Physiology Flashcards
Name 3 factors that stimulate the release of renin?
Reduced sodium in the distal convoluted tubule detected by macula densa
reduced renal perfusion pressure
Sympathetic innervation of JGA by B1 adrenoceptors
What inhibits the release of renin?
Atrial Natriuretic Peptide (ANP)
What is the most significant event to contribute to wound healing following injury?
Platelet degranulation
It is the earliest phase and results in haemostasis
What is the mechanism of action of corticosteroids?
Bind to intracellular receptors that travel to nucleus to affect gene transcription
Compare LCIS to DCIS?
DCIS more common and more likely to be invasive malignancy and need early intervention
LCIS more likely to be multifocal and metastasise to contralateral breast. Investigate with MRI breast first
What do secretin and cholecystokinin secrete into pancreatic juice from the pancreas?
Secretin - water and electrolytes
Cholecystokinin - enzymes
Commonest cause of blood stained nipple discharge in young women?
intraductal papilloma
What is Waterhouse- Friderichsen syndrome?
What is it most often caused by?
Adrenal gland failure due to bleeding into the adrenal glands
Caused by severe bacterial infection, most commonly meningococcus neisseria meningitidis
Which pancreatic cells release insulin?
Beta cells in the islets of langerhan release insulin
Beta cells are the most common types of cell found in the islet of langerhan
Compare the cell types in the islet of langerhan that produce glucagon, somatostatin and pancreatic polypeptide?
Glucagon - Alpha cells
Somatostatin - delta cells
F cells - pancreatic polypeptide
Which immunoglobulin involved in autoimmune conditions ?
IgG
Compare if fractures of the distal radius are volar or dorsally displaced in Smith’s or Colle’s fractures?
Colle’s - dorsal displacement of fracture
Smith’s - volar displacement of fracture
What caecal diameter in an obstructed patient is a sign of impending perforation and indication for prompt surgery?
Caecal diameter of >12cm
Also in the presence of caecal tenderness
If lesion causing large bowel obstruction lies in splenic flexure or transverse colon, which surgery should be carried out?
Extended right hemicolectomy with ileocolic anastomosis
Which surgical procedure is most likely to be carried out in rectal cancer or for distal sigmoid lesions?
High anterior resection +/- loop colostomy
In post menopausal women, what process accounts for most oestrogen production?
Aromatisation
Therefore, aromatase inhibitors (letrozole, anastrozole) are the preferred agents to treat breast cancer in this group
Which type of organisms in particular increase the risk of post splenectomy sepsis?
Encapsulated organisms
E.Coli, Strep Pneumoniae, salmonella, Klebsiella, H.Influenza
How should lesions suspicious of melanoma be treated?
Excision biopsy
Avoid incisional or punch biopsy of lesions suspected to be melanoma
Name 2 contraindications for using cell saver devices during surgery?
Infection and malignancy
In an incidental finding of an adrenal lesion, what is the most appropriate first line investigation?
Hormonal assay
If lesion is >4cm, it should usually be excised
Which type of oesophageal cancer is most associated with hx of Barrett’s oesophagus and short history of dysphagia?
Adenocarcinoma
SCC usually has longer, more progressive history of dysphagia
What thyroid neoplasm is responsible for a mass with oxyphil cells and scanty thyroid colloid?
Follicular carcinoma
Which thyroid cancer is a tumour of the parafollicular C cells?
Serum levels of what are often raised?
Medullary carcinoma
Serum calcitonin levels often raised
Following resection, what additional treatment is offered to patients with colorectal cancer and nodal mets?
Chemotherapy
What is TUR syndrome?
Trans urethral resection syndrome - occurs when irrigation fluid enters systemic circulation
What triad of features are seen in TUR syndrome?
Hyponatremia - dilutional
Fluid overload
Glycine toxicity
How is TUR (trans urethral resection) syndrome managed?
Fluid restriction and treatment of complications associated with hyponatremia
What is the difference between isograft and allograft?
Isograft - transplant between 2 individuals who are genetically identical
Allograft - transplant between 2 individuals from the same species, not genetically identical
What is an autograft?
Transplant of organ/tissue from one part of the body to another in the same individual
Which is the only type of diathermy to not have the risk of causing damage to end vessels?
Bipolar units
The electric current flows from one electrode to the other so heating is localised to area between two electrodes and surrounding tissue damage minimised
What is the best surgical strategy for avoidance of complete abdominal wound dehiscence?
Mass closure of midline wound is preferred
Known as Jenkins rule
How should lesions suspicious for malignant melanoma be biopsied ?
Excision biopsy always
incision biopsy can make subsequent histopathological assessment difficult
What margin should be excised in a suspicious lesion with breslow thickness of:
a) 2-4mm thick
b) >4mm thick
a) 2-4mm thick needs 2-3 cm margins
b) >4mm thick needs 3cm margins
Where is calcium mainly absorbed?
Which procedure will have greatest impact on patients calcium metabolism?
Absorbed in small bowel
Small bowel resection will have biggest impact on calcium absorption
What is more sensitive and specific than amylase when investigating for pancreatitis?
Serum lipase
When should a total duct excision (hadfields procedure) be performed rather than a microdochectomy?
In duct ectasia with severe symptoms, a total duct excision may be warranted
How should a failed colonoscopy be managed in the first instance?
CT Colonography
Which cell type to gliomas arise from?
Neuroglial cells
How is most splenic trauma managed?
