Block 14 Flashcards
Tidal volume
Volume of air inspired or expired with each normal breath in quiet breathing
Approx 500mL
Residual volume
Volume of air left in lungs after forced expiration
Inspiratory reserve volume
Volume of air that can be inspired over and above the normal tidal volume
Expiratory reserve volume
Extra volume of air that can be expired by foreceful expiration at the end of normal tidal expiration
What are the five lung capacities?
FRC
Inspiratory capacity
Expiratory capacity
Vital capacity
TLC
FRC=
RV + ERV
Inspiratory capacity
IRV + TV
Expiratory capacity
ERV + TV
Vital capacity
IRV + TV +ERV (or total lung capacity- RV)
TLC=
Vital capcaity + residual volume
What is the closest anatomical relation to the orign of the SMA
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
Relation of the SMA to the SMV
SMV lies to the right
Relationship of the splenic vein to the SMA
Splenic vein grooves the posterosuperior aspect of the pancreas and passes above the SMA
At what level is the third part of the duodenum?
L3
Risk factors for retinal detachment
Short-sighted (myopia)
Undergone cataract surgery
Detached retina in contralateral eye
Subjected to recent severe eye trauma
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
Retinal detachment
What are the three main types of emboli implicated in retinal artery occlusion
Fibrin platelet emoboli (from diseased carotids)
Cholesterol emboli
Calcific emboli
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)
Retinal artery occlusion
Why is the fovea preserved in retinal artery occlusion
As it has no supply from the retinal circulation but rather from the choroid
Management of retinal artery occlusion
IV acetazolamide
Ocular massage (to exert pressure on vessels)
Anterior paracentesis (to release aqueous and rapidly lower IOP)
CO2 re-breathing to cause vasodilation.
Pain on passive flexion of the toes
Loss of sensation to the 1st dorsal webspace
Previous tibial fracture
?Anterior compartment syndrome with deep peroneal nerve injury
How may continued liver bleeding following hepatic trauma present?
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
Management of trigger finger
Steroid infiltration may be effective in mild cases, though surgical release of the proximal portion of the A1 pulley may be necessary
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.
Phalangeal enchondroma
Loss of phalangeal bone opacity
Cavity of mass appears radiolucent with stippled calcification
Cortex of the bone may be thinned
Phalangeal enchondroma
Family screening in FAP
Starts at 10 years old and is yearly
Screening involves flexible sigmoidoscopy or colonoscopy
Epidemiology of FAP
Affects 1:10000
Men and women equally affected
1/3rd de novo
AD
Px in desmoid tumours
1/5 risk of death an an average age of 35
Features of POSSUM score
Comprises 12 physiological factors and 6 operative factors.
Can be used to calculate morbidity and mortality
Physiological factors in POSSUM score
Age
Cardiac status
ECG
Reparatory status
BP
Pulse rate
GCS
Hb
WCC
Urea
Na
K
Operative factors of POSSUm score
Operative complexity
Number of procedures
Blood loss
Peritoneal contamination
Extent of malignant spread
Mode of surgery (elective or emergency)
Which IL is also known as human cytokine synthesis inhibitory factor
IL-10
Contents of the foramen magnum
Medulla
Spinal portion of spinal accessory nerve
Anterior and posterior spinal arteries
Vertebral arteries
Reduced Fe and TIBC
Raised ferritin
Normal MCV
Anaemia of chronic disease
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
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
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
Maydl’s hernia
Howship-Romberg sign
Seen in obturator hernia.
Pain referred along the geniculate branch of the obturator nerve to the inner aspect of the knee
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
Pudendal hernia
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
Idiopathic megabowel
V/Q ratio at apex vs base in a standing person
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
What are the features of Primary Raynaud’s
Attacks triggered by exposure to cold or stress
Bilateral arm involvement
No necrosis
No underlying cause
No ANA
Normal inflammatory markers and capillaries
What percentage of Ca is available for buffering changes in Ca balance in the body?
1%
INK4a is associated with
Melanoma
CBF per 100g of brain
50-100ml/min
t1/2 of T3 in the blood
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
Impact of smoking 10 cigarettes per day on post-operative morbidity
Increases morbidity 6-fold
Which function of the knee allows increased flexion
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
Anasarca
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.
Arrangement of structures at the ACF from M->L
Median nerve, brachial artery, biceps tendon
Risk of breast cancer in BRCA1
50% risk of developing breast Ca by 50
Increasing to 80% by 90
Numbess in first, second and third toes and dorsum of the foot likely to be caused by
Damage to superficial peroneal nerve
Deep peroneal nerve innnervates the 1st webspace
Coagulase negative gram positive aerobic coccus
Staph epidermis
Causes of granulomatous sialoadenitits
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
Contents of the middle meatus
Contains the bulla ethmoidalis of the middle ethmoidal air sinus, which drains through a hiatus in the bulla
Views taken on mammogram
Craniocaudal
Mediolateral oblique
Cleft lip is more common on which side
Cleft lip is more common than right
Components of Child-Pugh score
ABCDE
Albumin
Bilirubin
Clotting
Distension (ascites)
Encephaloapthy
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
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
18 y/o presents with sudden onset testicular pain
O/E the testis feels firm and irregular at the apex of the scrotum
Testicular tumour
May be associated with sudden onset testicular pain
An irregular feeling testis should warrant an USS
Associations of hypospadias
Undescended testes
Inguinal hernia
Disorders of sexual development
Hydroceles
Classification of hypospadias
Anterior (most comon 50-80%)
Middle
Posterior: penoscrotal and perineal
Hypospadias repair is performed at what age
6-18 months
Complications of hypospadius repair
Urethrocutaneous fistula
Urethral stricture
Poor cosmesis
Urethral diverticulum
Meatal stenosis
Spraying of urine
Voiding dysfunction
Henry-Gauer reflex
Increased atrial pressure causing reduced ADH secretion
What proportion of colorectal cancers are sporadic
75%
What proportion of colorectal cancers are attributable to IBD
1%
Treatment of choice acute limb ischaemia caused by thrombosis
Intra-arterial tPA
What artery may be eroded into by a posterior gastric ulcer
Splenic artery
Pathophysiology of Mirizzi syndrome
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
Why are fistulae not classically seen in UC?
