Block 7 Flashcards
Facial canal path of the facial nerve
The canal passes superior to the vestibule of the inner ear
At the medial aspect of the middle ear, it becomes wider and contains the geniculate ganglion.
- 3 branches:
1. greater petrosal nerve
2. nerve to stapedius
3. chorda tympani
Passage of the facial nerve through stylomastoid foramen
Passes through the stylomastoid foramen (tympanic cavity anterior and mastoid antrum posteriorly)
Posterior auricular nerve and branch to posterior belly of digastric and stylohyoid muscle
Theme: Pancreatic tumours
A.Lymphoma
B.Gastrinoma
C.Insulinoma
D.Glucagonoma
E.Phaeochromocytoma
F.Carcinoid syndrome
G.Vasoactive Intestinal Peptide secreting tumour
H.Pancreatic adenocarcinoma
Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.
29.A 65 year old male attends surgical out patients with epigastric discomfort. He has recently been diagnosed with diabetes by the GP and is a heavy smoker. An OGD is normal.
A 50 year old male presents with recurrent episodes of abdominal pain and diarrhoea. Blood tests reveal mild iron deficiency anaemia and an upper GI endoscopy demonstrates multiple ulcers in the first part of the duodenum.
An obese 40 year old male presents with episodes of anxiety, confusion and one convulsive episode. CT brain is normal. An abdominal CT scan shows a small 1.5cm lesion in the head of the pancreas
Pancreatic adenocarcinoma
The dominant differential diagnosis should be of pancreatic adenocarcinoma in this setting. Glucagonomas are very rare and may be associated with a bullous rash.
Gastrinoma
Diarrhoea, abdominal pain and multiple ulcers should raise the suspicion of Zollinger Ellison syndrome caused by gastrinoma.
Insulinoma
These episodes are due to hypoglycaemia. Insulinomas are normally solitary tumours and may not be seen by radiological imaging. Resection is the treatment of choice.
Which of the following statements relating to abnormal coagulation is false?
Warfarin affects the synthesis of factor 2,7,9,10
The prothrombin time is prolonged in Haemophilia A
Cholestatic jaundice can cause vitamin K deficiency
Disseminated intravascular coagulation is associated with thrombocytopenia
Massive transfusion is associated with reduced levels of factor 5 and 8
In haemophilia A the APTT is prolonged and there is reduced levels of factor 8:C. The bleeding time and PT are normal. Cholestatic jaundice prevents the absorption of the fat soluble vitamin K. Massive transfusion (>10u blood or equivalent to the blood volume of a person) puts the patient at risk of thrombocytopaenia, factor 5 and 8 deficiency.
During a thyroidectomy the surgeons ligate the inferior thyroid artery. From which vessel does this structure usually originate?
External carotid artery
Thyrocervical trunk
Internal carotid artery
Subclavian artery
Vertebral artery
The inferior thyroid artery originates from the thyrocervical trunk. This is a branch of the subclavian artery.
A 27 year old lady presents with a breast lump. She has previously undergone a breast augmentation with an implant. What is the imaging technique of choice?
Ultrasound
CT scanning
MRI
PET CT
Mammography
Unless there are concerns about implant rupture, the imaging of a breast lump in a young patient with implants would be USS initially. If this is not conclusive then MRI should be performed.
Were there are specific concerns about a breast implant, rather than a lump, the imaging modality of choice is MRI scanning.
MRI scanning may be beneficial in screening younger patients with a family history and also in patients with lobular cancers who are being considered for breast conserving surgery.
A 56 year old man is left impotent following an abdomino-perineal excision of the colon and rectum. What is the most likely explanation?
Psychosexual issues related to an end colostomy
Damage to the sacral venous plexus during total mesorectal excision
Damage to the left ureter during sigmoid mobilisation
Damage to the hypogastric plexus during mobilisation of the inferior mesenteric artery
Damage to the internal iliac artery during total mesorectal excision
Autonomic nerve injury is the most common cause. Damage to the hypogastric plexus.
A 62 year old male is found to have colorectal cancer. He has Dukes C disease. What is his 5 year prognosis?
100%
90%
80%
70%
50%
50%
A 73 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate gland. To which of the following lymph nodes will the tumour drain primarily?
Para aortic
Internal iliac
Superficial inguinal
Meso rectal
None of the above
The prostate lymphatic drainage is primarily to the internal iliac nodes and also the sacral nodes. Although internal iliac is the first site.
Arterial supply of the prostate
Inferior vesical artery (from internal iliac)
A 19 year old student is involved in a head on car collision. He complains of severe chest pain. A Chest x-ray performed as part of a trauma series shows widening of the mediastinum. Which is the most likely injury in this scenario?
Rupture of the distal oesophagus
Rupture of the left main bronchus
Rupture of the aorta proximal to the left subclavian artery
Rupture of the aorta distal to the left subclavian artery
Rupture of the inferior vena cava
The aorta may be injured in deceleration accidents. In the setting of deceleration injury, chest pain and mediastinal widening the most likely problem is aortic rupture. This will typically occur distal to the left subclavian artery. Rupture of the proximal aorta may occur. However, survival is unlikely. It is important to note that the question uses the term Most likely injury as this is the component that distinguishes an ascending rupture from a descending rupture.
Mechanism of injury: Decelerating force i.e. RTA, fall from a great height
Most people die at scene
Survivors may have an incomplete laceration at the ligamentum arteriosum of the aorta.
Thoracic aorta rupture
CXR changes in thoracic aortic ruputre
Contained haematoma: persistent hypotension
Detected mainly by history, CXR changes
Which of the following statements relating to the vertebral column is false?
There are 7 cervical vertebrae
The cervical and lumbar lordosis are secondary curves developing after birth due to change in shape of the intervertebral discs
The lumbar vertebrae do not have a transverse process foramina
The lumbar vertebrae receive blood directly from the aorta
The spinous process is formed by the junction of the pedicles posteriorly
The spinous process is formed by 2 laminae posteriorly.
A 45 year old man has a 4 week history of epigastric discomfort which is relieved by eating. He develops haematemesis and undergoes an upper GI endoscopy. An actively bleeding ulcer is noted in the first part of the duodenum. What is the best management?
Whipples procedure
Truncal vagotomy and drainage
Distal gastrectomy
Injection with tranexamic acid
Injection with adrenaline
Current guidance is that bleeding peptic ulcers should be treated with dual therapeutic modalities. Adrenaline injection should be augmented with an additional therapy such as endoscopic clipping where this is available.
Bleeding duodenal ulcers will usually undergo adrenaline injection. This may be augmented by the placement of endoscopic clips or heat therapy with endoscopic heater probes. Following these interventions patients should receive a proton pump inhibitor infusion. Those who re-bleed, may require surgery. For ulcers in this location, laparotomy, duodenotomy and under-running of the ulcer is usually performed.
Patients with diffuse erosive gastritis who cannot be managed endoscopically and continue to bleed may require
Gastrectomy
Theme: Causes of abdominal pain
A.Acute on chronic mesenteric ischaemia
B.Ruptured aortic aneurysm
C.Acute Pancreatitis
D.Acute mesenteric embolus
E.Acute appendicitis
F.Chronic pancreatitis
G.Mesenteric vein thrombosis
Please select the most likely underlying diagnosis from the list above. Each option may be used once, more than once or not at all.
8.A 41 year old man is admitted with peritonitis secondary to a perforated appendix. He is treated with a laparoscopic appendicectomy but has a stormy post operative course. He is now developing increasing abdominal pain and has been vomiting. A laparotomy is performed and at operation a large amount of small bowel shows evidence of patchy areas of infarction.
A 68 year old man is admitted with abdominal pain and vomiting of 48 hours duration, the pain radiates to his back and he has required a considerable amount of volume replacement. Amylase is 741.
A 79 year old lady develops sudden onset of abdominal pain and collapses, she has passed a large amount of diarrhoea. In casualty her pH is 7.35 and WCC is 18.
Mesenteric vein thrombosis
Mesenteric vein thrombosis may complicate severe intra abdominal sepsis and when it progresses may impair bowel perfusion. The serosa is quite resistant to ischaemia so in this case the appearances are usually patchy.
Acute Pancreatitis
Although back pain and abdominal pain coupled with haemodynamic compromise may suggest ruptured AAA the 48 hour history and amylase >3 times normal go against this diagnosis.
Acute mesenteric embolus
Although mesenteric infarct may raise the lactate the pH may be raised often secondary to vomiting.
A 78 year old lady falls over in her nursing home and sustains a displaced intracapsular fracture of the femoral neck. A decision is made to perform a hemi arthroplasty through a lateral approach. Which of these vessels will be divided to facilitate access?
Saphenous vein
Superior gluteal artery
Superficial circumflex iliac artery
Profunda femoris artery
Transverse branch of the lateral circumflex artery
During the Hardinge style lateral approach the transverse branch of the lateral circumflex artery is divided to gain access. The vessels and its branches are illustrated below:
Normal angle between femoral head and femoral shaft is?
130 degrees
Intracapsular ligaments of the hip joint
Transverse ligament: joins anterior and posterior ends of the articular cartilage.
Head of femur ligament (ligamentum teres): acetabular notch to the fovea, contains arterial supply to head of femur in children
Extracapsular ligaments of the hip joint
Iliofemoral ligament: inverted Y shape. Anterior iliac spine to the trochanteric line
Pubofemoral ligament: acetabulum to lesser trochanter
Ischiofemoral ligament: posterior support. Ischium to greater trochanter.
Blood supply of the hip joint
Medial circumflex femoral and lateral circumflex femoral arteries (Branches of profunda femoris). Also from the inferior gluteal artery. These form an anastomosis and travel to up the femoral neck to supply the head.
Theme: Management of head and neck trauma
A.Observation
B.CT head within 1 hour
C.CT head within 8 hours
D.Urgent neurosurgical review (even before CT head performed)
E.3 view c-spine xray
F.2 view c-spine xray
G.CT c-spine
What is the best initial management plan for the injuries described? Each option may be used once, more than once or not at all.
12.A 22 year old mechanic is involved in a fight. He is hit on the head with a hammer. On examination he had clinical evidence of an open depressed skull fracture and a GCS of 6/15.
A 67 year old retired lawyer falls down the stairs. His GCS is 15/15 and he has some bruising over the mastoid.
A 52 year old secretary falls down the stairs. She complains of neck pain. She has a GCS of 15/15 and no neurology. She is unable to rotate her c-spine 45 degrees to the left and right.
Urgent neurosurgical review (even before CT head performed)
A patient with GCS <8 or = to 8 needs urgent neurosurgical review. Especially when an open fracture is present
CT head within 1 hour
This patient has a basal skull fracture, which is indicated by a positive Battle’s sign. He should have a CT head within 1h.
3 view c-spine xray
In the January 2014 NICE guidance relating to the diagnosis of head and spinal injury the evidence for initial imaging of the C spine was reviewed. The current UK practice is that “low risk” patients with pain but no neurology undergo a 3 view C spine x-ray. The more detailed 5 view x-ray was not found to be any better than 3 view films. In patients with high risk injuries (which the patient in the scenario does not have) there is a likelihood that 1 in 6 injuries would be missed on plain films alone and therefore CT scanning of the C spine is recommended in this group.
A 21 year old badminton player attends A&E with a painful, swollen right arm. He is right handed. Clinically he has dusky fingers and his upper limb pulses are present. An axillary vein thrombosis is confirmed. What is the best acute treatment to achieve vein patency?
Intravenous heparin
Warfarin
Catheter directed tPA
Low molecular weight heparin
Aspirin
Heparin and warfarin prevent propagation of the clot.
Overview of axillary vein thrombosis
1-2% of all deep venous thrombosis
Primary cause is associated with trauma, thoracic outlet obstruction or repeated effort in a dominant arm (young active individuals)
Secondary causes include central line insertion, malignancy, pacemakers
Clinical features of axillary vein thrombosis
Pain and swelling (non pitting)
Numbness
Discolouration: mottling, dusky
Pulses present
Congested veins
Ix in ?axillary vein thrombosis
FBC: viscosity, platelet function
Clotting
Liver function tests
D-dimer
Duplex scan: investigation of choice
CT scan: thoracic outlet obstruction
Treatment of axillary vein thrombosis
Local catheter directed TPA
Heparin
Warfarin
Which of the following is a not a diagnostic criteria for brain death?
No response to sound
No corneal reflex
Absent oculo-vestibular reflexes
No response to supraorbital pressure
No cough reflex to bronchial stimulation
No response to sound
Criteria for brain stem death testing
Deep coma of known aetiology.
Reversible causes excluded
No sedation
Normal electrolytes
Testing for brain death
Fixed pupils which do not respond to sharp changes in the intensity of incident light
No corneal reflex
Absent oculo-vestibular reflexes - no eye movements following the slow injection of at least 50ml of ice-cold water into each ear in turn (the caloric test)
No response to supraorbital pressure
No cough reflex to bronchial stimulation or gagging response to pharyngeal stimulation
No observed respiratory effort in response to disconnection of the ventilator for long enough (typically 5 minutes) to ensure elevation of the arterial partial pressure of carbon dioxide to at least 6.0 kPa (6.5 kPa in patients with chronic carbon dioxide retention). Adequate oxygenation is ensured by pre-oxygenation and diffusion oxygenation during the disconnection (so the brain stem respiratory centre is not challenged by the ultimate, anoxic, drive stimulus)
The test should be undertaken by two appropriately experienced doctors on two separate occasions. Both should be experienced in performing brain stem death testing and have at least 5 years post graduate experience. One of them must be a consultant. Neither can be a member of the transplant team (if organ donation contemplated).
A 28 year old African man is admitted with acute severe abdominal pain. He has just flown into the UK long haul and the pain developed whilst in flight. On examination he is tender in the left upper quadrant. His blood tests are as shown.
Hb 6 g/dl
Reticulocyte count 15%.
Ultrasound shows a spleen with a heterogeous texture and a few small gallstones but is otherwise normal.
What is the most likely diagnosis?
Pancreatitis
Parvovirus infection
Sickle cell anaemia
Pulmonary embolism
Beta Thalassaemia minor
A combination of a high reticulocyte count and severe anaemia indicates sickle cell anaemia, however another differential can be of a transient aplastic crisis due to parvovirus. This is less likely as this causes a reticulocytopenia rather than a reticulocytosis.
Parvovirus B19 infects erythroid progenitor cells in the bone marrow and causes temporary cessation of red blood cell production, patients who have underlying hematologic abnormalities are at risk of cessation of red blood cell production if they become infected. This can result in a transient aplastic crisis. Thus, patients with sickle cell anaemia are at risk. Typically, these patients have a viral prodrome followed by anaemia, often with haemoglobin concentrations falling below 5.0 g/dL and reticulocytosis.
Features of SCD
Autosomal recessive
Single base mutation
Deoxygenated cells become sickle in shape
Causes: short red cell survival, obstruction of microvessels and infarction
Sickling is precipitated by: dehydration, infection, hypoxia
Manifest at 6 months age
Africans, Middle East, Indian
Diagnosis: Hb electrophoresis
Sickle crises
Bone pain
Pleuritic chest pain: acute sickle chest syndrome commonest cause of death
CVA, seizures
Papillary necrosis
Splenic infarcts
Priapism
Hepatic pain
Hb in sickle cell crisis
Hb does not fall during a crisis, unless there is
Aplasia: parvovirus
Acute sequestration
Haemolysis
Surgical complications of sickle cell disease
Bowel ischaemia
Cholecystitis
Avascular necrosis
Long term complications of sickle cell disease
Infections: Streptococcus pneumoniae
Chronic leg ulcers
Gallstones: haemolysis
Aseptic necrosis of bone
Chronic renal disease
Retinal detachment, proliferative retinopathy
Which of the following statements relating to use of total parenteral nutrition is untrue?
It may cause steatosis and derangement of liver function tests
Administration via a central line or PICC line is preferable to peripheral administration
It is highly irritant to vessel walls
It should be administered when a patient has an albumin less than15
Administration of TPN for periods of less than 1 week is unlikely to produce noticable benefits
Albumin is a poor indicator of overall nutrition and the decision to start TPN should not be based on this parameter alone. Patients should ideally be fed enterally where possible and if this is likely to occur within 5-7 days then starting TPN is unlikely to confer benefit.
A 73 year old man undergoes a sub total oesophagectomy with anastomosis of the stomach to the cervical oesophagus. Which vessel will be primarily responsible for the arterial supply to the oesophageal portion of the anastomosis?
Superior thyroid artery
Internal carotid artery
Direct branches from the thoracic aorta
Inferior thyroid artery
Subclavian artery
The cervical oesophagus is supplied by the inferior thyroid artery. The thoracic oesophagus (removed in this case) is supplied by direct branches from the thoracic aorta.
Extent of the oesophagus
25cm
C6-> T11
Pierces diaphragm at T10
Squamous epithelium
Distance of cricoid cartilage from incisors
15cm
Distance of arch of aorta from incisors
22.5cm
Distance from left principal bronchus to incisors
27cm
Distance from diaphragmatic hiatus to incisors
40cm
Anterior relations of the oesophagus
Trachea to T4
Recurrent laryngeal nerve
Left bronchus, Left atrium
Diaphragm
Posterior relations of the oesophagus
Thoracic duct to left at T5
Hemiazygos to the left T8
Descending aorta
First 2 intercostal branches of aorta
Left relations of the oesophagus
Thoracic duct
Left subclavian artery
Right relations of the oesophagus
Azygos vein
Arterial supply of the oesophagus:
Upper 1/3rd
Inferior thyroid
Arterial supply of the oesophagus:
Mid third
Aortic branches
Arterial supply of the oesophagus:
Lower third
Left gastric
Venous drainage of the oesophagus:
Upper third
Inferior thyroid
Venous drainage of the oesophagus:
Mid third
Azygos branches
Venous drainage of the oesophagus:
Lower third
Left gastric
Lymphatic drainage of the oesophagus:
Upper third
Deep cervical
Lymphatic drainage of the oesophagus:
Mid third
Mediastinal
Lymphatic drainage of the oesophagus:
Lower third
Gastric
Muscularis externa of the oesophagus:
Upper third
Striated muscle
Muscularis externa of the oesophagus:
Mid third
Smooth & striated muscle
Muscularis externa of the oesophagus:
Lower third
Smooth muscle
Nervous supply of the upper half of the oesophagus?
RLN
Nervous supply of the lower half of the oesophagus?
Oesophageal plexus
Histology of the oesophagus
Mucosa :Non-keratinized stratified squamous epithelium
Submucosa: glandular tissue
Muscularis externa (muscularis): composition varies. See table
Adventitia
An 8 year old boy presented with a painless swelling on the superotemporal aspect of his orbit. It was smooth on examination, produced no visual disturbances. Following excision it was found to be lined by squamous epithelium and hair follicles. Which of the following lesions most closely matches these findings?
Dermoid cyst
Desmoid tumour
Lipoma
Sebaceous cyst
Schwannoma
Dermoid cysts are embryological remnants and may be lined by hair and squamous epithelium (like teratomas). They are often located in the midline and may be linked to deeper structures resulting in a dumbbell shape to the lesion. Complete excision is required as they have a propensity to local recurrence if not excised.
Desmoid tumours are a different entity, they most commonly develop in ligaments and tendons. They are also referred to as aggressive fibromatosis and consist of fibroblast dense lesions (resembling scar tissue). They should be managed in a similar manner to soft tissue sarcomas.
