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
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
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
Batson’s plexus
Vertebral venous plexus of the spine
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 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
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.
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
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.
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 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!
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
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
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 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 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
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
