Revision Flashcards
A 56-year-old man is having a spinal anaesthetic for a lower limb operation
as he has been told he is not fit enough for a general anaesthetic.
Which would be the most appropriate local anaesthetic agent?
A. Bupivacaine alone
B. Lidocaine
C. Lidocaine/prilocine mixture
D. Lidocaine with adrenaline
E. Prilocaine
A – Bupivacaine alone
Bupivacaine is a longer-acting anaesthetic that can be used without
adrenaline for spinal or epidural anaesthesia. Bupivacaine can also be
injected into surgical wounds with adrenaline to reduce post-operative
pain for up to 20 hours.
when does pancreatic pseudocyst form?
4weeks after acute pancreatitis
A 33-year-old man is brought into the emergency department following
an assault with a baseball bat. He has bruising over the abdomen and
right loin and complains of abdominal pain. On examination, his chest is
clear with good air entry but his abdomen is rigid. On arrival, his heart
rate is 140/min and blood pressure 90/60 mmHg. He is given O-negative
blood in the resuscitation room but his observations remain unchanged.
What would be the next step in his management?
A. Diagnostic peritoneal lavage
B. Laparotomy
C. Urgent CT scan
D. Urgent intravenous urogram
E. Urgent ultrasound scan
B – Laparotomy
This patient has suffered blunt abdominal trauma and is haemodynami-
cally unstable despite blood resuscitation. This is an indication for an
urgent laparotomy, to identify and manage the site of bleeding. From the
history there are no obvious sites of blood loss, so it can only be assumed
that it is being lost into the abdomen.
What is boerhaave syndrome?
Boerhaave syndrome describes spontaneous transmural rupture of the
oesophagus, often associated with forceful vomiting.
common site : left posteolateral wall of the lower third of the oesoph-
agus.
SX (Mackler’s triad:) vomiting, lower thoracic pain subcutaneous emphysema -common abdominal pain -chest pain -SOB.
How many types of jaundice ?
3 types
- pre hepatic
- hepatic
- post hepatic
what will you see in pre hepatic jaundice?
inability of the liver to handle an excess amount of bilirubin being produced; Associated with -hereditary sphero- cytosis - Gilbert syndrome
INV
- serum bilirubin +
- urine bilirubin +
- conjugated bilirubin (normal)
- unconjugated bilirubin +/-
- AST/ALT = normal
- ALP = normal
- Gamma GT- normal
- urine color= normal
- stool color = normal
What will you see in hepatic jaundice ?
caused by a primary failure of the hepatocytes to metabolise or excrete bilirubin;
Associated:
- viral hepatitis
-liver metastasis
INV
- -serum bilirubin +
- urine bilirubin +/-
- conjugated bilirubin (normal or low)
- unconjugated bilirubin (normal or reduce)
- AST/ALT = ++
- ALP =+/-
- Gamma GT- ++
- urine color= normal / dark
- stool color = normal
What will you see in post-hepatic jaundice?
caused by the obstruction of bile ducts. Associated -gallstone -carcinoma on head of pancrease
INV
- serum bilirubin +
- urine bilirubin +
- conjugated bilirubin +
- unconjugated bilirubin (normal)
- AST/ALT = normal/ +
- ALP = ++
- Gamma GT- normal/ +
- urine color= dark
- stool color =pale
A 37-year-old woman presents to the GP with a 3-week history of frequent,
loose motions. She is very tired and complains of muscle weakness. A subsequent colonoscopy demonstrates a 1.5 cm sessile growth that has
multiple projections. The remainder of the colon was unremarkable.
What is the most likely diagnosis?
A. Adenomatous polyp
B. Colorectal carcinoma
C. Infective colitis
D. Pseudomembranous colitis
E. Villous adenoma
E – Villous adenoma
Villous adenomas are large polyps which look like sea anemones. Villous
adenomas secrete mucus and potassium, hence they can present with
diarrhoea and features of hypokalaemia (muscle weakness, myalgia and
arrhythmias). Of all the rectal polyps, the villous adenoma has the high-
est potential for malignant change, so it must be removed.
What is the ASA grading system ?
Grade I = normal, healthy individual (0.05% anaesthetic mortality)
Grade II = mild systemic disease that does not limit activity (0.4%
mortality)
Grade III = severe systemic disease that limits activity but is not incapacitating
(4.5% mortality)
Grade IV = incapacitating systemic disease that is constantly life-threatening
(25% mortality)
Grade V = moribund, not expected to survive over 24 hours with or
without surgery (50% mortality)
A mother brings her 5-week-old son to the paediatric outpatient clinic.
