Block 13 Flashcards
MOA Tociliziumab
IL-6 antagonist
Which cell type from the following is responsible for predominantly releasing interleukins?
Beta cells
Fibroblasts
Eosinophils
Macrophages
T cells
Macrophages
How does the body respond to a reduction in core body temperature leading to a rise in circulating plasma thyroxine?
Release of TRH by the hypothalalmus which is thought to be the control centre for thermoregulation.
In which wounds are hypertrophic scars most commonly seen?
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
MOA suxamethonium
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
Rocuronium
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
Sellick’s manoeuvre
Application of cricoid pressure for RSI in all non-fasted patients as prevention against aspiration
Ix in colovesical fixtula
Cystoscopy and barium enema are the two most likely investigations to help
Riedel’s lobe
Congenital abnormality.
Projection of normally functioning liver tissue downward from the right lobe, below the costal margin and along the anterior axillary line
Formation of the vocal cords
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
What can be used to grade facial nerve palsy?
House-Brackman Scale of I (normal) to VI (complete paralysis)
What is the most important potential complication of facial nerve palsy?
Failure in eye closure leading to corneal ulceration (House-Brackmann III and above)
Formation of the denticulate ligaments
Part of the pia mater which help connect the SC to the arachnoid and dura mater.
Structural arrangement of the arachnoid mater of the spine
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
The plexus of nerves in the arachnoid mater of the SC derive from what?
The motor root of trigeminal, facial and accesory nerves
Droopy lip post carotid endarterectomy, which nerve damaged?
Marginal mandibular nerve
Nerves at risk during carotid endarterectomy?
Greater auricular
Hypoglossal
Marginal mandibular
Glossopharyngeal
Vagus nerve
What is the risk of aneurysms associated with a patient having an aneurysm already
25% of patients with one aneurysm will have other aneurysms elsewhere.
Rate of popliteal aneurysms in patients with AAA?
10-15%
Rate of AAA in patients with popliteal aneurysm?
30-50%
def: false aneurysm
Pseudoaneurysm
Collection of blood found between the muscularis and adventitia layers of an artery resulting from an arterial puncture or trauma to the artery.
Dissecting aneurysms
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.
Where is the intimal tear often seen in a dissecting aneurysm
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.
Most common locations of mycotic aneurysms
Femoral artery followed by aorta and intracranial arteries.,
Luetic aneurysms
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
Use of percutaneous biliary drainage in pancreatic malignancy
Used when endoscopic stent insertion is not possible
Management of benign biliary strictures
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
Intrahepatic duct dilatation
More commonly caused by tumours and strictures than gallstones
Elevated FSH
Reduced or absent spermatogensis
Masculinisation normal
?Seminiferous tubular dysfunction
CA 125 in stage 1 ovarian cancer
Elevated in less than 50% of patients
CA 19-9 in pancreatic carcinoma
Elevated in 75-90% of patients
National breast screening programme
50-70y/o every 3 years.
Has led to increased detection of CIS.
Has led to reduced numbers of benign breast biopsies
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
Naso-endoscopy.
Thorough examination with CXR, ENT examination should be performed
Attachments of the free edge of the lesser omentum?
Attached to first 2cm of the first part of the dudoenum and the fissure of the ligamentum venosum.
Vascular supply in the lesser omentum
RGA and LGA supply it as they lie between its two peritoneal layers
Maximum dose of 1% lidocaine with adrenaline that can be administered to a 60kg woman.
30mls
35ml
42ml
62ml
70ml
Maximum dose with adrenaline is 7mg/kg
1% lidocaine containes 10mg/ml.
60kg woman, maximum dose is 420mg. Which equates to 42ml
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
Ascites
Pancreatic ascites
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
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
?Pancreatic abscess
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
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.
Prevalence of UC
60/100000
FHx in UC
15% of patient have a first degree relative with IBD and wider FHx in 20-30% of cases
Causes of cardiac tamponade
Trauma
Breast /lung carcinomas
Aortic dissection
MI
Bacertial, viral or tuberculous pericarditits
Madura foot
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.
Rate of ischaemic colitis post AAA repair
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
Paraplegia following AAA repair
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.
Artery of Adamkiewicz
AKA great anterior radiculomedullary artery
Arises from AA at 9th-12th intercostal arteries and at risk during AAA repair.
Pathophysiology of trash foot
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.
Pain
Intact peripheral pulses
Livedo reticularis
?Trashfoot
Mean pulmonary arterial pressure
15mmHG
Suture material used in small bowel anastomosis
3 0 PDS
Absorbable materials used.
Stapling has become more prominent.
No evidence of different anastomotic leak rates between suturing and stapling
Mid-line abdominal wound closure material
1 PDS or 1 Nylon
Suture material for securing prosthetic mesh during incisional hernia repair
2 0 prolene
Non-absorbable suture most appropriate
Pathophysiology of septic arthritis
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.
Pathophysiology of pseudogout
Pyrophosphate is generated in cartilage by enzymatic activity and combines with calcium ions to form crystals
Associations of pseudogout
HyperPTH
Hypothyroidsim
Acromegaly
Haemochromatosis
Pattern in pseudogout
Fibrocartilage of the knee
Pubic symphysis
Intervertebral discs
Particularly common in women >60
Weakly positive bi-refringent rhomboid crystals in plane-polarised light
Pseudogout
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.
Still’s disease.
Recurrent abdominal pain may occur secondary to bouts of mesenteric adenitis.
