Block 8 Flashcards

Question

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

Answer 1

Transversus abdominis

Answer 2

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.

Answer 3

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

Answer 4

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

Answer 5

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.

Answer 6

50% (usually adenoid cystic)

Answer 7

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.

Answer 8

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

Answer 9

Stomach Followed by small intestine And recutm

Answer 10

CD117 RTk, mutation in c-KIT

Answer 11

Resection with 1-2cm margin of normal tissue

Answer 12

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.

Answer 13

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.

Answer 14

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

Answer 15

The internal carotid does not have any branches in the neck.

Answer 16

It contains the saphenous nerve and the superficial branch of the femoral artery.

Answer 17

Lateral border Vastus medialis Posterior border: Adductor longus, adductor magnus Roof- sartorius

Answer 18

Saphenous nerve (+ nerve to vastus medialis) Superficial femoral artery Superficial femoral vein

Answer 19

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.

Answer 20

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.

Answer 21

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.

Answer 22

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

Answer 23

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

Answer 24

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.

Answer 25

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.

Answer 26

Amiodarone

Answer 27

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.

Answer 28

The motor supply to the sternocleidomastoid is from the accessory nerve. The ansa cervicalis supplies sensory information from the muscle.

Answer 29

As this man is young and has full thickness prolapse a rectopexy is the most appropriate procedure. It will give the lowest recurrence rates.

Answer 30

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.

Answer 31

The portal vein, hepatic artery and common bile duct are occluded.

Answer 32

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

Answer 33

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.

Answer 34

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

Answer 35

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.

Answer 36

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.

Answer 37

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.

Answer 38

Na 137-147 K 4.5-5.5 Cl 95-105 Bicarbonate 22-25

Answer 39

Na 154 Cl 154

Answer 40

Na 30.6 Cl 30.6

Answer 41

Na 130 K 4 Cl 110 Lactate 28

Answer 42

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.

Answer 43

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

Answer 44

In Chiladitis sign, a loop of bowel may be interposed between the liver and diaphragm, giving the mistaken impression that free air is present.

Answer 45

Normal Should dissipate in 48-72 hours

Answer 46

Paralysis of a vocal cord implies extracapsular spread to mediastinal nodes and is an indication of inoperability.

Answer 47

SVCO FEV \<1.5 Malignant pleural effusion Vocal cord parlaysis General poor health Stage IIIb or IV (metastatic disease) Tumour near hilum

Answer 48

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

Answer 49

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

Answer 50

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.

Answer 51

Diuretics increase the risk of re-feeding syndrome through a process of increasing the risk of depletion of key electrolytes.

Answer 52

Hypophosphataemia Hypokalaemia Hypomagneseamia Abnormal fluid balance

Answer 53

Aim to re-feed at 50% energy and protein levels

Answer 54

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

Answer 55

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)

Answer 56

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.

Answer 57

Disappearance of taenia coli

Answer 58

Posterior upper third Posterior and lateral middle third Whole lower third

Answer 59

Mesorectal lymph nodes (superior to dentate line) Inguinal nodes (inferior to dentate line)

Answer 60

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.

Answer 61

The posterior scalp is supplied by C2-C3.

Answer 62

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.

Answer 63

Mandibular nerve

Answer 64

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.

Answer 65

SCM and trapezius muscles at the occipital bone

Answer 66

Posterior border of SCM

Answer 67

Anterior border of trapezius

Answer 68

Middle third of the clavicle

Answer 69

Accessory Phrenic Three trunks of the brachial plexus Branches of the cervical plexus: supraclavicular, transverse cervical, great auricular, lesser occipital nerve

Answer 70

EJV Subclavian

Answer 71

Inferior belly of omohyoid Scalene

Answer 72

Supraclavicular Occipital

Answer 73

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.

Answer 74

Birds are a recognised reservoir of campylobacter.

Answer 75

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.

Answer 76

Septic arthritis - most common organism: Staphylococcus aureus

Answer 77

Most common organism overall is Staphylococcus aureus In young adults who are sexually active Neisseria gonorrhoeae should also be considered

Answer 78

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

Answer 79

Most are sporadic and risk in subsequent pregnancies is not increased.

Answer 80

Pushing out of the scapula

Answer 81

LTN Spinal accessory nerve injury (denervating the trapezius) Dorsal scapular nerve injury

Answer 82

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.

Answer 83

Bladder canacer

Answer 84

In men the main cancers include: Mesothelioma Bladder cancer Non melanoma skin cancer Lung cancer Sino nasal cancer

Answer 85

15 years for solid tumours 20 years for leukaemia

Answer 86

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.

Answer 87

Primary intracerebral haemorrhage (PICH, c. 10%)

Answer 88

Total anterior circulation infarcts (TACI, c. 15%)

Answer 89

3/3 of: hemiparesis/hemisensory loss homonomyous hemianopia Higher cognitive dysfunction e.g. dysphasia/negelct

Answer 90

Partial anterior circulation infarcts (PACI, c. 25%)

Answer 91

Higher cognitive dysfunction or 2/3 TACI features

Answer 92

Lacunar infarcts

Answer 93

Posterior circulation infarcts

Answer 94

Lateral medullary syndrome

Answer 95

Dysphagia Ataxia (ipsilateral) Nystagmus (ipsilateral) Vertigo Anaesthesia: ipsilateral facial numbeness and absent corneal reflex, contralatearl pain loss Horner's syndrome: ipsilateral

Answer 96

Ipsilateral facial numbness and absent corneal reflex Contralateral pain loss

Answer 97

Weber's syndrome

Answer 98

ACA infarction

Answer 99

MCA infarct

Answer 100

Posterior cerebral artery

Answer 101

Pontine infarct

Answer 102

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.

Answer 103

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.

Answer 104

Cardiogenic Hypovolaemic- haemorrhagic, endocrine, excess loss, third spacing Obstructive: PE, DVT Distributive: sepsis, anaphylaxis, neurogenic

Answer 105

Infection that triggers a particular SIRS

Answer 106

Temp \<36 \>38 HR \>90 bpm RR \>20 WCC 12 or \<4 Altered mental state or hyperglycaemia in the absence of DM

Answer 107

Infection + 2 or more SIRS criteria

Answer 108

Those with sepsis and organ failure

Answer 109

Severe sepsis with refractory hypotension

Answer 110

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.

Answer 111

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.

Answer 112

Biceps brachii Brachialis Coracobrachialis

Answer 113

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

Answer 114

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.

Answer 115

Pelvic-ureteric obstruction (congenital or acquired) Aberrant renal vessels Calculi Tumours of renal pelvis

Answer 116

Stenosis of urethra Urethral valve Prostatic enlargement Extensive bladder tumour RPF

Answer 117

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)

Answer 118

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.

Answer 119

Giardia causes fat malabsorption, therefore greasy stool can occur. It is resistant to chlorination, hence risk of transfer in swimming pools.

Answer 120

\>3 loose or watery stools per day Acute \<14 Chronic \>14

Answer 121

Gastroenteritis Diverticulitis Abx Constipation causing overflow

Answer 122

IBS UC CD CRC Coeliac

Answer 123

Thyrotoxicosis Laxative abuse Appendicits with pelvic abscess or pelvic appendix Radiation enteritis

Answer 124

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.

