MRTMR Flashcards
Charlie is a 12-year-old boy referred by his GP with abdominal pain and fever. His GP suspects acute appendicitis. Which is true regarding the appendix?
A-The appendix receives its arterial supply from the SMA
B-The most common position of the appendix is retrocecal
C-The appendix is identified intraoperatively by following the convergence of the taenia coli
D-The appendix is rich in lymphoid tissue
E-All the above
The appendix is a blind tube (approx. 10 cm long) emerging from the base of the caecum. It is fully intraperitoneal and rich in lymphoid tissue. It receives its blood supply from the Appendicular branch of ileocolic artery (branch of SMA). The location of the appendix is highly variable in the abdomen, the most common location being retrocecal.
Other common positions of the appendix: -
• Pre-ileal
• Post-ileal
• Sub-ileal
• Pelvic
• Subcecal
• Para-cecal
Intraoperatively, the appendix is identified by tracing the taenia coli of the large bowel to their point of convergence at the tip of the appendix.
A 37-year-old man with a history of alcohol consumption for 20 years was diagnosed with CA pancreas. Prophylactic surgery must be done to reduce the risk of cancer in which condition?
A-Pancreas divisum
B-Annular pancreas
C-Anomalous pancreaticobiliary ductal junction
D-Ectopic pancreas
E-Ansa pancreatica
Anomalous pancreaticobiliary ductal junction: union of the pancreatic duct and common bile duct that occurs outside the duodenal wall to form a long common channel (>15 mm). Biliary drainage is not under the control of the sphincter of Oddi so reflux can happen and damage the biliary tree. Once diagnosed, prophylactic surgical correction is recommended to reduce the risk of developing biliary cancer.
A patient goes in for carpopedal spasm while measuring the blood pressure and his calcium levels are found to be very low and correction is being started.All of the following decrease renal calcium excretion except?
Decreased ECF volume
Increased plasma phosphate
Metabolic alkalosis
Vitamin D
Hypertension
The correct answer to the question “Which of the following does not decrease renal calcium excretion?” is Hypertension.
Explanation:
1. Decreased extracellular fluid (ECF) volume: This stimulates calcium reabsorption in the proximal tubule, thereby decreasing calcium excretion.
2. Increased plasma phosphate: Elevates the levels of parathyroid hormone (PTH), which reduces renal calcium excretion by increasing calcium reabsorption in the distal tubules.
3. Metabolic alkalosis: Enhances renal calcium reabsorption, reducing excretion.
4. Vitamin D: Promotes calcium reabsorption in the kidneys, lowering excretion.
However, Hypertension does not have a direct effect in reducing renal calcium excretion and may actually increase it.
Mr.Ashwin is on chemotherapy for carcinoma oral cavity.Which of the following drugs is an antimetabolite?
A 5FU
B Paclitaxel
C Cisplatin
D Cetuximab
E All of the above
The correct answer is A. 5FU (5-Fluorouracil).
Explanation:
• 5-Fluorouracil (5FU): This is an antimetabolite that inhibits thymidylate synthase, interfering with DNA synthesis. It is commonly used in the treatment of various cancers, including carcinoma of the oral cavity.
• Paclitaxel: A taxane that stabilizes microtubules and inhibits their depolymerization, disrupting cell division.
• Cisplatin: A platinum-based alkylating agent that forms DNA cross-links, leading to apoptosis.
• Cetuximab: A monoclonal antibody targeting the epidermal growth factor receptor (EGFR), used in certain head and neck cancers.
Thus, only 5FU is classified as an antimetabolite
What is the lymphatic drainage of caecum?
lleocolic
Inferior mesenteric
Internal iliac
Inguinal
All of the above
The correct answer is Ileocolic.
Explanation:
The caecum is primarily drained by lymph nodes associated with the ileocolic artery. The lymphatic drainage pathway is as follows:
1. Primary drainage: Lymph from the caecum flows into the ileocolic lymph nodes, located near the terminal branches of the ileocolic artery.
2. Secondary drainage: From the ileocolic nodes, lymph travels to the superior mesenteric lymph nodes.
Other options like the inferior mesenteric, internal iliac, and inguinal nodes do not contribute to the direct lymphatic drainage of the caecum
Mrs Nelson is being planned for distal pancreatectomy. What is the arterial supply to the distal pancreas?
A)Superior Mesenteric artery
B)Common Hepatic artery
c) Gastroduodenal artery
D)Pancreaticoduodenal artery
E) Splenic artery
The correct answer is E) Splenic artery.
Explanation:
The distal pancreas (tail and body) primarily receives its blood supply from branches of the splenic artery, which runs along the superior border of the pancreas. Key points:
• Splenic artery: Supplies the distal pancreas via its pancreatic branches, including the dorsal pancreatic artery, great pancreatic artery, and caudal pancreatic artery.
