Block 12 Flashcards
What proportion of Crohn’s disease is ileocaecal?
It is the commonest site- 50%
String sign of Kantor
RIF string like strictures on barium studies
Crohn’s disease
SCLC
Bowel obstruction
Pseudo-obstruction
Autoimmune inflammation/destruction of the myenteric plexus
Which gender is most commonly affected in Hirschprung’s?
M:F
5:1
Pathophysiology of Hirschprung’s disease?
Defective neural crest cell migration resulting in a congenital absence of the ganglia that make up the Auerbach (myenteric) and Meissner (submucosal) plexus.
Biopsy in Hirschprung’s
Suction biopsy of the narrowed segment
Full-thickness rectal biopsy is required if suction biopsy is inconclusive
Pain on passive plantar flexion of the big toe but not on passive dorsiflexion
Compartment syndrome of the anterior compartment of the leg.
EHL is the muscle being stretched. This muscle is in the anterior compartment
What is the normal location of the major duodenal papilla
Descending part of the duodenum (i.e. the site where the CBD and pancreatic duct join and enter the duodenum)
Which of the following statements is true regarding familial hypocalciuric hypercalcaemia?
Hypermagnesaemia may be seen
It is AR
It is associated with increased urinary Ca excretion
It is associated with low PTH levels.
The condition responds to parathyroidectomy.
AD condition which is associated with decreased Urinary Ca excretion (<200mg/24h).
No response to parathyroidectomy
Hypermagnesaemia may be seen.
PTH levels are normal or slightly elevated
During repair of spaghetti wrist, what is the maximum torniquet time you should use?
Muscle tolerates an ischaemia time of approximately 6 hours, however in prolonged operations, surgeons will reduce the tourniquet every 2 hours for a period of 15 minutes to establish muscle perfusion
The tendons of which of the following muscles of the forearm is most vulnerable to damage in a laceration on the central palmar aspect of the rist?
FCR
FPL
Abductor PL
Supinator
FCU
FCR is one of the five superficial muscles of the flexor compartment of the forearm, it arises from the medial epicondyle and inserts radial to the carpal tunnel. It would be at risk from a palmar wrist laceration.
Abductor pollucis longus is on the dorsal aspect of the hand
FPL is in the deep compartment
Supinator is in the deep posterior compartment.
FCU sits on the most ulnar aspect of the wrist and as such is less at risk from a central laceration
At what MAP does CBF reduce?
MAP of <60.
This does not occur until there is a loss of over 40% of the circulating volume in a normal individual
When is eschar seen in burns?
Full thickness burns
Relationship between axillary clearance and survival in breast Ca
It yields prognostic information but there is no evidence that axillary clearance in itself prolongs survival
Which of the following statements regarding the mechanism of fetal wound healing is correct.
Reduced inflammatory response
Decreased synthesis of total collagen
Involves a decreased expression of transforming growth factor b3
Involves a reduction in migration of fibroblasts
Involves decrease in hyaluronic acid synthesis
Fetal wounds have reduced pro-inflammatory signals and there is thus a reduction in the inflammatory infiltrate during the early phase of healing
Jefferson fracture
Blow out fracture of the atlas caused by axial loading.
Best visualised with a peg view on plain radiography.
Unstable injuries requiring careful specialist spinal input
Hangman’s fracture
Bilateral fracture of the pars interarticularis affecting axis
By what rate does tamoxifen increase the risk of endometrial carcinoma?
From 1:1000 to 1:50
Hence it is second line in the hormonal treatment of breast cancer in post-menopausal women
What proportion of tumours in post-menopausal women are ER +ve?
2/3rds
Presentation of medullary thyroid cancer?
Thyroid mass or local lymphadenopathy
May present with diarrhoea due to calcitonin but occasionally with other paraneoplastic manifestations e.g. ectopic ACTH production
Failure rates of surgery in testicular germ cell tumours
Surgery alone: 20%
3% when Sx in combination with RTx
Adenocarcinoma and radiation
Most adenocracinomas are RTx insensitive
What is the ebb phase?
Seen in the first few hours of a traumatic insult to the body.
Decreased O2 consumption
Lactic acidosis
Increased stress hormone levels
Decreased insulin levles
Hyperglycaemia
Insulin resistance
Increased substrate consumption
Immune activation
Hepatic acute-phase response.
What is the flow phase
Days to weeks post trauma
Increased body temeprature
Increased O2 consumption
Negative nitrogen balance
Increased stress hormone levels
Hyperglycaemia
Gluconeogenesis
Lipolysis
Immunosuppresssion
Into what segment of the lung is an aspirated object likely to land?
Superior segmental bronchus of the right inferior lobe
What hormonal analogues are used in the treatment of prostatic carcinoma?
Goserelin and buserelin- GnRH analogues
Should be taken in combination with an anti-androgen i.e. bicalutamide intitially to mitigate effects of tumour flare through increased stimulate
Rate of myocardial blood flow at rest?
250ml/min
5% of CO
Right coronary artery supplies what proportion of left ventricular blood?
1/3
In what direction does sigmoid volvulus occur?
Anti-clockwise
What is the main branch of the posterior tibial artery?
Peroneal artery
Para-oesophageal hernia
Occur when part of the stomach herniates through the oesophageal hiatus to lie next to the OG junction without herniation of the junction.
The more common sliding hiatus hernia occur when the oesophagogastric junction herniates through the hiatus
How does para-oesphogeal hernia cause palpitations?
Through pressure on the vagus nerve.
Action of aldosterone
Na and H2O conservation
K loss
In distal tubule
Also promotes secretion of H ions, thereby regulating plasma bicarb levels
Cope sign
Pain on flexion and internal rotation of the hip causing pain if the appendix if in close relation to obturator internus
Psoas sign
Hip extension causing RIF pain in retrocaecal appendix
Gray
Unit of radiation dose absorbed per unit mass
Granuloma is seen in which of the following?
Syphillis
Typhoid
Cholera
Ameobiasis
Shigellosis
Tertiary syphillis
Diffusion capacity in restrictive lung disorders?
Characteristically decreased
FEV1/FVC in restrictive disorders
Normal
TLC in restrictive lung disease?
Reduced
Location of the SFJ?
1-4cm inferolateral to the pubic tubercle
Ludwig’s angina
Cellulitis affecting the submental spaces bilaterally
Usually dental in origin
Results in a raised hard floor of mouth
Trsimus is always present and the patient is systemically unwell.
Early diagnosis is esssential due to risk of airway compromise
Where is the proton pump found on gastric parietal cell?
Apical membrane (luminal) and excretes H into the lumen of the stomach in exchange for K ions
Urine in chronic metabolic alkalosis
The urine may become acidic, not alkalotic as a result of increased proximal renal tubular bicarbonate resorption (a consequence of hypochloraemia)
Berry’s ligament
Connects the thyroid to the cricoid cartilage and upper trachea
Which of the parathyroid glands are in a more constant anatomical position?
Superior parathyroid glands.
Inferior glands undergo further embryological migration.
Which of the thyroid veins is the least constant?
Middle thyroid veins
Indications for CABG
Stable angina, symptomatic control but angiography shows evidence of LMS or proximal triple vessel disease.
Stable angina with suitable coronaries and symptoms not adequately controlled by optimised medical therapy and for whom PCI is not appropriate
Unstable angina not controlled with medications and PCI is not approrpiate
Indications for CABG
STUD
Stenosis of LMS
Triple vessel disease
Unstable angina
Depressed ventricular function
Use of angioplasty in coronary artery disease
Reserved for patients with single or double vessel disease or patients with triple vessel disease who would not be fit for cardipulmonary bypass operation
Distal passage of the radial artery
Crosses the floor of the anatomical snuffbox before piercing the first dorsal interosseous muscle to form the deep palmar arch.
It gives off its dorsal carpal branch in the proximal part of the snuffbox
Superficial palmar arch is the direct continuation of the
Ulnar artery
Most common site for laryngeal malignancy?
Vocal cords
Anterior relations of the lesser sac
Visceral peritoneum along the posterior stomach
Lesser omentum
Gastrocolic omentum
Lateral border of the lesser omentum
Formed by the gastrosplenic ligament
Limitations on the application of tourniquets
Should not be applied for >1.5h and the pressure should not exceed 300mmHg.
Most common effect on peripheral nerves is neuropraxia
Mechanical effects of compression ischaemia on nerves caused by tourniquets?
Focal demyelination
Branchial cysts and airway
May enlarge periodically due to infection but are not associated with airway difficulty.
Normal volume of saliva production?
1-2L per day
Perinephric abscess following an episode of severe pyelonephritis.
Which of the following structures is not likely to be in contact with the purulent exudates?
Cisterna chlyi
Costodiaphragmatic angle of the pleural cavity.
Ilioingunial nerve
Psoas muscle
Subcostal nerve.
Kidneys are retroperitoneal.
Mostly covered by the costal margin.
Both kidneys are in contact with the costodiaphragamtic recess, psoas muscle, subcostal and ilioinguinal nerves.
The cisterna chyli is found on the right of the aorta and lies between the aorta and kidneys without direct contact
Stimulators of GH secretion?
