Block 9 Flashcards
Important alpha haemolytic strep
Strep pneumonia (pneumococcus)
Strep viridans
Classification of beta haemolytic strep
Group A
Group B
Group A Beta haemolytic strep
Strep pyogenes
Group B beta haemolytic strep
Strep agalactiae
Diseases caused by group A strep
responsible for erysipelas, impetigo, cellulitis, type 2 necrotizing fasciitis and pharyngitis/tonsillitis
immunological reactions can cause rheumatic fever or post-streptococcal glomerulonephritis
erythrogenic toxins cause scarlet fever
Which of the following is not closely related to the capitate bone?
Lunate bone
Scaphoid bone
Ulnar nerve
Hamate bone
Trapezoid bone
The ulnar nerve and artery lie adjacent to the pisiform bone. The capitate bone articulates with the lunate, scaphoid, hamate and trapezoid bones, which are therefore closely related to it.
Articulations of the capitate
This is the largest of the carpal bones. It is centrally placed with a rounded head set into the cavities of the lunate and scaphoid bones. Flatter articular surfaces are present for the hamate medially and the trapezoid laterally. Distally the bone articulates predominantly with the middle metacarpal.
An 18 month old boy is brought to the emergency room by his parents. He was found in bed with a nappy filled with dark red blood. He is haemodynamically unstable and requires a blood transfusion. Prior to this episode he was well with no prior medical history. What is the most likely cause?
Necrotising enterocolitis
Anal fissure
Oesophageal varices
Meckels diverticulum
Crohns disease
Meckels diverticulum is the number one cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years.
Newborn causes of GI bleeding
Upper tract: haemorrhagic disease, swallowed maternal blood
Lower tract: anal fissure/ NEC
1 month to 1 year old causes of GI bleeding
Upper tract: oesophagitis/gastritis
Lower tract: anal fissure/intussuception
1-2 years old causes of GI bleed
Upper tract: peptic ulcer disease
Lower disease: polyps/ Meckel’s diverticulum
>2 years old causes of GI bleed
Varices
IBD/polyps/intussuception
Which of the following statements relating to sebaceous cysts is false?
When infected are also known as Cocks peculiar tumour
Typically contain pus
Are usually associated with a central punctum
Most commonly occur on the scalp
They will typically have a cyst wall
Sebaceous cysts usually contain sebum, pus is only present in infected sebaceous cysts which should then be treated by surgical incision and drainage.
What must happen to prevent sebaceous cyst recurrence
Excision of the cyst wall
Theme: Hand disorders
A.Malignant fibrous histiocytoma
B.Oslers nodes
C.Heberdens nodes
D.Bouchards nodes
E.Carpal tunnel syndrome
F.Complex regional pain syndrome
G.Osteoclastoma
H.Osteosarcoma
I.Ganglion
Please select the most likely diagnosis for the lesion described. Each option may be used once, more than once or not at all.
15.A 42 year old lady who has systemic lupus erythematosus presents to the clinic with a 5 day history of a painful purple lesion on her index finger. On examination she has a tender red lesion on the index finger.
A 62 year old lady presents with an non tender lump overlying the distal interphalangeal joint of the index finger. On examination she has a hard, non tender lump overlying the joint and deviation of the tip of the finger.
A 17 year old boy is brought to the clinic by his mother who is concerned about a lesion that has developed on the dorsal surface of his left hand. On examination he has a soft fluctuant swelling on the dorsal aspect of the hand, it is most obvious on making a fist.
Oslers nodes
Osler nodes are normally described as tender, purple/red raised lesions with a pale centre. These lesions occur as a result of immune complex deposition. These occur most often in association with endocarditis. However, other causes include SLE, gonorrhoea, typhoid and haemolytic anaemia.
Heberdens nodes
Heberdens nodes may produce swelling of the distal interphalangeal joint with deviation of the finger tip.
Ganglion
Ganglions commonly occur in the hand and are usually associated with tendons. They are typically soft and fluctuant. They do not require removal unless they are atypical or causing symptoms.
Fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully extended.
Caused by underlying contractures of the palmar aponeurosis . The ring finger and little finger are the fingers most commonly affected. The middle finger may be affected in advanced cases, but the index finger and the thumb are nearly always spared.
Progresses slowly and is usually painless. In patients with this condition, the tissues under the skin on the palm of the hand thicken and shorten so that the tendons connected to the fingers cannot move freely. The palmar aponeurosis becomes hyperplastic and undergoes contracture.
Commonest in males over 40 years of age.
Association with liver cirrhosis and alcoholism. However, many cases are idiopathic.
Treatment is surgical and involves fasciectomy. However, the condition may recur and many surgical therapies are associated with risk of neurovascular damage to the digital nerves and arteries.
Dupuytens contracture
Idiopathic median neuropathy at the carpal tunnel.
Characterised by altered sensation of the lateral 3 fingers.
The condition is commoner in females and is associated with other connective tissue disorders such as rheumatoid disease. It may also occur following trauma to the distal radius.
Symptoms occur mainly at night in early stages of the condition.
Examination may demonstrate wasting of the muscles of the thenar eminence and symptoms may be reproduced by Tinels test (compression of the contents of the carpal tunnel).
Formal diagnosis is usually made by electrophysiological studies.
Treatment is by surgical decompression of the carpal tunnel, a procedure achieved by division of the flexor retinaculum. Non - surgical options include splinting and bracing.
Carpel tunnel syndrome
painful, red, raised lesions found on the hands and feet. They are the result of the deposition of immune complexes.
Osler’s nodes
Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage.
Bouchards nodes
Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the fingertip sideways. It typically affects the DIP joint.
Heberdens nodes
Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise. They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the cysts are troublesome they may be excised.
Ganglion
Which of the following statements relating to the tympanic membrane is false?
The umbo marks the point of attachment of the handle of the malleus to the tympanic membrane
The lateral aspect of the tympanic membrane is lined by stratified squamous epithelium
The chorda tympani nerve runs medial to the pars tensa
The medial aspect of the tympanic membrane is lined by mucous membrane
The tympanic membrane is approximately 1cm in diameter
The chorda tympani runs medially to the pars flaccida. The relationship is shown from the medial aspect in the dissection below.
An injury to the spinal accessory nerve will have the greatest affect on which of the following movements?
Lateral rotation of the arm
Adduction of the arm at the glenohumeral joint
Protraction of the scapula
Upward rotation of the scapula
Depression of the scapula
The spinal accessory nerve innervates trapezius. The entire muscle will retract the scapula. However, its upper and lower fibres act together to upwardly rotate it.
Which one of the following reduces the secretion of renin?
Erect posture
Adrenaline
Hyponatraemia
Hypotension
Beta-blockers
Factors stimulating renin secretion
Hypotension causing reduced renal perfusion
Hyponatraemia
Sympathetic nerve stimulation
Catecholamines
Erect posture
Factors reducing renin secretion
Drugs: beta-blockers, NSAIDs
Which of the following is not contained within the middle mediastinum?
Main bronchi
Arch of the azygos vein
Thoracic duct
Pericardium
Aortic root
The thoracic duct lies within the posterior and superior mediastinum.
Theme: Thyroid disorders
A.Sick euthyroid
B.Hyperthyroidism
C.Hypothyroidism
D.Normal euthyroid
E.Anxiety state
F.Factitious hyperthyroidism
For each of the scenarios please match the scenario with the most likely underlying diagnosis. Each answer may be used once, more than once or not at all.
23.A 33 year old man is recovering following a protracted stay on the intensive care unit recovering from an anastomotic leak following a difficult trans hiatal oesophagectomy. His progress is slow, and the intensive care doctors receive the following thyroid function test results:
TSH 1.0 u/L
Free T4 8
T3 1.0 (1.2-3.1 normal)
24.A 28 year old female presents to the general practitioner with symptoms of fever and diarrhoea. As part of her diagnostic evaluation the following thyroid function tests are obtained:
TSH < 0.01
Free T4 30
T3 4.0
25.A 19 year old lady presents with palpitations. The medical officer takes a blood sample for thyroid function tests. The following results are obtained:
TSH > 6.0
Free T4 20
T3 2.0
Sick euthyroid
Sick euthyroid syndrome is caused by systemic illness. With this, the patient may have an apparently low total and free T4 and T3, with a normal or low TSH. Note that the levels are only mildly below normal.
Hyperthyroidism
The symptoms are suggestive of hyperthyroidism. This is supported by the abnormal blood results; suppressed TSH with an elevated T3 and T4.
Hypothyroidism
An elevated TSH with normal T4 indicates partial thyroid failure. This is caused by Hashimotos, drugs (lithium, antithyroids) and dyshormogenesis.
What is the investigation of choice to look for renal scarring in a child with vesicoureteric reflux?
Abdominal x-ray
Ultrasound
DMSA
CT KUB
Micturating cystourethrogram
DMSA
def: VUR
Vesicoureteric reflux (VUR) is the abnormal backflow of urine from the bladder into the ureter and kidney. It is relatively common abnormality of the urinary tract in children and predisposes to urinary tract infection (UTI), being found in around 30% of children who present with a UTI. As around 35% of children develop renal scarring it is important to investigate for VUR in children following a UTI
Pathophysiology of VUR
ureters are displaced laterally, entering the bladder in a more perpendicular fashion than at an angle
therefore shortened intramural course of ureter
vesicoureteric junction cannot therefore function adequately
Grade I VUR
Reflux into the ureter only, no dilatation
Grade II VUR
Reflux into the renal pelvis on micturition, no dilatation
Grade III VUR
Mild/moderate dilatation of the ureter, renal pelvis and calyces
Grade IV VUR
Dilation of the renal pelvis and calyces with moderate ureteral tortuosity
Grade V VUR
Gross dilatation of the ureter, pelvis and calyces with ureteral tortuosity
Ix in VUR
VUR is normally diagnosed following a micturating cystourethrogram
a DMSA scan may also be performed to look for renal scarring
Classification of hypovolaemia
Overt compensated hypovolaemia
Covert compensated hypovolaemaia
Decompensated hypovolaemia
Covert compensated hypovolaemia
Accounted for by the fact that class I shock will often produce no overtly discernible clinical signs. This is due, in most cases, to a degree of splanchnic autotransfusion. The most useful diagnostic test for detection of covert compensated hypovolaemia remains urinanalysis. This often shows increased urinary osmolality and decreased sodium concentration.
