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MRCS study > MRCS May 1/52 > Flashcards

MRCS May 1/52 Flashcards

1
Q

what compound can be used to identify parathyroid glands intraoperatively?

A

methylene blue

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2
Q

what drug should be given preoperatively for removal of carcinoid tumour?

A

octreotide

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3
Q

what drug should be given preoperatively for removal of phaeochromocytoma?

A

alpha and beta blockade

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4
Q

what is dumping syndrome?

A

post gastrectomy
posprandial giddiness, abdo pain
caused by distension of JJM due to food contents with subsequent osmotic expansion and diarrhea, release of insulin causes hypoglycaemic symptoms

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5
Q

describe the movement of ions in the myocardial action potential

A 
rapid depol: rapid influx of sodium
early repol: efflux of potassium
plataeu phase: slow influx of calcium
final repol: efflux of potassium
restoration of ionic conc: slow influx of Na via Na/K ATPase
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6
Q

definition of secondary haemorrhage in tonsillectomies?

A

5-10 days after

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7
Q

what is it called when bleeding occurs in first 6-8 hrs after tonsillectomy? and what is mx option

A

reactionary/primary haemorrage - return to theatre

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8
Q

describe Dieulafoy Lesions

A

AVM in gastric mucosa

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9
Q

difference in presentation between anterior and posterior duodenal ulcer?

A

anterior: more likely to erode and cause peritonitis
posterior: might erode into gastroduodenal artery and present with UBGIT

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10
Q

what arteries are more likely to be involved in gastric ulcers?

A

left gastric and splenic artery

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11
Q

how can H pylori cause ulcers in duodenum

A

increased acidity of the stomach/ddm causes ddm to undergo metaplasia to gastric type epithelium which can then be colonised by H pylori

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12
Q

what is the pathophysiology of h pylori gastric ulcers

A

h pylori produces urease which converts urea into ammonia, ammonia then stimulates production of gastrin which increases acidity of stomach, and causes chronic inflammation

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13
Q

what are the effects of stimulation of receptors alpha 1, alpha 2, b1, b2, d1, d2

A

a1 and a2 cause vasoconstriction
b1 increases cardiac contractility and HR
b2 causes vasodilation (and bronchodilation)
d1 renal and spleen vasodilation
d2 inhibits release of norad

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14
Q

which receptors does adrenaline target?

A

b1 and b2 and a1 and a2

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15
Q

which receptors does noradrenaline target?

A

mainly a1, but also a2 b1 b2

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16
Q

which receptors does dobutamine target?

A

mainly b1, some b2

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17
Q

which receptors does dopamine target?

A

mainly d1 and d2 but also a1/a2 and b1

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18
Q

description of mesenteric cysts?

A

smooth, mobile, non tender lumps, usually asymptomatic

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19
Q

if pancreatic necrosis is suspected, what is the next step of action to determine management?

A

FNA for cultures to determine infection

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20
Q

muscles in lateral compartment of leg

A

peroneus longus and peroneus brevis

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21
Q

innervation of peroneous longus

A

superficial peroneal nerve

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22
Q

characteristic of babies with choanal atresia?

A

cyanosis during feeds that improve when crying - switch to oropharyngeal airway breathing

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23
Q

which muscles in the forearm originate from the common extensor tendon?

A

ECR-B
ED
ECU
EDM

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24
Q

which muscles in forearm originate from common flexor trendon?

A 
FCU
PML
FCR
FDS
pronator teres
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25
Q

rise in serum pH leads to rise or fall in serum calcium?

A

fall, ionised calcium will increase binding to albumin

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26
Q

how many % of ECF calcium is in free ionised state and how many % is bound to albumin?

A

40% free ionised

50% bound to albumin

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27
Q

work up for hyperparathyroidism

A

ECG
bloods: FBC RP chlor bicarb CMP iPTH, Vit D
24h urine calcium
imaging

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28
Q

drug causes of hypercalcaemia

A

thiazide diuretics, Vit D excess, antacid excess, lithium

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29
Q

biochemical picture of pri hyperparathyroidism

A 
correct calcium - high
phosphate - low
PTH - high or abnormally normal (not surpressed)
chlor - mildly high
bicarb - low
pH - low 
Alk phos - high 
24hr urinary calcium - high
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30
Q

what is the half life of PTH

A

3-5 mins

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31
Q

indications for surgery in pri hyperparathyroidism

A 
very high calcium
hyper calciuria 
<30% crt clearance
1x life threatening hypercalcaemia episode
nephrolithiasis
age <50 
osteoporosis
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32
Q

biochemical picture of secondary hyperPTH

A

high PTH
low or normal Calcium
high phosphate
low Vit D

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33
Q

what genetic syndrome assoc with parathyroid hyperplasia?