Sleep
Exercise
Hypoglycaemia
Dietary protein
Estradiol
CSF rhinorrhoea in Le Fort fractures
More commonly seen in Le Fort III
Bilateral buttock and leg pain, worse when standing and walking.
Better with leaning forward.
Normal findings on examination
Spinal stenosis
Spinal stenosis
Due to narrowing of the spinal canal by either bony or soft tissue structures.
Patients present with neurogenic claudication.
MRI is the best investigation.
It is important to differentitate between neurogenic and vascular claudication
Hormonal therapy in endometrial caricnoma
Progestins are used
What is the most important factor in postoperative prosthetic function in a below knee amputation
Tibia should be divided approximately 15cm below the knee joint (at least 8cm is required) to fit a below knee prosthesis
Mortality in below knee amputation
10%
Mortality in above knee amputation
20-40%
Management of nerves in below knee amputation
Nerves are best cut cleanly under tension with a blade to reduce the incidence of neuroma.
Some surgeons insert one end of an epidural catheter into the sheath of the tibial nerve and bring out the other end through the skin.
LA can be run through this catheter to aid post-operative anaglesia and is said to help in the diminution of phantom pain
Classification of secondary osteoporosis
Nutritional
Endocrine
Drug related
Malignant
Systemic disease
Idiopathic
Origination of the hepatic portal vein
Posterior to the neck of the pancreas
Most common cause of surgical hypertension
Renovascular disease
Tumours most commonly metastasizing to the adrenal glands?
Lung and breast cancer
Pancreas tumours commonly metastasize to the
Liver
Procedure specific complications to TURP
Bladder perforation
ED
Incontinence
Haematuria
Retrograde ejaculation
UTI
Urethral stricture
Which of the following regarding the uterus is true?
Uterine wall consists of two layers, the myometrium and endometrium
Uterus is frequently retroverted in older women
Body of the uterus is enclosed between the layers of the round ligament
Principal support of the uterus is the uterosacral ligament
Peritoneum covers only the superior aspect of the uterus
Uterus is normally anteverted, however it is commonly retroverted in older women.
Wall consists of the perimetrium, myometrium, endometrium.
Body of the uterus is enclosed within the broad ligament.
Uterus is covered by peritoneum anteriorly and superiorly.
Principal support is the pelvic floor
Sterilisation of surgical materials
Autoclave
Sterilisation of endoscopes
Glutaraldehyde (disinfection)
Sterilisation of suture materials
Ethylene oxide
Sterilisation of surgical drapes?
Autoclave
Sterilisation of urinary catheters?
Ionising radiation
Lymphatic drainage of the cervix
External iliac nodes
Lymphatic drainage of the rectum
Para-aortic nodes
Definitive airway
Tube in the trachea with cuff inflated, connected to a form of oxygen enriched assisted ventilation with the airway secured in place with tape
Which of the following has a direct positive chronotropic effect on the heart?
Isoprenaline infusion
GTN infusion
Verapamil
IV furosemide
Disopyramide
Isoprenaline is a chronotropic agent and is occasionally used in bradycardic states
Chvostek’s sign
Spasm of the facial nerves following tapping the facial nerve below and in front of the ear.
Acute cheek swelling, lethargy, fluctuating pyrexia, pain on clenching jaw
Dental abscess
What can differentitate between sinusitis and dental problems
Sinusitis is very unlikely without nasal symptoms
What is the commonest casue of otological pain without ear involvement?
TMJ dysfunction
PAWP=
LV end diastolic pressure
Sac in exomphalos
Always present though may be ruptured
Has three layers- peritoneum, Wharton’s jelly, amnion.
Gastroschisis
Has no sac and is rarely associated with other congenital defects, though may be seen in conjunction with intestinal atresia.
Management of gastroschicisis
Clingfilm to prevent heat and moisture loss
IV acess-> IVF
Ix in mammary fistula
Mammography
Minimum length of time for callus to become visible on plain XR?
3-4/52
Lidocaine vs bupivacaine
Bupivacaine is more lipophillic so has a longer duration of action
What is a concerning symptom implying malignant transformation in pleomorphic adenoma?
Rapid enlargement
Colle’s fascia
Continuation of Scarpa’s fascia into the perineal tissues
Which clinical structure is likely to be damaged in a laceration of the dorsum of the foot anterior to the medial malleolus?
Great saphenous vein
Relationship between dorsalis pedis and EHL?
Dorsalis pedis lies between the EHL medially and the deep peroneal nerve, which lies between the two
What is the most common subtype of malignant melanoma?
Superficial spreading, accounts for 70% of cases
What is the epidemiology of acral lengtio melanoma?
Accounts for 2-8% of melanomas in caucasians but 80-90% in non-caucasians.
Affects the palms and soles of the feet or beneath the nail bed (subungal variant)
How to demonstrate sciatic nerve compression clinically?
Symptoms exacerbated by passive extension of the knee which can be combined with dorsiflexion of the foot.
And immediately relieved by knee flexion
65 y/o woman
Bone pain
Renal failure
Pneumoccocal pneumonia
Bone marrow biopsy likely to show?
Plasma cells- multiple myeloma
Supratrochlear nerve is a direct terminal branch of which nerve?
Frontal nerve
Supplies the superomedial orbital skin, superior to the medial canthus.
Divisions of V1?
Frontal
Lacrimal
Nasociliary
Branches of the nasociliary nerve?
Long and short ciliary nerves
Anterior and posterior ethmoidal nerves
Infra-trochlear nerve
Communicating branch to the ciliary ganglion
Innervation of the lacrimal nerve
No branches
Supplies the skin above the lateral canthus
Carries parasympathetic fibres from the ptergyopalatine ganglion to the lacrimal gland from the zygomaticotemporal nerve
54 y/o health conscious lady.
Takes multiple vitamin and mineral supplements.
Takes bendrofluazide 2.5mg for HTN.
Blood tests show Ca concentration of 2.84 mmol/l
What is the most likely cause?
Diuretic
High dietary Ca intake
High dietary Vit D intake
Occult malignancy
Primary hyperPTH
Thiazides cause hypercalcaemia but it is typically mild.
Vitamin D ingested in its non-hydoxylated form is metabolically inactive so is less commonly a cause of hypercalcaemia.
Intestinal absorption of Ca similarly is tightly regulated so high intake would not cause hypercalcaemia.
The two most common causes are hyperPTH and malignancy. In an asymptomatic individual, hyperPTH is more likely
Action of calcitonin?
Inhibits osteoclastic bone resorption
Increases renal excretion of Ca and phosphate
N2 in colorectal cancer staging?
N2 represents four or more peri-colic/peri-retal nodes containing disease
Hydraulic conductivity
Filtration rate per unit of pressure across a membrane
As Lp increases the net filtration will also
Meralgia paraesthetica
Irritation of the lateral cutaneous nerve of the thigh causing sensory changes in its distribution without any motor changes.
Piriformis syndrome
Occurs when the sciatic nerve is compressed or impeded by the piriformis muscle.
Should be considered if no spinal cause can be determined for symptoms of sciatica
What is the commonest associated condition with myelomeningocele that should be checked for?
Hydrocephalus, seen in 80-90%
If the pateints left hip drops while he stands on his right leg during Trendelenberg’s test, what is the cause?
Weakness of right hip abductor muscles
Anaplasia
Loss of differentiation of cells and of their orientation to each other
Neoplasia
Formation of new tissue, can be benign or malignant
Causes of MR
IF CREEP
Infective endocarditis
Functional (LV dilatation)
Cardiomyopathy/congenital
Rheumatic fever/rupture chordae tendinae
Elderly calcification
Ehlers-Danlos
Papillary musle dysfunction/rupture
Autosplenectomy
Seen in SCD by late childhood/teenage years
Vaso-occlusive crises are caused by sickle-shaped RBCs that obstruct blood flow to organs-> ischaemia, pain and organ damage.
The spleen is frequently affected.
It is usually infarcted before the end of childhood in children with SCA.
This autosplenectomy increases the risk of infection with encapsulated orgnanisms
On which adrenergic receptor dose salbutamol work?
Beta 2
Where are beta 3 adrenoreceptors found?
Adipose tissue
How is cardiopulmonary bypass usually instituted?
Via the ascending aorta and the right atrium
Ventilation in cardiopulmonary bypass
Not necessary as the machine oxygenates the blood
What is the risk of a second child having a cleft palate?
4%
10% weight loss has what benefit with respect to heart disease?
20% reduction in the risk of heart disease
At what rate does the mucociliary escalator move?
2cm/min
What protein is absent in kartagener’s syndrome?
Dynein
Integral cytoskeletal motor protein required to control the beat of the cilia lining the respiratory tract
Cartilage in the respiratory tract
Unlike bronchi, bronchioles do not have any cartilage in their walls
What factors reduce myocardial blood flow?
Pain and vasopression
Criteria for massive blood loss?
Loss of >50% of blood volume in 3h.
