Block 13

Question 1

MOA Tociliziumab

Answer 1

IL-6 antagonist

Question 2

Which cell type from the following is responsible for predominantly releasing interleukins?

Beta cells

Fibroblasts

Eosinophils

Macrophages

T cells

Answer 2

Macrophages

Question 3

How does the body respond to a reduction in core body temperature leading to a rise in circulating plasma thyroxine?

Answer 3

Release of TRH by the hypothalalmus which is thought to be the control centre for thermoregulation.

Question 4

In which wounds are hypertrophic scars most commonly seen?

Answer 4

Wounds crossing flexor surfaces

Wounds crossing tension lines

Areas of excessive skin tension and movement

Deep dermal burns

Wounds left to heal by secondary intention

Question 5

MOA suxamethonium

Answer 5

Depolarising NMJ blocker that works by activating postsynaptic nicotinic receptors in the NMJ, depolarising the muscle fibre endplate

The result is sustained activation of the VGIC triggering the characteristic initial muscular fasciculations before locking the channels in their depolarised inactivated configuration.

Its short half life means that its clinical effect usually only lasts 5-10 minutes but it rapidly induces a flaccid paralysis within 30-45 seconds

Question 6

Rocuronium

Answer 6

Rapid-acting non-depolarising muscle relexant of the aminosteroid class

Used at high doses it provides intubating conditions within 45-60 seconds and is increasing in popularity for RSI

Question 7

Sellick’s manoeuvre

Answer 7

Application of cricoid pressure for RSI in all non-fasted patients as prevention against aspiration

Question 8

Ix in colovesical fixtula

Answer 8

Cystoscopy and barium enema are the two most likely investigations to help

Question 9

Riedel’s lobe

Answer 9

Congenital abnormality.

Projection of normally functioning liver tissue downward from the right lobe, below the costal margin and along the anterior axillary line

Question 10

Formation of the vocal cords

Answer 10

Formed by the superior edge of the conus elasticus. Mostly yellow elastic tissue. It is the lateral part of the cricothyroid membrane. Superiorly its free edge forms part of the vocal ligaments

Question 11

What can be used to grade facial nerve palsy?

Answer 11

House-Brackman Scale of I (normal) to VI (complete paralysis)

Question 12

What is the most important potential complication of facial nerve palsy?

Answer 12

Failure in eye closure leading to corneal ulceration (House-Brackmann III and above)

Question 13

Formation of the denticulate ligaments

Answer 13

Part of the pia mater which help connect the SC to the arachnoid and dura mater.

Question 14

Structural arrangement of the arachnoid mater of the spine

Answer 14

Thin, delicate tubular membrane loosely investing the SC.

It consists of bundles of white fibrous and elastic tissue intimately blended together.

Its outer surface is covered with a layer of low cuboidal mesothelium

The inner surface and the trabeuculae are likewise covered by low type of cuboidal mesothelium which in places is flattened to a pavement type

Question 15

The plexus of nerves in the arachnoid mater of the SC derive from what?

Answer 15

The motor root of trigeminal, facial and accesory nerves

Question 16

Droopy lip post carotid endarterectomy, which nerve damaged?

Answer 16

Marginal mandibular nerve

Question 17

Nerves at risk during carotid endarterectomy?

Answer 17

Greater auricular

Hypoglossal

Marginal mandibular

Glossopharyngeal

Vagus nerve

Question 18

What is the risk of aneurysms associated with a patient having an aneurysm already

Answer 18

25% of patients with one aneurysm will have other aneurysms elsewhere.

Question 19

Rate of popliteal aneurysms in patients with AAA?

Answer 19

10-15%

Question 20

Rate of AAA in patients with popliteal aneurysm?

Answer 20

30-50%

Question 21

def: false aneurysm

Answer 21

Pseudoaneurysm

Collection of blood found between the muscularis and adventitia layers of an artery resulting from an arterial puncture or trauma to the artery.

Question 22

Dissecting aneurysms

Answer 22

Tear in the intima of the aorta allowing blood to collect in the intima-media space, propagating the tear along the wall of the vessel, dissecting its layers.

Question 23

Where is the intimal tear often seen in a dissecting aneurysm

Answer 23

In most cases, the intimal tear, that initiates dissection occurs in a disease free area of the aorta but quite commonly adjacent to a diseased area.

Question 24

Most common locations of mycotic aneurysms

Answer 24

Femoral artery followed by aorta and intracranial arteries.,

Question 25

Luetic aneurysms

Answer 25

Syphillitic aneurysms that occur in the aorta during the stage of tertiary syphillis following a chronic syphillitic aortitis. Very rare and do not result in rupture. They may cause aortic incompetence and are surgically repaired

Question 26

Use of percutaneous biliary drainage in pancreatic malignancy

Answer 26

Used when endoscopic stent insertion is not possible

Question 27

Management of benign biliary strictures

Answer 27

Often due to unrecognised damage to the bile duct or its vascular supply at the time of surgery. In the fit patient, surgical repair is the preferred definitive choice of treatment. Balloon dilatation has poor long-term patency rates, requiring repeated treatment. Stenting is complicated by occlusion due to stone formation or mucosal hyperplasia. Recurrent episodes of cholangitis can occur

Question 28

Intrahepatic duct dilatation

Answer 28

More commonly caused by tumours and strictures than gallstones

Question 29

Elevated FSH Reduced or absent spermatogensis Masculinisation normal

Answer 29

?Seminiferous tubular dysfunction

Question 30

CA 125 in stage 1 ovarian cancer

Answer 30

Elevated in less than 50% of patients

Question 31

CA 19-9 in pancreatic carcinoma

Answer 31

Elevated in 75-90% of patients

Question 32

National breast screening programme

Answer 32

50-70y/o every 3 years. Has led to increased detection of CIS. Has led to reduced numbers of benign breast biopsies

Question 33

Before carrying out a deep cervical node biopsy, which of the following tests should be undertaken? CTA CT thorax ECG Naso-endoscopy Post-nasal space EUA

Answer 33

Naso-endoscopy. Thorough examination with CXR, ENT examination should be performed

Question 34

Attachments of the free edge of the lesser omentum?

Answer 34

Attached to first 2cm of the first part of the dudoenum and the fissure of the ligamentum venosum.

Question 35

Vascular supply in the lesser omentum

Answer 35

RGA and LGA supply it as they lie between its two peritoneal layers

Question 36

Maximum dose of 1% lidocaine with adrenaline that can be administered to a 60kg woman. 30mls 35ml 42ml 62ml 70ml

Answer 36

Maximum dose with adrenaline is 7mg/kg 1% lidocaine containes 10mg/ml. 60kg woman, maximum dose is 420mg. Which equates to 42ml

Question 37

45y/o man recovering from severe acute pancreatitis develops abdo pain and distension. No palpable mass. CXR shows associated pleural effusion Necrosis Abscess Pseudoaneurysm Pseudocyst Ascites

Answer 37

Ascites

Question 38

Pancreatic ascites

Answer 38

Accumulation of free pancreatic fluid in the peritoneal cavity either from the disruption of the main pancreatic duct or leakage of a pesudocyst. The fluid has a high protein and amylase content. Pancreato-pleural fistula results in a pleural effusion

Question 39

Collection of purulent peripancreatic material resulting from the progressive liquefaction of necrotic tissue and infection. Diagnosis should be considered in patients who remain or become febrile 2/52 post attack of acute pancreatitis

Answer 39

?Pancreatic abscess

Question 40

3/52 post attack of severe acute pancreatitis. 36y/o man recovering in HDU develops abdo pain and an episode of haematemesis Necrosis Abscess Pseudocyst Ascites Pseudoaneurysm

Answer 40

Pseudoaneurysm. Most commonly affect the splenic aretery, followed by GDA, occur as a result of autodigestion and erosion of the walls of adjacent arteries. In most cases they present as GI bleeding.

Question 41

Prevalence of UC

Answer 41

60/100000

Question 42

FHx in UC

Answer 42

15% of patient have a first degree relative with IBD and wider FHx in 20-30% of cases

Question 43

Causes of cardiac tamponade

Answer 43

Trauma Breast /lung carcinomas Aortic dissection MI Bacertial, viral or tuberculous pericarditits

Question 44

Madura foot

Answer 44

Aka mycetoma Localised subcutaneous infection by fungi or filamentous bacteria. Most commonly caused by actinomycetes. Typically presents in agricultural workers following minor trauma to the foot.

Question 45

Rate of ischaemic colitis post AAA repair

Answer 45

1-3% following open repair. Lower rate in EVAR Intra-operative ligation of the IMA can cause left colon ischaemia in the absence of patent collaterals with the SMA to maintain flow

Question 46

Paraplegia following AAA repair

Answer 46

Can result from damage to the artery of Adamkiewicz intra-operatively. Arises from the AAA at the level of the 9th-12th intercostal arteries and supplies the SC from T8 to conus medullaris. At risk of ischaemia or occlusion during AAA repair. Anterior spinal artery syndrome may develop.

Question 47

Artery of Adamkiewicz

Answer 47

AKA great anterior radiculomedullary artery Arises from AA at 9th-12th intercostal arteries and at risk during AAA repair.

Question 48

Pathophysiology of trash foot

Answer 48

Acute lower limb ischaemia following aortic surgery thought to be due to cholesterol emboli dislodging from atheromatous plaque in the AA and blocking distal arteries.

Question 49

Pain Intact peripheral pulses Livedo reticularis

Answer 49

?Trashfoot

Question 50

Mean pulmonary arterial pressure

Answer 50

15mmHG

Question 51

Suture material used in small bowel anastomosis

Answer 51

3 0 PDS Absorbable materials used. Stapling has become more prominent. No evidence of different anastomotic leak rates between suturing and stapling

Question 52

Mid-line abdominal wound closure material

Answer 52

1 PDS or 1 Nylon

Question 53

Suture material for securing prosthetic mesh during incisional hernia repair

Answer 53

2 0 prolene Non-absorbable suture most appropriate

Question 54

Pathophysiology of septic arthritis

Answer 54

Direct wound extension, direct introduction, spread from osteomyelitis or haematogenously. Infection usually starts in synovial memrane and seropurulent exudate develops in the synovial fluid. Progressive destruction of articular cartilage and vascular damage may lead to death of epiphyseal bone.

Question 55

Pathophysiology of pseudogout

Answer 55

Pyrophosphate is generated in cartilage by enzymatic activity and combines with calcium ions to form crystals

Question 56

Associations of pseudogout

Answer 56

HyperPTH Hypothyroidsim Acromegaly Haemochromatosis

Question 57

Pattern in pseudogout

Answer 57

Fibrocartilage of the knee Pubic symphysis Intervertebral discs Particularly common in women \>60

Question 58

Weakly positive bi-refringent rhomboid crystals in plane-polarised light

Answer 58

Pseudogout

Question 59

13y/o 6/12 history of pain and swelling affecting upper limb joints. Also suffers with a grumbling appendix. B/L involvement of the shoulder joints, elbows and wrists. Splenomegaly.

