Block 14

Question 1

Tidal volume

Answer 1

Volume of air inspired or expired with each normal breath in quiet breathing

Approx 500mL

Question 2

Residual volume

Answer 2

Volume of air left in lungs after forced expiration

Question 3

Inspiratory reserve volume

Answer 3

Volume of air that can be inspired over and above the normal tidal volume

Question 4

Expiratory reserve volume

Answer 4

Extra volume of air that can be expired by foreceful expiration at the end of normal tidal expiration

Question 5

What are the five lung capacities?

Answer 5

FRC

Inspiratory capacity

Expiratory capacity

Vital capacity

TLC

Question 6

FRC=

Answer 6

RV + ERV

Question 7

Inspiratory capacity

Answer 7

IRV + TV

Question 8

Expiratory capacity

Answer 8

ERV + TV

Question 9

Vital capacity

Answer 9

IRV + TV +ERV (or total lung capacity- RV)

Question 10

TLC=

Answer 10

Vital capcaity + residual volume

Question 11

What is the closest anatomical relation to the orign of the SMA

Answer 11

SMA origin at L1 is directly posterior to the neck of the pancreas

It passes inferiorly passing anterior to the uncinate process and third part of the duodenum

Question 12

Relation of the SMA to the SMV

Answer 12

SMV lies to the right

Question 13

Relationship of the splenic vein to the SMA

Answer 13

Splenic vein grooves the posterosuperior aspect of the pancreas and passes above the SMA

Question 14

At what level is the third part of the duodenum?

Answer 14

L3

Question 15

Risk factors for retinal detachment

Answer 15

Short-sighted (myopia)

Undergone cataract surgery

Detached retina in contralateral eye

Subjected to recent severe eye trauma

Question 16

Floaters and flashing lights may precede the onset

As the condition progresses, the patient notices the development of visual field defect, often likened to a shadow or curtain coming down.

If the macula is affected there is a marked fall in visual acuity

Answer 16

Retinal detachment

Question 17

What are the three main types of emboli implicated in retinal artery occlusion

Answer 17

Fibrin platelet emoboli (from diseased carotids)

Cholesterol emboli

Calcific emboli

Question 18

Sudden onset, painful loss of all or part of the vision.

Sometimes this may be persistent or fleeting.

On fundoscopy the affected retina is oedematous (swollen and pale) while the fovea remains red (cherry spot)

Answer 18

Retinal artery occlusion

Question 19

Why is the fovea preserved in retinal artery occlusion

Answer 19

As it has no supply from the retinal circulation but rather from the choroid

Question 20

Management of retinal artery occlusion

Answer 20

IV acetazolamide

Ocular massage (to exert pressure on vessels)

Anterior paracentesis (to release aqueous and rapidly lower IOP)

CO2 re-breathing to cause vasodilation.

Question 21

Pain on passive flexion of the toes

Loss of sensation to the 1st dorsal webspace

Previous tibial fracture

Answer 21

?Anterior compartment syndrome with deep peroneal nerve injury

Question 22

How may continued liver bleeding following hepatic trauma present?

Answer 22

May present as a fall in Hb and an increase in fluid requirement rather than cardiovascular collapse so it is vital that Hb levels are checked regularly

Question 23

Management of trigger finger

Answer 23

Steroid infiltration may be effective in mild cases, though surgical release of the proximal portion of the A1 pulley may be necessary

Question 24

Benign tumour composed of mature, hyaline cartialge and presents as a slow-growing mass on the phalanx

Pain, swelling or deformity may be present

Patients may present with an acute pathological fracture through the cortex.

Answer 24

Phalangeal enchondroma

Question 25

Loss of phalangeal bone opacity Cavity of mass appears radiolucent with stippled calcification Cortex of the bone may be thinned

Answer 25

Phalangeal enchondroma

Question 26

Family screening in FAP

Answer 26

Starts at 10 years old and is yearly Screening involves flexible sigmoidoscopy or colonoscopy

Question 27

Epidemiology of FAP

Answer 27

Affects 1:10000 Men and women equally affected 1/3rd de novo AD

Question 28

Px in desmoid tumours

Answer 28

1/5 risk of death an an average age of 35

Question 29

Features of POSSUM score

Answer 29

Comprises 12 physiological factors and 6 operative factors. Can be used to calculate morbidity and mortality

Question 30

Physiological factors in POSSUM score

Answer 30

Age Cardiac status ECG Reparatory status BP Pulse rate GCS Hb WCC Urea Na K

Question 31

Operative factors of POSSUm score

Answer 31

Operative complexity Number of procedures Blood loss Peritoneal contamination Extent of malignant spread Mode of surgery (elective or emergency)

Question 32

Which IL is also known as human cytokine synthesis inhibitory factor

Answer 32

IL-10

Question 33

Contents of the foramen magnum

Answer 33

Medulla Spinal portion of spinal accessory nerve Anterior and posterior spinal arteries Vertebral arteries

Question 34

Reduced Fe and TIBC Raised ferritin Normal MCV

Answer 34

Anaemia of chronic disease

Question 35

In a patient with anaemia and normal lungs: Arterial pO2 is reduced Arterial-venous O2 concentration difference is increased Arterial SaO2 is reduced CO is reduced pO2 of mixed blood is reduced

Answer 35

Normal PaO2, as the position of the O2 dissociation curve is normal, the arterial saturation is normal. If the O2 consumption and CO are normal, the A-V O2 concentration difference will also be normal CO is someteimes reflexly increased in anaemia and if this occurs, arterial-venous O2 concentration will be decreased. The PO2 of mixed blood will fall, this is because the venous O2 concentration falls to a very low levels as the normal amount of O2 is extracted and so the venous pO2 is abnormally low

Question 36

Hernia characterised by a W-loop of small bowel lying in the sac, with strangulation of the intervening loop within the main abdominal cavity, by the constriciton of the neck of the sac. The loops of bowel outside of the abdominal cavity may appear normal

Answer 36

Maydl's hernia

Question 37

Howship-Romberg sign

Answer 37

Seen in obturator hernia. Pain referred along the geniculate branch of the obturator nerve to the inner aspect of the knee

Question 38

Lateral protrusion of peritoneum through a persistent hiatus of Schwalbe between the origin of the levator ani from the obturator internus, usually following surgical removal of pelvic organs

Answer 38

Pudendal hernia

Question 39

Severe infrequency of defacation, with several weeks between bowel movements. Usually passive leakage of stool as a result of overflow Diagnosis is confirmed on barium enema which reveals rectal and sometimes colonic dilatation. Rectal biopsy is normal

Answer 39

Idiopathic megabowel

Question 40

V/Q ratio at apex vs base in a standing person

Answer 40

V and Q increase moving from the apex to the base, with the patient in the upright position, however perfusion increases more rapidly than ventilation, this means that the V/Q ratio at the apex is higher than at the base

Question 41

What are the features of Primary Raynaud's

Answer 41

Attacks triggered by exposure to cold or stress Bilateral arm involvement No necrosis No underlying cause No ANA Normal inflammatory markers and capillaries

Question 42

What percentage of Ca is available for buffering changes in Ca balance in the body?

Answer 42

1%

Question 43

INK4a is associated with

Answer 43

Melanoma

Question 44

CBF per 100g of brain

Answer 44

50-100ml/min

Question 45

t1/2 of T3 in the blood

Answer 45

1day. Most of the T3 and T4 carried in the blood are bound to TBG and are inactive. Only 1% of T3 and 0.05% of T4 is free. T3 is the active hormone and formed from intracellular deiodination of T4. The t1/2 of T4 is 1/52

Question 46

Impact of smoking 10 cigarettes per day on post-operative morbidity

Answer 46

Increases morbidity 6-fold

Question 47

Which function of the knee allows increased flexion

Answer 47

Just before full extension, the lateral condyle of the femur stops moving before the medial condyle, so that extension stops on the lateral side. As a result, the femur medially rotates on the tibia. The flexion of the knee joint is maximised by the posterior rollback of the femur on the tibia during flexion

Question 48

Anasarca

Answer 48

Generalised oedema Characterised by widespread swelling of the skin due to effusion of fluid into the extraceullar space Caused by cardiac, liver or renal failure or through the over administration of exogenous IVF.

Question 49

Arrangement of structures at the ACF from M-\>L

Answer 49

Median nerve, brachial artery, biceps tendon

Question 50

Risk of breast cancer in BRCA1

Answer 50

50% risk of developing breast Ca by 50 Increasing to 80% by 90

Question 51

Numbess in first, second and third toes and dorsum of the foot likely to be caused by

Answer 51

Damage to superficial peroneal nerve Deep peroneal nerve innnervates the 1st webspace

Question 52

Coagulase negative gram positive aerobic coccus

Answer 52

Staph epidermis

Question 53

Causes of granulomatous sialoadenitits

Answer 53

Sarcoid, TB, syphillis or HIV Commonest cause of these is TB. TB sialoadenitis is most commonly secondary to regional LN involvement and most commonly affects the submandibular gland

Question 54

Contents of the middle meatus

Answer 54

Contains the bulla ethmoidalis of the middle ethmoidal air sinus, which drains through a hiatus in the bulla

Question 55

Views taken on mammogram

Answer 55

Craniocaudal Mediolateral oblique

Question 56

Cleft lip is more common on which side

Answer 56

Cleft lip is more common than right

Question 57

Components of Child-Pugh score ABCDE

Answer 57

Albumin Bilirubin Clotting Distension (ascites) Encephaloapthy

Question 58

The eustachian tube Can be obstructed by an enlarging palatine tonsil Closes during swallowing Drains the inner ear Gives attachment to the tensor veli palatini Pierces the pharygnobasilar fascia to drain into the oropharynx

Answer 58

Gives attachment to the tensor veli palatini muslce which is innervated by the nerve to medial pterygoid, a branch of V3 It opens during swalllowing It can be obstructed by enlarged adenoids It drains the middle ear It drains into the nasopharynx

Question 59

18 y/o presents with sudden onset testicular pain O/E the testis feels firm and irregular at the apex of the scrotum

Answer 59

Testicular tumour May be associated with sudden onset testicular pain An irregular feeling testis should warrant an USS

Question 60

Associations of hypospadias

Answer 60

Undescended testes Inguinal hernia Disorders of sexual development Hydroceles

Question 61

Classification of hypospadias

Answer 61

Anterior (most comon 50-80%) Middle Posterior: penoscrotal and perineal

Question 62

Hypospadias repair is performed at what age

Answer 62

6-18 months

Question 63

Complications of hypospadius repair

Answer 63

Urethrocutaneous fistula Urethral stricture Poor cosmesis Urethral diverticulum Meatal stenosis Spraying of urine Voiding dysfunction

Question 64

Henry-Gauer reflex

Answer 64

Increased atrial pressure causing reduced ADH secretion

Question 65

What proportion of colorectal cancers are sporadic

Answer 65

75%

Question 66

What proportion of colorectal cancers are attributable to IBD

Answer 66

1%

Question 67

Treatment of choice acute limb ischaemia caused by thrombosis

Answer 67

Intra-arterial tPA

Question 68

What artery may be eroded into by a posterior gastric ulcer

Answer 68

Splenic artery

Question 69

Pathophysiology of Mirizzi syndrome

Answer 69

Impaction of gallstones in the Hartmann's pouch or cystic duct results in Mirizzi syndrome either by Chronic and or acute inflammatory changes leading to contraction of the GB and common hepatic duct stenosis or Cholecystocholedochal fisutla formation due to direct pressure necrosis of adjacent duct walls from large impacted stones

Question 70

Why are fistulae not classically seen in UC?

Answer 70

As the inflammation is confined to the mucosa and submucosa rather than transmurally

Question 71

How does the ulnar nerve enter the forearm

Answer 71

By winding around the posterior aspect of the medial epicondyle of the humerus and travelling between the two heads of FCU in a fibro-osseous channel called the cubital tunnel.

