General points 1

Question 1

Hepatocellular adenoma

Answer 1

90% develop in women in their third to fifth decade
Linked to use of oral contraceptive pill
Lesions are usually solitary
They are usually sharply demarcated from normal liver although they usually lack a fibrous capsule
On ultrasound the appearances are of mixed echoity and heterogeneous texture. On CT most lesions are hypodense when imaged prior to administration of IV contrast agents
In patients with haemorrhage or symptoms removal of the adenoma may be required
Asymptomatic adenomas >5cm are usually excised
Adenomas in males are likely to be smaller but have a greater risk of malignant transformation
- Risk of rupture is greater in lesions larger than 5cm and those which are exophytic. Mortality rates from spontaneous rupture are 5-10%.

Question 2

Jugular Foramen

Answer 2

Anterior: inferior petrosal sinus
Intermediate: glossopharyngeal, vagus, and accessory nerves
Posterior: sigmoid sinus (becoming the internal jugular vein) and some meningeal branches from the occipital and ascending pharyngeal arteries

Question 3

Lumbar puncture procedure

Answer 3

During the procedure the needle passes through:

• The supraspinous ligament which connects the tips of spinous processes and the interspinous ligaments between adjacent borders of spinous processes
• Then the needle passes through the ligamentum flavum, which may cause a give as it is penetrated
• A second give represents penetration of the needle through the dura mater into the subarachnoid space. Clear CSF should be obtained at this point

Question 4

Gastric cell secretions

Answer 4

Parietal cells: secrete HCl, Ca, Na, Mg and intrinsic factor
Chief cells: secrete pepsinogen
Surface mucosal cells: secrete mucus and bicarbonate

Question 5

Berry’s sign

Answer 5

Absence of carotid pulse due to malignant thyromegaly -> Follicular thyroid cancer

Question 6

Rectus abdominis muscle

Answer 6

1. Above the costal margin the anterior sheath is composed of external oblique aponeurosis, the costal cartilages are posterior to it.
2. From the costal margin to the arcuate line, the anterior rectus sheath is composed of external oblique aponeurosis and the anterior part of the internal oblique aponeurosis. The posterior part of the internal oblique aponeurosis and transversus abdominis form the posterior rectus sheath.
3. 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.

Question 7

Arcuate Line

Answer 7

The point at which the inferior epigastric vessels enter the rectus sheath

Question 8

Define “massive transfusion”

Answer 8

Replacement of a patient’s total blood volume in less than 24 hours, or as the acute administration of more than half the patient’s estimated blood volume per hour

Question 9

Haemostatic resuscitation

Answer 9

Blood components are transfused in fixed ratios. During acute bleeding the practice of haemostatic resuscitation has been shown to reduce mortality rates. 
The typical therapeutic end points include:
- Hb: 8-10 g/dl
- Platelets > 100
- PT (INR) and APTT < 1.5
- Fibrinogen > 1.0 g/l
- Ca2+ > 1 mmol/l
- pH: 7.35-7.45
- BE: +/- 2
- Temperature > 36 °C

Question 10

Structures superficial to the retinaculum

Answer 10

Basilic vein
Dorsal cutaneous branch of the ulnar nerve
Cephalic vein
Superficial branch of the radial nerve

Question 11

Structures passing deep to the extensor retinaculum

Answer 11

Extensor carpi ulnaris tendon
Extensor digiti minimi tendon
Extensor digitorum and extensor indicis tendon
Extensor pollicis longus tendon
Extensor carpi radialis longus tendon
Extensor carpi radialis brevis tendon
Abductor pollicis longus and extensor pollicis brevis tendons