Loss of >100% of blood volume in 24h
or >150ml of blood loss per minute
What is true wr.t. colloids in peripheral oedema
Excessive use of colloids may worsen peripheral oedema, if there is loss of capillary wall integrity, the colloid will leak into the interstitial fluid compartment
Inheritance of a1AT disease?
AR metabolic condition associated with mutations in multiple genes predisposing to obstructive pulmonary disease and liver cirrhosis
Pathophysiology of a1AT deficiency
Antitrypsin is a serine protease inhibitor that normally binds to proteins released by WBCs in inflammatory conditions such as elastase, preventing their action in normal tissues.
In a1AT deficiency, protein configuration is altered, leading to prevention of its release from hepatocytes and therefore a reduction in the circulating concentration.
This allows elastase to digest alveolar walls and leads to pan-lobular emphysema in the lungs.
In the liver, conversely, it is the excess of a1-antitrypsin and its retention in the endoplasmic reticulum that leads to hepatocyte necrosis and liver cirrhosis.
Budd-Chiari syndrome
Abdominal ascites, hepatomegaly and abdominal pain.
Caused by obstruction of the hepatic venous system.
Can be thrombotic or non-thrombotic but venous stasis causes oedema of the tissues, hepatomegaly and severe pain with liver capsule stretching.
If it is not detected and treated early it can lead to sinusoidal necrosis and liver fibrosis.
In its fulminant form it can present with liver and renal failure but has not been assocaited with lung emphysema
CF in the liver
Most commonly presents as fatty liver.
Billiary cirrhosis and portal hypertension can also occur.
Surgical position in APER
Lloyd-Davies position
Llyod Davies
Supine with legs in supports that flex the hips and knees to 45 degrees.
The legs can then be separated to allow access to the abdomen and perineum at the same time.
Surgical position for long saphenous vein stripping
Trendelenberg
Trendelenberg position
Patient supine with head down tilt.
Helps alleviate pressure in the lower limb venous system and can decrease intra-operative blood loss.
Can also be used in pelvic surgery to keep bowel loops out of the operating field
Reverse trendelenberg
Head up position.
Where the abdominal contents need to fall away from the region of intervention
Surgical position for arthroscopic rotator cuff repair
Armchair
Where is the FAP gene?
5p
Nitric oxide is derived from what?
L-arginine by nitric oxide synthase
Nitric oxide
Used to be known as endothelium-derived relaxing factor.
Local cellular messenger derived from L-arginine by nitric oxide synthase.
It increases the levels of intracellular GMP.
Giacomini vein
Anatomical variation thought to be present in 75% of the population
It is a superior extension of the short saphenous vein that continues into the thigh.
To what confounding bias are screening programmes for cancer susceptible?
Lead-time bias
Lead-time bias
Occurs when screening advances the date at which diagnosis is made.
This lengthens the calculated survival time without necessarily altering the date of death.
Length-time bias
Can also affect screening programmes.
Tendency for screening to detect a disproportionate number of cancers that are slow growing and have a better prognosis anyway
Detection bias
Occurs when a phenomenon is more likely to be observed for a particular set of study subjects.
Leads to false inflation of a particular phenomenon because the study authors are more likely to look for it within a set group.
Painful arc
50 to 130 degrees of abduction
Acute response to hypoglycaemia
Increase in serum adrenaline
Glucagon
Both of which are gluconeogenic.
Formation of the internal jugular vein
Receives the facial, pharyngeal, lingual and superior and middle thyroid veins.
Formation of the external jugular vein
Arises from the junction of the posterior auricular vein and the posterior division of the retromandibular vein
What happens to the anterior portion of the retromandibular vein
Proceeds forward to the anterior facial vein and together they join to form the common facial vein.
Which of the following is a tributary of the IJV?
EJV
Inferior thyroid
Middle thyroid
Retromandibular
Transverse cervical
Middle thyroid
What proportion of cervical spine fractures are missed on lateral cervical spine views/
5-15%
Recommended FiO2 in trauma
0.85
Hypotension in trauma
Should be assumed to be due to hypovolaemia
Management of high risk papillary thyroid tumour?
Total thyroidectomy followed by radioactive iodine.
Management of multi-nodular goitre causing airway compression
Total thyroidectomy
Low risk in thyroid malignancy
Women 16-48
Papillary carcinomas <1cm
Minimally invasive follicular carcinoma <1cm
High risk factors in thyroid malignancy
Men and women outside of the 16-25 age range.
Differentiated carcinoma 1cm (>4cm having poorer prognsois)
As well as any associated with multifocality or local/distant spread
Hypovolaemia and lung compliance
Increases due to less blood in the lung making it easier to expand
Croup=
Acute laryngotracheobronchitis
What differentiates between acute laryngotracheobronchitis and acute epiglottitis?
Epiglottitis affects older children, there is supraglottic oedema (epiglottis is red and swollen and protrudes aove the tongue)= rising sun sign
What part of the airway is susceptible to obstruction due to heat injury?
Supraglottic ariway
Clinical indicators of inhalation injury
Facial burns
Singeing of the nasal hairs
Carbon deposits in the oropharynx
Carbonaecous sputum
Hoarseness
CarboxyHb >10%
How can the causes of hypokalaemia causing direct renal tubular cell injury be classified?
In the presence or absence of hypertension with reference also to plasma renin activity and urinary potassium excretion
Which of the following is a cause of hypokalaemia without hypertension but with high plasma renin actvitiy?
Liddle syndrome
Cushing’s
Liquorice excess
Renovascular disease
Gitelman’s syndrome
Gitelman’s syndrome
Hypokalaemic metabolic alkalosis with hypocalciuria and hypomagnesaemia and normal BP
Gitelman’s syndrome
Gitelman’s sydnrome
AR or AD
Hypokalaemic metabolic alkalosis with hypocalciuria and hypomagneseamia
BP is normal
Disorder caused by mutations resulting in the improper function of the thiazide sensitive Na-Cl symporter in the DCT
Hypokalaemia with hypertension (K excretion usually >30mmol/day) and low plasma renin activity
Liddle’s sydnrome
Liddle’s syndrome
AD syndrome of HTN and variable degrees of hypokalaemic metabolic alkalosis
Caused by excess reabsorption of Na and loss of K from the renal tubule.
Liquorice excess
11 beta hydroxysteroid dehydrogenase metabolises cortisol and prevents it from bindging tothe MC receptor
Liquorice inhibits 11 beta hydroxysteroid, preventing the metabolism of cortisol to coritsone.
These patients have a Conn’s phenotype
Surgical management of umbilical hernia
Mayo repair (vest-over pants approach)
What proportion of patients require re-operation in TURP?
2%
Which of the following conditions can cause a macrocytic anaemia?
ACD
Dietary Fe deficiency
Recovery from acute haemorrahge
Sideroblastic anaemia
Thalassaemia
Recovery from acute haemorrahge as it causes a reticulocytosis
Gumma of the testis
Due to syphillis
Hard insensitive mass involving the testis which is difficult to distinguish from a tumour
PaCO2 in severe exercise
PaCO2 is often lowered
Due to increase in ventilation
Which of the following may lead you to suspect inflammatory AAA?
Always associated with raised ESR
Can present with renal failure
More common in women
Responsible for 20% of all AAAs in smokers
Most commonly detected intra-operatively.
Inflammation involves the retroperitoneum-> RPF causing entrapment of the ureturs and subsequently progressive renal failure
Inflammatory AAAs
Variant of AAA found in 5-10% of all cases.
Found in younger patients, infrarenally and symptomatic.
RFs include male, smoker, FHx.
Commonly associated with raised ESR (90%).
CT finding in inflammatory AAA
Cuff of perianeurysmal tissue and inflammatory chagnes that spare the posterior wall.
Radiological appearances relate to thickening of the adventitaia with abdundant inflammatory cells.
Urine testing positive for blood but no RBCs seen on urine sediment microscopy may be caused by?
Myoglobinuria.
Can the subclavian artery be sacrificed if damaged intra-operatively?
No it supplies the thyroid, breast, rectus abdominus, brainstem and diapragm
How to calculate renal clearance of a substance?
UXV/P
where U= urine concentration
V= urine production ml/min
P= plasma concentration in mg/ml
What is the clearance of 10ml of an IV substance, which has been administered at 10mg/ml.
The plasma concentration at equilibration is 15mg/litre
Urine concentration is 150mg/litre
Subject produces 1440ml of urine during 24h collection?
10ml/min
Usual cause of jaundice in MODS?
Intrahepatic cholestasis and hepatocyte necrosis.
26y/o with passive faecal incontince 3 months post-partum
Sphincter disruption.
Obstetric trauma leads to transient feacal incontinence due to traction of the sphincteric complex and pudendal nerve
60y/o with four children presents wtih 3 year history of worsening urge faecal incontinence.
She had two prolonged instrumented deliveries
Pudendal neuropathy.
Multiple, traumatic vaginal deliveries will result in stretch injury to the pudendal nerve.
This results in a weakness in the EAS causing attenuated squeeze pressure.
Patients subsequently complain of an inability to defer defecation with incontinence
Treatment of pudendal neuropathy causing urge faecal incontinence
Amitryptilline may be of some benefit
Pathophysiology of faecal incontinence
Can be a disturbance of the passage or passenger.
