Block 5

Question 1

Associated with inflammatory bowel disease/RA

Can occur at stoma sites

Erythematous nodules or pustules which ulcerate

Answer 1

Pyoderma gangrenosum

Question 2

What condition most commonly leads to amputation in diabetics?

Answer 2

Plantar neuropathic ulcer

Question 3

Which of the following statements about blood clotting is untrue?

Platelet adhesion to disrupted endothelium is dependent upon von Willebrand factor

Protein C is a vitamin K dependent substance

The bleeding time provides an assessment of platelet function

The prothrombin time tests the extrinsic system

Administration of aprotinin during liver transplantation surgery prolongs survival

Answer 3

Administration of aprotinin during liver transplantation surgery prolongs survival

Although aprotinin reduces fibrinolysis and thus bleeding, it is associated with increased risk of death and was withdrawn in 2007. Protein C is dependent upon vitamin K and this may paradoxically increase the risk of thrombosis during the early phases of warfarin treatment.

Question 4

Which of the following upper limb muscles is not innervated by the radial nerve?

Extensor carpi ulnaris

Abductor digiti minimi

Anconeus

Supinator

Brachioradialis

Answer 4

Mnemonic for radial nerve muscles: BEST

B rachioradialis
E xtensors
S upinator
T riceps

Abductor digiti minimi is innervated by the ulnar nerve.

Question 5

Root values of the radial nerve

Answer 5

C5-T1

Question 6

Path of the radial nerve

Answer 6

In the axilla: lies posterior to the axillary artery on subscapularis, latissimus dorsi and teres major.

Enters the arm between the brachial artery and the long head of triceps (medial to humerus).

Spirals around the posterior surface of the humerus in the groove for the radial nerve.

At the distal third of the lateral border of the humerus it then pierces the intermuscular septum and descends in front of the lateral epicondyle.

At the lateral epicondyle it lies deeply between brachialis and brachioradialis where it then divides into a superficial and deep terminal branch.

Deep branch crosses the supinator to become the posterior interosseous nerve.

Question 7

Theme: Surgical analgesia

A.Amitriptylline

B.Pregabalin

C.Duloxetine

D.Paracetamol

E.Diclofenac

F.Nefopam

G.Morphine

Please select the most appropriate analgesic modality for the scenario given. Each option may be used once, more than once or not at all.

1.A 72 year old man attends vascular clinic after having an amputation 2 months ago. He is having difficulty sleeping at night due to persistent tingling at the amputation site. He is known to have orthostatic hypotension.

A 64 year old type 2 diabetic is referred to vascular clinic with painful foot ulcers. His ABPI is 0.6. On further questioning the patient reports a burning sensation in both of his feet.

A 24 year old man has had a fracture of the tibia after playing football. He arrives in the emergency room distressed and in severe pain.

Answer 7

Pregabalin

This patient has phantom limb pain which is a neuropathic pain. First line management is with amitriptylline or pregabalin. However this patient has orthostatic hypotension, which is a side effect of amitriptylline, therefore pregabalin is the treatment of choice.

Duloxetine

This NICE guidelines state that duloxetine should be used as a 1st line agent in diabetic neuropathic pain.

Morphine

This type of injury will require morphine. However, timely fracture splinting will have a significant analgesic effect.

Question 8

A 43 year old man from Greece presents with colicky right upper quadrant pain, jaundice and an urticarial rash. He is initially treated with ciprofloxacin, but does not improve. What is the most likely diagnosis?

Infection with Wucheria bancrofti

Infection with Echinococcus granulosus

Type III hypersensitivity reaction

Allergy to ciprofloxacin

Common bile duct stones

Answer 8

Infection with Echinococcus granulosus will typically produce a type I hypersensitivity reaction which is characterised by an urticarial rash. With biliary rupture a classical triad of biliary colic, jaundice and urticaria occurs. Whilst jaundice and biliary colic may be a feature of CBD stones they do not produce an urticarial rash. Antibiotic sensitivity with ciprofloxacin may produce jaundice and a rash, however it was not present at the outset and does not cause biliary colic.

Question 9

Hydatid cysts are endemic in Mediterranean and Middle Eastern countries. They are caused by the tapeworm parasite

Answer 9

Echinococcus granulosus

Question 10

Up to 90% cysts occur in the liver and lungs

Can be asymtomatic, or symptomatic if cysts > 5cm in diameter

Morbidity caused by cyst bursting, infection and organ dysfunction (biliary, bronchial, renal and cerebrospinal fluid outflow obstruction)

In biliary ruputure there may be the classical triad of; biliary colic, jaundice, and urticaria

Answer 10

Echinococcus granulosus

Question 11

Which of the following forms the floor of the anatomical snuffbox?

Radial artery

Cephalic vein

Extensor pollicis brevis

Scaphoid bone

Cutaneous branch of the radial nerve

Answer 11

The scaphoid bone forms the floor of the anatomical snuffbox. The cutaneous branch of the radial nerve is much more superficially and proximally located.

Question 12

Posterior border of the anatomical snuffbox

Answer 12

Tendon of extensor pollicis longus

Question 13

Anterior border of the anatomical snuffbox

Answer 13

Tendons of extensor pollicis brevis and abductor pollicis longus

Question 14

Proximal border border of the anatomical snuffbox

Answer 14

Styloid process of the radius

Question 15

Distal border of the anatomical snuffbox

Answer 15

Apex of snuffbox triangle

Question 16

Floor of the anatomical snuffbox

Answer 16

trapezium and scaphoid

Question 17

Contents of the anatomical snuffbox

Answer 17

Radial artery

Question 18

During a liver resection a surgeon performs a pringles manoeuvre to control bleeding. Which of the following structures will lie posterior to the epiploic foramen at this level?

Hepatic artery

Cystic duct

Greater omentum

Superior mesenteric artery

Inferior vena cava

Answer 18

The epiploic foramen has the following boundaries:
Anteriorly (in the free edge of the lesser omentum): Bile duct to the right, portal vein behind and hepatic artery to the left.
Posteriorly Inferior vena cava
Inferiorly 1st part of the duodenum
Superiorly Caudate process of the liver

Bleeding from liver trauma or a difficult cholecystectomy can be controlled with a vascular clamp applied at the epiploic foramen.

Question 19

Structure of the liver

Right lobe

Answer 19

Supplied by right hepatic artery

Contains Couinaud segments V to VIII (-/+Sg I)

Question 20

Structure of the liver

Left lobe

Answer 20

Supplied by the left hepatic artery

Contains Couinaud segments II to IV (+/- Sg1)

Question 21

Structure of the liver

Quadrate lobe

Answer 21

Part of the right lobe anatomically, functionally is part of the left

Couinaud segment IV

Porta hepatis lies behind

On the right lies the gallbladder fossa

On the left lies the fossa for the umbilical vein

Question 22

Structure of the liver

Caudate lobe

Answer 22

Supplied by both right and left hepatic arteries

Couinaud segment I

Lies behind the plane of the porta hepatis

Anterior and lateral to the inferior vena cava

Bile from the caudate lobe drains into both right and left hepatic ducts

Question 23

Anterior relations of the liver?

Answer 23

Diaphragm

Xiphoid process

Question 24

Posteroinferior relations of the liver?

Answer 24

Oesophagus

Stomach

Duodenum

Hepatic flexure of colon

Right kidney

Gallbladder

Inferior vena cava

Question 25

Location of the porta hepatis

Answer 25

Postero inferior surface, it joins nearly at right angles with the left sagittal fossa, and separates the caudate lobe behind from the quadrate lobe in front

Question 26

Porta hepatis transmits

Answer 26

Common hepatic duct Hepatic artery Portal vein Sympathetic and parasympathetic nerve fibres Lymphatic drainage of the liver (and nodes)

Question 27

2 layer fold peritoneum from the umbilicus to anterior liver surface Contains ligamentum teres (remnant umbilical vein) On superior liver surface it splits into the coronary and left triangular ligaments

Answer 27

Falciform ligament

Question 28

Ligament that joins the left branch of the portal vein in the porta hepatis

Answer 28

Ligamentum teres

Question 29

Remnant of ductus venosus

Answer 29

Ligamentum venosum

Question 30

Theme: Management of bleeding A.Ligate vessel B.Underrun vessel C.Use of diathermy D.Application of surgicell E.Digital pressure In each of the following scenarios the surgeon has encountered bleeding. Please select the most appropriate immediate management of the situation from the list below. Each option may be used once, more than once or not at all. 7.A 23 year old man is undergoing an open appendicectomy. The surgeons extend the incision medially and suddenly encounter troublesome bleeding. A 45 year old man is undergoing a laparotomy and following incision of the skin multiple bleeding points are identified in the dermis and sub dermal tissues. A 38 year old lady is undergoing a laparotomy when the surgeons damage the common iliac vein whilst commencing a pelvic dissection.

Answer 30

Ligate vessel Theme from April 2012 Exam Medial extension of an appendicectomy incision carries the risk of injury to the inferior epigastric artery. This can bleed briskly and is best managed by ligation. Use of diathermy Multiple bleeding points are best managed through the use of diathermy. Digital pressure Major venous bleeding such as this should be controlled with digital pressure in the first instance. The definitive management will usually consist of suturing the defect closed with prolene sutures. Transection of the common iliac vein will necessitate a major venous reconstruction.

Question 31

Management of superficial dermal bleeding

Answer 31

This will usually cease spontaneously. If it is troublesome then direct use of monopolar or bipolar cautery devices will usually control the situation. Scalp wounds are a notable exception and the bleeding from these may be brisk. In this situation the use of mattress sutures as a wound closure method will usually address the problem.

Question 32

Superficial arterial bleeding

Answer 32

If the vessel can be safely identified then the easiest method is to apply a haemostatic clip and ligate the vessel.

Question 33

Major arterial bleeding

Answer 33

If the vessel can be clearly identified and is accessible then it may be possible to apply a clip and ligate the vessel. If the vessel is located in a pool of blood then blind application of haemostatic clips is highly dangerous and may result in collateral injury. In this situation evacuating the clot and packing the area is often safer. The pack can then be carefully removed when the required instruments are available. Some vessels may retract and bleeding may then be controlled by dissection of surrounding structures or under-running the bleeding point.

Question 34

Major venous bleeding

Answer 34

The safest initial course of action is to apply digital pressure to the bleeding point. To control the bleeding the surgeon will need a working suction device. Divided veins may require ligation. Incomplete lacerations of major veins (e.g. IVC) are best repaired. In order to do this it is safest to apply a Satinsky type vascular clamp and repair the defect with 5/0 prolene.

Question 35

Achieving haemostasis in surgery: bleeding from raw surfaces

Answer 35

This may be mixed bleeding and can be troublesome. Spray diathermy and argon plasma coagulation are both useful agents. Certain topical haemostatic agents such as surgicell are useful in encouraging clot formation and may be used in conjunction with, or instead of, the above agents. Next question

Question 36

Lateral border of femoral canal

Answer 36

Femoral vein

Question 37

Medial border of femoral canal

Answer 37

Lacunar ligament

Question 38

Anterior border of femoral canal

Answer 38

Inguinal ligament

Question 39

Posterior border of femoral canal

Answer 39

Pectineal ligament

Question 40

Contents of the femoral canal

Answer 40

Lymphatic vessles Cloquet's lymph node

Question 41

Cloquet's lymph node

Answer 41

It is named for French surgeon Jules Germain Cloquet,or German anatomist Johann Christian Rosenmüller. It can be considered the uppermost of the deep inguinal lymph nodes or the lowest of the external iliac lymph nodes.

Question 42

Theme: Right iliac fossa pain A.Urinary tract infection B.Appendicitis C.Mittelschmerz D.Mesenteric adenitis E.Crohns disease F.Ulcerative colitis G.Meckels diverticulum Please select the most likely cause for right iliac fossa pain for the scenario given. Each option may be used once, more than once or not at all. 11.A 17 year old male is admitted with lower abdominal discomfort. He has been suffering from intermittent right iliac fossa pain for the past few months. His past medical history includes a negative colonoscopy and gastroscopy for iron deficiency anaemia. The pain is worse after meals. Inflammatory markers are normal. A 14 year old female is admitted with sudden onset right iliac fossa pain. She is otherwise well and on examination has some right iliac fossa tenderness but no guarding. She is afebrile. Urinary dipstick is normal. Her previous menstrual period two weeks ago was normal and pregnancy test is negative. A 21 year old male is admitted with a 3 month history of intermittent right iliac fossa pain. He suffers from episodic diarrhoea and has lost 2 kilos in weight. On examination he has some right iliac fossa tenderness and is febrile.

Answer 42

Meckels diverticulum This scenario should raise suspicion for Meckels as these may contain ectopic gastric mucosa which may secrete acid with subsequent bleeding and ulceration. Mittelschmerz Typical story and timing for mid cycle pain. Mid cycle pain typically occurs because a small amount of fluid is released at the time of ovulation. It will usually resolve over 24-48 hours. Crohns disease Weight loss and chronic symptoms coupled with change in bowel habit should raise suspicion for Crohns. The presence of intermittent right iliac fossa pain is far more typical of terminal ileal Crohns disease. Both UC and Crohns may be associated with a low grade pyrexia. The main concern here would be locally perforated Crohns disease with a small associated abscess.

Question 43

Mainly affects children Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp. Patients have a higher temperature than those with appendicitis If laparotomy is performed, enlarged mesenteric lymph nodes will be present

Answer 43

Mesenteric adenitis

Question 44

Both left and right sided disease may present with right iliac fossa pain Clinical history may be similar, although some change in bowel habit is usual When suspected, a CT scan may help in refining the diagnosis

Answer 44

Diverticulitis

Question 45

Ddx for RIF pain

Answer 45

Appendicitis Crohn's disease Mesenteric adenitis Diverticulitis Meckel's diverticulitis Perforated peptic ulcer Incarcerated right inguinal or femoral hernia Bowel perforation secondary to caecal or colon carcinoma Gynaecological causes Urological causes

Question 46

A 22 year old lady presents with an episode of renal colic and following investigation is suspected of suffering from MEN IIa. Which of the following abnormalities of the parathyroid glands are most often found in this condition? Hypertrophy Hyperplasia Adenoma Carcinoma Metaplasia

Answer 46

MEN IIa Medullary thyroid cancer Hyperparathyroidism (usually hyperplasia) Phaeochromocytoma In MEN IIa the commonest lesion is medullary thyroid cancer, with regards to the parathyroid glands the most common lesion is hyperplasia. In MEN I a parathyroid adenoma is the most common lesion.

Question 47

MEN1 Three Ps

Answer 47

Mnemonic 'three P's': Parathyroid (95%): Parathyroid adenoma Pituitary (70%): Prolactinoma/ACTH/Growth Hormone secreting adenoma Pancreas (50%): Islet cell tumours/Zollinger Ellison syndrome also: Adrenal (adenoma) and thyroid (adenoma)

Question 48

Most common presentation of MEN I?

Answer 48

Hypercalcaemia

Question 49

Gene causing MEN1?

Answer 49

MENIN gene (chromosome 11)

Question 50

MEN IIa

Answer 50

Phaeochromocytoma Medullary thyroid cancer (70%) Hyperparathyroidism (60%)

Question 51

Gene causing MEN IIa?

Answer 51

RET oncogene (Chromosome 10)

Question 52

MEN IIb

Answer 52

Same as MEN IIa with addition of: Marfanoid body habitus Mucosal neuromas

Question 53

Gene causing MEN IIb

Answer 53

RET oncogene (chromosome 10)

Question 54

Theme: Nasal diseases A.Ethmoid sinus cancer B.Maxillary sinus cancer C.Ethmoid adenoma D.Maxillary adenoma E.Ethmoidal fracture F.Nasal polyps G.Sphenoid osteoma H.Ethmoidal sinusitis I.Maxillary sinusitis Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all. 2.A 56 year old man presents with symptoms of nasal pain, anosmia and rhinorrhea. He has been well until recently and has worked as a wood carver for many years. A 32 year old female presents with recurrent episodes of rhinorrhoea, the discharge is watery. She has a medical history of asthma and intolerance of aspirin. On examination she has multiple soft, semi- transparent polyps within her nasal cavity. A child is brought to casualty complaining of a headache and a sensation of pressure between the eyes. On examination she is febrile with a smooth swelling overlying the superomedial aspect of the right eye. The eye is uncomfortable and there is a purulent discharge from the inner canthus.

Answer 54

Ethmoid sinus cancer Nasopharyngeal cancer is strongly associated with wood work. Most cases require an occupational exposure of greater than 10 years and are adenocarcinomas on histology. Most cases are ethmoidal in origin (Hadfield E. Ann R Coll Surg Engl. 1970 June; 46(6): 301319) Nasal polyps The combination of nasal polyps and atopy is well described. Some cases will respond favourably to systemic steroids and avoid surgery. Ethmoidal sinusitis Ethmoidal sinusitis may spread to the periorbital tissues resulting in periorbital cellulitis. The superomedial distribution makes a maxillary sinusitis less likely.

Question 55

What are the benign tumours of the nose and sinuses?

Answer 55

Simple papillomas Transitional cell papillomas Pleomorphic adenomas Benign osteomas Nasal poylps

Question 56

Benign nasal tumour may be an incidental finding or present with obstructive symptoms. Excision under general anaesthesia is sufficient management.

Answer 56

Simple papillomas

Question 57

Benign nasal tumour may be more extensive and produce obstructive symptoms. Erosion of local structures is a recognised complication. These lesions may rarely undergo malignant transformation and therefore careful and complete excision is required, some cases may require partial or total maxillectomy.

Answer 57

Transitional cell papillomas

Question 58

Benign nasal tumour of the maxillary sinuses are reported but are extremely rare, their symptoms typically include nasal obstruction and pain if the sinus is obstructed. Treatment is by complete surgical excision, the diagnosis is not infrequently made post operatively.

Answer 58

Pleomorphic adenomas

Question 59

Benign nasal/sinus tumours may develop in the paranasal sinuses, the frontal sinus is the most frequent location of such lesions. Symptoms include; pain, rhinorrhoea and anosmia. Most osteomas may be observed if asymptomatic, sphenoid osteomas should be resected soon after diagnosis as enlargement may compromise visual fields. Many sinus osteomas can now be resected endoscopically, complete surgical resection is required.

Answer 59

Osteomas

Question 60

Benign lesions of the ethmoid sinus mucosa. Many patients may also have asthma, cystic fibrosis and a sensitivity to aspirin. Symptoms include watery rhinorrhoea, infection and anosmia. The polyps are usually a semi transparent grey mass. They are rare in childhood. Treatment is either with systemic steroids or surgical resection. The latter should be combined with antral washout. Low dose, nasal, steroid drops may reduce the risk of recurrence.

