Block 10 Flashcards

Question

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

Answer 1

The phrenic nerve is the most anteriorly located structure in the lung root. The vagus nerve lies most posteriorly.

Answer 2

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.

Answer 3

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.

Answer 4

Signature fractures are synonymous with depressed skull fractures, they are usually low velocity injuries where the fracture impression resembles the injurious source.

Answer 5

TUR syndrome occurs when irrigation fluid enters the systemic circulation. The triad of features are: 1. Hyponatraemia: dilutional 2. Fluid overload 3. Glycine toxicity Management involves fluid restriction and the treatment of the complications associated with the hyponatraemia.

Answer 6

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

Answer 7

Glands \>45g Operating time \> 90 minutes Acute urinary retention as presenting feature

Answer 8

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.

Answer 9

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.

Answer 10

Sustained intra abdominal pressure \>20mmHg coupled with new organ dysfunction / failure

Answer 11

Diagnosis is typically made by transvesical pressure measurements coupled with an index of clinical suspicion.

Answer 12

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.

Answer 13

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.

Answer 14

Pressures lower than 7mm Hg are not usually compatible with satisfactory views. Pressures \>15mm Hg are usually associated with decreased venous return and hypotension.

Answer 15

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.

Answer 16

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.

Answer 17

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.

Answer 18

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.

Answer 19

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

Answer 20

Serratus anterior

Answer 21

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.

Answer 22

The deep posterior compartment lies anterior to soleus. The sural nerve is superficially sited and therefore not contained within it.

Answer 23

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.

Answer 24

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.

Answer 25

0. 9% Saline solution 0. 45% saline/ 5% glucose solutions carry a risk of hyponatraemia and is contra indicated- see below.

Answer 26

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.

Answer 27

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.

Answer 28

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.

Answer 29

Ulnar nerve The radial nerve is located near the lateral epicondyle.

Answer 30

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.

Answer 31

The arch of the azygos vein lies in the middle mediastinum.

Answer 32

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.

Answer 33

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.

Answer 34

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)

Answer 35

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.

Answer 36

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.

Answer 37

The rima glottidis is the narrowest part of the laryngeal cavity.

Answer 38

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

Answer 39

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.

Answer 40

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.

Answer 41

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.

Answer 42

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.

Answer 43

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

Answer 44

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.

Answer 45

At this position the oesophagus is still likely to be intrathoracic and located in the posterior mediastinum.

Answer 46

The trabeculae carnae are located in the right ventricle.

Answer 47

Musculi pectinati Crista terminalis Opening of the coronary sinus Fossa ovalis

Answer 48

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

Answer 49

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.

Answer 50

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.

Answer 51

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.

Answer 52

Tuberculosis Causes: Systemic (DM, Hyperbilirubinaemia, aplastic anaemia) Mechanical (diarrhoea, constipation, anal fissure) Infections (STDs) Dermatological Drugs (quinidine, colchicine) Topical agents

Answer 53

The retromandibular vein is formed from the union of the maxillary and superficial temporal veins.

Answer 54

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

Answer 55

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.

Answer 56

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.

Answer 57

Treatment with daily low dose flucloxacillin may speed ulcer healing

Answer 58

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.

Answer 59

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!).

Answer 60

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.

Answer 61

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.

Answer 62

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

Answer 63

Age under 60 years Clinical deficit in middle cerebral artery territory Decreased consciousness \>50% territory infarct

Answer 64

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.

Answer 65

CCK causes gallbladder contraction.

Answer 66

They lie in the carotid sinus and aortic arch.

Answer 67

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

Answer 68

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.

Answer 69

Point tenderness of chest wall more likely to be Teitze's syndrome

Answer 70

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.

Answer 71

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.

Answer 72

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.

Answer 73

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

Answer 74

Halothane Suxamethonium Antipsychotics (neuroleptic malignant syndrome)

Answer 75

Dantrolene- prevents Ca release from SR

Answer 76

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.

Answer 77

Ilioinguinal (anterior) nerve and the pudendal (posterior) nerve

Answer 78

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.

Answer 79

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.

Answer 80

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.

Answer 81

The vagus nerve is the most posteriorly located structure at the lung root. The phrenic nerve lies most anteriorly.

Answer 82

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.

Answer 83

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.

Answer 84

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.

Answer 85

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.

Answer 86

Macrophages

Answer 87

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

Answer 88

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.

Answer 89

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.

Answer 90

The middle finger has no attachment of the palmar interosseous.

Answer 91

APC mutations are found in familial adenomatous polyposis coli. These have multiple colonic adenomas.

Answer 92

Rapid sodium influx

Answer 93

\<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.

