Block 4

Question 1

What are some causes of oculogyric crisis?

Answer 1

Phenothiazines

Haloperidol

Metoclopramide

Postencephalitic Parkinson’s disease

Question 2

Half life of tamoxifen

Answer 2

7 days

Question 3

Action of tamoxifen

Answer 3

Synthetic partial oestrogen agonist

Question 4

What are the most common side effects of tamoxifen?

Answer 4

Climateric side effects, 3% stop taking the drug because of these

Question 5

How do aromatase inhibitors work in breast cancer?

Answer 5

Aromatase inhibitors are an alternative class of drugs, these work by blocking the peripheral aromatization of androgens (post menopausal women produce oestrogens in this way). They may treat cancers for which tamoxifen is no longer effective.

Question 6

Theme: Thyroid nodules

A.Toxic adenoma

B.Anaplastic carcinoma of thyroid

C.Follicular carcinoma of thyroid

D.Papillary carcinoma of thyroid

E.Medullary carcinoma of thyroid

F.Thyroid lymphoma

G.Multinodular goitre

H.Parathyroid gland tumour

For each scenario please select the most likely underlying diagnosis. Each option may be used once, more than once or not at all.

A 52 year old woman with known Hashimotos thyroiditis presents with a neck swelling. She describes it as rapidly increasing in size over 3 months and she complains of dysphagia to solids. On examination there is an asymmetrical swelling of the thyroid gland.
A 52 year old woman presents with a neck swelling. On examination she is noted to have single nodule on the thyroid gland. A CXR shows two mass lesions.

A 52 year old woman presents with a neck swelling. Her GP reports that her TSH value is low at 0.01. A scintigraphy demonstrates a hot nodule.

Answer 6

Thyroid lymphoma

Thyroid lymphoma (Non Hodgkin’s B cell lymphoma) is rare. It should be considered in patients with a background of Hashimoto’s thyroiditis and a rapid growth in size of the thyroid gland. Diagnosis can be made with core needle biopsy; however an incisional biopsy may be needed. Radiotherapy is the main treatment option.

Follicular carcinoma of thyroid

A solitary nodule with signs of haematogenous spread indicates a follicular tumour. Note that papillary tumours tend to be multinodular and spread via the lymphatic system. Lymphatic spread from a papillary thyroid cancer is nearly always to neck nodes in the first instance and mediastinal lymphadenopathy is vanishingly rare. Lung lesions are typically synonymous with haematogenous metastasis of which a follicular lesion is the most likely culprit.

Toxic adenoma

This lady has thyrotoxicosis (low TSH) and a hot solitary nodule indicating a toxic adenoma. Thyroid cancer rarely causes thyrotoxicosis or hot nodules.

Question 7

Lung lesion in ?thyroid malignancy

Answer 7

Follicular carcinoma- typically synonymous with haematogenous metastasis

Question 8

Theme: Tumour markers

A.Invasive ductal carcinoma of the breast

B.Prostate cancer

C.Gastric cancer

D.Ovarian cancer

E.Colorectal cancer

F.Pancreatic adenocarcinoma

G.Seminoma testicular cancer

H.Non-seminomatous testicular cancer

I.Hepatocellular carcinoma

For each tumour marker please select the most likely underlying malignancy. Each option may be used once, more than once or not at all.

50.Raised beta-human chorionic gonadotropin with a raised alpha-feto protein level

Elevated CA 19-9

Raised alpha-feto protein level in a 54-year-old woman

Answer 8

Non-seminomatous testicular cancer

A raised alpha-feto protein level excludes a seminoma

Pancreatic adenocarcinoma

Hepatocellular carcinoma

Question 9

Which of the following structures lies deepest in the popliteal fossa?

Popliteal artery

Popliteal vein

Tibial nerve

Common peroneal nerve

Popliteal lymph nodes

Answer 9

From superficial to deep:
The common peroneal nerve exits the popliteal fossa along the medial border of the biceps tendon. Then the tibial nerve lies lateral to the popliteal vessels to pass posteriorly and then medially to them. The popliteal vein lies superficial to the popliteal artery, which is the deepest structure in the fossa.

Question 10

Theme: Management of oesophageal cancer

A.Endo lumenal brachytherapy

B.Chemo-radiotherapy

C.Radiotherapy alone

D.Insertion of expanding metallic stent

E.Ivor-Lewis oesophagectomy

F.Total oesophagectomy

G.Segmental resection of mid oesophagus

H.Endoscopic mucosal resection

Please select the most appropriate intervention for the following patients with oesophageal cancer. Each option may be used once, more than once or not at all.

57.A 58 year old man with long standing Barretts oesophagus is found to have a nodule on endoscopic surveillence. Biopsies and endoscopic USS suggest this is at most a 1cm foci of T1 disease in the distal oesophagus 4 cm proximal to the oesophagogastric junction.

An 82 year old man presents with dysphagia and on investigation is found to have a stenosing tumour of the mid oesophagus with a single mestastasis in the right lobe of the liver (segment VI).

A 56 year old man presents with odynophagia and on investigation is found to have a squamous cell carcinoma of the upper third of the oesophagus. Staging investigations are negative for metastatic disease.

Answer 10

The correct answer is Endoscopic mucosal resection

EMR is an reasonable option for small areas of malignancy occurring on a background of Barretts change. Segmental resections of the oesophagus are not practised and the only resectional strategy in this scenario would be an Ivor- Lewis type resection. The morbidity such a strategy in T1 disease is probably not justified.

Insertion of expanding metallic stent

Distant disease in patients with oesophageal cancer is a contra indication to a resectional strategy and downstaging with chemotherapy is not routinely undertaken in this age group as the results are poor. An expanding stent will provide rapid and durable palliation.

The correct answer is Chemo-radiotherapy

SCC of the oesophagus is treated with chemo-radiotherapy in the first instance.

Question 11

Surgical options for oesophageal cancer

Answer 11

Endoscopic mucosal resection

Transhiatal oesophagectomy

Ivor Lewis oesophagectomy

McKeown oesophagectomy

Question 12

Treatment for early localised adenocarcinoma of the distal oesophagus. Survival mirrors that of surgical resection for Tis and T1 disease

Answer 12

Endoscopic mucosal resection

Question 13

Most commonly used for junctional (type II) (1) tumours where limited thoracic oesophageal resection is required. Less morbidity than two field oesophagectomy

Answer 13

Transhiatal oeosphagectomy

Question 14

Two stage approach for middle and distal tumours. Very commonly performed, intrathoracic anastomosis will result in mediastinitis in event of anastomotic leak. Lower incidence of recurrent laryngeal nerve injury

Answer 14

Ivor Lewis oesophagectomy

Question 15

Three field approach, may be useful for proximal tumours. Anastomotic leakage is less serious. Higher incidence of recurrent laryngeal nerve injury

Answer 15

McKeown oesophagectomy

Question 16

Adjuvant therapy in oesophageal cancer

Answer 16

Neoadjuvent radiotherapy alone prior to resection confers little benefit and is not routinely performed (2)

Preoperative chemotherapy is associated with a survival advantage (OE02 trial)

Peri operative (pre and post operative) chemotherapy confers a survival advantage in junctional tumours

Post operative chemotherapy is not generally recommended following oesophageal resections outside clinical trials

Question 17

Palliative strategies in oesophageal carcinoma

Answer 17

Combination chemotherapy improves quality of life and survival in non operable disease (3)

Trastuzumab may improve survival in patients with HER 2 positive tumours

Oesophageal intubation with self expanding metal stents is the treatment of choice in patients with occluding tumours >2cm from the cricopharyngeus

Covered metal stents are useful in cases of malignant fistulas

Laser therapy and argon plasma coagulation may be useful as therapies for tumour overgrowth and bleeding

Photodynamic therapy and ethanol injections confer little benefit and should not be routinely used

Question 18

A 6 year old boy pulls over a kettle and suffers superficial partial thickness burns to his legs. Which of the following will not occur?

Preservation of hair follicles

Formation of vesicles or bullae

Damage to sweat glands

Healing by re-epithelialisation

Pain at the burn site

Answer 18

Partial thickness burns are divided into superficial and deep burns, however, this is often not possible on initial assessment and it may be a week or more before the distinction is clear cut. Dermal appendages are, by definition, intact. Superficial partial thickness burns will typically heal by re-epithelialisation, deeper burns will heal with scarring.

Question 19

What is the approximate volume of pancreatic secretions in a 24 hour period?

100ml

200ml

500ml

1500ml

3000ml

Answer 19

Typically the pancreas secretes between 1000 and 1500ml per day.

Question 20

Causes of massive splenomegaly

Answer 20

Myelofibrosis

Chronic myeloid leukaemia

Visceral leishmaniasis (kala-azar)

Malaria

Gaucher’s syndrome

Question 21

Other causes of splenomegaly

Answer 21

Portal hypertension e.g. secondary to cirrhosis

Lymphoproliferative disease e.g. CLL, Hodgkin’s

Haemolytic anaemia

Infection: hepatitis, glandular fever

Infective endocarditis

Sickle-cell*, thalassaemia

Rheumatoid arthritis (Felty’s syndrome)

Question 22

Which of the positions listed below best describes the location of the coeliac autonomic plexus?

Anterolateral to the aorta

Posterolateral to the aorta

Anterolateral to the sympathetic chain

Anteromedial to the sympathetic chain

Posterior to L1

Answer 22

Anterolateral to the aorta

The coeliac plexus is the largest of the autonomic plexuses. It is located on a level of the last thoracic and first lumbar vertebrae. It surrounds the coeliac axis and the SMA. It lies posterior to the stomach and the lesser sac. It lies anterior to the crura of the diaphragm and the aorta. The plexus and ganglia are joined by the greater and lesser splanchnic nerves on both sides and branches from both the vagus and phrenic nerves.

Question 23

Rule of 2s in Meckel’s diverticulum

Answer 23

2% of population

2 inches in length

2 feet from ileocaecal valve

2x more common in men

2 tissue types involved

Question 24

Arterial supply of Meckel’s diverticulum

Answer 24

Omphalomesenteric artery

Question 25

Pathology of prostate cancer

Answer 25

95% adenocarcinoma In situ malignancy is sometimes found in areas adjacent to cancer. Multiple biopsies needed to call true in situ disease. Often multifocal- 70% lie in the peripheral zone. Graded using the Gleason grading system, two grades awarded 1 for most dominant grade (on scale of 1-5) and 2 for second most dominant grade (scale 1-5). The two added together give the Gleason score. Where 2 is best prognosis and 10 the worst. Lymphatic spread occurs first to the obturator nodes and local extra prostatic spread to the seminal vesicles is associated with distant disease.

Question 26

Treatment options for prostate cancer

Answer 26

Watch and wait RTx Surgery Hormonal therapy

Question 27

Indications for active surveillance in prostate cancer

Answer 27

In the UK the National Institute for Clinical Excellence (NICE) suggests that active surveillance is the preferred option for low risk men. It is particularly suitable for men with clinical stage T1c, Gleason score 3+3 and PSA density \< 0.15 ng/ml/ml who have cancer in less than 50% of their biopsy cores, with \< 10 mm of any core involved. Candidates for active surveillance should: have had at least 10 biopsy cores taken have at least one re-biopsy. If men on active surveillance show evidence of disease progression, offer radical treatment. Treatment decisions should be made with the man, taking into account co-morbidities and life expectancy.

Question 28

Radiotherapy options in prostate cancer

Answer 28

Radiotherapy (External)- Both potentially curative and palliative therapy possible. However, radiation proctitis and rectal malignancy are late problems. Brachytherapy is a modification allowing internal radiotherapy.

Question 29

Surgical options for prostate cancer

Answer 29

Radical prostatectomy. Surgical removal of the prostate is the standard treatment for localised disease. The robot is being used increasingly for this procedure. As well as the prostate the obturator nodes are also removed to complement the staging process. Erectile dysfunction is a common side effect. Survival may be better than with radiotherapy (see references).

Question 30

An intravenous drug user develops a false aneurysm and requires emergency surgery. The procedure is difficult and the femoral nerve is inadvertently transected. Which of the following muscles is least likely to be affected as a result? Sartorius Vastus medialis Pectineus Quadriceps femoris Adductor magnus

Answer 30

Adductor magnus is innervated by the obturator and sciatic nerve. The pectineus muscle is sometimes supplied by the obturator nerve but this is variable. Since the question states least likely, the correct answer is adductor magnus

Question 31

What is the nerve root value of the external urethral sphincter? S4 S1, S2, S3 S2, S3, S4 L3, L4, L5 L5, S1, S2

Answer 31

The external urethral sphincter is innervated by branches of the pudendal nerve, therefore the root values are S2, S3, S4.

Question 32

Theme: Management of occlusive vascular disease A.Aorto-bifemoral bypass graft B.Femoro-femoral cross over graft C.Femoro-popliteal bypass graft D.Femoro-distal bypass graft E.Axillo-bifemoral bypass graft F.Bilateral above knee amputation Please select the most appropriate arterial bypass method for the scenario described. Each option may be used once, more than once or not at all. 72.An 83 year old lady with a significant cardiac history is admitted with rest pain and bilateral leg ulcers. Imaging demonstrates bilateral occlusion of both common iliac arteries that are unsuitable for stenting. A 54 year old man presents to the vascular clinic with severe rest pain and an ulcer on his right foot that is not healing. On examination he has bilateral absent femoral pulses. Imaging demonstrates a bilateral occlusion of the common iliac arteries that is not suitable for stenting. A 78 year old man presents with left sided rest pain in his leg and a non healing arterial leg ulcer on the same leg. Imaging shows normal right leg vessels, on the left side there is a long occlusion of the external iliac artery that is unsuitable for stenting. He has a significant cardiac history.

Answer 32

Axillo-bifemoral bypass graft Theme from January 2012 Exam In patients with major cardiac co-morbidities the safest option is to choose an axillo-bifemoral bypass graft. The long term patency rates are less good than with aorto-bifemoral bypass grafts, however, the operation is less major. Aorto-bifemoral bypass graft In a young patient consideration should be given to aorto-bifemoral bypass grafts as these have the best long term functional outcome compared with an axillo-bifemoral bypass graft. Femoro-femoral cross over graft Femoro-femoral cross over grafts are an option for treatment of iliac occlusions in patients with significant co-morbidities and healthy contralateral vessels. In reality the idealised situation presented here seldom applies and the opposite vessels usually have some disease and one must be careful not to damage the "healthy" side.

Question 33

Factors that must be present for angioplasty to be sucessful

Answer 33

In order for angioplasty to be undertaken successfully the artery has to be accessible. The lesion relatively short and reasonable distal vessel runoff. Longer lesions may be amenable to sub-intimal angioplasty.

Question 34

Superficial femoral artery occlusion to the above knee popliteal

Answer 34

In the ideal scenario, vein (either in situ or reversed LSV) would the used as a conduit. However, prosthetic material has reasonable 5 year patency rates and some would advocate using this in preference to vein so that vein can be used for other procedures in the future. In general terms either technique is usually associated with an excellent outcome (if run off satisfactory).

Question 35

Rules in bypass surgery

Answer 35

Vein mapping 1st to see whether there is suitable vein (the preferred conduit). Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure. Essential operative procedure as for above knee fem-pop. If there is insufficient vein for the entire conduit then vein can be attached to the end of the PTFE graft and then used for the distal anastomosis. This type of 'vein boot' is technically referred to as a Miller Cuff and is associated with better patency rates than PTFE alone. Remember the more distal the arterial anastomosis the lower the success rate.

Question 36

Key concepts in bypasses for distal vascular disease

Answer 36

Femoro-distal bypass surgery takes longer to perform, is more technically challenging and has higher failure rates. In elderly diabetic patients with poor runoff a primary amputation may well be a safer and more effective option. There is no point in embarking on this type of surgery in patients who are wheelchair bound. In femorodistal bypasses vein gives superior outcomes to PTFE.

Question 37

Theme: Surgical drains A.Redivac suction drain B.Corrugated drain C.Wallace Robinson drain (non suction) D.Penrose tubing E.Latex T Tube drain F.Silastic T Tube drain G.No drain Please select the most appropriate surgical drainage system for the indication given. Each option may be used once, more than once or not at all. 75.A 56 year old lady undergoes an open cholecystectomy and exploration of common bile duct. The bile duct is closed over a drain. A 48 year old lady undergoes a mastectomy and axillary node clearance for an invasive ductal cancer of the breast with lymph node metastasis. A 75 year old man undergoes a Hartman's procedure for sigmoid diverticular disease with pericolic abscess and colovesical fistula.

Answer 37

Latex T Tube drain This will elicit a fibrotic response and encourage a track to form. Redivac suction drain The raw tissue exposed from the mastectomy site will often ooze serous fluid and may result in seroma formation when the drain is removed. Wallace Robinson drain (non suction) A non suction drain is the preferred option here

Question 38

Suction type of drain Closed drainage system High pressure vacuum system

Answer 38

Redivac

Question 39

Consist of small systems such as the lantern style drain that may be used for short term drainage of small wounds and cavities Larger systems are sometimes used following abdominal surgery, they have a lower pressure than the redivac system, which decreases the risks of fistulation May be emptied and re-pressurised

Answer 39

Low pressure drainage systems

Question 40

May be shaped (e.g. T Tube) or straight Usually used in non pressurised systems and act as sump drains Most often used when it is desirable to generate fibrosis along the drain track (e.g. following exploration of the CBD)

Answer 40

Latex tube drains

Question 41

May be large or small diameter (depending on the indication) Connected to underwater seal system to ensure one way flow of air

Answer 41

Chest drains

Question 42

Thin, wide sheet of plastic, usually soft Contains corrugations, along which fluids can track

Answer 42

Corrugated drain

Question 43

A 34 year old lady has just undergone a parathyroidectomy for primary hyperparathyroidism. The operation is difficult and all 4 glands were explored. The wound was clean and dry at the conclusion of the procedure and a suction drain inserted. On the ward she becomes irritable and develops stridor. On examination, her neck is soft and the drain empty. Which of the following treatments should be tried initially? Administration of intravenous calcium gluconate Administration of intravenous lorazepam Removal of the skin closure on the ward Direct laryngoscopy Administration of calcichew D3 orally

Answer 43

Exploration of the parathyroid glands may result in impairment of the blood supply. Serum PTH levels can fall quickly and features of hypocalcaemia may ensue, these include neuromuscular irritability and laryngospasm. Prompt administration of intravenous calcium gluconate can be lifesaving. The absence of any neck swelling and no blood in the drain would go against a contained haematoma in the neck (which should be managed by removal of skin closure).

