Block 8 Flashcards
Which of the following statements is false in relation to renal adenocarcinoma?
They account for over 75% cases of renal tumours
Renal biopsy should be performed in all cases considered for radical nephrectomy
They typically spread via the haematogenous route
Patients with completely resected T2 disease should not receive adjuvant chemotherapy
Partial nephrectomy gives equivalent oncological outcomes in patients with T1 disease
Routine chemotherapy is not effective in patients with renal adenocarcinoma and should not be used following R0 resections.
Routine renal biopsy should not be performed in cases for nephrectomy. Most cases of malignancy can be accurately classified on imaging.
Rare mucinous tumour
Most commonly arising from the appendix (other abdominal viscera are also recognised as primary sites)
Incidence of 1-2/1,000,000 per year
The disease is characterised by the accumulation of large amounts of mucinous material in the abdominal cavity
Pseudomyxoma Peritonei
Treatment of Pseudomyxoma
Is usually surgical and consists of cytoreductive surgery (and often peritonectomy c.f Sugarbaker procedure) combined with intra peritoneal chemotherapy with mitomycin C.
Survival is related to the quality of primary treatment and in Sugarbakers own centre 5 year survival rates of 75% have been quoted. Patients with disseminated intraperitoneal malignancy from another source fare far worse.
In selected patients a second look laparotomy is advocated and some practice this routinely.
A 30 year old man is suspected of having appendicitis. At operation an inflamed Meckels diverticulum is found. Which of the following vessels is responsible for the blood supply to a Meckels diverticulum?
Right colic artery
Vitelline artery
Appendicular artery
Internal iliac artery
External iliac artery
The vitelline arteries supply a Meckels these are usually derived from the ileal arcades.
Which of the following statements relating to osteomyelitis is false?
Is the result of haematogenous spread in most cases
Is due to Staphylococcus aureus in 50% cases
Should be treated by aggressive surgical debridement initially
Plain radiographs may be normal in the early stages
The presence of associated septic joint involvement will significantly alter management
It is managed medically in the first instance (with an antistaphylococcal antibiotic). This differs from the situation in septic joints where early joint washout is mandatory.
Causes of osteomyelitis
S aureus and occasionally Enterobacter or Streptococcus species
In sickle cell: Salmonella species
A 5 year old boy is found to have a Meckels diverticulum at an appendicectomy and it looks to be non inflamed. What type of epithelium is most likely to be found in the diverticulum?
Gastric mucosa
Non stratified squamous epithelium
Ileal mucosa
Stratified squamous epithelium
Jejunal mucosa
Most asymptomatic Meckels diverticulum will be lined by ileal mucosa. Those which present with bleeding are more likely to contain gastric type mucosa.
A 42 year old woman is admitted to surgery with acute cholecystitis. She is known to have hypertension, rheumatoid arthritis and polymyalgia rheumatica. Her medical therapy includes:
Paracetamol 1g qds
Codeine phosphate 30mg qds
Bendrofluazide 2.5 mg od
Ramipril 10mg od
Methotrexate 7.5mg once a week
Prednisolone 5mg od
You are called by the CT1 to assess this lady as she has become delirious and hypotensive 2 hours after surgery. Her blood results reveal:
Na+132 mmol/l
K+5.3 mmol/l
Urea7 mmol/l
Creatinine108 µmol/l
Hb12.4 g/dl
Platelets178 * 109/l
WBC15.4 * 109/l
What management is needed immediately?
Ceftriaxone IV
Hydrocortisone 50mg IV
CT scan abdomen
Urgent exploratory laparotomy
Hydrocortisone 100mg IV
This patient has acute adrenal insufficiency and urgently needs steroid replacement.
Causes of Addisonian crisis
Sepsis or surgery causing an acute exacerbation of chronic insufficiency (Addison’s, Hypopituitarism)
Adrenal haemorrhage eg Waterhouse-Friderichsen syndrome (fulminant meningococcemia)
Steroid withdrawal
Management of Addisonian crisis
Hydrocortisone 100 mg im or iv
1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic
Continue hydrocortisone 6 hourly until the patient is stable. No fludrocortisone is required because high cortisol exerts weak mineralocorticoid action
Oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days
Theme: Thoracic trauma
A.Thoracotomy
B.Manage conservatively
C.Intercostal tube drain insertion
D.CT scanning
E.Bronchoscopy
F.Negative pressure intercostal tube drainage
G.Video assisted thoracoscopy and pleurectomy
For each of the following scenarios please select the most appropriate management option from the list. Each option may be used once, more than once or not at all.
66.A 28 year old male is involved in a road traffic accident he is thrown from his motorbike onto the pavement and sustains a haemopneumothorax and flail segment of the right chest.
A 19 year old man is stabbed in the chest at a nightclub. He develops a cardiac arrest in casualty following an attempted transfer to the CT scanning room.
A 32 year old male falls over and sustains a small pneumothorax following a simple rib fracture. He has no physiological compromise.
Intercostal tube drain insertion
He requires a chest drain and analgesia. In general all haemopneumothoraces should be managed by intercostal chest drain insertion as they have a risk of becoming a tension pneumothorax until the lung laceration has sealed.
Thoracotomy
This is one indication for an ‘emergency room’ thoracotomy, there are not many others! Typical injuries include ventricular penetration, great vessel disruption and hilar lung injuries.
Intercostal tube drain insertion
Unlike spontaneous pneumothoraces most would advocate chest tube drainage in the context of pneumothorax resulting from trauma. This is because of the risk of the lung laceration developing a tension. Once there is no further evidence of air leak the chest drain may be removed and a check x-ray performed to check there is no re-accumulation prior to discharge.
At what level does the sciatic nerve usually bifurcate into the tibial and common peroneal nerves?
At the superior aspect of the popliteal fossa
At the inferior aspect of the popliteal fossa
At the inferior border of gluteus maximus
At the inferior border of the piriformis muscle
In the pelvis
The sciatic nerve passes vertically downwards over the posterior surface of the obturator internus and quadratus femoris to the hamstring compartment of the thigh, here it is crossed posteriorly by the long head of biceps femoris. In the buttock it lies under the cover of gluteus maximus. It separates into its tibial and common peroneal components at the upper aspect of the popliteal fossa.
A 28 year old man has a pleomorphic adenoma and the decision is made to resect this surgically. Which of the following structures is least likely to be encountered during surgical resection of the parotid gland?
External carotid artery
Retromandibular vein
Auriculotemporal nerve
Mandibular nerve
Zygomatic branch of the facial nerve
The mandibular nerve is well separated from the parotid gland.
The maxillary vein joins to the superficial temporal vein and they form the retromandibular vein which then runs through the parotid gland.
The auriculotemporal nerve runs through the gland. Following a parotidectomy this nerve may be damaged and during neuronal regrowth may then attach to sweat glands in this region. This can then cause gustatory sweating (Freys Syndrome).
The facial nerve branch is the marginal mandibular branch and this is related to the gland.
Structures passing through the parotid gland
Facial nerve and branches
External carotid artery (and its branches; the maxillary and superficial temporal)
Retromandibular vein
Auriculotemporal nerve
Freys Syndrome
The auriculotemporal nerve runs through the gland. Following a parotidectomy this nerve may be damaged and during neuronal regrowth may then attach to sweat glands in this region. This can then cause gustatory sweating
You have just completed a laparotomy for peritonitis due to a perforated peptic ulcer. What is the best surgical strategy for avoidance of a complete abdominal wound dehisence?
Use of skin clips to close the skin rather than sub cuticular sutures
Careful approximation of the peritonum with non absorbable sutures
Mass closure of the midline wound using a 1/0 polydiaxone suture
Direct apposition of the rectus muscle rather than linea alba aponeurosis
Mass closure of the midline wound using a 3/0 polypropylene suture
The incidence of post operative wound dehisence is minimise by following Jenkins rule which advocates mass closure of the midline wound. However, the suture strength is an important consideration and 3/0 sutures do not have sufficient tensile strength. Both polydiaxone (PDS) and polypropylene (Prolene) or nylon (Ethilon) are all equally suitable. Although separate closure of the peritoneum was practised it has no bearing on the incidence of abdominal wound dehisence.
Theme: Management of calcium metabolic disorders
A.No action needed
B.Intravenous fluid (0.9% N.Saline)
C.Risedronate and calcium supplements
D.Calcium supplements
E.Exploration and parathyroidectomy
F.DEXA bone scan
G.Pamidronate IV
For each scenario please select the most appropriate management plan. Each option may be used once, more than once or not at all.
72.An 80 year old woman has a hip fracture. Her calcium is normal. She has never been given a diagnosis of osteoporosis.
A 60 year old man presents with recurrent renal stones. He is found to have a calcium of 2.72 (elevated) and a PTH of 12 (elevated).
An 82 year old woman from a nursing home is admitted to the orthopaedic ward with a hip fracture. She is acutely confused and agitated. Her Calcium is 2.95 (elevated).
Risedronate and calcium supplements
The osteoporosis guidelines state if a postmenopausal woman has a fracture she should be put on bisphosphonates (there is no need for a DEXA scan).
Exploration and parathyroidectomy
This patient has primary hyperparathyroidism and nephrolithiasis, which is an indication for parathyroidectomy.
Intravenous fluid (0.9% N.Saline)
This patient needs rehydration due to hypercalcaemia. An intravenous bisphosphonate is indicated if the Ca is above 3.
What is the pathophysiology of DAI
- Multiple haemorrhages
- Diffuse axonal damage in the white matter
Up to 2/3 occur at the junction of grey/white matter due to the different densities of the tissue. The changes are mainly histological and axonal damage is secondary to biochemical cascades. Often there are no signs of a fracture or contusion.