A

MEN1, sometimes MEN2

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34
Q

what to suspect if PTH >1000

A

parathyroid carcinoma

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35
Q

blood supply of parathyroid glands

A

inferior thyroid arteries

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36
Q

where are the superior parathyroid glands located usually?

A

1st tracheal ring

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37
Q

what incision normally used for parathyroidectomy?

A

traverse incision 2cm about sternal notch

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38
Q

complications to watch out for post parathyroidectomy?

A

haematoma and airway obstruction
hypoparathyroidism - hypocalcaemia
damage to RLN - stridor

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39
Q

what to do if postthyroidectomy patient starts to show signs of airway obstruction

A

inform senior KIV anaesthetist
prepare crash cart, oxygen mask
tracheostomy kit
KIV release neck sutures and relieve haematoma

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40
Q

what oral supplement to give post parathyroidectomy?

A

1alpha-calcidol

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41
Q

name of structure that drains submandibular gland?

A

whartons duct

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42
Q

which familial cancer syndrome is associated with extra teeth?

A

gardner’s

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43
Q

which thyroid carcinoma characteristically shows more invasion and affects older women?

A

anaplastic carcinoma

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44
Q

What are 3 categories in the spectrum of breast cancer

A

1) hyperplasia with or without atypia
2) carcinoma in situ
3) invasive carcinoma

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45
Q

Describe breast hyperplasia w/ and w/o atypia and the increased risks of cancer

A

Simple ductal hyperplasia without atypia does not carry increase risk
But if atypia is found then up to 5x increase risk of breast ca, if severe atypia then up to 10x and and be mix with DCIS

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46
Q

5 classifications of breast cancer

A

1) histology type
2) TNM staging
3) cellular differentiation grading
4) HER/ER/PROG receptor status
5) pre or post menopausal

47
Q

How is DCIS often picked up

A

May or may not be a/w palpable mass, often found on screening mammography

48
Q

Describe the spread of DCIS

A

Not yet breached basement membrane, thus will show a branching pattern as it is confined within the ducts

49
Q

What is comedo necrosis

A

Large cells with pleomorphic nuclei and luminal necrosis

50
Q

Treatment options of DCIS and the considerations

A

Wide location excision with 2mm margins
KIV adjuvant RT after WLE if lesion is large or high grade
KIV mastectomy if DCIS is large/multifocal or central
KIV sentinel node biopsy if mastectomy done
KIV adjuvant tamoxifen

51
Q

What is lobular carcinoma in situ

A

Not actually cancer, often incidental finding on histology but associated with increased risk of developing cancer

52
Q

Described the increased risks of invasive cancer if LCIS is found with and without radiological changes

A

If a/w radiological changes then 30% of synchronous invasive cancer
If no radiological changes, 30% of developing breast ca in 15 years

53
Q

Management options if LCIS is found

A

In young women: surveillance mammography
If high risk due to fmhx, KIV prophylactic surgery
In older women: might not need to do anything

54
Q

what are the 5 subtypes of invasive ductal carcinoma

A 
No specific type - 80%
Medullary
Mucoid
Papillary 
Tubular ductal
55
Q

Which type of invasive ductal carcinoma a/w feeling spongy

A

Medullary type

56
Q

Which type of invasive ductal breast cancer has finger like projections, how is it treated as ?

A

Papillary, treated as DCIS

57
Q

Which type of invasive breast carcinoma is more a/w bilateral breast cancer?

A

Invasive lobular carcinoma

58
Q

What is the characteristic histological pattern seen in invasive lobular carcinoma

A

“Indian file” pattern, streaks of malignant cells

59
Q

Invasive lobular carcinoma is often seen on mammography T or F?

A

F

60
Q

What is inflammatory carcinoma, how is it treated

A

Breast cancer with local invasion a/w inflammation - poor prognosis, often aggressive. Treated with chemotherapy, mastectomy and axillary node clearance.

