Block 10 Flashcards
Diagnosis of HIV
antibodies to HIV may not be present
HIV PCR and p24 antigen tests can confirm diagnosis
A 58 year old lady presents with a mass in the upper outer quadrant of the right breast. Which of the following statements relating to the breast is untrue?
The internal mammary artery provides the majority of its arterial supply
Nipple retraction may occur as a result of tumour infiltration of the clavipectoral fascia
The internal mammary artery is a branch of the subclavian artery
Up to 70% of lymphatic drainage is to the ipsilateral axillary nodes
None of the above
Both skin dimpling and nipple retraction are features of breast malignancy. However, they usually occur as a result of tumour infiltration of the breast ligaments and ducts respectively. The clavipectoral fascia encases the axillary contents. The lymphatic drainage of the breast is to the axilla and also to the internal mammary chain. The breast is well vascularised and the internal mammary artery is a branch of the subclavian artery.
Where are accessory spleens not found?
Gonads
Tail of pancreas
Greater omentum
Splenorenal ligament
Ureter
Uretur
- 10% population
- 1 cm size
- locations: hilum of the spleen, tail of the pancreas, along the splenic vessels, in the gastrosplenic ligament, the splenorenal ligament, the walls of the stomach or intestines, the greater omentum, the mesentery, the gonads
A 34 year old woman with morbid obesity is referred for consideration of bariatric surgery. Which of the following options is associated with the highest long term failure rates?
Gastric band
Intra gastric balloon
Roux en Y bypass
Sleeve gastrectomy
Duodenal switch
Intragastric balloon is really only suitable as a bridge to a more definitive surgical solution.
Which of the following statements relating to Hirschsprungs disease is false?
It is more common in males.
Is typically associated with a dilated aganglionic segment of bowel.
May present with delayed passage of meconium.
Mucosal biopsies are inadequate for diagnosis.
Disease extending beyond 30cm of colon and rectum is unusual.
There is a transition zone from the contracted aganglionic segment (the abnormal area) to dilated normal bowel on barium enema. Males are more frequently affected than females. Surgery may involve a pull through procedure. A number of patients will have ongoing evacuatory disturbance.
A 44 year old lady presents with a pathological fracture of the left femur. She has previously undergone a renal transplant for end stage renal failure. Her blood test results are as follows:
Serum Ca2+ 2.80
PTH 88pg/ml
Phosphate 0.30
A surgeon decides to perform a parathyroidectomy on the basis of these results. When the glands are assessed histologically, which of the appearances is most likely to be identified?
Metaplasia the gland
Hypertrophy of the gland
Hyperplasia of the gland
Parathyroid carcinoma
Necrosis of the parathyroid gland
This is likely to be a case of tertiary hyperparathyroidism (high Calcium, high PTH, low phosphate). Therefore the glands will be hyperplastic. Hypertrophy is not correct as this implies an increase in size without an increase in cellularity. This mistake has cost many candidates marks in the MRCS exams over the years!
A 56 year old man presents with his first attack of diverticulitis. Which of these complications is least likely to ensue?
Formation of colonic strictures
Malignant transformation
Development of colovesical fistula
Formation of a pericolic abscess
Formation of a phlegmon
Diverticulitis may result in a number of complications. However, whilst malignant disease may coincide with diverticulitis it is not, in itself, a risk factor for colonic cancer.
Theme: Management of osteomyelitis
A.Lautenbach regime
B.Below knee amputation
C.Hindquater amputation
D.Above knee amputation
E.Removal of metalwork and implantation of local antibiotics
F.Removal of metalwork and bone grafting
G.Intravenous antibiotics
Which option is the best management plan? Each option may be used once, more than once or not at all.
40.A 65 year old type 2 diabetic with poor glycaemic control is admitted with forefoot cellulitis. X-ray of the foot shows some evidence of osteomyelitis of the 2nd ray but overlying skin is healthy.
A 28 year old infantryman is shot in the leg during combat. Primary debridement and lavage of the wound is undertaken. Several months post surgery there is ongoing discharge from a sinus originating in the proximal femur, X-ray and MRI shows evidence of osteomyelitis of the proximal femur. There are no obvious sequestra.
A 70 year old man undergoes a revision total hip replacement. 10 days post operatively the hip dislocates and pus is discharging from the wound. He is systemically unwell with a temperature of 38.5 and WCC 19.
Intravenous antibiotics
It is worth attempting to try and resolve this situation with antibiotics at first presentation. A primary amputation will not heal well and may result in progressive surgery.
Lautenbach regime
This involves local administration of antibiotics via intramedullary lines and is an intensive regime. However, the morbidity of a high above knee or hindquater amputation makes conservative management an attractive option.
Removal of metalwork and implantation of local antibiotics
Removal of metal work implantation of gentamicin beads and delayed revision is the mainstay of managing this complication.
Which of the following statements relating the fluid physiology of a physiologically normal 70 Kg adult male is false?
He will have more water per unit of body weight than a female of similar weight
Plasma will comprise 25% of his body weight
Interstitial fluid will account for up to 24% of body water
Approximately 65% of total body water is intracellular
60% of his body weight is composed of water
Plasma typically accounts for 4-6% of body weight in healthy individuals.
Males typically have more water per unit weight than females, as females have a higher fat content.
% volume intracellular
60-65%
% volume extracellular
35-40%
% volume plasma
5%
% volume interstitial fluid
24%
% volume transcellular
3%
Volume intracellular fluid
28L
Volume extracellular fluid
14L
Volume plasma
3L
Volume interstitial fluid
10L
Volume transcellular fluid
1L
Which of the following statements relating to qualitative data is false?
The data has no true numerical scale
It may comprise multiple data groups
May be reported using odds ratios
May be reported using frequency histograms
It is best analysed statistically using a students T test when multiple factors are present
The students T test should be performed if two sets of data have a normal distribution, the T test cannot be used to analyse multiple data sets.
What is the least likely examination finding in patients with Le Fort II fractures?
Excessive mobility of the palate
Paraesthesia in the region supplied by the inferior alveolar nerve
Malocclusion of the teeth
Enopthalmos
Parasthesia in the region supplied by the infraorbital nerve
Le Fort II fractures have a pyramidal shape. The fracture line involves the orbit and extends to involve the bridge of the nose and the ethmoids. In continues to involve the infraorbital rim and usually through the infraorbital foramen. As a result infraorbital parasthesia, palatal mobility and malocclusion are common findings. Severe fractures may result in endopthalmos. However, the fracture does not, by definition, involve the inferior alveolar nerve.
Which of the following drugs is not positively inotropic?
Dopamine
Glucagon
Theophylline
Sodium thiopentone
Dobutamine
Inotropes are a class of drugs that increase the force or cardiac contractility. This may improve cardiac output. Increased blood pressure may have direct beneficial effects for the heart in that it improves myocardial perfusion pressure. Dopamine and dobutamine are both commonly used inotropes, they should be administered via a central line and in a monitored setting. Glucagon and theophylline are also positive inotropes (although not commonly used for this purpose). In contrast sodium thiopentone causes marked myocardial depression.
Theme: Nerve injury
A.Median nerve
B.Ulnar nerve
C.Radial nerve
D.Anterior interosseous nerve
E.Posterior interosseous nerve
F.Axillary nerve
G.Musculocutaneous nerve
Please select the nerve at risk of injury in each scenario. Each option may be used once, more than once or not at all.
48.A 43 year old typist presents with pain at the dorsal aspect of the upper part of her forearm. She also complains of weakness when extending her fingers. On examination triceps and supinator are both functioning normally. There is weakness of most of the extensor muscles. However, there is no sensory deficit.
A 28 year teacher reports difficulty with writing. There is no sensory loss. She is known to have an aberrant Gantzer muscle.
A 35 year tennis player attends reporting tingling down his arm. He says that his ‘funny bone’ was hit very hard by a tennis ball. There is weakness of abduction and adduction of his extended fingers.
Posterior interosseous nerve
The radial nerve may become entrapped in the arcade of Frohse which is a superficial part of the supinator muscle which overlies the posterior interosseous nerve. This nerve is entirely muscular and articular in its distribution. It passes postero-inferiorly and gives branches to extensor carpi radialis brevis and supinator. It enters supinator and curves around the lateral and posterior surfaces of the radius. On emerging from the supinator the posterior interosseous nerve lies between the superficial extensor muscles and the lowermost fibres of supinator. It then gives branches to the extensors.
Anterior interosseous nerve
Anterior interosseous (B) lesions occur due to fracture, or rarely due to compression. The Gantzer (A) muscle is an aberrant accessory of the flexor pollicis longus and is a risk factor for anterior interosseous nerve compression. Remember loss of pincer grip and normal sensation indicates an interosseous nerve lesion.
Ulnar nerve
The ulnar nerve arises from the medial cord of the brachial plexus (C8, T1 and contribution from C7). The nerve descends between the axillary artery and vein, posterior to the cutaneous nerve of the forearm and then lies anterior to triceps on the medial side of the brachial artery. In the distal half of the arm it passes through the medial intermuscular septum, and continues between this structure and the medial head of triceps to enter the forearm between the medial epicondyle of the humerus and the olecranon. It may be injured at this site in this scenario.
loss of pincer grip and normal sensation indicates
Anterior interosseous lesion
A 72 year old man is undergoing a left pneumonectomy for carcinoma of the bronchus. As the surgeons approach the root of the lung, which structure will lie most anteriorly (in the anatomical plane)?
Vagus nerve
Phrenic nerve
Bronchus
Pulmonary vein
Pulmonary artery
The phrenic nerve is the most anteriorly located structure in the lung root. The vagus nerve lies most posteriorly.
In relation to the middle cranial fossa, which of the following statements relating to the foramina is incorrect?
The foramen rotundum transmits the maxillary nerve
The foramen lacerum is closely related to the internal carotid artery
The foramen spinosum lies posterolateral to the foramen ovale
The foramen ovale transmits the middle meningeal artery
The foramen rotundum lies anteromedial to the foramen ovale
The foramen spinosum transmits the middle meningeal artery. The foramen ovale transmits the mandibular nerve. As the foramina weaken the bone, a fracture at this site is not uncommon.
During an operation for varicose veins the surgeons are mobilising the long saphenous vein. Near its point of entry to the femoral vein an artery is injured and bleeding is encountered. From where is the bleeding most likely to originate?
Femoral artery
Profunda femoris artery
Superficial circumflex iliac artery
Superficial epigastric artery
Deep external pudendal artery
The deep external pudendal artery is a branch of the SFA and it runs medially under the long saphenous vein near its point of union with the femoral vein. The superficial external pudendal artery lies superior to the SFJ. Neither vessel is functionally important and if injured they are best ligated.
The term signature fracture is synonymous with which of the following injuries?
Depressed skull fracture
Le Fort II fracture
Orbital blow out
Oblique fracture of the tibia
Supracondylar fracture
Signature fractures are synonymous with depressed skull fractures, they are usually low velocity injuries where the fracture impression resembles the injurious source.
A 62 year old lawyer has a transurethral resection of the prostate which took 1 hour to perform. The ST2 contacts you as the patient has become agitated. He has a HR 105 bpm and his blood pressure is 170/100 mmHg. He is fluid overloaded. His blood results reveal a Na of 120mmol/l. What is the most likely cause?
Over administration of 0.9% Normal Saline
Syndrome of inappropriate antidiuretic hormone secretion
Congestive cardiac failure
TUR syndrome
Acute renal failure
TUR syndrome occurs when irrigation fluid enters the systemic circulation. The triad of features are:
- Hyponatraemia: dilutional
- Fluid overload
- Glycine toxicity
Management involves fluid restriction and the treatment of the complications associated with the hyponatraemia.
