) anteriorly related to the left inferior phrenic artery.
D) enters the stomach at the cardiac orifice.
E) prevents the gastric reflux by the longitudinal folds of the esophageal mucosa.
2. Structures related posterior to the head of the pancreas include,

A) Inferior vena cava.
B) Terminal part of the bile duct.
C) Right renal vein.
D) Aorta.
E) Left psoas muscle.
3. The superior mesenteric artery,

A) arises from anterior aspect of abdominal aorta at the level of 2nd lumbar vertebra.
B) supplies the descending colon
C) supplies the 1st and 2nd part of the duodenum.
D) supplies the ileocecal junction.
E) lies anterior to right renal vein.

4. Regarding anorectal junction,
A) It is anterior superior to tip of the coccyx.
B) It lies at the pelvic floor.
C) Puborectalis muscle takes major part in maintaining its angle.
D) It shows abrupt epithelial changes.
E) Its angle maintains fecal continence during rest.
5. Cystohepatic triangle (of Calot) is formed by,

A) Cystic duct.
B) Cystic artery.
C) Common hepatic duct.
D) Visceral surface of the liver.
E) Common hepatic artery.
6. Regarding the development of gut,

A) Primitive foregut give rise to the gall bladder.
B) Ventral mesentery extends from esophagus to the cloaca.
C) Rotation of stomach takes place in the clockwise direction.
D) Urorectal septum give rise to the perineal body.
E) Pancreas develops from the proximal end of midgut.
7. Regarding digestion and absorption of carbohydrates,

A) There are no carbohydrate splitting enzymes in the gastric juice
B) Salivary amylase requires Na+ for its activation
C.) Amylase hydrolyses the α(1-4) glyosidic bonds of polysaccharides
D) Glucose transport is a passive transport mechanism.
E) Pancreatic amylase hydrolyses dextrin into limit dextrin and maltose.
8. Intestinal movements those will help to mix the food include,

A) Peristalsis
B) Segmentation contractions
C)’Mass action contractions
D) Tonic contractions
E) Pyloric contractions
9. Acid secretion of parietal cells is stimulated by

A) Histamine
B) Gastrin
C) Somatostatin
D) Prostaglandin
E) Acetylcholine
10. Features of common bile duct obstruction include,

A) Pale stools
B) Bile salt in urine
C) Elevated conjugated bilirubin in blood
D) Steatorrhea

E) Folic acid deficiency
SBR
11. A 42-year old woman presents with right upper quadrant abdominal pain. CT imaging reveals that large
gallstones have ulcerated through the posterior wall of the fundus of the gallbladder into the intestine. Which of
the following parts of the intestine is most likely to initially contain gallstones?
A) Jejunum
B) lleum
C) Transverse colon
D) Ascending colon
E) Caecum
12. A 5-day-old baby is diagnosed with Hirschsprung disease. CT scan examination reveals an abnormally
dilated colon. Which of the following is the most likely embryologic mechanism responsible for Hirschsprung
disease?
A) Failure of neural crest cells to migrate into the walls of the colon
B) Incomplete separation of the cloaca
C) Failure of recanalization of the colon
D) Defective rotation of the hindgut
E) Oligohydramnios
13. Defecation is an autonomic reflex. Which of the following explain it?

A) Urge to pass stool occur when rectal pressure is about 18 mmHg
B) Spinal cord transection leads to fecal incontinence
C) Defecation can be facilitated by increasing intra-abdominal pressure
D) Defecation can be postponed by contraction of external anal sphincter
E) External and internal sphincter relax when anal pressure is about 55 mmHg
14. Pancreas secrete digestive enzyme but gland is not digested. What is the best explanation for that?
A) Trypsin inhibitor is found in the pancreas
B) Enzymes are activated in the intestine
C) Activation of enzymes under positive feedback control
D) Enteropeptidase is not found in the pancreas
E) Flow of fluid in the duct system removes the enzymes
15. After surgical removal of the gallbladder, a person must be especially careful to restrict dietary intake of,
A) Starch
B) Protein
C) Sugar
D) Fat
E) Fibre

1. A 31-year old sub-fertile woman is undergoing a laparoscopic examination of the pelvic cavity. The
physician performing the procedure carefully places the trocar lateral to the rectus abdominis muscle and its sheath
to avoid injury to a major artery.
1.1 Name the major artery that has been avoided for injury. (05 marks)
1.2 List three contents of rectus sheath. (10 marks)
1.3 Briefly describe the formation of rectus sheath. (25 marks)

1.4.1 Meckel diverticulum and its clinical implications (25 marks)
1.4.2 Blood supply and lymphatic drainage of stomach. (35 marks)
2.
2.1. Explain the physiological basis for,
2.1.1 the clinical features of late dumping syndrome (25 marks)
2.1.2 Vitamin B12 deficiency after the resection of terminal ileum (25 marks)
2.1.3. Peptic ulcer formation in gastrinoma. (25 marks)
2.2 Briefly describe the formation, extension and relations of the portal vein. (30 marks)
01). Last pg. 249

A. T (About 1 to 2 cm in length)
B. F. ( posterior surface of the left lobe of the liver)
C. F ( left inferior phrenic artery lies behind the esophagus)
D. T
E. T
02) Last pg 267

The posterior relations to head: • IVC • Right renal artery • Right renal vein • Left renal vein.
• Bile duct lies in the posterior surface of the head.
A. T
B. T
C. T
D. F (posterior to the body of the pancreas)
E. F (posterior to the body of the pancreas)
03) Last pg 244

A. F. ( at the level of the lower border of L1 vertebra)
B. F. ( SMA is supplied to mid gut derivatives – from distal part of duodenum to proximal 2/3 of Transverse colon)
C. F (proximal parts of duodenum is supplied by branches of the coeliac trunk)
D. T. (ileocolic artery one of the branches of the SMA)
E. F. (anterior to left renal vein)
04)
A. (2.5cm anterior to the tip of the coccyx)
B. T
C. T
D. T ( abrupt transition to become stratified squamous epithelium)
E. T
05)
Calot’s triangle is formed by liver, common hepatic duct and the cystic duct. - - - Last pg 265
A. T
B. F
C. T
D. .
E. F
06)
A. (gall bladder is one of the derivatives of foregut tube)
B. F. (Ventral mesentery present only in the region of the terminal part of the esophagus, the stomach, and the
upper part of the duodenum (derived from the septum transversum).
C. T. (It rotates 90° clockwise around its longitudinal axis)
D. T
E. F. ( pancreas is derivative of foregut tube)
07)
A. T ( in lecture note)
B. F. ( It requires Cl- ion for activation & ph 6.7)
C. T
D. F. ( 2 transport mechanism : facilitated transport & active transport)
E. T (& isomoltose)
08)
 Peristalsis
 Segmentation and mixing
 Segment specific –Swallowing –Gastric motility (e.g. receptive relaxation) –Tonic contraction in small
intestine –Mass action contraction in colon
A. T
B. T
C. T
D. T
E. F
09)
A. T
B. T
C. F. (inhibit the acid secretion)
D. F. (inhibit the acid secretion)
E. T
10)
A. T
B.T
C.T
D. T

E.
11)
Ans- C
Fundus lies on the commencement of the Transverse colon
12)
Ans – A
Hirschsprung disease or aganglionic megacolon occurs due to a congenital absence of the ganglion cells in both the
myenteric and submucous plexus of the segment of the distal colon, as a result of failure of the normal cranial to
caudal migration of the neural crest cells during development. Ganong pg 503
13)
Ans – A
 Deification is Initiated with increase pressure (distention) in the rectum
– Urge to defecate when rectal pressure is 18 mmHg
– When rectal pressure 55 mm Hg internal and external sphincter are relaxed and evacuate the rectum
– Occurs even in chronic spinal animals and humans
• Inhibited or facilitated voluntarily
– Facilitation - Relaxing external sphincter and contracting abdominal muscles
– Inhibition - Contracting external sphincter
14)
Ans – A
Trypsin inhibitor
 Found in pancreatic cells and in it’s secretion
• Trypsin is not activated in the gland and in ducts
• Therefore, other enzymes also not activated in the gland and in ducts
15)
Ans – D
Bile is secreted by liver and transported to gallbladder. Then passes to small intestine via bile duct system. Bile is
important to absorption of fat.
1.1) Inferior epigastric artery
1.2)
 ends of the lower six thoracic nerves

 Their accompanying posterior intercostal vessels
 Superior and inferior epigastric vessels
1.3)
 Formed by the 3 aponeurosis of the lateral abdominal muscles

 Arranged differently at 3 levels
I. Above the costal margin – aponeurosis of the external oblique forms the anterior lamina. Posteriorly
lies the thoracic wall

II. Between the umbilicus and the costal margin - aponeurosis of the internal oblique splits around the
rectus, external oblique aponeurosis joins the anterior layer and the aponeurosis of the transversus
abdominis joins the posterior layer
III. Below the arcuate line – all three aponeuroses pass in front of the rectus muscle.
1.4)
1.4.1) Ileal or Meckel’s diverticulum is present in 2% of individuals, 60cm from the cecum, and is 5cm long but the
length of the diverticulum is variable and its site may be more proximal.
Its blind end may contain gastric mucosa or liver or pancreatic tissue,
It represents the intestinal end of the vitellointestinal duct, and its apex may be adherent to the umbilicus or
connected thereto by a fibrous cord, a further remnant of the duct.
Clinical : ulceration and perforation of the tip can occur
1.4.2)
Blood supply of the stomach
 Branches from coeliac trunk

 L/gastric artery anastomoses with the R/gastric artery – supply to lesser curvature between the 2 layers of
the lesser omentum.
 6 short gastric artery from the splenic artery – supply to fundus and Upper part of the stomach
 R&L/gastroepiploic artery – supply to greater curvature
 Larger omental branch of L/gastroepiploic artery – supplies to omentum
 Posterior gastric artery which is a branch from splenic artery – may supply to stomach
Lymphatic drainage
 Above and right of the parallel line- R & L gastric nodes along the R & L gastric artery
 Pyloric part- hepatic nodes in the porta hepatis and ti sub pyloric and R /gastric nodes
 Upper left quadrant- L /gastro epiploic nodes directly to pancreatico splenic nodes at the splenic hilum
 Rest of the greater curvature – R/ gastro epiploic vessels which drain to sub pyloric nodes near the
gastroduodenal artery.
02)
2.1)
2.1.1) Dumping syndrome occurs due to the gastric bypass surgery. This syndrome develops in patients in whom
portion of the stomach has been removed or the jejenum has been anastomosed to the stomach. Therefore
reservoir function of stomach is lost.
In late dumping syndrome, symptoms develop about 2 hours after meals. If larger carbohydrate meals are eaten by
them, which leads to the rapid absorption of glucose from intestine. Therefore blood glucose level increases which
leads to the increased secretion of insulin. Due to the increased insulin, hypoglycaemic symptoms develop about 2
hours after meal. So these patients feel weakness, dizziness, and sweating after meals due to hypoglycaemia. These
are the clinical symptoms of late dumping syndrome.
2.1.2)
Vitamin B12 is mainly taken up by the body via foods. These food containing B12 is mainly absorbed in the terminal
ileum with the help of intrinsic factors which are secreted from the stomach. Resection of terminal ileum causes
deficiency in B12 absorption which leads to inability of body to properly utilise vit B12. Vit B12 is essential in RBC
development in human body. Vit B12 deficiency causes Megaloblastic anaemia which is a form of macrocytic
anaemia, a blood disorder that happens when bone marrow produces stem cells that make abnormally large red
blood cells.
2.1.3)
Gastrinoma is neuroendocrine tumor can occur in the stomach and duodenum, but most of them are found in the
pancreas which is characterized by the secretion of gastrin with resultant excessive gastrin. Gastrin causes prolonged
hypersecretion of acid, and severe ulcers are produced. In stomach acid is secreted by parietal cells. These cells have
receptors for gastrin which has an stimulatory effect on H+ secretion. Increased H+ secretion causes peptic ulcers
which is characterized by destruction of mucosa due to the imbalance of acidity and mucosal barrier. Therefore
weakness in mucosal barrier occurs which leads to the damage in stomach wall.
2.2)
Origin
Portal vein is the upward continuation of the superior mesenteric vein. Portal vein is formed by the joining of
superior mesenteric vein with the splenic vein behind the neck of the pancreas.
Extension & relation
 It lies in front of the IVC

 Lies behind the pancreas and the 1st part of the duodenum
 Loses contact with IVC by entering between the 2 layers of the lesser omentum
 It runs almost vertically upwards in the free edge, where the lesser omentum forms the anterior boundary of
the epiploic foramen, laying behind the bile duct and the hepatic artery and reaches the porta hepatis.
 Here it divides into R&L branch which enters the respective halves of the liver.

1 Regarding esophagus,
A) It extends from C6 to T10 vertebral level
B)
C) It is lying in front of the thoracic aorta above the diaphragm
D) Chemical digestion can be continued through the esophagus
E) VIP maintains the tone of the lower esophageal sphincter
2. Concerning salivary glands and its secretions,

A)
B) Salivary ducts are impermeable to water
C)
D) Saliva is hypotonic in the oral cavity
E) Sublingual gland is poor stained in H&E
3. Gall bladder,
A)
B) It has less smooth muscle on its wall
C) It drains into portal and hepatic veins
D) It fills with bile in intra digestive period
E)
4. Concerning small intestine,

A)
B) Gastro ileal reflex prevents ileal emptying
C) Segmentation of ileum
D)
E) Acetylcholine contracts the gallbladder
5. Regarding large intestine,

A) It absorbs 90% of water in chyme from ileum
B) Doesn't show peristalsis movement
C) Mass action contraction only in the colon
D) Sigmoid colon is completely in the peritoneum
E)
A) Pancreatic acini secrete high amount of HCO3-
B) Pancreatic enzymes are activated in duodenum
C) Bile duct joins the pancreatic duct at an angle about 60o
D) Uncinate process derived from pancreatic bud
E) Transverse mesocolon is attached to its superior border
7. Liver,
A) It is completely covered by visceral peritoneum
B)
C) It is innervated by anterior vagus nerve

D)
E)
8.
A)
B) Alpha amylase digests starch into glucose
C) Fructose, Galactose are transported by same transporter in brush border
D)
E) Cystic fibrosis leads to pancreatic insufficiency
9. Derivatives of the caudal limb of the foregut,

A) Jejunum
B) Ascending colon
C) Appendix
D) Mesoappendix
E) Sigmoid colon
10. Lesser omentum,

A) Extend between stomach and liver
B)
C)
D)
E)
SBR
11. A young boy diagnosed to have muted gastrin gene which secretes Gastrin-34 (big gastrin) in response to food.
Which of the following is diminished from his body?
A) Amino acids
B) Bile salt
C) Fatty acids
D) Hydrochloric acid
E)
12. 45-year old man had an accident and this caused to damage of the spinal cord at T5 region. Which of following
is most likely to happen?
Contraction of rectum Relaxation of the anal canal Contraction of external
sphincter anal sphincter
A) NO YES NO
B) NO YES YES
C) YES NO YES
D) YES YES NO
E) YES YES YES
13. Cystic fibrosis causes pancreatitis in infants. What is the most probable mechanism of pancreatitis induced
cystic fibrosis?
A)
B) Auto digestion of pancreas

C) Gall stone obstruction
D)
E)
14. What is the wrong pair?