Answer 60

Nasal polyps

Question 61

Malginancies encountered in the nose and paranasal sinuses?

Answer 61

Adenoid cystic carcinoma SCC Adenocarcinoma

Question 62

What carcinoma of the paranasal sinuses and nasopharynx is strongly linked to exposure to hard wood dust (after \>10 years exposure).

Answer 62

Adenocarcinoma

Question 63

Where do adenoid cystic carcinomas normally arise?

Answer 63

Smaller salivary glands

Question 64

Where do the majority of nasal cancers arise?

Answer 64

The majority of cancers (50%) arise from the lateral nasal wall, a smaller number (33%) arise from the maxillary antrum, ethmoid and sphenoid cancers comprise only 7%.

Question 65

Signs of malignancy in ?nasopharyngeal cancer?

Answer 65

Loose teeth CN palsies Lymphadenopathy

Question 66

Risk factors for nasopharyngeal cancers

Answer 66

Chinese/asian Wood working EBV

Question 67

Treatment of nasopharyngeal cancers?

Answer 67

RTx and CTx

Question 68

Common symptoms include post nasal discharge, pain, headache and toothache. Imaging may show a fluid level in the antrum. Common organisms include Haemophilus influenzae or Streptococcus pneumoniae. Treatment with antral lavage may facilitate diagnosis and relieve symptoms. Antimicrobial therapy has to be continued for long periods. Antrostomy may be needed.

Answer 68

Maxillary sinusitis

Question 69

Usually presents with frontal headache, nasal obstruction and altered sense of smell. Inflammation may progress to involve periorbital tissues. Ocular symptoms may occur and secondary CNS involvement brought about by infection entering via emissary veins. CT scanning is the imaging modality of choice. Early cases may be managed with antibiotics. More severe cases usually require surgical drainage.

Answer 69

Frontoethmoidal sinusitis

Question 70

Theme: Statistics A.LSD post hoc test B.Bonferroni test C.Mann Whitney U test D.Paired T test E.Chi squared test F.Fishers exact test G.Unpaired T Test Please select the statistical test that is most appropriate for the scenario provided. Each option may be used once, more than once or not at all. 6.A surgeon has conducted a piece of research and is try to make his data appear interesting for publication. To do this he is conducting multiple analyses of sub group data using multiple tests. A surgical unit are conducting a study to determine whether patients who have bowel preparation have a lower risk of colonic anastomotic leakage than those having none. The planned sample size is 25. A surgeon wishes to conduct a national study relating patient weight to the length of inpatient stay following all major operations.

Answer 70

Bonferroni test This is a process referred to as "data dredging" and can lead to erroneous results. Post hoc testing in general can be a problem in research and to try and minimise the potential for error some advocate the use of the Bonferroni method. This adjusts the test to take account of the number of tests that have been performed on the data. Fishers exact test It is likely to be underpowered with the number provided. However, it would be possible to classify such data into a 2x2 contingency table. However, when the sample size is small the Chi squared test is not suitable and in these situations the Fishers exact test is used. Unpaired T Test Weight is likely to be normally distributed and when a large size is used it is possible that this will be suitable for testing using a parametric method. The T Test is a powerful test providing it is used correctly and would probably be best suited for analysis of this data set.

Question 71

Data can be allocated a numerical code that is arbitrary. For example allocating people as alive or dead using codes of 0 or 1

Answer 71

Nominal

Question 72

Data using numbers that can be used on a scale. Severity of pain is often measured in this way

Answer 72

Ordinal data

Question 73

Data is measured numerically. However, the zero point is arbitrary

Answer 73

Interval scale

Question 74

Data is measured numerically where the numerical value is a real number and may be any value. Examples include height and weight

Answer 74

Continuous

Question 75

Parametric tests

Answer 75

Used to examine normally distributed data e.g. T test

Question 76

Non parametric data

Answer 76

Data that is not normally distributed e.g. Chi squared and Mann Whitney U tests

Question 77

Issues with Chi squared tests

Answer 77

There are some assumptions that are made in relation to Chi squared tests; these include the need to use 2 degrees of freedom (usually) and the minimum sample size. Where the sample size is small then a different test is appropriate and the Fishers exact test is often used.

Question 78

When may the paired T test be used?

Answer 78

In situations where data is normally distributed and paired samples are taken from the same individuals (such as following an intervention) then the paired T Test may be used.

Question 79

What can be used to adjust data to allow for post-hoc multiple analyses?

Answer 79

Bonferroni correction

Question 80

Which muscle is responsible for causing flexion of the distal interphalangeal joint of the ring finger? Flexor digitorum superficialis Lumbricals Palmar interossei Flexor digitorum profundus Flexor digiti minimi brevis

Answer 80

Flexor digitorum superficialis and flexor digitorum profundus are responsible for causing flexion. The superficialis tendons insert on the bases of the middle phalanges; the profundus tendons insert on the bases of the distal phalanges. Both tendons flex the wrist, MCP and PIP joints; however, only the profundus tendons flex the DIP joints.

Question 81

Arrangement of the interossei?

Answer 81

7 Interossei - Supplied by ulnar nerve 3 palmar-adduct fingers 4 dorsal- abduct fingers

Question 82

Arrangement of the lumbricals?

Answer 82

Flex MCPJ and extend the IPJ. Origin deep flexor tendon and insertion dorsal extensor hood mechanism.

Question 83

Innervation of the 1st and 2nd lumbricals?

Answer 83

Median nerve

Question 84

Innervation of the 3rd and 4th lumbricals?

Answer 84

Deep branch of the ulnar nerve

Question 85

Muscles of the thenar eminence? AOF (L-\>M)

Answer 85

Abductor pollicis brevis Opponens pollicis Flexor pollicis brevis

Question 86

Muscles of the hypothenar eminence?

Answer 86

Opponens digiti minimi Flexor digiti minimi brevis Abductor digiti minimi

Question 87

Arrangement of the palmar fascia

Answer 87

Continuous with antebrachial fascia and fascia of dorsum of the hand Thin over the thenar and hypothenar eminences but thicker in the middle. Apex of the palmar aponeurosis is conintuous with the flexor retinaculum and palmaris longus. Distally it forms four longitudinal digital bands that attach to the bases of the proximal phalanges, blending with the fibrous digital sheaths

Question 88

Where is the medial fibrous septum of the palm?

Answer 88

Extends from the medial border of the palmar aponeurosis to the 5th metacarpal. Medial to this are the hypothenar muscles

Question 89

Where is the lateral fibrous septum of the palm?

Answer 89

Extends from the lateral border of the palmar aponeurosis to the 3rd metacarpal The thenar compartment lies lateral to this area

Question 90

What are the contents of the central compartment of the palm?

Answer 90

Flexor tendons and their sheaths Lumbricals Superficial palmar arterial arch and the digital vessels and nerves

Question 91

What is the deepest muscular plane of the hand?

Answer 91

The adductor compartment which contains adductor pollicis

Question 92

Long flexor tendons and sheaths in the hand

Answer 92

Tendons of FDS and FDP enter the common flexor sheath deep to the flexor retinaculum Enter the central compartment and fan out to their respective digital synovial sheaths. FDS splits near the base of the proximal phlanax to allow passage of FDP. FDP is attached to the margins of the anterior aspect of the base of the distal phalanx The fibrous digital sheaths contain the flexor tendons and their synovial sheaths, extending from the heads of the metacarapls to the base of the distal phalanges

Question 93

A 33 year old lady develops a thunderclap headache and collapses. A CT scan shows that she has developed a subarachnoid haemorrhage. She currently has no evidence of raised intracranial pressure. Which of the following drugs should be administered? None Atenotol Labetolol Nimodipine Mannitol

Answer 93

Nimodipine is a calcium channel blocker. It reduces cerebral vasospasm and improves outcomes. It is administered to most cases of sub arachnoid haemorrhage.

Question 94

Most common cause of SAH

Answer 94

Intracranial aneurysms. Approximately 10% of cases will have normal angiography and the cause will remain unclear.

Question 95

Ix of SAH

Answer 95

CT scan for all (although as CSF blood clears the sensitivity declines) Lumbar puncture if CT normal (very unlikely if normal) CT angiogram to look for aneurysms.

Question 96

Mx of SAH

Answer 96

Supportive treatment, optimising BP (not too high if untreated aneurysm) and ventilation if needed. Nimodipine reduces cerebral vasospasm and reduces poor outcomes. Untreated patients most likely to rebleed in first 2 weeks. Patients developing hydrocephalus will need a V-P shunt (external ventricular drain acutely). Electrolytes require careful monitoring and hyponatraemia is common.

Question 97

Treatment of intracranial aneurysm

Answer 97

\>80% aneuryms arise from the anterior circulation Craniotomy and clipping of aneurysm is standard treatment, alternatively suitable lesions may be coiled using an endovascular approach. Where both options are suitable data suggests that outcomes are better with coiling than surgery.

Question 98

Theme: Oesophageal disease A.Oesophagectomy B.Endoscopic sub mucosal dissection C.Photodynamic therapy D.Insertion of oesophageal stent E.Chemotherapy F.Radiotherapy Please select the most appropriate treatment modality for the scenario given. Each option may be used once, more than once or not at all. 11.A 52 year old man with long standing Barretts oesophagus is diagnosed with high grade dysplasia on recent endoscopy. The lesions are multifocal and mainly distally sited. A 82 year old man presents with dysphagia. He is investigated and found to have an adenocarcinoma of the distal oesophagus. His staging investigations have revealed a solitary metastatic lesion in the right lobe of his liver. An 83 year old lady with long standing Barretts oesophagus is diagnosed with a 1cm focus of high grade dysplasia 3cm from the gastrooesophageal junction.

Answer 98

Oesophagectomy Some may argue for local therapy. However, in young patients who are otherwise fit, multifocal disease such as this should probably be resected. Insertion of oesophageal stent Although he may be palliated with chemotherapy a stent will produce the quickest clinical response. Metastatic disease is usually a contra indication to oesophageal resection. Endoscopic sub mucosal dissection As she is elderly and the disease localised EMR is an appropriate first line step. The technique involves raising the mucosa containing the lesion and then using an endoscopic snare to remove it. This technique is therefore minimally invasive. However, it is only suitable for early superficial lesions. Deeper invasion would carry a high risk of recurrence.

Question 99

Neoadjuvant therapy in oesophageal cancer

Answer 99

Given in most cases prior to surgery

Question 100

Use of Ivor Lewis oesophagectomy?

Answer 100

In patients with lower third lesions an Ivor - Lewis type procedure is most commonly performed. Very distal tumours may be suitable to a transhiatal procedure. Which is an attractive option as the penetration of two visceral cavities required for an Ivor- Lewis type procedure increases the morbidity considerably.

Question 101

Operative details of Ivor- Lewis procedure

Answer 101

Combined laparotomy and right thoracotomy

Question 102

McKeown oesophagectomy?

Answer 102

More proximal lesions will require a total oesphagectomy (Mckeown type) with anastomosis to the cervical oesophagus.

Question 103

Preparation for Ivor-Lewis oesophagectomy?

Answer 103

Staging with a combination of CT chest abdomen and pelvis- if no metastatic disease detected then patients will undergo a staging laparoscopy to detect peritoneal disease. If both these modalities are negative then patients will finally undergo a PET CT scan to detect occult metastatic disease. Only those in whom no evidence of advanced disease is detected will proceed to resection. Patients receive a GA, double lumen endotracheal tube to allow for lung deflation, CVP and arterial monitoring.

Question 104

Procedure in Ivor Lewis oesophagectomy?

Answer 104

A rooftop incision is made to access the stomach and duodenum. Laparotomy Right Thoracotomy

Question 105

Laparotomy in Ivor-Lewis oesophagectomy

Answer 105

The greater omentum is incised away from its attachment to the right gastroepiploic vessels along the greater curvature of the stomach. Then the short gastric vessels are ligated and detached from the greater curvature from the spleen. The lesser omentum is incised, preserving the right gastric artery. The retroperitoneal attachments of the duodenum in its second and third portions are incised, allowing the pylorus to reach the oesophageal hiatus. Some surgeons perform a pyloroplasty at this point to facilitate gastric emptying. The left gastric vessels are then ligated, avoiding any injury to the common hepatic or splenic arteries. Care must be taken to avoid inadvertently devascularising the liver owing to variations in anatomy.

Question 106

Right thoracotomy in Ivor Lewis?

Answer 106

Through 5th intercostal space Dissection performed 10cm above the tumour This may involve transection of the azygos vein. The oesophagus is then removed with the stomach creating a gastric tube. An anastomosis is created.

Question 107

Post-operative recovery following Ivor-Lewis oesophagectomy?

Answer 107

Patients will typically recover in ITU initially. A nasogastric tube will have been inserted intraoperatively and must remain in place during the early phases of recovery. Post operatively these patients are at relatively high risk of developing complications:

Question 108

Post-op complications following Ivor-Lewis

Answer 108

\* Atelectasis- due to the effects of thoracotomy and lung collapse \* Anastomotic leakage. The risk is relatively high owing to the presence of a relatively devascularised stomach. Often the only blood supply is from the gastroepiploic artery as all others will have been divided. If a leak does occur then many will attempt to manage conservatively with prolonged nasogastric tube drainage and TPN. The reality is that up to 50% of patients developing an anastomotic leak will not survive to discharge. \* Delayed gastric emptying (may be avoided by performing a pyloroplasty).

Question 109

A 23 year old man is stabbed in the right upper quadrant and is haemodynamically unstable. A laparotomy is performed and the liver has some extensive superficial lacerations and is bleeding profusely. The patient becomes progressively more haemodynamically unstable. What is the best management option? Pack the liver and close the abdomen Occlude the hepatic inflow with a pringles manoeuvre and suture the defects Occlude vascular inflow and resect the most severely affected area anatomically Perform a portosystemic shunt procedure Suture the defects without vascular occlusion

Answer 109

Packing of the liver is the safest option and resection or repair considered later when the physiology is normalised. Often when the packs are removed all the bleeding has ceased and the abdomen can be closed without further action. Definitive attempts at suturing or resection at the primary laparotomy are often complicated by severe bleeding.

Question 110

Trimodal death distribution following trauma

Answer 110

Immediately following injury. Typically as result of brain or high spinal injuries, cardiac or great vessel damage. Salvage rate is low. In early hours following injury. In this group deaths are due to phenomena such as splenic rupture, sub dural haematomas and haemopneumothoraces In the days following injury. Usually due to sepsis or multi organ failure.

Question 111

Aspects of trauma mangement

Answer 111

ABCDE approach. Tension pneumothoraces will deteriorate with vigorous ventilation attempts. External haemorrhage is managed as part of the primary survey. As a rule tourniquets should not be used. Blind application of clamps will tend to damage surrounding structures and packing is the preferred method of haemorrhage control. Urinary catheters and naso gastric tubes may need inserting. Be wary of basal skull fractures and urethral injuries. Patients with head and neck trauma should be assumed to have a cervical spine injury until proven otherwise.

Question 112

Thoracic traumatic injuries

Answer 112

Simple pneumothorax Mediastinal traversing wounds Tracheobronchial tree injury Haemothorax Blunt cardiac injury Diaphragmatic injury Aortic disruption Pulmonary contusion

Question 113

Management of simple pneumothorax in thoracic trauma?

Answer 113

insert chest drain. Aspiration is risky in trauma as pneumothorax may be from lung laceration and convert to tension pneumothorax.

Question 114

These result from situations like stabbings. Exit and entry wounds in separate hemithoraces. The presence of a mediastinal haematoma indicates the likelihood of a great vessel injury. All patients should undergo CT angiogram and oesophageal contrast swallow. Indications for thoracotomy are largely related to blood loss and will be addressed below

Answer 114

Mediastinal traversing wounds

Question 115

Unusual injuries. In blunt trauma most injuries occur within 4cm of the carina. Features suggesting this injury include haemoptysis and surgical emphysema. These injuries have a very large air leak and may have tension pneumothorax.

Answer 115

Tracheobronchial tree injury

Question 116

Usually caused by laceration of lung vessel or internal mammary artery by rib fracture. Patients should all have a wide bore 36F chest drain. Indications for thoracotomy include loss of more than 1.5L blood initially or ongoing losses of \>200ml per hour for \>2 hours.

Answer 116

Haemothorax

Question 117

Usually cardiac arrhythmias, often overlying sternal fracture. Perform echocardiography to exclude pericardial effusions and tamponade. Risk of arrhythmias falls after 24 hours.

Answer 117

Cardiac contusions

Question 118

Commonest cause of death after RTA or falls. Usually incomplete laceration near ligamentum arteriosum. All survivors will have contained haematoma. Only 1-2% of patients with this injury will have a normal chest x-ray.

Answer 118

Traumatic aortic disruption

Question 119

Common and lethal. Insidious onset. Early intubation and ventilation.

Answer 119

Pulmonary contusion

Question 120

Thoracic trauma Usually left sided. Direct surgical repair is performed.

Answer 120

Diaphragmatic injury

Question 121

What is most commonly injured in blunt trauma requiring laparotomy?

Answer 121

Spleen (40%)

Question 122

Abdominal stab wounds most commonly affect?

Answer 122

Liver

Question 123

Abdominal gunshot wounds most commonly affect?

Answer 123

Small bowel (50%)

Question 124

Outcome of patients with abdominal stab wounds and no peritoneal signs?

Answer 124

25% of stab wounds will not enter the peritoneal cavity

Question 125

Investigations in abdominal trauma?

Answer 125

DPL Abdominal CT USS

Question 126

Indication for DPL

Answer 126

Document bleeding in abdominal trauma if hypotensive

Question 127

Advantages of DPL

Answer 127

Early diagnosis and sensitive; 98% accurate

Question 128

Disadvantages of DPL

Answer 128

Invasive and may miss retroperitoneal and diaphragmatic injury

Question 129

Indications for abdominal CT scan post trauma

Answer 129

Document organ injury if normotensive

Question 130

Advantages of abdominal CT in trauma

Answer 130

Most specific for localising injury; 92 to 98% accurate

Question 131

Disadvantages of abdominal CT scan?

Answer 131

Location of scanner away from facilities, time taken for reporting, need for contrast

Question 132

Indication for USS in abdominal trauma?

Answer 132

Document fluid if hypotensive

Question 133

Advantages of abdo USS in trauma?

