September 2016 Flashcards
Neonate with weak urinary stream -
posterior urethral valves
lightheadedness following gastric surgery what is the diagnosis -
dumping syndrome
Transmission of MRSA?
Direct skin-to-skin contact with shared items
Transmission of clostridium difficile?
faecal oral route
Gastroenteritis in developing country -
Amoebiasis, faeocal oral, bloody diarrhoea, liver abscess
Causes of osteomyelitis in a child with sickle cell anaemia
Salmonella
Injury with a sewing needle, what’s an organism?
?Staph
Which of the following is true regarding the vertebral artery? Tell me everything
Originates from subclavian, to transverse process of C6, through each transverse foramen. once through transverse foramen of C1/ Atlas, they cross posterior arch of C1 and through the suboccipital Triangle, before entering foramen Magnum, forming midline basilar artery.
A patient has recurrent pulmonary embolism due to DVT. What is the best management?
IVC filter.
A question on the differential diagnosis of left iliac fossa pain
Gastroenteritis: Constipation Diverticulitis Volvulus: sigmoid volvulus Left inguinal/femoral hernia Appendicitis Ectopic Miscarriage Placental abruption Uterine Rupture
gallbladder mucocele
The term gallbladder mucocele refers to an overdistended gallbladder filled with mucoid or clear and watery content. Usually noninflammatory, it results from outlet obstruction of the gallbladder and is commonly caused by an impacted stone in the neck of the gallbladder or in the cystic duct.
Pancreatic cancer
Adenocarcinoma
Mainly occur in the head of the pancreas (70%)
Weight loss
Painless jaundice
Epigastric discomfort (pain usually due to invasion of the coeliac plexus is a late feature)
Pancreatitis
Trousseau’s sign: migratory superficial thrombophlebitis
Investigations
USS: May miss small lesions
CT Scanning (pancreatic protocol). If unresectable on CT then no further staging needed
PET/CT for those with operable disease on CT alone
ERCP/ MRI for bile duct assessment
Staging laparoscopy to exclude peritoneal disease
Management
Head of pancreas: Whipple’s resection (SE dumping and ulcers). Newer techniques include pylorus preservation and SMA/ SMV resection
Carcinoma body and tail: poor prognosis, distal pancreatectomy, if operable
Usually adjuvent chemotherapy for resectable disease
ERCP and stent for jaundice and palliation
Surgical bypass may be needed for duodenal obstruction
Oesophageal CA
Upper GI endoscopy is the first line test
Contrast swallow may be of benefit in classifying benign motility disorders
If CT does not show metastatic disease, then local stage may be more accurately assessed by use of endoscopic ultrasound.
If CT does not show metastatic disease, then local stage may be more accurately assessed by use of endoscopic ultrasound.
Treatment
Operable disease is best managed by surgical resection. The most standard procedure is an Ivor- Lewis type oesophagectomy. mobilisation of the stomach and division of the oesophageal hiatus. The abdomen is closed and a right sided thoracotomy performed. The stomach is brought into the chest and the oesophagus mobilised further. An intrathoracic oesophagogastric anastomosis is constructed. Alternative a- transhiatal resection (for distal lesions), a left thoraco-abdominal resection (difficult access due to thoracic aorta) and a total oesophagectomy (McKeown) with a cervical oesophagogastric anastomosis.
The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis this will result in mediastinitis. With high mortality. The McKeown technique has an intrinsically lower systemic insult in the event of anastomotic leakage.
In addition to surgical resection many patients will be treated with adjuvant chemotherapy.
A patient on multiple antibiotics and immunosuppressive drugs is complaining of dysphagia. What is the diagnosis?
A patient on multiple antibiotics and immunosuppressive drugs is complaining of dysphagia. What is the diagnosis? Candida.
A patient presented with breast cancer. What is the defective gene?
BRCA 1 (17q21) > BRCA 2 (13)
A patient with known lung cancer presented with nausea and headache. What is the best treatment?
Dexamethasone.