A 19 year old man presents with painful rectal bleeding and is found to have an anal fissure. Which of the following is least associated with this condition?
Leukaemia
Syphilis
Tuberculosis
Sickle cell disease
Crohn’s disease
SCD
Anal fissures are associated with:
Sexually transmitted diseases (syphilis, HIV)
Inflammatory bowel disease (Crohn’s up to 50%)
Leukaemia (25% of patients)
Tuberculosis
Previous anal surgery
A 78 year old man presents with a ruptured aortic aneurysm. This is repaired but the operation is difficult as it has a juxtarenal location. A supra renal cross clamp is applied. Post operatively he is found to be oliguric and acute renal failure is suspected. Which of the following statements relating to acute post-operative renal failure are untrue?
Intravenous dopamine does not prevent acute renal failure.
It is more common after emergency surgery.
Use of excessive amounts of intravenous fluids may lead to falsely normal serum creatinine measurements.
Vasopressor drugs have a strong renoprotective effect
It is minimised by normalisation of haemodynamic status.
Vasopressor use is linked to renal failure as they are a marker of haemodynamic compromise.
A 73 year old man has previously undergone a prostatectomy to treat prostate cancer. On review, his PSA has risen to 55 and he has developed pain in his lower back. Imaging shows osteosclerotic lesions in L4 and L3. What is the best treatment strategy?
Posterior spinal fusion
Vertebral body reconstruction
Bisphosphonates and radiotherapy
Androgen suppression, bisphosphonates and radiotherapy
Radiotherapy alone
In men with metastatic bone lesions from prostate cancer, the best outcomes are achieved with androgen suppression. Radiotherapy can also produced marked palliation. A 2010 Cochrane review has clearly demonstrated added benefit, in terms of symptom control, from the addition of a bisphosphonate.
Which of the following associations are incorrect?
Afro-Caribbean skin and keloid scarring
Extensive third degree burns and wound contraction
Chemotherapy and dehisence of healed wounds
Poor healing at the site of previous radiotherapy
Zinc deficiency and delayed healing
Chemotherapy and dehisence of healed wounds
Lies most superficially
Originates from 5th to 12th ribs
Inserts into the anterior half of the outer aspect of the iliac crest, linea alba and pubic tubercle
More medially and superiorly to the arcuate line, the aponeurotic layer overlaps the rectus abdominis muscle
The lower border forms the inguinal ligament
The triangular expansion of the medial end of the inguinal ligament is the lacunar ligament.
External oblique
Arises from the thoracolumbar fascia, the anterior 2/3 of the iliac crest and the lateral 2/3 of the inguinal ligament
The muscle sweeps upwards to insert into the cartilages of the lower 3 ribs
The lower fibres form an aponeurosis that runs from the tenth costal cartilage to the body of the pubis
At its lowermost aspect it joins the fibres of the aponeurosis of transversus abdominis to form the conjoint tendon.
Internal oblique
Innermost muscle
Arises from the inner aspect of the costal cartilages of the lower 6 ribs , from the anterior 2/3 of the iliac crest and lateral 1/3 of the inguinal ligament
Its fibres run horizontally around the abdominal wall ending in an aponeurosis. The upper part runs posterior to the rectus abdominis. Lower down the fibres run anteriorly only.
The rectus abdominis lies medially; running from the pubic crest and symphysis to insert into the xiphoid process and 5th, 6th and 7th costal cartilages. The muscles lies in a aponeurosis as described above.
Nerve supply: anterior primary rami of T7-12
Transversus abdominis
A 56 year old man presents with a painless swelling in the upper part of the anterior triangle of his neck. On examination a mass lesion involving the sub mandibular gland is identified. On CT scanning this is shown to be a solid lesion. There is no regional lymphadenopathy. Two fine needle aspirates have failed to be diagnostic. Which of the following is the most appropriate management option?
Sub mandibular gland excision
Incisional biopsy of the mass
Manage conservatively and repeat the CT scan in 6 months
Sub mandibular gland excision and radical neck dissection
Diagnostic excision of the superficial lobe of the submandibular gland
There is a 50% risk that this lesion is malignant (in some series up to 70%). Therefore the gland should be excised entirely. At this stage a radical neck dissection is not justified.
Features of sialolithiasis
80% of all salivary gland calculi occur in the submandibular gland
70% of the these calculi are radio-opaque
Stones are usually composed of calcium phosphate or calcium carbonate
Patients typically develop colicky pain and post prandial swelling of the gland
Investigation involves sialography to demonstrate the site of obstruction and associated other stones
Stones impacted in the distal aspect of Whartons duct may be removed orally, other stones and chronic inflammation will usually require gland excision
Features of sialadenitis
Usually occurs as a result of Staphylococcus aureus infection
Pus may be seen leaking from the duct, erythema may also be noted
Development of a sub mandibular abscess is a serious complication as it may spread through the other deep fascial spaces and occlude the airway
Features of submandibular tumours
Only 8% of salivary gland tumours affect the sub mandibular gland
Of these 50% are malignant (usually adenoid cystic carcinoma)
Diagnosis usually involves fine needle aspiration cytology
Imaging is with CT and MRI
In view of the high prevalence of malignancy, all masses of the submandibular glands should generally be excised.
What proportion of submandibular tumours are malignant?
50% (usually adenoid cystic)
A 45 year old woman is identified as having a gastric gastro-intestinal stromal tumour. What is the usual cell of origin of these lesions?
Brunners glands
Interstitial cells of Cajal
Primitive stem cells of the gut wall
Fundic glands
Antral goblet cells
GIST’s are derived from the interstitial pacemaker cells of Cajal. This means that they are often located extramucosally and macroscopically, demonstrate little mucosal disruption.
Features of GIST?
GIST’s are not common tumours (10 per million) and originate primarily from the interstitial pacemaker cells (of Cajal). Up to 70% occur in the stomach, the remainder occurring in the small intestine (20%) and the colon and rectum (5%). Up to 95% are solitary lesions and most are sporadic. The vast majority express CD117 which is a transmembrane tyrosine kinase receptor and in these there is a mutation of the c-KIT gen
What is the most common site for GISTs?
Stomach
Followed by small intestine
And recutm
Oncogenetics of GIST
CD117 RTk, mutation in c-KIT
Goal of surgery in GIST
Resection with 1-2cm margin of normal tissue
Px of GIST?
High local recurrence rate, the risk of which is related to site, incomplete resections and high mitotic count. Salvage surgery for recurrent disease is associated with a median survival of 15 months.
The prognosis in high risk patients is greatly improved through the use of imatinib, which in the ACOSOG trial (imatinib vs placebo) improved relapse rates from 17% to 2%.
In the UK it is advocated by NICE for use in patients with metastatic disease or locally unresectable disease.
A 23 year old man fractures his right tibia in a sporting accident. At which point in the healing process is fracture callus most likely to be visible radiologically?
1 day
7 days
8 weeks
6 weeks
3 weeks
Fracture callus is composed of fibroblasts and chondroblasts and the synthesis of fibrocartilage. It is typically visible on radiographs approximately 3 weeks following injury. If delayed then there may be risk of non union.
Process of bone fracture healing
Bone fracture
- Bleeding vessels in the bone and periosteum
- Clot and haematoma formation
- The clot organises over a week (improved structure and collagen)
- The periosteum contains osteoblasts which produce new bone
- Mesenchymal cells produce cartilage (fibrocartilage and hyaline cartilage) in the soft tissue around the fracture
- Connective tissue + hyaline cartilage = callus
- As the new bone approaches the new cartilage, endochondral ossification occurs to bridge the gap
- Trabecular bone forms
- Trabecular bone is resorbed by osteoclasts and replaced with compact bone
A 56 year old man is undergoing a carotid endarterectomy. The internal carotid artery is mobilised. How many branches does this vessel give off in the neck?
0
1
2
3
6
The internal carotid does not have any branches in the neck.
Which of the following is a content of the adductor canal?
Saphenous nerve
Sural nerve
Femoral nerve
Profunda branch of the femoral artery
Saphenous vein
It contains the saphenous nerve and the superficial branch of the femoral artery.
Borders of the adductor canal
Lateral border Vastus medialis
Posterior border: Adductor longus, adductor magnus
Roof- sartorius
Contents of the adductor canal
Saphenous nerve (+ nerve to vastus medialis)
Superficial femoral artery
Superficial femoral vein
Theme: Treatment of bowel cancer
A.Active observation
B.Long course chemoirradiation
C.Chemotherapy with oxaliplatin
D.Short course chemotherapy (5 days)
E.Proceed straight to surgery
F.Post operative radiotherapy
G.Chemotherapy with methotrexate
H.Brachytherapy
I.Anterior pelvic exenteration
Please select the most appropriate management option from the list below. Each option may be used once, more than once or not at all.
89.A 45 year old female is diagnosed as having a carcinoma of the caecum. She undergoes a CT scan which shows a tumour invading the muscularis propria with some regional lymphadenopathy.
A 55 year old man presents with tenesmus and rectal bleeding. On examination he has a large bulky rectal cancer at 5cm with tethering to the prostate gland. Imaging shows no distant disease.
A 43 year old women undergoes a sigmoid colectomy for carcinoma. The histology report shows Dukes C disease. She is otherwise well.
Proceed straight to surgery
Right sided colonic cancers should proceed straight to surgery. Radiotherapy to this area is poorly tolerated and almost never offered as first line treatment. The decision as to whether or not chemotherapy is given is dependent upon the final histology.