A) Increase conjugated bilirubin level – Obstructive jaundice
B)
C) Synthetic functions of liver- Bilirubin test
D)
E)
15. It was necessary to temporarily ligate the splenic artery near the coeliac trunk to stop hemorrhage from
ruptured spleen. The blood supply to which structure of least affected by the ligate.
A)
B) Body of stomach
C) Tail of pancreas
D) Fundus of stomach
E)
1.
A 45-year old male presented to ED with a heart burn and epigastric abdominal pain following NSAID treatment for
his fractured clavicle for one-week duration. After ED admission he vomited coffee colored vomitus. He was
undergone emergency upper gastrointestinal endoscopy (UGIE) that revealed multiple mucosal erosions with
bleeding in the antrum and body of the stomach. It was diagnosed as NSAID induced peptic ulcer disease. He was
treated with injection of proton pump inhibitor (Pantoprazole).
1.1 Briefly describe the development of the stomach (20 marks)
1.2 Briefly describe the arterial supply and the innervation of the stomach (30 marks)
1.3. Explain physiological basis of following,

1.3.1 NSAID induces peptic ulcer disease. (25 marks)
1.3.2 Vomits coffee ground vomitus (15 marks)
1.3.3 Proton pump inhibitor heals the peptic ulcers. (15 marks)
01)Last pg 208
A. F (begins at the lower border of cricoid cartilage - C6 level, passes through diaphragm - T10 level, ends at
the cardiac orifice of the stomach - T11 level)
B. .
C. T. (T7 level- deviates to the left and curves forward to pass in front of descending thoracic aorta, T10 level –
pierces the diaphragm 2.5cm to left of midline)
D. F. ( propels food to stomach. There is no enzymes to chemical digestion. It contains only mucus secretion
which helps to lubricate the lumen)
E. T. (Tone of LES under neuronal control. Acetylcholine from vagal endings – construction of intrinsic
sphincter. NO & VIP from interneurons - relaxation of intrinsic sphincter - - ganong pg 498)
02) Ganong pg 454

A. .
B. T (ducts are relatively impermeable to water)
C. .
D. T (hypotonic compared with plasma & alkaline)
E. T (sublingual glands have predominantly mucus secretory cells and produce a viscid secretion. Mucus is
easily washed out during histological preparation, which is why it stains very poorly with H&E)
03)
A. .
B. T
C. T (multiple small veins into hepatic vein and from the neck of the gallbladder into R/portal vein)
D. (The interdigestive period follows the digestive period and begins after the upper gastrointestinal tract is
cleared of food. During the digestive period cck level is high in the intestine & causes construction of
gallbladder. Remaining periods gallbladder stores bile)
E. .
04)
A. .
B. F (when food leaves the stomach the cecum relaxes and the passage of chyme through the ileocecal valve
increases which is called gastroileal reflex. It is a vagovagal reflex. )
C. (segmentation is one of the intestinal motility methods which mainly occurs in the small intestine)
D. .
E. T
05)
A.
B. F. (The movements of the colon: segmentation contraction, peristalsis waves and mass action contraction.
Peristaltic waves propel the contents towards the rectum although weak antiperistalsis also seen. - - ganong
pg 502)
C. T
D. T (Last pg 258)
E. .
06)
A. T
B. T (in active in pancreas due to the presence of trypsin inhibitors in pancreatic cells.)
C. T ( This joining occurs at the hepatopancreatic ampulla—last pg266) )
D. T (ventral pancreatic bud forms the uncinate process and inferior part of the pancreas)
E. F. (Transverse mesocolon is attached along the anterior border of the body of pancreas – last pg 268)
07)
A. T. (liver is an intraperitoneal organ. Organs inside of visceral peritoneum are called “intraperitoneal.)
B. .
C. (liver is innervated by sympathetic, both anterior and posterior vagal trunk.)
D. .
E. .
08) Ganong pg 478

A.

B. F (starch into maltose)
C. F. (SGLT-1--- glucose and galactose transport. Fructose by facilitated diffusion from the intestinal lumen into
the enterocytes by GLUT-5 and out of the enterocytes into the interstitium by GLUT-2)
D. .
E. T (Pancreatic insufficiency is the most common gastrointestinal complication of cystic fibrosis (CF)
09)
caudal limb of mid gut becomes the lower portion of the ileum, the cecum, the appendix, the ascending colon, and
the proximal 2/3 of the transverse colon.
A. F (cephalic limb of the loop develops into the distal part of the duodenum, the jejunum, and part of the
ileum.)
B. T
C. T
D. .
E. F (hind gut derivative)
10)
A. T ( extend between the liver and the upper border (lesser curvature) of the stomach - - Last pg 235)
B. .
C. .
D. .
E. .
11). Ans – A
Gastrin is a hormone that released by G cells in the antrum of the stomach. Gastrin has a specific role in prolonged
hypersecretion of hydro chloric acid by parietal cells of the stomach. Hcl activates the pepsinogen into pepsin which
is the main enzyme in the break down of proteins. Loss of the protein breakdown causes reduction of aminoacid leve
in the body
.
12) Ans – D
Damage to the T5 causes damage to celiac ganglion which leads to the loss of sympathetic activity of the stomach.
Therefore motility and tone of the stomach is increased which leads to the distension of the stomach initiates
construction of rectum and, frequently a desire to defecate. When the rectal pressure reaches 55mmHg, the
external and internal anal sphincter relax.
13) Ans –
Cystic fibrosis causes increased secretion of mucus in the pancreas which leads to the obstruction of all ducts in the
pancreas. Therefore enzymes and other secretions are unable to come out of the gland which causes pancreatitis.
Pancreatitis causes :
 Activation of enzymes in the gland leads to auto digestion of the gland.
• Formation of active phospholipase and trypsin
• Life threatening condition
14) Ans- C
liver synthetic function ---- albumin and prothrombin time test
To check the health of liver ---- bilirubin test
15) Ans- B
right gastroepiploic artery also gives supply to the body of the stomach.
01)

1.1)
4th week
• Appears as a fusiform dilation of the foregut
• In the following weeks, its appearance and position change greatly as a result of
1. the different rates of growth in various regions of its wall
2. and the changes in position of surrounding organs.
• It rotates 90° clockwise around its longitudinal axis, causing its left side to face anteriorly and its right side to face
posteriorly.
• So the left vagus nerve,
- initially innervating the left side will now innervates the anterior wall
- the right nerve innervates the posterior wall.
• During this rotation,
- new L/ side grows faster – greater curvature
- new R/ side - lesser curvatures
• The cephalic and caudal ends of the stomach originally lie in the midline.
• But during further growth the stomach rotates around an
anteroposterior axis,
- the caudal or pyloric part moves to the right and upward
- the cephalic or cardiac portion moves to the left and slightly
downward.
The stomach thus assumes its final position, its axis running from above left to below right.
Congenital defects of the stomach • Pyloric stenosis: narrowing of the pyloric antrum due to smooth muscle
hypertrophy of the pyloric
1.2)
Arterial supply :
 Branches from coeliac trunk
 L/gastric artery anastomoses with the R/gastric artery – supply to lesser curvature between the 2 layers of
the lesser omentum.
 6 short gastric artery from the splenic artery – supply to fundus and Upper part of the stomach
 R&L/gastroepiploic artery – supply to greater curvature
 Larger omental branch of L/gastroepiploic artery – supplies to omentum
 Posterior gastric artery which is a branch of splenic artery – may supply to stomach.

Nerve supply :
Sympathetic fibres – vasomotor and pyloric sphincter construction
Parasympathetic fibres from vagi - controls motility and secretion
Anterior vagal trunk – at the esophageal opening of the diaphragm. Branches of each anterior trunk:
I. One or two hepatic branches – upper part of the lesser omentum, anterior wall of the epiploic foramen to
reach the pylorus.
II. Several gastric branches – fundus and body
III. One large branch (greater anterior gastric nerve or anterior nerve of Latarget) – lesser omentum near the
lesser curvature, antrum and pyloric sphincter
Posterior vagal trunk – comprising mainly R/vagal fibers
I. Coeliac branches – along the L/gastric artery to coeliac plexus
II. Gastric branches – to the fundus and body
III. Large branch (greater posterior gastric nerve or posterior nerve of Latarget) – runs in the lesser omentum
behind the anterior trunk to reach the antrum but not the pyloric sphincter.
1.3.1)
Gastric and duodenal ulceration in humans is related primarily to a break down of the barrier that normally prevents
irritation and auto digestion of the mucosa by the gastric secretion. NSAID is nonsteroidal anti – inflammatory drugs
which inhibit the production of prostaglandins and consequently decrease mucus and HCO3- secretion. The NSAIDs
are widely used to combat pain and arthritis.
Prostaglandin has an inhibitor effect on gastrin secretion. Reduced secretion of prostaglandins cause increased
secretion of gastrin which causes prolonged hypersecretion of acids and severe ulcers are produced. Reduced
secretion of mucus and HCO3- also cause irritation and damage to muscle wall.
1.3.2)
Coffee ground vomitus indicates the upper gastrointestinal bleeding. Due to the increased intake of NSAID causes
multiple mucosal erosions with bleeding in the antrum and body of the stomach in this patient. Antrum and body of
the stomach are the parts of upper gastrointestinal tract. Bleeding of this part is the reason of vomiting coffee
ground vomitus in this patient.
1.3.3)
Gastric parietal cells are highly specialised for their unusual task of secreting concentrated acid. The cells are packed
with mitochondria that supply energy to drive the apical H+, K+ - ATPase, or proton pump, that moves H+ ions out of
the parietal cells against a concentration gradient of more than a million – fold. Proton pump inhibitors cause
inactivation of the function H+, K+ - ATPase which leads to the loss of the movement of H+ ions out of the cell to
secrete HCl in to the lumen. Therefore reduction in the HCl secretion protect the wall from irritation and damage
which help to heal the peptic ulcers.

PHASE 1 QUESTIONS
8th Batch
8th Proper - MCQs
7. The abdominal esophagus,

A) Enters the abdomen between the right & left crus of the diaphragm
B) Is enveloped by the peritoneum
C) Is closely related to both the anterior & posterior gastric nerves
D) Is closely related to the left lobe of the liver
E) Is surrounded by an external esophageal sphincter
14. True and false regarding the surface marking of the abdomen?
A) Transpyloric plane in the midway between suprasternal notch and the pubic symphysis
B) Subcostal plane is the level of tip of third thoracic vertebrae
C) Stomach lies in the subcostal plane
D) Neck of the pancreas in the transpyloric plane
E) Intertubercular plane lies between two pubic tubercle
15. The peritoneum,

A) Gives origin for spleen
B) Extends between the stomach and the liver as ligamentum teres
C) Extends into thorax as phreno-oesophageal ligament through esophageal hiatus
D) Extend into pelvic cavity up to anorectal junction
E) Become broad ligament on either side of the uterus in pelvic cavity
16. Regarding superior mesenteric artery,

A) Arises anteriorly from ascending aorta
B) Lies anterior to uncinate process
C) Supplies 1st and 2nd parts of duodenum
D) Supplies iliocecal junction
E) Lies anterior to right renal vein
17. The stomach,

A) Has complete peritoneal covering
B) Is completely covered the lesser sac anteriorly
C) Is solely supplied by branches of coeliac trunk
D) Epithelium is always simple columnar in type
E) Lymph drained into coeliac lymph node
18. Regarding caudate lobe of liver,

A) Lies between ligamentum teres and IVC
B) Connect the right lobe by the caudate process
C) It belongs to the functional right and left lobes
D) Belongs to segment 1
E) Covered by peritoneum

20. Portal vein,
A) Anastomoses with the branches of the hemiazygos vein
B) Receives blood from the spleen
C) Is formed by the union of the splenic and superior mesenteric veins
D) Crosses the left renal vein
E) Divides in to right and left branches which enters the corresponding lobes of the liver
37. Regarding gastrointestinal system,

A) Anal fissure is a tear in mucosa at the anal valve
B) Meckel’s diverticulum is a remnant of vitello intestinal duct
C) In highly selective vagotomy nerves of Latarjet are preserved
D) Portal vein is formed behind the neck of pancreas
E) Gall bladder receives fibers from left phrenic nerve
38. Achalasia cardia,

A) Vomiting is a common feature
B) PH in lower esophagus is lower than normal
C) Nerve degenerate in lower esophagus
D) Food accumulate in lower esophagus
E) Satiety appears due to the gastro-esophageal reflux
39. Bacteria colonized of colon,

A) Produce vitamin K
B) Activates the ABO agglutinin
C) Inhibit more animal growth
D) Stercobillirubin is converted to urobilinogen
E) Contribute to form feces volume
40. Portal vein,

A) Crosses the gall bladder
B) Anastomoses with the branches of the hemiazygous vein
C) Is formed in front of the neck of the pancreas posterior to the neck of the gall bladder
D) Receives blood from the spleen
E) Is formed by union of the splenic and superior mesenteric veins
SBR
41. A young boy comes to clinic with rupture of ligamentum teres. What is the artery that of its branch can be
damaged?
A) Medial circumflex femoral artery
B) Lateral circumflex femoral artery
C) Superior gluteal artery
D) Obturator artery
E) Inferior gluteal artery
48. In a fatty lady, ulcer in the gallbladder penetrates its posterior wall. Which part of bowel receives it?
A) Duodenum

B) Transverse colon
C) Ascending colon
D) Jejunum
E) Ileum
49. Secretin causes secretion of large amounts of HCO3- rich pancreatic juice. What is the best explanation for this
HCO3- rich pancreatic juice?
A) Secretin acts on the pancreatic acini to produce HCO3- rich pancreatic juice
B) Secretin inhibits the action of cholecystokinin on the pancreas
C) Secretin inhibits the H+ secretion from the pancreas
D) Secretin acts on the duct cells to produce HCO3- rich pancreatic juice
E) Secretin
50. What is the most correctly matching surgical incision in the abdominal viscera that can be approachable?
A) Right subcostal incision - duodenum
B) Right Pfannenstiel incision - stomach
C) Gridiron incision – Appendix
D) Left subcostal incision - Left kidney
E) Midline incision - Urinary bladder inhibits the action of vagus nerve on the pancreas
59. Which statement is true regarding abdomen?

A) Skin around umbilicus is supplied by T10 dermatome
B) Posterior rectus sheath is absent below the umbilicus
C) The number of tendinous intersection in rectus sheath is same above and below
D) All lymphatic of skin of abdomen drains into superficial inguinal lymph nodes
E) The blood flow of superficial epigastric vein towards umbilicus
60. Difference between the primary & secondary bile salts,

A) Secondary bile salts bind to taurine
B) Primary bile salts glycine
C) Primary bile salts formed by bacteria from secondary bile salts
D) Secondary bile salts formed by bacteria from primary bile salts
E) Secondary bile salts conjugated with taurine & glycine
8th Proper - SEQs
3.
3.1 List the muscles that involved in mastication (10 marks)
3.2 Describe the location extension & relations of the parotid gland & its duct (40 marks)
3.3 Describe the gross anatomy of duodenum (50 marks)
7)
A) F
Esophagus – through the esophageal hiatus T10 – 2.5cm to the left of the midline Aorta – median arcuate ligament
T12 – between left and right crus of the diaphragm

B) F
Esophagus is a retroperitoneal organ.
C) T
D) T
Grooves the posterior surface of the left lobe of the liver.
E) T
Esophagogastric junction; • extrinsic sphincter; crural portion of the diaphragm • intrinsic sphincter; lower
oesophageal sphincter
14)
A) T
Also approximately midway between the xipisternum and the umbilicus.
B) F
Body of the L3/ inferior margin of the 10th rib.
C) F
D) T
E) F
Intertubercular plane; the plane passing through the iliac tubercles corresponds to the level of the body of the L5.
15)
A) T
Spleen is an intra-peritoneal organ
B) F
The 2 layers of peritoneum that extend between the liver and the upper border (lesser curvature) of the stomach is
the lesser omentum or the gastrohepatic omentum. Ligamentum teres is the obliterated left umbilical vein.
C) F
The transversalis fascia blends with endothoracic fascia extends up through the esophageal hiatus as the phreno-
esophagel ligament.
D) F
Pouch of Douglas lies between the rectum and the uterus, it won’t extend up to the anorectal junction.
E) T
16)
A) F
From the descending aorta
B) T
Lies anterior to the left renal vein, the uncinate process of the pancreas and the third part of the duodenum, in that
order from above downwards.
C) F
First and second part of the duodenum – celiac trunk Rest of the duodenum – superior mesenteric artery
D) T
SMA supply from lower half of the second part of the duodenum up to 2/3rd of transverse colon.
E) F
17)
A) T The stomach is completely invested by peritoneum.
B) F
C) T

Stomach is a foregut derivative and is entirely supplied by the celiac trunk.
D) T
E) T
All lymph from the stomach eventually reaches the celiac nodes.
18)
A) F
Between ligamentum venosum and groove for inferior vena cava.
B) T
C) T
Caudate lobe divides partly to the left and partly to the right lobe.
D) T
Grant’s pg. 154 – fig.2.54
E) T
Liver in invested by the peritoneum except for the triangular bare area.
20)
A) F
Azygos vein. Repeat campaign 2K18 presented by 10th wms 280
B) T
C) T
D) T
E) T
Divides at the porta hepatis
37)
A) T
B) T
C) T
By preserving it the innervations and function of the pyloric antrum is preserved.
D) F Neck of the pancreas
E) F Right phrenic.
38)
A) F
Achalasia is a condition in which food accumulates in the esophagus and the organ can be massively dilated due to
the increased lower esophageal sphincter tone and incomplete relaxation on swallowing.
B) F
No reflux of gastric contents.
C) T
The myenteric plexus of the esophagus is deficient at the LES.
D) T
E) F No gastro-esophageal reflux.
39)
A) T
B) T
C) F

D) F
E) T
40)
A) F
B) F
Azygos vein
C) F
Behind the neck of the pancreas.
D) T Via the splenic vein
E) T
SBR
41) ANSWER – D
A branch from the obturator artery is the artery in the ligament of the head of the femur (ligamentum teres)
48) ANSWER – A
Body of the gall bladder is in contact with the first part of the duodenum.
49) ANSWER – D
of zymogen granules, rich in enzymes and low in volume
50) ANSWER – C
Right subcostal incision – gallbladder Pfannenstiel incision – made at the pubic hairline to approach the uterus.
Gridiron – appendix Left subcostal incisionMidline incision – access the stomach
59) ANSWER - A
60) ANSWER – D
3.
3.1 list five abdominal structures that lie in trans pyloric plane (10)
• L1 vertebral body
• Pylorus of the stomach
• End of the spinal cord
• Origin of the SMA , portal vein
• Neck of the pancreas
• 2 nd part of the duodenum
• Sphincter of the oddi
• Hilium of the each kidney
• Fundus of the gallbladder
• Duodenojejunal flexure
• Tip of the 9th costal cartilage

