PassMed round 2 Flashcards
What is the normal ICP range?
7-15 mmHg
The brain can accommodate pressures up to 24mmHg before clinical features become evident
What is the name of a hernia where part of the wall of the small bowel (usually anti-mesenteric border) is strangulated within the hernia?
Richeters hernia
They do not present with typical features of intestinal obstruction as luminal patency is preserved
What is the name of a hernia containing Meckel’s diverticulum?
Littres hernia
Resection of the diverticulum is usually required and will preclude a mesh repair
How should biliary atresia initially be treated in children?
Initially, a Roux-en-Y protojejunostomy (kasai procedure)
If kasai procedure fails or late recognition, a liver transplant becomes only option
Which part of the adrenal gland produces cortisol?
Zona fasciculata
In patients with oesophageal cancer, what is a contraindication to resectional strategy?
Distant metastatic disease
ie - oesophageal cancer with mets to liver
These patients need an expanding metallic stent to provide durable palliation
Where are gastrinomas most commonly located?
Duodenum
Which antiemetic targets the 5HTC chemoreceptor trigger zone?
Ondansetron
What does tranexamic acid inhibit? What does this result in?
Inhibits plasminogen acrtivation
This prevents fibrin degradation
(binding of plasminogen to fibrin induces fibrinolysis)
What is tranexamic acid a synthetic derivative of?
Lysine
It is an anti-fibrinolytic
Name 3 factors decreasing gastric acid production?
Somatostatin
Cholecystokinin
Secretin
In trauma, is aortic rupture most commonly proximal or distal to the left subclavian artery?
Most commonly distal to left subclavian
What are the layers of the adrenal cortex and what do they secrete?
“GFR ACD”
Zona glomerulosa - Aldosterone
Zona Fasciculata - Cortisol
Zona Reticularis - dihydroepiandosterone
What action does aldosterone have when it is released by zona glomerulosa?
Causes retention of Na+ in exchange for K/H in distal tubule
What type of bone tumour can complicate Paget’s disease of the bone?
Osteosarcoma
Surgical resection is main treatment
Name the 3 upward deflections in JVP waveform trace and what each one represents ?
A wave - atrial contraction
C wave - ventricular contraction
V wave- atrial venous filling
Which vitamin is involved in formation of collagen? Why is it required?
Vitamin C
It is needed for hydroxylation of proline during collagen synthesis
What is the most common type of collagen found in the body?
Type I collagen
Tissues with increased levels of flexibility have more collagen III
How should patients with a severe attack of UC be managed if they don’t respond to medical management within 5-7 days?
Sub total colectomy with end ileostomy
Avoid pan procolectomy in acutely unwell patients - v high risk
Compare histological findings in Comededo and Cribriform type ductal carcinoma in situ?
Comedo type = associated with micro calcifications
Cribriform type =multifocal but less likely to form microcalcifications
Name the 5 muscles that receive motor innervation from trigeminal nerve?
Muscles of mastication
Mylohyoid
Anterior belly of digastric
Tensor Tympani
tensor palati
Which muscle function is tested in Froment’s test?
Adductor pollicis
Name the pneumonic and branches of the posterior cord of brachial plexus?
ULNAR
Upper subscapular nerve
Lower sub scapular nerve
Nerve to Lat Dorsi
Axillary nerve
Radial nerve
Compare the drainage of lymph in the upper and lower ureters?
upper ureters = para aortic
Lower ureters = common iliac nodes
The recurrent laryngeal nerve innervates all muscles of the larynx except…? What is this muscle innervated by instead ?
Cricothyroid - innervated by the external branch of superior laryngeal nerve
Compare causes of bitemporal hemianopia and homonymous hemianopia?
Bitemporal hemianopia = optic chiasm lesion or pituitary tumours
Homonymous hemianopia = optic tract
What nerve is most closely related to the bladder?
Obturator nerve
What structure suspends the spinal cord in the dural sheath? It has intermittent projections attaching spinal cord to the dura mater?
Denticulate ligaments
What is the causative in malignant otitis externa?
Pseudomonas aeruginosa
Granulation tissue is seen on examination. Diabetes is one of the main risk factors
What structure is the tunica vaginalis derived from?
The Peritoneum
Which tumour type is found most frequently in a person with aggressive fibrzomatosis?
Desmoid tumours
May occur in abdominal and extra abdominal locations. Main risk factor is APC variant of FAP. Managed with surgical excision
Name 3 medication classes that inhibit the secretion of insulin?
Alpha adrenergic (adrenaline)
Beta blockers
Sympathetic nerves
Describe the anatomy of the popliteal fossa, from medial to lateral?
Popliteal artery
Popliteal vein
Tibial nerve
Common Peroneal nerve
Fascia from which muscle formed the pudendal canal? What does the canal contain?
Obturator internus muscle fascia forms the pudendal canal
Contains the internal pudendal artery and vein and pudendal nerve
What artery is dorsalis pedis a continuation of?
Anterior tibial artery
When undergoing excision of the submandibular gland, which structure is most superficial after encountering platysma and deep fascia?
Facial vein
Facial artery sits deeper, nearer mandible
Initial incision is made 4cm below the mandible to avoid the marginal mandibular nerve
Why should abdominal US be undertaken for a left sided varicocele?
Left sided varicocele is a recognised presenting sign of renal tumour occluding the renal vein
Where are oxyphil cells typically found?
Parathyroid
They are seen in Follicular thyroid cancer tho
Which type of bladder cancer may be treated with intravesical BCG?
TCC of the bladder
When looking to confirm histological diagnosis of breast lumps, what method should you use?
- Image guided core biopsy
If the histology remains unclear after this, then an excision biopsy will be required
Most commonly isolated organisms seen in Fournier’s Gangrene?
Compare this to most common organism causing nec fasc?