Other options:
• Superior mesenteric artery: Supplies parts of the small intestine and pancreas (head) via inferior pancreaticoduodenal branches.
• Common hepatic artery: Gives off the gastroduodenal artery but does not directly supply the distal pancreas.
• Gastroduodenal artery: Supplies the pancreas head and duodenum.
• Pancreaticoduodenal arteries: Primarily supply the head of the pancreas
Mr. Peter Robbins, a 27 year old gentleman, was admitted to ICU following right limb infection and sepsis. His vitals deteriorated progressively. He was diagnosed as having distributive shock. What is false regarding distributive shock?
A-Low systemic vascular resistance
B-High cardiac output
C-High venous pressure
D-High mixed venous saturation
D-High base deficit
The correct answer is C - High venous pressure.
Explanation:
Distributive shock (e.g., septic shock) is characterized by a significant reduction in systemic vascular resistance due to widespread vasodilation, leading to inadequate perfusion despite a relatively normal or high cardiac output. Let’s analyze each option:
1. Low systemic vascular resistance (A): True. Vasodilation causes a drop in systemic vascular resistance.
2. High cardiac output (B): True. As a compensatory mechanism, cardiac output is often elevated in early distributive shock.
3. High venous pressure (C): False. Venous pressure is typically low or normal due to decreased preload caused by vasodilation and capillary leakage.
4. High mixed venous saturation (D): True. Poor oxygen extraction by tissues leads to elevated mixed venous oxygen saturation.
5. High base deficit (D): True. Lactic acidosis from tissue hypoperfusion results in a high base deficit (metabolic acidosis).
Thus, high venous pressure is not a feature of distributive shock
A 34 year old male patient with a history of fever is diagnosed with infective endocarditis.The Duke ‘major’ criteria for the diagnosis of infective endocarditis include which one of the following?
Change in murmur
One positive blood culture
Raised C-reactive protein (CRP)
Roth spots
Vegetation detected on echocardiogram
The correct answer is Vegetation detected on echocardiogram.
Explanation:
The Duke Criteria are used to diagnose infective endocarditis and are divided into major and minor criteria. The major criteria include:
1. Positive blood cultures for typical organisms of infective endocarditis.
2. Evidence of endocardial involvement on echocardiography:
• Presence of vegetation.
• Abscess formation.
• New dehiscence of a prosthetic valve.
• New valvular regurgitation.
The options:
• Change in murmur: Not part of the Duke criteria.
• One positive blood culture: A major criterion requires persistent bacteremia with multiple positive blood cultures.
• Raised CRP: A minor criterion.
• Roth spots: A minor criterion.
• Vegetation detected on echocardiogram: A major criterion, as it indicates direct evidence of endocardial involvement
You are the core trainee and have just reviewed the case of a 30-year-old patient on the ward who has died following an emergency operation for a bowel perforation. You are required to fill in the death certificate in the bereavement office as soon as you are able.
Cases that should be referred to the coroner in England include which one of the following?
Death from a bowel perforation
Death from a notifiable disease such as meningitis
Death from AIDS or an HIV related ilnesses
Death in a patient under 50 years of age
Death related to industrial or occupational disease in former employment
Any death thought to have been caused by an industrial disease or industrial poisoning should be referred to the coroner. Recent surgery should also be referred to the coroner, particularly if it relates to the patient’s death.
The cause of death from a bowel perforation is known, explained and not unnatural. Assuming the patient has been seen by a doctor during their final illness and had no surgery this would not need to be referred to the coroner. Notifiable diseases have to be reported to the Consultant in Communicable Disease Control (CCDC). They do not need to be referred to the coroner. Age does not affect whether a case should or should not be referred to the coroner.
Deaths from AIDS or an HIV-related illnesses do not need to be reported to the coroner unless they meet another reason for reporting like an unknown cause of death, violent or unnatural death.
Deaths reported to a Coroner
A death is reported to a Coroner in the following situations:
• a doctor did not treat the person during their last illness
• a doctor did not see or treat the person for the condition from which they died within 28 days of death
• the cause of death was sudden, violent or unnatural such as an accident, or suicide
• the cause of death was murder
• the cause of death was an industrial disease of the lungs such as asbestosis
• the death occurred in any other circumstances that may require investigation
A death in hospital should be reported if:
• there is a question of negligence or misadventure about the treatment of the person who died
• they died before a provisional diagnosis was made and the general practitioner is not willing to certify the cause
• the patient died as the result of the administration of an anaesthetic
A death should be reported to a Coroner by the police, when:
• a dead body is found
• death is unexpected or unexplained
• a death occurs in suspicious circumstances
A death should be reported by the Governor of a prison immediately following the death of a prisoner no matter what the cause of death is.