3.2 describe briefly gross anatomy of the duodenum (40)
• part of small intestine
• c shaped tube
• in front and right of IVC and aorta
• first 2.5 cm is between peritoneum of lesser and greater sac
• reminder is retroperitoneal ( at the back of the peritoneum )
• divide into 4 parts
- at the level of L1 ( 5 cm)
- on right side of L2 (7.5 cm)
–crosses L3 (10 cm)
-left side of L2 (2.5 cm)
• total length is 25 cm
• first part
• upward and backward from pylorus
• first 2.5 cm lies between peritoneal folds of greater and lesser omentam
• forms lower boundary of the opening of the lesser sac
• remain 2.5 cm posterior surface is bare of peritoneum
• anterior relations – quadrate lobe of liver , gallbladder
• posterior relation – bile duct ,portal vein ,IVC ,gastro duodenal artery
• superior relations – epiploic formen
• inferior relation - head of the pancreas
• lateral relations – medial border of right kidney
• second part ,curves downward over the hilium of right kidney
• upper half lies in the supra colic compartment
• lower half – infra colic compartment
• lies alongside the head of the pancreas
• in posterior wall receives common opening of bile duct and main pancreatic duct
• at hepatopancreatic ampulla on the major duodenal papilla
• it located 10 cm from the pylorus
• 2 cm proximal to above opening small opening accessory pancreatic duct on the minor duodenal papilla
• Anterior relation – right lobe of liver , transverse colon ,root of the transverse meso colon ,small intestine
• Posterior relation – hilium of the right kidney , right renal vessels ,IVC ,right psoas , R ureter
• Medial relation – head of pancreas , bile duct
• Lateral relations – right colic flexure
• Third part curves forward from right pre vertebral gutter over the right psoas muscle
• Passes over IVC and aorta to reach the left psaos muscle
• Inferior border crosses aorta on the commencement of the IMA
• Upper border hugs lower border of the pancreas
• It crossed by SMA
• Lies in both right and left infra colic compartments
• Anterior surface is in contact with coils of jejunum
• Anterior – SMA ,SMV , root of mesentry
• Posterior – right psoas , R ureter ,IVC, R gonadal vessels ,abdominal aorta, left psoas , origin of IMA , vertebral
column
• Superior –head of pancreas
• Inferior – jejunum
• Fourth part – ascends to the left of the aorta

• Anterior – transverse colon , transverse mesocolon ,lesser sac , stomach
• Posterior –left sympathetic chain, L renal artery ,L gonadal artery ,IMV
• Superior – body of the pancreas
• Lateral – L kidney ,L ureter
• Blood supply – arterial supply
• Proximal to entry of bile duct –branch of coelic trunk , superior pancreaticoduodenal artery
• Remain part – branch of S MA , inferior pancreaticoduodenal artery
• First 2 cm (common site for ulceration ) receives blood from hepetic , gastroduoenal ,supraduodenal , right gastric
,right gastro epiploic artry
• Venous drainage to SMV and portal vein
• Lymph drainage –coeliac and Superior mesenteric nodes
• Nerve supply –coeliac and superior mesenteric nodes
3.3 Describe the gross anatomy of diaphragm (50)

• Musculotendinous sheet
• Double domed shape
• has a peripheral muscular part and central tendinous part
• separate thoracic and abdominal cavities
• pierce by structures
• chief muscle for inspiration
• consist of central tendon ,muscular part – right and left dome ,right and left crus
• muscular part –forms continous sheet
• based on the peripheral attachment divide into sterna ,costal ,lumbarpart
• sterna part –consist of two muscular part
• attached to the posterior aspect of the xiphisternal processes
• costal part –consist wide muscular slip
• attach to the internal surface of the inferior six costal cartilage and their adjoining ribs on each sides
• lumbar part –arise from 2 aponeurotic arches
• from the medial and lateral arcuate ligament and anterolateral surface of superior lumbar vertebra
• Crura of the diaphragm
• crura is musculotendinous bands
• attach to the anterolateral surface of bodies of upper lumbar vertebra ,the anterior longitudinal ligament ,and
intervertebral discs
• right crus arise from upper 3 lumbar vertebra
• larger and longer
• forms the oesophageal hiatus
• left crus arise from upper 2 lumbar vertebra
• some of fiber from the right crus pass up on the abdominal surface of the fibers from the left crus and surround
the oesophagus orifice
• medial arcute ligament is thickening of psoas fascia
• extend from side of body of L1 or L2 to anterior surface of transverse process of LV1
• lateral arcute ligament is thickening of anterior layer of lumbar fascia Repeat campaign 2K18 presented by 10th
wms 220
• extend from transverse process of L1 to middle of lower margin of 12 th rib
• median arcuate ligament
• tendinous fibres from the medial edges of each crus unit and arches over the anterior aspect of the aorta at the TV
12 level
• forms the aortic hiatus along the with right and left crus

• central tendon
• trefoil aponeurotic part
• inseparable from fibrous pericardium
• lies at the level of the xiphisternal joint
• has no bony attachments
• closer to the anterior part of thorax
• has vena cava opening
• right dome is higher than left dome
• diaphragm viewed from the above outline is kidney shaped
• viewed from the side j shaped
• blood supply – arterial supply
• costal margin of diaphragm –subcostal arteries , lower 5 intercostal arteries
• crura – right and left inferior phrenic arteries
• small contribution – superior phrenic branches , pericardiophrenic and musculophrenic arteries
• venous drainage – brachiocephalic and azygos vein
• nerve supply
• motar supply – phrenic nerve
• each half is supplied by own phrenic nerve
• fibers of right that loop to left around the oesophageal opening is supplied by left phrenic nerve
• sensory supply
• central part –phrenic nerves
• peripheral part –lower 6 inter costal nerves
• proprioceptive by periphery – lower intercosal nerves ,centrally – phrenic nerve
• lymphatic drainage –lymphatic plexus of the superior and inferior surfaces of the diaphragm communicate freely
• superior surface – anterior and posterior diaphragmatic lymph nodes
• inferior surface – anterior diaphragmatic phrenic, superior lumbar lymph nodes hiatuses of diaphragm
• 3 large openings and several small openings
• Arotic hiatus – opppsite TV 12 in midline
• Pass between the crura of the diaphragm Behind the median arcute ligament
• Transmit – aorta ,thoracic duct ,azygos vein
• Oesophageal opening –opposite TV 10
• Lies in fibrs of left crus but fibres of right crus loop around it
• Transmit – vagal trunk ,oesophageal branch of left gastric artery, vein and lymphatic accompany the oesophagus
• Vena cavel opening – opposite TV 8 Repeat campaign 2K18 presented by 10th wms 221
• Between midline and right leaves of central tendon
• Transmit - inferior vena cave , right phrenic nerve
• Small openings
• Hemiazygos vein – through left crus
• Greater and lesser splanchnic nerves – through each crus
• Sympathetic trunk- behind medial arcute ligament
• Left phrenic nerve – pierce left dome
• Sub costal nerve and vessels – behind lateral arcute ligament
• Clinical –para oesophageal and sliding hiatus hernia

9th Batch
9th Proper - MCQs
6. Regarding rectus sheath,

A) The anterior layer above the level of the costal margin is formed by the external oblique aponeurosis
B) The posterior layer above the level of the costal margin formed by the internal oblique aponeurosis
C) The subcostal nerve supplies it
D) The anterior layer above the pubic symphysis is formed by the fusion of aponeurosis of external and internal
oblique and transversus abdominis muscles
E) The posterior layer above the pubic symphysis is formed by the aponeurosis of the transversus abdominis muscle
8. Accessible parts of retroduodenum,

A) Drainage of superior mediastinal vein
B) Right side of hepatic area
C) Posterior to 2nd part of duodenum
D) Posterior gastroduodenal artery
E) Lesser sac
25. Coeliac trunk,

A) Supply entire stomach
B) Supply 1st part of duodenum
C) Lies at the body of T12 at inferior border of pancreas
D) Gives splenic artery which is in gastrosplenic ligament
E) Gives gastro duodenal artery which is anterior to 1st part of duodenum
26. Regarding the epiploic foramen,

A) Its lower boundary is the second part of the duodenum
B) Its upper boundary is the caudate process of the liver
C) Its posterior boundary is the superior mesenteric vein
D) Its anterior boundary is the free margin of the lesser omentum
E) The right subhepatic space communicates with the lesser sac via the epiploic foramen
28. Nerves that supply the muscles of the anterior abdominal wall include,
A) Sixth intercostal nerve
B) Subcostal nerve
C) Ilioinguinal nerve
D) Iliohypogastric nerve
E) Lateral femoral cutaneous nerve
29. Salivary secretion,

A) Is reduced by parasympathetic blockers
B) Gives innate immunity
C) Has more mucus parotid gland secretion than submandibular gland
D) Has less Na+ during meal than postprandial
E) Can be controlled voluntarily
30. Acid in stomach,

A) Secrete by oxyntic cell
B) Increase in Zollinger Ellison disease
C) Inhibited by gastrin
D) Increase after vagotomy
E) Convert pepsinogen to pepsin
31. Bacteria in colon,

A) Produce vitamin E
B) Contribute to bulk of stool
C) Does not enter into portal vein
D) Larger in milk fed babies than babies with milk formula
E) It is converted primary bile acid into secondary bile acid
32. Structures take part in forming the stomach bed,

A) Left crus of diaphragm
B) Left kidney
C) Lesser sac
D) Superior mesenteric artery
E) Splenic artery
33. Posterior relations of first part of duodenum,

A) Bile duct
B) Gall bladder
C) Gastroduodenal artery
D) Portal vein
E) Neck of pancreas
38. Esophagus,
A) Is composed of smooth muscles throughout its length
B) Crossed by left bronchus
C) Drain all its blood to azygos and hemiazygos
D) lies posterior to trachea through its length
E) Pierces diaphragm at T8 vertebral level
39. Lipid digestion enzyme in pancreas,

A) Hormone sensitive lipase
B) Phospholipase A1
C) Phospholipase A2
D) Cholesterol esterase
E) Lipoprotein lipase
SBR
48. What is the GIT hormone that causes positive feedback?

A) VIP
B) Gastrin
C) CCK
D) Secretion

E) Motilin
49. There are different gut movements in gut. Movement special to gut?
A) Migrations motor complex
B) Receptive contraction
C) Mass action contraction
D) Segmental contraction
E) Reverse peristalsis
9th Proper - SEQs
2.
2.1 Describe the gross anatomy of pancreas (45 marks)
2.2 Explain briefly the microscopic features of pancreas (15 marks)
2.3 Write a brief account on,

2.3.1 Lesser sac (20 marks)
2.3.2 Appendix (20 marks
9th Repeat - SEQs
3.1 Describe the gross anatomy of the visceral surface of the liver. (50 marks)

3.2.1. Histology of stomach (20 marks)
3.2.2. Gross anatomy of oesophagus (30 marks)
06)
A) T
B) F
The posterior layer above the level of the costal margin has no rectus sheath. The rectus muscle rests directly on the
fifth, sixth and seventh costal cartilages
C) T Seventh to eleventh intercostal nerves and subcostal nerve (12th thoracic nerve) supply it
D) T
E) F The posterior layer above the pubic symphysis is deficient and the rectus muscle rests directly on the fascia
transversalis
08) Retro duodenum – posterior to the duodenum

A) T drainage of superior mesenteric vein
B) F not retro duodenum
C)?
D) T
E) F

25)
A) T
B) T
supply up to opening of bile duct which is 10cm away from pylorus; 1st part is the 1st 5cm of the duodenum.
C) F Arise from the front of the aorta at the level of body of T12 vertebra along the superior border of body of
pancreas. Inferior border of body of pancreas is at origin of SMA (L)
D) F pass to the left along the upper border of pancreas to the hilum of left kidney. From there runs forward in the
splenorenal ligament to the hilum of the spleen.
E) F gastro duodenal artery pass down behind the 1st part of duodenum; it arise from common hepatic branch of
coeliac trunk
26)
A) F
Its lower boundary is the first part of the duodenum
B) T
C) F
The posterior boundary is the inferior vena cava covered by the parietal peritoneum of the posterior abdominal wall
D) T
The free margin of the lesser omentum contains between its two peritoneal layers the portal vein and anterior to it
the hepatic artery and bile duct
E) T
Left (lesser sac) and right sub hepatic spaces communicate with each other via the epiploic foramen
28)
A) F
Rectus abdominis and external oblique muscles are supplied by the lower intercostals (T7-T12) and subcostal (T12)
nerves; the internal oblique and transvers abdominis by the lower intercostals, subcostal, iliohypogastric and
ilioinguinal nerves and the lowest fibres of the internal oblique and transvers abdominis by the first lumbar fibres.
B) T
C) T
D) T
E) F
29)
A) T
parasympathetic stimulation causes to increase salivary secretion
B) T
innate immunity is nonspecific immunity/first line of defence. Saliva contain IG A. it also a part of innate immunity.
C) F
parotid-serous Sublingual-viscous Submandibular-mixed
D) F
in the ducts of salivary glands saliva is modified by adding K + ,HCO3 - and excreting Na+ and Cl- .during meal rate of
secretion is higher than during post prandial. When rate is high there is less time for modification.
E) F controlled entirely by autonomic nervous system
30)
A) T
parietal cells/oxyntic cells-secrete acid and intrinsic factor
B) T

zollinger-ellison syndrome-caused by gastrin secreting tumour or hyperplasia of islet cells in pancreas. Gastrin causes
prolonged hyper secretion of acid.it cause formation of severe ulcers
C) F
gastrin increase secretion of ECL cells (histamine) and parietal cells (acid), histamine also increase secretion of
parietal cells
D) F
parasympathetic stimulation (Ach) increase parietal and chief cell secretion.
E) T
31)
A) F
gut bacteria produce vitamin K, thiamine, folate, biotin, riboflavin, pantothenic acid
B) T
bacteria make up most of the flora in the colon and 60% of dry mass of the feces
C) F
70% of liver blood supplied from portal vein. Gut bacteria also enter the liver with blood. Kuffer cells in liver
eliminate most of them.
D) T breast milk, but not infant formula fosters colonies of micro biotic flora in new-born’s intestinal tract.
E) T
in the lumen of intestine primary bile acids converted to secondary bile acids by
 partial dehydroxilation by bacteria
 removal of glycine and taurine and glycine groups
32) Stomach bed formed by

 left crus
 dome of diaphragm
 splenic artery
 body of pancreas
 transverse mesocolon
 upper part of left kidney
 left suprarenal gland
 spleen
 left colic flexure
A) T
B) T
C) T stomach bed lies between two layers of lesser sac
D) F
E) T
33) Relations of 1st part of duodenum

 first 2.5cm Anteriorly- gall bladder Posteriorly- gastro duodenal artery, bile duct, portal vein, IVC
 second 2.5cm Anteriorly-peritoneum, Inferior surface of right lobe of liver Posteriorly-upper part of head of
pancreas, right kidney
A) T
B) F
C) T
D) T
E) F

38)
A) F
upper part-skeletal muscle Lower part-smooth muscle
B) T
in the posterior mediastinum crossed anteriorly by left bronchus and right pulmonary artery
C) F
upper part-brachiocephalic veins Middle part-azygous system of veins Lower part-left gastric veins
D) T
trachea is anterior throughout the length
E) F
at T10 level at the level of seventh left costal cartilage
39) Pancreatic juice-

 Colipase
 Pancreatic lipase For lipids
 Phospholipase A2
 Cholesteryl ester hydrolase
 Trypsin
 Chymotrypsin For protein
 Elastase
 Carboxypeptidase A and B
 Ribonuclease and deoxyribonuclease- for nucleotides
 Pancreatic amylase- for carbohydrates
A) T
mobilize free fatty acids from fat stores
B) F
hydrolyse phospholipids and produce 2-acyl lysophospholipid and fatty acids
C) T
release FA and lysophospholipids
D) T
release cholesterol from cholesterol esters
E) F
hydrolyse lipoproteins
48) ANSWER -E
A) VIP-Induce smooth muscle relaxation (lower oesophageal sphincter, stomach, Gallbladder) Inhibition of gastric
acid secretion Stimulate pancreatic bicarbonate secretion
B) Gastrin-stimulate secretion of gastric acid by parietal cells of stomach Aids in gastric motility
C) CCK-stimulate acinar cells of pancreas to release pancreatic digestive enzymes Increase production of hepatic bile
and stimulate the contraction of gallbladder and relaxation of Sphincter of oddi
D) Secretin-stimulate the pancreas to secrete digestive enzymes rich in bicarbonate
E) motilin-increase the gastro intestinal motility Stimulate the production of pepsin
49) ANSWER -A
A) Migration motor complex –distinct pattern of electromechanical activity observed in gastrointestinal smooth
muscle during periods between meals.
B) Receptive contractions-contraction of muscle in relation to receptive substances like nicotine. (Skeletal muscle)

