Science deck Flashcards
Upper GI bleed while being on lots of PPI
Gastrinoma and Zollinger Ellison Syndrome
Phaeochromocytoma and the rule of 10s
10% of cases are bilateral.
10% occur in children.
11% are malignant (higher when tumour is located outside the adrenal).
10% will not be hypertensive.
How can you tell if an incidental adrenal lesion is benign
Factors suggesting benign disease on CT include(4):
Size less than 3cm
Homogeneous texture
Lipid rich tissue
Thin wall to the lesion
What is the standard first-line treatment for anal cancer
Combined chemoradiotherapy is the standard treatment for anal cancer
Anal cancer
Arise inferior to the dentate line
Strongly linked to HPV type 16 infection
Other risk factors include ano-receptive intercourse, smoking and immunosuppression
Presenting symptoms include anal discomfort, discharge or pruritus
Lymphatic spread typically occurs to the inguinal nodes
Diagnosis is made by EUA and biopsies
Staging is with CT scanning of the chest, abdomen and pelvis
First-line treatment is typically with chemoradiotherapy
Second line treatment for non-metastatic disease is with salvage radical abdominoperineal excision of the anus and rectum
Where is the vomiting centre located?
Medulla oblongata
What are the indications for an escharotomy?
Indicated in circumferential full-thickness burns to the torso or limbs.
Careful division of the encasing band of burn tissue will potentially improve ventilation (if the burn involves the torso), or relieve compartment syndrome and oedema (where a limb is involved)
Which anaesthetic agent has the strongest ant emetic properties
Propofol
What type of hypersensitivity reaction is TB
Type 4 (delayed) - Granulomas delayed
Extra-intestinal features of IBD
Extraintestinal manifestation of inflammatory bowel disease: A PIE SAC
Aphthous ulcers
Pyoderma gangrenosum
Iritis
Erythema nodosum
Sclerosing cholangitis
Arthritis
Clubbing
Renal Stones management
Size First line option
Less than 5mm and asymptomatic Watchful waiting
Less than 10mm ESWL
10-20mm ESWL or ureteroscopy
Greater than 20mm (including staghorn calculi) PCNL
Ureteric stone
Size First line option
Less than 5mm Watchful waiting
5-10mm ESWL (if upper ureter)
10-20mm Ureteroscopy
Which type of renal stone most commonly develops in chemo patients
Uric acid stones, theses are radiolucent and will not show up on XRKUB. Chemotherapy and cell death can increase uric acid levels
Which clotting factors are affecting by temperature
Factors V and VIII are sensitive to temperature which is the reason why FFP is frozen soon after collection.
Klippel-Trenaunay-Weber (KTW)
port-wine stains, varicose veins, and bony or soft-tissue hypertrophy.
Breast Cancer
Surgery is performed in most patients suffering from breast cancer.
Chemotherapy may be used to downstage tumours and allow breast-conserving surgery. Hormonal therapy may also be used for the same purposes.
Radiotherapy is given to most patients who have undergone breast-conserving surgery (some older patients receiving hormone treatment and who have small low-grade tumours may safely avoid DXT.
Therapeutic mammoplasty is an option for some patients but requires symmetrizing surgery in most cases.
Patients who have undergone mastectomy may be offered a reconstructive procedure either in conjunction with their primary resection or as a staged procedure at a later date.
Surgical options
Mastectomy vs Wide local excision
Mastectomy Wide Local Excision
Multifocal tumour Solitary lesion
Central tumour Peripheral tumour
Large lesion in small breast Small lesion in large breast
DCIS >4cm DCIS <4cm
Patient Choice Patient choice
Central lesions may be managed using breast conserving surgery, where an acceptable cosmetic result may be obtained, this is rarely the case in small breasts
Axillary disease
As a minimum, all patients with invasive breast cancer should have their axilla staged. In those who do not have overt evidence of axillary nodal involvement this can be undertaken using sentinel lymph node biopsy.
Patients with a positive sentinel lymph node biopsy or who have imaging and cytological or histological evidence of axillary nodal metastasis should undergo axillary node clearance or axillary irradiation.
Axillary node clearance is associated with the development of lymphoedema, increased risk of cellulitis and frozen shoulder.
How would you manage any surgical bleed.
Bleeding is a process that is encountered in all branches of surgery. The decision as to how best to manage bleeding depends upon the site, vessel and circumstances.
Management of superficial dermal bleeding
This will usually cease spontaneously. If it is troublesome then direct use of monopolar or bipolar cautery devices will usually control the situation. Scalp wounds are a notable exception and the bleeding from these may be brisk. In this situation the use of mattress sutures as a wound closure method will usually address the problem.
Superficial arterial bleeding
If the vessel can be safely identified then the easiest method is to apply a haemostatic clip and ligate the vessel.
Major arterial bleeding
If the vessel can be clearly identified and is accessible then it may be possible to apply a clip and ligate the vessel. If the vessel is located in a pool of blood then blind application of haemostatic clips is highly dangerous and may result in collateral injury. In this situation evacuating the clot and packing the area is often safer. The pack can then be carefully removed when the required instruments are available. Some vessels may retract and bleeding may then be controlled by dissection of surrounding structures or under-running the bleeding point.
