Khaled's notes to be revised Flashcards

Question

Kocher criteria for septic arthritis Non-Weight Bearing? Temperature > 38.5°C or 101.3°F? Serum ESR > 40 mm/hr? Serum WBC > 12,000 cells / mm

Answer 1

A subsequent validation study by Kocher et al. in 2004 maintained a strong utility for this decision tool, though with lower predictive probabilities. The validation demonstrated that the risk for septic arthritis was 2% for a score of 0, 9.5% for 1, 35% for 2, 72.8% for 3, and 93% for 4.

Answer 2

RPF is calculated by the clearance of para-aminohippuric acid (PAH) GFR measured by inulin (Filtered but neither reabsorbed nor secreted)

Answer 3

95% of bile salts are reabsobed from terminal ilium (enterohepatic circulation); resection of terminal ilium will affect fat absorption, including fat-soluble vitamins.

Answer 4

MRCS Micro #Recalls Class ###----###---### A child with Sickle cell + osteomyelitis caused by =......salmonela Dirhea within hour...... Staph aureus Skin infection post op.... Staph aureus Dirhea at the end of the day.... C. Jujeni HIV / renal transplant diarrhea...... Cryptosporodium Silicon breast implant infection.... Staph epidermidis Cancer Colon..... Strept bovis Tonsillitis.... Strept pyogens Endocarditis native valve vigitations .... Strept Viridans if bovis search for cancer colon Endocarditis prosthetic valve = staph epidermidis Spleen auto rupture.... Mononucleosis ebv Gangrene... C pyrfringen Meleny / necrotising fascitis.... Ecoli+bacteroid Uti... Ecoli Post cholecystectomy leakage organism infection... Ecoli Used AB diarrhea.... C. Difficile Post perforated appendix infection.... Bacteroid Macrolid... Inhibit protien Quinolones... Dna Rifampicin... mRNA + vanco for MRSA

Answer 5

Bifurcation of: Carotid C4 Trachea T4 Aorta L4 IVC L5

Answer 6

There is minimum mixing of blood passing through the vessels.

Answer 7

The posterior cerebral arteries are formed by the bifurcation of the basilar artery and is connected to the circle of Willis via the posterior communicating artery. The posterior cerebral arteries supply the occipital lobe and part of the temporal lobe

Answer 8

accompanied by the facial nerve The posterior inferior cerebellar artery is the largest of the cerebellar arteries arising from the vertebral artery. The labyrinthine artery is long and slender and may arise from the lower part of the basilar artery. It accompanies the facial and vestibulocochlear nerves into the internal auditory meatus. The posterior cerebral artery is often larger than the superior cerebellar artery and it is separated from the vessel, near it's origin, by the oculomotor nerve. Arterial decompression is a well established therapy for trigeminal neuralgia.

Answer 9

Brocas area is usually supplied by branches from the middle cerebral artery.

Answer 10

The subclavian vein lies behind subclavius and the medial part of the clavicle. It rests on the first rib, below and in front of the third part of the subclavian artery, and then on scalenus anterior which separates it from the second part of the artery (posteriorly).

Answer 11

This small bone has a single articular facet. It projects from the triquetral bone at the ulnar aspect of the wrist where most regard it as a sesamoid bone lying within the tendon of flexor carpi ulnaris.

Answer 12

A Celiac Plexus Block can be used to treat intractable pain from upper abdominal cancers. The most commonly and effectively treated cancer with Celiac plexus blocks is Pancreatic Cancer Pain and associated metastasis. A Celiac Plexus Block is performed to lessen or eliminate Chronic Pancreatitis Pain. It also can help your physician find the cause of your pain (diagnostic nerve block).

Answer 13

The carotid sheath is crossed anteriorly by the hypoglossal nerves and the ansa cervicalis. The vagus lies within it. The cervical sympathetic chain lies posteriorly between the sheath and the prevertebral fascia.

Answer 14

The most likely lesion to occur in the cerebello-pontine angle is an acoustic neuroma. The trigeminal nerve has a broad base and involvement of at least part of this nerve is the most likely initial finding. The defect may be subtle such as loss of the ipsilateral corneal reflex. Ipsilateral hearing loss will also occur. Untreated, progressive lesions, may ultimately affect cranial nerve roots in this region

Answer 15

Cranial nerves carrying parasympathetic fibres X IX VII III (1973)

Answer 16

This describes a relative afferent pupillary defect (RAPD). RAPD is a defect in the direct response to light. It is due to damage in optic nerve or severe retinal disease. If an optic nerve lesion is present the affected pupil will not constrict to light when light is shone in the that pupil during the swinging flashlight test. However, it will constrict if light is shone in the other eye (consensual response). The most likely cause for this is an optic neuritis (not really surgical!). Other causes include ischemic optic disease or retinal disease, severe glaucoma causing trauma to optic nerve and direct optic nerve damage (trauma, radiation, tumor).

Answer 17

The glossopharyngeal nerve supplies this area and the ear and otalgia may be the result of referred pain.