Passage consists of the recutm and anal canal, which is composed of two rings of muscle, internal and external anal sphincter.
Pudendal nerve is a mixed nerve that provides motor function to the EAS as well as sensation to the anal canal that provides sensory input that forms part of the sampling reflex.
The passenger (feaces) if loose may cause incontinence even in the presence of a normally functioning anorectal sphincteric complex.
Alternatively, sphincteric disruption may lead to incontinence, even for normal stool
Rare form of chronic cholecystitis characterised by huge numbers of lipid-laden macrophages and giant-cells
Can easily be mistaken for carcinoma
Xanthogranulomatous cholecystitis
Life threatening conditions in the ATLS primary survey
ATOMIC
Airway obstruction
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Incipient flail chest
Cardiac tamponade
Management of bladder tumour T2-4a
Cystectomy +/- RTx + CTx
Muscle invasive bladder tumour
Pelvic lymph nodes
Cystectomy contraindicated
Use of M-VAC CTx is indicated instead
CTx in bladder Ca
M-VAC
Methotrexate
Doxorubicin
Cyclophosphamide
Course of the ejaculatory duct
Formed by the union of the duct from the seminal vesicles with the ductus deferens.
Commence at the base of the prostate and run forward and downward between its middle and lateral lobes along the sides of the prostatic utricle.
To end by slit like orifices close to the utricle in the prostatic urethra
Terminal part of the profunda femoris is sometimes known as?
The fourth perforator
Origin of FDP?
Upper 3/4 of the anterior and medial surfaces of the ulnar, interosseous membrane and deep fascia of the forearm.
Insertion of FDP
Into the base of the distal phalanx
Pathophysiology of gallstones in Crohn’s disease
Bile acids are normally excreted into the small bowel from the liver and gallbladder and are reabsorbed in the terminal ileum = enterohepatic circulation.
In terminal ileal Crohn’s this reabsorption of bile satls is impaired and there is net loss of the available bile salt pool.
There is insufficient concentraion of bile salts to emulsify the cholesterol which subsequently forms cholesterol gallstones
Indirect signs of facial fracture
Soft tissue swelling
Periorbital or intracranial air and fluid in the paranasal sinus
XR views in ?facial #
Water’s view (PA with cephalad angulation)
Caldwell (PA view)
Lateral view
Occipitosubmentovertex view
Water’s view
Tends to show all facial structures the best
Lines of Dolan
Three anatomic contours that correspond to facially important structures
- orbital
- zygomatic
- Maxillary
Caldwell view
Which of the following is most closeley associated with nasopharyngeal carcinoma?
Woodwork
Afro-caribbean
EBV
Vit DD
Female
EBV
Woodwork is associated with paranasal sinus (classically ethmoidal) carcinoma, not NP carcinoma
Alternative to MRI in ?cauda equina
CT myelogram in those unable to undergo MRI e.g. with pacemaker
From what area is most fat absorbed in the GIT?
Proximal small intestine
FFAs are taken up into enterocytes via a protein-dependent active transport.
Once in the enterocyte, they reform triglycerides and are repackaged into chylomicrons with cholesterol.
Some short chain FAs are transported via diffusion
What otological pathology is not detected by a bone conduction test?
Fibrosis causing fixation of the ossicles.
Because the choclea is embedded in bone, vibrations in the bone can be transmitted directly to the cochlear fluid.
Damage to the ossicles or tympanic membrane are thus not detected on a bone conduction test
Superficial to deep arrangement of structures at the lateral aspect of the knee?
Skin, fibular collateral ligament, popliteus muscle tendon, lateral meniscus
Natural history of appendicitis?
Resolve
Become gangrenous and perforate
or
Become surrounded by a mass of omentum and small bowel that walls of the inflammatory process (appendix mass).
>1/52 history of RIF pain.
Persistent low grade fever
Mild tachycardia
?Appendix mass
How to differentiate clinically between appendix mass and appendix abscess
Appendix abscess usually becomes systemically unwell with intermittent swinging pyrexia, rigors and profuse sweating.
Drainage is the best initial treament, in contrast to appendix mass where first line management is conservative
Modified Astler Coller staging system
Modification of Duke’s system
MAC A
Modified Astler-Coller
Limited to mucosa
MAC
B1
Tumour extending into but not through the muscularis propria
MAC
B2
Tumour penetrating through the serosa but no involvement of LNs
MAC
B3
Tumour invades adjacent structures
MAC
C1
Same as B1 plus regional node mets
MAC C2
Same as B2 plus regional node mets
MAC C3
Same as B3 plus regional node mets
MAC D
Distant mets
Why is the risk of HIV transmission higher with hollow needlestick injury?
Hollow needles potentially contain more blood and the risk of HIV transmission is related to the amount of blood and viral concentration load
Renal hypoperfusion is associated with what biochemical changes
Avid sodium retention with minimal excretion into the urine (<20mmol/l)
Increased osmolality and creatine excretion
Urinary osmolality >500
Urinary sodium excretion <20
Urinary creatinine >40
Pre-renal cause
Urinary osmolality <350
Urinary sodium excretion >40
Urinary creatinine <20
Renal cause
Double bubble sign on plain AXR in neonate
Duodenal atresia
Double bubble sign
?duodenal atresia
A “cone” on contrast enema in a neonate
Hirschprung’s disease
Cone on contrast enema- Hirschprung’s
Capacitation of sperm involves
Glycoprotein molecules coating the sperm are solubilised by uterine fluid.
This enhances sperm motility and allows the head to penetrate an egg
Which of the following is an example of a non-absorbable suture?
PDS
Polygalactin
Polyglycolic acid
Polygylconate
Polypropylene
Polypropelene (prolene)
Indications for tracheostomy
CRIMP PRINTS
Congenital (laryngeal webs, subglottic stenosis)
RTx causing neck stenosis
Infections e.g. epiglottitis
Malignancy
Protection of bronchotracheal tree
Paralysis (bilateral) of cords
Respiratory failures
Intubation (prolonged)
Neurological
Trauma to upper airway
Secretions (bronchial)
Impact of tracheostomy on anatomical dead space
Tracheostomy reduces the fraction of tidal volume not participating in gas exchange thereby reducing dead space.
Also assists in reducing the work of breathing
Impact of tracheostomy on V/Q mismatch
Reduces V/Q mismatch as reduces anatomical dead space
Impact of extracellular fluid depletion on [K]
ECF depletion leads to RAAS activation increasing renal Na reabsorption and K excretion
Action of glucagon
Acts on liver to promote gylcogenolysis and gluconeogenesis
Increases lipolysis in adipose tissues and increases ketone body production from FAs.
Action on adipose tissue mediated by cAMP to stimulate lipolysis producing FFAs that can act as a major alternative enregy source.
Catecholamines act in a similary way to glucagon but have effects on muscle
Definition of ARDS
Berlin definition
Acute <1/52 onset
Bilateral opacities consistent with pulmonary oedema on radiograph
Such changes are not secondary to cardiac failure or fluid overload.
Specific ventilatory requirements.
What are the specific ventilatory requirements required for a diagnosis of ARDS?
PaO2 ratio <300 mmHg with a minimum of 5cm H2O PEEP
A normal PF ratio is approximately 500mmHg and a PEEP of 5-15
Structures at risk of injury during midline sternotomy incision?
Brachiocephalic trunk
LCA
Left subclavian
Both brachiocephalic veins
Trachea
Oesophagus
Phrenic nerves
Both vagi
Thoracic duct
Left RLN
Thymus in children
Course in the internal thoracic/internal mamary arteries?
2cm lateral to the lateral edge of the sternal border
Mechanism of injury in posterior shoulder dislocation
Direct blow to the front of the shoulder or forced internal rotation when the arm is abducted.
Treatment of #shaft of humerus
Hanging cast, the weight of which maintains reduction
Clinical features of olecranon fracture
Two types of injury are commonly seen
First is comminuted fracture following direct trauma to the point of the elbow.
Second is a traction injury to the olecranon resulting in a transverse fracture. This typically occurs following a fall onto the hand with triceps contracted.
Transverse fractures tend to cause disruption of the extensor mechanism of the elbow as in the case described.
Displaced fractures may result in a palpable gap.
Muscles attached to the greater trochanter of the femur?
Piriformis
Gluteus medius
Gluteus minimus
Obturator internus
Obturator externus
Vastus lateralis
Gemeilli
Attachement of gluteus maximus to femur
Gluteal tuberosity
Pathophysiology of AV fistulae
Can present immediately after traumatic injury because bleeding occurs into a space that is confined by surrounding tissues.
If AV shunt is large, ischaemia of the distal extremity may occur.
The recirculation of large amounts of blood in a left to right shunt can lead to cardiac failure
Resolution of AV fistulae
Spontaneous resolution occurs in <3% usually via thrombosis.
As such early operative repair is usually indicated as most will increase in size
What is the most important preoperative test ahead of thyroglossal cyst removal
Thyroglossal cysts can contain the only functioning thyroid tissue in the body, isotope scans should thus be planned before surgery to identify all functioning thyroid tissue
Ix in 35y/o lady with passive and urge faecal incontinence following obstetric injury
Endoanal ultrasound- allows visualisation of the internal and external anal sphincters.