Most managed conservatively
Hilar injuries (grade IV) tend to require surgery
What is the difference between weber A, B and C ankle fractures?
Where the fracture is in relation to the syndesmosis
A - below syndesmosis - stable
B- in line with syndesmosis - variable
C - above syndesmosis - unstable
Describe the Bainbridge reflex?
The increase in heart rate mediated by atrial stretch receptors following a rapid infusion of blood
What system is very good for managing splenic bleeding?
Argon plasma coagulation system
Name the Ig involved in hyperacute organ transplant reactions?
Hyperacute - IgG class I antibodies in the recipient
Acute - IgA
Which type of breast cancer often occurs in pregnancy or lactation?
Inflammatory carcinoma
When is mastectomy favoured over WLE in DCIS?
If DCIS is >4cm, mastectomy is generally preferred
Although ultimately depends on size of breast
How should DALM lesions complicating ulcerative colitis be managed?
Panprocolectomy
Refers to dysplasia associated lesion or mass.
They have a high incidence of invasive foci
Which 2 clotting factors are most sensitive to temperature?
Factors V and VIII
This is the reason FFP is frozen so soon after collection
Which blood product is a rich source of Factor VIII and fibrinogen?
Cryoprecipitate
Which nerve can be damaged in post triangle LN biopsy?
Accessory nerve
What should be given first line in acute adrenal insufficiency?
Hydrocortisone 100mg IV
What artery supplies the greater curvature and lesser curvature of the stomach?
Greater curvature = Gastroepiploic artery (branch of gastroduodenal artery)
Lesser curvature = left gastric and right gastric branch of hepatic artery
Compare the most common cause of hypercalcemia in hospitalised patients and those in the community in the UK?
Hospital - metastatic malignancy
Community - primary hyperparathyroidism
What is the site of action of furosemide?
The ascending loop of Henle
Works to reduce the absorption of NaCl
What is considered the gold standard imaging for the detection of renal scarring?
DSMA scan
Which rare cutaneous tumour causes lymphovascualr invasion and is associated with visceral mets?
Merkel tumour
Rare but aggressive, purple lesion on sun exposed skin of elderly
Surgical excision 1st line
What disease are Reed Steenberg cells characteristically found in?
Hodgkins Lymphoma
Which heparin regime do vascular surgeons request prior to cross clamping to help prevent further intra arterial thromboses?
3,000 units of systemic heparin, 3-5 mins prior to cross clamping
Giving heparin at induction will cause bleeding during routine dissection
Describe the mechanism of action of heparin?
It prevents binding between antithrombin and thrombin and factor Xa
This prevents the conversion of fibrinogen to fibrin
Why is unfractionated heparin preferred in surgical patients over LMWH?
Unfractionated heparin has a shorter duration of action and is easier to reverse
Compare the origin of neuroblastoma and nephroblastoma in kids?
Which is more associated with hypertension?
Neuroblastoma - origin in adrenal gland
Nephroblastoma - origin in kidney
Nephroblastoma more associated with hypertension
How are neuro and nephroblastomas treated in kids?
Neuroblastoma - Surg resection, radiotherapy and chemotherapy
Nephroblastoma - surg resection and chemotherapy
How is unfractionated heparin reversed?
Protamine sulphate
Compare treatment for haemorrhoids and fissure
Haemorrhoids - rubber band ligation
Fissure - topical GTN +/- surgery
Haemorrhoids painless bleeding, fissure painful
Which corticosteroid does not interfere with lab analysis of serum cortisol?
Dexamethasone
it can be given as glucocorticoid replacement during testing for Addisons as it does not interfere with cortisol levels
Which part of the adrenal gland releases cortisol?
Zona fasciculata
What medication is administered in most cases of subarachnoid haemorrhage?
How does it work?
Nimodipine
Its a calcium channel blocker that reduces cerebral vasospasm and improves outcomes
When is the oxygen dissociation curve shifted to the Right?
Raised oxygen delivery to tissues is required
How does DPG work in terms of oxygen dissociation?
It binds to Hb molecule and releases O2 to tissues
Released from erythrocytes during glycolysis
In which conditions is 2,3 DPG increased?
Conditions associated with poor oxygen delivery to tissues
More 2, 3 DPG facilitates oxygen delivery to tissues
Chronic anemia causes increased 2,3,DPG
Compare how the Bohr and HaLdane effects affect O2 delivery to tissues?
HaLdane - shifts O2 curve to Left. Less O2 delivered to tissue (ie - increased saturation of Hb with O2)
Bohr - shifts O2 curve to Right. Raised O2 delivery to tissues. (ie- reduced saturation of Hb with O2)
What acid base disturbance does diarrhoea/high output stoma case?
Metabolic acidosis
Patients may compensate by hyperventilating
What Kidney stone composition causes a stag horn calculs?
Struvite
Seen in chronic infection with urease producing enzymes
What is the most common cause high output diarrhoea following terminal ileal resection?
How is this treated?
Malabsorption of bile salts
Treat with oral cholestyramine (a bile salt binding agent)
Which channels does lignocaine block?
Neuronal sodium channels
Which clotting factors are affected by heparin?
CFs 2, 9, 10, 11
Which clotting factors are affected by warfarin ?
CFs 2, 7, 9, 10
Warfarin is a vit K antagonist.
Vit K works to regulate production of CFs 2,7,9,10. If it is antagonised, less of these CFs will be produced
Name the medial and lateral walls of the femoral canal?
