Misc 8 Flashcards
What are the 4 subtriangles of the anterior triagnel of neck?
Submandibular
Submental
Carotid
Muscular
What are the 2 subtriagnels of the posterior triangle of neck?
Occipital
Subclavian
What innervates omohyoid?
Ansa cervicalis
Which nerve passes just anterior to the external carotid artery?
Hypoglossal
Why is ligating the facial artery ok in tersm of muscles not necrosing?
Anastomosis from lingual
Motor innervations of V3?
Masseter and muscles of mastication
Mylohyoid
Ant belly digastric
Level of tracheoseophageal junction?
T4/5
Which PNS ganglion innervates parotid?
Otic
Which region does pre aurigcular LN drain?
Superior deep cervical
What are diploic veins?
Venous connection between outer and inner cortical bones of skull
What bones comprise the pterion?
Sphenoid, frontal, parietal, temporal
Which 3 muscles attach to styloid process?
Stylohyoid
Styloglossus
Posterior belly digastric
What joint exists between peg and atlas?
Pivot synovial joint
What are the movements of the temporomandibular joint? What is responsible for them?
Protrusion - pterygoids
Retraction - temporalis, masseter, digastric, geniohyoid
Elevation - temporalis, masseter, medial pteyroids
Depgression - digastric, geniohyoid, mylohyoid
Lateral - lateral pterygoids
Blood supply to temporalis?
Deep temporal artery from maxillary from ECA
3 nreves at risk during submandibular gland surgery?
Hypoglossal, lingual and marginal mandibular
Surface anatomy of parotid duct?
Middle third of line between phylum and antitragic notch, 1 cm below zygomatic arch
What kind of secretions do parotid gland procude?
Serous
What connects spinal nerves to the sympathetic chain?
Rami communicantes
Blood supply to bladder?
Vesical arteries via internal iliac
What are the peritoneal relections of the bladder?
Superior and upper posterior surfaces (dome)
Innervation of detrusor?
PNS via pelvic splanchnic
What ligaments conrtubte to the stability of the atlanto-axial joint?
Cruciate - transverese and linogitdunial
Alar
What level is the hyoid?
C3
Why cant you feel the upper cervical spinous processes?
Bifid and atach to nuchal ligament
what level does the oesophagus begin?
C6
What is the main component of the deltoid ligament of ankle?
Tibionavicular lig
Which position is ankle most stable in? Why?
Dorsiflexion, widest diameter of talus
Define a hernia?
Protrusion of a viscus or part thereof from cavity which it is normally contained in
Describe how to examine the hand?
Ensure comfort, fully expose elbows and examine whole hand/forearm for scars e.g. CT release
Examine nails
Examine for muscle wasting or deformity
Feel - MCPJ squeeze as screen, ASB tenderness
Functional movements
CT tests - Tinels and Phalens
Ulnar test - Froment
De Quervains tenosynovitis - finkelsteins
Nerves - median (APB), ulnar (minimi abduction), radial (wrist ext)
Pulses
To complete - say would examine elbow
Full history and XRs
Describe how to examine the knee?
Full exposure to underweat to ankles
Look from front, back and sides for deformity/scars/wasting and gait assessment
Feel - warmth, effusions (gutter test and patella tap), along jointlines, patella tracking
Move - flexion/extension, hyperextend with foot lift and full flexion with heel to bottom
Specials - collateral legs, rawer tests, lackmann for ACL, mcmurrays for meniscus, SLR
To complete - examine hip and ankle, history and XRs and neurovascular function
Descrbiei how to examine the shoulder?
Full exposure ideally with top rmeoved
ensure comfort
Look for obvious deformity incl winging or swelling, scars from previous surgery, wasting of fossae/deltoid
Feel - from distal to prox- humerus, ACJ, clavicle, coracoid, scapula, SCJ
Move - full abduction + adduction, assess for painful arc, flex/ext, int rot, ext rot
Passive movements feeling GHJ and ACJ for crepitus
Resisted movements for rotator cuff
Neuro - axillary nerve - deltoid and regimental badge
Subacromial impingement - Hawkins/jobe
ACJ - scarf test
Instability - Drawer/aprehension test
Examine c-spine and elbow, history and Xrays
What are the differernt parts of painful arc shoulder ax?
