IUPA REV Flashcards
How does a fetal skull differ from an adults?
Large calvaria relative to face
No teeth
No mastoid or styloid process
Small nasal cavities
What form the borders between the cranial fossa?
Lesser wing sphenoid
Superior border petrous part of temporal bone
What are fontanelles?
Areas of unossified membranous gaps between flat bones of calvaria
When do the fontanelles close?
Anterior - 18 months to 2 years
Posterior - 1-3 months
Where is the bleeding in a cephalohaematoma, is the brain compressed?
between periosteum and bone.
No brain compression - outside skull.
Which vessels lie in the dense connective tissue layer of the scalp?
Vessels supplying scalp
Supraorbital + supratrochlear
Occipital, pre-auricular and superficial temporal
Which vessels lie in the loose connectivity tissue layer of scalp?
Emissery veins - connect vessels in dense ct layer with dural venous sinus.
How can scalp infections spread intracranially?
Emissery veins connecting vessels in deep ct layer to intracranial venous sinuses.
What space do bridging veins traverse?
Subdural space - drain cerebral veins in subarachnoid space into dural venous sinus
What does the MMA supply?
Bones of skull + dura
Where is the bleeding in an extradural haemorrhage?
Between skull and periosteal layer dura
Where is the bleeding in a subdural haemorrhage?
Subdural space - between dura and arachnoid mater
Which type of intracranial haemorrhage can be confirmed by lumbar puncture?
Subarachnoid -blood mix with CSF in subarachnoid space
Which artery has an important relationship with recurrent laryngeal nerve?
Inferior thyroid artery - from thyrocervical trunk
Which bone is the cavernous sinus in?
Sphenoid bone
What are 2 complications of infections spread intracranially from the face?
Cavernous sinus thrombosis
Meningitis
What is the significance of the ‘danger triangle’ of the face?
Infections in this region can spread through venous system to dural venous sinuses and intracranially. Pterygoid plexus (extracranial) via valveless emissary veins to cavernous sinus (intracranial).
Which skull hole does IJV pass through?
Jugular foramen
Branches from which arteries supply the nasal septum?
Ophthalmic - ant and post ethmoidal
Maxillary - sphenopalatine and greater palatine
Facial - superior labial
Which side is the thoracic duct? where does it drain into?
Left side
Subclavian vein
Which nodes may be enlarged in conjunctivitis, tonsillitis and mouth ulcer?
Pre-auricular
Jugulo-digastric (deep)
Submental
Where is the olfactory cortex?
Temporal lobe- uncus
What are 3 signs of CNIII nerve palsy?
Ptosis
Dilated pupil
Down and out position
Why does horners syndrome only cause partial ptosis?
LPS still functioning - supplied by CNIII
Sympathetics supplying superior tarsal affected.
Which cranial nerve emerges from the dorsal aspect of brainstem?
Trochlear
Which 2 cranial nerves emerge from midbrain?
CNIII - oculomotor
CNIV - trochlear
Which 4 cranial nerves emerge from pons?
V- trigeminal
VI- abducens
VII - facial
VIII - vestibulocochlear
Which cranial nerve is vulnerable if raised ICP, why?
Abducens - emerges at pontomedullary junction and courses close to bone into cavernous sinus.
What reflex tests the facial nerve?
Corneal reflex - orbicularis oculi
Which component of CNVIII do acoustic neuromas arise from?
Schwann cells of vestibular nerve
What are the symptoms of an acoustic neuroma?
Unilateral hearing loss Tinnitus Vertigo Numbness Weakness in half of face - compress facial n.
Which nerves pass through the jugular foramen?
Glossopharyngeal
Vagus
Spinal accessory
Explain 3 signs of horner’s syndrome.
Partial ptosis - superior tarsal muscle
Miosis - dilator pupillae
Anhydrosis - no sweat gland stimulation
Which structures are formed from the pouches of pharyngeal arches?
Eustacian tube and middle ear cavity
Palatine tonsils
Thymus and parathyroid glands
What is ramsey-hunt syndrome?
Reactivation of varicella zoster virus from geniculate nucleus
What ear pathology causes painless, smelly otorrhea?
Cholesteatoma
What are 4 causes of sensorineural hearing loss?
Acoustic neuroma
Meniere’s disease
Presbyacusis
Ototoxic medication
What are 4 causes of conductive hearing loss?
Wax
Otitis media
Glue ear
Otosclerosis
Where are the anterior chamber and posterior chamber of eye?
Anterior - between iris and cornea
Posterior - between iris and lens
How might closed-angle glaucoma present?