As the inflammation is confined to the mucosa and submucosa rather than transmurally
How does the ulnar nerve enter the forearm
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.
Boundaries of the cubital tunnel
Medial epicondyle (medial border)
Olecranon (lateral border)
Roof formed by the cubital tunnel retinaculum
Floor by the capsule of the elbow joint
Indications for proctocolectomy in UC
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
Potential complications of ileoanal pouch
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
In whom is pouch surveillance recommended
For those who have colonic dysplasia or neoplasm as there are rare case reports of neoplasm developing in the pouch
Features of ileo-anal pouch
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
Which of the following malignancies has multi-centric origin
Prostate
RCC
SCC penis
TCC
Wilm’s tumour
TCC can occur anywhere in the urothelium and mutlicentricity and resistance are common
Unwell child with unhealed burn must be
Treated for toxic shock syndrome until proven otherwise
Prostate cancer is exceedingly rare in which individuals
Men castrated prior to puberty or individuals deficient in 5 alpha reductase
Due to prostate’s reliance on testosterone and DHT for growth
Surgical management of malrotation
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
Pathophysiology of midgut volvulus
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
Lights criteria
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
How would you identify L4
Iliac crest
Line connecting the two iliac crest i.e. supracristal line= L4
What type of joint is the SCJ?
Saddle type of synovial joint
What type of joint is the MCPJ?
Condyloid synovial joint
What proportion of colorectal cancers arise from pre-existing polyps?
>80% which is what makes the disease suitable for screening
Colorectal cancer on which side of the colon tends to be exophytic and presents with anaemia
Right sided colon cancers
Why is diaphragmatic rupture more commonly diagnosed on the left
As the liver obliterates the defect or acts as a protection on the right
Classification of neuropathic bladder
Cerebral lesions (CVA, dementia, parkinsonism)
Spinal lesions (Trauma, MS, spina bifida)
Peripheral nerve lesions (following pelvic surgery or DM).
Neuropathic bladder caused by lesions of the sacral cord or peripheral nerves
Underactive detrusor and urethra
Neuropathic bladder lesion: supraspinal cord
Loss of inhibitory impusles, causing detrusor over-reactivity and uncoordinated activity of detrusor and urethra
Neruopathic bladder caused by lesions above the pons
Loss of cerebral inhibition- overactive detrusor
What retrovesical structure may be invaded by TCC
Anterior portion of the prostate
Bublospongiosus
Corpus spongiosum
Perineal body
Seminal vesicles
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
What are the components of the extrinsic pathway?
Factor VII and activated tissue factor
AutoAb in autoimmune hepatitis
Anti-mitochondrial antibodies
A PDE 3 inhibitor acting as both a positive inotrope and peripheral vasodilator. It is effective in cardiogenic shock
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
What is the second line investigation in ?phaeo
Clonidine suppression test
Clonidine suppression test
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
Use of MIBG scintigraphy
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
Cilostazol
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
Trapdoor appearance on plain XR/CT
?Orbital blowout fracture
What are the commonest signs of orbital blowout fracture
Enophthalmos
Diplopia, especially on upward gaze
Which of the following toxins is produced by E. Coli
Verotoxin
Hyaluronidase
Toxic shock toxin
Haemolysin
Enterotoxin
Verotoxin is produced by EHEC and similar to the shiga toxin produced by Shigella
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
Mesenteric cyst
Components of the cervix
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
What is the normal length of the ST segment
0.08s
What is the most comon type of benign lung neoplasm?
Pulmonary hamartoma.
What is sis w.r.t, cancer genetics?
Growth factor oncogene, it leads to the overproduction of platelet derived growth factor, which stimulates cells to grow
In what layers of the anterior abdominal wall are the inferior epigastric vessels found?
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
At what level does the IVC commence?
L5
At what level is the junction of the azgos vein with the SVC?
T4/5 intervertebral disk i.e. the manubriosternal joint
Which interleukin is involved in the coagulation cascade?
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
What is used for the radiological staging of parotid tumours?
MRI
Ranson’s criteria
GA LAW
Over next 48h COUCH
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%
Treatment of pancreatitis
PANCREAS
PPI
Analgesia
NBM
Catheterise
Rehydrate
NG
ABx (severe only)
Sliding scale
Complications of pancreatitis
PANCREAS
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
Causes of raised amylase
AMYLASE
AAA rupture/acidosis (DKA)
Mesenteric ischaemia
gYnaecological pathology
Liver disease
Anuria
Salivary gland disease/stomach ulcer (perforated)
Ectopic pregnancy
Why are PPIs used in pancreatitis
Stress-induced gastric erosions frequently occur, these can result in haemorrhage and resultant haematemesis and melaena. This is the most common cause of haemorrhage
Cause of hypoxia in pancreatitis
Usually due to hypoventilation secondary to pain but may be as a consequence of ARDS
Splenic rupture in pancreatitis
Very rare complication
Which part of the skull does the Eustachian tube penetrate?
Petrous temporal bone
What is the rate of patients developing ARDS post cardiopulmonary bypass surgery
0.5-1% of patients
What is the risk of stroke with cardiopulmonary bypass
1%
Cortisol response to cardiopulmonary bypass
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)
What is the relation of the thoracic duct to the oesophagus in the mediastinum
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
Ix in adrenal incidentaloma
Firstly establish that it is not metastatic disease
Then consider MRI to better delineate the lesion’s anatomy
Adrenal lesion >3cm in patient <50y/o
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
When is the earliest time at which a tracheostomy tube should be changed?
Day 3 post op to allow the tract to fully develop
Options for drains of the pleura
Require a closed system usually an underwater seal drain but alternatively a disposable flutter valve system or continuouous wall suction may be used.
