Science deck Flashcards

1
Q

Upper GI bleed while being on lots of PPI

A

Gastrinoma and Zollinger Ellison Syndrome

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2
Q

Phaeochromocytoma and the rule of 10s

A

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.

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3
Q

How can you tell if an incidental adrenal lesion is benign

A

Factors suggesting benign disease on CT include(4):
Size less than 3cm
Homogeneous texture
Lipid rich tissue
Thin wall to the lesion

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4
Q

What is the standard first-line treatment for anal cancer

A

Combined chemoradiotherapy is the standard treatment for anal cancer

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5
Q

Anal cancer

A

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

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6
Q

Where is the vomiting centre located?

A

Medulla oblongata

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7
Q

What are the indications for an escharotomy?

A

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)

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8
Q

Which anaesthetic agent has the strongest ant emetic properties

A

Propofol

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9
Q

What type of hypersensitivity reaction is TB

A

Type 4 (delayed) - Granulomas delayed

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10
Q

Extra-intestinal features of IBD

A

Extraintestinal manifestation of inflammatory bowel disease: A PIE SAC

Aphthous ulcers
Pyoderma gangrenosum
Iritis
Erythema nodosum
Sclerosing cholangitis
Arthritis
Clubbing

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11
Q

Renal Stones management

A

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

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12
Q

Ureteric stone

A

Size First line option
Less than 5mm Watchful waiting
5-10mm ESWL (if upper ureter)
10-20mm Ureteroscopy

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13
Q

Which type of renal stone most commonly develops in chemo patients

A

Uric acid stones, theses are radiolucent and will not show up on XRKUB. Chemotherapy and cell death can increase uric acid levels

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14
Q

Which clotting factors are affecting by temperature

A

Factors V and VIII are sensitive to temperature which is the reason why FFP is frozen soon after collection.

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15
Q

Klippel-Trenaunay-Weber (KTW)

A

port-wine stains, varicose veins, and bony or soft-tissue hypertrophy.

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16
Q

Breast Cancer

A

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.

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17
Q

How would you manage any surgical bleed.

A

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.

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18
Q

FACT

A

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

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19
Q

How do you manage paediatric hydrocele

A

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.

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20
Q

Which substance related to thyroid function has its effects mediated by a nuclear receptor

A

Triiodothyroxine

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21
Q

Which of the following blood products can be administered to a non ABO matched recipient?

A

Platelets

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22
Q

Where are the prosthetic heart valves usually located on CXR

A

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.

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23
Q

Duct ectasia

A

Dilatation breast ducts.
Most common in menopausal women
Discharge typically thick and green in colour
Most common in smokers