Answer 59

Still's disease. Recurrent abdominal pain may occur secondary to bouts of mesenteric adenitis. HSM, myocarditis and uveitis may complicate the condition

Question 60

Diagnostic criteria for Stills

Answer 60

At least two of: joint pain, swelling or limitation of movement affecting more than four joints for at least 3 months. Associated systemic symptoms of fever, macular rash and lymphadenopathy may predominate

Question 61

Diagnosis of Still's

Answer 61

90% seronegative and can thus only be diagnosed with snyovial biopsy

Question 62

Most common benign bone tumour affecting individuals \<21

Answer 62

Osteochondroma

Question 63

Most common complication of venous insufficency

Answer 63

Leg ulceration

Question 64

Signs of chronic venous insufficieny HEAVE

Answer 64

Haemosiderin deposition Eczema Ankle ulcers Varicose veins oEdema

Question 65

Which organ has the greatest blood flow per 100g of tissue?

Answer 65

Kidneys

Question 66

Pericardiocentesis

Answer 66

Broad-bore needle attached to three way syringe. Inserted into a point 1-2cm inferior to the left of the xiphochondral junction Adanced slowly while aspirating towards the tip of the left scapula whilst monitoring ECG for evidence of myocardial injury e,g, extreme ST-T waves or widened QRS complexes.

Question 67

qSOFA score

Answer 67

Quick sepsis-related organ failure assessment score Low BP (\<100) High RR \>22 Altered mentation GCS \<15. Presence of 2 or more points near the onset of infection associated with increased risk of death or prolonged ICU stay

Question 68

What proportion of anaphylaxis related deaths occur because of the late-phase reaction?

Answer 68

30%

Question 69

Why is hypothermia a greater issue in children who have suffered burn injuries

Answer 69

Higher SA to volume ratio Children \<1 do not have the shivering reflex

Question 70

Indications for inotropes in paediatric burns

Answer 70

\<1-2ml/kg/h UO with \>=10% TBSA may be an indicator for dopamine

Question 71

Pulse pressure in neurogenic shock

Answer 71

Widened due to proporionately higher fall in diastolic pressure

Question 72

Which vein is carried within the hepatoduodenal ligament?

Answer 72

Hepatic portal vein

Question 73

Type A lactic acidosis

Answer 73

Occurs with decreased tissue ATP in the setting of poor tissue perfusion or oxygenation

Question 74

Type B lactic acidosis

Answer 74

Occurs in the absence of evidence of tissue hypoperfusion/hypo oxyfgenation

Question 75

Type B1 lactic acidosis

Answer 75

Occurs in association with systemic disease e.g. renal and hepatic failure, DM and or malignancy

Question 76

Type B2 lactic acidosis

Answer 76

Drug associated

Question 77

Type B3 lactic acidosis

Answer 77

Due to inborn errors of metabolism

Question 78

Which of the following arteries supply the trochanteric anastomosis? Anterior spinal artery EIA Gluteal arteries Iliolumbar Posterior spinal

Answer 78

Superior and inferior branches of the gluteal arteries originate from the IIA. Their descending branches supply the trochanteric anastomosis of the hip, together with the ascending branch of the medial circumflex artery. They form the retinacular vessles that pierce the joint capsule and ascend the femoral neck

Question 79

Blood supply of the ASIS anastomosis

Answer 79

Iliolumbar arteries

Question 80

Which immunosuppressive drug acts by inhibiting IL-2 action? Sirolimus Ciclosporin Azathioprine MMF Tacrolimus

Answer 80

Sirolimus inhibits IL-2 action whereas ciclosporin and tracrolimus inhibit IL-2 production

Question 81

How much blood can the pulmonary vessels accomodate at rest?

Answer 81

500ml

Question 82

Development of lymphoedema in a female shortly after menarche Swelling around ankle up to the dorsum of the foot and spreads proximally.

Answer 82

Meige's disease (lymphoedema praecox)

Question 83

Which of the following is not contained within the carpal tunnel at the wrist? FDS PL Median nerve FDP FPL

Answer 83

PL is superficial to the flexor retinaculum

Question 84

Histopathology of iron overload

Answer 84

In HH, XS Fe is found primarily in parenchymal cells, whereas in secondary iron overload, accumulation tends to be in Kupffer cells. This can be demonstrated on liver biopsy

Question 85

Genes implicated in haemochromatosis

Answer 85

C282Y mutation or H63D

Question 86

Course of the sacral plexus

Answer 86

Formed by the lumbosacral trunk and the anterior division of the 1st sacral nerve plus portions of the anterior divisions of the 2nd and 3rd sacral nerves. Emerge through the anterior sacral foramina Joined by the lumbosacral trunk anterior to piriformis

Question 87

Surgical approach for ruptured kidney

Answer 87

Through the anterior abdominal wall by a midline incision. Simple nephrectomy is indicated in cases of non-functioning kidneys

Question 88

Relations of the left kidney

Answer 88

12th rib posteriorly. Upper pole of the left kidney may overlie 11th rib on XR, Overlies the iliohypogastric and ilioinguinal nerves. Renal artery is posterior to vein Tail of pancreas separates the hilum of the left kidney from the peritoneum

Question 89

Dynamic test in ?anastomotic leak

Answer 89

Gastrografin enema. CT scan just gives a static image. It may show a collection of fluid or gas bubble but is not accurate for showing an active leak such as with a contrast enema

Question 90

Large mucous containing cyst in the small of the mouth. Develops on one side of the floor of the mouth and slowly enlarges to form a bluish fluctuant swelling beneath the sublingual mucosa that transilluminates.

Answer 90

Ranula

Question 91

Answer 91

Ranula

Question 92

Aetiological factors in oral cavity cancers S

Answer 92

Spirits Smoking Syphillis Papillomavirus Sore tooth (trauma)

Question 93

Synchronous and metachronous tumours in carcinoma of the oral cavity

Answer 93

5 and 10% respectively

Question 94

Management of choledochal cyst

Answer 94

Roux-en-Y hepaticojejunostomy

Question 95

Congenital segmental cystic dilatation of the biliary tree. In Type 1 cysts, dilatation of the extrahepatic bile duct, treatment involves excision of the cyst and restoration of the biliary drainage using Roux-en-Y hepaticojejunostomy,

Answer 95

Choledochal cysts

Question 96

Double duct sign

Answer 96

Dilatation of both the pancreatic and biliary duct High indicative of pancreatic cancer but may also present in chronic pancreatitis

Question 97

T1 skin cancer

Answer 97

1mm

Question 98

T2 MM

Answer 98

1.01-2.00mm

Question 99

T3 MM

Answer 99

2.01-4.0mm

Question 100

T4 MM

Answer 100

\>4.0mm

Question 101

N0 MM

Answer 101

No lymph node involvement

Question 102

N1 MM

Answer 102

One LN

Question 103

N2 MM

Answer 103

Two or three LNs or satellite/in-transit lesions

Question 104

N3 MM

Answer 104

Four or more LNs

Question 105

M0 MM

Answer 105

No mets

Question 106

M1a MM

Answer 106

Distant skin or LN mets

Question 107

M1b MM

Answer 107

Lung mets

Question 108

M1c MM

Answer 108

All other visceral mets

Question 109

Stage 0 MM

Answer 109

Tis, N0, M0

Question 110

Stage I MM

Answer 110

T1a-T2a, N0, M0

Question 111

Stage III MM

Answer 111

Any T, N1-3, M0

Question 112

Stage IV MM

Answer 112

Any T, Any N, M1a-c

Question 113

a and b subscripts in T staging of MM

Answer 113

a indicates without ulceration b indicates with ulceration

Question 114

Extra-articular distal radial fracture with volar displacement

Answer 114

Smith's fracture

Question 115

Extra articular fracture with dorsal and radial displacement of distal fragment

Answer 115

Colle's

Question 116

Intra-articular distal radial fracture either volar or dorsal where the articular surface of the distal radius subluxes from the carpals

Answer 116

Barton's fracture

Question 117

Dragging sensation in pelvis Urinary, sexual and rectal evacuatory function impaired resulting in voiding difficulties/urinary incontinence.

Answer 117

?Uterovaginal prolapse

Question 118

Bladder pain and irritative bladder symptoms Pain worse on bladder distension and eased on micturition Negative urine cultures

Answer 118

?Painful bladder syndrome

Question 119

Diagnosis of painful bladder syndrome

Answer 119

Urine should be cultured for atypical organisms Cystometry and cystoscopy are useful and reveal low capacity, non-compliant bladder

Question 120

Most sensitive ultrasound finding in acute cholecystitis

Answer 120

Cholelithiasis in combination with sonographic murphy's sign

Question 121

Surgical management of subclavian steal syndrome

Answer 121

Carotid-subclavian bypass

Question 122

Bypass required following endovascular repair of thoracic aneurysm where the origin of the left carotid is covered by the stent graft

Answer 122

Carotid-carotid bypass

Question 123

Most effective method for preventing transmission of MRSA?

Answer 123

Good hygiene

Question 124

Embryological precursor of the prostate

Answer 124

Urogenital sinus

Question 125

In what proportion of critically ill patients is acute renal failure seen?

Answer 125

30%

Question 126

Morbidity and mortality associated with acute renal failure?

Answer 126

60% increase

Question 127

Roles of VIP

Answer 127

Vasoactive intestinal peptide has various roles in the intestine including: vasodilation in the GI resistance vessels Relaxation of enteric smooth muscle Inhibition of gastric acid secretion Stimulation of pancreatic juice and bile secretion

Question 128

What percentage burn accounts to the palmar area?

Answer 128

1%

Question 129

How to prevent tension pneumothorax when dressing open pneumothorax?

Answer 129

Tape dressing on three sides to create a flutter-type valve effect

Question 130

Most common cause of tension pneumothorax

Answer 130

Mechanical ventilation in patient with visceral pleural injury

Question 131

Respiratory consequence of hypoxia

Answer 131

Respiratory alkalosis through increased ventilation

Question 132

Causes of femoral nerve injury

Answer 132

Gunshot wound Traction during surgery Femoral triangle injury Massive haematoma Patients with DM Lumbar spondylosis

Question 133

Vital capacity

Answer 133

Approx 70ml/kg

Question 134

In which penile structure is the pathology of Peyronie's disease?

Answer 134

Peyronie's disease is a chronic inflammation of the tunica albuginea which surrounds the corpora cavernosa of the penis. With time, fibrous tissue develops which causes the abnormal curvature and other symptoms

Question 135

Mechanisms of development of posterior urethral valves

Answer 135

Hypertrophy of the urethral mucosal folds Abnormal development of the Wolffian duct Fusion of the verumontanum Persistence of the urogenital membrane

Question 136

Rare anterior midline defect of the infra-umbilical region affecting the pelvis, abdominal muscles, urinary tract and external gentialia Presents as incomplete closure of the lower abdominal wall at the midline and protrusion of the bladder through the defect. Typical examination findings are a low set umbilicus, red patch of mucosa freely draining urine. Wide pubic symphysis, open urethra, absent mons pubis and bifid clitoris

Answer 136

Bladder exstrophy

Question 137

Congenital defect where the urethral opening is found near the head of the penis on the inferior side rather than at the tip Caused by incomplete fusion of the urethral folds and commonly associated with undescended testes.