61
Q

What is the risk of breast and ovarian cancer with BRCA1 and BRCA2 mutations

A

Breast: BRCA1 = 70% BRCA2 = 55%
Ovarian: BRCA1 = 30-60% BRCA2 = 10-30%

62
Q

What is the recommended management for patients with high family history risk of breast ca and genetic mutation

A

Annual exam and mammography and consider prophylactic mastectomy with reconstruction

63
Q

what is the link between hodgkin’s lymphoma patients and breast cancer, how should they be managed

A

Might have prev irradiation to the chest to treat HL, manage as per high genetic risk group with annual exam and mammography

64
Q

What is taken into account in the nottingham prognostic index and what is the range of scores

A

NPI = 0.2 * size of tumor in cm + tumour grade (1 2 3) + lymph node involvement (1 2 3)

Ranges from 2.02 to over 6

65
Q

How is regional staging done in breast cancer

A

Examination of axilla, US +/- US guided biopsy, if US negative then proceed with sentinel lymph node biopsy

66
Q

Describe the process of sentinel lymph node biopsy

A

Radioactive compound e.g. technitium 99 colloid is injected into subareolar plexus preoperatively

Then followed by patent blue V dye.

During op, geiger meter is used to find radiactive nodes, guided by blue dye -> excise all sentinel nodes until no more radiactive or blue nodes

Send for histology either while pt is under GA or postop

If postive, patient to undergo axillary clearance

67
Q

which clotting parameter will vit K def cause a derangement in?

A

APTT and PT - increased

68
Q

what kind of ankle fractures can be treated conservatively? - what are the options?

A

stable fractures e.g. Weber’s A (moon boot, WBAT)

and some Weber’s B (below knee cast, NWB x6/52)

69
Q

what is osteopetrosis

A

dysfunction in osteoclast and bone resorption causing increased bone density

70
Q

would acute tubular necrosis respond to fluids?

A

no

71
Q

What is a bochdalek hernia?

A

Congenital diaphragmetic hernia with abdominal content inside thorax, may be a/w ipsilateral lung hypoplasia. Usually left posterior sided

72
Q

What is a morgagni hernia

A

Hernia of the diaphragm at the foreman of margagni - anteriorly where sternum and diaphragm meet

73
Q

What is a littres hernia?

A

Hernia of a meckel’s diverticulum

74
Q

Where are chordae tendinae found?

A

Ventricles

75
Q

What are chordae tendinae attached to

A

They hold the valve leaflets closed and attached to papillary muscle in the ventricle

76
Q

Where are pectinae muscles found

A

Atrium, more in left

77
Q

Contents of anterior mediastinum?

A

Thymus, fat, lymph nodes

78
Q

Contents of middle mediastinum

A

Pericardium, heart
Aortic root
Arch of azygos vein
Main bronchi

79
Q

Contents of posterior mediastinum

A 
Oesophagus + vagus nerve 
Thoracic aorta + thoracic duct
Azygos vein
Sympathetic nerve trunks
Splanchnic nerves
80
Q

What is found at the mid inguinal ligament point?

A

Deep inguinal ring

81
Q

Layers of scrotum from skin and what are they a continuation of from the anterior abdominal wall?

A

Skin -> dartos muscle (scarpa’s fascia) -> external spermatic fascia (ext oblique) -> cremasteric muscle and fascia (int oblique muscle and fascia) -> internal spermatic fascia (transversalis fascia) -> parietal tunica vaginalis (peritoneum) -> visceral tunica vaginalis (peritoneum)

82
Q

Origin of anterior interosseous nerve and what it supplies

A

From median nerve
Supplies FPL, pronator quadratus, radial half of FDP
No cutaneous sensory innervation

83
Q

Origin of posterior interosseous nerve and what it supplies

A

Radial nerve
Motor: ECRB, ED, EDM, ECU, supinator, EPB, EPL, EI
Sensory: no cutaneous sensory innervation

84
Q

Where is calcitonin released from

A

Thyroid gland

85
Q

what are acceptable margins for breast conserving surgery?

A

1mm for invasive disease, 2mm for DCIS

86
Q

Common sites of distant mets for breast cancer?