Indications for surgery in patients with BPH
Refractory urinary retention
Recurrent urinary tract infections due to prostatic hypertrophy
Recurrent gross haematuria
Renal insufficiency secondary to bladder outlet obstruction
Permanently damaged or weakened bladders
Large bladder diverticula that do not empty well secondary to an enlarged prostate
Risk factors for increased morbidity following TURP
Glands >45g
Operating time > 90 minutes
Acute urinary retention as presenting feature
A 55 year old man presents with an episode of frank haematuria and on investigation is found to have a T2 transitional cell carcinoma of the bladder. His staging investigations are negative for metastatic disease. What is the most appropriate treatment?
Radical cystectomy
Palliative radiotherapy
Intravesical BCG
Intravesical mitomycin C
Intravesical cisplatin
T2 lesions in a young fit patient are best managed surgically. Up to 25 % patients may develop perioperative complications. However, palliative treatments and intravesical chemotherapy (which does NOT include cisplatin) are not used curatively in this situation.
A 72 year old obese man undergoes an emergency repair of a ruptured abdominal aortic aneurysm. The wound is closed with an onlay prolene mesh to augment the closure. Post operatively he is taken to the intensive care unit. Over the following twenty four hours his nasogastric aspirates increase, his urine output falls and he has a metabolic acidosis. What is the most likely underlying cause?
Colonic ischaemia
Abdominal compartment syndrome
Peritonitis
Reactionary haemorrhage
Aorto-duodenal fistula
Obese patients with ileus following major abdominal surgery are at increased risk of intra abdominal compartment syndrome.The risk is increased by the use of prosthetic meshes, which some surgeons favor following a major vascular case as they may reduce the incidence of incisional hernia. They prevent abdominal distension and may increase the risk of intra abdominal hypertension in the short term. Although colonic ischaemia may occur following major aortic surgery it would not typically present in this way.
Normal intra-abdominal pressure in critically ill adults
5-7mmHg
Intra-abdominal hypertension pressure
12-25mmHg
What changes in abdominal pressure are associated with microvascular hypoperfusion?
>15mmHg
Def: abdominal compartment syndrome
Sustained intra abdominal pressure >20mmHg coupled with new organ dysfunction / failure
Dx of abdominal compartment syndrome
Diagnosis is typically made by transvesical pressure measurements coupled with an index of clinical suspicion.
Management of abdominal compartment syndrome
Gastric decompression
Improve abdominal wall compliance e.g. muscle relaxants/ sedation
Drain abdominal fluid collections.
Consider fluid restriction/ diuretics if clinically indicated.
In those whom non operative treatment is failing; the correct treatment is laparotomy and laparostomy. Options for laparostomy are many although the Bogota bag or VAC techniques are the most widely practised. Re-look laparotomy and attempts at delayed closure will follow in due course.
A 78 year old man is lifting a heavy object when a feels a pain in his forearm and is unable to continue. He has a swelling over his upper forearm. An MRI scan shows a small cuff of tendon still attached to the radial tuberosity consistent with a recent tear. Which of the following muscles has been injured?
Pronator teres
Supinator
Aconeus
Brachioradialis
Biceps brachii
Biceps inserts into the radial tuberosity. Distal injuries of this muscle are rare but are reported and are clinically more important than more proximal ruptures.
A 34 year old lady is due to undergo a laparoscopic cholecystectomy. Which of the following intrabdominal pressures should typically be set on the gas insufflation system?
4mm Hg
10mm Hg
20mm Hg
40mm Hg
60mm Hg
Pressures lower than 7mm Hg are not usually compatible with satisfactory views. Pressures >15mm Hg are usually associated with decreased venous return and hypotension.
Which of the following statements relating to the use of human albumin solution is false?
When administered in the peri operative period it does not increase the length of stay in hospital compared with crystalloid solutions
Concentrated solutions may produce diuresis in patients with liver failure
It may restore plasma volume in cases of sodium and water overload
It may be associated with risk of acquiring new variant Creutzfeld-Jacob disease
Hepatitis C remains a concern when large volumes are infused
Human albumin solution went out of vogue following the Cochrane review in 2004 that showed it increased mortality. This view has been challenged and subsequent studies have confirmed it to be safe for use. Viruses are inactivated during the preparation process. However, theoretical risks regarding new varient CJD still exist. Outcomes in the peri operative setting are similar whether colloid, crystalloid or albumin are used.
What is embryological origin of the pulmonary artery?
First pharyngeal arch
Second pharyngeal arch
Fourth pharyngeal arch
Fifth pharyngeal arch
Sixth pharyngeal arch
The proximal part of the sixth right pharyngeal arch gives origin to the right pulmonary artery. The distal part gives origin to the left pulmonary artery and the ductus arteriosus.
A 67-year-old man with colorectal cancer is currently taking MST 30mg bd for pain relief. What dose of oral morphine solution should he be prescribed for breakthrough pain?
5 mg
10 mg
15 mg
20 mg
30 mg
Breakthrough dose = 1/6th of daily morphine dose
The total daily morphine dose is 30 * 2 = 60 mg, therefore the breakthrough dose should be one-sixth of this, 10 mg.
Which of the following statements are not typically true in hypokalaemia?
It may occur as a result of mechanical bowel preparation
Chronic vomiting may increase renal potassium losses
It may be associated with aciduria
It may cause hyponatraemia
It often accompanies acidosis
It often accompanies acidosis
Potassium depletion occurs either through the gastrointestinal tract or the kidney. Chronic vomiting in itself is less prone to induce potassium loss than diarrhoea as gastric secretions contain less potassium than those in the lower GI tract. If vomiting produces a metabolic alkalosis then renal potassium wasting may occur as potassium is excreted in preference to hydrogen ions. The converse may occur in potassium depletion resulting in acid urine.
Hypokalemia is very commonly associated with metabolic alkalosis. This is due to 2 factors: 1) the common causes of metabolic alkalosis (vomiting, diuretics) directly induce H+ and K loss (via aldosterone) and thus also cause hypokalemia and 2) hypokalemia is a very important cause of metabolic alkalosis by three mechanisms. The initial effect is by causing a transcellular shift in which K leaves and H+ enters the cells, thereby raising the extracellular pH. The second effect is by causing a transcellular shift in the cells of the proximal tubules resulting in an intracellular acidosis, which promotes ammonium production and excretion. Thirdly, in the presence of hypokalemia, hydrogen secretion in the proximal and distal tubules increases. This leads to further reabsorption of HCO3-. The net effect is an increase in the net acid excretion.
Which of the following is not a form of primary brain injury?
Sub dural haemorrhage after being hit in the head with a hammer
Meningitis resulting from infected CSF rhinorrhoea after a basal skull fracture
A truck driver is involved in a road traffic accident and suffers an axonal stretch injury
A man is hit with a baseball bat and suffers a cerebral contusion
A man suffers an intraparenchymal haemorrhage after being hit in head during a car crash
Primary brain damage occurs at the point of injury. It includes contusions and diffuse axonal injury. Non reversible.
Secondary brain damage occurs after the injury. Complications include:
1. Haemorrhage
2. Meningitis
3. Herniation
4. Hypoxia
5. Oedema
6. Arterial damage: internal carotid, vertebral artery common
Which of the following muscles lies medial to the long thoracic nerve?
Serratus anterior
Latissimus dorsi
Pectoralis major
Pectoralis minor
None of the above
Serratus anterior
The thebesian veins contribute to the venous drainage of the heart. Into which of the following structures do they primarily drain?
Great cardiac vein
Atrium
Superior vena cava
Oblique vein
Small cardiac vein
The thebesian veins are numerous small veins running over the surface of the heart they drain into the heart itself. Usually this is to the atrium directly.
Which of the following is not contained within the deep posterior compartment of the lower leg?
Tibialis posterior muscle
Posterior tibial artery
Tibial nerve
Sural nerve
Flexor hallucis longus
The deep posterior compartment lies anterior to soleus. The sural nerve is superficially sited and therefore not contained within it.
A man is admitted after a period of prolonged self, induced starvation. Naso gastric feeding is planned. Which of the following is least likely to occur?
Hypokalaemia
Increased risk of cardiac arrhythmias
His haemoglobin will have decreased affinity for oxygen
Hypophosphataemia
Hypoalbuminaemia
The process of starvation may lower DPG levels, in practice this is unlikely to occur early as it is generated during glycolysis. Altered metabolism in starvation may be more acidotic and this would also tend to impair oxygen carriage.
When performing minor surgery in the scalp, which of the following regions is considered a danger area as regards spread of infection into the CNS?
Aponeurosis epicranialis
Skin
Pericranium
Connective tissue
Loose areolar tissue
Loose areolar tissue
This area is most dangerous as infections can spread easily. The emissary veins that drain this area may allow sepsis to spread to the cranial cavity.
A 4 year old is admitted with right iliac fossa pain and is due to undergo an appendicectomy. The nursing staff would like to give the child an infusion of intravenous fluid whilst waiting for theatre. Assuming electrolytes are normal, which of the following is an appropriate fluid for infusion in this situation?
10% Dextrose solution
- 9% Saline solution
- 45% saline/ 5% glucose solution
Gelofusin
None of the above
- 9% Saline solution
- 45% saline/ 5% glucose solutions carry a risk of hyponatraemia and is contra indicated- see below.
Which of the following structures are at risk of direct injury following a fracture dislocation of the femoral condyles?
Popliteal artery
Sciatic nerve
Plantaris muscle
Tibial artery
Tibial nerve
The heads of gastrocnemius will contract to pull the fracture segment posteriorly. The popliteal artery lies against the bone and may be damaged or compressed.
Theme: Management of chest trauma
A.Thoracotomy in operating theatre
B.36F intercostal chest drain
C.14F intercostal chest drain
D.Active observation
E.Thoracotomy in the emergency room
F.MRI of aortic arch
G.Bronchoscopy
H.Pericardiocentesis
I.Further transfusion
For each of the following scenarios please select the most appropriate next stage of management. Each option may be used once, more than once or not at all.
81.A 30 year old male is stabbed outside a nightclub he has a brisk haemoptysis and in casualty has a chest drain inserted into the left chest. This drained 750ml frank blood. He fails to improve with this intervention. He has received 4 units of blood. His CVP is now 13.
A 26 year old male falls from a cliff. He suffers from multiple fractures and has a right sided pneumothorax that has collapsed a 1/3 of his lung. He has no respiratory compromise.
An 18 year old male is shot in the left chest he was unstable but his blood pressure has improved with 1 litre of colloid. His chest x-ray shows a left sided pneumothorax with no lung visible.
Pericardiocentesis
This man has cardiac tamponade. The raised CVP in the setting of haemodynamic compromise is the pointer to this. Whilst he will almost certainly require surgery, he requires urgent decompression of his heart first.
14F intercostal chest drain
Simple observation is unsafe as he will almost certainly have suffered an oblique laceration to his lung. These can become tension pneumothoraces. In the absence of blood a 36 F drain is probably not required
36F intercostal chest drain
This man requires wide bore intercostal tube drainage. Smaller intercostal chest drains can become occluded with blood clot and fail to function adequately.
What is the commonest site in the abdomen for fluid to collect following a perforated appendix?