A patient presented with ischemic colitis. What is the most likely cause?
Thromboembolism in AAA repair as well Vs Hypoperfusion SIRS
A patient with esophageal varices. What are the involved veins?
Left gastric vein.
What forms the medial wall of the femoral canal?
Lacunar Ligament (LMAP/FLIP)
A infant with retractile testes. What is the abnormality?
Patent processus vaginalis.
A mediastinal lesion was biopsied and this shows Hassal bodies. What it is the lesion?
Thymus tumor (Hassall’s corpuscles (or thymic corpuscles (bodies)) are structures found in the medulla of the human thymus, formed from eosinophilic type VI epithelial reticular cells arranged concentrically.)
A man presented with abdominal pain. Abdominal radiograph shows multiple air-fluid levels small and large bowel. What is the most likely cause?
Paralytic ileus (?or adhesions)
A woman underwent short saphenous vein surgery for varicose veins. What is the most likely nerve to be damaged?
Sural nerve.
A man presented with flexion deformity affecting mainly the ring finger. What is the diagnosis?
Dupytrens contracture. (The ring finger followed by the little and middle fingers are most commonly affected)
A woman underwent surgery for Dupytrens contracture.
A nerve lying to the head of the fourth metacarpal was injured. What was this nerve? Communicating branch between ulna and median nerve or digital nerve
What part of the humerus articulates with the radius?
Capitalum
What is the investigation of choice for fracture in the face?
CT scan
A patient presented with episodes of fainting. She has a history of parathyroid disease. What is the diagnosis?
Insulinoma (MEN1)
A patient presented with newly onset diabetes mellitus and skin rash.
Glucagonoma (typically associated with a rash called necrolytic migratory erythema, weight loss, and mild diabetes mellitus, can be as part of MEN1 or sporadic)
Stimulant for gastric acid release?
histamine, acetylcholine and gastrin
Parietal cells - in the fundus and cardia
he enzyme hydrogen potassium ATPase (H+/K+ ATPase)
A patient develops sudden anuria post-operatively. There’s no hypotension or his temperature is normal. What is the cause? Catheter obstruction
Catheter obstruction.
Transplantation: iso, allo, auto, xeno
isograft (genetically identical twins), allograft (same species), autograft (same body) and xenograft (from different species).
Which type of bacteria develop in clean wounds?
Normal Flora - Staph
A patient has fistula between the vagina and rectum. What is the developmental anomaly?
urorectal septum reaches the cloacal membrane and divides it into anal and urogenital membranes.
What is the test that confirms carcinoid tumor?
Investigation 5-HIAA in a 24-hour urine collection Somatostatin receptor scintigraphy CT scan Blood testing for chromogranin A
Treatment
Octreotide
Surgical removal
Carcinoid tumours secrete serotonin
Originate in neuroendocrine cells mainly in the intestine (midgut-distal ileum/appendix)
Can occur in the rectum, bronchi
Hormonal symptoms mainly occur when disease spreads outside the bowel
Clinical features
Onset: insidious over many years
Flushing face
Palpitations
Pulmonary valve stenosis and tricuspid regurgitation causing dyspnoea
Asthma
Severe diarrhoea (secretory, persists despite fasting)
A patient has rectal adenoma. What is the likely electrolyte abnormality?
Hypokalemia?Hyponatraemia
What is the drug of choice for septic shock?
Noradrenaline
A patient has an urgency to pass urine while in a car. He was involved in an RTA. Upon waking up in the hospital he no longer has the urgency to void?
Bladder rupture
A patient with a lesion on his penis. There is inguinal lymph nodes involvement. I think they said it bleeds easily.
Squamous cell carcinoma.
A patient with an aneurysm . It was found that the left renal vein passes posterior to it. What is the artery involved?
SMA (Nut cracker Syndrome!)
The thoracic duct passes through which one of the diaphragmatic openings?
Aortic.
The cremastric muscle is formed from which layer of the abdominal wall ?
internal oblique.
Which nerve is at risk of injury in Gridrion incision?
