Block 9 Flashcards

Question

Which of the following is not contained within the middle mediastinum? Main bronchi Arch of the azygos vein Thoracic duct Pericardium Aortic root

Answer 1

The thoracic duct lies within the posterior and superior mediastinum.

Answer 2

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.

Answer 3

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

Answer 4

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

Answer 5

Reflux into the ureter only, no dilatation

Answer 6

Reflux into the renal pelvis on micturition, no dilatation

Answer 7

Mild/moderate dilatation of the ureter, renal pelvis and calyces

Answer 8

Dilation of the renal pelvis and calyces with moderate ureteral tortuosity

Answer 9

Gross dilatation of the ureter, pelvis and calyces with ureteral tortuosity

Answer 10

VUR is normally diagnosed following a micturating cystourethrogram a DMSA scan may also be performed to look for renal scarring

Answer 11

Overt compensated hypovolaemia Covert compensated hypovolaemaia Decompensated hypovolaemia

Answer 12

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.

Answer 13

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.

Answer 14

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.

Answer 15

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.

Answer 16

TRH stimulates prolactin release. Dopamine suppresses the release of prolactin.

Answer 17

Lupus vulgaris is not associated with the Koebner phenomenon.

Answer 18

Psoriasis Vitiligo Warts Lichen planus Lichen sclerosus Molluscum contagiosum

Answer 19

Aspirin usage

Answer 20

A: Age B: Blood pressure drop (Shock) C: Co-morbidity D: Diagnosis E: Evidence of bleeding

Answer 21

\<3= good prognosis \>8= high mortality

Answer 22

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.

Answer 23

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

Answer 24

Renal artery stenosis

Answer 25

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.

Answer 26

Vitamin B1

Answer 27

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.

Answer 28

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.

Answer 29

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.

Answer 30

The Kocher criteria do not consider blood culture results.

Answer 31

1. Non weight bearing on affected side 2. ESR \> 40 mm/hr 3. Fever 4. WBC count of \>12,000 mm3 - When 4/4 criteria are met, there is a 99% chance that the child has septic arthritis

Answer 32

Staph aureus

Answer 33

Inracerebral haematoma Areas of clot and fresh blood co-existing on same CT scan

Answer 34

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).

Answer 35

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.

Answer 36

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.

Answer 37

Piriformis Obturator internus Superior gemellus Inferior gemellus Quadrator femoris

Answer 38

Ventral rami S1, S2

Answer 39

Nerve to obturator internus

Answer 40

Nerve to obturator internus

Answer 41

Nerve to quadratus femoris

Answer 42

Nerve to quadratus femoris

Answer 43

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.

Answer 44

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.

Answer 45

Bleeding 0.9% (rises to 1.5% if sphincterotomy performed) Duodenal perforation 0.4% Cholangitis 1.1% Pancreatitis 1.5%

Answer 46

Middle cardiac vein

Answer 47

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.

Answer 48

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.

Answer 49

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.

Answer 50

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.

Answer 51

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.

Answer 52

Aortic stenosis Pulmonary stenosis, HOCM ASD, Fallot's

Answer 53

Mitral regurgitation Tricuspid regurgitation VSD

Answer 54

Mitral valve prolapse Coarctation of aorta

Answer 55

Aortic regurgitation Graham-Steel murmur (pulmonary regurgitation)

Answer 56

Mitral stenosis Austin-Flint murmur (severe aortic regurgitation)

Answer 57

Cohort studies - relative risk

Answer 58

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.

Answer 59

Trochlear nerve

Answer 60

Abducens nerve

Answer 61

\>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

Answer 62

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.

Answer 63

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.

Answer 64

The extensor hallucis longus tendon lies medial to the dorsalis pedis artery.

Answer 65

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.

Answer 66

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.

Answer 67

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.

Answer 68

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.

Answer 69

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.

Answer 70

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.

Answer 71

Consider thromboembolism in breast cancer patients on tamoxifen!

Answer 72

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.

Answer 73

Innervates: all intrinsic larynx muscles (excluding cricothyroid) The external branch of the superior laryngeal nerve innervates the cricothyroid muscle

Answer 74

age emphysema - this is due to loss alveolar walls and associated elastic tissue

Answer 75

pulmonary oedema pulmonary fibrosis pneumonectomy kyphosis

Answer 76

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

Answer 77

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.

Answer 78

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.

Answer 79

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.

Answer 80

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.

Answer 81

The subclavian artery passes anterior to the middle scalene.

Answer 82

The IVC passes through the diaphragm at T8.

Answer 83

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.

Answer 84

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.

Answer 85

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.

Answer 86

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.

Answer 87

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.

Answer 88

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.

Answer 89

TSH is typically elevated

Answer 90

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.

Answer 91

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).

Answer 92

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

Answer 93

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.

Answer 94

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.

Answer 95

Hypothermia Hypocalcaemia Hyperkalaemia Delayed type transfusion reactions TRALI Coagulopathy

Answer 96

Loss of one blood volume in 24 hours or 50% of circulating blood in 3hours or 150ml/minute

Answer 97

Blood is refrigerated Hypothermic blood impairs homeostasis Shifts Bohr curve to the left

Answer 98

Both FFP and platelets contain citrate anticoagulant, this may chelate calcium

Answer 99

Plasma of red cells stored for 4-5 weeks contains 5-10 mmol K+

Answer 100

Due to minor incompatibility issues especially if urgent or non cross matched blood used

Answer 101

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

Answer 102

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

Answer 103

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.

Answer 104

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.

Answer 105

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.

Answer 106

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.

Answer 107

This may occur during the axillary dissection and result in winging of the scapula.

Answer 108

. These nerves traverse the axilla. When they are divided (which they often are) the patient will notice an area of parasthesia in the armpit.

Answer 109

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.

Answer 110

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.

Answer 111

Usually complicates axillary node clearance or irradiation. Treatment is with manual lymphatic drainage and compression sleeves.

Answer 112

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.

Answer 113

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.

Answer 114

Complications include blockage, displacement and those related to the method of insertion.

Answer 115

Expensive Embed in surrounding tissues Displacement rare Blockage rare Contraindicated in resectable malignant disease

Answer 116

Cheap Do not usually embed Displacement common Blockage common May be used as a bridge to resectional surgery

Answer 117

The ureter is the most posterior structure at the hilum of the right kidney and would therefore be encountered first during a posterior approach.

Answer 118

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

Answer 119

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.

Answer 120

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

Answer 121

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.

Answer 122

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.

Answer 123

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

Answer 124

All of the situations listed are indications for parathyroidectomy.

Answer 125

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.

Answer 126

Signet ring cells are features of poorly differentiated gastric cancer associated with a increased risk of metastatic disease.

Answer 127

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")

Answer 128

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.

Answer 129

Double stranded DNA virus

Answer 130

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

Answer 131

Indicates adequate response, no further testing required. Should still receive booster at 5 years

Answer 132

Suboptimal response - one additional vaccine dose should be given. If immunocompetent no further testing is required

Answer 133

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

Answer 134

Chronic hepatitis (5-10%) Fulminant liver failure (1%) Hepatocellular carcinoma Glomerulonephritis Polyarteritis nodosa Cryoglobulinaemia

Answer 135

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

Answer 136

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)

Answer 137

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.

Answer 138

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.

Answer 139

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.

Answer 140

Generally risks with an incidence of 1% or greater are disclosed. Exceptions to this are where a rarer complication is particularly serious.

Answer 141

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.

Answer 142

1. Claudication of the buttocks and thighs 2. Atrophy of the musculature of the legs 3. Impotence (due to paralysis of the L1 nerve)

Answer 143

The musculocutaneous nerve lies between the biceps and brachialis muscles.

Answer 144

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

Answer 145

Corticosteroids at higher doses are able to induce apoptosis of activated lymphocytes. Necrosis is a different process and not induced by steroids.

Answer 146

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

Answer 147

The superior adrenal artery is a branch of the inferior phrenic artery.

Answer 148

Psammoma bodies consist of clusters of microcalcification. They are most commonly seen in papillary carcinomas.

Answer 149

The trachea is normally deviated to the right.

Answer 150

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

Answer 151

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.

Answer 152

Lead poisoning AIP

Answer 153

?Pb poisoning

Answer 154

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

Answer 155

Management - various chelating agents are currently used: Dimercaptosuccinic acid (DMSA) D-penicillamine EDTA Dimercaprol

Answer 156

The obturator nerve exits through the obturator foramen.

Answer 157

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.

Answer 158

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.

Answer 159

Endometriosis

Answer 160

US may show free fluid Laparoscopy will usually show lesions

Answer 161

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

Answer 162

Ovarian torsion

Answer 163

Ectopic gestation

Answer 164

Pelvic inflammatory disease

Answer 165

Ultrasound may show free fluid Laparoscopy is usually both diagnostic and therapeutic

Answer 166

Laparoscopy

Answer 167

Ultrasound showing no intra uterine pregnancy and beta HCG that is elevated May show intra abdominal free fluid

Answer 168

Laparoscopy or laparotomy is haemodynamically unstable. A salphingectomy is usually performed.