Pelvis
Hepatorenal pouch
Between small bowel loops
Right iliac fossa
Lesser sac
Following perforated appendicitis fluid is most likely to accumulate in the pelvis. Fluid may accumulate in the hepatorenal pouch although this is less common. Gravity favors the pelvis as the site of most collections. The incidence of these is higher with laparoscopic rather than open surgery.
A 24 year female is admitted to A&E with tingling of her hand after a fall. She is found to have a fracture of the medial epicondyle. What is the most likely nerve lesion?
Ulnar nerve
Radial nerve
Median nerve
Axillary nerve
Cutaneous nerve
Ulnar nerve
The radial nerve is located near the lateral epicondyle.
Theme: Urinary incontinence
A.Bladder diary for 3 days
B.Urodynamic studies
C.Bladder drill training for 6 weeks
D.Pelvic floor exercises for 3 months
E.Oxybutynin
F.IV urography
G.Dyes studies including phenazopyridine
H.None of the above
Choose the best management option for each clinical scenario. Each option may be used once, more than once or not at all.
94.A 75 year old lady reports urinary incontinence when coughing and sneezing. She has had 2 children with no complications. She has no significant past medical history and is on no medications. What is the most appropriate initial management?
A 26 year old pregnant woman is having her 1st child and has never had problems with incontinence.
A 67 year old lady reports urinary incontinence. She describes the sensation of needing to pass urine immediately. She has had 2 children and is on no medications. What is the most appropriate initial management?
Pelvic floor exercises for 3 months
A diagnosis of stress incontinence is obvious from the history, therefore there is no need for a bladder diary or urodynamic studies.
Pelvic floor exercises would be the first line management.
Pelvic floor exercises for 3 months
Pregnant women should receive instructions as to how to perform pelvic floor exercises during pregnancy as this may help to decrease subsequent risk of stress urinary incontinence.
Bladder diary for 3 days
The patient appears to be describing urge incontinence. A bladder diary is needed to establish the baseline frequency of micturition and amounts of urine passed. Then bladder training can be initiated to increase the volume of urine passed at reduced frequencies.
During a gangland gunfight a man is shot in the chest. The bullet passes through the posterior mediastinum (from left to right). Which of the following structures is least likely to be injured
Thoracic duct
Oesophagus
Vagus nerve
Descending thoracic aorta
Arch of the azygos vein
The arch of the azygos vein lies in the middle mediastinum.
A 34-year-old man is taken immediately to theatre with aortic dissection. You note he is tall with pectus excavatum and arachnodactyly. His condition is primarily due to a defect in which one of the following proteins?
Polycystin-1
Fibrillin
Type IV collagen
Type I collagen
Elastin
Although fibrillin is the primary protein affected (due to a defect in the fibrillin-1 gene) it should be noted that fibrillin is used as a substrate of elastin.
Pathophysiology of Marfan’s
Marfan’s syndrome is an autosomal dominant connective tissue disorder. It is caused by a defect in the fibrillin-1 gene on chromosome 15 and affects around 1 in 3,000 people.
Clinical features of Marfan’s
tall stature with arm span to height ratio > 1.05
high-arched palate
arachnodactyly
pectus excavatum
pes planus
scoliosis of > 20 degrees
heart: dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection, aortic regurgitation, mitral valve prolapse (75%),
lungs: repeated pneumothoraces
eyes: upwards lens dislocation (superotemporal ectopia lentis), blue sclera, myopia
dural ectasia (ballooning of the dural sac at the lumbosacral level)
Prognosis in Marfan’s
The life expectancy of patients used to be around 40-50 years. With the advent of regular echocardiography monitoring and beta-blocker/ACE-inhibitor therapy this has improved significantly over recent years. Aortic dissection and other cardiovascular problems remain the leading cause of death however.
Theme: Right iliac fossa pathology
A.Appendicitis
B.Mesenteric adenitis
C.Inflammatory bowel disease
D.Irritable bowel syndrome
E.Mesenteric cyst
F.Campylobacter infection
G.Appendix abscess
Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.
3.An 8 year old boy is examined by his doctor as part of a routine clinical examination. The doctor notices a smooth swelling in the right iliac fossa. It is mobile and the patient is otherwise well.
An 8 year old boy presents with abdominal pain,a twelve hour history of vomiting, a fever of 38.3 oC and four day history of diarrhoea. His abdominal pain has been present for the past week.
A 7 year old boy presents with a three day history of right iliac fossa pain and fever. On examination he has a temperature of 39.9o C. His abdomen is soft and mildly tender in the right iliac fossa.
Mesenteric cyst
Mesenteric cysts are often smooth. Imaging with ultrasound and CT is usually sufficient. Although rare, they most often occur in young children (up to 30% present before the age of 15). Many are asymptomatic and discovered incidentally. Acute presentations are recognised and may occur following cyst torsion, infarction or rupture. Most cysts will be surgically resected.
Appendix abscess
The high fever and diarrhoea together with vomiting all point to a pelvic abscess. The presence of pelvic pus is highly irritant to the rectum, and many patients in this situation will complain of diarrhoea.
Mesenteric adenitis
High fever and mild abdominal signs in a younger child should raise suspicion for mesenteric adenitis. The condition may mimic appendicitis and many may require surgery.
The space between the vocal cords is referred to as which of the following?
Piriform recess
Rima vestibuli
Vestibule
Glottis
Rima glottidis
The rima glottidis is the narrowest part of the laryngeal cavity.
A 8 year old boy with recurrent attacks of otitis media is suspected of developing a glue ear. If his sound conduction is tested, which of the following is most consistent with a unilateral middle ear effusion?
Negative Rinne’s test on the ipsilateral side
Positive Rinne’s test on the ipsilateral side
Positive Webers and Rinnes tests on the ipsilateral side
Positive Rinne’s test on the contralateral side
Negative Webers test only on the contralateral side
Rinne’s test will localise to the affected side (i.e. it is negative in conductive deafness). In a positive Rinne’s test sound heard by air conduction is better than that conveyed by bone conduction. Reduction of both air and bone conduction in equal measure is a feature of sensorineural hearing loss
How to confirm findings in Weber’s test
In a patient with asymmetrical hearing loss, the Weber tuning fork sound is heard louder in one ear versus the other. This clinical finding should be confirmed by repeating the procedure and having the patient occlude one ear with a finger; the sound should be heard best in the occluded ear.
Which of the following are not typical of Lynch syndrome?
It is inherited in an autosomal recessive manner
Affected patients are more likely to develop right colon mucinous tumours than the general population
Affected individuals have an 80% lifetime risk of colon cancer
Endometrial cancer is seen in 80% of women
Gastric cancers are more common
Lynch syndrome is inherited in an autosomal dominant fashion. It is characterised by microsatellite instability in the DNA mismatch repair genes. Colonic tumours in patients with Lynch syndrome are more likely to be right sided tumours and to be poorly differentiated.
Theme: Fracture management
A.Application of external fixator
B.Open reduction and internal fixation
C.Fasciotomy
D.Skeletal traction
For the following upper limb injuries please select the most appropriate initial management. Each option may be used once, more than once or not at all.
10.A 32 year old man falls from a ladder and sustains a fracture of his proximal radius. On examination, he has severe pain in his forearm and diminished distal sensation. There is a single puncture wound present at the fracture site.
A 32 year old man falls a sustains a fracture of his distal humerus. The fracture segment is markedly angulated and unstable. There is a puncture site overlying the fracture site.
A 24 year old man sustains a distal radius fracture during a game of rugby. Imaging shows a comminuted fracture with involvement of the articular surface.
Fasciotomy
Pain and neurological symptoms in a tight fascial compartment coupled with a high velocity injury carry a high risk of compartment syndrome and prompt fasciotomy should be performed.
Application of external fixator
Wide exposure to plate the humerus is generally inadvisable owing to its many important anatomical relations. Both intramedullary nailing and external fixation are reasonable treatments. However, in the presence of an open fracture application of an external fixator and appropriate tissue debridement would be most appropriate.
Open reduction and internal fixation
Meticulous anatomical alignment of the fracture segments is crucial to avoid the development of osteoarthritis and risk of malunion.
Theme: Gastric ulceration
A.Acute peptic ulcer
B.Adenocarcinoma
C.Carcinoid Tumour
D.Gastrointestinal stromal tumour
E.Chronic peptic ulcer
F.Lymphosarcoma
G.Leiomyoma
Please select the most likely cause of gastric ulceration for the scenario given. Each option may be used once, more than once or not at all.
14.A 53 year old man presents with dyspepsia. At upper GI endoscopy he has a punched out ulcer on the lesser curve of the stomach. It measures approximately 2cm in diameter and is seen to penetrate muscle with fibrosis present at the base.
A 42 year old man presents with epigastric pain. At endoscopy, he is found to have a punched out ulcer on the anterior wall of the stomach. It is shallow and measures 1cm in diameter.
A 65 year old man presents with epigastric discomfort. At endoscopy he is found to have an ulcer at the antrum, is has thick rolled edges and measures 3cm in diameter.
Chronic peptic ulcer
Fibrosis is usually a sign of chronic ulcer. It should be biopsied carefully, a proton pump inhibitor started and re endoscopy should occur at 6 weeks.
Acute peptic ulcer
The absence of fibrosis coupled with small size suggests a more acute ulcer. Management should include biopsy, PPI and repeat endoscopy at 6 weeks
Adenocarcinoma
Rolled edges and location favor tumour. Careful biopsies should be taken and staging CT performed.
A 23 year old man suffers a thermal injury to his left hand. It becomes red and painful. Which of the following mediators are not involved in this process?
Histamine
Free radicals
Prostaglandins
Leukotrienes
Serotonin
Acute inflammation is not mediated by free radicals
Chemical mediators facilitate the spread of inflammation into normal tissue
Chemical mediators include:
Lysosomal compounds
Chemokines such as serotinin and histamine (released by platelets and mast cells)
Other enzyme cascades producing inflammatory mediators include:
Complement, kinin, coagulation system and fibrinolytic system
A 53 year old man undergoes an elective right hemicolectomy. A stapled ileo-colic anastomosis is constructed. Eight hours later he becomes tachycardic and passes approximately 600ml of dark red blood per rectum. Which of the following processes is the most likely explanation for this occurrence?
Anastomotic leak
Discharging mesenteric haematoma
Bleeding peptic ulcer
Anastomotic staple line bleeding
Mesenteric infarct
Stapled anastomoses are associated with staple line bleeding and this may typically occur in the early post operative phase. They should be managed conservatively as most will settle.
Stapled anastomoses are quicker to perform. Ironically, although they may appear easy they can carry considerably more potential pitfalls than their hand sewn equivalent and should be used with caution by the inexperienced, this is especially true if the bowel is very thick walled.
A 63 year old man is undergoing an upper GI endoscopy for dysphagia. At 33 cm (from the incisors) a malignant looking stricture is encountered. The endoscopist attempts a balloon dilatation.Unfortunately the tumour splits through the oesophageal wall. Into which region will the oesophageal contents now drain?
Superior mediastinum
Posterior mediastinum
Middle mediastinum
Anterior mediastinum
Peritoneal cavity
At this position the oesophagus is still likely to be intrathoracic and located in the posterior mediastinum.
During a tricuspid valve repair the right atrium is opened, following establishment of cardiopulmonary bypass. Which of the following structures do not lie within the right atrium?
Crista terminalis
Tricuspid valve
Fossa ovalis
Trabeculae carnae
Musculi pectinati
The trabeculae carnae are located in the right ventricle.
Structures within the right atrium:
Musculi pectinati
Crista terminalis
Opening of the coronary sinus
Fossa ovalis
Adult lung volumes. Which statement is false?