Long course chemoirradiation
T4 rectal cancers are managed with long course chemoradiotherapy. A dramatic response is not uncommon. To embark on attempted resection at this stage is to court failure.
Chemotherapy with oxaliplatin
Chemotherapy for colonic cancer is usually with oxaliplatin. Neuropathy is a recognised side effect of this treatment.
A 24 year old man presents with a persistent and unwanted erection that has been present for the previous 6 hours. On examination the penis is rigid and tender. Aspiration of blood from the corpus cavernosa shows dark blood. Which of the following is the most appropriate initial management?
Discharge the patient home and review in 12 hours
Admit the patient to hospital and review in 12 hours
Aspirate further blood from the corpus cavernosa in an attempt to decompress
Use a trucut needle to induce an arteriovenous shunt
Administer intracavernosal adrenaline 1 in 500 concentration
Low flow priapism is a urological emergency. Aspiration of bright red blood is more reassuring and may indicate high flow priapism that may be actively monitored. Low flow priapism should be decompressed with aspiration of blood from the corpus cavernosum.
In relation to operating in the elderly which statement is false?
A 30 minute increment in operation length is associated with increase in mortality in patients over the age of 80
Hypoalbuminaemia is associated with increased mortality
Statins given preoperatively reduce perioperative cardiac events
Elevated brain (or B-type) natriuretic peptide (BNP) levels before undergoing non cardiac surgery is associated with high risk of cardiac mortality and all cause mortality
Beta blockers should be stopped acutely prior to surgery due to risk of perioperative hypotension
Beta blockers should not be stopped acutely prior to surgery as there may be a rebound effect associated with increased complications.
Brain natriuretic peptide is a neurohormone synthesized in the cardiac ventricles. Levels have been used to assess prognosis in heart failure and acute coronary syndromes. Preoperative elevated brain natriuretic peptide levels identify patients undergoing non cardiac surgery at high risk of cardiac mortality and all cause mortality.
All patients with peripheral vascular disease should take statins prior to vascular surgery as studies have shown a 50% risk reduction and a reduction in perioperative cardiac events.
POPS approach
Comprehensive geriatric assessment
MDT assessment preoperatively
Main predictors of complications are co-morbidities cardiac disease and reduced functional capacity - preoperative assessment is the key to preventing adverse postoperative outcomes
Patients screened for risk factors (albumin <30, co morbidities)
Management plan made and disseminated to all involved
Patients education: pain relief, post op exercises, nutrition
Fewer postoperative medical complications
Reduced length of stay by 4.5 days
Theme: Instrument cleaning
A.Immersion in glutaraldehyde
B.Gamma irradiation
C.Autoclaving
D.Ethylene chloride
E.Phenolic lavage
F.Disposal of instrument
Please select the most appropriate cleaning method of instrument for the situation described. Each option may be used once, more than once or not at all.
94.A company manufacturing scalpel blades wishes to sterilise them in bulk before use.
For sterilisation and cleaning of a colonoscope.
For cleaning instruments following a tonsillectomy in a patient who recieved human growth hormone extract in 1981
Gamma irradiation
Industry often uses gamma irradiation. It is not routinely used in hospitals
Immersion in glutaraldehyde
Washing systems using glutaraldehyde are often used although development of sensitivity in staff is well known and it is used in closed systems
Disposal of instrument
High risk of prion disease mandates disposal on instruments which is often undertaken following all tonsillectomy procedures regardless of level of percieved risk
From which of these foraminae does the opthalmic branch of the trigeminal nerve exit the skull?
Foramen ovale
Foramen rotundum
Foramen spinosum
Superior orbital fissure
Foramen magnum
Mnemonic:
Standing Room Only -Exit of branches of trigeminal nerve from the skull
V1 -Superior orbital fissure
V2 -foramen Rotundum
V3 -foramen Ovale
The opthalmic branch of the trigeminal nerve exits the skull through the superior orbital fissure.
A 56 year old lady with metastatic breast cancer develops an oestolytic deposit in the proximal femur. One morning whilst getting out of bed she notices severe groin pain. X-rays show that the lesser trochanter has been avulsed. Which muscle is the most likely culprit?
Vastus lateralis
Psoas major
Piriformis
Gluteus maximus
Gluteus medius
The psoas major inserts into the lesser trochanter and contracts when raising the trunk from the supine position. When oestolytic lesions are present in the femur the lesser trochanter may be avulsed.
Of the options below, which does not cause lymphadenopathy?
Kawasaki disease
Systemic Lupus Erthematosus
Phenytoin
Hydralazine
Amiodarone
Amiodarone
A 23 year old man is reviewed on the ward 10 days following a laparotomy. The wound is inspected and is healing well. Which of the following processes is least likely to be occurring in the wound at this stage?
Angiogenesis
Synthesis of collagen
Necrosis of fibroblasts
Secretion of matrix metalloproteinases by fibroblasts
Proliferation of fibroblasts
Vasculogenesis vs Angiogenesis
Vascu is new. Angi is pre
Vasculogenesis is new vessels developing in situ from existing mesenchyme.
Angiogenesis is vessels develop from sprouting off pre-existing arteries.
Fibroblasts are an important cell type in healing wounds. They typically proliferate in the early phases of wound healing. They release matrix metalloproteinases and these facilitate in the remodelling of the matrix within the healing wound. Necrosis in a healing wound would be unusual as wounds will tend to show clinical evidence of angiognesis by this time.
Which of the following nerves is responsible for the motor innervation of the sternocleidomastoid muscle?
Ansa cervicalis
Accessory nerve
Hypoglossal nerve
Facial nerve
Vagus nerve
The motor supply to the sternocleidomastoid is from the accessory nerve. The ansa cervicalis supplies sensory information from the muscle.
A 53 year old man presents with a full thickness external rectal prolapse. Which of the following procedures would be the most suitable surgical option?
Rectopexy
Delormes
Altmeirs
Thirsch tape
Abdomino-perineal excision of the rectum
As this man is young and has full thickness prolapse a rectopexy is the most appropriate procedure. It will give the lowest recurrence rates.
Which of the following is most suggestive of malnutrition?
Hypoalbuminaemia
BMI of 22 kg/m2 and unintentional weight loss of > 5% over 3-6 months
BMI of 18.5 kg/m2
Reduced skin turgor
Unintentional weight loss of > 10% over 3- 6 months in a 60 Kg female who is 1.6m tall
An unintentional weight loss of >10% in a three to six month period is highly suggestive of malnutrition. This is particularly true of people with a normal/ low BMI. Hypoalbuminaemia is not, in itself, a reliable marker of nutrition.
A 42 year old lady undergoes a difficult cholecystectomy and significant bleeding is occurring. The surgeons place a vascular clamp transversely across the anterior border of the epiploic foramen. Which of the following structures will be occluded in this manoeuvre?
Cystic artery
Cystic duct
Left gastric artery
Portal vein
None of the above
The portal vein, hepatic artery and common bile duct are occluded.
Structures occluded during Pringles manoeuvre
During liver surgery bleeding may be controlled using a Pringles manoeuvre, this involves placing a vascular clamp across the anterior aspect of the epiploic foramen. Thereby occluding:
Common bile duct
Hepatic artery
Portal vein
A 34 year old man is injured by farm machinery and sustains a laceration at the superolateral aspect of the popliteal fossa. The medial aspect of biceps femoris is lacerated. Which of the following underlying structures is at greatest risk of injury?
Gracilis
Sural nerve
Nerve to semimembranosus
Popliteal artery
Common peroneal nerve
The common peroneal nerve lies under the medial aspect of biceps femoris and is therefore at greatest risk of injury. The tibial nerve may also be damaged in such an injury (but is not listed here). The sural nerve branches off more inferiorly.
Glasgow criteria
PANCREAS
Pa O2 <60
Age >55
Neutrophils >15
Ca <2
Renal- urea >16
Enzyme (LDH) >600
Albumin <32
Sugar glucose >10
>3 positive criteria indicates severe pancreatitis
A 34 year old lady is admitted with pancreatitis. The aetiology is unclear and it is classified as an attack of moderate severity according to the Glasgow criteria. Her imaging shows no gallstones and fluid around the pancreas. Which of the following is the most appropriate initial management option?
Laparotomy
Laparoscopy
Radiological aspiration of the fluid
Active observation
Administration of octreotide
Acute early fluid collections are seen in 25% of patients with pancreatitis and require no specific treatment. Attempts at drainage may introduce infection and result in pancreatic abscess formation.
Theme: Timing of surgery
A.Immediate surgery
B.Surgery within 2 hours
C.Surgery within 6 hours
D.Surgery within 24 hours
E.Surgery within same hospital admission
F.Urgent elective surgery within 4 weeks
G.True elective surgery
For each procedure please select the most appropriate time interval for surgery. Each option may be selected once, more than once or not at all.
5.A 43 year old woman is admitted with acute cholecystitis, her USS confirms the diagnosis and LFT’s are normal. It is now 10 hours since admission.
A 5 year old boy is admitted with a suspected acute appendicitis. He has tenderness but no guarding as yet. He requires appendicectomy.
A 72 year old man is admitted with large bowel obstruction. He has been vomiting for 24 hours and his caecum is tender and measures 11cm.
Surgery within same hospital admission
Ideal case for acute cholecystectomy. This will enable prompt discharge and facilitate recovery. Whilst expedient surgery is desirable an emergency procedure is not justified.
Surgery within 6 hours
The kind of case that can wait till the following day if presenting out of hours. Appendicectomy may be deferred where peritoneal signs are absent. Where tenderness and guarding are present a more urgent approach is warranted.