Why are drains often indicated in urinary anastomoses
Urinary anastomoses often leak in the immediate post-operative period and drainage following an augmentation cystoplasty prevents urinoma formation
Management of LN mets in SCC of the tongue
Radical neck dissection
What medication should be used in patients suffering frostbite?
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
Classification of freezing cold injury
Similar to burns
mild/superficial or severe/deep
Distinction is based on final outcome
Indications for mechanical ventilation
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
Raised circulating levels of adrenaline will lead to?
Glycosuria
Excessive sweating
Bradycardia
Paroxysmal hypotension
Bronchospasm
Glycosuria due to increased hepatic glucose output
Sliding hernias vs rolling hiatus hernias
Sliding herniae are primarily associated with symptoms of GORD, whilst rolling herniae can cause gastric strangulation and necrosis and gangrene
What types of stains are used for FNA?
Romanowsky-type stain
Papanicolaou stain
Methoxamine
Inotrope than can be given to treat hypotension due to perihperal vasodilation through its action as a vasoconstrictor
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
Hidradenitis suppurativa
Pathophysiology of hidradenitis suppurativa
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
Consequences of chronic hidradenitis supppurativa
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
Embryological formation of horseshoe kidney
Arises from kidneys fusing at the inferior pole, having their ascent arrested by the present of the isthmus and the IMA.
Features of horseshoe kidney
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
Hallmarks of toxic megacolon
Nonobstructive colonic dilatation greater than 6cm with signs of systemic toxicity
Mortality rate of toxic megacolon
5-20%
Management of toxic megacolon
ABC with aggressive fluid and electrolyte replacement.
Broad spectrum Abx
All medications that may affect colonic motility must be stopped.
Bowel rest
NGT
Management of acute haemolytic transfusion reaction
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
What dermatome supplies the skin of the ring finger?
C8
What is the dermatome of the thumb and index finger?
C6
Spinal shock
Flaccidity and loss of reflexes seen after SC injury
Spinal cord injury with sacral sparing
May suggest incomplete spinal injury (only if voluntary control) the preservation of spinal reflexes alone does not qualify as an incomplete injury
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
Central cord syndrome
Pathophysiology of central cord syndrome
Thought to arise as a consequence of vascular compromise in the cord in the distribution of the anterior spinal artery
Release of what hormone will help correct excess fluid administration
ANP
Serum amylase in acute pancreatitis
Typically peaks in first 12-48h and returns to normal after 72h.
Which coagulation factor is activated by factor XIIa and produced in the liver?
Factor XI
It is a serine protease produced by the liver and circulates in its inavctive form
What is the deepest layer of the pyloric wall to be divided in Ramstedt’s pyloromyotomy?
Circular muscle
What are the most important factors predicting rebleeding in UGI bleed?
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)
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
Lymphangioma circumscriptum
Direction of chest drain
Should be pointed upward if ?pneumothorax and downard if fluid is being drained
Protein concentration of CSF w.r.t. plasma
Is approximately 0.5% that of plasma.
It prevents some proteins and amino acids acting as false neurotransmitters
What is the difference in electrolytes in CSF in comparison to plasma
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
Arrangement of structures at the renal hilum from anterior to posterior
VAU
Which muscle lies immediately posterior to the kidney?
Psoas major
LDLR deficiency causes
Familial hypercholesterolaemia
Liprotein lipase deficiency
Rare inherited cause of severe hypertriglyceridaemia.
Condition normally presents in childhood.
LPL is responsible for the clearance of VLDL and chylomicrons from the plasma
Changes in VLDL in XS EtOH intake
Hypertriglyceridaemia frequently occurs in association with high alcohol intake is due to increased synthesis of TG for incorporation into VLDL in the liver.
Development of the male urethra
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.
Endocardial cushions in the embryological heart
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
What masses may be found in the anterior mediastinum
Thymic lesions
Lymphoma (more likely to manifest in anterior mediastinum than middle mediastinum)
Germ cell tumours
Pleurpericardial cysts
Lymphadenopathy
What masses may be found in middle mediastinum
LN enlargement
Bronchogenic cysts
Enterogenic cysts
Causes of posterior mediastinum masses
Neural tumours
Thoracic meningocele
Oesophageal tumours
Aortic aneurysms
Paragangliomas
Causes of superior mediastinal masses
Thyroid
LN
Oesophageal tumours
Aortic aneurysms
Parathyroid lesions
Aggressiveness of testicular tumours
Teratomas are more aggressive than seminomas
Seminomas spread via the lymphatic to para-aortic nodes whereas teratomas spread haematogenously and occasionally to LNs
Why are varicoceles more likely to occur on the left even in the absence of renal malignancy
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
Why are inguinoscrotal herniae more likely to occur on the right?
As the right testicle descends later
What is the process of secondary bone healing
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
Glagows score of 0-2 mortality
2%
Glasgow score 3-4 mortality
15%
Glasgow score 5-6 mortality
40%
Glasgow score 7-8 mortality
100%
What proportion of cancers produce peptides implicated in paraneoplastic syndromes?
10%
Extensor nodule on the arm
Central necrotic area surrounded by palisaded histiocytic macrophages all enveloped by lymphocytes, plasma cells, fibroblasts
Positive RF
What proportion of oestrogen negative breast cancer will show sensitivity to tamoxifen?
5-10%
Contents of the femoral triangle from lateral to medial
Femoral nerve
Femoral artery
Femoral vein
Long saphenous
What is the most common location for the meatus in hypospadius
Ventral surface
70% are glanular
10% penile
20% scrotal
Perineal placement is associated with anorectal anomalies
Incidence of AVN in intracapsular #NOF
Up to 15% in nondisplaced
Increases to nearly 90% with untreated, completely displaced fractures
Tumours which arise from nests of non-chromaffin paraganglionic cells dervied from the neural crest
Paraganglionomas
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
Pearson’s correlation coefficient
Kurskall-Wallis test
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
Spearman’s rank correlation coefficient
Non-parametric measure of rank correlation which examines statistical dependence between the ranking of two variables
Wilcoxson signed-rank test
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
Complications of balloon tamponade in treatment of refractory oesophageal varices
Aspiration pneumonia
Mucosal ulceration
Oesophageal perforation
When do endoethlial cells appear during wound hearing?