Answer 125

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.

Answer 126

Parietal: inferior Temporal: superior

Answer 127

Pituitary: Upper field Cranipharyngiomas: lower field

Answer 128

Optic tract lesion

Answer 129

Optic radiation or occipital cortex

Answer 130

Lesion of occipital cortex

Answer 131

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.

Answer 132

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

Answer 133

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.

Answer 134

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

Answer 135

Internal mammary artery is best Radial artery Reverse long saphenous vein grafts

Answer 136

Increased risk of sternal wound ehisence

Answer 137

Ensure adequate ulnar collateral supply

Answer 138

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

Answer 139

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

Answer 140

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.

Answer 141

Obesity Low body weight is a risk factor for osteoporosis

Answer 142

Family history Female sex Increasing age Deficient diet Sedentary lifestyle Smoking Premature menopause Low body weight Caucasians and Asians

Answer 143

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

Answer 144

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.

Answer 145

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.

Answer 146

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.

Answer 147

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.

Answer 148

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.

Answer 149

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.

Answer 150

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.

Answer 151

Peroneus longus is innervated by the superficial peroneal nerve (L4, L5, S1).

Answer 152

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.

Answer 153

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.

Answer 154

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.

Answer 155

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.

Answer 156

Since it inhibits vagal tone, the use of atropine will typically result in an increased heart rate.

Answer 157

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.

Answer 158

Liver metastases are necessary for the presence of carcinoid syndrome.

Answer 159

A neuronal injury such as this will result in Wallerian degeneration even though the nerve remains in continuity. Neuromas may well form.

Answer 160

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.

Answer 161

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.

Answer 162

Obesity hormones leptin decreases appetite ghrelin increases appetite

Answer 163

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)

Answer 164

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

Answer 165

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.

Answer 166

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.

Answer 167

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.

Answer 168

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.

Answer 169

Macroscopic features include: Ulcers Fibrosis Granulomatous process It most commonly occurs as a primary event rather than as a result of acute inflammation.

Answer 170

Anal fissure Painful rectal bleeding in this age group is typically due to a fissure. Treatment should include stool softeners and lifestyle advice. Juvenile polyps These lesions are usually hamartomas and this accounts for the colour of the lesions. Although the lesions are not themselves malignant they serve as a marker of an underlying polyposis disorder. Ulcerative colitis The systemic features in the history are strongly suggestive of inflammatory bowel disease rather than the other causes.

Answer 171

Relatively rare

Answer 172

Diuretics TPN Diarrhoea Alcohol Hypokalaemia Hypocalcaemia

Answer 173

Paraesthesia Tetany Seizures Arrhythmias Decreased PTH secretion → hypocalcaemia ECG features similar to those of hypokalaemia Exacerbates digoxin toxicity Next question

Answer 174

The portal vein is the most posterior structure at the porta hepatis.The common bile duct is a continuation of the common hepatic duct and is formed by the union of the common hepatic duct and the cystic duct.

Answer 175

Usually open surgery is required for these lesions as customised grafts are not usually available for this type of repair yet.

Answer 176

More common than rupture of the abdominal aorta 33% of patients die within the first 24 hours, and 50% die within 48 hours if no treatment received Associated with hypertension Features of aortic dissection: tear in the intimal layer, followed by formation and propagation of a subintimal hematoma. Cystic medial necrosis (Marfan's) Most common site of dissection: 90% occurring within 10 centimetres of the aortic valve

Answer 177

90% occur within 10cm of the aortic valve

Answer 178

A: ascending aorta/aortic root B: descending aorta

Answer 179

Surgical: aortic root replacement

Answer 180

Medical therapy with antihypertensives

Answer 181

Ascending aorta: aortic arch, descending aorta

Answer 182

Ascending aorta only

Answer 183

Descending aorta distal to left subclavian artery

Answer 184

Aortic dissection

Answer 185

20mmHg difference in each arm

Answer 186

CXR: widened mediastinum, abnormal aortic knob, ring sign, deviation of the trachea/oesophagus CT angiography of the thoracic aorta MRI angiography Conventional angiography (now rarely used diagnostically)

Answer 187

HR 60-80bpm BP 100-120

Answer 188

Post transplant complications CMV: 4 weeks to 6 months post transplant EBV: post transplant lymphoproliferative disease. \> 6 months post transplant Post transplant lymphoproliferative disorder is most commonly associated with Epstein-Barr virus. It typically occurs 6 months post transplant and is associated with high dose immunosupressant therapy. Remember cytomegalovirus presents within the first 4 weeks to 6 months post transplant.

Answer 189

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.

Answer 190

Opsonisation will facilitate phagocytosis. The micro-organism becomes coated with antibody, C3b and certain acute phase proteins. The macrophages and neutrophils have up regulation of phagocytic cell surface receptors in these circumstances, a process mediated by pro-inflammatory cytokines. These cells then engulf the micro organism.

Answer 191

There is an absolute risk reduction of 15-12.5%= 2.5% for treatment A Therefore the NNT = 1/0.025 = 40

Answer 192

Decrease in risk of a given activity or treatment in relation to a control activity or treatment. It is the inverse of the number needed to treat

Answer 193

How many patients would need to receive a treatment to prevent one event. Absolute difference between two treatments

Answer 194

Vertigo and dysarthria suggest a posterior circulation event. In the scenario of a patient complaining of posterior symptoms and a sudden deterioration in consciousness, the main differential diagnosis is of a basilar artery occlusion.

Answer 195

The left adrenal gland is slightly larger than the right. It is crescent in shape and its concavity is adapted to the medial border of the upper part of the left kidney. The upper area is covered by peritoneum of the omental bursa which separates it from the cardia of the stomach. The lower area is in contact with the pancreas and splenic artery and is not covered by peritoneum. On the anterior surface is a hilum from which the suprarenal vein emerges. The lateral aspect rests on the kidney. The medial is small and is on the left crus of the diaphragm.

Answer 196

The short head of biceps femoris, which may occasionally be absent, is innervated by the common peroneal component of the sciatic nerve. The long head is innervated by the tibial division of the sciatic nerve.

Answer 197

The necrosis of a tumour may be suggestive of a high grade tumour which has out grown its blood supply. However, the grading of breast cancer which classically follows the Bloom -Richardson grading model will tend to favor nuclear appearances (which include mitoses, coarse chromatin and pleomorphism). Tubule formation is an important marker of the degree of differentiation with formation of tubular structures being associated with well differentiated tumours.

Answer 198

Positive predictive value = TP / (TP + FP) = 40 / (40 + 20) = 0.66

Answer 199

Scalenus anterior The axillary artery is the continuation of the subclavian artery. It is surrounded by the cords of the brachial plexus (from which they are named). The axillary vein runs alongside the axillary artery throughout its length.

Answer 200

The phrenic nerve lies anteriorly at the root of the right lung.

Answer 201

Most appendixes lie in the retrocaecal position. If a retrocaecal appendix is difficult to remove then mobilisation of the right colon significantly improves access.

Answer 202

GDA The gastroduodenal artery divides into the gastro-epiploic and pancreaticoduodenal arteries at the superior aspect of the pancreas.

Answer 203

The cuboid is located at the lateral aspect of the foot between the calcaneus posteriorly and the 4th and 5th metatarsals distally.

