Oxford SBA book Flashcards
Which cells are essential to wound forming
Monocytes/macrophages
PML not required for first stages
Collagen constitution and distriubution
Triple helix
Type I: bone, skin, tendon, uterus, arteries Type II: hyaline cartilage, eye tissues
Type III: skin, arteries, uterus, and bowel wall Type IV: basement membrane
Type V: basement membrane and other tissues
The normal ratio of type I to type III collagen in the skin is approximately 4:1.
Example of physiological metaplasia
squamous metaplasia occurring in the endocervix in response to hormonal surges during puberty
Columnar to squamous at transitional zone
Signs of pancreatitis
Relief sitting forward
Tachy and fever
Cullens and Grey turner
BP and CO after infrarenal cross clamping in AAA repair
Hypertension and increased CO
Unless severe aorta-iliac disease- in which collaterals would form
BP and SVR drop after unclamping
What to give during aortic clamping in AAA repiar and cardiac disease
Vasodilators
Patient with long haul flight, young, now presenting with weakness Ix?
TOE- patent foreamen ovale
What nerve could be damaged from nail in medial calcaneus
Medial plantar
How to calculate osmolality
2 (Na+k) + urea +glucose
What does portal hypertension cause in rectus
Varices not haemorrhoids
Most common place for Ependymomas
Fourth ventricle
Differentiating between haemophilia and VWD
Excessive bleeding in VWD
Bleeding in joints in haemophillia
Urethral injury ix
Retrograde urography
Artery of Adamkiewicz
Greater radicular artery
Usually arises from a left intercos- tal branch of the aorta between T8 and T12, and supplies the anterior spinal artery and distal spinal cord.
Where does the anterior spinal artery arise from
Vertebral arteries
Unite below foreamen magnum to form ASA
Unpaired
What does anterior spinal artery supply
Supplies the pia mater and anterior two-thirds of the spinal cord, including the anterior and lateral columns
Where do anterior and posterior spinal arteries anastomose
Conus medullaris- L1
Posterior vertebral arteries formation and supply
The posterior spinal arteries arise from the vertebral arteries. They pass down the spinal cord individually and supply the posterior one-third of the spinal cord (i.e. including the major sensory tracts).
CSF pathway
Made by choroid plexus in lateral and third
From lateral to third by foremen of Monroe
To fourth by aqueduct of Sylvius
Then to SA by lateral Luschka and middle Magendie
Law of Laplace
Aneurysmal expansion is governed by the law of Laplace
This states that the wall tension is proportional to the pressure multiplied by the radius.
As radius increases angle decreases therefore lateral tension increases
With increasing diameter, there is further increase in wall tension leading to an increased risk of rupture.
T = PR
When are diabetic meds taken before surgery
Night before
When should sliding scale be started for type 1
6am of day of surgery
Which thyroid cancer is FNA useful and unuseful for
Papillary - rueful
Follicular cells found with adenoma and carcinoma
Colloid and macrophages on thyroid FNA
highly suggestive of benign disease.
What are the 2 lobes of parotid separated by
Retromandibular vein
Frey Syndrome
Misdirected roflcopters auriculotemproal to sweat glands after super- ficial parotidectomy leads to Frey’s syndrome.
This typically develops about 6 months after sur- gery and mainly features sweating and vasodilatation of the skin supplied by the auriculotemporal nerve.
Where the majority of airway resistance occurs
Approximately 30% of airway resist- ance is located in the nose, pharynx, and larynx, and the remaining 70% of airway resistance is gen- erated by the trachea and subsequent airway division
When is lung compliance greatest
Lung compliance is greater during the expiration phase compared with the inspiration phase
Relationship between laminar vs turbulent flow with pressure
The relationship between laminar flow and pressure is one of direct proportionality.
However, during conditions of turbulent flow, pressure is indeed proportional to the square of the flow rate.
Risk of complication of direct vs indirect hernia
Indirect higher 2-5%
Direct- 0.5 %
Cardiorespiratory dysfunction within 72 hours of surgery in diabetic with no chest pain
Silent MI
Disorders increasing incidence of cerebral aneurysm
Adult polycystic kidney disease, Ehlers–Danlos type IV, neurofibroma- tosis type 1 and Marfan’s syndrome.
Calot triangle borders, contents and variation
Inferior border of liver- superiorly
Cystic duct inferiorly
Common hepatic duct medially
The triangle contains the cystic artery and a lymph node (Lund’s node or Mascagni’s lymph node).
An aberrant right hepatic artery running medial to
the common hepatic duct and arising from the superior mesenteric artery is seen in approxi- mately 15% of patients.
Differentials for hyponatraemia
Reduced ECF: dehydrated patients with urinary sodium >20 mmol/L suggests renal loss of sodium (e.g. Addison’s, renal failure, diuretics). Sodium <20 mmol/L suggests losses else- where (sweating, gastrointestinal (GI) tract).
Normal ECF: syndrome of inappropriate antidiuretic hormone (ADH) secretion or hypothyroidism.
Increased ECF: excessive water administration, heart failure, renal failure.
Urinary Na in SIADH
> 20 as water reabsorbed but not Na
Leading to concentrated urine
Bile produced per day
5L by liver
gallbladder concentrates this 5 L into 500 mL per day
SE of cholecystectomy
Absence of a gallbladder to concentrate bile, large volumes of it will flow into the duodenum and may cause biliary reflux
Fat intolerance and malabsorption of fat may result in colicky abdominal pain and
diarrhoea after fatty meals in post-cholecystectomy patients.