Overt compensated hypovolaemia
Blood pressure is maintained although other haemodynamic parameters may be affected. This correlates to class II shock. In most cases assessment can be determined clinically. Where underlying cardiopulmonary disease may be present the placement of a CVP line may guide fluid resuscitation. Severe pulmonary disease may produce discrepancies between right and left atrial filling pressures. This problem was traditionally overcome through the use of Swann-Ganz catheters.
Theme: Infectious disease
A.Clostridium difficile
B.Clostridium perfringens
C.Clostridium tetani
D.Streptococcus pyogenes
E.Steptococcus Bovis
F.Staphylococcus aureus
G.Staphylococcus epidermidis
H.Bacteroides fragilis
I.None of the above
Please select the most likely infective organism for the scenario given. Each option may be used once, more than once or not at all.
28.A 23 year old man is readmitted following a difficult appendicectomy. His wound is erythematous and, on incision, foul smelling pus is drained.
A 62 year old lady is unwell following a difficult acute cholecystectomy for acute cholecystitis. Her gallbladder spilled stones intraoperatively and she has been on ciprofloxacin intravenously for this for the past 4 days. She now has colicky abdominal pain and profuse, foul smelling diarrhoea.
A 21 year old man is admitted with crampy abdominal pain and diarrhoea. He attended a large wedding earlier in the day. Several other guests are also affected with the same illness.
Bacteroides fragilis
Bacteroides is commonly present in severe peritoneal infections and as it is facultatively anaerobic may be present in pus. It smells foul!
Clostridium difficile
C. difficile may complicate administration of broad spectrum antibiotics.
Clostridium perfringens
C. Perfringens is a common cause of food borne illness and its ability to form spores may make it relatively resistant to cooking. The timing of onset would favor C. Perfringens which typically evolves over several hours, rather than staphylococcus aureus poisoning which may occur sooner.
Theme: Levels of evidence
A.I
B.II
C.III
D.IV
E.V
Please select the level of evidence which is supplied by the following. Each option may be used once, more than once or not at all.
34.One of the senior surgeons in the hospital advises as to the best management of Merkel cell tumours of the skin in which she has a special interest.
A group of surgeons review a meta-analysis of a series of randomised controlled trials on the Cochrane database and decide that one type of hip replacement is superior to another.
A group of surgeons are trying to decide which type of mesh to use for incisional hernia repair. Their assimilated evidence includes two case series and one randomised controlled trial.
V
Personal expert opinion qualifies for level V evidence.
I
A meta- analysis of more than one well designed trials will typically represent level I evidence. It does, of course, depend on how well the trials were conducted and reported.
II
Data which includes at least one RCT will usually qualify for level II evidence.
Evidence obtained from systematic review of all relevant randomised controlled trials
I
Evidence derived from at least one properly designed randomised controlled trial
II
Evidence derived from well designed pseudo-randomised controlled trials (e.g. alternate allocation) or historical controls
III
Evidence derived from case series or case reports
IV
Panel or expert opinion
V
Which of the following stimulates prolactin release or action?
Leutinising hormone
Dopamine
Thyrotropin releasing hormone
Oestrogen
Follicle stimulating hormone
TRH stimulates prolactin release. Dopamine suppresses the release of prolactin.
Which of the following conditions is least likely to exhibit the Koebner phenomenon?
Vitiligo
Molluscum contagiosum
Lichen planus
Psoriasis
Lupus vulgaris
Lupus vulgaris is not associated with the Koebner phenomenon.
The Koebner phenomenon describes skin lesions which appear at the site of injury. It is seen in:
Psoriasis
Vitiligo
Warts
Lichen planus
Lichen sclerosus
Molluscum contagiosum
Which of the following variables is not included in the Rockall score?
Congestive cardiac failure
Liver failure
Systolic blood pressure < 100mmHg
Aspirin usage
Age
Aspirin usage
Mnemonic for Rockall score
ABCDE
A: Age
B: Blood pressure drop (Shock)
C: Co-morbidity
D: Diagnosis
E: Evidence of bleeding
Rockall score indicators
<3= good prognosis
>8= high mortality
A 55 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate gland. Which of the following vessels directly supplies the prostate?
External iliac artery
Common iliac artery
Internal iliac artery
Inferior vesical artery
None of the above
The arterial supply to the prostate gland is from the inferior vesical artery, it is a branch of the prostatovesical artery. The prostatovesical artery usually arises from the internal pudendal and inferior gluteal arterial branches of the internal iliac artery.
A 24-year-old female is referred to the acute surgical team as she is noted to have an absent left radial pulse. Apart from some dizziness and lethargy, the patient does not have any features suggestive of an acute ischaemic limb. Blood tests are as follows:
Na+ 136 mmol/l
K+ 4.1 mmol/l
Urea 2.3 mmol/l
Creatinine 77 µmol/l
ESR 66 mm/hr
What is the most likely diagnosis?
Turner’s syndrome
Takayasu’s arteritis
Kawasaki disease
Coarctation of the aorta
Breast carcinoma with local spread
Takayasu’s
Inflammatory, obliterative arteritis affecting aorta and branches
Females> Males
Symptoms may include upper limb claudication
Clinical findings include diminished or absent pulses
ESR often affected during the acute phase
What is associated with Takayasu’s arteritis
Renal artery stenosis
Theme: Vitamin deficiency
A.Vitamin A
B.Vitamin B1
C.Vitamin B12
D.Vitamin B3
E.Vitamin C
F.Vitamin K
G.Vitamin D
Please select the vitamin deficiency most closely associated with the situation described. Each option may be used once, more than once or not at all.
42.A 3 year old child presents with Rickets
A 44 year old lady presents with jaundice. Following a minor ward based surgical procedure she develops troublesome and persistent bleeding.
A 69 year old man who has been living in sheltered accommodation for many months, with inadequate nutrition notices that his night vision is becoming impaired.
Vitamin D
Vitamin D is needed to help mineralise bone. When this is deficient, mineralisation is inadequate and deformities mayt result.
Vitamin K
Patients who are jaundiced usually have impaired absorption of vitamin K. This can result in loss of the vitamin K dependent clotting factors and troublesome bleeding.
Vitamin A
Loss of vitamin A will result in impair rhodopsin synthesis and poor night vision.
Vit deficiency
Night blindness
Epithelial atrophy
Infections
Vitamin A
Beriberi
Vitamin B1
Vitamin deficiency
Dermatitis and photosensitivity
B2
Pellagra
B3
Pernicious anaemia
B12
Vitamin deficiency
Poor wound healing
Impaired collagen synthesis
Vitamin C
Which of the tumour types listed below is found most frequently in a person with aggressive fibromatosis?
Medullary thyroid cancer
Basal cell carcinoma of the skin
Desmoid tumours
Dermoid tumours
Malignant melanoma
Aggressive fibromatosis is a disorder consisting of desmoid tumours, which behave in a locally aggressive manner. Desmoid tumours may be identified in both abdominal and extra-abdominal locations. Metastatic disease is rare. The main risk factor (for abdominal desmoids) is having APC variant of familial adenomatous polyposis coli. Most cases are sporadic.
Treatment is by surgical excision.
Which nerve directly innervates the sinoatrial node?
Superior cardiac nerve
Right vagus nerve
Left vagus nerve
Inferior cardiac nerve
None of the above
No single one of the above nerves is responsible for direct cardiac innervation (which those who have handled the heart surgically will appreciate).
The heart receives its nerves from the superficial and deep cardiac plexuses. The cardiac plexuses send small branches to the heart along the major vessels, continuing with the right and left coronary arteries. The vagal efferent fibres emerge from the brainstem in the roots of the vagus and accessory nerves, and run to ganglia in the cardiac plexuses and within the heart itself.
The background vagal discharge serves to limit heart rate, and loss of this background vagal tone accounts for the higher resting heart rate seen following cardiac transplant.
Overview of the SAN
Located in the wall of the right atrium in the upper part of the sulcus terminalis from which it extends anteriorly over the opening of the superior vena cava.
In most cases it is supplied by the right coronary artery.
It has a complicated nerve supply from the cardiac nerve plexus that takes both sympathetic and parasympathetic fibres that run alongside the main vessels.
In paediatric orthopaedic surgery, which of the following does not fulfill the Kocher criteria for septic arthritis?
ESR > 40mm/h
Positive blood culture
Fever
White cell count > 12, 000
Non weight bearing on the affected side
The Kocher criteria do not consider blood culture results.
Kocher criteria for septic arthritis
- Non weight bearing on affected side
- ESR > 40 mm/hr
- Fever
- WBC count of >12,000 mm3
- When 4/4 criteria are met, there is a 99% chance that the child has septic arthritis
Commonest cause of paediatric septic arthritis
Staph aureus
Swirl sign
Inracerebral haematoma
Areas of clot and fresh blood co-existing on same CT scan
Which of the following statements relating to necrotising enterocolitis is false?
It has a mortality of 30%
Most frequently presents in premature neonates less than 32 weeks gestation.
Should be managed by early laparotomy and segmental resections in most cases.
Pneumostosis intestinalis may be visible on plain abdominal x-ray.
May be minimised by use of breast milk over formula feeds.
Most cases will settle with conservative management with NG decompression and appropriate support. Laparotomy should be undertaken in patients who progress despite conservative management or in whom compelling indications for surgery exist (eg free air).
A 30 year old man presents with back pain and the surgeon tests the ankle reflex. Which of the following nerve roots are tested in this manoeuvre?
S3 and S4
L4 and L5
L3 and L4
S1 and S2
S4 only
The ankle reflex is elicited by tapping the Achilles tendon with a tendon hammer. It tests the S1 and S2 nerve roots. It is typically delayed in L5 and S1 disk prolapses.
Which of the following structures is not closely related to the piriformis muscle?
Superior gluteal nerve
Sciatic nerve
Inferior gluteal artery
Inferior gluteal nerve
Medial femoral circumflex artery
The piriformis muscle is an important anatomical landmark in the gluteal region. The following structures are closely related:
Sciatic nerve
Inferior gluteal artery and nerve
Superior gluteal artery and nerve
The medial femoral circumflex artery runs deep to quadratus femoris.
What are the lateral hip rotators?
Piriformis
Obturator internus
Superior gemellus
Inferior gemellus
Quadrator femoris
Innervation of piriformis
Ventral rami S1, S2
Innervation of obturator internus
Nerve to obturator internus
Innervation of superior gemellus
Nerve to obturator internus
Innervation of inferior gemellus
Nerve to quadratus femoris
Innervation of quadratus femoris
Nerve to quadratus femoris
Innervation of tensor fascia lata
SGN
A 43 year old lady presents with severe chest pain. Investigations demonstrate a dissecting aneurysm of the ascending aorta which originates at the aortic valve. What is the optimal long term treatment?