Answer 204

Jaundice Multiple sclerosis is associated with pressure sores, however the cellular healing process is not affected.

Answer 205

D iabetes I nfection, irradiation D rugs eg steroids, chemotherapy ``` N utritional deficiencies (vitamin A, C & zinc, manganese), Neoplasia O bject (foreign material) T issue necrosis ``` H ypoxia E xcess tension on wound A nother wound L ow temperature, Liver jaundice

Answer 206

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.

Answer 207

The diaphragm is formed between the 5th and 7th weeks of gestation through the progressive fusion of the septum transversum, pleuroperitoneal folds and via lateral muscular ingrowth. The muscular origins of the diaphragm are somites located in cervical segments 3 to 5, which accounts for the long path taken by the phrenic nerve. The components contribute to the following diaphragmatic segments: Septum transversum - Central tendon Pleuroperitoneal membranes - Parietal membranes surrounding viscera Cervical somites C3 to C5- Muscular component of the diaphragm

Answer 208

Septum transversum

Answer 209

Pleuroperitoneal membranes

Answer 210

Cervical somites C3-5

Answer 211

Anteriorly located Minimal compromise on lung development Minimal signs on antenatal ultrasound Usually present later Usually good prognosis Usually through transverse septum

Answer 212

Posteriorly located Larger defect Often diagnosed antenatally Associated with pulmonary hypoplasia Poor prognosis Failure of pleuroperitoneal fusion

Answer 213

Scapohid abdomen because of herniation of the abdominal contents into the chest

Answer 214

Trisomy 21 and 18

Answer 215

Historically this was considered to be due to direct compression of the lung by herniated viscera. This view over simplifies the situation and the pulmonary hypoplasia occurs concomitantly with the hernial development, rather than as a direct result of it. The pulmonary hypoplasia is associated with pulmonary hypertension and abnormalities of pulmonary vasculature. The pulmonary hypertension renders infants at risk of right to left shunting (resulting in progressive and worsening hypoxia).

Answer 216

Malrotation

Answer 217

The mortality rate is 50-75% and is related to the degree of lung compromise and age at presentation (considerably better in infants \>24 hours old).

Answer 218

Stensens duct conveys secretions from the parotid gland and these enter the oral cavity at the level of the second molar tooth.

Answer 219

The posterior belly of digastric is innervated by the facial nerve and the anterior belly by the mylohoid nerve.

Answer 220

Pisiform This small bone has a single articular facet. It projects from the triquetral bone at the ulnar aspect of the wrist where most regard it as a sesamoid bone lying within the tendon of flexor carpi ulnaris.

Answer 221

Bronchoconstriction

Answer 222

The lunate lies medially in the anatomical plane. Fractures of the scaphoid that are associated with high velocity injuries may cause associated lunate dislocation.

Answer 223

No thromboprophylaxis Inguinal hernia repairs under local anaesthetic have a short operative time and patients are usually ambulant immediately afterwards. His family history is unlikely to be significant and he is at very low risk. No thromboprophylaxis In paediatric surgical practice the use of heparin type agents is rare. This is because, even with abdominal surgery, children are ambulant soon after surgery and DVT's vanishingly rare in this population. Low molecular weight heparin and pneumatic compression stockings Pelvic cancer surgery carries a very high risk of development of deep vein thrombosis. In a patient with normal renal function the use of a low molecular weight heparin is standard. However, many surgeons would only use this in the post operative setting. Intermittent compression devices in claudicants are not without risk, but on balance probably outweigh the risk of DVT in this specific case. The perfusion of the feet should be closely monitored and compression stopped if concerns develop.

Answer 224

Surgery greater than 90 minutes at any site or greater than 60 minutes if the procedure involves the lower limbs or pelvis Acute admissions with inflammatory process involving the abdominal cavity Expected significant reduction in mobility Age over 60 years Known malignancy Thrombophilia Previous thrombosis BMI \>30 Taking hormone replacement therapy or the contraceptive pill Varicose veins with phlebitis

Answer 225

Early ambulation after surgery is cheap and is effective Compression stockings (contra -indicated in peripheral arterial disease) Intermittent pneumatic compression devices Foot impulse devices

Answer 226

Binds antithrombin causing inhibition of factor Xa

Answer 227

Binds antithrombin III affecting thrombin and factor Xa

Answer 228

Orally administered direct thrombin inhibitor

Answer 229

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

Answer 230

Clostridium difficile infection Antibiotics are not routinely administered during an uncomplicated cholecystectomy. Indications for administration of broad spectrum antibiotics include intraoperative bile spillage. Delayed pelvic abscesses following bile spills are extremely rare since most surgeons will manage these intra-operatively.

Answer 231

Broad spectrum Abx PPI and H2R Infectious contacts

Answer 232

First-line therapy is oral metronidazole for 10-14 days If severe, or not responding to metronidazole, then oral vancomycin may be used Patients who do not respond to vancomycin may respond to oral fidaxomicin Patients with severe and unremitting colitis should be considered for colectomy

Answer 233

The vessel will be the gastroduodenal artery, this arises from the common hepatic artery.

Answer 234

Pylorus, proximal part of the duodenum, and indirectly to the pancreatic head (via the anterior and posterior superior pancreaticoduodenal arteries)

Answer 235

The gastroduodenal artery most commonly arises from the common hepatic artery of the coeliac trunk. It terminates by bifurcating into the right gastroepiploic artery and the superior pancreaticoduodenal artery

Answer 236

Triceps Anconeus Brachioradialis Extensor carpi radialis

Answer 237

Supinator Extensor carpi ulnaris Extensor digitorum Extensor indicis Extensor digiti minimi Extensor pollicis longus and brevis Abductor pollicis longus

Answer 238

The area of skin supplying the proximal phalanges on the dorsal aspect of the hand is supplied by the radial nerve (this does not apply to the little finger and part of the ring finger)

Answer 239

List the patient for colonoscopic polypectomy These polyps represent an alternative pathway to progression to carcinoma and may be diagnostically confused with hyperplastic polyps. Hyperplastic polyps are more common in the left colon and confer no increased risk. SSA's are more common in the right colon and are usually larger. Those with "traditional features" on histology have dysplasia with increased risk of malignant transformation.

Answer 240

Oral gastrograffin and CT This is consistent with oesophageal perforation. Gastrograffin and CT will accurately delineate the site of perforation and guide further therapy. Barium may produce a mediastinitis and should not be used. Gastrograffin contrast enema Occasionally the wrong end of bowel is brought up and fashioned as the end stoma, effectively leaving the bowel obstructed. A gastrograffin enema will easily demonstrate if this is the case. Abdominal CT scan with IV contrast An anastomotic leak is the most likely occurrence and may be visualised using CT scanning. A gastrograffin enema may demonstrate the leak but a CT scan will also provide information to guide management.

Answer 241

A prodromal period of fever and generalised malaise precedes abdominal pain (which may mimic appendicitis) and diarrhoea.

Answer 242

All cases should be treated with an Ilizarov frame initially unless there is minor deformity In most cases of Club Foot conservative measures should be tried first. The Ponsetti method is a popular approach. Severe cases may benefit from Ilizarov frame re-aligment.

