Block 7 Flashcards

Question

Overview of axillary vein thrombosis

Answer 1

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

Answer 2

Pain and swelling (non pitting) Numbness Discolouration: mottling, dusky Pulses present Congested veins

Answer 3

FBC: viscosity, platelet function Clotting Liver function tests D-dimer Duplex scan: investigation of choice CT scan: thoracic outlet obstruction

Answer 4

Local catheter directed TPA Heparin Warfarin

Answer 5

No response to sound

Answer 6

Deep coma of known aetiology. Reversible causes excluded No sedation Normal electrolytes

Answer 7

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).

Answer 8

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.

Answer 9

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

Answer 10

Bone pain Pleuritic chest pain: acute sickle chest syndrome commonest cause of death CVA, seizures Papillary necrosis Splenic infarcts Priapism Hepatic pain

Answer 11

Hb does not fall during a crisis, unless there is Aplasia: parvovirus Acute sequestration Haemolysis

Answer 12

Bowel ischaemia Cholecystitis Avascular necrosis

Answer 13

Infections: Streptococcus pneumoniae Chronic leg ulcers Gallstones: haemolysis Aseptic necrosis of bone Chronic renal disease Retinal detachment, proliferative retinopathy

Answer 14

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.

Answer 15

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.

Answer 16

25cm C6-\> T11 Pierces diaphragm at T10 Squamous epithelium

Answer 17

Trachea to T4 Recurrent laryngeal nerve Left bronchus, Left atrium Diaphragm

Answer 18

Thoracic duct to left at T5 Hemiazygos to the left T8 Descending aorta First 2 intercostal branches of aorta

Answer 19

Thoracic duct Left subclavian artery

Answer 20

Azygos vein

Answer 21

Inferior thyroid

Answer 22

Aortic branches

Answer 23

Left gastric

Answer 24

Inferior thyroid

Answer 25

Azygos branches

Answer 26

Left gastric

Answer 27

Deep cervical

Answer 28

Mediastinal

Answer 29

Striated muscle

Answer 30

Smooth & striated muscle

Answer 31

Smooth muscle

Answer 32

Oesophageal plexus

Answer 33

Mucosa :Non-keratinized stratified squamous epithelium Submucosa: glandular tissue Muscularis externa (muscularis): composition varies. See table Adventitia

Answer 34

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.

Answer 35

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.

Answer 36

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].

Answer 37

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.

Answer 38

Barcelona liver classification

Answer 39

Child-Pugh A Single lesion (less than 2cm) Normal portal pressures

Answer 40

Single nodule greater than 3cm or multiple nodules no more than 3 Child Pugh A/B

Answer 41

If associated disease then radiofrequency ablation If no associated disease then transplantation

Answer 42

May be up to 70^

Answer 43

Multiple nodules Child Pugh A/B

Answer 44

Trans arterial chemo-embolisation (usually with doxorubicin)

Answer 45

26% at 3 years

Answer 46

Advanced tumours Invasion of portal vein Child Pugh A/B

Answer 47

10.7 month survival

Answer 48

Child pugh C Advanced tumours

Answer 49

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.

Answer 50

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].

Answer 51

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

Answer 52

Both sides of cortex are breached

Answer 53

Oblique tibial fracture in infants

Answer 54

Stress on bone resulting in deformity without cortical disruption

Answer 55

Unilateral cortical breach only

Answer 56

Incomplete cortical disruption resulting in periosteal haematoma only

Answer 57

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

Answer 58

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.

Answer 59

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.

Answer 60

Bronchogenic cysts

Answer 61

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.

Answer 62

Thorascopic resection is the ideal treatment. Very young babies can be operated on once they reach six weeks of age.

Answer 63

They usually arise from C7.

Answer 64

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.

Answer 65

As sudden infant death syndrome is relatively rare a case-control design is more appropriate than a cohort study.

Answer 66

Randomised controlled trial

Answer 67

Cohort study

Answer 68

Case-control study

Answer 69

Cross-sectional survey

Answer 70

Cervical lymphadenopathy Otalgia Unilateral serous otitis media Nasal obstruction, discharge and/or epistaxis Cranial nerve palsies

Answer 71

Combined CT and MRI

Answer 72

RTx is first line

Answer 73

Parietal cells are responsible for the release of gastric acid. Brunners glands are found in the duodenum.

