Block 11 Flashcards
Post-ganglionic symapthetic fibres innervating the dilator pupillae muscle begin in the?
Superior cervical ganglion
Which vein is encountered on the anterior deltopectoral appraoch to the shoulder
Deltopectoral approach involves an incision following the line of the deltopectoral groove. The fascia is encountered first and the cephalic vein is surrounded in a layer of fat and is used to idenfiy the interval
Fractures of long bones or skull in children <12
Skull and long bones in young children are still ossifying and therefore more malleable than in adults.
Fractures to these areas in young children should therefore be treated with suspicion and NAI considered
MOA Herceptin
Monoclonal against EGRF-2 receptor found in 25-30% of breast cancers
Cimetidine as a cause of gynaecomastia
Dose-dependent side effect due to its interference with P450 system causing raised oestrogen levels
Tubercles of Montgomery
Sebaceous glands that surround the nipple in the areola
Retromammary bursa
Potential space that lies between the pectoral fascia and the breast
Inferior alveolar nerve block may result in?
Numbness of lower lip on injected side
Ineffective block for the lower incisor teeth
Numbness of hard palate
Inability to clench jaws
Transient ipsilateral facial weakness
Inferior alveolar nerve enters the deep aspect of the mandibule at the mandibular foramen and exits at the metnal foramne as the meental nerve. The mental nerve innervates the skin of the ipsilateral lower lip and chin.
Sensory innervation of the hard palate
Greater palatine nerve, branch of the maxillary division of the trigeminal nerve
Which of the following is true regarding colonic adenomas?
Typically encapsulated
Can arise in transitional epithelial cells
Typically invade the basement membrane
Are typically annular lesions
Do not contain dysplastic cells
Typically encapsulated
May contain dysplastic cells.
Annular lesions that cause stricturing tend to be malignant.
Extent of the breast
The breast extends from the lateral sternal border to the mid axillary line and from the 2nd to 6th rib vertically
The majority of the breast lies on the deep fascia and is bounded posteriorly by the pectoral fascia and fascia of serratus anterior
It is around 15-20 lobules supported and divided by Cooper’s ligaments
Sectretion of testosterone is predominantly by which cells?
Interstitial cells (Leydig cells) in the testes.
Which androgens are secreted in physiologically significant amounts by the adrenal cortex?
DHEA
Androstenedione
What is the most common distribution of diverticular disease?
50% of cases affect the sigmoid
Further 25% of cases affect the sigmoid and descending colon.
Sigmoid colon is involved in over 80% of cases in total
Which of the following is true regarding B cells and plasma cells
B cells and plasma cells have surface bound IgG
B cells and plasma cells have surface MHC II
Plasma cells undergo somatic hypermutation
B cells can undergo isotype switching
Plasma cells can undergo isotype switcing
B cells have surface IgG and MHC II, undergo somatic hypermutation and isotype switching (switching through Ig classes)
Plasma cells are terminally differentiated B cells and hence lack these features
Where does the majority of calcium absorption from the GIT take place?
In the duodenum and jejunum
?Crohn’s with normal colonoscopy
What next test would be appropriate
Barium meal with small bowel follow through
Mortality in EVAR vs open repair of AAA
EVAR1 trial show that 1 year all-cause mortality has no difference though there is significantly lower 30d mortality for EVAR
Classification of lasers
Lasers are classified according to their degree of hazard, the majority of medical lasers are class 4
What are the four testicular appendages?
Represent embryological remnants:
Appendix testis (hydatid of Morgani)
Paraepididymis (organ of Giraldes)
Vasa aberrantia
Appendix epididymis (pedunculated hydatid)
62 year old T2DM HTN suffers a PACI
Months later a CT scan shows large, 5cm cystic area in left parietal lobe cortex
This lesion is as a consequence of the resolution of which of these events
Apoptosis
Atrophy
Caseous necrosis
Coagulative necrosis
Liquefactive necrosis
Brain undergoes liquefactive necrosis with infarction
Changes in Ca homeostasis following crush injury
Hypocalcaemia is seen.
Hypoxic tissues absorb calcium due to reperfusion and hyperphosphataemia (2o to loss from damaged cells). This causes a relative hypocalcaemia
What is the route by which the phrenic nerve enters the chest?
Anterior to subclavian artery and posterior to subclavian vein. Medial to the lower border of scalenus anterior
Double heart border, dysphagia
Expanded oesophagus in achalasia
May also show air or fluid level behind the heart
Which of the following is the commonest activator of fibrinolysis?
Epsilon aminocaproic acid
Factor XII
Protein C
tPA
Tranexamic acid
EACA inhibits fibinolytic syndrome
Protein C inhibts blood clotting
Factor XII activates the fibrinolytic syndrome by promoting formation of kallikrein from prekallikrein
tPA is the commonest activator of fibrionlysis
Tranexamic acid reduces fibrin dissolution by inhibiting plasminogen activation and fibrinolysis
Histological appearance of granulation tissue
Proliferation of new capillaries, with fibroblasts and new collagen formation
At what level of bilirubin is clinically detectable jaundice seen?
Bilirubin >30
What muscles are attached to the tibial tuberosity
Ligamentum patellae which is the single strong tendon of quadriceps femoris.
Gaussian distribution=
Normal distribution
Unimodal
Mean = mode
What is the most effective way to calculate the central value in non-parametric data?
Median
Pre-malignant condition with irreuglar smooth to thickened whitish plaques on the tongue.
Cannot be scraped off easily
Leucoplakia
Pre-malignant condition characterised by smooth, velvety appearance of the tongue with a homogenous surface and without ulceration
Erythroplakia
Rare risk factor for oral cancer
Syphillis
Passage of the lumbosacral trunk
Passes anterior to the ala of the sacrum, under cover of the common iliac vessles and joins the S1 ventral rami deep to piriformis
Relation of lumbosacral trunk to common iliac vessels
Passes under the common iliac vessels
SCC tongue
Most common malignant oral cavity cancer
Cervical LNs common at presentation. Usually involves anterior triangle nodes first before spreading to posterior triangle nodes.
Risk factors for SCC oral cavity
Smoking
Betel nut chewing
EtOH
Leucoplakia
Which recipient vessel is commonly used in microanastomosis of free flap breast reconstruction?
Internal mammary artery
def: portal HTN
Increase in portal vein pressure of >10mmHg
Ligament of Treitz
Suspensory muscle of the duoenum is a thin sheet of muscle derived from the right crus of the diaphragm, it suspends the fourth part of the duodeum from the posterior abdominal wall
Pathophysioloy of CAH
Most common type is 21-hydroxylase deficiency.
Results in low cortisol, triggers ACTH release and adrenal hyperplasia.
Salt-losing crises can occur with very low cortisol levels.
Progesterone cannot be metabolised as the enzyme deficiency increases the manufacture of 17a hydroxyprogesterone and androgens which cause virilisation/precocious sexual development.
Late onset disease can be due to partial enzyme deficiency.
What does the ability of neoplastic cells to metastasise depend on?
Protease secretions
Transverse cervical artery severed in RTA.
Which muscle would be most affected?
Levator scapulas
Rhomboideus minor
Rhomboideus major
Trapezius
Lat dorsi
Transverse cervical supplies blood to traps
Levator scapulas and rhomboids receive blood from dorsal scapular artery
Lat dorsi receives blood from thoracodorsal artery
SNAP method of fistula management
Sepsis- control sepsis
N- nutrition
A- anatomy, delineate anatomy using contrast radiology.
P- plan as in management plan
Relation of the uterine artery to the uretur
Uterine artery lies anterior and superior to the uretur at the lateral portion of the fornix
What is the point of crossing of the uterine artery and the ureter?
2cm superior to ischial spine
RMP of neurones
In its resting state, the inside of a neurone is rich in chloride ions and a lesser amount of potassium ions.
The outside is rich in sodium ions
Causes of secondary haemorrahge
After 24 horus
Infection
Dislodgement of clot/slough
Ligature erosion
When should the ultrasound happen in ?DDH detected at newborn screening
At 2 weeks as the majority of lax capsules will tighten by this stage
What are the fours structures that comprise the H-shape divdiing the visceral surface of the liver?
GB
IVC
Ligamentum teres
Ligamentum venosum
Porta hepatis
Amount of air expelled during forced expiration following a maximal inspiration. Reduced in restrictive disease
FVC
Rectal biopsy showing inflammatory infiltrate with goblet cell depletion and crypt abscesses
UC
Gell Coombs- Abs and complement pathway
Type 3
How does glucagon elevate glucose
Acts on the liver to stimualte glycogenolysis by increasing intracelllular cAMP
High concentration of serum amino acids can also stimulate the release of glucagon
Which nerve accompanies the basilic vein in the forearm?
Basilic vein lies medial to biceps tendon in the cubital fossa and is medial to the medial cutaneous nerve of the forearm.
Complications of submandibular gland excision
Haematoma formation
Marginal mandibular nerve palsy
Lingual nerve palsy
Hypoglossal nerve damage
Patchy inflammation, fibrosis and strictures of the intrahepatic and extrahepatic bile ducts leading to beaded appearance
PSC
Otherwise known as strawberry gall-bladder, this condition gives the wall of the gall-bladder a strawberry like colour and visual texture as a result of high cholesterol
Cholesterosis
Which of the following tests in common usage has the highest combined sensitivity and specificty when used to detect H. pylori infection?
Culture of biopsy material
McNemar’s test
Biopsy urease test
Urea breath test
Serology/stool testing
Urea breath test
95% sensitivity, 96% specificity
Which of the following structures is the TMJ attached to posteriorly?
Articular disc
Articular eminence
Articular tubercle
Postglenoid tubercle
Squamo-tympanic fissure
TMJ is a synovial joint situated between the condyle of the mandible below and the mandibular fossa above.
Although it is a synovial joint, it is lined by fibrous cartilage (rather than hyaline cartilage).