Days 3-5
When do fibroblasts and myofibroblasts appear during wound healing
Days 2-4
Proteinuria, hypoalbuminaemia, oedema and hypercholesterolaemia
HIV, IVDU, previous renal transplant
Biopsy shows focal glomerular deposits of IgM
?Focal segmental glomerulosclerosis
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
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
What proportion of carotid bruit heard on auscultation are due to carotid stenosis?
70%
Patient with FAP who experiences jaundice
?Dudoenal tumour cause extrahepatic biliary obstruction
Rate of gastric carcinoma worldwide
Declining
Risk of gastric cancer in blood group A?
20% higher than blood group O
Where do cystine stones precipitate?
Acidic urine (6.5)
How can cystine stones be identified?
Ultrasonographically
No. 10 blade
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
No. 11 blade
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
No. 15 blade
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
Schwart’s test
Impulse felt over saphena varix when vein tapped from below
Cold abscess
TB
What is the cellular action of p53
Prevents cell entering the S phase
Renal blood flow to the cortex
Much higher than to the medulla
At what part of the nephron is the fluid hypotonic?
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
Where does the oesophagus classically tear in Boerhaave’s?
At its weakest point, the lower third
Use of Kaplan Meier graphs with log-rank test
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
Warfarin induced skin necrosis caused by?
Deficiency of protein C
Choice of prosthesis in hemi-arthroplasty of the hip
No benefit of bipolar Hastings arthroplasty of Austin-More unipolar arthroplasty
Repair on intertrochanteric fractures with reverse obliquity
Will need IM nailing as a DHS will fail because most of the weight will be transmitted through the DHS pin
Risk of gastric cancer in pernicious anaemia
3 fold
Most common organic cause of impotence
Diabetes
MOSF in pancreatitis
Multiple organ system failure scale is a dynamic pathophysiological scoring system used in acute pancreatitis which can be used daily to monitor disease progression
Feeding in pancreatitis
Best practice is via the enteral root via a feeding tube placed past the pancreatic duct into the third part of the duodenum
Other areas affected by mesothelioma
Can rarely affect periosteum, pericardium and tunica vaginalis
Alpha-fetoprotein
=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
Which type of melanoma occurs in a Hutchinson’s melanotic freckle
Lentigo maligna melona occurs within or is preceded by a Huthcinson’s melanotic freckle and has a pronounced horizontal growth phase
Complications of sclerotherapy for varicosities
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
Which trace element is required for RNA and DNA synthesis?
Zinc
Course of the uterine artery
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.
Erythropoietin
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.
Operative treatment of perforated duodenal ulcer
Defect is closed over with an omental patch, which is attached to its blood supply rather than being a free flap
Which tendon may be damaged following Colles’s fracture
Delayed rupture of the EPL tendon is a recognised complication due to attrition at the radial tubercle
Annular pancreas
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
What conditions are associated with annular pancreas?
Down’s
Pancreatitis
Pancreatic cancer
Gallstones and renal transplant
Relative contraindication for renal transplant.
Requires cholecystectomy before transplant
Three top causes of end-stage liver disease leading to transplantation in the UK
Alcohol
Hep C
PBC
What score can be used to prioritise liver transplants
MELD score
Serum bilirubin, Creat, INR
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
Fibromuscular dysplasia
Non-specific symptoms e.g. fever, malaise, anorexia etc.
CNS symptoms: transient monocular blindness and cerebral arteritis
PNS symptoms
Male 45-65
?PAN
Causes of secondary Raynaud’s
BAD CaT
Blood disorders
Arterial
Drugs
CTD
Trauma
Action of FSH in men
Helps to maintain sertoli cells
Stimulates the synthesis of androgen binding protein
What is the most common site of teratoma in newborn infant
Sacrococcygeal area
Where are the facial muscles found
They are all subcutaneous and in the same plane as platysma.
They originate on bone and insert onto the skin of the face.
In what part of the brain is pain perceived?
The thalamus
What part of the brain receives pain stimulation?
Postcentral gyrus
Which of the following increases CO?
Acidosis
Histamine
LT acclimatisation at altitude
Rapid arrhythmias
Standing from lyring
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
Feeding post Ivor-Lewis oesphagectomy
Feeding jejunostomy
Most formed at operation and used until a gastrograffin swallow demonstrates an intact anastomosis
Patient requiring enteral tube feeding for >1month
Should have a more permanent form of feeding tube inserted i.e. PEG feed.
PEG formation
Push or pull technique
Push technique of PEG insertion
Feeding tube pushed through the abdominal wall over a wire into the gut using fluoroscopic guidance.
Usually loop catheters or balloon catheters are placed
Pull technique of PEG insertion
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
Bowel length at risk of small gut syndrome
<200cm
What is the transmission rate for HIV following needlestick?
0.36%
Thoracic level of the xiphisternum
T9
Into what part of the greater trochanter do the gluteus medius and minimus insert?
Lateral part
Into what part of the greater trochanter do the external rotators of the hip insert?
Medial, superior and posterior surfaces of the greater torchanter
What is the most common causative organism of post-splenectomy sepsis
Strep pneumoniae
Batson’s plexus
Vertebral venous plexus of the spine
Which neve supplies the trachea
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
What is a late clinical sign of maxillary sinus carcinoma?
Visual disturbance
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
Ethmoid/maxillary sinus cancer (90% of sinus cancers affect these with only 10% affecting the frontal and sphenoidal)
Tumour markers in teratomas
Produce aFP in about 70%
bHCG in 60%
Secrete either in about 90%
What proportion of seminomas secrete bHCG?