In restrictive lung disease the FEV1/FVC ratio is increased
Residual volume is increased in emphysema
Functional residual capacity is measured by helium dilution test
The tidal volume is approximately 340mls in females
The vital capacity is increased in Guillain Barre syndrome
FEV1/FVC is normal or >80% in restrictive lung disease such as pulmonary fibrosis. The ratio is reduced in obstructive airways disease.
The functional residual capacity, residual volume and the total lung capacity cannot be measured with spirometry. They can only be measured by helium dilution.
The vital capacity is reduced in:
1. Pulmonary fibrosis/infiltration/oedema/effusions
2. Weak respiratory muscles e.g. MG, GBS, myopathies
3. Skeletal abnormalities e.g. chest wall abnormalities
An enthusiastic medical student approaches you with a list of questions about blood transfusion reactions. Which of her following points is incorrect?
Graft versus host disease involves neutrophil proliferation
Thrombocytopaenia may occur in women with a prior pregnancy
IgA antibodies may cause blood pressure compromise during transfusion
Hypocalcaemia can occur
Iron overload can be avoided by chelation therapy
GVHD results from lymphocytic proliferation. The patient’s own lymphocytes are similar to the donor’s lymphocytes, therefore don’t perceive them as being foreign. The donor lymphocytes, however, sees the recipient lymphocytes as being foreign. Therefore they proliferate causing severe complications.
Thrombocytopaenia occurs a few days after transfusion and may resolve spontaneously.
Patients with IGA antibodies need IgA deficient blood transfusions.
An 82 year old lady presents with a carcinoma of the caecum. Approximately what proportion of patients presenting with this diagnosis will have synchronous lesions?
<1%
60%
50%
20%
5%
Synchronous colonic tumours are seen in 5% cases and all patients having a flexible sigmoidoscopy should have completion colonoscopy if tumours or polyps are found
Synchronous lesions may occur in up to 5% of patients with colorectal cancer. A full and complete lumenal study with either colonoscopy, CT cologram or barium enema is mandatory in all patients being considered for surgery.
A 47 year old lady is diagnosed as suffering from a phaeochromocytoma. From which of the following amino acids are catecholamines primarily derived?
Aspartime
Glutamine
Arginine
Tyrosine
Alanine
Catecholamine hormones are derived from tyrosine, it is modified by a DOPA decarboxylase enzyme to become dopamine and thereafter via two further enzymic modifications to noradrenaline and finally adrenaline.
A 34 year old lady presents to her general practitioner with peri anal discomfort. The general practitioner diagnoses pruritus ani, which of the following is least associated with the condition?
Hyperbilirubinaemia
Anal fissure
Leukaemia
Syphilis
Tuberculosis
Tuberculosis
Causes:
Systemic (DM, Hyperbilirubinaemia, aplastic anaemia)
Mechanical (diarrhoea, constipation, anal fissure)
Infections (STDs)
Dermatological
Drugs (quinidine, colchicine)
Topical agents
Which of the following is a recognised tributary of the retromandibular vein?
Internal jugular vein
External jugular vein
Anterior temporal diploic vein
Maxillary vein
Inferior opthalmic vein
The retromandibular vein is formed from the union of the maxillary and superficial temporal veins.
Passage of the retromandibular vein
Formed by a union of the maxillary vein and superficial temporal vein
It descends through the parotid gland and bifurcates within it
The anterior division passes forwards to join the facial vein, the posterior division is one of the tributaries of the external jugular vein
Theme: Inguinal hernia management
A.Bassini repair
B.Inguinal herniotomy
C.Lichtenstein repair
D.Laparoscopic hernia repair
E.Shouldice repair
F.McVey repair
For the herniae described please select the most appropriate procedure from the list. Each option may be used once, more than once or not at all.
28.A 11 month old child presents with intermittent groin swelling, it has a cough impulse and is easily reducible.
A 25 year old builder presents with a reducible swelling in the right groin, it is becoming larger and has not been operated on previously.
A 28 year old man presents with a recurrent inguinal hernia on the left side of his abdomen and a newly diagnosed inguinal hernia on the right side.
Inguinal herniotomy
Infants usually suffer from a patent processus vaginalis (a congential problem). As a result a simple herniotomy is all that is required. A mesh is not required as there is not specific muscle weakness.
Lichtenstein repair
An open Lichtenstein repair using mesh is appropriate. There is a 0.77% recurrence rate with this technique. A Shouldice repair is an acceptable alternative if the surgeon is experienced
Laparoscopic hernia repair
Laparoscopic hernia repairs are specifically indicated where there are bilateral hernias or recurrence of a previous open repair.
Theme: Events in wound healing
A.Platelets
B.Neutrophil polymorphs
C.Endothelial cells
D.Lymphocytes
E.Myofibroblasts
F.Granulomas
Please select the dominant cell type present in a wound at the specified timeframe. Each option may be used once, more than once or not at all.
10 weeks following injury
25 seconds following injury
7 days following injury
Myofibroblasts
These differentiated cell types facilitate wound contraction.
Platelets
Platelet degranulation and haemostasis are some of the earliest events in wound healing.
Endothelial cells
Angiogenesis which is characterised by endothelial cell proliferation and microvessel formation is a key step in successful wound healing. It is maximal between 1 and 2 weeks following injury and wounds may have a reddish appearance during this time.
A 74 year old lady has a long standing venous leg ulcer overlying her medial malleolus. Which of the following statements relating to the management of this condition is false?
Pentoxifylline may speed ulcer healing
Treatment with daily low dose flucloxacillin may speed ulcer healing
Multilayer bandages may provide compression equivalent to 40mmHg
Large ulcers may be considered for skin grafting
They should not be treated with compression stockings if the ankle / brachial pressure index is 0.4
Treatment with daily low dose flucloxacillin may speed ulcer healing
Theme: Fracture management
A.Copious lavage and generous surgical debridement, followed by external fixation
B.Intramedullary nail
C.Open reduction and internal fixation
D.Immobilisation in plaster cast
E.External fixation using a frame device
F.Amputation
G.Application of external fixation device
H.Primary closure of wound and application of plaster cast
Please select the most appropriate management for the fractures described. Each option may be used once, more than once or not at all.
36.A 55 year old motorcyclist is involved in a road traffic accident and sustained a Gustilo and Anderson IIIc type fracture to the distal tibia. He was trapped in the wreckage for 7 hours during which time he bled profusely from the fracture site. He has an established distal neurovascular deficit.
A 25 year old ski instructor who falls off a ski lift and sustains a spiral fracture of the mid shaft of the tibia. Attempts to achieve satisfactory position in plaster have failed. Overlying tissues are healthy.
A 35 year old mechanic is hit by a fork lift truck. He sustains a Gustilo and Anderson type IIIA fracture of the shaft of the left femur.
Amputation
This man is unstable, and at 7 hours after extraction, the limb is not viable. The safest option is primary amputation.
Intramedullary nail
This would be a good case for intramedullary nailing. Open reduction and external fixation would strip off otherwise healthy tissues and hence is unsuitable. In some units the injury may be managed with an Ilizarov frame device but the majority would treat with IM nailing.
Copious lavage and generous surgical debridement, followed by external fixation
At the tissues are in better shape than in the first case and as there is no associated vascular injury the patient may be suitable for debridement of the area and external fixation. If debridement leaves a tissue defect then plastic surgical repair will be needed at a later stage.
Delayed treatment of open fractures with significant vascular injury may be best treated by primary amputation.
Theme: Causes of dysphagia
A.Oesophageal cancer
B.Post radiotherapy fibrosis
C.Benign stricture
D.Plummer Vinson syndrome
E.Oesophageal candidiasis
F.Neuropathy
G.Globus
Please select the most likely cause of dysphagia for the scenarios given. Each option may be used once, more than once or not at all.
39.A cachectic 32 year old man with severe perineal Crohns disease is receiving treatment with intravenous antibiotics. Over the past 72 hours he has complained of intermittent dysphagia and odynophagia.
A 78 year old lady presents 6 years following a successfully treated squamous cell carcinoma of the oesophagus. She has a long history of dysphagia but it is not progressive.
A 32 year old lady presents with dysphagia. She has a 10 year history of anaemia secondary to menorrhagia and has been strongly resistant to treatment.
Oesophageal candidiasis
Treatment with systemic antibiotics may result in development of candidiasis. Patients may present with odynophagia and episodic dysphagia. Endoscopic appearances are usually diagnostic and treatment is with an oral anti fungal agent.
Post radiotherapy fibrosis
SCC of the oesophagus is commonly treated with chemoradiotherapy. Fibrosis and dysphagia may occur in survivors.
Plummer Vinson syndrome
Plummer Vinson syndrome (oesophageal web) may occur in association with iron deficiency anaemia (although rare!).
Theme: Paediatric gastrointestinal disorders
A.Appendicectomy
B.Active observation
C.Discharge
D.Ultrasound of the abdomen
E.Colonoscopy
F.Pneumatic reduction under fluoroscopic guidance
G.Laparotomy
Please select the most appropriate form of management from the list above. Each option may be used once, more than once or not at all.
42.A 5 year old girl has been unwell for 3 days with occasional vomiting and lethargy, she had one episode of diarrhoea. On examination she has a soft abdomen with tenderness in the region of the right iliac fossa. Her temperature is 38.1. Urine dipstick shows leucocytes (+) and protein (+).
A 6 day old baby was born prematurely at 33 weeks. He has been suffering from respiratory distress syndrome and has been receiving ventilatory support on NICU. He has developed abdominal distension and is increasingly septic. Ultrasound of the abdomen shows free fluid and evidence of small bowel dilatation. His blood pressure has remained labile despite inotropic support
A 1 year old child has been unwell with a sore throat and fever for several days. He progresses to develop periumbilical abdominal discomfort and passes diarrhoea. This becomes blood stained. The paediatricians call you because the ultrasound has shown a ‘target sign’.
Appendicectomy
The most likely diagnosis is appendicitis. This can often present with less robust signs in paediatric than adult practice.
Laparotomy
He has necrotising enterocolitis and whilst this is often initially managed medically a laparotomy is required if the situation deteriorates.
Pneumatic reduction under fluoroscopic guidance
This child has an intussusception. The lymphadenopathy will have initiated it. A target sign is seen on ultrasound and is the side on view of multiple layers of bowel wall. Reduction using fluoroscopy with air is the usual first line management. Ileo-colic intussceceptions are generally most reliably reduced using this method, long ileo-ileal intussceceptions usually result in surgery.
Theme: Management of burns
A.Escharotomy
B.Endotracheal intubation
C.Broad spectrum intravenous antibiotics
D.Intravenous fluids calculated according to extent of burned area
E.Discharge with review in outpatients
F.Transfer to regional burn centre once stabilised
G.Split thickness skin graft
H.Full thickness skin graft
What is the best management for the scenario given? Each option may be used once, more than once or not at all.
45.A 34 year old women trips over and falls into a bonfire whilst intoxicated at a party. She suffers burns to her arms, torso and face. These are calculated to be 25% body surface area. She is otherwise stable. The burns to the torso are superficial, her left forearm has a full thickness burn and the burns to her face are superficial. There is no airway compromise. She has received 1000ml of intravenous Hartman’s solution, with a further 1000ml prescribed to run over 4 hours.
A 20 year old man is trapped in a warehouse fire. He has sustained 60% burns to his torso and limbs. The limb burns are partial thickness but the torso burns are full thickness. He was intubated by paramedics at the scene and is receiving intravenous fluids. His ventilation pressure requirements are rising.