Answer 243

Equinus of the hindfoot Adduction and varus of the midfoot High arch

Answer 244

Most cases in developing countries. Incidence in UK is 1 per 1000 live births. It is more common in males and is bilateral in 50% cases. There is a strong familial link(1). It may also be associated with other developmental disorders such as Down's syndrome.

Answer 245

Adducted and inverted calcaneus Wedge shaped distal calcaneal articular surface Severe Tibio-talar plantar flexion. Medial Talar neck inclination Displacement of the navicular bone (medially) Wedge shaped head of talus Displacement of the cuboid (medially)

Answer 246

Conservative first, the Ponseti method is best described and gives comparable results to surgery. It consists of serial casting to mold the foot into correct shape. Following casting around 90% will require a Achilles tenotomy. This is then followed by a phase of walking braces to maintain the correction. Surgical correction is reserved for those cases that fail to respond to conservative measures. The procedures involve multiple tenotomies and lengthening procedures. In patients who fail to respond surgically an Ilizarov frame reconstruction may be attempted and gives good results.

Answer 247

A locally perforated colonic tumour will typically cause an intense inflammatory response and if peritonitis is not present clinically then at the very least a localised abscess. This inflammatory process is the most likely (from the list) to falsely raise the serum ferritin level. Angiodysplasia and dieulafoy lesions are mucosal arteriovenous malformations and unlikely to result in considerable inflammatory activity.

Answer 248

IIA The rectus sheath also contains: superior epigastric vein inferior epigastric artery

Answer 249

First time renal tranplants and typically implanted in the left or right iliac fossae. The vessels are usually joined to the external iliac artery and vein as these are the most easily accessible. The Rutherford Morrison incision provides access to the external iliac vessels.

Answer 250

Leydig cell tumours are rare testicular sex cord stromal tumours (which also include sertoli cell tumours) which are associated with hormonal activity. Patients with Leydig cell tumours may present with gynaecomastia before they notice testicular enlargement. Majority are benign Histology: eosinophilic cells in columns

Answer 251

5 alpha reductase inhibitors have a more favorable side effect profile than α blockers. Alpha blockers have a faster onset of action (but lower reduction of complications from BPH) than 5 α reductase inhibitors.

Answer 252

Benign prostatic hyperplasia occurs via an increase in the epithelial and stromal cell numbers in the peri-urethral zone of the prostate. BPH is very common and 90% of men aged over 80 will have at least microscopic evidence of benign prostatic hyperplasia. The causes of BPH are still not well understood, but the importance of androgens remains appreciated even if the exact role by which they induce BPH is elusive.

Answer 253

Digital rectal examination to assess prostatic size and morphology. Urine dipstick for infections and haematuria. Uroflowmetry (a flow rate of \>15ml/second helps to exclude BOO) Bladder pressure studies may help identify detrusor failure and whilst may not form part of first line investigations should be included in those with atypical symptoms and prior to redo surgery. Bladder scanning to demonstrate residual volumes. USS if high pressure chronic retention.

Answer 254

Hepatic vein, inferior phrenic vein, pierces diaphragm

Answer 255

Suprarenal veins Renal vein

Answer 256

Gonadal vein

Answer 257

Lumbar veins

Answer 258

Common iliac vein, formation of IVC

Answer 259

Carbon dioxide is the agent of choice. It is rapidly re-absorbed, does not support combustion and is cheap. It is rapidly cleared from the lungs and so effects on pH are unusual.

Answer 260

Laparoscopic surgery may be performed in a number of body cavities. In some areas irrigation solutions are preferred. In the abdomen insufflation with carbon dioxide gas is commonly used. The amount of gas delivered is adjusted to maintain a constant intra-abdominal pressure of between 12 and 15 mmHg. Excessive intra-abdominal pressure may reduce venous return and lead to hypotension. Too little insufflation will risk obscuring the surgical view.

Answer 261

Median nerve The flexor digiti minimi brevis originates from the Hamate, on its under- surface lie the ulnar contribution to the superficial palmar arterial arch and digital nerves derived from the ulnar nerve. The median nerve overlies the flexor tendons.

Answer 262

Neuroblastomas are a relatively common childhood tumour and have a strong tendency to developing widespread lytic metastasis.

Answer 263

calcification very common: 90% encases vascular structures but does not invade them younger age group (\<2 years of age) poorly marginated more common to have extension into the chest elevates the aorta away from the vertebral column more commonly crosses the midline, especially behind the aort

Answer 264

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

Answer 265

The transversalis fascia forms the superolateral edge of the deep inguinal ring. The epigastric vessels form its inferomedial wall.

Answer 266

An RCT does not have to include concealment although many medical trials may do so. Indeed in the case of surgical research it may not be practicable or possible to include concealment in the protocol. This does not mean that the trial is not an RCT, simply that it is not blinded.

Answer 267

Proximal to the flexor retinaculum The 5th tendon sheath extends from the little finger to the proximal aspect of the carpal tunnel. This carries a significant risk of allowing infections to migrate proximally.

Answer 268

No further action needed Colocutaneous fistulae may occur as a result of anastomotic leakage following loop colostomy reversal. In the absence of abdominal signs a laparotomy is not necessarily required. Signs of wound sepsis may require antibiotics. Because there is not any distal obstruction (note normal pre-operative gastrograffin enema) these fistulae will usually close spontaneously. Total parenteral nutrition and octreotide This man has a high output and anatomically high fistula. Drying up the fistula with octreotide will not suffice, his nutrition is compromised and TPN will help. No further action needed When the bile duct is closed over a T Tube the latex in the T tube encourages tract fibrosis. This actually encourages a fistula to develop. The result is that when the tube is removed any bile which leaks will usually drain through the tract. Provided that there are no residual stones in the duct the fistula will slowly close. Persistent high volume drainage may be managed with ERCP and sphincterotomy.

Answer 269

Opponens pollicis

Answer 270

Vitamin K deficiency results from cholestatic jaundice and prolonged antibiotic therapy. Acquired factor 12 deficiency causes prolonged APTT.

Answer 271

Aneuryms greater than 5cm in diameter on USS should be formally assessed using CT scanning with arterial phases to delineate anatomy and facilitate surgical planning. 75%

Answer 272

Ilioinguinal nerve entrapment may be a cause of neuropathic pain following inguinal hernia surgery. The ilioinguinal nerve passes through the superfical inguinal ring and is routinely encountered when exploring the inguinal canal during hernia surgery. The iliohypogastric nerve pierces the aponeurosis of the external oblique muscle superior to the superficial inguinal ring.

Answer 273

Pseudopolyps are a feature of ulcerative colitis and occur when there is severe mucosal ulceration. The remaining islands of mucosa may then appear to be isolated and almost polypoidal.

Answer 274

Rectal involvement with diverticular disease almost never occurs. Because the rectum has a circular muscle coat (blending of of the tenia marks the recto-sigmoid junction), diverticular disease almost never occurs here. Right sided colonic diverticular disease is well recognised (though less common than left sided).

Answer 275

Periosteal preservation helps fractures to heal.

