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MRCS Part A > Block 13 > Flashcards

Block 13 Flashcards

1
Q

MOA Tociliziumab

A

IL-6 antagonist

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2
Q

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

Beta cells

Fibroblasts

Eosinophils

Macrophages

T cells

A

Macrophages

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3
Q

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

A

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

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4
Q

In which wounds are hypertrophic scars most commonly seen?

A

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

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5
Q

MOA suxamethonium

A

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

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6
Q

Rocuronium

A

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

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7
Q

Sellick’s manoeuvre

A

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

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8
Q

Ix in colovesical fixtula

A

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

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9
Q

Riedel’s lobe

A

Congenital abnormality.

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

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10
Q

Formation of the vocal cords

A

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

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11
Q

What can be used to grade facial nerve palsy?

A

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

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12
Q

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

A

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

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13
Q

Formation of the denticulate ligaments

A

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

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14
Q

Structural arrangement of the arachnoid mater of the spine

A

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

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15
Q

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

A

The motor root of trigeminal, facial and accesory nerves

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16
Q

Droopy lip post carotid endarterectomy, which nerve damaged?

A

Marginal mandibular nerve

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17
Q

Nerves at risk during carotid endarterectomy?

A

Greater auricular

Hypoglossal

Marginal mandibular

Glossopharyngeal

Vagus nerve

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18
Q

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

A

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

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19
Q

Rate of popliteal aneurysms in patients with AAA?

A

10-15%

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20
Q

Rate of AAA in patients with popliteal aneurysm?

A

30-50%

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21
Q

def: false aneurysm

A

Pseudoaneurysm

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

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22
Q

Dissecting aneurysms

A

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.

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23
Q

Where is the intimal tear often seen in a dissecting aneurysm

A

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.

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24
Q

Most common locations of mycotic aneurysms

A

Femoral artery followed by aorta and intracranial arteries.,

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25
Q

Luetic aneurysms

A

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

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26
Q

Use of percutaneous biliary drainage in pancreatic malignancy

A

Used when endoscopic stent insertion is not possible

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27
Q

Management of benign biliary strictures

A

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

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28
Q

Intrahepatic duct dilatation

A

More commonly caused by tumours and strictures than gallstones

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29
Q

Elevated FSH

Reduced or absent spermatogensis

Masculinisation normal

A

?Seminiferous tubular dysfunction

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30
Q

CA 125 in stage 1 ovarian cancer

A

Elevated in less than 50% of patients

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31
Q

CA 19-9 in pancreatic carcinoma

A

Elevated in 75-90% of patients

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32
Q

National breast screening programme

A

50-70y/o every 3 years.

Has led to increased detection of CIS.

Has led to reduced numbers of benign breast biopsies

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33
Q

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

A

Naso-endoscopy.

Thorough examination with CXR, ENT examination should be performed

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34
Q

Attachments of the free edge of the lesser omentum?

A

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

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35
Q

Vascular supply in the lesser omentum

A

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

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36
Q

Maximum dose of 1% lidocaine with adrenaline that can be administered to a 60kg woman.

30mls

35ml

42ml

62ml

70ml

A

Maximum dose with adrenaline is 7mg/kg

1% lidocaine containes 10mg/ml.

60kg woman, maximum dose is 420mg. Which equates to 42ml

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37
Q

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

A

Ascites

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38
Q

Pancreatic ascites

A

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

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39
Q

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

A

?Pancreatic abscess

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40
Q

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

A

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.

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41
Q

Prevalence of UC

A

60/100000

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42
Q

FHx in UC

A

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

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43
Q

Causes of cardiac tamponade

A

Trauma

Breast /lung carcinomas

Aortic dissection

MI

Bacertial, viral or tuberculous pericarditits

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44
Q

Madura foot

A

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.

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45
Q

Rate of ischaemic colitis post AAA repair

A

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

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46
Q

Paraplegia following AAA repair

A

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.

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47
Q

Artery of Adamkiewicz

A

AKA great anterior radiculomedullary artery

Arises from AA at 9th-12th intercostal arteries and at risk during AAA repair.

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48
Q

Pathophysiology of trash foot

A

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.

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49
Q

Pain

Intact peripheral pulses

Livedo reticularis

A

?Trashfoot

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50
Q

Mean pulmonary arterial pressure

A

15mmHG

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51
Q

Suture material used in small bowel anastomosis

A

3 0 PDS

Absorbable materials used.

Stapling has become more prominent.

No evidence of different anastomotic leak rates between suturing and stapling

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52
Q

Mid-line abdominal wound closure material

A

1 PDS or 1 Nylon

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53
Q

Suture material for securing prosthetic mesh during incisional hernia repair

A

2 0 prolene

Non-absorbable suture most appropriate

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54
Q

Pathophysiology of septic arthritis

A

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.

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55
Q

Pathophysiology of pseudogout

A

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

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56
Q

Associations of pseudogout

A

HyperPTH

Hypothyroidsim

Acromegaly

Haemochromatosis

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57
Q

Pattern in pseudogout

A

Fibrocartilage of the knee

Pubic symphysis

Intervertebral discs

Particularly common in women >60

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58
Q

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

A

Pseudogout

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59
Q

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.

A

Still’s disease.

Recurrent abdominal pain may occur secondary to bouts of mesenteric adenitis.