Endovascular stent
Medical therapy with beta blockers
Medical therapy with ACE inhibitors
Sutured aortic repair
Aortic root replacement
Proximal aortic dissections are generally managed with surgical aortic root replacement. The proximal origin of the dissection together with chest pain (which may occur in all types of aortic dissection) raises concerns about the possibility of coronary ostial involvement (which precludes stenting). There is no role for attempted suture repair in this situation.
A 43 year old lady with repeated episodes of abdominal pain is admitted with small bowel obstruction. A laparotomy is performed and at surgery a gallstone ileus is identified. What is the most appropriate course of action?
Remove the gallstone via a proximally sited terminal ileal enterotomy and decompress the small bowel. Leave the gallbladder in situ.
Remove the gallstone via a proximally sited terminal ileal enterotomy and decompress the small bowel. Remove the gallbladder.
Remove the gallstone via a proximally sited terminal ileal enterotomy and decompress the small bowel. Perform a choledochoduodenostomy.
Remove the gallstone from an enterotomy at the site of the obstruction and leave the gallbladder in situ.
Remove the gallstone from an enterotomy at the site of the obstruction and remove the gallbladder.
Gallstone ileus occurs as a result of the fistula developing between the gallbladder and the duodenum. These tend to become impacted somewhat proximal to the ileocaecal valve and cause small bowel obstruction. The correct management is to remove the gallstone from an enterotomy proximal to the site of stone impaction. The bowel at the site of impaction itself may not heal well and an enterotomy performed at this site may well result in the need for a resection. The standard surgical teaching is that under almost all circumstances the gallbladder should be left in situ, as the anatomy in this area is often hostile and unpredictable. Disconnecting it from the duodenum leaves a large defect that is difficult to close.
Risks of ERCP
Bleeding 0.9% (rises to 1.5% if sphincterotomy performed)
Duodenal perforation 0.4%
Cholangitis 1.1%
Pancreatitis 1.5%
Which of the following structures accompanies the posterior interventricular artery within the posterior interventricular groove?
Great cardiac vein
Middle cardiac vein
Small cardiac vein
Anterior cardiac vein
Coronary sinus
Middle cardiac vein
A 55 year old man develops an acute colonic pseudo-obstruction following a laminectomy. Despite correction of his electrolytes and ongoing supportive care he fails to settle. Which of the drugs listed below may improve the situation?
Buscopan
Neostigmine
Metoclopramide
Mebevrine
Sodium picosulphate
Neostigmine affects the degradation of acetylcholine and will therefore stimulate both nicotinic and muscarinic receptors. It may produce symptomatic bradycardia and should therefore only be administered in a monitored environment. In colonic pseudo-obstruction it produces generalised colonic contractions and its onset is usually rapid.
Features of colonic pseudo-obstruction
Colonic pseudo-obstruction is characterised by the progressive and painless dilation of the colon. The abdomen may become grossly distended and tympanic. Unless a complication such as impending bowel necrosis or perforation occurs, there is usually little pain.
Diagnosis of pseudo-obstruction
Diagnosis involves excluding a mechanical bowel obstruction with a plain film and contrast enema. The underlying cause is usually electrolyte imbalance and the condition will resolve with correction of this and supportive care.
Management of colonic pseudo-obstruction
Patients who do not respond to supportive measures should be treated with attempted colonoscopic decompression and/ or the drug neostigmine. In rare cases surgery may be required.
Theme: Cardiac murmurs
A.Pulmonary stenosis
B.Mitral regurgitation
C.Tricuspid regurgitation
D.Aortic stenosis
E.Mitral stenosis
F.Aortic sclerosis
What is the most likely cause of the cardiac murmur in the following patients? Each option may be used once, more than once or not at all.
60.A 35 year old Singaporean female attends a varicose vein pre operative clinic. On auscultation a mid diastolic murmur is noted at the apex. The murmur is enhanced when the patient lies in the left lateral position.
A 22 year old intravenous drug user is found to have a femoral abscess. The nursing staff contact the on call doctor as the patient has a temperature of 39oC. He is found to have a pan systolic murmur loudest at the left sternal edge at the 4th intercostal space.
An 83 year old woman is admitted with a left intertrochanteric neck of femur fracture. On examination the patient is found to have an ejection systolic murmur loudest in the aortic region. There is no radiation of the murmur to the carotid arteries. Her ECG is normal.
Mitral stenosis
A mid diastolic murmur at the apex is a classical description of a mitral stenosis murmur. The most common cause is rheumatic heart disease. Complications of mitral stenosis include atrial fibrillation, stroke, myocardial infarction and infective endocarditis.
Tricuspid regurgitation
Intravenous drug users are at high risk of right sided cardiac valvular endocarditis. The character of the murmur fits with a diagnosis of tricuspid valve endocarditis.
Aortic sclerosis
The most likely diagnosis is aortic sclerosis. The main differential diagnosis is of aortic stenosis, however as there is no radiation of the murmur to the carotids and the ECG is normal, this is less likely.
Ejection systolic
Aortic stenosis
Pulmonary stenosis, HOCM
ASD, Fallot’s
Pan-systolic
Mitral regurgitation
Tricuspid regurgitation
VSD
Late systolic
Mitral valve prolapse
Coarctation of aorta
Early diastolic
Aortic regurgitation
Graham-Steel murmur (pulmonary regurgitation)
Mid diastolic
Mitral stenosis
Austin-Flint murmur (severe aortic regurgitation)
A cohort study is being designed to look at the relationship between smoking and breast cancer. What is the usual outcome measure in a cohort study?
Odds ratio
Experimental event rate
Relative risk
Absolute risk increase
Numbers needed to harm
Cohort studies - relative risk
An 18 year old male presents to casualty with a depressed skull fracture. This is managed surgically. Over the next few days he complains of double vision on walking down stairs and reading. On testing ocular convergence, the left eye faces downwards and medially, but the right side does not do so. Which of the nerves listed below is most likely to be responsible?
Facial
Oculomotor
Abducens
Trochlear
Trigeminal nerve
The trochlear nerve has a relatively long intracranial course and this makes it vulnerable to injury in head trauma. Head trauma is the commonest cause of an acute fourth nerve palsy. A 4th nerve palsy is the commonest cause of a vertical diplopia. The diplopia is at its worst when the eye looks medially which it usually does as part of the accommodation reflex when walking down stairs.
Vertical diplopia (diplopia on descending the stairs) Unable to look down and in
Trochlear nerve
Convergence of eyes in primary position
Lateral diplopia towards side of lesion
Eye deviates medially
Abducens nerve
Theme: Nottingham prognostic index
A.<2.5
B.<3.4
C.3.4-5.4
D.>5.4
Please match the prognosis of patients who have undergone breast cancer surgery to the most appropriate Nottingham Prognostic Index score. Each option may be used once, more than once or not at all.
65.Worst prognostic group
Intermediate prognosis
Excellent prognosis
>5.4
The Nottingham prognostic index may be used to stratify patients into various prognostic groups (see below). An excellent prognosis is seen with a score of <2.4. Scores of over 5 equate to a greatly reduced survival rate.
3.4-5.4
<2.5
NPI Px
2-2.4
93%
NPI Px
2.5-3.4
85%
NPI Px
3.5-5.4
70%
NPI Px
>5.4
50%
The following features are typical of superficial partial dermal burns except:
Erythema
Absence of blisters
Spontaneous healing in most cases
No extension beyond proximal dermal papillae
Good capillary refill at the burn site
Superficial dermal burns are typically erythematous, do not extend beyond the upper part of the dermal papillae, capillary return and blisters are both usually present.
A 55 year old lady presents with discomfort in the right breast. On clinical examination a small lesion is identified and clinical appearances suggest fibroadenoma. Imaging confirms the presence of a fibroadenoma alone. A core biopsy is taken, this confirms the presence of the fibroadenoma. However, the pathologist notices that a small area of lobular carcinoma in situ is also present in the biopsy. What is the best management?
Whole breast irradiation
Simple mastectomy
Mastectomy and sentinal lymph node biopsy
Wide local excision and sentinel lymph node biopsy
Breast MRI scan
Lobular carcinoma in situ has a low association with invasive malignancy. It is seldom associated with microcalcification and therefore MRI is the best tool for determining disease extent. Resection of in situ disease is not generally recommended and most surgeons would simply pursue a policy of close clinical and radiological follow up.
A 77 year old man with symptoms of intermittent claudication is due to have his ankle brachial pressure indices measured. The dorsalis pedis artery is impalpable. Which of the following tendinous structures lies medial to it, that may facilitate its identification?
Extensor digitorum longus tendon
Peroneus tertius tendon
Extensor hallucis longus tendon
Extensor digitorum brevis tendon
Flexor digitorum longus tendon
The extensor hallucis longus tendon lies medial to the dorsalis pedis artery.
Theme: Management of prostatic disease
A.Commence alpha blocker
B.Commence 5 alpha reductase inhibitor
C.Transurethral resection of the prostate
D.Commence LnRH analogue
E.Radical prostatectomy
F.Transvesical prostatectomy
G.Unilateral orchidectomy
H.Watch and wait
I.Radical radiotherapy
For the prostatic disorders described please select the most appropriate management option. Each option may be used once, more than once or not at all.
71.A 49 year old man presents with a single episode of haematuria. Investigations demonstrate adenocarcinoma of the prostate gland. Imaging shows T2 disease and no evidence of metastasis.
A 72 year old man is admitted with acute urinary retention. On examination he has a small but palpable bladder. Digital rectal examination identifies a benign feeling enlarged prostate gland. He has been treated with finasteride for the past 9 months.
A 73 year old man presents with haematuria. Investigations demonstrate a localised, high risk, prostatic cancer. His co-morbidities include COPD and ischaemic heart disease. His staging investigations show no evidence of metastatic disease
Radical prostatectomy
In a young patient with local disease only a radical prostatectomy is the best chance of cure. Radiotherapy may be given instead but has long term sequelae (and inferior survival outcomes). A transvesical prostatectomy is a largely historical operation performed for BPH before TURP was established.
Transurethral resection of the prostate
Medical therapy has failed and although an alpha blocker may help his symptoms he would fare better with a TURP.
Radical radiotherapy
The co-morbidities of this patient make a surgical approach a less favorable option. Radical radiotherapy offers a more favorable alternative.