Question 44

A 45 year old man is stabbed in the abdomen and the inferior vena cava is injured. How many functional valves does this vessel usually have? 0 1 3 2 4

Answer 44

The lack of valves in the IVC is important clinically when it is cannulated during cardiopulmonary bypass, using separate SVC and IVC catheters, such as when the right atrium is to be opened. Note that there is a non functional valve between the right atrium and inferior vena cava.

Question 45

Mnemonic for the Inferior vena cava tributaries: I Like To Rise So High:

Answer 45

Iliacs Lumbar Testicular Renal Suprarenal Hepatic vein

Question 46

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.

Answer 46

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

Question 47

Brown to black, poorly defined, velvety hyperpigmentation of the skin. Usually found in body folds such as the posterior and lateral folds of the neck, the axilla, groin, umbilicus, forehead, and other areas. The most common cause of acanthosis nigricans is insulin resistance, which leads to increased circulating insulin levels. Insulin spillover into the skin results in its abnormal increase in growth (hyperplasia of the skin). In the context of a malignant disease, acanthosis nigricans is a paraneoplastic syndrome and is then commonly referred to as acanthosis nigricans maligna. Involvement of mucous membranes is rare and suggests a coexisting malignant condition.

Answer 47

Acanthosis nigricans

Question 48

Theme: Surgical access A.Gridiron B.Lanz C.McEvedy D.Midline abdominal E.Rutherford Morrison F.Battle (abdominal) G.Lower midline Please select the most appropriate incision for the procedure required. Each option may be used once, more than once or not at all. 86.A 78 year old lady is admitted with a tender lump in her right groin. It is within the femoral triangle and there is concern that there may be small bowel obstruction developing. A 45 year old woman with end stage renal failure is due to undergo a cadaveric renal transplant. This will be her first transplant. A slim 20 year old lady is suffering from appendicitis and requires an appendicectomy.

Answer 48

McEvedy This is one approach to an obstructed femoral hernia. It is possible to undertake a small bowel resection through this approach. Recourse to laparotomy may be needed if access is difficult. Rutherford Morrison This is the incision of choice for the extraperitoneal approach to the iliac vessels which will be required for a renal transplant. Lanz Either a Lanz or Gridiron incision will give access for appendicectomy. However, in the case described a Lanz incision will give better cosmesis and can be extended should pelvic surgery be required eg for gynaecological disease.

Question 49

Which of the following structures does not pass posteriorly to the medial malleolus? Posterior tibial artery Tibial nerve Tibialis anterior tendon Tendon of flexor digitorum longus Tendon of flexor hallucis longus

Answer 49

Tibialis anterior tendon

Question 50

Mnemonic for structures posterior to the medial malleolus: Tom Dick And Very Nervous Harry

Answer 50

T ibialis posterior tendon flexor Digitorum longus A rtery V ein N erve H allucis longus

Question 51

Which of the following is the most common childhood brain tumour? Glioblastoma multiforme Astrocytoma Medulloblastoma Ependymoma Meningioma

Answer 51

Glioblastoma multiforme is rare in childhood. In contrast, astrocytoma is the commonest brain tumour in children. Medulloblastoma is no longer the commonest CNS tumour in children (Cancer research UK)

Question 52

Which investigation is best for initial assessment of recurrence of follicular carcinoma of the thyroid? Free T4 Thyroid stimulating hormone Scintigraphy Serum thyroglobulin USS thyroid gland

Answer 52

Elevated thyroglobulin levels raises suspicion of recurrence.

Question 53

Cardiovascular receptor action Adrenaline

Answer 53

a1 a2 b1 b2

Question 54

Cardiovascular receptor action Norad

Answer 54

a1 (a2) (b1) (b2)

Question 55

Cardiovascular receptor action Dobutamine

Answer 55

B1 (B2)

Question 56

Cardiovascular receptor action Dopamine

Answer 56

(a1) (a2) (b1) D1 D2

Question 57

Effects of a1 and 2 adrenoreceptors

Answer 57

Vasoconstriction

Question 58

Effects of beta 1 adrenoreceptors

Answer 58

Increased cardiac contractility and HR

Question 59

Affect of beta 2 adrenoreceptors

Answer 59

Vasodilation

Question 60

Dopamine 1 receptor action

Answer 60

Renal and splenic vasodilation

Question 61

Dopamine 2 receptor action

Answer 61

Inhibits release of noradrenaline

Question 62

A 22 year old man presents with an infected sebaceous cyst. The cyst itself is swollen, discharging pus and has some surrounding erythema. What is the most appropriate treatment? Excision of the cyst of closure of the defect with interrupted 3/0 silk Excision of the cyst and closure of the defect with subcuticular 4/0 undyed nylon Incision and drainage with excision of the cyst wall and packing of the defect Incision and drainage with conservation of the cyst wall and packing of the defect Administration of oral co-amoxyclav and definitive surgery once the infection has cleared

Answer 62

The correct treatment for an infected sebaceous cyst is incision and drainage with removal of the cyst wall. Conservation of the cyst wall will invariably lead to recurrence. Under no circumstances should an infected wound like this be primarily closed. The administration of antibiotics without drainage of sepsis is futile.

Question 63

Adrenaline dose in anaphlyaxis

Answer 63

1:1000 0.5 ml IM

Question 64

Chlorphenamine dose in anaphylaxis

Answer 64

10mg IV

Question 65

Hydrocortisone dose in anaphylaxis

Answer 65

100-200mg IV

Question 66

A 16 year old boy develops a painful swelling of his distal femur. An osteoblastic sarcoma is diagnosed. To which of the following sites is this lesion most likely to metastasise? Inguinal lymph nodes Common iliac lymph nodes Liver Brain Lung

Answer 66

Lung Sarcomas often metastasise via the haematogenous route and the lung is a common site for sarcoma metastasis. The liver and brain are often spared (at least initially). A smaller number may develop lymphatic metastasis (see above).

Question 67

Sarcomas in which Lymphatic Metastasis is seen: 'RACE For MS'

Answer 67

R: Rhabdomyosarcoma A: Angiosarcoma C: Clear cell sarcoma E: Epithelial cell sarcoma For: Fibrosarcoma M: Malignant fibrous histiocytoma S: Synovial cell sarcoma

Question 68

What features of a mass should raise suspicion for a sarcoma?

Answer 68

Large \>5cm soft tissue mass Deep tissue location or intra muscular location Rapid growth Painful lump

Question 69

Commoner in males Incidence of 0.3 / 1, 000, 000 Onset typically between 10 and 20 years of age Location by femoral diaphysis is commonest site Histologically it is a small round tumour Blood borne metastasis is common and chemotherapy is often combined with surgery

Answer 69

Ewings sarcoma

Question 70

Mesenchymal cells with osteoblastic differentiation 20% of all primary bone tumours Incidence of 5 per 1,000,000 Peak age 15-30, commoner in males Limb preserving surgery may be possible and many patients will receive chemotherapy

Answer 70

Osteosarcoma

Question 71

Malignancy of adipocytes Rare, approximately 2.5 per 1,000,000. They are the second most common soft tissue sarcoma Typically located in deep locations such as retroperitoneum Affect older age group usually \>40 years of age May be well differentiated and thus slow growing although may undergo de-differentiation and disease progression Many tumours will have a pseudocapsule that can misleadingly allow surgeons to feel that they can 'shell out' these lesions. In reality, tumour may invade at the edge of the pseudocapsule and result in local recurrence if this strategy is adopted Usually resistant to radiotherapy, although this is often used in a palliative setting

Answer 71

Liposarcoma

Question 72

Tumour with large number of histiocytes Most common sarcoma in adults Also described as undifferentiated pleomorphic sarcoma NOS (i.e. Cell of origin is not known) Four major subtypes are recognised: storiform-pleomorphic (70% cases), myxoid (less aggressive), giant cell and inflammatory Treatment is usually with surgical resection and adjuvant radiotherapy as this reduces the likelihood of local recurrence

Answer 72

Malignant Fibrous Histiocytoma

Question 73

Most common sarcoma in adults?

Answer 73

Malignant Fibrous Histiocytoma

Question 74

Which of the following local anaesthetics is not an amino amide type? Lignocaine Xylocaine Procaine Bupivacaine Prilocaine

Answer 74

All local anaesthetics have a chemical bond linking an amine to either an amide or an ester. Most local anaesthetics are of the amino- amide types, these have a more favorable side effect profile and are more stable in solution. Procaine and benzocaine have amino - ester groups, these are metabolised by pseudocholinesterases.

Question 75

Infection with which of the following micro-organisms may result in a clinical picture resembling achalasia of the oesphagus? Epstein Barr virus Wuchereria Bancrofti Candida Spp Trypanosoma Cruzi Helicobacter Pylori

Answer 75

Protozoan Infection with Trypanosoma Cruzi may result in destruction of the ganglion cells of the myenteric plexus, resulting in a clinical picture similar to achalasia. Causes Chagas disease Carried by bugs which infect the skin whilst feeding Penetrate through open wounds and mucous membranes Intracellular proliferation Major infective sites include CNS, intestinal myenteric plexus, spleen, lymph nodes and cardiac muscle Chronic disease is irreversible, nifurtimox is used to treat acute infection Next question

Question 76

You are called to the acute surgical unit. A patient who has short gut syndrome has developed a broad complex tachycardia. You suspect a diagnosis of ventricular tachycardia. What is the most likely precipitant? Hypoglycaemia Bisoprolol Hypomagnesaemia Dehydration Hyperthyroidism

Answer 76

Hypomagnesaemia

Question 77

What are the two main types of VT?

Answer 77

monomorphic VT: most commonly caused by myocardial infarction polymorphic VT: A subtype of polymorphic VT is torsades de pointes which is precipitated by prolongation of the QT interval. The causes of a long QT interval are listed below

Question 78

Congenital causes of prolonged QT

Answer 78

Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal potassium channel) Romano-Ward syndrome (no deafness)

Question 79

Drugs causing prolonged QT

Answer 79

amiodarone, sotalol, class 1a antiarrhythmic drugs tricyclic antidepressants, fluoxetine chloroquine terfenadine erythromycin

Question 80

Other causes of prolonged QT

Answer 80

electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia acute myocardial infarction myocarditis hypothermia subarachnoid haemorrhage

Question 81

Based on the current guidelines, which option regarding management of head injuries is false? Opiates should be avoided Consider intubation if the GCS is \<8 or = 8 Immediate CT head if there is \> 1 episode of vomiting Half hourly GCS assessment until GCS is 15 Contact neurosurgeons if suspected penetrating injury

Answer 81

Opiates should be avoided

Question 82

Indications for immediate CT head

Answer 82

GCS \< 13 on admission GCS \< 15 2 hours after admission Suspected open or depressed skull fracture Suspected skull base fracture (panda eyes, Battle's sign, CSF from nose/ear, bleeding ear) Focal neurology Vomiting \> 1 episode Post traumatic seizure Coagulopathy

Question 83

Contact neurosurgeon in injury if?

Answer 83

Persistent GCS \< 8 or = 8 Unexplained confusion \> 4h Reduced GCS after admission Progressive neurological signs Incomplete recovery post seizure Penetrating injury Cerebrospinal fluid leak

Question 84

Failure rates of vasectomy

Answer 84

1 in 2000

Question 85

Reversal of vasectomy success rates

Answer 85

55% if within 10 years

Question 86

Which of the following statements relating to the root of the neck is false? The lung projects into the neck beyond the first rib and is constrained by Sibson's fascia The subclavian artery arches over the first rib anterior to scalenus anterior The roots and trunks of the Brachial plexus lie posterior to the subclavian artery on the first rib The roots and trunks of the Brachial plexus lie between scalenus anterior and scalenus medius muscles The thyrocervical trunk is a branch of the subclavian artery

Answer 86

The subclavian artery lies posterior to scalenus anterior, the vein lies in front. Sibson's fascia is another name for the suprapleural membrane

Question 87

A 23 year old man presents with blunt abdominal trauma and a splenic bleed is suspected. He is commenced on an infusion of tranexamic acid. Which of the following best describes its mechanism of action? Inhibition of plasmin Inhibition of thrombin Inhibition of factor II Inhibition of factor Xa Activation of factor VIII

Answer 87

Tranexamic acid inhibits plasmin and this prevents fibrin degradation. Tranexamic acid is a synthetic derivative of lysine. Its primary mode of action is as an anti fibrinolytic that competitively inhibits the conversion of plasminogen to plasmin. Plasmin degrades fibrin and therefore rendering plasmin inactive slows this process. The role of tranexamic acid in trauma was investigated in the CRASH 2 trial and has been shown to be of benefit in bleeding trauma when administered in the first 3 hours.

Question 88

Facultative anaerobe Gram positive coccus Haemolysis on blood agar plates Catalase positive 20% population are long term carriers Exo and entero toxin may result in toxic shock syndrome and gastroenteritis respectively Ideally treated with penicillin although many strains now resistant through beta Lactamase production. In the UK less than 5% of isolates are sensitive to penicillin. Resistance to methicillin (and other antibiotics) is mediated by the mec operon , essentially penicillin binding protein is altered and resistance to this class of antibiotics ensues Common cause of cutaneous infections and abscesses

Answer 88

Staphylococcus aureus

Question 89

Gram positive, forms chain like colonies, Lancefield Group A Streptococcus Produces beta haemolysis on blood agar plates Rarely part of normal skin microflora Catalase negative Releases a number of proteins/ virulence factors into host including hyaluronidase, streptokinase which allow rapid tissue destruction Releases superantigens such as pyogenic exotoxin A which results in scarlet fever Remains sensitive to penicillin, macrolides may be used as an alternative.

Answer 89

Streptococcus pyogenes

Question 90

Gram negative rod Facultative anaerobe, non sporing Wide range of subtypes and some are normal gut commensals Some subtypes such as 0157 may produce lethal toxins resulting in haemolytic-uraemic syndrome Enterotoxigenic E-Coli produces an enterotoxin (ST enterotoxin) that results in large volume fluid secretion into the gut lumen (Via cAMP activation) Enteropathogenic E-Coli binds to intestinal cells and cause structural damage, this coupled with a moderate (or in case of enteroinvasive E-Coli significant) invasive component produces enteritis and large volume diarrhoea together with fever. They are resistant to many antibiotics used to treat gram positive infections and acquire resistance rapidly and are recognised as producing beta lactamases

Answer 90

Escherichia coli

Question 91

Curved, gram negative, non sporulating bacteria One of the commonest causes of diarrhoea worldwide Produces enteritis which is often diffuse and blood may be passed Remains a differential for right iliac fossa pain with diarrhoea Self limiting infection so antibiotics are not usually advised. However, the quinolones are often rapidly effective.

Answer 91

Campylobacter jejuni

Question 92

Gram negative, helix shaped rod, microaerophillic Produces hydrogenase that can derive energy from hydrogen released by intestinal bacteria Flagellated and mobile Those carrying the cag A gene may cause ulcers It secretes urease that breaks down gastric urea\> Carbon dioxide and ammonia\> ammonium\>bicarbonate (simplified!) The bicarbonate can neutralise the gastric acid. Usually colonises the gastric antrum and irritates resulting in increased gastrin release and higher levels of gastric acid. These patients will develop duodenal ulcers. In those with more diffuse H-Pylori infection gastric acid levels are lower and ulcers develop by local tissue damage from H-Pylori- these patients get gastric ulcers. Diagnosis may be made by serology (approx. 75% sensitive). Biopsy urease test during endoscopy probably the most sensitive. In patients who are colonised 10-20% risk of peptic ulcer, 1-2% risk gastric cancer, \<1% risk MALT lymphoma.

Answer 92

Helicobacter pylori

Question 93

Infusion with which of the following blood products is most likely to result in an urticarial reaction? Packed red cells Fresh frozen plasma Platelets Cryoprecipitate Factor VIII concentrate

Answer 93

Pyrexia is the most common adverse event in transfusing packed red cells Urticaria is the most common adverse event following infusion of FFP

Question 94

Systemic AA amyloidosis

Answer 94

long-term complication of several chronic inflammatory disorders - e.g. rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, malignancies and conditions predisposing to recurrent infections

Question 95

AL amyloidosis

Answer 95

Results from extra-cellular deposition of fibril-forming monoclonal immunoglobulin light chains (most commonly of lambda isotype). Most patients have evidence of isolated monoclonal gammopathy or asymptomatic myeloma, and the occurrence of AL amyloidosis in patients with symptomatic multiple myeloma or other B-cell lymphoproliferative disorders is unusual. AL type amyloidosis is the most common variant.

Question 96

A 34 year old male donates a unit of blood. It is stored at 4 oC. After 72 hours which of the following clotting factors will be most affected? Factor V Factor II Factor VII Factor IX Factor XI

Answer 96

Factors V and VIII are sensitive to temperature which is the reason why FFP is frozen soon after collection.

Question 97

What is significant about Beriplex?

Answer 97

- Bereplex 50 u/kg - Rapid action but factor 6 short half life, therefore give with vitamin K

Question 98

Cortisol is predominantly produced by which of the following? Zona fasciculata of the adrenal Zona glomerulosa of the adrenal Zona reticularis of the adrenal Adrenal medulla Posterior lobe of the pituitary

Answer 98

Relative Glucocorticoid activity: ``` Hydrocortisone = 1 Prednisolone = 4 Dexamethasone = 25 ``` Cortisol is produced by the zona fasciculata of the adrenal gland.

Question 99

Theme: Hip fractures A.Conservative management B.Percutaneous pinning C.Fracture reduction and internal fixation D.Hemiarthroplasty E.Total hip replacement F.Dynamic hip screw G.Intramedullary femoral nail For each scenario please select the most appropriate management option. Each option may be used once, more than once or not at all. 10.A 60 year old male is admitted to A&E with a fall. He lives with his wife and still works as a restaurant manager. He has a past history of benign prostatic hypertrophy and is currently taking tamsulosin. He is otherwise fit and healthy. On examination there is right hip tenderness on movement in all directions. A hip x-ray confirms an intertrochanteric fracture. An 86 year old retired pharmacist is admitted to A&E following a fall. She complains of right hip pain. She is known to have hypertension and is currently on bendrofluazide. She lives alone and mobilises with a Zimmer frame. Her right leg is shortened and externally rotated. A hip x-ray confirms a displaced intracapsular fracture. A 74 year old male is admitted to A&E with a fall. He is known to have rheumatoid arthritis and is on methotrexate and paracetamol. He lives alone in a bungalow and enjoys playing golf. He is independent with his ADLs. He complains of left groin pain, therefore has a hip x-ray which confirms a displaced intracapsular fracture.