Answer 133

Early diagnosis, non invasive and repeatable; 86 to 95% accurate

Question 134

Disadvantages of abdominal USS in trauma

Answer 134

Operator dependent and may miss retroperitoneal injury

Question 135

A 22 year old man is admitted to hospital with a lower respiratory chest infection. He had a splenectomy after being involved in a car accident. What is the most likely infective organism? Haemophilus influenzae Staphylococcus aureus Rhinovirus Mycobacterium tuberculosis Moraxella catarrhalis

Answer 135

Organisms causing post splenectomy sepsis: Streptococcus pneumoniae Haemophilus influenzae Meningococci Encapsulated organisms carry the greatest pathogenic risk following splenectomy. The effects of sepsis following splenectomy are variable. This may be the result of small isolated fragments of splenic tissue that retain some function following splenectomy. These may implant spontaneously following splenic rupture (in trauma) or be surgically implanted at the time of splenectomy.

Question 136

Why does splenectomy increase the risk of sepsis from encapsulated organisms?

Answer 136

Hyposplenism, by whatever mechanism it occurs dramatically increases the risk of post splenectomy sepsis, particularly with encapsulated organisms. Since these organisms may be opsonised, but this then goes undetected at an immunological level due to loss of the spleen. For this reason individuals are recommended to be vaccinated and have antibiotic prophylaxis.

Question 137

Vaccinations and elective splenectomy

Answer 137

PCV, HIb and MCV 2 weeks prior to spleenctomy or two weeks following splenectomy

Question 138

Other vaccinations and splenectomy

Answer 138

Annual influenza vaccination

Question 139

Antibiotic prophlyaxis in patients without spleen

Answer 139

Antibiotic prophylaxis is offered to all. The risk of post splenectomy sepsis is greatest immediately following splenectomy and in those aged less than 16 years or greater than 50 years. Individuals with a poor response to pneumococcal vaccination are another high risk group. High risk individuals should be counselled to take penicillin or macrolide prophylaxis. Those at low risk may choose to discontinue therapy. All patients should be advised about taking antibiotics early in the case of intercurrent infections.

Question 140

In what patient groups is post-splenectomy sepsis greates risk?

Answer 140

Greatest risk immediately after spleenctomy \<16y/o or \>50y/o, Individuals with poor response to PCV.

Question 141

Prophylactic abx dosing post-splenectomy?

Answer 141

Pen V 500mg BD or amoxicillin 250mg BD

Question 142

A 28 year old male presents with painful, bright red, rectal bleeding. On examination he is found to have a posteriorly sited, midline, fissure in ano. What is the most appropriate treatment? Topical GTN paste Sub lingual GTN paste Anal stretch Advancement flap Tailored division of the external anal sphincter

Answer 142

Topical vasodilator therapy is the most commonly utilised treatment for fissure in ano. Surgical division of the internal anal sphincter is a reasonable treatment option in a young male. Division of the external sphincter will almost certainly result in incontinence and is not performed. Anal stretches were associated with a high rate of external sphincter injuries and have been discontinued for this reason.

Question 143

Most effective first line agents in anal fissure?

Answer 143

The most effective first line agents are topically applied GTN (0.2%) or Diltiazem (2%) paste. Side effects of diltiazem are better tolerated.

Question 144

A 34 year old lady undergoes a thyroidectomy for Graves disease. Post operatively she develops a tense haematoma in the neck. In which of the following fascial planes will it be contained? Gerotas fascia Waldeyers fascia Pretracheal fascia Sibsons fascia Clavipectoral fascia

Answer 144

The pretracheal fascia encloses the thyroid and is unyielding. Therefore tense haematomas can develop.

Question 145

Apex of thyroid

Answer 145

Lamina of thyroid cartilage

Question 146

Base of thyroid

Answer 146

4th-5th tracheal ring

Question 147

Anteromedial relations of the thyroid?

Answer 147

Sternothyroid Superior belly of omohyoid Sternohyoid Anterior aspect of sternocleidomastoid

Question 148

Posterolateral relations of the thyroid?

Answer 148

Carotid sheath

Question 149

Medial relations of the thyroid?

Answer 149

Larynx Trachea Pharynx Oesophagus Cricothyroid muscle External laryngeal nerve (near superior thyroid artery) Recurrent laryngeal nerve (near inferior thyroid artery)

Question 150

Posterior relations of the thyroid?

Answer 150

Parathyroid glands Anastomosis of superior and inferior thyroid arteries

Question 151

Relations of the isthmus of the thyroid

Answer 151

Anteriorly: Sternothyroids, sternohyoids, anterior jugular veins Posteriorly: 2nd, 3rd, 4th tracheal rings (attached via Ligament of Berry)

Question 152

Arterial supply of the thyroid?

Answer 152

Superior thyroid artery (1st branch of external carotid) Inferior thyroid artery (from thyrocervical trunk) Thyroidea ima (in 10% of population -from brachiocephalic artery or aorta)

Question 153

What proportion of the population have thyroid ima?

Answer 153

10%

Question 154

Venous drainage of the thyroid?

Answer 154

Superior and middle thyroid veins - into the IJV Inferior thyroid vein - into the brachiocephalic veins

Question 155

Theme: Management of vomiting A.Ondansetron B.Metoclopramide C.Cyclizine D.Erythromycin E.Cisapride F.Haloperidol Please select the most appropriate drug for the given scenario. Each option may be used once, more than once or not at all. 18.A 78 year old man with diabetes develops autonomic gastropathy with persistent and troublesome vomiting. A drug which blocks the chemoreceptor trigger zone in the area postrema. A 48 year old man with oesphageal varices has a profuse haemorrhage on the ward.

Answer 155

Erythromycin Unlike metoclopramide. the effects of erythromycin on gastric emptying are not mediated via the vagus nerve. Ondansetron 5 HT3 blockers are most effective for many types of nausea for this reason. Metoclopramide Intravenous metoclopramide causes increased oesophageal pressure and this may temporarily slow the rate of haemorrhage whilst more definitive measures are instigated.

Question 156

Where is the vomiting centre?

Answer 156

Medulla oblongata

Question 157

What locations have input on the vomiting centre?

Answer 157

Labyrinthine receptors of ear (motion sickness) Over distention receptors of duodenum and stomach Trigger zone of CNS - many drugs (e.g., opiates) act here Touch receptors in throat

Question 158

Which of the following cell types is least likely to be found in a wound 1 week following injury? Macrophages Fibroblasts Myofibroblasts Endothelial cells Neutrophils

Answer 158

Myofibroblasts Myofibroblasts are differentiated fibroblasts, in which the cytoskeleton contains actin filaments. These cell types facilitate wound contracture and are the hallmark of a mature wound. They are almost never found in wounds less than 1 month old. Remember the question asks about the cell type asks about which cells are least likely to be found.

Question 159

What are the phases of wound healing?

Answer 159

Haemostasis Inflammation Regeneration Remodelling

Question 160

Cells involved in wound haemostasis

Answer 160

Erythrocytes and plts

Question 161

Features of haemostasis in wound healing?

Answer 161

Vasospasm in adjacent vessles Platelt plug formation and generation of fibrin rich clot

Question 162

Cells involved in inflammation phase of wound healing?

Answer 162

Neutrophils, fibroblasts and macrophages

Question 163

Timeframe in the inflammation phase of wound healing?

Answer 163

Days

Question 164

Features of the inflammatory phase of wound healing?

Answer 164

Neutrophils migrate into wound (function impaired in diabetes). Growth factors released, including basic fibroblast growth factor and vascular endothelial growth factor. Fibroblasts replicate within the adjacent matrix and migrate into wound. Macrophages and fibroblasts couple matrix regeneration and clot substitution.

Question 165

Cells involved in regenerative phase of wound healing?

Answer 165

Fibroblasts, endothelial cells, macrophages

Question 166

Features of regenerative phase of wound healing?

Answer 166

Platelet derived growth factor and transformation growth factors stimulate fibroblasts and epithelial cells. Fibroblasts produce a collagen network. Angiogenesis occurs and wound resembles granulation tissue.

Question 167

Timescale of regenerative phase of wound healing

Answer 167

Weeks

Question 168

Timescale of remodelling phase of wound healing

Answer 168

6w to 1 year

Question 169

Cells involved in remodelling phase of wound healing?

Answer 169

Myofibroblasts

Question 170

Key features of remodelling phase of wound healing?

Answer 170

Longest phase of the healing process and may last up to one year (or longer). During this phase fibroblasts become differentiated (myofibroblasts) and these facilitate wound contraction. Collagen fibres are remodelled. Microvessels regress leaving a pale scar.

Question 171

The blood - brain barrier is not highly permeable to which of the following? Carbon dioxide Barbituates Glucose Oxygen Hydrogen ions

Answer 171

The blood brain barrier is relatively impermeable to highly dissociated compounds.

Question 172

A 43 year old presents to the urology clinic complaining of impotence. Which of the following will occur in response to increased penile parasympathetic stimulation? Detumescence Ejaculation Erection Vasospasm of the penile branches of the pudendal artery Contraction of the smooth muscle in the epididymis and vas deferens

Answer 172

Memory aid for erection p=parasympathetic=points s=sympathetic=shoots Parasympathetic stimulation causes erection. Sympathetic stimulation will produce ejaculation, detumescence and vasospasm of the pudendal artery. It will also cause contraction of the smooth muscle in the epididymis and vas to convey the ejaculate.

Question 173

Autonomic nerves of erection

Answer 173

Sympathetic nerves originate from T11-L2 and parasympathetic nerves from S2-4 join to form pelvic plexus. Parasympathetic discharge causes erection, sympathetic discharge causes ejaculation and detumescence.

Question 174

Somatic nerves of erection

Answer 174

Supplied by dorsal penile and pudendal nerves. Efferent signals are relayed from Onufs nucleus (S2-4) to innervate ischiocavernosus and bulbocavernosus muscles.

Question 175

def: priapsim

Answer 175

Prolonged unwanted erection, in the absence of sexual desire, lasting more than 4 hours.

Question 176

How can priapism be classified?

Answer 176

Low flow High flow Recurrent

Question 177

Low flow pripaism

Answer 177

Due to veno-occlusion (high intracavernosal pressures). Most common type Often painful Often low cavernosal flow If present for \>4 hours requires emergency treatment

Question 178

Blood flow in erection

Answer 178

Autonomic discharge to the penis will trigger the veno-occlusive mechanism which triggers the flow of arterial blood into the penile sinusoidal spaces. As the inflow increases the increased volume in this space will secondarily lead to compression of the subtunical venous plexus with reduced venous return. During the detumesence phase the arteriolar constriction will reduce arterial inflow and thereby allow venous return to normalise.

Question 179

High flow priapism

Answer 179

Due to unregulated arterial blood flow. Usually presents as semi rigid painless erection

Question 180

Recurrent priapism

Answer 180

Typically seen in sickle cell disease, most commonly of high flow type.

Question 181

Causes of priapism

Answer 181

Intracavernosal drug therapies (e.g. for erectile dysfunction\> Blood disorders such as leukaemia and sickle cell disease Neurogenic disorders such as spinal cord transection Trauma to penis resulting in arterio-venous malformations

Question 182

Ix in priapsim

Answer 182

Exclude sickle cell/ leukaemia Consider blood sampling from cavernosa to determine whether high or low flow (low flow is often hypoxic)

Question 183

Mx of priapsim

Answer 183

Ice packs/ cold showers/exercise If due to low flow then blood may be aspirated from copora or try intracavernosal alpha adrenergic agonists. Delayed therapy of low flow priapism may result in erectile dysfunction.

Question 184

A 32 year old lady complains of carpal tunnel syndrome. The carpal tunnel is explored surgically. Which of the following structures will lie in closest proximity to the hamate bone within the carpal tunnel? The tendon of abductor pollicis longus The tendons of flexor digitorum profundus The tendons of flexor carpi radialis longus Median nerve Radial artery

Answer 184

The carpal tunnel contains nine flexor tendons: Flexor digitorum profundus Flexor digitorum superficialis Flexor pollicis longus The tendon of flexor digitorum profundus lies deepest in the tunnel and will thus lie nearest to the hamate bone.

Question 185

What is interesting about the arrangement of carpal bones SLT?

Answer 185

No tendons attach to: Scaphoid, lunate, triquetrum (stabilised by ligaments)

Question 186

Theme: Surgical complications A.Anastamotic leak B.Chyle leak C.Air leak D.Biliary leak E.Deep vein thrombosis F.Portal vein thrombosis G.Biliary obstruction Please select the most likely complication for the scenario given. Each option may be used once, more than once or not at all. 25.A 67 year old female undergoes an oesophagogastrectomy for carcinoma of the distal oesophagus. She complains of chest pain. The following day there is brisk bubbling into the chest drain when suction is applied. A 20 year old man has a protracted stay on ITU following a difficult appendicectomy for perforated appendicitis with pelvic and sub phrenic abscesses. He has now deteriorated further and developed deranged liver function tests. A 63 year old man undergoes an Ivor - Lewis oesophagogastrectomy for carcinoma of the distal oesophagus. The following day a pale opalescent liquid is noted to be draining from the right chest drain.

Answer 186

Air leak Damage to the lung substance may produce an air leak. Air leaks will manifest themselves as a persistent pneumothorax that fails to settle despite chest drainage. When suction is applied to the chest drainage system, active and persistent bubbling may be seen. Although an anastomotic leak may produce a small pneumothorax, a large volume air leak is more indicative of lung injury. Portal vein thrombosis Such marked intra-abdominal sepsis may well produce coagulopathy and the risk of portal vein thrombosis. Chyle leak Damage to the lymphatic duct may occur during this procedure and some surgeons administer a lipid rich material immediately prior to surgery to facilitate its identification in the event of iatrogenic damage.

Question 187

Why is the Miller cuff used in distal bypass surgery?

Answer 187

Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure

Question 188

What is a Miller cuff?

Answer 188

If there is insufficient vein for the entire conduit of a distal graft then PTFE can be used for the body of the graft and the segment of vein used for the distal anastomosis. i.e. "vein boot"

Question 189

A 45 year old man sustains a significant head injury and a craniotomy is performed. The sigmoid sinus is bleeding profusely, into which of the following structures does it drain? Internal jugular vein Straight sinus Petrosal sinus Inferior sagittal sinus External jugular vein

Answer 189

The sigmoid sinus is joined by the inferior petrosal sinus to drain into the internal jugular vein.

Question 190

What is the significance of the cranial venous sinuses and the capacity for spreading sepsis?

Answer 190

The cranial venous sinuses have no valves

Question 191

Which nerve supplies the interossei of the fourth finger? Radial Median Superficial ulnar Deep ulnar Posterior interosseous

Answer 191

Deep ulnar Mnemonic: PAD and DAB Palmer interossei ADduct Dorsal interossei ABduct

Question 192

Action of dorsal interossei?

Answer 192

Abduct the fingers

Question 193

Action of the palmar interossei?

Answer 193

Adduct the fingers

Question 194

Where are the interossei found?

Answer 194

Occupy the spaces between the metacarpal bones. Each palmar interossei originates from the metacarpal of the digit on which it acts. Each dorsal interossei comes from the surface of the adajcent metacarpal on which it acts. As a consequence the dorsal interossei are twice the size of the palmar ones

Question 195

Where do the interossei insert?

Answer 195

The interossei tendons, except the first palmar, pass to one or other side of the MCPJ posterior to the deep transverse metacarpal ligament. They become inserted into the base of the proximal phalanx and partly into the extensor hood

Question 196

Clinical significance of the interossei?

Answer 196

Along with the lumbricals the interossei flex the metacarpophalangeal joints and extend the proximal and distal interphalangeal joints. They are responsible for fine tuning these movements. When the interossei and lumbricals are paralysed the digits are pulled into hyperextension by extensor digitorum and a claw hand is seen.

Question 197

In which of the following cranial bones does the foramen spinosum lie? Sphenoid bone Frontal bone Temporal bone Occipital bone Parietal bone

Answer 197

The foramen spinosum (which transmits the middle meningeal artery and vein) lies in the sphenoid bone.

Question 198

Which of the following is not considered a major branch of the descending thoracic aorta? Bronchial artery Mediastinal artery Inferior thyroid artery Posterior intercostal artery Oesophageal artery

Answer 198

The inferior thyroid artery is usually derived from the thyrocervical trunk, a branch of the subclavian artery.

Question 199

Branches of the thoracic aorta?

Answer 199

Lateral segmental branches: posterior intercostal arteries Lateral visceral: bronchial arteries supply bronchial walls and lung excluding the alveoli MIdline branches: oesophageal arteries

Question 200

An 18 year old lady with troublesome hyperhidrosis of the hands and arms is due to undergo a sympathectomy to treat the condition. Which of the following should the surgeons divide to most effectively treat her condition? Sympathetic ganglia at T1, T2 and T3 Sympathetic ganglia at T2 and T3 Sympathetic ganglia at T1 and T2 Stellate ganglion Superior cervical ganglion

Answer 200

To treat hyperhidrosis the sympathetic ganglia at T2 and T3 should be divided. Dividing the other structures listed would either carry a risk of Horners syndrome or be ineffective.

Question 201

General arrangement of the SNS?

Answer 201

Cell bodes of the pre-ganglionic efferent neurones are found in the lateral horn of the grey matter of the spinal cord in the thoraco-lumbar regions. Pre-ganglionic efferents leave the SC at T1-L2. These pass to the sympathetic chain. Lateral branches of the sympathetic chain connect it to every spinal nerve. These post ganglionic nerves will pass to sturctures that receive sympathetic innervation at the periphery

Question 202

Localtion of the cervical sympathetic chain?

Answer 202

Lie anterior to the transverse processes of the cervical vertebrae and posterior to the carotid sheath.

Question 203

Location of the thoracic sympathetic chains?

Answer 203

Lie anterior to the neck of the upper ribs and and lateral sides of the lower thoracic vertebrae.They are covered by the parietal pleura

Question 204

Location of the lumbar sympathetic chains?

Answer 204

Enter by passing posterior to the medial arcuate ligament. Lie anteriorly to the vertebrae and medial to psoas major.

Question 205

Superior cervical ganglion?

Answer 205

Lies anterior to C2 and C3

Question 206

Middle cervical ganglion?

Answer 206

C6

Question 207

Stellate ganglion

Answer 207

Anterior to transverse process of C7, lies posterior to the subclavian artery and cervical pleura

Question 208

Thoracic ganglia?

Answer 208

Usually segmentally arranged

Question 209

What is the usual number of lumbar ganglia?

Answer 209

4

Question 210

Issues with lumbar sympathectomy to treat vasospastic diseases of the lower limbs?

Answer 210

In patients with vascular disease of the lower limbs a lumbar sympathetomy may be performed, either radiologically or (more rarely now) surgically. The ganglia of L2 and below are disrupted. If L1 is removed then ejaculation may be compromised (and little additional benefit conferred as the preganglionic fibres do not arise below L2.