E.Coli and bacteroides
Most commonly causing nec fasc = streptococcus
Compare the lymphatic drainage of male spongy urethra and glans penis to the prostatic and membranous urethra?
Spongy urethra and glans penis = deep inguinal nodes
Prostatic and membranous urethra = internal iliac nodes
Name the 3 components in the adductor canal?
Saphenous nerve
Femoral vein
Superficial branch of femoral artery
The saphenous nerve can be blocked in an adductor canal block
What structure forms lateral border of adductor canal?
Vastus medialis
Compare predominant CSF cell type in viral vs bacterial meningitis?
Viral = lymphocytes
Bacterial = neutrophils
Name the 3 boundaries of the anterior triangle of the neck?
Anterior midline
Anterior border of the sternocleidomastoid
Lower border of the mandible
How is unfractionated heparin monitored?
What clothing factors are affected in by heparin?
APTT
Clotting factors 2, 9, 10, 11, 12 affected
Thrombin is CF IIa
What type of thyroid cancer is a patient with autoimmune thyroiditis (hashimotos) most at risk of developing?
Lymphoma
Which muscle is penetrated by the parotid duct?
Buccinator muscle
Parotid penetrates the buccinator to enter oral cavity opposite second upper molar tooth
Name the venous drainage of upper, mid and lower oesophagus?
Upper = inferior thyroid vein
Mid = azygous vein branches
Lower = Left gastric
Which structure lies between the submandibular gland and the mandible?
Facial artery
It can be ligated during excision of submandibular gland
Lingual artery may be encountered but that is usually later in procedure, when Whartons duct is being mobilised
Name the 3 hormones that are reduced in a stress response?
Insulin
Testosterone
Oestrogen
The 3 of them are often released in reduced quantities post op
Compare the types of epithelium found in meckels diverticulum if it bleeding and if it is not bleeding?
Bleeding - most likely to be gastric mucosa
Not bleeding/asymptomatic - most likely ileal
What is the most superficial structure on the parotid gland?
Facial nerve
Which type of Hogkins lymphoma is associated with popcorn cells?
Nodular lymphocyte predominant
Popcorn cells are the lymphohistocytic variant of reed steenberg cells
Which procedure can increase the risk of gallstone formation? Why?
Ileal resection
Bile salts are reabsorbed at the ileum - therefore cholesterol gallstones can occur as a result of ileal resection
Which structure seperates the ulnar artery from the median nerve?
Pronator teres - the ulnar artery lies deep to it, the median nerve lies superficial
Describe the initial location of the metanephric cap from which the kidney is derived?
Medial to the ureteric bud in the pelvis
Failure to migrate cranially results in a pelvic kidney
Which part of the kidney is responsible for reabsorbing up to 2/3’s of filtered water?
Proximal convoluted tubule
Name 3 substances that increase gastric acid secretion and 3 that inhibit gastric acid secretion?
Increase gastric acid secretion - vagal nerve innervation, gastrin, histamine
Reduce gastric acid secretion - somatostatin, cholecystokinin, secretin
Compare the location of duodenal ulcers causing peritonitis and those causing haematemesis/malaena?
Haematemesis - posterior duodenal ulcer - erodes into the gastroduodenal artery
Peritonitis - anterior duodenal ulcer - more likely to cause peritonitis
What is most common cause of osteolytic bone mets in children?
Neuroblastoma - a common childhood tumour with tendency of developing into widespread lytic mets
In metastatic prostate Ca, what should be given alongside luteinising hormone releasing hormone? Why?
Flutamide or cyproterone
They are anti-androgens. LHRH can cause a flare of metastatic disease in the short term - this can be reduced by administering anti-androgen
How does hyperventilation affect ionised calcium levels? How does this present?
50% of plasma calcium is ionised
Hyperventilation causes alkalosis, which will lower ionised plasma Ca levels
Reduced ionised calcium levels will cause spasms, confusion, numbness and tingling
What artery is the pancreatic artery a branch of?
The splenic artery (part of the coeliac axis)
Innervation of sternocleidomastoid and trapezius?
Accessory nerve
The accessory nerve has a number of LNs near to it on the surface of SCM muscle - it can be injured if the SCM is mobilised
What nerve supplies sensation to the lateral aspect of the foot?
Sural nerve
Compare innervation of dorsum (upper part) of foot and 1st web space?
Dorsum of foot = superficial peroneal (fibular)
1st webspace = deep peroneal (fibular)
Which vessel provides greatest contribution to arterial supply of the breast?
Internal mammary artery
It provides 60% of the arterial supply
External mammary and lateral thoracic arteries make a significant but lesser contribution
Describe the anterior, posterior, inferior and superior boundaries of the epiploic foramen?
Anterior= free edge of lesser omentum
Posterior = IVC
Inferior = 1st part of duodenum
Superior = caudate process of liver
What is the commonest cause of cardiac abnormality in pregnant women?
What type of murmur does this cause?
Mitral stenosis
Can be secondary to rheumatic disease
Causes mid-diastolic murmur
What can be used to reduce output from a pancreatic fistula?
Octerotide
Other than ABO mismatch, name the antibody and Ig involved in hyperacute organ rejection?
IgG anti HLA class 1 antibodies in the recipient
Acute organ rejection usually T cell mediated
What is a Ladd’s procedure used to treat?
Intestinal malrotation with volvulus
At what level do the renal arteries tend to branch off the aorta?
L2
There’s 2 kidneys!
Which brain tumour occurs in <3y/os, arise in 4th ventricle and can grow through the foramina of luschka and magendie?
Ependymoma
Compare the time of onset of haematocele and hydrocele following trauma to testicles?
Haematocele - develops over mins/hours
Hydrocele - develops over days/weeks
Which lab test is most accurate in identifying whether CSF is present or not?
Beta 2 transferrin assay
It is a carb free form of transferrin which is exclusively found in the CSF
What is the most important structure involved in supporting the uterus?