Medial wall = lacunar ligament
Lateral wall = femoral vein
DON’T mistake femoral canal for femoral triangle!
Which cell secretes the majority of tumour necrosis factor in humans?
Macrophages
Which skin condition is associated with crohn’s disease?
Pyoderma Gangrenosum
What imaging technique is used to investigate failing renal transplants?
MAG 3 renogram
It is the investigation of choice for imaging in patients with existing renal impairment
Which type of polyp has the greatest risk of malignant transformation?
Villous adenoma
Patients with hamartomatous polyp syndromes may have an increased risk of malignancy, but the polyps themself carry little risk
Which type of oesophageal cancer is most common in a patient with a history of GORD?
Adenocarcinoma
Squamous cell carcinoma usually doesn’t have as strong a history
In patients requiring long term ventilation, what is the best option to maintain airway?
Tracheostomy
Name 3 nerves at risk during excision of branchial cyst?
Mandibular branch of facial nerve
Greater Auricular nerve
Accessory nerve
Where in the intestine is iron best absorbed?
Duodenum and jejunum (proximal small bowel)
What is the difference between a CT with contrast and a CT without contrast?
Contrast enhances the visibility of blood vessels and soft tissues so essential in suspected neoplasms or to show inflammation
Non contrast CTs used for evaluating bone structures and acute haemorrhage
Which primary cancer site is most likely to cause hyper vascular secondary spread to bones?
Renal cell cancer
Which muscle relaxant induces neuromuscular excitability?
Suxamethonium
It may induce muscular contractions following administration, which can raise potassium
What do neutrophils produce as a microbicidal agent?
Hydrogen peroxide
What is a histological diagnostic feature of acute inflammation?
Presence of neutrophil polymorphs
Compare the urinary and serum diagnostic marker for carcinoid syndrome?
Urinary marker - 5-Hydroxyindoleacetic acid (5-HIAA)
Serum marker - Chromogranin A
What is secreted in carcinoid syndrome? Where does the syndrome typically originate?
Serotonin
Originates in neuroendocrine cells mainly in intestine
How is carcinoid syndrome treated?
Octerotide
or
Surgical removal
Which type of septicaemia is associated with carcinoma of the colon?
Streptococcus Bovis (a gram positive)
Deficiency of which electrolyte can cause hypocalcemia?
Magnesium - it is require for PTH secretion and action on target cells
Hypomagnesaemia can cause hypocalcemia
Which clotting factors will Disseminated Intravascular Coagulation consume quickest initially?
Factor V and VIII (and platelets) initially
DIC cause simultaneous coagulation and haemorrhage which ultimately leads to bleeding
Why do diverticulum almost never occur in the rectum?
The rectum has a longitudinal muscle coat
Compare the location and rate of progression of small cell and squamous lung cancers?
Small cell - located centrally, rapid rate of progression and dissemination. Typically arise in larger airways
Squamous cell carcinoma - located centrally, more slow growing
Which cell is most commonly encountered in acute inflammation?
Neutrophil polymorphs
Compare urinary tests for phaeochromocytoma and carcinoid syndrome ?
Phaeochromocytoma - urinary metanephrines
Carcinoid syndrome - Urinary 5-hydroxyindoleacetic acid (5-HIAA)
Name 4 causes of a raised anion gap metabolic acidosis?
- lactate (shock, hypoxia)
- ketones (DKA)
- urate (renal failure)
- acid poisoning (methanol, salicylates)
Name 4 causes of a normal anion gap acidosis?
- GI bicarb loss (diarrhoea)
- renal tubular acidosis
- addison’s disease
- drugs (acelazolamide)
Name 3 most common organisms causing post splenectomy sepsis?
Strep pneumoniae
H. Influenzae
Meningococci
Which tumour marker is elevated in colonic cancer?
Carcinoembryonic antigen (CEA)
What is the most common and important viral infection seen in solid organ transplant recipients? How is it treated?
Cytomegalovirus
Vague symptoms, treatment with IV ganciclovir
What is the normal range for anion gap?
10-18mmol/l
Compare the surgical management for gastric cancers if it is <5cm or >5cm from the OG junction?
<5cm from OG junction = total gastrectomy
> 5cm (to 10cm) from OG junction= subtotal gastrectomy
What is the name of the procedure used to treat paediatric intestinal malrotaiton with volvulus?
Ladds procedure
What proportion of calcium filtered at the glomerulus is reabsorbed by the renal tubules?
95%
Which local anaesthetic agent is most likely to induce adrenal suppression?
Etomidate
It also has a pretty favourable cardiac profile
What one characteristic differentiates invasive malignancy from in situ disease?
Invasion of the basement membrane
Which hepatitis is most commonly picked up by travellers (ie - infective hepatitis)?
Hepatitis A
Name the triad of symptoms in Lariche Syndrome?
- Impotence
- Atrophy of buttock and leg muscles
- Claudication of buttocks and thighs
It is atherosclerotic occlusive disease involving the abdominal aorta +/- iliac arteries
Which condition typically presents with abdominal and neuropsychiatric symptoms?
Acute Intermittent Porphyria
Often present with motor neuropathy, abdominal pain and depression
What is raised in acute intermittent porphyrias?
Urinary porphobilinogen
Compare the mediators involved in type I, II, III, IV hypersensitivity reactions?