<10% and very rarely do they secrete AFP
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
L4/L5 affects L5 nerve root, L5/S1 affects S1
Toe extension is mainly mediated by L5 nerve root
Long standing eczematous rash
Glossitis
Stomatitis
Diabetes
Wasting
Glucagonoma
What is combined to generate T3 and T4 in the thyroid?
Mono-iodotyrosine and di-iodotyrosine.
How does phosphate reabsorption in the PCT occur
Occurs via a carrier co-transport of phosphate and sodium
It is under the control of PTH
The superior cerebral veins drain into
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
What drains into the great cerebral veins?
Internal cerebral veins
What drains into the cavernous sinus
The superior and inferior ophthalmic veins
Sphenoparietal sinus
Superficial middle cerebral veins
all drain into the cavernous sinus
What does the inferior petrosal sinus drain
It drains the cavernous sinus, meeting the sigmoid sinus at the level of the jugular foramen to form the jugular vein
Superior petrosal sinus
Connects the cavernous sinus to the transverse sinus
EF=
Ratio of stroke volume to EDV
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)
Sialosis
How many lobes and bronchopulmonary segments in the right lung?
3 lobes comprising 10 bronchopulmonary segments
How many lobes and bronchopulmonary segments in the left lung?
2 lobes, 8 bronchopulmonary segments
How does CSF drain to the subarachnoid space from the ventricles?
Via the foramina of Megendie (medial) and Lushka (lateral) in the roof of the fourth ventricle
Foramen of Monro
Connects the two lateral ventricles to the thid ventricle
Cisterna magna
Largest of the 3 main openings in the subarachnoid space, located between the cerebellum and the dorsal surface of the medulla oblongata.
Shoulder weakness
Drop arm sign
Characteristic hunching of the affected shoulder
Inability to lift arm
Rotator cuff tear
Shoulder pain in all planes of movement except external rotation
?Calcific tendonitis
The lack of restriction in external rotation differentiates this condition from frozen shoulder
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
Ewing’s sarcoma
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).
Osteosarcoma
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
Osteoclastoma (Giant cell tumour)
Type 1 odontoid fractures
Involve the tip of the odontoid peg
Type 2 odontoid fractures
Are through the base of the dens, involving the junction of the odontoid peg with body
Type III odontoid fractures
At the base of the dens and extend obliquely into the body of the axis
Where does the common femoral artery divide?
3cm distal to the inguinal ligament
Order from superficial to deep of popliteal neurovascular structures
NVA (artery deepest)
What are the dynamic stabilisers of the patella?
Quadriceps muscles anteriorly
Hamstring muscles posteriorly
Gastrocnemius medially and laterally
When does the heart begin to beat
Fourth week
In which state is iron more readily absorbed from the GIT?
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
Action of endotoxins in septic shock
Act as a negative inotrope and can initiate both ARDS and DIC
Trauma
Bradycardia
Warm peripheries
No response to fluid resuscitation
Neurogenic shock
What is the most frequently affected dynamic stabiliser in pes planus?
Tibialis posterior tendon and it is the most powerful inverter of the foot
Painless lumpy jaw
Wooden lesion
Sulphur granules form a central purulence surrounded by neutrophils
Actinomycosis israelii
Relative risk of undescended testes
Testicular cancer is 8x higher
Reduced fertility is also a long-term complication
Classification of undescended testes?
Retractile
Ectopic
Incomplete descent: inta-abdominal, intra-inguinal, pre scrotal
Atrophic
Acquired (testes that have ascended)
Painless penile ulcer
Unprotected sex 1/12 previously
Hard raised hyperaemic edge
Inguinal lymphadenopathy
Chancrous ulcer (Syphillis)
What are the ligaments supporting the medial longitudinal arch of the foot?
Long planatar ligament
Short plantar ligament (plantar calcaneocuboid ligament)
Spring ligament (plantar calcaneonavicular)
Interosseous ligament
Deltoid
Plantar aponeurosis
Who sends information concerning cause of death to the office of population consensus and surery?
Registrar of births and deaths
On what day post-op is myocardial ischaemia most likely to occur?
Day 3
Location of the olfactory foramina
Located in the anterior cranial fossa, within the cribiform plate which is part of the ethomboid bone.
Deafness dizziness and tinnnitus
Meniere’s disease
All patients presenting with vertigo should have
Imaging to exclude acoustic neuroma
Be tested for syphillis as neurosyphillis may present this way
From where is cholecystokinin released?
I cells of the duodenum in response to pancreatic chyme entering the small bowel.
Indications for surgery in crohn’s?
Recurrent intestinal obstruction
Intestinal fistulae
Fulminant colitis
Malignant change
Peri-anal disease
Nitrogen and calorie requirement in severe injury or severe sepsis?
N2 requirement: 0.3-035g /Kg/day
35-40kcal/kg/day
How to differentiate clinically between epididymal cyst and hydrcocele
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
What is the most frequently observed activated oncogene in colorectal adenomas and carcinomas?
K-RAS
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
Fracture at the level of the mid-humerus
Radial nerve injury, what level
Inability to extend MCP joints with weakness of thumb abduction and interphalangeal extension
Compression at the level of the elbow (damage to posterior interosseous nerve)
What are the two main types of SCC?
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
Contents of Hunter’s canal
Adductor canal
Femoral artery and vein
Saphenous nerve
Nerve to vastus medialis
Why do transplants for burnt skin tend not to undergo rejection
As burnt tissue is relatively immunosuppressed
Why is the rate of rejection lower in liver transplants?
As liver cells are thought to express less class I MHC so HLA matching is less important
Why is the cornea relatively protected from rejection?
It is relatively avascular
Painless jaundice
Raised bilirubin AST, ALP and GGT
Macrocytosis
?ALD
What is the gold standard to investigate wound healing potential
Transcutaneous oxygen pressures
Why is serum magnesium not a good indicator of total body magnesium?
