Block 7

Question 1

Facial canal path of the facial nerve

Answer 1

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

Question 2

Passage of the facial nerve through stylomastoid foramen

Answer 2

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

Question 3

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

Answer 3

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.

Question 4

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

Answer 4

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.

Question 5

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

Answer 5

The inferior thyroid artery originates from the thyrocervical trunk. This is a branch of the subclavian artery.

Question 6

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

Answer 6

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.

Question 7

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

Answer 7

Autonomic nerve injury is the most common cause. Damage to the hypogastric plexus.

Question 8

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%

Answer 8

50%

Question 9

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

Answer 9

The prostate lymphatic drainage is primarily to the internal iliac nodes and also the sacral nodes. Although internal iliac is the first site.

Question 10

Arterial supply of the prostate

Answer 10

Inferior vesical artery (from internal iliac)

Question 11

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

Answer 11

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.

Question 12

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.

Answer 12

Thoracic aorta rupture

Question 13

CXR changes in thoracic aortic ruputre

Answer 13

Contained haematoma: persistent hypotension

Detected mainly by history, CXR changes

Question 14

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

Answer 14

The spinous process is formed by 2 laminae posteriorly.

Question 15

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

Answer 15

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.

Question 16

Patients with diffuse erosive gastritis who cannot be managed endoscopically and continue to bleed may require

Answer 16

Gastrectomy

Question 17

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.

Answer 17

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.

Question 18

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

Answer 18

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:

Question 19

Normal angle between femoral head and femoral shaft is?

Answer 19

130 degrees

Question 20

Intracapsular ligaments of the hip joint

Answer 20

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

Question 21

Extracapsular ligaments of the hip joint

Answer 21

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.

Question 22

Blood supply of the hip joint

Answer 22

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.

Question 23

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.

Answer 23

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.

Question 24

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

Answer 24

Heparin and warfarin prevent propagation of the clot.

Question 25

Overview of axillary vein thrombosis

Answer 25

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

Question 26

Clinical features of axillary vein thrombosis

Answer 26

Pain and swelling (non pitting)

Numbness

Discolouration: mottling, dusky

Pulses present

Congested veins

Question 27

Ix in ?axillary vein thrombosis

Answer 27

FBC: viscosity, platelet function

Clotting

Liver function tests

D-dimer

Duplex scan: investigation of choice

CT scan: thoracic outlet obstruction

Question 28

Treatment of axillary vein thrombosis

Answer 28

Local catheter directed TPA

Heparin

Warfarin

Question 29

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

Answer 29

No response to sound

Question 30

Criteria for brain stem death testing

Answer 30

Deep coma of known aetiology.

Reversible causes excluded

No sedation

Normal electrolytes

Question 31

Testing for brain death

Answer 31

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).

Question 32

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

Answer 32

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.

Question 33

Features of SCD

Answer 33

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

Question 34

Sickle crises

Answer 34

Bone pain

Pleuritic chest pain: acute sickle chest syndrome commonest cause of death

CVA, seizures

Papillary necrosis

Splenic infarcts

Priapism

Hepatic pain

Question 35

Hb in sickle cell crisis

Answer 35

Hb does not fall during a crisis, unless there is

Aplasia: parvovirus

Acute sequestration

Haemolysis

Question 36

Surgical complications of sickle cell disease

Answer 36

Bowel ischaemia

Cholecystitis

Avascular necrosis

Question 37

Long term complications of sickle cell disease

Answer 37

Infections: Streptococcus pneumoniae

Chronic leg ulcers

Gallstones: haemolysis

Aseptic necrosis of bone

Chronic renal disease

Retinal detachment, proliferative retinopathy

Question 38

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

Answer 38

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.

Question 39

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

Answer 39

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.

Question 40

Extent of the oesophagus

Answer 40

25cm

C6-> T11

Pierces diaphragm at T10

Squamous epithelium

Question 41

Distance of cricoid cartilage from incisors

Answer 41

15cm

Question 42

Distance of arch of aorta from incisors

Answer 42

22.5cm

Question 43

Distance from left principal bronchus to incisors

Answer 43

27cm

Question 44

Distance from diaphragmatic hiatus to incisors

Answer 44

40cm

Question 45

Anterior relations of the oesophagus

Answer 45

Trachea to T4

Recurrent laryngeal nerve

Left bronchus, Left atrium

Diaphragm

Question 46

Posterior relations of the oesophagus

Answer 46

Thoracic duct to left at T5

Hemiazygos to the left T8

Descending aorta

First 2 intercostal branches of aorta

Question 47

Left relations of the oesophagus

Answer 47

Thoracic duct

Left subclavian artery

Question 48

Right relations of the oesophagus

Answer 48

Azygos vein

Question 49

Arterial supply of the oesophagus:

Upper 1/3rd

Answer 49

Inferior thyroid

Question 50

Arterial supply of the oesophagus:

Mid third

Answer 50

Aortic branches

Question 51

Arterial supply of the oesophagus:

Lower third

Answer 51

Left gastric

Question 52

Venous drainage of the oesophagus:

Upper third

Answer 52

Inferior thyroid

Question 53

Venous drainage of the oesophagus:

Mid third

Answer 53

Azygos branches

Question 54

Venous drainage of the oesophagus:

Lower third

Answer 54

Left gastric

Question 55

Lymphatic drainage of the oesophagus:

Upper third

Answer 55

Deep cervical

Question 56

Lymphatic drainage of the oesophagus:

Mid third

Answer 56

Mediastinal

Question 57

Lymphatic drainage of the oesophagus:

Lower third

Answer 57

Gastric

Question 58

Muscularis externa of the oesophagus:

Upper third

Answer 58

Striated muscle

Question 59

Muscularis externa of the oesophagus:

Mid third

Answer 59

Smooth & striated muscle

Question 60

Muscularis externa of the oesophagus:

Lower third

Answer 60

Smooth muscle

Question 61

Nervous supply of the upper half of the oesophagus?