A - allergic/anaphylactic - IgE
C - cytotoxic- IgM, IgG
I- immune mediated - IgG, IgM, IgA
D - delayed - T cell mediated
Compare the reticulocyte count in sickle cell anaemia and transient aplastic crises due to parvovirus ?
Sickle cell anaemia = reticulocytosis (elevated retic count)
Transient aplastic crisis = reticulocytopenia (reduced retic count)
Describe the systemic vascular resistance in sepsis?
SVR is reduced in sepsis
What is the name of a hernia containing Meckels Diverticulum?
Littres hernia
Why is carbon monoxide used to calculate the transfer factor of the lungs?
Hb binds more strongly to CO than O2 or CO2
Therefore, the difference in the amount breathed in and the amount breathed out gives a maximum diffusion value
How does area of septum and thickness affect the volume of diffusion in the lung?
Vol of distribution = area/thickness
Area increases, vol of distribution increases
Thickness increases, vol of distribution decreases
How does pul haemorrhage affect TLCO?
Why?
Pulmonary haemorrhage causes raised TLCO.
Blood in the airways recruits CO
How does asthma affect TLCO?
Why?
Asthma causes raised TLCO
Bronchoconstriction means less air is expelled from airways and there is increased vascular recruitment around the alveoli
This increases transfer factor
Which aspect of wound healing is defective in diabetics?
Neutrophil recruitment into the wound
If a mottled limb with suspected limb ischemia blanches on pressure, is that an earlier or later sign than if it doesn’t blanch on pressure?
If mottled limb blanches on pressure, it is an earlier sign than if the limb does not blanch on pressure
No blanching suggests it has been ischemic for 12-24 hours and requires amputation
What is the treatment of choice for renal pelvis stones greater than 20mm?
Percutaneous Nephrolithotomy
Stones >20mm unlikely to pass spontaneously
Compare how renal stones 10-20mm and >20mm are treated?
10-20mm - shockwave lithotripsy
> 20mm - Percutaneous Nephrolithotomy
What is the primary event that results in AAA?
The loss of the intima with loss of elastic fibres from the tunica media
What is one of the most common causes of colovesical fistulas?
Diverticular disease
Fibroadenomas of the breast that have a diameter greater than what should be biopsied?
Diameter greater than 4mm
Via a core biopsy
What is the name given to the condition associated with chlamydia that causes pelvic inflammatory disease and perihepatic inflammation and adhesion formation?
How is it managed?
Fitz-Hugh Curtis syndrome
Managed medically - doxycycline or azithromycin
Describe the difference between Buckle and Greenstick fractures?
Greenstick fracture causes unilateral cortical disruption and haematoma
Buckle fracture shows periosteal haematoma formation only
Which component of the FBC is first to be affected following a splenectomy?
Reticulocyte and granulocyte count increase first
Then, reticulocyte count raises
What is the most common type of breast cancer in the older, postmenopausal women?
Invasive ductal carcinoma
What is the most common location to find an Ewing’s sarcoma?
Femoral Diaphysis
A sarcoma found in this location is more likely to be Ewing’s sarcoma than an osteosarcoma
Name 4 contraindications to lung cancer surgery?
FEV<1.5l
Vocal chord paralysis
SVC obstruction
Malignant pleural effusion
Describe the clinical picture seen in Brown-Sequard syndrome?
Ipsilateral paralysis, loss of proprioception and fine touch (DCML pathway)
Contralateral loss of pain and temperature sensation (spinothalamic tract)
In Brown Sequard syndrome, why is the loss of pain and temperature sensation contralateral to injured area?
The spinothalamic tract decussates at a level below the cord transection
Which thyroid cancer is associated with psammoma bodies? What are these comprised of?
Papillary thyroid cancer
Psammoma bodies made up of clusters of microcalcification
How should patients with metastatic bone disease secondary to prostate cancer be treated? (3 components)
Androgen suppression
Radiotherapy
Biphosphonates
What is the first line treatment for anal cancer ?
Radical chemoradiotherapy
What affect does adrenaline have on renin secretion?
It stimulates its release from the juxtaglomerular cells
Should chemotherapy be given for renal cell adenocarcinoma?
No - chemotherapy is not effective in patients with renal adenocarcinoma
Compare surgical options for T1 and T2 lesions in RCC? Is adjuvant therapy used?
T1 lesions - partial nephrectomy
T2 lesions - radical nephrectomy
There is no benefit to adjacent therapy in patients with completely resected disease
Is erection and ejaculation parasympathetic or sympathetic innervation?
Erection = parasympathetic
Ejaculation = sympathetic
“P is for Points, S is for Shoots”
Compare the arteriovenous structures affected by Klippel-Trenaunay syndrome and Sturge-weber syndrome?
Sturge Weber- affects face and CNS
Klippel-Trenaunay - affects a single extremity (leg most common site, usually affects blood and lymph vessels)
What is the name of an AV ulcer that has grown in size and become a squamous cell carcinoma?
Marjolin’s ulcer
Occur at site of chronic inflammation or prev injury
Compare the bone fractured and the site of dislocation in Monteggia and Galezzi fractures ?
Monteggia - Ulnar # with proximal radioulnar joint dislocation
Galezzi - Radial shaft # with distal radioulnar joint dislocation
What is aspirated from a joint in pseudogout?
Calcium Pyrophosphate crystals
weakly positively bifringent rhomboid shaped crystals
How does oxygen carrying capacity of stored transfusion blood compare to fresh blood?
It has an increased affinity for oxygen
It has less 2,3 DPG and therefore a higher affinity for O2
Compare Richter’s and Littre’s hernia?