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24
Q

Breast carcinoma

A

Often blood stained
May be underlying mass or axillary lymphadenopathy

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25
Intraductal papilloma
Commoner in younger patients May cause blood stained discharge There is usually no palpable lump
26
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
27
Which artery do you ligate in uncontrollable epistaxis
sphenopalatine artery
28
How are venous ulcers managed
Non compression bandaging
29
Which conditions are most likely to cause kobner phenomenon
Psoriasis Vitiligo Warts Lichen planus Lichen sclerosus Molluscum contagiosum
30
How does carbimazole work
Inhibition of the thyroid peroxidase enzyme
31
Hodgkins lymphoma and the reporting pathologist notes that popcorn cells are present
Nodular lymphocyte predominant
32
Which urinary stones are associated with inherited metabolic disorders
Cysteine stones
33
What is the approximate volume of pancreatic secretions in a 24 hour period?
1500mls
34
How does epirubicin work
It is a cytotoxic agent that causes DNA intercalation
35
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
36
Which of the anaesthetic agents listed below is associated with hepatotoxicity?
Halothane
37
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.
38
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)
39
What is B/L fascial nerve palsy a good sign of?
Sarcoid
40
Nerve root values of the external anal sphincter
S2, 3, 4 Keeps the poo off the floor
41
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.
42
How is anatomical dead space measured
Anatomical dead space is measured by Fowlers method.
43
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
44
Which colonic tumour types carry the highest risk of malignant transformation
Villous adenomas carry the highest risk of malignant transformation
45
What is the most common cause of hypercalcaemia in the UK in hospitalised patients?
Metastatic malignancy
46
What is the most common cause of hypercalcaemia in the UK community?
Primary hyperparathyroidism
47
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.
48
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
49
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
50
Which site produces DHEA
Adrenal cortex
51
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.
52
What are the diseases hypospadias is linked to
Cleft lip/palate Congenital HD Inguinal hernia Undescended testes
53
What kind of tissue change can you see in a patient with hypotensive ischemia
Liquefaction necrosis
54
What activates the release of pepsinogen
Acid pH and pre-existing pepsinogen
55
What happens to the renal blood flow when there is a ureteric stone obstruction
It initially increases and then decreases
56
What is the commonest pathology of the limping child between the ages 4-8
Perthes disease: Avascular necrosis of the femoral head.
57
How would you diagnose a gastric volvulus
Borchardt's triad: Epigastric pain, retching without vomiting and inability to pass NG tube
58
What are the physiological and histological changes associated with ARDS
Increased capillary permiability Interstitial and alveolar fibrosis and oedema Fibrin exudation Hyaline formation
59
FACT
Parasitic infections can cause Type 1 hypersensitivity reactions and liver flukes are parasites
60
What is thw maximum dose of levobupivocaine
2mg per kg
61
Post splenectomy
Poperdin will be absent and it is produced by the spleen
62
What is CD20
It is a B cell lymphoma marker
63
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.
64
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
65
At which of the following sites is the most water absorbed?
Jejunum
66
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.
67
What is the relation between Betablockers and insulin
Atenolol inhibits insulin release
68
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
69
Aschoff-Rokitansky sinuses
Chronic Cholecystitis sign on histology
70
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
71
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
72
Explain fluid compartmentalisation in the body
73
What does amyloidosis appear like on histology
Amyloidosis = apple green birefringence with polarised light
74
What type of virus is Hepatitis B?
Double stranded DNA virus
75
What is the most common cause of filariasis
W. Bancrofti is the commonest cause of filariasis leading to lymphatic obstruction
76
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
77
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
78
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
79
Histology of a carotid body tumour
Carotid body tumours are the commonest type of head and neck paraganglionoma.
80
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.
81
Managing splenic bleeds
The argon plasma coagulation system is very good for managing splenic bleeding.
82
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
83
Which thyroid cancer is most known to cause lymph node spread
Papillary
84
What are the different types of grafts
85
What is the % of patients that have synchronous colonic lesions
5%
86
Endoscopy and different kinds of prep
87
Flaps in BKA
Skew and Burgess flaps
88
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
89
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
90
About cleft lip
Left more common than the right and B/L
91
How do you treat actinic keratoses
Liquid nitrogen or 5FU
92
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
93
What is DNA proofreading
The method by which DNA errors are corrected. It detects base pair mismatch
94
What is commonly the result of injury to the middle meningeal artery
Extradural haematoma
95
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%
96
What are the mechanical effects of tourniquet
Can cause demyelination of peripheral nerves (neuropraxia is most common)
97
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.
98
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.
99
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.
100
Peritonsillar abscess
Strep pyo is the most common causative agent.
101
What is the most common cause of neonatal bowel obstruction
Meconium plugs
102
From which embryological structure is the ureter derived?
The mesonephric duct
103
How do margins of excision relate to Breslow depth
104
Infections from which organism causes the development of staghorn calculi
Proteus mirabilis
105
What is not included in TPN
Fibre
106
The normal adult blood volume is approximately what percentage of body weight
7%
107
Blood loss indication chart
108
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
109
What would you expect on a thalassemia trait blood panel
Hypochromic microcytic
110
CEA and smokers
CEA can be elevated in smokers, UC, pancreatitis and liver cirrhosis
111
When do you give prophylactic antibiotics
Contaminated Surgery; Clean-contaminated surgery; Placement of prosthesis and hip implants
112
Most common paraneoplastic syndrome in renal cancers
Hypercalcaemia
113
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.
114
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
115
Where is the majority of iron found in the body?
Hb
116
What T tube is common after CBD exploration
T tube drain that is latex as it helps in forming a tract
117
What is the half life of insulin in the circulation of a normal healthy adult?
Less than 30 mins
118
Which drugs cause pseudo haematuria
Rifampicin, phenytoin, levodopa, methyldopa, and quinine all cause pseudohaematuria.
119
Thing to know about temporal artery biopsy
50% may be non diagnostic
120
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
121
TK arteritis standard findings
Takayasu's arteritis most commonly affects young Asian females. Pulseless peripheries are a classical finding.
122
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.
123
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.
124
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.
125
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
126
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.
127
How likely is iliopsoas abscess recurrence
15-20%
128
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.
129
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.
130
From which of the following amino acids are catecholamines primarily derived?
Tyrosine
131
GIST tumour cells are located in
Cajal cells
132
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
133
What is the Nottingham prognostic index
134
FACT
ATN and kidney injury do not respond to IV fluids as the injury is inside the kidney already and not pre-renal
135
Mirzzi syndrome
Stones becoming impacted in the Hartmans pouch causing fistulation. This can make delineating the anatomy of the calots triangle really challenging
136
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.
137
Which anaesthetic drug is the least likely to release histamine
Suxa
138
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
139
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.
140
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
141
Where is most of the calcium absorbed
Ileum, only 10% is absorbed in the Colon.
142
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.
143
What in a spleen is most posterior
Lineorenal ligament
144
FACT
Young females at very high risk of breast cancer should undergo annual MRI.
145
Coagulation cascade and related
146
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.
147
What can increase 5 HIAA
Food: spinach, cheese, wine, caffeine, tomatoes Drugs: Naproxen, Monoamine oxidase inhibitors Recent surgery
148
What is the relation between vas deferens and cystic fibrosis
99% of males with cystic fibrosis will have absent vas
149
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
150
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
151
FACT
Fibular flap is a very vascular piece of bone and is commonly used for mandibular reconstruction
152
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
153
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
154
Organisms causing post-splenectomy sepsis
Organisms causing post splenectomy sepsis: Streptococcus pneumoniae Haemophilus influenzae Meningococci
155
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
156
Babinski sign = which tract lesion?
Pyramidal tract
157
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
158
Most common cause of diaphragm disease
Diaphragm disease of the small intestine is caused by NSAIDS in most cases and treated by surgical resection.
159
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.
160
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
161
What is the most common site of ureteric stone impaction
UVJ
162
Surgical procedure that requires one lung ventilation
VATS procedure
163
Cell type of the immune system that does not have Fc portion for iGG
T cells as they can only be activated by HLA
164
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
165
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.
166
VHL syndrome
Features cerebellar haemangiomas retinal haemangiomas: vitreous haemorrhage renal cysts (premalignant) phaeochromocytoma extra-renal cysts: epididymal, pancreatic, hepatic endolymphatic sac tumours
167
FACT
Low Mg also results in Low Ca Absorption
168
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.
169
Cancer associated with wood work
Paranasal sinus cancer is strongly associated with wood work.
170
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.
171
What is the investigation of choice for upper airway compression