Anorectal manometry and rectal sensory thyresholds may also be used
Part of the right bundle branch of the AV bundle is carried by which structure?
Moderator band, which runs from the interventricular septum to the anterior papillary muscle of the right ventricle. It carries the right bundle branch to the anterior papillary muscle.
What clinical feature may give a clue to early CMV pneumonitis in immunocrompromised?
Respiratory distress noticed at first during exercise.
Classical HTN in chronic rejection of transplanted kidney?
Diastolic classically rises in advance of systolic component
Fluid filled meningeal sac with CSF in the lower lumbar region without cord
Meningocele
Fluid filled sac in lower lumbar region filled with CSF and SC
Myelomeningocele
Where is folate absorbed?
Jejunum
UOQ breast lesion in 54 year old lady.
No abnormality on mammogram but 21mm irregular mass on USS
?lesion
Lobular carcinoma can be mammographically occult
Stability of pelvic fractures:
Lateral compression fracture
Rotationally unstable, vertically stable pelvic fracture.
Lateral compression pelvic fracture
Most common form of pelvic fracture
Transverse fracture of pubc rami and ipsilateral/contralateral to posterior injury.
Described by both anterior and posterior pathology.
Pelvic ring implodes or collapses and one side rotates medially towards and occasionally beyond midline.
Often these have rotational instability with verticle stability.
Association of lateral compresion pelvic fractures
Most common identifiable cause of death is closed head injury.
May result in major haemorrhage if one of fracture fragments directly tears one of the large pelvic vessles
Lateral compression fracture
Stability of pelvic fractures:
Open-book fracture
Rotationally unstable, vertically stable pelvic fracture
Open book pelvic fracture
Most often the result of high-energy trauma and are associated with significant morbidity and mortality due to associated vascular injuries
Result from AP compression injury to the pelvis and result in a combination of ligamentous rupture and or fractures to both the anterior and posterior arches.
May be associated with urethral injury
Open book fracture
Stability of pelvic fractures:
Vertical shear injury
Rotationally unstable, vertically unstable pelvic fractures
Vertical shear pelvic fracture
Unstable ipsilateral anterior and posterior fractures of the pelvic ring, with resultant superior displacement of one hemipelvis. Also known as the Malgaigne fracture.
High energy blunt trauma, with significant axial loading
Most commonly a fall or jump from a height with impact onto the lower extremities
Pelvic ring is disrupted, with both anterior pelvis injury (pubic rami), and ipsilateral posterior pelvis injury (sacrum, SI joint, iliac wing)
Ruptures the sacrotuberous and posterior sacroiliac ligaments which provide vertical stability to the pelvis
As a result, the “lateral fragment”, the fracture component containing the acetabulum, is displaced superiorly
Malgaigne fracture
Pelvic vertical shear fracture
Pelvic fracture stability:
Isolated iliac wing fracture
Rotationally and vertically stable
Vertical shear fracture
Isolated iliac wing fractures
Most are unstable.
Typically progress form iliac crest to GSF
Have high incidence of associated injuries- bowel injuries, bowel entrapment, soft tissue degloving
Pelvic fracture stability:
Isolated pubic ramus fracture
Rotaionally and vertically stable
Acid base disorder in aspirin posioning
Respiratory alkalosis and metabolic acidosis
What structure crosses the midline at T5?
Thoracic duct
Maliginant otitis externa
Erosive inflammatory process which occurs typically in immunocompromsied individuals
Open repair of inguinal hernia in women
Lower part of the mesh is fixed to the reflected edge of the inguinal ligament with the mesh positioned to reinforce the posterior wall of the canal (Lichtenstein repair)
Nerve block for inguinal hernia repair
Infiltration of the iliohypogastric and ilioinguinal nerves T12 and L1. 2cm medial from ASIS
and
Genitofermoal nerve 1-2cm lateral to the pubic tubercle
and
Local infiltration of the subcutaneous tissues along the line of incision
Consequence of superior laryngeal nerve damage?
Subtle and may only be noticed by professionals that rely on their voice.
Tracheolamalacia
Rare consequence of long-standing goitre where the tracheal cartilages become soft due to prolonged tracheal compression
Mortality in intermittent claudication?
30% of patients will be dead in 5 years, mainly from cardiac and cerebrovascular disease
FRC is approximately what in a healthy adult man?
2.5L
Features of thyroid malignancy
Hard fixed mass
Raised calcitonin levels
History of neck irradiation
Nerve palsy
What is the most common limiting cause of survival of LT heart transplants?
Cardiac allograft vasculopathy (i.e. coronary atherosclerosis)
What are the 3 mechanisms of heart transplant rejection?
- Acute cell mediated rejection T-cell mediated.
- Ab mediated rejection
- Cardiac allograft vasculopathy
Cardiac allograft vasculopathy
Form of accelerated coronary artery disease that presents in the transplanted heart months to years following transplantation.
It is though to occur to some extent in 42% of heart transplant patients 3 years after transplant.
Presents histologically as a diffuse proliferation of the intima involving the coronary arteries, intramyocardial vessles and coronary veins resulting in concentric luminal narrowing of the vessel.
This condition is the primary limiting factor for survival of heart transplant and is thought to be 2o to a combination of immune and non-immune factors with hyperlipidaemia and insulin resistance beign the two most significant non-immunological factors.
Causes of constrictive pericarditis
Infection
RTx
Cardiac surgery that required opening of the pericardium
Pericardial biopsy showing fibrous thickening, inflammation, granuloma and associated calcification
?constrictive pericarditis
Cardiac biopsy showing virus inclusions in myocardial fibres
?Cytomegalovirus myocarditis
Which artery is vulnerable to rupture in ACL injury?
Branches of the middle geniculate artery
What proportion of cancers are caused by oncoviruses?
Up to 20%
Cardiac conduction blocks occuring below the AVN known as
Infra-Hisian blocks
Where is Fe absorbed?
Duodenum
Gram positive, rod-shaped exotoxin producing bacteria that are spore bearing and area anareobes with varying degrees of resistance to o2 toxicity?
Clostridia
Haemorrhagic indication for emergency thoracotomy?
Persistent haemorrhage of at least 200ml/h for four or more hours
ITU syndrome
Illness that affects patients recovering from major illness or operations and manifests by impairment of memory and perception.
Patients may be unable to hold a conversation, this could be due to sleep deprivation, pain, anxiety or fear
What are the four anterior bursae of the knee?
Suprapatellar, prepatellar, superficial infrapatellar and deep infrapatellar
What are the two posterior bursae of the knee?
Popliteal and semimembranosus
Natriuresis in a dehydrated hyponatraemic patient suggets
Uncontrolled renal loss of sodium as occurs in adrenal failure
Cerebral salt wasting
Typically occurs following a head injury or brain surgery
Can cause dehydration and hyponatraemia due to excessive natriuresis
Significance of the parietal pleura in nephrectomy?
The lower border of the parietal pleura crosses the twelfth rib, the lateral border of the erector spinae and passes horizontally to the lower border of the twelfth thoracic vertebra. There is thus a triangle of pleura in the costovertebral angle below the medial part of the twelth rib behind the upper pole of the injury.
Likelihood of damage to adrenal glands during nephrectomy?
Relatively well protected anatomically, lying anterosuperior to the upper part of each kidney within their own compartment of renal fascia.
Approach to ureteric anastomosis following renal transplant
Extravesical approach: direct anastomosis to the bladder mucosa
Intravesical approach: through a submucosal tunnel and suturing inside the bladder through a separate incision in the bladder wall
End to side ansatomosis in renal transplant
Is to the external iliac artery and vein
End to end anastomosis in renal transplant
Is to the internal iliac artery
Free flap and radiotherapy
Radiotherapy affects vessel wall composure and immediate free transfers are thus easier than delayed
Flap necrosis in free flaps
Commonly occurs on the outer zones and for this reason the outer section is often discarded
Rate of DIEP flap loss?
Up to 10%
Vitamin K production
Vitmain K is a fat-soluble vitamin absorbed in the terminal ileum with bile salts.
Prolonged diarrhoea/high ilesotomy output may result in abnormalities of vitmain K absorption.
This, combined with treatment with broad-spectrum antibiotics may result in the suppression of noraml gut bacterial flora that are also an important producer of vitamin K.
Pre-operative localisation of parathyroid adenoma
Can be achieved with US or sestamibi radionucleotide scan
Which interleukin promotes mucous secretion
IL-1
Between what mean systolic BP values is CBF auto-regulated?
50-150mmHg
Indications for surgical repair of popliteal artery aneursym?
Sympomatic patients with acute limb ischaemia or severe claudication symptoms.
Asymptomatic patients with the presence of a thrombus (thrombus in the aneurysmal sac is at high risk of fragmentation with fleixion/extension movements of the knee and can lead to occlusion of the distal vessels and acute limb ischaemia)
Diameter of popliteal aneurysm prompting repair
>2cm
Mechanism through which tongue carcinoma causes death
Local complications or aspiration pneumonia
In what area of the tongue are carcinomas more common?
Anterior 2/3rds
What is supplied by the anterior interosseous nerve?
FPL and FDP
28y/o man
Right tibial pain with palpable swelling
XR shows lytic lesion involving the epihpysis and extending into the soft tissues .
Benign giant cell tumour
Chondroblastoma
Chrondroma
Chrondromyxofirboma
Osteoid osteoma
Benign giant-cell tumour
Occur in epiphyses and can erode the rest of the bone and extend into the soft tissues.
They are notorious for their tendency to recur.
Rarely they can metastasize but normally they remain histologicaly benign.
They have a lytic apperance on XR
Motorcyclist falls from bike.
On arrival in A+E, extension of the shoulder was severely limited.
Which nerve is he most likely to have damaged?
LTN
Medial pectoral
Suprascapular nerve
TD nerve
Upper subscapular nerve
TD is the only nerve listed that is involved in shoulder extension.
The TD innervates lat dorsi which extends and internally rotates the humerus
What can happen if central venous line is left open following insertion
Venous air emobilism
Type 1 endoleak following EVAR
Occurs at the proximal or distal ends of the stent graft as a result of an incomplete seal.
In such cases, the aneurysm will continue to expand and remain at risk of rupture
Type 2 endo leak
More common but less serious
Result in filling up of the aneurysm sac via back bleeding from its minor branches e.g. IMA and lumbar arteries.
They only require treatment if associated with increasing aneurysmal sac size
Causes of renal failure post EVAR
Contact toxicity
More rarely if the stent graft accidentally covers the origins of the renal arteries
Which nerve is at injury following a deep laceration to the thenar eminence
The recurrent branch of the median nerve
Alvarado score
Clinical and laboratory based scoring system which assesses the likelihood of the diagnosis of appendicitis
<5- unlikely
5-6 equivocal and may require scanning
>7 is strongly predictive
Components of the Alvarado score
Migratory RIF pain (1 point)
Anorexia (1 point)
N+V (1 point)
RIF tenderness (2 points)
Rebound tenderness (1 point)
Fever (1 point)
Leucocytosis (2 points)
Left shift in neutrophils (1 point)
Choledochal cysts
Congenital abnormalities of the bile duct
Children often present with jaundice and a palpable mass in the RUQ which may be accompanied by hepatomegaly.
Treatment is surgical with complete excision of the cyst and restoration of biliary continuity
Cupola
Cervical parietal pleuron which extends sliglhty above the level of the first rib into the root of the neck.
What proportion of invasive breast carcinomas are ductal
70-90%
Management of Grave’s disease when medical therapy has failed
Total thyroidectomy
What bony complication may be commonly expected following gastrectomy with duodenal exclusion?
Osteomalacia 10-20 years after surgery
What proportion of breast feeding women are affected by breast infections?
1 in 3 women,
5-10% of these are affected by a breast abscess
Plasma cell mastitis
Benign breast condition commonly seen in women >60 and is associated with thickened, calcified secretions in the ducts.
It tends to be bilateral and does not have an associated risk of breast cancer
Sclerosing adenosis
Proliferative condition of the breast in which there is an increased number of acini and glands in the terminal lobular units which presents as multiple, small firm but tender lumps in the breast.
The lobular units retain their structure but the acini become enlarged and distorted by stromal fibrosis surrounding the units.
It does not cause nipple fissuring
Action of the deltoid muscle
Abduction of the humerus
Flexion, medial rotation, extension and lateral rotation of the shoulder
Dumping syndrome
Following gastrectomy and due to absent gastric reservoir, abnormal post-operative gastric motor function and hormonal secretion alteration.
After eating, symptoms are related to the rapid transit of hyperosmolar contents into the small bowel.
Osmotic shifts lead to vasomotor symptoms
Symptoms can include postprandial pain, vomiting and dizziness
What proportion of men over 45 are affected by BPH?
50%
The submandibular gland
Has the facial artery running over it
Has the hypoglossal nerve running through it
Is deep to the hyoglossus muscle
Lies entirely below the lower mandible
Lies below the digastric muscle
Has the facial artery running over it.
The facial artery arises from the ECA on the anteromedial surface. It gives off an ascending palatine artery and tonsillar artery.
It passes deep to the posterior belly of digastric and runs on the posterior surface of the submandibular gland
Relation of the submandibular gland to the hypoglossal nerve
Hypoglossal nerve runs deep to the submandibular gland and is at risk of injury during gland excision
Imaging of suspicious renal masss when IV contrast is contraindicated
MRI is the chosen modality for staging assessment
MRI appears more accurate in delineating IVC or renal vein involvement in comparison to CT when staging renal carcinoma
Sensory innervation of the medial side of the palm
Palmar cutaneous branch of the ulnar nerve
Sensory innervation of the medial side of the palmar surface of the ring finger
Superficial branch of the ulnar nerve
Which of the following is the most likely component to be actively absorbed by the colon?
AAs
HCO3
Bile salts
Na
H2O
Na
80% of water is absorbed in the small intestine, additionally water absorption in the colon is passive and dependent on the absorption of Na and other solutes
Absorption of AAs
Majority absorbed in the jejunum and the remainder in the ileum
Radial nerve roots
C5-T1
Action of supraspinatus
Intiates the first 15 degrees of abduction and then continues to hold the head of the humerus against the glenoid cavity.
The deltoid muscle then takes over at about 90%
Fracture passing transversely across the maxillary sinus and pterygoid plates
Le Fort 1
Le Fort 3 aka
Craniofacial dysfunction
Ischial tuberosities in the female pelvis
Are farther apart in the female pelvis because of a wider pubic arch
Depth of the female pelvis
Wider and shallower than the male pelvis
Female pelvic apertures
Female pelvis has larger superior and inferior pelvic apertures
Obturator foramina in the female pelvis
Oval in females and round in males
Curve of the sacrum in the female pelvis
Less curved than in the male
How should a traumatically amputated digit be transferred for reimplantation
Wrapped in saline-soaked gauze and cooled in ice.
Young man stabbed in pericardial region with tachycardia, normotension and normal CXR
Next step
Echocardiography to evaluate for pericardial effusion
Vessel that passes posterior to the IVC, head of the pancreas and duodenum
Right renal artery
The early phase of raised ICP causes which of the following?
Decreased pulse pressure
Hyperventilation
Hypotension
Pupillary constriction
Tachycardia
Pupils constric intially due to external compression of overlying sympathetic fibres but later dilate when the oculomotor nerve is compressed. As herniation progresses, the contralateral oculomotor nerve may be compressed causing bilateral pupil dilation
Management of low flow priapism
Urgent decompression with aspiration of blood from the corpora
If there is no change after 10 minutes, try intracavernosal injection of alpha 1 adrenergic agonist every 5-10 minutes until detumesence occurs. Monitor BP and pulse during administration, if these fail after 1h surgical intervention may be required.
Management of high flow pripaism
Conservative treatment recommended in most cases.
Traumatic or delayed presentations require arteriography, embolisation or ligation of fistula
Inheritance of vWD
AD
Laboratory findings in vWD?
Prolonged APTT
Normal PT
Prolonged bleeding time due to platelet adhesion defect
Where does the submandibular duct (Wharton’s duct) open?
Near the midline in the anterior aspect of the floor of the mouth
Carcinoid syndrome is caused by
Excess secretion of 5-HT by artegraffin cells
Features of carcinoid heart disease
Characterised by pathognomic plaque-like deposits of fibrous tissue secondary to elevated levels of serum serotonin.
These deposits occur most commonly on the endocardium of vavlular cusps and leaflets, the cardiac chambers and occasionally on the intima of pulmonary arteries or aorta.
The right side of the heart is more commonly affected because the lung can inactivate humoral substances which protects the left heart
What can be used for intraoperative monitoring during carotid endarterectomy?
Transcranial doppler ultrasound which measures the flow in the middle cerebral artery and is useful in the intraoperative monitoring and investigation of postendarterectomy neurological episodes.
Following laceration to the mandibular branch of the trigeminal nerve, which of the following muscles would remain unaffected?
Anterior belly of digastric
Lateral pterygoid
Masseter
Medial pterygoid
Posterior belly of digastric
Posterior belly of digastric is innervated by the facial nerve
Alcock canal sydrome
Pudendal nerve entrapment
Regular cyclists are at risk.
Causes pain, typically worse at night.
Relieved by mild analgesics, especially aspirin.
Characteristic apperance is small radiolucent zone surrounded by larger sclertoic zone
Osteoid osteoma
What investigation can be performed when osteoid osteoma is suspected?
99Tc bone scan
Osteoid osteoma appears as a zone of increased uptake
Which of the following is an extra-pulmonary feature of sarcoidosis?
Candidiasis
Goitre
Lichen planus
Macroglossia
Splenomegaly
HSM is a rare manifestation of sarcoidosis
Cardiac involvement may also occur in 3% of cases
Good prongostic factors in osteosarcoma
Young adults
Distally located tumours
Management of pretibial lacerations in the elderly
Need careful management. The skin in this area is friable and wound healing poor.