Illioingional nerve (?Or iliohypogastric)
What are the marker for teratoma?
Alpha fetoprotein and hCG.
What is the marker for colorectal cancer?
CEA.
Digital Cysts
digital myxoid pseudocyst - semi-translucent, with a smooth shiny surface. It is most often located within a centimetre of the base of the nail. It often causes a groove in the nail.
A digital myxoid pseudocyst is a shiny papule found at the end of a finger or toe, close to the nail. It is called a pseudocyst because it is not surrounded by a capsule, unlike a true cyst. It is also called a myxoid cyst, a mucous cyst, a digital ganglion cyst, and a digital synovial cyst.
Seborrhoeic keratosis
Most commonly arise in patients over the age of 50
Usually multiple lesions over face and trunk
Flat, raised, filiform and pedunculated subtypes are recognised.
Variable colours and surface may have greasy scale overlying it
Treatment options consist of leaving alone or simple shave excision
Least reliable feature of compartment syndrome?
Pulse
A patient with low anal cancer. Lymphatic spread?
Superficial inguinal nodes.
Dermatome at the level of the umbilicus?
T10
A lady presented with tiredness. She has a high TSH and normal T4?
?Compensating primrary hypothyroidism.
Blow to cheek. Which is nerve is affected?
Infra-orbital.
A man involved in an RTA. Bilateral periocular discoloration. What bone was affected?
Anterior basal skull fracture - The anterior skull base (ASB) is formed laterally by the orbital plates of the frontal bone, medially by the cribriform plate and crista galli of the ethmoid bone, and posteriorly by the planum sphenoidale and lesser wings of the sphenoid bone
Anterior basal skull fracture - The anterior skull base (ASB) is formed laterally by the orbital plates of the frontal bone, medially by the cribriform plate and crista galli of the ethmoid bone, and posteriorly by the planum sphenoidale and lesser wings of the sphenoid bone
Obstruction of aqueduct of Sylvius. Aqueductal stenosis is a narrowing of the aqueduct of Sylvius which blocks the flow of cerebrospinal fluid (CSF) in the ventricular system. Blockage of the aqueduct can lead to hydrocephalus, specifically as a common cause of congenital and/or obstructive hydrocephalus.
The aqueduct of Sylvius is the channel which connects the third ventricle to the fourth ventricle and is the narrowest part of the CSF pathway
A patient presented with tongue weakness and deviation to one side when protruded. Where is the lesion?
Nucleus of hypoglossal (Medulla)
Mechanism of action of heparin?
Heparin binds to the enzyme inhibitor antithrombin III (AT), The activated ATIII then inactivates thrombin (Factor II) , factor Xa and other proteases.
What is the pattern of inheritance of achondroplasia?
Autosomal dominant.
A man presents 18 months following renal transplantation with lymphadenopathy. What is the cause?
EBV
Post-transplant <6months CMV,
>6months lymphoproliferative EBV
What is the process that facilitates bacterial phagocytosis?
Opsonization
atient was involved in an RTA. He received 6 L normal saline.What is the metabolic abnormality that will most likely result?
Hyperchloremic acidosis
A 28 year old woman presented with a lesion on her thyroid gland. There is associated cervical lymphadenopathy. What is the diagnosis?
Papillary carcinoma.
A woman presented the swelling in her thyroid gland. This is associated lesion in the humerus. What is the diagnosis?
Follicular carcinoma.
A woman with raised Ca and PTH (phosphate unknown) and GFR is 15:
tertiary hyperparathyroidism
Test to compare unpaired and possibly skewed data?
???
Patient with acute pancreatitis. His oxygen saturation is dropping and CXR showing bilateral pulmonary infiltratio
ARDS
Patient was diagnosed with acute pancreatitis. A table is provided showing different lab values. Gamma glutamyl transferase was 500. What is the caused of pancreatitis:
alcohol. (alkaline phosphatase was not raised. There was also hypertricylglyceridemia and this could be the cause but alcoholism is more common)
A patient with head injury that will need a long term nutrition:
endocopic gastrojejunostomy.