Major venous bleeding
The safest initial course of action is to apply digital pressure to the bleeding point. To control the bleeding the surgeon will need a working suction device. Divided veins may require ligation. Incomplete lacerations of major veins (e.g. IVC) are best repaired. In order to do this it is safest to apply a Satinsky type vascular clamp and repair the defect with 5/0 prolene.
Bleeding from raw surfaces
This may be mixed bleeding and can be troublesome. Spray diathermy and argon plasma coagulation are both useful agents. Certain topical haemostatic agents such as surgicell are useful in encouraging clot formation and may be used in conjunction with, or instead of, the above agents.
FACT
If there is a bowel resection, primary anastomosis and then bleeding is reported along with abdominal pain, it is more likely that the patient has Chron’s and not UC as resections are not undertaken for UC
How do you manage paediatric hydrocele
In children, a hydrocele is most commonly due to a persistent processus vaginalis. The swelling is intermittent and in most cases that are diagnosed in infancy the hydrocele resolves. Cases that persist beyond two years of age are best managed surgically and the surgical approach is usually made via the inguinal canal where the patent processus is identified and ligated.
Which substance related to thyroid function has its effects mediated by a nuclear receptor
Triiodothyroxine
Which of the following blood products can be administered to a non ABO matched recipient?
Platelets
Where are the prosthetic heart valves usually located on CXR
Remember AMT - 345
Aortic - 3
Usually located medial to the 3rd interspace on the right.
Mitral - 4
Usually located medial to the 4th interspace on the left.
Tricuspid - 5
Usually located medial to the 5th interspace on the right.
Duct ectasia
Dilatation breast ducts.
Most common in menopausal women
Discharge typically thick and green in colour
Most common in smokers
Breast carcinoma
Often blood stained
May be underlying mass or axillary lymphadenopathy
Intraductal papilloma
Commoner in younger patients
May cause blood stained discharge
There is usually no palpable lump
Anastomotic leak common areas
Rectal and oesophageal surgery have some of the highest rates of anastomotic leakage. Small bowel anastomosis are generally technically more forgiving
Which artery do you ligate in uncontrollable epistaxis
sphenopalatine artery
How are venous ulcers managed
Non compression bandaging
Which conditions are most likely to cause kobner phenomenon
Psoriasis
Vitiligo
Warts
Lichen planus
Lichen sclerosus
Molluscum contagiosum
How does carbimazole work
Inhibition of the thyroid peroxidase enzyme
Hodgkins lymphoma and the reporting pathologist notes that popcorn cells are present
Nodular lymphocyte predominant
Which urinary stones are associated with inherited metabolic disorders
Cysteine stones
What is the approximate volume of pancreatic secretions in a 24 hour period?
1500mls
How does epirubicin work
It is a cytotoxic agent that causes DNA intercalation
Common chemo agents and their modes of action
5 FU S Phase specific drug, mimics uracil and is incorporated into RNA
Doxorubicin Inhibits DNA and RNA synthesis by intercalating base pairs
Etoposide Inhibits topoisomerase II, prevents efficient DNA coiling
Cisplatin Crosslinks DNA, this then distorts molecules and induces apoptosis (similar to alkylating agents)
Cyclophosphamide Phosphoramide mustard forms DNA crosslinks and then cell death
Docetaxal Disrupts microtubule formation
Which of the anaesthetic agents listed below is associated with hepatotoxicity?
Halothane
How to deal with a nasal injury
Nasal injuries can be challenging to manage and where there is tissue loss, it can be difficult to primarily close them and still obtain a satisfactory aesthetic result. Debridement together with a rotational flap would obtain the best results here.
What are the indications for a parathyroidectomy
Elevated serum Calcium > 1mg/dL above normal
Hypercalciuria > 400mg/day
Creatinine clearance < 30% compared with normal
Episode of life-threatening hypercalcaemia
Nephrolithiasis
Age < 50 years
Neuromuscular symptoms
Reduction in bone mineral density of the femoral neck, lumbar spine, or distal radius of more than 2.5 standard deviations below peak bone mass (T score lower than -2.5)
What is B/L fascial nerve palsy a good sign of?
Sarcoid
Nerve root values of the external anal sphincter
S2, 3, 4 Keeps the poo off the floor
How would you diagnose a thyroid lymphoma
Thyroid lymphoma (Non Hodgkin’s B cell lymphoma) is rare. It should be considered in patients with a background of Hashimoto’s thyroiditis and a rapid growth in size of the thyroid gland. Diagnosis can be made with core needle biopsy; however an incisional biopsy may be needed. Radiotherapy is the main treatment option.
How is anatomical dead space measured
Anatomical dead space is measured by Fowlers method.
When performing minor surgery in the scalp, which of the following regions is considered a danger area as regards spread of infection into the CNS?
Loose areolar tissue
Which colonic tumour types carry the highest risk of malignant transformation
Villous adenomas carry the highest risk of malignant transformation
What is the most common cause of hypercalcaemia in the UK in hospitalised patients?