Answer 94

Asmyptomatic, incomplete blood vessel obstruction

Answer 95

Claudication when walking a distance \>200m

Answer 96

Claudication when walking \<200m

Answer 97

Necrosis +/- gangrene

Answer 98

Asymptomatic

Answer 99

Claudication

Answer 100

Minor tissue loss

Answer 101

Major tissue loss

Answer 102

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.

Answer 103

The radial nerve lies anterolateral to the humerus in the supracondylar area.

Answer 104

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.

Answer 105

Risk of metastasis to the contralateral breast is a classical feature of invasive lobular carcinoma.

Answer 106

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.

Answer 107

The muscles of the thenar eminence are supplied by the median nerve and atrophy of these is a feature of carpal tunnel syndrome.

Answer 108

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.

Answer 109

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.

Answer 110

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

Answer 111

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.

Answer 112

Peroneus brevis passes posterior to the lateral malleolus.

Answer 113

Sural nerve Short saphenous vein

Answer 114

Peroneus longus tendon Peroneus brevis tendon

Answer 115

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.

Answer 116

It should not contain red blood cells.

Answer 117

It inhibits pancreatic enzyme secretion.

Answer 118

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.

Answer 119

Howell-Jolly bodies Pappenheimer bodies Poikilocytes (Target cells) Erythrocyte containing siderotic granules Heinz bodies

Answer 120

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.

Answer 121

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.

Answer 122

The external jugular vein lies lateral (i.e. superficial) to the sternocleidomastoid.

Answer 123

The Bolam test defines if a decision made by a doctor is in agreement with the professional standard of medical practise.

Answer 124

The right triangular ligament is a continuation of the coronary ligament.

Answer 125

https://www.youtube.com/watch?v=T\_GlJu0dxkA

Answer 126

Neisseria gonorrhoea

Answer 127

Staph aureus

Answer 128

Cowden's disease

Answer 129

6-14% increased risk. RR 11

Answer 130

Leukoerythroblastic picture in peripheral blood. Prostatic adenocarcinoma or lung cancer are likely primaries

Answer 131

Leukoerythroblastic picture

Answer 132

Myeloma Malignancy Myelofibrosis Gaucher's

Answer 133

Hypokalaemic hypochloraemic metabolic alkalosis

Answer 134

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

Answer 135

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.

Answer 136

1a Systematic reviews (with homogeneity of RCTs) 1b: individual RCTs with narrow confidence interval 1c All or none RCTs

Answer 137

2a: systematic reviews with homogeneity of cohort studies 2b: indivdual RCTs (with narrow confidence interval) 2c: outcome research, ecological studies

Answer 138

3a: systematic review of case-control studies 3b individual case-control study

Answer 139

When at least 2/3 visceral arteries are involved

Answer 140

T0- subclinical T1- 2cm or less T2 \>2cm \<5cm T3 \>5cm T4 any size with chest wall or skin extension

Answer 141

N0 -no nodal involvement N1- ipsilateral axillary nodes (mobile) N2- ipsilateral axillary nodes (fixed) N3- internal mammary nodes

Answer 142

M0- no distant mets M1- distant mets

Answer 143

Gluteus maximus

Answer 144

Gluteus medius and minimus

Answer 145

Papillary (85% of radiation induced tumours are papillary)

Answer 146

Ilium, ischium and pubis

Answer 147

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

Answer 148

Malignant neoplastic infiltration

Answer 149

Prostaglandins

Answer 150

Hypertrophic Payer's patch is the lead point in up to 90% of cases

Answer 151

Feeling of emptiness on palpation with viscera abscent in RLQ on AXR. Seen in 15% of cases of intussuception

Answer 152

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

Answer 153

Styloglossus

Answer 154

Genioglossus

Answer 155

Hyoglossus

Answer 156

Internal laryngeal nerve (branch of X)

Answer 157

Short head originates from coracoid process of scapula Long head originates from the supraglenoid tubercle

Answer 158

Pec major L dorsi Teres major

Answer 159

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

Answer 160

Endothoracic fascia

Answer 161

Connective tissue between the inner aspect of the chest wall and the costal parietal pleura.