Answer 18

Arnold cough syndrome (Arnold branch of vagus) Cough with stimulation of external auditory meatus

Answer 19

1. Motor Innervation (Muscle Control) Hypoglossal nerve (Cranial Nerve XII): Supplies all intrinsic and most extrinsic muscles of the tongue (genioglossus, hyoglossus, styloglossus). Vagus nerve (Cranial Nerve X): Specifically innervates the palatoglossus muscle. 2. Sensory Innervation (General and Special Sensation) Anterior two-thirds (oral part): General sensation (touch, pain, temperature): Lingual nerve (branch of the mandibular division of the Trigeminal nerve, CN V3) Special sensation (taste): Chorda tympani nerve (branch of the Facial nerve, CN VII) via the lingual nerve. Posterior one-third (pharyngeal part): General and special sensation (taste and general): Glossopharyngeal nerve (CN IX) Base of the tongue (near the epiglottis): General and special sensation: Internal branch of the Superior Laryngeal nerve (branch of the Vagus nerve, CN X) 3. Autonomic Innervation Parasympathetic: Facial nerve (CN VII) via the chorda tympani for salivary gland secretion (submandibular and sublingual glands). Sympathetic: Derived from the superior cervical ganglion, regulating blood flow.

Answer 20

Tensor tympania and stapedius are the only two muscles of the middle ear. Contraction of tensor tympani will tend to dampen the vibrations produced by loud sounds, it is innervated by a branch of the trigeminal nerve. The stapedius dampens movements of the ossicles in response to loud sounds and is innervated by a branch of the facial nerve. The auriculotemporal nerve, which is derived from the mandibular branch of the trigeminal nerve supplies this area. Some areas may also be innervated by the vagus.

Answer 21

T1, T2, T3 We burn T2 and T3 only T1 is in close relation with the Stellate ganglion supplying sympathetic innervation to the upper limb. If injured, it will lead to HORNER SYNDROME. In patients with vascular disease of the lower limbs a lumbar sympathetomy may be performed, either radiologically or (more rarely now) surgically. The ganglia of L2 and below are disrupted. If L1 is removed then ejaculation may be compromised (and little additional benefit conferred as the preganglionic fibres do not arise below L2.

Answer 22

The posterior compartment of the lower leg has both superficial and deep posterior layers, together with the anterior and lateral compartments this allows for four compartments. Decompression of the deep posterior compartment during fasciotomy may be overlooked with significant sequelae.

Answer 23

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

Answer 24

The deep external pudendal artery is a branch of the SFA and it runs medially under the long saphenous vein near its point of union with the femoral vein. The superficial external pudendal artery lies superior to the SFJ. Neither vessel is functionally important and if injured they are best ligated.

Answer 25

The anterior interosseous nerve is a branch of the median nerve and is responsible for innervation of the lateral aspect of the flexor digitorum profundus.

Answer 26

Mnemonic for muscle attachment on greater trochanter is POGO: Piriformis Obturator internus Gemelli Obturator externus The quadratus femoris fibres pass laterally to be inserted into the quadrate tubercle on the intertrochanteric crest of the femur. The other muscles all insert on the trochanteric fossa lying medial to the greater trochanter.

Answer 27

ventral rami of the second, third, and fourth sacral nerves (S2, S3, S4). * Rectal nerve * Perineal nerve * Dorsal nerve of penis/ clitoris

Answer 28

The 5th tendon sheath extends from the little finger to the proximal aspect of the carpal tunnel. This carries a significant risk of allowing infections to migrate proximally.

Answer 29

The middle finger has no attachment of the palmar interosseous. Note that there are 4 palmar interossei. The first is a small slip of muscle which arises from the ulnar side of the base of the first metacarpal and passes between the head of the first dorsal interosseous and the oblique head of adductor pollicis to insert into the ulnar base of the of the proximal phalanx of the thumb. The second arises from the ulnar side of the body of the second metacarpal and is inserted into the ulnar side of the extensor hood of the index. The third and fourth palmar interossei arise from the radial sides of the bodies of the 4th and 5th metacarpals respectively and insert into the radial sides of the extensor hoods of the ring and little fingers.

Answer 30

The musculi pectinati are found in the atria, hence the reason that the atrial walls in the right atrium are irregular anteriorly. The musculi pectinati of the atria are internal muscular ridges on the anterolateral surface of the chambers and they are only present in the area derived from the embryological true atrium

Answer 31

The conus arteriosus (infundibulum) is the smooth walled outflow tract of the right ventricle leading to the pulmonary trunk.

Answer 32

Musculi pectinati Crista terminalis Opening of the coronary sinus Fossa ovalis The trabeculae carnae are located in the right ventricle

Answer 33

The inferior gluteal artery runs on the deep surface of the gluteus maximus muscle. It is a branch of the internal iliac artery. It is commonly divided during the posterior approach to the hip joint. During the Hardinge style lateral approach the transverse branch of the lateral circumflex artery is divided to gain access.

Answer 34

The anhidrosis will be mild as this is a distal lesion and at worst only a very limited area of the ipsilateral face will be anhidrotic.

Answer 35

Commonest RO (Ca oxalate) Inherited ( Cystein) Debilitating disease (Urate) UTI (Sturivate)

Answer 36

Latex allergy (Even if indication of catheterization retention)

Answer 37

Resp. acidosis Hypoxic Hypercapnic

Answer 38

Due to affection of parasympathetic fibers carried over the occulomotor nerve. Unopposed sympathetic.

Answer 39

Unlike all other arteries, IT'S FILLED DURING DIASTOLE

Answer 40

A large pulsatile swelling medial to the greater trochanter is most likely to affect the external iliac artery. The common iliac does not lie at this level. It would be very unusual for the inferior epigastric artery to develop an aneurysm.

Answer 41

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 42

Hypoglossal nerve Greater auricular nerve Superior laryngeal nerve

Answer 43

ul: 4 P AND 4 D ll: 3 P AND 4 D Remember PAD DAP

Answer 44

The posterior longitudinal ligament overlies the posterior aspect of the vertebral bodies. It also overlies the posterior aspect of the intervertebral disks

Answer 45

The posterior cruciate ligament is separated from the popliteal vessels at its origin by the oblique popliteal ligament.It is attached above to the upper margin of the intercondyloid fossa and posterior surface of the femur close to the articular margins of the condyles, and below to the posterior margin of the head of the tibia. The transverse ligament is located anteriorly.