Answer 99

Dynamic hip screw The blood supply to the femoral head may be intact and the fracture should heal with compression type devices such as gamma nails or dynamic hip screws. The latter device being the most commonly performed therapeutic intervention. Hemiarthroplasty Hemiarthroplasty is offered to older, less mobile individuals compared to fracture reduction and fixation in younger patients. Total hip replacement This patient has pre-existing joint disease, good level of activity and a relatively high life expectancy, therefore THR is preferable to hemiarthroplasty.

Question 100

NOF mortality

Answer 100

mortality associated with elderly hip fracture is 10% at one month, and 30% at one year. However, this has been improved in the UK with the introduction of multidisciplinary, orthogeriatric lead care and the National Hip Fracture Database and Best Practice Tariff.

Question 101

Vascular supply to the femoral head

Answer 101

The predominant blood supply to the femoral head and neck is from the medial and lateral femoral circumflex arteries (branches of profunda femoris). These anastomose and pierce the joint capsule at the base of the neck, mainly posteriorly. There is a small vascular contribution from the artery of the ligament teres. Understanding the blood supply is fundamental to the decision making process in treating NOF fractures.

Question 102

What can be used to classify elderly intracapsular NOF?

Answer 102

Garden classification

Question 103

Priority in repair of NOF in young?

Answer 103

The priority with the young patient is to retain the femoral head if possible, even with a displaced intracapsular fracture. The risk of avascular necrosis and non-union (and therefore revision surgery) associated with internal fixation needs weighing up against the sequelae of total hip replacement in the

Question 104

Management of intertrochanteric farctures

Answer 104

Intertrochanteric fractures vary greatly in their stability. If the trochanter (and therefore lateral wall), and medial calcar is in tact, then the fracture configuration bears stability. This can be treated with a DHS, as collapse of the fracture is predictable. Where either or both structures are involved in the fracture, stability becomes compromised and many surgeons will favour using an intramedullary device. This is an ongoing debate, and difficult to test in an exam setting.

Question 105

Answer 105

Question 106

Answer 106

Question 107

Which of the following are not generally supplied by the right coronary artery? The sino atrial node The circumflex artery The atrioventricular node Most of the right ventricle The right atrium

Answer 107

The circumflex artery is generally a branch of the left coronary artery.

Question 108

IVF in XS fluid loss from vomiting

Answer 108

Treated with crystalloid with potassium replacement. NS if hypochloraemia

Question 109

IVF in fluid loss from diarrhoea, ileostomy, ileus, obstruction

Answer 109

Hartmann's (should also be given in sodium losses 2o to diuretics)

Question 110

Maintenance fluids

Answer 110

Use 4%/0.18% dextrose saline or 5% dextrose in maintenance fluids. It should not be used in resuscitation or as replacement fluids.

Question 111

A 44 year old man has a malignant melanoma and is undergoing a block dissection of the groin. The femoral triangle is being explored for intra operative bleeding. Which of the following forms the medial border of the femoral triangle? Femoral artery Biceps femoris Adductor longus Sartorius Adductor magnus

Answer 111

Vastus medialis forms the lateral border of the adductor canal. The sartorius muscles forms the roof of the adductor canal. Adductor longus forms the medial boundary of the femoral triangle (see below).

Question 112

Contents of the femoral triangle

Answer 112

Femoral vein (medial to lateral) Femoral artery-pulse palpated at the mid inguinal point Femoral nerve Deep and superficial inguinal lymph nodes Lateral cutaneous nerve Great saphenous vein Femoral branch of the genitofemoral nerve

Question 113

A 45-year-old man presents to surgical outpatients with a long history of recurrent abdominal pain and vomiting. He is noted to have a peripheral motor neuropathy on examination. What is the most likely diagnosis? Huntington's disease Myeloma Acute intermittent porphyria Lawrence-Moon-Biedl syndrome Friedreich's ataxia

Answer 113

Neurological signs combined with abdominal pain is acute intermittent porphyria or lead poisoning until proven otherwise.

Question 114

Enzyme deficient in AIP

Answer 114

Porphobilinogen deaminase

Question 115

A 56 year old man presents with episodic facial pain and discomfort whilst eating. He has suffered from halitosis recently and he frequently complains of a dry mouth. He has a smooth swelling underneath his right mandible. What is the most likely underlying diagnosis? Stone impacted in Whartons duct Stone impacted in Stensens duct Benign adenoma of the submandibular gland Adenocarcinoma of the submandibular gland Squamous cell carcinoma of the submandibular gland

Answer 115

The symptoms are typical for sialolithiasis. The stones most commonly form in the submandibular gland and therefore may occlude Whartons duct. Stensens duct drains the parotid gland.

Question 116

Of the list below, which is not a cause of avascular necrosis? Steroids Sickle cell disease Radiotherapy Myeloma Caisson disease

Answer 116

P ancreatitis L upus A lcohol S teroids T rauma I diopathic, infection C aisson disease, collagen vascular disease R adiation, rheumatoid arthritis A myloid G aucher disease S ickle cell disease Steroid containing therapy for myeloma may induce avascular necrosis, however the disease itself does not cause it. Caisson disease as may occur in deep sea divers is a recognised cause.

Question 117

The foramen marking the termination of the adductor canal is located in which of the following? Adductor longus Adductor magnus Adductor brevis Sartorius Semimembranosus

Answer 117

The foramen marking the distal limit of the adductor canal is contained within adductor magnus. The vessel passes through this region to enter the popliteal fossa.

Question 118

Borders of the adductor canal?

Answer 118

Laterally: Vastus medialis Posteriorly: Adductor longus, adductor magnus Roof: sartorius

Question 119

Contents of the adductor canal

Answer 119

Saphenous nerve Superficial femoral artery Superficial femoral vein

Question 120

Interparietal hernia occurring at the level of the arcuate line Rare May lie beneath internal oblique muscle. Usually between internal and external oblique Equal sex distribution Position is lateral to rectus abdominis Both open and laparoscopic repair are possible, the former in cases of strangulation

Answer 120

Spigelian hernia

Question 121

The lumbar triangle (through which these may occur) is bounded by: Crest of ilium (inferiorly) External oblique (laterally) Latissimus dorsi (medially) Primary lumbar herniae are rare, most are incisional hernias following renal surgery - Direct anatomical repair with or without mesh re-enforcement is the procedure of choice

Answer 121

Lumbar hernia

Question 122

Herniation through the obturator canal Commoner in females Usually lies behind pectineus muscle Elective diagnosis is unusual most will present acutely with obstruction When presenting acutely most cases with require laparotomy or laparoscopy (and small bowel resection if indicated)

Answer 122

Obturator hernia

Question 123

Condition in which part of the wall of the small bowel (usually the anti mesenteric border) is strangulated within a hernia (of any type) They do not present with typical features of intestinal obstruction as lumenal patency is preserved Where vomiting is prominent it usually occurs as a result of paralytic ileus from peritonitis (as these hernias may perforate)

Answer 123

Richters hernia

Question 124

Occur through sites of surgical access into the abdominal cavity Most common following surgical wound infection To minimise following midline laparotomy Jenkins Rule should be followed and this necessitates a suture length 4x length of incision with bites taken at 1cm intervals, 1 cm from the wound edge Repair may be performed either at open surgery or laparoscopically and a wide variety of techniques are described

Answer 124

Incisional hernia

Question 125

Jenkin's Rule

Answer 125

suture length 4x length of incision with bites taken at 1cm intervals, 1 cm from the wound edge

Question 126

Typically congenital diaphragmatic hernia 85% cases are located in the left hemi diaphragm Associated with lung hypoplasia on the affected side More common in males Associated with other birth defects May contain stomach May be treated by direct anatomical apposition or placement of mesh. In infants that have severe respiratory compromise mechanical ventilation may be needed and mortality rate is high

Answer 126

Bochdalek hernia

Question 127

Rare type of diaphragmatic hernia (approx 2% cases) Herniation through foramen of Morgagni Usually located on the right and tend to be less symptomatic More advanced cases may contain transverse colon As defects are small pulmonary hypoplasia is less common Direct anatomical repair is performed

Answer 127

Morgagni Hernia

Question 128

Hernia through weak umbilicus Usually presents in childhood Often symptomatic Equal sex incidence 95% will resolve by the age of 2 years Surgery performed after the third birthday

Answer 128

Umbilical hernia

Question 129

Usually a condition of adulthood Defect is in the linea alba More common in females Multiparity and obesity are risk factors Traditionally repaired using Mayos technique - overlapping repair, mesh may be used though not if small bowel resection is required owing to acute strangulation

Answer 129

Paraumbilical hernia

Question 130

Hernia containing Meckels diverticulum Resection of the diverticulum is usually required and this will preclude a mesh repair

Answer 130

Littres hernia

Question 131

Theme: Infective organisms A.Clostridium difficle B.Cryptosporidium C.Escherichia coli D.Streptococcus bovis E.Staphylococcus epidermidis F.Clostridium botulinum G.Staphylococcus aureus H.Streptococcus pyogenes Please select the most likely microorganism for the infection scenarios given. Each option may be used once, more than once or not at all. 1.A 56 year old man undergoes a difficult colonoscopy for assessment of a caecal cancer. 48 hours after the procedure he is admitted with septicaemia. His abdomen is soft and non tender. Blood cultures grow gram positive cocci.

Answer 131

Streptococcus bovis Streptococcus bovis septicaemia is associated with carcinoma of the colon. It also can also cause endocarditis.

Question 132

Which of the following is the first vessel to branch from the external carotid artery? Superior thyroid artery Inferior thyroid artery Lingual artery Facial artery Occipital artery

Answer 132

Mnemonic The first branch of the external carotid artery is the superior thyroid artery. The inferior thyroid artery is derived from the thyrocervical trunk. The other branches are illustrated below. | (Order in which they branch off)Some (sup thyroid)Attendings (Ascending Pharyngeal)Like (Lingual)Freaking (Facial)Out (Occipital)Potential (Post auricular)Medical (Maxillary)Students (Sup temporal)

Question 133

Surface marking of the carotid

Answer 133

This is an imaginary line drawn from the bifurcation of the common carotid passing behind the angle of the jaw to a point immediately anterior to the tragus of the ear.

Question 134

Theme: Electrolyte disorders A.Hypotonic hypovolaemic hyponatraemia B.Hypotonic hypervolaemic hyponatraemia C.Pseudohyponatraemia D.Syndrome of inappropriate ADH secretion (SIADH) E.Hypertonic hyponatraemia F.Over administration 5% dextrose Please select the most likely reason for hyponatraemia for each scenario given. Each option may be used once, more than once or not at all. 5.A 73 year old man presents to pre operative clinic for an elective total hip replacement. He is on frusemide for hypertension. He is found to have the following blood results: Na 120 Urine Na 10 (low) Serum osmolality 280 (normal) A 67 year old man presents to pre operative clinic for an elective hernia repair. He is on frusemide for heart failure. He is found to have the following blood results: Na 120 Urine Na 35 (high) Urine osmolality 520 (high) Serum osmolality 265 (low) A 77 year old man presents to pre operative clinic for a total knee replacement. He is on frusemide for hypertension. He is known to have multiple myeloma. He is found to have the following blood results: Na 120 Serum osmolality 280 (normal) Urine osmolality normal Urine Na normal

Answer 134

Hypotonic hypovolaemic hyponatraemia The blood results reflect extra-renal sodium loss. The body is trying to preserve the sodium by not allowing any sodium into the urine (hence the low Na in the urine). Note with renal sodium loss the Urinary sodium is high. Syndrome of inappropriate ADH secretion (SIADH) This blood picture fits with SIADH. SIADH causes retention of fluid from the urine (concentrated urine) into the blood vessels, therefore diluting the fluid in the blood vessels (low osmolality). Management involves removing the cause and fluid restriction. Pseudohyponatraemia Hyperlipidaemia and multiple myeloma are known to cause a pseudohyponatraemia.

Question 135

Causes of pseudohyponatraemia

Answer 135

Hyperlipidaemia and mutliple myeloma are known to cause a pseudohyponatraemia

Question 136

How can hyponatraemia be classified?

Answer 136

Based on urinary sodium

Question 137

Causes of hyponatraemia: Urinary sodium \>20mmol/l

Answer 137

Sodium depletion, renal loss Patient often hypovolaemic Diuretics (thiazides) Addison's Diuretic stage of renal failure SIADH (serum osmolality low, urine osmolality high, urine Na high) Patient often euvolaemic

Question 138

Causes of hyponatraemia: Urinary sodium \<20mmol/l

Answer 138

Sodium depletion, extra-renal loss Diarrhoea, vomiting, sweating Burns, adenoma of rectum (if villous lesion and large)

Question 139

Causes of hyponatraemia: Water excess

Answer 139

Secondary hyperaldosteronism: CCF, cirrhosis Reduced GFR: renal failure IV dextrose, psychogenic polydipsia

Question 140

Management of acute hyponatraemia

Answer 140

Acute hyponatraemia with Na \<120: immediate therapy. Central Pontine Myelinolisis, may occur from overly rapid correction of serum sodium. Aim to correct until the Na is \> 125 at a rate of 1 mEq/h. Normal saline with frusemide is an alternative method.

Question 141

How can sodium requirement in hyponatraemia be calculated?

Answer 141

(125 - serum sodium) x 0.6 x body weight = required mEq of sodium Should be replaced at a rate of 1mEq/h

Question 142

Theme: Feeding options A.Feeding jejunostomy B.Percutaneous endoscopic gastrostomy C.Total parenteral nutrition D.Naso gastric feeding tube E.Elemental diet orally F.Normal oral intake Please select the most appropriate method of delivering nutrition in each of the following scenarios. Each option may be used once, more than once or not at all. 8.A 28 year old man is comatose, from head injuries, on the neurosurgical intensive care unit. Apart from a parietal fracture there is no bony injury. He is recovering well and should be extubated soon. A 56 year old man has undergone a potentially curative oesophagectomy for carcinoma A 43 year old man is recovering from a laparoscopic low anterior resection with loop ileostomy.

Answer 142

The correct answer is Naso gastric feeding tube The feeding of head injured patients was reviewed in a 2008 Cochrane report. They concluded that the overall evidence base was poor. However, there was a trend for the enteral route, with NG feeding in the later stages following injury. This is contra indicated if there are signs of basal skull fractures. Feeding jejunostomy Feeding jejunostomy is the standard of care in most centres. Naso jejunal tubes are preferred by some surgeons. However, if they become displaced the only alternative then becomes TPN. Normal oral intake Early feeding in this situation is both safe and will enhance recovery.

Question 143

Naso gastric feeding

Answer 143

Usually administered via fine bore naso gastric feeding tube Complications relate to aspiration of feed or misplaced tube May be safe to use in patients with impaired swallow Often contra indicated following head injury due to risks associated with tube insertion

Question 144

Naso jejunal feeding

Answer 144

Avoids problems of feed pooling in stomach (and risk of aspiration) Insertion of feeding tube more technically complicated (easiest if done intra operatively) Safe to use following oesophagogastric surgery

Question 145

Feeding jejunostomy

Answer 145

Surgically sited feeding tube May be used for long term feeding Low risk of aspiration and thus safe for long term feeding following upper GI surgery Main risks are those of tube displacement and peritubal leakage immediately following insertion, which carries a risk of peritonitis

Question 146

Percutaneous endoscopic gastrostomy

Answer 146

Combined endoscopic and percutaneous tube insertion May not be technically possible in those patients who cannot undergo successful endoscopy Risks include aspiration and leakage at the insertion site

Question 147

Total parenteral nutrition

Answer 147

The definitive option in those patients in whom enteral feeding is contra indicated Individualised prescribing and monitoring needed Should be administered via a central vein as it is strongly phlebitic Long term use is associated with fatty liver and deranged LFT's

Question 148

Which of the following cellular types or features is not seen in sarcoidosis? Reed Sternberg Cells T lymphocytes Macrophages Asteroid bodies B lymphocytes

Answer 148

Reed Sternberg cells are seen in Hodgkins disease. All of the other cell types are seen in sarcoid.

Question 149

A 41 year old lady with colicky right upper quadrant pain is identified as having gallstones on an abdominal ultrasound scan. What is the most appropriate course of action? Laparoscopic cholecystectomy Open cholecystectomy Liver function tests MRCP ERCP

Answer 149

Liver function testing is part of the core diagnostic work up of biliary colic and surgical planning cannot proceed until this (and the diameter of the CBD on USS) are known.

Question 150

What proportion of pateints receiving gallbladder surgery will have a stone in the CBD?

Answer 150

12%

Question 151

What is the composition of the majority of gallstones?

Answer 151

Mixed composition Pure cholesterol stones account for 20% of cases

Question 152

The classical symptoms are of colicky right upper quadrant pain that occurs post prandially. The symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal

Answer 152

Gallstones

Question 153

Right upper quadrant pain Fever Murphys sign on examination Occasionally mildly deranged LFT's (especially if Mirizzi syndrome)

Answer 153

Acute cholecystitis

Question 154

Colicky abdominal pain, worse post prandially, worse after fatty foods

Answer 154

Biliary colic

Question 155

Usually prodromal illness and right upper quadrant pain Swinging pyrexia Patient may be systemically unwell Generalised peritonism not present

Answer 155

Gallbladder abscess

Question 156

Patient severely septic and unwell Jaundice Right upper quadrant pain

Answer 156

Cholangitis

Question 157

Patients may have a history of previous cholecystitis and known gallstones Small bowel obstruction (may be intermittent)

Answer 157

Gallstone ileus

Question 158

Patients with inter current illness (e.g. diabetes, organ failure) Patient often systemically unwell Gallbladder inflammation in absence of stones High fever

Answer 158

Acalculous cholecystitis

Question 159

Management of biliary colic

Answer 159

If imaging shows gallstones and history compatible then laparoscopic cholecystectomy

Question 160

Management of acute cholecystitis

Answer 160

Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation) (2)

Question 161

Management of gallbladder abscess

Answer 161

Imaging with USS +/- CT Scanning Ideally surgery, sub total cholecystectomy may be needed if Calots triangle is hostile In unfit patients percutaneous drainage may be considered

Question 162

Management of cholangitis

Answer 162

Fluid resuscitation Broad spectrum intravenous antibiotics Correct any coagulopathy Early ERCP

Question 163

Management of gallstone ileus

Answer 163

Laparotomy and removal of gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction. The fistula between the gallbladder and duodenum should not be interfered with.