A 43 year old male with long standing chronic hepatitis is being followed up. Recently his AFP is noted to be increased and an abdominal USS demonstrates a 2cm lesion in segment V of the liver. What is the most appropriate course of action?
PET CT scan
Liver MRI
USS guided liver biopsy
Laparoscopic biopsy
Segmental resection of segment V
Liver MRI
Liver lesions that are suspicious of HCC should be scanned prior to resection as there is a risk of multifocal lesions that would either preclude or otherwise affect the decision to proceed with segmental resection.
What is the second leading cause of cancer death globally?
HCC
What criteria make HCC more likely in monitoring of liver
Rising AFP and
liver USS showing a nodule greater than 1cm in diameter makes HCC much more likely.
These patients should undergo MRI scanning.
The presence of adenomas in an otherwise healthy liver is a recognised risk factor for HCC [2, 3] and many surgeons will remove liver adenomas for this reason[4].
What is the characteristic CT finding for HCC?
Radiologically on CT the classical feature is a suspicious lesion which is highlighted during the arterial phase with washout during the venous phase, this reflects the hypervascularity of the lesions.
What can be used to classify management and prognosis in HCC?
Barcelona liver classification
What are the different stages of Barcelona Liver Clinic Classification
0
A
B
C
D
Features of BCLC Stage 0
Child-Pugh A
Single lesion (less than 2cm)
Normal portal pressures
Treatment of BCLC Stage 0
Resection
5ys in Stage 0 BCLC
40-70%
Features of stage A BCLC?
Single nodule greater than 3cm or multiple nodules no more than 3
Child Pugh A/B
Treatment of Stage A BCLC HCC
If associated disease then radiofrequency ablation
If no associated disease then transplantation
5ys in BCLC Stage A
May be up to 70^
Features of BCLC Stage B HCC
Multiple nodules
Child Pugh A/B
Treatment of BCLC Stage B disease
Trans arterial chemo-embolisation (usually with doxorubicin)
Px in BCLC Stage B disease
26% at 3 years
Features of Stage C BCLC HCC?
Advanced tumours
Invasion of portal vein
Child Pugh A/B
Px in Stage C BCLC HCC?
10.7 month survival
Treatment in BCLC Stage C disease?
Sorafenib
Features of Stage D BCLC HCC?
Child pugh C
Advanced tumours
Px in Stage D BCLC HCC?
<6months
Sorafenib
This is an oral multi tyrosine kinase inhibitor. It is the only drug that has been currently demonstrated to extend survival in individuals with advanced hepatocellular cancer[7]. The improvement in survival is from a median of 7 months to 10 months.
Surgical resections in HCC
In selected patients the best outcomes are achieved with surgical resection, or transplantation where surgical resection is precluded. Anatomical resections with minimum 2cm margins provide the best outcomes.
At the present time there is no evidence to recommend treatment with adjuvant chemotherapy[6].
A 4 year old boy falls and sustains a fracture to the growth plate of his right wrist. Which of the following systems is used to classify the injury?
Salter - Harris system
Weber system
Gustilo - Anderson system
Garden system
None of the above
The Salter - Harris system is most commonly used. The radiological signs in Type 1 and 5 injuries may be identical. Which is unfortunate as type 5 injuries do not do well (and may be missed!). One of our users has helpfully supplied a mnemonic for remembering the types (see above).
The mnemonic ‘SALTR’ can be used to help remember the first five types. This mnemonic requires the reader to imagine the bones as long bones, with the epiphyses at the base.
I “S” = Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate)
II “A” = Above. The fracture lies above the physis, or Away from the joint.
III “L” = Lower. The fracture is below the physis in the epiphysis.
IV “TE” = Through Everything. The fracture is through the metaphysis, physis, and epiphysis.
V “R” = Rammed (crushed). The physis has been crushed
Complete fracture
Both sides of cortex are breached
Toddlers fracture
Oblique tibial fracture in infants
Plastic deformity
Stress on bone resulting in deformity without cortical disruption
Greenstick fracture
Unilateral cortical breach only
Buckle fracture
Incomplete cortical disruption resulting in periosteal haematoma only
Features in NAI
Delayed presentation
Delay in attaining milestones
Lack of concordance between proposed and actual mechanism of injury
Multiple injuries
Injuries at sites not commonly exposed to trauma
Children on the at risk register
Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone.
Osteopetrosis
Bones become harder and more dense.
Autosomal recessive condition.
It is commonest in young adults.
Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone.
A 3 day old baby develops dyspneoa. A chest x-ray is performed and shows a radio-opaque shadow with an air-fluid level in the chest. It is located immediately anterior to the 6th hemivertebra. Which of the following is the most likely underlying diagnosis?
Bronchogenic cyst
Congenital diaphragmatic hernia
Infection with Staphylococcus aureus
Oesphageal duplication cyst
Hiatus hernia
A midline cystic mass of an infant in this age group is most likely to be a bronchogenic cyst. Hiatus hernia is unusual in the neonatal period. Oesophageal duplication cysts are very rare and respiratory symptoms are less common than with bronchogenic cysts. Midline congenital hernias are rare and would usually not include an air/ fluid level in the rare event that they occur at this site.
Most commonly arise as a result of anomalous development of the ventral foregut. They are most commonly single, although multiple cysts are described.
They often lie near the midline and most frequently occur in the region of the carina. They may be attached to the tracheobronchial tree, although they are seldom in direct connection with it.
Cases may be asymptomatic or present with respiratory symptoms early in the neonatal period.
They are the second most common type of foregut cysts (after enterogenous cysts) in the middle mediastinum. Up to 50% of cases are diagnosed prior to 15 years of age.
Bronchogenic cysts
Ix in bronchogenic cysts?
Many cases are diagnosed on antenatal ultrasound. Others may be detected on conventional chest radiography as a midline spherical mass or cystic structure. Once the diagnosis is suspected a CT scan should be performed.
Treatment of bronchogenic cysts?
Thorascopic resection is the ideal treatment. Very young babies can be operated on once they reach six weeks of age.
A 23 year old man presents with a brachial artery embolus. A cervical rib is suspected as being the underlying cause. From which of the following vertebral levels do they most often arise?
C7
C5
C4
C3
C2
They usually arise from C7.
Theme: Infective organisms
A.E-coli and bacteroides
B.Staphylococcus aureus
C.Streptococcus viridians
D.Staphylococcus epidermidis
E.Klebsiella
F.Clostridium tetani
G.Clostridium difficile
H.None of the above
Which is the most likely infective organism for the scenario given? Each option may be used once, more than once or not at all.
25.A 32 year old women undergoes mastectomy and latissimus dorsi flap reconstruction for breast cancer, to provide optimal cosmesis a McGhan implant is placed under the myocutaneous flap. Three weeks post operatively the patient continues to suffer from recurrent wound infections that have proved resistant to multiple courses of antibiotics.
A 68 year old man with diabetes presents with an area of necrosis of the perineum at the base of the scrotum, there is some surrounding erythema. He is systemically unwell and hypotensive.
A 68 year old women with previous rheumatic fever is admitted with pyrexia of unknown origin. Her blood cultures are unhelpful but transoesophageal echocardiography reveals vegetations on the mitral valve.
Staphylococcus epidermidis
This tends to colonise plastic devices and forms a biofilm which allows colonisation with other bacterial agents. It is notoriously difficult to eradicate once established and the usual treatment is removal of the device.
E-coli and bacteroides
This is likely to be Fournier’s Gangrene. A number of agents are implicated. E-coli and bacteroides are the most commonly isolated organisms. The key point is that both aerobic and anaerobic organisms must be present and only A has this option.
Streptococcus viridians
This is the most common organism affecting previously abnormal heart valves.
As part of a research project you are trying to ascertain whether the use of dummies in infants is linked to sudden infant death syndrome. What is the most appropriate form of study design?
Randomised controlled trial
Cross-over trial
Cross-sectional survey
Case-control study
Cohort study
As sudden infant death syndrome is relatively rare a case-control design is more appropriate than a cohort study.
Participants randomly allocated to intervention or control group (e.g. standard treatment or placebo)
Practical or ethical problems may limit use
Randomised controlled trial
Observational and prospective. Two (or more) are selected according to their exposure to a particular agent (e.g. medicine, toxin) and followed up to see how many develop a disease or other outcome.
The usual outcome measure is the relative risk.
Examples include Framingham Heart Study
Cohort study
Observational and retrospective. Patients with a particular condition (cases) are identified and matched with controls. Data is then collected on past exposure to a possible causal agent for the condition.
The usual outcome measure is the odds ratio.
Inexpensive, produce quick results
Useful for studying rare conditions
Prone to confounding
Case-control study
Provide a ‘snapshot’, sometimes called prevalence studies
Provide weak evidence of cause and effect
Cross-sectional survey
Presenting features of nasopharyngeal carcinoma?
Cervical lymphadenopathy
Otalgia
Unilateral serous otitis media
Nasal obstruction, discharge and/or epistaxis
Cranial nerve palsies
Imaging in nasopharyngeal carcinoma
Combined CT and MRI
Treatment of nasopharyngeal carcinoma
RTx is first line
A 34 year old man presents with a peptic ulcer. Which of the following is responsible for the release of gastric acid?
Chief cells
Parietal cells
Brunners Glands
G Cells
None of the above
Parietal cells are responsible for the release of gastric acid. Brunners glands are found in the duodenum.
Which of the following statements relating to use of tourniquets in surgery is false?
The use of an esmarch bandage tourniquet to exsanguinate the limb reduces the incidence of neuropraxia.
Excessive inflation pressures are amongst the commonest causes of nerve injury related to tourniquet use.
Tourniquet deflation causes a fall in CVP.
Children require lower inflation pressures than adults.
In patients developing neuropraxia related to tourniquets the radial nerve is most frequently affected.
The use of esmarch bandage tourniquet increases the risk of nerve injury as it increases pressure in the limb. Limb elevation is safer.
Systemic effects of tourniquets post inflation
Increased systemic vascular resistance, increased CVP and increased BP
Slower gradual increase in BP over time
Induced hypercoagulable state
Slow increase in core temperature
Systemic effects of tourniquets post deflation
Fall in CVP, BP and SVR
Increased end tidal carbon dioxide
Enhanced fibrinolysis
Fall in core temperature
Raised serum potassium and lactate levels
Absolute contraindications to tourniquets
AV fistula
Severe PVD
Previous vascular sx
Bone fracture or thrombosis at site of tourniquet application
Relative contraindications to tourniquet
SCD
History of VTE
Skin grafts
Localised inefction
Lymphoedema
A women is diagnosed as having pernicious anaemia. What is the most likely underlying explanation for this?
Autoimmune antibodies to parietal cells
Autoimmune antibodies to chief cells
Autoimmune antibodies to goblet cells
Autoimmune antibodies to Brunners glands
Autimmune antibodies to fundic cells
Parietal cell destruction is a major cause of pernicious anaemia and is usually autoimmune mediated. Other conditions such as bacterial overgrowth may produce mixed patterns and require more complex diagnostic evaluation.
Which of the following structures is not closely related to the brachial artery?
Ulnar nerve
Median nerve
Cephalic vein
Long head of triceps
Median cubital vein
The cephalic vein lies superficially and on the contralateral side of the arm to the brachial artery. The relation of the ulnar nerves and others are demonstrated in the image below:
Passage of the brachial artery
The brachial artery begins at the lower border of teres major as a continuation of the axillary artery. It terminates in the cubital fossa at the level of the neck of the radius by dividing into the radial and ulnar arteries.
Relations of the brachial artery
Posterior relations include the long head of triceps with the radial nerve and profunda vessels intervening. Anteriorly it is overlapped by the medial border of biceps.
It is crossed by the median nerve in the middle of the arm.
In the cubital fossa it is separated from the median cubital vein by the bicipital aponeurosis.
The basilic vein is in contact at the most proximal aspect of the cubital fossa and lies medially.
Theme: Blood transfusion reactions
A.Neutrophilic febrile reaction
B.Acute haemolytic transfusion reaction
C.Delayed haemolytic transfusion reaction
D.Pulmonary oedema
E.Sickle cell crisis
F.Transfusion associated lung injury
G.Graft vs. Host disease
Please select the most likely underlying cause for each scenario. Each option may be used once, more than once or not at all.
35.A 22 year old man is having a blood transfusion after losing blood from a peptic ulcer. He is normally fit and well. Four hours after the transfusion; he complains of sudden onset shortness of breath and chest pain. On examination his temperature is 37.2, saturations are 88% on air, blood pressure 100/55 mmHg and HR 110 bpm. He has crepitations bilaterally up to the midzones. He is given IV frusemide, but deteriorates and is admitted to ITU. A pulmonary catheter is inserted and the PCWP is 10 mmHg.
A 32 year male with leukaemia attends the day unit for a blood transfusion. Five days after the transfusion he attends A&E with a temperature of 38.5, erythroderma and desquamation.
A 22 year old man is having a blood transfusion after losing blood from haemorrhoids. He is normally fit and well. 3h during the transfusion he complains of sudden onset abdominal pain and nausea. His temperature is 39 degrees, Blood pressure 98/42 mmHg, HR 105 bpm and saturations 94% air. His urine appears dark.
Transfusion associated lung injury
The pulmonary catheter reading indicates that this is not a case of fluid overload (the PCWP should be high, normal values PCWP systolic 7mmHg, diastolic 10mmHg). Transfusion associated lung injury is a rare reaction causing neutrophilic mediated allergic pulmonary oedema. Patient’s have antibodies to donor leukocytes. It is important to consider this as a diagnosis when patients don’t respond to treatment for pulmonary oedema. Patients normally respond to supportive therapy including fluids and oxygen.
Graft vs. Host disease
This is associated with transfusion of unirradiated blood in immunosupressed patients. Transfusion associated GVHD can occur 4-30 days after a transfusion and follows a sub acute pathway. Patients may also have diarrhoea and abnormal liver function tests. Management involves steroid therapy.
Acute haemolytic transfusion reaction
Rapid intravascular haemolysis leading to shock, DIC and death can occur with this reaction.
Classification of psoas abscess
Psoas abscesses may be either primary or secondary. Primary cases often occur in the immunosuppressed and may occur as a result of haematogenous spread. Secondary cases may complicate intra abdominal diseases such as Crohns. Patients usually present with low back pain and if the abscess is extensive a mass that may be localised to the inguinal region or femoral triangle . Smaller collections may be percutaneously drained. If the collection is larger, or the percutaneous route fails, then surgery (via a retroperitoneal approach) should be performed.
Theme: Anatomy of the abdominal aorta
A.Common iliac artery
B.Median sacral artery
C.Left renal artery
D.Right renal artery
E.Inferior mesenteric artery
F.Superior mesenteric artery
G.Coeliac axis
H.Lumbar arteries
Please select the branch of the abdominal aorta that most closely matches the description provided. Each option may be used once, more than once or not at all.
41.An aortic branch that leaves the aorta approximately 1cm below the coeliac axis.
The most inferior single branch of the aorta.
The most inferior anterior branch of the aorta.
Superior mesenteric artery
The SMA leaves the aorta approximately 1cm below the coeliac axis. This is usually a level of L1. It’s crossed anteriorly by the splenic vein and the body of the pancreas. It runs downwards and forwards anterior to the uncinate process.
Median sacral artery
The median sacral artery leaves the aorta a little above its bifurcation. It descends in the midline anterior to L4 and L5.
Inferior mesenteric artery
The IMA leaves the front of of the aorta usually about 3 to 4cm superior to its bifurcation.
What are the branches of the abdominal aorta?
Inferior phrenic
Coeliac
SMA
Middle suprarenal
Renal
Gonadal
Lumbar
IMA
Median sacral
Common iliac
Inferior phrenic level?
Upper border of T12
Coeliac artery level
T12
SMA level
L1
Middle suprarenal level
L1
Renal artery level
L1-2
Gonadal artery level
L2
Lumbar artery levels
L1-L4
IMA level
L3
Median sacral level
L4
Common iliac artery level
L4
A 48 year old lady undergoes an ERCP for jaundice. 36 hours following the procedure she develops a fever and rigors. A blood culture is taken, which of the following organisms is most likely to be cultured?
Pseudomonas aeruginosa
Streptococcus
Enterobacter
Staphylococcus
Escherichia coli
Cholangitis
Combination of bacterial infection and biliary obstruction
Most common organisms are: (most frequent at top of list)
Escherichia coli
Klebsiella species
Enterococcus species
Streptococcus species
Reynolds pentad
Charcot’s triad (Fever, RUQ pain, Jaundice)
Plus confusion and hypotension
Which of the following does not lead to relaxation of the lower oesophageal sphincter?
Metoclopramide
Botulinum toxin type A
Nicotine
Alcohol
Theophylline
Metoclopramide acts directly on the smooth muscle of the LOS to cause it to contract.
Theophylline is a phosphodiesterase inhibitor (mimics action of prostaglandin E1) which causes relaxation of the LOS.
Difference between primary and secondary peristalsis
Primary peristalsis spontaneously moves the food from the oesophagus into the stomach (9 seconds)
Secondary peristalsis occurs when food, which doesn’t enter the stomach, stimulates stretch receptors to cause peristalsis
What are the three main types of peristaltic activity in the colon?
Segmental contractions
Antiperistaltic contractions towards ileum
Mass movements
Segmentation contractions
Localised contractions in which the bolus is subjected to local forces to maximise mucosal absorption
Antiperistaltic contractions towards ileum
Localised reverse peristaltic waves to slow entry into colon and maximise absorption
Mass movements
Waves migratory peristaltic waves along the entire colon to empty the organ prior to the next ingestion of food bolus
Which ligament keeps the head of the radius connected to the radial notch of the ulna?
Annular (orbicular) ligament
Quadrate ligament
Radial collateral ligament of the elbow
Ulnar collateral ligament
Radial collateral ligament
The annular ligament connects the radial head to the radial notch of the ulna. This is illustrated below:
A 52 year old male attends renal transplant clinic for a post operative assessment. You note that he is on ciclosporin and that a recent blood test shows that the ciclosporin level is elevated. Which of the following is a recognised side effect of ciclosporin?
Hyperthyroidism
Diabetes
Alopecia
Hypothermia
Nephrotoxicity
Ciclosporin- nephrotoxicity
This patient is at risk of nephrotoxicity and should be referred to the renal team as soon as possible. Alopecia is associated with azathioprine and diabetes is associated with tacrolimus.
Inhibits calcineurin, a phosphatase involved in T cell activation
Nephrotoxic
Monitor levels
Ciclosporin
Metabolised to form 6 mercaptopurine which inhibits DNA synthesis and cell division
Side effects include myelosupression, alopecia and nausea
Azathioprine
Lower incidence of acute rejection compared to ciclosporin
Also less hypertension and hyperlipidaemia
However, high incidence of impaired glucose tolerance and diabetes
Tacrolimus
Blocks purine synthesis by inhibition of IMPDH
Therefore inhibits proliferation of B and T cells
Side-effects: GI and marrow suppression
Mycophenolate mofetil (MMF)
Blocks T cell proliferation by blocking the IL-2 receptor
Can cause hyperlipidaemia
Sirolimus (rapamycin)
Selective inhibitors of IL-2 receptor
Daclizumab
Basilximab
In a 72 year old man undergoing a sigmoid colectomy for diverticular disease, which of the following interventions is most likely to reduce his risk of developing a post operative wound infection?