Surgery within 6 hours
The sun should not rise and set on unrelieved large bowel obstruction! This patient has a competent ileocaecal valve. As a result lack of surgery would result in caecal perforation leading to faecal peritonitis with and associated high mortality rate.
Which of the following intravenous fluid solutions has the greatest chloride content?
Dextrose / saline
Normal saline
Hartmanns solution
Ringers lactate
5% dextrose
Normal saline has the highest chloride content and excessive administration of normal saline is a recognised risk factor for the development of hyperchloraemic metabolic acidosis.
Electrolyte content of plasma
Na 137-147
K 4.5-5.5
Cl 95-105
Bicarbonate 22-25
Electrolyte content of 0.9% NS
Na 154
Cl 154
Electrolyte content of dextrose/saline
Na 30.6
Cl 30.6
Electrolyte composition of Hartmans
Na 130
K 4
Cl 110
Lactate 28
A 56 year old lady is admitted with colicky abdominal pain. A plain x-ray is performed. Which of the following should not show fluid levels on a plain abdominal film?
Stomach
Jejunum
Ileum
Caecum
Descending colon
Fluid levels in the distal colon are nearly always pathological. In general contents of the left colon transit quickly and are seldom held in situ for long periods, the content is also more solid.
Features that are usually abnormal on abdominal plain film
Large amounts of free air (colonic perforation), smaller volumes are seen with more proximal perforations
Positive Riglers sign
Caecal diameter >8cm
Fluid levels in the colon
Ground glass appearance to film
Sentinal loops
Chiladitis sign?
In Chiladitis sign, a loop of bowel may be interposed between the liver and diaphragm, giving the mistaken impression that free air is present.
Free intra abdominal air following laparoscopy / laparotomy, on AXR
Normal
Should dissipate in 48-72 hours
Air in billiary tree following ERCP
Normal
A 45 year old male is referred to clinic for consideration of resection of a lung malignancy. He reports shortness of breath and haemoptysis. Investigations reveal a corrected calcium of 2.84 mmol/l, an FEV 1 of 1.9L and histology of a squamous cell carcinoma. The patient is noted to have a hoarse voice. Which one of the following is a contraindication to surgical resection in lung cancer?
Haemoptysis
FEV 1 of 1.9 litres
Histology shows squamous cell cancer
Vocal cord paralysis
Calcium = 2.84 mmol/L
Paralysis of a vocal cord implies extracapsular spread to mediastinal nodes and is an indication of inoperability.
Contraindications to lung cancer surgery?
SVCO
FEV <1.5
Malignant pleural effusion
Vocal cord parlaysis
General poor health
Stage IIIb or IV (metastatic disease)
Tumour near hilum
FEV <1.5 in lung cancer surgery?
FEV1 < 1.5 for lobectomy or < 2.0 for pneumonectomy then some authorities advocate further lung function tests as operations may still go ahead based on the results
Surgical management of NSCLC
20% suitable for surgery
Mediastinoscopy performed prior to surgery as CT does not always show mediastinal LN involvement
Curative or palliative radiotherapy
Poor response to CTx
Theme: Knee injuries
A.Anterior cruciate ligament rupture
B.Posterior cruciate ligament rupture
C.Medial collateral ligament tear
D.Lateral collateral ligament tear
E.Torn meniscus
F.Chondromalacia patellae
G.Dislocated patella
H.Fractured patella
I.Tibial plateau fracture
What is the most likely injury for scenario given? Each option may be used once, more than once or not at all.
11.A 38 year old man is playing football when he slips over during a tackle. His knee is painful immediately following the fall. Several hours later he notices that the knee has become swollen. Following a course of non steroidal anti inflammatory drugs and rest the situation improves. However, complains of recurrent pain. On assessment in clinic you notice that it is impossible to fully extend the knee, although the patient is able to do so when asked.
A 34 year old woman is a passenger in a car during an accident. Her knee hits the dashboard. On examination the tibia looks posterior compared to the non injured knee.
A 28 year old professional footballer is admitted to the emergency department. During a tackle he is twisted with his knee flexed. He hears a loud crack and his knee rapidly becomes swollen.
Torn meniscus
Twisting sporting injuries followed by delayed onset of knee swelling and locking are strongly suggestive of a menisceal tear. Arthroscopic menisectomy is the usual treatment.
Posterior cruciate ligament rupture
In ruptured posterior cruciate ligament the tibia lies back on the femur and can be drawn forward during a paradoxical draw test.
Anterior cruciate ligament rupture
This is common in footballers as the football boot studs stick to the ground and high twisting force is applied to a flexed knee. Rapid joint swelling also supports the diagnosis.
Which of the following features does not put a patient at risk of refeeding syndrome?
BMI < 16 kg/m2
Alcohol abuse
Thyrotoxicosis
Chemotherapy
Diuretics
Diuretics increase the risk of re-feeding syndrome through a process of increasing the risk of depletion of key electrolytes.
Metabolic consequences of refeeding syndrome
Hypophosphataemia
Hypokalaemia
Hypomagneseamia
Abnormal fluid balance
Patient not eaten for >5d
Aim to re-feed at 50% energy and protein levels
High risk of refeeding
If one or more of the following:
BMI < 16 kg/m2
Unintentional weight loss >15% over 3-6 months
Little nutritional intake > 10 days
Hypokalaemia, Hypophosphataemia or hypomagnesaemia prior to feeding (unless high)
If two or more of the following:
BMI < 18.5 kg/m2
Unintentional weight loss > 10% over 3-6 months
Little nutritional intake > 5 days
History of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids
Prescription in refeeding syndrome
Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days
Start immediately before and during feeding: oral thiamine 200-300mg/day, vitamin B co strong 1 tds and supplements
Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium (0.2-0.4 mmol/kg/day)
A 56 year old lady undergoes a Hartmans style resection of the sigmoid colon, with ligation of the vessels close to the colon. Which of the following vessels will be responsible to supplying the rectal stump directly?
Superior mesenteric artery
Middle colic artery
Superior rectal artery
Inferior mesenteric artery
External iliac artery
This question is addressing the blood supply to the rectum. Which is supplied by the superior rectal artery. High ligation of the IMA may compromise this structure. However, the question states that during the Hartmans procedure the vessels were ligated close to the bowel. Implying that the superior rectal was preserved.
What marks the transition between the rectum and the sigmoid colon?
Disappearance of taenia coli
Extraperitoneal extent of the rectum
Posterior upper third
Posterior and lateral middle third
Whole lower third
Lymphatic drainage of the rectum
Mesorectal lymph nodes (superior to dentate line)
Inguinal nodes (inferior to dentate line)
Which of the nerves listed below is at greatest risk of injury with a laceration to the upper lateral margin of the popliteal fossa?
Common peroneal nerve
Sural nerve
Sciatic nerve
Saphenous nerve
Tibial nerve
Common peroneal
The sural nerve exits at the lower infero-lateral aspect of the fossa and is more at risk in short saphenous vein surgery. The tibial nerve lies more medially and is even less likely to be injured in this location.
Which option is false in relation to the trigeminal nerve?
The nerve originates at the pons
The posterior scalp is supplied by the trigeminal nerve
The maxillary nerve exits via the foramen rotundum
The maxillary nerve is purely sensory
The motor root is not in the trigeminal ganglion
The posterior scalp is supplied by C2-C3.
Path of the trigeminal nerve
Originates at the pons
Sensory root forms the large, crescenteric trigeminal ganglion within Meckel’s cave, and contains the cell bodies of incoming sensory nerve fibres. Here the 3 branches exit.
The motor root cell bodies are in the pons and the motor fibres are distributed via the mandibular nerve. The motor root is not part of the trigeminal ganglion.
Which of the trigeminal nerve branches has motor function?
Mandibular nerve
A patient has an appendicectomy and a 1.2cm carcinoid tumour is identified in the tip of the appendix. What is the most appropriate management?
Watchful waiting
Discharge
Right hemicolectomy
Limited ileocaecal resection
Radioisotope scan
Individuals with small carcinoids can be discharged (<2cm and limited to the appendix). Larger tumours should have a radioisotope scan. Where the resection margin is positive or where the isotope scan suggests lymphatic metastasis a right hemicolectomy should be performed.
Which of the following is not an absorbable suture material?
Chromic catgut
Nylon
Vicryl
Dexon
Poly diaxone (PDS).
Nylon
Apex of the posterior triangle of the neck
SCM and trapezius muscles at the occipital bone
Anterior border of the posterior triangle of the neck
Posterior border of SCM
Posterior border of the posterior triangle of the neck
Anterior border of trapezius
Base of the posterior triangle of the neck
Middle third of the clavicle
Nerves in the posterior triangle of the neck
Accessory
Phrenic
Three trunks of the brachial plexus
Branches of the cervical plexus: supraclavicular, transverse cervical, great auricular, lesser occipital nerve
Vessels in the posterior triangle of the neck
EJV
Subclavian
Muscles in the posterior triangle of the neck
Inferior belly of omohyoid
Scalene
LNs in the posterior triangle of the neck
Supraclavicular
Occipital
Which of the following statements relating to the regulation of renal blood flow is untrue?
In a healthy 70Kg male, the glomerular filtration rate will be the same at a systolic blood pressure of 120mmHg as a systolic blood pressure of 95 mmHg
Over 90% of the blood supply to the kidney is distributed to the cortex
The kidney receives approximately 25% of the total cardiac output at rest
A decrease in renal perfusion pressure will cause the juxtaglomerular cells to secrete renin
Systolic blood pressures of less than 65mmHg will cause the mesangial cells to secrete aldosterone
The kidney autoregulates its blood supply over a range of systolic blood pressures. Drop in arterial pressure is sensed by the juxtaglomerular cells and renin is released leading to the activation of the renin-angiontensin system. Mesangial cells are contractile cells that are located in the tubule and have no direct endocrine function.