Initiation = supraspinatus pathology
painful 70-100 degrees = GHJ painful arc e.g. subacromial impingenemtn
painful 170 degrees = pain due to ACJ
Describe how to examine the hip?
Full exposure down to underwear Standing ideally Loko - scars, deformity including limb length, rotation, scoliosis, pelvic tilt, muscle wasting Gait - antalgic/trendelenberg/ataxi/high stepping/circumduction Trendelendberg test Then on couch - feel joint, trochanter, asis, ramus/symphysis Measure apparent (symphysis to med mal) and true (ASIS to med mal) lengths Move - active then passive incl SLR Thomas test - for hip flexor contracture - fully flex both hips, hand under lordosis, extend each leg NV assessment, examine spine and knee, hx and XRs
What does a cirfcumducting gait suggest?
Weakness of hip flexors
Whta is a positive trendelenberg test?
Sound side sags - weakness of tested side hip abductors causing sagging of contralat normal side
How would you measure true and apparent leg lengths for hip exam?
True = ASIS to med mal Apparent = fixed midline point to med mal
What are you palpating for in hip exam?
Greater troch - bursitis
Movement with hand on ASIS for pain/crepitis
Questions ins the AMT?
Age/DOB Place/time/year Recognise Recall 20-1 Moarch/PM WW2 dates
Rough prognostic scores for Glasgow mortality in pancreatitis?
Score 0-2 = 2%
3-4 = 15% (severe pancreatitis)
5-6 = 40%
7-8 = 100%
Reasons for pancreatitis causing low Ca?
Fat saponification (fat digestion which releases free fatty acids which form calcium salts)
Low albumin
ARF causing hypoCa, hypoMg
How do pancreatic pseudocysts occur?
In severe pancreatitis, leakage of pancreatic fluids causes inflammatory response and encysts fluid with fibrous tissue
4 safety features of PCA?
Locked unit
Non-return valve on line
Measured dosing
Lockout if freq use
What are the SIRS criteria?
RR over 20
tachycardia over 90
temp over 38 or less than 36
WCC over 12 or less than 4
Level of epidural block depends on what 3 things?
Dose
Duration
Position
Lifespan of a RBC in body?
120 days
When do cross match, what 3 main things are being xmatched?
ABO
Rhesus
Kell
What are the 4 stages of fracture healing?
Haematoma and inflammation
Cartilagenous callus
Bony callus
Re-modelling
Crieteria for evacuating aSDH?
Associated with neurolgial deficit
Over 1cm thick
Over .5cm midline shift
Give the 5 portocaval anastamosis veins?
Left gastric (oesophageal branches) and short gastric to distal oesophageal veins
Slenic vein to left renal vein in lienorenal ligament
Retroperitoneum - SMV to petroperitoneal/lumbar veins to IVC
Paraumbilical vein to aubcutaneous periumbicilal veins
Anal - SRV to IMV, upper anal canal veins to iliac
Shelf life of platelets?
5 days
3 indications for platelet transfusion?
Massive transfusion over 4 units
Plaetelets less than 50 and symptomatic/for surgery
DIC
Give 3 mechanisms of haemostsis?
Vasospasm
Platelet plug
Coagulation
What does TPN contain?
Carbs, fluid, protoein, fat, electrolytes, nitrogen, trace elements
What are 4 issues with using continuous glucose as only energy source?
Hyperglycaemia
Poor utilization during stress
Excess is converted to fat
Produces excessive CO2
5 complications of TPN?
Sepsis from line Hyperglycaemia Electrolyte disturbances Cholestasis Bowel mucosal atrophy
What is the implication of mucosal atrophy in e.g. TPN use?
Translocation of bacteria to blood stream causing sepsis
Define ARDS?
Acute diffuse inflammatory lung injury leading to increased pulmonary vascular permeability, increased lung weight, loss of aerated lung tissue with hypoxaemia and bilateral radiographic opacities, associated with decreased lung compliance
Not fully explained by cardiac failure or fluid overload
What is the criteria for diagnosing ARDS called?