Answer 276

Excisional biopsy of the lesion Suspicious naevi should NOT be partially sampled as histological interpretation is severely compromised. Complete excision is mandatory where lesions fulfil diagnostic criteria. However, wide excision for margins may be deferred until definitive histology is available. Lesions that are suspicious for melanoma should be excised with complete margins. Radical excision is not routinely undertaken for diagnostic purposes and therefore if subsequent histopathological assessment determines that the lesion is a melanoma a re-exicision of margins may be required. Incisional punch biopsies of potential melanomas makes histological interpretation difficult and is best avoided.

Answer 277

An ileus in itself is seldom a cause of a pyrexia. It may serve as a proxy marker of other complications. In this scenario atelectasis would be the most likely underlying cause, as open extended right hemicolectomies will necessitate a long midline incision. Anastomotic leaks are less common after right sided colonic surgery and the timeframe for it is rather short (but are possible). Both wound infections and UTI's ,may complicate major abdominal surgery at any stage. We remind you to check the wording of the question, it asks for the "least likely" cause of pyrexia.

Answer 278

?anastomotic leak

Answer 279

Wound infection

Answer 280

Atelectasis

Answer 281

Central line sepsis

Answer 282

Urinary tract infection

Answer 283

P value Type 1 errors occur when a test rejects a true null hypothesis and is therefore related to the significance level of the test result. To explain consider the following arbitrary example. We hypothesise that bowel preparation vs no bowel preparation has no effect on anastomotic leak rates following left hemicolectomy. If we compare the rates of anastomotic leak and perform a Chi Squared test and obtained a P value of 0.95 we should conclude that we unable to reject the null hypothesis. Should we choose to do so then we are at risk of committing a type 1 error. In reality the knowledge that a type 1 error was committed is usually some time after the event. When other studies have been performed that have shown an effect. Power calculations are related to type 2 errors.

Answer 284

ST elevation of 1mm in leads II, III and aVF reflects significant cardiac ischaemia due to the right coronary artery occlusion. The medical registrar should be contacted to urgently assess the patient. Note right coronary artery occlusions puts the patient at risk of cardiac arrhythmias (due to blood supply to the sino atrial node).

Answer 285

ST elevation of \> 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL) OR New Left bundle branch block

Answer 286

alteplase tenecteplase streptokinase

Answer 287

active internal bleeding recent haemorrhage, trauma or surgery (including dental extraction) coagulation and bleeding disorders intracranial neoplasm stroke \< 3 months aortic dissection recent head injury pregnancy severe hypertension

Answer 288

haemorrhage hypotension - more common with streptokinase allergic reactions may occur with streptokinase

Answer 289

Longitudinal smooth muscle propels the food bolus through the oesophagus

Answer 290

Anaplastic carcinoma Marked local invasion is a feature of anaplastic carcinoma. These tumours are more common in elderly females. Papillary carcinoma Multifocal disease is a recognised feature of papillary lesions. Papillary adenomas are not really recognised and most well differentiated lesions are papillary carcinomas. Follicular carcinoma Follicular carcinomas are a recognised source of bone metastasis. Up to 60% will show vascular invasion histologically.

Answer 291

Laxative abuse This may occur as a result of laxative abuse and consists of lipofuschin laden marcophages that appear brown. Ischaemic colitis The IMA is commonly ligated during an AAA repair and this may then render the left colon relatively ischaemic, thereby causing mesenteric colitis. Treatment is supportive and most cases will settle with conservative management. Campylobacter jejuni infection Severe abdominal pain tends to favour Campylobacter infection.

Answer 292

In acute tubular necrosis there is no response to intravenous fluids because the damage occurs from within the renal system rather than as a result of volume depletion.

Answer 293

Normal or post-renal cause

Answer 294

pre-renal cause (urea absorption increased compared to creatinine)

Answer 295

Intrinsic renal damage (urea unable to be absorbed)

Answer 296

Mesenteric cysts may be associated with intra abdominal catastrophes where these occur they are typically either intestinal volvulus or intestinal infarction. They seldom cause intussusception. Cystic fibrosis may lead to the formation of meconium ileus equivalent and plugs may occasionally serve as the lead points for an intussusception.

Answer 297

he telescoping of the bowel produces mucosal ischaemia and bleeding may occur resulting in the passage of "red current jelly" stools

Answer 298

The decision as to the optimal treatment is dictated by the patients physiological status and abdominal signs. In general, children who are unstable with localising peritoneal signs should undergo laparotomy, as should those in whom attempted radiological reduction has failed. In relatively well children without localising signs attempted pneumatic reduction under fluroscopic guidance is the usual treatment.

Answer 299

Idiopathic of the ileocaecal valvae and terminal ileum

Answer 300

Right subclavian artery The axillary artery is a branch of the subclavian artery and although developmental anomalies may occur they are rare. The catheter may also enter the right carotid. There is no brachiocephalic artery on the left side.

Answer 301

The radial nerve runs in its groove on between the two heads. The ulnar nerve lies anterior to the medial head. The axillary nerve passes through the quadrangular space. This lies superior to lateral head of the triceps muscle and thus the lateral border of the quadrangular space is the humerus. Therefore the correct answer is the radial nerve.

Answer 302

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

Answer 303

Olecranon process of the ulna. Here the olecranon bursa is between the triceps tendon and olecranon. Some fibres insert to the deep fascia of the forearm, posterior capsule of the elbow (preventing the capsule from being trapped between olecranon and olecranon fossa during extension)

Answer 304

Can adduct the humerus and extend it from a flexed position

Answer 305

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

Answer 306

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

Answer 307

Anteriorly the capsule is in contact with the tendon of subscapularis, superiorly with the supraspinatus tendon, and posteriorly with the tendons of infraspinatus and teres minor. All these blend with the capsule towards their insertion.

Answer 308

The inferior extension of the capsule is closely related to the axillary nerve at the surgical neck and this nerve is at risk in anteroinferior dislocations. It also means that proximally sited osteomyelitis may progress to septic arthritis.

Answer 309

Two defects in the fibrous capsule; superiorly for the tendon of biceps. Anteriorly there is a defect beneath the subscapularis tendon.

Answer 310

MAG 3 Renogram Because it is excreted by renal tubular cells a MAG 3 renogram provides excellent imaging of renal function and is often used in investigating failing transplants. DMSA scan Although MAG 3 renograms may provide some information relating to the structural integrity of the kidney, many still consider a DMSA scan to be the gold standard for the detection of renal scarring (which is the main concern in PUJ obstruction and infections). MAG 3 Renogram In patients with long standing PUJ obstruction and renal scarring the main diagnostic question is whether the individual has sufficient renal function to consider a pyeloplasty or whether a primary nephrectomy is preferable. Since the CT has demonstrated scarring there is no use in obtaining a DMSA scan. Of the investigations listed both a DTPA and MAG 3 renogram will allow assessment of renal function. However, MAG 3 is superior in the assessment of renal function in damaged kidneys (as it is subjected to tubular secretion).