A 48 year old lady is admitted with crampy abdominal pain and diarrhoea. She has been unwell for the past 12 hours. In the history she complains that her milk bottles have been pecked repeatedly by birds, she otherwise has had no dietary changes. Which of the following is the most likely causative organism?
Staphylococcus aureus
Campylobacter jejuni
Clostridium difficile
Norovirus
Clostridium botulinum
Birds are a recognised reservoir of campylobacter.
Theme: Lower limb ulceration
A.Mixed ulcer
B.Chronic obliterative arterial disease
C.Superficial venous insufficiency
D.Deep venous insufficiency
E.Neuropathic ulcer
F.Basal cell carcinoma
G.Squamous cell carcinoma
Please select the most likely cause of ulceration for the scenario given. Each option may be used once, more than once or not at all.
25.A 65 year old diabetic female presents with a painless ulcer at the medial malleolus, it has been present for the past 16 years. On examination she has evidence of truncal varicosities and a brownish discolouration of the skin overlying the affected area.
A 71 year old man presents with a painful lower calf ulcer, mild pitting oedema and an ABPI of 0.3.
A 79 year old retired teacher has had an ulcer for 15 years. It is at the medial malleolus and has associated lipodermatosclerosis of the lower limb. The ulcer base is heaped up and irregular.
Superficial venous insufficiency
Venous ulcers are usually associated with features of venous insufficiency. These include haemosiderin deposition and varicose veins. Neuropathic ulcers will tend to present at sites of pressure, which is not typically at the medial malleolus.
Chronic obliterative arterial disease
Painful ulcers associated with a low ABPI are usually arterial in nature. The question does not indicate that features of chronic venous insufficiency are present. Patients may have mild pitting oedema as many vascular patients will also have ischaemic heart disease and elevated right heart pressures. The absence of more compelling signs of venous insufficiency makes a mixed ulcer less likely.
Squamous cell carcinoma
If after many years an ulcer becomes heaped up and irregular, with rolled edges then suspect a
squamous cell carcinoma.
A 50-year-old female with a history of rheumatoid presents with a suspected septic knee joint. A diagnostic aspiration is performed and sent to microbiology. Which of the organisms below is most likely to be responsible?
Staphylococcus aureus
Staphylococcus epidermidis
Escherichia coli
Neisseria gonorrhoeae
Streptococcus pneumoniae
Septic arthritis - most common organism: Staphylococcus aureus
Common organsism causing septic arthritis
Most common organism overall is Staphylococcus aureus
In young adults who are sexually active Neisseria gonorrhoeae should also be considered
Management of septic arthritis
Obtain synovial fluid before commencing treatment
IV abx with Gram +ve cocci- Fluclox (clind if penallergic)
6-12/52 Abx
Needle aspiration to decompress joint
Arthroscopic lavage may be required
Which of the following is not a feature of oesphageal atresia in neonates?
High incidence of polyhydramnios
Risk of recurrence in subsequent pregnancies of 80%
Distal tracheoesphageal fistula is the commonest variant
High incidence of associated imperforate anus
Absence of gastric bubble on antenatal ultrasound
Most are sporadic and risk in subsequent pregnancies is not increased.
Action of serratus anterior
Pushing out of the scapula
Other causes of winging of the scapula
LTN
Spinal accessory nerve injury (denervating the trapezius)
Dorsal scapular nerve injury
A 36 year old male is admitted for elective surgery for a lymph node biopsy in the supraclavicular region. Post operatively the patient has difficulty shrugging his left shoulder. What is the most likely reason?
Phrenic nerve lesion
Axillary nerve lesion
C5, C6 root lesion
C8, T1 root lesion
Accessory nerve lesion
The accessory nerve lies in the posterior triangle and may be injured in this region. Apart from problems with shrugging the shoulder, he may also have difficulty lifting his arm above his head.
Beta-naphthalamine is associated with which of the following malignancies?
Lung cancer
Bowel cancer
Bladder cancer
Liver cancer
Renal cancer
Bladder canacer
What are the main occupational cancers?
In men the main cancers include:
Mesothelioma
Bladder cancer
Non melanoma skin cancer
Lung cancer
Sino nasal cancer
Latency period between exposure and disease in occupational cancers
15 years for solid tumours
20 years for leukaemia
Theme: Types of stroke
A.Anterior cerebral artery infarct
B.Middle cerebral artery infarct
C.Posterior cerebral artery infarct
D.Pituitary mass
E.Lacunar infarct
F.Lateral medullary syndrome
G.Pontine infarct
H.Horner’s syndrome
I.Cerebellar infarct
Please select the most likely cause for the symptoms given. Each option may be used once, more than once or not at all.
34.A 53 year old teacher is admitted to the vascular ward for a carotid endarterectomy. Your house officer does a preoperative assessment and notes that there is a right homonymous hemianopia. There is no other neurology.
A 52 year man is admitted to the vascular ward for an amputation. The patient complains of unsteadiness. On further examination you detect right facial numbness and right sided nystagmus. There is sensory loss of the left side of the body.
A 48 year old type 2 diabetic complains of numbness in his left arm and leg. Otherwise there is no other neurological signs.
Posterior cerebral artery infarct
This patient has had a left occipital infarct, as there is only a homonymous hemianopia. If this patient had a temporal or parietal lobe infarct, there would be associated hemiparesis and higher cortical dysfunction. This is important to differentiate, as the carotid endarterectomy is inappropriate in this patient as the lesion is in the posterior cerebral artery.
Lateral medullary syndrome
A combination of ipsilateral ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy with contralateral hemisensory loss indicates this diagnosis.
Lacunar infarct
Isolated hemisensory loss is a feature of a lacunar infarct.
What proportion of strokes are PICH?
10%
What proportion of strokes are TACI?
15%
What proportion of strokes are PACI?
25%
What proportion of strokes are LACI?
25%
What proportion of strokes are POCI?
25%
Stroke
Presents with headache, vomiting, loss of consciousness
Primary intracerebral haemorrhage (PICH, c. 10%)
Involves middle and anterior cerebral arteries
Hemiparesis/hemisensory loss
Homonymous hemianopia
Higher cognitive dysfunction e.g. Dysphasia
Total anterior circulation infarcts (TACI, c. 15%)
Criteria for TACI
3/3 of:
hemiparesis/hemisensory loss
homonomyous hemianopia
Higher cognitive dysfunction e.g. dysphasia/negelct
Involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
Higher cognitive dysfunction or two of the three TACI features
Partial anterior circulation infarcts (PACI, c. 25%)
Criteria for PACI
Higher cognitive dysfunction or 2/3 TACI features
Involves perforating arteries around the internal capsule, thalamus and basal ganglia
Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
Lacunar infarcts
Vertebrobasilar arteries
Presents with features of brainstem damage
Ataxia, disorders of gaze and vision, cranial nerve lesions
Posterior circulation infarcts
Wallenberg’s syndrome
Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy
Contralateral: limb sensory loss
Lateral medullary syndrome
Lateral medullary syndrome
DANVAH
Dysphagia
Ataxia (ipsilateral)
Nystagmus (ipsilateral)
Vertigo
Anaesthesia: ipsilateral facial numbeness and absent corneal reflex, contralatearl pain loss
Horner’s syndrome: ipsilateral
Anaesthesia in lateral medullary syndrome
Ipsilateral facial numbness and absent corneal reflex
Contralateral pain loss
Ipsilateral III palsy
Contralateral weakness
Weber’s syndrome
Contralateral hemiparesis and sensory loss, lower extremity > upper
Disconnection syndrome
ACA infarction
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral hemianopia
Aphasia (Wernicke’s)
Gaze abnormalities
MCA infarct
Contralateral hemianopia with macular sparing
Disconnection syndrome
Posterior cerebral artery
Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
Lacunar
VI nerve: horizontal gaze palsy
VII nerve
Contralateral hemiparesis
Pontine infarct
How many fissures are present within the right lung?
One
Three
Two
Four
Five
The right lung has an oblique and horizontal fissure. The upper oblique fissure separates the inferior from the middle and upper lobes. The short horizontal fissure separates the superior and middle lobes.
A 52 year old man is recovering following an elective right hemicolectomy for carcinoma of the caecum. His surgery is uncomplicated, when should oral intake resume?
Only once bowels have been opened to stool
Only once the patient has passed flatus
Between 24 and 48 hours of surgery
More than 48 hours after surgery
Within 24 hours of surgery
As part of the enhanced recovery principles oral intake in this setting should resume soon after surgery. Administration of liquid and even light diet does not increase the risk of anastomotic leak.
What are the different types of shock?
CHOD
Cardiogenic
Hypovolaemic- haemorrhagic, endocrine, excess loss, third spacing
Obstructive: PE, DVT
Distributive: sepsis, anaphylaxis, neurogenic
Def: sepsis
Infection that triggers a particular SIRS
def: SIRS
Temp <36 >38
HR >90 bpm
RR >20
WCC 12 or <4
Altered mental state or hyperglycaemia in the absence of DM
Def: sepsis
Infection + 2 or more SIRS criteria
Severe sepsis
Those with sepsis and organ failure
Septic shock
Severe sepsis with refractory hypotension
Neurogenic shock
This occurs most often following a spinal cord transection, usually at a high level. There is resultant interruption of the autonomic nervous system. The result is either decreased sympathetic tone or increased parasympathetic tone, the effect of which is a decrease in peripheral vascular resistance mediated by marked vasodilation.