Using a plain clear incise type drape to cover the operative field
Administering mechanical bowel preparation pre operatively
Shaving his abdominal wall one day prior to surgery
Administration of single dose of broad spectrum antibiotics prior to the procedure
None of the above
Administration of prophylactic antibiotics will reduce the risk of wound infection. Plain incise drapes increase the risk of wound infections and should not be used. Iodophor impregnated drapes have been demonstrated to reduce the risk of wound infection. Shaving one day prior to surgery will increase the risk.
Which of the following patients should be referred for 1st line bariatric surgery?
BMI 30 kg/m2 and hypertension
BMI 28 kg/m2
BMI 35 kg/m2 and type 2 diabetes
BMI 32kg/m2
BMI 70kg/m2, COPD and type 2 diabetes
BMI 35 kg/m2 and type 2 diabetes
Case selection for bariatric surgery
BMI >/= 40 kg/m2 or between 35-40 kg/m2 and other significant disease (for example, type 2 diabetes, hypertension) that could be improved with weight loss.
Pre-requisites to bariatric surgery
All non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months.
Will receive intensive specialist management
They are generally fit for anaesthesia and surgery
They commit to the need for long-term follow-up
First-line option for adults with a BMI > 40 kg/m2 in whom surgical intervention is considered appropriate; consider orlistat if there is a long waiting list.
Surgical options in bariatric patients
Adjustable gastric band
Gastric bypass
Sleeve gastrectomy
Features of adjustable gastric band
Laparoscopic placement of adjustable band around proximal stomach.
Contains an adjustable filling port
Effective method for lifestyle control
Reversible
Takes longer to achieve target weight
Complications such as band erosion (rare), slippage or loss of efficacy may require re-intervention
Gastric bypass
Combines changes to reservoir size with malabsorptive procedure for more enduring weight loss.
Technically more challenging
Risks related to anastomoses (2% leak rate)
Irreversible
Up to 50% may become B12 deficient
Sleeve gastrectomy
Resection of stomach using stapling devices
Less popular now as initial promising results not sustained
Patients with suspected temporal arteritis are often sent for temporal artery biopsy. Which statement is true?
Temporal artery biopsy is only diagnostic if there is visual loss
Biopsy is typically taken from the non-symptomatic side to avoid the risk of blindness
Pre-operative localisation with duplex is mandatory
Biopsies may be non diagnostic in over 50% of cases
Biopsies are usually performed under general anaesthesia
Biopsies may be non diagnostic in over 50% of cases
Temporal artery biopsies are frequently non diagnostic. They should be taken from the symptomatic side and though not mandatory a duplex ultrasound is a helpful investigation, particularly if they mark the artery. It is usually performed under local anaesthetic.
Superficial temproal artery is a branch of?
Terminal branch of the external carotid
Indication for temporal artery biopsy
Age of onset older than 50 years
New-onset headache or localized head pain
Temporal artery tenderness to palpation or reduced pulsation
ESR > 50 mm/h
Vessel wall granulomatous arteritis with mononuclear cell infiltrates and giant cell formation
Temporal arteritis
Temporal artery biopsy- procedure
Position: supine, head 45 degrees
USS doppler to locate the superficial temporal artery or palpate
Local anaesthetic
Artery within temporoparietal fascia
Clamp and ligate the vessel
Cut 3-5cm
Ligate the remaining ends with absorbable suture
Close the skin
Contraindication to temporal artery biopsy
GC for >30 days
Nerves at risk during temporal artery biopsy
Facial or auriculotemporal nerve
A 38 year old man presents to the clinic with shoulder weakness. On examination he has an inability to initiate shoulder abduction. Which of the nerves listed below is least likely to be functioning normally?
Suprascapular nerve
Medial pectoral nerve
Axillary nerve
Median nerve
Radial nerve
Suprascapular nerve
Action of suprascapular nerve?
Supraspinatus and infraspinatus
Initiates abduction of the shoulder
What may be seen in suprascapular nerve injury?
If damaged, patients may be able to abduct the shoulder by leaning over the affected side and deltoid can then continue to abduct the shoulder.
Passage of suprascapular nerve
The suprascapular nerve arises from the upper trunk of the brachial plexus. It lies superior to the trunks of the brachial plexus and passes inferolaterally parallel to them. It passes through the scapular notch, deep to trapezius
Question 3 of 1124
A 49-year-old male sustained a severe blunt injury just below the bridge of the nose with industrial machinery. Imaging demonstrates a fracture involving the superior orbital fissure. On examination an ipsilateral pupillary defect is present and loss of the corneal reflexes. In addition to these examination findings, which of the following will not be present?
Altered cutaneous sensation from the forehead to the vertex
Ptosis
Complete opthalmoplegia
Nystagmus
Enopthalmos
Orbital apex syndrome
This is an extension of superior orbital fissure syndrome and includes compression of the optic nerve passing through the optic foramen. It is indicated by features of superior orbital fissure syndrome and ipsilateral afferent pupillary defect.
This type of injury will result in the orbital apex syndrome (See above). As such opthalmoplegia will be present and nystagmus cannot occur
Which of the following statements relating to the Cavernous Sinus is false?
The pituitary gland lies medially
The internal carotid artery passes through it
The temporal lobe of the brain is a lateral relation
The mandibular branch of the trigeminal and optic nerve lie on the lateral wall
The ophthalmic veins drain into the anterior aspect of the sinus
The veins that drain into the sinus are important as sepsis can cause cavernous sinus thrombosis. The maxillary branch of the trigeminal and not the mandibular branches pass through the sinus
Which of the following best describes the processes underpinning type IV hypersensitivity reactions?
Deposition of immune complexes of IgG and antigen at the site of inflammation
Deposition of IgA complexes at the site of inflammation
Deposition of IgM and IgG complexes at the site of inflammation
Degranulation of mast cells at the site of inflammation
T cell mediated response at the site of inflammation
Hypersensitivity reactions: ACID
type 1 –Anaphylactic
type 2 –Cytotoxic
type 3 –Immune complex
type 4 –Delayed hypersensitivity
T Cells are the mediators of type 4 hypersensitivity reactions which are characterised by the absence of immune complex deposition.
Theme: Management of biliary diseases
A.Acute laparoscopic cholecystectomy
B.Delayed laparoscopic cholecystectomy
C.Percutaneous cholecystostomy
D.Lithotripsy
E.Endoscopic retrograde cholangiopancreatography
F.Choledochoduodenostomy
G.Bile duct excision and hepatico-jejunostomy
H.Operative cholecystostomy
Please select the most appropriate management option for the scenario given. Each option may be used once, more than once or not at all.
6.A 43 year old women is admitted with acute cholecystitis and fails to settle. A laparoscopic cholecystectomy is being performed, at operation the gallbladder has evidence of an empyema and Calots triangle is inflamed and the surgeon suspects that a Mirizzi syndrome has occurred.
Following a difficult cholecystectomy a surgeon leaves a drain. 24 hours later bile is seen to be accumulating in the drain and this fails to resolve over the next 48 hours. The patient is otherwise well.
A 40 year old woman is admitted with abdominal pain. She has suffered from repeated episodes of this colicky right upper quadrant pain. On examination, she is pyrexial with right upper quadrant peritonism. Her blood tests show a white cell count of 23. However, the liver function tests are normal. An abdominal ultrasound scan shows multiple gallstones in a thick walled gallbladder, the bile duct measures 4mm.
Operative cholecystostomy
This will address the acute sepsis and resolve the situation. Attempts at completing the surgery at this stage, even in expert hands carries a very high risk of bile duct injury.
Endoscopic retrograde cholangiopancreatography
This will delineate the presence of potential bile duct injury. Usually this is result of leakage from the cystic duct and placement of a stent will allow free biliary drainage and the leak should settle.
Acute laparoscopic cholecystectomy
This lady has acute cholecystitis and needs an acute cholecystectomy. This operation should usually be performed within 48 hours of admission. Delay beyond this timeframe will usually result in increased operative complications and most surgeons would administer antibiotics and perform and interval cholecystectomy if the early window for an acute procedure is missed. A bile duct measuring 4mm is usually normal.
Which of the following is not a branch of the subclavian artery?
Superior thyroid artery
Vertebral artery
Thyrocervical trunk
Internal thoracic artery
Dorsal scapular artery
Superior thyroid artery is a branch of the external carotid artery.
Mnemonic for the branches of the subclavian artery: VIT C & D
V ertebral artery
I nternal thoracic
T hyrocervical trunk
C ostalcervical trunk
D orsal scapular
Which of the following is not released from the islets of Langerhans?
Pancreatic polypeptide
Glucagon
Secretin
Somatostatin
Insulin
Secretin is released from mucosal cells in the duodenum and jejunum
What hormones are released from islets of Langerhans
Beta cells- insulin
Alpha cells- glucagon
Delta cells- somatostatin
F cells- pancreatic polypeptide
Which option is not recommended during the management of compartment syndrome?
Anticoagulation
Keep limb level with the body
Intravenous fluids
Pain control
Fasciotomy
Anticoagulation will worsen compartment syndrome.
What are the two main fractures carrying the major risk of compartment syndrome?
Supracondylar fractures
Tibial shaft injuries
Treatment of compartment syndrome
This is essentially prompt and extensive fasciotomies
In the lower limb the deep muscles may be inadequately decompressed by the inexperienced operator when smaller incisions are performed
Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids
Where muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may have to be considered
Death of muscle groups may occur within 4-6 hours
Theme: Paediatric umbilical disorders
A.Omphalitis
B.Umbilical hernia
C.Umbilical granuloma
D.Paraumbilical hernia
E.Persistent vitello-intestinal duct
F.Persistent urachus
Please select the most likely underlying disorder for the umbilical condition described. Each option may be used once, more than once or not at all.
12.A 2 week old baby is referred to the surgical team by the paediatricians. They are concerned because the child has a painful area of macerated tissue at the site of the umbilicus. On examination a clear- yellowish fluid is seen to be draining from the umbilicus when the baby cries.
A premature neonate is born by emergency cesarean section at 29 weeks gestation. He initially seems to be progressing well. However, the team are concerned because he becomes systemically septic and on examination has a swollen and erythematous umbilicus.
A baby boy is born by elective cesarean section at 39 weeks gestation. He initially seems to progress well and is discharged from hospital the following day. The parents bring the child to the clinic at 10 days of age and are concerned at the presence of a profuse and foul smelling discharge at the site of the umbilicus. On examination the umbilicus has some prominent granulation tissue. When the baby cries a small trickle of brownish fluid is seen to pass from the umbilicus.
Persistent urachus
A patent urachus will present with umbilical urinary discharge. The skin may become macerated if not properly cared for. The discharge is most likely to be present when intra-abdominal pressure is raised. It is associated with posterior urethral valves.
Omphalitis
Infection from omphalitis may spread rapidly and cause severe sepsis especially in immunologically compromised, premature neonates.
Persistent vitello-intestinal duct
A persistent vitello-intestinal duct may allow the persistent and ongoing discharge of small bowel content from the umbilicus. This fluid may be very irritant to the surrounding skin.
Embryology of the umbilical cord
During development the umbilicus has two umbilical arteries and one umbilical vein. The arteries are continuous with the internal iliac arteries and the vein is continuous with the falciform ligament (ductus venosus). After birth the cord dessicates and separates and the umbilical ring closes.
What proportion of neonates will have an umbilical hernia
20%
Px in umbilical hernia in neonates
Majority will close spontaneously within 12m-3y
Features of paraumbilical hernia in neonates
These are due to defects in the linea alba that are in close proximity to the umbilicus. The edges of a paraumbilical hernia are more clearly defined than those of an umbilical hernia. They are less likely to resolve spontaneously than an umbilical hernia.
This condition consists of infection of the umbilicus. Infection with Staphylococcus aureus is the commonest cause. The condition is potentially serious as infection may spread rapidly through the umbilical vessels in neonates with a risk of portal pyaemia, and portal vein thrombosis. Treatment is usually with a combination of topical and systemic antibiotics
Omphalitis
These consist of cherry red lesions surrounding the umbilicus, they may bleed on contact and be a site of seropurulent discharge. Infection is unusual and they will often respond favorably to chemical cautery with topically applied silver nitrate.
Umbilical granuloma
This will typically present as an umbilical discharge that discharges small bowel content. Complete persistence of the duct is a rare condition. Much more common is the persistence of part of the duct (Meckels diverticulum). Persistent vitello-intestinal ducts are best imaged using a contrast study to delineate the anatomy and are managed by laparotomy and surgical closure.
Persistent vitello-intestinal duct
This is characterised by urinary discharge from the umbilicus. It is caused by persistence of the urachus which attaches to the bladder. They are associated with other urogenital abnormalities.
Persistent urachus
Chordoma may typically occur at the following sites, except?
Ribs
Clivus
Sacrum
Lumbar vertebra
Cervical vertebra
Ribs
Chordoma is a neoplasm originating from ectopic cellular remnants of the notochord and therefore arises from the midline of the axial skeleton. It accounts for 24% of all primary malignant bone tumours. Chordoma is the second commonest primary malignancy of the spine and accounts for over 50% of primary sacral tumours. The neoplasm has a predilection for the sacrococcygeal (50%) and clival (40%) regions, with other areas of the spine rarely involved. More than one vertebral body can be affected in half the cases. Chordomas most commonly present between 50 and 70 years of age. Sex incidence is equal below 40 years, but men are affected twice as often at older ages, particularly in the sacral region.
The most frequent radiographic appearance of chordoma is that of a destructive lesion of a vertebral body centered in the midline, with a large, associated soft-tissue mass.
What are the three histological variants of chordoma?
Classical, chondroid and de-differnetiated
lobulated tumor composed of groups of cells separated by fibrous septa. The cells have small round nuclei and abundant vacuolated cytoplasm.
The histological appearance of classical chordoma
Mx of chordoma
In most cases, complete surgical resection followed by radiation therapy offers the best chance of long-term control. Unfortunately, the lesion has a close proximity to the spine itself and this can compromise resection margins.
Chordomas are relatively radioresistant, requiring high doses of radiation to be controlled. The proximity of chordomas to vital neurological structures such as the brain stem and nerves limits the dose of radiation that can safely be delivered. Therefore, highly focused radiation such as proton therapy and carbon ion therapy are more effective than conventional x-ray radiation.
Theme: Bone tumours
A.Osteosarcoma
B.Fibrosarcoma
C.Osteoclastoma
D.Ewings sarcoma
E.Leiomyosarcoma
F.Chondrosarcoma
G.Rhabdomyosarcoma
H.Osteoid osteoma
I.Malignant fibrous histiocytoma
Please select the most appropriate lesion for the clinical scenario given. Each option may be used once, more than once or not at all.
16.A 16 year-old boy presents to his GP with loss of weight, pain and fever. On examination, a mass is palpable over the mid-thigh region.
A 75 year old lady presents with weight loss, pain and a swelling over her left knee. She has been treated for Pagets disease of the bone for some time.
A 17-year-old girl presents with a swelling over her right knee. Movements of her knee are restricted. A plain x-ray of the affected site shows multiple lytic and lucent lesions with clearly defined borders.
Ewings sarcoma
Ewing’s sarcoma is a malignant round cell tumour occurring in the diaphysis of the long bones in the children. These are not confined to the ends of long bones. X- Rays often show a large soft-tissue mass with concentric layers of new bone formation ( ‘onion-peel’ sign). The ESR may be elevated, thus suggesting an inflammatory or an infective cause such as osteomyelitis; although osteomyelitis usually affects the metaphyseal region in children. Treatment is with chemotherapy and surgical excision, an endoprothesis may be used to conserve the limb.
Osteosarcoma
Osteosarcoma may complicate Pagets disease of bone in up to 10% cases. Radiological appearances include bone destruction coupled with new bone formation, periosteal elevation may also occur. Surgical resection is the main treatment.
Osteoclastoma
Osteoclastoma has a characteristic appearance on x-ray with multple lytic and lucent areas (Soap bubble) appearances. Pathological fractures may occur. The disease is usually indolent.
During the repair of an atrial septal defect the surgeons note that blood starts to leak from the coronary sinus. Which structure forms the largest tributary of the coronary sinus?
Thebesian veins
Great cardiac vein
Oblique vein
Small cardiac veins
None of the above
The great cardiac vein runs in the anterior interventricular groove, and is the largest tributary of the coronary sinus. The thebesian veins drain into the heart directly.
Which one of the following is least associated with Tetralogy of Fallot?
Right ventricular outflow tract obstruction
Overriding aorta
Pan systolic murmur
Left-to-right shunt
Right ventricular hypertrophy
Right-to-left shunting is characteristic of Fallot’s. In some patients there can be bidirectional shunting (if there is mild pulmonary stenosis) and a few patients can even have pink tetralogy when there is a predominant shunt from left to right due to minimal infundibular stenosis.
What is the most common cause of cyanotic congenital heart disease?
ToF
Four characteristic features of ToF
VSD
RVH
RV outflow obstruction
Overriding aorta
cyanosis
causes a right-to-left shunt
ejection systolic murmur due to pulmonary stenosis (the VSD doesn’t usually cause a murmur)
a right-sided aortic arch is seen in 25% of patients
chest x-ray shows a ‘boot-shaped’ heart, ECG shows right ventricular hypertrophy
ToF
What is the most common cause of cyanotic congenital heart disease at birth?
At birth transposition of the great arteries is the more common lesion as patients with TOF generally present at around 1-2 months
Which one of the following statements regarding hepatitis C is correct?
Cannot be transmitted vertically from mother to child
Interferon-alpha and ribavirin are the treatments of choice
It is more infectious than hepatitis B following a needle stick injury
Breast feeding is contraindicated in mothers with hepatitis C
HCV RNA is the initial investigation of choice for at-risk groups
Interferon-alpha and ribavirin are the treatments of choice
Transmission of hepatitis C
the risk of transmission during a needle stick injury is about 2%
the vertical transmission rate from mother to child is about 6%
breast feeding is not contraindicated in mothers with hepatitis C
the risk of transmitting the virus during sexual intercourse is probably less than 5%
What proportion of patients develop acute hepaitis after exposure to HCV?
<20%
Cx of HCV
chronic infection (80-85%) - only 15-20% of patients will clear the virus after an acute infection and hence the majority will develop chronic hepatitis C
cirrhosis (20-30% of those with chronic disease)
hepatocellular cancer
cryoglobulinaemia
Management of chronic HCV infection
currently a combination of pegylated interferon-alpha and ribavirin are used
up to 55% of patients successfully clear the virus, with success rates of around 80% for some strains
Complications of ribavirin
side-effects: haemolytic anaemia, cough. Women should not become pregnant within 6 months of stopping ribavirin as it is teratogenic
Complications of IFN alpha
flu-like symptoms, depression, fatigue, leukopenia, thrombocytopenia
A 73 year old man with rest pain and ulceration of the foot undergoes a femoro-distal bypass graft with a PTFE graft. At the end of the procedure there are good distal foot pulses and a warm pink foot. Over the ensuing 60 days the foot becomes progressively cooler and the pulses diminish. What is the most likely underlying explanation for this process?
Embolus
Neo-intimal flap
Neo-intimal hyperplasia
Polyarteritis
Steal syndrome
Neo-intimal hyperplasia in distal arterial anastamoses may be reduced by use of a Miller Cuff when PTFE is the bypass conduit.
PTFE may induce neo-intimal hyperplasia with subsequent occlusion of the distal anastomosis. In more proximal arterial bypass surgery the process of neo-intimal hyperplasia is not sufficient to cause anastomotic occlusion. However, distal bypasses are at greater risk and if vein cannot be used as a conduit then the distal end of the PTFE should anastomosed to a vein cuff to minimise the risk of neo-intimal hyperplasia.
def: anastomosis
Restoration of luminal continuity
What are the three criteria for an anastomosis to heal?