She is concerned as he has been having episodes of forceful vomiting after
feeds for the last 2 weeks. She says her son always seems hungry and now
is beginning to appear lethargic. Examination of the child reveals mild
dehydration and the presence of a smooth, firm, non-tender mass in the
right upper quadrant of the abdomen. Blood tests are sent.
What biochemical abnormalities would you expect to find?
A. Hyperchloraemic, respiratory alkalosis
B. Hypernatraemic, hyperkalaemic, metabolic alkalosis
C. Hypochloraemic, hyperkalaemic, metabolic alkalosis
D. Hypochloraemic, hypokalaemic, metabolic alkalosis
E. Hyponatraemic, metabolic acidosis
D – Hypochloraemic, hypokalaemic, metabolic alkalosis
A 53-year-old man presents to the GP with a deep, painful ulcer over the
big toe. He gives a 3-month history of severe calf pain on walking which is
only eased on resting. Examination shows cool peripheries with reduced
distal pulses.
Which ulcer does the patient most likely have?
A. Arterial ulcer
B. Curling ulcer
C. Marjolin ulcer
D. Neuropathic ulcer
E. Venous ulcer
A – Arterial ulcer
Arterial ulcers are typically painful, deep, well demarcated and occur
on the heels, toes and over bony prominences
A 45-year-old man has walked into the emergency department follow-
ing his involvement in a road traffic collision. On arrival at the hospital
he is anxious, but otherwise fine. Later, he suddenly becomes faint. He is taken into the resuscitation room where he is found to have a heart rateof 46/min and a blood pressure of 80/48 mmHg. Primary examination is
unremarkable and the patient has warm peripheries.
Which of the following is the most likely cause of his symptoms?
A. Cardiogenic shock
B. Haemorrhagic shock
C. Hypovolaemic shock
D. Neurogenic shock
E. Spinal shock
D – Neurogenic shock
Neurogenic shock is caused by sudden disruption or injury to the sympathetic
nervous pathways, resulting in the loss of vasomotor tone and
pooling of blood in the peripheries. This leads to profound hypotension.
modified Glasgow criteria for pancreas ?
Mnemonic PANCREAS P =p02 < 8kPa A= age >55 yr N= neutrophil WCC >15x10 C= calcium =<2.0mmol/l R= urea >16 mmol/l E= enzyme (AST, LDH > 600mmol/l) A= albumin <32mmol/l S-sugar >19mmol/l
Severe disease is present if three or more of the criteria are present
within 48 hours.
A 50-year-old woman with known gallstones presents to the emergency
department with severe epigastric pain radiating to the back together
with nausea and vomiting. Examination reveals localized epigastric peri-
tonitis and investigations reveal an amylase of 650 μ/L.
Which of the following would indicate a poor prognosis in this condition? A. Amylase of 650 μ/L B. Arterial pO2 of 7.0 kPa C. Patient age of 50 years D. Pyrexia of 38.5°C E. White cell count of 10 × 103 /μL
B – Arterial pO2 of 7.0 kPa
Malunion of supracondylar fractures = ?
cubitus varus deformity (‘gunstock deformity’).
What will you see in volkmann ischaemic contracture ?
a flexion
contracture of the hand and wrist, caused by circulatory compromise
and ischaemia leading to fibrosis of the forearm compartment. It
is a recognized complication of supracondylar fractures, 2nd in compartment syndrome
Treatment of
Volkmann ischaemic contracture involves surgery to release the contracted
muscles.
A 6-year-old boy who had a fracture above the left elbow and was treated
in a plaster cast is brought into the GP practice by his mother a few days
after plaster removal. She is worried due to the abnormal positioning of
his forearm. On examination, his left forearm appears to be shortened
and held in flexion at the wrist and the fingers.
Which of the following complications has led to this appearance?
A. Brachial artery injury
B. Lack of physiotherapy
C. Malunion at fracture site
D. Median nerve injury
E. Ulnar nerve injury
A – Brachial artery injury
This boy has presented with Volkmann ischaemic contracture, a flexion
contracture of the hand and wrist, caused by circulatory compromise
and ischaemia leading to fibrosis of the forearm compartment
A 40-year-old man presents to the GP complaining of increasing diffi-
culty in swallowing over the last few months. He tells you he has been
working in Mexico for the last two years with a new business. He is other-
wise well and denies any other symptoms.
Which of the following is the most likely cause of his symptoms? A. Chagas disease B. Gastro-oesophageal reflux disease C. Myasthenia gravis D. Plummer-Vinson syndrome E. Zenker diverticulum
A – Chagas disease
Chagas disease is a parasitic disease of the tropics caused by the protozoan
Trypanosoma cruzi
A 30-year-old woman presents with multiple bilateral breast swell-
ings which cause her discomfort, particularly just before her periods.
They have been present for several years but appear to be getting worse. What is the most likely diagnosis? A. Duct ectasia B. Fat necrosis C. Fibroadenoma D. Fibrocystic disease E. Peau d’orange
D – Fibrocystic disease
Fibrocystic disease of the breast is a common benign condition affecting
more than half of women, commonly between the ages of 30 and 50.
You are called to see a 56-year-old man who is one day post appendicec-
tomy because he became acutely short of breath. He has just been given his
first dose of cyclizine to relieve nausea. On arrival, the patient is breath-
less with the following observations: heart rate 122/min, blood pressure
86/48 mmHg and saturations 85% in air. Which of the following would you administer first? A. Adrenaline B. Chlorphenamine C. Fluids D. Hydrocortisone E. Salbutamol
A – Adrenaline
This patient is in anaphylactic shock, an acute life-threatening emergency
which can rapidly cause death if untreated.
A 43-year-old man presents to the GP with a 2-month history of wors-
ening headaches. The headaches are almost constant and are worse in
the morning. On examination, his skin is thick and greasy and he is
hypertensive.
A 43-year-old man presents to the GP with a 2-month history of wors-
ening headaches. The headaches are almost constant and are worse in
the morning. On examination, his skin is thick and greasy and he is
hypertensive.
A – Acromegaly
The headache is characteristic of an intracranial space-occupying lesion.
This, along with the features of greasy skin and hypertension, suggests acromegaly as the most likely cause from the given list. Acromegaly is caused
by a growth hormone-secreting tumour of the anterior pituitary gland. The
functions of growth hormone include lipolysis, protein synthesis and gluconeogenesis
– in other words it is anabolic. Patients with acromegaly may present
with headaches, excessive sweating, thick/oily skin, hypertrophy of soft
tissues (large nose/lips/tongue, ‘spade-like’ hands), big viscera, prognathism
(protruding lower jaw) and prominent supraorbital ridges.
A 55-year-old man presents to the emergency department with increasing
itching and upper abdominal discomfort. His wife has noticed that he is
looking ‘yellow’. On examination, there is a non-tender mass in the right
upper quadrant. The patient has a history of ulcerative colitis, which is
currently in remission.
What is the most likely diagnosis?
A. Cholangiocarcinoma
B. Gallstones
C. Haemolysis
D. Hepatitis
E. Pancreatic carcinoma
A – Cholangiocarcinoma
Cholangiocarcinoma is an adenocarcinoma of the biliary tree and is
associated with ulcerative colitis, primary sclerosing cholangitis and to a
lesser extent Crohn disease. It usually presents between the ages of 50 and
70 poor prognosis with an average survival of 6 months
A 27-year-old man presents to the emergency department after being
stabbed in the back. He is now unable to move his right leg. On exami-
nation, you note that he cannot feel pain on the left leg, although motor
function in this limb is preserved. What is the most likely diagnosis? A. Anterior cord syndrome B. Brown-Séquard syndrome C. Central cord syndrome D. Posterior cord syndrome E. Syringomyelia
B – Brown-Séquard syndrome
Brown-Séquard syndrome describes the features of unilateral transection
(hemisection) of the spinal cord
A 70-year-old woman presents with a 2-month history of anal pain and
itching. More recently she had been having some fresh bleeding and
mucous discharge per rectum. On examination, there is an irregular ten-
der ulceration at the anal margin which appears to be extending into the
anal canal. What is the most likely diagnosis? A. Anal carcinoma B. Anal fissure C. Anal warts D. Fistula-in-ano E. Primary syphilis
A – Anal carcinoma
The symptoms of anal carcinoma may initially be non-specific, including
pain, discomfort, itching, intermittent bleeding and inguinal lymphadenopathy,
and as a result it is a diagnosis which may easily be missed in
the early stages, particularly as many patients may not have a palpable
lesion.
