Essential Facts Flashcards

Question

Anterior Pituitary Hormones

Answer 1

ACTH TH LH FSH GH Prolactin

Answer 2

Oxytoncin ADH

Answer 3

80% benign. (Pleomorphic adenoma (70%), Warthin’s tumor) 15% malignant. (Mucoepidermoid carcinoma, adenoid cystic carcinoma) - Facial nerve palsy suggests malignancy.

Answer 4

**Mutation of APC gene (**80% cases) - **AUTOSOMAL DOMINANT** Predisposes to hundreds of adenomatous polyps. 100% risk GI Ca by 40y. Associated with small bowel polyps and mandibular osteomas. Gardner syndrome (type of FAP): Associated with FAP - Osteomas of skull, epidermoid cyst, multiple desmoid tumours Screening: Annual colonscopy from age of 15. Assoc. with **Duodenal polyps (90%), Gastric fundal polyps (50%)**

Answer 5

**AUTOSOMAL DOMINANT - mutation on chromosome 19** Multiple hamartomatous polyps -\> episodic obstruction and intussception. Increased risk of GI cancers - Colorectal 20%. Increased risk of breast, ovarian, cervical, pancreatic Assoc. **Hyperpigmented macules** on **mouth** and **oral mucosa**

Answer 6

HNPCC / Lynch syndrome Germline mutations of DNA mismatch repair genes (MMR) **Colo rectal cancer 30-70% Endometrial cancer 30-70%** Gastric cancer 5-10% Scanty colonic polyps may be present Colonic tumours likely to be right sided and mucinous Colonoscopy every 1-2 years from age 25 Consideration of prophylactic surgery

Answer 7

mutation of mut Y human homologue (MYH) on chromosome 1p, **Recessive pattern** Multiple colonic polyps Later onset right sided cancers more common than in FAP 100% cancer risk by age 60

Answer 8

Hyper-acute Due to presence of recipient anti-bodies. Kidney swells and becomes necrotic, requires nephrectomy. Acute T-cell mediated diffuse lymphocytic infiltration. Reversible with high dose steroids Chronic Humoral system responsible for graft fibrosis and atrophy.

Answer 9

* Germ Cell Tumours * Seminoma * Non-Seminomatous * Teratoma * Embryonal Carcinoma * Choriocarcinoma * Yolk Sac Tumour * Mixed Germ Cell Tumour * Non Germ Cell

Answer 10

Peak Age - 30-40 Placental Alk Phos Radiotherapy effective (In effective for all non-seminomas) B-HCG and lactate for monitoring following treatment

Answer 11

Peak Age 20 - 30 markers: B-HCG, CEA, AFP (Also found in HCC)

Answer 12

\<0.75mm = 1cm margin \< 1mm = 2cm \> 1mm = 3cm

Answer 13

Primary healing Wound closed within hours of formation, usually with sutures or clips Secondary Healing Left open without formal closure - spontaneous closure via contraction and re-epithelialisation Tertiary Healing Initial debridement with normal closure at a later date.

Answer 14

Pneumococcal H. Influenza B Meningococcal Flu

Answer 15

A - Confined to tumour wall (95 - 100%) B - Through bowel wall (65 - 75%) C - Lymph node Mets (30 - 40%) D - Distant mets (5 - 10%) Nb Modified: C1 = Upper LN not involved C2 = Upper LN is involved

Answer 16

Tis - Mucosa T1 - Submucosa T2 - Muscularis T3 - Serosa T4 - Adjacent Organs N1 - \<=3 N2 - \> 3

Answer 17

Abnormal blood flow Hypercoagulable state Endothelial Injury Causes of thrombus

Answer 18

I - Pancreatic (usually gastrinoma), Parathyroid (hyperplasia), Pituitary (usually prolactinoma) IIa - Phaeochromocytoma, Parathyroid adenoma, Medullary Thyroid Ca IIb - As IIa with Marfanoid features + Mucosal Neuromatosis