Sudden onset of painful red eye
Irregular oval-shaped pupil
Nausea and vomiting
Eye hard and tender to palpate through eyelid
What is the main refractor of the eye?
Cornea
What complication can arise from ethmoid sinusitis?
Orbital cellulitis
Head and neck cancers are usually ___________.
squamous cell carcinoma
What investigation can be done if thyroid cancer suspected?
FNAC - fine needle aspiration for cytology
What is the most common type of thyroid cancer?
Papillary - adenocarcinoma
Give 4 differentials for scrotal swelling.
Testicular torsion
Hydrocele
Testicular cancer
Scrotal hernia
What does the cremasteric reflex test?
Genitofemoral nerve - L1
Where is the most common site of ectopic pregnancy?
Ampulla
What is the lymph drainage of the fundus of uterus?
Para-aortic
What is the lymph drainage of the body of the uterus?
Upper - external iliac
Lower - internal iliac
What is the lymph drainage of the cervix?
Internal iliac
Sacral
What is the lymph drainage of the thirds of the vagina?
External iliac
Internal iliac
Superficial inguinal
Give an example of a condition which causes hypergonadophic hypogonadism.
Turners syndrome - 45 XO = primary ovarian failure
What are GnRH agonists used to treat?
Endometriosis
Uterine fibroids
What do theca cells secrete?
Androgens -> Oestrogens
What do granulosa cells secrete?
Oestrogen
What happens during LH surge?
Granulosa cells become sensitive to LH and secretes progesterone
At which stage is the endometrium at max thickness?
Early secretory
Variations in menstrual cycle are due to which phase?
Follicular phase
Luteal phase strictly 14 days +-2
What effects do oestrogen and progesterone have on the myometrium?
Oestrogen - thickens and increases motility
Prog - thickens and decreases motility
How is secondary amenorrhoea defined?
No menstrual period for 6 months
What are causes of primary amenorrhoea?
Structural - agenesis, imperforate hymen
Chromosomal - Turner’s
Hormonal - HPA axis
What are causes of secondary amenorrhoea?
Pregnancy
Weight loss
Stress
PCOS - raised LH:FSH ratio
What is the MOA of sildenafil?
Inhibits phosphodiesterase, increased cGMP, increased NO.
What are 4 causes of erectile dysfunction?
Drugs - anti-depressants
Vascular - atheroma
Tears in tunica albuginea
Psychological inhibition
How does high dose progesterone act as contraception?
Inhibits positive feedback of oestrogen - No LH surge, inhibiting ovulation.
What are possible SE of taking COCP?
MI, stroke, thromboembolism
Increased risk of breast cancer + cervical cancer (no STI protection)
What is the commonest female cause of infertility?
Anovulation
What is the commonest cause of irregular, upper tract bleeding in females?
Anovulation
Which intrauterine device is used for patients with heavy bleeding?
IUS - progesterone secreting
What is the primary and secondary action of IUD?
Primary - Cu toxic to sperm and ovary
Secondary - endometrial inflammatory reaction inhibits implantation, thickens cervical mucus.
What are the disadvantages for intrauterine contraception?
No STI protection
Insertion unpleasant
Risk of uterine perforation
Displacement/expulsion possible
Which oral contraception has a risk of ectopic pregnancy?
Low dose progesterone (POP) - doesn’t inhibit ovulation.
What is the decidua?
Thickened endometrium
What are 2 examples of implantation defects?
Ectopic - ampulla
Placenta praevia - lower uterine segment blocking cervix, haemorrhage risk.
Where would you inject an epidural?
L4/5
What is used to assess fetal head position in birth canal?
Anterior fontanelle
What happens to vaginal pH after menopause?
increases - less glycogen, less lactic acid produced lactobacilli.
What are risk factors for prolapse?
Age Vaginal delivery Post-menopause Obesity - raised pressure Ct disorders
How is chlamydia trachomitis diagnosed?
Men - first catch urine
Women - vaginal swab
How is neisseria gonorrhoea diagnosed?
Swab and gram stain - gram -ve diplococcus (pink)
Which STI is protozoa?
Trichomonas vaginalis
How are genital ulcers treated?
Aciclovir - herpes simplex
What is the commonest cause of ectopic pregnancy?
Previous salpingitis - scarring of tube epithelium.
What is PID?
Infection of upper reproductive tract - travelled through cervix into uterus.
What is the treatment for PID?
Antibiotics for 14 days
Other than gonorrhoea and chlamydia, what can cause PID?
IUD - copper coil
How does PID present?
Fever
Lower abdominal pain and tenderness
Pain during intercourse
Vaginal discharge
What are 3 complications of PID?