How to calculate sensitivity ?
Sensitivity = number of true positives/(number of true positives +
number of false negatives) × 100
how to calculate specificity
Specificity = number of true negatives/(number of true negatives
+ number of false positives) × 100
How to calculate positive predictive value (PPV)
PPV = (number of true positives/total number of positives) × 100
How to calculate negative predictive value (NPV)
NPV = (number of true negatives/total number of negatives) × 100
A newborn baby boy is found to have visible intestine emerging from his
abdomen. There is no covering to the contents.
Which of the following is the most likely diagnosis?
A. Epigastric hernia
B. Exomphalos
C. Gastroschisis
D. Paraumbilical hernia
E. Umbilical hernia
C – Gastroschisis
Gastroschisis is a congenital defect in the anterior abdominal wall adjacent
to the umbilicus. Abdominal contents, such as the liver and intestines,
can herniated through this defect, but there is no sac covering the
contents. Management of gastroschisis is by immediately covering the
exposed viscera with clingfilm, followed by operative repair.
Exomphalos similar congenital abdominal wall defect where contents
of the gut, such as the intestines and liver, lie outside of the body
protruding through the umbilicus.
A 27-year-old woman is undergoing a routine surveillance colonoscopy
for ulcerative colitis. The endoscopist notes multiple small projections
throughout the bowel that are of a similar colour to the normal bowel
mucosa.
What is the most likely morphology of the polyps?
A. Adenomatous polyp
B. Hamartomatous polyp
C. Juvenile polyp
D. Metaplastic polyp
E. Pseudopolyp
E – Pseudopolyp
Pseudopolyps are found with inflammatory bowel disease. In an area of
oedematous, swollen bowel surrounded by ulcerations, it looks as if the
oedema is protruding from the walls of the bowel wall as a polyp. In reality,
these ‘polyps’ are merely areas of swollen bowel mucosa.
A 45-year-old woman presents to the orthopaedic clinic with a 6-week
history of shooting pains in her right foot, radiating to her toes, only
experienced when wearing her shoes. On examination, there is tenderness
between the third and fourth metatarsal heads. Foot X-rays are reported
as normal.
Which of the following is the most likely diagnosis?
A. Bunion
B. Gout
C. March fracture
D. Morton neuroma
E. Plantar fasciitis
D – Morton neuroma
Morton neuroma is a neuroma of the digital nerve of the foot that is most
common between the third and fourth metatarsals. It is a common cause
of foot pain and typically presents in women from the age of 40.
A 38-year-old woman presents to the GP with pain in the subareolar
region of the left breast associated with occasional blood-stained nipple
discharge. Apart from being extremely anxious she has no other associ-
ated symptoms. Examination is unremarkable.
What is the most likely diagnosis? A. Duct ectasia B. Galactocoele C. Intraductal papilloma D. Paget disease E. Prolactinoma
C – Intraductal papilloma
Intraductal papillomas are benign tumours of the lactiferous glands
that usually occur in pre-menopausal women. They commonly present
with pain within the nipple or areola, associated with discharge which
may be blood-stained.
A 76-year-old man presents to the GP with a rapidly growing lump in his
neck. It is now causing him difficulty swallowing. Examination reveals a
4 cm hard mass in the front of the neck that is fixed to the overlying skin.
What is the most likely diagnosis?
A. Anaplastic carcinoma
B. Follicular carcinoma
C. Graves disease
D. Papillary carcinoma
E. Toxic multinodular goitre
A – Anaplastic carcinoma
Anaplastic carcinoma is a rare subtype of thyroid cancer (3%) but its incidence
increases with age. It is an aggressive carcinoma which often presents
with a short history of a lump in the neck with local invasion causing
compression of surrounding structures leading to dysphagia, stridor and
hoarseness (recurrent laryngeal nerve involvement).
Etiology of acute pancreatitis
mnemonic GET SMASHED:
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom (Tityus trinitatis scorpion of Trinidad and Tobago)
Hyperlipidaemia, Hypercalcaemia, Hypothyroidism
Embolism, ERCP
Drugs (azathioprine, steroids, thiazide diuretics and the contraceptive pill)
A 32-year-old woman presents to the GP with a 1-month history of panic
attacks. She says the attacks are associated with sweating and the feeling
of her heart thumping in her chest. She cannot always think of a precipita-
tor to these attacks, but they are increasing in frequency. Examination is
unremarkable.
