Block 8 Flashcards
Which of the following statements is false in relation to renal adenocarcinoma?
They account for over 75% cases of renal tumours
Renal biopsy should be performed in all cases considered for radical nephrectomy
They typically spread via the haematogenous route
Patients with completely resected T2 disease should not receive adjuvant chemotherapy
Partial nephrectomy gives equivalent oncological outcomes in patients with T1 disease
Routine chemotherapy is not effective in patients with renal adenocarcinoma and should not be used following R0 resections.
Routine renal biopsy should not be performed in cases for nephrectomy. Most cases of malignancy can be accurately classified on imaging.
Rare mucinous tumour
Most commonly arising from the appendix (other abdominal viscera are also recognised as primary sites)
Incidence of 1-2/1,000,000 per year
The disease is characterised by the accumulation of large amounts of mucinous material in the abdominal cavity
Pseudomyxoma Peritonei
Treatment of Pseudomyxoma
Is usually surgical and consists of cytoreductive surgery (and often peritonectomy c.f Sugarbaker procedure) combined with intra peritoneal chemotherapy with mitomycin C.
Survival is related to the quality of primary treatment and in Sugarbakers own centre 5 year survival rates of 75% have been quoted. Patients with disseminated intraperitoneal malignancy from another source fare far worse.
In selected patients a second look laparotomy is advocated and some practice this routinely.
A 30 year old man is suspected of having appendicitis. At operation an inflamed Meckels diverticulum is found. Which of the following vessels is responsible for the blood supply to a Meckels diverticulum?
Right colic artery
Vitelline artery
Appendicular artery
Internal iliac artery
External iliac artery
The vitelline arteries supply a Meckels these are usually derived from the ileal arcades.
Which of the following statements relating to osteomyelitis is false?
Is the result of haematogenous spread in most cases
Is due to Staphylococcus aureus in 50% cases
Should be treated by aggressive surgical debridement initially
Plain radiographs may be normal in the early stages
The presence of associated septic joint involvement will significantly alter management
It is managed medically in the first instance (with an antistaphylococcal antibiotic). This differs from the situation in septic joints where early joint washout is mandatory.
Causes of osteomyelitis
S aureus and occasionally Enterobacter or Streptococcus species
In sickle cell: Salmonella species
A 5 year old boy is found to have a Meckels diverticulum at an appendicectomy and it looks to be non inflamed. What type of epithelium is most likely to be found in the diverticulum?
Gastric mucosa
Non stratified squamous epithelium
Ileal mucosa
Stratified squamous epithelium
Jejunal mucosa
Most asymptomatic Meckels diverticulum will be lined by ileal mucosa. Those which present with bleeding are more likely to contain gastric type mucosa.
A 42 year old woman is admitted to surgery with acute cholecystitis. She is known to have hypertension, rheumatoid arthritis and polymyalgia rheumatica. Her medical therapy includes:
Paracetamol 1g qds
Codeine phosphate 30mg qds
Bendrofluazide 2.5 mg od
Ramipril 10mg od
Methotrexate 7.5mg once a week
Prednisolone 5mg od
You are called by the CT1 to assess this lady as she has become delirious and hypotensive 2 hours after surgery. Her blood results reveal:
Na+132 mmol/l
K+5.3 mmol/l
Urea7 mmol/l
Creatinine108 µmol/l
Hb12.4 g/dl
Platelets178 * 109/l
WBC15.4 * 109/l
What management is needed immediately?
Ceftriaxone IV
Hydrocortisone 50mg IV
CT scan abdomen
Urgent exploratory laparotomy
Hydrocortisone 100mg IV
This patient has acute adrenal insufficiency and urgently needs steroid replacement.
Causes of Addisonian crisis
Sepsis or surgery causing an acute exacerbation of chronic insufficiency (Addison’s, Hypopituitarism)
Adrenal haemorrhage eg Waterhouse-Friderichsen syndrome (fulminant meningococcemia)
Steroid withdrawal
Management of Addisonian crisis
Hydrocortisone 100 mg im or iv
1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic
Continue hydrocortisone 6 hourly until the patient is stable. No fludrocortisone is required because high cortisol exerts weak mineralocorticoid action
Oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days
Theme: Thoracic trauma
A.Thoracotomy
B.Manage conservatively
C.Intercostal tube drain insertion
D.CT scanning
E.Bronchoscopy
F.Negative pressure intercostal tube drainage
G.Video assisted thoracoscopy and pleurectomy
For each of the following scenarios please select the most appropriate management option from the list. Each option may be used once, more than once or not at all.
66.A 28 year old male is involved in a road traffic accident he is thrown from his motorbike onto the pavement and sustains a haemopneumothorax and flail segment of the right chest.
A 19 year old man is stabbed in the chest at a nightclub. He develops a cardiac arrest in casualty following an attempted transfer to the CT scanning room.
A 32 year old male falls over and sustains a small pneumothorax following a simple rib fracture. He has no physiological compromise.
Intercostal tube drain insertion
He requires a chest drain and analgesia. In general all haemopneumothoraces should be managed by intercostal chest drain insertion as they have a risk of becoming a tension pneumothorax until the lung laceration has sealed.
Thoracotomy
This is one indication for an ‘emergency room’ thoracotomy, there are not many others! Typical injuries include ventricular penetration, great vessel disruption and hilar lung injuries.
Intercostal tube drain insertion
Unlike spontaneous pneumothoraces most would advocate chest tube drainage in the context of pneumothorax resulting from trauma. This is because of the risk of the lung laceration developing a tension. Once there is no further evidence of air leak the chest drain may be removed and a check x-ray performed to check there is no re-accumulation prior to discharge.
At what level does the sciatic nerve usually bifurcate into the tibial and common peroneal nerves?
At the superior aspect of the popliteal fossa
At the inferior aspect of the popliteal fossa
At the inferior border of gluteus maximus
At the inferior border of the piriformis muscle
In the pelvis
The sciatic nerve passes vertically downwards over the posterior surface of the obturator internus and quadratus femoris to the hamstring compartment of the thigh, here it is crossed posteriorly by the long head of biceps femoris. In the buttock it lies under the cover of gluteus maximus. It separates into its tibial and common peroneal components at the upper aspect of the popliteal fossa.
A 28 year old man has a pleomorphic adenoma and the decision is made to resect this surgically. Which of the following structures is least likely to be encountered during surgical resection of the parotid gland?
External carotid artery
Retromandibular vein
Auriculotemporal nerve
Mandibular nerve
Zygomatic branch of the facial nerve
The mandibular nerve is well separated from the parotid gland.
The maxillary vein joins to the superficial temporal vein and they form the retromandibular vein which then runs through the parotid gland.
The auriculotemporal nerve runs through the gland. Following a parotidectomy this nerve may be damaged and during neuronal regrowth may then attach to sweat glands in this region. This can then cause gustatory sweating (Freys Syndrome).
The facial nerve branch is the marginal mandibular branch and this is related to the gland.
Structures passing through the parotid gland
Facial nerve and branches
External carotid artery (and its branches; the maxillary and superficial temporal)
Retromandibular vein
Auriculotemporal nerve
Freys Syndrome
The auriculotemporal nerve runs through the gland. Following a parotidectomy this nerve may be damaged and during neuronal regrowth may then attach to sweat glands in this region. This can then cause gustatory sweating
You have just completed a laparotomy for peritonitis due to a perforated peptic ulcer. What is the best surgical strategy for avoidance of a complete abdominal wound dehisence?
Use of skin clips to close the skin rather than sub cuticular sutures
Careful approximation of the peritonum with non absorbable sutures
Mass closure of the midline wound using a 1/0 polydiaxone suture
Direct apposition of the rectus muscle rather than linea alba aponeurosis
Mass closure of the midline wound using a 3/0 polypropylene suture
The incidence of post operative wound dehisence is minimise by following Jenkins rule which advocates mass closure of the midline wound. However, the suture strength is an important consideration and 3/0 sutures do not have sufficient tensile strength. Both polydiaxone (PDS) and polypropylene (Prolene) or nylon (Ethilon) are all equally suitable. Although separate closure of the peritoneum was practised it has no bearing on the incidence of abdominal wound dehisence.
Theme: Management of calcium metabolic disorders
A.No action needed
B.Intravenous fluid (0.9% N.Saline)
C.Risedronate and calcium supplements
D.Calcium supplements
E.Exploration and parathyroidectomy
F.DEXA bone scan
G.Pamidronate IV
For each scenario please select the most appropriate management plan. Each option may be used once, more than once or not at all.
72.An 80 year old woman has a hip fracture. Her calcium is normal. She has never been given a diagnosis of osteoporosis.
A 60 year old man presents with recurrent renal stones. He is found to have a calcium of 2.72 (elevated) and a PTH of 12 (elevated).
An 82 year old woman from a nursing home is admitted to the orthopaedic ward with a hip fracture. She is acutely confused and agitated. Her Calcium is 2.95 (elevated).
Risedronate and calcium supplements
The osteoporosis guidelines state if a postmenopausal woman has a fracture she should be put on bisphosphonates (there is no need for a DEXA scan).
Exploration and parathyroidectomy
This patient has primary hyperparathyroidism and nephrolithiasis, which is an indication for parathyroidectomy.
Intravenous fluid (0.9% N.Saline)
This patient needs rehydration due to hypercalcaemia. An intravenous bisphosphonate is indicated if the Ca is above 3.
What is the pathophysiology of DAI
- Multiple haemorrhages
- Diffuse axonal damage in the white matter
Up to 2/3 occur at the junction of grey/white matter due to the different densities of the tissue. The changes are mainly histological and axonal damage is secondary to biochemical cascades. Often there are no signs of a fracture or contusion.
A 19 year old man presents with painful rectal bleeding and is found to have an anal fissure. Which of the following is least associated with this condition?
Leukaemia
Syphilis
Tuberculosis
Sickle cell disease
Crohn’s disease
SCD
Anal fissures are associated with:
Sexually transmitted diseases (syphilis, HIV)
Inflammatory bowel disease (Crohn’s up to 50%)
Leukaemia (25% of patients)
Tuberculosis
Previous anal surgery
A 78 year old man presents with a ruptured aortic aneurysm. This is repaired but the operation is difficult as it has a juxtarenal location. A supra renal cross clamp is applied. Post operatively he is found to be oliguric and acute renal failure is suspected. Which of the following statements relating to acute post-operative renal failure are untrue?
Intravenous dopamine does not prevent acute renal failure.
It is more common after emergency surgery.
Use of excessive amounts of intravenous fluids may lead to falsely normal serum creatinine measurements.
Vasopressor drugs have a strong renoprotective effect
It is minimised by normalisation of haemodynamic status.
Vasopressor use is linked to renal failure as they are a marker of haemodynamic compromise.
A 73 year old man has previously undergone a prostatectomy to treat prostate cancer. On review, his PSA has risen to 55 and he has developed pain in his lower back. Imaging shows osteosclerotic lesions in L4 and L3. What is the best treatment strategy?
Posterior spinal fusion
Vertebral body reconstruction
Bisphosphonates and radiotherapy
Androgen suppression, bisphosphonates and radiotherapy
Radiotherapy alone
In men with metastatic bone lesions from prostate cancer, the best outcomes are achieved with androgen suppression. Radiotherapy can also produced marked palliation. A 2010 Cochrane review has clearly demonstrated added benefit, in terms of symptom control, from the addition of a bisphosphonate.
Which of the following associations are incorrect?
Afro-Caribbean skin and keloid scarring
Extensive third degree burns and wound contraction
Chemotherapy and dehisence of healed wounds
Poor healing at the site of previous radiotherapy
Zinc deficiency and delayed healing
Chemotherapy and dehisence of healed wounds
Lies most superficially
Originates from 5th to 12th ribs
Inserts into the anterior half of the outer aspect of the iliac crest, linea alba and pubic tubercle
More medially and superiorly to the arcuate line, the aponeurotic layer overlaps the rectus abdominis muscle
The lower border forms the inguinal ligament
The triangular expansion of the medial end of the inguinal ligament is the lacunar ligament.
External oblique
Arises from the thoracolumbar fascia, the anterior 2/3 of the iliac crest and the lateral 2/3 of the inguinal ligament
The muscle sweeps upwards to insert into the cartilages of the lower 3 ribs
The lower fibres form an aponeurosis that runs from the tenth costal cartilage to the body of the pubis
At its lowermost aspect it joins the fibres of the aponeurosis of transversus abdominis to form the conjoint tendon.
Internal oblique
Innermost muscle
Arises from the inner aspect of the costal cartilages of the lower 6 ribs , from the anterior 2/3 of the iliac crest and lateral 1/3 of the inguinal ligament
Its fibres run horizontally around the abdominal wall ending in an aponeurosis. The upper part runs posterior to the rectus abdominis. Lower down the fibres run anteriorly only.
The rectus abdominis lies medially; running from the pubic crest and symphysis to insert into the xiphoid process and 5th, 6th and 7th costal cartilages. The muscles lies in a aponeurosis as described above.
Nerve supply: anterior primary rami of T7-12
Transversus abdominis
A 56 year old man presents with a painless swelling in the upper part of the anterior triangle of his neck. On examination a mass lesion involving the sub mandibular gland is identified. On CT scanning this is shown to be a solid lesion. There is no regional lymphadenopathy. Two fine needle aspirates have failed to be diagnostic. Which of the following is the most appropriate management option?
Sub mandibular gland excision
Incisional biopsy of the mass
Manage conservatively and repeat the CT scan in 6 months
Sub mandibular gland excision and radical neck dissection
Diagnostic excision of the superficial lobe of the submandibular gland
There is a 50% risk that this lesion is malignant (in some series up to 70%). Therefore the gland should be excised entirely. At this stage a radical neck dissection is not justified.
Features of sialolithiasis
80% of all salivary gland calculi occur in the submandibular gland
70% of the these calculi are radio-opaque
Stones are usually composed of calcium phosphate or calcium carbonate
Patients typically develop colicky pain and post prandial swelling of the gland
Investigation involves sialography to demonstrate the site of obstruction and associated other stones
Stones impacted in the distal aspect of Whartons duct may be removed orally, other stones and chronic inflammation will usually require gland excision
Features of sialadenitis
Usually occurs as a result of Staphylococcus aureus infection
Pus may be seen leaking from the duct, erythema may also be noted
Development of a sub mandibular abscess is a serious complication as it may spread through the other deep fascial spaces and occlude the airway
Features of submandibular tumours
Only 8% of salivary gland tumours affect the sub mandibular gland
Of these 50% are malignant (usually adenoid cystic carcinoma)
Diagnosis usually involves fine needle aspiration cytology
Imaging is with CT and MRI
In view of the high prevalence of malignancy, all masses of the submandibular glands should generally be excised.
What proportion of submandibular tumours are malignant?
50% (usually adenoid cystic)
A 45 year old woman is identified as having a gastric gastro-intestinal stromal tumour. What is the usual cell of origin of these lesions?
Brunners glands
Interstitial cells of Cajal
Primitive stem cells of the gut wall
Fundic glands
Antral goblet cells
GIST’s are derived from the interstitial pacemaker cells of Cajal. This means that they are often located extramucosally and macroscopically, demonstrate little mucosal disruption.
Features of GIST?
GIST’s are not common tumours (10 per million) and originate primarily from the interstitial pacemaker cells (of Cajal). Up to 70% occur in the stomach, the remainder occurring in the small intestine (20%) and the colon and rectum (5%). Up to 95% are solitary lesions and most are sporadic. The vast majority express CD117 which is a transmembrane tyrosine kinase receptor and in these there is a mutation of the c-KIT gen
What is the most common site for GISTs?
Stomach
Followed by small intestine
And recutm
Oncogenetics of GIST
CD117 RTk, mutation in c-KIT
Goal of surgery in GIST
Resection with 1-2cm margin of normal tissue
Px of GIST?
High local recurrence rate, the risk of which is related to site, incomplete resections and high mitotic count. Salvage surgery for recurrent disease is associated with a median survival of 15 months.
The prognosis in high risk patients is greatly improved through the use of imatinib, which in the ACOSOG trial (imatinib vs placebo) improved relapse rates from 17% to 2%.
In the UK it is advocated by NICE for use in patients with metastatic disease or locally unresectable disease.
A 23 year old man fractures his right tibia in a sporting accident. At which point in the healing process is fracture callus most likely to be visible radiologically?
1 day
7 days
8 weeks
6 weeks
3 weeks
Fracture callus is composed of fibroblasts and chondroblasts and the synthesis of fibrocartilage. It is typically visible on radiographs approximately 3 weeks following injury. If delayed then there may be risk of non union.
Process of bone fracture healing
Bone fracture
- Bleeding vessels in the bone and periosteum
- Clot and haematoma formation
- The clot organises over a week (improved structure and collagen)
- The periosteum contains osteoblasts which produce new bone
- Mesenchymal cells produce cartilage (fibrocartilage and hyaline cartilage) in the soft tissue around the fracture
- Connective tissue + hyaline cartilage = callus
- As the new bone approaches the new cartilage, endochondral ossification occurs to bridge the gap
- Trabecular bone forms
- Trabecular bone is resorbed by osteoclasts and replaced with compact bone
A 56 year old man is undergoing a carotid endarterectomy. The internal carotid artery is mobilised. How many branches does this vessel give off in the neck?
0
1
2
3
6
The internal carotid does not have any branches in the neck.
Which of the following is a content of the adductor canal?
Saphenous nerve
Sural nerve
Femoral nerve
Profunda branch of the femoral artery
Saphenous vein
It contains the saphenous nerve and the superficial branch of the femoral artery.