Question 72

Boundaries of the cubital tunnel

Answer 72

Medial epicondyle (medial border) Olecranon (lateral border) Roof formed by the cubital tunnel retinaculum Floor by the capsule of the elbow joint

Question 73

Indications for proctocolectomy in UC

Answer 73

Acute/emergency- toxic megacolon, fulminant UC uncontrolled by medical treatment, perforation, uncontrolled bleeding Elective- chronic steroid dependency or systemic side effects from treatment, dysplasia or adenocarcinoma on biopsy, refractory disease PSC in particular is associated with increased risk of CRC so is more likely to require proctoclectomy

Question 74

Potential complications of ileoanal pouch

Answer 74

50% of patients will have had episode of pouchitis at 10 years. Annual incidence of pouch failure is 5-15% per year Reasons include, pelvic sepsis, poor function, pouchitis

Question 75

In whom is pouch surveillance recommended

Answer 75

For those who have colonic dysplasia or neoplasm as there are rare case reports of neoplasm developing in the pouch

Question 76

Features of ileo-anal pouch

Answer 76

Pouch fashioned from terminal ileum and anastomosed to the anus 1-2cm above dentate line. Pouch is J shape and measures 15cm. Commonly used in UC and FAP. Ileal function is approximately 4-6 times per day and twice at night The benefit of the pouch is to eliminate urgency from simple ileo-anal anastomosis and avoid permanent ileostomy

Question 77

Which of the following malignancies has multi-centric origin Prostate RCC SCC penis TCC Wilm's tumour

Answer 77

TCC can occur anywhere in the urothelium and mutlicentricity and resistance are common

Question 78

Unwell child with unhealed burn must be

Answer 78

Treated for toxic shock syndrome until proven otherwise

Question 79

Prostate cancer is exceedingly rare in which individuals

Answer 79

Men castrated prior to puberty or individuals deficient in 5 alpha reductase Due to prostate's reliance on testosterone and DHT for growth

Question 80

Surgical management of malrotation

Answer 80

Ladd procedure Urgent laparotomy Rotate volvulus anticlockwise and return the small bowel to the right of the abdomen and the caecum and colon to the left and perform appendicectomy Twisting in an anticlockwise direction usually requires 2-3 twists After this it is possible to decide if bowel remains viable. The next step is identification and relief of any extrinsic obstruction to the duodenum and to check that no intrinsic obstruction remains, this is achieved by passing an NGT through the duodenum. An appendicectomy is performed to avoid the difficulty of diagnosing an appendicitis at later date due to its abnormal anatomical position

Question 81

Pathophysiology of midgut volvulus

Answer 81

During normal embryogenesis, the bowel herniates into the base of the umbilical cord and rapidly elongates As it returns to the abdominal cavity, it undergoes a complex 270 degree anticlockwise rotation, resulting in the DJ normally located to the left of midline and the terminal ileum located in the RIF This results in a broad mesentery running obliquely down from the DJ flexure to the ceacum and prevents rotation around the SMA In malrotation, this does not occur and as a result the mesentery has a short root, which allows it to act as a pedicle around which volvulus can occur

Question 82

Lights criteria

Answer 82

Pleural protein:serum protein \>0.5 Pleural LDH: serum LDH \>0.6 Effusion LDH level greater than 2/3 of the upper range of serum LDH

Question 83

How would you identify L4

Answer 83

Iliac crest Line connecting the two iliac crest i.e. supracristal line= L4

Question 84

What type of joint is the SCJ?

Answer 84

Saddle type of synovial joint

Question 85

What type of joint is the MCPJ?

Answer 85

Condyloid synovial joint

Question 86

What proportion of colorectal cancers arise from pre-existing polyps?

Answer 86

\>80% which is what makes the disease suitable for screening

Question 87

Colorectal cancer on which side of the colon tends to be exophytic and presents with anaemia

Answer 87

Right sided colon cancers

Question 88

Why is diaphragmatic rupture more commonly diagnosed on the left

Answer 88

As the liver obliterates the defect or acts as a protection on the right

Question 89

Classification of neuropathic bladder

Answer 89

Cerebral lesions (CVA, dementia, parkinsonism) Spinal lesions (Trauma, MS, spina bifida) Peripheral nerve lesions (following pelvic surgery or DM).

Question 90

Neuropathic bladder caused by lesions of the sacral cord or peripheral nerves

Answer 90

Underactive detrusor and urethra

Question 91

Neuropathic bladder lesion: supraspinal cord

Answer 91

Loss of inhibitory impusles, causing detrusor over-reactivity and uncoordinated activity of detrusor and urethra

Question 92

Neruopathic bladder caused by lesions above the pons

Answer 92

Loss of cerebral inhibition- overactive detrusor

Question 93

What retrovesical structure may be invaded by TCC Anterior portion of the prostate Bublospongiosus Corpus spongiosum Perineal body Seminal vesicles

Answer 93

In males, seminal vesicles lie in the rectovesical pouch, posterior to the posterior wall of the bladder, They are at risk from posterior wall bladder tumours

Question 94

What are the components of the extrinsic pathway?

Answer 94

Factor VII and activated tissue factor

Question 95

AutoAb in autoimmune hepatitis

Answer 95

Anti-mitochondrial antibodies

Question 96

A PDE 3 inhibitor acting as both a positive inotrope and peripheral vasodilator. It is effective in cardiogenic shock

Answer 96

Amrinone PDE III inhibitors that increase intracellular cAMP. They improve hypotension, principally caused by cardiogenic shock, by their dual action of increasing CO and decreasing SVR. The addition of dobutamine is considered to be synergistic

Question 97

What is the second line investigation in ?phaeo

Answer 97

Clonidine suppression test

Question 98

Clonidine suppression test

Answer 98

Relies on the fact that clonidine is a suppressor of physiological catecholamine secretion but has no effect over autonomous catecholamine secretion as in phaeo. 2 urinary collections are made, 1 before and 1 after clonidine. In a normal individual, urine catecholamines from the second collection, i.e. folowing clonidine administration should be greatly reduced when compared with the one before. In patients with phaeo, clonidine is unable to suppress catecholamine secretion

Question 99

Use of MIBG scintigraphy

Answer 99

Very specific test for phaeo involving the administration of iodine131-metaiodobenzylguanidine. There will be a focal area of uptake in the adrenal medulla in a patient with phaeo. It is also useful in detecting extra-adrenal tumours

Question 100

Cilostazol

Answer 100

PDE inhibitor, increases level of cAMP, thereby decreasing platelet function, relaxing vascular smooth muscle and increasing LPL activity. It is contraindicated in patients with heart failure of any severity

Question 101

Trapdoor appearance on plain XR/CT

Answer 101

?Orbital blowout fracture

Question 102

What are the commonest signs of orbital blowout fracture

Answer 102

Enophthalmos Diplopia, especially on upward gaze

Question 103

Which of the following toxins is produced by E. Coli Verotoxin Hyaluronidase Toxic shock toxin Haemolysin Enterotoxin

Answer 103

Verotoxin is produced by EHEC and similar to the shiga toxin produced by Shigella

Question 104

Typically present in the second decade of life as a painless swelling or with recurrent episdoes of abdominal pain. Acute abdominal pain may arise following rupture or bleeding. On examination the characteristic finding is that of a fluctuant, resonant spherical swelling, close to the umbilicus. The cyst is freely mobile in a plane at right angles to the root of the mesentery and may slip

Answer 104

Mesenteric cyst

Question 105

Components of the cervix

Answer 105

Anatomically divdied into two regions: Endocervix- proximal part of the cervix lined by simple columnar epithelium Ectocervix- distal part of the cervix which starts at the external os and projects into the vagina, it is lined by stratified squamous non-keratinised epithelium

Question 106

What is the normal length of the ST segment

Answer 106

0.08s

Question 107

What is the most comon type of benign lung neoplasm?

Answer 107

Pulmonary hamartoma.

Question 108

What is sis w.r.t, cancer genetics?

Answer 108

Growth factor oncogene, it leads to the overproduction of platelet derived growth factor, which stimulates cells to grow

Question 109

In what layers of the anterior abdominal wall are the inferior epigastric vessels found?

Answer 109

Lie on the inner surface of transversus abdominis and are covered by parietal peritoneum. Remember, the peritoneum lies over the inferior epigastric vessels to make the lateral umbilical fold

Question 110

At what level does the IVC commence?

Answer 110

L5

Question 111

At what level is the junction of the azgos vein with the SVC?

Answer 111

T4/5 intervertebral disk i.e. the manubriosternal joint

Question 112

Which interleukin is involved in the coagulation cascade?

Answer 112

IL-6 is released by macrophages and plays a role in activation of lymphocytes as well as playing an important role in coagulation. IL-6 along with TNF are the most influential cytokines in coagulation activatoin

Question 113

What is used for the radiological staging of parotid tumours?

Answer 113

MRI

Question 114

Ranson's criteria GA LAW Over next 48h COUCH

Answer 114

Glucose \>10mmol Age \>55 LDH \>350 AST \>250 WBC \>16 Calcium \<2 PaO2 \<6 Urea increase \>10 despite IV fluids Concealed i.e. estimated sequestered fluid \>6l Hct drop \>10%

Question 115

Treatment of pancreatitis PANCREAS

Answer 115

PPI Analgesia NBM Catheterise Rehydrate NG ABx (severe only) Sliding scale

Question 116

Complications of pancreatitis PANCREAS

Answer 116

Pseudocyst Airway problems (ARDS, pleural effusion, ascites, abscess) Necrosis Coagulation disorder e.g. DIC Renal failure Encephalopathy Arterial (splenic/mesenteric/portal vessel rupture or thrombosis) Sugar (diabetes)/SIRS/Sepsis

Question 117

Causes of raised amylase AMYLASE

Answer 117

AAA rupture/acidosis (DKA) Mesenteric ischaemia gYnaecological pathology Liver disease Anuria Salivary gland disease/stomach ulcer (perforated) Ectopic pregnancy

Question 118

Why are PPIs used in pancreatitis

Answer 118

Stress-induced gastric erosions frequently occur, these can result in haemorrhage and resultant haematemesis and melaena. This is the most common cause of haemorrhage

Question 119

Cause of hypoxia in pancreatitis

Answer 119

Usually due to hypoventilation secondary to pain but may be as a consequence of ARDS

Question 120

Splenic rupture in pancreatitis

Answer 120

Very rare complication

Question 121

Which part of the skull does the Eustachian tube penetrate?

Answer 121

Petrous temporal bone

Question 122

What is the rate of patients developing ARDS post cardiopulmonary bypass surgery

Answer 122

0.5-1% of patients

Question 123

What is the risk of stroke with cardiopulmonary bypass

Answer 123

1%

Question 124

Cortisol response to cardiopulmonary bypass

Answer 124

Different to the typical post surgical response. Serum cortisol drops immediately with initiation of bypass. ?2o haemodilution During the procedure the serum cortisol is significantly elevated and remains so for 48h (in normal surgery this elevated cortisol response is normally for 24h)

Question 125

What is the relation of the thoracic duct to the oesophagus in the mediastinum

Answer 125

Thoracic duct passes behind and to the left of the oesophagus at the level of T5. It then runs upwards on the left side of the oesophagus in the neck. Here it crosses the subclavian artery to enter the left brachiocephalic vein

Question 126

Ix in adrenal incidentaloma

Answer 126

Firstly establish that it is not metastatic disease Then consider MRI to better delineate the lesion's anatomy

Question 127

Adrenal lesion \>3cm in patient \<50y/o

Answer 127

Surgical resection should be considered though prior to surgery assessment is required to establish whether this is a metastatic lesion and then its functional status

Question 128

When is the earliest time at which a tracheostomy tube should be changed?

Answer 128

Day 3 post op to allow the tract to fully develop

Question 129

Options for drains of the pleura

Answer 129

Require a closed system usually an underwater seal drain but alternatively a disposable flutter valve system or continuouous wall suction may be used.

Question 130

Why are drains often indicated in urinary anastomoses

Answer 130

Urinary anastomoses often leak in the immediate post-operative period and drainage following an augmentation cystoplasty prevents urinoma formation

Question 131

Management of LN mets in SCC of the tongue

Answer 131

Radical neck dissection

Question 132

What medication should be used in patients suffering frostbite?

Answer 132

300mg aspirin to improve circulation to the extremities. Pathophysiology is complex but is likely a combination of intracellular ice crystal formation with cell membrane dysfunction/rupture alongside loss of microvascular haemostasis. The release of thromboxane and prostaglandin promotes platelet aggregation and thrombosis, aspirin can be utilised to reduce these effects

Question 133

Classification of freezing cold injury

Answer 133

Similar to burns mild/superficial or severe/deep Distinction is based on final outcome

Question 134

Indications for mechanical ventilation

Answer 134

Due to inadequate ventilation e.g. apnoea, RR \>35/min or low in asthmatic patient, inadequate ventilation despite 60% O2 Specific surgical indications e.g. head injury, unprotected airway, GCS \<8, raised ICP, facial trauma and burns Chest injury e.g. flail chest, pulmonary contusion High spinal trauma

Question 135

Raised circulating levels of adrenaline will lead to? Glycosuria Excessive sweating Bradycardia Paroxysmal hypotension Bronchospasm

Answer 135

Glycosuria due to increased hepatic glucose output

Question 136

Sliding hernias vs rolling hiatus hernias

Answer 136

Sliding herniae are primarily associated with symptoms of GORD, whilst rolling herniae can cause gastric strangulation and necrosis and gangrene

Question 137

What types of stains are used for FNA?

Answer 137

Romanowsky-type stain Papanicolaou stain

Question 138

Methoxamine

Answer 138

Inotrope than can be given to treat hypotension due to perihperal vasodilation through its action as a vasoconstrictor

Question 139

Chronic suppurative disease of the apocrine sweat glands with a predilection for the inter-triginal regions such as the axilla, groin and perineum Manifested by recurrent abscesses, sinuses and fistulae

Answer 139

Hidradenitis suppurativa

Question 140

Pathophysiology of hidradenitis suppurativa

Answer 140

Bacteria enter the apocrine system through hair follicles, become trapped and subsequently multiply in the nutrient rich environment. The glands may subsequently rupture leading to extension of infection-\> further local inflammation, tissue destruction and skin damage

Question 141

Consequences of chronic hidradenitis supppurativa

Answer 141

Progressive destruction of normal skin architecture, with the development of periductal and periglandular inflammation, dermal and subcutaneous fibrosis, scarring and contractures. Chronic disease of the axillary region could lead to limitation of shoulder abduction

Question 142

Embryological formation of horseshoe kidney

Answer 142

Arises from kidneys fusing at the inferior pole, having their ascent arrested by the present of the isthmus and the IMA.