Ectopic pregnancy - cilia damage
Infertility
Fitz- hugh- curtis syndrome - per-hepatitis after chlamydial PID.
What are risk factors for endometrial carcinoma?
Overweight - adipose tissue secrete oestrogen
Anovulation
Exogenous - HRT
Post-menopause
COCP is protective against which cancer?
Ovarian epithelial
What are risk factors for ovarian epithelial cancers?
Nulliparity or low parity
Heritable mutations - BRCA1/2
Smoking
What are signs of hepatocellular carcinoma?
Hepatomegaly - hard, irregular border
Ascites
What are virulence factors of H.Pylori?
Urease - converts urea to ammonium Ammonium toxic to epithelia Degrades mucus layer Flagella - adhere Cytotoxins - epithelial injury
What surface landmark can be used to locate the deep inguinal ring?
Midpoint of inguinal ligament - ASIS to pubic tubercle.
What is a complication of UC?
Toxic megacolon
How does smoking affect crohns and UC?
Crohns - worsens
UC - protective
What is the treatment for Crohns?
Sulphasalazine
Corticosteroids
Immunosuppressants - azathioprine
What are complications of CKD?
Fluid retention Hyperkalaemia Metabolic acidosis Uraemia Anaemia Mineral bone disease
List differentials of haematuria.
Cancer - RCC, TCC, prostate BPH Stones Infection Glomerular
What does RCC look like microscopically?
Clear cells
What can be used to treat prostate cancer?
GnRH agonists - desensitise to androgens which increase growth.
What are the types of urinary tract cancer?
TCC - transitional cell carcinoma
RCC - renal cell carcinoma
Which areas of the nephron are first to be damaged in ischaemia?
PCT and TAL - outer medulla
Name 3 endogenous nephrotoxins.
Myoglobin
Bilirubin
Urate
What host factors can increase risk of UTI?
Women - shorter urethra Obstruction - stasis Neurological - incomplete emptying Structural - duplex ureter, pelvic kidney Catheter Pregnancy
Give 3 reasons you might find sterile pyria.
Antibiotics already started
TB
Urethritis - chlamydia
What infections can cause immune-mediated glomerulonephritis?
Post-streptococcal
Endocarditis
Hep B + C
HIV
What drugs can be used to treat urge incontinence?
Anti-muscarinics
B3 agonist
Which AQP is inserted into the apical membrane by ADH?
AQP2
What produces the concentration gradient in the nephron?
Loop of henle acting as counter current multiplier
What maintains the concentration gradient in the nephron?
Vasa recta acting as counter current exchanger.
What is the aldosterone paradox during volume depletion?
Angiotensin II will also be raised - inhibits ROMK to limit K+ excretion while still increasing NaCl reabsorption to raise blood pressure.
What is the aldosterone paradox during hyperkalaemia?
Low AngII as blood volume fine - Inhibits NaCl absorption.
Aldosterone increases K+ secretion.
Where do PTH and Vit D act on kidney?
DCT
What acid-base balance does diarrhoea cause?
Metabolic acidosis - HCO3- and K+ loss
What acid-base disturbance does vomiting cause?
Metabolic alkalosis - H+ lost
What 2 buffers are used in PCT and DT?
PCT - ammonia
DT- phosphate
What is the main action of adenosine in auto regulation?
Dilate EA
What are the actions of ANP?
Inhibit Na reabsorption - natruresis
Vasodilation - AA increases GFR
What are 2 causes of renal artery stenosis?
Atheroma
Fibromuscular dysplasia
How might symptoms differ in unilateral renal artery stenosis compared to bilateral renal artery stenosis?
Unilateral - hypertension but no fluid overload as healthy kidney corrects.
Bilateral - hypertension and fluid overload as no volume correction.
How might you diagnose primary hyperaldosteronism/Conn’s syndrome?
Low renin:angiotension ratio
Hypertension refractory to treatment
What is the embryological kidney?
Mesonephros
Where does the ureteric bud sprout from?
Mesonephric duct
What is the kidney collecting duct system derived from?
Ureteric bud itself
What causes a pelvic kidney?
Ascent of kidney blocked by abdominal vessels - IMA at L3
What causes a horseshoe kidney?
Kidney hooked on IMA (lowest branch of aorta), inferior poles fuse.
What does the urachus form in an adult?
Median umbilical ligament.
Where is the main site for calcium reabsorption in the nephron?
DCT
What are the 3 sites of ureter constriction?
Pelviuretic junction
Bifurcation of common iliac artery
Entering bladder (vesicoureteric junction)
What is the level of the kidneys?
Left - T11-L2/3
Right - T12-L3/4
What is the lymphatic drainage of the kidney?