This results in decreased preload and thus decreased cardiac output (Starlings law). There is decreased peripheral tissue perfusion and shock is thus produced. In contrast with many other types of shock peripheral vasoconstrictors are used to return vascular tone to normal.
Cardiogenic shock
In medical patients the main cause is ischaemic heart disease. In the traumatic setting direct myocardial trauma or contusion is more likely. Evidence of ECG changes and overlying sternal fractures or contusions should raise the suspicion of injury. Treatment is largely supportive and transthoracic echocardiography should be used to determine evidence of pericardial fluid or direct myocardial injury. The measurement of troponin levels in trauma patients may be undertaken but they are less useful in delineating the extent of myocardial trauma than following MI.
When cardiac injury is of a blunt nature and is associated with cardiogenic shock the right side of the heart is the most likely site of injury with chamber and or valve rupture. These patients require surgery to repair these defects and will require cardiopulmonary bypass to achieve this. Some may require intra aortic balloon pump as a bridge to surgery.
Muscles innervated by musculocutaneous nerve
BBC
Biceps brachii
Brachialis
Coracobrachialis
Path of the musculocutaneous nerve
It penetrates the coracobrachialis muscle
Passes obliquely between the biceps brachii and the brachialis to the lateral side of the arm
Above the elbow it pierces the deep fascia lateral to the tendon of the biceps brachii
Continues into the forearm as the lateral cutaneous nerve of the forearm
Theme: Management of urinary obstruction
A.Discharge
B.Start oxybutynin
C.Intravenous antibiotics
D.Urethral catheter
E.Emergency nephrostomy
F.Antegrade ureteric stent
G.Retrograde ureteric stent
What is the best management for the scenario given? Each option may be used once, more than once or not at all.
41.A 68 year old man has a TCC of the bladder. He has a right hydronephrosis detected on ultrasound and deteriorating renal function. A DMSA scan shows a non functioning left kidney.
A 52 year old male with hypercalcaemia secondary to primary hyperparathyroidism presents with renal colic. USS demonstrates ureteric obstruction due to a stone. Multiple attempts at stone extraction are performed. However, the stone could not be removed. He is now septic with a pyrexia of 39.5 oc and he has been given antibiotics.
A 56 year old man is admitted with acute retention of urine. He has had a recent urinary tract infection. An USS shows bilateral hydronephrosis.
Antegrade ureteric stent
A TCC occluding the ureteric orifice will obscure its identification during surgery, so that passage of a retrograde stent is difficult. Therefore passage of a stent from the renal pelvis is preferable.
Emergency nephrostomy
The likely scenario is that this man has developed a calculus causing ureteric obstruction. The stagnant column of urine can become colonised and infected. An infected obstructed system is one of the few true urological emergencies. A nephrostomy is needed as the stone could not be removed.
Urethral catheter
Establishing bladder drainage will often correct the situation. These patients often have a significant diuresis with associated electrolyte disturbance.
Causes of unilateral hydronephrosis
PACT
Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis
Causes of bilateral hydronephrosis
SUPER
Stenosis of urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
RPF
Ix in hydronephrosis
USS- identifies presence of hydronephrosis and can assess the kidneys
IVU- assess the position of the obstruction
Antegrade or retrograde pyelography- allows treatment
If renal colic suspected: non contrast CT scan (majority of stones are detected this way)
A 6 month old boy is brought to the clinic with difficulty breathing and weight loss. On examination, he is found to have a firm para testicular mass. What is the most likely diagnosis?
Teratoma
Seminoma
Adenocarcinoma
Rhabdomyosarcoma
Malignant fibrous histiocytoma
Rhabdomyosarcomas are one of the more common malignant solid tumours in children (though all are rare). They have an aggressive behavior pattern and metastases are common. Teratomas are nearly always benign in younger children. Seminomas are very rare indeed. Malignant fibrous histiocytomas are almost never found in this location.
A 22 year old man presents with crampy abdominal pain diarrhoea and bloating. He has just returned from a holiday in Egypt. He had been swimming in the local pool a few days ago. He reports that he is opening his bowels 5 times a day. The stool floats in the toilet water, but there is no blood. What is the most likely cause?
Cryptosporidium
Salmonella sp
E.coli sp
Chronic pancreatitis
Giardia lamblia
Giardia causes fat malabsorption, therefore greasy stool can occur. It is resistant to chlorination, hence risk of transfer in swimming pools.
Def: diarrhoea
>3 loose or watery stools per day
Acute <14
Chronic >14
Causes of acute diarrhoea
Gastroenteritis
Diverticulitis
Abx
Constipation causing overflow
Causes of chronic diarrhoea
IBS
UC
CD
CRC
Coeliac
Other conditions associated with diarrhoea
Thyrotoxicosis
Laxative abuse
Appendicits with pelvic abscess or pelvic appendix
Radiation enteritis
A 56 year old man with Wilsons disease presents with right upper quadrant discomfort. An ultrasound scan is performed and this demonstrates a mass lesion in the right lobe of the liver. What is the most appropriate method of establishing the underlying diagnosis?
PET CT scan
Ultrasound guided biopsy
Measurement of serum alpha feto protein
MRI scan of the liver
CT scan of the liver
High AFP + chronic liver inflammation = Hepatocellular carcinoma.
This is likely to be a hepatocellulcar carcinoma. Diagnosis is usually made by AFP measurement (with further imaging depending on the result). Biopsy should not be performed as it may seed the tumour. Chronic liver diseases such as Wilsons disease (Hepato-lenticular degeneration) increase the risk.
Theme: Visual defects
A.Right homonymous hemianopia
B.Left homonymous hemianopia
C.Right superior quadranopia
D.Left superior quadranopia
E.Right inferior quadranopia
F.Left inferior quadranopia
G.Upper bitemporal hemianopia
H.Lower bitemporal hemianopia
What is the most likely visual field defect for the scenario given? Each option may be used once, more than once or not at all.
47.A 42 year old woman is admitted to the vascular ward for an endarterectomy. Her CT report confirms a left temporal lobe infarct.
A 22 year old man is referred to urology with possible urinary retention. He is passing huge amounts of urine. Post void bladder ultrasound is normal.
A 53 year old man is admitted to the vascular ward for a carotid endarterectomy. His CT head report confirms a left parietal lobe infarct.
Right superior quadranopia
Temporal lesions cause a contralateral superior quadranopia. Think temporal area is at the top of the head i.e. superior quadranopia.
Lower bitemporal hemianopia
This patient has diabetes insipidus due to a craniopharyngioma. Lesions at the optic chiasm classically produce a bitemporal hemianopia, however note lesions that spread up from below ie pituitary tumours, the defect is worse in the upper fields and if a lesion spreads down from above ie craniopharyngiomas, the visual defect is worse in the lower quadrants. Therefore this patient is likely to have a lower bitemporal hemianopia.
Right inferior quadranopia
Parietal lesions cause a contralateral inferior quadranopia.
Temporal vs parietal visual field defct
PITS
Parietal: inferior
Temporal: superior
Pituitary vs craniopharyngioma defect
Pituitary: Upper field
Cranipharyngiomas: lower field
Incongruous visual field defect
Optic tract lesion
Congruous visual field defect
Optic radiation or occipital cortex
Macula sparing visual field defect
Lesion of occipital cortex
A 66 year old man is admitted with severe angina. There is a lesion of the proximal left anterior descending coronary artery. Which of the following would be the most suitable conduit for bypass?
Long saphenous vein
Short saphenous vein
Cephalic vein
Internal mammary artery
Thoraco-acromial artery
The internal mammary artery is an excellent conduit for coronary artery bypass. It has better long term patency rates than venous grafts. The thoraco-acromial artery is seldom used.
Indications for surgery in cardiopulmonary bypass
Left main stem stenosis or equivalent (proximal LAD and proximal circumflex)
Triple vessel disease
Diffuse disease unsuitable for PCI
CABG is the preferred treatment in high-risk patients with severe ventricular dysfunction or DM
Technique in bypass
General anaesthesia
Central and arterial lines
Midline sternotomy or left sub mammary incision
Aortic root and pericardium dissected
Heart inspected
Bypass grafting may be performed using a cardiopulmonary bypass circuit with cardiac arrest or using a number of novel ‘off pump’ techniques.
Procedure of cardiopulmonary bypass
Aortic root cannulated
Right atrial cannula
Circuit primed and patient fully heparinised (30,000 Units unfractionated heparin) as the circuit is highly thrombogenic
Flow established through circuit
Aortic cross clamp applied
Cardioplegia solution instilled into the aortic root below cross clamp
Heart now asystolic and ready for surgery
What are the potential conduits for bypass?
Internal mammary artery is best
Radial artery
Reverse long saphenous vein grafts
Issues with bilateral internal mammary arteries being used for CABG
Increased risk of sternal wound ehisence
What must be done before radial artery is harvested for cardiopulmonary bypass?
Ensure adequate ulnar collateral supply
What should happen once flow is established through conduits for bypass
Once flow established
Anticoagulation reversed using protamine
Patient is taken off bypass
Inotropes given if needed
Sternum closed using sternal closure device or stainless steel wire
Complications of cardiopulmonary bypass surgery
Post perfusion syndrome: transient cognitive impairment
Non union of the sternum; due to loss of the internal thoracic artery
Myocardial infarction
Late graft stenosis
Acute renal failure
Stroke
Gastrointestinal
A 55 year old man has suffered from reflux oesophagitis for many years. During a recent endoscopy a biopsy is taken from the distal oesophagus. The histopathology report indicates that cells are identified with features of coarse chromatin and abnormal mitoses. The cells are confined to the superficial epithelial layer only. Which of the following accounts for this process?