Question 143

Features of horseshoe kidney

Answer 143

More common in men Anatomical location and blood supply is very variable They are more prone to infection and calculi formation due to relative upper tract stasis They are also more prone to trauma

Question 144

Hallmarks of toxic megacolon

Answer 144

Nonobstructive colonic dilatation greater than 6cm with signs of systemic toxicity

Question 145

Mortality rate of toxic megacolon

Answer 145

5-20%

Question 146

Management of toxic megacolon

Answer 146

ABC with aggressive fluid and electrolyte replacement. Broad spectrum Abx All medications that may affect colonic motility must be stopped. Bowel rest NGT

Question 147

Management of acute haemolytic transfusion reaction

Answer 147

Stop transfusion Large quanitites of IVF to promote UO of \>1.5ml/kg/h Diuretics to promote diuresis Central line if remains oliguric 100ml of 20% mannitol are recommended for renal protection Hyperkalaemia and DIC may both occur and require specific treatment

Question 148

What dermatome supplies the skin of the ring finger?

Answer 148

C8

Question 149

What is the dermatome of the thumb and index finger?

Answer 149

C6

Question 150

Spinal shock

Answer 150

Flaccidity and loss of reflexes seen after SC injury

Question 151

Spinal cord injury with sacral sparing

Answer 151

May suggest incomplete spinal injury (only if voluntary control) the preservation of spinal reflexes alone does not qualify as an incomplete injury

Question 152

Disproportionately greater loss of motor power in the upper limbs compared to lower limbs with varying degrees of sensory loss Usually seen after hyperextension injury to the cervical spine in a patient with pre-existing canal stenosis

Answer 152

Central cord syndrome

Question 153

Pathophysiology of central cord syndrome

Answer 153

Thought to arise as a consequence of vascular compromise in the cord in the distribution of the anterior spinal artery

Question 154

Release of what hormone will help correct excess fluid administration

Answer 154

ANP

Question 155

Serum amylase in acute pancreatitis

Answer 155

Typically peaks in first 12-48h and returns to normal after 72h.

Question 156

Which coagulation factor is activated by factor XIIa and produced in the liver?

Answer 156

Factor XI It is a serine protease produced by the liver and circulates in its inavctive form

Question 157

What is the deepest layer of the pyloric wall to be divided in Ramstedt's pyloromyotomy?

Answer 157

Circular muscle

Question 158

What are the most important factors predicting rebleeding in UGI bleed?

Answer 158

Presence of endoscopic stigmata of recent haemorrhage with a visible bleeding vessel Haemodynamic instability Posterior duodenal ulcer or lesser curve of the stomach ulcer \>60 Shock on admission (Hb \<10)

Question 159

Collection of dilated lymph sacs in the skin and subcutaneous tissues that fail to drain into the normal lymphatic system Larger cysts found purely in the subcutaneous tissue are known as cystic hygromas Tend to occur at the junction between the limbs and neck with the trunk. Commonly found in children Often can be red, brown or black in colour if they become blood filled

Answer 159

Lymphangioma circumscriptum

Question 160

Direction of chest drain

Answer 160

Should be pointed upward if ?pneumothorax and downard if fluid is being drained

Question 161

Protein concentration of CSF w.r.t. plasma

Answer 161

Is approximately 0.5% that of plasma. It prevents some proteins and amino acids acting as false neurotransmitters

Question 162

What is the difference in electrolytes in CSF in comparison to plasma

Answer 162

K Ca bicarbonate glucose and protein are all lower in CSF, this is to prevent high concentrations of these electrolytes inadvertently exciting neurones present within the brain substance

Question 163

Arrangement of structures at the renal hilum from anterior to posterior

Answer 163

VAU

Question 164

Which muscle lies immediately posterior to the kidney?

Answer 164

Psoas major

Question 165

LDLR deficiency causes

Answer 165

Familial hypercholesterolaemia

Question 166

Liprotein lipase deficiency

Answer 166

Rare inherited cause of severe hypertriglyceridaemia. Condition normally presents in childhood. LPL is responsible for the clearance of VLDL and chylomicrons from the plasma

Question 167

Changes in VLDL in XS EtOH intake

Answer 167

Hypertriglyceridaemia frequently occurs in association with high alcohol intake is due to increased synthesis of TG for incorporation into VLDL in the liver.

Question 168

Development of the male urethra

Answer 168

During 5th-7th week of embryonic development, the cloaca divides into the urogenital sinus and the anal canal. The cloaca makes the bladder, the urethra and the gential tubercle. Hypospadias occurs due to incomplete fusion of the urethral folds.

Question 169

Endocardial cushions in the embryological heart

Answer 169

Masses of mesenchymal tissue that form in the atrioventricular and conotruncal regions of the bulbus cordis, one dorsal and one ventral. These grow towards each other and fuse to form the atrial/ventricular septa, the atrioventricular canal and valves. The septae form between the 27th-37th day of dvelopment. Failure of fusion-\> AVSD

Question 170

What masses may be found in the anterior mediastinum

Answer 170

Thymic lesions Lymphoma (more likely to manifest in anterior mediastinum than middle mediastinum) Germ cell tumours Pleurpericardial cysts Lymphadenopathy

Question 171

What masses may be found in middle mediastinum

Answer 171

LN enlargement Bronchogenic cysts Enterogenic cysts

Question 172

Causes of posterior mediastinum masses

Answer 172

Neural tumours Thoracic meningocele Oesophageal tumours Aortic aneurysms Paragangliomas

Question 173

Causes of superior mediastinal masses

Answer 173

Thyroid LN Oesophageal tumours Aortic aneurysms Parathyroid lesions

Question 174

Aggressiveness of testicular tumours

Answer 174

Teratomas are more aggressive than seminomas Seminomas spread via the lymphatic to para-aortic nodes whereas teratomas spread haematogenously and occasionally to LNs

Question 175

Why are varicoceles more likely to occur on the left even in the absence of renal malignancy

Answer 175

Left testicular vein forms a greater angle with the left renal vein The left renal vein is crossed and may be compressed by the pelvic colon The left testicular vein is longer Terminal valve is frequently absent in the left testicular vein

Question 176

Why are inguinoscrotal herniae more likely to occur on the right?

Answer 176

As the right testicle descends later

Question 177

What is the process of secondary bone healing

Answer 177

Haematoma forms providing a source for haemopoietic cells, which produce growth factors. This is followed by fibroblast and mesenchymal cell migration to the fracture site, forming granulation tissue Later on, osteoblasts and fibroblasts proliferate to form soft callus

Question 178

Glagows score of 0-2 mortality

Answer 178

2%

Question 179

Glasgow score 3-4 mortality

Answer 179

15%

Question 180

Glasgow score 5-6 mortality

Answer 180

40%

Question 181

Glasgow score 7-8 mortality

Answer 181

100%

Question 182

What proportion of cancers produce peptides implicated in paraneoplastic syndromes?

Answer 182

10%

Question 183

Extensor nodule on the arm Central necrotic area surrounded by palisaded histiocytic macrophages all enveloped by lymphocytes, plasma cells, fibroblasts

Answer 183

Positive RF

Question 184

What proportion of oestrogen negative breast cancer will show sensitivity to tamoxifen?

Answer 184

5-10%

Question 185

Contents of the femoral triangle from lateral to medial

Answer 185

Femoral nerve Femoral artery Femoral vein Long saphenous

Question 186

What is the most common location for the meatus in hypospadius

Answer 186

Ventral surface 70% are glanular 10% penile 20% scrotal Perineal placement is associated with anorectal anomalies

Question 187

Incidence of AVN in intracapsular #NOF

Answer 187

Up to 15% in nondisplaced Increases to nearly 90% with untreated, completely displaced fractures

Question 188

Tumours which arise from nests of non-chromaffin paraganglionic cells dervied from the neural crest

Answer 188

Paraganglionomas

Question 189

Which of the following is a parametric test? Mann-Whitney U Kruskal-Wallis Pearson's coefficient Spearman's rank correlation coefficient Wilcoxson signed-rank test

Answer 189

Pearson's correlation coefficient

Question 190

Kurskall-Wallis test

Answer 190

Non-parametric statistical test based on ranking data to compare two or more independent samples. It is similar to Mann-Whitney U but can be used when there are more than two groups

Question 191

Spearman's rank correlation coefficient

Answer 191

Non-parametric measure of rank correlation which examines statistical dependence between the ranking of two variables

Question 192

Wilcoxson signed-rank test

Answer 192

Non-parametric test used to compare two related samples to assess whether their population mean ranks differ. Can be used to compare repeated measurements on a single sample

Question 193

Complications of balloon tamponade in treatment of refractory oesophageal varices

Answer 193

Aspiration pneumonia Mucosal ulceration Oesophageal perforation

Question 194

When do endoethlial cells appear during wound hearing?

Answer 194

Days 3-5

Question 195

When do fibroblasts and myofibroblasts appear during wound healing

Answer 195

Days 2-4

Question 196

Proteinuria, hypoalbuminaemia, oedema and hypercholesterolaemia HIV, IVDU, previous renal transplant Biopsy shows focal glomerular deposits of IgM

Answer 196

?Focal segmental glomerulosclerosis

Question 197

Which of the following statements best describes the respiratory physiological shunt It is greater than the anatomical shunt It is not present in an healthy adult Affects arterial CO2 more than arterial O2 Has the same effect on respiratory gas exchange as does physiological deadspace It is abolished when the subject breathes pure oxygen

Answer 197

A R-\>L shunt refers to O2 poor blood from the right heart that has entered the left heart without undergoing gas exchange in the alveolar capillaries (i.e. shunted away from sites of gas exchange) The physiological shunt is the sum of the anatomical shunt (bloods passing from right to left circulation without participating in gas exchange e.g. via bronchial veins) and the element of pulmonary alveolar capillary blood that has passed through non-aerated alveoli. Therefore the physiological shunt is always as great or greater than the anatomical shunt Shunting affects O2 tension more than CO2 arterial tension

Question 198

What proportion of carotid bruit heard on auscultation are due to carotid stenosis?

Answer 198

70%

Question 199

Patient with FAP who experiences jaundice

Answer 199

?Dudoenal tumour cause extrahepatic biliary obstruction

Question 200

Rate of gastric carcinoma worldwide

Answer 200

Declining

Question 201

Risk of gastric cancer in blood group A?

Answer 201

20% higher than blood group O

Question 202

Where do cystine stones precipitate?

Answer 202

Acidic urine (6.5)

Question 203

How can cystine stones be identified?

Answer 203

Ultrasonographically

Question 204

No. 10 blade

Answer 204

Curved cutting edge Used for making small incisions in skin and muscle Often also used in more specialist surgeries such as harvesting the radial artery during CABG, opening the bronchus during thoracic surgery

Question 205

No. 11 blade

Answer 205

Elongated triangular blade sharpened along the hypotenuse edge with a strong pointed tip making it ideal for stab incisions. Used in various procedures such as the creation of incisions for chest drains, opening coronary arteries, opening the aorta and removing calcifications in the aortic or mitral valves

Question 206

No. 15 blade

Answer 206

Small curved cutting edge Ideal for making short and precise incisisons. Used in a variety of surgical procedures inlcuding the excision of a skin lesion or recurrent sebaceous cysts and for opening coronary arteries

Question 207

Schwart's test

Answer 207

Impulse felt over saphena varix when vein tapped from below

Question 208

Cold abscess

Answer 208

TB

Question 209

What is the cellular action of p53

Answer 209

Prevents cell entering the S phase

Question 210

Renal blood flow to the cortex

Answer 210

Much higher than to the medulla

Question 211

At what part of the nephron is the fluid hypotonic?

Answer 211

Fluid in the distal end of the ascending loop of Henle is hypotonic regardless of the state of hydration because of the active reabsorption of NaCl but not water, which is impermeable in this tubular segment

Question 212

Where does the oesophagus classically tear in Boerhaave's?

Answer 212

At its weakest point, the lower third

Question 213

Use of Kaplan Meier graphs with log-rank test

Answer 213

Kaplan-Meier curves with log rank analysis, provide a comparison of outcomes between different groups over a period of time. The log-rank test assesses the statistical significance of difference between the curves

Question 214

Warfarin induced skin necrosis caused by?