Flow volume loop is the investigation of choice for upper airway compression.
172
Which CNS tumour most commonly displays necrosis
Significant necrosis is more commonly seen with glioblastomas than with other CNS tumours.
173
Why inguinal approach for orchidectomy
Oncological orchidectomy is routinely performed via an inguinal approach to avoid contamination of another lymphatic field.
174
Which one of the following cells secretes the majority of tumour necrosis factor in humans?
Macrophages
175
Infection in a breast feeding woman. Which organism
Staph Auerus
176
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.
177
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
178
What is the correct thing to do with lymph nodes when Hodgkins lymphoma is suspected?
Excision biopsy of the lymph node
179
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
180
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
181
Which mechanism is associated with avulsion fractures
Muscle contractions
182
What is the minimum amount of time required to see callus on an X ray
About 2-3 weeks
183
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
184
Causes of primary hyperparathyroid
Adenoma is the most common (80-90%) -> Hyperplasia (10-15%) next and then carcinoma (<1%)
185
LCIS of breast
Other breast may also be involved. It does not have any preceeding symptoms
186
What is the role of b12 in red cells
Aids in the maturation process
187
Swan Ganz catheter
Used to measure PAOP
188
What is a phyllodes tumour
Is like a fibroadenoma, fast growing and present in women with large breasts.
189
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
190
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
191
What are Psammoma bodies?
Psammoma bodies consist of clusters of microcalcification. They are most commonly seen in papillary carcinomas.
192
What is the hadfields procedure
Used to treat duct ectasia as there are multiple ducts involved Single duct pathology= microdochectomy
193
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
194
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
195
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
196
What is the first nerve to be affected in raised ICP
Abducens
197
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
198
FACT
Portacaths are very good for children as they only need to be looked at when accessing
199
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.
200
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.
201
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.
202
Gastric cell secretions
Parietal cells: secrete HCl, Ca, Na, Mg and intrinsic factor Chief cells: secrete pepsinogen Surface mucosal cells: secrete mucus and bicarbonate
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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
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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.
205
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.
206
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.
207
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
208
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.
209
What raises suspicion of a marjolins ulcer
Heaped or raised borders should raise suspicion of a marjolins ulcer.
210
Embryological origin stapes
Embryological origin stapes = 2nd pharyngeal arch
211
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
212
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
213
Diagnosing Perthes disease
MRI will show subtle changes in blood supply
214
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
215
FACT
The rectum can contain high levels of potassium
216
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.
217
Multiple sinuses and fistulae in wound
The presence of chronic sinuses together with gram positive organisms and sulphur granules is highly suggestive of Actinomycosis.
218
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.
219
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
220
FACT
LHRH analogues may cause flare of metastatic disease and anti androgens should be administered to counter this
221
How does the pancreas develop
The pancreas develops from a ventral and dorsal endodermal outgrowth of the duodenum.
222
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
223
Septic knee most common organism
Staph auerus
224
Fact
B Blockers reduce the secretion of renin
225
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.
226
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)
227
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.
228
Leriche syndrome
Leriche syndrome Classically, it is described in male patients as a triad of symptoms (Claudication, atrophy and impotence): 1. Claudication of the buttocks and thighs 2. Atrophy of the musculature of the legs 3. 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
229
Obesity hormones
Obesity hormones leptin decreases appetite ghrelin increases appetite (sounds like an animal is growling because of hunger)
230
Rockall score
Mnemonic for Rockall score ABCDE A: Age B: Blood pressure drop (Shock) C: Co-morbidity D: Diagnosis E: Evidence of bleeding
231
FACT
The prevalence of a condition is equal to pre test probability
232
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
233
FACT
Birds are a recognised reservoir of campylobacter.
234
Start and finish levels of the trackea
The trachea commences at C6. It terminates at the level of T5
235
Hernia repairs
First time hernias may be treated by performing an open inguinal hernia repair; the inguinal canal is opened, the hernia reduced and the defect repaired. A prosthetic mesh may be placed posterior to the cord structures to re-enforce the repair and reduce the risk of recurrence. Recurrent hernias and those which are bilateral are generally managed with a laparoscopic approach. This may be via an intra or extra peritoneal route. As in open surgery a mesh is deployed. However, it will typically lie posterior to the deep ring. Inguinal hernias in children are almost always of an indirect type and therefore are usually dealt with by herniotomy, rather than herniorraphy. Neonatal hernias especially in those children born prematurely are at highest risk of strangulation and should be repaired urgently. Other hernias may be repaired on an elective basis.
236
TOF
ventricular septal defect (VSD) right ventricular hypertrophy right ventricular outflow tract obstruction, pulmonary stenosis overriding aorta Shunting is from right to left Management: cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm
237
FACT
Prolapsed haemorroids are best managed surgically if symptomatic. Note that phenol injections are usually only used for minor internal haemorroids. Where phenol is used, low concentration phenol in oil is the correct agent,
238
What is VACTERYL
VACTERL, which is a combination of Vertebral, Ano-rectal, Cardiac, Tracheo-oesophageal, Renal and Radial limb anomalies. Half of babies with oesophageal atresia will have VACTERL. Problems that occur during feeding are more suggestive of proximal pathology.
239
Which lobe of the prostate is enlarged in BPH
The median lobe is usually enlarged in BPH
240
What is inflammatory breast cancer
Inflammatory breast cancers have an aggressive nature. Dissemination occurs early and is more resistant to adjuvant treatments than other types of breast cancer. Often occurs in pregnancy or lactation.
241
When is Rovsigns sign not present
Any advanced right iliac fossa pathology can result in a positive Rovsings sign. However, in retrocaecal appendicitis, it may be absent and this fact can contribute to a delayed diagnosis if undue weight is placed on the presence of the sign in making the diagnosis.
242
How do you know if a duodenal ulcer is anterior or posterior
Patients with duodenal ulcers will usually have a history of epigastric pain that occurs several hours after eating. The pain is often improved by eating food. They are most frequently located in the first part of the duodenum. Anteriorly sited ulcers may perforate and result in peritonitis, posteriorly sited ulcers may erode the gastroduodenal artery and present with haematemesis and/ or malaena
243
Management of appendix carcinoid tumours on resection
Individuals with small carcinoids can be discharged (<2cm and limited to the appendix). Larger tumours should have a radioisotope scan. Where the resection margin is positive or where the isotope scan suggests lymphatic metastasis a right hemicolectomy should be performed.
244
What is Ogilives syndrome
Patients with electrolyte disturbance and previous surgery may develop colonic pseudo-obstruction (Ogilvies syndrome). The diagnosis is made using a contrast enema and treatment is usually directed at the underlying cause with colonic decompression if indicated.
245
How do you do a transfusion in a major hemorrhage setting
1:1:1 rule of FFP, platelets and packed cells
246
At which of the following anatomical sites does dormant tuberculosis most frequently reactivate?
Apex of the lung
247
What is the SOFA score and what is considered?
sequential organ failure assessment (SOFA) tool PaO2, BP, Platelets, bilirubin, creatinine, GCS and urine output. A SOFA score of 2 or more reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection
248
FACT
In hernia repair, the mesh procedure is called an open Lichtenstein repair and suturing the defect shut with no mesh is a bassini repair
249
Which factors does DIC consume quickly
DIC Will tend to consume factors five and eight intially (and platelets)
250
What are the contraindications to lung cancer surgery
Contraindications to lung cancer surgery include SVC obstruction, FEV < 1.5, MALIGNANT pleural effusion, and vocal cord paralysis
251
After a circumcision, what is the correct instrument to achieve haemostasis
Bipolar. Any other method will carry a risk of damage to end vessels
252
What is the risk of a wound infection in a male undergoing a Hartmanns procedure for perforated sigmoid diverticular disease?
35% Infection risk may still be very high despite giving abx. Surgeons in this case may not close the skin.
253
FACT
Third nerve palsy and headache: Posterior communicating artery anuresym
254
Colonic polyp surviellance
255
FACT
Haemachromatosis can cause pseudogout and hence if you have suspicion of pseudo gout, order transferrin levels Risk factors hyperparathyroidism hypothyroidism haemochromatosis acromegaly low magnesium, low phosphate Wilson's disease
256
vWD which transfusion to give
Desmopressin
257
The space between the vocal cords is referred to as What?
Rima Glottis
258
What are the risk factors for osteoporosis
Risk factors Family history Female sex Increasing age Deficient diet Sedentary lifestyle Smoking Premature menopause Low body weight Caucasians and Asians
259
What are the radiological features of Perthes disease
In Catterall stage I disease there may be no radiological abnormality at all. In Stage II disease there may be sclerosis of the femoral head. Indication for treatment (aide memoire):Half a dozen, half a head Those aged greater than 6 years with >50% involvement of the femoral head should almost always be treated.
260
What does not interfere with lab analysis of cortisol
Dexamethasone
261
FACT
In NF type1, children may have one limb longer than the other as the fibrous tissue growing around nerves accelerates growth
262
What are the different fascias
Waldeyers fascia- Posterior ano-rectum Sibsons fascia- Lung apex Bucks fascia- Base of penis Gerotas fascia- Surrounding kidney Denonvilliers fascia- Between rectum and prostate
263