C) Mass action contraction-simultaneous contraction of large area of smooth muscle in in colon.
D) Segmental contraction-localized contraction of circular smooth muscles that constrict the intestine into segments.
E) Reverse peristalsis-radially symmetrical contraction and relaxation of muscles that propagates in a wave down a
tube, in an anterograde direction. (Oesophagus, ureter)
02.
2.1
 Composite gland
 Exocrine acini & group of endocrine cells (islet)
 15cm long Repeat campaign
 Largest digestive
 Shape- Same to walking stick or hook
 04 parts: head, neck, body, tail
 Location
Retroperitoneal (except tail)
Head and body
Neck – L1 / Trans pyloric plane
Tail – T12 / Intraperitoneal
 Extension
Lie obliquely, Posterior to stomach
At right side – duodenum
At left – Spleen
 Head & tail slop toward para vertebral gutter
 Neck & body curve forward over IVC & Aorta
 Body & tail extend towards the left kidney & spleen
 Transverse mesocolon attach to its anterior margin
Head
 Broadest part
 Surrounded by C Shaped concavity of duodenum
 Completely filled into duodenum
 Relations
 Posteriorly – IVC
Right & Left renal veins
Bile Duct
Right Renal Artery
 Anteriorly – 1 st part of duodenum
3 rd part of duodenum
Transverse mesocolon
 Left – Superior mesenteric vessels
2 nd part of duodenum
 Posterior surface
– Deeply indented
 Sometime tunneled by terminal part of bile duct
 Uncinate process

-Hook like projection of lower part of posterior part of head -Behind superior mesenteric vein & Artery -In
front of aorta
Neck
 Narrow band
 Relations –
Posteriorly - Commencement of portal vein
Inferiorly - Transverse mesocolon
Superiorly - Pylorus part of stomach
Body
 Passes from the neck to left
 Triangular space
 Relations
Posteriorly – Left renal vein
Aorta
Left crus of diaphragm
Left psoas muscle
Lower part of left suprarenal gland
 Triangular in cross section
 3 surfaces & 3 borders
 3 surfaces
Anterosuperior
Anteroinferior
Posterior
 3 borders
Superior
Anterior
Inferior
 Relations
 Superior border crosses the aorta at origin
 Splenic artery passes to left along superior border
 Inferior border alongside the neck crosses the origin of superior mescentric artery
 Transverse mesocolon attach along anterior border
 Splenic vein lies closely posterior surface
o -SMV join splenic vein behind body of pancreas in front of left renal vein
o -Lies over left psoas muscle
 Lies behind lesser sac because transverse mesocolon attach along the anterior border
 So, body forms a part of stomach bed
 Omental tuberosity of pancreas touches the omental tuberosity of liver
 They are separated by lesser omentum
Tail
 Lies with the 2 layers of splenorenal ligament
Pancreatic Duct
 Collect exocrine secretion
 From tail to head
 At junction of head & neck it turns sharp Y inferior direction
 At hepatorenal ampulla joins at a 60 angle with bile duct
 And joint opening into 2nd part of duodenum through major duodenal papillae 10cm from pylorus
Accessory Pancreatic Duct

 From uncinated process & lower part of the head
 Open to duodenum 2cm proximal to major papillae
Blood Supply
1. Mainly →splenic artery → Neck, Body, Tail
2. Superior & Inferior pancreaticoduodenal arteries→ Head
Venous Return
 Small veins → Splenic vein
 Head → Superior pancreaticoduodenal → Portal vein
→ Inferior pancreaticoduodenal → SMV
Lymph Drainage
 Follow the course of arteries
Nerve Supply
 Hormonal Control → more prominent
 Neural
 Sympathetic
 Parasympathetic
Sympathetic Parasympathetic
 Vagal  Vasoconstrictor
 Stimulate secretion  T 6-T 10 -> Via splenic nerve & coeliac plexus ->
Postganglionic fiber run with blood vessel
 Posterior vagal trunk & coeliac group
 Pain fibers accompany sympathetic supply
2.2
*Has both exocrine and endocrine parts.
*Covered by a thin collagen capsule.
*Which extend as a delicate fascia in between lobules.
*Mainly composed of bulk of acini (exocrine part, darkly stain)
*And islets of Langerhans cells (endo cells, pale stain)
*Exocrine part, closely packed secretory acini.
*Drain in to highly branched duct system.
*Occationally, adipocytes can be seen.
*Structure of acini – irregular cluster of pyramid shaped cells
*Apices of cells are projects towards the central lumen.
*Terminal ends of duct system open into the lumen.
*Basally placed prominent nuclei.
*Numerous ER, mitochondria, Golgi apparatus, and zymogen (inactive form of any enzyme) secreting granules can
be seen.
*Exocrine secretions directly drain in to central lumen via highly branched duct system.
*Via intercalated duct -> intra lobular duct -> inter lobuler ducts -> main/ accessory ducts.

*Intercalated ducts are lined by simple cuboidal cells.
*And become striated cuboidal in large ducts.
*Endocrine part – islets of langerhan
*Delicate collagen capsule surrounds each islets.
*Have rich blood supply with fenestrated capillaries.
*Various type of cells.
*Mainly α cells ---- Glucagon – arranged more pheriphery
β cells ----- insulin 2.3 2.3.1
*Also known as omental bursa.
*Large space of peritoneal cavity.
*Closed space.
*But, has an opening to the greater sac via the epipolic foreman (of winslow)
*Anterior wall formed by
1. Caudate lobe of liver.
2. lesser omentum.
3. stomach
4. anterior
2 layers of greater omentum.
*Posterior wall formed by stomach bed.
1. Neck and body of pancreas
2. Upper part of l/ kidney
3. l/suprarenal gland
4. splenic artery
5. commencement of abdominal aorta
6. coeliac trunk + plexus of nerves , lymph nodes
7. part of diagpharm
8. transvers mesocolon
9. part of duodenum
*upper border – reflection of peritoneum over diaphragm
*lower border – continuation of layers of greater omentum.
3.2
- Vermiform
- blind ending tube
- length 6-9 cm
- Open to posteromedial wall of ceacum below 2cm the ileoceacal value.
location :-
- Position of its base is constant in relation to the caecum.
- Lie variety position,
1. Retrocaecal position – Most common – 64%
2. Pelvic position
3. Subceacl
4. Preileal
5. Post ileal
 Has its own short mesentery -> Mesoappendix
- Triangular fold of peritoneum
- From left layer of mesentery of terminal ilium.
- 2 folds Ileocaecal fold

Vascular fold
- 2 recess Inferior ileocaecal recess Space between ileocaecal fold and Mesoapendix Superior
ileocaecal recess Space behind vascular fold.
Blood supply:-
 Appendicular artery
- may thrombosed in appendicitis.
- Leading to necrosis & rupture appendix.
- No collateral circulation.
- End artery.
 Corresponding vein.
Lymph nodes associated with iliocolic artery.
Nerve Supply:-
Parasympathetic
Sympathetic – derived from segment Tio
Pain fibers accompany vasoconstrictor nerves give rise to periumbilical pain,
If from midgut derivatives.
9th Repeat - SEQ ANSWERS
3.
3.1  8 th pr
3.2.1
 The mucosa is full of gastric glands and pits, and there is a prominent layer of smooth muscle - the muscularis
mucosa. The contraction of this muscle helps to expel the contents of the gastric glands.
 The muscularis externa layer has three layers of muscle. An innner oblique layer , a middle circular and an external
longitudinal layer.
 The contraction of these muscle layers help to break up the food mechanically
 The epithelium of the mucosa of the fundus and body of the stomach forms invaginations called gastric pits.
 The lamina propria contains gastric glands, which open into the bases of the gastric pits.
 These glands are responsible for the synthesis and secretion of the gastric juice.
 The lining epithelium of the stomach, and gastric pits is entirely made up of mucous columnar cells.
 These cells produce a thick coating of mucus, that protects the gastric mucosa from acid and enzymes in the
lumen.
3.2.2
 -Muscular tube
 - 25 cm long
 - Begins at lower border of cricoid cartilage (C6) end at cardiac orifice of stomach at level of T11
 - Has 4 parts ;
01.Cervical part
02. Superior mediastinal part
03. Posterior mediastinal part
04. Abdominal part
 CERVICAL PART
 - Lie in median plane
 - Deviate slightly left in thoracic inlet
 - Relations
 - Anteriorly - Trachea Thyroid gland
 Posteriorly - 6th- 7th cervical vertebrae Prevertebral fascia
 On either side - Common carotid arteries Recurrent laryngeal nerve
 Left side - Subclavian artery Terminal part of thoracic duct
 SUPERTOR & POSTERIOR MEDIASTINAL PART
 - Enter through thoracic inlet o superior mediastinum
 - Lie some what over left and then become midline at T5 & descend downward
 - Again come to slight left side at T7 level
 - Enter abdomen T10 level at level of 7th left costal cartilage
 Relations (above to downward)
 Anteriorly :- Crossed by trachea left bronchus Pericardium separating it from left atrium and diaphragm
 Posteriorly :- Thoracic vertebrae Thoracic duct Azygous vein its tubutaries
 Left side :- Left subclavian artery (1)
Left terminal part aortic arch (2)
Left recurrent laryngeal nerve (3)
Thoracic duct
Left pleura
 In posterior mediastinum :- Descending aorta (4)
 Right side :- Pleura Azygous vein
 - Below the root of the lung vagi form plexus
 - Left vagus lies anteriorly right vagus lies posteriorly
ABDOMINAL PART
 - At T10 level it enter to abdominal via esophageal hiatus of left crus of diaphragm
 - In abdominal esophagus lie in groove on posterior left lobe of liver
 - It covered anteriorly and left side by peritoneum
 - It has 3 narrow/constricted areas
 - Those from incisor teeth to 17 cm,28 cm, 43 cm
 - Corresponding :- Commencement of esophagus-15cm
Aortic arch crossed - 22cm
Crossed left principle bronchus – 27cm
Diaphragm – 38cm
 It is made of an outer connective tissue
 Muscular layer is,
 External longitudinal
 Internal circular
1/3 Skeletal
1/3 Skeletal & smooth
1/3 Smooth
 Submucosal layer contain mucous glands
 Mucosa contain stratified epithelium
 Passing downward ; change unto columnar epithelium in stomach Change is abrupt at cardiac arifice
BLOOD SUPPY
 - Mainly from
 Inferior thyroid artery Thoracic aorta Left gastric arteries
 - Venous drainage to ; Brachiocephalic Azygos Lower end via left gastric vein to portal vein

 LYMPH DRAINAGE
 Drain into ; Deep cervical nodes Posterior mediastinal nodes Thoracic bronchial nodes Ceoliac nodes Left gastric
nodes
 INNERVATION
 From re current laryngeal nerve
Mid cervical nerve
Thoracic sympathetic trunk
Greater splanchnic nerves
Parasympathetic nerves supply by vagus
10th Batch
10th Proper - MCQs
12. Regarding the thoracic part of esophagus,

A) Lies posterior to left bronchus.
B) Anterior to thoracic duct
C) Its wall is composed of smooth muscle
D) Right pulmonary artery is anterior to it
E) Drained by azygos vein
13. In Transpyloric plane,

A) Common lilac artery commence
B) Portal vein formed by superior mesenteric vein & splenic vein
C) Neck of pancreas
D) Inferior vena cava formation
E) Second part of duodenum
14. Relations of 1st part of duodenum are,

A) Anteriorly – Gallbladder
B) Posteriorly – Gastroduodenal artery
C) Inferiorly – Head of the pancreas
D) Superiorly – Epiploic foramen
E) Medially – Bile duct
15. Identification features of large intestine are,

A) Appendices epiploicae
B) Arterial arcades
C) Large caliber
D) Sacculation
E) Suspended from mesentery

17. The lesser omentum,
A) Contains a branch of the celiac artery
B) Contains the gastro-duodenal artery
C) Forms a part of the anterior wall of the mental bursa
D) Contains the right and left gastric arteries
E) Extend superiorly into the fissure for ligamentum teres
18. Structures related to the visceral surface of liver,

A) Duodenum
B) Stomach
C) Body of pancreas
D) Right kidney
E) Hepatic flexure

A) It is a retroperitoneal organ
B) It is developed from mid gut
C) Its body passing over the aorta at L2 vertebral level
D) Sphincter of Oddi regulate the flow of pancreatic juice through the accessory pancreatic duct
E) Tail of the pancreas lies within the splenorenal ligament near the hilum of the spleen
20. Suprarenal gland,

A) Asymmetrical
B) Covered by renal fascia
C) Medulla derived from endoderm
D) Innervation by postganglionic sympathetic fibers by coeliac plexus
E) Both glands receive blood directly from renal artery
37. T/F regarding the GI secretions,

A) GI secretions regulate by the hormonal and neuronal mechanisms
B) Secretin secrete by the pancreatic acinar cells
C) Surface cells that secret primarily mucus and bicarbonate
D) IF secrete by the chief cells
E) Pancreas secrete 1500ml pancreatic juice in 24hrs
SBR
38. Regarding vomiting,

A) Vomiting during travelling is due to hypersensitivity of vestibular organs.
B) Initiated by trigger zone in medulla
C) Coordination center is in cerebral cortex
D) Efferent include both somatic and autonomic components
E) Accompanied by vigorous contraction of stomach
47. Most significant feature of reflux esophagitis is,

A) Low PH in lower esophagus
B) Epigastric pain
C) High pressure in lower esophagus

D) Vomiting
E) Regurgitation of indigestible food
48. Which intestinal contraction is special for stomach?

A) Segmentation contraction
B) Isolated contraction
C) Mass action contraction
D) Peristalsis
E) Tonic contraction
53. False regarding defecation,

A) Foods containing indigestible carbohydrates facilitates defecation
B) Antimuscarinic drugs facilitate the defecation reflex
C) When rectal afferents are damaged, the sense of rectal distension is lost
D) When descending motor pathways are damaged, voluntary control of defecation is lost
E) Fecal retention is likely to occur during the spinal shock stage
55. Secretion of which of following is least depend on hormonal control,

A) Saliva
B) HCl
C) Pepsin
D) Pancreatic enzyme
E) Bicarbonate
56. What is the most appropriate status regarding the gut rotation,
A) Stomach rotates in an anticlockwise direction
B) Duodenum rotates 1800 clockwise
C) Physiological herniation occurs after the completion of the mid gut
D) Primary intestinal loops rotate in an axis formed by the inferior mesenteric artery
E) Rotation of the mid gut complete after 10th week of the development
57. A man underwent a surgery in gall bladder. During surgery the needle accidentally pierced the structure which
is immediately posterior to the epiploic foramen and caused blood accumulation in that area. What vessel is
involved?
A) Aorta
B) IVC
C) Superior mesenteric
D) Portal vein
E) Hepatic artery
60. False regarding the development of GIT system,

A) Accessory pancreatic duct is formed by proximal part of dorsal pancreatic duct
B) Dorsal bud gives rise to uncinate process
C) Duodenum gets dual blood supply
D) Haemopoietic Kuffer cells of liver are derived from septum transversum
E) Hepatocytes are derived from endodermic epithelium