Answer 311

``` Dimercaptosuccinic acid (DMSA) scintigraphy DMSA localises to the renal cortex with little accumulation in the renal papilla and medulla. It is useful for the identification of cortical defects and ectopic or aberrant kidneys. It does not provide useful information on the ureter of collecting system. ```

Answer 312

Diethylene-triamine-penta-acetic acid (DTPA) This is primarily a glomerular filtration agent. It is most useful for the assessment of renal function. Because it is filtered at the level of the glomerulus it provides useful information about the GFR. Image quality may be degraded in patients with chronic renal impairment and derangement of GFR.

Answer 313

MAG 3 renogram Mercaptoacetyle triglycine is an is extensively protein bound and is primarily secreted by tubular cells rather than filtered at the glomerulus. This makes it the agent of choice for imaging the kidneys of patients with existing renal impairment (where GFR is impaired).

Answer 314

This scan provides information relating to bladder reflux and is obtained by filling the bladder with contrast media (via a catheter) and asking the child to void. Images are taken during this phase and the degree of reflux can be calculated

Answer 315

This examination is conducted by the administration of intravenous iodinated contrast media. The agent is filtered by the kidneys and excreted and may provide evidence of renal stones or other structural lesions. A rough approximation of renal function may be obtained using the technique. But it is not primarily a technique to be used for this purpose. With the advent of widespread non contrast CT scan protocols for the detection of urinary tract calculi it is now rarely used.

Answer 316

It decreases the rate of gastric emptying.

Answer 317

The c wave of the jugular venous waveform is associated with the closure of the tricuspid valve.

Answer 318

Intussusception Sausage shaped mass (colon shaped) is common in intussusception. The other common sign is red jelly stool.

Answer 319

Levels of CRP are commonly measured in acutely unwell patients. CRP is a protein synthesised in the liver and binds to phosphocholine in bacterial cells and on those cells undergoing apoptosis. In binding to these cells it is then able to activate the complement system. CRP levels are known to rise in patients following surgery. However, levels of greater than 150 at 48 hours post operatively are suggestive of evolving complications.

Answer 320

This patient has neuropathic pain. Amitryptyline is the treatment of choice. Carbamazepine is mainly used for trigeminal neuralgia.

Answer 321

Hypovolaemia Cardiac output is lowered in hypovolaemia due to decreased preload. Cardiogenic shock In cardiogenic shock pulmonary pressures are often high. This is the basis for the use of venodilators in the treatment of pulmonary oedema. Septic shock Decreased SVR is a major feature of sepsis. A hyperdynamic circulation is often present. This is the reason for the use of vasoconstrictors.

Answer 322

The pulmonary artery occlusion pressure is an indirect measure of left atrial pressure, and thus filling pressure of the left heart. The low resistance within the pulmonary venous system allows this useful measurement to be made. The most accurate trace is made by inflating the balloon at the catheter tip and "floating" it so that it occludes the vessel. If it is not possible to occlude the vessel in this way then the measurement gained will be the pulmonary artery end diastolic pressure.

Answer 323

High Overload

Answer 324

Urinary measurement of 5- HIAA is an important part of clinical follow up.

Answer 325

By 16 years of age almost all foreskins should be retractile and if they are not circumcision should be considered at around this time.

Answer 326

At birth and in the neonatal period the normal foreskin is non retractile due to the presence of adhesions between the foreskin and glans. In most cases these will separate spontaneously. By the end of puberty 95% of foreskins can be retracted. In some children the non-retractile foreskin may balloon during micturition. This is a normal variant and requires no specific treatment.

Answer 327

Paraphimosis

Answer 328

Balanitis xerotica obliterans

Answer 329

This accessory vessel which usually lies at the inferior aspect of the gland is derived either from the brachiocephalic artery or the arch of the aorta.

Answer 330

Rings 2,3,4 make the isthmus flooor

Answer 331

Total Thyroidectomy Sub total thyroidectomy is no longer routinely undertaken in this group. Total Thyroidectomy Eye signs worsen with radioiodine. Thyroid lobectomy Persist refilling cysts may be associated with a well differentiated tumour and should be removed by lobectomy.

Answer 332

The penis takes autonomic nerves from the nervi erigentes that lie near the seminal vesicles. These may be compromised by direct surgical trauma (such as use of diathermy in this area) and also by radiotherapy that is used in these patients pre operatively. The result is that up to 50% of patients may develop impotence following rectal cancer surgery.

Answer 333

Widening of the joint space. Sub chondral linear lucency.

Answer 334

Slipped upper femoral epiphysis Slipped upper femoral epiphysis is the commonest adolescent hip disorder. It occurs most commonly in obese males. It may often present as knee pain which is usually referred from the ipsilateral hip. The knee itself is normal. The hip often limits internal rotation. The diagnosis is easily missed. X-rays will show displacement of the femoral epiphysis and the degree of its displacement may be calculated using the Southwick angle. Treatment is directed at preventing further slippage which may result in avascular necrosis of the femoral head. Perthes disease This is a typical presentation for Perthes disease. X-ray may show flattening of the femoral head or fragmentation in more advanced cases. Developmental dysplasia of the hip Developmental dysplasia of the hip. Usually diagnosed by Barlow and Ortolani tests in early childhood. Most Breech deliveries are also routinely subjected to USS of the hip joint. At this young age an arthrodesis may be preferable to hip replacement.

Answer 335

The application of cold compresses is indicated in doxorubicin extravasation. Warm compresses increase the risk of doxorubicin ulceration. Hyaluronidase is indicated in the extravasation of contrast media, TPN and vinca alkaloids. However, if administered following doxorubicin extravasation it will dramatically worsen the situation and is contra indicated. Up to 50% of those sustaining severe injuries will require delayed surgical reconstruction.

Answer 336

doxorubicin, vincristine, vinblastine, adriamycin, cisplatin, mitomycin and mithramycin.

Answer 337

Vinca alkaloid extravastation may be improved

Answer 338

Local administration of hyaluronidase

Answer 339

Tuberous sclerosis

Answer 340

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

Answer 341

developmental delay epilepsy (infantile spasms or partial) intellectual impairment

Answer 342

retinal hamartomas: dense white areas on retina (phakomata) rhabdomyomas of the heart gliomatous changes can occur in the brain lesions polycystic kidneys, renal angiomyolipomata

Answer 343

Hypokalaemia - U waves on ECG J waves are seen in hypothermia whilst delta waves are associated with Wolff Parkinson White syndrome.

Answer 344

U waves Small or absent T waves (occasionally inversion) Prolonged PR interval ST depression Long QT interval

Answer 345

The most likely lesion to occur in the cerebello-pontine angle is an acoustic neuroma. The trigeminal nerve has a broad base and involvement of at least part of this nerve is the most likely initial finding. The defect may be subtle such as loss of the ipsilateral corneal reflex. Ipsilateral hearing loss will also occur. Untreated, progressive lesions, may ultimately affect cranial nerve roots in this region.

Answer 346

Olfactory nerve

Answer 347

Optic nerve

Answer 348

Oculomotor nerve

Answer 349

Trochlear nerve

Answer 350

Trigeminal nerve

Answer 351

Abducens nerve

Answer 352

Facial nerve

Answer 353

Vestibulo-cochlear nerve

Answer 354

Glossopharyngeal nerve

Answer 355