The joint is surrounded by a capsule that is attached beyond the limits of the articular surfaces.
The capsule is strengthened medially and laterally by collateral ligaments.
Posteriorly it is attached to the anterior edge of the squamou-tympanic fissure.
Bowel prep ahead of elective terminal ileal resection
Clear fluids for 24h prior to procedure
Bowel prep prior to colonoscopy
Sodium picosulphate (1 satchet BD) and clear fluids for 24h prior to procedure
Bowel prep ahead of sigmoidoscopy
Phosphate enema prior to procedure
Bowel prep ahead of low AP for a partially obstructing rectal carcinoma
Clear fluids for 24h prior to procedure.
Stimulant laxatives would be hazardous due to obstruction
Basal cell naevus syndrome
AD
Multiple basal cell naevi on th skin with malignant changes arising during puberty
Jaw cysts
Pitting of the palm and soles
Colour change in skin of children with burns
Not always the same as those in adults.
Dark lobster red and slight mottling is indicative of deep partial or full-thickness burns and in a few days will usually become an opaque colour of an obviously deep burn
Inotropes in children with burns
May be indicated in children with 10% total body surface area burn
23 yo man with gynaecomastia.
Problem since childhood
Has issues with sense of smell
PMHx: cleft lip and palate repair
Kallman’s syndrome: hypothalamic gonadotrophin-releasing hormone deficiency and anosmia.
X-linked or AR
Gonadotrophin deficiency arises from a failure of embryonic migration of GnRH secreting neurones from their site of origin in the nose.
Same defect affects the olfactory neurones resulting in olfactory bulb aplasia.
More than half of patients have associated somatic stigmata, most commonly, nerve deafness , colour blindness, mid-line cranio-facial defomities e.g. cleft lip and palate and renal abdnormalities
Classification of drugs causing gynaecomastia
Oestrogens or drugs with similar activity
Drugs that enhance oestrogen synthesis
Drusg that inhibit testosterone synthesis
What proportion of parotid tumours are malignant?
20%
Overgrowth of normal mature cells with disordered cell architecture
Hamartoma
What are the three types of joints in the body?
Fibrous
Cartilaginous (primary and secondary)
Synovial (typical and atypical)
Primary cartilaginous joints
Formed when bone meets cartilage
Immobile and very strong
Adjacent bone may fracture but the bone-cartilage interface seldom separates.
All epiphyses and ribs attaching to costal cartilages are examples
Fibrous joints
Unite the bones of the vault of the skull at the sutures.
Movement negligible
Secondary cartilaginous joint
Union between bones whose articular surfaces are covered with a thin lamina of hyaline cartilage which in turn is frequently united by fibrocartilage.
All midline joints are secondary cartilaginous joints
Synovial joint
Bone ends are covered by hyaline cartilage and surrounded by a capsule enclosing a joint cavity.
Capsule is lined by synovial membrane and reinforced internally or externally by ligaments.
Atypical synovial joints
No hyaline cartilage
The cartilaginous epiphysis has no blood supply.
Course of the nasolacrimal duct
Membranous canal 18mm long extending from lower part of the lacrimal sac to the inferior meatus of the nose
Ends at the pica lacrimalis (Hasner’s fold), formed by a fold of the mucous membrane.
It is contained in an osseous canal formed by the maxilla, the lacrimal bone and the inferior nasal concha. It is narrower in the middle than at either end and is directed downwards, backwards and laterally.
It is covered in columnar epithelium which is ciliated in palces
When should axillobifemoral bypass be considered?
Very high risk surgical patient with critical ischaemia, not in patients with caludication
What has the highest patency rates of any bypass procedures to the femoral vessels?
Aortobifemoral bypass
Red area of depapillation in the middle of the dorsum of the tongue with sharply demarcated bordered
Median rhomboid glossitis
Recurrent appearance and disappearace of red areas on the tongue
Geographical tongue
Elongation of the filiform papillae, may turn the tongue black with infection by Aspergillus strains
Hairy tongue
High energy valgus force to the knee e.g. in RTA
Likely to result in bony damage e.g. tibial plateau fracture.
Similar force in a football match is likely to result in MCL injury.
What causes abduction and external rotation folowing midshaft femoral fracture due to its action at the greater trochanter
Gluteus medius.
Unopposed action of hip flexors causes proximal fragment flexion. Action of the gluteal muscles causes abduction and external rotation.
Where does the cephalic vein arise?
In the anatomical snuffbox from the dorsal venous plexus of the hand
General structure of bone
Epiphysis
Metaphysis
Diaphysis
What causes sun ray spicules in osteosarcoma
New bone formation once the cortex has been destroyed
What causes bone formation in Codman’s triangle?
Elevation of the periosteum by invasion of tumour through the cortex
What is the most common cause of acute osteomyelitis in a 22y/o male?
DM
IVDU
SCD
Smoking
Trauma
Trauma can account for up to 47% of osteomyelitis cases
Which of the following is a recognised complication of lap chole?
2% mortality
50% risk of conversion to open
5% CBD injury
5% risk of VTE
0.5% risk of CBD injury?
Risk of CBD injury is ~0.5%
Mortality <0.4%
Risk of conversion to open 5%
Risk of VTE without prophylaxis is 1-2%
The ophthalmic artery emerges through which foramina to reach the eye?
Optic canal
Ophthalmic is a branch of the ICA and enters the orbital cavity through the optic foramen below and lateral to the optic nerve. It then passes over the nerve to reach the medial wall of the orbit and thence horizontally foward, beneath the lower border of the SOF and divides into 2 terminal branches- frontal and dorsal nasal.
As the artery crosses the optic nerve it is accompanied by the nasocilliary nerve and is separated from the frontal nerve by superior rectus and LPS
How to perform Buerger’s test
Patient supine, legs elevated to 45 degrees and held there for 1-2 minutes.
Pallor indicates ischaemia and occurs when the arterial pressure is unable to overcome the effects of gravity.
The poorer the arterial supply, the less the angle which the legs have to be rasied for them to become pale.
The patient is then sat up and asked to dangle his legs down the side of the bed.
Gravity causes the colour to return to ischaemic feet which become blue (deoxygenated blood) and then red (reactive hyperaemia from post-hypoxic vasodilation).
Characteristic ECG changes in PE
S wave in I, Q wave in III and T wave in III
What is the commonest reason for dissatisfaction following thorascopic sympathectomy?
Compensatory sweating
Indications for referral to specialist burns unit
Partial/full thickness burns >10% of TBSA in <10 or >50
Partial/full thickness burns >20% of TBSA
Partial/FTB involving face, ears, hands, feet, genitalia, perineum or skin overlying major joints.
FTB >5%
Significant electrical burns including lightning
Significant chemical burns
Inhalation injury
Burn injury in patients with pre-existing illness likely to affect mortality
Any burn injury in context of concomitant trauma
Burn injuries in patients requiring special social support including NAI.
Children with burn injuries seen in hospitals without qualified personnel or equipment to manage their care
Blood film in thalassaemia trait?
Small and abnormally shaped RBCs due to abnormal Hb causing destruction i.e. hypochromic microcytic
44 y/o female seen in pre-op assessment prior to inguinal hernia repair.
Bloods; Ca 3.0, Na 136, K 3.7, Urea 5.5, Creat 50.
CXR normal
Which is the most likely cause of her hypercalcaemia?
Addison’s
CKD
DM
Sarcoid
Thyrotoxicosis
Thyrotoxicosis
As others precluded by other test results
Skin hyperpigmentation and expanding pituitary tumour following adrenalectomy?
Nelson’s syndrome
Skin pigmentation caused by ACT levels that resembles MSH
At what level does the SVC enter the RA?
Formed behind the first costal cartilage by the union of the right and left brachiocephalic veins.
Ends behind the third costal cartilage as it enters the RA
Long term renal damage following obstruction of urine?
Usually only occurs after 28 days of obstruction
Which of the following is correct in HPB surgery?
CBD runs anteriorly to the portal vein in the free edge of the lesser omentum
Hepatic artery runs to the right of the CBD
CBD contains non-striated muscle in its wall
Calot’s triangle is bordered by the cystic duct, common hepatic duct and superior edge of the liver.
Cystic artery usually arises from left hepatic artery
Common bile duct runs anteriorly to the portal vein in the free edge of the lesser omentum
What Igs are principally involved the complement classical pathway?
IgG and IgM
What are the components of the alternative pathway C3 convertase?
C3b and Bb
What are the components of the classical pathway C3 convertase?
C4b and C2a
Which complement polymerises in the MAC?
C9
To what portion of the Ab does C1q bind?
Fc rather than Fab
Why is elevated serum C3dg not a good marker of complement activation?
Clotting of blood can lead to complement activation and hence complement conversion products must be measured from plasma and not serum
Relationship between breast cancer risk and parity
Nulliparity increases the risk of breast cancer.
Having a child at an early age is a protective factor against developing breast cancer. However, a woman who has had her first child in her mid to late thirties is at higher risk of breast cancer than a nulliparous woman.
Breast cancer risk increases about 3% every year older a woman is when she first gives birth. It is thought that pregnancy reduces the susceptbility of mammary tissue to somatic mutations so conferring protection against breast cancer.
What proportion of lap choles are day cases?
60%
Hypercalcaemia secondary to PTHrP is most frequently related to which malignancy?
SCC bronchus
Pattern of pain in duodenal ulcers?
Pain is absent when patient awakens but appears mid-morning.
It is relieved by food but recurs in 2-3h after a meal. Pain that awakens a patient at night is highly suggestive of duodenal ulcers.
Duodenal ulcers are more common than gastric ulcers
What is the weakest part of the mandible?
Region of the mental foramen.
Due to the deep socket of the canine tooth
Fractures of the body of the mandible always cause what
Laceration to the buccal mucosa
Which bone in the body is last to decay
Mandible
Pathophysiology of increased susceptibility to encapsulated bacteria post-spelenctomy
Bacteria with capsules can only be removed via opsonisation.