Answer 74

The use of esmarch bandage tourniquet increases the risk of nerve injury as it increases pressure in the limb. Limb elevation is safer.

Answer 75

Increased systemic vascular resistance, increased CVP and increased BP Slower gradual increase in BP over time Induced hypercoagulable state Slow increase in core temperature

Answer 76

Fall in CVP, BP and SVR Increased end tidal carbon dioxide Enhanced fibrinolysis Fall in core temperature Raised serum potassium and lactate levels

Answer 77

AV fistula Severe PVD Previous vascular sx Bone fracture or thrombosis at site of tourniquet application

Answer 78

SCD History of VTE Skin grafts Localised inefction Lymphoedema

Answer 79

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.

Answer 80

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:

Answer 81

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.

Answer 82

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.

Answer 83

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.

Answer 84

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.

Answer 85

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.

Answer 86

Inferior phrenic Coeliac SMA Middle suprarenal Renal Gonadal Lumbar IMA Median sacral Common iliac

Answer 87

Upper border of T12

Answer 88

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

Answer 89

Charcot's triad (Fever, RUQ pain, Jaundice) Plus confusion and hypotension

Answer 90

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.

Answer 91

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

Answer 92

Segmental contractions Antiperistaltic contractions towards ileum Mass movements

Answer 93

Localised contractions in which the bolus is subjected to local forces to maximise mucosal absorption

Answer 94

Localised reverse peristaltic waves to slow entry into colon and maximise absorption

Answer 95

Waves migratory peristaltic waves along the entire colon to empty the organ prior to the next ingestion of food bolus

Answer 96

The annular ligament connects the radial head to the radial notch of the ulna. This is illustrated below:

Answer 97

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.

Answer 98

Ciclosporin

Answer 99

Azathioprine

Answer 100

Tacrolimus

Answer 101

Mycophenolate mofetil (MMF)

Answer 102

Sirolimus (rapamycin)

Answer 103

Daclizumab Basilximab

Answer 104

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.

Answer 105

BMI 35 kg/m2 and type 2 diabetes

Answer 106

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.

Answer 107

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.

Answer 108

Adjustable gastric band Gastric bypass Sleeve gastrectomy

Answer 109

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

Answer 110

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

Answer 111

Resection of stomach using stapling devices Less popular now as initial promising results not sustained

Answer 112

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.

Answer 113

Terminal branch of the external carotid

Answer 114

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

Answer 115

Temporal arteritis

Answer 116

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

Answer 117

GC for \>30 days

Answer 118

Facial or auriculotemporal nerve

Answer 119

Suprascapular nerve

Answer 120

Supraspinatus and infraspinatus Initiates abduction of the shoulder

Answer 121

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.

Answer 122

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

Answer 123

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

Answer 124

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

Answer 125

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.

Answer 126

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.

Answer 127

Superior thyroid artery is a branch of the external carotid artery.

Answer 128

V ertebral artery I nternal thoracic T hyrocervical trunk C ostalcervical trunk D orsal scapular

Answer 129

Secretin is released from mucosal cells in the duodenum and jejunum

Answer 130

Beta cells- insulin Alpha cells- glucagon Delta cells- somatostatin F cells- pancreatic polypeptide

Answer 131

Anticoagulation will worsen compartment syndrome.

Answer 132

Supracondylar fractures Tibial shaft injuries

Answer 133

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

Answer 134

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.

Answer 135

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.

Answer 136

Majority will close spontaneously within 12m-3y

Answer 137

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.

Answer 138

Omphalitis

Answer 139

Umbilical granuloma

Answer 140

Persistent vitello-intestinal duct

Answer 141

Persistent urachus

Answer 142

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.

Answer 143

Classical, chondroid and de-differnetiated

Answer 144

The histological appearance of classical chordoma

Answer 145

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.

Answer 146

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.

Answer 147

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.

Answer 148

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.