Berlin criteria
How to treat acute hypocalcaemia?
IV 10mls 10% calcium gluconate over 10 mins
Give 4 physiological roles of calcium in the body?
Cardiac
Nervous system
Haemostasis
Bone
2 reasons for post op hypocalcaemia in thyroidectyom
Ischaemia to parathyroids
Inadvertent removal
Why may hypoCa cause SOB?
Tetany - laryngoosapsm causing upper airway obstruction
hy is there paroxysaml aciduria in gastric outlet obstruction?
Chloride depletion means Na/Cl and Na/K/Cl pumps dont function properly in kidneys
Aldosterone Na/K exchanger utilised until K depleted
Then Na/H exchanger used to retain Na
So H booted out
How do the kidneys compensate long term for caidosis?
Produce and excrete ammonium - geneerate HCo3 which goes into circulation, and excreting H+ as phosphate and amoonia
What is bilirubin metabolised to (acids)
Glucoronic and taurocolic acids
The use of which fluid is impliacted in TURP syndrome? Why is it used?
Glycine - irrigating fluid
Used because electrocautery loop is used to pferorm, so cant use normal saline as could disseminate current
4 complications seen in TURP syndrome?
Hypervolaemia
Hypothermia
Hyponatraemia
Hyperammonaemia
Define ARDS (short version)?
Diffuse alveolar damage and lung capillary endothelial injury causing non-cardiogenic pulmonary oedema with reduced lung compliance and hypoxaemia
Define Barretts oesophagus?
Columnar metaplasia of stratified squamous epithelium of the esophagus yielding an increased risk of developing adenocarcinoma
What is Breslow thickness measured to and from?
From top of stratum granulosum to deepest point of tumour involvement
What is PVL and what is it seen in?
Cytotoxin seen in most community associated MRSA
What is the other way of staging mellanoma other thant Breslow?
Clarks level
What measurement can be used to identify ARDS?
Swan Ganz - PCWP less than 18
4 diagnostic citeria for ARDS?
Acute onset (less than 1 week)
Ratio - pao2:fio2 low
Diffuse pulmonary infiltrates on CXR
Swan Ganz catheter - PCWP less than 18
What is the principle of Mohs micrographic surgery?
Serial sectiosn taken and examined histologically until all margins are clear
What ventilatory factors might be useful in managing ARDS?
Mechanical - high PEEP, small tidal volumes
Proning
Inhaled nitric oxide
Give 4 benefits of using PEEP in ventilation?
Improves alveolar recruitment
Increases compliance
Increase functional residual capacity
Reduced physiological shunting and increased VQ ratio
Give 4 things that the blood brain barrier is permeable to?
Lipids
Lipid solube .e.g drugs
Glucose
Respiratory gases
What 2 things make up the blood brain barrier?
Tight junctiosn between cerebral capillary endothelial cells
Astrocytic foot processes at basal membranes of cererbal capillaries
What is the value of cerebral blood flow? How much of CO is this?
750ml per min
15% of CO
What is the normal CPP?
70-100mmHg
Which lung volumes on spirometry are directly measured?
Tidal volume
Vital capacity
Inspiratory capacity (via tidal volume + inspiratory reserve volume)
What is the functional residual capacity?
Volume of gas in lungs at the end of expiration
What level of COHb is abnormal and suggests carbon monoxide posioinoing?
Over 10%
Hoe is vitamin D producdes?
Vitamin D3 (colecalciferol) is formed in skin when cholesterol precursor exposed to UV light This is activated in liver (25 hydro) and then kidney (1 hydro) to activated vit D
Max safe dose of bupivocaine?
2ml/kg with or without adrenaline
Maximum safe dose of prilocaine?
6ml/kg
What is vicryl made of?
Polyglactin
2 monofilmanet absorbable sutures?
Monocryl and PDS
What are langers lines precisely and why are they important?