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
What is the best imaging technique to visualise the anatomy of the diaphragm?
MRI
What type of bronchoscopy is preferred for the removal of aspirated foreign bodies
Rigid bronchoscopy as it offers better protection of the airway and control of the foreign body as it is being recovered
Left-sided chest and abdominal pain 7 days post-spleenctomy
Febrile
Decreased air entry at left lung base
Dullness to percussion and LUQ tenderness
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
What is the most common site of actinomycosal infection?
Cervicofacial
Most common cause of primary adrenal insufficiency?
Autoimmune disease leading to adrenal atrophy
Major Duke criteria
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
HACEK group
Haemophilus
Aggregatibacter
Cardiobacterium
Eikenella
Kingella
Dukes minor criteria
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
Lundh meal
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
Small round blue cell tumour of bone
Ewing’s sarcoma
From which nerve roots do the pelvic splanchnic nerves arise?
S2-S4
How is the parotid gland separated from the carotid sheath?
By the styloid process and associated muscles (stylopharyngeus, stylohyoid, styloglossus)
Lesion to Broca’s area
Expressive dysphasia
Lesion to Wernicke’s area
Receptive dysphasia
Treatment of intratubular germ cell neoplasia of the testes
Inevitably develop into cancer, therefore should be treated prophylactically with radiotherapy
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
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
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
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.
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
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.
What vessel is the origin of the middle rectal artery?
Aorta
Inferior mesenteric artery
Superior mesenteric artery
Internal iliac artery
Internal pudendal artery
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
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
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.
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
Persist refilling cysts may be associated with a well differentiated tumour and should be removed by lobectomy.
Treatment of Grave’s disease with significant eye signs?
Total thyroidectomy
Treatment of Papillary thyroid cancer
Total thyroidectomy and central compartment nodal dissection (extended lymphadenectomy as required)
Treatment of follicular thyroid cancer
Total thyroidectomy (usually completion as already had hemithyroidectomy)
What is the origin of the superior gluteal artery?
Internal iliac artery
External iliac artery
Femoral artery
Common iliac artery
Circumflex femoral artery
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
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
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.
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
In young children, laparotomy is performed via transverse supra umbilical incision. Access via midline incisions is very poor and they should not be used.
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
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.
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
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.
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
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).
What is the arterial blood supply to the lacrimal apparatus?
Nasociliary artery
Supra orbital artery
Internal carotid artery
Ophthalmic artery
Supra trochlear artery
The ophthalmic artery supplies the gland
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
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.
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
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.
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
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
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
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.
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
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.
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
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.
White leg with sensorimotor deficit
Surgery and embolectomy
Dusky leg, mild anaesthesia
Angiography
Fixed mottling of leg
Primary amputation
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
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.
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
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.
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
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.
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
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!
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
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.
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
Cullens sign is seen with significant intra peritoneal haemorrhage.
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
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.
What are the four parasympathetic ganglia of the head and neck?
Ciliary
Submandibular
Pterygopalatine
Otic
Ciliary ganglion
Parasympathetic ganglion located behind the eye in the posterior orbit.
It is involved in the reuglation of pupil dilation/constriction
Otic ganglion
Located immediately behind the foramen ovale in the infratemporal fossa. It is functionally associated with glossopharyngeal nerve and innervates the parotid for salivation
Ptyergopalatine galngion
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
Submandibular ganglion
Involved in regulation of submandibulargland secretion (facial nerve)
Recommended local anaesthetic agent for open inguinal hernia region block
50:50 mixture of lignocaine and bupivacaine with the addition of 1:200000 adrenaline.
Mx of subacromial impingement
PT, oral anti-inflammatory medication
Subacromial steroid injection
Arthroscopic subacromial decompression by shaving away the undersurface of the acromion
Management of rotator cuff tear
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.
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.
Calcific tendonitis
Stages of calcification in calcific tendonitits
Formative phase characterized by calcific deposits
Resting phase deposit is stable, but presents with impingement problems
Resorptive phase phagocytic resorption. Most painful stage.
Treatment of calcific tendonitis
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.
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:
Frozen shoulder
Stages of frozen shoulder
Stage one the freezing and painful stage
Stage two the frozen and stiff stage
Stage three the thawing stage, where shoulder movement slowly improves
Treatment of frozen shoulder
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.
Treatment of glenohumeral arthritis
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.
Contents of the adductor cannal
Superficial femoral artery
Femoral vein
Saphenous nerve
Nerve to vastus medialis
Extent of the adductor canal
15cm long
Vastus medialis laterally
Adductor longus and magnus posteriorly
Begins where sartroius crosses over adductor longus and ends at the adductor hiatus
Which structure runs under brachioradialis, emerging distally on its medial side and enters the palm by piercing the first dorsal interosseous muscle?
Radial artery.
Crosses the floor of the anatomical snuffbox to enter the palm between the two heads of the first dorsal interosseous
Features of BrachioRadialis
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
Outline the knee jerk deep tendon reflex
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
How is glucose transported across the placental barrier?
Facilitated diffusion
Which of the following is a tributary of the IJV
EJV
Inferior thyroid vein
Middle thyroid vein
Retomandibular vein
Transverse cervical vein.
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
Why is blood volume maintained at normal levels in patients with DI?
Water intake is appropriately adjusted
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.
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.
What is the most acceptable way to manage MRSA in a hospital setting?
Eradication by Abx therapy is recommended for all known carriers.
What are the histological featurse of ARDS?
Increased capillary permeability
Interstitial and alveolar oedema
Fibrin exudation
Hyaline membrane fromation
and later
Diffuse late interstitial alveolar fibrosis
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
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.
Which of the following would suggest class II shock?
Decreased pulse pressure
Decreased BP
UO 5-15ml/h
PR >120
Confusion
Decreased pulse pressure
PR in Class II shock is 100-120
BP is maintained
UO is maintained at 20-30ml/h
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
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
What is the risk of post-operative reinfarcation 6/52 post MI?