Answer 46

Have no lymphatic drainage Rima glottidis : narrowest part of larynx and lies between both cords

Answer 47

A positive Tinel sign refers to a tingling, "pins and needles," or electric shock-like sensation that occurs when tapping over an irritated or compressed nerve. This sign is commonly used in clinical settings to help diagnose nerve compression or nerve regeneration conditions.

Answer 48

Lateral cutaneous nerve of thigh entrapment

Answer 49

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 50

Cardiooesophageal junction level = T11 A knowledge of this anatomic level is commonly tested.

Answer 51

Levels C4 Carotid bifurcation T4 Tracheal bifurcation T5 Right main bronchus T6 Left main bronchus T8 IVC T10 ESOPHAGUS T11 Cardioesophageal J T12 Aorta L4 Aortic bifurcation L1 Hamilton's L5 IVC formation L3-L4 or L4-L5 Lumbar puncture S2 End of dura matter

Answer 52

The lingual nerve is closely related to the third molar and up to 10% of patients undergoing surgical extraction of these teeth may subsequently develop a lingual neuropraxia. The result is anaesthesia of the ipsilateral anterior aspect of the tongue. The inferior alveolar nerve innervates the teeth themselves.

Answer 53

Medial : Serratus Lateral : Trapezius

Answer 54

The phrenic nerve lies anteriorly at the root of the right lung.

Answer 55

The cervical oesophagus is supplied by the inferior thyroid artery. The thoracic oesophagus (removed in this case) is supplied by direct branches from the thoracic aorta.

Answer 56

Remember that with impairment of flow through the portal system. The feeding vessels will be the gastric veins and drainage superiorly to the azygos system (i.e. reverse flow).

Answer 57

Killian’s Triangle is bounded superiorly by the lower border of the inferior constrictor and inferiorly by the cricopharyngeus. The Killian-Jamieson area is bounded by the oblique and transverse fibres of the cricopharyngeus. Boundaries of Laimer’s triangle: Superior: cricopharyngeus Inferior: circular muscle fibres of the upper esophagus

Answer 58

The pancreas develops from two foregut outgrowths (ventral and dorsal). During rotation the ventral bud and adjacent gallbladder and bile duct lie together and fuse. When the pancreas fails to rotate normally it can compress the duodenum with development of obstruction. Usually occurring as a result of associated duodenal malformation. The second part of the duodenum is the commonest site.

Answer 59

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 60

Oxyphil cells are typically found in parathyroid glands

Answer 61

Secretion of saliva by the parotid gland is controlled by nerve fibres originating in the inferior salivatory nucleus; these leave the brain via the tympanic nerve (branch of glossopharyngeal nerve (CN IX), travel through the tympanic plexus (located in the middle ear), and then form the lesser petrosal nerve until reaching the otic ganglion. After synapsing in the Otic ganglion, the postganglionic (postsynaptic) fibres travel as part of the auriculotemporal nerve (a branch of the mandibular nerve (V3) to reach the parotid gland.

Answer 62

Branch of V3 Frey's syndrome Friend of MMA Most often permenantly damaged during parotidectomy

Answer 63

The tibial nerve lies superior to the vessels in the inferior aspect of the popliteal fossa. In the upper part of the fossa the tibial nerve lies lateral to the vessels, it then passes superficial to them to lie medially. The popliteal artery is the deepest structure in the popliteal fossa

Answer 64

The radial nerve may become entrapped in the arcade of Frohse which is a superficial part of the supinator muscle which overlies the posterior interosseous nerve. This nerve is entirely muscular and articular in its distribution. It passes postero-inferiorly and gives branches to extensor carpi radialis brevis and supinator. It enters supinator and curves around the lateral and posterior surfaces of the radius. On emerging from the supinator the posterior interosseous nerve lies between the superficial extensor muscles and the lowermost fibres of supinator. It then gives branches to the extensors.

Answer 65

The Denonvilliers fascia separates the rectum from the prostate. Waldeyers fascia separates the rectum from the sacrum

Answer 66

The prostatic urethra is much wider than the membranous urethra and therefore resistance will decrease. The prostatic urethra is inclined superiorly

Answer 67

Aortic Usually located medial to the 3rd interspace on the right. Mitral Usually located medial to the 4th interspace on the left. Tricuspid Usually located medial to the 5th interspace on the right.

Answer 68

small bowel: <3 cm large bowel: <6 cm appendix: <6 mm cecum: <9 cm

Answer 69

Pes anserinus: GOOSE'S FOOT Combination of sartorius, gracilis and semitendinous tendons inserting into the anteromedial proximal tibia. Pes Anserinus Bursitis is common in sportsmen due to overuse injuries. The main sign is of pain in the medial proximal tibia. As the McMurray test is negative, medial meniscal injury is excluded

Answer 70

The dorsal carpal branch vessels supply 80% of the scaphoid via retrograde flow. There is a minor supply from the superficial palmar arch vessels that supplies the distal 20% of the scaphoid. ((This is from the scaphoid tubercle vessels that comprise 20% and the dorsal ridge vessels that supply 80%.))

Answer 71

The shoulder joint is a shallow joint, hence its great mobility. However, this comes at the expense of stability. The fibrous capsule attaches to the anatomical neck superiorly and the surgical neck inferiorly

Answer 72

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 73

A thoracic cord lesion causes spastic paraperesis, hyperrflexia and extensor plantar responses (UMN lesion), incontinence, sensory loss below the lesion and 'sensory' ataxia.These features typically manifest several weeks later, once spinal shock (in which areflexia predominates) has resolved.

Answer 74

The spinal cord is approximately 45cm in men and 43cm in women. The denticulate ligament is a continuation of the pia mater (innermost covering of the spinal cord) which has intermittent lateral projections attaching the spinal cord to the dura mater.

Answer 75

In lower motor neuron lesions everything is reduced 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 76

Upper dorsal mesogastrium Doesn’t store RBCs but stores platelets

Answer 77

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 78

There are 4 collateral venous systems: Azygos venous system Internal mammary venous pathway Long thoracic venous system with connections to the femoral and vertebral veins (2 pathways) Despite this, venous hypertension still occurs.

Answer 79

It lies deep to pronator teres and this separates it from the median nerve.

Answer 80

Chordoma is a neoplasm originating from ectopic cellular remnants of the notochord and therefore arises from the midline of the axial skeleton. It accounts for 24% of all primary malignant bone tumours. Chordoma is the second commonest primary malignancy of the spine and accounts for over 50% of primary sacral tumours. The neoplasm has a predilection for the sacrococcygeal (50%) and clival (40%) regions, with other areas of the spine rarely involved. More than one vertebral body can be affected in half the cases. Chordomas most commonly present between 50 and 70 years of age. Sex incidence is equal below 40 years, but men are affected twice as often at older ages, particularly in the sacral region.

Answer 81

Renal metastases have a tendency to be hypervascular. This is of considerable importance if surgical fixation is planned

Answer 82

Neuroblastomas are a relatively common childhood tumour and have a strong tendency to developing widespread lytic metastasis. It is unusual for CNS tumours to spread to involve the skeleton.

Answer 83

The features described are those of worsening graft function and acute rejection. The fact that there is a 10 day delay goes against hyperacute rejection. Cold ischaemic times are a major factor for delayed graft function. However, even 26 hours is not incompatible with graft survival.

Answer 84

Autologous transplant- same individual (genetically identical) Allograft - Genetically different The kidney is highly susceptible to HLA mismatches and hyperacute rejection may occur in patients with IgG anti HLA Class I antibodies. The liver is at far lower risk of rejection of this nature. Although the heart is sensitive to HLA mismatches this is less than the kidney. Cardiac valves and the cornea incite little immunological response. A 43 year old lady is recovering following a live donor related renal transplant

Answer 85

Cytomegalovirus is the most common and important viral infection in solid organ transplant recipients Primary infection with CMV typically occurs 6 weeks post transplantation in a seronegative individual who receives an organ from a seropositive donor. Symptoms may occur as early as 20 days but can occur up to 6 months post transplant . Symptoms are often vague, retinitis can be pathognomonic, but is rarely seen in the transplant population. CMV disease is seen in 8% of renal transplant patients. Intravenous ganciclovir is the treatment of choice in such patients. Unfortunately, relapses are not uncommon.

Answer 86

Post transplant complications CMV: 4 weeks to 6 months post transplant EBV: post transplant lymphoproliferative disease. > 6 months post transplant Post transplant lymphoproliferative disorder is most commonly associated with Epstein- Barr virus. It typically occurs 6 months post transplant and is associated with high dose immunosupressant therapy. Remember cytomegalovirus presents within the first 4 weeks to 6 months post transplant.

Answer 87

Fluid levels in the distal colon are nearly always pathological. In general contents of the left colon transit quickly and are seldom held in situ for long periods, the content is also more solid.

Answer 88

The keyword here is suspected. That being the case the investigation is CT. Although it is known that ionising radiation exposure can lead to cell death, mutation of germ cells, and carcinogenesis, there is no common modern radiographic procedure that results in radiation exposure to a level that threatens embryo or fetal well-being. Radiation exposure of <5 rads (a computed tomographic abdomen/pelvis study carries an exposure of 3.5 rads) has not been associated with fetal defects or loss. Careful shielding of the patient can also minimise exposure. Importantly, the use of ultrasound for diagnosis is clearly safe in pregnancy, although it should be used to evaluate and answer a defined clinical problem. A negative laparoscopy/ laparotomy poses signifcant foetal risks and at either procedure the enlarged uterus can result in missed pathology.

Answer 89

Rovsings sign- appendicitis * Boas sign -cholecystitis (refers to hyperaesthesia of the tip of the right scapula and is seen classically in association with acute cholecystitis.) * Murphys sign- cholecystitis * Cullens sign- pancreatitis (other intraabdominal haemorrhage) * Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage) * Pemberton sign-thoracic inlet syndrome

Answer 90

Any advanced right iliac fossa pathology can result in a positive Rovsings sign. However, in retrocaecal appendicitis, it may be absent and this fact can contribute to a delayed diagnosis if undue weight is placed on the presence of the sign in making the diagnosis.

Answer 91

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 92

Ileo-ileal intussusception are far less common than the ileo-colic variant. However, where they occur, they require surgery and are not amenable to pneumatic reduction.

Answer 93

The family history is irrelevant, an 87 year old developing colorectal cancer is sporadic chance. The patients risk of cancer is thus population baseline and at age 20 this is very low indeed. The main differential would be inflammatory bowel disease and a faecal calprotectin is a very sensitive screening test for this. This patient fulfills the Rome criteria for irritable bowel syndrome.

Answer 94

Core biopsy Vs fine needle aspiration cytology Core biopsy is preferred over FNAC by most surgeons. The reason for this is that FNAC often yielded inadequate tissue for assessment. When FNAC demonstrated benign changes, it had to be repeated at least once to confirm this. If it yielded cells that were indeterminate, then a core biopsy was needed. A core biopsy removes many of these stages and is thus more reliable. All discrete breast lumps, including those that seem benign, should have a confirmed histological diagnosis. In this case, a core biopsy has not yet been performed. This may yield a diagnosis that is concordant with imaging findings. In which case, this concludes the investigative process (if benign). If it remains unclear, excision biopsy will be needed

Answer 95

Mucinous carcinomas comprise 2-3% of all breast cancers. They are one of the special type of carcinomas. These have a better prognosis than is associated with tumours of Non Special Type (NST) and axillary nodal disease is rare in this group

Answer 96

Comedo necrosis is a feature of high nuclear grade ductal carcinoma in situ. It has a high risk of being associated with foci of invasion.

Answer 97

Medullary breast cancer is a breast cancer of special type. Histologically, it is characterised by a marked lymphocytic infiltrate. Many of the breast cancers of special type (which comprise less than 5% of all breast cancers) have a very good prognosis. These special type cancers include; medullary, tubular, mucinous, adenoid cystic

Answer 98

Wide local excision and excision biopsy are different procedures. The imaging and biopsy results are not concordant. At this stage an excision biopsy is the safest option. CT scanning is seldom helpful in breast surgery.

Answer 99

Wide local excision and excision biopsy are different procedures. The imaging and biopsy results are not concordant. At this stage an excision biopsy is the safest option. CT scanning is seldom helpful in breast surgery. MRI scanning may be beneficial in screening younger patients with a family history and also in patients with lobular cancers who are being considered for breast conserving surgery.

Answer 100

The most sensitive test for diagnosing hyperthyroidism is plasma T3 (which is raised). Note in hypothyroidism the plasma T4 and TSH are the most sensitive tests.

Answer 101

Where axillary nodal involvement is suspected from the outset it is important to establish whether this is the case prior to surgery. This is because, if axillary metastatic disease is present then the correct management would be an axillary node clearance and this is irrespective of the surgical plans for the breast primary. In the case of breast cancer, image guided FNAC is acceptable as it is accurate and if carcinoma cells are identified at FNA then axillary node clearance can be performed. If FNAC is negative then a sentinel node biopsy should accompany excision of the primary tumour. Where the axilla is clinically clear on palpation and imaging then a sentinel lymph node biopsy should accompany excision of the primary tumour.

Answer 102

A significant proportion of patients who take lithium treatment will develop a goitre and a number will become clinically hypothyroid. For this reason, monitoring of thyroid function tests is necessary during lithium therapy.

Answer 103

Dysplasia and cancer are not the same disease. All colonic adenomas are dysplastic. Adenomas greater than 2cm may harbor foci of malignancy within them. However, many have dysplastic cells only. These do not require segmental resection. When a cancer has been identified during endoscopy, it is safest to avoid undertaking polyp interventions as there is a risk of seeding. In summary, do NOT remove polyps until after the cancer has been resected.

Answer 104

Synchronous colonic tumours are seen in 5%

Answer 105

Ileostomy output is roughly in the range of 5-10ml/Kg/ 24 hours. Output in excess of 20ml/Kg/24 hours usually requires supplementary intravenous fluids. Excessive fluid losses are generally managed by administration of oral loperamide (up to 4mg QDS) to try and slow the output. Foods containing gelatine may also thicken output. Early high output is not uncommon and most patients (50%) will respond to conservative management

Answer 106

The inferior mesenteric artery may have been ligated and being an arteriopath collateral flow through the marginal may be imperfect.

Answer 107

Rectal varices are a recognised complication of portal hypertension. In the first instance they can be managed with medical therapy to lower pressure in the portal venous system. TIPSS may be considered. Whilst band ligation is an option, attempting to inject these in same way as haemorroids would carry a high risk of precipitating further haemorrhage.

Answer 108

Solitary rectal ulcers are associated with chronic constipation and straining. It will need to be biopsied to exclude malignancy (the histological appearances are characteristic). Diagnostic work up should include endoscopy and probably defecating proctogram and ano-rectal manometry studies.

Answer 109

This patient may well develop raised ICP over the next few days and intracranial pressure monitoring will help with management.

Answer 110

As a result the early symptoms will typically be those of circumoral paraesthesia and tinnitus, followed by falling GCS and eventually coma. * Stop injecting the anaesthetic agent * High flow 100% oxygen via face mask * Cardiovascular monitoring * Administer lipid emulsion (Intralipid 20%) at 1.5ml/Kg over 1 minute as a bolus * Consider lipid emulsion infusion, at 0.25ml/ Kg/ minute * If toxicity due to prilocaine then administer methylene blue

Answer 111

Prilocaine is a recognised cause of methaemoglobinaemia, this is characterised by the development of cyanosis and dyspnoea. This disorder occurs because of the change haemoglobin to a ferric subtype rather than ferrous (Fe2+). This type of change shifts the oxygen dissociation curve to the left and tissue hypoxia occurs. Methylene blue will revert the haemoglobin to the ferrous type and reverse this effect.

Answer 112

Triangle of safety * It is advised that chest drains are placed in the 'safe triangle'. The triangle is located in the mid axillary line of the 5th intercostal space. It is bordered by: * Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla.

Answer 113

As this man is relatively young and has full thickness prolapse a rectopexy is the most appropriate procedure. It will give the lowest recurrence rates. This could be a sutured rectopexy or ventral mesh rectopexy. If the latter procedure is adopted, it is important to counsel the patient around the risks of sexual dysfunction (close to prostate).

Answer 114

The aorta may be injured in deceleration accidents. In the setting of deceleration injury, chest pain and mediastinal widening the most likely problem is aortic rupture. This will typically occur distal to the left subclavian artery. Rupture of the proximal aorta may occur. However, survival is unlikely. It is important to note that the question uses the term Most likely injury as this is the component that distinguishes an ascending rupture from a descending rupture.

Answer 115

Patients with significant mediastinal and lung injuries are best operated on using a Clam shell thoracotomy; also called bilateral anterolateral thoracotomy. All modes of access involve a degree of compromise. A sternotomy would give good access to the heart. However, it takes longer to perform and does not provide good access to the lungs. Trauma should not be managed using laparoscopy.

Answer 116

Ameloblastomas are rare tumours of the odontogenic epithelium. They are slow growing and expand with a rim of periosteum that surrounds them. It is the palpation and disruption of this layer that gives rise to the crepitus.

Answer 117

Paranasal sinus cancer is strongly associated with wood work. Most cases require an occupational exposure of greater than 10 years and are adenocarcinomas on histology. Most cases are ethmoidal in origin

Answer 118

A combination of severe otalgia and facial nerve palsy in a diabetic should raise suspicion of malignant otitis externa. This is a condition caused by pseudomonas. It commences as otitis externa and then progresses to involve the temporal bone. Spread of the disease outside the external

Answer 119

Rinne's test will localise to the affected side (i.e. it is negative in conductive deafness). In a positive Rinne's test sound heard by air conduction is better than that conveyed by bone conduction. Reduction of both air and bone conduction in equal measure is a feature of sensorineural hearing loss.

Answer 120

If a stone cannot be removed at surgery then the chances of succeeding at ERCP are slim. In this case, its probably best to bypass the distal bile duct and a choledochoduodenostomy is the best way of achieving this. There are long term risks of cholangitis which are less of a concern in older patients.

Answer 121

This lady has acute cholecystitis and needs an acute cholecystectomy. This operation should usually be performed within 72 hours of admission. Delay beyond this timeframe will usually result in increased operative complications and most surgeons would administer antibiotics and perform and interval cholecystectomy if the early window for an acute procedure is missed. A bile duct measuring 4mm is usually normal.

Answer 122

Up to 10% of all patients may have stones in the CBD. Therefore, all patients should have their liver function tests checked prior to embarking on a cholecystectomy.

Answer 123

Liver function testing is part of the core diagnostic work up of biliary colic and surgical planning cannot proceed until this (and the diameter of the CBD on USS) are known.

Answer 124

When there are concerns that pancreatic necrosis may have become infected the usual approach is to perform an image guided FNA for culture. There is always the risk of seeding infection with such a strategy so it must be performed with care. Pancreatic necrosectomy is not usually undertaken until the presence of infection is proven

Answer 125

Greater Auricular Nerve (C2, C3) A branch of the cervical plexus. Provides sensory innervation to the skin over the parotid gland, ear, and angle of the mandible. Commonly sacrificed during parotidectomy, leading to numbness of the ear and jaw angle. Auriculotemporal Nerve (V3) A branch of the mandibular nerve (V3). Carries postganglionic parasympathetic fibers to the parotid gland. Damage can cause Freyer’s syndrome (gustatory sweating) but is less commonly injured during surgery. Accompany the middle meningeal artery.

Answer 126

This will account for the scenario given where there is a brief delay prior to death. The other options are less acute and a supratentorial herniation would not occur in this setting

Answer 127

A. 1 in 6000 Concussion, no skull fracture Orientated 1 in 6000 Concussion, no skull fracture Not orientated 1 in 120 Skull fracture Orientated 1 in 32 Skull fracture Not orientated 1 in 4

Answer 128

The absence of trauma here makes an acute sub dural and extra dural bleed unlikely. Chronic sub dural bleeds would usually cause a more gradual deterioration than is seen here. The absence of any skull fracture also makes an underlying intra cranial bleed less likely. Sudden onset headaches, together with sudden deterioration in neurological function are typical of a sub arachnoid haemorrhage

Answer 129

The time frame of deterioration of an acute sub dural bleed would fit with this scenario. They are highly lethal and not uncommon injuries. As the bleed enlarges, lateralising signs may be seen and eventually coning and death will occur

Answer 130

Painful third nerve palsy = posterior communicating artery aneurysm Given the combination of a headache and third nerve palsy it is important to exclude a posterior communicating artery aneurysm

Answer 131

Keratoacanthomas may reach a considerable size prior to sloughing off and scarring.

Answer 132

Pyogenic granulomas often appear at sites of Trauma

Answer 133

Punch biopsies are a useful option for obtaining a full thickness tissues sample with minimal tissue disruption. In this situation, the other differential would be AIN or VIN and punch biopsies would be useful in distinguishing these.

Answer 134

These lesions are often extensive and superficial. Shave excision will suffice, material must be sent for histology.

Answer 135

Birds are a recognised reservoir of campylobacter.

Answer 136

Clostridium difficile is a Gram positive rod often encountered in hospital practice. In the UK it can be found in 3% of normal adults and up to 66% of babies. It produces an exotoxin which causes intestinal damage leading to a syndrome called pseudomembranous colitis.

Answer 137

This may occur as a result of laxative abuse and consists of lipofuschin laden macrophages that appear brown.

Answer 138

Giardia causes fat malabsorption, therefore greasy stool can occur. It is resistant to chlorination, hence risk of transfer in swimming pools.

Answer 139

Infection with Ascaris lumbricoides usually occurs after individuals have visited places like sub Saharan Africa or the far east. Unlike ancylostoma duodenale infection there is usually evidence of both worms and eggs in the stool. The absence of pruritus makes enterobius less likely. The presence of coughing may be due to the migration of the larva through the lungs.

Answer 140

This tends to colonise plastic devices and forms a biofilm which allows colonisation with other bacterial agents. It is notoriously difficult to eradicate once established and the usual treatment is removal of the device.

Answer 141

Bacteroides is commonly present in severe peritoneal infections and as it is facultatively anaerobic may be present in pus. It has a pungent aroma.

Answer 142

Clostridium perfringens is the most likely pathogen to be associated with gangrene.

Answer 143

Clostridium difficile can spread rapidly on surgical wards. The use of broad spectrum prophylactic antibiotics during arthroplasty surgery can increase the risk.

Answer 144

Iatrogenic perforations of the oesophagus may be managed non operatively. This usually involves a nil by mouth regime, tube thoracostomy may be needed. Total parenteral nutrition is the safest option. Insertion of NG feeding tubes and PEG tubes may complicate the process or allow feed to enter the perforation site.

Answer 145

The decision as to how best to manage patients with re-bleeding is difficult. Whilst it is tempting to offer repeat endoscopy, this intervention is best used on those with small ulcers. Large posteriorly sited duodenal ulcers are at high risk for re-bleeding and the timeframe of this event suggests that primary endoscopic haemostasis was inadequate. Surgery thus represents the safest way forward.

Answer 146

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.

Answer 147

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. Drugs like ferrous sulphate impair the efficacy of purgatives and give poor endoscopic views as a result and should be stopped beforehand

Answer 148

The potassium will decline further if this deficiency is not addressed. Remember that potassium is predominantly an intracellular cation. U+E's measure the serum potassium which is relatively buffered by the intra cellular stores. Therefore a fall in serum potassium represents a very real intracellular deficiency. This requires supplementary potassium to correct the defect.

Answer 149

Insulin should not be stopped in patients with type 1 diabetes and omission of more than one meal will usually require a variable rate insulin infusion Type 1 diabetics who take insulin should have this continued through the perioperative period. Fluid guidelines in diabetics differ and are not well covered in NPSA fluid guidelines.

Answer 150

The argon plasma coagulation system is very good for managing splenic bleeding. Alternatives include topical haemostatic agents. Its not necessary to ligate the hilar vessels, if this is required, a splenectomy is the usual outcome.

Answer 151

Use of gauze is inappropriate and will be painful to redress. Abscess wounds should not be closed.

Answer 152

In children, its always best to use absorbable sutures where possible (removal is a very challenging undertaking). Most surgeons prefer vicryl rapide for this purpose and 5/0 provides adequate strength.

Answer 153

A laminar flow is the single most important intervention, many units will also use exhaust suits but these are less essential. Shaving skin on the ward increases infection rates. Extended chemoprophylaxis increases risks of antibiotic associated diarrhea.

Answer 154

Severe systemic disease of this nature is a constant threat to life. Especially as he also has evidence of cardiac failure.

Answer 155

Femoro-femoral cross over grafts are an option for treatment of iliac occlusions in patients with significant co-morbidities and healthy contralateral vessels. In reality, the idealised situation presented here seldom applies and the opposite vessels usually have some disease and one must be careful not to damage the healthy side

Answer 156

In patients with major cardiac co-morbidities the safest option is to choose an axillobifemoral bypass graft. The long term patency rates are less good than with aortobifemoral bypass grafts, however, the operation is less major.

Answer 157

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 as she is not ambulant.

Answer 158

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.

Answer 159

Posterior rib fractures are extremely unusual in neonates. The change in head size may be accounted for by hydrocephalus which may occur as a sequelae from head injury.

Answer 160

Viral illnesses can be associated with transient synovitis. The WCC should ideally be > 12 and the ESR > 40 to suggest septic arthritis.

Answer 161

This child is short, has hyperactivity (disruptive behaviour) and is within the age range for Perthes disease. Hyperactivity and short stature are associated with Perthes disease.

Answer 162

These lesions are usually hamartomas and this accounts for the colour of the lesions. Although the lesions are not themselves malignant they serve as a marker of an underlying polyposis disorder.

Answer 163

This is associated with transfusion of unirradiated blood in immunosuppressed patients. Transfusion associated GVHD can occur 4-30 days after a transfusion and follows a sub acute pathway. Patients may also have diarrhoea and abnormal liver function tests. Management involves steroid therapy.

Answer 164

The correct answer is Factor V Leiden A combination of thromboembolism and bleeding in a young woman should raise the possibility of antiphospholipid syndrome. Other features may include foetal loss, venous and arterial thrombosis and thrombocytopenia. Protein C is not associated with a prolonged APTT.

Answer 165

In patients with long standing PUJ obstruction and renal scarring the main diagnostic question is whether the individual has sufficient renal function to consider a pyeloplasty or whether a primary nephrectomy is preferable. Since the CT has demonstrated scarring there is no use in obtaining a DMSA scan. Of the investigations listed both a DMSA and MAG 3 renogram will allow assessment of renal function. However, MAG 3 is superior in the assessment of renal function in damaged kidneys (as it is subjected to tubular secretion).

Answer 166

This is most likely pyelonephritis and partially treated cystitis is a common cause

Answer 167

These tumours may often have paraneoplastic effects such as hypertension.