Spleen is pivotal in initiation of antibody response and the phagocytosis of opsonised encapsulated bacteria.
Suppression of ACTH on high dose dexamethasone suppresion test suggetss?
Pituitary disease
Failure to suppress is suggestive of ectopic ACTH
What is the most common organism causing bacterial flexor tenosynovitis?
Staph aureus
25 y/o primagravida aborts 2 month old embryo.
Which one of the following would have become evident by 8/52?
Eyelids are present in the shape of fold above and below the eye
Different parts of the auricula are not distinguishable.
Lower lip is completed
Neck is fully developed
Palate is completely developed
On day 37 (beginning of 6/52) a small sulcus forms above and below each eye known as the eyelid groove. As the groove deepens, eyelid folds develop into the eyelids and cover the eye. Closure of the eyelids is completed by the middle of 8/52.
Upper lip is completed by 8/52 not the lower lip.
External parts of the ear are distinguishable form week 6 of development.
Palate is completed at 10/52
Consideration in the management of burns with hydrofluoric acid
Hydrofluoric acid penetrates tissues deeply and even small burns can cause fatal systemic toxicity.
Copious lavage with water and treatment with topical calcium gluconate gel is the necessary first step.
Systemic calcium may be required as hydrofluoric acid sequesters Ca following the burn
Difference between alkali and acid burns
Acid burns generally more painful.
Alkali burns have delayed onset of pain.
Alkali burns generally more serious
Management of dry powder causing acid burns
Should be brushed away before irrigation with water
Horseshoe abscess
Ischiorectal abscess that extends to both sides of the anal canal forming a horseshoe space
Supralevator abscess
Form from an upward extension of an intersphincteric abscess into the supralevator space.
May also from from an intra-abdominal inflammation tracking down
Causes of a decreased anion gap?
Hypoalbuminaemia
Plasma cell dyscrasia
Monoclonal protein
Bromide intoxication
Normal variant
Loss of bicarbonate
Recovery from DKA
Ileostomy fluid loss
Carbonic anhydrase inhibtors (acetazolamide, dorzolamide, topiramate)
RTA
Arginine and lysine in parenteral nutrition
Causes of an elevated anion gap
Methanol
Uraemia
DKA
Propylene glycol
Isoniazid intoxication
Lactic acidosis
Ethanol ethylene gylcol
Rhabdomyoloysis/renal failure
Risk of infection in elective right inguinal hernia repair
Uncomplicated inguinal hernia repair should not involve any mucosal breach.
This wound is deemed clean with 2% risk of infection
Risk of infection in perforated DU
Extensive spillage results in a greater than 40% risk of infection i.e. dirty operation
Risk of infection in acute appendicitis
Uncomplicated appendicitis has a 10% risk of infection
Risk of infection in sigmoid colectomy
Large bowel resection is likely to lead to some spillage of GI contents.
Risk of infection ranges from 10-20%
Def: pre-eclampsia
Riased BP on two separate readings taken 6h apart
and
300mg of protein in 24h urine sample
What supplies the angle of the mandible?
Greater auricular nerve (C2-C3)
6 Ps of acutely ischaemic ling
Pain
Pallor
Pulselessness
Paraesthesia
Paralysis
Perishingly cold
What limits the extent of EDH spread?
Dura has strong attachments to the crania along the suture lines and as a result these limit the extent of the haematoma
Which tongue muscle is not innervated by the hypoglossal nerve?
Palatoglossus- vagus
What causes rapid haemarthrosis in ACL tear
One of the geniculate arteries runs within the ligament
Which of the following statements regarding acute empyema is correct?
It is a collection of pus in a newly formed cavity
It is commonly situated between two lobes of lung
It frequently produces a bronchopleural fistula
It may lead to frozen chest
It usually settles without further intervention
Chronic empyema results in thickening of the pleura and restricted chest movement, decreasing the space between the ribs-> scoliosis. Restrictive pattern.
Empyema is defined as a collection of purulent fluid in the pleural space and as such is within a pre-existing cavity.
It is commonly basal rather than inter-lobular.
Bronchopleural fistula is a relatively rare complication of empyema resulting from extension of the infection into the bronchus.
The empyema can also fistulate to the skin and cause a condition called empyema necessitates
Elevation in CVP >4cm after a fluid challenge
Indicates overfilling or a failing myocardium
What degree of intravascular expansion would be seen with 200ml of Gelofusin?
Equivalent to 1L NS
Pyomyositis
May be seen in HIV infected patients.
Presents with pain, tenderness and swelling with overlying skin being smooth and shiny, thereby mimicking an abscess
Clinical signs of hypothyroidism
Dull facial expression
Puffiness and periorbital swelling caused by infiltration with mucopolysaccharides
Decreased adrenergic drive
Lethargy
Bradycardia
Cold intolerance
34 y/o woman. 45% TBSA burns having set herself on fire.
Which GI disturbance would you expect to find as a result of her injury?
Acute gastric dilatation
Cushing’s ulcers
Increased gastric acid production
Splanchnic vasodilation
Terminal ileal lymphoid hyperplasia
Paralytic ileus and subsequent gastric dilation is common in burns >20% although GI function typically returns to normal within 48h.
Burn injuries result in decreased gastric acid production in the acute shock period.
Curling’s ulcers rather than Cushing’s are stress ulcers related to major burns. They have a propensity to major bleeding and have a poor prognosis.
Major burns are associated with splanchnic vasoconstriction.
Terminal ileal lymphoid hyperplasia is a rare condition of no known aetilogy and with no relation to burns
Macroscopic appearance of split thickness skin grafts
Tend to shrink and are associated with abnormal pigmentation.
Full thickness skin grafts resist contraction and have a potential for growth.
Management of skin graft donor sites
Split thickness- secondary intention
Full thickness- primary closure
Normal portal venous pressure
5-7mmHg and should be less than the pressure in the IVC by 5mmg.
If the pressure difference- Hepatic venous pressure gradient is >5 then portal HTN is diagnosed
What is the most common malignant salivary gland tumour?
Mucoepidermoid carcinoma is the most common malignant tumour of the parotid and the second most common malignancy of the submandibular and minor salivary glands (adenoid cystic is more common in these glands)
Which of the following decreases anatomical deadspace?
Adrenaline
Tracheostomy
Subject standing as opposed to lying supine
Increasing size
Increasing luing volume
Tracheostomy bypasses the anatomical dead space above the level of the tracheostomy.
Standing increases dead space.
25 year old male presents with significant facial trauma post RTA with proptosis of the R eye. CT scan demonstrates a fracture across the SOF with associated haematoma.
Which nerve is least likely to be affected
Frontal
Inferior division of oculomotor
Lacrimal
Nasociliary
Zygomatic
SOF is at the apex of the orbit bounded primarily by the greater and lesser wings of sphenoid. The tendons of LR divide the SOF into superior and inferior parts.
The trochlear, frontal and lacrimal nerves passs superiorly with the superior orbital vein.
Superior and inferior branches of the oculomotor nerve, abducens and nasociliary nerves pass inferiorly with the orbital vein.
Frontal and nasocliary nerves arise from the ophthalmic divison of trigeminal nerve in the lateral wall of the cavernous sinus.
The zygomatic nerve is a branch of the maxillary division of the trigeminal nerve that enters the orbit through the inferior orbital fissure
Contents of the SOF
Superior ophthalmic vein
CN III, IV, VI
V1
Contents of the inferior orbital fissure
Maxillary nerve
Zygomatic nerve
Orbital branches of pterygopalatine ganglion
Infraorbital vessels; inferior ophthalmic veins
Which type of calculi form in acidic urine?
Cystine and urate stones
Shelf life of platelets?
4-6 days
Shelf life of PRCs
35 days at 4 degrees
What blood products may stored for up to 36 months?
FFP and cryoprecipitate
What can be used to classify humeral neck fractures?
Neer Classification Group
What are the important anatomical relations to the humerus?
Axillary nerve and circumflex humeral vessles at the surgical neck.
Radial nerve and profund brachii vessels at the surgical groove
Ulnar nerve at the medial epicondyle
Surgical neck fracture of the humerus
Might cause axillary nerve damage
Anatomical neck of the humerus fracture?
Avascular necrosis
Greater tuberosity fractures of the humerus
May result in painful arc syndrome
Which of the following statements best reflects parastomal hernias?
They are commonly asymptomatic
It is more common when stoma is brought through rectus muscle
Occurs in 30% of colostomies
Should always be repaired
Should be repaired using a mesh
Usually asymptomatic
Mesh repairs are rarely performed due to risk of infection around stoma site
In what proportion of colostomies do parastomal hernias occur?
10%
Factors increasing risk of parastomal hernia
Obesity
Increasing age
Post-op infection
Malnutrition
Site of stoma (i.e. outside of rectus)
What is the sensory component of the RLN
Sensory inferior to the vocal folds
Cx of azathioprine
Myelosuppression
Acute pancreatitis
Fluid replacement in someone losing fluid via NGT
NS should be used to supply sufficient chloride ions to replace those lost in the gastric fluid.
If this is not done then metabolic alkalosis can ensue.
Harmtann’s as fluid replacement for NG losses
Should not be administered in patients at risk for alkalosis
Lactate is metabolised to bicarbonate, administration may result in or worsen metabolic alkalosis, seizure may be precipitated by the alkalosis but this is uncommon
Malignant changes in lentigo maligna
Thickening and development of a discrete tumour nodule
RFs for BCC
Smokers
Xeroderma pigmentosa
In previous RTx scars.
What parts of the cranium are commonly involved in basal skull fractures?