Central perineal tendon
It provides the main structural support to the uterus.
Damage to it is commonly associated with development of pelvic organ prolapse
Name the contents of the cavernous sinus?
O TOM CAT
Occulomotor nerve
Trochlear nerve
Ophthalmic nerve
Maxillary nerve
Carotid nerve
Abducent nerve
OTOM - lateral wall components
CA = components within sinus
Name the 5 structures passing through foramen ovale ?
OVALE
Otic ganglion
V3 (mandibular branch)
Accessory meningeal artery
Lesser petrosal nerve
Emissary veins
In which 2 types of nerve injury does Wallerian degeneration occur?
Axonotmesis
Neurotmesis
Wallerian degeneration does not occur in neuropraxia
What is wallerian degeneration?
Axonal degeneration occurring distal to the site of nerve injury
It does not occur in neuropraxia, where nerve is intact but electrical condition is affected
Describe the pneumonic used to remember the walls of the inguinal canal?
“MALT”
2Ms - superior wall - 2 muscles
2As - anterior wall- 2 aponeurosis
2Ls - inferior wall (floor) - 2 ligaments
2Ts - posterior wall - 2 structures beginning with T !
Name the structures making up superior wall of inguinal canal?
2M - 2 muscles
Internal oblique, transversus abdominus
Name the structures making up anterior wall of inguinal canal?
2As - 2 aponeurosis
Aponeurosis of internal oblique
Aponeurosis of external oblique
Name the structures making up inferior wall (floor) of inguinal canal?
2Ls - 2 ligaments
Inguinal ligament
Lacunar ligament
Name the structures making up posterior wall of inguinal canal?
2Ts - structures beginning with T
Transversalis fascia
Conjoint tendon
(and more laterally the deep inguinal ring)
Which nerves coordinate gastric emptying and provide coordinated contractions and timely relaxation of the pylorus?
The vagus nerves
How does damage to vagus nerves affect gastric emptying?
Which procedure in particular carries the risk of damaging the vagus nerves?
It delays gastric emptying
Risk of damage to vagus nerves in redo fundoplication surgery
What was the aim of truncal vagotomies?
To reduce gastric acid production
The were carried out prior to the invention of PPIs
But caused delayed gastric emptying - this required many patients to then have pyloroplasty or gastro-jejunostomy to improve gastric emptying times
Which nerve is responsible for sensory innervation to tonsillar fossa?
Glossopharyngeal nerve
Referred pain causing otalgia can occur following tonsillectomy
At what spinal level does the trachea begin?
C6
It terminates at T5
Which CN is most likely to be affected by a cerebello-pontine angle lesion?
CN V
Most likely lesion is an acoustic neuroma
Which type of intussusception in children are not amenable to pneumatic reduction?
Ileo-ileal intussusception - they are less common than ileo- colic variants and require surgery, not pneumatic reduction
Ileo-colic intussusception can be trialled with pneumatic reduction under fluoroscopic guidance if patient is stable
Describe the pathology seen in subclavian steal syndrome? How does this present clinically?
Stenosis/occlusion of the subclavian artery, proximal to the origin of the vertebral artery
During physical exercise, the increased metabolic needs of the arm causes retrograde blood flow from the vertebral artery, causing LOC
What is the most potent agent to be used in cases of hypercalcemia >3.5 alongside IV fluids?
IV pamidronate - it is most potent agent
Calcitonin has quickest onset of action but has short duration, so needs to be given alongside IV agent
IV zoledronate is used for malignancy associated with hypercalcemia
Name the 2 muscles in the superficial posterior and 3 muscles in deep posterior compartment of lower limb?
Superficial = gastrocnemius, soleus
Deep = tib posterior, flexor digitorum longus, flexor hallicus longus
All innervated by tibial nerve
Where in the gut does most water absorption occur?
Water absorption predominantly occurs in small bowel (jejunum and ileum)
Compare the ions involved in rapid depolarisation and early and final repolarisation of myocardial action potential?
Rapid depolarisation = rapid sodium influx
Early and final repolarisation = efflux of potassium
How should fractures of the anatomical neck of the humerus be managed?
Hemiarthroplasty
They are at significant risk of avascular necrosis
In pregnant women, which investigation is the most sensitive for identifying placental abruption?
CT scan - it remains first line investigation in major trauma where significant visceral injury is suspected
Where is most dietary iron absorbed?
Proximal small bowel - duodenum and jejunum
Absorbed in the Fe 2+ state
In cases of appendicectomy when appendix is retrocecal, division of which structure can aid access to appendix?
Lateral peritoneal attachments of the caecum
This allows mobilisation of the caecum. It is also performed in right hemicolectomy
Compare dystrophic and metastatic calcification seen in breast cancer?
Metastatic calcification is calcification that occurs in otherwise normal tissues - usually as a result of hypercalcemia
Dystrophic calcification may be present in breast malignancy and is the basis for breast screening programme
Most of the gut us derived from endodermal tissue. What is the one structure that is derived from another tissue?
The spleen
It is derived from mesenchymal tissue
Which vertebral level does the inferior thyroid artery enter the thyroid gland?
C6
List the most effective surgeries for longterm weight loss, from most to least effective?
Biliopancreatic diversion +/- duodenal switch (most complex)
Roux en Y gastric bypass
Gastric banding
Which type of tumour appears pink and fleshy, rather than the usual yellow or brown?
Transitional cell carcinoma
Which nerve lies medially to the lobes of the thyroid, in the groove between oesophagus and trachea?
Recurrent laryngeal nerve
In which space is a lumbar puncture performed?
Subarachnoid space
Which nerve lies close to the brachial artery in the antecubital fossa?
Median nerve - it can be at risk of injury during brachial embolectomy
How should Barrett’s oesophagus with low grade dysplasia be monitored?