Question 164

Management of acalculous cholecystitis

Answer 164

If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy

Question 165

Treatment of asymptomatic gallstones

Answer 165

Expectant management

Question 166

Approach to stones in the CBD

Answer 166

During the course of the procedure some surgeons will routinely perform either intra operative cholangiography or laparoscopic USS to either confirm anatomy or to exclude CBD stones. The latter may be more easily achieved by use of laparoscopic ultrasound. If stones are found then the options lie between early ERCP in the day or so following surgery or immediate surgical exploration of the bile duct. When performed via the trans cystic route this adds little in the way of morbidity and certainly results in faster recovery. Where transcystic exploration fails the alternative strategy is that of formal choledochotomy. The exploration of a small duct is challenging and ducts of less than 8mm should not be explored. Small stones that measure less than 5mm may be safely left and most will pass spontaneously.

Question 167

Risks of ERCP

Answer 167

Bleeding 0.9% (rises to 1.5% if sphincterotomy performed) Duodenal perforation 0.4% Cholangitis 1.1% Pancreatitis 1.5%

Question 168

Which of the following diseases is not considered a risk factor for gastric cancer? Polya gastrectomy for antral ulcer Atrophic gastritis Intestinal metaplasia of columnar type at the gastric cardia Patient with polyp showing medium grade dysplasia Long term therapy with H2 blockers

Answer 168

Although some acid lowering procedures increase the risk of gastric cancer the use of H2 blockers does not, at the present time, seem to increase the risk.

Question 169

How are tumours of the GOJ classified?

Answer 169

Type 1: True oesophageal cancers Type 2: Carcinoma of the cardia, arising from cardiac type epthielium or short segments with intestinal metaplsaia. Type 3: sub cardial cancers that spread across the junction. Involve similar nodal stations to gastric cancer

Question 170

What symptoms should prompt a referral to endoscopy in patients of any age with dyspepsia

Answer 170

Chronic GI bleeding Dysphagia Weight loss IDA Upper abdominal mass

Question 171

What symptoms should prompt a referral to endoscopy in patients without dyspepsia

Answer 171

Dysphagia Unexplained abdominal pain or weight loss Vomiting. Upper abdominal mass Jaundice

Question 172

What symptoms should prompt a referral to endoscopy in patients with worsening dyspepsia?

Answer 172

Barretts oesophagus Intestinal metaplasia Dysplasia Atrophic gastritis Patients \>55 with unexplanied or persistent dyspepsia

Question 173

Staging of gastric cancer

Answer 173

CT scanning of the chest abdomen and pelvis is the routine first line staging investigation in most centres. Laparoscopy to identify occult peritoneal disease PET CT (particularly for junctional tumours)

Question 174

Treatment of proximally sited gastric cancers?

Answer 174

Proximally sited disease greater than 5-10cm from the OG junction may be treated by sub total gastrectomy

Question 175

Treatment of gastric cancer if tumour is \<5cm from OGJ

Answer 175

Total gastrectomy if tumour is \<5cm from OG junction

Question 176

Treatment of type 2 gastric cancers?

Answer 176

For type 2 junctional tumours (extending into oesophagus) oesophagogastrectomy is usual

Question 177

Lymphadenectomy in gastric cancer

Answer 177

Lymphadenectomy should be performed. A D2 lymphadenectomy is widely advocated by the Japanese, the survival advantages of extended lymphadenectomy have been debated. However, the overall recommendation is that a D2 nodal dissection be undertaken. D2 esentially suggests that nodal stations 1 and 2 should be excised

Question 178

CTx in gastric cancer

Answer 178

Most patients will receive chemotherapy either pre or post operatively.

Question 179

Which of the following is the first radiological change likely to be apparent in a plain radiograph of a 12 year old presenting with suspected Perthes disease Multiple bone cysts Sclerosis of the femoral head Loss of bone density Joint space narrowing Collapse of the femoral head

Answer 179

In Catterall stage I disease there may be no radiological abnormality at all. In Stage II disease there may be sclerosis of the femoral head. Indication for treatment (aide memoire):Half a dozen, half a head Those aged greater than 6 years with \>50% involvement of the femoral head should almost always be treated

Question 180

Idiopathic avascular necrosis of the femoral epiphysis of the femoral head Impaired blood supply to femoral head, causing bone infarction. New vessels develop and ossification occurs. The bone either heals or a subchondral fracture occurs.

Answer 180

Perthes disease

Question 181

Males 4x's greater than females Age between 2-12 years (the younger the age of onset, the better the prognosis) Limp Hip pain Bilateral in 20%

Answer 181

Perthes disease

Question 182

What is used to stage Perthes disease?

Answer 182

Catterall staging

Question 183

Catterall 1

Answer 183

Clinical and histological features only

Question 184

Catterall 2

Answer 184

Sclerosis with or without cystic changes and preservation of the articular surface

Question 185

Catterall stage 3

Answer 185

Loss of structural integrity of the femoral head

Question 186

Catterall stage 4

Answer 186

Loss of acetabular integrity

Question 187

Management of Perthes disease

Answer 187

To keep the femoral head within the acetabulum: cast, braces If less than 6 years: observation Older: surgical management with moderate results Operate on severe deformities

Question 188

A 56 year old man is diagnosed as having a glioma. From which of the following cell types do these tumours usually originate? Schwann cells Oligodendrocytes Ependymal cells Squamous cells Neuroglial cells

Answer 188

Gliomas originate from glial (otherwise known as neuroglial) cells. These serve a structural function in the CNS. The tumours produced may resemble a number of CNS cell types. Tumours are therefore named according to the cells they resemble rather than the origin. Where this is not possible they are termed gliomas.

Question 189

Subtypes of gliomas

Answer 189

Ependymomas- Ependymal cells Astocytomas- Astrocytes (including glioblastoma) Oligodendrogliomas- Oligodendrocytes Mixed- e.g. oligoastrocytomas

Question 190

Normal anion gap metabolic acidosis

Answer 190

Hyperchloraemic: Gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula Renal tubular acidosis Drugs: e.g. acetazolamide Ammonium chloride injection Addison's disease

Question 191

Raised anion gap metabolic acidosis

Answer 191

Lactate Ketones Urate Acid poisoning

Question 192

A 78 year old man presents with unilateral deafness which has been present for the past 3 months. On examination, Webers test localises to the contralateral side and a CT scan of his head shows a thickened calvarium with areas of sclerosis and radiolucency. His blood tests show an elevated alkaline phosphatase, normal serum calcium and normal PTH levels. Which of the following is the most likely underlying diagnosis? Multiple myeloma with skull involvement Osteoporosis Pagets disease with skull involvement Lung cancer with skull metastasis Osteopetrosis with skull involvement

Answer 192

Of the conditions listed Pagets disease is the most likely diagnosis (skull vault expansion and sensorineural hearing loss). Multiple myeloma would typically result in multiple areas of radiolucency and usually raised calcium in this setting. Osteopetrosis is a recognised cause of the features described. However, it is a rare inherited disorder and usually presents in children in young adults. Presentation at this stage with no prior symptoms would be extremely rare and therefore this is not the most likelydiagnosis.

Question 193

Indications for treatment in Paget's disease?

Answer 193

Bone pain Skull or long bone deformity Fracture Periarticular Paget's

Question 194

Cx of Paget's

Answer 194

Deafness (cranial nerve entrapment) Bone sarcoma Fractures Skull thickening High output cardiac failure

Question 195

Theme: Anaesthetic agents A.Etomidate B.Ketamine C.Propofol D.Sodium thiopentone E.Methohexitone F.Metaraminol G.Midazolam Please select the most appropriate anaesthetic induction agent for the procedure described. Each option may be used once, more than once or not at all. 7.A 32 year old man is admitted for a trendelenberg procedure for varicose veins. He is known to have porphyria. A 77 year old lady with unstable ischaemic heart disease requires an emergency femoral hernia repair. She is volume depleted and slightly hypotensive. A 22 year old man is brought to theatre for an emergency apppendicectomy for generalised peritonitis. He is vomiting.

Answer 195

Propofol This is a daycase procedure for which propofol is ideal. Sodium thiopentone and etomidate are contraindicated in porphyria. Ketamine Ketamine is not negatively inotropic and will not depress cardiac output. Propofol and Sodium thiopentone will produce myocardial depression. Some doctors may also consider etomidate. However, it may cause adrenal suppression and post operative vomiting- which she is at high risk of developing. Sodium thiopentone Most anaesthetists would use sodium thiopentone for a rapid sequence induction (which this man will need).

Question 196

Rapid onset of anaesthesia Pain on IV injection Rapidly metabolised with little accumulation of metabolites Proven anti emetic properties Moderate myocardial depression Widely used especially for maintaining sedation on ITU, total IV anaesthesia and for daycase surgery

Answer 196

Propofol

Question 197

Extremely rapid onset of action making it the agent of choice for rapid sequence of induction Marked myocardial depression may occur Metabolites build up quickly Unsuitable for maintenance infusion Little analgesic effects

Answer 197

Sodium thiopentone

Question 198

May be used for induction of anaesthesia Has moderate to strong analgesic properties Produces little myocardial depression making it a suitable agent for anaesthesia in those who are haemodynamically unstable May induce state of dissociative anaesthesia resulting in nightmares

Answer 198

Ketamine

Question 199

Has favorable cardiac safety profile with very little haemodynamic instability No analgesic properties Unsuitable for maintaining sedation as prolonged (and even brief) use may result in adrenal suppression Post operative vomiting is common

Answer 199

Etomidate

Question 200

A tall 32 year old lady presents with a diffuse neck swelling a carcinoma of the thyroid medullary type is diagnosed.

Answer 200

This is a case MEN type IIb. It is associated with phaeochromocytomas and is transmitted in an autosomal dominant pattern if inherited. All MEN II tend to have medullary carcinoma of the thyroid as a presenting feature

Question 201

A 32 year old man is undergoing a splenectomy. Division of which of the following will be necessary during the procedure? Left crus of diaphragm Short gastric vessels Gerotas fascia Splenic flexure of colon Marginal artery

Answer 201

During a splenectomy the short gastric vessels which lie within the gastrosplenic ligament will need to be divided. The splenic flexure of the colon may need to be mobilised. However, it will almost never need to be divided, as this is watershed area that would necessitate a formal colonic resection in the event of division.

Question 202

Theme: Biological therapies A.Bevacizumab B.Infliximab C.Trastuzumab D.Basiliximab E.Imatinib F.Cetuximab Please select the most appropriate biological agent for the situation described. Each option may be used once, more than once or not at all. 14.A 32 year old lady has previously undergone a wide local excision and axillary node clearance (5 nodes positive) for an invasive ductal carcinoma. It is oestrogen receptor negative, HER 2 positive, vascular invasion is present. She has a lesion suspicious for metastatic disease in the left lobe of her liver. A 22 year old lady has severe peri anal crohns disease with multiple anal fistulae, the acute sepsis has been drained and setons are in place. She is already receiving standard non biological therapy. A 63 year old man presents with a locally unresectable gastrointestinal stromal tumour. Biopsies confirm that it is KIT positive.

Answer 202

Trastuzumab This ladies young age, coupled with ER negativity and extensive nodal disease with suspicion of metastatic disease makes her a candidate for treatment with trastuzumab (herceptin). Infliximab Infliximab is a popular choice in managing complex peri anal crohns. It is absolutely vital that all sepsis is drained prior to starting therapy. Imatinib Imatinib is licensed for treatment of GIST in the United Kingdom for this situation. The guidance from the National Institute of Clinical evidence is that patients be reviewed at 12 weeks after initiating therapy.

Question 203

TNF alpha inhibitor

Answer 203

Adalimumab Infliximab Etanercept

Question 204

Anti VEGF (anti angiogenic)

Answer 204

Bevacizumab

Question 205

HER receptor antagonist

Answer 205

Trastuzumab

Question 206

Tyrosine kinase inhibitor

Answer 206

Imatinib

Question 207

IL2 binding site

Answer 207

Basiliximab

Question 208

Epidermal growth factor inhibitor

Answer 208

Cetuximab

Question 209

Uses of bevacizumab

Answer 209

Colorectal cancer Renal Glioblastoma

Question 210

Uses of imatinib

Answer 210

Gastrointestinal stromal tumours Chronic myeloid leukaemia

Question 211

Use of cetuximab

Answer 211

EGF positive colorectal cancers

Question 212

Which structure separates the cephalic vein and the brachial artery in the antecubital fossa? Brachioradialis muscle Biceps muscle Origin of flexor digitorum profundus muscle Pronator quadratus muscle Origin of flexor digitorum superficialis muscle

Answer 212

Biceps muscle

Question 213

A 45 year old man presents with symptoms of urinary colic. In the history he has suffered from recurrent episodes of frank haematuria over the past week or so. On examination he has a left loin mass and a varicocele. The most likely diagnosis is: Renal adenocarcinoma Renal cortical adenoma Squamous cell carcinoma of the renal pelvis Retroperitoneal fibrosis Nephroblastoma

Answer 213

Renal adenocarcinoma are the most common renal malignancy and account for 75% cases. Patients may develop frank haematuria and have episodes of clot colic. A Grawitz tumour is an eponymous name for Renal Adenocarcinoma. May metastasise to bone.

Question 214

A 24 year old motor cyclist is involved in a road traffic accident. He suffers a tibial fracture which is treated with an intra medullary nail. Post operatively he develops a compartment syndrome. Surgical decompression of the anterior compartment will relieve pressure on all of the following muscles except? Peroneus brevis Peroneus tertius Extensor digitorum longus Tibialis anterior None of the above

Answer 214

The anterior compartment contains: Tibialis anterior Extensor digitorum longus Peroneus tertius Extensor hallucis longus Anterior tibial artery All the muscles are innervated by the deep peroneal nerve.

Question 215

Contents of the peroneal compartment

Answer 215

Peroneus longus Peroneus brevis

Question 216

Innervation of the peroneal compartment

Answer 216

Superficial peroneal nerve

Question 217

Contents of the superficial posterior compartment

Answer 217

Gastrocnemius Plantaris (absent in 10%) Soleus

Question 218

Innervation of the superficial posterior compartment

Answer 218

Tibial nerve

Question 219

Contents of the deep posterior compartment

Answer 219

Popliteus Flexor digitorum longus Flexor hallucis longus Tibialis posterior

Question 220

Innervation of the deep posterior compartment

Answer 220

Tibial

Question 221

A 43 year old lady underwent an attempted placement of a central line into the internal jugular vein. Unfortunately, the doctor damaged the carotid artery and this necessitated surgical exploration. As the surgeons incise the carotid sheath a nerve is identified lying between the internal jugular vein and the carotid artery. Which of the following is this nerve most likely to be? Glossopharyngeal nerve Hypoglossal nerve Superior laryngeal nerve Recurrent laryngeal nerve Vagus

Answer 221

The vagus lies in the carotid sheath. The hypoglossal nerve crosses the sheath, but does not lie within it.

Question 222

At what level does the carotid divide into the ECA and ICA?

Answer 222

At the upper border of the thyroid

Question 223

Path of the common carotid

Answer 223

Passes behind the SCJ to the upper border of the thyroid

Question 224

At what level is the carotid crossed by omohyoid?

Answer 224

C6

Question 225

What happpens to the carotid after being crossed by the omohyoid

Answer 225

Crossed by thyrohyoid, sternohyoid, sternomastoid

Question 226

Where is the carotid tubercle?

Answer 226

Transverse process of C6- compression here stops haemorrhage

Question 227

Relation between the inferior thyroid and CCA?

Answer 227

Inferior thyroid passes posterior to the CCA

Question 228

A patient has a chest drain insertion. There is fresh blood at the chest drain insertion area. Which vessel has been damaged? Pericardiophrenic artery Intercostal vein Right ventricle Vagus artery Intercostal artery

Answer 228

The intercostal vein is more superior than the artery and is thus slightly less susceptible to injury. Within the intercostal spaces there are thin, strong muscles, intercostal vessels, nerves and lymphatics. There are 3 intercostal muscle layers corresponding to the lateral abdominal wall; external, internal, innermost intercostals. At the mid axillary line there are thin intracostals which is an extension of the internal intercostal muscle. In each intercostal space lies the neurovascular bundle, comprising, from superior to inferiorly; the posterior intercostal vein, artery and nerve, lying protected in the subcostal groove of the rib above and situated between the second and third layer of the intercostal muscles. These blood vessels anastomose anteriorly with the anterior intercostal vessels, which arise from the internal thoracic artery and vein.

Question 229

Two teenagers are playing with an airgun when one accidentally shoots his friend in the abdomen. He is brought to the emergency department. On examination there is a bullet entry point immediately to the right of the rectus sheath at the level of the 1st lumbar vertebra. Which of the following structures is most likely to be injured by the bullet? Head of pancreas Right ureter Right adrenal gland Fundus of the gallbladder Gastric antrum

Answer 229

The fundus of the gallbladder lies at this level and is the most superficially located structure.

Question 230

Which of the following muscles inserts onto the lesser tuberostiy of the the humerus? Subscapularis Deltoid Supraspinatus Teres minor Infraspinatus

Answer 230

With the exception of subscapularis which inserts into the lesser tuberosity, the muscles of the rotator cuff insert into the greater tuberosity.