Adequate blood supply
Mucosal apposition
Minimal tension
Key points regarding vascular anastomoses
Always use non absorbable monofilament suture (e.g. Polypropylene).
Round bodied needle.
Correct size for anastamosis ( i.e. 6/0 prolene for bottom end of a femoro-distal bypass).
Suture should be continuous and from inside to outside of artery to avoid raising an intimal flap.
Theme: Diverticular disease management
A.Active observation
B.Colonoscopy acutely
C.Intravenous antibiotics
D.Abdominal CT Scan
E.Ultrasound scan
F.Defecating proctogram
G.Flexible sigmoidoscopy
H.Laparotomy
Please select the most appropriate immediate management for the diverticular presentations given. Each option may be used once, more than once or not at all.
23.A 40 year old man with known diverticular disease diagnosed on colonoscopy 1 year previously is admitted with acute abdominal pain. His abdomen is maximally tender in the left iliac fossa and he describes pneumaturia. His GP has been giving him metronidazole for 2 days.
An 83 year old lady with known diverticular disease is admitted with a brisk PR bleed. On assessment the bleeding is settling and her abdomen is soft. Hb 10.2, other blood tests are normal
A 72 year old man is admitted with large bowel obstruction and CT scan suggests diverticular stricture in the sigmoid colon.
Abdominal CT Scan
A colovesical fistula has formed and CT will help to delineate the other complications which may have occurred.
Active observation
Diverticular bleeds often settle spontaneously. Acute colonoscopy is rarely helpful. She may require an elective endoscopy. Isolated diverticular bleeds without evidence of infection do not necessarily require antibiotics.
70% of diverticular bleeds will settle with conservative management.
Laparotomy
The stricture could be benign or malignant and although a luminal study would establish aetiology the opportunity for that intervention has passed.
Theme: Complications of burns
A.Deep vein thrombosis
B.Curlings Ulcer
C.Contracture
D.Type I respiratory failure
E.Type II respiratory failure
F.Toxic shock syndrome
G.Compartment syndrome
H.Rhabdomyolysis
I.Disseminated intravascular coagulation
For each clinical scenario please select the most likely complication to have occurred. Each option may be used once, more than once or not at all.
26.A 10 year old child is admitted with severe 30% burns following a house fire. After wound cleaning and dressings he is admitted to critical care. 1 day following skin grafts he becomes tachycardic and hypotensive. He vomits twice and this shows evidence of haematemesis
A 26 year old electrician suffers a full thickness high voltage burn to his leg. On routine urine analysis he has + blood. His U+E’s show mild hyperkalaemia and a CK of 3000
A 45 year old man is admitted after his clothing caught fire. He suffers a full thickness circumferential burn to his lower thigh. He complains of increasing pain in lower leg and on examination there is parasthesia and severe pain in the lower leg. Foot pulses are normal
Stress ulcers may occur in the duodenum of burns patients and are more common in children.
Electrical high voltage burns are associated with rhabdomyolysis. Acute tubular necrosis may occur. Aggressive IV fluids should be given
Circumferential burns may constrict the limb and cause a compartment syndrome to develop. Eshcarotomy is required, and compartmental decompression.
A 19 year old male presents with bilateral gynaecomastia, poor vision and nipple discharge. Which of the following blood tests is most likely to be abnormal?
Oestrogen
Testosterone
β HCG
Prolactin
Calcitonin
A combination of nipple discharge, gynaecomastia and poor vision may well be associated with a prolactinoma. The poor vision results from compression of the optic chiasm resulting in bi temporal hemianopia.
Which of the following vessels provides the greatest contribution to the arterial supply of the breast?
External mammary artery
Thoracoacromial artery
Internal mammary artery
Lateral thoracic artery
Subclavian artery
60% of the arterial supply to the breast is derived from the internal mammary artery. The external mammary and lateral thoracic arteries also make a significant (but lesser) contribution. This is of importance clinically in performing reduction mammoplasty procedures.
On what do the breasts lie?
A layer of pectoral fascia and
Pec major
Serratus anterior
External oblique
Nerve supply of the breast
Branches of intercostal nerves (T4-6)
Arterial supply of the breast
Internal mammary (thoracic) artery
External mammary artery (laterally)
Anterior intercostal arteries
Thoraco-acromial artery
Venous drainage of the breast
Superficial venous plexus to subclavian, axillary and intercostal veins.
Lymphatic drainage of the breast
70% Axillary nodes
Internal mammary chain
Other lymphatic sites such as deep cervical and supraclavicular fossa (later in disease)
Which of the following muscles is supplied by the external laryngeal nerve?
Transverse arytenoid
Cricothyroid
Thyro-arytenoid
Posterior crico-arytenoid
Oblique arytenoid
Cricothyroid
The others are supplied by the RLN
Theme: Management of gastric cancer
A.Radical radiotherapy
B.Endoscopic submucosal resection
C.Polya Gastrectomy
D.Distal gastrectomy and anterior gastrojejunostomy
E.Distal gastrectomy and posterior gastrojejunostomy
F.Belsey Mark IV procedure
G.Sub total gastrectomy and Roux and Y reconstruction
H.Total gastrectomy and Roux en Y reconstruction
Please select the most appropriate management for the gastric cancer case described. Each option may be used once, more than once or not at all.
2.An otherwise fit 73 year old man presents with gastric outlet obstruction. An upper GI endoscopy shows a prepyloric tumour occluding the pylorus. Staging investigations show nodal disease at D2 and an involved paraaortic lymph node.
A 40 year old lady presents with a gastric carcinoma of the greater curvature of the stomach. Her staging investigations are negative for metastatic disease.
A 62 year old man presents with dyspepsia and a tumour of the gastric cardia is diagnosed. He has no evidence of metastatic disease.
Distal gastrectomy and anterior gastrojejunostomy
This man does not have disease amenable to curative surgical resection. However, good palliation can be achieved with a resection and chemotherapy. He is likely to have recurrent disease in the gastric bed and an anterior gastrojejunostomy is therefore preferred.
Sub total gastrectomy and Roux and Y reconstruction
This is amenable to potentially curative resection. The proximal stomach can be conserved.
Total gastrectomy and Roux en Y reconstruction
This will require a total gastrectomy. Retention of a gastric remnant is unlikely to achieve acceptable resection margins
A 56 year old man is diagnosed with an abdominal aortic aneurysm and undergoes a CT scan to asses the size of the aorta. During the course of his investigations a lesion of the adrenal gland is identified. It measures 1.5 cm in diameter and the gland is otherwise normal. What is the most likely diagnosis?
Adrenal gland metastasis
Adrenal gland arterio-venous malformation
Adrenal cyst
Phaeochromocytoma
Adrenal cortical adenoma
25% of all adrenal lesions >4cm in diameter are malignant
Incidentalomas of the adrenal gland are common and represent the most likely lesion in this scenario. Clearly the other lesions are all possibilities but are unlikely.
Prevalence of incidentaloma adrenal lesions?
Prevalences range from 1.5-9% in autopsy studies. Overall, 75% will be non functioning adenomas. However, a thorough diagnostic work up is required to exclude a more significant lesion.
Risk of malignancy in incidental adrenal lesions
The risk of malignancy is related to the size of the lesion and 25% of all masses greater than 4cm will be malignant. Such lesions should usually be excised. Where a lesion is a suspected metastatic deposit a biopsy may be considered. Smaller, innocent lesions are usually followed up by serial CT scans at 6, 12 and 24 months.
Theme: Lymphoedema Management
A.Homans operation
B.Charles operation
C.Frusemide at high doses
D.Frusemide at low doses
E.Multilayer compression bandaging
F.Lymphovenous anastomosis
Please select the most appropriate management for the lymphoedema scenario given. Each option may be used once, more than once or not at all.
7.A 52 year old lady develops lower leg swelling following redo varicose vein surgery. There is evidence of swelling of the left leg up to the knee. The overlying skin appears healthy.
A 57 year old lady has suffered from lymphoedema for many years. The left leg is swollen to the mid thigh. Severe limb deformity has developed as a result of process and in spite of compression hosiery. Lymphoscintography shows no patent lymphatics in the proximal leg. The overlying skin is healthy.
A 38 year old lady is troubled by lymphoedema that occurred following a block dissection of the groin for malignant melanoma many years previously. Despite therapy with compression bandages she has persistent lower leg swelling impairing her activities of daily living. She has no evidence of recurrent malignancy. Lymphoscintography demonstrates occlusion of the groin lymphatics. However, the distal lymphatic system appears healthy.
Multilayer compression bandaging
Unfortunately lymphoedema may complicate redo varicose vein surgery (in 0.5% of cases). As the presentation is mild, she should be managed using compression hosiery. Diuretics do not help in cases of true lymphoedema and a dramatic response suggests an alternative underlying cause.
Homans operation
Surgery is indicated in less than 10% of cases. However, severe deformity is one of the indications for surgery. Lymphovenous anastomosis is indicated where the proximal lymphatics are not patent. When the overlying skin is healthy (and limb deformity a problem), a Homans procedure is a reasonable first line operative option.
Lymphovenous anastomosis
In young patients with proximal disease and healthy distal lymphatics a lymphovenous anastomosis may be considered. Such cases are rare.
def: lymphoedema
Due to impaired lymphatic drainage in the presence of normal capillary function.
Lymphoedema causes the accumulation of protein rich fluid, subdermal fibrosis and dermal thickening.
Characteristically fluid is confined to the epifascial space (skin and subcutaneous tissues); muscle compartments are free of oedema. It involves the foot, unlike other forms of oedema. There may be a ‘buffalo hump’ on the dorsum of the foot and the skin cannot be pinched due to subcutaneous fibrosis.
Primary causes of lympohedema
<1 y/o
Congenital: sporadic, Milroy’s disease
Primary cause of lymphoedema
1-35 y/o
Sporadic
Meige’s disease
Primary cause of lymphoedema
>35y
Tarda
Secondary causes of lymphoedema
Bacterial/fungal/parasitic infection (filariasis)
Lymphatic malignancy
Radiotherapy to lymph nodes
Surgical resection of lymph nodes
DVT
Thrombophlebitis
Indications for sxical management of lymphoedema
Marked disability or deformity from limb swelling
Lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics suitable for a lymphatic drainage procedure
Lymphocutaneous fistulae and megalymphatics
Homans operation
For lymphodema
Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third.
Charles operation
For lymphoedema
All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure.
Lymphovenous anastamosis
Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.
A 22 year old man is undergoing an abdominal ultrasound scan as part of a series of investigations for abdominal pain. The radiologist notes that there is evidence of splenic atrophy. What is the most likely cause?
Letterer-Siwe disease
Coeliac disease
Malaria
Niemann-Pick disease
Sarcoidosis
Splenic atrophy may occur in coeliac disease together with the appearance of Howell-Jolly bodies in erythrocytes. Letterer - Siwe disease is a form of Histiocytosis X in which macrophages proliferate.
Theme: Causes of upper gastrointestinal haemorrhage
A.Antral gastric ulcer
B.Mallory Weiss tear
C.Oesphageal varices
D.Dieulafoy lesion
E.Gastritis
F.Duodenal ulcer anterior wall
G.Duodenal ulcer posterior wall
Please select the most appropriate likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.
11.A 35 year old man is admitted with an episode of collapse and passage of malaena. He has been suffering from post prandial abdominal pain for 5 weeks and this is most marked several hours after eating.
A 72 year old man is admitted with an episode of brisk haematemesis. Following resuscitation an upper GI endoscopy is performed and a prominent blood vessel is identified in the mucosa approximately 6 cm from the O-G junction on the lesser curve of the stomach.
A 56 year old man is admitted with a profuse upper gastro intestinal haemorrhage. He is relatively malnourished and has evidence of gynaecomastia.
Duodenal ulcer posterior wall
Patients with duodenal ulcers will usually have a history of epigastric pain that occurs several hours after eating. The pain is often improved by eating food. They are most frequently located in the first part of the duodenum. Anteriorly sited ulcers may perforate and result in peritonitis, posteriorly sited ulcers may erode the gastroduodenal artery and present with haematemesis and/ or malaena.
Dieulafoy lesion
These small arterial lesions are a rare cause of bleeding and are characterised by a single large tortuous arteriole in the sub mucosa. Extra gastric lesions may occur.
Oesphageal varices
Patients presenting with gastrointestinal bleeding and evidence of established liver disease may have portal hypertension and develop variceal haemorrhage. The patient may have evidence of jaundice, gynaecomastia, spider naevia, caput medusae and ascites. The bleeding is usually profuse and painless.
Which of the following has the greatest impact on the positive predictive value of a test?
Prevalence
Subjects who are true negatives
Specificity
Relative risk
None of the above
The positive predictive value (PPV) is the probability that an individual with a positive screening result has the disease. The sensitivity is the probability that an individual with the disease is screened positive and the specificity is the probability that an individual without the disease is screened negative.
Its value depends upon the prevalence of the condition being tested for and the sensitivity of the test used.
It may be calculated by dividing the number of true positives by the number of true positives and the number of false positives.
Sensitivity
proportion of true positives identified by a test
Specificity
proportion of true negatives correctly identified by a test
Positive predictive value:
proportion of those who have a positive test who actually have the disease
Negative predictive value:
: proportion of those who test negative who do not have the disease
Predictive values are dependent on
the prevalence
Likelihood ratio for a positive test result =
sensitivity/(1-specificity)
Likelihood ratio for a negative test result =
(1-sensitivity)/specificity
Likelihood ratios are not
prevalence dependent
What are the layers of the spermatic cord
Internal spermatic fascia (transvesalis fascia)
Cremasteric fascia (internal oblique)
External spermatic fascia (external oblique)
What are the contents of the spermatic cord?
(3 layers)
3 arteries
3 nerves
3 other structures
Testicular artery
Artery of vas deferens
Cremasteric artery
Genital branch of genitofemoral nerve
Sympathetic nervous fibres
Ilioinguinal nerve (not in the cord itself)
Vas deferens
Pampiniform plexus
Lymphatic vessels
Transmits sperm and accessory gland secretions
Vas deferens
Branch of abdominal aorta supplies testis and epididymis
Testicular artery
Artery in spermatic cord
Arises from inferior vesical artery
Artery of vas deferens
Artery in spermatic cord
Arises from inferior epigastric artery
Cremasteric artery
Venous plexus, drains into right or left testicular vein
Pampiniform plexus
Nerve that supplies cremaster
Genital branch of genitofemoral nerve
Lymphatic drainage of the scrotum?
Inguinal lymph nodes
Layers of the scrotum
SDECITT
S: skin.
D: dartos fascia and muscle.
E: external spermatic fascia.
C: cremasteric fascia.
I: internal spermatic fascia.
T: tunica vaginalis.
T: tunica albuginea.
Theme: Neck lumps
A.Dermoid cyst
B.Thyroglossal cyst
C.Sjogren’s syndrome
D.Mikulicz’s syndrome
E.Pleomorphic adenoma of the parotid
F.Carcinoma of the parotid
G.Cystic hygroma
H.Branchial cyst
I.Pharyngeal pouch
Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.
16.A dentist treating a women with rheumatoid arthritis for recurrent episodes of dental sepsis notices that both parotid and submandibular glands are symmetrically enlarged.
A patient presents with a facial nerve palsy. This occurred following repeat excision of a facial lump. The histology report remarks on the biphasic appearance of the lesion and mucinous connective tissue.
A patient is recovering from a Sistrunk’s procedure, what lesion was treated with this operation?
Sjogren’s syndrome
Sjogren’s is associated with autoimmune disorders. Mikulicz’s is similar but there is no sicca or arthritis.
Pleomorphic adenoma of the parotid
The histological features are as described with a classic biphasic (mixed stromal and epithelial elements), although benign local recurrence can complicate incomplete excision. As this is a benign lesion direct extension into the facial nerve is unlikely to occur. Facial nerve injury can happen during repeat parotid surger
Thyroglossal cyst
This is the procedure for excision of the cyst and its associated track. Excision must be complete and thus a small segment of the hyoid bone is removed to gain access to the upper part of the cyst tract.
During a carotid endarterectomy the internal carotid artery is cross clamped. Assuming that no shunt is inserted, which of the following vessels will not have diminished or absent flow as a result?
Anterior cerebral artery
Ophthalmic artery
Middle cerebral artery
Maxillary artery
None of the above
The maxillary artery is a branch of the external carotid artery.
Mnemonic for branches of the cerebral portion of the internal carotid artery ‘Only Press Carotid Arteries Momentarily’
Only = Opthalmic Press = Posterior communicating Carotid = Choroidal Arteries = Anterior cerebral Momentarily = Middle cerebral
A 72 year old lady with osteoporosis falls and sustains an intracapsular femoral neck fracture. The fracture is completely displaced. Which of the following vessels is the main contributor to the arterial supply of the femoral head?
Deep external pudendal artery
Superficial femoral artery
External iliac artery
Circumflex femoral arteries
Superficial external pudendal artery
The vessels which form the anastomoses around the femoral head are derived from the medial and lateral circumflex femoral arteries. These are usually derived from the profunda femoris artery.
What can be used to stage Hodgkin’s lymphoma?
Ann Arbor staging system
Ann Arbor I
Single LN region
Ann Arbor 2
Two or more LN regions on same side of diaphragm
Ann Arbor III
Involvement of LN regions on both sides of the diaphragm
Ann Arbor IV
Involvement of extra nodal sites
A 21 year old man is hit with a hammer and sustains a depressed skull fracture at the vertex. Which of the following sinuses is at risk in this injury?
Superior sagittal sinus
Inferior petrosal sinus
Transverse sinus
Inferior sagittal sinus
Straight sinus
The superior sagittal sinus is at greatest risk in this pattern of injury. This sinus begins at the front of the crista galli and courses backwards along the falx cerebri. It becomes continuous with the right transverse sinus near the internal occipital protuberance.
Arragnement of structures at the renal hilum
The renal vein lies most anteriorly, then renal artery (it is an end artery) and the ureter lies most posterior.
Contents of the renal sinus
- Branches of the renal artery
- Tributaries of the renal vein
- Major and minor calyces’s
- Fat
Theme: Gastro intestinal haemorrhage.
A.Proctoscopy and injection sclerotherapy
B.IV terlipressin
C.Pan Proctocolectomy
D.Sub total colectomy
E.Colonscopy and bleeding therapy
F.Barium enema
G.Angiography of mesenteric artery
Please select the most appropriate management option for the scenario given. Each option may be used once more than once or not at all
24.A 56 year old man is admitted with passage of a large volume of blood per rectum. On examination he is tachycardic, his abdomen is soft, although he has marked dilated veins on his abdominal wall. Proctoscopy reveals large dilated veins with stigmata of recent haemorrhage.
A 73 year old lady is admitted with dark red PR bleeding. She undergoes an OGD which is normal. Digital rectal examination shows blood but no masses. She becomes tachycardic and BP is 95/40.
A 68 year old man with ulcerative colitis is admitted with an exacerbation. You are called to see him because he is having brisk dark PR bleeding. He has been on intravenous hydrocortisone for 5 days. The gastroenterologists have done an OGD to exclude a duodenal ulcer, this was normal.
IV terlipressin
Rectal varices are a recognised complication of portal hypertension. In the first instance they can be managed with medical therapy to lower pressure in the portal venous system. TIPSS may be considered. Whilst band ligation is an option, attempting to inject these in same way as haemorroids would carry a high risk of precipitating further haemorrhage.