Answer 61

RLN

Question 62

Nervous supply of the lower half of the oesophagus?

Answer 62

Oesophageal plexus

Question 63

Histology of the oesophagus

Answer 63

Mucosa :Non-keratinized stratified squamous epithelium

Submucosa: glandular tissue

Muscularis externa (muscularis): composition varies. See table

Adventitia

Question 64

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

Answer 64

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.

Question 65

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

Answer 65

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.

Question 66

What is the second leading cause of cancer death globally?

Answer 66

HCC

Question 67

What criteria make HCC more likely in monitoring of liver

Answer 67

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].

Question 68

What is the characteristic CT finding for HCC?

Answer 68

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.

Question 69

What can be used to classify management and prognosis in HCC?

Answer 69

Barcelona liver classification

Question 70

What are the different stages of Barcelona Liver Clinic Classification

Answer 70

0

A
B
C

D

Question 71

Features of BCLC Stage 0

Answer 71

Child-Pugh A

Single lesion (less than 2cm)

Normal portal pressures

Question 72

Treatment of BCLC Stage 0

Answer 72

Resection

Question 73

5ys in Stage 0 BCLC

Answer 73

40-70%

Question 74

Features of stage A BCLC?

Answer 74

Single nodule greater than 3cm or multiple nodules no more than 3

Child Pugh A/B

Question 75

Treatment of Stage A BCLC HCC

Answer 75

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

Question 76

5ys in BCLC Stage A

Answer 76

May be up to 70^

Question 77

Features of BCLC Stage B HCC

Answer 77

Multiple nodules

Child Pugh A/B

Question 78

Treatment of BCLC Stage B disease

Answer 78

Trans arterial chemo-embolisation (usually with doxorubicin)

Question 79

Px in BCLC Stage B disease

Answer 79

26% at 3 years

Question 80

Features of Stage C BCLC HCC?

Answer 80

Advanced tumours
Invasion of portal vein
Child Pugh A/B

Question 81

Px in Stage C BCLC HCC?

Answer 81

10.7 month survival

Question 82

Treatment in BCLC Stage C disease?

Answer 82

Sorafenib

Question 83

Features of Stage D BCLC HCC?

Answer 83

Child pugh C

Advanced tumours

Question 84

Px in Stage D BCLC HCC?

Answer 84

<6months

Question 85

Sorafenib

Answer 85

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.

Question 86

Surgical resections in HCC

Answer 86

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].

Question 87

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

Answer 87

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

Question 88

Complete fracture

Answer 88

Both sides of cortex are breached

Question 89

Toddlers fracture

Answer 89

Oblique tibial fracture in infants

Question 90

Plastic deformity

Answer 90

Stress on bone resulting in deformity without cortical disruption

Question 91

Greenstick fracture

Answer 91

Unilateral cortical breach only

Question 92

Buckle fracture

Answer 92

Incomplete cortical disruption resulting in periosteal haematoma only

Question 93

Features in NAI

Answer 93

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

Question 94

Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone.

Answer 94

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.

Question 95

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

Answer 95

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.

Question 96

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.

Answer 96

Bronchogenic cysts

Question 97

Ix in bronchogenic cysts?

Answer 97

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.

Question 98

Treatment of bronchogenic cysts?

Answer 98

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

Question 99

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

Answer 99

They usually arise from C7.

Question 100

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.

Answer 100

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.

Question 101

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

Answer 101

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

Question 102

Participants randomly allocated to intervention or control group (e.g. standard treatment or placebo)

Practical or ethical problems may limit use

Answer 102

Randomised controlled trial

Question 103

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

Answer 103

Cohort study

Question 104

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

Answer 104

Case-control study

Question 105

Provide a ‘snapshot’, sometimes called prevalence studies

Provide weak evidence of cause and effect

Answer 105

Cross-sectional survey

Question 106

Presenting features of nasopharyngeal carcinoma?

Answer 106

Cervical lymphadenopathy

Otalgia

Unilateral serous otitis media

Nasal obstruction, discharge and/or epistaxis

Cranial nerve palsies

Question 107

Imaging in nasopharyngeal carcinoma

Answer 107

Combined CT and MRI

Question 108

Treatment of nasopharyngeal carcinoma

Answer 108

RTx is first line

Question 109

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

Answer 109

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

Question 110

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.

Answer 110

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

Question 111

Systemic effects of tourniquets post inflation

Answer 111

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

Question 112

Systemic effects of tourniquets post deflation

Answer 112

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

Question 113

Absolute contraindications to tourniquets

Answer 113

AV fistula

Severe PVD

Previous vascular sx

Bone fracture or thrombosis at site of tourniquet application

Question 114

Relative contraindications to tourniquet

Answer 114

SCD

History of VTE

Skin grafts

Localised inefction

Lymphoedema

Question 115

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

Answer 115

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.

Question 116

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

Answer 116

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:

Question 117

Passage of the brachial artery

Answer 117

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.

Question 118

Relations of the brachial artery

Answer 118

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.