HSM, myocarditis and uveitis may complicate the condition

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60
Q

Diagnostic criteria for Stills

A

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

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61
Q

Diagnosis of Still’s

A

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

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62
Q

Most common benign bone tumour affecting individuals <21

A

Osteochondroma

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63
Q

Most common complication of venous insufficency

A

Leg ulceration

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64
Q

Signs of chronic venous insufficieny

HEAVE

A

Haemosiderin deposition

Eczema

Ankle ulcers

Varicose veins

oEdema

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65
Q

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

A

Kidneys

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66
Q

Pericardiocentesis

A

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.

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67
Q

qSOFA score

A

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

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68
Q

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

A

30%

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69
Q

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

A

Higher SA to volume ratio

Children <1 do not have the shivering reflex

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70
Q

Indications for inotropes in paediatric burns

A

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

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71
Q

Pulse pressure in neurogenic shock

A

Widened due to proporionately higher fall in diastolic pressure

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72
Q

Which vein is carried within the hepatoduodenal ligament?

A

Hepatic portal vein

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73
Q

Type A lactic acidosis

A

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

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74
Q

Type B lactic acidosis

A

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

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75
Q

Type B1 lactic acidosis

A

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

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76
Q

Type B2 lactic acidosis

A

Drug associated

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77
Q

Type B3 lactic acidosis

A

Due to inborn errors of metabolism

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78
Q

Which of the following arteries supply the trochanteric anastomosis?

Anterior spinal artery

EIA

Gluteal arteries

Iliolumbar

Posterior spinal

A

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

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79
Q

Blood supply of the ASIS anastomosis

A

Iliolumbar arteries

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80
Q

Which immunosuppressive drug acts by inhibiting IL-2 action?

Sirolimus

Ciclosporin

Azathioprine

MMF

Tacrolimus

A

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

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81
Q

How much blood can the pulmonary vessels accomodate at rest?

A

500ml

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82
Q

Development of lymphoedema in a female shortly after menarche

Swelling around ankle up to the dorsum of the foot and spreads proximally.

A

Meige’s disease (lymphoedema praecox)

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83
Q

Which of the following is not contained within the carpal tunnel at the wrist?

FDS

PL

Median nerve

FDP

FPL

A

PL is superficial to the flexor retinaculum

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84
Q

Histopathology of iron overload

A

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

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85
Q

Genes implicated in haemochromatosis

A

C282Y mutation or H63D

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86
Q

Course of the sacral plexus

A

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

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87
Q

Surgical approach for ruptured kidney

A

Through the anterior abdominal wall by a midline incision.

Simple nephrectomy is indicated in cases of non-functioning kidneys

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88
Q

Relations of the left kidney

A

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

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89
Q

Dynamic test in ?anastomotic leak

A

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

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90
Q

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.

A

Ranula

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91
Q
A

Ranula

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92
Q

Aetiological factors in oral cavity cancers

S

A

Spirits

Smoking

Syphillis

Papillomavirus

Sore tooth (trauma)

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93
Q

Synchronous and metachronous tumours in carcinoma of the oral cavity

A

5 and 10% respectively

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94
Q

Management of choledochal cyst

A

Roux-en-Y hepaticojejunostomy

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95
Q

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,

A

Choledochal cysts

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96
Q

Double duct sign

A

Dilatation of both the pancreatic and biliary duct

High indicative of pancreatic cancer but may also present in chronic pancreatitis

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97
Q

T1 skin cancer

A

1mm

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98
Q

T2 MM

A

1.01-2.00mm

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99
Q

T3 MM

A

2.01-4.0mm

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100
Q

T4 MM

A

>4.0mm

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101
Q

N0 MM

A

No lymph node involvement

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102
Q

N1 MM

A

One LN

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103
Q

N2 MM

A

Two or three LNs or satellite/in-transit lesions

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104
Q

N3 MM

A

Four or more LNs

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105
Q

M0 MM

A

No mets

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106
Q

M1a MM

A

Distant skin or LN mets

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107
Q

M1b MM

A

Lung mets

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108
Q

M1c MM

A

All other visceral mets

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109
Q

Stage 0 MM

A

Tis, N0, M0

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110
Q

Stage I MM

A

T1a-T2a, N0, M0

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111
Q

Stage III MM

A

Any T, N1-3, M0

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112
Q

Stage IV MM

A

Any T, Any N, M1a-c

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113
Q

a and b subscripts in T staging of MM

A

a indicates without ulceration

b indicates with ulceration

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114
Q

Extra-articular distal radial fracture with volar displacement

A

Smith’s fracture

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115
Q

Extra articular fracture with dorsal and radial displacement of distal fragment

A

Colle’s

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116
Q

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

A

Barton’s fracture

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117
Q

Dragging sensation in pelvis

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

A

?Uterovaginal prolapse

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118
Q

Bladder pain and irritative bladder symptoms

Pain worse on bladder distension and eased on micturition

Negative urine cultures

A

?Painful bladder syndrome

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119
Q

Diagnosis of painful bladder syndrome

A

Urine should be cultured for atypical organisms

Cystometry and cystoscopy are useful and reveal low capacity, non-compliant bladder

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120
Q

Most sensitive ultrasound finding in acute cholecystitis

A

Cholelithiasis in combination with sonographic murphy’s sign

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121
Q

Surgical management of subclavian steal syndrome

A

Carotid-subclavian bypass

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122
Q

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

A

Carotid-carotid bypass

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123
Q

Most effective method for preventing transmission of MRSA?

A

Good hygiene

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124
Q

Embryological precursor of the prostate

A

Urogenital sinus

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125
Q

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

A

30%

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126
Q

Morbidity and mortality associated with acute renal failure?

A

60% increase

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127
Q

Roles of VIP

A

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

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128
Q

What percentage burn accounts to the palmar area?