Answer 137

Hypospadias

Question 138

Surgical managmenet of bladder exstrophy

Answer 138

Operation to close bladder and pelvis at birth Genitoplasty at 2y Bladder neck repair to achieve continence at 4-5y

Question 139

Rare congenital abnormalities in the form of diverticula that typically occur when there is a defect in the corpus spongiosum This leaves a thin walled uretha that balloons out during voiding. Rarer than posterior urethral valves. Can present with recurrent UTIs, dribbling or weak stream Diagnosis is with voiding studies showing a dilatatioin in the urethra US shows evidence of hydronephrosis,

Answer 139

Anterior uretrhral valves

Question 140

Renal regulation of potassium in respiratory acidosis

Answer 140

Renal excretion of potassium would fall since tubular secretion of potassium is inversely coupled to acid secretion

Question 141

Inguinal hernia repair approach

Answer 141

Litchenstein repair recommended

Question 142

Pseudobulbar palsy vs bulbar palsy

Answer 142

Bulbar palsy is LMN. Pseudobulbar is UMN

Question 143

Causes of anal fistula

Answer 143

Up to 80% are due to abscess Other causes include post-surgical, trauma, penetrating injury, TB, Crohn's

Question 144

Murmur in VSD

Answer 144

Continuous systolic murmur/pansystolic murmur

Question 145

Murmur in ASD

Answer 145

No murmur Split of the HS II is fixed throughout diastole and systole

Question 146

Where in the kidney is PO4 reabsorbed?

Answer 146

PO4 is reabsrobed in the PCT under the control of PTH

Question 147

Which part of the nephron receives its blood supply from the vasa recta?

Answer 147

Loop of Henle

Question 148

Location of calcium reabsorption in the kidney?

Answer 148

Ascending loop of Henle Distal tubule Collecting tubule

Question 149

What is absorbed in the PCT?

Answer 149

Actively reabsorbs sodium, establishing the osmotic gradient leading to water being drawn out of the tubule

Question 150

Borchardt's triad

Answer 150

Gastric volvulus Epigastric pain, retching without vomiting and inability to pass an NG tube

Question 151

What are the two planes in which gastric volvulus can occur?

Answer 151

Along the long axis of the stomach: organoaxial or Around the axis perpendicular to the stomach: mesenteroaxial

Question 152

Cervical lesion occuring secondary to OCP and must be distinguished from adenocarcinoma histologically

Answer 152

Endocervical polyp

Question 153

Endocervical polyp

Answer 153

Common benign growths of the cervix and endocervix which originate in the endocervical canal. Occur in 2-5% of women. Most are asymptomatic but they can cause IMB or PCB and can become infected causing purulent vaginal discharge. Normally reddish-pink, \<1cm and friable. Rarely malignant

Question 154

Which BZD is preferred in IV sedation?

Answer 154

Midazolam as it is shorter acting than diazepam and easier to control and reverse

Question 155

Opiate and sedative use

Answer 155

When sedation is given in conjuction with IV opiate analgesia, the sedative drug is best given a few minutes before

Question 156

What proportion of gastric cancers can be accounted for by H. pylroi?

Answer 156

65-80% of gastric carcinomas. But these occur in only 2% of infections

Question 157

Consequence of maltase deficiency?

Answer 157

Result in a reduction of maltose hydroylsis, leading to increased passage of maltose in stool.

Question 158

Young children with unhealed burns are at risk of?

Answer 158

Staphylococcus aureus medaited toxic shock syndrome as their immunity is compromised. Treatment is supportive with IVF, Ig therapy and Abx cover. Should be admitted to HDU under paediatrics/anaesthetics/plastics

Question 159

Endothelin-1

Answer 159

21 amino acid polypeptide Highly potent vasoconstrictor Levels increase when endothelium is stressed, e.g. trauma or oxidative stress. Modulates vascular tone. May also have a role in diseases such as Raynaud's

Question 160

ICAM-1

Answer 160

Cellular adhesion molecule which is increased during inflammation and by IL-1

Question 161

Presentation of spinal mets

Answer 161

90% present with back/bone pain followed by radicular pain. Sensory or motor neurology occurs in 50%

Question 162

What proportion of patients with palliative cancer have spinal mets?

Answer 162

30%

Question 163

Relative contraindication to surgical decompression in SC compression?

Answer 163

Complete paraplegia lasting \>24h

Question 164

Which of the following is correct regarding the mid-point of the inguinal ligament It is the surface marking of the femoral pulse It is halfway between ASIS and pubic symphysis It is immediately superior to the deep inguinal ring It lies closer to the midline on the left than right It lies laterally to the mid-inguinal point

Answer 164

It lies laterally to the mid-inguinal point. It is at a point halfway between ASIS and pubic tubercle and is the surface landmark of deep inguinal ring. It is lateral to the mid-inguinal point. The femoral pulse is at the mid-inguinal point

Question 165

Which of the following muscles is not found in the anterior compartment of the leg? Tibialis anterior EHL EDL Peroneus tertius Peroneus brevis

Answer 165

Peroneus brevis is found in the lateral compartment

Question 166

Which of the following clotting factors is not a serine protease? XI II IX XII XIII

Answer 166

XIII is a transglutaminase, the rest are serine proteases

Question 167

Causes of bilaterally small pupils

Answer 167

Opiates Destructive pontine lesion Metabolic encephalopathy

Question 168

13 y/o boy Tiredness, recurrent throat and chest infections, gradual loss of hearing. XR shows marble bone appearance

Answer 168

Osteopetrosis

Question 169

Autosomal recessive condition May present with symptoms of anaemia or thrombocytopenia and leucopaenia because of decreased marrow space Deafness and optic atrophy can result from cranial nerve compression Bloods may show a leucoerythroblastic picture Bones are dense and brittle. XR shows lack of differentiation between cortex and medulla described as marble bone

Answer 169

Osteopetrosis

Question 170

Cause of pseudoparalysis in scurvy

Answer 170

Subperiosteal bleeding may cause a haematoma and the child may remain still- pseudoparalysis

Question 171

Cupped apearance on XR

Answer 171

?Rickets

Question 172

Rate of remission in children with Grave's treated with antithyroid drugs?

Answer 172

1 in 3.

Question 173

The external laryngeal nerve must be identified before ligating which artery during thyroidectomy?

Answer 173

Superior thyroid artery

Question 174

Invasive nature of sarcoma

Answer 174

Spreads across fascial planes and metastasises haematogenously. Lungs are the most common site of mets They spread by pushing along tissue planes rather than by direct invasion. Fascia, major nerve sheaths and adventitia of large vessels are relatively resistant to invasion

Question 175

Colour of urine in hepatic jaundice?

Answer 175

Dark urine

Question 176

Mild jaundice Normal coloured urine and faeces Unconjugated bilirubin Normal transaminases Normal ALP

Answer 176

Prehepatic

Question 177

Variable jaundice severity Dark urine Normal stool Unconjugated and conjugated bilirubin Grossly increased transaminases Mildly elevated ALP

Answer 177

Hepatic

Question 178

Deep jaundice Dark urine Pale stool Conjugated bilirubin Normal or mild increase in transaminases Grossly elevated ALP

Answer 178

Post-hepatic

Question 179

25y/o Painless 8/12 scrotal swelling attributed to an injury playing football. Uniform swelling over testis which is firm and smooth with loss of testicular sensation

Answer 179

Testicular teratoma. Most men present with painless swelling. Usual presentation is heaviness in the testis and groin. Sensation is lost early and a small hydrocele may be present with a thickened spermatic cord from malignant infiltration

Question 180

42 y/o man of Asian origin presents with aching left sided scrotal pain with swelling for 18/12 O/E the left sided scrotum hangs lower, cough impulse present and left testis smaller than right. The swelling disappears on lying down

Answer 180

Varicocele. Swelling disappears on lying down as veins empty Long standing cases may cause testicular atrophy and are associated with infertility

Question 181

Seen in middle aged men. Common PC is scrotal swelling. Cough impulse absent O/E with dullness to percussion and able to get above it. Testis impalpable, fluctuant and transilluminates

Answer 181

Hydrocele

Question 182

MOA ketoconazole

Answer 182

Inhibits the biosynthesis of ergotsterol by blocking demethylation at the C14 site of the ergosterol precursor lanosterol. This results in the accumulation of lanosterol-like sterols in the cell, which alters the properties of the cell membrane and permits leakage of potassium ions

Question 183

MOA amphotericin and nystatin

Answer 183

Impair cell membrane permeability by directly complexing with the membrane sterol

Question 184

MOA griseofulvin

Answer 184

Inhibits microtubules

Question 185

MOA flucytosine

Answer 185

Incorporated into RNA after deamination and phosphorylated. Also interferes with DNA synthesis as it is a non-competitive inhibitor of thymidylate synthetase

Question 186

Cx of epididmyitis

Answer 186

Abscess formation Testis infarction Chronic pain and infection Infertility

Question 187

Incision line for episotomy

Answer 187

Posterolateral rather than median If a median incision is made then further tears during delivery are likely to extend along that incision line, posteriorly through to the EAS and rectum.

Question 188

Metastatic adenocarcinoma, aneurysms

Answer 188

Metastatic lung adenocarcinoma has been documented in the literature to cause intracerebral aneurysms but is not the cause of mycotic aneurysms

Question 189

NCEPDO classification

Answer 189

Classification of intervention that rationalises available theatre resources and delivers them to those who require care by urgency of injuries

Question 190

NCEPOD 1

Answer 190

Immediate life, limb or organ-saving intervention. Resuscitation simultaneous with intervention. Normally within minutes of decision to operate a Life-saving b Other e.g. limb or organ saving

Question 191

NCEPOD2

Answer 191

Urgent intervention for acute onset or clinical deterioriation of potentially life-threatening conditions for those conditions that may threaten the survivial of limb or organ, for fixation of fractures and for relief of pain or other distressing symptoms. Normally within hours of decision to operate

Question 192

NCEPOD 3

Answer 192

Expedited Patient requiring early treatment where the condition is not an immediate threat to life, limb or organ survival. Normally within days of decision to operate

Question 193

NCEPOD 4

Answer 193

Elective Intervention planned or booked in advance of routine admission to hospital

Question 194

Post-streptococcal glomerulonephritis Gel-Coombs classification

Answer 194

Type III as immune complex disease

Question 195

Action of segmentation w.r.t. GI motility

Answer 195

Segmentation efficiently mixes chyme with mucus and hydrolytic enzymes through contraction of isolated segments found at segments along the intestine

Question 196

Auer rods in peripheral blood film

Answer 196

AML

Question 197

Carbohydrate requirement per day?

Answer 197

2g/kg/d

Question 198

Nitrogen requirement per day

Answer 198

0.5-1g/kg/d

Question 199

Water requirement /day

Answer 199

35ml/kg/d

Question 200

Describe the two phases of testicular descent

Answer 200

First phase happens from the abdomen to the internal inguinal ring. Gubernaculum thickens and shortens, anchoring the testes in the first place. In the second phase, the muscular part of the gubernaculum, responding to androgens, grows and differnetiates, migrating the testis through the inguinal region by traction. In patients with undescended testis, the gubernaculum fails to undergo these changes.