Answer 149

VSD RVH RV outflow obstruction Overriding aorta

Answer 150

At birth transposition of the great arteries is the more common lesion as patients with TOF generally present at around 1-2 months

Answer 151

Interferon-alpha and ribavirin are the treatments of choice

Answer 152

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%

Answer 153

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

Answer 154

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

Answer 155

side-effects: haemolytic anaemia, cough. Women should not become pregnant within 6 months of stopping ribavirin as it is teratogenic

Answer 156

flu-like symptoms, depression, fatigue, leukopenia, thrombocytopenia

Answer 157

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.

Answer 158

Restoration of luminal continuity

Answer 159

Adequate blood supply Mucosal apposition Minimal tension

Answer 160

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.

Answer 161

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.

Answer 162

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.

Answer 163

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.

Answer 164

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.

Answer 165

A layer of pectoral fascia and Pec major Serratus anterior External oblique

Answer 166

Branches of intercostal nerves (T4-6)

Answer 167

Internal mammary (thoracic) artery External mammary artery (laterally) Anterior intercostal arteries Thoraco-acromial artery

Answer 168

Superficial venous plexus to subclavian, axillary and intercostal veins.

Answer 169

70% Axillary nodes Internal mammary chain Other lymphatic sites such as deep cervical and supraclavicular fossa (later in disease)

Answer 170

Cricothyroid The others are supplied by the RLN

Answer 171

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

Answer 172

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.

Answer 173

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.

Answer 174

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.

Answer 175

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.

Answer 176

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.

Answer 177

Congenital: sporadic, Milroy's disease

Answer 178

Sporadic Meige's disease

Answer 179

Bacterial/fungal/parasitic infection (filariasis) Lymphatic malignancy Radiotherapy to lymph nodes Surgical resection of lymph nodes DVT Thrombophlebitis

Answer 180

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

Answer 181

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.

Answer 182

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.

Answer 183

Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.

Answer 184

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.

Answer 185

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.

Answer 186

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.

Answer 187

proportion of true positives identified by a test

Answer 188

proportion of true negatives correctly identified by a test

Answer 189

proportion of those who have a positive test who actually have the disease

Answer 190

: proportion of those who test negative who do not have the disease

Answer 191

the prevalence

Answer 192

sensitivity/(1-specificity)

Answer 193

(1-sensitivity)/specificity

Answer 194

prevalence dependent

Answer 195

Internal spermatic fascia (transvesalis fascia) Cremasteric fascia (internal oblique) External spermatic fascia (external oblique)

Answer 196

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

Answer 197

Vas deferens

Answer 198

Testicular artery

Answer 199

Artery of vas deferens

Answer 200

Cremasteric artery

Answer 201

Pampiniform plexus

Answer 202

Genital branch of genitofemoral nerve

Answer 203

Inguinal lymph nodes

Answer 204

S: skin. D: dartos fascia and muscle. E: external spermatic fascia. C: cremasteric fascia. I: internal spermatic fascia. T: tunica vaginalis. T: tunica albuginea.

Answer 205

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.

Answer 206

The maxillary artery is a branch of the external carotid artery.