Answer 169

Full blood count- Leucocytosis Pregnancy test negative (Although infection and pregnancy may co-exist) Amylase - usually normal or slightly raised High vaginal and urethral swabs

Answer 170

Adductor canal compression syndrome most commonly presents in young males and is an important differential diagnosis in men presenting with symptoms of acute limb ischaemia on exertion. It is caused by compression of the femoral artery by the musculotendinous band from adductor magnus muscle. The treatment consists of the division of the abnormal band and restoration of the arterial circulation. Popliteal fossa entrapment is the main differential diagnosis, however the pulse disappears when the knee is fully extended.

Answer 171

Grade A - based on evidence from at least one randomised controlled trial (i.e. Ia or Ib)

Answer 172

Grade B - based on evidence from non-randomised controlled trials (i.e. IIa, IIb or III)

Answer 173

Grade C - based on evidence from a panel of experts (i.e. IV)

Answer 174

Prednisolone and it's metabolites can chemically mimic cortisol in radio-immunoassay techniques of laboratory analysis. Dexamethasone can be given as glucorticoid replacement during testing for addisons or adrenal insufficiency as it does not interfere with cortisol levels. For example, if you have a patient with polymyalgia rheumatica and they are on long term prednisolone, you can replace the prednisolone with dexamethasone to undertake a short synacthen test.

Answer 175

Drug treatment is with albendazole or mebendazole. Praziquantzel may be used in the pre operative stages.

Answer 176

The foramen spinosum is not at the base of the medial pterygoid plate. It is at the sphenoid bone

Answer 177

Neutrophils are the main cells of acute inflammation, important action against gram -ve and +ve bacteria Appearance of segmented nucleus and granulated cytoplasm Have a lifespan of 1-3 days (shorter when consumed during septic process, though 9 hours is unusual) Actions include: movement, opsonise microorganisms, phagocytosis & intracellular killing of microorganisms via aerobic (produce HYDROGEN PEROXIDE) & anaerobic mechanisms. Neutrophil disorders include chronic granulomatous diseases: rare AIDS associated with T cell deficiency

Answer 178

Patients with malabsorption may develop magnesium deficiency, although her TPN feeds may have contained magnesium it may not have been sufficient to correct her losses. Sodium, phosphate and potassium would not have this effect on serum calcium.

Answer 179

Magnesium is required for both PTH secretion and its action on target tissues. Hypomagnesaemia may both cause hypocalcaemia and render patients unresponsive to treatment with calcium and vitamin D supplementation. Magnesium is the fourth most abundant cation in the body. The body contains 1000mmol, with half contained in bone and the remainder in muscle, soft tissues and extracellular fluid. There is no one specific hormonal control of magnesium and various hormones including PTH and aldosterone affect the renal handling of magnesium. Magnesium and calcium interact at a cellular level also and as a result decreased magnesium will tend to affect the permeability of cellular membranes to calcium, resulting in hyperexcitability.

Answer 180

When it does occur is most common at 15 days When it does occur a burst abdomen is most common at 6 days and is usually the result of technical error when Jenkins rule is not followed and sutures are placed in the zone of collagenolysis. The choice of materials given above does not influence dehisence rates.

Answer 181

Being a non smoker is not included in the criteria, however poor respiratory function due to smoking may affect fitness for surgery.

Answer 182

Basal skull fracture Bruising over the mastoid process of the temporal bone is battle's sign caused by a basal skull fracture. Acute sub dural haematoma Sub dural haematomas are the commonest intracranial mass lesions resulting from trauma. They are classified as acute, sub acute or chronic according to tempo of onset. Acute sub dural haematomas will present within 72 hours of the original injury and have hyperdense, crescent shaped appearances on CT scanning. Diffuse axonal injury The baby is likely to be a victim of shaken baby syndrome. This may result in diffuse axonal injury causing extensive lesions in the white matter.

Answer 183

Angioplasty Short occlusions are generally reasonable candidates for primary attempts at angioplasty. Femoro-distal bypass graft using PTFE with Miller Cuff This man needs a bypass operation. Using PTFE alone will not give a good result as sub intimal hyperplasia will give poor outcome early. Using a vein cuff (Miller cuff) at the end of a PTFE graft will improve the situation. Above knee amputation A femoro-distal bypass graft would carry a high risk of failure and risk of peri-operative myocardial infarct. This lady would be well suited to primary amputation.

Answer 184

Rifampicin, phenytoin, levodopa, methyldopa, and quinine all cause pseudohaematuria

Answer 185

Flow volume loop is the investigation of choice for upper airway compression.

Answer 186

The vessel damaged is the epigastric artery. This originates from the external iliac artery (see below).

Answer 187

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.

Answer 188

The left renal vein runs across the surface of the aorta and may require deliberate ligation during juxtarenal aneurysm repair.

Answer 189

The LFTs clearly show a cholestatic picture. Given the background of HIV the most likely cause is sclerosing cholangitis.

Answer 190

The most common cause of biliary disease in patients with HIV is sclerosing cholangitis due to infections such as CMV, Cryptosporidium and Microsporidia Pancreatitis in the context of HIV infection may be secondary to anti-retroviral treatment (especially didanosine) or by opportunistic infections e.g. CMV

Answer 191

Mnemonic branches off the posterior cord S ubscapular (upper and lower) T horacodorsal A xillary R adial The musculocutaneous nerve is a branch off the lateral cord.

Answer 192

Erythema is a classical feature of acute inflammation. Potent mediators of vascular dilatation include; histamine, prostaglandins, nitric oxide, platelet activating factor, complement C5a (and C3a) and lysosomal compounds. Although serotonin is associated with acute inflammation it is a vasoconstrictor. The effects of serotonin are dependent upon the state of the vessels in the tissues. Intact and healthy tissues and vessels will respond to a serotonin infusion with vasodilation (hence the flushing seen in carcinoid syndrome). In contrast it worsens cardiac ischaemia in myocardial infarcts when released from damaged platelets.

Answer 193

Typically occurs with minimal initial injury Stimulus removed and normal tissue architecture results

Answer 194

Delayed removal of exudate Tissues undergo organisation and usually fibrosis

Answer 195

Typically formation of an abscess or an empyema Sequestration of large quantities of dead neutrophils

Answer 196

Coupled inflammatory and reparative activities Usually occurs when initial infection or suppuration has been inadequately managed

Answer 197

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.

Answer 198

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.

Answer 199

Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus.

Answer 200

Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint.

Answer 201

he syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL).

Answer 202

AP, lateral and mortise views (20 degrees of internal rotation)

Answer 203

Decreased tibiofibular overlap, medial joint clear space and lateral talar shift all indicate a syndesmotic injury. (In subtle cases of shift, imaging the uninjured ankle can be helpful as a proportion of the population have little or no tibiotalar overlap 2.)

Answer 204

Lauge-Hansen and Danis-Weber

Answer 205

Comprises two parts: first part is the foot position, and the second part is the force applied. Useful for understanding the forces involved and therefore predict the ligamentous or bony injury. Results in four injury patterns:

Answer 206

Supination - Adduction (SA) - 10-20% Supination - External rotation (SER) - 40-75% Pronation - Abduction (PA) - 5-20% Pronation - External rotation (PER) - 5-20%

Answer 207

Commonly used. Based on the level of the fibula fracture in relation to the syndesmosis. The more proximal, the greater the risk of syndesmotic injury and therefore fracture instability.

Answer 208

fracture below the level of the syndesmosis

Answer 209

fracture at the level of the syndesmosis / level of the tibial plafond

Answer 210

fracture above the level of the syndesmosis. This includes Maisonneuve fractures (proximal fibula fracture), which can be associated with ankle instability. Beware the high fibula fracture - it may be an ankle fracture!

Answer 211

Weber A - Unimalleolar Weber A Weber fractures by definition are stable and therefore can be mobilised fully weight bearing in an ankle boot.

Answer 212

Fractures tend to include syndesmotic disruption and are usually bimalleolar (either bony or ligamentous). They are therefore unstable and usually require operative fixation. In addition to the fracture fixation, the syndesmosis usually requires reconstruction/augmentation with screws to restore the joint integrity and function.

Answer 213

B fractures vary greatly. They can be part of a trimalleolar injury and therefore extremely unstable, requiring fixation. Alternatively, a uni-malleolar Weber B fracture can be a stable injury, and therefore mobilised immediately in an ankle boot. Defining the stability can be challenging, and often involves stress radiographs, or a trial of mobilisation and repeat radiographs. Defining stability is the subject of much ongoing research. However, treating undisplaced ankle fractures in a below knee plaster, non-weight bearing for six weeks is still widely practised, and a safe approach.

Answer 214

Ankle fractures generally take 6 weeks to unite enough to prevent secondary displacement. This is therefore an appropriate time period to keep a cast on in a conservatively managed patient. Weight bearing post-operatively depends on the quality of the fixation and bone quality, and preference varies between surgeons, ranging from aggressive early mobilisation to a period of non-weight bearing. Return to activities takes approximately three months, and often requires assistance of a physiotherapist to improve range-of-movement and muscle strengthening.

Answer 215

Boundaries of the deep inguinal ring: Superolaterally - transversalis fascia Inferomedially - inferior epigastric artery The deep inguinal ring is closely related to the inferior epigastric artery. The inferior epigastric artery forms part of the structure referred to as Hesselbach's triangle.