Typical stroke volume of a resting 70kg man
70 mls
264
Kippel trenaunay syndrome
The birth defect is diagnosed by the presence of a combination of these symptoms: One or more distinctive port-wine stains with sharp borders Varicose veins Hypertrophy of bony and soft tissues, that may lead to local gigantism or shrinking. An improperly developed lymphatic system
265
LF syndrome
Li-Fraumeni Syndrome Autosomal dominant Consists of germline mutations to p53 tumour suppressor gene High incidence of malignancies particularly sarcomas and leukaemias Diagnosed when: *Individual develops sarcoma under 45 years *First degree relative diagnosed with any cancer below age 45 years and another family member develops malignancy under 45 years or sarcoma at any age
266
Lynch syndrome
Lynch Syndrome Autosomal dominant Develop colonic cancer and endometrial cancer at young age 80% of affected individuals will get colonic and/ or endometrial cancer High risk individuals may be identified using the Amsterdam criteria Amsterdam criteria 3 or more relatives with an associated cancer (colorectal cancer, or cancer of the endometrium, small intestine, ureter or renal pelvis); 2 or more successive generations were affected; 1 or more relatives diagnosed before the age of 50 years; 1 should be a first-degree relative of the other two; Familial adenomatous polyposis (FAP) should be excluded in cases of colorectal carcinoma; Tumors should be verified by pathologic examination.[4]
267
CMV or EBV for transplant
Post transplant complications CMV: 4 weeks to 6 months post transplant EBV: post transplant lymphoproliferative disease. > 6 months post transplant
268
What are depressed skull fractures also called
Signature fractures are synonymous with depressed skull fractures, they are usually low velocity injuries where the fracture impression resembles the injurious source.
269
Why do patients develop impotence after rectal surgery
The penis takes autonomic nerves from the nervi erigentes that lie near the seminal vesicles. These may be compromised by direct surgical trauma (such as use of diathermy in this area) and also by radiotherapy that is used in these patients pre operatively. The result is that up to 50% of patients may develop impotence following rectal cancer surgery.
270
What is post gastrectomy syndrome
Post gastrectomy syndrome Rapid emptying of food from stomach into the duodenum: diarrhoea, abdominal pain, hypoglycaemia Complications: Vitamin B12 and iron malabsorption, osteoporosis Treatment: High protein, low carbohydrate diet. Replace B12/Fe/Ca
271
Shisto
Schistosomiasis is the most common cause of bladder calcification worldwide. Schistosoma mansoni typically resided in the colon from where it is excreted. Schistosoma haematobium causes haematuria
272
What is the investigation of choice for failing renal transplants
Because it is excreted by renal tubular cells a MAG 3 renogram provides excellent imaging of renal function and is often used in investigating failing transplants.
273
What is the first line treatment for meconium ileus
The most likely diagnosis here is meconium ileus. The first line treatment for uncomplicated cases is enemas of either dilute gastrograffin or N-acetyl cysteine. It's important to ensure the child is adequately hydrated first. They are contra indicated if there is a suspected underlying perforation.
274
FACT
Carbohydrate loading is one of the enhanced recovery principles. Hence, carbohydrate rich diet should be given after colonic surgery. High protein and low carb diet may be used post gastrectomy
275
Renal Tumour colour
Most renal tumours are yellow or brown in colour. TCC's are one of the few tumours to appear pink.
276
What is the most common abnormality associated with hypospadias
Hypospadias most commonly occurs as an isolated disorder. Associated urological abnormalities may be seen in up to 40% of infants, of these cryptorchidism is the most frequent (10%).
277
What are the CXR changes of thoracic aorta disruption
CXR changes Widened mediastinum Trachea/Oesophagus to right Depression of left main stem bronchus Widened paratracheal stripe/paraspinal interfaces Space between aorta and pulmonary artery obliterated Rib fracture/left haemothorax
278
What type of incision do you use for a femoral incarcerated hernia
A McEvedy incision is traditionally used to approach incarcerated femoral hernias. The disadvantage of the Lotheissen approach is that it weakens the inguinal canal and predisposes to inguinal hernia formation. The other incisions would not usually address femoral hernias. Given the features of bowel obstruction, a low approach would be inappropriate.
279
What are the indications for a coronary bypass
1. Left main stem stenosis or equivalent (proximal LAD and proximal circumflex) 2. Triple vessel disease 3. Diffuse disease unsuitable for PCI
280
What are the ECG changes that call for PCI or thrombolysis
ECG changes for thrombolysis or percutaneous intervention: ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL) OR New Left bundle branch block
281
FACT
Heparin can cause hyperkalaemia
282
FACT
Young females at very high risk of breast cancer should undergo annual MRI.
283
Pneumonic for transfusion reactions
Got a bad unit G raft vs. Host disease O verload T hrombocytopaenia A lloimmunization B lood pressure unstable A cute haemolytic reaction D elayed haemolytic reaction U rticaria N eutrophilia I nfection T ransfusion associated lung injury
284
What is a Klatskin tumour
A Klatskin tumor (or hilar cholangiocarcinoma) is a cholangiocarcinoma (cancer of the biliary tree) occurring at the confluence of the right and left hepatic bile ducts.
285
Splenic vein thromboses
Thrombosis of the splenic vein may complicate pancreatitis, pancreatic carcinoma, iatrogenic trauma and hypercoagulable diseases. The condition may predispose to the development of gastric varices, oesophageal varices are uncommon in splenic vein thrombosis alone. Diagnosis is made by CT angiography. Treatment is with splenectomy.
286
What is the most common type of solid organ tumour in children
Rhabdomyosarcomas as one of the more common malignant solid tumours in children (though all are rare). They have an aggressive behavior pattern and metastases are common. Teratomas are nearly always benign in younger children. Seminomas are very rare indeed. Malignant fibrous histiocytomas are almost never found in this location.
287
FACT
For humeral fractures, fracture through the anatomical neck is rare and needs to be replaced as there is a very high risk of avascular necrosis
288
FACT
The secretions of the proximal small bowel are hugely and directly affected by lumenal content osmolality. This can contribute to some of the symptoms of dumping syndrome that can be seen following gastric surgery. Jejunum in particular
289
How do you heal meniscal tears
Menisci have no nerve or blood supply and thus heal poorly. Established tears with associated symptoms are best managed by arthroscopic menisectomy.
290
MEN
291
FACT
If there are clear cells in the histology, then the metastatic disease origin is from the kidneys
292
FACT
Between 500 mL and 1.5 L of bile enters the small bowel daily. Most bile salts are recycled by the enterohepatic circulation. When the gallbladder contracts the lumenal pressure is approximately 25cm water, which is why biliary colic may be so painful.
293
Lintis plastica
Linitis plastica produces a diffuse infiltrating lesion, the stomach is fibrotic and rigid and will not typically distend. This may be described as a 'leather bottle stomach'. Diagnosis is made with a combination of pathology examination with endoscopy, radiological or surgical assessment. Pathologically signet-ring cell proliferation occurs.
294
Median arcuate ligament syndrome
Median arcuate ligament syndrome (MALS) occurs when the arc-shaped band of tissue in the chest area (median arcuate ligament) presses on the artery that sends blood to the upper abdomen. The artery is called the celiac artery. MALS can cause stomach pain in some people
295
Falsley elevated HIAA
Food: spinach, cheese, wine, caffeine, tomatoes Drugs: Naproxen, Monoamine oxidase inhibitors Recent surgery
296
What is the earliest sign of compartment syndrome?
Pain out of proportion to the injury. There is also pain on passive stretching of the muscle groups
297
How would you know that osteolytic lesions are due to bony mets
Multiple lesions along with cytokeratin positive cells are a sign of mets. Raised ALP also
298
FACT
Medullary thyroid carcinoma is sporadic in 80% of cases and familial in 20% of cases
299
What is the function of LH in males
Stimulate the production of testosterone
300
What is the most likely structure that is damaged during the insertion of a trachy
Thyroid Ima artery, 5%
301
In typhoid, Which part of the intestine is more likely to rupture
Ileum as it has the most payers patches and salmonella typhi accumulates in the payers patches
302
Thyroid carcinoma and age breakdown
Anaplastic: 60-70 and aggressive Lymphomas: 40-50 Papillary 30-40 Hurtle cell carcinoma 80-90
303
What is the commonest site for development of actinomycoses
Cervicofascial
304
Cystinuria
D-Penicillamine is used to help. Alkalising urine can also help as acidic urine causes it. 1-2% of stones and is less common
305
Saliva
Produce hypotonic solutions with more potassium than that in the plasma and also contains amylase and lipase. 1-2 L per day
306
Bladder cancer
If it is muscle invasive then cystectomy. If not then mitomycin or BCG is good
307
Lidocaine doses
Without adrenaline is 3mg/kg and with adrenaline is 7mg/kg
308
How to reduce the risk of dumping syndrome in a Gastroenterostomy
Preserve the pylorus
309
SIRS
Temp above 38 or below 36 Resprate above 20 with pCO2 <32 Wcc >12 or <4 HR >90 Only 2 of these conditions have to be met
309
Name an anti-inflammatory cytokine
IL10
309
Jaundice
Clinically detectable at 30u/L and obvious at 60
309
Name a very radiosensitive tumour
Seminomas
309
FACT
The ventromedial nucleus of the thalamus is responsible for satiety. If this is destroyed then it will lead to overeating
309
What are the three surgical lymph node clearance categories?
1: only those inferio-lateral to the pectoralis minor 2: posterior to pec minor 3: Superio-medial to pec minor
309
What is the maximum dose of bupivacaine and levobupivacaine
2mg/ kg
310
What causes normal anion gaps
Normal Gap Acidosis: HARDUP H - Hyperalimentation/hyperventilation A - Acetazolamide R - Renal tubular acidosis D - Diarrhoea U - Ureteral diversion P - Pancreatic fistula/parenteral saline
310
FACT
Steroids are associated with Na and water retention
311
What is a DALM lesion and how do you treat it
The term DALM lesion refers to a Dysplasia Associated Lesion or Mass. They may complicate dysplasia occurring in patients with longstanding ulcerative colitis. They have a high incidence of invasive foci. When they complicate longstanding ulcerative colitis, they should be treated by panproctocolectomy.
312
Accessory spleens
Accessory spleens - 10% population - 1 cm size - locations: hilum of the spleen, tail of the pancreas, along the splenic vessels, in the gastrosplenic ligament, the splenorenal ligament, the walls of the stomach or intestines, the greater omentum, the mesentery, the gonads
313
Drugs causing SIADH
Drugs causing SIADH: ABCD A nalgesics: opioids, NSAIDs B arbiturates C yclophosphamide/ Chlorpromazine/ Carbamazepine D iuretic (thiazides)
314
Management of penile fractures