Answer 162

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

Answer 163

Contains carotid artery IJV Vagus nerve

Answer 164

History and examination Radiology: USS or mammography Tissue diagnosis: cytology or biopsy

Answer 165

20-25% | (75% sporadic)

Answer 166

Calcitonin PGs 5-HT ACTH

Answer 167

Neuro-ectodermal in origin Located in upper 2/3rds of the thyroid and is usually multicentric and bilateral in familial form

Answer 168

Narrowed pulse pressure. Decrease in circulating blood-\> increased SVR. This increase in SVR will increase the resting vasomotor tone leading to an increase in DBP

Answer 169

UO 1ml/kg/h in children 0.5ml/kg/h in adults

Answer 170

Mucocele of the GB

Answer 171

Certain OCP Propylthiouracil Co-proxamol Isoprenaline Phenylbutazone

Answer 172

Gallstones

Answer 173

Cardiomegaly

Answer 174

Interstitial lung disease

Answer 175

Barlow's test- flexion and adduction

Answer 176

Single cuff pneumatic. Single cuff more frequently used in orthopaedic surgery Double cuffed used for Bier's blocks

Answer 177

Non-pneumatic Pneumatic

Answer 178

Horizontal- extends from nasal septum , laterally through the maxilla and thence backwards to the pterygoid region

Answer 179

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

Answer 180

RLN Consequently, during thryoidectomy it is preferable to ligate the artery lateral to the gland to avoid neural damage

Answer 181

Cyclical mastalgia Occurs for up to 3/4 of the menstrual cycle. Pain is usally present for the 2w leading up to the menstriual period and then settles. Usually bilateral, self resolves but can be recurring. EPO

Answer 182

Trigger point Musculoskeletal pain arising from a trigger point in pec major, inferior to the breast Pain is felt as hyperirritable and hypersensitive spot on the muscle, referring pain to the breast and can cause nipple hypersensitivity

Answer 183

Left subclavian

Answer 184

E coli Klebsiella Pseudomonas

Answer 185

Mucous membranes and parts of the body adjacent to structures that would be adversely affect by stringent antiseptics

Answer 186

Evaporation

Answer 187

Helium dilution technique.

Answer 188

Fall in SBP \>10mmHg on inspiration. Occurs in 1/10 cases of cardiac tamponade

Answer 189

Lateral sinus thrombosis causes paipillodemea, raised ICP and tenderness over the mastoid (Griesinger sign) If the thrombosis extends into the jugular bulb and IJV this can result in neck pain on rotation Compression of IX, X, XI can occur which would alter taste due to compression of the glossopharyngeal nerve and tachycardia due to compression of X

Answer 190

Used to measure physical status for patients who are receiving palliative care

Answer 191

Used to assess functional status of a patient at MDT. Rated 0-5 with 0 fully active.

Answer 192

ACL MCL Medial meniscus

Answer 193

IgA IgM and IgG uses the classical pathway.

Answer 194

Left throacotomy

Answer 195

Obstructive

Answer 196

4ml per kg per % burn 7560

Answer 197

Male Race Smoking Hypertension Age/Alcohol/AF Hyperlipideaemia Exercise and Eating Diabetes/drugs. Hypothyroidism and metabolic syndrome

Answer 198

Increased fibrinogen is an independent risk factor for CVD. It is also an acute phase reactant so elevated levels may be indicative of inflammation

Answer 199

Coccyx Lower sacrum Ischial spines Ischiorectal fossae Anorectal ring Cervix Uterosacral ligaments Sometimes, ovaries

Answer 200

Coccyx Lower sacrum Ischial spines Ischiorectal fossae Anorectal ring Prostate Normal seminal vesicles are nonpalpable

Answer 201

In late pregnancy, maternal blood volume increases by 50% HCt decreases to 30-35% After haemorrhge, pregannt women may lose 30% of their blood volume before exhibiting signs of shock. Blood is diverted away from gravid uterus and thus fetus is first to suffer. Fluid replacement must thus be aggressive and early. Pregnant women should be resuscitated in left lateral position to prevent IVC compression by gravid uterus

Answer 202

Diseases with reduced lung compliance

Answer 203

Disease with increased airway resitance e.g. emphysema, chronic bronchitis and asthma

Answer 204

Pancreatic dysplasia- loss of pancreatic enzymes Presence of abnormal mucus causes formation of thick meconium

Answer 205

Pain Vomiting Abdominal distension Reduced flatus-\> absolute constipation. Pain usually colicky due to excessive peristalsis but may become continuous if strangulation or perforation occurs

Answer 206

Early in high SBO Late in low SBO Delayed/absent in LBO

Answer 207

Jejunum has thicker wall Less mesenteric fat More plicae circulares Wider lumen Fewer Peyerr's patches Fewer arterial arcades than the ileum

Answer 208

Returns to 80-90% of pre-injury strength Depends on the type of collagen produced. Type III collagen is produced during the early phase of wound healing and is weaker than the later appearing T1 collagen.

Answer 209

Bicarbonate

Answer 210

Enucleation Most jaw cysts are benign Marsupialisation can also be used, but more commonly if infection is present to allow it to drain

Answer 211

Marsupialization is the surgical technique of cutting a slit into an abscess or cyst and suturing the edges of the slit to form a continuous surface from the exterior surface to the interior surface of the cyst or abscess. Sutured in this fashion, the site remains open and can drain freely.