An 18 year old man accidentally pours boiling water onto his left arm. The area is erythematous and has a blister measuring 5cm. The wound is extremely painful.
Transfer to regional burn centre once stabilised
This women has been resuscitated and requires transfer for specialist management.
Escharotomy
He requires an escharotomy as this will be contributing to impaired ventilation.
Discharge with review in outpatients
This is a superficial burn and should recover with no further input than simple dressings, an alternative would be deroofing the blister and applying dressings prior to outpatient review.
A 52 year old male type 2 diabetic is admitted to the vascular ward for a femoral popliteal bypass. He suddenly develops expressive dysphasia and marked right sided weakness. The Senior house officer arranges a CT head scan which shows a 60% left middle cerebral artery territory infarct. There are no beds on the stroke unit. Overnight the patient becomes unresponsive and a CT head confirms no bleed. What is the next best management option?
IV heparin
Clopidogrel
Burr hole surgery
Aspirin
Hemicranieotomy
The likely cause for the reduced consciousness is raised intracranial pressure due to increasing cerebral oedema related to the infarct. In this situation, urgent neurosurgical review is needed for possible decompressive hemicranieotomy to relieve the pressure. Ideally no further antiplatelet or anticoagulation therapy should be given until a plan for surgery is confirmed.
Indications for hemicranieotomy include:
Age under 60 years
Clinical deficit in middle cerebral artery territory
Decreased consciousness
>50% territory infarct
Indications for hemicranieotomy in stroke
Age under 60 years
Clinical deficit in middle cerebral artery territory
Decreased consciousness
>50% territory infarct
A 4 year old boy presents with symptoms of dysuria and urinary frequency. A urine dipstick is positive for blood and nitrites. A UTI is suspected. Which of the following follow up strategies is most appropriate?
Watchful waiting
Cystoscopy
DMSA scan
CT scan of pelvis
Renal MRI
A first presentation of an uncomplicated UTI (even in male children) may be managed expectantly. More than 1 UTI in a six month period should prompt further investigation. NICE guidelines from 2007 suggest that recurrent UTI and those with a non e-coli UTI should be imaged with USS and DMSA several months later.
Which of the following statements relating to the gallbladder is untrue?
The fundus is usually intra peritoneal
Arterial supply is from the cystic artery
The cystic artery is usually located in Calots triangle
Calots triangle may rarely contain an aberrant hepatic artery
Cholecystokinin causes relaxation of the gallbladder
CCK causes gallbladder contraction.
Where are the arterial baroreceptors located?
Carotid sinus and aortic arch
Carotid sinus only
Superior vena cava
External carotid artery
None of the above
They lie in the carotid sinus and aortic arch.
A 22 year old man undergoes a splenectomy for an iatrogenic splenic injury. On the second post operative day a full blood count is performed. Which of the following components of the full blood count is the first to be affected ?
Erythrocyte count
Reticulocyte count
Eosinophil count
Monocyte count
Lymphocyte count
Reticulocyte
The granulocyte and platelet count are the first to be affected following splenectomy. Then reticulocytes increase. Although a lymphocytosis and monocytosis are reported, these take several weeks to develop
A 28 year old lady presents with benign cyclical mastalgia. Which of the following is not a recognised treatment for the condition?
Evening primrose oil
Bromocriptine
Methotrexate
Danazol
Tamoxifen
Surgical excision of tender breast tissue is inappropriate
Methotrexate is used for the treatment of breast cancer. Whilst the use of tamoxifen is of benefit other agents such as flaxseed oil or evening primrose oil should be tried first. Danazol is effective, but many women dislike the side effects.
Differentiator between benign cyclical mastalgia and Tietze’s syndrome
Point tenderness of chest wall more likely to be Teitze’s syndrome
Theme: Wound management
A.VAC Device
B.Packing with alginate ribbon
C.Packing with ribbon gauze
D.Application of silver nitrate
E.Application of potassium permangenate
F.Use of iodine soaked gauze
G.Gauze soaked in proflavin
For each wound please select the most appropriate management option. Each option may be used once, more than once, or not at all.
54.A 56 year old man has a superficial dehisence of a midline sternotomy wound following an aortic valve replacement
A 72 year old man has discharge from a healed abdomino-perineal resection wound. On examination, it has almost completely healed but there is prominent granulation tissue at the apex of the wound. There is no evidence of an underlying collection and he is otherwise well.
A 23 year old man has an incision and drainage of an axillary abscess, there is no residual surrounding tissue infection.
VAC Device
Provided the sternum is stable a VAC device should promote granulation and healing. It is not indicated where the sternum has come apart.
Application of silver nitrate
Silver nitrate will cauterise the exuberant granulation tissue and promote healing.
Packing with alginate ribbon
Use of gauze is inappropriate and will be painful to redress.
Theme: Fistula
A.Recurrent urinary tract infection secondary to catheter
B.Nephroenteric fistula
C.Enterovesical fistula
D.High Enterocutaneous fistula
E.Low Enterocutaneous fistula
F.Enteroenteric fistula
G.Colocutaneous fistula
H.Wound infection
Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.
57.You are the specialist trainee asked to review a 39 year old man post gastrectomy for bleeding duodenal ulcers. He is hypotensive and tachycardic. His drain has increased output, contains pus and has bubbles. There is excoriated skin around the drain site.
A 43 year old female presents with recurrent urinary tract infections. She describes blood and frothy urine. She is 6 weeks post operative for a left hemicolectomy for crohn’s disease.
A 2 week infant has foul smelling material discharging from the umbilicus.
High Enterocutaneous fistula
Suspect an enterocutaneous fistula if there is excessive drainage and bubbles. Pus may confuse surgeons, leading them to make a diagnosis of wound infection. If there is any uncertainty, methylene blue can be given. If methylene blue is found in the drain, this confirms a fistula.
Enterovesical fistula
A nephroenteric fistula causes a chronic urinary tract infection, hence develops over a longer time frame.
Low Enterocutaneous fistula
This baby has an enterocutaneous fistula at the umbilicus due to complete failure of the omphalomesenteric duct to obliterate. This is treated with resection.
A 22 year old fit and well male undergoes an emergency appendicectomy. He is given suxamethonium. An inflamed appendix is removed and the patient is returned to recovery. On arrival in the recovery area; the patient develops a tachycardia of 120 bpm and a temperature of 40 ºC. He has generalised muscular rigidity. What is the most likely diagnosis?
Acute dystonic reaction
Malignant hyperthermia
Pelvic abscess
Epilepsy
Serotonin syndrome
Anaesthetic agents, such as suxamethonium, can cause malignant hyperthermia in patients with a genetic defect. Acute dystonic reaction normally is associated with antipsychotics (haloperidol) and metoclopramide. These lead to marked extrapyramidal effects. Serotonin syndrome is associated with the antidepressants selective serotonin reuptake inhibitors (SSRIs) and selective serotonin/norepinephrine reuptake inhibitors (SSNRIs). This causes a syndrome of agitation, tachycardia, hallucinations and hyper-reflexia.
Features of malignant hyperthermia
Condition seen following administration of anaesthetic agents ( rate of 1 in 15,000)
Characterised by hyperpyrexia and muscle rigidity
Caused by excessive release of Ca2+ from the sarcoplasmic reticulum of skeletal muscle
Associated with defects in a gene on chromosome 19 encoding the ryanodine receptor, which controls Ca2+ release from the sarcoplasmic reticulum
Neuroleptic malignant syndrome may have a similar aetiology
Causative agents in malignant hyperthermia
Halothane
Suxamethonium
Antipsychotics (neuroleptic malignant syndrome)
Mx of malignant hyperthermia
Dantrolene- prevents Ca release from SR
Which of the following nerves is the primary source of innervation to the anterior scrotal skin?
Iliohypogastric nerve
Pudendal nerve
Ilioinguinal nerve
Femoral branch of the genitofemoral nerve
Obturator nerve
The pudendal nerve may innervate the posterior skin of the scrotum. The anterior innervation of the scrotum is primarily provided by the ilioinguinal nerve. The genital branch of the genitofemoral nerve provides a smaller contribution.
Innervation of the scrotum
Ilioinguinal (anterior) nerve and the pudendal (posterior) nerve
The motor nucleus of cranial nerve V supplies all except which of the following muscles?
Masseter
Posterior belly of digastric
Temporalis
Tensor tympani
Tensor veli palatini
The posterior belly of digastric is supplied by the branchial motor component of the facial nerve. All of the other muscles are supplied by axons from the motor nucleus of cranial nerve V.
The transversalis fascia contributes to which of the following?
Pectineal ligament
Deep inguinal ring
Cremaster muscle and fascia
Inguinal ligament
External spermatic fascia
The internal spermatic fascia (derived from transversalis fascia) invests:
Ductus deferens
Testicular vessels
The principal outpouching of the transversalis fascia is the internal spermatic fascia. The mouth of the outpouching is the deep inguinal ring.
Theme: Pancreatitis management
A.Pancreatic necrosectomy
B.Staging laparotomy to assess severity
C.Endoscopic retrograde cholangiopancreatography
D.Emergency cystogastrostomy
E.Cholecystectomy within 4 weeks
F.Elective cystogastrostomy
G.Parenteral nutrition
Please select the most appropriate next stage in management for the scenario given. Each option may be used once, more than once or not at all.
65.A 34 year old women is admitted with cholangitis. Her bilirubin is 180 and alkaline phosphatase is 348. She becomes progressively more unwell and develops abdominal pain. The houseman checks her amylase which is elevated at 1080. Standard treatment is initiated and her Glasgow score is 3.
A 63 year old man is admitted to ITU with an attack of severe gallstone pancreatitis. He requires ventillatory support for ARDS. Over the past few days he has become more unwell and a CT scan is organised. This demonstrates an area of necrosis, culture from this area shows a gram negative bacillus. His CRP is 400 and WCC 25.1.
A 53 year old alcoholic develops acute pancreatitis and is making slow but reasonable progress. He is troubled by persisting ileus and for this reason a CT scan is undertaken. This demonstrates a large pancreatic pseudocyst. This is monitored by repeat CT scanning which shows no resolution and he is now complaining of early satiety.
Endoscopic retrograde cholangiopancreatography
She requires urgent decompression of her biliary system. An ERCP is the conventional method of performing this. It is important to ensure that her coagulation status is normalised prior to performing this procedure.
Pancreatic necrosectomy
This man requires necrosectomy as he has infected pancreatic necrosis and is haemodynamically unstable. A radiological drainage procedure is unlikely to be sufficient.
Elective cystogastrostomy
Drainage of this man’s pseudocyst is required. This could be accomplished radiologically or endoscopically or surgically. As the other options are not on the list this is the best option from those available.
A 63 year old man is undergoing a right pneumonectomy for carcinoma of the bronchus. As the surgeons approach the root of the lung, which structure will lie most posteriorly (in the anatomical plane)?
Phrenic nerve
Main bronchus
Vagus nerve
Pulmonary vein
Pulmonary artery
The vagus nerve is the most posteriorly located structure at the lung root. The phrenic nerve lies most anteriorly.
What proportion of patients presenting for cholecystectomy for treatment of biliary colic due to gallstones will have stones in the common bile duct?
10%
30%
2%
50%
25%
Up to 10% of all patients may have stones in the CBD. Therefore, all patients should have their liver function tests checked prior to embarking on a cholecystectomy.