A

Bone -> lung -> liver

87
Q

Options for breast conserving surgery

A

WLE or oncoplastic resections

88
Q

Margins necessary for breast conserving surgery

A

1mm for invasive cancer

2mm for DCIS

89
Q

What should be done after breast conserving surgery

A

Adjuvant RT

90
Q

Contraindications to breast conserving surgery

A

Large cancers >4cm or large tumour:tissue ratio
Multifocal
Central tumours
Male
Recurrence after previous conserving surgery
If not eligible for RT

91
Q

Risks to counsel patient for breast conserving surgery

A 
Recurrence
Need for reexision if margins not met
Unpredictable scarring
Change in breast shape
Poor cosmesis if >10% tissue removed
92
Q

Describe simple and modified radical mastectomy

A

Simple mastectomy - removal of nipple and all breast tissue

If also doing axillary clearance then = modified radical mastectomy

93
Q

What is a radical mastectomy

A

Mastectomy that includes removal of pectoralis muscles and axillary nodes

94
Q

Risks to counsel patient on for mastectomies

A 
Anaesthesia and surgical risks
Haematoma, seroma
Frozen shoulder 
Disease recurrence
PSY effects
95
Q

Risks to counsel for axillary clearance

A

Lymphodema on ipsilateral arm
Nerve damage - numb inner arm, lats dorsi, serratus anterior, pectoral nerves
Shoulder stiffness
Haematoma, seroma

96
Q

Difference between primary and adjuvant hormonal therapies, indications?

A

Primary hormonal therapy = no surgery. Indicated for patients where surgery is contraindicated, better outcomes if cancer strongly ER positive

Adjuvant = after surgery to reduce risk of recurrence/mets

97
Q

4 methods of hormonal therapy in breast cancer

A

SERMs = e.g. tamoxifen
aromatase inhibitors e.g. letrozole
LHRH antagonist
Ovarian ablation

98
Q

Describe indications of SERMs vs aromatase inhibitors in breast cancer

A

SERMs more indicated in pre-menopausal women

AI is more for postmenopausal women unless giving with LHRH antagonist as well

99
Q

Why is letrozole contraindicated in premenopausal women

A

Causes hyperstimulation of ovarian oestrogenesis due to gonadotrophin feedback

100
Q

Side effects of tamoxifen

A 
Hot flushes
Vaginal dryness
Increased VTE risk
Weight gain
Rare - endometrial cancer, cataract
101
Q

What is the optimal duration of therapy for tamoxifen, what happens if beyond?

A

5 years - increase endometrial cancer risk if beyond that

102
Q

Risk of aromatase inhibitor?

A

Osteoporosis

103
Q

Indications for radiotherapy in breast cancer?

A

After breast conserving surgery (invasive or DCIS)
If large breast cancer (>4cm, ≥3 nodes involvement, grade 3 cancer, lymphovascular invasion)
Can do RT to axillary if decline surgical clearance

104
Q

Risks to counsel for RT for breast cancer

A 
Skin changes - erythema, thickening, cellulitis, edema, necrosis
Osteonecrosis of rib
Radiation damage to heart/lung
Lymphodema if on axillary
Distortion to breast due to thicken skin
105
Q

When is chemotherapy considered in breast cancer

A

Younger, premenopausal
If ER negative
Poor prognosis
Lymph node positive

106
Q

How to investigate for distant mets of breast cancer

A

Bone - CMP, alk phos, xrays, bone scan, MRI
Lung - xray, CT, cytology
Liver - LFTs, US, biopsy
Brain - imaging

107
Q

what kind of ankle fractures can be treated conservatively? - what are the options?

A

stable fractures e.g. Weber’s A (moon boot, WBAT)

and some Weber’s B (below knee cast, NWB x6/52)

108
Q

what is osteopetrosis

A

dysfunction in osteoclast and bone resorption causing increased bone density

109
Q

would acute tubular necrosis respond to fluids?

A

no

110
Q

best option for large bowel obstruction due to ascending colon carcinoma?

A

right hemicolectomy with ileocolic anastamosis

111
Q

what is the lymph drainage of the vocal cords?

A

nil - watershed area

112
Q

what is the artery that supplies the posterior duodenal wall and its origin

A

gastroduodenal artery

113
Q

what lies between the two origins of pronator teres?

A

median nerve

114
Q

where does the radial and ulnar artery bifurcate?

A

brachial artery @ antebrachial fossa

MRCS study (9 decks)

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