Metastatic malignancy
What is the most common cause of hypercalcaemia in the UK community?
Primary hyperparathyroidism
How does hypovolaemic shock cause to urinalysis
Hypovolaemic shock is likely to compromise renal blood flow especially if blood pressure falls below the range at which the kidney is able to autoregulate its blood flow. The result of this will be an increase of the specific gravity as water retention occurs in an attempt to maintain circulating volume.
Which of the anaesthetic agents below is most likely to induce adrenal suppression?
Etomidate
it inhibits adrenal mitochondrial 11-β hydroxylase, the enzyme responsible for the final conversion of 11-deoxycortisol to cortisol
Different kinds of abscesses
Perianal - Most common and very superficial
Ischioanal abscess - Second most common cause of anal sepsis and lies lateral to the levetor ani
Horshoe - Basically IA but on both sides
Intersphincteric - between the sphincters
Supralevetor - As the name suggests, can happen from abdominal infections such as appendicitis tracking down
Which site produces DHEA
Adrenal cortex
Which is the most common type of melanomas
Superficial spreading is the most common and nodular is second. Legs and trunk are more affected in these two.
What are the diseases hypospadias is linked to
Cleft lip/palate
Congenital HD
Inguinal hernia
Undescended testes
What kind of tissue change can you see in a patient with hypotensive ischemia
Liquefaction necrosis
What activates the release of pepsinogen
Acid pH and pre-existing pepsinogen
What happens to the renal blood flow when there is a ureteric stone obstruction
It initially increases and then decreases
What is the commonest pathology of the limping child between the ages 4-8
Perthes disease: Avascular necrosis of the femoral head.
How would you diagnose a gastric volvulus
Borchardt’s triad: Epigastric pain, retching without vomiting and inability to pass NG tube
What are the physiological and histological changes associated with ARDS
Increased capillary permiability
Interstitial and alveolar fibrosis and oedema
Fibrin exudation
Hyaline formation
FACT
Parasitic infections can cause Type 1 hypersensitivity reactions and liver flukes are parasites
What is thw maximum dose of levobupivocaine
2mg per kg
Post splenectomy
Poperdin will be absent and it is produced by the spleen
What is CD20
It is a B cell lymphoma marker
Adductor canal compression vs popliteal fossa entrapment
Adductor canal compression syndrome most commonly presents in young males and is an important differential diagnosis in men presenting with symptoms of acute limb ischaemia on exertion. It is caused by compression of the femoral artery by the musculotendinous band from adductor magnus muscle.
The treatment consists of the division of the abnormal band and restoration of the arterial circulation. Popliteal fossa entrapment is the main differential diagnosis, however the pulse disappears when the knee is fully extended.
What is the most useful test for a 5 year old who has vesicoureteric reflux in whom there are concerns about the potential of renal scarring?
DMSA scan
At which of the following sites is the most water absorbed?
Jejunum
Dysphagia lusoria
Dysphagia lusoria is caused by compression of the esophagus from any of several congenital vascular abnormalities. The vascular abnormality is usually an aberrant right subclavian artery arising from the left side of the aortic arch, a double aortic arch, or a right aortic arch with left ligamentum arteriosum. The dysphagia may develop in childhood or later in life as a result of arteriosclerotic changes in the aberrant vessel.
Barium swallow shows the extrinsic compression, but arteriography is necessary for absolute diagnosis.
What is the relation between Betablockers and insulin
Atenolol inhibits insulin release
Gustilo and Anderson’s classifications
Key points in management of fractures
Immobilise the fracture including the proximal and distal joints
Carefully monitor and document neurovascular status, particularly following reduction and immobilisation
Manage infection including tetanus prophylaxis
IV broad spectrum antibiotics for open injuries
As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution)
Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury
Aschoff-Rokitansky sinuses
Chronic Cholecystitis sign on histology
What structures can arise from musculoaponeurotic structures
Desmoid tumours are fibrous neoplasms arising from musculoaponeurotic structures. They are usually treated (regardless of site) by radical surgical resection, in some patients radiotherapy and chemotherapy may be considered. High tendency for local recurrence
Why is a trachy a better option for ventilator-weaning patients
Work of breathing is decreased which is one of the reasons it is a popular option for weaning ventilated patients
Explain fluid compartmentalisation in the body
What does amyloidosis appear like on histology
Amyloidosis = apple green birefringence with polarised light
What type of virus is Hepatitis B?
Double stranded DNA virus
What is the most common cause of filariasis
W. Bancrofti is the commonest cause of filariasis leading to lymphatic obstruction
How do you identify medullary breast cancer on histology
Medullary breast cancer is a breast cancer of special type. Histologically, it is characterised by a marked lymphocytic infiltrate. Very good prognosis
Operation for lymphoedema
Hoomans operation: excision of the subcutaneous tissue beneath the affected skin and covering the defect with skin flaps or a full or split-thickness grafts
Factors contributing to poor wound healing
D iabetes
I nfection, irradiation
D rugs eg steroids, chemotherapy
N utritional deficiencies (vitamin A, C & zinc, manganese), Neoplasia
O bject (foreign material)
T issue necrosis
H ypoxia
E xcess tension on wound
A nother wound
L ow temperature, Liver jaundice
Histology of a carotid body tumour
Carotid body tumours are the commonest type of head and neck paraganglionoma.