Richter’s - part of the small bowel (usually anti mesenteric border) is strangulated within a hernia
Littre’s- hernia of a Meckel’s diverticulum
What size of suture material is best used to repair major veins damaged in surgery?
5/0 Prolene
Should biopsies be taken in suspected testicular cancer?
No - a biopsy runs the risk of spreading the cancer to another lymphatic field
An orchidectomy via inguinal approach should be carried out if cancer is suspected
What is most commonly the presenting feature of MEN II genetic condition?
Medullary carcinoma of the thyroid
Compare the approach to managing hydroceles in children and adults ?
Children - underlying pathology is patent processus vaginalis = inguinal approach used
Adults - scrotal approach used (Jaboulay or Lords procedure)
Which bacteria is resistant to chlorine and therefore common in returning travellers who have been swimming in pools?
Giardia Lamblia
Also causes fat malabsorption, so stools float and are greasy
What is the best investigation to assess for compression of the upper airways?
Flow volume loop
Which respiratory centre is depressed by opiates ?
Medullary respiratory centre
If time between onset of acute limb ischemia and surgery exceeds 6 hours, what procedure in addition to embolectomy should be considered?
Below knee fasciotomy
Delayed limb re perfusion increases risk of compartment syndrome
Compare discharge from patent urachus and persistent Vitelli-intestinal duct in babies?
Patent urachus = urinary discharge
Persistent vitello-intestinal duct = small bowel contents discharge
Describe the mechanism of action of tranexamic acid?
Inhibition of plasmin
This prevents fibrin degradation
It is an anti-fibrinolytic
In deceleration injuries, where is the aorta most likely to rupture with respect to the left subclavian artery?
Most commonly distal to the left subclavian artery
A raised CA 125 is indicative of which cancer?
Ovarian cancer
Compare which cancer is associated with the following tumour marker:
CA 125
CA 19-9
CA 15-3
CEA
CA 125 = ovarian
CA 19-9 = Pancreatic
CA 15-3 = Breast cancer
CEA = colorectal cancer
Which composition of renal stones are associated with an inherited metabolic disorder?
Cystine stones
Compare venous doppler and venous duplex scans?
Venous doppler: compressing the vessel manually to assess junctional incompetence. The simplest investigation
Venous duplex: provides info including flow, used to provide vein maps for bypass surgery. More detailed than CT angio
If there is no improvement after 5-7 days of cons management of UC, what procedure should be done?
Sub total colectomy and end ileostomy
Panprocolectomy should not be carried out in unwell patients
Which part of the colon is removed in Hartmann’s procedure?
The sigmoid colon is removed
The remaining part of the colon forms a colostomy
Which vertebral level do cervical ribs most commonly arise?
C7
Can compress subclavian artery or present with neurological symptoms
Which disorder is characterised by a PTEN mutation and intestinal hamartomas?
Cowden Disease
Which polyposis syndrome has a mutation of the APC gene?
Familial adenomatous polyposis
Name the 2 interventions considered for patents with infected pancreatic necrosis secondary to pancreatitis?
Either radiological drainage or surgical necrosectomy
Compare the approach to manage hydroceles in children and men?
Children - ligation of patent processus vaginalis via inguinal approach
Older men - excision of hydrocele sac via scrotal approach
Which syndrome has a mutation of the p53 tumour suppressor gene?
Which 4 malignancies are they predisposed to?
Li-Fraumeni syndrome
Sarcoma, breast Ca, brain and adrenal malignancies
High risk of developing leukaemia
Compare the management of inguinal hernias in children and adults?
Children - high risk of strangulation, an inguinal herniotomy is optimal treatment
Adults - Herniorraphy (repair of abdominal wall, can use mesh).
Herniotomy = removal of the hernial sac
Name the 2 therapies in current guidance for actively bleeding peptic ulcers?
Dual therapy guidelines
Adrenaline injeciton and endoscopic clipping
Following these therapies, patients should have PPI infusion
What must be rapidly excluded in a patient presenting with painful third nerve palsy?
Posterior communicating artery aneurysm
Which clotting factor is less likely to be affected in a patient with liver disease? Why?
Factor VIII
It is synthesised in the endothelial cells of the liver rather than the liver itself, so less prone to effects pf hepatic dysfunction
Compare the clotting factors affected by heparin and warfarin?
Heparin = 2, 9, 10, 11
Warfarin = 2, 7, 9, 10
What is a left sided varicocele a recognised presenting sign of?
What is most appropriate initial investigation?
Recognised sign of renal tumour occluding the renal vein
The left testicular vein drains into the renal vein
Abdominal US
Which clothing factor does von Willebrand stabilise?
Factor VIII
What are the most common organisms isolated in Fournier’s Gangrene?
E.Coli and bacteroides
Name the 2 most effective ways of raising core temperature in hypothermia?
- Extracorporeal circulatory devices
- Warmed intra peritoneal fluid
A defect in which function causes osteopetrosis?
Defective osteoclast function leads to increased bone density but defective architechture
Leads to brittle bones
What is the difference between schistosomia mansoni and schistosomia haematobium?
Haematobium = urinary schistosomiasis (risk factor for squamous cell bladder ca)
Mansoni = intestinal schistomiasis
What is the main anaesthetic risk in a patient with severe aortic stenosis?
They cannot increase their cardiac output if vasodilation occurs
Which substance can be used to achieve the most accurate measurement of glomerular filtration rate?