A

1%

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129
Q

How to prevent tension pneumothorax when dressing open pneumothorax?

A

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

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130
Q

Most common cause of tension pneumothorax

A

Mechanical ventilation in patient with visceral pleural injury

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131
Q

Respiratory consequence of hypoxia

A

Respiratory alkalosis through increased ventilation

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132
Q

Causes of femoral nerve injury

A

Gunshot wound

Traction during surgery

Femoral triangle injury

Massive haematoma

Patients with DM

Lumbar spondylosis

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133
Q

Vital capacity

A

Approx 70ml/kg

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134
Q

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

A

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

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135
Q

Mechanisms of development of posterior urethral valves

A

Hypertrophy of the urethral mucosal folds

Abnormal development of the Wolffian duct

Fusion of the verumontanum

Persistence of the urogenital membrane

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136
Q

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

A

Bladder exstrophy

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137
Q

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.

A

Hypospadias

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138
Q

Surgical managmenet of bladder exstrophy

A

Operation to close bladder and pelvis at birth

Genitoplasty at 2y

Bladder neck repair to achieve continence at 4-5y

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139
Q

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,

A

Anterior uretrhral valves

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140
Q

Renal regulation of potassium in respiratory acidosis

A

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

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141
Q

Inguinal hernia repair approach

A

Litchenstein repair recommended

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142
Q

Pseudobulbar palsy vs bulbar palsy

A

Bulbar palsy is LMN. Pseudobulbar is UMN

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143
Q

Causes of anal fistula

A

Up to 80% are due to abscess

Other causes include post-surgical, trauma, penetrating injury, TB, Crohn’s

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144
Q

Murmur in VSD

A

Continuous systolic murmur/pansystolic murmur

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145
Q

Murmur in ASD

A

No murmur

Split of the HS II is fixed throughout diastole and systole

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146
Q

Where in the kidney is PO4 reabsorbed?

A

PO4 is reabsrobed in the PCT under the control of PTH

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147
Q

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

A

Loop of Henle

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148
Q

Location of calcium reabsorption in the kidney?

A

Ascending loop of Henle

Distal tubule

Collecting tubule

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149
Q

What is absorbed in the PCT?

A

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

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150
Q

Borchardt’s triad

A

Gastric volvulus

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

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151
Q

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

A

Along the long axis of the stomach: organoaxial

or

Around the axis perpendicular to the stomach: mesenteroaxial

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152
Q

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

A

Endocervical polyp

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153
Q

Endocervical polyp

A

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

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154
Q

Which BZD is preferred in IV sedation?

A

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

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155
Q

Opiate and sedative use

A

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

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156
Q

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

A

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

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157
Q

Consequence of maltase deficiency?

A

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

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158
Q

Young children with unhealed burns are at risk of?

A

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

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159
Q

Endothelin-1

A

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

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160
Q

ICAM-1

A

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

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161
Q

Presentation of spinal mets

A

90% present with back/bone pain followed by radicular pain.

Sensory or motor neurology occurs in 50%

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162
Q

What proportion of patients with palliative cancer have spinal mets?

A

30%

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163
Q

Relative contraindication to surgical decompression in SC compression?

A

Complete paraplegia lasting >24h

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164
Q

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

A

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

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165
Q

Which of the following muscles is not found in the anterior compartment of the leg?

Tibialis anterior

EHL

EDL

Peroneus tertius

Peroneus brevis

A

Peroneus brevis is found in the lateral compartment

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166
Q

Which of the following clotting factors is not a serine protease?

XI

II

IX

XII

XIII

A

XIII is a transglutaminase, the rest are serine proteases

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167
Q

Causes of bilaterally small pupils

A

Opiates

Destructive pontine lesion

Metabolic encephalopathy

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168
Q

13 y/o boy

Tiredness, recurrent throat and chest infections, gradual loss of hearing.

XR shows marble bone appearance

A

Osteopetrosis

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169
Q

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

A

Osteopetrosis

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170
Q

Cause of pseudoparalysis in scurvy

A

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

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171
Q

Cupped apearance on XR

A

?Rickets

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172
Q

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

A

1 in 3.

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173
Q

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

A

Superior thyroid artery

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174
Q

Invasive nature of sarcoma

A

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

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175
Q

Colour of urine in hepatic jaundice?

A

Dark urine

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176
Q

Mild jaundice

Normal coloured urine and faeces

Unconjugated bilirubin

Normal transaminases

Normal ALP

A

Prehepatic

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177
Q

Variable jaundice severity

Dark urine

Normal stool

Unconjugated and conjugated bilirubin

Grossly increased transaminases

Mildly elevated ALP

A

Hepatic

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178
Q

Deep jaundice

Dark urine

Pale stool

Conjugated bilirubin

Normal or mild increase in transaminases

Grossly elevated ALP

A

Post-hepatic

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179
Q

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

A

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

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180
Q

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

A

Varicocele.

Swelling disappears on lying down as veins empty

Long standing cases may cause testicular atrophy and are associated with infertility

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181
Q

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

A

Hydrocele

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182
Q

MOA ketoconazole

A

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

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183
Q

MOA amphotericin and nystatin

A

Impair cell membrane permeability by directly complexing with the membrane sterol

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184
Q

MOA griseofulvin

A

Inhibits microtubules

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185
Q

MOA flucytosine

A

Incorporated into RNA after deamination and phosphorylated.

Also interferes with DNA synthesis as it is a non-competitive inhibitor of thymidylate synthetase

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186
Q

Cx of epididmyitis

A

Abscess formation

Testis infarction

Chronic pain and infection

Infertility

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187
Q

Incision line for episotomy

A

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.