Question 231

What is the mechanism of action of macrolides? Causes misreading of mRNA Interferes with cell wall formation Inhibits DNA synthesis Inhibits RNA synthesis Inhibits protein synthesis

Answer 231

Macrolides act by inhibiting bacterial protein synthesis. If pushed to give an answer they are bacteriostatic in nature, but in reality this depends on the dose and type of organism being treated. Erythromycin was the first macrolide used clinically. Newer examples include clarithromycin and azithromycin. Adverse effects of erythromycin gastrointestinal side-effects are common cholestatic jaundice: risk may be reduced if erythromycin stearate is used P450 inhibitor

Question 232

Inhibit cell wall formation

Answer 232

penicillins cephalosporins

Question 233

Abx Inhibit protein synthesis

Answer 233

aminoglycosides (cause misreading of mRNA) chloramphenicol macrolides (e.g. erythromycin) tetracyclines fusidic acid

Question 234

Abx: Inhibit DNA synthesis

Answer 234

quinolones (e.g. ciprofloxacin) metronidazole sulphonamides trimethoprim

Question 235

Abx inhibiting RNA synthesis

Answer 235

rifampicin

Question 236

You embark on a laparoscopic appendicectomy and find an appendix mass. There is no free fluid and the patient has no evidence of peritonitis. Which is the best option? Convert to a midline laparotomy and perform a limited right hemicolectomy and end ileostomy Convert to midline laparotomy and perform and appendicectomy after taking down the adhesions Place a drain laparoscopically and administer parenteral antibiotics Send the patient for CT guided drainage Wrap omentum around the area and avoid drainage

Answer 236

Attempt conservative management for appendix mass without peritonitis. Dissection of appendix masses can be associated with a considerable degree of morbidity, the gains of formally dissecting them over simple drainage and antibiotics are minimal. This was initially described as the Ochsner-Sherren regime and was based on the teachings of Albert Ochsner of Chicago and James Sherren of the London hospital. The key facts of both methods (which essentially consisted of non surgical management and careful observation) were combined and published by Hamilton Bailey in 1930 (Bailey H. The Oschner- Sherren treatment of acute appendicitis. BMJ 1930 Jan 25; 1(3603): 140143.)

Question 237

Classical history in appendicits

Answer 237

Peri umbilical abdominal pain (visceral stretching of appendix lumen and appendix is mid gut structure) radiating to the right iliac fossa due to localised parietal peritoneal inflammation. Vomit once or twice but marked and persistent vomiting is unusual. Diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation and some loose stools. A pelvic abscess may also cause diarrhoea. Mild pyrexia is common - temperature is usually 37.5 -38oC. Higher temperatures are more typical of conditions like mesenteric adenitis. Anorexia is very common. It is very unusual for patients with appendicitis to be hungry.

Question 238

Theme: Groin masses A.Femoral hernia B.Lymphadenitis C.Inguinal hernia D.Psoas abscess E.Saphenous varix F.Femoral artery aneurysm G.Metastatic lymphadenopathy H.Lymphoma I.False femoral artery aneurysm What is the likely diagnosis for groin mass described? Each option may be used once, more than once, or not at all. A 52 year old obese lady reports a painless grape sized mass in her groin area. She has no medical conditions apart from some varicose veins. There is a cough impulse and the mass disappears on lying down. A 32 year old male is noted to have a tender mass in the right groin area. There are also red streaks on the thigh, extending from a small abrasion. A 23 year old male suffering from hepatitis C presents with right groin pain and swelling. On examination there is a large abscess in the groin. Adjacent to this is a pulsatile swelling. There is no cough impulse.

Answer 238

Saphenous varix The history of varicose veins should indicate a more likely diagnosis of a varix. The varix can enlarge during coughing/sneezing. A blue discolouration may be noted. Lymphadenitis The red streaks are along the line of the lymphatics, indicating infection of the lymphatic vessels. Lymphadenitis is infection of the local lymph nodes. False femoral artery aneurysm False aneurysms may occur following arterial trauma in IVDU. They may have associated blood borne virus infections and should undergo duplex scanning prior to surgery. False aneurysms do not contain all layers of the arterial wall.

Question 239

Def: false aneurysm

Answer 239

Do not contain all the layers of the arterial wall

Question 240

Key questions regarding groin lumps

Answer 240

Is there a cough impulse Is it pulsatile AND is it expansile (to distinguish between false and true aneurysm) Are both testes intra scrotal Any lesions in the legs such as malignancy or infections (?lymph nodes) Examine the ano rectum as anal cancer may metastasise to the groin Is the lump soft, small and very superficial (?lipoma)

Question 241

A 48 year old women suffers blunt trauma to the head and develops respiratory compromise. As a result she develops hypercapnia. Which of the following effects is most likely to ensue? Cerebral vasoconstriction Cerebral vasodilation Cerebral blood flow will remain unchanged Shunting of blood to peripheral tissues will occur in preference to CNS perfusion None of the above

Answer 241

Hypercapnia will tend to produce cerebral vasodilation. This is of considerable importance in patients with cranial trauma as it may increase intracranial pressure.

Question 242

Theme: Causes of arterial occlusion A.Vasculitis B.Steal syndrome C.Thrombosis D.Foreign body embolus E.Clot embolus F.Vasospasm G.Direct arterial injury Please select the most likely underlying cause for the scenario provided. Each option may be used once, more than once or not at all. 31.A 73 year old lady develops a cold, pulseless hand 3 days following a myocardial infarction. A 6 year old child has suffered a displaced supracondylar humeral fracture. On examination, they have a cold and insensate hand with absent pulses.

Answer 242

Clot embolus The development of mural or atrial appendage thrombi may occur following a myocardial infarct and co-existing atrial fibrillation may contribute to the formation. They tend to present with classical features of an embolic event. Direct arterial injury Both vasospasm and arterial injury may complicate supracondylar fractures and are seen in 1% of all cases. Vasospasm is usually transient and more likely when the injury is minor and reduced early. Severely displaced injuries and those with more advanced signs are usually associated with direct arterial injury. Vasculitis This is likely to represent Buergers disease. It is commonest in young males who smoke heavily.

Question 243

Vasculitis affecting aorta and branches

Answer 243

Takayasu's Buergers GCA

Question 244

Vasculitis affecting large and medium sized arteries

Answer 244

Buerger's GCA PAN

Question 245

Vasculitis affecting medium sized muscular arteries

Answer 245

PAN Wegeners

Question 246

Vasculitis affecting small muscular arteries

Answer 246

Wegeners Rheumatoid

Question 247

Inflammatory, obliterative arteritis affecting aorta and branches Females\> Males Symptoms may include upper limb claudication Clinical findings include diminished or absent pulses ESR often affected during the acute phase

Answer 247

Takyasu's arteritis

Question 248

Segmental thrombotic occlusions of the small and medium sized lower limb vessels Commonest in young male smokers Proximal pulses usually present, but pedal pulses are lost An acuter hypercellular occlusive thrombus is often present Tortuous corkscrew shaped collateral vessels may be seen on angiography

Answer 248

Buergers disease

Question 249

Systemic granulomatous arteritis that usually affects large and medium sized vessels Females \> Males Temporal arteritis is commonest type Granulomatous lesions may be seen on biopsy (although up to 50% are normal)

Answer 249

Giant cell arteritis

Question 250

Systemic necrotising vasculitis affecting small and medium sized muscular arteries Most common in populations with high prevalence of hepatitis B Renal disease is seen in 70% cases Angiography may show saccular or fusiform aneurysms and arterial stenoses

Answer 250

Polyarteritis nodosa

Question 251

Predominantly affects small and medium sized arteries Systemic necrotising granulomatous vasculitis Cutaneous vascular lesions may be seen (ulceration, nodules and purpura) Sinus imaging may show mucosal thickening and air fluid levels

Answer 251

Wegeners granulomatosis

Question 252

A 73 year old lady is admitted for a laparoscopic cholecystectomy. During her pre-operative assessment it is noted that she is receiving furosemide for the treatment of hypertension. Approximately what proportion of the sodium that is filtered at the glomerulus will be subsequently excreted? Up to 25% Up to 75% Between 3 and 5% \<2% Between 1 and 2%

Answer 252

Up to 25% The loop diuretics can lead to marked increases in the amount of sodium excreted. They act in the medullary and cortical aspects of the thick ascending limb of the loop of Henle. This results in a decreased medullary osmolal gradient and increases free water excretion (as well as loss of sodium). Because loop diuretics result in the loss of both sodium and water they are less frequently associated with hyponatraemia than thiazide diuretics (these latter agents act in the cortex and do not affect urine concentrating ability).

Question 253

Location of effects: frusemide

Answer 253

Ascending limb

Question 254

Location of action: distal tubule

Answer 254

Thiazides

Question 255

Location of action: spironolactone

Answer 255

Cortical collecting tubule

Question 256

Channel inhibited by frusemide

Answer 256

Na/K/2Cl

Question 257

Carrier inhibited by thiazides

Answer 257

NaCl

Question 258

Carrier affected by spironolactone

Answer 258

NA/K ATPase

Question 259

% of filtered sodium excreted with thiazides

Answer 259

3-5%

Question 260

% filtered sodium excreted with spironolactone

Answer 260

1-2%

Question 261

Which of the following nerves is not contained within the posterior triangle of the neck? Accessory nerve Phrenic nerve Greater auricular nerve Ansa cervicalis Lesser occiptal nerve

Answer 261

Ansa cervicalis is a content of the anterior triangle of the neck.

Question 262

Boundaries of the posterior triangle of the neck

Answer 262

Apex: SCM adn trap at the occipital bone Ant: posterior border of sternocleidomastoid Post: anterior border of trapezius Base: middle third of clavicle

Question 263

Nerves in the posterior triangle of the neck

Answer 263

Accessory Phrenic Three trunks of the brachial plexus Branches of the cervical plexus: supraclavicular, transverse cervical, greater auricular, lesser occipital

Question 264

Vessels of the posterior triangle of the neck

Answer 264

EJV Subclavian

Question 265

Muscles in the posterior triangle of the neck

Answer 265

Inferior belly of omohyoid Scalene

Question 266

Lymph nodes in the posterior triangle of the neck

Answer 266

Supraclavicular Occipital

Question 267

A 42 year old lady is reviewed in the outpatient clinic following a routine surgical procedure. She complains of diminished sensation at the dorso-lateral aspect of her foot. Which of the following nerves is most likely to be affected? Sural Superficial peroneal Deep peroneal Medial plantar Lateral plantar

Answer 267

The sural nerve supplies the lateral aspect of the foot. It runs alongside the short saphenous vein and may be injured in short saphenous vein surgery.

Question 268

Innervation of the foot: Lateral planatar

Answer 268

Sural

Question 269

Innervation of the foot: Dorsum (not 1st web space)

Answer 269

Superficial peroneal

Question 270

Innervation of the foot: 1st web space

Answer 270

Deep peroneal

Question 271

Innervation of the foot: Extermities of toes

Answer 271

Medial and lateral plantar nerves

Question 272

Innervation of the foot: Proximal plantar

Answer 272

Tibial

Question 273

Innervation of the foot: Medial plantar

Answer 273

Medial plantar nerve

Question 274

Innervation of the foot: Lateral plantar (inferior aspect)

Answer 274

Lateral plantar nerve

Question 275

Arterial supply of the prostate

Answer 275

Inferior vesical artery (from internal iliac)

Question 276

Venous drainage of the prostate

Answer 276

Prostatic venous plexus (to paravertebral veins)

Question 277

Lymphatic drainage of the prostate

Answer 277

Internal iliac nodes

Question 278

Innervation of the prostate

Answer 278

Inferior hypogastric plexus

Question 279

Dimensions of the prostate

Answer 279

Transverse: 4cm AP: 2cm 3cm height

Question 280

Lobes of the prostate

Answer 280

Posterior lobe: posterior to urethra Median lobe: posterior to urethra, between ejaculatory ducts. Lateral lobes x2 Isthmus

Question 281

Zones of the prostate

Answer 281

Peripheral zone: subcapsular portion- most prostate cancers are here Central zone Transition zone Stroma

Question 282

Anterior relations of the prostate

Answer 282

Pubic symphysis Prostatic venous plexus

Question 283

Posterior relations of the prostate

Answer 283

Denonvilliers fascia Rectum Ejaculatory ducts

Question 284

Lateral relations of the prostate

Answer 284

Venous plexus (on prostate) Levator ani (immediately below the puboprostatic ligaments)

Question 285

A 73 year old man has an arterial line in situ. On studying the trace the incisura can be seen. What is the physiological event which accounts for this process? Atrial repolarisation Mitral valve closure Ventricular repolarisation Elastic recoil of the aorta Tricuspid valve closure

Answer 285

It is the temporary rise in aortic pressure occurring as a result of elastic recoil.

Question 286

Adrenoreceptors of the heart?

Answer 286

Beta 1

Question 287

What are the phases of the cardiac cycle

Answer 287

Mid diastole Late diastole Early systole Late systole Early diastole

Question 288

AV valves open. Ventricles hold 80% of final volume. Outflow valves shut. Aortic pressure is high.

Answer 288

Mid diastole

Question 289

Atria contract. Ventricles receive 20% to complete filling. Typical end diastolic volume 130-160ml.

Answer 289

Late diastole

Question 290

AV valves shut. Ventricular pressure rises. Isovolumetric ventricular contraction. AV Valves bulge into atria (c-wave). Aortic and pulmonary pressure exceeded- blood is ejected. Shortening of ventricles pulls atria downwards and drops intra atrial pressure (x-descent).

Answer 290

Early systole

Question 291

Ventricular muscles relax and ventricular pressures drop. Although ventricular pressure drops the aortic pressure remains constant owing to peripheral vascular resistance and elastic property of the aorta. Brief period of retrograde flow that occurs in aortic recoil shuts the aortic valve. Ventricles will contain 60ml end systolic volume. The average stroke volume is 70ml (i.e. Volume ejected).

Answer 291

Late systole

Question 292

All valves are closed. Isovolumetric ventricular relaxation occurs. Pressure wave associated with closure of the aortic valve increases aortic pressure. The pressure dip before this rise can be seen on arterial waveforms and is called the incisura. During systole the atrial pressure increases such that it is now above zero (v- wave). Eventually atrial pressure exceed ventricular pressure and AV valves open - atria empty passively into ventricles and atrial pressure falls (y -descent )

Answer 292

Early diastole

Question 293

Laplace's law:

Answer 293

It states that for hollow organs with a circular cross section, the total circumferential wall tension depends upon the circumference of the wall, multiplied by the thickness of the wall and on the wall tension.

Question 294

Starlings law

Answer 294

Increase in EDV will produce larger stroke volume

Question 295

Where are cardiac baroreceptors found?

Answer 295

Baroreceptors located in aortic arch and carotid sinus. Aortic baroreceptor impulses travel via the vagus and from the carotid via the glossopharyngeal nerve. They are stimulated by arterial stretch. Even at normal blood pressures they are tonically active. Increase in baroreceptor discharge causes:

Question 296

Where are atrial stretch receptors found?

Answer 296

Located in atria at junction between pulmonary veins and vena cava. Stimulated by atrial stretch and are thus low pressure sensors. Increased blood volume will cause increased parasympathetic activity.

Question 297

Bainbridge reflex

Answer 297

Very rapid infusion of blood will result in increase in heart rate mediated via atrial receptors: the Bainbridge reflex.

Question 298

A 59 year old man presents with recurrent episodes of urinary sepsis. In his history he mentions that he has suffered from recurrent attacks of left iliac fossa pain over the past few months. He has also notices bubbles in his urine. He undergoes a CT scan which shows a large inflammatory mass in the left iliac fossa. No other abnormality is detected. The most likely diagnosis is: Ulcerative colitis Crohns disease Mesenteric ischaemia Diverticular disease Rectal cancer

Answer 298

Diverticular disease is one of the commonest causes of colovesical fistula Recurrent attacks of diverticulitis may cause the development of local abscesses which may erode into the bladder resulting in urinary sepsis and pneumaturia. This would be an unusual presentation from Crohns disease and rectal cancer would be more distally sited and generally evidence of extra colonic disease would be present if the case were malignant and this advanced.

Question 299

Def: diverticular disease

Answer 299

Herniation of colonic mucosa through the muscular wall of the colon. The usual site is between the taenia coli, where vessels pierce the muscle to supply the mucosa. For this reason, the rectum is often spared

Question 300

Complications of diverticular disease

Answer 300

Diverticulitis Haemorrhage Development of fistula Perforation and faecal peritonitis Perforation and development of abscess Development of diverticular phlegmon

Question 301

What can be used to classif the severity of diverticulitis

Answer 301

Hinchey classification

Question 302

Hinchey 1

Answer 302

Para-colonic abscess

Question 303

Hinchey 2

Answer 303

Pelvic abscess

Question 304

Hinchey 3

Answer 304

Purulent peritonitis

Question 305

Hinchey 4

Answer 305

Faecal peritonitis

Question 306

Management of diverticulitis

Answer 306

Increase dietary fibre intake. Mild attacks of diverticulitis may be managed conservatively with antibiotics. Peri colonic abscesses should be drained either surgically or radiologically. Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative indication for a segmental resection. Hinchey IV perforations (generalised faecal peritonitis) will require a resection and usually a stoma. This group have a very high risk of post operative complications and usually require HDU admission. Less severe perforations may be managed by laparoscopic washout and drain insertion.

Question 307

A 56 year old lady is undergoing an adrenalectomy for Conns syndrome. During the operation the surgeon damages the middle adrenal artery and haemorrhage ensues. From which of the following structures does this vessel originate? Aorta Renal artery Splenic artery Coeliac axis Superior mesenteric artery

Answer 307

The middle adrenal artery is usually a branch of the aorta, the lower adrenal artery typically arises from the renal vessels.

Question 308

Arterial supply of the adrenals

Answer 308

Superior adrenal arteries- from inferior phrenic artery, Middle adrenal arteries - from aorta, Inferior adrenal arteries -from renal arteries

Question 309

def: cryptorchidism

Answer 309

A congenital undescended testis is one that has failed to reach the bottom of the scrotum by 3 months of age. At birth up to 5% of boys will have an undescended testis, post natal descent occurs in most and by 3 months the incidence of cryptorchidism falls to 1-2%. In the vast majority of cases the cause of the maldescent is unknown. A proportion may be associated with other congenital defects including:

Question 310

DDx for cryptorchidism

Answer 310

These include retractile testes and, in the case of absent bilateral testes the possibility of intersex conditions. A retractile testis can be brought into the scrotum by the clinician and when released remains in the scrotum. If the examining clinician notes the testis to return rapidly into the inguinal canal when released then surgery is probably indicated.