Bones that forms part of the pterion:
the parietal bone, the squamous part of temporal bone, the greater wing of sphenoid bone, the frontal bone
A man collapses suddenly while running a marathon. Died before getting to hospital:
sub arachnoid hemorrhage.
A surgeon is making an incision from a point below to the middle third of the clavicle to the deltopectoral groove to the. which of the following structures is least likely structure to be injured: i
Least likely to be encountered: Rotator cuff tendons Supraspinatus - Abducts Ifra + Teres minor Ext rotate (greater/middle/lesser) Subscap
Shoulder Anterior (Deltopectoral) Approach
Internervous plane deltoid muscle (axillary nerve.) pectoralis major (medial and lateral pectoral nerve)
Sup:
the deltopectoral fascia
the cephalic vein
Deep:
thort head of the biceps and coracobrachialis arise from the coracoid process
musculocutaneous nerve enters the biceps 5-8cm distal to the coracoid process
fascia on the lateral side of the conjoint tendon is incised to reveal the subscapularis
Osteolytic lesion of the sacrum:
chordoma (can be osteoblastoma or MM)
An old man (or woman can’t remember) with multiple osteolytic lesions on skull x-ray film
multiple myeloma (could be lymphoma/Langerhans cell histiocytosis or TB)
A player was injured in a game. His knee started to swell the next day and now it cannot be fully extended.
Meniscal Tear?
A man was involved in an RTA. His thigh is swollen and bruised and his leg externally rotated
Femoral Shaft fracture (bruised, swollen thigh, young - high energy, old - low energy)
A patient with an aneurysm. Which part of the aorta is defective
The primary event is the loss of the intima with loss of elastic fibres from the media.
A patient with acute pancreatitis. What would a biopsy show?
The acute pancreatitis (acute hemorrhagic pancreatic necrosis) is characterised by acute inflammation and necrosis of pancreas parenchyma, focal enzymic necrosis of pancreatic fat and vessel necrosis (haemorrhage). Inflammatory infiltrate rich in neutrophils
Histological features of chronic pancreatitis include loss of acinar cells, presence of an irregular interlobular fibrosis, infiltration of inflammatory cells, and relative conservation of intralobular ducts and islets.
A lesion was removed from a patient. Histopathology revealed 1 cm in situ malignant melanoma. What is the next step in the management?
If MM insitu - 5-10mm
Discharge people who have had stage 0 melanoma
stage IA melanoma, consider follow‑up 2–4 times during the first year after completion of treatment and discharging them at the end of that year.
stages IB–IIB melanoma or stage IIC melanoma with a negative SNLB, consider follow‑up every 3 months for the first 3 years after completion of treatment, then 6 months for next 2 years, and discharging at the end of 5 years
A man with a lesion in his scalp. The borders are rounded and there is telangiectasia. What is it? How to investigate?
?BCC - excision biopsy with a 4mm margin with direct closure
A man with back pain radiating to the leg. There’s loss of sensation on the sole of foot.
Which dermatome is affected? S1>L5
Posterior interosseous nerve injury
supplies all the muscles on the radial side and dorsal surface of the forearm, except the anconaeus, brachioradialis, extensor carpi radialis longus.
Deep branch becomes PIN after exiting supinator
Deep - ECRB + Supinator
Radial - Anconeus, Brachioradialis + ECRL
PIN - the rest - INCLUDING APL
boundary for the anatomical snuff box?
Ulnar (medial) border: Tendon of the extensor pollicis longus.
Radial (lateral) border: Tendons of the extensor pollicis brevis and abductor pollicis longus.
Proximal border: Styloid process of the radius.
Floor: Carpal bones; scaphoid and trapezium.
Roof: Skin
Psoas
Hip flexion
superficial part lateral surface of T12-L4
deep part - transverse processes of L1-L4
Lumbar plexus via anterior branches of L1-L3 nerve
Lesser trochanter
A man with Homer’s syndrome. Which nerve root is affected?