Angiography of mesenteric artery
This women is actively bleeding and mesenteric angiography may localise the bleeding. Colonoscopy in this situation is seldom helpful or successful.
Sub total colectomy
This man requires surgery to remove the bleeding segment of bowel. Medical management has failed here. Note that a pan proctocolectomy is not a suitable option in the emergency setting because there is increased morbidity from the pelvic dissection. In the unlikely event that a sub total colectomy did not address the bleeding then consideration may have to be given to removal of the rectum but this would not usually be the case.
Control of ventilation. Which statement is false?
Peripheral chemoreceptors are located in the bifurcation of the carotid arteries and arch of the aorta
Central chemoreceptors respond to changes in O2
The respiratory centres control the rate and depth of respiration
Involuntary control of respiration is from the medulla and pons
Irritant receptors cause bronchospasm
Central chemoreceptors: Respond to increased H+ in BRAIN INTERSTITIAL FLUID to increase ventilation.
What are the respiratory centres
Medullary respiratory centre
Apneustic centre
Pneumotaxic centre
Medullary respiratory centre
Inspiratory and expiratory neurones. Has ventral group which controls forced voluntary expiration and the dorsal group controls inspiration. Depressed by opiates.
Apneustic centre
Lower pons
Stimulates inspiration - activates and prolongs inhalation
Overridden by pneumotaxic control to end inspiration
Pneumotaxic centre
Upper pons, inhibits inspiration at a certain point. Fine tunes the respiratory rate.
What is most important in ventilation control?
Levels of pCO2
Where are peripheral chemoreceptors and what do they respond to?
Peripheral chemoreceptors: located in the bifurcation of carotid arteries and arch of the aorta. They respond to changes in reduced pO2, increased H+ and increased pCO2 in ARTERIAL BLOOD.
Central chemoreceptors
Central chemoreceptors: located in the medulla. Respond to increased H+ in BRAIN INTERSTITIAL FLUID to increase ventilation. NB the central receptors are NOT influenced by O2levels.
What are the lung receptors
Stretch receptors: respond to lung stretching causing a reduced respiratory rate
Irritant receptors: respond to smoke etc causing bronchospasm
J (juxtacapillary) receptors
Which of the following is not a typical feature of a chronic venous leg ulcer?
Heaped raised borders if the ulcer has been present more than 5 years
Evidence of surrounding lipodermatosclerosis
Irregular shape to the ulcer
20% of cases will have a previous history of deep vein thrombosis
Haemosiderin deposits in surrounding skin
The borders of the ulcer are often well defined even though they may be irregular. Heaped or raised borders should raise suspicion of a marjolins ulcer.
A 34-year-old man from Zimbabwe is admitted with abdominal pain to the Emergency Department. An abdominal x-ray reveals urinary bladder calcification. What is the most likely cause?
Schistosoma mansoni
Sarcoidosis
Leishmaniasis
Tuberculosis
Schistosoma haematobium
Schistosoma haematobium causes haematuria
Schistosomiasis is the most common cause of bladder calcification worldwide. Schistosoma mansoni typically resided in the colon from where it is excreted.
What are the two types of schistosomiasis
Schistosoma mansoni and Schistosoma intercalatum: intestinal schistosomiasis
Schistosoma haematobium: urinary schistosomiasis
Management of schistosomiasis haematobium
Single dose of oral praziquantel
Theme: Airway management
A.Cricothyroidotomy
B.Laryngeal mask
C.Endotracheal intubation
D.Tracheostomy
E.Oropharyngeal airway
Please select the most appropriate method of airway access for the scenario given. Each option may be used once, more than once or not at all.
1.A 63 year old man has been on the intensive care unit for a week with adult respiratory distress syndrome complicating acute pancreatitis. He has required ventilation and is still being mechanically ventilated.
A 23 year old man is undergoing an inguinal hernia repair as a daycase procedure and is being given sevoflurane
A 48 year old man is due to undergo a laparotomy for small bowel obstruction.
Tracheostomy
Tracheostomy is often used to facilitate long term weaning. The percutaneous devices are popular. These involve a seldinger type insertion of the tube. A second operator inserts a bronchoscope to ensure the device is not advanced through the posterior wall of the trachea. Complications include damage to adjacent structures and bleeding (contra indication in coagulopathy).
Laryngeal mask
This procedure will be associated with requirement for swift onset of anaesthesia and recovery. Muscle paralysis is not required and this would an ideal case for laryngeal mask airway.
Endotracheal intubation
Patients who are due to undergo laparotomies for bowel obstruction have either been vomiting or at high risk of regurgitation of gastric contents on induction of anaesthesia. A rapid sequence induction with cricothyroid pressure applied to occlude the oesophagus is performed. A cuffed endotracheal tube is then inserted. Once correct placement of the ET tube is confirmed the cricothyroid pressure can be removed.
A baby is found to have a Klumpke’s palsy post delivery. Which of the following is most likely to be present?
Loss of flexors of the wrist
Weak elbow flexion
Pronation of the forearm
Adducted shoulder
Shoulder medially rotated
A C8, T1 root lesion is called Klumpke’s paralysis and is caused by delivery with the arm extended.Loss of flexors of the wrist
Features of Klumpkes Paralysis
Claw hand (MCP joints extended and IP joints flexed)
Loss of sensation over medial aspect of forearm and hand
Horner’s syndrome
Loss of flexors of the wrist
Which statement relating to phaeochromocytoma is untrue?
They are tumours of chromaffin cells in the adrenal medulla.
They are bilateral in 10% of cases.
When located in an extra adrenal location have a higher incidence of malignancy.
May be associated with an elevated urinary VMA.
Up to 40% may have a blood pressure within the normal range.
Normotension is seen in around 10% cases. The remainder show a degree of hypertension.
A 22 year old man undergoes a superficial parotidectomy for a pleomorphic adenoma. The operation does not proceed well and a diathermy malfunction results in division of the buccal branch of the facial nerve. Which of the following muscles will not demonstrate impaired function as a result?
Zygomaticus minor
Mentalis
Buccinator
Levator anguli oris
Risorius
Mentalis
Muscles supplied by the buccal branch of the facial nerve
Zygomaticus minor
Risorius
Buccinator
Levator anguli oris
Orbicularis
Nasalis
Action of zygomaticus minor
Elevates upper lip
Action of risorius
Aids smile
Action of buccinator
Pulls corner of mouth backward and compresses cheek
Action of levator anguli oris
Pulls angles of mouth upward and towards midline
Action of orbicularis
Closes and tightens lips together
Action of nasalis
Flares and compresses nostrils
At which of the following vertebral body levels does the common carotid artery typically bifurcate into the external and internal carotid arteries?
C4
C2
C1
C6
C7
It terminates at the upper border of the thyroid cartilage, Which is usually located at C4.
A 69 year old man presents with a purple lesion on his forearm. It is excised and an a 3 cm Merkel cell tumour is diagnosed. Which of the following statements relating to this diagnosis is false?
He should undergo a sentinel lymph node biopsy.
Lymphovascular invasion is typically seen histologically
They are more common in immunosupressed patients
Histologically they may resemble pyogenic granuloma
They are associated with visceral metastasis
Merkel cell tumours are rare cutaneous tumours. Histologically they consist of sheets and nodules of hyperchromatic epithelial cells, with high rates of mitosis and apoptosis. As such they are relatively easy to distinguish from pyogenic granuloma which has no features of malignancy and would not show lymphovascular invasion.
Rare but aggressive tumour.
Develops from intra epidermal Merkel cells.
Usually presents on elderly, sun damaged skin. The periorbital area is the commonest site.
Histologically these tumours appear within the dermis and subcutis. The lesions consist of sheets and nodules of small hyperchromatic epithelial cells with high rates of mitosis and apoptosis. Lymphovascular invasion is commonly seen.
Merkel cell tumour of the skin
What virus is associated with merkel cell tumours of the skin?
Merkel Cell Polyomavirus seen in 80%
Treatment of merkel cell tumour
Surgical excision is first line. Margins of 1cm are required. Lesions >10mm in diameter should undergo sentinel lymph node biopsy. Adjuvant radiotherapy is often given to reduce the risk of local recurrence.
Px in Merkel cell tumours
With lymph node metastasis 5 year survival is 50% or less.
Small lesions without nodal spread are usually associated with a 5 year survival of 80%.
In examining a biopsy of a primary tumour, the clearest evidence of malignancy is provided by:
Absence of a capsule
Basophilia of the cytoplasm
Invasion of surrounding structures
Excess of mitoses
Nuclear aberrations
Invasion of surrounding structures
A man is stabbed in the chest to the right of the manubriosternal angle. Which structure is least likely to be injured in this case?
Right pleura
The trachea
Right phrenic nerve
Right recurrent laryngeal nerve
Brachiocephalic vein
The right recurrent laryngeal nerve branches off the right vagus more proximally and arches posteriorly round the subclavian artery. So of the structures given it is the least likely to be injured.
An 18 year old man is stabbed in the neck and has to undergo repair of a laceration to the internal carotid artery. Post operatively he is noted to have a Horners syndrome. Which of the following will not be present?
Apparent enopthalmos
Loss of sweating on the entire ipsilateral side of the face
Constricted pupil
Mild ptosis
Normal sympathetic activity in the torso
The anhidrosis will be mild as this is a distal lesion and at worst only a very limited area of the ipsilateral face will be anhidrotic.
You are the cardiothoracic surgical registrar reviewing a patient referred for an aortic valve replacement. The 40-year-old man is being investigated for progressive breathlessness in a previous respiratory clinic. The notes show he has smoked for the past 25 years. Pulmonary function tests reveal the following:
FEV11.4 L
FVC1.7 L
FEV1/FVC82%
What is the most likely explanation?
Asthma
Bronchiectasis
Kyphoscoliosis
Chronic obstructive pulmonary disease
Laryngeal malignancy
These results show a restrictive picture, which may result from a number of conditions including kyphoscoliosis. The other answers cause an obstructive picture.
We note that most people have chosen COPD as the answer. In COPD the FEV1/FVC would show an obstructive picture with the FEV1/FVC value being low (approximately less than 70%). In restrictive conditions the FEV1/FVC is normal or increased (greater than 70%). With the FEV1/FVC being over 70% the most likely answer is kyphoscoliosis
Obstructive pulmonary function picture
FEV1 significantly reduced
FVC reduced or normal
FEV1/FVC <70
Restrictive pulmonary function picture
FEV1 reduced
FVC significantly reduced
FEV1/FVC >70%
./ A 10 year old girl presents with epistaxis. From which of the following regions is the bleeding most likely to originate?
Posterior nasal space
Alar rim
Kiesselbach’s plexus
Cribriform plate
None of the above
Kiesselbachs plexus has an arterial supply derived from both the internal and external carotid arteries and is the commonest area for bleeding in idiopathic epistaxis.
Arterial supply of significance in epistaxis?
From internal and external carotid
An arterial plexus exists at Little’s area and is the source of bleeding in 90% cases
Major arterial supply is from the sphenopalatine and greater palatine arteries (branches of the maxillary artery)
The facial artery supplies the more anterior aspect of the nose
Ethmoidal arteries are branches of the ophthalmic artery. They supply the posterosuperior nasal cavity
Classification of epistaxis
Primary idiopathic epistaxis accounts for 75% of all cases
Secondary cases arise as a result of events such as anticoagulants, trauma and coagulopathy
Classification into anterior and posterior epistaxis may help to locate the source and becomes more important when invasive treatment is required
Management of epistaxis
Resuscitate if required
Subject should sit upright and pinch nose firmly
Nasal cavity should be examined using a headlight
Simple anterior epistaxis may be managed using silver nitrate cautery. If difficult to manage then custom manufactured packs may be inserted
Posterior packing or tamponade may be achieved by passing a balloon tamponade device and inflating it. This is indicated where anterior packing alone has failed to achieve haemostasis.
Post nasal pack patients should receive antibiotics
Failure of these methods will require more invasive therapy. Where a vascular radiology suite is available, consideration may be given to angiographic techniques. Direct ligation of the nasal arterial supply may also be undertaken. Of the arterial ligation techniques available, the endo nasal sphenopalatine arterial ligation procedure is most popular.
Theme: Liver tumours
A.Rhabdomyosarcoma
B.Yolk sac tumour
C.Hepatocellular carcinoma
D.Metastatic lesion
E.Haemangioendothelioma
F.Cholangiocarcinoma
G.Hepatoblastoma
H.Angiosarcoma
Please select the most likely diagnosis for the scenario given. Each answer may be used once, more than once or not at all.
18.A 56 year old man with long standing ulcerative colitis and a DALM lesion in the rectum is admitted with jaundice. On CT scanning the liver has 3 nodules in the right lobe and 1 nodule in the left lobe. Carcinoembryonic antigen levels are elevated.
A 48 year old lady with chronic hepatitis B infection is noted to have worsening liver function tests and progressive jaundice. Her alpha feto protein levels are grossly elevated.
A 55 year old man with long standing ulcerative colitis is admitted with cholangitis and weight loss. Blood tests reveal a markedly elevated CA 19-9.
Metastatic lesion
This is likely to be due to metastatic lesions from a colonic primary. DALM lesions should be excised by oncological colectomy for this reason. This burden of metastatic disease is unlikely to precipitate jaundice directly and nodal disease at the porta hepatis is the most likely cause in this case.
Hepatocellular carcinoma
This is most likely to be hepatocellular carcinoma and markedly elevated AFP levels in association with a compatible risk factor should make this the diagnosis.
Cholangiocarcinoma
This is most likely a cholangiocarcinoma. UC with sclerosing cholangitis increases the risk of cholangiocarcinoma. CA19-9 is elevated in approximately 80% cases.
Which of the following does not occur as a pathological response to extensive burns?
Plasma leakage into interstitial space
Absolute polycythaemia
Increased haematocrit
Keratinocyte migration during healing
Cardiac output reduction by 50% in first 30 minutes
Absolute polycythaemia
Haemolysis is the main pathological response.
Pathology in Burns
Haemolysis due to damage of erythrocytes by heat and microangiopathy
Loss of capillary membrane integrity causing plasma leakage into interstitial space
Extravasation of fluids from the burn site causing hypovolaemic shock (up to 48h after injury)- decreased blood volume and increased haematocrit
Protein loss
Secondary infection e.g. Staphylococcus aureus
ARDS
Risk of Curlings ulcer (acute peptic stress ulcers)
Danger of full thickness circumferential burns in an extremity as these may develop compartment syndrome
Theme: Chest pain
A.Pulmonary embolism
B.Acute exacerbation asthma
C.Physiological
D.Mitral valve stenosis
E.Aortic dissection
F.Mitral regurgitation
G.Bronchopneumonia
H.Tuberculosis
I.None of the above
What is the most likely diagnosis for the scenario given? Each option may be used once, more than once or not at all.
22.A 28 year old Indian woman, who is 18 weeks pregnant, presents with increasing shortness of breath, chest pain and coughing clear sputum. She is apyrexial, blood pressure is 140/80 mmHg, heart rate 130 bpm and saturations 94% on 15L oxygen. On examination there is a mid diastolic murmur, there are bibasal crepitations and mild pedal oedema. She suddenly deteriorates and has a respiratory arrest. Her chest x-ray shows a whiteout of both of her lungs.
A 28 year old woman, who is 30 weeks pregnant, presents with sudden onset chest pain associated with loss of consciousness. Her blood pressure is 170/90 mmHg, saturations on 15L oxygen 93%, heart rate 120 bpm and she is apyrexial. On examination there is an early diastolic murmur, occasional bibasal creptitations and mild peal oedema. An ECG shows ST elevation in leads II, III and aVF.
A 28 year old woman, who is 18 weeks pregnant, presents with sudden chest pain. Her blood pressure is 150/70 mmHg, saturations are 92% on 15L oxygen and her heart rate is 130 bpm. There are no murmurs and her chest is clear. There is signs of thrombophlebitis in the left leg.
Mitral valve stenosis
Mitral stenosis is the commonest cause of cardiac abnormality occurring in pregnant women. Mitral stenosis is becoming less common in the UK population, however should be considered in women from countries where there is a higher incidence of rheumatic heart disease. Mitral stenosis causes a mid diastolic murmur which may be difficult to auscultate unless the patient is placed into the left lateral position. These patients are at risk of atrial fibrillation (up to 40%), which can also contribute to rapid decompensation such as pulmonary oedema (hence cxr ‘whiteout’ of lungs). Physiological changes in pregnancy may cause an otherwise asymptomatic patient to suddenly deteriorate. Balloon valvuloplasty is the treatment of choice.
Aortic dissection
Aortic dissection is associated with the 3rd trimester of pregnancy, connective tissue disorders (Marfan’s, Ehlers- Danlos) and bicuspid valve. Patients may complain of a tearing chest pain or syncope. Clinically they may be hypertensive. The right coronary artery may become involved in the dissection, causing myocardial infarct in up to 2% cases (hence ST elevation in the inferior leads). An aortic regurgitant murmur may be auscultated.
Pulmonary embolism
Chest pain, hypoxia and clear chest on auscultation in pregnancy should lead to a high suspicion of pulmonary embolism.
Aortic dissection in pregnancy
Predisposing factors in pregnancy are hypertension, congenital heart disease and Marfan’s syndrome
Mainly Stanford type A dissections
Sudden tearing chest pain, transient syncope
Patient may be cold and clammy, hypertensive and have an aortic regurgitation murmur
Involvement of the right coronary artery may cause inferior myocardial infarction
Aortic dissection in pregnancy management:
<28/40
Aortic repair with fetus kept in utero
Aortic dissection in pregnancy management:
28-32/40
Dependent on fetal condition
Aortic dissection in pregnancy management:
>32/40
C-section followed by aortic repair at same time
In relation to patients with type 1 diabetes mellitus undergoing surgery, which of the following statements is untrue?
They should not receive oral carbohydrate loading drinks as part of enhanced recovery programmes
When a variable rate insulin infusion is required 0.45% sodium chloride and 5% dextrose with either 0.15% or 0.3% potassium are the fluids of choice
Hourly intraoperative blood glucose measurements are required
Insulin infusions are only required in patients who will miss more than two meals or who are nil by mouth for greater than 12 hours
Blood glucose levels persistently greater than 12 should initiate a change in therapy
Insulin should not be stopped in patients with type 1 diabetes and omission of more than one meal will usually require a variable rate insulin infusion
Type 1 diabetics who take insulin should have this continued through the perioperative period.
Fluid guidelines in diabetics differ and are not well covered in NPSA fluid guidelines.
Which of the following types of epithelium lines the lumenal surface of the normal oesophagus?
Non keratinised stratified squamous epithelium
Ciliated columnar epithelium
Keratinised stratified squamous epithelium
Non ciliated columnar epithelium
None of the above
The oesphagus is lined by non keratinised stratified squamous epithelium. Changes to glandular type epithelium occur as part of metaplastic processes in reflux.
A 54 year old lady has her serum calcium measured. Assuming her renal function is normal, what proportion of calcium filtered at the glomerulus will be reabsorbed by the renal tubules?
5%
15%
25%
50%
95%
Most filtered calcium is reabsorbed (95%) a rare disorder of familial hypocalcemic calciurea may affect this proportion.
A 3 year old boy is brought to the clinic with symptoms of urinary hesitancy and poor stream. Which of the following is the most likely underlying diagnosis?