Question 119

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.

Answer 119

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.

Question 120

Classification of psoas abscess

Answer 120

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.

Question 121

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.

Answer 121

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.

Question 122

What are the branches of the abdominal aorta?

Answer 122

Inferior phrenic

Coeliac

SMA

Middle suprarenal

Renal

Gonadal

Lumbar

IMA

Median sacral

Common iliac

Question 123

Inferior phrenic level?

Answer 123

Upper border of T12

Question 124

Coeliac artery level

Answer 124

T12

Question 125

SMA level

Answer 125

L1

Question 126

Middle suprarenal level

Answer 126

L1

Question 127

Renal artery level

Answer 127

L1-2

Question 128

Gonadal artery level

Answer 128

L2

Question 129

Lumbar artery levels

Answer 129

L1-L4

Question 130

IMA level

Answer 130

L3

Question 131

Median sacral level

Answer 131

L4

Question 132

Common iliac artery level

Answer 132

L4

Question 133

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

Answer 133

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

Question 134

Reynolds pentad

Answer 134

Charcot’s triad (Fever, RUQ pain, Jaundice)

Plus confusion and hypotension

Question 135

Which of the following does not lead to relaxation of the lower oesophageal sphincter?

Metoclopramide

Botulinum toxin type A

Nicotine

Alcohol

Theophylline

Answer 135

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.

Question 136

Difference between primary and secondary peristalsis

Answer 136

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

Question 137

What are the three main types of peristaltic activity in the colon?

Answer 137

Segmental contractions

Antiperistaltic contractions towards ileum

Mass movements

Question 138

Segmentation contractions

Answer 138

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

Question 139

Antiperistaltic contractions towards ileum

Answer 139

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

Question 140

Mass movements

Answer 140

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

Question 141

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

Answer 141

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

Question 142

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

Answer 142

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.

Question 143

Inhibits calcineurin, a phosphatase involved in T cell activation

Nephrotoxic

Monitor levels

Answer 143

Ciclosporin

Question 144

Metabolised to form 6 mercaptopurine which inhibits DNA synthesis and cell division

Side effects include myelosupression, alopecia and nausea

Answer 144

Azathioprine

Question 145

Lower incidence of acute rejection compared to ciclosporin

Also less hypertension and hyperlipidaemia

However, high incidence of impaired glucose tolerance and diabetes

Answer 145

Tacrolimus

Question 146

Blocks purine synthesis by inhibition of IMPDH

Therefore inhibits proliferation of B and T cells

Side-effects: GI and marrow suppression

Answer 146

Mycophenolate mofetil (MMF)

Question 147

Blocks T cell proliferation by blocking the IL-2 receptor

Can cause hyperlipidaemia

Answer 147

Sirolimus (rapamycin)

Question 148

Selective inhibitors of IL-2 receptor

Answer 148

Daclizumab

Basilximab

Question 149

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

Answer 149

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.

Question 150

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

Answer 150

BMI 35 kg/m2 and type 2 diabetes

Question 151

Case selection for bariatric surgery

Answer 151

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.

Question 152

Pre-requisites to bariatric surgery

Answer 152

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.

Question 153

Surgical options in bariatric patients

Answer 153

Adjustable gastric band

Gastric bypass

Sleeve gastrectomy

Question 154

Features of adjustable gastric band

Answer 154

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

Question 155

Gastric bypass

Answer 155

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

Question 156

Sleeve gastrectomy

Answer 156

Resection of stomach using stapling devices

Less popular now as initial promising results not sustained

Question 157

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

Answer 157

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.

Question 158

Superficial temproal artery is a branch of?

Answer 158

Terminal branch of the external carotid

Question 159

Indication for temporal artery biopsy

Answer 159

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

Question 160

Vessel wall granulomatous arteritis with mononuclear cell infiltrates and giant cell formation

Answer 160

Temporal arteritis

Question 161

Temporal artery biopsy- procedure

Answer 161

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

Question 162

Contraindication to temporal artery biopsy

Answer 162

GC for >30 days

Question 163

Nerves at risk during temporal artery biopsy

Answer 163

Facial or auriculotemporal nerve

Question 164

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

Answer 164

Suprascapular nerve

Question 165

Action of suprascapular nerve?

Answer 165

Supraspinatus and infraspinatus

Initiates abduction of the shoulder

Question 166

What may be seen in suprascapular nerve injury?

Answer 166

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.

Question 167

Passage of suprascapular nerve

Answer 167

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 168

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

Answer 168

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

Question 169

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

Answer 169

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

Question 170

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

Answer 170

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.

Question 171

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.

Answer 171

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.

Question 172

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

Answer 172

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

Question 173

Mnemonic for the branches of the subclavian artery: VIT C & D

Answer 173

V ertebral artery
I nternal thoracic
T hyrocervical trunk

C ostalcervical trunk
D orsal scapular

Question 174

Which of the following is not released from the islets of Langerhans?

Pancreatic polypeptide

Glucagon

Secretin

Somatostatin

Insulin

Answer 174

Secretin is released from mucosal cells in the duodenum and jejunum

Question 175

What hormones are released from islets of Langerhans

Answer 175

Beta cells- insulin

Alpha cells- glucagon

Delta cells- somatostatin

F cells- pancreatic polypeptide

Question 176

Which option is not recommended during the management of compartment syndrome?

Anticoagulation

Keep limb level with the body

Intravenous fluids

Pain control

Fasciotomy

Answer 176

Anticoagulation will worsen compartment syndrome.