Question 211

A 44 year old lady is recovering following a transphenoidal hypophysectomy. Unfortunately there is a post operative haemorrhage. Which of the following features is most likely to occur initially? Cavernous sinus thrombosis Abducens nerve palsy Bi-temporal hemianopia Inferior homonymous hemianopia Central retinal vein occlusion

Answer 211

The pituitary is covered by a sheath of dura and an expanding haematoma at this site may compress the optic chiasm in the same manner as an expanding pituitary tumour.

Question 212

Adenohypophysis hormones?

Answer 212

GH TSH ACTH Prolactin LH and FSH Melanocyte releasing hormone

Question 213

Neurohypophysis hormones?

Answer 213

Oxytocin ADH

Question 214

During a right hemicolectomy the caecum is mobilised. As the bowel is retracted medially a vessel is injured, posterior to the colon. Which of the following is the most likely vessel? Right colic artery Inferior vena cava Aorta External iliac artery Gonadal vessels

Answer 214

The gonadal vessels and ureter are important posterior relations that are at risk during a right hemicolectomy.

Question 215

Posterior relations of the caecum?

Answer 215

Psoas Iliacus Femoral nerve Genitofemoral nerve Gonadal vessels

Question 216

Why is the caecum the most likely site of eventual perforation in large bowel obstruction?

Answer 216

The caecum is the most distensible part of the colon and in complete large bowel obstruction with a competent ileocaecal valve the most likely site of eventual perforation.

Question 217

A 53 year old man with a carcinoma of the lower third of the oesophagus is undergoing an oesophagogastrectomy. As the surgeons mobilise the lower part of the oesophagus, where are they most likely to encounter the thoracic duct? Anterior to the oesophagus On the left side of the oesophagus On the right side of the oesophagus Immediately anterior to the azygos vein Posterior to the oesophagus

Answer 217

The thoracic duct lies posterior to the oesophagus and passes to the left at the level of the Angle of Louis. It enters the thorax at T12 together with the aorta.

Question 218

Def: thoracic duct?

Answer 218

Continuation of the cisterna chyli in the abdomen

Question 219

Location of the thoracic duct?

Answer 219

Enters the thorax at T12. Lies posterior to the oesophagus for most of its intrathoracic course. Passes to the left at T5.

Question 220

Lymphatic drainage of the left side of the head and neck?

Answer 220

Join the thoracic duct prior to its insertion into the left brachiocephalic vein

Question 221

Lymphatics draining the right side of the head and neck?

Answer 221

Lymphatics draining the right side of the head and neck drain via the subclavian and jugular trunks into the right lymphatic duct and thence into the mediastinal trunk and eventually the right brachiocephalic vein.

Question 222

Which of the following represents the root values of the sciatic nerve? L4 to S3 L1 to L4 L3 to S1 S1 to S4 L5 to S1

Answer 222

he sciatic nerve most commonly arises from L4 to S3.

Question 223

Where is the sciatic nerve formed?

Answer 223

At the inferior border of piriformis

Question 224

Medial relations of the sciatic nerve?

Answer 224

Inferior gluteal nerve and vessels and the pudendal nerve and vessels.

Question 225

Cutaneous innervation of the sciatic nerve?

Answer 225

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

Question 226

What is the only muscle in the foot not innervated by the tibial nerve?

Answer 226

Extensor digitorum brevis, which is innervated by the common peroneal nerve

Question 227

What is the inflammatory response to MTB infection?

Answer 227

T4HS

Question 228

Theme: Wound closure A.Split thickness skin grafting B.Full thickness skin graft C.Local flap D.Leave wound as it is and apply a simple dressing E.Primary closure using interrupted 3/0 silk F.Primary closure using 4/0 interrupted nylon G.Use of vacuum assisted closure device Please select the most appropriate wound closure modality for the scenario given. Each option may be used once, more than once or not at all. 11.A 68 year old man undergoes a wide local excision of a squamous cell carcinoma from the lateral aspect his nose. At the completion of the operation the alar cartilage is visible. A 68 year old man has a seborrhoiec wart on his left cheek this is removed by use of curretage leaving a superficial defect approximately 1cm in diameter.

Answer 228

Local flap This type of wound should be managed with a local rotational flap. Leave wound as it is and apply a simple dressing This type of superficial wound will re-epithelialise satisfactorily without grafting. Use of vacuum assisted closure device Ray amputations for diabetic foot infections do not heal well and should never be primarily closed. The use of vacuum assisted closure devices has been shown to improve healing rates.

Question 229

Types of surgical wound?

Answer 229

Incisional or excisional: Clean Clean contaminated Dirty

Question 230

The common peroneal nerve, or its branches, supply the following muscles except: Peroneus longus Tibialis anterior Extensor hallucis longus Flexor digitorum brevis Extensor digitorum longus

Answer 230

Flexor digitorum is supplied by the tibial nerve.

Question 231

Innervation of the common peroneal nerve?

Answer 231

This nerve supplies the skin and fascia of the anterolateral surface of the leg and the dorsum of the foot. It also innervates the muscles of the anterior and peroneal compartments of the leg, extensor digitorum brevis as well as the knee, ankle and foot joints.

Question 232

Where does the common peroneal nerve divide into its deep and superficial branches?

Answer 232

At the posterior aspect of the fibular head

Question 233

Branches of the common peroneal nerve in the thigh?

Answer 233

Nerve to short head of biceps Articular branch (knee)

Question 234

Branches of the common peroneal nerve in the popliteal fossa?

Answer 234

Lateral cutaneous nerve of the calf

Question 235

Lateral border of the femoral canal?

Answer 235

Femoral vein

Question 236

Medial border of the femoral canal?

Answer 236

Lacunar ligament

Question 237

Anterior border of the femoral canal?

Answer 237

INguinal ligamnet

Question 238

Posterior border of the femoral canal?

Answer 238

Pectineal ligament

Question 239

Theme: Upper limb injuries A.Pulled elbow B.Fracture of the coronoid process C.Scaphoid fracture D.Fracture of the distal humerus E.Bennets fracture F.Fracture of the shaft of the radius and ulnar G.Galeazzi fracture H.Fracture of the olecranon I.Fracture of the radial head Please select the most likely injury for the scenario given. Each option may be used once, more than once or not at all. 16.A 32 year old man presents with a painful swelling over the volar aspect of his hand after receiving a hard blow to his palm. On examination, he experiences pain on moving the wrist and on longitudinal compression of the thumb. A 26 year old man presents to the emergency department with a swelling over his left elbow after a fall on an outstretched hand. On examination, he has tenderness over the proximal part of his forearm, and has severely restricted supination and pronation movements. A 56 year old lady presents with a painful swelling over the lower end of the forearm following a fall. Imaging reveals a distal radial fracture with disruption of the distal radio-ulnar joint.

Answer 239

Scaphoid fracture Scaphoid fractures usually occur as a result of direct hard blow to the palm or following a fall on the out-stretched hand. The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb Fracture of the radial head Fracture of the radial head is common in young adults. It is usually caused by a fall on the outstretched hand. On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination). Galeazzi fracture Galeazzi fractures occur after a fall on the hand with a rotational force superimposed on it. On examination, there is bruising, swelling and tenderness over the lower end of the forearm. X- Rays reveal a displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.

Question 240

Fall onto extended outstretched hands Described as a dinner fork type deformity

Answer 240

Colles' fracture

Question 241

Volar angulation of distal radius fragment (Garden spade deformity) Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed

Answer 241

Smith's fracture

Question 242

What are the 3 features of Colles fracture?

Answer 242

1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulation

Question 243

Intra-articular fracture of the first carpometacarpal joint Impact on flexed metacarpal, caused by fist fights X-ray: triangular fragment at ulnar base of metacarpal

Answer 243

Bennett's fracture

Question 244

Dislocation of the proximal radioulnar joint in association with an ulna fracture Fall on outstretched hand with forced pronation Needs prompt diagnosis to avoid disability

Answer 244

Monteggia's fracture

Question 245

Radial shaft fracture with associated dislocation of the distal radioulnar joint Occur after a fall on the hand with a rotational force superimposed on it. On examination, there is bruising, swelling and tenderness over the lower end of the forearm. X Rays reveal the displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.

Answer 245

Galeazzi fracture

Question 246

Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation Fall onto extended and pronated wrist

Answer 246

Barton's fracture

Question 247

Commonest carpal fracture?

Answer 247

Scaphoid fracture

Question 248

Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal 1/3) The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb. Ulnar deviation AP needed for visualization of scaphoid Immobilization of scaphoid fractures difficult

Answer 248

Scaphoid fractures

Question 249

Common in young adults. It is usually caused by a fall on the outstretched hand. On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).

Answer 249

Radial head fracture

Question 250

A 20 year old man develops acute appendicitis, his appendix is removed and he makes a full recovery. Which of the following pathological processes is least likely to be present in the acutely inflamed tissues? Altered Starlings forces Sequestration of neutrophils Formation of fluid exudate Formation of granulomas None of the abov

Answer 250

Formation of granulomas Acute inflammation: 3 phases 1. Changes in blood vessel and flow: flush, flare, wheal 2. Fluid exudates (rich in protein i.e. Ig, coagulation factors) produced via increased vascular permeability 3. Cellular exudates mainly containing neutrophil polymorphs pass into extravascular space. Neutrophils are then transported to tissues via: a. Margination of neutrophils to the peripheral plasmatic of the vessel rather than the central axial stream b. Pavementing: Adhesion of neutrophils to endothelial cells in venules at site of acute inflammation c. Emigration: neutrophils pass between endothelial cells into the tissue

Question 251

Vascular changes in acute inflammation

Answer 251

Vasodilation occurs and persists throughout the inflammatory phase. Inflammatory cells exit the circulation at the site of injury. The equilibrium that balances Starlings forces within capillary beds is disrupted and a protein rich exudate will form as the vessel walls also become more permeable to proteins. The high fibrinogen content of the fluid may form a fibrin clot. This has several important immunomodulatory functions.

Question 252

Potential sequelae of acute inflammation

Answer 252

Resolution Organisation Suppuration Progression to chronic inflammation

Question 253

Theme: Liver lesions A.Haemangioma B.Hepatocellular carcinoma C.Hepatic metastasis D.Polycystic liver disease E.Simple liver cyst F.Hyatid cyst G.Amoebic abscess H.Mesenchymal hamartoma Please select the most likely liver lesion for the scenario given. Each option may be used once, more than once or not at all. 20.A 42 year old lady has suffered from hepatitis C for many years and has also developed cirrhosis. On routine follow up, an ultrasound has demonstrated a 2.5cm lesion in the right lobe of the liver. A 25 year old man from the far east presents with a fever and right upper quadrant pain. As part of his investigations a CT scan shows an ill defined lesion in the right lobe of the liver. A 42 year old lady presents with right upper quadrant pain and a sensation of abdominal fullness. An ultrasound scan demonstrates a 6.5 cm hyperechoic lesion in the right lobe of the liver. Serum AFP is normal.

Answer 253

Hepatocellular carcinoma In patients with cirrhosis the presence of a lesion \>2cm is highly suggestive of malignancy. The diagnosis is virtually confirmed if the AFP is \>400ng/mL. Amoebic abscess Amoebic abscesses will tend to present in a similar fashion to other pyogenic liver abscesses. They should be considered in any individual presenting from a region where Entamoeba histiolytica is endemic. Treatment with metronidazole usually produces a marked clinical response. Haemangioma A large hyperechoic lesion in the presence of normal AFP is likely to be a haemangioma. An HCC of equivalent size will almost always result in rise in AFP.

Question 254

90% develop in women in their third to fifth decade Linked to use of oral contraceptive pill Lesions are usually solitary They are usually sharply demarcated from normal liver although they usually lack a fibrous capsule On ultrasound the appearances are of mixed echoity and heterogeneous texture. On CT most lesions are hypodense when imaged prior to administration of IV contrast agents In patients with haemorrhage or symptoms removal of the adenoma may be required

Answer 254

Liver cell adenoma

Question 255

Biliary sepsis is a major predisposing factor Structures drained by the portal venous system form the second largest source Common symptoms include fever, right upper quadrant pain. Jaundice may be seen in 50% Ultrasound will usually show a fluid filled cavity, hyperechoic walls may be seen in chronic abscesses

Answer 255

Liver abscess

Question 256

Liver abscess is the most common extra intestinal manifestation of amoebiasis Between 75 and 90% lesions occur in the right lobe Presenting complaints typically include fever and right upper quadrant pain Ultrasonography will usually show a fluid filled structure with poorly defined boundaries Aspiration yield sterile odourless fluid which has an anchovy paste consistency Treatment is with metronidazole

Answer 256

Amoebic liver abscess

Question 257

Seen in cases of Echinococcus infection Typically an intense fibrotic reaction occurs around sites of infection The cyst has no epithelial lining Cysts are commonly unilocular and may grow to 20cm in size. The cyst wall is thick and has an external laminated hilar membrane and an internal enucleated germinal layer Typically presents with malaise and right upper quadrant pain. Secondary bacterial infection occurs in 10%. Liver function tests are usually abnormal and eosinophilia is present in 33% cases Ultrasound may show septa and hyatid sand or daughter cysts. Percutaneous aspiration is contra indicated Treatment is by sterilisation of the cyst with mebendazole and may be followed by surgical resection. Hypertonic swabs are packed around the cysts during surgery

Answer 257

Hyatid cysts

Question 258

Usually occurs in association with polycystic kidney disease Autosomal dominant disorder Symptoms may occur as a result of capsular stretch

Answer 258

Polycystic liver disease

Question 259

Rare lesions with malignant potential Usually solitary multiloculated lesions Liver function tests usually normal Ultrasonography typically shows a large anechoic, fluid filled area with irregular margins. Internal echos may result from septa Surgical resection is indicated in all cases

Answer 259

Cystadenoma

Question 260

Which of the following best accounts for the action of PTH in increasing serum calcium levels? Activation of vitamin D to increase absorption of calcium from the small intestine. Direct stimulation of osteoclasts to absorb bone with release of calcium. Stimulation of phosphate absorption at the distal convoluted tubule of the kidney. Decreased porosity of the vessels at Bowmans capsule to calcium. Vasospasm of the afferent renal arteriole thereby reducing GFR and calcium urinary loss.

Answer 260

PTH increases the activity of 1-α-hydroxylase enzyme, which converts 25-hydroxycholecalciferol to 1,25-dihydroxycholecalciferol, the active form of vitamin D. Osteoclasts do not have a PTH receptor and effects are mediated via osteoblasts.

Question 261

An 83 year old lady presents with a femoral hernia and undergoes a femoral hernia repair. Which of the following forms the posterior wall of the femoral canal? Pectineal ligament Lacunar ligament Inguinal ligament Adductor longus Sartorius

Answer 261

Pectineal ligament

Question 262

Embryology of the spleen

Answer 262

It develops from the upper dorsal mesogastrium, remaining connected to the posterior abdominal wall and stomach by two folds of peritoneum; the lienorenal ligament and gastrosplenic ligament. The lienorenal ligament is derived from peritoneum where the wall of the general peritoneum meets the omental bursa between the left kidney and spleen; the splenic vessels lie in its layers. The gastrosplenic ligament also has two layers, formed by the meeting of the walls of the greater sac and omental bursa between spleen and stomach, the short gastric and left gastroepiploic branches of the splenic artery pass in its layers. Laterally, the spleen is in contact with the phrenicocolic ligament.

Question 263

White pulp of the spleen

Answer 263

Immune function. Contains central trabecular artery. The germinal centres are supplied by arterioles called penicilliary radicles.

Question 264

Red pulp of the spleen

Answer 264

Filters abnormal red blood cells.

Question 265

Function of the spleen

Answer 265

Filtration of abnormal blood cells and foreign bodies such as bacteria. Immunity: IgM. Production of properdin, and tuftsin which help target fungi and bacteria for phagocytosis. Haematopoiesis: up to 5th month gestation or in haematological disorders. Pooling: storage of 40% platelets. Iron reutilisation Storage monocytes

Question 266

Splenomegaly in SCD?

Answer 266

\*the majority of adult patients with sickle-cell will have an atrophied spleen due to repeated infarction

Question 267

A 45 year man presents with hand weakness. He is given a piece of paper to hold between his thumb and index finger. When the paper is pulled, the patient has difficulty maintaining a grip. Grip pressure is maintained by flexing the thumb at the interphalangeal joint. What is the most likely nerve lesion? Posterior interosseous nerve Deep branch of ulnar nerve Anterior interosseous nerve Superficial branch of the ulnar nerve Radial nerve

Answer 267

This is a description of Froment's sign, which tests for ulnar nerve palsy. It mainly tests for the function of adductor pollicis. This is supplied by the deep branch of the ulnar nerve. Remember the anterior interosseous branch (of the median nerve), which innervates the flexor pollicis longus (hence causing flexion of the thumb IP joint), branches off more proximally to the wrist.

Question 268

Branches of the ulnar nerve?

Answer 268

Muscular branch Palmar cutaneous branch Dorsal cutaneous branch Superficial branch Deep branch

Question 269

Muscular branch of the ulnar nerve supplies?

Answer 269

Flexor carpi ulnaris Medial half of the flexor digitorum profundus

Question 270

Palmar cutaneous branch (Arises near the middle of the forearm) of the ulnar nerve supplies?

Answer 270

Skin on the medial part of the palm

Question 271

Dorsal cutaneous branch of the ulnar nerve supplies

Answer 271

Dorsal surface of the medial part of the hand

Question 272

Superficial branch of the ulnar nerve supplies?

Answer 272

Cutaneous fibres to the anterior surfaces of the medial one and one-half digits

Question 273

Deep branch of the ulnar nerve supplies

Answer 273

Hypothenar muscles All the interosseous muscles Third and fourth lumbricals Adductor pollicis Medial head of the flexor pollicis brevis

Question 274

Wasting and paralysis of intrinsic hand muscles (claw hand) Wasting and paralysis of hypothenar muscles Loss of sensation medial 1 and half fingers

Answer 274

Damage at the wrist

Question 275

Radial deviation of the wrist Clawing less in 4th and 5th digits

Answer 275

Damage at the elbow

Question 276

Which of the following drugs does not cause syndrome of inappropriate anti diuretic hormone release? Haloperidol Carbamazepine Amitriptylline Cyclophosphamide Methotrexate

Answer 276

Methotrexate Drugs causing SIADH: ABCD A nalgesics: opioids, NSAIDs B arbiturates C yclophosphamide/ Chlorpromazine/ Carbamazepine D iuretic (thiazides)

Question 277

Theme: Hand injuries A.Admission and surgical debridement B.Application of futura splint and fracture clinic review C.Application of tubigrip bandage and fracture clinic review D.Admission for open reduction and fixation E.Discharge with reassurance F.Commence oral prednisolone G.Commence oral diclofenac Which of the following options is the best management plan? Each option may be used once, more than once or not at all. 29.A 42 year old skier falls and impacts his hand on his ski pole. On examination he is tender in the anatomical snuffbox and on bimanual palpation. X-rays with scaphoid views show no evidence of fracture. A 43 year old man falls over landing on his left hand. Although there was anatomical snuffbox tenderness no x-rays either at the time or subsequently have shown evidence of scaphoid fracture. He has been immobilised in a futura splint for two weeks and is now asymptomatic. A builder falls from scaffolding and lands on his left hand he suffers a severe laceration to his palm. An x-ray shows evidence of scaphoid fracture that is minimally displaced.