Answer 207

``` Only = Opthalmic Press = Posterior communicating Carotid = Choroidal Arteries = Anterior cerebral Momentarily = Middle cerebral ```

Answer 208

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.

Answer 209

Ann Arbor staging system

Answer 210

Single LN region

Answer 211

Two or more LN regions on same side of diaphragm

Answer 212

Involvement of LN regions on both sides of the diaphragm

Answer 213

Involvement of extra nodal sites

Answer 214

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.

Answer 215

The renal vein lies most anteriorly, then renal artery (it is an end artery) and the ureter lies most posterior.

Answer 216

1. Branches of the renal artery 2. Tributaries of the renal vein 3. Major and minor calyces's 4. Fat

Answer 217

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.

Answer 218

Central chemoreceptors: Respond to increased H+ in BRAIN INTERSTITIAL FLUID to increase ventilation.

Answer 219

Medullary respiratory centre Apneustic centre Pneumotaxic centre

Answer 220

Inspiratory and expiratory neurones. Has ventral group which controls forced voluntary expiration and the dorsal group controls inspiration. Depressed by opiates.

Answer 221

Lower pons Stimulates inspiration - activates and prolongs inhalation Overridden by pneumotaxic control to end inspiration

Answer 222

Upper pons, inhibits inspiration at a certain point. Fine tunes the respiratory rate.

Answer 223

Levels of pCO2

Answer 224

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.

Answer 225

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.

Answer 226

Stretch receptors: respond to lung stretching causing a reduced respiratory rate Irritant receptors: respond to smoke etc causing bronchospasm J (juxtacapillary) receptors

Answer 227

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.

Answer 228

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.

Answer 229

Schistosoma mansoni and Schistosoma intercalatum: intestinal schistosomiasis Schistosoma haematobium: urinary schistosomiasis

Answer 230

Single dose of oral praziquantel

Answer 231

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.

Answer 232

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

Answer 233

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

Answer 234

Normotension is seen in around 10% cases. The remainder show a degree of hypertension.

Answer 235

Zygomaticus minor Risorius Buccinator Levator anguli oris Orbicularis Nasalis

Answer 236

Elevates upper lip

Answer 237

Aids smile

Answer 238

Pulls corner of mouth backward and compresses cheek

Answer 239

Pulls angles of mouth upward and towards midline

Answer 240

Closes and tightens lips together

Answer 241

Flares and compresses nostrils

Answer 242

It terminates at the upper border of the thyroid cartilage, Which is usually located at C4.

Answer 243

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.

Answer 244

Merkel cell tumour of the skin

Answer 245

Merkel Cell Polyomavirus seen in 80%

Answer 246

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.

Answer 247

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%.

Answer 248

Invasion of surrounding structures

Answer 249

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.

Answer 250

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.

Answer 251

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

Answer 252

FEV1 significantly reduced FVC reduced or normal FEV1/FVC \<70

Answer 253

FEV1 reduced FVC significantly reduced FEV1/FVC \>70%

Answer 254

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.

Answer 255

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

Answer 256

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

Answer 257

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.

Answer 258

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.

Answer 259

Absolute polycythaemia Haemolysis is the main pathological response.

Answer 260

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

Answer 261

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.

Answer 262

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

Answer 263

Aortic repair with fetus kept in utero

Answer 264

Dependent on fetal condition

Answer 265

C-section followed by aortic repair at same time

Answer 266

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.

Answer 267

The oesphagus is lined by non keratinised stratified squamous epithelium. Changes to glandular type epithelium occur as part of metaplastic processes in reflux.

Answer 268

Most filtered calcium is reabsorbed (95%) a rare disorder of familial hypocalcemic calciurea may affect this proportion.

Answer 269

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.

Answer 270

Posterior urethral valves

Answer 271

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.

Answer 272

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

Answer 273

The right renal vein is very short and lies more inferiorly.

Answer 274

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.

Answer 275

Proximal humerus #

Answer 276

Anterior and posterior humeral circumflex arteries

Answer 277

Neer classification

Answer 278

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.

Answer 279

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.

Answer 280

ORIF IM nail Hemiarthroplasty Total shoulder arthroplasty Reverse shoulder arthroplasty

Answer 281

Most commonly used. Plate and screw fixation. Can reconstruct complex fractures.

Answer 282

Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures.

Answer 283

Used for un-reconstructable fractures in the older patient who has good glenoid quality.