Which of the following investigations will be the most helpful in con-
firming the diagnosis?
A. 17-hydroxyprogesterone levels B. 24-hour urinary vanillylmandelic acid C. 24-hour urinary 5-hydroxyindole acetic acid D. Serum calcitonin E. Short synacthen test
B – 24-hour urinary vanillylmandelic acid
This woman presents with attacks of anxiety, sweating and palpitations.
Along with facial flushing and headaches these are classic presenting features
of phaeochromocytomas.
A 22-year-old woman presents to the GP practice with a scaly, well-
defined red rash on her cheeks. She has also noticed its appearance on her
scalp. There is some associated hair loss. What is the most likely diagnosis? A. Acne vulgaris B. Discoid lupus C. Erysipelas D. Impetigo E. Rosacea
B – Discoid lupus
Discoid lupus erythematosus (DLE) is a chronic inflammatory condition
with an autoimmune aetiology which results in cutaneous manifestations
An 18-year-old boy is brought into the emergency department follow-
ing an epileptic seizure. On recovery he complains of pain in the right
shoulder. Examination reveals the arm to be held adducted and internally
rotated with a fullness at the posterior aspect of the shoulder. There is
resistance to passive external rotation.
Which of the following injuries is the patient most likely to have
sustained?
A. Acromioclavicular dislocation
B. Anterior dislocation of the shoulder
C. Inferior dislocation of the shoulder
D. posterior dislocation of shoulder
E. Sternoclavicular dislocation
D. posterior dilocation of shoulder
common in epileptic seizures, electric shocks and
following a direct blow to the front of the shoulder. The arm will be held
internally rotated and adducted, and there is resistance to external rotation.
Anterior dislocation caused by fall onto outstretched
arm or the shoulder itself. The arm will be held in external
rotation and abduction
acromioclavicular dislocation caused by a direct fall onto
the shoulder and may be associated with a fractured clavicle. A step
may be felt at the point of separation,
Inferior dislocation caused by hyperabduction injuries
A 60-year-old Asian woman presents to the GP having noticed a dark brown lesion on the palm of her left hand which has been present for 2 months. She initially thought it was a bruise but it has been slowly enlarging.What is the most likely diagnosis?A. Acral lentiginous melanomaB. Amelanocytic melanomaC. Lentigo maligna melanomaD. Nodular melanomaE. Superficial spreading malignant melanoma
A – Acral lentiginous melanoma
A 12-year-old girl is brought to the GP by her mother having noticed a painless swelling on the left side of her neck following a recent cold. On examination, there is a smooth, fluctuant, non-tender swelling anterior to the sternocleidomastoid muscle.What is the most likely diagnosis?A. Branchial cystB. Cervical ribC. Cystic hygromaD.Sternocleidomastoid tumourE. Thyroglossal cyst
A branchial cyst is a smooth, nontender,
fluctuant swelling in the anterior triangle, anterior to the border
of the sternocleidomastoid muscle at the junction of its upper and middle
thirds
A 27-year-old man who was the driver of a car involved in a high speed col-lision with a truck is brought into the resuscitation room. On arrival, he is complaining of severe left-sided chest pain. You note that he is breathless, tachycardic and hypotensive. He has reduced air entry on the left side of the chest and the trachea is deviated to the right.What would you do next?A. Insert a chest drain into the fifth intercostal spaceB. Insert a wide bore cannula into the second intercostal spaceC. Request an urgent chest X-rayD. Request an urgent ECGE.Perform a pericardiocentesis
B – Insert a wide-bore cannula into the
second intercostal space
This patient has a tension pneumothorax. Air entering the pleural cavity
during inspiration cannot escape during expiration due to the pleura
acting as a one-way valve Decompression is by
insertion of a large bore cannula into the second intercostal space in the
mid-clavicular line of the affected side.