HSM, myocarditis and uveitis may complicate the condition
Diagnostic criteria for Stills
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
Diagnosis of Still’s
90% seronegative and can thus only be diagnosed with snyovial biopsy
Most common benign bone tumour affecting individuals <21
Osteochondroma
Most common complication of venous insufficency
Leg ulceration
Signs of chronic venous insufficieny
HEAVE
Haemosiderin deposition
Eczema
Ankle ulcers
Varicose veins
oEdema
Which organ has the greatest blood flow per 100g of tissue?
Kidneys
Pericardiocentesis
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.
qSOFA score
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
What proportion of anaphylaxis related deaths occur because of the late-phase reaction?
30%
Why is hypothermia a greater issue in children who have suffered burn injuries
Higher SA to volume ratio
Children <1 do not have the shivering reflex
Indications for inotropes in paediatric burns
<1-2ml/kg/h UO with >=10% TBSA may be an indicator for dopamine
Pulse pressure in neurogenic shock
Widened due to proporionately higher fall in diastolic pressure
Which vein is carried within the hepatoduodenal ligament?
Hepatic portal vein
Type A lactic acidosis
Occurs with decreased tissue ATP in the setting of poor tissue perfusion or oxygenation
Type B lactic acidosis
Occurs in the absence of evidence of tissue hypoperfusion/hypo oxyfgenation
Type B1 lactic acidosis
Occurs in association with systemic disease e.g. renal and hepatic failure, DM and or malignancy
Type B2 lactic acidosis
Drug associated
Type B3 lactic acidosis
Due to inborn errors of metabolism
Which of the following arteries supply the trochanteric anastomosis?
Anterior spinal artery
EIA
Gluteal arteries
Iliolumbar
Posterior spinal
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
Blood supply of the ASIS anastomosis
Iliolumbar arteries
Which immunosuppressive drug acts by inhibiting IL-2 action?
Sirolimus
Ciclosporin
Azathioprine
MMF
Tacrolimus
Sirolimus inhibits IL-2 action whereas ciclosporin and tracrolimus inhibit IL-2 production
How much blood can the pulmonary vessels accomodate at rest?
500ml
Development of lymphoedema in a female shortly after menarche
Swelling around ankle up to the dorsum of the foot and spreads proximally.
Meige’s disease (lymphoedema praecox)
Which of the following is not contained within the carpal tunnel at the wrist?
FDS
PL
Median nerve
FDP
FPL
PL is superficial to the flexor retinaculum
Histopathology of iron overload
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
Genes implicated in haemochromatosis
C282Y mutation or H63D
Course of the sacral plexus
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
Surgical approach for ruptured kidney
Through the anterior abdominal wall by a midline incision.
Simple nephrectomy is indicated in cases of non-functioning kidneys
Relations of the left kidney
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
Dynamic test in ?anastomotic leak
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
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.
Ranula
Ranula
Aetiological factors in oral cavity cancers
S
Spirits
Smoking
Syphillis
Papillomavirus
Sore tooth (trauma)
Synchronous and metachronous tumours in carcinoma of the oral cavity
5 and 10% respectively
Management of choledochal cyst
Roux-en-Y hepaticojejunostomy
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,
Choledochal cysts
Double duct sign
Dilatation of both the pancreatic and biliary duct
High indicative of pancreatic cancer but may also present in chronic pancreatitis
T1 skin cancer
1mm
T2 MM
1.01-2.00mm
T3 MM
2.01-4.0mm
T4 MM
>4.0mm
N0 MM
No lymph node involvement
N1 MM
One LN
N2 MM
Two or three LNs or satellite/in-transit lesions
N3 MM
Four or more LNs
M0 MM
No mets
M1a MM
Distant skin or LN mets
M1b MM
Lung mets
M1c MM
All other visceral mets
Stage 0 MM
Tis, N0, M0
Stage I MM
T1a-T2a, N0, M0
Stage III MM
Any T, N1-3, M0
Stage IV MM
Any T, Any N, M1a-c
a and b subscripts in T staging of MM
a indicates without ulceration
b indicates with ulceration
Extra-articular distal radial fracture with volar displacement
Smith’s fracture
Extra articular fracture with dorsal and radial displacement of distal fragment
Colle’s
Intra-articular distal radial fracture either volar or dorsal where the articular surface of the distal radius subluxes from the carpals
Barton’s fracture
Dragging sensation in pelvis
Urinary, sexual and rectal evacuatory function impaired resulting in voiding difficulties/urinary incontinence.
?Uterovaginal prolapse
Bladder pain and irritative bladder symptoms
Pain worse on bladder distension and eased on micturition
Negative urine cultures
?Painful bladder syndrome
Diagnosis of painful bladder syndrome
Urine should be cultured for atypical organisms
Cystometry and cystoscopy are useful and reveal low capacity, non-compliant bladder
Most sensitive ultrasound finding in acute cholecystitis
Cholelithiasis in combination with sonographic murphy’s sign
Surgical management of subclavian steal syndrome
Carotid-subclavian bypass
Bypass required following endovascular repair of thoracic aneurysm where the origin of the left carotid is covered by the stent graft
Carotid-carotid bypass
Most effective method for preventing transmission of MRSA?
Good hygiene
Embryological precursor of the prostate
Urogenital sinus
In what proportion of critically ill patients is acute renal failure seen?
30%
Morbidity and mortality associated with acute renal failure?
60% increase
Roles of VIP
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
What percentage burn accounts to the palmar area?
1%
How to prevent tension pneumothorax when dressing open pneumothorax?
Tape dressing on three sides to create a flutter-type valve effect
Most common cause of tension pneumothorax
Mechanical ventilation in patient with visceral pleural injury
Respiratory consequence of hypoxia
Respiratory alkalosis through increased ventilation
Causes of femoral nerve injury
Gunshot wound
Traction during surgery
Femoral triangle injury
Massive haematoma
Patients with DM
Lumbar spondylosis
Vital capacity
Approx 70ml/kg
In which penile structure is the pathology of Peyronie’s disease?