Metaplasia
Apoptosis
Autoimmune oesophagitis
Dysplasia
Infection with Helicobacter pylori
Dysplasia = pre cancerous
Dysplasia tends to develop as a result of prolonged stimulation by precipitants. Removal of these precipitants may possibly reverse these changes. Replacement of differentiated cells with another cell type describes metaplasia rather than dysplasia. The absence of invasion distinguishes this from malignancy.
Which one of the following confers the least risk of developing osteoporosis?
Obesity
Long term unfractionated heparin therapy
Gastrectomy
Osteogenesis imperfecta
Diabetes
Obesity
Low body weight is a risk factor for osteoporosis
Risk factors for osteoporosis
Family history
Female sex
Increasing age
Deficient diet
Sedentary lifestyle
Smoking
Premature menopause
Low body weight
Caucasians and Asians
Diseases predisposing to osteoporosis
Endocrine: glucocorticoid excess (e.g. Cushing’s, steroid therapy), hyperthyroidism, hypogonadism (e.g. Turner’s, testosterone deficiency), growth hormone deficiency, hyperparathyroidism, diabetes mellitus
Multiple myeloma, lymphoma
Gastrointestinal problems: inflammatory bowel disease, malabsorption (e.g. Coeliacs), gastrectomy, liver disease
Rheumatoid arthritis
Long term heparin therapy
Chronic renal failure
Osteogenesis imperfecta, homocystinuria
A 22 year old man has a full thickness burn on his chest. It is well circumscribed. In A&E his saturations are reduced to 92% on 15L Oxygen, Blood pressure 102/66 mmHg and HR 105bpm. What is the best management?
Haemodialysis
Escharotomy
Fasciotomy
Cardiac bypass
Non invasive ventilation
The chest burn and its associated oedema is limiting respiration. Therefore an escharotomy of the chest is indicated, this will remove the constriction on the chest wall and improve ventilation.
Theme: Muscle relaxants
A.Atracurium
B.Suxamethonium
C.Pancuronium
D.Vecuronium
E.Curare
Please select the muscle relaxant that applies to the scenario or description supplied. Each option may be used once, more than once or not at all.
An agent that is degraded by hydrolysis and may produce histamine release.
An agent which should be avoided in a 23 year old man with burns and bilateral tibial fractures after being trapped in a car accident for 2 hours.
An agent with a half life of less than 10 minutes
Atracurium
Atracurium is degraded by a process of ester hydrolysis. This uses non specific plasma esterases.
Suxamethonium
Suxamethonium may induce hyperkalaemia as it induces generalised muscular contractions. In patients with likely extensive tissue necrosis this may be sufficient to produce cardiac arrest.
Suxamethonium
Suxamethonium is extremely rapidly metabolised, acetylcholinesterases degrade the drug within minutes. In patients who lack this enzyme the drug may last far longer.
A 63 year old man has a history of claudication that has been present for many years. He is recently evaluated in the clinic and a duplex scan shows that he has an 85% stenosis of the superficial femoral artery. Two weeks later he presents with a 1 hour history of severe pain in his leg. On examination he has absent pulses in the affected limb and it is much cooler than the contra-lateral limb. Which process best accounts for this presentation?
Thrombosis
Embolus
Atheroma growth
Sub intimal dissection
Anaemia
In an existing lesion a complication such as thrombosis is more likely than embolus. These patients should receive heparin and imaging with duplex scanning. Whilst an early surgical bypass or intra-arterial thrombolysis may be indicated, an embolectomy should not generally be performed as the lesion is not an embolus and the operation therefore ineffective.
Which of the following statements relating to the posterior cerebral artery is false?
It supplies the visual cortex
It is closely related to the 3rd cranial nerve
It is a branch of the basilar artery
It is connected to the circle of Willis via the superior cerebellar artery
When occluded may result in contralateral loss of field of vision
The posterior cerebral arteries are formed by the bifurcation of the basilar artery and is connected to the circle of Willis via the posterior communicating artery.
The posterior cerebral arteries supply the occipital lobe and part of the temporal lobe.
Which of the following drugs causes hyperkalaemia?
Heparin
Ciprofloxacin
Salbutamol
Levothyroxine
Codeine phosphate
Both unfractionated and low-molecular weight heparin can cause hyperkalaemia. This is thought to be caused by inhibition of aldosterone secretion. Salbutamol is a recognised treatment for hyperkalaemia.
Which of the following statements relating to gastric banding for obesity is false?
It is one of the safest anti obesity operations
If successful up to 55% of excess weight may be lost over 2 years
Excessively tight gastric bands have increased risk of long term complications
It is associated with early satiety
It is contra indicated in patients with polycystic ovaries who are trying to conceive
Adjustable gastric bands are one of the most widely performed anti obesity procedures in the UK. They are relatively easy to insert. Weight loss is slightly slower than with some of the other weight loss procedures. Up to 15% patients may require revisional surgery.
An elderly lady falls and lands on her hip. On examination, her hip is tender to palpation and x-rays are taken. There are concerns that she may have an intertrochanteric fracture. What is the normal angle between the femoral neck and the femoral shaft?
90o
105o
80o
130o
180o
The normal angle between the femoral head and shaft is 130o. Changes to this angle may occur as a result of disease or pathology and should be investigated.
A 22 year old man suffers a compound fracture of the tibia. During attempted surgical repair the deep peroneal nerve is divided. Which of the following muscles will not be affected as a result?
Tibialis anterior
Peroneus longus
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
Peroneus longus is innervated by the superficial peroneal nerve (L4, L5, S1).
A 73 year old lady sustains a distal radius fracture and this is manipulated using a Biers block with prilocaine as the local anaesthetic agent. During the procedure the occlusion cuff deflates and the patient becomes progressively cyanosed. What is the treatment of choice?
Intravenous calcium gluconate
Exchange transfusion
Intravenous methylene blue
Intravenous sodium thiosulphate
Intravenous gelofusine
Prilocaine is a recognised cause of methaemoglobinaemia, this is characterised by the development of cyanosis and dyspnoea. This disorder occurs because of the change haemoglobin to a ferric subtype rather than ferrous (Fe2+). This type of change shifts the oxygen dissociation curve to the left and tissue hypoxia occurs. Methylene blue will revert the haemoglobin to the ferrous type and reverse this effect.
With which of the following blood products is iatrogenic septicaemia with a gram positive organism most likely?
Cryoprecipitate
Platelets
Packed red cells
Factor VIII concentrate
Factor IX concentrate
Platelets are stored at room temperature and must be used soon after collection. This places them at increased risk of culturing gram positive organisms. Iatrogenic infection with gram negative organisms is more likely with packed red cells as these are stored at 4 degrees.
Infections with blood products of this nature are both rare.
A 12 day old infant is brought to the emergency department by his anxious mother who notices that he has developed a right sided groin swelling. On examination the testes are correctly located but it is evident that the child has a right sided inguinal hernia. It is soft and easily reduced. What is the most appropriate management?
Surgery over the next few days
Reassure and discharge
Surgery at 1 year of age
Surgery once the child is 6 months old
Application of a hernia truss
Inguinal hernia in infants = Urgent surgery
The high incidence of strangulation necessitates an urgent herniotomy be performed. In infants with a reducible hernia this can be performed on a daycase list during the same week. Deferring surgery on the basis of age is not justified.
Management of paediatric inguinal hernia in young infants
Children presenting in the first few months of life are at the highest risk of strangulation and the hernia should be repaired urgently. Children over 1 year of age are at lower risk and surgery may be performed electively. For paediatric hernias a herniotomy without implantation of mesh is sufficient. Most cases are performed as day cases, neonates and premature infants are kept in hospital overnight as there is a recognised increased risk of post operative apnoea.
A patient receives atropine as pre medication prior to a laparotomy. Which of the following is least likely to occur?
Pupillary dilation
Dry mouth
Urinary retention
Bradycardia
Decreased salivation
Since it inhibits vagal tone, the use of atropine will typically result in an increased heart rate.
Atropine
Atropine is a muscarinic receptor antagonist (competitive antagonist for the muscarinic acetylcholine receptor). It therefore inhibits parasympathetic activity.It was traditionally used as a premedication for anaesthesia because it reduced bronchial secretions, salivary secretions and bradycardia from increased vagal tone on anaesthetic induction. Modern anaesthetic techniques have reduced the need for routine use of this drug. Its other effects include urinary retention and pupillary dilatation.
The following are true of carcinoid tumours except:
When present in the appendix tip and measure less than 2 cm have an excellent prognosis
Even when metastatic disease is present it tends to follow a protracted course
When present in the appendix body tend to present with carcinoid syndrome even when liver metastases are not present
May be imaged using 5 HIAA radionucleotide scanning
Advanced appendiceal carcinoids may require right hemicolectomy
Liver metastases are necessary for the presence of carcinoid syndrome.
During a difficult femoro-popliteal bypass operation the surgeon inadvertently places a clamp across the femoral nerve. It remains there for most of the procedure. At the end of the operation the nerve is inspected, it is in continuity but has evidence of being crushed. Which of the following is most likely to occur over the following weeks?
Wallerian degeneration
Rapid restoration of neuronal function because the axon itself is intact
Normal but delayed neuronal transmission due to disruption of the myelin
Absence of neuroma formation
None of the above
A neuronal injury such as this will result in Wallerian degeneration even though the nerve remains in continuity. Neuromas may well form.