10th Proper - SEQs
2.
2.1 A 42 years old business man was admitted to the hospital with the complaining of severe epigastric pain and pain
over his right shoulder. He was diagnosed to have perforated gastric ulcer in the posterior aspect of the body of the
stomach. During the surgery the left gastric artery was ligated.
2.1.1 List the structures that are at risk of damage by the gastric juice in the above condition. (10 marks)
2.1.2 Explain why this patient experiences pain over the shoulder? (10 marks)
2.1.3 Describe the blood supply of the stomach. (30 marks)
2.1.4 State how the stomach maintains adequate blood supply if the left gastric artery is ligated? (10 marks)
2.2 Describe the gross anatomy of the anal canal (40 marks)
4. Explain the physiological basis for occurrence of following in chronic bile duct obstruction.
4.1 Jaundice (30 marks)
4.2 Dark urine (15 marks)
4.3 Prolonged clotting time (45 marks)
4.4 Pale stools (10 marks)
12)
A) T
anterior relations; trachea, left bronchus, pericardium, diaphragm, left atrium, right pulmonary artery
B) F
posterior relations; thoracic vertebra, thoracic duct, azygos vein and its tributaries
C) T
first 1/3rd – only skeletal second 1/3rd – both skeletal and smooth Last 1/3rd – only smooth muscle
D) T
E) T
drained by upper part  brachiocephalic vein Middle part  azygos vein Lower part  left gastric vein
13)
A) F
Aorta divide into 2 common iliac artery at L4 level Transpyloric plane; bisects the line between jugular notch and
pubic symphysis.
 Tip of 9th costal cartilage
 Lower border of L1  Pylorus
 Head, neck body of pancreas
 Hila of kidney
 Fundus of gallbladder
 End of spinal cord
 Transverse mesocolon
 Duodojejunal flexure
B) T
C) T
D) F
At L5 – 2 common iliac arteries join to form IVC lies posterior and right to the aorta, just behind the right iliac artery
E) F
14)
A) T
anterior relations of 1st part of duodenum -; Liver, Gall bladder
B) T
posterior -; portal vein, common bile duct, gastroduodenal artery, IVC
C) T
superiorly -; epiploic foramen
D) T
E) F
inferiorly-; head and neck
15)
A) T
identification features of large intestine –
 Sacculations
 Large calibre
 Teania coli
B) F arterial arcades are present in jejunum and ileum in colon short vessels run to supply from a marginal artery
C) T
D) T
E) F mesentry cannot be used as an identification feature
17)
A) T
Lesser omentum contains hepatic artery proper, common bile duct, portal vein along the right free margin of the
lesser omentum. Along the lesser curvature of the stomach it contains right and left gastric vessels.
B) F
C) T
Omental bursa/ lesser sac has caudate lobe of liver, lesser omentum, stomach and anterior two layers of greater
omentum as its anterior borders.
D) T
E) F
Superiorly lesser omentum is attached to the fissure for the ligamentum venosum and to the margins of porta
hepatis in the form of an inverted L.
18)
A) T
Liver has 2 surfaces –
1. Diaphragmatic surface
2. Visceral surface
Relations of visceral surfaces –
 Stomach
 Duodenum

 Hepatic flexure of colon
 Right kidney
 Lesser omentum
 Body of pancreas
B) T
C) T
D) T
E) T
19)
A) T
retroperitoneal organs – organs that lie behind the peritoneum (SADPUCKER)
1. S – suprarenal gland
2. A – aorta
3. D – duodenum
4. P – pancreas
5. U – ureters
6. C – colon
7. K – kidneys
8. E – esophagus
9. R – rectum
15)
A) T
identification features of large intestine –
 Sacculations
 Large caliber
 Teania coli
B) F
arterial arcades are present in jejunum and ileum in colon short vessels run to supply from a marginal artery
C) T
D) T
E) F
mesentry cannot be used as an identification feature
17)
A) T
Lesser omentum contains hepatic artery proper, common bile duct, portal vein along the right free margin of the
lesser omentum. Along the lesser curvature of the stomach it contains right and left gastric vessels.
B) F
C) T
Omental bursa/ lesser sac has caudate lobe of liver, lesser omentum, stomach and anterior two layers of greater
omentum as its anterior borders.
D) T
E) F
Superiorly lesser omentum is attached to the fissure for the ligamentum venosum and to the margins of porta
hepatis in the form of an inverted L.

18)
A) T
Liver has 2 surfaces – 1. Diaphragmatic surface
2. Visceral surface
Relations of visceral surfaces –
 Stomach
 Duodenum
 Hepatic flexure of colon
 Right kidney
 Lesser omentum
 Body of pancreas
B) T
C) T
D) T
E) T
19)
A) T
retroperitoneal organs – organs that lie behind the peritoneum (SADPUCKER)
1. S – suprarenal gland
2. A – aorta
3. D – duodenum
4. P – pancreas
5. U – ureters
6. C – colon
7. K – kidneys
8. E – esophagus
9. R – rectum
B) F derivatives of foregut – oral cavity  upper half of 2nd part of duodenum.
1. Salivary glands
2. Bile duct
3. Pancreas
4. Upper and lower respiratory system
Derivatives of midgut – lower half of and 2nd part of duodenum  right 2/3rd of transverse colon
Hind gut  Left 1/3rd of transverse colon  anal canal
C) F only head crosses across L2 level Body passes over transpyloric plane
D) F sphincter of oddi guard only the main pancreatic duct.
E) T
20)
A) T
right  pyramidal shape
left cresenteric
B) T
lie within its own compartment
C) F
medulla  derived from migration of cells from the neural crest cells;

ectodermal origin Cortex intermediate mesoderm
D) T
E) F
directly from the aorta
37)
A) T
hormones – gastrin, CCK, secretin, somatostatin, GIP, VIP, motilin
Neural - enteric nervous system
B) F
S cells of upper small intestine
Pancreatic acinar cells  digestive system
C) T
surface mucus cells  mucus, HCO3- , trefoil peptide
D) F
parietal/oxyntic cells  IF + HCL Chief cells  pepsinogen
E) T
1.5 l per day
SBR
38)
A) T
B) T
area postrema – chemoreceptor trigger zone  in reticular formation in medulla
C) F
by the vomiting center in brainstem.
- If coordinated by cerebral cortex  must have the ability to control voluntary
D) T
Efferents;
1. Cranial nerves 5,9,10,12 relaxation of esophagus and pharynx
2. Spinal nerves  to diaphragm and contracts abdominal muscles
3. Autonomic  salivation, relaxation of sphincters, peristalsis in retrograde direction
E) T
47) ANSWER – A
GORD – LES incompetent  regurgitate gastric contents into esophagus.
48) ANSWER – E
Receptive relaxation; when food enters the stomach  fundus and upper portion of body relax and accommodate
food with little/ No any  in pressure
53) ANSWER – B
A) T
Dietary fibers-provide bulk to the feces & trap water, facilitate defecation.
B) F
Antimuscarinic drugs inhibits parasympathetic activity.
C) T
D) T

E) T
In spinal shock stage defecation reflex is lost
55) ANSWER – A
Gastrin  + parietal cells  HCl
Gastrin  + chief cells  pepsin
CCK  + pancreatic enzyme
Secretin HCO3-
56) ANSWER – E
Mid gut rotation axis superior mesenteric artery
Direction  270o anti clock wise
a) First 90o  during herniation
b) Then 180o  during return of intestine to abdomen (10th week)
57) ANSWER – B
Posterior relations to epiploic foramen  IVC
60) ANSWER – B
A) T
Accessory duct – Proximal part of dorsal pancreatic duct.
B) F
Uncinate process – Ventral pancreatic bud.
C) T
Superior pancreatico duodenal artery – Coeliac Trunk
Inferior pancreatico duodenal artery – Superior Mesenteric artery
D) T
Mesoderm of Septum Transversum
1. Hematopoietic cells
2. Kuffer cells.
3. Connective tissue.
E) T Endodermal epithelium of distal end of foregut Hepaticdiverticulum (liver bud) Penetrates Septum
Transversum  Liver Cords Hepatocyte
2.
2.1.1
 Lesser sac.
 Left crus of diaphragm/ left dome of diaphragm.
 Spleen.
 The left suprarenal gland.
 Upper part of the left kidney.
 Splenic artery and vein.
 Body of pancreas.
 Transverse mesocolon.
 Transverse colon
2.1.2
 Occurs due to referred pain same root value both diaphragm and shoulder. So damage to diaphragm can cause for
referred pain of shoulder.
 Diaphragm supplied by phrenic nerve.(C3—C5)
2.1.3
 Arterial supply.
o Supply from coeliac trunk.
o Left gastric artery which is origin from coeliac trunk.
o Supplies the lesser curvature and anastomosis with right gastric artery which is arise from hepatic artery.it
also supplies the lesser curvature.
o Short gastric artery (from splenic artery)—supply fundus and upper parts of the greater curvature.
o Right and left gastro epiploic—greater curvature. Posterior gastric artery also supplies to the stomach.
 Venous drainage.
o Veins accompany arteries.
o Drain into portal vein/ splenic vein/ superior mesenteric veins.
o Prepyloric vein drains into right gastric vein.
2.1.4
 Left gastric anastomose with right gastric artery.
 So right gastric artery supply the lesser curvature when left gastric artery ligated.
2.2
 Last 4cm of the GI tract shorter in female.
 Junction of rectum and anal canal is at pelvic floor.at this level puborectalis part of levetor ani clasps the gut angles
it forwards.
 It is in the 2.5cm in front of the tip of coccyx.
 Pass downwards and backwards to skin of the perineum.
 Muscles of the anal canal regarded as a tube within a funnel.
 Upper part of the funnel are lavetor ani.
 Stem of funnel is external sphincter. Tube is internal sphincter.
 External anal sphincter.
o Has 3 parts.(deep, superficial and subcutaneous)
o But all these parts blend with one another from a continuous tube.
o Its upper end formed by the circular skeletal muscle fibers and puborectalis.
o There are no levetor ani fibers in the middle at the front but sphincter forms a complete ring.
o Region where puborectalis fuse with external sphincter known as anorectal ring.(can palpable on rectal
examination)
o Fibro muscular strands from the middle parts of the external sphincter passes backwards to the posterior
surface of the coccyx to from anococcygeal ligament.
o Retrosphinchteric space filled with fat and there is fibro muscular raphe which is formed by the
iliococcygeal part of the levator ani.
o Lowerset part of the external sphincter carries inwards to lie below the lower end of the internal
sphincter.(intersphincteric groove at this level)

 Internal anal sphincter.
o Thickened downward continuation of the inner circular muscles of rectum.
o Conjoint tendon runs down between two sphincters.
o Strand of this penetrate the internal sphincter, lower part of the external sphincter, ishioanal fossa and
the perennial skin.
 Mucous membrane o Upper 1/3 mucous membrane shows 6-10 longitudinal ridges (anal columns).
o Lower end of these columns joint together from anal valves.
o Pocket formed above the valves known as anal sinuses.
o Mucous secreting glands open into anal sinuses.
o Pectineal line—level of anal valves.
o Below this level is pectin.(pale, smooth surfaced area).
o Continuous till intersphincteric groove.
o Below the groove a (unknown word) cutaneous area.contineous with the skin of the buttock.
o Small subcutaneous masses (anal cushions) comprising fibroelastic connective tissue, smooth muscle,
dilated venous spaces and arteriovenous anastomoses.
o Positions of the anal cushions in the anal canal at the left lateral (3), right posterior (7) and right anterior
(11 o` clock).
 Blood supply.
o Branches of superior rectal artery—upper end of canal.
o Terminations lying within columns.
o Median sacral arteries—small part
of the muscular wall.
o Inferior rectal arteries—lower end mucous membrane.
o Within the walls has good anastomosis between the various vessels.
 Venous drainage.
o Veins correspond to the arteries.
o Continuous with the rectal venous plexuses.
o Upper part of the canal and plexuses drain via the superior rectal and inferior mesenteric vein to the
internal iliac veins through the inferior and middle rectal veins.
o In this region has portal-systemic anastomosis at the anal columns.
 Lymph drainage.
o Upper part—lymphatics of the rectum.
o Lower part—superficial inguinal lymph nodes.
 Nerve supply.
o Inferior rectal branches of the pudendal nerves—external sphincter.sensory supply from 1-2cm above the
pectinate line downwards.
o Slow twitch fibers—external sphincter.
o Internal sphincter has sympathetic fibers from pelvic plexus and from first two lumbar segment,
parasympathetic fibers from the pelvic splanchnic nerves.
 Development.
o Upper part—cloaca (endodermal).
o Lower part—proctodeum (ectodermal).
o Pectinate line divide this upper and lower parts.

 Clinical.
o Anal abscesses.
o Anal fistulae.
4.
4.1 jaundice.
 Yellow color discoloration in the mucosa membrane, skin and sclera due to deposition of bilirubin. 
Normal bilirubin level is 1mg/dl.
 Jaundice occur when bilirubin level more than 3-5mg/dl in the blood.
 Normally bile pass to the intestine through the bile duct.
 Due to obstruction of bile duct prevention the passage of bile into the intestine.
 Also prevention the passage of conjugated bilirubin in to the intestine.
 So regurgitate the conjugate bilirubin into the blood.
 Increased amount of conjugated bilirubin than normal level.
 Deposition of excess bilirubin in skin, mucosa membrane and sclera.
 Jaundice occur. 4.2 Dark urine.
 Normally bile pass to the intestine through bile duct.
 Due to bile duct obstruction.
 Prevent the passage of bile into intestine.
 Prevent the passage of conjugated bilirubin into intestine.
 Regurgitate the conjugated bilirubin into blood.
 Conjugated bilirubin appear in the urine.
 Urinary bilirubin gives dark color to urine.
4.3 Prolonged clotting time.

 Vitamin K is essential for clotting.
 Precursor of clotting factor ii,v,vii,ix
Vitamin K
Activation of clotting factor ii, v, vii,ix

 Vitamin K need as a coenzyme for activation of clotting factor ii,v,vii,ix.
 In this condition, prevent the passage of bile into intestine.
 So impaired fat absorption.
 Vitamin k is fat soluble vitamin.
 No fat absorption occur.so impaired vitamin K absorption.
 Vitamin K deficiency occur.
 So impaired activation of clotting factors ii,v,vii,ix.
 So prolonged clotting time occur.
4.4 Pale stool.

 Normally, bile pass to the intestine through bile duct.
 Conjugated bilirubin enter the intestine with bile.
 Due to action of gut bacteria, conjugated bilirubin converted into urobilinogen.
Conjugated bilirubin colon → urobilinogen bacteria
 Some urobilinogen pass to the colon.

 In colon, urobilinogen converted to the stercobilin by colon bacteria.
Urobilinogen colon → bacteria stercobilin
 Stercobilin gives brown characterized color to stool.
 Due to this obstruction prevent passage of bile into intestine.
 So absence of above pathway.
 No formation of stercobilin.
 So pale stool.
11th Batch
11th Proper - MCQs
22. Regarding defecation,

A) Coordinated by sacral segment.
B) Afferents are in the sympathetic nerves.
C) Abolished by damage in mid thoracic spinal nerves.
D) Efferents are in pelvic nerves.
E) Urge to defecate 1st occur when rectal pressure increase to about 12mmHg.
23. Portosystemic anastomosis are seen at,

A) Rectal plexus.
B) Sinusoids of the liver.
C) Lower end of esophagus.
D) Umbilicus.
E) Spleen.
31. Regarding caudate lobe of the liver,

A) Lies between gallbladder & ligamentum teres.
B) Makes superior border of epiploic foramen.
C) Common for left & right functional lobes.
D) Connected with right lobe by caudate process.
E) Enclosed by peritoneum
32. In infants defecation often follows a meal. The cause of colonic contraction is
A) Histamine.
B) Increased circulating levels of CCK.
C) Gastrocholic reflex.
D) Increased circulating levels of somatostatin.
E) Enterogastric reflex.
33. A 60-year old woman undergo total pancreatectomy because of a pancreatic tumor. Which of the following
outcomes would not be expected after she recovers from the operation,
A) Steatorrhea.
B) Hyperglycemia.

C) Metabolic acidosis.
D) Weight gain.
E) Decreased absorption of amino acid.
34. Derivatives of the caudal limb of the primary intestinal loop,

A) Cecum.
B) Descending jejunum.
C) Superior part of ascending colon.
D) Duodenum.
E) Appendix.
35. About appendix,

A) Commonly in retrocaecal position.
B) Has taenia coli.
C) Attached to posteromedial wall of caecum.
D) Base lies on McBurney's point.
E) Referred pain on periumbilical region in appendicitis.
36. The anal canal,

A) is 4cm long.
B) Begins at S3 level.
C) Inferior 3rd is covered by skin.
D) Puborectalis acts as a sphincter.
E) Has the same 3 layers as the rectum in its upper 2/3
37. Large intestine,

A) Most of water is absorbed in the large intestine.
B) HCO3- secretion occurs.
C) Absorbs drugs.
D) Relate with gastrocholic reflex.
E) Has 3 types of wave patterns
38. T/ F regarding GI secretions,

A) Total secretion is about 3.5L.
B) About 98% solutes are absorbed.
C) Ionic content is similar to that of plasma.
D) Bile secretion can be stimulated by secretin.
E) Largest amount of water is absorbed in the ilium.
39. Regarding vomiting,

A) Can be produce by stimulation of the vestibule system.
B) Pain from genitalia can stimulate vomiting.
C) Can be inhibited by activation of the chemoreceptor trigger zone.
D) Bowel distention initiate vomiting.
E) Severe vomiting produces hypochloric alkalosis.
40. Deglutition,
A) Relaxation of soft palate.