Answer 216

Sub mental nodes

Answer 217

Amiodarone Drugs commonly implicated in parotid gland enlargement include: Thiouracil, isoprenaline, phenylbutazone, high oestrogen dose contraceptive pills.

Answer 218

Oesophageal candidiasis is associated with immunosupression; mainly in patients on chemotherapy, with haematological malignancy, HIV or inhaled steroids. In patients with HIV, oesophageal candidiasis is part of the spectrum of AIDS defining illnesses and usually occurs when the CD4 count is less than 200. Others include PCP pneumonia and CMV infections.

Answer 219

At the lower border of the femoral triangle the femoral artery passes under the sartorius muscle. This can be retracted to improve access.

Answer 220

The main purpose of this question is to differentiate the features of an UMN lesion and a LMN lesion. The features of a LMN lesion include: Flaccid paralysis of muscles supplied Atrophy of muscles supplied. Loss of reflexes of muscles supplied. Muscles fasciculation For lesions below L1 LMN signs will occur. Hence in an L3 lesion, there will be loss of the patella reflex but there will be no extensor plantar reflex.

Answer 221

Dopamine Dopamine is known to have a vasodilator effect in the renal circulation, elsewhere it typically exerts a vasoconstrictive effect. This led to the previously popular concept of using renal dose dopamine to improve renal function. This is now known to be ineffective. Milrinone Milrinone works by increasing intracellular cAMP concentration. Noradrenaline In a setting of septic shock with normal or high cardiac output and decreased SVR, a peripherally acting vasoconstrictor such as noradrenaline would be the primary choice.

Answer 222

Transitional cell carcinoma of the renal pelvis TCC of the renal pelvis may seed down the ureter. Squamous cell carcinoma of the renal pelvis SCC of the kidney usually arises in an area of chronic inflammation such as a staghorn calculus. Renal adenocarcinoma Renal adenocarcinoma on the left side may invade the gonadal vein and produce varicocele. They also have paraneoplastic phenomena such as hypercalcaemia.

Answer 223

Ogilvies syndrome Patients with electrolyte disturbance and previous surgery may develop colonic pseudo-obstruction (Ogilvies syndrome). The diagnosis is made using a contrast enema and treatment is usually directed at the underlying cause with colonic decompression if indicated. Diverticular stricture The long history of left iliac fossa pain and development of bowel obstruction suggests a diverticular stricture. These may contain a malignancy and most will require resection. Volvulus Sigmoid volvulus may present with an asymmetrical mass in an elderly patient. It may contain a fluid level, visible on plain films.

Answer 224

This man has developed an acute dystonic reaction. Administration of further anti dopaminergic drugs will worsen the situation. Procyclidine will help to reverse the event. This is most likely to have occurred because the patient is on long term anti psychotics and has then received metoclopramide.

Answer 225

Haemorrhage in the first 6 hours after surgery is termed reactionary haemorrhage. Feeding does not increase the risk and may actually lower the risks of infection developing. Haemorrhage is a feared complication following tonsillectomy. Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre. Secondary haemorrhage occurs between 5 and 10 days after surgery, it is often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary haemorrhage occurs in 3% of all tonsillectomies.

Answer 226

In patients who are colonised there is commonly evidence of fundal gastritis on endoscopy Helicobacter pylori accounts for \>75% cases of duodenal ulceration. It may be diagnosed with either serology, microbiology, histology or CLO testing. Helicobacter pylori rarely produces any typical features on endoscopy. Where infection is suspected the easiest course of action is to take an antral biopsy for Clo testing in the endoscopy suite.

Answer 227

The posterior cord gives rise to: Radial nerve ((innervates the triceps, brachioradialis, wrist extensors, and finger extensors) Axillary nerve (innervates deltoid and teres minor) Upper subscapular nerve (innervates subscapularis) Lower subscapular nerve (innervates teres major and subscapularis) Thoracodorsal nerve (innervates latissimus dorsi) This is a description of a posterior cord lesion. Remember that the posterior cord gives rise to the axillary and radial nerve.

Answer 228

The brachial plexus cords are described according to their relationship with the axillary artery. The cords pass over the 1st rib near to the dome of the lung and pass beneath the clavicle immediately posterior to the subclavian artery.

Answer 229

Anterior divisions of the upper and middle trunks form the lateral cord Origin of the lateral pectoral nerve (C5, C6, C7)

Answer 230

Anterior division of the lower trunk forms the medial cord Origin of the medial pectoral nerve (C8, T1), the medial brachial cutaneous nerve (T1), and the medial antebrachial cutaneous nerve (C8, T1)

Answer 231

Formed by the posterior divisions of the 3 trunks (C5-T1) Origin of the upper and lower subscapular nerves (C7, C8 and C5, C6, respectively) and the thoracodorsal nerve to the latissimus dorsi (also known as the middle subscapular nerve, C6, C7, C8), axillary and radial nerve

Answer 232

10% Only a minority of patients with fissure in ano will have an anteriorly sited fissure. They are particularly rare in males and an anterior fissure in a man should prompt a search for an underlying cause.

Answer 233

The choroid plexus lies in all ventricles.

Answer 234

Proctitis Nocturnal diarrhoea and incontinence are typical of inflammatory bowel disease. Anal cancer These are features of anal cancer. Anal cancers arise from the cutaneous epithelium and are therefore typically squamous cell. They are usually sensitive to chemoradiotherapy. Solitary rectal ulcer syndrome This is the typical presentation of SRUS. These patients require careful diagnostic work up to elicit the underlying cause of their altered bowel habit. The histological appearances of solitary rectal ulcers are characteristic and extensive collagenous deposits are often seen. This is usually termed fibromuscular obliteration.

Answer 235

Re-assess in 6 months Undescended testes are not uncommon in young children. They may be present in 4% of term infants, but only in 1.3% children at 3 months of age. In this scenario the testis is retractile and can be managed expectantly.

Answer 236

Bisphosphonates Calcitonin Prednisolone

Answer 237

Analogues of pyrophosphate Prevent osteoclast attachment to bone matrix and interfere with osteoclast activity. Inhibit bone resorption

Answer 238

Pyrexia Leucopaenia

Answer 239

Pamidronate

Answer 240

Used for malignancy associated hypercalcaemia

Answer 241

Quickest onset of action however short duration (tachyphylaxis) therefore only given with a second agent.

Answer 242

May be given in hypercalcaemia related to sarcoidosis, myeloma or vitamin D intoxication.

Answer 243

The interosseous membrane separates the anterior and posterior compartments. The deep and superficial compartments are separated by the deep transverse fascia. The peroneus brevis is part of the lateral compartment.

Answer 244

Tibialis posterior As an artery of the anterior compartment, the anterior tibial artery is closely related to tibialis anterior. The tibialis posterior is related to it at its origin.

Answer 245

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

Answer 246

Pectineus adducts and medially rotates the femur.

Answer 247

Piriformis Gemellus superior Obturator internus Gemellus inferior Obturator externus Quadratus femoris

Answer 248

Osteoclast function Also known as marble bone disease Rare disorder of defective osteoclast function resulting in failure of normal bone resorption Stem cell transplant and interferon-gamma have been used for treatment Next question

Answer 249

CT c-spine This man needs a CT scan of his c-spine. A CT scan will give the best resolution of any bony injury. CT head within 1 hour This lady has a head injury and vomiting \> 1, therefore an urgent CT head is indicated. Urgent neurosurgical review (even before CT head performed) A penetrating injury needs urgent neurosurgical review.

Answer 250

Inulin Creatinine declines with age due to decline in renal function and muscle mass. Glucose, protein (amino acids) and PAH are reabsorbed by the kidney.

Answer 251

The normal intracranial pressure is between 7 and 15 mm Hg. The brain can accommodate increases up to 24 mm Hg, thereafter clinical features will become evident.

Answer 252

Ventricular tachycardia - verapamil is contraindicated Verapamil should never be given to a patient with a broad complex tachycardia as it may precipitate ventricular fibrillation in patients with ventricular tachycardia. Adenosine is sometimes given in this situation as a 'trial' if there is a strong suspicion the underlying rhythm is a supraventricular tachycardia with aberrant conduction

Answer 253

If the patient has adverse signs (systolic BP \< 90 mmHg, chest pain, heart failure or rate \> 150 beats/min) then immediate cardioversion is indicated. In the absence of such signs antiarrhythmics may be used. If these fail, then electrical cardioversion may be needed with synchronised DC shocks

Answer 254

amiodarone: ideally administered through a central line lidocaine: use with caution in severe left ventricular impairment procainamide Verapamil should NOT be used in VT

Answer 255

electrophysiological study (EPS) implant able cardioverter-defibrillator (ICD) - this is particularly indicated in patients with significantly impaired LV function

Answer 256

Systems based audit Theme from April 2015 Exam Theme from April 2013 Exam This is primarily an issue of stock control. However, the system by which the materials are used within the theatre will need evaluation. Because it is the usage and stock that are a problem, rather than the sourcing the systems based audit will be more effective than an operational audit. Standards based audit This type of audit is widely undertaken in most trusts in the UK. Peer review In the situation where a surgeon performs an unfamiliar procedure a peer review is often the best way to evaluate the problem. This does not have to be externally based, but often is.