Theme: Pre operative preparation
A.Methylene Blue intravenously 1 hour pre-operatively
B.Lugol’s iodine
C.100ml single cream given 4 hours prior to surgery
D.Carbohydrate loading drink 2 hours prior to surgery
E.Picolax sachet
F.Fleet enema
G.Intravenous calcium chloride
H.1mg lorazepam orally 30 minutes pre operatively
I.Patent blue dye intravenously
For each procedure please select the most appropriate procedure specific preparation required. Each option may be used once, more than once or not at all.
71.A 45 year old man is due to undergo an Ivor Lewis oesophagectomy for a carcinoma of the distal oesophagus.
A 32 year old man is due to undergo a right hemicolectomy for a large caecal sessile polyp.
A 67 year old women is due to undergo a parathyroidectomy for a parathyroid adenoma.
100ml single cream given 4 hours prior to surgery
This will facilitate identification of the thoracic duct if it is inadvertently divided during the operation.
Carbohydrate loading drink 2 hours prior to surgery
This is now a standard feature of colonic enhanced recovery programmes.The administration of carbohydrate rich loading drinks results in lower incidence of ileus. The drink is usually administered 2 hours pre-operatively and is rapidly absorbed from the GI tract.
Methylene Blue intravenously 1 hour pre-operatively
Though not universally adopted, many endocrine surgeons will administer methylene blue as it will facilitate identification of the parathyroid glands.
Theme: Management of colonic disease
A.Reassure and discharge
B.Right hemicolectomy
C.Left hemicolectomy
D.Hot biopsy
E.Snare polypectomy
F.Single colonoscopy
G.Annual colonoscopy
H.Colonoscopy every 3-5 years
I.Panproctocolectomy
J.Measure faecal calprotectin
For each scenario given please select the most appropriate management option. Each option may be used once, more than once or not at all.
74.A 25 year old male presents with altered bowel habit. He is known to have familial polyposis coli. A colonoscopy shows widespread polyps, with high grade dysplasia in a polyp removed from the rectum.
A 19 year old female presents with colicky abdominal pain, bloating and alternating constipation/diarrhoea. Her grandmother died from colon cancer at the age of 77 years. A digital rectal examination and general physical examination are normal.
A 62 year old man is being investigated for iron deficiency anaemia. During a colonoscopy a flat polypoidal lesion is identified in the caecum. Biopsies of this lesion demonstrate high grade dysplasia.
Panproctocolectomy
There is a high risk of conversion to malignancy, therefore panproctocolectomy is the safest option.
Measure faecal calprotectin
This girl fulfills the Rome criteria for irritable bowel syndrome. Examination is normal, therefore it’s likely that this patient will have IBS. However, its prudent to exclude IBD and since endoscopy is poorly tolerated in patients with IBS, measurement of faecal calprotectin is a reasonable alternative.
Right hemicolectomy
High grade dysplasia in a flat villous lesion of the right colon is highly likely to be associated with an invasive lesion at this site. Hot biopsy of right sided colonic lesions is unwise an snare polypectomy would be unlikely to remove the entire lesion.
A 25-year-old man who has been morbidly obese for the past five years is reviewed in the surgical bariatric clinic. In this patient, release of which of the following hormones would increase appetite?
Leptin
Thyroxine
Adiponectin
Ghrelin
Serotonin
Obesity hormones
leptin decreases appetite
ghrelin increases appetite
Action of leptin
Leptin is thought to play a key role in the regulation of body weight. It is produced by adipose tissue and acts on satiety centres in the hypothalamus and decreases appetite. More adipose tissue (e.g. in obesity) results in high leptin levels.
Leptin stimulates the release of melanocyte-stimulating hormone (MSH) and corticotrophin-releasing hormone (CRH). Low levels of leptin stimulates the release of neuropeptide Y (NPY)
Action of ghrelin
Where as leptin induces satiety, ghrelin stimulates hunger. It is produced mainly by the fundus of the stomach and the pancreas. Ghrelin levels increase before meals and decrease after meals
Theme: Local anaesthetics
A.1% xylocaine with 1 in 200,000 adrenaline
B.1% Lignocaine
C.0.5% Bupivacaine with 1 in 200,000 adrenaline
D.0.5% Bupivacaine
E.Prilocaine 1%
F.Procaine 1%
G.Cocaine 4%
H.Cocaine 10%
Please select the local anaesthetic formulation most appropriate to the procedure indicated. Each option may be used once, more than once or not at all.
79.A 28 year old man has a sebaceous cyst of the scalp that requires excision.
A 32 year old man has an appendicectomy performed through a Lanz incision, which anaesthetic would you infiltrate the wound with to provide post operative analgesia.
A 43 year old man is due to undergo a vasectomy.
1% xylocaine with 1 in 200,000 adrenaline
As scalp wounds can bleed profusely an adrenaline containing solution is preferred. Xylocaine is similar to lignocaine in its onset and duration of action.
0.5% Bupivacaine
A long acting local anaesthetic is preferred.There is little advantage to adding a short acting local anaesthetic agent since by the time the patient has recovered following surgery the bupivacaine will be active.
1% Lignocaine
Plain lignocaine will suffice. This will give rapid onset of action. Bupivacaine will take too long to take effect. There would be little additional benefit derived for adding adrenaline.
A 16 year old man sustains a basal skull fracture and is suspected of having CSF rhinorrhoea. Which of the following laboratory tests would most accurately identify whether CSF is present or not?
Microscopy to identify red blood cells
Lab stix testing for glucose
Lab stix testing for protein
Beta 2 transferrin assay
Microscopy, gram stain and culture
Beta 2 transferrin is a carbohydrate free form of transferrin that is almost exclusively found in the CSF. Although lab stix testing for glucose is traditional it is associated with false positive results secondary to contamination with other glucose containing bodily secretions.
An 18 year old athlete attends orthopaedic clinic reporting pain and swelling over the medial aspect of the knee joint. The pain occurs when climbing the stairs, but is not present when walking on flat ground. Clinically there is pain over the medial, proximal tibia and the McMurray test is negative. What is the most likely cause of this patient’s symptoms?
Anterior cruciate ligament tear
Prepatellar bursitis
Medial meniscus injury
Pes Anserinus Bursitis
Fracture of tibia
Pes Anserinus Bursitis is common in sportsmen due to overuse injuries. The main sign is of pain in the medial proximal tibia. As the McMurray test is negative, medial meniscal injury is excluded.
Pes anserinus: GOOSE’S FOOT
Combination of sartorius, gracilis and semitendinous tendons inserting into the anteromedial proximal tibia.
A 56 year old lady presents with a large bowel obstruction and abdominal distension. Which of the following confirmatory tests should be performed prior to surgery?
Abdominal ultrasound scan
Barium enema
Rectal MRI Scan
Endoanal ultrasound scan
Gastrograffin enema
Patients with suspected large bowel obstruction due to tumour should have this confirmed with gastrograffin enema, sigmoidoscopy or CT scanning prior to surgery.
Patients with clinical evidence of large bowel obstruction, should have the presence or absence of an obstructing lesion confirmed prior to surgery. This is because colonic pseudo-obstruction may produce a similar radiological picture. A gastrograffin enema is the traditional test, as barium is too toxic if it spills into the abdominal cavity. An MRI scan will not provide the relevant information, unless the lesion is rectal and below the peritoneal reflection. A CT scan would be an acceptable alternative.
Which of the following statements relating to the greater omentum is false?
It is less well developed in children under 5.
It has no relationship to the lesser sac.
It contains the gastroepiploic arteries.
Has an attachment to the transverse colon.
It may be a site of metastatic disease in ovarian cancer.
It is connected with the lesser sac and the transverse colon. This plane is entered when performing a colonic resection. It is a common site of metastasis in many visceral malignancies.
From which structure is the central tendon of the diaphragm derived?
Septum transversum
Pleuroperitoneal folds
Diaphragmatic crura
Dorsal mesocardium
Oropharyngeal membrane
The septum transversum is a thick ridge of mesodermal tissue in the developing embryo that separates the thoracic and abdominal cavities and forms the central tendon of the diaphragm.
Features of Morgani hernia
Anteriorly located
Minimal compromise on lung development
Minimal signs on antenatal ultrasound
Usually present later
Usually good prognosis
Usually through transverse septum
Features of Bochladek hernia
Posteriorly located
Larger defect
Often diagnosed antenatally
Associated with pulmonary hypoplasia
Poor prognosis
Failure of pleuroperitoneal fusion
Features of Wilms tumour
calcification uncommon: 10-15%
displaces adjacent structures without insinuating between them
well circumscribed
claw sign with the kidney (normal parenchyma extends some way around the mass)
slightly older age group: peak 3-4 years of age
extension into IVC/renal vein
Origin of the triceps
Long head- infraglenoid tubercle of the scapula.
Lateral head- dorsal surface of the humerus, lateral and proximal to the groove of the radial nerve
Medial head- posterior surface of the humerus on the inferomedial side of the radial groove and both of the intermuscular septae
Into which of the following structures does the superior part of the fibrous capsule of the shoulder joint insert?
The surgical neck of the humerus
The body of the humerus
The bicipital groove
Immediately distal to the greater tuberosity
The anatomical neck of the humerus
The anatomical neck of the humerus
The shoulder joint is a shallow joint, hence its great mobility. However, this comes at the expense of stability. The fibrous capsule attaches to the anatomical neck superiorly and the surgical neck inferiorly
Features of the glenoid labrum
Fibrocartilaginous rim attached to the free edge of the glenoid cavity
Tendon of the long head of biceps arises from within the joint from the supraglenoid tubercle, and is fused at this point to the labrum.
The long head of triceps attaches to the infraglenoid tubercle
What are the cutaneous features of tuberous sclerosis?
depigmented ‘ash-leaf’ spots which fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum: butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
café-au-lait spots* may be seen