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188
Q

Metastatic adenocarcinoma, aneurysms

A

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

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189
Q

NCEPDO classification

A

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

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190
Q

NCEPOD 1

A

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

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191
Q

NCEPOD2

A

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

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192
Q

NCEPOD 3

A

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

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193
Q

NCEPOD 4

A

Elective

Intervention planned or booked in advance of routine admission to hospital

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194
Q

Post-streptococcal glomerulonephritis

Gel-Coombs classification

A

Type III as immune complex disease

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195
Q

Action of segmentation w.r.t. GI motility

A

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

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196
Q

Auer rods in peripheral blood film

A

AML

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197
Q

Carbohydrate requirement per day?

A

2g/kg/d

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198
Q

Nitrogen requirement per day

A

0.5-1g/kg/d

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199
Q

Water requirement /day

A

35ml/kg/d

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200
Q

Describe the two phases of testicular descent

A

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.

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201
Q

Allantois

A

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

202
Q

Complications of undescended testis

TESTIS

A

Trauma

Epididymo-orchitis

Sterility

Torsion

Intestinal hernia

Seminoma

203
Q

Genital tubercle

A

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

204
Q

Sun exposure pattern risk for melanoma

A

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

205
Q

Hawkin’s test is for

A

Subacromial impingement

206
Q

Jobe’s test is for

A

Supraspinatus

207
Q

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

A

Subscapularis

208
Q

What is the most important direct stimulus to respiration

A

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

209
Q

Ober’s test

A

For tight iliotibial band

210
Q

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

A

Total laryngectomy and neck dissection.

Surgical options for patients with advanced stage largneal cancer.

211
Q

Use of total laryngectomy in laryngeal carcinoma

A

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

212
Q

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

A

Excision of mucosa

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

213
Q

55y/o lady with glottic carcinoma involving anterior commissure

Total laryngectomy and neck dissection

RTx

CTx

Excision of vocal cord mucosa

A

RTx

214
Q

70y/o woman with large supraglottic carcinoma

Total laryngectomy and neck dissection

RTx

CTx

Excision of vocal cord mucosa

A

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

215
Q

Triad in laryngeal fracture

A

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

216
Q

Mx of ?laryngeal fracture

A

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

217
Q

Use of unpaired t-test

A

To compare two separate groups at the same point in time

218
Q

Use of paired t test

A

To compare one group at two points in time

219
Q

Use of Friedman test

A

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

220
Q

ANOVA

A

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

221
Q

Pearson correlation coefficient

A

Measure of the strength of linear relationship between two variables

222
Q

Damage to the external laryngeal nerve causes

A

Loss of high pitched phonation

223
Q

Approach to control of inferior thyroid vasculature during thyroidectomy

A

Artery should be ligated in continuity before the inferior thyroid veins

224
Q

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

A

Factor VII

225
Q

Aaron’s sign

A

Pain referred to epigastrium upon continuous firm pressure over McBurney’s point

Seen in appendicitis

226
Q

Dunphy’s sign

A

Increased abdominal pain with coughing.

Often seen in appendicitis

227
Q

From which sinus does osteomylelitis most commonly develop?

A

Frontal sinus

228
Q

Classification of the complications of sinusitis?

A

Intracranial

Orbital

Osteomyelitis

229
Q

Intracranial complications of sinusitis

A

Meningitis

Abscesses

CVST

230
Q

Orbital complications of sinusitis

A

Erosion of the orbital wall

Orbital cellulitis

Subperiosteal abscess

Eyeball destruction

231
Q

Plane to take in tracheostomy

A

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

232
Q

Position of the head during tracheostomy?

A

Head should be extended

233
Q

Tracheal rings incised during tracheostomy

A

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

234
Q

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

A

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.

235
Q

With what is Dupuytren’s disease associated?

A

Knuckle pads, Peyronies disease, Ledderhose disease,

Not RPF

236
Q

Ledderhose disease

A

Plantar fibromatosis

237
Q

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

A

Indications for immediate laparotomy

238
Q

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

A

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

239
Q

MCV=

A

HCt x 1000/RBC

240
Q

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

A

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

241
Q

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

A

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

242
Q

Interpretation of mammograms in breast cancer screening programmes

A

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

243
Q

Which coronary vessel supplies the AVN?

A

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.

244
Q

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

A

2 years

75% of asymptomatic patients are alive at 5 years

245
Q

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

A

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.

246
Q

What are the two types of dumping syndromes?

A

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

247
Q

Localised region of injection in the eye

A

?episcleritis/slceritis

248
Q

Differentiator between episcleritis and scleritis

A

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

249
Q

Blood in the anterior chamber of the eye

A

Hyphaemia

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

250
Q

Inflammation of the iris and ciliary body?

A

Anterior uveitis

251
Q

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

A

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.

252
Q

Which vein is most likely to be the cause of haemorrhage during routine tracheostomy?

Anterior jugular

EJV

IJV

Middle throid

Superior thyroid

A

Anterior jugular vein and inferior thyroid veins may be encountered.

The rest are too lateral

253
Q

Detrusor-external sphincter dyssynergia

A

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

254
Q

Transport of CO2 in the blood

A

Carboxyhaemoglobin is the transport of CO on Hb, not CO2

CO2 is transported dissloved in the blood

255
Q

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

A

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

256
Q

Def: detrusor overactivity

A

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.

257
Q

Most common cause of urinary fistulation in developed world

A

Gynaecological surgery

258
Q

Most common cause of urinary fistulation in developing world?