Borders of the adductor canal
Lateral border Vastus medialis
Posterior border: Adductor longus, adductor magnus
Roof- sartorius
Contents of the adductor canal
Saphenous nerve (+ nerve to vastus medialis)
Superficial femoral artery
Superficial femoral vein
Theme: Treatment of bowel cancer
A.Active observation
B.Long course chemoirradiation
C.Chemotherapy with oxaliplatin
D.Short course chemotherapy (5 days)
E.Proceed straight to surgery
F.Post operative radiotherapy
G.Chemotherapy with methotrexate
H.Brachytherapy
I.Anterior pelvic exenteration
Please select the most appropriate management option from the list below. Each option may be used once, more than once or not at all.
89.A 45 year old female is diagnosed as having a carcinoma of the caecum. She undergoes a CT scan which shows a tumour invading the muscularis propria with some regional lymphadenopathy.
A 55 year old man presents with tenesmus and rectal bleeding. On examination he has a large bulky rectal cancer at 5cm with tethering to the prostate gland. Imaging shows no distant disease.
A 43 year old women undergoes a sigmoid colectomy for carcinoma. The histology report shows Dukes C disease. She is otherwise well.
Proceed straight to surgery
Right sided colonic cancers should proceed straight to surgery. Radiotherapy to this area is poorly tolerated and almost never offered as first line treatment. The decision as to whether or not chemotherapy is given is dependent upon the final histology.
Long course chemoirradiation
T4 rectal cancers are managed with long course chemoradiotherapy. A dramatic response is not uncommon. To embark on attempted resection at this stage is to court failure.
Chemotherapy with oxaliplatin
Chemotherapy for colonic cancer is usually with oxaliplatin. Neuropathy is a recognised side effect of this treatment.
A 24 year old man presents with a persistent and unwanted erection that has been present for the previous 6 hours. On examination the penis is rigid and tender. Aspiration of blood from the corpus cavernosa shows dark blood. Which of the following is the most appropriate initial management?
Discharge the patient home and review in 12 hours
Admit the patient to hospital and review in 12 hours
Aspirate further blood from the corpus cavernosa in an attempt to decompress
Use a trucut needle to induce an arteriovenous shunt
Administer intracavernosal adrenaline 1 in 500 concentration
Low flow priapism is a urological emergency. Aspiration of bright red blood is more reassuring and may indicate high flow priapism that may be actively monitored. Low flow priapism should be decompressed with aspiration of blood from the corpus cavernosum.
In relation to operating in the elderly which statement is false?
A 30 minute increment in operation length is associated with increase in mortality in patients over the age of 80
Hypoalbuminaemia is associated with increased mortality
Statins given preoperatively reduce perioperative cardiac events
Elevated brain (or B-type) natriuretic peptide (BNP) levels before undergoing non cardiac surgery is associated with high risk of cardiac mortality and all cause mortality
Beta blockers should be stopped acutely prior to surgery due to risk of perioperative hypotension
Beta blockers should not be stopped acutely prior to surgery as there may be a rebound effect associated with increased complications.
Brain natriuretic peptide is a neurohormone synthesized in the cardiac ventricles. Levels have been used to assess prognosis in heart failure and acute coronary syndromes. Preoperative elevated brain natriuretic peptide levels identify patients undergoing non cardiac surgery at high risk of cardiac mortality and all cause mortality.
All patients with peripheral vascular disease should take statins prior to vascular surgery as studies have shown a 50% risk reduction and a reduction in perioperative cardiac events.
POPS approach
Comprehensive geriatric assessment
MDT assessment preoperatively
Main predictors of complications are co-morbidities cardiac disease and reduced functional capacity - preoperative assessment is the key to preventing adverse postoperative outcomes
Patients screened for risk factors (albumin <30, co morbidities)
Management plan made and disseminated to all involved
Patients education: pain relief, post op exercises, nutrition
Fewer postoperative medical complications
Reduced length of stay by 4.5 days
Theme: Instrument cleaning
A.Immersion in glutaraldehyde
B.Gamma irradiation
C.Autoclaving
D.Ethylene chloride
E.Phenolic lavage
F.Disposal of instrument
Please select the most appropriate cleaning method of instrument for the situation described. Each option may be used once, more than once or not at all.
94.A company manufacturing scalpel blades wishes to sterilise them in bulk before use.
For sterilisation and cleaning of a colonoscope.
For cleaning instruments following a tonsillectomy in a patient who recieved human growth hormone extract in 1981
Gamma irradiation
Industry often uses gamma irradiation. It is not routinely used in hospitals
Immersion in glutaraldehyde
Washing systems using glutaraldehyde are often used although development of sensitivity in staff is well known and it is used in closed systems
Disposal of instrument
High risk of prion disease mandates disposal on instruments which is often undertaken following all tonsillectomy procedures regardless of level of percieved risk
From which of these foraminae does the opthalmic branch of the trigeminal nerve exit the skull?
Foramen ovale
Foramen rotundum
Foramen spinosum
Superior orbital fissure
Foramen magnum
Mnemonic:
Standing Room Only -Exit of branches of trigeminal nerve from the skull
V1 -Superior orbital fissure
V2 -foramen Rotundum
V3 -foramen Ovale
The opthalmic branch of the trigeminal nerve exits the skull through the superior orbital fissure.
A 56 year old lady with metastatic breast cancer develops an oestolytic deposit in the proximal femur. One morning whilst getting out of bed she notices severe groin pain. X-rays show that the lesser trochanter has been avulsed. Which muscle is the most likely culprit?
Vastus lateralis
Psoas major
Piriformis
Gluteus maximus
Gluteus medius
The psoas major inserts into the lesser trochanter and contracts when raising the trunk from the supine position. When oestolytic lesions are present in the femur the lesser trochanter may be avulsed.
Of the options below, which does not cause lymphadenopathy?
Kawasaki disease
Systemic Lupus Erthematosus
Phenytoin
Hydralazine
Amiodarone
Amiodarone
A 23 year old man is reviewed on the ward 10 days following a laparotomy. The wound is inspected and is healing well. Which of the following processes is least likely to be occurring in the wound at this stage?
Angiogenesis
Synthesis of collagen
Necrosis of fibroblasts
Secretion of matrix metalloproteinases by fibroblasts
Proliferation of fibroblasts
Vasculogenesis vs Angiogenesis
Vascu is new. Angi is pre
Vasculogenesis is new vessels developing in situ from existing mesenchyme.
Angiogenesis is vessels develop from sprouting off pre-existing arteries.
Fibroblasts are an important cell type in healing wounds. They typically proliferate in the early phases of wound healing. They release matrix metalloproteinases and these facilitate in the remodelling of the matrix within the healing wound. Necrosis in a healing wound would be unusual as wounds will tend to show clinical evidence of angiognesis by this time.
Which of the following nerves is responsible for the motor innervation of the sternocleidomastoid muscle?
Ansa cervicalis
Accessory nerve
Hypoglossal nerve
Facial nerve
Vagus nerve
The motor supply to the sternocleidomastoid is from the accessory nerve. The ansa cervicalis supplies sensory information from the muscle.
A 53 year old man presents with a full thickness external rectal prolapse. Which of the following procedures would be the most suitable surgical option?
Rectopexy
Delormes
Altmeirs
Thirsch tape
Abdomino-perineal excision of the rectum
As this man is young and has full thickness prolapse a rectopexy is the most appropriate procedure. It will give the lowest recurrence rates.
Which of the following is most suggestive of malnutrition?
Hypoalbuminaemia
BMI of 22 kg/m2 and unintentional weight loss of > 5% over 3-6 months
BMI of 18.5 kg/m2
Reduced skin turgor
Unintentional weight loss of > 10% over 3- 6 months in a 60 Kg female who is 1.6m tall
An unintentional weight loss of >10% in a three to six month period is highly suggestive of malnutrition. This is particularly true of people with a normal/ low BMI. Hypoalbuminaemia is not, in itself, a reliable marker of nutrition.
A 42 year old lady undergoes a difficult cholecystectomy and significant bleeding is occurring. The surgeons place a vascular clamp transversely across the anterior border of the epiploic foramen. Which of the following structures will be occluded in this manoeuvre?
Cystic artery
Cystic duct
Left gastric artery
Portal vein
None of the above
The portal vein, hepatic artery and common bile duct are occluded.
Structures occluded during Pringles manoeuvre
During liver surgery bleeding may be controlled using a Pringles manoeuvre, this involves placing a vascular clamp across the anterior aspect of the epiploic foramen. Thereby occluding:
Common bile duct
Hepatic artery
Portal vein
A 34 year old man is injured by farm machinery and sustains a laceration at the superolateral aspect of the popliteal fossa. The medial aspect of biceps femoris is lacerated. Which of the following underlying structures is at greatest risk of injury?
Gracilis
Sural nerve
Nerve to semimembranosus
Popliteal artery
Common peroneal nerve
The common peroneal nerve lies under the medial aspect of biceps femoris and is therefore at greatest risk of injury. The tibial nerve may also be damaged in such an injury (but is not listed here). The sural nerve branches off more inferiorly.
Glasgow criteria
PANCREAS
Pa O2 <60
Age >55
Neutrophils >15
Ca <2
Renal- urea >16
Enzyme (LDH) >600
Albumin <32
Sugar glucose >10
>3 positive criteria indicates severe pancreatitis
A 34 year old lady is admitted with pancreatitis. The aetiology is unclear and it is classified as an attack of moderate severity according to the Glasgow criteria. Her imaging shows no gallstones and fluid around the pancreas. Which of the following is the most appropriate initial management option?
Laparotomy
Laparoscopy
Radiological aspiration of the fluid
Active observation
Administration of octreotide
Acute early fluid collections are seen in 25% of patients with pancreatitis and require no specific treatment. Attempts at drainage may introduce infection and result in pancreatic abscess formation.
Theme: Timing of surgery
A.Immediate surgery
B.Surgery within 2 hours
C.Surgery within 6 hours
D.Surgery within 24 hours
E.Surgery within same hospital admission
F.Urgent elective surgery within 4 weeks
G.True elective surgery
For each procedure please select the most appropriate time interval for surgery. Each option may be selected once, more than once or not at all.
5.A 43 year old woman is admitted with acute cholecystitis, her USS confirms the diagnosis and LFT’s are normal. It is now 10 hours since admission.
A 5 year old boy is admitted with a suspected acute appendicitis. He has tenderness but no guarding as yet. He requires appendicectomy.
A 72 year old man is admitted with large bowel obstruction. He has been vomiting for 24 hours and his caecum is tender and measures 11cm.
Surgery within same hospital admission
Ideal case for acute cholecystectomy. This will enable prompt discharge and facilitate recovery. Whilst expedient surgery is desirable an emergency procedure is not justified.
Surgery within 6 hours
The kind of case that can wait till the following day if presenting out of hours. Appendicectomy may be deferred where peritoneal signs are absent. Where tenderness and guarding are present a more urgent approach is warranted.
Surgery within 6 hours
The sun should not rise and set on unrelieved large bowel obstruction! This patient has a competent ileocaecal valve. As a result lack of surgery would result in caecal perforation leading to faecal peritonitis with and associated high mortality rate.
Which of the following intravenous fluid solutions has the greatest chloride content?
Dextrose / saline
Normal saline
Hartmanns solution
Ringers lactate
5% dextrose
Normal saline has the highest chloride content and excessive administration of normal saline is a recognised risk factor for the development of hyperchloraemic metabolic acidosis.
Electrolyte content of plasma
Na 137-147
K 4.5-5.5
Cl 95-105
Bicarbonate 22-25
Electrolyte content of 0.9% NS
Na 154
Cl 154
Electrolyte content of dextrose/saline
Na 30.6
Cl 30.6
Electrolyte composition of Hartmans
Na 130
K 4
Cl 110
Lactate 28
A 56 year old lady is admitted with colicky abdominal pain. A plain x-ray is performed. Which of the following should not show fluid levels on a plain abdominal film?
Stomach
Jejunum
Ileum
Caecum
Descending colon
Fluid levels in the distal colon are nearly always pathological. In general contents of the left colon transit quickly and are seldom held in situ for long periods, the content is also more solid.
Features that are usually abnormal on abdominal plain film
Large amounts of free air (colonic perforation), smaller volumes are seen with more proximal perforations
Positive Riglers sign
Caecal diameter >8cm
Fluid levels in the colon
Ground glass appearance to film
Sentinal loops
Chiladitis sign?
In Chiladitis sign, a loop of bowel may be interposed between the liver and diaphragm, giving the mistaken impression that free air is present.
Free intra abdominal air following laparoscopy / laparotomy, on AXR
Normal
Should dissipate in 48-72 hours
Air in billiary tree following ERCP
Normal
A 45 year old male is referred to clinic for consideration of resection of a lung malignancy. He reports shortness of breath and haemoptysis. Investigations reveal a corrected calcium of 2.84 mmol/l, an FEV 1 of 1.9L and histology of a squamous cell carcinoma. The patient is noted to have a hoarse voice. Which one of the following is a contraindication to surgical resection in lung cancer?
Haemoptysis
FEV 1 of 1.9 litres
Histology shows squamous cell cancer
Vocal cord paralysis
Calcium = 2.84 mmol/L
Paralysis of a vocal cord implies extracapsular spread to mediastinal nodes and is an indication of inoperability.
Contraindications to lung cancer surgery?
SVCO
FEV <1.5
Malignant pleural effusion
Vocal cord parlaysis
General poor health
Stage IIIb or IV (metastatic disease)
Tumour near hilum
FEV <1.5 in lung cancer surgery?
FEV1 < 1.5 for lobectomy or < 2.0 for pneumonectomy then some authorities advocate further lung function tests as operations may still go ahead based on the results
Surgical management of NSCLC
20% suitable for surgery
Mediastinoscopy performed prior to surgery as CT does not always show mediastinal LN involvement
Curative or palliative radiotherapy
Poor response to CTx
Theme: Knee injuries
A.Anterior cruciate ligament rupture
B.Posterior cruciate ligament rupture
C.Medial collateral ligament tear
D.Lateral collateral ligament tear
E.Torn meniscus
F.Chondromalacia patellae
G.Dislocated patella
H.Fractured patella
I.Tibial plateau fracture
What is the most likely injury for scenario given? Each option may be used once, more than once or not at all.
11.A 38 year old man is playing football when he slips over during a tackle. His knee is painful immediately following the fall. Several hours later he notices that the knee has become swollen. Following a course of non steroidal anti inflammatory drugs and rest the situation improves. However, complains of recurrent pain. On assessment in clinic you notice that it is impossible to fully extend the knee, although the patient is able to do so when asked.
A 34 year old woman is a passenger in a car during an accident. Her knee hits the dashboard. On examination the tibia looks posterior compared to the non injured knee.
A 28 year old professional footballer is admitted to the emergency department. During a tackle he is twisted with his knee flexed. He hears a loud crack and his knee rapidly becomes swollen.
Torn meniscus
Twisting sporting injuries followed by delayed onset of knee swelling and locking are strongly suggestive of a menisceal tear. Arthroscopic menisectomy is the usual treatment.
Posterior cruciate ligament rupture
In ruptured posterior cruciate ligament the tibia lies back on the femur and can be drawn forward during a paradoxical draw test.
Anterior cruciate ligament rupture
This is common in footballers as the football boot studs stick to the ground and high twisting force is applied to a flexed knee. Rapid joint swelling also supports the diagnosis.
Which of the following features does not put a patient at risk of refeeding syndrome?
BMI < 16 kg/m2
Alcohol abuse
Thyrotoxicosis
Chemotherapy
Diuretics
Diuretics increase the risk of re-feeding syndrome through a process of increasing the risk of depletion of key electrolytes.
Metabolic consequences of refeeding syndrome
Hypophosphataemia
Hypokalaemia
Hypomagneseamia
Abnormal fluid balance
Patient not eaten for >5d
Aim to re-feed at 50% energy and protein levels
High risk of refeeding
If one or more of the following:
BMI < 16 kg/m2
Unintentional weight loss >15% over 3-6 months
Little nutritional intake > 10 days
Hypokalaemia, Hypophosphataemia or hypomagnesaemia prior to feeding (unless high)
If two or more of the following:
BMI < 18.5 kg/m2
Unintentional weight loss > 10% over 3-6 months
Little nutritional intake > 5 days
History of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids
Prescription in refeeding syndrome
Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days
Start immediately before and during feeding: oral thiamine 200-300mg/day, vitamin B co strong 1 tds and supplements
Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium (0.2-0.4 mmol/kg/day)
A 56 year old lady undergoes a Hartmans style resection of the sigmoid colon, with ligation of the vessels close to the colon. Which of the following vessels will be responsible to supplying the rectal stump directly?
Superior mesenteric artery
Middle colic artery
Superior rectal artery
Inferior mesenteric artery
External iliac artery
This question is addressing the blood supply to the rectum. Which is supplied by the superior rectal artery. High ligation of the IMA may compromise this structure. However, the question states that during the Hartmans procedure the vessels were ligated close to the bowel. Implying that the superior rectal was preserved.
What marks the transition between the rectum and the sigmoid colon?
Disappearance of taenia coli
Extraperitoneal extent of the rectum
Posterior upper third
Posterior and lateral middle third
Whole lower third
Lymphatic drainage of the rectum
Mesorectal lymph nodes (superior to dentate line)
Inguinal nodes (inferior to dentate line)
Which of the nerves listed below is at greatest risk of injury with a laceration to the upper lateral margin of the popliteal fossa?
Common peroneal nerve
Sural nerve
Sciatic nerve
Saphenous nerve
Tibial nerve
Common peroneal
The sural nerve exits at the lower infero-lateral aspect of the fossa and is more at risk in short saphenous vein surgery. The tibial nerve lies more medially and is even less likely to be injured in this location.