Answer 19

Hepatocellular Carcinoma, Teratoma

Answer 20

Colon, Teratoma

Answer 21

Pancreatic

Answer 22

Graft from host eg skin grafting

Answer 23

Transplant between two individuals who are not genetically identicle

Answer 24

Transplant between genetically identicle individuals

Answer 25

Transplant between species

Answer 26

**Parathyroid Hormone**: Increases serum calcium. Causes osteoclasts to reabsorb calcium from bones (bodys main Ca store) **Increases reabsorption of Ca in the kidneys** but decreases the reabsorption of Ph. Activates Vit D which increases the reabsorption of Ca in the intestine. ## Footnote **NB as serum calcium levels fall levels of PTH rise**

Answer 27

Produced by Thyroid C cells **Inhibits** osteoclast activity in the bone. Stimulates **osteoblast** activity. Inhibits reabsorption of Ca in the Kidney therefore more will be present in the urine. Inhibits reabsorption of Ca in the intestine. Therefore overall effect **decreases plasma calcium and phosphate Can be used to treat osteoporosis and hypercalcaemia**

Answer 28

* Photoactivation (in the skin) is the primary source of Vitamin D. * It is converted to active form in the liver and kidney. * This increases: * Gut calcium absorption * Bone calcification * Bone reabsorption * Regulation is by PTH, phosphate and feedback inhibition. * **Increases plasma calcium and phosphate**

Answer 29

**Look at Serum Calcium and Serum Phosphate & Albumin** **Albumin** ↑ & Serum Calcium raised = **Dehydration** Serum Phosphate low and Calcium ↑**: PTH mediated hypercalcaemia:** Serum calcium ↑, PTH not suppressed **Primary hyperparathyroidism** (most common cause) - is a single adenoma in 90% cases **Serum phosphate** ↑**Calcium** ↑ **PTH LOW** Non PTH mediated hypercalaemia: **Bone metastasis** (from breast, kidney, lung, thyroid, prostate) **Granulomatous** conditions (sarcoidosis/TB) Endocrine: Thyrotoxicosis, primary adrenal insufficiency **Iatrogenic**: Thiazide diuretics (reduces calicum excretion), Vit D and A supplements Familial: Familial Hypocalciuric hypercalcaemia

Answer 30

Due to single adenomas (\>80%) Carcinoma is rare Involvement of multiple parathyroid adenomas also rare, may be part of familial syndromes eg MEN type 1 or 2a **Hypercalcaemia BP is raised (so check calcium everyone BP)**

Answer 31

* Females over 50 y/o * Polyuria and polydispsia, leads to acute dehydration * Renal colic **‘*Stones’*** * Dyspepsia and peptic ulceration **‘*Abdominal Groans*’** * Depression **‘*Moans’*** * Bone pain ***‘Bones’*** * Lethargy * Anorexia and nausea * Constipation * Drowsiness and impaired cognitive function

Answer 32

* Several fasting serum calcium and phosphate samples should be performed * In primary hyperparathyroidism: * Increased Ca²⁺ * Decreased phosphate * Normal or elevated PTH levels during hypercalcaemia. * Often mild hyperchloreamic acidosis (needs no treatment).

Answer 33

* Parathyroid hyperplasia is a response to low blood calcium due to: * Chronic renal failure * Malabsorption * Osteomalacia & Rickets (Vit D deficiency) * Leads to decreased Ca²⁺, and increased PTH:

Answer 34

**MEN 1 (Werner's syndrome)** * Primary hyperparathyroidism * Pituitary tumours * Pancreatic neuro-endocrine tumours (e.g. insulinoma, gastrinoma) **MEN 2 (Sipple's syndrome)** * Primary hyperparathyroidism * Medullary carcinoma of thyroid * Phaeochromocytoma * In addition, in MEN 2b syndrome there are phenotypic changes(including marfanoid habitus, skeletal abnormalities, abnormaldental enamel, multiple mucosal neuromas)****

Answer 35

**"Stones, Bones, Groans, Thrones and Psychiatric Overtones"** * **Stones** (renal or biliary) * **Bones** (bone pain) * **Groans** (abdominal pain, nausea and vomiting) * **Thrones** (polyuria) resulting in dehydration * **Psychiatric overtones** (Depression 30–40%, anxiety, cognitive dysfunction, insomnia, coma)