Question 311

Reasons for the correction of cryptorchidism

Answer 311

Reduce risk of infertility Allows the testes to be examined for testicular cancer Avoid testicular torsion Cosmetic appearance Males with undescended testis are 40 times as likely to develop testicular cancer (seminoma) as males without undescended testis The location of the undescended testis affects the relative risk of testicular cancer (50% intra-abdominal testes)

Question 312

Prognosis in cryptorchidism

Answer 312

After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy.

Question 313

Why is bupivacaine contraindicated in regional blockade?

Answer 313

It is cardiotoxic and is therefore contra indicated in regional blockage in case the tourniquet fails.

Question 314

What is used for regional anaesthesia?

Answer 314

Prilocaine

Question 315

Theme: Ankle brachial pressure index A.\>1.2 B.1.0 C.0.8 D.0.5 E.0.3 Please select the ankle brachial pressure index that is most likely to be present for the scenario given. Each value may be used once, more than once or not at all. 5.A 73 year old lifelong heavy smoker presents to the vascular clinic with symptoms of foot ulceration and rest pain. On examination her foot has areas of gangrene and pulses are impalpable. A 63 year old man presents with a claudication distance of 15 yards. He is a lifelong heavy smoker. On examination his foot is hyperaemic and there is a small ulcer at the tip of his great toe. A 77 year old morbidly obese man with type 2 diabetes presents with leg pain at rest. His symptoms are worst at night and sometimes improve during the day. He has no areas of ulceration.

Answer 315

0.3 This is critical limb ischaemia. Values of 0.3 are typical in this setting and urgent further imaging is needed. Debridement of necrosis prior to improving arterial inflow carries a high risk of limb loss. 0.5 Hyperaemia may occur in association with severe vascular disease and is referred to surgically as a "sunset foot". ABPI is usually higher than 0.3, but seldom greater than 0.5. Especially when associated with hyperaemic changes and ulceration. Urgent further imaging and risk factor modification is needed. 1.2 Type 2 diabetics may have vessel calcification. This will result in abnormally high ABPI readings. Pain of this nature in diabetics is usually neuropathic and if a duplex scan is normal then treatment with an agent such as duloxetine is sometimes helpful.

Question 316

ABPI \>1.2

Answer 316

Usually due to vessel calcification

Question 317

ABPI 1.0-1.2

Answer 317

Normal

Question 318

ABPI 0.8-1.0

Answer 318

Minor stenotic lesion Initiate risk factor management

Question 319

ABPI 0.50-0.8

Answer 319

Moderate stenotic lesion Consider duplex Risk factor management If mixed ulcers present then avoid tight compression bandages

Question 320

ABPI 0.5-0.3

Answer 320

Likely significant stenosis Duplex scanning to delineate lesions needed Compression bandaging contra indicated

Question 321

ABPI \<0.3

Answer 321

Indicative of critical ischaemia Urgent detailed imaging required

Question 322

A 73 year old lady suffers a fracture at the surgical neck of the humerus. The decision is made to operate. There are difficulties in reducing the fracture and a vessel lying posterior to the surgical neck is injured. Which of the following is this vessel most likely to be? Axillary artery Brachial artery Thoracoacromial artery Transverse scapular artery Posterior circumflex humeral artery

Answer 322

The circumflex humeral arteries lie at the surgical neck and is this scenario the posterior circumflex is likely to be injured. The thoracoacromial and transverse scapular arteries lie more superomedially. The posterior circumflex humeral artery is a branch of the axillary artery.

Question 323

Shoulder extension

Answer 323

Posterior deltoid Teres major Latissimus dorsi

Question 324

Shoulder flexion

Answer 324

Anterior part of deltoid Pectoralis major Biceps Coracobrachialis

Question 325

Shoulder adduction

Answer 325

Pectoralis major Latissimus dorsi Teres major Coracobrachialis

Question 326

Shoulder abduction

Answer 326

Mid deltoid Supraspinatus

Question 327

Shoulder medial rotation

Answer 327

Subscapularis Anterior deltoid Teres major Latissimus dorsi

Question 328

Shoulder lateral rotation

Answer 328

Posterior deltoid Infraspinatus Teres minor

Question 329

Which of the following sutures has the largest diameter? 6/0 Polypropylene 5/0 Silk 3/0 Nylon 1 Polypropylene 0 Polydiaxone

Answer 329

1- polypropylene The sizes of suture material are not related to the composition of the suture material.

Question 330

Which of the structures listed below lies posterior to the carotid sheath at the level of the 6th cervical vertebra? Hypoglossal nerve Vagus nerve Cervical sympathetic chain Ansa cervicalis Glossopharyngeal nerve

Answer 330

The carotid sheath is crossed anteriorly by the hypoglossal nerves and the ansa cervicalis. The vagus lies within it. The cervical sympathetic chain lies posteriorly between the sheath and the prevertebral fascia.

Question 331

A 46-year-old woman is referred to endocrine surgery for a possible thyroidectomy. She has a tender neck swelling. Blood results are as follows: TSH \<0.1 mU/l T4 188 nmol/l Hb 14.2 g/dl Plt 377 \* 10^9/l WBC 6.4 \* 10^9/l ESR 65 mm/hr Technetium thyroid scan shows decreased uptake globally What is the most likely diagnosis? Sick thyroid syndrome Acute bacterial thyroiditis Hashimoto's thyroiditis Subacute thyroiditis Toxic multinodular goitre

Answer 331

This patient does not need surgery! Subacute thyroiditis is suggested by the tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical. This should resolve without any active intervention.

Question 332

Thought to occur following viral infection and typically presents with hyperthyroidism Features Hyperthyroidism Painful goitre Raised ESR Globally reduced uptake on iodine-131 scan

Answer 332

Subacute (de Quervain's)

Question 333

immunological disorder in which lymphocytes become sensitised to thyroidal antigens. The three most important antibodies include; thyroglobulin, TPO and TSH-R. During the early phase the thyroglobulin antibody is markedly elevated and then declines.

Answer 333

Hashimoto's

Question 334

Hyperthyroidism Painful goitre Raised ESR Globally reduced uptake on iodine-131 scan

Answer 334

Sub acute thyroiditis

Question 335

Features Goitre and either euthyroid or mild hypothyroidism Progressive hypothyroidism (and associated symptoms)

Answer 335

Hashimotos thyroiditis

Question 336

Management of Hashimoto's thyroiditis

Answer 336

During the hyperthyroid phase of illness beta blockers may manage symptoms As hypothyroidism develops patients may require thyroxine

Question 337

Management of Subacute thyroiditis

Answer 337

Usually self-limiting - most patients do not require treatment Thyroid pain may respond to aspirin or other NSAIDs In more severe cases steroids are used, particularly if hypothyroidism develops

Question 338

A sprinter attends A&E with severe leg pain. He had forgotten to warm up and ran a 100m sprint race. Towards the end of the race he experienced pain in the posterior aspect of his thigh. The pain worsens, localising to the lateral aspect of the knee. The sprinter is unable to flex the knee. What structure has been injured? Anterior cruciate ligament Posterior cruciate ligament Semimembranosus tendon Semitendinosus tendon Biceps femoris tendon

Answer 338

The biceps femoris is commonly injured in sports that require explosive bending of the knee as seen in sprinting, especially if the athlete has not warmed up first. Avulsion most commonly occurs where the long head attaches to the ischial tuberosity. Injuries to biceps femoris are more common than to the other hamstrings.

Question 339

Origin of Long head biceps femoris

Answer 339

Ischial tuberosity

Question 340

Insertion of Long head bicep femoris

Answer 340

Fibular head

Question 341

Action of Long head biceps femoris

Answer 341

Knee flexion Lateral rotation tibia Extension hip

Question 342

Innervation of Long head biceps femoris

Answer 342

Tibial division of sciatic nerve (L5-S2

Question 343

Arterial supply of Long head biceps femoris

Answer 343

Profunda femoris artery, inferior gluteal artery, and the superior muscular branches of popliteal artery

Question 344

Origin of short head biceps femoris

Answer 344

Lateral lip of linea aspera, lateral supracondylar ridge of femur

Question 345

Insertion of short head bifceps femoris

Answer 345

Fibular head

Question 346

Action of short head biceps femoris

Answer 346

Knee flexion, lateral rotation tibia

Question 347

Innervation of short head biceps femoris

Answer 347

Common peroneal division of sciatic nerve (L5, S1, S2)

Question 348

Arterial supply of short head biceps femoris

Answer 348

Profunda femoris artery, inferior gluteal artery, and the superior muscular branches of popliteal artery

Question 349

Which of the following is least likely to occur in association with severe atrophic gastritis? Gastric ulcers Gastric cancer Anaemia Duodenal ulcers Gastric polyps

Answer 349

Due to the loss of gastric acid a duodenal ulcer is unlikely. Note that gastric polyps may form

Question 350

What are the types of gastritis

Answer 350

Type A Type B Reflux gastritis Erosive gastritis Stress ulceration Menetrier's disease

Question 351

Autoimmune Circulating antibodies to parietal cells, causes reduction in cell mass and hypochlorhydria Loss of parietal cells = loss of intrinsic factor = B12 malabsorption Absence of antral involvement Hypochlorhydria causes elevated gastrin levels- stimulating enterochromaffin cells and adenomas may form

Answer 351

Type A gastritis

Question 352

Antral gastritis Associated with infection with helicobacter pylori infection Intestinal metaplasia may occur in stomach and require surveillance endoscopy Peptic ulceration may occur

Answer 352

Type B gastritis

Question 353

Bile refluxes into stomach, either post surgical or due to failure of pyloric function Histologically, evidence of chronic inflammation, and foveolar hyperplasia May respond to therapy with prokinetics

Answer 353

Reflux gastritis

Question 354

Foveolar hyperplasia

Answer 354

Reflux gastritis

Question 355

Agents disrupt the gastric mucosal barrier Most commonly due to NSAIDs and alcohol With NSAIDs the effects occur secondary to COX 1 inhibition

Answer 355

Erosive gastritis

Question 356

This occurs as a result of mucosal ischaemia during hypotension or hypovolaemia The stomach is the most sensitive organ in the GI tract to ischaemia following hypovolaemia Diffuse ulceration may occur Prophylaxis with acid lowering therapy and sucralfate may minimise complications

Answer 356

Stress ulceration

Question 357

Gross hypertrophy of the gastric mucosal folds, excessive mucous production and hypochlorhydria Pre malignant condition

Answer 357

Menetriers disease

Question 358

Theme: Lung cancer A.Adenocarcinoma B.Small cell lung cancer C.Large cell lung cancer D.Squamous cell carcinoma Please select the most likely lung cancer variant for the scenario described. Each option may be used once, more than once or not at all. 17.A 73 year old heavy smoker presents with haemoptysis. On examination he is cachectic and shows evidence of clubbing. Imaging shows a main bronchial tumour with massive mediastinal lymphadenopathy together with widespread visceral metastases. A 68 year old female who has never smoked presents with a mass at the periphery of her right lung. An 85 year old man presents with a cough and haemoptysis. He has a modest smoking history of 15 pack years. He is found to have a tumour located in the right main bronchus, with no evidence of metastatic disease. He decides not undergo any treatment and he remains well for a further 12 months before developing symptomatic metastasis.

Answer 358

Small cell lung cancer Small cell carcinoma is associated with disseminated disease at presentation in the majority of cases. Most cases occur in the main airways and paraneoplastic features are common. Adenocarcinoma Adenocarcinomas are the most common tumour type present in never smokers. They are usually located at the periphery Squamous cell carcinoma Squamous cell carcinomas are reported to be more slow growing and are typically centrally located. Small cell carcinomas are usually centrally located. However, small cell carcinomas would seldom be associated with a survival of a year without treatment.

Question 359

What are the nonsmall cell lung cancers?

Answer 359

These share common features of prognosis and management. They comprise the following tumours: Squamous cell carcinoma (25% cases) Adenocarcinoma (40% cases) Large cell carcinoma (10% cases) Paraneoplastic features and early disease dissemination are less likely than with small cell lung carcinoma. Adenocarcinoma is the most common lung cancer type encountered in never smokers.

Question 360

What proportion of lung cancers are accounted for by NSLC

Answer 360

80%

Question 361

comprised of cells with a neuro endocrine differentiation. The neuroendocrine hormones may be released from these cells with a wide range of paraneoplastic associations. These tumours are strongly associated with smoking and will typically arise in the larger airways. They disseminate early in the course of the disease and although they are usually chemosensitive this seldom results in long lasting remissions.

Answer 361

SCLC

Question 362

Which of the following is not found on a blood film post splenectomy? Pappenheimer bodies Stipple cells Erythrocyte containing siderotic granules Howell-Jolly bodies Target cells

Answer 362

Stipple cells are found in lead poisoning/haemoglobinopathies. Blood film in hyposplenism: Howell-Jolly bodies Pappenheimer bodies Poikilocytes (Target cells) Erythrocyte containing siderotic granules Heinz bodies

Question 363

What changes may be seen in blood components post splenectomy

Answer 363

In the first few days after splenectomy target cells, siderocytes and reticulocytes will appear in the circulation. Immediately following splenectomy a granulocytosis (mainly composed of neutrophils) is seen, this is replaced by a lymphocytosis and monocytosis over the following weeks. The platelet count is usually increased and this may be persistent, oral antiplatelet agents may be needed in some patients.

Question 364

A surgical team wish to conduct a meta analysis of randomised controlled trials of the use of low molecular weight heparins in the prevention of post operative deep vein thrombosis. How would these results be best displayed graphically? Forest plot Box Whisker plot Violin plot Kaplan Meier graph None of the above

Answer 364

Data from multiple RCT's are best displayed using Forest plots. Funnel plots may be used to determine the effect of small studies and their overall effect on the data. Violin plots and Box Whisker plots are often used to graphically display non parametric data from single studies and are not generally used to display data from meta analyses.

Question 365

A 43 year old man has recurrent episodes of dyspepsia and treatment is commenced with oral antacids. Which of the hormones listed below is released in response to increased serum gastrin levels and decreases intra gastric pH? Cholecystokinin Histamine Somatostatin Insulin Vasoactive intestinal peptide

Answer 365

Histamine is released from enterochromaffin cells in the stomach mucosa which stimulates acid secretion. It is usually released in response to increased serum gastrin levels. Histamine blockers (e.g. cimetidine) were extremely popular treatments until the advent of proton pump inhibitors.

Question 366

Which of the following statements relating to omphalocele is false? The herniated organs lie outside the peritoneal sac Cardiac abnormalities co-exist in 25% The caecum is usually right sided The defect occurs through the umbilicus Mortality may be as high as 15%

Answer 366

Gastroschisis: Isolated abnormality, bowel lies outside abdominal wall through defect located to right of umbilicus. Exomphalos: Liver and gut remain covered with membranous sac connected to umbilical cord. It is associated with other developmental defects. They are contained within the peritoneal sac and therefore do not have the fluid losses seen in gastroschisis. True malrotation is unusual and minor variants may not result in a requirement for surgery.

Question 367

A 24 year old man falls and lands astride a manhole cover. He suffers from an injury to the anterior bulbar urethra. Where will the extravasated urine tend to collect? Lesser pelvis Connective tissue of the scrotum Deep perineal space Ischiorectal fossa Posterior abdominal wall

Answer 367

Connective tissue of the scrotum This portion of the urethra is contained between the perineal membrane and the membranous layer of the superficial fascia. As these are densely adherent to the ischiopubic rami, extravasated urine cannot pass posteriorly because the 2 layers are continuous around the superficial transverse perineal muscles.

Question 368

Theme: Voice disorders A.Vagus nerve injury B.Thyroid nerve injury C.Superior laryngeal nerve injury D.Unilateral inferior laryngeal nerve injury E.Bilateral inferior laryngeal nerves injuries F.Stroke G.Lacunar infarcts H.None of the above Please select the most likely reason for the scenarios given. Each option may be used once, more than once or not at all. 26.A 42 year old singer is admitted for a thyroidectomy. Post operatively she is only able to make a gargling noise. Her voice sounds breathy. A 42 year old singer is admitted for a thyroidectomy. Post operatively she is unable to sing high pitched notes. A 42 year old singer is admitted for a thyroidectomy. Post operatively the patient develops stridor and is unable to speak.

Answer 368

Unilateral inferior laryngeal nerve injury This patient has diplophonia which causes a gargling sound. This is associated with dysphagia. This can also be caused by a vagus nerve lesion, but the recurrent laryngeal nerve is more at risk of damage. Superior laryngeal nerve injury SLN lesions cause difficulty in voice pitch. Bilateral inferior laryngeal nerves injuries This patient has aphonia due to bilateral damage to the recurrent laryngeal nerve.

Question 369

What are the two main nerves involved in voice production?

Answer 369

SLN RLN

Question 370

SLN innervates?

Answer 370

Cricothyroid muscle

Question 371

SLN action?

Answer 371

Innervates the cricothyroid muscle Since the cricothyroid muscle is involved in adjusting the tension of the vocal fold for high notes during singing, SLN paresis and paralysis result in: a. Abnormalities in pitch b. Inability to sing with smooth change to each higher note (glissando or pitch glide)

Question 372

RLN innervates?

Answer 372

Intrinsic larynx muscles

Question 373

RLN action?

Answer 373

Innervates intrinsic larynx muscles a. Opening vocal folds (as in breathing, coughing) b. Closing vocal folds for vocal fold vibration during voice use c. Closing vocal folds during swallowing

Question 374

A footballer is injured in a match and is being assessed in the outpatient department. On examination he has a positive valgus stress test and minimal joint effusion. What is the most likely underlying injury? Injury to the lateral collateral ligament Injury to the medial collateral ligament Injury to the anterior cruciate ligament Injury to the posterior cruciate ligament Injury to the patellar tendon

Answer 374

A knee injury in the footballer with a positive valgus stress test is usually associated with MCL injury.

Question 375

Anatomy of the MCL?

Answer 375

The tibial collateral ligament is a broad, flat band. Its upper end has an extensive attachment to the medial epicondyle of the femur with some fibres projecting onto the adductor magnus tendon. The ligament passes downwards and forwards to the medial side of the tibia. The deepest fibres are fused with the medial meniscus.

Question 376

Anatomy of the LCL?

Answer 376

The fibular collateral ligament is round and cord like and stands clear of the thin, lateral part of the fibrous capsule. It is enclosed within the fascia lata. It passes from the lateral epicondyle of the femur to the head of the fibula in front of its highest point and splits the tendon of biceps femoris. On the lateral side of the joint the fibres are short and weak and bridge the interval between the femoral and tibial condyles. The popliteus tendon intervenes between the lateral meniscus and the capsule.