Penile fractures are a rare type of urological trauma that may be encountered. The injury is usually in the proximal part of the penile shaft and may involve the urethra. A classically history of a snapping sensation followed by immediate pain is usually given by the patient (usually during vigorous intercourse). On examination there is usually a tense haematoma and blood may be seen at the meatus if the urethra is injured. When there is a a strong suspicion of the diagnosis the correct management is surgical and a circumferential incision made immediately inferior to the glans. The skin and superficial tissues are stripped back and the penile shaft inspected. Injuries are usually sutured and the urethra repaired over a catheter.
315
Which of the following changes are most likely to be identified in the aortic wall of a 38 year old lady with a Marfans syndrome and a dissecting aortic aneurysm?
Cystic medial necrosis ( or cystic medial degeneration) occurs when basophils and mucoid material lie in between the intimal elastic fibres of the aorta. It is typically found in the aortic degeneration of Marfans syndrome, but may also be seen in aortic degeneration in older adults.
316
Treatment for axillary vein thrombosis
Catheter TPA
317
CSF rhinorrhea CSF confirmation
Beta 2 transferrin is a carbohydrate free form of transferrin that is almost exclusively found in the CSF. Although lab stix testing for glucose is traditional it is associated with false positive results secondary to contamination with other glucose containing bodily secretions.
318
Gritti stokes amputation
Gritti - Stokes amputation. During a Gritti - Stokes operation the patella is conserved and swung posteriorly to cover the distal femoral surface.
319
Seminomas
Seminoma is the commonest type of testicular tumour and is more common in males aged between 30-40 years. Classical seminoma is the commonest subtype and histology shows lymphocytic stromal infiltrate. Other subtypes include: 1. Spermatocytic: tumour cells resemble spermatocytes. Excellent prognosis. 2. Anaplastic 3. Syncytiotrophoblast giant cells: β HCG present in cells A teratoma is more common in males aged 20-30 years.
320
FACT
Merkel cell tumours and pyoderma gangrenosum are similar under histology
321
Hyperventilation and Ca
Reduction in Ca ionised as it alkalises the blood
322
The cell of origin for most pancreatic cancer
The ductular epithelium
323
Testicular tumours
Seminoma: 50%, AFP normal and HCG raised, older age Non seminoma: 50% and AFP and HCG both raised. Younger. Occasional ectopic tissue such as hair Leydig cell tumour associated with hormone imbalance
324
Posterior hip dislocation
Allis technique for relocation
325
What is to be expected one week post splenectomy
Thrombocytosis
326
Tumour most linked to HPTH and hypercalcaemia
Squamous cell lung cancer
327
MEckel divericulum rule of 2s
2 feet from the IC juntion 2 inches long 2% of population 2:1 male to female ratio 1 in 2 will contain ectopic gastric tissue 2% will be symptomatic Rectal bleeding in under 2s
328
Hinchey classifications
329
Between what MAPs is Cerebral auto reg
60-160
330
Classifications of lasers
Class 1 laser: Printer Class 2: BArcode scanners (eyes are naturally protected) Class 3R: May sometimes cause eye injury eg some laser pointers Class 3B: Sufficient to cause eye injury Class 4: Very dangerous (cataract surgery)
331
Fractional excretion of Na and renal pathology
<1% is pre renal 2-4% is intra >4% is post BUN creatinine ratio Prerenal >20:1 Intra >10:1 Post renal or normal is 10-20:1
332
Teratoma in the family and patient risk
Increased by 4 times
333
FACT
Majority of CO2 in the body is transported as bicarbonate
334
CT scanning and associated increased risk of fatal cancer
1 in 2000
335
Acute parotitis causative organism
Staph aur
336
Chemokine co-receptor for HIV viral entry into T cells
CCR-5
337
For MRSA
Decolonisation is attempted first before surgery and side room is not always needed. Marked decline in morbidity and mortality since 2006 There is insufficient evidence to support in widespread use of systemic and topical antimicrobial therapy. Severe infections can be treated with Vancomycin or teicoplanin
338
Tumours that metastasize to the bone
Particular Tumours Love Killing Bone P Prostate T Thyroid L Lung K Kidney B Breast
339
Which cell types naturally store heparin
Mast cells and basophils
340
How is intracellular pH mainly controlled
Cytoplasmic proteins
341
Gold standard for DVT diagnoses
Ascending contrast venogram
342
Breast cancer and chemotherapy
There is a risk of developing secondary leukemia. 22% increase in relative risk
342
Tamoxifen
It is a cause of post menopausal bleeding as it is an agonist to the oestrogen receptors in the uterus as opposed to antagonist in the breast 5-10% have shown tamoxifen to be effective despite no oestrogen positive receptors
343
Where is the bRCA 1 gene found
Chromosome 17
344
Inflammatory AAA
Presents with pain 5-10% increased risk in smokers Is a more severe form of AAA ESR is higher here and infected AAA will have a higher procalcitonin
345
FACT
Paediatric CO is usually dependent more on HR rather than SV. This is as they cannot increase their contractility as much as adults due to presence of fibrous tissue
346
Interesting facts about the spinal cord
Ends at L1 and L2 in adults and L3 in neonates Average male spinal cord is 18 inches long
347
Apocrine vs eccrine glands
Eccrine sweat glands occur over most of the body and open directly onto the skin's surface. Apocrine glands open into the hair follicle, leading to the surface of the skin. Apocrine glands develop in areas with many hair follicles, such as on the scalp, armpits and groin. Hidradenitis is inflammation of the apocrine glands
348
Sutures of the skull
Bregma: Is formed by closure of the anterior fontanelle Pterion and lambda are known Asterion: Behind the ear (transverse and sigmoid sinuses are here)
349
Ecto meso and endoderm
ECTO: CNS (surface ecto gives rise to hair, skin and nails) ENDO: GI tract and resp tract as well as organs of the abdomen Intermediate meso: Urogenital Lateral plate meso: skeleton
350
Liver syndromes
Gilbert: Is common and autosomal recessive. Bilirubin is unconjugated and hence there is no bilirubin in the urine Dubin Johnson and rotor: Have conjugated high bili and this is why it is present in the urine. Liver will be black in dubin
351
FACT
The mucociliary escilator travels 1mm/min in LRT and 5-10mm/min in URT 10-100 ml mucus is generated per day Bronchioles are 1mm in diameter
352
Tetanus vaccine
The tetanus immunoglobulin or prophylaxis is not required if the patient has had tetanus vaccine in the last 10 years
353
Salter Harris type fracture
354
Osteochondroma
Most common benign bone tumour and around 80% are noted in patients under thhe age of 21
355
Hereditary angioedema
Occurs due to C1 esterase inhibitors. FFP can be given to treat. It does not respond to adrenaline or anti-histamine treatement
356
Types of immunity
Innate - Complement system, acute phase proteins, NK cells Acquired - From previous exposure Active - Whole immune system is activated Passive - From fetus for eg Humoral Cellular
357
FACT
Leukaemia and solid tumors occur at an increased rate following ionising radiation.
358
% of CO
Brain 15% Kidneys 20% Liver 25% Muscles 20% Heart 5% Skin 5% other 10%
359
What are the Garden classification of fractures of the femoral neck
Type 1: Stable fracture and impaction Type 2: Complete fracture but non displaced Type 3: Partially displaced Type 4: Completely displaced
360
Adrenal gland emryology
Anatomic anomalies of the adrenal gland may occur. Because the development of the adrenals is closely associated with that of the kidneys, agenesis of an adrenal gland is usually associated with ipsilateral agenesis of the kidney, and fused adrenal glands (whereby the 2 glands join across the midline posterior to the aorta) are also associated with a fused kidney. IF the kidney is ectopic then the adrenal glads will develop in its usual position
361
How do you deal with thyroglossal cyst recurrence and infection
Recurrence following attempted resection of thyroglossal cysts is very common. Complete excision of the cyst and its track and origin is mandatory (Sistrunks procedure).
362
Hepatocellular adenomas in males
Hepatocellular adenomas in males have a greater risk of malignant transformation and resection should be considered.
363
FACT
If a lady has had a wide local excision and it shows ILC, send for completion mastectomy as ILC is multifocal and can reccur
364
This is the most common organism affecting previously abnormal heart valves.
Staph viridans Vir Dance in the heart!
365
Meckels diverticulum that is asymptomatic
Most asymptomatic Meckels diverticulum will be lined by ileal mucosa. Those which present with bleeding are more likely to contain gastric type mucosa.
366
What is the most important urinary acid base buffer?
Phosphate
367
Mesenteric venous thrombosis sign
Mesenteric vein thrombosis may complicate severe intra abdominal sepsis and when it progresses may impair bowel perfusion. The serosa is quite resistant to ischaemia so in this case the appearances are usually patchy.
368
Parsonage turner syndrome
This is a peripheral neuropathy that may complicate viral illnesses and usually resolves spontaneously. Parsonage-Turner syndrome causes sudden, intense pain in your shoulder and upper arm followed by muscle weakness.
369
What metastatic lesions are at greatest risk of a fracture
Peritrochanteric lesions have the greatest risks of fracture (due to loading). The lesions from breast cancer are usually lytic and therefore at higher risk rather than the sclerotic lesions from prostate cancer.
370
What is the common cell type that is identified in a fistula in ano
A fistula is an abnormal connection between two epithelial lined surfaces, in the case of a fistula in ano it will be lined by squamous cells.
371
What are the types of nerve injury
Nerve injury There are 3 types of nerve injury: Neuropraxia Nerve intact but electrical conduction is affected Full recovery Autonomic function preserved Wallerian degeneration does not occur Axonotmesis Axon is damaged and the myelin sheath is preserved. The connective tissue framework is not affected. Wallerian degeneration occurs. Neurotmesis Disruption of the axon, myelin sheath and surrounding connective tissue. Wallerian degeneration occurs. Wallerian Degeneration Axonal degeneration distal to the site of injury. Typically begins 24-36 hours following injury. Axons are excitable prior to degeneration occurring. Myelin sheath degenerates and is phagocytosed by tissue macrophages. Nerve repair Neuronal repair may only occur physiologically where nerves are in direct contact. Where a large defect is present, the process of nerve regeneration is hampered. It may not occur at all or result in the formation of a neuroma. Where nerve regrowth occurs it is typically at a rate of 1mm per day.
372
What is the procedure that is undertaken when a pilonidal cyst has failed to heal
BASCOM: This procedure is usually performed if a pilonidal abscess has failed to heal. The operation involves removing the infected tissue which is often more extensive than it appears on the surface. The operation should take about 45 minutes and is done under a general anaesthetic.
373
Which substance can be used to achieve the most accurate measurement of the glomerular filtration rate?
Inulin
374
What is first to be affected in a splenectomy
The granulocyte (the eosinophil component is seldom raised) and platelet count are the first to be affected following splenectomy. Then reticulocytes increase. Although a lymphocytosis and monocytosis are reported, these take several weeks to develop.
375
Pre-op and elderly patients