Answer 277

Application of futura splint and fracture clinic review A fracture may still be present and should be immobilised until repeat imaging can be performed. If clinical suspicion persists then subsequent imaging should be with MRI scanning or CT if MRI is contra-indicated. Discharge with reassurance This patient is at extremely low risk of having sustained a scaphoid injury and may be discharged. Admission and surgical debridement This is technically an open fracture and should be debrided prior to attempted fixation (which should occur soon after).

Question 278

80%s in scaphoid fracture

Answer 278

80% of all carpal fractures 80% occur in men 80% occur at the waist of the scaphoid

Question 279

Management of non-displaced scaphoid fracture

Answer 279

- Casts or splints - Percutaneous scaphoid fixation

Question 280

Management of displaced scaphoid fracture

Answer 280

Surgical fixation, usually with a screw

Question 281

Complications of scaphoid fracture?

Answer 281

Non union of scaphoid Avascular necrosis of the scaphoid Scapholunate disruption and wrist collapse Degenerative changes of the adjacent joint

Question 282

A 30 year old man is trapped in a house fire and sustains 30% partial and full thickness burns to his torso and limbs. Three days following admission he has a brisk haematemesis. Which of the following is the most likely explanation for this event? Dieulafoy lesion Curlings ulcers Mallory Weiss tear Depletion of platelets Depletion of clotting factors

Answer 282

Curlings ulcers typically occur secondary to thermal injuries and are caused by loss of GI protective mechanisms. They are at greater risk of perforation than stress ulcers and may also haemorrhage.

Question 283

Theme: Adrenal gland disorders A.Nelsons syndrome B.Conns syndrome C.Cushings syndrome D.Benign incidental adenoma E.Malignant adrenal adenoma F.Waterhouse- Friderichsen syndrome G.Metastatic lesion H.Walker - Warburg syndrome I.Phaeochromocytoma Please select the most appropriate adrenal disorder for the scenario given. Each disorder may be selected once, more than once or not at all. 33.A 19 year old lady is admitted to ITU with severe meningococcal sepsis. She is on maximal inotropic support and a CT scan of her chest and abdomen is performed. The adrenal glands show evidence of diffuse haemorrhage. A 34 year old lady is admitted with recurrent episodes of non-specific abdominal pain. On each admission all blood investigations are normal, as are her observations. On this admission a CT scan was performed. This demonstrates a 1.5cm nodule in the right adrenal gland. This is associated with a lipid rich core. Urinary VMA is within normal limits. Other hormonal studies are normal. A 38 year old man is noted to have a blood pressure of 175/110 on routine screening. On examination there are no physical abnormalities of note. CT scanning shows a left sided adrenal mass. Plasma metanephrines are elevated.

Answer 283

aterhouse- Friderichsen syndrome WaterhouseFriderichsen syndrome is defined as adrenal gland failure due to bleeding into the adrenal glands. It is caused by severe bacterial infection (most commonly the meningococcus Neisseria meningitidis). The bacterial infection leads to massive hemorrhage into one or (usually) both adrenal glands. It is characterised by overwhelming bacterial infection meningococcemia leading to massive blood invasion, organ failure, coma, haemodynamic shock, disseminated intravascular coagulation with widespread purpura, rapidly developing adrenocortical insufficiency and deat Benign incidental adenoma This is typical for a benign adenoma. Benign adenomas often have a lipid rich core that is readily identifiable on CT scanning. In addition the nodules are often well circumscribed. Phaeochromocytoma Hypertension in a young patient without any obvious cause should be investigated. Urinary VMA and plasma metanephrines are typically elevated.

Question 284

Which of the following statements relating to the right phrenic nerve is false? It lies deep to the prevertebral layer of deep cervical fascia Crosses posterior to the 2nd part of the subclavian artery It runs on the anterior surface of the scalene muscle On the right side it leaves the mediastinum via the vena cava hiatus at a level of T8 The right phrenic nerve passes over the right atrium

Answer 284

Crosses posterior to the 2nd part of the subclavian artery

Question 285

Phrenic nerve supplies

Answer 285

Diaphragm, sensation central diaphragm and pericardium

Question 286

Passage of the phrenic nerve?

Answer 286

The phrenic nerve passes with the internal jugular vein across scalenus anterior. It passes deep to prevertebral fascia of deep cervical fascia. Left: crosses anterior to the 1st part of the subclavian artery. Right: Anterior to scalenus anterior and crosses anterior to the 2nd part of the subclavian artery. On both sides, the phrenic nerve runs posterior to the subclavian vein and posterior to the internal thoracic artery as it enters the thorax.

Question 287

Passage of the right phrenic nerve

Answer 287

In the superior mediastinum: anterior to right vagus and laterally to superior vena cava Middle mediastinum: right of pericardium It passes over the right atrium to exit the diaphragm at T8

Question 288

Passage of the left phrenic nerve

Answer 288

Passes lateral to the left subclavian artery, aortic arch and left ventricle Passes anterior to the root of the lung Pierces the diaphragm alone

Question 289

A 43 year old man presents with dyspepsia and undergoes an upper GI endoscopy. During the procedure diffuse gastric and duodenal ulcers are identified. A Clo test confirms the presence of Helicobacter pyloriinfection. What is the most likely explanation for the ulcers? Decreased gastric motility Increased urease activity Decreased release of mucous and bicarbonate Decreased gastrin levels Increased acid production

Answer 289

H-Pylori has a number of pathological effects. In this question the main issue is by what mechanism the organism is able to induce both gastric and duodenal ulceration. Without modestly elevated acid levels, the duodenum would not undergo gastric metaplasia. H-Pylori cannot colonise duodenal mucosa and therefore the development of ulcers at this site can only occur in those who have undergone metaplastic transformation (mediated by increased acidity).

Question 290

It is a gram negative, helical shaped rod with microaerophillic requirements. It has the ability to produce a urease enzyme that will hydrolyse urea resulting in the production of ammonia. The effect of ammonia on antral G cells is to cause release of gastrin via a negative feedback loop.

Answer 290

H. Pylori

Question 291

Pathophysiology of H. pylori

Answer 291

Once infection is established the organism releases enzymes that disrupt the gastric mucous layer. Certain subtypes release cytotoxins cag A and vac A gene products. The organism incites a classical chronic inflammatory process of the gastric epithelium. This accounts for the development of gastric ulcers. The mildly increased acidity may induce a process of duodenal gastric metaplasia. Whilst duodenal mucosa cannot be colonised by H-Pylori, mucosa that has undergone metaplastic change to the gastric epithelial type may be colonised by H- Pylori with subsequent inflammation and development of duodenitis and ulcers.

Question 292

Complications of H. pylori colonisation

Answer 292

In patients who are colonized, there is a 10-20% risk of peptic ulcer, 1-2% risk gastric cancer and \<1% risk MALT lymphoma.

Question 293

Which of the following cranial foramina pairings are incorrect? Carotid canal and internal carotid artery. Foramen ovale and mandibular nerve. Optic canal and ophthalmic artery. Optic canal and ophthalmic nerve. Foramen rotundum and maxillary nerve.

Answer 293

The optic canal transmits the optic nerve. The ophthalmic nerve traverses the superior orbital fissure.

Question 294

A 22 year old man is involved in a fight and sustains a stab wound in his upper forearm. On examination there is a small, but deep laceration. There is an obvious loss of pincer movement involving the thumb and index finger with minimal loss of sensation. The most likely nerve injury is to the: Ulnar nerve Radial nerve Anterior interosseous nerve Axillary nerve Median nerve

Answer 294

The anterior interosseous nerve is a motor branch of the median nerve just below the elbow. When damaged it classically causes: Pain in the forearm Loss of pincer movement of the thumb and index finger (innervates the long flexor muscles of flexor pollicis longus & flexor digitorum profundus of the index and middle finger) Minimal loss of sensation due to lack of a cutaneous branch

Question 295

A 17 year old man undergoes an elective right hemicolectomy. Post operatively he receives a total of 6 litres of 0.9% sodium chloride solution, over 24 hours. Which of the following complications may ensue? Hyperchloraemic acidosis Hypochloraemic alkalosis Hyperchloraemic alkalosis Acute renal failure None of the above

Answer 295

Excessive infusions of any intravenous fluid carry the risk of development of tissue oedema and potentially cardiac failure. Excessive administration of sodium chloride is a recognised cause of hyperchloraemic acidosis and therefore Hartmans solution may be preferred where large volumes of fluid are to be administered.

Question 296

Which of the following changes are not typically seen in established dehydration? Rising haematocrit Urinary sodium \<20mmol/ litre Metabolic acidosis Decreased serum urea to creatinine ratio Hypernatraemia

Answer 296

Diagnosing dehydration can be complicated, laboratory features include: Hypernatraemia Rising haematocrit Metabolic acidosis Rising lactate Increased serum urea to creatinine ratio Urinary sodium \<20 mmol/litre Urine osmolality approaching 1200mosmol/kg

Question 297

A 66 year old man is undergoing a left nephro-ureterectomy. The surgeons remove the ureter, which of the following is responsible for the blood supply to the proximal ureter? Branches of the renal artery External iliac artery Internal iliac artery Direct branches from the aorta Common iliac artery

Answer 297

The proximal ureter is supplied by branches from the renal artery. For the other feeding vessels - see below.

Question 298

Theme: Paediatric gastrointestinal disorders A.Meconium ileus B.Biliary atresia C.Oesophageal atresia D.Pyloric stenosis E.Intussusception F.Malrotation G.Hirschsprung disease H.Mesenteric adenitis. What is the most likely diagnosis for each scenario given? Each option may be used once, more than once or not at all. 43.A 3 day old baby presents with recurrent episodes of choking and cyanotic episodes. There is a history of polyhydramnios. A 3 day old neonate is developing increasing problems with feeding. On examination she has a pan systolic murmur and her forearms have not developed properly.

Answer 298

Oesophageal atresia Diagnosis is confirmed when an nasogastric tube fails to reach the stomach. Oesophageal atresia This child has VACTERL, which is a combination of Vertebral, Ano-rectal, Cardiac, Tracheo-oesophageal, Renal and Radial limb anomalies. Half of babies with oesophageal atresia will have VACTERL. Mesenteric adenitis. Mesenteric adenitis may complicate upper respiratory tract infection and clinical exclusion of appendicitis can be difficult.

Question 299

VACTERL

Answer 299

VACTERL, which is a combination of Vertebral, Ano-rectal, Cardiac, Tracheo-oesophageal, Renal and Radial limb anomalies. Half of babies with oesophageal atresia will have VACTERL.

Question 300

Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations

Answer 300

Oesophageal atresia

Question 301

Genetics of Peutz-Jehgers

Answer 301

AD Responsible gene encodes serine threonine kinase LKB1 or STK11

Question 302

A 7 year old boy is due to undergo a circumcision for phimosis. Which of the following devices would be the most appropriate agent to use for achieving haemostasis? Monopolar unit in cutting mode Bipolar unit Monopolar unit in coagulation mode Monopolar unit in blend mode Monopolar unit configured to spray mode

Answer 302

The danger with the use of any source other than bipolar diathermy in this setting is the risk of causing trauma to end vessels. All the monopolar units, regardless of the setting will carry this risk.

Question 303

Theme: Paediatric orthopaedics A.Musculoskeletal pain B.Congenital dysplasia of the hip C.Slipped upper femoral epiphysis D.Transient synovitis E.Septic arthritis F.Perthes disease G.Tibial fracture Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all. 3.A 4 year boy presents with an abnormal gait. He has a history of recent viral illness. His WCC is 11 and ESR is 30. A 6 year old boy presents with groin pain. He is known to be disruptive in class. He reports that he is bullied for being short. On examination he has an antalgic gait and pain on internal rotation of the right hip. An obese 12 year old boy is referred with pain in the left knee and hip. On examination he has an antaglic gait and limitation of internal rotation. His knee has normal range of passive and active movement.

Answer 303

Transient synovitis Viral illnesses can be associated with transient synovitis. The WCC should ideally be \> 12 and the ESR \> 40 to suggest septic arthritis. Perthes disease This child is short, has hyperactivity (disruptive behaviour) and is within the age range for Perthes disease. Hyperactivity and short stature are associated with Perthes disease. Slipped upper femoral epiphysis Slipped upper femoral epiphysis is commonest in obese adolescent males. The x-ray will show displacement of the femoral epiphysis inferolaterally. Treatment is usually with rest and non weight bearing crutches.

Question 304

Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies.

Answer 304

Developmental dysplasia of the hip

Question 305

Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc

Answer 305

Developmental dysplasia of the hip

Question 306

Treatment of DDH

Answer 306

Splints and harnesses or traction- Pavlik. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision

Question 307

Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%.

Answer 307

Perthes Disease

Question 308

Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%.

Answer 308

Slipped upper femoral epiphysis

Question 309

X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment.

Answer 309

Perthes Disease

Question 310

X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 310

Slipped upper femoral epiphysis

Question 311

What gives degree of disease severity in SUFE?

Answer 311

Southwick angle

Question 312

Southwick angle

Answer 312

A Southwick angle is a radiographic angle used to measure the severity of a slipped capital femoral epiphysis (SCFE) on a radiograph. It was named after Wayne O. Southwick, a famous surgeon. The angle is measured on a frog lateral view of the bilateral hips. It is measured by drawing a line perpendicular to a line connecting two points at the posterior and anterior tips of the epiphysis at the physis. A third line is drawn down the axis of femur. The angle between the perpendicular line and the femoral shaft line is the angle. The angle is measured bilaterally. The slipped side is then subtracted from the normal side. The number calculated determines the severity. Mild is classified by \< 30°. Moderate is 30°-50°. Severe is \>50°. 12° is the normal control value and can be used in the case of bilateral involvement.

Question 313

Treatment of Perthes disease

Answer 313

Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly.

Question 314

Treatment of SUFE

Answer 314

Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required.

Question 315

Theme: Management of peripheral arterial disease A.Primary amputation B.Angioplasty C.Arterial bypass surgery using vein D.Arterial bypass surgery using PTFE E.Conservative management with medical therapy and exercise F.Watch and wait G.Duplex scanning Please select the most appropriate management for the scenario given. Each option may be used once, more than once or not at all. 6.A 63 year old man is admitted with rest pain and foot ulceration. An angiogram shows a 3 cm area of occlusion of the distal superficial femoral artery with 3 vessel run off. His ankle - brachial pressure index is 0.4. A 72 year old man present in the vascular clinic with calf pain present on walking 100 yards. He is an ex-smoker and lives alone. On examination he has reasonable leg pulses. His right dorsalis pedis pulse gives a monophasic doppler signal with an ankle brachial pressure index measurement of 0.7. All other pressures are acceptable. There is no evidence of ulceration or gangrene. An 83 year old lady is admitted from a nursing home with infected lower leg ulcers. She underwent an attempted long superficial femoral artery sub initimal angioplasty 2 weeks previously. This demonstrated poor runoff below the knee.

Answer 315

Angioplasty Short segment disease and good run off with tissue loss is a compelling indication for angioplasty. He should receive aspirin and a statin if not already taking them. Conservative management with medical therapy and exercise Structured exercise programmes combined with medical therapy will improve many patients. Should his symptoms worsen or fail to improve then imaging with duplex scanning would be required. Primary amputation Poor runoff and sepsis would equate to poor outcome with attempted bypass surgery.

Question 316

Indications for surgery to revascularise limb

Answer 316

Intermittent claudication Critical ischaemia Ulceration Gangrene Intermittent claudication that is not disabling may provide a relative indication, whilst the other complaints are often absolute indications depending upon the frailty of the patient.

Question 317

Assessment in peripheral vascular disease

Answer 317

Clinical examination Ankle brachial pressure index measurement Duplex arterial ultrasound Angiography (standard, CT or MRI): usually performed only if intervention being considered.

Question 318

Requirements for angioplasty success

Answer 318

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 319

Distal run off

Answer 319

Blood flow in post-stenotic region of a blood vessel

Question 320

Indications for surgery in PVD

Answer 320

Surgery will be undertaken where attempts at angioplasty have either failed or are unsuitable. Bypass essentially involves bypassing the affected arterial segment by utilising a graft to run from above the disease to below the disease. As with angioplasty good runoff improves the outcome.

Question 321

Procedure of superficial femoral artery bypass surgery

Answer 321

Artery dissected out, IV heparin 3,000 units given and then the vessels are cross clamped Longitudinal arteriotomy Graft cut to size and tunneled to arteriotomy sites Anastomosis to femoral artery usually with 5/0 'double ended' Prolene suture Distal anastomosis usually using 6/0 'double ended' Prolene

Question 322

Which of the following statements relating to the pharmacology of warfarin is untrue? Interferes with clotting factors 2,7,9 and 10 It may not be clinically effective for up to 72 hours The half life of warfarin is 40 hours Warfarin has a large volume of distribution It is metabolized in the liver

Answer 322

Factors 2,7,9,10 affected Warfarin interferes with fibrin formation by affecting carboxylation of glutamic acid residues in factors 2,7,9 and 10. Factor 2 has the longest half life of approximately 60 hours, therefore it can take up to 3 days for warfarin to be fully effective. Warfarin has a small volume of distribution as it is protein bound.

Question 323

If a 2 x 2 cm autologus skin graft is placed on an area of healthy granulation tissue. After about a week, a thin bluish - white margin appears around the graft and spreads at a rate of 1mm per day. What is it? Epidermis alone Epidermis and dermis Dermis alone Inflammatory exudate Fibrin

Answer 323

Epidermis alone This is the process of re-epithelialisation.