Sutures may further compromise the blood supply to the flap and place undue tension on the wound.
Adhesive strips are recommended as they keep the edges opposed but do not interfere with the underlying tissue.
Closure of fasciotomies
Split thickness skin grafting is the most common procedure to close fasciotomy wounds.
Where would you visualise an azygos lobe on CXR?
Azygos lobe is commonest accessory lobe and is an embryological variant.
Lobe is seen superior to the right hilum, separated from the rest of the lung by a groove containing the azygos vein. it is not a true lobe as it does not have its own separate bronchus
Azygos lobe
In what proportion of routine CXRs is azygos lobe seen?
0.5%
Glutathione peroxidases
Involved in scavenging free radicals
Selectins
Aid in the initial binding of leucocytes to endothelial surfaces
Management of paediatric femoral shaft fractures
Commonly treated by skin or skeletal traction, this allows fracture union before the child then commences mobilisation in an approrporiate cast
What is of note in the surgical management of paediatric fractures
Fixation of fractures, especially IM nailing through an epiphyseal growth plate can disturb bone growth, leading to shortening and malformation of the affected limb, hence it is restricted to the management of the polytraumatised child when plate fixation or external fixation may be used with care
Indications for surgical managment of clavicular fractures
Open fracture
Polytrauma
Neurovascular injury
Compromise of the overlying skin
Floating shoulder
Symptomatic non-union
Fractures of the lateral third proximal to or between the conoid trapezoid ligamnets
Effects of organophosphates on the heart
Decrease the rate of rhythmicity of the SAN by inducing hyperpolarisation due to prolonged stimulation with ACh though irreversible inhibition of AChE inhibitors
Muscles innervated by the dorsal scapular nerve
Rhomboids and levator scapula
These muscles help to retract and elevate the scapula
Length of recovery after surgery for unhappy triad of O’Donoghue
4-8 months
Alteration to the unhappy triad of O’Donoghue
Original description was of medial meniscal injury, this was revised in the early 1990s to describe lateral meniscal tears. Hence ACL, MCL and lateral meniscus are most commonly affected
Priority of treatment in unhappy triad of O’Donoghue
Reconstruction of ACL with graft from either the patellar tendon or semintendinosus.
During the procedure the meniscal tear can also be corrected.
Depending on the degree of injury, the MCL may heal with immobilisation
Impact of IPPV on CO
IPPV causes an increase in pulmonary vascular resistance and airway presure, a process that interferes with filling of the vena cava and right atrium-> reduced preload-> reduced CO
Impact of IPPV on UO
Reduces CO leading to ADH release and thus reduced UO
Chemotherapy in malignant melanoma
Not effective in management. Mainstay of treatment is with surgical excision
Which of the following is an example of a newly formed mediator?
Thromboxane
Histamine
Tryptase
Heparin
Eosinophilic cehmotactic factor of anaphylaxis
Thromboxane is not pre-formed and results from activation of COX on AA.
Which is the ideal suture in closure following ORIF following a fractured distal radius with a subcuticular stitch?
Dissolvable suture e.g. 4-0 monocryl
Which of the following stimulates the carotid body?
Fall in PaCO2
Fall in PaO2
Fall in pH
Fall in metaoblic rate
Fall in lactate
Carotid body is a peripheral chemoreceptort that is stimualted by a drop in PaO2 or rise in PaCO2.
To what stimuli do central chemoreceptors in the medulla on the ventral surface of the braisntem monitor w.r.t. ventilation
H ion concentration of CSF
Lymphoedema praecox
Primary lymphoedema occuring before 35 usually around puberty
Physiological effects of nitric oxide
Relaxation of gastrointestinal smooth muscle and bronchial smooth muscle
Maintenance of vascular integrity
Inhibition of smooth muscle migration and prolifeation
Action of LH in male
LH promotes testosterone secretion
Barium enema in acute colitis
Contraindicated due to risk of perforation which would be complicated by barium peritonitis
Associations with exomphalos major
ToF is the most common
Other abnormalities include renal and external gential anomalies, limb anomalies, ectopia cordis and bladder exostrophy.
Def: exomphalos major
>5cm defect
Associations with exomphalos minor
Chromosomal abnormalities
Syndromes
Dysmorphism
GI malformations
CNS malformations
Wilm’s tumour
What structures pierce the clavipectoral fascia?
Cephalic vein and lateral pectoral nerve
Rotter’s nodes
Lie between pectoralis major and minor
RFs for AAA
Smoking
Male
COPD
Previous aneurysm repair or peripheral aneurysm
HTN
CAD
Marfan’s
Ehler’s Danlos
CTD
Inflammation
Vasculitits
Triad in inflammatory AAA
Abdominal pain
Weight loss
Raised ESR
Causes of aneurysm
AMSCTB
Atherosclerosis
Mycotic (2o to endocarditis)
Syphillitic
CTD
Trauma
Berry aneurysm and other congenital aneurysms
Why is the pituitary gland vulnerable to damage as a consequence of post-partum haemorrahge
Low pressure portal venous supply.
Hyperplasia and hypertoorphy of lactotrophs in pregnancy cause it to increase in size
Sudden onset headache
Diplopia
Visual field defect
?Pituiatry apoplexy
Dopexamine
Potent splanchnic vasodilator, reducing afterload and improving blood flow to vital organs including the kindney
Action of dobutamine
Reduces SVR, decreasing afterload and ventricular filling pressures.
Used in cardiogenic shock and cardiac failure
Late findings in necrotising fasciitis
Severe pain
Purple or black skin discoloration
Blistering
Haemorrhagic bullae
Crepitus
Discharge of dishwater fluid
Severe sepsis
or SIRS
MODS
Classification of the complications of otitis media
Intratemporal e.g. facial nerve palsy, mastoiditis, petrosis
Extratemporal e.g. Bezold’s abscess
Intracranial e.g. intracranial abscess, VST.
Bezold’s abscess
A Bezold abscess is a complication of acute otomastoiditis where the infection erodes through the cortex medial to the attachment of sternocleidomastoid, at the attachment site of the posterior belly of the digastric muscle, and extends into the infratemporal fossa. Due to it being deep to the investing layer of the deep cervical fascia that envelops the sternocleidomastoid muscle and trapezius muscle, it is impalpable.
As the mastoid air cells pneumatise late in childhood, a Bezold abscess is seen usually in the adult population where the cortex is thinner.
Due to the close proximity to the internal jugular vein, internal jugular vein thrombosis is a recognised complication.
Management of Smith Fracture
ORIF using buttress plate because the distal fragment is unstable
Positioning to improve refractory hypoxaemia in ARDS
Prone or seated position has been shown to improve refractory hypoxaemia caused by ARDS
Action of fluoroquinolones
Block DNA replication by binding to DNA gyrase, causing ds-DNA breaks in bacterial chromosome
Which one of the following physiological responses suggests that a patient is in class II shock?
Decreased pulse pressure
Decreased BP
UO 5-15ml/h
PR >120bpm
Confusion
Decreased pulse pressure
Pulse rate is 100-120bpm in class II shock
BP is maintained
UO is 20-30ml/h
Confusion is present in class III shock
Does CSF contain less glucose than nasal mucous?
CSF contains more glucose than nasal mucus.
A positive glucose dipstix test of clear nasal discharge may indicate a CSF leak though is not a reliable test.
Beta 2 transferrin is more reliable
pH of CSF is
pCO2 is higher resulting in a lower pH
Ophthalmic artery is a branch of which?
ACA
ECA
Facial artery
ICA
MCA
ICA
Passes through the optic canal and supplies ethmoidal air cells, part of the lateral wall of the nose, the external nose, eyelids and forehead.
It also supplies all the muscles of the orbit
What is the key with mid-oesophageal tumours
To exclude tracheal invovlement. If endocsopic US is not possible rigid bronchoscopy could be the investigation of chocie.
How can hypoxia be classified?
Stagnant hypxoia
Anaemic hypoxia
Histotoxic hypoxia
Hypoxic hypoxia
Stagnant hypoxia
Results from reduced perfusion of tissues producing a fall in local PO2 where there is inadequate oxygen delivery and extraction to meet tissue demands
Anaemic hypoxia
Occurs with substantial reductions in blood Hb concentration.
Although PaO2 may be in the normal range, blood O2 content and hence O2 delivery are reduced resulting in local tissue hypoxia.
Similarly reducing the affinity of Hb for O2 also results in a fall in blood O2 content and may induce tissue hypoxia.
Hypoxic hypoxia
Results from a fall in PaO2 secondary to a reduction in inspired pO2
Histotoxic hypoxia
Occurs in the presence of metabolic poisons such as cyanide that acts intraceullarly to inihibit the mitochondrial respiratory electron transport chain
US features of cysts
Hypoechoic centres
Smooth walls
Sharp edges
Use of US in assessment of ?breast malignancy
Used as an adjunct to mammograph in patients >35
Often primary radiological modality in <35 as breast tissue is too dense for accurate mammographic interpretation
Management of bleeding gastric ulcer in patient with multiple comorbidities
Consider excision of ulcer due to shorter surgical time.