Stages of cell cycle
The cell cycle is divided into the M (mitosis) phase and interphases G1 (gap 1), S (synthesis) and G2 (gap 2) phases. G0 is a resting phase of variable duration and is permanent for terminally dif- ferentiated cells like neurons.
G1 has a high rate of biosynthetic activity.
At the restriction point (R) the cell decides whether to complete the cycle within G1.
DNA synthesis occurs in the S phase.
Further cell growth and differentiation occurs in G2 followed by cell division (both nuclear and cytoplas- mic) in the M (Mitosis) phase.
G1 phase is under the influence of p53
Muscles cut through in posterolateral approach to hip replacement
Gluteus medius and minimus
Short external rotators of the hip
Where does sympathetic trunk enter the skull
Carotid canal
Forms a plexus on the internal carotid arter
How IAP is measured
laparoscopically or via pressure transducers placed in the femoral vein, stomach, rectum, or bladder, the last being the most popular method
Presentation of prolapsed disc
Pain and neurological deficit in a single nerve root.
Usually Lumbosacral
Pterion formation
Between frontal, parietal, temporal, and sphenoidal bones.
Presentation of appendicitis in pregnancy, risks and when can you lap
Can present with pain in right hypochondrial
Higher chances of perf
Can lap before 26w
Bacterial peritonitis in children sx
Abdominal pain, pyrexia, nausea, vomiting, tachycardia, hypotension, and decreased urine output.
Abdominal examination may reveal board-like rigidity, rebound tenderness, and absent bowel sounds
Pathophysiology of pyloric stenosis
Hypertrophy and hyperplasia of the circular and longitudinal muscular layers of the pylorus, leading to a narrowing of the gastric antrum
Physiological effects of surgery on metabolism
Raised basal metabolic rate, which in the absence of adequate calorific intake, will result in proteolysis
Diabetic state- insulin resistance and high insulin
Glucose remain normal unless in shock or sepsis- hypoglycaemia
Ketones normal
In the proteolytic state, the action of glucocorticoids results in muscle breakdown and a negative nitrogen balance.
Sodium retention
Goodsall rule
If the external opening of a fistula lies behind a line drawn transversely across the anus the track should curve towards an internal opening in the midline posteriorly (i.e. at 6 o’clock).
However, if the external opening lies in front of the transverse anal line, the track is likely to pass radially in a straight line towards the internal open- ing.
Unless its is more than 3cm then it goes to the posterior midline
When to treat carotid stenosis
Symptomatic and stenosis >70%
When is elective cholecystectomy considered
Symptomatic gallstones failing conservative management (dietary manipulation) or by patient choice
Episodes of septic gallbladder complications to prevent recurrence (in patients who are fit for surgery)
Episodes of complications (e.g. pancreatitis) or to prevent recurrence of complications.
How much does atrial contraction lead to ventricular filling
10% at rest
40% during exercise
Bones affected and sign in basal skull fracture
Rof of the orbits, the sphenoid bone, and parts of the temporal bone
Periorbital haematoma
Subconjunctival haemorrhage
rhinorrhoea or otorrhoea- damage to cribriform plate
Battle sign- retromastoid bruising- last to develop
Duodenum in transpyloric plane and what lies behind it
Second part
Hilum of right kidney
Nerves arising form posterior cord
the upper sub- scapular nerve (C5 and C6),
middle subscapular nerve (i.e. the thoracodorsal nerve, supplying latissimus dorsi; C6, C7, C8)
lower subscapular nerve (C5 and C6)
axillary nerve (C5 and C6)
radial nerve (C5, C6, C7, C8, T1
Nerves arising from roots of brachial plexus
Dorsal scapular
Muscles to scalene
Long thoracic
Damage to internal laryngeal nerve risk
This nerve supplies sensa- tion to the laryngeal mucosa above the vocal folds. Damage to this nerve may therefore result in insensitivity of the mucous membrane of the superior part of the larynx to food, resulting in a loss of cough impulse and increased risk of aspiration.
Where is a fish bone likely to get stuck in laryngopharynx
Piriform recess
Boundaries of piriform recess
aryepiglottic folds medially
Thyroidcartilage laterally
Complications of colles fracture
EPL rupture
Median nerve damage
Sudeck’s atrophy: reflex sympathetic dystrophy, which leaves the hand painful, stiff, and hypersensitive
Commonest presentation of hyperparathyroid
Renal stones
Types of transplant rejection and cells involved
Hyperacute- minutrd- pre exisitng- HLA or ABO
Accelerated- 2-4d- cellular infiltrate (macrophages and T-lymphocytes)
Acute- 7–21 days post transplantation- T cells
Chronci- insidious - associated with fibrosis of the internal blood vessels
Use of case control over cohort
Can be used to investigate rarer diseases
Define oliguria
<0.5ml/kg/hour
Oliguria in the postoperative period is defined as a urine output of less than 30 mL/hour for 4 consecutive hours
Histological changes in dysplasia
Increased mitosis
z Abnormal mitosis (tripolar, tetrapolar, sunburst, or bizarre)
z An increase in the nuclear:cytoplasmic ratio
z Pleomorphism (variance of size and shape of tumour cells)
z Hyperchromatism (increased amounts of DNA leading to dark-stained nuclei).
In addition, there may be focal or extensive areas of haemorrhage and necrosis due to the abnormal vascularity associated with malignant changes.