Answer 36

**Investigations:** * Measure U&E’s, Mg²⁺, creatinine, Ca²⁺, PO₄³-, alk phos, PTH * CXR and CT for metastases, * Abdominal US for intra-abdominal malignancy if symptoms **Management:** * **Rehydration with normal saline** * To replace as much as a 4-6 L deficit * Moniter if renal failure / CCF * **Bisphosphonates** IV * Causes a fall in calcium which is maximal at 2-3 days and lasts a few weeks

Answer 37

**Most common: low albumin (↓**Albumin → **↓**Ca²⁺) as approx. 40% Calcium is bound to Albumin **Low PTH levels:** Hypoparathyroidism (frequently following surgery, radiotherapy or infiltartion e.g sarcoidosis or amyloidosis). **High PTH levels:** Vitamin D deficiency or abnormal metabolism. Hypomagnesaemia (causing PTH resistance) **Other causes:** Renal failure (no renal reabsorption) Medication. Acute pancreatitis.

Answer 38

**Tetany (intermittent muscle spasms)** * ***Chvostek's** sign* - gentle tapping over the facial nerve in the parotid causes twitching of the facial muscles. * ***Trousseau's** sign* - inflation of the **BP** cuff above systolic blood pressure for 3 minute induces carpal spasm of the fingers and wrist. * Note: Mg²⁺ depletion can also be a cause of tetany. **Pneumonic SPASMODIC** * *S**pasms (Trousseau's sign) * *P**erioral Paresthesia * *A**nxious * *S**eizures * *M**uscle tone increased in SM (colic, wheezing) * *O**rientation impaired * *D**ermatitis * *I**mpetigo * *C**hvosteks sign

Answer 39

Higher cortical dysfunction (agnosia, neglect, dysphasia) Hemianopia Motor or sensory deficit Note: hemianopia is on the same side as the hemiparesis The brain lesion will be on the other side eg if LEFT sided stroke will cause a right sided heminopia and right sided hemiparesis In a total anterior stroke all three are present in a partial 2 of the 3 are present.

Answer 40

Isolated hemiapnopia OR Cerebellar ataxia OR Cranial nn lesions

Answer 41

One motor or sensory deficit.

Answer 42

Bamford classification. Splits different strokes up into TACS, PACS, POCS and Lacunar based on the symptoms.

Answer 43

Right TACS as it will effect the left dominant hemisphere. TACS 60% PACS 15% LACS 10% Posterior circulation 20%

Answer 44

* *1st Arch: a Massive list of M’s** * *Nerve:** **M**axillary and **M**andibular nerves **Artery**: **M**axillary artery * *Cartilage: M**eckel’s Cartilage - **M**andible + spheno**M**andibular ligament - **M**alleus + Incus * *Muscles: MAT x 2** - **Muscles of Mastication** - **M**ylohyoid - **A**nterior belly of digastric - **A**nterior 2/3 of tongue - **T**ensor veli palatini - **T**ensor tympani

Answer 45

* *2nd arch: Second** * *Nerve**: Seventh nerve (facial nerve) **Artery**: Stapedial artery and hyoid artery * *Cartilage:** - **S**tapes - **S**tyloid - **S**tylohyoid ligament - le**SS**er horn of hyoid * *Muscles:** - Muscles of facial expression (**S**miling) - **S**tapedius - **S**tylohyoid - po**SS**terior belly of digastric

Answer 46

**3rd arch: think Glossopharyngeal nerve** * *Nerve:** - **Glosso**pharyngeal nerve * *Cartilage:** - **G**reater horn of hyoid * *Muscle:** - Stylo**pharyngeus** ## Footnote **Common and internal CAROTID**

Answer 47

**4th Arch: Swallowing + The exceptions to the 6th arch below** **Nerve:** **Superior Laryngeal** (branch of **vagus**) * *Cartilage:** - Thyroid cartilage * *Muscles:** - Pharyngeal constrictors - Levator veli palatini - Cricothyroid ## Footnote **R Subclavian artery and Left aortic arch**

Answer 48

**6th Arch: Speaking (Laryngeal)** **Nerve:** Recurrent laryngeal (branch of vagus) **Cartilage:** All laryngeal cartilages except thyroid cartilage **Muscles:** All instrinsic laryngeal muscles except cricothyroid **R & L pulmonary artery and ductus arteriosus**

Answer 49

18-25 they constitute up to 60% of all palpable breast lesions \<3cm - a policy of **watchful waiting** without biopsy may be adopted. \>4cm - core biopsy to exclude a **phyllodes tumour**. The natural history of fibroadenomas is that 10% will increase in size, 30% regress and the remainder stay the same.