Answer 214

Deficiency of protein C

Question 215

Choice of prosthesis in hemi-arthroplasty of the hip

Answer 215

No benefit of bipolar Hastings arthroplasty of Austin-More unipolar arthroplasty

Question 216

Repair on intertrochanteric fractures with reverse obliquity

Answer 216

Will need IM nailing as a DHS will fail because most of the weight will be transmitted through the DHS pin

Question 217

Risk of gastric cancer in pernicious anaemia

Answer 217

3 fold

Question 218

Most common organic cause of impotence

Answer 218

Diabetes

Question 219

MOSF in pancreatitis

Answer 219

Multiple organ system failure scale is a dynamic pathophysiological scoring system used in acute pancreatitis which can be used daily to monitor disease progression

Question 220

Feeding in pancreatitis

Answer 220

Best practice is via the enteral root via a feeding tube placed past the pancreatic duct into the third part of the duodenum

Question 221

Other areas affected by mesothelioma

Answer 221

Can rarely affect periosteum, pericardium and tunica vaginalis

Question 222

Alpha-fetoprotein

Answer 222

=fetal equivalent of plasma albumin and is produced by the fetal liver, yolk sac and intestine. It can be elevated in HCC, testicular teratoma, pancreatic, biliary, gastric and bronchial cancers. Increased levels are also seen in viral hepatitis. It is found in pregancny where high levels can be indicative of neural tube defects. It is not found in pure seminomatous germ cell tumours

Question 223

Which type of melanoma occurs in a Hutchinson's melanotic freckle

Answer 223

Lentigo maligna melona occurs within or is preceded by a Huthcinson's melanotic freckle and has a pronounced horizontal growth phase

Question 224

Complications of sclerotherapy for varicosities

Answer 224

Brown disclolration of the skin secondary to extravasation of the sclerosing agent Superficial thrombophlebitis VTE Pain at injection site Localised reaction to sclerotic agent Cutaneous necrosis leading to skin ucleration Nerve injury: saphenous and sural Neurological complications: increased risk of stroke in patients with PFO Anaphylaxis

Question 225

Which trace element is required for RNA and DNA synthesis?

Answer 225

Zinc

Question 226

Course of the uterine artery

Answer 226

Arises from the anterior division of the IIA and runs medially on the levator ani towards the uterine cervix. Crosses above and in front of the uretur, to which it supplies a small branch. Reaching the side of the uterus it ascends in a tortuous manner between the two layers of the broad ligament to the junction of the fallopian tube and uterus. It then runs laterally towards the hilum of the ovary and ends by anastomosing with the ovarian artery.

Question 227

Erythropoietin

Answer 227

Glycoprotein hormone produced primarily in the peritubular fibroblasts of the renal cortex in response to hypoxia. In premature and full-term infants, the liver is the primary site of EPO synthesis shortly after birth. Small amounts are also produced by adult hepatocytes. EPO production is stimulated by reduced O2 content in the renal arterial circulation.

Question 228

Operative treatment of perforated duodenal ulcer

Answer 228

Defect is closed over with an omental patch, which is attached to its blood supply rather than being a free flap

Question 229

Which tendon may be damaged following Colles's fracture

Answer 229

Delayed rupture of the EPL tendon is a recognised complication due to attrition at the radial tubercle

Question 230

Annular pancreas

Answer 230

Embryological anomaly that can result in duodenal obstruction. It occus due to failure of the ventral bud to rotate with the duodenum resulting in its encasement It can be complete or incomplete. It affects both children and adults causing post-prandial satiety, abdominal pain and vomiting. It is usually diagnosed using CT or MRI

Question 231

What conditions are associated with annular pancreas?

Answer 231

Down's Pancreatitis Pancreatic cancer

Question 232

Gallstones and renal transplant

Answer 232

Relative contraindication for renal transplant. Requires cholecystectomy before transplant

Question 233

Three top causes of end-stage liver disease leading to transplantation in the UK

Answer 233

Alcohol Hep C PBC

Question 234

What score can be used to prioritise liver transplants

Answer 234

MELD score Serum bilirubin, Creat, INR

Question 235

Angiopathy affecting medium sized vessels most commonly in women of reproductive age. Most common sites involed are renal and carotid arteries. Only in 5% of cases are limbs affected Asymptomatic or symptomatic dependent on which vessel affected e.g. in renal: refractory hypertension

Answer 235

Fibromuscular dysplasia

Question 236

Non-specific symptoms e.g. fever, malaise, anorexia etc. CNS symptoms: transient monocular blindness and cerebral arteritis PNS symptoms Male 45-65

Answer 236

?PAN

Question 237

Causes of secondary Raynaud's BAD CaT

Answer 237

Blood disorders Arterial Drugs CTD Trauma

Question 238

Action of FSH in men

Answer 238

Helps to maintain sertoli cells Stimulates the synthesis of androgen binding protein

Question 239

What is the most common site of teratoma in newborn infant

Answer 239

Sacrococcygeal area

Question 240

Where are the facial muscles found

Answer 240

They are all subcutaneous and in the same plane as platysma. They originate on bone and insert onto the skin of the face.

Question 241

In what part of the brain is pain perceived?

Answer 241

The thalamus

Question 242

What part of the brain receives pain stimulation?

Answer 242

Postcentral gyrus

Question 243

Which of the following increases CO? Acidosis Histamine LT acclimatisation at altitude Rapid arrhythmias Standing from lyring

Answer 243

CO is decreased on standing CO is increased in the ST when altitude is reached. ACidosis and alkalosis decrease contractilityl. Histamine causes reduced peripheral resistance, resulting in increased CO

Question 244

Feeding post Ivor-Lewis oesphagectomy

Answer 244

Feeding jejunostomy Most formed at operation and used until a gastrograffin swallow demonstrates an intact anastomosis

Question 245

Patient requiring enteral tube feeding for \>1month

Answer 245

Should have a more permanent form of feeding tube inserted i.e. PEG feed.

Question 246

PEG formation

Answer 246

Push or pull technique

Question 247

Push technique of PEG insertion

Answer 247

Feeding tube pushed through the abdominal wall over a wire into the gut using fluoroscopic guidance. Usually loop catheters or balloon catheters are placed

Question 248

Pull technique of PEG insertion

Answer 248

Feeding tube advanced through the patient's mouth into the stomach and pulled out through the abdominal wall by using a snare introduced through a fluorscopically guided direct gastric puncture site

Question 249

Bowel length at risk of small gut syndrome

Answer 249

\<200cm

Question 250

What is the transmission rate for HIV following needlestick?

Answer 250

0.36%

Question 251

Thoracic level of the xiphisternum

Answer 251

T9

Question 252

Into what part of the greater trochanter do the gluteus medius and minimus insert?

Answer 252

Lateral part

Question 253

Into what part of the greater trochanter do the external rotators of the hip insert?

Answer 253

Medial, superior and posterior surfaces of the greater torchanter

Question 254

What is the most common causative organism of post-splenectomy sepsis

Answer 254

Strep pneumoniae

Question 255

Batson's plexus

Answer 255

Vertebral venous plexus of the spine

Question 256

Which neve supplies the trachea

Answer 256

RLN which is sensory below the level of the vocal cords and motor to all muscles of the larynx with the exception of cricothyroid which is supplied by the SLN

Question 257

What is a late clinical sign of maxillary sinus carcinoma?

Answer 257

Visual disturbance

Question 258

Anosmia, nasal obstruction, epistaxis, toothache, tooth loosening, Proptosis and diplopia Invasion of nerves causing numbness of facial palate Exposed to dust from hardwood and nickel; mustard gas production; materials in boot making

Answer 258

Ethmoid/maxillary sinus cancer (90% of sinus cancers affect these with only 10% affecting the frontal and sphenoidal)

Question 259

Tumour markers in teratomas

Answer 259

Produce aFP in about 70% bHCG in 60% Secrete either in about 90%

Question 260

What proportion of seminomas secrete bHCG?

Answer 260

\<10% and very rarely do they secrete AFP

Question 261

Reduction in force of which movement would suggest L4/L5 disc prolapse rather than L5/S1? Ankle plantar flexion Foot eversion Extension of great toe Inversion of foot Knee extension

Answer 261

L4/L5 affects L5 nerve root, L5/S1 affects S1 Toe extension is mainly mediated by L5 nerve root

Question 262

Long standing eczematous rash Glossitis Stomatitis Diabetes Wasting

Answer 262

Glucagonoma

Question 263

What is combined to generate T3 and T4 in the thyroid?

Answer 263

Mono-iodotyrosine and di-iodotyrosine.

Question 264

How does phosphate reabsorption in the PCT occur

Answer 264

Occurs via a carrier co-transport of phosphate and sodium It is under the control of PTH

Question 265

The superior cerebral veins drain into

Answer 265

The 8-12 cerebral vein drain the superior, lateral and medial surfaces of the cerebral hemispheres and are mainly lodged in the sulci between the gyri They open into the superior saggital sinus

Question 266

What drains into the great cerebral veins?

Answer 266

Internal cerebral veins

Question 267

What drains into the cavernous sinus

Answer 267

The superior and inferior ophthalmic veins Sphenoparietal sinus Superficial middle cerebral veins all drain into the cavernous sinus

Question 268

What does the inferior petrosal sinus drain

Answer 268

It drains the cavernous sinus, meeting the sigmoid sinus at the level of the jugular foramen to form the jugular vein

Question 269

Superior petrosal sinus

Answer 269

Connects the cavernous sinus to the transverse sinus

Question 270

EF=

Answer 270

Ratio of stroke volume to EDV

Question 271

Recurrent swelling of the salivary glands in the absence of neoplasia or inflammation Swelling is typically painless and bilateral The gland remains soft and not indurated Occurs in association with endocrine disorders (myxoedema, Cushing's, DM), metabolic/nutritional disorders and certain durgs (co-proxamol, OCP, antipsychotics)

Answer 271

Sialosis

Question 272

How many lobes and bronchopulmonary segments in the right lung?

Answer 272

3 lobes comprising 10 bronchopulmonary segments

Question 273

How many lobes and bronchopulmonary segments in the left lung?

Answer 273

2 lobes, 8 bronchopulmonary segments

Question 274

How does CSF drain to the subarachnoid space from the ventricles?

Answer 274

Via the foramina of Megendie (medial) and Lushka (lateral) in the roof of the fourth ventricle

Question 275

Foramen of Monro

Answer 275

Connects the two lateral ventricles to the thid ventricle

Question 276

Cisterna magna

Answer 276

Largest of the 3 main openings in the subarachnoid space, located between the cerebellum and the dorsal surface of the medulla oblongata.

Question 277

Shoulder weakness Drop arm sign Characteristic hunching of the affected shoulder Inability to lift arm

Answer 277

Rotator cuff tear

Question 278

Shoulder pain in all planes of movement except external rotation

Answer 278

?Calcific tendonitis The lack of restriction in external rotation differentiates this condition from frozen shoulder

Question 279

Malignant tumour arising from the vascular endothelium of bone marrow Common in the 10-20y/o age group Occurs in the diaphysis of long bones Clinical features include pain and swelling, warm tender lump with ill-defined edges XR show a large soft tissue mass with concentric layers of new bone formation known as onion peel sign

Answer 279

Ewing's sarcoma

Question 280

Malignant tumour of bone, characterised by the direct formation of bone or osteoid tissue by a sarcomatous stroma. Typically affects the knee and the proximal humerus in the metaphyseal region. XR shows bone destruction and new bone formation, often with marked periosteal elevation. (Sunray spiculation and Codman's triangle).

Answer 280

Osteosarcoma

Question 281

Right knee sweeling XR reveals thinning of the cortex and fracture of the distlal femur An extraosseous soft tissue mass is seen on MRI Characteristic soap bubble appearance

Answer 281

Osteoclastoma (Giant cell tumour)

Question 282

Type 1 odontoid fractures

Answer 282

Involve the tip of the odontoid peg

Question 283

Type 2 odontoid fractures

Answer 283

Are through the base of the dens, involving the junction of the odontoid peg with body

Question 284

Type III odontoid fractures

Answer 284

At the base of the dens and extend obliquely into the body of the axis

Question 285

Where does the common femoral artery divide?

Answer 285

3cm distal to the inguinal ligament

Question 286

Order from superficial to deep of popliteal neurovascular structures

Answer 286

NVA (artery deepest)

Question 287

What are the dynamic stabilisers of the patella?

Answer 287

Quadriceps muscles anteriorly Hamstring muscles posteriorly Gastrocnemius medially and laterally

Question 288

When does the heart begin to beat

Answer 288

Fourth week

Question 289

In which state is iron more readily absorbed from the GIT?

Answer 289

In the ferrous state (Fe 2+) than in the ferric state (Fe 3+) and commercial iron preparations often contain vitamin C to prevent oxidation of Fe2 to Fe 3

Question 290

Action of endotoxins in septic shock

Answer 290

Act as a negative inotrope and can initiate both ARDS and DIC

Question 291

Trauma Bradycardia Warm peripheries No response to fluid resuscitation

Answer 291

Neurogenic shock

Question 292

What is the most frequently affected dynamic stabiliser in pes planus?

Answer 292

Tibialis posterior tendon and it is the most powerful inverter of the foot

Question 293

Painless lumpy jaw Wooden lesion Sulphur granules form a central purulence surrounded by neutrophils

Answer 293

Actinomycosis israelii

Question 294

Relative risk of undescended testes

Answer 294

Testicular cancer is 8x higher Reduced fertility is also a long-term complication

Question 295

Classification of undescended testes?

Answer 295

Retractile Ectopic Incomplete descent: inta-abdominal, intra-inguinal, pre scrotal Atrophic Acquired (testes that have ascended)

Question 296

Painless penile ulcer Unprotected sex 1/12 previously Hard raised hyperaemic edge Inguinal lymphadenopathy

Answer 296

Chancrous ulcer (Syphillis)

Question 297

What are the ligaments supporting the medial longitudinal arch of the foot?