Beta blockers should not be stopped acutely prior to surgery as there may be a rebound effect associated with increased complications. Brain natriuretic peptide is a neurohormone synthesized in the cardiac ventricles. Levels have been used to assess prognosis in heart failure and acute coronary syndromes. Preoperative elevated brain natriuretic peptide levels identify patients undergoing non cardiac surgery at high risk of cardiac mortality and all cause mortality. All patients with peripheral vascular disease should take statins prior to vascular surgery as studies have shown a 50% risk reduction and a reduction in perioperative cardiac events. Hypoalbumaenemia is associated with increased mortality
376
What are the different types of levels of evidence
1 - systematic review or meta-analysis 2 - RCT 3 - pseudo RCT 4 - case reports 5 - expert opinion
377
Genetics and surgical disease
Some of the more commonly occurring genetic conditions occurring in surgical patients are presented here. Li-Fraumeni Syndrome Autosomal dominant Consists of germline mutations to p53 tumour suppressor gene High incidence of malignancies particularly sarcomas and leukaemias Diagnosed when: *Individual develops sarcoma under 45 years *First degree relative diagnosed with any cancer below age 45 years and another family member develops malignancy under 45 years or sarcoma at any age BRCA 1 and 2 Carried on chromosome 17 (BRCA 1) and Chromosome 13 (BRCA 2) Linked to developing breast cancer (60%) risk. Associated risk of developing ovarian cancer (55% with BRCA 1 and 25% with BRCA 2). Lynch Syndrome Autosomal dominant Develop colonic cancer and endometrial cancer at young age 80% of affected individuals will get colonic and/ or endometrial cancer High risk individuals may be identified using the Amsterdam criteria Amsterdam criteria Three or more family members with a confirmed diagnosis of colorectal cancer, one of whom is a first degree (parent, child, sibling) relative of the other two. Two successive affected generations. One or more colon cancers diagnosed under age 50 years. Familial adenomatous polyposis (FAP) has been excluded. Gardners syndrome Autosomal dominant familial colorectal polyposis Multiple colonic polyps Extra colonic diseases include: skull osteoma, thyroid cancer and epidermoid cysts Desmoid tumours are seen in 15% Mutation of APC gene located on chromosome 5 Due to colonic polyps most patients will undergo colectomy to reduce risk of colorectal cancer Now considered a variant of familial adenomatous polyposis coli
378
What is osteopetrosis
Overview Also known as marble bone disease Rare disorder of defective osteoclast function resulting in failure of normal bone resorption Stem cell transplant and interferon-gamma have been used for treatment
379
How do you stage cancers of the rectum and colon
Once a malignant diagnosis is made patients with colonic cancer will be staged using chest / abdomen and pelvic CT. Patients with rectal cancer will also undergo evaluation of the mesorectum with pelvic MRI scanning. For examination purposes the Dukes and TNM systems are preferred.
380
How to manage a fistula
Some rules relating to fistula management: They will heal provided there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option Where there is skin involvement, protect the overlying skin, often using a well fitted stoma bag- skin damage is difficult to treat A high output fistula may be rendered more easily managed by the use of octreotide, this will tend to reduce the volume of pancreatic secretions. Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin. When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is present, this almost always worsens outcomes. When perianal fistulae occur secondary to Crohn's disease the best management option is often to drain acute sepsis and maintain that drainage through the judicious use of setons whilst medical management is implemented. Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intra abdominal source the use of barium and CT studies should show a track. For perianal fistulae surgeons should recall Goodsall's rule in relation to internal and external openings.
381
Glasgow criteria for pancreatitis
LEARN THIS! Mnemonic for the assessment of the severity of pancreatitis: PANCREAS (Ann R Coll Surg Engl 2000; 82: 16-17 P a02 < 60 mmHg A ge > 55 years N eutrophils > 15 x 10/l C alcium < 2 mmol/l R aised urea > 16 mmol/l E nzyme (lactate dehydrogenase) > 600 units/l A lbumin < 32 g/l S ugar (glucose) > 10 mmol/l > 3 positive criteria indicates severe pancreatitis.
382
Risk of haematoma in adults attending ED
Concussion with no skull fracture - oriented - 1 in 6000 Concussion with no frac - no oriented - 1 in 120 Concussion + frac - oriented - 1 in 32 concussion + frac - non oriented - 1 in 4
383
how does a persistent left sided SVC drain
Anomalies of the connection of the SVC are recognised. In some individuals a persistent left sided SVC drains into the right atrium via an enlarged orifice of the coronary sinus.
384
About standard deviations
About 68.27% of the values lie within 1 standard deviation of the mean. Similarly, about 95.45% of the values lie within 2 standard deviations of the mean. Nearly all (99.73%) of the values lie within 3 standard deviations of the mean
385
FACt
25% of people with aneurysms also have aneurysms elsewhere
386
Carcinomas of the tongue
Most likely cause of death is dysphagia related aspiration Like most carcinomas, it is sensitive to radiotherapy More common in men More common in anterior 2/3rd of the tongue
387
FACT
Lingual lipase digests 10-30% of the overall TGs, the rest is done by pancreatic lipase
388
FACT
The aim of a FAST scan is to detect intraperitoneal fluid. Hence, it is bad at identifying injury to retroperitoneal structures such as the liver
389
What are the neural tube defects
Spina bifida: Has overlying skin Meningocele: Has only CSF and no cord Myelomeningocele: Has CSF and cord
390
Why do fetal skin wounds heal fast?
Low inflammatory reaction at the site
391
What metabolic abnormalities does pyloric stenosis cause
Metabolic alkalosis, hyponat and hypokal
392
What kind of a joint is the manubriosternal joint
Secondary fibrocartlage
393
Urinary extravasation and trauma
Membranous urethra: 2 cm long and most commonly injured because of attachment with the puboprostatic ligaments. Goes into the retro pubic space Bulbous: Over the perineum Penile: Around the penis and scrotum VUJ: Urine will flow retrograde into the retroperitoneal space Bladder: Bladder will be collapsed on imaging if it has ruptured
394
Osteosarcoma
Codmans triangle is the most common feature peak is 10-25 years and >65 due to paget's Bone develops and grows towards medulla and cortex and breaks through forming a starry appearance.
395
Tuberculosis types
Bovis: Less common and causes GI TB Hominis: Most common and infects humans
396
Anal fissure tx protocol
initially GTN or diltiazem then EUA and BOTOX if secondary cause or paeds Sphincterotomy is the last option
397
Hickney classification of diverticulitis
Classification stage 0: clinical: mild clinical diverticulitis CT finding: diverticula with colonic wall thickening stage Ia: clinical: confined pericolic inflammation or phlegmon CT finding: pericolic soft tissue changes stage Ib: clinical: pericolic or mesocolic abscess CT finding: Ia changes and pericolic or mesocolic abscess stage II: clinical: pelvic, distant intra-abdominal or retroperitoneal abscess CT finding: Ia changes and distant abscess, usually deep pelvic stage III: clinical: generalized purulent peritonitis CT finding: localized or generalized ascites, pneumoperitoneum, peritoneal thickening stage IV: clinical: generalized fecal peritonitis CT finding: same as stage III
398
Physiological changes in the lungs post op
Lung compliance remains unchanged
399
Liver injury
1: <10% of one lobe and on surface 2: 10-50% 3: >50% and surface 4: 25-75% and associated parenchymal injury 5: >75% 6: Vascular involvement
400
Kohlers disease
Kohler disease is a rare bone disorder of the foot in children that may be the result of stress-related compression at a critical time during the period of growth. It is characterized by limping caused by pain and swelling in the foot. Affects 3-5 year olds Main pathology is avascular necrosis
401
Cell cycle steps
The cell cycle is a four-stage process in which the cell increases in size (gap 1, or G1, stage), copies its DNA (synthesis, or S, stage), prepares to divide (gap 2, or G2, stage), and divides (mitosis, or M, stage)
402
Anasarca
Anasarca is a medical condition in which there is a severe generalized accumulation of fluid or edema in the interstitial space. This accumulation of fluid occurs when capillary filtration exceeds the amount of fluid removed via lymphatic drainage or a change in the oncotic pressure from low protein states.
403
Merantic endocarditis and carcinoid heart diease
Merantic is non bacterial thrombotic endocarditis. Can me mets Carcinoid: Carcinoid tumours
404
FACT
Ileostomies can cause high output of magnesium and hence hypomagnesemia. This makes
405
Cardiac action potential regulation
Phase 0: Rapid Na influx Phase 1: Small efflux of potassium Phase 2: Slow influx of calcium Phase 3: Efflux of potassium Phase 4: Na, Ca and K efflux
406
In transplant patient, what causes the inhibition of IL2
Sirolimus (Rapamycin)
407
Fact
Post central gyrus receives sensory information and precentral is the motor strip
408
FACT
Hypertrophic payers patches will lead to intussusception in 90% of cases
409
Small round blue cells on histology
Ewing sarcoma
410
Omphacele minor vs major
In minor the defect is <4cm
411
Chagas disease
Mimics achalasia and is caused by Tryp cruzi. Causes destruction of ganglionic cells in the myenteric plexus. Can also cause myopathy and mimic malignancy
412
FACT
IL6 is secreted by muscles and macrophages and is very important in activation of the coagulation cascade
413
Cause of spinal canal stenosis
Lig flav
414
HUS cause
E coli secreting verotoxin
415
FACT
Max lidocaine dose is 200mg and hence if you do 3mg per kg and it is higher than this then do not give more
416
What are the zones of flexor tendon injury
417
Bosniak classification of renal cysts
1: Simple 2: Thin septae non enhancing and non calcium 2F: Thick septae and some calcifications 3: 55% malignant 4: Malignant
418
Mycotic AAA
Staph, strep and salmonella
419
Sarcomas
Initially spread through the fascial planes and can mets throught blood most commonly to the lung
420
Papillary carcinoma
Orphan annie nuclei are seen
421
How to calculate paediatric blood volume
80ml/kg
422
What is the procedure for contractures as a result of scarring
Z plasty
423
Antibodies
Antibodies to ABO are IgM and rhesus are IgG
424
Which cells commonly have perforin in its granulations
CD8 and NK cells.
425
Resp changes in pregnancy
PCO2 receptors are more sensitive in pregnancy due to the hight amount of circulating progesterone. This makes preg women hyperventilate and reduce pCO2
426
FACT
CA and PO4 are co-transported in the same direction. Thus, calcitonin will decrease Ca and PO4 absorbtion
427
Ectopic undescended testis
Can be found in the superficial inguinal pouch as the most common site. Can also be found at the base of the penis but this is less common
428
What is the commonest cardiac abnormality following a Swan Ganz catheter insertion
Right bundle branch block occurs in 5% of patients in the first 24hrs
429
FACT
Cortisol rises intra and post op, apart from CPBypass where it initially decreases and then increases CP bypass is also associated with thrombocytosis
430
Pancreatic scoring systems
Glasgow is for prognosis APACHE is for ITU patients Balthazaar is for CT scan and acute pancreatitis
431
TT and cancer risk
When testicular torsion is repaired, there is a risk of cancer developing in both testes. The reason for this is unclear
432
Burns
Acid are more painful but in alkali the pain is delayed and hence more tissue damage occurs before seeking aid. HF burns needs wash with water and topical CA gluconate due to impending systemic toxicity
433
definition of massive hemorrhage
150mls/min or >50% blood volume loss in the first 3h
434
Garden classificaton of NOFs
1: Incomplete 2: Complete and non-displaced 3: Complete and partially displaced 4: Complete and full displacement
435
Central necrosis and which CNS tumour
Gliomas
436
Hemisection of cord
Ipsilateral loss of fine touch and reflexes and muscle wasting Contralateral loss of pain and temperature
437
Lasers
Wavelength defines penetration and depth of effect
438
Hashimoto antibodies
Anti-TPO, Anti-thyroglobulin and anti microsomal
439
FACT
Intussusception is more common in males and in the winter as there are more viruses FACT: Post op MI is likely to occur at day 1
440
Liver abscesses
Klebsiella and e coli are the most common
441
Where does the CTZ lie
Outside the BBB and on the floor of the 4th ventricle
442
Nelson syndrome
Commonly can occur after excision of adrenal glands for Cushings syndrome Nelson syndrome is a disorder characterized by abnormal hormone secretion, enlargement of the pituitary gland (hypophysis), and the development of large and invasive growths known as adenomas. It occurs in an estimated 15 to 25 percent of people who undergo surgical removal of the adrenal glands for Cushing disease.
443
FACT
Zinc is essential for DNA and RNA synthesis
444
fact
Liver metastases are necessary for the presence of carcinoid syndrome.
445
Submandibular gland and structures that can be damaged
Facial artery, Marginal mandibular of the facial nerve, Hypoglossal and lingual nerve Retromandibular vein
446
Tourniquet
50mmHg over arterial and ovver 1 hour. Above 2 hours there is risk of injury
447
FACT
Branchial cysts contain cholesterol
448
Why does lupus activate the classical complement pathway?
The classical complement pathway typically requires antigen-antibody complexes (immune complexes) for activation (specific immune response), whereas the alternative pathway can be activated by C3 hydrolysis, foreign material, pathogens, or damaged cells
449
What happens to thyroxines immediately post op
It goes down and then normalises a few days later
450
What is the hydatid of morgagni
The appendix testis is a remnant of the Müllerian duct, meaning that it's a leftover part of something that previously existed. The appendix testis is also called testicular appendix or hydatid of Morgagn It is found in 90% of men and does not affect the functioning of the testes. However, it can be torsion and hence surgery may be required for symptomatic relief. Typically presents with a blue dot on testicular examination
451
Seminoma vs teratoma
Only HCG in seminoma and LDH AFP and HCG in teratoma (teratoma terrorizes and hence it has both present in it)
452
What are the child-pugh classification of liver disease
453
What is the typical resting pressure of the lower limbs
0-8 mmHg Compartment syndrome symptoms start to show >30
454
How does the spinal cord receive bloods
Anterior single spinal artery and paired posterior
455
How is surgical equipment sterilized?
Autoclaving at 134C, Ethylene oxide, low temp steam, hot air ovens, formaldehyde, irradiation
456
Dressings
Iodine based is bacteriocidal and hence used in DFI Alginate is wet and used in dry necrosis.
457
What is the sentinel node biopsy procedure
Identifying the first and only one node. Blue dye is now contraindicated in pregnancy
458
Which vessels are the most sensitive to the vasodilatory effects of nitrates
Large veins
459
Formation of external genetalia in males in utero
Dihydrotestosterone
460
FACT
For rectum, resection followed by radiotherapy, for others of the intestine, it is resection followed by chemo
461
Post splenectomy vaccine
4-6 weeks post op and then every 5 years
462
Bipolar
Low current with high frequency and low voltage
463
Tracheostomy
Between cricoid cartilage and the sternal notch. 3-4 cm transverse incision is made into the platysma and the pre-tracheal fascia and this is supposed to be a relatively avascular area
464
How would you manage nec ent in the first instance
Most cases will settle with conservative management with NG decompression and appropriate support. Laparotomy should be undertaken in patients do not who progress despite conservative management or in whom compelling indications for surgery exist
465
What is the recurrence rate of iliopsoas abscess
15-20%
466
Organisms associated with cecal cancer
S BOVIS
467
Organism associated with food bourne illness and can develop several hours post injection
C Perf
468
organism for vegetation
VIRIDANS
469
Organism for foul smell, pus and sever peritoneal infection
Bacteroides fragilis.
470
Which tube is used to identify whether sterilisation is complete
Brownes tube
471
What is Pes Cavus
Pes cavus is a descriptive term for a foot morphology characterized by high arch of the foot that does not flatten with weightbearing. No specific radiographic definition of pes cavus exists. The deformity can be located in the forefoot, the midfoot, the hindfoot, or a combination of these sites. Clawing of the toes may be seen
472
Which is the most common primary tumour spreading to the liver
Colorectal cancer
473
What is the constituent of cryo
F VIII and fibrinogen
474
Name some amino ester groups of anaesthetics
Most local anaesthetics are of the amino- amide types, these have a more favorable side effect profile and are more stable in solution. PROCAINE and BENZOCAINE have amino - ester groups, these are metabolised by pseudocholinesterases.
475
Choice of anaesthesia for Beirs block
Prilocaine without adrenaline
476
What is commonly associated with intestinal malrotation in children
Exomphalos and diaphragmatic herniae are commonly associated with malrotation.
477
Which of the following options is associated with the highest long term failure rates in bariatric surgery?
Balloon
478
Excess NaCL administration
Hyperchloraemic ACIDOSIS
479
How can you distinguish between squam lung Ca and small Ca from history alone
Squamous cell carcinomas are reported to be more slow growing and are typically centrally located. Small cell carcinomas are usually centrally located. However, small cell carcinomas would seldom be associated with a survival of a year without treatment.
480
Verapamil and broad complex tachy
Verapamil should never be given to a patient with a broad complex tachycardia as it may precipitate ventricular fibrillation in patients with ventricular tachycardia. Adenosine is sometimes given in this situation as a 'trial' if there is a strong suspicion the underlying rhythm is a supraventricular tachycardia with aberrant conduction
481
A 53 year old man is undergoing a radical gastrectomy for carcinoma of the stomach. Which of these structures will need to be divided to gain access to the coeliac axis?
Lesser omentum
482
A 53 year old man with a chronically infected right kidney is due to undergo a nephrectomy. Which of the following structures would be encountered first during a posterior approach to the hilum of the right kidney?
Ureter
483
WHat does pink seepage from a recent laparotomy wound mean
The seepage of pink serosanguineous fluid through a closed abdominal wound is an early sign of abdominal wound dehiscence with possible evisceration. If this occurs, you should remove one or two sutures in the skin and explore the wound manually, using a sterile glove. If there is separation of the rectus fascia, the patient should be taken to the operating room for primary closure.
484
Facts about peristalisis
Circular smooth muscle contracts behind the food bolus and longitudinal smooth muscle propels the food through the oesophagus Primary peristalsis spontaneously moves the food from the oesophagus into the stomach (9 seconds) Secondary peristalsis occurs when food, which doesn't enter the stomach, stimulates stretch receptors to cause peristalsis In the small intestine each peristalsis waves slows to a few seconds and causes mixture of chyme In the colon three main types of peristaltic activity are recognised (see below) Colonic peristalsis Segmentation contractions Localised contractions in which the bolus is subjected to local forces to maximise mucosal absorption Antiperistaltic contractions towards ileum Localised reverse peristaltic waves to slow entry into colon and maximise absorption Mass movements Waves migratory peristaltic waves along the entire colon to empty the organ prior to the next ingestion of food bolus
485
Difference in supply of anterior and posterior belly of diagastric
Anterior is mylohyoid nerve and posterior is facial
486
How many SVC collaterals exist
There are 4 collateral venous systems: Azygos venous system Internal mammary venous pathway Long thoracic venous system with connections to the femoral and vertebral veins (2 pathways)
487
For axillary node clearance
Lateral is level 1, level 2 is posterior and level 3 is medial to the pec minor
488
AAA screening
At this point continue with ultrasound surveillance. USS surveillance of AAA: 3cm- 4.4cm - 1 year 4.5-5.4cm- 3 monthly
489
Most malignant salivary gland carcinoma
The patient is most likely to have a malignant lesion within the parotid. Of the malignancies listed; adenoid cystic carcinoma has the greatest tendency to perineural invasion.
490
What is the most appropriate method of delivering early post-operative analgesia to a 6 month old child following an orchidopexy?
Caudal block
491
retroperitoneal bleed
Bruising of the flank is described as Grey Turners sign
492
How does carbimazole work
Carbimazole is used to treat hyperthyroidism. Carbimazole is a pro-drug as after absorption it is converted to the active form, methimazole. Methimazole prevents thyroid peroxidase enzyme from iodinating and coupling the tyrosine residues on thyroglobulin, hence reducing the production of the thyroid hormones T3 and T4. Clinical effects take some months to occur as thyroid globulin stores remain for some time after treatment commences.
493
Reason for unilateral cleft lip
Unilateral isolated cleft lip represents a failure of nasolabial ring fusion. It is not related to branchial arch fusion. Arch disorders have a far more profound phenotype and malformation sequences.
494
What is the best way in which PTH increases Ca
PTH increases the activity of 1-α-hydroxylase enzyme, which converts 25-hydroxycholecalciferol to 1,25-dihydroxycholecalciferol, the active form of vitamin D. Osteoclasts do not have a PTH receptor and effects are mediated via osteoblasts.
495
FACT
Serotonin normally is a vasodilator but in acute inflammation it is a vasocontrictor
496
The right and left pulmonary arteries are derived from which of the following embryological aortic arches?
6th
497
Which of the following muscle relaxants is an agent that is degraded by hydrolysis and may produce histamine release?
Atracurium
498
FACT
Opiates typically affect the medullary respiratory centre to depress respiratory activity.
499
Which investigation is best for initial assessment of recurrence of follicular carcinoma of the thyroid?
Elevated thyroglobulin levels
500
Lap Chole and % chance of common bile duct injury
0.5%
501
What has a good patency rate, above or below knee anastomosis