A 72-year-old man comes to see you in the GP practice complaining ofa 6-month history of urinary hesitancy, poor stream and occasional incon-tinence. He is increasingly troubled by his symptoms. Blood test results show a prostate specific antigen of 30 ng/mL.Which of the following is the most appropriate next step?A.AntibioticsB. Medical management with alpha-blockersC. Referral for transurethral resection of prostateD. Urgent referral for renal tract ultrasoundE. Urgent referral for transrectal ultrasound and prostate biopsy
E – Urgent referral for transrectal ultrasound
and prostate biopsy
normal PSA value < 5
A 64-year-old woman presents with a 2-day history of increasing left-sided abdominal pain with fever. On examination, she has localized peritonism
in the left iliac fossa. Her blood tests reveal a raised white cell count and C-reactive protein.Which of the following is the most likely diagnosis?A.ConstipationB. Diverticular diseaseC.DiverticulitisD. DiverticulosisE. Irritable bowel syndrome
C – Diverticulitis
A diverticulum is an outpouching of a hollow structure. Colonic diverticula
are examples of false diverticula – the walls are made up only of
the inner mucosal layer of the bowel.
A 14-year-old boy who has been complaining of pain and a localized ten-der swelling above his right knee for a month has been sent for X-rays by his GP. The X-ray shows an ill-defined breach in the lower end of the cor-tex of the femur with periosteal elevation and calcification.What is the most likely diagnosis?A. ChondrosarcomaB. Ewing sarcomaC. LipomaD. OsteomaE. Osteosarcoma
E – Osteosarcoma
Osteosarcomas are the second most common primary bone tumours after
multiple myeloma. Osteosarcomas occur most often in young adults, in
which case they may be associated with a history of retinoblastoma, and
in older people with Paget disease
Osteosarcomas present with a warm, painful swelling, usually
around the knee (50%).pain tends to be worse at night
X-ray features
are characteristic, showing cortical destruction, periosteal elevation
(Codman’s triangle) and calcification within the tumour but outside of the
bone (sunray spicules).
A 4-week-old baby girl is brought to the paediatrics clinic with swelling of both legs which the parents feel has been present since birth. On exami-nation there is oedema, which is non-pitting and firm to touch, of both lower limbs to the knee.What is the most likely diagnosis?A.ElephantiasisB.Hereditary angioedemaC. Lymphoedema praecoxD. Lymphoedema tardaE. Milroy disease
E – Milroy disease
Milroy disease – an inherited autosomal dominant congenital
lymphoedema, caused by a failure of lymph vessels to develop in
utero
An 8-year-old boy is brought to the emergency department with a 3-day history of left-sided flank and abdominal pain, fevers and reduced appe-tite. On examination, he has minimal left-sided flank and lower abdomi-nal tenderness, and there is a fluctuant, non-tender swelling in the child’s groin. You note that the child is walking with a limp and there is pain in the hip region on straight leg raising against resistance.How would this child be best managed?A.AppendicectomyB. Arthroscopic hip washoutC.Exploration of testesD. Incision and drainage with intravenous antibioticsE.Intravenous antibiotics alone
D – Incision and drainage with intravenous antibiotics
This boy has presented with the symptoms and signs of a psoas abscess.
A psoas abscess may be primary (and commonly caused by Staphylococcus
aureus) or secondary to spread of infection from structures adjacent to
the muscle,
A 74-year-old man presents to the emergency department with a 6-hour history of colicky lower abdominal pain accompanied by gross abdominal distension. He has had similar episodes in the past that have been relieved by opening his bowels. Today he is not even able to pass flatus. Abdominal X-ray shows a grossly dilated loop of large bowel.Which of the following is the most likely diagnosis?A.AdhesionsB.Faecal impactionC.IntussusceptionD.Sigmoid volvulusE.Strangulated inguinal hernia
D – Sigmoid volvulus
A volvulus is the twisting of a bowel loop around its mesenteric axis.
A 56-year-old man is having a spinal anaesthetic for a lower limb opera-tion as he has been told he is not fit enough for a general anaesthetic.Which would be the most appropriate local anaesthetic agent?A.Bupivacaine aloneB.LidocaineC.Lidocaine/prilocine mixtureD.Lidocaine with adrenalineE.Prilocaine
A – Bupivacaine alone
Bupivacaine is a longer-acting anaesthetic that can be used without
adrenaline for spinal or epidural anaesthesia. Bupivacaine can also be
injected into surgical wounds with adrenaline to reduce post-operative
pain for up to 20 hours. The maximum dose of bupivacaine is 2 mg/kg
A 68-year-old man presents with acute lower chest and upper abdominal pain following an episode of vomiting. On examination, he has marked tenderness in the epigastrium and you note the presence of subcutaneous emphysema. ECG shows a sinus tachycardia with no ST segment changes, and a chest X-ray demonstrates mediastinal air.Which of the following is the most likely diagnosis?A. Boerhaave syndromeB. Chest infectionC. Mallory-Weiss tearD. Myocardial infarctionE.Pulmonary embolus
A – Boerhaave syndrome
Boerhaave syndrome describes spontaneous transmural rupture of the
oesophagus, often associated with forceful vomiting
Boerhaave syndrome is characterized by Mackler’s triad: vomiting,
lower thoracic pain and subcutaneous emphysema
A 45-year-old man presents with episodic upper abdominal pain, severe heartburn, episodes of dark vomitus and diarrhoea. He has been tak-ing over-the-counter indigestion medication with no relief. On endos-copy, he has multiple ulcers throughout the duodenum, some of which are large.Which of the following is most likely to have caused this?A.AlcoholB. Aspirin useC. Gastrinoma D.Helicobacter pylori infectionE.Smoking
C – Gastrinoma
Peptic ulcers result from an imbalance between gastric acid secretion
and mucosal barrier protection.
What is Maydl hernia?
contains a ‘W’ loop of intestine, where the
middle segment is liable to become strangulated.
What is amyand hernia ?
contains the appendix within its sac
What is gluteal hernia ?
protrudes through the greater sciatic foramen
What is littre hernia ?
contains a Meckel diverticulum
What is obturator hernia ?
protrudes through the obturator canal pass through the obturator canal in the upper thigh,
especially in older women
What is sciatic hernia ?
protrudes through the lesser sciatic foramen
What is spigelian hernia ?
protrudes through the semilunar line
Type 1 hypersensitivity
Type I hypersensitivity (anaphylactic) reactions occur when exposure
to certain allergens results in IgE-mediated secretion of inflammatory
mediators by basophils and mast cells.
allergic asthma, hay fever (allergic rhinitis), and
peanut allergies.
Type II hypersensitivity
cytotoxic antibody mediated
Type III hypersensitivity
(complex) mediated by immune complexes
(antigen-antibody complexes). Immune complexes can deposit in various
sites in the body and result in localized tissue damage via complement
activation
glomerulonephritis
following a streptococcal throat infection, rheumatic fever and
systemic lupus erythematosus.
Type IV hypersensitivity
delayed type reactions
as features can take days to develop. contact dermatitis
(e.g. to nickel) and transplant rejection.
Type V hypersensitivity
describe the presence
of antibodies that bind to cell receptors and either stimulate or prevent
stimulation of the receptor
Graves disease (a stimulatory
response of autoantibodies binding to the TSH receptor of the
thyroid gland) and myasthenia gravis (an inhibitory response from
autoantibodies that bind to acetylcholine receptors at the neuromuscular
junction).
A 39-year-old man presents to the emergency department with a painful lump in the groin. He tells you that this lump has been present on and off for a few months and has previously been asymptomatic. Today, the lump has become painful. On examination, there is an erythematous, tender, irreducible lump above and medial to the pubic tubercle. The patient denies abdominal pain, vomiting or constipation.Which is the best descriptive term for the hernia above?A.Incarcerated herniaB.Perforated herniaC.Richter herniaD.Sliding herniaE.Strangulated hernia
C – Richter hernia
This man has a direct inguinal hernia that shows features of a Richter hernia.
A Richter hernia describes strangulation of one sidewall of the bowel
within a hernia sac
A 65-year-old woman presents to the emergency department with right wrist pain following a fall onto an outstretched hand. An X-ray shows a fracture of the distal radius with volar displacement of the distal frag-ment. There is no intra-articular involvement.Which of the following would be the most appropriate term to describe this fracture?A. Barton fractureB.Colles fractureC.Galeazzi fractureD.Monteggia fractureE. Smith fracture
E – Smith fracture
fracture of the distal radius with volar displacement of the distal frag-ment.
Colles fracture
a fracture of the distal 2.5 cm of the
radius with dorsal and radial displacement of the distal fragment (leading
to the classic ‘dinner fork’ deformity)
What will you see in osteoarthiritis X-ray ?
- Narrowing of joint space (due to cartilage loss)
- Osteophytes
- Subchondral sclerosis (laying down of new bone)
- Cyst formation
What will you see in rheumatoid arthritis X-ray ?