Answer 284

Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion)

Answer 285

Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement.

Answer 286

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.

Answer 287

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.

Answer 288

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.

Answer 289

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.

Answer 290

Anterior Posterior Inferior Superior

Answer 291

Anterior shoulder dislocation

Answer 292

Posterior shoulder dislocation

Answer 293

Inferior shoulder dislocation

Answer 294

Bankart lesion

Answer 295

Hill Sachs defect

Answer 296

Suprascapular nerve

Answer 297

Suprascapular nerve

Answer 298

Axillary nerve

Answer 299

Upper and lower subscapular nerve

Answer 300

Superior facet of greater tubersoity Supraspinatus fossa

Answer 301

Infraspinatus fossa Posterior facet of greater tuberosity

Answer 302

Lateral border of scapula Inferior facet of greater tuberosity

Answer 303

Subscapular fossa Lesser tuberoisty

Answer 304

Initiation of abduction

Answer 305

External rotation of humerus

Answer 306

External rotation of humerus

Answer 307

Internal rotation of huemrus

Answer 308

Subacromial Impingement

Answer 309

Rotator Cuff Tear

Answer 310

Rotator Cuff Arthropathy

Answer 311

Plain radiographs: AP of shoulder. Outlet view. USS: allows dynamic imaging of the cuff MRI: best modality for cuff pathology

Answer 312

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.

Answer 313

They are true aneurysms and have all 3 layers of arterial wall.

Answer 314

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

Answer 315

?through inhibition of aldosterone secretion

Answer 316

It is used in arteriovenous fistula surgery during a procedure known as a basilic vein transposition.

Answer 317

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.

Answer 318

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.

Answer 319

Most often used for percutaneous sampling of deep seated lesions or used intra operatively for visceral lesions

Answer 320

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.

Answer 321

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

Answer 322

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.

Answer 323

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.

Answer 324

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.

Answer 325

Streptococcus pyogenes Quinsy usually occurs as a result of bacterial tonsillitis and the most common cause of bacterial tonsillitis is streptococcal organisms.

Answer 326

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)

Answer 327

Abnormal connection between two epitheial surfaces

Answer 328

Fistulae will resolve spontaneously as long as there is no distal obstruction, this is particularly true of intestinal fistulae

Answer 329

Enterocutaneous

Answer 330

Enteroenteric or Enterocolic

Answer 331

Enterovesicular fistula

Answer 332

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.

Answer 333

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.

Answer 334

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.

Answer 335

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.

Answer 336

Deltoid ligament (medially) LCL Talofibular ligaments (both anteriorly and posteriorly) The calcaenofibular ligament is separate from the fibrous capsule of the joint

Answer 337

Antero-inferior tibiofibular ligament Postero-inferior tibiofibular ligament Inferior transverse tibiofibular ligament Interosseous ligament

Answer 338

Plantar flexion (55 degrees) Dorsiflexion (35 degrees) Inversion and eversion movements occur at the level of the sub talar joint

Answer 339

The oesophagus is not constricted at the level of the lower oesophageal sphincter.

Answer 340

When DNA cannot be repaired it will induce cellular apoptosis (not necrosis)

Answer 341

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.

Answer 342

Decreased plasma glucose Increased catecholamines Increased plasma aas SNS ACh CCK

Answer 343

Somatostatin Insulin Increased FFAs and keto acids Increased urea

Answer 344

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.

Answer 345

Klippel Trenaunay syndrome ## Footnote 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.

Answer 346

Klippel Trenaunay syndrome Absence of port wine stain= atypical Klippel Trenaunay syndrome

Answer 347

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.

Answer 348

Posterior circumflex humeral The other branches include: Subscapular Anterior circumflex humeral

Answer 349

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.

Answer 350

The posterior longitudinal ligament overlies the posterior aspect of the vertebral bodies. It also overlies the posterior aspect of the intervertebral disks.

Answer 351

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

Answer 352

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.

Answer 353

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

Answer 354

Third nerve palsy

Answer 355

Pupil dilated

Answer 356

Pupil sparing

Answer 357

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.

Answer 358

Size \>20mm (local recurrence rate of up to 15%) Depth greater than 4mm (risk of metastasis up to 30%)

Answer 359

Renal transplant and on immunosuppression Individuals with HIV Those who have received psoralen UVA therapy Chronic wounds (Marjolins ulcer) Xeroderma pigmentosum Oculocutaneous albinism

Answer 360

Surgical excision with 4mm margins if lesion \<20mm in diameter. If tumour \>20mm then margins should be 6mm.

Answer 361

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.