Question 377

Action of the collateral knee ligaments?

Answer 377

The tibial and fibular collateral ligaments prevent disruption of the joint at the sides. They are most tightly stretched in extension, and then their direction- the fibular ligament downwards and backwards, the tibial downwards and forwards- prevents rotation of the tibia laterally or the femur medially. Rotation may be demonstrated in the flexed knee.

Question 378

Which knee collateral is most susceptible to injury?

Answer 378

MCL

Question 379

Grade 1 collateral knee ligament injury

Answer 379

Minor tearing of ligament fibres Negative instability tests Conservative (analgesia and physiotherapy)

Question 380

Grade 2 knee collateral ligament injury

Answer 380

``` Ligament laxity (seen with knee in 30oflexion) Knee stable when joint extended ``` Usually splinting or casting for 4-6 weeks

Question 381

Grade 3 knee ligament injury

Answer 381

Ligament completely torn Joint instability Surgical ligament reconstruction

Question 382

Theme: Bilious vomiting in neonates A.Biliary atresia B.Intestinal malrotation C.Ileal atresia D.Necrotising enterocolitis E.Duodenal atresia F.Meconium ileus G.Viral gastroenteritis H.Pyloric stenosis Please select the most likely underlying cause of bilious vomiting for the situation described. Each option may be used once, more than once or not at all. 30.A male infant is born prematurely at 26 weeks gestation by emergency cesarean section. Following the birth he develops respiratory distress syndrome and is ventilated. He begins to improve twelve days after birth. Then he becomes unwell and develops abdominal distension and passes bloody stools and vomits a small quantity of bile stained vomit. A male infant is born by spontaneous vaginal delivery at 39 weeks gestation. He is well after the birth, established on bottle feeding and discharged home. His parents are concerned because he subsequently becomes unwell and vomits a large quantity of bile stained vomit approximately 2 days after discharge home. On examination he looks ill and his abdomen is soft and non distended. A female infant is born by cesarean section at 38 weeks gestation for foetal distress. The attending paediatricians notice that she has a single palmar crease and a mongoloid slant to her eyes. Soon after the birth the mother tries to feed the child who has a projectile vomit about 10 minutes after feeding. On examination she has a soft, non distended abdomen.

Answer 382

Necrotising enterocolitis Necrotising enterocolitis often has a delayed presentation and affected infants will typically pass bloody stools. Plain films may show air in the intestinal wall (Pneumatosis). Intestinal malrotation Intestinal malrotation with volvulus will typically compromise the vascularisation and lumenal patency of the gut. This will cause bilious vomiting and the vascular insufficiency will produce a clinical picture of illness at odds with the lack of overt abdominal signs. Delay in diagnosis and surgery will result in established necrosis, perforation and peritonitis. Duodenal atresia Proximally sited atresia will produce high volume vomits which may or may not be bile stained. Abdominal distension is characteristically absent. Whilst under resuscitated children may be a little dehydrated they are seldom severely ill. The presence of Trisomy 21 (palmar and eye signs) increases the likelihood of duodenal atresia.

Question 383

Billious vomiting in neonate 1 in 5000 (higher in Downs syndrome) Few hours after birth AXR shows "double bubble sign, contrast study may confirm

Answer 383

Duodenal atresia

Question 384

Treatment of duodenal atresia?

Answer 384

Dudodenoduodenostomy

Question 385

Billious vomiting in neonate Usually cause by incomplete rotation during embryogenesis Usually 3-7 days after birth, volvulus with compromised circulation may result in peritoneal signs and haemodynamic instability Upper GI contrast study may show DJ flexure is more medially placed, USS may show abnormal orientation of SMA and SMV

Answer 385

Intestinal malrotation with volvulus

Question 386

Treatment of malrotation with volvulus

Answer 386

Ladd's procedure

Question 387

Billious vomiting in neonate Usually caused by vascular insufficiency in utero, usually 1 in 3000 Usually within 24 hours of birth AXR will show air-fluid levels

Answer 387

Jejunal/ ileal atresia

Question 388

Treatment of jejunal/ileal atresia

Answer 388

Laparotomy with primary resection and anastomosis

Question 389

Billious vomiting in neonate Occurs in between 15 and20% of those babies with cystic fibrosis, otherwise 1 in 5000 Typically in first 24-48 hours of life with abdominal distension and bilious vomiting Air - fluid levels on AXR, sweat test to confirm cystic fibrosis

Answer 389

Meconium ileus

Question 390

Treatment of meconium ileus

Answer 390

Surgical decompression, serosal damage may require segmental resection

Question 391

Billious vomiting in neonate Up to 2.4 per 1000 births, risks increased in prematurity and inter-current illness Usually second week of life Dilated bowel loops on AXR, pneumatosis and portal venous air

Answer 391

NEC

Question 392

Treatment of NEC

Answer 392

Conservative and supportive for non perforated cases, laparotomy and resection in cases of perforation of ongoing clinical deterioration

Question 393

Theme: Diarrhoea A.Vibrio cholera B.Yersinia enterocolitica C.Clostridium difficile D.Campylobacter jejuni E.Salmonella spp. F.E. coli (Enterohaemorrhagic) G.E.Coli (Enteroinvasive) What is the most likely infective organism for the scenario given? Each option may be used once, more than once or not at all. 33.A 22 year old chef presents to the medical team with profuse bloody diarrhoea. On further questioning he describes tenesmus. They arrange a sigmoidoscopy which reveals necrosis and ulceration of the descending colon mucosa. A 22 year old Chef presents with abdominal pain in the right iliac fossa. There is an associated temperature and diarrhoea. The SHO takes the patient to theatre for an appendicectomy, but the appendix appears normal. The terminal ileum appears thickened and engorged. A 30 year old aid worker becomes unwell whilst helping at the scene of a recent earthquake. He develops vomiting and soon afterwards a diarrhoea that is loose and extremely watery.

Answer 393

E.Coli (Enteroinvasive) Necrosis and ulcers of the large bowel are a feature of enteroinvasive E.coli. It presents with a dysentery type illness similar to shigellosis. Yersinia enterocolitica Yersinia can be mistaken for acute appendicitis due to mesenteric lymphadenitis and ileitis. Yersinia infection of the terminal ileum typically produces more marked clinical changes of this segment of bowel than infection with campylobacter. Vibrio cholera The passage of very loose and watery stools distinguishes cholera. Most gastroenteric infections do not produce such watery motions.

Question 394

Most common cause of acute infective diarrhoea Spiral, gram negative rods Usually infects caecum and terminal ileum. Local lymphadenopathy is common May mimic appendicitis as it has marked right iliac fossa pain Reactive arthritis is seen in 1-2% of cases

Answer 394

Campylobacterjejuni

Question 395

Members of the enterobacteriaceae Gram negative bacilli Clinically causes dysentery Shigella soneii is the commonest infective organism (mild illness) Usually self limiting, ciprofloxacin may be required if individual is in a high risk group

Answer 395

Shigella spp.

Question 396

Facultatively anaerobic, gram negative, enterobacteriaceae Infective dose varies according to subtype Salmonellosis: usually transmitted by infected meat (especially poultry) and eggs

Answer 396

Salmonellaspp

Question 397

Enteropathogenic Enteroinvasive: dysentery, large bowel necrosis/ulcers Enterotoxigenic: small intestine, travelers diarrhoea Enterohaemorrhagic: 0157, cause a haemorrhagic colitis, haemolytic uraemic syndrome and thrombotic thrombocytopaenic purpura

Answer 397

E. coli

Question 398

Gram negative, coccobacilli Typically produces a protracted terminal ileitis that may mimic Crohns disease Differential diagnosis acute appendicitis May progress to septicaemia in susceptible individuals Usually sensitive to quinolone or tetracyclines

Answer 398

Yersinia enterocolitica

Question 399

Short, gram negative rods Transmitted by contaminated water, seafood Symptoms include sudden onset of effortless vomiting and profuse watery diarrhoea Correction of fluid and electrolyte losses are the mainstay of treatment Most cases will resolve, antibiotics are not generally indicated

Answer 399

Vibrio cholera

Question 400

A rapid finger-prick blood test to help diagnosis deep vein thrombosis is developed. Comparing the test to current standard techniques a study is done on 1,000 patients: DVT present DVT absent New test positive 200 100 New test negative 20 680 What is the specificity of the new test? 680/880 200/220 680/780 680/700 200/300

Answer 400

Specificity = true negatives / (true negatives + false positives) = 680 / (680 + 100)

Question 401

Sensitivity

Answer 401

TP / (TP + FN ) Proportion of patients with the condition who have a positive test result

Question 402

Specificity

Answer 402

TN / (TN + FP) Proportion of patients without the condition who have a negative test result

Question 403

Positive predictive value

Answer 403

TP / (TP + FP) The chance that the patient has the condition if the diagnostic test is positive

Question 404

Negative predictive value

Answer 404

TN / (TN + FN) The chance that the patient does not have the condition if the diagnostic test is negative

Question 405

Likelihood ratio for a positive test result

Answer 405

sensitivity / (1 - specificity) How much the odds of the disease increase when a test is positive

Question 406

Likelihood ratio for a negative test result

Answer 406

(1 - sensitivity) / specificity How much the odds of the disease decrease when a test is negative

Question 407

Difference between predictive values and likelihood ratios

Answer 407

Positive and negative predictive values are prevalence dependent. Likelihood ratios are not prevalence dependent

Question 408

A 22 year old man suffers 20% partial and full thickness burns in a house fire. There is an associated inhalational injury. It is decided to administer intravenous fluids to replace fluid losses. Which of the intravenous fluids listed below should be used for initial resuscitation? Dextran 40 5% Dextrose Fresh frozen plasma Hartmans solution Blood

Answer 408

In most units a crystalloid such as Hartmans (Ringers lactate) is administered initially. Controversy does remain and some units do prefer colloid. Should this leak in the interstial tissues this may increase the risk of oedema.

Question 409

Features of fluid resuscitation in burns?

Answer 409

\>15% total body area burns in adults (\>10% children) The main aim of resuscitation is to prevent the burn deepening Most fluid is lost 24 hours after injury First 8-12 hour fluid shifts are from intravascular to interstitial fluid compartments Therefore circulatory volume can be compromised. However fluid resuscitation causes more fluid into the interstitial compartment especially colloid (therefore avoided in first 8-24 hours) Protein loss occurs

Question 410

Fluid resuscitation formula=

Answer 410

Parkland formula (Crystallod only) 4ml x total burn surface area x body weight 50% in first 8 hours 50% in next 16 hours

Question 411

What is the resuscitation endpoint for fluids in burns?

Answer 411

Urine output of 0.5-1.0ml/kg/hr

Question 412

When is the starting point of fluid resuscitation in burns injury?

Answer 412

Time of injury

Question 413

What should happen after the first 24 hours in fluid resuscitaiton of burns injuries?

Answer 413

Maintenance crystalloid (usually dextrose-saline) is continued at a rate of 1.5 ml x(burn area)x(body weight) Colloids are rarely used (e.g. albumin) Antioxidants, such as vitamin C, can be used to minimize oxidant-mediated contributions to the inflammatory cascade in burns High tension electrical injuries and inhalation injuries require more fluid Monitor: packed cell volume, plasma sodium, base excess, and lactate Next question

Question 414

A 73 year old man presents with symptoms of mesenteric ischaemia. As part of his diagnostic work up a diagnostic angiogram is performed .The radiologist is attempting to cannulate the coeliac axis from the aorta. At which of the following vertebral levels does this is usually originate? T10 L2 L3 T8 T12

Answer 414

Coeliac trunk branches: Left Hand Side (LHS) Left gastric Hepatic Splenic The coeliac axis branches off the aorta at T12.

Question 415

Anterior relations of the coeliac axis?

Answer 415

Lesser omentum

Question 416

Right relations of the coeliac axis?

Answer 416

Right coeliac ganglion and caudate process of liver

Question 417

Left relation of coeliac axis

Answer 417

Left coeliac ganglion and gastric cardia

Question 418

Inferior relation of coeliac axis

Answer 418

Upper border of pancreas and renal vein

Question 419

A 45 year old man with long standing ulcerative colitis and rectal dysplasia presents with a DALM lesion in the rectum. What is the most appropriate management option? Snare polypectomy Repeat endoscopy in 2 years Discharge Anterior resection Panproctocolectomy

Answer 419

DALM lesions complicating ulcerative colitis should be managed with panproctocolectomy. An anterior resection is inadequate since it will only remove the rectum and ulcerative colitis affects the entire colon. Since many will be associated with invasion a snare polypectomy is not sufficient either.

Question 420

DALM lesion

Answer 420

The term DALM lesion refers to a Dysplasia Associated Lesion or Mass. They may complicate dysplasia occurring in patients with longstanding ulcerative colitis. They have a high incidence of invasive foci. When they complicate longstanding ulcerative colitis, they should be treated by panproctocolectomy.

Question 421

Which main group of receptors does dobutamine bind to? α-1 α-2 ß-1 ß-2 D-1

Answer 421

Dobutamine is a sympathomimetic with both alpha- and beta-agonist properties; it displays a considerable selectivity for beta1-cardiac receptors.

Question 422

Theme: Open fractures A.Immediate skeletal stabilisation and application of negative pressure dressing B.Combined skeletal and soft tissue reconstruction on a scheduled operating list C.Thorough wound debridement in the emergency department D.Immediate vascuIar shunting, followed by temporary skeletal stabilisation and vascular reconstruction E.Intravenous antibiotics, photography and application of saline soaked gauze with impermeable dressing F.Application of external fixator and conversion to internal fixation after two weeks G.Fasciotomy with four compartment decompression H.Skeletal fixation followed by vascular reconstruction Please select the most appropriate course of action for the scenario described. Each option may be used once, more than once or not at all. A 30 year old man is admitted overnight, following a road traffic accident. He has an open tibial fracture with a 20 cm wound and extensive periosteal stripping. He is neurovascularly intact and IV antibiotics and wound dressing have been administered in the emergency department. A 50 year old man is admitted after falling from scaffolding. He has an open fracture of his tibia with a 15 cm wound. He is neurovascularly intact. A 40 year old woman is admitted after being knocked off her bike. She has an open fracture of her tibia, with a 10 cm wound. No peripheral pulses are palpable. Intravenous antibiotics have been administered in the emergency department and the wound has been dressed.

Answer 422

Combined skeletal and soft tissue reconstruction on a scheduled operating list This patient has a Gustillo-Anderson Grade 3B open fracture. He will require definitive skeletal and soft tissue reconstruction, which should be performed on a combined ortho-plastic scheduled operating list, as per the BOA/BAPRAS guidelines. The surgery does not have to be performed out of scheduled hours unless there is marine/ sewage contamination, vascular compromise or it is a polytrauma. Whilst it is reasonable to apply an external fixator prior to definitive skeletal and soft tissue reconstruction, this should be converted to internal fixation within 72 hours. Intravenous antibiotics, photography and application of saline soaked gauze with impermeable dressing The initial management of open fractures should include administration of intravenous antibiotics, photography of wound and application of a sterile soaked gauze and impermeable film. The wound should only be handled to remove gross contamination. The patient is then likely to require definitive skeletal and soft tissue reconstruction. Immediate vascuIar shunting, followed by temporary skeletal stabilisation and vascular reconstruction This patient has a Gustillo-Anderson Grade 3C open fracture with vascular injury. Vascular impairment requires immediate surgery and restoration of circulation, ideally within 3-4 hours. This should follow the sequence of shunting, temporary skeletal stabilisation and then vascular reconstruction as per BOA / BAPRAS guidelines. Revascularisation using vascular shunts should be performed before skeletal fixation.

Question 423

def: open fracture

Answer 423

The term open fracture refers to a disruption of the bony cortex associated with a breach in the overlying skin. Any wound that is present in the same limb as a fracture should be suspected as being representative of an open fracture. One of the main problems with open fractures is the associated injuries to the surrounding soft tissues. Whilst the skin is usually relatively resistant to trauma, underlying muscle can be damaged or devitalised, nerves, blood vessels and periosteum may all be disrupted the degree to which this occurs correlates with the severity of the injury and the outcome.

Question 424

What can be used to grade the severity of open fracutres?

Answer 424

Gustilo and Anderson system

Question 425

Gustilo and Anderson system 1

Answer 425

Low energy wound \<1 cm

Question 426

Gustilo and Anderson system 2

Answer 426

Greater than 1cm wound with moderate soft tissue damage

Question 427

Gustilo and Anderson system 3

Answer 427

High energy wound \>1cm with extensive soft tissue damage

Question 428

Gustilo and Anderson system 3A

Answer 428

Adequate soft tissue coverage

Question 429

Gustilo and Anderson system 3b

Answer 429

Inadequate soft tissue coverage

Question 430

Gustilo and Anderson system 3C

Answer 430

Associated arterial injury

Question 431

What can be used to predict the need for primary amputation in Gustilo Andesron 3C injuries?

Answer 431

Mangled extremity scoring system (MESS)

Question 432

Initial management of open fractures?

Answer 432

Initial management should focus on careful patient examination to check for associated injuries, control of haemorrhage and the extent of injury. The area should be carefully imaged, distal neurovascular status established the wound covered with a dressing and antibiotics administered. Early debridement is the cornerstone of the management of open fractures. The aim of the debridement is to remove foreign material and devitalised tissue. In most cases the wound is left open. The wound should be irrigated, generally, 6 litres of saline is used. The fracture should be stabilised and an external fixator is often used in the first instance

Question 433

A 43 year old man is diagnosed as having a malignancy of the right adrenal gland. The decision is made to resect this via an open anterior approach. Which of the following will be most useful during the surgery? Division of the coronary ligaments of the liver Mobilisation of the colonic hepatic flexure Division of the right renal vein Division of the ligament of Trietz Division of the right colic artery

Answer 433

Mobilisation of the hepatic flexure and right colon are standard steps in open adrenal surgery from an anterior approach. Mobilisation of the liver is seldom required.

Question 434

Causes of craniomaxillofacial injuries in the UK?

Answer 434

Interpersonal violence (52%) Motor vehicle accidents (16%) Sporting injuries (19%) Falls (11%)

Question 435

Le Fort fracture

Answer 435