Bone cyst presentation
Benign fluid collection in metaphysic
Can cause pathological fractures
X ray
well-defined radiolucent area with sclerotic edges
Nerves from trunk of brachial plexus
Suprascapular nerve
Nerve to subclavius
Actions of insulin
It increases tissue uptake of glucose, amino acids, and lipids.
It stimulates glycogenesis, protein synthesis, and lipid oxidation.
Insulin also inhibits gluconeogenesis and promotes intracellular uptake of potassium and phosphate.
Features of Horners
Ptosis
Miosis
Enophthalmos
Decreased sweating of the affected side of the face, and loss of the ciliospinal reflex.
The ciliospinal reflex refers to pupillary dilatation caused by a painful stimulus to the head, neck or upper trunk.
Causes of Horners
Pancoast tumour
Carotid body tumours, carotid artery dissections or aneurysms, and syringomyelia.
Pancreatic resection- problems with absorption ?
ADEK
Loss of iron, ca, p absorption due to loss of alkalinization- OP
Formation of urinary system in embryo
pronephric duct, which is a duct that extends from the cervical region to the cloaca
Which forms mesonephric duct (Wollfain)- initially function as filtration and drainage in utero which sprouts ureteric bud
Ureteric bud forms metanephric blastema
Collecting system – derived from the ureteric bud.
Excretory system – derived from the metanephric blastema.
Kidneys formed from metanephros- ascending
And mesonephros descend and become the ejaculatory ducts.
Origin of bladder tissue
the cloaca and mesonephric ducts
Cloaca forms urogenital sinus
The bladder develops mostly from the vesicular part of the urogenital sinus, and the bladder trigone is formed from the mesonephric ducts being drawn into the bladder floor.
The transitional epithelium of the bladder is derived from the endoderm of the urogenital sinus
whereas the epithelium of the ureters and renal pelvis are derived from mesoderm.
Factors controlling ADH release
1) Hypothalamic osmoreceptors that secrete ADH in response to raised plasma osmolarity.
(2) Stretch receptors (baroreceptors) that are situated in the atria of the heart- resulting in inhibition of ADH secretion when streched
(3) Stretch receptors that are situated in the aorta and carotid arteries are stimulated when the circulating volume decreases and the blood pressure falls, thereby stimulating ADH secretion.
(4) Trauma, such
as head injury or burns, or any cause of prolonged hypoxia can also stimulate ADH secretion.
Areas affected ini prostate in BPH and cacner
Transitional- BPH
Posterior- cancer
Effects of NO
Vasodilation and muscle relaxation
Prevents platelet aggregation and adhesion as part of the negative feedback mechanism which ensures clot formation at the site of injury
Sites of narrowing of ureters
Pelviureteric junction
The point at which the iliac vessels cross the ureter
the vesicoureteric junction.
Major bleed with warfarin
withhold warfarin and administer IV vitamin K, together with either fresh frozen plasma (FFP) or prothrombin complex concentrate (PCC
Le Fort classification
- Le Fort I: transverse maxillary fracture with two segments; the floating palate contains the alveolus, palate, and pterygoid bones.
- Le Fort II: pyramidal fracture across nasal bones, the medial orbital wall, and down into the maxilla.
- Le Fort III: craniofacial dysfunction with detachment of the midfacial skeleton from the skull base.
Areas ini brain stimulating vomiting reflex
Chemoreceptor trigger zone senses potentially toxic substances in blood and initiates emesis.
Nausea due to motion sickness, inner ear disease, and disequilibrium produced by alcohol excess is sensed through the vestibular apparatus and mediated largely by acetylcholine and histamine receptors.
The central cortex and the limbic systems modulate complex experiences such as taste, smell, memory, and emotion
MOA of atropine
Anti muscarinic
Borders of omental foremen
z Anterior: the free border of the lesser omentum (i.e. the hepatoduodenal ligament). This has two layers and within these layers are the common bile duct, hepatic artery and hepatic portal vein.
z Posterior: the peritoneum covering the inferior vena cava.
z Superior: the peritoneum covering the caudate lobe of the liver.
z Inferior: the peritoneum covering the first part of the duodenum and the hepatic artery, the
latter passing forward below the foramen before ascending between the two layers of the
lesser omentum.
z Left lateral: gastrosplenic ligament and splenorenal ligament.
PBC findings
AMA
portal inflammatory infiltrate composed of lymphocytes, histiocytes, and macrophages surrounding the bile ducts causing peri-portal fibrosis and moderate biliary stasis.
Treatment of radiation prostatitis
sucralfate, metronidazole, prednisolone enemas or mesalazine enemas.
Absorption occurring in duodenum, jejenum and ileum
The duodenum is responsible mainly for the absorption of carbohydrates, protein, minerals
(e.g. calcium, magnesium, iron, chloride, sodium and zinc)
jejunum, responsible for the absorption of glucose, protein, folic acid, and vitamins C, B1 (thiamine), B2, and B6.
The terminal ileum, however, is the main site of absorption of amino acids, lipids, cholesterol, and the fat-soluble vitamins (e.g. A, D, E and K).
intrinsic factor-dependent receptors- can lead to B12 deficiency
Mx of meconium ileus - uncomplicated
Gastrografin enemas after adequate intravenous fluid administration. If this fails, laparotomy is indicated to evacuate the obstructing meconiu
Tx of Conns
Spiro
Surgery
Steps of angiogenesis
(1) proteolytic degradation of the parent vessel basement membrane, allowing formation of a capil- lary sprout;
(2) migration of endothelial cells towards the angiogenic stimulus;
(3) proliferation
of endothelial cells behind the leading front of migrating cells; and
(4) maturation of endothelial cells with organization into capillary tubes.