Answer 257

Financial audit

Answer 258

Operational audit

Answer 259

Departmental review

Answer 260

Standards based audit

Answer 261

Systems based audit

Answer 262

Urinary dye studies Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services. A dye stains the urine and hence identifies the presence of a fistula. Pelvic floor exercises 3 months The first line management of stress urinary incontinence, in this case arising for pelvic floor trauma is pelvic floor exercises. These will help a proportion of patients. Non responders should have urodynamics performed to confirm the diagnosis. Urodynamic studies Urodynamic studies are indicated when there is diagnostic uncertainty or plans for surgery.

Answer 263

Stress urinary incontinence (50%) Urge incontinence (15%) Mixed (35%)

Answer 264

Initial assessment urinary incontinence should be classified as stress/urge/mixed. At least 3/7 bladder diary if unable to classify easily. Start conservative treatment before urodynamic studies if a diagnosis is obvious from the history Urodynamic studies if plans for surgery. Stress incontinence: Pelvic floor exercises 3/12, if fails consider surgery. Urge incontinence: Bladder training \>6/52, if fails for oxybutynin (antimuscarinic drugs) then sacral nerve stimulation. Pelvic floor exercises offered to all women in their 1st pregnancy.

Answer 265

Carbamazepine SIADH - drug causes: carbamazepine, sulfonylureas, SSRIs, tricyclics Lithium can cause diabetes insipidus but this is generally associated with a high sodium. Lithium only tends to cause raised antidiuretic hormone levels following a severe overdosage.

Answer 266

Ectopic testes are those that come to lie outside the normal range of embryological descent (i.e. in the superficial inguinal pouch). Other sites of ectopic testes include; base of penis, femoral triangle and perineum.

Answer 267

The IJV does not lie in the posterior triangle. However, the terminal branches of the external jugular vein do.

Answer 268

Hip x-ray The main differential diagnosis in a boy over 10 years old is of slipped upper femoral epiphysis. Knee pain is a common presenting feature. An anteroposterior pelvic x-ray may miss a minor slip, therefore request a hip film. USS hip This child is at risk of developmental dysplasia of the hip (up to 20% will have DDH), so should have the hip joints scanned to exclude this. MRI Perthes disease should be suspected in boys over 4 years old presenting with a limp. Early disease can be missed on x-ray. An MRI will often demonstrate areas of hypoperfusion and subtle changes that allow for earlier diagnosis. A bone scan is an alternative option.

Answer 269

Crohns disease is worse in smokers and smoking is an independent risk factor for disease recurrence following resection. Fat wrapping of the terminal ileum is commonly seen in patients with ileal disease (the commonest disease site). The mesenteric fat in patients with IBD is often dense, hard and prone to considerable haemorrhage during surgery. At endoscopy, the mucosa in patients with Crohns disease is said to resemble cobblestones, mucosal islands (pseudopolyps) are seen in ulcerative colitis.

Answer 270

Human albumin solution 4.5% In patients who are hypoalbuminaemic the use of albumin solution may help promote a diuresis and manage fluid overload. Dextrose 10% Neonates are at considerable risk of hypoglycaemia following surgery and should receive 10% dextrose. Hartmans solution Of the solutions given Hartmans is the most suitable. Consideration should also be given to potassium supplementation.

Answer 271

Increased risk of renal failure

Answer 272

he marginal mandibular nerve lies deep to platysma. It supplies the depressor anguli oris and the depressor labii inferioris. If injured it may lead to facial asymmetry and dribbling.

Answer 273

T Test This will involve the comparison of absolute numbers of patients and therefore this can be assessed using a T -Test. It does make the assumption that the data is normally distributed. However, the other tests would not be suitable. Bonferroni test As more types of side effects are considered, it becomes more likely that the new drug will appear to be less safe than existing drugs in terms of at least one side effect. Methods are available to adjust the p value to reflect the multiple comparisons being made, the aim being to avoid spurious results. A frequently applied correction is the Bonferroni Method in which the observed p values are multiplied by the number of tests performed, any resulting p value which is greater than 1 is set to 1 and any which remains at less than 0.05 can be considered significant at the 5% level. Kruskall Wallis test In this scenario the data is derived from 5 groups of surgeons. If the data were normally distributed then an ANOVA could be considered. Since these assumptions cannot be met, or satisfied by transforming the data then the Kruskall-Wallis test provides a non parametric alternative. This is essentially an extension of the Wilcoxon Rank sum test and detects differences in median values between each group. To compare more accurately differences between two individual surgeons a Mann Whitney U test may be a more acceptable alternative.

Answer 274

Tacrolimus is metabolised by the P450 enzyme system. This is inhibited by a number of naturally occurring substances, these include grapefruit, watercress and St.Johns Wort. These should all be avoided in immunosupressed patients taking tacrolimus.

Answer 275

Bowel preparation with oral laxatives (e.g. picolax) Endoscopy requires full bowel preparation. In elderly patients, this can cause electrolyte disturbance and renal compromise and it is important to check the patients urea and electrolytes beforehand. No preparation required Formal bowel preparation for right sided colonic resection is unnecessary. The formal bowel preparation of elective patients for right sided resection results in increased post operative morbidity and delayed discharge. Phosphate enema For a limited endoscopy a simple enema will suffice. .

Answer 276

Cease activity and refer individual to GMC While most surgical and departmental problems can be handled in house is can be seen that this approach has been tried and failed. Given the deaths there is no other option than E Clinical audit Where there are clear guidelines, an audit is the best measure. Refer to research ethics committee Whenever patient tissue is taken for research it is necessary practice to gain ethics approval. Some units may have blanket policies in place for taking tissue for research to tissue banks but as a general rule most people should seek ethics approval PRIOR to starting research.

Answer 277

Staphylococcus aureus infection following splenectomy is no more common than in non splenectomised individuals. The other organisms are encapsulated, which is why they are more likely to cause overwhelming post splenectomy sepsis.

Answer 278

Escherichia coli, Streptococcus pneumoniae, Salmonella, Klebsiella pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa, Neisseria meningitidis, Bacteroides fragilis, and the yeast Cryptococcus neoformans

Answer 279

5 alpha reductase inhibitors reduce the risk of urinary retention. In the PLESS study, data show a reduction in the risk of urinary retention although the absolute risk reduction was small.

Answer 280

During a high anterior resection of such tumours, the inferior mesenteric artery is ligated. Note that the branches (mainly middle rectal branch) of the internal iliac artery are important in maintaining vascularity of the rectal stump and hence the integrity of the anastomoses.

Answer 281

It enters the temporal bone through the internal acoustic meatus and exits through the stylomastoid foramen.

Answer 282

Erythema multiforme

Answer 283

Aphthous ulcers Pyoderma gangrenosum Iritis Erythema nodosum Sclerosing cholangitis Arthritis Clubbing

Answer 284

Suprapubic catheter This patient has possible urethral injury based on the history. Urethral catheterisation is contraindicated in this situation.

Answer 285

500 mL Between 500 mL and 1.5 L of bile enters the small bowel daily. Most bile salts are recycled by the enterohepatic circulation. When the gallbladder contracts the lumenal pressure is approximately 25cm water, which is why biliary colic may be so painful.

Answer 286

Cholate and chenodeoxycholate.

Answer 287

Formed by bacterial action on primary bile salts. These are deoxycholate and lithocholate. Of these deoxycholate is reabsorbed, whilst lithocholate is insoluble and excreted.

Answer 288

Cholesterol Bile salts Lecithin

Answer 289

Blood group O is not a risk factor for oesophageal cancer. Achalasia is associated with the risk of developing squamous cell carcinoma of the oesophagus.

Answer 290

Aqueous iodine applied to the skin The patient will require skin preparation. However, use of glutaraldehyde or sodium hypochlorite would be an inappropriate choice. As the Mayo repair does not involve implantation of prosthetic mesh the use of antibiotics is not appropriate. Perform surgery in a lamninar flow theatre Laminar flow is more important than an exhaust suit although use of both is ideal. Administration of gentamicin Gentamicin is the preferred agent. Clindamycin is associated with high rate of clostridium dificile infection.

Answer 291

Serum calcitonin Measurement of basal or stimulated calcitonin concentrations is used to assess the completeness of surgical resection, and is of use in detecting diseases recurrences during follow up. Thyroglobulin antibodies Antibodies to thyroglobulin, the major constituent of colloid and precursor of thyroid hormones may be elevated in those with metastatic or recurrent thyroid cancer. Results may be erronoeous in those with other thyroid disorders. Thyroid peroxidase antibodies Antibodies to thyroid peroxidase are found in most patients with Graves disease or Hashimotos thyroiditis.

Answer 292

Atrial fibrillation is associated more with atrial septal defects

Answer 293

aortic regurgitation\* infective endocarditis Eisenmenger's complex right heart failure \*aortic regurgitation is due to a poorly supported right coronary cusp resulting in cusp prolapse

Answer 294

The motorcyclist has had an Erb's palsy (C5, C6 root lesion). This is commonly known to be associated with birth injury when a baby has a shoulder dystocia.

