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
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
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
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
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
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
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
Location of pharyngeal pouch
Killian’s dehiscence between thyropharyngeal and cricopharyngeal muscles
Location of the transverse pericardial sinus
Area of the pericardial cavity located behind the aorta and the pulmonary trunk and anterior to the SVC
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
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
3/12 old baby. Red lesion on forehead present since shortly after birth now reducing in size. Now lymphadenopathy
Strawberry naevus
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
What separates the second and third extensor compartments of the wrist?
Dorsal tubercle of the radius aka Lister’s tubercle
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
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
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
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
From what origin do medullablastomas in children originate?
The cerebellar vermis
?from microscopic remnants of the cerebellar external granular layer
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
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)
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
Osteochondritis of the calcaneal epipysis
Radiograph may demonstrate epiphyseal framgentation or sclerosis
Sever’s disease
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
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
Typhlitis
Potential life-threatening GI complication of CTx associated with nausea, vomiting, abdominal distension, fever, chills and pain