Question 201

Allantois

Answer 201

Evagination of the hindgut and becomes the urachus, connecting the fetal bladder to the yolk sac and aids the removal of waste products from the fetus

Question 202

Complications of undescended testis TESTIS

Answer 202

Trauma Epididymo-orchitis Sterility Torsion Intestinal hernia Seminoma

Question 203

Genital tubercle

Answer 203

Develops around the fourth week of gestation and will give rise to the clitoris in women and penis in men

Question 204

Sun exposure pattern risk for melanoma

Answer 204

Short periods of intesnse sun exposure thought to be more significant risk factor than cumulative sun exposure

Question 205

Hawkin's test is for

Answer 205

Subacromial impingement

Question 206

Jobe's test is for

Answer 206

Supraspinatus

Question 207

Internal rotation lag sign and greber's lift off test assess

Answer 207

Subscapularis

Question 208

What is the most important direct stimulus to respiration

Answer 208

Central chemoreceptors located in the ventral medulla are the most important stimulus They respond to increased H concentration of cerebral ECF (which is directly linked to CSF). H/HCO3 cannot directly cross the BBB but CO2 does. This frees H ions causing a low CSF pH and stimulates central chemoreceptors to fire

Question 209

Ober's test

Answer 209

For tight iliotibial band

Question 210

50y/o man with hoarse voice. Ix reveals small invasive carcinoma of left vocal cord invading thyroid cartialge. Left vocal cord is paralysed and there is a 4cm LN in the left anterior neck. Total laryngectomy and neck dissection RTx CTx Excision of vocal cord mucosa

Answer 210

Total laryngectomy and neck dissection. Surgical options for patients with advanced stage largneal cancer.

Question 211

Use of total laryngectomy in laryngeal carcinoma

Answer 211

Options for patients with: Tumours with cartilage destruction and anterior spread outside the larynx Posterior commissure or bilateral arytenoid joint involvement Circumferential submucosal disease Subglottic extension and invasion of the cricoid cartilage. Can be considered as a salvage options in patients who fail RTx or partial laryngectomy. Can be considered in patients with extralaryngeal tumours that have invaded the larynx such as advanced thyroid and base of tongue cancer. Adenocarcinomas are less RTx sensitive so surgical managment may be considered. Patients with radiation necrosis of the larynx and severe aspiration can also be offered total laryngectomy

Question 212

65 y/o with T1 carcinoma of vocal cord with absence of anterior commissure involvement Total laryngectomy and neck dissection RTx CTx Excision of vocal cord mucosa

Answer 212

Excision of mucosa RTx is as effective as surgery in the treatment of T1 tumours but the resulting voice quality is better after sx

Question 213

55y/o lady with glottic carcinoma involving anterior commissure Total laryngectomy and neck dissection RTx CTx Excision of vocal cord mucosa

Answer 213

RTx

Question 214

70y/o woman with large supraglottic carcinoma Total laryngectomy and neck dissection RTx CTx Excision of vocal cord mucosa

Answer 214

Nodal mets are found in 55% of supraglottic tumours. Therefore radical neck dissection is often required for large supraglottic tumours

Question 215

Triad in laryngeal fracture

Answer 215

Hoarseness of voice Subcutaneous emphysema Palpable fracture Other signs and symptoms include stridor, dysphagia, haemoptysis, laryngeal tenderness, odynophagia, anterior neck pain. There may be loss of thyroid cartilage prominence and ecchymosis in overlying skin

Question 216

Mx of ?laryngeal fracture

Answer 216

If airway is obstructed an attempt at endotracheal intubation is warranted (together with C-spine immobilisation if traumatic)

Question 217

Use of unpaired t-test

Answer 217

To compare two separate groups at the same point in time

Question 218

Use of paired t test

Answer 218

To compare one group at two points in time

Question 219

Use of Friedman test

Answer 219

Used to compare three or more groups if the data are non-parametrical

Question 220

ANOVA

Answer 220

Used to compare three or more groups if the data are parametrical

Question 221

Pearson correlation coefficient

Answer 221

Measure of the strength of linear relationship between two variables

Question 222

Damage to the external laryngeal nerve causes

Answer 222

Loss of high pitched phonation

Question 223

Approach to control of inferior thyroid vasculature during thyroidectomy

Answer 223

Artery should be ligated in continuity before the inferior thyroid veins

Question 224

Patient deficient in coagulation factor that forms a complex with TF to activate factors IX and X Which factor is most likely deficient? Prothrombin Fibrinogen Factor VII Factor XI Factor XII

Answer 224

Factor VII

Question 225

Aaron's sign

Answer 225

Pain referred to epigastrium upon continuous firm pressure over McBurney's point Seen in appendicitis

Question 226

Dunphy's sign

Answer 226

Increased abdominal pain with coughing. Often seen in appendicitis

Question 227

From which sinus does osteomylelitis most commonly develop?

Answer 227

Frontal sinus

Question 228

Classification of the complications of sinusitis?

Answer 228

Intracranial Orbital Osteomyelitis

Question 229

Intracranial complications of sinusitis

Answer 229

Meningitis Abscesses CVST

Question 230

Orbital complications of sinusitis

Answer 230

Erosion of the orbital wall Orbital cellulitis Subperiosteal abscess Eyeball destruction

Question 231

Plane to take in tracheostomy

Answer 231

Dissecting in the midline ensures a relatively avascular plane down to the pre-tracheal fascia. Large vessles lie lateral to the midline protected by sternocleidomastoid

Question 232

Position of the head during tracheostomy?

Answer 232

Head should be extended

Question 233

Tracheal rings incised during tracheostomy

Answer 233

2nd and 3rd (incision of the 1st i.e. the cricoid carilage will lead to airway compromise)

Question 234

Injury to the radial nerve in the spiral groove of the humerus causes loss of which of the following? Thumb abduction Elbow extension Pronation Supination Cutaneous sensation over the dorsal surface of the first webspace

Answer 234

The radial nerve divides into the deep motor (posterior interosseous) and superficial sensory branches, just proximally to the supinator at the lateral epicondyle. The superficial branch travels beneath brachioradialis to supply sensation to the radial dorsum of the hand tested at the first dorsal webspace. Sensation here would be lost. Pronation is performed by pronator teres, which is innervated by the median nerve. Thumb abduction is caused by median nerve injury generally (weakened by radial nerve injury) Branches to triceps occur before the radial groove of the humerus. Supination is achieved by the biceps brachii (musculocutaneous) and supinator (radial) hence it would not be lost.

Question 235

With what is Dupuytren's disease associated?

Answer 235

Knuckle pads, Peyronies disease, Ledderhose disease, Not RPF

Question 236

Ledderhose disease

Answer 236

Plantar fibromatosis

Question 237

High velocity penetrating gun shot wounds or low-velocity penetrating abdominal injury with hypotension or shock=

Answer 237

Indications for immediate laparotomy

Question 238

Which of the following is the anterior relation to the third part of the duodenum? Coeliac artery Pancreatic head Right psoas muscle Right renal artery SM vessels

Answer 238

SM vessels lie anterior to the third part of the duodenum The third part of the duodenum overlies the aorta and the beginning of the IMA. Root of the small bowel mesentery is attached near its termination on the left

Question 239

MCV=

Answer 239

HCt x 1000/RBC

Question 240

Which of the following anatomical structures is most closely related to the body of the pancreas? Greater curve of the stomach SMV Right kidney Transverse mesocolon Lies in the transpyloric plane

Answer 240

Transverse mesocolon is attached to the head, neck and body of the pancreas. The head of the pancreas overlies the right renal vessels but not the kidney itself. The transpyloric plane transects the pancreas obliquely, passing through the midpoint of the neck with most of the head below the plane and most of the body and tail above. The uncinate process lies posterior to the SM vessels and IMV passes behind the body of the pancreas when it joins the splenic vein. Entering the lesser sac between the transverse mesocolon and body of the pancreas is a common method for laparoscopic mobilisation of the splenic flexure

Question 241

Which vessel is at risk during elective right hemicolectomy and arises at L2, passing anteriorly to the IVC? Common iliac IMA Middle suprarenal artery Right ovarian Right renal

Answer 241

Gonadal vessles arise at L2 and dsecend into the pelvis anterior to IVC and ureturs. They should be identified and preserved during mobilisation of the left and right colon. The right renal artery passes posteriorly to the IVC

Question 242

Interpretation of mammograms in breast cancer screening programmes

Answer 242

2 view mammograms that are interpreted by 2 consultant radiologists with further imaging +/- biopsies organised as needed

Question 243

Which coronary vessel supplies the AVN?

Answer 243

AVN is supplied by the AVN branch, a branch of the posterior interventricular artery. In the vast majority of the population, the posterior interventricular artery arises from the RCA.

Question 244

Mean survival time from diagnosis to death or liver transplant in PSC?

Answer 244

2 years 75% of asymptomatic patients are alive at 5 years

Question 245

10y/o girl presents with severe headache and paralysis of CN VI. She has recently been treated by GP for an ear infection which has resolved. On examination you note papilloedema Brain abscess Lateral sinus thrombosis Mastoiditis Otitic hydrocephalus Peri-sinus abscess

Answer 245

Otitic hydrocephalus is a syndrome of raised ICP, most commonly in children and adolescents during or following middle ear infection without brain abscess Aetiology is unknown Otic hydrocephalus is an uncommon complication of otitis media. It is characterized by increased intracranial pressure without associated hydrocephalus. Patients present with headache, malaise, and vision changes. Papilledema and abducens palsy on ocular examination are common clinical finding. Lumbar puncture is indicated. When it demonstrates elevated cerebrospinal fluid (CSF) opening pressure, the diagnosis of otitic hydrocephalus is made. The pathophysiology and diagnostic work up including imaging modalities are reviewed. Ventriculoperitoneal shunting, emergency mastoidectomy with removal of granulation tissue near the sigmoid sinus is performed expeditiously. Medical treatment includes intravenous antibiotics and anticoagulants, diuretics, such as acetazolamide, and systemic steroids.

Question 246

What are the two types of dumping syndromes?

Answer 246

Early dumping: dizziness, sweating and palpitations within 5-45 minutes of eating. Late dumping: 2-4h after eating and due to rebound hypoglycaemia, small meals and glucose help symptoms

Question 247

Localised region of injection in the eye

Answer 247

?episcleritis/slceritis

Question 248

Differentiator between episcleritis and scleritis

Answer 248

Episcleritis is much less painful than scleritis, in which the inflammation is more extensive

Question 249

Blood in the anterior chamber of the eye

Answer 249

Hyphaemia Must be treated as an emergency as further bleeding may increase IOP and compromise sight

Question 250

Inflammation of the iris and ciliary body?

Answer 250

Anterior uveitis

Question 251

56y/o Trauma 5 days previously presenting with fluctuant swelling under scalp and bilateral swollen eyelids. O/E swelling extends from the frontal to occipital region. GCS 15

Answer 251

Subaponeurotic haematoma In contrast to localised scalp haematomas, subaponeurotic haematomas are diffuse, arising in the space between the galea and pericranium Usually occur a few days after a head injury.