Answer 295

Erbs Palsy C5, C6 lesion The features include: Waiter's tip position Loss of shoulder abduction (deltoid and supraspinatus paralysis) Loss of external rotation of the shoulder (paralysis of infraspinatus) Loss of elbow flexion (paralysis of biceps, brachialis and brachioradialis) Loss of forearm supination (paralysis of Biceps)

Answer 296

Water absorption in the gastrointestinal tract predominantly occurs in the small bowel (jejunum and ileum). The colon is an important site of water absorption, however, its overall contribution is relatively small. The importance of the colonic component to water absorption may increase following extensive small bowel resections.

Answer 297

Its secretory function is most effective at low systolic blood pressures (typically less than 100mmHg) The proximal convoluted tubule may undergo necrosis in situations such as compartment syndrome. It is responsible for reabsorbing up to two thirds of filtered water. Low systolic blood pressures (below the renal autoregulatory range) are a risk factor for acute tubular necrosis. Within the autoregulatory range the absolute value of systolic BP has little effect.

Answer 298

Microscopic colitis is a common condition characterised by normal endoscopic appearances, microscopic features of colonic inflammation and thickening of the sub epithelial collagen layer. Features such as granulomas are absent. It is the normal endoscopic appearance that makes the other options less likely. IBS is a diagnosis of exclusion and the features of inflammation activity would favor a different diagnosis. Severe cases can be treated with steroids. Other agents such as cholestyramine may be beneficial. It is important to exclude infection with a stool culture if this has not been done, not least because the precipitant of many cases of microscopic colitis is an episode of infective diarrhoea.

Answer 299

Residing at 4500M for 48 hours The patient has low oxygen tension and low carbon dioxide. The pH is normal so there is compensation for a long standing condition in which oxygenation is reduced. There is neither alkalosis, nor hypoventilation as the carbon dioxide is low. At very high altitude, the low oxygen tension can exceed the anaerobic threshold and carbon dioxide levels increase.

Answer 300

This baby is a full term and has \> 14 days of jaundice, therefore needs an urgent conjugated bilirubin check to rule out biliary atresia. If physiological jaundice the unconjugated bilirubin levels will be increased. Isotope scanning may be used in diagnosis, but a definitive diagnosis is normally made during a laparotomy.

Answer 301

Uraemia will typically cause a high anion gap acidosis. It is one of the unmeasured anions.

Answer 302

H - Hyperalimentation/hyperventilation A - Acetazolamide R - Renal tubular acidosis D - Diarrhoea U - Ureteral diversion P - Pancreatic fistula/parenteral saline

Answer 303

Do not confuse the early phase of Charcot foot with cellulitis Trauma (even if only minor) is a prerequisite. Patients cannot usually recall the traumatic event. The associated neuropathy means that patients continue to walk on the affected foot with subsequent deformity developing over time.

Answer 304

Protein C deficiency Lignocaine is widely used as a local anaesthetic. As a class IB antiarrhythmic it should not be used in people with unstable disorders of cardiac rhythm and ideally should not be co-administered with other anti-arhythmics.

Answer 305

Dystrophic calcification may be present in breast malignancy and is the basis for the breast screening programme. Metastatic calcification is calcification which occurs in otherwise normal tissues, usually as a result of hypercalcaemia. Invasive ductal carcinoma is the most common type of breast cancer, unless the tumour is very poorly differentiated there is usually some resemblance to ductal epithelial cells.

Answer 306

1. Nuclear pleomorphism 2. Coarse chromatin 3. Angiogenesis 4. Invasion of the basement membrane 5. Dystrophic calcification (may be seen on mammography) 6. Abnormal mitoses 7. Vascular invasion 8. Lymph node metastasis

Answer 307

The ileo - colic artery supplies the caecum and would require high ligation during a right hemicolectomy. The middle colic artery should generally be preserved when resecting a caecal lesion. This question is essentially asking you to name the vessel supplying the caecum. The SMA does not directly supply the caecum, it is the ileocolic artery which does this.

Answer 308

The annual probability of strangulation is up to 3% and is more common in indirect hernias. Elective repair poses few risks. However, emergency repair is associated with increased mortality, particularly in the elderly.

Answer 309

Silk 3/0 Silk is traditionally used for this purpose because of its reliable knotting. Polydioxanone 1/0 A large suture such as 1/0 PDS or 1/0 polypropylene is the standard material for this indication. From the list 1/0 PDS is the most appropriate. 3/0 Polypropylene 3/0 polypropylene is the suture of choice in this setting. 6/0 is too fine and will not withstand the tensile forces.

Answer 310

Transfer factor raised: asthma, haemorrhage, left-to-right shunts, polycythaemia low: everything else Where alveolar haemorrhage occurs the TLCO tends to increase due to the enhanced uptake of carbon monoxide by intra-alveolar haemoglobin.

Answer 311

asthma pulmonary haemorrhage (Wegener's, Goodpasture's) left-to-right cardiac shunts polycythaemia hyperkinetic states male gender, exercise

Answer 312

pulmonary fibrosis pneumonia pulmonary emboli pulmonary oedema emphysema anaemia low cardiac output

Answer 313

pneumonectomy/lobectomy scoliosis/kyphosis neuromuscular weakness ankylosis of costovertebral joints e.g. ankylosing spondylitis Next question

Answer 314

The transfer factor describes the rate at which a gas will diffuse from alveoli into blood. Carbon monoxide is used to test the rate of diffusion. Results may be given as the total gas transfer (TLCO) or that corrected for lung volume (transfer coefficient, KCO)

Answer 315

L3 nerve root compression

Answer 316

L5 nerve root compression

Answer 317

S1 nerve root compression

Answer 318

The prevalence is the proportion of a population that have the condition at a point in time whilst the incidence is the rate at which new cases occur in a population during a specified time period.

Answer 319

The proportion of people with the target disorder in the population at risk at a specific time (point prevalence) or time interval (period prevalence) For example, the prevalence of rheumatoid arthritis in the UK is 1%

Answer 320

The proportion of patients with that particular test result who have the target disorder Post-test probability = post test odds / (1 + post-test odds)

Answer 321

The odds that the patient has the target disorder before the test is carried out Pre-test odds = pre-test probability / (1 - pre-test probability)

Answer 322

The odds that the patient has the target disorder after the test is carried out Post-test odds = pre-test odds x likelihood ratio where the likelihood ratio for a positive test result = sensitivity / (1 - specificity)

Answer 323

Most commonly found in the duodenum (in up to 50% patients), then the pancreas (approximately 20%). Other ectopic areas include stomach, spleen, gallbladder and ovary

Answer 324

Cystic and common bile duct (Top) 2nd and 3rd part of the duodenum (Bottom) Neck and body of pancreas (Medial)

Answer 325

solitary and highly malignant.

Answer 326

1. Non beta islet cell tumours of the pancreas 2. Hypergastrinaemia 3. Severe ulcer disease

Answer 327

Diagnosis is based on 3 criteria: 1. Fasting hypergastrinaemia 2. Increased basal acid output 3. Secretin stimulation test positive

Answer 328

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

Answer 329

Vacuum Assisted Closure device (VAC) A VAC dressing may avoid the need for further surgery. Below knee amputation A below knee amputation is the best option here. The foot is non salvageable. However, she may ambulate with a prosthesis. Above knee amputation This patient will not be able to walk with a below knee amputation, therefore an above knee amputation would be preferable, as it guarantees better healing the short term. Consider above knee amputation in patients with fixed flexion deformity

Answer 330

Dead non viable Deadly- posing major threat to life Dead useless, viable but a prosthesis woud be preferable

Answer 331

Amputation is often undertaken as an option of last resort e.g. Limb salvage has failed and the limb is so non functional that mobility needs would be best met with prosthesis. Chronic fracture non union or significant limb shortening following trauma would fit into this category. Occasionally following major trauma a primary amputation is preferable. This would be the case in an open fracture with major distal neurovascular compromise and other more life threatening injuries are present.

Answer 332

The first two categories are the most prevalent. Diabetic foot sepsis is often a major cause of sepsis which can spread rapidly in the presence of established peripheral vascular disease. As a general rule the main issue in vascular surgery is to optimise vascular inflow prior to surgery. The more distal the planned amputation is to be, the more important this rule becomes. In other situations there has been something such as an embolic event that has not been revascularised in time. In this case the limb shows fixed mottling and an amputation will be needed.

Answer 333

Pelvic disarticulation (hindquarter) Above knee amputation Gritti Stokes (through knee amputation) Below knee amputation (using either Skew or Burgess flaps) Syme's amputation (through ankle) Amputations of mid foot and digits

Answer 334

The disease process being treated Desired functional outcome Co-morbidities of the patient

Answer 335

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

Answer 336

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.

Answer 337

Long posterior flap

Answer 338

Lateral flaps

Answer 339

Epidural This man is at high risk of atelectasis, hypoventilation can be avoided by minimising post operative pain through an epidural. A spinal block is short acting, therefore not appropriate. TAP block This is a localised infiltration of the abdominal wall with long acting local anaesthetic. This will provide optimal analgesia for the more limited pain that may occur with a laparoscopic procedure. Patient controlled analgesia This is more painful than a conventional appendicectomy, but conversion to a limited laparotomy was not anticipated. A PCA is the most effective and practically applicable modality in this case.

Answer 340

The lumbar arteries are posteriorly sited and are a common cause of back bleeding during aortic surgery. The other vessels cited all exit the aorta in the regions that have been cross clamped.

Answer 341

It inserts into the medial aspect of the upper part of the tibia.

Answer 342

Renal transitional cell carcinoma TCC is a rare form of renal cancer, accounting for approximately 7% of all renal tumours. Risk factors include exposure to chemicals in the textile, plastic and rubber industry. Nephroblastoma Wilm's tumour of the kidney is the most common renal tumour in children. Both nephroblastoma and neuroblastoma may occupy the adrenal and apex of the kidney. In the case of neuroblastoma the lesion will have arisen from the adrenal, in the case of nephroblastoma the lesion will have arisen from the kidney. Hypertension is more commonly associated with nephroblastoma. Neuroblastomas are usually calcified, whereas nephroblastomas are not and this may be of diagnostic usefulness pre operatively Angiomyolipoma This patient has tuberous sclerosis. This is associated with angiomyolipoma, which is present in 60-80% patients. It is a benign lesion.

Answer 343

Testicular tumours metastasise to Para aortic nodes and thus an inguinal rather than scrotal approach should be used. There are two main operations that are termed Lords procedure; one is for fissure in ano and the other is a procedure for hydrocele.

Answer 344

Children typically develop this complication.

Answer 345

Patients with coeliac disease tend to develop hypocalcaemia due to malabsorption of calcium by the bowel.

Answer 346

C alcium supplementation H yperparathyroidism I atrogentic (Drugs: Thiazides) M ilk Alkali syndrome P aget disease of the bone A cromegaly and Addison's Disease N eoplasia Z olinger-Ellison Syndrome (MEN Type I) E xcessive Vitamin D E xcessive Vitamin A S arcoidosis

Answer 347

Administration of antibiotics This is likely to represent epididymo-orchitis, this is usually due to infection with gonorrhoea or chlamydia in this age group. In addition to treatment with antibiotics contact tracing and appropriate swabs should also be performed. Orchidectomy via inguinal approach Hypoechoic masses within the testicle in the context are most likely to represent malignancy. He should have a staging CT scan, thereafter an orchidectomy should be performed via an inguinal approach. Percutaneous biopsy has no role in the management of testicular malignancy. Exploration of scrotum via scrotal approach This is likely to represent torsion, surgical exploration is warranted.

Answer 348

Decrease in pancreatic exocrine secretions Octreotide reduces exocrine pancreatic secretions so is used to treat high output pancreatic fistulae (though parenteral feeding is most effective). Other uses include variceal bleeding and treatment of acromegaly. Inhibits growth hormone and insulin release (when released from pancreas). Somatostatin is also released by the hypothalamus causing a negative feedback response on growth hormone.

Answer 349

Septic shock will typically result in end organ hypoperfusion and as a result lactate levels will often be high. In the surviving sepsis campaign it is suggested that elevated lactate levels are an independent indicator for vasopressor support in patient with sepsis. The WCC may be paradoxically low in severe sepsis, although it is most often elevated.

Answer 350

The urinary bladder has a rich venous plexus surrounding it, this drains subsequently into the internal iliac vein. The vesicoprostatic plexus may be a site of considerable venous bleeding during cystectomy.

Answer 351

Ketamine has a moderate to strong analgesic effect. It may be used for emergency procedures outside the hospital environment to induce anaesthesia for procedures such as emergency amputation.

Answer 352

When a diagnosis of lymphoma is suspected, the correct investigation is excision biopsy of a complete lymph node to confirm the diagnosis. Excision of a single node is appropriate. Lymphoma is usually treated with chemotherapy and axillary node clearance is therefore inappropriate. FNA and core biopsy will not allow accurate diagnosis and are therefore not appropriate.

Answer 353

TB reactivation most commonly occurs at the lung apex. This site is better oxygenated than elsewhere allowing the mycobacteria to multiply more rapidly and then spread both locally and distantly.

Answer 354

The standard surgical option for bleeding peptic ulcers is to underrun them. Resectional surgery is very much the option of last resort and is seldom helpful or easy. An isolated duodenal resection would almost never be performed.

Answer 355

The intestinal phase of gastric acid secretion accounts for only 10% of gastric acid produced.

Answer 356

Deep ulnar nerve

Answer 357

At the wrist divides into superficial and deep branches Superficial branch lies deep to palmaris brevis and divides into two to produce digital nerves which innervate the skin of the medial third of the palm and the palmar surface of one and a half fingers The deep branch arises from the nerve on the flexor retinaculum lateral to the pisiform bone. It passes posteriorly between the abductor and short flexor of the little finger supplying them, and supplying and piercing the opponens digiti minimi near its origin from the flexor retinaculum, turns laterally over the distal surface of the Hook of the Hamate bone. It eventually passes between the two heads of adductor pollicis with the deep palmar arch and ends in the first dorsal interosseous muscle. In the palm the deep branch also innervates the lumbricals and interosseous muscles. Next question

Answer 358

From the nerve on the flexor retinaculum, lateral to pisiform bone

Answer 359

Late graft stenosis is mainly associated with saphenous vein grafts 1. Left main stem stenosis or equivalent (proximal LAD and proximal circumflex) 2. Triple vessel disease 3. Diffuse disease unsuitable for PCI The right atrium is cannulated. The CHADS score assesses whether a patient should be warfarinised if they have atrial fibrillation. Cardioplegia can be undertaken at cold or warm temperatures.

Answer 360

50% of plasma calcium is ionised. Hyperventilation will induce a state of alkalosis which will lower ionised plasma calcium levels.

Answer 361

The superior mesenteric artery arises from the aorta and passes anterior to the lower part of the pancreas. Invasion of this structure is a relative contra indication to resectional surgery.

Answer 362

Nausea inhibits gastric secretion via higher cerebral activity and sympathetic innervation.

Answer 363

Aldosterone serves to conserve sodium and water. It is produced in the zona glomerulosa of the adrenal cortex.

Answer 364

Catecholamines: epinephrine norepinephrine dopamine

Answer 365

Glomerulosa Fasciculata Reticularis

Answer 366

MCs- aldosterone

Answer 367

GCs- cortisol

Answer 368

Sex steroids MCs GCs

Answer 369

The cephalic vein is a favored vessel for arteriovenous fistula formation and should be preserved in patients with end stage renal failure The cephalic vein penetrates the calvipectoral fascia (but not the pectoralis major) prior to terminating in the axillary vein.

Answer 370

Dorsal venous arch drains laterally into the cephalic vein Crosses the anatomical snuffbox and travels laterally up the arm At the antecubital fossa connected to the basilic vein by the median cubital vein Pierces deep fascia of deltopectoral groove to join axillary vein

Answer 371

Cystic medial necrosis ( or cystic medial degeneration) occurs when basophils and mucoid material lie in between the intimal elastic fibres of the aorta. It is typically found in the aortic degeneration of Marfans syndrome, but may also be seen in aortic degeneration in older adults.

Answer 372

This is most likely to represent Barretts oesphagus and is thus metaplasia. Dysplasia is less likely in this setting although biopsies are mandatory.

Answer 373

The finding of a scaphoid abdomen and respiratory distress suggests extensive intra thoracic herniation of the abdominal contents. This is seen most frequently with Bochdalek hernias. Morgagni hernias seldom present in such a dramatic fashion. The other options do not typically present with the symptoms and signs described.

Answer 374

Shave biopsy and cautery These lesions are often extensive and superficial. Shave excision will suffice, material must be sent for histology. Excision with 1 cm margin This man will require re-excision of margins so that a 1cm margin around the lesion is achieved. This can usually be achieved without skin grafting. Punch biopsy This is likely to represent Pagets disease of the nipple and is best diagnosed on punch biopsy.

Answer 375

95.4% of values lie within 2 SD of the mean. In statistics, the 68-95-99.7 rule or three-sigma rule, or empirical rule states that for a normal distribution, nearly all values lie within 3 standard deviations of the mean. About 68.27% of the values lie within 1 standard deviation of the mean. Similarly, about 95.45% of the values lie within 2 standard deviations of the mean. Nearly all (99.73%) of the values lie within 3 standard deviations of the mean

Answer 376

symmetrical i.e. Mean = mode = median 68. 3% of values lie within 1 SD of the mean 95. 4% of values lie within 2 SD of the mean 99. 7% of values lie within 3 SD of the mean this is often reversed, so that within 1.96 SD of the mean lie 95% of the sample values the range of the mean - (1.96 \*SD) to the mean + (1.96 \* SD) is called the 95% confidence interval, i.e. If a repeat sample of 100 observations are taken from the same group 95 of them would be expected to lie in that range

Answer 377

the standard deviation (SD) represents the average difference each observation in a sample lies from the sample mean SD = square root (variance)

Answer 378

Placenta percreta Pregnancy and frank haematuria, especially if there is a history of placenta previa or prior caesarean section, should indicate this diagnosis. There is invasive placental implantation into the myometrium, which can rarely extend into the bladder causing severe bleeding. Adult polycystic kidney disease APKD is associated with liver cysts (70%), berry aneurysms (25%) and pancreatic cysts (10%). Patients may have a renal mass, hypertension, renal calculi and macroscopic haematuria. Renal vein thrombosis Renal vein thrombosis is a common feature of renal cell carcinoma as it invades the renal vein. Other features include PUO, left varicocele and paraneoplastic endocrine effects due to erythropoietin factor, renin, ACTH and PTH like substance.

Answer 379

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.

Answer 380

The 8th and10th ribs lie more superiorly. The 12th rib is a closer relation posteriorly. Quadratus lumborum runs between the posterior part of the iliac crest, iliolumbar ligament and the transverse processes of the lower lumbar vertebrae to the medial part of the lower border of the last rib and transverse process of the upper lumbar vertebrae. In these last two locations it is posterior to the kidney.

Answer 381

An intention to treat analysis considers data according to the treatment to which the patient was randomised, rather than the treatment which was recieved. It includes those who cross over which is how it helps provide additional information relating to those groups.

Answer 382

The 11th and 12th ribs lie posterior to the kidneys and may be encountered during a posterior approach. A pneumothorax is a recognised complication of this type of surgery.

Answer 383

Splenectomy

Answer 384

Thrombosis of the splenic vein may complicate pancreatitis, pancreatic carcinoma, iatrogenic trauma and hypercoagulable diseases. The condition may predispose to the development of gastric varices, oesophageal varices are uncommon in splenic vein thrombosis alone. Diagnosis is made by CT angiography. Treatment is with splenectomy.

Answer 385

1 litre of Hartmans solution over 4 hours This man will have a contained haematoma and is awaiting surgery. Rapid, high volume infusions may cause this to dislodge with disastrous consequences

Answer 386

Apoptosis is not a feature of necrotic cell death. By this stage there would usually be attempted repair so angiogenesis and proliferation of fibroblasts would be expected. These cells may differentiate further to become osteoblasts which in turn will lay down new matrix.

Answer 387

Inhibition of DNA gyrase

Answer 388

The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath is a fascial tunnel containing both the femoral artery laterally and femoral vein medially. The canal lies medial to the vein.

Answer 389

Mastectomy This patient has an extensive disease process and lobular cancers are notorious for being multifocal. In this case a mastectomy is the safest next step. Radiotherapy This woman has a good prognosis. However, irradiation of the breast is mandatory after breast cancer has been treated using breast conserving surgery. Breast lump excision biopsy The imaging and biopsy results are not concordant. At this stage an excision biopsy is the safest option.

Answer 390

The components that are nearly always needed for power calculations are : Size of effect Significance level Sample size used to detect the effect Desired power value

Answer 391

Secretin Secretin causes secretion of water and electrolytes Cholecystokinin causes enzyme secretion While secretin will typically increase electrolyte and water volume of secretions, the enzyme content in increased by cholecystokinin. Somatostatin will decrease the volume of secretions. Aldosterone will tend to conserve electrolytes.

Answer 392

Psoas stretch sign Grey-Turner's sign Grey-Turners sign occurs in patients with severe haemorrhagic pancreatitis. In this situation the major vessels surrounding the pancreas bleed. The pancreatitis process also results in local fat destruction, this results in blood tracking in the tissue planes of the retroperitoneum and appearing as flank bruising. Murphy's sign Invariably present when patients are assessed in the emergency department! This sign occurs because the inflamed gallbladder irritates the parietal peritoneum in this manoeuvre.

Answer 393

Non specific abdominal pain is a commonly recorded diagnosis for patients presenting with acute abdominal pain. Following careful diagnostic work up, a proportion of patients may be identified with disorders such as coeliac disease and the diagnosis of non specific abdominal pain should not be used lightly.

Answer 394

strangulated intestine

Answer 395

A regime of 24 hours continuous feeding is recommended for ITU patients

Answer 396

Supraspinatus Infraspinatus

Answer 397

Subscapularis

Answer 398

Teres minor

Answer 399

Excessive intra-abdominal pressure may cause decreased venous return and hypotension. Since the preliminary laparoscopy did not show any major vascular catastrophe an emergency laparotomy would not be indicated. In most cases the release of pressure is often sufficient. In cases of a vaso-vagal episode (which may be induced by peritoneal stretching) a dose of atropine may be required.

Answer 400

Disease confined to the rectum

Answer 401

risk of colorectal cancer is 10-20 times that of general population the increased risk is mainly related to chronic inflammation worse prognosis than patients without ulcerative colitis (partly due to delayed diagnosis) lesions may be multifocal

Answer 402

disease duration \> 10 years patients with pancolitis onset before 15 years old unremitting disease poor compliance to treatment

Answer 403

Urethral injury This is classical for urethral injury. Features of a urethral injury include; pelvic fracture, high riding prostate on digital rectal examination and blood at the urethral meatus. Where this is the suspected diagnosis a suprapubic catheter and urethral contrast studies performed. Duodenal injury Retroperitoneal air is more likely with a duodenal injury. As it is largely retroperitoneal. A handlebar type injury is the commonest cause and the pancreas should be carefully inspected as it too may be injured. It would be unusual for the ileum to be injured in this type of scenario as it is mobile. Ileum injury Small bowel injury is the most common type of injury in this scenario. The enteric contents will tend to result in a large amount of intra abdominal fluid.

Answer 404

Proximal aortic dissection An inferior myocardial infarction and AR murmur should raise suspicions of an ascending aorta dissection rather than an inferior myocardial infarction alone. Also the history is more suggestive of a dissection. Other features may include pericardial effusion, carotid dissection and absent subclavian pulse. Boerhaave Syndrome The Mackler triad for Boerhaave syndrome: vomiting, thoracic pain, subcutaneous emphysema. It commonly presents in middle aged men with a background of alcohol abuse. Anterior myocardial infarction The most likely diagnosis is an anterior MI. As there are no ST changes in the inferior leads, aortic dissection is less likely.

Answer 405

When approaching the submandibular gland the facial vein and submandibular lymph nodes are the most superficially encountered structures. Each sub mandibular gland has a superficial and deep part, separated by the mylohyoid muscle. The facial artery passes in a groove on the superficial aspect of the gland. It then emerges onto the surface of the face by passing between the gland and the mandible. The facial vein is encountered first in this surgical approach because the incision is made 4cm below the mandible (to avoid injury to the marginal mandibular nerve).

Answer 406

PT: Vitamin K dependent factors 2, 7, 9, 10 APTT: Factors 8, 9, 11, 12 Jaundice will impair the production of vitamin K dependent clotting factors. This is most accurately tested by measuring the prothrombin time. APTT can be affected by vitamin K deficiency (due to factor 9 deficiency), however this occurs to a lesser extent and is normally associated with severe liver disease. The bleeding time is a measure of platelet function.

Answer 407

There is minimum mixing of blood passing through the vessels.

Answer 408

The adrenal gland releases adrenaline in response to increased sympathetic discharge from preganglionic sympathetic fibres of the splanchnic nerves. These cause the chromafin cells of the medulla to release adrenaline (which is preformed) by exocytosis.

Answer 409

In this setting a contained haematoma is the most likely cause. This will impair venous return resulting in laryngeal oedema and respiratory compromise.

Answer 410

The routine use of mechanical bowel preparation is not recommended. There is some recent evidence to support the use of selective gut decontamination. However, this is not in mainstream practice at present. If hair needs removal, use electrical clippers with single use head (razors increase infection risk)

Answer 411

During a TEP repair of inguinal hernia the only structure to lie posterior to the mesh is peritoneum. The question is really only asking which structure lies posterior to the rectus abdominis muscle. Since this region is below the arcuate line the transversalis fascia and peritoneum lie posterior to it. Bucks fascia lies in the penis.

Answer 412

Below the arcuate line the aponeuroses of all the abdominal muscles lie in anterior aspect of the rectus sheath. Posteriorly lies the transversalis fascia and peritoneum.

Answer 413

Ilioinguinal Arises from the first lumbar ventral ramus with the iliohypogastric nerve. It passes inferolaterally through the substance of psoas major and over the anterior surface of quadratus lumborum. It pierces the internal oblique muscle and passes deep to the aponeurosis of the external oblique muscle. It enters the inguinal canal and then passes through the superficial inguinal ring to reach the skin. Branches To supply those muscles of the abdominal wall through which it passes. Skin and fascia over the pubic symphysis, superomedial part of the femoral triangle, surface of the scrotum, root and dorsum of penis or labum majus in females. Next question

Answer 414

The auriculotemporal nerve is a direct branch of the mandibular nerve. Other branches of the mandibular nerve include: Lingual Inferior alveolar Nerve to the mylohyoid Mental

Answer 415

In bipolar units the flow of electricity is from one electrode to the other over a small area. As a result a contact plate is not used and coupling and capacitance injuries are uncommon. They have a low risk of thermal injury to adjacent structures and are preferred for this reason. However, they may cause sparks and ignite inflammable solutions.

Answer 416

Increased transferrin The acute phase response includes: Acute phase proteins Reduction of transport proteins (albumin, transferrin) Hepatic sequestration cations Pyrexia Neutrophil leucocytosis Increased muscle proteolysis Changes in vascular permeability

Answer 417

The defect is located ventrally and most often distally. Proximally located urethral openings are well recognised. Circumcision may compromise reconstruction.

Answer 418

Absent frenular artery Ventrally opened glans Skin tethering to hypoplastic urethra Splayed columns of spongiosum tissue distal to the meatus Deficiency of the foreskin ventrally

Answer 419

No routine cultural circumcisions Urethroplasty Penile reconstruction The foreskin is often utilised in the reconstructive process. In boys with very distal disease no treatment may be needed.

Answer 420

Radiotherapy Radiotherapy is routine following breast conserving surgery. Without irradiation the local recurrence rates are approximately 40%. Endocrine therapy using letrozole Elderly patients may be managed using endocrine therapy alone. Eventually most will escape hormonal control. In post menopausal women oestrogens are produced by the peripheral aromatization of androgens and aromatase inhibitors are therefore the most popular agent in this age group. Cytotoxic chemotherapy The combination of a grade 3 tumour and axillary nodal metastasis in a young female would attract a recommendation for chemotherapy. Some may also add herceptin (if they are HER 2 positive).

Answer 421

FEC fluorouracil epirbuicin cyclophosphamide

Answer 422

A flail chest segment may lacerate the underlying lung and create a flap valve. A tension pneumothorax can be created by intubation and ventilation in this situation. Sudden hypoxia and increased ventilation pressure are clues.

Answer 423

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.

Answer 424

Full thickness burns involve complete injury to the dermis and sub dermal appendages. They have a leathery, often white appearance. They are initially insensate although pain often occurs during healing following skin grafting. They do not blanch under pressure.

Answer 425

Experimental event rate, EER = 10 / 100 = 0.10 Control event rate, CER = 50 / 300 = 0.166 Therefore the relative risk = EER / CER = 0.1 / 0.166 = 0.6

Answer 426

is the ratio of risk in the experimental group (experimental event rate, EER) to risk in the control group (control event rate, CER)

Answer 427

is calculated by dividing the absolute risk change by the control event rate Using the above data, RRI = (EER - CER) / CER

Answer 428

The transverse cervical nerve lies within the posterior triangle. The anterior jugular vein is formed in the submental region and descends in the superficial fascia near the median plane. It passes inferior to enter the suprasternal space, it is linked to the contralateral anterior jugular vein by the jugular venous arch.

Answer 429

Diaphragmatic rupture A lateral blunt injury during a road traffic accident is a common cause of diaphragmatic rupture. Diagnosis is usually evident on chest x-ray. CXR changes include non visible diaphragm, bowel loops in the hemithorax and displacement of the mediastinum. In most cases direct surgical repair is the best option. Flail chest Multiple rib fractures with \> or = 2 rib fractures in more than 2 ribs is diagnosed as a flail chest. This is associated with pulmonary contusion. Aorta rupture He has a deceleration injury, with persistent hypotension (contained haematoma). This should indicate aorta rupture. Widened mediastinum may not always be present on a CXR. A CT angiogram will provide clearer evidence of the extent of injury. The presence of persistent hypotension, from a early stage is more consistent with haematoma than a tension pneumothorax in which it occurs as a final periarrest phenomena.

Answer 430

Malunion would be unusual with a femoral neck fracture. Because it is a weight bearing joint, if the fracture is not united then it does not heal at all. It is for this reason that most femoral neck fractures are fixed. Avascular necrosis is a well recognised complication and a total hip replacement or hemiarthroplasty is usually considered in the elderly.

Answer 431

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.

Answer 432

Patients can generally be managed without transfusion as long as the Hb is 7 or greater. The exact level depends upon patient factors such as co-morbidities. Old blood functions less effectively and should not be used during massive transfusions.

Answer 433

It terminates by dividing into the superficial temporal and maxillary branches. The external carotid has eight branches, 3 from its anterior surface ; thyroid, lingual and facial. The pharyngeal artery is a medial branch. The posterior auricular and occipital are posterior branches.

Answer 434

Most of the gut is derived endodermally except for the spleen which is from mesenchymal tissue.

Answer 435

inch thick, 3 inches wide, 5 inches long, weighs 7oz (150-200g), lies between the 9th and 11th ribs

Answer 436

The radial nerve passes through the triangular interval to leave the axilla. The superior border of this is bounded by the teres major muscle to which the radial nerve is closely related.

Answer 437

Duplex ultrasound She is likely to have mesenteric vascular disease. Proximal SMA disease would be the most serious variant. Ideally a CT angiogram would be the best test but with her impaired renal function and low BMI, make a duplex of the SMA is a reasonable first line investigation. Gut peristalsis may impair acquisition of magnetic resonance images. CT angiogram Sudden onset of abdominal pain followed by forceful evacuation are the classical presenting features of acute mesenteric infarction. This is best investigated by CT angiography, which has a sensitivity of 95% for the diagnosis. Abdominal CT with venous phase contrast Mesenteric venous thrombosis is the likely underlying cause and an angiogram is the sensible step as it will also facilitate the identification of areas of infarcted bowel , similar to that which may occur in the leg when massive DVT is present.

Answer 438

It drains to the internal jugular vein. Which is one of the reasons why it bleeds so copiously if a ligature slips.

Answer 439

Anterior gastrojejunostomy is one of the easiest gastric bypass procedures to perform and is still often used for reconstruction following distal gastrectomy. It is associated with impairment of gastric emptying and patients may have considerable problems with flatulent dyspepsia. Roux en Y methods provide the best function. Pyloroplasty enhances gastric emptying (and was historically performed following vagotomy for this reason). Pyloromyotomy is not associated with an increase in gastric transit times (though failed procedures may be).

Answer 440

Cardiooesophageal junction level = T11 A knowledge of this anatomic level is commonly tested. The oesophagus extends from C6 (the lower border of the cricoid cartilage) to T11 at the cardioesophageal junction. Note that in the neonate the oesophagus extends from C4 or C5 to T9.

Answer 441

Audits should compare performance against known standards. Where a novel technique is being introduced standards are unlikely to exist, sample sizes cannot therefore be accurately calculated. This is an example of research, which is not an audit.

Answer 442

The prognosis for localised papillary carcinomas is excellent. Survival rates at 5 years approach 90%.

Answer 443

Radial nerve The long head of the triceps muscle may be innervated by the axillary nerve and therefore complete loss of triceps muscles function may not be present even with proximally sited nerve lesions.

Answer 444

The long head arises from the infraglenoid tubercle. The fleshy lateral and medial heads are attached to the posterior aspect of the humerus between the insertion of the teres minor and the olecranon fossa.

Answer 445

The left ureter lies posterior to the left colon. The sigmoid colon and upper rectum may be more closely related to the iliac vessels. These are not typically found above L4.

Answer 446

Stylohyoid is innervated by the facial nerve.

Answer 447

A single, discrete episode of vomiting Whilst not an indication for immediate CT there should be a low threshold for admission and observation.

Answer 448

\* Loss of consciousness lasting more than 5 minutes (witnessed) \* Amnesia (antegrade or retrograde) lasting more than 5 minutes \* Abnormal drowsiness \* Three or more discrete episodes of vomiting \* Clinical suspicion of non-accidental injury \* Post-traumatic seizure but no history of epilepsy \* GCS less than 14, or for a baby under 1 year GCS (paediatric) less than 15, on assessment in the emergency department \* Suspicion of open or depressed skull injury or tense fontanelle \* Any sign of basal skull fracture (haemotympanum, panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign) \* Focal neurological deficit \* If under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head \* Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 m, high-speed injury from a projectile or an object)

Answer 449

This patient has a risk of asbestos exposure through his occupation as a builder. As there a is latent period of 30 years and a complicated effusion, the most likely cause is mesothelioma.

Answer 450

The ureter is not related to the round ligament of the uterus, it is related to the broad ligament and is within 1.5cm of the supravaginal part of the cervix.

Answer 451

Zinc is mainly absorbed in the duodenum and jejunum. Bile reflux may occur post gastrectomy. The risk of bile reflux is lower if a Roux en Y reconstruction is used.

Answer 452

Thyroid function

Answer 453

Pott's Bennett's Barton's Bartons fractures tend to have intra-articular involvement and dislocation may sometimes be present.

Answer 454

This structure will be the rectus sheath and when entered the rectus abdominis muscle will be encountered.

Answer 455

Mylohyoid is innervated by the mylohyoid branch of the inferior alveolar nerve.

Answer 456

GenioHyoid ThyroidHyoid Superior Omohyoid SternoThyroid SternoHyoid Inferior Omohyoid

Answer 457

Mucinous carcinoma Mucinous carcinomas comprise 2-3% of all breast cancers. They are one of the special type of carcinomas. These have a better prognosis that tumours of Non Special Type (NST) and axillary nodal disease is rare in this group. Paget's disease of the nipple Paget's is associated with DCIS or invasive carcinoma.Unlike eczema of the nipple which predominantly affects the areolar region, Pagets will usually affect the nipple first and then spread to the areolar area. Diagnosis is made by punch biopsy Ductal carcinoma in situ Comedo necrosis is a feature of high nuclear grade ductal carcinoma in situ. It is has a high risk of being associated with foci of invasion.

Answer 458

p24 antigen test

Answer 459

?HIV seroconversion