Answer 297

Long planatar ligament Short plantar ligament (plantar calcaneocuboid ligament) Spring ligament (plantar calcaneonavicular) Interosseous ligament Deltoid Plantar aponeurosis

Question 298

Who sends information concerning cause of death to the office of population consensus and surery?

Answer 298

Registrar of births and deaths

Question 299

On what day post-op is myocardial ischaemia most likely to occur?

Answer 299

Day 3

Question 300

Location of the olfactory foramina

Answer 300

Located in the anterior cranial fossa, within the cribiform plate which is part of the ethomboid bone.

Question 301

Deafness dizziness and tinnnitus

Answer 301

Meniere's disease

Question 302

All patients presenting with vertigo should have

Answer 302

Imaging to exclude acoustic neuroma Be tested for syphillis as neurosyphillis may present this way

Question 303

From where is cholecystokinin released?

Answer 303

I cells of the duodenum in response to pancreatic chyme entering the small bowel.

Question 304

Indications for surgery in crohn's?

Answer 304

Recurrent intestinal obstruction Intestinal fistulae Fulminant colitis Malignant change Peri-anal disease

Question 305

Nitrogen and calorie requirement in severe injury or severe sepsis?

Answer 305

N2 requirement: 0.3-035g /Kg/day 35-40kcal/kg/day

Question 306

How to differentiate clinically between epididymal cyst and hydrcocele

Answer 306

Epididymal cyst is found above and behind the superior pole of the tesits. The fluid of a hydrocele surrounds the testis and usually makes it impalpable

Question 307

What is the most frequently observed activated oncogene in colorectal adenomas and carcinomas?

Answer 307

K-RAS

Question 308

Radial nerve lesion. What level Wrist drop Inability to extend the MCP of the hand together with altered sensation over the anatomical snuff box Triceps reflex is present

Answer 308

Fracture at the level of the mid-humerus

Question 309

Radial nerve injury, what level Inability to extend MCP joints with weakness of thumb abduction and interphalangeal extension

Answer 309

Compression at the level of the elbow (damage to posterior interosseous nerve)

Question 310

What are the two main types of SCC?

Answer 310

Slow growing variety that is verrucous in nature and exophytic in appearance. This is lovally invasive, penetrating deeper structures and is more likely to metastasize. Nodular and indurated type, with rapid growth an early ulceration combined with local invasiveness. Metastasis is late in comparison to the verrucous type

Question 311

Contents of Hunter's canal

Answer 311

Adductor canal Femoral artery and vein Saphenous nerve Nerve to vastus medialis

Question 312

Why do transplants for burnt skin tend not to undergo rejection

Answer 312

As burnt tissue is relatively immunosuppressed

Question 313

Why is the rate of rejection lower in liver transplants?

Answer 313

As liver cells are thought to express less class I MHC so HLA matching is less important

Question 314

Why is the cornea relatively protected from rejection?

Answer 314

It is relatively avascular

Question 315

Painless jaundice Raised bilirubin AST, ALP and GGT Macrocytosis

Answer 315

?ALD

Question 316

What is the gold standard to investigate wound healing potential

Answer 316

Transcutaneous oxygen pressures

Question 317

Why is serum magnesium not a good indicator of total body magnesium?

Answer 317

Fluctuations in protein levels will significantly affect the plasma level It also only represents 0.3% of total body magnesium, with the rest found in the soft tissue and bones

Question 318

What is the best imaging technique to visualise the anatomy of the diaphragm?

Answer 318

MRI

Question 319

What type of bronchoscopy is preferred for the removal of aspirated foreign bodies

Answer 319

Rigid bronchoscopy as it offers better protection of the airway and control of the foreign body as it is being recovered

Question 320

Left-sided chest and abdominal pain 7 days post-spleenctomy Febrile Decreased air entry at left lung base Dullness to percussion and LUQ tenderness

Answer 320

Subphrenic abscess Post-operative haematomas are common post-splenectomy and may collect in the subphrenic space. Infection can readily lead to an abscess and they may cause an associated pleural effusion

Question 321

What is the most common site of actinomycosal infection?

Answer 321

Cervicofacial

Question 322

Most common cause of primary adrenal insufficiency?

Answer 322

Autoimmune disease leading to adrenal atrophy

Question 323

Major Duke criteria

Answer 323

Positive blood culture findings for infective endocarditis: Typical micro-orgnaism on two sepearate occasions: viridans, aureus, HACEK, strep bovis, community-acquired enterococci, micro-organsism consistent with inefctive endocarditis from positive blood cultures. Positive echocardiogram findings: vegetation, abscess, intracardial fistula, pseudoaneurysm, valvular perforaiton or new dehiscence of prosthetic valve, new valvular regurgitation

Question 324

HACEK group

Answer 324

Haemophilus Aggregatibacter Cardiobacterium Eikenella Kingella

Question 325

Dukes minor criteria

Answer 325

Fever \<38 Predisposing heart condition or IVDU Immunological phenomena: Osler's nodes, Roth spots, GN Microbiological evidence of positive blood culture not meeting major criteria Vascular phenomena

Question 326

Lundh meal

Answer 326

Combination of skimmed milk powdered with corn oil and dextrose It is used to assess pancreatic exocrine status, with serum lipase measurements taken following administration. Faecal elastase is increasingly used

Question 327

Small round blue cell tumour of bone

Answer 327

Ewing's sarcoma

Question 328

From which nerve roots do the pelvic splanchnic nerves arise?

Answer 328

S2-S4

Question 329

How is the parotid gland separated from the carotid sheath?

Answer 329

By the styloid process and associated muscles (stylopharyngeus, stylohyoid, styloglossus)

Question 330

Lesion to Broca's area

Answer 330

Expressive dysphasia

Question 331

Lesion to Wernicke's area

Answer 331

Receptive dysphasia

Question 332

Treatment of intratubular germ cell neoplasia of the testes

Answer 332

Inevitably develop into cancer, therefore should be treated prophylactically with radiotherapy

Question 333

55y/o Longstanding history of mild stridor and hoarseness that has suddenly worsened On palpation there is a large soft swelling over the thyrohyoid membrane. When pressure was applied, this swelling disppeared

Answer 333

Larnygocele Expansion of laryngeal saccule with air. May spread superiorly and present in the false cord (internal laryngocele) or pass through the thyrohyoid membrane and present as a lump in the neck

Question 334

A 73 year old lady is admitted with small bowel obstruction and following surgery is diagnosed as having diaphragm disease. Which of the agents listed below is the most likely precipitant? Alcohol abuse Oral non steroidal anti inflammatory drugs Abdominal radiotherapy Oral steroids Chronic laxative misuse

Answer 334

Diaphragm disease is seen when the lumen of the small bowel is divided into short compartments by circular membranes of mucosa and sub-mucosa; these membranes have a pinhole lumen leading to frequent bouts of intestinal obstruction. The condition is said to be rare and associated with prolonged or long-term usage of non-steroidal anti-inflammatory drugs (NSAIDs). It is more common in the elderly as this group are more likely to take non steroidal anti inflammatory drugs in the long term. It is usually treated by surgical resection as the condition typically results in small bowel obstruction.

Question 335

Which of the structures listed below accompanies the aorta as it traverses the aortic hiatus? Oesophagus Thoracic duct Vagal trunks Right phrenic nerve Left phrenic nerve

Answer 335

The aorta is accompanied by the thoracic duct as it traverses the aortic hiatus. The vagal trunks accompany the oesophagus which passes through the muscular part of the diaphragm on the right. The right phrenic nerve accompanies the IVC as it passes through the caval opening. The left phrenic nerve passes through the muscular part of the diaphragm anterior to the central tendon on the left.

Question 336

What vessel is the origin of the middle rectal artery? Aorta Inferior mesenteric artery Superior mesenteric artery Internal iliac artery Internal pudendal artery

Answer 336

The rectum is supplied by 3 main vessels Superior rectal artery from inferior mesenteric artery Middle rectal artery from the internal iliac artery Inferior rectal artery from the internal pudendal artery

Question 337

What is the most appropriate method of delivery early peri-operative analgesia to a 6 month old child following an orchidopexy? TAP block Caudal block Wound analgesic infusion catheter Spinal block Epidural block

Answer 337

Orchidopexy can be quite uncomfortable immediately following surgery. A caudal block can be a very effective adjunct and provides good analgesia. A spinal block and epidural would be inappropriate. A TAP block may cover the inguinal canal but this is not generally reliable and wound catheters are not used.

Question 338

A 29 year old man presents to the clinic with a recurrent thyroid cyst. It has been drained now on three occasions. Each time the cyst is aspirated and cytology is reassuring. What is the most appropriate course of action? Reassure and discharge Resection of the ipsilateral thyroid lobe Enucleation of the cyst Total thyroidectomy Radio-isotope scan

Answer 338

Persist refilling cysts may be associated with a well differentiated tumour and should be removed by lobectomy.

Question 339

Treatment of Grave's disease with significant eye signs?

Answer 339

Total thyroidectomy

Question 340

Treatment of Papillary thyroid cancer

Answer 340

Total thyroidectomy and central compartment nodal dissection (extended lymphadenectomy as required)

Question 341

Treatment of follicular thyroid cancer

Answer 341

Total thyroidectomy (usually completion as already had hemithyroidectomy)

Question 342

What is the origin of the superior gluteal artery? Internal iliac artery External iliac artery Femoral artery Common iliac artery Circumflex femoral artery

Answer 342

The inferior gluteal artery arises from the anterior trunk of the internal iliac artery The superior gluteal artery arises from the posterior trunk of the internal iliac artery

Question 343

In which of the conditions described below is Rovsing's sign most likely to be absent? Locally advanced caecal cancer Para ileal appendicitis Right sided colonic diverticulitis Retrocaecal appendicitis Severe terminal ileal Crohns disease

Answer 343

Any advanced right iliac fossa pathology can result in a positive Rovsings sign. However, in retrocaecal appendicitis, it may be absent and this fact can contribute to a delayed diagnosis if undue weight is placed on the presence of the sign in making the diagnosis.

Question 344

A 6 day old child is suspected of having a malrotation and requires urgent abdominal exploration. What is the most appropriate surgical approach? Midline abdominal incision Paramedian incision Transverse supra umbilical abdominal incision Transverse infra umbilical abdominal incision Battle incision

Answer 344

In young children, laparotomy is performed via transverse supra umbilical incision. Access via midline incisions is very poor and they should not be used.

Question 345

A 76 year old man presents with a painful right arm (he is right handed). On examination, he has a cool right forearm and absent radial and brachial pulses. A duplex scan shows thrombus occluding the brachial artery. What is the most appropriate course of action? Administration of therapeutic low molecular weight heparin Brachial embolectomy without fasciotomy Intra arterial thrombolysis Systemic thrombolysis Brachial embolectomy with fasciotomy

Answer 345

Options to treat upper limb embolic events include either anticoagulation or surgery. Background arterial lesions are very rarely present in the upper limb so embolectomy is usually successful. Anticoagulation with intravenous unfractionated heparin is a reasonable alternative. However, note that low molecular weight heparin is not used in this setting as its difficult to control perioperatively.

Question 346

What is the most appropriate analgesic modality for a 52 year old male undergoing an open elective resection of the splenic flexure colonic cancer? TAP block Local anaesthetic wound infiltration Spinal block Epidural anaesthetic Rectal diclofenac

Answer 346

An open resection of a splenic flexure cancer will require a long midline incision and carries the potential for respiratory compromise. This is best countered with a well placed epidural. An alternative would be rectus sheath catheter infiltration of local anaesthetic and PCA.

Question 347

What is the most likely explanation for a 63 year old male to complain of a painless blood stained mucous rectal discharge 6 months following a Hartmann's procedure? Pelvic abscess Crohns disease Dysplasia of the rectal stump Diversion proctitis Fissure in ano

Answer 347

Once the bowel has been disconnected, a degree of inflammation is commonly seen in the quiescent bowel. This is typically referred to as diversion colitis. Dysplasia is not usually seen in this context as a Hartmanns procedure is not usually a treatment modality used for IBD (which is the main risk factor for dysplasia).

Question 348

What is the arterial blood supply to the lacrimal apparatus? Nasociliary artery Supra orbital artery Internal carotid artery Ophthalmic artery Supra trochlear artery

Answer 348

The ophthalmic artery supplies the gland

Question 349

A 56 year old man is investigated with an abdominal CT scan for a change of bowel habit towards constipation. It shows no colonic lesions. However, a right sided adrenal lesion is noted and measures 2.5cm in diameter. What is the most appropriate course of action? Arrange an MRI of the adrenal gland Arrange an adrenal USS Arrange an image guided core biopsy Undertake an adrenalectomy Arrange a hormonal assay

Answer 349

Arrange a hormonal assay The vast majority of small adrenal lesions are incidental, benign and non functioning adenomas. Apart from minimal workup, no further investigation is needed. Of note, if there are concerns about malignancy, the only surgical option is adrenalectomy.