Question 252

Which vein is most likely to be the cause of haemorrhage during routine tracheostomy? Anterior jugular EJV IJV Middle throid Superior thyroid

Answer 252

Anterior jugular vein and inferior thyroid veins may be encountered. The rest are too lateral

Question 253

Detrusor-external sphincter dyssynergia

Answer 253

Higher centre for co-ordination of the bladder with urethral function lies in the pons and is known as pontine micturition centre The cell bodies of the PNS to the detrusor muscle S2-4 and somatic fibres innervating the striated urethral sphincter are located in the sacral SC. They receive descending impulses from the PMC which is therefore responsible for ensuring contraction of the bladder and relaxation of the sphincter occur simultaneously to allow voiding. In DESD, the PMC is disconnected from the sacral SC (e.g. SC injury) and patients lose bladder sphincter synchronisation. Subsequently the bladder contracts forcibly against closed urethral sphincter and these patients develop retention with high bladder pressure leading to back pressure and failure. As the patient tries to pass urine, the voiding cystourethrogram shows the external sphincter positioned between the prostatic and bulbar urethra, continuing to contract when it should be relaxing

Question 254

Transport of CO2 in the blood

Answer 254

Carboxyhaemoglobin is the transport of CO on Hb, not CO2 CO2 is transported dissloved in the blood

Question 255

Which structure in the lumbar spinal canal may be responsible for spinal stenosis Normal facet joints Normal intervertebral disc anteriorly Synovial facet cysts posteriorly Ligamentum flavum posteriorly Posterior longitudinal ligament

Answer 255

Ligamentum flavum can thicken and hypertrophy, narrowing the spinal canl causing stenosis

Question 256

Def: detrusor overactivity

Answer 256

Refers to objective contraction, spontaneous or provoked, during the filling phase of cystometry, while the patient is attempting to inhibit micturition. It is a urodynamic diagnosis and may result in the leakage of urine. May occur secondary to neuropathic lesions or bladder outflow obstruction in men. There is associated trabeculation in the case of chronic obstruction and increasing bladder irritability.

Question 257

Most common cause of urinary fistulation in developed world

Answer 257

Gynaecological surgery

Question 258

Most common cause of urinary fistulation in developing world?

Answer 258

Obstetric injury

Question 259

def: urinary incontinence

Answer 259

Involunatry loss of urine which is objectively demonstrable and a social or hygienic problem

Question 260

Classification of urinary incontinence?

Answer 260

Urethral Extra-urethral

Question 261

Urethral causes of urinary incontinence

Answer 261

Urethral sphincter incompetence Detrusor overactivity Overflow incontinence UTI Urethral diverticulum Functional

Question 262

Extra-urethral causes of urinary incontinence

Answer 262

Congenital e.g. ectopic uretur Fistula formation

Question 263

Most appropriate tourniquet pressure and time for distal limb

Answer 263

Pressure 50mmHg above DBP Time: 60 minutes

Question 264

Likely location of aspirated contents whilst standing

Answer 264

Right anterior basal

Question 265

Likely location of aspirated contents whilst lying

Answer 265

Right lateral basal

Question 266

Which vessel courses across the mediastinum in almost horizontal fashion?

Answer 266

Left brachiocephalic vein

Question 267

Arrangement of structures at the lung roots

Answer 267

Pulmonary artery superior Bronchus posteriorly Pulmonary veins inferiorly Bronchus at back AV top down alphabetical order

Question 268

What proportion of triglyceride digestion occurs due to lingual lipase in a healthy individual?

Answer 268

20%

Question 269

What auto-Abs are found most commonly in Hashimoto's thyroiditis?

Answer 269

Anti-TPO (anti-microsomal) Anti-thyroglobulin

Question 270

Gold standard Ix in ?aortic rupture

Answer 270

Arteriography

Question 271

Serum amylase in DKA

Answer 271

Patients in DKA often have elevated serum amylase activities as a result of decreased renal excretion of the enzyme.

Question 272

Indications for endovascular repair of Stanford B dissection

Answer 272

Persistent pain Increasing aortic diameter Evidence of malperfusion of organs supplied by branch vessels Evidence of periaortic/mediastinal haematoma

Question 273

Treatment of symptomatic liver cyst

Answer 273

Laparoscopic deroofing

Question 274

Treatment of liver cyst caused by entamoeba histolytica

Answer 274

Metronidazole for 5-10/7 and percutaneous drainage is not usually required

Question 275

Kasbach-Merritt Syndrome

Answer 275

Large hepatic haemangiomas with thrombocytopenia and DIC

Question 276

Clinical course of necrobiosis lipoidica

Answer 276

Dusky red-\> skin atrophy. May ulcerate in the centre, secondary to minimal trauma. A distinctive yellowish cast in the atrophic telangiectatic centre of the lesion is characteristic. Typically ulceration is slow to heal, painful and frequently complicated by infection

Question 277

Causes of unilateral non function on IVU

Answer 277

Absent kidney Thrombosis or avulsion of the renal artery Massive parenchymal disruption

Question 278

Root of the small bowel mesentery?

Answer 278

Overlies the right SI joint

Question 279

SIADH in lung cancer suggests?

Answer 279

Unresectable disease

Question 280

Mediastinal lymphadenopathy in bronchial carcinoma

Answer 280

Suggests distant mets Unresectable

Question 281

Trisomy 18

Answer 281

Edward syndrome

Question 282

Edward syndrome

Answer 282

Trisomy 18 Multiple developmental defects including talipesequinovarus and polydactyl

Question 283

What protein functions as cofactor in the thrombin induced activation of protein C?

Answer 283

Thrombomodulin, a membrane protein expressed by endothelial cells.

Question 284

Actions of thrombomodulin bound thrombin

Answer 284

Inhibits fibrinolysis Activates Protein C

Question 285

Merkel cell carcinoma

Answer 285

Rare but highly aggressive tumour derived from the Merkel-cell poplation, which are primitive neuroendocrine cells in the skin. Approximately half of the patients are dead within two years

Question 286

Whipple's triad

Answer 286

Hypoglycaemic symptoms during fasting Low fasting blood sugar levels Symptoms relieved by IV dextrose Characteristic of insulinomas

Question 287

Differential for cystic lesions in the pancreas?

Answer 287

Serous cystadenoma, mucinous cystic neoplasm, intraductal papillary mucinous neoplasm Serous cystadenomas are benign whereas the other two have malignant potential. Pancreatic pseudocysts are another differential though tend to be unilocular

Question 288

Hagen-Poiseullie law states that flow through a vessel is

Answer 288

Directly proportional to the pressure head of flow Directly proportional to the fourth power of radius Inversely proportional to viscosity Inversely proportional to length of the tube

Question 289

Significance of Hagen-Poiseuille law w.r.t. central and peripheral venous lines

Answer 289

Flow is greater through peripheral cannnual as they are short and wide whereas central lines are long with a narrow lumen

Question 290

To what part of the heart dose the sinus venosus (large quadrangular cavity located between the two vena caval vessels in embryonic heart) give rise?

Answer 290

Coronary sinus Gives rise to the smooth part of the right atrium and the coronary sinus In contrast to the auricle which develops from the primitive atrium, along with the trabeculated portion of the right atrium

Question 291

Formation of the fossa ovalis?

Answer 291

Formed through fusion of the septum primum and septum secundum

Question 292

Optimal time for interval appendicectomy?

Answer 292

~6 weeks

Question 293

Optimal time for reversal of Hartmann's?

Answer 293

6 months

Question 294

Rate of pancolitis in UC

Answer 294

10%

Question 295

Which nerve supplies the platysma

Answer 295

Facial nerve supplies all the muscles of facial expression including the platysma.

Question 296

Abx in the treatment of cryptosporidium?

Answer 296

Paromycin is the only effective treatment (other than supportive) Drug may have limited effect on the diarrhoea

Question 297

Which LNs are least likely to be sampled during mediastinoscopy for NSCLC? Paratracheal nodes Subcarinal nodes Tracheobronchial nodes Aortopulmonary nodes Pretrachaeal nodes

Answer 297

Aortopulmonary nodes are difficult to access via mediastinoscopy as the aorta is in the way. They are accessed via thorascopy.

Question 298

At what [bilirubin] does jaundice become clinically apparent?

Answer 298

\>40

Question 299

Deformity associated with myelmeningocele

Answer 299

Hydrocephalus (seen in 80%)

Question 300

Pierre Robin Sequence

Answer 300

Micrognathia Retraction of the tongue Upper airway obstruction

Question 301

Peanut farming increases the risk of what cancer?

Answer 301

Exposure to aflatoxin increases risk of HCC

Question 302

Painting and printing increase the risk of what cancer?

Answer 302

Benzopyrene exposure-\> increased risk of lung Ca

Question 303

Cantlie's line

Answer 303

Main portal scissura that divides the liver into functional right and left lobes

Question 304

Incidence of alloantibodies is higher in

Answer 304

Women because of non-self red-cell antigen exposure in pregnancy

Question 305

On what immune cells are the Fc receptors for IgG found?

Answer 305

Neutrophils and macrophages

Question 306

Rate of HPV infection in anorectal SCC

Answer 306

70% of patients test positive to the virus

Question 307

ECG changes seen following Swan-Ganz catheterisation

Answer 307

Transient RBBB seen in up to 5% of patients but usually resolves within 24 hours

Question 308

In what part of the nephron are most amino acids and glucose absorbed?

Answer 308

PCT

Question 309

Which vessel runs through the right coronary sulcus?

Answer 309

Right coronary artery

Question 310

Conus artery

Answer 310

Present in 45% of the population and can provide collateral circulation in LAD occlusion

Question 311

Attrition bias

Answer 311

Occurs when there is a difference between withdrawals and dropout between study groups-\> incomplete outcome data

Question 312

Average survival after diagnosis of metastatic prostate cancer

Answer 312

2 years

Question 313

What proportion of men over 50 have microscopic malignant changes in the prostate at autopsy?