Answer 212

T1a \<1cm T1b 1-2cm T1c 2-3cm

Answer 213

3-5cm across with minimal local invasion

Answer 214

Involves transplantation of a donor organ to a different anatomical site than that of existing organs in a recipient e.g. renal transplant into the iliac fossa

Answer 215

Botulinum toxin A

Answer 216

NdYAG Commonly used in GI sx, urology and ophthalmology

Answer 217

Ophthalmology and dermatology e.g. trabeculoplasty, diabetic retinopathy, port wine stain treatment

Answer 218

Otolaryngology and gynaecology e.g. haemostasis

Answer 219

Nitrogen CHO Fat Minerals (Ca, Mg, Fe, Zn, manganese, Cu, F, I, Cl) Vitamins

Answer 220

Usually treated with long course of Abx (4-6/52) If that fails surgical management may be used: thoracoscopy, US or CT guided drainage, finally with lobectomy.

Answer 221

In patients with severe acute pancreatitis 3-10/7 after the onset of symptoms to exclude necrosis

Answer 222

Infection of the sheath that forms the lubricating surface around the flexor tendons to the hand. It constitutes an emergency as severe infection can destroy these surfaces resulting in a painful and stiff finger. Most cases have a preceding hx of trauma

Answer 223

Diffuse swelling of the digit Partially flexed Tenderness along the flexor tendon sheath Pain on passive extension of the digit

Answer 224

Superomedial to pectoralis minor

Answer 225

Inferolateral to pec minor

Answer 226

Posterior to pec minor

Answer 227

K+ channels [K] is the determinant of RMP.

Answer 228

Tumour of the SNS and usually highly malignant Adrenal medulla, sympathetic neurones and melanocytes

Answer 229

Synthetic sutures are less irritating e.g. Nylon

Answer 230

Steel wire

Answer 231

Double bullbe

Answer 232

30-35mmHg or if the difference between DBP and the measured compartment pressure is \<30mmHg

Answer 233

Into muscularis propria but not penetrating it. No nodes

Answer 234

Penetrating muscularis propria No nodes

Answer 235

Into muscularis propria with nodes

Answer 236

Penetrating muscularis propria with nodes

Answer 237

Subglottic stenosis Pneumothorax Dislodgement of tube Obstruction of tube or trachea Tracheal stenosis Sepsis Cuff prolapse Intubation granuloma of vocal cords

Answer 238

If the first and second tracheal rings are damaged

Answer 239

?Duodenal atresia

Answer 240

30ml of air via NGT and taking radiograph

Answer 241

An incision should be made through the hypertrophied muscle as far as the mucosa, the mucosa should be left intact and will be seen to bulge from the site of the inciision

Answer 242

Vitamin A is necessary to maintain epithelia and squamous metaplasia of the respiratory tract can occur if there is defiency

Answer 243

Papillary tumours are TSH dependent and thyroxine reduces the risk of recurrence by suppressing TSH

Answer 244

Suggests no increased risk of complications or death

Answer 245

Suggests increased risk

Answer 246

Very high risk of post-op complications

Answer 247

At 50% on VO2max

Answer 248

Should be triaged to ITU

Answer 249

Branches of the ophthalmic divsion of the trigeminal nerve (frontal, lacrimal, nasociliary) Oculomotor Trochlea Abducens

Answer 250

Zygomatic branch of the maxillary nerve Ascending branches from the pterygopalatine ganglion Infraorbital vessles

Answer 251

Tongue Usually SCC 35% occur on tongue

Answer 252

Uretur descends towards the pelvis anterior to psoas major but posterior to gonadal artery. Crosses anterior to the bifurcation of the common iliac artery at the level of the pelvic brim before descending posterioinferiorly along the lateral pelvic side wall

Answer 253

Ascending contrast venography

Answer 254

Pain and calf tenderness from inflammation around the thrombus Increased pain on dorsiflexion of the foot

Answer 255

Serial troponin levels and ECG

Answer 256

Passes inferoposterior to the splenic vein

Answer 257

Aspergillus Mucor Enterobacter cloaca

Answer 258

Short gastric vessels need to be divided. Splenic artery is usually ligated along the upper border of the tail of the pancreas The artery is ligated before the vein to minimise splenic engorgement

Answer 259

Eisenhammer retractor Anal retractor commonly used to assist examination of the anorectum under anaesthesia

Answer 260

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

Answer 261

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

Answer 262

Debakey forceps

Answer 263

Thoracodorsal artery

Answer 264

Merkel's receptor

Answer 265

Rapidly-adaptive receptors to light touch and vibration

Answer 266

Receive sharp acute and chronic slow pain sensation

Answer 267

Rapidly adapting and especially detect vibration

Answer 268

Detect stretching of the skin

Answer 269

Tibialis posterior

Answer 270

Hip extension and lateral rotation

Answer 271

Increases CBF

Answer 272

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

Answer 273

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.

Answer 274

Deltoid ligament is attached above the ankle to the medial malloelus. Eversion injury can lead to deltoid rupture.

Answer 275

Ventromedial nucleus

Answer 276

Suprachiasmatic nucleus

Answer 277

It is outside the BBB and its main receptors are dopaminergic D2 Rs

Answer 278

Transection of the brainstem at the caudal end of the medulla. Rhythmic discharge of neurones in the medulla and pons produce automatic respiration and thus transection of the brainstem below the medulla stops respiration

Answer 279

It is invested in the axillary sheath along with the axillary vein and cords of the brachial plexus. The sheath is a continuation of the prevertebral fascia of the neck. The axillary artery gives of the superior thoracic artery from its first part. It is divided into 3 parts relative to pec minor The axillary artery runs anterior to the upper digitations of serratus anterior.

Answer 280

Bowie Dick test

Answer 281

Right renal artery lies posterior to the IVC

Answer 282

Occurs when the intrinsic muscles develop contractures and the long extensor to the toes (extensor digitorum), recruited to assist in akle dorsiflexion, cause claw toe deformity

Answer 283

Good inflow, outflow and nature of the graft. Above knee anastomoses have better patency rates than below knee.

Answer 284

Attached to the anterior intercondylar area of the tbia and passes upwards and backwards, laterally to the medial surface of the lateral femoral condyle

Answer 285

As the popliteus muscle runs between them

Answer 286

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

Answer 287

Protraction and rotation of scapula

Answer 288

Acidic pH and pre-existing pepsin

Answer 289

Renal papillary necrosis

Answer 290

Urethral caruncle

Answer 291

Run from the skin to the deep fascia behind the breast

Answer 292

Overlies pec major by 2/3rds and serratus anterior by 1/3

Answer 293

Indinavir is an anti-retroviral used in HIV that can classically cause radio-lucent stones

Answer 294

Perianal abscess 42%

Answer 295

Anterior division of CN has one senosry branch- buccal nerve to the skin of the cheek and mucosa of the vestibule. All of the other branches are motor. The lower jaw teeth are supplied by the inferior alveolar banch of the posterior divission of CN V.

Answer 296

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.

Answer 297

Terminal ileum is important in the absorption of bile salts, lipids, vit B12. Magnesium malabsorption can occur due to chelation with unabsorbed fatty acids-\> hypomagnesaemia. Magensium has an important role in regulating the secretion of PTH, subsequently in hypomagneseamia, PTH levels will fall

Answer 298

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.

Answer 299

Describes the intrinsic response of the heart ot changes in right atrial and aortic pressure. With an increase in ventricular filling, there is an increase in force of contraction and stroke volume. B is correct.,

Answer 300

Peptic ucleration Gastric acid hypersecretion Islet cell tumour of the pancreas

Answer 301

Intractable Cancer Haemorrhage Obstruction Perforation

Answer 302

Prolene Because of its inert and non-absorbable properties.

Answer 303

Surgery is only curative option

Answer 304

Any condition in which one lung has to be isolated and protected e.g. when other lung is severely contaminated. Another absolute indication is when the distribution of ventilation needs to be controlled e.g. damage to a main bronchus or unilateral bullae that may blow. The only surgical procedure that absolutely needs one-lung ventilation is video-assisted thorascopic surgery

Answer 305

Lingual Auriculo-temporal Inferior alveolar

Answer 306

Stratified squamous epithelium

Answer 307

Confusion Seizures Coma Peripheral neuropathy and ascending motor paralysis, similar to GBS may occur. Weakness of skeletal or smooth muscle is the most common clinical manifestation.

Answer 308

Sural- sensory Lateral sural- sensory Superficial fibular- mixed Deep fibular- mixed

Answer 309

2o leukaemia

Answer 310

Total volume of air in the lungs at the end of passive respiration Sum of RV and ERV and is approximately 2.5L in average adult

Answer 311

Azygos vein which arches over the superior aspect of the right main bronchus to join the SVC

Answer 312

Staph aureus Strep pyogenes

Answer 313

Gram negative species e.g. E. Coli and anaerobes (Bacteroides)

Answer 314

Excessive production of aldosterone HTN Renal damage HyperNa HypoK Alkalosis Muscle weakness Body is K depleted but urinary K content is high

Answer 315

AKA mandibular arch Involved in development of the face Develops maxillary and mandibular which form the upper and lower jaws respectively. Bones and muscles of this region are developed form mesoderm in the arch. Meckel's cartilage is the first arch cartialge, it ossifies to from the malleus and incus. Sphenomandibular ligament is derived from its perichondrium Muscles derived include temporalis, masseter, medial and lateral pterygoids, anterior belly of digastric, mylohyoid, tensor tympani and tensor palati. Trigeminal nerve is the motor supply

Answer 316

Is to the subclavian vein

Answer 317

Precentral gyrus is the location of the primary motor cortex.

Answer 318

Aka primary somatosensory cortex.

Answer 319

Suggest VWD due to abnormlaity in plts and factor 8

Answer 320

Non-bacterial thrombotic endocarditis describes range of lesions found on previous normal heart valves in the absence of infection. Associated with hypercoagulable states or advanced malignancy and most commonly affects the mitral and aortic vavles. Sterile vegetations that contain fibrin and plt.

Answer 321

Anencephaly

Answer 322

Internal diameter of the tube

Answer 323

One to one nursing RRT Fluid and electrolyte abnormalities Airway support +/- ventilation Respiratory failure requiring ventilation CV monitoring

Answer 324

i.e. ITU. In the presence of two or more reversible organ failures or the requirement for advanced respiratory support

Answer 325

i.e. HDU. In reversible single organ failure except for advanced respiratory support which requires ITU

Answer 326

COPD OSA Cardiogenic pulmonary oedema Acute exacerbation of COPD with respiratory acidosis Acute on chronic hypercarbic respiratory failure

Answer 327

Bilevel PAP system that uses two different pressures, an inspiratory positive airway pressure and a lower positive expiratory pressure.

Answer 328

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.

Answer 329

80% Rectal bleeding is the most common initial symptom (45% of cases)

Answer 330

Carcinoma is radiosensitive. Combination RTx and CTx is used as first line treatment APER is reserved for recurrent or resistant tumours

Answer 331

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.

Answer 332

Standing room only V3

Answer 333

SCC oesophagus

Answer 334

Aspirin cannot be reversed by PCC as it binds irreversibly to plts. If emergency surgery is required a plt transfusion may be warranted

Answer 335

Head is turned using the contralateral SCM, stimulated by impulses from the spinal accessory nerve. The cranial accessory nerve fibres join the vagus nerve after exiting the brain stem Movement takes place at the atlantoaxial joint about the odontoid proces of the axis and is limited by the vertical aligment of the two attachments of the contralateral SCM

Answer 336

NSCLC of which adenocarcinoma is the most common 30% of lung primarys are adenocarcinoma

Answer 337

Blood disorders: polycythameia Arterial: atherosclerosis, Buerger's Drugs: beta blockers, OCP CTD e.g. RA, SLE, CREST Trauma e.g. vibration injury

Answer 338

SAAG \<1.1 Exudative ascites associated with malignancy, pancreatitis, hereditary angioedema

Answer 339

SAAG \>1.1

Answer 340

Malignancy Cirrhosis Infection Hepatic vein obstruction Chronic pancreatitis CCF Hypoproteinaemia

Answer 341

Due to obstruction of the thoracic duct

Answer 342

Malignancy Ruptured ectopic Abdominal trauma Acute pancreatitis

Answer 343

Time taken for visible bleeding from a puncture wound to stop It is a test of plt function

Answer 344

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

Answer 345

T1 \<2cm T2 \>2 \<5cm T3 \>5cm T4 spread to chest wall and or overlying skin

Answer 346

Recurrent motor branch which is given off as it exits the carpal tunnel

Answer 347

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

Answer 348

Cystoplasmic proteins

Answer 349

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.

Answer 350

Malignant metastases within the ovaries. Primary site is normally GI, commonly associated with stomach carcinomas spreading to ovaries

Answer 351

For low rectal tumours where tumours are within 8cm of anal canal and following failure of radical RTx

Answer 352

Rare HCC variant affecting children and young adults

Answer 353

In men, mesonephric ducts give rise to the tubular system of the genito-urianry system i.e. epididymis, vas, uretur, renal pelvis, calyces, collecting tubules, seminal vesicle and ejaculatory duct. In women they only contribute to the tubular system of the urainry system.

Answer 354

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

Answer 355

Flexor tendon injury zones as described by Verden

Answer 356

Drains most of the scalp and side of the face Formed by the union of retromandibular and postauricular veins, receiving branches from the posterior external and transverse cervical veins

Answer 357

2 valves. Lower pair are at its entrace to the subclavian vein. Upper about 4cm above the clavicle.

Answer 358

Anterior to scalenus anterior and pierces the deep fascia of the neck, posterior to the clavicular head of the SCM muscle before draining into the subclavian vein.

Answer 359

Hypovolaemia Hypoxia Hypothermia Hyper/hypokalaemia Tension pneumothorax Cardiac tamponade Thromboembolism Toxicity

Answer 360

BLS adrenaline 1mg per 3 minutes

Answer 361

Nil action required. A dose of absorbed vaccine should be given if the risk of infection is especially high e.g. contamination with stable manure

Answer 362

Reinforcing dose of absorbed vacccine

Answer 363

No action required

Answer 364

Reinforcing dose of absorbed vaccine + dose of human tetanus Ig

Answer 365

Full 3 dose course

Answer 366

3 dose course Dose of human teatnus IG

Answer 367

CSF produced by choroid plexus Capillary loops covered by specialised ependymal cells in the ventricular system

Answer 368

20ml in the ventricles 45ml in cranial SA space and the rest in spinal SA space and central canal

Answer 369

Relies on synovial fluid for nutrients Avascular Rich in Type 2 collagen and forms a meshwork containing proteoglycan molecules that retain water. Intermittent pressure from joint loading is essential to maintain normal cartilage function. Chondrocytes secrete proteoglycans and collagen and are embedded in the cartilage, they migrate to the joint surface along with the matrix that they produce

Answer 370

5x greater than that of the general population

Answer 371

Round body needle

Answer 372

Rupture of EPL

Answer 373

1/3rd returns from the bronchial circulation via the azygos, hemiazyogs and intercostal veins. 2/3 drains into anastomoses or communicating vessels that empty into the pulmonary veins. This is known as the bronchopulmonary circulation

Answer 374

Subphrenic abscess. Classic complication following repair of a perforated DU is a subphrenic collection. This should be suspected in a patient with pyrexia, RUQ signs or right basal collapse

Answer 375

Staph Most common cause of septic arthritis. Can cause a pneumonia and is seen as a cavitating lesion.

Answer 376

Pain As it leads to a decreased respiratory effort. Standing increases VC Males on average have 20-25% greater vital capacity Vital capacity decreases with age

Answer 377

Posterior to the medial arcuate ligament over psoas major

Answer 378

4-6cm above the calcaneal insertion in the watershed hypovascular area

Answer 379

Casting in equinus- increased risk of re-rupture Surgical repair- increased risk of wound infection

Answer 380

3 monthly surveillance

Answer 381

\>5.5cm or \>4.5 cm with an increase in size of \>0.5cm in 6/12

Answer 382

In the absence of pregnancy and without hCG the corpus luteum demises and inhibin and progesterone levels fall. Progesterone withdrawal leads to menstrual shedding

Answer 383

Rib has an angle at its posterior end. The area just anterior to the angle is the weakest and therefore the most likely to fracture in trauma

Answer 384

Within 72h ideally

Answer 385

Vitamin deficiency Infection (local and general) Technique Arterial supply Malnutrition Icterus Necrotic tissue Sugar (DM) Anaemia/age Blood clot (haematoma) Cancer (local or distant) Drugs (cytotoxic agents and steroids) Edge tensions (especially in obesity)

Answer 386

Phrenic nerve palsy Atelectasis Diaphragmatic hernia Distended abdominal viscera

Answer 387

Elderly Beta blocked and Ca antagonists Hypothermia Patients with pacemaker

Answer 388

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

Answer 389

Pseudoachalasia caused by Trypanosoma cruzi Infection affects the reticulo endothelial system, muscles and nervous system. Is associated with cardiomyopathy, megacolon, megauretur, megaduodenum. Treatment is by cardiomyotomy, preferrablly laparoscopic. In unfit patients the alternative treatment is endoscopic pneumatic dilatation or botulinum toxin injections

Answer 390

Primarily metabolised in the liver into active metabolites and the major metabolite is desmethyldiazepam

Answer 391

Potentiates GABAergic inhibitory neurotransmission

Answer 392

Develops up to a week after transplantation Due to cell-mediated immune injury. Both delayed hypersensitivity and cytotoxicity are likely to be involved, it is usually irreversible

Answer 393

Banff system

Answer 394

Chronic rejection

Answer 395

Severe acute rejection

Answer 396

Ulceration associated with malignancy provides the pathway for Strep bovis to enter circulation and lead to endocarditis

Answer 397

Gerota's fascia is a layer of connective tissue that encapsulates the kidney and adrenal gland.