What is the number one cause of lower GI bleed in children of ages 1 & 2
Meckels diverticulum is the number one cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years.
Managing splenic bleeds
The argon plasma coagulation system is very good for managing splenic bleeding.
How to decide air insufflation pressures for Laparoscopic surgery
Pressures lower than 7mm Hg are not usually compatible with satisfactory views. Pressures >15mm Hg are usually associated with decreased venous return and hypotension. 10 is good
Which thyroid cancer is most known to cause lymph node spread
Papillary
What are the different types of grafts
What is the % of patients that have synchronous colonic lesions
5%
Endoscopy and different kinds of prep
Flaps in BKA
Skew and Burgess flaps
What is a good post op measure of recovery
Serum albumin levels. It is also a negative acute phase reactant and levels decrease in sepsis and inflammation
What is a good post cancer measure of recovery?
Serum albumin levels. It is also a negative acute phase reactant and levels decrease in sepsis and inflammation
About cleft lip
Left more common than the right and B/L
How do you treat actinic keratoses
Liquid nitrogen or 5FU
What are the different degrees of kidney injury
1 - Non expanding subcapsular haematoma
2 - Superficial laceration <1 cm not involving the collecting system
3 - >1cm and no collecting system or vessel involvements
4 - Urinary extravasation
5 - Shattered kidney and avulsion of renal vessels
What is DNA proofreading
The method by which DNA errors are corrected. It detects base pair mismatch
What is commonly the result of injury to the middle meningeal artery
Extradural haematoma
What is a significant perioperative risk for MI
Operation for an MI carried out within the last 3-6 months carries re-infarction risk of 10%
What are the mechanical effects of tourniquet
Can cause demyelination of peripheral nerves (neuropraxia is most common)
How do you treat the different stages of empyema
Thoracoscopy and decortication for stage 3 empyema. VATS for stage 2 and chest drain for stage 1/ early stage 2.
Indications for thoracoscopy are: Resp disability, Thich fibrous peel, multiloculated stage 3 empyema.
What is pott puffy tumour
A rare complication of sinusitis. Subperiosteal abscess present. Frontal sinus most commonly affected and presents with swelling of the forehead. HI can sometimes cause ot but most commonly staph and strep. MRI or CT to diagnose and treat with IV ABx.
What are the phases of raised ICP
Initially, pupils constrict due to sympathetic nerve fibres being squashed, but then dilate when the optic nerve is blocked. Complete third nerve palsy can also occur.
Peritonsillar abscess
Strep pyo is the most common causative agent.
What is the most common cause of neonatal bowel obstruction
Meconium plugs
From which embryological structure is the ureter derived?
The mesonephric duct
How do margins of excision relate to Breslow depth
Infections from which organism causes the development of staghorn calculi
Proteus mirabilis
What is not included in TPN
Fibre
The normal adult blood volume is approximately what percentage of body weight
7%
Blood loss indication chart
What is deficient in the platelets in grey platelet syndrome
Alpha granules. GPS is very rare but forms abnormally large, agranular platelets causing splenomegaly and myelofibrosis
What would you expect on a thalassemia trait blood panel
Hypochromic microcytic
CEA and smokers
CEA can be elevated in smokers, UC, pancreatitis and liver cirrhosis
When do you give prophylactic antibiotics
Contaminated Surgery; Clean-contaminated surgery; Placement of prosthesis and hip implants
Most common paraneoplastic syndrome in renal cancers
Hypercalcaemia
What is the relation between signet rings and gastric cancer
Signet ring cells are features of poorly differentiated gastric cancer associated with a increased risk of metastatic disease.
Re-do fundoplication and gastric emptying
Redo fundoplication surgery carries with it a risk of damaging the vagus nerves. If both are damaged, there will be delay to gastric emptying
Where is the majority of iron found in the body?
Hb
What T tube is common after CBD exploration
T tube drain that is latex as it helps in forming a tract
What is the half life of insulin in the circulation of a normal healthy adult?
Less than 30 mins
Which drugs cause pseudo haematuria
Rifampicin, phenytoin, levodopa, methyldopa, and quinine all cause pseudohaematuria.
Thing to know about temporal artery biopsy
50% may be non diagnostic
Why are right sided live donor kidney transplants extremely rare
Right sided live donor transplants are extremely rare. This is because the vena cava precludes mobilisation of the right renal artery. The short right renal artery that is produced therefore presents a major challenge
TK arteritis standard findings
Takayasu’s arteritis most commonly affects young Asian females. Pulseless peripheries are a classical finding.
Different forms of treatment of a rectal prolapse
Perineal approaches include the Delormes operation, this avoids resection and is relatively safe but is associated with high recurrence rates. An Altmeirs operation involves a perineal excision of the sigmoid colon and rectum, it may be a more effective procedure than a Delormes but carries the risk of anastomotic leak.
