April 2018 Flashcards
Statistics question… (Man Whitney?? Unpaired T test??)
Unpaired
• normally distributed — 2-sample t-test
• not normally distributed — Mann Whitney test
Paired
• normally distributed — paired t-test
• not normally distributed — Wilcoxon signed rank test (put your cocks together)
> two samples
• normally distributed —ANOVA (Analysis of variance)
• not normally distributed — Kruskal Wallis test
Mass in chest and liver hemangioma, Ix… (MRI liver, PET??)
MRI, Triphasic CT
Tc-99m RBC labelled SPECT can be sensitive for larger lesions
Causes hepatic metastases hepatocellular carcinoma hepatic cyst hepatic abscess regenerative nodules/dysplastic nodules cystic hepatic or biliary neoplasm haemangioendothelioma
Hereditary hemorrhagic telangiectasia (HHT), also known as Osler–Weber–Rendu disease. bnormal blood vessel formation in the skin, mucous membranes, and often in organs such as the lungs, liver, and brain.
Klippel–Trénaunay syndrome - blood vessels and/or lymph vessels fail to form properly. The three main features are nevus flammeus (port-wine stain), venous and lymphatic malformations, and soft-tissue hypertrophy of the affected limb
Von Hippel–Lindau disease. visceral cysts and benign tumors with potential for subsequent malignant transformation
Loss of weight, tiredness, hairy tongue lesion
Lichen planus - Hep C
Candidiasis - Patches look similar to Candida infection (oral thrush), except hairy leukoplakia lesions cannot be moved or dislodged. Both HIV/AIDS
Nerve injury, deltoid affection, which other muscle will be affecting
Deltoid - Axillary Nerve C5/6
- Teres Minor Ext R
lies at first behind the axillary artery, and in front of the subscapularis, and passes downward to the lower border of that muscle
Winds backward, in company with the posterior humeral circumflex artery, through a quadrangular space bounded above by the teres minor, below by the teres major, medially by the long head of the triceps brachii, and laterally by the surgical neck of the humerus, and divides into an anterior, a posterior, and a collateral branch to the long head of the triceps brachii branch..
Injury to knee and swelling, on 90 degrees tibia is more posterior than other side…
(PCL injury)
3 patients in surgical ward with Cl. Difficile, mode of infection
C. difficile is transmitted from person to person by the fecal-oral route, shed in faeces. Any surface, device, or material (e.g., toilets, bathing tubs, and electronic rectal thermometers) that becomes contaminated with faeces may serve as a reservoir for the C. difficile spores.
Test for rupture tendon achilles
Simmonds test
The sinus tarsi
the sinus tarsi, a canal between the articulations of talus and calcaneus.
Interosseous talocalcaneal ligament rund through it - binding the two bones.
There are three articulating facets between the talus and the calcaneus, delineated as the anterior, middle and posterior facets. The sustentaculum tali forms the floor of middle facet, and the anterior facet articulates with the head of the talus, and sits lateral and congruent to the middle facet. The posterior facet is the largest of the three, and separated from the others by the tarsal canal.
Testing for Extensor Pollicis Longus
Lift thumb with hand 90 degrees on table
EPB Dist R to PP (PIN)
EPL - Longer - from ulna to DP (PIN)
Ab PL - Ulnar to base of 1st MC (PIN)
Ab PB - scaph/trapezium to PP. recurrent branch of median.
Extensive Femoral Thrombus Management
Embolectomy if good inflow, operative angiogram - thrombolysis if occlusion, if no occlusion close arteriortomy.
If in poor health - heparin followed by iv infusion
Which hormone decreases in warm condition… TSH, ACTH, Vasopressin??
ACTH - Again fluid conservation
Vasopressin - AQP2 insertion into collecting duct - would likely increase!
TSH may decrease - less thermogenesis required.
Cleft Palate defect in
Failure of fusion occurs between primary palate (anterior section of premaxilla and attached four teeth) and secondary palate (hard and soft palate).
Cleft lip: On one or both sides of philtrum, occurring as failure of fusion of maxillary and frontonasal processes.
Mesonephric Duct
Trigone, prostatic urethra, epididymis, vas deferens and ejaculatory ducts.
Urinary bladder is formed partly from the cloaca and partly from the ends of the mesonephric ducts.