Answer 50

Palpable cysts constitute 15% of all breast lumps. They occur most frequently in perimenopausal females and are caused by distended and involuted lobules. imaging they will usually show a "**halo appearance**" on mammography. Ultrasound will confirm the fluid filled nature of the cyst

Answer 51

A **benign** local proliferation of breast ducts and stroma Ages **25-35 years** Macroscopically: 1-4cm in diameter Firm, rubbery, well circumscribed lesions Mobile 1/3 regress 1/3 stay the same 1/3 get bigger

Answer 52

**Fibrocystic change** Present in 40% women 10% all women present with clinical symptoms Hyperplastic overgrowth of components of the mammary unit ie lobules, ductules and stroma If unequal growth of the epithelial and stromal elements get **fibroadenoisis**

Answer 53

Palpable thickening & nodularity of breast tissue Tissue is rubbery in texture Varies in size with stage of hormonal cycle May also result in development of a single breast lump MUST be distinguished from malignancy

Answer 54

Affects 1 in 12 women, uncommon in men. Characteristically: Irregular outline Often Painless Firm or Hard May be within the breast tissue or extend into overlying tissue.

Answer 55

**Dimpling skin** but retraction skin mobile over tumour suggests **benign disease** Skin may be indrawn due to infiltratio of dermis by tumour **Fixed to skin** → malignant disease **Tethered to chest wall** fixed when pectoral muscle contracted **PEAU D'ORANGE →** obstruction intramammary lymphatics resulting in lymphoedema of the breast. Skin attached at hair follicles but swollen inbetween

Answer 56

Benign nipple inversion (**symmetrical** ) Inversion Nipple retraction → malignant disease **asymmetrical and distorting** **NB always investigate nipple discharge**

Answer 57

**Non-invasive ductal carcinoma in situ (5%)** Pre-malignant **Non-invasive lobular carcinoma in situ** Histological finding rather than a mass Pre-malignant but high chance of malignancy NB this risk is present for both breasts, not just affected breast

Answer 58

ductal pure, ductal mixed lobular tubular mucoid medullary

Answer 59

Invasive ductal carcinoma (70%)

Answer 60

**Invasive lobular carcinoma** High frequency of bilateral breast involvement compared to other tumour types

Answer 61

Familial breast cancer (5% cases) (BRACA1 & BRACA2) Geographical - developed countries Proliferative breast disease eg atypical duct hyperplasia **Uniterrupted Oestrogen exposure:** Early onset menarche Late birth first child / nulliparous state Late menopause Exogenous hormones

Answer 62

Triple Assesment: 1. **Clinical Examination** 2. **Radiology**: USS for \< 35 y/o, Mammography & USS for \> 35 y/o 3. **Histology** / **cytology:** **C**ystic lump → FNA or core biopsy Solid lump → Core biopsy

Answer 63

All large fibroadenomas should be excised Clinically apparent lesions in postmenopausal period should also be excised

Answer 64

Require no Tx unless they are associated with persistent lump or cyst fluid is blood stained USS can help to identify cysts that should be excised

Answer 65

**Nottingham prognostic index:** Based on 3 prognostic factors clinically stages breast tumours **Tumour size** (cm x 0.2) **Lymph node stage** (1 = node negative, 2 = 1-3 metastatic nodes, 3 = 4+ metastatic nodes) **Histological grade** (1-3 for good, moderate, poor) Score \< 3.4 indicated good prognosis Score 3.4-5.4 moderately good prognosis Score \> 5.4 poor prognosis