If perforation is high on the lesser curve, excision can be performed safely without injuring the gastric vasculature
At what level does the trachea begin?
Cricoid cartilage C6
Criteria for admission to hospital following a head injury
Patients with new clinically significant abnormalties on imaging
Patients who have not returned to GCS 15 after imaging, regardless of results.
When patient fulfills the criteria for CT scanning but this cannot be done within the appropriate period either because CT is not avaiable or because the patient is not sufficeintly co-operative.
Continuing worrying signs
Other sources of concern e.g. alcohol intoxication
Calcification in atherosclerosis
Dystrophic calcification
Metastatic calcification
Calcification occuring in otherwise normal tissue
Perineal hernia
Seen as a rare complciation fo AP resection and develops though a non-healing perineal wound
Excessive salivation
Grey discolouration of the mucous membranes of the mouth
Spreading to the cheeks, palate and nose and a strong odour
<10 years old
Associated with measles, TB and whooping cough
?Cancrum oris
Bacteria cultured in cancrum oris
Borrelia vincenti and fusiform bacilli
Pathophysiology of Curling’s ulcer?
?gastric erosion secondary to cell ischaemia as a consequence of hypovolaemia
Pathophysiology of Cushing’s ulcer
Either via direct vagal nerve stimulation or due to the Cushing reflex
Validity of health and welfare LPA
Does not come into effect until donor loses the capacity to make decisions.
This is in contrast to a financial LPA which can come into effect with permission immediately
Potential sequelae of psoas abscess
Damage to the femoral nerve
Saphenous nerve in adductor canal
Enters the adductor canal but leaves without passing through the adductor hiatus.
Courses with the greater saphenous vein.
Internal mammary arteries in cardiac bypass
LIMA commonly harvested as a pedicle.
RIMA generally skeletonised as injury to the RIMA pedicle may interfere with sternal wound healing.
Paget-Schroetter syndrome
Thoracic outlet syndrome
Which of the following CT findings would you see in EDH?
Crescent-shaped haematoma
Decreased attenuation of the haematoma
Haematoma crossing mid-line
Haematoma crossing suture lines
No associated skull fracture
Both SDH and EDH can cross the midline.
Decreased attenuation is a feature of chronic SDH
Crescent shaped haematomas are usually SDH.
EDH cannot cross suture lines and is usually associated with a skull fracture
Rate of malignancy in gastrinomas?
60% are malignant
Which chemokine R is the coR for HIV entry into T cells?
CCR5
Vascular supply of the SAN
60% supplied by RCA
40% by the LCA
Right coronary supplies AVN
Lupus vulgaris
Mycobacterium of the skin
Appears as sinlge or multiple cutaneous nodules (apple jelly-like) commonly over the face and neck.
Tend to heal in one area and extend to another.
Mucous membranes of nose and mouth sometimes affected.
Infection of the nasal cavity may lead to necrosis of the underlying cartilage.
Treatment is with antitubercular drugs
Leser-Tralet sign
Multiple seborrhoiec keratosis may rarely be associated with an internal malignancy e.g. CRC
Where does the ostea for the posterior ethmoidal sinus drain to?
Superior meatus
Where does the maxillary sinus drain to?
Middle meatus
Where does the frontal sinus drain to?
Infundibulum (hiatus semilunaris of middle meatus)
Where does the anterior ethmoidal sinus drain to?
Infundibulum
Where does the sphenoidal sinus drain to?
Spheno-ethmoidal recess
Anaesthetic approach to CABG?
Controlled hypotension, controlled hypothermia
Hypothermia reduces the metabolic demand and energy requirements of tissues
Hypotension minimises risk of aortic dissection as a result of the placement of an aortic cannula.
Hypotension also results from the reduced vascular resistance to CP bypass
Treatment of tonsillar sarcoma
Highly radiosensitive tumours.
Can be treated with tonsillectomy and radiotherapy to decrease the chance of recurrence
How to test for the anterior osseous branch of the median nerve
Flexion of the thumb at the IPJ
Indicator of aggressiveness in malignant melanoma?
Satellite lesions
Management of acute pulmonary oedema
ABC
High flow O2 non rebreathe
IV frusemide
IV morphine
S/L GTN
IV nitrates not routinely used unless concommitant myocardial ischaemia.
Nitroprusside can be used if SBP >100
If SBP 85-100 a vasodilator can still be used with caution or with an inotrope such as dobutamine
If the patient’s SBP <85 then dobutamine can be used but vasodilator should be avoided
CEA
Glycoprotein involved in cellular adhesion
Normally produced during foetal development but stops before birth and as such is not usually present in the blood of healthy adults though raised levels may be seen in heaby smokers
Which muscle tenses the vocal cords?
Cricothyroid
Course of the femoral artery in the adductor canal
Femoral artery is anterior to the vein.
It lies anterior to adductor longus and brevis
It gives of the descending genicular artery in the adductor canal
Mortality rate in faecal peritonitits
50%
Location of the carotid canal
Temporal bone
Most appropriate management of Colle’s fracture
Dorsal back slab applied with the distal fragment in palmar flexion and ulnar deviation
Immediate complications of #
Haemorrhage
Skin loss
Neurovascular compromise
Late complications of fracture
Mal-union
Non-union
Arthritis
Sudek’s atrophy
Most common testicular malignancy to arise in maldescended testes?
Seminomas
Why are women more prone to anterior anal fissures?
Due to the lack of anterior support to the anal canal
Anatomical relevance of the extradural space in LP?
Contains loose fat and the extensive vertebral venous plexus of veins
What is the most common exta-adrenal site of phaeo?
The organ of Zuckerkandl, by the aortic bifurcation
The organ of Zuckerkandl
The organ of Zuckerkandl is a chromaffin body derived from neural crest located at the bifurcation of the aorta or at the origin of the inferior mesenteric artery. It can be the source of paraganglioma.
Def: complete rectal prolapse
Involves all layers of the wall and more commonly seen in elderly women.
Partial prolapse only involves the mucosa and more commonly resolves with the conservative treatment
What is associated with complete rectal prolpase?
Increased risk of rectal carcinoma
S1 Q3 T3
S wave in lead I
Q wave along with inverted T in lead III
Infusion of amiodarone
Should be given via a central line
What is the risk of re-infarction post-opeartively in a patient who has had an MI 6/52 previously?
31-40%
Risk of re-infarction post-surgically 3-6/12 after recent MI?
16%
Risk of re-infarction post-op following MI in last 6/12
4-5%
How does GH increase blood glucose?
Decreases glucose utilisation and cellular uptake.
Increases the mobilisation of FAs from adipose tissues and increases the use of fatty acids for energy
Anterolateral border of the adductor canal?
Vastus medialis
What is the correct position for central venous cannulation with right subclavian line
1-2cm below and lateral to the junction between the medial one-third and middle one-third of the clavicle
Failed subclavian cannulation on one side
Advised not to try on other side due to risk of bilateral pneumothoraces
Subclavian line insertion with one unhealthy lung
Insert on ipsilateral side to avoid risk of pneumothrax in good lung
What is the most common fracture pattern following direct blow with a compressive force to the patella?
Stellate
Knee flexion trauma to patella, fracture pattern
Transverse
Management of displaced transverse patellar fractures
Surgical fixation
Management of comminuted patellar fractures?
Can be conservative
What may be required in patella fracture
Patellectomy may be required to prevent damage to the patellofemoral joint but complete patellectomy should be avoided when possible
Pathophysiology of beta-naphthylamine causing bladder cancer
Human bladder mucosa secretes beta-glucuornidase which splits beta-naphthylamine and releases a carcinogen.
Pathophysiology of swelling in meniscal tear
Reactive effusion rather than haemarthrosis
Haemarthrosis
Palpable step in tendon
Patient unable to perform a straight leg raise or actively straighten the knee
?Extensor mechanism disruption
Management of extensor mechanism disruption
Direct repair of the tendon as without intervention the mechanism is severely compromised
What proportion of patients attending A&E with acute haemarthrosis will have ACL injury
80%
Uncommon injury caused by twisting of the weight-bearing, flexed kneee
Can occur as isolated injury or in association with major trauma.
Classically known as horseback riders knee it is commonly associated with parachute junmping. Hypermobile individuals are more susceptible.
Examination reveals proximal tibio-fibular joint tenderness and movement of the ankle causes knee pain.
Integrity of the common peroneal nerve must be assessed
Proximal tibio-fiobular dislocation
Reduction of tibio-fibular dislocation
Pressure over the fibular head with the knee flexed
Where does gas exchange occur in the bronchoalveolar tree?
Final seven branches
What proportion of O2 is dissolved in plasma
1.5-2%
Presence of tumour infiltrating lymphocytes in melanoma
Recruited in vertical growth phase to a varying degree.
They can cause regression and are a good prognositc sign
Chemotherapy in GIST tumours?
Ab to c-kit (CD117) imantinib has shown to be effective in 80% of cases
How does the posterior interosseous nerve exit the antecubital fossa?
Between the two heads of supinator