Question 177

What are the two main fractures carrying the major risk of compartment syndrome?

Answer 177

Supracondylar fractures

Tibial shaft injuries

Question 178

Treatment of compartment syndrome

Answer 178

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

Question 179

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.

Answer 179

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.

Question 180

Embryology of the umbilical cord

Answer 180

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.

Question 181

What proportion of neonates will have an umbilical hernia

Answer 181

20%

Question 182

Px in umbilical hernia in neonates

Answer 182

Majority will close spontaneously within 12m-3y

Question 183

Features of paraumbilical hernia in neonates

Answer 183

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.

Question 184

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

Answer 184

Omphalitis

Question 185

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.

Answer 185

Umbilical granuloma

Question 186

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.

Answer 186

Persistent vitello-intestinal duct

Question 187

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.

Answer 187

Persistent urachus

Question 188

Chordoma may typically occur at the following sites, except?

Ribs

Clivus

Sacrum

Lumbar vertebra

Cervical vertebra

Answer 188

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.

Question 189

What are the three histological variants of chordoma?

Answer 189

Classical, chondroid and de-differnetiated

Question 190

lobulated tumor composed of groups of cells separated by fibrous septa. The cells have small round nuclei and abundant vacuolated cytoplasm.

Answer 190

The histological appearance of classical chordoma

Question 191

Mx of chordoma

Answer 191

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.

Question 192

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.

Answer 192

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.

Question 193

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

Answer 193

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.

Question 194

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

Answer 194

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.

Question 195

What is the most common cause of cyanotic congenital heart disease?

Answer 195

ToF

Question 196

Four characteristic features of ToF

Answer 196

VSD

RVH

RV outflow obstruction

Overriding aorta

Question 197

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

Answer 197

ToF

Question 198

What is the most common cause of cyanotic congenital heart disease at birth?

Answer 198

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

Question 199

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

Answer 199

Interferon-alpha and ribavirin are the treatments of choice

Question 200

Transmission of hepatitis C

Answer 200

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%

Question 201

What proportion of patients develop acute hepaitis after exposure to HCV?

Answer 201

<20%

Question 202

Cx of HCV

Answer 202

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

Question 203

Management of chronic HCV infection

Answer 203

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

Question 204

Complications of ribavirin

Answer 204

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

Question 205

Complications of IFN alpha

Answer 205

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

Question 206

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

Answer 206

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.

Question 207

def: anastomosis

Answer 207

Restoration of luminal continuity

Question 208

What are the three criteria for an anastomosis to heal?

Answer 208

Adequate blood supply

Mucosal apposition

Minimal tension

Question 209

Key points regarding vascular anastomoses

Answer 209

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.

Question 210

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.

Answer 210

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.

Question 211

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

Answer 211

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.

Question 212

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

Answer 212

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.

Question 213

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

Answer 213

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.

Question 214

On what do the breasts lie?

Answer 214

A layer of pectoral fascia and

Pec major

Serratus anterior

External oblique

Question 215

Nerve supply of the breast

Answer 215

Branches of intercostal nerves (T4-6)

Question 216

Arterial supply of the breast

Answer 216

Internal mammary (thoracic) artery

External mammary artery (laterally)

Anterior intercostal arteries

Thoraco-acromial artery

Question 217

Venous drainage of the breast

Answer 217

Superficial venous plexus to subclavian, axillary and intercostal veins.

Question 218

Lymphatic drainage of the breast

Answer 218

70% Axillary nodes

Internal mammary chain

Other lymphatic sites such as deep cervical and supraclavicular fossa (later in disease)

Question 219

Which of the following muscles is supplied by the external laryngeal nerve?

Transverse arytenoid

Cricothyroid

Thyro-arytenoid

Posterior crico-arytenoid

Oblique arytenoid

Answer 219

Cricothyroid

The others are supplied by the RLN

Question 220

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.

Answer 220

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

Question 221

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

Answer 221

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.

Question 222

Prevalence of incidentaloma adrenal lesions?

Answer 222

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.

Question 223

Risk of malignancy in incidental adrenal lesions

Answer 223

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.

Question 224

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.

Answer 224

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.

Question 225

def: lymphoedema

Answer 225

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.

Question 226

Primary causes of lympohedema

<1 y/o

Answer 226

Congenital: sporadic, Milroy’s disease

Question 227

Primary cause of lymphoedema

1-35 y/o

Answer 227

Sporadic

Meige’s disease

Question 228

Primary cause of lymphoedema

>35y

Answer 228

Tarda

Question 229

Secondary causes of lymphoedema

Answer 229

Bacterial/fungal/parasitic infection (filariasis)

Lymphatic malignancy

Radiotherapy to lymph nodes

Surgical resection of lymph nodes

DVT

Thrombophlebitis

Question 230

Indications for sxical management of lymphoedema

Answer 230

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

Question 231

Homans operation

Answer 231

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.

Question 232

Charles operation

Answer 232

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.

Question 233

Lymphovenous anastamosis

Answer 233

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

Question 234

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

Answer 234

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.

Question 235

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.

Answer 235

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.

Question 236

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

Answer 236

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.