31-40%
Malrotation
Less than 50cm of viable bowel
Action?
Untwist the bowel
Return to the abdomen
Relook laparotomy
What is the optimum choice of skin prep?
Iodine
From what nerve roots do the pelvic splanchnic nerves arise?
S2-S4
Where is TBG produced?
Liver
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
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.
Vinyl chloride exposure is associated with?
Angiosarcoma of the liver
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
Intracapsular NOF are most likely to heal slowly and develop non-union
This is due to the deficient proximal blood supply.
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
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
What force should be applied the proximal fragment of a long spiral fracture of the femur?
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.
What is the mechanism of inheritance in vWD?
Autosomal dominant
Which of the following is a known risk factor for oral cancer?
EBV
Crohn’s
Female sex
Lichen planus
Pernicious anaemia
Lichen planus.
EBV has been implicated but there is no clear evidence to establish a causal link
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
Central cord syndrome.
Most common incomplete spinal lesion. Motor signs affect the upper more than the lower limbs and sensory changes are variable
How to calculate the Well’s score?
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
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
Women >50 years are most affected by follicular carcinoma
What investigation regularly done post-heart transplant will be most sensitive for diagnosing rejection?
Biopsy of heart tisusues is the only current conclusive method and occurs regularly as part of routine f/u
What is the danger zone of the face for infections causing cavernous sinus thrombosis?
Upper lip
Nose
Medial part of cheek
What is another surgical condition potentially affecting the cavernous sinus?
Aneurysm of the ICA resulting in a caroticocavernous fistula presenting clinically as a pulsating proptosis
Pulsating propotosis
?Caroticocavernous fistula
Commonest site for Berry aneurysm?
ACA
Crista galli
Sharp triangular protrusion of the cribiform plate that forms an attachment for the falx cerebri
What is the location of Killian’s dehiscence?
Thyropharyngeus and cricopharyngeus
What is an essential part of pharyngeal pouch excision to prevent recurrence?
Cricopharyngeal myotomy
Mechanism of upper brachial plexus injury
Excessive lateral flexion of the neck (downward traction of the arm) away from the pectoral girdle
Mechanism of lower brachial plexus injury
Forced traction injury on an abducted arm (upward traction)
Location of the AVN
On the right atrium on the interarterial septum above the attachment of the septal cusp of the tricuspid valve
At what distance from the incisors is the GOJ?
40cm
What will happen with GOJ on OGD in GORD?
The GOJ will be encountered earlier, indicating tat the oesopghagus has been shortened due to oesophagitis from reflux
Significance of the lymphatic drainge of the oesophagus
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
Which portion of the CBD is compressed early in cancer of the pancreatic head?
Infraduodenal common bile duct
Divisions and extent of the CBD?
8cm long
Supraduodenal
Retroduodenal
Infraduodenal
Intraduodenal
Which structure is vulnerable when dissecting the neck of an infrarenal AAA?
Third part of the duodenum
Paritcularly in danger in an inflammatory aneurysm, where the duodenum is extremely adherent to theneck
What are the two approaches for accessing the pudendal nerve?
Transvaginal or perineal
What nerve root is responsible for the sensation of sitting?
S3
We stand mainly on what dermatome?
S1
Stone impacted at pelvic brim, what structure is causing this?
Common iliac artery bifurcation
Function of the internal urethral sphincter in men
To prevent retrograde ejaciulation by closing off bladder neck during ejaculation
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
Biceps femoris
How does GA contribute to loss of homeostasis?
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
Violent cyanotic shivering in the recovery room post operation
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
What is the differnece in peripheral shutdown caused by hypovolaemia secondary to oesophageal varices and that caused by hypothermia
In hypothermia, it is the temperature regulating centre that initaites peripheral vasconstriction where as in haematemesis it is the BP regulating centre
What is the main factor promoting survival in physiological response to stress
Cortisol mobilisation of glucose for energy
What is the cause of acute confusion following oesopgageal variceal bleed in patient with liver disease?
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)
What is the easiest way to calculate estimated blood volume of a normal patient?
70ml/kg
Estimated blood volume in obese patients?
45-55ml/kg
Estimated blood volume in children?
80-90ml/kg
Hartmann’s in liver failure
May be impaired hepatic lactate metabolism so may be at increased risk of lactic acidosis
What proportion of TBW is plasma volume?
1/4 of the ECF
What proportion of ECF is interstitial fluid?
3/4
What proportion of TBW is ECF?
1/3
What proportion of TBW is ICF?
2/3
Overall mortality from septic shock
50%
Most common cause of anaphylaxis under anaesthesia?
Muscle relaxants
What is the most accurate measure of preload?
Ventricular myocyte length
What factor is most important to the degree of coronary blood flow?
Coronary artery diameter as the Hagen-Poiseuille equation describes the value of resistance being proportional to the fourth power of the radius
What structure receives the greatest proportion of resting blood flow?
Liver/Splanchnic (25%)
Which nerve carries afferent information from the carotid baroreceptors?
Gloosopharyngeal nerve (information from aortic baroreceptors is carried via the vagus)
What are the factors determining the inspired concentration of oxygen?
Relative contribution of oxygen from delivery system (i.e. face mask)
Percentage of entrained air from the room
What is the importance of salivary secretions w.r.t. maintaining adequate oral hygiene
Copious amount of watery output from the parotids which is rich in calcium and phosphate
What reflex mechanism prevents aspiration during swallowing
Reflex elevation of the larynx (centre in the medulla oblongata)
Biochemical abnormalities in TURP syndrome
Hyponatraemia and increased blood ammonia (glycine is metabolised to ammonia by the liver)
Phenomenon typically seen in patients with spinal cord injuries caused by imbalanced sympathetic activation leading to life threatneing hypertension.