Lateral aortic nodes
What are the layers surrounding the kidney?
Capsule
Perirenal fat
Renal fascia
Pararenal fat
What epithelium is present in the nephron?
Simple squamous - bowman’s capsule + desc LH
Cuboidal - CD
Cuboidal + many microvilli - PCT
Cuboidal + few microvilli - DCT
Give differentials for haematuria.
Infection
Obstruction - renal calculi
Cancer - RCC, bladder TCC, upper tract TCC
BPH
What bony feature do the ureters descend anteriorly to.
Tips of transverse processes of lumbar vertebrae.
What artery supplies the superior surface of the bladder?
Umbilical artery
What passes anteriorly to the vas deferent in men and women?
Vas deferens - men
Uterine artery- women
Which part of the urinary tract can develop adenocarcinoma?
Apex of bladder - due to origin of tissue
What ligaments help secure the bladder neck in males and females?
Males - puboprostatic
Female - pubovesical
Which kidney is used in transplants?
Left - longer vein makes it easier
What complication can occur in patients with a horseshoe kidney?
Urinary stones - increased risk.
What is the significance of the trigone?
Part of bladder most strongly tethered in position.
What is the sternal angle?
Junction between manubrium and body of sternum
What is the conducting portion of the resp tract?
Nostrils to terminal bronchioles
What is the respiratory portion of the resp tract?
Resp bronchioles to alveoli
Where are clara cells found, what is there function?
Bronchioles
Secrete surfactant lipoprotein - prevent bronchiole walls sticking together
Produce protein - protects against toxins
Which lung cancer can secrete ACTH and ADH?
Small cell carcinoma
Which lung cancer can secrete PTH?
Squamous cell
Where in the bronchial tree is the main site of airway resistance?
Trachea - upper resp tract
What are accessory muscles of inspiration?
SCM, scalene, pec major and minor, trapezius
What are accessory muscles of expiration?
Internal intercostal, abdo wall
How does FRC change with age?
increases - lose elastic fibres with age
Give an example of a disease causing increased compliance.
Emphysema - can still stretch but loss of recoil
What forces favour inward lung movement?
Elastic recoil
Surface tension
What is compliance?
Volume change per unit pressure change.
What are the functions of surfactant?
Increase compliance
Stabilise lungs - prevent small alveoli collapsing into large
How would pneumothorax affect dead space?
Decrease anatomical dead space - bronchioles narrow
What physical signs might you see in a patient with a PE?
Pleural rub
Raised JVP
What investigation could you do if you suspected PE?
CT pulmonary angiography
Blood - d-dimer
What is the most common cause of chronic type 2 resp failure/hypoventilation?
COPD
What is the most important factor in COPD treatment?
Stop smoking
What test can be used to differentiate between COPD and asthma?
DLCO (diffusion capacity of lungs for CO) is reduced in COPD but normal in asthma.
What 3 ways can you measure eosinophilic inflammation in asthmatic patients?
- FBC
- Induced sputum
- FeNO
What is the 2 phase response in asthma?
- Immediate response- type 1: IgE + allergen
2. Late phase response - type 4: inflammatory cells
How can you diagnose CF?
Chloride sweat test - high levels as can’t reabsorb
Give an example of an URT commensal.
Viridans streptococci.
How will a CXR appear in acute bronchitis?
Normal - airways not parenchyma affected
What does haemophilus influenza look like on gram stain?
Pink rods - gram negative
What signs might you find on examination of a patient with pneumonia?
Dullness on percussion - exudate
Bronchial breathing
Crackles
What are complications of pneumonia?
Sepsis
Lung abscess
Empyema
Pleural effusion
Where is it normal to hear bronchial breath sounds?
Trachea
What is the difference between transudate and exudate?
Transudate - low protein, increased pressure
Exudate - high protein, increased vascular permeability
What would you expect to hear on percussion of pleural effusion?
Stony dull
When might you see a mediastinal shift on CXR?
Tension pneumothorax - one way valve
What does the presence of crackles on lung auscultation suggest?
Consolidation
When might there be mediastinal shift towards the side of abnormality?
Lobar collapse
Where does lung cancer metastasise to?
Brain Pleura Liver Pericardium Bone
Where is the bronchus located in the hilum?
Posteriorly (bronchus = back)
What is the lymph drainage of the lungs?
Hilar nodes (bronchopulmonary) which run to tracheobronchial nodes.
Where is the upper respiratory tract?
Nostrils to lower border cricoid cartilage.
When are the vocal cords closed?