Which option is false in relation to the trigeminal nerve?
The nerve originates at the pons
The posterior scalp is supplied by the trigeminal nerve
The maxillary nerve exits via the foramen rotundum
The maxillary nerve is purely sensory
The motor root is not in the trigeminal ganglion
The posterior scalp is supplied by C2-C3.
Path of the trigeminal nerve
Originates at the pons
Sensory root forms the large, crescenteric trigeminal ganglion within Meckel’s cave, and contains the cell bodies of incoming sensory nerve fibres. Here the 3 branches exit.
The motor root cell bodies are in the pons and the motor fibres are distributed via the mandibular nerve. The motor root is not part of the trigeminal ganglion.
Which of the trigeminal nerve branches has motor function?
Mandibular nerve
A patient has an appendicectomy and a 1.2cm carcinoid tumour is identified in the tip of the appendix. What is the most appropriate management?
Watchful waiting
Discharge
Right hemicolectomy
Limited ileocaecal resection
Radioisotope scan
Individuals with small carcinoids can be discharged (<2cm and limited to the appendix). Larger tumours should have a radioisotope scan. Where the resection margin is positive or where the isotope scan suggests lymphatic metastasis a right hemicolectomy should be performed.
Which of the following is not an absorbable suture material?
Chromic catgut
Nylon
Vicryl
Dexon
Poly diaxone (PDS).
Nylon
Apex of the posterior triangle of the neck
SCM and trapezius muscles at the occipital bone
Anterior border of the posterior triangle of the neck
Posterior border of SCM
Posterior border of the posterior triangle of the neck
Anterior border of trapezius
Base of the posterior triangle of the neck
Middle third of the clavicle
Nerves in the posterior triangle of the neck
Accessory
Phrenic
Three trunks of the brachial plexus
Branches of the cervical plexus: supraclavicular, transverse cervical, great auricular, lesser occipital nerve
Vessels in the posterior triangle of the neck
EJV
Subclavian
Muscles in the posterior triangle of the neck
Inferior belly of omohyoid
Scalene
LNs in the posterior triangle of the neck
Supraclavicular
Occipital
Which of the following statements relating to the regulation of renal blood flow is untrue?
In a healthy 70Kg male, the glomerular filtration rate will be the same at a systolic blood pressure of 120mmHg as a systolic blood pressure of 95 mmHg
Over 90% of the blood supply to the kidney is distributed to the cortex
The kidney receives approximately 25% of the total cardiac output at rest
A decrease in renal perfusion pressure will cause the juxtaglomerular cells to secrete renin
Systolic blood pressures of less than 65mmHg will cause the mesangial cells to secrete aldosterone
The kidney autoregulates its blood supply over a range of systolic blood pressures. Drop in arterial pressure is sensed by the juxtaglomerular cells and renin is released leading to the activation of the renin-angiontensin system. Mesangial cells are contractile cells that are located in the tubule and have no direct endocrine function.
A 48 year old lady is admitted with crampy abdominal pain and diarrhoea. She has been unwell for the past 12 hours. In the history she complains that her milk bottles have been pecked repeatedly by birds, she otherwise has had no dietary changes. Which of the following is the most likely causative organism?
Staphylococcus aureus
Campylobacter jejuni
Clostridium difficile
Norovirus
Clostridium botulinum
Birds are a recognised reservoir of campylobacter.
Theme: Lower limb ulceration
A.Mixed ulcer
B.Chronic obliterative arterial disease
C.Superficial venous insufficiency
D.Deep venous insufficiency
E.Neuropathic ulcer
F.Basal cell carcinoma
G.Squamous cell carcinoma
Please select the most likely cause of ulceration for the scenario given. Each option may be used once, more than once or not at all.
25.A 65 year old diabetic female presents with a painless ulcer at the medial malleolus, it has been present for the past 16 years. On examination she has evidence of truncal varicosities and a brownish discolouration of the skin overlying the affected area.
A 71 year old man presents with a painful lower calf ulcer, mild pitting oedema and an ABPI of 0.3.
A 79 year old retired teacher has had an ulcer for 15 years. It is at the medial malleolus and has associated lipodermatosclerosis of the lower limb. The ulcer base is heaped up and irregular.
Superficial venous insufficiency
Venous ulcers are usually associated with features of venous insufficiency. These include haemosiderin deposition and varicose veins. Neuropathic ulcers will tend to present at sites of pressure, which is not typically at the medial malleolus.
Chronic obliterative arterial disease
Painful ulcers associated with a low ABPI are usually arterial in nature. The question does not indicate that features of chronic venous insufficiency are present. Patients may have mild pitting oedema as many vascular patients will also have ischaemic heart disease and elevated right heart pressures. The absence of more compelling signs of venous insufficiency makes a mixed ulcer less likely.
Squamous cell carcinoma
If after many years an ulcer becomes heaped up and irregular, with rolled edges then suspect a
squamous cell carcinoma.
A 50-year-old female with a history of rheumatoid presents with a suspected septic knee joint. A diagnostic aspiration is performed and sent to microbiology. Which of the organisms below is most likely to be responsible?
Staphylococcus aureus
Staphylococcus epidermidis
Escherichia coli
Neisseria gonorrhoeae
Streptococcus pneumoniae
Septic arthritis - most common organism: Staphylococcus aureus
Common organsism causing septic arthritis
Most common organism overall is Staphylococcus aureus
In young adults who are sexually active Neisseria gonorrhoeae should also be considered
Management of septic arthritis
Obtain synovial fluid before commencing treatment
IV abx with Gram +ve cocci- Fluclox (clind if penallergic)
6-12/52 Abx
Needle aspiration to decompress joint
Arthroscopic lavage may be required
Which of the following is not a feature of oesphageal atresia in neonates?
High incidence of polyhydramnios
Risk of recurrence in subsequent pregnancies of 80%
Distal tracheoesphageal fistula is the commonest variant
High incidence of associated imperforate anus
Absence of gastric bubble on antenatal ultrasound
Most are sporadic and risk in subsequent pregnancies is not increased.
Action of serratus anterior
Pushing out of the scapula
Other causes of winging of the scapula
LTN
Spinal accessory nerve injury (denervating the trapezius)
Dorsal scapular nerve injury
A 36 year old male is admitted for elective surgery for a lymph node biopsy in the supraclavicular region. Post operatively the patient has difficulty shrugging his left shoulder. What is the most likely reason?
Phrenic nerve lesion
Axillary nerve lesion
C5, C6 root lesion
C8, T1 root lesion
Accessory nerve lesion
The accessory nerve lies in the posterior triangle and may be injured in this region. Apart from problems with shrugging the shoulder, he may also have difficulty lifting his arm above his head.
Beta-naphthalamine is associated with which of the following malignancies?
Lung cancer
Bowel cancer
Bladder cancer
Liver cancer
Renal cancer
Bladder canacer
What are the main occupational cancers?
In men the main cancers include:
Mesothelioma
Bladder cancer
Non melanoma skin cancer
Lung cancer
Sino nasal cancer
Latency period between exposure and disease in occupational cancers
15 years for solid tumours
20 years for leukaemia
Theme: Types of stroke
A.Anterior cerebral artery infarct
B.Middle cerebral artery infarct
C.Posterior cerebral artery infarct
D.Pituitary mass
E.Lacunar infarct
F.Lateral medullary syndrome
G.Pontine infarct
H.Horner’s syndrome
I.Cerebellar infarct
Please select the most likely cause for the symptoms given. Each option may be used once, more than once or not at all.
34.A 53 year old teacher is admitted to the vascular ward for a carotid endarterectomy. Your house officer does a preoperative assessment and notes that there is a right homonymous hemianopia. There is no other neurology.
A 52 year man is admitted to the vascular ward for an amputation. The patient complains of unsteadiness. On further examination you detect right facial numbness and right sided nystagmus. There is sensory loss of the left side of the body.
A 48 year old type 2 diabetic complains of numbness in his left arm and leg. Otherwise there is no other neurological signs.
Posterior cerebral artery infarct
This patient has had a left occipital infarct, as there is only a homonymous hemianopia. If this patient had a temporal or parietal lobe infarct, there would be associated hemiparesis and higher cortical dysfunction. This is important to differentiate, as the carotid endarterectomy is inappropriate in this patient as the lesion is in the posterior cerebral artery.
Lateral medullary syndrome
A combination of ipsilateral ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy with contralateral hemisensory loss indicates this diagnosis.
Lacunar infarct
Isolated hemisensory loss is a feature of a lacunar infarct.
What proportion of strokes are PICH?
10%
What proportion of strokes are TACI?
15%
What proportion of strokes are PACI?
25%
What proportion of strokes are LACI?
25%
What proportion of strokes are POCI?
25%
Stroke
Presents with headache, vomiting, loss of consciousness
Primary intracerebral haemorrhage (PICH, c. 10%)
Involves middle and anterior cerebral arteries
Hemiparesis/hemisensory loss
Homonymous hemianopia
Higher cognitive dysfunction e.g. Dysphasia
Total anterior circulation infarcts (TACI, c. 15%)
Criteria for TACI
3/3 of:
hemiparesis/hemisensory loss
homonomyous hemianopia
Higher cognitive dysfunction e.g. dysphasia/negelct
Involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
Higher cognitive dysfunction or two of the three TACI features
Partial anterior circulation infarcts (PACI, c. 25%)
Criteria for PACI
Higher cognitive dysfunction or 2/3 TACI features
Involves perforating arteries around the internal capsule, thalamus and basal ganglia
Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
Lacunar infarcts
Vertebrobasilar arteries
Presents with features of brainstem damage
Ataxia, disorders of gaze and vision, cranial nerve lesions
Posterior circulation infarcts
Wallenberg’s syndrome
Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy
Contralateral: limb sensory loss
Lateral medullary syndrome
Lateral medullary syndrome
DANVAH
Dysphagia
Ataxia (ipsilateral)
Nystagmus (ipsilateral)
Vertigo
Anaesthesia: ipsilateral facial numbeness and absent corneal reflex, contralatearl pain loss
Horner’s syndrome: ipsilateral
Anaesthesia in lateral medullary syndrome
Ipsilateral facial numbness and absent corneal reflex
Contralateral pain loss
Ipsilateral III palsy
Contralateral weakness
Weber’s syndrome
Contralateral hemiparesis and sensory loss, lower extremity > upper
Disconnection syndrome
ACA infarction
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral hemianopia
Aphasia (Wernicke’s)
Gaze abnormalities
MCA infarct
Contralateral hemianopia with macular sparing
Disconnection syndrome
Posterior cerebral artery
Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
Lacunar
VI nerve: horizontal gaze palsy
VII nerve
Contralateral hemiparesis
Pontine infarct
How many fissures are present within the right lung?
One
Three
Two
Four
Five
The right lung has an oblique and horizontal fissure. The upper oblique fissure separates the inferior from the middle and upper lobes. The short horizontal fissure separates the superior and middle lobes.
A 52 year old man is recovering following an elective right hemicolectomy for carcinoma of the caecum. His surgery is uncomplicated, when should oral intake resume?
Only once bowels have been opened to stool
Only once the patient has passed flatus
Between 24 and 48 hours of surgery
More than 48 hours after surgery
Within 24 hours of surgery
As part of the enhanced recovery principles oral intake in this setting should resume soon after surgery. Administration of liquid and even light diet does not increase the risk of anastomotic leak.
What are the different types of shock?
CHOD
Cardiogenic
Hypovolaemic- haemorrhagic, endocrine, excess loss, third spacing
Obstructive: PE, DVT
Distributive: sepsis, anaphylaxis, neurogenic
Def: sepsis
Infection that triggers a particular SIRS
def: SIRS
Temp <36 >38
HR >90 bpm
RR >20
WCC 12 or <4
Altered mental state or hyperglycaemia in the absence of DM
Def: sepsis
Infection + 2 or more SIRS criteria
Severe sepsis
Those with sepsis and organ failure
Septic shock
Severe sepsis with refractory hypotension
Neurogenic shock
This occurs most often following a spinal cord transection, usually at a high level. There is resultant interruption of the autonomic nervous system. The result is either decreased sympathetic tone or increased parasympathetic tone, the effect of which is a decrease in peripheral vascular resistance mediated by marked vasodilation.
This results in decreased preload and thus decreased cardiac output (Starlings law). There is decreased peripheral tissue perfusion and shock is thus produced. In contrast with many other types of shock peripheral vasoconstrictors are used to return vascular tone to normal.
Cardiogenic shock
In medical patients the main cause is ischaemic heart disease. In the traumatic setting direct myocardial trauma or contusion is more likely. Evidence of ECG changes and overlying sternal fractures or contusions should raise the suspicion of injury. Treatment is largely supportive and transthoracic echocardiography should be used to determine evidence of pericardial fluid or direct myocardial injury. The measurement of troponin levels in trauma patients may be undertaken but they are less useful in delineating the extent of myocardial trauma than following MI.
When cardiac injury is of a blunt nature and is associated with cardiogenic shock the right side of the heart is the most likely site of injury with chamber and or valve rupture. These patients require surgery to repair these defects and will require cardiopulmonary bypass to achieve this. Some may require intra aortic balloon pump as a bridge to surgery.
Muscles innervated by musculocutaneous nerve
BBC
Biceps brachii
Brachialis
Coracobrachialis
Path of the musculocutaneous nerve
It penetrates the coracobrachialis muscle
Passes obliquely between the biceps brachii and the brachialis to the lateral side of the arm
Above the elbow it pierces the deep fascia lateral to the tendon of the biceps brachii
Continues into the forearm as the lateral cutaneous nerve of the forearm
Theme: Management of urinary obstruction
A.Discharge
B.Start oxybutynin
C.Intravenous antibiotics
D.Urethral catheter
E.Emergency nephrostomy
F.Antegrade ureteric stent
G.Retrograde ureteric stent
What is the best management for the scenario given? Each option may be used once, more than once or not at all.
41.A 68 year old man has a TCC of the bladder. He has a right hydronephrosis detected on ultrasound and deteriorating renal function. A DMSA scan shows a non functioning left kidney.
A 52 year old male with hypercalcaemia secondary to primary hyperparathyroidism presents with renal colic. USS demonstrates ureteric obstruction due to a stone. Multiple attempts at stone extraction are performed. However, the stone could not be removed. He is now septic with a pyrexia of 39.5 oc and he has been given antibiotics.
A 56 year old man is admitted with acute retention of urine. He has had a recent urinary tract infection. An USS shows bilateral hydronephrosis.
Antegrade ureteric stent
A TCC occluding the ureteric orifice will obscure its identification during surgery, so that passage of a retrograde stent is difficult. Therefore passage of a stent from the renal pelvis is preferable.
Emergency nephrostomy
The likely scenario is that this man has developed a calculus causing ureteric obstruction. The stagnant column of urine can become colonised and infected. An infected obstructed system is one of the few true urological emergencies. A nephrostomy is needed as the stone could not be removed.
Urethral catheter
Establishing bladder drainage will often correct the situation. These patients often have a significant diuresis with associated electrolyte disturbance.
Causes of unilateral hydronephrosis
PACT
Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis
Causes of bilateral hydronephrosis
SUPER
Stenosis of urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
RPF
Ix in hydronephrosis
USS- identifies presence of hydronephrosis and can assess the kidneys
IVU- assess the position of the obstruction
Antegrade or retrograde pyelography- allows treatment
If renal colic suspected: non contrast CT scan (majority of stones are detected this way)
A 6 month old boy is brought to the clinic with difficulty breathing and weight loss. On examination, he is found to have a firm para testicular mass. What is the most likely diagnosis?
Teratoma
Seminoma
Adenocarcinoma
Rhabdomyosarcoma
Malignant fibrous histiocytoma
Rhabdomyosarcomas are one of the more common malignant solid tumours in children (though all are rare). They have an aggressive behavior pattern and metastases are common. Teratomas are nearly always benign in younger children. Seminomas are very rare indeed. Malignant fibrous histiocytomas are almost never found in this location.
A 22 year old man presents with crampy abdominal pain diarrhoea and bloating. He has just returned from a holiday in Egypt. He had been swimming in the local pool a few days ago. He reports that he is opening his bowels 5 times a day. The stool floats in the toilet water, but there is no blood. What is the most likely cause?
Cryptosporidium
Salmonella sp
E.coli sp
Chronic pancreatitis
Giardia lamblia
Giardia causes fat malabsorption, therefore greasy stool can occur. It is resistant to chlorination, hence risk of transfer in swimming pools.
Def: diarrhoea
>3 loose or watery stools per day
Acute <14
Chronic >14
Causes of acute diarrhoea
Gastroenteritis
Diverticulitis
Abx
Constipation causing overflow
Causes of chronic diarrhoea
IBS
UC
CD
CRC
Coeliac
Other conditions associated with diarrhoea
Thyrotoxicosis
Laxative abuse
Appendicits with pelvic abscess or pelvic appendix
Radiation enteritis
A 56 year old man with Wilsons disease presents with right upper quadrant discomfort. An ultrasound scan is performed and this demonstrates a mass lesion in the right lobe of the liver. What is the most appropriate method of establishing the underlying diagnosis?
PET CT scan
Ultrasound guided biopsy
Measurement of serum alpha feto protein
MRI scan of the liver
CT scan of the liver
High AFP + chronic liver inflammation = Hepatocellular carcinoma.
This is likely to be a hepatocellulcar carcinoma. Diagnosis is usually made by AFP measurement (with further imaging depending on the result). Biopsy should not be performed as it may seed the tumour. Chronic liver diseases such as Wilsons disease (Hepato-lenticular degeneration) increase the risk.