Benign prostatic hypertrophy
Posterior urethral valves
Neurogenic bladder
Urethral calculus
Hypospadias
Posterior urethral valves are one of the commonest causes of poor urinary stream and hesitancy in children. Prostatic disorders are rare.
Hypospadias is associated with urine that is difficult to control, but should not produce hesitancy.
What is the commonest cause of infravesical outflow obstruction in males?
Posterior urethral valves
Theme: Suture materials
A.Silk 3/0
B.Polyglactin 3/0
C.Polydioxanone 1/0
D.Stainless steel skin clips
E.Stainless steel wire 1/0
F.6/0 Polypropylene
G.1/0 Undyed polyglactin
H.Polypropylene 3/0
Please select the most appropriate suture for the scenario given. Each option may be used once, more than once or not at all.
Anastomosis of ileum to transverse colon following right hemicolectomy.
Distal anastomosis in a femorodistal bypass using vein.
Closure of skin following thyroidectomy for Graves disease.
Polyglactin 3/0
3/0 PDS would be an alternative, as would linear stapler but those are not in the list.
6/0 Polypropylene
Arterial anastomoses should be constructed using polypropylene. In this case a fine suture material such as 6/0 is indicated.
Stainless steel skin clips
Although some use sub cuticular stitches skin clips remain the standard of many. In the event of post operative haematoma causing respiratory obstruction, they are easier to remove.
A 23 year old man is stabbed in the neck, in the region between the omohyoid and digastric muscles, the injury is explored surgically. At operation a nerve injury is identified immediately superior to the lingual artery as is branches off the external carotid artery. Which of the following is the most likely result of this injury?
Paralysis of the ipsilateral side of the tongue
Abduction of the ipsilateral vocal cord
Winging of the scapula
Paralysis of the ipsilateral hemi diaphragm
Inability to abduct the shoulder
The hypoglossal nerve runs anterior to the external carotid, above the lingual arterial branch. If damaged then ipsilateral paralysis of the genioglossus, hyoglossus and styloglossus muscles will occur. If the patient is asked to protrude their tongue then it will tend to point to the affected side.
1= hypoglossal
Which of the following structures is not directly related to the right adrenal gland?
Diaphragm posteriorly
Kidney inferiorly
Right renal vein
Inferior vena cava
Hepato-renal pouch
The right renal vein is very short and lies more inferiorly.
A 23 year old man who plays rugby for a hobby presents with recurrent anterior dislocation of the shoulder. Which of the following abnormalities is most likely to be present to account for this?
Rotator cuff tear
Biceps tendon rupture
Bankart lesion
Axillary nerve injury
Infraspinatus tendinitis
A Bankart lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it.
Anterior dislocations are the most common. When recurrent, a Bankart lesion is the most common underlying abnormality. This is usually visualised by CT and MRI scanning and often repaired arthroscopically.
Third most common fragility fracture in the elderly.
Results from low energy fall in predominantly elderly females, or from high energy trauma in young males.
Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries.
Proximal humerus #
Vascular supply of the humeral head?
Anterior and posterior humeral circumflex arteries
What can be used for classification of proximal humeral #?
Neer classification
Neer classification of proximal humeral fractures
Most commonly used. Describes fracture as 2,3,or 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments:
-greater tuberosity
-lesser tuberosity
- articular surface
- shaft
Displacement: >1cm or angulation >45 degrees.
Treatment of minimally displaced proximal humeral fracture
The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks.
Options for surgical management of proximal humeral fracture
ORIF
IM nail
Hemiarthroplasty
Total shoulder arthroplasty
Reverse shoulder arthroplasty
ORIF proximal humeral #
Most commonly used. Plate and screw fixation. Can reconstruct complex fractures.
Intramedullary nail proximal humeral fractures
Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures.
Hemiarthroplasty in proximal humeral fracture
Used for un-reconstructable fractures in the older patient who has good glenoid quality.
Total shoulder arthroplasty
Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion)
Reverse shoulder arthroplasty
Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement.
Scapula fracture
Uncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury.
Imaging in scapula fracture
Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction.
Classification of scapula fracture
Based on the location of the fracture (coracoid, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton.
Treatment of scapular fracture
The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fractures.
Different types of shoulder dislocation
Anterior
Posterior
Inferior
Superior
Usually traumatic - anterior force on arm when shoulder is abducted, eternally rotated
Loss of shoulder contour - sulcus sign. Humeral head can be felt anteriorly.
Anterior shoulder dislocation
Shoulder locked in internal rotation. XR may show lightbulb appearance.
50% traumatic, but classically post seizure or electrocution
Posterior shoulder dislocation
Shoulder dislocation
Associated with pectorals and rotator cuff tears, and glenoid fracture
Inferior shoulder dislocation
Shoulder dislocation
Associated with acrominon/clavicle fracture
Superior
avulsion of the anterior glenoid labrum with an anterior shoulder dislocation
Bankart lesion
chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction.
Hill Sachs defect
Innervation of supraspinatus
Suprascapular nerve
Innervation of infraspinatus
Suprascapular nerve
Innervation of teres minor
Axillary nerve
Innervation of subscapularis
Upper and lower subscapular nerve
Attachments of supraspinatus
Superior facet of greater tubersoity
Supraspinatus fossa
Attachments of infraspinatus
Infraspinatus fossa
Posterior facet of greater tuberosity
Attachments of teres minor
Lateral border of scapula
Inferior facet of greater tuberosity
Attachments of subscapularis
Subscapular fossa
Lesser tuberoisty
Action of supraspinatus
Initiation of abduction
Action of infraspinatus
External rotation of humerus
Action of teres minor
External rotation of humerus
Action of subscapularis
Internal rotation of huemrus
The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis.
Associated with certain types of acromial morphology (Bigliani classification).
Presents as insidious pain which is exacerbated by overhead activities.
Subacromial Impingement
Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients.
Majority of tears are to the superior cuff (supraspinatus, infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement.
Tears present as pain and weakness when using the muscles in question.
Rotator Cuff Tear
Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly.
Associated with massive chronic cuff tears.
Rotator Cuff Arthropathy
Imaging in ?rotator cuff pathology
Plain radiographs: AP of shoulder. Outlet view.
USS: allows dynamic imaging of the cuff
MRI: best modality for cuff pathology
A 44 year old man is involved in a road traffic accident. He suffers significant injuries to his thorax, he has bilateral haemopneumothoraces and a suspected haemopericardium. He is to undergo surgery, what is the best method of accessing these injuries?
Bilateral thoracoscopy and mediastinoscopy
Midline sternotomy
Bilateral posterolateral thoracotomy
Clam shell thoracotomy
None of the above
Patients with significant mediastinal and lung injuries are best operated on using a Clam shell thoracotomy. All modes of access involve a degree of compromise. A sternotomy would give good access to the heart. However, it takes longer to perform and does not provide good access to the lungs. Trauma should not be managed using laparoscopy.
A 67 year old man is investigated for biliary colic and a 4.8 cm abdominal aortic aneurysm is identified. Which of the following statements relating to this condition is untrue?
The wall will be composed of dense fibrous tissue only
The majority are located inferior to the renal arteries
They occur most often in current or former smokers
He should initially be managed by a process of active surveillance
Aortoduodenal fistula is a recognised complication following repair.
They are true aneurysms and have all 3 layers of arterial wall.
Which of the following does not cause hyperkalaemia?
Haemolysis
Burns
Familial periodic paralysis
Type 4 renal tubular acidosis
Severe malnutrition
Severe malnutrition
‘Machine’ - Causes of Increased Serum K+
M - Medications - ACE inhibitors, NSAIDS
A - Acidosis - Metabolic and respiratory
C - Cellular destruction - Burns, traumatic injury
H - Hypoaldosteronism, haemolysis
I - Intake - Excessive
N - Nephrons, renal failure
E - Excretion - Impaired
How do LMWH and UFH cause hyperkalaemia?
?through inhibition of aldosterone secretion
With respect to the basilic vein, which statement is false?
Its deep anatomical location makes it unsuitable for use as an arteriovenous access site in fistula surgery
It originates from the dorsal venous network on the hand
It travels up the medial aspect of the forearm
Halfway between the shoulder and the elbow it lies deep to muscle
It is joined by the brachial vein to form the axillary vein
It is used in arteriovenous fistula surgery during a procedure known as a basilic vein transposition.
ECG changes in PE
No changes
S1, Q3, T3
Tall R waves: V1
P pulmonale (peaked P waves): inferior leads
Right axis deviation, Right bundle branch block
Atrial arrhythmias
T wave inversion: V1, V2, V3
Right ventricular strain: if identified is associated with adverse short-term outcome and adds prognostic value to echocardiographic evidence of right ventricular dysfunction in patients with acute pulmonary embolism and normal blood pressure.
Theme: Management of skin lesions
A.5mm punch biopsy
B.Shave biopsy
C.Excisional biopsy
D.Wide excision of 5cm
E.Tru cut biopsy
F.Incisional biopsy
For the skin lesions described please select the most appropriate management option. Each option may be used once, more than once or not at all.
7.An 83 year old lady presents with multiple patches of pigmented irregular, superficial lesions over the torso. They do not bleed but have become increasingly itchy.
A 65 year old man presents with a 5cm ulcerated area over his medial malleolus.
A 23 year old lady presents with an itchy, bleeding pigmented lesion on her right thigh.
Shave biopsy
This is most likely to be seborrhoeic warts. These are usually superficially sited and are best managed with shave biopsy and cautery.
5mm punch biopsy
This is likely to be a venous ulcer and should usually be managed with compression bandaging if there is no arterial compromise. Long standing lesions may be complicated by the development of malignancy and for this reason a punch biopsy of long standing or non healing lesions is advisable.
Excisional biopsy
This may represent a malignant melanoma. Complete excision is required to allow accurate histological assessment. If the diagnosis is confirmed then re-excision of margins may be required. Clearly if the lesion is benign then no further action is required.
Tru-cut biopsy
Most often used for percutaneous sampling of deep seated lesions or used intra operatively for visceral lesions
5mm punch biopsy
Used for diagnostic confirmation of lesions that are suspected to be benign or where the definitive management is unlikely to be surgical. Of limited usefulness in pigmented lesions where they do not include sufficient tissue for accurate diagnosis. May be used in non melanoma type skin disease to establish diagnosis prior to more extensive resection.
Wide excision
Where the complete excision of the lesion (with healthy margins) is the main objective. In cosmetically sensitive sites, or where the defect is large, this may need to be complemented with plastic surgical techniques
Incisional biopsy
Used mainly for deep seated or extensive lesions where there is diagnostic doubt (usually following core or tru-cut biopsy). Used rarely for skin lesions.
Diagnostic excision
Primarily used for lesions that are suspicious for melanoma, the lesion is excised with a rim of normal tissue. Excision of margins may be required subsequently.
A 72 year old man is recovering from an inguinal hernia repair when he suffers from an extensive CVA. He is managed on the rehabilitation unit. However, he is still not able to feed safely and repeated swallowing assessments have shown that he tends to aspirate. Which of the following is the best option for long term feeding?
PEG tube feeding
Feeding jejunostomy
Total parenteral nutrition
Long term naso gastric tube feeding
Withold feeding and palliate
A PEG tube is the best long term option although they are associated with a significant degree of morbidity. A feeding jejunostomy would require a general anaesthetic. TPN is not a good option. Long term naso gastric feeding is usually unsatisfactory.
A 22 year old man presents with a 5 day history of sore throat, malaise and fatigue. On examination he has a large peritonsillar abscess. What is the most likely underlying infective organism?
Epstein Barr Virus
Streptococcus pyogenes
Cytomegalovirus
Moraxella catarrhalis
Streptococcus viridans
Streptococcus pyogenes
Quinsy usually occurs as a result of bacterial tonsillitis and the most common cause of bacterial tonsillitis is streptococcal organisms.
A 34 year old man presents with symptoms attributable to a fistula in ano. He is examined in the lithotomy position and the external opening of the fistula is identified in the 7 o’clock position. At which of the following locations is the internal opening most likely to be identified?
7 o’clock
12 o’clock
9 o’clock
3 o’clock
6 o’clock
Goodsals rule:
Anterior fistulae will tend to have an internal opening opposite the external opening.
Posterior fistulae will tend to have a curved track that passes towards the midline.
According to Goodsalls rule the track of a posteriorly sited fistula will track to the posterior midline (i.e. 6 o’clock)
def: fistula
Abnormal connection between two epitheial surfaces
General rule in fistulas
Fistulae will resolve spontaneously as long as there is no distal obstruction, this is particularly true of intestinal fistulae
These link the intestine to the skin. They may be high (>500ml) or low output (<250ml) depending upon source. Duodenal /jejunal fistulae will tend to produce high volume, electrolyte rich secretions which can lead to severe excoriation of the skin. Colo-cutaneous fistulae will tend to leak faeculent material. Both fistulae may result from the spontaneous rupture of an abscess cavity onto the skin (such as following perianal abscess drainage) or may occur as a result of iatrogenic input. In some cases it may even be surgically desirable e.g. mucous fistula following sub total colectomy for colitis.
Enterocutaneous
This is a fistula that involves the large or small intestine. They may originate in a similar manner to enterocutaneous fistulae. A particular problem with this fistula type is that bacterial overgrowth may precipitate malabsorption syndromes. This may be particularly serious in inflammatory bowel disease.
Enteroenteric or Enterocolic
This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract infections, or the passage of gas from the urethra during urination.
Enterovesicular fistula
Genereal rules of fistula management
Will heal if no underlying IBD or distal obstruction- conservative management may thus be the best option.
Protect overlying skin if there is any skin invovlement
High output fistula can be managed with octreotide which will reduce the volume of pancreatic secretions.
Nutritional complications are common- may require TPN.
Theme: Proctology
A.Haemorrhoids
B.Rectal intussceception
C.Fistula in ano
D.Fissure in ano
E.Peri-anal abscess
F.Solitary rectal ulcer
G.Marjolins ulcer
Please select the most likely disorder for the scenario given. Each option may be used once, more than once or not at all.
3.A 38 year old lady presents with symptoms of obstructed defecation that date back to the birth of her second child by use of ventouse. She passes mucous and suffers from pelvic pain. Digital rectal examination and barium enema are normal.
A 23 year old male presents with bright red rectal bleeding that occurs post defecation onto the toilet paper. He has been suffering from severe pain associated with this. On external anal examination there is a skin tag located at the 6 O’clock position.
Rectal intussceception
Rectal intussceception (internal rectal prolapse) typically presents with symptoms of obstructed defecation. The pathology is best demonstrated by a defecating procotogram rather than barium enema.
Fissure in ano
This is a typical story for fissure and should be treated with laxatives and topical vasodilator (eg GTN) in the first instance.
Haemorrhoids
This is likely to be haemorrhoidal disease. A sigmoidoscopy should always be performed to exclude more sinister pathology.
Mobilisation of the left lobe of the liver will facilitate surgical access to which of the following?
Abdominal oesophagus
Duodenum
Right colic flexure
Right kidney
Pylorus of stomach
The fundus of the stomach is a posterior relation. The pylorus lies more inferolaterally. During a total gastrectomy division of the ligaments holding the left lobe of the liver will facilitate access to the proximal stomach and abdominal oesophagus. This manoeuvre is seldom beneficial during a distal gastrectomy.
The following statements relating to the ankle joint are true except?
Three groups of ligaments provide mechanical stability
The sural nerve lies medial to the Achilles tendon at its point of insertion
Eversion of the foot occurs at the sub talar joint
The flexor hallucis longus tendon is the most posterior structure at the medial malleolus
The saphenous nerve crosses the ankle joint.
The sural nerve lies behind the distal fibula. Inversion and eversion are sub talar movements. The structures passing behind the medial malleolus from anterior to posterior include: tibialis posterior, flexor digitorum longus, posterior tibia vein, posterior tibial artery, nerve, flexor hallucis longus.
Ligaments of the ankle joint
Deltoid ligament (medially)
LCL
Talofibular ligaments (both anteriorly and posteriorly)
The calcaenofibular ligament is separate from the fibrous capsule of the joint
Components of the syndesmosis at the ankle joint
Antero-inferior tibiofibular ligament
Postero-inferior tibiofibular ligament
Inferior transverse tibiofibular ligament
Interosseous ligament
What are the movements at the ankle joint
Plantar flexion (55 degrees)
Dorsiflexion (35 degrees)
Inversion and eversion movements occur at the level of the sub talar joint
The oesophagus is constricted at the following levels apart from:
Cricoid cartilage
Arch of the aorta
Lower oesophageal sphincter
Left main stem bronchus
Diaphragmatic hiatus
The oesophagus is not constricted at the level of the lower oesophageal sphincter.
Which of the following statements in relation to the p53 tumour suppressor protein is false?
It may induce necrosis of cells with non repairable DNA damage
It is affected in Li Fraumeni syndrome
It can induce DNA repair
It can halt the cell cycle
It may inhibit angiogenesis
When DNA cannot be repaired it will induce cellular apoptosis (not necrosis)
Which of the following statements is true of glucagon?
Produced in response to hyperglycaemia
Released by beta cells
Inhibits gluconeogenesis
Produced in response to an increase of amino acids
Composed of 2 alpha polypeptide chains linked by hydrogen bonds
Glucagon is a protein comprised of a single polypeptide chain.
Produced by alpha cells of pancreatic islets of Langerhans in response to hypoglycaemia and amino acids.
It increases plasma glucose and ketones.
Stimulants of glucagon
Decreased plasma glucose
Increased catecholamines
Increased plasma aas
SNS
ACh
CCK
Inhibitors of glucagon
Somatostatin
Insulin
Increased FFAs and keto acids
Increased urea
Theme: Bone disease
A.Osteogenesis imperfecta
B.Osteoporosis
C.Rickets
D.Pagets disease
E.Chondrosarcoma
F.Metastatic breast cancer
Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.
12.A 66 year old lady presents with pain in her right hip. It has been increasing over the previous three weeks and waking her from sleep. On examination she is tender on internal rotation. Blood tests reveal a mildly elevated serum calcium and alkaline phosphatase levels.
A 73 year old man presents with pain in the right leg. It is most uncomfortable on walking. On examination he has a deformity of his right femur, which on x-ray is thickened and sclerotic. His serum alkaline phosphatase is elevated, but calcium is within normal limits.
A 73 year old lady presents with pain in her left hip. She was walking around the house when she tripped over a rug and fell over. Apart from temporal arteritis which is well controlled with prednisolone she is otherwise well. On examination he leg is shorted and externally rotated.Her serum alkaline phosphatase and calcium are normal.
Metastatic breast cancer
Increasing pain at rest, together with increased serum calcium and alkaline phosphatase are most likely to represent metastatic tumour to bone. Chondrosarcomas do occur in the pelvis but are not associated with increased serum calcium and typically have a longer history.
Pagets disease
This is a typical scenario for Pagets disease.
Osteoporosis
The combination of age, female gender and steroids coupled with hip pain on minor trauma are strongly suggestive of osteoporosis.
A 22 year old man is referred to the surgical clinic. He has been complaining of varicose veins for many years. On examination he has extensive varicosities of the right leg, there are areas of marked port wine staining. The saphenofemoral junction is competent on doppler assessment. The most likely underlying diagnosis is:
Deep vein thrombosis
Klippel-Trenaunay syndrome
Varicose veins due to sapheno-popliteal junction incompetence
Sturge - Weber syndrome
Angiosarcoma
Klippel Trenaunay syndrome
Sturge - Weber syndrome is a an arteriovenous malformation affecting the face and CNS, the peripheral vessels are not affected. Simple varicose veins should not typically be associated with port wine staining, nor should a DVT or angiosarcoma.