A 55 year old man undergoes a laparotomy and repair of incisional hernia. Which of the following hormones is least likely to be released in increased quantities following the procedure?
Insulin
ACTH
Glucocorticoids
Aldosterone
Growth hormone
Insulin and thyroxine are often have reduced levels of secretion in the post operative period. This, coupled with increased glucocorticoid release may cause difficulty in management of diabetes in individuals with insulin resistance.
Theme: Muscle relaxants
A.Gallamine
B.Benzquinonium
C.Tubocurarine
D.Vecuronium
E.Pancuronium
F.Suxamethonium
G.Decamethonium halides
Please select the most appropriate neuromuscular blocking drugs for the procedure described. Each option may be used once, more than once or not at all.
75.A 56 year old man is undergoing a distal gastrectomy and just as the surgeon begins to close the deep abdominal muscle layer the patient develops marked respiratory efforts and closure cannot continue.
An agent that is associated with a risk of malignant hyperthermia.
An agent that may be absorbed from multiple bodily sites and causes histamine release.
Suxamethonium
Suxamethonium has a rapid onset with short duration of action. As this is the final stage of the procedure only brief muscle relaxation is needed.
Suxamethonium
Suxamethonium may cause malignant hyperthermia and 1 in 2800 will have abnormal cholinesterase enzyme and prolonged clinical effect.
Tubocurarine
It can be absorbed orally and rectally, though few would choose this route of administration. It is now rarely used.
Theme: Abdominal pain
A.Acute mesenteric embolus
B.Acute on chronic mesenteric ischaemia
C.Mesenteric vein thrombosis
D.Ruptured abdominal aortic aneurysm
E.Pancreatitis
F.Appendicitis
G.Acute cholecystitis
Please select the most likely underlying diagnosis from the list above. Each option may be used once, more than once or not at all.
78.A 72 year old man collapses with sudden onset abdominal pain. He has been suffering from back pain recently and has been taking ibuprofen.
A 73 year old women collapses with sudden onset of abdominal pain and the passes a large amount of diarrhoea. On admission she is vomiting repeatedly. She has recently been discharged from hospital following a myocardial infarct but recovered well.
A 66 year old man has been suffering from weight loss and develops severe abdominal pain. He is admitted to hospital and undergoes a laparotomy. At operation the entire small bowel is infarcted and only the left colon is viable.
Ruptured abdominal aortic aneurysm
Back pain is a common feature with expanding aneurysms and may be miss classified as being of musculoskeletal origin.
Acute mesenteric embolus
Sudden onset of abdominal pain and forceful bowel evacuation are features of acute mesenteric infarct.
Acute on chronic mesenteric ischaemia
This man is likely to have underlying chronic mesenteric vascular disease. Only 15% of emboli will occlude SMA orifice leading to entire small bowel infarct. The background history of weight loss also favours an acute on chronic event.
Theme: Management of head injuries
A.Intravenous mannitol
B.Parietotemporal craniotomy
C.Burr Hole decompression
D.Posterior fossa craniotomy
E.Insertion of intracranial bolt monitor
F.Discharge
G.Intravenous frusemide
What is the most appropriate definitive management plan for the injury described? Each option may be used once, more than once or not at all.
81.A 25 year old cyclist is hit by a bus traveling at 30mph. He is not wearing a helmet. He arrives with a GCS of 3/15 and is intubated. A CT scan shows evidence of cerebral contusion but no localising clinical signs are present
A 32 year old rugby player is crushed in a scrum. He is briefly concussed but then regains consciousness. He then collapses and is brought to A+E. His GCS on arrival is 6/15 and his left pupil is dilated.
A 30 year old women is injured in a skiing accident. She suffers a blow to the occiput and is concussed for 5 minutes. On arrival in A+E she is confused with GCS 10/15. A CT scan shows no evidence of acute bleed or fracture but some evidence of oedema with the beginnings of mass effect
Insertion of intracranial bolt monitor
This patient may well develop raised ICP over the next few days and Intracranial pressure monitoring will help with management.
Parietotemporal craniotomy
This man needs urgent decompression and extradural haematoma is the most likely event, from a lacerated middle meningeal artery. The debate as to whether Burr Holes or craniotomy is the best option continues. Most neurosurgeons would perform a craniotomy. However, rural units and those units without neurosurgical kit facing this emergency may resort to Burr Holes.
Intravenous mannitol
This women has raised ICP and mannitol will help reduce this in the acute phase.
Which of the following is not a major function of the spleen in adults?
Iron reutilisation
Storage of platelets
Storage of monocytes
Haematopoeisis in haematological disorders
Storage red blood cells
Storage red blood cells
The reservoir function of the spleen is less marked in humans than other animals (e.g. pigs) and in normal individuals it can sequester between 5 and 10% of the red cell mass. The other stated processes are major splenic functions and this accounts for the answer provided.
Which one of the following may be associated with an increased risk of venous thromboembolism?
Diabetes
Cannula
Hyperthyroidism
Tamoxifen
Amiodarone
Consider thromboembolism in breast cancer patients on tamoxifen!
A 23 year old man falls over whilst intoxicated and a shard of glass transects his median nerve at the proximal border of the flexor retinaculum. His tendons escape injury. Which of the following features is least likely to be present?
Weakness of thumb abduction
Loss of sensation on the dorsal aspect of the thenar eminence
Loss of power of opponens pollicis
Adduction and lateral rotation of the thumb at rest
Loss of power of abductor pollicis brevis
The median nerve may be injured proximal to the flexor retinaculum. This will result in loss of abductor pollicis brevis, flexor pollicis brevis, opponens pollicis and the first and second lumbricals. When the patient is asked to close the hand slowly there is a lag of the index and middle fingers reflecting the impaired lumbrical muscle function. The sensory changes are minor and do not extend to the dorsal aspect of the thenar eminence.
Abductor pollicis longus will contribute to thumb abduction (and is innervated by the posterior interosseous nerve) and therefore abduction will be weaker than prior to the injury.
The following muscles are supplied by the recurrent laryngeal nerve except:
Transverse arytenoid
Posterior crico-arytenoid
Cricothyroid
Oblique arytenoid
Thyroarytenoid
Innervates: all intrinsic larynx muscles (excluding cricothyroid)
The external branch of the superior laryngeal nerve innervates the cricothyroid muscle
Causes of increased lung compliance
age
emphysema - this is due to loss alveolar walls and associated elastic tissue
Causes of decreased lung compliance
pulmonary oedema
pulmonary fibrosis
pneumonectomy
kyphosis
From which embryological structure is the ureter derived?
Uranchus
Cloaca
Vitello-intestinal duct
Mesonephric duct
None of the above
The ureter develops from the mesonephric duct. The mesonephric duct is associated with the metanephric duct that develops within the metenephrogenic blastema. This forms the site of the ureteric bud which branches off the mesonephric duct
A 55 year old man is found to have a carcinoma of the sigmoid colon on screening colonoscopy. How should this be staged?
MRI of the abdomen and CT of the chest
Liver MRI and Chest CT
CT scanning of the chest, abdomen and pelvis alone
MRI of the rectum and CT of the abdomen and chest
Endoluminal USS and CT scanning of the abdomen
Colonic cancers are staged with CT scanning of the chest, abdomen and pelvis.
Rectal cancer is staged with MRI rectum (and sometimes endolumenal USS for low T1 lesions) together with CT scanning of the chest, abdomen and pelvis. Historically, colonic cancer was staged with liver USS and CXR. However, modern imaging has made this practice obsolete.
A 16 year old boy is hit by a car and sustains a blow to the right side of his head. He is initially conscious but on arrival in the emergency department is comatose. On examination his right pupil is fixed and dilated. The neurosurgeons plan immediate surgery. What type of initial approach should be made?
Left parieto-temporal craniotomy
Right parieto-temporal craniotomy
Posterior fossa craniotomy
Left parieto-temporal burr holes
None of the above
A unilateral dilated pupil is a classic sign of transtentorial herniation. The medial aspect of the temporal lobe (uncus) herniates across the tentorium and causes pressure on the ipsilateral oculomotor nerve, interrupting parasympathetic input to the eye and resulting in a dilated pupil. In addition the brainstem is compressed. As the ipsilateral oculomotor nerve is being compressed, craniotomy (rather than Burr Holes) should be made on the ipsilateral side.
Which of the following statements related to necrotising fasciitis is false?
Mainly polymicrobial
A feature may include ‘dirty dishwater fluid’ in the wound
The presence of crepitus is needed to make the diagnosis
Further surgery is mandatory 24-48h after initial surgery to review extension of infection
The muscles are relatively spared
Never attempt primary closure after the initial debridement of necrotising fasciitis.
Crepitus may be present in only 35% of cases, therefore its absence should not exclude a diagnosis of necrotising fasciitis.
Theme: Management of hip fractures
A.MRI scan
B.Hemiarthroplasty
C.Bone scintigraphy
D.Conservative management
E.Total hip replacement
F.Insertion of intra medullary nail
G.Hip arthrodesis
H.Internal fixation
For each fracture scenario please select the most appropriate management option from the list. Each option may be used once, more than once or not at all.
94.An otherwise fit 74 year old man presents with pain in the right hip following minimal trauma. On examination his leg is shortened and externally rotated. Plain films demonstrate a displaced intracapsular fracture of the femoral neck.
A 72 year old retired teacher is admitted to A&E with a fall and hip pain. He is normally fit and well. He lives with his son in a detached, 2 storey house. A hip x-ray and femur views confirm a sub trochanteric fracture.
A 72 year old lady stumbles and falls. On examination she is tender in the left groin and unable to weight bear. Attempts at internal rotation produce severe pain. Plain films of the hip show no obvious fracture.
Total hip replacement
In otherwise fit patients aged over 70, the best long term functional outcomes are obtained with total hip arthroplasty.
Insertion of intra medullary nail
Intramedullary devices are normally recommended for reverse oblique, transverse subtrochanteric fractures.
MRI scan
In those patients who present with a suspected hip fracture, but normal plain films, the most accurate investigation is an MRI or CT scan.
Which of the following relationship descriptions regarding the scalene muscles is incorrect?
The brachial plexus passes anterior to the middle scalene muscle
The phrenic nerve lies anterior to the anterior scalene muscle
The subclavian artery passes posterior to the middle scalene
The subclavian vein lies anterior to the anterior scalene muscle at the level of the first rib
The anterior scalene inserts into the first rib
The subclavian artery passes anterior to the middle scalene.