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
Mechanisms of development of posterior urethral valves
Hypertrophy of the urethral mucosal folds
Abnormal development of the Wolffian duct
Fusion of the verumontanum
Persistence of the urogenital membrane
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
Bladder exstrophy
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.
Hypospadias
Surgical managmenet of bladder exstrophy
Operation to close bladder and pelvis at birth
Genitoplasty at 2y
Bladder neck repair to achieve continence at 4-5y
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,
Anterior uretrhral valves
Renal regulation of potassium in respiratory acidosis
Renal excretion of potassium would fall since tubular secretion of potassium is inversely coupled to acid secretion
Inguinal hernia repair approach
Litchenstein repair recommended
Pseudobulbar palsy vs bulbar palsy
Bulbar palsy is LMN. Pseudobulbar is UMN
Causes of anal fistula
Up to 80% are due to abscess
Other causes include post-surgical, trauma, penetrating injury, TB, Crohn’s
Murmur in VSD
Continuous systolic murmur/pansystolic murmur
Murmur in ASD
No murmur
Split of the HS II is fixed throughout diastole and systole
Where in the kidney is PO4 reabsorbed?
PO4 is reabsrobed in the PCT under the control of PTH
Which part of the nephron receives its blood supply from the vasa recta?
Loop of Henle
Location of calcium reabsorption in the kidney?
Ascending loop of Henle
Distal tubule
Collecting tubule
What is absorbed in the PCT?
Actively reabsorbs sodium, establishing the osmotic gradient leading to water being drawn out of the tubule
Borchardt’s triad
Gastric volvulus
Epigastric pain, retching without vomiting and inability to pass an NG tube
What are the two planes in which gastric volvulus can occur?
Along the long axis of the stomach: organoaxial
or
Around the axis perpendicular to the stomach: mesenteroaxial
Cervical lesion occuring secondary to OCP and must be distinguished from adenocarcinoma histologically
Endocervical polyp
Endocervical polyp
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
Which BZD is preferred in IV sedation?
Midazolam as it is shorter acting than diazepam and easier to control and reverse
Opiate and sedative use
When sedation is given in conjuction with IV opiate analgesia, the sedative drug is best given a few minutes before
What proportion of gastric cancers can be accounted for by H. pylroi?
65-80% of gastric carcinomas. But these occur in only 2% of infections
Consequence of maltase deficiency?
Result in a reduction of maltose hydroylsis, leading to increased passage of maltose in stool.
Young children with unhealed burns are at risk of?
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
Endothelin-1
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
ICAM-1
Cellular adhesion molecule which is increased during inflammation and by IL-1
Presentation of spinal mets
90% present with back/bone pain followed by radicular pain.
Sensory or motor neurology occurs in 50%
What proportion of patients with palliative cancer have spinal mets?
30%
Relative contraindication to surgical decompression in SC compression?
Complete paraplegia lasting >24h
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
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
Which of the following muscles is not found in the anterior compartment of the leg?
Tibialis anterior
EHL
EDL
Peroneus tertius
Peroneus brevis
Peroneus brevis is found in the lateral compartment
Which of the following clotting factors is not a serine protease?
XI
II
IX
XII
XIII
XIII is a transglutaminase, the rest are serine proteases
Causes of bilaterally small pupils
Opiates
Destructive pontine lesion
Metabolic encephalopathy
13 y/o boy
Tiredness, recurrent throat and chest infections, gradual loss of hearing.
XR shows marble bone appearance
Osteopetrosis
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
Osteopetrosis
Cause of pseudoparalysis in scurvy
Subperiosteal bleeding may cause a haematoma and the child may remain still- pseudoparalysis
Cupped apearance on XR
?Rickets
Rate of remission in children with Grave’s treated with antithyroid drugs?
1 in 3.
The external laryngeal nerve must be identified before ligating which artery during thyroidectomy?
Superior thyroid artery
Invasive nature of sarcoma
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
Colour of urine in hepatic jaundice?
Dark urine
Mild jaundice
Normal coloured urine and faeces
Unconjugated bilirubin
Normal transaminases
Normal ALP
Prehepatic
Variable jaundice severity
Dark urine
Normal stool
Unconjugated and conjugated bilirubin
Grossly increased transaminases
Mildly elevated ALP
Hepatic
Deep jaundice
Dark urine
Pale stool
Conjugated bilirubin
Normal or mild increase in transaminases
Grossly elevated ALP
Post-hepatic
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
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
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
Varicocele.
Swelling disappears on lying down as veins empty
Long standing cases may cause testicular atrophy and are associated with infertility
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
Hydrocele
MOA ketoconazole
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
MOA amphotericin and nystatin
Impair cell membrane permeability by directly complexing with the membrane sterol
MOA griseofulvin
Inhibits microtubules
MOA flucytosine
Incorporated into RNA after deamination and phosphorylated.
Also interferes with DNA synthesis as it is a non-competitive inhibitor of thymidylate synthetase
Cx of epididmyitis
Abscess formation
Testis infarction
Chronic pain and infection
Infertility
Incision line for episotomy
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.
Metastatic adenocarcinoma, aneurysms
Metastatic lung adenocarcinoma has been documented in the literature to cause intracerebral aneurysms but is not the cause of mycotic aneurysms
NCEPDO classification
Classification of intervention that rationalises available theatre resources and delivers them to those who require care by urgency of injuries
NCEPOD 1
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
NCEPOD2
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
NCEPOD 3
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
NCEPOD 4
Elective
Intervention planned or booked in advance of routine admission to hospital
Post-streptococcal glomerulonephritis
Gel-Coombs classification
Type III as immune complex disease
Action of segmentation w.r.t. GI motility
Segmentation efficiently mixes chyme with mucus and hydrolytic enzymes through contraction of isolated segments found at segments along the intestine
Auer rods in peripheral blood film
AML
Carbohydrate requirement per day?