Disruption of sympathetic chain via C8 and/or T1 root avulsions
A woman with back pain. It is worse at the end of the day. Extension of the back is limited.
Most likely Lumbar stenosis - extension is limited, worst on standing
For my learning: Discogenic Back Pain - pain on flexing, bending and sitting - without radicular symptoms
Lumbar disc herniation - axial/lower back pain, worst with sitting, improves with standing, cauda equina
Synovial facet cyst - rare, mechanical back pain with radicular symptoms
What’s the extensor of the hip?
Gluteus maximus
Child with recurrent abdominal pain and per rectal bleeding
> IBD (Meckel’s (unless with gastric) and polyps is painless), it could be constipation and anal fissure
What is the histology of Meckle’s diverticulum
Usually small intestinal mucosa but 50% have gastric or pancreatic heterotopia, Contains all 3 layers of bowel wall
Patient with Menetrier’s disease. What is the possible complication?
gastrointestinal bleeding
adenocarcinoma
vascular thromboembolism
Massive gastric folds .Mucosal ulceration is also described and can result in gastrointestinal bleeding. Disease course tends to be progressive, leading to gastric adenocarcinoma in 2-15% of cases. Complications include severe or recurrent infections and vascular thromboembolism.
Risk factors for colorectal cancer
over 50, African American race, personal history of colorectal cancer or polyps, inflammatory intestinal conditions, fap and Lynch syndrome, Hnpcc, family history, low fibre high fat diet, lifestyle, diabetes, obesity, smoking, alcohol, previous radiotherapy
Patient (aged 31 years) with FAP
(panproctocolectomy with pouch).
A patient with ulcerative colitis responded to medical treatment, follow up
Follow up colonscopy every 1-2 years?
ulcers: foot is pale and cold
Arterial
Ulcer above the medial malleolus
Ulcer above the medial malleolus. Venous.
Mouth lesion - poor oral hygiene
gingivitis and periodontitis?
necrotising periodontal disease:
bacteria – especially spirochaetes and fusiform bacilli
viruses – including cytomegalovirus and herpes viruses
fungi/yeasts – such as candida species
hairy leukoplakia - Patches look similar to Candida infection (oral thrush), except hairy leukoplakia lesions cannot be moved or dislodged - EBV, Behcets, UC, Smokers
Hand foot and mouth disease - enterovirus infection, usually Coxsackie virus (CV) A16.
scarlet fever - 1–4 day incubation period, sore throat, swollen neck glands, headache, nausea, vomiting, loss of appetite, swollen and red strawberry tongue, abdominal pain, body aches, and malaise. The characteristic rash appears 12–48 hours after the start of the fever. The rash usually starts below the ears, neck, chest, armpits and groin before spreading to the rest of the body over 24 hours.
Conus medullaris in infant
Where SC Terminates
L1 in adults
L3 in children
CPP
(CPP) = (MAP)- (ICP)
ICP should be <15, >20mmHg = IH
Intrinsic System
Intrinsic = 12a,11a,9a+8a+Ca Extrinsic = 7a+ TF/III Common= 10a, thrombin/IIa, fibrin/Ia
VIII (Antihemophilic factor A)
IX (Antihemophilic factor B or Christmas factor)
protein C Inactivates Va and VIIIa
protein S Cofactor for activated protein C
plasmin, lyses fibrin and other proteins
Dermatomes L1 and L2
L1 - below inguinal ligament
L2 - Mid thigh - On the anterior medial thigh, at the midpoint of a line connecting the midpoint of the inguinal ligament and the medial epicondyle of the femur.
Diagnosis of diabetes
HbA1c more than 48 mmol/mol
random v ≥ 11.1
fasting ≥ 7.0
two hour plasma glucose concentration ≥ 11.1 mmol/l two hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT).
T1: C-peptide, ketosis, rapid weight loss, under 50, bmi <25, Fhx of AI disease
https://cks.nice.org.uk/diabetes-type-2
T2:
