Khaled's notes to be revised Flashcards
A 72 year old man is undergoing a repair of
an abdominal aortic aneurysm. The aorta
is cross clamped both proximally and
distally. The proximal clamp is applied
immediately inferior to the renal arteries.
Both common iliac arteries are clamped
distally. A longitudinal aortotomy is
performed. After evacuating the contents
of the aneurysm sac a significant amount
of ongoing bleeding is encountered. This is
most likely to originate from:
A. The coeliac axis
B. Testicular artery
C. Splenic artery
D. Superior mesenteric artery
E. Lumbar arteries
The lumbar arteries are posteriorly sited
and are a common cause of back bleeding
during aortic surgery. The other vessels
cited all exit the aorta in the regions that
have been cross clamped.
How many unpaired branches leave the
abdominal aorta to supply the abdominal
viscera?
A. One
B. Two
C. Three
D. Four
E. Five
There are three unpaired branches to the
abdominal viscera. These include the
coeliac axis, the SMA and IMA. Branches to
the adrenals, renal arteries and gonadal
vessels are paired. The fourth unpaired
branch of the abdominal aorta, the median
sacral artery, does not directly supply the
abdominal viscera. PARIETAL DORSAL BRANCH.
A 28 year old man is undergoing an
appendicectomy. The external oblique
aponeurosis is incised and the underlying
muscle split in the line of its fibres. At the
medial edge of the wound is a tough
fibrous structure. Entry to this structure
will most likely encounter which of the
following?
A. Internal oblique
B. Rectus abdominis
C. Transversus abdominis
D. Linea alba
E. Peritoneum
This structure will be the rectus sheath and
when entered the rectus abdominis muscle
will be encountered.
Names for inguinal ligament
Cooper’s Pectineal
Poupart’s Inguinal
Gimbernat’s Lacunar
PK Band
‘PK Band’ is a condensation of areolar tissue lateral to inferior epigastric vessels on either side. It extends from arcuate line to apex of triangle of doom. It is more condensed and prominent in the upper part. Lateral blunt dissection in the preperitoneal plane will definitely be restricted by this band. Forcing the scope laterally will cause tear of the peritoneum at that level. Muscle injury may also be caused by blunt dissection. Division of this band during laparoscopic hernia repair connects the space of Bogros with space of Retzius. This provides sufficient space necessary for proper placement of mesh and hence significantly reduce recurrence.
Jugular foramen
The jugular foramen may be subdivided into three compartments, each with their own contents.
The anterior compartment transmits the inferior petrosal sinus.
The intermediate compartment transmits the glossopharyngeal nerve, the vagus nerve,[1] and the accessory nerve.
The posterior compartment transmits the sigmoid sinus (becoming the internal jugular vein),[1] and some meningeal branches from the occipital artery and ascending pharyngeal artery.
The foramen marking the termination of
the adductor canal is located in which of
the following?
A. Adductor longus
B. Adductor magnus
C. Adductor brevis
D. Sartorius
E. Semimembranosus
The foramen marking the distal limit of the
adductor canal is contained within adductor
magnus. The vessel passes through this
region to enter the popliteal fossa
Guyon canal
Guyon canal syndrome is the second reason for compression syndromes at the wrist after carpal tunnel syndrome. Compression of the ulnar nerve at the Guyon’s canal leads to specific sensory and motor symptoms according to the location of the compression.
Hypothenar hand (hammer) syndrome is caused by repeated trauma to the hypothenar region, resulting in injury to the ulnar artery in Guyon space.
A 43 year old man is diagnosed as having a
malignancy of the right adrenal gland. The
decision is made to resect this via an open
anterior approach. Which of the following
will be most useful during the surgery?
A. Division of the coronary ligaments of
the liver
B. Mobilisation of the colonic hepatic
flexure
C. Division of the right renal vein
D. Division of the ligament of Trietz
E. Division of the right colic artery
Mobilisation of the hepatic flexure and right
colon are standard steps in open adrenal
surgery from an anterior approach.
Mobilisation of the liver is seldom required.
A 20 year old man presents to the
Emergency Department with a stab injury
to the thenar eminence. On examination,
he is found to have a 2 cm long laceration
with loss of sensation in the thumb and
index finger and weakness of the thenar
muscles. Which of the following structures
is most likely to have been injured?
A. Anterior interosseous nerve
B. Recurrent branch of the median
nerve
C. Sensory and motor branches of the
median nerve
D. Sensory and motor branches of the
radial nerve
E. Sensory and motor branches of the
ulnar nerve
The question describes both a motor and
sensory deficit. This means that injury
cannot be isolated to the recurrent branch
of the median nerve in isolation as this only
provides motor function. Sensation via the
palmar cutaneous branches must also be
compromised and it is for this reason the
correct answer is injury to motor and
sensory branches of the median nerve.
Movements of ankle joint
Plantar flexion (55 degrees)
Dorsiflexion (35 degrees)
Inversion and eversion movements occur at the
level of the sub talar joint
The structures passing behind
the medial malleolus from anterior to
posterior
tibialis posterior, flexor
digitorum longus, posterior tibial vein,
posterior tibial artery, nerve, flexor hallucis
longus
28 year teacher reports difficulty with
writing. There is no sensory loss. She is
known to have an aberrant Gantzer
muscle. Which of the following nerves has
been affected?
A. Posterior interosseous
B. Anterior interosseous
C. Median
D. Ulnar
E. Musculocutaneous
Anterior interosseous lesions occur due to
fracture, or rarely due to compression. The
Gantzer muscle is an aberrant accessory of
the flexor pollicis longus and is a risk factor
for anterior interosseous nerve
compression. Remember loss of pincer grip
and normal sensation indicates an
interosseous nerve lesion.
A 44 year old lady who works as an interior
decorator has undergone a mastectomy
and axillary node clearance to treat breast
cancer. Post operatively, she comments
that her arm easily becomes fatigued
when she is painting walls. What is the
most likely explanation?
A. Injury to the axillary nerve
B. Injury to the long thoracic nerve
C. Injury to the intercostobrachial
nerve
D. Injury to the thoracodorsal nerve
E. Injury to the median pectoral nerve
The most likely explanation for this is that
the thoracodorsal nerve has been injured.
This will result in atrophy of latissimus dorsi
and this will become evident with repetitive
arm movements where the arm is elevated
and moving up and down (such as in
painting). Injury to the pectoral nerves may
produce a similar picture but this pattern of
injury is very rare and the pectoral nerves
are seldom injured in breast surgery.
An injured axillary artery is ligated
between the thyrocervical trunk of the
subclavian and subscapular artery.
Subsequent collateral circulation is likely
to result in reversal of blood flow in which
of the vessels listed below?
A. Circumflex scapular artery
B. Transverse cervical artery
C. Posterior intercostal arteries
D. Suprascapular artery
E. Profunda brachii artery
It’s an easy question really, we just made
the wording difficult (on purpose). It is
asking about the branches of the axillary
artery and knowledge of the fact that there
is an extensive collateral network around
the shoulder joint. As a result, the occlusion
of the proximal aspect of the circumflex
humeral inflow (from the axillary artery)
ceases and there is then retrograde flow
through it from collaterals.
The circumflex scapular artery is a branch of
the subscapular artery and normally
supplies the muscle on the dorsal aspect of
the scapula. In this instance, flow is
reversed in the circumflex scapular and
subscapular arteries forming a collateral
circulation around the scapula.
Teres minor + Deltoid = Axillary nerve
Teres Major + Subscapularies = lower subscabular nerve
Supra and Infra spinatus = Suprascapular nerve
Teres minor + Deltoid = Axillary nerve
Teres Major + Subscapularies = lower subscabular nerve
Supra and Infra spinatus = Suprascapular nerve
Which of the following nerves innervates
the long head of the biceps femoris
muscle?
A. Inferior gluteal nerve
B. Tibial division of sciatic nerve
C. Superior gluteal nerve
D. Common peroneal division of sciatic
nerve
E. Obturator nerve
The short head of biceps femoris, which
may occasionally be absent, is innervated
by the common peroneal component of the
sciatic nerve. The long head is innervated by
the tibial division of the sciatic nerve.
Branches of internal iliac artery
Anterior division:
Some Old Uteruses May Get Prolapsed (female)
* S: superior vesical artery
* O: obturator artery
* U: uterine artery
* M: middle rectal artery
* G: (inferior) gluteal artery
* P: (internal) pudendal artery
The uterine artery can be replaced with inferior vesical for males. Mnemonic does not include the vaginal artery, which is often a branch of the uterine artery.
Posterior division:
Iliolumbar
Transverse sacreal
Superior gluteal artery
Branches of external iliac
Deep circumflex iliac artery
Inferior epigastric
The cords of the brachial plexus are most
closely related to which of the following
vessels?
A. Subclavian artery
B. Axillary artery
C. Axillary vein
D. Subclavian vein
E. Brachial artery
The trunks are related to the subclavian
artery superiorly. The cords of the plexus
surround the axillary artery, they are
named according to their positions relative
to this structure.
Which of the following most commonly
arises from the brachiocephalic artery?
A. Vertebral artery
B. Subscapular artery
C. Thyroidea ima artery
D. Left Subclavian artery
E. None of the above
Other occasional branches include the
thymic and bronchial branch.
A patient is due to undergo a right
hemicolectomy for a carcinoma of the
caecum. Which of the following vessels
will require high ligation to provide
optimal oncological control?
A. Middle colic artery
B. Inferior mesenteric artery
C. Superior mesenteric artery
D. Ileo-colic artery
E. None of the above
The ileo - colic artery supplies the caecum
and would require high ligation during a
right hemicolectomy. The middle colic
artery should generally be preserved when
resecting a caecal lesion.
This question is essentially asking you to
name the vessel supplying the caecum. The
SMA does not directly supply the caecum, it
is the ileocolic artery which does this.
Capitate
Capitate: This is the largest of the carpal bones. It is centrally placed with a rounded head set into the cavities of the lunate and scaphoid bones. Flatter articular surfaces are present for the hamate medially and the trapezoid laterally. Distally the bone articulates predominantly with the middle metacarpal.
A 32 year old lady complains of carpal
tunnel syndrome. The carpal tunnel is
explored surgically. Which of the following
structures will lie in closest proximity to
the hamate bone within the carpal tunnel?
A. The tendon of abductor pollicis
longus
B. The tendons of flexor digitorum
profundus
C. The tendons of flexor carpi radialis
longus
D. Median nerve
E. Radial artery
The carpal tunnel contains nine flexor
tendons:
Flexor digitorum profundus
Flexor digitorum superficialis
Flexor pollicis longus
The tendon of flexor digitorum profundus
lies deepest in the tunnel and will thus lie
nearest to the hamate bone.
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
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.
Renal blood flow
GFR
measured by
RPF is calculated by the clearance of para-aminohippuric acid (PAH)
GFR measured by inulin (Filtered but neither reabsorbed nor secreted)
Resection of terminal ilium will cause deficiency of fat-soluble vitamins?
95% of bile salts are reabsobed from terminal ilium (enterohepatic circulation); resection of terminal ilium will affect fat absorption, including fat-soluble vitamins.
Micro bullets
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
Bifurcation of:
Carotid C4
Trachea T4
Aorta L4
IVC L5
Bifurcation of:
Carotid C4
Trachea T4
Aorta L4
IVC L5
You are working as an anatomy
demonstrator and the medical students
decide to test your knowledge on the
Circle of Willis. Which of the following
comments is false?
A. The anterior communicating artery
links the right and left sides
B. Asymmetry of the circle of willis is a
risk factor for the development of
intracranial aneurysms
C. Majority of blood passing through
the vessels mix together
D. Includes the anterior
communicating artery
E. The circle surrounds the stalk of the
pituitary gland
There is minimum mixing of blood passing
through the vessels.
Which of the following statements relating
to the posterior cerebral artery is false?
A. It supplies the visual cortex
B. It is closely related to the 3rd cranial
nerve
C. It is a branch of the basilar artery
D. It is connected to the circle of Willis
via the superior cerebellar artery
E. When occluded may result in
contralateral loss of field of vision
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
Which of the following statements relating
to the basilar artery and its branches is
false?
A. The superior cerebellar artery may
be decompressed to treat trigeminal
neuralgia
B. Occlusion of the posterior cerebral
artery causes contralateral loss of
the visual field
C. The oculomotor nerve lies between
the superior cerebellar and
posterior cerebral arteries
D. The posterior inferior cerebellar
artery is the largest of the
cerebellar arteries arising from the
basilar artery
E. The labyrinthine branch is
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.
An occlusion of the anterior cerebral artery
may compromise the blood supply to the
following structures except:
A. Medial inferior surface of the frontal
lobe
B. Corpus callosum
C. Medial surface of the frontal lobe
D. Olfactory bulb
E. Brocas area
Brocas area is usually supplied by branches
from the middle cerebral artery.
A 35 year old man falls and sustains a
fracture to the medial third of his clavicle.
Which vessel is at greatest risk of injury?
A. Subclavian vein
B. Subclavian artery
C. External carotid artery
D. Internal carotid artery
E. Vertebral artery
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).
Which of the following carpal bones is a
sesamoid bone in the tendon of flexor
carpi ulnaris?
A. Triquetrum
B. Lunate
C. Pisiform
D. Scaphoid
E. Capitate
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.
The coeliac plexus is the largest of the autonomic
plexuses. It is located on a level of the last thoracic and
first lumbar vertebrae. It surrounds the coeliac axis and
the SMA. It lies posterior to the stomach and the lesser sac. It lies anterior to the crura of the diaphragm and the
aorta. The plexus and ganglia are joined by the greater and
lesser splanchnic nerves on both sides and branches from
both the vagus and phrenic nerves.
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).
Which of the structures listed below lies
posterior to the carotid sheath at the level
of the 6th cervical vertebra?
A. Hypoglossal nerve
B. Vagus nerve
C. Cervical sympathetic chain
D. Ansa cervicalis
E. Glossopharyngeal nerve
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.
A 43 year old lady develops a cerebellopontine
angle lesion. Which of the nerves
listed below is likely to be affected first?
A. CN X
B. CN III
C. CN V
D. CN IX
E. CN XII
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
Cranial nerves carrying parasympathetic
fibres.
Cranial nerves carrying parasympathetic
fibres X IX VII III (1973)
A 32 year old lady is admitted with
weakness, visual disturbance and peri
orbital pain. On examination, she is noted
to have mydriasis and diminished direct
response to light shone into the affected
eye. The consensual response is preserved
when light is shone into the unaffected
eye. Which of the cranial nerves listed
below is responsible for the diminished
direct response?
A. Abducens
B. Oculomotor
C. Optic
D. Trigeminal
E. Hypoglossal
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).
An 21 year old man undergoes an
uncomplicated tonsillectomy for recurrent
attacks of tonsillitis. Post operatively he
complains of otalgia. Which nerve is
responsible?
A. Trigeminal
B. Hypoglossal
C. Glossopharyngeal
D. Facial
E. Vagus
The glossopharyngeal nerve supplies this
area and the ear and otalgia may be the
result of referred pain.
Arnold cough syndrome
Arnold cough syndrome (Arnold branch of vagus) Cough with stimulation of external auditory meatus
Nerve supply of tongue
- 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. - 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) - 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.
Nerve supply of ear
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.
Roots responsible for hyperhiderosis (axillary and palmer)
lumbar sympathetomy
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.
How many compartments are there in the
lower leg?
A. 2
B. 1
C. 3
D. 5
E. 4
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.
A 78 year old man is undergoing a femoropopliteal
bypass graft. The operation is not
progressing well and the surgeon is
complaining of poor access. Retraction of
which of the following structures will
improve access to the femoral artery
distally?
A. Quadriceps
B. Adductor longus
C. Adductor magnus
D. Pectineus
E. Sartorius
At the lower border of the femoral triangle
the femoral artery passes under the sartorius
muscle. This can be retracted to improve
access.
During an operation for varicose veins the
surgeons are mobilising the long saphenous
vein. Near its point of entry to the femoral
vein an artery is injured and bleeding is
encountered. From where is the bleeding
most likely to originate?
A. Femoral artery
B. Profunda femoris artery
C. Superficial circumflex iliac artery
D. Superficial epigastric artery
E. Deep external pudendal artery
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.
Most sprained ankle ligament
ATFL
Strongest ankle ligament
Deltoid
Which of the nerves listed below is directly
responsible for the innervation of the
lateral aspect of flexor digitorum
profundus?
A. Ulnar nerve
B. Anterior interosseous nerve
C. Radial nerve
D. Median nerve
E. Posterior interosseous nerve
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.
Which muscle does not insert on the medial
or superomedial surface of the greater
trochanter?
A. Gemelli
B. Obturator internus
C. Piriformis
D. Quadratus femoris
E. Obturator externus
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.
3 divisions of the pudendal nerve:
ventral rami of the second, third, and fourth
sacral nerves (S2, S3, S4).
* Rectal nerve
* Perineal nerve
* Dorsal nerve of penis/ clitoris
A 22 year old man develops an infection in
the pulp of his little finger. What is the
most proximal site to which this infection
may migrate?
A. The metacarpophalangeal joint
B. The distal interphalangeal joint
C. The proximal interphalangeal joint
D. Proximal to the flexor retinaculum
E. Immediately distal to the carpal
tunnel
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.
Which of the following fingers is not a point
of attachment for the palmar interossei?
A. Middle finger
B. Little finger
C. Ring finger
D. Index finger
E. None of the above
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.
Where are the greatest proportion of
musculi pectinati found?
A. Right ventricle
B. Left ventricle
C. Right atrium
D. Pulmonary valve
E. Aortic valve
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
Inspection of the left ventricle reveals all
except which of the following?
A. Papillary muscles
B. Trabeculae carnae
C. Chordae tendinae
D. Conus arteriosus
E. Openings of the venae cordis
minimae
The conus arteriosus (infundibulum) is the
smooth walled outflow tract of the right
ventricle leading to the pulmonary trunk.
Structures within the right atrium
Musculi pectinati
Crista terminalis
Opening of the coronary sinus
Fossa ovalis
The trabeculae carnae are located in the
right ventricle
A 67 year old man is due to undergo a
revisional total hip replacement using a
posterior approach. After dividing gluteus
maximus in the line of its fibres there is
brisk arterial bleeding. Which of the
following vessels is likely to be responsible?
A. Profunda femoris artery
B. External iliac artery
C. Internal iliac artery
D. Obturator artery
E. Inferior gluteal artery
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.
An 18 year old man is stabbed in the neck
and has to undergo repair of a laceration to
the internal carotid artery. Post operatively
he is noted to have a Horners syndrome.
Which of the following will not be present?
A. Apparent enopthalmos
B. Loss of sweating on the entire
ipsilateral side of the face
C. Constricted pupil
D. Mild ptosis
E. Normal sympathetic activity in the
torso
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.
UT stones
Commonest RO (Ca oxalate)
Inherited ( Cystein)
Debilitating disease (Urate)
UTI (Sturivate)
Collapse after U catheter insertion
Latex allergy (Even if indication of catheterization retention)
Type 2 RF
Resp. acidosis
Hypoxic Hypercapnic
Dilated fixed pupil in head trauma
Due to affection of parasympathetic fibers carried over the occulomotor nerve.
Unopposed sympathetic.
Coronary arteries
Unlike all other arteries, IT’S FILLED DURING DIASTOLE
A 63 year old man is reviewed in the
vascular clinic as he is noted to have a
pulsatile swelling medial to the greater
trochanter. What vessel is most likely to be
affected?
A. Internal iliac artery
B. Inferior epigastric artery
C. Common iliac artery
D. Inferior mesenteric artery
E. External iliac artery
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.
Boundaries of the deep inguinal ring
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.
Nerves at risk during a carotid endarterectomy
Hypoglossal nerve
Greater auricular nerve
Superior laryngeal nerve
Number of interossei
ul: 4 P AND 4 D
ll: 3 P AND 4 D
Remember PAD DAP
Which of the following structures separates
the intervertebral disks from the spinal
cord?
A. Anterior longitudinal ligament
B. Posterior longitudinal ligament
C. Supraspinous ligament
D. Interspinous ligament
E. Ligamentum flavum
The posterior longitudinal ligament overlies
the posterior aspect of the vertebral bodies.
It also overlies the posterior aspect of the
intervertebral disks
Which of the following structures separates
the posterior cruciate ligament from the
popliteal artery?
A. Oblique popliteal ligament
B. Transverse ligament
C. Popliteus tendon
D. Biceps femoris
E. Semitendinosus
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.
Vocal cord
Have no lymphatic drainage
Rima glottidis : narrowest part of larynx and lies between both cords
Tinel sign
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.
Meralgia parathetica
Lateral cutaneous nerve of thigh entrapment
A 62 year old man is undergoing a left
hemicolectomy for carcinoma of the
descending colon. The registrar commences
mobilisation of the left colon by pulling
downwards and medially. Blood soon
appears in the left paracolic gutter. The
most likely source of bleeding is the:
A. Marginal artery
B. Left testicular artery
C. Spleen
D. Left renal vein
E. None of the above
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.
Cardiooesophageal junction level
Cardiooesophageal junction level = T11
A knowledge of this anatomic level is
commonly tested.
Levels
C4
T4
T5
T6
T8
T10
T11
T12
L4
L1
L5
L3-L4 or L4-L5
S2
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
A 21 year old man undergoes surgical
removal of an impacted 3rd molar. Post
operatively, he is noted to have
anaesthesia on the anterolateral aspect of
the tongue. What is the most likely
explanation?
A. Injury to the hypoglossal nerve
B. Injury to the inferior alveolar nerve
C. Injury to the lingual nerve
D. Injury to the mandibular branch of
the facial nerve
E. Injury to the glossopharyngeal nerve
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.
Winging of scapula
Medial : Serratus
Lateral : Trapezius
A 28 year old man is shot in the right chest
and develops a right haemothorax
necessitating a thoracotomy. The surgeons
decide to place a vascular clamp across the
hilum of the right lung. Which of the
following structures will lie most anteriorly
at this point?
A. Thoracic duct
B. Phrenic nerve
C. Vagus nerve
D. Pulmonary artery
E. Pulmonary vein
The phrenic nerve lies anteriorly at the root
of the right lung.
A 73 year old man undergoes a sub total
oesophagectomy with anastomosis of the
stomach to the cervical oesophagus. Which
vessel will be primarily responsible for the
arterial supply to the oesophageal portion
of the anastomosis?
A. Superior thyroid artery
B. Internal carotid artery
C. Direct branches from the thoracic
aorta
D. Inferior thyroid artery
E. Subclavian artery
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.
A 74 year old man is assessed as having
oesophageal varices at endoscopy. What is
the venous drainage of these varices?
A. Left gastric vein
B. Splenic vein
C. Portal vein
D. Hemiazygos vein
E. Renal vein
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).
Killian’s Triangle
Killian-Jamieson area
Laimer’s triangle
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
In patients with an annular pancreas where
is the most likely site of obstruction?
A. The first part of the duodenum
B. The second part of the duodenum
C. The fourth part of the duodenum
D. The third part of the duodenum
E. The duodeno-jejunal flexure
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.
During embryological development, which
of the following represent the correct origin
of the pancreas?
A. Ventral and dorsal endodermal
outgrowths of the duodenum
B. Ventral and dorsal outgrowths of
mesenchymal tissue from the
posterior abdominal wall
C. Ventral and dorsal outgrowths of the
vitellointestinal duct
D. Ventral and dorsal biliary tract
diverticulae
E. Buds from the inferior aspect of the
caudate lobe
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
A surgical resection specimen is analysed
histologically. The pathologist comments
that at the periphery of the resected
specimen, oxyphil cells are identified. In
which of the structures listed below are
these cells typically found?
A. Thymus
B. Thyroid gland
C. Parathyroid gland
D. Lymph node
E. Adrenal gland
Oxyphil cells are typically found in
parathyroid glands
Parasympathetic fibres innervating the
parotid gland originate from which of the
following?
A. Submandibular ganglion
B. Otic ganglion
C. Ciliary ganglion
D. Pterygopalatine ganglion
E. None of the above
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.
Auriculotemporal nerve
Branch of V3
Frey’s syndrome
Friend of MMA
Most often permenantly damaged during parotidectomy
A 65 year old man with long standing atrial
fibrillation develops an embolus to the
lower leg. The decision is made to perform
an embolectomy, utilising a trans popliteal
approach. After incising the deep fascia,
which of the following structures will the
surgeons encounter first on exploring the
central region of the popliteal fossa?
A. Popliteal vein
B. Common peroneal nerve
C. Popliteal artery
D. Tibial nerve
E. None of the above
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
A 43 year old typist presents with pain at
the dorsal aspect of the upper part of her
forearm. She also complains of weakness
when extending her fingers. On
examination triceps and supinator are both
functioning normally. There is weakness of
most of the extensor muscles. However,
there is no sensory deficit. Which of the
following nerves has been affected?
A. Anterior interosseous
B. Median
C. Posterior interosseous
D. Palmar cutaneous
E. Ulnar
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.
The Denonvilliers fascia separates the
rectum from the prostate. Waldeyers fascia
separates the rectum from the sacrum
The Denonvilliers fascia separates the
rectum from the prostate. Waldeyers fascia
separates the rectum from the sacrum
A 25 year old man is being catheterised,
prior to a surgical procedure. As the
catheter enters the prostatic urethra which
of the following changes will occur?
A. Resistance will increase significantly
B. Resistance will increase slightly
C. It will lie horizontally
D. Resistance will decrease
E. It will deviate laterally
The prostatic urethra is much wider than the
membranous urethra and therefore
resistance will decrease. The prostatic
urethra is inclined superiorly
PROSTHETIC HEART VALVES ON CHEST X-RAYS
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.
The 3-6-9 rule is a simple aide-memoire describing the normal bowel caliber
small bowel: <3 cm
large bowel: <6 cm
appendix: <6 mm
cecum: <9 cm
An 18 year old athlete attends orthopaedic
clinic reporting pain and swelling over the
medial aspect of the knee joint. The pain
occurs when climbing the stairs, but is not
present when walking on flat ground.
Clinically there is pain over the medial,
proximal tibia and the McMurray test is
negative. What is the most likely cause of
this patient’s symptoms?
A. Anterior cruciate ligament tear
B. Prepatellar bursitis
C. Medial meniscus injury
D. Pes Anserinus Bursitis
E. Fracture of tibia
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
A 24 year old man falls and sustains a
fracture through his scaphoid bone. From
which of the following areas does the
scaphoid derive the majority of its blood
supply?
A. From its proximal medial border
B. From its proximal lateral border
C. From its proximal posterior surface
D. Superficial palmar arch vessels
E. Dorsal carpal branch vessels
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%.))
Into which of the following structures does
the superior part of the fibrous capsule of
the shoulder joint insert?
A. The surgical neck of the humerus
B. The body of the humerus
C. The bicipital groove
D. Immediately distal to the greater
tuberosity
E. The anatomical neck of the humerus
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
Which nerve directly innervates the
sinoatrial node?
A. Superior cardiac nerve
B. Right vagus nerve
C. Left vagus nerve
D. Inferior cardiac nerve
E. None of the above
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.
man with lung cancer and bone metastasis
in the thoracic spinal vertebral bodies,
sustains a pathological fracture at the level
of T4. The fracture is unstable and the
spinal cord is severely compressed at this
level. Which of the findings below will not
be present 6 weeks after injury?
A. Extensor plantar reflexes
B. Spasticity of the lower limbs
C. Diminished patellar tendon reflex
D. Urinary incontinence
E. Sensory ataxia
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.
Which of the following structures suspends
the spinal cord in the dural sheath?
A. Filum terminale
B. Conus medullaris
C. Ligamentum flavum
D. Denticulate ligaments
E. Anterior longitudinal ligament
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.
A builder falls off a ladder whilst laying roof
tiles. He sustains a burst fracture of L2. The
MRI scan shows complete nerve
transection at this level, as a result of the
injury. Which clinical sign will not be
present initially?
A. Flaccid paralysis of the legs
B. Extensor plantar response
C. Sensory loss in the legs
D. Incontinence
E. Areflexia
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.
Most of the gut is derived endodermally
except for the spleen which is from
mesenchymal tissue
Upper dorsal mesogastrium
Doesn’t store RBCs but stores platelets
A 34 year old man with a submandibular
gland stone is undergoing excision of the
submandibular gland. The incision is sited
transversely approximately 4cm below the
mandible. After incising the skin, platysma
and deep fascia which of the following
structures is most likely to be encountered?
A. Facial artery
B. Facial vein
C. Lingual nerve
D. Hypoglossal nerve
E. Glossopharyngeal nerve
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).
A patient presents with superior vena caval
obstruction. How many collateral
circulations exist as alternative pathways of
venous return?
A. None
B. One
C. Two
D. Three
E. Four
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.
Which of the following structures separates
the ulnar artery from the median nerve?
A. Brachioradialis
B. Pronator teres
C. Tendon of biceps brachii
D. Flexor carpi ulnaris
E. Brachialis
It lies deep to pronator teres and this
separates it from the median nerve.
Chordoma may typically occur at the
following sites, except?
A. Ribs
B. Clivus
C. Sacrum
D. Lumbar vertebra
E. Cervical vertebra
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.
A 50 year old lady presents with pain in her
proximal femur. Imaging demonstrates a
bone metastasis from an unknown primary
site. CT scanning with arterial phase
contrast shows that the lesion is
hypervascular. From which of the following
primary sites is the lesion most likely to
have originated?
A. Breast
B. Renal
C. Bronchus
D. Thyroid
E. Colon
Renal metastases have a tendency to be
hypervascular. This is of considerable
importance if surgical fixation is planned
What is the most common cause of
osteolytic bone metastasis in children?
A. Osteosarcoma
B. Neuroblastoma
C. Leukaemia
D. Rhabdomyosarcoma
E. Medulloblastoma
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.
failure undergoes a cadaveric renal
transplant. The transplanted organ has a
cold ischaemic time of 26 hours and a warm
ischaemic time of 54 minutes. Post
operatively the patient receives
immunosuppressive therapy. Ten days later
the patient has gained weight, becomes
oliguric and feels systemically unwell. He
also complains of swelling over the
transplant site that is painful. What is the
most likely cause?
A. Acute tubular necrosis
B. Hyperacute rejection
C. Ureteric occlusion
D. Acute on chronic rejection
E. Acute rejection
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.
Which of the following transplants is most
susceptible to donor- recipient HLA
mismatches?
A. Autologous skin graft
B. Renal allograft
C. Liver allograft
D. Corneal allograft
E. Cardiac valve allograft
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
You review a 42-year-old woman six weeks
following a renal transplant for focal
segmental glomerulosclerosis. Following the
procedure she was discharged on a
combination of tacrolimus, mycophenolate,
and prednisolone. She has now presented
with a five day history of feeling generally
unwell with anorexia, fatigue and arthralgia.
On examination, she has a temperature of
37.9 and has widespread lymphadenopathy.
What is the most likely diagnosis?
A. Hepatitis C
B. Coxsackie virus
C. HIV
D. Hepatitis B
E. Cytomegalovirus
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.
You review a 42-year-old woman 8 months
following a renal transplant for focal
segmental glomerulosclerosis. She is on a
combination of tacrolimus, mycophenolate,
and prednisolone. She has now presented
with a five day history of feeling generally
unwell with jaundice, fatigue and arthralgia.
On examination she has jaundice,
widespread lymphadenopathy and
hepatomegaly. What is the most likely
diagnosis?
A. Hepatitis C
B. Epstein-Barr virus
C. HIV
D. Hepatitis B
E. Cytomegalovirus
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.
A 56 year old lady is admitted with colicky
abdominal pain. A plain x-ray is performed.
Which of the following should not show fluid
levels on a plain abdominal film?
Stomach
* Jejunum
* Ileum
* Caecum
* Descending colon
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.
A 33 year old lady is 32 weeks pregnant and it is suspected
that there may be a perforated abdominal viscus. What is
the most appropriate course of action?
* Arrange an abdominal CT scan
* Arrange an abdominal MRI scan
* Undertake a laparotomy
* Undertake a laparoscopy
* Undertake diagnostic peritoneal lavage
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.
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
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
In which of the conditions described below is
Rovsing’s sign most likely to be absent?
* Locally advanced caecal cancer
* Para ileal appendicitis
* Right sided colonic diverticulitis
* Retrocaecal appendicitis
* Severe terminal ileal Crohns disease
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.
A 28 year old female has suffered from diffuse
abdominal pain for the past 2 weeks since she was
started on the contraceptive pill. The pain has increased
significantly over the past 10 hours and has been
associated with vomiting. A pregnancy test is negative.
What is the most likely diagnosis?
* Mesenteric venous thrombosis
* Acute mesenteric embolus
* Chronic mesenteric ischaemia
* Ruptured ectopic pregnancy
* Inflammatory bowel disease
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.
A 14 month old child is admitted with colicky abdominal
pain and on investigation is found to have an ileo-ileal
intussusception. What is the best course of action?
-Attempt hydrostatic reduction with barium enema
-Attempt pneumatic reduction with air insufflation
-Undertake a laparotomy
-Undertake a colonoscopy
-Undertake a flexible sigmoidoscopy
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.
A 19 year old female presents with colicky
abdominal pain, bloating and alternating
constipation/diarrhoea. Her grandmother died from
colon cancer at the age of 87 years. A digital rectal
examination and general physical examination are
normal. What is the best course of action?
* Measurement of faecal calprotectin
* Arrange a barium enema
* Undertake a colonoscopy
* Undertake a proctoscopy
* Undertake a rigid sigmoidoscopy
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.
A 45 year old lady presented with a 2cm
mobile breast mass. A mammogram is
indeterminate (M3), USS shows benign
changes (U2), clinical examination is also
indeterminate (P3). What is the next most
appropriate course of action?
A. Re-assure and discharge
B. Fine needle aspiration cytology
C. Excision biopsy
D. Image guided core biopsy
E. Wide local excision
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
A 74 year old woman presents with a breast
lump. On examination, it has a soft
consistency. The lump is removed and sliced
apart. Macroscopically there is a grey,
gelatinous surface. Which of the following
tumour types is most likely?
A. Sarcoma
B. Invasive ductal carcinoma
C. Mucinous carcinoma
D. DCIS
E. Lobular carcinoma
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
A 53 year old woman presents with a bloody
nipple discharge. On mammography, there
is calcification behind the nipple areolar
complex. A core biopsy shows background
benign change, but cells that show comedo
necrosis which have not breached the
basement membrane. Which of the lesions
below is most likely?
A. Fibrocystic disease of the breast
B. Ductal carcinoma in situ
C. Invasive ductal carcinoma
D. Atypical ductal hyperplasia
E. Lobular carcinoma in situ
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.
A 53 year old lady undergoes a mastectomy
to remove a breast cancer. Microscopic
analysis the tumour shows a pronounced
lymphocytic infiltrate. Which of the tumour
types listed below is most often associated
with this finding?
A. Invasive ductal carcinoma
B. Tubular breast cancer
C. Medullary breast cancer
D. Mucinous breast cancer
E. Adenoid cystic carcinoma of the
breast
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
A 28 year old female presents with a
painless lump in the upper outer quadrant
of her left breast. Imaging using ultrasound
is indeterminate (U3). Two core biopsies
have now been performed and both show
normal breast tissue (B1). What is the most
appropriate course of action?
A. Arrange for imaging surveillance at 3
monthly intervals
B. Undertake a wide local excision of the
lump
C. Reassure the patient and discharge
D. Undertake an excision biopsy of the
lump
E. Arrange for a breast CT scan
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.
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.
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.
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.
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.
A 43 year old lady is diagnosed as having a
malignant lesion in the inferior aspect of her
left breast. There is palpable axillary
lymphadenopathy. What is the most
appropriate course of action?
A. Mastectomy and axillary node
clearance
B. Wide local excision and axillary node
clearance
C. Wide local excision and sentinel
lymph node biopsy
D. Image guided fine needle aspiration
of the axillary nodes
E. CT scanning of the chest, abdomen
and pelvis
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.
A 52 year old lady presents to the surgical
clinic with a goitre. She is taking medication
for an underlying psychiatric disorder.
Which of the drugs listed below is most
likely to be responsible?
A. Haloperidol
B. Imipramine
C. Amytryptiline
D. Lithium
E. Venlafaxine
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.
During a colonoscopy, a patient is found to have a
colonic cancer in the caecum and a 1cm polyp
(which looks adenomatous) in the sigmoid colon.
What is the correct management of the sigmoid
polyp?
* Undertake a snare polypectomy
* Leave in situ until the cancer has been resected
* Perform a hot biopsy
* Perform a cold biopsy
* Resect the sigmoid at the same time as the
cancer resection
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.
Synchronous colonic tumours are seen in 5%
Synchronous colonic tumours are seen in 5%
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
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
A 63 year old man presents with episodic rectal bleeding
the blood tends to be dark in colour and may be mixed with
stool. His bowel habit has been erratic since an abdominal
aortic aneurysm repair 6 weeks previously. What is the
most likely cause?
* Ischaemic colitis
* Diverticulitis
* Angiodysplasia
* Cancer
* Ulcerative colitis
The inferior mesenteric artery may have been ligated and
being an arteriopath collateral flow through the marginal
may be imperfect.
A 56 year old man is admitted with passage of a large
volume of blood per rectum. On examination, he is
tachycardic, his abdomen is soft, although he has
marked dilated veins on his abdominal wall.
Proctoscopy reveals large dilated veins with stigmata
of recent haemorrhage. What is the most appropriate
treatment?
* IV terlipressin
* Excisional haemorrhoidectomy
* Injection sclerotherapy
* Proctectomy
* Rectal pack insertion
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.
A 24 year old woman presents with a long history of
obstructed defecation and chronic constipation. She
often strains to open her bowels for long periods and
occasionally notices that she has passed a small
amount of blood. On examination, she has an
indurated area located anteriorly approximately 3cm
proximal to the anal verge. What is the most likely
diagnosis?
* Haemorrhoids
* Rectal cancer
* Ulcerative colitis
* Solitary rectal ulcer syndrome
* Fissure in ano
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.
A 25 year old cyclist is hit by a bus traveling at 30mph.
He was not wearing a helmet. He arrives with a GCS of
3/15 and is intubated. A CT scan shows evidence of
cerebral contusion but no localising clinical signs are
present. What is the most appropriate course of
action?
* Burr hole decompression
* Decompressive craniotomy
* Insertion of intra cranial pressure monitoring device
* Administration of intravenous mannitol
* Parietotemporal craniotomy
This patient may well develop raised ICP over the next
few days and intracranial pressure monitoring will help
with management.
Local anesthesia toxicity
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
A 73 year old lady sustains a distal radius
fracture and this is manipulated using a Biers
block with prilocaine as the local anaesthetic
agent. During the procedure the occlusion cuff
deflates and the patient becomes progressively
cyanosed. What is the treatment of choice?
* Intravenous calcium gluconate
* Exchange transfusion
* Intravenous methylene blue
* Intravenous sodium thiosulphate
* Intravenous gelofusine
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.
The insertion of chest drains for chest trauma is different from the seldinger sets that are often used by
physicians. In trauma it is usual to insert a wide bore chest drain (between 30 and 34Fr) using an open
technique (with trochar removed).
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.
A 53 year old man presents with a full thickness
external rectal prolapse. Which of the following
procedures would be the most suitable surgical
option?
* Rectopexy
* Delormes
* Altmeirs
* Thirsch tape
* Abdomino-perineal excision of the rectum
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).
A 19 year old student is involved in a head on car collision. He
complains of severe chest pain. A Chest x-ray performed as part
of a trauma series shows widening of the mediastinum. Which
is the most likely injury in this scenario?
* Rupture of the distal oesophagus
* Rupture of the left main bronchus
* Rupture of the aorta proximal to the left subclavian artery
* Rupture of the aorta distal to the left subclavian artery
* Rupture of the inferior vena cava
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.
A 44 year old man is involved in a road traffic
accident. He suffers significant injuries to his
thorax, he has bilateral
haemopneumothoraces and a suspected
haemopericardium. He is to undergo surgery,
what is the best method of accessing these
injuries?
* Bilateral thoracoscopy and mediastinoscopy
* Midline sternotomy
* Bilateral posterolateral thoracotomy
* Clam shell thoracotomy
* None of the above
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.
A 45 year old man presents with a facial
swelling. On examination, he has a swelling
that lies inferolaterally to the nose. When
the area is palpated, it feels like the
underlying bone is cracking. What is the
most likely diagnosis?
A. Maxillary sinus cancer
B. Ameloblastoma
C. Nasal polyps
D. Maxillary sinusitis
E. Mucocele
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.
A 56 year old man presents with symptoms
of nasal pain, anosmia and rhinorrhea. He
has been well until recently and has worked
as a wood carver for many years. What is
the most likely diagnosis?
A. Ethmoid sinus cancer
B. Ameloblastoma
C. Maxillary sinus cancer
D. Fibrous dysplasia
E. Haemangiopericytoma
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
An elderly diabetic male presents with a
severe deep seated otalgia and a facial
nerve palsy, he has completed a course of
amoxycillin with no benefit. What is the
most likely diagnosis?
A. Malignant otitis externa
B. Otosclerosis
C. Acoustic neuroma
D. Meniers disease
E. Viral illness
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
A 8 year old boy with recurrent attacks of
otitis media is suspected of developing a
glue ear. If his sound conduction is tested,
which of the following is most consistent
with a unilateral middle ear effusion?
A. Negative Rinne’s test on the
ipsilateral side
B. Positive Rinne’s test on the ipsilateral
side
C. Positive Webers and Rinnes tests on
the ipsilateral side
D. Positive Rinne’s test on the
contralateral side
E. Negative Webers test only on the
contralateral side
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.
An 82 year old lady is taken to theatre for a
common bile duct exploration. She has a
stone impacted at the distal aspect of the
common bile duct and despite best efforts it
proves impossible to remove it. What is the
best course of action?
A. Close the bile duct over a T Tube and
arrange for a stent to be placed
B. Undertake a
choledochoduodenostomy
C. Arrange for a repeat ERCP
D. Construct a hepaticojejunostomy
E. Bypass the gallbladder onto the
jejunum
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.
A 40 year old woman is admitted with 1 day
history of abdominal pain. She has suffered
from repeated episodes of this colicky right
upper quadrant pain. On examination, she is
pyrexial with right upper quadrant
peritonism. Her blood tests show a white
cell count of 23. However, the liver function
tests are normal. An abdominal ultrasound
scan done the day of admission, shows
multiple gallstones in a thick walled
gallbladder, the bile duct measures 4mm.
What is the best course of action?
A. Administration of broad spectrum
intravenous antibiotics and perform a
delayed open cholecystectomy in 3
months
B. Arrange a radiological
cholecystotomy
C. Undertake a laparoscopic
cholecystectomy
D. Undertake an open cholcystectomy
E. Administration of broad spectrum
intravenous antibiotics and perform a
delayed laparoscopic
cholecystectomy in 3 months
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.
What proportion of patients presenting for
cholecystectomy for treatment of biliary
colic due to gallstones will have stones in
the common bile duct?
A. 10%
B. 30%
C. 2%
D. 50%
E. 25%
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.
A 41 year old lady with colicky right upper
quadrant pain is identified as having
gallstones on an abdominal ultrasound scan.
What is the most appropriate initial course
of action?
A. Laparoscopic cholecystectomy
B. Open cholecystectomy
C. Liver function tests
D. MRCP
E. ERCP
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.
A 58 year old woman is admitted with an
attack of severe acute pancreatitis. She is
managed on the intensive care unit and is
making progress. She then deteriorates and
a CT scan shows extensive pancreatic
necrosis (>40%). There are concerns that
this may have become infected. What is the
correct course of action?
A. Undertake a fine needle aspiration of
the area
B. Perform a pancreatic necrosectomy
C. Perform a Whipples procedure
D. Arrange an ERCP
E. Perform a distal pancreatectomy
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
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.
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.
A 20 year old man is hit with a hammer on
the right side of the head. He dies on arrival
in the emergency department. Which of
these features is most likely to be found at
post mortem?
A. Hydrocephalus
B. Supra tentorial herniation
C. Laceration of the middle meningeal
artery
D. Sub dural haematoma
E. Posterior fossa haematoma
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
A 28 year old man falls and hits his head
against a wall. There is a brief loss of
consciousness. When assessed in accident
and emergency he is alert and orientated
with a GCS of 15, imaging shows no fracture
of the skull. What is his risk of having an
intracranial haematoma requiring removal?
A. 1 in 6000
B. 1 in 40
C. 1 in 4
D. 1 in 50,000
E. 1 in 120
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
A 50 year old alcoholic man attends the
emergency department. His main reason for
presenting is that he has no home to go to.
On examination, he has no evidence of
involvement in recent trauma, a skull x-ray
fails to show any evidence of skull fracture.
He is admitted and twelve hours following
admission he develops sudden onset
headache, becomes comatose and then
dies. What is the most likely cause?
A. Acute extra dural haematoma
B. Chronic sub dural haematoma
C. Sub arachnoid haemorrhage
D. Intraventricular haemorrhage
E. Acute sub dural haematoma
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
A 50 year old lady is admitted having fallen
down some stairs sustaining multiple rib
fractures 36 hours previously. On
examination, she is confused and agitated
and has clinical evidence of lateralising
signs. She deteriorates further and then dies
with no response to resuscitation. What is
the most likely explanation?
A. Intraventricular haemorrhage
B. Acute sub dural haemorrhage
C. Chronic sub dural haematoma
D. Sub arachnoid haemorrhage
E. Extra dural haematoma
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
A patient is referred due to the
development of a third nerve palsy
associated with a headache. On
examination, meningism is present. Which
one of the following diagnoses needs to be
urgently excluded?
A. Weber’s syndrome
B. Internal carotid artery aneurysm
C. Multiple sclerosis
D. Posterior communicating artery
aneurysm
E. Anterior communicating artery
aneurysm
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
A 72 year old man presents with a large
nodule on his face. It is friable. There is no
regional lymphadenopathy. He is lost to
follow up and re-attends several months
later. On this occasion the lesion has been
noted to resolve with scarring. What is the
most likely lesion?
A. Pyogenic granuloma
B. Keratoacanthoma
C. Melanoma
D. Basal cell carcinoma
E. Dermatitis artifacta
Keratoacanthomas may reach a considerable
size prior to sloughing off and scarring.
A 30 year old man cuts the corner of his lip
whilst shaving. Over the next few days a
large purplish lesion appears at the site
which bleeds on contact. What is the most
likely diagnosis?
A. Pyogenic granuloma
B. Keratoacanthoma
C. Melanoma
D. Squamous cell carcinoma
E. Adenocarcinoma
Pyogenic granulomas often appear at sites of
Trauma
A 58 year old lady presents with changes
that are suspicious of lichen sclerosus of the
perineum. What is the best course of
action?
A. Wide excision of the area and split
thickness skin grafts
B. Punch biopsy
C. Excision of area with 0.5cm margin
D. Excision of the area and full thickness
skin grafts
E. Excision of the area with 2cm margin
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.
A 89 year old woman presents with long
standing seborrhoeic warts of her
abdominal wall , they have caused
troublesome itching. What is the best
treatment?
A. Administration of topical steroids
B. Shave excision and cautery
C. Excision and primary closure
D. Excision and skin graft
E. Excision biopsy
These lesions are often extensive and
superficial. Shave excision will suffice,
material must be sent for histology.
A 48 year old lady is admitted with crampy
abdominal pain and diarrhoea. She has
been unwell for the past 12 hours. In the
history she complains that her milk bottles
have been pecked repeatedly by birds, she
otherwise has had no dietary changes.
Which of the following is the most likely
causative organism?
A. Staphylococcus aureus
B. Campylobacter jejuni
C. Clostridium difficile
D. Norovirus
E. Clostridium botulinum
Birds are a recognised reservoir of
campylobacter.
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.
- First-line therapy is oral metronidazole for 10-14
days - If severe, or not responding to metronidazole,
then oral vancomycin may be used - Patients who do not respond to vancomycin may
respond to oral fidaxomicin - Patients with severe and unremitting colitis
should be considered for colectomy
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.
A 23 year old lady has suffered from
diarrhoea for 8 months, she has also lost 2
Kg in weight. At colonoscopy, appearances
of melanosis coli are identified and
confirmed on biopsy. What is the most
likely cause?
A. Ischaemic colitis
B. Salmonella gastroenteritis infection
C. Laxative abuses
D. Irritable bowel syndrome
E. Clostridium difficile infection
This may occur as a result of laxative abuse
and consists of lipofuschin laden
macrophages that appear brown.
A 22 year old man presents with crampy
abdominal pain diarrhoea and bloating. He
has just returned from a holiday in Egypt.
He had been swimming in the local pool a
few weeks ago. He reports that he is
opening his bowels 5 times a day. The stool
floats in the toilet water, but there is no
blood. What is the most likely cause?
A. Cryptosporidium
B. Salmonella sp
C. E.Coli sp
D. Chronic pancreatitis
E. Giardia lamblia
Giardia causes fat malabsorption, therefore
greasy stool can occur. It is resistant to
chlorination, hence risk of transfer in
swimming pools.
A 25 year old man returns from a
backpacking holiday in India. He presents
with symptoms of coughing and also of
episodic abdominal discomfort. Peri anal
examination is normal. Stool microscopy
demonstrates both worms and eggs within
the faeces. What is the most likely infective
organism?
A. Cryptosporidium
B. Ancylostoma duodenale
C. Clonorchis sinensis
D. Ascaris lumbricoides
E. Enterobius vermicularis
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.
Campylobacter.
A 32 year old woman undergoes
mastectomy and latissimus dorsi flap
reconstruction for breast cancer, to provide
optimal cosmesis a McGhan implant is
placed under the myocutaneous flap. Three
weeks post operatively the patient
continues to suffer from recurrent wound
infections that have proved resistant to
multiple courses of antibiotics. Which of the
organisms listed below is most likely to be
responsible?
A. Staphylococcus epidermidis
B. Staphylococcus aureus
C. Streptococcus viridans
D. Streptococcus pyogenes
E. Staphylococcus saprophyticus
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.
A 23 year old man is readmitted following a
difficult appendicectomy. His wound is
erythematous and, on incision, foul smelling
pus is drained. Which of the organisms
listed below is responsible?
A. Streptococcus bovis
B. Bacteroides fragilis
C. Staphylococcus aureus
D. Streptococcus pyogenes
E. Clostridium perfringens
Bacteroides is commonly present in severe
peritoneal infections and as it is facultatively
anaerobic may be present in pus. It has a
pungent aroma.
A 72 year old man with peripheral vascular
disease develops a gangrenous toe. This
becomes infected and there is evidence of
infection in the surrounding tissues. On
clinical palpation there is crepitus present
within the tissues. What is the most likely
infective organism?
A. Staphylococcus aureus
B. Streptococcus pyogenes
C. Clostridium difficile
D. Clostridium perfringens
E. Clostridium botulinum
Clostridium perfringens is the most likely
pathogen to be associated with gangrene.
A 45 year old man is recovering in hospital
following a total hip replacement. He
develops a profuse and watery diarrhoea.
Several other patients have been suffering
from similar symptoms. Infection with
which of the following is the most likely
underlying cause?
A. Clostridium perfringens
B. Clostridium botulinim
C. Clostridium difficile
D. Clostridium welchi
E. Clostridium tetani`
Clostridium difficile can spread rapidly on
surgical wards. The use of broad spectrum
prophylactic antibiotics during arthroplasty
surgery can increase the risk.
A 45 year old man undergoes an upper
gastrointestinal endoscopy for a benign
oesophageal stricture. This is dilated and he
suffers an iatrogenic perforation at the site.
His imaging shows a small contained leak
and a small amount of surgical emphysema.
What is the most appropriate nutritional
option?
A. Nil by mouth and intravenous fluids
alone
B. Intravenous fluids and sips orally
C. Total parenteral nutrition
D. Nasogastric feeding
E. PEG tube feeding
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.
A 63 year old man undergoes an upper GI
endoscopy and adrenaline injection for a
large actively bleeding duodenal ulcer. He
remains stable for 6 hours and the nurses
then call because he has passed 400ml
malaena and has become tachycardic (pulse
rate 120) and hypotensive (Bp 80/40). What
is the best option?
A. Reassure that blood trapped in the
upper portion of the gastrointestinal
system will pass and that this episode
will resolve with phosphate enema
B. Perform a repeat upper GI endoscopy
C. Perform a laparotomy and underrunning
of the ulcer
D. Administer tranexamic acid and
intravenous proton pump inhibitors
E. Insert a Minnesota tube
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.
A 52 year old male presents with tearing central
chest pain. On examination, he has an aortic
regurgitation murmur. An ECG shows ST
elevation in leads II, III and aVF. What is the
likely explanation?
* Distal aortic dissection
* Anterior myocardial infarct
* Inferior myocardial infarct
* Proximal aortic dissection
* Pulmonary embolism
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.
Which of the following preparatory regimes should be
considered for a 63 year old man with normal renal
function who requires a diagnostic colonoscopy to
investigate iron deficiency anaemia for which he takes
ferrous sulphate?
* Stop ferrous sulphate 7 days pre procedure and
administration of oral purgatives the day prior to the
procedure
* Administration of oral purgatives the day prior to the
procedure and continue ferrous sulphate
* Continue ferrous sulphate and administration of
phosphate enemas on the day
* Cease ferrous sulphate 7 days pre procedure and
administration of phosphate enema 30 minutes pre
procedure
* No preparation required
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
A 45 year old man with previous laparotomy is admitted
with adhesional small bowel obstruction. He is managed
with prolonged nasogastric drainage. His U+E’s are as
follows:
Sodium 129
Potassium 3.4
Urea 8.4
Creatinine 89
Which of the following intravenous fluids should be
prescribed?
* 0.4%/0.18% dextrose saline
* 0.9% Sodium Chloride
* 0.9% sodium chloride with 40mmol potassium chloride
per litre
* Hartmanns solution
* 5% dextrose with 20mmol KCl
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.
In relation to patients with type 1 diabetes mellitus undergoing
surgery, which of the following statements is untrue?
* They should not receive oral carbohydrate loading drinks as
part of enhanced recovery programmes
* When a variable rate insulin infusion is required 0.45%
sodium chloride and 5% dextrose with either 0.15% or 0.3%
potassium are the fluids of choice
* Hourly intraoperative blood glucose measurements are
required
* Insulin infusions are only required in patients who will miss
more than two meals or who are nil by mouth for greater
than 12 hours
* Blood glucose levels persistently greater than 12 should
initiate a change in therapy
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.