Artery most commonly affected by mesenteric ischaemia
Middle colic
Metabolic complications of TPN
z Hypo/hyperglycaemia
z Deranged LFTs
z Hyperchloraemic acidosis
z Hypophosphataemia
z Hypercalcaemia
z Hypo/hyperkalaemia
z Hypo/hypernatraemia
z Deficiency of trace elements such as vitamins, essential fatty acids, folate, zinc, and
magnesium.
Management of achalasia
Balloon dilation
Hellers cardiomyotomy
Which nerves are at risk from different approach to hip surgery
Anterior- lateral femoral cutaneous
Posterior- sciatic
Lateral- superior gluteal
Most common oesophageal fistula
Distal
Presentation of oesophageal fistula and mx
Antenatal with polyhydramnios, or postnatal with frothy oral secretions and feeding difficulty. Pneumonitis and sepsis can occur due to aspiration. Early definitive surgical cor- rection is very successful with survival approaching 100%.
Thrombin time vs bleeding time
Thrombin- common pathway
Bleeding- platelet function
How jejunal biopsy is taken
Crosby–Watson capsule is swallowed and guided
When in position, a small sample of mucosa is obtained by suctio
What is seen with Whipples disease
Gastrointestinal symptoms that resemble other malabsorption syndromes
jejunal biopsy in Whipple’s disease reveals stunted villi, with macrophage deposition in the lamina propria containing periodic acid–Schiff (PAS)-positive granules
What are the cords of the brachial plexus related to
2nd part of axillary artery
Where innervation of erection and ejactulation occur
Erection- parasympathetic- peri-prostatic nerve plexus
Ejactulation- T11-L2- pudendal nerve
Most common type of fistula in ano
Intersphincteric
Factors of Goldman’s Cardiac Risk Index
The risk factors include: age greater than 70 years,
raised jugular venous pressure,
presence of a 3rd heart sound,
significant myocardial ischaemic event in the preceding 6 months (i.e. not simply angina pectoris),
surgery on the abdomen or thorax,
symptomatic aortic stenosis,
poor general condition, and emergency surgery.
Tumour above and below dentate line
Squamous below- since stratified squamous cells- ectoderm
Adeno above- columnar - endoderm
Blood supply of pancreas
Body and tail- pancreatic branches of splenic
Head and neck- superior pancreaticoduodenal artery - gastroduo- denal artery
inferior pancreaticoduodenal artery-superior mesenteric artery.
What can you do to control ICP
15 head tilt
Intubation- low CO2- to prevent vasodilation
Mannitol
An intraventricular catheter can be placed to measure the ICP and to allow therapeutic drainag
Stanford and DeBakey classification of aortic dissection
Stanford classification:
Type A: ascending aorta involved
Type B: ascending aorta not involved.
DeBakey classification:
Type I: ascending aorta extending into descending aorta
Type II: ascending aorta only
Type III: descending aorta distal to left subclavian artery
Type IIIa: Type III extending proximally and distally, mostly above the diaphragm
Type IIIb: Type III extending only distally, potentially extending below the diaphragm
firm lump in the anterior triangle on the right side of the neck, which moves up with deglutition
Berry’s ligament
Episiotomy cuts through
Perineal skin
Posterior wall of vagina
Perineal body
Attachment of bulbospongiosus muscle
Cells in stomach
Parietal (oxyntic)- body of stomach - of hista- mine and acetylcholine stimulated gastric acid production
Chief- pepsinogen in fundus
G cell- antrum- gastrin
Where does Wharton’s duct open
Either side of frenulum
Where are the most of calculi in salivary glands seen
Eighty per cent of the calculi in salivary glands are found in the submandibular gland and the Wharton’s duct because of the primarily mucoid secretions of the submandibular gland, and the upward drainage angle of Wharton’s duct.
Where does the sublingual ducts drain
Ducts of Rivinus
Either join the submandibular duct or open separately into the mouth on the elevated crest of mucous membrane -plica sublingualis
Phyllodes tumour contents
e fibroepithelial tumours composed of epithelial and stromal components.
Retroperitoneal structures
Suprarenal
Aorta
Duodenum- 2nd, 3rd
Pancreas- except tail
Ureters
Colon- ascending and descending
Kidney
Esophagus
Rectum
Largest branch of thyrocevical
Inferior thyroid
Melena and haematemesis years after aortic repair
Aorto-enteric fistula
Needle types and when they are used
Round-bodied needles tend to separate tissue fibres (i.e. instead of cutting them)- bowel and vascular anastomoses,
are used in friable tissue such as liver and kidney
Blunt round-point needles literally ‘dissect’ rather than cut, and are useful when suturing extremely friable vascular tissue (e.g. liver, kidney, and spleen) and mass closure of the abdominal wall.
potentially reduce the risk of blood borne virus infection from needlestick injuries.
Reverse cutting needles- tough tissues like skin, ligament and tendon
Blunt taperpoint needles - high risk patient
Analysis of Pus produced by pancreatitis
Sterile- due to sterile necrosis of the pancreas gland.
Cause of sterile pyuria
- A treated urinary tract infection, within 2 weeks of treatment
- Renal stones
- Prostatitis
- Chlamydia urethritis
- Tubulo-interstitial nephritis
- Interstitial cystitis
- Urinary tract neoplasm
- Polycystic kidney.
