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