Rectopexy - this is an abdominal procedure. The rectum is mobilised and fixed onto the sacral promontary. A prosthetic mesh may be inserted. The recurrence rates are low and the procedure is well tolerated (particularly if performed laparoscopically). Risks with ventral mesh rectopexy include chronic pain and visceral mesh erosions.
Thirsch tape- this is a largely historical procedure and involves encircling the rectum with tape or wire. It may be of use in a palliative setting.
What is a bankart lesion
A Bankart lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it.
What nerve is most commonly injured during axillary node clearance
The most likely explanation for this is that the thoracodorsal nerve has been injured. This will result in atrophy of latissimus dorsi and this will become evident with repetitive arm movements where the arm is elevated and moving up and down (such as in painting). Injury to the pectoral nerves may produce a similar picture but this pattern of injury is very rare and the pectoral nerves are seldom injured in breast surgery.
What is the receptor difference between coronary and cardiac
It’s cardiac effects are mediated via β 1 receptors. The coronary arteries which have β 2 receptors are unaffected by adrenaline
What is a Bolam test
The Bolam test defines if a decision made by a doctor is in agreement with the professional standard of medical practise.
How likely is iliopsoas abscess recurrence
15-20%
What is the definitive management of thyroid disease
The recurrence of symptoms following medical therapy attracts a recommendation for definitive treatment. Since radio-iodine can worsen eye signs, this is not a wise choice. Surgery in the form of a total thyroidectomy would be curative.
What is median arcuate ligament syndrome
Median arcuate ligament syndrome is largely a diagnosis of exclusion. The classic signs of epigastric pain with an audible bruit are only found in a minority. Where the condition is suspected, the diagnosis is usually apparent on duplex scanning (in thin patients) or with CT angiography.
From which of the following amino acids are catecholamines primarily derived?
Tyrosine
GIST tumour cells are located in
Cajal cells
Which of the following sutures is most suitable for the mass closure of an abdominal wall following a laparotomy?
1
Suture sizes are assessed on the French gauge scale. 1/0 is thicker than 6/0.
Note though that 1 is thicker than 1/0 and 5 is thicker than 1. When the /0 is removed they become thicker with ascending numerical value
What is the Nottingham prognostic index
FACT
ATN and kidney injury do not respond to IV fluids as the injury is inside the kidney already and not pre-renal
Mirzzi syndrome
Stones becoming impacted in the Hartmans pouch causing fistulation. This can make delineating the anatomy of the calots triangle really challenging
Malignancy after hellers for achalasia
Achalasia is a rare condition. However, even once treated there is an increased risk of malignancy. When it does occur it is most likely to be of squamous cell type.
Which anaesthetic drug is the least likely to release histamine
Suxa
What does having multiple myeloma do to the sodium
Hyperlipidaemia and multiple myeloma are known to cause a pseudo hyponatraemia, this is due to raised protein and oncotic pressure that causes dilution
What are the types of opioid receptors
4 Types of opioid receptor:
δ (located in CNS)- Accounts for analgesic and antidepressant effects
k (mainly CNS)- analgesic and dissociative effects
µ (central and peripheral) - causes analgesia, miosis, decreased gut motility
Nociceptin receptor (CNS)- Affect of appetite and tolerance to µ agonists.
What is the annual probability of strangulation of a direct hernia
The annual probability of strangulation is up to 3% and is more common in indirect hernias
Where is most of the calcium absorbed
Ileum, only 10% is absorbed in the Colon.
How is a laparotomy performed in children
In young children, laparotomy is performed via transverse supra umbilical incision. Access via midline incisions is very poor and they should not be used.
What in a spleen is most posterior
Lineorenal ligament
FACT
Young females at very high risk of breast cancer should undergo annual MRI.
Coagulation cascade and related
What is pes anserinus
Pes anserinus: GOOSE’S FOOT
Combination of sartorius, gracilis and semitendinous tendons inserting into the anteromedial proximal tibia.
Pes Anserinus Bursitis is common in sportsmen due to overuse injuries. The main sign is of pain in the medial proximal tibia. As the McMurray test is negative, medial meniscal injury is excluded.