Question 350

A 34 year old lady is undergoing a laparoscopic cholecystectomy for cholecystitis. She has been unwell for the past 10 days. On attempting to dissect the gallbladder (which is distended), all that can be seen are the gallbladder fundus and dense adhesions make it difficult to dissect Calots triangle. What is the best course of action? Perform an operative cholecystostomy Dissect the adhesions off Calots triangle and continue with the cholecystectomy Dissect out the bile duct and perform a cholangiogram Arrange an ERCP Arrange a PTC

Answer 350

The timeframe of 10 days makes attempts at proceeding with surgery hazardous even in experienced hands. However, the patient is unwell and this will not settle without some form of intervention. If only the fundus can be seen, then it may be difficult to even proceed with a sub total cholecystectomy. Therefore, a cholecystostomy can be performed and this will usually allow the situation to settle. Definitive surgery can then be undertaken in more favourable circumstances.

Question 351

A 40 year old female is diagnosed as having Dercums disease. Which of the lesions listed below are most likely to be identified on physical examination? Lipomas Neuromas Hamartomas Arteriovenous malformations Histiocytomas

Answer 351

Dercums disease is characterized by multiple lipomas. It is also referred to as adiposis dolorosa. Condition in which there is generalized obesity and multiple fatty tumours within adipose tissue Lesions are usually multiple and found around extremity joints Commonest in females Typically presents in middle age Treatments include analgesia and occasionally resection of the lesions, recurrence, however, is common

Question 352

A 17 year old male is admitted with lower abdominal discomfort. He has been suffering from intermittent right iliac fossa pain for the past few months. His past medical history includes a negative colonoscopy and gastroscopy for iron deficiency anaemia. The pain is worse after meals. Inflammatory markers are normal. What is the most likely cause? Appendicitis Crohns disease Peptic ulcer disease Meckels diverticulum Irritable bowel syndrome

Answer 352

This scenario should raise suspicion for Meckels as these may contain ectopic gastric mucosa which may secrete acid with subsequent bleeding and ulceration. The iron deficiency anaemia is makes a Meckels more likely than IBD.

Question 353

An 8 year old boy presents with abdominal pain,a twelve hour history of vomiting, a fever of 38.3 0C and four day history of diarrhoea. His abdominal pain has been present for the past week. What is the most likely cause? Coeliac disease Appendix abscess Irritable bowel syndrome Mesenteric adenitis Diverticulitis

Answer 353

The high fever and diarrhoea together with vomiting all point to a pelvic abscess. The presence of pelvic pus is highly irritant to the rectum, and many patients in this situation will complain of diarrhoea. Mesenteric adenitis is less likely to run such a protracted course. IBS does not typically produce such marked systemic symptoms. Diverticulitis is almost unheard of in children.

Question 354

A 74 year old man presents with a painful right leg. The pain developed suddenly the preceeding evening. However, he wondered if it might resolve overnight, instead, it has got worse. On examination, his right leg is cold and white with diminished distal sensation. A CT angiogram shows a thrombus occluding the external iliac artery with no atheromatous disease. What is the most appropriate course of action? Femoral embolectomy and below knee fasciotomy Femoral embolectomy alone Femoral popliteal bypass graft without fasciotomy Femoral embolectomy with above and below knee fasciotomy Femoro-femoro cross over graft with above and below knee fasciotomy

Answer 354

Delayed limb re-perfusion = Risk of compartment syndrome Delayed surgery for limb ischaemic carries a risk of re-perfusion injury and compartment syndrome. Where surgery is delayed beyond 6 hours, most surgeons would perform a fasciotomy at the same time as the embolectomy. However, whilst the compartments below the knee are vulnerable, its very rare for this to occur in the thigh and so, as a rule, the thigh is not treated in this manner.

Question 355

White leg with sensorimotor deficit

Answer 355

Surgery and embolectomy

Question 356

Dusky leg, mild anaesthesia

Answer 356

Angiography

Question 357

Fixed mottling of leg

Answer 357

Primary amputation

Question 358

A 24 year old woman presents with a long history of obstructed defecation and chronic constipation. She often strains to open her bowels for long periods and occasionally notices that she has passed a small amount of blood. On examination, she has an indurated area located anteriorly approximately 3cm proximal to the anal verge. What is the most likely diagnosis? Haemorrhoids Rectal cancer Ulcerative colitis Solitary rectal ulcer syndrome Fissure in ano

Answer 358

Solitary rectal ulcers are associated with chronic constipation and straining. It will need to be biopsied to exclude malignancy (the histological appearances are characteristic). Diagnostic work up should include endoscopy and probably defecating proctogram and ano-rectal manometry studies.

Question 359

A 55 year old man with no co-morbidity is due to undergo a Milligan Morgan haemorrhoidectomy, what is the most appropriate method of delivering immediate post operative analgesia? Pudendal nerve block Caudal block Rectal NSAIDS IV fentanyl Paracetamol

Answer 359

Following excisional haemorrhoidectomy, severe pain is not unusual, a well placed caudal anaesthetic will counter this. A pudendal nerve block is an alternative but is less effective than a caudal.

Question 360

A 21 year old women presents with right iliac fossa pain. She reports some bloodstained vaginal discharge. On examination, she is afebrile and has a pulse rate of 97 bpm, normal blood pressure. She has diffuse lower abdominal tenderness. What is the most appropriate course of action? Laparotomy Laparoscopy Abdominal and pelvic MRI scan Abdominal and pelvic CT scan Abdominal and pelvic USS

Answer 360

The history of blood stained discharge and tenderness makes an ectopic pregnancy a strong possibility, a USS should be performed and a pregnancy test undertaken. If the beta HCG is high then an intra uterine pregnancy should be found. If it is not, then an ectopic pregnancy is likely and surgery should be considered.

Question 361

A 4 year old child presents with a 4-5 day history of feeling generally unwell and also of having a sore throat. On examination, there is marked cervical lymphadenopathy, the oropharynx is covered with a thick grey membrane which bleeds following attempted removal. What is the most likely diagnosis? Acute streptococcal pharyngitis Infection with Epstein Barr virus Diptheria Ludwigs angina Ingestion of caustic soda

Answer 361

Infection with diphtheria classically causes a systemic illness that lasts several days. The tonsils or pharynx can be covered in a thick grey membrane which bleeds on attempted removal. There is often quite marked cervical adenopathy and some individuals can have a bulls neck appearance. Death can occur through airway compromise, which is why the often described attempted removal of the pseudomembrane so beloved of examiners, is, in practice rather a foolish thing to attempt in a young child!

Question 362

An 83 year old man is admitted on the acute surgical take. His presenting symptom is of painless, profuse rectal bleeding of dark blood. His medical history comprises a previous TIA for which he takes clopidogrel and a statin. What is the most likely underlying cause? Meckels diverticulum Colonic cancer Diverticular bleed Ischaemic colitis Diverticulitis

Answer 362

The majority of patients with colonic bleeding will be found to have bleeding secondary to diverticular disease. Of note, inflammation (i.e. diverticulitis) is not seen in such cases. Around 70% will stop bleeding spontaneously. Anti platelet and anti coagulants are sometimes complicating factors and may make bleeding less likely to cease spontaneously. Ischaemic colitis often has more dominant colitis symptoms.

Question 363

In which of the conditions listed below is Cullens sign most likely to be seen? Ruptured ectopic pregnancy Appendicitis Intestinal malrotation Perforated peptic ulcer Incarcerated femoral herni

Answer 363

Cullens sign is seen with significant intra peritoneal haemorrhage.

Question 364

An 80 year old lady is brought to the emergency department by her carers. She has been unwell for the past few days. On examination, she has a cold, pulseless leg with fixed mottling, below the knee. A duplex scan shows a stenosis of the profunda femoris and popliteal artery with no flow distal to this. What is the most appropriate course of action. Femoro-femoro cross over graft Axillo- femoral bypass graft Trans femoral amputation Gritti Stokes amputation Administration of intravenous unfractionated heparin

Answer 364

Fixed mottling is a sign of an unsalvageable limb and mandates either amputation or palliation. A through knee amputation (Gritti Stokes) is unlikely to heal in this setting.

Question 365

What are the four parasympathetic ganglia of the head and neck?

Answer 365

Ciliary Submandibular Pterygopalatine Otic

Question 366

Ciliary ganglion

Answer 366

Parasympathetic ganglion located behind the eye in the posterior orbit. It is involved in the reuglation of pupil dilation/constriction

Question 367

Otic ganglion

Answer 367

Located immediately behind the foramen ovale in the infratemporal fossa. It is functionally associated with glossopharyngeal nerve and innervates the parotid for salivation

Question 368

Ptyergopalatine galngion

Answer 368

Parasympathetic ganglion found in the ptergopalatine fossa, it is largely innervated by the greater petrosal nerve (branch of facial nerve) and it projects to the lacrimal glands and the nasal mucosa

Question 369

Submandibular ganglion

Answer 369

Involved in regulation of submandibulargland secretion (facial nerve)

Question 370

Recommended local anaesthetic agent for open inguinal hernia region block

Answer 370

50:50 mixture of lignocaine and bupivacaine with the addition of 1:200000 adrenaline.

Question 371

Mx of subacromial impingement

Answer 371

PT, oral anti-inflammatory medication Subacromial steroid injection Arthroscopic subacromial decompression by shaving away the undersurface of the acromion

Question 372

Management of rotator cuff tear

Answer 372

Consideration should be made to patient demographics and level of activity, Mild tears or tears in the elderly can be managed conservatively. Moderate tears can be managed arthroscopically. Massive or retracted tears may require open repair. Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence.

Question 373

Involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, it is associated with subacromial impingement and pain.

Answer 373

Calcific tendonitis

Question 374

Stages of calcification in calcific tendonitits

Answer 374

Formative phase characterized by calcific deposits Resting phase deposit is stable, but presents with impingement problems Resorptive phase phagocytic resorption. Most painful stage.

Question 375

Treatment of calcific tendonitis

Answer 375

Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management. Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required.

Question 376

Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture. Patients present with a painful and decreased arc of motion. Associated with prolonged immobilization, previous surgery, thyroid disorders (AI) and diabetes Classically three stages which can take up to two years to resolve:

Answer 376

Frozen shoulder

Question 377

Stages of frozen shoulder

Answer 377

Stage one the freezing and painful stage Stage two the frozen and stiff stage Stage three the thawing stage, where shoulder movement slowly improves

Question 378

Treatment of frozen shoulder

Answer 378

Non-operative NSAIDS, steroid injection and physiotherapy. Patience is required as condition can take up to 2 years to improve. Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy.

Question 379

Treatment of glenohumeral arthritis

Answer 379

NSAIDS, management of RA, physiotherapy, steroid injection. Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity. Arthroscopic debridement is useful if patient has isolated ACJ arthritis, but is rarely used for glenohumeral arthritis. Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival. Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity.

Question 380

Contents of the adductor cannal

Answer 380

Superficial femoral artery Femoral vein Saphenous nerve Nerve to vastus medialis

Question 381

Extent of the adductor canal

Answer 381

15cm long Vastus medialis laterally Adductor longus and magnus posteriorly Begins where sartroius crosses over adductor longus and ends at the adductor hiatus

Question 382

Which structure runs under brachioradialis, emerging distally on its medial side and enters the palm by piercing the first dorsal interosseous muscle?

Answer 382

Radial artery. Crosses the floor of the anatomical snuffbox to enter the palm between the two heads of the first dorsal interosseous

Question 383

Features of BrachioRadialis

Answer 383

Beer-raising muscle- flexes elbow with forearm in neutral Breaks Rule in that is is a flexor supplied by the radial nerve. Behind it is the radial nerve in the cubital fossa Attaches to the bottom of the radius

Question 384

Outline the knee jerk deep tendon reflex

Answer 384

Monosynaptic stretch reflex Passive stretch of the intrafusal spindle fibres throgh tapping the tendon with a tendon hammer, results in generation of afferent action potentials. These are transmitted by dorsal roots of the spinal nerves to the ipsilateral ventral grey matter. The efferent stimuli pass through the ventral spinal roots via alpha motor neurone which synapses with the motor end plate of the muscle fibres of the knee extensors

Question 385

How is glucose transported across the placental barrier?

Answer 385

Facilitated diffusion

Question 386

Which of the following is a tributary of the IJV EJV Inferior thyroid vein Middle thyroid vein Retomandibular vein Transverse cervical vein.

Answer 386

IJV receives the pharyngeal, lingual and superior and middle thyroid veins. EJV arises from the junction of the posterior auricular vein and the posterior divison of the retromandibular vein. The anterior portion of the retromandibular vein proceeds forward and joins with the anterior facial vein, together they join to form the common facial vein which drain into the IJV. The transverse cervical vein is a tributary of the EJV

Question 387

Why is blood volume maintained at normal levels in patients with DI?

Answer 387

Water intake is appropriately adjusted

Question 388

Which of the following best describes the anatomy of the normal thoracic arch It arches below the manubriosternal joint It arches directly over the right pulmonary artery It gives rise to the coronary arteries It is covered by pleura It lies anterior to the brachiocephalic veins.