A

Obstetric injury

259
Q

def: urinary incontinence

A

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

260
Q

Classification of urinary incontinence?

A

Urethral

Extra-urethral

261
Q

Urethral causes of urinary incontinence

A

Urethral sphincter incompetence

Detrusor overactivity

Overflow incontinence

UTI

Urethral diverticulum

Functional

262
Q

Extra-urethral causes of urinary incontinence

A

Congenital e.g. ectopic uretur

Fistula formation

263
Q

Most appropriate tourniquet pressure and time for distal limb

A

Pressure 50mmHg above DBP

Time: 60 minutes

264
Q

Likely location of aspirated contents whilst standing

A

Right anterior basal

265
Q

Likely location of aspirated contents whilst lying

A

Right lateral basal

266
Q

Which vessel courses across the mediastinum in almost horizontal fashion?

A

Left brachiocephalic vein

267
Q

Arrangement of structures at the lung roots

A

Pulmonary artery superior

Bronchus posteriorly

Pulmonary veins inferiorly

Bronchus at back

AV top down alphabetical order

268
Q

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

A

20%

269
Q

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

A

Anti-TPO (anti-microsomal)

Anti-thyroglobulin

270
Q

Gold standard Ix in ?aortic rupture

A

Arteriography

271
Q

Serum amylase in DKA

A

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

272
Q

Indications for endovascular repair of Stanford B dissection

A

Persistent pain

Increasing aortic diameter

Evidence of malperfusion of organs supplied by branch vessels

Evidence of periaortic/mediastinal haematoma

273
Q

Treatment of symptomatic liver cyst

A

Laparoscopic deroofing

274
Q

Treatment of liver cyst caused by entamoeba histolytica

A

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

275
Q

Kasbach-Merritt Syndrome

A

Large hepatic haemangiomas with thrombocytopenia and DIC

276
Q

Clinical course of necrobiosis lipoidica

A

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

277
Q

Causes of unilateral non function on IVU

A

Absent kidney

Thrombosis or avulsion of the renal artery

Massive parenchymal disruption

278
Q

Root of the small bowel mesentery?

A

Overlies the right SI joint

279
Q

SIADH in lung cancer suggests?

A

Unresectable disease

280
Q

Mediastinal lymphadenopathy in bronchial carcinoma

A

Suggests distant mets

Unresectable

281
Q

Trisomy 18

A

Edward syndrome

282
Q

Edward syndrome

A

Trisomy 18

Multiple developmental defects including talipesequinovarus and polydactyl

283
Q

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

A

Thrombomodulin, a membrane protein expressed by endothelial cells.

284
Q

Actions of thrombomodulin bound thrombin

A

Inhibits fibrinolysis

Activates Protein C

285
Q

Merkel cell carcinoma

A

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

286
Q

Whipple’s triad

A

Hypoglycaemic symptoms during fasting

Low fasting blood sugar levels

Symptoms relieved by IV dextrose

Characteristic of insulinomas

287
Q

Differential for cystic lesions in the pancreas?

A

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

288
Q

Hagen-Poiseullie law states that flow through a vessel is

A

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

289
Q

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

A

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

290
Q

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?

A

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

291
Q

Formation of the fossa ovalis?

A

Formed through fusion of the septum primum and septum secundum

292
Q

Optimal time for interval appendicectomy?

A

~6 weeks

293
Q

Optimal time for reversal of Hartmann’s?

A

6 months

294
Q

Rate of pancolitis in UC

A

10%

295
Q

Which nerve supplies the platysma

A

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

296
Q

Abx in the treatment of cryptosporidium?

A

Paromycin is the only effective treatment (other than supportive)

Drug may have limited effect on the diarrhoea

297
Q

Which LNs are least likely to be sampled during mediastinoscopy for NSCLC?

Paratracheal nodes

Subcarinal nodes

Tracheobronchial nodes

Aortopulmonary nodes

Pretrachaeal nodes

A

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

298
Q

At what [bilirubin] does jaundice become clinically apparent?

A

>40

299
Q

Deformity associated with myelmeningocele

A

Hydrocephalus (seen in 80%)

300
Q

Pierre Robin Sequence

A

Micrognathia

Retraction of the tongue

Upper airway obstruction

301
Q

Peanut farming increases the risk of what cancer?

A

Exposure to aflatoxin increases risk of HCC

302
Q

Painting and printing increase the risk of what cancer?

A

Benzopyrene exposure-> increased risk of lung Ca

303
Q

Cantlie’s line

A

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

304
Q

Incidence of alloantibodies is higher in

A

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

305
Q

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

A

Neutrophils and macrophages

306
Q

Rate of HPV infection in anorectal SCC

A

70% of patients test positive to the virus

307
Q

ECG changes seen following Swan-Ganz catheterisation

A

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

308
Q

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

A

PCT

309
Q

Which vessel runs through the right coronary sulcus?

A

Right coronary artery

310
Q

Conus artery

A

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

311
Q

Attrition bias

A

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

312
Q

Average survival after diagnosis of metastatic prostate cancer

A

2 years

313
Q

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

A

1/3rd

This increases to 90% over 90

314
Q

Ballance’s sign

A

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

315
Q

Kehr’s sign

A

Irritation of left diaphragm causing left shoulder tip pain

316
Q

Criteria for hypersplenism

A

Splenomegaly

Any combination of anaemia, leucopaenia or thrombocytopenia.

Bone marrow hyperplasia

Improvement after splenectomy

317
Q

Impact of preoperative carbohydrate loading in EPR

A

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

318
Q

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

A

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

319
Q

Originate from paraganglionic cells at the carotid bifurcation

5% metastasize within 10y if untreated

A

Chemodectoma

320
Q

Angiosarcoma

A

Develop in extremities.