Le Fort fractures are fractures of the midface, which collectively involve separation of all or a portion of the midface from the skull base. In order to be separated from the skull base, the pterygoid plates of the sphenoid bone need to be involved as these connect the midface to the sphenoid bone dorsally. The Le Fort classification system attempts to distinguish according to the plane of injury.

Question 436

Le Fort 1

Answer 436

The fracture extends from the nasal septum to the lateral pyriform rims, travels horizontally above the teeth apices, crosses below the zygomaticomaxillary junction, and traverses the pterygomaxillary junction to interrupt the pterygoid plates.

Question 437

Le Fort 2

Answer 437

These fractures have a pyramidal shape and extend from the nasal bridge at or below the nasofrontal suture through the frontal process of the maxilla, inferolaterally through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus; it then travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plates.

Question 438

Le Fort 3

Answer 438

These fractures start at the nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit through the nasolacrimal groove and ethmoid bones. The thicker sphenoid bone posteriorly usually prevents continuation of the fracture into the optic canal. Instead, the fracture continues along the floor of the orbit along the inferior orbital fissure and continues superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic arch. Intranasally, a branch of the fracture extends through the base of the perpendicular plate of the ethmoid, through the vomer, and through the interface of the pterygoid plates to the base of the sphenoid. This type of fracture predisposes the patient to CSF rhinorrhea more commonly than the other types.

Question 439

Superior orbital fissure syndrome

Answer 439

Severe force to the lateral wall of the orbit resulting in compression of neurovascular structures. Results in : Complete opthalmoplegia and ptosis (Cranial nerves 3, 4, 6 and nerve to levator palpebrae superioris) Relative afferent pupillary defect Dilatation of the pupil and loss of accommodation and corneal reflexes Altered sensation from forehead to vertex (frontal branch of trigeminal nerve)

Question 440

Severe force to the lateral wall of the orbit resulting in compression of neurovascular structures. Results in : Complete opthalmoplegia and ptosis (Cranial nerves 3, 4, 6 and nerve to levator palpebrae superioris) Relative afferent pupillary defect Dilatation of the pupil and loss of accommodation and corneal reflexes Altered sensation from forehead to vertex (frontal branch of trigeminal nerve)

Answer 440

SOF syndrome

Question 441

Typically occurs when an object of slightly larger diameter than the orbital rim strikes the incompressible eyeball. The bone fragment is displaced downwards into the antral cavity, remaining attached to the orbital periosteum. Periorbital fat may be herniated through the defect, interfering with the inferior rectus and inferior oblique muscles which are contained within the same fascial sheath. This prevents upward movement and outward rotation of the eye and the patient experiences diplopia on upward gaze. The initial bruising and swelling may make assessment difficult and patients should usually be reviewed 5 days later. Residual defects may require orbital floor reconstruction.

Answer 441

Orbital blow out fracture

Question 442

Features of nasal fracture

Answer 442

Common injury Ensure new and not old deformity Control epistaxis CSF rhinorrhoea implies that the cribriform plate has been breached and antibiotics will be required. Usually best to allow bruising and swelling to settle and then review patient clinically. Major

Question 443

Presentation of retrobulbar haemorrhage PPPPV

Answer 443

Rare but important ocular emergency. Presents with: Pain (usually sharp and within the globe) Proptosis Pupil reactions are lost Paralysis (eye movements lost) Visual acuity is lost (colour vision is lost first) May be the result of Le Fort type facial fractures.

Question 444

Rare but important ocular emergency. Presents with: Pain (usually sharp and within the globe) Proptosis Pupil reactions are lost Paralysis (eye movements lost) Visual acuity is lost (colour vision is lost first) May be the result of Le Fort type facial fractures.

Answer 444

Retrobulbar haemorrhage

Question 445

Management of retrobulbar haemorrhage

Answer 445

Mannitol 1g/Kg as 20% infusion, Osmotic diuretic, Contra-indicated in congestive heart failure and pulmonary oedema Acetazolamide 500mg IV, (Monitor FBC/U+E) Reduces aqueous pressure by inhibition of carbonic anhydrase (used in glaucoma) Dexamethasone 8mg orally or intravenously In a traumatic setting an urgent cantholysis may be needed prior to definitive surgery. Consider Papaverine 40mg smooth muscle relaxant Dextran 40 500mls IV improves perfusion

Question 446

Which of the metastatic bone tumours described below is at the greatest risk of pathological fracture ? Proximal humeral lesion from a prostate cancer Vertebral body lesions from a prostate cancer Peritrochanteric lesion from a carcinoma of the breast Proximal humeral lesion from a carcinoma of the breast Peritrochanteric lesion from a prostate cancer

Answer 446

Peritrochanteric lesions have the greatest risks of fracture (due to loading). The lesions from breast cancer are usually lytic and therefore at higher risk rather than the sclerotic lesions from prostate cancer.

Question 447

Features of metastatic bone disease

Answer 447

Metastatic bone tumours may be described as blastic, lytic or mixed. Osteoblastic metastatic disease has the lowest risk of spontaneous fracture when compared to osteolytic lesions of a similar size. Lesions affecting the peritrochanteric region are most prone to spontaneous fracture (because of loading forces at that site).

Question 448

What is the use of the Mirel Scoring system?

Answer 448

The factors are incorporated into the Mirel Scoring system to stratify the risk of spontaneous fracture for bone metastasis of varying types.

Question 449

Factors scoring 1 point on Mirel system

Answer 449

Upper extremity Blastic Less than 1/3 of bone involved Mild pain

Question 450

Factors scoring 2 points on Mirel scoring system?

Answer 450

Lower extremity Mixed 1/3 to 2/3 bone width Moderate pain

Question 451

Factors scoring 3 points on Mirel scoring system?

Answer 451

Peritrochanteric Lytic More than 2/3 bone width Pain aggravated by function

Question 452

Risk of # Mirel \>9

Answer 452

Impending (33%)

Question 453

Risk of # Mirel \<7

Answer 453

Not impending (4%)

Question 454

Risk of fracture Mirel 8

Answer 454

Borderline

Question 455

Treatment of Mirel \>9

Answer 455

Prophylactic fixation

Question 456

Treatment of Mirel 8

Answer 456

Consider fixation

Question 457

Treatment of Mirel 7 or less

Answer 457

Non operative management

Question 458

Features of calcitonin

Answer 458

Secreted by C cells of thyroid Inhibits intestinal calcium absorption Inhibits osteoclast activity Inhibits renal tubular absorption of calcium

Question 459

A 45 year old man presents with a lipoma located posterior to the posterior border of the sternocleidomastoid muscle, approximately 4cm superior to the middle third of the clavicle. During surgical excision of the lesion troublesome bleeding is encountered. Which of the following is the most likely source? Internal jugular vein External jugular vein Common carotid artery Vertebral artery Second part of the subclavian artery

Answer 459

The external jugular vein runs obliquely in the superficial fascia of the posterior triangle. It drains into the subclavian vein. During surgical exploration of this area the external jugular vein may be injured and troublesome bleeding may result. The internal jugular vein and carotid arteries are located in the anterior triangle. The third, and not the second, part of the subclavian artery is also a content of the posterior triangle

Question 460

Theme: Levels of spinal injury A.C2 B.C3 C.C4 D.C5 E.C6 F.L1 G.L2 H.L3 I.L4 J.L5 Please select the most likely spinal level for the injury described. Each option may be used once, more than once or not at all. 50.A 62 year old male complains of back pain. He has had a recent fall. Walking causes pain of the left lower leg. On examination he is noted to have reduced sensation over the knee. A 42 year old woman is found to have a burst fracture of the C5 vertebral body. After a few months where would the level of injury be? A 56 year old man suddenly develops severe back pain. His pain has a radicular pattern. On examination he is unable to extend his great toe.

Answer 460

L3 Sensation over the knee is equivalent to the L3 dermatome. The four nerves involved include the infrapatellar branch of the saphenous nerve, the lateral cutaneous nerve of the thigh, anterior cutaneous nerve of the thigh (both lateral and medial branches) C6 A C5 burst fracture usually injures the C6 spinal cord situated at the C5 vertebrae and also the C4 spinal roots that exit the spinal column between the C4 and C5 vertebra. Such an injury should cause a loss of sensations in C4 dermatome and weak deltoids. Due to oedema , the biceps (C5) may be initially weak but should recover. The wrist extensors (C6), however, should remain weak and sensation at and below C6 should be severely compromised. A neurosurgeon would conclude that there is a burst fracture at C5 from the x-rays, an initial sensory level at C4 (the first abnormal sensory dermatome) and the partial loss of deltoids and biceps would imply a motor level at C4 (the highest abnormal muscle level). Over time, as the patient recovers the C4 roots and the C5 spinal cord, both the sensory level and motor level should end up at C6. Such recovery is often attributed to 'root' recovery. L5 Extensor hallucis longus is derived from L5 and loss of EHL function is a useful test to determine whether this level is involved.

Question 461

Elbow flexors/Biceps

Answer 461

C5

Question 462

Wrist extensors

Answer 462

C6

Question 463

Elbow extensors/Triceps

Answer 463

C7

Question 464

Long finger flexors

Answer 464

C8

Question 465

Small finger abductors

Answer 465

T1

Question 466

Hip flexors (psoas)

Answer 466

L1 and L2

Question 467

Knee extensors (quadriceps)

Answer 467

L3

Question 468

Ankle dorsiflexors (tibialis anterior)

Answer 468

L4 and L5

Question 469

Toe extensors (hallucis longus)

Answer 469

L 5

Question 470

Ankle plantar flexors (gastrocnemius)

Answer 470

S1

Question 471

The anal sphincter is innervated by

Answer 471

S2,3,4

Question 472

Which of the following transplants is most susceptible to donor- recipient HLA mismatches? Autologous skin graft Renal allograft Liver allograft Corneal allograft Cardiac valve allograft

Answer 472

Autologous transplant- same individual (genetically identical) Allograft - Genetically different The kidney is highly susceptible to HLA mismatches and hyperacute rejection may occur in patients with IgG anti HLA Class I antibodies. The liver is at far lower risk of rejection of this nature. Although the heart is sensitive to HLA mismatches this is less than the kidney. Cardiac valves and the cornea incite little immunological response.

Question 473

Epidemiology of bladder cancer

Answer 473

Bladder cancer is the second most common urological cancer. It most commonly affects males aged between 50 and 80 years of age. Those who are current, or previous (within 20 years), smokers have a 2-5 fold increased risk of the disease. Exposure to hydrocarbons such as 2-Naphthylamine increases the risk. Although rare in the UK, chronic bladder inflammation arising from Schistosomiasis infection remains a common cause of squamous cell carcinomas, in those countries where the disease is endemic.

Question 474

Histopathology of bladder cancer

Answer 474

Transitional cell carcinoma (\>90% of cases) Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis) Adenocarcinoma (2%)

Question 475

Chance of malignancy in females \>50 with microscopic haematuria

Answer 475

10% once infection excluded

Question 476

What proportion of patients with TCC will present with painless macroscopic haematuira?

Answer 476

85%

Question 477

Staging of bladder cancer

Answer 477

Most will undergo a cystoscopy and biopsies or TURBT, this provides histological diagnosis and information relating to depth of invasion. Locoregional spread is best determined using pelvic MRI and distant disease CT scanning. Nodes of uncertain significance may be investigated using PET CT.

Question 478

Treatment of bladder cancer

Answer 478

Those with superficial lesions may be managed using TURBT in isolation. Those with recurrences or higher grade/ risk on histology may be offered intravesical chemotherapy. Those with T2 disease are usually offered either surgery (radical cystectomy and ileal conduit) or radical radiotherapy.

Question 479

Theme: Neck lumps A.Cystic hygroma B.Bartonella infection C.Mycobacterium tuberculosis infection D.Branchial cyst E.Thyroglossal cyst F.Pharyngeal pouch G.Follicular thyroid cyst H.Parathyroid adenoma I.None of the above Please select the most likely underlying disease process for the scenario given. Each option may be used once, more than once or not at all. 55.A 25 year old cat lover presents with symptoms of abdominal pain, lethargy and sweats. These have been present for the past two weeks. On examination she has lymphadenopathy in the posterior triangle. A 25 year old lady presents with an swelling located at the anterior border of the sternocleidomastoid muscle. The swelling is intermittent and on examination it is soft and fluctuant. A 38 year old lady presents with a mass in the midline of the neck immediately below the hyoid bone. It moves upwards on tongue protrusion.

Answer 479

Bartonella infection Bartonella infection may occur following a cat scratch. The organism is intracellular. Generalised systemic symptoms may occur for a week or so prior to clinical presentation. Branchial cyst Branchial cysts are remnants of the branchial cleft. They may become infected. Thyroglossal cyst Thyroglossal cysts are usually located in the midline and are linked to the foramen caecum and will thus move upwards on tongue protrusion.

Question 480

An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx Develop due to failure of obliteration of the second branchial cleft in embryonic development Usually present in early adulthood

Answer 480

Branchial cyst

Question 481

A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side Most are evident at birth, around 90% present before 2 years of age

Answer 481

Cystic hygroma

Question 482

The sciatic nerve lies deep to the following structures except: Gluteus maximus The femoral cutaneous nerve Long head of biceps femoris Gluteus medius Branch of the inferior gluteal artery

Answer 482

The gluteus medius does not extend around to the sciatic nerve.

Question 483

Origin of the sciatic nerve?

Answer 483

Spinal nerves L4 - S3

Question 484

Articular branches of the sciatic nerve?

Answer 484

Hip joint

Question 485

Muscular branches of the sciatic nerve in the upper leg?

Answer 485

Semitendinosus Semimembranosus Biceps femoris Part of adductor magnus

Question 486

Cutaneous sensation carried by the sciatic nerve?

Answer 486

Posterior aspect of thigh (via cutaneous nerves) Gluteal region Entire lower leg (except the medial aspect)

Question 487

Termination of the sciatic nerve?

Answer 487

At the upper part of the popliteal fossa by dividing into the tibial and peroneal nerves

Question 488

Make up of the upper limb branches of the sciatic nerve?

Answer 488

The nerve to the short head of the biceps femoris comes from the common peroneal part of the sciatic and the other muscular branches arise from the tibial portion.

Question 489

Bascom theory of pilonidal sinuses

Answer 489

Occur as a result of hair debris creating sinuses in the skin (Bascom theory).

Question 490

A 22 year old man presents with a discharging area on his lower back. On examination there is an epithelial defect located 6cm proximal to the tip of his coccyx and located in the midline. There are two further defects located about 2cm superiorly in the same position. He is extremely hirsute. What is the most likely diagnosis? Pre sacral tumour Sacrococcygeal teratoma Pilonidal sinus Fistula in ano Occult spina bifida

Answer 490

Pilonidal sinuses are extremely common in hirsute individuals and typically present as midline sinuses in the natal cleft

Question 491

Chronic pilonidal sinus disease may be a risk factor for?

Answer 491

Squamous cell carcinoma

Question 492

Bascom procedure

Answer 492

Treatment of pilonidal sinus- excision of the pits and obliteration of the underlying cavity

Question 493

Karydakis procedure

Answer 493

Treatment of pilonidal sinus: involves wide excision of the natal cleft such that the surface is recontoured once the wound is closed. This avoids the shearing forces that break off the hairs and has reasonable results.

Question 494

A 67 year old patient is due to undergo a femoro-popliteal bypass graft. Which heparin regime should the surgeon ask for prior to cross clamping the femoral artery? Single therapeutic dose of low molecular weight heparin on the ward prior to coming to theatre Single therapeutic dose of low molecular weight heparin the night before surgery Dose of 10,000 units of unfractionated heparin prior to induction of anaesthesia Dose of 3,000 units of unfractionated heparin, 3 minutes prior to cross clamping Dose of 30,000 units of unfractionated heparin, 3 minutes prior to cross clamping

Answer 494

As a rule most vascular surgeons will administer approximately 3,000 units of systemic heparin 3-5 minutes prior to cross clamping to help prevent further intra arterial thromboses. A dose of 30,000 units is given prior to going on cardiopulmonary bypass. Heparin given at induction will cause bleeding during routine dissection.

Question 495

Action of heparin

Answer 495

Causes the formation of complexes between antithrombin and activated thrombin/factors 7,9,10,11 & 12

Question 496

What is the half life of insulin in the circulation of a normal healthy adult? Less than 30 minutes Between 1 and 2 hours Between 2 and 3 hours Between 4 and 5 hours Over 6 hours

Answer 496

Insulin is degraded by enzymes in the circulation. It typically has a half life of less than 30 minutes. Abnormalities of the clearance of insulin may occur in type 2 diabetes.

Question 497

Structure of insulin

Answer 497

The human insulin protein is composed of 51 amino acids, and has a molecular weight of 5808 Da. It is a dimer of an A-chain and a B-chain, which are linked together by disulfide bonds.

Question 498

An 18 year old lady presents with extensive varicose veins of her left leg. There is associated port wine staining. What is the most likely diagnosis? Type 1 diabetes Osler syndrome Gardner's syndrome Proteus syndrome Klippel-Trenaunay-Weber syndrome

Answer 498

A less common cause of venous insufficiency is Klippel-Trenaunay-Weber (KTW) syndrome, which involves port-wine stains, varicose veins, and bony or soft-tissue hypertrophy.

Question 499

Features of venous insufficiency?

Answer 499

nclude oedema, brown pigmentation, lipodermatosclerosis, eczema

Question 500

Treatment of venous leg ulcers?

Answer 500

Management: 4 layer compression banding after exclusion of arterial disease or surgery If fail to heal after 12 weeks or \>10cm2 skin grafting may be needed

Question 501

Causes of venous leg ulcers

Answer 501

Most due to venous hypertension, secondary to chronic venous insufficiency (other causes include calf pump dysfunction or neuromuscular disorders)

Question 502

Squamous cell carcinoma Occurring at sites of chronic inflammation e.g; burns, osteomyelitis after 10-20 years Mainly occur on the lower limb

Answer 502

Marjolin's ulcer

Question 503

Occur on the toes and heel Painful There may be areas of gangrene Cold with no palpable pulses Low ABPI measurements

Answer 503

Arterial ulcers

Question 504

Commonly over plantar surface of metatarsal head and plantar surface of hallux The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients Due to pressure Management includes cushioned shoes to reduce callus formation

Answer 504

Neuropathic ulcers