Vagus nerve

Answer 356

Accessory nerve

Answer 357

Hypoglossal nerve

Answer 358

Suspected penile fractures should be surgically explored and the injury repaired.

Answer 359

Penile fractures are a rare type of urological trauma that may be encountered. The injury is usually in the proximal part of the penile shaft and may involve the urethra. A classically history of a snapping sensation followed by immediate pain is usually given by the patient (usually during vigorous intercourse). On examination there is usually a tense haematoma and blood may be seen at the meatus if the urethra is injured. When there is a a strong suspicion of the diagnosis the correct management is surgical and a circumferential incision made immediately inferior to the glans. The skin and superficial tissues are stripped back and the penile shaft inspected. Injuries are usually sutured and the urethra repaired over a catheter.

Answer 360

Phrenic [inferior] Celiac Superior mesenteric Suprarenal [middle] Renal Testicular ['in men' only] Lumbars Inferior mesenteric Sacral

Answer 361

Non accidental injury Delayed presentation is unusual and should raise concern. In addition spiral fractures are usually the result of rotational injury which is not compatible with the mechanism proposed by the parent. Accidental fracture The mechanism fits with the fracture pattern and the presentation is not delayed Non accidental injury Posterior rib fractures are extremely unusual in neonates. The change in head size may be accounted for by hydrocephalus which may occur as a sequelae from head injury.

Answer 362

Improved results when the degloved segment is left in situ as a temporary closure Degloving injuries typically involve extremities and are usually friction injuries e.g. arm being run over. There is abnormal motility of the overlying skin, pallor, loss of sensation. Early treatment is key and should involve skin grafting which may use the degloved segment. This however, should be formally prepared for the role and simple compression bandaging gives poor results.

Answer 363

This patient has received a carbohydrate rich diet without any thiamine or vitamin B co strong replacement. This has led to Wernickes encephalopathy, which classically presents with confusion, ataxia and opthalmoplegia. Characteristically it is associated with chronic alcoholism, however it is also known to occur post bariatric surgery.

Answer 364

Acute confusion Ataxia Opthalmoplegia

Answer 365

Duplex scan This patient needs a duplex scan to assess the patency of her deep venous system before surgery can be undertaken. Other indications for duplex scan include recurrent varicose veins or complications. Duplex scan Tibial fractures are a well recognised risk factor for occult lower limb deep venous thrombosis and most surgeons would perform a duplex scan to exclude deep venous insufficiency prior to surgery. Long saphenous vein stripped to the knee In the UK, NICE, suggest the use non operative measures such as endothermal ablation for first time varicose veins. Recurrences respond far less favourably and are best managed with surgery.

Answer 366

A combination of severe otalgia and facial nerve palsy in a diabetic should raise suspicion of malignant otitis externa. This is a condition caused by pseudomonas. It commences as otitis externa and then progresses to involve the temporal bone. Spread of the disease outside the external auditory canal occurs through the fissures of Santorini and the osseocartilaginous junction.

Answer 367

Acute otitis externa

Answer 368

Chronic otitis externa

Answer 369

Acute suppurative otitis media

Answer 370

Chronic suppurative otitis media

Answer 371

Simple pars tensa perforations may be managed non operatively or a myringoplasty considered if symptoms troublesome. Pars flaccida perforations will usually require a radical mastoidectomy

Answer 372

Perforation of pars flaccida

Answer 373

Perforation of pars tensa

Answer 374

Otosclerosis

Answer 375

Acoustic neuroma

Answer 376

Pre auricular sinus

Answer 377

Absent corneal reflex LMN facial palsy LR palsy Sensorineural deafness, vertigo, tinnits DANISH

Answer 378

CN 5, 6, 7, 8 and cerebellar signs

Answer 379

Crossed hemiplegia 6th and 7th CN palsy Contralateral hemiplegia Caused by pontine lesions

Answer 380

Unilateral isolated cleft lip represents a failure of nasolabial ring fusion. It is not related to branchial arch fusion. Arch disorders have a far more profound phenotype and malformation sequences.

Answer 381

Cleft lip and palate are the most common congenital deformity affecting the orofacial structures. Whilst they may be an isolated developmental malformation they are also a recognised component of more than 200 birth defects. The incidence is as high as 1 in 600 live births. The commonest variants are: Isolated cleft lip (15%) Isolated cleft palate (40%) Combined cleft lip and palate (45%) The aetiology of the disorder is multifactorial; both genetic (affected first degree relative increases risk) and environmental factors play a role.

Answer 382

Cleft lip occurs as a result of disruption of the muscles of the upper lip and nasolabial region. These muscles comprise a chain of muscles viz; nasolabial, bilabial and labiomental. Defects may be unilateral or bilateral.

Answer 383

The primary palate consists of all anatomical structures anterior to the incisive foramen. The secondary palate lies more posteriorly and is sub divided into the hard and soft palate. Cleft palate occurs as a result of non fusion of the two palatine shelves. Both hard and soft palate may be involved. Complete cases are associated with complete separation of the nasal septum and vomer from the palatine processes.

Answer 384

In relation to secondary hyperparathyroidism; there is a HIGH PTH and the Ca2+ is NORMAL or LOW. In secondary hyperparathyroidism there is hyperplasia of the parathyroid glands in response to chronic hypocalcaemia (or hyperphosphataemia) and is a normal physiological response. Calcium is released from bone, kidneys and the gastrointestinal system.

Answer 385

Elevated serum Calcium \> 1mg/dL above normal Hypercalciuria \> 400mg/day Creatinine clearance \< 30% compared with normal Episode of life threatening hypercalcaemia Nephrolithiasis Age \< 50 years Neuromuscular symptoms Reduction in bone mineral density of the femoral neck, lumbar spine, or distal radius of more than 2.5 standard deviations below peak bone mass (T score lower than -2.5)

Answer 386

Bone pain Persistent pruritus Soft tissue calcifications

Answer 387

Allow 12 months to elapse following transplant as many cases will resolve The presence of an autonomously functioning parathyroid gland may require surgery. If the culprit gland can be identified then it should be excised. Otherwise total parathyroidectomy and re-implantation of part of the gland may be required.

Answer 388

Give 10 kcal/kg/day initially, oral thiamine 200-300mg/day, vitamin B co strong1 tds and supplements. This patient is at high risk of refeeding syndrome.

Answer 389

Colloids are preferred initially as they reduce the incidence of coagulopathy Fresh blood is the fluid of choice when large volume blood loss complicates trauma. Mortality is doubled when blood \>3 weeks old is used.

Answer 390

The sural nerve is closely related and damage to this structure is a major cause of litigation. The other structures may all be injured but the risks are lower.

Answer 391

The ureter lies anterior to L2 to L5 and stones may be visualised at these points, they may also be identified over the sacro-iliac joints.

Answer 392

As it crosses the bony pelvis

Answer 393

Retroperitoneal structure overlying transverse processes L2-L5 Lies anterior to bifurcation of iliac vessels Lies beneath the uterine artery

Answer 394

Acute bacterial tonsillitis In acute tonsillitis the tonsils will often meet in the midline and may be covered with a membrane. Individuals who are systemically well are unlikely to have diptheria. Infectious mononucleosis A combination of pharyngitis and tonsillitis is often seen in glandular fever. Antibiotics containing penicillin may produce a rash when given in this situation, leading to a mistaken label of allergy. Quinsy Unilateral swelling and fever is usually indicative of quinsy. Surgical drainage usually produces prompt resolution of symptoms.