Question 324

Which of the following is not a typical feature of acute appendicitis? Neutrophilia Profuse vomiting Anorexia Low grade pyrexia Small amounts of protein on urine analysis

Answer 324

Profuse vomiting and diarrhoea are rare in early appendicitis Whilst patients may vomit once or twice, profuse vomiting is unusual, and would fit more with gastroenteritis or an ileus. A trace of protein is not an uncommon occurrence in acute appendicitis. A free lying pelvic appendix may result in localised bladder irritation, with inflammation occurring as a secondary phenomena. This latter feature may result in patients being incorrectly diagnosed as having a urinary tract infection. A urine dipstick test is useful in differentiating between the two conditions.

Question 325

Which of the following structures does not pass behind the lateral malleolus? Peroneus brevis tendon Sural nerve Short saphenous vein Peroneus longus tendon Tibialis anterior tendon

Answer 325

Tibialis anterior tendon passes anterior to the medial malleolus.

Question 326

Structures posterior to the lateral malleolus and superficial to superior peroneal retinaculum

Answer 326

Sural nerve Short saphenous vein

Question 327

Structures posterior to the lateral malleolus and deep to superior peroneal retinaculum

Answer 327

Peroneus longus tendon Peroneus brevis tendon

Question 328

A 78 year old man presents with symptoms consistent with intermittent claudication. To assess the severity of his disease you decide to measure his ankle brachial pressure index. To do this you will identify the dorsalis pedis artery. Which of the following statements relating to this vessel is false? It originates from the peroneal artery It is crossed by the tendon of extensor hallucis brevis Two veins are usually closely related to it It passes under the inferior extensor retinaculum The tendon of extensor hallucis longus lies medial to it.

Answer 328

The dorsalis pedis artery is a direct continuation of the anterior tibial artery.

Question 329

What are the two arches of the foot?

Answer 329

Longitudinal arch Transverse arch

Question 330

Longitudinal arch of the foot

Answer 330

The longitudinal arch is higher on the medial than on the lateral side. The posterior part of the calcaneum forms a posterior pillar to support the arch. The lateral part of this structure passes via the cuboid bone and the lateral two metatarsal bones. The medial part of this structure is more important. The head of the talus marks the summit of this arch, located between the sustentaculum tali and the navicular bone. The anterior pillar of the medial arch is composed of the navicular bone, the three cuneiforms and the medial three metatarsal bones.

Question 331

Transverse arch of the foot

Answer 331

The transverse arch is situated on the anterior part of the tarsus and the posterior part of the metatarsus. The cuneiforms and metatarsal bases narrow inferiorly, which contributes to the shape of the arch.

Question 332

What are the intertarsal joints?

Answer 332

Subtalar joint Talocalcaneonavicular joint Calcaneocuboid joint Transverse tarsal joint Cuneonavicular joint Intercuneiform joints Cuneocuboid joint

Question 333

Formed by the cylindrical facet on the lower surface of the body of the talus and the posterior facet on the upper surface of the calcaneus. The facet on the talus is concave anteroposteriorly, the other is convex. The synovial cavity of this joint does not communicate with any other joint.

Answer 333

Sub talar joint

Question 334

The anterior part of the socket is formed by the concave articular surface of the navicular bone, posteriorly by the upper surface of the sustentaculum tali. The talus sits within this socket

Answer 334

Talocalcaneonavicular joint

Question 335

Highest point in the lateral part of the longitudinal arch. The lower aspect of this joint is reinforced by the long plantar and plantar calcaneocuboid ligaments.

Answer 335

Calcaneocuboid joint

Question 336

The talocalcaneonavicular joint and the calcaneocuboid joint extend across the tarsus in an irregular transverse plane, between the talus and calcaneus behind and the navicular and cuboid bones in front. This plane is termed the transverse tarsal joint.

Answer 336

Transverse tarsal joint

Question 337

Formed between the convex anterior surface of the navicular bone and the concave surface of the the posterior ends of the three cuneiforms.

Answer 337

Cuneonavicular joint

Question 338

Between the three cuneiform bones.

Answer 338

Intercuneiform joints

Question 339

Between the circular facets on the lateral cuneiform bone and the cuboid. This joint contributes to the tarsal part of the transverse arch.

Answer 339

Cuneocuboid joint

Question 340

Muscles of the foot supplied by the medial plantar nerve?

Answer 340

Abductor hallucis Flexor digitorum brevis Flexor hallucis brevis

Question 341

Origin and insertion of abductor hallucis

Answer 341

Medial side of the calcaneus, flexor retinaculum, plantar aponeurosis Medial side of the base of the proximal phalanx

Question 342

Origin and insertion Flexor digitorum brevis

Answer 342

Medial process of the calcaneus, plantar aponeurosis. Via 4 tendons into the middle phalanges of the lateral 4 toes.

Question 343

Muscles of the foot supplied by the lateral plantar nerve

Answer 343

Abductor digit minimi Adductor hallucis

Question 344

Action of flexor digitorum brevis

Answer 344

Flexes all the joints of the lateral 4 toes except for the interphalangeal joint.

Question 345

Origin and insertion of flexor hallucis brevis

Answer 345

From the medial side of the plantar surface of the cuboid bone, from the adjacent part of the lateral cuneiform bone and from the tendon of tibialis posterior. Into the proximal phalanx of the great toe, the tendon contains a sesamoid bone

Question 346

Action of flexor hallucis brevis

Answer 346

Flexes the metatarsophalangeal joint of the great toe.

Question 347

Origin and insertion of the abductor digiti minimi

Answer 347

From the tubercle of the calcaneus and from the plantar aponeurosis Together with flexor digit minimi brevis into the lateral side of the base of the proximal phalanx of the little toe

Question 348

Origin and insertion of adductor hallucis

Answer 348

Arises from two heads. The oblique head arises from the sheath of the peroneus longus tendon, and from the plantar surfaces of the bases of the 2nd, 3rd and 4th metatarsal bones. The transverse head arises from the plantar surface of the lateral 4 metatarsophalangeal joints and from the deep transverse metatarsal ligament. Lateral side of the base of the proximal phalanx of the great toe.

Question 349

Action of abductor digit minimi

Answer 349

Abducts the little toe at the metatarsophalangeal joint

Question 350

Action of adductor hallucis

Answer 350

Adducts the great toe towards the second toe. Helps maintain the transverse arch of the foot.

Question 351

Muscles in the foot innervated by deep peroneal

Answer 351

Extensor digitorum brevis

Question 352

Origin and insertion of extensor digitorum brevis

Answer 352

On the dorsal surface of the foot from the upper surface of the calcaneus and its associated fascia Via four thin tendons which run forward and medially to be inserted into the medial four toes. The lateral three tendons join with hoods of extensor digitorum longus.

Question 353

Extensor digitorum brevis

Answer 353

Extend the metatarsophalangeal joint of the medial four toes. It is unable to extend the interphalangeal joint without the assistance of the lumbrical muscles.

Question 354

Passage of the lateral plantar nerve

Answer 354

Passes anterolaterally towards the base of the 5th metatarsal between flexor digitorum brevis and flexor accessorius. On the medial aspect of the lateral plantar artery. At the base of the 5th metatarsal it splits into superficial and deep branches.

Question 355

Passage of the medial plantar nerve

Answer 355

Passes forwards with the medial plantar artery under the cover of the flexor retinaculum to the interval between abductor hallucis and flexor digitorum brevis on the sole of the foot.

Question 356

What are the plantar arteries and where do they arise?

Answer 356

Arise under the cover of the flexor retinaculum, midway between the tip of the medial malleolus and the most prominent part of the medial side of the heel. Medial plantar artery. Passes forwards medial to medial plantar nerve in the space between abductor hallucis and flexor digitorum brevis.Ends by uniting with a branch of the 1st plantar metatarsal artery. Lateral plantar artery. Runs obliquely across the sole of the foot. It lies lateral to the lateral plantar nerve. At the base of the 5th metatarsal bone it arches medially across the foot on the metatarsals

Question 357

This vessel is a direct continuation of the anterior tibial artery. It commences on the front of the ankle joint and runs to the proximal end of the first metatarsal space. Here is gives off the arcuate artery and continues forwards as the first dorsal metatarsal artery. It is accompanied by two veins throughout its length. It is crossed by the extensor hallucis brevis

Answer 357

Dorsalis pedis artery

Question 358

Which of the following is not a content of the anterior triangle of the neck? Vagus nerve Submandibular gland Phrenic nerve Internal jugular vein Hypoglossal nerve

Answer 358

The phrenic nerve is a content of the posterior triangle. The anterior triangle contains the carotid sheath and its contents.

Question 359

A 32 year old attends neurology clinic complaining of tingling in his hand. He has radial deviation of his wrist and there is mild clawing of his fingers, with the 4th and 5th digits being relatively spared. What is the most likely lesion? Ulnar nerve damage at the wrist Ulnar nerve damage at the elbow Radial nerve damage at the elbow Median nerve damage at the wrist Median nerve damage at the elbow

Answer 359

The ulnar paradox- the higher the lesion, the less the clawing of the fingers seen clinically. At the elbow the ulnar nerve lesion affects the flexor carpi ulnaris and flexor digitorum profundus.

Question 360

Theme: Eponymous fractures A.Smith's B.Bennett's C.Monteggia's D.Colles' E.Galeazzi F.Pott's G.Barton's Link the most appropriate eponymously named fracture to the scenario described. Each scenario may be used once, more than once or not at all. 19.A 28 year old man falls on the back of his hand. On x-ray he has a fractured distal radius demonstrating volar displacement of the fracture. A 38 year old window cleaner falls from his ladder. He lands on his left arm and notices an obvious injury. An x-ray and clinical examination demonstrate that he has a fracture of the proximal ulna and associated radial dislocation. A 32 year old man falls from scaffolding and sustains an injury to his forearm. Clinical examination and x-ray shows that he has sustained a radial fracture with dislocation of the distal radio-ulna joint.

Answer 360

Smith's This is a Smith fracture (reverse Colles' fracture); unlike a Colles' this is a high velocity injury and may require surgical correction. Note that Colles' fractures are usually dorsally displaced. Monteggia's This constellation of injuries is referred to as a Monteggia's fracture. Galeazzi Isolated fracture of the radius alone can occur but is rare. Always check for associated injury.

Question 361

A 32 year old woman attends clinic for assessment of varicose veins. She has suffered for varicose veins for many years and can trace their development back to when she suffered a complex tibial fracture. On examination she has marked truncal varicosities with a long tortuous long saphenous vein. What is the most appropriate next step? Arrange a venogram Arrange a venous duplex scan List her for a trendelenberg procedure List her for injection foam sclerotherapy List her for multiple avulsion phlebectomies

Answer 361

This lady is likely to have deep venous incompetence as she will have been immobilised for her tibial fracture and may well have had a DVT. A duplex scan is mandatory prior to any form of surgical intervention. A venogram would provide similar information but is more invasive.

Question 362

def: varicose veins

Answer 362

Saccular dilation of veins

Question 363

Chronic venous insufficiency

Answer 363

Chronic venous insufficiency is a series of tissue changes which occur in relation to pooling of blood in the extremities with associated venous hypertension occurring as a result of incompetent deep vein valves.

Question 364

Symptoms of varicose veins

Answer 364

Cosmetic appearance Aching Ankle swelling that worsens as the day progresses Episodic thrombophlebitis Bleeding Itching

Question 365

Symptoms of chronic venous insufficiency

Answer 365

Dependant leg pain Prominent leg swelling Oedema extending beyond the ankle Venous stasis ulcers

Question 366

Typical features of venous ulcer

Answer 366

Located above the medial malleolus Indolent appearance with basal granulation tissue Variable degree of scarring Non ischaemic edges Haemosiderin deposition in the gaiter area (and also lipodermatosclerosis).

Question 367

Examination of varicose veins

Answer 367

Assess for dilated short saphenous vein (popliteal fossa) and palpate for saphena varix medial to the femoral artery Brodie-Trendelenburg test: to assess level of incompetence Perthes' walking test: assess if deep venous system competent

Question 368

Indications for surgery in varicose veins

Answer 368

Indications for surgery: Cosmetic: majority Lipodermatosclerosis causing venous ulceration Recurrent superficial thrombophlebitis Bleeding from ruptured varix

Question 369

Management of minor varicose veins without complications

Answer 369

Reassure/cosmetic

Question 370

Management of symptomatic uncomplicated varicose veins

Answer 370

In those without deep venous insufficiency options include; endothermal ablation, foam sclerotherapy, saphenofemoral / popliteal disconnection, stripping and avulsions, compression stockings

Question 371

Management of varicsoe veins with skin changes

Answer 371

Therapy as above (if compression minimum is formal class I stockings)

Question 372

Management of chronic venous insufficiency or ulcers

Answer 372

Class 2-3 compression stockings (ensure no arterial disease).

Question 373

Side effect of injection sclerotherapy for varicose veins?

Answer 373

Transient blindness

Question 374

First line treatment of varicose veins recommended by NICE?

Answer 374

In the United Kingdom the National Institute of Clinical Excellence guidance on varicose veins suggests that for patients with symptomatic varicose veins the first line procedure of choice should be endothermal ablation (see reference for more information). Where this is unavailable or unsuitable then foam sclerotherapy should be the second line option. Surgery is currently the third line treatment option.

Question 375

How to perform Trendelenburg procedure (SFJ ligation)

Answer 375

Head tilt 15 degrees and legs abducted Oblique incision 1cm medial from artery Tributaries ligated (Superficial circumflex iliac vein, Superficial inferior epigastric vein, Superficial and deep external pudendal vein) SF junction double ligated Saphenous vein stripped to level of knee/upper calf. NB increased risk of saphenous neuralgia if stripped more distally

Question 376

A 25 year old male pedestrian is involved in a road traffic accident. He sustains multiple injuries and is admitted to the intensive care unit, intubated and ventilated. Over the next week he develops adult respiratory distress syndrome. What is the main reason for hypoxaemia in this condition? Increased lung compliance Reduced diffusion Reduced surfactant Reduced elastase Left to right shunt

Answer 376

The diffuse lung injury, which is associated with loss of surfactant and increased elastase release from neutrophils, results in fluid accumulation. This leads to reduced diffusion, which is the main reason for hypoxaemia.

Question 377

def: ARDS

Answer 377

Defined as an acute condition characterized by bilateral pulmonary infiltrates and severe hypoxemia (PaO2/FiO2 ratio \< 200) in the absence of evidence for cardiogenic pulmonary oedema (clinically or pulmonary capillary wedge pressure of less than 18 mm Hg). It is subdivided into two stages. Early stages consist of an exudative phase of injury with associated oedema. The later stage is one of repair and consists of fibroproliferative changes. Subsequent scarring may result in poor lung function.

Question 378

Causes of ARDS

Answer 378

Sepsis Direct lung injury Trauma Acute pancreatitis Long bone fracture or multiple fractures (through fat embolism) Head injury (causes sympathetic nervous stimulation which leads to acute pulmonary hypertension)

Question 379

Management of ARDS

Answer 379

Treat the underlying cause Antibiotics (if signs of sepsis) Negative fluid balance i.e. Diuretics Recruitment manoeuvres such as prone ventilation, use of positive end expiratory pressure Mechanical ventilation strategy using low tidal volumes, as conventional tidal volumes may cause lung injury (only treatment found to improve survival rates)

Question 380

UC and ileitis

Answer 380

Ulcerative colitis is a form of inflammatory bowel disease. Inflammation always starts at rectum, does not spread beyond ileocaecal valve (although backwash ileitis may occur) and is continuous

Question 381

Extraintestinal manifestations of CD and UC related to disease activity

Answer 381

Arthritis: pauciarticular, asymmetric Erythema nodosum Episcleritis Osteoporosis

Question 382

Extraintestinal manifestations of CD and IBD unrelated to disease activity

Answer 382

Arthritis: polyarticular, symmetric Uveitis (UC) Pyoderma gangrenosum Clubbing Primary sclerosing cholangitis (UC)

Question 383

Red, raw mucosa, bleeds easily No inflammation beyond submucosa (unless fulminant disease) Widespread superficial ulceration with preservation of adjacent mucosa which has the appearance of polyps ('pseudopolyps') Inflammatory cell infiltrate in lamina propria Neutrophils migrate through the walls of glands to form crypt abscesses Depletion of goblet cells and mucin from gland epithelium Granulomas are infrequent

Answer 383

Ulcerative colitis

Question 384

Management of UC

Answer 384

Patients with long term disease are at increased risk of development of malignancy Acute exacerbations are generally managed with steroids, in chronic patients agents such as azathioprine and infliximab may be used Individuals with medically unresponsive disease usually require surgery- in the acute phase a sub total colectomy and end ileostomy. In the longer term a proctectomy will be required. An ileoanal pouch is an option for selected patients

Question 385

Which virus is associated with Kaposi's sarcoma? Human herpes virus 8 Human papillomavirus 16 Human T-lymphotropic virus 1 Epstein-Barr virus Human papillomavirus 18

Answer 385

Human herpes virus 8

Question 386

A 22 year old man is undergoing an endotracheal intubation. Which of the following vertebral levels is consistent with the origin of the trachea? C2 T1 C6 C4 C3

Answer 386

The trachea commences at C6. It terminates at the level of T5 (or T6 in tall subjects in deep inspiration)

Question 387

Aterial and venous supply of the trachea

Answer 387

Inferior thyroid arteries and the thyroid venous plexus.

Question 388

Which of the following is not a feature of Wallerian Degeneration? May result from an axonotmesis Typically occurs in the peripheral nervous systems The axon remains excitable throughout the whole process The distal neuronal stump is affected Is a component of the healing process following neuronal injury

Answer 388

The axon loses its excitability once the process is established. - Is the process that occurs when a nerve is cut or crushed. - It occurs when the part of the axon separated from the neuron's cell nucleus degenerates. - It usually begins 24 hours following neuronal injury and the distal axon remains excitable up until this time. - The degeneration of the axon is following by breakdown of the myelin sheath, a process that occurs by infiltration of the site with macrophages. - Eventually regeneration of the nerve may occur although recovery will depend on the extent and manner of injury

Question 389

Which of the following does not cause an increased anion gap acidosis? Uraemia Paraldehyde Diabetic ketoacidosis Ethylene glycol Acetazolamide

Answer 389

Acetazolamide Causes of increased anion acidosis: MUDPILES M - Methanol U - Uraemia D - DKA/AKA P - Paraldehyde/phenformin I - Iron/INH L - Lactic acidosis E - Ethylene glycol S - Salicylates

Question 390

Which statement regarding post operative cognitive impairment is true? Use of Benzodiazepines preoperatively reduces long-term post operative cognitive dysfunction Pain does not cause delirium Delirium has no impact on length of hospital stay A regional anaesthetic rather than a general anaesthetic is more likely to contribute to post operative cognitive impairment Visual hallucinations are not a feature of delirium

Answer 390

Anaesthetic technique and Post operative cognitive impairment (POCD): Use of benzodiazepines preoperatively reduces long-term POCD (9.9% vs. 5%) Do not stop drugs for cognitive function Regional techniques reduce POCD in first week, but no difference at 3 months

Question 391

A young child undergoes a difficult craniotomy for fulminant mastoiditis and associated abscess. During the procedure the trigeminal nerve is severely damaged within Meckels cave. Which deficit is least likely to be present? Anaesthesia over the ipsilateral anterior aspect of the scalp Loss of the corneal reflex Weakness of the ipsilateral masseter muscle Anaesthesia of the anterior aspect of the lip Anaesthesia over the entire ipsilateral side of the face

Answer 391

Anaesthesia over the entire ipsilateral side of the face The angle of the jaw is not innervated by sensory fibres of the trigeminal nerve and is spared in this type of injury. Remember the trigeminal nerve provides motor innervation to the muscles of mastication. The close proximity of the site of injury to the motor fibres is likely to result in at least some compromise of motor muscle function.