?Autonomic dysreflexia
Difference between anaphylactoid and anaphylactic reactions
Anaphylactoid involve direct activation of mast cells and are not immune mediated
Embryology of the thyroid
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
Which structure lies immediately lateral to the brachial artery in the antecubital fossa?
The median cubital vein lies on the subcutaneous tissue overlying hte cubital fossa and is anterior to the brachial artery
Which nerve supplies the anterior part of the nasal septum?
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.
Which of the following structures are contents of the posterior mediastinum?
Thoracic vertebrae
Greater splanchnic nerve
Trachea
Ascending aorta
Arch of azygos
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
Causes of rhabdomyolysis
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
Triad in rhabdomyolysis
Muscle weakness
Myalgia
Dark urine
Which of the following medications is most likely to contribute to gastric ulcers?
Aspirin
Clopidogrel
Omeprazole
Prednisolone
Ibuprofen
Aspirin
Which of the following parts of the genitourinary tract is dervied from mesoderm?
Prostate
Bladder trigone
Body of the bladder
Urachus
Pineal gland
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
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?
Superior oblique muscle as it is involved in medial rotation, depression and abduction
What do both kidneys lie on posteriorly?
Psoas major and quadratus lumborum
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?
The nerual tube closes anteriorly and should occur on day 26
Failure of the neural tube to close dorsally by day 24 is associated with?
Spina bifida
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
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.
MAP=
2x DP + SBP/3
Fat necrosis may be associated with?
Calcifications
Innervation of flexor pollicis brevis?
Superficial head is innervated by the recurrent branch of the median nerve
Deep head is innervated by the deep branch of the ulnar nerve
Where is the highest percentage of thyroid hormone found in the serum?
Bound to TBG
How to reverse atracurium
Neostigmine
At which gestational week of development does the foetal heart start beating?
Week 4
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
Acidity of chyme entering the duodenum
Which nerve supplies cutaneous innervation to the angle of the jaw?
Greater auricular nerve C2,3
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
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.
Which of the following is found in hypersplenism?
Punctate basophilia
Howell-Jolly bodies
Pancytopenia
Heinz bodies
Low fibrinogen
Pancytopenia
What is the main site of phosphate reabsorption in the nephron?
PCT
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
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
Long term steroid use disrupts what aspect of the HPA?
It suppresses ACTH
Russell bodies
Large eosinophilic inclusion containing Igs. They are found in areas of chronic inflammation such as in the peripheral edges of tumours
Malpighian bodies
Another term for the renal corpuscule which consists of the glomerulus and surrounding Bowman’s capsule
Haematoxylin body
Dense, basophilic collection of degraded nuclear material which is found in SLE
Division of the radial nerve
Just proximal to the elbow, the radial nerve divides into a superficial and deep branch.
The superficial branch is purely sensory.
Dorsal column supply to the lower limb is via?
Fasciculus gracilis
Dorsal column supply to the upper limb is via
Fasciculus cuneatus
Henoch-Schonlein purpura results from?
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
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
GS notch is narrow and almost 70 degrees
The subpubic angle is acute in males
What structure is prone to injury when mobilising the splenic flexure of the colon?
The splenic artery which runs in lieonorenal ligament and can be injured via excess traction intra-operatively
Nerve roots of the Achilles reflex?
S1/2
Site of action of frusemide?
Ascending limb of the loop of Henle
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
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.
Most likely injury following stretch or severe crush injury?
Axonotmesis
Neurotmesis requires high energy injury normally
NICE guidelines for treatment with HER2-positive early invasive breast cancer
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.
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
Anterior 1/3 of interventricular septum.
(LAD suipplies other 2/3rds)
What is the earliest manifestation of Cushing’s?
Loss of diurnal variation
What is the granuloma type found in sarcoidosis?
Epitheloid granulomas
Histiocytic granulomas seen in?
Foreign body or rheumatoid
Ability to grip a sheet of paper or make an OK sign relies on?
Action of FDP, FPL.
Both innervated by anterior interosseus branch of median nerve (along with pronator teres)
From which embryological structure do the superior parathyroid glands develop?
Dorsal wings of the fourth branchial arch
Which of the following muscles is supplied by the vagus nerve?
Tensor veli palatini
Levator veli palatini
Mylohyoid
Stylohyoid
Stylopharyngeus
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
Nervous supply of the first pharyngeal arch
Trigeminal nerve
Nerve supply of the second pharyngeal arch
Muscles of facial expression therefore- Facial
Nerve supply of the third pharyngeal arch
Glossopharyngeal nerve
Nerve supply of 4th-6th pharyngeal arches
Vagus
4th supplied by the superior larngeal
6th by recurrent laryngeal
What structure is most likely to be damaged in a stab wound to the left fifth ICS?
Left ventricle
Which of the following structures passes through the supraspacular foramen?
Suprascapular artery
Suprascapular nerve
Dorsal scapular nerve
Dorsal scapular artery
Suprascapular artery and nerve
Suprascapular nerve
Suprascapular artery passes above the foramen, superior to the transverse scapular ligament
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
Entero-enteric fistulae
RV in healthy 25y/o?
1200mL
Which Th produces IL-4, 5, 6, 9, 10?
Th2
Which Th prduces TNF beta, IFN gamma and IL-2?
Th1
From what is the arch of the aorta derived?
Fourth left aortic arch gives rise to the aortic arch from the LCCA to the left subclavian arteries
Incisura angularis marks
Junction between the body and fundus of the stomach
Which of the following factors does not contribute to prolonged neuromuscular blockade?
Hyperthermia
Alkalosis
Hyperkalaemia
Concurrent use of suxamtheonium chloride
Inhalational anaesthetics
Hyperthermia
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
Factor 10 deficiency
Location of SAN
Located anterolaterally, just deep to the epicardium at the junction of the SVC and right atrium, near the superior end of the sulcus terminalis
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.
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
Interobserver bias
Type of observer bias where different observers measure the same quantity differently
Intraobserver bias
Type of observer bias where the same observer measures a quantity differently