Theme: Visual defects
A.Right homonymous hemianopia
B.Left homonymous hemianopia
C.Right superior quadranopia
D.Left superior quadranopia
E.Right inferior quadranopia
F.Left inferior quadranopia
G.Upper bitemporal hemianopia
H.Lower bitemporal hemianopia
What is the most likely visual field defect for the scenario given? Each option may be used once, more than once or not at all.
47.A 42 year old woman is admitted to the vascular ward for an endarterectomy. Her CT report confirms a left temporal lobe infarct.
A 22 year old man is referred to urology with possible urinary retention. He is passing huge amounts of urine. Post void bladder ultrasound is normal.
A 53 year old man is admitted to the vascular ward for a carotid endarterectomy. His CT head report confirms a left parietal lobe infarct.
Right superior quadranopia
Temporal lesions cause a contralateral superior quadranopia. Think temporal area is at the top of the head i.e. superior quadranopia.
Lower bitemporal hemianopia
This patient has diabetes insipidus due to a craniopharyngioma. Lesions at the optic chiasm classically produce a bitemporal hemianopia, however note lesions that spread up from below ie pituitary tumours, the defect is worse in the upper fields and if a lesion spreads down from above ie craniopharyngiomas, the visual defect is worse in the lower quadrants. Therefore this patient is likely to have a lower bitemporal hemianopia.
Right inferior quadranopia
Parietal lesions cause a contralateral inferior quadranopia.
Temporal vs parietal visual field defct
PITS
Parietal: inferior
Temporal: superior
Pituitary vs craniopharyngioma defect
Pituitary: Upper field
Cranipharyngiomas: lower field
Incongruous visual field defect
Optic tract lesion
Congruous visual field defect
Optic radiation or occipital cortex
Macula sparing visual field defect
Lesion of occipital cortex
A 66 year old man is admitted with severe angina. There is a lesion of the proximal left anterior descending coronary artery. Which of the following would be the most suitable conduit for bypass?
Long saphenous vein
Short saphenous vein
Cephalic vein
Internal mammary artery
Thoraco-acromial artery
The internal mammary artery is an excellent conduit for coronary artery bypass. It has better long term patency rates than venous grafts. The thoraco-acromial artery is seldom used.
Indications for surgery in cardiopulmonary bypass
Left main stem stenosis or equivalent (proximal LAD and proximal circumflex)
Triple vessel disease
Diffuse disease unsuitable for PCI
CABG is the preferred treatment in high-risk patients with severe ventricular dysfunction or DM
Technique in bypass
General anaesthesia
Central and arterial lines
Midline sternotomy or left sub mammary incision
Aortic root and pericardium dissected
Heart inspected
Bypass grafting may be performed using a cardiopulmonary bypass circuit with cardiac arrest or using a number of novel ‘off pump’ techniques.
Procedure of cardiopulmonary bypass
Aortic root cannulated
Right atrial cannula
Circuit primed and patient fully heparinised (30,000 Units unfractionated heparin) as the circuit is highly thrombogenic
Flow established through circuit
Aortic cross clamp applied
Cardioplegia solution instilled into the aortic root below cross clamp
Heart now asystolic and ready for surgery
What are the potential conduits for bypass?
Internal mammary artery is best
Radial artery
Reverse long saphenous vein grafts
Issues with bilateral internal mammary arteries being used for CABG
Increased risk of sternal wound ehisence
What must be done before radial artery is harvested for cardiopulmonary bypass?
Ensure adequate ulnar collateral supply
What should happen once flow is established through conduits for bypass
Once flow established
Anticoagulation reversed using protamine
Patient is taken off bypass
Inotropes given if needed
Sternum closed using sternal closure device or stainless steel wire
Complications of cardiopulmonary bypass surgery
Post perfusion syndrome: transient cognitive impairment
Non union of the sternum; due to loss of the internal thoracic artery
Myocardial infarction
Late graft stenosis
Acute renal failure
Stroke
Gastrointestinal
A 55 year old man has suffered from reflux oesophagitis for many years. During a recent endoscopy a biopsy is taken from the distal oesophagus. The histopathology report indicates that cells are identified with features of coarse chromatin and abnormal mitoses. The cells are confined to the superficial epithelial layer only. Which of the following accounts for this process?
Metaplasia
Apoptosis
Autoimmune oesophagitis
Dysplasia
Infection with Helicobacter pylori
Dysplasia = pre cancerous
Dysplasia tends to develop as a result of prolonged stimulation by precipitants. Removal of these precipitants may possibly reverse these changes. Replacement of differentiated cells with another cell type describes metaplasia rather than dysplasia. The absence of invasion distinguishes this from malignancy.
Which one of the following confers the least risk of developing osteoporosis?
Obesity
Long term unfractionated heparin therapy
Gastrectomy
Osteogenesis imperfecta
Diabetes
Obesity
Low body weight is a risk factor for osteoporosis
Risk factors for osteoporosis
Family history
Female sex
Increasing age
Deficient diet
Sedentary lifestyle
Smoking
Premature menopause
Low body weight
Caucasians and Asians
Diseases predisposing to osteoporosis
Endocrine: glucocorticoid excess (e.g. Cushing’s, steroid therapy), hyperthyroidism, hypogonadism (e.g. Turner’s, testosterone deficiency), growth hormone deficiency, hyperparathyroidism, diabetes mellitus
Multiple myeloma, lymphoma
Gastrointestinal problems: inflammatory bowel disease, malabsorption (e.g. Coeliacs), gastrectomy, liver disease
Rheumatoid arthritis
Long term heparin therapy
Chronic renal failure
Osteogenesis imperfecta, homocystinuria
A 22 year old man has a full thickness burn on his chest. It is well circumscribed. In A&E his saturations are reduced to 92% on 15L Oxygen, Blood pressure 102/66 mmHg and HR 105bpm. What is the best management?
Haemodialysis
Escharotomy
Fasciotomy
Cardiac bypass
Non invasive ventilation
The chest burn and its associated oedema is limiting respiration. Therefore an escharotomy of the chest is indicated, this will remove the constriction on the chest wall and improve ventilation.
Theme: Muscle relaxants
A.Atracurium
B.Suxamethonium
C.Pancuronium
D.Vecuronium
E.Curare
Please select the muscle relaxant that applies to the scenario or description supplied. Each option may be used once, more than once or not at all.
An agent that is degraded by hydrolysis and may produce histamine release.
An agent which should be avoided in a 23 year old man with burns and bilateral tibial fractures after being trapped in a car accident for 2 hours.
An agent with a half life of less than 10 minutes
Atracurium
Atracurium is degraded by a process of ester hydrolysis. This uses non specific plasma esterases.
Suxamethonium
Suxamethonium may induce hyperkalaemia as it induces generalised muscular contractions. In patients with likely extensive tissue necrosis this may be sufficient to produce cardiac arrest.
Suxamethonium
Suxamethonium is extremely rapidly metabolised, acetylcholinesterases degrade the drug within minutes. In patients who lack this enzyme the drug may last far longer.
A 63 year old man has a history of claudication that has been present for many years. He is recently evaluated in the clinic and a duplex scan shows that he has an 85% stenosis of the superficial femoral artery. Two weeks later he presents with a 1 hour history of severe pain in his leg. On examination he has absent pulses in the affected limb and it is much cooler than the contra-lateral limb. Which process best accounts for this presentation?
Thrombosis
Embolus
Atheroma growth
Sub intimal dissection
Anaemia
In an existing lesion a complication such as thrombosis is more likely than embolus. These patients should receive heparin and imaging with duplex scanning. Whilst an early surgical bypass or intra-arterial thrombolysis may be indicated, an embolectomy should not generally be performed as the lesion is not an embolus and the operation therefore ineffective.
Which of the following statements relating to the posterior cerebral artery is false?
It supplies the visual cortex
It is closely related to the 3rd cranial nerve
It is a branch of the basilar artery
It is connected to the circle of Willis via the superior cerebellar artery
When occluded may result in contralateral loss of field of vision
The posterior cerebral arteries are formed by the bifurcation of the basilar artery and is connected to the circle of Willis via the posterior communicating artery.
The posterior cerebral arteries supply the occipital lobe and part of the temporal lobe.
Which of the following drugs causes hyperkalaemia?
Heparin
Ciprofloxacin
Salbutamol
Levothyroxine
Codeine phosphate
Both unfractionated and low-molecular weight heparin can cause hyperkalaemia. This is thought to be caused by inhibition of aldosterone secretion. Salbutamol is a recognised treatment for hyperkalaemia.
Which of the following statements relating to gastric banding for obesity is false?
It is one of the safest anti obesity operations
If successful up to 55% of excess weight may be lost over 2 years
Excessively tight gastric bands have increased risk of long term complications
It is associated with early satiety
It is contra indicated in patients with polycystic ovaries who are trying to conceive
Adjustable gastric bands are one of the most widely performed anti obesity procedures in the UK. They are relatively easy to insert. Weight loss is slightly slower than with some of the other weight loss procedures. Up to 15% patients may require revisional surgery.
An elderly lady falls and lands on her hip. On examination, her hip is tender to palpation and x-rays are taken. There are concerns that she may have an intertrochanteric fracture. What is the normal angle between the femoral neck and the femoral shaft?
90o
105o
80o
130o
180o
The normal angle between the femoral head and shaft is 130o. Changes to this angle may occur as a result of disease or pathology and should be investigated.
A 22 year old man suffers a compound fracture of the tibia. During attempted surgical repair the deep peroneal nerve is divided. Which of the following muscles will not be affected as a result?
Tibialis anterior
Peroneus longus
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
Peroneus longus is innervated by the superficial peroneal nerve (L4, L5, S1).
A 73 year old lady sustains a distal radius fracture and this is manipulated using a Biers block with prilocaine as the local anaesthetic agent. During the procedure the occlusion cuff deflates and the patient becomes progressively cyanosed. What is the treatment of choice?
Intravenous calcium gluconate
Exchange transfusion
Intravenous methylene blue
Intravenous sodium thiosulphate
Intravenous gelofusine
Prilocaine is a recognised cause of methaemoglobinaemia, this is characterised by the development of cyanosis and dyspnoea. This disorder occurs because of the change haemoglobin to a ferric subtype rather than ferrous (Fe2+). This type of change shifts the oxygen dissociation curve to the left and tissue hypoxia occurs. Methylene blue will revert the haemoglobin to the ferrous type and reverse this effect.
With which of the following blood products is iatrogenic septicaemia with a gram positive organism most likely?
Cryoprecipitate
Platelets
Packed red cells
Factor VIII concentrate
Factor IX concentrate
Platelets are stored at room temperature and must be used soon after collection. This places them at increased risk of culturing gram positive organisms. Iatrogenic infection with gram negative organisms is more likely with packed red cells as these are stored at 4 degrees.
Infections with blood products of this nature are both rare.
A 12 day old infant is brought to the emergency department by his anxious mother who notices that he has developed a right sided groin swelling. On examination the testes are correctly located but it is evident that the child has a right sided inguinal hernia. It is soft and easily reduced. What is the most appropriate management?
Surgery over the next few days
Reassure and discharge
Surgery at 1 year of age
Surgery once the child is 6 months old
Application of a hernia truss
Inguinal hernia in infants = Urgent surgery
The high incidence of strangulation necessitates an urgent herniotomy be performed. In infants with a reducible hernia this can be performed on a daycase list during the same week. Deferring surgery on the basis of age is not justified.
Management of paediatric inguinal hernia in young infants
Children presenting in the first few months of life are at the highest risk of strangulation and the hernia should be repaired urgently. Children over 1 year of age are at lower risk and surgery may be performed electively. For paediatric hernias a herniotomy without implantation of mesh is sufficient. Most cases are performed as day cases, neonates and premature infants are kept in hospital overnight as there is a recognised increased risk of post operative apnoea.
A patient receives atropine as pre medication prior to a laparotomy. Which of the following is least likely to occur?
Pupillary dilation
Dry mouth
Urinary retention
Bradycardia
Decreased salivation
Since it inhibits vagal tone, the use of atropine will typically result in an increased heart rate.
Atropine
Atropine is a muscarinic receptor antagonist (competitive antagonist for the muscarinic acetylcholine receptor). It therefore inhibits parasympathetic activity.It was traditionally used as a premedication for anaesthesia because it reduced bronchial secretions, salivary secretions and bradycardia from increased vagal tone on anaesthetic induction. Modern anaesthetic techniques have reduced the need for routine use of this drug. Its other effects include urinary retention and pupillary dilatation.
The following are true of carcinoid tumours except:
When present in the appendix tip and measure less than 2 cm have an excellent prognosis
Even when metastatic disease is present it tends to follow a protracted course
When present in the appendix body tend to present with carcinoid syndrome even when liver metastases are not present
May be imaged using 5 HIAA radionucleotide scanning
Advanced appendiceal carcinoids may require right hemicolectomy
Liver metastases are necessary for the presence of carcinoid syndrome.
During a difficult femoro-popliteal bypass operation the surgeon inadvertently places a clamp across the femoral nerve. It remains there for most of the procedure. At the end of the operation the nerve is inspected, it is in continuity but has evidence of being crushed. Which of the following is most likely to occur over the following weeks?
Wallerian degeneration
Rapid restoration of neuronal function because the axon itself is intact
Normal but delayed neuronal transmission due to disruption of the myelin
Absence of neuroma formation
None of the above
A neuronal injury such as this will result in Wallerian degeneration even though the nerve remains in continuity. Neuromas may well form.
Theme: Pre operative preparation
A.Methylene Blue intravenously 1 hour pre-operatively
B.Lugol’s iodine
C.100ml single cream given 4 hours prior to surgery
D.Carbohydrate loading drink 2 hours prior to surgery
E.Picolax sachet
F.Fleet enema
G.Intravenous calcium chloride
H.1mg lorazepam orally 30 minutes pre operatively
I.Patent blue dye intravenously
For each procedure please select the most appropriate procedure specific preparation required. Each option may be used once, more than once or not at all.
71.A 45 year old man is due to undergo an Ivor Lewis oesophagectomy for a carcinoma of the distal oesophagus.
A 32 year old man is due to undergo a right hemicolectomy for a large caecal sessile polyp.
A 67 year old women is due to undergo a parathyroidectomy for a parathyroid adenoma.
100ml single cream given 4 hours prior to surgery
This will facilitate identification of the thoracic duct if it is inadvertently divided during the operation.
Carbohydrate loading drink 2 hours prior to surgery
This is now a standard feature of colonic enhanced recovery programmes.The administration of carbohydrate rich loading drinks results in lower incidence of ileus. The drink is usually administered 2 hours pre-operatively and is rapidly absorbed from the GI tract.
Methylene Blue intravenously 1 hour pre-operatively
Though not universally adopted, many endocrine surgeons will administer methylene blue as it will facilitate identification of the parathyroid glands.
Theme: Management of colonic disease
A.Reassure and discharge
B.Right hemicolectomy
C.Left hemicolectomy
D.Hot biopsy
E.Snare polypectomy
F.Single colonoscopy
G.Annual colonoscopy
H.Colonoscopy every 3-5 years
I.Panproctocolectomy
J.Measure faecal calprotectin
For each scenario given please select the most appropriate management option. Each option may be used once, more than once or not at all.
74.A 25 year old male presents with altered bowel habit. He is known to have familial polyposis coli. A colonoscopy shows widespread polyps, with high grade dysplasia in a polyp removed from the rectum.
A 19 year old female presents with colicky abdominal pain, bloating and alternating constipation/diarrhoea. Her grandmother died from colon cancer at the age of 77 years. A digital rectal examination and general physical examination are normal.
A 62 year old man is being investigated for iron deficiency anaemia. During a colonoscopy a flat polypoidal lesion is identified in the caecum. Biopsies of this lesion demonstrate high grade dysplasia.
Panproctocolectomy
There is a high risk of conversion to malignancy, therefore panproctocolectomy is the safest option.
Measure faecal calprotectin
This girl fulfills the Rome criteria for irritable bowel syndrome. Examination is normal, therefore it’s likely that this patient will have IBS. However, its prudent to exclude IBD and since endoscopy is poorly tolerated in patients with IBS, measurement of faecal calprotectin is a reasonable alternative.
Right hemicolectomy
High grade dysplasia in a flat villous lesion of the right colon is highly likely to be associated with an invasive lesion at this site. Hot biopsy of right sided colonic lesions is unwise an snare polypectomy would be unlikely to remove the entire lesion.
A 25-year-old man who has been morbidly obese for the past five years is reviewed in the surgical bariatric clinic. In this patient, release of which of the following hormones would increase appetite?
Leptin
Thyroxine
Adiponectin
Ghrelin
Serotonin
Obesity hormones
leptin decreases appetite
ghrelin increases appetite
Action of leptin
Leptin is thought to play a key role in the regulation of body weight. It is produced by adipose tissue and acts on satiety centres in the hypothalamus and decreases appetite. More adipose tissue (e.g. in obesity) results in high leptin levels.
Leptin stimulates the release of melanocyte-stimulating hormone (MSH) and corticotrophin-releasing hormone (CRH). Low levels of leptin stimulates the release of neuropeptide Y (NPY)
Action of ghrelin
Where as leptin induces satiety, ghrelin stimulates hunger. It is produced mainly by the fundus of the stomach and the pancreas. Ghrelin levels increase before meals and decrease after meals
Theme: Local anaesthetics
A.1% xylocaine with 1 in 200,000 adrenaline
B.1% Lignocaine
C.0.5% Bupivacaine with 1 in 200,000 adrenaline
D.0.5% Bupivacaine
E.Prilocaine 1%
F.Procaine 1%
G.Cocaine 4%
H.Cocaine 10%
Please select the local anaesthetic formulation most appropriate to the procedure indicated. Each option may be used once, more than once or not at all.
79.A 28 year old man has a sebaceous cyst of the scalp that requires excision.
A 32 year old man has an appendicectomy performed through a Lanz incision, which anaesthetic would you infiltrate the wound with to provide post operative analgesia.
A 43 year old man is due to undergo a vasectomy.
1% xylocaine with 1 in 200,000 adrenaline
As scalp wounds can bleed profusely an adrenaline containing solution is preferred. Xylocaine is similar to lignocaine in its onset and duration of action.
0.5% Bupivacaine
A long acting local anaesthetic is preferred.There is little advantage to adding a short acting local anaesthetic agent since by the time the patient has recovered following surgery the bupivacaine will be active.
1% Lignocaine
Plain lignocaine will suffice. This will give rapid onset of action. Bupivacaine will take too long to take effect. There would be little additional benefit derived for adding adrenaline.
A 16 year old man sustains a basal skull fracture and is suspected of having CSF rhinorrhoea. Which of the following laboratory tests would most accurately identify whether CSF is present or not?
Microscopy to identify red blood cells
Lab stix testing for glucose
Lab stix testing for protein
Beta 2 transferrin assay
Microscopy, gram stain and culture
Beta 2 transferrin is a carbohydrate free form of transferrin that is almost exclusively found in the CSF. Although lab stix testing for glucose is traditional it is associated with false positive results secondary to contamination with other glucose containing bodily secretions.
An 18 year old athlete attends orthopaedic clinic reporting pain and swelling over the medial aspect of the knee joint. The pain occurs when climbing the stairs, but is not present when walking on flat ground. Clinically there is pain over the medial, proximal tibia and the McMurray test is negative. What is the most likely cause of this patient’s symptoms?
Anterior cruciate ligament tear
Prepatellar bursitis
Medial meniscus injury
Pes Anserinus Bursitis
Fracture of tibia
Pes Anserinus Bursitis is common in sportsmen due to overuse injuries. The main sign is of pain in the medial proximal tibia. As the McMurray test is negative, medial meniscal injury is excluded.
Pes anserinus: GOOSE’S FOOT
Combination of sartorius, gracilis and semitendinous tendons inserting into the anteromedial proximal tibia.
A 56 year old lady presents with a large bowel obstruction and abdominal distension. Which of the following confirmatory tests should be performed prior to surgery?
Abdominal ultrasound scan
Barium enema
Rectal MRI Scan
Endoanal ultrasound scan
Gastrograffin enema
Patients with suspected large bowel obstruction due to tumour should have this confirmed with gastrograffin enema, sigmoidoscopy or CT scanning prior to surgery.
Patients with clinical evidence of large bowel obstruction, should have the presence or absence of an obstructing lesion confirmed prior to surgery. This is because colonic pseudo-obstruction may produce a similar radiological picture. A gastrograffin enema is the traditional test, as barium is too toxic if it spills into the abdominal cavity. An MRI scan will not provide the relevant information, unless the lesion is rectal and below the peritoneal reflection. A CT scan would be an acceptable alternative.
Which of the following statements relating to chronic inflammation is true?
Chronic inflammation is mainly secondary to acute inflammation
Neutrophils are the predominant cells involved
Growth factors are not involved in the process
Appendicitis is mainly a form of chronic inflammation
Fibrosis is a macroscopic feature
Macroscopic features include:
Ulcers
Fibrosis
Granulomatous process
It most commonly occurs as a primary event rather than as a result of acute inflammation.
Theme: Paediatric ano-rectal disorders
A.Ulcerative colitis
B.Juvenile polyps
C.Haemorroids
D.Intussceception
E.Rectal cancer
F.Anal fissure
G.Arteriovenous malformation
Please select the most likely cause for the condition described. Each option may be used once, more than once or not at all.
93.A 4 year old boy is brought to the clinic. He gives a history of difficult, painful defecation with bright red rectal bleeding.
A 2 year old has a history of rectal bleeding. The parents notice that post defecation, a cherry red lesion is present at the anal verge.
A 12 year old is brought to the colorectal clinic with a history of rectal bleeding, altered bowel habit, weight loss and malaise. Abdominal examination is normal.
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.
Classical haemorrhoidal disease in children
Relatively rare
A 54-year-old woman is admitted to the Surgical Admissions Unit with abdominal pain. Blood tests taken on admission show the following:
Magnesium0.40 mmol/l (normal value 0.7-1.0 mmol/l)
Which one of the following factors is most likely to be responsible for this result?
Excessive resuscitation with intravenous saline
Digoxin therapy
Diarrhoea
Hypothermia
Rhabdomyolysis
Diarrhoea
Causes of hypomagnaseamia
Diuretics
TPN
Diarrhoea
Alcohol
Hypokalaemia
Hypocalcaemia
Features of hypomagnasaemia
Paraesthesia
Tetany
Seizures
Arrhythmias
Decreased PTH secretion → hypocalcaemia
ECG features similar to those of hypokalaemia
Exacerbates digoxin toxicity
Next question
Which of the following structures lies most posteriorly at the porta hepatis?
Cystic artery
Common hepatic artery
Left hepatic artery
Portal vein
Common bile duct
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.
Concerning proximal aortic dissection (Debakey types 1 and 2/ Stanford type A) which statement is false?
The intimal tear is typically >50% of the aortic circumference.
It is usually treated using an endovascular approach.
They have a 50% mortality in the first 2 days.
Arch reconstructions may require deep hypothermic circulatory arrest.
Target systolic pressure of <110mmHg should be maintained.
Usually open surgery is required for these lesions as customised grafts are not usually available for this type of repair yet.
Features of aortic dissection
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
What is the most common site of aortic dissection?
90% occur within 10cm of the aortic valve
Stanford classificaiton of Aortic dissection
A: ascending aorta/aortic root
B: descending aorta
Treatment of Stanford A dissection
Surgical: aortic root replacement
Treatment of Stanford B dissection
Medical therapy with antihypertensives
DeBakey I classification
Ascending aorta: aortic arch, descending aorta
DeBakey Type II
Ascending aorta only
DeBakey Type III
Descending aorta distal to left subclavian artery
Tearing, sudden onset chest pain (painless 10%)
Hypertension or Hypotension
A blood pressure difference (in each arm) greater than 20 mm Hg
Neurologic deficits (20%)
Aortic dissection
BP difference criteria for aortic dissection
20mmHg difference in each arm
Ix in aortic dissection
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)
Cardiovascular targets for descending aortic dissection
HR 60-80bpm
BP 100-120
You review a 42-year-old woman 8 months following a renal transplant for focal segmental glomerulosclerosis. She is on a combination of tacrolimus, mycophenolate, and prednisolone. She has now presented with a five day history of feeling generally unwell with jaundice, fatigue and arthralgia. On examination she has jaundice, widespread lymphadenopathy and hepatomegaly. What is the most likely diagnosis?
Hepatitis C
Epstein-Barr virus
HIV
Hepatitis B
Cytomegalovirus
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.
Which of the following statements relating to the greater omentum is false?
It is less well developed in children under 5.
It has no relationship to the lesser sac.
It contains the gastroepiploic arteries.
Has an attachment to the transverse colon.
It may be a site of metastatic disease in ovarian cancer.
It is connected with the lesser sac and the transverse colon. This plane is entered when performing a colonic resection. It is a common site of metastasis in many visceral malignancies.
Which of the following processes facilitates phagocytosis?
Apoptosis
Opsonisation
Proteolysis
Angiogenesis
Necrosis
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.
In a randomized study of chemotherapy drugs for bowel cancer, a group receiving treatment A had a recurrence rate of 12.5% and a group receiving treatment B had a recurrence rate of 15%. Both groups are matched for size and length of follow up. What is the number needed to treat to prevent a recurrence?
2.5
25
4
40
5
There is an absolute risk reduction of 15-12.5%= 2.5% for treatment A
Therefore the NNT = 1/0.025 = 40
Def: absolute risk reduction
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
def: NNT
How many patients would need to receive a treatment to prevent one event.
Absolute difference between two treatments
A 66 year old male is admitted to the vascular ward for an amputation. He reports episodes of vertigo and dysarthria to the house officer. He suddenly collapses with a Glasgow Coma Score of 3. What is the most likely diagnosis?
Cerebral haemorrhage in left temporal parietal area
Opiate overdose
Cerebral haemorrhage in right temporal parietal area
Diazepam overdose
Basilar artery occlusion
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.
A 48 year old man with newly diagnosed hypertension is found to have a phaeochromocytoma of the left adrenal gland and is due to undergo a laparoscopic left adrenalectomy. Which of the following structures is not directly related to the left adrenal gland?
Crus of the diaphragm
Lesser curvature of the stomach
Kidney
Pancreas
Splenic artery
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.
Which of the following nerves innervates the long head of the biceps femoris muscle?
Inferior gluteal nerve
Tibial division of sciatic nerve
Superior gluteal nerve
Common peroneal division of sciatic nerve
Obturator nerve
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.
Features which are evaluated for the grading of breast cancer include all the following, except:
Tubule formation
Mitoses
Nuclear pleomorphism
Tumour necrosis
Coarse chromatin
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.
A new blood test to screen patients for colorectal cancer is trialled on 500 patients. The test was positive in 40 of the 50 patients shown to have colorectal cancer by colonscopy. It was also positive in 20 patients who were shown not to have colorectal cancer. What is the positive predictive value of the test?
- 8
- 66
- 33
- 1
Cannot be calculated
Positive predictive value = TP / (TP + FP) = 40 / (40 + 20) = 0.66
A 72 year old male with end stage critical ischaemia is undergoing an axillo-femoral bypass. What structure is not closely related to the axillary artery?
Posterior cord of the brachial plexus
Scalenus anterior muscle
Pectoralis minor muscle
Axillary vein
Lateral cord of the brachial plexus
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.
A 28 year old man is shot in the right chest and develops a right haemothorax necessitating a thoracotomy. The surgeons decide to place a vascular clamp across the hilum of the right lung. Which of the following structures will lie most anteriorly at this point?
Thoracic duct
Phrenic nerve
Vagus nerve
Pulmonary artery
Pulmonary vein
The phrenic nerve lies anteriorly at the root of the right lung.
An 18 year old boy is undergoing an appendicectomy for appendicitis. At which of the following locations is the appendix most likely to be found?
Pre ileal
Pelvic
Retrocaecal
Post ileal
None of the above
Most appendixes lie in the retrocaecal position. If a retrocaecal appendix is difficult to remove then mobilisation of the right colon significantly improves access.
A 56 year old man is undergoing a pancreatectomy for carcinoma. During resection of the gland which of the following structures will the surgeon not encounter posterior to the pancreas itself?
Left crus of the diaphragm
Superior mesenteric vein
Common bile duct
Portal vein
Gastroduodenal artery
GDA
The gastroduodenal artery divides into the gastro-epiploic and pancreaticoduodenal arteries at the superior aspect of the pancreas.
Which of the following bones is related to the cuboid’s distal articular surface?
All metatarsals
5th metatarsal
Calcaneum
Medial cuneiform
3rd metatarsal
The cuboid is located at the lateral aspect of the foot between the calcaneus posteriorly and the 4th and 5th metatarsals distally.
Which of the following is associated with poor wound healing?
Jaundice
Patients taking carbamazepine
General anaesthesia using thiopentone
General anaesthesia using ketamine
Multiple sclerosis
Jaundice
Multiple sclerosis is associated with pressure sores, however the cellular healing process is not affected.
Factors affecting wound heaking
DID NOT HEAL
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
From which structure is the central tendon of the diaphragm derived?
Septum transversum
Pleuroperitoneal folds
Diaphragmatic crura
Dorsal mesocardium
Oropharyngeal membrane
The septum transversum is a thick ridge of mesodermal tissue in the developing embryo that separates the thoracic and abdominal cavities and forms the central tendon of the diaphragm.
Embryology of the diaphragm
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
What contributes to the central tendon of the diaphragm
Septum transversum
What contributes to the parietal membranes surrounding viscera
Pleuroperitoneal membranes
What contributes to the muscular component of the diaphragm
Cervical somites C3-5
Features of Morgani hernia
Anteriorly located
Minimal compromise on lung development
Minimal signs on antenatal ultrasound
Usually present later
Usually good prognosis
Usually through transverse septum
Features of Bochladek hernia
Posteriorly located
Larger defect
Often diagnosed antenatally
Associated with pulmonary hypoplasia
Poor prognosis
Failure of pleuroperitoneal fusion
Diaphragmatic hernia
Posteriorly located
Larger defect
Often diagnosed antenatally
Associated with pulmonary hypoplasia
Poor prognosis
Bochladek
Diaphragmatic hernia
Anteriorly located
Minimal compromise on lung development
Minimal signs on antenatal ultrasound
Usually present later
Usually good prognosis
Morgani
Classical examination findings in Bochlaedk hernias
Scapohid abdomen because of herniation of the abdominal contents into the chest
Chromosomal abnormalities associated with Bochladek
Trisomy 21 and 18
Mechanism of pulmonary hypoplasia in Bochladek hernias
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).
What other abnormality is associated with Bochladek hernia
Malrotation
Mortality rate in Bochladek diaphragmatic hernia
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).
Where does Stensens duct primarily open?
Immediately lateral to the foramen caecum
Floor of mouth
Opposite the second molar tooth
Opposite the fifth molar tooth
Into the post nasal space
Stensens duct conveys secretions from the parotid gland and these enter the oral cavity at the level of the second molar tooth.
Which of the following nerves is responsible for the innervation of the posterior belly of the digastric muscle?
Facial nerve
Hypoglossal nerve
Trigeminal nerve
Ansa cervicalis
Mylohoid nerve
The posterior belly of digastric is innervated by the facial nerve and the anterior belly by the mylohoid nerve.
Which of the following carpal bones is a sesamoid bone in the tendon of flexor carpi ulnaris?
Triquetrum
Lunate
Pisiform
Scaphoid
Capitate
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.
A 48 year old man undergoes a right hemicolectomy for a large caecal polyp. In the immediate post operative period which of the physiological processes described below is least likely to occur?
Glycogenolysis
Increased production of acute phase proteins
Increased cortisol production
Bronchoconstriction
Release of nitric oxide by vessels
Bronchoconstriction
A 70 year old man falls and fractures his scaphoid bone. The fracture is displaced and the decision is made to insert a screw to fix the fracture. Which of the following structures lies directly medial to the scaphoid?
Lunate
Pisiform
Trapezoid
Trapezium
None of the above
The lunate lies medially in the anatomical plane. Fractures of the scaphoid that are associated with high velocity injuries may cause associated lunate dislocation.
Theme: Thromboprophylaxis
A.Oral dabigatran alone
B.Oral dabigatran with compression stockings
C.Low molecular weight heparin and compression stockings
D.Warfarin
E.Low molecular weight heparin and pneumatic compression stockings
F.Low molecular weight heparin alone
G.No thromboprophylaxis
H.Unfractionated heparin and compression stockings
I.Unfractionated heparin alone
J.Unfractionated heparin and pneumatic compression stockings
Please select the most appropriate thromboprophylactic regime in the surgical scenarios described below. Each regime may be used once, more than once or not at all.
132.A 30 year old male is admitted electively for a right inguinal hernia repair under local anaesthesia. He is otherwise well but his grandfather died from a pulmonary embolism.
A 5 year old boy undergoes a closure of a loop colostomy.
An 83 year old man is admitted for an abdomino-perineal excision of the colon and rectum for a distal rectal tumour. His co-mobidities include diabetes and intermittent claudication. His renal function is normal.
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.
Risk factors for DVT in surgical patients
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
Mechanical thromboprophylaxis
Early ambulation after surgery is cheap and is effective
Compression stockings (contra -indicated in peripheral arterial disease)
Intermittent pneumatic compression devices
Foot impulse devices
Action of LMWH
Binds antithrombin causing inhibition of factor Xa
Action of UFH
Binds antithrombin III affecting thrombin and factor Xa
Action of Dabigatran
Orally administered direct thrombin inhibitor
LT complications of SCD
Infections: Streptococcus pnemoniae
Chronic leg ulcers
Gallstones: haemolysis
Aseptic necrosis of bone
Chronic renal disease
Retinal detachment, proliferative retinopathy
A 54-year-old female is admitted one week following a cholecystectomy with profuse diarrhoea. Apart from a minor intra-operative bile spillage incurred during removal of the gallbladder, the procedure was uncomplicated. What is the most likely diagnosis?
Campylobacter infection
E. coli infection
Clostridium difficile infection
Salmonella infection
Pelvic abscess
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.
RFs for C, diff
Broad spectrum Abx
PPI and H2R
Infectious contacts
Management of C. diff
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
A 55 year old man is admitted with a brisk haematemesis. He is taken to the endoscopy department and an upper GI endoscopy is performed by the gastroenterologist. He identifies an ulcer on the posterior duodenal wall and spends an eternity trying to control the bleeding with all the latest haemostatic techniques. He eventually asks the surgeons for help. A laparotomy and anterior duodenotomy are performed, as the surgeon opens the duodenum a vessel is spurting blood into the duodenal lumen. From which of the following does this vessel arise?
Left gastric artery
Common hepatic artery
Right hepatic artery
Superior mesenteric artery
Splenic artery
The vessel will be the gastroduodenal artery, this arises from the common hepatic artery.