Mr Singh is a 37-year-old construction worker brought to ED after a piece of construction equipment fell on his lower leg. Plain X ray excluded a fracture and he was given opioid analgesics for the pain and kept for overnight observation. During the night he has worsening pain requiring increased analgesic dose. The duty doctor found his leg to be red, swollen and severely tender. Pain increased on extending the foot or great toe passively. In which compartment of the leg is pressure likely to be elevated?
A Anterior compartment
B Lateral compartment
c Posterior superficial compartment
D Posterior deep compartment
E Medial compartment
The most likely compartment with elevated pressure in Mr. Singh’s case is the A) Anterior compartment.
-
Clinical Features:
- Severe pain out of proportion to the injury.
- Redness, swelling, and severe tenderness in the leg.
- Pain on passive extension of the foot or great toe: This is a key finding, as it suggests involvement of the muscles in the anterior compartment (tibialis anterior, extensor hallucis longus, extensor digitorum longus, and peroneus tertius), which are responsible for dorsiflexion of the foot and toes.
-
Compartment Syndrome:
- Compartment syndrome occurs when increased pressure within a closed fascial space compromises blood flow, leading to ischemia and muscle necrosis.
- The anterior compartment is the most commonly affected in the leg due to its relatively tight fascial boundaries and vulnerability to trauma.
-
Why Not Other Compartments:
- B) Lateral compartment: Involves the peroneal muscles (evert the foot). Pain would be elicited with passive inversion, not extension.
- C) Posterior superficial compartment: Involves the gastrocnemius and soleus (plantarflex the foot). Pain would be elicited with passive dorsiflexion, not extension of the toes.
- D) Posterior deep compartment: Involves the tibialis posterior, flexor digitorum longus, and flexor hallucis longus (invert the foot and flex the toes). Pain would be elicited with passive extension of the toes, but this compartment is less commonly affected.
- E) Medial compartment: Not a recognized compartment of the leg.
The findings of severe pain, swelling, and pain on passive extension of the foot or great toe strongly suggest anterior compartment syndrome. This is a surgical emergency, and prompt fasciotomy is required to prevent permanent muscle and nerve damage.
A young woman who had collapsed in the airport was rushed to your A&E. Her friend reports that she has no known medical illnesses. Your examination revels that she is slightly obese and has a swollen left leg. What will her ASA grade be?
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Solution
This is likely to be a case of pulmonary embolism. The patient is obese - a mild to moderate systemic condition - but is otherwise in good health (no functional impairment). The American Society of Anesthesiologists (ASA) classification is used to assess the preoperative physical status of patients. Based on the provided scenario:
• The patient is slightly obese.
• She has a swollen left leg, which could indicate deep vein thrombosis (DVT) or another vascular issue.
• No other medical illnesses are known.
ASA Classification:
• ASA I: A normal, healthy patient.
• ASA II: A patient with mild systemic disease (e.g., obesity, controlled hypertension).
• ASA III: A patient with severe systemic disease but not incapacitating.
• ASA IV: A patient with severe systemic disease that is a constant threat to life.
• ASA V: A moribund patient who is not expected to survive without the operation.
Given that obesity is considered a mild systemic disease and a swollen leg (potentially DVT) may indicate a vascular issue but not necessarily a life-threatening condition at this stage, ASA Grade II is the most appropriate classification .
Mr. Johnathan presented to your clinic with a complaint of a funny gait. Based on your clinical assessment, you suspect weakness of the superior gluteal nerve. Which muscle will be spared in this case?
A Gluteus maximus
B Gluteus medius
C Gluteus minimus
D Tensor fascia lata
E Both A and D
The superior gluteal nerve innervates the gluteus medius, gluteus minimus, and tensor fascia lata. If there is a lesion affecting this nerve, these muscles will be weakened, leading to a Trendelenburg gait. However, the gluteus maximus is spared because it is innervated by the inferior gluteal nerve .
Correct answer:
A. Gluteus maximus
An eight-year old female fell down while playing. She was complaining of pain and swelling of the left elbow. She had diffuse swelling of the left elbow without any external wound. The radial pulse was well palpated. There was wrist, thumb and fingers drop associated with hypoesthesia over the first web space indicating radial nerve palsy. Plain X-ray of the left elbow showed fracture of the lateral condyle (type I| Milch) and avulsed fracture of the medial epicondyle.Which of the following muscles originates from the medial epicondyle?
Brachioradialis
Extensor carpi ulnaris
Extensor digiti minimi
Anconeus
Pronator teres
The medial epicondyle of the humerus serves as the common origin for the muscles of the flexor compartment of the forearm, primarily those innervated by the median nerve (except for flexor carpi ulnaris and part of flexor digitorum profundus, which are supplied by the ulnar nerve).