The ureter and mesonephric duct come to open separately into the vesicourethral portion.
The mesonephric duct participates in the formation of the trigone and dorsal wall of the prostatic urethra.
Testicular cancer with normal AFP and HCG
Spermatocytic seminoma - 5%, older >54, germ cell tumour. Normal AFP + HCG
Classical seminoma, younger 15-35. Normal AFP. HCG elevated in 10%
Non seminomatous germ cell tumours (42%). Younger 20-30. Elevated AFP (70%) and HCG (40%).
Teratoma
Yolk sac tumour
Choriocarcinoma
Mixed germ cell tumours (10%)
Relation of ulnar nerve to artery
Ulnar nerve is most ulnar all the way
Dorsal root ganglion in neck
Sensory
Thenar atrophy
Median - recurrent motor branch
opponens pollicis,
abductor pollicis brevis, and
superficial part of flexor pollicis brevis.
Dermatome of the little finger
C8
Iatrogenic small injury to esophagus
TPN
Ix for rupture esophagus after endoscopy…
water soluble contrast
Reciprocal of absolute risk reduction
ARR =incidence in exposed – incidence in unexposed
NNT = number of patients who need to be treated in order to avoid one adverse event, which is the reciprocal of the absolute risk reduction
https://litfl.com/risk-and-numbers-needed-to-treat/
Cushing reflex/triad
(↑BP ↓HR ↓RR)
Child with irreducible groin mass
Indirect inguinal hernias are the most common incarcerated pediatric inguinal hernias,
although incarceration of other pediatric hernias, such as femoral, umbilical, spigelian,
epigastric, direct inguinal, and lumbar, has been reported in the literature.
6yo, kid with groin swelling
patent processus vaginalis
Intrinsic pathway
Intrinsic = 12a,11a,9a+8a+Ca Extrinsic = 7a+ TF/III Common= 10a, thrombin/IIa, fibrin/Ia
VIII (Antihemophilic factor A)
IX (Antihemophilic factor B or Christmas factor)
protein C Inactivates Va and VIIIa
protein S Cofactor for activated protein C
plasmin, lyses fibrin and other proteins
Old woman displaced # distal radius, reduced and put in slab/POP for 6 weeks, complaining of pain after 3 months…
Median nerve neuropathy (CTS)
most frequent neurologic complication.
Seen in 1-12% of low energy fxs and 30% of high energy fxs
prevent by avoiding immobilization in excessive wrist flexion and ulnar deviation
Type I - CRPS without evidence of nerve damage in the affected limb. Secondary to injury/trauma.
Type II - CRPS with evidence of nerve damage in the affected limb
t cervical lymphadenopathy… carcinoma, which Ix… CT, MRI??
If positive - MRI
FDG PET for staging
Diarrhea and egg in stools
Ascaris lumbricoides - Mebendazole
aka “Roundworm”
Pruritis Anii - Pinworm - enterobiasis - also mebendazole
Hypercholesterolemia
diet, obesity, inherited (genetic) diseases (such as LDL receptor mutations in familial hypercholesterolemia), or the presence of other diseases such as type 2 diabetes and an underactive thyroid.
familial hypercholesterolemia (Type IIa hyperlipoproteinemia) may be associated with xanthelasma palpebrarum (yellowish patches underneath the skin around the eyelids),[13] arcus senilis (white or gray discoloration of the peripheral cornea), and xanthomata (deposition of yellowish cholesterol-rich material) of the tendons, especially of the fingers. Type III hyperlipidemia may be associated with xanthomata of the palms, knees and elbows.[
dvantage of carbohydrate rich drink in enhanced recovery program…
decrease post-operative insulin resistance and negative nitrogen balance
What’s in direct contact with T5 body?
Azygous Vein
posterior: vertebral bodies of at least T5-T12, anterior longitudinal ligament, right posterior intercostal arteries
Aortic Arch finishes at lower border of T4
T5-T12 is posterior mediastinum
Shoulder pain between 60-120 degrees…
supraspinatus tendinitis
Gun shot to on right side below costal margin, injury to
Gallbaldder
https://bit.ly/37SN72b
Chinese man with LN enlargement and headache and deafness
nasopharyngeal carcinoma
nasopharyngeal cancer cause swelling around the part of your middle ear that connects up to the back of your nose (the eustachian tube). This swelling can cause conductive hearing loss, which makes it difficult to hear soft sounds.
Spastic LL paraplegia
ACA
Impotence and vascular insufficiency
Leriche syndrome
Femoral canal lateral border
Fascia of Fem Vein
LMAP/FLIP
Diagnosis of DVT by
Duplex Doppler compression ultrasound is the current study of choice for the diagnosis of suspected DVT
Color Doppler images are generally combined with grayscale (B-mode) images to display duplex ultrasonography images, allowing for simultaneous visualization of the anatomy of the area.
Patient with Barret’s esophagus
(adenocarcinoma)
Golfer with 1st metatarsal pain, XR showed narrowed joint space and subchondral cysts
DJD & Hallux Rigidus Degenerative Athritis, OA? first ray and 1st MTP pain and swelling worse with push off or forced dorsiflexion of great toe findings osteophytes, especially dorsal joint space narrowing subchondral sclerosis and cysts
Gas gangrene, causative organism
Cl. perfringens
Osteomyelitis causative organism
(Staph aureus)
Brown-Séquard syndrome - cord hemi-section
ipsi motor and proprioception + contra pain and temp
ECG changes in hypercalcaemia
Treatment
ECG changes in hypercalcaemia - shorted QT, J waves, VF
Calcium > 3.5 mmol/l
Reduced consciousness
Severe abdominal pain
Pre renal failure
Intravenous fluid resuscitation with 3-6L of 0.9% Normal saline in 24 hours
Concurrent administration of calcitonin will also help lower calcium levels
1 cm melanoma, best management…
Excision biopsy with 5mm
Extensive burn patient presents with lower leg edema after 3 days
hypoalbuminemia
Pain in testes and urethral discharge
gonorrhea
Post parotidectomy presents with dryness, which ganglion
Otic?
pterygopalatine?
Injury to head, fixed dilated pupil, cause
unopposed sympathetic fibers
Osteoporotic crush to vertebra, serum calcium is likely to be
Calcium level is usually normal in osteoperosis
Fall in blood BP, 1st reaction…
Reduced baroreceptor firing - medulla increasing in sympathetic
11yo child with special need, going for laparoscopy, type of consent
Consent form 2
Ligation of splenic hilum, avoid injury to what
tail of pancreas
Site of action of furosemide
Aascending loop of Henle ?25% NaCl
Site of action of thiazide
inhibit NaCl reabsorption from DCT
Bypass with graft, later is blocked…
neo intimal hyperplasia
COPD patient ABG
↑CO2 ↑HCO3
Anterior relation to right adrenal
IVC
Good prognosis for melanoma
<1mm
Ureter stone radiating to groin, which nerve root
Ureter T12-L2 segments
L1 Would be groin
What structure is in front of uncinate process
SMA
What forms the anterior border of the heart
SURFACES:
Anterior (or sternocostal) – Right ventricle.
Posterior (or base) – Left atrium.
Inferior (or diaphragmatic) – Left and right ventricles.
Right pulmonary – Right atrium.
Left pulmonary – Left ventricle.
BORDERS:
Right border – Right atrium
Inferior border – Left ventricle and right ventricle
Left border – Left ventricle (and some of the left atrium)
Superior border – Right and left atrium and the great vessels
Testing for Addison’s disease
adrenocorticotropic hormone (ACTH)
Addison’s disease, also known as primary adrenal insufficiency and hypocortisolism
Metastatic bone pain treatment
metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy
Ovarian mass and inner thigh numbness
Cutaneous branch of the obturator nerve
Bilateral cervical lymph node spread, which type of cancer
Central Tongue?
guidelines on people who received transfusion
They are no longer able to donate blood
Anterior compartment syndrome affecting
Late sign - deep peroneal nerve - 1st webspace
Pathology of berry aneurysm in 45yo
Most intracranial aneurysms are true aneurysms. The aneurysmal pouch is composed of thickened hyalinised intima with the muscular wall and internal elastic lamina being absent as the normal muscularis and elastic lamina terminate at the neck of an aneurysm.
https://radiopaedia.org/articles/saccular-cerebral-aneurysm
LP options
L3/L4
ulcer tip of penis
Balanitis Dermatitis of various kinds including contact allergy, e.g. to rubber condoms, fragrances or medicament Flexural psoriasis Reiter syndrome Lichen sclerosus Lichen planus Plasma cell balanitis Fixed drug eruption Penile intraepithelial neoplasia Syphilis - Treponema pallidum - Panless Scabies
ulcer tip of penis
Balanitis
Dermatitis of various kinds including contact allergy, e.g. to rubber condoms, fragrances or medicament
Flexural psoriasis
Reiter syndrome HLA-B27 - conjunctivitis + spondyloarthropathy
Lichen sclerosus >50 women
Lichen planus >40
Plasma cell balanitis - orange/red plaque
Fixed drug eruption
Penile intraepithelial neoplasia, can trasnform into SCC
Syphilis - Treponema pallidum - Panless
Scabies
Ix for pheochromocytoma
Urine analysis of vanillymandelic acid (VMA) is often used (false positives may occur e.g. in patients eating vanilla ice cream!)
Blood testing for plasma metanephrine levels.
CT and MRI scanning are both used to localise the lesion.
Angiotensin II
Angiotensin I is converted to angiotensin II (AII) through removal of two C-terminal residues by the enzyme angiotensin-converting enzyme (ACE), primarily through ACE within the lung
acts on the CNS to increase vasopressin production
acts on venous and arterial smooth muscle to cause vasoconstriction
Angiotensin II also increases aldosterone secretion
it acts as an endocrine, autocrine/paracrine, and intracrine hormone.
Aldosterone
mineralocorticoid hormone, is a steroid hormone produced by the zona glomerulosa
plasma half-life of under 20 minute
Acting on the nuclear mineralocorticoid receptors (MR) within the principal cells of the distal tubule and collecting duct
it upregulates and activates the basolateral Na+/K+ pumps
pregulates epithelial sodium channels (ENaCs) in the collecting duct and the colon
Renal Cancer staging
All confined: T1a: <4 cm T1b: >4 cm but <7 cm T2: >7 cm T2a: c7 cm - 10 cm T2b: >10 cm
T3a: Tumour grossly extends into the renal vein or its segmental (muscle-containing) branches, or tumour invades perirenal and/or renal sinus fat but not beyond the Gerota fascia
T3b: spread to infra diaphragmatic IVC
T3c: spread to supra diaphragmatic IVC or invades the wall of the IVC
T4: involves ipsilateral adrenal gland or invades beyond Gerota’s fascia
most likely risk factor for HCC
HBV is double-stranded DNA-containing virus that is able to integrate its DNA into the hepatic cells, act as a mutagenic agent and cause secondary chromosomal rearrangement and increasing genomic instability [10]. This is the reason why the risk of HCC development is 100-fold higher for patients who are infected with HBV
blurring of vision and headaches in the morning
?raised ICP
Malignant Melanoma Cells of origin
Epidermal/dermal melanocytes, upwards and downwards into papillary dermis/reticular
hypospadia congenital abnormality
Failure of fusion of urogenital Folds
most common associated difference is an undescended testicle
sometimes indicates a child has an intersex condition
injury, numbness lateral arm, which muscle will be affected as well?
Musculocutaneous nerve supplies BBC
Brachioradialis, biceps brachii and coracobrachialis
Heart valves are made of
fibrous tissue and collagen
Abdominal relations ureters
Lies anterior to bifurcation of iliac vessels
Lies behind renal and gonal arteries
Lies beneath uterine artery
pain on walking downhill but not uphill
Lumbar stenosis - extension is limited
Spinal extension (standing or walking downhill) exacerbates pseudo- or neurogenic claudication, while back flexion (sitting or walking uphill) improves symptoms.
Managing metastatic prostate cancer
Offer docetaxel chemotherapy to people with newly diagnosed metastatic prostate cancer
Offer bilateral orchidectomy to all people with metastatic prostate cancer as an alternative to continuous luteinising hormone-releasing hormone agonist therapy.
Radical treatment for localised or locally advanced prostate cancer
Low Risk - WAW
High Risk - Offer radical prostatectomy or radical radiotherapy to people with high-risk localised prostate cancer when it is likely the person’s cancer can be controlled in the long term.
Laparoscopic radical prostatectomy