Answer 313

1/3rd This increases to 90% over 90

Question 314

Ballance's sign

Answer 314

Occurs when a large blood clot forms around a ruptured spleen with free intraperitoneal blood on the right flank. O/E: both flanks are dull to percussion. On the right, the dullness shifts when the patient is tilted to the left. On the left the dullness is fixed

Question 315

Kehr's sign

Answer 315

Irritation of left diaphragm causing left shoulder tip pain

Question 316

Criteria for hypersplenism

Answer 316

Splenomegaly Any combination of anaemia, leucopaenia or thrombocytopenia. Bone marrow hyperplasia Improvement after splenectomy

Question 317

Impact of preoperative carbohydrate loading in EPR

Answer 317

Reduces postoperative insulin resistance and has been shown to reduce anxiety, thirst, nausea and hunger

Question 318

26y/o IVDU Admitted with ulcer around groin injection site and surrounding oedema Becomes acutely unwell over next 24h and ulcer develops a black eschar What diagnosis do you need to consider? Cellulitis Cutaneous anthrax Erysipelas Nec fasc Staphylococcus scalded skin syndrome

Answer 318

Cutaneous anthrax Develop 2-3 days following exposure and develop a black eschar 2-6 days after appearing Treatment is with Ig, ABx, ITU support and surgical debridgement

Question 319

Originate from paraganglionic cells at the carotid bifurcation 5% metastasize within 10y if untreated

Answer 319

Chemodectoma

Question 320

Angiosarcoma

Answer 320

Develop in extremities. Radiosensitive and respond to chemotherapy. Radical amputation still advised

Question 321

Haemangiosarcoma caused by viral infection

Answer 321

Kaposi's

Question 322

Tumour associated with buzzing sensation in head

Answer 322

Glomus jugulare tumour Arise from jugular bulb Should not be confused with glomus tumour

Question 323

What is the only true benign blood vessel tumour

Answer 323

Glomus tumour Cavernous haemangiomas are dilated blood spaces with thin walls. Port wine stains/telangiectasis are capillary malformations) Most occur on the upper limbs, especially the digits

Question 324

What are the paraganglionomas of the head and neck

Answer 324

Glomus tympanicum Glomus jugulare Glomus vagale Chemodectoma

Question 325

Nerves at risk during excision of glomus jugulare

Answer 325

X, XI, XII

Question 326

Relative frequencies of testicular germ cell tumours

Answer 326

Seminoma 40% Embryonal 25% Teratocarcinoma 25% Teratoma 5% Choriocarcinoma (pure) 1%

Question 327

Differences between right main bronchus and left

Answer 327

Right main bronchus is shorter and wider, running more vertically Gives off the lobe branch before entering the hilum and passes inferior to pulmonary artery before entering hilum of the lung

Question 328

Course of the azygos wrt root of the lung

Answer 328

Azygos branches over right main bronchus from the posterior aspect as it passes to the SVC The pulmonary artery lies inferior and anterior to it.

Question 329

Rate and management of isolated pulmonary mets from colorectal cancer

Answer 329

Occurs in 5% of patients Can be surgically removed with curative intent if patient will tolerate a thoracotomy.

Question 330

Management of multiple intracranial mets

Answer 330

Radiotherapy, whether over the whole brain or with stereotactic radiosurgery. Short term benefit may be achieved by RTx with steroids, CTx is of no benefit

Question 331

What is the most common form of brain neoplasm?

Answer 331

Astrocytoma

Question 332

?Burn depth Characterised by pain, erythema and absence of blisters

Answer 332

Superficial burns

Question 333

Where are the short gastric arteries found?

Answer 333

Within the gastrosplenic ligament, which connects the greater curve of the stomach to the hilum of the spleen. It also contains the gastroepiloic arteries

Question 334

Where does the hepatic artery proper branch

Answer 334

Just before entering the porta hepatis

Question 335

Which of the following would be true regarding the saliva of a lady with Sjogrens? Flow rate increased during nausea Secretion from the parotid would be predominantly mucous Secretion would cease altogether at night Volume production is reduced to 1.5L per day It would contain a low concentration of potassium

Answer 335

Salivary flow increases with nausea even in patients with Sjogren.s Parotid mainly produces serous saliva. Sublingual produces mainly mucous. Submandibular produces a mixter of the two.

Question 336

Volume of saliva produced/day

Answer 336

0.75-1.5L

Question 337

Post transfusion purpura

Answer 337

Defined as thrombocytopenia arising 5-12d after RBC transfusion Associated with the presence in the recipient of Abs directed against the human platelet antigen system. The patient becomes sensitised to foreign platelet antigen (commonly anti-PlA1) as a result of previous pregnancy or more rarely transfusion. If a patient receives blood carrying this antigen, a secondary response occurs, leading to destruction of the recipients own platelets.

Question 338

Purpura, nose bleeding post tranfusion Thrombocytopenic Normal coagulation screen

Answer 338

PTP

Question 339

Management of ABO-mismatch

Answer 339

Stop transfusion IVF to maintain BP and renal perfusion Adrenaline Chlorphenamine Hydrocortisone

Question 340

Most common age of presentation of WIlm's

Answer 340

0-3 y/o

Question 341

Wilm's tumour is bilateral in what proportion of cases?

Answer 341

10%

Question 342

Layers of the SCALP

Answer 342

Skin Connective tissue Aponeurosis Loose areolar tissue Pericranium

Question 343

Blood supply of the scalp

Answer 343

Comes from both the internal and external carotid arteries (supraorbital and supratrochlear branches of ICA)

Question 344

Management of short segment SFA occlusions

Answer 344

Angioplasty

Question 345

Management of iliac artery aneurysm rupture during angiography

Answer 345

Endovascular stent graft

Question 346

Irritative (filling) LUTS

Answer 346

Frequency Nocturia Urgency +/- urge incontinence Suprapubic pain

Question 347

Voiding (obstructive) LUTS

Answer 347

Hesitancy Poor flow Feeling of incomplete emptying Post-micturition dribble

Question 348

Causes of incorrect pulse oximetry reading?

Answer 348

Arrythmias, hypotension, vasoconstriction, abnormal Hb or pigments (e.g. bilirubin), movement, poor tissue perfusion Anaemia will not interfere with pulse oximetry readings

Question 349

Operative mortality for Whipple's procedure?

Answer 349

20%

Question 350

What proportion of patients with pancreatic carcinoma are suitable for operation at presentation?

Answer 350

13%

Question 351

Where is tracheostomy placed in adults?

Answer 351

2-4th tracheal ring

Question 352

Where is tracheostomy placed in children?

Answer 352

Second and fourth tracheal rings

Question 353

How does breathing into a bag correct respiratory alkalosis

Answer 353

Causes expired CO2 to be stored in this reservoir, increasing FiCO2 which increases the reabsorption of CO2

Question 354

Which nerve is contained in the palatine tonsilar bed?

Answer 354

Contains the glossopharygneal nerve, this is responsible for the referred otalgia when the tonsils become inflamed or when patients have undergone tonsillectomy. The tympanic branch of glossopharyngeal called Jacobson's nerve, is responsible for this phenomenon

Question 355

Venous drainage of the tonsils

Answer 355

External palatine vein drains the tonsil into the pharyngeal plexus which subsequently drains into the IJV. The venous plexus around the tonsillar bed is a common source of bleeding after tonsillectomy

Question 356

Floor of the palatine tonsillar bed

Answer 356

Superior constrictor muscle

Question 357

Arterial supply of the tonsils

Answer 357

Supplied by the tonsillar branch of the facial artery, which runs alongside styloglossus after which it penetrates the superior pharyngeal constrictor to enter the palatine fossa

Question 358

Location of the palatine tonsillar bed

Answer 358

Oropharynx rather than the oral cavity

Question 359

Anterior boundary of the oropharynx

Answer 359

Base of the tongue and the palatoglossal folds

Question 360

Superior boundary of the oropharynx

Answer 360

Soft palate

Question 361

Inferior boundary of the oropharynx

Answer 361

Superior surface of epiglottis

Question 362

Posterior boundary of oropharynx?

Answer 362

Posterior pharyngeal wall

Question 363

Management of cervical spine in trauma patient

Answer 363

Must be immobilised in all unconscious victims of trauma, those with blunt injury above the clavicle and those with multi-system trauma. The neck should be immobilised in the in-line position, not moved with traction. The head and neck may be carefully moved into the in-line position if found in a different position, if any resistance is encountered it is then immoblised in the position in which it was found. For immobilisation to be adequate, a collar sandbags and tape must all be used.

Question 364

Def: low perianal fistula

Answer 364

Low fistula's internal orifice is below puborectalis High fistula's orifice is above this

Question 365

Causes of high fistula

Answer 365

IBD- Crohn's and UC Diverticular diseasae Carcinoma TB

Question 366

Rare gram positive, non-AF, anaerobic to microaerophilic bacterial infection causing granulomatous and suppurative inflammation with pus containing sulphur granules Commoner in diabetics Highly sensitive to penicillin

Answer 366

Actinomycosis

Question 367

Child Episodic fever associated with arthritis RF negative ANA positive ESR raised

Answer 367

JIA

Question 368

Initial treatment of JIA

Answer 368

NSAIDs

Question 369

Flaccid areflexia Diaphragmatic breathing Ability to flex but not extend the elbow (Priapism)

Answer 369

?Cervical spine injury

Question 370

Pathophysiology of priapism in C-spine injury

Answer 370

Loss of sympathetic input and uncontrolled arterial inflow directly into the penile sinusoidal spaces.

Question 371

Surgical access for aortic transection at the junction of the aortic arch with descending thoracic aorta

Answer 371

Posterolateral thoracotomy

Question 372

Ddx for thick-walled gallbladder on USS

Answer 372

Normal physiological state after food Cholecystitis (acute and chronic) Infiltrative gall-bladder cancer Liver conditions such as cirrhosis

Question 373

NICE recommendations for prophylactic antibiotics in surgery

Answer 373

Clean surgery involving the placement of a prosthesis or implant Clean-contaminated surgery Contaminated surgery

Question 374

7 pillars of clinical governance

Answer 374

Service user, carer and public involvement Risk management Clinical audit Staffing and staff management Education and training Clinical effectiveness Clinical information

Question 375

Psammoma bodies on biopsy

Answer 375

Papillary thyroid carcinoma

Question 376

Rate of fluid resuscitation in burns

Answer 376

Parkland formula gives fluids for first 24 hours. Half should be given over first 8 hours, rest over subsequent 16

Question 377

What occurs in the secretory phase of the menstrual cycle?

Answer 377

Progesterone stimulates growth of the endometrium

Question 378

When does the secretory phase of the menstrual cycle begin?

Answer 378

After ovulation occurs

Question 379

When does progesterone peak in the menstrual cycle

Answer 379

Within the secretory phase, progesterone peaks 7 days after ovulation (day 21). Progesterone levls can be used to confrim ovulation

Question 380

Where does the brachial artery begin?

Answer 380

At the inferior border of teres major

Question 381

Course of the profunda brachii

Answer 381

Accompanies the radial nerve in the spiral groove of the humerus.

Question 382

Course of the brachial artery

Answer 382

Continues anterior to brachialis and medial to biceps brachii, where it can be palpated against the humerus on the medial arm

Question 383

Relation of the small bowel mesentery to the third part of the duodenum

Answer 383

It is to the left of the third part of the duodenum

Question 384

Biochemical features of acute renal failure

Answer 384

Hyperkalaemia Hyponatraemia Raised urea and creat

Question 385

What happens wrt woven bone during fracture healing

Answer 385

Replaced with lamellar bone

Question 386

Potential haematological complication of TPN

Answer 386

PN without giving folate or Vit B12 will lead to megaloblastic anaemia and eventually pancytopenia that can be life threatening

Question 387

Main acid-base disturbance caused by parenteral feeding

Answer 387

Hyperchloraemic metabolic acidosis, especially in patients with renal impairment. This is due to metabolism of cationic amino acids, with release of free H ions and the presence of XS chloride load in some feeding regimens

Question 388

Most common cause of pyogenic liver abscesses?