A 56 year old man is having a long venous line inserted via the femoral vein into the right atrium for CVP measurements. The catheter is advanced through the IVC. At which of the following levels does this vessel enter the thorax?
L2
T10
L1
T8
T6
The IVC passes through the diaphragm at T8.
A 23 year old man falls and injures his hand. There are concerns that he may have a scaphoid fracture as there is tenderness in his anatomical snuffbox on clinical examination. Which of the following forms the posterior border of this structure?
Basilic vein
Radial artery
Extensor pollicis brevis
Abductor pollicis longus
Extensor pollicis longus
It’s boundaries are extensor pollicis longus, medially (posterior border) and laterally (anterior border) by the tendons of abductor pollicis longus and extensor pollicis brevis.
Which of the following structures attaches periosteum to bone?
Sharpeys fibres
Peripheral lamellae
Elastic fibres
Fibrolamellar bundles
Purkinje fibres
Periosteum is attached to bone by strong collagenous fibers called Sharpey’s fibres, which extend to the outer circumferential and interstitial lamellae. It also provides an attachment for muscles and tendons.
def: periosteum
Periosteum is a membrane that covers the outer surface of all bones, except at the joints of long bones. Endosteum lines the inner surface of all bones.
Structural arrangement of periosteum
Periosteum consists of dense irregular connective tissue. Periosteum is divided into an outer “fibrous layer” and inner “cambium layer” (or “osteogenic layer”). The fibrous layer contains fibroblasts, while the cambium layer contains progenitor cells that develop into osteoblasts. These osteoblasts are responsible for increasing the width of a long bone and the overall size of the other bone types. After a bone fracture the progenitor cells develop into osteoblasts and chondroblasts, which are essential to the healing process.
Function of periosteum
As opposed to osseous tissue, periosteum has nociceptive nerve endings, making it very sensitive to manipulation. It also provides nourishment by providing the blood supply. Periosteum is attached to bone by strong collagenous fibers called Sharpey’s fibres, which extend to the outer circumferential and interstitial lamellae. It also provides an attachment for muscles and tendons.
Theme: Surgical incisions
A.Lanz incision
B.Gridiron incision
C.Kochers incision
D.Rutherford Morrison
E.Rooftop incision
F.McEvedy Incision
G.Lotheissen Incision
Please select the most appropriate incision for the procedure described. Each option may be used once, more than once or not at all.
101.A 78 year old lady is admitted with an incarcerated femoral hernia. Abdominal signs are absent and there are no symptoms of obstruction. AXR is normal.
A 15 year old girl presents with right iliac fossa pain and guarding, pregnancy test is negative and WCC is 16.
A 45 year old man is due to undergo a live donor renal transplant. This will be his first procedure.
McEvedy Incision
From the list, the McEvedy approach is the most appropriate. The Lotheissen incision may compromise the posterior wall of the inguinal canal and is best avoided. The author prefers a limited pfannenstial type incision for this procedure, as it gives better control of the hernia, but this is not on the list.
Lanz incision
She requires an appendicectomy. Although there is an increasing vogue for performing this procedure laparoscopically, an open procedure is entirely suitable. However, although both a Gridiron and Lanz incision are suitable for appendicectomy a Lanz will give a superior cosmetic result and would be the preferred option for most young females.
Rutherford Morrison
The Rutherford Morrison incision will typically give access to the iliac vessels and bladder for the procedure.
TSH in hyperthyroidism 2o to pregnancy
TSH is typically elevated
A 62 year old man is undergoing a left hemicolectomy for carcinoma of the descending colon. The registrar commences mobilisation of the left colon by pulling downwards and medially. Blood soon appears in the left paracolic gutter. The most likely source of bleeding is the:
Marginal artery
Left testicular artery
Spleen
Left renal vein
None of the above
The spleen is commonly torn by traction injuries in colonic surgery. The other structures are associated with bleeding during colonic surgery but would not manifest themselves as blood in the paracolic gutter prior to incision of the paracolonic peritoneal edge.
Marginal artery of Drummond
The marginal artery of Drummond, also known as the marginal artery of the colon, is a continuous arterial circle or arcade along the inner border of the colon formed by the anastomoses of the terminal branches of the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA).
Which of the following is not a risk factor for developing tuberculosis?
Gastrectomy
Solid organ transplantation with immunosupression
Intravenous drug use
Haematological malignancy
Amiodarone
Amiodarone
Risk factors for developing active tuberculosis include:
silicosis
chronic renal failure
HIV positive
solid organ transplantation with immunosuppression
intravenous drug use
haematological malignancy
anti-TNF treatment
previous gastrectomy
A man is undergoing excision of a sub mandibular gland. As the gland is mobilised, a vessel is injured lying between the gland and the mandible. Which of the following is this vessel most likely to be?
Lingual artery
Occipital artery
Superior thyroid artery
Facial artery
External jugular vein
The facial artery lies between the gland and mandible and is often ligated during excision of the gland. The lingual artery may be encountered but this is usually later in the operative process as Whartons duct is mobilised.
A 45 year old man is involved in a polytrauma and requires a massive transfusion of packed red cells and fresh frozen plasma. Three hours later he develops marked hypoxia and his CVP is noted to be 10mm Hg. A chest x-rays shows bilateral diffuse pulmonary infiltrates. What is the most likely diagnosis?
Pulmonary embolus
Myocardial stunning
Myocardial infarct
Fluid overload
Transfusion associated lung injury
Transfusion lung injury may occur after infusion of plasma components. Microvascular damage occurs in the lungs leading to diffuse infiltrates on imaging. Mortality is high.
What are the complications of massive transfusion
Hypothermia
Hypocalcaemia
Hyperkalaemia
Delayed type transfusion reactions
TRALI
Coagulopathy
Def: massive haemorrhage
Loss of one blood volume in 24 hours
or
50% of circulating blood in 3hours
or 150ml/minute
Hypothermia in massive transfusion
Blood is refrigerated
Hypothermic blood impairs homeostasis
Shifts Bohr curve to the left
Hypocalcaemia in massive transfusion
Both FFP and platelets contain citrate anticoagulant, this may chelate calcium
Hyperkalaemia in massive transfusion
Plasma of red cells stored for 4-5 weeks contains 5-10 mmol K+
Delayed type transfusion reactions
Due to minor incompatibility issues especially if urgent or non cross matched blood used
TRALI
Acute onset non cardiogenic pulmonary oedema
Leading cause of transfusion related deaths
Greatest risk posed with plasma components
Occurs as a result of leucocyte antibodies in transfused plasma
Aggregation and degranulation of leucocytes in lung tissue accounts for lung injury
Coagulopathy following massive blood transfusion
Anticipate once circulating blood volume transfused
1 blood volume usually drops platelet count to 100 or less
1 blood volume will both dilute and not replace clotting factors
Fibrinogen concentration halves per 0.75 blood volume transfused
Theme: Acute abdominal pain
A.Appendicitis
B.Henoch Schonlein purpura
C.Diabetes mellitus
D.Intussusception
E.Mittelschmerz
F.Pneumonia
G.Sickle cell crisis
H.Spontaneous bacterial peritonitis
I.Rupure of follicular cyst
Please select the most likely cause of abdominal pain for the scenario given. Each option may be used once, more than once or not at all.
109.An 11 month-old girl develops sudden onset abdominal pain. She has a high pitched scream and draws up her legs. Her BP is 90/40 mm/Hg, her pulse 118/min and abdominal examination is normal.
An 8 year-old West Indian boy presents with periumbilical abdominal pain. He has vomited twice and is refusing fluids. His temperature is 38.1oC and blood tests are as follows: Haemoglobin 8 g/dl, WCC 13 x 109/l, with a neutrophilia.
A 15-month-old girl presents with a three day history of periorbital oedema. She is brought to hospital. On examination she has facial oedema and a tender distended abdomen. Her temperature is 39oC and her blood pressure is 90/45 mmHg. There is clinical evidence of poor peripheral perfusion.
Intussusception
Intussusception should be considered in toddlers and infants presenting with screaming attacks. The child often has a history of being unwell for one to three days prior to presentation. The child may pass bloody mucus stool, which is a late sign. Examination of the abdomen is often normal as the sausage mass in the right upper quadrant is difficult to feel.
Sickle cell crisis
Sickle cell anaemia is characterised by severe chronic haemolytic anaemia resulting from poorly formed erythrocytes. Painful crises result from vaso-occlusive episodes, which may occur spontaneously or may be precipitated by infection. Consider this diagnosis in all children of appropriate ethnic background.
Spontaneous bacterial peritonitis
The 15-month-old girl is a patient with nephrotic syndrome. Patients with this condition are at risk of septicaemia and peritonitis from Streptococcus pneumoniae, due to the loss of immunoglobulins and opsonins in the urine.
Theme: Cranial nerves
A.Facial
B.Trigeminal
C.Vagus
D.Hypoglossal
E.Glossopharyngeal
For each of the following functions please select the most likely responsible cranial nerve. Each option may be used once, more than once or not at all.
Supplies the motor fibres of styloglossus.
Provides general sensation to the anterior two thirds of the tongue.
Supplies general sensation to the posterior third of the tongue.
Hypoglossal
The hypoglossal nerve supplies motor innervation to all extrinsic and intrinsic muscles of the tongue. The only possible exception to this is palatoglossus (which is jointly innervated by the vagus and accessory nerves.
Trigeminal
Taste to the anterior two thirds of the tongue is supplied by the facial nerve (chorda tympani), the trigeminal supplies general sensation, this is mediated by the mandibular branch of the trigeminal nerve (via the lingual nerve).
Glossopharyngeal
The glossopharyngeal nerve supplies general and taste sensation to the posterior third of the tongue and contributes to the gag reflex.
A 52 year old female renal patient needs a femoral catheter to allow for haemodialysis. Which of the structures listed below is least likely to be encountered during its insertion?
Great saphenous vein
Deep circumflex iliac artery
Superficial circumflex iliac artery
Femoral vein
Femoral branch of the genitofemoral nerve
Femoral access catheters are typically inserted in the region of the femoral triangle. Therefore the physician may encounter the femoral, vein, nerve, branches of the femoral artery and tributaries of the femoral vein. The deep circumflex iliac artery arises above the inguinal ligament and is therefore less likely to be encountered than the superficial circumflex iliac artery which arises below the inguinal ligament.
A 56 year old lady undergoes a mastectomy as treatment for multifocal ductal carcinoma in situ. Two weeks post operatively she attends the clinic and complains of a diffuse swelling at the surgical site. On examination she has a large, fluctuant area underlying the mastectomy skin flaps. She is otherwise well. What is the most likely cause?