Inulin
Creatinine declines with age due to reduced renal function and age
How can cystic stump leaks following cholecystectomy be managed?
ECRP, sphincterotomy and stent
Name the 3 antibodies involved in anti phospholipid syndrome?
Lupus anticoagulant
anti-cardiolipin
anti B2 glycoprotein
What 3 medications should be started in a postmenopausal women with a fragility fracture?
Biphosphonates, calcium and vit D
Compare direction of antegrade vs retrograde ureteric stents?
antegrade = pass from kidney to ureter
Retrograde = pass from bladder into ureter
How should most insulinomas be managed?
Enucleation of the lesion
What often causes diffuse parotid swelling, facial pain and facial nerve palsy?
Adenoid cystic carcinoma
It commonly infiltrates the facial nerve and may cause neuropathy
Which vessels are kidney transplants usually anastomosed to?
External iliac artery and vein
What type of epithelium is most likely to be found in Meckles diverticulum?
Ileal mucosa
If there is bleeding associated with it, gastric mucosa lining is more likely
On a Congo red stain, what would be consistent with a diagnosis of amyloidosis?
Positive bifringence and green staining of fibres under polarised light
Why can significant generalised oedema occur in patients with severe burns?
The significant burns results in loss of high molecular weight proteins, therefore reducing the capillary oncotic pressure
Therefore, fluid remains in the interstitium and will cause oedema
What is the commonest type of fistula in ano?
Intersphincteric fistuals
Describe the difference in mechanism of finasteride and tamsulosin?
Finasteride - stops conversion of testosterone to dihydrotestosterone. Stops growth of prostate and reduces risk of urinary retention
Tamsulosin - alpha blocker. Relaxes smooth muscle in prostate gland and bladder neck
In terms of HIV testing, compare the timeframes that HIV antibody test and p24 antigen test would show positive result?
p24 antigen test - usually positive from 1 week to 3/4 weeks after infection with HIV
HIV antibody test - most develop HIV antibodies at 4-6 weeks
What location is a Meckels diverticulum most commonly found?
60cm proximal to the ileoceacal valve
What is the mechanism of action of clopidogrel and how soon prior to surgery should it be stopped?
It decreases ADP induced platelet aggregation (ie - it makes platelets dysfunctional)
It persists for 120 hours following final dose so needs to be stopped 5-7 days prior to surgery
What is a cervical rib due to?
It is due to an elongation of the transverse processes of the 7th cervical vertebra
Name 2 classes of antibiotics that inhibit cell wall formation
Penicillins
Cephalosporins
What is the mechanism of action of tetracyclines, macrolides and aminoglycosides?
Inhibit protein synthesis
What is the main aim of fluid resuscitation in burns patients?
When is most fluid lost following a burn injury?
Prevent the burn deepening
Most fluid is lost 24 hours following burn injury
Why is the electrical burn infusion protocol different from other burn protocols?
What is the fluid infusion protocol for electrical burns?
Electrical burns have greater risk of rhabdo
Aim for urine output 100ml/hr
Use Hartmans at 4ml/kg/%total body surface
Which ions are responsible for rapid depolarisation phase of the myocardial action potential?
RAPID sodium influx
Which thyroid malignancy is synonymous with haematological spread resulting in lung lesions?
Follicular thyroid cancer
Papillary thyroid cancer tends to spread via lymphatics, and will go to neck nodes first
Where does vasopressin (ADH) work, and what is its action?
Works at distal tubule and collecting ducts of the kidneys
Recruits more aquaporin channels to increase permeability of distal tubule, resulting in more water uptake
Which type of brain infarct is associated with isolated hemisensory loss or hemiparesis?
Lacunar infarct
Name the 3 features seen in a Total Anterior Circulation Infarct (TACI)?
Hemiparesis/Hemisensory loss
Homonymous hemianopia
Higher cognitive disfunction (Dysphasia)
Compare the presentation of Total anterior circulation with partial anterior circulation infarct?
Partial anterior infarct will present with 2/3 of TACI symptoms
Ie - hemisensory/hemiplagia, homonymous hemianopia, higher cognitive dysfunction (dysphasia)
What is the cell of origin of almost all pancreatic carcinomas?
The ductular epithelium
Over 90% of pancreatic carcinomas are adenocarcinomas, therefore are ductular epithelium in origin
Which cell type provides the greatest contribution to complement protein and glycoprotein production?
Hepatocytes
Most soluble proteins are synthesised by the liver
Which thyroid cancer may metastasise to bone?
Follicular carcinoma of thyroid
Haematological spread, possibly to bone
Why may medullary thyroid cancer be associated with hypertension and a family history?
In medullary carcinoma, pheochromocytoma may also be present (part of MEN disorder, causing hypertension)
Medullary carcinoma may be inherited in AD fashion
Name the 3 features of an addisonian crisis?
How is it treated?
Hyponatremia
Hypoglycemia
Hyperkalemia
100mg IV hydrocortisone, 6 hourly until patient stable
Which thyroid cancer is associated with a fluctuant pulsatile mass on the forehead?
They also have a positive Berry’s sign…?
Follicular thyroid cancer
Berry’s sign = absent carotid pulse due to malignant thyromegaly
Which disease process may result in development of Aschoff-Rokitansky sinuses?
Recurrent, chronic cholecystitis
These sinuses are a result of hyperplasia and herniation of epithelial cells through fibromuscular layer of gallbladder wall
Name the 4 features seen in MEN IIB?