Question 237

Sensitivity

Answer 237

proportion of true positives identified by a test

Question 238

Specificity

Answer 238

proportion of true negatives correctly identified by a test

Question 239

Positive predictive value:

Answer 239

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

Question 240

Negative predictive value:

Answer 240

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

Question 241

Predictive values are dependent on

Answer 241

the prevalence

Question 242

Likelihood ratio for a positive test result =

Answer 242

sensitivity/(1-specificity)

Question 243

Likelihood ratio for a negative test result =

Answer 243

(1-sensitivity)/specificity

Question 244

Likelihood ratios are not

Answer 244

prevalence dependent

Question 245

What are the layers of the spermatic cord

Answer 245

Internal spermatic fascia (transvesalis fascia)

Cremasteric fascia (internal oblique)

External spermatic fascia (external oblique)

Question 246

What are the contents of the spermatic cord?

(3 layers)

3 arteries

3 nerves

3 other structures

Answer 246

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

Question 247

Transmits sperm and accessory gland secretions

Answer 247

Vas deferens

Question 248

Branch of abdominal aorta supplies testis and epididymis

Answer 248

Testicular artery

Question 249

Artery in spermatic cord

Arises from inferior vesical artery

Answer 249

Artery of vas deferens

Question 250

Artery in spermatic cord

Arises from inferior epigastric artery

Answer 250

Cremasteric artery

Question 251

Venous plexus, drains into right or left testicular vein

Answer 251

Pampiniform plexus

Question 252

Nerve that supplies cremaster

Answer 252

Genital branch of genitofemoral nerve

Question 253

Lymphatic drainage of the scrotum?

Answer 253

Inguinal lymph nodes

Question 254

Layers of the scrotum

SDECITT

Answer 254

S: skin.

D: dartos fascia and muscle.

E: external spermatic fascia.

C: cremasteric fascia.

I: internal spermatic fascia.

T: tunica vaginalis.

T: tunica albuginea.

Question 255

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?

Answer 255

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.

Question 256

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

Answer 256

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

Question 257

Mnemonic for branches of the cerebral portion of the internal carotid artery ‘Only Press Carotid Arteries Momentarily’

Answer 257

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

Question 258

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

Answer 258

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.

Question 259

What can be used to stage Hodgkin’s lymphoma?

Answer 259

Ann Arbor staging system

Question 260

Ann Arbor I

Answer 260

Single LN region

Question 261

Ann Arbor 2

Answer 261

Two or more LN regions on same side of diaphragm

Question 262

Ann Arbor III

Answer 262

Involvement of LN regions on both sides of the diaphragm

Question 263

Ann Arbor IV

Answer 263

Involvement of extra nodal sites

Question 264

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

Answer 264

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.

Question 265

Arragnement of structures at the renal hilum

Answer 265

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

Question 266

Contents of the renal sinus

Answer 266

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

Question 267

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.

Answer 267

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.

Question 268

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

Answer 268

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

Question 269

What are the respiratory centres

Answer 269

Medullary respiratory centre

Apneustic centre

Pneumotaxic centre

Question 270

Medullary respiratory centre

Answer 270

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

Question 271

Apneustic centre

Answer 271

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

Question 272

Pneumotaxic centre

Answer 272

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

Question 273

What is most important in ventilation control?

Answer 273

Levels of pCO2

Question 274

Where are peripheral chemoreceptors and what do they respond to?

Answer 274

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.

Question 275

Central chemoreceptors

Answer 275

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.

Question 276

What are the lung receptors

Answer 276

Stretch receptors: respond to lung stretching causing a reduced respiratory rate

Irritant receptors: respond to smoke etc causing bronchospasm

J (juxtacapillary) receptors

Question 277

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

Answer 277

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.

Question 278

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

Answer 278

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.

Question 279

What are the two types of schistosomiasis

Answer 279

Schistosoma mansoni and Schistosoma intercalatum: intestinal schistosomiasis

Schistosoma haematobium: urinary schistosomiasis

Question 280

Management of schistosomiasis haematobium

Answer 280

Single dose of oral praziquantel

Question 281

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.

Answer 281

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.

Question 282

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

Answer 282

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

Question 283

Features of Klumpkes Paralysis

Answer 283

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

Question 284

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.

Answer 284

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

Question 285

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

Answer 285

Mentalis

Question 286

Muscles supplied by the buccal branch of the facial nerve

Answer 286

Zygomaticus minor

Risorius

Buccinator

Levator anguli oris

Orbicularis

Nasalis

Question 287

Action of zygomaticus minor

Answer 287

Elevates upper lip

Question 288

Action of risorius

Answer 288

Aids smile

Question 289

Action of buccinator

Answer 289

Pulls corner of mouth backward and compresses cheek

Question 290

Action of levator anguli oris

Answer 290

Pulls angles of mouth upward and towards midline

Question 291

Action of orbicularis

Answer 291

Closes and tightens lips together

Question 292

Action of nasalis

Answer 292

Flares and compresses nostrils

Question 293

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

Answer 293

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

Question 294

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

Answer 294

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.

Question 295

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.

Answer 295

Merkel cell tumour of the skin

Question 296

What virus is associated with merkel cell tumours of the skin?

Answer 296

Merkel Cell Polyomavirus seen in 80%

Question 297

Treatment of merkel cell tumour

Answer 297

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.

Question 298

Px in Merkel cell tumours

Answer 298

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%.

Question 299

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

Answer 299

Invasion of surrounding structures

Question 300

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

Answer 300

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.

Question 301

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

Answer 301

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.

Question 302

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

Answer 302

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

Question 303

Obstructive pulmonary function picture

Answer 303

FEV1 significantly reduced

FVC reduced or normal

FEV1/FVC <70

Question 304

Restrictive pulmonary function picture

Answer 304

FEV1 reduced

FVC significantly reduced

FEV1/FVC >70%

Question 305

./ 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

Answer 305

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.