Abscess
Seroma
Haematoma
Disease recurrence
Arteriovenous malformation
Seromas are very common after breast surgery. The exposed raw surfaces created during the elevation of the skin flaps are a common cause. Treatment usually involves percutaneous drainage under aseptic conditions.
Complications of breast surgery:
LTN injuury
This may occur during the axillary dissection and result in winging of the scapula.
Complications of breast surgery:
Intercostobrachial injury
. These nerves traverse the axilla. When they are divided (which they often are) the patient will notice an area of parasthesia in the armpit.
Complications of breast surgery:
Injury to the thoracodorsal trunk
This nerve and vessels supply latissimus dorsi. If they are damaged the functional effects are not too serious, the greatest setback is that a latissimus dorsi flap cannot be used for reconstruction purposes.
Cx of breast surgery:
Infections
Cellulitis of the chest wall and arm may be a major problem if axillary nodal clearance is undertaken. Infections may run a protracted course and require polytherapy for treatment.
Complications of breast surgery:
lymphoedema
Usually complicates axillary node clearance or irradiation. Treatment is with manual lymphatic drainage and compression sleeves.
Complications of breast surgery:
Seroma
This is an accumulation of fluid at the site of surgery. The fluid is usually straw coloured and may re-accumulate despite drainage. Most will resolve with time.
A 43 year old lady presents with jaundice and is diagnosed as having a carcinoma of the head of the pancreas. Although she is deeply jaundiced, her staging investigations are negative for metastatic disease. What is the best method of biliary decompression in this case?
ERCP and placement of metallic stent
ERCP alone
ERCP and placement of plastic stent
Cholecystostomy
Choledochoduodenostomy
Metallic stents are contraindicated in resectable biliary disease
A plastic stent is the best option for biliary decompression in resectable disease. Surgical bypasses have no place in the management of operable malignancy as a bridge to definitive surgery.
Complications of pancreatic stents
Complications include blockage, displacement and those related to the method of insertion.
Features of metallic pancreatic stents
Expensive
Embed in surrounding tissues
Displacement rare
Blockage rare
Contraindicated in resectable malignant disease
Features of plastic pancreatic stents
Cheap
Do not usually embed
Displacement common
Blockage common
May be used as a bridge to resectional surgery
A 53 year old man with a chronically infected right kidney is due to undergo a nephrectomy. Which of the following structures would be encountered first during a posterior approach to the hilum of the right kidney?
Right renal artery
Ureter
Right renal vein
Inferior vena cava
Right testicular vein
The ureter is the most posterior structure at the hilum of the right kidney and would therefore be encountered first during a posterior approach.
Which of the following interventions is most likely to reduce the incidence of intra abdominal adhesions?
Peritoneal lavage with cetrimide following elective right hemicolectomy
Use of a laparoscopic approach over open surgery
Use of talc to coat surgical gloves
Performing a Nobles plication of the small bowel
Using stapled rather than a hand sewn anastamosis
Laparoscopy results in fewer adhesions. When talc was used to coat surgical gloves it was a major cause of adhesion formation and withdrawn for that reason. A Nobles plication is an old fashioned operation which has no place in the prevention of adhesion formation. Use of an anastamotic stapling device will not influence the development of adhesions per se although clearly an anastamotic leak will result in more adhesion formation
A 28 year old man is stabbed outside a nightclub in the upper arm. The median nerve is transected. Which of the following muscles will demonstrate impaired function as a result?
Palmaris brevis
Second and third interossei
Adductor pollicis
Abductor pollicis longus
Abductor pollicis brevis
Palmaris brevis - Ulnar nerve
Palmar interossei- Ulnar nerve
Adductor pollicis - Ulnar nerve
Abductor pollicis longus - Posterior interosseous nerve
Abductor pollicis brevis - Median nerve
The median nerve innervates all the short muscles of the thumb except the adductor and the deep head of the short flexor. Palmaris and the interossei are innervated by the ulnar nerve.
A 25-year-old female with a history of bilateral vitreous haemorrhage is referred with bilateral lesions in the cerebellar region. What is the likely diagnosis?
Neurofibromatosis type I
Neurofibromatosis type II
Tuberous sclerosis
Von Hippel-Lindau syndrome
Sarcoidosis
Retinal and cerebellar haemangiomas are key features of Von Hippel-Lindau syndrome. Retinal haemangiomas are bilateral in 25% of patients and may lead to vitreous haemorrhage
cerebellar haemangiomas
retinal haemangiomas: vitreous haemorrhage
renal cysts (premalignant)
phaeochromocytoma
extra-renal cysts: epididymal, pancreatic, hepatic
endolymphatic sac tumours
VHL
Theme: Leg swelling
A.Milroy’s disease
B.Meige’s disease
C.Lymphoedema tarda
D.Filariasis
E.Tuberculosis
F.Locally advanced bladder carcinoma
G.Malaria
Which is the most likely diagnosis for the scenario given? Each option may be used once, more than once or not at all.
124.The medical team refer a 72 year old lady with a bilateral swollen legs. Deep vein thrombosis has been excluded and there is no response to diuretics. On further questioning, the patient reveals that she was born with the swelling in both of her legs.
A 52 year old woman presents with rapid swelling of the left leg. The swelling is greater in the thigh compared to the calf.
A 34 year old African teacher attends A&E with a swollen leg. She has been in England for 2 weeks. She lives in an area prevalent with mosquitoes and where there is poor sanitation.
Milroy’s disease
Milroy’s disease is present from birth and is due to failure of the lymphatic vessels to develop. Note that Meige’s disease develops AFTER birth.
Locally advanced bladder carcinoma
Always consider a malignancy in an older adult with new lymphoedema in a limb, especially if the swelling is greater proximally than distally. If malignancy is excluded consider the diagnosis of lymphoedema tarda.
Filariasis
Filariasis is caused by the nematode Wuchereria bancrofti, which is mainly spread by mosquito. The oedema can be gross leading to elephantitis. Treatment is with diethylcarbamazine.
Theme: Acid - base disorders
A.pH 7.64 pO2 10.0 kPa pCO2 2.8 kPa HCO3 20
B.pH 7.25 pO2 8.9 pCO2 3.2 HCO3 10
C.pH 7.20 pO2 6.2 pCO2 8.2 HCO3 27
D.pH 7.60 pO2 8.2 pCO2 5.8 HCO3 40
E.pH 7.45 pO2 7.2 pCO2 2.5 HCO3 24
Please match the diagnosis with the arterial blood gas result. Each option may be used once, more than once or not at all.
1.Pulmonary embolus
High output ureterosigmoidostomy
Widespread mesenteric infarction
pH 7.45 pO2 7.2 pCO2 2.5 HCO3 24
A combination of hypoxia and respiratory alkalosis should suggest a pulmonary embolus. The respiratory alkalosis is due to hyperventilation associated with the pulmonary embolism.
pH 7.25 pO2 8.9 pCO2 3.2 HCO3 10
There is acidosis. To compensate the patient will attempt to raise the pH level in the blood by hyperventilating, hence the low CO2 level .
pH 7.25 pO2 8.9 pCO2 3.2 HCO3 10
This is usually associated with acidosis, hyperventillation and reduction in bicarbonate.
Ureterosigmoidostomy
is a surgical procedure where the ureters which carry urine from the kidneys, are diverted into the sigmoid colon. It is done as a treatment for bladder cancer, where the urinary bladder had to be removed.
Can cause a metabolic acidosis
You are the specialist trainee in endocrinology clinic. The medical team have referred a man for a parathyroidectomy who has a corrected calcium of 2.82 (elevated) and a PTH of 11 (elevated). Which of the following is not an indication for parathyroidectomy?
Nephrolithiasis
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
Age < 50 years
Episode of life threatening hypercalcaemia
None of the above
All of the situations listed are indications for parathyroidectomy.
A 52 year old man undergoes a laparotomy for perforated bowel after a colonoscopy. 2 days after surgery the nursing staff report there is pink, serous fluid discharging from the wound. What is the next most appropriate management step?
IV antibiotics for wound infection
No further management
Examine the wound for separation of the rectus fascia
Insert a drain into the wound
CT abdomen
The seepage of pink serosanguineous fluid through a closed abdominal wound is an early sign of abdominal wound dehiscence with possible evisceration. If this occurs, you should remove one or two sutures in the skin and explore the wound manually, using a sterile glove. If there is separation of the rectus fascia, the patient should be taken to the operating room for primary closure.
Which of the following is not true of gastric cancer?
There is an association with blood group A
Adenocarcinoma is the most common subtype
Individuals with histological evidence of signet ring cells have a lower incidence of lymph node metastasis
Lymphomas account for 5% cases
In Western Countries a more proximal disease distribution has been noted
Signet ring cells are features of poorly differentiated gastric cancer associated with a increased risk of metastatic disease.
A 22 year old man sustains a blow to the side of his head with a baseball bat during a fight. He is initially conscious. However, he subsequently loses consciousness and then dies. Post mortem examination shows an extradural haematoma. The most likely culprit vessel is a branch of which of the following?
Middle cerebral artery
Internal carotid artery
Anterior cerebral artery
Maxillary artery
Mandibular artery
The middle meningeal artery is the most likely source of the extradural haematoma in this setting. It is a branch of the maxillary artery. The middle cerebral artery does not give rise to the middle meningeal artery. Note that the question is asking for the vessel which gives rise to the middle meningeal artery (“the likely culprit vessel is a branch of which of the following”)
What is the most common presentation of a parotid gland tumour?
Parapharyngeal mass
Mass at anterior border of masseter
Mass inferior to the angle of the mandible
Mass behind the angle of the mandible
Mass anterior to the ear
Parotid tumours may present at any region in the gland. However, most lesions will be located behind the angle of the mandible, inferior to the ear lobe. Tumours of the deep lobe of the parotid may present as a parapharyngeal mass and large lesions may displace the tonsil.
A surgical trainee is incising a groin “abscess” in an intravenous drug abuser. Unfortunately the “abscess” is a false aneurysm and torrential bleeding ensues. In the panic of the situation the doctor then stabs himself in the finger. It transpires that the patient is a Hepatitis B carrier and the doctor is not immunised! What type of virus is Hepatitis B?