In rarer instances, Crohn’s disease of the terminal ileum m
Grading renal injury trauma
z Grade 1: contusion
z Grade 2: <1 cm laceration not affecting medulla/collecting system
z Grade 3: >1 cm laceration not affecting medulla or collecting system z Grade 4: laceration involving medulla or collecting system
z Grade 5: shattered kidney or avulsed renal artery or vein
UC histology
general inflammatory cell infiltration
goblet-cell mucus depletion
glandular distortion
mucosal ulceration
crypt abscesses.
HLA class 1 vs 2
Class 1- intracellular on all nucleated cells- A, B, C
2- expressed only by antigen presenting cells- DR, DP, DQ.
HLA B27 conditions
Sero-negative spondyloarthropathies
Psoriatic
AS
Enteropathic arthritis
Reactive arthritis
Sx of humeral head dislocation
The usual mechanism of injury is a fall onto the outstretched arm when the arm is abducted and externally rotated.
The pain is usually severe, and the patient is unwilling to attempt movements of the shoulder.
A swelling may be noticed in the delto- pectoral groove
Salter Harris affecting growth
1+2 do not affect germinal layer
In Salter–Harris types III and IV, the germinal layer is breached so growth disturbance is likely, although its incidence can be minimized by adequate fracture reduction.
Salter–Harris type V fractures are recognized as a crush injury of the epiphysis, following which, growth arrest is common.
This fracture is often diagnosed retrospectively, when disturbance of physeal growth becomes appar- ent as a limb deformity
Most common salter Harris
2
Action of protein C and S and what C is dependent on
Inactivate VIII and V
C is Vit K dependent
Respiratory centres, location and function
The medullary respiratory centre has inspiratory and expiratory centres, which control the rhythm of breathing.
The pneumotaxic centre is located in the upper pons and controls the duration of inspiration.
The apneustic centre is present in the lower pons and prolongs the inspiratory phase.
Central and peripheral chemoreceptors
Central- medulla- detects H+ in CSF(indirectly from CO2)
Peripheral- carotid body at bifurcation- respond to decrease PaO2, decreased pH and increased PCO2
Mx of patients with GORD resistant to medical management
Upper GI endo 6m prior to surgery
Nissen fundoplication
pH monitoring off meds
Attachment of long head of triceps and biceps
Triceps- infraglenoid tubercle of the scapula
Biceps brachii, which has a long head that extends inside the capsule to attach to the supraglenoid tubercle of the scapula
Foetal haemoglobin composition, affinity for substances
2a and 2y
Lower affinity to DPG and therefore higher for O2
Radical neck dissections vs modified
Excision of levels I–V lymphatic structures as well as three non-lymphatic structures: spinal accessory nerve, sternomastoid muscle and internal
jugular vein.
Modified
z Type 1: accessory nerve preserved
z Type 2: accessory nerve and jugular vein preserved
z Type 3: accessory nerve, sternomastoid and jugular vein preserved
Tx of VWD
Desmopressin for mild
Severe disease, von Willebrand’s factor concen- trate,
Cryoprecipitate or fresh frozen plasma are usually used in cases of bleeding
Contrast used in bowel obstruction
Gastrogaffin enema
Jejunum vs ileum
Jejenum- form single or double arterial arcades with long vasa recta
Lymphoid tissue is sparse
Red
Ileum- multiple arcades with short vasa recta
Peyer’s patches
Purple
Pasonage Turner syndrome
Inflammation of branches of the brachial plexus
Severe pain for days to weeks, followed by weakness and sensory loss over the corresponding territory of the brachial plexus (most com- monly C5–C7, as in this case
Elevated hemidiaphragm causes
phrenic nerve palsy
atelectasis
diaphragmatic hernia
distended abdominal viscera.
Diaphragm rupture
Epistaxis in elderly location
Posterior- from branches of sphenopalatine
Cause of normal anion gap acidosis
GI tract losses of bicarbonate ions, such as diarrhoea and pancreatic fistula losses
Dilutional causes
Drugs (e.g. acetazolamide)
Addison’s disease
Renal tubular acidosis- failure to acidify urine correctly and results in the loss of sulphate and phosphate anions. Electrical neutrality is maintained by renal reabsorption of chlo- ride anions, resulting in a hyperchloraemic metabolic acidosis with a normal anion gap
Transverse approach for appendectomy risk
Illihypogastric nerve
Perrforates the posterior part of the transversus abdominis muscle
and divides between this and the internal oblique muscle into lateral and anterior cutaneous branches, and muscular branches to both these muscle
Cytology of papillary carcinoma
nuclear grooves,
intranuclear inclusions or optically clear nuclei, Orphan Annie cells, and psammoma bodies.
Capsular invasion thyroid
Follicular carcinoma
Woody goitre in old lady
Anaplastic
Remnants of mullein duct in male
Appendix testis (Hydatid cyst of Morgagni)
Erbs palsy nerve root and features
C5,6
abducted and medially rotated with an extension of the elbow and pronation of the forearm
Pancoast tumour features
(1) pain in the shoulder region radiat- ing toward the axilla and scapula,
(2) pain and atrophy of small muscles of the hand due to ulnar nerve involvement,
(3) paraesthesia in the medial side of the arm,
(4) Horner’s syn- drome (ptosis, miosis, hemianhidrosis and enophthalmos),
(5) oedema of the arms due
to compression of the major vessels in the thoracic inlet
Borders of superior orbital fissure
superiorly by the lesser wing of the sphenoid, inferiorly by the greater wing, and medially by the body of the sphenoid.