Answer 388

The apex of the arch lies posteroinferior to the left brachiocephalic vein. the lower border of the arch lies in the transthoracic vein and is directly related to the left pulmoanry artery (the SVC lies over the right pulmonary artery) The arch is symmetrically covered by pleura from both sides which meet in the midline behind the manubriosternal joint.

Question 389

What is the most acceptable way to manage MRSA in a hospital setting?

Answer 389

Eradication by Abx therapy is recommended for all known carriers.

Question 390

What are the histological featurse of ARDS?

Answer 390

Increased capillary permeability Interstitial and alveolar oedema Fibrin exudation Hyaline membrane fromation and later Diffuse late interstitial alveolar fibrosis

Question 391

What would be seen in injury to the right dorsal scapular nerve? Skin on the upper back on the right side would be numb The point of the right shoulder would droop. Scapular retraction on the right would be weakened Extension of the right arm would be weakened Inability to adduct the right arm

Answer 391

The dorsal scapular nerve innervates the rhomboids and levator scapulae, these muscles help to retract and elevate the scapula. These movements would thus be weakened following damage. The skin of the upper back is innervated by the dorsal priamry rami of a spinal nerve.

Question 392

Which of the following would suggest class II shock? Decreased pulse pressure Decreased BP UO 5-15ml/h PR \>120 Confusion

Answer 392

Decreased pulse pressure PR in Class II shock is 100-120 BP is maintained UO is maintained at 20-30ml/h

Question 393

Which of the folllowing is true regarding the lumbosacral plexus Posterior rami supply the adductor muscles Lumbosacral trunk lies anterior to piriformis Lumbosacral trunk passes over the common ilaic vessels. Parasympathetic nerves originate from S4/5 spinal segments. Sympathetic trunk sends grey rami to S1-S5

Answer 393

Lumbosacral trunk passes anterior to the ala of the sacrum, under cover of the common iliac vessels and joins the S1 ventral ramus anterior to piriformis

Question 394

What is the risk of post-operative reinfarcation 6/52 post MI?

Answer 394

31-40%

Question 395

Malrotation Less than 50cm of viable bowel Action?

Answer 395

Untwist the bowel Return to the abdomen Relook laparotomy

Question 396

What is the optimum choice of skin prep?

Answer 396

Iodine

Question 397

From what nerve roots do the pelvic splanchnic nerves arise?

Answer 397

S2-S4

Question 398

Where is TBG produced?

Answer 398

Liver

Question 399

Which of the following is correct in regards to fracture healing? Bone necrosis becomes apparent within the first 24h Initially a vascular pannus is formed at the fracture site Lamellar bone is replaced by woven bone Osteoblasts lay down seams of uncalcified new bone Provisional callus is made up of lamellar bone

Answer 399

Osteoblasts lay down seams of uncalcified new bone. Osteoclasts resorb bone and play a key role in remodelling. Vascular pannus is associated with rheumatoid disesae.

Question 400

Vinyl chloride exposure is associated with?

Answer 400

Angiosarcoma of the liver

Question 401

Which of the following fractures is at most risk of developing non-union? Tibial plateau Intracapsular NOF Two-part proximal humeral Scaphoid Distal femur fracture

Answer 401

Intracapsular NOF are most likely to heal slowly and develop non-union This is due to the deficient proximal blood supply.

Question 402

Which of the following is correct in regards to airway of children in comparison to adults? Until the age of 2 months, infants are obligate nasal breathers In children the tracheal bifurcation is at a lower level than in adults The resting position of an infant's head is extension A child's trachea is shorter and wider than that of an adult. In a child, the trachea lies further to the left of the midline than in adults

Answer 402

Until the age of two months, infants are obligate nasal breathers- this explains why infections such as bronchiolitis can produce such profound respiratory compromise in infants. In children the trachea bifurcates at T3

Question 403

What force should be applied the proximal fragment of a long spiral fracture of the femur?

Answer 403

Adduction and extension as the proximal fragment will tend to lie in a flexed and externally rotated/abducted position. This is due to the action of iliopsoas on the lesser trochanter and the intact gluteal msucels and external rotators.

Question 404

What is the mechanism of inheritance in vWD?

Answer 404

Autosomal dominant

Question 405

Which of the following is a known risk factor for oral cancer? EBV Crohn's Female sex Lichen planus Pernicious anaemia

Answer 405

Lichen planus. EBV has been implicated but there is no clear evidence to establish a causal link

Question 406

A patient is in an RTA Reports to hospital complaining of weakness in both hands and loss of dexterity. Power is 4/5 deltoid and triceps. 3/5 wrist flexor and finger movements. Lower limb movements are normal

Answer 406

Central cord syndrome. Most common incomplete spinal lesion. Motor signs affect the upper more than the lower limbs and sensory changes are variable

Question 407

How to calculate the Well's score?

Answer 407

Active cancer (treatment within last 6/12 or palliative)= +1 Calf swelling \>3cm in comparison to asymptomatic calf Swollen unilateral superficial veins +1 Unilateral pitting oedema +1 Previous documented DVT +1 Swelling of entire leg +1 Localised tenderness along the deep venous system +1 Paralysis, paresis or recent cast immobilisation of lower extremities +1 Recent bedridden \>3d or major surgery requiring regional or GA in past 12/52 +1 Alternative diagnosis at least as likely -2

Question 408

50y/o woman with right sided neck lump Difficulty swallowing and solitary, firm mass 4cm to the right of the midline which moves on swallowing. She is otherwise well and there are no enlarged lymph nodes

Answer 408

Women \>50 years are most affected by follicular carcinoma

Question 409

What investigation regularly done post-heart transplant will be most sensitive for diagnosing rejection?

Answer 409

Biopsy of heart tisusues is the only current conclusive method and occurs regularly as part of routine f/u

Question 410

What is the danger zone of the face for infections causing cavernous sinus thrombosis?

Answer 410

Upper lip Nose Medial part of cheek

Question 411

What is another surgical condition potentially affecting the cavernous sinus?

Answer 411

Aneurysm of the ICA resulting in a caroticocavernous fistula presenting clinically as a pulsating proptosis

Question 412

Pulsating propotosis

Answer 412

?Caroticocavernous fistula

Question 413

Commonest site for Berry aneurysm?

Answer 413

ACA

Question 414

Crista galli

Answer 414

Sharp triangular protrusion of the cribiform plate that forms an attachment for the falx cerebri

Question 415

What is the location of Killian's dehiscence?

Answer 415

Thyropharyngeus and cricopharyngeus

Question 416

What is an essential part of pharyngeal pouch excision to prevent recurrence?

Answer 416

Cricopharyngeal myotomy

Question 417

Mechanism of upper brachial plexus injury

Answer 417

Excessive lateral flexion of the neck (downward traction of the arm) away from the pectoral girdle

Question 418

Mechanism of lower brachial plexus injury

Answer 418

Forced traction injury on an abducted arm (upward traction)

Question 419

Location of the AVN

Answer 419

On the right atrium on the interarterial septum above the attachment of the septal cusp of the tricuspid valve

Question 420

At what distance from the incisors is the GOJ?

Answer 420

40cm

Question 421

What will happen with GOJ on OGD in GORD?

Answer 421

The GOJ will be encountered earlier, indicating tat the oesopghagus has been shortened due to oesophagitis from reflux

Question 422

Significance of the lymphatic drainge of the oesophagus

Answer 422

Lymph from the middle one third drains first into the posterior mediastinal nodes. However, there are lymphatic channels within the oeosphageal walls which enables lymph to pass along the viscus, allowng cancer to spread through the submucosal lymphatic channels. Therefore, lymphatic cancer spread of the oesophagus is not segmental. A cancer of the middle one third of the oesophagus may thus have lymph nodal secondaries which may be extensive from the neck to the abdomen

Question 423

Which portion of the CBD is compressed early in cancer of the pancreatic head?

Answer 423

Infraduodenal common bile duct

Question 424

Divisions and extent of the CBD?

Answer 424

8cm long Supraduodenal Retroduodenal Infraduodenal Intraduodenal

Question 425

Which structure is vulnerable when dissecting the neck of an infrarenal AAA?

Answer 425

Third part of the duodenum Paritcularly in danger in an inflammatory aneurysm, where the duodenum is extremely adherent to theneck

Question 426

What are the two approaches for accessing the pudendal nerve?

Answer 426

Transvaginal or perineal

Question 427

What nerve root is responsible for the sensation of sitting?

Answer 427

S3

Question 428

We stand mainly on what dermatome?

Answer 428

S1

Question 429

Stone impacted at pelvic brim, what structure is causing this?

Answer 429

Common iliac artery bifurcation

Question 430

Function of the internal urethral sphincter in men

Answer 430

To prevent retrograde ejaciulation by closing off bladder neck during ejaculation

Question 431

Which of the following muscles that comprise the borders of the popliteal fossa have an insertion on to the head of the fibula? Biceps femoris Gastrocnemius Plantaris Semimembranosus Semitendonosus

Answer 431

Biceps femoris

Question 432

How does GA contribute to loss of homeostasis?

Answer 432

Depression of brain function leads to loss of various homeostatic reflexes Vasodilation caused by anaesthetic drugs leads to excessive heat loss by bringing increased flow of warm blood to the peripheries RMR falls partly due to decreased brain metabolism

Question 433

Violent cyanotic shivering in the recovery room post operation

Answer 433

Anaesthetic has caused loss of body temperature homeostasis due to suppression of brain function With recovery of reflex control of core temperature, shivering is initiated Homeostatic control of arterial blood oxygenation has lagged behind that of core temperature so oxygen intake is unable to keep up with the very large oxygen consumption associated with shivering. Hence the cyanosis

Question 434

What is the differnece in peripheral shutdown caused by hypovolaemia secondary to oesophageal varices and that caused by hypothermia

Answer 434

In hypothermia, it is the temperature regulating centre that initaites peripheral vasconstriction where as in haematemesis it is the BP regulating centre

Question 435

What is the main factor promoting survival in physiological response to stress

Answer 435

Cortisol mobilisation of glucose for energy

Question 436

What is the cause of acute confusion following oesopgageal variceal bleed in patient with liver disease?

Answer 436

Impaired metabolism of protein meal leading to excess blood ammonia (rather than urea which is one of the compensatory mechanisms for excessive blood ammonia levels)

Question 437

What is the easiest way to calculate estimated blood volume of a normal patient?

Answer 437

70ml/kg

Question 438

Estimated blood volume in obese patients?

Answer 438

45-55ml/kg

Question 439

Estimated blood volume in children?

Answer 439

80-90ml/kg

Question 440

Hartmann's in liver failure

Answer 440

May be impaired hepatic lactate metabolism so may be at increased risk of lactic acidosis

Question 441

What proportion of TBW is plasma volume?

Answer 441

1/4 of the ECF

Question 442

What proportion of ECF is interstitial fluid?

Answer 442

3/4

Question 443

What proportion of TBW is ECF?

Answer 443

1/3

Question 444

What proportion of TBW is ICF?

Answer 444

2/3

Question 445

Overall mortality from septic shock

Answer 445

50%

Question 446

Most common cause of anaphylaxis under anaesthesia?

Answer 446

Muscle relaxants

Question 447

What is the most accurate measure of preload?

Answer 447

Ventricular myocyte length

Question 448

What factor is most important to the degree of coronary blood flow?

Answer 448

Coronary artery diameter as the Hagen-Poiseuille equation describes the value of resistance being proportional to the fourth power of the radius

Question 449

What structure receives the greatest proportion of resting blood flow?

Answer 449

Liver/Splanchnic (25%)

Question 450

Which nerve carries afferent information from the carotid baroreceptors?

Answer 450

Gloosopharyngeal nerve (information from aortic baroreceptors is carried via the vagus)

Question 451

What are the factors determining the inspired concentration of oxygen?

Answer 451

Relative contribution of oxygen from delivery system (i.e. face mask) Percentage of entrained air from the room

Question 452

What is the importance of salivary secretions w.r.t. maintaining adequate oral hygiene

Answer 452

Copious amount of watery output from the parotids which is rich in calcium and phosphate

Question 453

What reflex mechanism prevents aspiration during swallowing

Answer 453

Reflex elevation of the larynx (centre in the medulla oblongata)

Question 454

Biochemical abnormalities in TURP syndrome

Answer 454

Hyponatraemia and increased blood ammonia (glycine is metabolised to ammonia by the liver)

Question 455

Phenomenon typically seen in patients with spinal cord injuries caused by imbalanced sympathetic activation leading to life threatneing hypertension.

Answer 455

?Autonomic dysreflexia

Question 456

Difference between anaphylactoid and anaphylactic reactions

Answer 456

Anaphylactoid involve direct activation of mast cells and are not immune mediated

Question 457

Embryology of the thyroid

Answer 457

Thyroid originates from an epithelial proliferation in the floor of the tongue and descends to its level in front of the tracheal rings in the course of its development The thyroglossal duct is formed along the path of thyroid migration. The foramen cecum is a pit at the junction of the anterior two-thirds and posterior one-third of the tongue representing the site of origin of the thyroid

Question 458

Which structure lies immediately lateral to the brachial artery in the antecubital fossa?

Answer 458

The median cubital vein lies on the subcutaneous tissue overlying hte cubital fossa and is anterior to the brachial artery

Question 459

Which nerve supplies the anterior part of the nasal septum?