Roof of the orbits
Sphenoid bone
Parts of the temporal bone
Ranson’s criteria at presentation
Age >55
WCC >16
Glucose >11
LDH >350
AST >250
Ranson’s criteria during first 48 hours
HCt fall >10%
BUN increase >1.8
Serum Ca <2
PaO2 <8
Base deficit >4
Fluid sequestration >6L
CT severity of pancreatitis
In the absence of IV contrast= Balthazar Ranson
In presence = CT severity index
AST in Glasgow score
>200
64 year old female smoker presents to hospital having been treated for a chest infection several months previously.
She defaulted from follow up and sought alternative therapies but now returns with night sweats and weight loss.
CT suggests a multi-loculated basal advanced empyema with pleural peel
Chest drain insertion
IV steroids
Open thoracotomy decortication
Oral Abx
Video-assisted thorascopic surgery debridement
Open thoracotomy most appropriate option for management as this is an organised, multi-loculated empyema with a thick fibrous peel.
Indications for thoracotomy decortication
Pleural peel history of 4-6/52
Disabling respiratory symptoms
Radiological evidence of trapped lung
Terminal branch of the musculocutaneous nerve?
Lateral cutaneous nerve of the forearm
What is the best way of investigating GORD?
Ambulatory pH monitoring
Areas of constriction of the oesophagus
Cricopharyngeal sphincter
Aortic arch
Left principle bronchus
Diaphragm
Features of the sphenopalatine artery?
Supplies posterior nasal mucosa.
Branch of the third part of the internal maxillary artery, passing through the sphenopalatine foramen into the cavity of the nose at the back of the superior meatus where it gives off its posterior lateral nasal branches which anastomose with the ethmoidal arteries and nasal branches of the descending palatine and assist in supplying the sinuses.
Artery can be ligated in severe posterior posterior bleeds.
Arteries contributing to Keisselbach’s pelxus
Anterior ethmoidal/posterior ethmoidal arteries
Superior labial arteries
Greater palatine artery
Sphenopalatine artery
Phase 0 of cardiac AP
Rapid sodium influx
Phase 1 of cardiac AP
Efflux of K
Phase 2 of cardiac AP
Slow efflux of calcium
Phase 3 of cardiac AP
efflux of K
Phase 4 of cardiac AP
Sodium/calcium efflux, K influx
5FU and folinic acid used in
CRC
Cyclophosphmide, methotrexate, 5FU used in
Breast Ca
Bleomycine, cisplatin, etoposide used in
Testicular seminoma
Occurs a few days after head injury
Large, diffuse and fluctuant swellling underneath the scalp extending from the frontal region to the occiput
May be associated with swollen eyelids.
Subaponeurotic scalp haematoma
What can be used to stage testicular tumours?
Royal Marsden staging system
Stage I testicular tumour
Confined to testis
IM= rising concentrations of serum markes with no other evidence of mestastasis
Stage II testicular tumour
Abdominal node metastases
IIA testicular tumour
<2cm in diameter
IIC testicular tumour
>5cm
IIb testicular tumour
2-5cm in diameter
III testicular tumour
Supradiaphragmatic node metastases
III ABC testicular tumours
Node stage as defined in stage II
III M testicular tumour
Mediastinal LNs
III N testicular tumour
Supraclavicular, cervical or axillary nodes
III O testicular tumour
No abdominal mets
Stage IV testicular tumour
Extralymphatic metastases
IV L1 testicular tumour
<3 mets to lung
IV L2 testicular tumour
>3 mets, all <2cm in diameter
IV L3 testicular tumour
>3 mets, one or more of which are >2cm in diameter
What two factors influence rate of stomach emptying?
Volume of stomach contents
Composition of stomach conents
ECG findings in hypermagnesaemia
Increased PR and QTc
Prolonged QTC complex
Peaked T waves
Flattened p waves
Complete AV block and asystole can occur
ECG features of hypocalcaemia
Narrowing of QRS complex
Reduced PR interval
T wave flattening and inversion
Prolongation of QT interval
Prominent U wave
Prolonged ST and ST depression
Thrombocytopenia
Abnormally large argranular platelets in perihperal blood smears
Almost total absence of platelet alpha granules and their constituents
Grey platelet syndrome
Pathophysiology of grey platelet syndrome
Failure of megakaryocytes to package secretory proteins into alpha granules.
Alpha granule contain a number of growth factors and other clotting proteins.
Patients with GPS are affected by mild to moderate bleeding tendencies
Phlegmasia cerulae dolens
Severe form of DVT affecting the major veins of one of the extremities as well as its collaterals
What are the causes of hip dislocation after the first year of life?
Pyogenic arthritis
Muscle imbalance e.g. CP
Trauma
Hip dislocation mechanism
Hip is flexed and adducted
Posterior dislocation is the commonest direction
Acetabular fracture may accompany hip dislocation in 50% of cases
Complications of hip dislocation
Sciatic nerve injury
Femoral head damage
Avascular necrosis of the femoral head
Post-traumatic ossification
Osteoarthritis
Management of acute presentation of hereditary angioedema
Treatment is with the inhibitor which is present in FFP.
Hyperkalaemia in renal failure
When GFR falls to <15-10
Hyporeninaemic hypoaldosteronism
ACEi
K sparing diuretics
Beta blockers
NSAIDs
Reflex roots
1,2 buckle my shoe
3,4 kick the door
5,6 pick up sticks
7, 8 shut the gate
S1, S2 ankle
L3, L4, knee
C5, C6 biceps
C7, C8 triceps
Pathophysiology of electrolyte abnormality in pyloric stenosis
Dehydrataion and hypokalaemic hypochloraemic metabolic alkalosis
Alkalosis is as a result of unbuffered hydrogen ions in gastric juice with concomitant retention of bicarbonate.
Fluid loss stimulates renal Na reabsorption but sodium can only be reabsorbed either with chloride or in exchange for H and K ions to maintain electroneutrality.
Gastric juice has a high concentration of chloride and patients losing gastric secretions become hypochloraemic. This means less sodium than normal can be reabsorbed with chloride.
Defence of ECF volume takes presence over acid-base homeostasis and further Na reabsorption occurs in exchange for H ions (perpetuating the alkalosis) and K ions (leading to potassium depletion.
This explains the apparently paradoxical findings of acidic urine in patients with py sten.
K is also lost from the gastric juice.
Risk of DVT in patients with previous DVT
50x higher
Mechanics of the PCL
Prevents the femur from sliding forwards off the tibial plateau.
In the weight bearing flexed knee it is the only stablising factor for the femur and the quadriceps.
Patients with PCL rupture may experience difficulty walking down stairs
What proportion of testicular appendage torsions are torsion of the hydatid of Morgani?
90%
Water requirements
40ml H2O/kg/24h
Branches of the internal iliac artery
I Love Going Places In My Very Own Underwear
Posterior:
Iliolumbar
Lateral sacral
Gluteal (superior and inferior)
Anterior:
Pudendal
Inferior vesical artery (uterine in females)
Middle rectal
Vaginal
Obturator
Umbilical artery
Branches of the external iliac artery
Inferior epigastric
Deep circumflex iliac
Common femoral artery
Where is thyroxine binding globulin mainly produced?
The liver
It binds both T3 and T4
Where is the location of the oval fossa within the right atrium
The two parts of the right atrium are separated externally by a groove on the posterior aspect of the atrium known as the sulcu terminalis and internally by the crista terminalis which extends between the two vena caval orifices.
The fossa ovalis is found on the interatrial septum which forms the posteriomedial wall of the right atrium
The opening of the coronary sinus is guarded by a semicircular valve that closes the orifice during right atrial contraction
Trauma
Tachycardia, tachypnoea, pyrexia, reduced consciousness and hypoxia.
May develop a petechial rash on upper chest and or conjunctiae, oral mucosa and reitinae
Fat embolism
What proportion of total hip arthroplasties are affected by aseptic loosening?
5-10%
RR in CRC
Individual with first-degree relative diagnosed with CRC <55y/o has a 2-5x risk than of someone with no FHx of CRC.
Isaac’s syndrome
Neuromyotonia
Paraneoplastic syndrome associated wtih SCLC with neural autoantibodies to K channels
Causes hyperexcitability and continuous firing of the peripheral nerve axons that activate muscle fibres
45 y/o HIV +ve gentleman presenting with acute on chronic urinary retention
MRI shows an irregular mass encasing the urethra in the deep perineal pouch
In realtion to the deep perineal pouch, which is the most likely structure/tissue the mass will invade?
Bulbourethral glands
IUS
Penile urethra
Pudendal nerve
Superficial perineal fascia
In men the deep perineal pouch contains the membranous urethra, sphincter urethra, bulbourethral glands, deep transverse perineal muscles, internal pudendal vessles and dorsal nerves of the penis.
The bulb of the penis lies in the superficial perineal pouch
Managment of stones >1cm in the lower pole calyx
Have poor clearance rates and thus PCNL is the preferred option
DMSA split function suggesting nephrectomy in staghorn calculus
<15%
Which of the following is associated with inadequately controlled DM
Abnormal fall of blood glucose following a meal
Abnormally low concentraiton of FAs in blood
Increased protein breakdown
High rate of glycogen synthesis in the liver
Decreased gluconeogenesis
Protein degradation
What are the visible landmark for the superficial inguinal ring in surgery?
Intercrural fibres that run at right angles across the external oblique aponeurosis
What are the cerebral nuclei involved in the suckling reflex?
Hypothalamic paraventricular and supraoptic nuclei
Entry of the ulnar nerve to the hand
Enters through Guyon’s canal on the superficial ulnar aspect of the wrist between the pisiform bone and the hook of the foreaarm
Why does haemodilution occur in loss of circulating blood volume?
Change in vascular pressures lead to an influx of extra-cellular water into the circulation, a phenomenon known as transcapillary refilling
Pathophysiology of cyanide poisoning
May occur from the production of hydrogen cyanide from burning plastics
Rapidly absorbed through the lungs and binds readily to the cytochrome system, inhibiting cell function.