Inguinal hernia containing appendix
Amyands
Richter, Liters, pantaloon, spigelian, grynfelt and petit hernia
Richter- inguinal hernia which only contains one side of the bowel wall
Litres- Meckel
Pantaloon- direct and indirect
Maydl hernia- 2 loops- W
Spigelian- lateral to rectus
Grynfelt- Superior lumbar
Petit- inferior lumbar
Hypertrophic vs keloid
Keloid- outside boundaries
Late in wound healing- >3m
Do not regress
Hypertrophic- limited to boundary
Early in healing
Spontaneously regress but not to normal
What anatomical structure to use to determine between direct and indirect hernia
Inferior epigastric
Direct- medial
Indirect- lateral
peritoneal carcinomatosis
Mets in peritoneum
It can lead to the development of ascites
Vertebral levels of thyroid cartilage, cricoid, thyroid
Thyroid cartilage- C4- same as carotid bifurcation
Cricoid- C6
Thyroid-C5-T1
Isthmus- C7
Damage after submandibular gland excision causing loss of sensation at mandible and unable to move upper lip
Marginal mandibular branch
SIRS criteria
temperature >38°C or <36°C; (2) heart rate >90/min; (iii) respiratory rate >20 or PaCO2 <4.3 kPa; and WCC >12,000 or < 4000 × 109/L
Formation of atherosclerosis
Lipoproteins deposited in intima
Macrophages ingest to form foam cells
Smooth muscles migrate - secrete to form fibrous capsule
Plaque breaks down at base to form lipids, necrotic debris which calcify
Jefferson fracture
Fractures of the anterior and posterior arches of atlas , and causes the lateral masses to be displaced laterally
No neurology
Atlanto- axial dislocation position and complication
Posterior dislocation of odontoid
Leads to sudden death as can compress spinal cord
Imaging for odontoid fractures
plain radiography using a lateral cervical-spine view or open-mouth odontoid views.
However, a CT scan may be required to further delineate the type and extent of the fracture.
Pierre robin syndrome
Mandibular hypoplasia
Cleft lip
Micrognathia and glossoptosis may cause severe respiratory and feeding difficulties as well as obstructive sleep apnoea in the newborn.
Otitis meadia
Hearing loss
Oligohydrominos
Mx of posterior hip dislocation
Theatre immediately
Closed reduction of hip
Which laryngeal muscle is unapaired
Transverse arytenoid muscle
How is continence maintained
Anorectal angle- minor
Internal anal sphincter
Endoanal cushions- plug anal canal
External anal sphincter
Mx of bladder cancer
T1/CIS- TURBT+Chemo, if widespread BCG- if that fails cystectomy and chemo
T2-3- cystectomy and chemo
T4- palliative
N1/M1- palliative
Mx of supracondylar fracture causing pallor
Manipulation of the fracture under general anaesthetic
If this is unsuccessful, surgical exploration of the brachial artery is warranted, and should be performed by a vascular surgeon. Lacerations of the artery are repaired either primarily (i.e. with sutures) or with vein grafts.
Mx of bleeding varices
Terli and ABx
Sclerotherapy
or band ligation
If ineffective - balloon tamponade (e.g. with a Sengstaken–Blakemore tube)- temporary
Subsequent definitive management would include radiological
(e.g. transjugular intrahepatic porto-systemic shunt or TIPS) or surgical (e.g. oesophageal transection, portosystemic shunting) procedures.
Innervation of levator ani
The levator ani muscles are mostly innervated by the pudendal nerve, perineal nerve and inferior rectal nerve in concert.
Which autonomic system is the accommodation refelx
Para in CN 3
Post ganglionic neurotransmitter sympathetic
Usually noradrenaline
Sweat- Ach
Brachial vs thyroglossal cyst on FNA
Branchial cysts usually produce an opalescent fluid containing cholesterol crystals or frank pus
thyroglossal cysts commonly contain serous fluid.
Dominance prevalence of coronary arteries
Dominance is based on the origin of the posterior interventricular artery. In right dominance (90%) the posterior interventricular artery is a large branch of the right coronary artery. Approximately 3% of hearts are co-dominant.
Phases of cardiac action potential of non-nodal cells
Phase 0- influx of Na
Phase 1: fast sodium channels close. The small downward deflection is due to continuing out-
flow of potassium and chloride.
Phase 2: plateau phase balancing the slow inflow of calcium and outflow of potassium.
Phase 3: slow calcium channels close while potassium channels remain open
Phase 4: resting membrane potential is restored.
Main cause of symptoms in refeeding
Low P
Those at risk of refeeding and when will it occur
Individuals with negligible nutrient intake for
5 consecutive days are at risk of this syndrome, which usually occurs within 4 days of recom- mencing feeding
Where is secretin produced and its action
Secretin is produced by the S cells
of the villi and crypts of the small intestine in response to acidification of duodenal contents.
Secretin stimulates pancreatic enzyme and bicarbonate release while inhibiting gastric acid and pepsin secretion. It also potentiates the action of cholecystokinin
What causes VIP production
Vagal stimulation of SI not food
Mirizzi syndrome and what it causes
Impaction of gallstones either in the cystic duct or Hartmann’s pouch of the gallbladder, which leads to external compression of the common hepatic duct and results in symptoms of obstructive jaundice
chronic and/or acute inflammatory changes leading to contraction of the gallbladder and stenosis of the common hepatic duct, or (2) cholecysto- choledochal fistula
Arteries contributing to spinal cord blood supply
Vertebral (directly off the aorta), ascending cervical, deep cervical, intercostal, lumbar and lateral sacral arteries
inferior portion of the spinal cord is supplied by the anterior and posterior segmental medullary arteries
The great anterior medullary artery (i.e. artery of Adamkiewicz) supplies blood to the inferior two-thirds of the spinal cord and is found on the left side in 65% of people.