Surveillance is safest with quadratic biopsies (ie - 4 biopsies, one from each quarter of oesophagus) every 6 months
If disease remains static at 2 months then screening frequency may be decreased
Describe the metaplastic transformation seen in Barrett’s oesophagus?
Squamous oesophageal epithelium is transformed to columnar gastric epithelium
How should all ascending aortic aneurysms be managed?
Where is the most common site of dissection?
Aortic root replacement
There is no role for attempted suture repair
90% of dissections occur within 10cm of the aortic valve
In the extrinsic clotting pathway, which CF does the released tissue factor bind with initially?
Which clotting factor is subsequently activated as a result of this bond?
Tissue factor binds to CF 7
This complex then activates CF 9
CF 9 works with CF 8 to activate CF 10
What is the most severe form of spina bifida?
Myelomeningocele
Associated with neurological deficits
Spina bifida occulta is present in up to 10% of the population and involves skin and tissues - hair patch or birth mark
Compare the drainage of lymph from the tip of the tongue to the midportion of tongue?
Tip of tongue - submental –> deep cervical
Midportion - submandibular –> deep cervical
Lateral midportion drains ipsilaterally, medial midportion may drain bilaterally
Into which vein does the inferior mesenteric vein drain?
Splenic vein
Which structure lies posterolaterally to the external carotid?
Internal carotid artery
Following CBD exploration, what material should the T tube be made of? Why?
Latex T tube - the latex will elicit a fibrotic response
Drain should be on passive, not active
What vertebral level does the IMA leave the aorta?
L3
Aorta bifurcates into common iliacs at L4
What is Boas sign and with which condition is it classically associated?
Refers to hyperaesthesia of the tip of the right scapula
Seen in acute cholecystitis
Name the 3 muscles that make up the pes anserinus?
Sartorius
Gracilis
Semitendinosus
What ligament keeps head of radius connected to the radial notch?
Annular (orbicular) ligament
What is the most likely finding in FAP genetic syndrome?
Multiple colonic adenomas
When should children with uncomplicated umbilical hernias be considered for surgery?
After 3 years of age
They will usually close spontaneously in 1st year of life
Compared with paediatric femoral hernias, strangulation is rare
What is the action of carbimazole in hyperthyroid?
Inhibition of thyroid peroxidase enzyme
What type of drug is atropine? Name some of its side effects?
A muscarinic receptor antagonist, therefore inhibits parasympathetic activity
Increased HR, reduced secretions, urinary retention, dry mouth
Name the 4 features seen in Erb’s palsy?
Loss of:
- Forearm supination
- Elbow flexion
- Shoulder ABDuction
- Shoulder external rotation
Where is the only site in the body where an artery passes completely through a venous structure?
Why is this thought to happen?
In the cavernous sinus - the internal carotid artery passes completely through the sinus
Thought to occur to allow heat exchange between warm arterial blood and cold venous
How may infection spread intracranially from extracranially via the superior ophthalmic vein ?
The superior ophthalmic vein anastomoses with the facial vein
This can allow infection to spread intracranially from the facial vein and is most common cause of a cavernous sinus thrombosis
Which bone do the 2 cavernous sinuses sit within?
The sella turcica of the sphenoid bone
The pituitary sits medial to the sinuses
What cell type in addition to specialised intestinal metaplasia need to be present for a diagnosis of Barretts oesophagus to be made?
Goblet cell
Endoscopic features of goblet cell metaplasia and oesophageal glands gives a concrete diagnosis of Barrett’s
Compare the visual field defect caused by pituitary tumours and craniopharyngioma?
Both occur at the optic chiasm so will cause bitemporal hemianopia
Pituitary tumours will cause upper bitemporal hemianopia
Craniophayrngioma will cause lower bitemporal hemianopia
Compare effects of an injury to the ulnar nerve at the wrist, and damage at the elbow?
Damage at wrist = wasting and paralysis of intrinsic hand muscles (CLAW HAND), hypothenar muscles and loss of sensation of medial 1.5 fingers
Damage at elbow = radial deviation of wrist, clawing less in 4th and 5th digits
Within which subdivision of the anterior triangle of the neck does the common carotid bifurcate into the internal and external carotid? What vertebral level is this?
Bifurcates in the carotid triangle at the level of C4
Name the superior, inferior and lateral borders of the carotid triangle in the anterior triangle of the neck?
Superior - digastric muscle (posterior belly)
Inferior - omohyoid muscle (superior belly )
Lateral - sternocleidomastoid (medial border)
Name the 5 cranial nerves found in the anterior triangle of the neck?
CN 7, 9, 10, 11, 12
Facial
Glossopharyngeal
Vagus
Accessory
Hypoglossal
Also the ansa cervicalis
Name the 4 nerves present in the posterior triangle of the neck?
Accessory nerve
Phrenic nerve
Brachial plexus (all 3 trunks)
Cervical plexus branches (transverse cervical nerve, great auricular nerve, lesser occipital nerve, supraclavicular nerve)
Compare the blood vessels found in anterior and posterior triangles of the neck?
Anterior = carotids, internal jugular
Posterior = external jugular, subclavian artery
What is almost always the cause of secondary hyperparathyroidism?
Why does this cause hyperparathyroidism?
Chronic renal failure is main cause
Chronic renal failure causes low calcium as the kidneys have lost their ability to convert vit D to its active form, which impairs intestinal calcium absorption
Phosphate levels are high due to reduced renal excretion of phosphate
What is the main source of blood supply to the omentum?
Gastroepiploic artery
Via omental branches
Compare what the right and left gastroepiploic arteries are branches of?
Right gastroepiploic - gastroduodenal artery
Left gastroepiploic - splenic artery (coeliac axis)
Compare reversal agents of heparin and warfarin?
Heparin - protamine sulphate
Warfarin - vitamin K
What medication is contraindicated in broad complex tachycardia? why?