Answer 395

Phosphaturia causes cloudy urine.

Answer 396

Binding to µ opioid receptors within the CNS

Answer 397

CNS Analgesic and antidepressant effects

Answer 398

CNS Analgesic and dissociative effects

Answer 399

Central and peripheral analgesia, miosis, decreased gut motility

Answer 400

Nociceptin receptor (CNS)- Affect of appetite and tolerance to µ agonists.

Answer 401

Cyclophosphamide is metabolised into a toxic metabolite acrolein. The effects may be attenuated by administration of large volumes of intravenous fluids and mesna (which neutralises the metabolite). The condition may be managed initially by bladder catheterisation and irrigation.

Answer 402

This patient has a condition causing poor absorption, loss of nutrients and high metabolism. Enteral feeds should be used where possible and many surgeons will site a jejunostomy for this purpose. Oral diet is not permitted following a resection until the anastamosis has had time to heal.

Answer 403

Dermoid cysts occur at sites of embryonic fusion and may contain multiple cell types. They occur most often in children. The lesion is unlikely to be a desmoid cyst as these are seldom located either at this site or in this age group. In addition they do not contain hair. Sebaceous cysts will usually have a punctum and contain a cheesy material. Epidermoid cysts contain keratin plugs.

Answer 404

Testis Ovary Uterine fundus

Answer 405

Because the kidney is present, rather than absent, the adrenal will usual develop and in the normal location.

Answer 406

Cortex is derived from the mesoderm of the posterior abdominal wall Medulla is derived from the ectoderm, arising from nerual crest cells that migrate to the medial aspect of the developing cortex

Answer 407

The fetal adrenal gland is relatively large. At 4 months' gestation, it is 4 times the size of the kidney; however, at birth, it is a third of the size of the kidney. This occurs because of the rapid regression of the fetal cortex at birth. It disappears almost completely by age 1 year; by age 4-5 years, the permanent adult-type adrenal cortex has fully developed.

Answer 408

Anatomic anomalies of the adrenal gland may occur. Because the development of the adrenals is closely associated with that of the kidneys, agenesis of an adrenal gland is usually associated with ipsilateral agenesis of the kidney, and fused adrenal glands (whereby the 2 glands join across the midline posterior to the aorta) are also associated with a fused kidney.

Answer 409

1. hypoplasia or absence of cortex with poorly formed medulla 2. disorganised cortex and medulla with no permanent cortex present

Answer 410

Adrenal heterotopia describes a normal adrenal gland in an abnormal location, such as within the renal or hepatic capsules

Answer 411

broad ligament or spermatic cord but can be found anywhere within the abdomen. Even intracranial adrenal rests have been reported

Answer 412

Intestinal causes Pancreatic causes Biliary causes Other causes

Answer 413

coeliac disease Crohn's disease tropical sprue Whipple's disease Giardiasis brush border enzyme deficiencies (e.g. lactase insufficiency)

Answer 414

chronic pancreatitis cystic fibrosis pancreatic cancer

Answer 415

biliary obstruction primary biliary cirrhosis

Answer 416

bacterial overgrowth (e.g. systemic sclerosis, diverticulae, blind loop) short bowel syndrome lymphoma

Answer 417

The deep peroneal nerve lies in the anterior compartment. The tibial nerve lies medially. At its termination it lies deep to the flexor retinaculum.

Answer 418

Larger terminal branch of the popliteal artery Terminates by dividing into the medial and lateral plantar arteries Accompanied by two veins throughout its length Position of the artery corresponds to a line drawn from the lower angle of the popliteal fossa, at the level of the neck of the fibula, to a point midway between the medial malleolus and the most prominent part of the heel

Answer 419

Tibialis posterior Flexor digitorum longus Posterior surface of tibia and ankle joint

Answer 420

Tibial nerve 2.5 cm distal to its origin Fascia overlying the deep muscular layer Proximal part covered by gastrocnemius and soleus Distal part covered by skin and fascia

Answer 421

Sub total colectomy In patients with fulminant UC a sub total colectomy is the safest treatment option. The rectum will be left in situ as resection of the rectum in these acutely unwell patients carries an extremely high risk of complications. Proctectomy Severe rectal Crohns that has developed complications such as haemorrhage and multiple fistulae is usually best managed with proctectomy. Although a diverting stoma may reduce the risk of local sepsis it is unlikely to reduce the bleeding. She is keen to conserve a rectum, however, an ileoanal pouch in this setting is unwise. Panproctocolectomy and ileoanal pouch In patients with UC where medical management is not successful, surgical resection may offer a chance of cure. Those patients wishing to avoid a permanent stoma may be considered for an ileoanal pouch. However, this procedure is only offered in the elective setting.

Answer 422

Disease that is requiring maximal therapy or prolonged courses of steroids Dysplastic transformation of the colonic epithelium with associated mass lesions- absolute indication.

Answer 423

Subtotal colectomy Excision of the rectum is a procedure with higher mobridity and is not performed in the emergency setting End ileostomy created and rectum stapled or if oedematous may be brough tot he surface as a mucous fistula

Answer 424

Restorative options in UC include an ileoanal pouch. This procedure can only be performed whilst the rectum is in situ and cannot usually be undertaken as a delayed procedure following proctectomy.

Answer 425

High incidence of DVT- thromboprophylaxis is mandatory

Answer 426

Anastomotic dehiscence Pouchitis Poor physiological function

Answer 427

Cx such as fistulae, abscess formation and strictures. Extensive small bowel resection may results in short bowel syndrome and localised stricutroplasty may allow preservation of intestinal length

Answer 428

Severe perianal and / or rectal Crohns may require proctectomy. Ileoanal pouch reconstruction in Crohns carries a high risk of fistula formation and pouch failure and is not recommended.

Answer 429

Staging of Crohns will usually involve colonoscopy and a small bowel study (e.g. MRI enteroclysis).

Answer 430

Pseudomyxoma peritonei Pseudomyxoma is classically associated with mucin production and the appendix is the commonest source. Retroperitoneal fibrosis Retroperitoneal fibrosis is an uncommon condition and its aetiology is poorly understood. In a significant proportion the ureters are displaced medially. In most retroperitoneal malignancies they are displaced laterally. Hypertension is another common finding. A CT scan will often show a para-aortic mass Metastatic adenocarcinoma of the pancreas Although not specific CA 19-9 in the context of this history is highly suggestive of pancreatic cancer over the other scenarios.

Answer 431

Is usually surgical and consists of cytoreductive surgery (and often peritonectomy c.f Sugarbaker procedure) combined with intra peritoneal chemotherapy with mitomycin C.

Answer 432

The Hurthle cell subtype have a worse prognosis.

Answer 433

It is not linked to cigarette smoking. When identified at an early stage a radical resection is the favored option. Radiotherapy is often given perioperatively. However, it is not a particularly radiosensitive tumour. Combination chemotherapy gives some of the best results and most regimes are cisplatin based.

Answer 434

Hyperacute graft rejection is due to pre-existent antibodies to HLA antigens and is therefore IgG mediated

Answer 435

Penicillin is the antibiotic of choice for group A streptococcal infections. The BNF suggests stopping flucloxacillin if streptococcal infection is confirmed in patients with cellulitis, due to the high sensitivity. This should be balanced however with the variable absorption of phenoxymethylpenicillin.

Answer 436

Alpha and beta haemolytic types