Phases of gastric secretion
z Cephalic phase: the excitatory stage (via odours and thoughts, processed in the cerebral cortex, hypothalamus, and medulla) is responsible for saliva production, some pancreatic juice production and 10% of gastric acid secretion.
z Gastric phase: this is mediated via the short gastric reflex (via local neurohormonal pathways in the stomach wall) and the long vagus reflex. It is responsible for 80% of gastric secretion.
z Intestinal phase: this is responsible for 10% of gastric secretion.
Cause of meconium ileus in CF
Failure of pancreatic secretion
Most superficial structure in popliteal fossa
Sural nerve
Symptoms of High PTH vs High Ca
Symptoms of raised PTH include: urinary tract stones due to excessive calcium excretion, bone pains, and pathological fractures due to osteopenia.
Symptoms of hypercalcaemia include fatigue, abdominal pain, vomiting, constipation, polyuria, polydipsia, and psychiatric disturbances (depression, confusion).
Where would a malignant parotid tumour drain
Deep cervical
Which RLN is more likely to be damaged and symptoms
Right is more medial
Hoarseness
Bilateral- trouble breathing
Action of traps and sx If accessory damaged
muscle elevates, laterally rotates and retracts the
scapula.
Patients with injury to the spinal accessory nerve (and subsequent dysfunction of the tra- pezius) present with an asymmetric neckline, drooping shoulder and winging of the scapula
Sx of Ludwig angina and cause
odontogenic infections
reveals bilateral, tense neck swellings with overlying erythema, and an elevated and protruding tongue
Risk of breast cancer
High risk: increasing age, family history of breast cancer
z Medium risk: high socioeconomic status, late first pregnancy (>30 years), past history of
breast cancer, breast irradiation <20 years
z Low risk: early menarche (<11 years), nulliparity, late menopause (>55 years), oral contra-
ceptive therapy, and postmenopausal use of hormone replacement therapy, obesity, alcohol.
1/9
Main complications of SAH
Death
Rebleeding
Ischaemia
Hydrocephalus
Zygomatic fracture symptoms
cheek appears to be flat and depressed
swelling and ecchymosis around his right eye
Diplopia
The zygomatic arch usually fractures at its narrowest point or at the suture between the zygomatic process of the temporal bone and the temporal process of the zygomatic bone.
Ann Arbor staging
Ann Arbor staging criteria (Stage I: involvement of a single lymph node area; Stage II: involvement of two or more lymph node regions on same side of the diaphragm; Stage III: involvement of lymph node regions on both sides of the diaphragm ± spleen; Stage IV: disseminated extralymphatic spread)
What blood test can be positive in Non Hodgkin lymphoma
High LDH
Which HLA are tested for transplant
HLA A
HLA B
HLA DR- most important - as highest incident of rejection
Oesophageal stent, now have dysphagia mx
Ingestion of a carbon- ated drink, which assists in dissolving the obstructing bolus. If this fails, endoscopy is required to ascertain the cause of obstruction, and to dislodge the food bolus, if necessary.
Bleeding from his nose, a salty taste in his mouth, Otoscopic examination reveals visible bleeding behind the left tympanic membrane
Basal skull fracture
What release PTH in parathyroid
Chief cells
Consequences of prolonged immobilisation post op
Initial hyperkalaemia from tissue breakdown, potassium is seen to fall as it is excreted with the loss of total body lean tissue mass.
The muscle mass is then replaced by adipose tissue.
Heart rate gradually increases while the stroke volume falls due to cardiac atrophy.
The cardiac output and blood pressure, however, are maintained due to the compensatory changes mentioned earlier.
With a reduction autonomic nervous system coupled with a fall in inotropic and cardiac output response, the patient’s adaptation to postural changes becomes impaired, making him unsteady on his feet.
The bones eventually demineralize and calcium, phosphate, and hydroxyproline will be excreted in the urine.
Path of facial nerve
Internal acoustic meatus. The facial nerve then passes through the facial canal (of the petrous temporal bone), widens to form the geniculate ganglion (which mediates taste and salivation) on the medial side of the middle ear. At this point, it deviates sharply (giving off the chorda tympani) to emerge through the stylomastoid foramen
Differentiating upper vs LMN of facial nerve
UMN- can wrinkle face
LMN- can’t
Stored blood and altitude effect on oxygen curve
High altitude increase DPG and therefore shift to right
Stored decreases DPG causing shift to left
Advantage of Roux en Y over subtotal gastro-jejunostom
Subtotal- bilious vomiting
The absence of a functioning pylorus allows bile to reflux into the stomach, which is now of reduced capacity, thereby increasing the chance of bilious vomiting
Proximal jejunum is disconnected from the loop gastro-jejunostomy and reattached at least 30 cm distally. Peristalsis should then direct the bile distally rather than back into
the stomach.
Mutation in MEN
RET proto oncoogene
Itchy rashes in MEN 2A
Cutaneous lichen amyloidosis
Which part of duodenum is crossed by colon
Second part
SIRS diagnosis
2 or more
Temp >38 or <36
HR >90
RR >20
WCC >12 <4
Sensation of parotid
auriculotemporal nerve (gland) Trigeminal
the great auricular nerve (fascia). Cervical plexus
Drainage into cavernous sinus and what it drains into
Ophthalmic veins- superior from facial vein
Central vein of the retina – drains into the superior ophthalmic vein, or directly into the cavernous sinus.