Question 306

Arterial supply of significance in epistaxis?

Answer 306

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

Question 307

Classification of epistaxis

Answer 307

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

Question 308

Management of epistaxis

Answer 308

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.

Question 309

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.

Answer 309

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.

Question 310

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

Answer 310

Absolute polycythaemia

Haemolysis is the main pathological response.

Question 311

Pathology in Burns

Answer 311

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

Question 312

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.

Answer 312

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.

Question 313

Aortic dissection in pregnancy

Answer 313

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

Question 314

Aortic dissection in pregnancy management:

<28/40

Answer 314

Aortic repair with fetus kept in utero

Question 315

Aortic dissection in pregnancy management:

28-32/40

Answer 315

Dependent on fetal condition

Question 316

Aortic dissection in pregnancy management:

>32/40

Answer 316

C-section followed by aortic repair at same time

Question 317

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

Answer 317

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.

Question 318

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

Answer 318

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

Question 319

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%

Answer 319

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

Question 320

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

Answer 320

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.

Question 321

What is the commonest cause of infravesical outflow obstruction in males?

Answer 321

Posterior urethral valves

Question 322

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.

Answer 322

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.

Question 323

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

Answer 323

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

Question 324

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

Answer 324

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

Question 325

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

Answer 325

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.

Question 326

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.

Answer 326

Proximal humerus #

Question 327

Vascular supply of the humeral head?

Answer 327

Anterior and posterior humeral circumflex arteries

Question 328

What can be used for classification of proximal humeral #?

Answer 328

Neer classification

Question 329

Neer classification of proximal humeral fractures

Answer 329

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.

Question 330

Treatment of minimally displaced proximal humeral fracture

Answer 330

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.

Question 331

Options for surgical management of proximal humeral fracture

Answer 331

ORIF

IM nail

Hemiarthroplasty

Total shoulder arthroplasty

Reverse shoulder arthroplasty

Question 332

ORIF proximal humeral #

Answer 332

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

Question 333

Intramedullary nail proximal humeral fractures

Answer 333

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

Question 334

Hemiarthroplasty in proximal humeral fracture

Answer 334

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

Question 335

Total shoulder arthroplasty

Answer 335

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

Question 336

Reverse shoulder arthroplasty

Answer 336

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

Question 337

Scapula fracture

Answer 337

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.

Question 338

Imaging in scapula fracture

Answer 338

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.

Question 339

Classification of scapula fracture

Answer 339

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.

Question 340

Treatment of scapular fracture

Answer 340

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.

Question 341

Different types of shoulder dislocation

Answer 341

Anterior
Posterior

Inferior

Superior

Question 342

Usually traumatic - anterior force on arm when shoulder is abducted, eternally rotated

Loss of shoulder contour - sulcus sign. Humeral head can be felt anteriorly.

Answer 342

Anterior shoulder dislocation

Question 343

Shoulder locked in internal rotation. XR may show lightbulb appearance.

50% traumatic, but classically post seizure or electrocution

Answer 343

Posterior shoulder dislocation

Question 344

Shoulder dislocation

Associated with pectorals and rotator cuff tears, and glenoid fracture

Answer 344

Inferior shoulder dislocation

Question 345

Shoulder dislocation

Associated with acrominon/clavicle fracture

Answer 345

Superior

Question 346

avulsion of the anterior glenoid labrum with an anterior shoulder dislocation

Answer 346

Bankart lesion

Question 347

chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction.

Answer 347

Hill Sachs defect

Question 348

Innervation of supraspinatus

Answer 348

Suprascapular nerve

Question 349

Innervation of infraspinatus

Answer 349

Suprascapular nerve

Question 350

Innervation of teres minor

Answer 350

Axillary nerve

Question 351

Innervation of subscapularis

Answer 351

Upper and lower subscapular nerve

Question 352

Attachments of supraspinatus

Answer 352

Superior facet of greater tubersoity

Supraspinatus fossa

Question 353

Attachments of infraspinatus

Answer 353

Infraspinatus fossa

Posterior facet of greater tuberosity

Question 354

Attachments of teres minor

Answer 354

Lateral border of scapula

Inferior facet of greater tuberosity

Question 355

Attachments of subscapularis

Answer 355

Subscapular fossa

Lesser tuberoisty

Question 356

Action of supraspinatus

Answer 356

Initiation of abduction

Question 357

Action of infraspinatus

Answer 357

External rotation of humerus

Question 358

Action of teres minor

Answer 358

External rotation of humerus

Question 359

Action of subscapularis

Answer 359

Internal rotation of huemrus

Question 360

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.

Answer 360

Subacromial Impingement

Question 361

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.

Answer 361

Rotator Cuff Tear

Question 362

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.

Answer 362

Rotator Cuff Arthropathy

Question 363

Imaging in ?rotator cuff pathology

Answer 363

Plain radiographs: AP of shoulder. Outlet view.

USS: allows dynamic imaging of the cuff

MRI: best modality for cuff pathology

Question 364

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

Answer 364

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.

Question 365

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.

Answer 365

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

Question 366

Which of the following does not cause hyperkalaemia?

Haemolysis

Burns

Familial periodic paralysis

Type 4 renal tubular acidosis

Severe malnutrition

Answer 366

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

Question 367

How do LMWH and UFH cause hyperkalaemia?