Radiosensitive and respond to chemotherapy.

Radical amputation still advised

321
Q

Haemangiosarcoma caused by viral infection

A

Kaposi’s

322
Q

Tumour associated with buzzing sensation in head

A

Glomus jugulare tumour

Arise from jugular bulb

Should not be confused with glomus tumour

323
Q

What is the only true benign blood vessel tumour

A

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

324
Q

What are the paraganglionomas of the head and neck

A

Glomus tympanicum

Glomus jugulare

Glomus vagale

Chemodectoma

325
Q

Nerves at risk during excision of glomus jugulare

A

X, XI, XII

326
Q

Relative frequencies of testicular germ cell tumours

A

Seminoma 40%

Embryonal 25%

Teratocarcinoma 25%

Teratoma 5%

Choriocarcinoma (pure) 1%

327
Q

Differences between right main bronchus and left

A

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

328
Q

Course of the azygos wrt root of the lung

A

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.

329
Q

Rate and management of isolated pulmonary mets from colorectal cancer

A

Occurs in 5% of patients

Can be surgically removed with curative intent if patient will tolerate a thoracotomy.

330
Q

Management of multiple intracranial mets

A

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

331
Q

What is the most common form of brain neoplasm?

A

Astrocytoma

332
Q

?Burn depth

Characterised by pain, erythema and absence of blisters

A

Superficial burns

333
Q

Where are the short gastric arteries found?

A

Within the gastrosplenic ligament, which connects the greater curve of the stomach to the hilum of the spleen.

It also contains the gastroepiloic arteries

334
Q

Where does the hepatic artery proper branch

A

Just before entering the porta hepatis

335
Q

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

A

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.

336
Q

Volume of saliva produced/day

A

0.75-1.5L

337
Q

Post transfusion purpura

A

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.

338
Q

Purpura, nose bleeding post tranfusion

Thrombocytopenic

Normal coagulation screen

A

PTP

339
Q

Management of ABO-mismatch

A

Stop transfusion

IVF to maintain BP and renal perfusion

Adrenaline

Chlorphenamine

Hydrocortisone

340
Q

Most common age of presentation of WIlm’s

A

0-3 y/o

341
Q

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

A

10%

342
Q

Layers of the SCALP

A

Skin

Connective tissue

Aponeurosis

Loose areolar tissue

Pericranium

343
Q

Blood supply of the scalp

A

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

344
Q

Management of short segment SFA occlusions

A

Angioplasty

345
Q

Management of iliac artery aneurysm rupture during angiography

A

Endovascular stent graft

346
Q

Irritative (filling) LUTS

A

Frequency

Nocturia

Urgency +/- urge incontinence

Suprapubic pain

347
Q

Voiding (obstructive) LUTS

A

Hesitancy

Poor flow

Feeling of incomplete emptying

Post-micturition dribble

348
Q

Causes of incorrect pulse oximetry reading?

A

Arrythmias, hypotension, vasoconstriction, abnormal Hb or pigments (e.g. bilirubin), movement, poor tissue perfusion

Anaemia will not interfere with pulse oximetry readings

349
Q

Operative mortality for Whipple’s procedure?

A

20%

350
Q

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

A

13%

351
Q

Where is tracheostomy placed in adults?

A

2-4th tracheal ring

352
Q

Where is tracheostomy placed in children?

A

Second and fourth tracheal rings

353
Q

How does breathing into a bag correct respiratory alkalosis

A

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

354
Q

Which nerve is contained in the palatine tonsilar bed?

A

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

355
Q

Venous drainage of the tonsils

A

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

356
Q

Floor of the palatine tonsillar bed

A

Superior constrictor muscle

357
Q

Arterial supply of the tonsils

A

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

358
Q

Location of the palatine tonsillar bed

A

Oropharynx rather than the oral cavity

359
Q

Anterior boundary of the oropharynx

A

Base of the tongue and the palatoglossal folds

360
Q

Superior boundary of the oropharynx

A

Soft palate

361
Q

Inferior boundary of the oropharynx

A

Superior surface of epiglottis

362
Q

Posterior boundary of oropharynx?

A

Posterior pharyngeal wall

363
Q

Management of cervical spine in trauma patient

A

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.

364
Q

Def: low perianal fistula

A

Low fistula’s internal orifice is below puborectalis

High fistula’s orifice is above this

365
Q

Causes of high fistula

A

IBD- Crohn’s and UC

Diverticular diseasae

Carcinoma

TB

366
Q

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

A

Actinomycosis

367
Q

Child

Episodic fever associated with arthritis

RF negative

ANA positive

ESR raised

A

JIA

368
Q

Initial treatment of JIA

A

NSAIDs

369
Q

Flaccid areflexia

Diaphragmatic breathing

Ability to flex but not extend the elbow

(Priapism)

A

?Cervical spine injury

370
Q

Pathophysiology of priapism in C-spine injury

A

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

371
Q

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

A

Posterolateral thoracotomy

372
Q

Ddx for thick-walled gallbladder on USS

A

Normal physiological state after food

Cholecystitis (acute and chronic)

Infiltrative gall-bladder cancer

Liver conditions such as cirrhosis

373
Q

NICE recommendations for prophylactic antibiotics in surgery

A

Clean surgery involving the placement of a prosthesis or implant

Clean-contaminated surgery

Contaminated surgery

374
Q

7 pillars of clinical governance

A

Service user, carer and public involvement

Risk management

Clinical audit

Staffing and staff management

Education and training

Clinical effectiveness

Clinical information

375
Q

Psammoma bodies on biopsy

A

Papillary thyroid carcinoma

376
Q

Rate of fluid resuscitation in burns

A

Parkland formula gives fluids for first 24 hours.

Half should be given over first 8 hours, rest over subsequent 16

377
Q

What occurs in the secretory phase of the menstrual cycle?

A

Progesterone stimulates growth of the endometrium

378
Q

When does the secretory phase of the menstrual cycle begin?

A

After ovulation occurs

379
Q

When does progesterone peak in the menstrual cycle

A

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

380
Q

Where does the brachial artery begin?

A

At the inferior border of teres major

381
Q

Course of the profunda brachii

A

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

382
Q

Course of the brachial artery

A

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

383
Q

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

A

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

384
Q

Biochemical features of acute renal failure

A

Hyperkalaemia

Hyponatraemia

Raised urea and creat

385
Q

What happens wrt woven bone during fracture healing

A

Replaced with lamellar bone

386
Q

Potential haematological complication of TPN

A

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

387
Q

Main acid-base disturbance caused by parenteral feeding

A

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

388
Q

Most common cause of pyogenic liver abscesses?

A

E Coli and Klebsiella

Most common cause is cholangitis associated with biliary stones, followed by diverticulitis

389
Q

Venous drainage of the bladder

A

Via the vesical venous plexus lying on the inferolateral surface.

Veins from this plexus then drain into the IIV

390
Q

Appearance of elbow ossification centres by age

CRITOL 2, 4, 6, 8, 10, 12

A

Capitellum 1-3

Radial head 3-5

Iternal or medial epicondyle 5-7

Trochlea 7-9

Olecranon 9-11

Lateral epicondyle 11-13

391
Q

Use of the protamine sulphate test

A

Used to test for DIC

392
Q

Bile stained vomiting in a previously well infant…

A

?Mid-gut volvulus

393
Q

Frothy 4 hour old neonate

Mother had polyhydramnios

A

?Oesophageal atresia

394
Q

Mortality of cardiogenic shock

A

70-90%

395
Q

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

A

20ml O2/100ml blood

396
Q

Delay in self-ventilation following anaesthetic

A

Known as suxamethonium or scoline, apnoea.

In normal individual, the effects only last a few minutes until it has been metablised

397
Q

35y/o has anaesthetic for laparoscopy.

SBP rapidly drops to 70mmHg and a wheeze is audible.

What is the responsible drug?

A

Sodium thiopentone

Complications of marked hypotension, anaphylaxis and bronchospasm

398
Q

Which anaesthetic agent is associated with severe hepatotoxicity?

A

Halothane

399
Q

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

A

Nitrous oxide as it will diffuse into any air containing space

400
Q

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

A

Volkmann’s ischaemic contracture

401
Q

Pathophysiology of colonic pseudo-obstruction

A

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.

402
Q

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

A

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 .

403
Q

Most common enzymatic cause of congential adrenal hyperplasia?

A

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

404
Q

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

A

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

405
Q

What is the primary function of the menisci?

A

Decrease friction and stress shielding

406
Q

Aschner-Dagnini reflex

A

Oculocardic reflex

Decrease in pulse rate associated with compression of the eyeball

407
Q

Haptoglobin levels in haemolytic anaemia

A

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

408
Q

Borders of the femoral triangle

SAIL

A

Sartorius

Adductor longus

Inguinal

Ligament

409
Q

How many sections are there to the WHO checklist?

A

3

Before the induction of anaesthesia

Time out before skin incision

Sign out at the end of the procedure

410
Q

How is the action potential transmitted through skeletal muscle?

A

Spreads outwards to all parts via T tubes

411
Q

Action of UV light on DNA

A

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

412
Q

Most common genetic abnormalities in TCC bladder?

A

Chromosome 9 deletion

Alterations to p53 and Rb

413
Q

Most likely site of perforation in Typhoid fever

A

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

414
Q

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

A

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.

415
Q

What is the best way to identify parathyroid adenoma histologically

A

Intra-operative frozen section

416
Q

Malignant potential of UC

A

10 years- 2%

20 years- 8%

30 years- 18%

417
Q

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.

A

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

418
Q

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

A

Damage to intercostobrachial nerve

419
Q

Why is dry mouth not a commonly encountered problem following parotidectomy

A

Becuase of the presence of other major and minor salivary glands

420
Q

Which factor is respsonsible for cross-linking of fibrin?

II

VII

VIII

XII

XIII

A

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

421
Q

The axillary nerve is damaged in what proportion of shoulder dislocations

A

5%

422
Q

How to detect lat dorsi parlaysis

A

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

423
Q

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

A

?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

424
Q

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

A

UC

425
Q

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

A

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

426
Q

Site of Na reabsorption in kidney

A

PCT

427
Q

Site of renal faculative K reabsorption

A

DCT

428
Q

Pathophysiology of irritative symptoms in BPH

A

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

429
Q

Zones of penetrating neck injury

A

Zone 1- clavicle to cricoid cartilage

Zone 2- cricoid cartilage to angle of mandible

Zone 3- angle of mandible to base of skull

430
Q

Is Meckel’s a true or false diverticulum?

A

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

431
Q

High temperature

Deranged liver function tests

Positive blood cultures

Post-operatively following liver tranplant

A

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

432
Q

Which RLN is posterior to the ligamentum arteriosum

A

Left RLN

433
Q

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

A

10%

434
Q

Diagnostic work up in asymptomatic proteinuria with normal U+Es

A

History

BP

Albumin:creatinine ratio

Fasting blood glucose

Urine protein electrophoreisis

435
Q

Exomphalmos is associated with which syndromes?