Tissues supplied by the GDA
Pylorus, proximal part of the duodenum, and indirectly to the pancreatic head (via the anterior and posterior superior pancreaticoduodenal arteries)
Path of the GDA
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
Motor- main nerve functions of the radial nerve
Triceps
Anconeus
Brachioradialis
Extensor carpi radialis
Motor (posterior interosseous branch) function of radial nerve
Supinator
Extensor carpi ulnaris
Extensor digitorum
Extensor indicis
Extensor digiti minimi
Extensor pollicis longus and brevis
Abductor pollicis longus
Sensory function of the radial nerve
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)
A 56 year old lady has just undergone a colonoscopy and a 1.5cm lesion was identified in the caecum. The histology report states that biopsies have been taken from a sessile serrated polyp with traditional features. What is the best management option?
Perform a right hemicolectomy
List the patient for colonoscopic polypectomy
Discharge the patient
Re scope the patient in 6 months
Re scope the patient at 3 years
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.
Theme: Management of complications
A.Gastrograffin contrast enema
B.Barium enema
C.Oral gastrograffin and CT
D.Barium meal
E.Ultrasound of the thorax
F.Endoanal ultrasound
G.Anorectal physiology studies
H.Biofeedback
I.Abdominal CT scan with IV contrast
Please select the most appropriate intervention from the list given. Each option may be used once, more than once or not at all.
6.A 65 year old male with carcinoma of the oesophagus undergoes endoscopic dilatation. Following which he develops pleuritic chest pain and sub cutaneous emphysema.
A frail 73 year old lady is admitted with intractable faecal incontinence. She undergoes a laparoscopic defunctioning of the rectum with an end colostomy. 48 hours later her stoma has still not worked and her abdomen is distended and painful.
A 43 year old man develops fast atrial fibrillation 5 days following a low anterior resection of the rectum for cancer. On examination he has lower abdominal tenderness and a WCC 19.
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.
Which of the following is not a feature of Campylobacter jejuni infection?
Infection may present in a similar manner to acute appendicitis
Pyrexia is unusual
They are gram negative organisms
Infection accounts for 26% case of Guillain-Barre syndrome
It is the commonest cause of infective diarrhoea arising from non viral causes
A prodromal period of fever and generalised malaise precedes abdominal pain (which may mimic appendicitis) and diarrhoea.
Which statement relating to talipes equinovarus is untrue?
It has an annual incidence of around 1 in 1000 in the UK.
The muscles involved in the disorder are intrinsically abnormal.
The cuboid is classically displaced medially.
All cases should be treated with an Ilizarov frame initially unless there is minor deformity.
The talocalcaneal angle is typically less than 20 degrees in club foot.
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.
Features of talipes equinovarus
Equinus of the hindfoot
Adduction and varus of the midfoot
High arch
Epidgemiology of Talipes equinovarus
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.
Key anatomical deformities in talipes equinovarus
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)
Management of talipes equinovarus
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.
A 73 year old female is referred to the surgical clinic with an iron deficiency anaemia. As part of the diagnostic work up the doctor requests a serum ferritin level. Which of the conditions listed is most likely to lead to a falsely elevated result?
Locally perforated sigmoid colonic adenocarcinoma
Colonic angiodysplasia
Dieulafoy lesion of the stomach
Transitional cell carcinoma of the bladder
Endometrial adenocarcinoma
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.
Which of the following is not a content of the rectus sheath?
Pyramidalis
Superior epigastric artery
Inferior epigastric vein
Internal iliac artery
Rectus abdominis
IIA
The rectus sheath also contains:
superior epigastric vein
inferior epigastric artery
A 48 year old woman with end stage renal failure is undergoing a live donor renal transplant. The surgeon decides to implant the kidney in the left iliac fossa via a Rutherford Morrison incision. To which of the following vessels should the transplanted kidney be anastomosed?
Aorta and inferior vena cava
Internal iliac artery and vein
Common iliac artery and vein
External iliac artery and vein
Inferior epigastric artery and vein
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.
A 30 year old male presents with gynaecomastia. Clinically, he is noted to have a nodule in the left testis. What is the most likely diagnosis?
Oestrogen abuse
Seminoma with syncytiotrophoblast giant cells
Teratoma
Choriocarcinoma
Leydig cell tumour
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
A 65 year old man presents with significant lower urinary tract symptoms and is diagnosed as having benign prostatic hyperplasia. Which of the following drug treatments will produce the slowest clinical response?
Tamsulosin
Alfuzosin
Doxazosin
Finasteride
Terazosin
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.
Pathophysiology of BPH
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.
Ix in ?BPH
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.
IVC T8
Hepatic vein, inferior phrenic vein, pierces diaphragm
IVC L1
Suprarenal veins
Renal vein
IVC L2
Gonadal vein
IVC L1-5
Lumbar veins
IVC L5
Common iliac vein, formation of IVC
A 43 year old lady is due to undergo a diagnostic laparoscopy. Which of the agents listed below should be used for inducing pneumoperitoneum?
Argon
Helium
Air
Carbon dioxide
Nitrogen
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.
Gases used for laparoscopic surgery
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.
An 18 year old man develops a severe spreading sepsis of the hand. The palm is explored surgically and the flexor digiti minimi brevis muscle is mobilised to facilitate drainage of the infection. Which of the following structures is not closely related to this muscle?
The hook of hamate
Median nerve
Superficial palmar arterial arch
Digital nerves arising from the ulnar nerve
None of the above
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.
What is the most common cause of osteolytic bone metastasis in children?
Osteosarcoma
Neuroblastoma
Leukaemia
Rhabdomyosarcoma
Nephroblastoma
Neuroblastomas are a relatively common childhood tumour and have a strong tendency to developing widespread lytic metastasis.
Features of neuroblastoma
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
Features of Wilms tumour
calcification uncommon: 10-15%
displaces adjacent structures without insinuating between them
well circumscribed
claw sign with the kidney (normal parenchyma extends some way around the mass)
slightly older age group: peak 3-4 years of age
extension into IVC/renal vein
A 19 year old man undergoes an open inguinal hernia repair. The cord is mobilised and the deep inguinal ring identified. Which of the following structures forms its lateral wall?
External oblique aponeurosis
Transversalis fascia
Conjoint tendon
Inferior epigastric artery
Inferior epigastric vein
The transversalis fascia forms the superolateral edge of the deep inguinal ring. The epigastric vessels form its inferomedial wall.
Which of the following statements relating to randomised controlled trials is false?
Consist of a control group recruited during the same time interval as the treatment group.
Are not applicable to retrospectively analysed data even if captured on a prospectively created database.
They require concealment of treatment throughout the duration of the study.
They require concealment of treatment until after randomisation.
They are less susceptible to researcher bias than non-randomised controlled trials.
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.
A 22 year old man develops an infection in the pulp of his little finger. What is the most proximal site to which this infection may migrate?
The metacarpophalangeal joint
The distal interphalangeal joint
The proximal interphalangeal joint
Proximal to the flexor retinaculum
Immediately distal to the carpal tunnel
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.
Theme: Fistula management
A.No further action needed
B.Intravenous fluids
C.Intravenous fluids and nasogastric tube
D.Total parenteral nutrition and octreotide
E.Defunctioning stoma
F.Insertion of seton
G.Intravenous octreotide
H.Lay open fistula
What is the best management for the following types of fistula? Each option may be used once, more than once or not at all.
30.A 45 year old man develops a colocutaneous fistulae following reversal of a loop colostomy fashioned for the defunctioning of an anterior resection. Pre-operative gastrograffin enema showed no distal obstruction or anastamotic stricture.
A 43 year old man has suffered from small bowel Crohns disease for 15 years. Following a recent stricturoplasty he develops an enterocutaneous fistula which is high output. Small bowel follow through shows it to be 15 cm from the DJ flexure. His overlying skin is becoming excoriated.
A 33 year old lady presented with jaundice secondary to common bile duct stones. A cholecystectomy and common bile duct exploration is performed and the bile duct closed over a T tube. Six weeks post operatively a T tube cholangiogram is performed and shows no residual stones. The T tube is removed and five hours after removal a small amount of bile is noted to be draining from the T tube site.
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.
Which of the following muscles is not innervated by the deep branch of the ulnar nerve?
Adductor pollicis
Hypothenar muscles
All the interosseous muscles
Opponens pollicis
Third and fourth lumbricals
Opponens pollicis
Which of the following is least likely to cause a prolonged prothrombin time?
Cholestatic jaundice
Disseminated intravascular coagulation
Prolonged antibiotic treatment
Liver disease
Acquired factor 12 deficiency
Vitamin K deficiency results from cholestatic jaundice and prolonged antibiotic therapy. Acquired factor 12 deficiency causes prolonged APTT.
A 67 year old male is diagnosed as having a 7cm infra renal abdominal aortic aneurysm. What is the likely risk of rupture over the next 5 years?
<10%
20%
25%
75%
35%
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%
5y risk of AAA rupture
5-5.9cm
25%
5y risk of AAA rupture:
6-6.9cm
35%
5y risk of AAA rupture
>7cm
75%
During an inguinal hernia repair the surgeon identifies a small nerve whilst mobilising the cord structures at the level of the superficial inguinal ring. Which nerve is this most likely to be?
Subcostal
Iliohypogastric
Ilioinguinal
Obturator
Pudendal
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.
Which of the following features are not typical of Crohns disease?
Complex fistula in ano
Small bowel strictures
Skip lesions
‘Rose thorn ulcers’ on barium studies
Pseudopolyps on colonoscopy
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.
At which of the following sites is the development of diverticulosis least likely?
Caecum
Ascending colon
Transverse colon
Sigmoid colon
Rectum
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).
Which of the following is least likely to impair bone fracture healing?
Radiotherapy
Osteoporosis
Administration of non steroidal anti inflammatory drugs
Preservation of periosteum
Presence of osteomyelitic sequestra
Periosteal preservation helps fractures to heal.
A 32 year old lady presents with a 1.5cm pigmented lesion on her back. The surgeon is concerned that this may be a melanoma. What is the most appropriate course of action?
2mm punch biopsy from the centre of the lesion
4mm punch biopsy from the centre of the lesion
Wide excision of the lesion with 3cm margins
Excisional biopsy of the lesion
Wide excision of the lesion with 1cm margins
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.
A 63 year old man is recovering following an open extended right hemicolectomy for carcinoma of the colonic splenic flexure. Two days post operatively he develops a persistent pyrexia. What is the least likely cause?
Ileus
Atelectasis
Anastomotic leak
Wound infection
Urinary tract infection
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.
Swinging pyrexia
Ileus
Increasing abdominal pain
Raised inflammatory markers
Post abdominal Sx
?anastomotic leak
Evidence of superficial erythema, discharge of pus or increasing pain
Usually mild pyrexia (unless major or deep seated wound infection)
May be accompanied by evidence of wound dehisence
Inflammatory markers raised
Wound infection
Usually complicates abdominal surgery
Most common after midline laparotomies (pain impairs ventilation)
Pyrexia usually mild and non swinging
Most patients will have chest signs on examination
Inflammatory markers raised
Atelectasis
Patients with complex venous access
May have marked pyrexia
Access site may show evidence of erythema
Diagnosis is by blood culture from line, line removal and subsequent tip culture
Groin lines and those for TPN have the highest risk
Inflammatory markers raised
Central line sepsis
Common in surgical patients
Usually occur in patients with indwelling urinary catheters
Diagnosis is by dipstick and CSU and signs of raised inflammatory markers
Treatment is with antibiotics (to cover hospital acquired organisms)
Urinary tract infection
Which of the following most closely describes the risk of a type I statistical error?
Power calculation
P value
Odds ratio
Relative risk
None of the above
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.
A 68 year old male is admitted to the surgical ward for assessment of severe epigastric pain. His abdomen is soft and non tender. However the Nurse forces you to look at the ECG. It looks abnormal. Which of the following features is an indication for urgent coronary thrombolysis or percutaneous intervention?
Right bundle branch block
ST elevation of 1mm in leads V1 to V6
Ventricular tachycardia
Q waves in leads V1 to V6
ST elevation of greater than 1mm in leads II, III and aVF
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).
ECG changes for thrombolysis or percutaneous intervention:
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
Examples of thrombolytic agents
alteplase
tenecteplase
streptokinase
Contraindications to thrombolysis
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
Side-effects of thrombolysis
haemorrhage
hypotension - more common with streptokinase
allergic reactions may occur with streptokinase
Which statement about peristalsis is true?
Longitudinal smooth muscle propels the food bolus through the oesophagus
Secondary peristalsis occurs when there is no food bolus in the oesophagus
Food transfer from the oesophagus to the stomach is 4 seconds
Circular smooth muscle is not involved in peristalsis
Peristalsis only occurs in the oesophagus
Longitudinal smooth muscle propels the food bolus through the oesophagus
Time from movement of food into the oesophagus to the stomach
9 seconds
Theme: Thyroid neoplasms
A.Follicular carcinoma
B.Follicular adenoma
C.Papillary carcinoma
D.Papillary adenoma
E.Anaplastic carcinoma
F.Medullary carcinoma
Please select the most likely underlying diagnosis for the thyroid masses described. Each option may be used once, more than once or not at all.
51.A 78 year old lady presents to the surgical clinic with symptoms of both dysphagia and dyspnoea. On examination there is a large mass in the neck that moves on swallowing. CT scanning of the neck shows a locally infiltrative lesion arising from the thyroid and invading the strap muscles.
A 25 year old female presents with a lump in her neck. On examination she has a discrete nodule in the right lobe of the thyroid. A fine needle aspirate shows papillary cells. An adjacent nodule is also sampled which shows similar well differentiated papillary cells.
A 45 year old man presents with a fracture of his right humerus. On examination there is a lytic lesion of the proximal humerus and a mass in the neck, this moves on swallowing.
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.
Theme: Causes of diarrhoea
A.Campylobacter jejuni infection
B.Salmonella gastroenteritis infection
C.Crohns disease
D.Ulcerative colitis
E.Irritable bowel syndrome
F.Ischaemic colitis
G.Laxative abuse
H.Clostridium difficile infection
Please select the most likely cause of diarrhoea for each scenario given. Each option may be used once, more than once or not at all.
54.A 23 year old lady has suffered from diarrhoea for 8 months, she has also lost 2 Kg in weight. At colonoscopy appearances of melanosis coli are identified and confirmed on biopsy
A 68 year old lady has recently undergone an abdominal aortic aneurysm repair. The operation was performed electively and was uncomplicated. Since surgery she has had repeated episodes of diarrhoea.
A 23 year old man is admitted to hospital with diarrhoea and severe abdominal pain. He was previously well and his illness has lasted 18 hours.
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.
A 24 year old man is injured in a road traffic accident. He becomes oliguric and his renal function deteriorates. Which of the options below would favor acute tubular necrosis over pre renal uraemia?
No response to intravenous fluids
Urinary sodium < 20mmol/L
Bland coloured urinary sediment
Increased urine specific gravity
None of the above
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.
Urinary sodium in pre-renal uraemia
<20mmol
Fractional sodium excretion in pre-renal uraemia
<1%
Fractional urea excretion in pre-renal uraemia
<35%
Urine:plasma osmolality in pre-renal uraemia
>1.5
Urine:plasma urea in pre-renal uraemia
>10:1
Specific gravity in pre-renal uraemia
>1020
Urea: Creatinine
40-100:1
Normal or post-renal cause
Urea:creatinine
>100:1
pre-renal cause (urea absorption increased compared to creatinine)
Urea:creatinine
<40:1
Intrinsic renal damage (urea unable to be absorbed)
Urinary sodium in ATN
>30
Fractional sodium excretion in ATN
>1%
Fractional urea excretion in ATN
>35%
Urine:plasma osmolality in ATN
<1.1
Urine:plasma urea in ATN
<8:1
Specific gravity in ATN
<1010
A 6 year old child presents with colicky abdominal pain, vomiting and the passage of red current jelly stool per rectum. On examination the child has a tender abdomen and a palpable mass in the right upper quadrant. Imaging shows an intussusception. Which of the conditions below is least recognised as a precipitant?
Inflammation of Peyers patches
Cystic fibrosis
Meckels diverticulum
Mesenteric cyst
Mucosal polyps
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.
Aetiology of redcurrant jelly in intussuception
he telescoping of the bowel produces mucosal ischaemia and bleeding may occur resulting in the passage of “red current jelly” stools
Diagnosis of intussuception
USS
Management of intussuception
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.
Most common cause of intussuception
Idiopathic of the ileocaecal valvae and terminal ileum
During an arch aortogram the brachiocephalic artery is entered with an angiography catheter. The radiologist continues to advance the catheter. Into which of the following vessels is it likely to enter?
Left subclavian artery
Left axillary artery
Right subclavian artery
Right axillary artery
None of the above
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.
Which of the following structures lie between the lateral and medial heads of the triceps muscle?
Radial nerve
Median nerve
Ulnar nerve
Axillary nerve
Medial cutaneous nerve of the forearm
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.
Origin of the triceps
Long head- infraglenoid tubercle of the scapula.
Lateral head- dorsal surface of the humerus, lateral and proximal to the groove of the radial nerve
Medial head- posterior surface of the humerus on the inferomedial side of the radial groove and both of the intermuscular septae
Insertion of the triceps
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)
Action of the long head of triceps
Can adduct the humerus and extend it from a flexed position
Into which of the following structures does the superior part of the fibrous capsule of the shoulder joint insert?