Among the given options, Pronator teres is the only muscle that originates from the medial epicondyle.
Explanation of the options:
• Brachioradialis – Originates from the lateral supracondylar ridge.
• Extensor carpi ulnaris – Originates from the lateral epicondyle.
• Extensor digiti minimi – Originates from the lateral epicondyle.
• Anconeus – Originates from the lateral epicondyle.
• Pronator teres – Originates from the medial epicondyle.
Correct answer:
Pronator teres
You are examining a patient with discomfort during swallowing in the clinic.Examination reveals a swelling in the posterior tongue in the midline.What is the most likely tissue of origin of this swelling?
A Filiform papillae
B Fungiform papillae
C Lymphoid tissue
D Palatine tonsil
E Circumvallate papillae
A midline swelling in the posterior tongue is most likely arising from lymphoid tissue, specifically the lingual tonsils. The posterior third of the tongue contains lymphoid aggregates that are part of Waldeyer’s ring, which can become hypertrophied or inflamed, leading to discomfort during swallowing.
Explanation of the options:
• Filiform papillae – These are the most numerous papillae on the anterior tongue and lack taste buds. They are not located in the posterior tongue.
• Fungiform papillae – Found on the anterior part of the tongue, especially at the tip and sides, and are involved in taste sensation.
• Lymphoid tissue – Correct answer; the posterior third of the tongue contains lingual tonsils, which can enlarge and present as a midline swelling.
• Palatine tonsil – Located laterally in the oropharynx, not in the midline of the posterior tongue.
• Circumvallate papillae – Large papillae arranged in a V-shape at the posterior tongue but not typically forming a prominent swelling.
Correct answer:
C. Lymphoid tissue
A 57-Year-Old Heart Transplant Recipient Is Keen To Join The Cardiac Rehabilitation Programme. Which Of The Following Factors Is Most Likely To Increase Cardiac Output In This Patient During Moderate Exercise?
A Decreased Negative Intrathoracic Pressure
B Decreased Venous Tone
C Decreased Ventricular Compliance
D Increased Atrial Filling
E None of the above
Increased atrial filling enhances cardiac output during exercise, especially in patients with heart transplants. In a heart transplant recipient, the heart is denervated, meaning it lacks autonomic nervous system regulation. This has significant effects on how cardiac output (CO) increases during exercise.
How does a transplanted heart increase cardiac output?
1. Loss of autonomic control – The transplanted heart does not respond to direct sympathetic stimulation or vagal inhibition.
2. Cardiac output mainly increases via the Frank-Starling mechanism, which relies on increased venous return to enhance stroke volume.
3. Increased atrial filling (preload) leads to increased stroke volume, as the transplanted heart responds mainly to changes in preload rather than neural control.
Analysis of the options:
• A. Decreased negative intrathoracic pressure – This would reduce venous return, decreasing cardiac output (incorrect).
• B. Decreased venous tone – This would reduce preload and lower cardiac output (incorrect).
• C. Decreased ventricular compliance – This would limit ventricular filling, reducing cardiac output (incorrect).
• D. Increased atrial filling – Correct; increased venous return (preload) enhances stroke volume via the Frank-Starling mechanism, which is the primary way a denervated heart increases cardiac output.
• E. None of the above – Incorrect, as increased atrial filling is a valid mechanism.
Correct answer:
D. Increased Atrial Filling
What is the pharmacological basis behind prescribing a thiazide and loop diuretic together?
A Antagonism
B Synergism
C Agonism
D None of the above
E All of the above
The correct answer is:
B. Synergism
Pharmacological Basis:
• Loop diuretics (e.g., furosemide, bumetanide, torsemide) act on the Na⁺-K⁺-2Cl⁻ symporter in the thick ascending limb of the loop of Henle, leading to potent diuresis by preventing sodium and water reabsorption.
• Thiazide diuretics (e.g., hydrochlorothiazide, chlorthalidone, metolazone) act on the Na⁺-Cl⁻ symporter in the distal convoluted tubule (DCT) to promote sodium and water excretion.
Why are they used together?
1. Sequential nephron blockade:
• Loop diuretics cause increased sodium delivery to the DCT, where the thiazide diuretics further inhibit sodium reabsorption.
• This leads to an enhanced diuretic effect (synergism).
2. Overcoming diuretic resistance:
• In conditions like heart failure or chronic kidney disease (CKD), the kidney adapts to long-term loop diuretic use by increasing sodium reabsorption in the DCT.
• Adding a thiazide diuretic blocks this compensatory mechanism, enhancing diuresis.
3. Enhanced natriuresis (sodium excretion):
• This combination leads to greater sodium and water loss, making it effective in treating severe edema and fluid overload.
Incorrect options explained:
• A. Antagonism – Incorrect, as they do not work against each other.