Verapamil is contraindicated
It may precipitate VF in patients with VT
Which structure does CSF flow from the 3rd to 4th ventricle?
Aqueduct of Sylvius
Which structure divides the posterior triangle of the neck into 2?
The inferior belly of omohyoid
The omohyoid travels in a superio-medial direction and divides the posterior triangle into occipital and subclavian triangles
Name the 4 structures that drain into the portal venous system, rather than into the systemic venous system?
Gallbladder
Pancreas
Spleen
Abdominal part of GIT
They transport nutrient rich blood from food to the liver for processing
Which 2 structures anastomose to form the portal vein?
At what vertebral level does this anastomosis occur?
Superior mesenteric vein
Splenic vein
At level of L2
Name the 4 veins that drain into the splenic vein?
Short gastric veins
Left gastro-omental veins
Pancreatic veins
INFERIOR mesenteric vein
Compare the drainage of the left and right gastro-omental veins?
Left gastro-omental - drains into splenic vein
Right gastro-omental - drains into superior mesenteric vein
Where does the coeliac plexus lie in relation to the aorta? At what vertebral level?
Lies anterior to aorta at T12-L1
Surrounds coeliac axis and SMA
What nerves supply the coeliac plexus?
Parasympathetic - vagus nerves
Sympathetic - superior and inferior splanchnic nerves
What is the drainage of the entire female urethra?
Internal iliac nodes
In comparison to males - posterior 1/2 drains to deep inguinal, anterior 1/2 drains to internal iliac
What is the synthetic alternative to somatostatin and is appropriate treatment for symptomatic carcinoid syndrome?
Octerotide
What tumour contains clonal proliferations of myofibroblasts? What autosomal dominant condition are they associated with?
Desmoid tumours
Associated with FAP
They should bi allelic APC mutations. Most commonly occurring in post partum women, treated with radical surgical resection, prone to recurrence
Why may some patients with aortic dissection have inferior ST elevation on ECG?
The right coronary artery may become involved in the dissection, causing a myocardial infarct
What vertebral level does the hyoid bone sit?
C3
Which vein empties into the femoral vein within the femoral triangle?
Great saphenous vein
(at the saphenofemoral junction)
The longest vein in the body and the largest (alongside vena cava)
What is the most common organism implicated in cholangitis infections?
E.Coli
In neonates, how does intestinal malrotation and volvulus present initially?
Bilious vomiting - it is always a surgical emergency and is intestinal malrotation and volvulus until proven otherwise
How should bilious vomiting in a neonate be managed?
- Upper GI contrast study
- If study inconclusive or shows malrotation, laparotomy is required
Which amino acid is present in all types of collagen?
Glycine
The small size of the glycine molecule enables collagen to form a tight helical structure
From which vessel does the thyrocervical trunk originate?
Subclavian artery
Which region of the male urethra is entirely surrounded by Buck’s fascia?
Spongiose part
From which cell type do giant cells most commonly originate?
Macrophages
In the parotid gland, which vein lies slightly more deep than the facial nerve?
Retromandibular vein
Formed from union of maxillary and superficial temporal vein
Which nerve conveys sensory innervation from the laryngeal mucosa?
Laryngeal branches of the vagus nerve
What is the arterial blood supply to the lacrimal apparatus? What is this a branch of?
Lacrimal artery
A branch of the Ophthalmic artery (which is a branch of internal carotid)
Which nerve supplies sensory innervation to the lacrimal gland?
What is this nerve a branch of?
Lacrimal nerve (branch of the ophthalmic nerve (V1), a branch of the trigeminal nerve)
In people with achalasia, what oesophageal cancer are they at increased risk of?
Squamous cell carcinoma
Usually late presentations with poor prognosis
As it exits the axilla, which muscle does the radial nerve pass under the inferior border of?
Teres major
Compare the source of bleeding that causes Grey Turner and Cullens sign?
Grey Turner = retroperitoneal haemorrhage (flank bruising)
Cullens sign = intraabdominal haemorrhage (umbilical bruising)
Which nerve is responsible for supplying taste to the ant 2/3 of tongue?
Facial nerve, via the chord tympani
Which 2 structures lie posterior to the mesh sited for an inguinal hernia repair ?
Peritoneum
Transversalis fascia
What type of renal stones are made more likely by chemotherapy? Why?
Uric acid stone
Chemotherapy and cell death increases uric acid levels
What is the appendicular artery a branch of?
The ileocolic artery
Appendicular artery supplies the appendix
Compare the most common adverse events to occur in PRC and FFP transfusion?
Packed red cells = pyrexia
Fresh frozen plasma = urticaria
In young children, what is the most appropriate surgical approach when performing laparotomy?
Transverse supra umbilical abdominal incision
Access via midline incisions is very poor and should not be used
Compare which structures of the pancreas are formed by the dorsal and ventral outgrowths?
Dorsal is the larger one - forms the anterior part of head, body and tail of pancreas
Ventral- forms the uncinate process and adjacent region of head
During embryloggical development of the pancreas, how can intestinal obstruction sometimes result?
As the ventral process of the pancreas rotates to fuse with the dorsal, sometimes an annular pancreas can result
The annular pancreas can result in intestinal obstruction
Which type of thyroid cancer may cause lymph node metastasis?
Papillary thyroid carcinoma
What is the most appropriate investigation in suspected lymphoma?
Excision biopsy of a complete lymph node
What is the vertebral level of the trans-pyloric plane?
L1
Sits halfway between suprasternal notch and pubic symphysis
Which traumatic brain injury often causes rupture of the middle meningeal artery?
Extra dural haematoma
Associated with a lucid interval
Which renal stone composition is associated with chronic UTIs?
Struvite - occur as a result of urease producing bacteria and are associated with chronic infections
Can show as a stag horn calculi
Which cranial foramen transmits the middle meningeal artery?