2g/kg/d
Nitrogen requirement per day
0.5-1g/kg/d
Water requirement /day
35ml/kg/d
Describe the two phases of testicular descent
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.
Allantois
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
Complications of undescended testis
TESTIS
Trauma
Epididymo-orchitis
Sterility
Torsion
Intestinal hernia
Seminoma
Genital tubercle
Develops around the fourth week of gestation and will give rise to the clitoris in women and penis in men
Sun exposure pattern risk for melanoma
Short periods of intesnse sun exposure thought to be more significant risk factor than cumulative sun exposure
Hawkin’s test is for
Subacromial impingement
Jobe’s test is for
Supraspinatus
Internal rotation lag sign and greber’s lift off test assess
Subscapularis
What is the most important direct stimulus to respiration
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
Ober’s test
For tight iliotibial band
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
Total laryngectomy and neck dissection.
Surgical options for patients with advanced stage largneal cancer.
Use of total laryngectomy in laryngeal carcinoma
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
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
Excision of mucosa
RTx is as effective as surgery in the treatment of T1 tumours but the resulting voice quality is better after sx
55y/o lady with glottic carcinoma involving anterior commissure
Total laryngectomy and neck dissection
RTx
CTx
Excision of vocal cord mucosa
RTx
70y/o woman with large supraglottic carcinoma
Total laryngectomy and neck dissection
RTx
CTx
Excision of vocal cord mucosa
Nodal mets are found in 55% of supraglottic tumours. Therefore radical neck dissection is often required for large supraglottic tumours
Triad in laryngeal fracture
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
Mx of ?laryngeal fracture
If airway is obstructed an attempt at endotracheal intubation is warranted (together with C-spine immobilisation if traumatic)
Use of unpaired t-test
To compare two separate groups at the same point in time
Use of paired t test
To compare one group at two points in time
Use of Friedman test
Used to compare three or more groups if the data are non-parametrical
ANOVA
Used to compare three or more groups if the data are parametrical
Pearson correlation coefficient
Measure of the strength of linear relationship between two variables
Damage to the external laryngeal nerve causes
Loss of high pitched phonation
Approach to control of inferior thyroid vasculature during thyroidectomy
Artery should be ligated in continuity before the inferior thyroid veins
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
Factor VII
Aaron’s sign
Pain referred to epigastrium upon continuous firm pressure over McBurney’s point
Seen in appendicitis
Dunphy’s sign
Increased abdominal pain with coughing.
Often seen in appendicitis
From which sinus does osteomylelitis most commonly develop?
Frontal sinus
Classification of the complications of sinusitis?
Intracranial
Orbital
Osteomyelitis
Intracranial complications of sinusitis
Meningitis
Abscesses
CVST
Orbital complications of sinusitis
Erosion of the orbital wall
Orbital cellulitis
Subperiosteal abscess
Eyeball destruction
Plane to take in tracheostomy
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
Position of the head during tracheostomy?
Head should be extended
Tracheal rings incised during tracheostomy
2nd and 3rd (incision of the 1st i.e. the cricoid carilage will lead to airway compromise)
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
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.
With what is Dupuytren’s disease associated?
Knuckle pads, Peyronies disease, Ledderhose disease,
Not RPF
Ledderhose disease
Plantar fibromatosis
High velocity penetrating gun shot wounds or low-velocity penetrating abdominal injury with hypotension or shock=
Indications for immediate laparotomy
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
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
MCV=
HCt x 1000/RBC
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
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
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
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
Interpretation of mammograms in breast cancer screening programmes
2 view mammograms that are interpreted by 2 consultant radiologists with further imaging +/- biopsies organised as needed
Which coronary vessel supplies the AVN?
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.
Mean survival time from diagnosis to death or liver transplant in PSC?
2 years
75% of asymptomatic patients are alive at 5 years
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
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.
What are the two types of dumping syndromes?
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
Localised region of injection in the eye
?episcleritis/slceritis
Differentiator between episcleritis and scleritis
Episcleritis is much less painful than scleritis, in which the inflammation is more extensive
Blood in the anterior chamber of the eye
Hyphaemia
Must be treated as an emergency as further bleeding may increase IOP and compromise sight
Inflammation of the iris and ciliary body?
Anterior uveitis
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
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.
Which vein is most likely to be the cause of haemorrhage during routine tracheostomy?
Anterior jugular
EJV
IJV
Middle throid
Superior thyroid
Anterior jugular vein and inferior thyroid veins may be encountered.
The rest are too lateral
Detrusor-external sphincter dyssynergia
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
Transport of CO2 in the blood
Carboxyhaemoglobin is the transport of CO on Hb, not CO2
CO2 is transported dissloved in the blood
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
Ligamentum flavum can thicken and hypertrophy, narrowing the spinal canl causing stenosis
Def: detrusor overactivity
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.
Most common cause of urinary fistulation in developed world
Gynaecological surgery
Most common cause of urinary fistulation in developing world?
Obstetric injury
def: urinary incontinence
Involunatry loss of urine which is objectively demonstrable and a social or hygienic problem
Classification of urinary incontinence?