A 39 year old lady has undergone surgery for breast cancer. As part of the histopathology report the pathologist provides the surgeon with a Nottingham Prognostic Index score of 6.4. He also states that the tumour size is 2cm. Which of the following inferences can be made in relation to this statement?
The tumour is likely to be grade 1
Vascular invasion is present
Lymph node metastasis are definitely present
The tumour is oestrogen receptor positive
None of the above
A score of this value is unlikely to be reached with a grade 1 tumour and a size of 2cm. Therefore lymph node metastasis are definitely present. In addition since the maximal score for lymph node metastasis is 3 the tumour is likely be of a higher grade (see below). The Nottingham Prognostic Index provides no information about oestrogen receptor status or the presence or absence of vascular invasion.
A 43 year old lady is undergoing an axillary node clearance for breast cancer. The nodal disease is bulky. During clearance of the level 3 nodes there is suddenly brisk haemorrhage. The most likely vessel responsible is:
Thoracoacromial artery
Cephalic vein
Thoracodorsal trunk
Internal mammary artery
Posterior circumflex humeral artery
The thoracoacromial artery pierces the pectoralis major and gives off branches within this space. The level 3 axillary nodes lie between pectoralis major and minor.Although the thoracodorsal trunk may be injured during an axillary dissection it does not lie within the level 3 nodes.
A 73 year old lady with long standing atrial fibrillation develops a cold and pulseless white arm. A brachial embolus is suspected and a brachial embolectomy is performed. Which of the following structures is at greatest risk of injury during this procedure?
Radial nerve
Cephalic vein
Ulnar nerve
Median nerve
None of the above
The median nerve lies close to the brachial artery in the antecubital fossa. This is the usual site of surgical access to the brachial artery for an embolectomy procedure. The median nerve may be damaged during clumsy application of vascular clamps to the artery.
Which one of the following cells secretes the majority of tumour necrosis factor in humans?
Neutrophils
Macrophages
Natural killer cells
Killer-T cells
Helper-T cells
Macrophages
Action of TNF alpha
Activates macrophages and neutrophils
Acts as costimulator for T cell activation
Key mediator of body’s response to Gram negative septicaemia
Similar properties to IL-1
Anti-tumour effect (e.g. phospholipase activation)
TNF-alpha binds to both the p55 and p75 receptor. These receptors can induce apoptosis. It also cause activation of NFkB
Endothelial effects include increase expression of selectins and increased production of platelet activating factor, IL-1 and prostaglandins
TNF promotes the proliferation of fibroblasts and their production of protease and collagenase. It is thought fragments of receptors act as binding points in serum
Systemic effects include pyrexia, increased acute phase proteins and disordered metabolism leading to cachexia
TNF is important in the pathogenesis of rheumatoid arthritis - TNF blockers (e.g. infliximab, etanercept) are now licensed for treatment of severe rheumatoid
Which of the following is false during the pre operative preparation for surgery in pancreatic cancer?
IV antibiotics should be given intra operatively
Endotoxaemia can be reduced with lactulose
Subcutaneous heparin should be avoided
Endotoxaemia can be reduced with IV mannitol
There is a higher risk of complications if the bilirubin is greater than 150
Subcutaneous heparin should be avoided
Vitamin K should be given to correct abnormal clotting initially, however there is still a risk of thrombosis so low molecular weight heparin should be used. Bile salts can also be given to reduce endotoxaemia. Biliary obstruction should be relieved. In the case of biliary obstruction, if a stent is used it should be a made of plastic. Metallic stents will become embedded and may compromise attempts at resection.
A 28 year old male presents with a discharging sinus in his natal cleft. He is found to have a pilonidal sinus. Which statement is false?
Can occur in webs of fingers and the axilla
After drainage pilonidal abscesses should not be primarily closed
A rare complication is squamous cell carcinoma
In a patient with an acute abscess the Bascoms procedure is the treatment of choice.
Treatment involves excising or laying open the sinus tract.
When performing incision and drainage for pilonidal abscess try to avoid making the incision in the midline of the natal cleft.
Acute pilonidal abscesses should receive simple incision and drainage. Definitive treatments such as a Bascoms procedure should not be undertaken when acute sepsis is present.
Which of the following fingers is not a point of attachment for the palmar interossei?
Middle finger
Little finger
Ring finger
Index finger
None of the above
The middle finger has no attachment of the palmar interosseous.
A 20 year old male is referred to the clinic. He has undergone genetic testing because his father died from colorectal cancer at the age of 21. His testing revealed a mutation of the APC gene. A colonoscopy is proposed. What is the most likely finding?
Multiple colonic hamartomas
Carpet villous adenoma of the rectum
Caecal carcinoma
Multiple colonic adenomas
Multiple colonic hyperplastic polyps
APC mutations are found in familial adenomatous polyposis coli. These have multiple colonic adenomas.
Which of the following is responsible for the rapid depolarisation phase of the myocardial action potential?
Rapid sodium influx
Rapid sodium efflux
Slow efflux of calcium
Efflux of potassium
Rapid calcium influx
Rapid sodium influx
Theme: Ankle Brachial pressure index measurements
A.>1
B.0.6- 0.8
C.1
D.0.4-0.6
E.<0.4
For the scenarios described below, please select the most likely ankle brachial pressure index measurement. Each option may be used once, more than once or not at all.
85.An 83 year old male with rest pain.
A 45 year old man who develops calf pain after walking 600 yards. It resolves during periods of rest.
A 43 year old lady with long standing diabetes who complains of calf pain. It is worse at night and during minor exercise.
<0.4
Rest pain is typically associated with low ABPI values.
0.6- 0.8
Since this is a long claudication distance it may be that only a minor lesion is present. Whilst resting ABPI may be normal, they are usually abnormal following exercise.
>1
Diabetes may be complicated by vessel calcification and neuropathic pain. Therefore individuals may present with pain which is atypical for claudation both in terms of its tempo of onset and location.
Fontaine classification
Stage 1
Asmyptomatic, incomplete blood vessel obstruction
Fontaine
Stage IIa
Claudication when walking a distance >200m
Fontaine
Stage IIb
Claudication when walking <200m
Fontaine
Stage III
Rest pain
Fontaine
Stage IV
Necrosis +/- gangrene
Rutherford
Grade 0
Asymptomatic
Rutherford
Grade 1
Claudication
Rutherford
Grade II
Rest pain
Rutherford
Grade III
Minor tissue loss
Rutherford
Grade IV
Major tissue loss
A 33 year old man sustains an injury to his forearm and wrist. When examined in clinic he is unable to adduct his thumb. What is the most likely underlying nerve lesion?
Radial nerve
Superficial branch of the ulnar nerve
Median nerve
Posterior interosseous nerve
Deep branch of the ulnar nerve
Damage to the deep branch of the ulnar nerve may result in an inability to adduct the thumb. This is tested clinically by trying to withdraw a piece of paper from a patients hand grasped between thumb and index finger.
A 6 year old sustains a supracondylar fracture of the distal humerus. There are concerns that the radial nerve may have been injured. What is the relationship of the radial nerve to the humerus at this point?
Anterolateral
Anteromedial
Posterolateral
Posteromedial
Immediately anterior
The radial nerve lies anterolateral to the humerus in the supracondylar area.
Which of the following muscles is penetrated by the parotid duct?
Medial pterygoid
Buccinator
Levator anguli oris
Temporalis
Masseter
The duct crosses the masseter muscle and buccal fat pad and then penetrates the buccinator muscle to enter the oral cavity opposite the second upper molar tooth.
Which of the following breast tumours is most commonly associated with a risk of metastasis to the contralateral breast?
Invasive ductal carcinoma
Invasive lobular carcinoma
Phyllodes tumour
Pagets disease of the breast
Atypical ductal hyperplasia
Risk of metastasis to the contralateral breast is a classical feature of invasive lobular carcinoma.
Theme: Head and neck lesions
A.Dermoid cyst
B.Thyroglossal cyst
C.Sjogren’s syndrome
D.Mikulicz’s syndrome
E.Pleomorphic adenoma of the parotid
F.Carcinoma of the parotid
G.Cystic hygroma
H.Branchial cyst
I.Pharyngeal pouch
Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.
92.The parents of a 2 year old child are concerned after he develops a lump in his neck. On examination there is a swelling in the subcutaneous tissue of the posterior triangle which transilluminates.
A 40 year old female presents with a painless neck lump. There is a mass noted beneath the sternocleidomastoid muscle. There is a long history and somewhat unkindly her husband remarked on her rather noticeable halitosis.
A 32 year old lady is referred to the clinic with recurrent infections and abscesses in the neck. On examination she has a midline defect with an overlying scab, which moves upwards on tongue protrusion.
Cystic hygroma
This is a classical description. Collection of dilated lymphatic sacs which are fluctuant and brilliantly transilluminable. Recurrence is common.
Pharyngeal pouch
Usual history of regurgitation of undigested food or coughing at night. Associated with halitosis and throat infections.
Thyroglossal cyst
Thyroglossal cyst is always located in the midline as it is this route that the thyroid takes during its embryological descent. Its connection with the foramen caecum means it will move on tongue protrusion.
The following are true of the ulnar nerve except:
It innervates the palmar interossei
Derived from the medial cord of the brachial plexus
Supplies the muscles of the thenar eminence
Supplies the medial half of flexor digitorum profundus
Passes superficial to the flexor retinaculum
The muscles of the thenar eminence are supplied by the median nerve and atrophy of these is a feature of carpal tunnel syndrome.
Theme: Colonic resections
A.Right hemicolectomy and ileocolic anastomosis
B.Extended right hemicolectomy and ileocolic anastomosis
C.Hartman’s procedure
D.Defunctioning loop ileostomy only
E.Anterior resection and colo-rectal anastomosis
F.Abdomino-perineal excision of colon and rectum
Please select the most appropriate resection for the scenario given. Each option may be used once, more than once or not at all.
97.A 58 year old man with a tumour of the splenic flexure that requires resection.
A 63 year old man presents with a carcinoma of the upper rectum. Staging investigations demonstrate localised disease and he is not deemed to require and neo adjuvent therapy.
A 66 year old lady presents with a tumour of the low rectum. There is a projection inferior to within 1cm of the dentate line.
Extended right hemicolectomy and ileocolic anastomosis
Beware of the anatomy at the base of the middle colic which will require high ligation.
Anterior resection and colo-rectal anastomosis
Upper rectal tumours are usually amenable to restoration of intestinal continuity and therefore an anterior resection is a reasonable treatment option.
Abdomino-perineal excision of colon and rectum
Low rectal tumours such as this will require APER.
Theme: Causes of ulceration
A.Marjolin’s ulcer
B.Neuropathic ulcer
C.Arterial ulcer
D.Deep venous dysfunction
E.Superficial venous dysfunction
F.Rheumatoid arthritis
G.Pyoderma gangrenosum
H.Pressure ulcer
Please select the most likely cause of ulceration for the scenario given. Each option may be used once, more than once or not at all.
100.A 62 year old diabetic man presents with long standing plantar ulcer he has clinical evidence of a charcot foot.
A 66 year old female has long standing mixed arteriovenous ulcers of the lower leg. Over the past 6 months one of the ulcers has become much worse and despite a number of different topical therapies is increasing in size.
A 28 year old man undergoes a ileocaecal resection and end ileostomy for Crohn’s disease. One year later he presents with a deep painful ulcer at his stoma site.
Neuropathic ulcer
Plantar ulcers in association with peripheral neuropathy are often neuropathic. They classically occur at pressure points.