• C. Agonism – Incorrect, as they do not act on the same receptor.
• D. None of the above – Incorrect, as synergism is the correct explanation.
• E. All of the above – Incorrect, since only synergism applies.
A patient with vomiting and abdomen pain and has been diagnosed with annular pancreas.Where is the site of obstruction in this patient?
A The first part of the duodenum
в 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.
A new test to screen for COVID 19 was trialled in 800 patients.The test was positive in 30 of the 60 patients shown to have COVID 19 by a gold standard test. It was also positive in 10 patients who were shown not to have COVID. What is the positive predictive value of the test?
A-66
B-75
C-50
D-33
E-80
Positive predictive value: proportion of those who have a positive test who actually have the disease.
Positive Predictive Value = number of true positives / (number of true positives + number of false positives)
True positive = 30, False positive = 10
PPV = 30/ (30+10) × 100
= 30 / 40 × 100 = 75
You are performing a diagnostic endoscopy on a 50 year old male patient which reveals gastric polyps.The most common type of gastric polyps are:
A Hyperplastic polyps
B Fundic polyps
C Inflammatory polyps
D Neoplastic polyps
E None.
The most common type of gastric polyps found during diagnostic endoscopy are fundic gland polyps. These polyps are typically benign and are associated with the use of proton pump inhibitors (PPIs) or, less commonly, with familial adenomatous polyposis (FAP).
B. Fundic polyps
- Fundic gland polyps are the most common type of gastric polyps, accounting for 47-77% of all gastric polyps in some studies.
- They arise from the fundus and body of the stomach and are often discovered incidentally during endoscopy.
- These polyps are usually small, multiple, and benign, though they may rarely undergo dysplastic changes, especially in patients with FAP.
- A. Hyperplastic polyps: These are the second most common type of gastric polyps. They are often associated with chronic gastritis, Helicobacter pylori infection, or bile reflux. However, they are not as common as fundic gland polyps.
- C. Inflammatory polyps: These are rare and are associated with chronic inflammation or injury to the gastric mucosa.
- D. Neoplastic polyps: These include adenomas and other potentially malignant polyps. They are less common than fundic gland polyps and hyperplastic polyps.
- E. None: Incorrect, as fundic gland polyps are the most common.
Thus, the correct answer is B. Fundic polyps.
Mrs.Jones, a 56 year old patient diagnosed with hepatocellular carcinoma now has malignant ascites. Which among the following Investigations would you perform to visualise her biliary system?
CT
MRI
Ultrasound
Hepatobiliary scintigraphy
PET СТ
The best investigation to visualize the biliary system in
The best investigation to visualize the biliary system in a patient with malignant ascites and hepatocellular carcinoma would be:
MRI (Magnetic Resonance Imaging), specifically MRCP (Magnetic Resonance Cholangiopancreatography).
Explanation:
• MRI (MRCP) is the gold standard for non-invasive imaging of the biliary tree and pancreatic ducts. It provides detailed images of biliary obstruction, strictures, and masses without the need for contrast.
• CT scan is useful for detecting hepatic tumors and metastases, but it does not provide clear imaging of the biliary tree unless contrast is used (CT cholangiography).
• Ultrasound is a good initial test for assessing liver lesions and ascites, but it is limited in evaluating the biliary system.
• Hepatobiliary scintigraphy (HIDA scan) is mainly used for functional assessment of the biliary system (e.g., gallbladder dyskinesia, bile leaks) but is not preferred for anatomical visualization.
• PET-CT is useful for detecting metastatic disease, but it is not the best choice for detailed biliary imaging.
Best Answer: MRI (MRCP)
DEBATE: Mortimer cevabı sintigrafi: Cancer patients may have intra-abdominal fluid or malignant ascites that complicates interpretation of pericholecystic fluid or gallbladder wall thickening on ultrasound or CT imaging. Hepatobiliary scintigraphy may be required to confirm the diagnosis of cholecystitis.
You are seeing a 17 year old male patient with type 1 diabetes at the clinic.All of the following are true about type 1 diabetes except?
A Age at onset is < 20 years
B Insulin is low or absent
C Glucagon is high and resistant to suppression
D Insulin sensitivity is normal
E All are true
The statement that is not true about type 1 diabetes is:
C. Glucagon is high and resistant to suppression
In type 1 diabetes, glucagon levels are often normal or slightly elevated, but they are not typically resistant to suppression. Glucagon is a hormone that works to raise blood glucose levels, and in type 1 diabetes, the primary issue is the lack of insulin production by the pancreas, leading to hyperglycemia. The other statements (A, B, and D) are generally accurate descriptions of type 1 diabetes.
A renal transplant patient has developed pure red cell aplasia following intake of immunosuppressants.Which of the following drugs might be responsible for this?