Can result in LOC, neurotoxicity and convulsions.
It is gradually metabolised by the liver enzyme rhodenase.
Lethal levels are 1.0mg/litre
Bicarbonate may be used in severe toxicity to neutralise lactic acidosis.
Cyanide intoxication is often fatal because washout of cyanide from the blood while breathing oxygen at atmospheric pressure does not occur as effectively as for CO intoxication
What parameter can be measured usng a helium washout techinque
FRC
Nernst potential
Membrane potential at which there is no net flow of a specific ion across the membrane
Which of the following imparts the greatest risk for develop malignant breast Ca?
Sclerosing adenosis
Duct ectasia
Fibroadenoma
Apocrine metaplasia
LCIS
LCIS- 10x risk
Erythorplasia of Queyrat
SCC in situ of the penis
Malignancy risk of erythroplakia
20% risk of malignancy over 5y
Tumour markers in testicular teratoma
70% secrete AFP
60% secrete beta HCG
90% screen for one or the other
MOA tamsulosin
A1 adrenoreceptor antagonist.
Causes relaxation of the bladder neck and prostate capsule
Where is the sciatic nerve likely to be found on posterior approach to gluteal region during hip arthroplasty?
Deep in UOQ
Deep to obturator internus
Deep to piriformis
Medial to inferior gluteal vessels
On the capsule of the hip joint
Appears in the gluteal region below the lower border of piriformis muscle in the vast majority of cases
53 year old man underoges CABG for LMS atherosclerosis.
During weaning from bypass he is noted to have a poor MAP and requires CV support.
Which of the following will increase the coronary artery perfusion and SBP
Intra aortic balloon pump
Norad
Pulmonary artery catheter
Dopamine
GTN
Aortic balloon pumps inflate during diastole, reducing afterload and increasing coronary artery perfusion.
It deflates in systole, increasing forward blood flow by reducing afterload through a vacuum effect
Benign causes of raised CEA
Severe benign liver disease
Inflammatory conditions of the GIT
Trauma
Infection
Collagen diseases
Renal impairment
Smoking
What is CEA?
Water-soluble glycoprotein
Causes of delayed fracture union
Is
Inadequate blood supply
Infection
Incorrect immobilisation
Intact fellow bone e.g. fibula in tibial fracture
Reversed vein femoropopliteal graft 5 year patency
70%
Fem-femoral graft 5 year patency
80%
Axillofemoral graft 5 year patency
60%
Femoropopliteal PTFE below knee graft 5 year patency
35%
Aortobifemoral graft 5 year patency
90%
69 year old
Confirmed upper third rectal carcinoma
Scheduled for pre-operative RTx in an attempt to downsize tumour and make surgery more feasible.
What type of stoma?
Loop colostomy.
Patients who have large tumours may be suitable for pre-operative Rtx to downsize lesion. They will require loop colostomy to divert the faecal stream, this is commonly performed at the transverse or sigmoid colon
Secretion of testosterone by interstitial (Leydig) cells in the testes is stimulated by secretion of which cell type?
Pituitary basophils (gonadotrophs) responsible for secreting LH
HRT pre-op
Should consider stopping oestrogen-containing oral contraceptives or HRT 4/52 before elective surgery.
Local anaesthetic for open inguinal hernia regional block?
50:50 mix of lignocaine and bupivacaine with the possibility of the addition of adrenaline 1:200000
Which structure crosses the superficial submandibular gland
Lingual nerve
Mylohyoid muscle
Cervical branch of facial nerve
IJV
ECA
Cervical branch of facial nerve
DALM occurs in
UC
Types of microscopic colitis
Collagenous
Lymphocytic
Triad in collagenous colitis
Chronic watery diarrhoea
Normal mucosa on colonoscopy
Characteristic histological changes in the mucosal biopsy.
When there is significant lymphocytic infiltration in the lamina propria the disease may be termed lymphocytic colitis.
When there is fibrotic thickening of the subepithelial collagen layer, the disease is called collagenous colitis
61 y/o renal transplant patient
Acute onset severe bloody diarrhoea
Clinically very unwell
No Hx of bowel problems
?CMV colitis
Can cause severe dirarhoea and torrential even life-threatning rectal bleeding.
Which of the following neoplasms is most likely to be associated with endometrial hyperplasia?
Choriocarcinoma
Fibrothecoma
Krukenburg tumour
Mature cystic teratoma
Sertoli-Leydig tumour
Fibrothecoma is a benign ovarian tumour.
The thecoma component gives the tumour a yellowish appearance because of thelipid content and can also produce oestrogen which is responsible for endometrial hyerplasia.
They arise from the ovarian stroma and are bilateral in 10% of cases.
A right sided hydrothorax in association with this tumour is known as Meig’s syndrome
Orphan Annie nuclei
Papillary thyroid carcinoma
Passage of the phrenic nerve
C3,4,5
Deep to scalenus anterior and medius muscles.
Runs on scalenus anterior over the anterior part of the dome of te pleura to enter the mediastinum posterior to the subcalvian vein.
Here the right phrenic nerve spirals forward to lie on the SVC, right atrium and IVC and transverses the diaphragm via the caval orifice
The infusion of 1 L of which of the following solutions will intiially lead to the greatest increase in ECF volume?
Gelatin colloid solution e.g. Gelofusin
Hypertonic NaCL
NS
5% dextrose
Pure water
Hypertonic NaCl.
Exerts effect on whole extracellular compartment, gelofusin will remain intravascular
Aetiology of hypotension in spinal anaesthesia
Due to a reduction in sympathetic tone causing splanchnic vasodilation and venous pooling.
It can managed with IVF or inotropes if refractory to fluid management
Into what space is spinal anaesthesia introduced?
SAH space
Incidence of symptomatic dural tap
1-5% of cases
Complications of IPPV
Alveolar damage due to the wall being subjected to high inflation pressures
Pneumothorax
VAP
O2 toxicity
ALI
How can hepatic function be compromised in IPPV
Very rarely. Generally in patients with pre-existing liver pathology.
IPPV-> reduced venous return and preload leading to reduced CO. Results in proportional reduction in hepatic blood flow.
Increased intrathoracic pressure also causes intrahepatic venous congestion and dysfunction in portal vein flow.
IPPV and ICP
Increases ICP
IPPV and BP
Causes reduction in blood presssure because an increaed intrathoracic pressure increases RAP. THis event causes an impediment to venous return and a reduction in CO-> reduced BP
WHO criteria for diagnosis of T2DM
HbA1c of 48mmol (6.5%)
Dx of DM on glucose
Fasting plasma glucose >7
Random plasma glucose >11.1
Management of scar contracture
Z plasty
Phlegmasia alba dolens
Deep vein occlusion and reliant on superficial venous system.
However the superficial system is under pressure of high flow from arterial system which leads to a painful oedematous white leg. if this progresses, all venous outflow is occluded leading to cerulea dolens
What is the most reliable way to diagnose coeliac disease?
Detection of the typical appearance of subtotal villous atrophy on a small bowel biopsy is the hold standard
What is an issue with the blue dye used in sentinal node biopsy
Contraindicated in pregancny
Shape of the right suprarenal galnd
Pyramidal
Shape of the left supra-renal gland
Semi-lunar or crescenteric
Characterised by pain and impingement during 60-120 degrees of shoulder abduction
Supraspinatus tendonitis
Pain during the last degrees of shoulder abduction
?OA
What XR view may be required to see posterior shoulder dislocation
Scapulohumeral view
38 y/o stabbed in the thorax
Stab wound at the level of the 6th costal cartilage and lateral to the left sternal border
What is most likely to have been injured?
Aorta
Left atrium
L ventricle
R atrium
R ventricle?
R ventricle. Most anterior chamber of the heart and thus most likely to be injured in penetrating trauma to the chest
35 year old man
Pain and tenderness over elbow region and upper forearm
Angulated fracture at the junction of the proximal and middle third of the ulna and the head of the radius is dislocated anteriorly
Monteggia
55 year old lady
RTA
Painful swelling over left distal forearm
Fracture at middle and distal third of the radius with the fragment of the radius tilted towards the ulna
Disruption of distal radio-ulnar joint
Galeazzi’s
Monteggia
Galeazzi
Transport of glucose in the renal tubular cells occurs via
Secondary active transport with Na
Causes of normoblastic macrocytic anaemia
Hypothyroidism
Alcohol
Liver disease
Conditions associated with an increased reticulocyte count
Which approach to hip joint exposure risks injury to the SGN?
Anterior Smith-Peterson
Anterolateral Watson Jones
Anteromedial Ludloff approach
Lateral Hardinge approach
Posterior approach
Lateral Hardinge approach
How does NS cause metabolic acidosis
Causes hyperchloraemic acidosis. Rise in chloride relative to sodium which results in greater amounts of HCl and thus acidosis
Chi-squared
Non parametric data
Observations classified into mutually exclusive classes and the null hypothesis gives the probability that an observation falls into the corrseponding classes
Kruskall-Wallis
Non-parametric data
Used for comapring two or more independent samples of equal or different sizes
Mann-Whitney
Non-parametric
To compare two sample means from the same population
Can be used as an alternative to the t-test when data are not normally distributed
Two-way ANOVA
Used for parametric data and aims to understand if there is an interaction between the two independent variables on the dependent variable
Indication for FNA in pancreatitis
Patients with persistent symptoms and >30% pancreatic necrosis and those with smaller areas of necrosis and clinical suspicion of sespis.