Answer 367

?through inhibition of aldosterone secretion

Question 368

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

Answer 368

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

Question 369

ECG changes in PE

Answer 369

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.

Question 370

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.

Answer 370

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.

Question 371

Tru-cut biopsy

Answer 371

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

Question 372

5mm punch biopsy

Answer 372

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.

Question 373

Wide excision

Answer 373

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

Question 374

Incisional biopsy

Answer 374

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.

Question 375

Diagnostic excision

Answer 375

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.

Question 376

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

Answer 376

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.

Question 377

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

Answer 377

Streptococcus pyogenes

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

Question 378

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

Answer 378

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)

Question 379

def: fistula

Answer 379

Abnormal connection between two epitheial surfaces

Question 380

General rule in fistulas

Answer 380

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

Question 381

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.

Answer 381

Enterocutaneous

Question 382

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.

Answer 382

Enteroenteric or Enterocolic

Question 383

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.

Answer 383

Enterovesicular fistula

Question 384

Genereal rules of fistula management

Answer 384

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.

Question 385

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.

Answer 385

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.

Question 386

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

Answer 386

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.

Question 387

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.

Answer 387

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.

Question 388

Ligaments of the ankle joint

Answer 388

Deltoid ligament (medially)

LCL

Talofibular ligaments (both anteriorly and posteriorly)

The calcaenofibular ligament is separate from the fibrous capsule of the joint

Question 389

Components of the syndesmosis at the ankle joint

Answer 389

Antero-inferior tibiofibular ligament

Postero-inferior tibiofibular ligament

Inferior transverse tibiofibular ligament

Interosseous ligament

Question 390

What are the movements at the ankle joint

Answer 390

Plantar flexion (55 degrees)

Dorsiflexion (35 degrees)

Inversion and eversion movements occur at the level of the sub talar joint

Question 391

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

Answer 391

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

Question 392

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

Answer 392

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

Question 393

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

Answer 393

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.

Question 394

Stimulants of glucagon

Answer 394

Decreased plasma glucose

Increased catecholamines

Increased plasma aas

SNS

ACh

CCK

Question 395

Inhibitors of glucagon

Answer 395

Somatostatin

Insulin

Increased FFAs and keto acids

Increased urea

Question 396

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.

Answer 396

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.

Question 397

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

Answer 397

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.

Question 398

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

Answer 398

Klippel Trenaunay syndrome

Absence of port wine stain= atypical Klippel Trenaunay syndrome

Question 399

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

Answer 399

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.

Question 400

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

Answer 400

Posterior circumflex humeral

The other branches include:

Subscapular

Anterior circumflex humeral

Question 401

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

Answer 401

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.

Question 402

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

Answer 402

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

Question 403

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

Answer 403

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

Question 404

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

Answer 404

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.

Question 405

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

Answer 405

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

Question 406

eye is deviated ‘down and out’

ptosis

pupil may be dilated

Answer 406

Third nerve palsy

Question 407

Surgical third nerve palsy

Answer 407

Pupil dilated

Question 408

Medical third nerve palsy

Answer 408

Pupil sparing

Question 409

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

Answer 409

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.

Question 410

Poor prognostic factors in SCC

Answer 410

Size >20mm (local recurrence rate of up to 15%)

Depth greater than 4mm (risk of metastasis up to 30%)

Question 411

Groups at high risk of SCC

Answer 411

Renal transplant and on immunosuppression

Individuals with HIV

Those who have received psoralen UVA therapy

Chronic wounds (Marjolins ulcer)

Xeroderma pigmentosum

Oculocutaneous albinism

Question 412

Treatment of SCC

Answer 412

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

Question 413

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.

Answer 413

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.

Question 414

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

Answer 414

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

Question 415

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

Answer 415

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

Question 416

Causes of DIC

DISSEMINATED

Answer 416

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)

Question 417

prolonged clotting times, thrombocytopenia, decreased fibrinogen, increased fibrinogen degradation products

Answer 417

DIC

Question 418

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

Answer 418

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

Question 419

Def: hypothermia

Answer 419

Core body temperature <35

Severe when <30

Question 420

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.

Answer 420

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.

Question 421

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

Answer 421

Ankylosing spondylitis

Question 422

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

Answer 422

Scheuermann’s disease

Question 423

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

Answer 423

Scoliosis

Question 424

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

Answer 424

Spina bifida

Question 425

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

Answer 425

Spondylolysis

Question 426

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

Answer 426

Spondylolisthesis

Question 427

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

Answer 427

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.

Question 428

Path of the phrenic nerve

Answer 428

The phrenic nerve passes with the internal jugular vein across scalenus anterior. It passes deep to prevertebral fascia of deep cervical fascia.

Left: crosses anterior to the 1st part of the subclavian artery.

Right: Anterior to scalenus anterior and crosses anterior to the 2nd part of the subclavian artery.

On both sides, the phrenic nerve runs posterior to the subclavian vein and posterior to the internal thoracic artery as it enters the thorax.

Question 429

Relation of the left phrenic nerve to the subclavian

Answer 429

Crosses anterior to the 1st part of the subclavian artery

Question 430

Relation of the right subclavian nerve to the subclavian artery

Answer 430

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

Question 431

Relationship of the phrenic nerves to the subclavian vein and internal thoracic artery

Answer 431

Run posterior to both

Question 432

Right phrenic nerve in the mediatsinum

Answer 432

Superior: anterior to right vagus and laterally to SVC

Middle: right of pericardium

Passes over the right atrium to exit diaphragm at T8

Question 433

Relation of right phrenic nerve to diaphragm

Answer 433

Exits the diaphragm at T8

Question 434

Passage of left phrenic nerve in the thorax

Answer 434

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

Question 435

Relation of the left phrenic nerve to the diaphragm

Answer 435

Pierces the diaphragm alone

Question 436

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

Answer 436

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.