One or more distinctive port-wine stains with sharp borders
Varicose veins
Hypertrophy of bony and soft tissues, that may lead to local gigantism or shrinking.
An improperly developed lymphatic system
Klippel Trenaunay syndrome
Absence of port wine stain= atypical Klippel Trenaunay syndrome
Theme: Anaesthetic agents
A.Halothane
B.Propofol
C.Ketamine
D.Etomidate
E.Sodium thiopentone
F.Flumazenil
G.Naloxone
H.Sevoflurane
Please select the drug which most closely matches the description given. Each option may be used once, more than once or not at all.
17.An agent which reverses the action of midazolam
An agent which is associated with hepatotoxicity
An agent with antiemetic properties
Flumazenil
Flumazenil antagonises the effects of benzodiazepines by competition at GABA binding sites. Since may benzodiazepines have longer half lives than flumazenil patients still require close monitoring after receiving the drug.
Halothane
Halothane is hepatotoxic. Despite this it remains in mainstream use. It should be avoided in patients with hepatic dysfunction, and scavengers should be used in theatres as accumulation of the drug may be injurious to theatre staff.
Propofol
Propofol is rapidly metabolised and has mild/ moderate anti emetic properties. It is the agent of choice in most day case operations for this reason.
Which of the following is a branch of the third part of the axillary artery?
Superior thoracic
Lateral thoracic
Dorsal scapular
Thoracoacromial
Posterior circumflex humeral
Posterior circumflex humeral
The other branches include:
Subscapular
Anterior circumflex humeral
A 73 year old lady presents with progressive dysphagia and is diagnosed with oesophageal cancer and liver metastases, it is located 8cm proximal to the gastro-oesophageal junction. Which of the following treatment options would be the the most appropriate management?
Insertion of Celestin tube
Insertion of Minnesota tube
Insertion of self expanding metal stent
Photodynamic therapy
Trans hiatal oesphagectomy
Most cases of malignant oesophageal obstruction can be managed by the placement of self expanding metal stents. The Celestin tube requires a laparotomy and is therefore obsolete. A resectional procedure would be inappropriate in the presence of liver metastasis. The main contra indication to metallic stent placement are very proximal tumours as it can be difficult to get proximal control in this situation and chemotherapy may be more appropriate.
Which of the following structures separates the intervertebral disks from the spinal cord?
Anterior longitudinal ligament
Posterior longitudinal ligament
Supraspinous ligament
Interspinous ligament
Ligamentum flavum
The posterior longitudinal ligament overlies the posterior aspect of the vertebral bodies. It also overlies the posterior aspect of the intervertebral disks.
A 28 year old man undergoes a completion right hemicolectomy for treatment of a 5cm appendiceal carcinoid. As part of his follow up he is due to undergo 24 hour urine collection for 5-HIAA. Which of the following causes an elevated 5-HIAA in a 24-hour urine collection?
Naproxen
Oranges
Flucloxacillin
Amiodarone
Beef
It is important to be aware of what can falsely elevate 5-HIAA to avoid diagnosing carcinoid syndrome incorrectly. These include:
Food: spinach, cheese, wine, caffeine, tomatoes
Drugs: Naproxen, Monoamine oxidase inhibitors
Recent surgery
A 23 year old man is due to undergo a mitral valve repair for mitral regurgitation. Which of the following is a feature of the mitral valve?
Its closure is marked by the first heart sound
It has two anterior cusps
The chordae tendinae attach to the anterior cusps only
The chordae tendinae anchor the valve directly to the wall of the left ventricle
It is best auscultated in the left third interspace
The mitral valve is best auscultated over the cardiac apex, where its closure marks the first heart sound. It has only two cusps. These are attached to chordae tendinae which themselves are linked to the wall of the ventricle by the papillary muscles.
A patient is referred due to the development of a third nerve palsy associated with a headache. On examination, meningism is present. Which one of the following diagnoses needs to be urgently excluded?
Weber’s syndrome
Internal carotid artery aneurysm
Multiple sclerosis
Posterior communicating artery aneurysm
Anterior communicating artery aneurysm
Painful third nerve palsy = posterior communicating artery aneurysm
Given the combination of a headache and third nerve palsy it is important to exclude a posterior communicating artery aneurysm
eye is deviated ‘down and out’
ptosis
pupil may be dilated
Third nerve palsy
Surgical third nerve palsy
Pupil dilated
Medical third nerve palsy
Pupil sparing
A 68 year old man presents with an ulcerated lesion on his right cheek. It is excised and on histological assessment a squamous cell carcinoma is diagnosed. It measures 25mm in diameter and is 4mm deep. Which of the following statements relating to this condition is false?
In this particular case margins of at least 6mm are required
Use of cryosurgery to treat this patients lesion would have been unsafe
Use of radiotherapy to treat this lesion would have been unsafe
This patients local recurrence rate may approach 15%
The disease usually spreads via lymphatics
This man has an SCC with significant risk of metastasis. Although cryotherapy may be used to treat SCC it would be most unsafe in this setting as the lesion extends deeply. However, radiotherapy is a safe treatment modality for SCC and may be used in selected cases. It is unwise to use radiotherapy in areas prone to radionecrosis e.g. the nose.
Poor prognostic factors in SCC
Size >20mm (local recurrence rate of up to 15%)
Depth greater than 4mm (risk of metastasis up to 30%)
Groups at high risk of SCC
Renal transplant and on immunosuppression
Individuals with HIV
Those who have received psoralen UVA therapy
Chronic wounds (Marjolins ulcer)
Xeroderma pigmentosum
Oculocutaneous albinism
Treatment of SCC
Surgical excision with 4mm margins if lesion <20mm in diameter. If tumour >20mm then margins should be 6mm.
Theme: Nerve lesions
A.Intercostobrachial
B.Median
C.Axillary
D.Radial
E.Ulnar
F.Musculocutaneous
G.Brachial plexus upper cord
H.Brachial plexus lower cord
Please select the most likely nerve injury for the scenarios given. Each option may be used once, more than once or not at all.
4.A 23 year old rugby player sustains a Smiths Fracture. On examination opposition of the thumb is markedly weakened.
A 45 year old lady recovering from a mastectomy and axillary node clearance notices that sensation in her armpit is impaired.
An 8 year old boy falls onto an outstretched hand and sustains a supracondylar fracture. In addition to a weak radial pulse the child is noted to have loss of pronation of the affected hand.
Median
This high velocity injury can often produce significant angulation and displacement. Both of these may impair the function of the median nerve with loss of function of the muscles of the thenar eminence
Intercostobrachial
The intercostobrachial nerves are frequently injured during axillary dissection. These nerves traverse the axilla and supply cutaneous sensation.
Median
This is a common injury in children. In this case the angulation and displacement have resulted in median nerve injury.
A 23 year old lady with sialolithiasis of the submandibular gland is undergoing excision of the gland. Which of the following nerves is at risk as the duct is mobilised?
Lingual nerve
Buccal nerve
Facial nerve
Glossopharyngeal
Vagus
The lingual nerve wraps around Whartons duct. The lingual nerve provides sensory supply to the anterior 2/3 of the tongue.
A 73 year old man undergoes an emergency amputation for severe lower limb sepsis and gangrene. Post operatively he develops disseminated intravascular coagulation. Which of the following clotting factors will be most rapidly consumed in this process?
Factor V and VIII
Factor I
Factor I and III
Factor III and VII
Factor VI and VIII
DIC Will tend to consume factors five and eight intially (and platelets).
Causes of DIC
DISSEMINATED
D-Dx: D dimer
I-Immune complexes
S-Snakebite, shock, heatstroke
S-SLE
E-Eclampsia, HELLP syndrome
M-Massive tissue damage
I-Infections: viral and bacterial
N-Neoplasms
A-Acute promyelocytic leukemia
T-Tumor products: Tissue Factor (TF) and TF-like factors released by carcinomas of pancreas, prostate, lung,
colon, stomach
E-Endotoxins (bacterial)
D-Dead fetus (retained)
prolonged clotting times, thrombocytopenia, decreased fibrinogen, increased fibrinogen degradation products
DIC
A 21 year old man falls down a ravine whilst skiing and is trapped for several hours. He is finally brought to the emergency department profoundly hypothermic with a core temperature of 29oC. Which method is most effective at raising the core temperature?
Re-warming with electric blankets
Increasing the room temperature
Instillation of warm intravesical fluid
Instillation of warmed rectal fluid
Instillation of warmed intra peritoneal fluid
Visceral cavity re-warming be it lung or abdomen (or both) provides rapid rewarming. Only extracorporeal circulatory devices provide faster rates of re-warming.
Def: hypothermia
Core body temperature <35
Severe when <30
Theme: Disease of the vertebral column
A.Spondylolysis
B.Spina bifida occulta
C.Spondylolisthesis
D.Meningomyelocele
E.Meningocele
F.Functional scoliosis
G.Structural scoliosis
H.Ankylosing spondylitis
I.Scheuermanns disease
Please select the most likely underlying diagnosis for the condition described. Each condition may be used once, more than once or not at all.
10.A 19 year old female is involved in an athletics event. She has just completed the high jump when she suddenly develops severe back pain and weakness affecting both her legs. On examination, she has a prominent sacrum and her lower back is painful.
A 15 year old boy is brought to the clinic by his mother who is concerned that he has a mark overlying his lower spine. On examination the boy has a patch of hair overlying his lower lumbar spine and a birth mark at the same location. Lower limb neurological examination is normal.
A 19 year old female presents to the clinic with progressive pain in her neck and back. The condition has been progressively worsening over the past 6 months. She has not presented previously because she was an inpatient with a disease flare of ulcerative colitis. On examination, she has a stiff back with limited spinal extension on bending forwards.
Spondylolisthesis
Young athletic females are the group most frequently affected by spondylolythesis who have a background of spondylolysis. Whilst the latter condition is a risk factor for spondylolythesis the former condition is most likely in a young athletic female who presents with sudden pain.
Spina bifida occulta
Spina bifida occulta is a common condition and may affect up to 10% of the population. The more severe types of spina bifida have more characteristic skin changes. Occasionally the unwary surgeon is persuaded to operate on these cutaneous changes and we would advocate performing an MRI scan prior to any such surgical procedure in this regio
Ankylosing spondylitis
Ankylosing spondylitis is associated with HLA B27, there is a strong association with ulcerative colitis in such individuals. The clinical findings are usually of a kyphosis affecting the cervical and thoracic spine. Considerable symptomatic benefit may be obtained using non steroidal anti inflammatory drugs. These should be used carefully in patients with inflammatory bowel disease who may be taking steroids.
Chronic inflammatory disorder affecting the axial skeleton
Sacro-ilitis is a usually visible in plain films
Up to 20% of those who are HLA B27 positive will develop the condition
Affected articulations develop bony or fibrous changes
Typical spinal features include loss of the lumbar lordosis and progressive kyphosis of the cervico-thoracic spine
Ankylosing spondylitis
Epiphysitis of the vertebral joints is the main pathological process
Predominantly affects adolescents
Symptoms include back pain and stiffness
X-ray changes include epiphyseal plate disturbance and anterior wedging
Clinical features include progressive kyphosis (at least 3 vertebrae must be involved)
Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation
Scheuermann’s disease
Consists of curvature of the spine in the coronal plane
Divisible into structural and non structural, the latter being commonest in adolescent females who develop minor postural changes only. Postural scoliosis will typically disappear on manoeuvres such as bending forwards
Structural scoliosis affects > 1 vertebral body and is divisible into idiopathic, congential and neuromuscular in origin. It is not correctable by alterations in posture
Within structural scoliosis, idiopathic is the most common type
Severe, or progressive structural disease is often managed surgically with bilateral rod stabilisation of the spine
Scoliosis
Non fusion of the vertebral arches during embryonic development
Three categories; myelomeningocele, spina bifida occulta and meningocele
Myelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defect
Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch
The incidence of the condition is reduced by use of folic acid supplements during pregnancy
Spina bifida
Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5
May be asymptomatic and affects up to 5% of the population
Spondylolysis is the commonest cause of spondylolisthesis in children
Asymptomatic cases do not require treatment
Spondylolysis
This occurs when one vertebra is displaced relative to its immediate inferior vertebral body
May occur as a result of stress fracture or spondylolysis
Traumatic cases may show the classic “Scotty Dog” appearance on plain films
Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation
Spondylolisthesis
Which of the following is true in connection with the phrenic nerves?
They both lie anterior to the hilum of the lungs
They are derived from spinal roots C 2,3,4
They pierce the diaphragm at the level of T7
They consist of motor fibres only
None of the above
They both lie anterior to the hilum of the lung. The phrenic nerves have both motor and sensory functions. For this reason sub diaphragmatic pathology may cause referred pain to the shoulder.
Path of the phrenic nerve
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.
Relation of the left phrenic nerve to the subclavian
Crosses anterior to the 1st part of the subclavian artery
Relation of the right subclavian nerve to the subclavian artery
Passes anterior to scalenus anterior and crosses anterior to the 2nd part of the subclavian artery
Relationship of the phrenic nerves to the subclavian vein and internal thoracic artery
Run posterior to both
Right phrenic nerve in the mediatsinum
Superior: anterior to right vagus and laterally to SVC
Middle: right of pericardium
Passes over the right atrium to exit diaphragm at T8
Relation of right phrenic nerve to diaphragm
Exits the diaphragm at T8
Passage of left phrenic nerve in the thorax
Lateral to the left subclavian artery, aortic arch and left venricle, anterior to the root of the lung
Relation of the left phrenic nerve to the diaphragm
Pierces the diaphragm alone
A pregnant women suddenly develops bilateral leg swelling. Her mother and aunt were troubled by the same problem. What is the most likely underlying abnormality?
Anti endomysial antibodies
Anti nuclear antibodies
Anti cardiolipin antibodies
Anti thyroid antibodies
Anti mitochondrial antibodies
Antiphospholipid syndrome, is an autoimmune, hypercoagulable state caused by antiphospholipid antibodies. APS provokes blood clots (thrombosis) in both arteries and veins as well as pregnancy-related complications such as miscarriage, stillbirth, preterm delivery, or severe preeclampsia.
The diagnostic criteria requires one clinical event, i.e. thrombosis or pregnancy complication, and two positive blood tests spaced at least 3 months apart. These antibodies are: lupus anticoagulant, anti-cardiolipin and anti-β2-glycoprotein.
Antiphospholipid syndrome can be primary or secondary. Primary antiphospholipid syndrome occurs in the absence of any other related disease. Secondary antiphospholipid syndrome occurs with other autoimmune diseases, such as systemic lupus erythematosus (SLE). In rare cases, APS leads to rapid organ failure due to generalised thrombosis; this is termed catastrophic antiphospholipid syndrome (CAPS) and is associated with a high risk of death.
Antiphospholipid syndrome often requires treatment with anticoagulant medication such as heparin to reduce the risk of further episodes of thrombosis and improve the prognosis of pregnancy. Warfarin is not used during pregnancy because it can cross the placenta, unlike heparin, and is teratogenic.
AutoAbs in antiphospholipid syndrome
Lupus anticoagulant
Anti-cardiolipin
Anti-Beta 2 glycoprotein
Antithrombin inactivates thrombin and factor XII a, XIa, IXa and Xa
Rare defect, inherited in autosomal dominant fashion
10x increase in risk of thrombotic events
Heparin may be ineffective because it works via antithrombin
Antithrombin deficiency
These are natural anticoagulants (vitamin K dependent synthesis)
Protein C produced by liver
Protein S produced by liver, megakaryocytes, Leydig cells and endothelial cells
Protein C and S bind to form activated complex which binds to factor V
Deficiency accounts for up to 5% of thrombotic episodes
Protein C and S deficiency
Resistance to anticoagulant effect of activated protein C
May account for up to 20% or more of thrombotic episodes
Prevalence of 7% in Europe
Most common genetic defect accounting for DVT
FVL
What is the most common thrombophilia in Europeans?
FVL
Multi organ disease
Pregnancy involvement common
Arterial and venous thromboses
Either Lupus anticoagulant or Anti cardiolipin antibodies
APTT usually prolonged
Antibodies may be elevated following surgery, drugs or malignancy
Need anticoagulation with INR between 3 and 4
Antiphospholipid syndrome
A 32 year old man presents with an inguinal hernia and undergoes an open surgical repair. The surgeons decide to place a mesh on the posterior wall of the inguinal canal to complete the repair, which of the following structures will lie posterior to the mesh?
Transversalis fascia
External oblique
Rectus abdominis
Obturator nerve
None of the above
This is actually quite a straightforward question. It is simply asking for the structure that forms the posterior wall of the inguinal canal. This is composed of the transversalis fascia, the conjoint tendon and more laterally the deep inguinal ring.
A 22 year old man is involved in a fight and is stabbed in the posterior aspect of his right leg. The knife passes into the popliteal fossa. He sustains an injury to his tibial nerve. Which muscle is least likely to be compromised as a result?
Tibialis posterior
Flexor hallucis longus
Flexor digitorum brevis
Soleus
Peroneus tertius
Peroneus tertius is innervated by the deep peroneal nerve.
Muscles innervated by tibial nerve
Popliteus
Gastrocnemius
Soleus
Plantaris
Tibialis posterior
Flexor hallucis longus
Flexor digitorum brevis and longus
A 57 year old man is coming off the cardiac bypass circuit following a successful coronary artery bypass procedure. Which drug should be administered to normalise the patients clotting prior to decannulation and chest closure?
Intravenous vitamin K
Protamine sulphate
Aprotinin
Fresh frozen plasma
None of the above
Since cardiac bypass circuits are thrombogenic large doses of intravenous heparin are administered. This is reversed with protamine sulphate. FFP may be effective but would carry a significant risk of fluid overload.
A 63 year old Japanese man presents with epigastric discomfort and iron deficiency anaemia. He undergoes an upper GI endoscopy, where the following appearances are found:
Image sourced from Wikipedia
The most likely diagnosis is:
Squamous cell carcinoma
Linitis plastica
Leiomyosarcoma
Gastric varices
None of the above
Linitis plastica produces a diffuse infiltrating lesion, the stomach is fibrotic and rigid and will not typically distend. This may be described as a ‘leather bottle stomach’. Diagnosis is made with a combination of pathology examination with endoscopy, radiological or surgical assessment. Pathologically signet-ring cell proliferation occurs.
Theme: Genetics and cancer
A.Multiple endocrine neoplasia type I
B.Multiple endocrine neoplasia type II
C.Gardner’s syndrome
D.Lynch Syndrome
E.Kartagener’s syndrome
F.Neurofibromatosis Type I
G.Neurofibromatosis Type II
Please select the most likely condition for the disease process described. Each option may be used once, more than once or not at all.
19.A 40 year old male is found to have multiple colonic polyps during a colonoscopy. He mentions that he has extra teeth.
A 10 year old boy who has learning difficulties, reports a difference in size between his two legs.
A 22 year old is found to have bilateral acoustic neuromas.
Gardner’s syndrome
Gardner’s syndrome is an AD disorder, characterised by: Colonic polyps, supernumerary teeth, jaw osteomas, congenital hypertrophy of retinal pigment. osteomas of the skull, thyroid cancer, epidermoid cysts, fibromas and sebaceous cysts.