Answer 459

Anterior ethmoidal nerve Passes through the anterior ethmoidal foramen and enters the anterior cranial fossa on the upper surface of the cribiofrm plate of the ethmoid. It enters the nasal cavity through a slit cavity alongside the crista galli.

Question 460

Which of the following structures are contents of the posterior mediastinum? Thoracic vertebrae Greater splanchnic nerve Trachea Ascending aorta Arch of azygos

Answer 460

Greater splanchnic nerve (sympathetic fibres from T5-10 form the nerve which courses along the thoracic paravertebral border in the posterior mediastinum) Trachea is in the superior mediastinum Ascending aorta is in the middle mediastinum Arch of azygos is in the middle mediastinum, the azygos and hemiazygos veins are in the posterior mediastinum

Question 461

Causes of rhabdomyolysis

Answer 461

Can be hereditary e.g. associated with metabolic conditions Or acquired Extreme physical activity Drug use Malignant hyperthermia Infections (e.g. streptococcus, C. diff, leigonella), toxins, trauma

Question 462

Triad in rhabdomyolysis

Answer 462

Muscle weakness Myalgia Dark urine

Question 463

Which of the following medications is most likely to contribute to gastric ulcers? Aspirin Clopidogrel Omeprazole Prednisolone Ibuprofen

Answer 463

Aspirin

Question 464

Which of the following parts of the genitourinary tract is dervied from mesoderm? Prostate Bladder trigone Body of the bladder Urachus Pineal gland

Answer 464

Trigone is derived from mesoderm, the rest of the bladder originates from endoderm Prostate is derived from outgrowths of the endoderm Urachus is dervied from endoderm as is pineal gland

Question 465

Patient presents with a left eye that tends to drift upwards and outwards, away from the nose Palsy of which extra-ocular muscle is the most likely cause?

Answer 465

Superior oblique muscle as it is involved in medial rotation, depression and abduction

Question 466

What do both kidneys lie on posteriorly?

Answer 466

Psoas major and quadratus lumborum

Question 467

Which embryological defect is associated with anencephaly? Failure of neural tube to close dorsally on day 24 Failure of neural tube to close dorsally on day 26 Failure of neural tube to close anteriorly on day 24 Failure of neural tube to close anteriorly on day 26 Failure of cartilaginous ring formation in the mesoderm surrounding the neural tube?

Answer 467

The nerual tube closes anteriorly and should occur on day 26

Question 468

Failure of the neural tube to close dorsally by day 24 is associated with?

Answer 468

Spina bifida

Question 469

Why are the maxillary sinuses particularly prone to infection? Because they drain into the medial meatus via infundibulum Because they drain into the middle meatus through hiatus semilunaris Because they drain into the superior meatus Because they drain near the site of drainage of the frontal sinuses Because their floor is related to the roots fo the premolars and molar teeth

Answer 469

Because they drain into the middle meatus through hiatus semilunaris Each maxillary sinus drains by an opening- the maxillary ostium, into the middle meatus of the nasal cavity. Because of the superior location of this opening, it is impossible for the sinus to drain while the head is erect until the sinus is full. Their ostia are commonly small and are located high on their superomedial walls. When the mucous membrane of the sinus is congested, the ostia are often obstructed. Because the ostia are on the medial sides, only one sinus will drain when lying on one's side, i.e. right sinus will drain when lying on left side. The infundibulum is the site of drainage of the frontal sinus.

Question 470

MAP=

Answer 470

2x DP + SBP/3

Question 471

Fat necrosis may be associated with?

Answer 471

Calcifications

Question 472

Innervation of flexor pollicis brevis?

Answer 472

Superficial head is innervated by the recurrent branch of the median nerve Deep head is innervated by the deep branch of the ulnar nerve

Question 473

Where is the highest percentage of thyroid hormone found in the serum?

Answer 473

Bound to TBG

Question 474

How to reverse atracurium

Answer 474

Neostigmine

Question 475

At which gestational week of development does the foetal heart start beating?

Answer 475

Week 4

Question 476

Which of the following is the main factor stimulating release of secretin into the blood stream? Activation of Brunner's glands Increasing duodenal pH Parasympathetic stimulation Acidity of chyme entering the duodenum H2 antagonists

Answer 476

Acidity of chyme entering the duodenum

Question 477

Which nerve supplies cutaneous innervation to the angle of the jaw?

Answer 477

Greater auricular nerve C2,3

Question 478

Which of the following is true regarding the lymphatic drainage of the breast? Axillary LNs receive 45% of lymph drained from breast The medial part of hte breast usually drains into the axillary nodes and the lateral part fo the breast drains into the internal mammary nodes Lymphatics in the breast start from the breast lobules that drain into the subareolar plexus known as Sappey's plexus The axillary LNs can be divided into four groups: apical, brachial, central, subscapular The internal mammary nodes run alongside the internal mammary artery and vein, deep to the visceral pleura

Answer 478

Lymphatics in the breast start from the breast lobules that drain into the subareolar plexus known as Sappey's plexus. From the subareolar plexus drainage can take one of three routes- axillary pathway, internal mmary pathway, retromammary pathway. Axillary LNs receive about 75% of lymphatic drainage. The axillary LNs are divided into 6 groups.

Question 479

Which of the following is found in hypersplenism? Punctate basophilia Howell-Jolly bodies Pancytopenia Heinz bodies Low fibrinogen

Answer 479

Pancytopenia

Question 480

What is the main site of phosphate reabsorption in the nephron?

Answer 480

PCT

Question 481

Which is true about the ciliary ganglion? It is a sympathetic ganglion It is a parasympathetic ganglion, but sympathetic fibres also synapse in it It is situated posterior to the orbit It receives parasympathetic preganglionic fibres from the facial nerve Post ganglionic fibres leave the ganglion in short ciliary nerves

Answer 481

Post ganglionic fibres leave the ganglion in short ciliary nerves Sympathetic fibres pass through it but do not synapse in it. It is in the posterior part of the orbit, not posterior to it. It receives preganglionic fibres via the oculomotor nerve

Question 482

Long term steroid use disrupts what aspect of the HPA?

Answer 482

It suppresses ACTH

Question 483

Russell bodies

Answer 483

Large eosinophilic inclusion containing Igs. They are found in areas of chronic inflammation such as in the peripheral edges of tumours

Question 484

Malpighian bodies

Answer 484

Another term for the renal corpuscule which consists of the glomerulus and surrounding Bowman's capsule

Question 485

Haematoxylin body

Answer 485

Dense, basophilic collection of degraded nuclear material which is found in SLE

Question 486

Division of the radial nerve

Answer 486

Just proximal to the elbow, the radial nerve divides into a superficial and deep branch. The superficial branch is purely sensory.

Question 487

Dorsal column supply to the lower limb is via?

Answer 487

Fasciculus gracilis

Question 488

Dorsal column supply to the upper limb is via

Answer 488

Fasciculus cuneatus

Question 489

Henoch-Schonlein purpura results from?

Answer 489

Deposition of IgA in vessels. Systemic vasciulitis that is the result of IgA and complement component 3-containing complexes within the vessels. Presents with palpable purpura, abdominal pain, proteinuria and haematuria

Question 490

Which of the following is true regarding the male pelvis? Pelvic inlet is more rounded and wider than in females Subpubic angle is obtuse (90-100) Obturator foramen is oval GS notch is narrow and almost 70 degrees The ischial tuberosities are everted

Answer 490

GS notch is narrow and almost 70 degrees The subpubic angle is acute in males

Question 491

What structure is prone to injury when mobilising the splenic flexure of the colon?

Answer 491

The splenic artery which runs in lieonorenal ligament and can be injured via excess traction intra-operatively

Question 492

Nerve roots of the Achilles reflex?

Answer 492

S1/2

Question 493

Site of action of frusemide?

Answer 493

Ascending limb of the loop of Henle

Question 494

Which of the following is true regarding the micturition reflex? Sympathetic stimulation relaxes the detrusor muscle Contraction of the membranous urethra expels any urine remaining in the urethra post-voiding External sphincter is not under voluntary control Parasympathetic stimulation causes contraction of the internal urethral sphincter Pontine micturition centre is located in the medulla

Answer 494

Sympathetic stimulation relaxes the detrusor during the storage phase. IUS is contracted. This is under sympathetic control. Excretion of any urine remaining in the urethra is aided by contraction of bulbospongiosus. EUS is under somatic control. Parasympathetic stimulation causes IUS relaxation.

Question 495

Most likely injury following stretch or severe crush injury?

Answer 495

Axonotmesis Neurotmesis requires high energy injury normally

Question 496

NICE guidelines for treatment with HER2-positive early invasive breast cancer

Answer 496

Should receive trastuzumab for one year at three week intervas. If there is recurrence before the completion of one year then trastuzumab should be stopped.

Question 497

Which of the following is supplied by the LCA in the majority of people? AVN Anterior 1/3 of interventricular septum Apex of heart SAN Pulmonary trunk

Answer 497

Anterior 1/3 of interventricular septum. (LAD suipplies other 2/3rds)

Question 498

What is the earliest manifestation of Cushing's?

Answer 498

Loss of diurnal variation

Question 499

What is the granuloma type found in sarcoidosis?

Answer 499

Epitheloid granulomas

Question 500

Histiocytic granulomas seen in?

Answer 500

Foreign body or rheumatoid

Question 501

Ability to grip a sheet of paper or make an OK sign relies on?

Answer 501

Action of FDP, FPL. Both innervated by anterior interosseus branch of median nerve (along with pronator teres)

Question 502

From which embryological structure do the superior parathyroid glands develop?

Answer 502

Dorsal wings of the fourth branchial arch

Question 503

Which of the following muscles is supplied by the vagus nerve? Tensor veli palatini Levator veli palatini Mylohyoid Stylohyoid Stylopharyngeus

Answer 503

Levator veli palatini (as it is derived from the fourth pharyngeal arch) The stylopharyngeus derives from the third pharyngeal arch and is thus innervated by the glossopharyngeal nerve

Question 504

Nervous supply of the first pharyngeal arch

Answer 504

Trigeminal nerve

Question 505

Nerve supply of the second pharyngeal arch

Answer 505

Muscles of facial expression therefore- Facial

Question 506

Nerve supply of the third pharyngeal arch

Answer 506

Glossopharyngeal nerve

Question 507

Nerve supply of 4th-6th pharyngeal arches

Answer 507

Vagus 4th supplied by the superior larngeal 6th by recurrent laryngeal

Question 508

What structure is most likely to be damaged in a stab wound to the left fifth ICS?

Answer 508

Left ventricle

Question 509

Which of the following structures passes through the supraspacular foramen? Suprascapular artery Suprascapular nerve Dorsal scapular nerve Dorsal scapular artery Suprascapular artery and nerve

Answer 509

Suprascapular nerve Suprascapular artery passes above the foramen, superior to the transverse scapular ligament

Question 510

Which of the following is the best morphological feature to distinguish UC from Crohn's? Mucosal abscess Pseudopolyps Mucosal oedema Entero-enteric fistulae Mucosal lymphoid aggregates

Answer 510

Entero-enteric fistulae

Question 511

RV in healthy 25y/o?

Answer 511

1200mL

Question 512

Which Th produces IL-4, 5, 6, 9, 10?

Answer 512

Th2

Question 513

Which Th prduces TNF beta, IFN gamma and IL-2?

Answer 513

Th1

Question 514

From what is the arch of the aorta derived?

Answer 514

Fourth left aortic arch gives rise to the aortic arch from the LCCA to the left subclavian arteries

Question 515

Incisura angularis marks

Answer 515

Junction between the body and fundus of the stomach

Question 516

Which of the following factors does not contribute to prolonged neuromuscular blockade? Hyperthermia Alkalosis Hyperkalaemia Concurrent use of suxamtheonium chloride Inhalational anaesthetics

Answer 516

Hyperthermia

Question 517

Autosomal recessive condition. Excessive bleeding following crircumcision. Easy bruising, recurrent epistaxis, haematuria With severe form may have severe umbilical cord stump, intracranial or bleeding into soft tissues and muscles. Blood tests reveal a prolonged PT and APTT. TCT is normal

Answer 517

Factor 10 deficiency

Question 518

Location of SAN

Answer 518

Located anterolaterally, just deep to the epicardium at the junction of the SVC and right atrium, near the superior end of the sulcus terminalis

Question 519

#Neck of fibula Which following sign may be found O/E Calcaneovalgus Decreased sensation on the sole of the foot Decreased sensation over the upper part of the posterolateral surface of the leg Decreased sensation over the lower part of the poterolateral surface of the leg Decreased sensation over the skin on the anteromedial surface of the leg.

Answer 519

Decreased sensation over the upper part of the posterolateral surface of the leg This area of skin is innervated by the lateral cutaneous nerve of the calf, a terminal branch of the common peroneal nerve which is vulnerable to injury in this fracture. Sural nerve is a branch of the tibial nerve

Question 520

Interobserver bias

Answer 520

Type of observer bias where different observers measure the same quantity differently

Question 521

Intraobserver bias

Answer 521

Type of observer bias where the same observer measures a quantity differently