What can increase 5 HIAA
Food: spinach, cheese, wine, caffeine, tomatoes
Drugs: Naproxen, Monoamine oxidase inhibitors
Recent surgery
What is the relation between vas deferens and cystic fibrosis
99% of males with cystic fibrosis will have absent vas
Anal fissures are most common anterior or posterior
painful mucocutaneous defect in the posterior midline (90% cases). Anterior is 10% and should be investigated for the source
What are the different types of lactic acidosis
Type A - Reduced tissue ATP due to poor oxygenation
Type B1 - systemic disease
B2 - Drugs
B3 - Abnormalities in metabolism
FACT
Fibular flap is a very vascular piece of bone and is commonly used for mandibular reconstruction
What are the things that can cause hypercalaemia
Mnemonic for the causes of hypercalcaemia:
CHIMPANZEES
C alcium supplementation
H yperparathyroidism
I atrogentic (Drugs: Thiazides)
M ilk Alkali syndrome
P aget disease of the bone
A cromegaly and Addison’s Disease
N eoplasia
Z olinger-Ellison Syndrome (MEN Type I)
E xcessive Vitamin D
E xcessive Vitamin A
S arcoidosis
How do you manage seborrhoeic warts
These are usually superficially sited and are best managed with shave biopsy and cautery. These can also be irregular and multi-coloured
Organisms causing post-splenectomy sepsis
Organisms causing post splenectomy sepsis:
Streptococcus pneumoniae
Haemophilus influenzae
Meningococci
Sickle cell disease and low Hb
Sudden anaemia and a LOW reticulocyte count indicate parvovirus. High reticulocyte count can be seen in sequestration and haemolysis
Babinski sign = which tract lesion?
Pyramidal tract
Common transfusion reactions
Pyrexia is the most common adverse event in transfusing packed red cells
Urticaria is the most common adverse event following infusion of FFP
Most common cause of diaphragm disease
Diaphragm disease of the small intestine is caused by NSAIDS in most cases and treated by surgical resection.
What is the most common method of sterilisation for operating theatre
Saturated Steam (Autoclaving): Hold time is 3 minutes under 134C and 15 mins under 121C.
Bankart vs hill Sachs lesions
Hill Sach - Posterior-lateral humeral head dislocation causing lesion in the back
Bankart - Opposite
https://www.youtube.com/watch?v=a6BWiufgmsc
What is the most common site of ureteric stone impaction
UVJ
Surgical procedure that requires one lung ventilation
VATS procedure
Cell type of the immune system that does not have Fc portion for iGG
T cells as they can only be activated by HLA
Brain necrosis
Infarction causes liquefactive necrosis. Coagulative necrosis is more common where there is fatty tissue and hence very uncommon in the brain. Caseous necrosis is most commonly seen in TB infections
Because MRCS prep, turns your brain into liquid, hence, liquifactive (colliquative) necrosis
Which lung lesion is the least likely to undergo a surgical resection
That being the case, the correct answer is small cell lung cancer as they are nearly always disseminated at diagnosis.
VHL syndrome
Features
cerebellar haemangiomas
retinal haemangiomas: vitreous haemorrhage
renal cysts (premalignant)
phaeochromocytoma
extra-renal cysts: epididymal, pancreatic, hepatic
endolymphatic sac tumours
FACT
Low Mg also results in Low Ca Absorption
Suxa and crush fractures
Suxamethonium may induce hyperkalaemia as it induces generalised muscular contractions. In patients with likely extensive tissue necrosis this may be sufficient to produce cardiac arrest.
Cancer associated with wood work
Paranasal sinus cancer is strongly associated with wood work.
Ameloblastoma
Rare cancer and crepitus is felt
Ameloblastoma is a rare, noncancerous (benign) tumor that develops most often in the jaw near the molars. Ameloblastoma begins in the cells that form the protective enamel lining on your teeth. The most common type of ameloblastoma is aggressive, forming a large tumor and growing into the jawbone.
What is the investigation of choice for upper airway compression
Flow volume loop is the investigation of choice for upper airway compression.
Which CNS tumour most commonly displays necrosis
Significant necrosis is more commonly seen with glioblastomas than with other CNS tumours.
Why inguinal approach for orchidectomy
Oncological orchidectomy is routinely performed via an inguinal approach to avoid contamination of another lymphatic field.
Which one of the following cells secretes the majority of tumour necrosis factor in humans?
Macrophages
Infection in a breast feeding woman. Which organism
Staph Auerus
Why is a mucus fistula made
They are typically seen following a sub total colectomy where the distal sigmoid colon is deemed too friable to close and it then brought onto the skin as a mucous fistula.
What is the pneumonic for the causes of gynaecomastia
Mnemonic for drugs causing gynaecomastia: DISCO
D igitalis
I soniazid
S pironolactone
C imetidine
O estrogen
Mnemonic for causes of gynaecomastia: METOCLOPRAMIDE
M etoclopramide
E ctopic oestrogen
T rauma skull/tumour breast, testes
O rchitis
C imetidine, Cushings
L iver cirrhosis
O besity
P araplegia
R A
A cromegaly
M ethyldopa
I soniazid
D igoxin
E thionamide
What is the correct thing to do with lymph nodes when Hodgkins lymphoma is suspected?
Excision biopsy of the lymph node
Which of the following laryngeal tumours will not typically metastasise to the cervical lymph nodes?
Glottic as the vocal cords themselves have no lyphatic drainage and hence acts as a watershed region
Which of the following surgical energy devices would be most appropriate for the dissection of the posteriomedial aspect of the thyroid gland during thyroidectomy
Bipolar as the diathermy is contained between the electrodes and this reduces damage to the recurrent laryngeal nerve
Which mechanism is associated with avulsion fractures
Muscle contractions
What is the minimum amount of time required to see callus on an X ray
About 2-3 weeks
Which vein does prostate cancer spread from
Internal vertebral venous plexus. This is also called the Batson’s plexus and it is clinically relevant as the vein is valveless and hence a route for metastatic spread
Causes of primary hyperparathyroid
Adenoma is the most common (80-90%) -> Hyperplasia (10-15%) next and then carcinoma (<1%)
LCIS of breast
Other breast may also be involved. It does not have any preceeding symptoms
What is the role of b12 in red cells
Aids in the maturation process
Swan Ganz catheter
Used to measure PAOP
What is a phyllodes tumour
Is like a fibroadenoma, fast growing and present in women with large breasts.
Important information about carcinoid tumours
Rule of thirds:
1/3 multiple
1/3 small bowel
1/3 metastasize
1/3 second tumor
Liver metastases need to be present in order to have carcinoid syndrome
Most common secretion in the splenic bed post-splenectomy
Amylase as the pancreatic head of often times damaged and amylase will drain into the splenic bed via the pancreatic duct
What are Psammoma bodies?
Psammoma bodies consist of clusters of microcalcification. They are most commonly seen in papillary carcinomas.
What is the hadfields procedure
Used to treat duct ectasia as there are multiple ducts involved
Single duct pathology= microdochectomy
Some key facts about neutrofils
Neutrophils are the main cells of acute inflammation, important action against gram -ve and +ve bacteria
Appearance of segmented nucleus and granulated cytoplasm
Have a lifespan of 1-3 days (shorter when consumed during septic process, though 9 hours is unusual)
Actions include: movement, opsonise microorganisms, phagocytosis & intracellular killing of microorganisms via aerobic (produce HYDROGEN PEROXIDE) & anaerobic mechanisms.
Neutrophil disorders include chronic granulomatous diseases: rare
AIDS associated with T cell deficiency
What are the Kocher criteria for paediatric orthopaedic surgery
Kocher’s ‘WIFE’ is:
WCC >12
Inability to weight bear
Fever
ESR >40
= >90 chance of septic arthritis
Prosthesis infection most common infective agent
Staph epidermis. Makes a biofilm and is usually very difficult to eradicate. Treatment usually involves removal of the implant
What is the first nerve to be affected in raised ICP
Abducens
Ventricle tumours in children
Ependymoma account for up to 33% of CNS tumours in those under age of 3. They commonly arise in the 4th ventricle and can grow through the foramina of Luschka and Magendie
FACT
Portacaths are very good for children as they only need to be looked at when accessing
FACT
In patients with major cardiac co-morbidities the safest option is to choose an axillo-bifemoral bypass graft. The long term patency rates are less good than with aorto-bifemoral bypass grafts, however, the operation is less major.
A 73 year old lady sustains a distal radius fracture and this is manipulated using a Biers block with prilocaine as the local anaesthetic agent. During the procedure the occlusion cuff deflates and the patient becomes progressively cyanosed. What is the treatment of choice?
Methyline blue
Prilocaine is a recognised cause of methaemoglobinaemia, this is characterised by the development of cyanosis and dyspnoea. This disorder occurs because of the change haemoglobin to a ferric subtype rather than ferrous (Fe2+). This type of change shifts the oxygen dissociation curve to the left and tissue hypoxia occurs. Methylene blue will revert the haemoglobin to the ferrous type and reverse this effect.
When should you operate on umbilical hernias in children
Many umbilical hernias will close in the first year of life. Defer surgery until the child is 3 years or older.
Gastric cell secretions
Parietal cells: secrete HCl, Ca, Na, Mg and intrinsic factor
Chief cells: secrete pepsinogen
Surface mucosal cells: secrete mucus and bicarbonate
GA type fracture classifications
1 <1cm injury
2 >icm injury with moderate soft tissue injury
3 10cm or more with soft tissue damage
3a Adequate soft tissue coverage
3b inadequate soft tissue coverage
3c Associated arterial injury
What is the main reason for hypoxia in ARDS
The diffuse lung injury, which is associated with loss of surfactant and increased elastase release from neutrophils, results in fluid accumulation. This leads to reduced diffusion, which is the main reason for hypoxemia.
Breast reconstruction preferred closure
The use of a pedicled latissimus dorsi flap is a common method of providing breast reconstruction over an implant. Free flaps do not heal as reliably as pedicled ones and these would therefore be used in preference in this particular setting.
What kind of affinity for oxygen does stored blood have
Stored blood has less 2,3 DPG and therefore has a higher affinity for oxygen, this reduces its ability to release it at metabolising tissues.
When should patients commence food post bowel surgery
As part of the enhanced recovery principles oral intake in this setting should resume soon after surgery (within 24 hours). Administration of a liquid and even light diet does not increase the risk of anastomotic leak.
Also administration of carbohydrate-rich drink 3 hours before op is common
FACT
Dextrans are branched polysaccharide molecules. Dextran 40 and 70 are available. The higher molecular weight dextran 70 may persist for up to 8 hours. They inhibit platelet aggregation and leucocyte plugging in the microcirculation. Thereby improving flow through the microcirculation, primarily of use in sepsis.