Patient unfit for cholecystectomy but needing definitive treatment for gallstones
?ERCP and sphincterotomy
Pigmentation in Peutz-Jeghers
Circumoral skin, buccal mucosa, hands genitalia
Early complications of RTx
Desquamation lesions of the skin and GIT (inflammation, bleeding, ulceration)
Infertility
BM suppression-> BM failure
Prognosis in facial nerve inury following parotid resection
Facial weakness if usually present but resolves with time to affect <20%
Amyand’s hernia
Inguinal hernia containing inflamed appendix
Management of chyle leak secondary to thoracic duct injury
Adequate drainage
Pressure dressings
Serial aspirations
Nutritional modfifications- medium chain triglycerides which are absorbed directly into the portal system bypassing the lymphatics
Normal range for cardiac index
2.5-3.5
Starling’s equation
Fluid movement= Net filtration pressure minus net oncotic pressure
Malignant potential of Peutz-Jehgers polyps
Have no malignant potential themselves but are associated with increased risk of other malignant gut polyps
Which of the following warrants urgent referral to ENT ?malignancy
Bilateral nasal polyps
Hearing loss
Loss of smell
Persistant rhinorrhoea
Ulcer on helical aspect of the pinna
Ulcer on the pinna may represent a skin malignancy
Location of pharyngeal pouch
Killian’s dehiscence between thyropharyngeal and cricopharyngeal muscles
Which hormone stimulates respiration and causes pCO2 to fall in pregnancy?
Progesterone increases the sensitivity of hypothalamic respiratory centres to small increases in PCO2 and lowers the set point.
A small rise in pCO2 results in increased ventilation of 6L/min, Normal pCO2 falls from 40-32 during pregnancy
What proportion of patients with GORD develop Barrett’s?
5-15% of patients
Risk of Ca in Barrett’s?
0.13%
Contralateral heminaeaesthesia, burning or aching sensation accompanied by mood swings.
Following stroke affecting thalamus
Dejerine-Roussy Syndrome
35 y/o with recurrent attacks of pancreatitis, eruptive xanthomas, increaesd plasma TGs associated with chylomicrons
Deficiency of which of the following is the likely cause of symptoms?
ApoB-100Rs
ApoB-48 Rs
HMG-CoA reductase
LDL Rs
LPL enzyme
LPL enzyme: features in this vignette are suggestive of hyperTG secondary to LPL deficiency. LPL deficiency leads to hypertriglyceridaemia
LDLR disorders result in familial hypercholesterolaemia.
Apo B100 mutations are associated with familial hypercholesterolaemia
ApoB 48 mutations may affect chylomicron levles but wouldn’t cause the hyperTG
HMG-CoA mutations would lead to reduced cholesterol levels
Which hormone prevents menstruation immediately post-partum (up to 40d)
Prolactin
Fluid resuscitation if myoglobulinuria?
Fluid administration should maintain a UO of at least 100ml/h
Cardiac monitoring following electrical burn
If cardiac injury is diagnosed, monitoring is not indicated if echo is normal and there was no history of LOC
Subtype of NSCLC that grows along the alveoli and respects septal boundaries
Arsies from T2 pneumocytes and presents radiographically as single or diffuse nodules as well as segmental/lobar consolidation.
Bronchoalveolar carcinoma
Which of the following is a possible complication of submandibular gland excision?
Anaesthesia of the contralateral half of the tongue
Damage to the retromandibular artery
Deviation of the tongue to the contralateral side on protrusion
Frey’s syndrome
Weakness of the angle of the mouth
Weakness of the angle of the mouth due to potential facial nerve injury
Other structures to be avoided at submandibular gland excision:
mandibular branch of VII, hypoglossal and lingual nerves, facial artery and retromandibular vein
Commonest benign tumour of the oesophagus?
Leiomyoma
Which muscle is most important in the active opening of the mouth?
Lateral pteryogid
First line management in solitary rectal ulcer syndrome?
Biofeedback
Treatment of radiation proctitis
4% formalin topically
Other options include YAG laser and surgery in the form of a coloanal sleeve anastomosis
Use of iodine based dressings
Management of infected and exuding wounds, particularly diabetic foot ulcers
Location of the transverse pericardial sinus
Area of the pericardial cavity located behind the aorta and the pulmonary trunk and anterior to the SVC
What proportion of microscopic haematuria is associated with malignancy?
<10%
All cases of microscopic haematuria should be investigated
ST segment depression in V1 and V2
Chest pain
What artery?
Posterior descending coronary artery
What are the toxins produced by staph aureus?
Haemolysins
Fibrinolysin
Hyaluronidase
Leucocidin
Coagulase
Enterotoxin
TSST
Epidermolytic toxin
What proportion of patients have anomalies of the GB and biliary tree
10%
What are some possible anatomical abnormalities of the hepatobiliary tree?
Long cystic duct travelling alongside the common hepatic duct
GB opening directly into the side of the CBD i.e. cystic duct is absent
Variation in blood vessel arragnement supplying the GB e.g. Right hepatic artery crossing in front of the common hepatic duct instead of behind it
Def: nonfunctioning kidney
Function of <15%
What is associated with oesophageal atresia prenatally
Polyhydramnios
Which of the following may cause a decreased anion gap?
Hypoalbuminaemia
Hypocalcaemia
Hypomagnesamemia
Lactic acidosis
Uraemia
Hypoalbuminaemia
Other causes include hypercalcaemia, hypermagnesaemia, Li intoxiciation, hypergammalgobulinaemia
Hyperviscosity or halide intoxication
Effect of albumin can be accounted for by adjusting the anon gap 2.5mmol/l for every 10g/l fall in albumin
How does the splenic artery reach the spleen?
Via the lienorenal ligament
Grade I renal injury
Contusion or non-expanding subscapular haematoma
No laceration
Grade 2 renal injury
Non-expanding perirenal haematoma
Cortical laceration <1cm deep without extravasation
Grade 3 Renal haematoma
Cortical laceration >1cm without urinary extravasation
Stage 4 renal trauma
Laceration through corticomedullary junction into collecting system
or
Vascular segmental renal artery or vein with contained haematoma
Stage 5 Renal trauma
Shattered kidney
or
Renal pedicle injury or avulsion
Mortality in blunt liver injury
60%
What nerve is affected in tarsal tunnel syndrome?
Tibial nerve
Management of large multifocal thyroid papillary tumours
Completion total thyroidectomy
There is no evidence to support radical block dissection of the neck for cases of localised papillary thyroid cancer
Causes of prolonged thrombin clotting time?
Hypofibrinogenaemia
TCT used to assess fibrin formation. Prolonged TT is due to either fibrin abnormalities, impairment of formation or due to inhibition of thrombin e.g. heparin
Formation of the posterior cord of the brachial plexus
Formed from the posterior divisions of all three trunks.
Axillary nerve and radial nerve are the terminal branches
Swellings in the midline of the neck
Thyroglossal cysts
Neoplasms
Pharyngeal pouches
Plunging ranulae
Subhyoid bursae
Laryngoceles
Lesions in the thyroid isthmus
Causes of Cushing’s syndrome
Exogenous GC administration
Endogenous:
Pituitary adenoma producing excess ACTH
Adrenal cortical adneoma/carcinoma
Ectopic ACTH production
Tests for Cushings
Our Tests For Cushings
Overnight DMST
24h urinary free cortisol
48h dexamethasone suppression test
Circadian rhythm of cortisol secretion
Why do ITU patients in acute renal failure requiring haemodialysis requires continuous venous haemodiafiltration
20-30% of patients with ARF who are haemodialysed become hypotensive with huge associated osmotic shifts- disequilibrium syndrome.
Many ICU patients are intolerant of such shifts. Moreover, the haemodynamic changes that occur i.e. hypotension may worsen the pre-existing renal injury by increasing the ischaemic insult
How long does a vitamin B12 deficiency take to develop and where is it stored?
5 years
Liver
PIP in fixed flexion, DIP in hyperextension
Boutonniere deformity
Swan neck deformity
DIP flexion
PIP hyperextension
What can exogenous noradrenaline cause?
Acts more or less as a pure vasoconstrictor and often results in a reflex bradycardia
In what proportion of patients does the left circmflex give rise to the posterior interventricular branch
15%
Posterior interventricular artery is usually a branch of the RCA
6 year old boy with deep purple lesion over right zygoma. Present since birth, otherwise well. No associated lympadenopathy
Deep capillary naevus aka. Port-wine stain
Associations of deep capillary naevi
With intracranial vascular malformations- Sturge Weber syndrome
Congenital glaucoma if lesion occurs in the ophthalmic division
Hypertrophy of underlying tissues e.g. the limb causing abnormal growth known as haemangiectatic hypertrophy
def: Lentigo
Pigmented lesion that consists of excess melanocytes in a normal position.
E.g. Buccal lesions in Peutz-Jeghers
3/12 old baby. Red lesion on forehead present since shortly after birth now reducing in size. Now lymphadenopathy
Strawberry naevus
What amount of air needs to be injected to be fatal
5ml/kg
How to monitor LMWH?
Anti-Xa assay
Rate of graft occlusion in CABG
During the first year 15% of grafts occlude
Between 1 and 2% per year
4% per year from years 6-10
By 10 years post-op only 60% are patent and only 50% are free of significant stenosis
How many extensor comparments are there in the extensor retinaculum of the wrist?
6
Contents of the first extensor compartment of the wrist?
EPB and Abd PL
Contents of the 2nd extensor compartment at the wrist?
ECRL, ECRB
Contents of the 3rd extensor compartment
EPL
Contents of the 4th extensor compartment
ED and EI
Contents of the 5th extensor compartment
EDM
Contents of the 6th extensor compartment
ECU
What separates the second and third extensor compartments of the wrist?
Dorsal tubercle of the radius aka Lister’s tubercle
Empty sella syndrome
Pituitary normally located within the sella turcica and empty-sella syndrome occurs when the pituitary gland shrinks or becomes flattened meaning it cannot be seen on an MRI scan.
The sella is often filled with CSF
In most cases there are no symptoms or loss of pituitary function
At what level is the intercristal plane?
L4/L5
Which of the following patients is likely to have a hyperplastic arteriosclerosis with fibrinoid necrosis, petechial haemorrhages and microinfarcts in the kidneys in conjunction with a markedly elevated plasma renin?
56 year old man with acute MI
6 year old boy with albuminuria
62y/o woman with ESRD
15 year old with recent strep infection
45 y/o with scleroderma
Diffuse form of scleroderma can be associated with hyperplastic arteriosclerosis and malignant HTN
Kidney
Thickened arteries
Globally sclerotic glomeruli
Interstitial scarring with chronic inflammation
End-stage kidney
Fusion of foot processes on electron microscopy
Minimal-change disease
Why is voice hoarseness as a consequence of lung malignancy more likely to be due to left RLN palsy?
Nerve loops around the remnant of the ductus arteriosus on the left, passing below the arch of the aorta whereas it passes below the subclavian artery on the right. This makes it susceptible to left hilar pathologies as it is more closely related to the left lung hilum
What vascular structures are positioned on the same anatomical plane as the manubriosternal joint?
Aortic arch and junction of the azygos vein and SVC
Fluid resuscitation in trauma patients
Excessive crystalloid administration is associated wsith ARDS
The increase in filtration pressure and decreased oncotic pressure promote increased alveolar capillary permeability
Central necrosis on liver biopsy
?Actue hepatitis
Septal fibrosis
Lobular fibroiss
Periportal fibrosis
On liver biopsy
Chronic hepatitis
Spread of HAV?
Faecal oral
Water borne and food-borne epidemics occur
Eating contaminated raw shellfish is sometimes responsible
Man presents with acute urinary retention, history of prostatism. Serum Creat is 520. Which one of the following is most suggestive of a chronic component to his renal failure?
Hyperkalaemia
Hyperuricaemia
Hypocalcaemia
Hyponatraemia
Low serum bicarb
Hyperkalaemia and hyperuricaemia (due to decreased excretion), hyponatraemia (due to continued water intake with decreased ability to excrete it) and metabolic acidosis occur in both acute and chronic renal failure.
Presence of hypocalcaemia is more suggestive of longstanding disease and is due to reduced renal synthesis of calcitriol
When must plts be used following donation
<5 days from donation
Micromovement in fracture union?
Promotes callus and is not a cause of delayed fracture union
Short head of biceps femoris is supplied by?
Common peroneal part of sciatic nerve
What is the main cutaneous branch of the tibial nerve in the popliteal fossa?
Sural nerve
Def: primary healing
Occurs when a wound is closed within 12-24h of its creation as in a clean surgical incision or a clean laceration
Ulcers in Zollinger-Ellison syndrome
Duodenal ulcers are more common than gastric ulcers
Action of COX-1
Integral to the production of prostaglandins that stimulate mucous secretion from the stoamch.
Mucous protects the stomach from gastric acid.
38y/o female. 1 year history of intermittent epigastric pain.
Presents with vomiting and abdominal distension. Plain AXR shows dilated loops of small bowel and aerobilia.
Emergency laparotomy
ERCP
Lap chole
Percutaneous drainage of the gallbladder
Surgical closure of cholecystoduodenal fistula
Patient has SBO 2o to gallstone ileus.
This is a surgical emergency requiring laparotomy.
The gallstone usually impacts proximal to the ileocaecal valve and so should be massaged through the large intestine or extracted via a proximal enterotomy thus relieving the obstruction.
The gallstone will have passed into the small bowel throug a biliary-enteric fistula but this does not usually require surgical repair.
Such fistulae often lead to aerobilia which can be seen on AXR
During thyroidectomy, the inferior laryngeal branch of the right RLN was injured resulting in an inability to abduct the right vocal cord
Which muscle is most likely to be affected?
Thyroarytenoid
Arytenoid
Lateral cricoarytenoid
Posterior cricoarytenoid
Cricothyroid
Posterior cricoarytenoid is innervated by the inferior laryngeal nerve which is a continuation of the RLN.
It is is the only muscle that abducts the vocal folds.
If the muscle is denervated, the vocal folds may be paralysed in an adducted position preventing air from entering the trachea
Which of the following increases the risk of breast Ca
BMI <30
Cyclical mastalgia
Multiparity
Previous fibroadenoma
Phyllodes tumour
Phyllodes tumour.
Up to 25% of the benign tumours undergo malignant transformation
When is MAG3 scan preferred over DTPA?
Neonates
Patients with impaired function
Patients with suspected obstruction
Due to its more efficient extraction
Why does Hartmann’s contain lactate rather than bicarbonate
It is not possible to store bicarbonate in a solution that contains Ca.
Instead lactate is used which is metabolised to bicarbonate by the liver
What proportion of crystalloid solutions must be used to replace an intravascular volume deficit
3:1 replacement rule i.e. 300 cc of crystalloid is required to compensate for each 100cc of blood lost
What proportion of RCCs present with metastasis?
30%
What are the anatomical differences between adults and children that make intubation more difficult?
Children have a relatively larger head which tends to flex the head on the neck making obstruction more likely.
The relatively larger tongue in children tends to flop back and obstruct the airway in the obtunded child, which means that there is less room in the mouth for intubation.
The larynx is more cephallically positioned in children.
The trachea is shorter
The narrowest point of a child’s airway is the cricoid ring whereas in adults it is the glottis
Bilirubin in Gilbert’s
Unconjugated and as such does not appear in the urine.
What are the urease producing bacteria associated with staghorn calculi?
Proteus
Klebsiella
Pseudomonas
Enterobacter
Histological features of ARDS
Increased capillary permeability
Interstitial and alveolar oedema
Fibrin exudation
Hyaline membrane formation
later
Diffuse late interstitial and alveolar fibrosis
Pre-hepatic causes of portal hypertension
Portal vein thrombosis
Post-hepatic causes of portal HTN
Tricspid incompetence
Budd-Chiari- hepatic vein thrombosis
Garden I fracture
Stable fracture with impaction in valgus
Garden II fracture
Complete but non-displaced femoral neck #
Garden 3 fracture
Paritially displcaed (often externally rotated and angulated) with varus displacement but still has some contact between the two fragments
Garden IV fracture
Completely dispalced and there is no contact between the fracture fragments
Newborn
Barium enema shows affected part of the bowel to have a conical appearance?
Hirschprung’s disease
Due to dilatation of the proximal ganlgionic oclon and the failure of the distal aganglionic part to distend
What is the most common location in which to find an ectopic testis?
Superficial inguinal pouch (most common)
Base of penis
Perineum
Femoral region
Risk factors for RCC?
Smoking
Genetics
High intake of fat, oil and milk
Exposure to toxins such as Pb, cadmium ,asbestos and petroleum products
Neuroblastoma and the midline
Neuroblastoma often crosses the midline which is in contrast to nephroblastoma.
Increase in urinary frequency
Painful micturition
Renal pain
Haematuria
Consitutional symptoms (evening rise in temperature)
Sterile pyuria
?Renal TB
What is the best way to visualise strictures 2o to Crohn’s disease?
Barium follow-through
Genotype of LCIS
Usually oestrogen positive, HER negative and negative for expression of e-cadherin
What is the lifetime risk of LCIS becoming invasive breast carcinoma?
20-25%
At what level does the azygos vein enter the SVC?
T4
Passage of the azygos vein
Formed at the level of the right renal vein (either as a posterior tributary of the IVC) or as a confluence of the ascending lumbar vein and right subcostal.
Passes through the diapghragm via the aortic opening at T12 and ascends on the right side of the vertebral bodies, posterior to the oesophagus.
Terminates by arching over the hilum of the right lung to enter the SVC at the T4 level
Drainage of the 2nd, 3rd and 4th intercostal veins?
Drain into the right superior intercostal vein which itself drains into the azygos vein.
Other tributaries include the lower right posterior intercostal veins, bronchial and oesophageal veins and the 2 hemiazygos veins
Epidemiology of medulloblastoma
84% of all neuroglial neoplasms
Occurs predominantly in children with the greatest incidence in children aged 5-9 y/o
From what origin do medullablastomas in children originate?
The cerebellar vermis
?from microscopic remnants of the cerebellar external granular layer
Relationship between anatomical dead space and lung volume?
Anatomical dead space increases when lung volumes increase.
Pain causes shallower breathing and decreases the anatomical dead space
Pott’s puffy tumour
Rare complication of sinusitis characterised by subperiosteal abscess and osteomyelitis related to the frontal sinus and sometimes also the mastoid.
The patient will have a swelling of the forehead.
Most common pathogens are strep and staph and anaerobes that colonised the RUI.
Imaging with CT or MRI and treatment with surgical drainage and IV abx
Pain mangaement of capsular stretching in hepatic metastases
WHO ladder
NSAIDs can have excelllent additive effect.
Steroids can reduce swelling, inflammation and pain, with dexamethasone being the drug of choice
Behaviour of soft-tissue tumours
Grow centripetally
Respect fascial boundaries and remain confined in the compartment of origin until late stages of disease .
Local neurovascular structures are usually compressed rather than invaded.
What are the components of the juxtaglomerular apparatus?
JG cells
Macula densa
Lacis cells
Clothing and burns
In flame burns, all clothing and jewellery should be removed as soon as possible.
Skin that is adherent and peels off with clothing is non-viable and it is essential to remove all dead tissue
NGT in burns
Helps to decompress the stomach and ensures mucosal integrity, minimising the risk of endogenous infection and bacterial translocation
Innervation of the external anal sphincter
Voluntary muscle
Innervated by the somatic inferior rectal nerves, originating from the pudendal nerves
Innervation of the internal anal sphincter
Involuntary and is innervated by post-ganglionic parasympathetic fibres
Paraneoplastic effects of medullary carcinoma of the thyroid
Can rarely produce ectopic ACTH
Lusitrope
Drug that affects the rate of relaxation of the heart
Stalks of epithelial cells (papillae)
Psammoma bodies in 50% of cases - represent calcific collections
Orphan Anne eye nuclear incluions
Papillary thyroid carcinoma
Action of the lumbricals
Flex the MCPJs and extend the IPJs
Explain the ulnar paradox
When the ulnar nerve is transected at the wrist, power is lost to the lubmicrals of the little and ring finger as well as the other intrinsic muscles of the hand, leading to unopposed extension at the MCPJs (lumbricals flex the MCPJs and extend the IPJs)
If the lesion is at the level of the wrist, the power to the ulnar half of FDP is preserved and the IPJs are therefore flexed, leading to claw hand appearance of extended MCPJs and flexed IPJs in the ring and little fingers.