Answer 168

The likely scenario is that this man has developed a calculus causing ureteric obstruction. The stagnant column of urine can become colonised and infected. An infected obstructed system is one of the few true urological emergencies. A nephrostomy is needed as the stone could not be removed.

Answer 169

Antegrade ureteric stents pass from the kidney to the bladder Retrograde stents pass from the bladder to the kidney A TCC occluding the ureteric orifice will obscure its identification during surgery, so that passage of a retrograde stent is difficult. Therefore passage of a stent from the renal pelvis is preferable.

Answer 170

Infection with Proteus mirabilis accounts for 90% of all proteus infections. It has a urease producing enzyme. This will tend to favor urinary alkalinisation which is a relative prerequisite for the formation of staghorn calculi.

Answer 171

LHRH analogues may cause flare of metastatic disease and anti androgens should be administered to counter this. Surgical orchidectomy reduces testosterone levels within 8 hours (but fails to reduce adrenal androgen release). Cyproterone and flutamide are androgen blockers that may be considered as add on therapy to reduce the risk of tumour flare when commencing treatment with LH RH analogues

Answer 172

This patient has tuberous sclerosis. This is associated with angiomyolipoma, which is present in 60-80% patients. It is a benign lesion.

Answer 173

Clear cell tumours are a sub type of renal cell cancer it is associated with specific genetic changes localised to chromosome 3.

Answer 174

Cystine stones are associated with an inherited metabolic disorder.

Answer 175

Acute haematocele: tense, tender and non transilluminating mass. The testis will need surgical exploration to evacuate the blood and repair any damage.

Answer 176

The onset is relatively slow for torsion and the presence of fever favors epididymoorchitis.

Answer 177

Rhabdomyosarcoma are paratesticular tumours with a bimodal distribution. Because the mass is felt separate to the testis, this is the more likely diagnosis. 5% of testicular tumors Most often arises in distal portion of spermatic cord and may invade testis of surrounding tissues 60% occur in the first 2 decades of life Bimodal age distribution - 3-4 months - 16 years

Answer 178

This is a Weber B fracture and therefore potentially unstable. Medial malleolar tenderness indicates deltoid ligament injury. As the fracture is currently undisplaced and the ankle mortise is congruent, the injury can be initially managed conservatively in a moon boot but the patient should be monitored in the outpatient clinic for fracture displacement in the first few weeks.

Answer 179

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.

Answer 180

Twisting sporting injuries followed by delayed onset of knee swelling and locking are strongly suggestive of a menisceal tear. Arthroscopic menisectomy is the usual treatment.

Answer 181

A patella dislocation is a common cause of haemarthrosis and many will spontaneously reduce when the leg is straightened. In the chronic setting physiotherapy is used to strengthen the quadriceps muscles.

Answer 182

Athletic boys and girls may develop this condition in their teenage years. It is caused by multiple micro fractures at the point of insertion of the tendon into the tibial tuberosity. Most cases settle with physiotherapy and rest.

Answer 183

The patient has a frailty fracture and by definition therefore will have osteoporosis and should therefore commence treatment, a DEXA scan will not change this decision. The osteoporosis guidelines state if a postmenopausal woman has a fracture she should be put on bisphosphonates (there is no need for a DEXA scan). A bisphosphonate, calcium and vitamin D supplementation should be given to all patients aged over 75 years after having a fracture. A DEXA scan is only needed of the patient is aged below 75 years. Hormone replacement therapy has been shown to reduce vertebral and non vertebral fractures, however the risks of cardiovascular disease and breast malignancy make this a less favourable option.

Answer 184

This is a typical presentation of pseudogout. An elevated transferrin saturation may indicate haemochromatosis, a recognised cause of pseudogout. A high ferritin level is also seen in haemochromatosis but can be raised in a variety of infective and inflammatory processes, including pseudogout, as part of an acute phase response

Answer 185

This is a peripheral neuropathy that may complicate viral illnesses and usually resolves spontaneously

Answer 186

Acromioclavicular joint (ACJ) dislocation normally occurs secondary to direct injury to the superior aspect of the acromion. Loss of shoulder contour and prominent clavicle are key features. Note; rotator cuff tears rarely occur in the second decade.

Answer 187

A. Potts disease: Affects the spine (TB-related) but causes structural damage, not dissociated sensory loss or upper limb Charcot joints. B. Tabes dorsalis: Causes Charcot joints (typically lower limbs) and sensory deficits, but primarily affects dorsal columns (loss of proprioception/vibration), not spinothalamic tracts. C. Transverse myelitis: Results in acute, bilateral sensory/motor deficits at a spinal level, not chronic dissociated sensory loss. E. Subacute cord degeneration (B12 deficiency): Involves dorsal and lateral columns (ataxia, vibration/proprioception loss), not spinothalamic tracts. Conclusion: The combination of upper limb dissociated sensory loss, Charcot joints, and pain insensitivity is pathognomonic for syringomyelia.

Answer 188

Fracture of the radial head is common in young adults. It is usually caused by a fall on the outstretched hand. On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).

Answer 189

This patient has an acute respiratory acidosis, however this is on a background of chronic respiratory acidosis (due to COPD) with a compensatory metabolic alkalosis (the elevated bicarbonate is the main clue to the chronic nature of the respiratory acidosis). This blood gas picture is typical in a COPD patient who has received too much oxygen; these patients lose their hypoxic drive for respiration, therefore retain CO2 and subsequently hypoventilate leading to respiratory arrest. If the bicarbonate was normal, then the answer would be acute respiratory acidosis secondary to pneumonia.