Sirolimus
Mycophenolate
Azathioprine
Tacrolimus
Cyclosporine
• The principal toxicities of Mycophenolate mofetil are Gl and hematologic: leuko- penia, pure red cell aplasia, diarrhea, and vomiting. There also is an increased incidence of some infections, especially sepsis associated with cytomegalovirus.
• The use of sirolimus in renal transplant patients is associated with a dose-dependent increase in serum cholesterol and triglycerides that may require treatment. Although immunotherapy with sirolimus per se is not considered nephrotoxic, patients treated with cyclosporine plus sirolimus have impaired renal function compared to patients treated with cyclosporine alone.Lymphocele, a known surgical complication associated with renal transplantation, is increased in a dose-dependent fashion by sirolimus, requiring close postoperative follow-up.Other adverse effects include anemia, leukopenia, thrombocytopenia, mouth ulcer, hypokalemia, and GI effects.
• Nephrotoxicity; neurotoxicity (e.g., tremor, headache, motor disturbances, seizures); Gl complaints; hypertension; hyperkalemia; hyperglycemia; and diabetes all are associated with tacrolimus use.
• The major side effect of azathioprine is bone marrow suppression, including leukopenia (common), thrombocytopenia (less common), or anemia (uncommon). Other important adverse effects include increased susceptibility to infections (especially varicella and herpes simplex viruses), hepatotoxicity, alopecia, Gl toxicity, pancreatitis, and increased risk of neoplasia.
• The principal adverse reactions to cyclosporine therapy are renal dysfunction and hypertension; tremor, hirsutism, hyperlipidemia, and gum hyperplasia also are frequently encountered. Hypertension occurs in about 50% of renal transplant and almost all cardiac trans- plant patients. Hyperuricemia may lead to worsening of gout, increased P-glycoprotein activity, and hypercholesterolemia. Nephrotoxicity occurs in the majority of patients and is the major reason for cessation or modification of therapy. Combined use of calcineurin inhibitors and glucocorticoids is particularly diabetogenic, although this seems more problematic in patients treated with tacrolimus. Cyclosporine, as opposed to tacrolimus, is more likely to produce elevations in LDL cholesterol.
A new technique of rectus closure is designed to prevent the risk of dehiscence is undergoing clinical trials. 100 patients are subjected to the new technique. During a three week period 20 of the patients have an episode of dehiscence. In the control group there are 200 patients who are subjected to the usual method of closure. In this group 50 people have dehiscence during the same time period. What is the relative risk of having a dehiscence when the new technique is used?
A 0.4
B 0.8
C 0.7
D 0.35
E 0.23
B 0.8
Relative risk (RR) = Incidence among exposed/ Incidence among non-exposed
Incidence among exposed = 20/100 = 0.2
Incidence among non exposed = 50/200 = 0.25
RR = 0.2/0.25 =0.8
A 40 year old male sustains extraperitoneal bladder rupture following a road traffic accident.Which among the following is true about the urinary bladder?
A The apex of the bladder faces anteriorly
B Apex is attached to medial umbilical ligament
C The base lies above the level of the rectovesical pouch
D The inferolateral surfaces are the lowest part of the bladder
E Superior surface is devoid of peritoneum
The empty bladder is situated entirely within the pelvic cavity. As the bladder distends it domes up into the abdominal cavity. The empty bladder is a flattened three-sided pyramid, with the sharp apex pointing forwards to the top of the pubic symphysis and a triangular base facing backwards in front of the rectum or vagina. There are two inferolateral surfaces cradled by the anterior parts of levator ani, a neck where the urethra opens, and a superior surface on which the small intestine and sigmoid colon or uterus lie.
The apex has the remains of the urachus attached to it, the latter forming the median umbilical ligament which runs up the midline of the anterior abdominal wall in the median umbilical fold of peritoneum.
Most of the base, or posterior surface, lies below the level of the rectovesical pouch and only the uppermost portion is covered by peritoneum between the vas deferens on each side Each inferolateral surface slopes downwards and medially to meet its fellow, lying against the front part of the pelvic diaphragm and obturator internus.
The lowest part of the bladder is its neck, where the base and inferolateral surfaces meet and which is pierced by the urethra at the internal urethral orifice.
The superior surface is covered by peritoneum which sweeps upwards onto the anterior abdominal wall.
You are working in a colorectal clinic where you have seen several patients at risk of bowel malignancy. Which of these conditions does not warrant regular colonoscopies?
A Familial Adenomatous Polyposis
B Hereditary Non-Polyposis Colorectal Cancer
C Family history of colonic cancer
D Long standing Crohn’s disease
E Previous history of colorectal malignancy
Those with a strong family history of colonic cancer are advised to undergo genetic testing. In the absence of a genetic condition (such as FAP or Lynch syndrome), a colonoscopy is advised between the ages of 35 and 45. Further routine colonoscopy is only indicated in the presence of polyps or other suspicious pathology.