Urethral
Extra-urethral
Urethral causes of urinary incontinence
Urethral sphincter incompetence
Detrusor overactivity
Overflow incontinence
UTI
Urethral diverticulum
Functional
Extra-urethral causes of urinary incontinence
Congenital e.g. ectopic uretur
Fistula formation
Most appropriate tourniquet pressure and time for distal limb
Pressure 50mmHg above DBP
Time: 60 minutes
Likely location of aspirated contents whilst standing
Right anterior basal
Likely location of aspirated contents whilst lying
Right lateral basal
Which vessel courses across the mediastinum in almost horizontal fashion?
Left brachiocephalic vein
Arrangement of structures at the lung roots
Pulmonary artery superior
Bronchus posteriorly
Pulmonary veins inferiorly
Bronchus at back
AV top down alphabetical order
What proportion of triglyceride digestion occurs due to lingual lipase in a healthy individual?
20%
What auto-Abs are found most commonly in Hashimoto’s thyroiditis?
Anti-TPO (anti-microsomal)
Anti-thyroglobulin
Gold standard Ix in ?aortic rupture
Arteriography
Serum amylase in DKA
Patients in DKA often have elevated serum amylase activities as a result of decreased renal excretion of the enzyme.
Indications for endovascular repair of Stanford B dissection
Persistent pain
Increasing aortic diameter
Evidence of malperfusion of organs supplied by branch vessels
Evidence of periaortic/mediastinal haematoma
Treatment of symptomatic liver cyst
Laparoscopic deroofing
Treatment of liver cyst caused by entamoeba histolytica
Metronidazole for 5-10/7 and percutaneous drainage is not usually required
Kasbach-Merritt Syndrome
Large hepatic haemangiomas with thrombocytopenia and DIC
Clinical course of necrobiosis lipoidica
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
Causes of unilateral non function on IVU
Absent kidney
Thrombosis or avulsion of the renal artery
Massive parenchymal disruption
Root of the small bowel mesentery?
Overlies the right SI joint
SIADH in lung cancer suggests?
Unresectable disease
Mediastinal lymphadenopathy in bronchial carcinoma
Suggests distant mets
Unresectable
Trisomy 18
Edward syndrome
Edward syndrome
Trisomy 18
Multiple developmental defects including talipesequinovarus and polydactyl
What protein functions as cofactor in the thrombin induced activation of protein C?
Thrombomodulin, a membrane protein expressed by endothelial cells.
Actions of thrombomodulin bound thrombin
Inhibits fibrinolysis
Activates Protein C
Merkel cell carcinoma
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
Whipple’s triad
Hypoglycaemic symptoms during fasting
Low fasting blood sugar levels
Symptoms relieved by IV dextrose
Characteristic of insulinomas
Differential for cystic lesions in the pancreas?
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
Hagen-Poiseullie law states that flow through a vessel is
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
Significance of Hagen-Poiseuille law w.r.t. central and peripheral venous lines
Flow is greater through peripheral cannnual as they are short and wide whereas central lines are long with a narrow lumen
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?
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
Formation of the fossa ovalis?
Formed through fusion of the septum primum and septum secundum
Optimal time for interval appendicectomy?
~6 weeks
Optimal time for reversal of Hartmann’s?
6 months
Rate of pancolitis in UC
10%
Which nerve supplies the platysma
Facial nerve supplies all the muscles of facial expression including the platysma.
Abx in the treatment of cryptosporidium?
Paromycin is the only effective treatment (other than supportive)
Drug may have limited effect on the diarrhoea
Which LNs are least likely to be sampled during mediastinoscopy for NSCLC?
Paratracheal nodes
Subcarinal nodes
Tracheobronchial nodes
Aortopulmonary nodes
Pretrachaeal nodes
Aortopulmonary nodes are difficult to access via mediastinoscopy as the aorta is in the way. They are accessed via thorascopy.
At what [bilirubin] does jaundice become clinically apparent?
>40
Deformity associated with myelmeningocele
Hydrocephalus (seen in 80%)
Pierre Robin Sequence
Micrognathia
Retraction of the tongue
Upper airway obstruction
Peanut farming increases the risk of what cancer?
Exposure to aflatoxin increases risk of HCC
Painting and printing increase the risk of what cancer?
Benzopyrene exposure-> increased risk of lung Ca
Cantlie’s line
Main portal scissura that divides the liver into functional right and left lobes
Incidence of alloantibodies is higher in
Women because of non-self red-cell antigen exposure in pregnancy
On what immune cells are the Fc receptors for IgG found?
Neutrophils and macrophages
Rate of HPV infection in anorectal SCC
70% of patients test positive to the virus
ECG changes seen following Swan-Ganz catheterisation
Transient RBBB seen in up to 5% of patients but usually resolves within 24 hours
In what part of the nephron are most amino acids and glucose absorbed?
PCT
Which vessel runs through the right coronary sulcus?
Right coronary artery
Conus artery
Present in 45% of the population and can provide collateral circulation in LAD occlusion
Attrition bias
Occurs when there is a difference between withdrawals and dropout between study groups-> incomplete outcome data
Average survival after diagnosis of metastatic prostate cancer
2 years
What proportion of men over 50 have microscopic malignant changes in the prostate at autopsy?
1/3rd
This increases to 90% over 90
Ballance’s sign
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
Kehr’s sign
Irritation of left diaphragm causing left shoulder tip pain
Criteria for hypersplenism
Splenomegaly
Any combination of anaemia, leucopaenia or thrombocytopenia.
Bone marrow hyperplasia
Improvement after splenectomy
Impact of preoperative carbohydrate loading in EPR
Reduces postoperative insulin resistance and has been shown to reduce anxiety, thirst, nausea and hunger
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
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
Originate from paraganglionic cells at the carotid bifurcation
5% metastasize within 10y if untreated
Chemodectoma
Angiosarcoma
Develop in extremities.
Radiosensitive and respond to chemotherapy.
Radical amputation still advised
Haemangiosarcoma caused by viral infection
Kaposi’s
Tumour associated with buzzing sensation in head
Glomus jugulare tumour
Arise from jugular bulb
Should not be confused with glomus tumour
What is the only true benign blood vessel tumour
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
What are the paraganglionomas of the head and neck
Glomus tympanicum
Glomus jugulare
Glomus vagale
Chemodectoma
Nerves at risk during excision of glomus jugulare
X, XI, XII
Relative frequencies of testicular germ cell tumours
Seminoma 40%
Embryonal 25%
Teratocarcinoma 25%
Teratoma 5%
Choriocarcinoma (pure) 1%
Differences between right main bronchus and left
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
Course of the azygos wrt root of the lung
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.
Rate and management of isolated pulmonary mets from colorectal cancer
Occurs in 5% of patients
Can be surgically removed with curative intent if patient will tolerate a thoracotomy.
Management of multiple intracranial mets
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
What is the most common form of brain neoplasm?
Astrocytoma
?Burn depth
Characterised by pain, erythema and absence of blisters
Superficial burns
Where are the short gastric arteries found?
Within the gastrosplenic ligament, which connects the greater curve of the stomach to the hilum of the spleen.
It also contains the gastroepiloic arteries
Where does the hepatic artery proper branch
Just before entering the porta hepatis
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
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.
Volume of saliva produced/day
0.75-1.5L
Post transfusion purpura
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.
Purpura, nose bleeding post tranfusion
Thrombocytopenic
Normal coagulation screen
PTP
Management of ABO-mismatch
Stop transfusion
IVF to maintain BP and renal perfusion
Adrenaline
Chlorphenamine
Hydrocortisone
Most common age of presentation of WIlm’s
0-3 y/o
Wilm’s tumour is bilateral in what proportion of cases?
10%
Layers of the SCALP
Skin
Connective tissue
Aponeurosis
Loose areolar tissue
Pericranium
Blood supply of the scalp
Comes from both the internal and external carotid arteries (supraorbital and supratrochlear branches of ICA)
Management of short segment SFA occlusions
Angioplasty
Management of iliac artery aneurysm rupture during angiography
Endovascular stent graft
Irritative (filling) LUTS
Frequency
Nocturia
Urgency +/- urge incontinence
Suprapubic pain
Voiding (obstructive) LUTS
Hesitancy
Poor flow
Feeling of incomplete emptying
Post-micturition dribble
Causes of incorrect pulse oximetry reading?
Arrythmias, hypotension, vasoconstriction, abnormal Hb or pigments (e.g. bilirubin), movement, poor tissue perfusion
Anaemia will not interfere with pulse oximetry readings
Operative mortality for Whipple’s procedure?
20%
What proportion of patients with pancreatic carcinoma are suitable for operation at presentation?
13%
Where is tracheostomy placed in adults?
2-4th tracheal ring
Where is tracheostomy placed in children?
Second and fourth tracheal rings
How does breathing into a bag correct respiratory alkalosis
Causes expired CO2 to be stored in this reservoir, increasing FiCO2 which increases the reabsorption of CO2
Which nerve is contained in the palatine tonsilar bed?
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
Venous drainage of the tonsils
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
Floor of the palatine tonsillar bed
Superior constrictor muscle
Arterial supply of the tonsils
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
Location of the palatine tonsillar bed
Oropharynx rather than the oral cavity
Anterior boundary of the oropharynx
Base of the tongue and the palatoglossal folds
Superior boundary of the oropharynx
Soft palate
Inferior boundary of the oropharynx
Superior surface of epiglottis
Posterior boundary of oropharynx?
Posterior pharyngeal wall
Management of cervical spine in trauma patient
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.
Def: low perianal fistula
Low fistula’s internal orifice is below puborectalis
High fistula’s orifice is above this
Causes of high fistula
IBD- Crohn’s and UC
Diverticular diseasae
Carcinoma
TB
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
Actinomycosis
Child
Episodic fever associated with arthritis
RF negative
ANA positive
ESR raised
JIA
Initial treatment of JIA
NSAIDs
Flaccid areflexia
Diaphragmatic breathing
Ability to flex but not extend the elbow
(Priapism)
?Cervical spine injury
Pathophysiology of priapism in C-spine injury
Loss of sympathetic input and uncontrolled arterial inflow directly into the penile sinusoidal spaces.
Surgical access for aortic transection at the junction of the aortic arch with descending thoracic aorta
Posterolateral thoracotomy
Ddx for thick-walled gallbladder on USS
Normal physiological state after food
Cholecystitis (acute and chronic)
Infiltrative gall-bladder cancer
Liver conditions such as cirrhosis
NICE recommendations for prophylactic antibiotics in surgery
Clean surgery involving the placement of a prosthesis or implant
Clean-contaminated surgery
Contaminated surgery
7 pillars of clinical governance
Service user, carer and public involvement
Risk management
Clinical audit
Staffing and staff management
Education and training
Clinical effectiveness
Clinical information
Psammoma bodies on biopsy
Papillary thyroid carcinoma
Rate of fluid resuscitation in burns
Parkland formula gives fluids for first 24 hours.
Half should be given over first 8 hours, rest over subsequent 16
What occurs in the secretory phase of the menstrual cycle?
Progesterone stimulates growth of the endometrium
When does the secretory phase of the menstrual cycle begin?
After ovulation occurs
When does progesterone peak in the menstrual cycle
Within the secretory phase, progesterone peaks 7 days after ovulation (day 21). Progesterone levls can be used to confrim ovulation
Where does the brachial artery begin?
At the inferior border of teres major
Course of the profunda brachii
Accompanies the radial nerve in the spiral groove of the humerus.