Marjolin’s ulcer
Marjolin’s ulcer is a squamous cell carcinoma occurring at sites of chronic inflammation or previous injury.
Pyoderma gangrenosum
Pyoderma gangrenosum is associated with inflammatory bowel disease (this patient had a stoma for crohns!). It is commonly found on lower limbs and described as being painful, the size of an insect bite and growing. It looks like a margarita pizza (with a red base and yellow topping!) Treatment involves steroids.
A 47-year-old woman presents with loin pain and haematuria. Urine dipstick demonstrates:
Blood++++
NitritesPOS
Leucocytes+++
Protein++
Urine culture shows a Proteus infection. An x-ray demonstrates a stag-horn calculus in the left renal pelvis. What is the most likely composition of the renal stone?
Xanthine
Calcium oxalate
Struvite
Cystine
Urate
Stag-horn calculi are composed of struvite and form in alkaline urine (ammonia producing bacteria therefore predispose)
Renal stones on x-ray
cystine stones: semi-opaque
urate + xanthine stones: radio-lucent
Which of the following options in relation to the liver is true?
Ligamentum venosum is an anterior relation of the liver
The portal triad comprises the hepatic artery, hepatic vein and tributary of the bile duct
The liver is completely covered by peritoneum
There are no nerves within the porta hepatis
The caudate lobe is superior to the porta hepatis
The caudate lobe is superior to the porta hepatis
‘VC goes with VC’
The ligamentun Venosum and Caudate is on same side as Vena Cava [posterior].
Ligamentum venosum is posterior to the liver. The portal triad contains the portal vein rather than the hepatic vein. There is the ‘bare area of the liver’ created by a void due to the coronary ligament layers being widely separated. There are sympathetic and parasympathetic nerves in the porta hepatis.
Which of the following structures does not pass anterior to the lateral malleolus?
Anterior tibial artery
Extensor digitorum longus
Lateral branch of the superficial peroneal nerve
Peroneus brevis
Peroneus tertius
Peroneus brevis passes posterior to the lateral malleolus.
Structures posterior to the lateral malleolus and superficial to superior peroneal retinaculum
Sural nerve
Short saphenous vein
Structures posterior to the lateral malleolus and deep to superior peroneal retinaculum
Peroneus longus tendon
Peroneus brevis tendon
Theme: Surgical access
A.Kocher’s
B.Lanz
C.Rooftop
D.Pfannenstiel’s
E.Midline
F.Paramedian incision
G.Mcevedy
Please select the most appropriate incision for the procedure described. Each option may be used once, more than once or not at all.
106.A 19 year old girl who is 39 weeks pregnant goes into labour. The labour is prolonged and she is found to have an undiagnosed breech baby.
A 49 year old woman presents with jaundice and abdominal pain. She is haemodynamically unstable. An USS shows a dilated common bile duct and gallstones in the gallbladder.
A 42 year old man with history of alcohol abuse is diagnosed with pancreatic cancer and requires a Whipples resection.
Pfannenstiel’s
This patient needs an emergency cesarean section.
Kocher’s
This lady needs a cholecystectomy and bile duct exploration.
Rooftop
A pancreatectomy is usually performed through a roof top incision. This provides excellent access to the upper abdomen.
Which of the following is not a feature of normal cerebrospinal fluid?
It has a pressure of between 10 and 15 mmHg.
It usually contains a small amount of glucose.
It may normally contain up to 5 red blood cells per mm3.
It may normally contain up to 3 white blood cells per mm3.
None of the above
It should not contain red blood cells.
Which of the following is not an effect of somatostatin?
It stimulates pancreatic acinar cells to release lipase
It decreases gastric acid secretion
It deceases gastrin release
It decreases pepsin secretion
It decreases glucagon release
It inhibits pancreatic enzyme secretion.
The following statements regarding the rectus abdominis muscle are true except:
It runs from the symphysis pubis to the xiphoid process
Its nerve supply is from the ventral rami of the lower 6 thoracic nerves
It has collateral supply from both superior and inferior epigastric vessels
It lies in a muscular aponeurosis throughout its length
It has a number of tendinous intersections that penetrate through the anterior layer of the muscle
Rectus abdominis
Arises from the pubis.
Inserts into 5th, 6th, 7th costal cartilages.
The muscle lies in the rectal sheath, which also contains the superior and inferior epigastric artery and vein.
Action: flexion of thoracic and lumbar spine.
Nerve supply: anterior primary rami of T7-12.
The aponeurosis is deficient below the arcuate line.
Which is the characteristic finding on a blood film post splenectomy?
Stipple cell
Tear drop cell
Reticulocytes
Howell-Jolly bodies
Schistocyte
Howell-Jolly bodies
Pappenheimer bodies
Poikilocytes (Target cells)
Erythrocyte containing siderotic granules
Heinz bodies
A 23 year old lady presents with a posteriorly sited fissure in ano. Treatment with stool softeners and topical GTN has failed to improve matters. Which of the following would be the most appropriate next management step?
Lords procedure
Injection of botulinum toxin
Lateral internal sphincterotomy
Endoanal advancement flap
Surgical division of the external anal sphincter
The next most appropriate management option when GTN or other topical nitrates has failed is to consider botulinum toxin injection. In males a lateral internal sphincterotomy would be an acceptable alternative. In a female who has yet to conceive this may predispose to delayed increased risk of sphincter dysfunction. Division of the external sphincter will result in faecal incontinence and is not a justified treatment for fissure.
Which statement relating to actinomycosis is false?
They are gram positive bacilli
They are strict aerobes
It may be a cause of chronic multiple abscesses
Abdominal cases may develop in the appendix
Open biopsy of the lesions is the best diagnostic test
They are facultative anaerobes and may be difficult to culture. Direct visualisation of organisms and sulphur granules from lesions themselves is the easiest way to make a diagnosis. It remains a differential of conditions such as hydradenitis supprativa, particularly if it is occurring in odd locations and with deeper abscesses than usual.
Which of the following statements relating to sternocleidomastoid is untrue?
The external jugular vein lies posteromedially.
It is supplied by the accessory nerve.
It has two heads of origin
It inserts into the lateral aspect of the mastoid process.
It marks the anterior border of the posterior triangle.
The external jugular vein lies lateral (i.e. superficial) to the sternocleidomastoid.
Which of the following statements is false in relation to consent?
All adults by law are assumed to be competent
The Bolam test defines if a patient has capacity or not
Consent 2 is the form signed by parents on behalf of their children
Implied consent is a form of consent
Consent 4 is the form signed when a patient is unable to consent for a treatment or investigation
The Bolam test defines if a decision made by a doctor is in agreement with the professional standard of medical practise.
During liver mobilisation for a cadaveric liver transplant the hepatic ligaments will require mobilisation. Which of the following statements relating to these structures is untrue?
Lesser omentum arises from the porta hepatis and passes the lesser curvature of the stomach
The falciform ligament divides into the left triangular ligament and coronary ligament
The liver has an area devoid of peritoneum
The coronary ligament is attached to the liver
The right triangular ligament is an early branch of the left triangular ligament
The right triangular ligament is a continuation of the coronary ligament.
Draw the lumbosacral plexus
https://www.youtube.com/watch?v=T_GlJu0dxkA
Most common cause of septic arthritis in adults <50
Neisseria gonorrhoea
What is the second most common cause of septic arthritis in adults <50
Staph aureus
AD condition associated with multiple hamartomas (breast, thyroid, skin and mucosal membranes)
Increased incidence of breast and endometrial cancer in women as well as thyroid and renal cancers
Cowden’s disease
What is the risk of developing oesophageal adenocarcinoma in Barret’s disease?
6-14% increased risk.
RR 11
What virus in HIV infected patients increases the risk of oesophageal SCC?
HPV
72 year old man has chronic back pain. Weight loss. Afebrile.
FBC: WCC 9.8x10^9. with a differential of 63 PMs, seven bands, 2 metamyelolcytes, 2 myelocytes, 18 lymphocytes, eight monocytes and four nucelated RBCs.
Hb is 12.2 with an Hct of 37.1%.
MCV of 84 and plt 124.
Which of the following most likely to be associated with findings.
CLL
HA
Metastatic carcinoma
Previous splenectomy
Staph aureus osteomyelitis
Leukoerythroblastic picture in peripheral blood.
Prostatic adenocarcinoma or lung cancer are likely primaries
normocytic normochromic anemia with numerous poikilocytes
normoblasts (nucleated red cells)
low-grade reticulocytosis (2-5%)
circulating immature white cells, generally myelocytes and promyelocytes
thrombocytopenia is more common than thrombocythemia
Leukoerythroblastic picture
Causes of leukoerythroblastic picture
Myeloma
Malignancy
Myelofibrosis
Gaucher’s
What electrolyte abnormality is seen in persistent vomiting?
Hypokalaemic hypochloraemic metabolic alkalosis
Which of the following will not rise in sepsis as part of acute phase response
Glucose
Albumin
C3
Alpha-1 antityrypsin
Haptoglobin
Albumin is negative responder
Glucose increases due to cortisol and GH release
C3 is raised as it is part of the complement system
A1AT is a proteinase that may be release following tissue damage.
Haptoglobin will increase, it is an iron binding protein
Acute renal tubular dysfunction post surgery
Usually due to ischaemia of the medulla.
Can be treated initially with osmotic diuretics that may have a free radical scavenging effect.
Majority of causes will resolve with supportive treatment and careful fluid management.
Subdivisions of level 1 based evidence
1a Systematic reviews (with homogeneity of RCTs)
1b: individual RCTs with narrow confidence interval
1c All or none RCTs
Level 2 evidence subdivisions
2a: systematic reviews with homogeneity of cohort studies
2b: indivdual RCTs (with narrow confidence interval)
2c: outcome research, ecological studies
Level 3 evidence subdivisions
3a: systematic review of case-control studies
3b individual case-control study
When do symptoms in chronic mesenteric ischaemia usually develop
When at least 2/3 visceral arteries are involved
T staging of breast cancer
T0- subclinical
T1- 2cm or less
T2 >2cm <5cm
T3 >5cm
T4 any size with chest wall or skin extension
N staging of breast cancer
N0 -no nodal involvement
N1- ipsilateral axillary nodes (mobile)
N2- ipsilateral axillary nodes (fixed)
N3- internal mammary nodes
M staging of breast cancer
M0- no distant mets
M1- distant mets
Which muscle extends thigh at hip
Gluteus maximus
What muscles abduct the hip
Gluteus medius and minimus
Which thyroid tumour is associated with radiation exposure
Papillary (85% of radiation induced tumours are papillary)
Which bones form the acetabulum
Ilium, ischium and pubis
How is the acetabulum commonly fractured
In RTAs where vehicles collide head on, driving the engine and steering column into the lower limbs, driving the femur posteriorly into the acetabulum with force, causing a fracture
What is the most common cause of secondary lymphoedema in the UK?
Malignant neoplastic infiltration
A 60 year-old previously fit and well man dies suddenly after two separate syncopal episodes.
At PM, which of the following congenital cardiac defects might be found?
Dextrocardia with situs inversus
PFO
Bicuspid aortic valve
VSD
Single coronary artery
A 68 year old woman is admitted to the coronary care unit following MI. Her renal blood flow and renal perfusion pressure fall, causing a drop in UO.
Which of the following factors are responsible for increasing these?
Angiotensinongen
ADH
Endothelin
Insulin
PGs
Prostaglandins
What proportion of intracranial tumours are accounted for by pituitary adenomas?