Answer 388

E Coli and Klebsiella Most common cause is cholangitis associated with biliary stones, followed by diverticulitis

Question 389

Venous drainage of the bladder

Answer 389

Via the vesical venous plexus lying on the inferolateral surface. Veins from this plexus then drain into the IIV

Question 390

Appearance of elbow ossification centres by age CRITOL 2, 4, 6, 8, 10, 12

Answer 390

Capitellum 1-3 Radial head 3-5 Iternal or medial epicondyle 5-7 Trochlea 7-9 Olecranon 9-11 Lateral epicondyle 11-13

Question 391

Use of the protamine sulphate test

Answer 391

Used to test for DIC

Question 392

Bile stained vomiting in a previously well infant...

Answer 392

?Mid-gut volvulus

Question 393

Frothy 4 hour old neonate Mother had polyhydramnios

Answer 393

?Oesophageal atresia

Question 394

Mortality of cardiogenic shock

Answer 394

70-90%

Question 395

How much O2 is normally carried /100ml of blood?

Answer 395

20ml O2/100ml blood

Question 396

Delay in self-ventilation following anaesthetic

Answer 396

Known as suxamethonium or scoline, apnoea. In normal individual, the effects only last a few minutes until it has been metablised

Question 397

35y/o has anaesthetic for laparoscopy. SBP rapidly drops to 70mmHg and a wheeze is audible. What is the responsible drug?

Answer 397

Sodium thiopentone Complications of marked hypotension, anaphylaxis and bronchospasm

Question 398

Which anaesthetic agent is associated with severe hepatotoxicity?

Answer 398

Halothane

Question 399

What anaesthetic agent should not be used in patients who have recently been diving?

Answer 399

Nitrous oxide as it will diffuse into any air containing space

Question 400

Muscle replaced by inelastic fibrous tissue following arterial injury or compartment syndrome

Answer 400

Volkmann's ischaemic contracture

Question 401

Pathophysiology of colonic pseudo-obstruction

Answer 401

Reactive dilatation and ileus presumed to be secondary to disturbed autonomic (cholinergic) innervation. Classic conditions that precipitate it include sepsis, especially chest; CVA/neuroSx, #NOF, spinal/retroperitoneal surgery.

Question 402

Which part of the myocardium would be affected in occlusion of the posterior descending coronary artery?

Answer 402

The posterior one third of the interventricular septum and the right and left ventricles. It is a branch most commonly from the RCA in right dominant system .

Question 403

Most common enzymatic cause of congential adrenal hyperplasia?

Answer 403

21-hydroxylase (90% of cases). Essential in cortisol synthesis, reduced cortisol levels result in increased ACTH-\> increased coritsol precursors which are instead used for testosterone production

Question 404

Which muscles are attached to the linea aspera on the posterior aspect of the femur?

Answer 404

Vastus lateralis, vastus medialis, gluteus maxmius, adductor magnus, adductor longus, adductor brevis and the short head of biceps femoris

Question 405

What is the primary function of the menisci?

Answer 405

Decrease friction and stress shielding

Question 406

Aschner-Dagnini reflex

Answer 406

Oculocardic reflex Decrease in pulse rate associated with compression of the eyeball

Question 407

Haptoglobin levels in haemolytic anaemia

Answer 407

In haemolysis, free Hb combines with haptoglobin so serum levels fall

Question 408

Borders of the femoral triangle SAIL

Answer 408

Sartorius Adductor longus Inguinal Ligament

Question 409

How many sections are there to the WHO checklist?

Answer 409

3 Before the induction of anaesthesia Time out before skin incision Sign out at the end of the procedure

Question 410

How is the action potential transmitted through skeletal muscle?

Answer 410

Spreads outwards to all parts via T tubes

Question 411

Action of UV light on DNA

Answer 411

Causes the formation of pyrimidine dimers altering the form of DNA and interfering with base pairing during DNA synthesiss

Question 412

Most common genetic abnormalities in TCC bladder?

Answer 412

Chromosome 9 deletion Alterations to p53 and Rb

Question 413

Most likely site of perforation in Typhoid fever

Answer 413

S typhi accumulates within Peyer's patches and causes mucosal ulceration The ileum has the highest concentration of Peyer's patches and as such is the most likely site of subsequent perforation

Question 414

Which of the following is true about the thoracic aortic arch? Arches below manubriosternal joint Arches directly over right pulmonary artery Gives rise to the coronary arteries Covered by pleura Lies anterior to the brachiocephalic vein

Answer 414

The apex of the arch which gives attachment to the pretracheal fascia lies posterioinferior to the left brachiocephalic vein. The lower border is in the transthoracic plane and is directly related to the left pulmonary artery. The arch is symmetrically covered by pleura from both sides which meet in the midline behind the manubriosternal joint.

Question 415

What is the best way to identify parathyroid adenoma histologically

Answer 415

Intra-operative frozen section

Question 416

Malignant potential of UC

Answer 416

10 years- 2% 20 years- 8% 30 years- 18%

Question 417

23y/o otherwise fit and well 2h history of RIF pain which started whilst running and has become increasingly severe. No history of fever or vomiting. He is in obvious discomfort and has a very tender mass palpable low in RIF.

Answer 417

Rectus sheath haematoma Occurs following rupture of the inferior epigastric artery, typicallly after coughing or straining. Site is usually at the level of the arcuate line and produces a mass in the RIF. It is related to the muscles of the anterior abdominal wall which makes it indistinct. Bruising may not always be apparent. Condition occurs in three distinct groups: elderly women, pregnant women, athletic muscular men Exploration of anterior abdominal wall, haematoma evacuation and ligation of the bleeding vessel may be required though small haematomas can be managed conservatively

Question 418

Why is an anaesthetic patch on upper medial arm a recognised complication of axillary clearance

Answer 418

Damage to intercostobrachial nerve

Question 419

Why is dry mouth not a commonly encountered problem following parotidectomy

Answer 419

Becuase of the presence of other major and minor salivary glands

Question 420

Which factor is respsonsible for cross-linking of fibrin? II VII VIII XII XIII

Answer 420

Factor XIII aka fibrin stabilisting factor, cross-links fibrin, It is activated by thrombin into Factor XIIIa (requiring Ca as a cofactor) and forms the insoluble clot

Question 421

The axillary nerve is damaged in what proportion of shoulder dislocations

Answer 421

5%

Question 422

How to detect lat dorsi parlaysis

Answer 422

Patient unable to fold the arm behind the back and reach up to the opposite scapula

Question 423

15y/o passenger in RTA Wearing a seat belt and escapes apparent injury Post-accident he is unable to raise arm easily and has visited the ED with two episodes of spontaneous shoulder dislocation

Answer 423

?Suprascapular nerve palsy which can be injured by sudden tightening of car seatbelt Increased suscpetiblity to shoulder dislocation is because of comrpomise of the rotator cuff due to paralysis of the supraspinatus and infraspinatus

Question 424

In which IBD are pyoderma gangrenosum, ank spond and toxic megacolon more common?

Answer 424

UC

Question 425

Why is a sudden loud sound more likely to damage the cochlea than a loud sound that develops slowly?

Answer 425

When a loud sound is transmitted into the CNS, an attenuation reflex occurs after a latent period of 40-80ms The reflex invovles the contraction of two muscles that pull the malleus and stapes towards each other, causing the entire ossicular system to develop a high degree of rigidity. In turn, the ossicular conduciotn of low-frequency sounds to the cochlea can be reduced by as much as 30-40 decibels. Since loud sounds are usually low frequency, the attenuation reflex can protect the cochlea from damage when they develop slowly

Question 426

Site of Na reabsorption in kidney

Answer 426

PCT

Question 427

Site of renal faculative K reabsorption

Answer 427

DCT

Question 428

Pathophysiology of irritative symptoms in BPH

Answer 428

Bladder detrusor compensates for increased outflow resistance with muscular hypertrophy and an increase in collagen that results in trabeculation. Trabeculation is asymptomatic but the detrusor becomes increasingly irritable

Question 429

Zones of penetrating neck injury

Answer 429

Zone 1- clavicle to cricoid cartilage Zone 2- cricoid cartilage to angle of mandible Zone 3- angle of mandible to base of skull

Question 430

Is Meckel's a true or false diverticulum?

Answer 430

True diverticulum, containing all the layers of the ileal wall. It is a remnant of the vitelline duct which connects the yolk sac to the embryonic gut

Question 431

High temperature Deranged liver function tests Positive blood cultures Post-operatively following liver tranplant

Answer 431

Pathognomic of hepatic artery thrombosis Doppler US is used to assess hepatic artery patency Patients presenting in the early post-operative period usually require re-transplantation

Question 432

Which RLN is posterior to the ligamentum arteriosum

Answer 432

Left RLN

Question 433

What proportion of non-protein energy in TPN is derived from fat?

Answer 433

10%

Question 434

Diagnostic work up in asymptomatic proteinuria with normal U+Es

Answer 434

History BP Albumin:creatinine ratio Fasting blood glucose Urine protein electrophoreisis

Question 435

Exomphalmos is associated with which syndromes?

Answer 435

Beckwith-Wiedemann, Edward and Patau

Question 436

Potter syndrome

Answer 436

Relates to renal abnormalities. Oligohydramnios as a result of renal abnormatlities, urinary tract obstruction or amniotic fluid leakage may lead to fetal compression wirth joint contractures (arthrogryposis), pulmonary hypoplasia and squashed facies

Question 437

What percentage of cardiac output is received by the skin?

Answer 437

9%

Question 438

For what disorders are UK blood donations screened?

Answer 438

HBsAg HCV DNA HIV1 and 2 Abs Treponema pallidum antibody

Question 439

Def: Pain

Answer 439

Unpleasant sensory and emotional experience associated with actual or potential tissue damage

Question 440

Cardinal signs of flexor tendon sheath infection

Answer 440

Partially flexed finger Fusiform swelling of the finger Tenderness along the entire flexor tendon sheath Severe pain on passive extension of the finger

Question 441

Examination findings in Achilles tendon rupture

Answer 441

Dorsiflexion is exaggerated as it is normally limited by the Achilles tendon Plantar flexion is limited and the patient is unable to stand on tiptoes, some plantar flexion is still possible due to the action of the other long flexors of the toes. Thompson test is positive which is a lack of plantar flexion when the calf is squeezed

Question 442

Pyramidal facial fracture running from middle of the nasal bone across the lacrimal bones to fracture the pterygoid laminae halfway up

Answer 442

Le Fort II

Question 443

Low level facial fractures not associated with bilateral subconjunctival haemorrhages

Answer 443

Le Fort I

Question 444

Low level facial fracture with downward displacement of the fracture line, associated with massive facial oedema

Answer 444

Le Fort I in association with Le Fort II

Question 445

Facial fracture associated with dishface deformity

Answer 445

Le Fort III

Question 446

Which of the following is a systemic effect of 60% TBSA burns? Glycogenosis Hypervolaemia Hypothermia Immunosuppression Reduced metabolic rate

Answer 446

Immunosuppression is due to the depression of many facets of the immune mechanism, both cellular and humoral. Burn injury results in a hypermetabolic state caused by the secretion of stress hormones, including cortisol, catecholamines and glucagon. In addition there is suppression of or resistance to anabolic hormones. Clinically these changes are expressed as tachycardia and hyperthermia.