Question 392

A 62 year old woman presents with acute bowel obstruction. She has been vomiting up to 15 times a day and is taking erythromycin. She suddenly complains of dizziness. Her ECG shows torsades de pointes. What is the management of choice? IV Atropine IV Potassium IV Magnesium sulphate IV Bicarbonate IV Adrenaline

Answer 392

Torsades de pointes: Treatment IV magnesium sulphate This woman is likely to have hypokalaemia and hypomagnasaemia as a result of vomiting. In addition to this, the erythromycin will predispose her to torsades de pointes. The patient needs Magnesium 2g over 10 minutes. Knowledge of the management of this peri arrest diagnosis is hence important in surgical practice.

Question 393

Theme: Nerve lesions A.Iliohypogastric nerve B.Ilioinguinal nerve C.Lateral cutaneous nerve of the thigh D.Femoral nerve E.Saphenous nerve F.Genitofemoral nerve Please select the most likely nerve implicated in the situation described. Each option may be used once, more than once or not at all. 35.A 42 year old woman complains of a burning pain of her anterior thigh which worsens on walking. There is a positive tinel sign over the inguinal ligament. A 29 year old woman has had a Pfannenstiel incision. She has pain over the inguinal ligament which radiates to the lower abdomen. There is tenderness when the inguinal canal is compressed. A 22 year man is shot in the groin. On examination he has weak hip flexion, weak knee extension, and impaired quadriceps tendon reflex, as well as sensory deficit in the anteromedial aspect of the thigh.

Answer 393

Lateral cutaneous nerve of the thigh The lateral cutaneous nerve supplies sensation to the anterior and lateral aspect of the thigh. Entrapment is commonly due to intra and extra pelvic causes. Treatment involves local anaesthetic injections. Ilioinguinal nerve Femoral nerve This is a classical description of a femoral nerve injury.

Question 394

Which one of the following is least associated with thrombocytopenia? Heparin therapy Rheumatoid arthritis Infectious mononucleosis Liver disease Pregnancy

Answer 394

Rheumatoid arthritis, unlike systemic lupus erythematous, is generally associated with a thrombocytosis. In some cases of Felty's syndrome thrombocytopaenia may be seen secondary to hypersplenism. This however represents a small percentage of patients with rheumatoid arthritis.

Question 395

Causes of severe thrombocytopenia

Answer 395

ITP DIC TTP haematological malignancy

Question 396

Causes of carpal tunnel syndrome

Answer 396

MEDIAN TRAP Mnemonic Myxoedema Edema premenstrually Diabetes Idiopathic Acromegaly Neoplasm Trauma Rheumatoid arthritis Amyloidosis Pregnancy

Question 397

Management of carpal tunnel syndrome

Answer 397

Conservative: Spontaneous resolution. Avoid precipitants. Night time splints. Medical: Local steroid injections. Surgical: Complete division of flexor retinaculum and decompression of tunnel (successful in 80% of patients)

Question 398

An 28 year old man presents with a direct inguinal hernia. A decision is made to perform an open inguinal hernia repair. Which of the following is the best option for abdominal wall reconstruction in this case? Suture plication of the transversalis fascia using PDS only Suture plication of the hernial defect with nylon and placement of prolene mesh anterior to external oblique Suture plication of the hernia defect using nylon and re-enforcing with a sutured repair of the abdominal wall Sutured repair of the hernial defect with prolene and placement of prolene mesh over the cord structures in the inguinal canal Sutured repair of the hernial defect using nylon and placement of a prolene mesh posterior to the cord structures

Answer 398

Sutured repair of the hernial defect using nylon and placement of a prolene mesh posterior to the cord structures Laparoscopic repair- bilateral and recurrent cases During an inguinal hernia repair in males the cord structures will always lie anterior to the mesh. In the conventional open repairs the cord structures are mobilised and the mesh placed behind them, with a slit made to allow passage of the cord structures through the deep inguinal ring. Placement of the mesh over the cord structures results in chronic pain and usually a higher risk of recurrence. Laparoscopic inguinal hernia repair is the procedure of choice for bilateral inguinal hernias. Types of surgery include: Onlay mesh repair (Lichtenstein style) Inguinal herniorrhaphy Shouldice repair Darn repair Laparoscopic mesh repair Open mesh repair and laparoscopic repair are the two main procedures in mainstream use. The Shouldice repair is a useful procedure in cases where a mesh repair would be associated with increased risk of infection, e.g. repair of case with strangulated bowel, as it avoids the use of mesh. It is, however, far more technically challenging to perform.

Question 399

Boundaires of Hesselbach's triangle

Answer 399

Medial: Rectus abdominis Lateral: Inferior epigastric vessels Inferior: Inguinal ligament

Question 400

Which of the following is not a branch of the external carotid artery? Facial artery Lingual artery Superior thyroid artery Mandibular artery Maxillary artery

Answer 400

Mandibular artery External carotid artery branches mnemonic: 'Some Angry Lady Figured Out PMS' Superior thyroid (superior laryngeal artery branch) Ascending pharyngeal Lingual Facial (tonsillar and labial artery) Occipital Posterior auricular Maxillary (inferior alveolar artery, middle meningeal artery) Superficial temporal

Question 401

External carotid branches

Answer 401

Superior thyroid (superior laryngeal artery branch) Ascending pharyngeal Lingual Facial (tonsillar and labial artery) Occipital Posterior auricular Maxillary (inferior alveolar artery, middle meningeal artery) Superficial temporal

Question 402

Arrangement of the branches of the carotid artery

Answer 402

Three in front Two behind One deep

Question 403

Three arteries in front: ECA

Answer 403

Superior thyroid Lingual Facial

Question 404

Two arteries behind ECA

Answer 404

Occipital Posterior auricular

Question 405

One deep ECA branch

Answer 405

Ascending pharyngeal

Question 406

Passage of the ECA

Answer 406

The external carotid commences immediately lateral to the pharyngeal side wall. It ascends and lies anterior to the internal carotid and posterior to the posterior belly of digastric and stylohyoid. More inferiorly it is covered by sternocleidomastoid, passed by hypoglossal nerves, lingual and facial veins. It then pierces the fascia of the parotid gland finally dividing into its terminal branches within the gland itself.

Question 407

Origin and insetion of adductor longus

Answer 407

Anterior body of pubis Inserting into middle third of linea aspera

Question 408

Action of adductor longus

Answer 408

Adducts and flexes thigh, medially rotates hip

Question 409

Innervation of addcutor longus

Answer 409

Anterior division of obturator (L2, L3 L4)

Question 410

Which of the following statements relating to the basilar artery and its branches is false? The superior cerebellar artery may be decompressed to treat trigeminal neuralgia Occlusion of the posterior cerebral artery causes contralateral loss of the visual field The oculomotor nerve lies between the superior cerebellar and posterior cerebral arteries The posterior inferior cerebellar artery is the largest of the cerebellar arteries arising from the basilar artery The labyrinthine branch is accompanied by the facial nerve

Answer 410

The posterior inferior cerebellar artery is the largest of the cerebellar arteries arising from the basilar artery The posterior inferior cerebellar artery is the largest of the cerebellar arteries arising from the vertebral artery. The labyrinthine artery is long and slender and may arise from the lower part of the basilar artery. It accompanies the facial and vestibulocochlear nerves into the internal auditory meatus. The posterior cerebral artery is often larger than the superior cerebellar artery and it is separated from the vessel, near it's origin, by the oculomotor nerve. Arterial decompression is a well established therapy for trigeminal neuralgia.

Question 411

Formation of the circle of Willis

Answer 411

1. Anterior communicating artery 2. Anterior cerebral artery 3. Internal carotid artery 4. Posterior communicating artery 5. Posterior cerebral arteries and the termination of the basilar artery

Question 412

Passage of the vertebral arteries

Answer 412

Enter the cranial cavity via foramen magnum Lie in the subarachnoid space Ascend on anterior surface of medulla oblongata Unite to form the basilar artery at the base of the pons

Question 413

Branches of the vertebral artery

Answer 413

Posterior spinal Anterior spinal PICA

Question 414

Branches of the basilar artery

Answer 414

Anterior inferior cerebellar artery Labyrinthine artery Pontine arteries Superior cerebellar artery Posterior cerebral artery

Question 415

Branches of the ICA

Answer 415

Posterior communicating artery Anterior cerebral artery Middle cerebral artery Anterior choroid artery

Question 416

Theme: Abdominal closure methods A.Looped 1 PDS (polydiaxone) B.Looped 1/0 silk C.1/0 Vicryl (polyglactin) D.1/0 Vicryl rapide E.2/0 Prolene (Polypropylene) F.Re-inforced 1 Nylon G.Re-inforced 1/0 Silk H.Application of VAC system without separation film I.Application of VAC System with separation film J.Application of a 'Bogota Bag' Please select the most appropriate wound closure method (for the deep layer) for the abdominal surgery described. 44.A 59 year old man with morbid obesity undergoes a laparotomy and Hartmans procedure for perforated sigmoid diverticular disease. At the conclusion of the procedure the abdomen cannot be primarily closed. The Vac system is not available for use. A 73 year old lady undergoes a low anterior resection for carcinoma of the rectum. A 67 year old is returned to theatre after developing a burst abdomen on the ward. She has originally undergone a right hemicolectomy and the SHO who closed the wound had failed to tie the midline suture correctly. The wound edges appear healthy.

Answer 416

Application of a 'Bogota Bag' Application of a Bogota bag is safest as attempted closure will almost certainly fail. Repeat look at 48 hours to determine the best definitive option is needed. Looped 1 PDS (polydiaxone) Mass closure obeying Jenkins rule is required and this states that the suture must be 4 times the length of the wound with tissue bites 1cm deep and 1 cm apart. Re-inforced 1 Nylon Attempt at re-closing the wound is reasonable, in which case 1 nylon is often used in preference to a dissolvable suture.

Question 417

How can abdominal wound dehiscence be categorised?

Answer 417

It can be subdivided into superficial, in which the skin wound alone fails and complete, implying failure of all layers.

Question 418

Factors increasing risk of abdominal wound dehiscence

Answer 418

\* Malnutrition \* Vitamin deficiencies \* Jaundice \* Steroid use \* Major wound contamination (e.g. faecal peritonitis) \* Poor surgical technique (Mass closure technique is the preferred method-Jenkins Rule)

Question 419

Jenkins rule

Answer 419

The suture must be 4 times the length of the wound with tissue bites 1cm deep and 1 cm apart.

Question 420

Management of sudden wound dehiscence

Answer 420

\* Analgesia \* Intravenous fluids \* Intravenous broad spectrum antibiotics \* Coverage of the wound with saline impregnated gauze (on the ward) \* Arrangements made for a return to theatre

Question 421

What are the options for the surgical management of wound dehiscence?

Answer 421

Resuturing Application of wound manager Application of Bogota bag Application of VAC dressing system

Question 422

Resuturing in abdominal wound dehiscence

Answer 422

This may be an option if the wound edges are healthy and there is enough tissue for sufficient coverage. Deep tension sutures are traditionally used for this purpose.

Question 423

Wound manager

Answer 423

This is a clear dressing with removable front. Particularly suitable when some granulation tissue is present over the viscera or where there is a high output bowel fistula present in the dehisced wound.

Question 424

Bogota bag

Answer 424

This is a clear plastic bag that is cut and sutured to the wound edges and is only a temporary measure to be adopted when the wound cannot be closed and will necessitate a return to theatre for definitive management.

Question 425

VAC dressing in abdominal wound dehiscence

Answer 425

These can be safely used BUT ONLY if the correct layer is interposed between the suction device and the bowel. Failure to adhere to this absolute rule will almost invariably result in the development of multiple bowel fistulae and create an extremely difficult management problem.

Question 426

A 30 year old male presents with a painless swelling of the testis. Histologically the stroma has a lymphocytic infiltrate. The most likely diagnosis is : Differentiated teratoma Malignant undifferentiated teratoma Classical seminoma Spermatocytic seminoma Anaplastic seminoma

Answer 426

Seminoma is the commonest type of testicular tumour and is more common in males aged between 30-40 years. Classical seminoma is the commonest subtype and histology shows lymphocytic stromal infiltrate. Other subtypes include: 1. Spermatocytic: tumour cells resemble spermatocytes. Excellent prognosis. 2. Anaplastic 3. Syncytiotrophoblast giant cells: β HCG present in cells A teratoma is more common in males aged 20-30 years.

Question 427

What proportion of testicular cancers are germ cell tumours?

Answer 427

95%

Question 428

How can germ cell tumours be categorised?

Answer 428

Seminoma Non seminomatous germ cell tumours

Question 429

What are the non-seminomatous germ cell tumours

Answer 429

Teratoma Yolk sac tumour Choriocarcinoma Mixed germ cell tumours (10%)

Question 430

Testicular tumour Commonest subtype (50%) Average age at diagnosis = 40 Even advanced disease associated with 5 year survival of 73% AFP usually normal HCG elevated in 10% Lactate dehydrogenase; elevated in 10-20% (but also in many other conditions)

Answer 430

Seminoma

Question 431

Testicular tumour Younger age at presentation =20-30 years Advanced disease carries worse prognosis (48% at 5 years) Retroperitoneal lymph node dissection may be needed for residual disease after chemotherapy AFP elevated in up to 70% of cases HCG elevated in up to 40% of cases Other markers rarely helpful

Answer 431

Non-seminomatous germ cell tumour

Question 432

Testicular tumour Sheet like lobular patterns of cells with substantial fibrous component. Fibrous septa contain lymphocytic inclusions and granulomas may be seen.

Answer 432

Seminoma

Question 433

Testicular tumour Heterogenous texture with occasional ectopic tissue such as hair

Answer 433

Non seminomatous germ cell tumours

Question 434

RFs for testicular cancer

Answer 434

Cryptorchidism Infertility Family history Klinfelter's syndrome Mumps orchitis

Question 435

A painless lump is the most common presenting symptom Pain may also be present in a minority of men Other possible features include hydrocele, gynaecomastia

Answer 435

?testicular cancer

Question 436

Diagnosis of testicular tumours

Answer 436

Ultrasound is first-line CT scanning of the chest/ abdomen and pelvis is used for staging Tumour markers (see above) should be measured

Question 437

Mx of testicular tumours

Answer 437

Orchidectomy (Inguinal approach) Chemotherapy and radiotherapy may be given depending on staging Abdominal lesions \>1cm following chemotherapy may require retroperitoneal lymph node dissection.

Question 438

Prognosis in testicular cancer

Answer 438

5 year survival for seminomas is around 95% if Stage I 5 year survival for teratomas is around 85% if Stage I

Question 439

Which of the following muscles does not recieve any innervation from the sciatic nerve? Semimembranosus Quadriceps femoris Biceps femoris Semitendinosus Adductor magnus

Answer 439

The sciatic nerve is traditionally viewed as being a nerve of the posterior compartment. It is known to contribute to the innervation of adductor magnus (although the main innervation to this muscle is from the obturator nerve). The quadriceps femoris is nearly always innervated by the femoral nerve.

Question 440

A 23 year old man is involved in a fight and is stabbed in his upper arm. The ulnar nerve is transected. Which of the following muscles will not demonstrate compromised function as a result? Flexor carpi ulnaris Medial half of flexor digitorum profundus Palmaris brevis Hypothenar muscles Pronator teres

Answer 440

M edial lumbricals A dductor pollicis F lexor digitorum profundus/Flexor digiti minimi I nterossei A bductor digiti minimi and opponens Innervates all intrinsic muscles of the hand (EXCEPT 2: thenar muscles & first two lumbricals - supplied by median nerve) Pronator teres is innervated by the median nerve. Palmaris brevis is innervated by the ulnar nerve

Question 441

Which of the structures listed below overlies the cephalic vein? Extensor retinaculum Bicipital aponeurosis Biceps muscle Antebrachial fascia None of the above

Answer 441

None of the above he cephalic vein is superficially located in the upper limb and overlies most the fascial planes. It pierces the coracoid membrane (continuation of the clavipectoral fascia) to terminate in the axillary vein. It lies anterolaterally to biceps.

Question 442

Path of the cephalic vein

Answer 442

Dorsal venous arch drains laterally into cephalic vein Crosses the anatomical snuffbox and travels laterally up the arm Connected to the basilic vein at the ACF by the median cubital vein Pierces deep fascia of deltopectoral groove to join axillary vein

Question 443

Which of the following pairings are incorrect? Aortic bifurcation and L4 Transpyloric plane and L1 Termination of dural sac and L4 Oesophageal passage through diaphragm and T10 Transition between pharynx and oesophagus at C6

Answer 443

Vena cava T8 (eight letters) Oesophagus T10 (ten letters) Aortic hiatus T12 (twelve letters) The dural sac terminates at S2, which is why it is safe to undertake an LP at L4/5 levels. The spinal cord itself terminates at L1.

Question 444

Theme: ASA scoring A.ASA 1 B.ASA 2 C.ASA 3 D.ASA 4 E.ASA 5 The American society of anaesthesiologists physical status scoring system is a popular method for stratifying patients physical status. Please select the most appropriate ASA grade for each of the following scenarios. Each option may be used once, more than once or not at all. 6.A 66 year old man is admitted following a collapse whilst waiting for a bus. Clinical examination confirms a ruptured abdominal aortic aneurysm. He is moribund and hypotensive A 23 year old man with a 4cm lipoma on his flank is due to have this removed as a daycase. He is otherwise well. A 72 year old man is due to undergo an inguinal hernia repair. He suffers from COPD and has an exercise tolerance of 10 yards. He also has pitting oedema to the thighs.