Course of the brachial artery
Continues anterior to brachialis and medial to biceps brachii, where it can be palpated against the humerus on the medial arm
Relation of the small bowel mesentery to the third part of the duodenum
It is to the left of the third part of the duodenum
Biochemical features of acute renal failure
Hyperkalaemia
Hyponatraemia
Raised urea and creat
What happens wrt woven bone during fracture healing
Replaced with lamellar bone
Potential haematological complication of TPN
PN without giving folate or Vit B12 will lead to megaloblastic anaemia and eventually pancytopenia that can be life threatening
Main acid-base disturbance caused by parenteral feeding
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
Most common cause of pyogenic liver abscesses?
E Coli and Klebsiella
Most common cause is cholangitis associated with biliary stones, followed by diverticulitis
Venous drainage of the bladder
Via the vesical venous plexus lying on the inferolateral surface.
Veins from this plexus then drain into the IIV
Appearance of elbow ossification centres by age
CRITOL 2, 4, 6, 8, 10, 12
Capitellum 1-3
Radial head 3-5
Iternal or medial epicondyle 5-7
Trochlea 7-9
Olecranon 9-11
Lateral epicondyle 11-13
Use of the protamine sulphate test
Used to test for DIC
Bile stained vomiting in a previously well infant…
?Mid-gut volvulus
Frothy 4 hour old neonate
Mother had polyhydramnios
?Oesophageal atresia
Mortality of cardiogenic shock
70-90%
How much O2 is normally carried /100ml of blood?
20ml O2/100ml blood
Delay in self-ventilation following anaesthetic
Known as suxamethonium or scoline, apnoea.
In normal individual, the effects only last a few minutes until it has been metablised
35y/o has anaesthetic for laparoscopy.
SBP rapidly drops to 70mmHg and a wheeze is audible.
What is the responsible drug?
Sodium thiopentone
Complications of marked hypotension, anaphylaxis and bronchospasm
Which anaesthetic agent is associated with severe hepatotoxicity?
Halothane
What anaesthetic agent should not be used in patients who have recently been diving?
Nitrous oxide as it will diffuse into any air containing space
Muscle replaced by inelastic fibrous tissue following arterial injury or compartment syndrome
Volkmann’s ischaemic contracture
Pathophysiology of colonic pseudo-obstruction
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.
Which part of the myocardium would be affected in occlusion of the posterior descending coronary artery?
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 .
Most common enzymatic cause of congential adrenal hyperplasia?
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
Which muscles are attached to the linea aspera on the posterior aspect of the femur?
Vastus lateralis, vastus medialis, gluteus maxmius, adductor magnus, adductor longus, adductor brevis and the short head of biceps femoris
What is the primary function of the menisci?
Decrease friction and stress shielding
Aschner-Dagnini reflex
Oculocardic reflex
Decrease in pulse rate associated with compression of the eyeball
Haptoglobin levels in haemolytic anaemia
In haemolysis, free Hb combines with haptoglobin so serum levels fall
Borders of the femoral triangle
SAIL
Sartorius
Adductor longus
Inguinal
Ligament
How many sections are there to the WHO checklist?
3
Before the induction of anaesthesia
Time out before skin incision
Sign out at the end of the procedure
How is the action potential transmitted through skeletal muscle?
Spreads outwards to all parts via T tubes
Action of UV light on DNA
Causes the formation of pyrimidine dimers altering the form of DNA and interfering with base pairing during DNA synthesiss
Most common genetic abnormalities in TCC bladder?
Chromosome 9 deletion
Alterations to p53 and Rb
Most likely site of perforation in Typhoid fever
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
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
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.
What is the best way to identify parathyroid adenoma histologically
Intra-operative frozen section
Malignant potential of UC
10 years- 2%
20 years- 8%
30 years- 18%
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.
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
Why is an anaesthetic patch on upper medial arm a recognised complication of axillary clearance
Damage to intercostobrachial nerve
Why is dry mouth not a commonly encountered problem following parotidectomy
Becuase of the presence of other major and minor salivary glands
Which factor is respsonsible for cross-linking of fibrin?
II
VII
VIII
XII
XIII
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
The axillary nerve is damaged in what proportion of shoulder dislocations
5%
How to detect lat dorsi parlaysis
Patient unable to fold the arm behind the back and reach up to the opposite scapula
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
?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
In which IBD are pyoderma gangrenosum, ank spond and toxic megacolon more common?
UC
Why is a sudden loud sound more likely to damage the cochlea than a loud sound that develops slowly?
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
Site of Na reabsorption in kidney
PCT
Site of renal faculative K reabsorption
DCT
Pathophysiology of irritative symptoms in BPH
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
Zones of penetrating neck injury
Zone 1- clavicle to cricoid cartilage
Zone 2- cricoid cartilage to angle of mandible
Zone 3- angle of mandible to base of skull
Is Meckel’s a true or false diverticulum?
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
High temperature
Deranged liver function tests
Positive blood cultures
Post-operatively following liver tranplant
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
Which RLN is posterior to the ligamentum arteriosum
Left RLN
What proportion of non-protein energy in TPN is derived from fat?
10%
Diagnostic work up in asymptomatic proteinuria with normal U+Es
History
BP
Albumin:creatinine ratio
Fasting blood glucose
Urine protein electrophoreisis
Exomphalmos is associated with which syndromes?
Beckwith-Wiedemann, Edward and Patau
Potter syndrome
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
What percentage of cardiac output is received by the skin?
9%
For what disorders are UK blood donations screened?