Marfanoid appearance
Medullary thyroid cancer
Phaeochromocytoma
Mucosal neuroma
In the coagulation cascade, which pathway needs tissue factor released by damaged tissue?
The extrinsic pathway
It is the main pathway
Compare the clotting factors involved in the intrinsic and extrinsic pathway?
Intrinsic = factors 8,9,11,12
Extrinsic = factor 7
Which test is best for initial assessment of recurrence of follicular carcinoma of the thyroid?
Elevated serum thyroglobulin
When would an axillo-bifemoral bypass graft be favoured over an aorto-bifemoral bypass graft?
In patients with major co-morbidities
Axillo-bifemoral graft isn’t as major an operation but doesn’t have as good long term patency rates
What is the first line management for ureteric stones with diameter of less than 10mm?
Extra corporeal shock wave lithotripsy
If this is unsuccessful, then consider ureteroscopy
What size do renal stones for percutaneous nephrolithotomy to be considered 1st line management?
> 20mm or a staghorn calculi
In terms of lymphoedema, compare Meiges disease and Milroy’s disease?
Milroy’s disease is present from birth (is congenital)
Meige’s disease develops after birth
What is the most common congenital heart disease to present with cyanosis in a neonate who has just been delivered?
Transposition of the great vessels- most common at birth
Tetralogy of Fallot is most common overall
What is the most common acyanotic congenital heart disease?
Ventricular septal defect (account for 30% of congenital heart disease)
What disease process are Reed Steenberg cells synonymous with?
Hodgkins lymphoma
Name the 3 B symptoms seen in Hodgkins lymphoma?
10% weight loss, fever, night sweats
Which artery is prone to damage in an extra dural haematoma?
Middle meningeal artery
Appearances of melanosis coli on colonoscopy is indicative of what?
Laxative abuse
Consists of lipofuschin laden macrophages that appear brown
Compare what Stensens and Whartons duct drains?
Stensen’s duct - drains parotid gland
Wharton’s duct - drains the submandibular gland
What is the eponymous name for a distal radius fracture (Colles/Smith) with associated radoiocarpal dislocation?
Barton’s fracture
The radiocarpal dislocation is a defining feature and differentiates it from Colles/Smith fracture
Compare Galeazzi and Monteggia fractures?
Galeazzi - “Glasgow Rangers” - Radial shaft fracture with distal radioulnar joint dislocation
Monteggia - Ulnar shaft fracture with proximal radioulnar joint dislocation
How to remember the fracture site and where radioulnar dislocation occurs in Galeazzi fracture?
Galeazzi fracture = Glasgow Rangers
Radial shaft fracture with distal radioulnar joint dislocation
Distal because rangers are far down the table
What hormone is secreted by zona glomerulosa?
Aldosterone
What hormone is secreted by the zona fasiculata?
Glococorticoids
What hormone is secreted by zona reticularis?
Androgens
Describe in more depth how achalasia is a failure of muscle relaxation rather than a stricture?
Achalasia is due to degeneration of the ganglion cells in the myenteric plexus in oesophageal wall
This leads to failure of the LOS to relax and a loss of peristalsis of the distal oesophagus
În orchidectomy for malignancy, what is the route taken? Inguinal or scrotal approach?
Inguinal approach
There is no role for orchidectomy via scrotal approach
Which cancer is associated with Epstein Barr virus?
Nasopharyngeal carcinoma
Rare in most parts of the world other than southern China
What spinal tract is specifically affected by syringomyelia? How does this present ?
Syringomyelia specifically affects the spinothalamic tracts
Will result in a loss of pain and temperature sensation
What causes adrenaline to be released from the adrenal medulla?
Increased sympathetic discharge from preganglionic sympathetic fibres of the splanchnic nerves
Compare the most common adverse event seen during transfusion of PRCs and FFP?
PRCs = pyrexia
FFP = urticaria
Where in the gut is the main site of occult blood loss and IDA?
Right colon
Describe the calcium, phosphate and alk phos levels in someone with osteomalacia?
Calcium and phosphate LOW
Alk phos HIGH
What is the usual presenting feature of renal artery thrombosis in a renal transplant patient?
Presenting feature is sudden cessation of urine output
Rare, but usually occurs early post transplant
What is released from the sympathetic nervous system to stimulate the adrenal medulla?
Acetyl Choline
This stimulates adrenaline release
Which murmur is most associated with rheumatic fever?
Mitral valve stenosis
Which organism is most likely to cause a staghorn calculus?
Proteus Mirabilis
How are rectal cancers managed initially?
Chemoradiotherapy it T4 disease
if T1,2,3/N0 disease, should proceed straight to surgery
Which liver lesion has strong links to the oral contraceptive pill?
Liver cell adenomas
90% of patients with liver cell adenomas have used the OCP in the past
Which type of congenital hernia is associated with lung hypoplasia? Which lung is most commonly affected?
Bochdalek congenital hernia
85% of cases located in left hemidiaphragm, so Left lung most commonly affected
Compare the anatomical structures that may herniate in Bochdalek and Morgagni hernias?
Bochdalek = stomach may herniate
Morgagni = transverse colon may herniate
Compare treatment options for Bochdalek and Morgagni hernia?
Bochdalek = direct anatomical apposition or placement of mesh
Morgagni = direct anatomical repair
Which monoclonal antibody is used to treat KIT positive gastrointestinal stroll tumours?