Answer 444

ASA 5 Patients who are moribund and will not survive without surgery are graded as ASA 5. ASA 1 Absence of co-morbidities and small procedure with no systemic compromise will equate to an ASA score of 1 ASA 4 Severe systemic disease of this nature is a constant threat to life. Especially as he also has evidence of cardiac failure.

Question 445

ASA 1

Answer 445

No organic physiological, biochemical or psychiatric disturbance. The surgical pathology is localised and has not invoked systemic disturbance

Question 446

ASA 2

Answer 446

Mild or moderate systemic disruption caused either by the surgical disease process or though underlying pre-existing disease

Question 447

ASA 3

Answer 447

Severe systemic disruption caused either by the surgical pathology or pre-existing disease

Question 448

ASA 4

Answer 448

Patient has severe systemic disease that is a constant threat to life

Question 449

ASA 5

Answer 449

A patient who is moribund and will not survive without surgery

Question 450

A 22 year old man is involved in a fight. He sustains a laceration to the posterior aspect of his wrist. In the emergency department the wound is explored and the laceration is found to be transversely orientated and overlies the region of the extensor retinaculum, which is intact. Which of the following structures is least likely to be injured in this scenario? Dorsal cutaneous branch of the ulnar nerve Tendon of extensor indicis Basilic vein Superficial branch of the radial nerve Cephalic vein

Answer 450

The extensor retinaculum attaches to the radius proximal to the styloid, thereafter it runs obliquely and distally to wind around the ulnar styloid (but does not attach to it). The extensor tendons lie deep to the extensor retinaculum and would therefore be less susceptible to injury than the superficial structures.

Question 451

Attachments of the extensor retinaculum

Answer 451

The pisiform and triquetral medially The end of the radius laterally

Question 452

Structures superifical to the extensor retinaculum

Answer 452

Basilic vein Dorsal cutaneous branch of the ulnar nerve Cephalic vein Superficial branch of the radial nerve

Question 453

Structures passing deep to the extensor retinaculum

Answer 453

Extensor carpi ulnaris tendon Extensor digiti minimi tendon Extensor digitorum and extensor indicis tendon Extensor pollicis longus tendon Extensor carpi radialis longus tendon Extensor carpi radialis brevis tendon Abductor pollicis longus and extensor pollicis brevis tendons

Question 454

Passage of the radial artery into the hand

Answer 454

The radial artery passes between the lateral collateral ligament of the wrist joint and the tendons of the abductor pollicis longus and extensor pollicis brevis.

Question 455

What passes between the lateral collateral ligament of the wrist joint and the tendons of the abductor pollicis longus and extensor pollicis brevis.

Answer 455

Radial artery

Question 456

How does proteus infection predispose to staghorn calculus?

Answer 456

Infection with Proteus mirabilis accounts for 90% of all proteus infections. It has a urease producing enzyme. This will tend to favor urinary alkalinisation which is a relative prerequisite for the formation of staghorn calculi.

Question 457

Effect of eating on renal stone formation

Answer 457

Urine pH will show individual variation (from pH 5-7). Post prandially the pH falls as purine metabolism will produce uric acid. Then the urine becomes more alkaline (alkaline tide). When the stone is not available for analysis the pH of urine may help to determine which stone was present.

Question 458

What is mean urine pH?

Answer 458

~6

Question 459

What stones form in acidic urine?

Answer 459

Uric acid

Question 460

What stones form in alkaline urine?

Answer 460

Ca PO4 Struvite

Question 461

Hypercalciuria is a major risk factor (various causes) Hyperoxaluria may also increase risk Hypocitraturia increases risk because citrate forms complexes with calcium making it more soluble Stones are radio-opaque (though less than calcium phosphate stones) Hyperuricosuria may cause uric acid stones to which calcium oxalate binds

Answer 461

Calcium oxalate

Question 462

Inherited recessive disorder of transmembrane cystine transport leading to decreased absorption of cystine from intestine and renal tubule Multiple stones may form Relatively radiodense because they contain sulphur

Answer 462

Cystine

Question 463

Uric acid is a product of purine metabolism May precipitate when urinary pH low May be caused by diseases with extensive tissue breakdown e.g. malignancy More common in children with inborn errors of metabolism Radiolucent

Answer 463

Uric acid stone

Question 464

May occur in renal tubular acidosis, high urinary pH increases supersaturation of urine with calcium and phosphate Renal tubular acidosis types 1 and 3 increase risk of stone formation (types 2 and 4 do not) Radio-opaque stones (composition similar to bone)

Answer 464

Calcium phosphate

Question 465

Stones formed from magnesium, ammonium and phosphate Occur as a result of urease producing bacteria (and are thus associated with chronic infections) Under the alkaline conditions produced, the crystals can precipitate Slightly radio-opaque

Answer 465

Struvite

Question 466

A 27 year old man sustains a single gunshot wound to the left thigh. In the emergency department, he is noted to have a large haematoma of his medial thigh. He complains of parasthesia in his foot. On examination, there are weak pulses palpable distal to the injury and the patient is unable to move his foot. The appropriate initial management of this patient is: Conventional angiography Immediate exploration and repair Fasciotomy of the anterior compartment Observation for resolution of spasm Local wound exploration

Answer 466

The five P's of arterial injury include pain, parasthesias, pallor, pulselessness and paralysis. In the extremities, the tissues most sensitive to anoxia are the peripheral nerves and striated muscle. The early developments of paresthesias and paralysis are signals that there is significant ischemia present, and immediate exploration and repair are warranted. The presence of palpable pulse does not exclude an arterial injury because this presence may represent a transmitted pulsation through a blood clot. When severe ischemia is present, the repair must be completed within 6 to 8 h to prevent irreversible muscle ischemia and loss of limb function. Delay to obtain a conventional angiogram or to observe for change needlessly prolongs the ischemic time. A CT angiogram may be a reasonable alternative. Fasciotomy may be required but should be done in conjunction with and after re-establishment of arterial flow. Local wound exploration is not recommended because brisk hemorrhage may be encountered without the securing of prior vascular control.

Question 467

Management of vascular trauma

Answer 467

Almost always operative. Obtaining proximal and distal control of affected vessels is crucial. Simple lacerations of arteries may be directly closed, or a vein patch applied if there is a risk of subsequent stenosis. Transection of the vessel should be treated by either end to end anastomosis (often not possible) or an interposition vein graft. Use of PTFE in traumatic open injuries will invariably result in infection.

Question 468

Assessment of vascular trauma

Answer 468

Check for signs of distal perfusion Doppler signal distally (monophasic/ biphasic or triphasic) Anatomical location (which vessel is likely to be involved) Duplex scanning and angiography are "gold standard" tests but may not be immediately available in the trauma setting

Question 469

Theme: Neonatal gastrointestinal disease A.Ano-rectal atresia B.Pyloric stenosis C.Hirschsprungs disease D.Duodenal atresia E.Meconium ileus F.Intussusception G.Necrotising enterocolitis H.Intestinal volvulus I.Tracheo-oesophageal fistula Please select the most likely diagnosis to account for the case described. Each option may be used once, more than once or not at all. 12.A newborn baby boy presents with mild abdominal distension and failure to pass meconium after 24 hours. X- Ray reveals dilated loops of bowel with fluid levels. The anus appears normally located. A premature infant (30-week gestation) presents with distended and tense abdomen. She is passing blood and mucus per rectum, and she is also manifesting signs of sepsis. A newborn baby boy presents with gross abdominal distension. He is diagnosed with cystic fibrosis and his abdominal x ray shows distended coils of small bowel, but no fluid levels.

Answer 469

Hirschsprungs disease Hirschsprung's disease is an absence of ganglion cells in the neural plexus of the intestinal wall. It is more common in boys than girls. The delayed passage of meconium together with distension of abdomen is the usual clinical presentation. A plain abdominal x ray will demonstrate dilated loops of bowel with fluid levels and a barium enema can be helpful when it demonstrates a cone with dilated ganglionic proximal colon and the distal aganglionic bowel failing to distend. Necrotising enterocolitis Necrotising enterocolitis is more common in premature infants. Mesenteric ischemia causes bacterial invasion of the mucosa leading to sepsis. Terminal ileum, caecum and the distal colon are commonly affected. The abdomen is distended and tense, and the infant passes blood and mucus per rectum. X -Ray of the abdomen shows distended loops of intestine and gas bubbles may be seen in the bowel wall. Meconium ileus One in 5,000 newborns will have a distal small bowel obstruction secondary to abnormal bulky and viscid meconium. Ninety percent of these infants will have cystic fibrosis and the abnormal meconium is the result of deficient intestinal secretions. This condition presents during the first days of life with gross abdominal distension and bilious vomiting. x Ray of the abdomen shows distended coils of bowel and typical mottled ground glass appearance. Fluid levels are scarce as the meconium is viscid.

Question 470

x Ray of the abdomen shows distended coils of bowel and typical mottled ground glass appearance. Fluid levels are scarce

Answer 470

Meconium ileus

Question 471

A 54-year-old man presents to the Emergency Department with a 2 day history of a swollen, painful left knee. You aspirate the joint to avoid admission to the orthopaedic wards. Aspirated joint fluid shows calcium pyrophosphate crystals. Which of the following blood tests is most useful in revealing an underlying cause? Transferrin saturation ACTH ANA Serum ferritin LDH

Answer 471

This is a typical presentation of pseudogout. An elevated transferrin saturation may indicate haemochromatosis, a recognised cause of pseudogout. A high ferritin level is also seen in haemochromatosis but can be raised in a variety of infective and inflammatory processes, including pseudogout, as part of an acute phase response.

Question 472

form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate in the synovium

Answer 472

Pseudogout

Question 473

Risk factors for pseudogout

Answer 473

hyperparathyroidism hypothyroidism haemochromatosis acromegaly low magnesium, low phosphate Wilson's disease

Question 474

knee, wrist and shoulders most commonly affected joint aspiration: weakly-positively birefringent rhomboid shaped crystals x-ray: chondrocalcinosis

Answer 474

Pseudogout

Question 475

Management of pseudogout

Answer 475

aspiration of joint fluid, to exclude septic arthritis NSAIDs or intra-articular, intra-muscular or oral steroids as for gout

Question 476

Which of the following is not a content of the porta hepatis? Portal vein Hepatic artery Cystic duct Lymph nodes None of the above

Answer 476

The cystic duct lies outside the porta hepatis and is an important landmark in laparoscopic cholecystectomy. The structures in the porta hepatis are: Portal vein Hepatic artery Common hepatic duct These structures divide immediately after or within the porta hepatis to supply the functional left and right lobes of the liver. The porta hepatis is also surrounded by lymph nodes, that may enlarge to produce obstructive jaundice and parasympathetic nervous fibres that travel along vessels to enter the liver.

Question 477

Which of the following will increase the volume of pancreatic exocrine secretions? Octreotide Cholecystokinin Aldosterone Adrenaline None of the above

Answer 477

Cholecystokinin will often increase the volume of pancreatic secretions.

Question 478

Theme: Facial nerve palsy A.Adenoid cystic carcinoma B.Cerebrovascular accident C.Petrous temporal fracture D.Warthins tumour E.Sarcoidosis F.Pleomorphic adenoma G.Cholesteatoma Please select the most likely cause of facial nerve palsy for the scenario given. Each option may be used once, more than once or not at all. 18.A 22 year old man presents with symptoms of lethargy and bilateral facial nerve palsy. On examination he has bilateral parotid gland enlargement. A 21 year old man presents with a unilateral facial nerve palsy after being hit in the head. On examination he has a right sided facial nerve palsy and a watery discharge from his nose. A 43 year old lady presents with symptoms of chronic ear discharge and a right sided facial nerve palsy. On examination she has foul smelling fluid draining from her right ear and a complete right sided facial nerve palsy.

Answer 478

Sarcoidosis Facial nerve palsy is the commonest neurological manifestation of sarcoid. It usually resolves. The absence of ear discharge or discrete lesion on palpation is against the other causes. Petrous temporal fracture Nasal discharge of clear fluid and recent head injury makes a basal skull fracture the most likely underlying diagnosis. Cholesteatoma Foul smelling ear discharge and facial nerve weakness is likely to be due to cholesteatoma. The presence of a neurological deficit is a sinister feature

Question 479

Which of the following structures is not closely related to the carotid sheath? Sternothyroid muscle Sternohyoid muscle Hypoglossal nerve Superior belly of omohyoid muscle Anterior belly of digastric muscle

Answer 479

Anterior belly of digastric muscle At its lower end the carotid sheath is related to sternohyoid and sternothyroid. Opposite the cricoid cartilage the sheath is crossed by the superior belly of omohyoid. Above this level the sheath is covered by the sternocleidomastoid muscle. Above the level of the hyoid the vessels pass deep to the posterior belly of digastric and stylohyoid. Opposite the hyoid bone the sheath is crossed obliquely by the hypoglossal nerve.

Question 480

Theme: Paediatric emergencies A.Manage conservatively B.Immediate emergency theatre C.Treat in emergency department D.Treat in emergency department under sedation E.Operate on next emergency list Please select the most appropriate intervention for the scenario given. Each option may be used once, more than once or not at all. 22.A 3 year old child inserts a crayon into their external auditory meatus. Attempts to remove it have not been successful. A 2 year old accidentally inhales a peanut. They arrive in the emergency department extremely distressed and cyanotic. Imaging shows it to be lodged in the left main bronchus. A 10 year old boy is shot in the head with an airgun pellet. He is concerned that he will get into trouble and the injury remains concealed for 10 days. Imaging using CT scanning shows it to be lodged in the frontal lobe.

Answer 480

Operate on next emergency list They would not tolerate removal in the emergency department. The tympanic membrane should be carefully inspected and again this will be easier under general anaesthesia. Immediate emergency theatre As they are cyanosed it requires immediate removal and this should be undertaken in a fully staffed theatre. Ideally a rigid bronchoscopy should be performed. Manage conservatively The pellet is small and no serious injury has occurred at this stage. This should therefore be managed conservatively.

Question 481

Tonsilar artery is a branch of?

Answer 481

Facial artery

Question 482

Venous drainage of the tonsil?

Answer 482

Its veins pierce the constrictor muscle to join the external palatine or facial veins. The external palatine vein is immediately lateral to the tonsil, which may result in haemorrhage during tonsillectomy.

Question 483

Lymphatic drainage of the tonsil

Answer 483

Lymphatic drainage is the jugulodigastric node and the deep cervical nodes.

Question 484

Why may delayed otalgia follow tonsillectomy?

Answer 484

Due to irritation of the glossopharyngeal nerve

Question 485

Which statement is false about pethidine? It is thirty times more lipid soluble than morphine Structurally similar to morphine Pethidine has a toxic metabolite (norpethidine) which is cleared by the kidney Pethidine is metabolized by the liver Can be given intramuscularly

Answer 485

It has a different structure. It is much more lipid soluble than morphine. It produces less biliary tract spasm than morphine.

Question 486

What are the bulk forming laxatives?

Answer 486

Bran Psyllium Methylcellulose

Question 487

What are the osmotic laxatives

Answer 487

Magnesium sulphate Magnesium citrate Sodium phosphate Sodium sulphate Potassium sodium tatrate Polyethylene glycol

Question 488

What are the stimulant laxatives

Answer 488

Docusates Bisacodyl Sodium picosulphate Senna Ricinoleic acid

Question 489

MOA senna

Answer 489

Senna contains glycosides. It passes unchanged into the colon where bacteria hydrolyse the glycosidic bond, releasing the anthracene derivatives. These stimulate the myenteric plexus.

Question 490

A 59 year old lady is referred from the NHS breast screening program. A recent mammogram is reported as showing linear, branching microcalcification with coarse granules. Which disease process is the most likely underlying cause of these appearances? Invasive lobular cancer Lobular carcinoma in situ Cribriform type ductal carcinoma in situ Comedo type ductal carcinoma in situ Fibroadenosis

Answer 490

Comedo type DCIS is usually associated with microcalcifications. Cribriform lesions are usually multifocal but less likely to form microcalcifications. Lobular cancers and in situ lesions rarely form microcalcifications and are difficult to detect using mammography.

Question 491

Subtypes of DCIS

Answer 491

Comedo, cribiform, micropapillar and solid

Question 492

Which DCIS is most likely to form microcalcifications?

Answer 492

Comedo DCIS

Question 493

Which DCIS are most likely to be multifocal?

Answer 493

Cribiform and micropapillary

Question 494

Lobular carcinoma and axillary node invovlvement

Answer 494

When an invasive component is found it is less likely to be associated with axillary nodal metastasis than with DCIS

Question 495

Theme: Wound infections A.\<5% B.5-10% C.15-25% D.25-40% E.0% F.75-100% Please select the anticipated risk of surgical site infections for the procedures described. Each option may be used once, more than once or not at all. 30.A patient is undergoing a Hartmans procedure for perforated sigmoid diverticular disease. A 23 year old male is undergoing an elective inguinal hernia repair. A 43 year old women is undergoing a laparoscopic choelcystectomy for uncomplicated biliary colic.

Answer 495

25-40% This is a 'dirty' procedure and carries an SSI risk of 25-40 %. \<5% This is a clean procedure and carries the lowest risk of SSI. 5-10% This is a clean contaminated procedure as the cystic duct is divided. Inadvertent spill of bile converts the operation to a contaminated one and the risk of infection rises.

Question 496

A new test to screen for pulmonary embolism (PE) is used in 100 patients who present to the Emergency Department. The test is positive in 30 of the 40 patients who are proven to have a PE. Of the remaining 60 patients, only 5 have a positive test. What is the sensitivity of the new test? 8.33% 30% 40% 66.66% 75%

Answer 496

The sensitivity is therefore 30 / (30 + 10) = 75%

Question 497

Which of the following anaesthetic agents is least likely to be associated with depression of myocardial contractility? Propofol Etomidate Sodium thiopentone Ether None of the above

Answer 497

Of the agents mentioned, etomidate has the most favorable cardiac safety profile.

Question 498

A man has an incision sited that runs 8cm from the deltopectoral groove to the midline. Which of the following is not at risk of injury? Cephalic vein Shoulder joint capsule Axillary artery Pectoralis major Trunk of the brachial plexus

Answer 498

This region will typically lie medial to the joint capsule. The diagram below illustrates the plane that this would transect and as it can be appreciated the other structures are all at risk of injury.

Question 499

Origin and insertion of pec major

Answer 499

From the medial two thirds of the clavicle, manubrium and sternocostal angle Lateral edge of the bicipital groove of the humerus