The surgical neck of the humerus
The body of the humerus
The bicipital groove
Immediately distal to the greater tuberosity
The anatomical neck of the humerus
The anatomical neck of the humerus
The shoulder joint is a shallow joint, hence its great mobility. However, this comes at the expense of stability. The fibrous capsule attaches to the anatomical neck superiorly and the surgical neck inferiorly
Features of the glenoid labrum
Fibrocartilaginous rim attached to the free edge of the glenoid cavity
Tendon of the long head of biceps arises from within the joint from the supraglenoid tubercle, and is fused at this point to the labrum.
The long head of triceps attaches to the infraglenoid tubercle
Anterior relations of the fibrous capsule of the shoulder
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.
Clinical significance of the inferior extension of the shoulder capsule
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.
What are the two defects in the fibrous capsule of the shoulder?
Two defects in the fibrous capsule; superiorly for the tendon of biceps. Anteriorly there is a defect beneath the subscapularis tendon.
Theme: Renal imaging
A.Non contrast abdominal CT scan
B.DMSA scan
C.PET/CT scan
D.MAG 3 Renogram
E.Renal ultrasound scan
F.DTPA Scan
G.Micturating cystourethrogram
H.Intra venous urography
Please select the most appropriate imaging modality for the scenario descrived. Each agent may be used once, more than once or not at all.
64.A 43 year old female has undergone a renal transplant 12 months previously. Over the past few weeks there have been concerns about deteriorating renal function.
A 5 year old boy presents with recurrent urinary tract infections and left sided loin pain. On investigation he is found to have a left sided PUJ obstruction, there are concerns that he may have developed renal scarring
A 17 year old man is referred to the urology clinic. As a child he was diagnosed as having a right sided PUJ obstruction. However, he was lost to follow up. Over the past 7 months he has been complaining of recurrent episodes of right loin pain. A CT scan shows considerable renal scarring.
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).
Features of DMSA scan
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.
Features of DTPA scan
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.
Features of MAG3 renogram
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).
MCUG
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
CTU
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.
Which of the following is not an effect of cholecystokinin?
It causes gallbladder contraction
It increases the rate of gastric emptying
It relaxes the sphincter of oddi
It stimulates pancreatic acinar cells
It has a trophic effect on pancreatic acinar cells
It decreases the rate of gastric emptying.
Which part of the jugular venous waveform is associated with the closure of the tricuspid valve?
a wave
c wave
x descent
y descent
v wave
The c wave of the jugular venous waveform is associated with the closure of the tricuspid valve.
A 7 month old girl presents with vomiting and diarrhoea. She is crying and drawing her legs up. There is a a sausage shaped mass in the abdomen.
Intussusception
Sausage shaped mass (colon shaped) is common in intussusception. The other common sign is red jelly stool.
Levels of CRP in surgical patients
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.
A 73 year old man undergoes a right below knee amputation for end stage peripheral vascular disease. He is reviewed in the clinic 8 weeks post operatively and complains of a persistent, burning discomfort over his amputation site stump. On examination his wound has healed and proximal pulses have a biphasic signal on doppler ultrasound. What is the post appropriate management?
Commence amitryptyline
Commence fentanyl patch
Arrange duplex scan
Arrange MRI scan of the stump
Commence carbamazepine
This patient has neuropathic pain. Amitryptyline is the treatment of choice. Carbamazepine is mainly used for trigeminal neuralgia.
Theme: Critical care
A.Hypovolaemia
B.Normal
C.Cardiogenic shock
D.Septic shock
For each of the scenarios outlined in the tables below, please select the most likely diagnosis from the list. Each option may be used once, more than once or not at all.
1.A 45 year old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
Pulmonary artery occlusion pressure Cardiac output Systemic vascular resistance
Low Low High
A 75 year old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
Pulmonary artery occlusion pressure Cardiac output Systemic vascular resistance
High Low High
A 22 year old lady is admitted to the intensive care unit following a laparotomy. She has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
Pulmonary artery occlusion pressure Cardiac output Systemic vascular resistance
Low High Low
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.
def: PAOP
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.
Normal PAOP
8-12mmH
PAOP <5
Low
PAOP < 5 with pulmonary oedema
ARDS
PAOP >18
High
Overload
What is the urinary diagnostic marker for carcinoid syndrome?
B-HCG
Histamine
Chromogranin A
5-Hydroxyindoleacetic acid
5-Hydroxytryptamine
Urinary measurement of 5- HIAA is an important part of clinical follow up.
A 6 year old child develops ballooning of the foreskin on micturition and is brought to the clinic by his anxious mother. One examination the foreskin is non retractile but otherwise normal. By which age are 95% of all foreskins retractile
2 years
16 years
8 years
5 years
10 years
By 16 years of age almost all foreskins should be retractile and if they are not circumcision should be considered at around this time.
Foreskin retractility in the child
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.
This is inflammation of the glans penis. It may occur in both circumcised and non-circumcised individuals.
Posthitis
This is inflammation of the foreskin. It may occur as a result of infections such as gonorrhoea and other STD’s. It may also complicate diabetes. Posthitis may progress to phimosis and as this may make cleaning of the glans difficult and allow progression to balanoposthitis.
Posthitis
Prolonged retraction of the foreskin proximal to the glans may allow oedema to occur. This may then make foreskin manipulation difficult. It can usually be managed by compression to reduce the oedema and replacement of the foreskin. Where this fails a dorsal slit may be required and this followed by delayed circumcision.
Paraphimosis
This is inability to retract the foreskin and may be partial or complete. It may occur secondary to balanoposthitis or balanitis xerotica obliterans. Depending upon the severity and symptoms treatment with circumcision may be required.
Phimosis
This is a dermatological condition in which scarring of the foreskin occurs leading to phimosis. It is rare below the age of 5 years. Treatment is usually with circumcision.
Balanitis xerotica obliterans
During a difficult thyroidectomy haemorrhage is noted from the thyroidea ima vessel. From which structure does this vessel usually arise?
External carotid artery
Internal carotid artery
Brachiocephalic artery
Axillary artery
Superior thyroid artery
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.
Location of thyroid isthmus
Rings 2,3,4 make the isthmus flooor
Theme: Management of thyroid disease
A.Total Thyroidectomy
B.Thyroid lobectomy
C.Sub total thyroidectomy
D.Radioactive iodine
E.Carbimazole
F.Tru cut biopsy
G.Further fine needle aspiration
H.Observation
For each scenario please select the most appropriate management option. Each option may be used once, more than once or not at all.
9.A 59 year old man is referred with symptoms of dysphagia. On examination he has a large goitre and on imaging there is significant retrosternal extension and features of a multinodular goitre.
A 48 year old lady with thyrotoxicosis is referred to the clinic, she was poorly controlled on carbimazole and has received orbital radiotherapy for severe proptosis. This has improved matters but she relapsed on stopping her carbimazole.
A 23 year old lady has re attended the clinic on three occasions with a cyst in her thyroid that refills. Cytology on each occasion is reassuring.
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.
A 49 year old man undergoes a low anterior resection for cancer. He is assessed in the outpatient clinic post operatively. His wounds are well healed. However, he complains of impotence. Which of the following best explains this problem?
Sciatic nerve injury
Damage to the internal iliac artery
Damage to the nervi erigentes
Damage to the vas
Damage to the genitofemoral nerve
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.
The cephalic vein pierces the clavipectoral fascia to terminate in which of the veins listed below?
External jugular
Axillary
Internal jugular
Azygos
Brachial
Axillary
Early plain x-ray changes in Perthes Disease:
Widening of the joint space.
Sub chondral linear lucency.
Theme: Disorders of the hip
A.Perthes disease
B.Developmental dysplasia of the hip
C.Osteoarthritis
D.Slipped upper femoral epiphysis
E.Septic arthritis
F.Rheumatoid arthritis
G.Intra capsular fracture of the femoral neck
H.Extra capsular fracture of the femoral neck
Please select the most likely underlying diagnosis for the scenario given. Each option may be used once, more than once or not at all.
14.An obese 14 year old boy presents with difficulty running and mild knee and hip pain. There is no antecedent history of trauma. On examination internal rotation is restricted but the knee is normal with full range of passive movement possible and no evidence of effusions. Both the C-reactive protein and white cell count are normal
A 6 year old boy presents with pain in the hip it is present on activity and has been worsening over the past few weeks. There is no history of trauma. He was born by normal vaginal delivery at 38 weeks gestation On examination he has an antalgic gait and limitation of active and passive movement of the hip joint in all directions. C-reactive protein is mildly elevated at 10 but the white cell count is normal.
A 30 year old man presents with severe pain in the left hip it has been present on and off for many years. He was born at 39 weeks gestation by emergency caesarean section after a long obstructed breech delivery. He was slow to walk and as a child was noted to have an antalgic gait. He was a frequent attender at the primary care centre and the pains dismissed as growing pains. X-rays show almost complete destruction of the femoral head and a narrow acetabulum.
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.
A 43 year old lady is receiving chemotherapy for the treatment of metastatic breast cancer. You are called because it has become apparent that her doxorubicin infusion has extravasated. What is the most appropriate course of action?
Stop the infusion and administer dexamethasone through the infusion device
Stop the infusion and administer hyaluronidase through the infusion device
Stop the infusion and apply a cold compress to the site
Stop the infusion and apply a warm compress to the site
Stop the infusion and administer sodium bicarbonate through the infusion device
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.
What proportion of CTx may be complicated by extravasation reactions?
6%
What CTx agents are recognised causes of extravasation reactions?
doxorubicin, vincristine, vinblastine, adriamycin, cisplatin, mitomycin and mithramycin.
Use of warm compresses in extravasation injuries
Vinca alkaloid extravastation may be improved
Management of extravasation of TPN
Local administration of hyaluronidase
What proportion of extravasation injuries are complicated by ulceration?
30%
A 35-year-old female is admitted to hospital with hypovolaemic shock. CT abdomen reveals a haemorrhagic lesion in the right kidney. Following surgery and biopsy this is shown to be an angiomyolipomata. What is the most likely underlying diagnosis?
Neurofibromatosis
Budd-Chiari syndrome
Hereditary haemorrhagic telangiectasia
Von Hippel-Lindau syndrome
Tuberous sclerosis
Tuberous sclerosis
What are the cutaneous features of tuberous sclerosis?
depigmented ‘ash-leaf’ spots which fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum: butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
café-au-lait spots* may be seen
What are the neurological feaures of tuberous sclerosis
developmental delay
epilepsy (infantile spasms or partial)
intellectual impairment
What are the other features of tuberous sclerosis?
retinal hamartomas: dense white areas on retina (phakomata)
rhabdomyomas of the heart
gliomatous changes can occur in the brain lesions
polycystic kidneys, renal angiomyolipomata
Inheritance of tuberous sclerosis
AD
A 72-year-old woman is admitted to the acute surgical unit with profuse vomiting. Admission bloods show the following:
Na+131 mmol/l
K+2.2 mmol/l
Urea3.1 mmol/l
Creatinine56 µmol/l
Glucose4.3 mmol/l
Which one of the following ECG features is most likely to be seen?
Short PR interval
Short QT interval
Flattened P waves
J waves
U waves
Hypokalaemia - U waves on ECG
J waves are seen in hypothermia whilst delta waves are associated with Wolff Parkinson White syndrome.
ECG changes in hypokalaemia
U waves
Small or absent T waves (occasionally inversion)
Prolonged PR interval
ST depression
Long QT interval
A 43 year old lady develops a cerebello-pontine angle lesion. Which of the nerves listed below is likely to be affected first?
CN X
CN III
CN V
CN IX
CN XII
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.
May be injured in basal skull fractures or involved in frontal lobe tumour extension. Loss of olfactory nerve function in relation to major CNS pathology is seldom an isolated event and thus it is poor localiser of CNS pathology.
Olfactory nerve
Problems with visual acuity may result from intra ocular disorders. Problems with the blood supply such as amaurosis fugax may produce temporary visual distortion. More important surgically is the pupillary response to light. The pupillary size may be altered in a number of disorders. Nerves involved in the resizing of the pupil connect to the pretectal nucleus of the high midbrain, bypassing the lateral geniculate nucleus and the primary visual cortex. From the pretectal nucleus neurones pass to the Edinger - Westphal nucleus, motor axons from here pass along with the oculomotor nerve. They synapse with ciliary ganglion neurones; the parasympathetic axons from this then innervate the iris and produce miosis. The miotic pupil is seen in disorders such as Horner’s syndrome or opiate overdose.
Mydriasis is the dilatation of the pupil in response to disease, trauma, drugs (or the dark!). It is pathological when light fails to induce miosis. The radial muscle is innervated by the sympathetic nervous system. Because the parasympathetic fibres travel with the oculomotor nerve they will be damaged by lesions affecting this nerve (e.g. cranial trauma).
The response to light shone in one eye is usually a constriction of both pupils. This indicates intact direct and consensual light reflexes. When the optic nerve has an afferent defect the light shining on the affected eye will produce a diminished pupillary response in both eyes. Whereas light shone on the unaffected eye will produce a normal pupillary response in both eyes. This is referred to as the Marcus Gunn pupil and is seen in conditions such as optic neuritis. In a total CN II lesion shining the light in the affected eye will produce no response.
Optic nerve
supplies all ocular muscles apart from lateral rectus and superior oblique. Thus the affected eye will be deviated inferolaterally. Levator palpebrae superioris may also be impaired resulting in impaired ability to open the eye.
Oculomotor nerve
The eye will not be able to look down and in
Trochlear nerve
Largest cranial nerve. Exits the brainstem at the pons. Branches are ophthalmic, maxillary and mandibular. Only the mandibular branch has both sensory and motor fibres. Branches converge to form the trigeminal ganglion (located in Meckels cave). It supplies the muscles of mastication and also tensor veli palatine, mylohyoid, anterior belly of digastric and tensor tympani. The detailed descriptions of the various sensory functions are described in other areas of the website. The corneal reflex is important and is elicited by applying a small tip of cotton wool to the cornea, a reflex blink should occur if it is intact. It is mediated by: the naso ciliary branch of the ophthalmic branch of the trigeminal (sensory component) and the facial nerve producing the motor response. Lesions of the afferent arc will produce bilateral absent blink and lesions of the efferent arc will result in a unilateral absent blink.
Trigeminal nerve
The affected eye will have a deficit of abduction. This cranial nerve exits the brainstem between the pons and medulla. It thus has a relatively long intra cranial course which renders it susceptible to damage in raised intra cranial pressure.
Abducens nerve
Emerges from brainstem between pons and medulla. It controls muscles of facial expression and taste from the anterior 2/3 of the tongue. The nerve passes into the petrous temporal bone and into the internal auditory meatus. It then passes through the facial canal and exits at the stylomastoid foramen. It passes through the parotid gland and divides at this point. It does not innervate the parotid gland. Its divisions are considered in other parts of the website. Its motor fibres innervate orbicularis oculi to produce the efferent arm of the corneal reflex. In surgical practice it may be injured during parotid gland surgery or invaded by malignancies of the gland and a lower motor neurone on the ipsilateral side will result.
Facial nerve
Exits from the pons and then passes through the internal auditory meatus. It is implicated in sensorineural hearing loss. Individuals with sensorineural hearing loss will localise the sound in webers test to the normal ear. Rinnes test will be reduced on the affected side but should still work. These two tests will distinguish sensorineural hearing loss from conductive deafness. In the latter condition webers test will localise to the affected ear and Rinnes test will be impaired on the affected side. Surgical lesions affecting this nerve include CNS tumours and basal skull fractures. It may also be damaged by the administration of ototoxic drugs (of which gentamicin is the most commonly used in surgical practice).
Vestibulo-cochlear nerve
Exits the pons just above the vagus. Receives sensory fibres from posterior 1/3 tongue, tonsils, pharynx and middle ear (otalgia may occur following tonsillectomy). It receives visceral afferents from the carotid bodies. It supplies parasympathetic fibres to the parotid gland via the otic ganglion and motor function to stylopharyngeaus muscle. The sensory function of the nerve is tested using the gag reflex.
Glossopharyngeal nerve
Leaves the medulla between the olivary nucleus and the inferior cerebellar peduncle. Passes through the jugular foramen and into the carotid sheath. Details of the functions of the vagus nerve are covered in the website under relevant organ sub headings.
Vagus nerve
Exists from the caudal aspect of the brainstem (multiple branches) supplies trapezius and sternocleidomastoid muscles. The distal portion of this nerve is most prone to injury during surgical procedures.
Accessory nerve
Emerges from the medulla at the preolivary sulcus, passes through the hypoglossal canal. It lies on the carotid sheath and passes deep to the posterior belly of digastric to supply muscles of the tongue (except palatoglossus). Its location near the carotid sheath makes it vulnerable during carotid endarterectomy surgery and damage will produce ipsilateral defect in muscle function.
Hypoglossal nerve
A 22 year old man is participating in vigorous intercourse and suddenly feels a snap and his penis becomes swollen and painful. The admitting surgeon suspects a penile fracture. Which of the following is the most appropriate initial management?
MRI scan of the penis
Immediate surgical exploration
CT scan of the penis
USS of the penis
Cystogram
Suspected penile fractures should be surgically explored and the injury repaired.
Features of penile fracture
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.
Which of the following is not a branch of the abdominal aorta?
Inferior mesenteric artery
Inferior phrenic artery
Superior mesenteric artery
Superior phrenic artery
Renal artery
‘Prostitutes Cause Sagging Swollen Red Testicles [in men] Living In Sin’:
Phrenic [inferior]
Celiac
Superior mesenteric
Suprarenal [middle]
Renal
Testicular [‘in men’ only]
Lumbars
Inferior mesenteric
Sacral
Theme: Paediatric fractures
A.Non accidental injury
B.Accidental fracture
C.Rickets
D.Metabolic bone disease of prematurity
E.Hypophosphataemic rickets
F.Osteopetrosis
G.Osteogenesis imperfecta
H.Hypoparathyroidism
I.Osteoporosis
Please select the most likely explanation for each of the following injury scenarios. Each option may be used once, more than once or not at all.