Answer 362

The lingual nerve wraps around Whartons duct. The lingual nerve provides sensory supply to the anterior 2/3 of the tongue.

Answer 363

DIC Will tend to consume factors five and eight intially (and platelets).

Answer 364

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)

Answer 365

Visceral cavity re-warming be it lung or abdomen (or both) provides rapid rewarming. Only extracorporeal circulatory devices provide faster rates of re-warming.

Answer 366

Core body temperature \<35 Severe when \<30

Answer 367

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.

Answer 368

Ankylosing spondylitis

Answer 369

Scheuermann's disease

Answer 370

Spina bifida

Answer 371

Spondylolysis

Answer 372

Spondylolisthesis

Answer 373

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.

Answer 374

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.

Answer 375

Crosses anterior to the 1st part of the subclavian artery

Answer 376

Passes anterior to scalenus anterior and crosses anterior to the 2nd part of the subclavian artery

Answer 377

Run posterior to both

Answer 378

Superior: anterior to right vagus and laterally to SVC Middle: right of pericardium Passes over the right atrium to exit diaphragm at T8

Answer 379

Exits the diaphragm at T8

Answer 380

Lateral to the left subclavian artery, aortic arch and left venricle, anterior to the root of the lung

Answer 381

Pierces the diaphragm alone

Answer 382

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.

Answer 383

Lupus anticoagulant Anti-cardiolipin Anti-Beta 2 glycoprotein

Answer 384

Antithrombin deficiency

Answer 385

Protein C and S deficiency

Answer 386

Antiphospholipid syndrome

Answer 387

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.

Answer 388

Peroneus tertius is innervated by the deep peroneal nerve.

Answer 389

Popliteus Gastrocnemius Soleus Plantaris Tibialis posterior Flexor hallucis longus Flexor digitorum brevis and longus

Answer 390

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.

Answer 391

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.

Answer 392

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,

Answer 393

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.

Answer 394

The recurrent laryngeal nerve may be injured at this site during ligation of the inferior thyroid artery.

Answer 395

It's cardiac effects are mediated via β 1 receptors. The coronary arteries which have β 2 receptors are unaffected.

Answer 396

Causes narrow pulse pressure

Answer 397

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.

Answer 398

GenioHyoid ThyroidHyoid Superior Omohyoid SternoThyroid SternoHyoid Inferior Omohyoid

Answer 399

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.

Answer 400

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).

Answer 401

The common peroneal nerve bifurcates at the neck of the fibula (where it is most likely to be injured).

Answer 402

The plantaris muscle lies within the superficial posterior compartment of the lower leg.

Answer 403

Tibialis posterior Flexor hallucis longus Flexor digitorum longus Popliteus

Answer 404

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.

Answer 405

Contraindicated as they may fistulate and have major post-operative complications

Answer 406

Granulomas (non caseating epithelioid cell aggregates with Langerhans' giant cells)

Answer 407

Crypt abscesses, Inflammatory cells in the lamina propria

Answer 408

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.

Answer 409

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.

Answer 410

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.

Answer 411

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.

Answer 412

Retromandibular vein

Answer 413

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.

Answer 414

tumour, especially metastatic lesions.

Answer 415

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.

Answer 416

Direct closure Grafting techniques Flap technique Prelamination techniques Tissue expansion

Answer 417

Split thickness Full thickness Skin Substitute Composite

Answer 418

Local: Transposition Pivot Alphabetplasty (e.g. Z-Y) Regional: Myocutaneous Fasciocutaneous Neurocutaneous Distant: Free tissue transfer

Answer 419

Allows creation of specialised flaps e.g. buccal mucosa

Answer 420

Involves placement of tissue expanders to increase amount of tissue at donor sites

Answer 421

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

Answer 422

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

Answer 423

Split thickness skin grafts

Answer 424

Full thickness grafts

Answer 425

Composite grafts

Answer 426

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.

Answer 427

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.

Answer 428

Froment's sign

Answer 429

Phalen's test

Answer 430

Tinel's sign

Answer 431

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.

Answer 432

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.

Answer 433

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

Answer 434

Median nerve The median nerve supplies cutaneous sensation to this region. Median nerve Ulnar nerve This area is innervated by the ulnar nerve.

Answer 435

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%)

Answer 436

Streptococcus

Answer 437

Syngeristic superficial bacterial infection on the trunk

Answer 438

Necrotising fasciitis affecting the perineum Polymicrobial with E-coli and Bacteroides acting in synergy

Answer 439

Pancreatic pseudocyst

Answer 440

Pancreatic psuedocysts

Answer 441

Pancreatic necrosis

Answer 442

Pancreatic abscess

Answer 443

Pancreatic haemorrhage