Foramen spinosum
Compare the tissue sampling objectives of core and punch biopsy?
Punch biopsy - gives histological diagnosis of unclear skin lesions
Core biopsy - gives diagnosis for tissue samples
ie - skin lesion, do punch biopsy, tissue lesion, do core biopsy
What is the most radio dense renal stone type on XR?
Which stone type is radiolucent?
Calcium phosphate
Uric acid stones are radiolucent
Compare the most common causes of cyanotic and acyanotic congenital heart disease?
Cyanotic = transposition of the great arteries
acyanotic = ventricular septal defect
What liver lesion is most likely to show as hyperechoic on USS and have a normal AFP?
Haemangioma - large hyper echoic lesion in presence of normal AFP
Where in the duodenum is the ampulla of Vater located?
Medial aspect of the 2nd part of the duodenum
In the adrenal medulla, what is released to stimulate adrenaline release?
Acetylcholine
Which structure does the long head of tricep arise from?
Infraglenoid tubercle
The lateral and medial heads arise from posterior aspect of humerus between teres minor and olecranon fossa
What vessel does the inferior epigastric artery arise from?
External iliac artery
It branches off external iliac artery immediately above inguinal ligament
Which nerve is at risk in a Holstein-Lewis fracture?
Radial nerve
It is a fracture of the distal humerus
Which type of tumour is associated with necrolytic migratory erythema, weight loss and diarrhoea?
Glucagonoma
Necrolytic migratory erythema is erythematous blisters with irregular border over buttocks and abdomen
Glucagonoma is a rare pancreatic tumour of alpha cells
What does the anatomical snuffbox contain?
Radial artery
The floor is made up of trapezium and scaphoid
Which nerve is at risk in anatomical neck of humerus fracture?
Axillary nerve
Radial nerve is at risk in humeral mid shaft/surgical neck fractures
What is the hormonal antagonist to insulin?
Glucagon
Glucagon results in increased plasma glucose level
What is glucagon released in response to?
Hypoglycemia and raised amino acids
Where does the ulnar artery sit in relation to the ulnar nerve at the wrist?
Ulnar artery sits lateral to ulnar nerve at the wrist
Ulnar artery lies on brachialis and flexor digitorum profundus
What separates the median nerve from median artery in the forearm?
The ulnar head of the pronator teres
Which nerve is most likely to be injured if damage occurs at the medial epicondyle?
Ulnar nerve
Remember the ulnar paradox - more proximal lesions will not cause the classical claw hand appearance
Which vessel is at greatest risk in a fracture to medial third of clavicle?
Subclavian vein
It sits behind medial part of the clavicle, resting on 1st rib. It sits more medially than the subclavian artery
What is the investigation of choice for Hirschsprung’s disease?
How is it treated definitively?
Full thickness suction rectal biopsies
Hirschsprung’s disease is likely if newborn has not passed meconium in 72 hours and has a soft non tender abdomen
Managed with washouts initially and then definitive surgery between 9-12 months
Describe the effect somatostatin has on pancreas excorine secretions, insulin and GH?
Somatostatin reduces exocrine pancreas secretions, reduces insulin and GH secretion
Octerotide is synthetic somatostatin - can be used if high output pancreatic fistula
On histology, which lesion has a biphasic appearance with mixed stromal and epithelial elements?
Pleomorphic adenoma
It is benign and unlikely to extend into the facial nerve
Which structure lies deepest in the popliteal fossa?
Popliteal artery
What is the name of a distal radius fracture with associated radoiocarpal dislocation?
Barton’s fracture
Fall onto extended and pronated wrist
Involvement of joint is a defining feature
Which condition often has asteroid bodies found on histology?
Sarcoid
The asteroid bodies found in the granulomas are rarely associated with necrosis, unlike TB
What is the most common childhood brain tumour?
Astrocytoma
What side affect can cause tetany in a patient following thyroidectomy?
Hypoparathyroidism
Patients can present with hypocalemic tetany (muscle spasm) and oculogyric crises
Tx - IV calcium
Which is the only muscle of the foot innervated by the common peroneal nerve?
Extensor digitorum brevis
The rest are innervated by tibial nerve
How does biliary atresia most commonly present?
Most commonly presents with prolonged conjugated jaundice in the neonatal period
Kasai procedure best carried out in first 8 weeks of life
How is the damage seen in neuropraxia different from damage seen in axonotmesis and neurotmesis?
In neuropraxia, the nerve is in tact structurally, but electrical conduction is affected
In axonotmesis, the axon is damaged but myelin sheath preserved
In neurotmesis, axon, myelin sheath and connective tissue is damaged
What is an acute haemolytic transfusion reaction most often due to?
What test can be done to confirm this?
ABO incompatibility
Do a direct Coomb’s test
Haemolysis of the transfused cells occurs, which can be confirmed by a Coomb’s test
Coomb’s tests for antibodies against the RBCs which induce haemolysis
What is the external aspect of the tympanic membrane lined by? Why is this clinically significant?
External tympanic membrane = Stratified squamous epithelium
Clinically significant in development of middle ear infections - it may migrate into middle ear
Closure of which 2 valves results in the 1st heart sound?
Mitral and tricuspid valves
All valves have 2 anterior cusps, other than mitral valve, which only has one
Closure of which 2 valves results in 2nd heart sound?
Aortic valve and pulmonary valve
Neither of them have any chordae attached to them
Mitral and tricuspid valve are both attached to chordae tendinae
Which coag blood test most accurately tests the vit K dependant clotting factors?
PT time - tests vit K dependant factors 2, 7, 9, 10
It is useful pre op for any biliary or hepatic cases
Which nerve forms the lower trunk of the brachial plexus and is therefore most commonly affected by a crutch palsy?
Radial nerve
Crutch palsy can cause radial nerve injury and result in a wrist drop
Ulnar nerve arises from medial cord so is rarely affected
Describe the pathology in achalasia?