Imatinib
First line treatment of meconium ileus in newborns?
N-acetyl cysteine or gastrograffin enemas
Name the site that a spigelian hernia occurs?
Lateral to the rectus muscle at the level of the arcuate line
Abdominal contents pushes through the rectus abdominus and internal oblique aponeurosis
What is a Meckel’s diverticulum lined by?
If asymptomatic, likely to be lined with ileal cells
If bleeding, likely to be lined with ectopic gastric mucosal tissue and produce bleeding
Can cause IDA
What does histology of classical seminoma often show?
Lymphocytic stromal infiltrate
Seminoma is the commonest type of testicular cancer and more common in 30-40 y/os
Teratoma more common in 20-30 y/os
What is the best course of action for undisplaced fractures of the proximal pole of the scaphoid?
Surgical Fixation
Proximal pole fractures should be fixed as non-union rates of up to 34% can be seen when cast immobilisation alone is attempted
In which thyroid condition is intense lymphocytic infiltrate with acinar destruction and fibrosis seen?
Hashimoto’s Thyroiditis
How are asymptomatic hepatocellular adenomas in males managed?
They are usually excised - they have greater risk of malignant transformation, especially in males
Compare the sites affected by malignancy in FAP and Lynch syndrome?
FAP- usually affects colon and rectim
Lynch syndrome - malignancy usually affects right side of the colon
(Lynch syndrome = mutation of mismatch repair genes)
What metabolic disturbance can occur if excessive amounts of 0.9%NaCl is administered?
Hyperchloraemic acidosis
Compare management of a spontaneous small pneumothorax and one occurring due to trauma?
Spontaneous pneumothorax - observation
Traumatic pneumothorax - chest drain insertion. They are more likely to progress to tension pneumothorax
What calculation can be used to establish the MAP?
MAP = diastolic + 0.333(systolic - diastolic)
How can cerebral perfusion pressure be calculated?
Cerebral perfusion pressure = MAP - ICP
How is splenic vein thrombosis diagnosed and managed?
Diagnosed = CT angiogram
Managed = splenectomy
Thrombosis of the splenic vein can complicate pancreatitis
What medication is first line for thrombolysis in a patient with a life threatening, massive PE?
Alteplase 50mg bolus is recommended 1st line for thrombolysis
Which type of malignant mass is associated with stag horn calculus?
Squamous cell carcinoma
SCC of the kidney usually arise in an area of chronic inflammation, such as stag horn calculus
What is the single most important prognostic factor in breast cancer?
Nodal status
It serves as a marker of tumour metastatic potential
Damage to which nerve during rectal surgery can cause impotence?
Nervi Erigentes
These autonomic nerves lie near the seminal vesicles and can be compromised by diathermy or radiotherapy
Which nerve is damaged if patient has vertical diplopia and unable to look down and in?
Trochlear nerve
Has longest intracranial course
How should oesophageal SCC be managed?
Radical chemoradiotherapy
How should middle and distal oesophageal tumours be managed?
Ivor lewis oesophagectomy
Which part of the GIT is most potassium excreted from?
The rectum
This is why patients with villous adenoma of the rectum can end up having hypokalaemia
Compare the innervations in voice production?
Ie- innervation of cricothyroid muscle and the intrinsic larynx muscles?
Cricothyroid muscle = Superior laryngeal nerve
Intrinsic larynx muscles = Recurrent laryngeal nerve
Why must erythrocytes produce ATP from anaerobic respiration?
They lack mitochondria
Which breast cancer shows lymphocytic infiltrate on histology?
Medullary breast cancer
How is APTT and prothrombin time affected in haemophilia A?
APTT prolonged
Prothrombin time unaffected
There is reduced levels of factor 8:C in haemophilia A
What is the most appropriate management for junctional (type 2) oesophageal tumours where limited oesophageal resection is required?
Transhiatal oesophagectomy
What is most appropriate management for middle and distal oesophageal tumours?
Ivor Lewis oesophagectomy
If the adenocarcinoma is in distal oesophagus and is classed as Tis or T1 disease, an endoscopic mucosal resection would be more appropriate
What is the commonest cause of an amoebic liver abscess?
Entamoeba Histolytica
What is the follow up plan for a patient who has high risk polyp findings on colonoscopy?
One off surveillance colonoscopy at 3 years
High risk findings = more than 2 premalignant polyps including >1 advanced colorectal polyp or more than 5 premalignant polyps
Administration of what agent is most useful in managing bleeding from the commonest type of vWB?
(clue- its not a clotting factor)
Desmopressin/tranexamic acid
It would have a vasoconstrictor approach, which is likely to be of brief duration but effective enough
What structure is best to be used for coronary artery bypass?
Internal mammary artery
Jaundice will affect which clothing factors?
Which part of a coag screen will reflect this best?
Jaundice affects vit K dependant clotting factors
ie - clotting factors 2, 7, 9, 10
Best reflected by Prothrombin time
What is bleeding time a measure of?
Platelet function
If there is an implant related concern in breast surgery, what is the imaging modality of choice?
MRI
Also the imaging of choice if there are concerns about ?malignant changes
Where are the reticulo-endothelial cells concentrated within the spleen?
Within the white pulp
The reticulo-endothelial cells are concerned with the immune functions of the spleen
What is the purpose of the red pulp in the spleen?
It contains fine erythrocyte fenestrations, which the blood flows over
The fenestrations trap and destroy any old or deformed erythrocytes