Genetic conditions like FAP or HNPCC (aka Lynch syndrome) are associated with high risk of bowel cancer and hence managed with annual colonoscopies.
Patients with IBD are also at higher risk of colonic malignancy, though the exact risk depends on a variety of factors (age, duration and severity of illness, sites affected, etc.) The screening usually starts 10 years after onset of the condition with routine colonoscopies every 1 to 5 years (depending on the risk).
Previous history of colorectal malignancy also predisposes to a subsequent cancer and requires screening every few years.
57 year old male patient presented with altered bowel habit, abdominal pain and distension.Colonoscopy Reveals narrowing and thickening at distal left colon of about 4 cm segment. Biopsy revealed Adenocarcinoma of colon. Which is the Most insidious site of colon cancer?
Cecum
Ascending colon
Descending colon
Transverse colon
Sigmoid colon
Correct Answer: Cecum
Explanation:
The cecum is the most insidious site for colon cancer because:
• Tumors in the cecum and ascending colon can grow large before causing symptoms due to the wide lumen and liquid stool content.
• Patients often present late with iron deficiency anemia from chronic occult bleeding rather than obstructive symptoms.
• Right-sided colon cancers are often diagnosed at advanced stages compared to left-sided tumors, which cause earlier symptoms like obstruction or altered bowel habits.
Why Not the Other Options?
• Ascending Colon – Similar to the cecum, but cecal tumors are usually more insidious.
• Descending Colon – Left-sided tumors tend to present earlier with obstruction, tenesmus, or rectal bleeding.
• Transverse Colon – Intermediate presentation, but not as silent as the cecum.
• Sigmoid Colon – More common site for cancer, but presents earlier with obstructive symptoms due to narrower lumen.
Conclusion:
Cancers in the cecum grow silently for a long time, making it the most insidious site for colon cancer.
Mr Thomas Cook is a 65-year-old man who has come to the GP. He is very concerned about having bowel cancer, as he has been suffering from diarrhoea for a week, and has also suddenly lost weight. He reports that he is using the bathroom 5 to 6 times a day, and has noticed that the stools are hard to flush as they float on the water. He gives a history of recently returning from a holiday 2 weeks ago, where he says he spent a lot of time swimming at the hotel pool. He claims he only drank bottled water and did not eat any raw/uncooked food. What infectious agent is likely to be the cause of his diarrhoea?
Enterotoxigenic E.coli
Shigella sonnei
Salmonella typhi
Rotavirus
GiGiardia lamblia
Giardia lamblia, also known as Giardia intestinalis and Giardia duodenalis, is a flagellated, anaerobic protozoon, which is an important cause of persistent diarrhoea or malabsorption.
Giardia has an outer membrane that makes it possible to retain life even when outside of the host body which can make it tolerant to chlorine disinfection. There are multiple transmission methods including drinking infected water, which is the most common method of transmission for this parasite. It is also common in day-care centers (among children) where poor/undeveloped hygiene practices lead to feco-oral transmission.
Suspect diarrhea when :
• Acute diarrhea lasts more than a week
• Traveller’s diarrhea that has not resolved in over 10 days, and the symptoms started after return, with associated weight loss.
• Diarrhea in day-care centers/ palliative care facilities.
Investigation is usually via stool microscopy OC&P (ova, cysts and parasites).
Superficial spreading melanoma differentiates from Paget’s disease of breast by
S-100 positive
CEA positive
CA19-1 positive
Cytokeratin 19 positive
Pathognomonic of Paget’s disease is the presence of large, pale, vacuolated cells (Paget cells) in the rete pegs of the epithelium. Paget’s disease may be confused with superficial spreading melanoma. Differentiation from pagetoid intrepithelial melanoma is based on the presence of S-100 antigen immunostaining in melanoma and carcinoembryonic antigen immunostaining in Paget’s disease. Surgical therapy for Paget’s disease may involve lumpectomy or mastectomy, depending on the extent of involvement of the nipple-areolar complex and the presence of DCIS or invasive cancer in the underlying breast parenchyma.
None of the above
A 46 year old lean woman is referred to you by the Dermatologist after he diagnosed her with necrolytic migratory erythema. She gives you a history of anticoagulation therapy for recurrent episodes of DVT and long standing Diabetes Mellitus. What according to you is the most likely diagnosis in this patient?