Progressive degeneration of the ganglion cells in myenteric plexus in the oesophageal wall
This leads to failure of relaxation of LES and loss of peristalsis in distal oesophagus
No stricture, but failure of muscle relaxation
What is the number one cause of painless massive GGI bleeding requring transfusion in children between 1-2 years?
Meckels diverticulum
Describe how leptin and ghrelin affect appetite?
Ghrelin increases appetite
Leptin reduces appetite
Compare how risk can be described in type 1 and type 2 statistical errors?
Type 1 error = P value
Type 2 error = power calculation
Why should the infra hyoid strap muscles be divided in their upper half rather than their lower half?
The nerve supply from the ansa cervicalis enters in their lower half
Name the 4 strap muscles and the mnemonic used to remember them?
TOSS
Thyrohyoid
Omohyoid
Sterohyoid
Sternothyroid
Each one is innervated by a branch of the ansa cervicalis
What is the first branch of the axillary artery?
Superior thoracic artery
Name the mnemonic and branches of the axillary artery?
Screw The Lawyer Save A Patient
Superior thoracic artery
Thoraco-acromial artery
Lateral thoracic artery
Subscapular artery
Anterior circumflex humeral artery
Posterior circumflex humeral artery
Name the first 2 components of FBC to be raised on splenectomy?
Granulocyte count raised first, mainly neutrophils
Then reticulocyte count is raised
What is the active form of vit K called?
Hydroquinone is the active form of vit K
It is inhibited by warfarin, which prevents formation of CFs 2, 7, 9, 10 and protein C
What does the sigmoid sinus drain into?
The internal jugular vein
(sigmoid sinus joins with inferior petrosal sinus to drain into IJV)
What does the sigmoid sinus drain from?
The transverse sinus
Which nerve innervates the Abductor pollicus longus, Extensor pollicus brevis and supinator ?
Posterior interosseous branch of the radial nerve
The post interosseous branch of radial nerve innervates all extensors as well as abductor pollicis longus
“BEST” - biceps, extensors, supinators, triceps
Compare the innervation of the long and short head of the biceps femoris muscle?
What is the blood supply to both?
Long head - Tibial division of the sciatic nerve
Short head - Common peroneal division of sciatic nerve
Arterial supply - profouna femoris artery
What muscle divides the sciatic foramen into the suprapiriform and infrapiriform foramina?
Piriformis muscle
Name the contents of the suprapiriform foramen?
Superior gluteal artery and vein
Superior gluteal nerve
Name the contents (6) of the infrapiriform foramen?
Sciatic nerve
Pudendal nerve
Inferior gluteal artery and vein
Inferior gluteal nerve
Posterior femoral cutaneous nerve
Name components of lesser sciatic foramen?
Pudendal nerve
internal pudendal artery and vein
Nerve and tendon to obturator internus
Which condition causes an isolated rise in APTT on blood test?
Lupus anticoagulant
Manifests as an isolated rise in APTT - is prothrombotic and a risk factor for arterial and venous thrombosis
Within the femoral triangle, what is the function of the femoral canal?
What structure lies lateral to it?
The femoral canal provides dead space to allow distension of the adjacent femoral vein (for increased venous return or raised intra-abdominal pressure
The femoral vein forms the lateral border
lacunar ligament forms the medial border of femoral canal
What must be present for it to be classed as carcinoid syndrome, rather than just a carcinoid tumour?
Liver mets must be present for it to be classed as carcinoid syndrome
Carcinoid tumours secrete serotonin and usually originate in neuroendocrine cells in the distal ileum/appendix
In well children without localising signs, how should intussusception be managed?
Pneumatic reduction under fluoroscopic guidance
If there is concerns re impending perforation or unstable with localising signs, they should undergo laparotomy
Which organism most commonly affects structurally abnormal heart valves?
Strep viridians
(ie - rheumatic fever)
Which primary site is most likely to cause hyper vascular secondary mets?
Renal cell cancer
What is the most important structure in providing support to the duodenojejunal flexure?
Ligament of Treitz
It is the suspensory muscle of the duodenum
Attaches onto right crus of diaphragm
Which 2 cords of the brachia plexus combine to form the median nerve?
Lateral (C5,6,7) and medial (C8 and T1) cords of the brachial plexus
Compare the vertebral levels the the hilums of the right and left kidney sit at?
What muscle do the kidneys sit anterior to?
Left kidney hilum = L1
Right kidney hilum = L1-2
Sit on the anterior surface of psoas major
What medication can be given in cases of protracted colonic pseudo-obstruction?
How does it act?
Neostigmine
It affects degradation of acetylcholine so will stimulate both nicotinic and muscarinic receptors
It rapidly produces generalised colonic contractions
Which type of breast cancer shows pronounced lymphocytic infiltrate on histology??
Medullary breast cancer
It has a good prognosis
Definition and calculation for sensitivity?
Sensitivity = proportion of patients with condition that have a positive test result
TP/TP + FN
Definition and calculation for specificity
Specificity = proportion of patients without the condition that have a negative test result
TN/TN+FP
Is shunting in Tetralogy of Fallot Left to right or Right to Left?
Right to left shunting
Other features:
- Right ventricular hypertrophy
- Right ventricular outflow tract obstruction, pulmonary stenosis
- Overriding aorta
- VSD
Name the most common cause of cyanotic congenital heart disease at birth and at 1-2 months?
Birth - transposition of the great vessels
1-2 months - tetraology of fallot (it is the most common cause of cyanotic heart disease overall)
Which AD condition is associated with numerous hamartomas and pigmented freckles on lips, face, palms and soles?
Peutz Jeghers syndrome
Hamartomas are in the GI tract and 50% of patients will have died from a GI tract cancer by age 60
Which vessel is responsible for blood supply to a Meckels Diverticulum?