Question 437

AutoAbs in antiphospholipid syndrome

Answer 437

Lupus anticoagulant

Anti-cardiolipin

Anti-Beta 2 glycoprotein

Question 438

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

Answer 438

Antithrombin deficiency

Question 439

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

Answer 439

Protein C and S deficiency

Question 440

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

Answer 440

FVL

Question 441

What is the most common thrombophilia in Europeans?

Answer 441

FVL

Question 442

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

Answer 442

Antiphospholipid syndrome

Question 443

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

Answer 443

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.

Question 444

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

Answer 444

Peroneus tertius is innervated by the deep peroneal nerve.

Question 445

Muscles innervated by tibial nerve

Answer 445

Popliteus

Gastrocnemius

Soleus

Plantaris

Tibialis posterior

Flexor hallucis longus

Flexor digitorum brevis and longus

Question 446

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

Answer 446

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.

Question 447

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

Answer 447

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.

Question 448

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.

Answer 448

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,

Question 449

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

Answer 449

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.

Question 450

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

Answer 450

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

Question 451

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

Answer 451

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

Question 452

Effect of adrenaline on BP?

Answer 452

Causes narrow pulse pressure

Question 453

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

Answer 453

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.

Question 454

Muscles innervated by ansa cervicalis

GHost THought SOmeone Stupid Shot Irene

Answer 454

GenioHyoid
ThyroidHyoid
Superior Omohyoid
SternoThyroid
SternoHyoid
Inferior Omohyoid

Question 455

What is the anatomical importance of the ansa cervicalis?

Answer 455

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.

Question 456

Muscles supplied by anterior interosseous nerve?

Answer 456

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).

Question 457

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

Answer 457

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

Question 458

Nerve roots of the common peroneal

Answer 458

L4-S2

Question 459

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

Answer 459

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

Question 460

Muscles of the deep posterior compartment of the lower limb

Answer 460

Tibialis posterior

Flexor hallucis longus

Flexor digitorum longus

Popliteus

Question 461

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.

Answer 461

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.

Question 462

Ileo-anal pouch in Crohn’s

Answer 462

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

Question 463

Histological features of UC?

Answer 463

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

Question 464

Histological appearance of UC?

Answer 464

Crypt abscesses, Inflammatory cells in the lamina propria

Question 465

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.

Answer 465

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.

Question 466

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

Answer 466

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.

Question 467

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

Answer 467

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.

Question 468

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

Answer 468

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.

Question 469

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

Answer 469

Retromandibular vein

Question 470

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.

Answer 470

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.

Question 471

Deep seated pain in the proximal forearm especially during the night and at rest may be due to

Answer 471

tumour, especially metastatic lesions.

Question 472

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.

Answer 472

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.

Question 473

Outline the reconstructive ladder

Answer 473

Direct closure

Grafting techniques

Flap technique

Prelamination techniques

Tissue expansion

Question 474

What are the different grafting techniques?

Answer 474

Split thickness

Full thickness

Skin Substitute

Composite

Question 475

What are the different flap techniques

Answer 475

Local:

Transposition

Pivot

Alphabetplasty (e.g. Z-Y)

Regional:

Myocutaneous

Fasciocutaneous

Neurocutaneous

Distant:

Free tissue transfer

Question 476

What are prelamination techniques?

Answer 476

Allows creation of specialised flaps e.g. buccal mucosa

Question 477

Tissue expansion

Answer 477

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

Question 478

Features of skin grafts

Answer 478

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

Question 479

Features of flaps

Answer 479

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

Question 480

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

Answer 480

Split thickness skin grafts

Question 481

Grafts

Most commonly used for facial reconstruction

Include dermal appendages

Provide superior cosmetic result

Answer 481

Full thickness grafts

Question 482

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.

Answer 482

Composite grafts

Question 483

Features of flaps

Answer 483

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.

Question 484

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

Answer 484

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.

Question 485

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).

Answer 485

Froment’s sign

Question 486

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.

Answer 486

Phalen’s test

Question 487

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.

Answer 487

Tinel’s sign

Question 488

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

Answer 488

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.

Question 489

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

Answer 489

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.

Question 490

Features of cluster RCTs

Answer 490

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

Question 491

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

Answer 491

Median nerve

The median nerve supplies cutaneous sensation to this region.

Median nerve

Ulnar nerve

This area is innervated by the ulnar nerve.

Question 492

Overview of necrotising fasciitis

Answer 492

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%)

Question 493

What is the most common organism in isolated pathogen infection causing gas gangrene?

Answer 493

Streptococcus

Question 494

Melaeney’s gangrene

Answer 494

Syngeristic superficial bacterial infection on the trunk

Question 495

Fournier gangrene

Answer 495

Necrotising fasciitis affecting the perineum

Polymicrobial with E-coli and Bacteroides acting in synergy

Question 496

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

Answer 496

Pancreatic pseudocyst

Question 497

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

Answer 497

Pancreatic psuedocysts

Question 498

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

Answer 498

Pancreatic necrosis

Question 499

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

Answer 499

Pancreatic abscess

Question 500

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

Answer 500

Pancreatic haemorrhage