Insulinoma
Gastrinoma
VIPoma
Glucagonoma
Somatostatinoma
Glucagonoma syndrome is a rare syndrome, with a classic presentation of the “4 D’s”: diabetes, dermatitis, deep vein throm-bosis, and depression. It is also characterised by a severe catabolic state with weight loss, depletion of fat and protein stores, and associated vitamin deficiencies. The characteristic skin lesion, a necrolytic migrating erythema, is noted in approximately two thirds of patients and often appears before other symptoms of the syndrome
Mrs Meenakshi has been diagnosed with Parkinson’s disease.She is on a drug which inhibits catechol-o-methyltransferase.Which among the following drugs acts by the above mentioned mechanism?
A Levodopa
B Trihexyphenidyl
C Amantadine
D Tolcapone
E Ropinirole
D Tolcapone
• Levodopa is the single most effective agent in the treat- ment of PD.The effects of levodopa result from its decarboxylation to
DA. In clinical practice, levodopa is almost always administered in combination with a peripherally acting inhibitor of AADC, such as carbidopa or benserazide, drugs that do not penetrate well into the CNS. If levodopa is administered alone, the drug is largely decarboxylated by enzymes in the intestinal mucosa and other peripheral sites so that relatively little unchanged drug reaches the cerebral circulation, and probably less than 1% penetrates the CNS.
• Dopamine receptor agonists are proposed to have the potential to modify the course of PD by reducing endogenous release of
DA as well as the need for exogenous levodopa, thereby reducing free-radical formation. Two orally administered DA receptor agonists are commonly used for treatment of PD: ropinirole and pramipexole.Ropinirole,pramipexole and rotigotine may produce hallucinosis or confusion, similar to that observed with levodopa, and may cause nausea and orthostatic hypotension. They should be initiated at low dose and titrated slowly to minimize these effects.
• COMT inhibitors block this peripheral conversion of levodopa to 3-O-methylDOPA, increasing both the plasma t1/2 of levodopa and the fraction of each dose that reaches the CNS.The COMT inhibitors tolcapone and entacapone reduce significantly the
“wearing off” symptoms in patients treated with levodopa/carbidopa. Common adverse effects of both agents include nausea, orthostatic hypotension, vivid dreams, confusion, and hallucinations. An important adverse effect associated with tolcapone is hepatotoxicity.
• Selective MAO-B inhibitors are used for the treatment of PD: selegiline and rasagiline. These agents selectively and irreversibly inactivate MAO-B. Both agents exert modest beneficial effects on the symptoms of PD. Selegiline can lead to the development of stupor, rigidity, agitation, and hyperthermia when administered with the analgesic meperidine
• Amantadine, an antiviral agent used for the prophylaxis and treatment of influenza A, has antiparkinsonian activity. Amantadine appears to alter DA release in the striatum, has anticholinergic properties, and blocks NMDA glutamate receptors. It is used as initial therapy of mild PD. It also may be helpful as an adjunct in patients on levodopa with dose-related fluctuations and dyskinesias. Dizziness, lethargy, anticholinergic effects, and sleep disturbance, as well as nausea and vomiting, side effects are mild and reversible.
• Antimuscarinic drugs currently used in the treatment of PD include trihexyphenidyl and benztropine mesylate, as well as the antihistaminic diphenhydramine hydrochloride, which also interacts at central muscarinic receptors. The biological basis for the therapeutic actions of muscarinic antagonists is not completely understood. Adverse effects result from their anticholinergic properties. Most troublesome are sedation and mental confusion. All anti- cholinergic drugs must be used with caution in patients with narrow-angle glaucoma, and in general anticholinergics are not well tolerated in the elderly
A football player sustains an injury to his right foot and there is a 2 x0.5cm laceration over the dorsum of the foot.WHich among the following pathological changes will not be present at the site of injury?
A Vasodilation
B Increased permeability of vessel wall
C Chemotaxis of leukocytes
D Granuloma formation
E None of the above
Acute inflammation has three major components:
• Dilation of small vessels leading to an increase in blood flow
• Increased permeability of the microvasculature enabling plasma proteins and leukocytes to leave the circulation; and
• Emigration of leukocytes from the microcirculation, their accumulation in the focus of injury, and their activation to eliminate the offending agent
Granuloma formation is a feature of chronic inflammation.
Nina Foster is a 78 year old woman who is being moved from her own residence to a nursing care home, as she is unable to manage her day-to-day activities independently. You are the doctor who attends the nursing home and have been asked to give her a general check-up. While she is generally in good health, you note that she has some hard nodules on her fingers in the proximal interphalangeal joint. What is the likely diagnosis?
A Osler’s nodes secondary to Lupus
B Osler’s nodes secondary to endocarditis
C Heberden’s nodes secondary to osteoarthritis
D Bouchard’s nodes secondary to osteoarthritis
E Ganglion cyst
This is a Bouchard node. The hard, bony growths in the PIP joint are exostoses, and are usually asymptomatic. They can occasionally cause finger tip deviation. Usually, Bouchard nodes are indicative of severe systemic osteoarthritis.