Answer 66

**TNM** Early cancer: 1-2 Advanced breast cancer: 3-4 **T** T0 – carcinoma in situ or microinvasion T1 – tumour \< 2cm T2 – tumour 2-5cm T3 – tumour \> 5cm T4 – Overlying skin or underlying muscle attachment **N** N0 – no axillary nodal involvement N1 – free axillary nodes (histologically less than 3 nodes involved) N2 – more than 3 nodes involved or fixed axillary nodes N3 – Supraclavicular nodes involved **M** M0 – no metastasis M1 – metastatic disease present

Answer 67

CAT scan of lung & liver Bone scan Blood tests: FBC, LFTs, **carcinoembryonic antigen (Ca15.3)**

Answer 68

**Local Tx:** Lumpectomy + Radiotherapy Simple mastectomy **Tx for axillary lymph nodes:** Axillary dissection Radiotherapy to the axilla **Prevention systemic spread:** **Tamoxifen** (Oestrogen receptor blocker) Adjuvant chemotherapy

Answer 69

**Distant spread at time of diagnosis** Treatment of late breast cancer is usually palliative and mostly medical Local treatment is directed at controlling local recurrence: lumpectomy/mastectomy/radiotherapy **Distant metastases:** radiotherapy to relieve pain from bony metastases; chemotherapy (tamoxifen, cytotoxics, aminoglutethimide) to control tumour load

Answer 70

**Early cancer:** overall 80% 10-year survival rate **Advanced cancer:** poor, only 30-40% respond to treatment with mean survival of 2 years, by which time the non-responders have usually died If metastasis are present then only 15% of patients will survive for 5 years; life expectancy (50% mortality) is 2-3 years.

Answer 71

Requires investigation if blood stained Important to determine if the discharge is from multiple ducts or a single duct If bilateral and milky → **serum prolactin (rule out physiological discharge)**

Answer 72

Usually **Intraductal Papilloma** (usually benign) Follow up with Triple Assesment Confirm presence of blood in discharge with dipstick

Answer 73

women aged between 50 and 70 for screening every 3 years 2 seperate mammograms performed. If any abnormalities suspected then patients are called back within 2 weeks

Answer 74

**Skin:** The first symptom is usually an **eczema-like rash**. The skin of the nipple and areola may be red, itchy and inflamed **Discharge**. straw-colored or bloody Some women have a burning sensation

Answer 75

Asthma, bronchitis and empysema **Characterised by Airway Narrowing -\>** maximum expiratory flow is limited by dynamic compression of small intrathoracic airways -\> limiting the volume that can be expired -\> **Hyperinflation of the chest** which can become extreme if elastic recoil is also lost due to parenchymal destruction, as in empysema

Answer 76

Diseases which causes lung inflammation &/or scarring and fibrosis fibrosing alveolitis, scoliosis -\> **loss of lung volume with normal expiratory flow rates** Gas exchange is impaired both by parenchymal destruction (empysema) & by interstitial disease which interupts venitlation and perfusion matching

Answer 77

FEV₁ is disproportionately reduced in airflow obstruction resulting in FEV₁/VC ratios of less than 70%. When obstruction is seen spirometry should be repeated following inhalation of SABA

Answer 78

Dilution of an inert gas (usually helium) Measures the vilume of intrathoracic gas which mixes quickly with tidal intrathoracic gas volume including poorly ventilated areas Can also have 0.3% CO which is used with a breath hold test to look at exchange of gas THis is termed K_CO(gas transfer per unit lung volume)

Answer 79

**e.g. MI, valve abnormality** **increased SVR** (vasoconstriction in response to low BP) **increased HR** (sympathetic response) decreased cardiac output decreased blood pressure

Answer 80

* *blood volume depletion** e. g. haemorrhage, vomiting, diarrhoea, dehydration, third-space losses during major operations **increased SVR increased HR** decreased cardiac output decreased blood pressure

Answer 81

**Septic shock:** occurs when the peripheral vascular dilatation causes a fall in SVR similar response may occur in anaphylactic shock, neurogenic shock **reduced SVR** (due to extensive cytokine release) increased HR normal/increased cardiac output decreased blood pressure

Answer 82

**Adrenaline:** 500 mcg (0.5ml 1 in 1,000) **Hydrocortisone:** 200 mg **Chlorphenamine:** 10mg