10-15%
What is the most common lead point in intussuception
Hypertrophic Payer’s patch is the lead point in up to 90% of cases
Dance’s sign
Feeling of emptiness on palpation with viscera abscent in RLQ on AXR.
Seen in 15% of cases of intussuception
Which pro-inflammatory cytokine secreted by macrophages is also secreted by muscle?
IL-6
Secreted by T cells and macrophages in immune response to trauma especially burns.
It is also a myokine, elevated in response to muscle contraction.
Osteoblasts also secrete IL-6 to stimualte osteoclast formation.
Inhibitos of IL-6 (oestrogens) can be used to inhibit post-menopausal osteoporosis
What muscle retracts the tongue back and up?
Styloglossus
What muscle protrudes the tongue?
Genioglossus
What muscle depresses the tongue?
Hyoglossus
What nerve supplies the base of the tongue?
Internal laryngeal nerve (branch of X)
What is the site of renin production?
JGA
Origins of biceps
Walk a SHORT way to the street CORner Ride a LONG way on the SUPRA high way
Short head originates from coracoid process of scapula
Long head originates from the supraglenoid tubercle
Insertions into the intertubercular sulcus of the humerus
Lady between to majors
(L->M)
Pec major
L dorsi
Teres major
Where does the oesophagus pass through the diaphragm
T10
It passes through the muscular part of the diaphragm to the left of the central tendon, through the muscular sling of the right crus
Features of the endothoracic fascia
Connective tissue between the inner aspect of the chest wall and the costal parietal pleura.
Which of the following structures is least likely to be encountered on left carotid endarterectomy?
Facial vein
Pleural membranes
Sympathetic chain
Thoracic duct
Vagus nerve
Pleural membranes are usually deep and lateral to the site of endarterectomy.
Vagus travels in the carotid sheath in the neck
Sympathetic trunk lies alongside the cervical vertebrae, immedaitely behind the carotid.
Thoracic duct may seen
Facial vein has to be ligated and divided to mobilise the internal jugular vein
Le Fort 1 fracture
Horizontal- extends from nasal septum , laterally through the maxilla and thence backwards to the pterygoid region
Le Fort 2
Pyramidal
Le Fort 3
Transverse
Anatomically complex, often bilateral which extends across the frontoethmoid regions, superior and lateral orbits to the zygomatic arch laterally and through the ethomid to the sphenoid
It is a form of craniofacial dysjunction
Which of the following vessels normally arise from the aortic arch?
Left subclavian
Left vertebral
Right internal mammary
Right CCA
Right subclavian
Left subclavian
What differentiates the jejunum from the ileum
Jejunum has thicker wall
Less mesenteric fat
More plicae circulares
Wider lumen
Fewer Peyerr’s patches
Fewer arterial arcades than the ileum
What is the anatomical level to which a level 3 axillary clearance operation should go?
Superomedial to pectoralis minor
What instrument is commonly used to gain exposure in a Milligan-Morgan haemorrhoidectomy?
Eisenhammer retractor
Anal retractor commonly used to assist examination of the anorectum under anaesthesia
What is the most appropriate forceps to enclose the tip of the appendix and facilitate its subsequent dissection
Babcock forceps
Tissue-holding forceps designed to grasp rather than crush contained viscera, aboiding damage and possible spillage.
Other tissue-holding forceps include Allis, Littlewood, Lane
What is the instrument most commonly used to clamp the main vascular pedicles before division and ligation during colectomy.
Robert clamp
Long robust and partially curved clamp that is commonly employed for medium to large structures such as vascular pedicles.
Smaller clamps include Dunhill, Mosquite.
More curved clamps are Moynihan, Lloyd Davis, Lahey
What dissecting forceps are suitable for performing vascular surgery
Debakey forceps
Gartner’s duct
Derived from the remnants of the mesonephric ducts in women. Persists between the layer of the broad ligament and wall of the vagina, can give rise to a cyst
Urachal cyst
Urachus is a remnant of the allantois, involutes before birth and remains a fibrous cord attaching the umbilicus to the bladder.
Urachal cyst results from closure of both ends of the tubes with a central open portion that is fluid filled.
Relation of the right renal artery to the IVC
Right renal artery lies posterior to the IVC
Attachment of the ACL
Attached to the anterior intercondylar area of the tbia and passes upwards and backwards, laterally to the medial surface of the lateral femoral condyle
Why is the lateral collateral ligament not attached to the lateral meniscus?
As the popliteus muscle runs between them
Features of trans-sphincteric fistulae
Have a primary tract that passes through both sphincters at varying levels into the ischiorectal fossa where they may lead to ischiorectal abscess formation.
The fistula may be described as high, mid- or low depending on where it crosses the sphincter, i.e. above, at or below the level of the dentate line
Inflammatory tumour 1-1.5cm in diameter of the urethral meatus in women most frequently at the 6 o’clock position.
They are very vascular and covered with transitional epithelium
Frequently asymptomatic but may give rise to spotting and microscopic aematuria.
Urethral caruncle
34 year old woman
Keen jogger
Presents with numbness in first, second and third toes.
Which nerve is most likely to have been affected.
Deep peroneal
Lateral cutaneous nerve
Lateral plantar nerve
Medial plantar nerve
Sural nerve
Medial plantar nerve
Branch of posterior tibial and supplies the medial 3.5 toes on the plantar surfaces and dorsal surfaces proximal to the nail bed.
Excessive stretching of the medial plantar nerve can result in tarsal tunnel syndrome.
What anatomical feature should be considered when interpreting a cerebral angiogram?
MCA is the largest of the cerebral arteries.
PCA is clearly seen on a lateral carotid angiogram
Vertebral arteries meet at the foramen magnum to form the basilar artery.
MCA courses over the lateral aspect of the temporal lobe of the cerebrum
MMA is an extracranial branch of the ICA.
MMA is a branch of maxillary artery, terminal branch of the ECA.
PCA arises from the termination of the basilar artery which itself arises from the two vertebral arteries that meet on the undersurface of the brainstem. Can only be visualised by vertebral angiography.
MCA is the largest artery among the cerebral arteries.
What are the three major branches of the posterior division of the mandibular division of the trigeminal?
Lingual
Auriculo-temporal
Inferior alveolar
An 82 year old man develops hilar lymphadenoapthy 2o to haematological malignancy that affects predominantly the superior aspect of the right main bronchus.
Which structure is most likely to be compressed?
Azygos
Hemiazygos
Right phrenic
Right RLN
Right vagus
Azygos vein which arches over the superior aspect of the right main bronchus to join the SVC
Hemiparesis following stroke. Which brain region affected.
Cerebellar vermis
Occipital lobe
Precentral gyrus
Postcentral gyrus
Sylvian fissure
Precentral gyrus is the location of the primary motor cortex.
Postcentral gyrus
Aka primary somatosensory cortex.
Itching sensation from the skin immediately over the base of the spine of the scapula is mediated through the
Accessory nerve
Dorsal primary ramus of T2
Dorsal root of T2
Ventral primary ramus of T2
Ventral root of T2
Dorsal primary ramus of T2
Dorsal rami provide sensory innervation to the skin over the back and motor innervation to the true back muscles.
Ventral rami supply sensory innervation to the skin of the limbs and the ventral side of the trunk.
Ventral rami also give motor innervation to the skeletal muscles of the neck, trunk and extermities.
Kohler’s disease
Osteochondritis of the navicular bone
Occurs in children 3-5 yeas old
Thought to be due to a disturbance of blood supply causing AVN and delayed ossification.
Pathophysiology of oesophageal varices
LGV receives blood from the superficial oesophageal veins which drain the lower third of the oesophagus.
LGV drains into the portal system.
Oesophageal veins, which drain the upper 2/3 of the oesophagus drain to the azygous sysem.
The superficial oesophageal veins become variceal in portal HTN
What branch of the median nerve must be avoided during division of the flexor retinaculum?
Recurrent motor branch which is given off as it exits the carpal tunnel
78 year old man is due to undergo left CEA
Anaesthetist has decided on a cervical plexus block
Which of the following nerves lies superficial to SCM and may be affected by this block?
Greater occipital nerve
Hypoglossal nerve
Phrenic nerve
Suprascapular nerve
Transverse cervical nerve
Cervical plexus is in the posterior triangle and is formed by union of the anterior rami of the first four cranial nerves
Local anaesthetic can be injected along the posterior border of SCM (between the superior and inferior thirds).
The transverse cervical nerve emerges as a single trunk behind the posterior borer of SCM and is superficial to the muscle
29 year old male presents to clinic concerning a lump on posterior 1/3 of tongue.
Which of the following is this most likely to represent?
Filiform papillae
Fungiform papillae
Lymphoid tissue
Palatine tonsil
Vallate papillae?
Three types of papillae are present on the upper surface of the anterior two-thirds of the tongue.
Namely filiform, fungiform and vallate papillae.
The mucous membrane covering the posterior one third of the tongue is devoid of papillae but has a nodular irregular surface caused by the presence of the underlying lymphatic tissue, the lingual tonsil.
Embryology of the female reproductive system
Fallopian tubes, uterus, cervix, upper part of vagina and vaginal wall develop from Mullerian duct aka paramesonephric ducts.
The paramesonephric ducts regress in men due to secretion of anti-Mullerian hormone
What system can be used to describe flexor tendon injuries?
Flexor tendon injury zones as described by Verden
Tubular structure lying anterior to scalenus anterior which receives a branch from the retromandibular vein before piercing the deep cervical fascia and joining the subclavian vein
EJV
Which of the following statements is correct about the portal vein?
Formed by the confluence of the splenic and IMV
Portal vein accounts for 75% of O2 supply to liver
Divides into three main branches
Segments IV and V are supplied by the left portal vein
Portal vein is located posteriorly to the neck of the pancreas at L1
Portal vein is located posteriorly to the neck of the pancreas at L1. It is formed from the confluence of the SMV and splenic vein posterior to the pancreatic neck.
The portal vein provides 75% of the blood supply to the liver but only 50% of its oxygen
Stage 1 RCC
<7cm and confined to kidney
Stage 2 RCC
>7cm but still confined to the kidney
Stage III RCC
Tumours extending into the renal vein or VC, or which have spread to one local LN
Stage IV RCC
Tumours extending beyond Gerota’s fascia or to more than one local node, involving the ispilateral adrenal gland and/or perinephric fat or with distant metastases
What structure divides the posterior triangle of the neck into an upper and lower triangle?
Anterior belly of digastric
Inferior belly of omohyoid
Posterio belly of digastric
Scalene anterior
Superior belly of omohyoid
Inferior belly of omohyoid.
Elderly man with pre-existing cervical spondylsosis falls and sustains hyperextension injury to his neck. O/E he has a motor deficit worse in UL than LL
Which SC injury explains this presentation?
Complete injury
ACS
Brown-Sequard
Central cord syndrome
PCS
Central cord syndrome
Thought to be due to vascular compromsie of the cord in the distribution of the anterior spinal artery.
Characterised by disproportionately greater loss of motor power in upper extremities than in the lower extremities with varying degrees of sensory loss.
The arms and hands are most severely affected since the motor fibres to the cervical segments are topograhpically arranged towards the centre of the cord
Anterior cord syndrome
Paraplegia and dissociated sensory loss with loss of pain and temperature sensation.
Dorsal column sensations are all preserved
Posterior cord syndrome
Rare incomplete lesion with primary damage to the posterior cord featuring preservation of motor function, pain and temperature sensation with loss of proprioception and fine touch sensation below the level of the lesion