Double stranded DNA virus
Single stranded DNA virus
Double stranded RNA virus
Single stranded RNA virus
Retrovirus
Double stranded DNA virus
Features of immunisation against HBV
Contains HBsAg absorbed onto aluminium hydroxide adjuvant and is prepared from yeast cells using recombinant DNA technology
Most schedules give 3 doses of the vaccine with a recommendation for a one-off booster 5 years following the initial primary vaccination
At risk groups who should be vaccinated include: healthcare workers, intravenous drug users, sex workers, close family contacts of an individual with hepatitis B, individuals receiving blood transfusions regularly, chronic kidney disease patients who may soon require renal replacement therapy, prisoners, chronic liver disease patients
Around 10-15% of adults fail to respond or respond poorly to 3 doses of the vaccine. Risk factors include age over 40 years, obesity, smoking, alcohol excess and immunosuppression
Testing for anti-HBs is only recommended for those at risk of occupational exposure (i.e. Healthcare workers) and patients with chronic kidney disease. In these patients anti-HBs levels should be checked 1-4 months after primary immunisation
Anti HBS >100
Indicates adequate response, no further testing required. Should still receive booster at 5 years
Anti-HBs level (mIU/ml)
10 - 100
Suboptimal response - one additional vaccine dose should be given. If immunocompetent no further testing is required
Anti-HBs level (mIU/ml)
< 10
Non-responder. Test for current or past infection. Give further vaccine course (i.e. 3 doses again) with testing following. If still fails to respond then HBIG would be required for protection if exposed to the virus
Cx of HBV
Chronic hepatitis (5-10%)
Fulminant liver failure (1%)
Hepatocellular carcinoma
Glomerulonephritis
Polyarteritis nodosa
Cryoglobulinaemia
Treatment of HBV
Pegylated interferon-alpha used to be the only treatment available. It reduces viral replication in up to 30% of chronic carriers. A better response is predicted by being female, < 50 years old, low HBV DNA levels, non-Asian, HIV negative, high degree of inflammation on liver biopsy
However, due to the side-effects of pegylated interferon it is now used less commonly in clinical practice. Oral antiviral medication is increasingly used with an aim to suppress viral replication (not in dissimilar way to treating HIV patients)
Examples include lamivudine, tenofovir and entecavir
A 72 year old man with carcinoma of the lung is undergoing a left pneumonectomy. The left main bronchus is divided. Which of the following thoracic vertebrae lies posterior to this structure?
T3
T7
T6
T10
T1
The left main bronchus lies at T6. Topographical anatomy of the thorax is important as it helps surgeons to predict the likely structures to be injured in trauma scenarios (so popular with examiners)
Which of the following regions of the male urethra is entirely surrounded by Bucks fascia?
Preprostatic part
Prostatic part
Membranous part
Spongiose part
None of the above
Bucks fascia is a layer of deep fascia that covers the penis it is continuous with the external spermatic fascia and the penile suspensory ligament. The membranous part of the urethra may partially pass through Bucks fascia as it passes into the penis. However, the spongiose part of the urethra is contained wholly within Bucks fascia.
Theme: Electrosurgery
A.Cutting current
B.Coagulation current
C.Blended current
D.Fulguration
E.Desiccation
For each of the following electrosurgical applications please select the most likely modality used. Each option may be used once, more than once or not at all.
13.In this modality the active electrode is placed in direct contact with the tissue and is characterised by low current and high voltage over a broad area.
An electrosurgical mode whereby the electrode is held away from the tissue. The current utilises a low amplitude and high voltage.
A modality in which a sinusoidal, non modulated waveform is produced and vaporises the tissues.
Desiccation
In desiccation the device is placed in direct contact with the tissues (unlike fulguration). Because it is applied over a broad area it tends not to cause protein damage (unlike coagulation).
Fulguration
Fulguration typically avoids contact between the electrode and the tissue with the current configured to favor arc formation.
Cutting current
The high energy levels result in tissue vaporisation and cleavage of tissues.
Which of the following statements relating to the knee joint is false?
It is the largest synovial joint in the body
When the knee is fully extended all ligaments of the knee joint are taut
Rupture of the anterior cruciate ligament may result in haemarthrosis
The posterior aspect of the patella is extrasynovial
The joint is innervated by the femoral, sciatic and obturator nerves
The posterior aspect is intrasynovial and the knee itself comprises the largest synovial joint in the body. It may swell considerably following trauma such as ACL injury. Which may be extremely painful owing to rich innervation from femoral, sciatic and ( a smaller) contribution from the obturator nerve. During full extension all ligaments are taut and the knee is locked.
Which of the following statements relating to consenting patients for surgery is false?
Consent should be taken by a person who has sufficient knowledge of the procedure
All risks with a frequency of 1 in 500 or greater must be disclosed
Patients who have received sedating pre medication may no longer be able to provide informed consent
Written consent is required for operative procedures performed under local anaesthesia
Where a procedure (or part thereof) consists of research this should be recorded on a separate research consent form
Generally risks with an incidence of 1% or greater are disclosed. Exceptions to this are where a rarer complication is particularly serious.
A 52 year old male is referred to urology clinic with impotence. He is known to have hypertension. He does not have any morning erections. On further questioning the patient reports pain in his buttocks, this worsens on mobilising. On examination there is some muscle atrophy. The penis and scrotum are normal. What is the most likely diagnosis?
Leriche syndrome
S3-S4 cord lesion
Pudendal nerve lesion
Psychological impotence
Beta blocker induced impotence
Leriche syndrome, is atherosclerotic occlusive disease involving the abdominal aorta and/or both of the iliac arteries. Management involves correcting underlying risk factors such as hypercholesterolaemia and stopping smoking. Investigation is usually with angiography.
Triad in Leriche syndrome
- Claudication of the buttocks and thighs
- Atrophy of the musculature of the legs
- Impotence (due to paralysis of the L1 nerve)
In the distal third of the upper arm, where is the musculocutaneous nerve located?
Between the biceps brachii and brachialis muscles
Between the brachialis and brachioradialis muscles
Between the brachioradialis and triceps muscles
Between the brachialis and triceps muscles
Between the humerus and brachialis muscles
The musculocutaneous nerve lies between the biceps and brachialis muscles.
Location of axillary artery branches
1
2
3
1st part: 1 branch
Highest throacic
2nd part: 2 branches
Thoraco-acromial
Lateral thoracic
3rd part: 3 branches
Subscapular
Posterior humeral circumflex
Anterior humeral circumflex
A 38 year old man is recovering following a live donor related renal transplant. The surgeon prescribes corticosteroids to reduce the risk of graft rejection. Which of the following will not occur as a result of their administration?
Suppression of macrophage activation
Reduction of expression of major histocompatability complex antigens on the graft
Reduction in the proliferation of lymphocytes
Necrosis of activated lymphocytes
Reduction of expression of endothelial cell adhesion molecules
Corticosteroids at higher doses are able to induce apoptosis of activated lymphocytes. Necrosis is a different process and not induced by steroids.
A 23 year old man presents with diarrhoea and passage of mucous. He is suspected of having ulcerative colitis. Which of the following is least likely to be associated with this condition?
Superficial mucosal inflammation in the colon
Significant risk of dysplasia in long standing disease
Epsiodes of large bowel obstruction during acute attacks
Haemorrhage
Disease sparing the anal canal
Large bowel obstruction is not a feature of UC, patients may develop megacolon. However, this is a different entity both diagnostically and clinically. Ulcerative colitis does not affect the anal canal and the anal transitional zone. Inflammation is superficial. Dysplasia can occur in 2% overall, but increases significantly if disease has been present over 20 years duration. Granulomas are features of crohn’s disease.
Other features:
Disease maximal in the rectum and may spread proximally
Contact bleeding
Longstanding UC crypt atrophy and metaplasia/dysplasia
A 48 year old lady is undergoing a left sided adrenalectomy for an adrenal adenoma. The superior adrenal artery is injured and starts to bleed, from which of the following does this vessel arise?
Left renal artery
Inferior phrenic artery
Aorta
Splenic
None of the above
The superior adrenal artery is a branch of the inferior phrenic artery.
A 23 year old lady undergoes a total thyroidectomy as treatment for a papillary carcinoma of the thyroid. The pathologist examines histological sections of the thyroid gland and identifies a psammoma body. What are these primarily composed of?
Clusters of calcification
Aggregations of neutrophils
Aggregations of macrophages
Giant cells surrounding the tumour
Clusters of oxalate crystals
Psammoma bodies consist of clusters of microcalcification. They are most commonly seen in papillary carcinomas.
Which of the following is not a feature found on a CXR in traumatic aortic disruption?
Widened mediastinum
Trachea deviated to the left
Depression of the left main stem bronchus
Obliteration of the aortic knob
Widened paraspinal interfaces
The trachea is normally deviated to the right.
CXR changes in thoracic aortic disruption
Widened mediastinum
Trachea/Oesophagus to right
Depression of left main stem bronchus
Widened paratracheal stripe/paraspinal interfaces
Space between aorta and pulmonary artery obliterated
Rib fracture/left haemothorax
A 52 year old woman attends clinic for investigation of abdominal pain and constipation. On examination you note blue lines on the gum margin. She mentions that her legs have become weak in the past few days. What is the most likely diagnosis?
Acute intermittent porphyria
Lead poisoning
Constipation
Guillan Barre syndrome
Rectal carcinoma
This would be an impressive diagnosis to make in the surgical out patient department! The combination of abdominal pain and a motor periperal neuropathy, should indicate this diagnosis. The blue line along the gum margin can occur in up to 20% patients with lead poisoning.
Combination of abdominal pain and neruological signs
Lead poisoning
AIP
Features
abdominal pain
peripheral neuropathy (mainly motor)
fatigue
constipation
blue lines on gum margin (only 20% of adult patients, very rare in children)
?Pb poisoning
Ix in Pb poisoning
Blood lead level is usually diagnositc
Microcytic anaemia: basophilic stippling and clover-leaf morphology
Raised serum and urine levles of delta aminolaevulinic acid may be seen making it difficult to differentiate from AIP
Mx of Pb poisoning
Management - various chelating agents are currently used:
Dimercaptosuccinic acid (DMSA)
D-penicillamine
EDTA
Dimercaprol
Which of the following does not exit the pelvis through the greater sciatic foramen?
Superior gluteal artery
Internal pudendal vessels
Sciatic nerve
Obturator nerve
Inferior gluteal nerve
The obturator nerve exits through the obturator foramen.
Theme: Vasculitis
A.Wegeners granulomatosis
B.Polyarteritis nodosa
C.Giant cell arteritis
D.Takayasu’s arteritis
E.Buergers disease
For each of the scenarios provided please select the most likely underlying diagnosis from the list below. Each option may be used once, more than once or not at all.