26.A toddler aged 3 years presents to the Emergency Department with swelling of his leg and is found to have a spiral fracture of the tibia. His mother reports that he had tripped and fallen the previous day but she had not noticed any sign of injury at the time. She is a single parent with little family support. The child is not on the child protection register.
A 5 month baby boy presents with swelling of his right arm and is found to have a spiral fracture of the humerus. He had been in the care of her mother’s boyfriend who reported that he had nearly dropped him that day when reaching for his bottle and had inadvertently pulled on his arm to save him. He was immediately taken to the Emergency Department.
An infant is admitted with symptoms and signs of respiratory infection and is found to have several posterior rib fractures on chest radiograph. He was born prematurely at 37 weeks’ gestation and was observed overnight on the special care baby unit for tachypnoea which settled by the following day. On assessment it is also apparent that his head circumference has increased at an excessive rate and has crossed 3 centiles since birth.
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.
Which of the following is not typically associated with a degloving injury?
Overlying pallor of the skin
Abnormal motility of the overlying skin
History of friction type injury
Improved results when the degloved segment is left in situ as a temporary closure
Poor results when primary compression treatment is used in preference to skin grafting
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.
A homeless 42 year old male had an emergency inguinal hernia repair 24 hours previously. He has a BMI of 15. He has been put on a feeding regime of 35 kcal/kg/day with no additional medications. The nursing staff contact you as he has become confused and unsteady. On examination the patient is disorientated to place, has diplopia and nystagmus. What is the most likely diagnosis?
Cerebellar stroke
Acute dystonic reaction
Cerebrovascular accident
Parkinsonism
Wernickes encephalopathy
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.
Triad in Wernicke’s
Acute confusion
Ataxia
Opthalmoplegia
Theme: Venous disease
A.No further management needed
B.Injection sclerotherapy using 0.5% Sodium tetradecyl sulphate
C.Injection sclerotherapy using 5% phenol
D.Long saphenous vein ligation
E.Long saphenous vein stripped to the ankle
F.Long saphenous vein stripped to the knee
G.Doppler scan
H.Duplex scan
I.Endothermal ablation
Please select the most appropriate management plan for the scenario given. Each option may be used once, more than once or not at all.
31.A 42 year old teacher presents with an ulcer associated with varicose veins in the long saphenous vein territory. Apart from a DVT 1 year ago, she has no other past medical history.
A 42 year old accountant presents with thrombophlebitis of a long standing varicosity of the inner thigh. His past medical history is unremarkable apart from a conservatively managed tibial fracture of the ipsilateral limb 10 years ago. Doppler and clinical assessment demonstrate saphenofemoral junction incompetence.
A 43 year old lady presents with a thigh varicosity in the territory of the long saphenous vein. She underwent endovenous laser therapy 5 years previously. On duplex assessment she has a patent deep venous system and sapheno-femoral junction incompetence.
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.
An elderly diabetic male presents with a severe deep seated otalgia and a facial nerve palsy, he has completed a course of amoxycillin with no benefit. What is the most likely diagnosis?
Malignant otitis externa
Otosclerosis
Acoustic neuroma
Meniers disease
Viral illness
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.
Acute pain on moving the pinna
Conductive hearing loss if lesion is large
When rupture occurs pus will flow from ear
Boil in external auditory meatus
Acute otitis externa
Chronic combined infection in the external auditory meatus usually combined staphylococcal and fungal infection
Chronic discharge from affected ear, hearing loss and severe pain rare
Chronic otitis externa
Viral induced middle ear effusions secondary to eustacian tube dysfunction
Most common in children and rare in adults
May present with symptoms elsewhere (e.g. vomiting) in children
Severe pain and sometimes fever
May present with discharge is tympanic rupture occurs
Acute suppurative otitis media
May occur with or without cholesteatoma
Those without cholesteatoma have a perforation of the pars tensa
Those with cholesteatoma have a perforation of the pars flaccida
Those without cholesteatoma may complain of intermittent discharge (non offensive)
Those with cholesteatoma have impaired hearing and foul smelling discharge
Chronic suppurative otitis media
Treatment of chronic suppurative otitis media
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
Chronic suppurative otitis media with cholestatoma
Perforation of pars flaccida
Chronic suppurative otitis media without cholesteaoma
Perforation of pars tensa
Progressive conductive deafness
Secondary to fixation of the stapes in the oval window
Treatment is with stapedectomy and insertion of a prosthesis
Otosclerosis
Symptoms of gradually progressive unilateral perceptive deafness and tinnitus
Involvement of the vestibular nerve may cause vertigo
Extension to involve the facial nerve may cause weakness and then paralysis.
Acoustic neuroma
Common congenital condition in which an epithelial defect forms around the external ear
Small sinuses require no treatment
Deeper sinuses may become blocked and develop episodes of infection, they may be closely related to the facial nerve and are challenging to excise
Pre auricular sinus
Features of cerebellopontine angle syndrome
Absent corneal reflex
LMN facial palsy
LR palsy
Sensorineural deafness, vertigo, tinnits
DANISH
Effects of CPA lesion
CN 5, 6, 7, 8 and cerebellar signs
Millard-Gubler syndrome
Crossed hemiplegia
6th and 7th CN palsy
Contralateral hemiplegia
Caused by pontine lesions
A newborn infant is noted to have a unilateral cleft lip only. What is the most likely explanation for this process?
Incomplete fusion of the second branchial arch
Incomplete fusion of the nasolabial muscle rings
Incomplete fusion of the first branchial arch
Incomplete fusion of the third branchial arch
Incomplete fusion of the secondary palate
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.
What the common variants of cleft lip and palate?
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.
Pathophysiology of cleft lip
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.
Pathophysiology of cleft palate
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.
A 72 year old woman with back pain and chronic renal failure has the following blood test results:
Reference range
Ca2+2.032.15-2.55 mmol/l
Parathyroid hormone10.41-6.5 pmol/l
Phosphate0.800.6-1.25 mmol/l
What is the most likely diagnosis?
Hypoparathyroidism
Primary hyperparathyroidism
Secondary hyperparathyroidism
Tertiary hyperparathyroidism
Pseudohypoparathyroidism
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.
Indications for surgery in primary hyperparathyroidism
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)
Indications for surgery in secondary hyperparathyroidism
Bone pain
Persistent pruritus
Soft tissue calcifications
Management of tertiary hyperparathyroidism
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.
A homeless 42 year old male had an emergency inguinal hernia repair 24 hours previously. He has a BMI of 15. His electrolytes are normal. What is the best initial feeding regime?
Give 10 kcal/kg/day initially, oral thiamine 200-300mg/day, vitamin B co strong1 tds and supplements.
Give 35 kcal/kg/day initially, oral thiamine 200-300mg/day, vitamin B co strong 1 tds and supplements.
No change to diet needed
Oral thiamine 200-300mg/day, vitamin B co strong1 tds and supplements.
Give 35 kcal/kg/day initially
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.
Which of the following statements relating to large volume blood loss in trauma is incorrect?
Tranexamic acid reduces the incidence of rebleeding following surgery
Hypocalcaemia may complicate resuscitation
Colloids are preferred initially as they reduce the incidence of coagulopathy
When patients receive over 5 units of whole blood mortality increases when blood products greater than 3 weeks old are utilised
In the battlefield setting a ratio of 1:1:1 for blood, plasma and platelets is used
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.
A 40 year old lady presents with varicose veins, these are found to originate from the short saphenous vein. As the vein is mobilised which structure is at greatest risk of injury?
Sciatic nerve
Sural nerve
Common peroneal nerve
Tibial nerve
Popliteal artery
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.
A 23 year old man is admitted with a suspected ureteric colic. A KUB style x-ray is obtained. In which of the following locations is the stone most likely to be visualised?
The tips of the transverse processes between L2 and L5
The tips of transverse processes between T10-L1
At the crest of the ilium
Over the S3 foramina
Over the sacrococcygeal joint
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.
Where does the uretur become three muscular layers?
As it crosses the bony pelvis
Location of the ureturs
Retroperitoneal structure overlying transverse processes L2-L5
Lies anterior to bifurcation of iliac vessels
Lies beneath the uterine artery
Theme: Pharyngitis
A.Infectious mononucleosis
B.Acute bacterial tonsillitis
C.Quinsy
D.Lymphoma
E.Diptheria
Please select the most likely underlying cause for the following patients presenting with pharyngitis. Each option may be used once, more than once or not at all.
42.An 8 year old child presents with enlarged tonsils that meet in the midline and are covered with a white film that bleeds when you attempt to remove it. He is pyrexial but otherwise well.
A 10 year old child presents with enlarged tonsils that meet in the midline. Oropharyngeal examination confirms this finding and you also notice peticheal haemorrhages affecting the oropharynx. On systemic examination he is noted to have splenomegaly.
A 19 year old man has had a sore throat for the past 5 days. Over the past 24 hours he has notices increasing and severe throbbing pain in the region of his right tonsil. He is pyrexial and on examination he is noted to have a swelling of this area.
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.
Which of the following does not cause red urine?
Rifampicin
Phosphaturia
Beetroot
Rhubarb
Blackberries
Phosphaturia causes cloudy urine.
A 22 year old lady receives intravenous morphine for acute abdominal pain. Which of the following best accounts for its analgesic properties?
Binding to δ opioid receptors in the brainstem
Binding to δ opioid receptors at peripheral nerve sites
Binding to β opioid receptors within the CNS
Binding to α opioid receptors within the CNS
Binding to µ opioid receptors within the CNS
Binding to µ opioid receptors within the CNS
Delta opioid receptor location and effects
CNS
Analgesic and antidepressant effects
Kappa opioid receptor location and effects
CNS
Analgesic and dissociative effects
Mew opioid receptor location and effects
Central and peripheral
analgesia, miosis, decreased gut motility
Nociceptin opioid receptor location and effects
Nociceptin receptor (CNS)- Affect of appetite and tolerance to µ agonists.
From the list below, which drug is known to cause haemorrhagic cystitis?
Rifampicin
Methotrexate
Dexamethasone
Leflunomide
Cyclophosphamide
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.
A 72 year old man is due to undergo an oesophagectomy for malignancy. His BMI is 17.5. What is the best feeding regime immediately following surgery?
Total parenteral nutrition.
Feeding jejunostomy.
Feeding duodenostomy.
Liquid diet orally.
Soft solids orally.
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.
A 4 year old boy is brought to the clinic by his mother who has noticed a small lesion at the external angle of his eye. On examination there is a small cystic structure which has obviously been recently infected. On removal of the scab, there is hair visible within the lesion. What is the most likely diagnosis?
Dermoid cyst
Desmoid cyst
Sebaceous cyst
Epidermoid cyst
Keratoacanthoma
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.
Organ sites that may metastasise (early) to the para-aortic lymph nodes:
Testis
Ovary
Uterine fundus
In a patient with an ectopic kidney where is the adrenal gland most likely to be located?
In the pelvis
On the contralateral side
In its usual position
Superior to the spleen
It will be absent
Because the kidney is present, rather than absent, the adrenal will usual develop and in the normal location.
From what embryonic tissues are the adrenal medulla and cortex derived
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
What accounts for changes in size of the adrenal gland during fetal life
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.
Basis for anatomical abnormalities of the adrenal glands
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.
What are the two possible forms of adrenal hypoplasia
- hypoplasia or absence of cortex with poorly formed medulla
- disorganised cortex and medulla with no permanent cortex present
Adrenal heterotopia
Adrenal heterotopia describes a normal adrenal gland in an abnormal location, such as within the renal or hepatic capsules
Accessory adrenal tissue (adrenal rests), which is usually comprised only of cortex but seen combined with medulla in some cases, is most commonly located in
broad ligament or spermatic cord but can be found anywhere within the abdomen. Even intracranial adrenal rests have been reported
How can the causes of malabsorption be classified?
Intestinal causes
Pancreatic causes
Biliary causes
Other causes
Intestinal causes of malabsorption
coeliac disease
Crohn’s disease
tropical sprue
Whipple’s disease
Giardiasis
brush border enzyme deficiencies (e.g. lactase insufficiency)
Pancreatic causes of malabsorption
chronic pancreatitis
cystic fibrosis
pancreatic cancer
Biliary causes of malabsorption
biliary obstruction
primary biliary cirrhosis
Other causes of malabsorption
bacterial overgrowth (e.g. systemic sclerosis, diverticulae, blind loop)
short bowel syndrome
lymphoma
Which of the following structures is not closely related to the posterior tibial artery?
Soleus posteriorly
Tibial nerve medially
Deep peroneal nerve laterally
Flexor hallucis longus postero-inferiorly
Popliteus
The deep peroneal nerve lies in the anterior compartment. The tibial nerve lies medially. At its termination it lies deep to the flexor retinaculum.
Path of the posterior tibial artery
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
Anterior relations to the posterior tibial artery form proximal to distal
Tibialis posterior
Flexor digitorum longus
Posterior surface of tibia and ankle joint
Posterior relations to the posterior tibial artery from proximal to distal
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
Theme: Surgery for inflammatory bowel disease
A.Proctectomy
B.Anterior resection
C.Panproctocolectomy
D.Panproctocolectomy and ileoanal pouch
E.Sub total colectomy
F.Right hemicolectomy
Please select the most appropriate surgical modality for treating the inflammatory bowel disease scenarios described. Each option may be used once, more than once or not at all.
1.A 22 year old man presents with his first presentation of ulcerative colitis. Despite aggressive medical management with steroids, azathioprine and infliximab his symptoms remain unchanged and he has developed a megacolon.
A 22 year old lady has a long history of severe perianal Crohns disease with multiple fistulae. She is keen to avoid a stoma. However, she has progressive disease and multiple episodes of rectal bleeding. A colonoscopy shows rectal disease only and a small bowel study shows no involvement with Crohns.
A 22 year old man has a long history of ulcerative colitis. His symptoms are well controlled with steroids. However, attempts at steroid weaning and use of steroid sparing drugs have repeatedly failed. He wishes to avoid a permanent stoma.
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.
Indications for sx in UC
Disease that is requiring maximal therapy or prolonged courses of steroids
Dysplastic transformation of the colonic epithelium with associated mass lesions- absolute indication.
Emergency surgery for UC
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
Features of ileoanal pouch
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.
What is an important post-operative consideration for surgery in patients with IBD
High incidence of DVT- thromboprophylaxis is mandatory
Cx of ileoanal pouch
Anastomotic dehiscence
Pouchitis
Poor physiological function
Indications for surgery in Crohn’s
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
Severe perianal disease in Crohn’s
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.
Staging of Crohn’s
Staging of Crohns will usually involve colonoscopy and a small bowel study (e.g. MRI enteroclysis).
Theme: Intra abdominal malignancies
A.Metastatic adenocarcinoma of the pancreas
B.Metastatic appendiceal carcinoid
C.Metastatic colonic cancer
D.Pseudomyxoma peritonei
E.MALT lymphoma
F.Retroperitoneal liposarcoma
G.Retroperitoneal fibrosis
For the disease given please give the most likely primary disease process. Each option may be used once, more than once or not at all.
4.A 32 year old man is admitted with a distended tense abdomen. He previously underwent a difficult appendicectomy 1 year previously and was discharged. At laparotomy the abdomen is filled with a gelatinous substance.
A 62 year old man is admitted with dull lower back pain and abdominal discomfort. On examination he is hypertensive and a lower abdominal fullness is elicited on examination. An abdominal ultrasound demonstrates hydronephrosis and intravenous urography demonstrated medially displaced ureters. A CT scan shows a periaortic mass.
A 48 year old lady is admitted with abdominal distension. On examination she is cachectic and has ascites. Her CA19-9 returns highly elevated.
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.
Ureteric displacement in RPF
Medial
Ureteric displacement in retroperitoneal malignancies
Laterally
Curative treatment in pseudomyxoma peritonei
Is usually surgical and consists of cytoreductive surgery (and often peritonectomy c.f Sugarbaker procedure) combined with intra peritoneal chemotherapy with mitomycin C.
Which of the following are not true of follicular thyroid cancer?
They often appear to be encapsulated.
Those with a Hurthle cell subtype have an excellent prognosis.
Haematogenous metastasis is more common than in Papillary carcinoma.
The overall mortality rate is 24%.
Vascular invasion is seen in up to 60% of cases.
The Hurthle cell subtype have a worse prognosis.
Which of the following statements relating to malignant mesothelioma is false?
It may be treated by extrapleural pneumonectomy.
It is linked to asbestos exposure.
It is linked to cigarette smoking independent of asbestos exposure.
It may occur intra abdominally.
It is relatively resistant to radiotherapy
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.
A 28-year-old female undergoes a renal transplant for focal segmental glomerulosclerosis. Within hours of the operation the patient becomes unwell with features consistent with severe systemic inflammatory response syndrome. The patient is immediately taken back to theatre and the transplanted kidney is removed. What type of immunoglobulins are responsible for the graft rejection?
IgE
IgM
IgG
IgD
IgA
Hyperacute graft rejection is due to pre-existent antibodies to HLA antigens and is therefore IgG mediated
A 53-year-old woman is diagnosed with cellulitis surrounding her leg ulcer. A swab is taken and oral flucloxacillin is started. The following result is obtained:
Skin swab:Group A streptococcus
How should the antibiotic therapy be adjusted?
No change
Add topical fusidic acid
Add clindamycin
Add penicillin
Add erythromycin
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.
Classification of streptococci
Alpha and beta haemolytic types