Topological lines drawn on map of human body correspodning to natural orientation of collagen fibres in dermis, and generally parallel to orientation of underlying muscle fibres. Promote good wound healing
When doing FNAC, how many times should you pass through the needle
5-6 times through tissue
Describe how to do surgical cricothyroidotomy?
2cm vertical incision over cricothyroid membrane
Horiztonal incision through membrane
Tracheal hook in to stabilise trachea
Insert dilator
Take dilator out and insert tube into trachea
Where is a tracheostomy tube inserted?
Between 2nd and 3rd tracheal rings, following division of the thyroid isthmus
How to size a hard collar?
Top of shoulder to bottom of jaw, with finger widths
Then apply to collar adjustment bit
Clotting factors in intrisic pathway?
8-12
Clotting factors in extrinsic pathway?
2, 7, 10
What is the difference between metatstatic and dystrophic calcification? Example of latter
Metastatic = calcification of normal tissue in hypercalcaemia Dystrophic = deposition of calcium in abnormal tissues e.g. vascular collagen diseases, with normal calcium. e.g. DCIS breast Ca
Why is stapling not used in primary anastaomsosis in the setting of bowel obstruction?
Bowel usually thick and inflamed, too thick to hold staples
What are the signs of viability in bowel?
Pink, peristalsing, perfused
What is the difference between the adreanl venous drainage on right vs left?
Right straight into IVC
Left into renal vein
What is the difference between a ghon focus and ghon complex?
Focus = primary pulmonary TB lesion Complex = lesion plus affected LN
What infusion may be used to inentigy parathydoi tissue when doing parathyroidectomy?
Methylene blue
What should you check to confirm resection in hyperPTH resection?
Frozen section
Measure PTH in serum - should normalise after 30 mins
What effect does PTH have on PO4 and why?
Lowers it - via phosphaturia to increase Ca reabsorption
3 factors inducing release of pancreatic exocrine secretion?
Vagal mediated cephalic stimulus - sight and smell of food
Vagal mediated gastric phase - gastric distension
Hormonal intestinal phase - CCK, and secretin (biarcb)
What med might be useful in pancreatic fistula with high output and why?
Somatostatin analgoue e.g. octreotide - reduces exocrine secretion
How would you examine and manage an anal fistula?
Lithotomy position DRE + rigid sigmoid/proctoscopy Vertical incision over abscess and evacuate pus Irrigate, curette Insert alginate based pack
What is Goodsall’s rule for fistula in ano?
If anterior to transverse anal line and within 2cm of anal canal, will have straight tract to internal opening
If posterior to line and witihin 2cm of canal, will curve posteriorly to open in posterior midline
Potential management strateiges for anal fistula?
Setons
Fistulotomy
Advancement flaps, glue, plugs etc
What causess the dicrotic notch in art line?
Elastic recoil of arteries as heart ceases to eject column of blood
Calculating MAP?
DBP + 1/3 SBP-DBP
Define renal clearance of a substance?
Volume of plasma completetly cleared of a substance in 1 minute
4 factors that make inulin ideal for measuring GFR?
Freely filtered at glomerulus
Not secreted or reabsorbed in tubules
Not metabolised by kideny
NDoesnt in itself afect the GFR
What is the Hawthorne effect in audit?
Perforamnce affected by knowledge that process or prerson is being monitored
3 ECG signs of hyperK?
Flattening of p waves
Tenting of t waves
Widening of QRS
Why can hyperventilation cause low Ca?
Increased excretion of CO2 and resp alkalosis
H+ ions dissociate from albumin, which then preferentially binds calcium
So ionised calcium level falls
Describe metabolism of bilirubin?
Formed via breakdown of red cells in Kuppfer cells of liver - unconjugated and transported to the liver, where is conjugated with glucoronic acid and secreted in bile
Conjugated bili not absorbed from small bowel due to size, hydrolysed in terminal ileum and then reduced to uro/stercobilinogen
Res tis reabsorbed and enters enterohepatic circulation
Usual capnoperitoneum pressure?
10-12mmHg
How does herparin work?
Activated antithrombin 3 inactivates thrombin
What test might be useful in vWD patients pre op?
Desmopressin challenge