Sphenoparietal sinus
Superficial middle cerebral vein
Pterygoid plexus
It empties into the superior and inferior petrosal sinusus (and subsequently into the internal jugular vein)
Tx of prolactinoma
If microadenoma- <1cm Bromocriptine/carbogerline
If macro >1cm-then surgery
Surgery usually reserved for those who are resistant to medical treatment, patients who develop adverse effects to dopamine agonists and, in patients desiring pregnancy with tumor size of more than one centimeter.
Which part of trachea is incised in tracheostomy
2-4th rings
Survival rates in Dukes staging
A- within bowel -95% 5y
B- MP, then extra colonic but no LN 80%
C- LN involvement- few 60%, many 30%
D- distant mets- 5%
Lymph node in calots triangle
Mascagni’s lymph node (or node of Lund), and is the sentinel lymph node of the gallbladder.
What is the mutation of FAP and what other effects does it have
rare autosomal dominant condition which results from the deletion of the long arm of chromosome 5- inheritanly benign
Congenital hypertrophy of the retinal pigment epithelium occurs in as many as 95% of individuals with FAP.
Gastro and duodenal involvement
Cause of Pneumobilia
GI connection
Cholangitis
incompetence of the sphincter of Oddi
ERCP
Whipples
Biopsy of Hirschprungs
Histologically devoid of ganglion cells in the Meissner’s (submucosal) and Auerbach’s (myenteric) plexus but demonstrates immunohisto- chemical evidence of increased acetylcholinesterase activity.
Mx of Hirschprungs
Rectal irrigation or emergency colostomy formation may be required before a definitive ‘pull-through’ procedure is performed.
Osteomyelitis pathogens
S aureus
Sickle- Salmonella
Haemodialysis- pseudomonas
Floor of snuffbox
Scaphoid and trapezium
Frey syndrome pathology
Auriculotemporal
t is caused by sprouting of the divided parasympathetic nerve branches to the parotid into the divided sympa- thetic nerve fibres to the sweat glands
Management of post op haematoma in breast
Observe
Floor of femoral triangle
Laterally of psoas major and ili- acus, and medially by pectineus and adductor longus.
Palpated on psoas
Phases of teste descent
z Indeterminate phase (up to 8 weeks): the urogenital ridge and development of male and female gonads is similar up to 8 weeks.
z Transabdominal phase (weeks 8–15): this phase in controlled by Anti-Müllerian hormone secreted by the Sertoli cells. It causes regression of the cranial suspensory ligament of the testes and enlargement of the gubernaculums.
z Processus vaginalis (weeks 20–25): this is a peritoneal diverticulum attached to the lower pole of the testis, which elongates further along with the gubernaculum towards the base of the scrotum.
z Inguinoscrotal phase (weeks 28–35): under the guidance of the gubernaculum, the testis descends with the processus vaginalis along the inguinal canal and into the scrotum. The descent is controlled by testosterone and CGRP. CGRP is released by the genitofemo- ral nerve in response to androgen. It causes rhythmic contraction and shortening of the gubernaculums.
When before splenectomy should vaccines be given
At least 2 weeks
What does the diaphragm form from
The diaphragm develops from the dorsal oesophageal mesentery, pleuroperitoneal membranes, lateral body walls and the septum transversum (i.e. which forms the central tendon).
How much of saline vs dextrose stays intravascular
1 L of normal saline in a healthy adult, only 25% (250 mL) will stay in the intravascular space. The remaining 75% will be distributed within the interstitial space.
When 1 L of 5% dextrose is infused, only 8% (80 mL) will remain in the intravascular space and 92% will be redistributed in the interstitial and intracellular space.
Cause of spiral fractures in leg
Falls
Hypernatraemia post head injury
Diabetes insipidus
Low osmolality urine
Which structure is vulnerable in incision into ischoanal fossa
Pudendal nerve
Urine in pyloric stenosis
Acidic urine
Due to aldosterone stimulation
Hyperthyroid with cold nodule
Graves With Papillary
Difference between class 2 and 3 shock
2- not low
3-BP low
How pH affects available Ca
acidosis, the decrease in protein binding (i.e. albumin binding) with calcium leads to an increase in ionized calcium. The converse is also true (i.e. decreased ionized calcium levels with alkalosis) and may result in symptoms of hypocalcaemic tetany in alkalosis.
TNM of colon cancer
T1- submucosa
2-MP
3-subserosa
4- other structures
N0
1- 1-3
2- >4
SIRS, Sepsis, severe, shock
Sepsis is SIRS plus infection source
Severe sepsis- BP <90
or lactic acidosis
Shock-hypotension despite fluid resuscitations
Where to do pericardiocentesis
Level hemiazygous crosses and joins azygous
T8/9
What does the hemiazygous drain
he hemiazygos vein drains the right poste- rior thorax, lumbar regions, lower oesophagus and parts of the mediastinum
CT neg but blood on LP SAH what next
Four vessel angiogram
Differentiating cord syndromes
Anterior - temp, pain, motor
Posterior- sensory, motor
Central- Cervical >lower
Brown sequard- resulting in ipsilateral loss of motor function, vibration and proprioception; with contralateral loss of pain and temperature sensation.
Pain in cholecysitis vs colic
Constant vs waves