Unlike many other intravenous fluids Dextrans are a recognised cause of anaphylaxis.
What raises suspicion of a marjolins ulcer
Heaped or raised borders should raise suspicion of a marjolins ulcer.
Embryological origin stapes
Embryological origin stapes = 2nd pharyngeal arch
What is most commonly seen on hyperacute rejection of solid organ histology
Thrombosis is more commonly seen in the hyperacute phase. neo intimal hyperplasia is more commonly seen in the chronic setting
Interpretation of JVP waves
JVP
3 Upward deflections and 2 downward deflections
Upward deflections
a wave = atrial contraction
c wave = ventricular contraction
v wave = atrial venous filling
Downward deflections
x wave = atrium relaxes and tricuspid valve moves down
y wave = ventricular filling
Diagnosing Perthes disease
MRI will show subtle changes in blood supply
Insulinomas
Insulin producing tumours of the pancreatic β cells
Incidence of 1 per 1,000,000 per year
90% of lesions are benign
Most tumours less than 2cm in size
Between 5 and 10% have MEN type 1
75% of patients with MEN 1 will develop pancreatic islet cell tumours
Treatment is enucleation of the lesion
FACT
The rectum can contain high levels of potassium
Causes of hyperacusis
Damage to the nerve in the bony canal may result in impaired innervation to stapedius and therefore sounds are no longer dampened. Another cause of hyperacusis is increased activity in the tensor tympani muscle, this is innervated by the trigeminal nerve.
Multiple sinuses and fistulae in wound
The presence of chronic sinuses together with gram positive organisms and sulphur granules is highly suggestive of Actinomycosis.
Heparin regime for vascular procedures
As a rule most vascular surgeons will administer approximately 3,000 units of systemic heparin 3-5 minutes prior to cross clamping to help prevent further intra arterial thromboses. A dose of 30,000 units is given prior to going on cardiopulmonary bypass. Heparin given at induction will cause bleeding during routine dissection.
Gastric tumour resection rules
Proximally sited disease greater than 5-10cm from the OG junction may be treated by sub total gastrectomy
Total gastrectomy if tumour is <5cm from OG junction
For type 2 junctional tumours (extending into oesophagus) oesophagogastrectomy is usual
FACT
LHRH analogues may cause flare of metastatic disease and anti androgens should be administered to counter this
How does the pancreas develop
The pancreas develops from a ventral and dorsal endodermal outgrowth of the duodenum.
What do you do with a diverticular stricture causing large bowel obstruction
Diverticular strictures have a high complication rate with stent insertion. Where patients present with large bowel obstruction, the best option is to resect the affected area. Given the fact that there is underlying colonic obstruction, a primary anastomosis would be unwise. Diverticular strictures should not be dilated.
Perform Hartmann’s
Septic knee most common organism
Staph auerus
Fact
B Blockers reduce the secretion of renin
About hamartommas
A benign neoplasm that is comprised of tissue structures normally found within that site or organ.
The lung is one of the commonest site of hamartoma formation and they comprise around 5% of all lung lesions.
They generally have a good prognosis and do not require excision unless symptomatic.
What is the goodsals rule
Goodsals rule:
Anterior fistulae will tend to have an internal opening opposite the external opening. (straight)
Posterior fistulae will tend to have a curved track that passes towards the midline. (curved)
Anaesthesia on applying deodarant
The intercostobrachial nerves traverse the axilla and innervate the overlying skin. These can be injured or divided during axillary surgery and the result is anaesthesia of the overlying skin.
Leriche syndrome
Leriche syndrome
Classically, it is described in male patients as a triad of symptoms (Claudication, atrophy and impotence):
- Claudication of the buttocks and thighs
- Atrophy of the musculature of the legs
- Impotence (due to paralysis of the L1 nerve)
Leriche syndrome, is atherosclerotic occlusive disease involving the abdominal aorta and/or both of the iliac arteries. Management involves correcting underlying risk factors such as hypercholesterolaemia and stopping smoking. Investigation is usually with angiography.
Can be treated with angioplasty and or stent insertion
Obesity hormones
Obesity hormones
leptin decreases appetite
ghrelin increases appetite (sounds like an animal is growling because of hunger)
Rockall score
Mnemonic for Rockall score
ABCDE
A: Age
B: Blood pressure drop (Shock)
C: Co-morbidity
D: Diagnosis
E: Evidence of bleeding
FACT
The prevalence of a condition is equal to pre test probability
Drugs that can cause hypercalcaemia
Mnemonic of the drugs causing hyperuricaemia as a result of reduced excretion of urate
‘Can’t leap’
C iclosporin
A lcohol
N icotinic acid
T hiazides
L oop diuretics
E thambutol
A spirin
P yrazinamide
FACT
Birds are a recognised reservoir of campylobacter.
Start and finish levels of the trackea
The trachea commences at C6. It terminates at the level of T5
Colonic polyp surviellance
MEN
Hinchey classifications
Salter Harris type fracture
What are the zones of flexor tendon injury
What are the child-pugh classification of liver disease