If the nerve is transected at the elbow, power to the ulnar half of FDP is also lost, leading to less flexion at the IPJs and therefore a less deformed but less functional hand
Patient suffers trauma that injures a nerve resulting in loss of action of the muscle inserting on to the crest of the lesser tubercle of the humerus.
Which nerve is damaged?
Lower subscapular
Subscapularis originates in the subscapular fossa and inserts into the lesser tubercle of the humerus (only muscle to do so)
In what part of the prostate are most cancers found?
70% arise in the peripheral zone
20% in the transitional zone
10% in the cenral zone
What are the preconditions for a good screening test?
Important health problem
Accepted treatment
Facilities for dx and treatment must be available
Latent stage
Screening test should have high sensitivity and specificity
The test should be acceptable to the population
Natural history of the disease should be adequately understood.
There should be an agreed policy on which patients should be treated.
Dx and treatment should be relatively cost-effective.
Screening should be an ongoing process
What electrolyte is vital for the clotting cascade?
Ca
Citrate or EDTA is used as anticoagulants in blood sample bottles as they chelate calcium to stop clotting from occuring
Risk factor for non-lactational breast abscesses in lower outer quadrant?
Diabetes
What are the relations of the stellate ganglion
The first rib is related to the lower two roots of the brachial plexus, C8 and T1
The cervicothoracic ganglion, otherwise known as the stellate ganglion, lies in front of the neck of the first rib
28y/o with halitosis, regurgitation and flatulence
Most likely to be caused by a hiatus hernia.
Pharyngeal pouches are more commonly seen in the elderly
RBC lifespan
120d
Commonest cause of parotitis
Viral (mumps)
Acute bacterial parotitis can occur, particularly in neonates and the elderly and debilitated.
Poor oral hygiene and dehydration are risk factors.
Commonest bacterial cause is staph aureus
Codman’s triangle: cortical penetration with peri-osteal elevation.
Sunray appearance as a result of new bone formation.
Osteosarcoma
Smoking and high alcohol intake for oral SCC
Synergistic risk factors increasing the risk x6
What organ secretes enzymes responsible for breaking down complex starches?
Pancreas
Fixation of torted testis
Suture both testes to the midline with non-absorbable sutures leaving them invaginated in the tunica vaginalis
Refractory hypoxaemia
Alveolar inflammation and oedema
Reduced compliance and a PaO2 to FiO2 <200
?ARDS
Hx of sharp pain over dorsum of foot radiating to toes.
Fine point tenderness in the cleft between third and fourth toes.
Morton’s metatarsalgia
Pathophysiology of Morton’s metatarsalgia
Thought to occur following entrapment of a digital nerve between the metatarsal heads with thickening and formation of a neuroma.
The nerve most commonly affected lies between the third and fourth metatarsal heads.
Pain in sole of foot and dorsal aspect of second toe
O/E: callosities over PIP of the second toe which appears flexed under the second metatarsal head.
The second matetarsophalagneal and DIPJ appear hyperextended
Hammertoe
Pain occuring as a result of callosities forming over pressure areas
Mostly likely cause of a painful heel in a child
Sever’s disease
Osteochondritis of the calcaneal epipysis
Radiograph may demonstrate epiphyseal framgentation or sclerosis
Sever’s disease
Recurrent venous and pulmonary embolisms
Young man
?cause
Antithrombin II deficiency
Level of the transpyloric plane
L1
Surface marking mid-way between the suprasternal notch and the pubic symphysis
Imaging of spine in pateints with pacemaker
CT myelogram
What is the most common complication of THR?
Asymptomatic DVT which occurs in 50% of cases despite prophylaxis but rarely progresses to PE
Heterotopic ossification affects 10% of cases
Dislocation occurs in 2-5%
Retention is a problem, especially in elderly men
MOA cyclophosphamide
Alkylating agent activated by microsomal enzymes of the liver.
What is the active component of the prodrug cyclophosphamide?
4-hydroxycyclophosphamide
Advantage of ifosfamide over cyclophosphamide?
Less myelotoxic, equally effective
What can be used to prevent haemorrhagic cystitis following administration of cyclophosphamide?
Mensa
What has replaced the McEvedy incision as access for strangulated femoral hernia?
Transverse “unilateral” Pfannsteil which can be extended to complete Pfannsteil if formal laparotomy required
Surgical access for perforated peptic ulcer
Upper midline
Alcock’s tunnel
Fascial tunnel on the lateral wall of the ischiorectal fossa which conveys the pudendal nerve and vessels.
Duct of Santorini
Accessory pancreatic duct
Management of intersphincteric fistula
Fistulotomy as it only encircles a proportion of the internal sphincter muscles which when laid open are unlikely to result in significant continence disturbance
Two common surgical options for haemorrhoidectomy?
Milligan and Morgan’s sharp excision and stapled haemorrhoidectomy
What is the mortality rate of ruptured AAA presenting to hospital?
50%
Overall mortality is 75%
Pathophysiology of protein C deficiency
Patients are unable to inactivate the active forms of the procoagulant factors Va and VIIIa
MOA LMWH
Binds with antithrombin which in turn accelerates the inhibition of factor Xa
Where is Factor VIII mainly synthesised?
Vascular endothelium
What are the three points at which the uretur narrows?
PUJ
VUJ
Where the iliac vessels cross it
Gluconeogenesis=
Generation of glucose from non carbohydrate sources
What structure forms the lateral one-third of the posterior wall of the inguinal canal?
Transversalis fascia
Action of leukotrienes
Increased vascular permeability
Bronchoconstriction
Chemotaxis
Blood supply of the scaphoid
Via the dorsal carpal branch of the radial artery with some contribution from the superficial palmar branch of the radial artery on the palmar surface.
Both of these arteries supply the distal pole and the proximal pole via retrograde interosseous perforators
What stimulates glycogenosis in the liver?
Insulin
Treatment of patients with thrombosed varicose veins and cellulitis
Elevation
Rest
NSAIDs
Abx
Most appropriate repair bilateral direct inguinal hernias
Totally extraperitoneal repair
Different repairs of inguinal hernia
Lichenstein mesh or shouldice repair or totally extra-peritoneal repair
Current favoured method is the TEP repair as it has equivalent recurrence rates to Lichtenstein repair and return to work is quicker
What factors can help with compensation of impaired ventilation through tachypnoea
Increase in vertical dimension of the chest on inspiration
Upwards and outwards movement of the ribs
Rise and fall of the hemidiaphragms
Serratus anterior is involved in respiration
Note first rib does not move during respiration
Parasympathetic innervation of the sigmoid colon?
Pelvic splanchnic nerves
Up to where in the GIT does the vagus nerve provide paraympathetic innervation?
The end of the transverse colon
Function of the vitelline duct?
Joins the yolk sac to the primitive embryo.
Persistence= Meckel’s diverticulum
Volume of fluid in the pleural space of the lung?
5-10ml
DNA proofreading
The process by which genetic errors are corrected.
DNA polymerases may have 3->5 exonuclease activity that can replace miscinorporated nucleotides
Borders of the antecubital fossa?
Proximal- line connecting the medial and lateral epicondyles of the humerus
Medially- pronator teres
Laterally- brachioradialis
Roof: bicipital aponeurosis, antebrachial and brachial fascia, subcutaneous fat and skin
Floor: brachialis and supinator muscles
Contents of the antecubital fossa
Really Need Booze To Be At My Nicest
Lateral-> medial
Radial nerve
Biceps Tendon
Brachial Artery
Median Nerve
Dominant hemisphere temporal lobe abscess is most likely to cause what symptom?
Dysphasia/problems with speech.
What is the most likely aetiological agent in chemotherapy associated infection
85% of chemotherapy associated infections are caused by commensal organisms from the GIT and oral cavity
Typhlitis
Potential life-threatening GI complication of CTx associated with nausea, vomiting, abdominal distension, fever, chills and pain
What CTx agent is used as the basis of nearly all regimens of adjuvant and palliative treatment of colorectal carcinoma?
5-FU
What are the derivatives of the endoderm?
Epithelium of the GIT and its associated glands as well as glandular cells of the liver and pancreas, epithelium of the urachus, urinary bladder, epithelium of respiratory passages, epithelial parts of the tonsils, parathyroids, tympanic cavity and thymus and epithelial parts of the anterior pituitary
What factors contribute to the medial longitudinal arch of the foot to prevent flatfoot defomity
Posterior tibial tendon
Static support of the ligaments and capsule (including the calcaneonavicular- spring ligament)
Use of mini-tracheostomy
Used for mid-to long-term tracheobronchial toilet in those patients not requiring invasive ventilatory support
Where does the left renal vein cross the arota?
Infront of the aorta and inferior to the SMA
What is the arrangement of structures passing through the diaphragmatic apertures?
Each of the the three holes has three structures passing through them
3 structures passing through the caval orifice of the diaphragm?
T8
IVC
Lymphatics
Right phrenic nerve (left phrenic nerve pierces the diaphragm separately)
What are the three structures passing through the oesophageal hiatus?
Oesophagus
Vagal trunks
Left gastric vessels
What are the three structures passing through the aortic hiatus?
Aorta
Thoracic duct
Azygos vein
What proportion of SBO is caused by gallstones?
1%
90% of stones entering the intestine will impact in the terminal ileum