Vitelline artery
Usually derived from ileal arcades
Meckels diverticulum arises due to incomplete obliteration of the vitello-intestinal duct
If a patient can’t sing high notes following a thyroid lobectomy, which muscle has been damaged?
What is it innervated by?
Cricothyroid
Innervated by the superior laryngeal nerve
Name the 4 cranial nerves that carry parasympathetic fibres?
1973
III - occulomotor
VII - facial
IX - glossopharyngeal
X - vagus
Where are the reticulo-endothelial cells concentrated within the spleen?
Within the red pulp
Reticulo-endothelial cells are responsible for the immune function, clearance of old/damaged RBCs and recycling of iron
Which artery is responsible for bleeding at the posterior duodenal wall?
What is this artery a branch of?
Proximal duodenum and pylorus supplied by the gastroduodenal artery
This is supplied by common hepatic artery
Compare how rectal and sigmoid cancer is staged?
Sigmoid cancer = CT CAP
Rectal cancer = MRI rectum and CT CAP
What is the dominant necrosis pattern in the CNS?
Colliquative necrosis
Occurs in tissues with no supporting stroma
Necrotic site may eventually become encysted
Administration of which dye can facilitate identification of parathyroid glands intraoperativley?
Methylene blue IV
Which hernia occurs lateral to rectus muscle at level of arcuate line?
Spegelian hernia
Occurs at level of arcuate line
Richters hernia - part of the small bowel wall (usually anti-mesenteric border) strangulated in hernia
Which hernia type do not present with bowel obstruction as intestinal patency is preserved?
Richter’s hernia
Hernia of the small bowel wall, usually the anti mesenteric border
If pateint vomiting may be due to peritonitis secondary to perforation
How should suspected lobular carcinoma in situ be investigated? Why?
MRI - it is more diffuse and less focal than DCIS, so can often be missed on WLE.
It is also often associated with microcalcifications, which can be picked up on MRI
Has a less invasive profile than DCIS so is often managed with close monitoring
Which thyroid lesion is associated with intense lymphocytic infiltrate?
Hashimoto’s thyroiditis
Dense lymphatic type tissue only is seen in lymphoma
Compare where the dura and the spinal cord terminates?
Dura terminates at S2
Spinal cord terminates at L1
Which kidney hilum sits at the level of the transpyloric plane at L1?
Left Kidney hilum (L1 = Left 1!)
What is the first structure encountered during a lumbar puncture?
Name the 2 structures that are then passed through, which may both cause a “give”?
Supraspinous ligament first
Ligamentum flavum (give 1)
Dura mater (give 2)
(then into subarachnoid space)
Describe the relationship of the subclavian artery and vein with respect to the scalenus anterior?
The subclavian vein sits anterior to the scalenus anterior
The subclavian artery sits posterior to the scalenus anterior (but anterior to the middle scalene muscles)
What condition in a women with a NOF# causes hypocalcemia and hypophosphatemia and raised ALP?
Osteomalacia
Known as soft bone disease due to lack of vit D, calcium or phosphate
How should proximal SCC of the oesophagus with no metastatic disease be managed?
Compare this with distal oesophageal SCC management?
Combined radical chemotherapy and radiotherapy - no need for segmental resection
Localised SCCs are responsive to chemoradiotherapy
If malignancy was in distal oesophagus –> Ivor Lewis oesophagectomy
What is most likely to be seen on histology of a carotid body tumour?
Paraganglioma
Carotid bodies are commonest head and neck paraganglioma
Where do all tenia coli converge?
The base of the appendix
Compare the venous drainage of the superior, middle and inferior thyroid veins?
Superior and middle thyroid veins drain into internal jugular vein
Inferior thyroid vein drains into brachiocephalic vein
Where is a paneth cell most likely to be identified?
Crypt of Lieberkuhn
What is the most common vascular abnormality seen in dysphagia lusoria?
An aberrant right subclavian artery arising from the left side of the aortic arch
This causes compression of the oesophagus and is best imaged with CT angiogram
Which nerve conveys sensation from the external ear?
Auriculotemporal nerve
A branch of V2 (mandibular branch of trigeminal nerve)
Which pair of cranial nerves most likely to be compressed by a tumour of cerebellopontine angle?
Facial and vestibulococchear nerve
Commonest lesion to affect the angle is an acousitc neuroma
Name the 4 muscles that attach on to the greater trochanter?
POGO
Piriformis
Orbturator Externus
Gemilli
Orbturator internus
Glut medius attaches to lateral greater trochanter
Glut minimis attaches to anterior greater trochanter
Which area of the larynx has no lymphatic drainage?
Glottic
The vocal cords have no lymphatic drainage so the area serves as lymphatic watershed
Which type of cell secretes the majority of tumour necrosis factor?
Macrophages
Damage to which 2 nerves can result in hyperacousia?
Facial nerve or Trigeminal nerve
Damage to facial nerve will result in impaired innervation to stapedius so sounds are no longer dampened
Increased activity in the tensor tympani muscle can cause hyperacusis. - innervated by trigeminal nerve
What is the main reason for hypoxaemia in ARDS?
Reduced diffusion
Diffuse lung injury associated with loss of surfactant and increased elastase release from neutrophils results in fluid accumulation, which leads to reduced diffusion
What is always offered to pateints with colonic cancer when they have nodal disease following resection?
Chemotherapy
Why is an acute mesenteric infarct more likely in the SMA than the IMA?
SMA has wider diameter and originates at a sharper angle off the aorta
SMA has fewer collaterals than IMA so cant cope with occlusions as well
SMA has a much greater demand for blood than IMA due to the portion it supplies
What is the anion gap if excess IV NaCl is given to patient?
What is the acid base disturbance?
Normal anion gap
Hyperchloremic acidosis
What is the agent of choice for regional anaesthesia?
Why?
Prilocaine
It is much less cardiotoxic