Question 447

Pathophysiology of Boutonniere deformity

Answer 447

Rupture of the middle slip of the extensor tendon. At this stage there is no more than a failure to extend the PIP, however if the tendon is not repaired, the lateral slips slide down towards the volar surface allowing the knuckle to buttonhole through the extensor hood, causing the DIP to be drawn into hyperextension

Question 448

RA Rapid onset of breathlessness, progressing over a few months to complete incapacity or death Pulmonary function tests show considerable reduction in vital capacity with gross hyperinflation though CXR usually normal

Answer 448

Bronchiolitis obliterans

Question 449

Which of the following is true regarding low denisty lipoproteins 50% of their fat content is triglyceride Concentration is highly correlated with dietary cholesterol content They are involved in reverse cholesterol transport They are synthesised de novo in the liver They contain apolipoprotein B-110

Answer 449

The major fat in LDLs in cholesterol, but the concentration is determined mainly by the rates of hepatic synthesis and peripheral clearance. Dietary sat fat intake correlates more strongly with LDL-choletserol concentration than dietary cholesterol intake. LDLs are formed from VLDL and IDL by successive removal of triglyceride and its removal. Each particle contains one molecule of apolipoprotein B100, the ligand for LDL R

Question 450

U+Es pre-op are indicated for which patient group

Answer 450

Patients over 60 Those with CV and renal disease Diabetics Those on steroids/ACEi or diuretics

Question 451

Which of the following drugs works primarily by blocking transmission in postsynaptic autonomic fibres? Suxamethonium Hexamethonium Bupivacaine Pentazocine Fentanyl

Answer 451

Hexamethonium is a non-depolarising ganglionic blocker, its action is to block transmission in the postsynaptic autonomic fibres at the ganglions of both the parasympathetic and sympathetic systems.

Question 452

What are the potential complications of complete rectal prolapse?

Answer 452

Incontinence (75%) which may be the patients prsenting symptom Incarceration Ulceration and necrosis Strangulation Rectal carcinoma

Question 453

What is the second most common cause for cancer death in the UK?

Answer 453

Colonic malignancy

Question 454

Cancer risk following torsion

Answer 454

There is evidence to suggest that there is an increased risk of testicular cancer in both the ipsilateral and contralateral testis following torsion

Question 455

What proportion of prostate cancers are in the peripheral zone and multifocal

Answer 455

75% of adenocarcinomas are in the peripheral zone, with 85% being multifocal

Question 456

Physiological anaemia of pregnancy

Answer 456

Red cell volume increases, but this frequently lags behind the plasma volume, resulting in a reduced Hct and Hb concentration

Question 457

Conservative management of oesophageal perforation

Answer 457

Broad spectrum ABx PN NG suction witrh gastric acid suppression

Question 458

Sympathetic innervation of the adrenal medulla

Answer 458

Unique in that there is no synpase between the SC and the organ. The "preganglionic" neurone innervates the chromaffin cells of the adrenal medulla through ACh causing the direct release of catecholamines into the blood stream

Question 459

Where are the preganglionic cell bodies in the sympathetic nervous system?

Answer 459

Intermediolateral horn of the SC

Question 460

What are the spinal origins of the sympathetic nerves?

Answer 460

Efferent nerves originate from segments T1-L2 Leave the SC in the anterior roots and pass to the paired sympathetic chains

Question 461

Skin cancer with keratin pearl fromation

Answer 461

SCC

Question 462

Skin cancer with palisading basal cells at the periphery of tumour islands

Answer 462

BCC

Question 463

At what level does the thoracic duct pass through the diaphragm

Answer 463

At the aortic hiatus T12 and ascends the superior and posterior mediastinum between the descending thoracic aorta (to its left) and the azygos vein to its right

Question 464

Into what structure does the thoracic duct drain?

Answer 464

The left brachiocephalic vein

Question 465

Path of the palmar cutaneous branch of the median nerve

Answer 465

Given off proximal to the carpal tunnel (an average of 4cm proximal to the distal wrist crease) Enters the palm superficial to the flexor retinaculum to supply sensation to the palm. It remains as one distinct branch as it passes into the palm, usually underlying the thenar crease, but may branch proximal to the distal wrist crease. The incision in carpal tunnel surgery must be planned to avoid transection of the palmar cutaneous branch Its absence from the carpal tunnel explains the lack of palmar symptoms in carpal tunnel syndrome (digital cutaneous nerves are branches of the median nerve proper as it emerges from the carpal tunnel)

Question 466

39y/o motorcyclist High speed RTA Sustained severe trauma to right upper back when he fell on the road There is bruiding and tenderness over this region. He has drooping of the right shoulder with lengthening of the arm. Movement of the shoulder is severely restricted and the arm is held in adduction

Answer 466

Fracture of the neck of scapula. Scapular fractures are usually caused by high energy trauma to the upper back. Patients present with bruising and tenderness over the scapular region on the affected side. Maximal tenderness is over the lateral humeral head. There is also drooping of the affected shoulder with apparent lengthening of the arm, particularly with fracture of the neck of the scapula. Patients with scapular neck fractures resist all shoulder movements and will hold the limb in adduction. Fractures of the scapula, first or second ribs or sternum suggest an injury mechanism so severe that head and C-spine trauma must be excluded

Question 467

Neer's classification

Answer 467

Used to classify fractures of the proximal end of the humerus. Can be callsed 2-part, three part or four part fractures

Question 468

Incision in thyroidectomy

Answer 468

Made following the skin creases 4cm above the sternoclavicular joints. Skin, subcutaneous tissue and platysma muscle. The anterior jugular veins, lying in the plane between the platysma are divided. The majority of surgeons rarely divide strap muscles. The ansa cervicalis, embedded in the carotid sheath is not usually sought, unlike the RLN

Question 469

Remote carcinogen

Answer 469

A precursor of a carinogenic agent e.g. beta naphthylamine

Question 470

Proximate carcinogen

Answer 470

Metabolite of a chemical carcinogen that is itself carcinogenic

Question 471

Ultimate carcinogen

Answer 471

Activated, and chemically reactive, form of a carcinogen or procarcinogen that is capable of direct covalent binding to nucleic acid and/or protein macromolecules

Question 472

Pathophysiology of beta-naphthylamine in TCC

Answer 472

Beta naphthylmaine is not in itself intrinsically carcinogenic (a remote carcinogen) It undergoes conjugation in the liver to create a water soluble carcinogen (proximate carcinogen) The conjugated carcinogen is excreted by the kidneys and stored in the bladder. Here micro-organisms secrete glucuronidase which releases the ultimate carcinogen into the bladder. This can result in TCC

Question 473

How much of 1L of 5% dextrose will remain in the intravascular compartment?

Answer 473

\<100mls. It has no oncotic properties, therefore it will be distributed amongst total body water

Question 474

What proportion of IV 0.9% NS will remain in the intravascular space?

Answer 474

1/4

Question 475

From what is the axillary vein formed?

Answer 475

The union of the basilica vein and the vena comitantes

Question 476

Which of the following bones are at risk of AVN? Calcaneus NOF Olecranon Patella Talus

Answer 476

Dislocation of the talus ruptures the blood supply and AVN results after reduction

Question 477

Where is an ectopic implanatation most likely to occur?

Answer 477

Ampulla of the Fallopian (uterine) tube(80%)

Question 478

What are the components of the fallopian tube?

Answer 478

Infundibulum Ampulla Isthmus Intramural portion

Question 479

What is the second most common site of ectopics

Answer 479

Isthmus of uterine ube (12%)

Question 480

Sudden breast pain Tender subcutaneous cord attached to the skin

Answer 480

Mondor's disease

Question 481

Rare condition characterised by sclerosing thrombophlebitis of the subcutaneous veins of the anterior chest wall Imaging studies tend to be unremarkable Benign and self-limiting though a fibrous subcutaneous band may remain

Answer 481

Mondor's disease

Question 482

Complications of sphincterectomy in ERCP

Answer 482

Division of the sphincter of Oddi may cause pancreatitis, duodenal perforation or bleeding

Question 483

When does the PSA elevate following ejaculation?

Answer 483

1 hour post-ejaculation, returning to baseline after 24h

Question 484

Pain in breast cancer

Answer 484

Uncommon feature but when it does occur it is typically described as an ache or prickling sensation

Question 485

Valgus deformity of the knee most commonly seen in?

Answer 485

Rheumatoid arthritis Varus is more classical of severe osteoarthritis

Question 486

19y/o man Hx of intermittent pain and swelling in left knee with episodes of locking, which he relieves by manoeuvring the leg. Complains of knee giving way. No hx of trauma Small effusion noted and a small mobile body is felt in the suprapatellar pouch

Answer 486

Osteochondritis dissicans Condition in which an osteocartilaginous fragment separates from one of the femoral condyles and is rendered avascular

Question 487

Pathophysiology of Bochladek's hernia

Answer 487

Occur posterolaterally due to a defect in the posterior attachment of the diaphragm during its formation (8th week of gestation) It is thought to be due to failure of the pleuroperitoneal membrane to close or failure of the muscle cellls to migrate, making the diaphragm vulnerable and allowing protrusion of abdominal viscera into the thoracic cavity-\> pulmonary hypoplasia

Question 488

5Bs of Bochladek hernia

Answer 488

Bad, Big occur in babies and found at back of chest

Question 489

Which of the following happens in the ebb phase or trauma? Plasma pH increases Plasma levels of FFAs decreases Hypoglycaemia Plasma level of non-protein nitrogen decreases Plasma glycerol increases

Answer 489

Plasma glycerol increases due to increased lipolysis (this also increases the levels of FFAs) Usually there is an acidosis. Hyperglycaemia is seen An increased level of non-protein nitrogen is seen in a catabolic state

Question 490

Action of kinins

Answer 490

Proteins that attract phagocytes They promote vasodilation They increase the permeability of blood vessels

Question 491

Segmental innervation of forearm pronation

Answer 491

C7 and C8

Question 492

Segmental innervation for supination of the forearm

Answer 492

C6

Question 493

Segmental innervation of elbow flexion

Answer 493

C5 6

Question 494

Segmental innervation of elbow extension

Answer 494

C7 C8

Question 495

Segmental innervation of thumb and finger flexion

Answer 495

C7 C8

Question 496

Segmental innervation of finger and thumb extension

Answer 496

C7 C8

Question 497

FRC=

Answer 497

Sum of the residual volume and the expiratory reserve volume i.e. the total volume of air in the lungs at the end of normal expiration

Question 498

What are the components of spirometry to remember?

Answer 498

Four lung volumes 5 capacities

Question 499

W.r.t. spirometry, what is a capacity

Answer 499

It is a value made up of two or more lung volumes

Question 500

What are the four lung volumes

Answer 500

Tidal volume Residual volume Inspiratory reserve volume Expiratory reserve volume