9.A 20 year old lady is referred to the vascular clinic. She has been feeling generally unwell for the past six weeks. She works as a typist and has noticed increasing pain in her forearms whilst working. On examination she has absent upper limb pulses. Her ESR is measured and mildly elevated.
A 32 year old man presents to the vascular clinic with symptoms of foot pain during exertion. He is a heavy smoker and has recently tried to stop smoking. On examination he has normal pulses to the level of the popliteal. However, foot pulses are absent. A diagnostic angiogram is performed which shows an abrupt cut off at the level of the anterior tibial artery, together with the formation of corkscrew shaped collateral vessels distally.
A 78 year old man presents with symptoms of headaches and deteriorating vision. He notices that there is marked pain on the right hand side of his face when he combs his hair.
Takayasu’s arteritis
Takayasus arteritis may be divided into acute systemic phases and the chronic pulseless phase. In the latter part of the disease process the patient may complain of symptoms such as upper limb claudication. In the later stages of the condition the vessels will typically show changes of intimal proliferation, together with band fibrosis of the intima and media.
Buergers disease
Buergers disease is most common in young male smokers. This demographic is changing in those areas where young female smokers are more common. In the acute lesion the internal elastic lamina of the vessels is usually intact. As the disease progresses the changes progress to hypercellular occlusive thrombus. Tortuous corkscrew collaterals may reconstitute patent segments of the distal tibial or pedal vessels.
Giant cell arteritis
Temporal arteritis may present acutely with symptoms of headache and visual loss, or with a less acute clinical picture. Sight may be threatened and treatment with immunosupressants should be started promptly. The often requested temporal artery biopsy (which can be the bane of many surgeons) is often non diagnostic and unhelpful.
Theme: Abdominal pain
A.Appendicitis
B.Threatened miscarriage
C.Ruptured ectopic pregnancy
D.Irritable bowel syndrome
E.Mittelschmerz
F.Pelvic inflammatory disease
G.Adnexial torsion
H.Endometriosis
I.Degenerating fibroid
Please select the most likely cause of abdominal pain for the clinical scenario given. Each option may be used once, more than once or not at all.
12.An 18 year-old girl presents to the Emergency Department with sudden onset sharp, tearing pelvic pain associated with a small amount of vaginal bleeding. She also complains of shoulder tip pain. On examination she is hypotensive, tachycardic and has marked cervical excitation.
A 25 year-old lady presents to her GP complaining of a two day history of right upper quadrant pain, fever and a white vaginal discharge. She has seen the GP twice in 12 weeks complaining of pelvic pain and dyspareunia.
A 16 year old female presents to the emergency department with a 12 hour history of pelvic discomfort. She is otherwise well and her last normal menstrual period was 2 weeks ago. On examination she has a soft abdomen with some mild supra pubic discomfort.
Ruptured ectopic pregnancy
The history of tearing pain and haemodynamic compromise in a women of child bearing years should prompt a diagnosis of ectopic pregnancy.
Pelvic inflammatory disease
The most likely diagnosis is pelvic inflammatory disease. Right upper quadrant pain occurs as part of the Fitz Hugh Curtis syndrome in which peri hepatic inflammation occurs.
Mittelschmerz
Mid cycle pain is very common and is due to the small amount of fluid released during ovulation. Inflammatory markers are usually normal and the pain typically subsides over the next 24-48 hours.
25% asymptomatic, in a further 25% associated with other pelvic organ pathology.
Remaining 50% may have menstrual irregularity, infertility, pain and deep dyspareurina.
Complex disease may result in pelvic adhesional formation with episodes of intermittent small bowel obstruction.
Intra-abdominal bleeding may produce localised peritoneal inflammation.
Recurrent episodes are common.
Endometriosis
Ix in endometrosis
US may show free fluid
Laparoscopy will usually show lesions
Mx of endometriosis
Usually managed medically, complex disease will often require surgery and some patients will even require formal colonic and rectal resections if these areas are involved
Passage of the inferior epigastric artery
The inferior epigastric artery arises from the external iliac artery immediately above the inguinal ligament. It then passes along the medial margin of the deep inguinal ring. From here it continues superiorly to lie behind the rectus abdominis muscle.
Theme: Ankle injuries
A.Surgical fixation
B.Below knee amputation
C.Application of below knee plaster
D.Application of ankle boot
E.Application of external fixation device
F.Application of compression dressing and physiotherapy
G.Immediate reduction and application of backslab
Please select the most appropriate management for the injury type described. Each option may be used once, more than once or not at all.
39.A 45 year old man has been admitted after being knocked off his bicycle. His ankle is grossly deformed with bilateral malleolar tenderness with severe ankle swelling and tenting of the medial soft tissues.
A 40 year old marine injures his ankle on an assault course. On examination he has a severely swollen ankle, as well as tenderness over the medial malleolus and proximal fibula. X-rays demonstrate a medial malleolar fracture, spiral fracture of the proximal fibula and widening of the syndesmosis.
A 60 year old female injures her ankle after a falling from a horse. On examination she has severe swelling and bruising of the ankle with x-rays demonstrating a comminuted intra-articular distal tibia fracture. The ankle has been temporarily reduced and splinted in the emergency department.
Immediate reduction and application of backslab
This is an unstable ankle injury that is likely to require surgical fixation. The immediate management of a displaced ankle fracture is to reduce the fracture to prevent soft tissues compromise and help reduce swelling. This can be performed before an x-ray is obtained if performing the x-ray will significantly delay reduction.
Surgical fixation
This is a Maisonneuve fracture of the proximal fibula. It indicates an unstable ankle injury with likely injury to the interosseous membrane. In the setting of radiographic evidence of syndesmotic widening, this requires surgical fixation to reduce and stabilise the syndesmosis.
Application of external fixation device
This is a pilon fracture, which a high energy injury of the distal tibia. The patient will ultimately require surgical fixation but early management involves applying a spanning external fixator to temporarily reduce the fracture and allow soft tissue swelling to settle. A CT scan should then be performed to aid surgical planning.
Osseous anatomy of the ankle
The ankle (or mortise) joint consists of the distal tibia (tibial plafond and posterior malleolus), the distal fibula (lateral malleolus), and the talus. The main movement at the ankle joint is plantar and dorsiflexion.
Passage of the anterior tibial artery
Begins opposite the distal border of popliteus
Terminates in front of the ankle, continuing as the dorsalis pedis artery
As it descends it lies on the interosseous membrane, distal part of the tibia and front of the ankle joint
Passes between the tendons of extensor digitorum and extensor hallucis longus distally
It is related to the deep peroneal nerve, it lies anterior to the middle third of the vessel and lateral to it in the lower third
A 34 year old man presents with varicose veins and it is suspected that these are part of the Klippel-Trenaunay syndrome. Which of the following is not a characteristic of this condition?
Presence of varicose veins
Gigantism of a limb
Long saphenous vein involvement
Port wine stains with clear borders
Arteriovenous fistulae
Long saphenous vein involvement
The Klippel-Trenaunay vein is a large, lateral, superficial vein sometimes seen at birth. This vein begins in the foot or the lower leg and travels proximally until it enters the thigh or the gluteal area. Otherwise, varicosities may not be clinically evident until the child begins to ambulate.
Varicosities may be extensive, though they often spare the saphenous distribution. They are seen below the knee, laterally above the knee, and occasionally in the pelvic region. Varicosities may affect the superficial, deep, and perforating venous systems.
Surgical exploration has demonstrated atresia and agenesis of deep veins, compression due to fibrous bands, aberrant arteries, abnormal muscles, or venous sheaths.
Rarely, varicosities have been found in the bladder, the colon, and the pulmonary vessels
Features of above knee amputations
Quick to perform
Heal reliably
Patients regain their general health quickly
For this benefit, a functional price has to be paid and many patients over the age of 70 will never walk on an above knee prosthesis.
Above knee amputations use equal anterior-posterior flaps
Features of below knee amputation
Technically more challenging to perform
Heal less reliably than their above knee counterparts.
However, many more patients are able to walk using a below knee prosthesis.
In below knee amputations the two main flaps are Skew flaps or the Burgess long posterior flap. Skew flaps result in a less bulky limb that is easier to attach a prosthesis to.
It is worth remembering that whilst it may be technically feasible to offer a below knee amputation there may be circumstances where an above knee option is preferable. For example, in fixed flexion deformities of the lower limb, little functional benefit would be gained from below knee amputation surgery.
Burgess flap
Long posterior flap
Skew flap
Lateral flaps
Which of the following statements relating to sartorius is untrue?
It is supplied by the femoral nerve
It forms the lateral boundary of the femoral triangle
The middle third forms the roof of the adductor canal
It is a flexor of the hip and knee
It inserts into the medial femoral condyle
It inserts into the medial aspect of the upper part of the tibia.
Where does the deep branch of the ulnar nerve arise?
From the nerve on the flexor retinaculum, lateral to pisiform bone
Which of the following structures are not closely related to the adductor longus muscle?
Long saphenous vein
Tendon of iliacus
The profunda branch of the femoral artery
Pectineus muscle
Femoral nerve
Adductor longus forms the medial border of the femoral triangle. It is closely related to the long saphenous vein which overlies it and the profunda branch of the femoral artery. The femoral nerve is related to it inferiorly. However, the tendon of iliacus inserts proximally and is not in contact with adductor longus.
During embryological development, which of the following represent the correct origin of the pancreas?
Ventral and dorsal endodermal outgrowths of the duodenum
Ventral and dorsal outgrowths of mesenchymal tissue from the posterior abdominal wall
Ventral and dorsal outgrowths of the vitellointestinal duct
Ventral and dorsal biliary tract diverticulae
Buds from the inferior aspect of the caudate lobe
The pancreas develops from a ventral and dorsal endodermal outgrowth of the duodenum. The ventral arises close to, or in common with the hepatic diverticulum, and the larger, dorsal outgrowth arises slightly cranial to the ventral extending into the mesoduodenum and mesogastrium. When the buds eventually fuse the duct of the ventral rudiment becomes the main pancreatic duct.
A 63 year old man is due to undergo a splenectomy. Which splenic structure lies most posteriorly?
Gastrosplenic ligament
Splenic vein
Splenic artery
Splenic notch
Lienorenal ligament
The lienorenal ligament lies most posteriorly. The antero-lateral connection is via the phrenicocolic ligament. Anteriorly the gastro splenic ligament. These structures condense around the vessels at the splenic hilum.