Answer 398

UOQ is where 45% of breast lesions are seen

Answer 399

Loss of sensation to the 1st web space which is supplied by the deep peroneal nerve suggests a higher level of injury

Answer 400

For primary varicose vein disease 2o to SF valve incompetence. Spinal anaesthesia. Patient supine with 30 degree head down. LSV identified at SFJ as well as its tributaries and is flush ligated to the femoral vein. Following this, the upper 10cm length of the LSV is excised. Associated with high recurrence rate. It should no be performed in the presence of DVT in which the LSV provides collaterals as it can precipitate venous claudication

Answer 401

Very painful ulcer of lower leg that develops in association with poorly controlled HTN

Answer 402

\<7cm and confined to kidney

Answer 403

\>7cm but still confined to the kidney

Answer 404

Tumours extending into the renal vein or VC, or which have spread to one local LN

Answer 405

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

Answer 406

Inferior belly of omohyoid.

Answer 407

Occipital Sublcavian

Answer 408

Haemophilus and strep pnneumonia occur with this condition

Answer 409

Fracture at one point usually indicates a corresponding fracture elsewhere

Answer 410

Coronary blood flow is decreased by ADH, pain and distension of the gut and bladder. It is increased by an increase in pCO2 and decreased by alkalosis

Answer 411

90% are adenocarcinomas. SCC are the second most common and account for \<10% of cases

Answer 412

Increased catecholamine levels- SNS stimulation from arterial receptors Direct effects of hyponatraemia on JGA Reduction of RBF via afferent arteriolar baroreceptors

Answer 413

Percutaneous drainage has a high infection risk and is rarely successful due to high recurrent rate. Laparoscopic drainage of the collection is the treatment of choice

Answer 414

In a stable patient, urgent OGD can be used. However a CTA and selective angiogram would be indicated in this patient. Diverticulitis is usually painful If bleeding is brisk fresh red blood PR may come from UGI tract. Angiographic techniques can pick up bleeding at the rate of 0.5ml/min in experienced hands

Answer 415

In the mid-thorax, the aorta, thoracic duct and azygos vein are all posterior to the oesophagus. In that oder from left to right. The oesophagus is most likely injured in this situation The SVC and trachea are not located in the mid-throax

Answer 416

Sensory nerve fibres are more susceptible to ischaemia than motor fibres

Answer 417

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

Answer 418

Paraplegia and dissociated sensory loss with loss of pain and temperature sensation. Dorsal column sensations are all preserved

Answer 419

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

Answer 420

Testis usually descended by birth Covered with thick tunica albuiginea Lymphatic drainaige follows the arterial supply to para-aotic nodes. Spermatic cord contains the pampiniform plexus- single testicular vein is formed more distally over psoas major. Nerve supply is via lesser splanchnic nerves and coeliac ganglion with postganlionic fibres accompanying the testicular arteries

Answer 421

Primary Secondary Tertiary Quaternary

Answer 422

Result from direct effects of pressure wave and cause injuries to most gas containing organs. Tympanic membrane is most vulnerable and may rupture if pressure exceeds 2atm. Lung tissues may develop contusion, oedema and rupture-\> pneumothorax. Rupture of the pulmonary veins produces potential for air embolism and sudden death. Intraocular haemorrahge and retinal detachments are common ocular manifestations of primary blast injury. Intestinal rupture may also occur

Answer 423

Result from flying debris and bomb fragments, these are penetrating injuries and can affect any part of the body

Answer 424

Result from individuals being thrown into things by blast and can affect any body part and commonly are fractures, traumatic amputations or head injuries

Answer 425

Any blast injuries not due to the other three phases e.g. bruns, crush injuries and worsening of pre-existing conditions

Answer 426

Azygos vein arches posteriroly of the right main bronchus to join the SVC adjacent to the root of the righ lung. Care must also be taken to spare the vagus nerve which lies posterior to the right main bronchus

Answer 427

Pretibial myxoedema and clubbing are rare Exopthalmos is common

Answer 428

Progesterone inhibits lactation during pregnancy. The fall in serum progesterone with passage of the placenta seems to be the important event in establishment of lactogenesis. Once lactogenesis is initiated, prolactin is the key hormone in milk synthesis. Oestrogen and progesterone have no effect on lactation once it is initaited

Answer 429

Factor IX is one of the serine proteases of the coagulation system. Deficiency causes haemophilia B It is activated by factor Xa or Factor VIIa It acts by hydrolysing one arginine-isoleucine bond in factor X to form factor Xa It requires Ca, membrane phospholipids and factor VIII as co-factors to do so.

Answer 430

Very aggressive with most patients dying before developing a phaeo or hyperparathyroidism

Answer 431

AD disorder characterised by severe HTN and hypokalaemia Due to unrestrained Na reabsorption in the distal nephron due to mutations in eNaC transporter. Inappropriate reabsorption of Na results in HTN and renal K wasting

Answer 432

Retain moisture or provide rehydration and are thus useful in dry, necrotic wounds

Answer 433

Highly absorbent, have haemostatic properties and are useful in packing cavities.