- Narrowing of joint space
- Soft tissue swelling
- Juxta-articular erosions
- Joint subluxation
An 81-year-old woman from a nursing home is brought into the emer-gency department following a fall. She is complaining of pain in her left hip. On examination, her left leg is shortened and externally rotated. The home tells you this woman has dementia but is able to mobilize indepen-dently with a frame. An X-ray shows a displaced intracapsular femoral neck fracture.Which of the following would be the most suitable management option?A. Allow the patient to try to mobilizeB. Dynamic hip screwC.HemiarthroplastyD. Open reduction and internal fixationE. Total hip replacement
C – Hemiarthroplasty The blood supply to the femoral head comprises the intramedullary vessels, the vessels in the retinaculum of the joint capsule and through the ligamentum teres (although at this age this may be obsolete).
A 56-year-old man presents to the emergency department with a 3-hour history of severe abdominal pain and vomiting. On examination, the abdomen is rigid. A CT scan confirms free air in the peritoneum and a perforation of a sigmoid diverticulum.What is the most appropriate operation?A.Abdominoperineal resectionB. Extended right hemicolectomyC. Hartmann procedureD.Left hemicolectomyE.Right hemicolectomy
C – Hartmann procedure
Hartmann procedure involves resection
of the rectosigmoid colon with closure of the rectal stump and formation
of a colostomy.
Staging of tumor ?
Duke system of grading CRC Dukes A → confined to the bowel wall Dukes B → invade through the bowel wall but there is no lymph node involvement Dukes C →→→ invade the bowel wall and involve lymph nodes C1 = apical node not involved C2 = apical node involved Dukes D → distal metastases present
A 27-year-old man is admitted to the high dependency ward having sus-tained a significant head injury. Two days later he starts vomiting blood.Which of the following is the most likely cause? A.Curling ulcer B.Cushing ulcer C. Decubitus ulcer D. Dendritic ulcer E. Martorell’s ulcer
B – Cushing ulcer
A Cushing ulcer is the development of acute peptic ulceration in the setting
of raised intracranial pressure, e.g. after intracranial bleed or traumatic
brain injury. These ulcers most commonly develop within the
antrum of the stomach, although the first part of the duodenum may also
be affected.
A 65-year-old man presents to the GP surgery complaining of increas-ing pain in his back and lower left leg. His mobility is now very limited. On examination, he has a marked kyphosis of the spine and bowing of the left lower limb. Locally the leg is markedly warm. Blood tests are taken.Which of the following biochemical abnormalities would one expect to find?A. Hypercalcaemia and hyperphosphataemiaB. Hypocalcaemia and hypophosphataemiaC. Hypocalcaemia and raised alkaline phosphataseD. Raised alkaline phosphatase and normal calciumE. Reduced parathyroid hormone levels and normal calcium
D – Raised alkaline phosphatase and normal calcium
This patient has presented with features of Paget bone disease.
Paget disease is a disorder of bone remodelling,
characterized by excessive bone reabsorption by osteoclasis, followed by a
compensatory increase in bone formation by osteoblasts
A 33-year-old woman presents to the surgical outpatient clinic with increasing dysphagia for solids and liquids, retrosternal chest pain on eating, regurgitation of undigested food and weight loss. Oesophageal and gastric biopsy at endoscopy was normal. Oesophageal manometry showed impaired relaxation of the lower oesophageal sphincter and barium swallow revealed a dilated proximal oesophagus with distal narrowing.Which of the following surgical procedures would be indicated?A. Billroth IB. Billroth IIC.Heller myotomyD.Ramstedt procedureE.Whipple procedure
C – Heller myotomy
This patient has presented with the symptoms and signs of oesophageal
achalasia, a condition where there is failure of relaxation of the lower end
of the oesophagus, due to a loss of ganglion cells in the myenteric plexus
Ramstedt pyloromyotomy is a similar procedure performed for pyloric
stenosis.
Whipple procedure is used in resecting pancreatic carcinomas
Billroth I is a partial gastrectomy and Billroth II is partial gastrectomy
with anastomosis of the stomach to the jejunum. These procedures have
been used in the treatment of gastric ulcers and malignancies.
Burn score wallace rule of 9?
Head + neck → 9% Upper limb → 9% each Anterior torso → 18% Posterior torso → 18% Lower limb → 18% each Perineum → 1%