Neurofibromatosis Type I
Neurofibromatosis type I. A hallmark finding is a plexiform neurofibroma, which is a sheet of neurofibromatosis tissue which encases major nerves. In children this attracts extra blood circulation, which can accelerate growth of the affected limb.
Other features include:
Schwannoma, > 6
Cafe au lait spots, axillary freckling, Lisch nodules, Optic glioma. Meningiomas, Glioma, or Schwannoma.
Neurofibromatosis Type II
In NF2 bilateral acoustic neuromas are characteristic with a family history of Neurofibroma,
Which of the following overlies the outer muscular layer of the intrathoracic oesophagus?
Serosa
Meissners plexus
Auerbach’s plexus
Loose connective tissue
None of the above
The oesophagus has no serosal covering and hence holds sutures poorly. The Auerbach’s and Meissner’s nerve plexuses lie in between the longitudinal and circular muscle layers and submucosally. The sub mucosal location of the Meissner’s nerve plexus facilitates its sensory role.
Which nerve lies medially on the thyroid gland, in the groove between the oesophagus and trachea?
Vagus nerve
External laryngeal nerve
Recurrent laryngeal nerve
Ansa cervicalis
Phrenic nerve
The recurrent laryngeal nerve may be injured at this site during ligation of the inferior thyroid artery.
A 52 year old man develops septic shock following a Hartmans procedure for perforated diverticular disease. He is started on an adrenaline infusion. Which of the following is least likely to occur?
Peripheral vasoconstriction
Coronary artery vasospasm
Gluconeogenesis
Lipolysis
Tachycardia
It’s cardiac effects are mediated via β 1 receptors. The coronary arteries which have β 2 receptors are unaffected.
Effect of adrenaline on BP?
Causes narrow pulse pressure
Which of the following nerve roots contribute nerve fibres to the ansa cervicalis?
C1 only
C1, C2 and C3
C2, C3 and C6
C2, C4 and C5
C4, C5 and C6
The ansa cervicalis is composed of a superior and inferior root, derived from C1, C2 and C3. The superior root arises where the nerve crosses the internal carotid artery. It descends anterior to the carotid sheath in the anterior triangle. It is joined in the region of the mid neck by the inferior root. The inferior root may pass either superficially or deep to the internal jugular vein.
Muscles innervated by ansa cervicalis
GHost THought SOmeone Stupid Shot Irene
GenioHyoid
ThyroidHyoid
Superior Omohyoid
SternoThyroid
SternoHyoid
Inferior Omohyoid
What is the anatomical importance of the ansa cervicalis?
The ansa cervicalis lies anterior to the carotid sheath. The nerve supply to the inferior strap muscles enters at their inferior aspect. Therefore when dividing these muscles to expose a large goitre, the muscles should be divided in their upper half.
Muscles supplied by anterior interosseous nerve?
Supplies the deep muscles on the front of the forearm except medial portion of FDP
The anterior interosseous nerve classically innervates 2.5 muscles:
Flexor pollicis longus
Pronator quadratus
The radial half of flexor digitorum profundus (the lateral two out of the four tendons).
At which of the following anatomical locations does the common peroneal nerve bifurcate into the superficial and deep peroneal nerves?
Immediately anterior to the linea aspera
At the lateral aspect of the neck of the fibula
Within the substance of tibialis anterior muscle
At the inferomedial aspect of the popliteal fossa
Under the medial head of gastrocnemius
The common peroneal nerve bifurcates at the neck of the fibula (where it is most likely to be injured).
Nerve roots of the common peroneal
L4-S2
A 48 year old motor cyclist sustains a complex lower limb fracture in a motor accident. For a time the popliteal artery is occluded and eventually repaired. Subsequently he develops a compartment syndrome and the anterior and superficial posterior compartments of the lower leg are decompressed. Unfortunately, the operating surgeon neglects to decompress the deep posterior compartment. Which of the following muscles is least likely to be affected as a result?
Flexor digitorum longus
Plantaris
Tibialis posterior
Flexor hallucis longus
None of the above
The plantaris muscle lies within the superficial posterior compartment of the lower leg.
Muscles of the deep posterior compartment of the lower limb
Tibialis posterior
Flexor hallucis longus
Flexor digitorum longus
Popliteus
Theme: Management of inflammatory bowel disease
A.Ileo-anal pouch
B.Panproctocolectomy
C.Sub total colectomy
D.Hartmans procedure
E.Right hemicolectomy
F.Intravenous steroids
G.Infliximab
H.Proctectomy
Please select the most appropriate management option from the list. Each option may be used once, more than once or not at all.
32.A 20 year old man is admitted with bloody diarrhoea. He has been passing 10 stools per day, Hb-8.0, albumin-20. Stool culture negative. Evidence of colitis on endoscopy. He has been on intravenous steroids for 5 days and has now developed megacolon. His haemoglobin is falling and inflammatory markers are static.
A 19 year old lady has a long standing history of diarrhoea and weight loss. She is investigated with an upper gastro intestinal endoscopy which is normal. A small bowel contrast study shows a terminal ileal stricture. A colonoscopy was performed which was normal but the endoscopist was unable to intubate the terminal ileum. One week after the colonoscopy she is admitted with small bowel obstruction. Steroids are administered but despite this she fails to improve.
A 28 year old man is reviewed in the clinic. He has suffered from Crohns disease for many years, he has recently undergone a sub total colectomy. However, he has residual Crohns in his rectum and this is the cause of ongoing symptoms. Medical therapy is proving ineffective.
Sub total colectomy
This man requires a sub total colectomy. Conservative management has failed. Patients with ulcerative colitis should undergo colectomy if there is no significant improvement in 5-7 days after initiating medical therapy if they have a severe attack of the disease.
Right hemicolectomy
It is likely that this lady has terminal ileal disease. Although , first presentation of Crohns disease is usually managed with IV steroids, these have been trialled here and failed. A resection will remove the stricturing disease. If proximal small bowel disease has not been excluded pre-operatively then this must be evaluated “on table” during surgery to exclude other small bowel strictures.
Proctectomy
In Crohns patients who have rectal disease and a previous sub total colectomy, a proctectomy is the best option. An ileo-anal pouch is contra indicated in Crohns as they may fistulate and have major post operative complications.
Ileo-anal pouch in Crohn’s
Contraindicated as they may fistulate and have major post-operative complications
Histological features of UC?
Granulomas (non caseating epithelioid cell aggregates with Langerhans’ giant cells)
Histological appearance of UC?
Crypt abscesses, Inflammatory cells in the lamina propria
Theme: Tissue sampling
A.Fine needle aspiration cytology
B.Surgical excision biopsy
C.Smear cytology
D.Core cut biopsy
E.Conventional surgical excision
F.Tru cut biopsy
G.Punch biopsy
Please select the most appropriate sampling method for the situation given. Each option may be used once, more than once or not at all.
36.A 45 year old patient undergoes a CT scan of the abdomen and is noted to have a 6cm mass in the right adrenal gland. Urinary catecholamines and other endocrine investigations are negative. CT of the chest and remainder of the abdomen is otherwise normal.
A 67 year old lady is suspected of having Pagets disease of the nipple.
A 23 year old lady presents with a nodule in the right lobe of the thyroid. Examination of the neck is otherwise unremarkable and clinically she is euthyroid. Imaging shows a solid nodule at the site.
Conventional surgical excision
Most surgeons would excise a mass of this size rather than attempt biopsy. Further information relating to adrenal masses is covered under this topic.
Punch biopsy
This is a relatively clear indication for a punch biopsy. If cellular atypia is present on punch biopsy then any in situ malignancy should be considered. FNAC would be unsuitable.
Fine needle aspiration cytology
FNAC is the first line investigation in this setting.Where as FNAC has declined in popularity recently, it remain a very popular option in the investigation of thyroid masses. It cannot reliably diagnose a follicular tumour.
A 23 year old lady is undergoing a trendelenberg procedure for varicose veins. During the dissection of the saphenofemoral junction, which of the structures listed below is most liable to injury?
Superficial circumflex iliac artery
Superficial circumflex iliac vein
Femoral artery
Femoral nerve
Deep external pudendal artery
The deep external pudendal artery runs under the long saphenous vein close to its origin and may be injured. It is at greatest risk of injury during the flush ligation of the saphenofemoral junction. Provided an injury is identified and vessel ligated, injury is seldom associated with any serious adverse sequelae.
Considering the pituitary gland, which of the following is false?
The anterior pituitary secretes thyroid stimulating hormone
The anterior pituitary develops from Rathkes pouch
Patients with craniopharyngioma may develop bi temporal hemianopia
The pituitary is in direct contact with the optic chiasm
The posterior pituitary secretes oxytocin via a positive feedback loop
Although the optic chiasm is closely related to the pituitary, and craniopharyngiomas may compress this structure leading to bitemporal hemianopia, it is separated from the chiasm itself by a dural fold.
A 24 year old man is involved in a fight and his face is cut with a knife. The wound lies immediately anterior to the tragus of the ear and extends anteriorly. The wound is surgically explored and the laceration is found to be mainly superficial. It extends slightly more deeply immediately inferior to the main trunk of the facial nerve. Bleeding is observed, from which of the following is it most likely to originate?
External carotid artery
Retromandibular vein
Occipital artery
Maxillary artery
Ascending pharyngeal artery
Retromandibular vein
The retromandibular vein lies slightly more deeply than the facial nerve in the parotid gland. It is formed from the maxillary and superficial temporal vein.
Formed by a union of the maxillary vein and superficial temporal vein
It descends through the parotid gland and bifurcates within it
The anterior division passes forwards to join the facial vein, the posterior division is one of the tributaries of the external jugular vein
Retromandibular vein
Theme: Shoulder pain
A.Impingement syndrome
B.Rotator cuff tear
C.Adhesive capsulitis
D.Calcific tendonitis
E.Biceps tendon rupture
F.Parsonage - Turner syndrome
G.Labral tear
Please select the most likely cause for shoulder pain from the list. Each option may be used once, more than once or not at all.
42.A 63 year old lady undergoes an axillary clearance for breast cancer. She makes steady progress. However, 8 weeks post operatively she still suffers from severe shoulder pain. On examination she has reduced active movements in all planes and loss of passive external rotation.
A 78 year old man complains of a long history of shoulder pain and more recently weakness. On examination active attempts at abduction are impaired. Passive movements are normal.
A 28 year old man complains of pain and weakness in the shoulder. He has recently been unwell with glandular fever from which he is fully recovered. On examination there is some evidence of muscle wasting and a degree of winging of the scapula. Power during active movements is impaired.
Adhesive capsulitis
Frozen shoulder passes through an initial painful stage followed by a period of joint stiffness. With physiotherapy the problem will usually resolve although it may take up to 2 years to do so.
Rotator cuff tear
Rotator cuff tears are common in elderly people and may occur following minor trauma or as a result of long standing impingement. Tears greater than 2cm should generally be repaired surgically. The length of the history in this scenario is suggestive of a tear complicating impingement.
Parsonage - Turner syndrome
This is a peripheral neuropathy that may complicate viral illnesses and usually resolves spontaneously.
Deep seated pain in the proximal forearm especially during the night and at rest may be due to
tumour, especially metastatic lesions.
Theme: Management of wounds
A.Split thickness skin graft
B.Full thickness skin graft
C.Insertion of tissue expander at donor site and delayed split thickness skin graft
D.Myocutaneous flap reconstruction (pedicled)
E.Direct primary closure
F.Delayed primary closure
Please select the most appropriate management for the wound described. Each option may be used once, more than once or not at all.
45.A 34 year old man has a tissue defect measuring 3 cm by 1 cm following an excision of a lipoma from the scapula.
A 72 year old lady has a 4cm basal cell carcinoma excised from her right cheek. There is a rhomboid defect measuring 4cm by 4cm.
A 5 year old suffers 20% burns to the torso. On examination there is fixed pigmentation and the affected area has a white and dry appearance.
Direct primary closure
This wound should be amenable to primary closure. There is minimal associated tissue loss and the surgery is minor and uncontaminated.
Full thickness skin graft
Facial wounds that are large and irregularly shaped are best managed with full thickness skin grafts.
Split thickness skin graft
This is a full thickness burn and will require split thickness skin grafting. Meshing the graft may increase the donor site yield. However, this is at the expense of cosmesis.The burn itself must be debrided first to ensure an adequate wound bed.
Outline the reconstructive ladder
Direct closure
Grafting techniques
Flap technique
Prelamination techniques
Tissue expansion
What are the different grafting techniques?
Split thickness
Full thickness
Skin Substitute
Composite
What are the different flap techniques
Local:
Transposition
Pivot
Alphabetplasty (e.g. Z-Y)
Regional:
Myocutaneous
Fasciocutaneous
Neurocutaneous
Distant:
Free tissue transfer
What are prelamination techniques?
Allows creation of specialised flaps e.g. buccal mucosa
Tissue expansion
Involves placement of tissue expanders to increase amount of tissue at donor sites
Features of skin grafts
No size limit (split)/ relative size limit (full thickness)
Rely on wound bed for blood supply
Take better on clean, well vascularised wound beds
Split skin graft donor site typically heals in 12/7
Donor site may be reused
Features of flaps
Size limited by territory of blood supply
Tissue has its own blood supply
Will survive independent of the wound bed
Direct closure of donor site or secondary skin graft
Donor site cannot be reused
Available in range of thicknesses.
Thigh is the commonest donor site
Size may be increased by meshing the graft. However this comes with compromise on cosmesis.
Donor sites, especially if thin grafts are taken can be reused following re-epithelialisation
Split thickness skin grafts
Grafts
Most commonly used for facial reconstruction
Include dermal appendages
Provide superior cosmetic result
Full thickness grafts
These are grafts containing more than one tissue type, such as skin and fat. They are usually used to cover small defects in cosmetically important areas.
Composite grafts
Features of flaps
Flaps have their own blood supply and may be pedicled or free.
May have multiple components e.g. skin, skin + fat, skin + fat + muscle.
They will have the ability to take regardless of the underlying tissue bed.
The type of intrinsic blood supply is important. For example in breast surgery pedicled latissimus dorsi flaps will be less prone to failure than microsvascular anastomosed free Diep flaps.
An ENT surgeon is performing a radical neck dissection. She wishes to fully expose the external carotid artery. To do so she inserts a self retaining retractor close to its origin. Which of the following structures lies posterolaterally to the external carotid at this point?
Superior thyroid artery
Internal carotid artery
Lingual artery
Facial artery
None of the above
The internal carotid artery lies posterolaterally to the external carotid artery at it’s origin from the common carotid. The superior thyroid, lingual and facial arteries all arise from its anterior surface.
Assess for ulnar nerve palsy
Adductor pollicis muscle function tested
Hold a piece of paper between their thumb and index finger. The object is then pulled away. If ulnar nerve palsy, unable to hold the paper and will flex the flexor pollicis longus to compensate (flexion of thumb at interphalangeal joint).
Froment’s sign
Assess carpal tunnel syndrome
More sensitive than Tinel’s sign
Hold wrist in maximum flexion and the test is positive if there is numbness in the median nerve distribution.
Phalen’s test
Assess for carpal tunnel syndrome
Tap the median nerve at the wrist and the test is positive if there is tingling/electric-like sensations over the distribution of the median nerve.
Tinel’s sign
A 22 year old man is involved in a fight outside a nightclub. He is stabbed in the back, on the left side, approximately 3cm below the 12th rib in the mid scapular line. The structure most likely to be injured first as a result is the:
Spleen
Left kidney
Left adrenal gland
Left ureter
None of the above
The left kidney lies in this location and is the most likely structure to be injured. The Spleen lies more superiorly, and the left adrenal and ureter are unlikely to be injured in isolation.
Considering cluster randomised trials, which of the following statements is false?
They consider interventions targeted at groups
They require increased recruitment to achieve the same level of statistical power as individual trials
If results are analysed on an individual basis a lower P value may be obtained
They are less prone to unit of analyses errors than trials involving individual observations
The statistical analyses for these trials is more complex than that required for trials based on individuals
Cluster randomised trials are more prone to unit of analyses errors than individual based trials. Clustering needs to be considered in trial design and data analysis. One of the commonest errors is where a study is a cluster study but researchers have failed to recognise this fact. This will then result in the incorrect analysis being pursued. A lower P value will then result and a false positive error will occur.
Features of cluster RCTs
Groups are randomised rather than individuals
Avoids cross contamination amongst participants
Participants in any one cluster are more likely to respond in a similar fashion
Higher risk of unit of analysis error as these studies should be analysed as clusters rather than on an individual basis. This leads to a higher false positive rate.
It is possible to adjust for clustering in statistical analyses
Theme: Cutaneous innervation
A.Ulnar nerve
B.Fifth cervical spinal segment
C.Radial nerve
D.Musculocutaneous nerve
E.Median nerve
F.None of these
Please select the source of innervation for the region described. Each option may be used once, more than once or not at all.
54.The skin on the palmar aspect of the thumb
The nail bed of the index finger
The skin overlying the medial aspect of the palm
Median nerve
The median nerve supplies cutaneous sensation to this region.
Median nerve
Ulnar nerve
This area is innervated by the ulnar nerve.
Overview of necrotising fasciitis
Advancing soft tissue infection associated with fascial necrosis
Uncommon, but can be fatal
In many cases there is underlying background immunosuppression e.g. Diabetes
Caused by polymicrobial flora (aerobic and anaerobic) and MRSA is seen increasingly in cases of necrotising fasciitis
Streptococcus is the commonest organism in isolated pathogen infection (15%)
What is the most common organism in isolated pathogen infection causing gas gangrene?
Streptococcus
Melaeney’s gangrene
Syngeristic superficial bacterial infection on the trunk
Fournier gangrene
Necrotising fasciitis affecting the perineum
Polymicrobial with E-coli and Bacteroides acting in synergy
Occur in 25% cases of pancreatitis
Located in or near the pancreas and lack a wall of granulation or fibrous tissue
May resolve or develop into pseudocysts or abscesses
Since most resolve aspiration and drainage is best avoided as it may precipitate infection
Pancreatic pseudocyst
In acute pancreatitis result from organisation of peripancreatic fluid collection. They may or may not communicate with the ductal system.
The collection is walled by fibrous or granulation tissue and typically occurs 4 weeks or more after an attack of acute pancreatitis
Most are retrogastric
75% are associated with persistent mild elevation of amylase
Investigation is with CT, ERCP and MRI or Endoscopic USS
Symptomatic cases may be observed for 12 weeks as up to 50% resolve
Treatment is either with endoscopic or surgical cystogastrostomy or aspiration
Pancreatic psuedocysts
Pancreatic necrosis may involve both the pancreatic parenchyma and surrounding fat
Complications are directly linked to extent of parenchymal necrosis and extent of necrosis overall
Early necrosectomy is associated with a high mortality rate (and should be avoided unless compelling indications for surgery exist)
Sterile necrosis should be managed conservatively (at least initially)
Some centres will perform fine needle aspiration sampling of necrotic tissue if infection is suspected. False negatives may occur. The extent of sepsis and organ dysfunction may be a better guide to surgery
Pancreatic necrosis
Intra abdominal collection of pus associated with pancreas but in the absence of necrosis
Typically occur as a result of infected pseudocyst
They are usually managed by placement of percutaneous drains
Pancreatic abscess
Infected necrosis may involve vascular structures with resultant haemorrhage that may occur de novo or as a result of surgical necrosectomy.
When retroperitoneal haemorrhage occurs Grey Turners sign may be identified
Pancreatic haemorrhage