Cough
Phonation
What is a bronchopulmonary segment
Area of lung supplied by a segmental bronchus and accompanying segmental artery. Drained by segmental pulmonary vein.
Surgery - segments removed without bleeding or interference.
What is the blood supply to the alveoli?
Pulmonary artery
What is the nerve supply of the lung?
Parasympathetic - vagus nerve to bronchial SM and mucous glands
Sympathetic trunk - vasoconstrictor and bronchodilator.
What are the effects of hypercapnia?
Acidosis
Impaired CNS function - drowsy, confusion, coma,flap
Vasodilation - warm hands, bounding pulse
Cerebral vasodilation - headache
What are the effects of hypoxia?
Impaired CNS
Central cyanosis
Cardiac arrhythmia
Hypoxic vasoconstriction
What are the 3 main causes of bronchiectasis?
Post-infective
Immune deficiency
Mucociliary clearance defects - CF
What are complications of COPD?
Recurrent pneumonia
Pneumothorax - bulla formation and rupture
Resp failure
Cor pulmonale
What must be given alongside isoniazid, why?
Vit B6 - prevent nerve damage
How can you differentiate between latent and active TB?
CXR
Sputum smear
Why can bronchial breath sounds be heard over consolidation?
Exudate fluid present - sound travels better through fluid than air.
What are features of pleuritic pain?
Worse on inspiration
Sharp
Well localised
How can you tell between acute and chronic subdural haemorrhage on CT?
Acute - hyperdense = white
Chronic - hypodense = darker
What attaches to the superficial temporal line?
Temporalis
Why is dietary history important in neurology?
Vegan diet predisposes to B12 deficiency - demyelination of large neurones.
Which muscles move the eye directly up?
Superior rectus and Inferior Oblique
Which muscles move the eye directly down?
Inferior rectus and superior oblique
When is diplopia worst with trochlear nerve palsy?
Looking down and medially
When is diplopia worst with abducens nerve palsy?
Horizontal gaze
Which pharyngeal muscle is not innervated by the vagus nerve?
Stylopharyngeus - glossopharyngeal
Where is the pterygoid venous plexus?
Infratemporal fossa
What is used to treat gonorrhoea?
Ceftriaxone
What is used to treat trichomoniasis and bacterial vaginosis?
Metronidazole
What are the nerve roots of the pudendal nerve?
S2,3,4
What type of hemolysis does strep pneumonia produce?
alpha - incomplete, green
What is a cause of viral pneumonia?
Influenzae
How is aspiration pneumonia treated?
Co-amoxiclav
What are the causative organisms in aspiration pneumonia?
Mixed - anaerobes + viridans streptococci.
Where is a cannula inserted to treat tension pneumothorax?
2nd intercostal space in mid clavicular line
What spirometry parameter is likely to be increased in asthmatic patients?
Residual volume
What might cause pleural effusion with high protein content (exudate)?
Cancer
Infection - pneumonia
PE
By what gestational age is surfactant production sufficient?
30 weeks
Production starts at 26 weeks
Why is pregnancy associated with increased urinary incontinence?
Uterus presses on bladder as it grows
How does smoking in pregnancy affect oxygen delivery to fetus?
Increased CO in women who smoke, reduces O2 circulating and released to fetus.
What are signs and symptoms of pre-eclampsia?
Severe headache
Visual disturbances
Hyper-reflexia
What might you ask a mother at a 20 week scan?
Has she felt any movements?
Why is oligohydramnios associated with asymmetrical growth restriction?
Placental insuffiency is the most common cause
What is asymmetrical growth restriction?
Normal size head
Small abdomen
At what stage in fetal development is urine first produced?
10
What maternal condition might cause a high fetal abdominal circumference compared to head could indicate what?
Gestational diabetes - macrosomia.
What spinal levels are blocked in epidural?
Given L4/5 sitting up as want to diffuse to S2-S4 region where pelvic nerves orginate.
What effect can stress have on oxytocin release?
Increase
Why is sigmoid volvulus most common?
Mesentery more mobile - twists easily.
In relation to the inguinal ligament, how do femoral hernias differ from inguinal hernias?
Femoral - leave posterior to inguinal ligament
Inguinal - leave anterior to inguinal ligament
What lies anteriorly and posteriorly to the lesser momentum?
Anterior- stomach
Posterior- transverse mesocolon
Where does the portal vein form?
Behind the neck of the pancreas
Which nerves are vulnerable in anterior dislocation of temporomandibular joint?
Facial n.
Auriculotemporal n.
Which muscles are responsible for elevation of TMJ?
Masseter
Temporalis
Medial pterygoid
Which muscle is responsible for depression of TMJ?
Lateral pterygoid