B) Relaxation of upper esophageal sphincter.
C) Take a deep inspiration.
D) Close the glottis.
E) Cease the respiration.
SBR
41. Inguinal canal,

A) In female, conduct round ligament of uterus.
B) Is the passage between internal and external inguinal orifices.
C) May have persistent peritoneal sac within it.
D) Ilioinguinal nerve goes through it.
E) Transversalis fascia forms the anterior wall.
42. In an arteriogram of a 65-year old man, there was a 90% block in the Inferior mesenteric artery at the aorta.
What will provide the collateral supply to the descending colon?
A) Gastroduodenal artery.
B) Splenic artery.
C) Middle colic artery.
D) Sigmoidal artery.
E) Superior rectal artery.
43) The GIT is controlled by,

A) Its own intrinsic nervous system. (Auerbrach’s and Meissner’s plexus)
B) Sympathetic N.S.
C) Parasympathetic N.S.
D) Only B & C.
E) Only A, B & C.
59. Stomach,
A) Receive blood from the main arteries of celiac trunk.
B) Lined only by acid secreting cells.
C) Receive secreto-motor fibers from vagus.
D) Cardia is the most fixed part.
E) Passes downward and right across supracolic compartment.
60. Which of the following secretion has only neural influence?

A) Saliva
B) Pepsin
C) HCL
D) Pancreatic juice
E) Intestinal secretion

11th Proper - SEQs
2.
2.1 Describe briefly the location, parts and structural relations of the duodenum

2.2.1 Nerve supply of parotid salivary gland
2.2.2 Development and lymphatic drainage of anal canal
22) Regarding defecation

A )T
Coordinated by Parasympathetic nervous system (S2-S4) and Myenteric Plexus(weak)
B )F Both Afferent and Efferents pass through Pelvic (Parasympathetic) Nerve
C )F Will be patent as Sacral segments are intact, but higher control will be lost
D) T Both afferent and efferent pass through Pelvic Nerve
E )F 18mmHg
23)
portosystemic anastomosis are seen at following sites
A) T Superior rectal Vein+ Middle and Inferior Rectal Veins
B) F
C) T Left Gastric Vein+ Azygos Vein
D )T Superior Epigastric Vein + Inferior Epigastric Vein
E) F
31. Regarding caudate lobe of the liver

A )F Between IVC and fissure for Ligamentum Venosum
B )T Upper border- Caudate Lobe of Liver
Lower border- 1
st part of Duodenum
Posteriorly- IVC
Anteriorly- Right free margin of Lesser Omentum
C) F Left Lobe. Lasts Page-261
D) T
E )T Bare area is the only part of liver hat is not covered by peritoneum
32) In infants defecation often follows a meal. The cause of colonic contraction is
A )F
B )F
C) T (Page 507 Ganong)
Gastrocolic reflex increase motility of the colon or mass movements, in response to
stretch in the stomach
D )F
E )F

33)
A) F Pancreatic enzymes are important for lipid digestion
B) F Insulin secretion is absent as Isles of Langherhans has been removed
C) F Ketoacidosis is a complication of Type 1 Diabetes Mellitus (Absence of Insulin secretion)
D )T Digestion is hindered by the lack of pancreatic enzymes; Hence weight is lost
E) F Pancreatic enzymes are important for Protein digestion
34)Derivatives of the caudal limb of the primary intestinal loop

A) T
• Cecum
• Appendix
• Caudal portion of Ilium
• Ascending Colon
• Proximal 2/3 of Transverse Colon
B) F
C )T
D) F
E) T
35) About appendix

A )T Commonly Retrocecal position; Then Pelvic position
B) F Three Taenia of Cecum merge into a complete longitudinal layer for appendix
C )T 2 cm below Iliocecal valve
D) T
E )T Midgut derivatives give rise to midgut pain
36) The anal canal

A )T Last 4cm of GIT
B )T Continuation of rectum
C )T Part of anal canal below Pectineal line is cutaneous
D) T By blending with External Anal Sphincter
E) F Not 3,
it has 4 layers
I.
Mucosa
II.
Submucosa
III.
Muscularis propia
IV.
serosa
37) Large intestine

A) F Small Intestine
B) T HCO3- helps neutralize acidic end products of bacterial action in Large Intestine
C )T Drugs can be administered per rectal route

D )T Distension signals from stomach causes evacuation of colon
E )T Segmentation, Peristalsis and Mass movement
38) T/ F regarding GI secretions

A) F 6.7l
B )T
C) F Ph, Na+ and K+
concentration varies of that with plasma
D) F Secretin stimulates Biliary HCO3-
secretion, CCK stimulates gallbladder contraction
E) T
39)
Regarding vomiting
A) T Receptors of Vestibular Labyrinth of Inner ear->Vestibular Nuclei-> Cerebellum-
>Chemoreceptor Trigger Zone-> Vomiting Center
B) T Visceral pain is often accompanied with nausea and vomiting
C) F Activation of CTZ initiates Vomiting
D )T Bowel distention, excessive irritation and even over excitability of bowel can initiate
vomiting (Guyton-847)
E) T Gastric HCL is lost through Vomitus
40) Deglutition,
A) F Soft palate is pulled upwards to close posterior nares to prevent reflux of food into nasal
cavities (Stage-2)
B) T Thus, food moves freely from posterior pharynx into upper esophagus (Stage-2)
C) F Stop Mid inspiration
D )T Stage-2
E )T
SBR
41)Inguinal canal
A) T Round Ligament of Uterus
B) T starts from the internal inguinal orifice, extends medially and inferiorly through the
abdominal wall layers and ends in the external inguinal orifice
C) T Indirect Inguinal Hernia
D) T Enters Inguinal Canal by piercing Internal Oblique muscle
E )F Posterior wall
Answer (E)
42)
A)
Left Branch of middle Colic Artery anastomose with Ascending Branch of Left Colic Artery
B)
C )T
D)
E)

Answer (C)
43)
A
Controlled by both Enteric and Autonomic system
Answer (E)
2
2.1. Describe briefly the location, parts and structural relations of duodenum.
• C shaped tube
• 25cm long
• Widest, shortest and most fixed part of small intestine.
• Extends from pylorus to duodeno-jejunal junction.
•1
st 25cm is intraperitoneal.
• Remaining part is retroperitoneal.
• Has 4 parts
o 1 st part(superior)- L1
o 2 nd part(descending)- L2(Right side)
o 3 rd part(horizontal)- crosses in front of L3
o 4 th part(ascending)- left to L2
1) 1 st part
• Runs to right, upwards and backwards from pylorus.
• 5cm long
• 1 st 2.5cm lies between peritoneal folds of greater and lesser omentum, forms lower
boundary of opening into lesser sac.
• Relations
• Peritoneum (duodenal cap)

• Gallbladder
• Inferior surface of right lobe of liver
• Bile duct
• Gastroduodenal artery
• Hepatic portal vein
• IVC
• Epiploic foramen
• Neck of gall bladder
• Head of pancreas
• Next 2.5cm is retroperitoneal part.
• Passes backward and upward on head of pancreas to medial border of right kidney

2) 2 nd part
• Retroperitoneal
• 7.5 cm long
• Upper half is supracolic- to left of hepato-renal pouch
• Lower half is infracolic- medial to inferior pole of right kidney.
• Relations-
• Right lobe of liver

• Transverse colon
• Coils of jejunum
• Root of transverse mesocolon
• Peritoneum
• Hilum of right kidney

• Renal vessels
• Right ureter
• Right psoas major
• IVC
• Head of pancreas
• Pancreatic duct
• Bile duct
• Hepatic colic flexure

• Inferior pole of right kidney
art. (at
hepatopancreatic ampulla) - opens into major duodenal papillae 10cm from pylorus.
3) 3 rd part
• 10cm long
• Curves forward from right paravertebral gutter over slope of right psoas muscle
Relations
rior mesenteric artery

3rd part lies in both right and left infracolic compartments.
4) 4 th part
• 2.5cm long
• Ascends to the left of aorta
• Terminal part curves forward and to right.
• Then turn anteriorly and become jejunum at duodeno-jejunal flexure.
• Relations -
eft psoas muscle
E )F Posterior wall
Answer (E)
of pancreas
Inferiorly
3rd part lies in both right and left infracolic compartments.
4) 4 th part
• 2.5cm long
• Ascends to the left of aorta
• Terminal part curves forward and to right.
• Then turn anteriorly and become jejunum at duodeno-jejunal flexure.
• Relations -
Anteriorly
Posteriorly
mesenteric vein

Medially
2.2.
Nerve supply of parotid gland
Preganglionic fibers of Inferior salivary nucleus (in medulla)

Travel by way of
- Glossopharyngeal nerve
- its tympanic branch
- tympanic plexus
- Lesser petrosal nerve
to otic ganglion
From otic ganglion the Postganglionic fibers,secretomotor fibers
Hitch hike along auriculotemporal nerve
pass backward along mandibular neck
-ascend behind temporomandibular joint
-contact with anteromedial surface of gland,
-this surface penetrated by nerve filaments
Sympathetic
Vasoconstrictor fibers,
Reach gland from superior cervical ganglion by way of plexus on external carotid, middle meningeal arteries
2.3.Describe the development and lymphatic drainage of anal canal.

Lymphatic drainage
• Shows a watershed corresponding to the vascular pattern.
• Upper canal drains upward to join the lymphatics of rectum.
• Lymph from lower end passes to palpable superficial inguinal group.
Development
• Upper part of anal canal is a derivative of hindgut.
• The terminal portion of hindgut enters into posterior region of cloaca, the
primitive anorectal canal.
• Cloaca is an endoderm lining cavity, covered at ventral boundary by surface
ectoderm.
• This boundary between endoderm and ectoderm form cloacal membrane.
• At the end of 7th week, cloacal membrane ruptures, creating anal opening.
• The upper part (2/3) of anal canal derived from endoderm of hindgut.
Lower part (1/3) derived from ectoderm around proctoderm.
• Junction between endoderm and ectoderm regions of anal canal -
pectinate line
Just below the anal columns.
• At there is epithelium changes from columnar to stratified squamous

12th Batch
12th Proper - MCQs
4. Transverse mesocolon attach,

A) Left kidney
B) Body of pancreas
C) 2nd part of duodenum
D) Spleen
E) Stomach
5. Posterior relation of pancreas,

A) Splenic artery
B) Left kidney
C) Portal vein
D) 1st part of duodenum
E) Gastroduodenal artery
17. Portal vein,

A) Is formed by superior and inferior mesenteric veins
B) Is anterior to the neck of the pancreas
C) Gastroduodenal artery is located anteriorly to it
D) Is located anteriorly to the IVC
E) Obstruction of the portal system can cause portal hypertension
31. Gastric acid secretion,

A) Can be decreased by inhibiting H2 receptors
B) Is inhibited by the fat in the duodenum
C) Is inhibited by the secretion
D) is increased by stimulating of gastric secreting cells
E) Is stimulated by CCK-P2
38. Regarding gastric emptying,

A) Distension of stomach increases the rate of emptying
B) Vagal stimulation in the distal part of the stomach decreases gastric emptying
C) Gastric emptying is slowed by fat in ileum
D) Gastric emptying slowed by acidic and hypertonic chyme in duodenum
E) early dumping can be seen after partial gastrectomy.
SBR
41. An artery is affected due to a tumor in the tail of the pancreas. In which organ, the ischemic condition can be
happened?
A) Spleen
B) Left kidney
C) Left suprarenal gland
D) Body of the pancreas
E) Stomach

56. Which of the following statement on phase of deglutition is incorrect?
A) The pharyngeal phase typically lasts one second
B) The deglutition center exists within the medulla
C) The esophageal phase begins with the relaxation of the cricopharyngeus muscle
D) The UES is tonically contracted at rest, under the influence of the vagus
E) Following relaxations of the UES there is a short period of hypercontraction
60. What is the reflex of children initiate the defecation soon after diet?
A) Enterogastric reflex
B) Gastrocolic reflex
C) Action of the CCK
D) Gastric acid secretion
E) Gastroesophageal reflex
12th Proper - SEQs
4.
4.1 Nerve supply & lymphatic drainage of stomach
4.2 Compare & contrast the anatomical features of jejenum & ileum
4.3 Gross anatomy of visceral surface of liver
5. A middle aged obese woman underwent partial gastrectomy for the purpose of reducing body weight. She
managed to lose 30% of excess weight in next 6 months. But, she complained of frequent episodes of dizziness &
palpitations following food intake.
5.1 Explain Physiological basis of
5.2 Gastrectomy for weight loss
5.3 Dizziness & palpitations after meals
4)
A) F
B) F
C) F
D) F
E) F
5)
A) T
B) T
C) T
D) T
E) T

17.
a) F
b) F
c) T portal vein and bile duct are posterior relation of gastroduodenal artery
d) T portal vein lies infront of IVC
e) T
31.
A) There are H2 Histamine receptors at parietal cells of stomach, which induces HCL secretion in response to
histamine which is secreted by Enterochromaffin cells of stomach. (true)
B) Fat in the duodenum activates, K cells & I cells of duodenum. K cells secrete ‘Gastric Inhibiting Peptide’, which in
turn reduces secretion of gastrin from G cells. Gastrin is a substance which increases HCL secretion from parietal
cells. (true)
C) Secretin directly inhibits G cells, reducing the Gastrin secretion, so the HCL secretion. (true)
D) Gastrin secreting cells are G cells. (true)
E) CCK reduces G cell secretion. (true)
38)
A) T
B) F (From vagal stimulation – para sympathetic stimulation, so increase gastric emptying
C) F (Gastric emptying depends on the type of food ingested. & hyper osmolality of the duodenal contents.
D) T
E) T (Early dumping syndrome occurs 10 to 30 minutes after a meal . It results from rapid movement of fluid
into the intestine. Weakness, dizziness and sweating after meals are the symptoms.
SBR
41) A (Behind the tail , splenic artery & vein . They supply mainly to the spleen. So ischemic condition can be
happened in spleen.)
56) E
F
F both medulla and pons
F
F upper esophageal sphincter is contracted by glossopharyngeal and branches of vagus
T
60) B
4.
4.1.
Nerve supply of stomach
- along with arterial branches- innervates the stomach
plexus in posterior mediastinum
1)Anterior vagal trunk (mainly left vagus)
Lies in contact with esophageal wall1/2 hepatic branches

Several gastric branches to fundus and body
Anterior nerve of lartaget( great anterior gastric nerve) –runs down in
lesser Omentum
subdivided like cow's foot
supply antrum + pylorus
2)Posterior vagal trunk (mainly right vagus)
Not in contact with posterior surface of the esophagus
Lymph drainage of the stomach
Divided into 3 areas. Watershed line is parallel to greater curvature.
Aortic nodes
Area 1 - right 2/3 of stomach to- left and right gastric nodes
Area 2 - upper 2/3 of left 1/3 of stomach - gastro-epiploic nodes - sub plyloric nodes
Area 3 - lower 1/3 of left 1/3 of stomach - splenic nodes - supra pancreatic nodes
Note that all lymphatics of the stomach ultimately drain to

Coeliac nodes - Intestinal Lymph Trunk - Cisterna ChylI
4.2

4.3)
Peritoneal Attachments – Liver is enclosed in peritoneum (Ventral), Except bare area
Ventral part
Falciform lig. – Attached to liver & anterior abdominal wall Inferior margin - Ligamentum teres hepatis (Remnant of
L. Umbilical V.)
Right & left triangular ligaments
Coronary ligament – Superior & Inferior layers
Dorsal part
sser omentum – arise from inverted ‘L’ attachment
o Vertical limb - Ligamentum venosum (Remnant of Ductus Venosus)
o Horizontal limb - margins of porta hepatis
Anatomical Division
Diaphragmatic surface – Falciform lig.
Visceral surface – Fissure for Ligamentum Venosum + Fissure for Ligamentum Teres
o Right Lobe
-Between IVC groove & Fissure for Ligamentum venosum -Caudate process – Inferior to the right,
connecting to the right lobe - Papillary process – Inferior to the left
lobe -Between GB fossa & Fissure for Ligamentum Teres
-Arrangement (behind forwards)

V – Portal V.
A – Hepatic A.
D – Common Hepatic Duct
o Left Lobe
– near the fissure for Ligamentum venosum
Functional Division – According to distribution of BD, HA, PV Oblique plane through the GB Fossa & IVC groove
(Middle hepatic V. lies)
– -5 Surfaces
Anterior Surface
-●Diaphragm
●Pleura
●Anterior Abdominal Wall
● Xiphoid Process
Posterior Surface-
Right Lobe (Bare Area – Area that grows in to the Septum Transversum)
●Diaphragm
● IVC + Hepatic V.
●Suprarenal Impression - R. Suprarenal Gland
Left Lobe
●Oesophageal Impression - Oesophagus
●2 Crura
●Aortic Opening
●Celiac Trunk
Inferior Surface
*Right Lobe
● Gall Bladder
●Colic Impression - Hepatic Flexure

●R. Kidney - Renal Impression
* Left Lobe
● Gastric Impression - Stomach
●Fissure For Ligmentum Teres
* Quadrate Lobe
●Pylorus Of Stomach
●Duodenal Impression -1st Part of Duodenum
Superior Surface
●Right & Left Domes of Diaphragm
Right Surface
- ●Upper 1/3-Lung, Pleura, Diaphragm (In Mid Axillary Line)