HBsAg
HCV DNA
HIV1 and 2 Abs
Treponema pallidum antibody
Def: Pain
Unpleasant sensory and emotional experience associated with actual or potential tissue damage
Cardinal signs of flexor tendon sheath infection
Partially flexed finger
Fusiform swelling of the finger
Tenderness along the entire flexor tendon sheath
Severe pain on passive extension of the finger
Examination findings in Achilles tendon rupture
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
Pyramidal facial fracture running from middle of the nasal bone across the lacrimal bones to fracture the pterygoid laminae halfway up
Le Fort II
Low level facial fractures not associated with bilateral subconjunctival haemorrhages
Le Fort I
Low level facial fracture with downward displacement of the fracture line, associated with massive facial oedema
Le Fort I in association with Le Fort II
Facial fracture associated with dishface deformity
Le Fort III
Which of the following is a systemic effect of 60% TBSA burns?
Glycogenosis
Hypervolaemia
Hypothermia
Immunosuppression
Reduced metabolic rate
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.
Pathophysiology of Boutonniere deformity
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
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
Bronchiolitis obliterans
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
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
U+Es pre-op are indicated for which patient group
Patients over 60
Those with CV and renal disease
Diabetics
Those on steroids/ACEi or diuretics
Which of the following drugs works primarily by blocking transmission in postsynaptic autonomic fibres?
Suxamethonium
Hexamethonium
Bupivacaine
Pentazocine
Fentanyl
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.
What are the potential complications of complete rectal prolapse?
Incontinence (75%) which may be the patients prsenting symptom
Incarceration
Ulceration and necrosis
Strangulation
Rectal carcinoma
What is the second most common cause for cancer death in the UK?
Colonic malignancy
Cancer risk following torsion
There is evidence to suggest that there is an increased risk of testicular cancer in both the ipsilateral and contralateral testis following torsion
What proportion of prostate cancers are in the peripheral zone and multifocal
75% of adenocarcinomas are in the peripheral zone, with 85% being multifocal
Physiological anaemia of pregnancy
Red cell volume increases, but this frequently lags behind the plasma volume, resulting in a reduced Hct and Hb concentration
Conservative management of oesophageal perforation
Broad spectrum ABx
PN
NG suction witrh gastric acid suppression
Sympathetic innervation of the adrenal medulla
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
Where are the preganglionic cell bodies in the sympathetic nervous system?
Intermediolateral horn of the SC
What are the spinal origins of the sympathetic nerves?
Efferent nerves originate from segments T1-L2
Leave the SC in the anterior roots and pass to the paired sympathetic chains
Skin cancer with keratin pearl fromation
SCC
Skin cancer with palisading basal cells at the periphery of tumour islands
BCC
At what level does the thoracic duct pass through the diaphragm
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
Into what structure does the thoracic duct drain?
The left brachiocephalic vein
Path of the palmar cutaneous branch of the median nerve
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)
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
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
Neer’s classification
Used to classify fractures of the proximal end of the humerus.
Can be callsed 2-part, three part or four part fractures
Incision in thyroidectomy
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
Remote carcinogen
A precursor of a carinogenic agent e.g. beta naphthylamine
Proximate carcinogen
Metabolite of a chemical carcinogen that is itself carcinogenic
Ultimate carcinogen
Activated, and chemically reactive, form of a carcinogen or procarcinogen that is capable of direct covalent binding to nucleic acid and/or protein macromolecules
Pathophysiology of beta-naphthylamine in TCC
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
How much of 1L of 5% dextrose will remain in the intravascular compartment?
<100mls.
It has no oncotic properties, therefore it will be distributed amongst total body water
What proportion of IV 0.9% NS will remain in the intravascular space?
1/4
From what is the axillary vein formed?
The union of the basilica vein and the vena comitantes
Which of the following bones are at risk of AVN?
Calcaneus
NOF
Olecranon
Patella
Talus
Dislocation of the talus ruptures the blood supply and AVN results after reduction
Where is an ectopic implanatation most likely to occur?
Ampulla of the Fallopian (uterine) tube(80%)
What are the components of the fallopian tube?
Infundibulum
Ampulla
Isthmus
Intramural portion
What is the second most common site of ectopics
Isthmus of uterine ube (12%)
Sudden breast pain
Tender subcutaneous cord attached to the skin
Mondor’s disease
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
Mondor’s disease
Complications of sphincterectomy in ERCP
Division of the sphincter of Oddi may cause pancreatitis, duodenal perforation or bleeding
When does the PSA elevate following ejaculation?
1 hour post-ejaculation, returning to baseline after 24h
Pain in breast cancer
Uncommon feature but when it does occur it is typically described as an ache or prickling sensation
Valgus deformity of the knee most commonly seen in?
Rheumatoid arthritis
Varus is more classical of severe osteoarthritis
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
Osteochondritis dissicans
Condition in which an osteocartilaginous fragment separates from one of the femoral condyles and is rendered avascular
Pathophysiology of Bochladek’s hernia
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
5Bs of Bochladek hernia
Bad, Big occur in babies and found at back of chest
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
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
Action of kinins
Proteins that attract phagocytes
They promote vasodilation
They increase the permeability of blood vessels
Segmental innervation of forearm pronation
C7 and C8
Segmental innervation for supination of the forearm
C6
Segmental innervation of elbow flexion
C5 6
Segmental innervation of elbow extension
C7 C8
Segmental innervation of thumb and finger flexion
C7 C8
Segmental innervation of finger and thumb extension
C7 C8
FRC=
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
What are the components of spirometry to remember?
Four lung volumes
5 capacities
W.r.t. spirometry, what is a capacity
It is a value made up of two or more lung volumes
What are the four lung volumes
Tidal volume
Residual volume
Inspiratory reserve volume
Expiratory reserve volume