A

Beckwith-Wiedemann, Edward and Patau

436
Q

Potter syndrome

A

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

437
Q

What percentage of cardiac output is received by the skin?

A

9%

438
Q

For what disorders are UK blood donations screened?

A

HBsAg

HCV DNA

HIV1 and 2 Abs

Treponema pallidum antibody

439
Q

Def: Pain

A

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

440
Q

Cardinal signs of flexor tendon sheath infection

A

Partially flexed finger

Fusiform swelling of the finger

Tenderness along the entire flexor tendon sheath

Severe pain on passive extension of the finger

441
Q

Examination findings in Achilles tendon rupture

A

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

442
Q

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

A

Le Fort II

443
Q

Low level facial fractures not associated with bilateral subconjunctival haemorrhages

A

Le Fort I

444
Q

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

A

Le Fort I in association with Le Fort II

445
Q

Facial fracture associated with dishface deformity

A

Le Fort III

446
Q

Which of the following is a systemic effect of 60% TBSA burns?

Glycogenosis

Hypervolaemia

Hypothermia

Immunosuppression

Reduced metabolic rate

A

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.

447
Q

Pathophysiology of Boutonniere deformity

A

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

448
Q

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

A

Bronchiolitis obliterans

449
Q

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

A

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

450
Q

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

A

Patients over 60

Those with CV and renal disease

Diabetics

Those on steroids/ACEi or diuretics

451
Q

Which of the following drugs works primarily by blocking transmission in postsynaptic autonomic fibres?

Suxamethonium

Hexamethonium

Bupivacaine

Pentazocine

Fentanyl

A

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.

452
Q

What are the potential complications of complete rectal prolapse?

A

Incontinence (75%) which may be the patients prsenting symptom

Incarceration

Ulceration and necrosis

Strangulation

Rectal carcinoma

453
Q

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

A

Colonic malignancy

454
Q

Cancer risk following torsion

A

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

455
Q

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

A

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

456
Q

Physiological anaemia of pregnancy

A

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

457
Q

Conservative management of oesophageal perforation

A

Broad spectrum ABx

PN

NG suction witrh gastric acid suppression

458
Q

Sympathetic innervation of the adrenal medulla

A

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

459
Q

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

A

Intermediolateral horn of the SC

460
Q

What are the spinal origins of the sympathetic nerves?

A

Efferent nerves originate from segments T1-L2

Leave the SC in the anterior roots and pass to the paired sympathetic chains

461
Q

Skin cancer with keratin pearl fromation

A

SCC

462
Q

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

A

BCC

463
Q

At what level does the thoracic duct pass through the diaphragm

A

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

464
Q

Into what structure does the thoracic duct drain?

A

The left brachiocephalic vein

465
Q

Path of the palmar cutaneous branch of the median nerve

A

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)

466
Q

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

A

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

467
Q

Neer’s classification

A

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

468
Q

Incision in thyroidectomy

A

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

469
Q

Remote carcinogen

A

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

470
Q

Proximate carcinogen

A

Metabolite of a chemical carcinogen that is itself carcinogenic

471
Q

Ultimate carcinogen

A

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

472
Q

Pathophysiology of beta-naphthylamine in TCC

A

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

473
Q

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

A

<100mls.

It has no oncotic properties, therefore it will be distributed amongst total body water

474
Q

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

A

1/4

475
Q

From what is the axillary vein formed?

A

The union of the basilica vein and the vena comitantes

476
Q

Which of the following bones are at risk of AVN?

Calcaneus

NOF

Olecranon

Patella

Talus

A

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

477
Q

Where is an ectopic implanatation most likely to occur?

A

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

478
Q

What are the components of the fallopian tube?

A

Infundibulum

Ampulla

Isthmus

Intramural portion

479
Q

What is the second most common site of ectopics

A

Isthmus of uterine ube (12%)

480
Q

Sudden breast pain

Tender subcutaneous cord attached to the skin

A

Mondor’s disease

481
Q

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

A

Mondor’s disease

482
Q

Complications of sphincterectomy in ERCP

A

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

483
Q

When does the PSA elevate following ejaculation?

A

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

484
Q

Pain in breast cancer

A

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

485
Q

Valgus deformity of the knee most commonly seen in?

A

Rheumatoid arthritis

Varus is more classical of severe osteoarthritis

486
Q

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

A

Osteochondritis dissicans

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

487
Q

Pathophysiology of Bochladek’s hernia

A

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

488
Q

5Bs of Bochladek hernia

A

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

489
Q

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

A

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

490
Q

Action of kinins

A

Proteins that attract phagocytes

They promote vasodilation

They increase the permeability of blood vessels

491
Q

Segmental innervation of forearm pronation

A

C7 and C8

492
Q

Segmental innervation for supination of the forearm

A

C6

493
Q

Segmental innervation of elbow flexion

A

C5 6

494
Q

Segmental innervation of elbow extension

A

C7 C8

495
Q

Segmental innervation of thumb and finger flexion

A

C7 C8

496
Q

Segmental innervation of finger and thumb extension

A

C7 C8

497
Q

FRC=

A

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

498
Q

What are the components of spirometry to remember?

A

Four lung volumes

5 capacities

499
Q

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

A

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

500
Q

What are the four lung volumes

A

Tidal volume

Residual volume

Inspiratory reserve volume

Expiratory reserve volume

MRCS Part A (15 decks)

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