Above
502
What would you use to repair a flexor tendon
Round body knife as this would minimise damage to adjacent tissues
503
Submandibular gland anatomy
Lingual nerve is related to the duct and the MMN of the facial nerve is the most superficial and is hence implicated during the incision
504
What is responsible for hind foot equinus deformity
Achilles tendon
505
What is the action of kalkierein
Hista release and vasodil
506
PE and rythm
Gallop
507
Important thing to measure in burns
Cap refill and pulse
508
Bone cancers
Kidney - lytic Prostate - sclerotic Lung - mix Breast - mix Thyroid - Lytic
509
At what temperature do thermoregulatory mechanisms fail
30 degrees
510
what are fordyce granules
White spots in the lips that are commonly mistaken for disease
511
Cholesteatoma
Should be completely excised on first surgery
512
What kind of thyroid cancer is caused by non therapeutic radiation
Non therapeutic irradiation of the neck is most closely linked to papillary gland cancer.
513
A 74 year old woman presents with a breast lump. On examination, it has a soft consistency. The lump is removed and sliced apart. Macroscopically there is a grey, gelatinous surface. Which of the following tumour types is most likely?
Mucinous carcinomas: Mucinous carcinomas comprise 2-3% of all breast cancers. They are one of the special type of carcinomas. These have a better prognosis than is associated with tumours of Non Special Type (NST) and axillary nodal disease is rare in this group.
514
Left sided SVC
Will drain into the coronary sinuses. Persistent left superior vena cava is the most common anomaly of the thoracic venous system. It is prevalent in 0.3% of the population and is a benign entity of failed involution during embryogenesis.
515
What is paul bunnel test
EBV test
516
FACT
Calcitonin is released from the thyroid gland
517
India stomach pain
Ascaris lumbricoides
518
What is the most superficial structure of the parotid fland
Most superficial structure on the parotid gland = facial nerve
519
What is the only way to know that the parathyroid gland has been sectioned?
Intraoperative frozen section
520
What proportion of TG digestion occurs by lingual lipase
25%
521
FACT
Adjuvant chemo to the breast can lead to secondary leukaemia
522
FACT
TPN can cause hypokalaemia
523
what are Oslers nodes and how do they arise
Osler nodes are normally described as tender, purple/red raised lesions with a pale centre. These lesions occur as a result of immune complex deposition. These occur most often in association with endocarditis. However, other causes include SLE, gonorrhoea, typhoid and haemolytic anaemia.
524
What to do when someone has a frost bite
Give aspirin and Ibuprofen
525
Commonest enzyme def in CAH
21 - Hydroxylase
526
Lidocaine
3 and 7 rule but also remember that max is 500 with adrenaline and 200 without
527
Who should undergo BRCA 1 and 2 testing
women aged 50 that have a triple neg breast cancer.. Negative for oestrogen, progesterone and HER
528
Which factor cross links fibrin
Factor 13
529
Fluids in children
100ml/kg in the first 10kg 50ml/5kg in 10-20 20ml./kg for all weight above 20
530
Inflammatory AAA
Can be caused by smoking, ESR will be high and there will be weight loss as well as fever. They are more common in men and there is also an association with takatsubo Procalcitonin is high in infective AAA
531
What is the paediatric blood volume
80mls/kg
532
What is the difference between partial and complete congenital adrenal hyperplasia
Partial 21- Hydroxylase causes partial symptoms as there is still an ability to produce cortisol and aldosterone In complete there is complete incompetence
533
What is the berry's ligament
It connects the cricoid to the thyroid and has important implications as it contains the recurrent laryngeal nerve
534
Radiological investigations for Rhem Arth
XR for late and US for early symptoms
535
When is intussusception more common?
It is more common in boys and it is more common in the winter as viruses pre-dispose them to developing this condition
536
How much blood can cell salvage collect
4-5 units
537
Main histological finding associated with sarcoidosis
Asteroid bodies
538
How is TLCO affected
Transfer factor raised: asthma, haemorrhage, left-to-right shunts, polycythaemia low: everything else
539
What is a gantzer muscle
Anterior interosseous lesions occur due to fracture, or rarely due to compression. The Gantzer muscle is an aberrant accessory of the flexor pollicis longus and is a risk factor for anterior interosseous nerve compression. Remember loss of pincer grip and normal sensation indicates an interosseous nerve lesion.
540
FACT
Long term catheters can cause SCC of the bladder
541
What may be required when treating burns due to HF acid
Ca gluconate gel in the wound and lavage with water is required, however, systemic Ca may also be needed due to the fact that HF binds to Ca and hence reduces it plasma volume
542
What happens to CO in exercise
It increases 6 fold
543
Aortic dissection on CXR
Shows widened mediastinum
544
What is linked to gynaecomastia in males
Liver cirrhosis as there is increased activity of aromatase enzyme that converts stuff to oestrogen, thus tipping the balance
545
What toxin is produced by staph auerus
Haemolysin
546
Some stats nonsense
Unpaired T test is for 2 groups at the same point in time Paired T-test is for one group at 2 different points in time Pearson correlation co-efficient is to judge how strong the relationship between 2 things is Friedmans is 3 or more groups Analysis of variance is between 3 or more groups
547
What interleukin produces intestinal mucus secretion
IL1
548
What are the tumors that most commonly metastasize to the adrenal glands?
Lung and breast
549
Endocervical polyps
Endocervical polyps or micro glandular hyperplasia is common after COCP use. They are usually reddish pink and are barely malignant
550
Phosphate absorption
Occurs in the PCT and is actively co-transported with Na. Absorbtion is inhibited by PTH
551
What is the mortality rate for infected and necrotic pancreatic cancer
25%
552
Cancer and CT scan association
1 in 2000 risk of getting a serious type of cancer
553
What are the carb and water requirements per day
0.5 - 1 of nitrogen 35ml/kg/day of water
554
Noninfectious endocarditis
Marantic, It is most commonly diagnosed at autopsy
555
What to do for rectal cancers with threatened resection margins
Rectal cancers with threatened resection margins are managed with radiotherapy and chemotherapy initially. This is not the case with colonic cancers which are usually primarily resected.
556
What is the pathophysiology of SCC of the kidney arising
SCC of the kidney usually arises in an area of chronic inflammation such as a staghorn calculus. They are rare.
557
Fact
Diuretics increase the risk of re-feeding syndrome through a process of increasing the risk of depletion of key electrolytes.
558
About fat emboli
Early reduction of the fracture is the best. It is also associated with retinal petechia
559
About actinic keratoses
Narrow resection margins are fine as it is a premalignant lesion and can be treated with liquid nitrogen
560
Etomidate
Causes adrenal suppression but has a good cardiac safety profile
561
Where does PAOP measure pressure
Left atrium
562
What type of diathermy is used in colonic polypectomy
Blend
563
FACT
In Type IIIc injuries, the mangled extremity scoring system (MESS) can help to predict the need for primary amputation.
564
What to be careful about while performing a splenctomy
Be careful not to damage the tail of the pancreas, if you do then this will need to be formally removed and the pancreatic duct closed.
565
Schistosoma haematobium treatment
Single oral dose of praziquantel
566
Warfarin
Warfarin interferes with fibrin formation by affecting carboxylation of glutamic acid residues in factors 2,7,9 and 10. Factor 2 has the longest half life of approximately 60 hours, therefore it can take up to 3 days for warfarin to be fully effective. Warfarin has a small volume of distribution as it is protein bound.
567
What is the type of thyroid cancer in which oxyphil cells predominate
Hurthle cell Hurthle cell tumours are a variant of follicular neoplasms in which oxyphil cells predominate. They have a poorer prognosis than conventional follicular neoplasms.
568
Metastatic bone pain
metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy
569
JVP abnormalities
Jugular venous pressure Absent a waves = Atrial fibrillation Large a waves = Any cause of right ventricular hypertrophy, tricuspid stenosis Cannon waves (extra large a waves) = Complete heart block Prominent v waves = Tricuspid regurgitation Slow y descent = Tricuspid stenosis, right atrial myxoma Steep y descent = Right ventricular failure, constrictive pericarditis, tricuspid regurgitation
570
Signet rings and gastric cancer
If the gastric cancer has signet rings, this means that the cancer is poorly differentiated and hence has a higher risk of metastatic spread
571
Amsterdam Criteria
The Amsterdam criteria (Box 3‐4) requires the presence of at least three family members with colorectal cancer, extending over at least two generations, with at least one person diagnosed before the age of 50 years, and one affected person a first‐degree relative of the other two. 3-2-1 rule
572
Inherited cancers
Li-Fraumeni Syndrome Autosomal dominant Consists of germline mutations to p53 tumour suppressor gene High incidence of malignancies particularly sarcomas and leukaemias Diagnosed when: *Individual develops sarcoma under 45 years *First-degree relative diagnosed with any cancer below age 45 years and another family member develops malignancy under 45 years or sarcoma at any age. BRCA 1 and 2 Carried on chromosome 17 (BRCA 1) and Chromosome 13 (BRCA 2) Linked to developing breast cancer (60%) risk. Associated risk of developing ovarian cancer (55% with BRCA 1 and 25% with BRCA 2). Lynch Syndrome Autosomal dominant Develop colonic cancer and endometrial cancer at young age 80% of affected individuals will get colonic and/ or endometrial cancer High risk individuals may be identified using the Amsterdam criteria Gardners syndrome Autosomal dominant familial colorectal polyposis Multiple colonic polyps Extra colonic diseases include: skull osteoma, thyroid cancer and epidermoid cysts Desmoid tumours are seen in 15% Mutation of APC gene located on chromosome 5 Due to colonic polyps most patients will undergo colectomy to reduce risk of colorectal cancer Now considered a variant of familial adenomatous polyposis coli
573
MEN and genes
MEN 1 = MENIN gene on chromosome 11 MEN 2a and 2b = RET and chromosome 10
574
Polyposis syndrome and which chromosome
COWDEN = PTEN (MACROCEPHALY and multiple colonic polyps) FAP = APC MYH = MYH 1p Peutz Jegers syndrome = STK11 on c19 Lynch syndrome = Germline mutations of DNA mismatch repair genes
575
Brain death
No corneal, vestibulo ocular reeflex, no resp effort 5 mins after turning of ventilator, no change when supraorbital pressure is applied. PaCO2 up to 6 after turning off ventilator (6.5 if retainer). Adequate oxygenation given before hand The test should be undertaken by two appropriately experienced doctors on two separate occasions. Both should be experienced in performing brain stem death testing and have at least 5 years post graduate experience. One of them must be a consultant. Neither can be a member of the transplant team (if organ donation contemplated)
576
What happens to the bloods affinity of oxygen when there is malnutrition/ starvation
There is a decreased level of 2,3 BPG and hence there will be more affinity for oxygen
577