●Middle 1/3-Pleura, Diaphragm
5)
5.2. Patients who are morbidly obese often undergo a surgical procedure which called as gastrectomy .
Partial gastrectomy means remove part of stomach and rest of stomach is stapledThus reservior function of stomach
is reduced therefore food rapidly comes to small intestine without storing stomach. Weight loss occur due to this
condition
As a result patient must eat frequent small meals. If large meals are eaten because of rapid absorption of glucose
from intestine and results hyperglycemia
13th Batch
13th Proper - MCQs
4. Porta Hepatis,
A) is enclosed by lesser omentum
B) is contain portal vein
C) Is contain lymph nodes
D) Portal vein anterior to the hepatic artery
E) Contain hepatic branch of vagus nerve
5. Lesser omentum,
A) Is attached superiorly to porta hepatis
B) Extend inferiorly to transverse colon
C) Separate lesser and greater sac of peritoneum
D) Form part of boundary of foramen of lesser omentum
E) Contain portal vein
6. Regarding Appendix,
A) Commonly situated in paracecal position
B) Extraperitoneal organ
C) Afferent pain nerve fibers accompany the sympathetic nerve & enter the level of T10
D) Blood supply from branch of posterior cecal artery
E) The tip of the appendix cannot reach down into pelvic cavity
7. Anterior abdominal wall,

A) Fibro muscular sheath.
B) Innervated by lower 6 intercostal nerves.
C) No deep fascia.
D) Protect abdominal viscera.
E) Drain into superficial lymph nodes below the umbilicus.
8. Investing layer of deep fascia superiorly attached to the,

A) mastoid process of the temporal bone
B) Zygomatic arch
C) internal surface of the mandible
D) hyoid bone
E) transverse process of cervical vertebrae
9. Regarding peritoneal reflexion,

A) Bare area in between right and left triangular ligament
B) Coronary ligament continue with falciform ligament
C) IVC form a boundary of bare area
D) Lesser omentum reflect around porta hepatic
E) Bare area is in contact with right colic flexor
10. Regarding development of gut,

A) Mid gut rotates in an anti-clockwise direction.
B) Primitive midgut give rise to the gallbladder.
C) Uterorectal septum give rise to the perineal body.
D) Dorsal mesentery forms the lesser sac.
E) Physiologic vermis is settled by the 10th week of gestation.
14. Spleen,
A) Can be palpable beyond the left costal margin in its normal size
B) Drain into portal venous system
C) Has gastric impression between notched anterior border and hilum
D) Can be present in the mesentery of small intestine as accessory spleen
E) Bleed due to penetration of fractured end of 11th rib
15. Regarding identification features of Large intestine,

B) Arterial arcades
C) Haustrations
D) Suspended by mesentery
E) Taenia coli
16. Head of the pancreas lies anterior to,

A) Bile duct

C) Left renal vein
D) Portal vein
E) Superior mesenteric artery
18. Diaphragm,
A) Pericardium attached to central tendon
B) Descending occur during parturition
C) Sensory supply to the periphery phrenic nerve
D) Aorta descend down through the medial arcuate ligament
E) Esophagus descend down at T8 level via esophageal hiatus
26. Gastrin,
A) Is secreted by G cells in the stomach
B) Stimulates secretion of H+ in the stomach
C) Promotes the growth of intestinal mucosa
D) Concentration is high in Zollinger-Ellison syndrome
E) Secretion is inhibited by secretin
27. In the stomach,

A) pH rarely falls below 4.0
B) pepsinogen is converted to pepsin by HCL
C) mucosal cells containing high concentration of carbonic anhydrase
D) acid secretion is inhibited by gastrin
E) emptying is facilitated by activity of sympathetic nerves
28. Functions of large intestine,

A) H2O absorbtion
B) Mucous secretion
C) Intrinsic factor form
D) Bile salts absorb
E) K+ secretion
29. Following about salivation,

A) Daily 250ml of it is produced
B) Reflex is induced by parasympathetic stimulation
C) Parasympathetic stimulation increase blood flow to glands
D) Mucous secretion will be increased by parasympathetic stimulation
E) Parotid secretion rich in enzymes
SBR
46. A 36-year old women admitted in hospital with rectal bleeding. Physical examination and rectal examination
reveals abnormal mass of tissue protruding below the pectinate line. Biopsy reveals the presence of an
adenocarcinoma. Which lymph node first receive lymph from area of pathology?
A) Internal iliac
B) External iliac
C) Middle rectal
D) Superficial inguinal

E) Deep inguinal
47. Which of the following structure is used as a landmark to determine the position of the duodeno-jejunal
junction in a laparoscopy?
A) Inferior mesenteric artery
B) Phrenicolic ligament
C) Superior mesenteric artery
D) Ligament of treitz
E) Uncinate process
55. Which of the following has highest pH?

A) Saliva
B) Gastric juice
C) Pancreatic juice
D) Intestinal contents
E) Colic contents
13th Proper - SEQs
6.
6.1. Describe the arterial supply of the stomach. (35marks)
6.2. Describe the course of the common bile duct with its relations and blood supply. (35marks)
6.3. Describe the general structure of pharynx and state the features of nasopharynx (excluding the Blood supply and
nerve supply) (30marks)
04) last page no 259

A) T
B)T
C)T
D)F
E)T
05) Lesser omentum

A)T It's attached to its superior extent to the fissure of porta hepatis
B)F Greater omentum
C)T
D)T Anteriorly the foramen is bounded by right free margin of the lesseromentum
E)T
06)
Appendix
A)

False
Most common in retrocaecal position
B)
False
Intraperitoneal organ
C)
True
D)
False
Appendicular artery
E)
False
07)
Anterior abdominal wall
A)
False
Musculo - aponeurotic wall
B)
False
T7-T12 T7-T11=5 intercostal nerve
T12=subcostal nerve
C)
True
D)
True
Last page - 226
E)
True
08)
Investing layer of deep fascia superiorly attached to the
A)
True
Moore page- 987
B)
True
C)
True
D)
True
E)
True
09)
Regarding peritoneal reflexion
A)
True

B)
True
C)
True
D)
False
E)
True
10)
Regarding development of gut
A)
True
B)
False
C)
True
D)
False
Dorsal mesentery - greater omentum
ventral mesentery - lesser omentum
E)
False
12th week embryo
14)
Spleen
A)
F
Last page 271
B)
F
Splenic vein
C)
T
Last page 271
D)
T
Along the splenic vessels / in the peritoneal attachments
E)
T
15)
Large intestine
A)
T
B)

F
Small intestine (jejunum & ileum)
C)
T
D)
F
Both large & small intestine
E)
T
16)
Pancreas
A)
T
Posterior relations of the head of the pancreas
B)
T
C)
T
D)
F
Posterior to neck of the pancreas
E)
F
Posterior to neck of the pancreas
18)
Diaphragm
A)
T
Last page 185
Central tendon is in separable from the fibrous pericardium.(Same
embryonic origin)
B)
T
Last page 187
To increase intrabdominal pressure to facilitate delivery of baby.
C)
F
Motor
Proprioceptive
-> phrenic
Periphery -> lower intercostal nerves

D)
F
Aorta
Opposite T12 vertebra

E)
F
Esophageal hiatus
26)
Gastrin
A)
T
B)
T
Functions of Gastrin
C)
F
D)
T
Zollinger-Elliston syndrome (Z-E syndrome)
resulting in peptic ulcer
tumor that secretes a hormone called Gastrin

E)
T
Gastrin secretion inhibited by
feedback]
peptide), VIP (vasoactive intestinal peptide), Glucagon & calcitonin
27)
Stomach
A)
F
P
h in stomach -> acidic (1.5 to 3.5)
Level maintained by H/K ATPase
B)
T
C)

T
Carbonic Anhydrase present in
D)
F
Initiated by Gastrin (G cells)
E)
F
Gastric emptying
Parasympathetic -> relaxes sphincter muscles in the digestive tract
28)
Large intestine
A)
T
Functions
B) T
C)
F
D)
F
Bile salts absorbed by small intestine ( mainly ileum)
E)
T
29)
Salivary glands
A)
F
-> (0.5 - 1.5) L
-> (0.3 -0.4) ml/min
-> 0.1 ml/min during sleep
-> about 4, 0.5, 0 ml/min during eating,
chewing & other stimulating activities.

B)
F
C)
T
D)
T
E)
T
Parotid gland
Sublingual glands
SBR
46)
D
Lymph drainage below the pectineal line -> superficial inguinal lymph
nodes
47 )
D
Duodenal-jejunal flexure is suspended from the ligamentum of teres
serves as its surgical landmark and gives its unique shape
55.
C
Saliva - 6.7 to 7.4
Gastric juice - 1.5 to 3.5
Pancreatic juice - 8 to 8.3
Intestinal contents - 6 to 7.4
Colic contents - ceacum - 5.7
Rectum - 6.7
6)
6.1. Describe the arterial supply of the stomach.
(35marks)
The stomach is supplied by branches from the coeliac trunk. Along the lesser curvature between
the two layers of the lesser omentum the left gastric artery which is origin from coeliac trunk supplies
the lesser curvature and anastomoses with the right gastric artery which is arise from hepatic artery. It
also supplies the lesser curvature; these arteries may be double.
The fundus and upper left part of the greater curvature receive about six short gastric arteries from the

splenic artery in the gastrosplenic ligament. The rest of the grater curvature is supplied by the left and
right gastroepiploic vessels, which run between the two layers of the greater omentum and
anastomoses with each other. The right gastroepiploic artery is closer to the grater curvature than the
left gastroepiploic artery.
A branch from the splenic artery as it runs along the upper border of the pancreas, the posterior gastric
artery may also supply the stomach.
6.2. Describe the course of the common bile duct with its relations and blood supply. (35marks)
The common bile duct is about 6 to 8cm long and its normal diameter does not exceed 8mm. There is
three parts. The upper (supra duodenal) third lies in the free edge of the lesser omentum – in front of
the portal vein and the right of the hepatic artery, where the lesser omentum forms the anterior
boundary of the epiploic foramen.
The middle (retro duodenal) third runs behind the first part of the duodenum and slopes down to the
right, away from the almost vertical portal vein which now lies to the left of the duct with the
gastroduodenal artery. The inferior vena cava is behind the duct.
The lower (Para duodenal) third slopes down further to the right in a groove on the back of the head of
the pancreas. And Infront of the right renal vein.
It joins the pancreatic duct at an angle of 600
at the hepatopancreatic ampulla (of Vater). The ampulla
and the ends of the two ducts are each surrounded by sphincter muscles, the whole constituting the ampullary
sphincter (of Oddi). Sometimes the muscle fibers surrounding the ampulla and the pancreatic
duct are absent, leaving only the bile duct sphincter.
When all three are present the arrangements allow for independent control of flow from bile and
pancreatic duct. The ampulla itself opens into the posteromedial wall of the second part of the
duodenum at the major duodenal papilla, which is situated 10 cm from the pylorus.
Blood supply
The extrahepatic biliary tract receives small branches from the cystic and right hepatic arteries and the
posterior branches of the superior pancreaticoduodenal artery; they form anastomosis.
6.3. Describe the general structure of pharynx and state the features of nasopharynx (excluding the
blood supply and nerve supply
(30marks)
Pharynx is a funnel-shaped tube extends from the internal nares to the esophagus posteriorly and
the larynx anteriorly. It composed of skeletal muscle & lined by mucus membrane. Nasopharynx
functions only in respiration. Oropharynx and laryngopharynx have both digestive and respiratory
function. It performs swallowing/ deglutition. Food that is swallowed passes from the mouth to
oropharynx before passing into the esophagus.
Pharynx is anteriorly deficient fibro-muscular funnel like tube. It forms the proximal dilated part of the
digestive tract and common passage for air and food/ liquid. It is 12 cm in length, 5 cm in diameter at
upper level, 1.5 cm in diameter at lower level.
Pharynx is the most posterior visceral organ in the neck. Extend from the base of the skull (CV1) tocricoid cartilage
(CV6) in the neck and continues as esophagus down. It communicates anterior to nasal
cavity, oral cavity and larynx.
Pharynx divides into three parts.
1. Nasopharynx
2. Oropharynx

3. Laryngopharynx
to larynx
Pharynx has several layers. It has mucosa, submucosa, muscle layer and loose areolar tissue. In
nasopharynx there is a ciliated columnar epithelium. Oro and laryngopharynx have stratified squamous
non-keratinized epithelium. Muscle layer is thin layer. Fibrous layer has two fasciae. Pharyngobasilar
fasciae is a internal fascia up to hard palate level. It is rigid membrane and thickened submucosa.it lies
from base of the skull to upper border of superior constrictor. It maintains the patency of the nasopharynx.
Buccopharyngeal fascia is external fascia. It lies from buccinator muscle to pretrachial
facia.
There are two muscle layers. External circular layer (pharyngeal constrictors) has superior constrictor,
middle constrictor and inferior constrictor. Internal longitudinal layer has palatopharyngeus,
stylopharyngeus and salphyngopharyngeus.
Nasopharynx
Nasopharynx extend from base of the skull to the soft palate. It lies behind the nasal cavity and
communicates through choanae. Soft palate act as a door-close aperture which connects nasopharynx
with rest of pharynx. Important structures in nasopharynx are nasopharyngeal tonsil/ the adenoids,
orifice of the pharyngo-tympanic tube/ auditory tube/ eustachian tube and pharyngeal recess.
Nasopharynx covered back and side by pharyngobasillar fascia. Posteriorly prevertebral space/ fascia
and body of C1 vertebra. Anteriorly choanae and back of soft palate. Inferiorly soft palate and
pharyngeal isthmus. Superiorly pharyngeal tonsil, sphenoid and occiput. Epithelium is ciliated columnar.
It has opening of auditory tube, pharyngeal tonsil, tubal tonsil, pharyngeal recess, salphingopharyngeus and levator
palati
14th Batch
14th Proper - MCQs

8. Superficial inguinal ring,

A) Oval shaped.
B) Defect in superficial facia
C) Immediately above and lateral to pubic tubercle
D) Has crura connect with spermatic facia
E) Transmits ilioinguinal nerve.
9. Regarding the rotation of the gut,

A) The stomach rotates in an anticlockwise direction.
B) The duodenum rotates 900 clockwise.
C) Mid gut loop rotates 900 anticlockwise at 6th week of intrauterine life
D) Mid gut rotation is complete at 16th week of intrauterine life.
E) Physiological umbilical herniation occurs after completion of mid gut rotation.
10. Greater curvature of the stomach is supplied by,

A) Left gastric artery.
B) Right gastric artery.
C) Short gastric artery.
D) Left epiploic artery.
E) Right epiploic artery.
11. Caecum,
A) Is completely covered by peritoneum.
B) Is supplied by inferior mesenteric artery.
C) Has taenia coli.
D) Lies over the iliacus and psoas muscle.
E) Has the lateral cutaneous nerve of thigh anterior to it.
12. Lesser sac,

A) It connects to greater omentum by epiploic foramen.
B) Left kidney is laterally related.
C) Stomach posterior to it.
D) Lienorenal ligament and gastrosplenic ligament form lateral border.
E) Anteriorly greater omentum.
37. Gastric emptying is accelerated by,

A) Vagal stimulation
B) Meal rich in fat
C) Acidity of duodenal chyme
D) Larger meal size
E) Hyperosmolar chyme in the duodenum
38. Acinar cells of pancreas,

A) Secrete bicarbonate
B) Are stimulated by vagus nerve
C) Secrete CCK-pancreozymin
D) Are the major source of lipase
E) Are stimulated by secretin
39. Functions of small intestine,

A) Absorption is the exclusive function
B) Highest absorption is in jejunum
C) Water is completely absorbed by the small intestine
D) Intestinal cells have special carriers for protein transport
E) Bile salts are absorbed in the large intestine

40. Functions of bile salts,
A)
B) Emulsification of lipid
C) Neutralizing duodenal chyme
D) Digestion and absorption of dietary lipids
E) Immune function
SBR
47. At lower esophageal level which vein has the anastomotic connection with left gastric vein?
A) Azygos venous system
C) Superior vena cava
D) Brachiocephalic
E)
52. Serum bilirubin level is detected by,

A) Ehrlich's test
B) Forchet's test
C) Hay's test
D) Seliwanoff's reaction
E) Van den bergh reaction
53. In a fatty lady ulcer in the gallbladder penetrates its posterior wall. Which part of bowel receives it,
A) Duodenum
B) Transverse colon
C) Ascending colon
D) Jejunum
E) Ileum
14th Proper - SEQs
4.2. Persistent vomiting could lead to,

4.2.1 Dizziness
4.2.2 Muscle spasm
Explain the physiological basis of the above symptoms following persistent vomiting
(2 x 25 marks)
14th Repeat SEQs
2.
2.1 Write an account on portosystemic anastomosis with its clinical importance. (30 marks)
2.2. Describe the gross anatomy of the duodenum. (45 marks)
2.3 Briefly describe the development of stomach. (25 marks)

07)
A. F
Lies anterior to T12 vertebra
B. T
Between right and left crura
C. F
The sympathetic trunk passes behind the medial arcuate ligament.
D. F
T12 :- Aortic
Azygos vein
Thoracic duct
T10:- Esophagus
Vagus R & L
Branches of left gastric artery
Lyphatics
T8 :- IVC
Right phreni
E. F
LAST PAGE 185
08)
A. F
A V shaped gap.
B. F
This is a defect in the external oblique aponeurosis.
C. T
Is situated above and just lateral to pubic tubercle.
D. F
E. T
09)
A. F
90 degree clockwise
B. F
C. T
D. F
10th
E. F
During intiation at 6th week
10)
A. F
LAST PAGE 249
B. F

Greater curvature supplied by
• Six short gastric arteries
• Left gastroepiolic artery
• Right gastro epiploic artery
• (splenic artery)
C. T
D. T
E. T
11)
A. T
Last’s anatomy page 259
B. F
Caecum is supplied by anterior and posterior caecal arteries. They are branches of the ileocolic artery. Ileocolic
artery is a branch of superior mesenteric artery.
C. T
Longitudinal muscles of the caecum is concentrated into three flat band; taeniae coli
D. T
E. F
The lateral femoral cutaneous nerve of thigh posterior to caecum.
12)
A. F
Lesser sac connect to greater sac by epiploic foramen
B. F
Left kidney is posteriorly related.
C. F
Stomach anterior to it.
D. T
E. T
Anterior wall of the lesser sac is formed by anterior two layers of the greater omentum.
37)
a. T (increase pyloric opening)
b. F
c. F (by releasing secretin )
d. F
e. F
39)
A. T
B. F
(ileum)
C. F
D. T
E. F

(terminal part of ileum)
40)
A. F
B. T
C. T ( HCO3 ions)
D. T
E. T ( innate immunity by activating gut immune cells)
SBR
47) A
this is a site where a portal/systemic anastomosis occurs between the esophageal branches of left gastric vein and
esophageal branches of the azygos venous system.
52) E
53) A
4.2
persistent vomiting could lead to
4.2.1 Dizziness
4.2.2 Muscle spasm Explain the physiological basis of above symptoms.
4.2.1
Vomiting is the oral excretion of upper gastro intestinal contents .
When this is for a considerable period of time it leads to hydrogen ion loss along with water loss.
During persistent vomiting considerable amount of body fluid loss occurs.
This leads to the reduction of venous return to the right atrium through superior vena cava and inferior vena cava.
This leads to the reduction of end diastolic volume of left ventricle.
The ultimate result is the reduction of cardiac output.
Cardiac output reduction leads to the reduction of mean arterial pressure which is considered as the factor which
decides the blood flow to the peripheral.
Dizziness can use to describe a clinical condition with feeling faint, woozy and weak unsteady feeling.
Reduction of mean arterial pressure leads to the reduction of cerebral blood flow.
The oxygen and nutrient supply to the brain tissue become reduced leading to this dizziness.
4.2.2.
As mentioned above the vomiting leads to a considerable loss of electrolytes along with body fluid if it occurs for a
long time period.
In case of electrolyte loss it is not only about the hydrogen ions but also calcium ions as well as potassium.
Calcium is known as important for muscle contraction. Potassium is known as important as peripheral vasodilator
which leads to increase the blood flow to muscles specially they are continuously contracting.
During vomiting the reduction of mean arterial pressure occurs as explained above. It also leads to the reduction of
blood supply to these muscles.
Muscles get oxygen and essential nutrients via blood.

Lack of oxygen may lead to anaerobic respiration causing accumulation of lactic acids also.
All above mentioned causes lead to difficulty in muscle contraction with less efficient and more pain known as
muscle spasm
15th Batch
15th Proper - MCQs
11. Peritoneum,
A) Layers of serous membrane
B) Parietal layer doesn’t extend to the pelvic cavity
C) Supplied by intercostal nerves over the diaphragm
D) Visceral layer is attached firmly to organs
E) Peritoneal fluid communicates with blood vessels
12. Rectum does not have,

A) Taenia coli
B) Mesorectum
C) Haustrations
D) Semilunar fold
E) Appendices epiploicae
13. Identifying features of the ileum from the jejunum,

A) Payer’s patches
B) Shorter plicae circularis
C) Shorter vasa recta
D) More arcuate arteries
E) Greater fat content
14. Duodenum relations,

A) 1st part of duodenum lies in L2 level
B) It also contains an intra peritoneal part
C) It forms lower boundary of epiploic foramen
D) Anterior to the IVC
E) Gallbladder anterior to the Duodenum
15. Between the internal oblique and transverse abdominis muscles there is a neurovascular plan that contains,
A) Iliohypogastric nerve
B) Deep circumflex artery
C) Superior epigastric artery
D) Subcostal nerve
E) Ilioinguinal nerve
16. Regarding the development of the gut,

A) Mid gut rotates in anti-clockwise direction
B) Primitive foregut gives rise to thymus
C) Anorectal septum gives rise to perineal body
D) Ventral mesentery forms the lesser sac
E) Physiological herniation ends at the 10th week
26. Regarding digestion and absorption of protein,

A) Amino acids are absorbed via Na+ co-transport mechanism
B) Amina acids transported across the apical membrane via facilitated diffusion into Circulation
C) Chemical digestion begins in stomach
E) Pepsin break polypeptide into Amino acids
29. Factors altered in liver cirrhosis,

A) Capillary osmotic pressure
B) Capillary hydrostatic pressure
C) Filtration coefficient
D) Intestitial colloid osmotic pressure
E) Interstital hydrostatic pressure
38. Benefits of colonic bacteria,

A) Synthesize vitamin
B) Prevent constipation
C) Digest undigested substance
D) Detoxification
E) Growth promotion
39. Identification features of large intestine are,

B) Arterial arcades
C) Suspended from mesentery
D) Sacculation
E) Large caliber
SBR
41. A 56-year old man admitted to emergency unit, after an elephant attack. He had pain over The left
hypochondrium. Examination revealed a fluid like leaky hemorrhage in the Hepatorenal pouch. Which organ
would’ve most probably damaged?
A) Left kidney
B) Liver
C) Spleen
D) Pancreas
E) Stomach
44. 30-year old young man presented with severe upper abdominal pain radiating to back. Physical examination
revealed hypotension and tender distended abdomen. CT abdomen & Angiogram revealed perforated ulcer in the
1st part of the duodenum & bleeding of an Artery posterior to it. What is the artery?
A) Splenic artery
B) Gastroduodenal artery

C) Superior pancreaticoduodenal artery
D) Inferior pancreaticoduodenal artery
E) Right hepatic artery
55. Which initiate small intestinal digestion,

A) Trypsin
B) Trypsinogen
C) Enterokinase
D) Pancreatic lipase
E) Pancreatic protease
15th Proper - SEQs
2.
2.1 Briefly describe the location, relations including their significance and blood supply of the head of the pancreas
(40 marks)
2.2 Briefly describe the internal features of the anal canal (30 marks)
2.3 Explain anatomical basis of fecal incontinence in lumbosacral nerve root lesion (15 marks)
2.4 List five structures that lie in the transpyloric plane (15 marks)
4.3 Explain the physiological basis for,

4.3.1 Use of Histamine 2 (H2) receptor blockers to treat peptic ulcers (30 marks)
4.3.2 dental caries is commoner in patients with deficient salivary secretion (xerostomia)
11.
A) T
B) F
C) F
D) T
E)
12.
A) T
B) F
C)
D) F
E) T
13.
A) T
B)
C) T
D) T
E) T

14.
A) F
B) T
C) F
D) T
E) T
15.
A) T
B)
C)
D) T
E) T
16.
A) T
- The primary intestinal loop rotates around an axis formed by the superior mesenteric artery. When viewed from
the front this rotation is counter clockwise, and it amounts to approximately 270° when it is complete.
B) F
– Thymus - epithelium of ventral region of 3rd pharyngeal pouch Foregut derivatives - Esophagus , trachea, lung
buds, stomach, duodenum proximal to the entrance of bile duct, liver, pancreas, biliary apparatus
C) T
D) F
E) T
- Starts at 6th week & ends at 10th week
26.
A) T
B) T
C) T
D)
E) F
29.
A) T
B)
C) F
D)
E)
38.
A) T
B) T
C) T
D)
E)

39.
A) T
B) F
C) T
D) T
E)
Special Features of large intestine:
• Appendices epiploicae
• Taenia coli
• Sacculations
• Mesocolon
SBR
41. C
44. B
55. C
SEQ
2.
2.1 Briefly describe the location, relations including their significance and blood supply of the head of the Pancreas
(40 marks)
Head is the Broadest part Surrounded by C Shaped concavity of duodenum Completely filled into duodenum
Relations:
• Posteriorly – IVC Right & Left renal veins Bile Duct Right Renal Artery
• Anteriorly – 1 st part of duodenum 3rd part of duodenum Transverse mesocolon
• Left – Superior mesenteric vessels 2nd part of duodenum
•Posterior surface – Deeply indented Sometime tunneled by terminal part of bile duct.
• Uncinate process
– Hook like projection of lower part of posterior part of head
– Behind superior mesenteric vein & Artery
– in front of aorta
Blood supply:
★ Superior & Inferior pancreaticoduodenal arteries → Head of pancreas
★ Head → Superior pancreaticoduodenal → Portal vein → Inferior pancreaticoduodenal → SMV
2.2 Briefly describe the internal features of the anal canal (30 marks)
Page 315 – Last’s Anatomy
[simple columnar above the pectinate line, stratified squamous below the pectinate line. Lower 8mm resembles true
skin with sweat and sebaceous glands.
Above the pectinate line mucosa forms longitudinal folds called anal columns. Upper 3⁄4 - circular muscle layer
forms the internal anal sphincter. Outer longitudinal muscle layer is thin. Outer to this is the external anal sphincter
made of skeletal muscles]
In the upper third of the anal canal the mucous membrane shows 6 to 10 longitudinal ridges, the anal columns. They
are prominent in children. At their lower ends adjacent columns are joined together by small horizontal folds, the
anal valves; the pockets so formed above the valves are the anal sinuses, into which open mucus- secreting anal
glands. About half the anal glands are submucosal and the rest penetrate through the internal sphincter. Infection in
these glands results in anal abscesses and fistulae. The level of the anal valves is the pectinate line (also called the
dentate line) below which is a pale, smooth-surfaced area, the pecten, which extends down to the intersphincteric

groove. Below the groove is a truly cutaneous area, continuous at the anus (anal margin) with the skin of the
buttock. Histologically the lining below the groove is typical skin with keratinized stratified squamous epithelium,
hair follicles, sebaceous glands and sweat glands. The lining of the pecten is non-keratinized stratified squamous
epithelium, with no hair follicles, sebaceous glands or sweat glands. The anal column area, being continuous with
rectal mucosa, has typical columnar intestinal cells and tubular glands. But immediately above and below the
pectinate line there is a zone of variable, often mixed epithelial structure, so that there is no abrupt line of change
from the single- layered gut type to multilayered pecten type. (This contrasts with the gastro-oesophageal junction
where there is an abrupt change from stratified squamous to columnar epithelium.)
Small submucosal masses, comprising fibroelastic connective tissue, smooth muscle, dilated venous spaces and
arteriovenous anastomoses, form anal cushions at left lateral (3), right posterior (7) and right anterior (11 o’clock)
positions in the upper anal canal. Smaller cushions may be located in between. By their apposition these anal
cushions assist the sphincter in maintaining watertight closure of the canal. Excessive straining at stool may cause
enlargement of these cushions and the formation of hemorrhoids (piles).
The lining of the upper part of the anal canal is embryologically derived from the cloaca, i.e. it is endodermal; the
lower part is from the proctodeum or anal pit and is ectodermal (see p. 29). The dividing line between these
territories is usually considered to be at the pectinate line.
2.3 Explain anatomical basis of fecal incontinence in lumbosacral nerve root lesion (15 marks)
Bowel / fecal incontinence is an inability to control bowel movements, resulting in involuntary soiling. sacral nerves
control the muscles and organs that contribute to overall bowel control, such as the anal sphincter and pelvic
floor.The external anal sphincter receives somatic innervation from the inferior anal nerve, a branch of the pudendal
nerve (S2-S4). As a result, this muscle is under voluntary control. In case of a lesion to these nerves its function is
limited depending on the depth of the damage. The voluntary control of the muscle is lost hence the soiling.
2.4 List five structures that lie in the transpyloric plane (15 marks)
• L1 vertebral body
• Pylorus of the stomach End of the spinal cord Origin of the SMA ,
• portal vein
• Neck of the pancreas
• 2 nd part of the duodenum
• Sphincter of the Oddi
• Hilum of the each kidney
• Fundus of the gallbladder
• Duodenojejunal flexure
• Tip of the 9th costal cartilage
4.3 Explain the physiological basis for,

4.3.1 Use of histamine (H2) receptor blockers to treat peptic ulcers (30 marks)
Peptic ulcer is a breakdown of the barrier that normally prevents irritation and auto digestion of the mucosa by the
gastric secretion. Gastric secretions are HCl and Pepsinogen which are secreted respectively by Parietal cells and
Chief cells. There are many causes which result in ulcers. One of that is prolonged excessive secretion of acid (HCl).
This type of ulcers occur in the ZollingerEllison syndrome. This syndrome is seen in patients with gastrinomas.
Gastrin causes prolonged hypersecretion of acid, and produce severe ulcers. H2 blockers block the binding of
histamine to H2 receptors present on the parietal cells of the gastric mucosa. It reduces the level of cAMP. It
decreases the activity of H + /K+ motor pump. Thus, gastric acid secretion will be reduced.
4.3.2. dental caries is commoner in patients with deficient salivary secretion (xerostomia) (20 marks)
Saliva is the viscous, clear, watery fluid secreted from the parotid, submandibular , sublingual and smaller mucous
glands of the mouth. The ph of saliva is slightly acidic and the flow down the salivary duct it become alkaline because

of secretion of bicarbonate from the duct epithelium ,it will reduce the ph in the mouth and protect from dental
caries ,and also saliva contain proline which is protect the enamel of teeth . xerostomia is the condition in which
decreased secretion of saliva ,this cause dryness of mouth cause oral infection. Decreased salivary secretion affect
the buffering acidity of mouth and cause dental caries
529 Reasons to Cherish….


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Presented by 15th Batch 1 FHCS | EUSL

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Presented by 15th Batch 2 FHCS | EUSL

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Presented by 15th Batch 3 FHCS | EUSL

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Presented by 15th Batch 4 FHCS | EUSL

PHASE 01 QUESTIONS ............................................................................................................................................. 63

CARDIOVASCULAR SYSTEM ............................................................................................................... 138

PHASE 1 QUESTIONS ............................................................................................................................................. 191

Presented by 15th Batch 5 FHCS | EUSL

METABOLISM .......................................................................................................................................... 253

PHASE 1 QUESTIONS ............................................................................................................................................. 327

GASTROINTESTINAL SYSTEM ........................................................................................................... 395

Presented by 15th Batch 6 FHCS | EUSL

Presented by 15th Batch 7 FHCS | EUSL

10th Batch (EME) – MCQs

1. Regarding paranasal sinuses

2. Regarding development of respiratory system

4. Regarding tracheobronchial tree

5. total lung capacity in healthy young

08. Both hypoxia and hypercapnia would be seen in

9. Changes occurs in high altitude

10. Simulation of central chemo receptors occurs in

Presented by 15th Batch 10 FHCS | EUSL

14. Most of carbon dioxide transported as

10th Batch EME - SEQs

01.write brief accounts on

10th Batch (EME) – MCQ ANSWERS

Presented by 15th Batch 11 FHCS | EUSL

Presented by 15th Batch 12 FHCS | EUSL

Presented by 15th Batch 13 FHCS | EUSL

10th Batch EME – SEQ ANSWERS

Presented by 15th Batch 14 FHCS | EUSL

The parietal pleurapleura

Presented by 15th Batch 15 FHCS | EUSL

The visceral pleura

Blood supply to the parietal pleura

Blood supply to the visceral pleura

Innervation to the pleura

Presented by 15th Batch 16 FHCS | EUSL

External intercostal muscle

The vessels comprise,

Presented by 15th Batch 17 FHCS | EUSL

Presented by 15th Batch 18 FHCS | EUSL

11th Batch (EME) – MCQs

2. T/F regarding to the respiratory system

3. Which of the following is true during inspiration?

4. T/F regarding oxygen dissociation curve

Presented by 15th Batch 19 FHCS | EUSL

6. Regarding gas transfer across the alveolar capillary membrane

7. Which of following is T/F concerning type 1 respiratory failure

8. Reduction of arterial partial pressure of O2 can be caused

9. According to physiological dead space

10. Regarding to larynx

Presented by 15th Batch 20 FHCS | EUSL

13. Patient with,

11th Batch (EME) - SEQs